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AN AMERICAN 
 
 TEXT-BOOK OF SURGERY, 
 
 FOR 
 
 PRACTITIONERS AND STUDENTS. 
 
 BY 
 
 PHIXEAS S. CONNER, iM. D., FREDERIC S. DENNIS. M. D., 
 
 WILLIAM W. KEEN, M. D., CHARLES B. NANCREDE, M. D. 
 
 ROSWELL PARK, M. D.. LEWIS S. PILCHER, M. D . 
 
 NICHOLAS SENN, M. D., FRANCIS J. SHEPHERD. M. D., 
 
 LEWIS A. STIMSON, M. D.. J. COLLINS WARREN, M. D., 
 
 AND J. WILLIA:\I WHITE. M.D. 
 
 EDITED BY 
 
 WILLIAM W. KEEN, M. D., LLD., 
 
 AND 
 
 J. WILLIAM WHITE, M. D., Ph.D. 
 
 THIRD EDITION, THOROUGHLY REVISED. 
 
 PHILADELPHIA: 
 
 W. B. SAUNDERS, 
 
 925 Walnut Street. 
 
 1899. 
 
Copyright, 1899, by 
 W. B. SAUNDERS. 
 
 ELECTROTVPED BY PRESS OF 
 
 WESTCOTT A THOMSON, PMILAD^ ^, B. SAVNDERS, PHILADA. 
 
TO THE 
 
 MEDICAL PROFESSION AND MEDICAL STUDENTS OF AMERICA 
 
 THEIR CO-WORKERS AND FELLOW STUDENTS, 
 
 THE AUTHORS. 
 
LIST OF AUTHORS. 
 
 PHINEAS S. CONNER, M. D., LL.D., 
 
 Professor of Surgery, Medical College of Ohio and Dartmouth Medical College; Surgeon 
 to the Cincinnati and Good Samaritan Hospitals. 
 
 FREDERIC S. DENNIS, M. D., F. R. C. S., 
 
 Professor of Clinical Surgery, Cornell University, New York City ; Attending Surgeon to 
 the Bellevuc and St. Vincent Hospitals ; Consulting Surgeon to the Montefiore Home, New 
 Yoi-k City. 
 
 WILLIAM W. KEEN, M. D., LL.D., 
 
 Professor of the Principles of Surgery and of Clinical Surgery, Jefferson Medical College, 
 Philadelphia: Surgeon to the Jefferson Medical College Hospital; Consulting Surgeon to 
 the Philadelphia Orthopedic Hospital and Infirmary for Nervous Diseases, to St. Agnes' 
 Hospital, and to the Woman's Hospital; Membre correspondant etranger de la Societ^ de 
 Chirurgie de Paris ;' Membre honoraire de la Societe Beige de Chirurgie. 
 
 CHARLES B. NANCREDE, M. D., LL.D., 
 
 Professor of Surgery and of Clinical Surgery, University of Michigan ; Surgeon to the 
 University Hospital, Ann Arbor; Emeritus Professor of General and Orthopedic Surgery in 
 the Philadelphia Polyclinic and School for Graduates in Medicine ; late Major and Chief 
 Surgeon, U. S. V. 
 
 ROSWELL PARK, M. D., 
 
 Professor of Surgery, Medical Department of the University of Buffalo; Attending Sur- 
 geon to the Buffalo General Hospital ; Consulting Surgeon to the Fitch Accident Hospital. 
 
 LEWIS STEPHEN PILCHER, M. D., 
 
 Surgeon to the Methodist Episcopal Hospital, New York City. 
 
 NICHOLAS SENN, M. D., Ph.D., LL.D., 
 
 Professor of Surgery, Rush Medical College, in affiliation with the Chicago University ; 
 Professor of Surgery, Chicago Polyclinic ; Attending Surgeon to the Presbyterian Hospital ; 
 Surgeon-in-Chief to St. Joseph's Hospital. 
 
 FRANCIS J. SHEPHERD, M. D., C. M., 
 
 Professor of Anatomy and Lecturer on Operative Surgery, McGill University; Senior 
 Surgeon to the Montreal General Hospital. 
 
 LEWIS A. STIMSON, B. A., M. D., 
 
 Professor of Surgery in Cornell University ; Attending Surgeon to the New York and 
 Hudson Street Hospitals ; Consulting Surgeon to Bellevue Hosjiital, New York City ; Cor- 
 responding Member of the Societe de Chirurgie, Paris. 
 
 J. COLLINS WARREN, M. D., LL.D., 
 
 Professor of Surgery, Harvard University ; Surgeon to the Massachusetts General 
 Hosi>ital. 
 
 J. WILLIAM WHITE, M. D., Ph.D., 
 
 Professor of Clinical Surgery, University of Pennsylvania; Surgeon to the University 
 Hospital ; Consulting Surgeon to the Maternity and Samaritan Hospitals. 
 
PREFACE TO THE THIRD EDITION. 
 
 Of the two former editions of the Ameriraii Text-book of Surgery there 
 have been 'sold nearly 29,000 copies. This and its adoption as a text-book 
 in over 100 medical colleges have been gratifying evidences of the approval 
 of the profession and a stimulus to the authors to keep the work abreast of 
 the times by another careful revision ; indeed, to all copies of the second 
 edition printed during the last two years a chapter on the use of the Ront- 
 gen rays and a number of illustrations were added without waiting for an 
 entirely new edition. This chapter has now been brought up to date throuc^h 
 the kindness of Dr. C. L. Leonard. 
 
 In the present edition, among the new topics introduced are a full con- 
 sideration of orrho- (serum-) therapy ; leucocytosis ; post-operative insanity ; 
 the use of dry heat, at high temperatures ; Kronlein's method of locating 
 the cerebral fissures ; Hoffa's and Lorenz's operations for contrenital disloca- 
 tions of the hip; Allis's researches on dislocations of the hip-joint; lumbar 
 puncture; the forcible reposition of the spine in Pott's disease; the treatment 
 of exophthalmic goitre; the surgery of typhoid fever; gastrectomy and 
 other operations on the .stomach; several new methods of operating upon the 
 intestines; the use of Kelly's rectal specula; the surgery of the ureter; 
 Schleich's infiltration-method and the use of eucaine for local anesthesia; 
 Krause's method of skin-grafting; the newer methods of disinfecting the 
 hands ; the use of gloves, etc. 
 
 The sections on Appendicitis, on Fractures, and on Gynecological Opera- 
 tions have been revised and enlarged, and many other changes and improve- 
 ments have been introduced throughout the book. 
 
 A considerable number of new illustrations, including a colored plate 
 of several specimens of appendicitis (which we owe to the courtesy of Dr. 
 Maurice H. Richardson, of Boston), have been added, and enhance the value 
 of the work. 
 
 Our thanks are due to our co-authors for their willing aid, to Prof. J. 
 Chalmers DaCosta and Dr. Alfred C. Wood for much assistance in the revis- 
 ion, and to Mr. W. B. Saunders, the Publisher, for valuable services ren- 
 dered through his Editorial Department. 
 
 The increasing specialization of the surgery of the eye and the ear, and 
 the growth of the American Text-hook in size, have compelled the editors 
 to omit these two chapters. This has been done with great reluctance, and 
 in spite of the mo.st sincere appreciation of the admirable work of Drs. 
 Burnett and Thomson. 
 
 William W. Keen, \ 
 J. William White.) 
 
PREFACE TO THE SECOND EDITION. 
 
 The success of the American Text-Book of Surgery, as evinced by its 
 extraordinary sale and its adoption as a text-book in over one hundred medical 
 schools in this country, as well as by a large sale abroad, has been most grati- 
 fvin<T both to the editors and to their colleagues. Tiie three years that have 
 elapsed since the first edition was published have been years fruitful in sur- 
 gical progress, and, accordingly, a number of topics have been added to the 
 text, as well as others expanded which seemed to have had inadecjuate treat- 
 ment in the first edition. An endeavor has been made to take advantage of 
 the kindly criticism in the medical press to make good many deficiencies 
 and to correct some errors. It is impossible to enumerate all of the many 
 changes in the text, but among others may be mentioned the effect of 
 modern small-arms in military surgery ; a new section on Acromegaly ; the 
 Ilartlev-Krause method of removing the Gasserian ganglion ; the osteo- 
 plastic method of resection of the skull, with a number of additions to ope- 
 rations and methods in endocranial and spinal surgery ; in the surgery of 
 the chest, a description of Schede's operation ; in the surgery of the digestive 
 tract, Witzel's method for gastrostomy ; the use of Murphy's button in 
 intestinal anastomosis : the consideration of retro-peritoneal tumors and of 
 castration for enlarged prostate ; a chapter on Symphyseotomy ; Macewen's 
 method of compressing the aorta in amputation at the hip-joint, etc. 
 
 The sections dealing with Fractures and Dislocations, Appendicitis, the 
 Radical Cure of Hernia, and the more recent methods in Ampirtations of the 
 Breast have been especially enlarged, particularly in the matter of treat- 
 ment. Displacements of the Uterus have been also regrouped and the chap- 
 ter largely rewritten. A new section on the use of the Rontgen rays in 
 surgery ha.^ also been a<lded. 
 
 Many of the illustrations have been redrawn, and a number of new ones 
 
 have been substituted for old ones. In the present edition each illustration 
 
 that is not original has been credited to its author immediately under the 
 
 cut, instead of the credit being given in a List of Illustrations. The names 
 
 of instrument-makers have been removed from the cuts, and credit has been 
 
 given to the makers in a separate list, which Avill be found at the end of 
 
 the Index. 
 
 WiLLi.AM W. Keen, 
 
 J. "WiLLiA.M White, 
 
 Editors. 
 
PREFACE. 
 
 The great advances which have been made in the Science and Art of 
 Surgery within the last few years have created a need for new sources of 
 reference, both for the student and the practitioner — a need which has been 
 met to some extent abroad, but not so thoroughly in this country. For 
 this reason the present Text-Book has been prepared by American authors 
 who are teachers of surgery in leading medical schools and hospitals. Many 
 of the most important subjects are considered from a new standpoint, and 
 especial prominence has been given to Surgical Bacteriology, and to the 
 most recent methods of treatment, particularly in relation to Asepsis and 
 Antisepsis, and to the newer methods in those departments in which of late 
 such notable progress has been made, as in cerebral, spinal, abdominal, and 
 pelvic surgery, etc. 
 
 The entire book has been submitted in proof-sheets to all of the authors 
 for mutual criticism and revision. As a whole, the book may therefore be 
 said to express upon important surgical topics the consensus of opinion of 
 the surgeons who have joined in its preparation. Minor differences of 
 opinion necessarily exist, and are recognized in the text. 
 
 The Editors assume the responsibility for the orthography, for the general 
 plan of the book, and for the method of mutual criticism and of unsigned 
 chapters. 
 
 Very many of the illustrations are original, among them the bacterio- 
 logical colored plates and the numerous half-tone plates, which are reproduced 
 with great fidelity from photographs of patients or of specimens, and which it 
 is believed add to the value of the work both artistically and surgically. A 
 large number of the wood-cuts and some of the colored plates have been taken 
 from other authors, and are credited to them in the List of Illustrations ; and 
 the Editors desire to express their thanks, not only to the authors, but to the 
 publishers of the various works, both xlmerican and foreign, from which these 
 
X PREFACE. 
 
 illustrations have been taken, for their uniform courtesy and li])crality in aid- 
 ing their work as far as possible. 
 
 The Editors desire also especially to thank Dr. J. Chalmers DaCosta for 
 preparing the index and for valuable aid in other -ways, and Mr. Joseph 
 McCreery for his very careful revision of the proof-sheets, and to express 
 their appreciation of the unvarying courtesy and efficient co-operation of 
 
 Mr. Saunders. 
 
 William W. Keen, 
 
 J. William White, 
 
 PHiLADELrniA, Augiist 1, 1892. Ediion. 
 
CONTENTS. 
 
 BOOK I. 
 GENERAL SURGERY. 
 
 CHAPTER I. 
 
 PAGE 
 
 Surgical Bacteriology 1 
 
 CHAPTER II. 
 Inflammation 10 
 
 CHAPTER III. 
 The Process of Repair 25 
 
 CHAPTER IV. 
 The Traumatic Fevers 34 
 
 CHAPTER V. 
 Suppuration and Abscess 40 
 
 CHAPTER VI. 
 Ulceration and Fistula 48 
 
 CHAPTER VII. 
 Gangrene 52 
 
 CHAPTER VIII. 
 Thrombosis and Embolism , 58 
 
 CHAPTER IX. 
 Septicemia 60 
 
 CHAPTER X. 
 Pyemia 63 
 
 CHAPTER XI. 
 Erysipelas 66 
 
xii CONTENTS. 
 
 CHAPTER XII. 
 
 TAOE 
 
 Tetanus 70 
 
 CHAPTER XIII. 
 Scurvy 72 
 
 CHAPTER XIV. 
 Tuberculosis 74 
 
 CHAPTER XV. 
 Rhachitis 85 
 
 CHAPTER XVI. 
 Contusions and Wounds 87 
 
 CHAPTER XVII. 
 
 Syphilis 139 
 
 CHAPTER XVIII. 
 Hereditary Syphilis 176 
 
 CHAPTER XIX. 
 Tumors 194 
 
 BOOK II. 
 SPECIAL SURGERY. 
 
 CHAPTER I. 
 Surgery of the Vascular System 221 
 
 CHAPTER II. 
 Surgery of the Osseous System 2H2 
 
 CHAPTER III. 
 Fractures 282 
 
 CHAPTER IV. 
 Diseases and Injuries of the Muscles, Tendons, and Burs^ 333 
 
 CHAPTER V. 
 Orthopedic Surgery 346 
 
CONTENTS. xiii 
 
 CHAPTER VI. 
 Surgery of the Nerves 
 
 CHAPTER VII. 
 Surgery of Joints ^ ' 
 
 PAGE 
 
 359 
 
 CHAPTER VIII. 
 
 Dislocations 
 
 423 
 
 CHAPTER IX. 
 Diseases and Injuries of Lymphatics 463 
 
 CHAPTER X. 
 
 Surgical Diseases of the Skin and its Appendages 475 
 
 BOOK III. 
 REGIONAL SURGERY. 
 
 CHAPTER I. 
 Diseases and Injuries of the Head 489 
 
 CHAPTER II. 
 Surgery of the Spine ^^' 
 
 CHAPTER III. 
 Surgery of the Respiratory Organs 589 
 
 CHAPTER IV. 
 Diseases and Injuries of the Neck ^^^ 
 
 CHAPTER V. 
 
 CCA 
 
 Surgery of the Digestive Tract .... 
 
 CHAPTER VI. 
 Diseases and Injuries of the Abdomen 701 
 
 CHAPTER VII. 
 Surgery of the Genito-urinary Tract 
 
XIV cnxThwrs. 
 
 CHAITER VIII. 
 
 PAfiE 
 
 Surgery of the Female Generative Oimjaxs wo 
 
 CHAPTER IX. 
 Diseases axd Injuries of the Breast ln40 
 
 BOOK IV. 
 OPERATIVE SURGERY. 
 
 CHAPTER I. 
 General Principles 1071 
 
 CHAPTER II. 
 Anesthesia 1092 
 
 CHAPTER III. 
 Plastic Surgery 1104 
 
 CHAPTER IV. 
 Ligation of Arteries 1113 
 
 CHAPTER V. 
 
 Operations on Bones and Joints 1132 
 
 CHAPTER VI. 
 Amputations 1151 
 
 CHAPTER VII. 
 Minor Surgery 11"5 
 
 CHAPTER VIII. 
 The Use of the X 011 Rontgen Rays in Surgery 1101 
 
 INDEX 1107 
 
LIST OF PLATES. 
 
 I. Fig. 1. Staphylococcus Pyogenes Aureus and Albus (Original) • . opposite 
 
 Fig. 2. Streptococcus Pyogenes (Original) " 
 
 II. Fig. 1. Bacilli of Tuberculosis in Sputum (Original) " 
 
 Fig. 2. (4onococcus (Original) " 
 
 Fig. 3. Bacillus Tetani (Original) " 
 
 III. Fig. 1. Bacillus of ^lalignant OOdenia (Original) " 
 
 Fig. 2. Bacillus Anthracis (Original) " 
 
 IV. Fig. 1. Giant Cells of Tuberculosis (Original) " 
 
 Fig. 2. Giant Cells of Tuberculosis (Original) " 
 
 V. Wound healing by First Intention (third day) (Original) " 
 
 VI. Moist Gangrene from Laceration of Feinoral Artery (by permission 
 
 of the Surgeon-General U. S. A.) " 
 
 VII. Large Chondroma of Ilium (Original) " 
 
 VIII. Large Sarcoma of Buttock (Original) " 
 
 IX. Fig. L Ulcerated Epithelioma of Neck and Chin (Original) ... " 
 
 Fig. 2. Malignant Lymphoma (Hodgkin's Disease) (Original) . . " 
 X. Sequestrum of Entire Shaft of Femur; Involucrum riddled with 
 
 Cloacse; the result of Acute Osteo-Myelitis (Original) .... " 
 
 XI. Fig. 1. Central Sequestrum and Osteo-sclerosis (Original) .... " 
 
 Fig. 2. Tubercular Foci in lower Epiphysis of Fenuir (Original) . " 
 
 XII. Fig. 1. Abscess in the Great Trochanter (Original) " 
 
 Fig. 2. Impacted Fracture of i^eck of Femur (Original) ** 
 
 XIII. Fig. 1. Linear Fracture of Vault of Skidl (Original) " 
 
 Fig. 2. Depressed Fracture of Vault of Skull (from within) (Orig- 
 inal) " 
 
 Fig. 3. Depressed Fracture of Vault of Skull (from without) (Orig- 
 inal) • . . " 
 
 XIV. Fig. 1. Fracture of Base of Skull (Original) " 
 
 Fig. 2. Gunshot Fracture of Lower Jaw and Cranium (Original) . " 
 
 XV. Lateral Curvature of Spine (Scoliosis) (Original) " 
 
 XVI. Pott's Disease of the Spine (Spondylitis) (Original) " 
 
 XVII. Fracture of the Spine (Original) " 
 
 XVIII. Various Forms of Appendicitis (Richardson) " 
 
 XIX. Fig. 1. Inguinal Hernia (Original) " 
 
 Fig. 2. Femoral Hernia (Original) " 
 
 XX. Fig. ]. Large Scrotal Hernia (Original) " 
 
 Large Labial Hernia (Original) " 
 
 XXI. Fig. 1. Diverticulum of the Bladder (Original) " 
 
 Fig. 2. Hypertrophy of the Median Lobe of the Prostate (Wat- 
 son) 
 
 XXII. General Enlargement of the Prostate (White and Wood) .... " 
 
 XXIII. Fig. 1. Sarcoma of Breast (Original) " 
 
 Fig. 2. Scirrhus of Breast (Original) 
 
 XXIV. Fig. 1. Ulcerated Scirrhus of Breast (Original) " 
 
 Fig. 2. Recurrent Scirrhus of Breast (Original) ** 
 
 XXV. Surgical Anatomy of the Neck (Maclise) 
 
 XXVI. Surgical Anatomy of the Neck (Maclise) 
 
 XXVII. Surgical Anatomy of the Axilla (Maclise) " 
 
 XXVIII. Surgical Anatomy of the Arm (Maclise) _. " 
 
 XXIX. Surgical Anatomy of the Forearm (Maclise) 
 
 XXX. Surgical Anatomv of the Hand (Maclise) " 
 
 XXXI. Surgical Anatomv of the Pelvis and Thigh (MacliBe) " 
 
 XXXII. Surgical Anatomy of the Leg (Maclise) " 
 
 XXXIII. Surgical Anatomy of the Leg (Maclise) " 
 
 XXXIV. Bandages (Original) 
 
 XXXV. Bandages (Original) " 
 
 XXXVI. Bandages (Original) " 
 
 XXXVII. Bandages (Original) 
 
 XXXVIII. Rontgen Rays (Original) || 
 
 XXXIX. Rontgen Rays (Original) 
 
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AN AMERICAN 
 TEXT-BOOK OF SURGERY. 
 
 *BOOK I. 
 
 GEJYERAL SURGERY. 
 
 CHAPTER I. 
 
 SUEGICAL BACTERIOLOGY. 
 
 Bacteria or micro-organisms, or microbes, as they are variously 
 called, belong to the lowest order of the vegetable kingdom, and are closely 
 allied to the algae. They derive their name from j^axrijpiov, a rod, which 
 some of them resemble in shape. The developed organism is, in form, a cell, 
 consisting of a membrane enclosing a protoplasm. This protoplasm can be 
 strongly stained by aniline dyes. The membrane, with difficulty separated 
 from the contents, consists of a substance closely allied to cellulose. There 
 is a gelatinous intercellular substance present in varying amounts and at 
 times forming a distinct demonstrable capsule surrounding the microorgan- 
 ism. During the process of division this holds the organisms together, and 
 as they multiply may form the zooglea or glue-like mass in which they are 
 sometimes grouped. Many bacterial growths are highly colored, being red, 
 yellow, or blue ; according to some observers, the coloring-matter is in the 
 protoplasm ; according to others, it lies in granules which have been exuded 
 — both observations are true. Many bacilli and spirilla have the power of 
 motion, which is attained either by means of flagella or by serpentine move- 
 ments of the protoplasm. Micrococci and some bacilli, as the bacilli of 
 tuberculosis and of anthrax, have no motility. 
 
 The principal forms of bacteria are the micrococcus or globular 
 form (xoxxoc, a berry), the bacillus or staff shape (bacillus, a little rod or 
 staff), and spirillum or spiral shape. 
 
 The micrococci, when developing rapidly, are seen often in the stage of 
 division, and, being grouped in "pairs," are called diplococci. When 
 arranged in rows or " chains " they are called streptococci (azpsTZTO^, a 
 chain); when bunched together in "grape-like" masses they are called 
 staphylococci {(rraifuhj, a bunch of grapes). Bacterial forms undergo no 
 essential changes, although under differing conditions of soil, warmth, and 
 moisture they may have an altered appearance. They multiply by fission, the 
 
2 AN AMKRKAy TEXT- HOOK OF SURGERY. 
 
 process bcitii; more rcutlily observed in the eoeei than in tht," ])aeilli. A 
 number of the baeilli and a few spirilhi undergo germination, spore-formation 
 taking phice within the eell before it is finally destroyed. There may be only 
 one spore to oaeh cell, the spore thus formed ])ossessing an extremely dense 
 enveloj)ing meml»rane, which protects it from external influences until it can 
 find conditions favorable for future growth. The cell is usually distended either 
 in the middle or at one end by the spore, and when the latter has reached its 
 full developuient the cell-membrane undergoes a gelatinous softening, the cell 
 breaks up. and the spore is free. When the spore begins to develop into a 
 bacillus it loses its tough envelope, and is then nmch more readily destroyed. 
 
 Bacteria are to be found everywhere, even occasionally in the interior of the 
 healthy living tissues. They exist in the air, the soil, the water, in our clothing, 
 on the* surface of our bodies, and on the mucous membrane of the intestinal and 
 respiration tracts. They grow best in alkaline or neutral media. They multiply 
 under favorable conditions with great rapidity : according to Cohn, a bacillus 
 divides into two in the space of an hour, into four at the end of a second hour, 
 and so on. In twenty-four hours the nuui])er of bacteria derived from a 
 single bacillus will amount to sixteen and a half millions. It is chiefly in 
 dead organic substances that they find a favorable soil, and it is through 
 them that the process of decomposition is carried on. Those concerned in 
 this process are called saprophytic or saprogenic. A certain number 
 grow in the living body, causing by their presence morbid conditions, and 
 are known as the pathogenic or disease-producing bacteria, among which 
 those producing pus, the pyogenic bacteria, are of the greatest surgical 
 importance. 
 
 Pasteur divided bacteria into aerobic, or those which live best in the pres- 
 ence of oxygen, and anaerobic, or those Avhich live without oxygen. The 
 greater portion of the l)acteria are aerobic. Some are so sensitive that a slight 
 diminution in the amount of oxygen is sufficient to prevent their development. 
 These are called the oblijjate aerobic bacteria. Others, however, can grow 
 well in media rich in oxygen, but are also able to grow where there is no oxy- 
 gen. These are called the facultative aerobic bacteria. Most of the pathogenic 
 bacteria belong to this variety, the oxygen of the body not being found in 
 large quantities and being soon consumed by the micro-organisms in their 
 growth. It is rare that we find a strictly anaerobic pathogenic form. An 
 example of this variety is the bacillus of tetanus. The presence of sunlight 
 is unfavorable to the growth of bacteria. 
 
 The growth of the saprophytic, and particularly the anaerobic, bacteria 
 upon albuminoid nuitter, whether animal or vegetable, causes the jirocess of 
 decomposition, in the course of which the complex organic material is broken 
 up and new chemical comjtounds are formed, some of whicii have been iso- 
 lated and are called ptomaines {-ribna, a dead body). They are the animal 
 bases derived from the direct action of the bacteria on albuminoid bodies, 
 and have an excess of hydrogen and little or no oxygen in their make-up, 
 and are, therefore, oxidizable. The sepsin of Bergmaiin and the cadaverin 
 and putrescin of Brieger are examples of these chemical substances. The 
 ptomaines are frequently very poisonous. Thus bacteria, harmless if intro- 
 duced into the living animal, may by their growth in articles of food 
 develop poisons which can cause the severest toxic symjjtoms (])tomaine- 
 poisoning). 
 
 The pathogenic bacteria, having gaineil entrance into an organism and 
 multiplying there, cause disease in virtue of toxini< which they produce dur- 
 ing their development. These toxins are set free or secreted by the bacteria, 
 
SURGICAL IIACTERIOLOGY. 3 
 
 and are analogous to the active principle of the venom of snakes and to the 
 so-called extractives from our excreta. They apj)ear to be of an albuminoid 
 nature and are more closely allied to the nueleo-albumins, though often ap- 
 pearing to belong to the class of nucleins or proteids. From a physiological 
 point of view, it is necessary to compare them with soluble ferments or 
 enzymes, as they act by their power to split up or peptonize proteid bodies. 
 If this action takes place locally, there is an inflammatory reaction devel- 
 oped ; if the toxin becomes diffused through the body, constitutional svmp- 
 toms apjiear. through the ferment-like action of the toxin upon the tissues of 
 the boily and upon the thermic centers. In the most localized conditions, 
 however, there is usually "septic absorption " enough to cause some general 
 disturbance. 
 
 It has been observed that while some animals are very susceptible to a 
 given form of pathogenic bacteria, otliers are much less so. and still others 
 are immune, and it has been found that immunity can be conferred upon sus- 
 ceptible animals in various ways — by vaccines, by the injection of gradually 
 increasing doses of the bacteria or their toxins, or by the blood-serum either 
 of a naturally immune animal or of one that has been made immune. This 
 immunity is probably due to cell activity in the organism. When the tissues 
 are threatened by any pathogenic organisms and their toxins, new cells are 
 called to the seat of the invasion by what is known as the chemotactic action of 
 the bacteria. Some of the cells probably actually destroy the bacteria by a 
 phagocytic action ; but by far the most important action of these cells is to 
 furnish to the organism a material, the antitoxin, which is capable of neu- 
 tralizing the toxin. In bacterial diseases these plasma, connective-tissue 
 cells, and leucocytes by their action enable the organism to overcome the 
 poisonous effect of the bacteria ; but in fatal cases the amount of toxin is 
 sufficient to overcome the organism before these cells either make their 
 appearance or develop in sufficient quantities to neutralize the toxins. For 
 the consideration of Orrhotherapy (Serumtherapy) see page 81. 
 
 The question of the direct transmission of microbic disease from parent 
 to offspring is one not susceptible of easy demonstration. There are two 
 routes through which hereditary disease may be communicated : through the 
 placenta during intra-uterine life, or during the act of conception through the 
 semen as a vehicle. Placental infection has been observed in small-pox, 
 erysipelas, typhoid, and intermittent fever. Glanders has been transmitted 
 in this wav from mare to foal, and the bacilli of anthrax, glanders, and malicr- 
 nant oedema have been shown by experiment to pass through the placenta to the 
 foetus. The tubercle bacillus has been found in the seminal fluid of consump- 
 tives not suffering from tuberculosis of the genital organs: Tubercular lesions 
 have been found in the human foetus at varying periods of intra-uterine life. 
 There is therefore no doubt that this disease may be transmitted from parent 
 to child : it is merely at the present time a question of the frequency and 
 method of transmission of the disease (Baumgarten). It is also well known 
 that syphilis may be acquired through both the semen (by impregnation) 
 and the placenta, although the fact that no specific organism has as 
 yet been discovered renders it impossible to furnish the bacteriological 
 proofs. 
 
 Most bacteria grow best at a temperature varying from 86° to 104° F. 
 The saprophytic or putrefactive organisms prefer a temperature of about 75° F., 
 or the ordinary house temperature. The pathogenic bacteria grow best at a 
 temperature of from 95° to 104° F. Subjecting solutions containing bacteria 
 to freezing temperatures does not generally kill the micro-organisms. They 
 
4 AX A mi: RICA X TEXT-BOOK OF SURGERY. 
 
 all lose the power of movement and reproduction at this temperature, but may 
 preserve the power to resume their activity at a higher temperature. Cohn 
 has reduced the tc-mperature of liquids containing bacteria as low as — 186° F. 
 without destroying their vitality. Cold is therefore an agent which can- 
 not be employed to destroy these organisms. Experiments show that organ- 
 isms containing aporen^ like the bacilli of anthrax, are much more difficult 
 to kill than the micrococci, which do not contain spores. If dry heat is 
 used as a means of sterilization, it is necessary to expose the latter to a 
 temperature of 212° F. for an hour and a half in order to destroy them. 
 Bacilli containing spores, however, must be subjected to a temperature of 
 284° F. for three hours before they are rendered incapable of further growth. 
 The dry heat, moreover, does not always penetrate easily to the centre of arti- 
 cles subjected to this process, and most materials, and particularly instruments, 
 are permanently injured by such high temperatures. 
 
 The fact that boiling ivater will kill all kinds of organisms and spores in a 
 few minutes suggested the application of hot steam for the purpose of disinfec- 
 tion. Experiments showed that moist heat had in fact a much greater germicidal 
 value than dry heat. In Koch's sterilizer all kinds of bacteria are destroyed 
 in half an hour when subjected to a temperature of 212° F., even in those cases 
 where the organisms were surrounded by voluminous dressings and materials 
 of different kinds. Most of the ordinary pyogenic bacteria are micrococci, and 
 therefore produce no spores. They are not tenacious of life, but are easily 
 destroyed by heat. The bacilli of anthrax, malignant oedema, and tetanus, 
 spore-bearing surgical bacteria, can practically be left out of consideration 
 in the sterilization of surgical instruments. The following experiment shows 
 how readily the ordinary surgical bacteria can be destroyed : Agar-agar tubes 
 planted with a mixed growth of cocci were exposed to the action of steam in 
 the Arnold sterilizer, and one tube was removed at the end of five minutes, 
 a second tube at the end of ten minutes, and so on. A second series of tubes 
 "was inoculated from the first tube removed, and all of them remained sterile. 
 No further growth occurred in the original tubes, showing that the micrococci 
 were destroyed by the action of the steam for the minimum length of time, five 
 minutes (A. K. Stone), 
 
 The Arnold sterilizer, which is cheap and convenient, and is in common 
 use in America at present, furnishes a rapid and easy method of generating 
 steam, by which surgical dressings and instruments may be sterilized. The 
 best method, however, for the sterilization of instruments is to boil them for 
 five minutes in water to which sodium bicarbonate, in the proportion of a 
 teaspoonfnl to a quart, has been added. This prevents rusting by neutraliz- 
 ing the carbonic acid in the water. 
 
 The most powerful of bactericidal drugs is corrosive sublimate. A solution 
 of 1 : 1,000,000 exercises a marked retarding influence upon the develop- 
 ment of bacteria. A solution of 1 : 20,000 kills the spores of bacilli in ten 
 minutes, and a solution of the strength of 1 : 1000, according to Koch, destroys 
 the most powerful organism in a few minutes, without any previous preparation 
 of the object to be disinfected. Aqueous solutions of carbolic acid, in the 
 strength of 1 : 100, destroy in two minutes sporeless anthrax bacilli, and in 
 the strength of 1 : 30 is sufficient for all ordinary surgical purposes, as it retards 
 the development of the spores and kills the mature organisms. But solu- 
 tions in oil have not the least influence upon the life of micro-organisms. 
 Boric acid and salicylic acid have been regarded as useful antiseptic drugs, 
 but their gennicidal power is now known to be almost nil. Iodoform is not a 
 germicide, but markedly retards the growth of bacteria ; used as a powder, it 
 
SURGICAL BACTERIOLOGY. Plate I. 
 
 m. 
 
 1. staphylococcus pyogenes aureus and albus : a, pus-cell with nuclei ; b, free nuclei. 
 [Camera Lucida. Zeiss Apochromalic objective 2.0 mm. ocular 6.] 
 
 WM 
 
 
 2. Streptococcus pyogenes in pus : a, pus-cell with nuclei ; b, free nuclei. 
 [Same power as fig. 1.] 
 
SURGICAL BACTERIOLOGY. 5 
 
 has a tendency to stop serous oozhi>f, a condition favorable to bacterial growth. 
 When moistened it liberates iodine, which has a certain antiseptic value. It 
 does not procure asepsis of material, instruments, or wounds. 
 
 The inicroseo/jicdl stiuh/ of bacteria has been greatly facilitated by the use 
 of the Abbd condenser, which is placed Ijeneath the object-glass and throws a 
 cone of ravs Avith a very broad base, thus giving powerful illumination of the 
 section and making it possible to use higher powers wdiich would otherwise cut 
 off the light. By this means the section is flooded with light and the structure 
 of the tissues is made quite transparent. If now we use aniline dyes, which 
 stain the micro-organisms, and wash the sections afterward in alcohol or acetic 
 acid, the coloring matter will be in great part removed from the tissues, and the 
 bacteria alone will retain the dye. In this way the bacteria are readily dis- 
 tinguished from other objects, when examined Avith suitable lenses. For this 
 purpose immersion lenses alone are reliable. Furthermore, contrast-stains 
 can be often advantageously employed, by means of which the tissues are given 
 a decidedly different though paler hue. Fragments of tissue which it is desired 
 to examine for bacteria should be cut in pieces half an inch square and placed 
 immediately in absolute alcohol. This should be changed once or twice, and 
 in tAvo days the specimen is ready for cutting. The sections are placed for five 
 to fifteen minutes in dilute solutions of fuchsin or gentian-violet. They are 
 then decolorized in acidulated Avater, and afterAvard washed in water; after 
 alcohol has been used to remove the water from the specimen it is mounted in 
 Canada balsam. 
 
 It is often necessary to examine the tirine or the sjnifa for tubercle bacilli, 
 for the purposes of diagnosis. The urine, Avhich should be collected in con- 
 siderable quantity, is alloAved to deposit a compact sediment. A small portion 
 of this sediment is spread upon a thin cover-glass held by a pair of forceps. 
 It is best to let this become nearly or completely dry, and then to pass the 
 cover-glass three times gently through the flame of an alcohol lamp in order 
 better to fix upon the glass the material it is proposed to examine. If the 
 sediment is light, a second or even a third drop is added, and each time 
 evaporated to dryness. The cover-glass is noAV placed in the following solution, 
 (Ziehl), Avhich has been slightly warmed, for from five to ten minutes : ^ 
 
 Fuchsin, 1 gram ; 
 
 Carbolic acid solution (5 ^), 80 c.c. ; 
 Alcohol (95 %), 20 c.c. 
 
 It is then decolorized by placing it in a 5 per cent, solution of strong sul- 
 phuric acid, Avhich removes the fuchsin from all but the bacilli. The length 
 of time necessary for the bleaching process must be determined by experi- 
 ment, and is hastened by transferring to 60 per cent, alcohol. The coA^er- 
 glass is next Avashed thoroughly Avith distilled Avater, and is then placed 
 in a strong Avatery solution of methyl-blue for about five minutes. The 
 glass is finally washed in distilled Avater, dried thoroughly, and mounted in 
 Canada balsam upon a glass slide. The bacilli appear under the micro- 
 scope as minute red rods scattered about upon a blue background. The same 
 
 1 Koch-Ehrlich Stain for the Barjlltis of Tuberculosis.— 1. Sections or cover-glass preparations are 
 left in aniline-water fuchsin (or gentian-violet) solution for twenty-four hours in the cold. 2. 
 Transfer to a solution of nitric acid (1 part to 3 of water if sections, 1 part to 4 of water if 
 cover-glasses) for two to three seconds (just long enough to pass them through). 3. Then transfer 
 to 60 per cent, alcohol for a moment, to complete the decolorization. 4. Wash in water. 5. A 
 contrast-stain may be made with a watery solution of methylene-blue (if fuchsin be the first 
 stain) or vesuvin (if gentian-violet be first" used). 6. Wash thoroughlv in water, dry, and mount, 
 if cover-glasses. Dehydrate, clear in oil of cedar, and mount, if sections. 
 
6 AN AMA'BICAX TEXT-JiOOK OF SUltGERY. 
 
 method of staininj^ is applicable to the detection of tlie tu])ercle bacillus in the 
 sputa of jihtiiisical jiaticnts. A drop of the sputum is selected from one of the 
 tough yello^v clumj)s Hoatiiig in the sputum and placed upon the cover-glass; 
 a second cover-glass is then placed on top of it, and the sputum is pressed out 
 into a thin layer. The glasses are then separated and dried, and furnish two 
 specimens for the coloring process. 
 
 Bacteria are not usuaUy found in the healthy tissues of the body, although 
 occasionally they may be concealed in certain structures "which show no symp- 
 toms of disease, and first make themselves manifest after the infliction of an 
 injury or during the course of some intlamnuitory process. Cocci and spores may 
 remain latent in cicatrices for a considerable length of time, awaiting a suitable 
 opportunity for development. It is not uncommon to discover the presence of 
 tubercle bacilli in individuals apjiarently healthy. An injury or a slight bruise 
 under such circumstances "would offer an opportunity for their development 
 either as a local or a general tul)erculosis. Micrococci are often found tem- 
 porarily in the blood of individuals "whose vital powers are enfeebled. They 
 may disappear quite rapidly — even in a tew hours — without having given rise 
 to any Avell-defined pathological process. 
 
 Bacteria are found in all kinds of true inflammations. The term '' sim- 
 ple inflammation" is intended to designate that variety in which no micro- 
 organisms are found. This form of inflammation is a more limited one than 
 was formerly supposed, and is confined chiefly to those jjrocesses "which follow 
 injury and are concerned in repair if bacteria are excluded (Senn). 
 
 The forms of bacteria most frequently met "with in surgical diseases are 
 those "which produce suppuration. These organisms are known as the pus 
 microbes or pyogenic cocci. 
 
 The Pus microbes consist of several varieties, but the most common 
 form is the staphylococcus pyogenes aureus (PI. I, Fig. 1), so called 
 from the grouping of the cocci in clusters. Its shape is globular, and it meas- 
 ures from 0.7 to 0.87 micromillimeters in diameter. It multiplies by division, 
 but the line of fission is difficult to see. It is a very resistant organism, and 
 requires several minutes' boiling or steaming to destroy its power of gro"wth. It 
 is readily stained by all the coloring agents. It grows well at the ordinary house 
 temperature, but is more active "when growing at a temperature nearer that of 
 the body. It does not need a large amount of oxygen for its growth. When 
 cultivated in the test-tube upon beef gelatin it forms at first a yellowish-white 
 layer, which later changes to an orange color ; hence the last part of its name 
 — aureus. If thrust deeply into the gelatin, the upper surface softens as the 
 growth forms, and becomes liquefied in virtue of peptonizing action exerted by 
 the organism. It has a peculiar odor of sour paste. The aureus is found abun- 
 dantly outside of the human body. It can be obtained from dirty dish-water, 
 the soil, or the air, particularly in foul hospital wards, but its most conmion 
 seat is the superficial layers of the skin, particularly of the axill» and other 
 moist parts, and also under the ends of the finger-nails. It is also found in 
 the mucus of the pharynx and digestive tract. 
 
 Other forms of the'])yogenic cocci, but less frequently seen than the aureus, 
 are the staphylococcus pyogenes albus and the staphylococcus pyo- 
 genes citreus. These may occur alone or be combined with the aureus. 
 
 The Streptococcus pyogenes (PI. I, Fig. 2), is an important variety 
 of the pus cocci. The arrangement of the organism is in chains or rows, six 
 to ten being usually attached together. These cocci measure about one micro- 
 millimeter in diameter. On culture-media the growth reaches its development 
 in four or five days, and has at first a transparent whitish look, but later a 
 
SURGICAL BACTERIOLOGY. Plate II. 
 
 1. Bacilli of tuberculosis in sputum. 
 [Camera Lucida. Zeiss apochrornatie objective 2.0 mm. ocular 6.] 
 
 
 
 T ; 
 
 / 
 
 
 
 
 2. Gonococcus from gonorrheal pus. 3. Bacillus tetani. Cover-glass preparation 
 
 [Sawie power as fig. 1.] from culture by Kitasato. 
 
 [Same power as fig. 1.] 
 
SURGICAL BACTERIOLOGY. 7 
 
 brownish color. Tlie streptococci are found under normal conditions in the 
 saliva, socrctions dt" the nostrils, vaj^ina, and urethra. 
 
 The Bacillus pyocyaneus is an organism wiiieh is found in green or blue 
 pus. It is a small, thin rod with distinctly rounded ends. It has no spores, 
 has a flagellum at one end, and is actively motile. The pigment is deposited 
 from the bacilli when in contact with oxygen, and is then seen principally on the 
 exposed edges of dressings. The substance thus found is termed injocyanine. 
 
 The pyogenic cocci are found in all acute abscesses. I'he staphylococci are 
 found in circumscribed abscesses, as boils, carbuncles, suppurating glands, em- 
 pveraa, osteomyelitis, etc. The streptococci are more frequently seen in the 
 spreading inflammations, as phlegmonous cellulitis, erysipelas, ulcerative endo- 
 carditis, and metastatic abscesses such as are seen in pyemia. 
 
 In order that suppuration should take place it is not simply necessary that 
 the pyogenic cocci sliould be introduced into the living tissues. It is found 
 that other conditions are of ecjual imj)ortance. Cheyne has shown by experi- 
 ment that the number of bacteria injected is an important factor. The dose 
 must be sufficiently large. It is owing, probably, to this fact that many cases 
 of imperfect asepsis in surgical operations often heal well. Doses of less than 
 18,000,000 of the Proteus vulgaris when injected into the muscular tissue of 
 a rabbit seldom cause any result, and it rec^uires so large a number as 
 250,000,000 to produce a circumscribed abscess. 
 
 But the Htate of tKe tissues in Avhich the organisms are arrested is also a 
 matter of great importance. Tissues which have been damaged by injury or 
 inflammation are not so resistant to tlie action of bacteria as Avhen in a state 
 of health. A healthy peritoneum may receive and absorb a large number of 
 bacteria, but if damaged during a laparotomy, so that a considerable portion 
 of its secreting surface has been destroyed and at the same time considerable 
 oozing of blood and serum has taken place from the injured surfaces, a soil 
 favorable for the growth of the organisms is provided and a septic peritonitis 
 may result. Tense sutures are more likely to be followed by " stitch abscesses " 
 than where the sutured margins of the wound come easily together. 
 
 The question has arisen. Can sujJjniration take place without the presence 
 of bacteria ? Steinhaus has shown that calomel, and also nitrate of silver, 
 when injected into the tissues can produce pus in certain animals. Even the 
 chemical substances formed by the pyogenic cocci, when separated from them 
 and injected, can produce non-bacterial pus. But, as Senn remarks, the matter 
 remains practically where it was before, as clinically we do not meet Avith 
 examples of acute" suppuration without the introduction of the pyogenic cocci 
 into the system. Foreign bodies or mechanical irritation cannot produce pus 
 without the aid of bacteria. The pus-producing power of the cocci lies in their 
 ability to liquefy the fibrinous exudation of inflammation. 
 
 The pyogenic cocci are not usually found in cold abscesses. It was sup- 
 posed that this form of abscess was produced by the tubercle bacillus only, but 
 Ernst and others have found the aureus and albus in several cases of psoas 
 abscess. It is possible that the failure to obtain cultures from this kind of pus is 
 due to the dying out of the organism owing to the age of the abscess. 
 
 The Streptococcus erysipelatis resembles closely in all respects the 
 streptococcus pyogenes, and the weight of evidence is at present strongly in 
 favor of their identity. In all cases it is the cause of the disease, and direct 
 proof has been given of its power by inoculation of open wounds in the human 
 subj ect. 
 
 The Gonococcus (PI. II, Fig. 2) is the specific organism which pro- 
 duces gonorrhea. It measures 1.25 micromillimeters in diameter, and is 
 
8 AN AMERICAN TEXT- HOOK OF SURGERY. 
 
 usually arran^iod as a dijilococcus. One of the most striking peculiarities 
 ■which distinguishes it from nearly all other forms of micrococci is its ability to 
 penetrate cells and multiply rajiidly within them. In this way it may he read- 
 ily recognized under tiie microscope. It is difficult to cultivate, as it will oidy 
 grow on blood-serum ami when isolated from other cocci. The gonococci are 
 stained well with methyl-blue, and may be prepared for examination by the 
 cover-glass method mentioned previously. The organisms grow more readily 
 on those mucous membranes which possess a cylinder epithelium or one closely 
 allied to it, as the membranes of the male and female urethra, the uterus, and 
 the conjunctiva. It does not penetrate below the epithelial layer, the more 
 deep-seated suppuration, such as bubo, being due to the presence of the pyo- 
 genic cocci. 
 
 The Tetanus bacillus (I'l. II, Fig. 3) is a large, slender rod with somewhat 
 rounded ends. Spore-formation takes place at the end of the bacillus, and, as it 
 enlarges the cell considerably, gives it the so-called drumstick shape. It is mov- 
 able, belongs to the strictly anaerobic organisms, and rapidly dies when exposed 
 to the air. It is readily colored by methyl-blue and fuchsin. It can be culti- 
 vated in cultures of gelatin mixed with grape-sugar, and grows well at the 
 bottom of the inoculation puncture, whence it sends out innumerable little pro- 
 longations, giving the growth the appearance of the fir tree. It is difficult to 
 separate from other organisms, but improved laboratory techniijue has made 
 it comparatively easy to obtain pure cultures. The spores are found in 
 garden soil, in masonry, in decomposing liquids, and in manure. Hence the 
 frequency of the disease in those employed about stables. It is quite frequently 
 met with in the dust of the streets, but owing to its anaerobic nature is not easily 
 inoculated into the living tissues. Brieger has obtained from cultures a number 
 of toxines, to one of which he has given the name tetanin, and inasmuch as the 
 same group of symptoms are obtained experimentally by the toxines as by the 
 bacilli, and as the latter are hard to find in the blood and internal organs in 
 individuals who have died of tetanus, it has been thought probable that the 
 symptoms of the disease are produced, in a great measure, by this substance. 
 
 The Tubercle Bacillus (PI. II, Fig. 1). — This organism was first seen 
 under the microscope by Bauingarten, but Koch cultivated and fully identified 
 the organism with the disease in 1882. The bacilli are small, thin rods, two 
 to four micromillimeters in length — that is, about one-half the diameter of a 
 red blood-corpuscle. The rod is slightly bent in the middle and its ends some- 
 what rounded. The longest rods are usually seen in phthisical sputa. They 
 are usually single, occasionally being found in pairs or arranged in the form of 
 the letter V. They do not possess the power of motion. The bacillus possesses 
 great powers of resistance to destructive agencies, the organisms in tuberculous 
 sputa being destroyed only after twenty minutes' boiling. The expectoration 
 can be kept for months and even years in a dried state without destruction of 
 the bacilli. They are stained by the ordinary aniline dyes with far greater dif- 
 ficulty than any other bacteria, and, in common with the bacilli of leprosy, which 
 they closely resemble, do not yield to bleaching fluids like all other bacteria. 
 The bacilli are found between the leucocytes in the tubercles, in the epithelioid 
 cells, and also in sm:dl numbers in the giant cell, being generally seen at its 
 periphery. The organism is very difficult to cultivate, and grows well only on 
 a hardened blood-serum or a combination of the ordinary nutrient media with 
 glycerin, for which latter agent it appears to have a special predilection. When 
 cultivated on agar the first signs of the growth appear at the end of fourteen days, 
 and one to two weeks more pass before full development has taken place. It 
 appears then as thick scales of a dull grayish-white color, which are very dry 
 
SURGICAL BACTERIOLOGY. Plate 111. 
 
 \ 
 \ 
 
 / 
 
 \ 
 
 / 
 
 1. Bacillus of malignant oedema. Cover-glass preparation from spleen of white mouse. 
 [ Camera -Lucida. Zeiss apochrmnatic objective i.O mm. ociilar h.] 
 
 
 / 
 
 x' 
 
 \ 
 
 
 2. Bacillus anthracis. (/'over-glass preparation from spleen of white mouse. 
 [iSame p(/wer as Jig J.J 
 
SURGICAL llM'TFJUOUKiY. 9 
 
 and brittle. The material lor culture is usually obtained by inoculatin<r a 
 iTuinea-pi<^ with tuberculous material. The experiment-anitnals are killed in 
 from four to six weeks and cultures made from the enlar«^ed lymj)h-<i;lands. 
 
 The tubercle bacilli are true parasitic organisms, as they are unable to grow 
 outside of the living tissues of man and animals. Inoculation may take place 
 through the skin, tVdlowing slight bruises or cuts. The organism is very re- 
 sistan" to the action of the digestive fluids, and animals fed experimentally 
 with tubercle bacilli have develoj^ed general tuberculosis. It is probable, 
 therefore, that they can penetrate the mucous membrane, and may be carried 
 into the svstem with the food. H. C. Ernst has shown that ^ix dropn of the 
 milk from' a tuberculous cow, injected subcutaneously into a guinea-pig, may 
 develop a tuberculosis. The milk of tuberculous cows is therefore a very dan- 
 gerous article of food. The breathing of infected air is the most frequent mode 
 of acquiring the disease. The frequency of pulmonary tuberculosis is sugges- 
 tive of this'' mode of infection. Cornet has shown that the dust of infected 
 localities is dangerous. The organisms are distributed through the air when 
 in a dry state, and are found in the dust of hotels or hospitals occupied by 
 consumptives, and in Victories and prisons. The tuberculous sputa should not 
 be allowed to dry, being harmless when kept moist. All tuberculous patients 
 therefore shouhrexpectorate into a cup containing an antiseptic solution. 
 
 Bacillus of Malignant CZdema (PI. HI, Fig. 1).— This bacillus was 
 first described by Pasteur, but its present name was given to it by Koch. It 
 is occasionally found in traumatic gangrene. It is a saprophytic organism, 
 and is found in decomposing substances and in rich garden soil. The bacilli 
 have an active motion and contain large spores. The cultivation is attended 
 with the evolution of gas, and when the bacilli are inoculated into animals they 
 produce a gangrenous oedema as in man. This bacillus, like that of tetanus, 
 is strictly anaerobic 
 
 In noma, a gangrenous inflammation of the mouth and female genitals in 
 young children, LirTgard has found long bacilli, and Ranke has found strepto- 
 cocci. No specific organism for traumatic gangrene has yet been found. It is 
 probable that the ptomaines play an important part in the process. No bacte- 
 rial examinations have been made of hospital gangrene, as, thanks to antisepsis, 
 it is now almost an historical disease only. Studies made as early as 1872 
 show the presence of enormous numbers of streptococci, but these are unreli- 
 able from a more modern standpoint. 
 
 The Syphilis Bacillus, — It is very probable that syphilis is of bacterial 
 origin, but the organism has not yet been satisfactorily identified. Lustgarten 
 des'cribed a bacillus in 1884 which is slightly curved or S-shaped and is found in 
 the tissues and discharges of syphilitic ulcers, but he was unable to cultivate it. 
 It has been grown upon a gelatin prepared from the bladder of the Russian 
 sturgeon. Similar bacilli have been found in the preputial and vulvar smegma. 
 Bacilli and also micrococci have been found in the blood and tissues of syphi- 
 litic patients by other observers. Fragments of chancres have been placed in 
 nutrient bouillon, and the bacilli thus obtained have been inoculated into 
 monkeys, and eruptions resembling those of syphilis have been observed. All 
 these observations require repetition and confirmation. 
 
 Bacillus Mallei. — This organism was discovered in 1882 by Lofiler and 
 Schutz in the tissues of animals afllicted Avith glanders. They cultivated it 
 artificially, and made successful inoculations in animals, reproducing the disease. 
 It is shorter and thicker than the bacillus of tuberculosis. Grown on boiled 
 potato, these bacilli form a characteristic yellow, transparent, honey-like layer 
 which appears on the second day. Later' the border acquires a greenish hue. 
 
10 AX AMERICAN TEXr-HOOK OF SURGERY. 
 
 The bacilli are found ^roupeil in the centre of tlie diseaf^ed nodules. Horses 
 acfjuire the disease by inhalation, but man is usually inoculated through cuts or 
 scratches. 
 
 Bacillus Anthracis. — This ])aeillus (Pi. 111. Fi^'. 2) produces the dis- 
 ea.se known in man as inali;:;nant pustule and wool-sorters disease, and in animals 
 a.s anthrax. It was discovered Ity Davaine in lHr>0, and has been called the 
 keystone to the arch of bacteriolofry. It is very large, being 1.5 micromilli- 
 meters in thickness and 3 to G micromillimeters in length. The spores when 
 forming are seen as bright, glistening bodies in the centre of the rods. The 
 bacilli are comj)aratively delicate, but the spores belong to the most durable of 
 bacterial organisms, and are therefore generally used as a standard test of the 
 values of disinfectants. In animals, chieHy cattle, they produce the disease 
 known as anthra.x or splenic fever, and are found in immense numbers in 
 the caj)illaries of the internal organs. Pasteur succeeded in weakening the 
 strength of these bacilli by cultivating them at high temperatures or for a 
 long time, and thus produced an attenuated virus by means of which he was 
 able to protect animals from the disease by "vaccination." The immunity, 
 however, is not permanent, and does not protect against infection through 
 the intestinal canal. 
 
 CHAPTER II. 
 INFLAMMATION. 
 
 Inflammation is a disturbance of the mechanism of nutrition, and affects 
 the structures concerned in this function. It is "the response of living tissue 
 to injury." It was formerly supposed to be an increased nutrition of the palt, 
 but the more modern view, as expressed by Sanderson, is that the condition 
 is the result of damage which, if not severe enough to cause death of the part, 
 will be followed by a series of characteristic changes in the blood-vessels and 
 the surrounding connective tissue. As the result of this disturbance, however, 
 we have conditions favorable for the process of repair or for the neutralization 
 or removal of the primary microbic cause. These changes give rise to tlie Jive 
 cardinal HjimptoniH of inflammation — pain, heat, redness, swelling, and 
 Impaired function (dolor, calor, rubor, tumor, functio l;csa). 
 
 In an acute inflammation of the connective tissue (cellulitis) we find the 
 part greatly swollen and sensitive. The tissues also become much firmer than 
 they were before. The skin is not only redder than natural, but is much 
 warmer to the touch. The patient complains of a thro]tl)ing pain in the part, 
 and if an incision is made through the skin the flow of blood is unusually I'apid 
 and copious. The function of the limb affected for the time being is impaired, 
 and the muscles in the immediate neighborhood become more or less rigid. 
 As the disease progresses all these symptoms are intensified, and finally at the 
 point of severest pain the part becomes softer, an examination shows that fluid 
 is collecting beneath the skin, and we recognize that suppuration has taken 
 
SURGilCAL liACTElllOLOCJY. 
 
 Plate IV. 
 
 Isjc^^* «™. 
 
 .-^^^ ^SSS!^J^ 
 
 
 e B o 
 
 m 
 
 o^»' 
 
 I 
 
 hi i' i'-o 
 
 
 i-^-k 
 
 / 
 
 
 1. Section of human tonarue showing priant-cells of tuberculosis, aurronnded with inflammatory 
 tissue [submiliary tubercle]: a, muscular liber [^Vamera Lucida. Zeiss ohjeclive Ul) ocular U] 
 
 
 
 "^ 
 
 V 
 
 2. Giant-cell of tuberculosis of human tongue before stage of cheesy degenerations showing bacilli. 
 [Camera Lucida. Zeiss apochromatic objective 2.0 mm. octUar 6'.] 
 
INFLAMMA TION. 
 
 11 
 
 place. The symptoms may, however, hegin to abate before this stage is 
 reached, and the part may gradually return to its normal condition. The 
 intianimation is then said to have terminated by resolution. 
 
 In order to understand the meaning of these symptoms a study of the 
 patliology of inflammation is necessary. 
 
 The changes seen in the blood-vessels claim our first attention. 
 The experiments of Cohnheim in 18G7 greatly increased our knowledge of 
 this part of the process. Previous to that time the great number of cells 
 found in an inflamed part were supposed to be due to the proliferation of the 
 cells of the connective tissue, but Recklinghausen showed that many of the 
 connective-tissue cells possessed the power of motion and wandered into the 
 inflamed tissues. They are called amoeboid cells from their resemblance to 
 the amoeba. Following this discovery came that of Cohnheim, who identified 
 the cells in the inflamed tissue with the white corpuscles of the blood or the 
 leucocytes. 
 
 If Ave paralyze a frog with curare, and draw a loop of his intestine through 
 an incision made on one side of the abdomen, we obtain in the exposed mesen- 
 
 FlG. 1. 
 
 Fig. 2. 
 
 Normal Vessels and Blood-Stream 
 (original). 
 
 Dilatation of the Vessels in Inflammation 
 (original). 
 
 tery a thin, transparent membrane, in which the circulation can be studied 
 with ease under the microscope. It may also be readily observed in the web 
 of a frog's foot or in the frog's tongue. The exposure of the mesentery is 
 sufficient in itself to produce an inflammation, but an application of a caustic 
 will be necessary, in the case of the web or the tongue, to bring about the 
 same result. If we examine such an area under the microscope, we can gen- 
 erally see an arteriole with its rapid pulsating current of blood, and near by 
 a small vein in Avhich the blood flows with a more steady movement. The 
 red blood-corpuscles occupy the axis of the blood-vessel, and the few white 
 corpuscles which are seen float i« the more sluggish stream of plasma which 
 occupies the borders of the lumen and appears as a transparent layer 
 (Fig. 1). The capillaries are not readily seen, but careful observation 
 
12 
 
 AN AMERICAN TEXT-BOOK OF SURGERY 
 
 will detect the elianiiels through wliieh, occasionally, a few hlood-corpnscles 
 pass. 
 
 At the beginning of" the inHaniniatory process the rajiidilif of the fliiiv of 
 blood is iireatli/ iiicrcascd and a greater amount of blood is observed in the 
 part. Tlie Imiuni of the artcn/ is yreater than before, and the column of red 
 corpuscles is much broader and fills a comparatively greater portion of the 
 lumen of the vessel. The capillaries are now quite distinctly seen, and nre 
 crowded with blood-corpuscles. They appear to be considerably larger than 
 they were before. The tlow of blood is also more rapid in the veins, and it is of 
 a brighter and more arterial color. This condition of the circulation is known 
 as Jiypi'vemia (Fig. 2), and is presently succeeded by a slowing of the current, 
 
 which soon becomes much more 
 ^"^•- '^ sluggish than in the normal state. 
 
 This is first noticed in the capilla- 
 ries, and soon after in the veins. 
 The })ulsation, however, continues 
 in the arteries. As a result of this 
 diminution of speed the column of 
 blood-corpuscles becomes broader, 
 and almost completely fills the in- 
 terior of the vessels. In the veins 
 a great aceuriiulation of tvhite cor- 
 puscles takes place on the interior 
 of the walls. Being of a lower 
 specific gravity than the red cor- 
 puscles, the leucocytes are not 
 forced onward with the same mo- 
 mentum, and are drop])ed, as it 
 were, here and there on the vessel- 
 wall. Finally they are so greatly 
 increased in numbers that the 
 entire Avail of the vessel appears 
 to be lined Avith leucocytes. The 
 Avhite corpuscles also accunmlate 
 in the capillaries, but not to the 
 same extent. In the arterioles these corpuscles cling more readily to the 
 Avail during the diastole, but they are soon swept aAvay again into the blood- 
 current. 
 
 Another step in the process, beginning concurrently Avith the sloAving of the 
 blood-stream, is the emigration of the leucocijtes from the interior of the veins 
 (diapedesis) (Figs. 3 and 4). Many leucocytes, b}' a change of shape, send 
 out little prolongations of protoplasm into the substance of the Avail, and slight 
 protuberances are soon seen projecting from its outer surface. These enlarge, 
 and Ave noAv see the corpuscles presenting an hour-glass appearance. The por- 
 tions Avithin the vessel soon folloAv those Avithout, and the leucocytes escape 
 from all contact Avith the vessel. Many corpuscles appear to folloAv one another 
 through the same point in the wall. AVhether there are actual holes (stomata) 
 between the endothelial cells of the vessel through Avhich the leucocytes escape 
 or not is still a disputed question. The amoeboid movements of the leuco- 
 cytes are effected by a poAver of those cells to change their shape. Processes 
 (pseudopodia) are throAvn out from the protoplasm of the cell, Avhich noA\' 
 becomes elongated or fiask-shaped. As the ])rotoplasmic mass resumes its 
 more or less globular form, the main portion folloAvs the protruded mass, and 
 
 stasis of Blood and Diapedesis of White Corpuscles in 
 Inflammation (original). 
 
INFLAMMA TION. 
 
 13 
 
 a change iu the position of the cell results. The white corpuscle is a minute 
 mass of granular, or, according to some authors, reticulated, protoplasm, con- 
 
 FiG. 4. 
 
 10.30 P.M. 
 
 10.40. 
 
 11. 
 
 11.15. 
 
 11.40. 
 
 12.20. 
 
 Stages of the Migration of a Single White Blood-corpuscle, through the Wall of a Vein in One Hour and 
 Fifty Minutes (mesentery of the frog ; Caton). 
 
 taining one or more nuclei, and without any limiting membrane. The cells 
 which accumulate in large numbers outside the walls of the blood-vessels in 
 
 Fig. 5. 
 
 Changes seen in the Leucocyte of a Frog during Ten Minutes (original). 
 
 inflammation have the same appearance. Migration takes place to a limited 
 extent also from the capillary vessels, but no such process is observed in the 
 walls of the arteries. 
 
 Leucocytosis. — In most local inflammatory processes, as well as in most 
 acute infectious diseases and in many toxemic conditions, the number of 
 polynuclear leucocytes in the circulating blood is greatly increased. This is 
 usually considered to be due to what is known as chemotaxis, by which is 
 to be understood an attraction exerted by the products of bacterial activitv 
 
14 ^iV^ AMERICAN TEXT-BOOK OF SURGERY. 
 
 upon the leucocytes in tlie blood-iuiikinf]; organs, which arc probably stimu- 
 lated to an increased rate of production. The number of leucocytes jier 
 c.cm. of blood is thus increased from HUGO ± (the normal number) up to 
 20,000-40,000 or even 100,000, according to the severity of the infection 
 
 and the resisting power 
 '"'^*- ^- ^"■' '^- of the organism. Viru- 
 
 lent infections well re- 
 sisted cause the greatest 
 leucocytosis. Where the 
 infection is very mild, 
 or where it is so 
 overwhelmingly violent 
 that the resistance of 
 the system is easily 
 overpowered, the leuco- 
 , T., , rrv. 1,1 , 1 . ■ cyte count may be nor- 
 
 Normal Blood. The Blood in Leucocvtosis. "^ , , -^ , 
 
 mal or subnormal. 
 
 Any suppurative process, such as appendicitis, felon, osteomyelitis, ischio- 
 rectal abscess, perinephric abscess, etc., usually gives rise to leucocytosis. 
 In a general way, the course of the leucocytosis follows that of the tem- 
 perature ; but the leucocytes may increase while the temperature falls, and 
 in some cases {e. ^., in appendicitis) the increasing leucocytosis may be 
 evidence of* a spreading peritonitis which temperature and other signs 
 would not indicate. 
 
 In the diagnosis of deep-seated suppurative processes, septicemia, and 
 pyemia the leucocyte count is not infre(|uently of value. 
 
 After free drainage of an abscess cavity has been established by incision 
 or otherwise, the leucocyte count falls rapidly to normal and remains so, 
 despite a free purulent discharge. If, however, the proper drainage is in 
 any Avay interfered with, the leucocyte count again rises. "Nervousness" 
 never increases the leucocyte count. The examinations should always be made 
 directly before a meal, since a slight increase (up to 15,000 or 17.000) may 
 be caused by the influence of proteid digestion. 
 
 The blood-plaques probably comprise several different elements, into 
 the nature of Avhich it is not profitable here to enter. They are colorless, 
 irregularly oval or grape-like masses, from 1.5 to 3.5 fx in diameter, and 
 usually cling together in masses. No nucleus can be made out. In various 
 inflammatory conditions they may be increased in number. Normally, they 
 are about 200,000 per c.mm. 
 
 The changes seen in the circulation account for two of the cardinal symp- 
 toms — viz. heat and redness. The rapid return of color seen after pressing 
 the finger on an inflamed surface indicates the increased amount of blood. 
 The copious bleeding from incisions in an inflamed tissue shows the increased 
 detei'mination of blood to the part and the distention of even the smallest 
 capillaries. The bright scarlet redness is also an indication of the active 
 hyperemia Avhich exists in acute inflammation. In the more chronic forms, 
 or in those in which the congestion is very intense and the flow of blood is 
 consequently not so rapid, there is a bluish tinge to the reddened surface. 
 If the color cannot be entirely pressed away Avith the finger, this is due either 
 to decomposition of the coloring matter of the blood, which leaves a yellowish 
 tinge behind, or, if a reddish tint remains, it is caused by the presence of 
 red blood-corpuscles which have been forced out of the vessels by the inten- 
 sity of the pressure. This "hemorrhagic" form of inflammation has often 
 
INFLA MM A TION. \ 5 
 
 a much deeper and more irregular coloring than is usually seen in acute 
 inflammation. Redness is entirely absent in bloodless parts, as in the cor- 
 nea, but in this case we find a hyperemia of the vessels of the conjunctiva, 
 and later an actual development of vascular loops in the direction of the 
 inflamed spot. It was at one time su])posed that the increased warmth of the 
 part was due to a local production of heat. It is now known that the local 
 rise of temperature is due to the greater amount of blood which flows throu'^h 
 the vessels. 
 
 One of the most constant symptoms of inflammation is the swelling. This 
 is rarely absent, and is seen even in non-vascular parts. The increase<l amount 
 of blood in the vessels of the part does not add materially to its size. We 
 must seek for an explanation of this phenomenon in the altered condition of 
 the tissues of the part. On making an incision into an inflamed spot we find 
 the meshes of tissue distended with an abundant exudation of blood-serum and 
 leucocytes escaping through the walls of the dilated blood-vessels. The tissues 
 are saturated with this material often to such an extent that it may be difticult for 
 the surgeon to recognize the difference between muscles, fasciie, and vessels. The 
 exudation consists not only of leucocytes, but, in addition, of a certain amount 
 of fluid which closely resembles the liquor sanguinis, and from which fibrin is 
 formed giving a certain firmness to the part. The tissues are also crowded with 
 leucocytes. The increased number of cells in the part was at one time attributed 
 to the division or "proliferation" of the pre-existing cells of tlie inflamed 
 tissues, but Cohnheim maintained tliat the new cells were the escaped Avhite 
 blood-corpuscles, and that the so-called fixed connective-tissue cells played no 
 part in the process, being incapable of proliferation. This doctrine he illus- 
 trated by experiments upon the cornea. The opacity produced by an artificial 
 inflammation was found to be due to the presence of numberless leucocytes, 
 while the corneal corpuscles were found to be unchanged. Subsequent obser- 
 vations have, however, shown that the fixed cells of the cornea also undergo 
 proliferation and take part in the process. Cohnheim thought that the immense 
 number of cells found in an inflamed part were all derived from the white cor- 
 puscles, and that by subsequent proliferation they were increased in number 
 and formed what is known as granulation-tissue^ which he assumed played a 
 prominent part in the healing process. It is a well-known fact, however, at 
 the present time, that the fixed connective-tissue corpuscles and other cells in 
 tissues of the body are capable of division. According to the latest views on the 
 origin of the granulation-tissue, the round cells with single nuclei are mostly 
 formed by the proliferation of connective-tissue and other fixed-tissue cells. 
 Later, many of these cells, as also the leucocytes, become polynuclear cells, and 
 as such are incapable of taking any further active part in the process. Accord- 
 ing to Ziegler, the polynuclear leucocytes appear to be taken up and destroyed 
 by the proliferating connective-tissue cells, the leucocytes apparently serv- 
 ing simply as nutriment for these cells. The process of multiplication by 
 cell-division is now much better understood than formerly, and the mode of 
 indirect division (karyokinesis, p. 29) in which the nucleus plays a prominent 
 part is the one most frequently observed. 
 
 The meshes of the tissue are distended with coagulated lymph, and the 
 connective-tissue fibres are swollen and softer than usual, and here and there 
 terminate suddenly, as if broken off", giving them a club-shaped appearance. 
 In the organs afl"ected we find the epithelial cells altered in appearance, being 
 in the condition known as that of "cloudy swelling;" that is, their protoplasm 
 is granular and more opaque, and containing frequently fatty granules. Dur- 
 ing the development of the inflammatory process the leucocytes are seen infil- 
 
16 
 
 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 A Phagocyte destroying a Bacillus (Landcrer). 
 
 trating the tissue between the pre-existing cells, arranged in rows or irregular 
 masses or scattered about singly. They are more numerous in the immediate 
 neighborhood of the small veins and capillaries. At the height of the inflam- 
 mation the part may be completely filled with small round cells, many of them 
 leucocytes and many of them derived from the cells of th-e inflamed part. 
 
 Various views are held as to the function of the leucocytes. Cohnheim 
 regarded them as the active agents in the process of repair. By others they 
 
 have been regarded as the scaven- 
 ^^^' °' gers which appropriate to themselves 
 
 the broken-down materials which 
 result from inflammation, and thus 
 aid in the process of absorption. 
 Fragments of dirt or blood-clots or 
 carmine granules, when used experi- 
 mentally, are found in the proto- 
 plasm of these cells. MetschnikoflF 
 has advanced the theory known as 
 phagocytosis, according to which 
 the cells of the inflamed part, in virtue of their al)ility to consume foreign sub- 
 stances, attack and destroy the invading bacteria (Fig. 8). These cells are called 
 phagocytes {(fdyco, to eat, and xuto(:, a cell). If they are able to destroy 
 the bacteria, the system is protected from the invading organisms. The 
 leucocytes are called micro-phagocytes (or microphages), and the larger cells 
 developed from the fixed connective-tissue cells are called the macro-phagocytes 
 (or macrophages). The latter may consume the smaller cells after their 
 struggle with the bacteria, and thus assist in the process of absorption. A 
 large number of experiments were performed by Metschnikoff in support 
 of this theory. Other writers have, however, shown that the leucocytes 
 may be the vehicles by which the bacteria are conveyed to distant portions 
 of the body, and that they are therefore capable of spreading infection. 
 The doctrine has not been generally accepted as an explanation of the 
 immunity which certain animals or individuals possess against the attacks of 
 certain diseases. The rich cell-infiltration of an inflamed part may, however, 
 exert a protective influence in other ways. The lymph-spaces of inflamed 
 tissue are usually crowded Avith leucocytes, and absorption of chemical or 
 bacterial poison is thus prevented. The mechanical protection which the gran- 
 ulating surface of a wound afibrds is in striking contrast to the rapidity Avith 
 which a freshly-exposed tissue Avill absorb a virus. 
 
 Returning to the microscopical changes to be seen in inflamed tissues, we 
 find that when granulation-tissue has formed the intercellular substance is not 
 so easily seen as before, and the part appears to be composed almost exclusively 
 of cells. It is, however, rich in blood-vessels, as can be easily demonstrated by 
 special methods of preparation. Much of the intercellular substance and many 
 of the fibers have disappeared, and a granular intercellular substance has taken 
 their place. This condition exists usually in the more indurated j)ortions of the 
 inflamed part, and gives rise to the characteristic "cake-like" hardening so 
 often felt. In the surrounding softer and more pulpy structures Ave find a 
 large amount of coagulated fibrin and serum, Avhich latter substance may at 
 times be excessive in quantity, and then produces a condition that is knoAvn 
 as inflammatory oedema. Such collections of the fluid products of inflamma- 
 tory transudations are most marked in loose connective tissues, as in the eyelids 
 and the prepuce. When an oedematous SAvelling of this character takes place 
 in the mucous membrane of the larynx fatal complications may arise. 
 
INFLAMMATION. 17 
 
 When mucous membranes are inflamed the exudation usually shows itself 
 in the form of an increased and altered secretion on its surface, in certain con- 
 ditions even assuming the consistence of a false membrane. When serous 
 surfaces are inflamed the transudation will take the form of an effusion into 
 the serous cavity involved, as in the pleura or the cavity of the knee-joint. 
 The cells which are a part of the exudation may, however, form a membrane 
 on the walls of these cavities, and give rise to adhesions which interfere with 
 the motion of the two surfaces upon each other. 
 
 The next symptom of inflammation is pain, which is due to the pressure 
 or tension produced by the swelling upon the terminal branches of the nerves ; 
 it may also be due to exalted sensibility from hyperemia, and to the 
 chemical irritation of ptomaines. It is most severe in the early stages 
 of the inflammation, before the tissues have had an opportunity to accom- 
 modate themselves to the pressure exerted by the exudation. It will vary 
 greatly with the anatomical nature of the part. In bone, where the tis- 
 sues yield less rapidly than elsewhere, it will be very severe, and even in 
 the chronic forms of inflammation the pain will be of a boring character, 
 which is proverbially hard to bear. The throbbing pain is'^due to the 
 pulsation of the hyperemic vessels of the part, and the peculiar lancinating 
 pain which pus causes in its efforts to escape is characteristic of an abscess 
 which is about to discharge. Pain may, however, be entirely wanting. This 
 is the case in nerveless tissues, and also in severe inflammations which rapidly 
 destroy the vitality of a part. 
 
 The fifth symptom of inflammation, disturbance of function, will show 
 itself in various ways, according to the part affected : an inflamed muscle will 
 become rigid and contracted; an inflamed gland will cease to give forth its 
 natural secretion. The special senses may also be impaired, or even perma- 
 nently affected, by the inflammatory process. 
 
 Inflammation does not begin spontaneously. Old writers recognized an 
 idiopathic form of inflammation, but the term, if intended to mean more than 
 non-traumatic, should be discarded. Inflammation is due to some cause which 
 acts in an injurious or destructive manner upon the tissues, such as heat, cold, 
 chemical action, injury or trauma, the temporary removal of blood from a part', 
 as m laboratory experiments or in frost-bite, and, finally, infection, or the action 
 of micro-organisms and their products upon the tissues. There is a tendency 
 at the present time to ascribe all inflammation to the action of bacteria. 
 According to Senn, inflammation proper should be made to embrace patho- 
 logical conditions which are caused by the action of micro-organisms or 
 ptomaines upon the histological elements of the blood and fixed tissue-cells. 
 Hueter also believed in the universal agency of bacteria in inflammation, and 
 regarded it as an epidemic and contagious disease existing everywhere. All 
 other forms of inflammation would, according to this view, be regarded as the 
 phenomena accompanying the process of repair. 
 
 The question of the action of the nerves in inflammation, at one time dis- 
 carded, has been recently revived by Lister. It is claimed that the most 
 striking clinical example of this type of inflammation is the so-called urethral 
 fever which follows the use of the catheter. The inflammation of the genito- 
 urinary tract thus brought about, and the accompanying chill and fever, are 
 supposed to be due to a reflex action of the nerves of the part. Doubtless 
 many of these cases may be ascribed to a septic infection by the instrument 
 or to injury of already infected organs. The value of counter-irritation as a 
 method of treatment is brought forward to show the probability of an abnormal 
 action of the nerves. The so-called trophic action of the nerves in inflam- 
 
18 ^1-V A.VERICAX TEXT-BOOK OF SURGERY. 
 
 mation was at one time regarded with favor. Division of the vagus nerve in 
 animals was found to be followed by pneumonia. These cases are, however, 
 now explained satisfactorily by bacterial infection following removal of the 
 protective nerve influence of the part. The list of inflammations to be ascribed 
 to the action of the bacteria and their products is no doubt constantly enlarging, 
 but we are not yet in a position to discard all other supposed inflammatoiy 
 agencies. 
 
 Cohnheim believed that all these agencies acted upon the walls of the 
 blood-vessels and produced a molecular change in them by means of which the 
 phenomena of inflammation were produced. Virchow advanced the '-abstrac- 
 tion "" theory, in which the cells of the tissues played a prominent part. Lan- 
 derer does not think we ought to separate the capillaries from the tissues in 
 which they lie in considering the seat of inflammation. When the cause of 
 inflammation acts upon the tissues they become relaxed, the equilibrium between 
 blood and tissues is disturbed, and we have a leakage or exudation into the 
 inflamed part. 
 
 Most traumatic inflammations take their origin in the tissues, as these are 
 acted upon directly by the inflammation-producing agent. Other inflammations, 
 as the more deep-seated foiTns. are produced by an agent acting through the 
 blood-vessels or the lymph-channels. In this way those types of inflammation 
 known as parenchymatous or interstitial are produced. 
 
 From a study of the pathology of this aff"ection we are justified in assuming, 
 therefore, that the phenomena of inflammation are evidences of injury to the 
 nutrition of the part, while the consequent flushing of the part with increased 
 blood-supply, by preventing mural implantation of bacteria, and exudation, 
 assist in the removal of injurious substances, and leave the tissues in a condi- 
 tion favorable to a return to tlie normal state. 
 
 There are several varieties of inflammation to be considered. For- 
 merly the terais traumatic and idiopatJdc were used to designate respectively 
 inflammation caused by injury and that which arises spontaneously ; but we 
 hear little of the idiopathic form at the present time. Inflammation may be 
 simple or infective. The simple inflammations are limited in extent, and tend 
 to recovery as soon as the inflammatory agent ceases to act. The infective 
 inflammations are caused by bacteria, and have a tendency to spread. 
 
 Inflammations are said to be sthenic or asthenic according to the severity 
 of the symptoms. The sthenic type is seen in a young and vigorous subject 
 when affected with acute inflammation. The asthenic fonns occur cliiefly in 
 old and feeble individuals. In the parenchymatous inflammations the part 
 attacked is the specific cells of an organ or its parenchyma. These cells undergo 
 a ''cloudy swelling," and later proliferation may occur, or even destnaction of 
 the cells may result. An inflammation is called interstitial when the connective- 
 tis.sue stroma which supports the parenchyma appears to be the part principally 
 affected. We see then a cellular infiltration in the stroma of the organ. There 
 is no essential difference in these two types, as the connective tissue is usually 
 increased in direct proportion to the destruction of the parenchyma. 
 
 When an inflammation affects the walls of a serous cavity, we may have 
 considerable accumulation of fluid. The term serous inflammation is then 
 used to denote the type which produces a collection of fluid in the joints or the 
 pleural cavity. The amount of serum discharged from a wound may at times 
 be very large, and drainage-tubes are often employed to conduct away the fluid. 
 Adhesive or iihrinous inflammations are seen best in the peritoneal cavity 
 when two surfaces of peritoneum are quickly united by the process. The 
 rapidity with which this membrane may become united to itself exceeds that 
 
INFLAMMA TION. \ 9 
 
 of any other in the body. In a few liours the adhesion will already have 
 formed, and the peritoneal cavity may in this way be protected from the intru- 
 sion of poisonous substances such as pus or feces. The same result may be 
 obtained in the interior of joints or the pleural cavity. The motion of the parts 
 will stretch these new adhesions, which may thus be drawn out into bands of 
 considerable length. When extensive adhesions occur between the opposing 
 surfaces of a joint or in the folds of its capsule, anchylosis or great impairment 
 of motion will result. 
 
 When bacteria are present, particularly the pyogenic cocci, these organisms 
 exert a solvent action upon the exudation, and fibrin does not form ; the 
 tendency is therefore to a liquefaction of the tissues, and suppuration takes 
 place. This we call suppurative inflammation, or, less correctly, phlegmonous 
 inflammation. 
 
 Hemorrhagic inflammations occur when the red blood-corpuscles are present 
 in unusual numbers in the exudation-fluid. This condition is found in very 
 intense forms of inflammation, when the congestion has been extreme and 
 large numbers of corpuscles are forced through the Avails of the vessels by the 
 unusual pressure. Black measles and hemorrhagic small-pox are familiar 
 types, as are also some of those extremely septic forms of inflammation which 
 the surgeon meets with. Small hemorrhages may occur in the inflammations 
 of the aged and feeble or those affected with cardiac disease, or in scorbutic 
 patients. The presence of blood in a serous exudation is suggestive of intense 
 congestion of a part, as in strangulated hernia, or of the existence of malignant 
 disease. 
 
 When a false membrane forms upon the surface of an inflamed mucous 
 membrane the inflammation is called croupous. The exudation-cells and 
 newdy-formed cells of the part are caught in a fine reticulum of fibrin. Avhich 
 forms on the surface and prevents their escape in the mucous discharges. 
 There is more or less destruction of the epithelial cells which, when intact, exert 
 a preventive influence against the formation of such a membrane. This form 
 of inflammation is due to the presence of bacteria, which, as they invade the 
 tissues more deeply, produce a sort of coagulation-necrosis of the more super- 
 ficial layers of the tissues, and form what is known as a diphtheritic membrane. 
 The principal distinction between a ci'oupous membrane and a diphtheritic 
 membrane lies in their anatomical situation. The former is on the surface of 
 the mucous membrane, the latter is situated in the mucous membrane itself. 
 There is probably no important etiological diff'erence between the two pro- 
 cesses. 
 
 Coagulation-necrosis is caused by arrested nutrition or by the action of 
 chemical or thermal agencies. The changes seen in the dead tissues are due 
 partly to a coagulation of lymph which flows into the part, and partly to a 
 change in the cells of the part, the nuclei of which lose their power to be 
 stained by dyes. The cells and intercellular substance become subsequently 
 transformed into a more or less homogeneous tissue. 
 
 G-angrenous inflammations belong to the most malignant types. Death of 
 a part may occur either from the virulence of the poison which invades it or 
 from the great distention of the tissues by swelling, and a consequent stasis of 
 the blood-current. The anatomical character of the tissues aff'ected will serve 
 as an important factor. In bone, which is unyielding, we frequently see death 
 or necrosis of the tissue in acute inflammation. 
 
 The non-bacterial forms of inflammation have no tendency to spread. In 
 simple inflammation the disease is confined to the part originally affected. In 
 the infective inflammations we find the tissues involved for a considerable 
 
20 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 distance from the original starting-point. In mucous membranes the inflam- 
 mation has a tendency to spread ahjng the surface rather tlian to deeper parts, 
 and the same is true of inflammation of the skin. In the phlegmonous types 
 of inflammation the process will involve deeper parts, and the subcutaneous 
 connective tissue may become the seat of abscesses. Dense fasciae and bone 
 may resist the invasion of the inflammatory process, but the softer tissue of the 
 interior of bones is a frequent seat of infective inflammations. 
 
 Not only will the part attacked feel the influence of the inflammatory agent, 
 but the whole system may be affected, and we then have what is known as 
 constitutional disturbance — i. e. fever. The nature and extent of the febrile 
 process depends upon the materials which are taken up and absorbed from the 
 inflamed area. 
 
 In chronic inflammations the symptoms are much less marked. The swell- 
 ing is only moderate in amount, and there is very little increase of temperature. 
 There Avill be some pain, of a neuralgic or boring character according to the 
 locality of the part, but it will not be continuous, as in the acute form. Micro- 
 scopically we find an abundant connective-tissue growth, containing a large 
 amount of fibers, but comparatively few cells. Many degenerative changes are 
 seen in such tissues : the fibers are often transformed into a gelatinous trans- 
 parent tissue, and they appear to have been absorbed or destroyed. The num- 
 ber of leucocytes in such forms of inflammation is probably small, and the new 
 cells found in the tissue are probably derived chiefly from the fixed cells of the 
 part. We find degenerative changes in their nuclei and protoplasm, and also 
 evidences of proliferation of the cells going on at the same time. Here and 
 there we see clusters of granulation-cells with epithelioid and giant cells. In 
 other cases a dense fibrous tissue is formed, or, in bone, bony growths which 
 lead to a hypertrophy of the part. The causes of this form of inflammation 
 are malnutrition of the part and a continuous .action of the inflammatory agent. 
 Loss of nerve-supply by section of the nerve or injury to the spinal cord so 
 diminishes the vitality of the tissues that the slightest injuries give rise to 
 Inflammation. Repeated slight injuries will also produce a chronic inflam- 
 matory process. The most frequent causes are the chronic forms of bacterial 
 disease, such as syphilis or tuberculosis. The results of sucli inflammation 
 may lead to adhesion in joints or thickening and deformity of bones. A 
 class of swellings known as the granulomata are produced by the bacterial 
 growths. Chronically inflamed parts are often much discolored and pigmented, 
 and slight injuries may lead to ulceration which heals with difficulty. 
 
 Subacute inflammation is a term used to denote a type intermediate, in 
 regard to the severity of its symptoms, between acute and chronic. 
 
 Inflammation may terminate by resolution, suppuration, gangrene, or tissue- 
 production. Resolution implies that the various symptoms gradually subside, 
 and the part Avill return to its normal condition without any appreciable altera- 
 tion of its tissues. The granulation-tissue which has formed will gradually 
 disappear by absorption of the leucocytes and eff'used lymph. Many of the 
 leucocytes return into the circulation through the lymphatic vessels and the 
 capillaries and veins ; others are broken down and disintegrated. The same 
 fate meets also the proliferated cells of the j)art. New fibres are formed in the 
 place of those which have been destroyed during the inflammatory process, and 
 the injury done to the tissues is thus repaired. With the al)Sorption of the 
 products of inflammation the inflammatory agents also disappear. 
 
 When suppuration takes place there is a loss of substance, and after the 
 pus has been discharged a more extensive process of repair is needed to produce 
 a healing of the wound and the formation of the cicatrix. 
 
INFLAMMATION. 21 
 
 Very severe forms of inflammation will lead to gangrene. The dead tissue 
 is gradually separated from the living, to which it is attached, by the formation 
 of a line of demarcation — that is, by suppuration — and Avhen the slough has 
 separated healing by granulation takes place. As absorption takes place, the 
 red blood-corpuscles found in the exudation are broken up and part with their 
 coloring matter, which remains behind and frequently produces pigmentation. 
 Many of the cellular elements undergo fatty degeneration, which may occasion- 
 ally occur on so extensive a scale that the material is not all absorbed, but 
 remains behind as masses of cheesy degeneration. In some cases lime-salts 
 are eventually deposited in the unabsorbed material, and calcareous concre- 
 tions are formed. Tissue-production is considered in the next chapter. 
 
 Treatment. — The principal method of treating inflammation a generation 
 ago Avas the so-called antiphlogistic treatment. This was based on the theory 
 that inflammation was an inflammable condition of the part, which, like a fire, 
 must be subdued by appropriate measures. It did not take into account the 
 causes of the process, which are now so much better understood. This method 
 consisted in the use of emetics, venesection, cupping and leeching, and the 
 administration of drugs, like mercury, which were supposed to have an anti- 
 phlogistic tendency. This method has given place to antiseptic treatment, which 
 has the important advantage of dealing directly with the cause of disease. 
 Some of the older measures are, however, still retained, and may occasionally 
 be used to advantage in relieving some of the symptoms of inflammation. 
 
 Local Treatment. — This varies according to the different stages of 
 inflammation. In the first stage congestion may be relieved by local blood- 
 letting. The use of leeches, wet cups, or, rarely, venesection, is then indi- 
 cated. In cases of extreme congestion the withdrawal of blood and serum 
 by a free incision will relieve tension and may prevent stasis and gangrene. 
 
 When there is not so much tension of the part applications of heat or 
 cold favor absorption of the exudation and relieve pain, which is greatest at 
 this period. In cases of virulent sepsis a prompt and deep incision may 
 prevent extension of the septic process. An early incision into an inflamed 
 mass may prevent the formation of pus. 
 
 In the later stages of inflammation, when suppuration has been estab- 
 lished, the abscess should freely be laid open and the walls of the abscess 
 cavity scraped or scrubbed clean with gauze sponges to arrest the further 
 progress of the bacteria. Free drainage is then important to prevent the 
 formation of pus and to favor a rapid healing of the wound. In case sup- 
 puration does not occur the products of inflammation may be absorbed by 
 counter-irritation, which stimulates the absorbent vessels to conduct off" the 
 exuded material. This can be accomplished by leeching or blistering. 
 
 As the majority of surgical inflammations are of a septic nature, the anti- 
 septic treatment is the more rational method to pursue in most cases. This 
 method is described in its appropriate place, as also the aseptic treatment, 
 Avhich may be regarded as the prophylactic treatment of surgical inflammation. 
 
 Counter-irritation was another of the weapons of the antiphlogistic 
 system, but, although much less used at the present time than formerly, has 
 not been wholly discarded. It is a remedy of more value in chronic inflamma- 
 tions than in those of an acute type, and may act, possibly, through the nerves 
 of the part by a reflex process, and thus produce a change in its nutrition 
 and promote absorption. The actual cautery is still occasionally used in deep- 
 seated inflammation of the joints. It should be lightly applied at a white 
 heat over a considerable extent of skin near the inflamed part, and should 
 act only on the superficial layers of the skin. Repeated blistering is also of 
 
22 AN AMERICAN TEXT- HOOK OF SUJldEltY. 
 
 benefit in producing absorption in an enbirged gland or a "'weeping sinew," (jr 
 of an exudation which is slow to disappear. Iodine may be used for the same 
 purpose, but probably acts in virtue only of its power to produce a local irrita- 
 tion on the surface, not from any special sorbefacient (juality ])ossessed by it. 
 
 Compression is a valuable agent ki the treatment of both the eai'iy and the 
 late stages of inflaunnation. In the acute stage it restrains the tendency to exces- 
 sive swelling of the part and the collection of serous or bloody discharges between 
 the lips of a wound. It must be applied, however, with great care during this 
 period, as sloughing or even gangrene may be the result of tight bandages on 
 a part when the circulation is enfeebled by injury. In the later stages com- 
 pression may be employed with great advantage, and is one of the most val- 
 uable agents which the surgeon possesses to promote absorption and resolution. 
 It is most useful in chronic inflammation. The beneficial effect of pressure 
 upon a varicose ulcer by plaster or a rubber bandage is an admirable illustra- 
 tion of this power, as is also the effect produced upon the serous eff'usion in a 
 knee-joint by elastic bandages made of rubber or flannel. A most efficient 
 ttieans of obtaining compression of the knee-joint is with compressed sponge : 
 two coarse sponges may be flattened over-night under a heavy piece of furni- 
 ture ; one is put on either side of the joint, which is placed on a posterior 
 splint ; a long cotton bandage is now firmly applied, after which a stream of 
 water is allowed to trickle into the sponges. This dressing may be left on for 
 one or two days, sufficient moisture being supplied to keep the bandages tight. 
 
 Cold and heat are used for the purpose of reducing the hyperemia and to 
 relieve pain. Cold may be applied either by evaporating lotions or by the 
 use of ice. Evaporating lotions can be used on exposed parts, but must be 
 changed very frequently to have the desired eff'ect. They are less used than 
 formerly. Ice may be applied in thin rubber bags. Cold can also be applied 
 by the "ice-coil," by means of which a current of ice-water is allowed to flow 
 through a coil of rubber or metal tubing over the part. Care must be taken to 
 avoid freezing the superficial layers of the skin if a prolonged use of the remedy 
 is intended. The ice-bag is comforting in cases of rapid swelling folloAving 
 injury, to a tender and swollen knee-joint, or to an inflamed throat. It is 
 dangerous in cases of extreme congestion, as in strangulated hernia. 
 
 Heat may be applied in the form of fomentations, hot-water bags, or the hot 
 douche. It acts, doubtless, in various Avays. A hot fomentation when first used 
 produces a powerful counter-irritation ; later, it acts through the circulation, 
 relieving stasis and favoring an absorption of exudation. If the heat be main- 
 tained at a high point by frequent application of the hot douche, a constriction 
 of the blood-vessels takes place, and congestion is thus diminished. The flax- 
 seed poultice is now discarded in the treatment of wounds, but may still be 
 used with advantage Avhen no wound exists. The antiseptic poultice, now used 
 for wounds in certain cases, is practically a hot fomentation to which some anti- 
 septic agent has been added. 
 
 Incisions are often of great value in certain types of inflammation, even 
 when suppuration has not taken place. In cases of intense congestion of the 
 inflamed part, Avhen the integuments are thick and brawny, one or more incis- 
 ions are followed by a free gush of blood and serum which greatly relieves the 
 tension of the part and wards off' not only threatening deep-seated supjiuration, 
 but also gangrene of the parts. The incision should be made completely through 
 the skin and cellular tissue, but should not be over two inches in length in 
 most cases. Early interference of this kind is imperatively needed in the 
 rapidly spreading forms of inflammation such as occur often in the hand and 
 forearm, which may not only ruin a hand, but endanger a life. 
 
INFLAMMATION. 23 
 
 Elevation of the inflamed part, combined with rest by splints, etc., is of 
 the utmost importance in controlling the progress of an inflammation. Other 
 remedies will be of little use if the congestion is favored by allowing the limb 
 to be dependent, and if motion is permitted to interfere with the natural tend- 
 encies toward resolution and repair. 
 
 Pliifsiological rest of injured as well as of internal organs is also indicated, 
 to enable the disturbed function to be restored. The importance of absolute 
 rest after injuries to the brain has long been recognized. A chronic cystitis 
 may be cured by cystotomy when all other remedies have failed. 
 
 Parenchipnatous injections were proposed at one time to arrest the prog- 
 ress of bacterial infection. Hueter employed 3 per cent, solution of carbolic 
 acid in this way around the area of erysipelatous inflammation. This method, 
 in general, has not met with favor. It is possible, however, that the hypo- 
 dermatic syringe may have a future in surgical diseases which is not yet 
 apj)arent. 
 
 The results of inflammation which remain in the shape of stiifened joints, 
 contracted or enfeebled muscles, and thickened integuments can best be dealt 
 with by massage^ Avhich not only favors absorption, but is a powerful restora- 
 tive of the physiological action of the part. 
 
 Constitutional Treatment. — It is essential to remember that local 
 treatment, whatever its nature may be, is not the only method to be employed 
 to restore the patient to health. The careful surgeon will always pay due 
 attention to the general condition of the patient. The presence of organic 
 disease elsewhere must not be allowed to pass undiscovered. 
 
 Stimulants may be used during the progress of the fever to sustain 
 strength. Alcohol can be used freely in all cases where there is an abnormal 
 consumption of tissue, whether the result of acute febrile disturbance or of 
 chronic wasting disease. Here alcohol becomes a food, and one of the most 
 valuable kind." Patients who cannot bear the usual doses of alcohol often 
 experience benefit from minute quantities. Dram doses of whiskey are often 
 well borne, and are of service in such cases. In the " typhoidal " state which 
 accompanies profound septic infection astonishingly large quantities will be 
 assimilated even by patients unaccustomed to its use. Flushing of the face is 
 an indication that the dose should be diminished in quantity. Champagne is 
 a good substitute for whiskey or brandy wdiere the stomach is sensitive. Beer 
 and ale are useful during convalescence or in chronic types of inflammation. 
 
 The use of antipyretics has little permanent influence on the pyrexia, and 
 does not appear to give that relief to symptoms which is obtained by it in 
 so-called medical diseases. A much more reliable method of controlling the 
 constitutional disturbance is careful attention to the local conditions of the 
 wound or inflamed part. 
 
 A large variety of medicines have been used in former times on account of 
 their supposed virtues in arresting or shortening the inflammatory process. 
 Among these may be mentioned quinine and mercury. Quinine is still 
 much used, on account of its tonic action even during the febrile state. Its 
 employment in large doses of 20 grains or more is confined chiefly to malarial 
 regions, where perhaps there is a tendency to use it to excess. In doses of 
 5 grains it may be given, three times a day, in any form of fever in which a 
 tonic effect is desired. It is still used largely in erysipelas. 
 
 Mercury was formerly used internally in every form of inflammatory 
 process; on the theory that it had a powerful antiphlogistic action. It was 
 supposed to dissolve the fibrinous exudation. Much of its reputation was 
 probably due to the eff'ect it had upon unrecognized forms of syphilis. Calo- 
 
24 AN AJfERICAN TEXT-BOOK OF SURGERY. 
 
 mel, in whicli form it -was usually adiiiinistt'red, has now «riven place to corro- 
 sive sublimate, -which as an antiseptic takes the highest rank. Calomel may 
 also have exerted a beneficial effect in virtue of its cathartic action. 
 
 Purgatives were used freely as part of the antiphlogistic system of treat- 
 ment, and are still valuable in certain forms of inflammation. They are part 
 of the routine treatment of head injuries, and, if administered promptly in 
 coma following these injuries or in apoplexy, are snpi)()si'd to remove sources of 
 irritation and to leave the system in a condition unfavorable to meningeal or 
 cerebral inflammation. Six grains of calomel placed upon the tongue is an 
 easy means of acting upon the bowels under these circumstances. The dose 
 may be followed in two hours by an aloes enema (one dram of powdered 
 aloes to a pint of hot soapsuds). Such a mode of treatment is suj)posed to 
 exert a "derivative" action, by means of which irritation is removed from 
 the brain and its coverings to distant parts of the economy. The tendency to 
 hyperemia is in this way diminished. The treatment of peritonitis by purga- 
 tives, particularly after laparotomy, has lately come into vogue. It seems to 
 be based upon the power of the cathartic to remove gas, and consequently to 
 relieve the tympanites, and by its production of watery stools also to relieve 
 the engorgement of the intestinal vessels, and eliminate germs or ptomaines 
 by causing the emptier vessels to absorb the peritoneal exudates. A Seidlitz 
 powder or a dose of Epsom salts will often promptly remove alarming symptoms. 
 Smaller doses of salts, repeated every hour or half hour, may be substituted 
 for the single larger dose. 
 
 DiapJioretics, although but little used in surgery, may occasionally be 
 found of value, owing to their antipyretic action. AVater can almost always 
 be given freely if taken in small quantities from time to time. Sweet spirits 
 of nitre in dram doses, when largely diluted in water, will favor diaphoresis, 
 and at the same time is useful as a sedative and also as a diuretic. 
 
 The importance of diuretics in inflammation of the bladder need not be 
 insisted upon here. Their value will be discussed in another chapter. 
 
 Emetics have long since been discarded as a means of controlling inflam- 
 mation, though they are useful when the stomach is overloaded. They were 
 formerly used in connection with venesection. 
 
 Anodynes are of the greatest value in the treatment of inflammation. 
 They relieve the most disagreeable symptom of inflammation — namely, pain — 
 and also the malaise and nervous disturbance Avhich are the accompaniments 
 of fever. First among these is opium, which not only relieves pain, but con- 
 tracts the peripheral vessels. The crude drug is rarely given except in a sup- 
 pository. Morphine is on the whole the most useful of its derivatives. The 
 subcutaneous injection of morphine should be reserved for the more acute forms 
 of pain. It is well to avoid the habit of giving the alkaloid in this way too 
 freely, as it is a powerful remedy, acting with double the power of the same 
 doseVhen given by the mouth, and is sometimes followed by symptoms of col- 
 lapse or opium narcosis. The liquor morphiniTe sulphatis (gr. j to 5J) can be 
 given by the mouth in teaspoonful doses, and repeated every hour or half hour 
 until pain is relieved. If it is desired to avoid the disagreeable eff'ects of mor- 
 phine upon the stomach, it can be given by suppository. This is an exceed- 
 ingly convenient way of administering opium for pain in any part of the body. 
 The relief from pain' brings with it rest — a most important element in the treat- 
 ment. The production of obstinate vomiting by even the smallest dose of 
 opium or its derivatives is of occasional occurrence. It is usually a personal 
 idiosyncrasy. In important cases its possible existence should not be lost sight 
 of. The nervous disturbance will be also relieved by this drug, but we must 
 
THE PROCESS OF REPAIR. 25 
 
 rely more upon chloral, the bromides, sulphonal, or other hypnotics for the 
 relief of this symptom and to obtain sleep. 
 
 The diet is of the greatest importance in all forms of inflammation. The 
 fallacy that low diet is necessary under these circumstances is now well exposed. 
 The stomach should be supplied with food of the most nutritious character, but 
 in a form that can be easily digested. Milk is the most valuable of all liquid 
 forms of food. It may be given pure, mixed with lime-water, peptonized, or 
 sterilized, or it may be taken in the form of gruel. Alcohol may be given 
 with it. A very excellent combination is wine-whey. Clear beef-tea has but 
 little nourishing power. Meat-broths are, however, nutritious and valuable 
 articles of diet for the sick. Pure beef-juice is a most reliable form of concen- 
 trated and digestible nourishment. When food cannot be taken by the stomach, 
 enemata may be given by the rectum. These may consist of beef-broths, with 
 or without brandy. Some of the various peptonized forms of meat may be 
 found useful for this purpose. A few drops of laudanum may be given Avith 
 the enema when there is any difficulty in retaining it. 
 
 After the inflammation and fever subside the solid forms of food may be 
 used more freely. Light wines or beer can be used if any alcohol be needed 
 at this period. Tonics are now indicated, as iron, quinine, calisaya-bark, and 
 the phosphites. They improve the appetite and favor the local process of 
 repair and the return of the system to a normal condition. 
 
 CHAPTER III. 
 
 THE PEOCESS OF EEPAIK. 
 
 It was formerly supposed that inflammation was necessary for the healing 
 of a wound, but from the present point of view the processes of inflammation 
 and repair are regarded as distinct from one another. Under the condition of 
 asepsis we are now able to see wounds heal without the usual phenomena of 
 inflammation. The symptoms of inflammation are brought about by the dis- 
 turbed functions of tissues which have been damaged. Repair, on the other 
 hand, is the result of an active process by means of which the cells of the part 
 are enabled to replace tissues which have been destroyed. 
 
 Healing of a wound is said to take place either by first intention or by 
 second intention. 
 
 In healing by first intention, or primary union, repair takes place without 
 suppuration. When an incision is made through the skin and superficial tissues, 
 the edges of the wound separate from one another according to the elasticity 
 of the different structures which have been divided : the wound is said to gape. 
 The bleeding of the smaller vessels soon ceases spontaneously, owing to the con- 
 traction of their lumen and to the retraction of the arterioles into their sheaths, 
 where they are soon obstructed by the formation of a clot. The largest vessels 
 are controlled by pressure, torsion, or ligature. When the blood has been 
 washed or wiped away the edges of the wound are carefully adjusted by means 
 of sutures. If such a wound has been kept perfectly aseptic — that is, if no 
 bacteria have been allowed to gain access to it — we shall see but little change 
 in the appearance of its edges during the healing process. There will be a 
 slight swelling of the lips of the wound, and the tissues in the immediate 
 neighborhood of the linear incision and around the stitch holes will be some- 
 
2G A^y AMERICAN TEXT-BOOK OF SURGERY. 
 
 what firnier than in the natural state. This is due to the (iistiiiliance in the 
 circulation owing to division of the vessels, and to the injury done to the 
 tissues. There is no redness, as hyperemia is usually absent, ))ut a moderate 
 amount of exudation occurs, which results in the formation of fibrin, by means 
 of which the surfaces brought in contact are tem])orarily glued together. In 
 large wounds the amount of exudation may be considerable, and, unless it 
 be conducted off by a drainage-tube, may accumulate in spaces which have not 
 been accurately brought in contact, and thus separate the o])posing surfaces. 
 In order to avoid this either buried sutures or pressure must be employed to 
 keep the raw surfaces of the wound in contact, or a drainage-tube must be 
 inserted to conduct off the exudation, and thus allow the raw surfaces to 
 adhere. 
 
 It was at one time thought that the edges of a Avound might unite by what 
 was called immediate union — that is, by an adhesion of the microscoj)ical 
 structures of the part, without any reparative effort. It is now known that 
 such a union is merely the temporary adhesion of fibers to fibers by means of 
 fibrin, which is preliminary to final union l)y the formation of new tissue. 
 
 In all large wounds, no matter how careful the adjustment of the parts has 
 been, there are always places where the Avails have not come accurately in 
 contact. If we examine under the microscope a wound healing by first inten- 
 tion, we find these small spaces occupied by blood-corpuscles and masses of 
 coagulated fibrin. There will also be found some fragments of bruised and 
 injured tissue, and here and there small portions of tissue which have under- 
 gone a necrosis owing to the impairment of their blood-supply. At the 
 end of the first twenty-four hours there Avill be an accumulation of leucocytes 
 along the line of the wound. The number of these cells is usually small, but 
 when inflammation is present to any extent they may accumulate in sufficient 
 numbers to obscure the pre-existing elements of the tissue. At this period the 
 vessels are not seen near the margins of the Avound, but Thiersch has shoAvn 
 by injection preparations that a system of plasma-canals exists, Avhich com- 
 municate directly Avith the adjacent vessels, and that many of the red blood- 
 corpuscles and masses of fibrin, apparently extravasated in the tissues, lie in 
 these spaces, Avhich thus are able to provide nutriment to the part until new 
 blood-vessels are formed. As the process of repair proceeds the number of 
 cellular elements of the part — indifferent cells, as they are called — increases 
 perceptibly (PI. V). 
 
 As the cells increase the fibers of the old tissue become more obscure, and 
 many of them, and of other elements Avhich have undergone retrograde changes, 
 disappear, and the cells seem soon to be supported in a ncAv granular or fibril- 
 lated or reticulated intercellular substance, and the so-called granulation or 
 embryonic tissue is formed. At first this is composed of round cells ; in 
 the course of a few days, hoAvever, a large number of spindle-shaped cells are 
 found mingled Avith these, and other large cells Avith one or more nuclei, Avhicb 
 are called e])ithelioid cells. A high-poAver microsco))e Avill shoAV, in fact, the 
 greatest variety of shapes at this time. Later the sj^indle-shaped cells become 
 more numerous, and the ncAv tissue begins to present a fibrous appearance. 
 The origin of the cells of the granulation-tissue is a subject about Avliich there 
 has been much dispute. According to Cohnheim, these cells are the emigrated 
 leucocytes, Avhich are able by proliferation to produce other cells like them- 
 selves, and are the active agents in the formation of the ncAv tissue. The vicAV 
 that the fixed cells of the connective tissue and the parenchyma cells of organs 
 are able to proliferate and form ncAV cells during the process of repair has been 
 gradually regaining its lost position, and the very latest views are as folloAA's : 
 
PROCESS OF REPAIR, 
 
 Plate ^^ 
 
 P- 
 
 
 
 
 ■5 t! 
 
 
 0' 
 
 i 
 
 
 5 
 
 
 ^^•._ 
 
 
 1/ 
 
 
 ,v 
 
 u. 
 
 
 Left margin of wound healing by first intention on the 3d day: a, epidermic layer showing cells 
 undergoing karyokinesis ; b, leucocytes accumulating on the edge of the wound ; c, blood-cloi filling 
 dead space— commencing " organization ;" d, vein from which leucocytes are emigrating. 
 
THE PROCESS OF REPATR. 27 
 
 Granulation-tissue contains many leucocytes, ])ut they take no active part in 
 the healing process, serving simply as food for the other cells as soon as they 
 have reached a certain stage in their career, known as the polynuclear stage, 
 a point beyond Avhich they are unable to develop. The cells coming from the 
 proliferating tissue-cells are the constructors of the new tissue, and they have 
 in early life amoeboid movements (Ziegler). It is not possible to distinguish 
 the two kinds of cells in granulation-tissue, and Avhen cells of either kind 
 become polynuclear they are no longer able to take an active part in the 
 growth of tissue (Grawitz). It is proposed by Marchand to call the leucocytes 
 found in granulation-tissue " exudation-cells," and the proliferating connective- 
 tissue cells the "formative cells." Soon after the first day of the healing 
 
 Fig. 9. 
 
 \my- 
 
 -y^Yf^ 
 
 ■aiiim \>\ i.raiuilaii' 
 
 ia'ocess new vessels begin to form in loops which develop from the pre-exist- 
 ing vessels. On the surface of a capillary loop a mass of granular protoplasm 
 is seen, which gradually increases in size and grows to an elongated mass of 
 solid nucleated protoplasm which projects toward the edge of the wound. 
 These prolongations either become attached to the wall of another vessel, or 
 unite with similar outgrowths from other vessels or with the cells of the sur- 
 rounding tissue. Later, the central portion of these newly-formed structures 
 melts away, and they become hollow and establish a communication with the 
 vessels from which they spring. The wall of the new vessel is at first homo- 
 geneous, but later becomes nucleated and lined with endothelium. In this w^ay 
 a mass of capillary loops form on either side of the wound, eventually becoming 
 united and forming an exceedingly rich capillary network in the new tissue. 
 As cicatrization completes itself many of the spindle cells and round cells dis- 
 appear. Some undergo granular degeneration and are absorbed ; others wander 
 into the adjacent lymph-spaces, and are taken up again into the circulation; 
 many, after reaching a certain stage of development, are destroyed by the more 
 active cells in the reparative process. As the cells vanish new fibers make 
 their appearance, and the wound becomes thus firmly united. In the mean 
 time, on the surface a clot or crust of broken-down blood-corpuscles, epithelial 
 scales, and exudation-material has formed, underneath w^hich new epithelium 
 develops from the deeper layers of the rete mucosum which covers in the sur- 
 face of the wound. 
 
 When from loss of tissue or other cause it has not been possible to close a 
 wound, and the lips are separated widely from one another, union can only take 
 place by the process of healing by granulation, or second intention (Fig. 9). 
 If we watch such a wound with the naked eye we shall observe, in the course of 
 an hour, that a film has formed upon the surface ; the wound has become glazed 
 by the deposition of a thin layer of coagulated fibrin. This layer, at first trans- 
 parent, soon becomes stained with masses of coagulated blood and fragments of 
 
28 AN AMERICAN TEXT-BOOK OE SURGERY. 
 
 fibers torn from their surroun(lin<^s and lyin^ upon tlie surface. This hiyer is 
 also soon occupied by numbers of emigrated leucocytes. In this way the wound 
 is covered over so that the structures beneath can no longer be recognized. The 
 discharge which flows from the wound is at first of a reddisli liue, and consists 
 chiefly of bloody serum in which are floating fragments of broken-down tissue. 
 This gradually changes to a grayish color, and is found to contain more white 
 corpuscles and fewer red corpuscles as time goes on. In a few days the dirty 
 layer covering the surface of the wound is washed away by the discharge, 
 which has now assumed the yellowish-white or creamy color of pus, and the 
 wound is said, in surgical parlance, to clean off". As the d6bris is swept away 
 we find underneath a surface of bright and irregular-shaped nodules wliich are 
 called granulations. The time which granulations take to form may vary 
 from two or three days to a week, according to the health of the individual or 
 the nature of the tissue involved. Microscopically, tbe tissue consists chiefly 
 of small round cells mingled with epithelioid or larger cells, such as are seen in 
 the so-called granulation-tissue, the origin of which has already been described. 
 The velvety appearance of a granulating surface is due to the little elevations 
 on the surface produced partly by growth of colls near the blood-vessels and 
 partly by the oedema of certain portions of the tissue. 
 
 The cavity of the wound is gradually obliterated, partly by the growth of 
 the granulations and partly by cicatricial contraction by wdiich the edges of the 
 wound are approximated. In the mean time the epidermic cells by prolifera- 
 tion begin to cover in the margins of the open surfiice of the wound, and a 
 thin bluish-white border indicates the presence of a fresh epithelial cell-growth. 
 New formation of epithelial cells cannot occur in the center of the wound 
 unless some fragment of epithelial structure, such as a portion of a papilla, 
 sweat-ducts, or hair-follicles, may have remained, from which such an outgrowth 
 could take place; hence cicatrization always progresses from the circumference 
 toward the centre. Occasionally the growth of granulations is so exuberant 
 that they project above the surface of the skin, and the epithelium may then be 
 unable to cover in all the surface. This "proud flesh," as it is popularly 
 called, must be removed with the knife or caustic before the healing process 
 can be completed. Healing may take place by direct union of granulating 
 surfaces, or healing- by third intention. It readily occurs in wounds ren- 
 dered aseptic and kept so by the use of iodoform or sterilized gauze. The 
 gauze being removed on the second or third day, the surfaces from which little 
 or no secretion exudes are brought in apposition and unite. 
 
 After the cicatrix has freely developed, it consists of fibers interwoven in 
 various directions possessing great contractile powers, which cause many of 
 the delicate vessels to disappear and the red scar to grow pale. In extensive 
 scars this contraction gives rise to groat deformities, particularly Avhen the 
 wound is situated in regions where two adjacent portions of the body may be 
 thus bound together by a dense scar. Examples of tliis may be seen after 
 burns on the neck or at the flexures of the joints (see Burns). 
 
 Granulations are not always firm and red: occasionally they are pale and 
 flabby, which appearance is due to an unusually oedcmatous condition. These 
 are often seen in tubercular processes. Erothistic granulations bleed easily 
 and are excessively painful. They appear to be caused by some mechanical 
 disturbance of the wound. The surface of the wound will sometimes be 
 found covered with a membrane which has a diphtheritic appearance, and is 
 caused by imperfect development of the capillary vessels or is due to their 
 obstruction by inflammation. A coagulation-necrosis of the upper layers of 
 the granulation is thus produced. 
 
THE PROCESS OF REPAIR. 
 
 29 
 
 The healing of subcutaneous wounds does not differ essentially from 
 the j)rocess already described. Kejjair, however, usually takes place without 
 suppuration. In this case we find the seat of the wound occupied by a blood- 
 clot, sometimes of considerable size. As repair progresses the extravasated 
 blood is gradually absorbed, and granulations j)usli out from the surrounding 
 connective tissue and ramify in the clot, which furnishes a favorable culture 
 soil for the new cell-growth. The amount of inflammation which will accom- 
 pany this process depends upon the degree of injury or upon bacterial infec- 
 tion. In the case of infection by sloughing of the integuments or of intra- 
 vascular infection, suppuration will take place and an abscess will form. 
 
 The same mode of healing under a blood-clot occurs when an open 
 sterile wound has been filled with an ase})tic blood-clot which is allowed to 
 remain. The layer of clot which covers the surface becomes hard and dry, 
 and gradually loses its dark color. As the clot shrinks the epithelial margins 
 follow close upon its edges, while the connective tissue-growth beneath has 
 been substituting itself for the fibrin and blood-corpuscles which are gradually 
 absorbed. When the wound has healed the remains of the surface clot break 
 up and come away with the dressings, and a firm cicatrix is disclosed. If 
 infection of the wound has taken place, the clot will break down and be swept 
 
 Fig. 10. 
 
 
 6- 
 
 Process of Repair of a Wound : a, cells forming connective-tissue ; 6, leucocytes ; c, newly-formed blood- 
 vessels (original). 
 
 away with pus which forms, and the wound Avill then heal by granulation. 
 This method of healing by organization of the blood-clot, as it has been 
 called, is the one which usually occurs in ruptures of the internal organs, such 
 as the liver or the kidneys. 
 
 The formation of fibrillar connective tissue is accomplished by the prolifera- 
 tion of the fixed cells of the connective tissue. Cell-division takes place either 
 directly or indirectly. Direct cell-division (Fig. 10), which is simply a segmen- 
 tation of the nucleus followed by a division of the whole cell, was thought to be 
 the ordinary mode of cell-growth, but the indirect method is the one which 
 usually occurs. This latter is known as karyokinesis (Fig. 11). When such 
 
30 
 
 AN AMi:i!I('AX Ti:XT-lU)OK OF SLRUKllY 
 
 a mode of cell-division is iil)oiit tf) take ])lacc, the delicate reticulum of fiber of 
 which the nucleus is composed when in the (juiescent state — an<l which is called 
 chromatine substance, from its capacity to take staining fluids — becomes con- 
 
 Fk;. 1 1. 
 
 Karyokinesis, or Iiulirect Cell-division (Zieglon : «, cell with nucleus in iiwiescent state. The nucleus 
 contains nucleoli and a network of threads ; h, formation of coarse chromatine threads in nucleus ; 
 f, disappearance of nucleolus and membrane of nucleus ; arrangement of threads in loops forming 
 the " rosette " ; </, angles of loops directed toward the poles of the cell, which are formed of achro- 
 matic threads; c, beginning division of the cell; this is followed by a gradual return of the nucleus 
 to the quiescent state (a). 
 
 verted into a skein of contorted filaments, wliicli rrradually assumes the shape of 
 a rosette, and subsequently a star. Mean-vvhile the wall of the nucleus has dis- 
 appeared. In a later or equatorial starje of the process the star-shaped mass of 
 filaments separate into two groups, which dispose themselves around the two poles 
 of the nucleus, leaving a clear space in the plane of the equator. When the 
 nucleus has thus divided the filaments return to their former quiescent state. The 
 protoplasm is contracted along the line of equatorial division, and the division 
 of the cells becomes complete (Quain). The new cells, or fihrohlasis, as they are 
 called, become elongated by the formation of prolongations from their extremi- 
 ties, and, as shown above, develop fibrillse by a differentiation of their proto- 
 phism. 
 
 Examples of ivoimds of hJoodlcKn tissues are seen in the cornea and in car- 
 tilage. When the cornea is divided and the wound gapes, it is filled in at first 
 partly by a coagulum of fibrin, and partly by a growth of e])ithelial cells. At 
 the end of a few days the corneal corpuscles begin to proliferate and push aside 
 the elements which occupy the cleft, and thus permanently close the wound. 
 In cartilage, owing to the poor supply of nutriment, the cells appear to take but 
 a feeble ])art in the process of repair. Incised wounds of joint-cartilage are 
 found many weeks after the injury filled with a clot of fibrin, which eventually 
 is replaced by connective tissue. The cartilage-cells near the wound become 
 polynucleated, and the intercellular substance becomes fibrillated, but this is 
 probably only a retrograde metamorphosis. 
 
 Neiv epidermis is formed by proliferation of the epithelial cells. New 
 epithelial cells possess amoeboid movements, and may wander a short distance 
 from ilie margin of the wound. The deep layers of the rete mucosum furnish 
 cells which multiply rapidly, and it is this layer of the skin which is utilized 
 by Reverdin in transplanting small grafts to the granulations. The success 
 of the Thiersch method, which consists in the transplantation of portions of 
 skin several inches in length to the freshly-cut surface of open wounds, is due 
 to this fact. The grafts are cut with the razor and are exceedingly thin, so 
 that only the most superficial portions of the skin are removed. 
 
 Refjeneration of striped muscular liher occurs to some extent in slight injuries. 
 The cicatrix following a wound in the muscle is, however, usually composed of 
 connective tissue, and the fragments of the muscle are thus united by a tendin- 
 ous mass. At first an increase in the size and number of the muscular nuclei 
 
THE PROCESS OF REPAIR. 31 
 
 are seen. Some observers have noticed karyokinetic changes in tliese nuclei. 
 These new cells or sarcoblasts assume a spindle shape and are arranged in rows, 
 and at the end of the third week begin to show striations. Each spindle cell 
 elongates, and finally forms a muscular fiber. Regeneration of muscular fiber 
 has been observed in myocarditis, and has also been produced experimentally 
 in animals. Attempts to graft the muscle of a dog into a wound of the 
 biceps following extirpation of a tumor did not succeed. Large loss of 
 substance of muscle, ho^^ever, may not be followed by much impairment of 
 motion. 
 
 Refieneration of nerve-tissue is sufficiently perfect to unite the ends of 
 divided nerves which have been sutured, and to restore even the continuity 
 of nerves which have been resected in their trunks for the cure of pain. 
 Views differ as to the histological changes which occur during the process of 
 repair. Gi'owth appears to be more active from the central end, although 
 it may take place from the peripheral end also. The axis-cylinders become 
 elongated and divide into several fibers, which later are covered by the medul- 
 lary sheaths. According to another view, the axis-cylinders may be formed 
 by'^a growth of spindle cells, neuroblasts, which takes place from both ends 
 of the divided nerve and unites the two fragments. Around these cylinders 
 medullary substance is deposited later, and new sheaths are thus produced. 
 The completion of the process takes several months. When the ends of the 
 nerve are separated by a distance of over one inch in length, repair can rarely 
 take place spontaneously. The ends of the nerves have then a club-shaped 
 enlargement, due chiefly to a growth of the neurilemma, and many of the fibers 
 become degenerated. Suturing of the ends of a divided nerve, with restora- 
 tion of function, has been accomplished over a year after the injury. 
 
 When a tendon is divided the two ends are separated from each other in 
 the tendon-sheath, and a flow of blood fills the intervening space with clot. 
 A growth of cells takes place from the sheath and surrounding tissue, and 
 granulations force their way into the clot, which is absorbed. The new tissue 
 gradually assumes the appearance of a fibrous tissue running parallel with the 
 fibers of"^the tendon. The tendon does not at first appear to take any part in 
 the process of repair ; later it is difficult to distinguish between the old and the 
 new fibers. The new tissue appears to be derived chiefly from the connective 
 tissue. 
 
 When a hone is broken the new tissue which unites the fragments is usually 
 bone (Fie. 12). A true regeneration of bone, therefore, does take place. The tis- 
 sue Avhich first forms around and between the ends of the bone is of a temporary 
 character, and is called the provisional callus ; that formed from the periosteum 
 is called the external callus : and. that from the medullary tissue, the internal 
 callus. The intermediate callus lies between the ends of the bone, and is at 
 first, in part, a growth from both of these regions ; but it is here that the per- 
 manent cicatrix is finally developed from the bone-forming tissue. The size 
 of the callus will depend upon the amount of traumatism and the amount of 
 displacement and of motion during the process of repair. Later the provisional 
 callus is absorbed, and cicatrization is sometimes so perfect that it is difficult 
 to detect the precise seat of an old fracture. In groicing hone the cells which 
 are most active in the process of development are found in the deeper layers of 
 the periosteum. Here an active cell-growth takes place, and medullary spaces 
 containing the bone-forming cells or osteoblasts are developed. A growth of 
 bone also occurs in the deeper layers of the cartilage. Bone-salts are deposited 
 between the cartilage-cells, and the spaces occupied by them are converted into 
 jaedullary spaces, and the medullary cells, and probably also cartilage-cells, 
 
32 
 
 AN AMERICAN TEXT- BOOK OF SURGERY. 
 
 become converted into osteoblasts. The osteoblasts form new bone by a chanf^e 
 of their protoplasm into a finely fibrillated or homogeneous material, -which by 
 a deposit of lime-salts is transformed into bony lamellnc. Absorption of bony 
 substance is accomplished by giant cells, now known as osteoclasts, which are 
 derived from the protoplasm of the various kinds of cells which come in contact 
 with bony tissues (Tillmans). These cells are said to form carbonic dioxide, 
 ■which dissolves the lime-salts. 
 
 The ossification of the external callus is accomplished by the osteoblasts. 
 These cells are observed developing in the granulation-tissue Avhich has 
 formed between the bone and the periosteum. The osteoblasts develop an 
 osteoid tissue which subsequently, by deposit of lime salts, becomes true bone ; 
 or the bone-formation may be preceded by the development of cartilage from 
 these formative cells. In the second week an osteophytic growth is already 
 seen on the surface of the bone, and by the end of the third week the peri- 
 osteal callus usually consists of firm, spongy bone. A similar formation of 
 bony tissue occurs in the medullary cavity in the development of the internal 
 callus (Fig. 13). The amount of this growth varies greatly in different 
 
 Fig. 13. Fig. 14. 
 
 Fracture One Week : blood- 
 clot contain^ fragment 
 of bone (original). 
 
 Callus of Fracture (dog) Four 
 Weeks : commencing ossi- 
 fication of external callus 
 (original). 
 
 Femur of a Child Fifth Week after 
 Fracture (original). 
 
 cases. Formation of cartilage also occurs here near the seat of fracture, but 
 is not so constant or extensive as in the periosteal callus. The provisional 
 callus becomes converted into a permanent cicatrix by a condensation of its 
 tissue. An absorption of its more superficial and deeper portions also takes 
 place — a process which is brought about mainly by the action of the osteo- 
 
THE PROCESS OF REPAIR. 
 
 33 
 
 Fig. 15. 
 
 clasts. Tlio dense cortical bone at the point of fracture shows at first no 
 change, but subsecjuently becomes porous and finally unites with the adjoining 
 fragment. It is eventually changed again into dense bone by the action of 
 the osteoblasts. Tlie medullary cavity of the bone, sometimes completely 
 broken in its continuity by an overlapping of the fragments, is finally more 
 or less completely restored (Fig. 14). 
 
 The healing of arteries after ligature is not unlike that of bone in the 
 sequence of events. We liave here also a provisional growth Avhich forms 
 around the ligature and encloses the two ends of the vessel ; as in the bone, 
 the size of the ''callus," as it may be called, will depend upon the amount of 
 traumatism. In the interior of the vessel a thrombus forms, which in purely 
 aseptic operations is exceedingly small, and it has been maintained by some 
 observers to be absent altogether under these conditions. The proximal 
 thrombus is usually larger than the distal one. The external growth or 
 "callus" is composed of granulation-tissue, and as the walls about the ligature 
 are infiltrated with leucocytes, the ligature loosens its hold upon the vessel, 
 and the two ends retract and separate slightly from one another, but are still 
 held enclosed in the external callus. The ends of the vessel now open slightly, 
 and admit a growth of granulation-tissue which infiltrates the thrombus. 
 Subsequently this granulation-tissue is absorbed, and as it disappears it 
 becomes apparent that a growth has taken place from 
 the walls of the vessel which forms the permanent cica- 
 trix. In the interior a formation of new tissue has 
 taken the place of the thrombus, which now has disap- 
 peared. If the thrombus has been a large one, there 
 will be a considerable growth of connective tissue filled 
 with vascular spaces. A new growth of endothelium 
 covers this tissue and lines the new vessels contained in 
 it. In aseptic wounds the amount of connective-tissue 
 growth is small, and we then find, when the process is 
 completed, a crescent-shaped cicatrix at the end of the 
 cul-de-sac formed by the ligatured vessel. The surface 
 of this cicatrix is covered with a new endothelium ; 
 below this is a new layer of muscular cells which have 
 developed from the media, and externally is a connec- 
 tive-tissue growth from the adventitia (Warren). The 
 two ends of the vessel are now united by a ligamentous 
 bond. The usual method of ligature is to apply a 
 single thread around the vessel with sufficient force to 
 rupture the internal coats. Unless this is done there 
 is a possibility that the lumen of the vessel may not 
 
 be obliterated. According to Senn, however, two ligatures can be applied 
 near each other, without sufficient force to rupture the coats, with speedy 
 obliteration of the vessel. Ballance and Edmunds believe that the cicatrix 
 is composed of ordinary scar -tissue formed from the connective-tissue elements 
 in the vessel-walls. They also recommend a double ligature, the material 
 being tendon or peritoneum. Their sta^ knot, recommended for large vessels, 
 is tied as follows : The first hitch of a reef knot should be made on each 
 ligature separately, and the ligatures should be so tightened that the loop lies 
 in contact with the vessel without constricting it. Then, taking the corre- 
 sponding ends of the two ligatures in the two hands, constrict the vessel so as 
 to occlude it. Then complete the reef knot, treating the two ends in each 
 hand as if they were a single thread. In amputation-stumps the ligatured 
 
 Carotid Artery of Horse, 
 Two Months after Liga- 
 ture : a, thrombus ; 6, 
 callus : r, arterial wall; 
 d, ligature sinus (orig- 
 inal). 
 
34 
 
 AN AMERICAN TEXT-BOOK OF SURGERY, 
 
 artery does not terminate abruptly in a cul-de-sac at the point of ]if];ature, 
 but is partially obliterated for some distance from the ligature by a growth 
 from the intima and other coats of the vessel. This compensatory end- 
 arteritis ada])ts the vessel to the greatly diminished blood-suj)ply needed for 
 the stump. After ligature in continuity the branches given off above and 
 below the ligature become enlarged, and, anastomosing with one another, 
 establish a collateral circulation. 
 
 CHAPTER IV. 
 
 THE TRAUMATIC FEVERS. 
 
 The fever which occurs after the infliction of a wound may be aseptic or 
 septic, according to the conditions which prevail at the time of the trauma or 
 injury. 
 
 Clinically, surgical fevers may be divided into two main groups, the 
 benign and the malignant types of fever. It is the former group only which 
 is considered in this chapter. 
 
 The benign group includes those forms which are described usually 
 as traumatic fever, and includes aseptic fever, septic or " surgical " fever, 
 as it was formerly called, and suppurative fever. To these may be added 
 certain special forms, such as surgical scarlet fever and urethral fever. 
 
 The malignant group comprises septicemia, sapremia, and pyemia.' Sep- 
 ticemia and sapremia may be regarded as malignant types of surgical fever, 
 and pyemia the malignant type of suppurative fever. 
 
 Aseptic fever is characterized by a pyrexia which accompanies wounds 
 healing by first intention. It was formerly supposed that fever was a symp- 
 
 FlG. 1«. 
 
 
 1 
 
 2 
 
 3 
 
 4 
 
 5 
 
 6 
 
 7 
 
 8 
 
 9 
 
 10 
 
 II 
 
 12 
 
 13 
 
 107° 
 106° 
 IOS° 
 104* 
 103* 
 102' 
 101* 
 100° 
 
 99* 
 
 98° 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 A 
 
 
 
 
 
 
 
 
 
 
 
 
 y\ 
 
 /\ 
 
 1 
 
 
 
 
 
 
 
 
 
 
 / 
 
 / ^ 
 
 v 
 
 ^^ > 
 
 ^. 
 
 ,^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Temperature Chart of a case of Aseptic Fever (original). 
 
 torn necessarily associated with infection of the wound, but after the anti- 
 septic treatment of wounds was perfected it was discovered that many wounds 
 thus treated were accompanied by a considerable rise of temperature, par- 
 
 1 See pp. 60 and 63. 
 
THE TRAUMATIC FEVERS. 35 
 
 ticularly those in whicli a large amount of blood-clot existed between the lips 
 of the wound, or in large wounds where, necessarily, more or less bruising 
 of the tissues has occurred (Fig. 16). 
 
 It has been shown by experiment that a large number of chemical sub- 
 stances when introduced into the circulation will produce a rise of tempera- 
 ture. Among them is the fluid obtained from defibrinated blood, which 
 contains a substance known as fibrin-ferment. When injected into animals 
 this ferment produces extensive coagulation of blood in the vessels and death. 
 Other substances, as pepsin, and even water, when injected will produce 
 febrile disturbance. 
 
 During the healing of a large wound there is necessarily a breaking down 
 of minute portions of tissue and blood-clot, which, Avith eifused serum, are 
 absorbed in greater or lesser quantity. These chemical substances are but 
 slightly altered from their normal condition, but when absorbed appear to 
 have what is known as a pyrogenous or fever-producing action. 
 
 The normal temperature of the body is 98.4° F., or 37° C. During this 
 form of constitutional disturbance the temperature may rise to 102° F., and 
 not return to normal for several days. Beyond the pyrexia there are but few 
 symptoms in aseptic fever. The patients thus affected do not suffer from 
 malaise or delirium, and are rarely conscious of feeling ill. They may be 
 able to sit up in bed or to move about the room. 
 
 This form of fever is seen during the healing of simple fractures and of 
 wounds in which no drainage has been employed, or in very large wounds 
 which are healing by first intention. 
 
 Traumatic, Septic, or Surgical Fever. — Before the introduction of the 
 antiseptic method of treatment all wounds healed with more or less inflam- 
 mation, even when suppuration did not occur, and this Avas supposed to be a 
 part of the process of repair. The amount of constitutional disturbance was 
 considerable, and was called surgical or traumatic fever. Examples of this 
 type are seen to-day in Avounds that have not been treated antiseptically, partic- 
 ularly those Avhich are d\ie to injuries and have been exposed to septic infection. 
 The presence of bacteria of various kinds in the secretions of such wounds 
 gives rise to a fermentative process during Avhich ptomaines are developed 
 and are absorbed, producing fever. Very fcAv bacteria are found in the blood 
 during this type of fever, and if present they are rapidly eliminated. There 
 is no progressive development of bacteria in the system, as in septicemia. 
 
 Surgical fever is not to be confounded with suppurative fever, for, although 
 suppuration may occur in inflammations Avhich produce the former, the tem- 
 perature falls when suppuration takes place, and the decomposing fragments 
 of tissue, together with the ptomaines they produce, are Avashed aAvay. Sur- 
 gical fever is produced by the products of decomposition rather than by those 
 of suppuration. 
 
 The constitutional symptoms correspond pretty accurately with the con- 
 dition of the wound and the amount of inflammation. There is a sharp rise 
 of temperature a day or tAvo after the operation or injury ; the skin is hot 
 and dry, the pulse rapid, and the tongue coated. The subjective symptoms 
 are also more marked; the patient suffers greatly from heat, thirst, and rest- 
 lessness, and there may be delirium. The urine is scanty and highly colored. 
 On the evening of the second day the thermometer indicates a temperature 
 of 102° or more in the axilla. The folloA\dng morning the temperature 
 drops a degree, to rise higher than before in the evening. On the third or 
 fourth day, when suppuration is established, the wound cleans off, granula- 
 tions spring up, the chemical substances which have caused the pyrexia are 
 
36 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 no longer absorbed, and the temperature falls. Surgical fever does not last 
 over a week, by the end of uhich time the symptoms of fever liave entirely 
 disappeared. 
 
 ihe constitutional disturbance in this form of fever usually corresponds 
 pretty accurately with the local condition of the wound. Wlien, therefore, 
 all symi)toms are well marked, infection of the Avound siiould be suspected 
 and the dressing should be removed for a thorough examination. The lips of 
 the wound are usually found red, swollen, and tender, and on pressure decom- 
 posed blood-clot, and perhaps pus, may ooze at one or two points from between 
 the lips of the wound. The stitches should be removed, the wound opened 
 and disinfected, and a moist dressing in the form of antiseptic fomentations 
 should be applied. 
 
 In slight disturbances such a dressing may suffice to carry off all decom- 
 posing secretions without removing the stitches, and the wound may heal 
 after all by first intention. Experience only will enable the surgeon to 
 decide whether to interfere or to leave the wound undisturbed. 
 
 Suppurative fever, or, as it is sometimes called, secondary fever, 
 is a term employed to denote that febrile condition which prevails after sup- 
 puration has been established. It occurs only in those cases in which pus is 
 retained, so that some of its constituents are absorbed. 
 
 If at the usual period of defervescence of surgical fever we find the tem- 
 perature remains high, or there is a rise after the usual fall, it is highly 
 probable that an accumulation of pus has taken place between the lips of the 
 wound and is unable to escape. The pyrexia is probably produced by the 
 absorption of a chemical substance which has been formed by the pyogenic 
 organisms. The micrococci are not found to any extent in the blood or 
 tissues, and the fever curve drops as soon as the pus is evacuated. It is 
 evident, therefore, that there is no progressive infection of the system by 
 virus already absorbed, as in pj^emia. 
 
 When pus is confined in a wound the constitutional disturbance is usually 
 well marked. There is a sharp rise of temperature, accompanied perhaps by 
 a chill. If the pus is evacuated promptly, the suppurative process may be 
 arrested, but occasionally the surrounding tissues become affected and the 
 pus burrows in various directions. 
 
 The fever corresponds pretty accurately Avith the degree of local inflam- 
 mation. During the acute stage the fever remains high with slight diurnal 
 variations ; later, when a state of chronic suppuration has been established 
 and pus is to be found accumulating at the bottom of numerous sinuses, the 
 fever curve assumes a remittent type, falling in the morning to the normal 
 point, to rise again several degrees in the evening. This is the type of the 
 so-called hectic fever (Ixr^zor, a habit), accompanying the chronic suppura- 
 tions Avhich are so marked a complication of the tubercular process. ^^ ith 
 the continuance of the fever there are marked emaciation and prostration. 
 The pulse becomes weak and rapid. Diarrliea and night-sweats are often 
 prominent symptoms, and unless the sup])uration is checked the patient may 
 succumb to septic poisoning or to exhaustion. In the more chronic form the 
 emaciation is gradual. Enlargements of the lymphatic glands and amyloid 
 degeneration of the internal organs are often found. 
 
 The treatment of acute suppuration consists in the establishment of 
 thorough drainage with disinfection of the entire suppurating surface. For 
 this purpose free incisions should be made in order to lay open the pus-cavity 
 and render its walls accessible to the curette. After all the infected material 
 that can be removed is scraped away, the remaining surfaces should be 
 
THE TRAUMATIC FEVERS. 37 
 
 thonnighlv cleansed with peroxide of ljydro«ren or sulphurous acid (1 : 30) and 
 disinfected with solutions of carbolic acid, corrosive sublimate, or zinc chloride. 
 
 When joints are involved the question of resection must be considered. 
 The presence of an amyloid degeneration of the kidneys, as revealed by an 
 examination of the urine, is a contraindication to resection, and in these 
 cases amputation may offer a better chance of saving life. 
 
 Free stimulation and a nutritious diet are indispensable. In many cases 
 placing the patient in the open air for several hours daily may bring about 
 a decided improvement, even in serious cases. When, however, those pro- 
 cesses are associated with tuberculosis the prognosis is most unfavorable. 
 
 Surgical Scarlet Fever. — A scarlet rash may occur after surgical opera- 
 tions, and the eru))tion may bo followed by desquamation. In many of these 
 cases there has been an infection of the system through the wound^ with the 
 virus of scarlet fever. Such infections are more likely to occur if the wound 
 involves a mucous membrane, as in cases of lithotomy. The appearance of the 
 symptoms of surgical scarlet fever are, according to Paget, quite "disorderly," 
 the period of incubation, for instance, being much shorter than usual. 
 Scarlet rashes may occur also as the result of vaso-motor disturbances, or 
 from the absorption of a chemical poison from the wound, or from bacterial 
 invasion, as in pyemia and septicemia. 
 
 Urethral fever is a term given to the chill and pyrexia which often 
 folloAv the introduction of a catheter or sound into the bladder. It has been 
 cited as an example of the purely nervous origin of fever. 
 
 Many of these cases are probably due to the infection of a wound of the 
 mucous membrane caused by the instrument, but some cases are not to be 
 accounted for in this way, but are to be explained only by reflex nervous 
 action. 
 
 Traumatic Delirium. 
 
 This term is used to denote those forms of delirium which occur as the 
 result of injury, and are not due to alcoholism. 
 
 The anatomical seat of delirium is in the cortical gray matter of the brain. 
 The delirium is due either to functional disturbance or anemia of that region or 
 to inflammations of the cortex and meninges — more particularly of the middle 
 and posterior lobes (Hunt). The causes of delirium are as numerous almost as 
 the injuries which give rise to constitutional disturbance, but there are certain 
 lesions which seem more prone to this form of functional disturbance than 
 others. In some cases of shock there is considerable mental exaltation and 
 excitement which are quite characteristic, the condition being known as "pros- 
 tration with excitement." There is usually no marked delirium, but at times 
 a temporary mental aberration of a well-defined character. It may precede 
 and accompany cerebral lesions, such as hemorrhage from trauma, or throm- 
 bosis and embolism. 
 
 Delirium is often noticed in children and the aged after capital operations, 
 after operations for cataract, and also in many forms of chronic inflamma- 
 tion in aged, anemic, and feeble patients. Among other surgical lesions, 
 severe burns and scalds and facial erysipelas may be mentioned as par- 
 ticularly liable to be accompanied by delirium. In some individuals pain 
 alone is often sufficient to produce a temporary mental aberration, which dis- 
 appears immediately upon the subsidence of the pain. This form of delirium 
 is allied to the so-called delirium nervosum of the German writers — a condition 
 of nervous disturbance which comes on after injuries in hysterical subjects. It 
 may occur in the stage of convalescence following erysipelas and other inflam- 
 
38 AN AMERICA y TEXT-BOOK OF SURGERY. 
 
 matory diseases in nervous patients. It is characterizetl by considerable mental 
 depression. Transitory psychical disturbances may also follow sur<^ical opera- 
 tions, and there may be developed at times not only melancholia, but a suicidal 
 mania. A nervous delirium without fever is occasionally noticed after opera,- 
 tions upon portions of the body supplied with unusually sensitive nerves. The 
 operation for phimosis, with an unusual am(»unt of irritation of the ;^lans penis, 
 is an example. Severe nervous disturbance and delirium following operations 
 or injuries, without a corresponding amount of inflammation or fever, should 
 cause the surgeon to inquire as to the possibility of poisoning by iodoform or 
 carbolic acid — conditions readily shown by an examination of the urine. 
 
 The treatment of this form of delirium consists in the removal of all local 
 sources of irritation, in the application of ice to the head in some ca,ses, and in 
 the use of the bromides and hyj)notics. If due to cerebral anemia from loss of 
 blood, suitable stimulation is indicated. Opium is usually not well borne, and 
 should be reserved for those violent cases which cannot be controlled in any 
 other way. 
 
 Post-operative Insaxity. 
 
 Occasionally after an operation or an accident, even when the head 
 was not the part involved, a condition of genuine insanity develops. This 
 condition is afebrile, occurs in those who are weak and exhausted, is 
 especially common in persons who possess a hereditary tendency toward 
 the development of psychoses, and is similar to and identical with post- 
 febrile insanity. 
 
 The most common form encountered is characterized by great mental 
 confusion (confusional insanity of Wood), but either mania, melancholia, or 
 delusional insanity may arise. The prognosis, as a rule, is favorable if sys- 
 tematized delusions are not present. The treatment consists in the adminis- 
 tration of large amounts of nourishment, the use of tonics, and proper men- 
 tal exercise. Most of these cases should be treated in a hosj)ital for the 
 insane. 
 
 Delirium Tremens. 
 
 This disease is a form of mental disturbance characterized by delirium, 
 and accompanied by a peculiar tremor of the muscles, occurring in individuals 
 habitually intemperate in the use of alcoholic stimulants. It follows either 
 a debauch or some injury which suddenly confines such a patient to bed; 
 hence its consideration here. It is said to be much less common in countries 
 where wine and beer are the national beverages than in those in which spiritu- 
 ous liquor is consumed. The habitual use of various drugs is said to produce 
 it, as opium, tobacco, and cannabis indica, and even tea and coffee. The 
 term mania-a-potu is used to denote an acute type of delirium following a 
 debauch, in which the patient may become maniacal. 
 
 Delirium tremens was formerly supposed to be due to an inflammation of 
 the brain. Usually, however, the post-mortem appearances indicate no sign 
 ef active inflammation beyond some thickening of the meninges. According 
 to Hunt, there is a condition so characteristic that it has been called "wet 
 brain," consisting of a passive congestion with serous exudation in and under 
 the pia mater, filling the ventricles and following the convolutions. Chronic 
 gastric catarrh is also found to exist, and atheromatous degeneration of the 
 arteries, fotty liver, and Bright's disease. 
 
 The symptoms of delirium set in gradually. The patient, removed 
 from his ordinary surroundings, complains of feeling uncomfortable ; he is 
 
THE TRAUMATIV FEVERS. ;i9 
 
 restless and tremulous; there is inueli depression of spirits, and his sleeji is 
 disturbed with nightmares ; he talks in his sleep, and may wander about during 
 the night, but the next morning asserts that he has slept well. When it fol- 
 lows an injury, the onset of the disease is usually sudden. With the full 
 develoj>nient of the disease there is complete insomnia, with a muttering delir- 
 ium fre((uently broken by loud cries, and a peculiar tremor of all the mus- 
 cles. The patient is constantly employed pulling the bed-clothes about, tear- 
 ing off dressings and splints, and endeavoring to get out of bed. He appears 
 to be more or less insensible to pain, and may walk upon a broken leg Avithout 
 showing any signs of suffering. He is the victim of all manner of delusions, 
 usually of a horrible nature. The hallucinations take the form of hideous 
 animals and insects ; occasionally they are obscene in cliaracter. The patient 
 may be momentarily recalled to himself sufficiently to give an intelligent 
 answer, but relapses immediately into his previous condition. There is little 
 fever, although occasionally there may be a marked rise of temperature. The 
 pulse is weak and quick, and there is rapid loss of strength, due to the small 
 amount of nourishment taken during the debauch and the later inability to 
 retain food. 
 
 In favorable cases, after two or three days of insomnia sleep comes sud- 
 denly, and on awakening the delirium is found to have disappeared. In severe 
 or fatal forms the prosti^tion increases rapidly and is a marked feature, the 
 pulse foiling greatly in strength. The patient may die suddenly from heart 
 failure. Pneumonia, a complication unusually frequent in alcoholic subjects, 
 may supervene, and bring about a fatal issue. The prognosis of the disease is, 
 however, usually favorable. Among the most reliable symptoms which give a 
 clue to the patient's condition are the pulse and temperature. The weak and 
 rapid pulse is a measure of the prostration, and the rise of temperature is a 
 warning of complications such as pneumonia or septic infection of the wound. 
 
 The prophylactic treatment consists in the employment of alcoholic stim- 
 ulants in moderate quantities, of capsicum and digitalis, and of nourishing food. 
 The last is only secondary in importance to sleep. By these means the nervous 
 system is steadied and the strength of the patient maintained. Any indica- 
 tion of nervousness or insomnia should be met Avith a free use of the bromides. 
 An attack may in this way be warded oif. During the attack mild stimulation 
 with liquor or beer is usually advisable, although the use of stimulants must 
 be determined by the circumstances of each case. The drugs which are most 
 frequently used at the present time are chloral hydrate and the bromides. It 
 is probable that sulphonal in sufficient doses to cause sleep has rather too depress- 
 ing an influence upon the heart's action. The question of the use of opium in 
 this disease has been much discussed. In mild cases it is not necessary, but it 
 may be of much value in quieting restlessness when it is of great importance 
 that splints or dressings should not be disturbed, or when the delirium is of so 
 acute a type that all other remedies fail to control the patient. 
 
40 AN AMERICAN TEXT-HOOK OF SIJROEHY. 
 
 CHAPTER V. 
 
 SUPPURATION AND ABSCESS. 
 SECTION I— SUPPURATION. 
 
 Suppuration is due to the action of the pyogenic cocci upon the tissues, 
 •ind is the usual termination of infective infianiniation. It is the process by 
 means of which the exudate and the tissues involved become liquefied and con- 
 verted into pus. The organisms most frequently found in pus are the staphylo- 
 coccus pyogenes aureus and albus. They have a tendency to accumulate in 
 clusters, and when growing in the tissues produce circumscribed forms of 
 sup];uration. The streptococcus, which is sometiuies present, on the other 
 hand, shows less tendency to cause local suppuration, but spreads rapidly 
 through the tissues by the lymphatics, and eventually gives rise to a diffused 
 form of suppuration. When grown on beef gelatin the staphylococcus causes a 
 liquefaction of the culture medium in virtue of its peptonizing action, which is 
 due to the presence of a soluble peptonizing ferment, and it is in consequence 
 of this action that the fibrinous exudate and the inflamed tissues become 
 converted into pus. 
 
 That the pyogenic cocci are the cause of suppuration has been abundantly 
 shown by microscopical investigation and experiment. They are found in the 
 pus of all acute abscesses, and sometimes in cold abscesses. The failure to 
 find them in the latter class of abscess has been explained in various ways. By 
 some these abscesses are supposed to be caused by the bacillus of tuberculosis 
 alone, but the most probable explanation is the dying out of the organisms and 
 the deposition of their remains as a sediment. Experiments on animals show that 
 these organisms when injected in sufficient quantity under the skin will produce 
 suppuration. When absorption takes place rapidly, however, a larger (juantity 
 can be injected without producing suppuration. In man inoculation through 
 abrasions or Avounds, and even through the uninjured skin, will cause suppu- 
 ration. Garre produced furuncles of the forearm by rubbing in a culture of 
 the aureus. The question of suppuration without the agency of bacteria has 
 been carefully studied recently. Ex})criments on animals with the injection of 
 calomel, mercury, turpentine, and croton oil show that certain drugs can produce 
 in certain animals pus, or, as it would be better called, " puruloid material," 
 containing no bacteria. Non-bacterial pus can also be produced by introducing 
 cultures of cocci which have been sterilized by heat. In this case the organ- 
 isms have been removed, but their chemical products still remain, and are 
 undoubtedly important factors in the production of inflammation and suppu- 
 ration. Practically, however, the surgeon never has to deal with non-bacterial 
 suppuration. 
 
 Among the predisposing causes of suppuration may be mentioned diminished 
 vitality of the tissues. The healthy body is intolerant of bacteria, and will 
 resist the invasion of a mass of organisms which an inflamed or diseased part 
 may be unable to withstand. The milder types of inflammation seem partic- 
 ularly well adapted to encourage bacterial growth. Some of the severest types 
 of suppuration, such as acute osteo-myelitis, follow often slight blows or inju- 
 ries. The delicate reticulum of blood-vessels found in the medullary cavities 
 of bones furnishes a convenient lodging-place for swarms of bacteria, owing to 
 the slowness of the blood-current and tlie tortuous course of the blood-channels. 
 When the circulation has been impaired or arrested by an extravasation of 
 blood or a congestion of the part, the conditions are favorable for an intravas- 
 
SUPPURATION AND ABSCESS. 41 
 
 cular infection if organisms happen to be circulating in the l^lood at the time. 
 As we have seen, micro-organisms may from time to time be found in the cir- 
 culating blood, particularly in individuals of feeble constitutions. The ana- 
 tomical nature of the part will therefore fjivor suppuration in certain localities. 
 A most familiar example is the lymphatic gland tissue. There the organisms 
 which have invaded the tissues through a wound, and have found their way 
 into the lympliatic vessels, are arrested, and a glandular abscess results. The 
 condition of tlie blood is also a predisposing cause, as tlie tendency to carbun- 
 cular inlianniKition in dia])etes shows. 
 
 The material which forms as the result of suppurative inflammation is 
 pus. 
 
 Pus is a yellowish-white fluid of the consistency of milk or cream, of an 
 alkaline reaction, and commonly nearly odorless. It has a specific gravity of 
 about 1030, and when allowed to stand it separates into a clear fluid known 
 as pus serum, and a sediment which averages from 10 per cent, to 20 per cent, 
 of the whole amount. 
 
 The liquor puris, or pus serum, is a pale greenish-yellow fluid which does 
 not coagulate spontaneously, and contains an albuminous substance known as 
 peptone. The salts which it contains are present in about the same proportion 
 as in the blood. 
 
 The sediment consists of pus-corpuscles, the pyogenic cocci and the other 
 forms of micro-organisms that may be present, and fragments of broken-down 
 tissue. 
 
 Most of the pus-corpuscles are the altered leucocytes which have escaped 
 from the blood-vessels with the exudation; others are derived from the prolif- 
 erated fixed connective-tissue cells. When first taken from a fresh abscess 
 many of them are found to possess amoeboid movements. They are a little 
 larger than the white blood-corpuscles. Their protoplasm is somewhat gran- 
 ular, and when acetic acid is added to them they are found to contain several 
 nuclei. This polynuclear condition was supposed to be evidence of an ability 
 of the pus-corpuscles to proliferate, but it is now recognized as a sign of degen- 
 eration. They also occasionally contain drops of fat ; others are full of large 
 granules, which, Avhen they break up, liberate a granular detritus Avhich may 
 be seen suspended in the fluid. 
 
 The color of pus is occasionally blue. This is due to the presence of the 
 bacillus pyocyaneus, ordinarily considered a harmless organism, but the presence 
 of which indicates slowness of repair. Orange-colored pus is caused by the 
 presence of hematoidin crystals, and is found in some forms of inflammation. 
 It is probably due to the fact that many red corpuscles in the exudation have 
 been broken up by the septic process, 
 
 The peculiar foul odor of pus which comes from the neighborhood of the 
 vagina or rectum is due to the presence of the bacillus pyogenes foetidus. The 
 thick creamy, odorless pus which flows from an acute abscess was formerly 
 known as healthy or laudable pus. It contains comparatively few bacteria. 
 Pus may occasionally undergo decomposition ; in this case the micro-organisms 
 of putrefaction also are found in it, and the pus-corpuscles are broken down and 
 much diminished in number. This is known as ichorous pus, and Avhen mixed 
 with blood which is seen flowing from a rapidly-spreading abscess is called 
 sanious pus. These unhealthy forms of pus are very acrid and give an acid 
 reaction. 
 
 A microscopical examination of the connective tissue in suppurative inflam- 
 mation shows that in the early stages of the process the stellate cells of the 
 tissue lose their prolongations, become rounded, and undergo karyokinesis, and 
 
42 .l.V AMElilL'Ay TEXT-BOOK <jT .)iLB(JTJn'. 
 
 multiply in this way. In the mean time the intercellular su})stance underfrocs 
 a softenin;; process, is transformed into a homo^ieneoiis sulistance, and the 
 proliferated connective-tissue cells are in a state of jiolynuclear defeneration. 
 This sta<re is the one immediately preceding that of pus formation. Many of 
 these degenerated cells are therefore of connective-tissue origin, and under 
 some circumstances they may even outnumber the leucocytes. When the 
 polynuclear stage has been reached, it is impossible to tell the origin of these 
 cells. 
 
 Suppuration is always to be regarded, as it has been aptly described as a 
 "battle of cells," the bacteria exerting, in all probability, a clicmotactic 
 attraction which for weakened cells is irresistible. 
 
 When acute suppuration takes place the symptoms of inflammation all 
 become more marked. There is great increase in redness and swelling, and 
 the part is exceedingly hot and is the seat of a throbbing pain. The formation 
 of pus is often ushered in by a chill or rigor, and a change in the conditions 
 of the part will indicate the locality of the pus. The skin at this spot becomes 
 adherent to the parts beneath, and later presents to the touch the sense of 
 fluctuation. A deeper color is also present at this point, and in the centre of 
 the focus a whiter zone indicates the stage immediately preceding the breaking 
 down of the abscess and the discharge of pus. 
 
 The diffused forms of suppuration in connective tissue are called 
 phlegmonous injirimmations. This variety is usually seen after compound 
 fracture when septic infection has occurred, and may involve the greater portion 
 of the limb, as the forearm, the arm, or the leg. An acute swelling, with 
 oedema of the connective tissues, ushers in the process, and areas of bogginess or 
 fluctuation will make themselves manifest later. The constitutional disturbance 
 will usually be great. A sharp rise of temperature, accompanied perhaps with 
 a chill, will mark the beginning of the suppuration, and the pyrexia will 
 remain until free incisions and thorough drainage have arrested the progress of 
 the pus. The route which pus takes under these circumstances depends upon 
 the anatomical structure of the part, upon gravity, and also upon the nature 
 of the organisms. In many cases pus will continue to burrow until the integu- 
 ments have been freely divided and the margins of the suppurating area have 
 been fully exposed. The improvement following such free incisions is due to 
 the fact that the bacteria growing in the wall of the abscess are thus freely 
 exposed to the air, a condition less favorable for their growth, and are more 
 readily reached by antiseptic agents. Small incisions are of little use in the 
 more rapidly-spreading forms of cellulitis, and incisions from six to twelve 
 inches in length are sometimes required to arrest the progress of the disease. 
 If the treatment adopted fail to arrest suppuration, it may pass into a chronic 
 stage ; the pus will then burrow slowly and make its appearance at many 
 different spots. There will also be considerable constitutional disturbance, 
 marked by a progressive emaciation and gradual exhaustion of the patient. 
 The febrile disturbance will be of the remittent type known as hectic fever. 
 
 Purulent infiltration of a limb is a still more malignant form of inflam- 
 mation. Originating in a suppuration perhaps at first trivial, it will spread 
 rapidly, and its involvement of the lymphatics of the limb will be plainly indi- 
 cated by red lines extending up to the axilla or the groin. The protective 
 influence of the lymphatic glands will be shown by their filtration from the 
 lymph-stream of the cocci and their ptomaines. This leads to the fonnation 
 of an abscess just above the elbow or in the axilla or groin, which temporarily 
 arrests further progress of the supj)uration. More rarely the entire limb will 
 be involved in an acute inflammatory swelling with little tendency to suppura- 
 
SUI'I' I 7.'. 1 riOX . I M> . 1 BSCKSS. 43 
 
 tion. In this ease the whole part is apt to become gangrenous. Free incisions 
 are foHowod by the escape of a sero-punileiit iliiid. There is profound constitu- 
 tional disturbance with perhaps acute septicemia. Probaldy in these cases there 
 is a mixed infection, and bacilli of putrefaction are mingled with the micrococci. 
 
 When infection of a wound takes place the slight swelling which ordi- 
 narily accompanies the healing process is much increased at some portion of 
 the wound, and is accompanied by reddening and induration. This will usually 
 occur around one of the stitches which has been the source of infection, or pus 
 may collect in some part of the wound Avhere the surfaces were not accurately 
 brought in apposition and where the Avound fluids have accumulated from 
 imperfect drainage. The rise of temperature will give speedy warning of the 
 approach of suppuration in such cases. 
 
 The general plan of treatment to be adopted in cases of spreading 
 suppuration is the emploA'ment of free incisions which expose the extreme 
 limits of the suppurating area. This operation should be accompanied by a 
 thorough curetting of the surface of the pus-cavity to remove the bacteria 
 from the surrounding tissues and by thorough disinfection with appropriate 
 antiseptic drugs. In the case of an extremity this can best be accomplished by 
 immersion of the limb in an antiseptic bath. The agent used should be largely 
 diluted (sublimate 1 to 10,000, or carbolic acid 1 to 500) to prevent poisoning 
 by the drug. Following the bath antiseptic fomentations may be applied. 
 For this purpose some of the milder drugs containing carbolic acid, as sulpho- 
 naphthol, may be used. When other methods fail, irrigation is often successful. 
 Sterilized water may be used for this purpose or. extremely Aveak solutions of 
 disinfectants. If a dry dressing is preferred, iodoform or aristol or boric acid 
 may be dusted freely upon the part, and the Avound may then be packed with 
 an antiseptic gauze. The use of stimulants and careful feeding should be the 
 chief feature of the general treatment of the case. 
 
 SECTION II.— ABSCESS. 
 
 An abscess is a circumscribed collection of pus, and is caused usually by 
 the presence of the staphylococci in the tissues. When these organisms invade 
 a part, Ave find even at the end of tAventy-four hours an enormous number of 
 leucocytes in the exudation which takes place. The connective-tissue fibers are 
 SAA^ollen and the lymph-spaces are distended and filled with cells. As we have 
 already seen, the fixed cells of the tissue undergo changes of an active nature, 
 and form nucleated cells Avhich cannot be distinguished from the leucocvtes : 
 they are, however, usually much less numerous than the latter. The small 
 vessels are dilated and distended with blood, and in many cases with leucocytes. 
 The cocci in the mean time inci^ease in number and tend to group in masses. 
 As they exert a peptonizing action upon the intercellular substance and 
 the fibrin of the exudation, liquefaction takes place in the center of the 
 inflamed tissue, and an abscess is formed. The walls of the pus-cavity are 
 formed by a zone of granulation-tissue, the cells and intercellular substance 
 of which have not been broken down by the action of the bacteria, and remain 
 to form a protecting layer betAveen the infected area and the surrounding healthy 
 tissues. This is the mode of development of an abscess in some of the looser 
 tissues like connective tissue. In the denser structures and in the internal 
 organs when a plug of microccocci becomes arrested at some point in the circu- 
 laton, as, for instance, in a glomerulus of the kidney or in a lymphatic gland or 
 in the cutis vera, Ave find that the tissue immediately surrounding it undergoes 
 a chemical change due to the action of the ptomaines upon its cells, the 
 
44 AX AMKRICAX TKXT-li( )<)k' OF SURGERY. 
 
 result of which is that coaofulation-nccrosis of the tissue takes plaee. This 
 ring of dead tissue is readily seen in sections taken for microscopic })ur- 
 poses, as the necrosed area does not take any of the staininjr fluids ■\\hicii 
 act upon the surrounding tissues. Outside of this area a ring of granulation- 
 tissue forms. Eventually the necrosed area is invaded both by the bacteria 
 and the leucocytes, and becomes liquefied by the action of the cocci. An 
 abscess of this type, when examined microscopically, will show a mass or 
 plug of bacteria in the center, around which is a layer of pus and shreds of 
 tissue enclosed in a zone of granulation-tissue, the miscalled pyogenic membrane 
 of the older ])athologists, who thouglit that the wall of an abscess was a sort of 
 secreting surface from which pus was formed. 
 
 The symptoms of an acute abscess are usually well marked. The large 
 amount of local swelling, Avith a varying amount of pain according to the 
 density of the tissues which lie between the cavity of the abscess and the 
 surface, is accompanied frequently by a chill or a gradual rise of temperature 
 as pus begins to form. As the abscess forms a progressive softening of the 
 integuments takes place until the pus reaches the surface. Considerable resist- 
 ance will be offered by certain tissues, as fascia, a joint capsule, or bone, and 
 the pus may take a devious path before the abscess begins to point. Fluctua- 
 tion will now be distinctly felt, and redness witli oedema of the skin and subcu- 
 taneous tissue will indicate the near approach of pus. The skin becomes 
 stretched and thin and its vessels compressed, and over a certain area the 
 blood Avill not circulate ; death of this area occurs, and the abscess then easily 
 breaks through it. 
 
 It is not usually difficult to diagnosticate the presence of an acute abscess. 
 Acute forms of inflammation may occur, however, in which the sensation of 
 fluctuation is apparently well marked when an incision fails to reveal the pres- 
 ence of pus. No harm is done, the inflammation may be relieved by such an 
 operation, and the impending abscess prevented. 
 
 Deeply seated abscesses under a dense fascia, as in the neck, may be over- 
 looked, as no fluctuation can be felt. The local oedema and brawny feel, with 
 other signs of suppuration, are always a sufficient warrant for a deep but care- 
 ful exploratory incision at an early date to prevent wide and dangerous burrow- 
 ing of the pus under the fascia. An aneurysm may, however, be mistaken for 
 abscess, particularly when its presence is obscured by the symptoms of inflam- 
 mation, and the use of the knife in such a case Avould be a grave error. An 
 aneurysm will declare itself by its less acute history, by the thrill, bruit, and 
 expansile pulsation, and can exist only in connection Avith a large vessel. 
 Some forms of rapidly-growing malignant tumors may also simulate suppura- 
 tive processes. In all such cases the use of the aspirator or of the hypoder- 
 matic needle is of great value. The heat of the part, the sense of fluctuation, 
 the local oedema, and the rise of temperature, as shown by the thermometer, 
 are all important diagnostic symptoms, and will usually be sufficient to estab- 
 lish the presence of an abscess. 
 
 When an acute abscess breaks the pus which is discharged is of a thick 
 cream-like consistency, and is frequently mingled with soft sloughs of con- 
 nective tissue or fascire, or fragments of lymphatic glands Avhich have under- 
 gone a necrosis due either to the great tension of the part or to the formation 
 of destructive chemical substances by the pyogenic cocci. 
 
 The treatment of acute abscess consists in incision as soon as it can be 
 definitely ascertained that pus has formed, and sometimes even earlier. 
 Nothing is to be gained by delay, and extensive injury may be inflicted upon 
 the surrounding tissues if the abscess is not opened early. In some regions 
 
SUPPURATION AXI> ABSCESS. 45 
 
 the (lan^'crs of delay are very great. An abscess in tlie neighborhood of the 
 appendix verniifonnis may produce a fatal peritonitis if allowed to remain 
 unopened. ])eep-seated abscesses of the neck may burrow widely, and mav 
 seriously interfere with res])iration by pressure upon the trachea. An abscess 
 near the rectum should be opened as soon as induration is discovered, in order 
 to prevent a fistula. If no pus has formed the incision may prevent it. 
 
 The incision, as a rule, should be a free one, and so made as to favor drainage 
 and to leave the least conspicuous scar. The finger should then be introduced to 
 determine the size and situation of the various pockets. In case of abscesses 
 near large vessels or other important structures Hilton's method may be used 
 to advantage. This consists in making an incision through the skin and deep 
 fascia by the knife. The seat of the pus can be ascertained by pushing in a 
 pair of closed hemostatic forceps or blunt scissors or a sinus dilator, and the 
 opening so made can be easily enlarged by drawing them out open. If neces- 
 sary, to facilitate the escape of the pus by gravity, a counter-opening can often 
 be made by pushing the hemostatic forceps entirely through the tissues to the 
 opposite skin, and cutting between its partly opened blades. The cavity of 
 the abscess should be thoroughly emptied, curetted, and syringed out with anti- 
 septic solutions. These may consist of corrosive sublimate 1 : 5000 or carbolic 
 acid 1 : 100, or if a milder antiseptic fluid is needed phenyl (sulpho-naphthol) 
 1 : 250. When the pus. and sloughs have been thoroughly removed in this 
 way, a drainage-tube of a sufficient size should be inserted, and retained either 
 by a safety pin inserted through its extremity or by stitching it to the skin to 
 avoid its falling out of the abscess, or, still worse, of being lost in its cavity. 
 An antiseptic poultice (made of aseptic cotton and cheese-cloth and wrung out 
 of a weak antiseptic solution) may be applied, or a dry absorbent dressing may 
 be used. In freely-discharging abscesses the dressing should be changed at 
 the end of twelve hours or less, and the cavitv Avashed out again. The fountain 
 syringe fitted with a tube ending in a conical glass point is well adapted for 
 this purpose. It gives a continuous stream, and causes but little pain to the 
 patient in its application. In a few days the inner surface of the abscess-wall 
 "cleans off" and healthy granulations make their appearance. The tube can 
 be shortened daily as the cavity shrinks, but the time of its removal will depend 
 entirely upon the length and ramifications of the cavity. 
 
 Cold abscess is caused in the great majority of cases by tubercular 
 infection, although occasionally it may be of syphilitic origin. In the ordinary 
 tubercular cold abscess we find a peculiar membranous wall formerly called 
 the "pyogenic membrane" (the " pyophylactic membrane" of Park), which 
 is readily scraped off and is infiltrated Avith tubercles. In the syphilitic 
 abscess no such condition exists. This membrane, as also the pus of 
 cold abscess, is more fully described in the chapter on Tuberculosis. The 
 organisms found in the contents of the abscesses before they are opened 
 are the bacilli of tuberculosis. Sometimes before, and always after they 
 have opened spontaneously or have been opened without due antiseptic 
 precautions, there is added the infection with pyogenic cocci, or the bacteria 
 of putrefaction. This is an example of what is called mixed infection. 
 Clinically, we find few of the symptoms of acute abscess. There is in most 
 cases no redness of the part until the abscess is about to break. Pain and 
 heat are usually wanting. The swelling is frequently quite large and fluctua- 
 tion is distinct. Such abscesses may exist for months before they burst. Dur- 
 ing their formation the constitutional disturbance is usually slight. There may 
 be, however, considerable emaciation due to the progress of the tuberculosis. 
 The temperature is usually slightly raised, and in cases of doubtful diagnosis 
 
46 A\ AMi:i:icAX 'nixr-nooK of surgery. 
 
 the tlieruiometer ■will give valuable inroriuation. (.)iie of the most coniiuon 
 seats of cold abscess is the vicinity of the spinal colunin, and such abscesses 
 are due to tubercular disease of the vertebra} (Pott's disease). The \)\\^ bur- 
 rowino; along the psoas muscle (])soas abscess) points above or below J*(»uj»art's 
 lig;»ment or on the thiixh external to the vessels, or it may ))oint in the lumbar 
 region near the margin of the (juadratus lumborum muscle (lumltar abscess). 
 
 Treatment. — These abscesses should be opened with every antiseptic 
 precaution, otherwise true suppuration with hectic fever will follow from the 
 mixed infection which inevitably occurs. They must lie tlioioughly scraped 
 out and the wound stuff'ecl with iodoform gauze. Such treatment is best 
 adapted to those abscesses which have few ramifications, and the walls of which 
 are evervAvhere accessible to the curette. Treves treats psoas abscess by an 
 opening in the loin which passes external to the latissimus dorsi and erector 
 spinas muscles and through the quadratus lumborum and psoas muscles. The 
 diseased vertebra is first explored, and fragments of bone are removed, and 
 the abscess-wall is repeatedly scraped and wijied out, and also washed out 
 with a douche of corrosive sublimate, 1 : 5000, at 100° F. The wound is 
 then closed and dressed with an iodoform dressing retained by a bandage. 
 The patient should be kept at rest in the recumbent position for many 
 months. If the abscess-cavity refills, the operation should be repeated. 
 
 In many cases of cold abscess it is well to evacuate the contents with the 
 aspirator and to inject some preparation of iodoform. A large canula is 
 sometimes necessary, owing to the thick plugs of cheesy matter which obstruct 
 the flow of pus. The cavity is now washed out with a 3 per cent, solution of 
 boric acid. Among the preparations of iodoform recommended is a 5 per 
 cent, ethereal solution, but not more than three ounces should be injected 
 for fear of iodoform-poisoning. It causes considerable pain. A 10 per 
 cent, emulsion of iodoform in olive oil can be introduced safely. The fol- 
 lowing emulsion is also sometimes used, and is considered safe so far as poi- 
 soning is concerned : Iodoform 10 parts ; glycerin 20 ; mucilag. gum. Acac. 
 5 ; carbolic acid 1 ; and Avater 100 parts. From one to three ounces should be 
 injected, and the abscess-cavity should be carefully manipulated so as to intro- 
 duce the drug into all the pouches. Tavo or three such injections are made at 
 intervals of three or four weeks. A cure may not be obtained for several 
 months. Equal parts of iodoform and olive oil may be injected freely into 
 tubercular sinuses which have resulted from the burstinff of such abscesses. 
 If this treatment fails, recourse may be had to incision, as above described. 
 
 The general treatment consists of good food, cod-liver oil and other tonics, 
 and a careful selection of climate. Mechanical contrivances may be needed 
 for the support of joints or bones. 
 
 Abscesses of different regions of the body ])ossess characteristic 
 peculiarities. The most common form of abscess in the integuments is the 
 furuncle or boil. This is caused by a growth of the cocci from the deeper 
 layers of the epidermis doAvnward along the sheaths of the hair-follicles, and a 
 final accumulation near the root of a hair. If the cocci are arrested in their 
 groAvth at the mouth of the follicle, a pustule is formed, but in many cases the 
 development contiimes doAvnAvard and a true furuncle is developed. The boil 
 in its early stages appears as a pustule. The amount of coagulation-necrosis is 
 considerable, and the result is a '"core" Avhich is discharged Avhen the abscess 
 breaks. A crucial incision Avill promptly arrest the groAvth of a boil in its early 
 stages, or an application of the liquefied crystals of carbolic acid may be used 
 if it is desired to avoid a scar. A carbuncle is a suppuration and necrosis 
 of the subcutaneous tissue, and is situated most frequently under the thick 
 
srrrrRATioN and abscess. 47 
 
 skin of the back of the neck. Like tlie ])oil, it is at first superficial, ])ut 
 rapidly spreads to the deeper parts. It has erroneously been called a collec- 
 tion of boils, owing to the fact that numerous points of })us a]»))ear on the 
 surface, and when opened it ])resents a honevcond)ed appearance. This 
 peculiarity of the carbuncle is due to the anatomical structure of the skin 
 and subcutaneous tissues of this part of the body. The pus forms in the 
 dense fibrous reticulum -which underlies the thick cutis, and makes its Avay to 
 the surfiice through the columniie adipostc, in which the fine lanugo hairs are 
 situated, causing disintegration of the parts and sloughing of the tissues and 
 the formation of a central crater (Warren). ^Phe carbuncle should be freely 
 incised and all the sloughs removed by the sharp spoon or scissors, and the 
 part disinfected as thoroughly as possible. Complete excision of the car- 
 buncle with thorough disinfection of the parts will often lead to an arrest of 
 the process and a speedy convalescence. Abscess of the lymjjhatic glands 
 may form in the groins, as the result of suppuration complicating venereal 
 disease; in the neck, following inflammation of an adjacent mucous membrane; 
 in the axilla, as the result of suppuration in the fingers or hand ; or in the 
 saphenous glands, from suppuration in the toes or foot. A deep abscess of 
 the neck should be opened by Hilton's method. A retropharyngeal ab- 
 scess should be opened through the neck, the incision being made at the 
 anterior or posterior edge of the sterno-cleido-mastoid muscle. Felons and 
 palmar abscesses are often supposed to be caused by direct local trauma, 
 but are more frequently due to indirect infection by pyogenic cocci which 
 probably follows an injury of some kind. The precise seat of the suppura- 
 tion will vary according to the situation of the infection. Nowhere is an 
 early incision of more importance, as the usefulness of the finger or hand is 
 at stake. 
 
 When abscesses form in and around the internal organs they are usually 
 designated by special names derived from the parts with which they are asso- 
 ciated, as perinephric, psoas, or subdiaphragmatic abscesses. Sub- 
 phrenic abscess, as the latter is sometimes called, is usually due to a circum- 
 scribed peritonitis caused by a perforating ulcer of the stomach, duodenum, 
 or appendix, and more rarely of some other portion of the intestinal tract 
 or to inflammation of the liver, spleen, or kidney. The abscess sometimes 
 contains air and may resemble pyopneumothorax. It may be treated by an 
 intercostal or an abdominal incision (Mason). Abscesses of the liver are 
 occasionally observed in America. They are caused by inflammations in the 
 intestinal tract and contain a brown grumous material, in which is found the 
 amoeba coli {vide infra). 
 
 Abscess is found in bones near the epiphyseal line (" Brodie's abscess ") 
 in acute inflammation (osteomyelitis), and tuberculous abscesses are often 
 seen near the ends of long bones in connection with joint-disease {vide infra). 
 Abscesses in the brain are occasionally observed as metastatic abscess or in 
 connection with middle-ear suppurations or after injuries. 
 
 Pus in the thorax is most frequently found in the pleural cavity, consti- 
 tuting empyema. An empyema can rarely be cured by aspiration, but 
 should be promptly opened and drained. A cure may be retarded by the 
 mechanical difficulty of bringing the abscess walls together, owing to the 
 contraction of the lung and the rigidity of the chest Avail. In these cases 
 resection of several ribs is necessary to allow the thoracic wall to come in 
 contact with the lung (Estlander's or Schede's operation). Tuberculosis is 
 often a complication of this variety of suppuration. Abscesses occur also, 
 but much more rarely, in the lung itself. These can be opened and drained 
 
48 AN AMERICAN TEXT- BOOK OF SURGERY. 
 
 by ail incision bet^vceii tlio ribs or by resection of one or more ril)s. The 
 operation is much simplified if adhesion of the lung to the thoracic wall has 
 already taken place. 
 
 Details regarding abscesses of special regions will be found in their 
 appropriate places. 
 
 CHAPTER VI. 
 ULCERATION AND FISTULA. 
 
 SECTION I. ULCERATION. 
 
 An ulcer is a loss of substance due to inflammation of a superficial 
 structure. There is also a tendency to necrosis or death of the granulations 
 which are formed by the tissues in an effort at repair. If the retrograde 
 changes equal the reparative, the ulcer will remain stationary ; but if the for- 
 mer exceed the latter, the ulcer will constantly increase in size. 
 
 The causes of ulceration are of widely different origin. Some develop 
 during the course of certain infectious diseases, particularly those of a chronic 
 type, as syphilis, tuberculosis, leprosy, and glanders. Another kind of ulcer 
 depends upon widespread disturbances in nutrition. These are known as 
 dyscrasic or constitutional ulcers. To this class belong the scorbutic ulcers, 
 which appear to form as a result of disease of the blood-vessels brought about 
 by the absence of a sufficient variety of nutriment ; also the cachectic ulcers, 
 due to exhaustion of the system from starvation, exposure, or disease. 
 
 Ulceration may also be ftivored by certain local conditions. A passive 
 hyperemia due to retardation in the venous circulation may be the cause of 
 the varicose ulcer. Decubitus, or bed-sore, is due to a feeble circulation, which 
 is easily arrested by continuous pressure from lying in bed, causing death of 
 the part. Neuro-paralytic ulcers are caused by diminished innervation. 
 The so-called trophic disturbance belongs in this class. A striking example 
 of this variety is the ''mal perforant," or perforatm;/ ulcer of the foot, for 
 which the nerves of the leg have been stretched with success. We may also 
 have ulceration as the result of the breaking down of maJif/uaut (/rowt/is, as 
 sarcoma and carcinoma, particularly in the epithelial forms of the disease. 
 
 Finally, ulcerations occur which are the result of certain mechanical dif- 
 ficulties obstructing the healing process. Extensive loss of substance, burns 
 of the skin, or avulsion of the scalp may result in the existence of a permanent 
 granulating surface constantly contracting or enlarging, but never fully healing. 
 Sloughing of the flaps of an amputation-stump may be followed by an adhe- 
 sion of the integuments to the ends of the bones, which protrude slightly and 
 are covered with granulations. Wounds may be prevented from healing by 
 mechanical irritation, such as chafing or rubbing or the application of irritating 
 ointments or acids. 
 
 A section taken from an ulcer and examined microscopically shows 
 generally a thickening of the tissues around the ulcer due to a hypertrophy 
 of the papilli^J and an accumulation of the epidermic cells, which sometimes 
 form an overhanging mass, giving the appearance of " callous edges. In the 
 deep layers of the rete mucosum and in the papillary layer of the true skin 
 deposits of blood pigment are often seen. The surface of the ulcer is covered 
 with a layer of granulation-tissue. This tissue may resemble the type seen in 
 
ULCERATION AND FISTULA. 49 
 
 healthy granuhitions, being composed of roiuul cells closely packed together 
 and supplied with a rich capillary network of blood-vessels, or we may find 
 a condition of coagulation-necrosis due to breaking down of portions of the 
 granulations. In old ulcers the cell-growth is much less abundant, and a gelat- 
 inous intercellular substance is seen in which clusters of cells are scattered 
 here and there. The granulation layer is quite superficial, and beneath it we 
 see either the nearly normal tissue or a mass of fibrous cicatricial tissue. 
 
 Ulcers are either acute or chronic. An acute ulcer is a spreading ulcer, 
 in and about which acute destructive inflammation exists. Such an ulcer is 
 of irregular outline, its floor is sloughy, its discharge is purulent, and the 
 parts about are inflamed. In such a case the ulcer is rendered aseptic and 
 the parts about it are treated as is any case of acute inflammation. 
 
 A chronic ulcer is an ulcer which does not tend to heal or which heals 
 very slowly. In treating a chronic ulcer it is necessary to discover the cause 
 which prevents healing and remove it. Such ulcers occasionally develop 
 epithelioma at their margins, but this is very rare. In such cases they 
 should be freely excised at an early date, together with any enlarged glands. 
 
 Ulcers are classified not only on the basis of their mode of origin, but also 
 according to certain peculiarities which are characteristic. Thus an ulcer may 
 be healthy, fungous, erethistic, callous or atonic, phagedenic, etc. 
 
 A liealtluf ulcer is one in which the granulations are small and florid and 
 the edges show a bluish border of cicatrization. If it be small, it may be 
 allowed to scab and cicatrize under the crust. If larger, carbolated oxide- 
 of-zinc ointment, with or without calomel (3J@§j), with suitable protection by 
 a bandao-e, and rest, is all that is needed as a rule. Simple avoidance of irrita- 
 tion by means of a bit of "protective or gutta-percha tissue under an anti- 
 septic dressing is often better than ointments. If slow in healing, stimulation 
 by the occasional light application of nitrate of silver or a solution of chloral 
 (gr. X @ ^j) or potassio-tartrate of iron (gr. v @ 5J) will be useful. Skin-grafting 
 is required in large ulcers, and is now done early in many cases of large loss 
 of tissue which would result in an ulcer at a later period. For the details 
 of its application see the chapter on Plastic Surgery. 
 
 If the granulations are too exuberant or are fungous, the application of the 
 solid nitrate of silver, a solution of sulphate of copper (gr. i-x («; 3J), or shaving 
 off" the exuberant granulations with a bistoury, followed by compression by 
 Martin's rubber bandage or strapping or skin-grafting, will favor the healing 
 of such ulcers. When the fungous granulations are pale and edematous, they 
 may be due to tubercular disease, and in this case a thorough curetting of 
 the surface should precede the application of caustic or actual cautery. 
 
 The erethistic, irritable, or painful ulcer is a name applied to ulcers which 
 are extremely sensitive. The cause of this sensitiveness is not always clear. 
 They are found in regions liberally supplied with sensitive nerve-fibers, as the 
 anus or matrix of the nail, and are then doubtless due to an exposure of the 
 terminal nerve-branches in the w^ound. They are found frequently in the lower 
 extremities about the ankle or over the surface of carious bone, as the tibia. 
 Fissure of the anus is a good instance of this kind of ulcer, which by inducing 
 constipation and other digestive disturbances often seriously undermines the 
 general health. It is easily overlooked unless carefully sought for in the folds 
 of the anal mucous membrane. It is best treated by forcible dilatation of the 
 sphincter muscle. Ingrotving nail or ulceration of the matrix of the nail is 
 due to irritation from a sharp corner of the nail, which should be removed. 
 The local treatment consists of drying and soothing powders, such as iodo- 
 form, or, better, the removal of the sensitive granulations with the curette 
 
 4 
 
50 ^iV^ AMERICA X TEXT- HOOK OF SURGERY. 
 
 or kiiitc imder cocaine anesthesia, and protection of the raw surface by daily 
 packing a very small bit of absorbent cotton under the edge of the so-called 
 "ingrowing" nail. It is really "overgrowing granulation" rather than 
 " intrrowiim' nail." 
 
 The calloH>i nicer is sometimes called indolent or atonic, and is due to a 
 diminution to the minimum of the reparative process. The thickened edges are 
 caused by the ineflectual attempts of the surrounding skin to form cicatricial 
 tissue and epidermis. It is found in laboring and ill-nourished people, and is 
 often due to the presence of varicose veins (varicose ulcers) or to eczema of the 
 skin. Occasionally we find, as the result of long-standing disease and neglect 
 in old people, a general hypertrophy of the affected leg, simulating elejjhantiasis. 
 The treatment of such ulcers consists in rest in bed, elevation of the limb, 
 and the employment of antiseptic or emollient dressings, and later perhaps 
 skin-grafting. These ulcers are likely to recur unless support is given to the 
 part b}' an elastic stocking or a bandage of flannel cut bias, or Martin's rubber 
 bandage. When circumstances render it imjjossible for the patient to rest in 
 bed, the ulcer may be treated by strapping with adhesive plaster, and a band- 
 age made of some elastic material to give support to the blood-vessels of 
 
 Fig. 17. 
 
 riiroiiic rioers of the Legs. 
 
 the limb. The strips of adhesive plaster should be an inch wide and long 
 enough to encircle two-thirds of the limb, and should overlap each other from 
 below upward like the clapboards of a frame house. Concentric incisions made 
 through the indurated tissues around an indolent ulcer may relieve the cicatricial 
 pressure on the circulation and enable the edges of the ulcer to cicatrize. 
 
 The thickened margins, consisting of contracting cicatricial tissue, so inter- 
 fere with the access of arterial and the egi'ess of venous blood that the foi-mation 
 of healthy granulations is impossible. As much of the healing of all ulcers 
 results from the reduction in size effected by the contraction of their bases, 
 caused by the organization of the deep layers of the granulation-tissue into 
 young connective tissue, rather than by epidermization, the fixation of the 
 margins and base of a chronic ulcer to the subjacent parts must prevent healing. 
 Upon this fact depends the utility of incisions a little distance from the margins 
 of the ulcer. Blisters and the pressure of strapping owe much of their efl'ect 
 to the removal by absorption of the constricting effect of the old cicatricial 
 tissue upon the circulation through the ulcer. 
 
 The j^hagedenic ulcer is due to infection by different forms of micro- 
 organisms. When seen on the genitalia it usually follows venereal disease. In 
 
ULCERATION AND FISTULA. 51 
 
 other regions of the body it ma}^ be caused by constitutional conditions combined 
 ■with unhealthy suiToun(lino;s. Jnteni])enince and scurvy are predisposing 
 causes, and wlien individuals affected in this -way are crowded together in 
 barracks or hospitals in time of war, such types of ulceration are not uncommon. 
 The surface of the ulcer is devoid of granulations, and is covered with a mass 
 of slougliing tissue. Its edges are sharply defined and appear as if eaten out, 
 and it spreads with great rapidity. The treatment consists in curetting by a 
 sharp spoon and removal of the overhanging edges by the knife or scissors, 
 followed by a thorough disinfection of the part by the application of antiseptic 
 agents, such as pure carbolic acid, bromine, sublimate solution 1 : 500, and, if 
 these fail, in the use of the Paquelin cautery. Constitutional treatment by means 
 of tonics and stimulants and favorable hygienic surroundings should be employed. 
 In mild cases pure iodoform or aristol or cliloral (gr. x-xx (a^ gj), or the potassio- 
 tartrate of iron (gr. v@sj), Avill often effect a cure. 
 
 Ulcers depending upon specific origin, such as the strumous, scorbutic, lupoid, 
 and syphilitic ulcers, will be considered more fully under their appropriate head- 
 ings. The ulcerations seen in malignant diseases are chiefly carcinomatous. 
 One of the most frequent forms is rodent ulcer, which is situated on the nose 
 and cheeks, and often resembles specific or tuberculous ulcerations. It is, 
 however, due to the breaking down of a genuine epithelial growth (Warren). 
 Deep-seated cancers, when they reach the surface, enter upon an ulcerating 
 stage, and may affect large surfaces in this way. Sarcomatous ulcers are com- 
 paratively rare. 
 
 SECTION II.— FISTULA AND SINUS. 
 
 A FISTULA is an abnormal opening into a normal canal or organ — e. g. the 
 rectum or the duct of a salivary gland — or a communicating passage between 
 two adjacent mucous cavities — e. g. the bladder and vagina, etc. Such a fistula 
 when it communicates with an unhealed wound or old abscess-cavity is usually 
 called a sinus. The terms are often used interchangeably. There is a great 
 variety of fistulse, each kind being named from the organ with which it commu- 
 nicates. Fistulas may be due to congenital deformity, as a branchial fistula, 
 •which is formed by the non-union of one of the branchial clefts. They may be 
 the result of injury or sloughing, as the salivary or vesico- vaginal fistula. Si- 
 nuses which result from the failure of an abscess to heal, and which have opened 
 into some canal or cavity, are usually called fistulee, as the urinary fistula and 
 fistula in ano. 
 
 A SINUS is usually a canal opening upon the surface of the skin or a mucous 
 membrane and terminating in the cavity of an old abscess. It may, however, 
 result from the burrowing of pus beneath the skin, and will then form a tor- 
 tuous series of canals extending in various directions. The failure of such a 
 pus-cavity to heal is usually due to the presence of some secretion which pours 
 into it, or to the pi'esence of a foreign body, as a piece of dead bone, or to the 
 inability of the walls of the cavity to collapse and come in contact with each 
 other, as in empyema or abscess in the spongy end of a bone. Frequently the 
 diseased condition of the Avails of the sinus is an obstacle to repair. Many 
 such sinuses are due to the presence of the bacillus of tuberculosis. In such 
 cases they are lined with a membrane resembling that of cold abscesses, which 
 must always be carefully extirpated or cauterized. 
 
 The treatment consists, first, in the removal of all irritating or diseased 
 substances. It is often necessary to lay the fistula fully open and thoroughly to 
 curette its walls before healthy granulations Avill s])ring uj) and aid in the heal- 
 ing process. Special fistulie will be considered under their respective regions. 
 
52 
 
 ^^V AMERICAN TEXT-BOOK OF SURGERY 
 
 CHAPTER VII 
 
 GAXGRENE. 
 
 Gangrene is a term employed to denote death of a part of the body in 
 mass. Necrosis and mortification are terms used in a simihir sense, but in sur- 
 gery necrosis is often limited to death of bone : it is applied also to death of 
 internal organs where, owing to the absence of bacteria, putrefaction does not 
 take place and the dead mass is absorbed, new tissue growing in from the sur- 
 rounding healthy parts to take its place. Gangrene results either from a ces- 
 sation of the arterial blood-supply or from an obstruction to the venous outflow, 
 or purely from a stasis of blood in the capillary vessels. It may also take place 
 independently of any disturbance of the circulation by the direct action of 
 destructive agents upon the cells of the tissues. 
 
 The most frequent non-traumatic cause of deprivation of arterial blood- 
 supplv is a diseased condition of the arteries, such as is seen in senile gangrene. 
 It mav also be due to arterial spasm, such as is produced by the action of ergot 
 or disturbance in function of the vaso-motor nerves. Obstruction to the flow of 
 venous blood is usually of a purely mechanical origin, as in strangulated hernia, 
 or it may be the result of a venous thrombosis. Many causes act directly upon 
 the tissues of the part, such as pressure, mechanical or chemical injuries, inflam- 
 matory swelling, heat or cold, and bacterial infection. The state of the tissue, 
 due to an impaired nutrition of the body, is often favorable to the development 
 of wano-rene. This is observed during the progress of fevers or in individuals 
 suffering from grave constitutional conditions, such as diabetes, or in parts 
 deprived of their nerve-supply. , 
 
 Typical gangrene occurs chiefly in two forms, the moist and the dry, which 
 present striking contrasts to each other in their physical appearances. 
 
 Dry gangrene (Fig. 18), or mummification, is a condition produced by the 
 loss of water from the tissues. The skin becomes black and wrinkled, and is 
 often of a leather-like hardness. The amount of decomposition which occurs 
 in this form is very slight, and the dead part in typical cases causes but slight 
 disturbance to the adjacent living tissues. In this form of gangrene there is a 
 gradual diminution in the supply of arterial blood, while the outflow of venous 
 
 Fig. 18. 
 
 Dry Gangrene (original). 
 
 blood continues unobstructed. In this way, aided by evaporation, water is 
 gradually removed from the part. 
 
GANGRENE. 53 
 
 The most typical form of this variety is known as senile gangrene, due 
 to arterial sclerosis, the result of an obliterating endarteritis or of atheromatous 
 changes in the walls of the vessels, combined with feeble heart-action. The 
 calcareous condition of the arteries can often be easily detected at the wrist. 
 The circulation in the capillaries becomes very feeble, and a slight bruise suf- 
 fices to produce permanent stasis. Senile gangrene usually occurs in the lower 
 extremities, involving the toes, where the circulation is least vigorous. The 
 tibial arferies are frequently the seat of an endarteritis which materially dimin- 
 ishes their lumen, and a serious lessening of the blood-supply may exist in 
 all the regions supplied by these vessels. The arterial blood may also be cut 
 oft' by the presence of an embolus derived from valvular growths incidental to 
 cardiac disease. In this case the disturbance in the circulation may occur so 
 rapidly that mummification may not take place and moist gangrene will result. 
 Dry gangrene may, however, be produced by embolism, and a large portion of 
 an upper or lower extremity may occasionally be involved. 
 
 Symptoms. — The disease usually originates in some slight injury, as the 
 bruising of a toe or the tearing of a portion of the nail, and is recognized by 
 the change of color in the part, the dark -red congestion which at first appears 
 gradually assuming a purple hue. The surrounding tissues are deeply con- 
 gested, and the boundary-line between them and the dead tissue is at first 
 imperfectly marked. The gangrene slowly advances beyond the limits of the toe 
 in which it originated, and the adjacent toes may also become involved. When 
 the progress of the disease is arrested, the inflamed parts set up a barrier of 
 granulation-tissue and the line of demarcation is formed. The suppura- 
 tion which follows separates the dead tissue from the living, and a spontaneous 
 cure may be eff"ected in this way. As the line of demarcation forms, the colors 
 of the respective parts stand out in strong contrast. The inflamed tissues 
 assume a brighter tint, while the purple hue of the dead part changes to black. 
 An attempt on the part of the adjacent tissue to form a barrier to the advance 
 of the disease often fails, and the gangrene spreads and may involve the whole 
 foot, and even all the parts supplied by the tibial arteries. In the milder forms 
 of the disease the amount of constitutional disturbance is slight, but when a 
 large portion of a foot or leg is involved there is more or less septic infection, 
 and a rise of temperature will indicate the presence of fever. This type is 
 sometimes called uliopathie gangrene. The amount of pain is not great in this 
 variety : during the early stages there may be a stinging or smarting pain, but 
 after the formation of a line of demarcation this disappears. The pain in dry 
 gangrene due to embolism is, however, much more severe, and generally is the 
 cause of much intense sufiering. 
 
 Occasionally obliteration of the arteries of internal organs may take place 
 also, and infarctions Avith necrosis may be associated Avith senile gangrene. 
 
 Moist gangrene (PI. VI) is caused by a sudden arrest of the arterial blood- 
 supply or a similar obstruction to the return of the blood through the veins. 
 It is likely to occur in deeply-seated tissues where evaporation cannot easily 
 take place, as in strangulated hernia. Idiopathic gangrene may be of the 
 moist type when the obstruction of the circulation is rapidly brought about and 
 involves a large portion of a limb. 
 
 Severely contused or lacerated wounds of the soft parts, or fractures com- 
 plicated with laceration of the large vessels, are a frequent cause of moist gan- 
 grene, known in this case as traumatic gangrene. Acute inflammations 
 may be attended with such intense congestion and swelling that the circulation 
 may be arrested over a considerable area, and death of the part will then occur. 
 The same result will ensue from burns and frost-bites. In this form of fran- 
 
54 ^.V AMERIVAX TEXT-BOOK OF SURGERY. 
 
 grene — localized traumatic gangrene — tlie tissues become soft iuid jmlpy, 
 the skin is discolored and clianges to a deep purple or black or is covered Avith 
 green and black spots. A thin brownish fluid filters through the skin, and 
 raises the epidermis in the form of blisters or exudes from the open surface of 
 wounds. Decomposition takes place tlirough the agency of the saprogenic 
 bacteria. In most cases a line of demarcation forms around the area affected 
 by the destructive agency. 
 
 There is. however, another form of traumatic gangrene — spreading 
 traumatic gangrene — in which the disease extends with frightful raj)idity, 
 due to an acute infectious process. These are cases in which the main artery 
 or vein has been ruptured and the blood-supply of a portion of an extrem- 
 ity is suddenl}' cut off, followed by infection. In other cases acute inflammation 
 of severe type, together with the intense septic infection, produces the death 
 of the part. The gangrene spreads rapidly, even hour by hour, up the limb. 
 Acute putrefaction sets in and spreads through the agency of micrococci or 
 bacilli. The changes in color are rapid and striking : a deep bronze hue, like 
 rind of bacon, spreads rapidly along the line of extension of the disease, and 
 is accompanied by streaks of green and black. The part feels dense and 
 brawmy. The evolution of gas produced by the changes brought about by the 
 putrefactive bacteria sometimes gives an emphysematous crackling to the sub- 
 cutaneous tissue — a condition which is often observed somewhat in advance of 
 the gangrenous changes. Constitutional disturbance is by this time very 
 marked, and is due to the absorption of ptomaines, which the process of decom- 
 position forces into the lymphatic channels and connective-tissue spaces or 
 beneath fasciae or along the course of tendon sheaths. As the parts through 
 which the gangrene spreads are beyond the point of injury, no opportunity 
 offers itself for the escape of these chemical poisons, and they spread upward 
 through the circulation. The result is septicemia of a grave type, from 
 which the patient succumbs unless the progress of the gangrene has been 
 arrested by amputation. This type of gangrene is sometimes known as ful- 
 minating gangrene or gangrenous emphysema. 
 
 Fortunately, such grave results do not always follow death of a part from 
 trauma. The gangrene may be limited to the part the circulation in Avhich has 
 been arrested, and a line of demarcation will soon separate it from the adjacent 
 healthy parts. This form occurs frequently in a stump after amputation for 
 railroad injury when the limb has not been removed at a point sufficiently 
 remote from the seat of injury. A considerable portion of a limb may be 
 destroyed by injury without a tendency of the gangrene to spread. In. this 
 case the numerous lacerations permit an escape of blood and serum, and the 
 conditions for the development and spreading of the intense forms of decom- 
 position are less favorable. 
 
 Smaller portions of dead tissue, such as the flap of an amputation-stump or 
 masses of connective tissue or skin, are usually called sloughs. These are 
 separated from the living parts by the septic inflammation which ensues and 
 which results in suppuration ; and, as the wound cleanses itself and the sloughs 
 are thrown off, healthy granulations are found covering its surface. 
 
 Gangrene may residt occasionally from pressure, but unless the latter is 
 excessive this occurs only in parts where the circidation is already feel)le and the 
 conditions are favorable for complete stasis. Decubitus, or bed-sore, is pro- 
 duced in this way from long rest in the recumbent posture in individuals debili- 
 tated by fevers or long-standing chronic disease. When the slough has separated 
 the ulcer thus formed may enlarge, and sometimes becomes quite formidable in 
 size, and may be a complication more serious than the original disease. The 
 
H.-VI 
 
 il' 
 
 > 
 
 ■"^^^ 
 
 AMtmcftN (.rTHOoR«pmc«o 
 
 Schullzc. pin •, 
 
 GANGRENE FOLLOWING A SHOT LACERATION OF THE FEMORAL ARTERY. 
 
GANGRENE. 55 
 
 parts most frequently attacked are the integuments lying over the sacrum and 
 coccyx, or, more rarely, the shoulder-blades and great trochanters. Sloughs 
 may also be produced by bandages and splints wlien applied to a iVactured limb. 
 A tVe(iuent seat of such a "splint-sore" is the posterior aspect of the heel or 
 the skin covering the tendo A chillis. 
 
 This form of local gangrene is much more likely to occur if the parts sub- 
 jected to pressure have been deprived of their accustomed nerve-supply. Neuro- 
 pathic gangrene, as it is sometimes called, is frequently observed after fractures 
 of the spine. Sloughs Avill form "with great rapidity under the heels and sacrum. 
 This predisposition to death of the part has been ascribed to a functional dis- 
 turbance of the vaso-motor nerves or to an abnormal action of the so-called 
 ''trophic nerves" which are supposed to preside over the nutrition of a part. 
 
 A type of gangrene more clearly due to abnormal vaso-motor action is the 
 symmetrical gangrene, or Raynaud's disease. This appears most fre- 
 quently upon the tips of the fingers or the toes. It may also be found in various 
 other parts of the body, as the tip of the nose, the cheeks, the knee, and other 
 salient points where the heat of the body is less than in deeper parts. It is 
 due to a spasm of the vaso-constrictors brought about by reflex action. It 
 is extremely rare in America. The "cold finger" often observed in bathers 
 is ascribed to a similar cause. In symmetrical gangrene the parts affected are 
 at first the seat of abnormal pallor and numbness, then of a purplish dis- 
 coloration, and a small slough finally forms which is thrown off and is followed 
 by healing of the sore thus produced. Several fingers are simultaneously 
 affected on both hands. 
 
 A similar spasm of the vaso-motor nerves is produced by the prolonged 
 use of ergot, and epidemics of gangrene have been observed in France and else- 
 where which were due to the presence of ergot of rye (tSecale cornutum) in the 
 grain employed as food. 
 
 Individuals affected with diabetes are frequently attacked with diabetic 
 gangrene. This is often seen in elderly people subjects of the disease, and may 
 be mistaken for senile gangrene. The presence of sugar in the urine should 
 therefore be carefully sought for. Operations upon such persons are supposed to 
 be followed by gangrene or sloughing of the lips of the wound, and it is advised 
 by some authorities to abstain from surgical operations if they can be avoided. 
 A more extended experience with aseptic surgery, however, will probably not 
 bear out this view. In one case known to the writer both legs were success- 
 fully amputated for diabetic gangrene. There was an interval of one or two 
 years between the two operations. 
 
 Noma, or cancrum oris, is a gangrene of the cheek usually occurring 
 in children as a complication of the eruptive fevers — e. g. scarlatina. It is the 
 result of a gangrenous stomatitis, and is of bacterial origin, producing capillary 
 thrombosis. The disease may even attack the bone, and in the majority of 
 cases is fatal. If recovery takes place a large defect usually results which 
 must be restored by a plastic operation. 
 
 Gangrene from frost-bite may result partly from the intensity of the cold 
 and partly from the enfeebled condition of the individual. The part at first is 
 blanched, but subsequently turns black. It may assume the dry or the moist 
 condition. It may be limited to the toes, which are the most frequent seat of 
 this form of gangrene, or the whole foot may be involved. It is frequently 
 quite superficial, and no attempt at surgical interference should be made until 
 the line of demarcation is clearly established. 
 
 Treatment. — The prophylactic treatment of gangrene consists in the 
 removal, as far as possible, of the causes Avhich may favor the development of 
 
56 AN AMERICAN TEXl-BOOK OF SURGERY. 
 
 gangrene, and in the adoption of" such measures as uill promote the circula- 
 tion of blood in the part. 
 
 If inflammation threatens to terminate in gangrene, free incisions may 
 relieve the tension sufficiently to avert the impending danger. Division of the 
 constricting ring of a strangulated hernia Avill remove the obstruction to the 
 circulation in the bowel. 
 
 If, however, the obstruction cannot be removed, as in embolism or throm- 
 bosis, attention must be given to the establishment of the collateral circulation 
 in the limb by favoring as much as possible the flow of venous blood and 
 preserving thewarmth of the part. Moderate elevation of the limb and gentle 
 massage may favor the return of Itlood through the superficial veins. Slightly 
 flexing the joints will favor the flow of blood through the larger vessels. An 
 equable temperature of the desired degree may be maintained by enveloping 
 the limb in dry cotton-wool, which should be loosely applied. 
 
 Minute abrasions or sores about the nails in feeble individuals should 
 receive careful attention, but meddlesome interference should be avoided, as 
 these are frequently the starting-points of senile gangrene. If death of the 
 part is unavoidable, great care should be taken to prevent infection and 
 decomposition. The gangrenous part must be disinfected witli the same care 
 as for an operation, and then be kept dry and odorless. Antiseptic dressings 
 containing powders, as iodoform, boric acid, or aristol, should be applied. If 
 the fluid products of decomposition are retained beneath the surface, they 
 should be released by incisions into the gangrenous tissues, or if pus is bur- 
 rowing, openings should be made into the living tissues to evacuate it. 
 
 It was at one time the almost universal custom to wait for the line of 
 demarcation to form in senile gangrene before making any attempt to remove 
 the dead mass, and as a rule it is better to adopt this plan. If the gangrene 
 shows a disposition to localize itself, it would be bad practice to interfere in 
 any way Avith the processes that are going on in the enfeebled living tissues, as 
 any disturbance of them might cause the gangrene to spread still farther. As 
 soon as the gangrene involves the sole or the dorsum of the foot, the question 
 of amputation will become one of vital importance. In determining the point 
 at which to amputate the pathology of the disease should be kept in mind. 
 If we have to deal with a disease of the tibial arteries, it will be necessary 
 to decide at what point in their course the circulation is of sufficient volume 
 to maintain the life of the stump. Never amputate low down. Heidenhain 
 recommends amputation of the thigh as close above the condyles as possible. 
 An amputation of the leg below the tubercle of the tibia in some cases may 
 be sufficiently high, but generally it is necessary to remove the leg at or 
 above the knee. The latter point is often to be preferred, since the flaps will 
 then be largely nourished by branches of the profunda femoris, which is 
 rarely thrombosed. A considerable number of cases which in former times 
 were allowed to die without surgical interference are now undoubtedly saved 
 by amputation. 
 
 In gangrene from embolism amputation should be performed well above the 
 gangrenous area as soon as the extent of the gangrene has been determined by 
 the establishment of a line of demarcation. 
 
 In traumatic gangrene involving portions of the integuments it is not 
 necessary to attempt removal of the sloughs until the line of demarcation 
 indicates clearly the extent of the injury. A partial removal of the dead skin 
 may, however, favor drainage of the parts below. 
 
 When a portion of a limb is destroyed by injury, the question of an imme- 
 diate amputation should first be carefully considered. If this is not done and 
 
GANGRENE. 57 
 
 gangrene sets in, and there are any signs of its spreading, this should prompt 
 the surgeon to urge the necessity ofainputiition. 
 
 If the gangrene is localized, the general condition of the patient "will enable 
 one to decide whether it is best to remove the dead portion of a limb immedi- 
 ately or not. The effect of the presence of such a putrescible mass must be 
 weighed against the danger of an operation in a patient suffering from shock 
 and possibly other severe injuries. The conditions of each case will enable 
 one to decide whether it is better to remove the limb at the line of demarcation 
 or to amputate through sound tissue. 
 
 In spreading traumatic gangrene it will of course be necessary to amputate 
 instantly and tar away ; that is, sufficiently high to remove all tissues involved 
 in the septic process. There is perhaps no atlection in the whole domain of 
 surgery which demands such prompt interference in order to avert impending 
 death. 
 
 The constitutional treatment consists in attention to the condition of shock 
 and in supporting the strength of the patient. Absolute rest, careful nursing, 
 and a diet that will be nutritious without interfering with the digestive func- 
 tions will best meet these indications. Alcoholic stimulants are also of great 
 value and should be used freely, but with due regard to the patient's powers 
 of assimilation. 
 
 The treatment of bed-sores is largely prophylactic by frequent change of 
 posture, and — thanks to the present system of nursing — the attention of the 
 physician or surgeon is now rarely called to this affection. Dry dressings are 
 to be preferred, as moisture favors the enlargement of ulcers produced in this 
 way. Mechanical support to relieve pressure and strict attention to antisepsis 
 will usually arrest the progress of the disease. 
 
 The rules for the treatment of diabetic gangrene vary but slightly from 
 those laid down for senile gangrene. The disease is not necessarily a contra- 
 indication to amputation. In any event a most careful attention to the diet 
 will form an important factor in the prognosis of the case. 
 
 Little operative interference is necessary in symmetrical gangrene: the 
 main points in the treatment of such cases are attention to the diet and 
 hygienic surroundings and the administration of tonics. 
 
 Hospital gangrene is one of the traumatic infective diseases, and is 
 characterized by a septic inflammation of the surface of a wound, causing 
 ulceration and the formation of sloughs, and is accompanied by more or less 
 constitutional disturbance. The disease at the present time has almost com- 
 pletely disappeared, oAving to the general employment of aseptic and antiseptic 
 treatment. It formerly occurred when patients were crowded together in small 
 quarters with insufficient attendance and food and under poor hygienic condi- 
 tions. The principal varieties usually described are the diphtheritic, the ulcer- 
 ating, and the pulpy forms. The disease has been regarded by some as iden- 
 tical Avith diphtheria, but, as the latter disease has continued its activity for 
 twenty years after gangrene has disappeared, this assumption does not appear 
 probable. No bacteriological studies of value have been made, but some 
 writers report large numbers of streptococci, and Koch produced in mice a 
 disease resembling hospital gangrene in which the streptococcus was found. 
 
 The diphtheritic form is characterized by the occurrence of coagulation- 
 necrosis in the granulations. There is, moreover, less inflammation in the mar- 
 gin of the wound in proportion to the depth to which the tissues are involved. 
 The discharge is at first diminished, but later becomes more watery in char- 
 acter, the sloughs separate, the wound has a crater shape, and its edges are 
 eroded. In the ulcerating form there is a progressive enlargement of the 
 
58 AN AMERICAN TEXT-BOOK OF SUROERY. 
 
 wound, cliielly on tlic .surface, accompanied by an unhealthy or grayish dis- 
 coloration of the granulations. The edges break down, recede daily, and 
 have a gnawed look, and the wound may finally become very large. This 
 type is sometimes called pliagedcna. 'Die j)ul|)y form is more common in 
 epidemics. The granulations swell, become oedeiuatous and necrotic, the 
 surface of the wound is soon enormously swollen, and a fetid discharge wells 
 up in large (}uantities from its depths. Its margins become swollen, everted, 
 and are ex(iuisitely sensitive. There are great discoloration and swelling of 
 the surrounding parts, with profound constitutional disturbance. The wound 
 increases in size with great rapidity, and secondary hemorrhage often occurs. 
 Joints are laid open and muscles dissected out as the disease spreads, and if the 
 disease is not arrested, the ])aticiit finally succumbs to se[)ticemia. 
 
 The prophylactic treatment consists in the application of the rules of 
 aseptic surgery, and when, as in time of war, these cannot be observed with 
 sufficient care, in avoiding the accumulation of great numbers of patients in 
 confined ((uarters and their prompt isolation if the disease appears. 
 
 Tiie local treatment consists in a thorough disinfection of the surface of the 
 wound and the surrounding infected tissues. This may be accomplished by 
 removing the diseased tissue with the curette or scissors, and by the sub- 
 sequent application of the cautery, bromine, fuming nitric acid, or acid 
 nitrate of mercury. The operation will require anesthesia, as even the ordi- 
 nary dressing of such a wound is exceedingly painful. For milder cases a weak 
 solution of nitric acid may }je used with advantage, or the wound may be freely 
 dusted with iodoform. Perchloride of iron was used with success by the 
 French in their last war. Whatever the agent employed, it must be applied as 
 directly as possible to the living tissues. The constitutional treatment consists 
 in the free use of stimulants and supporting diet. An entire change of the 
 patient's surroundings may bring about a prompt improvement. Epidemics 
 have been broken up by moving the patients from the wards of a hospital into 
 tents. All clothing and bedding and dressings should be changed at the same 
 time. Amputation may be sometimes called for, and can be successfully done 
 under strict antiseptic precautions. The disease being distinctly contagious, 
 isolation and the non-use of sponges, towels, basins, etc., from patient to patient, 
 are evidently necessary. 
 
 CHAPTER VIII 
 THROMBOSIS AND EMBOLISM. 
 
 A THROMBUS is a clot of blood Avhich forms in the blood-vessels during 
 life. An embolus is a detached fragment of a thrombus, a fragment of a 
 vegetation on one of the valves of the heart, a globule of fat or of air, etc., 
 which has been transported to some other part of the arterial system and acts 
 as a plug. 
 
 Coagulation of l)lood may take place in one of two ways : "When blood is 
 allowed to remain stagnant in a fiask, the clot which forms is nearly as large 
 as the whole amount of blood, and is of a deep-red color, which still remains 
 after the serum has been pressed out. It contains chiefly red corpuscles held 
 together by fibrin. It is such a clot that is found in the red thrombus. 
 
 The clot from blood beaten with a stick loses its red color, and is of a yel- 
 
Tl[h'()}riiOSIS ANJ) KMliOIJSM. 
 
 59 
 
 Fk;. 19. 
 
 lowisli-wliite tiiifje, consisting of a tough mass of fibrin containing' but few 
 red corpuscles. As has been shoAvn else^vhere, this coaguluni contains chiefly 
 broken-(h)wn white corpuscles which have yielded up their fibrin-j)roducing 
 material. This is one way in which a w/iifc thnnnbuH is formed. 
 
 Coagulation appears to be due to slowing of the current and also to 
 roughness of the inner wall of the vessel, to injury to the wall of the vessel, 
 or to septic infection. 
 
 A thrombus usually forms in a vein, but it may also form in the distal 
 portions of the arterial system and in the heart. After a thrombus has 
 formed it may undergo several changes. It may become organized, young 
 tissue growing into it from the vessel-wall and forming cicatricial tissue. 
 As portions of the clot are disintegrated and absorbed spaces are h^ft, and the 
 thrombus is then said to be canalized. Blood flows through these channels, 
 and the circulation is in this Avay partly re-established. At other times 
 the fibrin and leucocytes break up and form a slimy fluid, which is swept 
 away and the thrombus disappears. When sep- 
 tic infection takes j)lacc the thrombus is said to 
 undergo a " puriform softening." A thrombus 
 thus disorganized may break into fragments, 
 which become detached and are swept into the 
 circulation as infective .emboli. Such thrombi 
 are often found in the cerebral venous sinuses or 
 in the large veins of the extremities in septic 
 inflammations. 
 
 A thrombus once formed may grow by addi- 
 tions of coagulated blood, and, when it has devel- 
 oped so as to project into a large vessel, a por- 
 tion of the protruding clot may become detached 
 and give rise to embolism. Pulmonary embo- 
 lism, a fatal complication, is produced in this 
 way, and may follow phlebitis or capital opera- 
 tions, such as hysterectomy. Very small emboli 
 may pass through the lungs and enter the arterial 
 system. 
 
 Emboli are found in the arteries and also 
 in the veins of the liver. When an embolus is 
 
 lodged 
 
 in a 
 
 terminal" artery^ the part sup- 
 
 A Thrombus in a Vessel. The de- 
 tached fragment about to be 
 carried away in the direction 
 of the blood-stream is an em- 
 bolus (Billroth). 
 
 plied by this vessel is deprived of its circulation 
 and becomes anemic, or occasionally a backward flow of blood takes place 
 from the veins into the emptied vessels and a congestion with extrava- 
 sation or a "hemorrhagic infarction" occurs. If the embolus is an 
 infected one, suppuration will take place and a metastatic abscess 
 forms. 
 
 Emltoli which are detached from the endocardium are lodged in the 
 peripheral portions of the arterial system. Those found in the brain are of 
 little practical interest, as they produce conditions not amenable to surgical 
 interference. Emboli are occasionally arrested in the arteries of the extrem- 
 ities, and produce that form of gangrene known as embolic gangrene. Such 
 emboli are found in the brachial arteries or one of the arteries of the fore- 
 arm ; but more often in one of the tibial arteries. When a large vessel is 
 thus plugged a thrombus begins to form upon the proximal side of the em- 
 
 ' Terminal arteries are arteries without anastomoses, and are found in the brain, lung, 
 spleen, and kidney. 
 
60 .l.V AMKRICAX TEXT-BOOK OF SURGERY. 
 
 bolus, and often extends a long distance toward the main trunk, tims increas- 
 ing the extent of the gangrenous area. 
 
 Thrombi are also occasionally found in the terminal portions of the 
 diseased arteries of aged or infirm individuals, and may give rise to 
 gangrene. 
 
 Embolism of a mesenteric artery may give rise to gangrene of the 
 intestine ; but if the embolus is small enough to find its way into one of 
 the intestinal branches, no serious results may be feared, as the anasto- 
 mosis is very free. Thrombosis of the mesenteric veins occurs as the 
 result of marasmus, cirrhosis of the liver, or thrombophlebitis. Elliot 
 successfully removed four feet of intestine which had become gangrenous 
 from this cause. 
 
 The treatment of thrombosis or embolism is mainly prophylactic. Care 
 should be taken that the thrombus does not give rise to emboli. The part 
 therefore should be kept at rest until organization or absorption of the thrombus 
 has taken place. 
 
 The danger of embolism from thrombosis usually ceases about three weeks 
 from the time of the development of the thrombus, as the clot by this time 
 has become firmly adherent to the vessel-wall. 
 
 When an artery of an extremity has been plugged the limb should be 
 kept warm : no constricting dressings should be applied, and every oppor- 
 tunity for the establishment of a collateral circulation should be given. 
 
 CHAPTER IX, 
 SEPTICEMIA. 
 
 Septicemia is a disease due to the absoi-ption of the products of putrefac- 
 tion into the system, or to the introduction into the blood and tissues of bacteria 
 which rapidly multiply there. It is characterized by grave constitutional 
 disturbance, with acute fever, disorders of the nervous system, inflammation 
 of certain viscera, and a local infection of the wound. The nature of the poison 
 which produces the disease is not yet fuUy understood. Experiments on 
 animals have .shown that there are two varieties of this form of blood-poisoning. 
 In certain cases .symptoms supervene immediately upon the inoculation, and the 
 animals die of a chemical poison, no bacteria being found in the blood or tis- 
 sues (sapremia, toxemia, or septic intoxication). In other cases the 
 symptoms come on le.-s rapidly. an<l <leaTli is caused Ijv the presence of bacilli 
 or micrococci in the blood (septic infection). Many observers have sought 
 for bacteria in the blood in the .septicemia of man, and micrococci have been 
 found occasionally, but not with sufficient regularity to identify them with the 
 disease. Since the existence of ptomaines as a product of decomposition has 
 been understood, it is generally recognized that the poisons elaborated by bac- 
 teria play a prominent part in the production of the disea.se. 
 
 Clinically, we find the same two types of the disease in man. One is due 
 clearly to the absorption of a chemical substance or ptomaine. The .'symptoms 
 of this variety cea.se as soon as further introduction of the chemical substance 
 is prevented by a cleansing of the wound. In the other variety there are 
 progressive changes coming on gradually, as in the bacterial type in animals, 
 
i^EPTICEMIA. 
 
 61 
 
 and continuing fre(|uently to a fatal termination in spite of efforts to check them 
 by treatment of the ■wound. This variety suggests the action of bacteria, and 
 these organisms are found in some cases, those most frequently observed being 
 the streptococci. 
 
 The method by which infection of the system takes place is through a wound 
 ■which is undergoing putrefactive changes owing to decomposition of the blood- 
 clot or wound-iiuids (sjiprouiia), or through the diffusion and multiplication 
 of the bacteria from an infected wound, even of a trivial character (septic 
 infection). Tiiis is most likely to occur before the wound has become covered 
 by healthy granulations. It may also take place through the intestinal 
 mucous membrane (sepsis intestinalis), as in cases of tyrotoxicon-poisoning, 
 and more rarely through the urogenital tract. 
 
 Sapremia. — The toxic form of septicemia is frequently seen in obstetrical 
 cases in which putrefaction of retained clots or placenta has taken place within 
 the uterus. The poison may be absorbed through the mucous membrane of 
 the vagina or uterus, or through open wounds in these regions or through the 
 uterine sinuses. The disease is ushered in with a sharp rise of temperature, 
 the chill usually being absent. The temperature continues high, and is accom- 
 panied later with delirium. The skin is cold and clammy, and there is more 
 or less tendency to diarrhea. A prompt removal of all decomposing substances 
 from the interior of the uterus will be followed in a few hours by a disappear- 
 ance of all alarming symptoms. Conditions favorable for such a type of 
 poisoning are rare in general surgery, although a large, ill-drained wound, or 
 decomposition occurring in the contents of a psoas or other abscess, is a not 
 uncommon cause : these conditions also may be found in abdominal Avounds 
 ■where extensive injury of the peritoneum has favored oozing and the accumu- 
 lation of blood-clot in the peritoneal cavity. 
 
 Fig. 20. 
 
 
 \ 
 
 2 
 
 3 
 
 A 
 
 5 
 
 6 
 
 7 
 
 8 
 
 9 
 
 10 
 
 II 
 
 12 
 
 13 
 
 107* 
 
 106' 
 
 105' 
 
 |0«' 
 
 103* 
 
 102* 
 
 101° 
 
 100° 
 
 99° 
 
 98° 
 
 97° 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 / 
 
 
 
 
 
 
 
 
 
 
 
 
 
 / 
 
 
 
 
 
 
 
 
 
 
 A 
 
 
 / 
 
 / 
 
 
 
 
 
 
 
 
 
 / 
 
 /' 
 
 H 
 
 ./ 
 
 
 
 
 
 
 
 
 
 
 / 
 
 
 
 V 
 
 
 
 
 
 
 
 
 
 
 / 
 
 
 
 
 
 
 
 
 
 
 
 
 r^^ 
 
 ^ 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 / 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Temperature Chart of a Case of Septicemia (original). 
 
 Symptoms of Septic Infection. — In true septicemia or septic infection 
 the development of the disease is more gradual. The fever curve is of the con- 
 tinuous type as in sapremia, and as the fatal end approaches the temperature 
 will range higher. In certain cases the temperature is, however, subnormal, 
 as is seen occasionally in strangulated hernia or in gunshot injuries of the abdo- 
 men. There is great prostration with headache and anorexia, and a typhoid 
 condition supervenes which renders the patient indifferent to surroundings. 
 
02 A\ AMKRKAy Tl.XT-llOi )K OF SVItdEllY. 
 
 Diarrhea frequently <levelops. and may at times be accompanied with vomiting, 
 but it is usually not severe. There is a tendency to the enlargement of the lym- 
 phatic glands throughout the body, and more particularly of the sjdecn. The 
 skin is j)ale and dusky, but an icteric tinge is not so common as in ])yemia. The 
 hue is due to the rapid deterioration of the blood caused by the presence of 
 the virus. A scarlet eruption may occur resembling closely that seen in scar- 
 let fever. The skin in the early stages is hot and dry, but later is bathed in 
 perspiration, and finally becomes cold and clammy. The sallow hue becomes 
 more marked. The senses are dulled and the countenance is listless. The 
 tongue is covered with a brownish fiir. The pulse is now weak and rapid ; 
 diarrhea increases, and the urine is concentrated and scanty. Delirium is 
 followed by coma, and the patient becomes moribund. 
 
 The pathological changes observed in the internal organs are slight. 
 The blood is thin, of a tarry color, shows no tendency to coagulation, and 
 contains numbers of micro-organisms. Cloudy swelling of the liver or 
 kidneys is usually found. In the alimentary canal there is evidence of a 
 gastro-intestinal catarrh. The mucous membrane is swollen and mottled, and 
 punctiform hemorrhages are found at certain points. Enlargement of the lym- 
 phatic glands is noticeable, particularly of the spleen. The wound occasionally 
 is in an extremely septic condition ; at other times there is little evidence of 
 anv pathological change. When septicemia follows the infliction of a disnect- 
 ing wound or other injury by Avhich material already loaded with the bacteria 
 of putrefaction is inoculated into the tissues, there is a diflFused septic inflam- 
 mation about the wound which develops rapidly and spreads along the line of 
 lymphatics leading from the part, as shown by red streaks running to the adja- 
 cent chain of lymphatic glands. In very malignant cases oedema of the adja- 
 cent tissues involving a considerable area will be observed. 
 
 The original focus from which septicemia is sometimes developed may be a 
 wound involved in gangrene or erysipelas, or some deep-seated infective inflam- 
 mation around the kidney or appendix or in the medulla of bone, or a tract 
 of connective tissue infiltrated with foul urine. 
 
 The principal diagnostic signs of septicemia are the continued fever, 
 the absence of chills, the peculiar condition of euphoria or apathy, the intesti- 
 nal catarrh, and the presence of an increased area of dulness about the region 
 of the spleen. The general appearance of the patient and the condition of 
 the pulse will prove valuable guides in enabling the surgeon to distinguish 
 between this type and the less malignant forms of surgical fever which occur 
 independently of suppuration. The condition of the wound and the presence or 
 absence of pronounced suppuration will also aid in the diagnosis, although it 
 should be remembered that septicemia may develop even during the suppura- 
 tive process, provided the conditions for putrefaction exist in the wound. 
 
 The prognosis of the disease is always grave, but its duration may vary 
 greatly according to the intensity of the virus. In sapremia of a pure type 
 the prognosis is much more favorable, as the fever will disappear as soon as the 
 local mass of putrefaction is removed ; but inasmuch as it is quite diflicult to 
 say in any given case whether there is not also a true septic infection in addi- 
 tion to the toxic poisoning, the opinion expressed by the .surgeon must be a 
 guarded one. The weakness and frequency of the pulse, the extremes of tem- 
 perature, and the mental condition are important .symptoms as guides in estimat- 
 ing the gravity of a given case. In the acute type we have to deal with one of 
 the most fatal of diseases. When the disea.se takes a more chronic course, as it 
 occasionally does, we may have rea.son to hope for a cure, although a very large 
 proportion of these cases also terminate fatally. 
 
PYEMIA. 63 
 
 Treatment. — The prophylactic treatment consists in the application of 
 the rules ot" aseptic and antiseptic surgery, which have greatly diminished the 
 number of cases of sejjticeniia at the present time. ^Vhen the disease makes 
 its appearance the attention of the surgeon should at once be directed to the 
 condition of the wound, and no time should be lost in carrying out a thorough 
 disinfection of its entire surface. Stitches should be removed and sinuses care- 
 fully exposed. All collections of blood-clot or decomposing fluids should be 
 washed out with corrosive sublimate, 1 : 1000, and subse(iuently the tissues 
 should be disinfected with strong solutions of carbolic acid (1 : 20, or pure 
 crystals) or chloride of zinc (1 : 10). The wound can then be packed with 
 gauze containing a large amount of iodoform powder, or antiseptic poultices 
 can be applied to favor a free discharge (carbolic acid 1 : 1000, or corrosive 
 sublimate 1 : 20,000). When the wound has deep recesses or pockets which 
 cannot easily be reached, irrigation with boiled water, boric acid (4 per 
 cent.), or a saturated solution of acetate of aluminum may be employed. In 
 septicemia following laparotomy the prognosis is so grave that little success 
 can be expected from local treatment. An attempt to save life, however, 
 should be made by reopening the wound and by a thorough hot-water 
 douching of the peritoneal cavity, followed by drainage. In sapremia douch- 
 ing of the wound is generally followed by an immediate, and frequently by a 
 permanent, improvement.. In puerperal fever from this cause the antiseptic 
 washing of the uterus is productive of most satisfiictory results. 
 
 The constitutional treatment consists principally in the fearless use of stim- 
 ulants. Very large quantities will be assimilated under these conditions without 
 producing alcoholism. The use of drugs taken internally for their antiseptic 
 action has not proved sufficiently successful to encourage a further trial at pres- 
 ent. The heart's action should not be hampered by any depressing agents. 
 On the other hand, a free use of digitalis and other heart tonics may prove a 
 valuable aid to stimulation. One of the best is strychnia administered sub- 
 cutaneously in doses of gr. ^^ ^^ every two to six hours. Nutritious diet 
 should be administered in such form as not to impede digestion and to favor 
 rapid assimilation. 
 
 CHAPTER X, 
 
 PYEMIA. 
 
 Pyemia is an infective disease developed during the process of suppuration, 
 and is due to the absorption of pyogenic organisms into the circulation. It is 
 characterized by the development of multiple or metastatic abscesses in differ- 
 ent portions of the body, frequent chills, and an intermittent type of fever. 
 The name given to it by Piorry is derived from tz'jov, pus, and aJfia, blood. 
 The old view that pus formed in the wound obtained an entrance into the cir- 
 culation has long since been abandoned, but we now know that certain elements 
 of pus may find their way into the circulation and produce metastatic abscesses. 
 
 Etiology. — Reliable investigations on the special forms of bacteria which 
 are found in cases of pyemia have been made only within the last decade. 
 Among the most important are those of Koch, who succeeded in producing the 
 disease in rabbits. He found in the vessels chain-like cocci which caused the 
 blood-corpuscles to adhere and form thrombi. Ogston showed that the pyogenic 
 
(U 
 
 AiV AMERICAN TEXT-BOOK OF SURdERY. 
 
 cocci were jmrtly anaerobic, and grew more readily iu deep sinuses and pockets, 
 and tlnis readily obtained an entrance into the circulation. The examination 
 of the blood of individuals ill with pyemia has shown that both the staphylo- 
 coccus and the streptococcus may be the active agents in the formation of 
 metastatic abscesses. When the conditions become favoralile for an unusual 
 development of these bacteria, the barrier of granulation-tissue does not prevent 
 their growth into the surrounding tissues. From these they obtain an entrance into 
 the system through the blood-vessels more often than through the lymphatics. 
 Coming in contact with the wall of a vein, an infective inflammation is started 
 which terminates in a thrombo-phlebitis. Rough places are formed on the 
 intima which lead to the formation of parietal thrombi and the subseijuent 
 development of an extensive thrombus, which undergoes a puriform softening ; 
 or a zobglea mass of micrococci may accumulate on the inner surface of the 
 wall of the vein and may be swept oflF into the circulation as an embolus. 
 Minute emboli may pass the pulmonary ca])illaries, and, entering the arterial 
 system, become lodged in the glomeruli of the kidney or other capillary dis- 
 tricts, or even in the valves of the heart. . 
 
 Larger emboli detached from the softened thrombus may be lodged in the 
 capillaries of the lung. At all these points infective inflammation and sup- 
 puration may occur, and metastatic abscesses are thus developed. As a 
 rare occurrence pus from an abscess may fin<l its way directly into the circula- 
 tion by the breaking of the abscess into a vein. The bacterial infection may 
 also occasionally take place through the lymphatic system. The so-called spon- 
 taneous pyemias occur by a process of intravascular infection. In individuals 
 in feeble health micrococci are sometimes found circulating in the blood tem- 
 porarily. If under such conditions a slight internal bruise or wound is received 
 — as, for instance, in the medulla of bone from a fall — the micro-organisms 
 gain an entrance from the blood-vessels into the injured part, and an acute 
 osteomyelitis is developed which may become the starting-point of a pyemia. 
 
 Fic;. 21. 
 
 Temperature Chart of a Case of Pyemia (original). 
 
 Symptoms. — The first symptoms of the disease are noticed usually in the 
 second week of the healing process at a period when suppuration has been 
 fully established. These are ushered in with a chill which may be of a widely 
 varying degree of intensity. The occurrence of such a symptom should always 
 put the surgeon upon his guard, and the wound should be carefully inspected. 
 
PYEMIA. 65 
 
 An increase in the local inflaniniation may or may not be discovered. A sec- 
 ond chill will probably occur on the following day, and frequent repetition of 
 the chill is a characteristic feature of the disease. The fever is of an irregular 
 intermittent tyjie, and varies not only according to the frecjuency of the chill, 
 but has an almost hourly variation of its own. The undulating character of 
 the daily fever curve is quite characteristic of pyemia, and a fall to the normal 
 point in acute cases is rarely observed (Fig. 21). 
 
 The development of metastatic abscess is indicated by a febrile exacerbation 
 and by the symptoms of local inflammation. A sharp pain in the side, with 
 respiratory disturbance and fever, accompanies the formation of an abscess in 
 the lung or a septic eff'usion into the pleura. The joints are also a frequent 
 seat of inflammation, and this is accompanied- wMth considerable swx'lling of the 
 adjacent soft parts. The next point attacked may be the parotid gland. The 
 skin is always markedly discolored, and frequently assumes a deep yellow hue. 
 With the development of the icterus there is already marked emaciation, which, 
 in chronic cases, is extreme. Erythematous rashes, which subsequently become 
 pustular, are occasionally noticed. The tongue is furred and coated, but may 
 vary greatly in appearance. The pulse is rapid, and as the disease progresses 
 becomes weaker. 
 
 The mental condition of the patient is usually not affected. There is, 
 however, in the later stages great hyperesthesia, and such patients are con- 
 stantly complaining of pain in various parts of the body, due not only to 
 metastatic inflammations, but to the sensitiveness of the nerves. An examina- 
 tion of the heart-sounds may reveal the presence of an infective endocarditis. 
 Brain symptoms are rarely present, although metastatic inflammations may 
 occur in the brain, and hemiplegia may result from emboli due to the endo- 
 carditis. The mind usually remains clear until the development of delirium 
 and coma in the latest stages of the disease. 
 
 The duration of the disease will vary according totheacutenessof the attack. 
 Chronic pyemia may be prolonged for Aveeks or even months. Usually in acute 
 cases a fotal termination will be reached in the course of a week or ten days. 
 
 Pathological Anatomy. — The wound is of a gangrenous color or odor, 
 or the granulations are still present and have a glazed and indolent appearance. 
 Extensive thrombi are found in the adjacent veins. In amputation-stumps 
 of the loAver extremitv the femoral vein mav be filled as high as Poupart's 
 ligament with a puriform mass. In the lungs metastatic abscesses are found 
 chiefly in the lower lobes and near the pleural surface. Infarctions are also 
 not infrequent. The pleural cavity may be the seat of a serous effusion. The 
 liver is in a state of cloudy swelling, and, less frequently than in the lung, meta- 
 static abscesses are found. Miliary abscesses may be found in the kidney, in 
 the valves of the heart, in the intestinal mucous membrane, and, in fact, in 
 almost any organ of the body. Metastatic inflammations are also seen in the 
 connective tissue and in the joints. The synovial membrane is at first con- 
 gested, and later suppuration may occur. The knee and shoulder are the joints 
 most frequently affected. The bones may also be the seat of metastatic foci. 
 Icterus is caused by the breaking down of the red blood-corpuscles, and is said 
 therefore to be hematogenous {i. e. of blood origin). 
 
 Diagnosis. — In the early stages of traumatic inflammation a chill may be 
 due to the development of some other form of infective disease, as erysipelas, 
 but repeated chills are characteristic only of pyemia. The clearness of the 
 mind, the hyperesthesia, the emaciation and great prostration, are all well marked 
 and significant in this disease. The presence of metastatic abscess and joint 
 inflammations when they finally occur leave no doubt as to the diagnosis. 
 
66 .l.V AMERICAN TEXT- BO OK OF SURGERY. 
 
 The prognosis is exceedingly grave. It lias been maintained that no 
 case of pyemia ever gets well, but many cases of undoubted recovery hav^e 
 been rep<>rtt'(l. particularly in the chronic forms of the disease. 
 
 Treatment. — The prophylactic treatment consists in the prevention of 
 suppuration. The antiseptic treatment of wounds has almost abolished the 
 disease in hospitals, where it was formerly of frecjuent occurrence. When 
 the first septic disturbances have developed in the wound and adjacent veins 
 an attempt should l)e made to arrest the further progress of the disease by a 
 thorough disinfection, not only of the wound, but of the interior of the vein. 
 Such attempts liave been successfully carried out in thrombosis of the lateral 
 sinuses and jugular veins following suppuration in the mastoid cells. If the 
 interior of the vein cannot be th(ti'oughly disinfected, a ligature may be placed 
 upon it at a point between the puriform thrombus and the heart. When the 
 infected area is seated in an extremity amputation may be performed, provided 
 the surgeon can be reasonably certain that the thrombus does not extend above 
 the point selected for the operation. When it is possible all metastatic ab- 
 scesses or suppurating joints should be laid open and thoroughly disinfected. 
 
 Drugs are of little use in the internal treatment of the disease. Anti- 
 streptococcic serum has been advocated and tried, but its usefulness is still 
 in doubt. Antipyretics depress the hearts action. Carbonate of ammonium 
 and digitalis are more likely to be of service during the stage of prostration. 
 Alcohol should be given freely, and in as large quantities as the patient will 
 bear. Easily-digested food should also be administered unsparingly. If the 
 patient is in a hospital, he should be immediately isolated from all other 
 patients, and as strict a quarantine as possible of those in attendance should 
 be preserved. Ventilation should be free, and the patient may be placed in 
 a tent, or even for a portion of the time in the open air, in certain cases. 
 
 CHAPTER XI, 
 ERYSIPELAS. 
 
 Erysipelas is an acute infective inflammation spreading along the upper 
 layers of the integuments of the body and mucous membranes tlirough the 
 lymphatic system. It is accompanied by a remittent type of fever and shows 
 a tendency to recur. The name is probably derived from ioo&oo^, red, and 
 TrikXa, skin. Erysipelas was known to the ancients, but authentic accounts 
 are of comparatively recent date. Severe epidemics of erysipelas raged in 
 France in 1750. in Great Britain in 1800, and in 1842-43 both Europe and 
 America were visited by an epidemic of a most virulent type. Since then 
 there are no records of epidemics of similar severitv. Although much less 
 frequently met with since the introduction of the antiseptic treatment, it is the 
 most common of the traumatic infective diseases seen at the present time. 
 
 Etiology. — The organism Avhich is the cause of the disease is the strepto- 
 coccus erysipelath. This has been abundantly proved by experiments in ani- 
 mals and man. Opinions vary as to the identity of the streptococcus pyogenes 
 with the streptococcus of erysipelas. The cocci grow in serpentine chains ; 
 each measures from 0.3 to 0.4 micro-millimeters in diameter. These cocci 
 are said to be somewhat larger than the streptococcus pyogenes, but smaller 
 than the staphylococcus. They are found in the capillary lymphatics of the 
 
ERYSIPELAS. 67 
 
 skin cliielly, but tliov may also be seen occasionally in the capillary blood- 
 vessels, 'riiey are most active near the mar<fin of the erysipelatous blush, and 
 the lymphatics are cnjwded with them at this point. They are not found in 
 any numbers in the circulation, but it is probable that the constitutional 
 disturbance is due to their presence or to the })resence of ptomaines in the blood. 
 The organism usually obtains an entrance through a wound. In idiopathic 
 erysipelas, Avhen no wound is seen, it is probable that small a})rasions of the 
 skin are the route through which the virus enters the body. Probably also 
 cases of internal infection occur, the organisms having been previously absorbed 
 through the respiratory or digestive tract. 
 
 The contagiousncHS of erysipelas had been abundantly proved clinically 
 before the nature of the poison was understood. The disease has been conveyed 
 to a large number of children through the medium of vaccine virus taken from 
 a child affected with erysipelas. Instances of er^^sipelas carried from a distance 
 to certain localities where no such disease had existed previously, and produ- 
 cing there an epidemic, abound in literature. The close relationship between 
 erysipelas and puerperal fever has long been recognized, and examples of the 
 transmission of the virus of erysipelas to puerperal women by the medical 
 attendant, and the consequent production of puerperal fever, are far too 
 numerous. Both diseases are produced by the streptococcus, and experiment 
 has shown that this organism can be cultivated from a puerperal case and can 
 then be injected into rabbits, producing erysipelas. It seems probable that 
 the disease is more prevalent at certain seasons of the year, particularly in the 
 early spring months. 
 
 Symptoms. — This disease is usually ushered in with a chill which is 
 accompanied with vomiting or more or less gastric disturbance. In chil- 
 dren a convulsion not uncommonly takes the place of the chill. An 
 examination of the wound at the time shows no perceptible change, although 
 the nearest lymphatics are apt to be enlarged, and it is not until the 
 end of twenty-four hours or longer that a blush is seen in the skin at this 
 point. There is an increased tension in the part, accompanied by an itching 
 or burning sensation. When the local inflammation has developed the color 
 of the skin is a yellowish red, and there is considerable infiltration of the 
 inflamed part, which has a doughy feel. The area invaded is well defined and 
 its margins are quite irregular, presenting a zigzag outline. During the height 
 of the inflammation vesicles form on the surface and sometimes become quite 
 large. When resolution takes place there is considerable desquamation. The 
 inflammation does not remain long in one spot. It spreads widely, and may 
 involve large areas or even the whole surface of the body. In the mean time, 
 at the end of three or four days the part first attacked begins to improve. 
 During the heicrht of the inflammation the constitutional disturbance is well 
 marked. The temperature ranges from 102° to 104° F. The pulse is rapid 
 and shows a tendency to become Aveak. The tongue is heavily coated and the 
 urine is charged with urates. With each fresh outbreak of the cutaneous 
 inflammation there is an increased pyrexia and the fever curve presents a most 
 irregular outline. There are marked remissions, but usually no return to 
 normal until the dermatitis has subsided. The duration of the disease is quite 
 uncertain. In favorable cases it Avill last no longer than a week or ten days, 
 but frequently the attack may last a month. Toward the close of the disease 
 when the case is terminating favorably there is usually a tendency to subnormal 
 temperature, show^ing the great prostration Avhich the disease has produced. 
 This depression of the vital powers is a feature of the affection which it is 
 always important to bear in mind. 
 
G8 AN AMERICAN TKXT-JiOOK OF SURGERY. 
 
 Varieties. — When the virus does not confine itself to the superficial capil- 
 hiry lymphatics, l)ut spreads to the subcutaneous connective tissue, we have the 
 varietv known as philegmonous crvsipelas. Under these circumstances sup- 
 puration, -which is extremely rare in ordinary erysipelas, is likely to occur. 
 The foul, acrid, and thin pus infiltrates large areas, and there are sloughs 
 of the connective tissue which are discharged in masses. In some of the 
 severe epidemics of this type the muscles were attacked and the periosteum 
 was destroyed, giving rise to necrosis. Gangrene of the skin may also 
 occasionally occur from deprivation of blood due to death of the underlying 
 connective tissue. The presence of a jjhlegmonous inflammation is indicated 
 by the increased amount of local swelling and constitutional disturbance. 
 Fluctuation or bogginess is soon felt, and if the pus is not liberated by 
 incision it burrows freely in all directions. 
 
 Pinlegmonous cellulitis, or inilammation of the subcutaneous cellular 
 tissue, is regarded as identical with phlegmonous erysipelas by many writers. 
 It is probable that the streptococcus rather than the staphylococcus is most 
 frequently found in this form of inflammation, but the question must remain 
 open until the identity or non-identity of the streptococcus pyogenes and the 
 streptococcus erysipelatis is settled. Clinically, the two types are readily dis- 
 tinguished by the absence of cutaneous erysipelas in phlegmonous cellulitis. 
 
 There are other forms of rapidly-spreading inflammations of the skin and 
 cellular tissue, particularly those Avhich follow infected wounds of the fingers or 
 hand, Avhich are regarded by some authors as akin to erysipelas. These at 
 times take the form of lymphangitis ; at other times they occur as acute swell- 
 ings of the integuments and connective tissue, extending with great rapidity, 
 showing but slight tendency to suppuration, and frequently terminating fotally 
 with symptoms of acute septicemia. They are probably due occasionally to 
 infection Avith streptococci or Avith saprogenic bacilli. 
 
 Facial erysipelas, which at one time was regarded as idiopathic ery- 
 sipelas, is now supposed to be due to infection through some slight wound or 
 abrasion on the face. It usually begins with a blush near the root of 
 the nose or the lachrymal duct and spreads laterally toward the ears. The 
 color is a scarlet red, and the amount of swelling is usually great and is accom- 
 panied with oedema about the eyelids, obliterating all facial expression and 
 causing entire closure of the lids. Vesicles and bullne also form on the cheeks. 
 The inflammation may extend to the scalp or the neck, but the chin is rarely 
 involved. The glands at the back of the neck are enlarged. In some forms 
 the fever runs high, and there is usually considerable delirium. This may be 
 due to reflex irritation of nerves or rarely to a suppurative meningitis, the 
 result of a direct extension of suppuration in the orbit or to the meninges. 
 Ordinarily, the delirium disappears when the fever subsides. There is 
 more or less conjunctivitis, and some oedema in the orbital tissues. If sup- 
 puration should occur, blindness may result, a complication which is for- 
 tunately rare. 
 
 Erysipelas neonatorum occurs usually in epidemic form in hospitals. 
 It begins as a slight inflammation about the umbilicus, but as it s]ireads to the 
 genitals and thighs the constitutional disturbance is great and the prognosis 
 grave. It may be complicated w'ith phlebitis of the umbilical veins extending 
 to the liver. 
 
 Erysipelas may involve the mucous membranes. In severe epidemics 
 of erA'-sipelatous angina the tonsils are greatly inflamed and the tongue is often 
 swollen. Diphtheritic or gangrenous inflammation of the fauces may also 
 occur. These epidemics are rarely seen at the present time. Erysipelas may 
 
FJi VSIPELAS. 69 
 
 extend to the "glottis, and erysipelatous pneumonia, or imeunionia migrans, is 
 described by some aiitbors. The female genitals and tlie rectum may also be 
 invaded by the disease. 
 
 The curative influence of erysipelas is shown not only in the effect pro- 
 duced by it on old ulcers, but even by the Avound itself, which, when in the 
 granulating stage, appears to heal more rapidly. Tumors also have sometimes 
 disa]>peared during an attack. Lympho-sarcoma of the neck has been absorbed, 
 tiie cells having uiulergone fatty degeneration. Both lupus and epithelial ulcers 
 of tlie face have been known to break down, healthy granulations su))sequently 
 appearing which healed rapidly. Fehleisen took advantage of this circum- 
 stance to inoculate certain ulcers with cultures of the streptococci of erysipelas, 
 and thus demonstrated the identity of the virus of the disease (p. 207). 
 
 '^\\Q prognosis of erysipelas is usually favorable, as there is a tendency to 
 self-limitation. The severity of the disease cannot, how^ever, be predicted in 
 any given case, but in small granulating wounds the disease is usually lighter 
 than in large fresh wounds. Danger frequently arises from complications, as 
 oedema of the glottis or secondary hemorrhage. 
 
 Treatment. — Attempts to restrain the infective process by antiseptic 
 applications have thus for not been very successful. The apparent success of 
 many drugs may be due to the spontaneous arrest of the process which so often 
 occurs. Hot fomentations, containing corrosive sublimate of the strength of 
 1 : 10,000 or 1 : 15,000, or carbolic acid may be used ; but care must be taken 
 to avoid increased local irritation or poisoning by absorption of the drugs when 
 a large surface is covered. An ointment of carbolic acid and vaseline, 1 to 
 100, may be brushed on the face with a soft brush or applied to other surfaces 
 and protected with a thin layer of gutta-percha tissue or oiled paper. Zinc 
 ointment, or an ointment of ichthyol (25 per cent.), is often useful. In 
 phlegmonous erysipelas free incisions are indicated. The slough should be 
 removed, and the pus-cavities must be disinfected as thoroughly as possible. 
 Pressure with plasters or bandages in situations where they can be conveniently 
 applied, has been advised to arrest the spread of the disease. 
 
 The constitutional treatment should always be supporting, and any deplet- 
 ing measures should be carefully avoided. The presence of delirium does not 
 necessarily contraindicate the use of stitnulants. Tincture of the chloride of 
 iron has been recommended in large and frequent doses on account of its action 
 upon the red blood-corpuscles, which are found crenated, and when placed 
 under the microscope run together readily. This method was at one time 
 received with great favor, but is less used at present. Quinine has also enjoyed 
 a great popularity. Antipyretics as a rule have little effect upon the fever, 
 and should be avoided, owing to the depressing influence upon the heart's 
 action which many of them exert. Opium in some form and hypnotics are 
 indispensable to allay the pain and procure sleep. Food should be carefully 
 and frequently administered. When the blush has disappeared a complete 
 change of bedding and clothing, with careful disinfection, may serve to pro- 
 tect the patient from a relapse due to a reinfection of the system. 
 
70 .l.V AMKIUCAX TKXT-nOOK OF SLlKiEUY. 
 
 CHAPTER XII. 
 TETANUS. 
 
 Tetanus is an infective disease, almost always originating from a wound. 
 The central nervous system is the region chiefly affected by the bacterial poison 
 which is the cause of the disease. 
 
 The bacillus of tetanus (PI. IT, Fig. T)) was discovered in 1885 by 
 Nicolaier. It is a siiort rod with an enlargement at one end. due to sporulation, 
 which gives it the characteristic drumstick shape. Although it is found in 
 the dust of the street, it rarely finds an opportunity to grow in the living ti.ssues, 
 owing to its anaerobic properties ; hence the rarity of the disease. It is found 
 principally in the tissue near the wound, and is rarely, if ever, seen in the 
 internal organs or blood. Several ptomaines have been extracted from the 
 cultures of this bacillus, such as tetanine and tetano-toxine, and it is probable 
 that most of the symptoms of irritation of the nervous system are due to the 
 presence of these substances, as but few bacilli are found there. 
 
 Punctured wounds naturally offer the best opportunity for the growth of the 
 anaerobic bacillus, and if such wounds are inflicted in dirty parts of the body, 
 as the hands or feet, or foreign bodies covered with dust containing the bacilli 
 are lodged in the tissues, the conditions favorable for infection are obtained. 
 The state of the weather is said to have an influence upon the development of 
 the disease. It has appeared in epidemic form with sudden changes in the 
 weather after battles. It is also said to be much more common in tropical 
 climates. 
 
 Tetanus is said to be traumatic or idiopathic. It is probable, however, 
 that all cases of tetanus are traumatic, but tliat the wound is so slight in many 
 cases as to escape notice. It has been known to follow such injuries as simple 
 fracture, in which case internal infection probably occurs. 
 
 Acute tetanus most fre((uently makes its appearance at the end of the first 
 week after the infliction of an injury, although tliis period varies considerably. 
 
 The first symptom complained of is a stiff neck, which the patient 
 attributes to a slight cold. The muscles of the face and jaw are next involved, 
 and the patient is unable to open his mouth, this symptom giving rise to the 
 popular name " lock-jaw." The muscles of the fauces and the pharynx are 
 often in a state of spasm, rendering deglutition difficult. The muscles of the 
 thorax and abdomen are next involved, and the muscles of the back are so 
 painfully contracted that the head is thrown l)ack, the spine is arched, and the 
 body assumes the position known as opisthotonos. The lower extremities 
 may also become rigid ; the arms are, hoAvcver, only partially affected. The 
 muscular spasms, which are tonic, permit of little rest, and the sufferings of 
 the patient are excessive and almost continuous. The expression of the face 
 is totally changed by the contraction of the various muscles, which jn-oduces 
 the characteristic risus sardonicus. The patient often experiences considerable 
 difiiculty in passing urine or in having a movement of the bowels. Any dis- 
 turbing influence, especially noise, instantly evokes the muscular contractions 
 and adds to the patient's sufterings. These have been known at times to be 
 so severe as to produce rupture of a muscle or fracture of a bone. Such a 
 condition permits of little sleep, and in the acute cases the patient rarely 
 obtains any rest from the moment the disease makes its appearance. The 
 temperature is usually not much elevated, but the skin is bathed in perspira- 
 tion. The pulse is weak and rapid, and as the disease progresses the exhaus- 
 tion becomes marked, owing to loss of food and sleep. Sudden death often 
 
TiyrAxcs. 71 
 
 occurs in :i jKiroxysm of dysj)iieii. The niiiid is usually clear to the last. 
 Such an attack will run its course usually in two or three days. 
 
 In chronic tetanus the disease makes its appearance at a later date. 
 The muscles arc extensively involved, but there are ])eri()ds of comparative 
 relief, and as these intervals become <!;radually |)rolonged the jiatient has an 
 oj)p()rtunity to sleej). In the chronic form the disease may last several weeks. 
 There is little change to be observed in the wound, although in some cases there 
 are evidences of an infective inflammation. 
 
 Trismus is a name given to a milder form of the disease when the con- 
 tractions an limited to the group of muscles alxtut the neck and face. 
 
 Cephalic tetanus or tetanus hydrophobicus occurs after injuries 
 in the region of distribution of the twelve cranial nerves. It is accompanied 
 by paralysis of the facial nerve, usually on the side affected, and there is 
 often spasm of the pharyngeal muscles, causing difficulty in swallowing. 
 There is also trismus, and sometimes the muscles of the trunk are affected. 
 It may be either acute or chronic. Many recoveries from the chronic form 
 are re|)orted. 
 
 Tetanus neonatorum or trismus nascentium is a general affection 
 of the muscles in the newborn infant, beginning with trisnnis, and is due to an 
 infection through the navel. It occurs occasionally in epidemic form in lying- 
 in hospitals, and is a fatal disease. From 1860 to 1865, on the island of St. 
 Kilda, S4 out of 125 children died of this disease within 14 days after birth. 
 In 18tt2, following the introduction of iodoform dressing for the umbilical 
 cord, not a single death occurred from this cause. 
 
 Post-mortem examinations of cases of tetanus do not usually show 
 any evident pathological changes. Some observers have found hyperemia of 
 the medulla and cord, but others have detected no change. BroAvn-S^quard 
 described an ascending neuritis, and Lockhart Clarke observed softening of 
 portions of the gray substance of the cord. 
 
 The diagnosis of tetanus is usually not difficult in the acute cases, but in 
 the milder forms it may be mistaken for other affections, as rheumatic inflamma- 
 tion of the jaws or hysterical contractions of the masseter muscles and excessive 
 muscular spasm during the dressing of a sensitive wound. In strychnia-pois- 
 oning the muscles of the jaw are not rigid at first. Where the dose is small 
 and repeated there w'ill be intervals of rest. There is hyperesthesia of the 
 retina and objects are colored green. 
 
 Tetany is a disease characterized by attacks during which tonic spasms 
 of the various groups of muscles occur, principally of the upper extremities. 
 According to Weiss, these attacks are due to an irritable condition of the gray 
 matter of the medulla and spinal cord. It sometimes foUow's childbed and 
 fevers and some mental shocks. It has also been frequently observed after 
 operations for the removal of goitre. The spasms are tonic and give rise to 
 great rigidity of the muscles. Between the attacks the p&tient appears well. 
 The majority of cases get well without treatment. It occurs chiefly in young 
 persons. Opisthotonos may occur, but trismus is absent. Pressure upon the 
 nerve-trunk leading to the afi"ected muscles will always bring on an attack. 
 It is a rare disease in America. 
 
 Hydrophobia, which is popularly thought to resemble tetanus, is easily 
 distinguished from it. The paroxysm of hydrophobia is not a true muscular 
 spasm, and is limited to the muscles of respiration. The intervals of repose 
 in early stages and the mania in later stages are also distinctive. One who has 
 once seen the two affections would not be likely to mistake them a second time. 
 
 The prognosis of acute tetanus is of the gravest character. The only 
 
72 ^l.V AMKIilCAX TKXT-IKJOK OF SLIldKIiV. 
 
 liopo in such cases is that the acute form may <rra(hially assume a chronic type. 
 According to Yandell's statistics, those ])atients wlio live beyond the fifth day 
 are more likely to recover. Every day beyond this period improves the 
 chances for recovery. Cases occurring after injury received in battle are 
 much more fatal. 
 
 The prophylactic treatment consists in the thorough disinfection of all 
 suspicious Avounds. As soon as symptoms appear the patient shoulil be iso- 
 lated and kept in a darkened room, and extreme care should be taken to disturb 
 him as little as possible. Any method of treatment which involves motion should 
 therefore be avoided. Of all drugs, chloroform appears to have the most sooth- 
 ing effect uiKin the nervous system, and can be administered in small (juantities 
 by inhalation at frecjuent intervals. Chloral can also be given Avith the same 
 end in view, and it may be combined with bromide of potassium. Inhalations 
 of nitrite of amyl often act well, the relief persisting for some time after each 
 inhalation. Morphine may be injected subcutaneously. Calabar bean has 
 been used successfully. All of these drugs must be given in unusually large 
 doses and for a considerable time, as a hesitating policy entails great suffering 
 upon tlie patient. Retention of urine must be relieved by catheterization, and 
 if the muscular spasm of the throat is excessive it may be necessary to admin- 
 ister nutrient enemata. There are few diseases where skilled nursing is of so 
 much importance. Several authors have recently published cases of cure by 
 injections of the tetanus antitoxin of Tizzoni and Cattani (see p. 81). 
 
 Kitasato has shown that injections of iodoform render an animal immune 
 to tetanus, and it seems possible that this drug may be of value in the actual 
 treatment of the disease. 
 
 CHAPTER XIII 
 
 SCURVY. 
 
 Scurvy is a constitutional disease ti-aceable to the use of improper diet, 
 defective chiefly in suitable vegetable food, and to imperfect hygienic surround- 
 ings. It is characterized by great disturbances of nutrition and a tendency to 
 hemorrhage in the various tissues of the body. 
 
 History teems Avith accounts of diseases strongly resembling scurvy, but 
 no reliable descriptions of any epidemic are to be found before the fifteenth 
 century, when the great extension of navigation exposed the crews of vessels 
 to prolonged privations such as had not before been experienced. During the 
 present century it has been noticed chiefly in Arctic voyages and in many 
 wars. The Allied armies suffered from this disease in the Crimea, and during 
 the late Civil "War the troops on both sides were affected. Perhaps the most 
 striking epidemic of any occurred at Andersonville. During the siege of 
 Paris in 1871 many cases of scurvy were discovered and carefully studied. 
 It is rarely seen at the present time, and no opportunity has been obtained for 
 studying it with the care which modern methods of investigation offer. 
 
 Scurvy has been supposed to be a contagious disease and also one of 
 miasmatic origin, but it is now conclusively proved that imperfect nutrition 
 is the most important factor in the causation of the disease. All are agreed 
 that a deficiency in the variety of the diet is the principal cause of scurvy, but 
 opinions differ widely as to the particular alimentary substance the absence of 
 which brings out the symptoms of the disease. Some have supposed that the 
 disorder Avas due to tlie lack of fresh vegetables. Others have thought that 
 
SCUB VY. 73 
 
 tlic excessive use of salt meats produced conditions favoral)le for the disease. 
 Garrod's theory that a deficiency of easily assimilated potassium salts in the 
 food is one of the causes of scurvy has excited a good deal of attention. The 
 most important factor, however, is certainly the absence of variety in diet. 
 In certain instances the use of impure water has caused an outbreak of the 
 disease, as was the case in Rankes ex})edition into the interior of Australia. 
 Unhealthy surroundinfrs, as foul quarters in a ship ; a bad state of the health, 
 such as might result from great fatigue or dissipation ; and mental depression, 
 such as might occur among convicts, — are all predisposing causes. 
 
 Symptoms. — The early stages of the disease are marked by a condition 
 of extreme lassitude. On slight exertion the heart's action becomes rapid and 
 the respiration is increased in frequency. The patient complains of muscular 
 pains in various portions of the body and is extremely sensitive to low tempera- 
 tures. He is drowsy and apathetic and has an appearance of depression. 
 There is no febrile disturbance and the pulse is slow and feeble. The skin is 
 of a pale yellow hue, and is mottled here and there with brownish-colored spots. 
 The epidermis is dry and brittle and there is considerable desquamation. The 
 cutaneous follicles are unusually prominent, giving the appearance of " goose- 
 flesh." This condition will last for several weeks before the symptoms dis- 
 tinctly characteristic of scurvy make their appearance. The gums then begin 
 to be swollen and oedematous, and the mucous membrane of the mouth assumes 
 a bluish tinge. The alveolar membrane is sensitive and bleeds easily, and 
 the breath has a characteristic foul odor. 
 
 Petechise and numerous small extravasations are seen beneath the surface 
 of the skin. They are at first observed about the roots of the hair, and appear 
 as round bluish-red spots the size of a pin's head, which do not disappear on 
 pressure. Later, some of the extravasations Avhich take place are of consider- 
 able size and appear like bruises. Small vesicles form Avhich later grow 
 to large size and become occasionally the starting-points of ulcerations. The 
 latter may, however, result from a septic infection and breaking down of the 
 extravasations themselves. The ulcers vary in size, are covered with a 
 brownish scab, and are surrounded by a violet discoloration of the skin. The 
 granulations are unhealthy and give vent to a foul-smelling discharge. The 
 muscles and the connective tissue are also the seat of hemorrhages, some of 
 which break down and discharge an ichorous fluid. At other times they 
 indicate their presence only by peculiar indurations to be felt in those tissues. 
 Hemorrhages may occur also from the mucous and serous membranes. Inflam- 
 matory hemorrhagic efiusions may take place in the periosteum. Swellings 
 occur at the epiphyseal line, and the epiphyses may be separated from the 
 shafts of the bones. The joints also may be involved. Even the eyes may be 
 afl'ected, and more or less disturbance of vision result (hemeralopia). The 
 quantity of the urine is decreased, as also the urea and all the solid elements 
 of urine. Fever is present during the height of the disease only when inflam- 
 matory complications prevail. 
 
 The j)08t-mortem changes observed are the hemorrhagic eff"usions in various 
 parts of the body and such inflammatory complications as may have occurred, 
 especially croupous pneumonia and ulcerative endocarditis. Hemorrhagic 
 infarctions are often found, the result of embolism derived from thrombi which 
 form in the right auricle. Analyses of the blood have not as yet thrown much 
 light upon the hemorrhagic tendency so conspicuous in this disease. Water 
 is found in excess and an increased number of white corpuscles is observed. 
 It is probable that a diminished power of resistance exists in the walls of the 
 capillaries. 
 
74 AX AMi:iUl'Ay TEXT-noOK OF ,Sl'R(i KUV. 
 
 Diagnosis. — Scnrvv may bo (listiniruislieJ from purpura by tlie cachexia 
 ami the persistent pains and the fetid breatli accompanyiiif^ the jieculiar con- 
 dition of the gums. It may be distinguished in the same way from anemia, 
 hemophilia, and leucocythemia. 
 
 Tlie prognosis of the disease will depend greatly upon the stage at which 
 the ])atient comes under treatment. Under favorable conditions imj)rovement 
 soon begins in most cases, but the duration of the convalescence is usually 
 a prolonged one. If the use of the limbs is regained after a few days of 
 treatment, the prospects of ultimate recovery are excellent. The recovery in 
 uncomplicated cases is usually a complete one. 
 
 The pro j)hy lactic treatment consists in strict attention to the hygienic 
 conditions, especially as to dryness and cleanliness on sliips and in laying in a 
 supply of live-stock. Among the antiscorbutics of repute at the })resent time 
 may be enumerated eggs, milk, potatoes, beets, carrots, cabbages, onions, fruits, 
 cocoanuts, pickles, cranberries, cider, lemonade, and lime-juice. The various 
 meat extracts are also valuable and portable articles of food. Good drinking- 
 water is also of the greatest importance as a prophylactic. 
 
 The curative treatment of the disease is almost exclusively dietetic. Nitrate 
 of potassium is said to be of especial value. It may be used alone or mixed 
 with vinegar (Wales). Antiseptic mouth-washes and lotions for the ulcers are 
 also indicated. Any medication contemplated should be of a distinctly tonic 
 character. 
 
 CHAPTER XIV. 
 TUBERCULOSIS. 
 
 The inoculability of tuberculous material Avas regarded as a possibility 
 by Laennec and others, but Yillemin in 18(35 was the first to demonstrate the 
 fact that the disease could be transmitted by inoculation to animals, and 
 was therefore infectious like small-pox or syphilis. These views were con- 
 firmed in 1877 by Cohnheim, Avho successfully inoculated the anterior 
 chamber of the eye in animals, and was able to observe through the trans- 
 parent cornea, after a period of incubation, a development of numerous miliary 
 tubercles in the iris. 
 
 The search for the bacillus was from this time pursued with energy, but 
 the observations of Baumgarten gave the only reliable results. His discoveiy 
 of the bacillus was almost simultaneous with that of Koch, who, however, in 
 1882 was the first to establish fully the identity of the organism and to culti- 
 vate it successfully. 
 
 The length of the bacillus tuberculosis is about one-half the diameter 
 of a red blood-corpuscle. It is a thin rod, found single, in pairs, or in clusters. 
 In tubercle in the human subject it is seen usually either single or in .small 
 numbers, and at times is quite difficult to demonstrate. It is found, however, 
 in large numbers in experimental tuberculosis in certain stages of development, 
 and therefore when it is not possible to discover bacilli with the microscope a 
 diagnosis can be made by inoculation of a suspected tubercle into animals. 
 
 The miliary tubercle consists of a minute gray non-vascular nodule 
 about the size of a mustard-seed. Under the microscope it is seen to contain 
 a mass of leucocytes, near the centre of which are to be found a number of 
 larger cells with one or more nuclei known as epithelioid cells and one or more 
 
TUBERCULOSIS. 75 
 
 giant-cells. The appearance of such a cluster of cells is so characteristic that 
 a tubercle can usually be recognized by the presence of the giant-cells without a 
 demonstration of the bacilli, although these cells are also found in other growths 
 besides tubercle (PI. IV, Fig. 1). The structure of these giant-cells is peculiar, 
 the nuclei being arranged in a somewhat radiating manner around the periphery 
 of the cell, the center of which is made up of a granular protoplasm in a more 
 or less advanced stage of degeneration. In studying experimentally the 
 development of a tubercle it has been found that the first change consists in 
 a division of the fixed cells of the part involved (by karyokinesis), by means 
 of which process the epithelioid cells are formed. The giant-cell formation is 
 due to the fiict that the epithelioid cells do not show a tendency in the less 
 active forms of tuberculosis to ])roliferate, but the division of the nuclei of 
 certain cells continues, and the unusual cell-growth is thus produced. In acute 
 miliary tuberculosis the cell-division is more active and giant-cells are less 
 frequently found. 
 
 As the growth of tissue-cells begins to subside, the number of leucocytes 
 which have Avandered in from without begins to increase. The fine reticulum 
 or network of fibers which supports the cells of the tubercle does not appear 
 to be a new formation, but is merely the remains of the intercellular substance 
 of the pre-existing tissue. 
 
 The bacilli are found either in the larger cells or between them ; at times 
 but one or two bacilli are found in the giant-cells. They are seen usually near 
 the nuclei at the border of the cell. More rarely they are found in large num- 
 bers in the human subject. How^ they are brought to the part affected is not 
 clear : it is thought by some that, not possessing any movements of their 
 own, they are transported by the leucocytes, but this view would not accord 
 with that first expressed (Baumgarten) — namely, that the leucocytes appear only 
 at a later stage in the process of development. The bacilli are rarely found in 
 the circulating blood. 
 
 Sections of tubercle are well shown by the double staining process, the 
 fibers of the tissue being colored red by eosine, and the giant-cells being well 
 brought out by the hematoxylin. In order to show the tubercle bacilli a 
 special staining method is necessary. The staining fluid consists of the follow- 
 ing ingredients : Saturated alcoholic solution of fuchsin, 10 parts ; 5 per cent, 
 aqueous solution of carbolic acid, 90 parts. 
 
 The section should be placed in a small quantity of this fluid in a watch- 
 glass, and allowed to remain from one to twenty-four hours according to the 
 degree of staining required. The section should then be decolorized with a 
 5 per cent, solution of sulphuric acid for a few seconds. If, when the specimen 
 has been washed in alcohol 60 per cent., it is found not to be sufficiently 
 decolorized, it should be replaced in the sulphuric acid. It should finally 
 be dehydrated in absolute alcohol, cleared in oil of cloves, and mounted in 
 Canada balsam. 
 
 Tubercle shows a tendency at an early period of its existence to undergo a 
 caseous degeneration. This tendency is fiivored by the absence of blood- 
 vessels, and the pjart which first succumbs to this process is the center of the 
 tubercle, the portion farthest removed from the supply of nutriment. The 
 change is principally due to a coagulation-necrosis, presumably caused by the 
 action of the bacilli upon the cells. As a result of this change the mass pres- 
 ently assumes the appearance of a caseous nodule. If the progress of the dis- 
 ease is arrested at this point, the tubercle becomes enclosed in a fibrous layer 
 the result of a reactive inflammation, and is said to be encapsuled, and the cells, 
 having all undergone cheesy degeneration, are finally absorbed or the caseous 
 
70 .1-v AMi:ni<AX 'iiix'r- !',(>( n< <)isii;(;i:in'. 
 
 product is calcified. If, however, the process extends, the caseons nodule 
 becomes laro;er, the necrosed material breaks up into a granular d(''bris, and a 
 fluid is produced which in appearance resembles true pus. These products of 
 degeneration frequently contain the bacilli, and when inoculated into animals 
 may re])roduce the disease. 
 
 This tuherruIouH pus or puruloid material contains the broken-down masses 
 of cells and a certain numl)er of leucocytes and fragnu-nts of the coagulation- 
 necrosis. The contents of cold abscesses arising from tuberculous processes are 
 usually of this character, but occasionally the pyogenic organisms are found in 
 this fluid, in which case true suppuration occurs. The tubercular pus is thin 
 and of a peculiar white or chalk-like color: it contains lumps of cheesy matter 
 the product of tubercular softening, and fragments of sloughs of the connective 
 tissiu'. Crumbs of bone may occasionally be felt in it. If the tubercular 
 nodule is on the surface of the skin or a membrane, such degenerative changes 
 will lead to ulceration. 
 
 The local spreading of tubercular inflannnation is caused by the growth of 
 the bacilli, Avhich involve new areas of tissue. Adjacent cavities or organs 
 mav thus be invaded. By the breaking down of bone-tissue the bacilli may 
 gain an entrance into a joint, or the peritoneum may become infected from a 
 tuberculosis of the intestine. When the bacilli enter the blood-vessels or 
 lymphatics, they may be transported alone, or in the interior of small 
 emboli, to a distant organ, and a general miliary tuberculosis may be thus 
 produced. 
 
 Tuberculosis is probably the most common of all diseases, for it is estimated 
 that IS per cent, of all cases of death occur from this cause. According to 
 Baumgarten, it arises more frequently by inheritance than in any other way ; 
 but, although the bacillus may undoubtedly ])e transmitted from parent to off- 
 spring, it is probable that only a predisposition to the disease is the more fre- 
 quent result of heredity. The disease easily arises then in such predisposed 
 persons when the bacillus gains an entrance to the body through the respiratory 
 organs, Avhether inhaled with the air as dust arising from dried sputa and other 
 excretions, or taken into the alimentary canal with food and penetrating the 
 intestinal mucous membrane. It may also be introduced through wounds of 
 the skin, chiefly of a trifling character, such as bruises or scratches. It is 
 undoubtedly an infectious disease, and may be contracted by persons of healthy 
 ancestry by continued exposure to its germs. 
 
 Tiiherculosis of the skin includes a number of diseases which until recently 
 have been regarded as diff'erent aflcctions. The most frequent form is that 
 known as lupus. This disease is now recognized as a lesion due to the pres- 
 ence of the bacillus of tuberculosis, although it is often extremely difficult to 
 find the organism. The tendency of the disease is to remain local, but it may 
 occasionally lead to a general tuberculosis. Lupus vuJ(/an's is most frequently 
 seen on tlie face, but other portions of the body may be the scat of the affection, 
 particularly the extremities. It is characterized by a chronic inflammatory 
 process, forming brown-red nodules with a tendency to ulceration and sul)se- 
 quent cicatrization. In this way a considerable area gradually may be involved. 
 When the tendency to ulceration is excessive we have the form known as lupus 
 exedens, although this name is often given erroneously to ulcerating forms of 
 cancer of the face. 
 
 In other cases the amount of granulation-tissue may be a prominent feature, 
 and then we have the form known as Jup}(s hi/pfrfropJu'eus. When there is a 
 tendency to the formation of cicatricial tissue the disease may produce exten- 
 sive superficial alterations in the skin, and give rise to great deformity, the 
 
TUBEJicrLOSIS. 77 
 
 whole surface of the face bring occasionally involved. l*atients with lupus 
 not infre(iuently die of pulmonary tuberculosis. 
 
 The aft'ection known to surgeons as anatomical tubercle, and frequently 
 found on the fingers and hands of assistants in the autopsy and dissecting 
 rooms, is now recognized as tubercular, and is regarded as almost identical with 
 the variety known chietly as tuberculosis verrucosa cutis or verruca necrogenica. 
 It is characterized by plaques situated chiefly on the backs of the hands, arms, 
 and fingers, looking at first sight like a cluster of inflamed warts. There are 
 also erythematous patches and pustules. 
 
 Scrofuloderma is a name applied to certain tuberculous affections of the 
 skin which formerly were not regarded as allied to lupus. It occurs as a more 
 or less deep-seated, chronic inflammatory process in any part of the skin, prefer- 
 ably on the neck, body, or extremities, and shows a tendency to the formation 
 of granulation-tissue, which breaks down and gives rise to sinuses or minute 
 ulcerations. It is occasionally associated with disease of the lymphatic glands 
 and bones. It is sometimes called scrofulous gumma, owing to its resemblance 
 to syphilis. 
 
 Primary tuberculosis of the panniculus adiposus is observed, particularly in 
 children, in the form of flat subcutaneous nodules which gradually soften and 
 break down and discharge. In some cases they may burrow extensively with- 
 out coming to the surface- Tubercular abscesses of the deeper connective tissue 
 are, however, usually secondary to some affection of the bones or joints or lym- 
 phatic glands. The larger abscesses, generally known as cold abscesses, 
 originate most frequently from tuberculous disease of the bones. Such 
 cavities, when opened, present a characteristic appearance. The walls are 
 covered with a membrane of a grayish-yellow or grayish-red color, which is 
 loosely attached, and can readily be removed with the finger or sharp spoon 
 in large fragments. It consists of a very soft and slimy material, which con- 
 tains great numbers of miliary tubercles closely packed together and imbed- 
 ded in masses of fibrin. AVhen scraped away healthy tissue is exposed. At 
 one spot the persistence of a small islet of granulations indicates the opening 
 of a fistulous track which leads to diseased bone. Occasionally no such fistula 
 can be found. This is the case in the so-called peri- or para-articular abscess 
 when the septic infection of the connective tissue is transmitted from a diseased 
 bone or joint through the lymphatics. Such abscesses, although at first not 
 communicating with the affected joint, may later establish an opening into it. 
 Fistulse leading to tubercular abscesses are also lined Avith a tuberculous mem- 
 brane. The pus of these abscesses may contain a few leucocytes, but consists 
 chiefly of the products of caseous degeneration. The presence of the bacilli 
 of tuberculosis, although not easily determined with the microscope, is often 
 demonstrated by experimental inoculation in guinea-pigs. In the tyj^ical cold 
 abscess pyogenic cocci are not usually found under the microscope, nor can 
 they be obtained from cultures of this pus. The absence of fever in cases where 
 these large abscesses are found is thus explained, and the constitutional dis- 
 turbance which frequently follows the opening of a cold abscess is undoubtedly 
 due to a subsequent additional infection with the pyogenic cocci. 
 
 Adjacent muscles are rarely infected by tubercular abscess: it is now well 
 understood that striped muscular fiber is not liable to tuberculous disease. 
 
 Tuberculosis of the mucous membranes may follow or accompany lupus of 
 the skin. A direct extension may take place from the alae of the nose or from 
 the lips to the nostrils, gums, or pharynx. 
 
 Tuberculosis of the tongue is a comparatively rare affection, and is liable to 
 be mistaken for cancer or syphilis. It appears as a chronic inflammatory pro- 
 
78 AN AMEJIICAX TEXT-BOOK OF srUdKRV. 
 
 cess Avhicli produces an infiltration extending to the dee|)er muscular tissue. 
 On the surface ulceration may take place. It may he associated Avith tuhercu- 
 losis elsewhere, and the presence of pulmonary signs or fistula in ano ■would 
 serve as aids to diagnosis. The prognosis will depend largely upon the general 
 condition of the patient. 
 
 Lupus of the vcluiii, totis/Ls, and pliarjpix is often found associated with 
 lupus of the skin, and, according to Lennox IJrowne, is more likely to be seen 
 in skin than in throat clinics. It appears in the form of numerous suj)er- 
 ficial ulcerations surrounded l)y inflamed and thickened borders, which show 
 a tendency to become confluent. There is less loss of substance than in 
 syphilitic lesions of these parts, as the ulcer tends to cicatri/-e. The adjacent 
 mucous membrane is often found studded with miliary nodules, which run 
 together, break down, and form new ulcerations. The miliary tubercles are 
 situated immediately beneath the epithelial layer, and may also involve the 
 intermuscular and connective tissue. The giant-cells are numerous and well 
 developed; the number of bacilli is, however, usually small. Many of the 
 patients wlio are the subjects of these affections succumb to pulmonary tuber- 
 culosis. 
 
 Tuberculosis of the throat or lungs may give rise to tubercular disease of 
 the intestinal canal. As a result of such infection ulcers may form in the 
 neighborhood of the caecum and appendix, and may perforate the bowel 
 and give rise to a tubercular abscess. Tubercular inflammation of the large 
 intestine has been known to give rise to so much obstruction as to necessitate 
 laparotomy, which has been successfully performed. The development of 
 tubercular peritonitis from this source is supposed to be much less common 
 than from the Fallojiian tubes. 
 
 Most cases of fistula in ano are tuberculous. They are characterized 
 by the formation of fungous granulations and a tendency to burrow beneath 
 the skin and mucous membrane. In many of these cases symptoms of pul- 
 monary disease are also present, and the prognosis is then exceedingly unfiivor- 
 able. 
 
 All portions of the f/enito-urinari/ tract appear to be affected by tuber- 
 culosis. Lupus is found occasionally on the labia majora. Cornil has found 
 the bacilli in ulcerations of the vagina adjoining a vesico-vaginal fistula. In 
 six autopsies of cases of tuberculosis of the uterus he found in three a number 
 of bacilli. Tubercular infection of the Fallopian tubes often supervenes upon 
 a clnonic catanlial salpingitis in cases of tubercular disease of other portions 
 of the genital mucous membrane. It is possible that infection of the female 
 o-enital organs may result from coitus, as the bacilli of tuberculosis have been 
 found in the semen of tuberculous men even in cases where the genital organs 
 are not the seat of tuberculous disease. Tuberculous peritonitis not infre- 
 quently accompanies tuberculous pyosalpinx. 
 
 Tuberculosis of the mamma is rare. Tuberculous ulcerations or sinuses 
 may occasionally be seen about the nipple, and yield readily to treatment. 
 Several cases are reported by Cornil where miliary tubercles containing giant- 
 cells and bacilli were found in the ducts of the gland. Tillmans recommends, 
 in every case of tuberculosis of the mamma, extirpation of the breast and the 
 lymphatic glands. 
 
 Tuberculosis of the 7nale genital organs has usually an unfavorable prog- 
 nosis. Tuberculosis of the testicle occurs most frequently in early adult life. 
 Many cases of cure occur without operative interference, although there is 
 danger that the disease may propagate itself along the course of the vas 
 deferens to the vesiculae seminales, the prostate, and the bladder if the testicle 
 
TUBERCULOSIS. 7!) 
 
 is not removed. Tubercles are found in tlic uictlii;!, in llie nienibninous por- 
 tion chiellvi but the disease is more fre(iuently described as existing in the 
 bladder. It nuiy at times be quite extensive and involve the kidneys. It is 
 one of the most difficult forms of the affection to deal with, and early diagnosis 
 by detection of bacilli in the urine is therefore important. 
 
 The tubercular affections oi' bones are found most frec^uently in the vascular 
 spongy tissue of the epiphyseal ends of the long bones. Tuberculosis of the 
 shaft of' the long bones is comparatively rare. The disease is found in the 
 short spongy bones, as the bodies of the vertebraj and the bones of the tarsus 
 and carpus. It is also seen occasionally in the fiat bones, as those of the skull 
 and the pelvis, the orbital portion of the superior maxilla, and the ribs. In 
 the epiphysis the tuberculous nodule is usually formed some little distance from 
 the cartilage. On section of the bone one sees, in the beginning of the disease, 
 a yelloAvish-'white or pure yellow well-defined mass lying in the spongy tissue, 
 which even with low powers can be seen to be made up of miliary tubercles, 
 some of them already in a state of cheesy degeneration. As this nodule grows 
 in size it becomes softened, and finally forms a cavit}'^ containing a more or less 
 softened material mingled with minute fragments of bone ; or the degenerated 
 bone becomes necrosed in a mass and forms a sequestrum. This is generally 
 of a roundish form and frequently as large as a walnut, and is surrounded by 
 a layer of granulation-tissue which is also infected with tubercle bacilli. More 
 rarely the tuberculous nodule may break down and form a small abscess. Such 
 pus-cavities are most often seen in the extremities of the tibige. Occasionally 
 the nodule may remain for a long time unaltered, and is then surrounded by 
 a dense capsule. Sclerosis or eburnation of the surrounding bone may occur 
 under these circumstances. The bacilli reach the epiphysis usually through 
 the circulation. They are most frequently conveyed there as single organisms 
 floating in the blood, but they may be transmitted in emboli, possibly from 
 a tubercular mass in the bronchial glands. If such an embolus should plug 
 a terminal arteriole, an infarction of the bony tissue may result, forming a 
 wedge-shaped sequestrum with its base directed toward the joint and the apex 
 pointing toward the diaphysis. These Avedge-shaped tubercular infarctions 
 have been produced experimentally in animals by injecting tuberculous pus 
 into the tibial artery. It is possible that a growth of granulations may invade 
 the tubercular mass, and that complete absorption may take place ; and the 
 part may be thus restored to its normal condition. Even a tubercular seques- 
 trum may be disposed of in this way under favorable conditions. Usually, 
 however, the nodule softens and the tubercular pus breaks into the joint or 
 into the adjacent connective tissue. When the joint is involved, tubercular 
 infection of its surface will occur and disorganization will probably take place- 
 When the pus discharges through the periosteum, a cold abscess will form 
 which may burroAv extensively and finally break externally. 
 
 Tuberculous osteomyelitis of the shaft of the long bones occurs chiefly in 
 the phalanges of the hands and feet. The disease appears first in the marrow, 
 which with the cortical bone is changed into granulation-tissue : at the same 
 time the periosteum is stimulated into a new bone-formation, which in its turn 
 becomes involved. In consequence of these progressive changes the bone is 
 much distended in the middle of its shaft, the so-called spina ventosa. The 
 disease may undergo spontaneous cure or suppuration may take place. Con- 
 siderable deformity may be caused by atrophy of the affected bones in early life. 
 
 Tuberculosis is also frequently observed in the short spongy bones, par- 
 ticularly in the bodies of the vertehroe, giving rise to Pott's disease, and in 
 the bones of the carpus and tarsus. The changes produced in bone-tissue by 
 
80 AN AMKUICAX TEXT-BOOK OF SURGERY. 
 
 the bacillus of tuberculosis is that known hitherto as caries; that is, an absorp- 
 tion of the bony tissue, giving it a worm-eaten appearance. Necrosis is more 
 freciuently the result of acute inflannnation produced l)y the ])resence of the 
 pyogenic cocci, but, as we have seen, it may occasionally be due to the action 
 of the bacilli of tuberculosis. 
 
 Tuberculosis of the joints (known often as white swelling, tumor albus, hip 
 disease, ankle disease, etc.) usually results from infection by the opening of a 
 primary nodule from the bone into the joint. A primary tuberculosis of the 
 synovial membrane, however, may also occur. As the consequence of infiltra- 
 tion with miliary tubercles we find a thickening of the membrane with forma- 
 tion of granulation-tissue which may not be accompanied by any collection of 
 fluid in the joint. At other times there is considerable turbid or bloody fluid, 
 or suppuration may take place and the joint contain the characteristic thin and 
 pale tubercular pus. AVhen the tendency to the formation of granulation- 
 tissue is excessive, the condition known as caries sicca exists. Little or no 
 pus is formed, but there is extensive loss of bone as the result of caries. 
 Occasionally circumscribed tubercular nodules form on the synovial membrane 
 and project into the joints as small pedunculated tumors, consisting of fibrous 
 tissue, but containing a softened tuberculous mass in the interior. In the serous 
 form of tuberculous synovitis numerous '■'rice bodies'' or '■'melon-seed" bodies 
 are seen in some cases, either free in the joint or attached to the capsule by a 
 pedicle. They are composed of concentric layers of fibrin, a substance which 
 is so often associated with the formation of tubercles. 
 
 As the disease progresses the articular cartilage is attacked by the granu- 
 lation-tissue in the joint, and ulceration takes place, or granulation-tissue may 
 form in the epiphyses and perforate the cartilage from beneath. In cases of 
 long standing the disease spreads from the capsule to the surrounding tissues, 
 and the connective tissue, the tendons, and even the muscles, become involved 
 in a gelatinous degeneration. This peculiar change is supposed by some to be 
 a saturation of the diseased tissue with a fluid of a mucous or synovial character. 
 Under favorable conditions a more or less complete restoration of the joint- 
 cavity may take place, but when the disease is once Avell develo|)t'd the best 
 that can be hoped for is a fibrous or bony ankylosis. If suppuration takes 
 place, the abscess may open externally, and fistuhie communicating with the 
 joint may be established. In long-standing cases of joint-suppuration amyloid 
 changes are found in the internal organs. 
 
 Tuberculosis of the tendon sheaths is usually secondary to bone or joint 
 disease, but it occurs occasionally as a primary affection. A thickening of the 
 tendon sheaths takes place and develops into a cylindrical doughy swelling, 
 Avhich is usually not painful. Rice or melon-seed bodies often form. A por- 
 tion of the new tissue softens down and fistulous openings occur. If the sheath 
 is laid open by a longitudinal incision, a mass of gelatinous tissue is found 
 which can easily be stripped off. Such an operation may result in cure. 
 
 Tuberculosis of the hpnphatic glands is a very common affection. Enlarged 
 glands may be found at the autopsies of children dying of almost any disease, 
 and on examination prove to be the seat of tubercle. The disease may occur 
 in the glands secondarily to the involvement of some adjacent organ, as in the 
 bronchial or mesenteric glands from pulmonary or intestinal tuberculosis. In 
 the glands of the neck, which are by far most frequently affected, the disease 
 often appears to occur primarily, but is in reality usually secondary to a catarrh 
 of a mucous membrane or to a cutaneous eczema. The bacilli are few in num- 
 ber except in the glands nearest to the primary focus, and in many glands they 
 cannot be found. In abscesses of lymphatic glands they may be found in the 
 
TUBERCULOSIS. 81 
 
 tuberculous membrane which lines their walls. In the ))r(jnchiiil glands the 
 bacilli are often seen in the capsule and the periglandular tissue. As a result 
 of caseous degeneration and infection with pus cocci abscesses may form, and a 
 spontaneous cure may be rarely eifected. Where an extensive invasion of the 
 lymphatic system takes place the bacilli eventually reach the circulation, and 
 acute miliary tuberculosis may result; but this is brought about more freciuently 
 by the entrance of the bacilli into the veins and their dispersion in emboli to 
 diflferent parts of the body. 
 
 The diagnosis of tuberculosis can usually be established by the clinical 
 symptoms and history of the case, but in doubtful cases a microscopic examina- 
 tion may reveal the presence of the bacilli. This can be done by an exami- 
 nation of the sputa or urine. (See Surgical Bacteriology.) If the case is one 
 of doubtful lupus, a fragment can be punched out Avith the Mixter exploring 
 canula, and sections can thus be obtained for microscopical study. In those 
 cases in which the bacilli cannot be found recourse must be had to experimental 
 inoculation. A fragment of the suspected tissue can be implanted into the 
 subcutaneous connective tissue of the groin of a guinea-pig, and if the speci- 
 men is tuberculous a miliary tuberculosis will be produced in from five to six 
 weeks. 
 
 The prognosis of the disease depends greatly upon its locality. In tuber- 
 culosis of the skin and Superficial tissues it is more favorable than that of 
 internal organs. In children the prognosis is generally more favorable than in 
 adults. Any tuberculous nodule is always a source of danger, and should not 
 be allowed to remain if it can be removed. There is always the possibility of 
 recurrence even after operation. 
 
 The operative treatment consists either in complete removal of the dis- 
 eased tissue by incisions carried through the surrounding healthy tissue 
 or in a thorough curetting, followed by free irrigation with iodine-water 
 or painting with tincture of iodine, packing with iodoform, or occasionally 
 by the actual cautery. In laying open healthy tissues the possibility of an 
 infection of the system with bacilli should not be forgotten ; hence thorough 
 removal or no operation is the rule. Tuberculous cavities, like cold abscess 
 or tuberculosis of the joints, may be treated by the injection of an emulsion 
 of iodoform. A 10 per cent, suspension of iodoform in glycerin may be used 
 for this purpose, or a 10 per cent, suspension of iodoform in Avater with 20 
 per cent, glvcerin, 5 per cent, gum arabic, and 1 per cent, carbolic acid. The 
 cavity should be first irrigated with a 3 per cent, solution of boric acid. 
 The emulsion is tlien introduced with a trocar about 2 mm. in diameter. 
 The special methods ol dealing with the local conditions Avill be considered in 
 their appropriate places. The general treatment of the disease is of the 
 greatest importance. This consists chiefly in the selection of a suitable 
 nourishing diet and an appropriate climate. When change of residence can- 
 not be effected the patient should be kept as much as possible in the open 
 air. Among the most valuable of internal remedies are cod-liver oil, the 
 hypophosphites, and alcohol. 
 
 Orriiotherapy (Serumtherapy). 
 
 The brilliant results which have followed the introduction of orrhotherapy 
 in diphtheria, and the large number of attempts to apply similar principles 
 to other diseases of bacterial origin, make it necessary that all should under- 
 stand, as far as possible, the theories upon which this form of medication is 
 based, what its present status is, and what may be hoped from it in the future. 
 
 6 
 
82 .l.V A.Vi:i{r('AX TEXT-BOOK OF SFRf; KHY. 
 
 Tlie threat difficulty wliich lies in the way of further lulvance i.s the incom- 
 pleteness of our knowledge of the toxins and antitoxins with which we have 
 to deal. A short sketch of the general suhject will give the student some 
 idea of the j)rohlenis involved. 
 
 The starting-point lies in the fact that certain animals are found to he 
 immune to the attacks of bacteria which are specially virulent to other ani- 
 mals. Thus rats, dogs, and the carnivora generally are not harmed by anthrax 
 bacilli, while mice, cattle, guinea-pigs, and rabbits are vet}' susceptible. Next, 
 it was observed that all fresh blood had some bactericidal pi'operties which it 
 lost if allowed to stand or was heated to .')0° C. (131° F. ). The blood of 
 different animals varied much in its germicidal powers. The potent part 
 was found to lie in the serum, and not in the cellular elements of the blood. 
 Still further study showed that though a given serum or blood might have 
 but little bactericidal |)Ower, yet it might be able to modify the toxin in 
 virtue of which the bacteria exerted their disease-producing power. 
 
 It was argued that if the bloo<l-serum of immune animals was capable of 
 protecting the immune aninial. that this protection could be conferred upon 
 susceptible animals by the introduction of the serum into their circulation. 
 But it was found that neither artificial immunity nor cures could be brought 
 about in this way in any number of cases, but that artificial immunity could 
 frequently be produced by the continued introduction of at first very small 
 followed bv orraduallv increasing doses of the pathogenic bacteria or of their 
 toxic products. 
 
 The natural immunity is characterized for the most part by the presence 
 in the blood-serum of alexins/ which have bactericidal properties, produce 
 coagulation, and destroy blood-corpuscles ; and are unstable and destroyed by 
 heat (o0°-5o° C. ; 122°-131° F.) and sunlight. 
 
 The artificial immunity is induced by the development of antitoxins, which 
 are neither bactericidal nor globucidal. are more resistant to sunlight, and are 
 only destroyed by a temperature of 70°-s0° C. (158°-176° F.j. As to the 
 mode of action of the antitoxins produced, there is still dispute. Their pro- 
 duction is doubtless due to increased cell-activity called into play by the action 
 of the bacteria, or their toxins, upon the tissues of the organism into which 
 they have been introduced. Whether these plasma-cells and leucocytes, which 
 are called into being by the toxin, secrete a distinct antitoxin, or a "' fi'rmi-nt" 
 which is capable of setting up cell-activity when introduced into the tissues 
 of a person or animal suffering from the same bacterial disease, is as yet unde- 
 cided, though the weight of authority inclines to the former supposition. The 
 practical working is the same in either case. It is attempted to secure a 
 blood-serum from an animal which Avill produce a large amount of serum of 
 strong antitoxic potency. Whenever it can be employed, horse-serum pre- 
 sents the most desired qualifications, as the blood can be easily obtained in 
 large amounts, and when allowe<l to stand a clear amber-colored serum sepa- 
 rates from the clot, and the simplicity of technique renders it easy to secure 
 sterility. 
 
 Tetanus. — The poison of tetanus is extremely virulent, as shown by the 
 fact tliat a dose of 0.00005 c.c. of toxin will kill a jzuinea-pig, Avcighing 550 
 grams, in four days with tyj)ical symptoms. This will serve to ex])lain the 
 seriousness of even smnll wounds thus infected, and the small number of 
 bacilli usually present in them. 
 
 Immunity to the poison of the tetanus bacillus can be gradually induced 
 
 ' An alexin acts by destroying the bacteria; an antitoxin, by neutralizing their toxic 
 product. 
 
Tl li KR CUL OSIS. 83 
 
 and antitoxic properties develop in tlie blood during its acquisition. The 
 horse is the animal which is used, and the amount of antitoxin developed 
 may be so great that .2') c.c. of serum will neutralize toxin sufficient for 
 40.000 fatal doses. Though this power is very great when the toxins and 
 antitoxic serum are mixed in vitro (in a glass dish), yet the ability to check 
 the disease diminishes ra])idly as time goes on. This is possibly to be 
 explained by the theory that the toxin combines with certain cells of the 
 body, particularly with the neuron, and this union gradually becomes firmer 
 and firmer, and the antitoxin, therefore, is unable to neutralize the toxin, as 
 it has undergone chemical change. To secure success a large quantity, 100- 
 200 CO.. of serum should be injected at the earliest possible moment. Its 
 intra-cerebral injection after trephining is the latest method of using it, but 
 this method is too recent to make any autiioritative statement as to its value. 
 
 The mortality in severe acute cases probably has not been diminished by 
 the use of antitoxin, but it would seem as though in chronic cases more 
 favorable results were obtained than before its introduction, Lambert having 
 collected 61 chronic cases treated with the serum, with a mortalit}^ of 16.4 
 per cent., instead of 40 per cent., the average mortality in chronic cases 
 heretofore. 
 
 This serum can be obtained from the Boards of Health of several States 
 and from some manufacturers. 
 
 Anthrax. — Although the toxin of the anthrax bacilli has received a great 
 deal of attention, and the induction of artificial immunity has been successful 
 to a large degree, nevertheless but little j)rogress has been made in its orrho- 
 therapy, and even uniform laboratory results have not been obtained. 
 
 By various methods of attenuation, as, for example, growing the anthrax 
 cultures at unfavorable temperatures, protective vaccines have been produced 
 which have ffreatlv diminished the mortalitv in cattle from anthrax. Thus 
 in twelve years in France there were 1,788.677 sheep and 200.902 cattle inoc- 
 ulated, with a mortality, including deaths from the inoculations, of .94 per 
 cent, for the sheep and .34 per cent, for the cattle, against a mortality of 
 about 10 per cent, for sheep and 5 per cent, for cattle previous to the intro- 
 duction of protective inoculations. 
 
 Streptococcus. — Marmorek has obtained a serum from horses immu- 
 nized with streptococcus cultures, which, though toxic if drawn during the 
 time that the injections are being practised, becomes protective after a period 
 of about four weeks. With this serum some, though by no means constantly, 
 favorable reports have been obtained in streptococcus septicemia. The ques- 
 tion is an open one whether the good results did not arise from the simple 
 stimulative action of the horse-serum upon the tissue-cells, especially as 
 equally favorable results have come from the use of this serum in cases 
 in which there were probably no streptococci present. 
 
 The .still unsolved question, whether all the various forms of streptococci 
 with pyogenic properties are practically one and the same or are varieties 
 having di.stinct toxins, adds much to the difficulties in the way of the solu- 
 tion of the problem of streptococcic diseases. 
 
 Staphylococcus. — But little, and for the most part contradictory, work 
 has been done with this organism, and the work has not yet passed the labor- 
 atory-stage. The blood of animals treated with the toxin is said to be both 
 bactericidal and antitoxic, if obtained several weeks after the treatment. The 
 difficulty in the way of the solution of this problem seems to lie in the absence 
 of any immunity conferred by this organism upon the human subject. 
 
 Bubonic Plague. — Horses react vigorously to the action of the poison, 
 
84 ^^y AMERICAN TEXT-BOOK OF SURGERY. 
 
 become iiukIi oiiuiciatetl, and finally iiumunc Tlic' blood is drawn tlirce 
 weeks after stojijiin<r the injections. Yersin has treated sonic cases with 
 favorable results, when the injections of serum were Itegun early in the dis- 
 ease. In the cases reported death only occurred in patients when the injec- 
 tion was begun on the iifth day. The doses have been from 20 to |H> c.c. of 
 the serum. 
 
 Hydrophobia or Rabies. — Orrhotherapy of rabies is quite different 
 from tile method of treatment introduced by Pasteur, lie treated patients 
 who had been bitten by rabid dogs, by injecting emulsions made from the 
 spinal cords of rabbits which had died of rabies, beginning with cords that 
 had been removed for two weeks, and repeating the injection each day or 
 every other day with fresher cords, the theory being that by the time the 
 period of incubation had passed the ))atient would be rendered immune. 
 There has been marked success from this method of treatment, although it 
 has been subjected to much adverse criticism. In the attemj)ts at orrho- 
 therapy, sheep and dogs have been immunized in the above manner, and 
 from their serum a precipitate has been obtained which it is hoped will neu- 
 tralize the poison of rabies and at the same time do away with most of the 
 objectionable features of the Pasteur treatment. 
 
 Snake-venom. — Calmette maintains that the active toxin of all snake-, 
 lizard-, and scorpion-venom is identical, and that by immunizing a horse with 
 repeated doses of cobra-poison, the strongest of the snake-venoms, he is able 
 to produce a serum of antivenomous properties and capable of neutralizing 
 the poison of the most venomous serpents. The dose of this serum is about 
 20 c.c, and the serum Avill bear transportation to the tropics and yet retain 
 its antivenomous power. A number of very favorable cases are reported in 
 which lives have been saved by its use (see p. 127). 
 
 Glanders ; Mallein. — This disease is common to both animals and man. 
 The mallein, which is a glycerin extract of the toxins of the bacillus of glan- 
 ders has a twofold use — diagnostic and immunizing. Injected into a horse 
 having glanders, a characteristic "reaction" takes place. At the end of 
 four to six hours there is a rise of temperature which reaches its maximum 
 of 2^^ C. (3.6° F.) in eight to sixteen hours, rarely longer, and returns to 
 normal in twenty-four to thirty-six hours. This result does not take place 
 in unaffected horses. 
 
 Immunity follows the injection of gradually-increasing doses, and it is 
 asserted that cures have occurred both in man and in animals in chronic 
 cases treated in a similar manner. 
 
 Tuberculin. — The treatment of tuberculosis presents many difficulties. 
 In the first place, there seems to be no such thing as immunity. One patient 
 may have a tuberculous process continue for years, and another who has a 
 healed tuberculous lesion appears to be specially susceptible to reinfection. 
 The only conditions in which anything like immunity is obtained are those 
 in which there is a general dispersion of bacilli through the whole organism, 
 as in acute miliary tuberculosis or the form seen in guinea-pigs. 
 
 If dead bacilli are injected into living tissues, they |)roduce sterile abscesses. 
 The first attempt to secure cure and immunity was by the use of tuberculin, 
 which was a glycerin extract of the toxins of the bacilli of tuberculosis. The 
 iniection of this material gave a distinct characteristic "reaction," or rise of 
 tempei'ature. Tuberculous processes were seen to improve after its use. and as 
 the doses were increased the patient ceased to react even to large doses of the 
 tuberculin. This was a toxin-immunity, and not a bacterial immunity, and 
 only partly a toxin-immunity, as there are other toxins than those extracted 
 
BIIA CJIiriS. 85 
 
 with ;:;lyct'rin. 'I'lio iiiiprovc'iiK'Ht observed was doubtless due to the stimu- 
 hiting action of th<; toxin upon the tissue-cells. 
 
 Its use as a diagnostic agent has distinct value. Koch and many others 
 assert tliat there is no danger of setting bacilli free and causing a spread of 
 the disease, as others have maintained to be the case. Some people and some 
 animals react either when the tuberculosis is absent or when it is of but small 
 im]>ortance from a diagnostic point of view, being absolutely latent. Hence, 
 in its use, one has to take this fact into consideration. 
 
 Koch's new tuberculin, or tuberculin T. R., as it is called, is made with an 
 attempt to overcome the faults of the old glycerin extract. It is impossible, 
 as stated above, to introduce bacilli of tuberculosis and to have them absorbed 
 without abscess-formation. Hence the bacilli are mechanically broken up by 
 grinding in an agate mortar, are put in distilled water, and are centriiugalized. 
 The upper portion of the mass has the properties of the old tuberculin, while 
 the residue at the bottom has different properties, and is called Tuberculin 
 T. R. This contains the constituents of the bacilli insoluble in glycerin, pro- 
 duces no abscess or rise of temperature, and has immunizing power. This 
 immunization takes place in the course of about three weeks in guinea-pigs. 
 The period in man is also short — from four to six weeks. 
 
 The method of treatment is to begin with a dose of 5^75- of a milligram, 
 doubling the dose each day until a dose of 20 milligrams has been reached. 
 The course of treatment, therefore, covers about four w eeks' time if there are 
 no unpleasant reactions. Lupus and other surface-lesions seem to be most 
 easily affected. 
 
 Enough time has not yet elapsed to determine finally the exact curative 
 value of the proceeding. Though many favorable cases have been reported, 
 the results are not as satisfactory as could be wished. 
 
 Serum of horses treated with tuberculin has been tried, but without 
 special success, and now some are advocating the serum of horses that have 
 been treated with tuberculin T. R. 
 
 In tuberculosis, as in all cases in which orrhotherapy is employed, it is 
 well to begin the treatment in the earliest stage of the disease, in order to 
 secure the best results. 
 
 CHAPTER XV. 
 EHACHITIS. 
 
 The term rhachitis is derived from pd-'/e', the spine. The English name 
 rickets is. however, more commonly used. It is a general disturbance of the 
 nutrition of the body in infancy and childhood, and consists principally in an 
 insufficient deposit of lime-salts and in absorption of already-formed bone. 
 
 Etiology. — It is a disease seen chiefly among the poor in large cities, less 
 frequently in the country. It is much more common and severe in Europe 
 than in America. In America the disease is neither very prevalent nor very 
 severe, and except in colored children or in Italians and Portuguese very 
 great deformity is rare (Bradford). Bad hygienic influences, such as poor venti- 
 lation, damp dwellings, and crowded rooms, are frequent causes of the disease, but 
 the most important cause of all is improper feeding. The substitution of patent 
 foods for the mother's breast-milk is said to favor its development In menag- 
 eries, where animals live under highly artificial conditions, the disease is frequently 
 
86 A.\ AMKRICAX TEXT-llOOK OF SURGERY. 
 
 observed. In congenital sj'philis changes in the bones closely resembling those 
 of rickets are occasionally seen. The disease begins in the first or second year 
 of life, exceptionally after the fifth or sixth. It is not often seen in newborn 
 infants, but rliachitic changes are occasionally found in the bones during fetal life. 
 
 The pathological changes are due to the formation of incompletely 
 calcified bone. '* Osteoid tissue " persists, therefore, much longer than usual. 
 At the epiphyses there is an absence of the line of calcification ; there is a 
 great increase in size of the zone of cartilage-growth, and the medullary tissue 
 grows into the cartilage area in the most irregular manner. The cortical 
 portion of the bone becomes porous, and the trabeculne of the spongy bone 
 become thinner or disappear entirely. After the disease has run its course 
 calcification may take place on an increased scale, and sclerosis of the bone 
 may occur. Rhachitic bones are frequently so soft that they can be cut with 
 the knife, and as a result of this change great deformity often occurs. In 
 older children such changes are seen in the bones of the thorax, spine, and 
 extremities ; less frequently in the skull. The ligaments are relaxed and 
 movements of the joints are often painful. The promontory of the sacrum 
 is depressed, and the pelvis thus greatly narrowed. Curvatures of the spine, 
 as scoliosis or lateral deviation, kt/phosis or curvature with convexity back- 
 ward, and lordosis or curvature with convexity forward, are also observed. 
 In the skull the bones are often unnaturally thin and crackle under pressure 
 like parchment. This condition is known as craniotahes. Dentition is often 
 delayed, and during convalescence progresses with great rapidity. It is 
 always irregular. 
 
 The brain may be hypertrophied, and sometimes is sclerosed ; hydro- 
 cephalus may also occur. The bronchial tubes are filled with mucus, and 
 emphysema of the lungs is occasionally found. Evidences of intestinal catarrh 
 are seen. The spleen is often enlarged. 
 
 Among the early symptoms is restlessness at night, Avith a tendency to 
 profuse perspiration especially about the head ; the bowels are constipated and 
 the belly becomes distended. The urine is large in amount and loaded with 
 phosphates. In the bones the earliest changes are seen at the epiphyses, which 
 become thickened chiefly at the end of the radius, and in the ribs, where the 
 row of beaded enlargements is quite characteristic. "With the softening of the 
 bones deformities of the spine and extremities begin. The head is increased in 
 size, particularly the forehead and the frontal eminences. The distortion of 
 the ribs gives rise to the characteristic pigeon-breasted deformity. Catarrhal 
 affections, as bronchitis, and even pneumonia, may occur as complications, as 
 also laryngismus stridulus. Among important diagnostic symptoms are delayed 
 dentition and delayed closure of the anterior fontanel. A search for the 
 epiphyseal enlargements will usually settle the diagnosis. Rickety children 
 are often stunted in stature. 
 
 The prognosis is usually favorable. Deformity disappears in 90 per cent, 
 of the cases. A few cases terminate fatally from complications, such as 
 broncho-pneumonia. 
 
 In the treatment of rickets careful regulation of the diet is of the utmost 
 importance. Fresh food should be given in preference to prepared foods; 
 fresh milk properly diluted for infants, and meat-juice or raw beef for older 
 children. Fresh air and light in the nursery should be obtained if possible. 
 Salt-water bathing is highly recommended. Cod-liver oil is considered the 
 most valuable of drugs. Phosphorus is also a favorite remedy ; syrup of the 
 iodide of iron is perhaps to be preferred. Lacto-phosphate of lime is given on 
 theoretical grounds chiefly, but is a good tonic for children. Those modem 
 
CONTUSIONS AND WOUNDS. 87 
 
 inventions, "sea-.shore homes" and "clay nurseries," are particularly adajited 
 for the treatment of this disease. The surgical operations for deformities of 
 bones are described elsewhere. 
 
 CHAPTER XVI. 
 
 CONTUSIO^'S AND WOUNDS. 
 SECTION I.— CONTUSIONS. 
 
 An injury produced by a blunt body in which tissue-elements are more or 
 less rent asunder, but in Avhich there is no gross or manifest external breach 
 of tissue, constitutes a contusion. In a simple contusion or bruise the area of 
 damage is limited by the area of impact of the bruising body, but the amount 
 of damage may be of any grade, from the imperceptible molecular division of 
 a slight bruise to the pulpification of large masses of tissue. The element of 
 contusion is present as a complication of most wounds, and in many constitutes 
 a grave and most important factor. The distinction between a contusion and 
 wound is therefore one of degree and not of kind. A contusion should be 
 defined more properly as a hidden wound, the firmer tissues of the skin being 
 able to resist the rending effect of the blow, which produces its greater effect 
 upon softer tissues underneath. Whether an injury shall be defined as a con- 
 tusion or a wound depends also upon the character of the injured structures and 
 the nature of the tissues which lie underneath the surface. Thus a hard, bony 
 surface, so related to the tissues on which a blow is struck that they are forced 
 against it by the bruising body, will necessarily aggravate an injury, and much 
 more readily cause an absolute destruction of all the tissues, including the skin, 
 and so produce a wound, than if a thick cushion of soft tissue alone is involved. 
 The results of blows over the shin are examples of the first, while those upon 
 the surface of the abdomen or upon the fleshy masses of the nates or the thighs 
 are examples of the second. 
 
 Pathology. — The pathology of a contusion is that of a subcutaneous 
 wound. The more delicate and easily-torn tissues suffer first and most exten- 
 sively ; ruptured blood-vessels give rise to more or less hemorrhage; injured 
 nerve-fibrils are the sources of pain ; functional disability follows according 
 to the extent and character of the tissues injured; local swelling, both from 
 hemorrhage and from serous effusion, quickly ensues. When the effused blood 
 ahows itself as a somewhat diffused subcutaneous discoloration, an ecchymosis is 
 said to be present ; when, however, it is collected in a more or less well-defined 
 cavity, so as to constitute a blood-tumor, it is known as a hematoma. When 
 blood-vessels of some size are involved in a contusion, special conditions of 
 hemorrhage may ari.se ; thus they may be either ruptured outright or their walls 
 so bruised that they subsequently slough, and so occasion a later hemorrhage. 
 The hemorrhage from the smaller vessels is usually soon controlled after moder- 
 ate escape of blood by the reactive pressure of the surrounding engorged tissues. 
 The force of the blood-current in large veins and in most arteries is likely to 
 be such as to cause a considerable loss of blood, especially when it escapes into 
 any of the great cavities of the body or when the locality involved is one in 
 which there is present much loose connective tissue. Contusions of nerves 
 may produce more or less paralysis of the regions supplied by them. A pro- 
 gressive degeneration of a nerve may result from the changes produced in it 
 
88 A.\ AMI'JilCAX TKX'l-BOOK OF SrUCKHY. 
 
 by a violent contusion. The effects of contusions of muscles depend upon the 
 extent of the damage done ; local soreness and pain upon movement attend 
 less severe injuries ; rapid recovery under rest and proper treatment is to be 
 expected in such instances ; from even quite extensive lacerations ultimate 
 rectnerv with full functional power often takes place. In less favorable cases, 
 however, atrophy, contracture, and permanent loss of power may result. The 
 contusions of bone Avhen short of absolute fracture are usually rapidly recov- 
 ered from, but may develop into acute or chronic inflammatory conditions or 
 determine caries or necrosis, or even the development of malignant changes. 
 
 Diagnosis. — The symptoms which indicate the occurrence of a contusion 
 are easily recognized. The part is tender and quickly becomes somewhat 
 swollen, with some elevation of temperature. In simple and superficial con- 
 tusions discoloration of the skin soon declares itself as the result of the 
 subcutaneous hemorrhage. In cases where deeper structures are especially 
 contused the appearance of the external discoloration may be delayed for some 
 days, owing to tlie slowness with which the effused blood finds its way to the 
 surface. Loss of function may be present, dependent upon the character of 
 the tissues injured and the extent of the injury inflicted. The amount of 
 pain in the part may vary. At first there is numbness, followed quickly by 
 severe acute pain, which gradually subsides with the lapse of time. Shock is 
 almost always present to some extent. Contusions of moderate severity pro- 
 duce a degree of shock characterized by momentary stunning ; others of greater 
 severity may produce faintness or total loss of consciousness for a variable 
 period ; while in the more severe cases, as in contusions of the abdomen, 
 immediate death may ensue. 
 
 Treatment. — For the general shock and the local pain the treatment 
 required for such conditions accompanying any injury is indicated. For 
 the contusion itself the first thing to be secured is rest to the injured part. 
 This is especially important when the contusion is severe and the injuries to 
 deeper structures are extensive. For securing rest, if voluntary immobiliza- 
 tion is not sufficient, the use of apparatus of some kind may be required. 
 Bandages, slings, splints, a recumbent position in bed, all may have their use. 
 By rest local irritation is diminished, hemorrhage and inflammatory effusions 
 are restricted, the absorption of effused fluids and of necrotic tissue is favored, 
 and the normal repair of the injured tissue is fostered. Of all means for 
 treating these injuries, rest is the one of primary and greatest importance. 
 
 Next, hemorrhage and serous effusion may require attention. Equable, 
 elastic, and firm compression is to be recommended for their control. Com- 
 presses of cotton wool secured by proper bandages are especially serviceable for 
 this purpose. A simple flannel bandage alone will often be of great service. 
 When, for any cause, the use of compresses and bandages is inconvenient or 
 undesirable, some advantage may be obtained from the ap])lication of cold, by 
 ice-bags, evaporating lotions, or affusions of cold water. In the more severe 
 forms of contusion cold is to be used with caution, since by its continued use the 
 vitality of the parts is depressed, and tissues which under more stimulating 
 treatment might be preserved from necrosis and regain their normal condition 
 may be precipitated into absolute death. In the slighter and more superficial 
 forms of contusions evaporating lotions are frequently both convenient and effi- 
 cient. As an example of such a lotion a solution of chloride of annnonium and 
 alcohol (gr. v (o^ f5j) is to be recommended. Tincture of camphor, tincture of 
 arnica, tincture of witch-hazel, all favorite popular Applications for contusions, 
 are of use, but depend for their efficiency chiefly upon the alcohol which they 
 contain. 
 
COXTUSIOXS AXl) WOUNDS. 89 
 
 In eases in Avhieli much bruising and disorganization of tissues are present 
 great care must be taken to avoid everything which may still further depress 
 the vitality of the part. The indications are, then, to support and stimulate. 
 In addition to the rest already recommended, a moderate amount of heat will 
 be of use ; hot-water bags, the hot-water coil, masses of cotton wool, or flan- 
 nel previously heated, may be found useful. In the later history of many 
 contusions massage and stimulating liniments are of value. Thev promote the 
 activity of circulation in the part, break up and diffuse among the tissues 
 blood-clots and serous accumulations, and hasten their absorption ; they pro- 
 mote the nutrition of the injured tissues, break up adhesions, and expedite 
 the return of the normal functional activity of the contused parts. Blood- 
 extravasations as a rule should be left to the natural processes of absorption 
 for their removal. 
 
 Blood-effusions Avidely dispersed along connective-tissue planes, infiltrating 
 tissues already lowered in their vitality by a contusion, present conditions 
 eminently favorable for the development of widespread and disastrous septic 
 infection, for which reason an attempt to evacuate a hematoma by incision 
 under ordinary circumstances is always to be deprecated. When, however, 
 continuous subcutaneous hemorrhage is present, showing the existence of a 
 wound of a vessel of importance, it is imperative to make a free incision, so as 
 fully to expose the wounded vessel, and to apply a ligature to it. In such 
 cases the incisions through the external parts should be very free, and all 
 recesses into which the effused blood has found its way should if possible be 
 opened up. All clots should be turned out, and the most perfect disinfec- 
 tion and drainage of the infiltrated areas provided for. Circumscribed blocd- 
 tumors may sometimes be relieved by aspiration. After the lapse of two or 
 three weeks from the time of the original injury any persisting blood-tumcr 
 may be more freely laid open and its contents evacuated ; by this time it will 
 be surrounded by a layer of condensed connective tissue reinforced by inflam- 
 matory exudation ; the surrounding tissues will have recovered from the state 
 of depression immediately following the injury ; and as the result of these con- 
 ditions the danger of septic infection will have greatly diminished. 
 
 Severe inflammatory reaction following contusion must be treated upon 
 general surgical principles, including rest, elevation of the parts, evaporating 
 lotions, together with such constitutional measures as may be required for 
 relieving pain, reducing temperature, and lessening the intensity of the general 
 febrile reaction. If suppuration occurs, adequate incisions must be made for the 
 evacuation of the pus ; if local gangrene threatens, stimulating applications are 
 first required, as dry heat or stimulating liniments, until the line of demarcation 
 of the slough is distinctly formed. Fomentations should now be used, composed 
 of compresses wet with some antiseptic solution and covered with rubber dam 
 or oil silk, to hasten the separation of the slough. If phlegmonous inflamma- 
 tion advances into adjacent parts, free incision into the inflamed tissues, with 
 abundant antiseptic irrigation and iodoform tampons, should be used. 
 
 SECTION II. — WOUNDS. 
 
 A "WOUND is a solution of continuity of any tissue, produced either directly or 
 indirectly by sudden mechanical force. The occurrence of a solution of continu- 
 ity in any of the solid tissues of the body may be due to slowly-acting causes, as 
 the gradual waste of atrophy, or the more active disintegration of ulceration ; 
 but a breach of tissue thus affected would not be a wound. There is involved 
 in the idea of a wound the action of a force outside of the tissue itself, which 
 by mechanical violence has rent or divided its substance. The term " wound," 
 
90 
 
 .-l.V AJfKL'fCAX TKXT-JiOOK o/' SI ' l;( ; i:i! V. 
 
 tlierefore, is susceptible of a very wide range of application. Contusions, 
 sprains, fractures, subcutaneous as well as cutaneous breaches of tissue, are 
 included in the term. In all essential particulars they are identical accidents, 
 involving the same methods of repair and subject to the same principles of 
 treatment, the apparent differences depending upon accidental differences of 
 structure, function, nutrition, relation to other parts, extent of traumatism suf- 
 fered and of exposure to intiuences from without. In the present chapter the 
 ■wounds of bones will not be considered. 
 
 Classification. — Wounds may be divided primarily into the two great 
 classes of subcutaneous and open wounds. Subcutaneous wounds include all 
 which are unaccompanied by breach of the skin. Protected by the unbroken 
 skin from external irritation and infection, their repair is usually rapid and 
 undisturbed by untoward irritations. The preceding paragraphs devoted to the 
 consideration of contusions are descriptive of the greater number of subcuta- 
 neous wounds. Open wounds, as a class, include all in which there has been a 
 breach of the skin or mucous membrane. 
 
 Open wounds are subdivided, according to the manner in which they are 
 produced, into incised, punctured, contused, lacerated, gunshot, or poisoned 
 wounds, according as the wounding agent has been a sharp cutting edge, a 
 penetrating point, a dull and bruising body, a tearing force, a projectile 
 impelled by the force of an explosive, or one which carries with it into the 
 wound a poison. Penetrating wounds are those in which the vulnerating 
 body enters a cavity without emerging ; perforating wounds, those in which 
 the vulnerating body both enters and emerges from the cavity. 
 
 All wounds are accompanied by death of tissue in their track ; even the path 
 of the keenest knife-edge through a tissue is lined by disorganized particles 
 that have been killed by its impact. Between a slight and clean incised wound, 
 in which the destruction of tissue is limited to the molecules traversed by the 
 
 Fig. 22. 
 
 Showing the Extensive and Frightful Effects of a Severe Accident (original i. 
 
 cutting instrument, and an extensive lacerated wound (Fig. 'I'l), with roughly 
 torn and contused edges, or between a slight bruise and a contusion producing 
 the death and disorganization of large masses of tissue, the diff'crence is one 
 of degree and not of kind. The important practical difference which has 
 
COATi)SJOA\S AND WOUNDS. 91 
 
 always been recognized in the healing of these different classes of wounds 
 depends simply upon the difference between tlie facility with which the devi- 
 talized tissue is j)revented from becoming a source of disturbance to the heal- 
 ing of the wound in the several instances. 
 
 Wounds may be again classed as aseptic and septic. Asejitic wounds include 
 all which are preserved from contamination by poisonous bacterial products, 
 whether such poison come in contact with the wound directly or be generated in 
 it by the action of germs that gain access to it. An aseptic condition in a wound 
 may be obtained either by the protection which the wound received from the first 
 against the access of any septic agent, or by the power of tissues to resist and 
 destroy septic agents, or by the application to the wound of substances which 
 destroy them. Subcutaneous wounds, as a rule, remain aseptic in consequence 
 of the protecting covering which the skin affords; operative wounds inflicted 
 under certain precautions may be aseptic ; all open wounds in which union by 
 first intention is secured without special and adequate aseptic precautions are 
 examples of the power of living tissues to resist septic infection. Septic wounds 
 include all those in which any agent capable of exciting fermentation or putre- 
 faction lodges and grows. In all cases they are attended Avith some degree of 
 inflammation and suppuration and with sloughing of dead tissue. 
 
 Symptoms. — The symptoms indicative of a wound are local, dependent 
 upon the efi'ects produced at the point at which the wound is inflicted, and con- 
 stitutionalj dependent upon the effects on the body at large. 
 
 Local Symptoms. — First, Impairment of Fuxctiox. — A certain 
 amount of disability is the inevitable result of a division of tissue. Its extent 
 and nature will depend upon the amount of injury and the tissue injured. The 
 duration of the disability will depend upon the promptness of healing and the 
 susceptibility of the wounded tissue for perfect repair. 
 
 Divided tissues tend to retract from each other, and thus a greater or less 
 amount of gaping becomes a wound-symptom. 
 
 Pain is a usual accompaniment of a wound. It is due to the irritation 
 sustained by the sensory nerves. The amount of pain is of variable quantity. 
 At the moment of the infliction of a wound no pain at all may be experienced, 
 owing to mental preoccupation or excitement or to the rapidity with which the 
 wound was inflicted. The temperament of the individual may modify the 
 amount of pain. Some individuals experience great pain from causes which in 
 others produce but little suffering. The sharp pain usually felt at the moment 
 of the infliction of a wound soon gives way to a dull aching or smarting pain, 
 which may last for some hours, but will finally subside and disappear, provided 
 the Avounded parts are kept at rest and their repair progresses without disturb- 
 ance. Attempts at motion in a wounded part, which tend to pull apart the 
 divided tissues, or the occurrence of a high orrade of inflammation, causing 
 tension and excessive congestion, awakens pain anew. "When large sensory 
 nerve-trunks have been involved in wounds, later and continuous pain may be 
 due to slight inflammatory conditions extending from the wound upward along 
 these nerves ; hence the pain often complained of in the stumps of amputated 
 limbs during the first few days following operation. 
 
 Hemorrhage. — Some amount of bleeding is the immediate effect of every 
 wound. It is always the invariable and most manifest symptom that a Avound 
 has been inflicted, but the amount of the blood lost may vary greatly according 
 to the constitutional condition of the wounded person, to the character of the 
 tissue wounded, and to the size of the blood-vessels implicated. In scorbutic 
 conditions of the system, and in those occasional instances where a hemor- 
 rhagic diathesis exists, prolonged and even dangerous loss of blood may result 
 
92 .L^' AMERICAN TEXT- HOOK OF SLRGEliY. 
 
 from a trifling wound. Ordinarily, when merely capillai-ics or small arterioles 
 or venules are divided, spontaneous cessation of licinorrhajije quickl}- occurs, 
 especially if the tissues wounded are retractile, so that the wounded vessels 
 become withdrawn among and embraced by them. AVhatevcr favors the 
 production and retention of a clot about a wounded vessel favors the arrest of 
 hemorrhage; hence lacerated wounds, where the wound-edges are ragged and 
 the openings of the vessels themselves irregular, the coats of the larger vessels, 
 being unevenly divided, are not likely to bleed much, on account of the entan- 
 glement of the blood-fibrin in the irregularities of the wound-surfaces and the 
 speedy production of blood-clot. When large blood-vessels are opened profuse 
 and speedily fatal hemorrliage may occur. 
 
 Shock. — The primary constitutional symptom of a wound is "shock." 
 Shock is that condition of general vital depression which marks the immediate 
 effect upon the individual as a whole produced by the local wound. It may 
 be of any grade of intensity, from a slight, evanescent, and hardly appreci- 
 able disturbance of mental force to the most profound general depression and 
 speedy death. Its manifestations are through the nervous system, and are 
 exhibited most markedly by depressed action of the circulatory organs — vaso- 
 motor paralysis. Shock is to be distinguished from the effects of hemorrhage ; 
 and in cases of surgical operations from the effects of anesthetics, although in 
 many instances it may be aggravated by either or both. Martin and Hare 
 have recently proposed to use the hemoglobinometer as a means of distinguish- 
 ing hemorrhage, especially intra-abdominal, from shock. In shock the hemo- 
 globin would be unaltered ; in hemorrhage the hemoglobin would be greatly 
 diminished. The pathology of shock cannot be determined by the ordinary 
 methods of research. In such cases death leaves no change which can be 
 detected in any of the tissues. The eff"ects manifest themselves chiefly through 
 the agency of the nervous system in the same way as all the phenomena of life 
 which are controlled by that system. Sometimes, however, as seems to have 
 been shown by Goltz, a marked distention of the intra-abdominal veins exists. 
 The phenomena of shock must be accepted as the measure of the ability of an 
 individual to resist hurtful influences from without. The same injury will 
 produce different degrees of shock in different individuals, and diff"erent degrees 
 likewise in the same individual at different times. Women, as a class, are less 
 susceptible to shock than men. Persons who are inured to suffering, or who 
 by long confinement to bed or by. the influence of drugs have acquired a cer- 
 tain torpidity of the nervous energies, are less susceptible to shock than indi- 
 viduals whose nervous forces are in a high degree of activity. Temperament 
 modifies the manifestations of shock. The phlegmatic and lymphatic tem- 
 peraments resist shock ; the sanguine and mobile temperaments favor it 
 in the highest degree. Mental conditions modify shock ; fear, despair, despond- 
 ency, disappointment, depressed mental states of any kind, aggravate shock ; 
 on the contrary, hope, joy, cheerfulness, glad expectation, success, diminish 
 shock. Age modifies shock. The young bear injuries well, and rally 
 quickly from shock Avhen unaccompanied with much loss of blood ; in the 
 aged the frequent presence of organic disease often renders shock more severe 
 and })rolonged. In the absence of organic derangements the dulled nervous 
 susceptibility of the aged diminishes their liability to shock. 
 
 Symptoms of Shock. — The symptoms of shock are those of geno-al depres- 
 sion : the skin is pale and cool ; the pulse is feeble and rapid, the respiration 
 is shallow and irregular; the body-temperature is lowered; a sense of faintness 
 is experienced by the individual, and in the more severe forms total loss of 
 consciousness ensues ; the functional activity of all the organs of the body is 
 
CONTUSIONS AND WOUNDS. 93 
 
 retarded ; musc-ular tone is diminished, with a sense of general muscular pow- 
 erlessness ; the sphincters may fail to act, causing involuntary evacuations ; 
 nausea and vomiting often occur. Every degree of intensity in these symp- 
 toms of depression which have been enumerated may exist in diff'erent cases, 
 from a transient feeling of weakness and momentary mental confusion to abso- 
 lute death. The symptoms of shock are the immediate consequence of the 
 injury sustained. The assumption of the possibility of a condition of delayed 
 shock is not consistent with what has been said as to the nature of shock 
 itself. Whenever a condition of sudden and marked depression declares itself 
 some time after the reception of an injury, it is always due to some dis- 
 tinct cause other than the original injury, and when recovery from shock is 
 delayed and manifests oscillations of improvement and retrogression, distinct 
 diseased conditions, possibly directly resulting from the injury, are always its 
 cause. For this reason the terms which are found in older text-books, and 
 which are still often used in ordinary surgical parlance — namely, delayed 
 shock, secondary shock, and imperfect reaction from shock — may be misleading, 
 as they tend to divert the attention from real conditions. The conditions 
 which most frequently cause these symptoms of later depression are concealed 
 hemorrhage, septic infection, and fat embolism. Pulmonary oedema and renal 
 congestion are also possible conditions always to be inquired after when a 
 sudden unfavorable turn occurs in the condition of a patient soon after an 
 injury has been sustained, especially when ether has been used as an anesthetic. 
 The occurrence of any of these conditions may, of course, produce its own 
 shock, but this shock arises de novo. 
 
 Prognosis of Shock. — Very quick and complete recovery from a state 
 of most profound shock may occur. The chief elements upon which recovery 
 from shock depend are these: First, whether the injury has to do with a vital 
 part ; and second, whether it entails a continued source of irritation and depres- 
 sion. Thus in injuries to the head the immediate shock may be overwhelm- 
 ing in consequence of the vital relations of the injured part, or Avhen not at 
 once fatal may be continued and masked by inflammatory conditions arising 
 in the cerebral tissues as a consequence of the injury. So in crushing 
 injuries of the extremities: the immediate shock of the injury may be pro- 
 longed and intensified by the pain and irritation arising in the mangled tissues, 
 so that the surgeon is often called upon, even in the presence of much general 
 shock, to run the risks of subjecting his patient to the additional brief shock 
 of an amputation, rather than to leave him exposed to the continued irritation 
 of his mangled limb, with possible added septic infection, while waiting for reac- 
 tion to be established. In general it may be said that Avhen an injury is not 
 primarily fatal through shock, and continually renewed shock can be prevented, 
 speedy recovery therefrom may be confidently looked for under proper treat- 
 ment. Severe shock is so often complicated with the acute anemia caused by 
 loss of blood that it is difficult to separate its prognosis and its treatment from 
 those of the latter condition ; nor in practice is it essential to do so. 
 
 Reaction. — The symptoms which indicate the passing away of the effects of 
 shock are a gradual increase of the strength and volume of the pulse, a dimi- 
 nution in its frequency, a more natural color and heat of the skin, return of con- 
 sciousness, and the manifestation of muscular power, as the shifting of his position 
 by the patient. The appearance of such favorable symptoms constitutes w^hat 
 is termed a state of reaction. In the most favorable cases reaction is gradual 
 and progressive, though it may occupy many hours or even days in its course. 
 Returning color to the face and an increased power in the heart's action are 
 unmistakable signs of its occurrence. In certain cases fluctations in the reac- 
 
94 A.y A.VKIUCAX TEXT-IIOOK OF SintdKRY. 
 
 tioH occur, relapse alternating with improvement for a variable time. The real 
 significance of such fluctuations has already been (hvelt upon. In other cases, 
 before perfect reaction ha»s been accomplished, there supervenes a condition 
 characterizeil by a rapid and weak heart's action, cerebral excitement and 
 delirium, muscular tremor, and high body-temperature. These are the signs 
 of septic infection. Reaction from shock is commonly attended by some ele- 
 vation of the body-temperature, quickening of the pulse, thirst, derangement of 
 the secretions, restlessness, and headache. This fever attending reaction may be 
 so trifling and evanescent as to escape notice. Its grade of severity depends 
 chiefly upon the nervous activity of the patient, his previous constitutional 
 condition, and the amount of local irritation produced by the injury, ("liil- 
 dren manifest it most readily. It makes its appearance usually within a few 
 hours after the reception of an injury, and may be expected to decline on or 
 after the second day. This aseptic fever is to be distinguished from the 
 traumatic or surgical fever which sometimes complicates the repair of injuries, 
 which does not develop until two or three days after an injury, and which is 
 dependent upon general blood-infection by absorption of septic matter from 
 the injured part. 
 
 Propliylaxh of Shock. — In cases of surgical operations it is possible for 
 the surgeon to diminish to some extent the shock resulting from the wounds 
 inflicted. These means include moral, physical, and medicinal measures. The 
 patient should be inspired to believe that success will crown the surgeon's 
 efl"orts. and to place implicit reliance upon his skill. However plainly the 
 surgeon should state the possibilities of mischance to the friends of the patient, 
 nothing but hope and happy expectation should usually be expressed to the 
 patient himself. Among physical means are included all measures of a general 
 character which tend to diminish nervous irritability and promote the general 
 resisting power of the individual. Confinement to the bed for some days is of 
 value as a nervous sedative. The regulation of all the secretions of the body 
 80 as to secure as nearly a perfect condition of well-being as possible is not to be 
 overlooked. The choice of the period of the day for operating when the vital 
 powers are at their best is likewise to be considered. As a rule, this is during 
 the morning hours. All unnecessary exposure of the body occasioning loss of' 
 body-heat is to be avoided ; if the operation is to be long, artificial heat by hot- 
 water bags and bottles should be applied during the operation. Hemorrhage 
 is to be carefully guarded against and restrained. 
 
 Medicinal measures include the use of narcotics, as opiates, the bromides, 
 and the free administration of alcohol. These may be of benefit when a state of 
 excessive nervous irritability has to be antagonized. They are of special value 
 in preparing alcoholic subjects for operation. In patients the subjects of 
 malarial cachexia the free preliminary use of quinine should be resorted to. 
 The administration of an anesthetic should be conducted with great care, lest 
 the depressing eff"ect of excessive anesthesia should be added to that of the 
 surgical procedure, but at the same time complete anesthesia should be secured. 
 For the same reason, while avoiding undue haste, operations should be done a? 
 quickly as possible. Strychnia may be used hypodermatically in full medicinal 
 dose, "517 ^^ TmT ^^ ^ grain, after anesthesia has been induced, at the beginning of 
 serious surgical procedures, as a prophylactic against shock through its stim- 
 ulating action upon the cerebro-spinal centers. 
 
 Treatment of Shock. — Shock, having once become established in a severe 
 degree, requires prompt treatment. If it occurs in the course of a surgical 
 operation, the operation must be brought to a conclusion as speedily as possible, 
 or may even have to be suspended. The head should be lowered and the body 
 
CONTUSIONS AND WOUNDS. 95 
 
 placed ill tlio reeuiiibciit j)()sitioii, if it is not already so. l{esj)iration should be 
 kept free from impediment, and when practicable thestiinulatiiiiT effect of inhala- 
 tions of oxyijen should be resorted to. Tloat should be applied not only to the 
 extremities, but to tlie whole surface of the body as far as juacticahle. Hot- 
 water bottles and hot blankets should iiave been ])r(»vided for this j)urpose. In 
 cases of severe shock an ellicient and S})eedy method of api)lyiii<f heat is to wrap 
 the whole body in bhmkets wrung out of hot water. Diffusive stimulants 
 should be instantly and freely administered. The most (juickly acting and 
 reliable stimulation is obtainable by an intravenous injection of a hot (48.3°- 
 44.5° C. : 110°-112° F.) normal saline solution (.^ to ()j). Such injection 
 is especially important when the injury has been accompanied with loss of 
 blood. As the right heart feels the pressure of the injected fluid, the lieart- 
 beats become lengthened and more forcible, and the blood-pressure in the 
 peripheral vessels rises. To ensure permanence in this cardiac and vascular 
 reaction the amount of fluid thrown in should be large — from one to two 
 quarts; or, better, repeated injections of smaller quantities — twenty to forty 
 fluidounces — should be made; renewal of the injection being made as the 
 effects of the previous one are found to be waning. Ilypodermoclysis — an 
 injection into the subcutaneous cellular tissue — is valuable as a substitute for 
 intravenous injection, in cases of less emergency, or in the absence of facil- 
 ities for its proper performance. The injecting-needle may be thrust into 
 the loose tissue under each breast, where from twenty to thirty ounces of 
 fluid can be readily forced into the connective-tissue spaces. (The technique 
 of transfusion and of hypodermoclysis, and the best formula for the solution, 
 will be found under Minor Surgery.) High enemata of hot liquids, a quart 
 or more, are of great value, either alone or as an adjuvant to the measures 
 named. An infusion of black coffee (f.5iij) and whiskey (f.^), or an emul- 
 sion of turpentine (f 5ss of the turpentine), adds additional stimulating power 
 to such enemata. 
 
 Strychnia, in dose of -^^ grain, repeated every half-hour until four doses 
 have been given, and afterward at intervals of four hours, is most valuable 
 in maintaining cardiac energy. It should be used in connection with the 
 diff'usible stimulants. Nitroglycerin, in doses of -^^ grain, may be given 
 with the strychnia. 
 
 In the lesser degrees of shock dependence may be placed on Avhiske}^ 
 half an ounce by the mouth every half-hour, or one dram under the skin 
 every fifteen minutes, till reaction has been secured. Recovery from shock 
 under proper treatment, if it occurs at all, is usually quite speedy ; delay in 
 recovery or alternations of improvement and relapse, as has already been 
 stated, are due to the nature of the injury itself or to new complications in- 
 troduced, and are not to be attributed to or classed as shock. 
 
 Death from shock may be immediate or gradual. When instantaneous death 
 takes place the nerve-centers must be considered as having been overwhelmed 
 beyond the power of resistance. In some such cases the heart has been 
 found contracted and empty. More commonly the fatal issue occurs only after 
 some minutes or hours of struggle against the inevitable. The fatal approach 
 is then more gradual ; the action of the heart becomes more and more feeble ; 
 the pulse, weak and thready and counted with difficulty on account of its 
 rapidity, becomes finally lost ; the extremities become cool, the face pinched 
 and haggard ; the mind, apathetic, gradually sinking into unconsciousness ; 
 the temperature continues to fall until it becomes a degree or more subnormal ; 
 the respiration is feeble and shallow, until finally, by combined respiratory and 
 cardiac failure, death closes the scene. 
 
•JG .l.V AMERICA y Ti:XT-Ji(j(JK OF .Sf/.'f./J/n'. 
 
 Fat Emrolijs.m. — Injuries, especially those c»f bones and of soft jtarts 
 involving much adipose tissue, when there is much crushing of the parts, 
 through the fact that many fat-cells are broken down and minute fat-globules 
 set free, mingling with the eftused fluids and wound-secretions, may exhibit a 
 train of symptoms which are due to the entrance into the circulation of this 
 fluid fat. The condition is known as fat embolism. In extensive compound 
 and multiple fractures its most severe forms are likely to be developed, causing 
 symptoms complicating and succeeding those of shock, and often resulting in 
 death. These deaths have commonly been attributed to shock ; their real 
 cause has only been appreciated within a few years, and even now is fre- 
 quently overlooked. Fat embolism is rare in children, because their skeletons 
 contain relatively little fat. The severity of the symptoms depends on the 
 quantity of fat which has gained entrance to the circulation, on the rapidity 
 with which it has entered, and on the proximity of its source to the heart. 
 Having once gained access to the general venous current, the fatty globules 
 are carried to the right heart, and thence are driven with the blood-stream 
 into the pulmonary capillaries, which they plug up to a greater or less degree, 
 and by their presence here determine the first symptoms of fat embolism. 
 When the amount of fatty material which is poured into the capillaries of the 
 lungs is not verv great or when it arrives but slowlv. the disturbance which 
 it causes may be but slight ; gradually the oil-molecules are forced through 
 and pass on into the general circulation. They may now again be arrested 
 in the capillaries of the brain or spinal cord, and here excite the special 
 disturbances incident to lesions of these organs. More frequently they are 
 arrested and disposed of in the liver and in the kidneys. The urine secreted 
 by kidneys thus blocked up by fat will present oil-globules floating on its 
 surface. 
 
 The symptoms of fat embolism as a rule develop within from thirty-six to 
 seventy-two hours after an injury, though fatal cases are recorded in which the 
 symptoms developed and ran their entire course in less than twelve hours. The 
 symptoms indicative of the lesser degrees of fat embolism are restlessness, 
 anxiety, slight dyspnea, and accelerated breathing, with quickening of the 
 pulse. In the more severe degrees these conditions become aggravated, general 
 prostration rapidly increases, the countenance becomes pallid and anxious, and 
 later cyanosis, mental excitement, delirium, somnolence, and coma succeed in 
 turn. The dyspnea becomes intense, the respiration very rapid, and finally 
 stertorous. CEdema pulmonum develops : hemoptysis may occur; the pulse is 
 weak, frequent, irregular, and finally imperceptible. The temperature at first 
 is subnormal, and may remain so, or may rise later, according to the develop- 
 ment of secondary complications. The urine will display oil-globules floating 
 on its surface. 
 
 Diagnosis of Fat Embolism. — Fat embolism is to be distinguished from 
 shock, the effects of anesthetics, acute septicemia, acute congestions of the 
 lungs and of the kidneys, and cerebral hemorrhage or embolism. It is to be 
 distinguished from shock by the fact that its symptoms make their appearance 
 at a time when the symptoms of shock should have greatly subsi<led, and in 
 many cases where in the first place the amount of shock has never been verv 
 great. The remote effects of ether are not so easily to be distinguished from 
 the effects of fat embolism. The irritative effects upon the lungs and the kid- 
 neys of the prolonged administration of ether to persons predisj)osed to pul- 
 monary or renal congestion often declare themselves in severe congestion, which 
 determines symptoms not unlike those of fiit embolism. In cases, tnerefore, in 
 which such administration of ether has been resorted to the diagnosis mav be 
 
COXTUSIOXS AM) WOIWDS. 97 
 
 made obscure. The appearance of oil-globules floating on tlie urine would be 
 sufficient to determine the presence of fat embolism. The symptoms of acute 
 septicemia are later in their development than those of embolism. They are 
 acconi])anied by marked elevation of temperature. They arc more gradual 
 in their onset, however active their course may be, and not infrequently are 
 engrafted upon those of fat embolism. The sequence of the conditions of 
 shock, ftit embolism, and acute septicemia is not infrequent, and, when its pos- 
 sibility is borne in mind by the surgeon, will readily explain the course of 
 many otherwise anomalous cases. Acute inflammatory states of the lungs 
 arising from conditions entirely independent of fat embolism may develop 
 rapidly after operations or injuries, and are to be distinguished from the efi'ects 
 of fat embolism, which may also be present and which may be masked by them. 
 The symptoms indicative of such acute inflammatory lung congestion are suffi- 
 ciently clear for diagnostic purposes if attention is only directed to them. The 
 danger is rather that the symptoms of fat embolism will be confounded with 
 them than that they should be mistaken for fat embolism. The not infrequent 
 occurrence of acute renal congestion, with total arrest of the urinary secretions, 
 after a severe operation, is to be borne in mind by the surgeon in making his 
 diagnosis as to the cause of threatening symptoms which complicate or super- 
 vene upon the shock of the original operation or injury. The disturbance of 
 cerebral conditions likew;ise, through embolism or cerebral hemorrhage, is to be 
 borne in mind as a possible occurrence. 
 
 Prognosis of Fat Embolism. — AVhen the symptoms indicating the presence 
 of fat embolism are severe the probabilities of recovery are very slight. In 
 its lesser degrees the disturbances caused by it are transient and are speedily 
 and spontaneously recovered from. The prognosis depends upon tAvo factors 
 especially — the amount of fat that has gained access to the circulation, and the 
 ability of the heart to force the oil-globules through the capillaries of the lungs. 
 Should this first danger have been overcome, possibilities of renewed danger 
 from arrest of oil-globules in the capillaries of the brain or spinal cord in 
 vital regions still exist. In such conditions a fatal result is not long delayed, a 
 few hours only sufficing to bring the case to a close. When the pulmonary 
 trouble is the chief one, a longer time may be ret^uired to determine the final 
 result, whether recovery or death. At best, however, the struggle is a brief 
 one, and is determined one way or the other within less than forty-eight hours. 
 Treatment of Fat Embolism. — The first indication for treatment is to pre- 
 vent, if possible, and at all events to diminish, the entry of fatty matter into 
 the blood-current. The two conditions that foster this accident are the churn- 
 ing up of bruised and broken fatty tissue by movements of a part, and the 
 tension resulting from the accumulation of wound-secretions that have no vent. 
 Immobilization of the injured part and relief to tension by provision for free 
 drainage are therefore of primary importance. The second indication for 
 treatment is to sustain and stimulate the action of the heart. For this purpose 
 alcohol, digitalis, and strychnia in full doses will be found useful. 
 
 REPAIR OF WOUNDS. 
 
 The repair of all breaches of tissue is accomplished by essentially the same 
 process, subject only to minor peculiarities of structure. This process has been 
 described in a preceding section (Process of Repair). By reference to this 
 section it will be seen that the essential element of repair consists in a modifi- 
 cation of the normal nutritive processes at the seat of injury, by which the 
 tissues to be repaired return to their embryonic state and new embryonic tissue 
 
•98 .l.V AMKh'K'AX TEXr- IK )<>K OF SCUdl.HY. 
 
 is i"(>niic(l between tliein. witli wliicli tlicv hlcml. \\\ the or^raiii/ation aiul 
 development of" the new tissue a |)erniaiient ttoiid of" uiiioTi is foimccl. In no 
 case is union of divided tissue effected without tlie inteijtosition of new material. 
 AVheii divided tissues are at once hrouf^ht into jx'rfect apposition, and there 
 retained and shielded from disturbance, the amount of new tissue required 
 for the accomplishment of union will be extremely small, and may be with 
 difficulty recognizal)le ; but its existence in some degree is nevertheless 
 undeniable. 
 
 When the process of i-ejiair wliereby the union of divided surfaces is secured 
 proceeds without comj)lication or interruption, union by first intention or by 
 primary adhesion is said to have taken place. (See Cha])ter TIL) This pri- 
 mary union is the ideal to be sought for whenever possible. To secure it it is 
 necessary that the divided surfaces be brought together and kept in close 
 apposition ; that the wound be protected and kept from all further injury ; and 
 that adefjuate local nutritive conditions be maintained. Wliatever interferes 
 ■with any of these conditions will introduce a complication in the healing of a 
 ■wound. It is not infrequently the case that wounds occur in which from the 
 outset it is apparent to a surgeon that in some one or all of these respects it 
 will be impossible to secure the necessary conditions, so that no attempt to 
 secure union by first intention can be made. Thus the loss of tissue may be 
 so great that apposition of the <livirled surfjices is impracticable, or some motion 
 is unavoidable, or there is pre-existing infection, or such relation of the wound to 
 the bodily excretions or secretions exists that some contamination is inevitable. 
 The presence of any of these conditions will make it obvious that a wound 
 should not be closed. Again, the tissues bordering the wound may be so 
 bruised or reduced in their vitality by general or local causes that their power 
 of sustaining the necessary processes of repair is uncertain, perhaps obviously 
 hopeless. In all such cases the method adopted by the surgeon for the treat- 
 ment of the wound will be quite different from those in which primary union 
 is expected. Healing by second intention is the process which is now the 
 resource of the surgeon, as it is also in those cases in which attempts at primary 
 union have been made and have failed. By its means the ultimate healing of 
 the Avound is secured. 
 
 The conditions which may thwart the ideal primary rej)air of the wound 
 •will have to do with either the apposition, the ])rotection. or the nutrition 
 of the ■wounded parts. Under the first of these headings the surgeon must 
 consider the natural gaping of divided tissues and the necessity of supply- 
 ing adequate means of retaining them in coaptation. The inevitable aggrava- 
 tion of this natural gaping by certain positions of the body or of the limbs 
 and by motion at joints suggests at once the necessity of considering a favor- 
 able posture for wounded parts, so that relaxation of the injured tissues 
 as complete as possible may be secured. The accumulation of blood and of 
 wound-secretions between the divided surfaces is a frequent cause of lack of 
 success in attempts at securing primary union. Under conditions of typically 
 perfect protection from external infection, as in most subcutaneous wounds, and 
 in some operation-wounds made under rigid conditions of ase])sis. such accumu- 
 lations of blood and wound-secretions may not introduce any serious complica- 
 tion into the healing of the wound. Later, these effusions become absorbed, 
 or they are diffused among the adjacent connective tissue-spaces, and the nat- 
 ural processes of repair proceed. In yet other cases the blood-clot, remaining 
 as an intervening mass between the wound-surfaces, serves as a su])j)ort and 
 scaffolding for new tissue ■which is thrown out from the surrounding ])arts, and 
 "which penetrates the mass of the clot and coalesces with it, and finally replaces 
 
COXTL'S/OXS AX/) WOUNDS. 99 
 
 it by fibrous tissue that unites the previously separated wound- surfaces. 
 Union by secondary intention is thus accom])lished Avithout suppuration or 
 waste of nutritive material. As a rule, the most assiduous effort of the 
 surgeon must be to prevent any accumulation of Ijlood or \vound-secretions 
 in any Avound uhich he is called upon to treat. Perfect apposition may, 
 again, be prevented by the presence of foreign matter between the wound- 
 surfaces. Shreds of clothing, splinters of wood, sponges, bits of foreign matter 
 of every conceivable character, at times are found in wounds, and their removal 
 is to be carefully secured by the surgeon. 
 
 For the protection of a wound it is requisite that it be guarded first from 
 motion, since by motion the apposition of the wound-surfaces is disturbed, the 
 delicate new adhesive material which has already been formed is ruptured, and 
 the conditions of the original injury are renewed in tissues already weakened 
 by that injury. The wound must be protected also from mechanical violence, 
 such as rude handling, friction, and gross mechanical injuries of every kind. 
 It must be protected from chemical irritants, and especially from the products 
 of decomposition of retained secretions or of portions of dead tissue ; and, lastly, 
 it must be protected from infection from poisonous agents, especially the more 
 common infecting organisms everywhere abounding in nature. 
 
 The local nutritive conditions to which attention must be paid have to do 
 with the circulation and the innervation of the parts to be repaired. A depend- 
 ent position of the injured part or an impediment to the free return circulation 
 by improper bandaging may produce excessive and persistent congestion 
 and interfere with its repair. Temperature is not unimportant : prolonged 
 cold w'ill impair nutrition, and too high a temperature may cause local death. 
 Too great tension of wound-flaps or tension from pent-up secretions impairs 
 local nutrition by obstructing the flow of blood in the capillaries, as well as 
 by the reflex effects of irritated nerve-fibrils, and also mechanically prevents 
 rest and coaptation of deeper parts. The details of treatment to be applied in 
 every wound have their rational basis in the principles thus outlined, which will 
 serve for the safe guidance of the practitioner. 
 
 Treatment of Wounds. — Arrest of Hemorrhage. — To stop bleeding 
 is the first care of the surgeon in his treatment of a Avound. The physi- 
 ology of spontaneous hemostasis and the methods of securing artificial arrest 
 of hemorrhage are given at length under Injuries of the Blood-vessels. 
 The aim of the surgeon should always be to secure the arrest of bleeding 
 by means that shall cause the least disturbance in the future repair of the 
 wound. Unnecessary ligatures are therefore always to be avoided. When 
 ligatures are unavoidable, those made of absorbable material, as catgut, are 
 to be preferred, and the size of the thread should be as small as is consistent 
 with the strength required to occlude the vessel. When non-absorbable mate- 
 rials are used for ligatures, as silk thread, if it has been perfectly disinfected 
 and primary union of the wound can reasonably be expected, this too may be 
 cut off and left buried in the wound. The first and most generally applicable 
 means for restraining hemorrhage is that of direct pressure made upon the bleed- 
 ing point. This may be by the finger or by a tampon, or by an instrument, as a 
 pressure-forceps. These means are often, in the nature of the case, but temporary 
 expedients. In many instances, however, the temporary use of pressure will 
 be all that will be required for the arrest of hemorrhage that at first was very 
 abundant. When copious and continuous capillary oozing persists, it may 
 frequently be controlled by pressure with compresses wrung out in water as hot 
 as can be born by the hand — 115° to 120° F. The use of heat as a hemostatic 
 is to be preferred to cold, as being more favorable to local nutrition and subse- 
 
100 AiV AMKIUCAX TEXT-HOOK OF SLJlOKliV. 
 
 quent active repair. The use of hemostatic forceps, wliicli when once apjdied 
 automatically compress the orifices of bleedirif^ vessels, is a very efficient and 
 convenient means of applying pressure. Many vessels, which at first bleed 
 freely, after a few moments' compression in this manner will no longer bleed 
 when the forceps are removed. If the bleeding does persist, torsion may be 
 applied, Avhich, being effectual in many instances, will reduce the ultimate need 
 for ligatures to a minimum. As a rule, hemostatic agents which produce 
 tough clots of blood, as the salts of iron, or Avhich are strong irritants, 
 such as turpentine, or which destroy tissue outright, as the actual cauter}', are 
 to be carefully avoided. The free access of cold air is an active hemostatic 
 and the least harmful. Often when continuous oozing persists from a wound 
 under a mass of soft blood-clot, if the wound is freely opened and the accumu- 
 lated clot thoroughly removed further oozing becomes definitelv arrested. A 
 dilute solution of iodine has both hemostatic and antiseptic properties, and may 
 sometimes be used with advantage. Iodoform added to a compress applied upon 
 a bleedino; surface has a distinct hemostatic effect. From amono- all these 
 resources the surgeon will be called in a given case to make use of those 
 which shall be available, efficient, and least harmful, keeping in view always 
 the ideal of wound treatment — subsequent union by primary intention. 
 
 Complete immediate hemostasis is not to be sought for in the treatment of 
 wounds in which easy apposition of the wound-surfaces cannot be obtained, and 
 in which dead spaces or open defects remain which it is possible for the surgeon 
 to fill in by tissue organized in and supported by a moist blood-clot. When a 
 surgeon is master of a sufficiently perfect antiseptic technique to secure healing 
 under such a blood-clot, and the circumstances are favorable, he may make the 
 attempt. He will then encourage, or even provoke, sufficient bleeding to fill 
 up all the dead spaces and the wound-defects with blood previous to the appli- 
 cation of a dressing, and will subsequently protect the clot from adhesion to or 
 disturbance by the external dressing. (See page 29.) 
 
 Cleansing of the Wound. — Great care should be taken to remove from a 
 wound not only all foreign matter which may have been deposited within it, 
 but also all dead or dying tissue, and, as a rule, all blood-clots. The means 
 required for effecting such cleansing must be adapted to the nature of the 
 material to be removed. The forceps, scissors, curette, sponge, irrigating 
 stream, each may find its use. By means of these simply the more gross and 
 perceptible impurities may be removed. Of greater importance ofttimes is the 
 cleansing of the wound of those microscopic organisms which may induce 
 suppuration and putrefaction. (For the consideration of the means required 
 for this latter degree of cleanliness or sterilization see Operative Surgery.) 
 Suffice it here to say that in his treatment of wounds the surgeon should 
 never lose sight of the natural resisting power of living tissue to such organisms, 
 and that in his efforts at sterilization he should irritate and injure the living 
 tissue as little as possible. Strong and irritating antiseptic lotions are there- 
 fore, as a rule, to be avoided as direct applications to wound-surfaces. 
 
 When, however, a wound is already manifestly contamiiuited, it will be 
 good practice to irrigate it thoroughly for a considerable period of time with a 
 germicidal lotion of sufficient strength to secure the destruction of whatever 
 septic material may have gained access to it. A solution of carbolic acid, 
 1 : 40, or of corrosive sublimate, 1 : 1000, will be found most generally suit- 
 able for such a purpose. When the full sterilization of a wound, even by the 
 use of antiseptic irrigations, is impracticable, or it is so situated that it cannot 
 be kept free from subsequent renewed contamination, as in many wounds 
 involving the outlets of mucous canals or when the wound opens into suppurat- 
 
CONTUSIONS AND WOLN^DS. 1<>1 
 
 ing cavities, resort must be had to taiii])oning the wound-cavities with materials 
 impregnated with a permanent antiseptic, as iodoform or boric or salicylic 
 acid. In these latter cases, of course, union by granulation is what commonly 
 occui's, but what is practically primary union may sometimes be attained by 
 "secondary sutures." 
 
 Coaptation. — In the coaptation of wounds the aim of the surgeon must 
 be to bring the severed parts as far as possible into the same relations with 
 each other as existed before the wound was inflicted, and especially to 
 secure the closest possible apposition of eveiy portion of the wound-surfaces. 
 When im})ortant nerves, muscles, and tendons have been divided, especial care 
 must be taken to bring and secure together the divided ends ; all dead spaces 
 where secretions may gather are to be prevented ; and by various means and 
 devices the tissues are to be retained in their restored relation until definite 
 reunion has been accomplished. Under the term " coaptation " all the various 
 aims and methods referred to are included. In the section devoted to Minor 
 Suro-erv the means of accomplishing coaptation ai'e described in detail. Here, 
 however, it will be proper to speak of the general principles which should 
 guide the surgeon in the choice of means and methods. 
 
 First, much tension must be avoided. When tissues are put unduly upon 
 the stretch in an effort to bring them together, the circulation of the blood 
 within them is impeded, ' nutrition is impaired, the formation of sloughs is 
 invited, and suppurative disturbances are promoted. It is far better to be 
 content with whatever amount of coaptation can be easily secured, and to seek 
 for the healing of any surfaces left uncovered, either by granulation and ulti- 
 mate cicatrization or by skin-grafts. In the second place, care must be 
 taken w^ile securing coaptation to avoid such adjustment of sutures or other 
 retentive apparatus as would be likely to produce strangulation of any portion 
 of the tissue. Sutures too closely applied and too tightly drawn are a frequent 
 cause of necrosis of wound-edges : the pressure of compresses and bandages 
 may likewise be so great as to produce local tissue-necrosis, so that good judg- 
 meiat should always be used in their application. Thirdly, the relaxation of 
 tissues by position should not be overlooked by the surgeon. The spontaneous 
 gaping or falling together of wounds in varying attitudes of a wounded part 
 need but be noticed to suggest the advantage to be derived from placing a part 
 in that position or attitude in which any tendency to gape during the healing 
 process will be reduced to a minimum. The general rule is, therefore, in 
 order to favor coaptation of a wound, to put the part in that position in which 
 the greatest relaxation of the wounded structures can be secured, and in this 
 position they should be fixed and held until firm union has been accomplished. 
 As an accessory to the use of position for securing relaxation is the device of 
 sliding toward the wound tissues somewhat distant from it. By the use of 
 sutures traversing a deeper portion of the wound, and made to embrace portions 
 of tissue on either side at a considerable distance from the wound-edges, and then 
 secured after the manner in which an upholsterer secures the two sides of a 
 mattress together, wounds which gape widely at first may often have their edges 
 so approximated that they are easily brought together without tension. 
 
 The choice of materials for ensuring continued coaptation is worthy of con- 
 sideration. When a wound is small and there is no tendency to gape, or when 
 that tendency has been overcome by attention to position, the use of a simple 
 compress held in place by a roller bandage may be all that is required to 
 ensure undisturbed healing. In general, however, additional means for secur- 
 ing undisturbed coaptation will be required. For this purpose are used adhe- 
 sive strips and sutures. 
 
102 AX AMi:iil<AX TEXT- HOOK OF SCliOICRY. 
 
 AdJiesive strips^ as direct applications to ^voun(l-ilaj).s to secure tlieir appo- 
 sition, should rarely be used. Bein«j; disinfected uith difficulty, they are 
 always to be looked upon as surtjically unclean. They favor infection likewise 
 by retaining wound-discharges underneath them and in their substance ; they 
 cover up a wound from the surgeon's inspection ; they often irritate the skin 
 to which they are applied ; and, finally, from their tendency to become loos- 
 ened, they are unreliable in the support which they give. Strips of gauze 
 fixed with collodion are more effective and are perfectly aseptic. For purposes 
 of supidementary support, however, placed o?/^side of the immediate wound- 
 dressing to prevent tension, to produce compression, and to ensure fixation of 
 the dressings, adhesive strips are invaluable. 
 
 Sutures. — The most certain, e.xact, and generally available of the means 
 for retaining divided surfaces in coaptation is the suture. As "stitches of 
 coaptation,"' applied superficially and close to the Avound-margins, they keep 
 the cutaneous edges of the wound together. As "stitches of approximation," 
 having been passed more deeply and at a greater distance from the wound- 
 margins, they approximate and hold together the deeper surfaces. As 
 "stitches of relaxation," embracing tissues at some distance on either side of 
 the wound, they relax the adjacent tissues, so that the wound-surfaces may be 
 brought together and tension be avoided. The materials available for sutures 
 
 or? ^ 
 
 will be discussed elsewhere. (See Operative Surgery.) Whatever form of 
 thread is chosen should have been rendered aseptic by previous preparation, 
 and should likewise be immersed anew in tlie antiseptic solution at the time it 
 is used. 
 
 Drainage. — As the surgeon proceeds with his efforts at securing coaptation 
 of a wound he must make provision for the escape of the secretions which are 
 the immediate result and accompaniment of every wound. When perfect 
 coaptation, deep as well as superficial, has been secured, and when by the 
 most scrupulous and exact observance of antiseptic precautions the surgeon is 
 assured that his wound when dressed is as free from infection as a subcutaneous 
 one, means of drainage may be dispensed with, and the local absorbents may 
 be relied upon to remove whatever secretions are poured out in excess of the 
 quantity needed for repair. As a rule, however, it will be important for the 
 surgeon to provide means for the free and continuous escape of wound-secretions. 
 It will often be sufficient to leave open the most dependent portion of the wound. 
 In some cases enlargement of Avounds by free incisions or the making of coun- 
 ter-openings may be practised for the purpose of securing free escape of secre- 
 tions. In many instances it will be good practice to introduce the sutures at 
 the operation, but not to tie them until after the cessation of the primary copious 
 bloody and serous oozing which occurs during the first tAvelve to twenty-four 
 hours after the occurrence of a wound (secondary suture). Septic infection 
 having been prevented by the use of antiseptic dressings, at the end of this 
 period the wound-surfaces may be brought together, Avith an increased prob- 
 ability of securing union by first intention Avithout the necessity of any further 
 means of drainage. Fre([uently, hoAvever, the surgeon Avill be compelled to 
 resort to the introduction into a Avound of some foreign material for the purpose 
 of conducting aAvay i^s discharges. This substance may act by capillarity, 
 serving to keep the Avound-surfaces apart and permitting the outfiow of liquid 
 along the interstices among its strands, or there may be provided tubes through 
 Avhich free flow of the discharge is secured. For the escape of pus a tubular drain 
 is always required, and whenever provision is to be made for the escape of much 
 secretion, if absolute certainty of drainage is desired such a tube must be used. 
 Rubber tubing is the most universally applicable means of drainage, being 
 
<<)\Tf S/OX.S AAI> \\()UM)S. lO.'i 
 
 Hoxiblo, uiiirritating, easy to manipulate, easily sterilized, nearly ahvays 
 attainable, and eheap. A drainage-tube, of Avliatever substance composed, is 
 a foreign body, and as long as it remains in a wound is liable to produce 
 disturbance. It should therefore be removed as soon as the period of profuse 
 secretion which made its original use necessary has passed away, or as soon as 
 the cavity which it was intende<l to drain has become obliterated. 
 
 Dressings. — In the treatment of a wound after hemorrhage has been 
 checked, its surface has been cleansed and purified, coa[itatiori has been 
 accomplished, and drainage has been provided for, a suitable dressing must be 
 applied. Two main objects are to be accomplished by a dressing : first, the 
 absorption of whatever secretions may come to the surface ; and second, the 
 protection from infection and from injury and motion. The materials which 
 may be available for surgical dressings are fully treated of in the section devoted 
 to Operative Surgery. Here, however, some general considerations concerning 
 dressings are in place. Septic infection is to be guarded against by cover- 
 ing the part with soft and absorbent material that will receive and keep 
 aseptic the discharges that drain away from a wound, and that will prevent 
 the access of septic infection from other sources to the wound. For this 
 purpose many substances may be found useful : among those more com- 
 monly employed are cotton w^ool, loosely-woven cotton cloth from which 
 all oily matter has been, removed, jute, sawdust, moss, etc. While all these 
 substances are more or less hygroscopic, their usefulness as absorbent dress- 
 ings depends chiefly upon the multitude of minute spaces existing between 
 their meshes or fibers, and a certain degree of openness of mesh or loose- 
 ness of fiber is requisite to enable them continuously to absorb thick and 
 viscid fluids. It is not enough that these materials Avhen applied should 
 themselves be simply sterile, for when they are filled with wound-secretions 
 they may then be infected from without and become the medium of conveying 
 infection to the wound. It is better that portions of the dressings should 
 themselves be impregnated with antiseptic materials, which could actively 
 antagonize or inhibit the activity of any septic matter that might gain access 
 to the secretions imbibed by them. The necessity of this is realized if the 
 extreme difficulty, almost impossibility, of sterilizing absolutely the skin of 
 the patient or the fingers of the surgeon is recalled. For this reason the best 
 results in securing the healing of their wounds will be obtained by those 
 surgeons, all other things being equal, w^ho make use of wound-dressings 
 containing proper proportions of corrosive sublimate, the double cyanide of 
 zinc and mercury, boric or salicylic or carbolic acid, or similar antiseptic 
 agents. By the use, further, of very voluminous dressings it is possible to 
 give additional security against the conveyance of infection from without to 
 a wound, and to protect it more certainly from mechanical violence and from 
 motion. 
 
 Changes of dressings are made at long intervals, and thus the ideal rest is 
 secured to the injured part while repair is going on. As to when such changes 
 are required, various considerations must determine the action of the surgeon. 
 The body-temperature of the patient, as indicated by the thermometer, should 
 be especially relied upon as an index to the character of the processes going on 
 in the wound. If, after an elevation of one or two degrees above the normal 
 for the first forty-eight or seventy-two hours after a Avound has been inflicted 
 and dressed, the temperature sinks to nearly the normal point, and remains 
 there with but slight fluctuation, the surgeon is assured that undisturbed repair 
 is progressing, and that no demand for interference is present by reason of any- 
 thing in the wound itself. If, however, the temperature continues elevated 
 
104 AX AMKRICAX TEXT-HOOK OF sriidERY. 
 
 after the first t^vo or three days, or if, after having once fallen, it again rises, 
 and especially if a series of morning remissions and evening exacerbations 
 show themselves, the evidences are unniistaka])le that inflammatory and sup- 
 purative (listur])ances, with retention of secretion and septic al)sorption, are 
 going on, and that a change of dressing with thorough exploration of the wound 
 is required. When also the external hiyers of the dressings become moist with 
 the secretions that have been imbibed from within, it is imperative that the 
 dressings be renewed. This does not apply, however, to the frequent staining 
 of the external layers of a dressing by the copious sero-bloody primary wound- 
 secretion, which, when very hygroscopic materials are used, often occurs within 
 a short time after the ap])lication of a dressing. In these cases the dressings 
 quickly become and remain dry, and do not require to be changed. When 
 drainage-tubes have been employed it is desirable that they be removed, in 
 most cases, within a week or ten days, or often much earlier, for which purpose 
 the dressing must be renewed. When for the purpose of controlling hemorrhage 
 tampons have been left in sitii, these should be removed as early as the third 
 day, and thus they would form another indication for a change of dressing. 
 If the wound becomes the seat of suppuration or of sloughing, such fre- 
 quency of dressings is required as may be needful to secure the adequate 
 drainage and cleansing of the infected part. In general, changes of dressings 
 should be made as rarely as possible, and only for the purpose of meeting dis- 
 tinct indications. In changing dressings the same strict antisepsis should be 
 observed as in the operation itself. 
 
 Local Treatment. — While proper attention is being given to a wound 
 the needs of the wounded part should not be overlooked. Nothing which 
 could interfere in any Avay with its most perfect well-being should be con- 
 sidered insignificant. The natural warmth of the part, perfect freedom of the 
 circulation, tlie control of muscular spasm, and the most perfect quiet and 
 comfort are all of importance to be secured. 
 
 Position. — A position that will be comfortable to the patient should if pos- 
 sible be selected. This will always be one in which the muscles are relaxed 
 and the return circulation of the blood to the heart is fiivored. The relation 
 of position to drainage should be kept in mind, and in the arranging of the 
 means for drainage whenever possible the drains should be so placed as to be 
 most efficient when the part shall have been placed in a position of the greatest 
 comfort. 
 
 Compression. — Gentle, uniform, and continuous pressure is of great value 
 in promoting rapid repair after injury. It restrains excessive local hyperemia, 
 limits effusion, and promotes absorption of effusions already present ; h antag- 
 onizes muscular spasm and contributes to rest of the ])art. A greater and 
 more methodical application of pressure than is needful for maintaining simple 
 apposition of the separated parts is required in order to obtain the full power 
 of compression in favoring the repair of a wound. Comjn-ession should be 
 smooth and uniform, gentle but firm, carefully avoiding any constriction. In 
 most cases it may be best effected by covering the wounded part with layers of 
 cotton wool and applying compression with bandages. The wool by its elas- 
 ticity tends to distribute evenly the compression exercised by the bandage and 
 to keep the pressure continuously uniform. 
 
 Immobilization. — While the means of compression just described will in 
 many instances be sufficient to give whatever extraneous aid is required to pre- 
 vent motion in the wounded part, in many others there will be needed some 
 further assistance in securing the desired immol)ility. For this purpose splints 
 of various kinds are available. Whenever any form of plastic splint can be 
 
COXTUSIONS AXI> WOUNDS. 105 
 
 used, it should be chosen ; such splints accurately take the shape of the part, 
 forming a firm mould that encases and fixes the limb ^ithont pressing unduly 
 on anv one ])oint. As a result, such splints are borne "vvith comfort, and thus 
 indirectly contribute still more to the well-doing of the wound. In an emer- 
 gency, however, the ingenuity of the surgeon may be able to bend to his pur- 
 pose, for giving support and fixation to a wounded part, a multitude of difter- 
 ent substances. 
 
 Constitutional Treatment. — The existence of pain or general restless- 
 ness riMjuirc's the administration of opiates for their relief. The age of the 
 patient, his previous constitutional condition, the coexistence of disease or 
 tendencies to disease, and the hygienic conditions in which he is placed, each 
 must engage the attention of the surgeon in order that whatever special indica- 
 tions they present may be met, and every possible influence that might inter- 
 fere with re])air be guarded against. Even the mental state of the wounded 
 should be regarded. The surgeon who is able to arouse hope, expectation, 
 and faith in the minds of his patients will see their wounds heal more rapidly 
 and certainly than when opposite states of mind exist. As regards the influ- 
 ence of age upon the healing of wounds, although in some cases aged persons 
 display unimpaired ability to repair their wounds, yet as a rule in the aged 
 healincr is much more sluggish and more likelv to suffer from disturbance. In 
 aged patients especial attention must be paid to their nutrition, to maintaining 
 their bodily warmth, and to giving them the stimulating effects of abundant 
 sunlight and pure air. 
 
 In all cases whatever departures from a perfect standard of health a patient 
 may present should engage the attention of the surgeon. Plethora, anemia, 
 obesity ; that peculiar vulnerability associated with the scrofulous diathesis ; 
 alcoholism ; the exhaustion from overwork, underfeeding, or mental strain ; 
 the depression produced by vicious habits and the habitual inhalation of 
 vitiated air, — these are some of the conditions for the relief of which the 
 surgeon should see that proper constitutional treatment be given. 
 
 Closely allied to the conditions just named are certain well-marked diseased 
 states, such as s^^philis, tuberculosis, malaria, diabetes mellitus, and scurvy, 
 which by the nutritive defects which they determine delay repair, often arrest 
 it, and subject wounds to the most serious complications. The pre-existence 
 of pyemia, septicemia, erysipelas, phlebitis, or any diffuse inflammation will 
 add special dangers to any traumatism. Diseases of the various organs of 
 the body, and particularly cardiac, pulmonary, hepatic, and renal diseases, 
 modify the effects of wounds, both directly by the constitutional states which 
 they create and w^hich are unfavorable to repair and diminish the resisting 
 powers of the tissues in general, and indirectly by the reaction of the injury 
 upon the pre-existing affection, producing in it temporary exacerbation or per- 
 manent and excessive aggravation, with, not infrequently, speedy death. Each 
 of the conditions named when present will demand constitutional treatment 
 in order to neutralize as far as possible any influence for evil which it might 
 exert upon the healing of the wound. 
 
 The general hygiene of the patient should be made as favorable as 
 possible. Food insufficient in quantity or bad in quality, extremes of tem- 
 perature, absence of sunlight, depressing climatic conditions, lack of exercise, 
 insufficient and impure air, — these not only create previous constitutional con- 
 ditions unfavorable to repair, but, when continued after the reception of a 
 wound, directly diminish the activity of its reparative processes. The diet of 
 the patient should be regulated so'^that his supply of food should be ample, 
 palatable, and digestible, due regard being paid to personal taste and instincts. 
 
lUG .l.V AMi:iiI('AN TEXT-BOOK OF SURGERY. 
 
 In connection with the sul)joct of aliincut.ition attention should he paid to 
 the action of the bowels and all the excretions and secretions of the body. 
 
 An abundant supply of sunliglit and of pure air is es[)e('ially iinjwrtant for 
 the well-doing of a person who is confined by a wound to one place, and thus 
 is dependent upon what is brought to him from without for the purification 
 and renewal of the air which he must breathe. This is alike necessary for 
 isolated cases in their own homes and for those in the crowded wards of 
 a hospital. 
 
 After-Treatment. — The least possible interference with a wound while 
 the healing process is going on is a cardinal principle in surgery. Too 
 early and too frequent interference inevital)ly prevents the steady progress 
 of the healing process. Infrequent dressing is eminently conducive to that 
 absolute I'est which is to be kept in view whatever method of treatment 
 is adopted. When the first dressing of the wound has been conducted in 
 accordance with the principles that have been described, the after-care from 
 the surgeon will be limited to a watchful oversight of the means of protection 
 and immobilization, of drainage, and of apposition that have been employed, 
 so that they may be removed, substituted, or reinforced by others as soon as they 
 are no longer called for or have become inefficient. The prevention of the access 
 of septic organisms, and the removal as fast as formed of materials that may 
 decompose or become the lodging-places of these organisms, constitute two great 
 indications, to fulfil both of Avhich the surgeon must continually strive to the 
 best of his ability if he would acquit himself of reproach for the results of dis- 
 turbance that may supervene in the progress of the wound. Inflammatory, 
 erysipelatous, gangrenous, or septicemic complications attacking wounds are not 
 always to be regarded as unfortunate and unavoidable accidents, but must some- 
 times be accepted as the results of errors or failures in the treatment which the 
 wounds have received. When in the first dressing of a wound it has been possible 
 to close it after perfectly satisfying the indications for treatment that have been 
 detailed, it should not be disturbed until a sufficient time has elapsed for the 
 adhesion of the wounded parts to become firm. From ten to fourteen days 
 may often be permitted to pass before the dressings are removed. The indica- 
 tions which might call for earlier interference, such as the removal of drainage- 
 tubes, have been detailed in a preceding paragraph ; but whenever the external 
 jH'otective dressings remain dry, the wound is free from pain and fetor, and there 
 is no acceleration of the pulse or elevation of the temperature, the dressings 
 may be left undisturbed. Sutures may be allowed to remain as long as their 
 support seems to be desirable, provided they are not causing irritation or sup- 
 puration. In the latter case they should be removed at once. It is impossible 
 to fix arbitrarily the periods for the renewal of the dressings : each case must 
 be a law unto itself. In the changing of the dressings and in all the manipu- 
 lations required about the wound the utmost gentleness should be used. 
 
 INTERCURRENT COMPLICATIONS. 
 
 The regular course of the healing of a wound may become disturbed by 
 inflammation, entailing suppuration and possibly gangrene, and if healing is 
 ultimately secured it is accomplished only by a prolonged process of granula- 
 tion. By the absorption into the general circulation of materials formed in 
 wounds thus complicated the general phenomena of septicemia and of pyemia 
 may be produced. 
 
 "^Inflammation. — With but few exceptions an inflamed wound is a septic 
 wound, and the cause of the inflammation is the irritation of the products of 
 
COXTUSIOXS AM) WOrXDS. 107 
 
 (lecomposition of retained secretions. It is accordingly those wounds in which 
 the retention of sccrt'tions is most difficult to prevent, as of wounds of joints 
 and other cavities, wounds leading down to fractured }»one, and deep irregular 
 punciured Avounds, in which severe inflamnuition is frecjuently met with. To 
 give free vent, therefore, to all wound-secretions that may have Hbeen retained is 
 the first thing to be attended to in the treatment of such a wound. Tliis may 
 require nothing more than the cutting of a stitch, so that the luitural gaping 
 of the wound nuiy suffice for the reijuired vent, or it may re(|uire counter-incis- 
 ions and tlie use of drains. AVhenever an inflannnation shows a tendency to 
 spread into the adjacent parts, abundant, thorough, and systematic incisions 
 into the affected area must be made, sufficient to provide for the free escape of 
 all irritating secretions. Wherever there is a possibility of a foreign substanee 
 having been left in the wound, such as a splinter of wood, a piece of glass, a 
 rusty nail, a bit of clothing, a detached piece of bone, etc., it should be care- 
 fully souirlit for and removed. If the inflammation has been caused or asirra- 
 vated by mechanical irritation, by motion, or by the premature use of the 
 wounded part, the recognition of such a fact will at once lead to its correction. 
 When the causes of the inflammation have been removed, the parts should be 
 placed in an elevated and comfortable position and subjected to such additional 
 means for relieving the pain, heat, and swelling of the part, and overcoming 
 the vascular congestion on which these depend, as the judgment of the surgeon 
 may determine. In brief, however, it may be said that for the relief of 
 inflamed wounds the surgeon will find of especial value the use of irrigation 
 with cooling antiseptic solutions. 
 
 Gangrene. — The appearance of gangrene in a wound calls for the imme- 
 diate adoption of even more energetic and thorough antiseptic methods of 
 treatment than have been prescribed in the preceding paragraphs. All loose 
 gangrenous tissue should be removed at once Avith knife and scissors, and the 
 living tissues exposed should be freely and thoroughly cauterized by an 8 per 
 cent, chloride-of-zinc solution, which should be injected into every cavity and 
 recess of the wound. Free incisions and counter-incisions should be made into 
 the swollen and infiltrated tissues leadins; from the firansrenous focus, so as to 
 permit the escape of secretions and debris and to enable the disinfecting liquid 
 to reach every infected part. The Avound should be left uncovered, and contin- 
 uous irrigation Avith an antiseptic solution established. For such irrigating 
 liquid a 1 per cent, solution of carbolic acid or of acetate of aluminium or a 
 1 : 15,000 sublimate solution may be used. The antiseptic irrigation should 
 be continued until permanent arrest of the gangrenous process is manifest, all 
 necrotic tissues have come away, and a healthy granulating surface has formed. 
 
 Erysipelas. — The appearance of erysipelas is ahvays due to some defect 
 or neglect in the antiseptic precautions. It is ahvays of specific septic origin, 
 and it most especially calls for that method of treatment adapted to septic 
 Avounds. (For a full consideration of this subject see Erysipelas.) 
 
 Suppuration. — The occurrence of suppuration in a Avound makes it neces- 
 sary that full provision should at once be made for the easy and perfect escape 
 of the pus. This has already been considered in Avhat has been said in regard 
 to drainage. Some further thought, hoAvever, should be given to the manage- 
 ment of a suppurating Avound, Avith a vicAV to the restriction of the process of 
 suppuration and the hastening of the healing of the Avound as much as possible. 
 When the Avound is shalloAv and Avidely open, and not too extensive, iodoform 
 gauze may be applied upon its Avhole surface as a dressing, and Avill diminish 
 greatly the amount of pus secreted and stimulate the granulating process. The 
 final healing may then be accelerated by the application of a secondary suture 
 
1U8 AN AMEHlCAy TKXT-JiOOK OF SlJiGERY. 
 
 ■when possible or the employment of skin-grafts. When the supj)uratinif cavity 
 is deep or tortuous, or its external ojx'iiing is conij)aratively small, antiseptic 
 irrigations are of value. Care should be taken in the use of all such irriga- 
 tions not to inject the fluid with so much force as to break up adhesions already 
 formed. Care must also be taken that the possibly poisonous antiseptic be not 
 retained in the wound. This is best accomplished by finally flushing the wound 
 with warm boiled water to wash away the antiseptic solution. Injecting a fr^'sh 
 solution of pero.xide of hydrogen into a suppurating wound answers the same 
 purpose, and is an efficient means of decomposing any retained pus and of 
 sterilizing the Avound-cavity. Solutions of bichloride of mercury, 1 : 2000, 
 of carbolic acid, 2 per cent., or of boro-salicylic acid in saturated solution, are 
 also efficient. "When, notwithstanding the use of these means, the granulating 
 process remains sluggish and the wound-cavities delay in contracting and 
 healing, more strongly stimulating applications are indicated. Naphthalin in 
 powder freely sprinkled over the sluggish surface, or tlie balsams of Peru or of 
 copaiba freely instilled, or tampons of gauze saturated with these agents, may 
 be used. If these are not efficient, superficial cauterizing agents, such as 
 carbolic acid of full strength, fused nitrate of silver, or an 8 per cent, solution 
 of chloride of zinc may be used. In all these cases constant attention should 
 be paid to keeping the deeper parts of the Avound-cavities in apposition by 
 properly-applied pressure, and to securing absolute rest for the injured parts. 
 Especial care must be taken that the external dressings that are applied are 
 such as Avill freely absorb the pus which is brought to the surface. Nothing 
 \eill more aggravate the condition of a suppurating Avound than a dressing that 
 dams back and causes retention of its secretions. Viscid pus is not absorbed 
 to any great degree by the ordinary cotton dressings, and if they are used they 
 must be frequently removed and the Avound cleansed. In ordinary pine saAv- 
 dust of moderate coarseness the surgeon Avill alwaA'S find an easily obtainable 
 substance Avhich absorbs pus freely. It can be made aseptic by baking, and 
 then antiseptic by Avetting Avith a sublimate solution. This saAvdust made into 
 convenient-sized pads by enclosing in any thin gauzy stuff", like cheese-cloth, 
 may be used as a dressing, Avith a certainty that retention Avill not be caused by 
 it, so that infrequent dressing may be the rule even in such Avounds. 
 
 When by any of the means described a vigorous granulating surface has 
 been obtained and the case is not suitable for secondary suture or skin-grafting, 
 the further treatment of the granulating surface must be one of protection 
 Avhile the gradual process of cicatrization by extension of the cuticle from 
 the edges is going on. Bland or mildly stimulating ointments spread on soft 
 antiseptic dressings of some kind are commonly used for this purpose. Suit- 
 able material for such ointments are the simple cerate of the Pharmacopeia, 
 oxide-of-zinc ointment Avith which a little carbolic acid has been incorporated 
 (f^ss to 5j), boric-acid ointment 15 per cent., iodoform Avith a petroleum basis, 
 such as carbolated cosmoline (sj to .5j), make invaluable a]>plications to such 
 surfaces, and should be employed by preference Avhen the Avound is near a 
 mucous outlet or other possible source of infection. An efficient protection, and 
 one even more cleanl}' and in harmony Avitli ideal asepsis, is to be found in 
 strips of rubber gauze or in the fine oiled-silk material knoAvn as "protective." 
 These should be sterilized by immersion in a carbolic or bichloride lotion of 
 suitable strength for some time before they are used, and Avhen applied upon a 
 granulating surface Avhich has previously been sterilized, and then covered by 
 a suitable antiseptic absorbent dressing, the Avhole forms an ideal dressing for 
 a granulating surface. AVhenever the granulating surface is of any size, resort 
 should be had to skin-grafting for the purpose of hastening its cicatrization 
 
COXTCSKjys AM) WOUNDS. 109 
 
 whenever practicable. Tliis is a most valuable means for shortening the period 
 of cure in cases of open wounds, and deserves to be frequently used by surgeons. 
 (For the technique of skin-grafting see the chapter on Plastic Surgery.) 
 
 INCISED WOUNDS. 
 
 By incised wounds are meant those clean-cut divisions of tissue which 
 are produced by the edges of a sharp instrument. They may vary in size 
 from the most trivial to formidable and deep incisions of many inches in 
 length — from a superficial scratch to wounds opening deep cavities or almost 
 severing entire members from the body. Their surfaces present in a minimum 
 degree an imperceptible layer of devitalized tissue destroyed by the impact 
 of the cutting instrument, tissue, which is quickly removed in the early 
 stages of normal repair and produces no disturbance in the healing of the 
 w^ound. For this reason they present conditions most favorable for speedy 
 healing, and deserve from the surgeon careful attention to all the details of 
 cleansing, apposition, and rest which have been described in previous pages, 
 so that primary union may be obtained. 
 
 Symptoms. — Pain resulting from an incised wound is severe and sharp 
 at the moment of its infliction, subsiding into a smarting or burning which 
 persists for some time ; . hemorrhage is free, and the gaping of the tissues is 
 restrained only by the limits of the contractility of the tissues divided. 
 
 Treatment. — In the arrest of hemorrhage, Avhich in general will be 
 accomplished with but little diflSculty, care must be taken to avoid any means 
 or agents which could later prove a source of disturbance in the heal- 
 ing process. The use of all styptic agents should be especially avoided. 
 Bleeding from all but vessels of considerable size will be arrested by temporary 
 pressure, by exposure to the air, or by the application of hot water aided by 
 compression. The mutual pressure of the wound-surfaces against each other 
 after they have been brought into apposition serves to restrain any tendency 
 to further hemorrhage. When large blood-vessels are wounded ligatures are 
 required ; w^ounds involving such vessels are most dangerous, and may quickly 
 terminate fatally from loss of blood, so that the most energetic and instant 
 resort to measures for the arrest of hemorrhage is called for in such cases. 
 When a vessel is but partially divided, it is more difficult to stay the bleeding 
 from it than if it is cut through entirely. In such cases the first thing to be 
 done is to complete the division of the vessel, ligating it later if necessary. 
 
 The drainage of incised Avounds, when Avith proper care their deeper parts 
 can be maintained in apposition, is very simple. In the more extensive 
 wounds capillary drains or small tubular drains during the first twenty-four or 
 thirty-six hours will suffice. In a large proportion of cases where compression 
 and immobilization of the part can be effected no provision for drainage is 
 required. The apposition of the wounded surfaces should be attended to with 
 the utmost care and minuteness, so that, by the use of sutures, compresses, 
 bandages, and position, coaptation of every part should be perfect and no spaces 
 be left for the collection of secretions. The protective dressings required by 
 incised wounds the coaptation of the surfaces of which is possible are very 
 simple. Exposure of the line of suture to the air, so that the desiccation of 
 the slight amount of secretion that gathers there may form a protective crust, 
 gives excellent results Avhen the conditions of the wound are such as to make 
 it practicable. A light, dry, clean absorbent dressing of some kind is all that 
 is required at any time. The provisions for rest in the case of incised wounds 
 may and should be made absolute by splints. The removal and readjustment of 
 
no AN AMFJilCAX TKXT-IK tOK OF SriidKHY. 
 
 dressing should be long deferred. The ideal to be aimed at is perfect healing 
 without local discomfort or constitutional disturbance under a single dressing. 
 
 LACERATED AND CONTUSKD WOUNDS. 
 
 A lacerated wound is one in which the tissues have been forcibly torn 
 asunder ; a contused wound, one in which the wounding force has been of a 
 crushing character. In many instances both the lacerating and crushing 
 elements are mingled. In any case the character and course of both classes 
 of wounds arc similar, so that they may properly be considered together. The 
 surface of such wounds is irregular, shreddy, possibly presenting long flangling 
 strips of fibrous and tendinous tissue, with more or less blood-clot filling the 
 exposed cavities, and with a variable amount of dead or partially disorganized 
 tissue scattered upon its surface. The skin-wound is irregularly torn, less in 
 extent than the wounds of the deeper structures, from which it is more or less 
 separated, while its borders present an area of variable dimensions that is livid 
 and cold, ready to fall into necrosis. The great increase in the use of machin- 
 ery in modern times, and of rapidly-moving and heavy vehicles operated by 
 steam, electric, and horse-power, has vastly multiplied the frequency of lace- 
 rated and contused wounds. 
 
 Such wounds produce greater shock than do incised wounds, but arc accom- 
 panied by less appreciable pain. The pain is dull and aching in character; 
 the hemorrhage is generallv slight, owing to the surface irregularity that favors 
 the coagulation of the blood fiowing over it, and to the fact that the larger 
 blood-vessels have had their coats so irregularly torn that an occlusive clot is 
 at once formed in the torn ends. The tissue-interspaces for some distance 
 from the wound-opening become infiltrated with diffused and clotted blood, 
 and in many instances foreign material, dirt of every conceivable character, 
 is ground into the Avound-surfiices, so as to defy every effort to remove it 
 entirely. In cases of severe injury of this kind the partial syncope resulting 
 from shock so diminishes the force «f the circulation as also materially to 
 lessen the tendency to hemorrhage. Although for these reasons primary 
 hemorrhage is generally slight, serious later hemorrhage is not infrequent, 
 either within a few hours, when the heart's action has regained its power and 
 local reaction has set in ('Mntermediate " or ''reactionary" or "consecutive" 
 hemorrhage), or at a more distant period, when by the separation of sloughs the 
 vessels are again opened (" secondary " hemorrhage). The external apjjcarance 
 of these wounds often gives no suggestion of the extent of the damage which has 
 been done. They should therefore always be examined with great care, and the 
 possibilities of far-extending subcutaneous injury should be kept in mind. 
 
 JNIore or less death of tissue is inevitable in the after-course of such wounds. 
 Some tissue, often much, is killed outright by the violence, while yet more is 
 left in a seriously damaged state, prone to fail into necrosis from the defective 
 nutrition that for a time exists in the part. Much of the abundant and irreg- 
 ularlv diffused blood-clot which is present will subsef[uently disintegrate and 
 liquefy. AVhen, with greater or less rapidity according to the activity of the 
 nutritive processes in' the part, all necrotic tissue has separated and been 
 removed, and the blood-clot has either been absorbed or has broken down and 
 escaped, there remains behind a uniform granulating surface, and the further 
 course of the wound is toward healing by granulation. 
 
 All the conditions presented by these wounds are such as to render them 
 specially liable to septic infection of serious character. 
 
 Treatment. — Although there may be but little hemorrhage at the time of 
 
COyTUSIONS AND WOUNDS. Ill 
 
 the first dressing of a lacerated or contused wound, yet if vessels of any size 
 have been torn it is the part of -wisdom to a])])ly ligatures to them, though they 
 may not be bleeding at the time. The period of reaction from shock is to be 
 watched with especial care to guard against possil)le hemonhage. Should 
 this hemorrhage at any time occur, the application of a ligature is imper- 
 ative, even though the bleeding may have ceased spontaneously as the lieart's 
 action is Aveakened ; for so soon as the reaction again comes on and the heart 
 beats strongly once moi'e, the hemorrhage will surely recur. The j)rimary 
 cleansing of the wound should be conducted with great care by rubbing sweet 
 oil thoroughly over the surface, including the adjacent skin, then cleansing 
 by soa]) and warm Avater well scrubbed on, following this by washing with 
 alcohol, and finally l)y thorough scrubbing with suldimate solution, 1 : 1000. 
 All detached particles of bone and of the soft parts should be carefully 
 removed, and tissues into Avhich foreign matter has been so ground that 
 the complete removal of the dirt is impossible should be trimmed away 
 with scissors or knife. Bruised portions of tissue that are still attached 
 should be carefully cleansed and replaced and preserved from further traumat- 
 ism, since much that appears to be hopelessly destroyed may be saved in 
 many cases by care in fostering its nutrition. Thorough scrubbing and 
 irrigation of a contused and lacerated wound with a warm antiseptic lotion 
 until no element of sepsis • is left within it is important, for all the conditions 
 of these wounds are such as to create and present to a large degree the material 
 favorable for the rank development of septic organisms. The natural resisting 
 power of the tissues, which enables the surfaces exposed in ordinary incised 
 wounds to resist the development of sepsis and to preserve the minute devital- 
 ized fragments of tissue that are present from undergoing putrefaction, is no 
 longer to be relied on, for the bruised wound-surfaces have to struggle to retain 
 their own vitality, and large masses of devitalized tissue and more copious 
 effusions of putrefiable secretions have to be disposed of. 
 
 The fullest provision must be made for drainage from all the recesses of the 
 wound. Free counter-incisions must be made wdierever necessary for this pur- 
 pose. Efforts at accomplishing apposition of the wound-surfaces must be sub- 
 ordinated to the need for drainage and the provision for the unhindered separa- 
 tion of necrotic tissue. In cases of severe contusion a degree of uncertainty 
 will always exist as to the ability of the injured tissue to retain its vitality, and a 
 certain amount of necrosis is to be expected and provided for. This necrosis will 
 be reduced to a minimum in proportion as the provisions for making and keep- 
 ing the wound aseptic are thorough and successful. When adequate antiseptic 
 measures are practicable, greater efforts at securing coaptation of the wound- 
 surfaces are proper. Special care should be observed to avoid all tension of 
 the Avounded tissues in the endeavor to approximate them. In a large propor- 
 tion of contused and lacerated wounds there will be such an amount of destruc- 
 tion of tissue that any attempt at closing them to secure primary union will be 
 manifestly contraindicated. In such cases the efforts of the surgeon should be 
 chiefly directed toward protecting the Avound from sources of disturbance dur- 
 ing the time that the separation of the sloughs and the process of granulation 
 are going on. These are the cases in Avhich local septic inflammations, gan- 
 grene, erysipelas, and general septic infection are most prone to occur. The 
 manner in Avhich such disturbances are to be met has been fully discussed in 
 preceding pages. While the constitutional symptoms produced by them Avill 
 often require special treatment, they Avill spontaneously subside if adequate 
 local antiseptic measures are employed. The latter, therefore, should ahvays 
 engage the first and most constant attention of the surgeon. 
 
112 AN AMERICAN TENT- HOOK OF SURGERY. 
 
 Brush Buhx. — By tliis term is meant a peculiar form of" siiperfieial lace- 
 rated and contused wound caused by friction applied to the surface of the body, 
 as when a portion of skin is brouujht into contact with a rapidly-nioving belt 
 of machinery, or by an involuntary slide down a steep incline, or by the slip- 
 ping of a rope through the closed hand. In this injury the superficial tissiies 
 are ground off and an eschar of considerable depth results. They should be 
 treated by antiseptic fomentations until the eschar has separated and a granu- 
 lating surface has formed, which should then receive the treatment elsewhere 
 described. 
 
 PUNCTURED WOUNDS. 
 
 Deeply perforating wounds made by pointed substances will partake of the 
 nature of either incised or contused and lacerated wounds, according to the 
 sharpness of the point of the wounding instrument. Punctured wounds made 
 with sharp, clean-pointed instruments, as pins, needles, trocars, dagger and 
 stiletto points, partake of the nature of limited incised wounds, and unless in 
 their course they have wounded organs of im])ortance, as large blood-ves- 
 sels or nerves, the Avithdrawal of the instrument is followed by rapid and per- 
 fect recovery. Should the puncturing instrument, however, be contaminated 
 with active septic material, an acute septic inflammation will result, depending 
 upon its depth from the surface for its importance, and demanding free incisions 
 for the relief of the pent-up secretions. For its further care those measures 
 which have been described as required for inflamed and infected incised wounds 
 will be indicated. Punctured wounds which are formed by the thrusting into 
 the tissues of irregularly-shaped and blunt substances, such as splinters of 
 wood, nails, a bayonet, and the like, form deep and narrow wound-tracks, the 
 walls of which are contused and lacerated, Avhile minute fragments of devitalized 
 tissues or small fragments of infected material are driven in and deposited 
 in the depths of the wound. The dangers and difficulties attending ordinary 
 contused and lacerated wounds are aggravated in these cases by the long 
 and narrow track which leads from their bottom to the surface. Should 
 no septic material have been introduced by the wounding body, such wounds 
 may yet be expected to heal kindly and promptly if care is taken to avoid 
 their subsequent infection from Avithout and to keep the wounded part at rest 
 while repair is taking place. In view of the impossibility of ade([uately disin- 
 fecting such a wound by mere applications to the surface at the time of the dress- 
 ing, as a general rule it should be freely laid open to the bottom by additional 
 incisions, and there should be thorough disinfection of the wound and the adjacent 
 integument. It should then be covered with an abundant antiseptic dressing, 
 which should be supplemented by any posture or by the application of whatever 
 apparatus that may be required to keep the part at rest. If, notwithstanding 
 this, inflammation of the deeper part of the wound develo))s, immediate resort 
 should be had to suitable free incisions to give vent to pent-up eflusions and for 
 subsequent disinfection and drainage. The more deep and narrow the wound- 
 track, the more important that free and early incisions should be made. Still 
 more important, if possible, are such early incisions when the puncture has 
 involved strong fasciae, the thecfe of tendons, or joint-cavities. Delay in resort- 
 ing to such incisions is not only sure to produce extensive local damage, but 
 may even prove dangerous to life. 
 
 Not infrequently portions of puncturing bodies are broken off and left 
 imbedded in the tissues. In some cases such imbedded substances may 
 remain innocuous for an indefinite period of time. In yet other instances their 
 presence provokes irritative symptoms of a marked character. Foreign 
 
VOXTUSIONS AM> WOUNDS. 113 
 
 bodies in the iK'i^liltorhood of joints, or piercing nerves, tendons, or blood- 
 vessels, are sure to be followed by excessive pain, muscular spasm, or hemor- 
 rhage. Diligent effort should be made to detect and remove foiipign bodies 
 at the bottom of punctured wounds whenever there is reason to suppose 
 from the nature of the body or the nature of the tissues wounded that 
 they will become a source of peril or discomfort if allowed to remain, 
 or in any case when the conditions are favorable to making such a search 
 without an unduly extended or dangerous dissection. The instrument inflict- 
 ing the wound should always be inspected to determine whether an}^ of it has 
 been broken off and left in the tissues. For the removal of such bodies the 
 enlargement of the original wound may suffice, or possibly counter-openings 
 at distant points may be re(iuired, so as to give more ready access to the 
 body sought for. Such counter-openings may be of additional value in pro- 
 viding means for thorough drainage. In attempting the removal of minute 
 bodies, such as the fragment of a needle or a small bit of glass, the search may 
 often be facilitated by raising a triangular flap in the centre of the base of 
 which is the original point of puncture, the apex of the flap lying in the direc- 
 tion toward which the body has penetrated. This flap should include the skin 
 and superficial fascia, and Avhen raised gives more easy access to the deeper 
 tissues, and permits a more free and thorough search for any small body which 
 may be imbedded among- them. To make such an operation bloodless, Es- 
 march's bandage is often of the greatest use. The removal of a puncturing 
 body when it projects from the surface, or lies so near the surface that it can 
 be readily seized, is usually easy, but in some cases, by reason of the irreg- 
 ularity of its surface or its being barbed, as a fish-hook or arrow-head, its 
 removal is difficult. Whenever the location of such an entangled body 
 permits it to be easily pushed through to the other side, such a course should 
 be adopted. When this manoeuvre is not feasible, whatever incisions may be 
 required to free the body from entanglement and allow it to be easily plucked 
 out should be made. 
 
 The hemorrhage in punctured wounds is usually slight and requires no 
 special attention. Should it be at all free, the possibility of the wounding of 
 a large vessel should suggest itself, and a careful review of the anatomical 
 relations of the puncture should be made. Should the hemorrhage not be 
 easily controlled by pressure, the wound should be enlarged, the bleeding point 
 identified, and a ligature applied. A false aneurysm is the not infrequent 
 result of partial divisions of arteries in punctured wounds. Punctured wounds 
 impaling a vein and an artery lying in contact with each other are occasionally 
 the cause of arterio-venous aneurysms. Such sequeli^ call in many cases for 
 free incisions and for exposure of the wounded vessels and ligature above and 
 below the point of Avound. 
 
 GUNSHOT WOUNDS. 
 
 The term " gunshot wound " is applied generically to injuries inflicted by 
 missiles, whatever their character, whose force is derived from the explosive 
 power of gunpowder. This definition, therefore, includes every grade of mis- 
 sile, from the smallest bird shot to the immense projectile fired from mammoth 
 pieces of heavy ordnance, and every grade of injury, from the mere peppering 
 of the surface of the skin Avith grains of gunpowder or minute shot to the 
 laceration and comminution of extensive portions of the body. 
 
 The character of the injury produced when the missile has penetrated the 
 tissues, which is usually the case, is that of a contused, lacerated, punctured 
 wound ; when the surface is merely grazed, it partakes of the nature of the 
 
114 
 
 l.V AMERICAN TEXT-HOOK OE SURGERY. 
 
 brush burn, as already described. In occasional instances a large missile mov- 
 ing with slight momentum fails to break the skin, but produces extensive 
 damage to the subcutaneous tissue. The missiles which are more frequently 
 met with in gunshot wounds are {a) the shot used in fowling-pieces, which are 
 of various sizes, from that of a buck shot, which weighs 133 grains, to that of 
 the smallest bird shot, one of which weighs only ^ of a grain ; {b) pistol bul- 
 lets, varying in size from about ^ of an inch to | of an inch in diameter, and 
 weighing from 20 grains to 240 grains. The size of a pistol bullet is usually 
 designated according to the decimal part of an inch which makes its diameter; 
 thus a 22-caliber bullet is one whose diameter is 22-hundredths of an inch. 
 {<•) The rifle bullet, which is the missile of the modern arm of precision, long 
 and generally conoidal, and weighing from | to 1^ ounces. For military use 
 yet larger missiles have been devised which hardly arrive at the dignity of can- 
 non shot, and yet are heavier than the rifle balls of the infantryman, such as 
 the projectiles thrown by the mitrailleuse, (jatling. and llotchkiss guns. 
 
 The rifles which are now in general use as military weapons project bullets 
 of small caliber (.25-.32 caliber; 6.5 to 8 millimeters in diameter), which, by 
 the use of cellulose-powder, shells of cupro-nickled steel, and a more abrupt 
 
 rifling, are driven with greatly increased velocity, 
 and made to revolve upon their longitudinal axis 
 at the rate of over two thousand revolutions during 
 the first second, and to carry to a much greater 
 distance. The destructive effect of the missile is 
 correspondingly greater. It penetrates and de- 
 stroys every tissue with which it comes in contact, 
 pulpefies such organs as the liver and kidneys, 
 and extensively shatters bones. These explosive 
 efti'Cts are not developed at short ranges, but are 
 especially marked at distances of 500 to 2500 
 
 Fk;. 2R 
 
 ber lead bullet (powder, 6<j gr., penetration, 3.2 in.) ; B, new .:50-ealiber Kerman-silver-jarketed bnllet 
 (iKtwder, 37 gT., penetration, 5.3 in. i : c, oupro-nickeled-steel-jaokcted 30-caliber bullet (powder, 37 gr., 
 penetration, 19.5 in.i. (By kind permission of the chief ordnance oflScer, U. S. A.) 
 
 yards. Its effects will be to increase greatly the number of fatalities upon the 
 battle-field, both on account of the large number of men injure»l by a single 
 bullet and because of the necessary removal to a far greater distance from the 
 battle-field of the field-hospital, so as to be beyond the range of the firing. 
 Fig. 23 shows (.a) the relative penetration in oak, across the grain, of the 
 .45-caliber lead bullet and the great deformation of the ball ; (b). the .30-cali- 
 ber German-silver-jacketed bullet and its deformation : and fr). the .30-caliber 
 cupro-nickled-steel-jacketed bullet, which still retained its original form. 
 
 The repair of gunshot wounds is often disturbed by foreign matter carried 
 into the wound by the projectile, such as portions of clothing, gun-wadding, 
 buttons, pieces of coin, splinters of wood, etc. The mere explosion of powder 
 from a gun fired at short range may produce a serious injury which combines 
 the characters of a burn with those of contusion and laceration. 
 
 Gun.shot wounds derive especial significance from — 1. The special tissue or 
 organ injured; 2. The conditions under which the wound was inflicted; 3. 
 The presence or absence of septic infection. 
 
CONTUSIOXS AND WO CNDS. 115 
 
 Injuries to Special Tissues. — The Skin. — The efteets of grazing tlie 
 skin and of contusion without penetration have already been referred to. 
 When a penetrating wound has been inflicted, the wound of entrance is gener- 
 ally small and less in diameter than that of the missile itself, owing to the 
 elasticity of the skin, which has been stretched by the ball before being pene- 
 trated by it. It is also apt to be dirty, both from the powder if the wound 
 was at short range, and from wiping the dirt from the ball as it enters. Such 
 a wound will appear insignificant to one unfamiliar with its real gravity. 
 Should other foreign matter be carried in with the ball, the wound of entrance 
 will be correspondingly increased in size. Should the ball pass clear through 
 the body or limb, the wound of exit will be larger and more ragged than that 
 of entrance, the diflerence being determined by the lessened momentum of the 
 ball and the want of support to the tissues at the point of exit, as a nail 
 driven through a board splinters largely the under side or point of exit. 
 Conical bullets, having greater penetrating power than round, produce in the 
 skin-wounds Avhich they make much less diflerence in size than formerly 
 resulted from tlie use of round bullets. By subsequent sloughing of the con- 
 tused marcfins of the wound of entrance it often becomes after a few days of 
 greater magnitude than that of exit. 
 
 Fascice. — Especial interest attending wounds of fasciae arises from the fact 
 that their interlacing fibers are often to a considerable degree split and 
 crowded aside by the ball as it passes through them, so that the orifice that 
 they present is much less free than is found in the softer tissues on either side, 
 and tends to interfere materially with the drainage of the deeper parts of the 
 wound. Dense fasciae again frequently present sufficient resistance to a ball, 
 especially if it is a round one, to deflect it from its original course. 
 
 Muscles when involved are subjected to widespread damage through con- 
 tusion and laceration of their substance and extensive infiltrations of blood. 
 
 Tendons, by reason of the resisting nature of their structure and their 
 roundness and mobility, are more frequently either pushed out of the way or 
 deflect the bullet. 
 
 Blood-vessels, especially arteries, whose walls are more resistent and elastic 
 than those of veins, are not infrequently pushed aside. Even in such cases, 
 however, such contusion of their structure is often inflicted as to determine 
 subsequent sloughing and secondary hemorrhage. Both partial and complete 
 division of large blood-vessels is a frequent concomitant of gunshot wounds, 
 and is also the most frequent cause of immediate death by reason of the hemor- 
 rhage following. Traumatic aneurysm and arterio-venous aneurysm may result 
 in certain cases, as has already been noted in ordinary punctured wounds. 
 
 Nerves. — Large nerve-trunks when wounded present no special symptoms 
 that call for extended notice here. The functional disability resulting from 
 such wounds will depend upon the special function of the particular nerve, and 
 may be more or less complex and important. Severe pain may result primarily 
 from inflammatory processes in the injured nerve, or later from its being 
 involved in a contracting cicatrix or by development upon its end of a neuroma. 
 Trophic changes of every degree are among the ultimate results of nerve-injuries. 
 (See Injuries of Nerves.) 
 
 Bones. — A ball striking upon a bone usually inflicts much damage upon 
 it, splitting and comminuting it, often producing fissures that extend into 
 neighboring joints. The bullet may become lodged in the bone, remaining as 
 a source of irritation, and often of suppurative inflammation, until removed. 
 
 The Great Cavities of the Body. — Balls penetrating the cranial cavity will 
 produce symptoms according to the region of the brain injured ; though always 
 
IIG AN AMEItlVAy TEXT-JiOOK OF SVUGEUY. 
 
 serious, the wounds they inflict are not necessarily fatal. Penetrating wounds 
 of the thorax may involve the lun<^s, the heart, or the <.'reat vessels, and, if not 
 immediately fatal, present S[)ecial diiliculties in the inflammatory complications 
 or in the resulting extensive pleural or pericardial eftusions. Penetrating 
 wounds of the abdominal cavity, in addition to the dangers from hemorrhage 
 and from ordinary inflammatory complications, have the special dangers inci- 
 dent to possible wounds of the stomach, intestines, bladder, and the various 
 other alxlominal viscera. (See Wounds of the Abdomen and its A'iscera.) 
 
 The Conditions under which the Wound is Inflicted. — Gunshot 
 wounds differ especially from the ordinary operative wounds inflicted by a sur- 
 geon in the special conditions incident to warfare which make it difficult, often 
 impossible, to give to the patients the full degree of care which they require, 
 and Avhich often expose them to further injury that greatly aggravates the 
 original severity of the wounds. In dealing with these conditions is found 
 the special field of military surgery. In civil life, however, it often happens 
 that gunshot wounds are sustained under conditions that resemble those of 
 military campaigning, as in the case of accidental wounds occurring among 
 hunting-parties in regions remote from help. The frequent absence of skilled 
 help and of the materials for the proper dressings for such wounds adds 
 greatly to the dangers which attend them. The necessary transportation 
 of wounded men for long distances, often with the most crude resources for 
 their comfort, is another fruitful source of evil, and has many times demanded 
 the sacrifice of a limb or has occasioned the loss of a life which under more 
 favorable circumstances could have been saved. In the accidental gunshot 
 wounds of civil life also it is by no means the rule that adequate Surgical skill 
 and proper dressing materials are at once attainable. 
 
 The Presence or Absence of Septic Infection. — This is a factor of the 
 highest importance in determining the favorable or unfavorable course of a 
 gunshot wound. If such a wound is preserved from septic infection, the wound 
 of entrance is quickly closed and its remaining track, however long it may be, 
 or however much lined by contused necrotic tissue, or whatever organ it may 
 have traversed or bones it may have shivered, is reduced to the condition of a 
 subcutaneous injury, and is tliereby saved from a thousand dangers that might 
 otherwise complicate its healing. Fortunately, experience has shown that in 
 many instances a penetrating bullet does not carry w^ith it septic material, and 
 that if a- wound Avhich has been thus made is preserved from subsequent infec- 
 tion, an aseptic course of healing will take place. The question of the removal 
 of the bullet itself in such cases becomes a secondary matter, depending entirely 
 upon the importance of the later symptoms of disturbance wliich its presence in 
 the tissues might occasion. On the other hand, the introduction of sepsis into 
 a gunshot wound is sure to determine inflammatory and suppurative symptoms 
 of the most pronounced type, and to call for the most energetic and thor- 
 ough interference on the part of the surgeon. Secondary hemorrhages are 
 to be feared ; necrotic debris and the pent-up products of septic inflamma- 
 tion will require to be evacuated; increased dangers to life and limb will be in- 
 curred ; and in the most favorable event a prolonged convalescence w ill result. 
 
 Diagnosis. — The circumstances attending the infliction of a gunshot 
 wound will usually be sufficiently clear to settle the fact that a given 
 wound is due to the penetration of the tissues by a projectile driven by the 
 explosive force of gunpowder ; but the surgeon in investigating the case may 
 find it important to determine the course which the missile has taken, the 
 organs injured, and the final resting-place of the missile, provided it has not 
 already escaped by an aperture of exit. The external marks of injury may 
 
coy^TcsiONS Axn woryns. iii 
 
 give no clue Avhatever to the character and extent of the deeper injuries 
 which have been received. In forming any conclusion as to the extent and 
 nature of the wound which has been received, a careful investigation, there- 
 fore, must be made into all the symptoms attending the injury, such as shock, 
 hemorrhage, functional disturbance, local pain, and tenderness, as well as an 
 inspection of the external signs of wounding. All such investigations should 
 be made with the most scrupulous care to avoid touching the wound itself unless 
 under the most rigid antiseptic precautions. When it is possible to ascertain 
 the direction from which the missile came and the position of the body or limb 
 at the time the wound was received, valuable information as to the course 
 which the missile has taken through the tissues may sometimes be gained 
 by putting the parts again into the same position. The possible deflection 
 of the bullet by bone or fasciae is not to be forgotten, and must be given due 
 weiiT'ht in explaining otherwise confusing symptoms. The slight differences 
 which have already been remarked upon as existing between the orifices of 
 entrance and exit should be borne in mind in determining the point of primary 
 penetration when two apertures exist. The amount of pain attending the 
 reception of a gunshot wound varies much, and is of little value as a diagnostic 
 symptom. In the excitement of the moment many wounds are received with 
 no consciousness of the fact on the part of the injured person, who discovers it 
 later only through the hemorrhage or the functional disability which results. In 
 other cases a sharp stinging pain or a dull, numb sensation indicates to the 
 person that he has been wounded. Sometimes the shock of even slight wounds 
 is very great. 
 
 Probing a Wound. — When the circumstances of the case or the symptoms 
 which are present make it important that the deeper recesses of the wound 
 should be searched, this is to be accomplished by the insertion of the finger of 
 the surgeon if possible, or by the use of suitable probes, and all the steps 
 of the process of search should be conducted with most careful regard to the 
 requirements of rigid antisepsis. Such probings are not to be done as a mat- 
 ter of routine, but only when some distinct indication is present. Free enlarge- 
 ment of the external wound should be made without hesitation whenever it will 
 facilitate the prosecution of the search, and as far as possible reliance should be 
 placed upon the finger of the surgeon for gaining the desired information to the 
 exclusion of metallic or other probes. When it is necessary to pursue the 
 investigation into depths which are beyond the reach of the finger, a metallic 
 probe of suitable length and having a bulbous tip of considerable size may be 
 used. Such a probe having the tip made of porcelain biscuit, and known as 
 Nekton's probe, has the special value that when the tip comes in contact with 
 the bullet at the bottom of the wound it retains the mark of the lead upon it, 
 and thus gives an absolute demonstration that it has been in contact with the 
 bullet or a fragment of it. Before using it its freedom from any similar prior 
 stain must be ascertained. The stem of an ordinary clay pipe has been used 
 extemporaneously for the same purpose. The "telephonic probe" of Girdner 
 is an ingenious application of the telephone which may occasionally assist 
 in identrfying the location of a bullet in the tissues. This device may be 
 extemporized whenever an ordinary telephone receiver is accessible : one of 
 the wires of the telephone having been attached to the probe, the other is 
 made fast to a metallic plate, which is placed upon any portion of the surface of 
 the body previously moistened. The probe is now inserted into the wound 
 for the purpose of the search, while the telephone receiver is held to the ear 
 of an assistant ; whenever the probe comes in contact with the bullet a distinct 
 elick is heard in the telephone — a click which is not elicited except by contact 
 
118 AX AMKRICAX TEXT-BOOK OF sriiGERY. 
 
 •with metal. Other methods for utilizing the electric current for detecting and 
 locating a bullet imbedded in the tissues have been devised ; some of these 
 are ingenious and successful as experiments, but none are susceptible of being 
 utilized in general practice. 
 
 Probing should be done with gentleness antl care. It cannot be too 
 strongly impressed on the mind of the surgeon that all ])robing should be 
 abstained from until such time as the final, thorough examination and dre.ssincr 
 of the wound can be done, when once for all tiie probe may be resorte<l to in 
 accordance with the restricted indications for its use liereafter mentioned. 
 
 Treatment. — Shock is to be combated in accordance with general princi- 
 ples. Persistent hemorrhage of sufficient extent to refjuire special interference 
 for its arrest indicates a wound of a vessel of considerable size. In such cases 
 the rule is imperative to enlarge the wound sufficiently to expose freelv the 
 bleeding vessel and to ligate it upon both the proximal and distal sides. 
 Should the vessel not have already been completely severed by the ball, it 
 should be divided between the ligatures after their application. Hemorrhage 
 occurring secondarily during the after-histon,' of the wound demands the same 
 treatment, and often involves an extensive dissection in the necrotic tissue. 
 When, by reason of its anatomical position or the difficulty of finding it in the 
 sloughing tissues, it is not practicable to expose the wounded vessel in this wav, 
 ligation of the main artery of supply in its continuity must be resorted to. but 
 only after a determined effort has been made to ligate it in the wound itself 
 
 From the standpoint of treatment gunshot wounds are divisible into two 
 classes — first, those which are capable of primary occlusion of the external 
 wound and of conversion into practically subcutaneous wounds ; and secondly, 
 those which must be treated as open wounds throughout. A large proportion 
 of gunshot wounds are capable of being kept within the first of these two 
 classes. 
 
 First class. — The first efibrt of the surgeon, therefore, should always be 
 scrupulously to protect the wound from contamination from without, Tiie one 
 exception to this rule is found when necessity for interference for the arrest of 
 hemorrhage is so great that its urgency may compel the disregard of every other 
 precaution. The external wound may be of such extent as to be manifestly 
 incapable of being sealed up by primary occlusion, but such a condition gives no 
 warrant for the neglect of every possible effort at antisepsis from the beginning. 
 The mere lodgment of a bullet in the tissues is not of itself an indication for 
 the introduction of an exploring finger or probe, nor is it justifiable to disturb 
 the wound by the new traumatism of an exploration until distinct evidence has 
 appeared that the missile is seriously interfering with the repair of the wound by 
 its presence, or unless there is good reason to believe that there has been car- 
 ried into the wound with the bullet septic material, such as fragments of cloth- 
 ing. That exploration of a gunsliot wound which is called for by reason of 
 such manifest extensive laceration and destruction of tissue that the questions 
 of excision and amputation require to be decided, is of an entirely different 
 character from that which has as its end the quest for a bullet and its removal. 
 Such explorations are made on general surgical principles, and become a part 
 of the more formal and extensive operative procedures to which they lead. 
 It is not infrequent, in cases where the foreign body has been allowed to 
 remain undisturbed in its new position among the tissues, and satisfactory and 
 rapid healing of the original wound has been secured, that the body subse- 
 quently becomes a source of irritation, so that its extraction is necessitated. 
 A late operation of this kind, when it can be surrounded by every precaution, 
 and is done among tissues which are no longer infiltrated and from which all 
 
CONTUSIOXS AND WO ('XI)S. 119 
 
 bloody oxtravusatioii lias loiiji; bt-en absorbed, is attended with much less dan- 
 ger than a primary o[)eration would have been. 
 
 A gunshot wound from the time that it is received until adequate antiseptic 
 cleansing and dressings can l)e applied should be left exposed to the air without 
 any covering whatever, inasmuch as the air is less likely to be septic than any 
 ordinary (h'cssing which coidd be applied. By such exposure desiccation of 
 the secretions about the wound-aperture is favored and a protective crust is 
 formed. As early as possible after the infliction of the wound the external 
 aperture and the surrounding area of skin for a number of inches should be 
 thoroughly cleansed with soap and water and sterilized by the free application 
 of a solution of corrosive sublimate, 1 : 1000, or of carbolic acid, 1 : 80. It 
 should then be covered with an abundant dressing of absorbent antiseptic 
 material. Almost anywhere ordinary linen or other similar dressings can be 
 used after being made aseptic by heating in an oven to a point just short 
 of burning. The wound-opening itself should by preference be covered by 
 a bit of oiled silk or rubber protective previously sterilized, but this is not 
 absolutely essential ; the j)art should now be immol)ilized, if it is a limb that 
 has been injured, by an adequate splint, which should extend sufficiently far 
 above and below the wound to keep at rest all the muscular tissue of the part 
 from origin to insertion. The wound should not be disturbed until definite 
 healing has been accomplished, unless symptoms of septic infection should 
 declare themselves, especially by a rise of temperature, thus converting the 
 wound into one of the second class, next to be considered. 
 
 Tlie second class of cases, which must be treated as open wounds, include 
 those in which the extent of the wound is too great to give any hope from the 
 first of securing its primary occlusion ; those in which these attempts have been 
 made, but have failed ; and those in which such attempts have been deferred or 
 omitted until the wound has become manifestly septic by reason of its exposure, 
 its having been subjected to uncleanly and premature explorations, or the 
 application to it of contaminated dressings. Even in this second class of cases 
 all explorations and other operative measures should be deferred, if possible, 
 until they can be done with the necessary disinfection, and can be accompanied 
 by adequate protective dressing. Treatment should be conducted with scrupu- 
 lous attention to the thorough disinfection of every accessible recess of the 
 wound and to perfect freedom of drainage. The appearance of high fever, 
 inflammatory swelling, progressive infiltration, gangrene, and other evidence 
 of progressive septic contamination calls for the energetic and thorough 
 application of all the resources for the control of sepsis which are within the 
 command of the surgeon. 
 
 The primary examination and cleansing of the w^ound should be conducted 
 with the view of making it aseptic if possible. Frequent partial cleansings 
 should be avoided ; repeated probings, cuttings, irrigations, and squeezing for 
 the purpose of evacuating the wound-secretions and debris, which keep up a 
 continued irritation of the wound, should be replaced by one thorough primary 
 examination and cleansing. This should be conducted under an anesthetic, 
 with deliberation and minute attention to the ultimate object in view — the 
 destruction and prevention of sepsis. The external wound should be freely 
 enlarged when necessary, so as to permit the introduction of a cleansed and 
 disinfected finger for purposes of exploration. Bullets, splinters of bone 
 entirely detached, pieces of clothing, and other foreign bodies which are found 
 during the examination should be carefully extracted. A bullet, after having 
 in the early part of its course inflicted injuries which require to be treated by 
 the open method, not infrequently continues its course in such a manner that 
 
120 AN AMKinCAX TEXr-llOOK OF SURGERY. 
 
 the second part of its track may lu'al primaiily lu'liiml ir, nnd the bullet remain 
 shut otVlVoiii the first part of the woiiihI. and there, becoming encysted, remain 
 permanently without inducing further misehief. 
 
 The treatment of such a deep wound-track should be conducted on the 
 same principles as those which control the more superficial wounds ; it should 
 not be i)robed nor irrigated, nor in any manner interfered with, unh'ss evidences 
 of inilaiiiniatory disturbances of its walls appear ; no search should be made 
 along it for the bullet ; much less should the presence of the bullet at its bottom 
 be considered an indication for an attempt at its removal, unless easily accessible 
 from the opposite side, when it should be removed antiseptically. The dis- 
 infection and drainage of the superficial portion of the wound should be 
 conducted with all care and thoroughness. Should deeper disturbances 
 manifest themselves, the exploration, cleansing, and drainage of that portion 
 of the wound would then be required. Enlargement of the aperture of com- 
 munication with the superficial wound, and free counter-incisions to the extent 
 required for its easy and perfect drainage and for the removal of any foreign 
 and irritating bodies along its track, will be necessary. 
 
 A certain proportion of these injuries will require primary resections of joints, 
 partial or complete, and amputations, as a part of the care required in the pri- 
 mary dressing. The necessity for these more important operative procedures 
 will have become revealed in the course of the explorations which have been 
 made. The judgment and experience of the surgeon as to his ability to ward 
 off the dangers which threaten badly shattered joints and bones and exten- 
 sively-mangled soft tissues, and to conduct the wound to a satisfactory healing 
 so as to preserve a useful limb, must influence the decision in many cases as to 
 whether a conservative method of treatment or the opposite should be adopted. 
 In yet other cases, when, in addition to extensive injury to a bone or penetra- 
 tion of a joint, the main vessels or nerves of the limb are injured, or when 
 extensive loss of the soft tissues has taken place, or when a part of the limb 
 has been carried away, no alternative is left to the surgeon but amputation. 
 
 When the necessity of amputation is unquestionable, it should be done as 
 soon after the shock from the primary wound has passed away as is practicable, 
 provided this is before septic infection, inflammatory infiltration, and secondary 
 traumatic fever have developed. This is the period characterized by old authors 
 as the primary 'period ; which, in pre-antiseptic days, extended over the first 
 thirty-six to forty-eight hours. This is followed by a period extending 
 over a variable time, during which there is progressive local inflammatory 
 infiltration and general fever. This period is termed the iiifi^niicdittn/ period- 
 During this period no operative interference is to be attempted other than that 
 required for the removal of necrotic tissues or for affording adequate drainage, 
 unless spreading gangrene of the wound develop, when distant amputation 
 through tissues yet sound should be done as quickly as possible. When the 
 primary inflammatory infiltration has become limited and begins to subside, 
 and free suppuration from the wound-surfaces has become established, another 
 period is said to have been reached, known as the seeondart/ period. When 
 the secondary period has been reached, amputation through tissues yet sound 
 should be done without further delay. 
 
 The prolongation of the primary stage by antiseptic treatment — continuous 
 antiseptic irrigation being the method which in general is best adapted to 
 these cases — makes it possible for the surgeon to delay amputation until such 
 time as, in his judgment, the patient will be in the most favorable condition to 
 bear the operation. In some cases it will happily have served to demonstrate 
 the possibility of recovery without amputation, for in not a few instances the 
 
CONTUSIONS AND WOUNDS. 121 
 
 possibility of saving a limb will depend entirely upon the success of the efforts 
 to prevent the wound from being invaded by septic infection. As soon as it is 
 evident that these eftbrts have not been successful, amputation should be pro- 
 ceeded with, before the full local and constitutional symptoms of sepsis have 
 developed. 
 
 Point of Amputation. — The choice of the point at which the amputa- 
 tion shall be made may be greatly influenced by the facilities at the command 
 of the surgeon for keeping the wound aseptic. If these be adequate for the 
 purpose, the section may be made at whatever point may lie desirable to give 
 the patient the most useful stump, even though bruised and lacerated parts be 
 included in the flaps. These are preserved from inflammatory disturbance, their 
 full vitality is regained, and they participate in the formation of the stump 
 without disaster from sloughing. When, for any reason, the wound cannot 
 receive adequate antiseptic treatment, amputation, if possible, should be made 
 at a point sufficiently far above the injury to exclude all bruised and lacerated 
 tissues from the flaps. A blind groping for a bullet at the bottom of a deep 
 sinus should never be attempted. The enlargement of the external aperture 
 and the dilatation of the deeper track, as required for the purposes of the 
 cleansing and drainage of the wound or the counter-incisions made when the 
 length of the track and the location of the ball demand it, should be ample 
 enough to permit the sufficient exposure and ready seizure of the bullet if it is 
 to be removed at all. For the purpose of facilitating the removal of a bullet 
 when exposed many styles of forceps have been devised ; it is not necessary 
 that mention of any special one should be made. Any pair of forceps with 
 slender and firm jaws, with slightly projecting teeth or with roughened points 
 to increase the security of the grasp upon the bullet, will answer. The bullet 
 will commonly be found to be somewhat battered and misshapen and entangled 
 in interlacino: strands of fibrous tissue that hold it closely, so that some little 
 difficulty is often experienced in freeing the bullet so that it can be removed 
 after it has once been exposed. If the bullet is firmly impacted in bone, it 
 must be first loosened by the chisel or elevator, and then removed. 
 
 Gunpowder grains imbedded in the skin may be picked out by a sharp- 
 pointed bistoury and a fine curette, or be left to spontaneous discharge by 
 suppuration. In an\^ event, a permanent tattooing will remain as a mark of 
 the wound. 
 
 Arroiv-tvounds. — The wound made by an arrow is a punctured incised 
 wound. Such wounds demand special mention only in connection with the 
 question of the treatment of the arrow when any portion of it is lodged in the 
 wound. The barbed head of the arrow, by becoming entangled in the tissues 
 which close over it after it has penetrated them, forms a condition that is espe- 
 cially difficult to overcome if the arrow has penetrated to any depth. The 
 general principles of surgery which are applicable to the search for and removal 
 of all foreign bodies imbedded in the tissues are equally applicable to imbedded 
 arrow-heads. If the shaft of the arrow is still attached to the head, it affords 
 a valuable guide along which the dissection of the surgeon may be made for 
 adequate exposure and disentanglement of the arrow-head. It should never be 
 pulled upon for the purpose of removing the arrow, for the effort will certainly 
 be futile, and if the shaft becomes separated from the head its further service as 
 a guide is lost. If, however, the arrow has so far penetrated the tissues as to 
 make it feasible to push it clear through and out on the other side, that treat- 
 ment should be adopted ; and in that case the shaft should be used to push out 
 the head, the exit of which through the skin should be helped by the proper 
 use of the knife. The head and the ribbon which attaches it to the shaft being 
 
122 AX AMKliJCAN TEXT-BOOK OF SLUGERY. 
 
 then removed, the shaft itself can be withdrawn. Arrow-heads (h> not 
 become encysted like bullets. The experience of military surgeons is 
 uniform that an arrow-head lodged in the soft tissues invariably produces 
 serious results. Hence the rule is without exception that an arrow-head 
 left behind and lodged in the tissues must be removed as soon as j)o.ssible, 
 even \i this removal should recjuire the severest and most dangerous ope- 
 ration (Bill). 
 
 Injuries t)'otn Electric Currents. — Lii/Iit)iiti(/-!<tro/cc. — The passage through 
 the body of electric currents of high voltage, an accident of frequent occur- 
 rence since the introduction into common use of such currents for illu- 
 minating and mechanical purposes, is ])roductive of ])rofound inhibition, 
 immediate unconsciousness, and often of instant death. An alternating 
 current is more damaging than a continuous current of the same strength ; 
 legal electrocutions have shown tiiat no human being can survive the passaf^e 
 through his body of an alternating current of more than loOO volts for a 
 period of tAventy seconds (MacDonaldj. A momentary exposure to a high 
 degree of electrical force may be less disastrous than a longer exposure to a 
 current of less intensity. Intense general muscular rigidity is instantly 
 induced by the current and persists during its continuance; but relaxation 
 occurs as soon as the current is broken. No recognizable changes in the 
 tissues or organs of the body have been discovered in electrocuted subjects, 
 excepting slight local burns of the skin at the points of application of the 
 electrodes and minute petechial spots on several organs (A''an Giesen). The 
 coagulability of the blood is lessened or abolished. In cases of lightning- 
 stroke violent disruptive effects have sometimes -been noted, even to the 
 extent of the fracture of bones and the laceration or avulsion of entire 
 limbs. 
 
 Asphyxia, from paralysis ot the respiratory muscles, is an imminent 
 danger in cases in which instant death by inhibition is escaped. Efforts at 
 artificial respiration have resulted eventually in recovery even after apparent 
 death. In D'Arsonval's case there was apparent death in half an hour, but 
 recovery followed artificial respiration. 
 
 In non-fatal cases the phenomena induced are those of pronounced shock, 
 unconsciousness lasting from a few hours to days, muscular pareses, areas of 
 superficial anesthesia, and transitory impairment of some of the special 
 senses, especially of sight and hearing. Gradual recovery from these eff"ects 
 is the rule, after variable periods. 
 
 Treatment. — If a man is caught in electric wires, shut off" the current if 
 possible. If this cannot be done and if rubber gloves can be obtained, let 
 some one put on the gloves and lift the wires away. If the clothing is dry, 
 it is safe to pull the victim from the wires by catching his coat-tails. If a 
 dry cloth is pushed under the body, it can be safely moved. In all cases 
 artificial res])iration with tongue-traction should be tried and persisted in 
 until its futility has been demonstrated or natural breathing is resumed. At 
 the same time apply cold douches to the head, give hot enemata, wrap the 
 patient in warm blankets, put a mustard-plaster over the heart, but do not 
 give alcoholic stimulants. In some cases venesection has proved useful. The 
 later treatment of paralytic and sensory disturbances, and that of the local 
 burns, if any exist, is conducted as in cases of similar disturltances due to 
 other causes. Electric burns are apt to slough extensively and are very slow 
 to heal. Iodoform and corrosive sublimate irritate them very much. They 
 should be dressed with gauze wet with hot, normal salt solution. When the 
 slough separates they may be dressed with dry, sterile gauze. 
 
CO XT us IONS AND WOUNDS. 12.3 
 
 POISONED WOUNDS. 
 
 Certain wounds remain to be considered which are associated with the 
 inocuhition of special hurtful substances. They have long been classed 
 together as poisoned wounds, although in some the poison injected is of 
 a chemical character, while in others it is microbic. A distinction, however, 
 should be made between Avounds that are subjected to microbic and those 
 subjected to chemical influences. The former constitute the general class 
 of infected wounds, in which are to be grouped not only all those heretofore 
 described as subject to the usual septic infection, but also those which are 
 infected by special microbes, as rabies, glanders, anthrax, actinomycosis, etc. 
 Chemical poisons difter from microbic poisons in that they are incapable of 
 self-reproduction, and that their deleterious effects are proportionate to the 
 amount of the poison at first introduced into the body. In this class are to be 
 grouped the bites and stings of insects and of reptiles. It is not be overlooked 
 that in ordinary infected wounds the local and general symptoms which are 
 produced are due largely to the action of the chemical poisons or ptomaines 
 which are generated by the micro-organisms that infest the wound, and not to 
 the presence of the micro-organisms themselves. Such Avounds are there- 
 fore of a double nature. In all cases where there is a tendency to spreading 
 gangrene this mixed character of the poison is especially marked. The acrid 
 ptomaine by its chemical effect upon the tissues with Avhich it comes in contact 
 produces their death and converts them into a fertile soil for the rapid multipli- 
 cation of the invading micro-organisms, Avhich, again, as they multiply, produce 
 a rencAved supply of the ptomaine, that attacks a fresh layer of tissue : and 
 thus the vicious circle is completed and the progressively destructive proc- 
 ess is maintained. There are, therefore, three great classes of poisoned 
 wounds : 
 
 First, that of mixed or bio-chemical infection, Avhich includes all the 
 ordinary septic Avounds that have been treated of in the preceding pages, and 
 likewise those special Avounds Avhich are at times accompanied AA'ith marked 
 tendencies to spreading inflammation and gangrene, such as those received in 
 the dissecting-room, during post-mortem examinations, by butchers and fish- 
 dealers from tainted meat and fish, and those resulting in that rapidly-extend- 
 ing gangrenous process knoAvn as "malignant oedema." 
 
 Second, ciiemical poisons alone — the bites of insects and reptiles. 
 
 Third, microbic infection alone — rabies, glanders, etc. This latter class 
 difi"ers so Avidely and materially in every respect from the first two as to deserve 
 an entirely separate consideration. We shall accordingly group the first tAA'o 
 under the one head of Poisoned Wounds j)ropey\ while the latter class w^e shall 
 treat under the designation Surgical Diseases due to Microhic Infection. A 
 number of these are usually derived from animals. 
 
 POISONED AVOUNDS PROPER. 
 
 Dissection Wounds. — The term "dissection wounds "is applied to septic 
 wounds of special virulence contracted in the dissection of dead bodies, both in 
 the dissecting-room and especially in post-mortem examinations. It is applica- 
 ble also to a similar class of injuries sustained by surgeons in operating on the 
 living ; similar wounds occur also in butchers, fish-dealers, cooks, and othei 
 persons whose vocations may demand their handling putrefying animal material. 
 Only a very small proportion of the pricks inflicted upon themselves by medi- 
 cal students and surgeons in dissecting the bodies of the dead or in operating 
 
124 AX AMERICAN TEXT-liOOK OF SURGERY. 
 
 upon the living are followed by any serious consequences. For the develoj)- 
 ment of the more grave results it is necessary that there shall be some special 
 virulence in the tissues or fluids by which the wound is inoculated, or that the 
 individual who receives the wound should be in a condition of general consti- 
 tutional depression, so that the natural resisting power of liis tissues is greatly 
 diminished. The worst cases occur when both these conditions happen to be 
 combined. Exi)erience has shown that the tissues of the recently dead are more 
 frequently capable of communicating serious infection than those in which the 
 process of decomposition is well advanced. The dissection of bodies in which 
 death has been caused by virulent infective processes, as puerperal fever, ery- 
 sipelas, or pyemia, is especially dangerous. Occasionally the wetting of the 
 hands, on which there is no perceptible scratch or breach of surface, by the 
 acrid fluids of a body dead of virulent infective disease may be attended with 
 all the results for which the presence of a prick or scratch or abraded surface 
 of some kind is usually necessary. 
 
 Symptoms. — The symptoms presented by a dissection wound may be 
 those of any grade of septic infection, from that of slight local inflammation 
 and suppuration to that of rapid, pi-ogressive gangrenous inflammation, with 
 extreme general prostration from septic absorption, the development of pyemic 
 foci in other parts of the body, and death. A not uncommon form is that in 
 which the inflammation extends especially along the lymphatics, which appear 
 as red lines, and produces marked swelling of the axillary glands. 
 
 Treatment. — The treatment of these Avounds differs in no Avay from that 
 which has been laid down for a septic wound in general. When an indivi<lual 
 is conscious of the reception of the wound at the time, energetic local antiseptic 
 treatment should be immediately instituted ; thorough scrubbing and cleansing 
 of the Avound and the surrounding integument over a wide area should be made; 
 the wound itself, if a puncture, should be enlarged sufficiently to permit of the 
 certain introduction to its deepest point of the antiseptic to be used. The 
 wound should then be thoroughly swabbed out with some such strong antiseptic 
 agent as pure carbolic acid, solution of corrosive sublimate, 1 : oOO, or solution 
 of chloride of zinc, 8 per cent. ; the part should be covered with an abundant 
 dressing of absorbent material, Avhich should be kept wet Avith a solution of 
 corrosive sublimate, 1 : 2000, for three or four days ; that is to say, until suffi- 
 cient time has elapsed to demonstrate Avhether or not the disinfection of the 
 wound has been successful. When this has been assured, any simple emollient 
 protective dressing may be substituted until complete healing of the Avound has 
 taken place. AVlien, through the neglect or inefficiency of primary antiseptic 
 care, advancing phlegmonous inflammation or lymphatic irritation and glandu- 
 lar enlargement begin to develop, the surgeon should not wait until suppuration 
 and sloughing of tissue have taken place before incising the inflamed and mfil- 
 trated regions, but should at once make sufficiently free incisions to open up 
 thoroughly every infected district and to permit the free exit of the inflamma- 
 tory secretions Avitli Avhich the tissues are infiltrated. The early resort to free 
 incisions of this character Avill prevent much destruction of tissue and serious 
 impairment of function, will relieve pain, and greatly abbreviate the course of 
 the attack. Abundant antiseptic irrigations should be practised upon all the 
 tissue-spaces opened up by these incisions; the incisions themselves should be 
 kept open by tents of iodoform gauze until all tendency to spreadmg inflam- 
 mation has subsided and a healthy granulating process has developed. Mean- 
 Avhile, the Avhole limb should be kept enveloped in Avet bichloride dressings. 
 Abscesses, Avhenever and Avherever formed, should be opened as soon as possible 
 and treated after the iieneral manner already described. The constitutional 
 
CONTUSIONS AND WOUNDS. 125 
 
 treatment required will be conducted on general principles, and will include 
 stimulants in large doses, opiates, and tonics. 
 
 Malignant (Edema, known also as Gangrenous Emphysema and G-an- 
 (jreiie Foudroi/antc, is a rapidly-spreading gangrenous inflammation in which the 
 affected tissues become distended with the gaseous products of decomposition, due 
 to infection by a special micro-organism. (PI. Ill, Fig. 1). This micro-organism 
 was identified by Koch in 1882, and is a rod-like bacillus, resembling in form 
 and size that of anthrax, but somewhat smaller, with rounded ends. The bacilli 
 are joined together in threads after a peculiar fashion. Unlike the anthrax 
 bacillus, they have the property of spontaneous motion and of spore-formation 
 in the living body; they grow only in the absence of oxygen; they only 
 rarely enter the animal body with any activity ; they abound in garden soil, 
 and may be met with in any kind of soil or dust. The gangrenous and putre- 
 factive phenomena Avhich are marked features of the disease in question are said 
 not to be primarily produced by the bacillus, but to be due to the admixture with 
 it of the ordinary putrefactive forms. According to Park (Mutter Lectures on 
 Surgical Pathologg, 1890 and 1891), when a pure culture of these specific 
 bacilli is injected there results an extensive hemorrhagic oedema of the sub- 
 cutaneous cellular tissue, without any appearance of putrefactive action and 
 quite free from gas-formation ; but when an impure culture is injected or when 
 garden earth is used for inoculation, the distinctive oedema of the previous 
 instance becomes a mixture of emphysemic oedema and gangrene. These organ- 
 isms must be planted subcutaneously in the areolar tissues in order to produce 
 the typical results. Inoculations upon abrasions or open wounds are harmless, 
 owing to the free access of the inhibiting oxygen of the atmosphere. 
 
 Symptoms. — The local symptoms of the disease are those of a rapidly- 
 extending gangrene surrounded by an extensive ever-spreading area of swollen, 
 livid tissue, infiltrated by foul-smelling, acrid secretion and the gaseous prod- 
 ucts of decomposition. The oedematous tissues emit a fine crepitus when 
 pressed by the finger ; the overlying cuticle is raised into blebs filled with red- 
 dish offensive serum ; the sloughing tissues are bathed in a thin putrid fluid. 
 The general state of the patient is one of great prostration and profound 
 septicemia, accompanied by apathy and sometimes by delirium. Death super- 
 venes usually Avithin from one to two days ; after death putrefaction goes on 
 with great rapidity. Examination of the viscera shows them to be congested 
 and oedematous and the subject of multiple hemorrhagic infarcts. 
 
 The diagnosis of malignant oedema is simple. The clinical picture which 
 it presents is clear and not likely to be mistaken for anything else. The first 
 symptom is hemorrhagic oedema of the subcutaneous cellular tissue, to which 
 is added infection with ordinary putrefactive organisms ; a rapidly-spreading 
 gangrene results, with the addition of an emphysemic element to the previously 
 existing oedema from the gases of putrefaction. This mixture of emphysemic 
 oedema and gangrene is the pathognomonic clinical feature of the disease. 
 Microscopic examination of the oedema fluid will show numerous bacilli of the 
 disease. The prognosis is always grave ; with rare exceptions the disease 
 marches rapidly to a fatal termination. 
 
 Treatment. — The treatment must be heroic and radical from the moment 
 of the recognition of the disease. If a limb is attacked, immediate amputa- 
 tion should be done at a point well above the line to which the disease has 
 extended. When amputation is not feasible, a radical excision of the affected 
 tissues should be done, with the most thorough, continuous, subsequent antiseptic 
 treatment. The general strength should be sustained by vigorous stimulation 
 and by other tonic and supporting treatment. 
 
12G J.V AMI'JUCAX TKXT-JiOOK OF SURGEUY. 
 
 BITES AND STINGS OF INSECTS AND REPTILES. 
 
 These are minute punctured wounds into which has been injected some 
 poisonous secretion from distinct poison-glands or from modified salivary glands 
 of the animal inflicting the bite. 
 
 Insect-bites and Stings. — In tlie case of insects tlie poison inoculated is 
 acid in its nature : the results (»f its injection present everv dcfrree of variation in 
 severity, from that of the simple local irritation produced'by the minor and more 
 common insects, such as the flea, the mosquito, bedbug, various forms of mites, 
 etc., to the greater local reaction and considerable constitutional disturbance 
 following the stings of the more aggressive and venomous hymenoptera, 
 such as bees, wasps, hornets, and yellow-jackets, and the still more virulent 
 and dangerous centipedes, spiders, tarantula?, and scorpions. As a rule, 
 the stings of even the most venomous of insects are unattended with dan- 
 ger to life, but where many have been inflicted or when the person is 
 weak and feeble severe constitutional disturbance, marked by chills, fever, 
 and great prostration, and even ultimate death, may result, the severity of the 
 symptoms depending upon the amount of the poison which has been absorbed 
 into the general circulation. The wounds inflicted even by spiders and scor- 
 pions of the largest size rarely prove fatal. 
 
 Treatment. — Alkaline local applications should be used, such as dilute 
 aqua aiiiinuniie or solution of bicarbonate of sodium. Ordinary loam mixed 
 with water to form a mud poultice is useful as an extemporaneous application. 
 Local inflammatory disturbances must be treated upon general principles ; 
 constitutional symptoms must also be combated according to the special indica- 
 tions of the particular case. 
 
 Serpent-bites. — In the United States naturalists have discovered twenty- 
 seven species of poisonous serpents and one poisonous lizard ; eighteen 
 species of these are true rattlesnakes : the remaining are divided between 
 varieties of the moccasin or copperhead and of the viper. The poisonous 
 lizard is the Texan reptile known as the " Gila monster." In all these 
 serpents the poison fluid is seci'eted in a gland which lies against the side 
 of the skull below and behind the eye, from which a duct leads to the base 
 of a hollow tooth or fang, one on each side of the upper jaw ; Avhich fsing, 
 except in the case of the vipers, is movable and susceptible of erection and 
 depression. When not in use, the fang hugs the upper jaw and is ensheathed in 
 a fold of mucous membrane. In the vipers the fiing is permanently erect. In the 
 act of biting the contents of the poison-sac are forcibly ejected through the hol- 
 low fang. In India venomous snakes abound, of which the chief are the hooded 
 cobra, the viper, and the bungarus. In Europe the most dreaded serpent is the 
 common viper, while Africa, South America, and Australia and the islands of 
 the Pacific are not wanting in many varieties of venomous serpents. The 
 physical appearances of all serpent-venom are nearly alike : it is a viistcid fluid, 
 varying in color from a pale amber to a deep yellow, and containing in solution 
 certain albuminoid principles which are the toxic elements, the nature of which 
 has not yet been made out. According to the researches of Mitchell and 
 Reichert, venom induces rapid necrotic changes in living tissues with which it 
 is brought in contact. It renders the blood incoagulable, disintegrates the red 
 blood-corpuscles, and produces such a change in the capillary blood-vessels that 
 their walls are unable to resist the normal blood-pressure, and wide and rapid 
 blood-extravasation results. Profound depression of the respiratoiy nerve- 
 centers is the most common cause of death from serpent-venom, although 
 cardiac paralysis, hemorrhages into the medulla, and general disorganiza- 
 
COXTUSIONS A XI) WOCXDS. 127 
 
 tion of the rod l)lood-coi'pu.scles niiiy likewise each be a sufficient cause of 
 death. 
 
 Symptoms. — Much siinihirity characterizes the effects wliicli follow bites 
 of all Viirieties of ])()isonous serpents. The amount of the venom injected and 
 the rapidity with which it enters the circulation govern the intensity and the 
 rai)idity of the symptoms ])roduced. The local symptoms are pain — at first 
 slight, but later becoming more severe — with rapid tumefaction and ecchymotic 
 discoloration in the vicinity of the wound. Symptoms of cardiac and respira- 
 tory depression soon manifest themselves by feeble and fluttering pulse, faint- 
 ness, cold perspirations, mental distress, nausea and vomiting, and labored 
 respiration. In the more intense cases of poisoning death may result in a 
 short time by the paralyzing effect of the venom upon the heart, but more 
 frequently the struggle extends over a number of hours. When life is pro- 
 longed over forty-eight hours, the special symptoms of venom-poisoning give 
 place to those which are due to the disintegrating effect of the venom upon 
 the blood and the tissues ; that is to say, a sapremia of intense form remains, 
 which may prove fatal by exhaustion or may be slowly recovered from. When 
 death takes place from the primary effects of the venom, it is ushered in by 
 delirium and coma, with intensification of all the primary symptoms. 
 
 The post-mortem appearances are those which would follow the blood-changes 
 and the visceral disturbances that have been described. In the neighborhood 
 of the bite the tissues are infiltrated with hemorrhages and with the results of 
 rapidly-extending gangrene, the right heart is engorged, the general blood-mass 
 is fluid, and all the internal organs, especially the brain, spinal cord, and kid- 
 neys, are congested and present multiple ecchymoses. 
 
 Treatment. — When a bite by a venomous serpent has been received, 
 instantaneous and energetic efforts must be made to prevent the entrance of the 
 venom into the general circulation. When the bite has been upon any portion 
 of a limb, a ligature should at once be thrown around the limb above the 
 wound, and by twisting be drawn so tightly as absolutely to check the circu- 
 lation of blood in the part. This ligature should be a broad one, so as to 
 diminish later pressure-effects ; then free excision of the wounded part should 
 be done. When the bite is upon a part of the body other than a limb, imme- 
 diate excision should be practised, and, when this is impracticable, vigorous 
 suction of the wound should be made, which can be done without fear if no 
 cracks or abrasions of the lips or mouth are present, for the poison is harmless 
 when taken into the mouth. Should a hot iron be accessible, its vigorous and 
 free application within the wound might safely replace excision or suction. When 
 none of these procedures are practicable or have been only imperfectly applied, 
 there remains the device of permitting the poison to be admitted into the gene- 
 ral circulation in instalments by slackening the ligature a little at intervals, 
 and then tightening it again, while constitutional treatment is being resorted 
 to for the purpose of antidoting the poison thus slowly admitted into the 
 circulation. Permanganate of potassium, in 1 per cent, aqueous solution, freely 
 injected by means of a hypodermatic syringe into a serpent's bite, or calcium 
 hypochlorite, in an 8 per cent, solution, freshly prepared and diluted at 
 time of use with nine volumes of water, injected into the tissues in the region 
 of the bite, and also at intervals in other parts of the body, in doses of from 
 20 to 30 C.C., are reported to have acted as effectual antidotes to serpent- 
 venom. The hypodermatic injection of an antitoxic serum, derived from an 
 animal rendered immune to snake-poison by repeated injections of venom in 
 doses of graduated strength, it has been asserted, will act as an antidote to 
 the effects of a bite of a venomous snake, even if the injection is delayed as 
 
128 AN AMERICAN TKXT-J'.OOK OF SURGERY. 
 
 lonfj as an hour after the bite. The close varies according to the species of 
 the snake, the age of the person bitten, and tlie time of administration. 
 Twenty c.cm. is the average dose for an adult. Together with these pro- 
 cedures, the patient should be rubbed, given coffee or tea, and warmly cov- 
 ered so as ti) induce perspiration. 
 
 Strychnia, in doses of yW grain of the nitrate. rej)eated every two hours 
 until the symptoms produced by the venom have been <tvercome. has ap- 
 peared to produce recovery in many reported cases. The strychnia injec- 
 tions are to be begun only after the symptoms of snake-poisoning have 
 become pronounced. 
 
 In the absence of the agents named, or in the case of bites from mod- 
 erately venomous snakes, the free use of alcoholic stimulants should be 
 resorted to. The state of the pulse is to be taken as the guide to indicate 
 when the proper amount of stimulation has been reached, it being remem- 
 bered that alcohol does not act as an antidote to the poison, but simply sus- 
 tains the vascular and nervous systems while the poison is being eliminated 
 through the natural emunctories. The toxic sequelae in cases that survive 
 are to be treated upon general principles. 
 
 SUEGICAL DISEASES DUE TO MICEOBIC INFECTION. 
 
 As the result of bacteriological investigation, the number of surgical 
 affections Avhich have been demonstrated to be due to infection by a specific 
 microbe has become quite considerable. The processes of suppuration and 
 the general septic disturbances of infected wounds have already received full 
 attention as respects their bacteriological relation. To these must be added a 
 series of distinct surgical diseases in the causation of each of which a specific 
 micro-organism has been demonstrated to be the active agent. This list 
 includes the following diseases : Anthrax, Rahies, Glanders. Actinomycosis, 
 Erysipelas. Tetanus. Gonorrhea. Tuberculosis, and Leprosy. Of these the last 
 five are described elsewhere. The first four it seems proper to consider along 
 with " Poisoned Wounds." They are usually derived from animals. 
 
 Rabies is generally admitted to belong to this class, and is accordingly 
 included in the present study, although a satisfacton,- demonstration of its 
 specific micro-organism has not yet been made. 
 
 There is much evidence to show that syphilis also should be included in 
 this list, but the complete and indisputable evidences of its microbic origin 
 are still wanting. 
 
 ANTHRAX, 
 
 Malignant Pustule, Wool-sorter s Disease, Charhon. or Mihhraml. — A disease 
 caused by infection with a peculiar rod-like bacillus, and characterized by 
 an acute inflammatory primary local lesion, with subsequent general infection 
 of the fluids and tissues of the body, with tendency to rapidly fatal ending. 
 The bacillus of anthrax is the largest of the pathogenic organisms, and was 
 the first to be detected, having been identified as early as 18-49 by Pollender 
 in the blood of cattle suffering from the disease. The organism is a straight 
 rod. from o to 10 micro-millimeters in length and 1 to 1.25 micro-millimeters 
 in breadth ; it is devoid of motion, and in the bodies of living animals multiplies 
 exclusively by segmentation. Under certain conditions in dead nutrient media 
 spore-production also occurs. The disease, according to Pasteur, is spread among 
 animals by germinating spores, which, having become attached to plants and 
 grass, are taken in with the food and develop the primary lesion in the mouth 
 
CONTUSIONS AND WOUNDS. 129 
 
 or in the walls of the intestines. The tenacity of life of these spores is very 
 great. 
 
 Among animals the herbivora are especially susceptible to the disease, less 
 so the oninivora, and least so the carnivora. The disease occurs in all latitudes 
 and in any portion of the world. It is most widely spread in Russia and 
 Siberia, and is particularly coiiinioii in Ilunrrary and in certain parts of France 
 and Germany. The disease in man is always acquired from affected animals 
 or from the products of such animals. Any part or tissue of an animal dead 
 from anthrax is capable of communicating the disease. In its dried state the 
 bacillus is able to preserve its virulence for many years, and through any 
 substance to which it may become attached the disease may be communicated ; 
 even the feet and probosces of flies which have alighted upon the diseased animal 
 or upon the infected product may carry the disease, and earth-worms carry it 
 from the buried animals to the grass above. Persons who work in industrial 
 establishments where the products of diseased animals may be among the 
 objects of their labor, as hides, horse-hair, and wool, are peculiarly subject 
 to the disease ; hence one of the names by which it has been known, Wool- 
 sorter's disease. i i i -n • u 
 Infection may occur equally from inoculation with the bacillus or with 
 spores. When the skin is the site of the primary lesion, some minute scratch, 
 abrasion, or insect-bite may suffice for the inoculation; the unbroken skin 
 aff'ords ample protection from the virus, but the spores when inhaled or swal- 
 lowed may reach the circulation through a healthy mucous surface. 
 
 Symptoms and Course.— The attention of the surgeon is required only 
 in those cases in which the primary lesion is external ; cases in which the 
 bacillus enters the organism through the gastro-intestinal canal or the respi- 
 ratory passages fall under the domain of internal pathology, and for their 
 description the student is referred to text-books on general medicine. 
 
 The character of the primary lesion when external infection has taken 
 place depends upon the anatomical structure of the part aff"ected. If it is dense 
 and vascular, a circumscribed carbuncular inflammation develops— anthrax 
 carbuncle, malignant pustule; if the infection is in the midst of loose 
 connective tissue with comparativelv scanty blood-supply, a diff"used inflam- 
 matory infiltration manifests itself— anthrax oedema. In either case after 
 infection a variable period of incubation intervenes before the manifestation of 
 special symptoms. This period may be from a few hours to three days ; m rare 
 instances a longer period, even of ten to fourteen days, has occurred. 
 
 Anthrax Carbuncle.— A slight burning and itching at the point of 
 infection, with the rapid development of a papule surmounted by a small 
 vesicle, which, bursting, discloses a central eschar, are the first manifestations 
 of the disease. The inflammatory infiltration at the base and circumference of 
 this primary papule rapidly increases, with development of a ring of secondary 
 vesicles around the margin of the primary eschar, and with gradual extension 
 of the tissue-necrosis. In rare instances the progress of the disease becomes 
 spontaneously limited at this point; a gradual subsidence of the swelling takes 
 place ; the slouc^h becomes detached by suppurative inflammation, and the ulcer 
 heals by granufation. More commonly, the oedema and infiltration continue to 
 spread, the eschar extends, phlebitis and lymphangitis develop, and symptoms 
 of general intoxication follow, terminating speedily in death. 
 
 Anthrax CEdema manifests itself by the appearance at the point ot 
 infection of a livid diff"use oedema which rapidly spreads in all directions ; the 
 swelling may become enormous in its extent and size, and at diff'erent points 
 local gangrene of the skin and subcutaneous tissue may occur, preceded by the 
 
 9 
 
i;JO ^i.v j.]//;A'/r.i.v rKxr-iiooK of surgery. 
 
 formation of blehs upon tin- surface, filltMl wiili Itloodv scrum. In rare instanee8 
 spontaneous recoverv from this variety of antliiax takes ])lace. 
 
 The local pain is slight, and, sis long as the diseased process is limited, 
 there is but little general elevation of temperature, the patient often continuing 
 to bo about and manifesting simply slight chills and mild fever, (ieneral 
 infection is shown by well-marked rigors, high fever, with great weakness, 
 delirium, feel)le ])ulse, sweating, diarrhea, and acute pains in many jiortions of 
 the body. Cough, rapid respiration, and cyanosis indicate pulmonary disturb- 
 ance. Collapse, often sudden in its development, closes the scene. 
 
 Pathology. — The tissue-changes wiiich are discernible in cases of anthrax 
 are de])endent upon the multiplication and diffusion of the bacilli in the capil- 
 laries and lymphatics. The local changes of cedema aiul necrosis are due to 
 the blocking uj) of the caj)illaries by the bacilli and to their irritating eflect 
 upon the capillary walls, Avliich produces such abundant intlammatory exuda- 
 tion into the paravascular and connective-tissue spaces that acute ischemia 
 results. When general infection has taken place, the capillaries in every part 
 of the body teem with bacilli, which accumulate in largest numbers at points 
 where the blood-current is slowest. In the most vascular organs, like the 
 spleen, liver, and kidneys, the bacilli especially abound. They form thrombi 
 in the capillaries and lymphatics, from which multiple and more or less exten- 
 sive extravasations into all the tissues result, and transudations into the various 
 serous cavities are produced. 
 
 Diagnosis. — The typical anthrax carbuncle is not likely to be confounded 
 with any other aftection. The early superficial depressed eschar, the tough 
 slough closely attached to the surrounding tissues, the lack of sensitiveness of 
 the swelling, the widely-extending infiltration, the absence of suppuration, and 
 the general symptoms Avhich attend its later course form a picture distinct from 
 that which characterizes simple inflammatory carbuncle with its prominent cen- 
 ter, its multiple soft, suppurating, sloughing foci, its local pain, and indolent 
 inflammatory course. The nmltiple small carbuncles of glanders have little in 
 common with the carbuncle of anthrax. Anthrax oedema at its outset may be 
 confounded with acute })hlegmonous inflammation or with malignant oedema. 
 Phlegmonous inflammation is characterized by its tendency to suppuration, 
 which at once distinguishes it from anthrax. In malignant oedema the necrosis 
 is attended with rapid disintegration and liquefiiction of the dead tissue, in 
 marked contrast with the tough and adherent sloughs of anthrax. 
 
 In all cases of suspected anthrax microscojjic examimition of the fluids of 
 the aff'ected part should be made. The anthrax l)acillus can be readily stained 
 and identified under the microscope. ]Microscopic findings may be made still 
 more positive by inoculation experiments. 
 
 Prognosis. — External anthrax which is allowed to take its own course, or 
 in which the treatment is too long delayed, is very grave, but when an early 
 diagnosis is made and energetic, rational treatment is at once instituted, the 
 prognosis is usually favorable. When general infection of the system has 
 occurred, the result is uniformly fatal. The prognosis of the oedcmatous vari- 
 ety is more grave than that of the carbuncular, in consequence of the greater 
 liability to general infection which attends the former. In either case the fatal 
 termination is due, probably, as indicated by the most recent researches of 
 bacteriologists (Bollinger), to toxic ptomaines formed in the body by the 
 bacilli as the products of their growth. 
 
 Treatment. — All treatment must be conducted ujion antiseptic lines, and 
 should be energetic, and instituted at the earliest possible moment. Excision 
 of the infected area should, if possible, be done, the incisions being carried 
 
CONTUSIONS AN J) UOlNnS. 131 
 
 wido of till' (lisoiisc, tliroiigli healthy tissue if ])ossible; special care must be 
 taken to ))revent infection of the oj)enitivc wound from the diseased mass that 
 is excised. To ^uard against the results of possible infection, the exposed sur- 
 face remain int; after the excision should be thoroughly mopped over with a 
 strong solution of carbolic acid, 1 : 10, or oven with the pure acid, or of cldo- 
 ride of zinc, 1 : 8, or the actual cautery may be applied. The innnediate appli- 
 cation of the actual cautery at the seat of inoculation, whenever such an inocu- 
 lation is recognized as having taken place, will destroy the virus and prevent 
 subse(iuent evil. When excision of the entire infected area is impracticable, 
 multiple deep crucial incisions should be made into it, accompanied by injec- 
 tions of carbolic acid, 1 : 10, by means of a hypodermatic syringe, systemati- 
 cally administered so as to diffuse the carbolic solution throughout the entire 
 extent of the base of the affected tissue and through the surrounding healthy 
 tissue. The punctures should be made just outside the borders of infiltration, 
 the needle passed to the center of the infected area, and the solution slowly 
 expelled as the needle is withdrawn. The carbolic solution should be mopped 
 freely into the cuts, and injections should also be made into the substance of 
 the diseased mass, so as to thoroughly saturate it with the antiseptic, while at 
 the same time an ice-bag should be kept applied upon its surface, and the 
 whole part sliould be enveloped in compresses saturated with sublimate solution, 
 1:1000. The carbolic injections maybe repeated every six hours until the 
 disease is manifestly under control or until symptoms of carbolic-acid poisoning 
 are developed. The treatment of the subsequent slough is to be conducted on 
 general antiseptic principles. 
 
 The constitutional symptoms of prostration and threatening collapse are to 
 be met by stimulant, tonic, and supporting measures. 
 
 HYDROPHOBIA (rABIES, LYSSA). 
 
 Hydrophobia in man is an infectious disease resulting from the inoculation 
 of a specific virus from an animal suffering from rabies. After a variable 
 period of incubation following the primary inoculation, the disease declares 
 itself by certain spasmodic muscular phenomena, followed by great general 
 prostration and ultimate rapidly-ascending paralysis, significant of lesions of 
 the spinal cord, in which organ, especially the medulla oblongata, the effects 
 of the virus are chiefly centered. 
 
 Etiology. — Hydrophobia in man is always the result of inoculations with 
 the virus of a rabid animal, most frequently the dog (90 per cent.), less fre- 
 quently cats, wolves, and foxes. Not all persons bitten by rabid animals 
 develop hydrophobia. It is often impossible to secure reliable statistics on 
 this point. In many cases, certainly, bites are inflicted by dogs supposed to be 
 rabid, but that are in fact not so ; in other cases bites have been inflicted bv dogs 
 really rabid in which the infecting saliva was wiped off by the clothing through 
 Avhich the teeth passed, and the wounds Avere thus preserved from infection. 
 In yet other cases wounds that were really infected have been subjected to 
 adequate immediate cauterization, and thus the later development of the disease 
 prevented. There is, however, sufiicient experience to warrant the general 
 statement that about 12 to 14 per cent, of those who are bitten develop the dis- 
 ease (Roux), and of these all die. As regards immunity, no relation is trace- 
 able either to age or sex. 
 
 While the ordinary medium of infection is the saliva of a rabid animal, the 
 disease can also be produced by inoculation with other fluids and tissues of 
 such an animal. All the conditions relating to the propagation, development, and 
 
132 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 course of the disease indicate that it is due to a specific micro-organism, which, 
 by its multiplication within the body, finally causes the ultimate overwhelming 
 symptoms of the disease. This micro-organism, however, has not as yet been 
 satisfactorily demonstrated. 
 
 Pathology. — No well-defined, gross pathological changes attend hydro- 
 phobia. Microscopic examination of the medulla oblongata and the spinal 
 cord shows irritative lesions, marked by an infiltration of the perivascular 
 sheaths with leucocytes, which at points may be accumulated in considerable 
 number. Hyperemia and moderate oedema of the brain and spinal cord and 
 their membranes as a rule are present. The pharynx, fauces, and neigliboring 
 lymphatic glands are usually congested, as is also the mucous membrane of 
 the stomach and intestinal canal ; the lungs and kidneys present general dif- 
 fused, congestive conditions, the whole condition indicating the presence in the 
 circulating fluid of an intense irritant. The heart, spleen and liver are, as a 
 rule, normal. 
 
 Symptoms. — ^tage of Incubation. — A period varying greatly in length 
 intervenes between the time of inoculation and the appearance of any constitu- 
 tional disturbance. The average period of incubation is about six weeks ; it 
 is seldom less than fourteen days, and may be protracted to some months. 
 There is credible evidence that in extremely rare cases this period has been 
 prolonged to between one and two years. During this time the persons bitten 
 feel well and present no symptoms whatever of the dormant disease ; the local 
 ■wound heals kindly. In the young the period of incubation averages less than 
 in the old. 
 
 Premonitory Stage. — The outbreak of general symptoms is usually pre- 
 ceded by a brief period, generally not more than twenty-four hours, rarely 
 extended to two or three days, during Avhieh ill-defined premonitoiy symptoms 
 manifest themselves ; some uneasiness or pain is felt in the region of the wound, 
 the cicatrix of which may become congested and tender ; in other cases all such 
 local symptoms are absent. Symptoms of constitutional disturbance declare 
 themselves with headache, loss of appetite, sleeplessness, and much mental 
 depression and irritability, with tendency to aimless Avandering about, accom- 
 panied by great anxiety and apprehension, especially if the patient recalls the 
 fact that he has been bitten. A general hyperesthesia soon shows itself, as 
 evinced by sensitiveness to currents of air and to light. The stage of the full 
 development of the disease is now ushered in by noticeable spasms of the mus- 
 cles of deglutition, causing a sense of tightness and choking about the pharynx, 
 producing difficulty in speaking and in swallowing, and hence dread of fluids, 
 although there is intense thirst. Examination of the pharynx will show that 
 its mucous membrane is congested and that there is an abundant secretion of 
 viscid saliva, which, since it cannot be swallowed, causes frequent hawking and 
 spitting to get rid of it. Occasionally the precursory symptoms are absent, 
 and the first manifestations of the disease are spasmodic contractions of the 
 pharynx occurring while attempting to drink or precipitated by some mental 
 agitation ; at other times some oppression of breathing is first noticed, culmi- 
 nating in marked suffocative attacks from spasmodic contractions of the upper 
 respiratory muscles, combined usually with the already described pharyngeal 
 symptoms. 
 
 Stage of Excitement. — The disease has now fully declared itself. The 
 spasms of the muscles of deglutition and respiration are more marked and 
 more easily excited ; swallowing becomes impossible; the mere suggestion of 
 it suffices to bring on spasm. Currents of air, an unexpected touch, the 
 slightest source of agitation, will suffice to provoke the convulsion. The 
 
CONTUSIONS AND WOUNDS. 133 
 
 embarrassment of the breathing caused by the spasms of the respiratory mus- 
 cles is often great, producing a sensation of impending suffocation ; trequently 
 the entire muscuhir system will share in the convulsive attacks Ihese suc- 
 cessive muscular spasms are separated by periods of complete relaxation, there 
 bein'T no tonic spasms, as in tetanus. • i i v. 
 
 The mental faculties remain for the most part unimpaired, though excite- 
 ment anxiety, and terror occupy the mind. Intervals during which hallu- 
 cinations develop are common. The duration of the convulsive paroxysms is 
 variable • they rarely continue longer than from one-half to three-quarters ot 
 an hour,' and" usually for a much shorter period. During the paroxysms the 
 excitability and restlessness of the patient, combined with dyspnea and with 
 hallucinations, may produce a condition similar to mama. In the intervals 
 between the attacks the mind appears clear: these intervals are likewise ot 
 variable lencrth, very brief at times, at others prolonged for several hours. In 
 rare instances the convulsive paroxysms are completely absent, the patient 
 complaining merely of great anxiety and difficulty in breathing. In excep- 
 tional cases the patient is able to swallow food during the entire course of the 
 disease, although the act is accompanied by pain. As a rule, the taking ot 
 solid food is impossible, but in exceptional cases such food is swallowed without 
 difficulty. The pulse at the beginning of the attack is normal in character, 
 but, as the disease progresses, grows gradually weaker and quicker, until as 
 death approaches it is no longer perceptible. The body-temperature is some- 
 what increased, ranging from 100° to 103° F., seldom rising as high as lOo 
 The urine is scanty, free from albumen, and frequently contains an appreciable 
 
 amount of sugar. , . . ^ ^ u • 
 
 This sta^re of excitement may prevail from thirty-six to seventy-two hours , 
 during its c^'ourse death may occur amid the convulsions from exhaustion or 
 from asphyxia; more frequently there is a gradual transition to a state ot 
 comparative tranquillity— the last stage of the disease, the stage of paralysis. 
 There is then a gradual remission of the severe symptoms ; the reflex nervous 
 excitability diminishes, resulting in freer respiration and the recovery ot 
 the ability to swallow, while the general debility and prostration rapidly 
 increase. The convulsions become feebler and cease entirely. It lite is 
 sufficiently prolonged, a condition of rapidly-ascending paralysis supervenes, 
 and symptoms of respiratory and cardiac failure develop, terminating in 
 death. The duration of the final stage of hydrophobia is brief, being, as a 
 rule, between two and eighteen hours. 
 
 Diagnosis.— Hydrophobia is to be distinguished from tetanus, trom the 
 effects of mental agitation and fear simulating hydrophobia (hydrophobia 
 imaginaria, lyssophobia), and from certain forms of hysteria and epilepsy m 
 which symptoms affecting the organs of deglutition are manifested analogous to 
 those observed in genuine rabies. The positive history of a bite from a prob- 
 ably rabid animal, the prolonged period of incubation m hydrophobia, the tact 
 that in this disease the spasms affect the muscles of deglutition, and not those ot 
 mastication, as in tetanus, and are not tonic in their character, and that the respi- 
 ratory embarrassment is due to spasm of the laryngeal muscles, and not to those 
 of the chest, will suffice to distinguish between these affections if any doubt 
 should otherwise exist. The pseudo-hydrophobic symptoms which are sometimes 
 manifested in the course of other affections of the nervous system are distin- 
 guished, as a rule, by the absence of the general reflex excitability which is a 
 marked feature of genuine hydrophobia. The development of symptoms closely 
 simulating genuine hydrophobia, through the effects of fear and anxiety, in 
 persons of hTghly excitable and imaginative temperament who have been bitten 
 
134 AN AMERICAN TEXT-JiOOK OF SUUaEliV. 
 
 by animals which Avere not rabid, is avcII authenticated. Such cases may even 
 proceed to a fatal termination, although, as a rule, under appropriate treatment 
 recovery takes ])lace ; which fact is sufficient to demonstrate that the case was 
 not one of true hydrophobia. Upon the result of an examination of all the 
 circumstances that surround the case must depend the conclusion as to the real 
 character of such an attack. 
 
 Prognosis. — The i)rognosis is absolutely hopeless in genuine hydrophobia 
 when once the symptoms of the disease have declared themselves. 
 
 Treatment. — Palliative treatment is all that any case admits of, but the 
 utmost importance attaches to prophylaxis. The patient should be kept in a 
 dark and quiet room, and as absolutely free from every sourc(i of agitation as 
 possible. Morphia should be administered hypodermatically in amounts suf- 
 ficient to relieve pain. The severity of the spasmodic paroxysms should be 
 mitigated by inhalations of chloroform. Thirst should be relieved as far as 
 possible by rectal cnemata. 
 
 Prophylaxis. — Every wound inflicted by a possibly rabid animal should be 
 subjected as soon as possible either to free excision or to thorough cauteriza- 
 tion. In any interval that must elapse until this can be done constriction 
 should be applied upon the proximal side of the wound if possible. If the 
 part bitten is one in which the knife can be used freely, excision is preferable, 
 the cuts being made wide of the bitten part, the resultant wound being 
 thoroughly disinfected and sutured or treated openly as its special conditions 
 may require. If cauterization is more feasible, it should be done with the 
 actual cautery if possible, which should be applied deeply and thoroughly. 
 Of chemical caustics, caustic potash or fuming nitric acid is to be preferred. 
 
 Prophylactic inoculations with emulsions of the dried spinal cords of rab- 
 bits infected Avith hydrophobia, after the method of Pasteur, have certainly 
 been proved to be of value in establishing absolute immunity against the 
 strongest hydrophobic infection if the series of inoculations is conq»leted a 
 sufficient time before the actual development of constitutional symptoms. The 
 earlier the inoculations are begun after the infection has been received, the 
 greater the certainty of the immunity conferred by them. The practical appli- 
 cation of the method depends upon the discovery that the virulence of such 
 infected spinal cords may be reduced progressively from the highest degree to 
 nothing, according to the length of time during which the cord is preserved 
 in a dry and pure atmosphere, fourteen days' drying being sufficient to destroy 
 all virulence. Injections are made, beginning with emulsions of the weakest 
 virulence and passing gradually to the strongest. The duration of treatment 
 varies slightly according to the severity of the bites. In bites about the head 
 the incubation period is often very short ; in such cases, therefore, promptness 
 of action is especially necessary, and in order to save time the number of 
 injections made during the earlier days of the treatment is increased. 
 
 Institutions for carrying on this method of treatment have been established 
 in various parts of the world. About 15 per cent, of persons bitten by sup- 
 posedly rabid animals develop hydrophobia, and the mortality is lUO j)er cent. 
 As the result of these inoculations the mortality among persons who were 
 believed to have been bitten by rabi<l animals and avIio were submitted to 
 the treatment was reported in 1890 to have been but .U2 per cent. In 18U4 
 there was reported from the same institute a mortality of but .50 per cent. ; 
 in St. Petersburg in 1893 a mortality of .84 per cent. ; in Turin in 1894 the 
 mortality for ten years was .95 per cent. In view, therefore, of these results, 
 and in view of the great danger of the possible development of hydrophobic 
 symptoms in a person bitten by an animal snITering from rabies, and the utter 
 
rONTUSTONS A XI) W'orXDS. 1^,5 
 
 hopelessness of any otlier treatment if tlic disease develops, it would be the 
 part of wisdom in all oases of bites from ])r('sumably rabid animals to subject 
 the patients to the Pasteur treatment if possible. 
 
 GLANDERS (fAHCY ; EQUINIA). 
 
 Glanders is a contagious, eruptive, ulcerative disease, primarily of horses 
 and their congeners, asses and nniles, caused by their infection with a, specific 
 micro-organism, the haclllus mallei (p. 9). It is capal)le of being transmitted 
 to men, as well as to many of the lower animals, by inoculation. The special 
 manifestations and course of the disease vary much, being dependent upon the 
 location and cliaracter of the tissues first inoculated and the amount and viru- 
 lence of the inoculating material. 
 
 The bacillus of glanders is a small rod, somewhat shorter and broader than 
 the tubercle bacillus ; it is either straight or slightly curved, rounded at its 
 ends, and is usually found in pairs, the two lying parallel with each other and 
 held together by a delicate pellicle. The existence of spores is in doubt. 
 The bacilli may be killed by exposure for ten minutes to a temperature 
 of 131° F, (55° C). Carbolic acid in 5 per cent, solution destroys them 
 in five minutes, and corrosive sublimate in 1 : 5000 solution in two minutes. 
 Their tenacity of life, under ordinary circumstances is great, so that v^irus 
 that has been in the dried condition for many months may be eifective. 
 
 Etiology. — Infection occurs usually through some abrasion or wound ; the 
 possibility, however, of infection through an unbroken skin by rubbing the 
 virus into the hair-follicles has been demonstrated. Inoculation through an 
 unbroken surface along the mucous lining of the nasal and respiratory pas- 
 sages, or the conjunctiva, is not rare through the lodgment thereon of par- 
 ticles of infected muco-pus deposited there by the snortings of infected animals. 
 As a rule, diseased horses are the source of infection in the human subject; in 
 rare instances the disease has been transmitted from man to man. But a small 
 proportion of the persons who are exposed to infection develop the disease. 
 
 Pathological Anatomy. — The histological changes determined by the 
 presence of the bacillus in the tissues consist of a low grade of inflammation, 
 resulting in the formation of nodules of embryonal or granulation-tissue, 
 which speedily break down into pus, forming more or less extensive abscesses, 
 which, when they open upon free surfaces, degenerate into ill-conditioned 
 phagedenic ulcers with undermined edges, surrounded by extensive areas of 
 inflammation. Dissemination of this series of diseased processes may take 
 place throughout all the organs and regions of the body by continuous exten- 
 sion, by transmission along lymphatic channels, and by emboli carried in the 
 blood-stream. The lesions of glanders appear first in the skin and the subcu- 
 taneous cellular tissue, and upon the mucous membrane of the nares and respi- 
 ratory passages. Post-mortem examinations show similar lesions in the lungs, 
 many of the muscles, the larger joints, and the great viscera. The cartilages 
 and bones are likewise involved, sometimes primarily, but more frequently 
 secondarily through contiguity. The lesions of ordinary pyemia are super- 
 added to the specific lesions of glanders as soon as the suppurative processes 
 become at all general. 
 
 Symptoms. — The symptoms that follow infection with glanders maybe 
 rapid in their course, manifesting a high grade of malignancy, and terminating 
 in death within tw^o or three weeks, or they may be slower in their develop- 
 ment and progress, extending over a period of many months ; hence the classi- 
 fication which has been made into Acute and Ohronic Glanders. When the 
 
136 AX AMKIiirAX TEXT-BOOK OF Si'RGKIiV. 
 
 lesions are well marked ami ahnmlant in the skin, the special term Farcy has 
 been aj)jtlii'<l, more )»articularly to the disease amont: horses. 
 
 After infection a stage of incubation of varvinfr len<rth elapses, usually of but 
 a few (lays, but possibly prolonged to two or three weeks. "S'aguc symptoms of 
 general malaise usher in the special symptoms of the disease ; an inflammatory 
 nodule appeai-s at the point of inoculation, attended with pain and an extend 
 ing zone of inflammatory congestion, involving especially the lymphatic trunks ; 
 fever develops ; the primary nodule suppurates and breaks down into an ill- 
 conditioned phagedenic ulcer. If the primary lesion is in the mucous mem- 
 brane of the nose, the progressive ulceration soon destroys the soft parts and 
 attacks the bones, the neighboring tissues of the face, pharynx, and palate 
 become involved, and the whole of the face and neck becomes swollen and 
 inflamed. In the further course of the disease, without regard to the seat of 
 the priman- lesion, multiple nodules develop on diff'erent parts of the skin ; 
 these quickly suppurate and degenerate into off"ensive ulcers, or larger swellings 
 and abscesses are formed which become converted into extensive and deeply- 
 burrowing ulcers. These diffused skin lesions may appear within one or two 
 days from the onset of the attack, or their appearance may be delayed some 
 weeks. In the second or third week of the attack an outbreak occurs upon 
 the mucous surfaces, primarily that of the nose if it has not been the seat 
 of tlie original lesion. Other mucous surfaces — of the eye, mouth, fauces, 
 respiratoi-y and gastro-intestinal tracts — rapidly take on the same conditions. 
 If the infection has been an internal one. the gastro-intestinal disturbance, the 
 fever, and the general prostration may cause the case to simulate for a time 
 tvphoid fever. The due development of external manifestations suflSces in 
 time to correct the eiTor. In cases running an acute course febrile exacerba- 
 tions become marked. The emaciation and prostration increase, all the symp- 
 toms of profound septic infection develop, with delirium, terminating in stupor 
 and final death in collapse. In some cases the fatal result is accelerated by the 
 disturbances consequent upon bronchial and pulmonary conditions. 
 
 In those cases which pursue a chronic course the development of the 
 lesions is more gradual and less generalized. The constitutional symptoms 
 depend upon the number, size, and situation of the local lesions, and upon the 
 amount of general septic infection which is present. Often, cases after pursu- 
 ing a chronic course for a time take on an acute character and rapidly hasten 
 to a fatal termination ; in other cases death occurs from exhaustion and 
 septicemia or from pulmonary and bronchial complications. Many chronic 
 cases, however, ultimately display a gradual amelioration of all the symptoms ; 
 cicatrization of the ulcers and healing of the abscesses .«lowly take place, 
 and eventual recovery is secured, more or less perfect, but the patient is always 
 seriously crippled. The average duration of the chronic form is about four 
 months. 
 
 Diagnosis. — The acute form in its earlier stages is liable to be confounded 
 with acute suppurative lesions, and even, in some of its manifestations, with 
 rheumatism and typhoid fever. Its later manifestations may be referred to 
 pyemia, which usually complicates it. but when the local phenomena are once 
 fully developed the diagnosis is free from uncertainty: the knowledge that a 
 patient has had to do with horses will aid in forming a diagnosis. The chronic 
 form is more likely to be confounded with syphilis or tuberculosis. Where 
 doubt exists search should be made for the specific micro-organisms in the 
 nodules or the discharges : their detection will render the diagnosis positive. 
 Inoculation experiments on animals may also be resorted to. 
 
 Prognosis. — The acute form of glanders is always fatal. When it man- 
 
CONTUSIONS AND WOUNDS. 
 
 13' 
 
 ifests a tendency to run a chronic course the prognosis is relatively favorable, 
 for about one-half such cases ultimately recover. As long as the lesions remain 
 limited to regions accessible to direct surgical treatment hope may be enter- 
 tained of securing a cure. 
 
 Treatment. — Prophylaxis is of the utmost importance. This consists 
 simply in the immediate destruction of all animals affected or suspected ; the 
 burning of all substances soiled with the infecting discharges ; and the utmost 
 carefulness on the part of all persons having to do with infected animals to 
 guard against the possibility of inoculation. 
 
 When a point of inoculation has occurred, immediate thorough disinfection 
 and cauterization should be done. If nodules and abscesses develop, they 
 should be at once thoroughly laid open, curetted, and disinfected. Chloride 
 of zinc in solution, 1 : 8, is to be recommended for such disinfection. All sur- 
 faces that have been affected should be subjected to continuous antiseptic 
 applications. The general treatment must consist of tonics, nutrients, and 
 stimulants freely administered. 
 
 Fig. 24. 
 
 ACTINOMYCOSIS. 
 
 Actinomycosis is an infectious disease due to the presence in the tissues of 
 a peculiar fungus, termed actinomyces (ray fungus), and characterized by the 
 development of tumor-like masses at the points of infection, which readily 
 undergo softening and suppuration, with continuous extension of the original 
 process into adjacent tissue (Fig. 24). 
 
 Etiology. — The source from which the infecting fungus is derived has not 
 been determined. The disease has as yet been found only among herbivor- 
 ous and omnivorous animals, including man. The medium of infection is 
 probably some article of food. The recognition of the disease as a specific 
 one is of recent origin. Bollinger first, in 1877, described the relation of 
 the fungus to certain swellings of the lower jaw in cattle. Its recognition in 
 man is due to the labors of Israel and Pon- 
 fick, especially the latter, the results of whose 
 researches were published in 1882. Since at- 
 tention was called to it many cases, not a few 
 of which have occurred in the United States, 
 have been identified by different observers. 
 The disease has heretofore been confounded 
 with sarcoma, since the granulation-tissue 
 which composes the greater mass of the tumors 
 has the microscopical structure of the round- 
 cell sarcoma. Section through the tumor, how- 
 ever, will show many soft, sulphur-yellow col- 
 ored spots in strong contrast with the general 
 reddish tissue of the growth. If the tumor has 
 already fallen into suppuration, the pus will be 
 found to contain numbers of sulphur-yellow 
 miliary bodies ; these are frequently united 
 together in clusters, and have a soft consist- 
 ence and an unctuous feel. By pressure these 
 clusters are easily separated into smaller gran- 
 ules. These little granules, when viewed under the microscope, are found to 
 consist of intertwined mycelia, the single threads of which have bulbous ter- 
 mini. In many cases a single filament will terminate in a mass of bulba 
 
 Actinomyces (Coplin and Bevan). 
 
138 ^i.V AMERICAN TEXT-BOOK OF SUIiOEEY. 
 
 branchiiicr in various directions. A frequent, and appirently tlie lii^rliest. type 
 of develojjnu'iit is when the *rranule is eonipose<I of a niultitu(h' of fihmients 
 radiatinir from a coninion center, tlieir bulbous termini presentiii;: upon the 
 periphery. 'J'hat this ray fungus is the specific cause of the disease has heen 
 establislied by cidtivation and inoculation experiments. 
 
 Pathological Anatomy. — The primary effect of the lodgment of the 
 fungus in the tissues is to excite a low grade of chronic inflammation, resulting 
 in the accumulation of a mass of granulation-tissue, in the midst of which the 
 fungus is iuibedded. By tlie continued formation and accumulation of such 
 masses swellings of considerable size result. The disease may remain stationary 
 in this stage for an indefinite time, though, as a rule, degenerative processes 
 begin early, the breaking down of the tumor resulting from a process of sup- 
 purative inflammation. The fungus is probably not itself pyogenic : the sup- 
 puration that occurs is due to secondary infection with pus-microbes. 
 
 Symptoms. — In cattle the disease occurs most frequently in the lower jaw, 
 hence the name " lumpy jaw " by which it has been characterized: in man, 
 likewise, the lower jaw is most frequently aifected, and in a very* large propor- 
 tion of cases the disease has its site in some tissue adjacent to the mouth (of 
 73 cases reported by Moosbruegger, in 41 the jaws, mouth, throat, tongue, or 
 oesophagus were involved; in 14. the respiratory tract; in 11, the intestines; 
 in the remaining 7 the point of infection was not ascertained). Wherever the 
 disease is, the symptoms are those of an ill-defined, slowly-increasing swelling. 
 The lymphatics are not involved, and there are no glandular enlargements 
 until secondary infection has occurred ; suppuration sets in early when the 
 growth is in regions most likely to be infected with pus-microbes. A 
 chronic abscess is now inaugurated, and the local and constitutional symp- 
 toms which follow are due to the activity of the secondary infective pro- 
 cess and the extent of the septic infection which results. Diff'usion of the 
 actinomyces, with the development of the disease in distant organs and parts 
 of the body, may occur when the fungus or its spores have obtained entrance 
 into the general circulation through an opening in a vein-wall which may have 
 occurred during the process of ulceration : such general dissemination is of rare 
 occurrence. In general, the disease remains localized, and extends steadily 
 from the original point of infection into adjacent tissues, invading every tissue 
 •with which it comes in contact, irrespective of its anatomical structure. Before 
 suppuration takes place the swelling is quite firm on pressure and free from pain 
 and tenderness ; the condition of suppurative inflammation, once established, 
 favors the growth and extension of the specific disease l)y setting free and dif- 
 fusing the actinomyces. The pus discharging from actinomycotic abscesses 
 always contains the actinomyces, which can usually be detected by the naked 
 eye as minute yelloAvish granules. 
 
 Diagnosis. — The presence of the specific fungus in the granulation-tissue 
 or mingled with the pus is the one diagnostic feature of actinomycosis. It has 
 been most frecjuently confounded with sarcoma ; in some of its manifestations 
 it may be mistaken for syphiloma or tuberculosis; sarcoma does not su]i]iurate 
 and break down as early as the actinomycotic granuloma. Tuberculosis is 
 attended with glandular infection, actinomycosis, previous to secondary infec- 
 tion, not at all ; in suspected syphiloma adequate specific treatment will suffice 
 to establish its presence or absence within a few Aveeks. In any case, resort to 
 the microscope should be made as early as possible, and the detection of the 
 fungus will positively establish the diagnosis. 
 
 Prognosis. — The clinical course of actinomycosis is that of a malignant 
 tumor. Without radical surgical treatment it tends to indefinite extension, and 
 
SYPHILIS. 139 
 
 ultimate deatli by exhaustion, sepsis, or pyemia. When the disease is early 
 recognized and the afteeted part is susceptible of thoroiiifb extii pjition, a ciii-e 
 may be obtained. 
 
 Treatment. — Absolute extirpation of all infected tissue should be done 
 whenever practicable, the incisions bcini; ciirried through sound tissue at 
 some distance from the visibly infected ])art. If this is impracticable, the sup- 
 purating cavities and sinuses sliould be laid o])en freely and the surrounding 
 infecteil tissue should be excised as far as j)Ossible ; thorough curetting of the 
 remaining diseased tissue should be done, followed by numerous injections of 
 a strong carbolic solution (1:20) into the substance of the tumor that may 
 still remain. Into any sinuses that have not been fully laid open tampons 
 saturated with solution of chloride of zinc (1 : 8) should be packed, and the 
 whole diseased surface that has been exposed should be dressed with similar 
 tampons. The wound should be kept open and the curetting and cauteriza- 
 tion repeated as often as any suspicious points show themselves. Recently- 
 published experiences of veterinarians indicate that iodide of potassium given 
 internally in full doses, pushed to the point of iodism, has a specific curative 
 effect upon actinomycosis in a large proportion of cases in cattle. It should 
 therefore be given a trial in cases in human beings. 
 
 CHAPTER XVII. 
 
 SYPHILIS. 
 
 Syphilis^ is an infectious, contagious, and inoculable disease, transmissible 
 also by heredity. It first manifests itself by an indurated or infecting chancre, 
 followed by general lymphatic enlargement, afterward by eruptions of the skin, 
 usually symmetrical and at first superficial, and by allied conditions of the mucous 
 membranes, later by chronic inflammation and infiltration of the cellulo-vascu- 
 lar tissue and bones and periosteum, and finally by special productions in the 
 form of small swellings, which may invade any tissue or organ of the body, 
 but chiefly involve the connective tissue, and are known as gummata. 
 
 During all the acute symptoms, and for a period extending over several 
 years, the patient has acquired an immunity against fresh infection. The dis- 
 ease is probably caused by the entrance of a specific microbe into the system, 
 and although the final and conclusive evidence, consisting of the isolation, cul- 
 ture, propagation, and re-inoculation of the micro-organism, is still lacking, 
 the clinical facts alone are sufficient, in the light of our present knowledge of 
 the microbic diseases, to place syphilis in that class. Considered in this man- 
 ner, as has been done by Finger, the various symptoms and stages of syphilis 
 are to be explained as follows : 
 
 The general symptoms in the primary stage of syphilis — the languor, fever, 
 malaise, pain, etc. — are due to intoxication by the ptomaines produced by the 
 virus, as these symptoms are too ephemeral and changing to be ascribed to 
 localizations of the virus. In the secondary stage the vai'ious eruptions on the 
 skin and mucous membranes are caused by local deposits of the virus. Their 
 virulence proves this ; but a great many of the so-called secondary symptoms 
 
 ' The histology and patholog}' of syphilis will doubtless before long have to be rewritten 
 from the bacteriological standpoint. At present the observations of Cornil are the most accu- 
 rate and reliable in our possession, and have been closely followed in this work. (See Comi] 
 On Syphilis, American edition.) 
 
140 ^l.V AMKRK'AX TEXT- HOOK OF SL'RUERY. 
 
 are of intoxicative character, bein;^ due to tispue-prodncts passing into the cir- 
 culation, and causing a general, often severe, nutritive derangement. After the 
 second stage comes a long stage of latency — for many a period of cure ; for 
 others, only an interval between the second and third stages. That the virus 
 still exists in the body is shown in many cases by its hereditary transmis- 
 sion. The general health is not perfect. The immunity again.st fresh infection 
 is the chief characteristic of the above latent jjeriod. "We do not know how 
 long it lasts, but its duration is certainly limited, in some cases at least, as the 
 undoubted cases of re-infection show. The immunity, as mentioned, began 
 even in the primary period. It is an immunity only against fresh virus. The 
 first virus which caused the infection may still cause relapses. 
 
 The immunity in the primary stage is due to tissue-products of the virus in 
 the circulation, the infected foci being still strictly localized. In support of 
 this there is the undeniable fact that, under certain conditions, persons may 
 acquire immunity against syphilis without passing through its stages. Heredi- 
 tary syphilis teaches us this. The specific products of syphilis have been taken 
 into account in explaining the following two kinds of immunity from syphilis: 
 1. Colles's immunity ; 2. Profeta's immunity. By Colles's immunity is meant 
 that which is shown by those healthy mothers who, owing to syphilis in the 
 father, have borne syphilitic children, but have themselves apparently escaped 
 infection. This immunity has been proved in thousands of cases, and there is 
 no longer any doubt that it may exist. Caspary and Neumann even inoculated 
 without result, and Finger has done so three times. The immunity in such 
 cases is due to the tissue-products of the syphilitic vinis which have passed 
 from the foetus, by diffusion, into the maternal circulation, causing immunity 
 from syphilis without the symptoms of syphilis. It is true exceptions are pub- 
 lished, but they are few and uncertain. Profeta's immunity {''la hide Pro- 
 feta," Fournier) is the immunity of the children of syphilitic parents, either 
 or both being syphilitic. The children in many such cases are bom healthy 
 and remain healthy, but some of them are proof against the contagion of 
 syphilis just as if they had had the disease. This immunity also is due to 
 tissue-products of the vims passing into the foetal blood, and not to the 
 entrance of the virus itself. 
 
 In fact, all immunity from syphilis (and the same holds with all other infec- 
 tious diseases) is due to the "tissue-products" of its organized virus passing 
 into the circulation : for (1) this immunity occurs even in the primary period ; 
 (2) it outlasts the period of activity, and even that of the presence of the virus 
 in the body ; (3) it can be transferred independently of the virus itself. How 
 this immunity is to be explained essentially is, however, still an open question. 
 Tertiary symptoms are not due to the syphilitic virus per se, but to its tissue- 
 products. " A moderate amount of tissue-products of the virus (or only slight 
 virulence or greater resistance of the body) causes simple immunity ; an 
 increased amount or greater virulence of morbid products of the virus causes 
 tertiary syphilis. It has frequently been asserted that there is no relation 
 between the various stages of syphilis, as there is none between the character 
 of the syphilis of the person who supplies the poison and that of the one who 
 receives the infection. Certain cases, however, will be grave or "malignant 
 from the earliest period, and the dosage of virus or a feeble power of resist- 
 ance in normal cells may well be factors in determining this gravity. The defi- 
 nition given above includes all the periods of the disease, which are as follows : 
 First. Period of primary incubation, or that intervening between the 
 exposure to contagion and the ajipearanee of the chancre, on an average about 
 three weeks. 
 
SYPHILIS. 1^1 
 
 Second. Period of primary symptoms (chancre and adenitis). 
 Third. Period of secondary incubation, or that between the appear- 
 ance of the ohinuTc and tiie deveh)i.m(Mit of secondary symptoms, on an aver- 
 
 ao;e about six weeks. 
 
 Fourth. Period of secondary symptoms (syphdides of the .skin and 
 mucous membranes, mucous patches, roseola, papules, pustules, etc.). ihis 
 period mav last from one to three years. 
 
 Fifth ■ Intermediate period, during which there may be no symptoms, 
 or irre-nilar, sli.-ht, and le.ss-symmetrical and le.ss-generalized maniiestations. 
 The palient is protected as regards fresh contagion, but if he begets chile ren 
 they are likely to suffer. This period is very variable, lasting from two to four 
 years and ending in complete recovery or in 
 
 Sixth Period of tertiary symptoms (tuberculo-ulcerous syphilides, 
 periostitis, osteitis, gummata, etc.). The duration of this period is unlimited. 
 
 This separation of syphilis into periods is, to a certain extent, artificial, but 
 it correspomls, however, to the course of most cases, and is desirable for pur- 
 poses of dogmatic description. ^^^■ -^ 
 
 In consi°lering the methods of transmission of syphilis it must never 
 be forc-otten that it is not necessarily a venereal disease. AN hile it most tre- 
 Quentfv has its origin in sexual connection, yet it quite often occurs from the 
 contact of the buccal mucous membrane of a nursing chi d with the nipple of its 
 nurse, or vice versd, or by the common use of the same drmkmg-glasses etc or 
 midwives and physicians may be infected in practising the vaginal touch, it is 
 the secretion from a chancre or mucous patch which most frequently determines 
 the disease : the result is always an infecting chancre. The theory of the trans- 
 mission of syphilis from all the lesions of venereal disease— z. e. the doctrine 
 of the identity of gonorrhea and chancres— prevailed without opposition dur- 
 inc. several centuries. At the present time it is entirely abandoned. 
 
 ° When a person is exposed to impure connection, the lesions do not imme- 
 diately intervene; there occurs a period of from two to four weeks, an aver- 
 acre of twenty-one to twenty-five days, before any symptoms appear, and some- 
 times a longer time elapses— six weeks or two months. . o ■ i .a 
 This penod of incubation, which precedes the appearance of the indurated 
 chancre, is known as the period of primary incubation. AMienever an 
 inoculation, whether intentional (as in some unjustifiable experiments which ha^ e 
 been made) or accidental, with the secretion or pus of a secondary lesion or with 
 the blood, is successful, it produces a chancre, preceded by this long period of 
 incubation, and the symptoms of syphilis are then developed m their regular 
 evolution and successively appear. Mucous patches and moist papules not 
 only have the power of causing a chancre and syphilis by contact, but aie 
 probably the most frequent source of its transmission. Syphilis transmitted 
 by a syphilitic nursing infant suffering with mucous patches of the lips is seen 
 as a chTncre upon the^nipple of the nurse, provided the latter is not its mother 
 and has never had syphilis. Again, syphilitic papules of the nipples of a syph- 
 ilitic nurse occasion'a chancre upon the lip of a healthy infant. 
 
 Secondary lesions of syphilis may extend over a long time. Syphilis may 
 thus be communicated by a syphilitic person for several yeai;s after the begin- 
 nincr of the disease. In marrying during this period there is danger of com- 
 municating the disease to the wife and of 1^^^°^/^?^/^^^^^^^;}^,^^;^:^^^ 
 
 There has been, as far as we know, not one trustworthy c^e of the tiansmis- 
 sion of syphilis by means of inoculation of any of the normal -cretions, ev^n 
 ^^here the most careful and persistent attempts have been made T theie 
 are no authenticated cases of syphilitic contagion by the spermatic tiuid oi of 
 
142 AN AM/:/i'/('AX Th'.V'/- /iOOh' ()/■' SCUd i:iiV. 
 
 iiiociihitioii \)\ this liiiuid. Tlic tears and Siiliva ohtaiiiccl from sy])liiliti(; per- 
 sons liave boon inoculatcil upon liealthy persons witliout ])roducing tlio disease. 
 As the blood itself" is iin(loul)tedly eontaj^ious and inoculable, while the fluids 
 of the various secretions do not possess these ))roperties, it is very probable that 
 the passage of the serum of the blood through the glandular membranes and 
 cells arrests the contagious particles and renders the secreted fluids liannless. 
 Whatever may be the lesion or fluid or organism determining the transmission 
 of syphilis, it appears that except in cases of hereditary syphilis the result is 
 always the same, an infecting chancre, preceded by a period of incubation. 
 
 SECTION I.— PRIMARY SYPHILIS. 
 
 The Chancre. — AVe are not in possession of absolutely conclusive evi- 
 dence as to whether or not the virus of syphilis remains localized during the 
 period of primary incubation, but it is probable that when inserted under the 
 skin it remains there a certain length of time Avithout any other action than 
 gradually to pre]>are the cells which are in immediate relation with it for the 
 hyperplasia which soon constitutes the chancre. 
 
 The chancre ahvays appears at the point of inoculation. If Ave suppose 
 that the syphilitic poison is from the first carried everywhere in the economy, 
 it is difficult to understand why there is not, during one or two months, any 
 other lesion elsewhere than at the point of entrance. The primary lesion is 
 invariably met Avith at the point inoculated, never elscAvhere ; and secondarily, 
 a neighboring gland is SAVollen after the appearance of the chancre, then sev- 
 eral glands ; such glands, as we know from our study of other diseases, arrest 
 for some time the diffusion or generalization of morbid products and tumors. 
 
 This conception of the localization of the virus at the beginning of the con- 
 tamination is very important in a practical point of view. It Avould indicate 
 that the destruction of the chancre at the moment of its appearance Avould pre- 
 vent syphilis. While there is great difference of opinion among syphilogra- 
 phers upon this point, the weight of authority is against the probability of the 
 abortion of syphilis by excising or otherAvise destroying the chancre. Most 
 authorities are agreed, how'ever, that cauterization or excision of an abraded 
 or absorbing surface soon after exposure, and before the development of the 
 chancre, is strongly indicated, and has probably in several cases prevented 
 constitutional infection. 
 
 The infecting chancre has a period of incubation varying from ten days to 
 six weeks, the average being about three Aveeks. 
 
 It is an excellent general rule for prognosis in cases of suspicious ulcers 
 upon the genitals to assume that if an interval of ten days or more has elapsed 
 between the last exposure to contagion and the development of the sore, the 
 latter is probably the initial lesion of syphilis. 
 
 It begins sometimes by a superficial papule, Avhich generally extends in 
 circumference and depth ; sometimes by an excoriation or a superficial fissure, 
 often very slight. As it spreads upon the skin there are seen accom])anying 
 redness and desquamation of the epidermis : upon the mucous membranes a 
 superficial abrasion or an ulceration covered by a grayish or yelloAvish false 
 membrane ; there is also observed an induration, sometimes giving the sensation 
 of a hard nodule, fibrous or cartilaginous ; at other times, that of a thin plate 
 like parchment or paper. There may be no absolute loss of epidermis over the 
 surface of a chancre, but merely a gradual thinning of the e])idermic layers 
 from the margins of the sore tOAvard its center. Ulceration, Avhen it exists, is 
 a simple cup-shaped depression ; its surface is smooth and the margins are not 
 
.SYPHILIS. 143 
 
 iibnipt. At the center of the ehanere there is fouii<l a false membrane, 
 beneath ■which is a ra\v vascidar htyer, bleedinji; readily. 
 
 Section of a chancre shows, in addition to the usual lesions of cutaneous 
 inflannnation, a special and characteristic chancre — a sclerosis or thickening 
 of the coats of the venules and arterioles, aflecting chiefly the tunica adven- 
 titia. This thickening of the arterioles and venules is very important. In con- 
 nection with the preservation of the firm trabecule of the derm and of most 
 of the fasciculi of the connective tissue and of the elastic tissue, it gives to the 
 infecting chancre its most essential clinical character — the induration. 
 
 The induration may be either superficial or deep, (Icpcnding ujjon the 
 arrangement of the vessels, which form on the skin two horizontal networks — 
 one beneath the papilh«, the other deeper at the base of the derm. When the 
 former is affected we have a superficial induration. If the sclerosis has involved 
 at the same time both sets of vessels, the intermediate branches being ef[ually 
 affected, we have a more extensive nodule, varying in thickness according to 
 the region of the skin involved. 
 
 In the first case the induration is foliaceous or parchment-like ; in the sec- 
 ond it is woody and gives the sensation of cartilage. Almost always the sclero- 
 sis is continued along the coats of the vessels farther than the induration itself. 
 These lesions do not develop very rapidly ; which fact, taken in connection 
 with the changes of the tissues involved, explains the long duration of a chan- 
 cre and the persistence of the indurated nodule. 
 
 The induration of a chancre usually occurs at the end of the first week, 
 dating from its appearance ; it may not show itself until much later. The indu- 
 ration is progressively developed from the surface — that is, from the papillary 
 network — to the deep cutaneous and subcutaneous layers. 
 
 The variations in thickness of the affected part give rise to different 
 degrees of induration. Laminated induration is thinner and less distinct 
 than the parchment variety, and gives to the fingers the sensation of a piece 
 of paper. Parchment induration is that which gives to the fingers applied 
 to the circumference of the chancre the sensation of a piece of parchment 
 forming; the base of the erosion. Nodular induration is that in which the 
 base of the chancre is hard and thick, feeling between the fingers like a 
 nodule of cartilage or wood ; it is the most characteristic. Annular indura- 
 tion is that in which only the margins of the chancre are indurated and form 
 a hard ring, the tissue in the center retaining its normal elasticity. 
 
 The most readily recognized and the most characteristic chancre has the 
 shape of a cup-like depression seated upon the indurated and elevated skin. 
 
 The histological relations of the connective tissue and vessels beneath the 
 chancre will explain the anatomical reasons for these several forms of inchira- 
 tion. The laminated or parchment induration corresponds to a sclerosis limited 
 to the papilhie of the derm and to the vascular network of the papillae ; deeper 
 or nodular induration corresponds to a sclerosis of the cutaneous and sub- 
 cutaneous connective tissue and of the vascular network of these parts, which 
 latter is much larger than the superficial network, and is therefore slower in 
 forming and in disappearing than a similar lesion of small vessels. 
 
 Traces of induration have been observed four or five years after the begin- 
 ning- of the chancre. Ricord has found remains of the induration ten and 
 fifteen years subsequent to the primary lesion. 
 
 The induration and its extent are best appreciated by seizing the chancre 
 at its margin between the thumb and finger, drawing it upward, so that it may 
 move upon the subcutaneous tissue, and then using slight pressure in a direc- 
 tion parallel to the surface of the chancre. 
 
144 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 The degree of induration varies very nmeli according; to the seat or region of 
 the primary lesion. When occurring upon the glans penis, upon the mucous mem- 
 brane of tlie jirepuce, or in the fossa ghindis, the chancre is generally very dis- 
 tinctly indurated; upon the skin of the ])enis and the general integuments the 
 induration is not so marked or extensive. In women the induration of the chancre 
 is greater upon the labia majora than upon the labia minora and fourchette. 
 
 The induration of an infecting chancre is not only variable, but. in rare 
 cases, it may be absent. Therefore it is not positive and constant, and Cornil 
 believes that induration is a symptom less important in infecting chancre than 
 the characters of the erosion and the condition of the surface of the chancre, 
 especially if, in addition to these, we take cognizance of the several indurated, 
 movable, painless, and hypertrophied lymphatic glands, which never supjnirate 
 unless the chancre has been irritated by caustic or other applications followed 
 by infection with pyogenic microbes. 
 
 The induration generally does not remain at its height longer than three or 
 four weeks, and the chancre heals entirely in five or six weeks ; but the indu- 
 rated nodule, if it were primarily large and cartilaginous, may persist and be 
 still recognizable for years. 
 
 According to Fournier, three times in four the indurated chancre is single. 
 Multiple infecting chancres all begin at the same time, for the primary lesion 
 of syphilis is not, as a rule, auto-inoculable, and therefore it has no tendency to 
 be reproduced alongside of the primary sore, as is the case with chancroid. 
 
 The appearance of infecting chancre is varied. Between an erosion or 
 slight abrasion situated upon a parchment-like base that may be readily over- 
 looked, and an ulceration with a nodular cartilaginous base of considerable 
 size, even an inch in diameter, there are found several intermediate degrees. 
 
 The most frequent seat of chancres is the genital region ; they are very 
 seldom met with upon other parts of the body ; this is especially true Avith men, 
 less so in the case of women. 
 
 The usual seat of chancres of the genital organs with men is the glans 
 penis, the internal surface of the prepuce, and especially the fossa glandis and 
 frenum. Three-fourths of all chancres are found in these localities. At times 
 they are found upon the skin of the penis, at the meatus urinarius, upon the 
 scrotum, in the urethra, or upon the groin. 
 
 In women the labia majora are the most common seat of genital chancres; 
 then follow the fourchette, the labia minora, the clitoris, the skin of the pubes 
 or groin, the neck of the uterus, etc. 
 
 It is doubtful if an infecting chancre has in a single instance been found 
 upon the vagina, and yet this canal is certainly the part most exposed to con- 
 tagion. This immunity may possibly be due to the structure of the vaginal 
 mucous membrane, which is covered with thick layers of pavement epithelial 
 cells, and to the absence of glandular orifices over its entire surfiice : the vaginal 
 mucous membrane possessing papilhie and prominent villi, but no glands. 
 
 Extra-genital chancres, particularly those of the anus, are very much 
 more common in women than in men, yet all chancres of the anus in women do 
 not indicate unnatural sexual relations : the anal orifice is so situated that in 
 dorsal decubitis the fluids from the vulva flow over and often contaminate it. 
 
 Anal chancres are usually situated at the margin of the anus, at the bot- 
 tom of one of the radiating folds of skin produced by the contraction of the 
 external sphincter. The ulceration is apt to follow the lines of these folds, 
 and thus to assume an elongated or linear character. They are hard, and do 
 not give rise to the painful symptoms of fissures of the anus. They have 
 been observed as high as the upper margin of the internal sphincter. 
 
SYPHILIS. 145 
 
 The seats of extra-genital chancres are the anus, mouth, lips, tongue, 
 uvula, palatine arches, tonsils, cheek, nipple, etc. A cephalic chancre is almost 
 always infecting. Chancroid is scarcely ever seen upon the lips or fiice. 
 
 The diagnosis of chancre is a matter of such great practical import- 
 ance that it may be well, even at the risk of repetition, to enter into it some- 
 what fully : ' 
 
 1. In dealing with lesions apparently non-venereal in their origin and 
 character we should consider carefully the following points : 
 
 (a) The anatomical situation and the course of the lesion. Among those 
 particularly to be viewed with suspicion may be mentioned herpetiform erosions 
 of the lips, papules on the tip of the tongue, squamous or "scabby" ulcera- 
 tions of the skin, scratches which obstinately refuse to heal, chronic inflamma- 
 tions at the tip of the fingers resembling felons, etc. 
 
 (b) Indolence, absence of suppurative tendericies, and persistence in spite 
 of treatment are negative signs which should lead us to believe that any 
 cutaneous or mucous lesion is not of a simple nature. 
 
 (c) If the morbid products are slight, rather serous than purulent, tend to 
 form into crusts or to assume a pseudo-membranous form upon an eroded sur- 
 face, syphilis should be suspected. 
 
 (d) The consistence of the base upon which the lesion is situated is one of 
 the most important diagnostic points, and should always be carefully investi- 
 gated. If, upon palpation, instead of the usual inflammatory swelling and 
 thickening, shading off into the surrounding tissue, we meet with a cartilaginous, 
 elastic, sharply-circumscribed resistance, we may immediately suspect very 
 strongly that we are dealing with a syphilitic lesion, although even this symp- 
 tom cannot be considered as infallible. 
 
 (e) If the hjmpliatics of the groin become slightly swollen and painful and 
 progress no farther, or if these symptoms occurring in a single gland subside 
 spontaneously, it is probable that they are due to a sympathetic adenitis, such 
 as follows many irritations of the skin or mucous membrane. If, on the con- 
 trary, they steadily augment in size and hardness, are almost painless, and 
 constitute a chain of little tumors including several or all the inguinal glands, it 
 may be considered strong presumptive evidence of specific disease, though even 
 yet not conclusive. 
 
 In addition to these points the history of the case must carefully be inquired 
 into — the probabilities of infection, in regard to w hich we should not be misled 
 by the beliefs cf the patient — and the period of incubation, which, when it can 
 be clearly established, is of great value. 
 
 Confrontation — i. e. examination of the person from Avhom the disease has 
 probably been contracted — will often, not invariably, decide the matter, but, in 
 this country at least, is rarely obtainable. 
 
 Difiiculties of diagnosis are greatest during the first week or ten days, and 
 steadily diminish with the age of the lesion, which, if syphilitic, is almost cer- 
 tain to assume in time a definite character. The chief points among those 
 mentioned are the period of incubation, the presence or absence of induration, 
 and the condition of the nearest lymphatic glands. If, however, all of these 
 seem to point to syphilis, the experienced observer will still refrain from giving 
 a positive opinion^ no symptom or group of symptoms being absolutely conclu- 
 sive as to the specific character of any primary lesion ; certainty only being 
 attained by the development of some of those general or constitutional 
 phenomena which in from six to eight weeks follow the infecting chancre. 
 
 1 In doing so we shall follow closely the paper of Ch. Mauriac, which is the best r^sum^ 
 of this subject with which we are acquainted. 
 10 
 
146 AX AMi:nicAX Ti:xT-ii(jok' or scrgery. 
 
 2. The region occupied by a chancre may cause errors or difficulties in 
 diagnosis. 
 
 (rt) In the cephalic region chancres of the //'///•// acalp^ of the supi-aoriutal 
 prominences, and of the chin and cheeks are the most deceptive. They always 
 assume an ecthyniatous form, and are so concealetl by the hair that it is 
 impossible to judge of the character of their surface. In all such cases 
 the hair must be carefully shaved, and if we then find that we are dealing Avith 
 an ulceration lacking the ordinary characteristics of ecthyma, and glazed, flat, 
 or even elevated, our suspicious should be aroused, and after eight or ten days 
 will usually be confirmed, if the sore is syphilitic, by the development of 
 induration and of neighboring lymphatic enlargement. 
 
 Razor-cuts on the chin, cheeks, or lips which, after having healed, reopen 
 and become covei'ed with a crust, should on a p)riori grounds be suspected. 
 This is equally true of pseudo-furuncles, acneiform pustules, cracks around the 
 circumference of the nostrils, etc., which persist without giving rise to pain, 
 and become bloody, encrusted, and surrounded by an area of subinflammatory, 
 oedematous swelling. We should then carefully examine the preauricular, 
 parotidean, and submaxillary lymphatic glands. 
 
 A stiie which behaves in an unaccustomed manner or is accompanied by 
 hyperplasia of the lid, or a conjunctivitis which becomes localized and causes 
 an isolated swelling, should be attentively watched. 
 
 In the neighborhood of the mouth errors of diagnosis should be less frequent 
 than in other portions of the cephalic region, because it has been shown so 
 often that the lips, tongue, and fauces are frequently brought into contact 
 with syphilitic discharges and constitute one of the principal channels of 
 infection. Here, however, as elsewhere, the chancre assumes at the very 
 outset the appearance of ordinary lesions. Thus, upon the lips the chap, crack, 
 or fissure often found in the median line, the little aphthous erosions, herpetic 
 ulcerations, and cigar or cigarette burns, simulate very closely the characters 
 of the initial lesion, and, as the latter will almost invariably be attributed by 
 patients to some such ordinary cause, ma}'' give rise to serious error. 
 
 At the end of the first week, however, the specific characters of labial 
 chancre are usually so distinct as to render diagnosis easy. 
 
 In several instances these chancres have been mistaken for epithelioma, and 
 have been excised. The diagnostic differences may be indicated as follows : 
 
 Labial Chancre. Epithelioma. 
 
 No marked difference between the sexes. Twenty times more common in males than 
 
 in females. 
 The ulcer may involve either lip. Almost invariably situated upon the lower 
 
 lip. 
 Occurs at any a^i^e. Rarely occurs before middle life. 
 
 Patient often strong and robust. Patient usually in impaired health. 
 
 Is insensitive. Often sharp, burnin<r, lancinatinfr pains. 
 
 Regular in outline, smooth surface, elevated. Irre^rular in outline, ragged, tilled with 
 
 fungous granulations, bleeding easily. 
 Indurated and sharply circumscribed base. Induration less cartilaginous, unequal, not 
 
 clearly circumscribed, and more extensive. 
 Evolution of sore usually occupies a few Sore may lie months in developing after its 
 
 weeks at the most. first appearance. 
 
 Glandular involvement follows closely on Glands are not implicated for three or four 
 
 appearance of sore. months, often not until later. 
 
 No marked odor from secretion of sore. Odor often extremely offensive. 
 
 History of exposure to syphilitic inoculation Frequently no such history. 
 
 often obtainable. 
 Heals rapidly or disappears under mercurial Not affected or rendered worse by such 
 treatment. treatment. 
 
SYPHILIS. 147 
 
 While tliore is a possiliility of error in diagnosis between a chancre and an 
 epithelioniatous ulcer when a niaerosco])ical examination alone is made, there is, 
 on the contrary, no such ap})reliension when a microscopical examination of the 
 lesions is instituted. The histological structure and arrangement are so very 
 distinct and unlike in these lesions that a mistake cannot well occur. In the 
 e})itlielioma we have the ingrowing of the interpapilhuy layers of epithelial cells, 
 the branching or budding outgrowths from the sebaceous glands which consti- 
 tute the very characteristic ej)itheliomatous pegs, and the formation of the 
 cell-nests or pearls upon these pegs, which are all so strikingly different, when 
 contrasted with the histological structure of a chancre, that no doubt as to 
 diagnosis remains. 
 
 Upon the sides of the tongue ulcerations, produced by the continual contact 
 of that organ with rough and carious teeth, have been mistaken for chancres. 
 This error should ])e guarded against, but is not so serious in its results as the 
 failure to recognize the specific lesion when it is situated at the point of the 
 tongue, the possibility of its communication to innocent people being, in such 
 cases, an element of unusual importance.^ In the first five or six days it is 
 impossible to diagnosticate it, but if the original little inflamed papule enlarges 
 and extends, becoming elevated above the surrounding parts ; if its epithelial 
 covering drops off and its surface becomes diphtheritic ; if superficial cauteri- 
 zation with crayons of nitrate of silver, which so rapidly cure the common small 
 painful papule of the tongue, have no effect upon it, — there is a strong presump- 
 tion that it is chancre. This will be confirmed later by the appearance of 
 submaxillary glandular enlargement and induration of the sore. 
 
 Of all the chancres of the cephalic region, however, that of the tonsils or 
 of the isthmus of the fauces presents the greatest diagnostic difficulties, on 
 account of the effacement of its characteristics by the surrounding inflam- 
 mation. If in a case of prolonged sore throat there be an appearance resembling 
 a single mucous patch, and there be no history of antecedent syphilitic poison- 
 ing, it becomes probable that the trouble is chancrous ; and this probability 
 is greatly increased if any induration can be felt by palpation with one finger 
 in the pharynx and another external to its walls ; if enlargement of the glands 
 above the angle of the jaw occurs ; or, of course, if the patient confesses to 
 having been peculiarly exposed to contamination. 
 
 The sore is much more common in this region in females than in males, 
 Mackenzie noting the fact that out of 7 cases of primary syphilis of the ton- 
 sils Avhich he had met with, 6 were women. 
 
 (6) Superior- and Inferior Extremities. — Chancres of the hands are often 
 seated at the margin of the nail and closely resemble simple whitlows. They 
 may be diagnosed by their long duration, their abrupt limitation, the hardness 
 of the tissues around and beneath them, and the consecutive engorgement of 
 the epitrochlear ganglion. Upon the dorsal face of the phalanges the initial 
 lesion at first simulates an inflamed papule or boil, but is less painful, dis- 
 charges no "core," and is elevated, not excavated. 
 
 The anterior face of the forearm in both sexes, the anterior surface of the 
 thigh in men and the posterior surface in women, are the parts most exposed to 
 contagion. 
 
 The chancre of vaccino-syphilis occurs after the evolution of the vaccine 
 sore. It can only be confounded with the ulcerations described by Blot under 
 the name of "vaccinal phagedenism," which are rounded with abrupt borders 
 and indurated bases, and are often accompanied with engorgement of the axil- 
 
 ^ The same remark applies to mucous patches of the tongue and lips with even more force, 
 &o they are so much more frequent than primary sores. 
 
148 
 
 AN AMERICAN TEXT-BOOK OF SURGERY, 
 
 lary lymphatic glands. The diagnosis from appearances is difficult, but may 
 be made by noticing the fact that these sores run an acute course, and are read- 
 ily cured by poultices or emollient applications, which, of course, have no effect 
 on chancre. 
 
 ((■) Upon the trunk the mammary and hypogastric regions are those most 
 frequently involved. In the former locality the initial lesion is most likely to 
 be mistaken for eczematous excoriations, fissures, and small furuncular or papil- 
 lary tumors. The diagnosis rests upon the presence of the characteristic indu- 
 ration, elevation, etc., and upon the polyganglionic axillary enlargement. In 
 cases where syphilis has been transmitted during suckling confrontation is 
 almost invariably possible and furnishes the most satisfactory guide. 
 
 Chancres of the hypogastrium are generally large and ulcerating, and are 
 most liable to be mistaken for chancroids. 
 
 {d) G-enital Organs. — The diagnosis of sores situated in this locality is 
 chiefly between chancre, chancroid, and herpetic ulceration, 
 table given below expresses the main points of diff'erence. 
 
 The diagnostic 
 
 Chancre. 
 Origin : 
 Due to contagion from a chan- 
 cre, a syphilitic lesion, or 
 blood or pus from a person 
 having syphilis. 
 
 Incubation : 
 Not less than ten days ; often 
 thi ee weeks ; very rarely 
 six to eight weeks. 
 
 Situation : 
 Most frequent upon the geni- 
 tals. Often seen on the 
 hands, nipples, lips, etc. 
 
 Commencement : 
 Begins as an erosion, papule, 
 tubercle, or ulcer. May 
 remain without ulceration 
 through its entire course. 
 
 Kumber: 
 Single or simultaneously mul- 
 tiple; occasionally, but rare- 
 ly, successively multiple. 
 
 Shape : 
 Round, oval, or symmetri- 
 cally irregular. 
 
 Chancroid. 
 
 Usually due to contact with 
 pus from a similar sore, 
 or to accidental inoculation 
 of the secretion of a chan- 
 croid upon a person already 
 affected with syphilis ; of- 
 ten to the irritation of pus 
 from other sources. 
 
 None. 
 
 Almost always upon the 
 glans penis or prepuce; 
 rare upon other portions 
 of the genitals ; scarcely 
 ever seen elsewhere. 
 
 Begins as a pustule or ulcer. 
 
 Herpetic Ulceration. 
 
 Mechanical irritation ; fric- 
 tion, as in sexual inter- 
 course ; chemical irritation, 
 as of acrid discharges ; un- 
 cleanliness. Occasionally 
 follows cold or fever ; may 
 be a neurosis. 
 
 None. 
 
 Glans penis and inner layer 
 of prepuce. 
 
 Begins as a group of vesi- 
 cles, which may coalesce 
 or may ulcerate singly. 
 
 Often multiple, frequently by Multiple; apt to be conflu- 
 auto-inoculation. ent. 
 
 Round, oval, or unsymmetri- 
 cally irregular, with bor- 
 der described by segments 
 of large circles. 
 
 Hollow, excavated, or 
 "punched out." 
 
 Depth : 
 Usually superficial — cup- 
 shaped or saucer-shaped 
 — or may be elevated. 
 
 Surface : 
 Smooth, shining, red, glazed ; Rough, uneven, " worm-cat- 
 diphtheritic membrane or en," warty, whitish-gray- 
 Bcab. ish, pultaceous. 
 
 Irregular ; edges serrated or 
 described by segments of 
 small circles. 
 
 Superficial. 
 
 Same as local ulcer, but more 
 superficial. 
 
SYPHILIS. 
 
 149 
 
 Secretion : 
 Scanty, serous, auto-inocula- 
 blo witli <;reat diflioulty, 
 produc-inj; either a chan- 
 croidal sore or, in rare 
 cases, a second sore like 
 the first. 
 
 Induraiion : 
 Almost always present ; firm, 
 cartilaiiiiious, or parch- 
 ment-like -, circumscribed, 
 terminating^ abruptly; 
 movable upon subjacent 
 parts ; skin not adherent ; 
 usually persistent : disap- 
 pears under specific treat- 
 ment. 
 
 Sensibiliii/ : 
 
 Very little or no pain. 
 Course : 
 
 Usually regularly progressive 
 toward health, the sore 
 often healing spontaneous- 
 ly. Phagedena uncommon. 
 Second attack also very 
 rare. 
 
 Histology : 
 A new cell-growth. Very 
 little destruction of tissue. 
 
 Bubo : 
 Constant, painless, multiple. 
 
 Abundant, purulent ; readily 
 auto-inoculated 
 
 Only exceptionally present ; 
 may be caused by caustics 
 or other irritants, or by 
 simple inflammation ; bog- 
 gy, inelastic, shades ott" 
 into surrounding parts, to 
 which it is adherent ; dis- 
 appears soon after cicatri- 
 zation. 
 
 Painful. 
 
 Irregular ; may cicatrize rap- 
 idly or may extend, taking 
 on phagedenic action. No 
 protection against a second 
 attack. 
 
 An ulceration, with more or 
 less loss of substance. 
 
 In one-third of the cases 5 
 painful, inflammatory, sin- 
 
 Moderate secretion •, auto-in- 
 oculated with difficulty. 
 
 Same as local ulcer. 
 
 More serious, locally, on ac- 
 count of loss of tissue 5 
 occasional refusal to heal, 
 and possibility of jjhage- 
 dena. Ve^y rarely is fol- 
 lowed by syphilis. 
 
 Local treatment curative. 
 
 Painful. 
 
 May spread, in exceptional 
 cases, by the appearance 
 of successive crops of 
 vesicles. Usually heals 
 promptly under mild local 
 treatment. Likely to recur, 
 especially in uncleanly 
 patients with long fore- 
 skins. 
 
 Originally an elevation of 
 the epidermis in spots by 
 an effusion of serum. 
 
 Rare. When it does occur, 
 painful, single, inflamma- 
 tory. 
 
 Always good if the diagnosis 
 be absolute. Should be 
 guarded when there is the 
 least doubt as to the her- 
 petic character of the 
 affection. 
 
 Local treatment curative. 
 
 Prognosis : 
 Good locally ; constitutional 
 syphilis will follow in the 
 great majority of cases, 
 but in a few may not ap- 
 pear or may be prevented 
 by treatment. 
 
 Treatment : 
 Excision when seen early ; 
 other local treatment of 
 minor importance. 
 
 Chancres of the meatus are more often syphilitic than simple in their cha- 
 racter. In the former case they are attended with little or no ulceration, are 
 confined to one lip of the meatus, are accompanied by the usual induration and 
 glandular involvement, and are often, indeed usually, not discovered by the 
 patient, who imagines he has a gonorrhea. Chancroid of the meatus is irreg- 
 ular in shape, ulcerated, involves both lips, is painful, and does not have the 
 characteristic induration. 
 
 The diagnosis between infecting urethral chancre and gonorrhea may be 
 tabulated as follows : 
 
150 
 
 .4.V AMERICAN TEXT-BOOK OF SURGERY. 
 
 Urethral Chancre. 
 
 Symptom? ayipear after a period of incuba- 
 tion rarely less than ten days, often two 
 or three weeks. 
 
 Confined to meatus or its immediate neigh- 
 borhood. 
 
 Ardor urinae felt only at lips ; no chordee. 
 
 Discharge moderate, never purulent, often 
 bloody. 
 
 Induration perceptible to touch, usually in- 
 volving only one lip of meatus. 
 
 Invariable enlargement of chain of inguinal 
 lymphatics, which are painless and freely 
 movable, and almost never suppurate. 
 
 Sore can almost always be seen as a loss of 
 continuity of mucous membrane. 
 
 Constitutional symptoms follow after from 
 six to eight weeks. 
 
 Use of syringe painful at meatus. 
 
 Urethritis. 
 
 Symptoms follow suspicious intercourse in 
 
 from twenty-four hours to a week, rarely 
 
 at a longer interval. 
 Begins at meatus, but extends some distance 
 
 backward. 
 Ardor urinae felt along the urethra ; chordee 
 
 often present. 
 Discharge more profuse, decidedly purulent, 
 
 not so often or so largely stained with 
 
 blood. 
 No induration. 
 
 If lymphatics are involved at all, only one 
 is affected, which often goes on to sup- 
 puration. 
 
 No loss of continuity perceptible. 
 
 No constitutional symptoms. 
 
 Use of syringe not usually painful. 
 
 The small hard tumors which occa.sionally appear or may be felt aloncj the 
 under surface of the penis during an attack of gonorrhea, and which are due 
 to inflammation and enlargement of the follicles, should not be confused with 
 chancre. They usually feel like grains of sand or small peas directly beneath 
 the skin, are situated behind the fossa navicularis, have no characteristic 
 induration, and subside spontaneously or go on to suppuration. 
 
 When phimosis exists the diagnosis between subpreputial chancres and 
 chancroidal, herpetic, or balanitic ulcerations is often one of great difiBculty. 
 It should be founded on the followins: considerations : 
 
 Subpreputial Chancre. 
 
 The incubation is that of chancres, ten to 
 twenty-one days or more. 
 
 If the site of the original trouble can be felt 
 or can be described by the patient, it will 
 be found to be single. 
 
 Inflammatorv phenomena comparatively 
 slight. 
 
 Swelling hard, dry, indurated character- 
 istically. 
 
 The discharge from the preputial orifice is 
 moderate, thin, serous or bloody, not 
 readily inoculable. 
 
 The margins of the preputial orifice are not 
 markedly inflamed or ulcerated. 
 
 At some point the induration can probably 
 be isolated from the surrounding tissues 
 and raised and felt between the thumb 
 and finger. 
 
 Syphilitic buboes are invariably present. 
 
 Subpreputial Ulceration fnon-syph- 
 iliticj. 
 
 The interval between the exposure and the 
 subsequent ulceration, swelling, etc. is 
 much shorter. 
 
 Several points of ulceration, abrasion, or 
 pustulation will usually be found or de- 
 scribed. 
 
 Inflammatory phenomena — heat, pain, red- 
 ness, swelling — very marked. 
 
 Swelling oedematous. sero-purulent, like that 
 of phlegmonous erysipelas. 
 
 Discharge profuse, purulent, usually very 
 irritating, and apt to be inoculable, both 
 accidentally and experimentally. 
 
 Almost invariably ulcerated. 
 
 This is usually not possible, no distinct 
 dividing line existing. 
 
 Buboes, if present at all, are of an inflam- 
 matory character. 
 
 The diagnosis between a new indurated chancre and an ulceration occupy- 
 ing the site of an old chancre, the induration of which has never entirely dis- 
 appeared — '• relapsing chancre " — is extremely difficult, and, unless a clear 
 history of the case can be obtained, is impossible. The latter cases are often 
 reported as instances of a second syphilitic infection. The opinion must be 
 
SYPHILIS. l-^^l 
 
 ba^ed upon the presence or absence of a syphilitic history and the circumstances 
 of the exposure, inculnition. etc. The possible effect of local irritation on an 
 old indurated iiui.ss should always be taken into account. , , «• ■ 
 
 The prognosis of syphilitic chancre, considered as a local attection, 
 depends chietiv upon the seat of the lesion. A chancre of the conjunctiva 
 nrfv crive rise to a ?rave ophthalmia; a chancre of the tongue or of the fauces 
 maV 'cause <rreat debilltv through interference with mastication, deglutition, 
 and dicre^tio^n. As regards the genital organs, however, the prognosis is 
 almost uniformlv favorable. Phagedenic or gangrenous processes are rare; 
 ulceration even'is usuallv very slight, or, if seemingly extensive, is apt to be 
 at the expense of the neoplasm, and not of the normal tissues. 
 
 The relation between the constitutional disease of which the chancre is the 
 precursor and the sore itself is a question of great interest. It mav be at once 
 acknowledged, however, that our information upon this pomt is deficient. We 
 are able n'either to predict the form of local lesion from the character of the 
 source of infection, nor, on the other hand, can we, with any accuracy, fore- 
 cast the constitutional condition Avhich will result from any given sore, ihe 
 varieties of the chancre in form, extent, etc. depend more upon local causes or 
 upon the idiosyncrasies of the patient than upon any special source or pecu- 
 liarity of the Virus. Every svphilographer of experience has seen the most 
 widelV-differincr forms of initial lesion derived from the same individual, and 
 a similar diversity exists in the fonus of constitutional disease arising Irom 
 a -iven focus of mfection. The amount of glandular implication is also an 
 ennrelv unreliable Lniide and presents all sorts of variable phenomena. 
 
 The Treatment of Chancre.— Every surgeon whose work has brought 
 him in contact with large numbers of cases of venereal sores must recognize 
 the fact that between the typical soft, suppurating local sore and the distinctly 
 indurated chancre there are large numbers of doubtful ulcers which partake of 
 the characteristics of both : local sores with deceptive mflammatoiy hardening, 
 an.l true chancres with equally deceptive inflammatory softening, suppuration, 
 and even loss of substance. Nearly every specialist who has written upon 
 the subject has recognized and been influenced by this well-known fact 
 
 Fournier, perhaps the most eminent living syphilographer, has recorded 
 a case which bears most strongly upon the question under consideration: 
 A female child, six years old, was said to have been mfec ed with syphdis 
 durinc. an attempt at rape. She had marked vulvitis and upon he labia 
 three "crayish. shallow, indolent, indurated ulcers covered witb a diphtheritic- 
 looking membrane and raised a little above the general surface In both 
 groins there were enlarged, multiple lymphatic glands. He positively liag- 
 Sosticated chancre, but, conforming to his custom m medico-legal cases, declined 
 to testify for a few days. During this time, under a simple dressing, the 
 symptoms disappeared, and the patient, who was carefully observed for seyera 
 months, never showed any subsequent signs of infection. Fournier be le^es 
 that the case demonstrates that small inflammatory lesions may so closely 
 resemble chancres as to deceive the most experienced surgeon, and adds hat 
 in medico-legal cases the diagnosis should not be made upon the local le.ions 
 alone, but should depend upon the development of constitutional symptoms 
 
 The surcreon who is daily called upon to give an opinion m cases which 
 involve the whole future of ihe individual, his relations to the other sex his 
 determination toward celibacy or matrimony his matrimonial relations if he 
 should be already married, the question of the influence of paternity the 
 institution of a course of treatment extending over years, the diagnosis of any 
 obscure visceral troubles which he may develop later in lite, the profoundly 
 
152 AN AMERICAN TEXT-HOOK OF SURGERY. 
 
 depressinfj mental effect wbicli a knowledge of sypliilltic infection usually has 
 upon intelligent j)eoj)le, — the surgeon who renienihers these facts and recalls 
 the views above cited as to the possiliility of error sliould surely hesitate about 
 beginning a course of treatment which will jiossibly obscure or render alto- 
 gether impossible the diagnosis. While there is no positive advantage in delay 
 as regards the subsequent course of the case, yet, on the other hand, the gain 
 from the immediate treatment during the primary sore is not sufficient to 
 counterbalance the doubt and uncertainty which that treatment often throws 
 about the future life of the patient. Certainly the cases are comparatively 
 rare in which a careful surgeon would be willing to make an absolute diagno- 
 sis of syphilis during the existence of the primary sore alone. A few neces- 
 sary exceptions to this rule may be included under the following heads: 
 
 1. Where confrontation is possible and the sore is distinctly a typical one. 
 2. Where with a typical sore its continued existence would destroy or imperil 
 the conjugal relations of two people or possibly the happiness of an entire 
 family. 8. Sores with characteristic induration, but "with marked tendency to 
 spread and involve important regions. 4. Sores in such conspicuous positions, 
 as upon the lips or the nose, that their continuance would involve a general 
 knowledge of the patient's condition. 
 
 With these exceptions it is the part of wisdom to wait until tlie development 
 of glandular enlargement at some point removed from the initial lesion, and 
 not, therefore, by any possibility a result of simple adenitis, demonstrates the 
 constitutional character of the trouble. It is to be hoped — and, indeed, may 
 be confidently expected — that the progress of bacterial investigation will in 
 the near future enable us to make a very early and positive diagnosis, but we 
 cannot do so as yet. It is not necessary, however, to wait for the syphilo- 
 dermata. Treatment may be safely begun when, after a suspicious sore upon 
 the genitals, consecutive enlargement of the epitrochlear or post-cervical lym- 
 phatic glands takes place. 
 
 The argument above used against the mercurial treatment of chancre 
 applies with equal force to the local abortive measures which have from time 
 to time been recommended. These include excision ; cauterization ; antiseptic 
 measures ; and various local applications of mercurial preparations by means 
 of ointments, hypodermatic injections, or otherwise. Taking them in the order 
 mentioned, their relative advantages and disadvantages seem to be as follows : 
 
 As to excision, it appears unquestionable that it can be of service in 
 but a very small proportion of venereal sores as they usually come under the 
 notice of the practitioner. The opinions of syphilographers, however, vary 
 greatly in regard to the value of this form of treatment, and in the light of the 
 opposing views a safe general rule for practice is to assume that a sore seen 
 within a few days after its appearance, and as yet unaccompanied by any 
 enlargement of the inguinal glands, is still a localized lesion. If favorably 
 situated — /. e. upon the skin of the prepuce or of the genitals — it may be 
 removed, the surgeon picking up the sore and surrounding tissue with a pair 
 of toothed forceps, and removing it by a single sweep of the knife or by means 
 of scissors curved on the flat, afterward dressing the wound with iodoform or 
 boracic powder. By this plan of treatment we give our patients whatever 
 small chance there may be of avoiding constitutional disease, while at the same 
 time we expose them to the minimum degree of local pain and disturbance. 
 
 When the patient refuses this treatment, or when the sore is so situated 
 that its removal would cause considerable pain, hemorrhage, or deformity, 
 destructive cauterization with fuming nitric acid may be employed. In all 
 cases (and these comprise the majority which come for treatment) in which 
 
SYPHILIS. 153 
 
 a week or more lias elapsed since the development of the sore, and in 
 ■which involvement of the dorsal lymphatics of the penis and the in^^uinal 
 lymphatic glands is ohservahle, cauterization as a routine method of treatment 
 should be rejected, on account of its undoubted uselessness at that stage in 
 preventing constitutional disease ; the pain which it causes ; the inflammatory 
 action which follows it, and which often produces enough oedema and swelling 
 to cause i)liiniosis, and thus convert an open sore into a hidden one ; the sub- 
 sequent effusion of lymph, which sinndates true induration and confuses the 
 diagnosis ; and, fiiudly, the greater liability to the production of suppurative 
 action in the ordinarily indolent bubo of syphilis. 
 
 The so-called antiseptic treatment of the initial lesion of syphilis is a mis- 
 nomer, so far as the essential character of the sore is concerned, uidess it be 
 meant to include only the thorough destructive cauterization of all portions of 
 the infected tissue. - Applied simply to superficial dressings jjlaced over the 
 chancre, it can refer only to the prevention of the development of pyogenic 
 organisms upon the surface of the sore. As the tendency of infecting chancres 
 to suppuration is generally unimportant, we can hardly expect advantages from 
 the employment of aseptic or antiseptic methods which are at all commensurate 
 with those obtained by the same methods in ordinary surgical conditions. 
 
 The local treatment by hypodermatic injection of mercurials beneath the 
 base of the initial lesion and into the mass of indurated lymphatic glands rests 
 upon the view that mercury acts as an antidote when brought directly into con- 
 tact with the syphilitic germs, and that this influence would probably be espe- 
 cially active if the drug were brought to bear directly upon the local lesions 
 which are the foci of infection during primary syphilis. If we believe that the 
 virus remains localized for a time after inoculation, and is not disseminated 
 through the general system, and that mercury acts by its germicidal influence, 
 this treatment is not unphilosophical, but seems inferior to the more thorough 
 plan of excising both the chancre and the enlarged lymphatics of the groin. 
 The latter procedure would be less likely to result in local troubles, such as 
 abscess or cellulitis, and would certainly be more effective. The rules as to 
 the treatment of chancre may accordingly be expressed as follows : 
 
 1. While it is unquestionably desirable to begin mercurial treatment at the 
 earliest proper moment, and while that treatment undoubtedly either suppresses 
 or renders milder the subsequent secondary manifestations, and while there is 
 every reason to believe that in this way the liability to later or tertiary lesions 
 is somewhat lessened, nevertheless the sum-total of these advantages does not 
 warrant the employment of mercury one moment before the diagnosis of con- 
 stitutional disease is absolutely assured. 
 
 2. While in many cases that diagnosis can be made with a high degree of 
 probability from the appearance of the primary sore alone, yet it cannot be 
 said that all possibility of error is excluded until some general symptom, such 
 as the enlargement of distant lymphatic glands, has shown itself. 
 
 3. The administration of mercury during the existence of the primary sore, 
 unaccompanied by general symptoms, for the purpose of suppressing or "abort- 
 ing" syphilis, is not, therefore, justifiable, unless by confrontation the diagnosis 
 can be confirmed, or unless there are urgent and unquestionable reasons for 
 securing rapid cicatrization of the chancre. 
 
 4. It is proper to employ cauterization or excision, according to the site of 
 the chancre, in cases in which it is seen very soon after its appearance, and 
 especially when \l is known to have followed intercourse with a syphilitic per- 
 son. The chances of preventing constitutional infection in this way, while 
 slight, may yet be considered sufficient in such cases to counterbalance the dis- 
 
164 A.y AMERICAN TEXT-BOOK OF SC'liGEJiY. 
 
 advanta<::es of the method, such as pain, swelling, the production of phimosis 
 or of suj>puniting bubo, and the obscuring of tlie diagnosis by the resulting 
 inflammatory exudation. 
 
 5. Aseptic or antiseptic measures, while harmless, cannot be considered 
 especially indicated in the local treatment of chancre, and in all probability 
 can have no true abortive influence. 
 
 6. The local use of mercurials, hypodermatically or by inunction, is perhaps 
 worth a trial, but it is probably inferior to the more radical methods based 
 essentially upon the same principles — namely, excision and cauterization. 
 
 Chancroid. — The form of sore known as soft sore, soft chancre, simple 
 chancre, uon-infccting chancre, and chancroid is variously ascribed to the 
 inoculation of a specific virus (the chancroidal), to infection with pus-microbes, 
 and to a mixed (syphilitic and purulent) infection. There is some reason to 
 think that there is a specific virus for chancroid. Xo final conclusion can yet 
 be stated, though bacteriology will doubtless definitely settle the matter at no 
 distant period. In the mean time Ave may be content to consider chancroid 
 as a sore which has a very diff"erent appearance and runs a very different 
 course from an infecting chancre. 
 
 In the case of a chancroid there are observed from the first certain phe- 
 nomena. Tlie first day we see a small red point, which on the second day 
 becomes a papule, and is converted into a pustule by the end of the second or 
 third day, especially in a region where the skin is delicate. The pustule soon 
 breaks, and beneath the lowest epidermic layers we find a deep suppurating 
 ulcer, which rapidly extends in circumference and depth, becoming at the end 
 of the first week deep and crater-like with perpendicular or undermined edges ; 
 its surface is granulating, irregular, and infiltrated Avith pus, which is abundant 
 and gives it a gravish color. The serum upon the surface of an indurated 
 chancre, on the contrary, is small in amount and transparent. 
 
 In the chancroid there is no sclerosis of the vascular walls ; we meet with 
 the phenomena of inflammation, but there is no induration or thickening of 
 the Avail and no narroAving of the caliber of the vessels. The fibrous trabeculje 
 of the derm of the region involved are not preserved intact. The fibrils sepa- 
 rated by the lyraph-cells are themselves destroyed by the softening of the tissue 
 and by the suppuration. These changes upon the surface of a chancroid result 
 in the fibrous tissue losing its firmness and elasticity ; its fibrous trabecuhe have 
 a tendency to disappear. The lymph-cells, which collect in great numbers in 
 the granulations and neighboring connective tissue, are large, turgid, and 
 become free by softening the fibrils between Avhich they are placed. The 
 absence of specific induration comparable to that of the indurated chancre, 
 and also a tendency to a progressive destructive involvement of neighboring 
 tissues, result from this anatomical arrangement of elements. From this it 
 will be seen that betAveen chancre and chancroid there is a marked histolog- 
 ical diff"erence, one being essentially a prominent papule or ncAv groAvth, the 
 other an ulcer. A chancroid is apt to be painful and itching ; the pus, Avhich 
 is secreted in large amount, is inoculable upon the patient. avIio frefpiently inoc- 
 ulates himself inadvertently or from uncleanliness, so that it is often multiple. 
 
 Phagedena. — Either a chancroid or a chancre, but oftener the former, 
 may be accompanied by such intense local infection and tissue-necrosis that 
 it spreads Avith great rapidity both on the surface and toAvard the deeper 
 structures. It may thus produce one of the most destructive and most 
 obstinate forms of ulceration. It is not knoAvn certainly Avhether this indi- 
 cates essentially a lessened poAver of resistance or a new microbic infection. 
 Probably both conditions coexist in the majority of cases. 
 
CHANCROID. 156 
 
 When tlio lynipliatic fjlands are affected tlier(? may oecur a true sii])piirating 
 bubo, especially if the patient be broken down in health or if he has been 
 nef!;ligent of treatment. In this case an inguinal gland is swollen, fixed, and 
 becomes very large ; the skin reddens u])on its surface, and we soon feel a super- 
 ficial fluctuation, due to pus formed in tlie cellulo-adipose tissue surrounding the 
 gland. When this abscess is opened the gland in some cases suppurates, and 
 there is formed an irregular cavity which secretes sanious pus ; the skin consti- 
 tuting its borders is red, inflamed, and separated from the tissue beneath. 
 These glandular abscesses, like the chancroid, sometimes become phagedenic. 
 
 Chancroid is variable in its duration, which is sometimes (juite short, last- 
 ing three, four, or five weeks ; at other times it continues several months, and 
 sometimes, if it is phagedenic, one or more years. 
 
 The Treatment of Chancroid. — While it has been for many years the 
 custom to cauterize freely all soft or suppurating venereal ulcers — i. e. all 
 sores diagnosticated as chancroid, Avhether situated in the genital regions or 
 elsewhere — the introduction into surgery of the principles of antisepsis, and 
 with them of such drugs as iodoform, has greatly modified this routine treat- 
 ment. It is safe to say that chancroids are neither so frequent nor so severe 
 as they were years ago, and that by the application of antiseptic methods to 
 their treatment a great advance has been made in the ease and certainty with 
 which they can be cured. 
 
 In a large majority of cases daily irrigation with sublimate solution of 
 1 : 500 or 1 : 1000, folloAved by free dusting with iodoform or by the applica- 
 tion of an ointment consisting of one and one-half drams of iodoform to one 
 ounce of carbolated cosmoline, will be followed by speedy cicatrization. If 
 these fail, the continuous application by means of pledgets of cotton or lint of a 
 lotion containing sublimate, boric acid, and peroxide of hj^drogen will often cure. 
 If, in spite of this, the sore deepens and extends, destructive cauterization with 
 fuming nitric acid or the acid nitrate of mercury is at once the safest and 
 speediest method of cure. 
 
 The objections to the cauterization of chancroids are as follows, and are 
 similar to those mentioned in relation to chancres : First. The pain to which it 
 gives rise. Second. The inflammatory action which follows, and which often in 
 the case of the male produces enough oedema and swelling to cause phimosis, and 
 thus to conceal the sore and prevent the proper application of remedies. Third. 
 The subsequent eff"usion of lymph, which is apt to cause an induration closely 
 resembling that of the true chancre, and thus greatly to obscure the diagnosis. 
 
 The general rule may be followed of meeting indications — that is. of using 
 sedative lotions, lead-water, or lead-water and laudanum, or sulphate of 
 zinc and opium — in the acutely inflamed, painful sores ; and of using stimulat- 
 ing washes — sulphate of copper, strong zinc solutions, nitrate of silver, etc. — 
 upon indolent, pale, and flabby ulcers. Special indications having been met, 
 iodoform will generally complete the cure. 
 
 SYPHILITIC BUBOES. 
 
 Almost at the same time that the chancre becomes indurated the lymphatic 
 glands, connected with it by means of the lymphatic vessels, undergo hyper- 
 trophy. The glands nearest to an infeccmg chancre become enlarged and hard ; 
 they roll readily beneath the skin ; they are painless and do not suppurate. These 
 clinical characters are unvarying. They are found in the groin when the chancre 
 is upon the external genitals ; in the submaxillary glands when the chancre is 
 upon the lips ; in the axilla when the chancre is upon the nipple or hand. 
 
156 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 The glands of tlie groin, *in connection with a cliancre upon the genital 
 organs, are successively involved, the gland first affected being the most interior 
 of the group upon the diseased side. When the chancre is situated at one side 
 of the frenum, it is not uncommon to find the buboes in both "roins, a cer- 
 tain amount ol decussation occurring between the lymphatics of the former 
 region. The inguinal glands are all hypertrophied, but are distinct one from 
 another, the skin remaining healthy. 
 
 About a month and a half after this enlarrrement of the glands near- 
 est to the chancre all the lymphatic glands of the body are successively 
 invaded, at least all those which are visible. They appear a little inflamed 
 before or at the same time with the eruption of the cutaneous syphilides. Prob- 
 ably all the glands of the economy are aifected, and cases of enlargement of 
 the glands in front of the sacral, lumbar, and dorsal vertebrae have been 
 reported. The subcutaneous glands affected by syphilis are the cervical, 
 maxillary, occipital, etc. Among the most important glands for diagnostic 
 purposes are the post-cervical, which do not enlarge from local causes so fre- 
 quently as the anterior chains of cervical lymphatics (glandulae concatenatse), 
 and which are therefore almost pathognomonic when they undergo painless mul- 
 tiple enlargement at about the period for the appearance of the early secondaries. 
 
 In syphilitic lymphatic glands the follicles of the delicate reticulated tissue 
 are hypertrophied, and occasion small lobulated projections upon their surface 
 when the capsule is removed. These glands remain more or less enlarged, 
 not only during the active period of the secondary lesions, but frequently after 
 the syphilides have disappeared. 
 
 The following tables Avill serve to contrast the buboes and lymphangitis 
 characteristic of the two chief forms of venereal sores : 
 
 Syphilitic Bubo. Inflammatory Bubo. 
 
 Always accompanies or follows infecting Occurs in only one-third of the cases of 
 
 chancre. chancroid ; occasionally, but more rarely, 
 
 in herpetic or balanitic ulceration or in 
 gonorrhea; may follow an infected wound 
 of the lower extremity. 
 
 Several glands involved, making a group or One gland implicated, rarely bilateral, 
 chain of small, movable glands in one 
 groin or often in both. 
 
 Appears soon after chancre. No definite time of appearance. 
 
 Slight enlargement. Great enlargement. 
 
 Cartilaginous induration. Inflammatory hardness. 
 
 No inflammatory symptoms. Always present. 
 
 Glands freely movable. Gland fixed (periadenitis). 
 
 Skin normal, not adherent. Skin red, adherent. 
 
 Painless. Painful. 
 
 Indolent, slow. Runs an acute course. 
 
 Terminates by resolution, rarely by suppura- Usually suppurates, rarely undergoes resolu- 
 tion, tion. 
 
 No marked tendency to phagedena. Phagedena not very uncommon. 
 
 No local treatment effective. Local treatment required. 
 
 Mercurial treatment hastens resolution. Mercury has no influence upon the condition. 
 
 Syphilitic Lymphangitis. Inflammatory Lymphangitis. 
 
 Lymphatic vessels feel hard, like the vas Same, but less hardness. 
 
 deferens ; size of a knitting-needle. 
 
 Painless to touch. Painful. 
 
 No pain on erection. Erection gives rise to pain. 
 
 Skin normal. Skin red over inflamed vessel. 
 
 Terminates by resolution. Resolution or suppuration. 
 
 Local treatment unnecessary and ineffective. Local treatment of great use. 
 
SYPHILIS. 157 
 
 SECTION II. : GENERAL SYPHILIS. 
 
 At about the time of the general lymphatic enlargement — and coincident 
 with or preceding the earliest eruption — we have a characteristic group of 
 symptoms — viz. : 1. Fever, varying fnmi 100° F. to 101° F., coming on toward 
 evening and associated with moderate anorexia and malaise. 2. MuHcidar <uid 
 artieidar j>(tiii)<, chietiy aft'ecting the muscles and joints of the chest, back, and 
 upper extremities, but sometimes very general and c^uite severe. 3. Alopecia, 
 not confined to the scalp, but involving the hairs of the whole body, distin- 
 guished from ordinary baldness by that fact, by the concomitant symptoms of 
 syphilis, and by the irregtdar, moth-eaten character of tlie bald spots. 
 
 Constitutional syphilis may be diagnosticated when an indurated genital 
 chancre is followed by a painless, hard swelling of the inguinal glands and of 
 others like the post-cervical, which are remote from the spot of local irritation. 
 The change of the lymphatic gland is so characteristic that from it alone the 
 diagnosis of syphilis is possible Avhen the cervical, maxillary, supratrochlear, 
 and other lymphatic glands are invaded, as well as those in the inguinal region, 
 and still more easily when the fever, pains, and alopecia are present. 
 
 SECONDARY SYPHILIS. 
 
 The eruptions of the skin and mucous membranes soon make 
 their appearance, and constitute the first manifestations of the secondary stage. 
 
 These syphilides usually appear about six weeks after the beginning of 
 the infecting chancre, sometimes sooner ; at other times later, even two or two 
 and a half months from the date of the chancre. They are seldom as late as 
 three or four months, yet in rare cases they have occurred after five months 
 have elapsed. Mercurial treatment, when given during the existence of the 
 chancre, has been accused of causing this retardation, and doubtless does so ; 
 but it must not be forgotten that the evolution of the disease is very variable. 
 
 Cutaneous and mucous syphilides are more superficial when they are more 
 recent, and grow deeper as they grow older. Thus the syphilides of the first 
 period of secondary lesions affect only the papillary surfate and epidermic lay- 
 ers. These are erythemata, or superficial spots, as roseola ; or limited, slight, 
 and temporary inflammations of the papillary and epidermic layers, as papules. 
 The older syphilides, on the contrary, belonging to the later secondary period, 
 appear as pustules or tubercles,^ which affect the deep cutaneous and subcuta- 
 neous layers in connection with the papillary network and epidermis ; they are 
 destructive and are followed by cicatrices. 
 
 A classification of syphilides similar to that adopted by Cornil and based on 
 their pathological histology is both useful and practical. It is as follows : 
 
 1st. Erythematous syphilides — erythema; macules; roseola. 
 
 2d. Papular syphilides — conical, lichen-like syphilide ; large papules. 
 — Patches of papulo-lenticular syphilide ; papulo-squamous. 
 
 3d. Pustular syphilides — acneiform; impetiginous; ecthymatous; rupial. 
 
 4th. Vesicular syphilides are very rarely encountered. Most so-called 
 vesicles met with in syphilis are in reality pustules, and result from the puru- 
 lent softening of the apices of papules. 
 
 5th. Gummatous and tubercular syphilides. 
 
 In this classification there is indicated the gradual passage of the superficial 
 lesions of the early period of secondary symptoms into the deeper and later 
 
 ' The word " tubercle " is often used to designate one of the eruptions of syphilis. It refers 
 simply to its visible characteristics, and does not mean that there is any infection with the bacilli 
 of tuberculosis. 
 
158 ^I^V AMimiCAN TEXT-BOOK OF SURGERY. 
 
 lesions of tlio second period, and finally into the rupia, tubercles, and gum- 
 mata of the third period. 
 
 Syj)liilides of the first period are almost always iioh/iitorjiliouH ; that is, the 
 eruptions j)resent at the same time the dift'erent varieties of roseola, papules, 
 and small pustules or squamous papules. In ordinary eczema or imjietigo we 
 have the same elementary lesion of the skin at all j)oints, and the same appear- 
 ance of all the regions affected ; but, on the contrary, there are found in syph- 
 ilis varied elementary lesions, spots of erythema alongside of papules and 
 vesico-})ustules, and other lesions modified according to their location. In 
 other cases there will be seen a papular syphilide in a somewhat chronic state ; 
 the papules when upon the skin of the limbs appear dry, their ej>idermis desqua- 
 mating. In those regions where the skin is in folds, as upon a dependent 
 mammary gland, the papule, instead of being dry, is moist ; upon the palm of 
 the hand, where the epidermis is corneous and thick, the epidermic layers 
 over the papule form hard scales, which have incorrectly been compared with 
 psoriasis. This polymorphous condition and the blending together of the 
 elementary lesions are among the best diagnostic characteristics of syphilides. 
 Syphilides of the late secondary period frequently involve all the layers of the 
 derm and epiderm, and are given compound names, as papulo-vesicular, papulo- 
 pustular, tuberculo-pustular, etc. — names which define themselves. 
 
 The syphilides have a coIoj- Avhich is said to resemble that of copper or of 
 ham ; this is owing particularly to extravasations of red blood-coi-puscles. and 
 is marked in the eruptions of the first period. The copper color is not seen in 
 lesions of the mucous membranes. Another distinctive characteristic of syph- 
 ilides, except diffused erythematous roseola, is that they all have a regularly 
 round shape, whether isolated or in groups. They form small circles, figures-of-H, 
 etc. Finally, the lymphatic glands are often affected in the region invaded by 
 the eruptions, and the action of mercury upon these eruptions is to cause their 
 rapid disappearance. 
 
 The earliest cutaneous symptom in syphilis is almost equally apt to be an 
 erythema or a roseola, the former a diffused mottling of the surface, affecting 
 chiefly the trunk and abdomen and without appreciable elevation ; the latter, 
 somewhat darker in color and apt to show a tendency to become papular. 
 Roseola may indeed be considered as an eruption intermediate between the 
 erythematous and papular syphilides. The diagnosis is usually easy, and can 
 readily be made from simple roseola, the roseola caused by copaiba, by expo- 
 sure to the atmosphere, by measles, by bites of insects, etc., if the patient be 
 examined Avith care, if enlarged lymphatic glands and mucous patches are 
 looked for, and, finally, if the special color of the papules and the history of 
 the case be remembered. 
 
 The papular syphilides may be small or large, and may be associated 
 with such an accumulation of epidermic scales as to receive the name of the 
 papulo-squamous syphilides. The first variety (small papules) has received the 
 name of lichen-like or miliary syphilide. The color of the papule is very clia- 
 racteristic. The elevation of the skin is due to a thickening of the papilhv and 
 epidermic layers ; but at the summit of the papule and over all the surface 
 forming it the most superficial layers of the corneous epidermis have desqua- 
 mated, while those at the margin of the papule are continuous with the normal 
 skin of the periphery. The papules remain a varying length of time ; they 
 usually disappear in three or four Aveeks when mercurial treatment has been 
 employed : at other times they continue for two and three months. They are 
 modified according to their location. The mucous patches corresponding to 
 this variety may be small and acuminated. Upon the scalp the eruption appears 
 
SYPHILIS. I'/J 
 
 as small pustules or papules covered with a yellowish or brown scab ; upon the 
 palmar surface of the hands the papules are covered with hard epidermic scales 
 or they are depressed and surrounded by a corneous epidermis. 
 
 The s,i'ond variety of papular syphi'lides is characterized by large papules, 
 havin«r a diameter of from half an inch to an inch, or even larger. In its 
 beginning a pimple is noticed with regular edges and pink surface, which soon 
 ass'umes tlie characteristic color, and upon which the most superficial layers of 
 the epidermis are desquamating ; at the periphery of the papule the des.iuama- 
 tion is arrested, and here is seen a thickened epidermic border. Ihe surface 
 of the papule is smooth and circular. "i i i • i 
 
 In the papular eruptions generalized over the entire body the skin where 
 thev are situated often becomes so thick as to warrant the term papulo-tuber- 
 culous ; thev unite and form large bands ; for example, upon the forehead- 
 corona wnem— or surround the mouth and ah« of the nose; they also form 
 circles upon the shoulders, neck, and trunk, and extend over the surface of the 
 limbs. Often, durins: the period of acme, they are covered with thick scales, 
 which may be removed in irretrular fragments by scratching ; this form is termed 
 papulosquamous. Their color is always very distinct, intense, deep copper-red. 
 The essential histological changes which enter into the formation of a 
 syphilitic papule are a hvpertrophy of the papillre of the skin, an increase m the 
 number of epithelial laVers which form the epidermis, and a proliferation ot 
 the cells of the rete inucosum. The blood-vessels are congested, and there 
 occurs an extravasation of the blood-elements into the tissue of the derm 
 which crives the characteristic coloration to the lesion. Desquamation of the 
 superficial layers of the skin is one of the features of the papule. The changes 
 are not limited to the papillae and superficial corium, but m some varieties 
 extend to the subcutaneous adipose tissue. There is no vascular sclerosis 
 comparable to that met with in the chancre. These changes are modified by 
 situation, duration, etc. vrc i rpx. 
 
 The diagnosis of a large papular svphilide is never very ditiicuit. Ihe 
 special color and the arrangement of the papules, the involvement of the palms 
 of the hands and soles of the feet, also of the palmar surface of the fangers 
 and plantar surface of the toes, the enlargement of the lymphatic glands, the 
 frequent existence of mucous patches, are all characteristic. The papular 
 svphilide is indeed the most distinctive of all, and the most common after rose- 
 ola. It is seldom that a svphilide with large papules continues less than two 
 months, and frequently it' remains three, four, or five months, especially it 
 mercurial treatment has not been employed at all or too timidly. There is no 
 form of medical treatment in which the curative power of a remedy is so evi- 
 dent and so admirable as in the use of mercury in cutaneous syphihdes, and 
 particularly in the severe forms of papulo-squamous eruption. 
 
 Mucous Patches.— A transformation of a syphilitic papule into a mucous 
 patch takes place whenever it is under the continuous influence of warmth, 
 moisture, and friction, as on a mucous membrane at a muco-cutaneous junction 
 or in the creases or folds of skin. Under these circumstances the overlying 
 epidermis or epithelium is macerated and disappears: the papule, originally 
 small, rapidly extends in superficial area; it becomes grayish or opalescent in 
 appearance i"f seated on a mucous surface ; red, smooth, and polished if on the 
 skin. In either case it is moist and has a free secretion, often oflensive. and 
 
 always highly contagious. ^ • i i ^ ^i • 
 
 The most common seats of mucous patches are, first, m the order ot their 
 frequency, the genital oraans and region of the anus. Their location varies 
 according to the sex. With women mucous patches of the labia and ot the 
 
IGO AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 vulva arc almost constant ; with men, on the contrary, they are not very 
 freciuently met with on the prepuce or glans, the most common seats being 
 the scrotum and anus. With women the anus is also frequently the seat of 
 mucous ])atches. 
 
 The /ifstologieal structure of nmcous patches consists in a thickening of 
 the epidermic layers and an increase in the size of the papillae of the skin by 
 a development of the elements entering into their structure. This increase in 
 size of the papilhx; causes a corresponding increase in the lengtli of the inter- 
 papillary prolongations of cells of the rete mucosum. The blood-vessels of the 
 papilljie are distended with l)lood. The tissue of the derm is found jirolifer- 
 ating. 
 
 Diagnosis of Mucous Patches. — It is almost impossible to mistake 
 a mucous patch after a number have been seen. They are formed upon a 
 papule — that is, an inflammatory swelling of the corium and papillae ; their 
 surface is oozing, and the epidermis or epithelium Avhich covers them is satu- 
 rated or desquamated. Thus, u])on the labia majora and minora there are seen 
 whitish patches or small points which resemble moist or pulpy paper, and 
 consist of epidermic cells or changed superficial epithelium ; upon a mucous 
 membrane, as on the lips or palate, the epithelium is whitish, opaline, resem- 
 bling a surface which has been touched with nitrate of silver. The mucous 
 patch, if eroded, has a surface Avhich is red and smooth after the superficial 
 epithelium has desquamated ; the shape of the patch is always circular or 
 regularly oval, and the derm is thickened upon its surface. The patches of 
 the vulva and k.bia majora, likewise of the anus and of the scrotum and scroto- 
 femoral folds, even when in process of healing are very distinct ; as the epider- 
 mis forms, the derm remains a little papular and the surface dull red. 
 
 The syphilitic papules, covered with thick superficial layers of corneous 
 epidermis — that is, with scales — are termed papuio-squamous syphilides. 
 They are generally very obstinate, since the layers of the epidermis repose 
 upon the thickened and chronically inflamed derm. These squamous papules, 
 covered with or deprived of their epidermic layers, when situated upon 
 the palms of the hands and soles of the feet, are called palmar or plantar 
 sypliilides. The papules are modified simply on account of their seat and 
 the structure of the skin of the hands and feet. Here the corneous epidermis 
 attains considerable thickness and resistance ; it forms a layer which at times 
 measures a millimeter in thickness and is dense and hard like parchment. 
 Thus it offers more or less resistance to the development of the papules, 
 especially at their beginning. Later, however, the epidermis covering the 
 papule is raised, cracked, and partly or completely eliminated, or it forms hard 
 and irregular stratifications. 
 
 With syphilitic papules, and at the same time with secondary syphilides, 
 there occurs a lesion allied to the lesions of the epidermis — viz. the changes 
 of the nails. 
 
 Syphilitic Onychia is a disease of the nails, the peculiarities of which 
 result from the anatomical structure of the matrix of the nail and of the peri- 
 and subungual papillo-epidermic tissue. There are described two varieties — 
 the dry and the moist. 
 
 The drt/ variety of onychia generally accompanies the papular and papulo- 
 squamous eruptions situated upon the fingers and toes, the ends of which are 
 attacked by papules, which pass around their extremities or may be seated at 
 the roots and edges of the nails or under them. Sometimes the nail is cracked 
 and readily broken ; it is dry and separated from the skin. Sometimes, when the 
 papules exist at the ungual matrix, there is a swelling of the skin at this region, 
 
1SYPHILIS. 161 
 
 and the formation of the epidermic hiyers of the nail is very much interfered 
 with. At times there is an irregular thickening of the nail by hard scabs, 
 which are stratified and occasion a dense, irregular elevation. 
 
 The moist variety of onycliia occurs with vesiculo-pustular or pustular 
 syphilides. Sometimes true whitlow is met with. 
 
 These conditions often terminate in tlie destruction of the nail, and neces- 
 sitate rest, antiseptic fomentations, and afterward some simple dressing'. 
 
 Pustular Syphilides. — The pustular syphilide is found in the form of 
 acne, of impetigo, or of ecthyma. Syj)hilitic acne is always early and super- 
 ficial. Impetigo and ecthyma may also occur in the first stages and without 
 any element of gravity, but in other cases, where they appear very early, may 
 be of graver import : during the later eruptions they assume a still more serious 
 aspect, and tend to rapid extension both in depth and superficial area, resulting 
 in pustulo-crustaceous ulcers, of long duration and of extent corresponding to 
 the amount of suppuration and the tendency to confluence of the lesions, which 
 are often accompanied by symptoms of general cachexia, and in exceptional 
 cases even terminate in death. 
 
 SyphiUtie acne is as much a papule as a pustule in its structure and 
 evolution. It forms a small conical projection, upon the top of which appears 
 a very slight epidermic elevation, caused by a small quantity of serous effusion, 
 which rapidly becomes purulent. The pustule is of short duration, and is soon 
 replaced by a little crust, and then by scales, leaving only a stain, Avithout 
 cicatrix. This eruption appears in successive crops upon the face, the shoulders, 
 the trunk, and thighs, in which latter situation the pustules are often confluent. 
 There are generally at least as many papules or papulo-squamous spots as well- 
 formed pustules, the papular elevation remaining after all traces of the pustule 
 have disappeared from its summit. It is an eruption of the early stages, and 
 behaves like the papular syphilide. It is distinguished from acne vulgaris by 
 its distribution — for it especially affects the belly and thighs, while acne vulgaris 
 is found on the face and shoulders — by its copper color and its greater dryness, 
 and by the absence of white permanent cicatrices. 
 
 Syphilitic impetigo appears in the form of little pustules covered by crusts 
 and resembling isolated pimples, or as patches formed by the union of many 
 pustules. The pustulo-crustaceous form is commonly found upon the scalp at 
 the same time that a syphilitic roseola or mucous patches have invaded the 
 general integumental surface. 
 
 The impetigo may be the predominant eruption, the scalp, face, and fore- 
 head being the points of election. The reason for the transformation of a 
 papular syphilide into the pustulo-crustaceous form upon the face and scalp is 
 found in the abundance of sebaceous glands with which those parts are supplied. 
 These glands, when involved in the inflammatory action, produce a papule; 
 upon the cutaneous surface their secretion is modified, and consists then of a 
 sebaceous liquid more or less intermingled with blood-corpuscles. As a result 
 there is seen either a w^ell-formed pustule, a sebaceous concretion, or a crust 
 upon the surface of the papule. 
 
 Usually the pustules are seated upon a reddish, copper-colored patch or 
 papule. When the eruption is confluent it covers large surfaces with scabs. 
 
 Syphilitic ecthyma may be superficial or deep. The former variety occurs 
 usually on the lower limbs, and appears as a large pustule with a thick dark 
 crust. It leaves behind it ecchymotic stains. 
 
 Deep ecthyma at first appears as a collection of pus under a large elevation 
 of superficial epidermis, as occurs in the variety already described. The pus- 
 tule is regularly circular ; the contents inspissate by evaporation, and form a 
 11 
 
162 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 crust ■which increases by the addition of successive layers. These crusts in 
 superimposed strata, greenish or brown in hue, imbricated like the shell of an 
 oyster, dry, resistant, are also met with in rupia, having the same configuration 
 and immediately suggesting syphilis. Under this crust, which continues to 
 enlarge antl thicken, the pustule itself extends in breadth and dejtth. The 
 crust overlaps tiie border of the ulcer, or, when the latter is the larger, is set 
 within it like a watch-crystal in its case. When it falls off there is disclosed 
 an ulceration extending to the papillae or even deeper into the skin. These 
 pustules are sometimes spread singly over a large portion of the body, most 
 fre(iuently the inferior extremities ; in other cases they are grouped in the form 
 of circles or crescents. 
 
 The diagnosis of syphilitic ecthyma from scrofulous ecthyma is frequently 
 difficult. The latter ulceration is often deep and with perpendicular borders, 
 as in the syphilides ; the crusts, however, in syphilis are drier, darker, and 
 more imbricated, the cachectic lesion suppurating earlier and more freely, con- 
 sequently permitting of less adhesion of the crusts. This is not an invariable 
 distinction, as in certain cases syphilitic ulcerations are attended with the 
 formation of large quantities of pus. When the eruption is distributed upon 
 the face and body as well as upon the limbs, the diagnosis of syphilis should 
 be made, as the ecthyma due to scrofula is observed only upon the inferior 
 extremities. 
 
 The history and concomitant symptoms almost always lead to a recognition 
 of the disease, as it is a persistent eruption, lasting for months or even for a 
 year, and often reappearing with all its original characteristics. It necessitates 
 a guarded prognosis on account of its persistence and of the continual suppura- 
 tion caused by it, especially when it is widespread. It is formidable also 
 because it indicates a grave form of syphilis, particularly when it appears soon 
 after the initial lesion. 
 
 Rupia manifests itself at first by large elevations of the epidermis filled 
 ■with a clear or bloodstained serum, soon becoming turbid and purulent. The 
 bulla bursts, allows some of the liquid to escape, and as it desiccates is covered 
 with a crust, which dries, accumulates new layers, and becomes imbricated with 
 brown and greenish strata, as in the variety of ecthyma just described. Rupia 
 is, of all the syphilides, the one attended with the largest, thickest, darkest, 
 and most characteristic crusts, as it is also the one presenting the most exten- 
 sive ulcerations. Under these crusts the papillary layer and the entire derm 
 are undergoing suppuration, as in the last two eruptions considered. 
 
 In the tubercles and gummata of the skin are seen the latest and 
 deepest manifestations of cutaneous syphilis. 
 
 Syphilitic tubercles and gummata have striking analogies. They appear 
 at the same stage of syphilis, are of the same clinical import, and are caused 
 by the same pathological changes ; the chief distinction being that the tuber- 
 cles are more superficial, only involve the derm, do not extend into the sub- 
 cutaneous tissue, and give rise to a less abundant cellular infiltration. 
 
 Tubercular syphilides represent deep and enormously swollen papules, 
 and are intermediate pathologically between the papule and the gumma. They 
 appear as single, flattened pimples, attended with an induration of the entire 
 skin, from the superficial epidermis to the deepest layer of the derm ; they are 
 sometimes solitary, sometimes in groups, and may be scanty or may be widely 
 extended. Their favorite situation is upon the face, at the mucous outlets, 
 upon the nose, ears, forehead, back, neck, and inferior extremities, especially 
 the legs. 
 
 There are two varieties, the dry and the ulcerating. The dry tubercular 
 
SYPHILIS. 163 
 
 svpliilide is usually copper-colored and covered with thick scales, almost crusts; 
 there may be no ulceration, and healing may occur, with the production of a 
 white or pigmented cicatrix, without any ulcerative process having taken place. 
 
 The ulcerative tubercular syphilides are more grave on account of the 
 abundant sup})uration caused by them. They may be isolated, but are usually 
 in groups, often very extensive. 
 
 Histologically, gummata and tubercles consist essentially in the forma- 
 tion of embryonal cells, which in the former, the gummata, occupy a position 
 deep in the derm, infiltrating all the tissues, and in some instances even involv- 
 in<^ the deeper structures, bone, cartilage, etc. The tubercles are similar in 
 their histological structure, but are limited more particularly to the skin, not 
 affecting the subcutaneous tissues. 
 
 The disease for which an ulcerating tubercular syphilide is most likely to 
 be mistaken is lupus vulgaris, which is a cellular new-growth due to infection 
 with the bacillus of tuberculosis, and results in various papular or tubercular 
 patches which are usually followed by ulceration. It has no relation with 
 syphilis, and should be carefully distinguished from it, as the treatment bene- 
 ficial in one case is useless or absolutely harmful in the other. The main 
 diagnostic points may be tabulated as follows : 
 
 Tubercular Syphilide. Lupus Vulgaris. 
 
 Occurs chiefly among adults. Occurs commonly in young persons ; when 
 
 in adults there is often a history of a 
 similar eruption in childhood. 
 Considerable infiltration of skin. Not so marked. 
 
 Tubercles opaque and of a deep brownish- Tubercles often translucent and lighter in 
 
 red color. color. 
 
 The characteristic ulcer produced in a month The same amount of ulceration would require 
 or two. several months or even years for its devel- 
 
 opment. 
 Ulcers usually distinct. Ulcers apt to be confluent. 
 
 Ulcers deep and extensive. More superficial and involving smaller area. 
 
 Ulcers small, circular, punched out. No regular form or perpendicular edges. 
 
 Secretion copious, sometimes ofi'ensive. Secretion slight, inofl"ensive. 
 
 Crusts bulky, greenish. Crusts thin and dark-colored. 
 
 Scales irregular in shape and attachment. Scales arranged more regularly, attached in 
 
 the centre and loosened at the edges. 
 Cicatrices soft, white, circular. Cicatrices distorted, irregular, puckered. 
 
 History and concomitant symptoms of syph- No such history except as a coincidence. 
 
 ilis. 
 Local treatment inefi"ective. Internal spe- Eruption disappears only under very active 
 cific treatment effects a cure, local treatment, as curetting, or under the 
 
 influence of tuberculin. 
 
 Gummata of the skin make their appearance at variable intervals after 
 the contraction of syphilis ; sometimes very late — twenty or thirty years after 
 the chancre — sometimes, on the contrary, very early, during the first year, or 
 €ven in the first four or five months ; this occurs in the grave and abnormal 
 varieties of the disease ; most frequently they develop three or four years after 
 the chancre. The favorite localities are the face, scalp, shoulders, neck, arms, 
 thighs, and legs, but they may appear in any region of the body. 
 
 Cutaneous gummata are inflammatory tumors of the subcutaneous tissue — ■ 
 the cellulo-adipose connective tissue— which terminate by discharging exter- 
 nally : they cause a loss of substance to great depths, more considerable in 
 extent at the bottom than at the cutaneous orifice, the disintegrated tissue 
 being slowly throAvn off like the core of a furuncle. 
 
 in the development of a gumma there are four jJeriods, which include the 
 processes of formation, softening, ulceration, and repair. The first period 
 
164 AN AMEBIC AN TEXT- BOOK OF SUBCERY. 
 
 is of lon^ duration, and. as the tumor is painless, the patient usually discovers 
 it by chance as a rounded or slii^htly flattened nodule seated deeply beneath 
 the skin, which latter is slightly raised The nodule is movable in the sub- 
 cutaneous tissue, is bard, consistent, and gives rise to no subjective symptoms. 
 The tumor grows slowly until it acquires a volume varying from one centimeter 
 in diameter to that of a hen's egg. Ordinarily it lias a diameter of from one- 
 half to three-quarters of an inch. The skin over the surface of the gumma 
 remains normal, until suppuration begins. After a time the tumor softens, 
 becomes doughy, and then Huctuation takes place. Soon the skin reddens, 
 grows thin at the most prominent point, and is finally perforated. Tlie small 
 circular opening gives exit at first only to a small quantity of purulent or 
 gunnny liquid ; an open gumma not resembling in the least a discharging 
 abscess. The gumma does not at once empty itself when it is opened. The 
 inflamed connective tissue adheres by its deeper portions to the subcutaneous 
 cellular tissue, which is thrown off in the form of small sloughs. Granulations 
 forming at the bottom soon fill the cavity, the solution of continuity is repaired, 
 and cicatrization takes place. The resulting cicatrix is depressed, often 
 adherent to the deeper tissues or to the bone itself. 
 
 The clinical characteristics of the group of cutaneous syphilides may 
 be stated as follows : 
 
 1. General or constitutional symptoms are usually' absent, Avith the excep- 
 tion of the syphilitic fever which precedes or accompanies the early eruptions. 
 
 2. Additional evidences of syphilis will usually be found, and should be 
 carefully searched for — the chancre, its cicatrix or its induration, the buboes, 
 sore throat, baldness, mucous patches, etc. — if an early eruption be in ques- 
 tion ; osteocopic pains, nodes, and other bone-lesions in the later stages. 
 
 3. The eruptions, especially the early ones, are apt to be polymorphous, or 
 to present at the same time a variety of forms of cutaneous lesion, macules, 
 papules, and pustules being usually intermingled. This is due to the chronic, 
 slow evolution of the disease, which permits of the development of new symp- 
 toms during the gradual fading of previous ones. 
 
 4. The patches of eruption are apt to have a rounded or crescentic form, 
 due to the anatomical arrangement of the cutaneous capillaries, and when 
 seated upon the extremities occupy the side of flexion — the anterior surface of 
 the forearm, the palm of the hand, the sole of the foot, etc. 
 
 5. The characteristic color of the syphilitic eruptions is a yellowish-red, 
 usually described as " coppery." Its peculiar dusky tint is due to the absence 
 of the active hyperemia and arterial excitement which usually exist in the non- 
 specific eruptions, the color of syphilides being the result of slow changes in 
 the coloring matter of the blood which has exuded under pressure, and not the 
 accompaniment of acute inflammation. 
 
 6. There is an absence of pain and itching which is very distinctive, and 
 which is also due to the non-inflammatory character of the eruption. It is quite 
 common to find patients who are not aware of the presence of an extensive 
 syphiloderm until their attention is directed to it by the surgeon. 
 
 7. The early eruptions are superficial, general, and symmetrical, indicating 
 by these characters the infection of the blood to Avhich they are due. During 
 their evolution the disease is transmissible by contagion. 
 
 8. The early eruptions are frequently scaly, the pressure of the cell-prolif- 
 eration, which is always present, cutting off the supply of nutriment to the 
 superficial epidermic layers, which accordingly dry, desiccate, and are exfoliated. 
 
 9. The scales are Avhitish, superficial, and usually not adherent, there being 
 nc plastic or inflammatory exudation to fasten them to the subjacent part. 
 
SYPHILIS. ICO 
 
 10. The later eruptions are not contagious, are irregular in distribution, 
 extend to the cutis vera or beneath it into the connective tissue, and are 
 described as local lesions or as sequehc following the acute or secondary stage, 
 and due either to relapses in parts previously diseased or to new-growths result- 
 ing from changes effected by syphilis. 
 
 11. The later eruptions have thick, irregular, or imbricated crusts, often 
 occur in groups, and leave scars even if no ulceration has occurred. 
 
 12. Ulcers resulting from the breaking down of syphilitic deposits have 
 rough, abrupt edges, are irregularly crescentic or circular in shape, covered 
 with an unhealthy greenish-yellow secretion, and, as a rule, are painless. 
 
 13. The cicatrices caused by syphilis are at first pigmented, then whitish, 
 shining, rounded, or radiating, and depressed below the level of the surround- 
 ing surface ; they often show very small apertures, the sites of pre-existing 
 follicles. 
 
 14. The therapeutic test in all very doubtful cases is an extremely valu- 
 able one, although it should be necessary to resort to it only in extremely 
 exceptional instances. The amenability of nearly all the cutaneous symp- 
 toms to w^ll-directed specific treatment often renders this test very conclusive. 
 
 The tertiary lesions of the mucous membranes are characterized 
 by growths occupying tlie deeper portion of tlic mucous membrane or extend- 
 ing beyond it, and by gummata identified with those just described. They 
 are nearly always ulcerative, but are not covered by crusts, owing to the facility 
 with which the accumulated secretions are detached from the surface. Thus, 
 in cases where upon the skin there would be a scab, upon the mucous membrane 
 there is found an ulcer discharging pus more or less freely. Like the deep 
 syphilodermata, they are limited and localized, for, as the disease grows older, 
 instead of being extended and superficial and symmetrical, it becomes limited 
 to a special locality and deeply involves and destroys its tissues. 
 
 The most important mucous membranes affected by tertiary lesions are the 
 tongue, soft palate, and pharynx. 
 
 Tertiary Syphilis of the Mouth. — The most important of the late man- 
 ifestations of syphilis in this region are the gummata of the tongue, which may 
 be either submucous or muscular in their origin. 
 
 The submucous gummata are of the size of a pea or a cherry-stone, single 
 or multiple. They begin as small, hard tumors, and their softening, their dis- 
 charge through a small aperture, their excavated appearance and characteristic 
 base, do not diff"er from those of other gummata : this is also true of their dura- 
 tion and of their mode of healing. 
 
 The muscular gummata are larger: they may occupy either the lateral 
 or median aspects of the tongue, or may afiect its tip, its base, or its edges. 
 They reach the size of a hazel-nut. They open by what is first a very nar- 
 row channel, which enlarges or extends in the direction of the muscular fibers. 
 
 In these aff"ections of the tongue it is rare to find enlarged cervical or sub- 
 maxillary lymphatic glands, and the same is true of gummata of the pharynx. 
 
 The differential diagnosis of syphilitic diseases of the tongue is one of some 
 importance, especially in regard to non-syphilitic aifections which simulate them. 
 Gummata of the tongue may be mistaken only for tubercular ulcers or for epithe- 
 liomata. From tubercular ulcers it would be difficult, if not impossible, to make 
 a diagnosis from the character of the ulcer alone. The sides and edges of ulcer- 
 ating tubercles often .show, however, a few small yellow points with opaque 
 centers, which are tubercular granulations undergoing caseous degeneration. 
 These latter are finally thrown off" by ulceration, and are never seen in syphilis. 
 The evolution of tubercles of the tongue is entirely diff"erent from that of gum- 
 
106 
 
 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 mata. The gumma bcfrins as a single mass, submucous or muscular in position, 
 opening after a time by a contracted passage, ulcerating, and discharging like a 
 furuncle and having a sloughing base. The tubercles, on the contrary, begin 
 on the surface as small nodules. V>y the union of many of these a large, irreg- 
 ular ulcer is formed, slower in its evolution than a gumma. As it extends in 
 depth there are successive eruptions of tubercles, too minute to be detected by 
 the naked eye, and situated between the muscular fibers. The ulcer has jagged 
 edges and usually suppurates less than the gumma. In cases of doubt the chest 
 should be carefully examined, as pulmonary tuberculosis often exists at the 
 same time. The family history may also aid in the decision. 
 
 Lingual epithelioma may always be detected by microscopic examination 
 of the fragments of tissue from the cancerous ulceration, large pavement-cells 
 and epidermic nests being found. In addition, the epithelioma never becomes 
 stationary or recedes, that of the tongue being especially grave and rapid, often 
 running its course and terminating in death in a year or eighteen months. 
 
 The diagnosis between ulcerating epithelioma of the tongue and ulcerating 
 gumma of the tongue has been tabulated by Fournier, as follows : 
 
 Epithelioma. 
 
 Chiefly affects persons between fifty and sev- 
 enty years of age. 
 
 Often a history of cancer in near relatives or 
 ancestors. 
 
 No history of syphilis. 
 
 The appearance which has been described as 
 "lingual psoriasis" often precedes the 
 cancerous disease. 
 
 Is generally single and confined to one side.' 
 
 Is sometimes found on the under surface of 
 the tongue. 
 
 Begins as a hard swelling upon the surface 
 of the organ, and ulcerates rapidly and 
 superficially : sometimes begins as a fissure 
 or ulcer, without previous swelling or in- 
 duration. 
 
 Induration follows cancerous ulceration. 
 
 No cavity resembling that of an abscess. 
 
 Surface bleeds when touched or spontane- 
 ously. 
 
 Edges turned outward, with the border ele- 
 vated, irregular. 
 
 Secretion profuse, offensive, irritating. 
 
 Lancinating pain, often darting toward the 
 ear, thought to be pathognomonic. 
 
 Great disturljance of deglutition, mastication, 
 speech, etc. 
 
 General cachexia supervenes. 
 
 Microscopic examination shows the charac- 
 teristic ingrowing of the interpapillary 
 epithelium, the large squamous cells, 
 pearly bodies, and other histological pecu- 
 liarities of epithelioma. 
 
 Submaxillary lymphatic glands progressively 
 enlarged and indurated. 
 
 Specific treatment useless or harmful. 
 
 Gumma. 
 Is apt to occur at an earlier period of life. 
 
 No such history, as a rule. 
 
 Such history almost always obtainable. 
 Nothing which resembles this has been seen. 
 
 May Vjc multiple and bilateral. 
 
 Never seen except upon the dorsum or side 
 of the tongue. 
 
 Begins as a rounded mass beneath the sur- 
 face, and then opens like a furuncle, leav- 
 ing a hollow, deep ulcer. 
 
 Induration precedes ulceration. 
 
 An excavation like an abscess-cavity. 
 
 Ulcer covered by an irregular slough which 
 does not bleed. 
 
 Edges abrupt, perpendicular, "punched out," 
 sharply defined. 
 
 Secretion moderate, not so apt to be offen- 
 sive. 
 
 Painless or nearly so. 
 
 Tongue much more mobile ; functional trou- 
 bles not so marked. 
 
 No cachexia. 
 
 The microscope shows an infiltration of the 
 part by embryonal cells in various stages 
 of granular degeneration. 
 
 Glands not involved, or, at the most, a little 
 
 swollen and tender. 
 Specific treatment curative. 
 
 Gummata of the soft palate, or of the palatine arch, usually result in 
 a perforation of the palatine bones, causing a communication between the oral 
 and nasal cavities. These gummata are slow and insidious in their onset. 
 
SYPHILIS. 167 
 
 The patient experiences no pain or discomfort. The soft palate is red, thick- 
 ened, and either noduhir in its entirety or at one j)oint. The in(hiration and 
 thickening may be felt with the finger. 
 
 If the patient be asked to utter sounds renuiiiiii:- tlic assistance of the 
 soft palate for their production — ah, for example — wiiilst the throat is 
 being examined, it will be seen that the palate is elevated incompletely or 
 not at all. 
 
 The immobility of the palate is a valuable symptom, and, taken in conjunc- 
 tion with the induration, the thickening, and the prominence often presented 
 by the gumma itself, permits of an early diagnosis, Avhich it is especially import- 
 ant to make as soon as possible in order to avoid perforation. If the patient 
 be left without treatment, the gumma ulcerates and discharges, and if it be of 
 the kind above mentioned, involving both the anterior and posterior mucous 
 surface, complete perforation of the palate will follow with great rapidity, often 
 taking place in a single day or night. 
 
 A gumma of the soft palate does not invariably give rise to perforation, 
 especially if mixed treatment (see p. 176) be at once commenced. It may affect 
 only one surface of the palate, and then it will heal Avithout interfering with 
 function. There may be even a small but complete perforation at the moment 
 of the evacuation of the gumma, Avhich will entii'ely heal. 
 
 Syphilis of Muscles. — Muscular syphilis is rare; it may manifest itself 
 by contraction due to myositis, which at first appears to be idiopathic, as it is 
 not accompanied by tumors or changes in size or apparent lesions ; in other 
 cases gummata develop in the interior of the muscles. 
 
 Syphilitic contracture of the muscles is chiefly an affection of the mus- 
 cles of the arm, and more particularly of the biceps. It appears about six 
 months to a year after the chancre. The first symptom is a stiffness of the 
 elbow. Gradually extension becomes more and more limited, and the forearm 
 remains flexed upon the arm at an angle varying from a large obtuse angle to 
 one quite acute. No tumors or inequalities of surface are discoverable : if the 
 muscle be examined during forced extension, it is found prominent and like a 
 tightly-drawn cord. 
 
 It has been denied that this affection has any essential relation to syphilis, 
 and it has been attributed to rheumatism, to traumatism, and to other causes. 
 The weight of evidence is, however, in fiivor of its syphilitic origin ; nine out 
 of ten cases observed by Mauriac had a distinct history of syphilis and were 
 accompanied by unmistakable eruptions, chiefly papular and papulo-squamous. 
 He believes it to be a subacute myositis. In every one of six cases reported 
 by Notta syphilitic symptoms were present. In none of them was there any 
 association with rheumatism. 
 
 Grummata of muscles have a more important significance than these simple 
 contractures. They consist of tumors, often of considerable size, which may 
 discharge externally, may give rise in various ways to serious results, and may 
 even invade the caVdiac muscles. The tongue appears to be the muscle most 
 frequently affected, and those of the sides and nape of the neck are often 
 involved. Murchison has recorded a case of gumma of the diaphragm. Some- 
 times, instead of distinct tumors, a general infiltration occurs. White has seen 
 a case in which all the posterior cervical muscles, including the trapezius, were 
 thus infiltrated. Mixed treatment effected a rapid cure. 
 
 Syphilis of the Bones. — Among the most important and most common 
 late effects of syphilis are the osseous lesions, which are often of much gravity. 
 Both in adults and in children affected with hereditary syphilis the order, the 
 seat of the lesions, and even the anatomical condition of the diseased bones, 
 
168 >1^V AMERICAN TEXT-BOOK OF SURGERY. 
 
 are so characteristic that the diagnosis of syphilis is rendered easy. Osseous 
 syphilis is met with during any of the periods of the malady. 
 
 The determining cause of the osseous lesion and of its seat, in tertiary as 
 in secondary syphilis, is generally some form of traumatism, which is usually 
 slight, but fre([uently rei)eated at the same point. It is owing to this fact that 
 the superficial bones, as the frontal bone, clavicle, sternum, radius, tibia, etc., 
 are the most common seats of the disease. Only the lesions of adults are here 
 referred to. In cases of infiintile syphilis traumatism is not the determining 
 cause ; the active development of the bones sufiiciently accounts fur the local- 
 ization of the disease. 
 
 Tlie lesions of the bones from an anatomical point of view are very numerous, 
 varying from simple periostitis and osteitis to gunnnata ; their final consequences 
 also vary from the development of exostoses to tlie formation of sequestraj in 
 pus-cavities. 
 
 The following lesions may be successively described : 
 
 1. Simple osteo-periostitis. 
 
 2. Rarefying osteitis. 
 
 3. Intense rarefying osteo-myelitis or gummatous osteo-periostitis. 
 
 Then the consecutive lesions of these difierent states, which are : formative 
 osteitis or eburnation, the exostoses, the necroses, and the sequestrse ; and 
 finally the osseous lesions of infantile syphilis. (See p. 184.) 
 
 1. Syphilitic osteo-periostitis does not differ materially from ordinary 
 osteo-periostitis. Limited to the superficial layers of the bone and the perios- 
 teum, it most frequently occurs at the end of the secondary or in the tertiary 
 period, attacking the tibia, clavicle, sternum, bones of the head, etc. 
 
 2. When the inflammation is more intense there occurs a rarefying oste- 
 itis. The subperiosteal inflammation extends into the Haversian canals ; the 
 subperiosteal tissue and the osseous marrow contain numerous small cells with 
 transuded red blood-corpuscles. These elements are free, with a small amount 
 of granular intercellular substance. The original bone is eroded or destroyed. 
 This lesion, which is observed so often in diseases of the phalanges and short 
 bones, is named ^pina ventom. It is frequently a result of syphilis. 
 
 3. Gummatous osteo-myelitis and gummatous osteo-periostitis 
 are nothing; more than a rarefvino; osteitis in which the abundant subperiosteal 
 embryonal tissue or the medullary tissue assumes the arrangement tliat is 
 observed in the gummata. The lesions are seen in the form of tumors, vary- 
 ing in size and having a tendency to become caseous. Gumma of bone is 
 thus merely a circumscribed osteo-periostitis with destruction of the osseous 
 lamella; by a rarefying osteitis. It is the localization and form of the lesion 
 which sive it its distinctive characters. 
 
 The histological changes of the osseous tissue, as met with m the various 
 forms of syphilitic lesions of the bones, therefore resemble similar lesions due 
 to other causes. In osteo-periostitis there is a proliferation of the cells within 
 the Haversian canals or the medullary elements of the bone which causes an 
 increase in the size of these canals, the marrow itself becoming embryonic in 
 nature. A continuation of this same process in a more intense degree results 
 in the absorption of the osseous tissue, an enlargement of the Haversian canals, 
 an increase in the amount of embryonal marrow, or, in brief, a rarefying oste- 
 itis, which in syphilis constitutes a gumma ; that is, a gumma of bone is a local- 
 ized intense osteo-periostitis in Avhich there is a destruction of the osseous 
 trabecule by the formation of granulation or embryonal tissue, which later 
 undergoes retrograde metamorphosis and absorjjtion. The bone in which the 
 gumma or rarefying osteitis has been developed after the absorption of the 
 
SYPHILIS. 109 
 
 gummatous tissue takes on reparative action, and there occurs a formative 
 osteitis, in which there is a new formation of osseous tissue, the process 
 resembling that of the physiological (lovelopment of bone. This process con- 
 tinuing, there results a condensing osteitis of the part, in which the daminje 
 surrounding the Haversian canals are increased to such an extent as finally to 
 obliterate the lumina of the canals and cause a sclerosis or eburnation of the 
 bone. An exostosis is nothing more than a slow formative osteitis, which 
 results in the gradual addition of new osseous layers to the original bone ; if 
 the process becomes active there is produced an eburnation of the new-formed 
 bone, or if very intense there occurs that form of osteitis known as rarefying, 
 and if still more active there may even be a complete destruction of the" new 
 osseous tissue. It is thus seen that the several lesions occurring in bones, and 
 due to syphilis, are, to a great extent, the continuation or stages of one process 
 which varies in its intensity and results. 
 
 Symptoms of Syphilitic Osseous Lesions. — The osseous lesions of 
 syphilis are not ahvays recognized during life, but in ordinary cases, when 
 subcutaneous bones are involved, the symptoms are well marked. 
 
 The essential symptoms of syphilitic osteo-periostitis are pain and swellincr. 
 The pain is peculiar in that it is more intense during the night than during 
 the day. It is very acute at times. It prevents sleep, and by its persistence 
 may become of considerable gravity. The slightest touch to the tumor causes 
 exquisite suffering. After two or three days' treatment with iodide of. 
 potassium it is usually relieved and often is entirely removed. 
 
 The symptoms of syphilitic osteitis are very variable, depending upon the 
 bone affected and its connections. They differ, of course, very much with the 
 variations in form of the lesions, which, as has been explained, mav vary 
 from a simple swelling of the periosteum and bone to the suppuration and 
 necrosis with fistulous tracts met with in intense gummatous osteo-periostitis. 
 
 The most simple and most frequent cases are those of osteo-periosteal 
 tumors of the superficial bones — the tibia, clavicle, sternum, frontal bone. etc. 
 The nodular swelling, the single or multiple nodes of differing size, and the 
 special pain upon firm pressure or upon percussion, are all characteristic. The 
 pain occurs spontaneously during the early part of the night, before retiring. 
 
 The periostoses of the clavicle are readily seen on account of the position 
 of the bone, and most frequently are oval in shape, with their long axes parallel 
 to the long axis of the bone. 
 
 Osteo-periostitis of the anterior surface of the sternum and of the bones of 
 the cranium, Avhen recent, generally appears as a flattened swelling, varying 
 in size and of the shape of the segment of a sphere. It is then elastic to the 
 touch, and may disappear under mixed treatment. Later, when an osseous 
 formation is developed around its circumference, it feels hard at the margins, 
 while its central part is relatively soft. 
 
 As regards bones in general, the differences between syphilitic and tuber- 
 cular inflammations may be stated as follows : 
 
 Syphilitic Osteitis. Tubercular Osteitis. 
 
 Syphilitic osteitis occurs in persons in vary- Osteitis of tuberculosis occurs in persons 
 ing physical conditions. Avho have other symptoms of this disease. 
 
 Begins most frequently in the periosteum. Begins in the medulla. 
 
 Tends to the formation of new bone or to Tends to disintegration of the parts, 
 necrosis. 
 
 Is often unaccompanied with suppuration. Generally terminates in the formation of pus. 
 
 Does not involve neighboring articulations. Apt to do so. 
 
 Frequent in bones of the cranium. Almost never found in this situation. 
 
170 AX AM KN /('AN TEXT-BOOK OFSlRdKRY. 
 
 Syphilitic Osteitis. Tubercular Osteitis. 
 
 Histoloj^ically, consists of a rolutivcly large Made up of a varying nuiiil)cr of tu])crcle- 
 mass of granulation-tissue. granulations ami surrounded by isolated 
 
 granules. 
 
 In the majority of eases can be cured, or at We know of nothing sliort of ojx'rativc in- 
 least arrested, if taken in time, by judi- terferenee which materially affects the 
 cious speeilic treatment. course of this disease. 
 
 Syphilitic dactylitis occurs at various periods of tlio disease, and in two 
 varieties. One of these aj)j)ears usually in the hite seeonchiry stage, and 
 involves eliieliy the ])eriosteuni and the fibrous and integumentary tissues 
 surrounding a joint. It is characterized by slow, almost painless, swelling and 
 discoloration of the affected member. This is due to a gummatous infiltration, 
 which, upon subsiding, leaves tlie fiiiger or toe temporarily stif!", but not 
 perm an en t ly d i sa b 1 cd . 
 
 The second form is a specific osteo-myelitis Avitli accompanying inilammation 
 of the periosteum, and appears from five to fifteen years after the infection 
 with syphilis. It is chiefly limited to the bones and periosteum, the integu- 
 ment being but seldom involved ; erosion of the articular cartilages often takes 
 place ; the ligaments and the capsule become thickened, and the function of 
 the joint is sometimes entirely lost. 
 
 The absence of acute symptoms in the subcutaneous variety enables us to 
 diagnosticate it from paronychia, Avhitlow, and gout, l^heumatoid arthritis 
 begins in the joints, is associated with other sjnnptoms, deformity of the fingers 
 comes on early in the disease, and the sheaths of the tendons are involved. 
 
 The second variety might be taken for enchondroma or exostosis, but 
 these swellings involve only a limited portion of the bone, increase very 
 slowly, and present dense, circumscribed tumors. 
 
 Syphilis of the Nervous System. — The dura mater is frequently 
 the seat of tertiary syphilis, chiefly owing to its intimate connection with the 
 cranial bones, toward which it bears the relation of a periosteal lining. The 
 internal surface of this membrane, in contact with the pia mater and m ith the 
 surface of the brain, is frequently attacked at the same time — an accident 
 which manifests itself by various cerebral symi)toras : intense cephalalgia, 
 trembling, dulness, intellectual torpor, loss of memory, and coma. 
 
 Besides these peri-encephalic lesions, the pia mater, and even the brain- 
 substance and the spinal cord, may be the seat of sclerosis or of gummata. 
 
 The pia mater presents two varieties of lesions: A chronic inflammation, 
 followed by fibrous thickening and by adhesions to the surface of the brain ; 
 and gummata, lesions much more characteristic than the foregoing. 
 
 Cerebral gummata may be found in two forms: 
 
 1st. As large gummatous masses developed on the surface of the brain 
 within the convolutions and in the gray substance or encroaching upon the 
 white substance, and usually attacking the base, the cerebral peduncles, the 
 pons Varolii, and the optic tract. They are also found upon the cerebellum 
 and upon the superior surface of the cere])nnn. 
 
 2d. In the form of smaller nodules accompanying the cerel)ral arteries, and 
 in particular the middle cerebral arteries. 
 
 These two varieties of syphilitic lesions do not differ materially as regards 
 their structure ; their evolution is slightly different. The latter are generally 
 accompanied by endarteritis, which results in a limited anemic softening of 
 the brain. 
 
 Symptoms of Cerebral Syphilis. — The symptoms depending upon the 
 
SYPHILIS. 171 
 
 different alterations of tlie meninges, of the hrain, and of the vessels diff"er, it 
 is needless to say, according to the region of the brain which is affected by 
 them. The lesions of the dura mater, of the pia mater, and often those of the 
 cranial bones, coincide with gummata or with more or less extended softening in 
 such a manner that nudtiple manifestations have to be analyzed and explained. 
 Despite these dilliculties, the progress of these encephalopathies, a certain num- 
 ber of characteristics whicli appertain to them, and, in doubtful cases, the ante- 
 cedents of the patients and trial of the iodide treatment, will ordinarily indicate 
 their nature. 
 
 The most common initial phenomenon is headache, which is frontal, occipi- 
 tal, or parietal, very intense, often worse during the night, and accompanied 
 fre(iuently by vertigo and mental dulness, and sometimes by convulsions. This 
 pain is at times intolerable, or, on the contrary, there may be a stupor resem- 
 bling coma. The headaclie may last for a long time before any other symptom 
 shows itself. If syphilis has been suspected from the antecedents of the patient, 
 and iodide of potassium has been given with the result of lessening the pain or 
 causing it to cease, the diagnosis is assured. During the headache the patients 
 often experience a diminution of their intellectual faculties, forgetfulness of cer- 
 tain words or of their actions of the day before, etc. Diff'erent forms of paral- 
 ysis supervene. They are at first very limited. The nerves at the base of the 
 cranium are those most frequently attacked. The paralysis of muscles sup- 
 plied by the common oculo-motor nerve produces, for example, external strabis- 
 mus, diplopia, etc. The diminution of the sense of taste, and even its complete 
 abolition, the loss of the sense of smell, the diminution or the loss of hearing, 
 have also been noted. The disturbances of vision are exceedingly variable, 
 and depend upon the seat of the lesion — whether it is localized in the cuneus, 
 in the optic tracts before their intercrossing, at the optic chiasm, or upon the 
 optic nerves beyond the chiasm. Subjective symptoms are observed, such as 
 muscce volitantes, circles of fire, etc., the perception of only a portion of objects, 
 hemianopsia, or a partial or total loss of vision. These conditions are fre- 
 quently cured by iodide of potassium. 
 
 The partial paralysis first shows itself in a limb — in the lower extremity 
 of one side, for example — and is followed by amelioration if iodide of potas- 
 sium employed in time has produced its curative action ; if the lesion contin- 
 ues its progress, complete hemiplegia may supervene. This is generally pro- 
 gressive, slow at the commencement, with incomplete aphasia, especially if the 
 paralysis is on the right side. These cases of hemiplegia are not accompanied, 
 like those of copious hemorrhages or of apoplectiform softening, by a total loss 
 of consciousness. Patients preserve, on the contrary, to a great extent, their 
 consciousness, as is the' case in certain forms of cerebral softening, and the 
 paralysis affects only the power of motion. Finally, along with several other 
 phenomena connected with the intelligence or the poAver of motion, convulsive 
 symptoms often predominate — veritable attacks of epilepsy. 
 
 The diagnosis of cerebral syphilis is based less upon the symptoms 
 taken singly or in groups than upon the progress of the affection and upon the 
 therapeutic action of iodide of potassium. An intense headache of long dura- 
 tion, which is cured or benefited by the iodide, but relapses, and which is accom- 
 panied by loss of memory, hebetude, slight paralysis ; then a paralysis very 
 slow in progress, ending in hemiplegia, aphasia, and epileptiform convulsion, — 
 such are the symptoms upon which the diagnosis is established. These symp- 
 toms are slow in showing themselves, and they grow more intense very 
 gradually. At their commencement they are benefited or cured by the 
 iodide of potassium. Each of them presents some characteristic peculiar to 
 
172 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 syphilis in such a way that recognition of the cause is possible in the great 
 majority of cases. The diagnosis from apoplexy and softening is generally 
 easy. The sudden onset of an attack with absolute loss of consciousness and 
 complete hemiplegia excludes the idea of syphilis. It is more easy to confuse 
 it with chronic softening ; but in syphilis there are the violence of the head- 
 ache, the effects of the iodide, the epileptiform convulsions, and especially the 
 presence of old syphilitic lesions. Cerebral tumors are easily confounded 
 with syphilis, but the consideration of cerebral tubercle is unnecessary, as 
 it is an aft'ection of infancy. Sarcomata might be mistaken for gummata; 
 however, they are exceedingly rare, and the symptoms which characterize them 
 are progressive, without its being possible to benefit them by the iodide treat- 
 ment. 
 
 The prognosis of cerebral syphilis is very grave. 
 
 Syphilis, wlien it affects the spinal cord, may involve the meninges by 
 a specific pachymeningitis, or the cord itself may be invaded by gummata 
 originating either in its substance or in the membranes. The symptoms 
 are those connected with pressure upon or degeneration of the cord itself, and 
 the diagnosis is to be made chiefl}'^ by the presence of concomitant lesions of 
 syphilis or by the effects of treatment. The interesting question of the rela- 
 tion of locomotor ataxia to syphilis is not yet settled, but there is enough 
 evidence to justify the following recommendations : 
 
 In every case of ataxia careful and minute search should be made for 
 evidences of antecedent syphilis, either acquired or inherited. If this be found 
 to have existed, the patient should be placed at once upon vigorous specific 
 treatment, and should be directed to continue it through long periods. If only 
 a fair presumption of previous syphilis exist, the same treatment should be 
 employed, as it would, at the most, be useless, but not hurtful. If the disease 
 be recognized in its earliest stages, and found to be associated with s^^philis, 
 and treated in this manner, a prognosis may safely be given of a more favor- 
 able character than at present seems justifiable in any other variety or under 
 any other mode of treatment. 
 
 Unlike cerebral syphilis, in which the question of operative treatment is 
 often discussed, syphilis of the intestinal tract in the a<lult has little interest 
 for the surgeon. The involvement of the liver, and especially that of the 
 spleen, in newborn children are of great diagnostic importance, but will be fully 
 considered in the chapter on Hereditary Syphilis. 
 
 Syphilis of the respiratory tract is of greater surgical interest and 
 importance, on account of its relation to the larynx, where it may simulate 
 carcinoma or tubercle. 
 
 Some help in the diagnosis of tertiary Tilcers of the larynx from those of 
 pthisis and cancer may be found in the points which have been tabulated as 
 follows : 
 
 Syphilis. Phthisis. Cancer. 
 
 Development of ulcer acute, Development slow ; follows Intermediate in time ; ap- 
 
 occupying only a few days. throat symptoms after sev- pearance of ulcers in a 
 
 eral months. few weeks. 
 
 Considerable irregular in- Uniform, pale swelling, look- Nodular excrescences and 
 
 flammatory or oedenuitous ing like an infiltration. acute inflammation of 
 
 swelling. neighboring mucous mem- 
 brane. 
 
 Epiglottis aflected, if at all. Lower surface. No uniformity. 
 
 on upper surface. 
 
 Ulcer solitary ; rarely more Numerous. Solitary, 
 than two. 
 
^SYPHILIS. 
 
 173 
 
 Syphilis. 
 
 Proceeds from center to 
 periphery, or from above 
 downward. 
 
 Deep, round, or oval. 
 
 Diameter of 1 to IJ centi- 
 meters. 
 
 No cachexia. 
 
 Treatment usually highly 
 beneficial. 
 
 Phthisis. 
 The reverse is true. 
 
 Generally round. 
 2 or 3 millimeters. 
 
 Phthisical appearance. 
 Treatment has but 
 moderate effect. 
 
 very 
 
 Cancer. 
 
 Irregular in their course. 
 
 Irregular in shape. 
 2 or o millimeters. 
 
 Cachexia. 
 No eSect. 
 
 Syphilis of the Testicles. — Syphilitic lesions of the testicles may consist 
 in gummatous nodules of the epididymis, wiiich appear at the end of the sec- 
 ondary period, or later in orchitis, which may be either interstitial or gum- 
 matous. There is also a syphilitic interstitial orchitis of newborn children. 
 
 Grummata of the Epididymis. — Toward the end of the secondary period 
 there is occasionally observed upon the epididymis a limited induration, gen- 
 erally at its head, varying in size from that of a bean to that of a walnut or 
 larger, connected with the testicle, hard and indolent. More rarely it is situ- 
 ated upon the body of the epididymis. It may be uni- or bilateral. There 
 is no accompanying affection of the tunica vaginalis or of the skin. The 
 tumor very soon disappears under treatment by mercury and iodide of 
 potassium. 
 
 Interstitial Orchitis. — Interstitial orchitis of the adult belongs to the period 
 of the later tertiary lesions. It seldom occurs before the third year. It may 
 affect one or botli sides. The testicle is the seat of a chronic interstitial inflam- 
 mation. The epididymis is seldom affected ; if it be involved, it is its head 
 that is changed. At the beginning of interstitial orchitis the gland is a little 
 larger than normal, but its shape is retained. If the disease is not treated, 
 the gland gradually atrophies, still remaining indurated. There is frequently 
 a notable effusion into the tunica vaginalis, which is inflamed. 
 
 The following table clearly presents the main points of difference between 
 syphilis, encephaloid carcinoma, and tubercle of the testicle : 
 
 Syphilitic Orchitis. 
 Syphilitic history. 
 
 Usually occurs at about twen- 
 ty-five or thirty years of 
 age. 
 
 Begins in the testicle. 
 
 Is situated primarily in the 
 connective tissue. 
 
 Tends to fibrous overgrowth. 
 
 Slow in its progress. 
 Skin of the scrotum rarely 
 involved. 
 
 Ulceration or suppuration 
 
 rare. 
 Fistulae uncommon. 
 A feeling of great weight, 
 
 with only such pain as 
 
 results from dragging on 
 
 the cord. 
 
 Encephaloid Carcinoma 
 
 of Testicle. 
 No history of any special 
 
 condition. 
 Any age. 
 
 Begins in the body of the 
 organ. 
 
 Begins by the deposit of 
 small nodules in the semin- 
 iferous tubules. 
 
 Tends to formation of patches 
 of softened, white, pulta- 
 ceous material. 
 
 Kapid in its course. 
 
 Skin of the scrotum finally 
 involved. 
 
 Ulceration and fungus com- 
 mon. 
 
 Fistulas common. 
 
 Pain severe and lancinating 
 in advanced stages. 
 
 Tubercular Orchitis. 
 Tubercular history. 
 Not often seen after thirty. 
 
 Begins in the epididymis. 
 
 Exists primarily in the 
 tubules. 
 
 Tends to fatty, caseous, or 
 purulent degeneration. 
 
 Slow in its progress. 
 
 Skin involved only just be- 
 fore the formation of ab- 
 scess. 
 
 Suppuration common. 
 
 Fistulae common. 
 Little pain. 
 
174 
 
 A.y AMKRICAX TKXT-JIOOK OF SriiCEnv. 
 
 Syphilitic Orchitis. 
 Tumor very lianl, unilonii. 
 
 Skin of scrotum iiuridi-sh, 
 l)ut unafrt'ctcd. 
 
 Of moderate size ; rarely ex- 
 ceeds twice its normal 
 diameter. 
 
 Painless on pressure. 
 
 Both testicles often affected. 
 
 Fungus rare. 
 
 No discharge or bleeding. 
 
 Lasts many years. 
 
 Curable. 
 
 No involvement of inguinal 
 glands as a rule. 
 
 Encephaloid Carcinoma Tubercular Orchitis, 
 of Testicle. 
 
 Soft and fluctuating. At first hard, knotty, irregu- 
 
 lar. 
 Network of large veins over Skin congested . but other- 
 surface of tumor. wise unair»'iti-il. 
 
 Attains jfreat size. 
 
 Painless on pressure. 
 
 General!}- only one testicle 
 affected. 
 
 Fungus alwa^'s present in 
 advanced stages. 
 
 Bleeds freely ; offensive dis- 
 charge. 
 
 Rarely extends beyond twen- 
 ty months. 
 
 Usually fatal. 
 
 Inguinal, iliac, and lumbar 
 glands and cord affected. 
 
 Of moderate size. 
 
 Often painful on pressure. 
 Often both testicles affected. 
 
 Fungus common. 
 
 Not so apt to bleed ; dis- 
 charge not so offensive. 
 Lasts several years. 
 
 Generally incurable. 
 Usually no inflammation of 
 triands. 
 
 TKEAT-MENT OF SYPHILIS. 
 
 Serum-therapy has been employed in the treatment of syphilis, but the 
 results are not encouraging. Scrum of animals which are naturally refractory 
 to syphilis has been tried (lambs, horses, dogs, rabbits). A'icrviorovsky has 
 injected the blood-serum of robust individuals who had passed through the 
 secondary stage. Ricliet and Hdricourt injected an ass with the blood of 
 a man with secondary syphilis, and subsequently used the ass's serum in the 
 treatment of active syphilis. Gilbert and Fonrnier conclude that some few 
 cases have been improved by serum-treatment, but that many others have 
 not been benefited by it. 
 
 The prejudice which for many years existed against the employment of 
 mercurials in syphilis has largely disappeared. A careful and impartial review 
 of the testimony as to the results of the mercurial and of the non-mercurial 
 treatment of syphilis will prove convincingly the far superior efficacy of the 
 former method. Without denying that certain cases of syphilis do well without 
 any treatment or with simple attention to hygiene, diet, etc., or even while admit- 
 ting that in the majority of instances at the present day the disease tends to a 
 spontaneous cure, it may still be considered as well established that, without 
 detriment to health, the probability of that cure can be increased and the 
 duration of the active stage of the malady lessened by a careful administration 
 of some form of mercury. Similar, though not quite so conclusive, evidence 
 exists in favor of a continuous as opposed to an intermittent plan of treatment, 
 although various circumstances may render the latter desirable. The reasons 
 which have been advanced for the employment of mercury in syphilis are — 
 
 1. The clinical evidence of its usefulness in the control of early symptoms 
 and the prevention of later developments. 2. Its "tonic" action, which, l)y 
 counteracting the anemic tendencies of syphilis, lessens the severity of the 
 disease. 3. Its action as a physiological antidote to the syphilitic poison, which 
 it destroys probably through its antibacterial or germicidal power. 4. Its 
 properties as a promoter of destructive metamorphosis and fatty degeneration, 
 through which it renders possible the absorption and removal of the new cell- 
 growth which cau.ses the secondary symptoms. 
 
 With regard to the beneficial influence of the iodides in the later stages, 
 a therapeutic fact established beyond all possibility of contradiction, a similar 
 
SYPHILIS. 175 
 
 diversity ot" opinion ;is to their mode of action prevails. A tonic eflect is 
 again claimed as one of the causes of the good results obtained by the admin- 
 istration of these preparations. The views held as to their melius operandi 
 will depend upon the ])artieular theory of the tertiary stage which is adopted. 
 However this may be, the clinical evidence is <{uite sufficient to justily the 
 emph^yment of these drugs, and the })ropev methods of administering them may 
 be epitomized as follows, beginning witli the a])pearance of the initial lesion: 
 
 1. Do not employ mercurial treatment until either by confrontation or by 
 the development of constitutional symptoms the diagnosis of syphilis is assured. 
 Mercury always retards the appearance of the secondary symptoms, and some- 
 times prevents it altogether. As no venereal sore can with al)solute certainty 
 be pronounced syphilitic, it is unwise to add an element of uncertainty to the 
 case by delaying indefinitely the outbreak of unmistakable symptoms. There 
 is sufficient evidence to prove that the subsequent course of the case is not 
 materially affected by this delay. 2. When the time has arrived for the admin- 
 istration of mercury, it is well to explain to the patient the necessity for long- 
 continued treatment and to point out the risks of neglect. Having done this, 
 in the majority of cases the most satisfactory method of giving the drug will 
 be by the mouth, a useful preparation being the protiodide of mercury in pill 
 form, in the dose of ^ to |^ of a grain, three or four times daily : 
 
 I|i. Hydrarg. iodid. vir., gr. xx ; 
 
 Confect. rosae, q. s. 
 
 M. et ft. pill. no. Ix. 
 
 If these should disagree with the stomach and produce dyspeptic symptoms, or 
 should give rise to colicky pains and diarrhea, from -Jg- to -^ gr. of opium may 
 with advantage be added to each pill. At the same time a saturated solution 
 of chlorate of potassium should be given as a mouth-wash, to be used twdce 
 daily as a prophylactic against salivation. 3. To ascertain the proper dose ol 
 the drug in each individual case, continue gradually to increase the dose until 
 slight tenderness of the gums or of the posterior molars is noticed. Then dimin- 
 ish it to two-thirds, or even to one-half, of that dose, when its further adminis- 
 tration for an indefinite period will be possible with no unpleasant results. 4. 
 If the preparation selected agrees with the patient and controls the symptoms, 
 and if there are no intercurrent complications, pursue this treatment contin- 
 uously for two years. If, however, the protiodide gives rise to persistent 
 bowel trouble, as it does in a small number of cases, substitute for it the 
 bichloride in solution or in combination with a tonic : 
 
 I^. Hydrarg. chlorid. corros., gr. iss ; 
 Tinct. cinchonse co., f§iv. 
 
 M. et sig. One teaspoonful in water after meals. 
 
 Hydrargyrum cum creta in one-grain doses four to six times daily is a very 
 useful preparation in cases of gastro-intestinal irritability. A half-grain to a 
 grain of Dover's powder added to each dose will often control any tendencv to 
 diarrhea. In some cases of irritable stomach, or when it becomes desirable to 
 intensify the mercurial influence, inunction should be employed, and it is a 
 useful addition to the routine treatment of every case of svphilis. If once 
 in six weeks or two months the administration of mercurv'bv the mouth be 
 intermitted and a dram of mercurial ointment rubbed into different portions 
 of the cutaneous surface once daily for a week, it intensifies the mercurial 
 influence without affecting digestion or nutrition. The uncleanliness of 
 the procedure and the almost certain eczematous ir^-itation of the skin 
 
17G AN AMERICAN TEXT-BOOK OE SURGERY. 
 
 which it pro(hiees render it unsuitahle for loii<i;-coMtinnc(l use. Vapor 
 hat/is of" mercury may be taken in various "ways, the simplest being the 
 vohitilization by means of an alcohol lamp of a dram of calomel, the 
 a])paratus being placed beneath a chair upon -which the patient sits, a 
 blanket extending from his shoulders to the ground serving to retain the 
 fumes in contact with his body. 5. By whatever method the mercurial 
 influence is kept up, the dose should be temporarily raised whenever new 
 symptoms make their appearance, and, after they have vanished, should be 
 dropped to the standard dose for the particular patient. 0. The local treat- 
 ment of symptoms is of secondary importance, and altogether subservient to 
 the constitutional treatment. It may, however, be useful as an adjuvant. 
 Mucous patches should be treated with sulphate of copper or nitrate of silver 
 if on mucous membranes ; when on cutaneous surfaces they sli.iuld be dusted 
 with powder of starch and calomel or of calomel and lycopodium. The scaly 
 and tubercular syphilides will be benefited by the application of a salve con- 
 sisting of equal parts of citrine ointment and cosmoline, or by ammoniated 
 mercury and cosmoline, two drams to the ounce, or by any other stimulating 
 and absorbent ointment. Ulcers may be dressed with iodoform, or, when 
 sluiTJzish, touched with nitrate of silver or acid nitrate of mercurv. Enlarged 
 glands may be painted with iodine or let alone ; they rarely run on to sup- 
 puration. 7. At the end of two years small doses of iodide of potassium 
 should be added to the mercurial, and this "mixed treatment" should be 
 persevered in for six months longer. If during this period any symptom of 
 syphilis makes its appearance, the six months of mixed treatment should be 
 dated from that time. In other Avords, some such formula as this : 
 
 I^ Hydrarg. biniodid., gr. ij ; 
 Potass, iodid., sij ; 
 
 Syr. sarsaparillae co. 
 Aquae, da. fSiij- 
 
 M. et sig. A dessertspoonful in water after each meal, 
 
 should be administered for the last six months of the treatment, and should be 
 recommenced and continued for six months if any symptoms appear later. 
 Great care should be taken to give the mixture largely diluted, and so to vary 
 it as to do away as far as possible Avith any irritation of the intestinal tract. 
 In obstinate tertiary conditions the dose of the iodide may Avith impunity be 
 run up to twenty, thirty, or sixty grains, or even more, four times daily. If 
 this be done, the cases Avhich refuse to come under its control Avill be very 
 rare. 8. At the end of two and a half years the patient should be kept under 
 observation for another full year, and if during that time no symptoms are 
 developed, he may consider himself as in all probability cured. If such symp- 
 toms do appear, however, he sliould recommence treatment, and should con- 
 tinue it for at least six months after their subsidence. 
 
 CHAPTER XVIII. 
 HEREDITARY SYPHILIS. 
 
 The most important points bearing upon the general subject of hereditary 
 syphilis may be enumerated as follows : 
 
 I. Is syphilis transmissible in all its stages (a) to the wife or husband, or 
 
HEREDITARY SYPHILIS. 177 
 
 [h) to tlie oftspring ? In otlier words, is it ever proper to consent to the mar- 
 riage of a person who has had syphilis? If so, under what circumstances? 
 
 II. By what means or througli what cliannels can the disease of the parente 
 reach the chikl? 
 
 III. What are the pathology and symptoms of hereditary syphilis? 
 
 IV. What is the treatment — {a) prophylactic, applied to the parents, 
 (6) curative ? We shall take these up seriatim. 
 
 I. Is Syphilis Transmissible in All its Stages? — No more important 
 questions can be submitted to the surgeon than those pertaining to the marriage 
 of syphilitics. Involving as it does the welfare of many individuals, modify- 
 in <t or fixing the conditions of one or more lives, his opinion should be excep- 
 tionally definite and well grounded. 
 
 There are two distinct methods of arriving at an answer to the question 
 under discussion : First, by considering the probabilities in regard to the essen- 
 tial nature of syphilis ; and second, by carefully weighing the clinical evidence 
 in the matter. It seems evident that belief in any particular theory of syphilis, 
 assi^^nino- it to this or that class of disease, must have an important influence in 
 determining the opinion which is held as to its curability, or, at least, as to its 
 indefinite transmissibility. 
 
 In- regard to the first, the main point is the recognition of the fact that 
 modern syphilographers, as a rule, regard the tertiary or late symptoms as 
 indicative" of damage done during the active period — as relapses or sequelae, 
 and not as fresh outbreaks of a highly contagious and transmissible disease. 
 Their time of appearance, their entire want of symmetry, their non-contagious- 
 ness, their non-inoculability, all favor this view, and much corroborative evi- 
 dence may be obtained from clinical facts. 
 
 It is necessary to admit that there seems to have been but little doubt in 
 the minds of many syphilographers that in rare instances syphilitic children 
 have been born to parents who had long passed the limits of the secondary 
 period. At least, the majority of writers upon this subject speak confidently 
 of the exceptional occurrence of such cases, and assert that syphilis may be 
 transmitted during any of its stages. If, however, we look for positive evi- 
 dence in this respect, we shall find very little that is entirely satisfactory. 
 Cases are reported, to be sure, in which eight, ten, tw^elve, or even fifteen or 
 twenty years after the primary sore, syphilitic patients have become the parents 
 of children who showed unniistakable indications of the disease. When we 
 examine the history of these cases, we find usually that many important points 
 have been omitted without Avhich it is impossible to be certain of their true 
 character. Were both parents originally affected ? If not, has a recent case 
 of syphilis occurred in the one who at first escaped ? If they were both dis- 
 eased originally, has either been subsequently re-infected ? — a much more fre- 
 quent accident than has been commonly supposed. On applying these tests 
 it will be found that few if any are thoroughly convincing. 
 
 Fournier, whose immense experience and acuteness of observation entitle 
 his opinion to the utmost consideration, says that in cases of paternal heredity the 
 duration of the power of transmission never exceeds, at the maximum, three or 
 four years. Of the many hundreds he has observed, in no case has he known 
 a syphilitic father to infect a child — the mother being healthy — at a later period 
 than the one mentioned. And he is equally positive that the gradual diminu- 
 tion and final extinction of the syphilitic reaction of the parents upon the chil= 
 dren constitute a veritable pathological law, "absolutely demonstrated." Mr. 
 Hutchinson says : " It is almost an acknowledged law that parents in the late 
 tertiary stages do not transmit tnint." 
 
 12 
 
178 AN AMi:in(A.\ 'nixriiooK of srncKHY. 
 
 Those ((notations indicate what is now the prevailinir view — viz. that tlie 
 period of transniissibility of" syphilis is more or less strictly limited even when 
 the disease is allowed to pro<;ress without treatment. As to the fact that it 
 becomes milder with time, so that with each succeeding; year after the termina- 
 tion of the secondary period the chances of escape of the product of c<iiiception 
 increase in a rapidly au<:mcntin^ ratio, there is no difference of opinion whatever. 
 Neither is it seriously disj)iited that the length of time during which the disease 
 remains active, as well as the degree of its activity, may be markedly influ- 
 enced by treatment. Under proper medication patients who have married in 
 the height of the secondary period have had children born healthy who never 
 subse<iuently manifested any symptoms of the disease. 
 
 We may therefore assume safely that syphilis after a certain period, not 
 extending nmch over four years Avliere the disease is alloAved to run its own 
 course, and probably somewhat reduced by treatment, ceases to be a contagious 
 disease, and at about the same time or somewhat later loses, in the majority 
 of cases, its capability of being transmitted by parent to offspring. As there 
 are ])robably exceptions to the rule that this power of transmission disappears 
 spontaneously within any specified time, it is never safe to trust altogether to 
 nature, but a vigorous and sufficient specific treatment must be employed. 
 
 Given, however, the lapse of a sufficient time — say from three to four years 
 as a minimum — and the history of a proper and continuous plan of treatment, 
 the risks of marriage are so reduced as to warrant a careful surgeon in permitting 
 it. And, conversely, of course in any doubtful case Avhere such a history can 
 be elicited, and Avhere all these precautions have been observed, it is improba- 
 ble that any taint of syphilis has been transmitted. Beyond this in positive- 
 ness it is not safe to go. There may be exceptions to these as to most other 
 hygienic or therapeutic rules, but they will be of excessive rarity. 
 
 Before considering the methods by which syphilis can reach the child from 
 one or the other of its parents, it may be well to mention the modes in which 
 the parents can infect each other. 
 
 The man can derive syphilis from the woman only in the usual way — /. e. 
 by contagion through a breach of surface permitting of the direct absorption 
 of the poison, the development of the disease being attended by the usual phe- 
 nomena — chancre, lymphatic enlargement, skin eruptions, etc. The woman 
 may — and in the majority of cases does — acquire the disease from the man in a 
 similar manner. But the mother may also become infected through the medium 
 of the child, which receives its syphilis directly from the father, the mother up 
 to the time of conception having escaped contagion. More than this, it appears 
 to be highly probable that no woman ever bears a syphilitic child and remains 
 herself absolutely free from the disease. 
 
 No surgeon of large experience in this class of cases can fail to have seen 
 some in which the husband, having had syphilis and having married after an 
 insufficient interval or an imperfect course of treatment, has infected his wife 
 with the disease, although at the time no discoverable symptom is to be found 
 upon his body. An ecjually careful inspection of the woman will also in such 
 cases be attended by negative results as regards the primary sore, and yet she 
 will be found with immistakable evidences of constitutional syphilis. There is 
 a clue to all such cases which Avill immediately resolve the difficulty. In every 
 instance, provided that no mistake has been made and that both husband and 
 wife are really free, the one from any contagious lesion, the other from any 
 evidence of a present or previous primary sore, it will be found that pregnancy 
 has occurred; that the woman has either been delivered of a syphilitic child or 
 has had an abortion or miscarriage at some time before the outbreak of the 
 
J I /•; /.' i:i> iTAin- sYi'JuiJs. i " 9 
 
 symptoms of syphilis. Another arfrumcnt lies in tlie application to the case 
 in ( uestion of the well-known " law of Colics," which, from the date of its 
 first enunciation in 1887 down to the present day, has heen found to be 
 absolutely without exception. It may he fjiven in his own won s : 'One 
 fact well "deserving our attention is this: that a child horn of a motlier who is 
 without obvious venereal symptoms, and which, without being exposed to any 
 infection sul)sequent to its birth, shows this disease when a few weeks old,— 
 thi^ child will infect the most healthy nurse, whether she suckle it or merely 
 h-uidlc and dress it ; and yet this child is never known to infect its own mother, 
 even thou.^h she suckle it while it has venereal ulcers of the lips and tongue. 
 As to the" absolute and unvarying truth of this law there is not a shadow 
 of doubt. There can be but one rational explanation of these tacts— viz. 
 that the mothers who have thus acquired immunity have done so by hrst 
 acquiring the disease through pregnancy. /ix t .u^ 
 
 We may conclude, then, that the husband may infect his wife— (1) in the 
 usual manner or by direct contagion ; (2) through the medium of the child, or 
 at any rate by the production of conception. _ 
 
 There is no proof whatever that the semen of a syphilitic man is contagious 
 or can transmit the disease in any way but that above discussed. On the con- 
 trary, it has been shown experimentally that it is entirely non-inocu able 
 AU'other theories as to methods of contagion are so entirely hypothetical and 
 unsupported bv trustworthy evidence that we can aflord to disregard tlienu 
 
 II. We may now consider the ways by which syphilis reaches the 
 child. These may be broadly classified into— 
 
 1 Descent from father; 2. Descent from mother ; -3. Direct infection. 
 
 1 As a matter of course, the influence of the father upon the child, so far as 
 recrards heredity, ceases at the moment of conception, or, to be more exact no 
 subsequent condition of the male parent, no development or acquirement of 
 disease, can exert any further effect. That the existence of active s> phil.s in 
 the father mav result in the transmission of the malady to the chdd cannot be 
 doubted. The relative effect of paternal as compared with maternal influence 
 may be considered after we have described the latter. 
 
 2 Descent from the mother may occur theoretically in consequence of— 
 
 a. Infection of the mother previous to conception; b. Infection of the 
 mother at the moment of conception; c. Infection of the mother during the 
 
 period of utero-gestation. . . . ,. ,, _ • i-..!^ 
 
 a As to the first of these methods of transmitting the disease there is little 
 if any difference of opinion. Even those who claim the most for paternal 
 influence include among the conditions which may give rise to svphdis m the 
 child disease of the ovule, and it may be stated as incontrovertible t^at ecent 
 or active syphilis in the mother at the time of conception will almost ceitamly 
 be followed by syphilis in the child. The cases in which treatment of the 
 father has resulted in healthy children, whereas without treatment he pro- 
 created syphilitic children, the mother being without either symptom or treat- 
 ment hSe been urged as' evidence of the direct descent of -f ^;"; 
 father to the child without the intervention or participa ion of the mother 
 But it does not follow because the mother has latent or hidden ^vp^^ibs hat 
 she must infect her child. In those cases in which she does not do so he t eat 
 ment of the father will remove the only active source of ^yP^^^l^^^^,. "f^^^.^X 
 b. The second method, or that in which the mother becomes syphilitic at the 
 moment of conception, is. strictly speaking, an example of paternal heredity 
 Tthe resulting germ is syphilitic, not because the ovule of he mother was 
 infected, but on account of the disease of the spermatozoid of the fathei. 
 
ISO AN AMEJUCAX TKXT-nnOh' OF SI'RC.'KJn'. 
 
 c. There remains for consideration the influence upon the child of a syph- 
 ilis acquired by tlie mother during some period of utcro-frestation. That under 
 these circumstances the child can become infected has been and is still abso- 
 lutely denied by some very respectable authorities. All that is necessary for 
 proof of its occurrence is, however, (1) freedom of both parents from syj)hilis 
 at the time of conception, or, in other ■words, syphilis must have been acc^uired 
 by both — not alone by the mother — after the beginning of pregnancy ; (2) 
 that the syphilis of the child be unmistakably prenatal — that is, not acquired 
 by some accident during or after birth. Several cases reported by acute 
 observers seem to combine both these requisites, and, after reading them 
 carefully, there seems to be no reasonable escape from the conclusion that in 
 some manner the poison of syphilis may find its "way from the mother to the 
 child. The old idea that the latter was directly infected in utero from the 
 semen of the father is, of course, altogether without foundation. 
 
 3. Direct infection of the child during birth does not properly come under 
 the head of Hereditary Syphilis. There is no possible reason why, when the 
 mother has contagious lesions of the genitals, acquired too late to infect the 
 child in utero, this shoukl not occur, but as a matter of fact no such case has 
 ever been recorded. One explanation of this circumstance may be found in 
 the protective covering of vernix and mucus Avhich coats the infant's body and 
 lessens greatly the risk of absorption. This hardly accounts satisfactorily, 
 however, for the entire absence of such cases from medical literature, and it is 
 fair to suppose that in all except those cases in which the primary sore is ac- 
 quired during the last month of gestation — Avhich for obvious reasons are ex- 
 cessively rare — the infant acquires some immunity which protects it from its 
 mother, and is similar to that which, under Colles's law, operates in her favor. 
 In other Avords, even though apparently free from syphilis at birth — a not un- 
 common event, as we shall see — it has a latent or modified syphilis which pro- 
 tects it from contagion. (Profeta's law, see p. 140.) 
 
 We may now briefly restate the conclusions at which we have arrived : 
 
 1. After a certain interval, not less than four years, and after thorough 
 specific treatment, a person Avho has contracted a syphilis not especially severe 
 or malignant in its type may be permitted to marry. The assent to marriage 
 will then be based on a belief in the curability of syphilis or in a cessation of 
 its contagiousness, its inoculability, and, in the vast majority of cases, its 
 transmissive power, at the end of the secondary stage. 
 
 2. It may be inherited from either parent or from both, and the ])robability 
 that this will occur increases in a direct ratio with the nearness of the time of 
 conception to the date of their infection with the disease. The severity of 
 the inherited disease in the child increases in the same proportion. 
 
 3. It is undoubted that, tlie father being healthy and the mother syphilitic, 
 the child may, and in all probability will, have the disease. 
 
 4. It is probable, but less so than in the preceding case, that, the mother 
 being healthy and the father syphilitic, the child will be infected. 
 
 5. It is highly probable that in all cases where a child becomes syphilitic 
 through paternal influence the mother is also the subject of syphilis, which 
 may, however, assume a latent form, the only evidence of its presence in a 
 few cases being the protection which it affords against contagion through the 
 medium of the child. 
 
 6. Syphilis may be transmitted from mother to child even when it is ac- 
 quired by the former as late as the seventh month of utero-gestation. 
 
 III. The Pathology and Symptoms of Hereditary Syphilis.— 
 Syphilis of tlie placenta is of especial interest in its relation to the abortions 
 
HEREDITARY SYPHILIS. 181 
 
 ami stillbirths so tVe(jueiit in syi)liilis. V wnvx the iiilluoiice of tliat disease cell- 
 proliferation begins in the villi, which are normally only sj)arin<5ly supplied with 
 cells, and extends to the connective-tissue stroma and the epithelium. This 
 proceeds to such an extent that it leads to compression of the vessels, and finally 
 ol)literates them. The vascular spaces into which the villi dip become filled 
 up and narrowed, and often disappear. In this way, and also by reason of 
 the thickening of the epithelium, the interchange between the maternal and 
 the foetal blood is interfered with, and at last is prevented. If this process is 
 spread over the whole placenta, the foetus perishes before it is complete. If it 
 is limited to circumscribed areas, it may live for a shorter or longer period. 
 
 Syphilis in the parents will manifest* itself in the children in one of several 
 ways, which are determined chiefly by tAvo factors — viz. first, the length of the 
 interval between the infection of the parent and the date of conception ; and, 
 second, the thoroughness of the treatment of the parents during that interval. 
 To these may be added as subsidiary, but still of definite importance, a third, 
 the type of disease which has affected the fiither or the mother, whether mild 
 or severe, benign or malignant. 
 
 From what has already been said in reference to the question of marriage, 
 it will at once be understood that the danger to the offspring in untreated 
 cases, and in those where conception has occurred during the early secondary 
 period of the disease, is of extreme gravity. In such cases the usual result 
 of pregnancy is abortion at from the first to the fifth or sixth month, the foetus 
 sometimes exhibiting the evidences of syphilis in the shape of large bullae 
 upon the palms and soles, or in the presence of characteristic visceral lesions, 
 but quite as often showing nothing distinctive. It has generally undergone 
 more or less maceration, and the skin, which is readily detachable, is of a con- 
 gested, purplish color. At least one-third of syphilitic children are dead-born. 
 As time goes on and other pregnancies follow, either the abortion occurs at a 
 later period of pregnancy or the children are brought alive into the world. 
 Even then, however, and although at birth they may show no evidences of 
 the disease, their chance of escape is but small. One-fourth of them die within 
 the first six months. If they survive that period, the chances for life are 
 slightly in their favor, but those for health or for freedom from deformity and 
 disease are still overwhelmingly against them. 
 
 The Primary Stage is never found in true hereditary syphilis. Of 
 course in congenital or infantile syphilis, in which by direct contagion, 
 either from the'' mother or from any one else, the disease was acquired by the 
 child, the course would not differ materially from that observed in the adult, 
 and the primary sore would be present. But as this stage of acquired syphilis 
 corresponds to the period during Avhich the poison is finding its way into the 
 system through the lymphatics, it is not found in the child who is infected from 
 the moment of conception or who receives the poison from the mother directly 
 into the circulation. 
 
 The Secondary Stage. — For from one to three weeks the newborn 
 infant often shows no symptoms of the disease. In 158 cases collected by 
 Diday, 86 manifested symptoms before the expiration of the first month, and 
 60 of the remainder before the end of the third month. When to these are 
 added the statistics of Roger, we find that of a total of 172 cases 159 showed 
 syphilitic symptoms before the end of the third month. When these symptoms 
 are present at birth, they consist largely in a general withered, atrophied, 
 weazened appearance of the child ; a hoarse cry, due to swelling, with sub- 
 acute inflammation, or even ulceration, of the laryngeal mucous membrane ; 
 a coryza, due to a similar condition of the Schneiderian membrane; and 
 
182 .l.V AMERICAN TEXT-BOOK OF SURGERY. 
 
 certain cutaneous eruptions, tlie most common of wliicli at this early date is 
 the hirfre vesicuhn- or bullous eru])tion known as s_v])hilitic pemphi^nis. 
 
 J'l'/iiphii/ioi. — With regard to the specific or non-specific character of tliis 
 eruption tiiere has been much difterence of o))inion, and, as it is often the 
 earliest distinctive expression of syphilis, a diajmosis of which could liardly 
 be founded on the general appearance of the child, or even on the hoarse cry 
 and the coryza, it becomes important to have definite ideas upon the subject. 
 Nearly a century ago it was denied that this eruption was a manifestation of 
 venereal disease ; and this view has found sup])orters down to the present day. 
 The progress of clinical and ])athological knowledge enables us now to assert, 
 however, that although, as an exception, bulhc may sometimes be due to a 
 profound cachexia not dependent on syphilis, yet in the large majority of cases 
 they are specific in their character. 
 
 If we find an infiint at or immediately after birth presenting on the soles, 
 the palms, the fingers and toes, or on the limbs an eruption consisting of blebs 
 more or less perfectly distended with a licjuid which may be clear, cloudy, or 
 bloody, circular or oval in shape, sometimes irregular, seated on inflamed, red- 
 dish skin, and surrounded by trifling areolae, we may strongly suspect the 
 presence of syphilis in an active and most menacing form. And this suspicion 
 becomes a certainty if, in combination with such an eruption, the general 
 cutaneous surface is yellowish or muddy in hue, is hard and dry, without 
 elasticity or softness — owing to the al)sence of subcutaneous fat — and, for the 
 same reason, is furroAved and wrinkled about the face, imparting an appearance 
 of senility ; if the child has a hoarse cry, and a discharge from the nostrils ; 
 and, of course, if there are at the same time other syphilodermata. This 
 eruption is specially important, however, because upon the recognition of its 
 specific character in cases of stillbirth or in those in which the child survives 
 onlv a few days — not long enough for the development of further symptoms — 
 will depend the opinion as to the cause of death, which, whether expressed or 
 not, will determine the future treatment of both parents during the interval 
 between pregnancies and of the mother during the next pregnancy. 
 
 Goryza is one of the most characteristic, and at the same time one of the 
 most important, of the early symptoms of syphilis in its influence on the health 
 of the child. It is due to the same condition of the mucous mem])rane lining 
 the nasal fossae which manifests itself simultaneoush^ or soon afterward on the 
 skin in the shape of erythema, roseola, or papules ; in other words, it is a 
 hyperemia with papillary infiltration. The excessive supply of blood to the 
 parts induces a catarrhal condition which shows itself in a thin, watery dis- 
 charge. As the child during suckling is compelled to breathe through the 
 nose, this discharge is rapidly dried into crusts, causing the peculiar nasal, 
 noisy respiration which has given the aff"ection the popular name of nniifiieH. 
 
 Roseola is apt to present itself about the second or third week after birth. 
 As in the adult, it begins upon the abdomen in the form of little oval, circular, 
 or irregular spots, dull red in color and disappearing upon pressure. Later 
 the color becomes deeper, the eruption extends to the trunk and limbs, and, as 
 exudation and cell-proliferation succeed to simple capillary stasis, it ceases to 
 disappear when pressed upon. It is often moist, and sometimes excoriated, 
 owing to the thinness of the epidermis. Occasionally it is confluent, and covers 
 large areas with an almost unbroken sheet of deep-red color. 
 
 The diagnosis in the early stage is often difficult on account of the resem- 
 blance to the simple erythema of infancy. As the disease progresses, hoAvever, 
 maculfe form here and there ; the cell-infiltration involves the papillae, several 
 of which coalesce, forming flat papules ; the nutrition of the superficial layers 
 
HEBEDITAIIY HYPHIlJfi. 1»3 
 
 of the epiaermis is interfered «ith, especially where it is thick, as on/ho P^'™' 
 ami solcHn.l the crurtio,, in these regions hecomes scaly: and then the 
 
 '"';:ti^» ^^'"£'!>'« V',..,./...-In the cdinary evolution of the dis- 
 ease tlfe next manifestation is usually the devel<,,.n,ent of papules on the 
 Zeril cutaneous surface and of mucous patches on the tongue, l,ps, and 
 ehoek • nroSlv also on other mucous n.e.uhranes not exposed to exam na- 
 tion Tl~les for the reason already mentioned-the thmness -"'>"«>»"••« 
 If ,h. ivin-are apt to be of the broad, flat kind, especially, as in the adult, 
 of the ^1^'" •"*•'?;.' I, „ ..leuients of xvarmtli and friction are supera.lded to 
 llstre^afTtle^f itof skin tbout the genitalia, the neck, the flexures 
 
 ""'"i;;S^ t,S;?Zt are due to hypertrophic changes in tlie papules 
 whi h'Serthe inil'uence of heat and moisture in -ta.n regions coales^ and 
 
 ••^""^hTVirtchin'dL^S.^reirtX^rt^ndU^rrbya 
 nror'by an olnXe Te^S:.' They are found most commonly about the 
 
 '°X<tfa'^S,S«l!-A"Me later in the secondary period, usually at 
 abo.U tt tixrh'Cek, but sometimes much earlier the papules may become 
 
 ^-t^^X:^C%^X^^^^ of'- develop^ 
 
 mei't^^ftrer oUrence .h»^^^^^^ 
 
 described, is iritis. In spjte of its ^"'y' t^^^'^^^;'; g,^ tUt occlusion of 
 
 Pn?treTnd.£^:LlXve|\he .,■..«.«. is not us^^^^^^ 
 
 is irregular, especially under atropine; f-e =n. freaks o I™ b,^j^^^ 
 
 :::i'':Sy",re\et^nbllro;ir%;"e::n^^^^^^^^^ 
 
 "''"The progn^n. depends on the stage at which the P»«™*/°";f nrobabJrt 
 ment. ^he^ymph, \ recent no -"^rwiU^tert ?grtCt ev': 
 absorbed under mercurial treatment, ivhich will o"™ »« w occurred 
 in those cases in which a certain am°«nt "f ^-"'f ™ seconX" period of 
 The foregoing symptoms "^ f;™";^"-^,; t more commonh^from the 
 hereditary syphilis, or that extending "»"> ^f ^ ^ 
 
 age of three or f»'"7^;^l^^j° ^''.'''''eorv.a with snufiles ; 'an erythematous, 
 be agam enumerated »«. '°''™\; ?-'. mucous patches on the lips, tongue, 
 Set'etiratrkTrWt:t-ral wasting ^ a hoarse cry or cough ; 
 
184 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 senility of aspect; iritis. The majority of syi)liilitic' cliiMrcii horn alive die 
 during this stage. 
 
 Before its termination, sometimes even at hirth, other lesions have been 
 noticed (especially those aftecting the liver), which, however, may be better 
 described in connection with the special organ or organs involved. 
 
 Succeeding this stage — /. c beginning in about a year or eighteen months — 
 comes an intermediate period, which extends to second dentition, to puberty, 
 or even much later, and which is characterized rather negatively — that is, by 
 the absence of symptoms — than otherwise. The evidence of the general diath- 
 esis will of course be present in the shape possibly of malnutrition, stunted 
 growth, or retarded development, perhaps shown in the weazened or withered 
 face, the sunken nose, the pallor of the skin, the premature loss of the first 
 upper incisor teeth, or the malformation of the others if they have erupted. 
 
 There is but little tendency to recurrence or relapse of any of the secondary 
 symptoms : and in certain cases this stage extends through life, or, in other 
 words, as is freijuently the case with the adult w^ho has followed a proper course 
 of treatment, the disease appears to terminate with the secondary stage. In 
 other cases, however, it recurs, and the symptoms which it then ))resents may 
 be taken up in connection with the different organs or tissues involved. 
 
 Syphilis of the ear is for obvious reasons not often discoverable until the 
 patient has reached an age at which interference with the function of hearing 
 becomes a noticeable phenomenon. The only symptom likely to be noticed 
 during the stage of inherited syphilis which we are now considering is a catarrh 
 of the middle ear. This may lead to perforation of the membrana tympani, 
 purulent infiltration of the m'astoid cells, etc., and wdien accompanied by an 
 otorrhea which attracts attention to the ear will be easily discovered by the 
 surgeon. 
 
 The affections of the middle ear and Eustachian tube are said to be contem- 
 poraneous with the keratitis which appears in the neighborhood of puberty, 
 while those of the auditory nerve are somewhat later in point of time, and are 
 almost always conjoined with retinitis, choroiditis, and optic neuritis. 
 
 Syphilitic disease of the liver in newborn children is distinguished 
 especially by increase in size and weight of the organ. This increase depends 
 upon a proliferation of cells from the connective tissue between the acini, or 
 from the adventitia of the interlobular vessels, this growth becoming trans- 
 formed into connective tissue. The change is quite analogous to that which is 
 taking place at the same time in the skin, the mucous membranes, and other tis- 
 sues. It does not, however, go on to organization, but may be just as suscepti- 
 ble of absorption and resolution as are the papules or maculne of the skin. A 
 portion of the enlargement may be due to a passive congestion caused by the 
 presence of this cell-accumulation. 
 
 As to the diagnosis of hepatic syphilis in infants, the symptoms are indef- 
 inite, or they are identical with those often ol^served in chihb-en who have poor 
 or insufficient nourishment. The only physical sign which properly belongs to 
 hepatic syphilis, when it exists at all, is increase in the size of the liver. 
 
 Bone syphilis in children is essentially of the nature of the syphilitic 
 bone troubles with which we are ffimiliar in the acquired form of the disease, 
 consisting primarily and throughout of an unnatural accumulation of cell-ele- 
 ments, Avhich in the later stages by their pressure produce various degenerations 
 of surrounding structures, and which, as they occur during the process of bone- 
 formation, are accompanied by irregular and abnormal deposits of lime-salts. 
 They especially affect the junctions of the epiphyses and diaphyses, because at 
 that time those points are the seats of great physiological activity. 
 
HEREDITARY SYPHILIS. 
 
 185 
 
 The symptoms wliicli ohtuin in tliis condition of syphilitic osteochondritis are 
 as follows. There is a swelling at the (lia|)hyso-e])ij)hyseal junction of one of tiie 
 long bones, which in the emaciated subjects of liereditai-y sypliilis is often visible 
 and can always be discovered by ])al|)ation. This consists of a ring or collar 
 which more or less completely surrounds the bone, is apt to be smooth rather 
 than irregular, and, when two bones situated near to each other are simulta- 
 neously affected, may conjoin them. A moderate amount of synovitis is often 
 present. This affects chietly the elbow^ and the knee, but may appear in any 
 joint. It is readily influenced by specific treatment and Avell-regulated pres- 
 sure. When the last stage is reached, or tliat of the formation of granu- 
 lation-tissue, with degenerative changes of the cartilages and of the bones 
 themselves, deformity often becomes more marked. There are unnatural 
 curves or angles in the bones, with more or less complete separation at the 
 point of junction. 
 
 The most inn)ortant differential diagnosis to be made in these cases is 
 between tlie rhachitis of young children and the form of syphilis in (juestion. 
 The points of resemblance are manifest, just as they are between a syphilitic 
 and a variolous pustule, but they end in both cases when we come to study the 
 evolution of the phenomena either from an anatomical or from a clinical stand- 
 point. They may be expressed as follows in tabular form : 
 
 Osseous Lesions due to Inherited 
 Syphilis. 
 
 The swellings, particularly those of the long 
 
 bones, show themselves at or soon after 
 
 birth. 
 A history of syphilis or evidence of existing 
 
 syphilis in one or both parents. 
 Preceded or accompanied by snuffles, coryza, 
 
 and cutaneous and mucous lesions. 
 No such prodromata in most cases. 
 
 Cachexia absent or moderate. 
 
 Physiognomical peculiarities of syphilis pres- 
 ent. 
 
 Circumscribed tumors on frontal and parietal 
 bones, rarely on occiput. 
 
 Ribs not markedly affected. 
 
 Disease of ribs, vrhen existent, not ordinarily 
 coincident with that of other bones. 
 
 Fontanels close at usual period. 
 
 Other syphilitic symptoms present — enlarge- 
 ment of phalanges, metatarsal bones, etc. 
 
 Often accompanied by sinuses, synovitis, ab- 
 scesses, cutaneous ulcers, etc. 
 
 Generally disappears by resolution, without 
 leaving any permanent change. 
 
 Mortality among children in whom many 
 bones are involved is very great. 
 
 Specific treatment useful. 
 
 In the first stage there is an exuberant cal- 
 cification of the ossifying cartilage, caus- 
 ing necrosis of the new-formed tissue and 
 a consecutive inflammation, which termi- 
 nates in the separation of tlie epiphyses.^ 
 
 Rickets. 
 
 Rarely appear before six months, generally 
 
 still later. 
 
 No such history necessarily. 
 No such prodromata. 
 
 Pallor, restlessness, sweating, nausea, diar- 
 rhea, etc. constitute a combination of 
 symptoms which often precede the bone 
 disease. 
 
 Cachexia marked. 
 
 Not present as a group. 
 
 Cranial bones thickened in spots, usually 
 
 upon the occiput. 
 All or nearly all involved. 
 Nearly always so. 
 
 Closure delayed. 
 
 Syphilitic symptoms absent. 
 
 Little external or surrounding involvement. 
 
 Usually leaves some bending of shaft and 
 
 distortion of the neighboring joint. 
 Much less. 
 
 Of no benefit. 
 
 This is less marked. There is formed, in- 
 stead, a soft and non-calcified osteoid 
 
 tissue. 
 
 ^ This table is founded on one published in the translation of Cornil On Syphilis, by Drs. 
 Simes and White, and is compiled chiefly from the excellent work of Dr. Taylor on thifi 
 subject. 
 
1«G 
 
 ^l.Y AMERICAN TEXT-BOOK OE SURGERY. 
 
 The bone lesions of hereditary exostosis ean readily be reeo;^nized by the 
 facts that they are stationary, appear later, and are of larger size, by the ab- 
 sence of syphilitic history or symptoms and by their I'esistance to specific treat- 
 ment. The diagnosis from accidental separation of the epiphysis or from 
 fractures may be made from the history of the case. 
 
 In cases of separation of the epiphysis, complicated with suppuration, 
 sinuses, etc., the trouble may be mistaken for a similar condition due to non- 
 specific inflammation. In all the recorded instances, however, the latter has 
 occurred much later in life, is attended with much more acute inflammatory 
 symptoms, lymphangitis, etc., and is of course without concomitant symittoms 
 of syphilis. In l)Otli cases there is a decided osteo-periostitis, and, as so much 
 depends on the early and vigorous use of specific treatment, it may be worth 
 while to contrast the two forms of the disease. 
 
 Syphilitic Osteo-periostitis. 
 Occurs in infants under three montlis of age. 
 
 History of syphilis in child and its parents. 
 
 Implication of other bones. 
 
 Coincident with the development of the shaft 
 of the bone. 
 
 Other lesions of syphilis — nodes, skin ei-up- 
 tions, etc. 
 
 All the local symptoms comparatively mild. 
 
 Disease sharply localized. 
 
 Lymphatics of limb unaffected. 
 
 Beneficial effect of specific treatment if em- 
 ployed early. 
 
 Non-specific Osteo-periostitis. 
 
 Seldom if ever occurs in children under one 
 year of age. 
 
 No histoi-y of syphilis ; sometimes a history 
 of traumatism. 
 
 Usually confined to one l)one. 
 
 Coexists with the ossification of the epiph- 
 yses. 
 
 No such symptoms. 
 
 Pain, redness, and swelling very marked. 
 Involves neighboring parts. 
 Lymphangitis sometimes present. 
 No such effect. 
 
 Fifi. 2-5. 
 
 Syphilitic Dactylitis (Fig. 25) in the inherited variety of the disease, as 
 in the acquired, consists of two varieties. The one of these which generally 
 appears earlier aff"ects chiefly the periosteum and the fibrous and integumentary 
 
 structures surrounding a joint, usually a nieta- 
 carpo- or metatarso-phalangeal articulation, involv- 
 ing a phalanx, and is characterized by slow, almost 
 painless, swelling and discoloration of the affected 
 member. This is due to a gummatous infiltration, 
 which, after absorption under proper treatment, 
 leaves the toe or finger temporarily stiff, but not 
 permanently disabled. 
 
 The second form is a specific osteo-myelitis, 
 with periostitis, coming on later, and often destroy- 
 inec the bone or the articulation involved. 
 
 The absence of acute inflanniiatory symptoms 
 in the first variety distinguishes it from paronychia, 
 whitlow, and gout. Rheumatoid arthritis begins 
 in the joints and is associated with other symp- 
 toms ; deformity of the fingers comes early in the 
 disease, and there is a teno-synovitis with contrac- 
 tion. 
 
 The second variety might be taken for enchon- 
 droma or exostosis, but these growths increase much more slowly, involve only 
 a limited portion of the bone, are of greater density, and are much more strictly 
 circumscribed. 
 
 Ulcerated Syphilitic Dactylitis 
 (original). 
 
HE HE I) I T. \I:Y S ) I'll ILLS. 1 87 
 
 As a rule, especially in cases ^vlli(•ll aic recognized early and treated 
 actively, the proi/mis/'s is n-ood. 
 
 Syphilis of the Teeth. — Syphilis of the teeth lias its chief interest from 
 its very important hearing on diagnosis. Manifesting itself at an age when 
 the child is not apt to present the active and unmistakahle cutaneous and 
 mucous lesions of the disease, the recognition of which is therefore often 
 extremely difficult, this diagnostic importance is greatly increased. 
 
 The teeth of the fin<t denfitiott, althouirli exhihitin"; the usual sicrns of 
 interference Avith nutrition in their irregular development, oi)a(jue and chalky 
 enamel deficient in (juantity and unevenly distributed, soft and friable dentine, 
 incongruity of size individually and relatively, and proneness to decay, do not 
 often display any distinctive evidence of syphilis. The same conditions may, 
 and often do, depend on other causes, and are commonly associated with 
 various cachexi.e. 
 
 In the permanent teeth, likewise, the same condition may be due to the 
 same causes. Stomatitis, however produced — by mercury, by gastro-intestinal 
 derangements, by local irritation of any kind — is apt to result in imperfectly 
 organized dental structures. Mercurial teeth, for example, are usually irregu- 
 larly aligned, horizontally seamed, honeycombed, scraggy, malformed, of an 
 unhealthy dirty-yellow color, separated too widely, and deficient in enamel. 
 The diseases of childhood by temporarily arresting or greatly interfering with 
 nutrition during the developmental period of the teeth often cause horizontal 
 furrows across their crowns. 
 
 None of these conditions, however, are in the least degree characteristic of 
 syphilis, the special expression of which in the mouth is to be found only in 
 the permanent upper median incisors. It may be considered 
 as well established that when these teeth are stunted, abnor- Fig. 26. 
 
 mally narrow at the cutting edge, crescentically rounded 
 with the convexity upward, and the surface inclined upward 
 and forward, instead of backward as in normal teeth, widely upper Median incisors 
 separated, but converging at their lower edges, they are !" Hereditary syph- 
 pathognomonic of hereditary syphilis (Fig. 26). They are vier). 
 generally known as '■'• Hutehinson s teeth.'' They are often Fig, 27. 
 
 described as pegged, having been likened to a row of pegs 
 stuck in the gums. This appearance is due to the facts 
 that they are shortened, often projecting not more than 
 half the normal distance from the gum, and are also Avidely 
 separated; which abnormalities often affect the adjoining 
 teeth, and sometimes the entire denture. A mistake which is frequently made 
 is the confusing of the serrations of the cutting edges of recently-erupted normal 
 incisors (Fig. 27) Avith the peculiar crescentic edges of syphilitic teeth. 
 
 Interstitial Keratitis. — The frequency of this form of diffuse inflamma- 
 tion of the cornea, and the diagnostic significance which has been so positively 
 attributed to it — and as positively denied — render it of special interest. It 
 begins, commonly, as a slight, diffused haziness situated in the substance of 
 the cornea itself, usually not far from the centre, and at first affecting only one 
 eye. This condition may persist for one or two months, after which the other 
 cornea is nearly always attacked, and is similarly affected, although the disease 
 is apt to pass through its different stages rather more rapidly than in the first 
 eye. When the height of the disease is reached the cornese are nearly opaque, 
 a bare perception of light remaining. Then the cornea Avhich Avas first in- 
 volved begins to clear ; this is soon folloAved by improvement in the other one, 
 which in the course of a year or tAvo results in a return to fairly good sight, 
 
188 A^^ AMERICAN TEXT-liOOK OF SURGERY. 
 
 although in most cases there remain a slight haziness and an abnormal ex- 
 pansion of the cornea. 
 
 The diagnosis of this condition may generally be made -with ease. The 
 ground-glass appearance in the earlier stages and the dull pink or salmon color 
 in the more vascular stage are very characteristic. The vascularity differs 
 from that attending other chronic forms of keratitis, granular lids, "etc., in 
 which the vessels are large and superficial : in syphilitic keratitis they are 
 much deeper and very closely interwoven, so that the effect is almost that 
 of an ecchymosis. In non-syphilitic cases both eyes are not so apt to be 
 affected nor is the tendency to spontaneous cure so marked. The absence 
 of ulceration and the very slight degree of accompanying sclerotic or ciliary 
 congestion are also valuable features. The chief point of interest, however, 
 in the diagnosis of interstitial keratitis is its association with other symptoms 
 of syphilis, upon which, for the general practitioner at least, the diagnosis will 
 usually depend. There is such unequivocal clinical evidence in this direction 
 that it is safe to say, as of the question of syphilitic teeth, that the burden 
 of disproof rests with the doubters, and we may venture the assertion that 
 interstitial, diffuse, or parenchymatous keratitis is a symptom of inherited 
 sy})hilis, and that the unmistakable presence of the former disease is sufficient 
 proof of the existence of the latter. 
 
 Syphilis of the Nerve-centres and Nerves. — Until a compara- 
 tively recent period our only guide to the course of the nerve diseases of 
 inherited syphilis was to be found in analogy. We knew, for instance, that 
 in acquired syphilis three forms of cerebral disease could be recognized in a 
 general way : one characterized by a sudden attack of paralysis, in which the 
 lesion was usually thrombosis from specific endarteritis ; one in which the 
 symptoms of brain-tumor were present, and in Avhich gummata were the cause 
 of the difficulty ; and one in Avhich pain, headache, and various functional or 
 convulsive disturbances — chorea, epilepsy, paralysis of single nerves, etc. — 
 were the customary phenomena, and in which periosteal, meningeal, or neu- 
 roglial thickenings constituted the pathological basis. The last two are often 
 intermingled both symptomatically and histologically. 
 
 In spite of certain striking differences — more apparent than real, however — 
 between inherited and acquired syphilis as regards cause, duration of stages, 
 etc., the essential pathological changes are the same. When syphilis in its 
 later periods attacks the brain or spinal cord or nerve-trunks or vessels of a 
 foetus, it proceeds just as in the adult, the same characteristic accumulation of 
 cells taking place and setting up an arteritis or a meningitis, thickening the 
 sheaths of nerves, or constituting a pericranial node or a gumma, according to 
 their number and their situation. We find, thus, that in these patients men- 
 ingitis, growths, and arterial disease constitute the three clinical divisions of 
 the disease which have thus far been distinctly differentiated, and the reported 
 cases, with or without autopsy, fall natui'all}'- into these classes. 
 
 Syphilis of the Spleen. — Disease of this organ in inherited syphilis is 
 especially important from two points of view. It is a valuable aid to diagnosis, 
 and by the size of the organ and the degree of persistence of the swelling gives 
 an approximate indication of the severity of the case. Enlargement of the liver, 
 although it ought to be noted because it is often present in hereditary syphilis, 
 has but little value as a confirmatory symptom : first, because the liver is dis- 
 proportionately large in infancy, and it is difficult to state the limit of what is 
 actually normal ; and, secondly, because other causes besides congenital syphilis 
 lead to its enlargement. With regard to enlargement of the spleen the case is 
 different. Gee's observation, that in the early stage of infantile syphilis somo 
 
HEREDITARY SYPHILIS. 189 
 
 enlargement of the spleen occurs in a large number of" cases, has been abun- 
 dantly confirmed. The importance of this sign is greatest when noted early, 
 as, for example, when the child is from two to three months old, for at that 
 period the enlargement of the spleen due to rickets can hardly come into ques- 
 tion. The condition of' the spleen during this })eriod of enlargement seems to 
 be simply that of hyperemia, or at the most of hyper[jlasia. 
 
 The cause seems to be in all probal)ility the Avell-known effect of syphilis 
 on the glandular system in general and on the lymphatic system in particular^ 
 to which the spleen is now usually assigned. The analogy between this slow^ 
 persistent, painless enlargement preceding the cutaneous symptoms, unaccom- 
 panied by inflammatory symptoms, unattended by any breaking down of tissue, 
 subsiding slowly but evenly under specific treatment, and the behavior of the 
 buboes of acquired syphilis, is certainly very striking. 
 
 In most cases of hereditary syphilis there are evidences of disturbance of 
 the gastro-intestinal tract. Vomiting, diarrhea, colic, anorexia, and ema- 
 ciation are well-known, but of course not at all characteristic, symptoms. 
 
 It has been supposed that the mucous membrane of the entire tract is 
 probably, during the early period at least, and coincidently with the cutaneous 
 eruption, in a condition of hyperemia and irritation comparable to that of the 
 skin. Whether this is so, or whether it is due to associated involvement of 
 the glandular apparatus,' has not yet been determined. 
 
 Syphilis of the Larynx. — The hoarse cry of the newborn infant, so cha- 
 racteristic of hereditary syphilis, depends upon the presence of hyperemia, of 
 mucous patches, or even of extensive ulceration, in the larynx. The first is 
 probably the most common, as, if it were otherwise, cases of death from oedema 
 glottidis or other forms of laryngeal obstruction would be oftener met with. 
 When ulceration does exist it is generally, but not invariably, secondary to 
 pharyngeal ulcers. 
 
 Bronchial catarrh, giving rise to cough, and sometimes to considerable 
 embarrassment of respiration, is a not infrequent complication of laryngeal 
 syphilis. Later troubles of the larynx in connection with inherited syphilis 
 have not yet been studied carefully enough to warrant us in draAving any dis- 
 tinction between them and the usual symptoms seen in the acquired disease. 
 
 Syphilis of the testicles is found to consist of a true interstitial orchitis, 
 very closely resembling that seen in the syphilitic testicles of adults. The dis- 
 ease usually occurs at from two months to three years of age ; both testicles 
 are generally involved, and are enlarged, hard, inelastic, and frequently nodu- 
 lated. Mercurial treatment generally causes a marked improvement unless the 
 inflammation has already resulted in the development of a new fibroid forma- 
 tion, in which case it Avill be likely to remain unaffected by treatment. Inunc- 
 tions with diluted mercurial ointment, iodoform, etc. are useful adjuvants. 
 
 The Diagnosis and Prognosis of Inherited Syphilis. — In reviewing 
 the general course of a case of inherited syphilis it seems evident that the differ- 
 ences between it and the acquired disease which have been so much dwelt upon 
 are apparent rather than real. The primary stage is of course missing, and on 
 any theory of the essential nature of syphilis this is readily comprehensible. 
 Whether the chancre is the first symptom of a constitutional disease, or is the 
 simple accumulation at the point of original inoculation of the cells affected 
 by the syphilitic virus, it would naturally be in the first case undiscoverable, 
 in the second non-existent. 
 
 The secondary stage, characterized in the acquired form chiefly by lymphatic 
 engorgement and symmetrical, Avidely-spread, polymorphic cutaneous and mucous 
 eruptions, and pathologically by a marked tendency to the proliferation of cer- 
 
190 AS AMK/i'JCAy TF.XT-noOK OF SlJidKIiY. 
 
 tain new small round inicleated cells, upon the {tresence of which depen<l all 
 the nianitestutioii.s ot" tlie disease, is in inherited syphilis strictly analo;rous. 
 The lymphatic engorgement either exists in the infant as in the adult, or has 
 its analogue in the eidargement of the spleen and of the liver, especially the 
 former. 
 
 The tertiary stage, except in the fact that its ]»lu'nomena may ajipear unusu- 
 ally early and may be connningled with those of the secondary period, does not 
 widely differ in the hereditary form from that of the acquired disease. 
 
 In considering the question of diagnosis, therefore, we have an excellent 
 guide in the facts that the disease conforms in most respects to the general laws 
 of acquired syphilis, and that our knowledge of the latter affection Avill be a 
 valuable aid to recognition of the former. 
 
 The chief elements of diagnosis and prognosis of inherited syphilis in its 
 various stages mav, then, be summarized as follows: A history of sv))hilis in 
 either parent is important just in proportion to the shortness of the interval 
 between the time of infection and the date of conception. If both parents 
 were syphilitic at or before the time of conception, the probability that the 
 disease will be transmitted, and in a severe form, is much increased. There is 
 no sufficient evidence that inheritance from one parent results in a graver 
 variety of the disease than when it is derived from the other. 
 
 A history of abortion or miscarriage on the part of the mother should have 
 weight in the determination of any given case, and if such accidents have been 
 very frequent their diagnostic importance is greatly increased. 
 
 Upon examining the product of abortion or stillbirth the most easily observ- 
 able symptoms will be those of the skin. Maceration of the epidermis and its 
 elevation into bullae are in themselves hardly characteristic, though both of 
 them — and especially the latter — may be regai'ded as suspicious. If the cuta- 
 neous lesions are, however, distinctly papular or pustular or ulcerative, or if 
 the bullse have all the characteristics of syphilitic pemphigus, the diagnosis is 
 assured. 
 
 The most distinctive symptom — one whicli may really be considered 
 pathognomonic — is, however, the inflammation of the diaphyso-epiphyseal 
 articulations, with or without their disjunction. Distinct enlargement of the 
 spleen or of the liver and arachnitis with hydrocephalus are valuable diagnostic 
 points, and the presence of gummata. which arc not very infrequent, Avould 
 of course be conclusive. 
 
 At birth the syphilitic child may be small, stunted, emaciated, Aveazened, 
 senile in appearance : this would properly give rise to suspicion, but might be 
 associated with any disorder of nutrition on the part of either child or mother. 
 It may also disclose cutaneous or mucous eruptions evidently specific in charac- 
 ter. In any event, marked symptoms at birth render the prognosis highly 
 unfavorable. 
 
 It is quite common, however, for the subject of hereditary syphilis to give 
 no evidence of the disease at birth, but even to appear healthy and well 
 nourished. In such cases the first symptoms of the disease appear, on an 
 average, in from six weeks to two or three months, and consist principally of 
 coryza, snufl^es, hoarseness of voice, and syphilodermata. 
 
 Mucous patches on the tongue, cheeks, tonsils, and pharynx are common, 
 often extending to the larvnx. increasing the hoarseness, and to the nasal 
 cavities, aggravating the snuffles. Both of these occurrences, bv interfermg 
 with the respiration of the child and rendering its nursing interrupted and 
 insufficient, greatly add to the gravity of the case. Enlargement of the spleen 
 
HEREDITAR V SYPHILIS. 191 
 
 (common), eulargoment (jf tlie liver (less so), and iritis (rare) may be mentioned 
 amon<!; the phenomena of this stage often assoeiated with the skin eruptions. 
 
 About the time of the subsidence of the rash there may be devehjped the 
 specific infhunmation at the junction of epiphyses and diaphyses which pro- 
 duces a swelling of the long bones near their ends. The child will be noticed 
 to cry a little when, for example, the wrist or elbow on one side is washed, and 
 not to use these joints as much as the corresponding ones on the other side. 
 The parts are slightly tender, and as yet there is but little swelling. Later, 
 the droop and disuse of the aftected limb become more noticeable and simulate 
 ififantile paralysis. There is, however, no wasting, no alteration of reaction 
 by faradism, no real loss of power, so that the term pseudo-paralysis is an ap- 
 propriate one. In a w^eek or two similar symptoms will occur in the bone on 
 the opposite side, and finally the ends of all the long bones will be aff'ected ; 
 ordinarily the elbows, wrists, knees, and shoulders are the joints involved. 
 Suppuration is rare, disjunction of the epiphysis from the diaphysis common. 
 Recovery is apt to take place spontaneously Avithin a month. The associated 
 changes are chiefly endosteal at the junction of the shaft with the epiphysis, 
 but there is also a little periostitis or perichondritis, which is the principal 
 cause of the external swelling. Moderate deformity may ensue. 
 
 Similar changes occurring in the cranial bones give rise to Avhat has been 
 called the natiform skull. During the first year it is very common for syphilitic 
 children to develop a number of lenticular swellings on the cranium, which 
 appear symmetrically around the anterior fontanel, but at a little distance 
 from it — L e. one on each frontal and one on each parietal bone. They are 
 said to be " bossed." They are originally circumscribed, and in a child nine 
 or ten months old often measure from three-quarters of an inch to an inch in 
 diameter. They are at first circular, afterward more irregular, and finally tend 
 to organize, becoming difl"used and massive and causing a permanent thicken- 
 incr of the skull. 
 
 The symptoms which have been described are the prominent ones occur- 
 ring during the first six, eight, or twelve months of life. If they do not 
 manifest themselves before the eighth month, it is highly probable, even in a 
 case with a syphilitic parental history, either that the child will escape alto- 
 gether or that the secondary stage has been very slight and altogether intra- 
 uterine and unattended w4th noticeable phenomena. If during this first year 
 the child's cachexia is marked, if there are any intercurrent diseases, if the 
 symptoms show themselves early, if the nasal or laryngeal affection is severe, 
 if the eruptions are markedly bullar or pustular or ulcerative, if the enlarge- 
 ment of the spleen is great or the osseous lesions are precocious or grave, and 
 if, especially, there is any intermingling of tertiary symptoms, gummata, nodes, 
 etc., the prognosis will be unfavorable. 
 
 From adolescence through adult life the diagnosis of inherited syphilis will 
 depend on the following points : First, of course, the history of parental or of 
 infantile syphilis, or of both. Then a group of physical and physiognomical 
 peculiarities, which are not definitely characteristic, and are of little value when 
 taken separately, but of considerable impoi'tance when all or a majority are 
 present in any given case. These are low stature or puny development pro- 
 portionate to the severity of the intra-uterine and infantile symptoms : a pasty, 
 leaden, or earthy complexion, a relic of previous syphilodermata, probably also 
 a result of malnutrition ; a prominent forehead, bulging in the middle line at 
 and within the frontal eminence, and due either to thickening of the skull or 
 to a previous arachnitis and hydrocephalus before the ossification of the fon- 
 tanels ; a flat, sunken bridge of the nose, due to the coryza of infancy ex- 
 
192 AN AMERICAN TKXT-liOOK OF SI'IiGKRY. 
 
 tending to the periosteum of the delieate nasal bones, and either interfering 
 with their nutrition or j)artially destroying them ; dryness and thinness of the 
 hair, with brittleness and splitting of the nails ; synechia) and dulness of the 
 iris (rare) ; ulcerations of the hard palate; and periosteal thickenings or en- 
 largements of the shafts of the long ])ones near the ends, or slight angular 
 deformity, the result of the osteochondritis of infancy. 
 
 A much more valuable grouj) of symptoms, however, are tlie following, 
 which are mentioned in the order of their importance, any one of the first three 
 being almost or quite conclusive: 
 
 Dwarfed permanent median upper incisors, broader at the top than at the 
 cutting edge, which is crescentically notched, separated by an undue interval, 
 and converging toward each other. 
 
 Evidence of past or present keratitis — a dusky and thin sclerotic in the 
 ciliary region and slight clouds here and there in the corneal substance, there 
 being no scars on its surface ; or of disseminated choroiditis ; patches of absorp- 
 tion, especially around the periphery. 
 
 A radiating series of narrow cicatricial scars extending across the mucous 
 membrane of tlic lips, or a network of linear cicatrices on the u])per lip and 
 around the nostrils, as Avell as at the corners of the mouth and on the lower lip. 
 Periosteal nodes on one or many of the long bones ; sudden, symmetrical, 
 and complete deafness, without otorrhea and unattended by pain or other sub- 
 jective symptoms. 
 
 Late or tardy hereditary syphilis is rarely dangerous to life. The prognosis 
 is almost unvaryingly favorable unless some grave visceral complication, such 
 as interstitial pneumonia, ginumata of the brain, liver, or kidney, or meningeal 
 and periosteal inflammation within the cranium, should occur. 
 
 Treatment. — The prophylactic treatment, or that directed to the health 
 and sexual relations of the parents previous to conception, has already been 
 sufficientlv considered. That of the mother during pregnancy, after having 
 conceived'^from a syphilitic husl^and, or having had antecedent syphilis, or hav- 
 ing contracted it by direct contagion subsequent to impregnation, is simply that 
 of acquired syphilis in either adult or child. Mercury in its full physiological 
 dose is the drug indicated. It may not be amiss to combine with it iodide of 
 potassium in moderate doses, but the practice of employing the latter to the 
 exclusion of the former is both theoretically and clinically unsound. Care 
 should especially be taken to give it in such a manner, either by inunction or 
 vaporization or so guarded Avith opium, that it shall not produce any irritating 
 effect on the intestinal canal, the sympathy betAveen wlpcli and the uterus may, 
 in the event of a strong purgative action being set up, lead to an abortion. 
 
 As we have seen that the pathology, the stages, and the general course of 
 hereditary syphilis are all closely related to or identical with the same phe- 
 nomena ill the acquired disease, and so know that they both deju'iid upon the 
 same ultimate cause, it follows that the same principle should govern us in the 
 treatment of the one as in that of the other. 
 
 We know from clinical experience that mercury exercises an almost con- 
 trolling influence over the secondary manifestations of acquired syphilis. '^^ e 
 know also that iodide of potassium, probably by virtue of its powerful stimu- 
 lating influence on the lymphatic system, has an equal power over the tertiary 
 growths. In hereditary syphilis, however, there are two elements Avhich should 
 modify the treatment somewhat, and must be taken into consideration. These 
 are — 1st. The existence of a more or less profound cachexia influencing all the 
 nutritive and formative processes, and in itself, entirely apart from any definite 
 specific involvement of vital organs, threatening life. 2d. The not infrequent 
 
HEREDITA BY S YPHILIS. 1 93 
 
 occurrence during the secondary period of symptoms — notably gummata — 
 belonging to the tertiary stage. 
 
 Tlie first indication is met by making the treatment from first to last not 
 only antisyphilitic, l)ut also supporting or even stinndating; and with this 
 object in view especial attention should be paid to nutrition. It may be stated, 
 axiomatically, that for every reason, whenever it is within the bounds of pos- 
 sibility, the nurse of a syphilitic child should be its mother. To her it is 
 harmless ; to every other woman, not already syphilized, it is in the highest 
 decree dangerous. If neither mother nor wet-nurse can be had to suckle the 
 child, it nnist be fed by cow's, goat's, or ass's milk or by artificial alimenta- 
 tion ; but its prospect of life will be immeasurably reduced. In addition to 
 careful feeding, a little tonic treatment should be employed from the first, in 
 conjunction with the specific remedies, iodide of iron, cod-liver oil, and jjrepa- 
 rations of the phosphates being the most useful drugs. 
 
 The existence of the second condition wliich exercises a modifying influ- 
 ence upon treatment — the early appearance of tertiary symptoms — is probably 
 due, in many cases at least, to an overwhelming of the lymphatic system by 
 the new cell-growth. This leads us to combine with the mercury from the 
 beginning, at least in all cases where bony or periosteal involvement, suppura- 
 tion, or the existence of gummata point to this condition, small doses of iodide 
 of potassium or of some' other soluble and easily-decomposed iodine salt. 
 
 The principle of treatment being recognized, the routine procedure may be 
 thus described : Give mercury as soon as the diagnosis of syphilis is assured — 
 preferably by inunction. Sir Benjamin Brodie's opinion, expressed many 
 years ago, still represents that of the profession : "I have tried different ways 
 of treating such cases. I have given the child gray powder internally and 
 given mercury to the wet-nurse. But mercury exhibited to the child by the 
 mouth generally gripes and purges, seldom doing any good, and given to the 
 wet-nurse it does not answer very well, and certainly is a very cruel practice. 
 The mode in which I have treated cases for some years past is this : I have 
 spread mercurial ointment, made in the proportion of a dram to an ounce, 
 over a flannel roller and bound it around the child once a day. The child kicks 
 about, and, the cuticle being thin, the mercury is absorbed. It does not either 
 gripe or purge, nor does it make the gums sore, but it cures the disease. I 
 have adopted this practice in a great many cases with signal success. Very 
 few children recover to whom mercury is given internally, but I have not seen 
 a case where this method of treatment has failed." 
 
 When, for any reason, as irritation of the skin, this cannot be employed, 
 probably the best form of giving mercury by the mouth is in the following 
 formula : 
 
 I^. Hydrarg. cum creta, gr. j-vj ; 
 Sacch. alb., gr. xij. 
 
 M. et div. in chart. No. xij. 
 Sig. One powder three times a day, to be taken soon after nursing. 
 
 Iodide of potassium may be given separately in a syrupy solution in doses 
 of a half-grain to a grain, or, if there are any marked tertiary symptoms, even 
 in much larger doses, three or four times daily. The treatment of course 
 should be continued long after the disappearance of syphilitic symptoms, and 
 it would probably be well to continue the mixed treatment intermittently until 
 after puberty. 
 
 The cases of visceral syphilis in very young children are generally fatal. 
 Those that recover do so in response to the active use of the above remedies. 
 
 13 
 
194 AX AMERTCAX TEXT-BOOK OF SrUdEUY. 
 
 Later, the pro^j^nosis is more fiivorablc, the treatnient the same. Of course 
 moist eruptions shouUi be dusted with some astringent or absorbent powder; 
 mucous patches should be cauterized or stimulated ; and great attention should 
 be paid to avoidance of sources of cutaneous irritation, by fre(|U('nt clian^nng 
 of diapers, etc., but the general methods are the same as in the adult. 
 
 CHAP T E R XI X 
 TUMORS. 
 
 A TUMOR is a new growth or neoplasm Avhich produces a localized enlarg(>. 
 ment of a part or an organ, has no tendency to spontaneous cure, has no useful 
 function, in most cases tends to grow during the whole of the individual's life, 
 its development and growth, except in rare instances, being uninfluenced by 
 druf^s or by the greater or less general vigor of the individual. The exceptions 
 to which the above definition does not apply are — first, such new growths as 
 tubercle, lupus, etc. ; second, certain epitheliomata and the withering scirrhus of 
 the breast, which do not produce enlargement; and third, cysts not the result 
 of new growth. Lymphadenoma or lympho-sarcoma, a malignant disease of 
 the lymphatic glands, in a few instances temporarily, or more rarely perma- 
 nently, seems to have undergone cure from the use of arsenite of sodium given 
 internally in increasing doses. 
 
 All tiimors originate from the pre-existing tissues (except when of meta- 
 static origin), and are composed of tissue-elements resembling those of these 
 tissues either in their fully-developed or in their embryonic state. "When limited 
 to the tissue in which it starts, the tumor merely displaces the tissues, and is, 
 almost without exception, constituted of fully-developed cells similar to the 
 tissue from wliich it started, as fat, fibrou;:, or muscular tissue : to this class of 
 tumors, which are generally benign, the term homologous has been applied. 
 When the new-growth no longer remains confined to the tissue in which it 
 starts, but infiltrates the surrounding tissues, its component elements tending 
 to be more embryonic in their type, it is usually malignant; such growths 
 have been termed heterologous. " Nearly all secondary tumors — i. e. those 
 forming in parts distant from the primary growth, as in the lymjihatics or the 
 viscera — are therefore heterologous. Both innocent and malignant growths may 
 be multiple. Multiple malignant growths are usually the result of lymphatic 
 or vascular embolism, but cases are not uncommon where more than one primary 
 focus has been observed ; thus two or three portions of the lip or of the tongue 
 may be simultaneously attacked. 
 
 Tumors Originate from Many Causes. — Some, as mvvi, are con 
 genital, or the tendency to their development in later life is inherited. Of 
 the causes initiating those occurring in later life, the following are regarded as 
 most effectiveand un(|uestioned. While inflammatory new formations cannot be 
 regarded as tumors, there is little doubt that injury — especially that following 
 a contusion and fractures — stands in fre(|uent causative relation to many new 
 growths, notably the sarcomata. Anything which acts chemically or mechan- 
 ically so as to maintain a constant but slight degree of undue vascularity of a 
 part, such as the irritation of soot (scrotal cancer), the hot, rough stem of a 
 clay pipe (labial epithelioma), a jagged tooth (carcinoma lingua), favors the 
 development of a malignant growth. Abnormal conditions of parts where the 
 epithelial elements are in excess, as certain benign growths, such as warts 
 (cutaneous papillomata), pigmented moles, and leucoma of the tongue (a 
 
TUMORS. 195 
 
 clironic inilaiiuiiatorv atVcetioii iiivolviii*^^ ilie surface of that organ), prerlis- 
 pcse t»» the foniiatioii of lualignaiit growths. Age and sex predispose to 
 tunior-forniation. Thus carcinoma is a rarity under thirty years of ao^e ; 
 the mannnary gland of the female is infinitely more liahle to carcinoma 
 than that of the male, owing to their diflciing functional activity; while, on 
 the otiier hand, the (esophagus, lip, and tongue in the male seem to he more 
 lial)le to he attacked hy malignant disease than the same organs in the 
 female. The depressing emotions long continued, such as sorrow or anxiety, 
 generally considered as predisposing causes, can act only, as does age, by low- 
 ering the vitality of the tissues, inducing as it were premature senescence : their 
 action is therefore doubtful. 
 
 Since malignant growths present some slight apjjarent resemblances to 
 certain ])henomena of the infectious diseases, observers have of late years 
 sought to ascribe their origin to bacteria. Still later, microscopic appear- 
 ances simulating those presented by certain parasitic protozoa have led 
 enthusiastic observers to the belief that the spheroidal or irregular bodies 
 found in and between the epithelial cells are in reality developmental forms 
 of certain sporozoa, and that their presence is not accidental, but causal. 
 The arguments in support of this view rest upon the morphological resem- 
 blances of these bodies to psorospermige and to the corpuscles of molluscum 
 contagiosum. The diversity in size, form, and staining qualities of the sup- 
 posed parasites, the lack of evidence that these bodies are either growing or 
 developing, and the failure of all culture methods, have caused most authori- 
 ties to believe that the alleged sporozoa of carcinoma are really degeneration- 
 products of the epithelial cells. The possibility that carcinoma may yet 
 prove to be of parasitic origin is not denied, but certainly no positive evidence 
 in support of this view has been adduced. 
 
 Growth. — This is dependent upon its structure primarily, and to a less 
 degree upon the part in which the tumor starts. Oceteris jjaribus, the more 
 embryonal the structure, the more rapid the increase and the more malignant 
 the tumor, but tumors of similar structure pursue widely differing courses accord- 
 ing to the organ in which they originate. This is partly due to their lymphatic 
 and vascular connections, partly to the importance to life of the part involved 
 or of neighboring parts which may become diseased by contiguity, or mechan- 
 ically rendered partially or wholly useless ; thus a small carcinoma of the 
 pylorus will terminate life by starvation ; a tumor of the larynx will early 
 endanger life by suffocation. 
 
 Clinically, tumors are divided into the benign and the malignant. A 
 benign tumor is usually composed of tissues resembling those in which it 
 originates, and is circumscribed, because »usually encapsulated, Avhence its 
 mobility among the circumjacent tissues. Its vascular supply is small : hence 
 generally it grows slowly. It is painless ; it never infiltrates surrounding tis- 
 sues, but displaces them ; it does not recur when thoroughly removed, does not 
 give rise to enlargement of the lymphatic glands intervening between it and the 
 venous circulation, and consequently does not affect distant parts. A malig- 
 nant tumor usually consists of tissues widely different from those in which it 
 originates ; its growth is rapid, and therefore often painful ; it infiltrates all 
 the surrounding tissues, however resistant, even bone, because it is almost 
 never encapsulated ; it thus early becomes immovable ; the superjacent skin is 
 apt to become adherent, especially when the breast is involved ; sooner or later 
 it usually infects the group of lymphatic glands intervening between it and the 
 venous circulation, and from these new centres or directly through the veins 
 gives rise to secondary deposits in the internal organs. 
 
196 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 Diagnosis. — In general terms this must depend upon the history, age, 
 sex, situation, rate of growth, fixity to the surrounding parts and overlying 
 skin, or the reverse, lymphatic or visceral involvement, and the physical cha- 
 racters of the growth. 
 
 Tlie Jiahilitif of tumors to degenerations resulting from disease or injury — 
 since morbid growths are no more exempt from sucli influences than normal 
 tissues — should be clearly recognized and constantly kept in mind. Thus the 
 vascular supply predisposes to the occurrence of ulcerative inflammation in 
 both benign and malignant growths. For instance, an ordinary sessile fatty 
 tumor (lipoma) is no more liable to be attacked by ulceration than any other 
 portion of the normal fatty tissue ; but when such tumors become jiendulous, 
 with narrow pedicles, the blood-supply is often interfered with — especially the 
 venous i-eturn — and ulceration may occur from trivial causes. Again, epithe- 
 lial carcinomata are chiefly formed of masses of cells the majority of which 
 are distant from any direct blood-supply ; thus they readily undergo fatty de- 
 generation and break down early ; the overlying skin becomes infected, gives 
 way, and ulceration is initiated. This process is often so active that the major 
 part of the growth ulcerates or sloughs away, while at the periphery the disease 
 extends into the adjacent tissues. Very rarely, from injury, gangrene of the 
 whole growth ensues, resulting in its total destruction and the cure of the 
 disease. One most important class of malignant neoplasms — viz. the sarcomata 
 — are liable to such developmental transformations into structures resembling 
 normal tissues, as to give rise to errors both in diagnosis and in prognosis. It 
 must, then, never be forgotten that any of the structures normally developed 
 from connective tissue may form either the bulk of some of the most malig- 
 nant growths or isolated portions of them : thus cartilage, bone, or fibrous 
 tissue may form the mass of a malignant growth ; but these changes into 
 tissues of a permanent type in no way modify the malignancy of the remain- 
 ing tissues of the embryonal type. Such benign groAvths as fibromata may un- 
 dergo calcification : cartilaginous tumors may soften (undergo mucoid change). 
 
 Treatment. — The only effectual treatment is removal or destruction of the 
 growth. Benign growths should be removed if much inconvenience or deformity 
 is present, or if disturbance of health or danger to life — present or prospective 
 — is undoubted. It is needless to say that all malignant growths should be 
 promptly removed, including, when possible, the whole of the organ attacked 
 and" the neighboring lymphatics and glands, as the entire breast with the axil- 
 lary contents in cancer of that organ ; the whole tibia by amputation in sarcoma 
 of that bone. Special therapeutic indications will be considered when treating 
 of each particular class of growths. 
 
 Classification of Tumors. — Tumors are best classed according to their 
 supposed origin and their histological structure ; thus — 
 
 I. Mesoblastic or Connective-Tissue Tumors. 
 
 A. Those conforming to the types of fully-formed connective tissues i 
 
 1. Fibrous Tumors (Fibroma, plural Fibromata) ; 
 
 2. Fatty Tumors (Lipomata) ; 
 
 3. Cartilaginous Tumors (Chondromata) ; 
 
 4. Osseous Tumors (Osteomata) ; 
 
 5. Mucous Tumors (Myxomata). 
 
 B. Those conforming to the types of the higher connective tissues : 
 
 1. Muscular Tumors (Myomata) ; 
 
 2. Vascular or Erectile Tumors (Angeiomata) ; 
 
 3. Lymphatic (vessel) Tumors (Lymphangeiomata); 
 
 4. Nerve Tumors (Neuromata). 
 
TUMORS. 
 
 197 
 
 C. Those conform iiiii to the type of embryonic connective tissue: 
 
 1. liound-cclletl Sarcomata; 
 
 2. Spindle-celled Sarcomata; 
 
 3. Myeloid Sarcomata. 
 
 D. Tumors intermediate between the sarcomata and the carcinomata : 
 
 The Endotheliomata. 
 
 II. Epiblastic and Ilypohlmtic Tumors — i. e. those conforming to the type 
 
 of Epitlu'UaJ Tissues : 
 
 A. Warty or Villous Tumors (Papillomata). 
 
 B. Glandular Tumors (xVdenomata). 
 
 C. The Acinous or Spheroidal-celled Carcinomata: 
 
 1. Hard Spheroidal-celled (Scirrhous, or Chronic Carcinomata^ ; 
 
 2. Soft Spheroidal-celled (Encephaloid or Acute Carcinomata) ; 
 
 3. Colloid Carcinomata. 
 
 D. Epithelial carcinomata : 
 
 1. Squamous-celled Epitheliomata ; 
 
 2. Cylindrical- or Columnar-celled Epitheliomata. 
 
 III. Tumors composed of Epiblastic, Hypohlastic, and Mesohlastic Ele- 
 
 ments : 
 Teratomata, tumors containing bone, hair, teeth, etc., situated in 
 the ovaries or testicles. 
 
 I. Mesoblastic or Connective-Tissue Tumors. 
 
 A. Tumors conforming to the types of fully-formed connective 
 tissues : 
 
 1. Fibrous Tumors, or Fibromata (Fig. 28). — Consisting of fibrous 
 tissue, they may be as dense and firm as a tendon or as soft as the subcutaneous 
 areolar tissue. They commonly possess a distinct capsule ; when completely 
 removed they neither recur locally nor become generalized, and consequently 
 are absolutely innocent tumors. They 
 rarely consist solely of pure white fi- 
 brous tissue, but the firmer varieties are 
 composed of a dense mass of interlacing 
 bundles of this tissue, intermingled with 
 a few yellow elastic fibers and connect- 
 ive-tissue corpuscles. The bundles 
 may form concentric circles around the 
 blood-vessels in some fibromata, but 
 usually they present no definite arrange- 
 ment. On section they are smooth, 
 glistening, firm, and of a grayish-white 
 color. Usually the blood-supply is 
 scanty, the vessels being small and thin- 
 walled, but some naso-pharyngeal polypi 
 are excessively vascular, being trav- 
 ersed by large cavernous blood-spaces. 
 The softer varieties consist of a more 
 or less loose, succulent, fibrous tissue 
 permeated with numerous large blood- 
 vessels, and according to the propor- 
 tions of the different forms of fibrous tissue which enter into their composition 
 they will appear more or less yellowish, glistening, semi-transparent, or gelatin- 
 
 Fibro-cystic Tumor of Parotid Region (original). 
 
108 jy AMERICAN TEXT-liOOk' OF SURGERY. 
 
 ous; a serous fluid can be expressed f'n.iii their cut .surfaces. When super- 
 ficial thoy often become pedunculated. 
 
 Fibrous tumors are jiioue to uii(k'r<;o certain secondary degenerative changes 
 — vi/. caleificatioii. luucdid eliaiiLTc. and ulceration. 
 
 Seats of Predilection. — Fil^-oniata may occur wherever filtrous tissue is 
 found in any of its forms, but the commonest seats are the periosteum, espe- 
 cially that of the jaws, for the harder forms, when the tumor is called a fibrous 
 epulis; in the uterus; in the neurilemma of nerves — then miscalled neuroma 
 (false neuroma) ; in the subcutaneous tissue on terminal nerve-fihuiients, termed 
 painful subcutaneous tubercles; in the rectum and naso-pharynx, forming 
 fibrous polypi. Hard fibromata are also found in the testis or may sprin<r from 
 the sheaths of tendons. The softer forms originate chiefly from the intermus- 
 cular septa or the subcutaneous and submucous tissues, and are oftenest found 
 in the scrotum, labia majora, or scalp. The soft fibroma was formerly called 
 fibro-cellular : the ordinary nasal polypus is a typical example of this variety. 
 Fibromata attack adults chiefly, but have been observed at all ages ; they are 
 usually single, but may be multiple when springing from the nerves (false neu- 
 romata), the skin (molluscum fibrosum), and the uterus. Pure fibromata and 
 fibro-lipomata sometimes form large renal tumors. 
 
 Diagnosis. — In general terms, fibromata are ovoidal, hard, nodular, or 
 bosselated, of uniform consistence, of slow growth, painless — cxce})t when 
 involving nerves — movable, those in the breast and subcutaneous tissues being 
 unattached to the skin or circumjacent tissues. In these situations, or when 
 arising from the jaws or other bones, in their earlier stages it is difficult to dis- 
 tinguish them from the harder sarcomata, the latter being often encapsulated. 
 The slow growth, the regular contour, and the non-involvement of the overlying 
 tissues in the case of fibrous growths are the chief points of distinction. Car- 
 tilaginous and bony tumors present the same characteristics, but are much harder 
 and more nodular. The softer fibromata are smooth, globular, elastic, soft, and 
 painless. 
 
 Treatment. — When possible, they should be completely removed, either 
 by enucleation with their capsules, as in most of those occurring in the breast, 
 the interior of the jaAv, etc., or sometimes by a dissection, which may be tedious. 
 Recurrence never takes place except where a sarcoma — portions of whose mass 
 in certain instances consist largely of fibrous tissue — has been mistaken for the 
 benign growth. 
 
 2. Fatty Tumors, or Lipomata, consist of adipose tissue identical with 
 normal fat. They are innocent, grow slowly, may reach a large size, are usu- 
 ally single, but occasionally multiple, are almost never painful, occur chiefly 
 during adult life, and do not recur after removal. Composed of masses of fat- 
 vesicles bound together by delicate connective tissue in Avhich the blood-vessels 
 ramify, they are usually surrounded by a thin capsule which is attached by 
 fibrous septa to the skin. Fatty tumors may undergo such secondary changes 
 as calcification, mucoid softening, inflammation from pressure, and, as a result 
 of this in some rare instances, ulceration. 
 
 Seats of Predilection. — On the shoulders, back, nates — possi])ly from 
 the hyperemia induced by pressure of the suspenders, from sitting, etc. 
 
 Diagnosis. — A fatty tumor forms a circumscribed, usually painless, lobu- 
 lated, soft, pseudo-fluctuant, inelastic, flattened growth — if subcutaneous, caus- 
 ing dimpling of the skin when this is pinched up, due to the passage of the 
 fibrous septa from the skin to the capsule. It is best distinguished from 
 chronic abscess — with which it may be confounded — by its dimpling and by 
 
HEREDITARY >sy/'JIJLI6'. 193 
 
 occurrence during the secondary period of symptoms — notably gummata — 
 belonging to the tertiary stage. 
 
 The first indication is met by making the treatment from first to last not 
 only antisyphilitic, but also supjjorting or even stimulating; and with this 
 object in view especial attention should be paid to nutrition. It may be stated, 
 axiomatically, that for every reason, whenever it is within the bounds of pos- 
 sibility, the nurse of a syphilitic child should be its mother. To her it is 
 harmless ; to every other woman, not already syphilized, it is in the highest 
 degree dangerous. If neither mother nor wet-nurse can be had to suckle the 
 cliiid, it must be fed by cow's, goat's, or ass's milk or by artificial alimenta- 
 tion ; but its prospect of life will be immeasurably reduced. In addition to 
 careful feeding, a little tonic treatment should be employed from the first, in 
 conjunction with the specific remedies, iodide of iron, cod-liver oil, and prepa- 
 rations of the phosphates being the most useful drugs. 
 
 The existence of the second condition which exercises a modifving influ- 
 ence upon treatment — the early appearance of tertiary symptoms — is probably 
 due, in many cases at least, to an overwhelming of the lymphatic system by 
 the new cell-growth. This leads us to combine with the mercury from the 
 beginning, at least in all cases where bony or periosteal involvement, suppura- 
 tion, or the existence of gummata point to this condition, small doses of iodide 
 of potassium or of some other soluble and easily-decomposed iodine salt. 
 
 The principle of treatment being recognized, the routine procedure may be 
 thus described : Give mercury as soon as the diagnosis of syphilis is assured — 
 preferably by inunction. Sir Benjamin Brodie's opinion, expressed many 
 years ago, still represents that of the profession : " I have tried different ways 
 of treating such cases. I have given the child gray powder internally and 
 given mercury to the wet-nurse. But mercury exhibited to the child by the 
 mouth generally gripes and purges, seldom doing any good, and given to the 
 wet-nurse it does not answer very well, and certainly is a very cruel practice. 
 The mode in which I have treated cases for some years past is this : I have 
 spread mercurial ointment, made in the proportion of a dram to an ounce, 
 over a flannel roller and bound it around the child once a day. The child kicks 
 about, and, the cuticle being thin, the mercury is absorbed.*^ It does not either 
 gripe or purge, nor does it make the gums sore, but it cures the disease. I 
 have adopted this practice in a great many cases with signal success. Very- 
 few children recover to whom mercury is given internally, but I have not seen 
 a case where this method of treatment has failed." 
 
 When, for any reason, as irritation of the skin, this cannot be employed, 
 probably the best form of giving mercury by the mouth is in the following 
 formula : 
 
 I^. Hydrarg. cum creta, gr. j— vj ; 
 Sacch. alb., gr. xij. 
 
 M. et div. in chart. 'No. xij. 
 Sig. One powder three times a day, to be taken soon after nursing. 
 
 Iodide of potassium may be given separately in a syrupy solution in doses 
 of a half-grain to a grain, or, if there are any marked tertiary symptoms, even 
 in much larger doses, three or four times '^daily. The treatment of course 
 should be continued long after the disappearance of syphilitic symptoms, and 
 it would probably be well to continue the mixed treatment intermittently until 
 after puberty. 
 
 The cases of visceral syphilis in very young children are generally fatal. 
 Those that recover do so in response to the active use of the above remedies. 
 
 13 
 
194 AX A^fEliI<'AN TEXT-BOOK OF SriidKUY. 
 
 Later, the pro^no.sis is more favoralde, tlie treatment the same. Of course 
 moist eruptions shouhl be dusted with some astriii<:eiit or al)Sorbent pow(k'r ; 
 mucous patches should be cauterized or stimuhited ; and great attention shouhl 
 be paid to avoidance of sources of cutaneous irritation, by frequent ciian<ring 
 of diapers, etc., but the general methods are the same as in the adult. 
 
 CMI AFTER XIX. 
 TUMORS. 
 
 A TUMOR is a new growth or neoplasm which produces a localized enlarg(>- 
 ment of a ])art or an organ, has no tendency to spontaneous cure, has no useful 
 function, in most cases tends to grow during the Avhole of the individual's life, 
 its development and growth, except in rare instances, being uninfluenced by 
 drugs or by the greater or less general vigor of the individual. The exceptions 
 to which the above definition does not apply are — first, such new growths as 
 tubercle, lupus, etc. ; second, certain epitheliomata and the withering scirrhus of 
 the breast, which do not produce enlargement ; and third, cysts not the result 
 of new growth. Lymphadenoma or lympho-sarcoma, a malignant disease of 
 the lymphatic glands, in a few instances temporarily, or more rarely perma- 
 nently, seems to have undergone cure from the use of arsenite of sodium given 
 internally in increasing doses. 
 
 All tumors originate from the pre-existing tissues (except when of meta- 
 static origin), and are composed of tissue-elements resembling those of these 
 tissues either in their fully-developed or in their embryonic state. When limited 
 to the tissue in which it starts, the tumor merely displaces the tissues, and is, 
 almost Avithout exception, constituted of fully-developed cells similar to the 
 tissue from Avhich it started, as fat, fibrous, or muscular tissue: to this class of 
 tumors, which are generally benign, the term homologous has been applied. 
 When the new-growth no longer remains confined to the tissue in which it 
 starts, but infiltrates the surrounding tissues, its component elements tending 
 to be more embryonic in their type, it is usually malignant ; such growths 
 have been termed heterologous. Nearly all secondary tumors — i. e. those 
 forming in parts distant from the primary growth, as in the lymphatics or the 
 viscera — are therefore heterologous. Both innocent and malignant growths may 
 be multiple. Multiple malignant growths are usually the result of lymithatic 
 or vascular embolism, but cases are not uncommon where more than one primary 
 focus has been observed ; thus two or three portions of the lip or of the tongue 
 may be simnltanconsly attacked. 
 
 Tumors Originate from Many Causes. — Some, as njievi, are con 
 genital, or the tendency to their develo])ment in later life is inherited. Of 
 the causes initiating those occurring in later life, the following are regarded as 
 most effective and uncjuestioned. While intlammatory new formations cannot be 
 regarded as tumors, there is little doubt that injury — especially that following 
 a contusion and fractures — stands in fre(juent causative relation to many new 
 growths, notably the sarcomata. Anything which acts chemically or mechan- 
 ically so as to maintain a constant but slight degree of undue vascularity of a 
 part, such as the irritation of soot (scrotal cancer), the hot. rough stem of a 
 clay pipe (labial epithelioma), a jagged tooth (carcinoma linguae), favors the 
 development of a malignant groAvth. Abnormal conditions of parts where the 
 epithelial elements are in excess, as certain benign growths, such as warts 
 (cutaneous papillomata), pigmented moles, and leucoraa of the tongue (a 
 
TUMORS. 195 
 
 chroiiir intliiiiiiiiatorv affeetion iiivolviiii^ the surface of that or<:an), predis- 
 pose to the formation of malignant growths. Age and sex predispose to 
 tumor-formation. Tiius carcinoma is a rarity under thirty years of age ; 
 the mammary ghmd of the female is inlinitely more liable to carcinoma 
 than that of the male, owing to their diftering functional activity ; while, on 
 the other hand, the tesophagus, lip, and tongue in the male seem to be more 
 liable to be attacked by malignant disease than tlie same organs in the 
 female. The depressing emotions long continued, such as sorrow^ or anxiety, 
 generally considered as predisposing causes, can act only, as does age, by low- 
 ering the vitality of the tissues, inducing as it were premature senescence : their 
 action is therefore doubtful. 
 
 Since malignant growths present some slight apparent resemblances to 
 certain phenomena of the infectious diseases, observers have of late years 
 sought to ascril)e their origin to bacteria. Still later, microscopic appear- 
 ances simulating those presented by certain parasitic protozoa have led 
 enthusiastic observers to the belief that the spheroidal or irregular bodies 
 found in and between the epithelial cells are in reality developmental forms 
 of certain sporozoa, and that their presence is not accidental, but causal. 
 The arguments in support of this view rest upon the morphological resem- 
 blances of these bodies to psorospermire and to the corpuscles of molluscum 
 contagiosum. The diversity in size, form, and staining qualities of the sup- 
 posed parasites, the lack of evidence that these bodies are either growing or 
 developing, and the failure of all culture methods, have caused most authori- 
 ties to believe that the alleged sporozoa of carcinoma are really degeneration- 
 products of the epithelial cells. The possibility that carcinoma may yet 
 prove to be of parasitic origin is not denied, but certainly no positive evidence 
 in support of this view has been adduced. 
 
 Growth. — This is dependent upon its structure primarily, and to a less 
 degree upon the part in which the tumor starts. Oceter is paribus, the more 
 embryonal the structure, the more rapid the increase and the more malignant 
 the tumor, but tumors of similar structure pursue widely differing courses accord- 
 ing to the organ in which they originate. This is partly due to their lymphatic 
 and vascular connections, partly to the importance to life of the part involved 
 or of neighboring parts which may become diseased by contiguity, or mechan- 
 ically rendered partially or wholly useless ; thus a small carcinoma of the 
 pylorus will terminate life by starvation ; a tumor of the larynx will early 
 endanger life by suffocation. 
 
 Clinically, tumors are divided into the benign and the malignant. A 
 benign tumor is usually composed of tissues resembling those in which it 
 originates, and is circumscribed, because usually encapsulated, whence its 
 mobility among the circumjacent tissues. Its vascular supply is small ; hence 
 generally it grows slowly. It is painless ; it never infiltrates surrounding tis- 
 sues, but displaces them ; it does not recur when thoroughly removed, does not 
 give rise to enlargement of the lymphatic glands intervening between it and the 
 venous circulation, and consequently does not affect distant parts. A malig- 
 nant tumor usually consists of tissues widely different from those in which it' 
 originates ; its growth is rapid, and therefore often painful ; it infiltrates all 
 the surrounding tissues, however resistant, even bone, because it is almost 
 never encapsulated ; it thus early becomes immovable ; the superjacent skin is 
 apt to become adherent, especially when the breast is involved ; sooner or later 
 it usually infects the group of lymphatic glands intervening between it and the 
 venous circulation, and from these new centres or directly through the veins 
 gives rise to secondary deposits in the internal organs. 
 
196 ^l^V AMERICAN TEXT-BOOK OF SUROERV. 
 
 Diagnosis. — In general terms this must dt'j)end upon the history, age, 
 sex, situation, rate of growth, fixity to the surrounding parts and overlying 
 skin, or the reverse, lymphatic or visceral involvement, and the physical cha- 
 racters of the growth. 
 
 The Uabi'Iifi/ of tumors to degenerations resulting from disease or injury — 
 since morbid growths are no more exempt from such influences than iK)rmal 
 tissues — shouM he clearly recognized and constantly kept in mind. Thus the 
 vascular supply predisposes to the occurrence of ulcerative inflajnniation in 
 both benign and malignant growths. For instance, an ordinary sessile fatty 
 tumor (lipoma) is no more liable to be attacked by ulceration than any other 
 portion of the normal fatty tissue ; but when such tumors become [)endulous, 
 with narrow pedicles, the blood-supply is often interfered with — especially the 
 venous return — and ulceration may occur from trivial causes. Again, ej>ithe- 
 lial carcinomata are chiefly formed of masses of cells the majority of which 
 are distant from any direct blood-supply ; thus they readily undergo fatty de- 
 generation and break down early ; the overlying skin becomes infected, gives 
 way, and ulceration is initiated. This process is often so active that the major 
 part of the growth ulcerates or sloughs away, while at the periphery the disease 
 extends into the adjacent tissues. Very rarely, from injury, gangrene of the 
 whole growth ensues, resulting in its total destruction and the cure of the 
 disease. One most important class of malignant neoplasms — viz. the sarcomata 
 — are liable to such developmental transformations into stnictures resembling 
 normal tissues, as to give rise to errors both in diagnosis and in prognosis. It 
 must, then, never be forgotten that any of the structures normally developed 
 from connective tissue may form either the bulk of some of the most malig- 
 nant growths or isolated portions of them : thus cartilage, bone, or fibrous 
 tissue may form the mass of a malignant growth ; but these changes into 
 tissues of a permanent type in no way modify the malignancy of the remain- 
 ing tissues of the embryonal type. Such benign growths as fibromata may un- 
 dergo calcification: cartilaginous tumors may soften (undergo mucoid change). 
 
 Treatment. — The only effectual treatment is removal or dotruction of the 
 growth. Benign growths should be removed if much inconvenience or deformity 
 is present, or if disturbance of health or danger to life — present or prospective 
 — is undoubted. It is needless to say that all malignant growths should be 
 promptly removed, including, when possible, the whole of the organ attacked 
 and the neighboring lymphatics and glands, as the entire breast with the axil- 
 lary contents in cancer of that organ ; the whole tiljia by amputation in sarcoma 
 of that bone. Special therapeutic indications will be considered when treating 
 of each particular class of growths. 
 
 Clas.sificatiox of Tumors. — Tumors are best classed according to their 
 supposed origin and their histological structure; thus — 
 
 I. Mesohlastic or Connective- Tissue Tumors. 
 
 A. Those conforming to the types of fully-formed connective tissues : 
 
 1. Fibrous Tumors (Fibroma, plural Fibromata) ; 
 
 2. Fatty Tumors (Lipomata) ; 
 
 3. Cartilaginous Tumors (Chondromata) ; 
 
 4. Osseous Tumors (Osteomata) ; 
 
 5. Mucous Tumors (Myxomata). 
 
 B. Those conforming to the types of the higher connective tissues : 
 
 1. Muscular Tumors (Myomata) ; 
 
 2. Vascular or Erectile Tumors (Angeiomata) ; 
 
 3. Lymphatic (vessel) Tumors (Lymphangeiomata); 
 
 4. Nerve Tumors (Neuromata). 
 
TUMORS, 
 
 107 
 
 C. Those confunniiiji: to the type of embryonic connective tissue: 
 
 1. Round-celled Sarcomata ; 
 
 2. Spindle-celled Sarcomata; 
 
 3. Myeloid Sarcomata. 
 
 D. Tumors intermediate between the sarcomata and the carcinomata : 
 
 The Endotheliomata. 
 
 II. Epihlastic and Jiypohlastic Tumors — /. e. those conforming to the type 
 
 of Epithelial Tissues : 
 
 A. Warty or Villous Tumors (Papillomata). 
 
 B. Glandular Tumors (Adenomata). 
 
 C. The Acinous or Spheroidal-celled Carcinomata: 
 
 1. Hard Spheroidal-celled (Scirrhous, or Chronic Carcinomata) ; 
 
 2. Soft Spheroidal-celled (Encephaloid or Acute Carcinomata) ; 
 
 3. Colloid Carcinomata. 
 
 D. Epithelial carcinomata : 
 
 1. Squamous-celled Epitheliomata ; 
 
 2. Cylindrical- or Columnar-celled Epitheliomata. 
 
 III. Tumors composed of Epiblastic, Hypohlastic, and Mesohlastic Ele- 
 
 tnents : 
 Teratomata, tumors containing bone, hair, teeth, etc., situated in 
 the ovaries or testicles. 
 
 I. Mesoblastic or Connective-Tissue Tumors. 
 
 A. Tumors conforming to the types of fully-formed connective 
 tissues : 
 
 1. Fibrous Tumors, or Fibromata (Fig. 28). — Consisting of fibrous 
 tissue, they may be as dense and firm as a tendon or as soft as the subcutaneous 
 areolar tissue. They commonly possess a distinct capsule ; when completely 
 removed they neither recur locally nor become generalized, and consequently 
 are absolutely innocent tumors. They 
 
 rarely consist solely of pure white fi- Ft«. 28. 
 
 brous tissue, but the firmer varieties are 
 composed of a dense mass of interlacing 
 bundles of this tissue, intermingled with 
 a few yellow elastic fibers and connect- 
 ive-tissue corpuscles. The bundles 
 may form concentric circles around the 
 blood-vessels in some fibromata, but 
 usually they present no definite arrange- 
 ment. On section they are smooth, 
 glistening, firm, and of a grayish-white 
 color. Usually the blood-supply is 
 scanty, the vessels being small and thin- 
 walled, but some naso-pharyngeal polypi 
 are excessivel}' vascular, being trav- 
 ersed by large cavernous blood-spaces. 
 The softer varieties consist of a more 
 or less loose, succulent, fibrous tissue 
 permeated with numerous large blood- 
 vessels, and according to the propor- 
 tions of the difi'erent forms of fibrous tissue w^hich enter into their composition 
 they will appear more or less yellowish, glistening, semi-transparent, or gelatin- 
 
 Fibro-cystic Tumor of Parotid Region (original). 
 
198 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 ous ; a serous fluid can be expressed from their cut surfaces. When super- 
 ficial they often become peduncuhited. 
 
 Fibrous tumors are prone to undergo certain secondary degenerative changes 
 — viz. calcifieation. mucoid change, and ulceration. 
 
 Seats of Predilection. — Fibromata may occur wherever fibrous tissue is 
 found in any of its forms, but the commonest seats are the periosteum, espe- 
 cially that of the jaws, for the harder forms, when the tumor is called a fibrous 
 epulis; in the uterus; in the neurilemma of nerves — then miscallod neuroma 
 (false neuroma) ; in the subcutaneous tissue on terminal nerve-filaments, termed 
 painful subcutaneous tubercles ; in the rectum and naso-pharynx, forming 
 fibrous polypi. Hard fibromata are also found in the testis or may spring from 
 the sheaths of tendons. The softer forms originate chiefly from the intermus- 
 cular septa or the subcutaneous and submucous tissues, and are oftenest found 
 in the scrotum, labia majora, or scalp. The soft fibroma Avas formerly called 
 fibro-cellular : the ordinary nasal polypus is a typical example of this variety. 
 Fibromata attack adults chiefly, but have been observed at all ages ; they are 
 usually single, but may be multiple when springing from the nerves (false neu- 
 romata), the skin (molluscum fibrosum), and the uterus. Pure fibromata and 
 fibro-lipomata sometimes form large renal tumors. 
 
 Diagnosis. — In general terms, fibromata are ovoidal, hard, nodular, or 
 bosselated, of uniform consistence, of sIoav growth, painless — except Avhen 
 involving nerves — movable, those in the breast and subcutaneous tissues being 
 unattached to the skin or circumjacent tissues. In these situations, or when 
 arising from the jaws or other bones, in their earlier stages it is difficult to dis- 
 tinguish them from the harder sarcomata, the latter being often encapsulated. 
 The slow growth, the regular contour, and the non-involvement of the overlying 
 tissues in the case of fibrous growths are the chief points of distinction. Car- 
 tilaginous and bony tumors present the same characteristics, but are much harder 
 and more nodular. The softer fibromata are smooth, globular, elastic, soft, and 
 painless. 
 
 Treatment, — When possible, they should be completely removed, either 
 by enucleation Avith their capsules, as in most of those occurring in the breast, 
 the interior of the jaw, etc., or sometimes by a dissection, which may be tedious. 
 Recurrence never takes place except where a sarcoma — portions of whose mass 
 in certain instances consist largely of fibrous tissue — has been mistaken for the 
 benign growth. 
 
 2. Fatty Tumors, or Lipomata, consist of adipose tissue identical with 
 normal fat. They are innocent, grow slowly, may reach a large size, are usu- 
 ally single, but occasionally multiple, are almost never painful, occur chiefly 
 during adult life, and do not recur after removal. Composed of masses of fat- 
 vesicles bound together by delicate connective tissue in which the blood-vessels 
 ramify, they are usually surrounded by a thin capsule which is attached by 
 fibrous septa to the skin. Fatty tumors may undergo such secondary changes 
 as calcification, mucoid softening, inflammation from pressure, and, as a result 
 of this in some rare instances, ulceration. 
 
 Seats of Predilection. — On the shoulders, back, nates — possibly from 
 the hyperemia induced by pressure of the suspenders, from sitting, etc. 
 
 Diagnosis. — A fatty tumor forms a circumscribed, usually painless, lobu- 
 lated, soft, pseudo-fluctuant, inelastic, flattened growth — if subcutaneous, caus- 
 ing dimpling of the skin when this is pinched up, due to the passage of the 
 fibrous septa from the skin to the capsule. It is best distinguished from 
 chronic abscess — with which it may be confounded — by its dimpling and by 
 
TUMORS. 
 
 Plate VII. 
 
 Enormous chondroma of ilium. 
 
TUMORS. 199 
 
 the slipping away of the edge of the tumor from beneath the finger when pressed 
 luxin : ])os!ril)lv the grooved needle may be requisite. Certain variations should 
 be noted. Tlius there is a diffuse form, producing symmetrical swellings at the 
 back of the neck, or beneath the chin, forming so-called " double neck " and 
 "double chin." Again, the presence of more fibrous tissue than usual may 
 render lipomata unusually firm. They may be deep-seated, springing from 
 the intermuscular septa or even from the surface of a bone. Moreover, they 
 occasionally become pedunculated. Lastly, some of the most typical cases of 
 "painful subcutaneous tubercle" are composed of fat. The average case can 
 be readily diagnosticated from a cyst, a chronic abscess, or a bursal enlargement 
 by the symptoms given above, while the deeper-seated can hardly be mistaken 
 for any other than soft fibrous or myxomatous growths— an error of no practical 
 moment, since both should be removed. 
 
 Treatment. — For the circumscribed variety a free incision, opening the 
 capsule, should be employed, when the tumor will usually shell out ; if more 
 adherent, some dissection with the knife may be necessary : all portions of the 
 growth must be removed, since occasionally, although rarely, the portions left 
 have formed the starting-point of a new tumor. Multiple growths, unless pain- 
 ful ones, seldom require removal. The diffused form should not usually be 
 attacked with the knife. The prolonged internal use of liquor potassne m 
 10-minim doses, t. d., has in certain instances caused their disappearance. 
 
 3. Cartilaginous Tumors, Chondromata or Enchondromata (PI. YII.), 
 are composed of some variety of cartilage, forming hard, elastic, slowly enlarg- 
 ing crrowths, often nodular or lobulated. They may consist of a single mas? 
 or'' of a number of small masses each enclosed in its capsule, all bound 
 toc^ether by connective tissue and blood-vessels. They are homogeneous or 
 coarsely granular on section, presenting a translucent, bluish-gray or pinkish- 
 white surface, sometimes marked out into irregular lobules. Histologically, 
 they are usually composed of hyaline- or fibro-cartilage. Where unattached 
 to bone their fibrous capsule serves as a perichondrium, and when exposed to 
 friction a bursal sac often forms between them and the superjacent parts. 
 Fatty or mucoid secondary changes may render some of the nodules centrally 
 diffluent, producing cyst-like cavities "containing synovia-like fluid, thus so 
 completely metamorphosing the tumors that they sometimes are hardly recog- 
 nizable as chondromata; while, on the contrary, some become calcified or ossified. 
 This latter change is especially apt to affect chondromata springing from the 
 juxta-epiphyseaf region of the long bones, the change progressing so far that 
 only a thin" layer olf cartilage caps them, forming what are termed cancel- 
 lous exostoses. Chondromata are apt to be single, but they are often multiple 
 and symmetrical, as those attacking the phalanges. While pure cartilaginous 
 growths are benign, sarcomata are often partly, or even chiefly, composed of 
 cartilaf^e. especially those found in the testicle and the parotid. Multiple chon- 
 dromata of the hand, if of rapid growth, should be viewed with suspicion as 
 possibly cartilaginous sarcomata. Occurring at any age, they are more com- 
 mon in the young, especially those springing from the long bones near the 
 epiphyses. Sometimes the tendency to their formation seems to be inherited, 
 the tumors being similarly located in both parents and children. While they 
 often attain a large size,'^they grow slowly, so that unusual bulk with rapid 
 growth would justify a strong suspicion of the intermixture of sarcomatous 
 elements. Mixed tumors containing cartilage have been already referred 
 
 Seats of Predilection.— The bones, especially on or in the phalanges of 
 
200 AN AMERICAN TEXT- HOOK OE ^SUIKJERY. 
 
 the fingers or tors ; the lower jiixta-opipliysoal region of the femur ; tlie upj)er 
 ends of the tibia, fibuhi, and humerus, the seapuhi and ilium, on or in tlie jaw.s, 
 especially the upper; the salivary glands, notal)ly the parotid : the testicle ; in or 
 arouixl joints attacked by rheuniatoiil arthritis; and the subcutaneous tissues. 
 
 Diagnosis. — This must depend on the hardness yet elasticity of the tumor, 
 its nodular circumscribed outlines, and its slow continuous growth ; later, 
 on the development of softened spots indicative of cystic degeneration, and on 
 the location of the tinnor, as upon a young bone near an epiphysis. A carti- 
 laginous sarcoma — the growth with which chondromata are most likely to be 
 confounded — presents less definite outlines — /, e. infiltrates somewhat, is apt 
 to be of unequal consistence from the outset, and grows with much greater 
 rapidity. 
 
 Treatment. — Complete removal of a pure chondronui will secure future 
 immunity, and should always be adopted when possible. Mixed chondromata 
 containing sarcomatous elements commonly recur. In the ])arotid gland and sub- 
 cutaneous tissues they can usually be enucleated with their capsules, and some- 
 times this can be done when the phalanges are involved, but more often in the 
 latter event and when the testicle is attacked the whole part or organ must be 
 sacrificed : usually those springing from the surfaces of the larger bones can be 
 removed without sacrificing the bone, with but small chance of their recurrence. 
 
 4. Osseous Tumors, or Osteomata, are formed of true bone, and are gene- 
 rally composed almost solely of either cancellous or compact bone. The can- 
 cellous have been just described as resulting from the ossification of chondro- 
 matous growths springing from the juxta-epiphyseal portions of such long 
 bones as the tibia, femur, humerus, fibula, etc., Avhere they form exostoses. 
 The ungual surface of the distal phalanx of the great toe is often the site of 
 such a tumor, producing a subungual growth. The compact osseous tumors 
 rarely grow from any other bones than those of the cranium. Certain exostoses, 
 called from their hardness " ivory exostoses," are said to differ from other bony 
 growths by the absence of Haversian canals, and are composed of " layers of 
 bone lamelh>2 laid concentrically over a central point or pedicle," They rarely 
 attain a greater size than that of a small walnut, are so dense that they can 
 hardly be cut by any instrument, and it is difiicult by the exercise of great 
 force to fracture their pedicles, even when comparatively slender. The ivory 
 exostosis sprintrs from the exterior of one of the cranial bones, while the more 
 ordinary forms of compact osteomata origniate m the cranial or nasal smuses, 
 grow slowly, and thrust aside or cause absorption of adjacent structures, thus pro- 
 ducing marked deformities. Although usually single, osseous tumors in some 
 patients may be multiple, being found by the score, in such cases commonly 
 commencing at a very early age, being then hereditary and often symmetrical. 
 
 Seats of Predilection. — These have been mentioned above in describ- 
 ing these growths. 
 
 Diagnosis. — This is usually easy, depending on the evident connection of 
 the tumor with bone or cartilage, for tumors growing apart from these struc- 
 tures in the connective tissue are probably tumors of some other class which 
 have undergone osseous change, or are structures, such as tendons, muscles, etc., 
 which have undergone calcification or ossification. The jjcdunculated form 
 when the osteoma occurs as an exostosis, the dense, hard, irregularly nodulated 
 surface when the tumor is non-pedunculated, and its slow growth, serve as dis- 
 tinguishing points. The more rapid growth and une((ual consistence of the 
 calcifying or ossif^nng sarcomata serve to distinguish this variety of malignant 
 growth from the benign osseous tumors. 
 
TUMORS. 2r)l 
 
 Treatment. — Altliough operation alone can remove these growths, not 
 every one shoiihl l)e nK'thlled witli, l)ut only those should be attacked which 
 are steadily growino; and are painful or produce great deformity or loss of 
 function, and the proposed o})eration on -which will not unduly risk the life of 
 the patient. Thus, most of the exostoses of the flat and long hones and certain 
 osteomata of the upper and lower jaAvs should be removed, for valid reasons, 
 such as those just given. Those of the facial and cranial bones, which are 
 ill defined and often extend so deeply as to involve the base of the skull, 
 should not be touched. It was formerly taught that it was inadvisable to c.t- 
 tempt the removal of non-pedunculated, sessile exostoses of the long bones, 
 which are usually covered by thick masses of muscle, because of the risk of 
 profuse and deep-seated suppuration ; but with modern methods of operating 
 such complications ought to be avoided, so that if good reasons exist for their 
 removal such tumors should be subjected to operation. 
 
 With the exception of the cancellous exostosis of the ungual phalanx of 
 the great toe, a pure osteoma when removed does not return, even Avhen 
 some of the surface from which it has sjirung is allowed to remain. An ossi 
 fying sarcoma, for which osteoma has sometimes been mistaken, will of course 
 return. In the exceptional case mentioned the distal portion of the pha- 
 lanx should be removed with the tumor to obviate any risk of recur- 
 rence. 
 
 5. Mucous Tumors, or Myxomata, resemble both to the naked eye and 
 to the microscope the Whartonian jelly of the umbilical cord and the vitreous 
 humor of the eye. They grow slowly, and may attain a large size, but are in- 
 nocent tumors, not returning when pure and if completely removed. Sarcomata 
 may undergo an analogous change — i. e. mucous softening — and of course such 
 tumors are apt to recur. Mucoid softening also attacks fibromata, chondro- 
 mata, and other connective-tissue tumors, so that many tumors called myxo- 
 mata are chondromata, fibromata, or sarcomata undergoing mucoid (myxo- 
 matous) change. 
 
 Structurally, a true myxoma is soft, gelatinous, semi-translucent, encapsu- 
 lated, and intersected by septa of fibrous tissue. Their cut surfaces are pinkish- 
 or vellowish-gray, and exude large quantities of glairy fluid containing much 
 mucin. Microscopically, they are seen to be composed of numerous anasto- 
 mosing stellate cells, with branching processes which form a delicate stroma 
 in which the gelatinous basis-substance is contained : some round and spin- 
 dle cells are also found. Inflammation, fatty degeneration, ulceration, and 
 the formation of blood-cysts from rupture of capillary vessels are the secondary- 
 changes to which these tumors are liable. 
 
 Seats of Predilection. — The nasal cavities, in which they form gelatin- 
 ous polypi ; the mammary gland ; the intermuscular spaces ; the submucous and 
 subserous tissues ; more rarely the periosteum, the bone medulla, and sheath? 
 of nerves. 
 
 Diagnosis. — Before removal their close physical resemblance to fatty and 
 fibro-cellular tumors renders certainty impossible, since they present the same 
 soft, elastic feel, and may even seem to fluctuate, thus simulating a chronic 
 abscess : in such cases the hypodermatic needle would settle the diagnosis. 
 
 Treatment. — This should be removal when practicable. This is usually 
 readily eff'ected, the growth shelling out of its capsule ; but careful dissection is 
 required when they spring from large nerves, since these not uncommonly pass 
 through the center of the tumor, so that sections of the nerve have been 
 accidentally removed when excising such growths. 
 
202 AN AMERICAN TEXT- HOOK OF sriidERY. 
 
 B. Tumors conforming to the types of the higher connective 
 tissues : 
 
 1. Muscular Tumors, or Myomata. — Only tliose of conjrcnital oriiiin 
 seeiu to be composed of striated innsele-eleineiits (/•/i((b<h)-)/ii/<>)ii<i), hut even in 
 sueli tumors tlie bulk of the neoplasm is not usually composed of muscle-cells. 
 
 New "ijrowtlis made up in part of smooth, iiott-xtriated muscle-cells {Jeio- 
 myoma) fre(iuently occur in the uterus, forminj; such considerable portions of 
 most fibromata of that organ as to induce many writers to term then) myomata 
 of the uterus. In like manner most enlarged prostates are composed in great 
 part of unstriped muscle. Prostatic enlargements are more apt to be due to 
 fibro-myomatous growths involving the whole organ or an entire lobe, altiiough 
 distinct pedunculated growths are not uncommonly found; while those of 
 the uterus, often very large, consist usually of an aggregation of separate 
 tumors. Uterine fibromata also often assume the polypoid form, from the 
 extrusive efforts of the organ excited by the presence of the growth. Situated 
 elsewhere, myomata rarely attain a great bulk. Wherever situated, they grow 
 slowly and are quite innocent, although from their size or position they often 
 cause the utmost inconvenience or even danger to life. They are firm, some- 
 times smooth, but more often nodular, their cut surfaces closely resembling 
 those of a fibrous tumor, owing to the presence of varying quantities of true 
 fibrous tissue ; glandular structures form part of prostatic tumors. 
 
 Diagnosis. — As they are at the outset so situated as to be inaccessible to 
 sight or touch, the reader is referred to the sections on Diseases of the Prostate 
 and the Uterus. When the oesophagus, stomach, or intestines have been the 
 parts aff'ected, the nature of the tumors has rarely been diagnosticated. 
 
 Treatment. — When accessible, they should be removed. Not seldom this 
 may require total hysterectomy. 
 
 2. Vascular or Erectile Tumors, or Angeiomata. — Under this head 
 are classed all neoplasms the chief constituents of which are blood-vessels, 
 either arteries, veins, or capillaries, or in which tlie blood is contained in cav- 
 ernous spaces not true vessels. Many sarcomata, and some fibromata and car- 
 cinomata, are permeated Avith enormous (quantities of blood-vessels or channels 
 of large caliber, but the essential element composing each tumor is not the 
 vascular tissue, but the sarcomatous, fibrous, or carcinomatous element. 
 
 3. Both Angeiomata and Lymphangeiomata will be more thoroughly dis- 
 cussed in the chapters on Diseases of the Blood-vessels and Lym])hatics, Avhere 
 their treatment by excision, cauterization, ligature, or electrolysis is described. 
 
 4. Nerve Tumors, or Neuromata. — Such growths are of rare occurrence, 
 whether composed of medullated or of non-medullated nerve-fibres. To a void repe- 
 tition, the student is referred to the section on Injuries and Diseases of the Nerves. 
 
 C. Tumors conforming to the type of embryonic connective 
 tissue. 
 
 These neoplasms, called Sarcomata (PI. VIII and Fig. 26), closely imi- 
 tate in their structure normal embryonic or immature connective tissue, 
 and to this class belong the fibro-nucleated, fibro-plastic, myeloid, recur- 
 rent fibroid, and many of the encephaloid cancers of the older authors. 
 While normal embryonic connective tissue goes on to the formation of 
 fibrous tissue, cartilage, bone, and so on, the sarcomata always retain the 
 embryonic character at their circumference — /. e. their growing, advancing 
 
TUMORS. 
 
 Plate VIII. 
 
 Enormous sarcoma of buttock. 
 
rrMORS. 
 
 m.\ 
 
 border, and therefore their youn^^est and least mature part— even in cases 
 in which the okler portions may have developed almost normally into fibrous 
 tissue, cartilage, or bone. Therefore any rapidly-growing tumor of the connec- 
 tive-tissue tvjie must have its periphery especially subjected to careful micro- 
 scopic examination to determine whether sarcomatous elements exist there. Wlnle 
 the sarcomata vary much in their structure and clinical course, they all present the 
 following characteristics. The component cells contain one or more nuclei, the 
 masses of protoplasm of which they are formed not being surrounded by any dis- 
 tinct cell-wall, and the cell-bodv is large as compared with the nucleus. The cells 
 are " in constant relation with" the stroma"— z. e. the intercellular cement, that 
 which corresponds to stroma, surrounds each cell, varies in amount, and has no 
 definite arrangement, no alveoli being formed as in carcinoma. The blood-vessels 
 ramify among the cells, not, as in the carcinomata, running in the stroma, because 
 of the absence of any such structure, and are very thin-walled. Indeed, they often 
 
 Fig. 29. 
 
 Sarcoma of the Arm (Keenj. 
 
 appear to be nothing more than mere spaces bounded by the cells of the growth 
 themselves. A consideration of these peculiarities of structure and of the dis- 
 tribution of the blood-supply readily explains the frequent occurrence of hemor- 
 rhage into the substance of sarcomata. The fact that dissemination takes place 
 almost invariably by the blood-vessels, and not by the lymphatics, as is the case 
 with carcinomata, is also explainable by the peculiar relation of the vessels and 
 cells. Again, for the same reasons, the lungs, being the organs first reached by 
 the blood after fragments of the growth have been swept away by the current, 
 are the organs most often the seat of secondary deposits. The metastatic deposits 
 are usually similar in structure to the primary growth. Since sarcomata grow 
 by infiltrating the surrounding tissues, they are exceedingly apt to recur locally, 
 doubtless because some infiltrated tissue has been left. Secondary lymphatic 
 glandular involvement, except when the tonsil or testis is implicated, is the rare 
 
204 AN AMERICAN TEXT-IK )()K OF SURGERY. 
 
 exception — as is alleged, because of the absence of lymphatic vessels in mo.st 
 sarcomata: if tlii' organs just mentionod are attacked, glandular involvtMucnt 
 is the rule. Their growth is not slow and steady as in the carcinomata, but 
 spasmodic, now fast, now slow. While carcinoma attacks old or senescent 
 tissues, sarcoma most frequently occurs in organs or tissues which are develop- 
 ing, are in active function, or are at least in their prime ; hence it is a disease 
 of youth or early middle life. Another point in which it differs from carci- 
 noma is that scraping a freshly-cut section docs not yield a milky juice like 
 that obtainal)le from the latter form of malignant growth. Not infrequently 
 sarcomata result from an injury, such as a blow or a fracture. 
 
 So closely does one of tlie varieties of sarcoma — the round-celled — resemble 
 ordinary granulation-tissue that they cannot be distinguished from each other 
 microscopically. They both consist of small round cells similar to the 
 white cells of the blood, separated from one another by a very small amount 
 of homogeneous intercellular material permeated by delicate capillary vessels 
 arranged in the form of loops. The sarcomata exhibit nearly every step in 
 the development of the connective tissues, from this round-celled, immature 
 tissue to bone. Thus, the cells become elongated and spindle-shaped, while the 
 intercellular substance may show an attempt at fibrillation ; or further develop- 
 mental changes may ensue, converting the major part of the growth in some 
 instances almost Avholly into fibrous tissue, cartilage, or even bone, although, 
 as has been already said, sarcomatous elements are always discoverable at the 
 growing margins, while its malignancy, as shown by invasion of the surround- 
 ing tissues and dissemination throughout the internal organs, is in no way less- 
 ened. Calcification is often mistaken for true ossification, which is seldom met 
 with except in bone sarcomata, and while it is true that bone may form part of 
 any variety of sarcoma, yet it is most common in the spindle-celled and the mixed 
 forms. Where the new bony spicule, in any tumor connected with a long 
 bone, grow at ri^ht andes to the shaft of that bone, thev will usually be found 
 to be surrounded by some soft tissues, which upon microscopic examination will 
 prove to be of a sarcomatous nature : this arrangement of the bony spiculne is 
 the exact reverse of that commonly prevailing in the structure of true osteo- 
 mata. where they pursue a course parallel to the long axis of the bone and are 
 surrounded by cartilage or periosteum. 
 
 Sarcomata may be grouped in three main classes — viz. the round-celled, the 
 spindle-celled, and the myeloid or giant-celled. 
 
 1. The Round-celled Sarcomata usually form soft, vascular, and very 
 rapidly growing tumors, often becoming very large, and early giving rise to 
 metastatic deposits in distant parts and in the viscera. Microscopically, tliey 
 consist of round cells of varying size closely resembling leucocytes, imbedded 
 in a small amount of granular or homogeneous intercellular basis-substance. On 
 section they so much resemble brain-matter in consistence and vascularity that 
 the old terms encephaloid and medullary seem not inappropriate. Many of those 
 tumors formerly called encephaloid cancer or fungus ha^matodes were really 
 round-celled sarcomata. A variety of round-celled sarcoma, where the cells 
 lie within a stroma formed of delicate meshes closely resembling that of 
 lymphatic tissue, is often described as lymplio-sarcoma. Such tumors must 
 be distinguished from irritative enlargements of lymph-glands and the 
 adenoid hyperplasias of leukemia and Ilodgkin's disease. It has been 
 thought to have been palliated, or even to be curable in rare instances, by the 
 internal use of arsenic. ^lucoid softening, fatty degeneration, and ulcera- 
 tion are common secondary changes, together w ith the extravasation of blood 
 
TUMORS. 2().> 
 
 into their substance, resnltinc; in tlie formation of cysts (sarcomatous blood- 
 cysts). 
 
 Seats of Predilection. — They attack most freiiuently the periosteum, 
 bone, lymphatic <,'lantls, subcutaneous tissue, testicle, eye, ovary, uterus, lungs, 
 kidneys, and more rarely the skin, although they may originate wherever 
 fibrous tissue exists. 
 
 Sub- varieties. — {a) The glioma grows from the connective tissue (neu- 
 roglia) of nerve-eenters, and its basis-substance resembles that structure ; the 
 cells are apt to be small. It occurs in the retina and brain. According to the 
 latest investigations, as the neuroglia develops from the epiblast. gliomata can- 
 not properly be considered sarcomata, but form a special group by themselves. 
 {b) The lymphosarcoma, growing in lymphatic glands, is composed of cells 
 usually of large size, lying in a reticulum resembling lymphoid tissue, (c) The 
 psammoma or nest-celled sarcoma is of rare occurrence, attacking only the 
 pineal gland, (d) The alveolar sarcoma is so called because the basis-sub- 
 stance encloses each cell in a separate space or alveolus, (e) In the melanotic 
 sarcoma both the cells and the intercellular basis-substance are pigmented. Both 
 the alveolar and the melanotic form may be of the spindle-celled variety. The 
 melanotic form is found as a primary growth only in parts normally contain- 
 ing pigment, as the skin and the choroid coat of the eye, becomes rapidly dis- 
 seminated — the secondary growths being usually also pigmented — is probably 
 the most malignant of the sarcomata, and by the older writers was called 
 melanotic cancer or melanosis. Warts are sometimes pigmented, and thus look 
 like this form of sarcoma, but warts are firm, often pedunculated or lobulated, 
 and of slow growth : in rare instances pigmented w^arts undergo epitheliomatous 
 change, when their rapid growth excites the suspicion that they are pigmented 
 sarcomata, but in the epithelial grow^ths the glands early become implicated. 
 
 2. The Spindle-celled Sarcomata are formed of cells varying much 
 in size, some tumors being composed of very small oat-shaped cells, others of 
 greatly elongated bodies with long, fine, tapering extremities. Often the cells 
 are arranged in the form of trabeculse, w^hich so closely imitate fibrous bands 
 that the tumor may be diagnosticated as a fibrous or even a muscular growth. 
 
 The sub-varieties are the melajiotic, ^nst mentioned, and the small-celled 
 and large-celled. AVhen portions of these tumors have undergone developmental 
 changes they are sometimes called chondro-sarcoma, osteo-sarcoma, etc. 
 
 Seats of Predilection. — The skin and subcutaneous tissue, the fasciae 
 and intermuscular septa, the periosteum and the interior of bones, the eye, the 
 antrum, the breast, and the testicle. 
 
 Sarcomata consisting of an admixture in varying proportions of round 
 and spindle cells, or of cells of many diff'erent forms and sizes, are sometimes 
 called mixed-celled sarcomata. To the naked eye they present the same cha- 
 racteristics as the round- and spindle-celled forms, and they may undergo the 
 same developmental and degenerative changes. 
 
 Seats of Predilection. — Chiefly the bones. 
 
 3. The Myeloid or Giant-celled Sarcomata consist chiefly of large 
 elements formed of masses of protoplasm, containing two or more nuclei — up to 
 twenty, or even fifty — with a varying number of round, spindle, or mixed cells. 
 They usually spring from the interior, cancellous tissue of bones, and vary in 
 consistence from that of jelly to almost that of muscle. A section appears 
 smooth, shining, succulent, but presents no appearance of fibrillation, and is 
 of a greenish or of a livid red or maroon color, varied by pink or darker red 
 
206 .i.v AMi.incAX Ti:xr-i'.<K)h' or srnar.m'. 
 
 spots, duo to oxtraviisatioiis of" hldod. Tlicy have Ix'cii coiiiijarr'd in color to 
 the inusculiir tissue; of tlio heart. 
 
 Seats of Predilection. — Tlie lower jaw, the lower end (»f the femur, 
 and the he.id of the tihia ; altlujugh thoy may occur el.'sewhere. 
 
 The courses pursued by the several forms of sarcomata are partly depend- 
 ent upon their structure, ]>artly ujx)!! the organ or tissue which they attack. 
 For exanii)le, the connuonest form attacking the mamma, the spindle-celled, 
 occurs most frequently between thirty and forty years of age, is at first 
 encapsulated — therefore freely movable — hard and nodular, grows with great 
 raj)idity, and sooner or later, from softening or the development of cysts, is 
 apt to ])resent points of une(iual consistence, some of the conse((uent bosses 
 actually feeling fluctuant. The tumor remains for a considerable time isolable 
 from the mammary gland ])roper, thrusting this to one side. The skin 
 does not usually become adherent, even when intracystic growths fungate, 
 after having caused ulceration ; although, if the tumor is left to pursue its 
 natural course, in time not only the skin but also the subjacent parts will be 
 infiltrated, and death will ensue from sloughing or involvement of the lungs, 
 liver, or other viscera ; the axillary glands remain uninvolved. 
 
 Examine the other extreme as exemplified by the course pursued by a 
 giant-celled sarcoma, usually occurring in an adult over forty years of age, and 
 attacking the body of the lower jaw, slowly expanding the bone into a smooth 
 tumor, involving both its inner and its outer surface, the bony walls of which 
 are often so thin as to crackle under pressure, yet growing so slowly that 
 years may elapse before it attains the bulk of a Avalnut ; the growth does not 
 become adherent to the surrounding tissues, and consequently rarely ulcerates; 
 involvement of the lymphatic glands seldom occurs. 
 
 From the preceding remarks it Avill be seen hoAv difficult the diagnosis of 
 sarcoma often is, varying as the symptoms do with the organ attacked. Occur- 
 ring at all ages, sarcoma is more apt to attack the young — i. e. the tissues 
 during the developmental period. Although it is the rule for sarcomata to 
 grow rapidly, especially the secondary growths, yet some of the primary ones 
 develop slowly, the rate of growth and bulk attained depending largely upon 
 the tissue attacked. Those of the eye or brain are apt to be small, while those 
 of bone often reach a huge size. While those which attack the subcutaneous 
 tissue, the fascite, an<l the intermuscular ])lanes are usually surrounded with 
 a capsule, there is none for those springing from the surfaces of bones, nor for 
 those arising in the interior of such organs as the lymphatic glands, the tonsil, 
 etc., which are soon entirely infiltrated by the growth. 
 
 Infiltration of the surrounding tissues, even those external to its capsule 
 (when such exists), is a peculiarity of sarcoma : this is especially true of 
 the small spindle-celled variety (recurrent fibroid of Paget), which occurs 
 chiefly in the subcutaneous tissue and sometimes in the breast, recurring in 
 the course of many years a dozen or more times, while distant parts and the 
 lymphatic glands rarely become infected. Attention has already been called 
 to the early implication of the glands in sarcomata of certain organs, as the 
 testicle, etc. The subperiosteal sarcomata are very apt to give rise to secondary 
 tumors in other bones, the skin, the subcutaneous tissue, and the viscera, 
 lymphatic involvement being the rare exception. Finally, certain of the softer 
 sarcomata by hemorrhage into their substance ])ecome completely broken down 
 and converted into cyst-like tumors filled with blood, ])artly fluid, jiartly 
 coagulated. These if punctured bleed profusely, the hemorrhage being often 
 difficult to control ; without a microscopical examination it may be impossible 
 to distinguish such a growth from a true hematoma (blood-cyst). 
 
TUMOR.'S. 207 
 
 Diagnosis. — Tliis is often difficult, and must depend on a careful con- 
 sideration of the f()re<roin<2; facts, together with tliose now to be <»;iven. The 
 consistence of the tumor varies much in difierent parts; cysts are of fre(|uent 
 occurrence, especially when aftectin^ the bones, breast, or testicle ; moreover, 
 these develop, as does the growth, with a rapidity unknown in benign cystic 
 growths ; sarcomata are more a{)t to ulcerate than benign tumors — this is 
 peculiarly true of recurrent growths; the ulceration, whether the giving Avay 
 of the skin be due to infiltration, as is the rule, or merely to advancing pressure, 
 is apt to be preceded by a reddened, tender, hot skin, thus presenting such 
 symptoms of intlannuation as will embarrass the diagnosis in doubtful cases. 
 In any given case the (juestions to be considered are — Is it an inflammatory 
 trouble, or is it a malignant growth ? If a malignant groAvth, is it sarcoma 
 or carcinoma? The first (juestion can probably be answered by the history, 
 by the absence of the systemic indications of an acute sup})urative inflammation, 
 and, above all, by the marked differences of consistence exhibited by different 
 portions of the tumor. The second query, as to the class of malignant disease 
 to which any given growth belongs, can, with the exception of primary growths 
 attacking the tonsil, the testicle, or the lymphatic glands themselves, be settled 
 by the early involvement of the lymphatic glands in carcinoma and their immu- 
 nity in sarcoma, and by the frequent presence of cysts, the greater mobility, 
 the freedom of the overlying skin, the enlargement of the superficial veins, and 
 the greater rapidity of growth in the latter disease. Retraction of the nipple 
 in a case of tumor of the breast points to carcinoma rather than to sarcoma. 
 The peculiar features assumed by sarcoma as it affects each organ often afford 
 valuable information, and for this the student is referred to the appropriate 
 sections of this work. 
 
 The prognosis varies with the site of the disease; thus, a myeloid (giant- 
 celled) sarcoma of the lower jaw is not uncommonly curable by operation, while 
 a sarcoma of the tonsil or lymphatic glands destroys life with great rapidity. 
 As has just been pointed out, recurring small-celled sarcoma of the subcutaneous 
 tissue may be repeatedly removed, the system remaining free ; or amputation, 
 if a limb be involved, will probably cure the disease. It also varies with the 
 variety of the disease: the more embryonic the form the greater the malignancy. 
 Thus the round-celled variety is by far the most malignant form, the spindle- 
 celled usually less so, and the myeloid the least. 
 
 Treatment. — This depends partly on the variety, partly on the organ 
 attacked. While it is true that a myeloid tumor of the lower jaw may after 
 thorough enucleation never recur, it is far safer to remove at the same time as 
 much of the surrounding tissue as can be done with safety. When the long 
 bones are the seat of sarcoma, amputate high up — if possible, through the joint 
 above : this is likewise good practice when sarcomata of the soft parts of the 
 extremities recur, especially if they are of the round-celled type. If the upper 
 jaw is attacked, the wdiole maxilla of that side must be removed, but the prog- 
 nosis will be bad. Sarcomata of the lymph-glands or of the tonsil are so little 
 influenced for good by operation that, except as a mere palliative, removal, as 
 a rule, should not be attempted. Tumors of the subcutaneous tissue or inter- 
 muscular fascia should be removed as often as they recur, or amputation may be 
 resorted to when a limb is concerned. It has been long known that occasion- 
 ally an attack of erysipelas will cure a sarcoma. Lately, the treatment of 
 inoperable sarcomata by hypodermatic injections of the toxins of erysipelas, 
 instead of the streptococcus itself, has been revived, especially by Coley. 
 The toxin of the bacillus prodigiosus added to that of erysipelas increases 
 the reaction. A few cases of apparent cure have been reported by Coley, 
 
208 AN AMFJilCAN TKXT-nOOK OF SlRaERY. 
 
 Mynter, aiul .sevt-rul others, Ijiit most other surireons have met only with 
 failure. 
 
 D. The Endotheliomata. 
 
 Tliese, as yet, little-kiiowii tumors, occupying apparently tlic ])(»nlcr-land 
 between sarcomata and carcinomata, must be l)riefly considered, sinee it ap- 
 pears pro])ablc that some sarcomata of tlie testicle are of this nature, and, 
 deveh)ping at least in part from the endothelium of the lymphatics, give rise 
 to that early infection of the glands so characteristic of testicular sarcoma, and 
 yet so contrary to the natural history of the disease as it occurs in nearly every 
 other situation. 
 
 When arising in the pia mater, structurally and from their mode of origin 
 many of these endotheliomata are alveolar sarcomata, while those originating 
 in the pleura or peritoneum are carcinomatous, consisting of nests and clusters 
 of epithelial cells presenting at their periphery a columnar appearance, these 
 cell-masses being surrounded by a dense fibrous stroma : the cells follow very 
 exactly "the course of the lymphatic vessels." They present themselves in 
 the form of " multiple flattened nodular growths, white in color, and either 
 isolated or connected by neoplastic bands, the intervening serous membrane 
 being more or less thickened;" metastasis is common, giving rise, when the 
 pleura, for instance, is the seat of the primary tumor, usually to secondary 
 growths in the peribronchial fibrous tissue, the bronchial glands, and the 
 thoracic muscles. Attacking as they do chiefly the pleura and peritoneum, 
 nothing definite can be said concerning their diagnosis or treatment, and they 
 have been mentioned here because of their apparent etiological relations to 
 other malignant growths, and because, although rare, recorded cases are becom- 
 ing more frequent. 
 
 A. Warty or Villous Tumors, or Papillomata, closely resemble in their 
 structure hypertrophied papillae of the skin or mucous membrane, some of the 
 varieties receiving other special names, as condylomata, mucous tul>ercles, and 
 "benign villous tumors." They are often due to some form of ii'ritation, as in 
 the case of those which develop on the glans penis from the action of acrid 
 discharges, or those on the hands from dust and dirt. Rarely attaining a large 
 size, and attacking only the skin or the mucous membranes, they are innocent 
 growths, although during the cancerous period of life they are apt to degenerate 
 into epithelioma, and the villous tumor of the bladder may destroy life by the 
 hemorrhage to which such a growth often gives rise. Structurally, they are 
 composed of a varying amount of connective tissue surrounding one or more 
 central blood-vessels, and are covered in by one or several layers of epithelial 
 cells resembling those of the skin or mucous membrane from which they are 
 developed ; but the cells never transgress their connective-tissue limit — i. e. 
 they do not infiltrate, as epithelioma does. 
 
 Warts or warty grotvths either occur as circumscribed growths, or more 
 rarely form cauliflower masses, large relatively to the size of the part, such as 
 those occurring in the larynx. The enlarged papilbv are covered by a layer or 
 layers of horny epithelium, and their vascular supply, as a rule, is small. 
 
 Mucous tubercles and condylomata consist of flattened elevations composed 
 of enlarged papillre ; their connective tissue, of rapid growth, is infiltrated with 
 numerous small round cells, and their epithelial covering is moist and sodden. 
 They are most commonly due to syphilis. 
 
 Villous tumors, when springing apparently from the vesical uuu-ous mem- 
 brane, where papillae do not normally exist, originate from the subepithelial con- 
 
TUMORS. l^y 
 
 the slipping away of the edge of the tumor from heneath the finger when pressed 
 upon : possibly the grooved needle may be requisite. Certain variations should 
 be noted. Tlius there is a diffuse form, producing symmetrical swellings at the 
 back of the neck, or beneath the chin, forming so-called "double neck " and 
 "double chin." Again, the presence of more fibrous tissue than usual may 
 render lipomata unusually firm. They may be deep-seated, springing from 
 the intermuscular septa or even from the surface of a bone. Moreover, they 
 occasionally become pedunculated. Lastly, some of the most typical cases of 
 "painful subcutaneous tubercle" are composed of fat. The average case can 
 be readily diagnosticated from a cyst, a chronic abscess, or a bursal enlargement 
 by the symptoms given above, while the deeper-seated can hardly be mistaken 
 for any other than soft fibrous or myxomatous groAvths — an error of no practical 
 moment, since both should be removed. 
 
 Treatment. — For the circumscribed variety a free incision, opening the 
 capsule, should be employed, when the tumor will usually shell out ; if more 
 adherent, some dissection with the knife may be necessary : all portions of the 
 growth must be removed, since occasionally, although rarely, the portions left 
 have formed the starting-point of a new tumor. Multiple growths, unless pain- 
 ful ones, seldom require removal. The diff"used form should not usually be 
 attacked with the knife. The prolonged internal use of liquor potassie in 
 10-minim doses, t. d., has in certain instances caused their disappearance. 
 
 3. Cartilaginous Tumors, Chondromata or Enchondromata (PI. VII.), 
 are composed of some variety of cartilage, forming hard, elastic, slowly enlarg- 
 ing growths, often nodular or lobulated. They may consist of a single mas? 
 or of a number of small masses each enclosed in its capsule, all bound 
 together by connective tissue and blood-vessels. They are homogeneous or 
 coarsely granular on section, presenting a translucent, bluish-gray or pinkish- 
 white surfiice, sometimes marked out into irregular lobules. Histologically^ 
 they are usually composed of hyaline- or fibro-cartilage. Where unattached 
 to bone their fibrous capsule serves as a perichondrium, and when exposed to 
 friction a bursal sac often forms between them and the superjacent parts. 
 Fatty or mucoid secondary changes may render some of the nodules centrally 
 diffluent, producing cyst-like cavities containing synovia-like fluid, thus so 
 completely metamorphosing the tumors that they sometimes are hardly recog- 
 nizable as chondromata ; while, on the contrary, some become calcified or ossified. 
 This latter change is especially apt to affect chondromata springing from the 
 juxta-epiphyseal region of the long bones, the change progressing so far that 
 only a thin layer of cartilage caps them, forming what are termed cancel- 
 lous exostoses. Chondromata are apt to be single, but they are often multiple 
 and symmetrical, as those attacking the phalanges. While pure cartilaginous 
 growths are benign, sarcomata are often partly, or even chiefly, composed of 
 cartilage, especially those found in the testicle and the parotid. Multiple chon- 
 dromata of the hand, if of rapid growth, should be viewed with suspicion as 
 possibly cartilaginous sarcomata. Occurring at any age, they are more com- 
 mon in the young, especially those springing from the long bones near the 
 epiphyses. Sometimes the tendency to their formation seems to be inherited, 
 the tumors being similarly located in both parents and children. While they 
 often attain a large size, they grow slowly, so that unusual bulk Avith rapid 
 growth would justify a strong suspicion of the intermixture of sarcomatous 
 elements. Mixed tumors containing cartilage have been already referred 
 to. 
 
 Seats of Predilection. — The bones, especially on or in the phalanges of 
 
200 AX A.VrjnrrAX TEXT-BOOK OF ST^ROERV. 
 
 the fingers or toes ; the lower juxta-epiphyseal region of the femur ; the upper 
 ends of the tibia, fibuha, and humerus, the scapula and ilium, on or in the jaws, 
 especially the ujiper; the salivary glands, notably the parotid ; the testicle ; in or 
 around joinrs attacked by rheumatoid arthritis; and the subcutaneous tissues. 
 
 Diagnosis. — This must de|)end on the hardness yet elasticity of the tumor, 
 its nodular circumscribed outlines, and its slow continuous growth ; later, 
 on the development of softened spots indicative of cystic degeneration, and on 
 the location of the tumor, as upon a young bone near an epiphysis. A carfi- 
 lai/inous aarcoma — the growth with which chondromata are most likely to be 
 confounded — j)resents less definite outlines — /. e. infiltrates somewhat, is apt 
 to ])e of unequal consistence from the outset, and grows with much greater 
 rapidity. 
 
 Treatment. — Complete removal of a pure chondroma will secure future 
 immunity, and should always be adopted when possible. Mixed chondromata 
 containing sarcomatous elements commonly recur. In the parotid gland and sub- 
 cutaneous tissues they can usually be enucleated with their capsules, and some- 
 times this can be done when the phalanges are involved, but more often in the 
 latter event and Avhen the testicle is attacked the whole part or organ must be 
 sacrificed : usually those springing from the surfaces of the larger bones can be 
 removed without sacrificing the bone, with but small chance of their recurrence. 
 
 4. Osseous Tumors, or Osteomata, are formed of true bone, and are gene- 
 rally composed almost solely of either cancellous or compact bone. The can- 
 cellous have been just described as resulting from the ossification of chondro- 
 matous growths springing from the juxta-epiphyseal portions of such long 
 bones as the tibia, feumr, humerus, fibula, etc., where they form exostoses. 
 The ungual surface of the distal phalanx of the great toe is often the site of 
 such a tumor, producing a subungual growth. The compact osseous tumors 
 rarely grow from any other bones than those of the cranium. Certain exostoses, 
 called from their hardness "ivory exostoses," are said to differ from other bony 
 growths b}' the absence of Haversian canals, and are composed of "layers of 
 bone lamellae laid concentrically over a central point or pedicle." They rarely 
 attain a greater size than that of a small walnut, are so dense that they can 
 hardly be cut by any instrument, and it is difficult by the exercise of great 
 force to fracture their pedicles, even wdien comparatively slender. The ivory 
 exostosis springs from the exterior of one of the cranial bones, while the more 
 ordinary forms of compact osteomata originate in the cranial or nasal sinuses, 
 grow slowly, and thrust aside or cause absorption of adjacent structures, thus pro- 
 ducing marked deformities. Although usually single, osseous tumors in some 
 patients may be multiple, being found by the score, in such cases commonly 
 commencing at a very early age, being then hereditary and often symmetrical. 
 
 Seats of Predilection. — These have been mentioned above in describ- 
 ing these growths. 
 
 Diagnosis. — This is usually easy, depending on the evident connection of 
 the tumor Avith bone or cartilage, for tumors growing apart from these struc- 
 tures in the connective tissue are probably tumors of some other class which 
 have undergone osseous change, or are structures, such as tendons, muscles, etc., 
 which have undergone calcification or ossification. The pedunculated form 
 when the osteoma occurs as an exostosis, the dense, hard, irregularly nodulated 
 surface when the tumor is non-pedunculated, and its slow growth, serve as dis- 
 tinguishing points. The more rapid growth and unequal consistence of the 
 calcifying or ossifying sarcomata serve to distinguish this variety of malignant 
 growth from the benign osseous tumors. 
 
Tr^fORs. 201 
 
 Treatment. — Although operation alone can remove these growths, not 
 every one should he meddled with, hut only those should be attacked which 
 are steadily growing and are painful or ])ioduce great deformity or loss of 
 function, and the ])roposed o])eration on which will not unduly risk the life of 
 the patient. Thus, most of the exostoses of the flat and long bones and certain 
 osteomata of the upper and lower jaws should be removed, for valid reasons, 
 such as those just given. Those of the facial and cranial bones, which are 
 ill defined and often extend so deeply as to involve the base of the skull, 
 should not be touched. It Avas formerly taught that it was inadvisable to r^t- 
 tempt the removal of non-pedunculated, sessile exostoses of the long bones, 
 which are usually covered by thick masses of muscle, because of the risk of 
 profuse and deep-seated suppuration ; but with modern methods of operating 
 such complications ought to be avoided, so that if good reasons exist for their 
 removal such tumors should be subjected to operation. 
 
 With the exception of the cancellous exostosis of the ungual phalanx of 
 the great toe, a pure osteoma when removed does not return, even when 
 some of the surface from which it has sprung is allowed to remain. An ossi 
 fying sarcoma, for which osteoma has sometimes been mistaken, Avill of course 
 return. In the exceptional case mentioned the distal portion of the pha- 
 lanx should be removed with the tumor to obviate any risk of recur- 
 rence. 
 
 5. Mucous Tumors, or Myxomata, resemble both to the naked eye and 
 to the microscope the Whartonian jelly of the umbilical cord and the vitreous 
 humor of the eye. They grow slowly, and may attain a large size, but are in- 
 nocent tumors, not returning when pure and if completely removed. Sarcomata 
 may undergo an analogous change — i. e. mucous softening — and of course such 
 tumors are apt to recur. Mucoid softening also attacks fibromata, chondro- 
 mata, and other connective-tissue tumors, so that many tumors called myxo- 
 mata are chondromata, fibromata, or sarcomata undergoing mucoid (myxo- 
 matous) change. 
 
 Structurally, a true myxoma is soft, gelatinous, semi-translucent, encapsu- 
 lated, and intersected by septa of fibrous tissue. Their cut surfaces are pinkish- 
 or yellowish-gray, and exude large quantities of glairy fluid containing much 
 mucin. Microscopically, they are seen to be composed of numerous anasto- 
 mosing stellate cells, with branching processes which form a delicate stroma 
 in which the gelatinous basis-substance is contained : some round and spin- 
 dle cells are also found. Inflammation, fatty degeneration, ulceration, and 
 the formation of blood-cysts from rupture of capillary vessels are the secondary 
 changes to which these tumors are liable. 
 
 Seats of Predilection. — The nasal cavities, in which they form gelatin- 
 ous polypi ; the mammary gland ; the intermuscular spaces ; the submucous and 
 subserous tissues ; more rarely the periosteum, the bone medulla, and sheaths 
 of nerves. 
 
 Diagnosis. — Before removal their close physical resemblance to fatty and 
 fibro-cellular tumors renders certainty impossible, since they present the same 
 soft, elastic feel, and may even seem to fluctuate, thus simulating a chronic 
 abscess : in such cases the hypodermatic needle would settle the diagnosis. 
 
 Treatment. — This should be removal when practicable. This is usually 
 readily eff'ected, the growth shelling out of its capsule ; but careful dissection is 
 required "when they spring from large nerves, since these not uncommonly pass 
 through the center of the tumor, so that sections of the nerve have been 
 accidentally removed when excising such growths. 
 
202 AN AMERICAN TEXT-HOOK OFSl'IiOEIiY. 
 
 V>. Tumors conforming to the types of the higher connective 
 tissues : 
 
 1. Muscular Tumors, or Myomata. — Only those of con<!;enital origin 
 seem to be composed of striated muscle-elements {rhahdo-inyoma), but even in 
 such tumors the bulk of the neoplasm is not usually composed of muscle-cells. 
 
 New jrrowths made up in part of smooth. 7ton-!<triafn] muscle-cells (leio- 
 mi/0))ia) frc(iuciitly occur in the uterus, formiiijr such considerable portions of 
 most fibromata of that ort^an as to induce many writers to term them myomata 
 of the uterus. In like manner most enlarged prostates are composed in great 
 part of unstriped muscle. Prostatic enlargements are more apt to be due to 
 libro-myomatous growths involving the whole organ or an entire lobe, although 
 distinct pedunculated growths are not uncommonly found; while those of 
 the uterus, often very large, consist usually of an aggregation of separate 
 tumors. Uterine fibromata also often assume the polypoid form, fnmi the 
 extrusive efforts of the organ excited by the presence of the growth. Situated 
 elsewhere, myomata rarely attain a great bulk. Wherever situated, they grow 
 slowly and are quite innocent, although from their size or position they often 
 cause the utmost inconvenience or even danger to life. They are firm, some- 
 times smooth, but more often nodular, their cut surfaces closelv resembling 
 those of a fibrous tumor, owing to the presence of varying quantities of true 
 fibrous tissue ; glandular structures form part of ])rostatic tumors. 
 
 Diagnosis. — As they are at the outset so situated as to be inaccessible to 
 sight or touch, the reader is referred to the sections on Diseases of the Prostate 
 and the Uterus. When the oesophagus, stomach, or intestines have been the 
 parts affected, the nature of the tumors has rarely been diagnosticated. 
 
 Treatment. — When accessible, they should be removed. Not seldom this 
 may require total hysterectomy. 
 
 2. Vascular or Erectile Tumors, or Angeiomata. — Under this head 
 are classed all neoplasms the chief constituents of which are blood-vessels, 
 either arteries, veins, or capillaries, or in which the blood is contained in cav- 
 ernous spaces not true vessels. Many sarcomata, and some fibromata and car- 
 cinomata, are permeated with enormous quantities of blood-vessels or channels 
 of large caliber, but the essential element composing each tumor is not the 
 vascular tissue, but the sarcomatous, fibrous, or carcinomatous element. 
 
 3. Both Angeiomata and Lymphangeiomata will be more thoroughly dis- 
 cussed in the chapters on Diseases of the Blood-vessels and Lymphatics, where 
 their treatment by excision, cauterization, ligature, or electrolysis is described. 
 
 4. Nerve Tumors, or Neuromata. — Such growths are of rare occurrence, 
 whether composed of medullated or of non-medullated nerve-fibres. To avoid repe- 
 tition, the student is referred to the section on Injuries and Diseases of the Nerves. 
 
 C. Tumors conforming to the type of embryonic connective 
 tissue. 
 
 These neoplasms, called Sarcomata (PI. Mil aiid Fig. 26), closely imi- 
 tate in their structure normal embryonic or immature connective tissue, 
 and to this class belong the fibro-nucleated, fibro-plastic, myeloid, recur- 
 rent fibroid, and many of the encephaloid cancers of the older authors. 
 W'hile normal embryonic connective tissue goes on to the formation of 
 fibrous tissue, cartilage, bone, and so on, the sarcomata always retain the 
 embryonic character at their circumference — i. e. their growing, advancing 
 
TUMORS. 
 
 Plate VIII. 
 
 Enormous sarcoma of buttock. 
 
rrMORS. 
 
 20.) 
 
 border, and therefore their youngest and least mature part— even in cases 
 in wliieii the ohler portions may have developed almost normally into fibrous 
 tissue, cartilage, or bone. Therefore any rapidly-growing tumor of the connec- 
 tive-tissue tyi)e nmst have its periphery especially subjected to careful micro- 
 scopic examination to determine whether sarcomatous elements exist there. AVhde 
 the sarcomata vary much in their structure and clinical course, they all ])resent the 
 following characteriiitics. The component cells contain one or more nuclei, the 
 masses oi' protoplasm of which they are formed not being surrounded by any dis- 
 tinct cell-wall, and the cell-body is 'large as compared with the nucleus. The cells 
 are '^ in constant relation with" the stroma"—/, e. the intercellular cement, that 
 which corresi)oruls to stroma, surrounds each cell, varies in amount, and has no 
 definite arrangement, no alveoli being formed as in carcinoma. The blood-vessels 
 ramify among the cells, not, as in the carcinomata, running in the stroma, because 
 of the absence of any such structure, and are very thin-walled. Indeed, they often 
 
 Fig. 29. 
 
 .■sarcoma of the Arm ^Keun). 
 
 appear to be nothing more than mere spaces bounded by the cells of the growth 
 themselves. A consideration of these peculiarities of structure and of the dis- 
 tribution of the blood-supply readily explains the frequent occurrence of hemor- 
 rhage into the substance of sarcomata. The fact that dissemination takes place 
 almost invariably by the blood-vessels, and not by the lymphatics, as is the case 
 with carcinomata, is also explainable by the peculiar relation of the vessels and 
 cells. Again, for the same reasons, the lungs, being the organs first reached by 
 the blood after fragments of the growth have been swept away by the current, 
 are the organs most often the seat of secondary deposits. The metastatic deposits 
 are usually similar in structure to the primary growth. Since sarcomata grow 
 by infiltrating the surrounding tissues, they are exceedingly apt to recur locally, 
 doubtless because some infiltrated tissue has been left. Secondary lymphatic 
 glandular involvement, except when the tonsil or testis is implicated, is the rare 
 
204 AN AMERICAN TEXT- HOOK OF SURGERY. 
 
 exception — as is alleged, because of the absence of lymphatic vessels in most 
 sarcomata: if tlie organs just mentioned are attacked, glandular involvement 
 is the rule. Their growth is not slow and steady as in the carcinomata, but 
 spasmodic, now fast, now slow. AVhile carcinoma attacks old or senescent 
 tissues, sarcoma most freijuently occurs in organs or tissues which are develop- 
 ing, are in active function, or are at least in their j)rime ; hence it is a disease 
 of youth or early middle life. Another point in which it differs from carci- 
 noma is that scraping a freshly-cut section does not yield a milky juice like 
 that obtainable from the latter form of malignant growth. Not infrequently 
 sarcomata result from an injury, such as a blow or a fracture. 
 
 So closely does one of the varieties of sarconui — the round-celled — resemble 
 ordinary granulation-tissue that they cannot be distinguished from each other 
 microscopically. They both consist of small round cells similar to the 
 white cells of the blood, separated from one another by a very small amount 
 of homogeneous intercellular material permeated by delicate capillary vessels 
 arranged in the form of loops. The sarcomata exhibit nearly every step in 
 the development of the connective tissues, from this round-celled, immature 
 tissue to bone. Thus, the cells become elongated and spindle-shaped, while the 
 intercellular substance may show an attempt at fibrillation ; or further develop- 
 mental changes may ensue, converting the major part of the growth in some 
 instances almost wholly into fibrous tissue, cartilage, or even bone, although, 
 as has been already said, sarcomatous elements are always discoverable at the 
 grooving margins, while its malignancy, as sho^vn l)y invasion of the surround- , 
 ing tissues and dissemination throughout the internal organs, is in no way less- 
 ened. Calcification is often mistaken for true ossification, which is seldom met 
 with except in bone sarcomata, and while it is true that bone may form part of 
 any variety of sarcoma, yet it is most common in the spindle-celled and the mixed 
 forms. Where the ncAV bony spiculiTe, in any tumor connected with a long 
 bone, grow at right angles to the shaft of that bone, they will usually be found 
 to be surrounded by some soft tissues, which upon microscopic examination will 
 prove to be of a sarcomatous nature : this arrangement of the bony spicule is 
 the exact reverse of that commonly prevailing in the structure of true osteo- 
 mata, where they pursue a course parallel to the long axis of the bone and are 
 surrounded by cartilage or periosteum. 
 
 Sarcomata may be grouped in three main classes — viz. \h.Q round-celled, the 
 spindle-celled, and the myeloid or yiant-celled. 
 
 1. The Round-celled Sarcomata usually form soft, vascular, and very 
 rapidly growing tumors, often becoming very large, and early giving rise to 
 metastatic deposits in distant parts and in the viscera. ^Microscopically, they 
 consist of round cells of varying size closely resembling leucocytes, iml)cdded 
 in a small amount of granular or homogeneous intercellular basis-substance. On 
 section they so much resemble brain-matter in consistence and vascularity that 
 the old terms encephaloid and medullary seem not inappropriate. Many of those 
 tumors formerly called encephaloid cancer or fungus luematodes were really 
 round-celled sarcomata. A variety of round-celled sarcoma, where the cells 
 lie within a stroma formed of delicate meshes closely resembling that of 
 lymphatic tissue, is often described as lymplio-sareoma. Such tumors must 
 be distinguished from irritative enlargements of lymph-glands and the 
 adenoid hyperplasias of leukemia and Hodgkin's disease. It has been 
 thought to have been palliated, or even to be curable in rare instances, by the 
 internal use of arsenic. Mucoid softening, fatty degeneration, and ulcera- 
 tion are common secondary changes, together with the extravasation of blood 
 
TUMORS. 205 
 
 into their suhstance, resulting in the formation of cysts (sarcomatous blood- 
 cysts). 
 
 Seats of Predilection. — They attack most freciucntly the ])enosteum, 
 bone, lymphatic glands, subcutaneous tissue, testicle, eye, ovary, uterus, lungs, 
 kidney's, and more rarely the skin, although they may originate wherever 
 librous tissue exists. 
 
 Sub-varieties. — ('■0 The gliomn grows iVoin the connective tissue (neu- 
 ron;lia) of nerve-centers, and its basis-suhstance resembles that structure ; the 
 ceUs are apt to be small. It occurs in the retina and brain. According to the 
 latest investigations, as the neuroglia develops from the epiblast, gliomata can- 
 not properly be considered sarcomata, but form a special group by themselves. 
 {b) The li/mj)ho-sarcovia, growing in lymphatic glands, is composed of cells 
 usually of large size, lying in a reticulum resembling lymphoid tissue, (c) The 
 psananoma or nest-celled sarcoma is of rare occurrence, attacking only the 
 pineal gland, (d) The alveolar sarcoma is so called because the basis-sub- 
 stance encloses each cell in a separate space or alveolus, {e) In the melanotic 
 sarcoma both the cells and the intercellular basis-substance are pigmented. Both 
 the alveolar and the melanotic form may be of the spindle-celled variety. The 
 melanotic form is found as a primary growth only in parts normally contain- 
 ing pigment, as the skin and the choroid coat of the eye, becomes rapidly dis- 
 seminated — the secondary growths being usually also pigmented — is probably 
 the most malignant of the sarcomata, and by the older writers was called 
 melanotic cancer or melanosis. Warts are sometimes pigmented, and thus look 
 like this form of sarcoma, but warts are firm, often pedunculated or lobulated, 
 and of slow growth : in rare instances pigmented warts undergo epitheliomatous 
 change, when their rapid growth excites the suspicion that they are pigmented 
 sarcomata, but in the epithelial growths the glands early become implicated. 
 
 2. The Spindle-celled Sarcomata are formed of cells varying much 
 in size, some tumors being composed of very small oat-shaped cells, others of 
 greatly elongated bodies with long, fine, tapering extremities. Often the cells 
 are arranged in the form of trabecule, which so closely imitate fibrous bands 
 that the tumor may be diagnosticated as a fibrous or even a muscular growth. 
 
 The sub-varieties are the melanotic, pist mentioned, and the small-celled 
 and large-celled. When portions of these tumors have undergone developmental 
 chancres they are sometimes called chondro-sarcoma, osteo-sarcoma, etc. 
 
 Seats of Predilection. — The skin and subcutaneous tissue, the fasciae 
 and intermuscular septa, the periosteum and the interior of bones, the eye, the 
 antrum, the breast, and the testicle. 
 
 Sarcomata consisting of an admixture in varying proportions ot round 
 and spindle cells, or of cells of many different forms and sizes, are sometimes 
 called mixed-celled sarcomata. To 'the naked eye they present the same cha- 
 racteristics as the round- and spindle-celled forms, and they may undergo the 
 same developmental and degenerative changes. 
 
 Seats of Predilection.— Chiefly the bones. 
 
 3. The Myeloid or Giant-celled Sarcomata consist chiefly of large 
 elements formed of masses of protoplasm, containing two or more nuclei — up to 
 twenty, or even fifty — Avith a varying number of round, spindle, or mixed cells. 
 They usually spring from the interior, cancellous tissue of bones, and vary in 
 consistence from that of jelly to almost that of muscle. A section appears 
 smooth, shining, succulent, but presents no appearance of fibrillation, and is 
 of a greenish or of a livid red or maroon color, varied by pink or darker red 
 
206 J.V AMEnTCAX TKXT-l\OOk' OF smCKliY. 
 
 spots, due to extravasations of blood. 'Tlioy liave been (•(tiii]i;iicil in color to 
 the muscuhir tissue of the heart. 
 
 Seats of Predilection. — The lower jaw, tlic htwcr cud of the fcimir, 
 and tile licad of the tibia ; althouLlh they uuiy occur elsewhere. 
 
 The courses ])ursued by the several forms of sarcomata are partly depend- 
 ent u})on their structure, ])artly upon the organ or tissue which they attack. 
 For exam[)le, tiie commonest form attacking the mamma, the spindle-celled, 
 occurs most frequently between thirty and forty years of age, is at first 
 enca))sulated — therefore freely movable — hard and nodular, grows with great 
 rapidity, and sooner or later, from softening or the development of cysts, is 
 apt to pi'esent points of uneciual consistence, some of the conse((uent bosses 
 actuallv feeling ilucfuant. The tumor remains for a considerable time isolable 
 from the mauuuary gland ])roper, thrusting this to one side. The skin 
 does not usually become adherent, even when intracystic growths fungate, 
 after having caused ulceration ; although, if the tumor is left to pursue its 
 natural course, in time not only the skin but also the subjacent parts will be 
 infiltrated, and death will ensue from sloughing or involvement of the lungs, 
 liver, or other viscera ; the axillary glands renuiin uninvolved. 
 
 Examine the other extreme as exemplified by the course pursued by a 
 giant-celled sarcoma, usually occurring in an adult over forty years of age, and 
 attacking the body of the lower jaw, slowly expanding the bone into a smooth 
 tumor, involving l)oth its inner and its outer surface, the bony walls of which 
 are often so thin as to crackle under ])ressure, yet growing so slowly that 
 years may elapse before it attains the bulk of a walnut ; the growth does not 
 become adherent to the surrounding tissues, and consequently rarely ulcerates ; 
 involvement of the lymphatic glands seldom occurs. 
 
 From the preceding remarks it will be seen how difficult the diagnosis of 
 sarcoma often is, varying as the symptoms do with the organ attacked. Occur- 
 ring at all ages, sarcoma is more apt to attack the young — i. e. the tissues 
 during the developmental period. Although it is the rule for sarcomata to 
 grow rapidly, especially the secondary growths, yet some of the primary ones 
 develop slowly, the rate of growth and bulk attained depending largely upon 
 the tissue attacked. Those of the eye or brain are apt to be small, while those 
 of bone often reach a huge size. While those which attack the subcutaneous 
 tissue, the fascia, and the intermuscular planes are usitally surrounded with 
 a capsule, there is none fi)r those s|)ringing from the surfaces of bones, nor for 
 those arising in the interior of such organs as the lymphatic glands, the tonsil, 
 etc., which are soon entirely infiltrated by the growth. 
 
 Infiltration of the surrounding tissues, even those external to its capsule 
 (Avlien such exists), is a peculiarity of sarcoma : this is especially true of 
 the small spindle-celled variety (recurrent fibroid of Paget), which occurs 
 chiefly in the subcutaneous tissue and sometimes in the breast, recurring in 
 the course of many years a dozen or more times, while distant parts and the 
 lymphatic glands rarely become infected. Attention has already been called 
 to the early implication of the glands in sarcomata of certain organs, as the 
 testicle, etc. The subperiosteal sarcomata are very apt to give rise to secondary 
 tumors in other bones, the skin, the subcutaneous tissue, and the viscera, 
 lymphatic involvement being the rare exception. Finally, certain of the softer 
 sarcomata bv hemorrhafie into their substance become completely broken down 
 and converted into cyst-like tumors filled with blood, partly fluid, partly 
 coagulated. These if punctured bleed profusely, the hemorrhage being often 
 difficult to control ; without a microscopical examination it may be impossible 
 to distinguish such a groAvth from a true heuuitoma (blood-cyst). 
 
TUMORS. 207 
 
 Diagnosis. — This is often difficult, and must depend on a careful con- 
 sideration of the fore<:;oin^ facts, to;i;ether with those now to he i^iven. The 
 consistence of the tumor varies much in different parts; cysts are of frequent 
 occurrence, especially when affecting the bones, breast, or testicle ; moreover, 
 these develop, as does the growth, with a rapidity unknown in benign cystic 
 growths; sarcomata are more apt to ulcerate than benign tumors — this is 
 peculiai-ly true of recurrent growths; the ulceration, whether the giving way 
 of the skin be due to infiltration, as is the rule, or merely to advancing i)ressure, 
 is apt to be preceded by a reddened, tender, hot skin, thus presenting such 
 symptoms of inffanunation as -will embarrass the diagnosis in doubtful cases. 
 In any given case the (questions to be considered are — Is it an inflammatory 
 trouble, or is it a malignant growth ? If a malignant growth, is it sarcoma 
 or carcinoma? The first question can probably be ansAvered by the history, 
 by the absence of the systemic indications of an acute suppurative inflammation, 
 and, above all, by the marked differences of consistence exhibited by different 
 ])ortions of the tumor. The second query, as to the class of malignant disease 
 to which any given growth belongs, can, with the exception of primary growths 
 attacking the tonsil, the testicle, or the lymphatic glands themselves, be settled 
 by the early involvement of the lymphatic glands in carcinoma and their immu- 
 nity in sarcoma, and by the frequent presence of cysts, the greater mobility, 
 the freedom of the overlying skin, the enlargement of the superficial veins, and 
 the greater rapidity of growth in the latter disease. Retraction of the nipple 
 in a case of tumor of the breast points to carcinoma rather than to sarcoma. 
 The peculiar features assumed by sarcoma as it affects each organ often afford 
 valuable information, and for this the student is referred to the appropriate 
 sections of this work. 
 
 The prognosis varies with the site of the disease; thus, a myeloid (giant- 
 celled) sarcoma of the lower jaw is not uncommonly curable by operation, Avhile 
 a sarcoma of the tonsil or lymphatic glands destroys life with great rapidity. 
 As has just been pointed out, recurring small-celled sarcoma of the subcutaneous 
 tissue may be repeatedly removed, the system remaining free ; or amputation, 
 if a limb be involved, Avill probably cure the disease. It also varies with the 
 variety of the disease : the more embryonic the form the greater the malignancy. 
 Thus the round-celled variety is by far the most malignant form, the spindle- 
 celled usually less so, and the myeloid the least. 
 
 Treatment. — This depends partly on the variety, partly on the organ 
 attacked. While it is true that a myeloid tumor of the lower jaw may after 
 thorough enucleation never recur, it is far safer to remove at the same time as 
 much of the surrounding tissue as can be done with safety. When the long 
 bones are the seat of sarcoma, amputate high up — if possible, through the joint 
 above : this is likewise good practice wdien sarcomata of the soft parts of the 
 extremities recur, especially if they are of the round-celled type. If the upper 
 jaw is attacked, the whole maxilla of that side must be removed, but the prog- 
 nosis Avill be bad. Sarcomata of the lymph-glands or of the tonsil are so little 
 influenced for good by operation that, except as a mere palliative, removal, as 
 a rule, should not be attempted. Tumors of the subcutaneous tissue or inter- 
 muscular fascia should be removed as often as they recur, or amputation may be 
 resorted to when a limb is concerned. It has been long known that occasion- 
 ally an attack of erysipelas will cure a sarcoma. Lately, the treatment of 
 inoperable sarcomata by hypodermatic injections of the toxins of erysipelas, 
 instead of the streptococcus itself, has been revived, especially by Coley. 
 The toxin of the bacillus prodigiosus added to that of erysipelas increases 
 the reaction. A few cases of apparent cure have been reported by Coley, 
 
208 ^liV^ AMERICAN TEXT-BOOK OF SURGERY. 
 
 Mynter, and .several others, but iiKj.st other surgeons have met only with 
 failure. 
 
 D. The Endotheliomata. 
 
 The.^e. as yet, little-known tumor.s, occupying apparently the border-land 
 between sarcomata and carcinomata, must be briefly considered, since it ap- 
 pears probable that some .sarcomata of the testicle are of this nature, and, 
 developing at least in part from the endothelium of the lymphatics, give rise 
 to that early infection of the glands so characteristic of testicular sarcoma, and 
 yet so contrary to the natural history of the disease as it occurs in nearly every 
 other situation. 
 
 When arising in the pia mater, structurally and from their mode of origin 
 many of these endotheliomata are alveolar sarcomata, while those originating 
 in the pleura or peritoneum are carcinomatous, consisting of nests and clusters 
 of epithelial cells presenting at their periphery a columnar appearance, these 
 cell-masses being surrounded by a dense fibrous stroma : the cells follow very 
 exactly "the course of the lymphatic vessels." They present themselves in 
 the form of " multiple flattened nodular growths, white in color, and either 
 isolated or connected by neoplastic bands, the intervening serous membrane 
 being more or less thickened;" metastasis is common, giving rise, Avhen the 
 pleura, for instance, is the .seat of the primary tumor, usually to secondary 
 growths in the peribronchial fibrous tissue, the bronchial glands, and the 
 thoracic muscles. Attacking as they do chiefly the pleura and peritoneum, 
 nothing definite can be .said concerning their diagnosis or treatment, and they 
 have been mentioned here because of their apparent etiological relations to 
 other malignant growths, and because, although rare, recorded cases are becom- 
 ing more frequent. 
 
 A. Warty or Villous Tumors, or Pai^illomata, closely resemble in their 
 structure hypertrophied papillae of the skin or mucous membrane, some of the 
 varieties receiving other special names, as condylomata, mucous tubercles, and 
 "benign villous tumors." They are often due to some form of irritation, as in 
 the case of those which develop on the glans penis from the action of acrid 
 discharges, or those on the hands from dust and dirt. Rarely attaining a large 
 size, and attacking only the skin or the mucous membranes, they are innocent 
 growths, although during the cancerous period of life they are apt to degenerate 
 into epithelioma, and the villous tumor of the bladder may destroy life by the 
 hemorrhage to which such a growth often gives rise. Structurally, they are 
 composed of a varying amount of connective tissue surrounding one or more 
 central blood-vessels, and are covered in by one or several layers of epithelial 
 cells resembling those of the skin or mucous membrane from which they are 
 developed ; but the cells never transgress their connective-tissue limit — i. e. 
 they do not infiltrate, as epithelioma does. 
 
 ^ Warts or warty groivths either occur as circumscribed growths, or more 
 rarely form cauliflower ma.sses, large relatively to the size of the part, such as 
 those occurring in the larynx. The enlarged papillne are covered by a layer or 
 layers of horny epithelium, and their vascular supply, as a rule, is small. 
 
 Mucous tubercles and condyhmata consist of flattened elevations composed 
 of enlarged papillse ; their connective tissue, of rapid growth, is infiltrated with 
 numerous small round cells, and their epithelial covering is moist and sodden. 
 They are mo.st commonly due to .syphilis. 
 
 Villous tumors, when springing apparently from the vesical mucous mem- 
 brane, where papillae do not normally exist, originate from the subepithelial con- 
 
TUMORS. 20i) 
 
 nective tissue and owe their ])apillarv form to tlie concentric arrangement of the 
 connective tissue and epithelium an)iin<l the hlood-vessels. These can, however, 
 best be described here. Such groAvths assume the branching, dendritic form of 
 the villi of the chorion, and are very vascular, the vessels being often dilated 
 and thus liable to give way, producing the frequent and serious hemorrhages 
 common to this aifection of the bladder. Their epithelial layer is thin, and 
 often removed mechanically, being passed in the urine, where it can be detected 
 by the microscope. 
 
 Seats of Predilection. — Warts and warty grotvths occur most fre- 
 quently on the skin, especially of the hands and genitalia, and on the mucous 
 membrane of the larynx. Mucous tubercles and condylomata are most com- 
 monly found about the anus and genitals or in the mouth and throat. The 
 villous growths attack the bladder, rectum, and larynx. 
 
 Such secondary and degenerative changes as pigmentation, ulceration, and 
 atrophy are common, while with advancing years the epithelial elements may 
 infiltrate the connective tissue, resulting in epithelioma. 
 
 Diagnosis. — The signs and diagnosis of tumors attacking such diverse 
 organs cannot be profitably discussed here, and can be best studied in the arti- 
 cles on the Skin, Bladder, Rectum, Larynx, and Syphilis. 
 
 Treatment. — As this varies with the parts involved, it can only be said, 
 in a general way, that these growths should be removed by such means as sul- 
 phuric or nitric acid, etc., which will destroy the base from which they spring; 
 or this base, after their excision by the knife or scissors, must be destroyed by 
 a caustic or by the actual cautery in some form. 
 
 B. Glandular Tumors, or Adenomata, are innocent growths, and 
 originate only from pre-existing glandular tissue, which they closely imitate. As 
 of normal gland-tissue, so of these tumors there are two types, the acinous and 
 the tubular. The acinous are composed of acini lined with spheroidal epithe- 
 lium, intercommunicating by duct-like channels : mammary adenomata are 
 of this type. The acini are bound together by a varying amount of connective 
 tissue in which the blood-vessels ramify. Pure adenomata are rare, the inter- 
 acinous tissue usually being replaced by a considerable amount of fibrous tissue 
 (adeno-fibroma), mucous tissue (adeno-myxoma), or sarcomatous cells (adeno- 
 sarcoma) ; again, the admixture of fibrous tissue with the sarcomatous elements, 
 or of mucous tissue similarly disposed, results in other growths (adeno-fibro-sar- 
 coma, adeno-myxo-sarcoma) ; still further, from obstructive pressure the acini 
 or ducts may become dilated, forming cysts into Avhich proliferating growths 
 (intracystic growths) may project: such growths receive their names from the 
 character of the interacinous and intertubular tissue, being termed adeno-cys- 
 toma, cysto-sarcoma, etc. 
 
 The Tubular Adenomata consist of tubules lined with cylindrical epithe- 
 lium, and therefore spring from mucous membranes the glands of Avhich are 
 similarly constructed, as from that of the intestines. Closely resembling carci- 
 nomata in many respects, unlike them the epithelial elements do not infiltrate 
 the connective tissue. 
 
 Seats of Predilection. — The acinous occurs chiefly in the mammae — 
 generally in the form of adeno-fibroma — in the lip, ovary, testis, prostate, 
 thyroid, parotid, lachrymal gland, the cutaneous and sebaceous glands : the 
 tubular variety occurs in the intestine, especially the rectum. Secondary 
 degenerations, such as mucoid softening of the stroma and fatty degeneration 
 of the epithelium, frequently produce cystic changes by obstructive pressure 
 on the acini or duct-like portions of these growths. 
 
 14 
 
210 ^.V AMERirAX TEXT-BOOK OF ^SURGERY. 
 
 II. EpIBLASTIC AM) IIvPOBLA^iTrC) TUMORS, OR TROSE CONFORMING TO THE 
 
 Types of Epithelial Tissues — the Caucinomata. 
 
 The malignant tumors of this chiss are composed of cells of the epithelial 
 type "in constant relation with one another" — /. e. no visible intercellular 
 matrix is discoverable — forming nests surrounded by more or less fibrous 
 stroma. This alveolar arrangement of the cells is due to the fact that tlie cells, 
 having broken through their "connective-tissue limit," now occupy the inter- 
 stices of this tissue — i. c. the radicles of the lymph-system — forming inter- 
 communicating cohimns of cells, which in cross-section, surrounded with their 
 fibrous stroma, jjresenf the appearance of true alveoli. Unlike adenomata, the 
 cell-groups are not limited by any basement membrane, while tlie vessels differ 
 from those of sarcomata by having walls of normal thickness and construction ; 
 moreover,they ramify in the stroma, not among the cells themselves. Two points 
 should be noted — viz. that although the individual cells differ somewhat from 
 one another, they retain the type of the parent epithelium, being more or less 
 spheroidal when originating from a gland, squamous if derived from the skin, 
 S({uamous or more often columnar when springing from a, mucous membrane. 
 Still further, the cells of the secondary growths usually closely resemble those 
 of the primary tumor. The normal connective tissue of the part, which at first 
 forms the stroma, is infiltrated with numerous cells, which later, by develop- 
 ment into fibrous tissue, produce the denser stroma characteristic of some forms 
 of carcinomata. 
 
 The development of this fibrous tissue, studied in connection with the dispo- 
 sition of the blood-vessels, explains the differing behavior of the rapidly- 
 growing tumors and those of slower growth. In the former the vascular supply 
 is rich and tolerably evenly distributed throughout the growth, while there 
 is relatively little stroma, Avhat is present probably being not much more 
 than the normal connective tissue of the part incapable of active contraction 
 and consequent obliteration of the blood-vessels. In the tumors of slower 
 growth the blood-supply is more scanty originally, and is found chiefly at tlie 
 periphery of the growth, having been obliterated in the more central older 
 portions by the contraction of the large amount of newly-formed fibrous 
 tissue. Hence the ftitty degeneration of those portions, resulting in their 
 breaking down, with loss of substance, when occupying a free surfice or after 
 giving way of the skin in more deeply situated growths : this is the so-called 
 ulceration of ncjv growths. Owing to the abundance of blood-vessels and the 
 lack of support afforded by the scanty stroma of the rapidly-growing carcino- 
 mata, hemorrhage into their substance is not uncommon, with free bleeding 
 from the surface when ulceration has taken place. Carcinomata possess no 
 capsule at any stage of their development, growing by endogenous cell-division 
 and by infiltration of the surrounding tissues, as a rule sooner or later break- 
 ing down and ulcerating. As the cells proliferate in the lym])hatic spaces 
 of the connective tissue, or, as is alleged for the breast, originate in what 
 are said to be spaces in direct continuity with the lymphatic vessels, the nearest 
 lymphatic glands early become involved, then those next in order, and finally 
 the viscera. In external carcinoma the general health does not usually suffer 
 until after ulceration, with its consequent purulent and bloody discharges, or 
 secondary implication of one or more of the important viscera, has occurred, 
 when what is known as "the cancerous cachexia" sets in, characterized by a 
 peculiar sallow, earthy hue of the skin, anxious, careworn facies, and more or 
 less marked emaciation. Death finally results from the combined effect of the 
 
TUMORS. 211 
 
 purulent aiul lieuiorrliii^ic disehargcs, from tlic impairment of nutrition through 
 involvement of important viscera, and from pain, anxiety, and loss of sleep. In 
 internal carcinoma, especially of the digestive organs, this cachexia soon sets 
 in, inasmuch as the general nutrition of the body is disturbed very early in 
 the disease. Possibly filso the absorj)tion and diffusion of secondary products 
 of the carcinoma may have some influence in causing this cachexia. 
 
 Carcinomata are divisible into two itiahi classes, with certain sub-classes: 
 
 (C) The acinous or spheroidal-celled : 
 
 1. The hard spheroidal-celled (scirrlms); 
 
 2. The soft spheroidal-celled (encephaloid) ; 
 
 3. The colloid, probably a degenerative form of one of the preceding 
 
 varieties. 
 
 (D) The epithelial : 
 
 1. The squamous-celled ; 
 
 2. The cylindrical- or columnar-celled. 
 
 (C) Acinous or Spheroidal-celled Carcinoma originates only from 
 the epithelium of the acinous glands or from that lining the tubular glands 
 possessing glandular epithelium. The essential difference between the two 
 chief divisions of this class is in the relative amounts of stroma and cells, 
 the hard form containing large amounts of fibrous tissue, while in the soft 
 carcinomata the cells preponderate. The term Scirrhus has been applied 
 indiscriminately to the harder forms of spheroidal-celled carcinomata and to 
 the whole class. 
 
 1. Hard Spheroidal-celled Carcinoma, or Scirrhus, appears as a hard, 
 irregular, tuberous growth of moderate size ; if originating in a glandular struct- 
 ure, it is continuous with it; at the outset freely moving with the gland, 
 but later by infiltration losing this mobility because adherent to the skin, fascia, 
 muscles, etc. Implication first of the nearest group of lymphatic glands, and 
 next of the viscera, and finally ulceration of the superjacent tissues, complete 
 the natural history of the growth. The carcinomatous ulcer is irregular in 
 outline and depth, has hard, nodular, everted margins, while the base is indu- 
 rated and irregular, sometimes more or less covered with sloughs, and but rarely 
 presents any evidences of granulations, although in very exceptional cases these 
 exist with slight attempts at cicatrization. The duration of life in this affection 
 is about two years, but occasionally patients live for many years, even twenty, 
 during much of which time ulceration may exist. Of course these remarks 
 apply only to external tumors. Owing to the large amount of newly-formed 
 connective tissue in the hardest forms of scirrhus, in some instances the tumor, 
 instead of frrowinji; larger as time goes on, becomes smaller, the surrounding 
 tissues being irregularly puckered and drawn in toward the small central 
 shrivelled lump which forms the tumor ; this is the so-called witliering or 
 atrophic scirrJtus, best seen in the breast, where after it has existed for years 
 nothing but an irregular mass resembling a cicatrix is to be found, blending 
 into one inseparable growth what formerly was skin, mammary gland, and chest- 
 wall. Unfortunately, the malignant tendencies of the growth are not abolished 
 by its shrinkage, for secondary tumors develop in the viscera, destroying the 
 patient. (See Diseases and Injuries of the Breast.) 
 
 On section, hard carcinomata are firm, of a white color, often traversed by 
 fibrous septa, and creaking under the knife; the cut surface is cupped. The 
 section is succulent, yielding on pressure or scraping a milky fluid, the so-called 
 cancer-Juice. Howsoever circumscribed the tumor may appear, it is one of the 
 rai'est of pathological curiosities to find it encapsulated. Islets of normal tis- 
 
212 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 sue or fjit can often be detected at the periphery of the new growth surrounded 
 by carcinomatous tissue ; indeed, no definite tumor is discoverable in certain 
 cases, the neoplasm being disposed throughout the affected organ in the form 
 of nodules and cord-like bands. 
 
 Seats of Predilection. — The mammary gland, the alimentary tract, 
 especially the pyloric end of the stomach, and, in a few instances, the glands 
 of the skin : a few have been reported in other localities. 
 
 2. Soft Spheroidal-celled (Medullary or Encephaloid) Carcinoma. 
 — Diff"ering, as already said, from the preceding variety merely by the amount of 
 fibrous tissue, in its typical form soft carcinoma on section closely resembles 
 brain-tissue both in appearance and in consistence. Clinically, the chief points 
 wherein it diff"ers from the hard form are the greater softness of the growth — so 
 soft as at times to simulate and be mistaken for abscess — the greater bulk 
 attained, the short time required to reach this size, and the rapidity with which 
 it runs its course. In form the soft carcinoraata differ according to the organ 
 attacked. Thus those of the testicle form large, bossellated masses, while mam- 
 mary groAvths tend to form a large globular mass or one composed of an aggre- 
 gation of rounded masses. When ulceration has taken place a fungating, 
 readily-bleeding mass often forms ; hence the old name of '■''funyuH Jicematodes." 
 The secondary and degenerative change which these carcinomata undergo is 
 softening at their central older portions, due chiefly to fatt}^ degeneration, but 
 partly to giving way of the blood-vessels, which often results in the formation 
 of such large fluctuating areas that, as has been said, they have not infrequently 
 been mistaken for abscesses. Such tumors on section show that their central 
 portions are converted into a soft, diffluent mass, Avhile the periphery of the 
 growth presents the ordinary grayish-white or cream-colored, brain-like surface, 
 blotched here and there with blood. This softening also results in cyst-like 
 cavities of considerable size, giving to the tumor the appearance of a true 
 cystic growth. In some carcinomata of the testicle, the mamma, and other 
 glands true retention-cysts form. 
 
 Locally, carcinomata extend by infiltration of the circumjacent tissues; 
 this accounts for the clinical phenomena of adhesion of the tumor to neighbor- 
 ing parts, its decreasing mobility as it grows, and its final absolute fixation. 
 With occasional exceptions, as in some carcinomata attacking the e^'e, the 
 antrum, or the pylorus, early secondary lymphatic involvement is the rule, the 
 secondary growths usually resembling the parent one. Occasionally they are of 
 the soft form, even though the primary tumor is of the hard variety, thus demon- 
 strating the essential unity of both forms. The organs and viscera most apt to 
 be aff'ected by metastatic deposits are the skin, the bones, especially tlie vertebrae, 
 the liver, the lungs, the kidneys, and the brain. Even Avhen, after operation, 
 no local recurrence takes place, the possibility of this visceral implication must 
 never be lost sight of, especially if pains in the lower limbs are complained of, if 
 so-called " spontaneous " fracture of a long bone occurs, preceded or not by pain 
 or tumor, if obscure symptoms of vertebral disease or if jjoculiar cerebral symp- 
 toms appear. Among surgical rarities is the secondary carcinomatous involve- 
 ment of the medulla of many bones Avithout the formation of distinct tumors 
 in any, but so reducing their strength that numerous fractures occur, either 
 from the application of trifling force or, as it is said, " spontaneousl3\" 
 
 Seats of Predilection. — The testicle, liver, bladder, kidney, ovary, 
 fundus oculi, and more rarely the breast. 
 
 3. Colloid Carcinoma. — This is really one of the preceding varieties 
 
TUMORS. 
 
 Plate IX. 
 
TUMORS. 2l;i 
 
 the cells of wliicli have undergone mucoid or colloid dejieneration and so dis- 
 tend the alveoli that these can be seen by the naked eye. 1'he colloid material 
 is a semi-translucent, glistening, jelly-like substance, in some parts of the 
 growth being even diffluent : generally here and there a few spheroidal cells 
 are found ; it pursues a course similar to, but somewhat slower than, that of 
 other carciiioniata. 
 
 Seats of Predilection. — The stomach, intestine, omentum, ovary, and 
 occasionally the mammary gland. 
 
 Diagnosis of the Carcinomata. — They are exceedingly rare before 
 thirty years of age, and are common after forty years ; early lymphatic involve- 
 ment is the rule — contrary to what is true of the sarcomata. Innocent growths 
 occur, as a rule, in younger patients, do not grow so rapidly, do not infiltrate 
 the organ or neighboring parts — i. e. do not become adherent — and almost 
 never ulcerate ; and when ulceration does occur, the characteristics of the result- 
 ino- ulcer diifer widely from those of the ulcer attendant upon carcinoma. 
 It is said that carcinoma never attacks the testicle in the child, but that 
 at any age a malignant tumor of the testicle which on section contains either 
 cartilage or bone cannot be carcinomatous, but is sarcomatous. While it is 
 usually easy to make the diagnosis of carcinoma, yet at times this is difficult 
 or impossible, competent surgeons having removed breasts, believing them 
 to be carcinomatous, when the disease was simply cystic or merely a chronic 
 abscess. There is no means of distinguishing that very rare condition, encap- 
 sulated carcinoma, from a benign tumor — e. g. a fibroma. Between chronic 
 mastitis or abscess and carcinoma the association of pregnancy or lactation in 
 most instances when the mamma is the organ involved will assist in the 
 diagnosis, while the greater density of carcinoma and its unequal consistence 
 in its different parts when undergoing softening will often remove all doubt. 
 Unfortunately, the skin over a chronic abscess and that over a softening car- 
 cinoma are not so dissimilar in appearance as to preclude all chance of error, 
 especially as the glands may be enlarged in both affections. The decided 
 elasticity of a cyst, even if fluctuation cannot be detected, its circumscription, 
 and its free mobility, serve to distinguish this class of tumors from carcinoma. 
 It is far better, in any case of doubt whether the tumor is really an abscess, 
 a cyst, or a softening carcinoma, either to explore with a hypodermatic needle 
 or at the time of operation to make first an exploratory incision directly into 
 the tumor. 
 
 (D) The Epitiielial Carcinomata. — 1. The Squamous-celled Epithe- 
 LIOMATA always spring either from free epithelium-clad sui'faces, as the skin or 
 mucous membranes, or from the glands of the same, since the hair and sebaceous 
 glands in certain instances have been observed to take the initiative in the carci- 
 nomatous process. These growths appear w ith great frequency at the points of 
 junction of mucous and cutaneous surfaces (PI. IX, Fig. 1), probably because there 
 subjected to more frequent and varied forms of mechanical and chemical irrita- 
 tion. Structurally, they are composed of pegs or columns of squamous cells, which 
 infiltrate first the subjacent connective tissue, then every underlying structure, 
 including bone, in their track. The epithelial ingrowths contain globular masses 
 of flattened cells, the so-called " cell-nests ' ' or epidermic pearls. The surrounding 
 fibrous stroma is usually infiltrated with small cells. Epithelioma commences 
 either as a wart-like growth, a flattened tubercle, or a fissure, ulceration in all 
 these forms setting in early. In many instances this proceeds with such rapidity 
 that the tumor-formation barely keeps pace with it, the resulting disease resem- 
 
-^1 t J.V AMERICAN TEXT-IIOOK OF sriiCEIiY. 
 
 bling — luid bciii;^ ofton mistaken for — an ulcer, the indurated hasc and margins 
 either escaping detection or being looked upon as inflammatory. The other ex- 
 treme is often met with where tumor-formation is in excess, only supcrfuial ulcer- 
 ation obtaining until the growth is of considerable size. Epitheliimiata are not 
 encapsulated, although upon section their margins ajipear sharjdydeiiiicd from the 
 surrounding tissues, while the cut surface is white, dense, homogeneous, poor 
 in juice, but if compressed laterally giving vent to milk-white, tAvisted, thread- 
 like masses which have been likened to the " comedones " that can be pressed 
 out from the sebaceous glands of the skin. The consistence varies much, but is 
 distinctly greater than that of the surrounding tissues, and the part feels dense 
 and inelastic. Although an epitheliomatous ulcer may resemble that residting 
 from any other form of carcinoma, yet sometimes it is a mere fissure with indu- 
 rated margins, a relatively indolent ulcer with the same peculiarities, or has 
 superadded numerous papillary projections, producing a warty or cauliflower- 
 like growth. When originating from an old wart — a not unusual occurrence — 
 ulceration is apt to be the first symptom, with subsequent induration of the base 
 of the growth. The same remarks are applicable to many cases of c))ithelioma 
 of the tongue, where an indolent ulcer may last for weeks before the charac- 
 teristic induration of its base and margins can be detected. The rate of growth 
 varies with the vascularity and looseness of texture of the tissues. Thus, when 
 attacking the lower lip the progress is slow, lasting sometimes for a year or more 
 before the tumor attains a size greater than that of a cherry, Avhile relativelv 
 bulky tumors will form in a few months in carcinoma linguiie. 
 
 " Spontaneous fracture " or gradual bending of the tibia is not unconnuon 
 from the infiltration of that l)one by cancerous tissue, either when an old ulcer 
 undergoes a malignant change (Marjolin's ulcer), or when a scar, after long-indo- 
 lent ulceration, commonly starting at its center, becomes similarly diseased. In 
 like manner complete solution of continuity of the lower jaw may result from 
 epithelioma of the lip extending to the gums and thence to the bone. Local 
 recurrence is common after operation when the removal has been imperfect, and 
 death usually results from the exhaustion incident to ulceration and hemorrhage. 
 Secondary lymphatic involvement occurs with most squamous-celled epithelio- 
 mata, but usually late in the disease, when the antrum, the interior of the larynx, 
 or the skin of the eyelids, nose, and other parts of the face is attacked. In these 
 latter situations, indeed, the disease being apt to be superficial and of that form 
 called "rodent ulcer," the glands are rarely affected. The exception in the 
 case of the intrinsic parts of the larynx is the more striking l)ecause epithe- 
 lioma of the extrinsic parts affects the glands certainly and early. Visceral 
 involvement is rare, the liver, lungs, kidneys, bone, and skin suffering most 
 frequently. 
 
 Seats of Predilection. — Any cutaneous or mucous surface covered with 
 squamous epithelium. When the disease attacks the skin, the parts most com- 
 monly involved are the nose, the lower lip, the j)enis and scrotum, the vulva, the 
 anus, and more rarely the hands and feet. The nnicous surfaces most commonly 
 affected are those of the tongue, palate, gums, tonsils, larynx, pharynx, and 
 oesophagus down to the cardiac orifice of the stomach, the bladder, and os uteri. 
 
 Diagnosis. — The disease is very uncommon under thirty years of age ; it 
 is quite common after forty : it is limited in some of its forms, as epithelioma 
 of the lower lip, almost exclusively to men, and, wherever occurring, attacks 
 men much more fret^ucntly than women. If, then, a man of from forty to 
 seventy years of age develops a small tumor in the lower lip which ulcerates 
 early, giving rise to an indolent, slowly-extending sore, with indurated base and 
 margins, no evidence of surrounding inflammation being detectable, the ulcer per- 
 
TUMORS. 215 
 
 hai)s prescnitinp; tliepoonliar AN artv,eanlillo\\ or surface mentiono(l,an(l es])ecially 
 if the subnuixilhiry <fhiiids are enlarged, the disease may be safely considered car- 
 cinomatous. Or, again, an obstinate fissured ulcer, often scabbed over, forms in 
 the same situation, discharging a watery matter, ^s\i\\ induration extending in all 
 directi(uis for full one-fourth to one-half of an inch, involving notoidy the mucous 
 and cutaneous tissues, but all the structures of the lij); perhaps in addition the 
 j)atient states that the disease first a])peared as a Avart Avhich had been picked off 
 or cauterized — /. e. had been irritated, not destroyed. Epithelioma of the tongue 
 may appear at an earlier age, and in from three to six months will often reach a 
 considerable size in the rarer form, -where the disease appears as a hardened, non- 
 inflauuMl mass on the free border of the tongue — not uncommonly near a broken 
 tooth — its surface eventually becoming fissured, ulcerated, and painful. Or, 
 again, there may be merely an indolent, slowly-extending, unhealthy ulcer with 
 indurated base and margins situated as just mentioned. Although the diagnosis 
 between carcinoma and tubercle or syphilis of the tongue is often difficult, coex- 
 isting syphilitic lesions or old scars of the tongue, with antisyphilitic treatment, 
 will usually settle the question, while signs of tubercle elsewhere ought to 
 arouse grave doubt of the carcinomatous nature of the ulcer. Further diag- 
 nostic points are given in the section on Syphilis. 
 
 Warts on the hands or scrotum, or elsewhere, in elderly chimney-sweeps 
 or in coal-tar- or paraffin-workers should be vicAved with suspicion, especially if 
 they are growing and if their bases are becoming indurated, because in such 
 cases, sooner or later, an unhealthy ulcer, discharging foul matter, usually forms, 
 presenting all the clinical evidences of epithelioma. It hardly needs to be said 
 that epithelioma is evidently induced by persistent irritation, since the localities 
 where it occurs are subjected to frequent slight traumatisms, and the occupations 
 which give rise to it supply constant sources of mechanical and chemical irritation. 
 
 Local recurrence is common after operation as a consequence of imperfect 
 removal of the disease, and death in these cases, as Avell as in those not operated 
 upon, results from the exhaustion incident to ulceration and hemorrhage rather 
 than to dissemination, which, as has been already pointed out, is of rare occur- 
 rence. 
 
 2. Cylindrical- or Columnar-celled Epithelioma. — This is a less 
 common form of carcinoma than the spheroidal-celled or the squamous-celled 
 varieties, and originates from either the cylindrical surface epithelium of a 
 mucous membrane or that of its glands, closely imitating these structures in 
 microscopical appearance; no "cell-nests" are found. These growths form 
 indurated, infiltrating masses in the walls of the organs attacked, and vary 
 much in the rapidity of their course, producing considerable stenosis of the 
 lumen of such hollow viscera as the rectum and small intestines, which may ter- 
 minate life by producing more or less intestinal obstruction ; ulceration occurs 
 early. Dissemination throughout the liver, lungs, and other organs occurs, as 
 a rule, only after infection of the intervening lymph-glands. (See Diseases of 
 the Intestines and Rectum.) 
 
 Seats of Predilection. — The rectum, uterus, and intestinal tract. 
 
 Diagnosis. — This is to be made by attention to certain secondary results, 
 which will be found detailed in the sections on Diseases of the Intestines and 
 Rectum. 
 
 Treatment of the Carcinomata. — The first question to be answered is, 
 Can this case be treated radically, or does it admit only of palliation ? If it 
 can be treated radically, the whole organ should be excised, including as much 
 
21(1 AN AMERICAN TEXT- HOOK OF SURGERY. 
 
 as can safely be removed of tlie surrounding aj^j^arentlij healthy tissues, before 
 lymphatic involvement has occwred, if possible : after this involvement lias taken 
 place the primary growth must be removed with an unsparing hand, while the 
 lymphatic glands and peri-adenoid tissues must be thoroughly cleared out. 
 Indeed, if this last all-essential recjuisite cannot be secured, removal of the r)ri- 
 mary growth is indicated only for the relief of }>ain, or, if ulceration has set in, to 
 get rid of a disgusting sore. For instance, in a case of mammary carcinoma, if 
 axillary glandular involvement is present, and there is any question as to the pos- 
 sibility of clearing the axilla, as a preliminary to further operative interference 
 an incision should be made into the armpit to determine whether all diseased tissue 
 can be removed. If this cannot be done — unless the breast tumor is ulcerated, 
 when removal may be indicated as a palliative measure — the wouikI should 
 be closed and the breast allowed to remain, since its removal would add a risk 
 with no compensating advantage. (See Diseases of the Breast.) Amputation 
 of the limb high up, with extirpation of any diseased glands, is always in- 
 dicated where epithelial carcinoma has invaded the bone from an overlying 
 tumor, as, for instance, the tibia. Malignant disease of such parts as the penis 
 and the tongue is properly treated by amputation of these organs, even Avhen 
 secondary glandular disease is beyond removal, merely as a palliative measure 
 to secure urination in the former case and painless swallowing in the latter. 
 
 Epitheliomata of the lips, nose, and eyelids can often be successfully 
 removed by the knife even when extensive, and the defects can be repaired by 
 plastic operation or by Thiersch's method of skin-grafting. The more super- 
 ficial forms can often be effectively handled by freezing with rhigolene spray, 
 thoroughly curetting, the application of pyrogallic acid, and an after-dressing 
 with an ointment of the same (grs. x@3j), until healthy granulations are 
 formed, when ordinary measures will secure healing or Thiersch's skin-grafting 
 may be used. Potassa fusa or the actual cauterj^ may be employed as the destruc- 
 tive agent, and, after separation of the slough, the defect may be left to Nature's 
 efforts or skin-grafting may be resorted to. The chances of cure vary with the 
 part involved, but even Avith extensive glandular comi)lications, where complete 
 extirpation is possible, some carcinomata of the lip, tongue, and breast do not 
 recur either locally or in the viscera. Carcinomata of the testicle, oesophagus, 
 or tonsil are rarely benefited by operation, except for the palliation effected. 
 When operation is concraindicated, opium to relieve pain, local aj)plications 
 of lead-Avater and laudanum, extract of aconite and Ijelladonna rendered of a 
 proper consistence by glycerin, or other similar remedies, with attention to the 
 general health, constitute the treatment in non-ulcerated carcinomata. For 
 ulcerated carcinomata measures to control pain, to lessen discharge or hemor- 
 rhage, and to arrest fetor are the main indications. Iodoform with mor})hine in 
 proper amount dusted over the surface, cocaine in solution apjdicd either by 
 spray or by painting, solutions of carbolic acid, Labarraque's solution, or a solu- 
 tion of chloral may be used, as far as possible employing dry dressings or those 
 which favor rapid drying of the discharges — i. e. lessen putrefactive changes. 
 Esmarch's arsenical powder also serves an admirable purpose. No internal 
 remedies of the many recommended having as yet proved of any real value, 
 none need now be mentioned. Finally, the profession should clearly under- 
 stand, and endeavor to educate the public in the belief, that carb/ and radical 
 operations ivill cure a considerable proportion of cases, and render life endura- 
 ble in many more where a cure is impossible. 
 
 III. Tumors composed of Epiblastic, Hypoblastic, and Mesoblastic 
 Elements, and containing bone, hair, teeth, etc. (Teratomata), situated in 
 
TUMORS. 217 
 
 the ovaries and testicles. These are considered with these organs, especially 
 with the ovaries. 
 
 Cysts. 
 
 A cyst may be defined as a cavity bounded by a distinct envelope composed 
 of fibrous tissue lined with endothelium, and called the cyst-wall; or it may 
 be covered by epithelium and contain secreting structures : the cyst-contents 
 may be either fluid or semi-fluid ; intracystic growths may nearly or completely 
 fill the cavity. A cyst may result from the increase of the normal secretion of 
 an already-formed space or cavity by extravasation into it, or the cavity may 
 be of new formation. 
 
 I. Cysts formed hy the Distention of Preformed Cavities or Sjjcices : 
 
 {a) Exudation cysts ; 
 (/>) Retention cysts ; 
 ((') Extravasation cysts. 
 
 II. Cysts of New Formation : 
 
 (a) Simple cysts ; 
 
 (b) Blood cysts. 
 
 III. Cysts of Congenital Origin. 
 
 IV. Cysts due to Parasites. 
 
 I. Cysts formed by the Distention of Preformed Cavities or Spaces. 
 
 Exudation Cysts result w'hen excessive secretion takes place into closed 
 cavities, such as bursse, cysts, bronchoceles, etc. 
 
 Retention Cysts. — These possess a distinct fibrous wall lined with 
 epithelium, and are caused by obstruction of the duct of a gland or portion of 
 a gland, the continuous secretion producing dilatation of the duct or gland- 
 acinus. In most instances, as a result either of inspissation of the contents 
 or of the mingling with them of exudation-products from the cyst-walls, the 
 normal character of the secretion is totally altered. According to their origin, 
 three sub-classes are usually described — viz. (1) >S'<'irt<?^'o«s (atheromatous) cysts, 
 formed by the dilatation of sebaceous glands ; (2) 3Iucous cysts, due to the 
 dilatation of mucous glands ; and (3) Cysts formed by the distention of large 
 ducts — i. e. the salivary, lacteal, hepatic, renal, etc. 
 
 (1) Sebaceous (atheromatous) Cysts present themselves as smooth, flattened 
 ovoidal, sometimes semi-fluctuant tumors, usually movable on the deeper parts, 
 but often adherent to the skin. At times the orifice of the obstructed duct 
 can be seen, indicated by a small black spot. 
 
 Seats of Predilection. — The scalp and face chiefly, but they may be 
 found on any part of the body, and are often multiple. When situated in the 
 scalp they are sometimes apparently hereditary. Unlike dermoid cysts, the 
 pultaceous, cheesy contents — often of an oft'eusive odor — contain no hairs, 
 while the cyst-wall possesses neither papillie nor hair-follicles. Certain second- 
 ary changes may greatly alter their appearance and obscure the diagnosis. 
 Thus by inflammation a sebaceous cyst may be converted into an abscess : 
 after spontaneous opening the thinned coverings may ulcerate, abundant fungous 
 granulations may form, and the margins and base of the sore may become indu- 
 rated and elevated, closely resembling epithelioma. These fungous sores may also 
 undergo actual epitheliomatous change : a portion of the coverings ulcerating, 
 the secretion may be gradually forced out, drying as it protrudes, thus in time 
 
•2\^ AN AMERICAN TF.XT-HOOK OF SURGERY. 
 
 forming a cutanoous Lorn, sometimes inelies iu Icugth ; linally, calcification of 
 the cyst-wall may take place. 
 
 Diagnosis. — They are most apt to be mistaken for fatty tumors or chronic 
 abscess. From the former they can be distinjfuished by the fact that the edge 
 of a cyst does not slip away from the finger wjicn pressed upon, l)y the absence 
 of dimpling of the overlying skin, and when present by the l)lack punctum 
 indicating the duct-mouth ; from the latter, by the absence of symptoms of 
 inHannuation and by the use of the grooved needle. When suppuration has 
 occurred, one of the degenerative changes already mentioned, the symptoms 
 of suppurative inflanunation, the increase in size, and the exploring needle if 
 recjuisite, will demonstrate the condition. In those rare instances where a 
 fungating ulcer follows sujipuration of a cyst, proper tlierapeutie measures will 
 cause it to heal in a reasonable time, thus demonstrating tliat it is not epithe- 
 liomatous. If healing cannot be secured, the ulcer has probably undergone 
 epitheliomatous change in whole or in part. When such change has attacked 
 the ulcer before the surgeon sees the case, the diagnosis must depend upon the 
 })resence of the characteristics described as indicative of this disease, together 
 with the history. 
 
 Treatment. — AVhen situated upon the face, if the orifice of the obstructed 
 duct can be discerned, it may be dilated with a small probe and the contents 
 of the sac pressed out, this procedure being repeated from time to time, thus 
 avoiding any scar ; but final success is rarely attained, and the method is of 
 very little value. Removal of every portion of the cyst-wall is usually the best 
 treatment, and this can be most readily done by transfixion of the cyst and over- 
 lying integument with a curved bistoury, pressing out the contents, and tlien 
 grasping the edges of the cyst-wall Avith two pairs of forceps, twisting and pull- 
 ing out each half. If too adherent for this, careful dissection Avill be recpiired. 
 
 2. Mucous Cysts arise from dilatation of raucous glands, their walls being 
 comparatively thin and their contents a, viscid mucoid fluid in Avhich cholesterin 
 is sometimes present. They form in the mouth one variety of rcmula : so-called 
 dropsy of the antrum is sometimes due to cystic dilatation of one of the mucous 
 glands of its lining membrane. 
 
 Seats of Predilection. — The lips, mouth, antrum, labia, and indeed 
 wherever mucous glands exist. 
 
 Treatment. — Excision of a considerable portion of the cyst-wall, and 
 applications to tbe interior which will destroy the secreting surface. (See 
 Diseases of the Mouth and Antrum.) Descriptions of cysts formed by the 
 dilatation of such ducts as those of Wharton (forming ranula), of the 
 breast {(/alactocele), etc. will be found in the sections on the diseases of 
 those organs. 
 
 3. Extravasation Cysts result from hemorrhage into closed cavities, 
 as that of the tunica vaginalis testis (hematocele). Some authors describe 
 extravasations into softened portions of solid tumors, or into the cellular tissue 
 which condenses around the effusion, as extravasation cysts. 
 
 II. Cysts of New Formation. 
 
 (a) Simple or Serous Cysts (Fig. 30) possess a thin wall lined with 
 endothelial cells, and contain a serous or thick mucoid fluid. They originate 
 from effusion, which takes place into the lymph-spaces of the connective 
 tissue from the local irritation of pressure, and ])ush aside the bundles cov- 
 ered with endothelial plates until they are condensed into a cyst-wall covered 
 
TUMORS. 
 
 219 
 
 Serous Cyst of the Neck (original). 
 
 more or less complctoly witli eiidotliclial cells : this is the method of forma- 
 tion of an adventitious hursa. Sini])le cysts of the hi'cast are siiuihirly pro- 
 duced, and ))ossibly. some of the neck, although most of these are of congeni- 
 tal origin, the result of abnormal- 
 ities of the lymphatic vessels pro- ^^o- 30. 
 ducing cavernous changes. Avhile 
 those occupying the nn-dian line 
 of the neck arise from effusion into 
 some of the normal bursal sj)aces 
 of that region — /. f. antethyroid or 
 infrahyoid bursse. 
 
 {b) Hkmatomata, or Blood- 
 Cysts. — There are two varieties, 
 the first being usually found in the 
 cervical region, and consisting of 
 thin-walled cavities containing pure 
 blood : their mode of origin is 
 doubtful, but they appear to have 
 some direct communication with 
 the veins, because if tapped or in- 
 cised they often bleed profusely. 
 The second variety arises from the 
 mechanical and inflammatory con- 
 densation of the tissues around an 
 extravasation of blood, which may 
 eventually be absorbed or undergo 
 so-called organization ; or the blood may remain liquid, disintegrate, and be 
 absorbed; or suppuration may ensue. This form results from injury, and is 
 situated most commonly beneath the scalp, especially in newborn infants. 
 (See Cephalhematoma.) 
 
 So-called compound proliferous cysts, such as those found in the breast and 
 ovary, are merely instances of primary cystic change in these organs, Avhere, 
 as a result of secondary developmental changes, ingrowths occur arising from 
 the cyst-walls. 
 
 III. Cysts of Congenital Origin. 
 
 These result either from inclusion of a portion of the epiblastic layer within 
 the mesoblast, or from the distention of the cavity of some persistent foetal 
 structure which should normally have become obliterated ; for instance, broad- 
 ligament cysts developing from the parovarium, and, dermoid cysts, as alleged, 
 by the inclusion of a blighted ovum in either the testicle or the ovary. Since 
 all except dermoid cysts of the external parts will receive special mention 
 elsew'here, only this variety of cyst Avill be here described. The cyst-wall contains 
 hair-follicles and sebaceous glands, while the contents are formed of the secretion 
 of these structures, of disintegrated epithelial cells, and of hairs Avhich have been 
 shed. They often have absolutely no connection with the skin, and, occurring 
 about the face and head where in the embryo fissures exist, are probably the 
 result of inclusion of a portion of epiblast. Similar tumors of the ovary and 
 testicle which contain bone, cartilage, and, in the case of the ovary, teeth, as 
 before said, have been ascribed to inclusion of a blighted ovum, but this is at 
 least non-proven. 
 
 Seats of Predilection. — The outer angle of the orbit, over the root of 
 the nose, the ovaries, and the testicle. 
 
2'2y) AX AMEItrCAN TEXT-BOOK OF .SURGERY. 
 
 Diagnosis. — This must depend ui)uii the detection of a glohular, tense, 
 smooth tumor, usually situated at the outer angle of the orbit, unattached to 
 the skin, trenerally freely movable ui)on the deeper parts, if overlyin;: the bone 
 often causing its partial or complete absorption, and of congenital origin. 
 Processes of these cysts sometimes extend deej)ly into the orl)it, or even into 
 the cranial cavity. (For Ovarian and Testicular Dermoid Cysts, see the 
 aj)pr(ii)riate sections.) 
 
 Treatment. — Removal by careful dissection, making the necessary incis- 
 ions in such a manner, if possible, that they shall coincide with the natural 
 wrinkles of the parts, or that some other structure, as the evebrow, shall 
 conceal the scar. Removal of congenital hydroceles of the neck bv the knife 
 is sometimes impracticable. From their great extent and irregularities any 
 treatment by injection and drainage requires the strictest asepsis lest serious 
 consequences result. 
 
 IV. Cysts due to the Presence of Parasites. 
 
 The only parasitic cyst of surgical importance — the hydatid — is that pro- 
 duced by the Taenia echinococcus, which infests the intestines of the dog. 
 The ova reach the human alimentary tract with the food or water, are there 
 hatched, migrate, reach the blood-current, and lodge in some organ, develop- 
 ing into a hydatid tumor. The external layer of the cyst-wall is composed 
 of a '"'' highly elastic, lamellar cuticle ;" the internal layer consists of " granu- 
 lar matter, cells, muscle-tissue, and a water-vascular system " (Sutton). A 
 more or less complete adventitious fibrous capsule isolates the true cyst-wall 
 from the surrounding tissues. Upon attaining the diameter of an inch or 
 more, from the mother-cyst small vesicles or '" broad capsules " form, which 
 develop retractible heads or ''scolices," each about 0.3 mm. long, having 
 four '"sucking-disks and a circlet of minute, blunt booklets." Daughter- 
 cysts form from the '"blood-capsules," and possibly from the '" scolices, " the 
 rapid enlargement seen where pressure does not interfere resulting from the 
 increase in number of these capsules and daughter-cysts. Sometimes even 
 large cysts contain neither capsules nor vesicles, being then sterile, but are 
 recognizable by the characteristic lamellation of the cyst-wall. Multiloeular 
 hydatids consist of aggregations of innumerable small vesicles — usually ster- 
 ile — varying in size, few larger than a pea, which are not contained in a 
 mother-cyst. The bones and spinal cord are the usual sites for this variety. 
 Hydatids eventually cease to grow, die, shrivel, and become calcified, leaving 
 only the booklets to enable the microscopist to determine the nature of the 
 mortar-like mass. Rapid growth of daughter-cysts may produce necrosis of 
 the mother-cyst with rupture. "When related to the trachea, stomach, or 
 intestines, pressure-absorption may permit osmosis of gas, fluid, or air ; the 
 hydatid dies, septic germs gain access, and suppuration ensues. Hydatids 
 may also rupture into some one of the hollow viscera, a termination to be 
 dreaded, as possibly productive of instant death or secondary changes ulti- 
 mately lethal, although cure sometimes results. 
 
 Seats of Predilection. — Liver, kidney, omentum, bones, thyroid gland, 
 spinal canal, brain, lungs, and connective tissue. 
 
 Treatment. — The cyst, when possible, must be removed entire. If total 
 removal is not feasible, incise, evacuate; when possible remove the cyst-wall, 
 leaving the capsule, and carefully drain. Never aspirate or merely puncture 
 except for diagnostic p>urposes. 
 
BOOK IT. 
 
 SPECIAL SURGERY. 
 
 CHAPTER I. 
 
 SURGERY OF THE VASCULAR SYSTEM. 
 SECTION I.-DISEASES OF THE HEART AND PERICARDIUM. 
 
 The diseases of tlie heart which may demand surgical interference are 
 those which are accompanied by over-distention of the ventricles or by eflusion 
 nto the pericardial sac In order to understand how to relieve these conditions 
 by surgical means it is necessary to study the anatomy of the heart and of its 
 covering. In the healthy chest the heart is contained m a space extending 
 oblique!y in front from the third to the sixth costal cartilage, am horizontally 
 generallv from half an inch to the right of the right border of the sternum to 
 a point half an inch to the right of the left nipple. Posteriorly it occupies the 
 space corresponding to that between the fourth and eighth dorsal spines. The 
 au cles ai/on a Tevel with the third costal cartilage. The pu monary artery 
 covers anteriorly the left auricle. The right ventricle is partly behind the 
 steinum and partly to the left of it. The left ventricle, except at its apex, is 
 
 behind the right ventricle. , . , , i . • ^ ■ a tv..:. 
 
 The pericSrdium is a fibro-serous sac in which the heart is contained The 
 base of the sac is at the diaphragm, and the apex is above and by its fibrous 
 layer is connected with the deep cervical fascia. 
 
 ^ OVER-DISTENTION OF THE HEART occurs in cases of pulmonaij congestion 
 of an acute character. The operation of iai^ping the cavity c>f the h<^^^rt h^ 
 been suggested with the view of relieving the dangerous condition under which 
 the heaif labors. The right auricle is the place selected for punc.ui. because 
 the position of that cavity is less sub ect to alteration m its relation to the sui- 
 rouifdi . parts, and because the antero-posterior internal diameter is greater 
 San tha°t Jf the ventricle, the walls of which are also much thicker than those 
 
 '^ 'The besf place to perform paracentem anricvli is the third intercostal space 
 at the ri'ht edge of the sternum. The needle should be thrus directly back- 
 wa d! The op^eration should be performed as quickly as possible and in order 
 To abstract a sufficient quantity of blood with celerity it is necessar^ o mt-du ^ 
 an aspirating needle about three times the size of a hypodermatic needle. Ihe 
 needle hould be rendered perfectly aseptic before it is thrust into he auricle 
 and the end of the needle should be attached to the tube of an aspirator becau e 
 the blood-pressure is not sufficient to force the blood out through a canula. The 
 needle must pierce the skin and fascia, the edge of the rig^lit lung and the 
 nleural sac covering, it, as well as both layers of the pericardial sac before it 
 tZtrZi^^L-.^^^- Tapping the cavity of the heart is fraught -th ext e 
 dancer, and cannot be commended except in special and unusual cases, and even 
 then should be resorted to only after consultation. 
 
222 AN AMERICAN TEXT-BOOK OE SURGERY. 
 
 Effusion into the pericardium occurs as a result of acute aiici clironic 
 pericarditis, both of Avliich conditions may arise from various causes, including 
 traumatism. Usually the effusion is moderate and undergoes absorption. Occa- 
 sionally, however, the (juantity becomes excessive and gives rise to alarming 
 symptoms; under these circumstances ta])ping of tlie pciicardial sac is indi- 
 cated. 
 
 The symptoms dciioting great effusion in the sac are precordial oj)pres- 
 sion, syncojjc, dysjjnea, a])lionia, feeble and irregular pulse, difficulty of deglu- 
 tition, and dilatation of the veins of the neck, in addition to the signs of pericar- 
 ditis during the different stages. An inspection of the chest shows that the 
 pericardial sac is dilated and that the respiratory movement of the left side 
 is impaired. 
 
 The physical examination, if made before the pericardial surfaces are sep- 
 arated by the fluid, demonstrates the presence of a pericardial frictiori-sound, 
 which must not be mistaken for an endocardial murmur. The distinKuishin<r 
 feature of the pericardial friction-sound is that it does not possess the same 
 regularity of rhythm as an endocardial murmur, and is not propagated beyond 
 the limits of the precordia. Percussion reveals the presence of flatness over an 
 enlarged precordial space both laterally and vertically. The flatness maps out 
 a quadrilateral or a pyriform area with the base below and extending to both 
 sides of the heart-apex. Auscultation demonstrates the absence of vocal reso- 
 nance and of fremitus, and shows muflling of the heart-sounds. The apex-beat 
 is pushed upward and to the left on account of the eff"usion, and in some cases 
 it is lost. 
 
 Paracentesis pericardii should be employed when the symptoms threaten 
 life. For purposes of positive diagnosis and with a view to ascertaining the 
 character of the fluid an aseptically clean hypodermatic needle can be introduced 
 before tapping, after which an aspirating needle can be used, or even a trocar, 
 according to the consistency of the fluid. The best point for introducing the 
 needle is at the fifth intercostal space, two inches to the left of the left border 
 of the sternum. This will puncture the pericardium external to the internal 
 mammary artery. The direction of the needle should be backward. The 
 fluid should be withdrawn very slowly, and the eff"ects of the removal of the 
 eff'usion carefully watched. The operation should of course be done under the 
 strictest antiseptic precautions. 
 
 Incision and drainage of the pericardium has been employed in cases of 
 empyema of the pericardial sac. The incision, irrigation, and drainage of the 
 sac should be resorted to only in the purulent form of the exudation. The 
 operation should be performed at the same point as paracentesis pericardii. If 
 necessary, part of a rib may be resected. Although this operation has as yet- 
 been done but seldom, the great mortality of empyema of the pericardium war- 
 rants its performance. 
 
 SECTION II.— INJURIES OF THE HEART AND PERICARDIUM. 
 
 Rupture of the heart has followed complete obstruction of one of the 
 branches of the coronary arteries, the obstruction having been caused by a 
 thrombus or by an embolus in the artery. Mechanical distention of the heart 
 has caused rupture, as when its cavities have suddenly been filled with blood 
 escaping from a bursting aneurysm, or when an a])scess of the cardiac walls 
 has burst into the ventricles. Rupture of the heart has also been a cause of 
 death in tetanus. 
 
 Wounds of the heart are not infreciuent. These may result from severe 
 
SURGERY OF THE VASCULAR SYSTEM. 22;i 
 
 injury of the chest-wall, or from penetration by a fragment of a fractured rib, or 
 by a stab or a gunshot wound. A wound of tlie heart is not necessarily fatal, 
 as is shown in the case where a needle was removed by Callender from the 
 substance of the heart. Other cases of like nature have been reported by 
 Halin, Agnew, Stelzner, and others. 
 
 The symptoms of wound of the heart are not characteristic. Ilemor- 
 rhai'e is usually present, but a stab wound may occur with little or no hemor- 
 rhage. The absence of hemorrhage is due to the anatomical arrangement 
 of the muscular fibers of the heart. Pain is present as a constant symptom, 
 and attacks of synco{)e occur at frequent intervals. If hemorrhage has taken 
 place into the pericardium, the percussion note is flat and its area is increased, 
 owing to the presence of the fluid, and the heart-sounds are less distinct than 
 normal. 
 
 Tlte cause of sudden death in wounds of the heart may be syncope from 
 pressure on the heart due to over-distention of the pericardium with blood; or 
 the inability of the heart to contract, owing to the wound of the cardiac wall, 
 may produce fatal cerebral anemia. Shock and pulmonary anemia also have 
 caused death in cardiac wounds. Death is not always sudden, but may be 
 deferred for hours (Agnew). 
 
 Treatment. — The heart has been sutured successfully in several re- 
 })orted cases. 
 
 In a stab-wound of the heart Rehn resected the fifth rib, and exposed a 
 stab-wound of the right ventricle 1^ cm. long. He sutured the wound with 
 «ilk and packed the pericardium with gauze, and the patient recovered. Par- 
 rozzani sutured a stab-wound of the left ventricle, and the patient recovered. 
 Durante has reported a case in which a stab-wound of the left ventricle was 
 •sutured by Fareni. The patient lived for several days, and died from a cause 
 unconnected with the heart-injury. Cappelan, in a case of stab-wound of the 
 heart, resected the third and fourth ribs and sutured the wound, and the 
 patient lived for two and a half days. In the light of the reports of Rehn, 
 Parrozzani, Durante, and Cappelan, it becomes evident that wounds of the 
 heart should be sutured. 
 
 Traumatic Carditis and Pericarditis. — The results of inflammation 
 of the walls of the heart have been observed in cases of injury of the organ 
 where the patients have died after a fortnight. In these cases the substance 
 of the heart was studded with inflammatory exudates. 
 
 Inflammation of the pericardial sac is a more frequent result of traumatism 
 than inflammation of the heart itself. The physical signs of a pericarditis of 
 traumatic origin are substantially identical with those of an ordinary pericarditis. 
 
 The treatment of wounds of the heart and of traumatic carditis and 
 pericarditis includes constitutional as well as local measures. The patient 
 should lie with the head low, in order to prevent syncope from cerebral 
 anemia. Absolute quietude should be insisted upon, and opium should be 
 administered with a view to control subsequent inflammation, to tranquillize 
 the circulation, and to relieve pain. Artificial warmth should be applied 
 if indicated by the presence of collapse. It must not be overlooked that 
 a certain amount of collapse is a favorable condition through its influence in 
 checking; hemorrhage and inflammation, and that over-stimulation must be 
 carefully guarded against. In some cases violent reaction follows and neces- 
 sitates the administration of cardiac sedatives. 
 
 If a patient survives beyond the period of reaction, the stage of inflamma- 
 tion ensues. This condition must be treated in the same manner as a peri- 
 carditis depending upon idiopathic causes. 
 
224 ^^V AMERICAN TEXT-HOOK OF SURGERY. 
 
 SECTION III.— DISEASES OF THE BLOOD-VESSELS. 
 PART I. DISEASES OF THE VEINS. 
 
 Before discussing diseases of the veins it is necessary to review some points 
 in tlie anatomy of the vessels. A vein, like an artery, has three coats. The 
 internal coat of the veins is the same as the internal coat of the arteric-s, and its 
 continuation forms the only coat which the capillaries possess. The middle coat 
 is composed of longitudinal and circular elastic fibers, interlacing with which 
 are involuntary mu.scular fibers that are not so abundant in the veins as in the 
 arteries. The external coat is composed chiefly of white fibrous tissue. The 
 coats of the veins differ from those of the arteries in the thinness of the mus- 
 cular coat and in the presence of valves in the internal coat of the superficial 
 and a few of the deep veins ; they correspond with those of the arteries in the 
 presence of a common external fibro-cellular tunic and the internal endothelial 
 coat. The thinness of the muscular coat of the veins prevents them from 
 having that rotundity, elasticity, and contractility which are so characteristic 
 of the arteries ; it also permits the temporary distention or bulging of the 
 vessels when there is some mechanical impediment to the free return of venous 
 blood to the heart. To serve this purpose the veins possess an inherent 
 capacity of limited distention which is never required in the case of the 
 arteries. It is important to remember this fact when the subject of wounds 
 of veins is considered. Notwithstanding the thinness of the walls of the 
 veins, they are relatively as strong as those of the arteries. 
 
 The jyresence of valves is a peculiarity of veins. These valves support 
 the column of blood mechanically. They are found in the superficial venous 
 system, and especially in the lower extremities. In the portal and hemor- 
 rhoidal systems there are no valves ; and this fact has an important influence 
 upon the development of certain di.seases in connection with these veins. 
 
 I. Inflammatiox of Veixs, or Phlebiti.'^. — Inflammation of a portion 
 of a vein produces changes in its coats in the .same manner as inflammation of 
 the coats of an artery alters the arterial coats. The disease is much more 
 common than arteritis. Phlebitis may be acute or subacute. 
 
 Acute Phlebitis is diffuse, and is the result of some irritation of a vein, 
 as puncture or any other injury accompanied by infection; sometimes it follows 
 the ligation of a vein in its continuity or after an amputation. It especially 
 follows any septic traumatism, and is then very dangerous, leading generally 
 to pyemia. 
 
 Subacute Phlebitis is circumscribed, and is not ordinarily so dangerous 
 as the acute diffuse form. The subacute variety generally supervenes upon 
 some chronic disease of the coats of the vein which has led to their thickening 
 by deposit of fibrinous matter, thus occluding the vein. An abscess may 
 develop, and must be opened as an ordinary abscess. There is no hemorrhage 
 from the vein, as it has been blocked up by external pressure or by an intra- 
 venous inflammatory product ; hence its lumen does not communicate with the 
 abscess. Should the fibrinous deposit break down, micro-organisms and their 
 ptomaines get into the vein, and acute diffuse phlebitis is engrafted upon the 
 chronic variety and pyemia results. 
 
 The symptoms of phlebitis are pain and tenderness along the course 
 of the vein, with discoloration of the skin and acute (edema below the obstruc- 
 tion. There are present also .symptoms of a constitutional nature, such as 
 rapid and irritable pulse, rigors, elevation of temperature, dry and brown 
 tongue, and pain in the joints if pyemia has developed. 
 
 Treatment of Phlebitis. — The patient .should be kept perfectly quiet, 
 
SURGERY OF THE VASCULAR SYSTEM. 
 
 225 
 
 the affected limb elevated, so as to favor the return circulation, and leeches 
 applied in certain cases along the inflamed veins. Goulard's extract or a lead- 
 and-opium wash should be used, or hot antiseptic fomentations, if a circum' 
 scribed abscess is forming. Opium is indicated to relieve pain. Abscesses 
 should be opened, for if they are not incised the micro-organisms and the 
 ptomaines may break down the plug in the vein and the softened thrombus 
 obtain access to the general circulation. The patient's general condition must 
 be kept up with nourishing food and stimulants, as there is a great tendency 
 to exhaustion following certain forms of phlebitis. 
 
 II. Varix, or Varicose Veins. — By this is meant an enlarged, elongated, 
 tortuous, knotty condition of the veins. The term "varicose veins" is 
 restricted in general use to the veins of the extremities, and especially to 
 those belonging to the lower extremity. The internal saphenous vein is 
 the one most freipiently affected (Fig. 31). The disease begins by a slow 
 dilatation of the vein, which gradually becomes thickened and tortuous. 
 The inner lining membrane, or endothelial coat, of the vein is altered, 
 and the valves are shortened, and thus rendered insufficient to support 
 the column of blood. Besides these alterations in the inner coat of the 
 vein, the outer coat becomes thickened on account of the connective-tissue 
 infiltration and of the 
 
 inflammatory new for- ^'^^''- '•^^■ 
 
 mation (periphlebitis). 
 
 The varicose con- 
 dition affects, as a 
 rule, chiefly the super- 
 ficial veins. When 
 these are largely di- 
 lated the circulation 
 becomes sluggish and 
 is carried on by the 
 deep veins. Occasion- 
 ally it happens that 
 the deep veins are pri- 
 marily affected. In- 
 stead of the outer coat 
 of the vein being 
 thickened, this coat 
 sometimes becomes ex- 
 cessively attenuated, 
 and separates at places, 
 so that the internal coat 
 protrudes through the 
 slit and forms a protru- 
 sion which may even 
 become pedunculated. 
 This pathological con- 
 dition is, however, 
 rare. When the vari- 
 cose veins begin where 
 the venous radicles 
 arise from the capil- 
 lary system, the varicosity appears as a fine capillary injection with an 
 
 15 
 
 Varicose Veins of the Legs (original). 
 
■2-2i\ JiV AMKincAy TKXT-liOOK OF SURGERY. 
 
 arl)Oi'c'sc('iit Mppcanini't'. Tliis cninlition is more f'lUMjiiciitlv foiiinl in women. 
 AVhen the lar;ie trunks are aftected, tlie veins are dilated, tortuous, and knotty. 
 They rise above the level of the skin, and if pressure is made over them the 
 presence of blood in the vessels becomes at once manifest. When the disease 
 has existed for a long while, they may burst from excessive thinness of the coats, 
 and a serious or even fatal hemorrhage may result. Again, instead of the veins 
 standing out Itoldly al)ovc the skin-level, there may be a passive exudation into 
 the surrounding eellular tissue of the limb, which causes it to become (edenuitous. 
 This is not the ordinary fjcdema from obstructed venous return, but a s(jlid non- 
 resisting tedema, ^vhich has a marble-like appearance and does not pit ui)on light 
 pressure. Upon this peculiar ^edematous condition there is often engrafted a 
 most obstinate eczema. If the eczema is allowed to j)rogress without any 
 treatment, it will degenerate into a superficial ulceration which will beccnue 
 chronic and may extend down into the tissues and give rise to " varicose 
 ulcer." These ulcers may involve a vein and give rise to fatal hemorrhage. 
 
 There is another condition arising from the presence of varicose veins 
 ■which does not appear until late in the progress of the disease. ThromJii 
 may be formed within the vein, which may become disintegrated and break 
 down, forming an a])scess, if infection takes place (suppurative thrombo-])hle- 
 bitis), or under certain conditions they may organize and comijletely occlude 
 the vein (plastic thrombo-])hlebitis), and thus bring about a radical cure. The 
 thrombi may also become shrunken and contracted, and frequently laminae of 
 fibrin are deposited upon them. Small hard concretions which have been called 
 veinstones or phleboliths have been observed. These are formed of laminated 
 fibrin, phosphate of calcium, and the sulphates of calcium and potassium. 
 
 Varix of the internal saphenous vein (Fig. 31) may give rise to symptoms 
 similar to those of femoral hernia. In varix there is a tumor at the saphenous 
 opening at the place where a femoral hernia presents. The varix disappears 
 when the patient assumes the recumbent position, as in femoral hernia. Both 
 swellings reapj)ear u|)on the patient's coughing or assuming the upright 
 position. The differential diagnostic point is that in varix of the saphenous 
 vein, if pressure is made at the saphenous opening while the patient is in a 
 recumbent position, the swelling will reappear when he assumes the upright 
 
 f)osition, even though pressure is maintained. In femoral hernia, on the other 
 land, the tumor will not reappear under the same conditions. 
 
 The causes of varicose veins are — I. Predisposing, and II. Exciting. 
 
 I. Among the predisposing causes may be mentioned — 
 
 {a) Sex. Varicose veins are most frequent in the female, and are apt to 
 follow uterine enlargement from any cause. 
 
 (6) Age. The tendency to the production of varicose veins increases as age 
 advances. 
 
 {c) Obstruction to the free return of blood in the veins, as tight garters worn 
 below the knee or other constrictions obstructing venous circulation. 
 
 (d) Occupations which re(juire habitual standing. 
 
 II. Among the exciting causes may be mentioned — 
 
 (a) Tumors in the abdomen or pelvis. It is evident that any obstruction 
 to the return venous circulation has a tendency to develop varicose veins ; thus, 
 tumors of any variety which press upon the iliac veins will give rise to varico.se 
 veins of the leg. It has been stated that the left leg is more frequently the 
 seat of this disease than the right, on account of the sigmoid flexure, which 
 when distended presses upon the left iliac vein. The caecum, however, when 
 distended, Avould press nearly as much upon the right iliac vein, and as a 
 clinical fact the right leg is affected with equal frequency. 
 
SURGERY OF Till-: VASCULAR Sl^STEM. 227 
 
 (b) Diseases of the Heart and Lu)i(/s. — In tbesc conditions there is found 
 an inij)ortant exciting cause. It" the heart is t'eel)le in acti<jn, tiie po^ver to 
 drive the blood back is lessened, and as a consequence the column of blood 
 moves very slowly and becomes stagnant in places. The develo[nnent of the 
 ascites (hydroperitoneum) often incidental to heart affections also f(n"ms by 
 pressure upon the veins a barrier to the free ivturn of the venous blood. 
 
 (f) PreiinatK-ji by pressure of the gravid uterus upon the iliac veins. 
 In a first pregnancy the veins of the extremities are not much altered patho- 
 logically, and if attention is paid to this incipient stage of the disease, which 
 is amenable to treatment, subsequent pregnancies will not be so likely to 
 produce an incurable condition of varicose veins. 
 
 Treatment. — I. Palllatirc, and II. liadieal. 
 
 Palliative treatment is to be directed to the removal of the causes of the 
 obstruction and also of their efi'ects, as far as possible, without an operation. 
 This object is best fulfilled by attention to the condition of the bowels, to the 
 state of the liver, to the affections of the heart and lungs ; by enforcing quiet 
 and rest in a recumbent position, Avhich favors venous return circulation, and 
 by attention to the general health, and often by out-door exercise in a suitable 
 climate. The local j)aniative treatment consists in the application of an elastic 
 bandage or a perfectly-fitting silk elastic stocking which shall afford support 
 to the vessels, thereby equalizing the circulation. This elastic support has a 
 tendency to turn the flow of venous blood from the superficial veins into the 
 deep veins, which do not, as a rule, become varicose. The silk stocking 
 should be made to order from accurate measurement of the limb, and should 
 extend from below at the toes, where the trouble begins, to or above the knee, 
 where it should be loose. 
 
 The radical treatment has for its object the complete obliteration of the 
 vein. Many surgical procedures have been devised for this purpose. 
 
 Multiple ligatures were introduced by Phelps, who ties the vein in thirty 
 or forty places. Excision of the vein in six, eight, or more places is a suc- 
 cessful procedure. Trendelenburg ties the saphenous vein just below the 
 saphenous opening. Schede makes a circular incision around the leg down 
 to the deep fascia, as if he were about to amputate, ties the veins, and sutures 
 the wound. All such operations on veins must be done with the most strin- 
 gent antisepsis, or an acute septic phlebitis and pyemia may readily follow. 
 
 III. An Angioma is a tumor composed of a congeries of blood-vessels 
 lying in fat. There are three varieties of angioma — 1. The simple nevus. 
 2. The cavernous nevus. 3. The plexiform angioma (J. Bland Sutton). 
 
 Simple Nevus. — This is situated in the 
 skin and subcutaneous tissue. It may be com- Fig- 32. 
 
 posed of arterioles or of venules. \Vhen the 
 nevus affects the arterioles there is a slightly 
 elevated area of skin of a scarlet or purple 
 color. Nevi are sometimes found upon the 
 trunk, but generally upon the face. They 
 vary in size from that of a pin's head to that 
 of a silver dollar, or even may involve an area 
 nearly as large as the hand. They are un- 
 sightly, but seldom give rise to any physical 
 discomfort unless they undergo ulceration, in Nevus (original). 
 
 which event a troublesome and in some cases 
 
 even alarming hemorrhage ensues. The vessels consist of capillaries held 
 together by areolar tissue. The term telangiectasis is often applied to this 
 
228 AN AMERICAN TEXT- HOOK OF SURGERY. 
 
 form of ucvus, auJ it is j)o})ularly called mother h mark (Fig. 32). A nevus 
 may appear as a "port-wine stain," a widespread superficial distention of 
 arterioles or venules, varying in color from pink to blue. 
 
 Cavernous angiomata are composed of tissue resembling that of the 
 corpora cavernosa, and are found beneath the skin as well as in the skin. 
 They are also seen in the orbit and in the liver and other viscera. Ihey 
 pulsate, and are much larger than the capillary nevi. They can be made 
 partially to disappear by pressure, but reappear when the pressure is dis- 
 continued. T'he anatomical structure is similar to that of carcinoma, but 
 instead of the spaces being filled with epithelial cells they contain blood. 
 They are painless. If punctured, they give rise to alarming iiemorrhage. 
 
 A plexiform angioma is what used to be called an aneurysm by 
 anastomosis, and is now known as a cirsoid aneurysm (see Cirsoid Aneur- 
 ysm). 
 
 Treatment. — The operations for the removal of nevi are many. The 
 best recognized surgical treatment includes ligation, excision, electro-punc- 
 ture, the cautery, and coagulating injections. 
 
 Small nevi occasionally disappear spontaneously a few weeks after birth. 
 If a small nevus persists or begins to enlarge, it may often be destroyed 
 by touching it with a glass rod moistened with fuming nitric acid. A 
 nevus can be removed by ligation. Ligation is done by passing a pin 
 under the mass and throwing a ligature around the base of the nevus below 
 the pin. If large, a double ligature can be passed under and at right 
 angles to the pin, and the nevus tied in two halves. Setons lead to what 
 may be a dangerous suppuration, and coagulating injections may produce 
 extensive thrombosis or distant embolism, and thus cause death. Nevi about 
 the face and scalp should never be injected, on account of the danger of 
 thrombi and emboli. The best treatment for a nevus is excision. The sur- 
 geon makes two elliptical incisions well clear of the growth, ties the vessels 
 of supply, and sutures the Avound. In large cavernous angiomata electrolysis 
 and excision have been employed Avith good results. A port-wine stain of 
 small size can be destroyed by making a series of parallel incisions through 
 the vessels, and crossing these cuts by a series of transverse incisions. Elec- 
 trolysis may be successful. A port-wine stain of large size cannot be cured. 
 
 PART II. — DISEASES OP THE ARTERIES. 
 ARTERITIS. 
 
 I. The word arteritis signifies inflammation of an artery. Each coat of aft 
 artery may be primarily separately inflamed. Thus we distinguish inflammation 
 of the internal coat, of "the middle coat, and of the external coat. These inflam- 
 mations are called, respectively, Endarteritis, Mesarteritis, and Periarteritis. 
 All these different varieties may be either acute or chronic. 
 
 1. Acute Arteritis. — This is a rare surgical disease, and is due to an 
 inflammation excited by an infectious or poisonous embolus lodged in the 
 artery. The internal coats become swollen and infiltrated with pus-cells. The 
 suppurative inflammation is transmitted to the other coats of the artery and to 
 the surrounding parts, and may result in abscess. 
 
 Acute Periarteritis is also usually secondary in origin, and is due to an 
 extension of inflammation from the surrounding parts. The exudation is apt 
 to be purulent. In these destructive inflammations of the arterial coats the 
 lumen of the artery generally becomes occluded by a thrombus before perfora- 
 
SURGERY OF THE VASCULAR SYSTEM. 229 
 
 tive ulceration occurs. Sliould this thrombosis not take place, severe and 
 souK'tinies fatal hemorrhage may arise if the artery be of a sufficient 
 size. 
 
 It is still an open (question whether acute arteritis occurs as a primary 
 affection. A few doubtful cases have been recorded in which severe pain and 
 tenderness existed along the course of an artery, in some instances accompanied 
 by a certain amount of redness and swelling. The diagnosis of acute arteritis 
 has been made, but, as the termination has been favorable, the pathological 
 proof of its existence is Avanting. 
 
 2. Chronic Arteritis. — This is the atheroma of most authors, and its 
 relation to the production of aneurysm is a subject of great surgical interest. 
 By atheroma is meant a chronic inflammation of the internal coat characterized 
 by a fatty degeneration, Avith a tendency to cheesy collections and calcareous 
 deposits. The middle coat is not usually involved until late. The external 
 coat becomes affected secondarily, and is hypertrophied and inelastic. As a 
 result of the fatty degeneration the inner coat of the artery swells, the circula- 
 tion is disturbed in that part, and an ulcer is formed by the rupture of a caseous 
 mass into the lumen of the artery. 
 
 Traumatism aff"ecting the artery, alcoholic excesses, syphilis, Bright's dis- 
 ease of the kidney, gout, and rheumatism are among the diseases which are 
 recognized as the causes of atheroma. This condition ordinarily involves the 
 larger arteries, and in this respect differs from syphilitic arteritis, which, as has 
 been pointed out, aff'ects chiefly the vessels of smaller size. Occasionally the 
 lime-salts are deposited in the ulcer and a calcareous plate is formed. Atheroma 
 is usually seen in persons of advanced age. 
 
 Calcification of the artery consists in a low grade of inflammation in the 
 middle coat, and is characterized by the deposit of earthy matter, chiefly car- 
 bonate of calcium and the phosphates. This deposit may be in plates, and it 
 is then termed laminar calcification, or it may be arranged in a concentric 
 manner around the muscular fibers, when it is termed annular calcification, and 
 when the latter form is spread over a considerable area it is termed tubular 
 calcification. This disease aff'ects arteries in the extremities, and as a result 
 the parts beyond are inadequately supplied with blood, owing to the narrowed 
 lumen of the vessel and to its loss of elasticity. When the disease is extensive 
 enough completely to occlude the artery, gangrene of the limb may result. 
 When it affects the vessels in the extremities, the calcification can be readily 
 recognized by the finger placed upon the vessel. This is often observed in 
 the radial artery, the vessel becoming roughened and rigid and hard like a 
 pipe-stem. 
 
 The treatment of arteritis depends upon the variety. If due to syphilis, 
 the iodides and mercury are useful ; if to rheumatism or gout, the remedies 
 that are indicated in these affections should be employed. Little can be done 
 to cure the disease, and the treatment should be directed toward the prevention 
 of any extension of the inflammation. Great importance must be attached to 
 the avoidance of all kinds of violent exercise, which might lead to rupture of 
 the vessel with its attendant consequences. 
 
 ANEURYSM. 
 
 The word aneurysm is derived from the two Greek words d.vd, "through," 
 and eopOvco, " I widen." 
 
 An aneurysm is a tumor containing blood and communicating with the 
 interior of an artery. There are some forms of blood-tumor which do not 
 
230 
 
 AN AMERICAN TEXT- HOOK OF SURGERY. 
 
 strictly come Avitliiii the limits of this (U'liiiitioii. 'riicsc -will l)c (lisciissctl 
 before taking up aneurysm pro})er. 
 
 The fii'st variety is arterial varix. Tiii.s cun.sist.s in an ebjn^ution and 
 dilatation of a single artery of medium or small size. The vessel is pouched, 
 sacculated, and tortuous. Tliis condition is similar to that of a varicose vein. 
 The superficial temporal, <)ccij)ital, and posterior auricular arteries are often 
 the seat of this disease. The skin over the dilated vessel is exceedingly thin, 
 or even ulcerated, and this condition may give rise to alarming hemorrhages. 
 
 Cirsoid aneurysm is the next variety, and consists in a dilatation and 
 elongation of a number of arteries of medium and small size. 
 
 If a single artery is involved, and it is pouched and tortuous and dilated 
 after the same manner as a varicose vein, the term arterial varix is applied. 
 
 If a munber of arteries held togetlier by connective tissue are affected by 
 these pathological changes, the tumor is called a cirsoid aneurysm (Fig. 33). 
 Such an aneurysm usually involves also the capillaries in its immediate vicin- 
 ity. The cause of this disease is supposed to be an injury in which the vaso- 
 motor nerves have been paralyzed. The tumor thus formed is irregular in 
 shape, compressible, bluish in appearance, and pulsating in character. The 
 temperature within the circumscribed area of the outgrowth may be elevated 
 on account of the increased vascular supply. Cirsoid aneurysm is distin- 
 guished from a true aneurysm by the situation of the growth, the number 
 of vessels involved, the superficial bruit and pulsation, the peculiar spongy, 
 doughy feel, and the difference in the pressure-effects. 
 
 The treatment of cirsoid aneurysm is usually unsatisfactory, and often 
 attended with great danger from hemorrhage. The lack of success in treat- 
 ment is in part due to a lack of comprehension of the nature of the disease. 
 
 Fig. 33. 
 
 Cirsoid Aneiirysui iImuij 
 
 Extirpation, the lines of incision being carried wide of the tumor, multiple 
 ligation of the individual afferent arteries, the application of the galvano- 
 cautery, the injection of coagulating ffuids, the introduction of the electro- 
 puncture needle alone or associated with circular compression of the afferent 
 
SURGERY OF THE VASCULAR SYSTEM. 
 
 2;n 
 
 vessels, acupressure of the luain feeding artery, and ligation of the main 
 trunk, are among the recognized methods of treatment ; often two or more 
 of these may be combined with advantage. 
 
 Preliminary ligature of afferent vessels followed by cutting the tissue 
 around the tumor has proved curative. Removal by e.vcision is the only 
 method which offers a reasonable certainty of cure, and this operation should 
 be immediately preceded by the ligation of every tributary. Bad cases of 
 cirsoid aneurysm of the hand require amputation. 
 
 All aneurysms may be divided into two groups — the idiopatJac and the 
 tranmatir. In the idiopathic variety there is a sac formed of one or more of 
 the arterial coats, and the blood within the sac is in direct communication with 
 the lumen of the artery. In the traumatic variety there is also a sac, but its 
 walls are composed of inflammatory lymph and a proliferation of the con- 
 nective-tissue cells. 
 
 Idiopathic aneurysms are divided into — 
 1. Tubulated. 
 
 2. Sacculated 
 
 f a, true, 
 ' \ b, false, 
 
 1, circumscribed. 
 
 2, diffused. 
 3. Dissecting. 
 
 The tiihrdatcd aneurysm (Fig. 84) is the fusiform aneurysm of some authors. 
 In this variety the three coats of the artery are simultaneously dilated, in the 
 
 Vui. .31 
 
 Tubulated or Fusiform Aneurysm (urigiiial). 
 
 circumference as w-ell as in the length of the vessel. The middle coat is not 
 preserved as a continuous layer, but its elements are separated. This aneurysm 
 
 Fig. 3.5. 
 
 Sacculated Aneurj'sm (original). 
 
 is found in the cranial, thoracic, and abdominal cavities. The tubulated aneu- 
 rysm rarely grows to be of any size, and scarcely ever ruptures unless a saccu- 
 lated aneurysm is engrafted upon it. The sac in this form of aneurysm seldom 
 
2:52 AN AMERICAN TEXT-BOOK OE SURGERY. 
 
 contains any laminated librin. It, however, ;i;ives rise to <^reat discomfort, iuid 
 often causes severe pain by pressure upon important organs. 
 
 Tlie sacculated aiwunjsin (Fig. 35) is one which ])rojects from a tubulated 
 aneurysm or which sj)rings from the side of an artery, the interior of which is 
 in connnunication with the sac by an oj)ening which is called the mouth. 
 
 The sacculated aneurysm is subdivided into fnie and fahe. The true 
 sacculated aneurysm is one in which all three of the coats of the artery are 
 equally expanded to form the sac. It seldom grows larger than an orange. 
 
 In the false sacculated aneurysm the inner layer is the thickened and 
 altered intima enlarged by successive additions so as to cover the vastly 
 increased surface ; traces of the middle coat are to be found only near the neck 
 of the sac ; the wall is niaiidy formed by the condensed and nniltiplied con- 
 nective tissue of the surrounding parts. In short, the wall of the aneurysm 
 contains little or nothing of the original wall of the artery, except that its 
 internal layer is continuous with and similar in character to the intima. This 
 variety of aneurysm may grow to an enormous size. 
 
 False sacculated aneurysms are subdivided into the circH)iiscn'l>cd, in which 
 the blood is confined within a sac composed of some part of the arterial coats, 
 and the diffuse, in which the sac is ruptured and the blood has extravasated 
 into the neighboring tissue ; or else the sac is ruptured, and the blood is con- 
 fined Avithin a cavity the walls of which consist of lymph and condensed areolar 
 tissue. 
 
 The dissecting aneurysm is one in which the internal coat of the artery 
 has given Avay, owing to some erosion caused by an atheromatous patch, and 
 the blood dissects or makes its way through the middle coat (Fig. 36). The 
 blood may burrow for some distance through the middle coat until it comes in 
 contact with an eroded patch situated upon the outer coat, through which it 
 bursts, and finally extravasates into the surrounding areolar tissue ; or it may 
 burrow for some time through the substance of the middle coat until it comes 
 in contact with an eroded patch situated upon the internal coat, and then the 
 
 Fig. sn. 
 
 Plan of a Dissecting Aneurysm (Holmes). 
 
 blood again enters the artery ; or it may burrow for some distance and meet 
 no eroded patches in either outer or inner coat, and may thus remain in a 
 small sac formed by the circumscribed separation of the arterial coats. 
 
 Tlie component parts of an aneurysm are (1) the sac, (2) the contents. 
 The sac is composed of one or all three coats of the artery, unless the aneurysm 
 is traumatic, in which case the walls are formed by lymph and condensed 
 areolar tissue. The sac may be formed by the internal and external coats, 
 the middle coat having been ruptured ; or by the dilatation of the external 
 coat, the internal and middle coats having been ruptured ; or by the dilatation 
 of the internal coat, the middle and external coats having given way. If the 
 latter condition is ever present, which has been denied, the aneurysm would 
 be called an aneurysmal hernia. The mouth of the sac is the narrow opening 
 
SURGEliY OF THE VASCULAR SYSTEM, 233 
 
 which establishes a coinnmiiication between the interior of tlie sac and the 
 lumen of the artery from which the aneurysm develops. 
 
 In the fusiform aneurysm there is no mouth, as the aneurysm results from 
 a uniform dilatation of the coats of the artery. In the sacculated variety a 
 mouth is present, and its situation relative to the lumen of the vessel influences 
 the amount of fibrin deposited, as well as the j^rowth of the aneurysm. 
 
 The contents of the sac vary according to the stage of the disease. In the 
 first stage the sac is very thin, and contains only iluid l)lood. In the second stage 
 the wall of the sac is very thick, and contains fluid blood 
 in the center and laminae of fibrin (Fig. 37) around the ^^^*- ^'^• 
 
 periphery. 
 
 The blood is in greater proportion than the fibrin 
 at first, but later the coaguium or laminated filtiin is in 
 excess of the fluid blood. These laminae of fibrin vary 
 in firmness and consistency in the different parts of the 
 sac. Thus upon the extreme periphery the layers of 
 fibrin are dry, friable, and opaque, while the layers ap- 
 proaching the center of the tumor are soft and of a red- 
 dish color. 
 
 In the sacculated variety the fibrin is rapidly de- laminated coaguium (Key 
 posited, and the rapidity with which it is formed depends and Bryant). 
 
 upon the relation of the mouth of the sac to the sac itself. The greater the 
 obstruction to the free flow of blood into the sac, the greater the tendency to 
 the deposition of fibrin. 
 
 In the fusiform aneurysm, where there is no retardation in the current of 
 blood owing to the absence of a mouth in the sac, there is no deposition of 
 fibrin, or at least it is deposited in exceptional cases only. 
 
 The natural terminations of aneurysm are — (1) spontaneous cure, (2) 
 death. 
 
 The spotitmieous cure of aneurysm is occasionally effected by nature 
 unaided by the surgeon. Such a case occurs very seldom, but that a cure 
 under certain conditions may thus be brought about is no longer open to 
 dispute. In the cases of spontaneous cure the aneurysm has always been 
 found solid and firm, — which leads to the belief that a deposition of fibrin had 
 already taken place. A deposition of fibrin takes place in consequence of the 
 -slower current in the sac, and finally fills it. The clot thus formed within the 
 sac may extend into the vessel, and thus add to the permanence of the cure. 
 Occasionally the aneurysm is spontaneously cured by an embolus, when a clot is 
 washed out of the sac into the efferent artery and occludes it, so that the current 
 is completely arrested within the sac ; the latter then fills with a firm coaguium. 
 Sometimes a spontaneous cure is effected when the sac becomes large enough 
 by its own weight to cause mechanical pressure upon the artery sufficient to 
 retard, or even to arrest, the circulation in the vessel. Finally, a spontaneous 
 cure is accomplished in some cases when the sac becomes acutely inflamed and 
 the coagulation of the blood within it is thereby promoted. 
 
 Death is the other natural termination. There are various ways by which 
 an aneurysm destroys life : 1st. By rujiture of the sac. The aneurysm extends 
 to the surface of the body or to a mucous canal or a serous cavity. When the 
 aneurysm has reached the surface of the body the thin skin over the sac sloughs, 
 and when the slough comes away there is a slight hemorrhage through a small 
 opening. This hemorrhage is arrested by a coaguium, but after a while is 
 renewed, until finally the patient dies from repeated hemorrhages. In case an 
 aneurysm bursts into a mucous canal the process is the same. The rupture 
 
2;u 
 
 AN AMERICAN TEXT-BOOK OF .SUlKiERY. 
 
 may open into the trachea, oesophagus, intestine, or bladder. Here, again, the 
 sac is first rendered thin by absorption, and when the sh)ugh separates tlie 
 hemorrhage occurs. An aneurysm may destroy lite by bursting into one of the 
 pleural cavities, generally the left, or into the ])erit(»neal or tbe ])ericardial sac. 
 In this situation the serous membrane gives way in a rent, and death follows 
 instantly. 
 
 2d. Aneurysm also destroys life by pressure upon important orgarns. If 
 the aneurysm presses upon the trachea or the bronchi or the lungs, it produces 
 asphy.xia ; if upon the oesophagus or the thoracic duct, it causes inanition; if 
 upon the vertebrae and the ribs, absorption of these bones results (Fig. 38), 
 followed by spinal irritation and meningitis, with severe neuralgia from pressure 
 on the intercostal nerves. 
 
 Fig. 38. 
 
 Absorption of the Vertebrae and Ribs from Pressure by an Aneurysm (original). 
 
 3d. Aneurysm, again, destroys life by septicemia and pyemia, due to acute 
 inflammation and suppuration of the sac ; also, 4th, by embolism, in which case 
 the small migratory clot is carried by the cerebral arteries to the brain if the 
 situation of the aneurysm is in the arch of the aorta ; finally, 5tli, by ;jan;/reiie 
 of the extremity caused by obstruction. In this case the gangrene causes 
 blood-poison and death results from septic infection. 
 
 Etiology of Aneurysm. — In general terms, any disturbance of the 
 proper relations between the force of the heart on the one hand and the elas- 
 tic resistance of the artery on the other, especially if an increase of the former 
 is combined with a diminution of the latter, will give rise to aneurysm. 
 
 The causes of aneurysm may be divided into I. Predisposing, and II. Ex- 
 citing. 
 
 i. Predisposing Causes. — (a) Degeneration of the Arterial Coats. — This is 
 tbe principal predisposing cause, since in some form it is always present except 
 in traumatic aneurysm. The degeneration most commonly associated with the 
 development of aneurysm is the atheromatous and fatty, frequently accompanied 
 by a calcareous deposit that renders the vessels less elastic. As a result of 
 this atheromatous and fatty condition the artery fails to contract after the 
 
tiURGERY OF THE VASVULAU >sy.S7EM. 235 
 
 systolic action of tlie heart, gradually yields and dilates, until finally an aneurysm 
 is formed. It is lield by Von KecklinglKiiisen and others that the influence of 
 atlieroma upon the development of aneurysm has been exaggerated. It is 
 believed that changes in the middle coat, either inflammatory or degenerative, 
 are among the most frequent predisposing causes. 
 
 (h) Si/pJiilis is a freifuent predisposing cause of aneurysm, in consequence 
 of the changes in the arterial walls. 
 
 ((•) Over-action of t/ic Hecoi. — Hypertrophy of the heart, by increasing the 
 strength of the impulse, drives the blood with greater force into the arteries. 
 These are likely to distend under the impulse of an hypertrophied heart if 
 they have undergone the slightest degenerative changes. Hypertrophy of the 
 heart associated with chronic nephritis, in which the arterial tension is increased 
 and the vessels are weakened by atheroma, affords another illustration of the 
 combined action of these two causes. 
 
 {d) Certain violent oceupations, as riding and hunting, it has been asserted, 
 predispose a patient to aneurysm. Thus coachmen and postilions, owing to the 
 nature of their occupations, are especially liable to the disease. This clinical 
 fact is explained by the obstruction of the popliteal arteries on account of the 
 constant bending of the knee in horseback riding and sitting on the box, as 
 well as by the contractions of the gastrocnemii and solei muscles when the feet 
 are placed firmly against the footboard or the stirrups. The arteries, too, are 
 bent or stretched in these positions, and the jar and motions of the rider or 
 driver must increase the force of the circulation. 
 
 (e) Age. — This has a marked influence. Aneurysms are most frequently 
 found between the ages of thirty and forty years, because the arteries begin 
 to lose their elasticity at this period, while the heart has not yet lost any of 
 its force or the muscles any of their strength. Aneurysms in very young 
 people are merely surgical curiosities. 
 
 (/) Sex. — Seven to one of the entire number of aneurysms are found in 
 males, presumably because of their more active occupations. 
 
 II. Exciting Causes. — («) A partial ruptiire of one or more of the arterial 
 coats, produced by external violence, is without doubt a prominent cause of 
 aneurysm. 
 
 (b) A direct wound of an artery also produces aneurysm, since it leads to 
 extravasation of the blood from the artery into the surrounding tissues. In 
 this case the aneurysm is termed traumatic, because the sac is not formed by 
 the coats of the artery. 
 
 (c) Fractures and dislocations are exciting causes of aneurysm, since the 
 artery is torn or stretched so as to weaken the coats, thus permitting subse- 
 quent dilatation. 
 
 (d) Straiyis have been considered exciting causes of aneurysm, since they 
 produce irregular and forced action of the heart. Strains may also act directly 
 upon the vessel by forcing blood through it while it is under unusual tension, 
 thus causing pressure at right angles to the axis of the vessel, or by stretching 
 the artery in its long axis. 
 
 The signs and symptoms of aneurysm may be described as belong- 
 ing to two stages : First Stage. — This includes the period from the beginning of 
 the formation of the aneurysm until the tumor is firm from the deposit of fibrin. 
 Second Stage. — This includes the period after the aneurysm has become firm 
 and resisting by reason of the presence of the deposit of laminated fibrin. This 
 stage may be absent, as in some aneurysms no such deposit takes place. 
 
 First Stage. — {a) Pulsation which is distinct, expansile, and synchronous 
 with the action of the heart. * 
 
23() AN AMERICAN TENT-JiOOK OF SURUEHY. 
 
 The pulsation is distinct in the first stage, because the aneurysm contains 
 only fluid Mood and tiie sac is thin, 'riie pulsation is excentric and exj)ansile 
 in character. If" l)otli hands are placed upon the sides of" the tumor, they will 
 be separated from each other with every pulsation. The pulsation in this stage 
 is simultaneous with the contraction of the heart. The pulsation of an abscess 
 lying on an artery would be up and down in mass, and not expansile. 
 
 \l>) Premure on the artery above the tiunor diinhuHhcs the size of the latter; 
 when applied helow the tumor inereases its size; and in both cases cauKex the 
 pulsation to diminish or cease. If the artery above the sac is conii)resseil, the 
 flow of blood into the sac is arrested, the blood can l)e s([uee'/ed out of the sac, 
 and the tumor disappears. This can be beautifully illustrated in the first stage 
 while the contents of the sac are composed of fluid blood and the walls of the 
 sac are thin. If, after having compressed the artery above the sac and emptied 
 the latter of blood, the hands are ])laced firmly over the sac and the pressure is 
 removed from above, the l)lood will rush into the sac, and as soon as the sac has 
 filled pulsation will return and will separate the hands. In abscess, on the 
 other hand, the instant the pressure from the artery above is relieved, the trans- 
 mitted pulsation, or upheaval, is felt. If the artery below the sac is com- 
 pressed, the sac will rapidly enlarge and the pulsation will diminish or cease. 
 If the pulsation in the efferent artery at some distance from the sac on its distal 
 side be felt, it will not be simultaneous Avith the ])ulsation of the corresponding 
 artery of the opposite side of the body. Besides the apjireciable delay in pulsa- 
 tion as compared with the opposite artery, the force of the pulsation will be 
 markedly diminished. The sphygmographic tracing of the pulse upon both 
 sides of the body will also reveal a wide difference (Fig. 39). 
 
 Fia. 39. 
 
 Sphygmographic Trnriiifrs of tlio Kndinl rnlso of ft Patient with AniMirysni of tin- llight Hrachial Artery: 
 1, Left Kadiiil I'ulse ; 2, KifilU Kadial I'lilse (Malioiiudl. 
 
 (c) A bruit is heard over the aneurysm, and also along the artery for some 
 distance from the sac. The bruit is a noise caused by the rush of blood into, 
 through, and out of the sac, the internal lining membrane of which is rough- 
 ened.° The bruit is blowing or loud and rasping like the noise made by a saw. 
 This blowing murmur is not always present, but its absence will not exclude 
 the possible existence of an aneurysm. In malignant vascular tumors the 
 bruit is sometimes present, but is heard only over the area of the tumor, and 
 is never transmitted along the artery leading from the sac, as it is in aneurysm. 
 
 Second Stage. — This stage "includes the period after the aneurysm has 
 become firm and resisting by the (lei)osit of laminated fibrin. 
 
 (a) Indistinct Pulsation. — When the aneurysm becomes firm and its sac is 
 lined with fibrin, the pulsation is indistinct and rnay even be altogether lost. 
 There are certain points over the sac where the pulsation is felt more distinctly 
 than at others. This is because the fibrin is not equally distributed over the 
 interior of the sac. 
 
 (6) Pressure. — Owing to the deposition of fibrin, the tumor cannot be effaced 
 by pressure on the artery above the sac, as in the first stage. 
 
SUBGERY or THE VASCULAR SYSTEM. 
 
 2;i7 
 
 ((•) The bruit is fjoiu'riilly present, althouj^h it is heard witli varying degrees 
 of distinctness over the tumor, and also can be heard at a distance from the sac. 
 
 It will be observed that these symptoms, which were so marked and almost 
 pathognomonic in the first stage, are of rather negative character in the second 
 stage. There are, however, additional signs : 
 
 ((/) Pain. — The pain is sharp and lancinating, like that of carcinoma, or 
 aching or boring, like that of ulceration. It arises after the aneurysm has 
 attained some size and makes pressure upon the nerves. Thus in popliteal 
 aneurysm the pain is intense along the course of the popliteal nerve. The 
 nerve is sometimes flattened out upon the sac. Pain may be at times an 
 early symptom of aneurysm, but it is generally more pronounced later on in 
 the course of the disease. 
 
 {e) (Edema. — This is produced by the pressure of the sac upon the veins. 
 (Edema of the limb is constant after the tumor has attained a certain size. 
 The oedema, if excessive, produces a great deal of discomfort to the patient, 
 and may terminate in extensive ulceration and sloughing. 
 
 (/) Gangrene sometimes occurs late in the course of the disease, and gen- 
 erally follows the oedema, but may come suddenly as the result of an embolus. 
 
 [g) Pressure-ejfects vary according to the parts pressed upon and the 
 amount of pressure exercised by the tumor. 
 
 If the aneurysm presses upon bone, it produces a severe aching, boring, 
 gnawing pain, and finally causes the absorption of the osseous tissue (Figs. 38 
 and 40) ; if upon glands, it destroys 
 
 their function ; if upon the trachea, ^^^' '*^- 
 
 respiration is rendered difficult, and 
 there is an obstinate distressing metallic 
 cough and altered voice produced by 
 pressure upon the I'ecurrent laryngeal 
 nerve. This is termed the brassy 
 cough of aneurysm. If the aneurysm 
 presses upon the oesophagus or the 
 thoracic duct, deglutition or nutrition 
 is interfered with and the patient dies 
 from inanition. If the pressure be on 
 the phrenic nerve, hiccough often is 
 produced : and if on the sympathetic 
 nerve, marked capillary congestion. 
 
 Diagnosis of Aneurysm. — If 
 the aneurysm has not consolidated, the 
 symptoms which have been enumerated 
 will enable the surgeon to establish a 
 diagnosis. But it often happens that 
 after consolidation of the aneurysm by 
 fibrin many of the signs and symptoms 
 become obscure and a diagnosis is ren- 
 dered somewhat difficult. Again, cer- 
 tain other tumors under exceptional 
 circumstances may present signs almost 
 identical with those of an aneurysm. 
 
 In a case of consolidation the history 
 of the disease, and occasionally the use of the hypodermatic syringe, are the 
 only safe guides for the surgeon. In pulsating tumors which resemble aneu- 
 rysm the diagnosis must be made with great care. 
 
 Absorption and Perforation of the Sternum from 
 Pressure by an Aneurj-sm (original). 
 
238 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 The (liffovent tumors Avitli Avliicli a surgeon may confound an aneurysm are 
 the ))ulsatinii; eiice)»hah)i(l, tlie vascular soft sarcoma, erectile tumors of all 
 kinds, jiulsating tumors of hone, an ahscess over an artery, and hematocele of 
 the neck. 
 
 There are also tumors Avhieh are not, strictly speaking, pulsating which 
 have led to error in diagnosis and treatment, such as lymphatic enlargement 
 and cystic disease of the thyroid gland, and certain other diseases, as neuralgia 
 and rheumatism, the pain in both of Avhich has been mistaken for tliat of 
 beginning aneurysm in the thoracic cavity. 
 
 Duration of Aneurysm. — An aneurysm may grow very ra|)idly, but 
 this is rare. The growth, as a rule, is slow, and may extend over several years. 
 The aneurysm is likely to grow as long as the cause is present. Its duration 
 is influenced by the force of the circulation, its situation, the size of the mouth 
 of the sac, the coagulating tendency of the blood, the nature of the surround- 
 ing parts, the condition of tlie sac, and the patient's habits and manner of 
 living. 
 
 Treatment. — The surgeon must aim in his treatment to effect a cure by 
 precisely those means which nature adopts. The essential conditions for suc- 
 cess in any plan of treatment are obliteration of the cavity of the sac and 
 occlusion of the afferent and efferent vessels. 
 
 There are several ways in which obliteration of the sac and the vessels can 
 be accom{)lishe(l, but often the best results will be obtained by a combination 
 of various methods of treatment. In order to occlude the sac it is necessary to 
 diminish the force of the circulation, thus causing coagulation of the blood in 
 the aneurysmal sac. When this has been eff'ected a cure may be expected. 
 
 The methods resorted to may be either medical or surgical. 
 
 The medical methods which have met with the greatest success in curing 
 aneurysm arc those suggested by Langenbeck and l)y Tufnell. Laiu/cnbeck's 
 method consists in the hypodermatic injection of ergotin. This drug slows 
 the action of the heart, and hence favors deposit of fibrin ; it contracts the 
 muscular fibers of the middle coat of the arteries leading into the sac, and 
 produces increase of blood-pressure. All these are favorable to the deposition 
 of fibrin and the consolidation of the aneurysm. Iodide of potassium has also 
 been used in the medical treatment, largely upon the supposition tliat aneu- 
 rysms are due to the eff"ects of syphilis, but it probably acts as a lieart depres- 
 sant. Acetate of lead has been employed to equalize the circulation. Bromide 
 of potassium has been used to relieve the cough and pain. 
 
 TufnelVs method is a modification of a plan of treatment originally suggested 
 by Valsalva. It is especially applicable to internal aneurysms : but a brief 
 description of it is proper here, as external aneurysm has been thus successfully 
 treated, and as a list of the diff'erent methods of curing aneurysms would be 
 incomplete without reference to this peculiar plan of treatment. 
 
 In 1875, Tufnell, an Irish physician, published his experience in what may- 
 be termed the rest treatment of aneurysm. Tufnell required his aneurysmal 
 patients to assume the recumbent position in bed for several months. The 
 object of the treatment was to reduce the watery elements of the l)lood and 
 to increase its solid constituents. Rest, regimen, and remedial agents Avere 
 the three means he employed. He showed that in the recumbent position the 
 circulation Avas tranquillized and the action of the heart became regular and 
 slow. He maintained that recumbency placed the same check upon the circu- 
 lation in internal aneurysm that mechanical compression does in the treatnuMit 
 of external aneurysm. He demonstrated this pro))osition in the fi)llowing way : 
 A patient before assuming the recumbent position had a pulse of 9(3 a minute; 
 
SURGERY OF THE VASCULAR SYSTEM. 239 
 
 after a few d.ws' lying supine in bed it fell to 66 a minute. Thus there was a 
 difference of 30 beats a minute caused by position. ]\Iidtii)lying 30 beats by 
 00, the iiuuiber of minutes in an hour, the result is 1800 beats an hour, and 
 this multiplied by 24 — the number of hours in a day — gives 43,200 beats per 
 diem ; that is to say, a patient suff'ering from aneurysm and occupying the 
 recumbent position has his aneurysmal sac distended 43,200 times less frequently 
 in a day than it would be if he remained in th(; standing position. Tufnell 
 held that there was no remedial agent in the Pharmacopeia that would produce 
 such an action upon the heart without injury or danger. Recumbency is the 
 secret of cure, but it must be continued for three months. The diet was 
 restricted to 10 ounces of solid and 6 ounces of fluid in the twenty-four hours. 
 This reduction of nourishment diminished the action of the heart and increased 
 the plasticity of the blood, and hence favored the consolidation of the aneurysm, 
 Tufnell also directed certain remedial agents to be combined with rest, such as 
 lactucarium to quiet the patient and induce sleep, and opium to soothe pain. 
 Compound powder of jalap was used at intervals, to reduce the quantity of cir- 
 culating fluid by withdrawing the serum from the blood. He gives an analysis 
 of 10 cases treated by his method : 7 were cured, and 3 died during treatment. 
 One of the successful cases was an aneurysm of the popliteal artery, cured in 
 twelve days. 
 
 The surgical treatment of aneurysm may be subdivided into — 1st, those 
 methods which embrace some form of compression ; 2d, those which embrace some 
 form of surgical operation ; 3d, those which may be classed as miscellaneous. 
 
 1. Compression. — The treatment of aneurysm by compression was employed 
 over two hundred years ago, but only in cases of traumatic aneurysm. The 
 manner of employing compression in the seventeenth century for the cure 
 of aneurysm was essentially different from that employed at the present time, 
 both in its principle and in its application. 
 
 The principle upon wdiich surgeons based the treatment of traumatic aneu- 
 rysm by compression in the seventeenth century was this : the compression was 
 supposed to prevent the further dilatation of the aneurysm and to squeeze the 
 blood out of the sac into the arteries, as water would be squeezed out of a 
 sponge ; the edges of the cut artery were thought to be thus brought into 
 apposition and to become adherent, and the blood to pass through the restored 
 artery as if nothing had happened. From this description it is evident that 
 little was known of the nature or pathology of aneurysm. That the prin- 
 ciple upon which the treatment was based was erroneous Avill be seen when 
 we study the subject in the light which modern pathology has thrown upon it. 
 
 In the eighteenth century Heister was the first to propose to extend the 
 plan of treatment of traumatic aneurysm by compression from the bi'achial 
 artery, to which compression had been limited, to the popliteal artery, but 
 he did not carry his plan into execution. It was reserved for Guattani, an 
 Italian surgeon, in the year 1772 to treat the first case of popliteal aneurysm 
 by compression. He applied compression directly upon the sac and also band- 
 aged the entire limb, believing that the aneurysm was cured upon the same 
 principle that has been mentioned. The cases treated by this means usually 
 resulted fatally. By direct compression a circumscribed aneurysm Avas often 
 transformed into a diffiise one ; the sac became inflamed and suppurated ; the 
 limb became gangrenous, and half of the patients died. This was the state of 
 affairs when, in l785, John Hunter tied the femoral artery in Hunter's canal 
 for the cure of a popliteal aneurysm, and announced a new principle, which 
 changed all the opinions then held as to the way in which compression cured 
 an aneurysm, and was followed by a complete revolution in practice. 
 
240 ^l.y AMERICAN TEXT- BO OK OF SURGERY. 
 
 Desault ligatcd the popliteal at some distance above the sac earlier in the 
 same year, and a claim ot" priority has been based upon this fact. The Ilun- 
 terian method is mentioned in this connection only to show the change produced 
 by it in the treatment by compression. In another place it will be considered 
 at length. The new principle involved was this: that it was necessary to arrest 
 only partially, and not completely, the current of blood through the aneurysmal 
 sac, which, from its own inherent elasticity, tends to diminish in size so soon 
 as the full force of the heart's action is taken off: this contractility of the sac 
 is an imj)ortant element in the cure of circumscribed aneurysms l)y any method, 
 and its absence in diffused as in traumatic aneurysms explains the failure of 
 ligation and compression in the majority of such cases. Upon this i)rinciple 
 and after Hunter's time compression was employed above the aneurysm, 
 instead of, as always before, directly over it, and with greatly improved results. 
 When this method is employed, the cessation of pulsation in the sac after the 
 compression is relaxed, the absence of the thrill and bruit, together with the 
 fact that the collateral circulation is fully established, indicate that the aneu- 
 rysm is cured. 
 
 The enlargement and })ulsation in the collateral vessels do not take place 
 until the aneurysmal sac is obliterated by the deposition of fibrin ; therefore the 
 establishment of the collateral circulation is in itself a reason for supposing that 
 the aneurysm is cured. It is through this collateral circulation that the extrem- 
 ity is supplied with blood. This prevents gangrene from attacking the parts 
 below the sac. The collateral vessels soon develop into vessels of important 
 size. The pain which has been recorded in the cases in which spontaneous 
 cure was effected, as well as in those cases in which compression accomplished 
 a cure, has been said to have been due to the sudden enlargement of the anas- 
 tomosing vessels consequent upon the complete solidification of the sac, and 
 may thus occasionally be considered a favorable symptom. 
 
 Instrumental conipi^ession is carried out by the employment of one of the 
 many different varieties of tourniquets or compressors. Whatever instrument 
 is employed for the purpose (Figs. 41, 42), only the artery must be compressed, 
 
 Fi(i. 41. Fig. 42. 
 
 Signorini's Tourniquet. Skey's Tourniquet. 
 
 and at no time during the period in which the instrument is applied must the 
 pressure be greatly relaxed. A piece of chamois-skin should be placed over 
 the artery, so that the pressure of the instrument shall not excoriate the skin. 
 The time required to cure an aneurysm by compression varies from one 
 to several days. The instrument must be kept on the artery until the 
 pulsation in the sac has ceased, and then the amount of pressure during the 
 following twenty-four hours can be lessened gradually. This gradual diminu- 
 
SURGERY OF THE VASCULAR SYSTEM. 241 
 
 tion of the amount of compression after pulsation has ceased is necessary, 
 because otherwise the current of blood might disintegrate the clot in the sac 
 before it is firm and solid. 
 
 Digital pri'ssior was first employed by Jonathan Knight of New Haven, 
 Conn., in 1848. In the same year Dr. Willard Parker and Dr. James R. 
 Wood of New^ York City each cured an aneurysm by digital pressure. The 
 pressure is maintained by relays of students or assistants for from one to 
 two days, and this method is preferred by many surgeons to all other methods 
 of compression. The same principle of treatment has been carried out by the 
 use of instrumental pressure instead of digital, with fairly satisfactory success. 
 A bag of shot, suspended over the bed by means of clastic tubing, has been 
 used to secure uniform pressure upon the artery above the sac. 
 
 Flexion of the joint was brought to the attention of the profession in 1858 
 by Mr. Hart of England. The })rinciples involved in this method are similar 
 to those involved in compression. The plan is usually applicable only to aneu- 
 rysm at the bend of the elbow and in the ham, although it has been success- 
 fully employed also in aneurysm of the external iliac. The leg is flexed upon 
 the thigh and the thigh upon the pelvis ; or the forearm is flexed upon the arm. 
 The entire extremity is bandagecl before flexion. Flexion causes compression 
 directly upon the tumor itself, and also impedes the circulation through the 
 sac, and probably dislodges a small clot which closes the mouth of the sac. 
 This method is not suitable where the aneurysm is large, because of the liability 
 of the sac to rupture, and is contraindicated if there is much oedema of the leg 
 or inflammation of the sac. In ordinary cases it may be tried, since no liarm 
 follows if the treatment is unsuccessful. It is especially applicable to cases in 
 w'hich the tumor is small, the sac not inflamed, and the joint not involved. 
 
 Rapid Cure by EsmarcJis Elastic Bandage. — In 1864, Murray, an English 
 surgeon, anesthetized a patient suffering from an aneurysm of the abdominal 
 aorta, and applied an instrument which completely checked the flow of blood 
 through the arteries leading into the sac. The treatment resulted in cure. In 
 this the so-called "rapid method" the object was to produce complete stag- 
 nation of a mass of blood in the sac until it coagulated. In 1875, Reid of the 
 British navy treated aneurysms successfully by the rapid method by employing 
 Esmarch's elastic bandage. The formation of a blood-clot in the sac is essen- 
 tial in order to effect the cure of an aneurysm by this method. That variety 
 of blood-clot which is formed while blood is at rest is required (the red blood- 
 clot), and not the one that is formed while blood is in motion (the fibrinous or 
 "white blood-clot). In order to accomplish the formation of a blood-clot in con- 
 tradistinction to the formation of fibrin there must be a stasis of blood in the 
 sac, followed by coagulation of the blood. This clot does not finally undergo 
 organization, but contracts. Its chief object is to aid in the formation of a 
 thrombus in the afferent and efferent vessels leading into and out of the aneu- 
 rysm. Not all aneurysms are amenable to this treatment. There should be no 
 vascular degeneration except in the aneurysm, likewise no renal disease, and 
 the sac itself should be free from inflammation. The administration of the 
 iodides and restricted albuminous diet are useful adjuvants. 
 
 The patient should have a hypodermatic injection of morphine before taking 
 ether, and just enough of the anesthetic should be administered to keep him quiet 
 and free from pain during the treatment. The elastic bandage should be firmly 
 applied from below upward till the aneurysmal sac is reached, then carried very 
 lightly over the sac itself, and reapplied firmly above it, so as to confine a quan- 
 tity of fluid blood in the sac. The patient must be kept under ether for an hour 
 or an hour and a half. A tourniquet should be adjusted above the aneurysm, 
 
242 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 to moderate tlie hlood-curreiit iind prevent its disturbing and wasliing out the 
 clot in the sac and the thrombi in the afferent and efferent arteries. The 
 tourni(iuet ean be kept on the linil) for from sixteen to twenty-four hours after 
 the removal of the bandage, and nmst be unscrewed gradually, so as to restore 
 the blood-supply in proper (juantity. The two dangers to be guarded against 
 are, on the one hand, washing out the clot before it is solid, and on the other 
 the production of gangrene of the limb by too long-continued pressure. The 
 effect of the arrest of the blood-supply must be carefully watched from hour to 
 hour as the tourni(|uet is gradually unscrewed. The collateral circulation will 
 soon be established. The risks of the sudden rise and fall of arterial tension, 
 the compression of nerves, the rupture of the sac, the development <»f kidney 
 disease, and the possibility of gangrene, are all to be considered. These dan- 
 gers also accompany other methods, but perhaps are as little likely to occur 
 after this plan as after any other operative interference or after compression 
 applied in any one of the many ways already described. 
 
 The treatment of aneurysm by any of the different methods of compression 
 is not without difficulties. If the instrument is not adapted to the exigencies 
 of the case, if the patient is irritable and cannot bear pain well, or if the 
 aneurysm is unfavorably situated for the application of an instrument or of 
 digital compression, there will arise difficulties which Avill discourage the 
 patient as well as the surgeon. If, hoAvever, after even wrecks of perseverance 
 no good has been accomplished, both patient and surgeon should remember 
 that no great risks have been incurred involving the life of the patient, and 
 no conditions absolutely contraindicating a trial of operative measures have 
 been produced. Few cases in which the treatment by compression in some 
 form has been faithfully persevered in for a long time have been unattended with 
 improvement. 
 
 2. Those metliods tvhieh embrace some form of surgical operation. 
 
 The Old Operation of Antyllus (Fig. 43). — The earliest recorded treatment 
 of aneurysm is that devised by Antyllus, who lived in the fourth century. At 
 that time it was employed only 
 
 in cases of small traumatic Fig. 43. 
 
 aneurysms situated at the bend 
 of the elbow. The method 
 was simple, and was described 
 by him as follows : an incis- 
 ion was made along the inner Old Operation of AntyUus for Aneurysm (original). 
 
 aspect of the arm over the 
 
 brachial artery. The vessel, having been exposed, Avas tied on each side of 
 the aneurysm. The aneurysm Avas then laid open and the contents of the 
 sac Avere turned out. 
 
 This operation Avas performed for several hundred years, and it Avas not until 
 the eighteenth century that any other was practised even in idiopathic aneurysm. 
 The great mortality in this form of aneurysm Avas due to the fact that the 
 artery Avas tied immediately above and beloAV the sac, ivhere the vessel tvas 
 unsound, and hence secondary hemorrhage and exhaustive suppuration, with 
 ankylosis of the joint, folloAved. The principle involved in the ohl opera- 
 tion, with certain omissions and modifications, is still applicable iu axil- 
 lary and gluteal aneurysms and in traumatic aneuysm at the bend of the 
 
 elboAv. , . 1 
 
 AneVs Operation (Fig. 44).— Anel in the year 1710 (levised anil per- 
 formed a ncAv operation for the cure of aneurysm. He did not open the 
 sac as in the old operation, or tie the artery above and below the sac, or 
 
SURGERY OF THE VASCULAR SYSTEM. 
 
 243 
 
 Fig. 44. 
 
 Stuff the uonnd with myrrh. lie thou^lit that the tumor would collapse 
 if the main artery leading into it were tied near the aneurysm. He was suc- 
 cessful,, and thenceforward the treatment of 
 aneurysm rested upon a scientific basis. 
 
 Anel, however, did not ap))reliend cor- 
 rectly the principle which his operation in- 
 volved, lie thought the tumor simj)ly col- 
 lapsed, and it was not until some years 
 afterward that the true principle underlying 
 this operation of ligaturing the artery upon 
 the cardiac side of the aneurysm was 
 brought to light — not indeed until John Hunter, in 1785, on account of the 
 many failures in the treatment of aneurysm by compression, was led to 
 
 Aiiel's Operation for Aneurysm (original) 
 
 Fig. 45. 
 
 Hunter's Operation for Aneurysm (original). 
 
 investigate the subject from a pathological point of view, and devised the 
 operation for its cure which has made his name immortal. 
 
 Hunterian Operation (Fig. 45). — Hunter demonstrated by experiments upon 
 dogs that weakness alone was not the cause of dilatation of an artery, but that 
 there must be some previous disease of the coats of the artery itself before the 
 force of the circulation would develop an aneurysm. He proved that the disease 
 was not confined to the artery at the seat of enlargement only, but extended 
 some distance from the sac ; and this fact, he thought, explained the cause of 
 failure of treatment by Anel's method, in which the artery was tied at a point 
 where it was diseased, permitting the ligature to come away too soon and second- 
 ary hemorrhage to occur. 
 
 Hunter proposed, therefore, to tie the artery at a distance from the sac, at a 
 point where the vessel w^as healthy, and thus diminish the risk of secondary 
 hemorrhage. He thought, moreover, that if the force of the circulation were 
 taken off from the aneurysmal sac the disease would be arrested, and the 
 sac and its contents would be absorbed. The conclusion which he drew' from 
 his observations was that simply taking off the force of the circulation from 
 the aneurysmal artery is sufficient to effect a cure of the disease, or at least to 
 put a stop to its progress, and enable the processes of nature to restore the parts 
 to a normal state. 
 
 The conditions under which the Hunterian operation is indicated are as 
 follows: the aneurysm must be of moderate size; it must be of slow growth; 
 and the sac mus"t not be inflamed. Slight oedema w^ould not contraindicate 
 the operation. Gangrene would preclude all operations except amputation. 
 
 The accidents following the Hunterian operation are — secondary hemor- 
 rhage, return of pulsation in the sac, inflammation and suppuration of the sac, 
 gangrene of the extremity, pyemia, and septicemia. 
 
 Brasdors Operation (Fig. 46) consists in ligating the artery upon the 
 distal side of the sac, so that the circulation upon that side is completely 
 
•2i\ 
 
 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 arrested. The cases in which this method can be adopted are aneurysms of 
 the carotid artery, of the external iliac, etc. 
 
 Wardrop's Operation (Fig. 47) consists in tying the artery or one of its 
 branches upon the distal side of the sac, the principle on which it is founded 
 
 Fig 
 
 Brasdor's Operation (Holmes). 
 
 Wardrop's Operation (Holmes). 
 
 being the same as that in Brasdor's. It arrests the circulation to a great extent, 
 but still permits the escape of blood through one or more branches. It is 
 applicable only to aneurysm of the innominate artery or of the arch of the 
 aorta. The carotid or the subclavian alone, or both of these vessels, may be 
 tied, and the two operations may be either simultaneous or consecutive. The 
 branches of the subclavian between the ligature and the aneurysm keep up a 
 diminished circulation. 
 
 Before dismissing the subject of ligation, the advantages of compression 
 over ligation will be considered. These advantages are that — 
 
 1st. Compression effects a cure in accordance with nature's laws. The sac 
 after compression consolidates just as in spontaneous cure; only the sac itself 
 is consolidated, and not all the arteries up to the point where pressure is 
 made, as is the case after ligation. 
 
 2d. Compression is less dangerous than ligation. If any danger arises 
 during compression, the treatment can be discontinued and then resumed. 
 Not so with ligation, for then the patient may be in great danger for many 
 days after operation. 
 
 3d. Compression is more likely to be attended Avith success than ligation. 
 There are not so apt to be complications, such as secondary hemorrhage, slough- 
 ing of the sac, phlebitis, gangrene, or pyemia, occurring during compression 
 and preventing a cure. 
 
 4th. Compression is more likely to be permanent than ligation. A second 
 aneurysm has been known to form after ligation, and also suppuration to be 
 set up in the sac ; neither of these is likely to occur after compression, though 
 both are possible. 
 
 3, Those methods which may he classed as miscellaneous. 
 
 Introduction of Foreign Bodies into the Sac. — This method consists in 
 puncturing the sac with a canula and introducing through it several yards of 
 fine wire. Moore, in 1864, passed twenty-six yards of fine wire into an 
 aneurysmal sac. The patient died of pericarditis and inflammation of the sac. 
 Recently, Loreta introduced some silvered copper wire into the sac of an 
 abdominal aneurysm. A firm clot was formed, but the patient died two months 
 after the operation. Besides wire, other materials have been employed, such 
 
SURGFAiV OF THE VASCULAR SYSTEM. 245 
 
 as catgut, silk, ainl liorsc-liair. AVliatcvcr iiKitci-ial is used, the operation is 
 attended with some danger; l)ut Stewart has re])orted two cases of aortic 
 aneurysm in whieli great improvement took phiee after filling the sac with wire. 
 
 Matupuhttid)!. — This method was introduced hy Fergusson in 1852. The 
 object is to disphice some of the fibrin in the sac by manipulating the aneur- 
 ysm, and thus to block the artery upon the distal side of the sac. The 
 aneurysm is first emptied by making pressnre'on the afferent artery, and then, 
 the sac is kneaded and rubbed in order to detach a small embolus which shall 
 be swe])t into the efferent artery and thus obstruct it mechanically. The ope- 
 ration has fallen into disuse, owing to the fact that emboli were carried to the 
 brain, causing aphasia, hemiplegia, and even death. 
 
 Galvrfno-pimcture is a method suggested by Phillips in 1829. The object 
 is to produce coagulation of the blood in the sac without the intervention of 
 any foreign body. A galvanic current of 5 or 6 milliamperes is passed through 
 an insulated needle which is brought near to but not in contact with the point 
 of another insulated needle introduced into the sac about an inch from the point 
 of entrance of the first needle. The needles are left in place for an hour after 
 the clot is formed. Suppuration of the sac, hemorrhage through the punctures 
 in the sac-wall, and embolism are among the dangers that attend this method. 
 
 AcHjmncfure by means of very fine gilded needles has been employed. 
 They are introduced into the sac so as to cross each other, and the blood coag- 
 ulates around them. They are left in the sac several days, and then withdrawn. 
 
 Extirpation of the aneurysm was first practised by Philagrius of Macedon 
 in the fourth century. A most formidable operation in those days, it has 
 been revived of late with marked success by the aid of anesthetics and with 
 the certainty of aseptic healing. 
 
 The technique of the operation consists of a free incision over the site of 
 the aneurysm, so as fully to expose the continuity of the vessel. Two liga- 
 tures are now applied to the artery upon the proximal side of the sac, a short 
 distance from it, and the vessel divided between the ligatures. The same 
 procedure is to be followed upon the distal side of the aneurysm after care- 
 fully dissecting out the entire sac with its contents and severing them from 
 their connections. 
 
 The special advantages of extirpation of the aneurysmal sac over proximal 
 ligature, compression, or any other method are the removal of the dangers 
 of emboli which might cause gangrene, the absolute permanency of the cure, 
 the absence of secondary hemorrhage, the freedom from sepsis, and, finally, 
 the lessened mortality — advantages not secured by the other methods. 
 
 The mortality of proximal ligature has been placed by Delbet at 18 per 
 cent., that of total extirpation of the sac at 11 per cent. ; the occurrence of 
 gangrene after proximal ligature about 8 per cent., after extirpation onlv 3 
 per cent. Ransohoff collected twenty-eight extirpations of major aneur3^sms 
 of the extremities without a single death. 
 
 Extirpation of the aneurysm is especially indicated in the traumatic vari- 
 ety, notably those situated upon the extremities. It is also indicated when 
 the sac has ruptured or when other methods have ftiiled to cure the disease. 
 
 Amputation is required in certain aneurysms. This is necessary if an 
 aneurysm has burst, if hemorrhages are frequent, if a joint is involved, if 
 caries of bone has ensued, or if gangrene of the extremity has occurred. 
 
 Coagulating Itijeetions. — In this method injections of certain drugs are 
 made into the sac with a view of causing coagulation of the blood. Such 
 injections should not be employed in aneurysms situated in the neck, because 
 emboli may be transmitted to the brain and cause instant death. In aneurysms 
 
246 
 
 AX AMERICAN TEXT-BOOK OF SURGERY, 
 
 involving the extremities, injections of Monsel's solution of iron, tannin, acetate 
 of lead, and otlior dnijjs have hcon finployod. Whatever injection is used, pres- 
 sure should he made for some little time ujM»n liotli the allcrcnt and the efferent 
 arteries, to prevent end)oli from hein<i; swept into the circulation. 
 
 Maceivens Methud, which consists in inducing the formation of white 
 thrombi within the sac, is a recent plan of treatment which will sometimes 
 be useful. The formation of these thrombi is accomplished by irritating the 
 lining membrane of the aneurysmal sac in such a way as " to induce infiltration 
 of the parietes with leucocytes, and a segregation of them from tlie blood- 
 stream at the point of irritation." The amount of irritation should be 
 sufficient to cause merely a reparative exudation, as any irritation beyond this 
 stage would result in softening of the sac-W'all, which in turn might lead to 
 rupture. The irritation should be evenly applied within the whole surface of 
 the sac, or at least from many foci distributed uniformly throughout its interior. 
 The techni({ue of the operation is as follows. The skin over the sac having 
 been made aseptic, a long, strong cylindrical needle, also rendered aseptic, is 
 introduced into the interior of the sac. The point of the needle should be 
 allowed to impinge upon the opposite wall of the sac, so as to irritate the lining 
 membrane, or else the needle should be held lightly in this position for a few 
 moments, so as to allow- the impulse of the blood-current to phiy on it. It 
 should be shifted to otlier parts of the sac at intervals of ten minutes, until the 
 whole sac has been uniformly irritated. The simultaneous use of a second or 
 even a third needle at distant points may be necessary. The time ref(uired to 
 irritate the Avhole sac varies from a few hours to forty-eight hours. "While the 
 needle is left in situ in the sac, an antiseptic gauze dressing should be applied 
 to the surrounding region. It may be necessary to repeat the operation from 
 time to time for weeks or even for months. This method should not be employed 
 
 Fic4. 48 
 
 Difftise Traumatic Aneurysm of the Brachial Artery (White). 
 
 if there is any inflammation in the walls of the sac, any superficial ulceration, 
 or any erysipelatous induration. 
 
 Traumatic Aneukysm (Figs. 48, 49). — This variety of aneurysm differs 
 
 Fig. 49. 
 
 Traumatic Aneurysm hiiil open and Vesbcls tied (White). 
 
 from all the others in the manner of its causation, as well as in the condition 
 of the parts involved. In all varieties of aneurysm except the traumatic, the 
 
SURGERY OF THE VASCULAR SYSTEM. 247 
 
 disease is situated in tlie coats of the arteries. In the traumatic variety the 
 lesion, as its name implies, is the result of a direct injury to tlie vessel, and 
 an arterial hematoma results. 
 
 This form of aneurysm is caused by a stab or gunshot wound, or by the 
 giving way of cicatricial tissue Avhich has imperfectly healed a wound of an 
 artery. The blood escapes from the injured artery, and extravasates through- 
 out the tissues until by mechanical [)ressure the hemorrhage is arrested. 
 The pressure of so much extravasated blood in the tissues with superadded 
 infection by pyogenic microbes causes an inflammation of the parts, and if 
 not treated an abscess may possibly form, the opening of which may result 
 in an alarming hemorrhage. 
 
 The symptoms of traumatic aneurysm depend upon its situation and 
 the size of the vessel wounded. The presence of a tumor suddenly devel- 
 oped after an injury to a vessel, accompanied by severe pain and tension, 
 with pulsation and bruit, and absence of pulsation beyond the aneurysm, is 
 indicative of this form of aneurysm. In addition to these signs, a certain 
 redness of the skin from inflammatory tension soon appears, and unless this 
 tension is relieved sloughing is apt to occur, and in some cases even gangrene 
 of an extremity. 
 
 Traumatic aneurysm must not be mistaken for an abscess, which it often 
 resembles. The diagnosis between the two conditions can be made by the 
 history, by the symptoms, and, if necessary, by introducing a hypodermatic 
 needle. Fluid blood indicates an aneurysm, while pus suggests an abscess. 
 The fact that an abscess may be the direct result of a traumatic aneurysm must 
 not be overlooked. 
 
 The treatment of traumatic aneurysm is based upon the same principles 
 that would guide the surgeon in the management of a primary wound of an 
 artery. If in an extremity, an Esmarch elastic bandage should be applied 
 and the tumor cut down upon until the injured artery is found. The vessel 
 should be completely divided and the two ends securely ligatured. The wound 
 should then be thoroughly disinfected and dressed antiseptically, in order to 
 secure healing by primary intention. In cases in which an elastic bandage 
 cannot be employed — e. g. in the neck — a serious difficulty arises. When this 
 is the case the surgeon should carefully dissect down to the aneurysm, and 
 make an opening sufficiently large to admit his finger into the tumor, by which 
 he should seek for the opening into the artery on the proximal side of the 
 aneurysm, in order to arrest the hemorrhage by pressure. The finger may be 
 guided to the opening in the vessel by feeling the current of warm arterial 
 blood impinge upon it. When the opening has been occluded, the surgeon can 
 enlarge the wound so that he may be enabled quickly to turn out the fluid 
 blood and the coagula in the false sac. The vessel is then tied between the 
 finger and the heart by means of a' curved aneurysm needle armed W'ith a 
 catgut or silk ligature. The artery on the distal side of the aneurysm must 
 then be secured by a similar ligature, otherwise, if the collateral circulation has 
 been established before the operation is done, very troublesome hemorrhage 
 would arise from this point. If the vessel is in an extremity, is very large, 
 and the traumatic aneuiysm is situated near the trunk, an amputation may be 
 necessary, especially if the injury to the vessel has been caused by a gunshot 
 wound. 
 
 An Aneurysmal Varix is a communication between an artery and a vein 
 without the intervention of a sac. It may result from unskilful venesection, 
 from the thrust of a sharp instrument, from a pistol-shot wound, etc. If an 
 artery and a vein have been wounded by venesection, for example, so that 
 
24S AX AMERICAN TEXT- HOOK OF SURGERY. 
 
 a communication is cstahlislicd hctwocii them, an anciirvsiii:il varix is f'oniMMl. 
 When this accident happens, a ])a(l or compress is hiid Hrml v over the wounded 
 part, so as to arrest the hemorrliajre. The walls of the artery and vein in con- 
 sequence of the slight inflammatory action become adherent to each other at 
 
 Fuj. 50. 
 
 J( 
 
 Plan of an Aneurysmal Varix (original i. Varicose Aneurysm (Spence). 
 
 the margins of the Avound, but the wound itself does not lieal. since at each 
 pulsation of the heart a stream of arterial blood is thrown through the opening 
 into the vein. The blood thus projected from the artery into the vein finally 
 dilates the latter (Fig. 50). The blood as it enters the vein comes in contact 
 with the opposing venous stream, and so produces a Avhizzing sound Avhich is 
 pathognomonic of an aneurysmal varix. Once heard, the sound will never be 
 mistaken. It has been compared to many noises. One of the best compari- 
 sons (which is as ludicrous as it is forcible) was suggested by tlie late Mr. 
 Spence — viz., the noise which a bluebottle fly imprisoned in a thin paper bag 
 makes in its efforts to regain its freedom. Valentine Mott compared the noise 
 to the purring of a kitten. 
 
 Aneurysmal varix may exist for years and give rise to no serious disturb- 
 ance. There is some alteration in the coats of the vein and of the artery, but 
 none that Avould offer resistance to the flow of blood, as is the case in an aneu- 
 rysm. There is dilatation of the vein, but not enough to cause ulceration or 
 rupture. The veins beyond the varix are always more or less dilated and 
 enlarged. 
 
 Treatment. — In some cases of aneurysmal varix no operative interfer- 
 ence is called for. All that is then nece.ssary is to apply an elastic bandage, 
 which prevents further enlargement. The disease, however, sometimes extends 
 and occasions pain and disturbance in the circulation. In these cases pressure 
 by means of a firm compress should be made upon the artery above and upon 
 the vein below, and also directly over the aneurysmal varix. If this does not 
 cure the disease after a fair trial, the tumor should be treated by operation. 
 The aneurysm should be exposed l)y dissection, a ligature placed above and 
 below the opening in both the artery and the vein, and the aneurysm extirpated. 
 In aneurysmal varix of the carotid and the internal jugular and of the common 
 femoral vessels operative interference should be undertaken only when the 
 reasons are very urgent. 
 
 Varicose Aneurysm. — A varicose aneurysm is similar to an aneurysmal 
 varix, since in both there is a communication between an artery and a vein ; but 
 in the varicose aneurysm there is a sac between the artery and the vein. The 
 arterial blood is projected into this sac, and from the sac into the accompany- 
 ing vein (Fig. 51). 
 
 Both aneurysmal varix and varicose aneurysm are often called arterio- 
 venous aneurysm. 
 
 A'aricose aneurysm, like aneurysmal varix, is the result of a wound both of 
 the artery and of the vein ; but in the case of varicose aneurysm if not treated, 
 or if the compress which was placed over the wound at the time of the acci- 
 dent was not firm enough, blood will have extravasated between the walls of 
 
SURGERY OF THE VASCULAR SYSTEM. 241) 
 
 the artcrv and the vein and se])arated the two vessels. InHannnatory lymph 
 has then been deposited around this space, and thus a false aneurysm has been 
 fornuMl. coniniunifating with both vessels; its sac consists of condensed effused 
 lyni])h. This intervening sac which comes from the false aneurysm must not 
 be confounded with an ordinary false aneurysm the result of a wounded artery 
 alone. In the ordinary false aneurysm there is no communication with a vein. 
 
 On account of the slight arterial pressure exerted by the force of the circula- 
 tion upon the walls of the sac of a varicose aneurysm, the sac is not subject to 
 great enlargement. In an ordinary aneurysm the force of the blood-current 
 impinges directly upon the aneurysmal sac; in a varicose aneurysm the blood- 
 current finds its way through the aperture into the vein, and thus its force is 
 distributed into the vein instead of impinging directly upon the sac. While, 
 then, enlargement of the sac is not common, yet in view of the liability of the 
 sac to slough, and the danger of gangrene of the limb or of the false aneurysm's 
 becoming diffuse, the indication for surgical interference is plain. 
 
 The symptoms are nearly the same as in aneurysmal varix, with the 
 exception of the presence of a sac, which sometimes can be made out by pal- 
 pation, and over which can be heard a soft bruit. 
 
 Treatment. — Varicose aneurysm must not be left to itself, for it will finally 
 ulcerate and become diffuse. Compression is not suitable, as the already dilated 
 and varicosed veins would become greatly enlarged, and finally cause much 
 oedema and expose the patient to the risk of gangrene. In most cases of vari- 
 cose aneurysm, especially if the aneurysm is small, ligature of both vessels 
 above and below the disease, followed by extirpation, is a well-recognized opera- 
 tion. In cases of varicose aneurysm situated in the neck or in the anterior 
 femoral region, this procedure would be attended with great danger. The Hun- 
 terian operation of tying the femoral artery above the sac in healthy tissue has 
 been tried in two cases, and death followed in both instances. The reason for 
 the failure of ligation of the artery by Hunter's method is that the conditions 
 in an ordinary aneurysm and in the varicose aneurysm are different. In the 
 ordinary aneurysm the ligation of the artery causes deposition of fibrin in the 
 sac on account of the lessened amount of blood slowly entering the sac ; in the 
 varicose aneurysm the communication through the sac with the vein offers an 
 unimpeded passage of the blood into the venous circulation, and the return 
 venous circulation through the sac prevents coagulation, for blood in motion 
 will not coagulate. 
 
 The late Mr. Spence of Edinburgh devised and carried into successful 
 execution an operation for varicose aneur^^sm which meets the theoretical as 
 well as the practical indications. To use his own words, he cuts down upon 
 the artery above the sac, and then below the sac, but does not open the sac or 
 disturb the vein. The application of two ligatures to the artery at the places 
 mentioned removes the disturbino; influence in the retrograde current of 
 arterial blood, and thus permits the blood in the sac to remain unagitated by 
 the meeting of tAvo currents and to coagulate, causing the consolidation of 
 the tumor. 
 
 ANEURYSMS OF SPECIAL ARTERIES. 
 
 Carotid aneurysm is usually situated at the point where the artery 
 bifurcates upon either side of the neck. Upon the right side the aneurysm 
 may develop at the origin of the vessel. It begins with the appearance of a small 
 tumor, which may groAv slowly or very rapidly. The symptoms of carotid 
 aneurysm are those common to any other aneurysm, with, in addition, dyspnea, 
 difficult deglutition, vertigo, hoarseness, brassy cough, and ringing in the ears. 
 
2.J) AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 The diagnosis of carotid aneurysm is often attended with great difficulty. 
 The affections for which this disease may be mistaken have ah'cady l)ecn con- 
 sidered under tlie differential diagnosis of Aneurysm. 
 
 Tlie treatment of carotid aneurysm is hest carried out hy means of a 
 ligature upon the ju-oximal side of the sac if there is sufficient room, otherwise 
 upon the distal side. Among the accidents that may follow ligature of the 
 carotid may be mentioned embolism, cerebral softening, hemiplegia, syncope, 
 secondary hemorrhage, and suppuration of the sac. 
 
 If it becomes necessary to ligate both carotid arteries, they should not be 
 tied simultaneously, as this double operation has been attende<l ])\ fatal coma. 
 
 Subclavian aneurysm is found most frequently in the third portion 
 of the vessel. The tumor appears under the clavicular origin of the sterno- 
 cleido-mastoid muscle, the direction of its long axis corresponding with the 
 direction of the artery. Besides all the syra])toms common to aneurysm in 
 general, subclavian aneurysm has some special signs. Among these may be 
 mentioned pain along the nerves belonging to the bracliial ])lexus, if on the 
 right side a brassy cough from irritation of the recurrent laryngeal nerve, a 
 varicose condition of the jugular veins, delayed radial pulsation, and finally 
 oedema of the arm and hand. These symptoms increase in severity as the 
 tumor enlarges. 
 
 The diagnosis of a subclavian aneurysm in the third portion of the artery 
 from one involving the lower portion of the carotid or the subclavian in its 
 first portion, or even the innominate, must be made. The chief diagnostic 
 points of subclavian aneurysm in its third portion are the simultaneous 
 pulsation of the carotid arteries and the delayed radial pulsation upon the 
 affected side. The simultaneous delay of the carotid and radial pulsations of 
 the right side indicates an aneurysm of the innominate artery instead of the 
 third portion of the subclavian. 
 
 Treatment. — If the aneurysm is small and limited to the third portion, 
 digital pressure upon the proximal side of the subclavian, although difficult for 
 anatomical reasons, may be attempted in conjunction with constitutional treat- 
 ment. Pressure directly upon the sac has been successful in a few cases. If 
 compression fails, the artery should be ligated upon the distal side, since prox- 
 imal ligation has rarely proved effectual. It may be necessary, where other 
 means have failed, to ligate the artery on the proximal side as a preparatory 
 step, and then immediately to amputate at the shoulder-joint. 
 
 Axillary aneurysm may be idiopathic or traumatic. The idiopathic 
 variety may be developed by the stretching of the vessel in reducing an old 
 dislocation or by a too free movement of the shoulder-joint, or by atheroma 
 of the vessel. This variety of aneurysm grows very raj)idly, owing to the 
 laxity of the surrounding tissues, which permits it to dilate without early 
 mechanical obstruction. It quickly attains a large size, and the situation 
 of the sac renders it especially prone to inflammation. The pressure of the 
 aneurysm soon causes venous obstruction, and (edema of the forearm ensues. 
 The pain is often very severe, on account of the irritation of the brachial 
 plexus. The pulse at the wrist corresponding to the side of the aneurysm is 
 delayed when compared with that of the opposite side. If the sac continues 
 to grow, the shoulder-joint is invaded, the ribs are eroded, and the correspond- 
 ing lung is compressed. The movement of the arm is soon interfered with, 
 and ankylosis of the shoulder follows. This variety of aneurysm may cause a 
 dry pleurisy or a hyperplastic pneumonia. 
 
 The treatment consists in applying digital or instrumental compression to 
 the third portion of the subclavian artery, and, in the event of failure, in tying 
 
SURGERY OF THE VASCULAR SYSTEM. 251 
 
 this portion of the vessel. The a})})lie!iti()ii of an ehistic ])aii(lage to tlie 
 arm, eonil)ined Avith jiressiire uj)on the proximal side of tlie sac. can also be 
 tried. Other methods of treatment in this form of aneurysm are fraught with 
 danger, and must not be undertaken without deliberate consideration. 
 
 In the traumatic variety of axillary aneurysm the injury may be produced 
 by a stab or gunshot wound, or even, as has been said above, by external vio- 
 lence in atteiiijiting to reduce an old dislocation. In the treatment of traumatic 
 aneurysm Mr. Syme has suggested a modification of the old operation of Antyl- 
 lus. The subclavian is compressed firmly in its third portion, and the axillary 
 sac is then opened, the coagula turned out, the wound found, the artery com- 
 pletely divided, and both ends ligated. 
 
 Brachial aneurysm may be situated either along the course of the artery 
 or at the bend of the elbow. The most frequent variety of aneurysm is the 
 traumatic ; but aneurysmal varix, and also varicose aneurysm, are found at the 
 bend of the elbow as a result of unskilful venesection. For the treatment of 
 these varieties of aneurysm see pp. 229-249. 
 
 In idiopathic aneurysm of the brachial artery compression or the modified 
 operation of Antyllus or the Hunterian operation may be employed. In rare 
 cases gangrene of the forearm may result from an aneurysm in this situation. 
 This condition calls for amputation. 
 
 Iliac aneurysm may involve the common trunk of the vessel, the internal 
 or the external iliac artery, or their branches. In aneurysm of the common 
 iliac artery the treatment consists in compression upon the cardiac side of the 
 aneurysm. The pressure should be made as much as possible over the artery, 
 and not over the sac. The results of ligation of the common iliac for aneurysm 
 Bhow a mortality of nearly 75 per cent. 
 
 The internal iliac artery is seldom the seat of idiopathic aneurysm. The 
 sciatic and gluteal branches have, however, been the seats of aneurysm both of 
 the traumatic and the idiopathic variety. If the aneurysm is idiopathic, the 
 treatment should consist in proximal compression, and, if this fails, in the injec- 
 tion of remedies with a view to coagulating the blood. Recently, ligation of 
 the vessel by a median laparotomy has been employed. 
 
 If the gluteal or sciatic aneurysm is traumatic, compression must be made 
 above upon the main artery, the sac be laid open, the clots turned out, and 
 the vessel tied above and below the wound. 
 
 The external iliac arterj^ is often the seat of idiopathic as well as of trau- 
 matic aneurysm. In the idiopathic variety the method by compression should 
 be first employed, and if this fails the ligature of the vessel above the sac is 
 indicated. The vessel can be reached by a median laparotomy. If the 
 aneurysm is of the traumatic variety, the modified operation of Antyllus is 
 indicated. 
 
 Femoral aneurysm may be traumatic or idiopathic. From the exposed 
 situation of the femoral artery, fjilse aneurysms are of frequent occurrence. 
 The treatment should consist in the application of a tourniquet to the artery 
 as it passes over the brim of the pelvis, incision of the sac, and ligation of 
 both ends of the divided artery. If the aneurysm is idiopathic, compression 
 above the sac should be first tried, and in the event of failure the Hunterian 
 operation should be employed. 
 
 Popliteal aneurysms are usually idiopathic, but occasionally the trau- 
 matic variety is seen. The latter should be treated according to the rules 
 given for the management of this form of aneurysm situated in any other part 
 of the body. The idiopathic variety can be treated by the flexion method, by 
 the Hunterian method, by proximal compression, or by the elastic bandage. 
 
252 AN AMERICAN TEXT-JiOOK OF SURGERY. 
 
 SECTION IV. — INJURIES OF THE BLOOD-VESSELS. 
 
 Hemorriiace is iiivari:il)ly present wlien a vessel is wounded. The blood 
 may escape tlirou<2;h tlie broken skin, or may extravasate beneath the skin and 
 form a hematoma. The oeeurrenee of severe hemorrha<:e is always attended with 
 great danirer to life, and the larger the caliber of the wounded vessel the greater 
 the immediate danger. There is no other emergency which the surgeon is 
 called upon to meet that requires so much judgment and presence of mind as 
 the proper management of alarming hemorrhage. 
 
 There are four varieties of hemorrhage : 
 
 1. Arterial hemorriiauk, cliaiacteri/ed by bright-red blood sjiurting 
 out in jets synchronously with the action of the heart. The bright-red color 
 is due to the presence of oxygen in the blood. Arterial blood may be deprived 
 of its characteristic color when the oxygen is greatly diminished and carbonic 
 acid gas is present in excess, as in profound narcosis or when an operation is 
 undertaken to avert death from apnea. During an operation, therefore, the 
 surgeon should always look to the anesthetic if the blood from the wound 
 becomes dark-colored. 
 
 2. Venous hemorrhage, characterized by the blood flowing in an unin- 
 terrupted stream and by its dark color. The steady flow of the blood from 
 the veins is due to the fact that the intermittent cardiac impulse is lost. For 
 the same reason blood from the distal end of a wounded artery also flows in a 
 steady stream. The dark color is caused by the non-oxygenation of the blood 
 and by the presence of carbonic acid gas. The walls of the veins collapse, 
 with the exception of the veins of the liver ; the portal system, however, is 
 seldom taken into account by the surgeon. 
 
 3. Capillary hemorrhage, characterized by its constant oozing on the 
 one hand, and by its spontaneous arrest on the other. This variety of hemor- 
 rhage is alarming in exceptional cases only, but its persistence often makes it a 
 troublesome variety to treat. The ca])illaries in the mucous membranes bleed 
 more profusely than those situated in the integument. This is due to the fact 
 that in the former the capillaries are larger and more abundant. Hemor- 
 rhage from capillaries situated in the skin usually ceases owing to the con- 
 traction of the wound. 
 
 4. Parenchymatous hemorrhage, characterized by absence of the 
 features Avhich distinguish the other three varieties, and also by the foct that 
 it is found where there is a peculiar anatomical arrangement of the blood- 
 vessels, or among diseased tissues, as when the main vein is thrombosed. This 
 variety of hemorrhage is seen in those organs or parts of the body where the 
 small arteries empty into small veins without the intervention of a capillary 
 system. Such an arrangement is found in the corpora cavernosa and in the 
 erectile tissue of the female genitalia, as well as in the spleen. 
 
 Hemorrhage may be divided upon another basis than an anatomical one — 
 viz. a clinical one. It may be termed — I. Primary ; II. Intermediary ; III. 
 Secondary. 
 
 I. Primary hemorrhage occurs immediately after the wound in the vessel. 
 The characteristics of a primary hemorrhage vary according as it is arterial, 
 venous, or capillary, as above described. 
 
 II. Intermediary or reactionary or consecutive hemorrhage occurs shortly 
 after an injury to a vessel or after a surgical operation, during what is termed 
 the period of reaction. This variety of hemorrhage usually takes place within 
 twenty-four hours, and is caused by a ligatures coming away, or by the action 
 
;subgi:Ji'v of ti/e vascular system. 'iry.i 
 
 of till' lioart \n driving out coa^ulii IVoiii tlu' dividod cud ol" a vosscl, or by some 
 movt'UR'Ut of the wouuded part. 
 
 III. S'rrttndan/ Iie)norrIi<i(/e occurs after twenty-four hours and before 
 oro;anizati()U (^f tlio thrombus and cicatrization of the wound, and most fre- 
 quently between the fiftli and tenth days. It usually occurs durin<f suppura- 
 tion, and is caused by disease of the walls of the vessel, by slou<^hing of the 
 wound, by ulceration of the v^essel, by sepsis, or by the too rapid absorption of 
 a catgut ligature. Secondary hemorrhage is often seen in gunshot injuries and 
 in wounds wlicre there have been extensive contusion and sloughing. 
 
 The constitutional symptoms of hemorrhage are rapid, feeble 
 pulse; subnormal temperature; frei^uent and irregular respiration; convulsive 
 movements ; lividity of the lips and blueness of the finger-nails ; dilatation of 
 the i\\x nasi ; nausea and vomiting ; pale face and pallid mucous surfaces ; great 
 dvspnea ; jirofuse f)erspiration ; muttering delirium; tinnitus aurium ; syncope; 
 colhqjse ; disturbances of sight and hearing ; unconsciousness. 
 
 The symptoms just enumerated are present to a greater or lesser degree 
 according to the amount of blood lost, the size of the vessel injured, and the 
 general condition and the age of the patient. Infants and children do not 
 tolerate the loss of blood well, but they recuperate rapidly. Aged people like- 
 wise are seriously affected by the loss of blood, and, unlike children, do not 
 rally (|uickly. Adults in health endure well the loss of blood, and women 
 during parturition tolerate hemorrhages which under other circumstances would 
 prove rapidly fatal. 
 
 After hemorrhage has been arrested and the patient has rallied, the symp- 
 toms denoting the existence of hemorrhage change and a slight febrile disturb- 
 ance follows. To this condition the term "hemorrhagic fever" has been 
 applied. The elevation of temperature is due to the nervous irritation conse- 
 quent upon the hemorrhage and to the absorption of the "fibrin ferment," 
 as after operation. (See p. 35.) The pulse is accelerated and often irregular, 
 and its wave is apparently more distinct than normal, owing to the relaxation of 
 the coats of the vessel due to the absence of the natural stimulus of the blood. 
 
 The patient is in an asthenic condition from exhaustion consequent upon 
 the loss of blood, and septic pi'ocesses are likely to develop under these circum- 
 stances. The lowered vitality in hemorrhagic fever predisposes the patient to 
 unhealthy inflammations, and great care must be exercised to guard against 
 the onset of these pathological changes. The mental condition in hemorrhagic 
 fever is characteristic. The patient is affected with a low form of muttering 
 delirium, never becoming maniacal or violent. The intellect is restored in 
 proportion to the general improvement in the symptoms. The distinguishing 
 feature of hemorrhagic fever is that it is not due to absorption of any septic mate- 
 rial, but is due chiefly to an altered nervous condition consequent upon the loss 
 of blood, Avhich fails to supply the proper nutriment to the great nerve-centers. 
 
 Spontaneous arrest of hemorrhage may be effected by a combina- 
 tion of several agencies. Contraction and retraction of the divided vessel and 
 coagulation of the blood are among the means which nature adopts. Cardiac 
 syncope is also sometimes a most important factor in bringing about an arrest 
 of hemorrhage, because this condition of the heart reduces the force of the 
 blood-current, and thus permits coagulation in the wounded vessel. Con- 
 traction of the middle and internal coats and retraction of the entire vessel 
 within its sheath help to form a barrier to the exit of blood at the divided end 
 of the artery. Coagulation of the blood is brought about by the diminished 
 flow of blood and also by its exposure to atmospheric influences. The hemor- 
 rhage after laceration of the vessel is controlled by nature, owing to the fact 
 
254 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 that the internal and middle coats curl up and the external cDat and .-^lieatli are 
 twisted over the open mouth of the vessel. This phenomenon explains the small 
 amount of blood lost in cases where the extremities are torn from the body. 
 
 The diagnosis of hemorrhage is attended with no diHiculty when blood 
 makes its appearance externally. ^Vhen the hemorrhage occurs within the 
 great cavities of the body, and is therefore concealed, the diagnosis is fraught 
 with uncertainty. Hemorrhage into the pleural, peritoneal. ])elvic, or cranial 
 cavity must be diagnosticated u})on the special evidences manifest in each case. 
 The "general symptoms of hemorrhage are present, but in numy resi)ects they 
 are so similar to those found in shock that a discrimination must l)e made with 
 great care. (See p. 92.) The aseptic hypodermatic needle can sometimes be 
 utilized Avith great advantage. If the hemorrhage is within the cranial cavity, 
 the study of the nervous phenomena will aid in the diagnosis. (See Intra- 
 cranial Hemorrhage.) If it is within the pleural, peritoneal, or pelvic cavity, 
 physical signs wilt establish the diagnosis when taken in connection Avith the 
 history of the case. 
 
 The treatment of hemorrhage is divided into constitutional and 
 local. The constitutional treatment consists in the judicious administration 
 of cardiac stimulants, such as strychnine, tincture of digitalis, carbonate of 
 ammonium, nitro-glycerin, and hypodermatic injections of ether, brandy, or 
 whiskey. As a rule, the remedies to excite the action of the heart should be 
 given hypodermatically in order to secure an immediate eftect, and great care 
 should be taken lest the patient be suddenly over-stimulated. Ergot of rye has 
 been used to cause contraction of the involuntary muscular fibers of the vessels. 
 In view of the subnormal temperature, artificial heat should be applied to the 
 surface of the body. This can be accomplished by warm blankets, bottles of 
 hot w^ater, and hot-air baths. In the use of bottles of hot water or hot-water 
 bags care must be exercised lest the patient be burned, an accident as unfortu- 
 nate as it is frequent. An enema of brandy, or of turpentine and hot water, 
 can be employed as a valuable adjuvant. 
 
 The head should be placed low, to prevent cerebral anemia, and the patient 
 kept as quiet as possible. An abundance of fresh air should be supplied to a 
 patient suffering from profuse hemorrhage. The application of Esmarch's 
 elastic bandage to the extremities, elevation of the arms and legs, and raising 
 the foot of the bed should be employed, in order to increase the amount of 
 blood in the brain and internal organs. Galvanism or sinapisms may be applied 
 over the precordial region. Towels wrung out of hot water and applied to the 
 head will help to bring about reaction. Warm fluids can be given as soon as 
 the patient is able to swallow, and a good nutritious diet as soon as possible. 
 Opium should be administered during reaction, especially if nervous excitement 
 is present. 
 
 Transfusion of normal salt solution after hemorrhage has been resorted 
 to in cases in Avhich sudden loss of a large amount of blood has occurred. 
 The operation of transfusion as formerly employed consisted in the injection 
 of blood from a healthy person into tlie blood-vessels of a patient suffering 
 from hemorrhage. It Avas attended Avith a high death-rate, and investigation 
 into the causes of death demonstrated the fiict that the mortality Avas due to 
 the presence of emboli. Entrance of air Avas another source of danger. 
 
 The local treatment of hemorrhage consists in the arrest of the bleeding 
 either by compression, ligation, torsion, or acupressure. If the hemorrhage 
 proceeds from an injured vein, compresses should be placed over the Avound 
 Avith uniform e(piabie compression of the limb. Tiiis will suffice to control 
 the bleedinj: in venous hemorrhage. If the hemorrhage is from a Avounded 
 
SURGERY OF TIIK VASCULAR SYSTEM. 
 
 2.J5 
 
 artery tlu' l)U'c<lin<r vessel must be sought for iuid tied at both ends. The 
 divided en.l of the artery, without any surrounding tissue, shouhl be seized 
 Avith a pair of artery forceps or hemostatic forceps, and the ligature should 
 then be tied by means of the reef knot (Fig. 52). Catgut and sterilized 
 silk are the materials employed for tying wounded arteries, iorsion ot 
 the vessel is applicable especially after amputation, as the vessel in this 
 case is completely divided. In a wound in the continuity of the artery 
 the vessel must be divided before torsion is applied. If the wound is a 
 lacerated one, it can be converted into an incised one and the divided 
 vessel caught and ligated or twisted. In applying torsion the vessel 
 should be seized with the torsion forceps as if to ligate it (J^ig. o-^). 
 A second pair of forceps may be placed upon the artery at right 
 ancrles with and a short distance above the first pair. The open end of 
 the artery is now to be twisted by the forceps on the long axis of the artery, 
 which is held securely by the second pair of forceps. Only a few turns 
 
 Fig. 52. 
 
 Fig. 53. 
 
 Trunk of 
 Artery. 
 
 The Reef Knot. 
 
 Fk;. 54. 
 
 Tirinted end 
 I if Artery. 
 
 Everted end -i/' Inner Coats. 
 
 Effects of Torsion on Femoral Artery. 
 (Bryant). 
 
 Artery laid open to show Turning Up of Inner and 
 Middle Coats from Torsion (Erichsen). 
 
 should be made or the end of the artery may be twisted off. The effects of 
 torsion on the inner and middle coats of an artery are shown in Fig. 54. 
 
 Acupressure (Fig. 55) is occasionally useful ; one method consists m passing 
 ^ a needle under the vessel 
 
 Fig. 55. and compressing it pre- 
 
 cisely in the same manner 
 as the stem of a rose is 
 fastened in the lapel of a 
 coat by a pin. 
 
 If the hemorrhage is 
 capillary, gentle pressure 
 can be employed. Hot 
 water at 120° F. will act 
 as an astringent, and is 
 one of our most con- 
 venient and reliable means of arresting hemorrhage. Ice is sometimes employed. 
 Heat and cold both act by stimulating the muscular fibers of the vessels to 
 contract. The actual cautery is a powerful hemostatic, but it has the great 
 disadvantage of causing a slough. Styptic cotton, though generally objection- 
 able, may be useful in hemorrhage from places Avhere the ligature is inadmissible. 
 The 'position of the part, according to the laws of hydraulics, should be such as 
 to diminish the force of the circulation and to favor venous return. Elevation 
 of the limb will accomplish this result if the wound is in an extremity. 
 
 Diiferent Modes of Applying Acupressure (Bryant). 
 
250 ^i.v A mi:/: /(AX rr.XT-iiook' or scudKRY. 
 
 In hemophilia bleeding does not occur from large vessels, but there 
 is a continuous ca|tillarv oozing. Many expedients have been suggested, 
 from elevation and pressure to the actual cautery. The internal admin- 
 istration of chloride of calcium is advised by Wright. The local appli- 
 cation to the wound of blood from a healthy man has been recently 
 advised. Carnot uses a solution of gelatin in normal salt solution (1 : 
 16). Continual compression with sponges soaked in hot water may prove 
 efficient. 
 
 Comparative Merits of Various Methods of Treatment. — In all 
 cases of heiuorrhage the constitutional treatment is the same. The local treat- 
 ment, however, is subject to certain variations. The ligature or torsion is the 
 preferable method. If catgut or sterilized silk is used for ligatures, both ends 
 may be cut short, the wound closed, and primary union obtained. Acupressure 
 possesses no special advantage over ligature or torsion since the principles of 
 antiseptic surgery have been applied to wound treatment. 
 
 Transfusion should be employed in any case of hemorrhage in which the 
 symptoms become alarming. A patient may have lost a great quantity of 
 blood, and may even be apparently moribund, but if the heart's action is per- 
 ceptible, transfusion is indicated.*^ It has often saved life even under these 
 extreme circumstances. 
 
 In the after-treatment of hemorrhage the patient should be kept perfectly 
 quiet both physically and mentally, and all visitors should be excluded. 
 Any tendency to syncope must be combated by lowering the head, and cardiac 
 stiniulants should be judiciously employed. The surface of the body should 
 be kept warm by artificial means, and warm drinks be given until the eciuilib- 
 rium of the circulation is restored. A nutritious diet, fresh air, and hygienic 
 surroundings should be provided. After the alarming symptoms have passed 
 away, attention must be directed to the use of iron in some form, wine in mod- 
 erate quantities, and a free diet. Oxygen may be inhaled several times a day 
 with advantage. If the wound has been antiseptically dressed and drained, 
 union by primary intention should follow. If it has been improperly dressed, 
 or if, owing to some condition for which the surgeon is not responsible, suppu- 
 ration is likely to follow, the wound should be thoroughly disinfected and free 
 drainage provided, so as to repair the damage with as little constitutional and 
 local disturbance as possible. From what has already been said in regard to 
 the treatment of hemorrhage the following rules may be formulated: 
 
 1. (a) If primary hemorrhage is serious and bleeding is actually going on, 
 apply an Esmarch bandage or a tourniquet above the injury to the vessel, open 
 the wound, turn out the blood-clot, find the wounded artery, divide the vessel 
 at this point, unless it has been already divided, and tie the proximal and distal 
 ends with aseptic catgut. 
 
 {h) If primary hemorrhage is serious, but bleeding is not actually going on 
 and the patient is in collapse, apply a toilVniquet above the wound and stuflF 
 into it sponges soaked in hot 1 : 4000 bichloride solution, administer stimulants, 
 and when everything is in readiness relax the tourniquet and proceed as already 
 described under the first rule. 
 
 (c) In general oozing apply hot water (120° F.) by compresses. If an artery 
 spurts from the sawn end of a bone, introduce an acupressure needle and 
 lacerate the vessel or plug it Avith a strand of catgut. 
 
 2. {a) In secondary hemorrhage, if it is slight, open the wound or stump, 
 turn out the coagula, and apply a compress. 
 
 {h) If the hemorrhage is alarming, apply a tourniquet or an Esmarch 
 bandage, open the wound, and tie the ends of the vessel if possible. If this is 
 
SURGERY OF THE VASVIJLAR SYSTEM. 
 
 257 
 
 not prac-ti cable on account of diseased or sloughing tissue, ligate the vessel 
 above in its continuitv according, to the Iluntcrian method. 
 
 (c) If secondary hemorrhage occurs after ligation of a vessel in its continu- 
 ity, apply a tourniquet, ojjcn the wound, turn out the clots, and tie the artery 
 above and below the bleeding point if the tissues are not too much lacerated. 
 
 {d) If this fails, tie the artery higher uj) in its continuity, or amputate. 
 
 WOUNDS OF ARTERIES. 
 
 These may be punctured, contused, lacerated, gunshot, or incised. Besides 
 the varieties just mentioned there may also be rupture. 
 
 A piinctured wound is caused by the penetration of the artery by a sharp 
 or a thin blunt instrument. If the opening is very small hemorrhage may not 
 result, but if the puncture is of any size bleeding occurs. A punctured wound 
 of an artery usually gives rise to a traumatic aneurysm, and must be treated as 
 
 such. 1 f i? 
 
 A contused wound of an artery may be insignificant, or it may be ot sut- 
 ficient magnitude to cause gangrene by obliteration of the vessel or death by 
 secondary hemorrhage. A slight contusion of tlie arterial wall may be fol- 
 lowed by an inflammation which leads to a thickening of the walls of the 
 vessel and complete occlusion. This condition may give rise to gangrene. 
 If a thrombus forms in a contused artery which supplies some internal organ 
 with blood, the viscus, having been deprived of its nutriment. Avill undergo de- 
 generation. The contusion may be extensive enough to destroy the coats of the 
 vessel, so that a fatal secondary'^hemorrhage follows the separation of the slough. 
 
 A lacerated wound of an artery deserves special attention, because the 
 results are likely to become serious. If an artery is stretched or torn suf- 
 ficiently, the middle and internal coats snap. In the middle coat the circular 
 fibers separate from each other so as to leave a space, and the separated circu- 
 lar fibers contract upon the internal coat, which is torn completely across 
 and curls up within the lumen of the vessel in the same manner as it does 
 after the application of a ligature. In a lacerated wound of an artery the 
 external coat is draAvn out so as completely to lose its normal elasticity, in the 
 same manner as a piece of rubber tubing will lose its elasticity when it is 
 overstretched. Such an injury to an artery of large or small size may occur 
 without any bleeding. The vessel is, hoAvever, permanently injured. 
 
 A gunshot wound of an artery derives its special importance from the fact 
 that secondarv hemorrhage is likely to occur. The vessel may be only contused 
 by a bullet, aitid no bleeding occur until some days after the injury, when serious 
 hemorrhage supervenes as a result of sloughing. A gunshot wound of an artery 
 is often associated with injury to the accompanying vein, and an aneurysmal 
 varix is formed. In case an extremity is bloAvn off by shot or shell, the hemor- 
 rhage is often slight, on account of the fact that the vessels are lacerated, the 
 middle and internal coats contract, curl up, and a plug is formed at the open end 
 of the vessel. If, however, a rifle bullet enters the body when it is travelling 
 at great speed, it may cut an artery like a knife, causing immediate and alarm- 
 ing hemorrhage. In addition to the primary or secondaiy hemorrhage which 
 may be produced by a gunshot Avound of an artery, the contusion of the vessel 
 may lead to the formation of a thrombus, which may cause occlusion of the 
 artery and be followed by gangrene. Pyemia is also a serious complication in 
 gunshot wounds ; and often a secondary hemorrhage ushers in a fatal septicemia. 
 
 An incised wound of an artery is an injury inflicted by some sharp cutting 
 instrument. The hemorrhage is always profuse in such a wound, because there 
 
 17 
 
258 AN AMF.h'IVAX TEXT-BOOK OF SURGERY. 
 
 is no mechanical obstacle to tlic oiitllow of hlood through the ()]K'iiiii<f, such as 
 is often found at the open mouth of a torn artery, and also because the con- 
 traction of the two ends of the vessel causes the "svound in the artery to gape. 
 The direction of the incised wound may be transverse, oblique, or longitudinal. 
 The hemorrhage is very profuse in a transvei'se cut of an artery, while it is 
 not so abundant in an oblique incision. If the artery is upon the stretch and 
 is wounded longitudinally, the bleeding is very slight, but may become very 
 alarming wlien tiie artery is relaxed. In case of a partially divided artery the 
 proper rule to follow is to divide the vessel completely and tie botli ends. 
 
 Rupture of one or all of the coats of an artery is an injury that occurs 
 under certain circumstances. The rupture may be partial, for example, wlien 
 the internal and middle coats are torn and the external coat is stretched. This 
 accident is not followed by hemorrhage, but it is a condition favorable to the 
 production of secondary hemorrhage by sloughing, or to the development of an 
 aneurysm. The same condition may also cause thrombosis or embolism of the 
 vessel", and gangrene of the extremity or part may result. The rupture may 
 be complete, in which case the artery is in the condition of a lacerated vessel. 
 If it is subcutaneous, a traumatic aneurysm develops. If the rupture is partial 
 and a clot has formed sufficient to occlude the vessel, then the pulsation below is 
 lost and gangrene may supervene. 
 
 The treatment of wounds of arteries must necessarily vary according to 
 the character of the injury. If the opening is of any size, the vessel should 
 be completely divided and both ends tied. In case a traumatic aneurysm has 
 developed as a result of a punctured wound of an artery, the rules prescribed 
 for the management of this condition must be followed — i. e. it is a wounded 
 artery, and should be treated as such. 
 
 If the wound is a contmed one, the treatment consists in securing as much 
 physical rest for the artery as possible by tranquillizing the circulation. This 
 is eftected by absolute rest and the administration of cardiac depressants. The 
 possibility of the occurrence of secondary hemorrhage must not be forgotten, 
 and measures to arrest it must be instituted immediately if it appears. The 
 area or extremity which may be deprived of blood as a result of a contusion of 
 an artery must be kept artificially w^arm in order to encourage the determination 
 of blood to the part and to stinmlate the collateral circulation. 
 
 If the wound is a lacerated one, the primary hemorrhage is usually slight on 
 account of the curling up of the internal coat and the contraction of the mid- 
 dle coat, and the coagulation of the blood at the torn end of the vessel ; but on 
 account of the danger of secondary hemorrhage both ends of the vessel should 
 be diligently sought, by a careful dissection if necessary, and securely tied. 
 
 If the wound is a gunshot one, the primary hemorrliage must l)e treated 
 according to the same principles that would guide the surgeon in the manage- 
 ment of an ordinary wounded artery. If the vessel is one of large size, digital 
 pressure directly upon the artery and in the wound is indicated for the instan- 
 taneous arrest of tlie bleeding ; in no case should styptics be employed. An 
 Esmarch elastic bandage should now be applied, and tlie surgeon should cut 
 down immediately u])on the bleeding vessel, completely divide it at the seat of 
 injury, and tie both ends of the artery with aseptic catgut. If the hemorrhage 
 comes from an artery situated in the neck, or in any other place where the 
 application of an elastic bandage is impracticable, the surgeon must be guided 
 by the rules for the management of traumatic aneurysm. The dressing of such 
 a wound should be conducted with the most rigid adherence to the principles 
 of aseptic surgery in order to prevent secondary hemorrhage, a danger which is 
 peculiarly frec^uent after gunshot wounds. The occurrence of gangrene is also 
 
8URGERY OF THE VASCULAR SYSTEM. 
 
 259 
 
 a coinplit-atiou of an exceedingly fatal character in gunshot wounds, since septi- 
 cemia rapidly develops. If the main artery of the limb is injured, and also its 
 accompanying vein and nerve, even without "a fracture of the bone, as a rule 
 amputation is necessary to avert gangrene, which would almost surely follow. 
 
 If secondary luMuorrhage occurs, it will be during the second or third week — 
 that is, at tlie time when the sloughs separate. The l)]eeding should be arrested, 
 if possible, at the site of the hemorrhage; but when this is impossible, a ligature 
 should be applied according to the Hunterian principle — ^'. e. in healthy tissue 
 upon the proximal side of the wound. If the hemorrhage is alarming and it 
 comes from several points, and the suppuration is extensive, with sepsis, ampu- 
 tation of the limb is indicated. The best way to prevent secondary hemor- 
 rhage is to keep the wound aseptic and to provide sufficient drainage. Good 
 nutritious diet is required in order to maintain a high standard of vitality, 
 which conduces to repair of the wound and averts the dangers of exhaustion, 
 suppuration, and septicemia. 
 
 If the wound is an incised one and involves the neck or axilla, digital pres- 
 sure must be promptly employed, and at once preparations should be made to 
 search for the wounded vessel. This should be completely severed at the point 
 of injury and a proximal and distal ligature of aseptic catgut or silk should be 
 applied. If the incised artery is in an extremity an Esmarch bandage can be 
 applied in the same mariner as already described in the management of primary 
 hemorrhage in gunshot wounds. The application of the bandage permits the 
 surgeon to make a bloodless dissection and secure with certainty and ease the 
 wounded vessel. 
 
 In ease of a riiptured artery the treatment is practically the same as would 
 govern the surgeon in the management of a contused or lacerated vessel. 
 
 Murphy of Chicago has recently sutured wounds of arteries and veins. 
 The chief points to be insisted upon are rigid asepsis, the exposure of 
 the vessel with as little damage as possible, the temporar}^ arrest of the 
 blood-stream, the control of the vessel during the anastomosis or sutur- 
 ing, the approximation of the walls of the vessel, and absolute freedom 
 from hemorrhage after removal of the temporary hemostasis. The most 
 
 Method of Sutiiring a Blood-vessel (Murphy). 
 
 rigid asepsis must be observed, as the tunica intima, like the peritoneum, 
 is a serous membrane. External septic infection may penetrate the ves- 
 sel wall and cause such a change in the endothelial coat as to produce 
 thrombosis. 
 
 The hemorrhage at the time of operation may be controlled with Bill- 
 roth forceps provided with a graduated catch and broad blades, over which 
 is passed a section of rubber drainage-tube, to prevent injury to tlie vessel, 
 
260 AN AMERICAN TEXT- BOOK Of SURGERY. 
 
 or the vessel may be occluded witli tcinporary li<^atur('s. The pressure must 
 not be too great, and tlio knot must not be tied so tightly as to cause injury 
 of the tunica intima. Fine cambric needles and silk are used. The vessel 
 wall is seized with fine rat-tootlied forceps. The best material for suture 
 is the twisted silk to fit exactly the eye of the needle. In longitudinal 
 wounds the sutures are placed one-sixteenth of an inch apart, and enter 
 and emerge at the same distance from the Avound. The needle should, of 
 course, never touch the tunica intima, but only the outer and middh' coats 
 are traversed by the suture. In transverse wounds the same technitjue is 
 used. The sutures must be exactly o]>i>osite each other. Murphy recom- 
 mends the insertion of the first one in the middle, and the next at the two 
 angles. 
 
 If more than one-half of the vessel is cut, a resection must be done 
 and the proxiuuil end anastomosed by invagination. The sutures should 
 penetrate only the outer and the middle coats. Fig. 56 shows Murphy's 
 method of inserting the sutures. If any oozing occurs after the removal 
 of the temporary hemostatics, the bleeding can be controlled by gentle 
 pressure with the fingers or a sponge until a small clot forms at the 
 point of entrance of the needle. 
 
 WOUNDS OF SPECIAL ARTERIES. 
 
 The carotid artery may be wounded as a result of gunshot injury, a stab, 
 or other wound, or during the performance of an operation upon the neck. 
 The wound of so large a vessel is necessarily a most serious event. If the 
 vessel is entirely cut across, the patient usually (but not always) expires in a 
 few minutes ; but if the carotid is partially wounded, the hemorrhage may be 
 arrested by compression until the vessel is secured and ligatured. This artery 
 is seldom divided in an attempt at suicide, especially when the head is thrown 
 back, because of its anatomical situation deep in the neck ; but the superior 
 thyroids lying in front and more superficially are often wounded ; the incision 
 rarely extends deeper than these vessels. In all cases of Avounds of these 
 larger vessels of the neck the treatment is based upon the general principles 
 which govern the surgeon in his management of hemorrhage. A ])riniary 
 hemorrhage should be treated by dividing the vessel at the point of injury, 
 if not already divided, and instantly tying both ends of the vessel. A secondary 
 hemorrhage must be controlled by methods already mentioned. In wounds 
 of the carotid and its branches the possibility of the occurrence of oedema 
 glottidis must not be overlooked, and a projdiylactic tracheotomy should be 
 performed if this occur. 
 
 The vertebral artery may be injured in any of the ways mentioned in 
 reference to wounds of other vessels. Compression has effected an arrest of 
 the hemorrhage ; but, as a rule, a search for the wounded vessel may be made, 
 and if possible the artery be divided and tied at both ends. There is danger 
 of escape of blood into the spinal canal and compression of the cord when a 
 wound of the vertebral artery occurs. 
 
 The subclavian artery has been wounded in the various ways that have 
 been described, and possibly by a puncture from a fragment in fracture of 
 the clavicle or of the first rib. A wound of this vessel is most serious on 
 account of its size and its situation. A large traumatic aneurysm is developed, 
 and must be treated after the manner described in the management of such an 
 aneurysm. 
 
 The axillary artery is subject to the same injuries as other vessels, and 
 
SURGERY OF THE OSSEOUS SYSTEM. 2(11 
 
 is additionally exposed to the danger of rupture in reducing old dislocations 
 of the shoulder-joint. Fortunately, in the wounds of the axillary artery due 
 to complete laceration of the vessel the artery retracts and contracts and the 
 hemorrhage may be spontaneously arrested. In injuries of this artery, as a 
 rule, the vessel should be exposed, completely divided, and botli ends secured 
 by a ligature. In rupture from attempts at reducing an old dislocation this 
 procedure has been uniformly fatal, and should be replaced by compression, 
 ligature of the subclavian, or amputation at the shoulder-joint. 
 
 The femoral artery is often exposed to injury, and on account of its 
 superficial situation the hemorrhage is easily controlled. The same rules 
 govern the surgeon in the management of wounds of this vessel as in those 
 of other arteries. After ligation of the artery the limb should be elevated and 
 artificial warmth should be applied to prevent gangrene. 
 
 The popliteal artery is seldom wounded, owing to its deep situation and 
 to the protection which is afforded to it by the joint in front. In case of an 
 injury to the vessel an Esmarch bandage should be applied, the vessel found, 
 and both ends of the divided artery ligated. 
 
 In case of a wound of any of the other arteries in the body — in the fore- 
 arm, arm, leg, or foot, or upon the trunk — the principle of searching for the 
 bleeding vessel and ligating it at both ends must always be kept in mind- 
 The hemorrhage from an intercostal or from the internal mammary is serious, 
 because generally some of the thoracic viscera are also implicated. It has been 
 suggested to introduce a finger-shaped tampon made of a piece of antiseptic 
 gauze, which is pushed between the ribs with a probe, and then to fill the 
 tampon with strips of iodoform gauze and draw the entire mass outward, so 
 as to make firm pressure against the inner wall of the thorax and the two 
 corresponding ribs. It is, however, best to secure the two ends of the divided 
 vessel by ligatures in the manner already described. A rib may be resected if 
 necessary. 
 
 WOUNDS OF VEINS. 
 
 A wound of a vein is in some respects less dangerous than a wound of an 
 artery of the corresponding size ; but serious complications may readily follow a 
 wound of a vein, unless kept aseptic. The hemorrhage from a small vein is 
 less than that from an artery of the same size, because the vein collapses and 
 the force of the circulation is not so great as in the corresponding artery. A 
 considerable quantity of blood is extravasated in the surrounding tissues, so 
 that external pressure will also contribute to the arrest of the hemorrhage. 
 The loss of blood from a large vein, however, is so rapid and excessive as to 
 endanger life in a few minutes. 
 
 The symptoms of venous hemorrhage upon which the diagnosis is 
 based, are — 1st, the escape of dark-colored blood in a continuous stream ; 2d, 
 the special eff'ects of pressure : if applied upon the distal side of the wound, it 
 causes the hemorrhage to cease ; but it causes it to increase if the pressure is 
 applied upon the cardiac side of the wound. 
 
 The complications that follow an injury to a vein depend chiefly upon the 
 size of the vessel and upon the septic or aseptic conditions attending the injury. 
 Among the complications are phlebitis, oedema, thrombosis, embolism, ulcera- 
 tion, metastatic abscesses in organs directly connected with the wounded vein, 
 gangrene, and secondary hemorrhage. 
 
 The treatment of a wounded vein depends upon the size and situation of 
 the vessel. If the vessel is small and situated superficially, elevation of the 
 limb, a compress applied upon the distal side, and rest will be all that is neces- 
 
262 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 sary. If the vein is large and deeply situated, the injured vessel should be 
 found and both ends of the divided vein secured by an aseptic ligature. Of 
 course thorough asepsis of the Avound must be secured. If the Avounded vein 
 is "within one of the tln-ee great cavities of the body, an operation of great 
 magnitude may be indicated in order to reach the bleeding vessel. If a vein 
 is wounded laterally, the slit can be picked up with a pair of forceps and a 
 ligature applied to it, so that the lumen of the vessel will not be obliterated. 
 In the case of a large vein Avliere the tissues are abundant this method of treat- 
 ing a wounded vein has many advantages. Hemostatic forceps may be applied 
 and left in sitd for forty-eight hours. They should of course be entirely 
 covered by the dressing. 
 
 Wounds of Special Veins. — A wound of the internal jugular vein is 
 generally quickly fatal from the loss of blood or occasionally from the entrance 
 of air into the vein. The direction of the wound influences the prognosis, 
 because a longitudinal slit Avill not gape, while a transverse one is held wide 
 open by the action of the deep cervical fascia. If the internal jugular is 
 wounded near its entrance into the skull, besides the dangers arising from the 
 loss of blood and also the entrance of air, there is the additional danger of 
 cerebral septic infection and venous and sinus thrombosis. 
 
 Injuries of the subclavian and axillary veins are also very serious, for the 
 same reasons that have been mentioned in reference to the jugular vein. 
 
 A wound of the femoral vein, besides the loss of blood, has an additional 
 danger — gangrene of the leg — which may follow the ligation required to arrest 
 the hemorrhage. Ligation of the popliteal vein may also be attended with the 
 same complication. After either of these ligations the limb should be elevated 
 to help the venous return, and be enveloped in cotton and hot-water bottles to 
 keep up the temperature of the leg. If gangrene intervenes, amputation must 
 be done. 
 
 For Wounds of the Cerebral Sinuses see Injuries of the Head. 
 
 CHAPTER II. 
 
 SURGERY OF THE OSSEOUS SYSTEM. 
 
 As the ossous tissue differs in no material respect from the soft parts except 
 in the added lime-salts that give it firmness, its injuries and diseases are in the 
 main of like character and course, wounds, inflammations, and tumors termi- 
 nating in more or less complete return to the normal state or in constructive or 
 destructive changes. The soft structures in the cancellous and medullary spaces, 
 in the Haversian canals, and upon the exterior of the bone, though for con- 
 venience' sake and with a seeming anatomical and pathological basis they may 
 be separately considered, are but parts of a common whole, a lesion of which 
 may be general or limited according to its nature and intensity. 
 
 The most numerous and important affections are the inflammations conse- 
 quent upon injury; upon the existence of special diathetic states, as the tuber- 
 cular or syphilitic; upon a general infective disease, as typhoid fever; or upon 
 the presence and action of pyogenic organisms. They may be acute or chronic^ 
 and end in resolution, in organization of an exudate, or in destruction, limited 
 or extensive, molecular or in mass, of the part involved. According to the 
 presence or absence of the pyogenic microbes suppuration will or will not occur. 
 
SURGERY OF THE OSSEOUS SYSTEM. 2G3 
 
 Liquefaction to a greater or less extent is an ordinary effect of the syphilitic 
 invasion, still more of the tubercular. 'We intensity of the symptoms is always 
 greater in the suppurative than in the non-suppurative affections. The pyo- 
 genic organisms (generally the staphylococcus aureus or, but much less fre- 
 quently, the streptococcus pyogenes) gain admission to the diseased area either 
 through an open wound or by the blood-stream, having been taken up at some 
 distant and often small pus-depot, or by the lungs, or the intestinal canal, to 
 which they have been brought from without the body. 
 
 These inflammations may be considered under the general heads of osteo- 
 periostitis and osteo-mi/elitis, since pure periostitis is of very infrequent occur- 
 rence, perhaps is only met with as a syphilitic manifestation, and pure myelitis 
 is equally infre(i[uent. 
 
 OSTEO-PEEIOSTITIS. 
 
 This condition usually exists in cases commonly thought to be examples 
 of periostitis, in which not only the periosteum, but the superficial layers of 
 the bone also are diseased. It may be acute or chronic, plastic or suppurative, 
 limited or diffused. It is the result of cold, of wounds or contusions, of 
 strains from undue traction on inserted tendons, of contiguous inflammations, 
 as from old ulcers, or of special infections, syphilitic, tubercular, or pyogenic. 
 The more superficial the bone, the more likely is osteo-periostitis to occur, 
 because of the greater exposure to injuries and the action of cold. The perios- 
 teum both in its outer and inner layers is thickened and reddened and its cells 
 increased in number. More or less of the surface of the underlying bone is simi- 
 larly affected, and its blood-supply may be so diminished in consequence of the 
 separation and occlusion of the vessels by the swollen periosteum as superficially 
 to destroy its vitality. When neither suppurative nor tubercular, the disease 
 terminates either in resolution or in permanent thickening with new formation 
 of bone, or, but much more rarely (and chiefly on the head in cases of syphilis), 
 in thinning and absorption. 
 
 When suppurative and limited, after evacuation of the pus repair takes place 
 with either little or no thickening, with decided hypertrophy, or with some loss 
 of substance. When diffused, unless very promptly arrested, extensive destruc- 
 tion of membrane and bone commonly follows. These purulent varieties are 
 rarely, if ever, primary, though the antecedent deeper inflammation may be but 
 slight. 
 
 The symptoms vary somewhat according to location and cause, being 
 least marked in the traumatic non-suppurative cases, but pain and swelling 
 are always present, the former, as a rule, severe and worse at night. If it is 
 a deeply-situated bone that is affected, it is often impossible to recognize the 
 swelling, but if a subcutaneous one, for example the tibia, as is so frequently 
 the case, the spindle-shaped thickening can be readily felt ; there is much ten- 
 derness on pressure and the overlying soft parts are oedematous and reddened. 
 In the suppurative varieties constitutional symptoms are present, and are of a 
 high grade in the diffused phlegmonous form. In the chronic syphilitic inflam- 
 mations the pain is, as a rule, not acute. 
 
 The treatment in the beginning is by rest and the application of either 
 cold or heat as is more comfortable to the patient. 
 
 If speedy resolution does not take place and the pain is great, subcutaneous 
 punctures of the swelling should be made, or, if pus is present, the parts should 
 be freely laid open. When the disease is due to syphilis, the knife should not 
 be used, but reliance should be placed upon the administration of the ordinary 
 antisyphilitic remedies. 
 
264 AK AMI.L'ICAX TKXT-liOOK OF SURGERY. 
 
 OSTEO-MYELITIS. 
 
 Osteo-myelitis (wliicli includes both osteitis and mcdnllitis — i. e. myelitis of 
 bone) is the more common form of bone inflammation, the cause of ■which may 
 be either local, general, or septic. 
 
 As in inflammation of the soft tissues, the parts are congested, the blood- 
 vessels dilated, oftusion and exudation take place, and there is increased cell- 
 growth. If the disease is slight and due to traumatism, and if resolution quickly 
 tbllows, no organic change is produced in the bone-layers ; but ordinarily there 
 occurs more or less destruction, either in mass (necrosis) or molecular 
 (caries), limited or extensive according to the degree of the inflammation 
 and its exciting cause. In necrosis the dead part is called a scf/iiestnim 
 (p. 269). When perforation of the overlying tissues has taken place, upon 
 })robing necrosed bone is to be recognized by its hardness and its sharp, clear 
 percussion note when struck, carious bone giving out a dull sound, if any, 
 and being generally readily penetrated by the instrument. 
 
 These two forms of bone-death are to the osseous system what gangrene 
 and ulceration are to the soft parts — necrosis, like gangrene, being due to a 
 cause which directly or indirectly cuts off" the blood-supply to or interrupts 
 the outflow from an area large enough to be recognizable by the unaided eye; 
 while in caries, as in ulceration, the cells of an abnormally succulent part 
 melt down and are discharged. 
 
 As met with in practice, necrosis is commonly due to a non-traumatic 
 infective inflammation. At times it is consequent upon injuries (e. g. frac- 
 tures permitting of the entrance of pyogenic organisms or severe contusions), 
 or, less often, exposure to severe cold or high heat. In the bones of the 
 head and face it not rarely is of syphilitic origin. 
 
 Caries — the ulceration of bone — is almost always due to tubercular 
 infection. 
 
 Osteo-myelitis is either acute oi% more frequently, chronic. If the inflam- 
 mation is acute and severe, the resistance of the rigid walls of the central 
 cavity and of the Haversian canals generally causes such compression of the 
 vessels (which often become strangulated by the newly-formed cell-masses) 
 that the vitality of the part cannot be preserved ; necrosis then necessarily 
 results (Fig. 57). Such death in mass in greater or less measure is always 
 to be looked for in the acute infective or suppurative inflammations. 
 
 When the process is a slower one, there may still be an arrest of circulation 
 with resulting necrosis, but generally the death of the- bone-layers is a molec- 
 ular one, due in part to the disintegrating action of the excess of fluid, but 
 chiefly to the pressure made by the enlarged vessels and the newly-formed cells 
 and to the destructive action of the latter. These are especially abundant in 
 the Haversian canals over the flexures of the vessels, and as a consequence the 
 ■walls of such canals break down unevenly and are pitted, the depressions being 
 commonly spoken of as the Hoivship laeunce. As the result of the softening 
 and disappearance of the bone the cancellous spaces enlarge, the central cavity 
 widens, and the Haversian canals increase in diameter, granulation-tissue 
 becoming more and more abundant and progressively occupying the places 
 from which the bone has been removed. In other words, a condition of osteo- 
 porosis has been developed, and the affection is a rarefying osteitis, which may 
 be, on the one hand, of very limited extent, or, on the other, involve a large 
 part of the bone, even from center to cortex. Outside the area of rarefaction 
 there will often be found a space of greater or less width in which formative 
 changes have occurred, the bone being thicker and denser than normal, osteo- 
 
SURGERY OF THE OSSEOUS SYSTEM. 
 
 265 
 
 Fig. 57 
 
 sclerosis instead of osteo-porosis being present. Sueli secondary changes may 
 affect parts of limited extent previously in a state of rarefaction, which when 
 the inllannnation has entirely disappeared will remain unduly hard, with their 
 Haversian canals abnormally narrow. 
 
 During the rarefying action small pieces of bone may be destroyed and 
 separated (necrotic caries). The great majority of the cases of caries, nine- 
 tenths if not more, are of tubercular origin, the deposit taking place readily, 
 as the result of slight traumatisms, in the cancellous tissue, the vessels of which 
 are numerous and thin-walled and the capillaries very large in proportion to the 
 size of their associated arteries and veins. It is during the years of growth 
 in the parts of the bone in which such growth chiefly 
 occurs, as about the ej)ipliyscal lines and in those 
 portions of the skeleton particularly subject to blows, 
 shocks, and the action of cold, that this form of dis- 
 ease is ordinarily observed. 
 
 Here as everywhere else the bacilli cause soften- 
 ing of the parts immediately about them. If few in 
 number and limited in action, they may be rapidly 
 destroyed or shut in, so that either by cicatrization 
 or encapsulation recovery takes place. This often 
 occurs ; in the great majority of cases, however, the 
 disease is not so arrested, but infected granulation- 
 tissue continues to be developed in the cancellous 
 spaces, in the Haversian canals, and in the central 
 medulla, more and more bone is softened down or 
 pieces of appreciable size are deprived of their blood- 
 supply, and consequently die. Thus the tubercular 
 area grows larger with accompanying liquefaction 
 and caseation, and the rarefaction extends farther 
 and flirther. 
 
 When it is the presence and action of the pyo- 
 genic microbes that excite the inflammation the osteo- 
 myelitis may be either acute or chronic, limited or 
 widespread, with accompanying destruction of bone 
 and corresponding intensity of local and general 
 symptoms. Though there are a number of the pyo- 
 genic organisms that may cause these septic diseases 
 of bone, the staphylococcus aureus is the one most 
 commonly met with, and next to it the streptococcus 
 pyogenes. 
 
 Associated with certain of the acute infectious 
 diseases, especially typhoid fever, there occurs an 
 inflammation, generally superficial, which causes a 
 necrosis commonly of limited extent and with a 
 strong tendency to become symmetrical — e. g. to si- 
 multaneous or consecutive development in like parts 
 on both sides of the body. Whether because the dis- 
 ease-germ is itself pyogenic or because of a double infection, these typhoid 
 inflammations are as a rule suppurative. Osteo-sclerosis is a very frequent 
 eff'ect of syphilitic infection, but both necrosis and caries often occur, and in 
 different portions of the same skeleton the three forms of osteitis, condensing, 
 rarefying, and hypertrophic, may be observed. 
 
 In phosphorus-workers severe and extensive necrosis of the jaws is at times, 
 
 Necrosis of the Diaphysis, follow- 
 ing Acute Osteo-myelitis of the 
 Humerus (Duplay and Reelus). 
 
266 AN AMERICAN TKXT-IKX >k' OF smCEin'. 
 
 though now very rarely, produced by the action of the poison that has gained 
 access to the bone throu<^h decayed teeth. 
 Acute osteitis is eitlicr H'nnpli' or septic. 
 
 Simple acute osteitis is consecjuent upon traumatism, and occurs in parts 
 protected against the action of the pyogenic micro-organisms either by an 
 unbroken soft covering or by antiseptic treatment. It is of comparatively lit- 
 tle importance, aTid usually terminates by resolution in a short time. Its symp- 
 toms are few. J*ain is the most j)rominent symptom, and is often not severe ; it 
 is apt to be deep-seated, boring or gnawing, worse at night, aggravated by the 
 dependent position, and increased by pressure. If it is superficially located — 
 when, indeed, it is an osteo-periostitis rather than a simple osteitis — it may be 
 associated with some oedema of the soft parts and discoloration of the skin. 
 Rest, elevation of the limb, fomentations, and moderate compression are the 
 local remedial measures to be adopted, pain being controlled by opiates. If 
 the suftering is very severe and does not quickly subside, the overlying soft 
 parts should be incised, and if this does not relieve, the bone should be asepti- 
 cally drilled at one or more points, thus lessening the tension. 
 
 Of the septic inflammations of bone there are tivo varieties: (1) the one 
 associated with an open wound, originating ordinarily in the shaft of a long 
 bone and generally met with in adults ; (2) the other, without such associated 
 wound, beginning in the parts near the epiphyseal line. The latter is pecu- 
 liarly a disease of childhood. It may, however, occur later in life, and is then 
 in the great majority of instances a recurrence of a similar inflammation of 
 early life, some of the causative germs of which had been encapsulated. 
 Boys are attacked three times as often as girls, and nearly half of the patients 
 are adolescents between the ages of thirteen and seventeen. 
 
 The first variety, since the introduction of antiseptic surgery, is compara- 
 tively rare. Typical examples in former years Avere often seen in cases of 
 compound fracture, especially gunshot fractures, and after amputations, infec- 
 tion of the wound having taken place at the time of injury, during the opera- 
 tion, or later. The severity of the inflammation varies, from that in which 
 there are but little suppuration and limited destruction of bone to that in which 
 the parts quickly become putrid ; the whole bone is destroyed, and the patient 
 dies early of septicemia or pyemia, even within twenty-four or forty-eight hours, 
 in the most malignant of the latter cases. 
 
 "When associated Avith a compomid fracture, in addition to the ordinary 
 conditions, such as congestion, extravasations, and cell-development, following 
 an injury of this character, pus is present, with the general symptoms com- 
 monly attendant upon suppuration. Since the great danger lies in the develop- 
 ment of septic infection, the local treatment should consist in securing free 
 drainage and in rendering the diseased area aseptic. 
 
 When the disease arises after amjmtation, the medulla appears discolored 
 by extravasated blood, and in the severer cases bleeds upon slight pressure 
 and protrudes beyond the level of the sawn surface, at times to a large extent, 
 covering the end'of the bone Avith a fungous mass. The discharge is al)undant 
 and sero-purulent, often having a very off'ensive odor. As the result of the 
 inflammation, Avhen the constitutional infection is not such as to cause early 
 death, the bone about the medullary cavity necroses, and after a time is sepa- 
 rated in the form of a tubular sequestrum (Fig. 60), much worm-eaten on its 
 exterior, of greater or lesser length, thick at the base, irregularly thinning out 
 higher up, and ending in sharp points. The constitutional symptoms, increase 
 of temperature, acceleration of pulse, mental hebetude, etc., are of varying 
 intensitv. 
 
SURGERY OF TUN OSS NO IS SYSTEM. 
 
 2G7 
 
 The local treatment sliould consist in the free removal ot" the infected 
 medulla and in curetting the avails of the cavity, followed by its thorough dis- 
 infection and drainage and by antiseptic dressing of the stump, thus limiting, 
 as far as possible, the extension of the septic inflammation. When the dead 
 bone has been loosened from the living, chiefly by a process of rarefying osteitis 
 in the latter, it should be ])r()iiii)tly removed, since, its extrusion unaided by 
 surgery Avould be eflected slowly, and while in {)rogress there would be 
 liability to extension of the suppurative inllaunuation, with further destruction 
 of bone. 
 
 The second variety, acute epiphysitis, arises when the pyogenic organ- 
 isms have not found entrance through an open wound, but have been brought 
 to the affected area in the blood-stream. The eflect then produced is very 
 variable. In a comparatively small projjortion of cases intense and rapidly- 
 destructive inflammation of the bone follows. It is this variety of osteo- 
 myelitis that is most frequently met with at the 
 present time, wounds involving bone, however pro- 
 duced, being protected in the great majority of 
 cases against the action of the pyogenic cocci by 
 aseptic and antiseptic treatment, provided they 
 come under the care of the surgeon before infec- 
 tion has taken place. • 
 
 As has been stated, it is a disease of childhood 
 and adolescence, and has its starting-point in the 
 tissues near an epiphyseal line, due to the frequency 
 of juxta-epiphyseal strains, the femur and the tibia 
 being the bones most commonly affected. Fig. 58 
 shows arrest of development of the ulna followed by 
 deformity of both ulna and radius consequent upon 
 such an inflammation near the epiphyseal line of the 
 ulna. 
 
 The symptoms are, in the beginning, high 
 fever (with often an initial chill), delirium, and 
 great pain, gnawing or boring in character and located 
 ordinarily near the end of a long bone, with a pe- 
 culiar helplessness of or inability to move the limb 
 by its own muscles. The attack comes on suddenly, 
 generally at night, after exposure to cold and damp- 
 ness, combined sometimes with unusual exertion. 
 Sitting on a stone doorstep and unduly prolonged 
 swimming are common causes, even in summer. If 
 the inflammation is at first deeply seated in the can- 
 cellous tissue, no change in the overlying soft parts, 
 either in thickness or in color, will be observed for a 
 number of days, even in the graver cases, though 
 there is from the first sensitiveness to pressure over 
 the aff"ected area, and frequently the superficial veins 
 are abnormally distinct. Before long, however, the 
 external layers of the bone and periosteum become 
 involved, and swelling of the soft parts and redness of the skin occur, with 
 quickly-following fluctuation, indicating the presence of pus. When the disease 
 originates near the surface, these latter symptoms will be noticed early, the 
 rapidly-forming and widely-spreading pus lifting the periosteum off" the shaft 
 for a variable distance, in the graver cases from end to end and around the 
 
 Arrest of Development of the 
 Ulna following Osteitis near 
 Epiphysis ; continued Growth 
 and Deformity of the Radius 
 (Poneet). 
 
2»i.S A\ AMKUK'Ay TKXT-JiOOK OF SURGERY. 
 
 uhole circumference of the bone. The tenqierature continuts liigh, with daily 
 fluctuations of two, three, or more degrees, and the pain is excessive until ten- 
 sion is relieved by the spontaneous opening of the abscess or by operation. 
 As soon as there is such an opening, probing will almost certainly reveal the 
 presence of dead bone. The neighboring joint generally soon ])ecomes inflamed, 
 ■with resulting eff'usion into its capsule, the fluid often becoming purulent after 
 a time, either from direct communication with the suppurating area in the bone 
 or from transmission of the pyogenic cocci through the blood-vessels or the 
 lymphatics. 
 
 In young children the acute epiphysitis that at times occurs is very apt to 
 cause separation of the epiphysis, followed by suddenly produced displacement, 
 resulting in shortening and deformity (Fig. 58). This variety of bone-inflam- 
 mation is usually located at the hip, knee, or shoulder. 
 
 At times, though not often, the pyogenic organisms are carried from one 
 ind of the bone to the other without involvement of the intervening shaft, two 
 entirely distinct areas of inflammation being produced in the same bone. 
 
 The intensity of all the symptoms will vary according to the character and 
 number of the infecting organisms. In the most severe cases, fortunately very 
 rare, only pain and the temperature and typhoid state of an acute septicemia 
 are observed, death occurring quickly. Generally, swelling and abscess-forma- 
 tion are added. These abscesses are extensive and developed early in the graver 
 cases, but are limited and appear more slowly in the milder ones, the latter 
 being those more commonly met with. In certain cases the attack may be so 
 mild that pus is not formed, but a synovia-like fluid, chiefly subperiosteal, the 
 nature of which is not discovered until after its evacuation ; or perhaps pus is 
 formed and undergoes a later mucoid degeneration. This periostitis albuvii- 
 nosa has been observed only a very few times. 
 
 The diagnosis in the earlier hours or days may be uncertain, the affection 
 being often regarded as a typhoid fever or an acute rheumatism, or, in the 
 periosteal variety, because of the redness of the skin, as an erysipelas. But if 
 due regard be had to the age of the patient, the location of the pain close to 
 but not in the joint (commonly the knee, the ankle, or the hip), its peculiar 
 gnawing, boring character so indicative of bone-inflammation, and the sud- 
 denness of appearance and severity from the start of the constitutional symp- 
 toms, with the absence of the progressive daily rise of temperature that belongs 
 to typhoid fever in its first week, there will seldom be any doubt as to the 
 nature of the disease. 
 
 The prognosis as respects both part and life is grave. Death from sep- 
 ticemia in a few intensely infective cases takes place so soon (within one, two, 
 or three days) that its osteo-myelitic origin is not recognized. When it origi- 
 nates superficially, the disease is less dangerous than when of central origin, 
 as the pus more readily and rapidly reaches the surface and is more quickly 
 evacuated. 
 
 Though the prognosis is much affected by the intensity of the inflammation, 
 it is more influenced by treatment. This to be effective must be operative, 
 and the sooner the diseased area is cut down upon and the bone drilled or 
 trephined, the greater the likelihood of arresting the inflammation and lessen- 
 ing the local destruction. The application of heat, pressure, tincture of iodine, 
 etc. will not stop the disease; tension must be relieved, pus evacuated, the 
 bone trephined and the bone cavity scraped, and the parts irrigated with a 
 sublimate solution in order to kill the staphvlococci. 
 
 When the medulla is extensively involved, much benefit will follow tre- 
 phining at two different levels or at many points, scraping out the intervening 
 
SURGERY OF TlIK OSSEOUS SYSTEM. 
 
 269 
 
 Fig. ()0. 
 
 Fig. 59. 
 
 m 
 
 M 
 
 infected tissue, even to tlie removal of the whole medulla of a long bone, such 
 as the tibia, and thoroughly irrigating with antiseptic solutions. In the super- 
 ficial variety (even in the so-called acute piilegmonous periostitis), when the 
 periosteum has been extensively separated, it may regain attachment to the 
 bone to a large extent after early free incision and irrigation and the vitality 
 of the shaft in the main be preserved. 
 
 If, as is generally the case, from neglect of treatment or in spite of it, 
 necrosis has resulted, the dead bone should be removed as soon as it has 
 become detached ; but often in the more severe 
 cases, in order that the profuse discharge and pro- 
 gressive exhaustion may be stopped, an early opera- 
 tion will be required at the end of four, five, or six 
 weeks, even at the risk of taking away too much 
 or too little of the shaft and having little or no 
 regeneration of bone follow. 
 
 Sequestra — The dead piece of bone, whether 
 large or small, is called a sequestrum ; when 
 upon the exterior it is superficial (Fig. 59) ; in the 
 interior it is central; when of limited thickness, 
 but involving the entire circumference, as after 
 amputation, it is tuhidar- (Fig. 60) or ring-shaped 
 according as it extends for a considerable distance 
 up the bone or is confined to the sawn end ; when 
 it embraces the whole shaft, with or without the 
 epiphysis, it is complete. For a long time the frag- 
 ments in a compound fracture have been spoken of 
 as sequestra — primary when completely separated at 
 the time of the injury, secondary when for a time 
 held by periosteal or muscular attachments, and 
 tertiary when later destroyed by inflammation ; but 
 the term should be restricted to the latter, since the 
 others are not at first dead nor in a large proportion 
 of cases will they die if suppuration be prevented. 
 
 AVhen not exposed to the air, sequestra are 
 almost always of a dull-white color ; when so exposed, they are generally black. 
 When struck by a probe, the note is clear and high-pitched, altogether different 
 from that given out by healthy or by carious bone. The orifice of a sinus 
 communicating with the sequestrum is more or less open, the granulations are 
 pouting, and the bony rim is firm to the touch. 
 
 When the periosteum with its deeper layer is not destroyed, and especially 
 when the external layers of the bone are living, if sufficient time is afforded for 
 the production of new bone an osseous envelope is formed, called the invo- 
 lucrum. This more or less completely shuts in the sequestrum. Avhose outer 
 surface is either smooth if the new formation is of periosteal origin, or rough 
 and worm-eaten if the separation has been produced by a rarefying osteitis. 
 
 Where there has been ulceration through the periosteum and bone-layers 
 outside the sequestrum, no such re-formation occurs at these points, and the 
 involucrum is pierced by openings of a size corresponding to the parts 
 destroyed ; these openings are called cloacae. Plate X shows on the exterior 
 the involucrum pierced by numerous cloacae and on the interior the sequestrum 
 of the entire shaft of the femur, the result of an acute osteo-myelitis. 
 
 When the necrosed piece is central, the living bone about it often becomes 
 so sclerosed that it can be cut through only with difficulty. Occasionally, 
 
 [♦i ^V' 
 
 Superficial 
 
 Sequestrum 
 
 (original). 
 
 Tubular 
 
 Sequestrum 
 
 (original) 
 
270 AN AMF.incAX TEXT-IIOOK OF sruCKUY. 
 
 though rarrly. tliis coinh-iised l)one is not perforated ))y even a single .sinus 
 and the se([iiestriini is eoniph'tely enclosed. (PI. XI. Fig. 1.) 
 
 The separation of the dead hone from the living is a comparatively slow 
 process, occupying two, three, or more months, hut it should nearly always he 
 waited for when removal by operation is to be effected, so that only the 
 dead bone may be taken away and time be afforded for the formation of a firm 
 involucrum : the only exception to this rule is found in those more severe cases 
 of acute osteo-myelitis in whicli an early removal is demanded in order that 
 fatal exhaustion from profuse suppuration may he ])revented. That such 
 separation has taken place may generally be recognized by the mobility of the 
 sequestrum when pressed upon through one or more of the cloacae, though 
 occasionally movement is prevented by the firm hold of the granulations upon 
 the dead ])iece. Detachment from the living bone must then be inferred from 
 the length of time that has elapsed. Though a non-infected sequestrum may 
 in very rare instances be absorbed or remain shut in and innocuous for a long 
 time, dead bone, as commonly met with, is an irritating foreign body, which 
 must be got rid of either by spontaneous extrusion, by chemical solvents, or 
 by operative removal before a healthy condition of the affected region can be 
 secured. Small sequestra, especially superficial ones, may make their way to 
 the surface and be thrown oft", but the process is a very slow one. 
 
 Treatment by the application of a dissolving fluid, such as dilute nitric or 
 hydrochloric acid, is uncertain, tedious, and to be advised only in those rare 
 cases in which the sequestrum is so placed that it cannot readily and safely be 
 got at ])y operation. In the great majority of cases the removal of the seques- 
 trum will be by operation — sequestrotomy. 
 
 Sequestrotomy. — When practicable, the parts should be rendered blood- 
 less by the Esmarch bandage, or, better, when tlie disease involves an extremity, 
 by elevation for four or five minutes, followed by the a))])lication of the rub- 
 ber band. If there is a cloaca large enough to permit of the introduction of a 
 forceps, the dead bone is seized through it, and if of small size is dragged 
 away. When necessary the opening should be enlarged and the sequestrum 
 divided before removal. When the necrosed piece is a large one it will 
 generally be necessary to cut away with chisel or gouge a portion of the 
 involucrum, it may be for nearly the entire length of the bone. The dead 
 bone having been lifted out, the granulations in which it has rested are to be 
 thoroughly scraped away, the parts Avell irrigated, the cavity stuffed with iodo- 
 form or other antiseptic gauze, an antiseptic dressing applied, and the limb 
 immobilized. When the involucrum is quite thin or im|)erfectly developed, it 
 may be broken in the removal of the sequestrum, but repair, as a rule, readily 
 and rapidly takes place after immobilization. Usually the progress of the 
 case is very satisfactory : the cavity more or less completely fills up by the 
 formation of new bone, and after a few weeks the patient can begin to use the 
 part if, as is generally the case, the operation has been done on one of the 
 extremities. Only rarely, and when there has been great general weakness or 
 when the wound becomes infected, is the result a fatal one. If the gap in the 
 bone is long and deep, much of the involucrum having been cut away, an 
 effort should l)e made to fill it up, either by an organizable blood-clot, by bone- 
 <:hips, by breaking down and bending in the edges of the involucrum, or by 
 skin-flaps turned in and attached at the bottom ; preferably the first or second. 
 The decalcified bone-chips, originally employed by Senn, generally serve the 
 purpose of a framework or scaffolding on which new bone is built up, the 
 chips themselves undergoing absorption. In Liicke's " Osteoplastic Necrot- 
 omy," in the shafts of the long bones a longitudinal incision is made through 
 
INFLAMMATION OF BONE. 
 
 Plate X. 
 
 
 
 . ■ 1 
 
 i 
 
 i 
 
 I^^L 
 
 '^^■« -« 
 
 
 ' 
 
 
 j 
 . - 'i 
 
 Sequestrum of entire shaft of femur, involucrum riddled with cloacae ; the result of acute 
 
 osteo-myelitis. 
 
iSURGKHV or THE OSSEOUS SYSTEM. 271 
 
 the skill and periosteum, as nearly as possible in the line of the cloacae, and 
 a section of involiicrmn chiseled out corresj)on(lin<; with this incision. At 
 either end where the sequestrum-cavity terminates tiie soft parts are divided 
 transversely and the bone correspondingly chiseled through. With a small 
 chisel the base of the skin-periosteum-bone-flap, thus obtained, is divided 
 from within the se((uestrum-cavity so that the entire Haji may be turned back 
 out of the Avay. Such a lla|) may be made on one or both sides of the cavity. 
 After cleaning out the bone the flaps are bent inward so as to fill the cavity 
 as far as possible. In order that success may follow the adoption of any of 
 these methods the wound must be made aseptic and kept so. 
 
 THE CHRONIC INFLAMMATIONS OF BONE. 
 
 The chronic inflammations of bone are generally such from the begin- 
 ning. They are of much more frefjuent occurrence than the acute, and, like 
 them, are of pyogenic, syphilitic, malignant, or tubercular origin. They are 
 very rarely traumatic and unassociated with pyogenic infection, though, as is 
 seen in the vertebnie pressed upon by an aneurysm, ulceration from prolonged, 
 frequently-repeated injuries may take place. 
 
 The prevailing tyjie is the rarefying. Molecular death occurs to some 
 degree in all cases ; death in mass results chiefly in those due to syphilitic or pyo- 
 genic infection ; often extensive new formation, both in length and thickness, 
 takes place in the syphilitic, and, to a certain extent, in the pyogenic. 
 
 The diseases induced by the different causes are located by preference in 
 diff'erent parts of the skeleton : thus, syphilis infects chiefly the long bones and 
 those of the head and fixce ; sarcoma and carcinoma, the long bones, the pelvis, 
 and the jaws; pus infection, the long bones; tuberculosis, the bones of the 
 hands and feet and the spongy tissue in close relation w^itli the hip-, knee-, and 
 elbow-joints. 
 
 Children and adolescents are the ordinary subjects of osteo-myelitis, tuber- 
 culosis, and inherited syphilis ; young adults, of sarcoma, acquired syphilis, and 
 the relapses of the inflammjftions of youth ; persons of middle and advanced 
 life, of syphilis and cancer. 
 
 Symptoms. — Pain is the most common symptom, its intensity, however, 
 being very variable even in cases having a like origin. As a rule, it is worse 
 at night, the increased fulness of the veins and capillaries due to the more 
 sluggish circulation making greater the tension-pressure upon the nerve-fibers. 
 It is aching, gnawing, boring, or, in tubercular cases in which there is inflam- 
 mation of the subarticular layer of osseous tissue, starting. 
 
 With or without the development of an abscess a sinus may form, through 
 which more or less discharge may take place, the discharge being often gritty 
 or having in it small yet readily detected spicules of bone, show'ing, as does the 
 bone itself, that the aff"ection is truly a caries or decay of the osseous tissue. 
 
 When the inflammation is located upon the surface, examination by the 
 eye, the finger, or the probe, or of the cleaned and dried specimen, shows that 
 the process is an ulcerative one, producing an ulcer with all the characteristics 
 of an ulcer of the soft parts ; and the same is true, certainly as respects the 
 process, when it is centrally developed. The granulations may be numerous 
 and moist, as is commonly the case, or large and abundant with little fluid 
 (fungous caries), or very feebly developed with no discoverable fluid (dry 
 caries), as in a few cases of syphilitic or tubercular origin. 
 
 This caries sicca is frequently observed upon the skull and in the 
 upper ends of the humerus (Fig. 61) and femur. The bone-destruction is 
 
272 
 
 AN A}fi':iii<'.\x Ti:xr-ii<)<)K of srnarjiv. 
 
 Fig. 61. 
 
 Caries 
 
 iltuiK in 
 
 Absorption aiifl Deform- 
 ity of the Head of the 
 Humerus (Duplay and 
 Reclus). 
 
 often extensive, ami in the loiij; Ixjiics is due in :i measure to tlie wearing 
 effect of" the pressure of contiguous parts. Not sehlom its existence is indi- 
 cated only by impairment of function and by severe 
 pain, very persistent, and irremediable except by re- 
 moval of the diseased part. 
 
 This form of osteitis, if left to itself, (1) may termi- 
 nate in arrest of formation of the granulations, absorp- 
 tion or elimination of the dead tissue, and sclerosis of 
 the new layers and of the ])arts aro md. with or without 
 l^^-^^^^^S^B^k overgrowth of the affected bone, which when it occurs 
 (? ■' «tf:" ' '. ^S^ ^mM causes permanent alteration even to the extent, it may 
 be, of marked deformity ; or (2) ma} continue for a long 
 time without material local change or the development 
 of visceral lesions ; or (3) may often lowly but steadily 
 advance, destroying more and more widely the bone, 
 involving otlier portions of the skeletoi causing marked 
 general debility, and inducing grave lisease of inter- 
 nal organs, especially the lungs, the kidney, and the 
 intestine. 
 
 The treatment, in general, is made up of measures 
 calculated to relieve irritation and to hasten the elimi- 
 nation of dead tissue — measures therapeutic and opera- 
 tive, considered in detail under the separate heads of the various classes of 
 bone-inflammations, septic, specific, malignant, and tubercular. 
 
 Tubercular Inflammation of Bone. — The most frequent and most 
 typical of these inflammations is the tnhereular, and is often secondary to some 
 distant primary focus of the disease. Infected granulation-tissue forms more 
 or less rapidly, vshowing, as a rule, comparatively few bacilli, and these chiefly 
 in the new growths farthest from the point or points of original deposition ; such 
 tissue, by its pressure and after-caseation with its associated fluid, produces wast- 
 ing of the osseous trabeculge. 
 
 Caseation and liquefaction so affect the cells of the growth that, together 
 with the altered layers of bone, they may be scraped away as grayish-yellow 
 masses saturated with fluid. At times little or no fluid is to be seen, though the 
 bone has become so soft as to be easily cut with a knife. Cavities, larger or 
 smaller, few or many, filled with fluid degenerated cells and bone detritus, are 
 of frequent formation (PI. XI, Fig. 2). In the long bones infiltration of the 
 medulla of the central canal may occur throughout its length or be limited to a 
 few distinct areas. Usually, hoAvever, the new growth is in the cancellous spaces 
 of the extremities and in the Haversian canals, pushing toward the exterior of 
 the bone. After the bone itself is involved, there is subperiosteal new forma- 
 tion, which, if caseation has not occurred, may remain for a considerable time 
 as a semi-solid mass, the adjacent bone and periosteum undergoing thickening 
 and hardening. Sooner or later, and quite rapidly as a rule when caseation 
 has taken place, the periosteum is infected and destroyed, the adjacent soft 
 parts become tubercular, and by one or several tortuous channels following the 
 lines of least resistance the disease reaches the skin, the piercing of which com- 
 pletes the formation of the sinus or sinuses. The walls of such sinus, from its 
 mode of formation, are necessarily tubercular, and its outlet is filled with granu- 
 lations more or less exuberant, more or less dark-colored, readily bleeding when 
 torn, and at times quite sensitive. A probe being introduced, often with much 
 difficulty because of the flexures of the canal, softened, easily-penetrated bone 
 may be felt, but its presence may escape detection because of the heavy granula- 
 
INFLAMMATION OF BONE. 
 
 Plate XI. 
 
 F 
 
SURGERY OF THE OSSEOUS SYSTEM. 273 
 
 tioii-Iayer covering it. The dificrencc in the ai)j)ejir:ince of the external granu- 
 lations, in the resistance to the probe offered by the bony walls, and in the 
 percussion note elicited by the probe (which is here flat), enables one readily to 
 distinguish caries from necrosis. 
 
 When a circumscribed area of bone has broken down and litjuefaction of 
 the caseated granulation-tissue in it has taken place, such a collection of fluid 
 has long been spoken of as an abscess ; and the same is true of the similar 
 collections between the periosteum and bone and in the overlying soft parts. 
 But, though accumulations of a fluid in appearance much like pus, they are not, 
 properly speaking, abscesses, since true pus is not present (unless it be a fact 
 that at times the bacillus is a pyogenic organism) except when a double or 
 mixed infection has taken place. This is not often the case until a communica- 
 tion with the external air has been established by the spontaneous or operative 
 opening of the sinus. When such an opening has been made, the previously 
 pent-up liquid, with its associated characteristic cheesy, curdy material, escapes, 
 and the continuous development of similar fluid, now probably become puru- 
 lent, keeps up the discharge. This varies in amount from a few drops to 
 many ounces a day, and lasts indefinitely, with occasional temporary stoppages 
 from blocking up of the canal at one point or another. Its complete arrest 
 can be secured only by destruction of the infected area. This prolonged sup- 
 puration, by the exhaustion and amyloid visceral changes which it induces, 
 often has much to do with the production of a fatal termination. 
 
 In consequence of plugging of the vessels necrosis may take place, the pro- 
 duced sequestrum. being often of considerable size. If centrally located in the 
 cancellous tissue, it is surrounded by the infected granulations, and remains until 
 removed by art or until, after a long time, it has broken down, Avhen it may 
 be discharged piecemeal. Often in the extremity of a long bone, because of 
 the arrangen»ent of the vessels which have been plugged by a tubercular embo- 
 lus or by a thrombus resulting from the mural implantation of tubercle bacilli, 
 it is conical in shape, its base directed toward the articulation ; and to its 
 presence may be due rapid involvement of the articulation in the morbid action. 
 
 In its earlier stages the progress of tubercular osteitis is ordinarily insidi- 
 ous, often the only symptoms of its existence being impaired function of the 
 part, rigidity of the muscles about the neighboring joint, and pain in the 
 affected area. Muscular rigidity, which is a reflex condition and protective 
 in its action (or intended to be such), is of great diagnostic value. It is often 
 the only symptom present, and when observed is deserving of careful con- 
 sideration, for if no other cause for its existence is apparent, it may be safely 
 assumed that there is something abnormal in the neighboring joint. The 
 pain may be spontaneous or exist only as tenderness on pressure over the 
 diseased spot, but it can always be developed by such pressure. By the ther- 
 mometer slight increase in the heat of the region may at times, or possibly 
 always, be detected ; but a long-recognized peculiarity of this form of inflam- 
 mation is the absence of any decided elevation of temperature. 
 
 The appearance of the overlying skin is generally unchanged, even after 
 infection of the superficial soft parts ; though, because of interference with the 
 circulation by pressure, there may be some general discoloration or certain of 
 the veins may become unduly prominent. 
 
 Even up to the time of the establishment of a communication with the exte- 
 rior the symptoms are far from severe, pain, swelling, and impairment of func- 
 tion being present, but no decided constitutional symptoms, and the patient 
 may go about as if in health. But when septic infection has taken place all 
 
 the local symptoms are aggravated and the constitutional ones become decided., 
 18 " 
 
274 AN A}fi:i^'I<A.\ TEXT- HOOK OF SVROERY. 
 
 The only disease with wliicli tlie affection is tli<ii liktly to Ije confounded is 
 protracted osteo-myelitis of pyogenic orijrin ; and this, thou;,'h more common 
 than is often su])posed, is far less fn.Mjucutly met with than tubercular osteitis, 
 and seldom if ever attacks the parts of the skelctun which ai-e so often the 
 seat of the latter disease — the vertebrie, the tarsus and carpus, the upper end of 
 the femur, and the bones of the elbow. It is largely to the prevention of sec- 
 ondary pyogenic disturbances that the present favorable course and prognosis, 
 as compared with tliose of but a few years ago, are to be attributed. Under any 
 treatment, and especially under inefficient or no treatment, the course of the 
 affection is ordinarily slow, occupying many weeks, it may be months. At any 
 stage it may be arrested sj)()ntaneously (1) by removal of the diseased tissue, 
 which is followed by condensation of the surrounding bone with or without 
 cicatricial obliteration of the cavity ; or (2) by encapsulation of the infected 
 tissue, which permanently or temporarily protects the part. Very often it is 
 temporary, since recurrence fre(iuently takes place. 
 
 The treatment is mechanical, therapeutic, or operative — more frequ<'ntly 
 the first and second, but often all three methods, are employed either simultane- 
 ously or successively. 
 
 Mechanical treatment may be held to include all measures adapted to ensure 
 rest of the diseased part, whether by position, immobilization, or the applica- 
 tion of fixation apparatus of one sort or another. Rest is of prime importance 
 at any stage of the affection, and is especially valual)le in the earliest, when it 
 may be sufficient to bring about arrest of morbid action and more or less 
 complete restoration to health. Simple confinement to bed .may be all that is 
 needed, or an immobilizing dressing — e. g. the plaster-of-Paris or a properly 
 constructed and applied splint — may be required. Under such treatment, 
 even when there has been much destruction of bone and "cold abscess" has 
 formed, the symptoms may subside. This will be because of absorption and 
 contraction, it may be calcification, of the tubercular masses, condensation 
 taking place in and around the carious area, and functional action being 
 resumed; though, as a rule, there will be more or less impairment, more or 
 less deformity, and an ever-existing danger of a recurrence of the disease. 
 
 The therapeutic treatment is geneial and local. The former consists in the 
 administration of remedies serving to improve nutrition and increase the general 
 strength ; and of these cod-liver oil has lon<»; been regarded as the most valu- 
 able. The local treatment consists in the injection into and around the dis- 
 eased center of agents calculated to destroy the infecting germs and produce 
 condensation of the surrounding bone and of the uninfected new-formation 
 layers, thus bringino; about cicatrization. The remedies of this class that have 
 proved of decided value are the acid phosphate of lime, the chloride of zinc, 
 and iodoform ; the latter of which in ethereal solution, or, better, suspended 
 in glycerin (10 per cent.) or in oil (5 to 25 per cent.), has been found of great 
 value as a substitute for the operative removal of the morbid tissue, or em- 
 ployed after it. These solutions are carried down by means of a syringe to 
 and into the diseased area, and injected in small quantity, the injections being 
 repeated every three, seven, or ten days according to circumstances. 
 
 Operative treatment consists in the removal of the diseased area by scrap- 
 ing or excision. Amputation is rarely demanded, at least in properly treated 
 cases. Scraping, to be effective, must be thorough, and special care must be 
 taken to clean away the walls of sinuses, to remove infected deposits in the 
 medullary canal of a long bone, and in the foot and hand to leave no part of 
 a softened bone (unless it be perhaps the shell of the os calcis, and this, as a 
 rule, should be taken away). No associated tubercular growth in the tendon 
 
,si'ii(ij:in' OF 'nil-: osseous system. 275 
 
 sheaths, the synovial pouches, or the superficial fascia or skin should in any 
 case be allowed to remain. 
 
 Ignipunc-ture by means of the thermo-cautery has been practised by a few 
 surgeons \\\x\\ good efiect. 
 
 Cases of visceral tuberculosis are generally much benefited, and not seldom 
 cured, by change of climate and altitude, and strumous children often rapidly 
 imj)rove at the seaside. Much good would unquestionably be effected, in the 
 earliest stages especially, by sending patients with chronic bone disease to the 
 coast, the highlands, or the ))ine woods. 
 
 Chronic pyogenic osteitis is almost always the sequel of an acute osteo- 
 myelitis that occnn-ed, it may be, many years before, and is the cause of two 
 very different conditions — abscess and overgrowth. It is usually circumscribed, 
 and may be located in the medullary canal, or, much more often, in the can- 
 cellous extremity of a long bone, especially in the head of the tibia or the lower 
 end of the femur. It pro))ably is due ordinarily to the newly-aroused activity 
 of long-latent pyogenic organisms leftover from an osteo-myelitis of childhood; 
 but at times it may be consequent upon a new infection attacking parts less 
 resistant than others because of their having previously been the seat of a 
 septic inflammation. 
 
 Rarefaction of the bone takes place in a limited area ; condensation goes 
 on around it, though rarely to the extent of producing necrosis, except, it 
 may be, of very limited amount ; pus may be almost altogether absent or may 
 be present in considerable quantity and form a chi'onic abscess in the interior 
 of the hone (PI. XII, Fig. 1). This is especially frequent in the cancellated 
 tissue in the lower end of the femur or in either end of the tibia. The most 
 characteristic symptom is pain, severe, often intense, gnawing or boring, 
 decidedly worse at night, limited to a small space, pressure over which is usually 
 painful, sometimes because of associated periostitis, at times disappearing for 
 weeks or months to reappear again, often Avithout any apparent cause. The 
 bone is frequently decidedly enlarged as the result of its early inflammation or 
 of the hypertrophying effect of the long-continued secondary osteitis. 
 
 No treatment is of value except drilling or trephining, by which exit is 
 afforded the pent-up pus, thus taking off the tension. Careful exploration with 
 a long pin or fine drill, carried in various directions through different openings 
 or from the sides of the trephine-well, should be made before deciding that pus 
 is not present. Even if no pus can be found, relief is afforded and the so- 
 called neuralgic condition is removed. Not seldom the pierced bone is abnor- 
 mally dense. When pus is found it is wise not to be content with simple 
 evacuation of the matter, but to scrape away the softened bone, letting the 
 resulting cavity fill up or contract as it may, or, better, endeavoring to secure 
 its rapid and complete closure by means of a blood-clot or bone-chips, for the 
 success of which attempt complete asepsis is required. 
 
 The overgrowth from irritation resulting from this form of osteitis may 
 affect a part or the whole of a bone. At times it is very great, producing 
 marked deformity. Although a chronic process, it is very generally the result 
 of the early osteo-myelitis, and the process never having been altogether 
 arrested, it can hardly be considered a part of the phenomena of chronic pyo- 
 genic osteitis unless there is joined with it the limited suppuration already con- 
 sidered. Overgrowth in length consequent upon the irritative action of a 
 tubercular osteitis is at times observed, and has occurred after excision, par- 
 ticularly of the lower articulating extremity of the femur, the region of the 
 epiphyseal line not having been removed. 
 
 Much more often after both tubercular and septic inflammations, whether 
 
27G 
 
 AN AMERICAN TKXT-liOOK OF SURGERY 
 
 an operation has been done or not, there is arrest of development. :iiid as a 
 result shortening, which in children is apt to be progressive up to the time of 
 full maturity. 
 
 Atrophi/, evidenced by lessened solidity, thickness, or lenjith, or by all of 
 these conditions, is the necessary result of long-continued defective nutrition 
 due to feebleness of the general circulation or to disturbed innervation of the 
 part. It is a common phenomenon of chronic osteitis. It may be temporary, 
 as after fracture, or permanent, as in infantile paralysis and in old age. It 
 causes more or less impairment of the functional value of the bone and strongly 
 predisposes to fracture. No special treatment is of value, unless it be the 
 production of hyperemia, as by frequent applications for a limited time of the 
 Esmarch bandajxc or bv drillino; the bone. 
 
 EHACHITIS. (See Chapter xv., p. 85.) 
 OSTEO-MALACIA (mOLLITIES OSSIUM, MALACOSTEON). 
 
 This is a disease of adult life, and is very rarely met with in children or old 
 persons. In the great majority of cases it affects Avomen, chiefly those who are 
 pregnant or Avho have borne children. It is characterized by progressive soft- 
 ening of the various parts of the skeleton, with resulting deformities (Fig. 62), 
 usually goes on from bad to worse, and after it may be a number of years causes 
 death, chiefly from exhaustion or disease of the lungs. It has been attributed 
 
 to the action of many causes, such 
 ^^" ^"' as defective nutrition, excess of 
 
 lactic acid, disease of the trophic 
 nerves, ovarian and uterine 
 changes, etc., but the real excit- 
 ing cause is uncertain. 
 
 The bone lesions are great 
 increase of vascularity with re- 
 sulting hemorrhages, degenera- 
 tion of the medulla and its ulti- 
 mate conversion into a pulp re- 
 sembling splenic tissue, absorp- 
 tion of the lime salts, destruction 
 of the trabeculre, formation of 
 cavities or more rarely tumor-like 
 enlargements, and absorption of 
 the cortical layers. The perios- 
 teum is ordinarily thicker and more vascular than normal, and serves as a pro- 
 tective envelope to the broken-down bone. Fracture from muscular action or 
 from slight movement is of frequent occurrence, and deformity to a greater or 
 lesser extent is sure to be produced in other than the mildest cases, the distor- 
 tion at times becoming excessive and most peculiar. 
 
 Until such deformity has occurred, or until at least the softening has 
 advanced so far as to permit of bending of the bone, the diagnosis is difficult 
 and uncertain, since the progress of the disease is for a considerable time an 
 insidious one. The early-developed and persistent pain ordinarily causes the 
 affection to be regarded as rheumatic; but the multiplicity of the painful areas, 
 the sex of the patient, the existence of pregnancy, and the presence of large 
 quantities of the lime salts in the urine, should direct attention to the probable 
 existence of osteo-malacia. 
 
 Deformed I'elvis fn.m » tbtLu-malacia (Oilier) 
 
INFLAMMATION OF BONE. Plate XII. 
 
 1. Abscess in the great trochanter. 2. Impacted fracture of neck of femur. 
 
SURGERY or THE OSSEOUS SYSTEM. 277 
 
 Thoufih commonly for a time not exerting any unfavorable influence upon 
 life, and occasionally ceasing to advance, even being recovered from, though 
 very rarely, its prognosis is grave, the disease usually ending fatally. Medi- 
 cal treatment by the use of phosphorus and the phosphates, the lime salts, cod- 
 liver oil, etc. has proved of little or no value. The best possible hygienic 
 surroundings should be secured and the patient kept quiet and free from pain. 
 Proper retentive dressing should be api)lied to prevent fracture and lessen 
 deformity. Of late in a few cases the ovaries and uterus have been removed 
 with reported decided benefit. When this operation is not done, pregnancy 
 should be prevented, as childbearing exerts a powerful and deleterious influence 
 upon the progress of the disease. 
 
 FRAGILITAS OSSIUM. 
 
 Abnormal brittleness due to rarefaction and predisposing to the occurrence 
 of fracture upon the infliction of slight violence is sometimes observed in cases 
 of syphilis, of malignant tumors, and of trophic disturbances after injuries of 
 bones and joints necessitating long confinement. It is also seen in the earlier 
 stages of rickets, in general paralysis, and in tabes. But, besides this condition, 
 which is a sequel of disease, there is at times seen a pure and simple fragility, 
 accompanied, so far as can be discovered, by no pathological changes, general 
 or local. This fragilitas ossium is, as a rule, an inherited peculiarity manifest- 
 ing itself in infants (even in the fetus in utero), in children, and in adolescents, 
 and ceasing to exist when full maturity is reached. Fracture after fracture in 
 one or in several bones or in many parts of the skeleton occurs, presenting 
 the usual symptoms and followed by rapid recovery. As the cause is un- 
 known, nothing can be done further than to protect the individual from injury 
 as much as possible, and to treat the fractures in the usual way. 
 
 SYPHILIS OF BONE. (See Syphilis.) 
 
 TUMORS OF BONE. 
 
 Bone tumors, like tumors of other parts, are benign or malignant ; the 
 former being commonly exostoses, fibromata, or chondromata, the latter sar- 
 comata or carcinomata. 
 
 Exostoses are homologous outgrowths differing from hypertrophies in 
 that but a limited part of the circumference of the bones is involved. They 
 are either spontaneous, and appear first during the period of development, or 
 are symptomatic of osteitis, traumatic or non-traumatic, usually syphilitic. 
 They are located chiefly upon the long bones, the skull, or the maxillae, and 
 are generally cancellous in structure, but at times compact, even of ivory 
 hardness ; this is particularly true of the syphilitic exostoses of the skull. 
 When developmental, originating in childhood, though the outgrowths may 
 be found upon any part of the skeleton, even upon many and generally sym- 
 metrical parts at the same time (Fig. 63), they are commonly in connection 
 with a long bone near its epiphyseal line. If primarily upon the diaphyseal 
 side of the cartilage of conjunction, they may apparently be carried upward 
 as the shaft elongates, so as ultimately to occupy a level much above the 
 articular exti-emity. They may be either broad-based or pedunculated, and 
 not seldom the free extremity is covered by a bursa resulting from friction or 
 the separation of a part of the synovial sac in the outgrowth of an originally 
 subsynovial spur. Their growth ceases, as a rule having few exceptions, at 
 or before the twenty-fifth vear. 
 
27S 
 
 I^V AMERICAN TEXT- HOOK OF sriiCEUY. 
 
 The diagnosis is coniiiiMiily cusy, tlie tumor ht'iii;^ hard and fixed and 
 readily felt or seen. Pain is seldom present, and whatever local damage 
 
 results is from pressure causinf^ atrophy or 
 ulceration of the overlyin;^ soft parts (and 
 this is not of coiiiinon occurrence) or from 
 position interfering with the free use, espe- 
 cially with flexion, of the limh, as in sitting 
 or riding. In a large proportion of cases 
 no serious inconvenience is experienced. 
 When the mass is upon the inner side of 
 the skull (of di))loic origin, as a rule), a 
 resulting compression of the brain may 
 give rise to serious cerebral disturbances, 
 but often no appreciable effect is produced, 
 and the existence of the tumor is not dis- 
 covered until after death. 
 
 The only effective treatment is opera- 
 tive, removal of tlie growtii, or the break- 
 ing of it off, the former being preferable, 
 the latter practicable only when the attach- 
 ment is by a pedicle. In many cases no 
 treatment is required. 
 
 Fibromata. — Springing from the peri- 
 osteum or, much less freijuently, central in 
 origin, the fibrous tumors of bone are found 
 generally in connection with the maxillse 
 and the base of the skull, though they are 
 occasionally located upon the vertebne, the 
 pelvis, or the long bones. When of long 
 standing they are likely to undergo degen- 
 eration, fatty, cystic, or, particularly, cal- 
 careous, rarely becoming ossified. Not sel- 
 dom they are either primarily or secondarily 
 mixed in character — fibro-sarcomata, fibro- 
 chondromata. Their development is slow, 
 and they often cease to enlarge about the 
 time when the skeleton has reached full 
 maturity, after which they may atrophy, 
 or even completely disappear. 
 
 If superficially placed, they can gen- 
 erally be readily diagnosticated by their 
 more or less irreijular contour, tiieir firm- 
 ness but not bony hardness, their evident 
 close connection with bone, and their grad- 
 ual enlargement. The most common of 
 these growths are the ndso-pharjiuiieal polyp 
 and epulis, both of which are often decidedly 
 sarcomatous. The former is a disease of 
 adolescence. It originates from the under surface of the sphenoid, fills up 
 the naso-pharynx, pushes into the nasal fossae and the antrum on one or both 
 sides, and, it may be, outwardly through the spheno-palatine foramen, causing 
 extensive destruction of the bones of the face by pressure. It is dangerous 
 because of the attending hemorrhages, which, as a rule, are profuse and fre- 
 
 Exostoses of Various Dimensions (Pierret). 
 
SURGERY OF Till: OSSEOUS SYSTEM. 271) 
 
 (|iu'iitly recurring. Tlie character of the central tumors, which are often 
 cystic, will not be recoirnizcd .so long as they are surrounded by a bony 
 envelope, and usually is not determined until after their removal. 
 
 Treatment. — Extirpation, preferably by enucleation or, when this is not 
 practicable, by excision of the portion of the bone to which the growth is 
 attached, is the proper treatment, though, as has been stated, nature some- 
 times affords relief through atrophy. 
 
 The naso-])haryngeal polyp, if not rapidly growing or often bleeding, may 
 be let alone in the hope of s])ontaneous disappearance when the patient shall 
 have reached the age of twenty- F • rj 
 
 five years or a little more ; but 
 in the majority of cases the risk 
 of death from exhaustion conse- 
 quent upon repeated hemorrhage 
 will forbid such delay. (See 
 Diseases of the Nose.) 
 
 Choxdromata. — As might 
 be expected, the cartilaginous are 
 the most common of the benign 
 osseous tumors, their chief places , ^ , 
 
 „ , . , . 1 , \ Multiple Chondromata of the Hand (Leo). 
 
 Oi election being the long bones 
 
 (in their extremities) and those of the hands and feet (Fig. 64). They may 
 be either peripheral or central, and are not seldom mixed in character, the 
 addition of sarcomatous elements being particularly frequent. Even when 
 microscopical examination has apparently shown them to be pure chondromata 
 they have at times the characteristics of malignant growths, in so far as they 
 recur after removal and by transference of their cell-elements develop visceral 
 disease in the lungs, the liver, or the spleen, especially the first. It is possible, 
 however, that these are examples of mixed tumors, all portions of which had 
 not been subjected to examination. The more nearly their histological struct- 
 ure approaches that of embryonic cartilage, the greater is the liability to sec- 
 ondary manifestations. Traumatism is often an exciting cause. Their grow^th 
 is generally slow ; they frequently become cystic, and always tend toward 
 destructive changes both in their own tissues and in the part in which they are 
 developed. The overlying skin may be unaff'ected for a long time, but ulti- 
 mately becomes ulcerated, and a sinus is established communicating with the 
 breaking-down tumor-mass. 
 
 As a rule, they are not painful except when there is involvement of or 
 pressure upon adjacent nerves, either of which is comparatively rare; but by 
 their presence they may interfere with free muscular or articular movements. 
 
 If externallv located, as upon the hands or feet, their diagnosis is easy: 
 when upon the long bones it can be made as a strong probability if regard is 
 had to their position, their slow growth, their elastic firmness, which though 
 decided is not that of bone, and their irregular contour. When softened or 
 cystic their nature may be misunderstood until after incision or puncture. When 
 of mixed sarcomatous character, because of rapid growth and associated consti- 
 tutional weakness they may be readily mistaken for osteo-sarcomata — a mistake, 
 however, of no practical importance, since the treatment of the two aifections is 
 the same. The central growths cannot be recognized until they have reached 
 considei'able size, and even then their character will not generally be deter- 
 mined before removal. 
 
 The only treatment of value is operative, the growth being removed either 
 by itself when it is external and pedunculated, or with a part or the whole of 
 
280 .Lv .\}ri:i:f(AX TKxr-iiooK of svuckiiy. 
 
 the bone in which it rests ; in other words, hy taking it out and scraj»in<: away 
 the tissue immediately about it, by excision of the diseased portion of the 
 bone, or by amputation. 
 
 Kk.. I!'). 
 
 Osteo-sarconm of the Femur (original). 
 
 Malignant Tumors. — The malicrnant bone-tumors are either carcinoma- 
 tous or sarcomatous. The former are comparatively rare and always secondary ; 
 the latter are of frequent occurrence and primary^ except when following upon 
 like disease of tne adjacent soft parts or upon melanotic .sarcoma. Unlike osteo- 
 carcinoma, osteo-sarcoma is a disease of early life, even of infancy and childhood, 
 only a very small proportion of the cases observed occurring in individuals 
 over forty years of age. Histologically, it is of three varieties — round-celled, 
 epindle-c'elled, and giant-celled ; locally, there are two varieties — central and peri- 
 osteal. Its malignancy structurally is in inverse proportion to the size of the 
 cells, being greatest in those tumors made up of small round and spindle cells, 
 least in those composed chiefly of giant cells. As respects location, when 
 orif'inally external it progresses more rapidly, has earlier and more frequently 
 secondary visceral manifestations, and is more certainly fatal than when inter- 
 nal. It especially affects the maxilh\i and the long bones: of the latter, those 
 of the lower extremities much oftener than those of the upper. The adjacent 
 ends of the femur and tibia are the most common sites (Fig. 65). Local injury 
 is a strongly predisposing cause. 
 
 Osteo-sarcoma affects a neighboring joint comparatively seldom, even at 
 times passing outside the articulation from one 1)one to anotlier. Often the 
 bone in which it is situated is so weakened by it that spontaneous fracture 
 occurs, and this is occasionally the first indication of its existence. Its rate 
 of growth is variable, though with rare exceptions it is rapid as compared 
 with that of the benign tumors. The size which it may attain is usually 
 not great, but is occasionally enormous. The central growths, which, speaking 
 generally, are giant-celled at the extremities of the long bones, and round- or 
 spindle-celled in their shafts, have for a time an osseous envelope, so thin in 
 some cases as to yield and crepitate on pressure, and later a complete or partial 
 osteo-peri osteal capsule. This is not the case with the external growths, the lim- 
 iting wall of which is periosteum until that membrane has become involved and 
 the disease has pushed through it into the adjacent soft parts. The vascularity 
 of the internal tumors may be so great as to render them pulsatile, apparently 
 aneurysmal. Without doubt nearly all the reported cases of aneurysm of 
 bone have been sarcomata of this character. Hemorrhage into the substance 
 of the tumor is of frequent occurrence, and degenerations, fatty, cystic, and, 
 especially in the periosteal growths, calcareous or to a greater or lesser extent 
 bony, commonly take place. Dissemination, with resulting disease of remote 
 parts, bony or visceral, is chiefly by way of the blood-vessels, affections of the 
 
SURGERY OF THE OSSEOUS SYSTEM. 281 
 
 lymphatic glands being infrequently observed. When present it is in large 
 measure only irritative in character. 
 
 The cliief symptoms are pain, wjiich is seldom absent, and at times is 
 intense; swelling, recognized early in the external, ))Ut much later in the 
 internal, variety, in shaj)e globubir, pear-shaped, or conical near the end of a 
 long bone, spindle-shaped upon the shaft; and increased heat, as determined 
 by the hand or the surface thermometer. There is little or no impairment oi 
 the joint motions for a consideralde time. 
 
 The diseases with whicli it is most likely to be confounded are rheumatism, 
 because the pain is usually in the neigliborhood of a joint, and tul^ercular dis- 
 ease, because of the location of the swelling. But, taking into consideration 
 the age of the patient, the non-existence of other evidences of any diathetic 
 affection, the absence of joint disease, the firmness of the growth, especially 
 in its earlier stage, the rapidity of its enlargement, and the local temperature- 
 changes, a strongly probable, if not absolute, diagnosis can usually be readily 
 established. Puncture or exploratory incision may be made if necessary. It 
 may also be mistaken for an abscess. 
 
 The treatment to be effective must be radical, the affected bone being 
 removed, or in an extremity amputation being done at or above the nearest 
 joint rather than in the continuity of the bone, except in cases of central giant- 
 celled growths in the lower end of the bones of the leg or of the femur. When 
 necessity seems to demand disarticulation at the hip, it is very questionable if 
 any operative interference should be resorted to, in view of the risks of the 
 amputation and the almost absolute certainty of an early recurrence of the 
 disease in the stump or viscerally. After amputation other than at the hip the 
 probability of reappearance is strong: even in the least malignant variety, the 
 central giant-celled, it occurs in about one patient out of five. 
 
 ACTINOMYCOSIS. (See p. 137.) 
 ACROMEGALY. 
 
 Enlargement of many of the bones of the skeleton, especially of the face 
 and head, the thorax, the pelvis, and the foot and hand, is a very constant 
 symptom of the peculiar and rare nervous affection first described by Marie 
 in 1886, and by him named acromegaly. Such enlargement is a true hyper- 
 trophy, new growth taking place under the periosteum and at the cancellous 
 extremities. The bones of the hands and feet and the lower jaw are early 
 and markedly affected. The cause of the disease has not been determined. 
 By some it has been assumed to arise from an abnormal vascular development; 
 by others, from changes in the central and peripheral nervous systems ; by yet 
 others, from a special affection of the pituitary body. In a large proportion 
 of cases examined post mortem the pituitary body has been found diseased, 
 but certainly not in all ; and further, in some cases similar changes in the 
 pituitary body have been discovered when there was no acromegaly. 
 
 The more common surgical diseases with which it is likely to be con- 
 founded are osteitis deformans and arthritis deformans. From the former it 
 may be differentiated by the earlier age at which it appears, by the almost 
 constant affection of the feet and hands, by the absence of curvature of the 
 long bones, by its being generally symmetrical, and by the ordinarily much 
 greater disease of the face than of the head ; from the latter, by the great 
 overgrowth of the hands and feet, and by the absence of the pain, the 
 deformity, and the later ankylosis that are symptomatic of the joint affection. 
 
 The disease is of long duration and incurable, and no treatment has any 
 special influence upon the progressive hypertrophy. 
 
2.S2 
 
 AN A.vi'jncAX 'rExr-iiooK OF srii(n:HY 
 
 CHAPTER III. 
 
 FRACTURES. 
 
 Definition. — The sudden, forcible destruction of the continuity of a bone,, 
 in whole or in part, except when done Avith a cutting instrument, is called a 
 fracture. A simple fracture, in the common use of the term, is one that is not 
 compound (see below) ; a spontaneous fracture is one produced by very slight 
 violence ; a patholoqical fracture is one made easy by partiiil destruction of the 
 bone by disease; an ununited fracture is one in which bony union has not yet 
 taken place after the lapse of a period of time that is usually sufficient for repair. 
 
 The injury is a common one ; it occurs about three times as frequently in 
 males as in females, but the proportion varies at different ages : in infants- 
 and between the ages of fifty and seventy years both sexes are about equally 
 affected ; in middle life fractures are ten times as fre({uerit in men as in women ; 
 and after the age of seventy women are much more frequently affected than 
 men, the commonest fracture then being that of the neck of the femur. The 
 majority of fractures occur in the first and third decades of life, but if the 
 number of people living at the diff"erent ages be considered, the greatest rela- 
 tive frequency will be found at about the age of sixty years. 
 
 The following table shows the relative frequency of fractures of the dif- 
 ferent bones. The italics mark bones with more than 10 per cent. : 
 
 Fractures Treated in the London Hospital, 1842-77. 
 
 Skull . . 
 Face . . 
 Spine 
 Pelvis . 
 Coccyx . 
 Rihi . . 
 Sternum 
 Scapula 
 Clavicle . 
 Arm . . 
 Forearm 
 Hand 
 Thigh . 
 Patella . 
 Leg . . 
 Foot . . 
 
 Hospital. 
 
 Out- 
 patients. 
 
 Total. 
 
 730 
 
 27 
 
 757 
 
 732 
 
 513 
 
 1245 
 
 169 
 
 3 
 
 172 
 
 139 
 
 3 
 
 142 
 
 5 
 
 10 
 
 15 
 
 4784 
 
 3477 
 
 8261 
 
 45 
 
 7 
 
 52 
 
 135 
 
 290 
 
 425 
 
 382 
 
 7458 
 
 7840 
 
 1064 
 
 3020 
 
 4084 
 
 709 
 
 8731 
 
 9440 ; 
 
 856 
 
 4899 
 
 5755 , 
 
 3072 
 
 171 
 
 3243 
 
 649 
 
 15 
 
 664 
 
 8067 
 
 256 
 
 8323 
 
 965 
 
 555 
 
 1520 
 51,938 1 
 
 22.503 
 
 29.435 
 
 Per cent. 
 
 1.4.57 
 2 397 
 0.331 
 0.273 
 0.028 
 
 15.905 
 0.100 
 0.818 
 
 15.094 
 7.863 
 
 18.175 
 
 11.080 
 6.243 
 1.278 
 
 16.024 
 2.926 
 
 Number by Regions. 
 
 ) Head, 
 I t' 2,002. 
 
 Il 
 
 t I Trunk, 
 I 1^,067. 
 I 
 
 J 
 1 
 
 I Upper extremity, 
 
 27,119. 
 
 Per cent. 
 
 3.854 
 
 17.457 
 
 52.214 
 
 1 Lower extremity, ) i oft 179 
 r 13,750. ' j I ^^-"^^^ 
 
 Varieties. — The varieties of fracture are numerous, the differences depend- 
 ing upon the extent, direction, and seat of the fracture, the number of bones 
 involved, the associated injury of the .soft parts, and the character or mode of 
 action of the cau.sative violence. They may be grouped as follows : 
 1. Incomplete fractures. 
 (a) Fis.su re. 
 
 (6) True incomplete fracture, "green-stick" fracture. 
 {<;) Depressions. 
 (cl) Separation of a splinter or of an apophysis. 
 
FRACTURES. 
 
 283 
 
 Fig 
 
 2. Complete fractures, subdivided, accordiiij^ to — 
 
 {(i) Direction of the line of fracture, into transverse, oblique, longi- 
 tudinal, toothed, V-slia))ed, T-shaped ; 
 
 (/)) Seat of the fracture, into fracture of the shaft, neck, condyle, etc., 
 separation of the epiphysis ; 
 
 ((*) Ixelatiiinti to nci(/hhori)ig joints, into intra-articular, extra-capsu- 
 lar, intra-capsular ; 
 
 ((/) 3Iode of production, into fractures by direct violence, by indirect 
 violence, by muscular action ; 
 
 {e) Number of fractures or of bones fractured, or the extent and 
 character of the crushing, into multiple, comminuted, impacted, 
 and fractures with crushing. 
 
 3. Compound fractures, including, as a special class. 
 
 Gunshot fractures. 
 
 1. Incomplete Fractures. — This class includes fractures of long bones 
 in which the continuity of the bone has not been entirely lost, and fractures of 
 the flat bones in which the line of fracture does not extend completely across 
 the bone or through its entire thickness. 
 
 Fissure, or fissured fi'acture, is a split or crack of limited extent; the most 
 frequent examples are in the bones of the cranium and in connection with 
 complete fractures of other bones. 
 
 True incomplete, or ^^ gree7i-stick," fracture is one involving part of the 
 thickness of a long bone, and accompanied by some longitudinal splitting and 
 by a permanent bending of the unbroken portion. Possibly 
 in some cases there is only permanent bending without visible 
 fracture. It occurs in the young, and especially in the clavicle 
 and forearm (Fig. 66). In correcting the deformity, which is 
 best done by bending the bone in the opposite direction, the 
 fracture is frequently made complete. 
 
 Depression is the crushing of a portion of the thickness of 
 a bone; it perhaps belongs more properly among "wounds of 
 bone" than among fractures. The class also includes certain 
 rare "fractures by depression," in w^iich by the forcible bend- 
 ing of a flat bone a frag-ment is broken from the side toward 
 which the bone is bent, as in isolated fracture of the inner 
 table of the skull : it does not include " depressed fractures 
 of the skull," in which the entire thickness of the bone is 
 broken. 
 
 Separation of a Spli7iter or of an Apophysis. — Direct 
 violence, as by a bullet or a sword, may break off" a piece 
 without completely fracturing the bone, or the violent con- 
 traction of a muscle or a strain exerted through a ligament 
 may tear off a scale of bone or an apophysis to which the 
 tendon or ligament is attached. 
 
 2. Complete Fractures. — {a) Subdivided according to the Direction of 
 the Line of Fracture. — The fracture is termed transverse (Fig. 67) if its line 
 is exactly or nearly transverse to the long axis of the bone and regular ; 
 longitudinal (Fig. 68) if it runs for a considerable distance more or less 
 exactly parallel to the long axis ; oblique (Fig. 69) if its direction is inter- 
 mediate between the two preceding. The division is of course somewhat 
 arbitrary. The fracture is termed toothed or dentate (Fig. 70) if its line is 
 broken by sharp points and depressions, which may constitute a serious 
 obstacle to complete reduction. V-shaped fracture of the tibia (Fig. 71) is 
 
 Partial or Green- 
 stick Fracture 
 of the Radius 
 (Stimson). 
 
284 
 
 AN AMERICAN TEXT- HOOK OF SURGERY. 
 
 Fig. 07. 
 
 fig. 
 
 characterized by a prominent triangular j)rojc'ction at the lower v\n\ of tlie 
 
 U])j)er fragment on its inner aspect; its 
 L'S]»i'cial importance, otliei' than the (occa- 
 sional (litliculty of reduction, is due to 
 a fissure \vhich may extend from the 
 corresponding re-entrant angle on the 
 lower fragment down to the ankle-joint. 
 T-xhaped fractures are found at the 
 lower end of the humerus and femur, 
 and are sometimes termed mtercondy- 
 loid (Fig. 72): there is a transverse line 
 of fracture above the condyles, and a 
 longitudinal one running from the trans- 
 verse line downward between the con- 
 dyles. 
 
 (^b) Subdivided accordinfi to the Seat 
 of the Fracture. — The fracture receives 
 a name indicative of the portion of the 
 bone involved in it : thus, fracture of 
 the shaft, of the neck, of a condyle, or 
 of a specific process, as the malleo- 
 lus, greater tuberosity of the humerus, 
 olecranon. The term separation of an 
 eptpki/sis also indicates that the frac- 
 ture lies wholly or mainly at the carti- 
 laginous junction between the epiphysis 
 and the shaft ; this variety is found, 
 of course, only in persons whose growth is not yet complete ; that is, as a 
 rule, only in those who have not yet reached the age of twenty-four or 
 
 Transverse Frac- 
 ture of the Fe- 
 mur (Gurlt). 
 
 Longitudimil Fracture of 
 the Tibia (Stimson). 
 
 Fig. 69. 
 
 Oblique Fracture of the Clavicle (Stimson). 
 
 twenty-five years ; the date of consolidation of the epiphysis with the shaft 
 varying with the sex, the individual, and the different bones. Separation of 
 the epiphysis is more easily effected than a fracture of the same bone by cross- 
 strain : the periosteum is usually stripped up from the shaft for a considerable 
 distance, varying with the displacement, and remains attached to the ej)iphysis. 
 The injury is of especial importance because of frequent difficulty of reduction, 
 and because the irritation of the traumatism may lead to premature ossification 
 of the cartilage, with consequent local arrest of growth. This consideration is 
 of most importance at the knee, the upper end of the humerus, aufl the lower 
 end of the radius and of the ulna, where the princijoal growth in length of 
 the respective bones occurs. 
 
 (c) Subdivided aecordinjj to the Ilelations to Neighboring Joints. — The 
 term intra-articular indicates that the line of fracture extends into a joint — a 
 complication that is important because of the possible inflammation of the joint 
 
FRA CTURES. 
 
 285 
 
 an.l of possible change in the relations of the fragment, either of whbh may 
 permanently restrict the mobility of the joint. Intracapsular and extra- 
 
 FiG. 71. 
 
 Intercondyloid Fractun- of the 
 Humerus (Stimson). 
 
 Fig. 73. 
 
 Toothed Fracture of the 
 Femur (Stimson). 
 
 V-shaped Frac- 
 ture (Stimson). 
 
 Comminuted Gunshot Fracture of the 
 Head of the Humerus, with Impacted 
 Ball (Army Med. Mus.). 
 
 capsular are terms used almost solely in ^^onnection with fractures of the ned^^ 
 of the femur to indicate the position of the line of fracture within oi .Mthout 
 the attachment of the capsule to the femur. . 
 
 (d) Subdivided according to the Mode of Products on. -l<r.ctnves by d^;ect 
 
 violence are those in which the fracture takes place at the point where the blow 
 
 Lr ceTved ; fractures by indirect violence are those in which it takes p ace at a 
 
 distance from that point; fractures by muscular action ^ve those m which the 
 
 fracture is produced by the action of the patient s muscles. ^ , ^ 
 
 % Subdivided according to the Number of Fractures or of Bones Fractured 
 
 or to the Extent and Character of the Crushing .-'^\^e term muliiple "^^hcates t^ o 
 
 or more separate fractures of a bone, or the fracture of two or more bones other 
 
 than the tibia and fibula or the radius and ulna of the same limb. A -...uj .cZ 
 
 fracture (Figs. 73 to 76) is one accompanied by considerable splintenng of the 
 
 boTe which is broken into several small fragments. K^mmcted fracture 
 
 is one in which one main fragment is driven into and firmly fixed in the 
 
 other "hi^h is commonly the expanded spongy end of the bone: the spongy 
 
 porticJn into which the other fragment is driven is ^^cessardy more or le s 
 
 cru hed thereby, and if the crushing and splintering are such that the entei- 
 
*286 
 
 Ay A.u/:/i'/(A\ Ti: XT- HOOK OF sii:(;i:i!Y. 
 
 ing piece is not firmly impacted, the fracture is said to be one ivith cruxhing. 
 Both conditions are more common in advanced life, and, as the crushing 
 amounts to an actual loss of substance, some deformity must persist. 
 
 Vu:. 74. 
 
 Fm. :.■). 
 
 Comminuted Perforating Gun- Comiiiinuled Fracture of the Comminuted Fracture of the Neck 
 
 shot Fracture of the Head Lower End of the Radius, of the Femur (Stimson). 
 
 of the Huincrns lArmy Med. palmar aspect (Stimson). 
 Mus.K 
 
 3. Compound Fractures. — A compound fracture is one which com- 
 municates with the exterior tlirough a wound of the overlying soft parts. 
 The latter wound may be directly caused by the same violence that pro- 
 duces the fracture, as in the passage of a wheel of a wagon across the 
 leg, or it may be made from within outward by the forcible projection 
 of the end of one of the fragments through the skin ; or a simple frac- 
 ture may become compound through sloughing of the soft parts occa- 
 sioned either by bruising inflicted at the time of the accident, or by 
 the pre.'jsure of a di.^jjlaced fragment, or tlirough careless handling, or by the 
 movements of the patient while delirious. The injury is much more serious 
 than a simple fracture, because of the possibility of infection of the wound, with its 
 train of consequences — suppuration, necrosis, failure of union, septicemia, and 
 loss of limb or life. Excluding the hand and foot, compound fractures, accord- 
 ing to Gurlt, are most frequent in the leg, being 17.96 per cent, of all com- 
 pound fractures; those of the forearm form 11.68 per cent.; those of the 
 femur, 7.0.5 per cent. : those of the humerus, Cy.QQ per cent. The prognosis is 
 serious in compound fractures by direct violence, because the soft parts are usu- 
 ally so bruised and lacerated that primary union cannot be obtained ; whereas 
 in fractures by indirect violence in which the wound of the skin is made by the 
 end of a fragment the prognosis is much better, for the wound is generally small 
 and clean, and if properly treated will usually unite promptly, and the fracture 
 will thus be transformed into a sinii>le one. Tlie diagnosis of the compound 
 character of a fracture, when in any doubt, may be made in case of necessity 
 bv careful exploration of the wound with the purified finger, but usually, and 
 especiallv whenever the wound is small and bruising or laceration is abi>ent or 
 slight, it is better to abstain from completing the diagnosis by any measures 
 that niav increase the chance of infection, and to direct all efforts to obtaining 
 the prompt disinfection and closure of the wound. 
 
FRA CTURES. 
 
 287 
 
 Gunshot fractures(Figs. 73, 74, 77) constitute an especially seven- form of 
 ooiiij)()iiii(l tVactiiros Itocause of" the usually extensive comniinution and lissui-in<^ 
 of" the bone, the bruising of" the soft parts along the track of the bullet, and the 
 greater frequency of associated injury of important blood-ves- 
 sels and nerves. A small bullet may make a clean perforation Fio. 77. 
 with but little splintering ; a large one literally smashes the l)one 
 at the point of contact and produces fissures that may exteml 
 to a great distance ; the bullet may pass completely througli 
 the bone or may lodge in it. In fractures produced by a 
 charge of shot the associated laceration of the soft parts is 
 usually the dominant feature of the case. Amputation and 
 excision have been the rule in the past, and discussion has 
 turned mainly on the respective merits of primary and second- 
 ary operations. Antise})tic surgery has not yet been put to a 
 sufficient test in Avar to determine fully the extent to which it 
 will modify previous rules of treatment, but it will undoubted- 
 ly avail to save a much larger proportion of limbs and lives. 
 In civil practice it has been clearly shown that suppuration 
 and infection can be prevented in a large proportion of bullet 
 wounds, and that the removal of the bullet is not a necessary 
 preliminary to successful treatment. The guiding principle is 
 to abstain as far as possible from exploration of the wound 
 with probe or fingei% to disinfect it thoroughly by antiseptic 
 washing, and to seek its prompt healing under a single dress- 
 ing combined with measures to immobilize the fracture : this 
 failing, counter-openings, drainage, and irrigation to meet the 
 needs created by suppuration. 
 
 Displacements. — The following six classes comprise the 
 common changes in the relations of the principal fragments, — 
 the name indicating, in all but the fifth, the direction in which 
 the change has taken place : 1, transverse displacement ; 2, 
 angular ; 3, rotary ; 4, overriding ; 5, impaction or crushing ; Gunshot Fracture of 
 6, direct longitudinal separation. Commonly two or more are Med. muso"^ ^^^ 
 associated in any given case. 
 
 Transverse or lateral displacement may take place in any direction at right 
 angles to the long axis of the bone, and may be complete or partial. In angular 
 displacement one fragment deviates obliquely from the line that represents the 
 normal relation of its long axis to that of the other fragment. In rotary displace- 
 ment one fragment has been separately turned about its long axis. In overriding, 
 the upper and lower ends of the bone are brought nearer to each other by the 
 passage of the broken surfaces past each other : it is common in oblique frac- 
 tures, and is necessarily associated Avith some transverse displacement, and usu- 
 ally with angular displacement. In impaction or crushing the bone is 
 shortened by the forcing of one fragment into the other, or in spongy bones 
 an angular displacement is effected by the crushing of the bone at the angle 
 on the side toward which it is bent. Direct longitudinal separation is most 
 commonly seen after fracture of the patella and olecranon, and is then due 
 to the contraction of the attached muscle; but it may be produced after frac- 
 ture of the humerus by the unsupported weight of the lower part of the arm 
 and the forearm. 
 
 Displacement may be caused at the time of the accident by the force 
 which produces the fracture, or subsequently by the action of gravity or of 
 the attached muscles upon the fragments. The tonicity of the muscles and 
 
288 AN AMERK'AX TEXT-llOOK OF SURGERY. 
 
 their contraction when excited by pain habitually tend to produce angular 
 displacement, and overriding when the character of the displacement per- 
 mits it. (See Figs. 07 and 09.) 
 
 Etiolocjy. — 1. Predisposing Causes. — These are of two kinds, normal 
 and pathological. Nonual predisposing causes are found in the shape, struc- 
 ture, and functions of the different bones, with such modifications as are pro- 
 duced by advancing years. A long bone is exposed by its very length, as well 
 as by the uses which that length subserves, to fracture by indirect violence, by 
 cross-strain, or by torsion ; length is to that extent a predisposing cause. A 
 short bone or the spongy end of a long one is fitted by its texture and its 
 breadth to receive and transmit violence w^ith the minimum of damage to the 
 bone with which it is in contact, but the same texture and breadth expose it to 
 easy crushing and splintering when the violence is unusually great or is abnor- 
 mally directed. To that extent its spongy texture is a predisposing cause. 
 The normal curves found in so many long bones, and the transformation of 
 the segments of a limb into the equivalent of a single sharply-bent bone by 
 the rigidity of the strongly-contracted muscles, tend to diminish the risk of 
 dangerous violence to the trunk and viscera in a fall, but in thus protecting 
 vital organs they become themselves more exposed to fracture. 
 
 As age advances the bones become more fracrile by rarefaction of their 
 spongy and compact tissue: the change is an actual diminution of the amount 
 of bone-tissue in the bone, not an alteration in the proportions of the diff'erent 
 elements that compose that tissue ; there appears to be no increase in the amount 
 of the earthy matter, either actually or relatively. As an habitual incident 
 of advanced age this senile atrophy may be deemed a normal predisposing 
 cause, but when it appears prematurely or in an excessive degree it is patho- 
 logical. Such premature and excessive fragility, dependent upon causes that 
 are not always understood, may be inherited or acquired. Cases have been 
 reported in which successive generations have shoAvn remarkable liability 
 to fracture from infancy ; in one instance a child received fourteen fractures 
 before he was thirteen years old. In other cases some or all of the childi-en 
 of a family have shown it, the parents being free from it ; thus, a girl suf- 
 fered thirty-one fractures between tlie ages of three and fourteen years, and 
 her sister nine between the ages of eight months and six years, while two 
 brothers and a third sister showed no such predisposition. The cases are 
 much more numerous in which a similar liability to fracture has developed later 
 in life, the bones breaking under the slightest violence or muscular effort. 
 Such fractures commonly unite within the usual time. Post-mortem examina- 
 tion has shown great thinning and rarefaction of the bone. Fragility may be 
 developed by disuse, as in limbs that have remained dislocated, and in conjunc- 
 tion with certain diseases of the nerve-centers. Ilhachitis is a predisposing 
 cause in childhood, through the incomplete development of the bone-tissue 
 to which it leads, the bone remaining spongy instead of developing a firm, com- 
 pact, cylindrical formation. Syphilis, cancer and other tumors, and caries may 
 predispose to fracture by destroying a portion of the bone. Kheumatism has 
 been alleged to be a predisposing cause, because some patients have suff"ered 
 aching pain in certain bones for some time before they have broken under slight 
 violence or, more commonly, by muscular action. The widespread disposition to 
 call such pains " rheumatic " accounts for the supposed connection. Fracture 
 of the patella is not infrequently preceded by such pain, which seems possibly 
 to be evidence of previous slight injury or partial fracture. 
 
 2. Immediate or Determining Causes of Fracture. — The immediate 
 cause of a fracture mav be violence received at some point upon the surfi;ice of the 
 
FliACTURES. 289 
 
 body, or exerted upon the bone that is broken by the muscles that are attached 
 directly or indirectly to it. The former are termed fractures hy extertial vio- 
 lence, the \'A.iXov fractures hy muscular action. The latter class does not include 
 cases in whieli, -while tlic causative force ori<rinates in the contraction of the 
 patient's nmsclos, an additional and essential factor is created by external resist- 
 ance, as in the breaking of the leg by a sudden turn or forward movement of 
 the body Avhile the foot is held fast, or of the arm by striking it against some 
 object. 
 
 Fractures by external violence are divided into two classes which have 
 important clinical diffcrwiccs — those by direct and those by indirect violence. 
 Fractures by direct violence are those in which the bone is broken at a point 
 corresponding to that upon the surface where the blow is received ; fractures by 
 indirect violence are those in which the bone is broken at a distance from the 
 point where the blow is received. An important clinical difference is that in 
 the former the overlying soft parts are contused, and often to such an extent 
 that the fracture is or soon becomes compound, and primary union of the 
 wound is difficult or impossible; in fractures by indirect violence the injury to 
 the soft parts is habitually less, and if the fracture is compound the edges of the 
 wound in the skin are not so contused that primary union is difficult to obtain. 
 
 Fractures by muscular action are most common at the patella, the 
 bone being broken by the powerful contraction of the quadriceps ; in other 
 cases the muscles produce the fracture by exaggerating the normal curve of the 
 bone, as the humerus or femur in spasmodic or voluntary contraction, or the 
 ribs in coughing, or the sternum in straining during labor ; or by tearing off 
 an apophysis to which the muscle is attached, as the coracoid process or the pos- 
 terior end of the calcaneum ; and in others by creating in portions of the body 
 conditions of momentum which act in the same manner as external violence, as 
 in fracture of the humerus by throwing a stone, of the femur by kicking at, 
 but not striking, an object, of the neck in throwing the head back. 
 
 Symptoms and Diagnosis. — Before proceeding to the examination of the 
 injured region inquiry should be made into the circumstances connected with 
 the injury, and the question should always be asked if the part has been pre- 
 viously injured, in order that an old deformity may not be mistaken for a 
 recent one. 
 
 1. Objective Symptoms. — Deformity.— Under this term are included 
 changes in the appearance of the injured region, in the dimensions of the 
 limb, and in the relations of different bones or parts of bones to one another. 
 Swelling occurs promptly, and is often associated with heat and redness. 
 Ecchymoses appear rather tardily in fractures by indirect violence, and usually at 
 some distance from the seat of fracture. Large blebs, containing a liquid that 
 is at first yellow and later bloody, sometimes appear during the first or second 
 day, especially in fractures- of the leg and forearm. Most of the various displace- 
 ments that have been above described may be readily recognized by the eye 
 or finger when the bone is not thickly covered by soft parts ; angular displace- 
 ment is often shoAvn by a change in the direction of the segments of the limb ; 
 and overriding or impaction is demonstrated by measurement of the length of 
 the bone or of the limb. When the two ends of a bone can be readily recog- 
 nized, as those of the forearm or leg, its length can be directly measured, but 
 in fractures of the femur or the humerus it is necessary to measure from points 
 on other bones, the ilium and the acromion respectively ; and then it is essential 
 to accuracy that the injured limb and its fellow Avith which the comparison is 
 made should be symmetricall}'' placed with reference to the bone on which one 
 of the fixed points is taken. Two other possible sources of error in measuring 
 
 19 
 
290 AN AMERICAN TEXT-BOOK OF .sriiGEIi'V. 
 
 should always be borne in mind : one is previous injury or disease that may 
 have affected the lent^th of either limb ; the other is the normal inequality in 
 the len^'tli of the limbs which exists in many people; this rarely amounts to 
 more than a ([uarter of an inch, although it may reach an inch or more, and 
 its existence is usually unknown to the individual until revealed by meaisure- 
 ment. 
 
 By abnormal mobility after fracture is meant the independent mobility 
 of the fragments of a fractured bone which is normally one unbroken structure, 
 or the mobility of a joint in an abnormal direction or to an abnormal extent 
 in consequence of the fracture of a portion of the end of one of the bones that 
 constitute it. It is usually present and recognizable with great ease when the 
 fracture occupies the shaft of a long bone, but it may be absent or unrecog- 
 nizable when the fracture is close to the end of the bone. It is habitually 
 accompanied bv a sensation of grating which may be heard or felt, and which is 
 technically known as crepitus. This is produced by the rubbing of the broken 
 surfaces upon each other. Abnormal mobility and crepitus are pathognomonic 
 of fracture, but it must be remembered that in not a few fractures either or both 
 are absent or unrecognizable, and that failure to obtain them is not a proof 
 of the non-existence of a fracture. Furthermore, the manipulations necessary 
 to recognize them are, in some cases, actually harmful, and the diagnosis must 
 be made on other symptoms. 
 
 2. Subjective Symptoms. — These are chiefly diminution or loss of func- 
 tion, and pain. The history of the case is also of much value. The extent of 
 the interference with function depends upon the importance of the broken 
 bone to that function, the relations of the fragments to each other, and pain 
 or fear of pain. After fracture of the thigh or leg the patient is, as a rule, 
 entirely unable to walk or to lift the limb from the bed when he is recumbent, 
 but, on the one hand, the disability may be much less, and, on the other, equal 
 disability may be caused by a simple contusion. Pain, either spontaneous or 
 aroused by pressure or movement, is a constant accompaniment of fracture, and 
 when limited to a small area and invariably aroused by pressure with the end 
 of the finger or by slight movements communicated to the limb, is a valuable 
 sign of fracture — one upon Avhich a diagnosis of fracture in certain regions can 
 be safely made when the history of the accident indicates that such a fracture 
 may have been produced. 
 
 "^ The examination should be made quietly and systematically; movements 
 communicated to the bone in the search for abnormal mobility and crepitus 
 should be slight and gentle, and if the muscles are spasmodically contracted, 
 or the patient timid, or the injury obscure and of doubtful character in the 
 neighborhood of a joint, an anesthetic should be employed. 
 
 Repair of Fracture. — In simple fractures there is at first some rise of 
 temperature, the limb swells promptly, blebs sometimes appear on the surface, 
 ecchymoses and yellow discoloration of the skin extend to a considerable dis- 
 tance : then the swelling subsides, and a firm ovoid mass, which is tender on 
 pressure, can be felt about the seat of fracture. This gradually grows smaller 
 and harder and the abnormal mobility diminishes. After a lapse of time, the 
 length of which varies with many conditions, abnormal mobility entirely disap- 
 pears and the fracture is said to'be united. The length of time requisite for 
 such union is greatest, as a rule, when the fracture is of the shaft of the femur 
 in an adult, in which case it is usually from six to eight Avecks ; it is least at 
 the spongy ends of the bones, less in children than in adults, and greater when 
 there is much permanent displacement. After final healing the limb slowly 
 regains its usefulness, the muscles fill out, and the skin becomes soft, but for 
 
FRACTURES. 291 
 
 many weeks the limb may show a tendency to venous conf^estion and oedema 
 and the movements of its joints be restricted. In compound fractures that do 
 not promptly become simple, if left to itself the wound suppurates, the pus bur- 
 rows, neighboring abscesses form, union of the fracture is delayed, and even 
 after it has taken place the wound may be kept open for weeks or months by 
 8upj)uration about a loose or attached necrotic fragment. 
 
 The lesions of a fracture comprise the breaking of the bone into two or 
 more fragments, the tearing of the periosteum, and the laceration of the soft 
 parts. A portion of the periosteum habitually remains untom, although 
 stripped up for a greater or less distance from one or both fragments, and con- 
 stitutes a remaining bond, a "periosteal bridge," between the fragments. This 
 plays an important part in the repair of the fracture. The periosteum thickens, 
 and on its under surface ajjpears a layer, at first soft, then cartilaginous, which 
 extends along the periosteal bridge from one fragment to the other, as well as 
 under the periosteum that remains adherent ; the portion belonging to the 
 periosteal bridge thickens and spreads between the fragments, and ultimately 
 becomes bony and continuous with the granulations coming from the bone 
 itself. This is the only portion of the callus which passes through a carti- 
 laginous stage. The bone becomes rarefied by enlargement of its Haversian 
 canals, and at its broken edge and on the adjoining surface of the medullary 
 canal granulations appear which increase until they meet those coming from 
 the periosteal bridge and from the other fragments, and fill the space between 
 them, and also usually the medullary canal at the seat of fracture. 
 
 These granulations become fibrous and finally bony, and thus is formed the 
 callus, Avhich, when complete, fills the gap between the fragments, occupies 
 the medullary canal for some distance, and forms a layer on the outside of the 
 bone for a greater or less distance above and below the fracture. As time 
 passes this callus becomes smaller, and the portion that forms the medullary 
 plug may entirely disappear, and thus the continuity of this canal may be 
 restored. If there is much permanent displacement, or if the fragments are 
 not effectually immobilized during repair, the callus will be larger than under 
 other circumstances, and tendons and fibrous tissue attached to the bone near 
 the fracture may be included in the area of irritation and become ossified. 
 Such ossification at a distance may be destructive to the functions of the limb, 
 as when a fracture is in the neighborhood of a joint, or in the case of the 
 radius and ulna, which may become united to each other with consequent loss 
 of rotation of the forearm. Sometimes a neighboring joint becomes entirely 
 obliterated by bony union of its opposing articular surfaces. 
 
 Fragments that are entirelv detached, even from the periosteum, mav regain 
 their vital connection with the body, apparently by the growth of new vessels 
 into their Haversian canals, and again form an integral part of the bone. 
 Others may remain imbedded in the callus, but without vascular connection, 
 and be tolerated for years : under the influence of various causes they may 
 ultimately lead to suppuration. 
 
 Occasionally the evolution of the callus is arrested at the fibrous stage, and 
 union is then said to have failed or to be fibrous. Fibrous union may be so 
 close and firm or so well supplemented by the interlocking of the different 
 parts of the callus that have ossified that the limb is \er\ useful. The common 
 causes of fibrous union are separation of the fragments and insufficient 
 immobilization. 
 
 Complications and Late Consequences. — With the healing of the 
 fracture the limb is not immediately restored to a normal condition ; it is 
 
292 AN AMERICAN TEXT-DOOK OF SrUGERY. 
 
 shrunken, the skin is dry and rough, the limb swells on use, and its joints are 
 more or less stiff. 
 
 Most of these abnormal conditions gradually disappear, but in the aged 
 the limb may long remain sensitive to free use and to changes in the weather, 
 and the stiffness of the joints may persist. The latter is due in 
 great part to the inflammatory conditions that have existed in and about the 
 joint as a direct consequence of the fracture, or to the implication of neigh- 
 boring tendons ; but in the joints of the fingers it may be due to the immobili- 
 zation, and is much more likely to arise when the fingers have Ijcen kept 
 extended. It has been clearly shown that prolonged immobilization of the 
 large joints, per se, is not a cause of permanent stiffness, and that passive 
 motion of the joint is not necessary, or even desirable, during treatment of 
 the fracture, to prevent it. If the joint is inflamed, the best means of reducing 
 the inflammation and restricting its results is to keep the joint at rest. Per- 
 sistent swelling of the limb, especially of the leg, is apparently the result of 
 interference with the venous floAv, and may be the cause of or be associated 
 with much trouble and annoyance, especially if the callus is large and adherent 
 to the skin. The nutrition of the limb is interfered with, persistent ulcers 
 form, and eczema torments the patient. 
 
 Persistent paralysis of one or more groups of muscles may appear as a 
 consequence of injury of a nerve-trunk at the time of the accident, or of its 
 later inclusion in the callus ; the latter has been observed only in the musculo- 
 spinal nerve after fracture of the shaft of the humerus. 
 
 Exuberant and Painful Callus — Excessive size of the callus may 
 cause trouble by interference with the circulation, or by stretching the skin, 
 or by pressure on a nerve. The second cause is not uncommon in the leg, and 
 may call for relief by chiselling away the bone. Pressure upon a nerve may 
 occur at any point where a nerve lies in close proximity to the bone, as in the 
 case of the ulnar nerve at the back of the elbow. Persistent pain in the callus 
 may be due to an inflammatory process, as suppuration about a sequestrum, or 
 to a non-inflammatory condition of unknown character which has been termed 
 osteo-neuralgia ; occasionally it has been traced to inclusion of a nerve-filament 
 in cicatricial tissue. 
 
 The other complications to be described are those that arise during the 
 earlier period of the case and put the patient's life in danger. Most of them 
 are extremely rare. 
 
 Embolism, — The thrombus of the small veins that have been torn may 
 extend to the large ones, and a portion may be detached and lodge in the heart 
 or in the pulmonary artery. For the symptoms and course the reader is 
 referred to the section on Thrombus and Embolism (p. 58). Fat embolism 
 (see p. 96) has been recently recognized as an occasional cause of death in 
 the first few days after the receipt of a fracture. Liquid fat set free by the 
 crushing of the marrow passes into the open veins and lodges in the pulmonary 
 capillaries. The symptoms are not constant or characteristic ; there may be 
 sudden dyspnea with subsequent oedema of the lungs, or there may be only 
 prostration without dyspnea, but with cyanosis, quick, feeble pulse, and coarse 
 rdles. In some cases the symptoms resemble those of shock, from which the 
 affection is to be distinguished by its antecedent period of comparative well- 
 being. 
 
 Rupture of a large artery may be caused by stretching or by perfora- 
 tion ; the blood escapes freely until the resistance of the soft parts checks it, 
 and then a traumatic aneurysm forms. The general })ractice is to postpone 
 active treatment of the injury of the artery, if possible, until repair of the 
 
FRACTURES. 293 
 
 fracture has taken place. The l)rnisiii;f of an artery nuiy l>o followed within a 
 few linins l)y tlie formation of an obstruetiiif^ thrombus witliin it. 
 
 Gangrene may be the result of direct bruising of the soft ])arts or of 
 interference with the circulation in the large vessels arising from their injury 
 or compression by a displaced fragment or from the pressure of a bandage. It 
 may be partial or may involve the limb as far up as the seat of the fracture. 
 
 Septicemia and pyemia occur, as a rule, only after compound fracture, 
 and, it" the fracture is treated antiseptically, are very rare. 
 
 Tetanus is a rare complication, and is seen most frequently after com- 
 poun-d fracture. 
 
 Delirium tremens is a frequent complication of fracture in adults addicted 
 to the use of alcohol. It is, as a rule, milder than the delirium tremens that 
 develops without an injury. Warning of its approach is given by agitation 
 and in.somnia, and it can often be aborted or arrested by the vigorous use of 
 sedatives. The outbreak seems generally to be due to the cutting off of the 
 daily ration of alcohol, which is usually the result of the accident and the 
 admission to a hospital; and this indicates the advisability of continuing mode- 
 rate stimulation for the first week or two in patients Avho are habitual drinkers. 
 
 Treatment. — By the reduction or setting of a fracture is meant the res- 
 toration of the displaced fragments to their normal position, or at least to that 
 in which it is desired that reunion shall take place. The manipulations com- 
 monly employed are traction upon the lower fragment to correct overriding or 
 angular displacement, and direct pressure to correct lateral displacement or 
 longitudinal separation. Reduction should be made as completely and as 
 promptly as circumstances will permit, having regard to the condition of the 
 patient and of the limb. If there are severe associated injuries and the shock 
 is great, it is Avell to wait for reaction, and meanwhile to immobilize the parts 
 in partial reduction with simple dressings ; if the limb is greatly swollen it 
 may be impossible to restore it to its full length without causing dangerous 
 pressure. An anesthetic may be required to overcome the opposition of the 
 muscles; and in the case of a fracture near to or involving a joint anesthesia 
 is doubly valuable, both to recognize the details of the fracture and to facili- 
 tate the complete and accurate readjustment of the parts. 
 
 Usually no greater force is required to effect reduction than that which can 
 be exerted by the hands of the surgeon or of an assistant, but in some impacted 
 fractures the fragments are so firmly wedged together or one is so small or inac- 
 cessible that reduction cannot be made. Traction is made by grasping the 
 lower segment of the limb and pulling firmly and steadily upon it ; coaptation 
 is made by the direct pressure of the fingers and thumbs upon the fragments 
 close to the fracture; angular displacement in "green-stick " fracture, and in 
 others where it is not combined with overriding, is corrected without traction 
 by forcibly bending the bone back into line. If there is so much crushing of 
 the spongy end of a bone that the restoration of the fragments to their normal 
 position would leave an important gap between them, the restoration should 
 not be made, but the fragments should be left in contact. 
 
 Permanent dressings have for their main object the prevention of dis- 
 placement of the fragments by the action of the muscles or by external forces, 
 especially gravity. The means by which this object is to be attained vary 
 greatly in the different fractures, but in most cases they consist of some form 
 of lateral support, often combined with permanent traction upon the lower seg- 
 ment of the limb. Dressings applied circularly about a limb expose it to the 
 danger of constriction, and consequent gangrene, if swelling should occur after 
 the dressing has been applied, and therefore, as a general rule, such should not 
 
294 
 
 ,LV A.VEEICAX TKXT-noOk' OF SURGERY. 
 
 Fig. 78. 
 
 be used during the first few days, or if used should be frequently inspected. 
 If applied while the limb is swollen, they are lialde to be made too loose by the 
 subsidence of the swelling and to need renewal or readjustment. As a general 
 rule, a roller bandage should not be applied to the limb under the splints ; it 
 will rarely do good, and may do great harm. Another rule is to include in the 
 dressings the joints at either end of the broken bone. 
 
 The simplest form of lateral support is that furnished by wooden splints : 
 they should be longer than the broken bone, of such breadth and tliickness 
 that they will not yield under the weight of the limb, and siiould be thickh' 
 padded with cotton to fit the contour of the limb or placed over detached cush- 
 ions made for the purpose ; they are made fast, one on each side, with strips 
 of adhesive plaster, straps, or a roller bandage ; they should be so wide that 
 the enveloping bands will not circularly constrict the limb. Projecting bony 
 points should be protected by thick padding about them, not on them. Carved 
 wooden splints made to fit average limbs rarely have advantages 
 commensurate with their cost. Gooch's flexi])le Avooden splints 
 (Fig. 78) made of thin strips of wood fastened close together on a 
 muslin backing are convenient in some cases. They can be easily 
 made by fastening the strips upon a sheet of adhesive plaster. 
 
 Fracture-boxes are essentially a combination of lateral and pos- 
 terior splints, and are used only for fractures of the leg. They 
 consist of a long rectangular piece of Avood with two hinged sides 
 and a movable foot-piece. The central posterior piece is first well 
 covered with cotton, oakum, or bran ; the limb is laid upon it and 
 the foot bound to the foot-piece ; then the sides are turned up, Avith 
 interposed padding, and bound to each other across the front of the 
 leg by cords or bands running through holes made for the purpose. 
 To avoid troublesome pressure upon the heel the foot may be sus- 
 pended by a long and not too narrow strip of adhesive plaster run- 
 ning from the middle of the calf along the back of the leg to the 
 Gooch's heel, and up past the sole of the foot to the top of the foot-piece. 
 
 Flexible . ^ . ^ . 
 
 Wooden After application of a fracture-box or any equivalent apparatus 
 
 (Stimson). suspension from a horizontal bar held up by tAvo vertical side-pieces 
 
 is often of great advantage. 
 
 Volkmann s splint is a convenient substitute for a fracture-box, and very 
 
 useful as a temporary dressing for fractures of the leg. It is a shalloAv gutter 
 
 of tin with a foot-piece and a movable support by AA'hich the loAver end is held 
 
 at a convenient height above the bed. 
 
 Wire gauze is a convenient dressing for fractures, since it is flexible enough 
 to adapt itself to the varying dimensions of the limb under the pressure of a 
 roller bandage, and ca.n be bent to fit the elboAV or ankle by cutting it partly 
 through on the sides. 
 
 Moulded splints can be made of any material that can be temporarily soft- 
 ened so as to be fitted to the limb and Avill then harden and retain the shape 
 that has been given to it. For the lighter splints plaster of Paris, pasteboar(l. 
 leather, felt, and gutta-percha are used ; for the heavier ones plaster of Paris is 
 the most convenient. To make a, plaster-of-Paris splint (Fig. 79) the surgeon 
 cuts strips of gauze, coarse muslin, or thin blanketing of the desired length 
 and width, and soaks them Avith freshly-prepared plaster of the consistency of 
 thick cream ; he then squeezes out the superfluous Avater, covers the limb tliickly 
 with vaseline, applies the splint, and secures and at the same time moulds it to 
 the limb Avith a roller bandage ; after it has hardened he removes the roller and 
 secures the splint by circular turns at two or three points. If sharp angles are 
 
FBA CTURES. 
 
 295 
 
 made, as at the elbow or ankle, the fit can be improved by notching the splint 
 while it is still soft and slipping one edge of the cut under the other. Such 
 
 Fig. 79. 
 
 Fig. 80. 
 
 Posterior Plasterof-Faris Splint or Gutter 
 (Stimson). 
 
 Plaster-of-Paris Dressing, made of coarse saclicloth 
 (Esmarch). 
 
 splints are very useful in the treatment of fractures of the leg, but are not 
 strong enough for those of the femur; they may be applied Avhile the injury is 
 still recent, and permit inspection without having to be removed. 
 
 The plaster-of -Paris bandage for complete encasement of the limb is most 
 conveniently made by using gauze rollers that have been prepared by thorough 
 filling with dry plaster. The limb is enveloped in cotton or other soft material, 
 and then the prepared roller bandages, after having been thoroughly wet, are 
 applied in the usual manner. Or strips of some coarse material soaked m pias- 
 ter cream may be applied, as shown in Fig. 80. They can be fenestrated at 
 any point by 'cutting out a piece after the plaster has hardened, or may be 
 "interrupted," the two segments being attached to each other by iron bands 
 n set into the dressing.' Similar dressings can be made with sili- 
 
 cate of soda, dextrin, starch, or glue. 
 
 In order that such a dressing shall prevent shortening of the limb within 
 it, it is essential that it should have a bearing against bony prominences or a 
 flexed secrment of the limb above and below the fracture : such points ot counter- 
 pressure "are easily found in the leg and forearm, but with difficulty m fractures 
 of the arm and thigh. i r ^■ a 
 
 If any splint, or still more any circular encasement, has been applied 
 shortly after the receipt of the injury, it should be inspected at intervals of 
 a few hours for the first day or two, with the view of loosening it at once it 
 it should prove to have been too tightly applied or if it should 'have beconie 
 too tight in conse(iuence of the subsequent inflammatory swelling of the limb. 
 The patient and his friends should be warned of the possibility of strangula- 
 
296 
 
 AN AMERICAN TEXT- HOOK OF SURGERY. 
 
 tion of the limb, and instructed to watch the color and temperature of its 
 distal portion, which, for this reason, should always be left uncovered by the 
 dressing. It is almost always advisable to use during the first few days splints 
 that can be easily loosened or which will permit swelling to take place without 
 causing dangerous constriction ; and then after the swelling has notably 
 diminished to readjust the splints or apply a permanent immovable dressing. 
 
 Ambulant Treatment. — In fijicture of the leg a i)lasterspliiit can be made 
 so that the patient can walk about on it after the first week. Alaverof cotton two 
 inches thick is bound under the sole by a few turns of the bandage, and then a 
 plaster sole, made of eight or ten layers of gauze, added and firmly included in the 
 dressing. The foot is to be in moderate flexion, so that the patient is made to walk 
 ujion his heel. Theleg portion ofthes))lint should be applied directly to the skin, 
 or with only a thin layer of cotton interposed, and should be snugly moulded 
 to fit the expanded upper portion of the tibia and fibula. If the fracture is 
 above the lower third, the dressing should be carried up above the knee. 
 Patients with fracture of the thigh can also be enabled to walk about by 
 supplying them with a plaster dressing and adding an apparatus like the 
 splints used in cases of hip disease. The advantages claimed for this " ambu- 
 latory method " are the avoidance of the risks of confinement to bed, less 
 atrophy of the muscles and stiffness of joints, and shorter convalescence. 
 
 The methods for applying continuous traction to the lower segment 
 of the broken limb include the double inclined plane, suspension, Buck's exten- 
 sion, and india-rubber bands in combination with side-splints. 
 
 The double inclined plane (Fig. 81) is sometimes used in fractures of the 
 
 Fig. 81 
 
 Jismarch"s Double Inclined Plane (^Esmarch and Kowalzig). 
 
 thigh ; it is made of a short thigh- and a long leg-piece hinged together at tne 
 knee, and hinged at the upper end of the thigh-piece to a long underlying third 
 piece, as shown in the figure. Traction is made by the weight of the pelvis as 
 it sinks in the bed. 
 
 In Buck's extension, a very popular method of treating fractures of the 
 femur, the traction is effected by a weight attached to the leg by a cord which 
 runs over a pulley at the foot of the bed. This attachment is made by adhesive 
 plaster, the introduction of which constituted an immense improvement in the 
 treatment of these fractures. It is applied as follows : A strip of stout adhe- 
 sive plaster, four or five inches wide and long enough to reach from well above 
 the knee loosely around the sole of the foot and back to the same height above 
 
 Fig. 82. 
 
 Adhesive Plaster cut for Buck's Extension (Stimson). 
 
 the knee, is cut as shown in Fig. 82 ; a piece of wood five by three inches and 
 perforated at its center is placed at the middle of the strip, the edges of 
 
FRA CTUBE8. 
 
 297 
 
 A\ bicli are turned down ovtjr it and over each other, as shown in Fig. 83 ; a 
 stout cord is then passed through the hole in the piece of wood and its end 
 
 Fio. 83. 
 
 Adhesive Plaster folded for Buck's Extension (Stimson). 
 
 is tied in a knot. A roller bandage is applied to the foot and the lower third 
 of the leg ; the adhesive plaster is then applied to the sides of the leg and 
 thigh above it, and secured by continuing the bandage upward (Fig. 84). 
 The cord is then carried over a pulley at the foot of the bed and attached to 
 the weight, ten to twenty pounds according to circumstances. The foot of 
 the bed must be raised, to obtain the counter-extension by the weight of 
 the body. Outward rotation is prevented by securing the limb to a long 
 
 Adhesive Plaster applied for Extension (Stimson). 
 
 side-splint having a cross-piece at its lower end that rests on the bed, 
 or, better, by placing the leg on a Volkmann's sliding rest (Fig. 85) which 
 
 Fig. 85. 
 
 Buck's Apparatus with Volkmann's Sliding Rest for Fractures of the Thigh. 
 
 is composed of two side-pieces about two feet long and eight inches apart, on 
 which rest by two cross-pieces a posterior splint and foot-piece, to which the 
 
298 
 
 AN AMERICAN TEXT- HOOK OF srilGKllY. 
 
 foot and leg are attached in the usual manner. Instead of the weight and jiul- 
 li'V an india-rubber cord may be used, ^riu' attachment to tlio limb is made by 
 adhesive plaster. Fig. 8G shows such an a})i)aratus in use for fractures of the 
 
 Double pulley. 
 
 !3KS!?ra^ 
 
 3^ 
 
 3: 
 
 Ind. Rubber Aecumulalor. 
 
 Cripps' Splint. 
 
 thigh. Vertical suspension of the limb by a rubber cord attached to the limb 
 by adhesive plaster is sometimes useful in fractures of the humerus close to 
 the elbow, and is common in the treatment of fractures of the thigh in young 
 children. 
 
 Nathan R. Smith's anterior splint (Fig. 87) acts like the double inclined 
 
 Fig. 87. 
 
 Nathan K. Smith's Autcmu- .■'jilinl. 
 
 plane when the suspension is vertical, and like Buck's extension when it is 
 oblique. 
 
 Hodgens splint (Fig. 88) acts on the princijde of Buck's extension, and 
 has the additional advantages of slight flexion of the knee and of greater facil- 
 ity in moving the patient in bed. It consists of two lateral iron rods con- 
 nected by a straight cross-piece at the lower end and a curved one at the 
 upper end. Lateral strips of adhesive plaster are applied to the limb, as in 
 Buck's extension, and their projecting ends made fast to the foot-piece. Five 
 or six narrow compresses or pieces of bandage are run across from one rod to 
 the other beneath the limb, and so adjusted as to give uniform support to it 
 Avhen the apparatus is raised from the bed. The point of attachment of the 
 supporting cord should be at least four feet above the bed, and the cord should 
 be inclined about ten degrees from the vertical (toward the foot of the bed, 
 of course). The greater the inclination the greater the traction. 
 
 Treatment of Compound Fractures. — Oneof the chief advances made 
 possible by antiseptic surgery is in the results now achieved in the treatment 
 of compound fractures. Formerly they were excessively dangerous accidents 
 from septic infection ; now this danger has been almost entirely eliminated. 
 But all depends on the proper and thoroughly anti.septic character of the first 
 dressing. 
 
 This dressing of a compound fracture is often ecjuivalent to a major 
 
FBA CTURES. 
 
 29i> 
 
 surgical operation, re([uiring the aid of anesthesia, the use of instruments, and the 
 protection of antiseptic measures. After anesthetization, the surface of the limb 
 
 Fig. 
 
 Hodgen's Splint (original). 
 
 all about the wound is thoroughly washed, shaved, and purified. By " purifying " 
 is meant securing the most thorough antiseptic cleansing of the entire interior 
 as well as exterior of the wound in every nook and corner of possible infec- 
 tion. This is a sine qud non. If covered with machinery grease, etc., thorough 
 rubbing with sweet oil or with turpentine and alcohol before scrubbing with 
 soap and water greatly facilitates the proper cleansing. Blood-clots and loose 
 splinters are removed, wounded vessels tied, divided nerves and tendons sutured, 
 the ends of the fragments sparingly trimmed if necessary, contused tissues cut 
 away, counter-openings made for drainage, and the cutaneous wound sutured. 
 A thick antiseptic dressing is applied, and over all is placed such retentive 
 apparatus as is suitable. The main indication is to secure early union of the 
 cutaneous Avound : while this is taking place it is desirable that the fragments 
 should remain properly reduced ; but this is, in a measure, of secondary import- 
 ance, for a final readjustment can usually be made in the second or even the 
 third week. But if the wound in the skin is small and clean, it is advisable 
 to limit interference to its irrigation, to the setting of the fracture as if it were 
 simple, and to the application of an antiseptic dressing, and then after the lapse 
 of a week, when the wound will probably have healed, to remove the dressing 
 and make permanent reduction and retention if it has been impossible to effect 
 this at the primary dressing. 
 
 The use of metallic sutures and similar devices to maintain the fragments 
 in contact with each other is rarely advisable, since sufiicient support can 
 usually be given by an external apparatus, and the presence of the foreign 
 body appears somewhat to retard bony union. 
 
 If siqrpuration follow from prior infection, the limb must be placed in a 
 splint that will permit the removal of the dressings with the minimum of dis- 
 
:i()0 AX AMERICAN TEXT-llOOK OF SURGERY. 
 
 turbance of the fra<i;ments. Somo form of int('rni|)tcMl piaster or suspended 
 splint may be applied, and later indications mot as they arise. 
 
 Concerning the propriety of in-'unarij atiiputation or excision of a joint 
 definite rules cannot be laid down ; each case must be judged according to the 
 extent of the injury, the probable usefulness of the limb if saved, and the 
 ability to protect against suppuration and septic infection. The protection 
 afforded by attention to the modern principles of treatment of wounds is such 
 that in doubtful cases the patient may safely take the l)enefit of the doubt and 
 be given an opportunity to shoAv whether or not the limb can be saved. 
 
 After-treatment. — After union of a broken bone has been obtained 
 the surgeon's attention may be directed to hastening the complete return of 
 function, the disappearance of congestion and turgescence, the reduction of 
 the stiffness of neighboring joints, and the strengthening of the muscles. 
 The roughness of the skin, turgescence of the limb, and weakness of the 
 muscles can be relieved by massage and electricity, and in the case of the leg 
 comfort Avill often be promoted by snug bandaging during the day. Stiffness 
 of joints at a distance from the fracture will usually disappear under ordinary 
 use, but special attention may be needed at the ankle to obtain dorsal flexion 
 within a right angle. Stiffness of the fingers in the old and rheumatic is 
 very likely to folloAV simple immobilization and to be very persistent. It 
 should be guarded against by leaving the fingers uncovered during treatment 
 of the fracture whenever that is possible, and encouraging the patients to use 
 them ; when it is necessary to immobilize them during treatment, they should 
 be kept flexed, since stiffness is less likely to take place in that than in the 
 extended position. 
 
 When the fracture is in the immediate neighborhood of a joint, nothing 
 should be done in the way of passive or voluntary motion until after union 
 is complete or at least nearly so, and then should be done with great care. 
 The same should be the rule also Avhen the fracture actually involves the 
 joint, as at the elbow. The most that is permissible is the occasional slight 
 change of the angle at which the joint is immobilized. 
 
 As regards passive motion, it is rarely re(iuired or even useful, and as so 
 often employed, under ether or with production of pain, it is actually harm- 
 ful. The stiffness of a joint after fracture involving it or in its immediate 
 neighborhood is due either to mechanical changes in the joint-surfaces or the 
 relations of the bones, which cannot be materially changed by passive motion, 
 or to periarticular thickening the result of the traumatism, which will disap- 
 pear, if its disappearance is possible, under ordinary (juiet use, and will only 
 be increased and prolonged by forcible motion, which means the infliction of 
 further injury. 
 
 PsEUDARTHROSiS AND DELAYED Union.* — When abnormal mobility has 
 not ceased after the usual lapse of time, the condition is described as delayed 
 union ; if tliis condition persists after some additional weeks, it is termed 
 pseudarthrosis, or failure of union, or ununited fracture. Delayed 
 union is not very uncommon, but failure of union is relatively rare; most of the 
 sases occur in middle life, and most frequently in the humerus, tibia, and femur 
 in the order mentioned. In proportion to the number of fractures of the respect- 
 ive bones, delayed union and fiiilure of union occur more frequently after frac- 
 ture of the shaft of the femur than after that of the tibia. Anatomically, two 
 distinct varieties exist : in one the fragments are more or less closely bound 
 together by solid bands of fibrous tissue, sometimes enclosing nodules of bone; 
 
 ' The fibrous union witli ])ersistent mobility wliich is the rule after fracture of the patella 
 and of some apophyses will not be here considered. 
 
FBA CTURES. 30i 
 
 in the otlier similar fibrous bands enclose a central cavity containing a viscid 
 synovia-like licjuid, into which tlie ends of the fragments may project; and 
 these ends may be smooth and eburnated or even covered by hyaline cartilage 
 — a complete new joint. The clinical difference between the two varieties is 
 important, as will appear when their treatment is considered. 
 
 The reason of delay or of failure of union, in the great majority of cases, 
 lies in the arrest of the evolution of the callus before it has entered upon 
 the stage of ossification — /. e. its persistence as fibrous tissue ; in others the 
 separation of the fragments is so great and the gap so broken by interposed 
 muscle that a continuous callus, formed by granulations springing from the 
 bones, has never existed, and the fibrous bond is composed solely of the thick- 
 ened surrounding connective tissue. The ends of the fragments are variously 
 affected in accordance with the extent of the rarefying and productive pro- 
 cesses which follow the injury ; according as one or the other predominates the 
 ends are diminished in size, sometimes to slender conical points, or enlarged by 
 the formation of irregular masses of bone upon them. In a very few cases 
 the rarefying process has gone so far that a large portion, or even the whole, of 
 the shaft has gradually disappeared. This tendency to excessive rarefaction, 
 when present, is a serious obstacle to the success of operations undertaken to 
 secure union, and it has seemed to some writers to be increased by the presence 
 of metallic sutures binding the fragments together. Occasionally the fragments 
 are in close apposition by their broad surfaces, the fibrous bond is short and 
 complete, and the fragments are enlarged by peripheral productions of bone, 
 and yet ossification of the short fibrous bond fails. 
 
 The resultant disability varies with the amount of abnormal mobility and 
 the uses to which the limb is put : thus, failure of union in the leg or thigh 
 may make the limb wholly useless, while in the arm or forearm it may interfere 
 but slightly with its usefulness. 
 
 With respect to the cause, certain general conditions have seemed at times 
 to delay repair, such as syphilis, pregnancy, and acute general diseases, but 
 the common causes are local. Advanced age is not a cause. The local causes 
 are separation of the fragments (by displacement or by loss of substance), the 
 interposition of a foreign body or of a portion of muscle, disease of the bone, 
 defective blood-supply, defective innervation, inflammation on the surface of 
 the limb, and faulty treatment. 
 
 The first three act mechanically by creating a gap that cannot be filled by 
 the granulations, and, in addition, in the third the surfaces may be so modified 
 by the disease (syphilis, caries, cancer, etc.) that they are unfit to furnish 
 the necessary granulations. Defective blood-supply, the result of injury to 
 the nutrient artery of the bone or to the main artery of the limb, has often 
 been alleged as a cause, but satisfactory proof is lacking and theoretical con- 
 siderations do not furnish much support. The influence of defective innerva- 
 tion has been shown in some fractures of the lower limb combined with injury 
 to the lower part of the spinal column ; it appears to arise not from the same 
 cause that produces the paralysis of motion, for such delay does not occur in 
 paraplegia due to injury at the upper part of the spinal column, but from injury 
 to trophic centers in the lower part of the cord. The influence of surface 
 inflammation has been occasionally shown in the delay of repair or in the soften- 
 ing of a firm callus coincidently with the appearance of an erysipelas or a 
 phlegmon of a limb. 
 
 Excluding incomplete reduction, the fault in treatment which is most likely 
 to delay or prevent repair is insufiicient immobilization. Its influence is 
 
302 AN AMERI(A.\ TKXT-nOOK OF SURGERY, 
 
 unquestionable, altliough of course it is knoAvn that union may take place 
 in spite of it. It is tii()ut:;ht that the relative frequency of lailure of union 
 after fracture of the humerus is largely due to this cause. The local applica- 
 tion of cold is also thought to retard union. It has been asserted also that 
 treatment by couq)lete encasement of the limb in a plaster-of-Paris bandage is 
 followed by a larger proportion of delays and failures than is the case where 
 other methods are enqjloyed, and that the increase is due to the shutting out 
 of air and light from the limb : a more probable explanation of the frecjuency, 
 if it actually exists, is defective immobilization. Piemature use of the limb 
 may be followed by a gradual return of the abnormal mobility, as well as by 
 distinct refracture ; and a similar occurrence has been observed under the 
 influence of intercurrent diseases weeks or even months after union appeared 
 to be complete. 
 
 Treatment. — If a general cause exists, such as syphilis or malnutrition, 
 measures should be taken to remove it, whether the case is one of delayed 
 union or of failure of union. In delayed union of short duration, and with 
 only slight mobility and displacement, much is to be hoped from time, aided by 
 accurate immobilization by splints that will permit the patient to leave his bed. 
 
 A gratifvino; number of successes in fractures of the letj and thigh have 
 been obtained by the use of orthopedic splints. In a number of cases of 
 delayed union of the leg union has gradually become complete while the patient 
 was using the limb under the protection of a suitable splint : it is thought that 
 the slight irritation caused by bearing the weight upon the limb favors ossifica- 
 tion. On the same theory percussion of the bone at the fracture has been used. 
 If the case is of longer standing and the mobility greater, a more decided local 
 irritation is required — one that will bring the parts more nearly to the condi- 
 tion of a recent fracture and start the process of repair afresh. Under anesthe- 
 sia the limb is forcibly bent at the seat of fracture, care being taken not to 
 injure main vessels and nerves. The bending should be nearly or quite to a 
 right angle, and the laceration should be sufficient to permit a jfiiirly complete 
 reduction if there has been previous displacement. The fracture is then treated 
 as a recent one. 
 
 Direct irritation of the ends of tlie bones can be produced by subcutaneous 
 drilling, but it seems better, and, if antiseptically done, is equally safe, to expose 
 the bone by incision and apply the drill under the guidance of the eye and 
 finger : it should be forced into the end of each fragment at several points. 
 This plan is, in the writer's judgment, more efficient than the permanent intro- 
 duction of metallic, bone, or ivory pins. 
 
 Excision of the fibrous tissue and of the end of each fragment is the only 
 means that will cure old cases and those in which a joint-cavity has formed 
 between the fragments. Under the protection of antiseptic treatment of the 
 wound it has become a popular method, and has proved safe and efficient. The 
 bones should be freely exposed, and their surfaces freshened and fitted to each 
 other — preferably by a transverse section, if that does not recjuire the removal 
 of too much tissue — and the periosteum should be stitched together as exten- 
 sively as is practicable. Buried or temporary sutures of silver wire or of strong 
 silk are sometimes used to bind the fragments together and prevent displace- 
 ment ; as are also long, narrow metal plates on each side of the bone, crossing 
 the line of fracture and secured to the fragments by long pins that are left pro- 
 jecting beyond the skin and are removed after two or three weeks, the plates 
 being left to heal in. 
 
 The attempt has been successfully made in a few instances to obtain union, 
 when there was a considerable gap between the fragments due to loss of substance, 
 
FRA CrURES. 
 
 303 
 
 by aiUnq the gap with small pieces of sterilized decalcified bone or of fresh bone 
 taken from aiiimals: tlie intermediate fibrous tissue is removed, the ends of the 
 fragments freshened, and the 
 skin closed over the inserted 
 pieces ; perfect asepsis is neces- 
 sary to success. 
 
 Finally, amputation may be 
 required to rid the patient of a 
 useless and troublesome limb. 
 
 Faulty Union. — An opera- 
 tion may be required to relieve 
 a disability due to union -with 
 deformity or to exuberant cal- 
 lus : thus, the femur may have 
 united with an angular displace- 
 ment that causes effective short- 
 ening of the leg in such man- 
 ner that the foot does not rest 
 squarely on the ground or is 
 outside the line of support ; or 
 the bones of the forearm may 
 unite with a callus that prevents 
 rotation ; or an exuberant callus 
 may compress a nerve. Fig. 
 89, from a photograph, is an 
 example of union with extreme 
 deformity. The measures employed are subcutaneous refracture, osteotomy, 
 and chiselling away of exuberant bone. (See Operations on Bones.) 
 
 Faulty Union after Fracture (original). 
 
 SPECIAL FRACTUKES. 
 FEACTUEES OF THE SUPEEIOE MAXILLA AND MALAE BONES. 
 
 These are caused only by direct violence, are generally comminuted, and 
 unite with great rapidity. Displacements may often be corrected by direct 
 pressure, and, except in *^the case of the alveolar border, require no retentive 
 apparatus. If the anterior wall of the antrum has been driven in. an incis- 
 ion is made at the junction of the lip and gum, and the seat of fracture is 
 exposed. The depressed portion of bone is drawn into place with a blunt 
 hook or a gimlet, and the incision is sutured. When a portion of the alveo- 
 lar border, with more or less of the adjoining bone, is loosened, it may need 
 to be retained by wiring its teeth to the neighboring ones or by keeping the 
 lower jaw pressed against it. 
 
 FEACTUEE OF THE NASAL BONES. 
 
 This is produced by direct violence, and is often compound, either through 
 the skin or through the mucosa. The fracture may extend to the superior 
 maxilla or to the cribriform plate of the ethmoid; the latter is a dangerous 
 complication because of the possibility of septic meningitis. Cellular emphysema 
 of the face and evelids, due to the forcing of air through the lacerated mucosa 
 by efforts to clear the nostrils, may appear. Repair takes place so rapidlv that 
 it is necessary to recognize and reduce displacements promptly. Reduction is 
 
304 
 
 AN AMERICAN TEXT- HOOK OF SURGERY. 
 
 best made by pressure with a small stiff metal rod, like: a director, |)iissc'd into 
 the nostril. Ordinarily there is but little tendency to recurrence of the dis- 
 placement, but it may sometimes be necessary to oppose it. A plan that has 
 yielded good results is to transfix the nose close beneath the fragments -with a 
 stout pin, and steady them ^vitil a piece of Iiidia-nililier or adiiesive j)Lastcr 
 crossing the bridge of the nose and caught uiion the ends of the pin. The 
 pin may be removed in a week or ten days. 
 
 Suppuration may be followed by necrosis of the fragments. Possibly it 
 could be prevented by irrigating the nostrils Avith an antiseptic solution and 
 plugging the passage with iodoform gauze. This should always be done very 
 carefully if injury to the cribriform jdate is suspected. (See Fractures of 
 the Base of the Skull in the section on Injuries of the Head.) 
 
 FEACTUEE OF THE LOWEE JAW. 
 
 This may be single or double : single fractures are most common at or near 
 the median line ; those of the ramus and condyloid process are much rarer. 
 Double fractures may occupy one or both sides, or one of the fractures may be 
 in the median line. They are quite common. Fractures of the body of the 
 bone are usually compound ; those of the coronoid process are extremely rare, 
 and have been found only in connection with fractures of the condyle, zygoma, 
 and malar bone. 
 
 The displacement in fractures of the body is almost invariably such that the 
 level of the teeth on one side of the fracture is lower than on the other, and 
 with this is often associated an antero-posterior or lateral displacement accord- 
 ing to the position of the fracture ; sometimes there is overriding. In fracture 
 of the ramus there is usually little or no displacement. 
 
 The common cause is violence received upon the chin or cheek. 
 The diagnosis is readily made in fractures of the body by recognition of 
 the change in the relations of the teeth, of abnornuil mobility and crepitus, and 
 
 usually of looseness of the adjoining teeth and 
 bleeding from the gums. In fracture of the 
 ramus the only symptom may be pain on pres- 
 sure or on tightly closing the jaws. The pain 
 should be sought for by making pressure with 
 the finger within the mouth as well as on the 
 cheek. 
 
 The course is marked by swelling of the 
 face and gums, and often by sujipuration at 
 the seat of fracture, the pus escaping into the 
 mouth alongside the teeth, and also often open- 
 ing through the skin near the lower border of 
 the jaw. Suppuration may be maintained for 
 a long time by necrosis, and may lead to a 
 considerable loss of bone with consequent fail- 
 ure of union and great disability. 
 
 Reduction can almost always be readily 
 eflecte<l l)y direct ])ressure, but the prevention 
 of recurrence may be very difficult. In sim- 
 ple cases treatment consists in the application 
 of a "four-tailed bandage" (Fig. iMj), -which 
 should be worn for four weeks ; in the more difficult cases recourse has been 
 had to a great variety of interdental splints and methods of wiring the bones 
 
 ' Four-tailed Randape " for Fracture of 
 the Jaw (Stimson). 
 
FRACTURES. 
 
 305 
 
 or tho teeth t(),!iether. For the eoiistruetion of most of these the surgeon will 
 re([iiire the services of a dentist. 
 
 FRACTURE OF THK UVUID l50Ni;. 
 
 This is exceedingly rare, and in the few recorded cases has been caused by 
 direct violence and has almost always involved one of the greater cornua. 
 The svmptoms are sharp pain, swelling, marked dysphagia, and sometimes 
 bleedin.- from the mouth due to perforation of the mucous membrane by the 
 fragments. Death from ccdema of the glottis may occur. In these cases 
 intubation or tracheotomy may be demanded. 
 
 The patient is placed semirecumbent in a bed-rest, and wears tor tour 
 weeks a pasteboard collar and a ban<lage around the head, neck, and slioulders. 
 
 FRACTURE OF THE STERNUM. (See also Dislocations.) 
 
 This fracture is rare ; it may be incomplete, multiple, transverse, longitu- 
 dinal or oblique, but the common form is transverse and situated at or near 
 the junction of the manubrium and bodv of the bone. As a complete joint 
 sometimes exists between the manubrium and body, it may be impossible to 
 say whether a separation exactly following the line of their junction is a frac- 
 ture or a dislocation. Displacement may be absent, or may be angular or 
 transverse with or without overriding, either piece lying in front of the other. 
 The periosteum on the posterior surface appears habitually to remain untorn. 
 When the fracture takes place at the junction of the first and second pieces, 
 the second rib usually remains in contact with the manubrium. Fractures of 
 the bodv are most common in its upper half; those of the ensiform process, 
 including its separation from the body, are extremely rare. 
 
 The fracture has been caused in several cases by straining during labor 
 and by lifting heavy objects ; external violence may cause fracture directly, as 
 in a blow upSn the breast, or indirectly by bending the trunk backward. 
 
 The diagnosis is made by recognition of the displacement when it is 
 present, localized pain, and the history of the case. There is sometimes irreg- 
 ularity of the heart with dyspnoea. -^ -i -c \. 
 
 The treatment consists in reduction by direct pressure, aided, it there is 
 overridincr, by extension of the trunk and by deep inspiration by the patient, 
 and in relention by a broad band of adhesive plaster around the chest. The 
 patient should be kept in bed in the semi-erect position for four weeks, but 
 the plaster should be left for a week longer. 
 
 FRACTURE OF THE RIBS. 
 
 This fracture is of frequent occurrence ; it may be partial or complete, 
 sintrle or multiple. Incomplete fractures are rare, whether by bending or by 
 fraSure of a piece from one border of the bone. Complete fracture may 
 involve one or several ribs, or one or more ribs at two points each ; the ribs 
 most frequently broken are the fifth to the ninth ; fracture of the floating ribs 
 is almost unknown, and that of the upper ribs apparentlv very rare, although 
 there is some reason to think that fracture of the first rib is not infrequent, 
 but usually passes unrecognized. , , i .-. • v^^i 
 
 Unless two or more adjoining ribs are simultaneously broken, there is little 
 or no displacement ; if thev are thus broken, the displacement may be angu- 
 lar with the apex directed inward or outward, and overriding may be produced 
 by 'the sinkincr in of the chest-wall. If a rib has been broken at two places, the 
 intermediate piece mav move in and out as the patient breathes. Associated 
 
 20 
 
306 ^i.v AMKL'HA.x 'riixi'- ii(j( )K OF Si i^(n:i:y. 
 
 injurij to tJir hill;/ ]>\ the point of" a tV;i;^MiK'iit is coniiiioii, as sliowii l)_v ciiipliv- 
 sema or bloody expectoration ; and extensive laceration of the lun<;,s or heart 
 may be produced when the violence is great. Serious hemorrhage from a 
 wounded intercostal artery is rare. 
 
 The common cause of the fracture is external violence, but it mav also be 
 caused by muscular action, especially in coughing. External violence may 
 produce the fracture directly, or indirectly by exaggerating the curve of the 
 bone. 
 
 The symptoms in the less extensive cases are pain on deep inspiration or 
 coughing and when pressure is made upon the broken rib ; abnormal mobility 
 can often be recognized by placing a finger on the rib on each side of the 
 fracture and noticing that movement communicated to one fragment is not 
 transmitted to the other: during this manipulation crepitus may be perceived, 
 or it may sometimes be heard by listening with the ear upon the chest while 
 the patient breathes deeply. Bloody expectoration is frequent. The presence 
 of cellular emphysema, in the absence of a wound or other sufficient cause, is 
 pathognomonic. In the severer cases, in which several adjoining ribs are 
 broken, the fracture is readil}^ recognized by the deformity; associated symp- 
 toms due to laceration of the lung may be very urgent. 
 
 The treatment is habitually limited to immobilization of the chest by 
 means of a broad band of adhesive plaster placed about it at the end of expi- 
 ration and worn for four weeks. Angular displacement outward can be cor- 
 rected by direct pressure upon the projection ; it has been propose<l to raise 
 a depressed rib by cutting down upon it or by passing a sharp hook uiuler 
 it, but this is very rarely necessary. For the treatment of associated injuries 
 of the thoracic viscera, pneumothorax, and hemothorax, the reader is referred 
 to the chapter on Injuries of the Thorax. 
 
 FRACTURE OF THE COSTAL CARTILAGES. 
 
 This may be caused by direct or indirect violence or by muscular action ; 
 it appears to occur more frequently near the junction with the rib than at other 
 points, and to involve the seventh and eighth cartilages more freiiuently than 
 others. Marked symptoms, when present, are due to associated lesions, injury 
 of the heart or lungs, or other effects of the crushing violence that has caused 
 the fracture. The diagnosis is made on the local pain and the deformity. The 
 treatment is the same as that of fracture of the ribs. 
 
 FRACTURES OF THE CLAVICLE. 
 
 The clavicle is broken more frequently than any other one bone, with the 
 possible exception of the radius, and the injury is very much more common in 
 the young than in adults, about half the cases occurring in children under five 
 years of age. The fracture may be partial (green-stick) or complete, simple 
 or compound, single or multiple. The partial (in the very young) and simple 
 complete (in the adult) of the middle third of the bone are the common forms; 
 fracture of the outer third is second in order of frequency ; that of the inner 
 third is infrequent. The division of fractures into those of the inner, middle, 
 and outer thirds is justified by important anatomical and resultant clinical 
 differences, the chief of which arise from the firm ligamentary attachments of 
 the outer third to the coracoid process of the scapula. 
 
 Fracture of the middle third (Fig. 69,), the most common variety, may 
 be oblique or transverse, the latter form being found mainly in children ; the 
 line of oblique fracture runs from above downward and inward, so that the 
 point of the outer fragment underlies that of the inner one — an important element 
 
fltACTURES. 307 
 
 in ,1,0 prclnotion of tl,e usual .lisplaceuionl; the scat of f™'^'' ™ ^ "!"f '^ ^3 
 rt,o outc'i- lu.lf of this tliinl. Tlu. loss of support occas.oncd bv lie "»<•'" '^'^ 
 Vn. , 1 bv tbofalli..!; of tl,cshoul.lc.- dmnnvard, forward, and ""':'"-<^'jl''^l' 
 1 , n o ,„r f,-,Tn,R.i,t uiukT the inner one, and thus .-a.ses the bvokcn 
 ir^oV tt la"^'-am«v"nu.nt .hi.* is son.etin,es aided by the contvae.ton of 
 the cleirmastoid. If the line of fraeture is so nearly transverse that over- 
 ridinTctrt oeeur, the displacement is transverse or angular «,tl, the apex 
 
 ^'■it::Ctft rt^M:tr^::th is n,ueb ,„. ^eq-t 'ha„ «he P. 
 ccdino, the line of fracture is more often transverse than oblique, and tic dis- 
 placement is usually angular Nvith the ape. directed backward, but it may 
 
 "" irLTm" t innT'thlrd, which is ,uite rare, the line is commonly 
 
 SE-^dt'ri^^i^^i^^---^^^^^ 
 
 SimuuVneous fracture of both clavicles has been caused by direct v o- 
 lence a the k ck of a horse, each hoof striking one bone, or, more frequently 
 bvmlirec violence, the force acting upon both shoulders to press them t«gethci. 
 Ked dyspnea, attributed to the weight of the shoulders resting on the tho- 
 rnT T.nd relieved by dorsal decubitus, was observed in some. 
 
 C causes of fracture of the clavicle are in.lirect violence, as in a fa 
 upon'be hand or shoulder; muscular action, as in lifting or striking; and direct 
 
 Tircourse is uneventful, and union is usually complete .vithm a mon li in 
 
 ^^^-rtsrnitrriiitinTr^^^^^^^^^^ 
 
 ufJ:Xf^.^ara, ana oat.ard to its -rmal position a«l«l -1- ncces- y bj 
 
 f=,rtotaSni^ sh.^M:^rtlr■prt^,r s ..'-^-i- 
 
 un™^^^ ^vei..ht of the shoulder is the cause of the displacement. Ihis 
 rt!ide,::!:^t"hf fore^rttog on the chest, meets the indication by remov- 
 
308 
 
 .l.V AMERICA X TEXr-liOOK <>!' Si' lid K I: Y 
 
 ing the ciiiise, but the conJineiMrnt is too irksome to be endured except when 
 the importance of avoiding any irreguhirity in the bone is great. 
 
 Sat/re's (lnKsin(/ (Figs. 91, '92) is in very general use ; it requires two strips 
 of adhesive phister, each three indies wide and long enough to go once and a 
 half around the chest. The end of one strip is fixed loosely about the arm of 
 the injured side just below the axilla, and the strip is carried around the back 
 and the opposite side to the chest in front, so as to hold the elbow a little behind 
 the axillary line ; the second strip is then carried from the top of the shoulder 
 on the uninjured side, across the back, to the opposite elbow, and up along 
 the flexed forearm to the place of beginning, meanwhile pressing the elbow 
 
 Fig. 91. 
 
 Fig. 92. 
 
 Sayre's Adhesive Plaster Dressing for Fracture of the 
 Clavicle (Stimson). 
 
 Velpcau's Dressing for Fracture of tne 
 Clavicle (Stimson). 
 
 forward, inward, and upAvard. It is well to leave the hand uncovered by the 
 second strip. A few turns of a roller bandage about the arm and chest will 
 give additional support. In this and all similar cases care must be taken 
 not to allow the bare skin of the forearm to rest on that of the chest, in order 
 to prevent retention of moisture, maceration of the epidermis, and even ulcer- 
 ation. Cotton wadding, linen, or other similar material should always be 
 interposed between the two cutaneous surfaces. 
 
 Velpeaiis dressmg (Fig. 93) is made with a roller bandage ; the hand is 
 placed on the opposite shoulder, the elbow pressed upward, and a series of 
 turns with the roller applied, which, beginning at the opposite axilla, pass 
 upward across the back, over the injured shoulder, downward in front of the 
 arm, and under the elbow to the point of beginning : after several turns have 
 been thus made the bandage is carried circularly about the body, covering in 
 the arm from below upward. 
 
 A Jigure-of-8 bandar/e of plaster of Paris, passing in front of each shoulder 
 and crossing at the back, meets the indication very well, but is liable to inter- 
 fere with the circulation in the arms. Short crutches fastened to the chest 
 by adhesive plaster or bandages have been in occasional use for many years 
 to maintain the shoulder in the desired position. 
 
 When the fracture is at the extreme acromial end, and the dis])lacement 
 is like that of dislocation of the acromial end upward, the method of treat- 
 ment of the latter injury by a strip of adhesive plaster passing under the 
 elbow and crossing on top of the shoulder is equally efficient. In some cases 
 of fracture of the clavicle it is impo.ssible to reduce the deformity by ordi- 
 nary methods. Such persistent deformity may be due to the interposition of 
 
FRA CTURES. 309 
 
 inusclo or fascia between the {Va^nneiits. Tlie proper treatment for cases of 
 tliis description is to make an incision, hrinjr tlie fragments into position and 
 wire them together or suture them with kan;4aroo tendon. 
 The dressings shoiihl he worn for three or four weeks. 
 
 FRACTURES OF THE SCAPULA. 
 
 These fractures may be grouped as— 1, of the body ; 2, of the inferior angle ; 
 3, of the upper angle ; 4, of the spine ; 5, of the acromion ; 6, of the coracoid 
 process ; T, of the^'neck ; 8, of the glenoid fossa. 
 
 Fractures of the body are caused by direct violence, and may be partial, 
 complete, or comminuted ; when there is a single line of fracture crossing the 
 body directly or obliquely, either fragment may project outwardly and over- 
 ride the other. ^ i j- i . v. 
 
 The diaqnosis can usually be made by recognition of tlie displacement by 
 touch, es})eeially along the vertebral border of the bone ; by independent 
 mobility, recognized by grasping and moving the lower angle ; and by c-repitus. 
 The treatment consists in immobilization of the shoulder and arm for four 
 weeks. If suppuration ensues in consequence of bruising of the soft parts, 
 early opening of the abscess is required, with especial attention to the dram- 
 age of the portion which lies on the costal surface of the bone. 
 
 Fracture of the inferior angle is caused by direct violence or by muscu- 
 lar action ; the small lower fragment is displaced forward and upward by the 
 attached muscles, and even if it can be restored to its place it cannot be main- 
 tained there. 
 
 Fracture of the upper angle is very rare, is caused by direct violence, is 
 followed by but little displacement, and is to be treated by immobilization of 
 
 the arm. i, v j 
 
 The entire spine, including the acromion, may be separated from the body 
 of the bone, or a portion may be broken off, leaving the acromion attached to 
 the body. The cause is direct violence ; the displacement is slight ; the treat- 
 ment is* immobilization, as in fracture of the body. 
 
 Fracture of the acromion process may be caused by external violence 
 
 acting either directly or through the humerus ; or by muscular action (contraction 
 
 of the deltoid). The line of fracture is in most cases in front of the articulation 
 
 with the clavicle, less frequently at the root of the process. The spjijjtoins 
 
 are localized tenderness, abnormal mobility, and crepitus. Non-union of the 
 
 epiphysis at the external extremity of the spine, which is not very uncommon, 
 
 may, 'if combined with a contusion, be mistaken for a fracture. Bony union 
 
 is apparently the exception, but the failure to secure it creates no disability. 
 
 The treatment consists in immobilization of the arm at the side of the body, 
 
 with the elbow a little forward, and the humerus pressed well upward against 
 
 the acromion (the Velpeau position). Dressings to be worn for four weeks. 
 
 Fracture of the coracoid process may be caused by external violence or 
 
 by muscular action, and has been observed both alone and in combination with 
 
 other injuries. The symptoms are abnormal mobility, with or without crepitus, 
 
 obtained, where present, by pressure with the finger against the tip of the process. 
 
 Displacement downward by the action of the attached muscles is the rule, as is 
 
 also fibrous union. The treatment consists in immobilization of the arm upon the 
 
 side of the chest with the elbow directed a little backward for four or five weeks. 
 
 Fracture of the surgical neck includes all cases in which the detached 
 
 fragment comprises the attachment of the long head of the triceps. The upper 
 
 portion of the line of fracture may end in the suprascapular notch, or in front 
 
 of the coracoid, or in the glenoid fossa. The symptoms are flattening of the 
 
310 
 
 AX AMERICA X TEXT-P.dOK OF SURGERY 
 
 shoulder, duo to the sinking of the liuinenis in consequence of tlie h)ss of 
 support by tlie triceps (this is k'ss Avheii the fnicture passes tliroii;^rli the siipra- 
 scapuhir notch, because the fragment is then supporte<l by the coraco-chivicuhir 
 ligament) ; its prompt disappearance when the arm is pressed upward, and its 
 immediate return when the pressure is removed ; the presence of a movable 
 hard lump deep in the axilla, felt by following with the finger the axillary 
 border of the scapula u})\vard ; and crepitus, obtained by pressing it upward 
 and backward. Bony union with some displacement appears to be the rule. 
 The indication for treatment is to prevent the sinking of the humerus. This 
 can be efi'ected by bandages or a strip of adhesive plaster passing under the 
 flexed elbow and over the top of the shoulder, to be worn for five weeks. 
 
 Fracture of the rim of the glenoid fossa is a complication of dislocation 
 of the shoulder. ISome authors speak of stellate fractures of the fossa, appar- 
 ently the result of crushing violence acting through the head of the humerus. 
 
 FRACTURES OF THE HUMERUS. 
 
 These, which constitute about 8 per cent, of all fractures, may be con- 
 veniently grouped clinically as fractures of the upper end, of the shaft, and of 
 the lower end. 
 
 Fractures of the upper end include those of the head; of the anatomical 
 neck, with or without part of the tuberosities ; of the tuberosities ; separation 
 of the epiphysis; and fracture of the surgical neck. 
 
 Fracture of the head is very rare, if from the group are excluded those 
 indentations which are sometimes associated with dislocation {q. v.). It cannot 
 be recognized clinically. 
 
 Fracture of the anatomical neck is rare: the majority of cases probably 
 occur in connection with anterior dislocation, the head being split off by the 
 
 inner lip of the glenoid fossa acting as a 
 wedge along the line of the neck. In 
 other cases it appears to have been caused 
 by external violence acting upon the 
 elbow to press the humerus against the 
 scapula, or by a fall upon the shoulder. 
 When associated with dislocation the 
 diagnosis can be made by recognizing 
 the independent mobility of the head, 
 but when not so associated it cannot be 
 grasped by the fingers so as to permit 
 the recognition of this fact, and the 
 diagnosis cannot be made with certainty. 
 Symptoms that may be present are 
 crepitus on rotation of the arm, with 
 preservation of the continuity of the 
 greater tuberosity with the shaft, and 
 pain on pressing the elbow upward, but 
 in a case reported by Stimson there was 
 entire absence of objective symptoms. 
 Hutchinson's supposition that the toni- 
 city of the scapulo-humeral muscles, by 
 drawing the shaft upv.ard, tended to 
 force the head out of the socket has not 
 been confirmed. The treatment is im- 
 mobilization of the arm by binding it to the chest for about four weeks; a 
 
 Fk;. ni. 
 
 Impacted Fracture of the iluiin,rii> u 
 Tuberosities (K. W. Smith). 
 
 lUgii the 
 
FRA CTURES. 
 
 ill 
 
 Fig. 95. 
 
 thin compress or a layer of absorbent cotton placed between the arm and the 
 chest to absorb the perspiration will add to the patient's comfort. 
 
 Fracture through the tuberosities (Fi<i^. 94), the line of fracture 
 running partly along the anatomical neck, and usually through the greater 
 tuberosity, is apparently less rare than j)ure fracture along the anatomical 
 neck : the fragments are commonly impacted with comminution, and in some 
 cases the upper one has been turned completely over. 
 
 The treatment is immobilization of the limb, aided possibly by permanent 
 traction downward. 
 
 Fracture of the greater tuberosity, complete or partial, is rarely seen 
 except in connection with anterior dislocation ; it may be caused by direct 
 violence or by the forcible contraction of the attached muscles. The line of 
 fracture runs along the anatomical neck adjoining the tuberosity, down the 
 bicipital groove, and through or below the tuberosity; the fragment may remain 
 partly attached by untorn periosteum or may be entirely separated and drawn 
 backward. Tlie symptoms are loss of voluntary outward rotation, pain, crepitus, 
 and swelling. 
 
 Of fracture of the lesser tuberosity only three examples have been 
 reported, two of them in connection with the very rare dislocation of the 
 shoulder upward, the third without history. 
 
 Separation of the epiphysis (Fig. 95) is caused by external violence, 
 and quite frequently in the new-born by traction upon the arm or in the axilla 
 during delivery. The displacement 
 when not complete is transverse and 
 angular, the apex of the angle directed 
 forward and upward ; when the dis- 
 placement is complete the lower frag- 
 ment lies on the inner side of the upper. 
 The epiphysis includes the tuberosities, 
 and is so shaped that the upper end 
 of the shaft has the form of a low 
 cone or wedge. The symptoms are 
 commonly very characteristic in this 
 respect, that a distinct prominence 
 can be seen and felt on the front of 
 the shoulder about an inch below the 
 acromion, and that a false point of 
 motion can be recognized by grasp- 
 ing the head and gently rotating the 
 shaft ; when the displacement is in- 
 ward this prominence is found beneath 
 the coracoid. Reduction is difficult 
 because of the smallness of the upper 
 fragment, but may be effected by carrying the elbow forward and upward, as 
 the posterior portion of the capsule attached to the upper fragment prevents it 
 from sharing in the movement. In a few cases recourse has been had to open 
 incision. Occasionally the growth of the limb at this point is arrested in 
 consequence of the injury, either because the displacement persists or because 
 the epiphyseal cartilage ossifies prematurely. 
 
 Fracture of the Surgical Neck (Fig. 96). — The surgical neck of this bone 
 is the part between the upper expanded end and the insertion of the pectoralis 
 major and latissimus dorsi. This is by far the most frequent fracture at the 
 upper end ; it is commonly caused by a blow upon the upper part of the» arm 
 
 Separation of the Upper Epiphysis of the Humerus ; 
 Displacement Forward of the Lower Fragment 
 (Moore). 
 
312 
 
 AN A^fKRl(\\N TEXT-HOOK OF SURGERY. 
 
 Fjg 
 
 or by a fall on tlie hand or elbow. The line of fracture may be irregular or 
 obli(|ue. In the latter case the lower fra;riiient lies oftenest on the inner side 
 of the upper one, drawn tliither l)y the latissinius dorsi and pectoralis major. 
 Sj/>7i}tt<>vif(. — Abnormal moltility and (•re])itns are recognized l^y grasping 
 the head of the humerus with the tiiunil) and fingers of one hand and gently 
 rotating the elbow with the other. Pain is caused by pressing the ellxiw u])- 
 ward and by local ])ressure at the seat of fracture. 
 
 Treatment. — Reduction is made by traction and coaptation and slowly 
 bringing the lower fragment into line with the uj>|>er one, and, if the deform- 
 ity obstinately returns, may be maintained by ])ermanent traction with weight 
 and ])ulley combined with the supj)ort of a plaster-of-Paris gutter on the back 
 and sides of the shoulder and arm. If the line of fracture is such that the 
 tendency to displacement is slight, or if confinement to bed is very undesir- 
 able, s})lints or encasement in plaster of Paris may be used. In such a case 
 the forearm should be Hexed, and supported only at the wrist by a sling, in 
 order that the weight of the limb may make traction while the patient is 
 erect, or occasionally an additional weight of not more than five pounds ma}^ 
 be hung from the elbow. A dressing consisting of a folded 
 towel placed against the side of the chest and extending into 
 the axilla and a little above its borders, a shoulder cap, and 
 a slinsc at the wrist, gives most excellent results. The arm 
 should be bound to the side by circular turns of a bandage, 
 and the shoulder cap should be held in place by a spica. A 
 splint may be used on the outer side, resting against the 
 acromion and the elbow, the lower fragment being secured to 
 the splint by a bandage: it opposes the displacement of the 
 latter inward by its counter-pressure against the acromion, 
 but does little or nothing to prevent shortening. The scap- 
 ular muscles attached to the upper fragment tend to tilt its 
 lower end forward and outward, and when this tendency is 
 manifested it must be met by keeping the lower fragment 
 in a corresponding position, either by traction in bed with 
 the arm abducted or by a triangular splint or cushion placed 
 between the arm and the side and maintaining the arm in the desired posi- 
 tion. If, as is usual, union is quite firm after the expiration of a month, 
 the splint may be removed and the forearm supported in a sling for a week 
 or two longer. 
 
 When the fracture is cornpUcated Inj simultaneous dislocation of the head, 
 the latter may sometimes be reduced by direct manipulation under an anes- 
 thetic, or, as recently done by McBurney, cutting down through the 
 deltoid to the lower part of the upper fragment, drilling a hole in it, and 
 inserting in this hole a strong right-angled hook, by means of which ibrcible 
 traction and rotation can be made upon the fragment. If these fail, the sur- 
 geon has his choice betAveen securing union of the fracture and making a 
 subsecjuent attempt to reduce the dislocation and the establishment of a false 
 joint. 
 
 Fracture of the shaft may be caused by direct or indirect violence, or 
 by musodar action : all the varieties of fracture and displacement seen in the 
 shafts of other long bones have been seen here. Among observed complica- 
 tions: are rupture, throm1)osis, and aneurysm of the brachial artery and injury 
 of a main nerve, especially the musculo-s])iral. either at the time of the accident 
 or subsequently by inclusion in the callus. The diagnosis is readily made by 
 attention to the common signs of fracture, all of which are usually present. 
 
 Fracture of the 
 Surgical Neck 
 of the Humerus 
 (Stimson). 
 
FRACTUREH. 313 
 
 Union takes place in from four to six weeks, but it is to be remembered tliat 
 failure of iinion is more frequent after fracture of the shaft of the humerus 
 than after that of any other long bone. The trcatmerif is by an internal anjrular 
 splint, a shoulder cap, and a sliiif^ at the wrist; by moulded splints; or by 
 encasement in jdaster of Paris, which should include the forearm (flexed at a 
 right angle) and the shoulder. Unless measures are taken to prevent it, this 
 latter dressing will show after a few days a distinct gap above the shoulder, due 
 to the shortening of the arm — a gap that will admit one or two fingers : this 
 may sometimes be prevented by adding a spica aljout the chest, but more surely 
 and conveniently by a weight attached to the ell)ow. If the skin is so bruised 
 that a permanent dressing cannot be applied, the limb nnist be supported on 
 cushions in a suitable position or bound to the side of the chest. The dressing 
 should be worn from three weeks in the young to five or six weeks in the adult. 
 
 Fractures of the Lower End of the Humerus. — In this group are 
 included fracture close above the condyles ; al)ove and between the condyles ; 
 of either condyle; of either epicondyle; and se{)aration of the epiphysis. 
 
 In fracture above the condyles, or supracondyloid fracture, the 
 line of fracture passes through the expanded lower end of the humerus, and 
 may open into the joint through the olecranon and coronoid fossae; the line 
 may be transverse or oblique, either laterally or antero-posteriorly, and in a few 
 cases has been almost vertical and transverse — L e. parallel to the anterior sur- 
 face, crossing the bone close behind the trochlea and capitellum. 
 
 Symptoms. — The usual displacement is of the lower fragment backward, and 
 the injury is often compound because of perforation of the skin by the sharp end 
 of either fragment, especially the upper. The brachial artery or median nerve 
 may be dangerously stretched across the end of the upper fragment. When 
 the usual displacement is present the general appearance of the region resembles 
 that of dislocation backward of the elbow. The diagnosis is then made by 
 attention to the relations of the olecranon and head of the radius to the 
 epicondyles. 
 
 Treatment. — Reduction, which is sometimes very difficult, is made by trac- 
 tion and coaptation with the elbow flexed at a right angle or fully extended, 
 and is maintained by posterior and anterior rectangular splints or by a moulded 
 posterior splint or trough that extends well around to the front on both sides. 
 The dressing is to be worn for four or five weeks. Passive motion is begun 
 in the third or fourth week. Occasionally vertical suspension for a fortnight 
 with the elbow extended is best, especially if the fracture is compound; and this 
 attitude has the advantage of being followed by less primary stillness of the joint 
 than is usual after treatment in flexion. In compound fractures excision of the 
 end of one or both fragments may be needed to secure permanent reduction. 
 
 Intercondyloid fracture, sometimes called T- or Y-fracture, differs from 
 the preceding by the addition of a line of fracture running from the transverse 
 one downward through or between the condyles ; it is usually caused by direct 
 violence, a blow or fall upon the elbow, and is often comminuted or compound. 
 
 Syynptoms. — It may closely resemble a supracondylar fracture, the condyles 
 preserving their relations with each other, or the latter may be widely sepa- 
 rated, with the lower end of the upper fragment and the olecranon interposed 
 between them. 
 
 Treatment. — Complete reduction, in attempting which the aid of anesthesia 
 should always be had, is very difficult, as is also its maintenance. It is to 
 be expected that the movements of the joint after recovery will be seriously 
 restricted, and it is well, therefore, to keep the limb during treatment, or at 
 least during the later weeks of treatment, in the attitude which will be the 
 
;n4 
 
 A^^ AMi.nicAy text- hook of siiiarjiv. 
 
 most useful if ankylosis ensues. A broad, heavy, posterior moulded splint 
 reat'liintr fn>ni the shoulder to the wrist, with the elhow flexed at a rif.'ht an»rle, 
 extendiniT well around to the front of the linil), and allowed to harden while 
 anesthesia is maintained, is ))rohably the best. It may be aided by permanent 
 traction at the elbow in the direction of the long axis of the arm. Full exten- 
 sion during the first two weeks with the arm in a padded anterior splint is 
 thought by many surgeons to prevent the displacement upward and backward 
 which often occurs. Whatever method of treatment is first employ e<l, after ten 
 days or two weeks it is desirable to flex the elbow and to change the angle of 
 flexion from time to time, in the hope of increasing the range of motion. In 
 compound fractures advantage may sometimes be taken of the wound to pin 
 the fragments together with steel drills passed through them ; in other cases 
 excision of the lower end of the humerus is advisable with the object of 
 obtaining a movable, though weaker, joint. 
 
 Fracture of the internal epicondyle may be caused by direct violence 
 or bv forced abduction of the extended forearm ; in the latter case dislocation 
 of the elbow usually follows in consequence of the continuation of the violence, 
 and the fracture becomes a complication or an incident of the more important 
 injury. 
 
 The diagnosis in the pure cases is made by recognition of the mobility of 
 the small fragment, possibly with crepitus : in those in which it complicates a. 
 dislocation backward the diagnosis is made in the same manner ; but in dis- 
 locations outward the fragment is liable to be drawn down below the trochlea, 
 where it cannot be felt, and the diagnosis must then be made upon its absence. 
 The treatment is by immobilization of the joint for about a fortnight in 
 flexion at or within a right angle, to diminish the effect of the attached flexor 
 muscles upon the fragment. 
 
 Fracture of the external epicondyle is very rare; the diagnosis must 
 be made upon tiie recognition of a small movable fragment at the seat of the 
 epicondyle. 
 
 Fracture of the Internal Condyle (Fig. 97). — The line of fracture ex- 
 tends from a point on the inner side of the humerus above the epicondyle down- 
 ward and outward into the joint at the center of the trochlea 
 or between the center and the capitellum. The usual displace- 
 ment is of the fragment upward and l)ackward, and, even if 
 it is but slight, the persistence produces marked deformity 
 by changing the relations of the long axis of the arm and 
 making the external condyle unduly prominent. The toni- 
 city of the triceps appears to favor recurrence of this dis- 
 placement, as does also pressure upon the up]>er part of the 
 ulna when the elbow is flexed. This undesirable pressure 
 may be readily exerted by a su])porting sling, with or with- 
 out a splint, and consequently the arm should be su})ported 
 only at the wrist. 
 
 Treatment. — If care be taken to avoid such pressure 
 and to make complete reduction in the first instance, satis- 
 factory results can usually be obtained by treatment in a 
 posterior rectangular or moulded splint or trough, or even 
 Fracture of the Inter- in a plaster-of-Paris dressing, worn for five weeks ; but it 
 H^um^rus^'dispia^e^ is advisable to examine the joint at the end of a week or 
 mtiii upward and in- j^jj davs, and to corrcct tile (lisi)lacement if it has recurred. 
 
 ward (Uurlt). ,,, •/ ' . , , . . • ,. ,, , • i i 
 
 Treatment with the joint in lull extension enables us more 
 surely to avoid this displacement of the condyle upward, and has given 
 
 Fig. 97. 
 
FRACTURES. 
 
 315 
 
 many cxcclloiit results; but the attitude is not so convenient to the patient as 
 that of flexion, and in some cases there is a tendency to displacement for- 
 ward or tilting of the fragment in the extended [)Osition. If it is employed 
 at all, it is perhaps sullicient to employ it during the first fortnight, and tiien 
 to substitute flexion. The ultimate result in the young may be greatly ini- 
 paired by excessive formation of callus. 
 
 A eompUcation occasionally seen is coincident dislocation of the radius 
 backward ; that is, both bones of the forearm and the internal condyle are 
 displaced backward, the ulna preserving its relations with the latter and with 
 the radius. Recurrence after reduction is best avoided by keeping the elbow 
 flexed at less than a right angle. 
 
 Fracture of the External Condyle. — In this the line of fracture runs 
 from a point on the supinator ridge downward and inward through the capitel- 
 lum or the outer part of the trochlea. Ordinarily the displacement is .slight, 
 but it may be considerable, with coincident displacement of the ulna from the 
 internal condyle outward or backAvard, the head of the radius maintaining its 
 relations with the capitellum and ulna. The treatment is immobilization in a 
 posterior rectangular splint or immovable dressing. 
 
 Separation of the epiphysis is not a frequent accident, and there have 
 been but few opportunities for direct examination of specimens. The lower 
 fragment usually comprises the entire epiphysis, which is composed of several 
 distinct pieces; but it is possible that either or both epicondyles may remain 
 attached to the upper fragment. The lower fragment tends to displacement 
 backAvard and inward. As it has frequently been mistaken for dislocation, 
 the examination should always be made under an anesthetic. Treatment is 
 by a posterior plaster splint, the joint flexed to or within a right ano-le. 
 
 Diagnosis and Treatment of Fracture at or near the Elbow. — In 
 all doubtful cases an anesthetic should be 
 used to make the diagnosis complete and 
 to facilitate reduction. Moulded (plaster) 
 splints are, as a rule, to be preferred be- 
 cause of their more accurate fit, and great 
 care must be taken in supracondyloid frac- 
 ture and fracture of the internal condyle 
 that the sling which supports the arm does 
 not press the flexed elbow upward, for 
 otherwise the direction of the transverse 
 axis of the joint is changed by the ascent 
 of the internal condyle, and the forearm 
 is thereby adducted with production of the 
 "gunstock " deformity. 
 
 Complete extension of the forearm has 
 been recommended ; but this requires rest 
 in bed ; and if anchylosis occur, the arm 
 is useless. Jones of Liverpool has recom- 
 mended as an excellent treatment, after 
 reduction, complete flexion of the forearm, 
 so that the ball of the thumb rests on the 
 neck. Flexion is maintained by a leather 
 band around the wrist and a bandage 
 around the neck, the bandage passing 
 through a rubber tube to protect the neck from friction and pressure. 
 Frazier has devised a jacket (Fig. 98) to hold the arm in this position. 
 
 Fig. 98. 
 
 Frazicr's modificution of .Ioik'<'s drrbsing 
 for injuries of the elbow-joint. 
 
31 ti AX A.UKh'/CAX TKXT-llOOK OF SURGERY. 
 
 The splints or other apparatus should be worn from tliroe to six weeks, 
 according to the age of the patient, and for a longer time in sujtraeondylar 
 fractures than in condylar fractures. 
 
 After-treatment of Fracture at or near the Elbow. — When union 
 after iVaetiire ahout the elbow is complete and tiie sjdints are laitl aside, the 
 elbow is usually very stiff, and much anxiety may be felt concerning its future 
 usefulness; but in the great majority of cases the range of motion will rapidly 
 increase under natural use of the limb, and the surgeon can do but little to 
 hasten it. Daily forcing of the joint is more likely to do harm than good, and 
 the best results are obtained by simply encouraging the patient to make as 
 much use as possible of the limb, and perhaps aiding him by elastic traction 
 from the wrist to the shoulder to increase flexion, and making him carry a 
 weight in the hand to increase extension. 
 
 FRACTURES OF THE RADIUS AND ULXA. 
 
 Fracture of the olecranon may be caused by the contraction of the 
 triceps or by external violence received upon the olecranon or upon the ulna 
 near it, the commonest cause being a fall or blow upon the elbow. The line 
 of fracture may be at right angles to the long axis of the bone in both planes, 
 or oblique in either plane, or irregular. The displacement may be slight, the 
 periosteum being in great part untorn, or the fragment may be drawn one or two 
 inches upward by the triceps. The symptoms are localized pain, independent 
 mobility, and- crepitus when there is but little displacement, and the absence 
 of the olecranon from its proper place and its presence at a higher point when 
 there is much displacement. 
 
 Treatment. — If the displacement is slight and the olecranon accompanies 
 the ulna in the flexion of the elbow, no other treatment is required than immo- 
 bilization of the limb in a sling or an immovable dressing; but if the olecranon 
 is completely detached and drawn upward, the elbow must be immobilized for 
 three or four weeks in full extension by a long anterior splint, and the frag- 
 ment be held down by strips of adhesive plaster, or india-rubber traction, or 
 the turns of a roller bandage. After the limb has been kept extended for 
 three weeks the patient is anesthetized, the forearm is bent to a right angle 
 with the arm, an anterior angular splint is applied, and during the next four 
 weeks passive motion is employed every other day. Five weeks after the 
 accident the splint may be discarded. Of the various methods, one of the 
 simplest and most effective is a U-shaped strip of adhesive plaster, the curve 
 of which lies on the back of the arm close above the fragment, and the sides 
 are carried down upon the forearm. In a few cases the fragments have been 
 exposed by incision and wii-ed together; but, except in old cases with failure 
 of union and much disability, this is hardly justifiable. Union may be bony or 
 fibrous; and even when union fails active extension is not always entirely lost. 
 
 Fracture of the coronoid process is almost unknown except as a 
 complication of dislocation of the elbow backward; the tendency to displace- 
 ment is not great, for the only muscle that is attached to the process, the 
 brachialis anticus, is also broadly attached to the front of the ulna below it, 
 and this broad attachment must be broken before the muscle can draw the 
 fragment upward. The fragment can sometimes be felt as a small movable 
 body in the flexure of the elbow. The treatment is by immobilization of the 
 joint flexed at a right angle for four weeks. 
 
 Fracture of the head of the radius has been observed mainly in con- 
 nection with fracture of the coronoid process of the ulna as a complication of 
 
FRACTl'RKS. 317 
 
 dislocation of tlic elbow ; it is j)jirtial, the fVa<^ment beiii^ the inner or ante- 
 rior portion of the head. If the fra^rment is so far displaced that a positive 
 diagnosis can be made, it should be removed. 
 
 Of fracture of the neck of the radius a few cases have been recorded: 
 it may be followed by suj)piirati<)n of the joint or by bony union. The clinical 
 histories arc not sufficient to permit a systematic description : possibly the 
 di<((/>ioi</s could be made by localized pain and by recognition of the failure 
 of the head to share in rotatory movements of the shaft of the radius. Re- 
 moval of the head of the bone is generally necessary to prevent anchylosis. 
 
 Fracture of the Shaft of One or of Both Bpnes of the Forearm. 
 — Fracture of both bones is frequent in the lower and middle thirds, rare in 
 the upper third. Usually the radius is broken at a somewhat higher point than 
 the ulna. They may be broken by direct or indirect violence, and rarely by 
 muscular action. Partial, "green-stick,"' fractures are not uncommon in the 
 young. Fracture of the ulna alone is commonly due to direct violence, a blow 
 upon the raised arm, but it may be caused by a fall upon the hand, and is then 
 occasionally complicated by dislocation of the head of the radius forward and 
 upward. Fracture of the radius alone is less frequent than that of the ulna, 
 and may be caused by direct or indirect violence. 
 
 The displaeement may be angular or lateral or Avith overriding, and is of 
 especial importance because of its effect, if unreduced, upon the function of 
 rotation of the forearm. Rotatory displacement of the upper fragment of the 
 radius occurs especially when 
 
 the fracture is above the in- ^^^- ^^• 
 
 sertion of the pronator radii v^^^a 
 
 teres; the unopposed action '^ ' > 
 
 of the biceps supinates it, and 
 the result, if uncorrected, is 
 to limit supination of the 
 limb : a study made by Cal- 
 lender of the specimens in 
 the London museums showed 
 
 ■1 T 1 , • -I Fracture of the Forearm, angular displacement, and union be- 
 
 SUCh displacement varying be- tween the bones (Stimson). 
 
 tween six and forty degrees. 
 
 The action of the biceps may also produce angular displacement by flexing the 
 upper fragment. Rotation of the forearm may be lost in consequence of 
 excessive formation of callus, of the union of the callus on the two bones (Fig. 
 99), or of ossification of the interosseous ligament. 
 
 The diagnosis of fracture of both bones is easy, that of either bone alone 
 may be more difficult : independent mobility in the radius may be recognized 
 by observing that the head of the radius does not share in slight rotatory move- 
 ments communicated to the lower end ; in isolated fracture of the ulna there is 
 localized pain, often a corresponding irregularity in outline that is easily rec- 
 ognizable, and sometimes independent mobility can be obtained. The position 
 of the head of the radius should always be verified in case of fracture of the 
 ulna alone, for its dislocation forward and upward is a not infrequent compli- 
 cation. 
 
 Treatment. — Reduction is made by traction, with or without pressure upon 
 the projecting angle Avhen one exists, pressure being necessary in "green- 
 stick " fractures; and by deep pressure with the fingers in front and behind to 
 press the bones apart if they have been approximated. Anterior and posterior 
 padded splints, long enough to reach from below the palm to the elbow and 
 ■wide enough to prevent circular constriction of the limb by the bandage that 
 
318 
 
 .l.V AMERICAN TEXT-llOOK OF SURGERY. 
 
 secures them in place, are usually sufficient to maintain reduction. Tlie fore- 
 arm should be midway Itetwoon pronation and su)>ination. P'requcnt inspection 
 is necessary at first to detect dan^jferous constriction. (langrene has occurred 
 from pressure of the upper end of the palmar splint ajiainst the brachial artery 
 at the bend of the elbow. This splint may, therefore, with advantage be made 
 from one to three inches shorter than the posterior one. For the same reason 
 it is well to apply the splints -while the forearm is flexed upon the arm. The 
 supporting sling should not rest against the ulna. If there is reason to guard 
 against supination of the upper fragment by the bice])s, the wrist must be 
 correspondingly supinated ; this position is somewhat irksome, and has the 
 disadvantage of bringinguhe bones nearer together at the center than they are 
 when the limb is in the midway position. After two or three weeks a moulded 
 plaster-of-Paris dressing may be substituted for the splints. All dressings are 
 discarded after four or five weeks. In simple fracture of the radius or ulna 
 alone witliout disphicement moulded plaster of Paris may be safely used even 
 earlier. If dislocation of the head of the radius forward and upward has 
 occurred in connection with fracture of the ulna alone, the limb should be 
 dressed after reduction, Avith the elbow flexed at less than a right angle. 
 
 Fracture of the lower end of the radius (Colles's Fracture) 
 is one of the most common of all fractures; it is seen at all ages, but with 
 the greatest frequency in the old. It is generally produced by a fall upon 
 the palm of the hand. The line of fracture is usually situated at from one- 
 third to three-fourths of an inch above 
 
 Fig. 100. 
 
 Fig. 10 
 
 the articular edge, and is transverse, 
 but may be oblique in either direc- 
 tion, and sometimes the lower frag- 
 ment is comminuted. In the young 
 it occasionally follows the epiphyseal 
 line. The commonest di)<placeinent 
 is of the lower fragment backward 
 (Figs. 100 and 101), with ascent of 
 the styloitl process by crushing, and 
 of the posterior articular border by 
 tilting or angular displacement, so 
 that the articular surface looks down- 
 ward and backward instead of down- 
 ward and forward. The periosteum 
 on the back of the bone remains 
 untorn, but is stripped up from the 
 upper fragment so as to form a '' ))eri- 
 osteal bridge:" the consequent fonna- 
 tion of bone in the interval gives to 
 specimens of old unreduced fractures 
 the appearance of deep penetration 
 of the lower by the upper frngment. Exceptionally the styloid process of the 
 ulna may also be broken off. or even the shaft of the idna l)roken close above 
 its lower end. 
 
 The symptoms are a characteristic deformity, consisting in a prominence 
 on the back of the forearm close above the wrist corresponding to tlie lower 
 fragment, producing what is often called the '' silver- fork " deformity (Fig. 
 102), and a fulness on the palmar surface at a somewhat higher level, cor- 
 responding to the end of the upper fragment; the ascent of the styloid process 
 of the radius to or above the level of that of -the ulna; pain on pressure along 
 
 Rerently-united Fracture 
 of the Lower End of the 
 Radius (R. W. Smith). 
 
 Fracture of the Lower 
 Knd of the Radius, 
 displaeemeiit of bro- 
 ken fragment back- 
 ward (Stimson). 
 
FBA CTUBES. 
 
 31!) 
 
 the line of the fracture posteriorly ; and swelling of the front of the wrist, 
 with deepening of the transverse lines between it and the hand. Crepitus 
 and abnormal mobility are often absent. Because of the swelling of the 
 soft parts the palmar and dorsal prominences are more marked than the 
 displacement of the fragment, and may even be present Avhen there is no 
 displacement. 
 
 Fig. 102. 
 
 " Silver-fork " Deformity of CoHes's Fracture, photographed half an hour after the accident (original). 
 
 Treatment. — Eeduction, which at times is very difficult and even impos- 
 sible, should be first attempted by traction upon the hand and. direct pressure 
 upon the fragments ; if that fails, the wrist should be placed in forced extension 
 and the fragment pressed downward by the surgeon's thumbs while his fingers 
 grasp the forearm above the fracture. If this also fails, an anesthetic should 
 be given, and the fragment mobilized by pressing it backward, and then forced 
 forward into place. It is of great importance to the appearance of the limb 
 that the posterior displacement should be fully corrected : that which is due to 
 the crushing of the spongy tissue and shortening of the outer border of the 
 bone cannot be corrected. If reduction is well made, there is but little 
 tendency to recurrence. The limb is then placed between short anterior and 
 posterior splints, the former padded lightly at the point co^i-esponding to the 
 end of the upper fragment, and the latter more thickly where it rests against 
 the lower fragment, and the splints fastened by a circular strip of adhesive 
 plaster near each end and at the middle, or held in place by a roller bandage. 
 The posterior splint should end at the wrist ; the anterior one may end at the 
 same level, or may be carried to the palm with a pad at its lower end, over 
 which the fingers may partly close. Similar anterior and posterior moulded 
 splints of plaster of Paris are very convenient and equally secure. Many 
 surgeons prefer after reduction to place the hand in flexion on a Levis's 
 metallic splint. In cases where there is little tendency to displacement 
 of the lower fragment a Bond's splint with the wedge-shaped compresses, 
 as above, Avill give excellent results. The dressing of Barton is that pre- 
 ferred by some surgeons, and varies a little from the one just described. 
 Two wedge-shaped compresses and two light, well-padded splints, long 
 enough to reach from the elbow to the tips of the fingers, are employed. 
 The compresses are placed over the region of the fracture, one on the dorsum 
 of the wrist with its base upward and resting on the upper end of the lower 
 fragment, the other on the front of the wrist, its base downward and correspond- 
 ing to the lower end of the upper fragment. They are held in place by a few 
 turns of a roller ; the anterior splint (the shorter of the two) is next put in 
 
320 AN AMERICAN TEXT-IiOOk' OF SURGERY. 
 
 position, ;iii(l the roller is carried over it while extension is kept up by 
 an assistant, and then the posterior splint is applied. The arm is kept 
 midway between pronation and supination ; the thumb is left free. Pas- 
 sive motion of the finj^ers should be constantly made. The splint is to 
 be worn for three weeks. Passive motion of the wrist is to be commenced 
 after a week. In the young, growth of the bone may be arrested by the 
 traumatism, with a resultant deformity resembling that of a fracture with 
 much crushing of the spongy tissue. As there is sometimes a lateral 
 spreading of the lower fragment by comminution, especially when the 
 causative violence has been great, lateral pressure at that point may be 
 advantageous, as by a circular strip of adhesive plaster, as recommended 
 by Pilcher, or by making the palmar plaster splint broad enough to cover 
 the sides of the wrist and pressing it against them with moderate force 
 while it is hardening. The <lressing should be worn about three weeks, 
 and the patient should be directed to use the fingers freely in the mean- 
 time. 
 
 Fracture of the anterior or posterior lip of the lower end of the 
 radius is an occasional accompaniment of dislocation of the carpus forward or 
 backward respectively; the latter is known as Barton s fracture. 
 
 Fracture of a metacarpal bone may be produced by direct or indirect 
 violence ; the diagnosis is made by localized pain increased by pressing the 
 corresponding finger upward, and perhaps by abnormal mobility and crepitus. 
 The tendency to displacement is slight, and no special treatment is required 
 other than a palmar splint padded to preserve the concavity of the metacarpus. 
 
 Fractures of the phalanges are usually the result of direct violence, 
 and are often compound. In fracture of the proximal phalanx there is a 
 marked tendency to angular displacement with the apex directed forward, 
 which if left unreduced is the source of considerable disability. A convenient 
 and efficient treatment is to close the fingers over a cylindrical roller bandage 
 of suitable size, and bind them there with longitudinal strips of adhesive 
 plaster or another roller bandage outside ; or a padded palmar splint may be 
 employed. 
 
 FRACTURES OF THE PELVIS. 
 
 These fractures include complete fractures at one or more points of either 
 or both innominate bones, and fractures of any of the three bones constituting 
 the innominate. 
 
 Fracture of the ring of the pelvis is caused by great external vio- 
 lence, such as the passage of the wheel of a wagon across the bone, the fall of 
 a heavy object, the caving in of an embankment, the kick of a horse, or a fall 
 from a height. It may be single, double, or multiple. The most frequent 
 seat is in the pubic bone, the line of fracture passing through the upper ramus 
 just internally to the ilio-pectineal eminence, and through the lower ramus near 
 its junction with the ischium. With the anterior fracture may be associated 
 a posterior one (double vertical fracture of the pelvis), either in the ilium behind 
 the acetabulum or in the sacrum, or partly in either bone and partly along the 
 sacro-iliac synchondrosis, or another anterior one through the opposite pubic 
 bone. Sejjaration of either symphysis is the practical equivalent of a fracture, 
 but separation of the pubic symphysis alone may be occasioned by much 
 slighter violence than that which is rerjuired for a fracture ; separation of both 
 symphyses is caused only by great violence, and is usually described as disloca- 
 tion of the OS innominatum. The pubes is sometimes broken in two places or 
 comminuted. An exceptional form of fracture of the lateral portion of the ring 
 
FRACTURES. 321 
 
 is that in wliicli the violence is exerted through the femur and produces a 
 radiating fracture of the acetabuhnn. 
 
 Associated injuries are common and severe : the most freijuent in the male 
 is rupture of the membranous portion of the urethra (see Injuries of the 
 Urethra), the laceration extending in severe cases through the perineum and 
 around the rectum and anus ; rujiture of the bladder is next in frequency, and 
 then injuries of other abdominal viscera. 
 
 The displacement is sometimes very marked, so that it is easily recognized 
 by the finger and eye ; in other cases the diagnosis must be made by localized 
 pain caused by direct pressure or by pressure inward or backward upon the 
 wing of the ilium. The patient is unable to raise the leg from the bed. Rup- 
 ture of the urethra is indicated by bleeding from the meatus. 
 
 The treatment of the fracture consists in immobilization of the pelvis by a 
 girdle, aided in donlde vertical fracture by traction upon tlie limb, us after 
 fracture of the thigli. Immobilization is maintained for six weeks. If the 
 fracture is compound, ample drainage must be provided ; and if the urethra 
 is injured, perineal section must be made. 
 
 Transverse fracture of the sacrum is very rare, and has always 
 been caused by direct violence. It is fretjuently associated with paralysis of 
 the bladder, rectum, and lower limbs. The displacement is angular, with the 
 apex directed backward, and can be corrected by pressing the coccyx forward. 
 
 Fracture of the coccyx, which is very rare, resembles in symptoms and 
 treatment dislocation of the same bone. 
 
 Fractures of the wing and processes of the ilium are compara- 
 tively frequent. The crest of the ilium may be broken ofl" by direct violence, 
 the size of the fragment varying greatly in the different cases. The anterior 
 superior spinous process has been broken off by direct violence and by muscular 
 action; the posterior inferior and the anterior inferior, by direct violence. 
 The diagnosis is made by recognition of a movable fragment with crepitus. 
 No special treatment other than rest in bed is required. 
 
 The ischium has been broken in a few cases by direct violence, as a fall 
 upon the buttocks ; the fragment in some cases has included almost the entire 
 bone, in others only the tuberosity. 
 
 Fracture of the pubes not extending across both rami is rare : we have 
 seen one case in which the upper half of the body and the adjoining part of 
 the horizontal ramus W'ere broken off; the fracture w'as compound, and the 
 fragment was removed. 
 
 Fracture of the rim of the acetabulum is a complication of disloca- 
 tion of the hip. 
 
 FRACTUEES OF THE FEMUR. 
 
 Fracture of the Neck of the Femur. — This is far more common in 
 elderly people, especially in women, than in the young or middle-aged, and is 
 generally caused in them by comparatively slight violence, as a fall while 
 walking, a misstep, or even the effort to avoid a fall. The old classification 
 as intra- and extra-capsular fractures, which was always unsatisfactory 
 and took no account of the large group of "mixed" fractures in which the 
 line lay partly within and partly without the capsule, has now in great part 
 given place to a division into fractures at the base of the neck and fractures 
 at the small part of the neck. 
 
 In fractures at the small part of the neck (Fig. 103) the line of 
 fracture crosses the neck transversely or obliquely, and is rarely impacted ; 
 a portion of the periosteum, usually on the anterior and inferior surface, 
 
 21 
 
322 
 
 ^i^v A mi: UK AX text-book of suroeuy 
 
 conimonly remains untorn and aids in supplying blood to the head. ])oiiv 
 union is possible, but unlikely. Separation of tlie epiphysis, \\liich is consti- 
 tuted by the head alone, oeeasionally ha]i|)cns, ami belongs in this group. 
 
 In fracture at the base of the neck (Fig. 104). the more common 
 variety, the line of fracture follows more or less closely the junction of the 
 
 Fio. 103. 
 
 Fk;. 104. 
 
 Fig. lOo. 
 
 Fracture at the Small Fart of the 
 Neck of the Femur (Stimson). 
 
 Fracture at the Base of the Neck 
 of the Femur, with splitting of 
 the great trochanter (Stimson). 
 
 Impacted Fracture at the Base of 
 the Cervix Femoris, with heud- 
 inp of the head backward (Bige- 
 low). 
 
 shaft and neck ; the fragments are often impacted (PI. XII, Fig. 2), and the 
 great trochanter split ; the crushing or impaction appears commonly to be 
 greater at the back than at the front, so that the neck is inclined backward 
 from its normal position Avith reference to the shaft, or, in other words, the 
 shaft is in outward rotation upon the neck (Fig. 105). Bony union is the 
 rule, and often with excessive production of bone about the fracture and the 
 trochanter. 
 
 The srimptoms of both varieties are inability, often complete, to use or 
 move the limb ; but occasionally the patient has been able to raise the limb 
 from the bed or even to walk a short distance. As a rule, however, the 
 limb lies straight and helpless on the bed, the foot is everted, the upper part 
 of the thigh is fuller and rounder than usual. Complaint is made of pain 
 at the hip, and often in the anterior and inner part of the middle of the 
 thigh. Pain is caused by pressure in front of or behind the neck, against 
 the trochanter, or upward at the knee or ankle ; but sometimes the limb can 
 be pressed quite forcibly upward without causing pain. If eversion of the 
 foot is absent, it will nevertheless be found that passive inversion is less 
 complete than normal. Occasionally the foot is fixed in inversion. Pres- 
 sure over the front of the neck shows that the tissues are less depressible 
 than on the other side — a valuable si<<;n in obscure cases. On jxentle rota- 
 tion of the limb the trochanter is found to share in the movement, and occa- 
 sionally crepitus is felt. 
 
 Measurement (in making which care must be taken to place the limbs sym- 
 metrically Avith reference to the pelvis, as mentioned on page 289) shows the 
 injured limb to be shorter than its fellow, the diiferenee varying between a 
 small fraction of an inch and two inches. This is best done l)y marking the 
 site of the spines with an aniline pencil, and then measuring from the fixed 
 
FRA CTURES. 323 
 
 niiilleolns to the mark over spine \vitlioiit touching the skin at the latter 
 point. Similarly, the trochanter is found to occupy 
 a higher position than its fellow with reference to a 
 line'^lrawn across it from the anterior superior spi- 
 nous process of the ilium to the tuberosity of the 
 ischium (Nelaton's line) (Fig. 106). If a line be 
 drawn through the two anterior superior spines, and 
 the distancefrom the summits of the trochanters to 
 this line be measured, it will be found shorter on 
 
 the injured sule (Bryant's line) (Fig. 106). ^ ^ ^ ^^^^^^^^^^^^ 
 
 The diagnosis between the two vaiieties can- Triangle; a B.Neiaton's Line 
 not always be made with certainty: a positive '-Owen). 
 sign of fracture at the base of the neck is enlarge- , , • r 
 
 ment of the trochanter, due to its splitting ; and it is thought that in frac- 
 ture of the small part of the neck the shortening is more likely to be slight 
 at first and to increase suddenly and rapidly during the first few days from 
 separation of the interlocked fragments. The opinion once very widely held, 
 and even now occasionally encountered, that the differential diagnosis can be 
 made bv consideration of the age of the patient (intracapsular fractures in 
 those more than sixty years old) or of the way in which the violence was 
 received (intracapsular by a fall on the knee or foot, extracapsular by a fall 
 upon the trochanter) has proved to be wholly untrustworthy. 
 
 It may even be impossible to say with certainty that a fracture is present, 
 but in anv case in which an elderhj person, especially a woman, has fallen and 
 complains of imin at the hip, with inahility to use the limb, a fracture is prob- 
 able, and the case should be treated as such for at least three weeks and until 
 all pain and soreness have ceased. It has happened, often enough to justify 
 great caution in giving an opinion, that the positive signs of fracture have not 
 appeared until after a number of days, perhaps after the patient has been 
 assured that he has suffered no serious injury and has been encouraged to use 
 the limb. In not a few cases the patient has remained disabled long after the 
 surgeon has ceased his attendance, and has sued the latter for malpractice. 
 
 The indications for treatment are, in the order of their importance, m the 
 case of the old and feeble, to guard against the danger to the life of the patient 
 arisincr from the traumatism and the necessary confinement, to secure firm 
 union? and to have the minimum of deformity. The vital indication requires 
 that the patient's strength should not be further taxed by dressings that cause 
 pain or by prolonged confinement to bed if its ill eff'ects become manifest and 
 threaten to become serious. In the latter case, if necessary, union of the frac- 
 ture must be sacrificed to the preservation of life. Special attention must be 
 given to securing comfort and good nourishment and to the avoidance of bed- 
 sores. Local treatment is limited to making only so much reduction of the 
 shortening as can be efi"ected bv moderate traction, and to immobilization by 
 traction arid cushions or by a fixed dressing. Complete removal of the short- 
 enincr is liable to break up an impaction that would be valuable m securing 
 union. Traction bv Buck's extension (Fig. 84) with a weight of five, or at 
 most ten, pounds prevents further shortening and promotes comfort, and small 
 firm cushions or sand-bags placed behind the trochanter and along the outer side 
 of the thigh aid the immobilization. Hodgen's suspended splint (Fig. 88) is even 
 better than Buck's. For immobilization without permanent traction either a 
 lono- side-splint, extending from the side of the chest to the foot, or a plaster- 
 of-Paris dressing, including the entire limb and the pelvis, may be employed. 
 Lateral pressure in non-impacted fractures is of great importance m securing 
 
324 AX AMERICAN TEXT- HOOK OF SriKiKRY. 
 
 bony union, and on this account Senn recommends with the latter dressing the 
 use of direct pressure inward against the trochanter, made through a fenestra by 
 a pad at the end of a screw that passes through an iron supjwrt iiiihedck'd in the 
 plaster. A well-applied plaster dressing apjjcars to meet the indication suffi- 
 ciently well. The dressing should be worn for about two months if tlic patient's 
 condition permits. 
 
 It is to be expected that some shortening and outward rotation of the limb 
 will persist ; and the range of motion of the joint may be considerably restricted 
 by the consequences of the arthritis or by an exuberant callus. Even if union 
 fails or is fibrous, the patient may still be able to make fair use of the limb, 
 the support being given by the Y-ligament, which secures a bearing against the 
 ilium in the ascent of the shaft. In a few cases in which union has failed and 
 the disability has been great and the condition painful, operations have been 
 done to obtain union by freshening the surfaces and suturing or pinning the 
 fragments toorether, or to remove the detached head. 
 
 Fracture of the great trochanter has been occasionally caused by 
 direct external violence. The patients have usually been able to walk not- 
 withstanding the injury. In the specimens obtained after death the fracture 
 has always been found to be entirely outside the joint. The fragment may 
 be large or small, and in the young may comprise the entire trochanteric 
 epiphysis, separated along the conjugal cartilage. The diayni>><iH must be 
 made on the independent mobility of the fragment and localized ])ain. The 
 treatment is rest, aided perhaps by a bandage to oppose the retraction of the 
 fragment upward and backward by muscular action. 
 
 Fracture of the shaft may be caused by direct or indirect violence or 
 by muscular action. All the varieties of fracture of the shafts of long bones are 
 found here, but the commonest is oblique fracture, often with the splitting oflF 
 of a lateral piece, and Avith either or both main fragments ending in a long 
 sharp point : transverse fracture appears to be quite common in children. 
 
 Symptoms. — Angular displacement and overriding are greatly favored by 
 the contraction of the muscles, both those connecting the lower fragment with 
 the pelvis and those that flex and abduct the upper one. Outward rotation of 
 the lower fragment may be produced by the unsupported weight of the foot, 
 which turns to tlie outer side ; outward rotation of tlie up])er fragment may be 
 caused in like manner by the unsupported weight of the upper and outer por- 
 tion of the thigh, the foot being meanwhile held upright. The latter displace- 
 ment is equivalent to inward rotation of the lower fragment, and when the 
 patient begins to walk he finds that the toes turn in. Compound fracture and 
 associated injury to the large vessels are infrequent. Distention of the knee- 
 joint by an effusion immediately after the injury is the rule, and is probably 
 due to a concomitant sprain. 
 
 The diagnosis is made by pain, loss of function, shortening, abnormal 
 mobility, and crepitus. Measurement is made, as in fracture of the neck of 
 the femur, from either the malleolus or the knee to the anterior superior spine 
 of the ilium, and the same precautions are needed to ensure symmetry of posi- 
 tion. The fact that the shortening has occurred in the shaft, and not in the 
 neck, is shown by the normal relation of the trochanter to N(?laton's line. 
 Abnormal mobility can be recognized by passing the hand under the limb at 
 the suspected point and gently raising it, or by grasping the upper ])art of the 
 thigh firmly and moving the foot inward and outward, or by observing that the 
 trochanter does not share in gentle rotatory movements communicated to the 
 lower portion of the limb. Steady traction overcomes or diminishes the short- 
 ening. The thickness of the overlying muscles usually prevents recognition 
 
FRA ( 'TUBES. 325 
 
 ot" till' details of the fViieture aiid displaeeiiieiit. Sometimes the sharp cud of 
 one fragment perforates the muscles and the slcin, commonly the upper frag- 
 ment in front; the penetration can be relieved by flexing the thigh upon the 
 pelvis and the leg upon the thigh, the movement drawing the nmscle down 
 past the fragment. 
 
 Treatment is commoidy by one of the methods of continuous traction, 
 Buck's extension by weight and pulley (Fig. ''^4) or suspension by Ilodgcn's 
 (Fig. 88) or N. R. Smith's anterior splint (Fig. 87) in adults, or vertical sus- 
 pension in infants and young children. Ilodgen's splint is especially useful in 
 compound fractures, because of the facility with which it permits the dressings 
 of tlie wouiul to be changed. The methods of a{)plying Buck's extension and 
 the suspended splints have been already described. The plaster-of-Paris dress- 
 ing, including the pelvis, is still in use, but its results are not so satisfactory 
 as those obtained by the other methods. Vertical suspension in young children 
 is very usefid, because of the ease Avith wdiich the position can be maintained 
 and the child kept clean. The suspension is made by two india-rubber cords 
 attached to a cross-bar above the bed and one to each leg by adhesive plaster, 
 as in Buck's extension; the limbs are kept parallel by attaching the feet to a 
 short foot-})iecc. The traction should be just sufficient to raise the buttocks 
 slightly from the bed. 
 
 Union is complete in the adult in from six to eight weeks ; in young children, 
 in three or four. It is advisable to keep the patient in bed for a week after 
 the dressings have been removed, and to insist upon the use of crutches for a 
 week or two thereafter. Usually some shortening persists. 
 
 Fractures at the Lower End of the Femur. — In this group are 
 included the supracondylar, intercondyloid, fracture of either condyle, and 
 separation of the epiphysis. 
 
 Supracondyloid fracture is commonly produced by indirect violence, as 
 a fall upon the feet ; the line of fracture is oblique or transverse ; and the usual 
 displacement is of the lower fragment backward. Flexion of the lower frag- 
 ment upon the tibia by the action of the gastrocnemii, by which its fractured 
 surface is directed somewhat backw'ard, occasionally occurs, but is by no means 
 so frequent as has been alleged. A dangerous complication 
 is sometimes found in rupture or stretching of the popliteal ^^- ■^^^• 
 
 vessels. The diagnosis is easily made by recognition of the 
 common signs of fracture. Treatment is by the plaster-of- 
 Paris dressing or by suspension in Ilodgen's or Smith's an- 
 terior splint. 
 
 Separation of the epiphysis is commonly caused 
 by torsion or hyperextension of the leg. The treatment is 
 the same as in the preceding variety. 
 
 In intercondyloid fracture (Fig. 107) the condyles 
 are separated from the shaft and from each other. It is 
 caused by great violence, as in a fall from a height, and is 
 
 consequently often compound and accompanied with much 
 
 displacement. It is always a serious injury, and if com- intercondyloid Fracture 
 pound, a grave one. Continuous traction by Buck's exten- of Femur (Bryant). 
 sion or a suspended splint is advisable for the first two or three weeks, after 
 which, if all is going well, the limb can be put in plaster. If compound, it is, of 
 course, to be treated antiseptically. 
 
 Fracture of either condyle may be caused by direct violence, as in a 
 fall upon the flexed knee, or by lateral flexion of the leg: the line of frac- 
 ture runs from the intercondyloid notch more or less obliquely upward. The 
 
326 ^lA^ AMERICAN TF.XT-liOOK OF SVIiaKli V. 
 
 fragment remains attached to the tihia hy its latonil linaincnt, an<l the «lis- 
 |)lacement is therefore usually sli^^iit, alt'hou<^h the fra;,rujent is soiuftiiues 
 carried forward or l)ackward by rotation of tlie leg. The courmc is usually 
 simple and the result good, but in a few cases suppuration of llie joint or 
 necrosis of the fragment lias followed. The dicujuoaia is made by the recogni- 
 tion of abnormal mobility and crepitus ; sometimes the only sign is localized 
 pain on pressure, or on lateral flexion of the leg toward the injure<l side. The 
 treatment is reduction of the displacement, if any, by bringing the leg to its 
 proj)er position in full extension, and immobilization, preferably in plaster. 
 
 Fracture of the patella is an injury of frequent occurrence between 
 the ages of twenty and fifty years, especially in males. It is usually the 
 result of muscular action, but sometimes of direct violence, and sometimes of 
 forcible flexion of the partially stiff" knee when the descent of the patella is 
 prevented by adhesions; the latter is the common method of production of 
 refracture. Dull pain is occasionally felt in the patella for some days before 
 it breaks. Simultaneous fracture of both patellae has been reported a num- 
 ber of times. 
 
 The line of fracture is almost always transverse, and, while generally near 
 the middle of the bone, may be close to either end; exceptionally it may be 
 oblique. In fractures by direct violence it is more or less comminuted, and is 
 likely to be compound, or to become so by the sloughing of the bruised skin 
 The upper fragment is drawn upward by the quadriceps to a greater or Icsst^r 
 distance, but in some cases, and especially in fractures by direct violence, so 
 much of the periosteum remains untorn that the separation is very slight. As 
 a rule, the periosteum ruptures at a different level from that of the fracture, 
 and thus is produced a narrow fringe which lies between the fragments 
 when they are approximated, and to which much importance has been attributed 
 as a cause of failure of bony union. The capsule is torn transversely on each 
 side to a distance that varies with the separation, and the cavity of the joint 
 promptly fills with blood and synovia, which still further increase the separa- 
 tion by distention. 
 
 The symptoyns are loss of the power of active extension of the leg, inde- 
 pendent lateral mobility of the fragments, and usually a distinct transverse gap 
 between them which can be closed by pressing them together. 
 
 The treatment is immobilization of the extended knee for about two months, 
 usually combined with dressings arranged to keep the fragments in contact with 
 each other. When the periosteal covering is not torn and the separation is 
 slight, a plaster-of-Paris dressing, extending from the ankle to the upper 
 third of the thigh, is sufficient, but in other cases special dressings are 
 needed. Of these the variety is great. The simplest form consists of turns 
 of a roller bandage, with a long iKJSterior splint, applied obliijucly above 
 and below the fragments, so as to press and hold them together (Fig. 108) ; 
 the patient should be kept in bed with the foot raised. Agnew's splint 
 (Fig. 109) consists of a piece of pine board thirty inches long, five inches 
 wide at the top, and four at the lower end, with four lateral pegs. Fig. 
 110 shows the manner of its application, the fragments of the fractmx'd 
 patella being drawn together by the adhesive ])laster stri))s. Another 
 method is by elastic traction applied to the upper fragment: a ])iece of 
 rubber tubing is made fast to each end of a strip of adhesive plaster 
 about eight inches long and two inches wide; the adhesive plaster is then 
 placed transversely close above the upper fragment, and the ruljber cords 
 are stretched down on each side of the leg and made fast to the posterior 
 si)lint. After eight weeks the patient is permitted to walk with the 
 
FBA CTUBES. 
 
 327 
 
 aid of a crutch or cane, with light side-splints of pasteboard to the knee. 
 Mal.'aicrno's hooks (Fig. Ill) are used by forcing one through the skin into 
 the ui)Jer border of the upper fragment, the other into the lower border 
 of the lower fragment, and then bringing them together by means ol the 
 
 Fig. 108. 
 
 Hamilton's Dressing for Fracture of the Patella. The final turns of the roller in front of the knee are 
 
 not shown in the cut. 
 
 screw. Treves employs them after a preliminary exposure and freshen- 
 ing of the fragments, as in the operation of suturing, over which he thinks 
 this procedure" has some advantages. In any of these methods the effu- 
 sion in the joint may often be promptly removed by the use of a rubber 
 
 Fig. 109. 
 
 Fig. 110. 
 
 Agnew's Splint for Fractured Patella. 
 
 Agnew's Splint Applied. 
 
 bandage, or the joint may be primarily emptied by aspiration of its 
 
 contents. m, /> 
 
 Operative measures include various forms of suture. The first to be em- 
 ployed was an open arthrotomy wuth direct suturing of the fragments with 
 
 Fig. 111. 
 
 Malgaigne's Hooks. 
 
 silver wire : it has given many brilliant successes, but also cases of suppuration 
 of the joint, some with loss of the limb or loss of life — a risk which, in the 
 opinion of some surgeons, the nature of the injury rarely justifies. The ope- 
 ration should only be done under strict antisepsis and in healthy subjects. In 
 
328 AiX AMERICAA TEXT-IK >< >!< O/ sri!(; EL' Y. 
 
 coinpouiiil t'nictures it is not «jnly pcriui.ssible, but is otteu clotirly indicated. 
 The operation is done by exposing the fragments, freshening the fractured sur- 
 faces if the fracture is an ohl one, or dissecting away the fibrous tissue and 
 fragments of periosteum or synovial meniltrane often found interposed, and 
 drilling the bones in the median line, the diill-holcs ruTiuing (jbliijuely from the 
 anterior surface of the attached border of each fragment toward the posterior 
 edges of the fractured surfaces. Silver wire is then introduced and the 
 fragments are approximated, the wire being cut short and the ends ham- 
 mered into the bone, or else left to protrude from the wound to be with- 
 drawn later. 
 
 The substitution of a silk ligature through the tendon of the quadriceps 
 and the ligamentum patelhx^ for the wire suture through the bone is {^referred 
 by some. The joint must not be invaded by the ligature. An antiseptic 
 dressing is applied, and the limb kept on a posterior splint for a week. If 
 all has then gone well, a plaster-of-Paris dressing is applied and Avorn for a 
 month ; after that, for another month it is worn only in the daytime and 
 removed at night. The silk should be boiled and all antiseptic rules should 
 be most rigidly followed; if suppuration occurs, free exit should be promptly 
 given to the pus, to diminish the risk of invasion of the joint. The ligature 
 may be employed subcutaneously by means of a long, slightly-curved needle 
 introduced and brought out in turn through four small incisions, two above 
 and two below the patella, or, better (Stimsou), through a longitudinal median 
 incision four or five inches long, fully exposing the bone, and the tendons. 
 After the joint has been emptied and the fringe, if present, raised from the 
 broken surface, the silk ligature is passed by means of a curved needle trans- 
 versely through the tendon of the quadriceps and the ligamentum patella 
 close to the bone, drawn tightlv to brincr the broken surfaces into contact, 
 tied and cut short. The fibrous layers between it and the patella should be 
 smoothed out, and, Avhen necessary, catgut sutures applied to close the 
 lateral rents in the capsule. Recent experience has sIiOAvn that catgut 
 sutures in the fibro-periosteal layer give all the support needed. In this 
 form the operation is the simplest and safest, and is as efficient as any 
 other. 
 
 Among other methods that have been recommended may be mentioned 
 subcutaneous longitudinal drillin(T of the fragments and the use of a silver 
 suture ; transverse drilling of each fragment, the drills being left in place and 
 tied together on each side. Barker's operation (Figs. 112, 118), which hasfound 
 much favor with many surgeons, is done as follows: The lower fragment of the 
 patella is steadied by the finger and thumb, and a narrow-bladed knife thrust 
 into the joint, edge upward, in the middle line of the ligamentum patelh\? at 
 its attachment to the lower fragment. Through the wound thus made a stout- 
 handled pedicle needle is thrust into the joint behind the lower fragment, and 
 pushed up behind the upper fragment and through the quadriceps tendon in 
 the middle line as close to the border of the bone as possible, the upper frag- 
 ment at this time being forced down and steadied. When the point of the 
 needle becomes apparent beneath the skin, the latter is drawn upward and 
 an incision made upon the needle, the eye of which is then threaded with 
 sterilized silk and the needle Avithdrawn, carrying the thread behind the frag- 
 ments. The needle is next unthreaded and passed through the same skin 
 wound below and out of the upper wound, but this time in front of and close 
 to both fragments. Here it is threaded with the upper end of the suture and 
 
 withdrawn. The two fragments are then brought together, friction is made 
 
 . . . 
 
 to displace clots or other foreign material, and the ligature tied tightly over 
 
FRAC'TriiES. 
 
 329 
 
 the lower border of the patella. Tlie two ends of the li^xatnre are cut short 
 and the wounds closed. Union of the skin-wound is by first intention. 
 Passive motion is begun on the tenth day. 
 
 Union /.v almoat inrnridhli/ fi/iroux in cases treated without the suture, and 
 the bond of union habitually leuirtlicns somewhat under use, but this does not 
 materially affect the usefulness of the limb. In cases treated by the suture the 
 union is closer, and may occasionally be bony. 
 
 Rupture of the bond or rcfraeture of the bone at another point occasion- 
 ally liaj)})ens : the common cause is forcible flexion of the knee, in which the 
 upper fragment is prevented from moving by adhesions that unite it to the 
 femur or by shortening of the capsule on each side, which does not allow it to 
 pass below the condyles. The injury may become compound by rupture of the 
 adherent skin along the line of fracture. 
 
 In old cases, in which the disability is great because of the wide separation 
 
 Fig. 112. 
 
 Fj(;. 118. 
 
 Barker's Operation for Transverse Fracture 
 of the Patella (first stage). 
 
 Barker's Operation for Transverse Fracture of 
 the Patella (second stage). 
 
 of the fragments, open arthrotomy with suture has been done many times. 
 Since modern aseptic methods have come into use, the proportion of success- 
 ful cases has been much larger than formerly. 
 
 FRACTUEES OF THE LEG. 
 
 Fractures at the Upper End. — The tibia may be broken at its upper 
 end by direct or indirect violence, and the fibula may be simultaneously broken 
 or its upper end dislocated, or it may be uninjured. The fracture may be 
 transverse, oblique, or comminuted and impacted, or the line may run from the 
 side of the head into the joint, separating only one condyle, or it may follow the 
 epiphyseal line (separation of the epiphysis). In fractures by direct violence, 
 usually by a heavy blow upon the front of the bone, there may be marked angu- 
 lar displaceinent, the apex directed backward, or backward displacement of the 
 lower fragment, with the possibility of serious injury to the main vessels. In 
 fracture by a fall upon the feet the lower fragment is driven into the upper one, 
 splitting it and opening the joint. When the fibula is neither broken nor dis- 
 
330 .l.V AMUncAX TEXT- HOOK OF Si IlCKRY. 
 
 located, disphu-einent of the tibia is slight. The jirogiiosis is serious heciiuse- 
 of the probability of implication of the joint in the inflammatory reaction, and 
 it has been noted that repair of the fracture takes an exceptionally long time. 
 After separation, of the epiphysis the growth of the bone may be arrested. 
 
 The treatDwnt consists in the reduction of the displacement, and in exten- 
 sion by continuous traction, or by splints, according to circumstances. Manv 
 of these cases can be well treated ujion a double inclined plane, which is 
 used for six weeks. 
 
 Fracture of the Upper End of the Fibula may be caused by muscular 
 action (vigorous contraction of the biceps), by forced adduction of the leg, or 
 by direct violence. The fragment may remain in place or may be drawn 
 upward by the biceps. In several cases the external popliteal nerve has been 
 injured, either in the accident or in the process of repair, with consequent 
 paralysis of the anterior and peroneal groups of muscles. The treatment is 
 immobilization, with the knee flexed to relax the biceps. This is maintained 
 for five weeks. 
 
 Fracture of the Shaft may be caused by direct or indirect violence, 
 and in the latter case is more frequently situated at or near the junction of the 
 middle and lower thirds. It may be transverse, oblique, V-shaped, or commi- 
 nuted, and is frequently compound, either by the direct action of the violence 
 upon the overlying soft parts or by perforation of the skin by the sharp end of 
 one of the fragments, especially the upper one. When both bones are broken 
 the fracture of the tibia is commonly at a lower level than that of the fibula. 
 The common displacement is angular with overriding, the lower end of the 
 upper fragment being displaced forward. The injury can be readily recognized 
 by palpation of the subcutaneous surface of the tibia ; abnormal mobility, 
 ■which is greater when both bones are broken ; and crepitus. Fracture of 
 the fibula alone is shown by localized pain, and sometimes by abnormal 
 mobility. 
 
 Treatment. — After reduction by traction and coaptation the limb may be 
 secured by lateral splints or in a Yolkmann splint or fracture-box for a few 
 days until the swelling shall have subsided, and then in a plaster-of-Paris 
 dressing, or it may be secured at once in moulded plaster-of-Paris splints, 
 posterior and lateral. Care must be taken to prevent angular displacement 
 by the sinking of the foot, and it is always advisable to remove the dressings 
 and inspect the fracture after the first fortnight, when it is still possible to 
 correct angular displacement. Union commonly takes place in about six 
 weeks, but sometimes is long delayed. 
 
 Compound fractures should be dressed in accordance with general ])rin- 
 ciples, and the limb placed in a fracture-box or Volkmann splint ; if the 
 fracture has not become simple by the end of the first fortnight, interrupted 
 plaster splints arranged for suspension will be found convenient. Delayed 
 union and failure of union are not uncommon if there has been mucli loss of 
 substance of the tibia by splintering ; and if the fibula has maintained its 
 length a piece should be cut from it in order that the fragments of the tibia 
 mav be broujrht toirether. 
 
 Fractures at the Lower End. — Of these the most common and import- 
 ant is the one known as Pott's fracture at the ankle, which is caused by 
 forcible eversion and abduction of the foot : rarely by inversion and adduc- 
 tion of the foot. Fig. 114 shows the mechanism of both varieties. In a 
 typical case there are three separate lines of fracture (Fig. 115): one of the 
 fibula about three inches above the tip of the malleolus, and commonly 
 extending oblifjuely downward for an inch or more ; one of the internal mal- 
 
FRA CTURES. 
 
 331 
 
 leolus; and one of the outer lower edge of the tibia; but in the place of the 
 last two there is often rupture of the internal lateral ligament of the ankle 
 and also rujjtureof the lower tibio-fibular ligaments, or possibly their avulsion 
 from the tibia with a small scale of bone. In place of the fracture of the 
 internal malleolus there is often rupture of tlie internal lateral ligament. The 
 essential feature of the injury is the sei)aration of the external malleolus from 
 
 Fig. 114. 
 
 Fig. 11- 
 
 Diagrams to Illustrate the Mechanism involved in Fracture of the Lower End of the Fibula: .1, parts in 
 normal position: a, tibio-fibular ligament; b, external lateral ligament; c, internal lateral liganient , 
 B, fracture of fibula due to eversion of foot ; C, fracture of fibula due to inversion of foot (original). 
 
 the tibia and its displacement outward in company with the foot. "When the 
 injury is caused by pure eversion of the sole the fibula is broken less obliquely 
 and the internal malleolus is broken square across ; when abduction of the 
 front of the foot is associated with eversion, the fracture of the fibula is more 
 obli(iue and rupture of the internal lateral ligament is 
 much more frequent than fracture of the internal mal- 
 leolus ; if the latter occurs, it is oblique, the anterior 
 portion only being broken off. 
 
 The symptoms are the characteristic deformity (Figs. 
 116, 117), Consisting in outward displacement of the foot 
 and prominence of the internal malleolus, the existence 
 of three points of localized pain on pressure correspond- 
 ing to the three lines of fracture or the equivalent in- 
 juries, and the possibility of moving the foot from side 
 to side within the widened tibio-fibular mortise. Occa- 
 sionally the (broken) internal malleolus is forced through 
 the skm and the joint thus opened, or if the displace- 
 ment remains unreduced the .skin overlying the malle- 
 olus may slough in consequence of the pressure. The 
 foot has\ decided tendency to slip backward, sometimes 
 so far that the body of the astragalus lies entirely behind the tibia ; and this 
 displacement is frequently overlooked. 
 
 The essential point in treatment is to reduce the displacement completely 
 and prevent its recurrence ; the former is easy, and so too is the latter if suit- 
 able dressings are used, but each requires close attention and full appreciation 
 of the needs. Reduction is made bv grasping the leg firmly with one hand 
 and the foot with the other, and then, after lifting the latter forward, press- 
 ing it forcibly inward until the external malleolus is felt to rest against the 
 tibia. An efficient dressing is made of moulded plaster-of-Paris splints, one 
 
 L sual Three Lines of Frac- 
 ture in Pott's Fracture 
 at the Ankle (Stimson). 
 
332 
 
 A^' AMERICAN TEXT-JiOOK OF SURGE HY. 
 
 of wliich is placed posteriorly from just below tlie kiieo, alon^' the calf, the 
 heel, and the sole, to and beyond the toes ; the other begins on the dorsum 
 of the foot, crosses the outer border and the sole, and is carried up the inner 
 side of the leg: circular turns are placed above the ankle and at the uj)j»(t 
 ends of the splints. It is advisable to invert the sole of the foot, in order to 
 make sure that the lateral reduction is complete. While the splints are hard- 
 ening the foot must be held in place by the surgeon or by an assistant who 
 appreciates the necessity and the means of maintaining the reduction, both 
 inward and forward. This dressing is to be preferred to complete encase- 
 ment in plaster, because it permits inspection of the region. Good results 
 can also be obtained, though with less security, bv the use of an internal 
 lateral splint (Dupuytren's splint) projecting below the foot. A wedge- 
 shaped pad is placed between this splint and the leg, the base of the wedge 
 being just above the internal malleolus. The foot is then secured to this 
 
 Fig. 116. 
 
 Fig. 117. 
 
 Potts Fracture, showing Outward Displacement 
 ioriginal). 
 
 Pott's Fracture, showing also Backward Displacement 
 (original). 
 
 internal splint in adduction. Great care must bo taken to protect the skin 
 from too great pressure. The apparatus should be Avorn for five weeks. 
 
 Fracture by Inversion. — Forcible inversion of the foot, aided by the 
 weight of the body, breaks the external malleolus (or the lower part of 
 the fibula) and the tibia obliquely above the base of the internal malleolus, 
 and displaces the latter fragment upward and inward. 
 
 The Hj/mptomH are pain on pressure along the lines of fracture and the 
 recognizable displacement of the tibial fragment. The treatment is reduction 
 by traction upon and abduction of the foot and direct pressure on the frag- 
 ment, and immobilization in splints, preferably plaster The injury is likely 
 to bo followod by niarkc(l limitation of motion in the ankle-joint. 
 
 Fracture of the External Malleolus is caused by an inward twist of 
 the foot, by wliich the astragalus is so turned in its mortice as to force the 
 malleolus outward and break it. The line of fracture is lower than in Pott's 
 fracture, and lies within the lowest inch or inch and a half; sometimes separation 
 of the fibula from the tibia at the lower tibio-fibular articulation is produced 
 instead of fracture, as .shown by pain on pressure over the front of the joint ; 
 and. much more rarely, the tip of the internal malleolus is sometimes broken off 
 by the pressure of the astragalus against it in the .same twist of the foot. The 
 diagnosis of the fracture of the fibida is made by local tenderness on pressure 
 at its seat and on twisting the foot inward, and possibly by abnormal mobility 
 
DISEASES AND INJURIES OF THE MUSCLES, ETC. 333 
 
 recognized by pressure inward against the tip of the malleolus ; it is supported 
 by the history of the accident and the appearance by the second or third day of 
 an ecchymosis below the malleolus. No treatment is needed except rest and the 
 support of a dressing to prevent the occurrence of another twist of the foot. 
 
 FRACTURES OF THE BONES OF THE FOOT. 
 
 The astragalus may be broken by a fall upon the foot, the line of fracture 
 passing through the body or the neck, and the injury is frequently associated 
 with dislocation of one of the fragments. An exact diagnosis may be difficult 
 or impossible except when dislocation is present. The choice of treatment lies 
 between immobilization and removal of one or both fragments; the latter is 
 obligatory when the fracture is compound or when the associated dislocation 
 is such that the skin will slough or that the subsequent disability will be 
 great. The functional results after removal of the astragalus are very good. 
 
 The calcaneum may be broken by a fall upon the foot or by forcible 
 contraction of the nniscles attached to the tendo Achillis. In the latter case 
 a larger or smaller posterior fragment is torn off and may be displaced upward ; 
 the treatment is immobilization Avith the knee and ankle so flexed as to relax 
 the calf-muscles. Fractures due to a fall are usually comminuted, with 
 depression of the central part of the bone ; the diagnosis must be made upon 
 the flattening and broadening of the sole and heel (which can be best seen by 
 making the patient kneel and then comparing the soles of the two feet), and 
 by the relaxation of the tendo Achillis. The treatment is by massage and 
 immobilization, but the patient should be encouraged to use the limb as soon 
 as possible. 
 
 Fracture of the Metatarsal Bones is commonly caused by direct 
 violence, and is frequently compound ; the first and fifth are the most frequently 
 broken. The diagnosis is made by pain on pressure at the seat of fracture 
 or on pressing the corresponding toe directly backward, and by abnormal 
 mobility in the case of the first and fifth or when several toes are broken. 
 In simple cases no treatment is required except rest, with the foot elevated,, 
 and massage. 
 
 CHAPTER IV. 
 
 DISEASES AND INJURIES OF THE MUSCLES, TENDONS, AND BURSiE. 
 SECTION I.— DISEASES AND INJURIES OF THE MUSCLES. 
 
 The muscles, with very few exceptions, are situated beneath the external 
 layer of the deep fascia. By virtue of their contractility they bind together and 
 move the parts of the skeleton, contract and compress organs to which they 
 are attached, and aid in the protection of vessels and nerves, and of the viscera 
 in the great cavities. Their essential sarcous elements are held in place and 
 maintained in proper relation by connective-tissue investments ; their power is 
 transmitted through inelastic fibrous bands — the tendons — in part inserted into 
 the bones, in part blending with the periosteum or the great fascial planes. 
 Like other structures, they are at times the seat of disease and injury, though 
 much less frequently than might be thought probable from their number, size^ 
 and location. 
 
;334 AX AMlUncAN TKXT-llOOK OF SURGERY. 
 
 Myalgia. — Pain located in a imiscle, and to a jfrcatcr or loss extent pre- 
 venting its use, is of very frtMjuent occurrence, and dcjx'iids upon the action 
 of many causes, such as strain, twist, or slight laceration of the fibres, acute 
 infectious disease, poisoning, as by lead or syphilis, etc. Muscle-pain is the 
 one common symptom. In the majority of cases it is neuralgic, but may at 
 times be intiammatory. It is easily diagnosticated, and usually quickly sub- 
 sides, either spontaneously or in consequence of the employment of heat, elec- 
 tricity, anodynes, or anesthetics ; or it disaj)pears with the removal of the 
 exciting cause. 
 
 Rupture. — Blows from without or undue and sudden unopposed contrac- 
 tion may cause laceration, varying in degree from a tear so slight as not to be 
 distinguishable from simple stretching to a complete pulpification ; and in 
 result from speedy and perfect recovery to destruction of the part or even to 
 loss of life. Spo;itaneous rupture of liealthy muscle can occur only when the 
 contraction is sudden, unexpected, or of unusual character, as in the " lawn- 
 tennis leg" or "arm" of those unaccustomed to that form of exercise. But 
 when, in consequence of disease, especially typhoid fever, and, nmch less 
 frequently, scarlet fever, yellow fever, or other acute grave pyrexia, the fibers 
 have undergone granular or vitreous degeneration, their extreme brittleness 
 makes it possible for rupture to follow voluntary movement of slight extent. 
 The rectus abdominis, the rectus femoris, the adductors of the thigh, the calf 
 muscles, the psoas, and the flexors of the forearm are those most frequently 
 affected, and in the order given. Except in cases of laceration occurring in 
 the progress of general diseases, the occurrence of rupture is generally indi- 
 cated by a sudden sharp pain, accompanied with the sensation of snapping or 
 of the "giving way" of something in the injured region, by a well-marked 
 depression or a wide gap at the seat of injury, and by extravasation of blood, 
 with the subsequent color-changes in the skin. The ability to use the muscle is 
 either wholly or in great measure lost. Complete recovery may be expected 
 ■when the laceration is but slight, and even when quite extensive the ultimate 
 damage may not be great. When the abdominal muscles are the ones injured, 
 intestinal obstruction, simulating strangulated hernia or peritonitis, may be 
 developed. 
 
 In the treatment of these injuries the chief reliance must generally be 
 placed upon rest and the approximation of the edges of the laceration by posi- 
 tion and due compression. In rupture of healthy muscle sutures may advanta- 
 geously be employed, but are of little or no value when the muscle has under- 
 gone degenerative changes, since the stitches Avill ordinarily quickly tear out. 
 
 Hernia of Muscle. — Occasionally, in consocjuence of the imperfect heal- 
 ing of a w^ound of the overlying deep fascia, limited protrusion of the muscle 
 is observed to take place, Avith resulting impairment of muscular power. Such 
 a hernia is readily recognized by the marked fulness in the region at the time 
 of muscular contraction, disappearing when relaxation occurs, and by the 
 detection of an opening in the aponeurosis, the rounded edges of which may 
 readily be felt through the skin. In recent cases rest and methodical pressure 
 will generally effect a cure. When the hernia has long existed the edges of 
 the opening should be freshened and united by stitches. If. as is often the 
 case, the inconvenience resulting from the presence of the hernia is but slight, 
 the w-earing of a bandage may be all that will be required. 
 
 Myositis. — Muscle inflammation is almost always due to traumatism, to 
 contiguous inflammation, to diathetic states, or to the presence of parasites. 
 If consefjuent upon injury, it is usually a matter of but little im])ortance in 
 comparison with the other conditions dependent upon the traumatism. Sup- 
 
DISEASES AM) IXJURIES OF THE MUSCLES, ETC. 335 
 
 puration rarely takes place unless the injury be of the psoas muscle, and when 
 it iloos occur is usually followed by recovery. Occasioually, and especially 
 in badly-nourished individuals, there occurs a diffused iiilhiumiation of great 
 severity, aluiost always of septic oi'igin, in which the aft'ected muscle (juickly 
 breaks down, the patient generally dying speedily of septicemia. Only rarely 
 can it be cut short by early free incision. 
 
 So-called rheumatic myositis {myositis a frigore, muscidar rheumatism) 
 often affects the muscles of the back, the chest, or the neck, and is generally 
 attributed to sudden chilling of an exposed part. It is probably, in the great 
 majority of cases, not an intlanniiation at all, but the result of a sprain or a 
 twist of the muscle, the symptoms and treatment being those of myalgia. 
 
 During the course of a gonorrhea myositis has occasionally been observed, 
 generally in the muscles in relation with an inflamed elbow or knee, such 
 inflammation differing from the ordinary one only in its cause, which is proba- 
 bly a mild sapremia. 
 
 Unless associated with joint or bone disease, a slowly-developed chronic 
 myositis is almost always syphilitic in origin. Generally in these cases the 
 affected part is so much indurated that the hardness has been characterized as 
 "woody." An exceedingly annoying myositis of the sphincter ani has been 
 observed in syphilitics, in women more often than in men. 
 
 Contractures. (See also Orthopedic Surgery.) — Persistent shortening of 
 a muscle — that is, the fixed approximation, more or less, of its points of origin 
 and insertion, with resulting change in the position of the parts to which it is 
 attached — may be due to the action of very many causes. Among these may 
 be mentioned loss of substance, intra- or extra-muscular, followed by cicatricial 
 contraction ; inflammation, either traumatic, infective, specific, or toxic ; con- 
 tiguous bone or joint disease, with associated deviation from pathological causes 
 01" from gravity ; weakened ac- 
 tion of its proper antagonist; Fm, 118. 
 paralysis, with resulting con- 
 nective-tissue sclerosis, due to 
 a central lesion, either cerebral 
 or spinal : reflex irritation from 
 local injury, with or without 
 retention of a foreign body ; or 
 it may be but a symptom of a 
 general nervous affection, hys- 
 teria, chorea, etc. 
 
 As ordinarily met with in 
 non-traumatic cases, it is asso- 
 ciated with disease of the cord 
 or brain, with infantile paral- 
 ysis in children, or, much more 
 rarely, with cerebral paralysis 
 and intracranial hemorrhage in 
 adults. In the former it is of 
 late appearance, and is observed most commonly in the legs, chiefly because 
 of diminished resistance by opposing groups of muscles. In adults it is either 
 early, transitory, variable, increased upon voluntary motion, absent or greatly 
 lessened in sleep, and irritative in character; or late, degenerative, increasing, 
 permanent, and especially affecting the upper extremity. The face and neck, 
 occasionally also the lower extremities, may be contractured, but never so alone. 
 It produces, as a rule, abnormal flexions in the upper extremity, but extension 
 
 Anderson's Method of Lengthening a Tendon. 
 
336 Ai\ AM ERICA y TEXT- HOOK OE SUlid FJiV. 
 
 at the knee and ankle ; ^vllen, liowever, the contractions occur in connection 
 with chronic spinal inflammation there is strong flexion at the hip and 
 knee. 
 
 When it is due to or indicative of an inflammation of a neighboring joint 
 and is developed early, it is protective in character, producing such fixation of 
 the articulation as is likely to lessen the disease in it by afllbrding rest. Not 
 seldom ^hen unassociated "vvith joint disease or paralysis a contracture "vvill be 
 found to be of syphilitic origin ; and this is especially true of that affecting the 
 biceps cubiti. 
 
 Lately Anderson and several other surgeons have simultaneously proposed to 
 lengthen tendons by a definite amount in cases of contracture. Fig. 118 shows 
 very -well how this is accomplished by splitting the tendon, sliding one end up 
 or down, and then suturing the ends, thus securing a definite amount of length- 
 ening of the tendon. 
 
 Hypertrophy. — The enlargement of a muscle may be real, the sarcous 
 elements being increased in number or in size ; or apparent, due to change in 
 the amount of fat or connective tissue or to an overgrowth of the lympliatics 
 and blood-vessels. It may be physiological and consequent upon increased 
 action of the affected muscle, as in certain classes of workmen, or associated 
 with pathological states, when, as in the enlarged heart or the thickened blad- 
 der, it may be compensatory, and therefore to some extent salutary. Lessened 
 use of the part, or rest, aided by compression, may effect a reduction in 
 size. 
 
 In adults there has occasionally been observed a progressive muscular 
 hypertrophy affecting chiefly the upper extremity, as a rule on one side only, 
 which is usually attended with lessened rather than increased functional 
 strength. 
 
 Atrophy. — Diminished size of muscles is of frequent occurrence, and may 
 be due to disuse, to diseases of joints, to nerve-injury, to disease of the spine or 
 the brain (rarely observed except when the pons is affected), or to a general 
 depraved or poisoned state of the blood. As met with in connection with 
 lesions of bones or joints, it is in great measure, if not wholly, due to reflex 
 disturbance of the trophic nerves, and not to the enforced quietude of the 
 affected part. Very often it is associated with degeneration, granular, pigment- 
 ary, fatty, or waxy, the latter two being the more common and the more im- 
 portant. 
 
 In the fatty degeneration there may be a substitution of fat for the true 
 muscular elements, or. still oftener, for the connective tissue, occurring slowly 
 and of limited extent, or, as in cases of pliosphorus-poisoning, rapidly developed 
 and largely generalized; or, as is much oftener the case, the fat may be 
 present as an infiltration or accumulation in relation with the connective-tissue 
 framework of the muscle. In the former, though the deposit may be absorbed 
 and muscular redevelopment follow, there is generally permanent destruction 
 of the affected fibers ; while in the second either no effect is produced upon the 
 contractile substance or it is affected only through pressure. 
 
 In certain of the acute infectious fevers, especially yellow fever and typhoid, 
 in not a few cases of tetanus, and occasionally, though rarely, after nerve-inju- 
 ries, the muscular elements appear as a transparent. Avaxy, very brittle mass 
 which breaks up into cuboidal blocks, the connective tissue at the same time 
 taking on increased growth. Pain, weakness, impaired function, and liability 
 to rupture are the effects of this vitreous degeneration. It is always destruc- 
 tive to the affected fibers, — which may be few in number or may constitute the 
 greater part or the whole of the muscle. In three diseases (progressive muscular 
 
DISEASES A.\l> /.X./r/i'/ES OF THE MUSCLES, EIC. 337 
 
 atrophy, pseiulo-hyj)ertrophic paralysis, and infantile paralysis) muscle atrophy 
 is a strongly-niarked symptom, of medical rather than surgical interest, except 
 so far as resulting weakness and deformity, especially in infantile paralysis, 
 necessitate the use of supporting and correcting mechanical appliances with or 
 without operative interference. 
 
 Ossification'. — Inflammation following long-continued irritation may result 
 in the formation of bone in tlie belly of a nmscle, or, as is more often the case, 
 in its tendon, such, for example, as the bone-plates in muscles close to exuberant 
 callus after a fracture, or as the so-called exercise or rider's bone, the latter 
 being of not infrequent occurrence in the upper or lower tendon of the adductor 
 magnus femoris. At times the ossification is of syphilitic origin. If it is in 
 one of the superficial muscles, the bone-plate can readily be felt when near the 
 attached end of the tendon, the only (question being whether it is tendon, 
 bone, or a true exostosis ; but if deeply placed its existence remains undetected 
 during life. To whatever cause it is due, the bony growth is permanent unless 
 removed by operation. This may occasionally be rendered necessary by exist- 
 ing pain or impairment of function, which at times is consequent upon the size 
 or location of the osseous mass. 
 
 A few cases have been observed of an early-commencing, slowly-advancing, 
 general muscle inflammation, starting usually in the neck and back, in which 
 after a time the atrophied parts become the seat of bone-formation, myositis 
 ossificans, the cause of which is as yet undetermined. Generally very pro- 
 tracted in its course, it resists all treatment, death resulting from involvement 
 of the respiratory muscles or from simple exhaustion. 
 
 Tumors. — These may be either benign or malignant, located in the belly 
 of the muscle or in its tendon. The majority of those which are not sarco- 
 matous or carcinomatous are of syphilitic origin, the specific disease affecting 
 any muscle, but particularly the sterno-cleido-mastoid and the biceps cubiti. 
 The malignant tumors are very rarely primary. In an interesting, though 
 fortunately seldom observed, class the developing cause is parasitic — /. e. the 
 presence in the muscle of the echinococcus, the cysticercus, or the trichina. 
 The diagnosis will be based upon the history of the case and the recognition 
 of a more or less well-defined swelling intimately connected with the muscle or 
 the tendon ; in the parasitic form the microscopic examination of an excised 
 portion of the tumor will establish the diagnosis. The treatment will depend 
 upon the nature of the growth, which will either be left untouched or taken out 
 of the muscle, or removed Avith the part in which it has grown. 
 
 Wounds,' — These may be either subcutaneous or open wounds. The former 
 are sometimes accidental, but usually operative ; the latter are most frequently 
 incised or lacerated. Hemorrhage and separation of the edges are the chief 
 symptoms, the latter, of course, being much more marked in complete than in 
 partial transverse section. If protected from septic infection, their gravity is 
 very slight, and unless there has been extensive loss of substance the repair 
 functionally is very good, union taking place ordinarily through the medium of 
 a connective-tissue scar, though when the wound is small and its edges have 
 been early and closely approximated true muscular regeneration may occur. 
 
 The treatment consists in securing close apposition and in the mainte- 
 nance of rest. Incised wounds and lacerated and contused ones in which the 
 parts can be brought together, after trimming of the torn edges if necessary, 
 should be united with catgut or silk buried sutures rather than treated simply 
 by strapping and bandaging, since, when sepsis is prevented, the stitches do 
 not readily tear out, and a quicker, closer repair is secured. 
 
338 
 
 AN AMERICAN TEXT-BOOK OF SIROERY. 
 
 SECTION II.— DISEASES AND INJURIES UF TENDONS. 
 
 Teno-synovitis, or Thecitis, and Palmar Abscess. — Inflammation of 
 a tendon sheath may be either acute or chronic. The acute form is chiefly due 
 to traumatism, and is suppurative or non-suppurative accordin"; to the presence 
 or the absence of [)yogenic microbes ; the chronic form is of tubercuLir origin. 
 The acute form may follow a wound or a slight but froipiently repeated 
 contusion, as in certain classes of workmen, or it may result from a strain or 
 be connected with rheumatism, syphilis, or gonorrhea. In the nun-suppurative 
 variety there are present pain and swelling along the course of the tendon, with 
 early-developed crepitation, due to the rubbing of the exudation-lined surfaces. 
 Such crackling disappears as the .'^heath becomes distended with fluid, to 
 reappear again for a while as absorption takes place. The associated constitu- 
 tional symptoms are ordinarily slight, except in cases of the special diseases 
 mentioned, when they are those of such diseases. The duration of the aff'ection 
 varies, according to its severity and to the treatment, from a few days to three 
 or four weeks, terminating commonly in complete recovery, though at times 
 some dry crackling remains for a while. Rest and pressure by sjjlint and 
 bandage are usually all that is required in the way of treatment, though hot- 
 or cold-water applications are often of service at first, and the use of the 
 tincture of iodine is thought highly of by many. Opiates may be needed to 
 relieve pain. 
 
 When the thecitis is suppurative the severity of the inflammation is great : 
 unless free incision is promptly made, destruction of the sheath and its contained 
 tendon will take place, often with wide extension of the disease along the ten- 
 don and in the neighboring connective tissue, foUoAved. it may be, by general 
 infection. The pain is intense and throbbing, the tenderness excessive, the 
 swelling marked and rapidly developed, the overlying skin red, the constitu- 
 tional symptoms of high grade. Elevation 
 and rest of th<3 part, as complete as possible, 
 must be secured, and hot applications made ; 
 but the first and most imperative demand is 
 for free opening of the sheath, curetting, and 
 thorough antiseptic drainage and dressing. 
 If, notwithstanding these measures, the sup- 
 puration extends, other and more free incis- 
 ions must be made, and thus destruction be 
 limited as far as possible. 
 
 The disease often affects the flexor sheath 
 of a finger, and, unless promptly arrested, 
 palmar abscess is very likely to follow. 
 This danger is much greater if the disease 
 attacks the thumb or the little finger rather 
 than the other three fingers, since, while the 
 proximal closed end of the sheath in the 
 index, middle, and ring fingers (Fig. lli> h) 
 is separated from the cavitv of the general 
 
 S>-novial Sheaths of Flexor Tendons of „...,„..• ] oVip^tli nf nil tbp* tpndons in the 
 Fingers : a. general sheath common to S} UOMai SncaiU 01 311 lUt leiiuuns Jii iiie 
 
 the tendons in the palm and those of pj^|,jj /^^\ about half an inch, the shcaths of 
 
 the thumb and little finger ; b, separate r v / , i t i r> 
 
 sheaths of the fore, middle, and ring the thumb and the little finger coiumunicate 
 fingers (original). directly with it. Whether secondary to teno- 
 
 synovitis of the finger, or primary and due to direct infection and inflammation 
 of the palmar fascia and the connective tissue under it, it is a serious matter. 
 
 Fig 
 
DISEASES AND INJURIES OF TIIK MUSCLES, ETC. 339 
 
 It may be liinitod or general, according to the intensity of the infection, and 
 is indicated by the presence of symptoms similar to those already mentioned 
 as characteristic of thecitis — pain, swelling, restrained at first by the firm fascia, 
 high fever, etc. Freijuently a small superficial serous or purulent effusion early 
 shows itself in the palm, which has often been mistaken for the real affection, 
 to tlie serious injury of the patient because of the resulting delay in freely lay- 
 ing open the parts. If untreated, or it may be in spite of treatment, the pus 
 may pass between the bones to the dorsum of the hand or under the anterior 
 annular ligament, upward beyond the palmar pouch into the connective tissue of 
 the forearm, along the planes of which it may be carried to or even beyond the 
 elbow. Here, again, free incision nmst be made in the line of a metacarpal bone 
 and disinfection and drainage secured. The incision may be made fearlessly up 
 to a line transverse to the web of the thumb, as the palmar arches both lie above 
 this line. Beyond that the vessels should be avoided, or if divided botJi ends 
 must be tied. At the best, some stiffness of the fingers and impairment of the 
 functional value of the part not seldom results, and the hand is often " griffed " 
 (claw-hand). Necrosis of the carpus may occur, necessitating, at times, ampu- 
 tation ; there may be troublesome, even dangerous, hemorrhage from the vessels 
 of the hand or forearm ; and in a small proportion of cases death takes place 
 because of exhaustion or septic infection. 
 
 Chronic teno-syrrovitis, as has been stated, is a tubercular disease, pre- 
 senting itself either as a firm swelling (Fig. 120) conse([uent upon the presence 
 of a thick mass of granulation-tissue in and upon the sheath ; a more or less dis- 
 tinctly fluctuating swelling in wdiich there is less deposit upon the walls, but 
 
 Fig. 120. 
 
 Fig. 121. 
 
 Chronic (Tubercular) Teno-synovitis or Thecitis of the Sheaths of the Extensor Tendons (original). 
 
 fluid in considerable quantity in the cavity of the sac ; or a similar swelling con- 
 taining in addition small bodies resembling rice-kernels {riziform, or melon-seed 
 bodies. Fig. 121) attached to the walls or floating free. Tu- 
 bercle bacilli in greater or less number are almost invariably 
 present in each form of the affection. It is observed most fre- 
 quently, indeed in nearly four-fifths of the cases, in the fore- 
 arm. It may be developed in connection with any of the 
 tendons, but especially those of the fingers and those in the 
 vicinit}^ of the knee and ankle. Though very slow in its 
 
 course, particularly in the cystic varieties, its tendency is to 
 
 extend upward and downward along the affected tendon mce-kernei or Meion- 
 (which in the fungous variety is invaded and in part or wholly sarne^case^(Fig™ 120I 
 destroyed), to attack other tendons in close proximity, and to original), 
 pass into underlying joints. Frequently it is secondary to joint tubercu- 
 losis. As it is attended by little or no pain, for a long time it may cause 
 
340 .I.V AMFJiKAX TKXT-noOK OF SURGERY. 
 
 no material functional iiuijairniciit. A cry rarely it spontaneously disappears. 
 The contents liavin;^ In-oken down the sheath and escaped externally (and this is 
 very much more common in the fungous variety j, an ordinary tubercular abscess 
 generally follows, the spontaneous or non-aseptic opening of which permits of 
 infection by pyogenic organisms with resulting extensive suppuration. 
 
 The locality of the swelling, its more or less spindle shape, its slow course, 
 and the little attendant inconvenience are the diagnostic signs of the dis- 
 ease in general ; the degree of resistance to touch and the absence or presence 
 of fluctuation, those of the variety, fungous or cystic ; a peculiar crepitation 
 elicited by pressure or upon movement indicates the presence of the riziforn. 
 bodies. AVhen located in the palm of the hand, affecting the several flexor 
 tendons and extending up to the wrist, the swelling of this so-called " compound 
 ganglion " is more or less hour-glass in shape because of the constriction made 
 by the anterior iininilar ligament. 
 
 The treatment to be effective must be operative, by tapping and injec- 
 tion, by evacuation and scraping, or by excision. AVhen there is but little 
 thickening of the sheath and the contents of the sac are simply fluid, aspira- 
 tion or limited incision, with injection of iodoform, will generally bring about 
 a cure ; when the melon-seed bodies are present the sheath must be laid open 
 to such extent as to permit a complete evacuation and thorough scraping of 
 the walls (in the palmar ganglion the annular ligament, if necessary, being 
 divided and later reunited) ; when the case is fungous, relief can be afforded 
 only by complete removal of all the infected tissue outside the sheath, in the 
 sheath itself, and in the tendon. The parts should be rendered bloodless by 
 the Esmarch l)andage, so as to permit of the recognition and careful dissection 
 of Avhat must be taken away, and great care should be exercised to do as little 
 damage as possible to contiguous healthy structures. If it becomes necessary 
 to remove any considerable part of the tendon, much benefit will follow sutur- 
 ing to the upper end of the lower fragment a piece secured by splitting from 
 the upper fragment and turned down. Relapses very often occur, and not 
 seldom the patient ultimately dies of one form or other of visceral tuberculosis. 
 In all operations for teno-synovitis and in the after-treatment it is of extreme 
 importance to prevent sepsis, since pyogenic infection is very dangerous to the 
 part and to life. 
 
 Paroxyciiia, Whitlow, or Felon is an inflammation of a finger, rarely of 
 a toe, consequent upon traumatism, usually of slight character: it may be but a 
 scratch or prick or little abrasion, permitting of the entrance of septic germs. 
 It may be of moderate or great severity according to the virulence of the 
 organism and the general state and resisting power of the individual affected. 
 It is more common upon the right than the left hand, and usualh' commences 
 upon the last phalanx. It may be superficial or deep, in the latter case begin- 
 ning as such or becoming so by extension from the under surface of the derm, 
 favored in the pulp of the finger by the fibrous threads that tie it down to the 
 bone. 
 
 The superficial variety is the more common and the least troublesome, affect- 
 ing one finger or several in succession or at the same time, as is often the case 
 in debilitated subjects, especially children, and located generally around and 
 under the nail. The inflannnation may be slight and subside (luickly ; or some- 
 vhat more severe, causing subepidermal serous or purulent eftusions. The former 
 is absorbed in a few hours or days ; the latter is associated with ulceration, but 
 soon heals, though often leaving a scar which is red and tender for some time. 
 In much-enfeebled individuals the inflammation may be of a high grade, the pain 
 intense, the swelling decided, the suppuration abundant, and may cause loss of 
 
DISEASES AND INJURIES OF THE MUSCLES, ETC. 341 
 
 part or the whole of the nail and the development of fungous granulations, the 
 disease often in nejilected eases lastin"; for weeks or months until the necrosed nail 
 is thrown oft". The treatment varies with the severity of the inflammation. 
 Rest and elevation of the part and cold applications are all that is required in 
 the milder cases. The use of hot fomentations, simple or medicated, together 
 with ])rompt and complete evacuation of the pus, is indicated when suppuration 
 occurs. In the graver cases early incision and the administration of tonics 
 and anodynes are necessary. Change of residence, if it can be eftected, is use- 
 ful. The nail must be removed as soon as it is evident that it must be lost, and 
 iodoform, corrosive sublimate, carbolic acid, nitrate of lead, or other similar 
 agent may be applied to the ulcerated surface. 
 
 The deep whitlow usually commences on the palmar aspect of the last 
 phalanx, though it may originate in an injury of the second or first phalanx, 
 or, more rarely, upon the dorsum. In a few hours it may be, or more commonly 
 within a day or two, after the receipt of the injury, the finger becomes painful, 
 tense, hot, and throbbing, with accompanying elevation of temperature and 
 acceleration of pulse. These symptoms rapidly increase in severity, especially 
 the pain and tension, and are both aggravated by the dependent position. 
 Resolution rarely occurs, suppuration usually taking place. Associated with 
 the deep collection of pus there is often a superficial abscess that may be 
 mistaken for the real disease. 
 
 Though at times the application of cold, of the tincture of iodine, of car- 
 bolic acid, or of a blister has aff'orded relief, in the great majority of cases such 
 treatment is of no value. Carbolic acid has been known to produce gan- 
 grene of the finger. So strong is the probability of the formation of pus, that 
 it is better to employ hot antiseptic solutions or fomentations from the begin- 
 ning, and if within two or at most three days decided improvement does not 
 take place, free incision should be made — to the bone when it is the last pha- 
 lanx that is affected, to the tendon when the first or second, since in the former 
 locality the disease is almost certain to have gone down to the periosteum, 
 while in the latter it very probably is as yet only a teno-synovitis, and the 
 integrity of the tendon may be preserved by opening the sheath. The after-treat- 
 ment should be thoroughly antiseptic. Often in spite of early incision and 
 proper dressing necrosis of the last phalanx occurs. When it does, it is likely 
 to stop at the epiphyseal line, and the dead bone can be removed later without 
 opening the articulation. Necrosis of the second or first phalanx will gene- 
 rally necessitate amputation, though a tolerably useful finger may at times be 
 secured by simple removal of the necrosed bone. 
 
 GrANGLioisr. — Closely connected with a tendon, especially upon the back of 
 the hand, there is often found a small round swelling, firm to the touch, at times 
 almost as hard as bone, slowly developed as a rule, and causing little inconve- 
 nience except when in consequence of the occupation of the patient the tendon 
 has been largely exercised. The contents of this swelling are a viscid honey- 
 like fluid. At any period of its development the little swelling may disappear 
 or cease to grow. Formerly regarded as a dropsy of the tendon sheath (hence a 
 common name, " Aveeping sinew "), it is probably an outgrowth of the s^^novial 
 follicles of these sheaths, more rarely of the synovial pouches or the subsynovial 
 bodies of Henle, or perhaps it is a new growth, a colloid cyst, having nothing 
 to do with the tendon sheath except that it lies in close apposition with it. 
 It is diagnosticated by its shape, location, and feel, and is to be treated by 
 subcutaneous evacuation or by excision. Generally the former method is 
 adopted, though refilling of the sac often occurs. By pressure of the thumb 
 a thin-walled ganglion may be readily burst, and even a somewhat thick-walled 
 
342 ^liV^ AMHUKAX TEXT-I'.Oi >K OF SlUdEIlY. 
 
 one, by a smart hlow. J'ivfV'r;il)ly, however, tlie sac should he subcutaneously 
 divided hy a small kiiite or spear-poiiiti^d needle, and the contents pressed out 
 alon<^side the instrument or into the surroundin<f tissue, wiien rapid absorption 
 ordinarily takes place. When tlic tumor is very hard or very large, or there 
 liave been several recurrences, excision should be done, the sac being freely 
 exposed and carefully dissected oft' the tendon. Under proper antiseptic dress- 
 ing primary union may be expected. 
 
 RuPTriiE OF A Tendon. — Sudden violent efibrts are at times followed by 
 ru])ture of a tendon, indicated by a snap which may be both felt and heard, by 
 jiain, by cessation of the action of the associated nmscle, and often by a fall Avhen 
 the tendon is in the lower extremity. A gap at the seat of injury, increased 
 upon extension, may frequently be recognized on palpation, and a depression 
 may be seen. At the knee there will soon In; marked effusion into the joint, and 
 if the ligamentum ])atell;e is ru})tured the ])atella may be more or less displaced 
 upward. The rupture may be complete or partial, generally the former. The 
 tendon of the rectus femoris above or below the patella, or the tendo Achillis 
 in the lower extremity, and those of the triceps or biceps in the arm, are the 
 ones usually torn. The treatment consists sometimes of approximation by 
 position of the separated ends as much as jjossible, and maintenance of the same 
 by splints, bandages, or apparatus until reunion takes place, which commonly 
 occurs in from four to eight weeks. Generally, however, the better method is 
 by suture, especially when the existing gap is a wide one or the tendon is that 
 of a muscle in which contraction can be controlled only imperfectly or with 
 great difficulty. In the leg esj)ecially operation is indicated unless great age 
 or other contraindication exists. The old-time objections to exposing and 
 operating upon a tendon no longer hold good, since se[)tic infection can very 
 generally be prevented. This is especially important at the knee, as the joint 
 may be opened at the operation. 
 
 Wounds of Tendons. — These are either punctured, subcutaneous, or open. 
 The former are of no importance unless accompanied by the entrance of pyo- 
 genic organisms, when they may be very destructive from the inflannuation of 
 the tendon, its sheath, and the surrounding parts. Subcutaneous wounds, when 
 complete, as in the operation of tenotomy, are attended with a snap and sejiara- 
 tion of the ends, causing the formation of a depression both seen and felt ; 
 they are accompanied ordinarily with but slight hemorrhage and little pain. 
 Repair takes place readily without any decided local or general disturbance, 
 the connective-tissue callus being shorter or longer according to the amount of 
 approximation secured. When formal tenotomy is done a])position of the ends 
 is not Avanted, and by position considera])le separation is maintained, the func- 
 tional value of the part ultimately becoming nearly or quite perfect. Open 
 wounds are dangerous or not according as they do or do not become infected. 
 If aseptic, they arc quickly recovered from, and modern experience has so 
 clearly demonstrated this that to-day, l)y preference, most such operations are 
 performed openly in cases in which until recently the greatest care was exer- 
 cised to prevent any extensive division of the overlying soft parts. After 
 operative tenotomy the treatment is by position and pressure. After acci- 
 dental division, however, the treatment should invariably be by suture, the stitch 
 being of buried catgut or silk. At the wrist. Avhere several tendons may be 
 simultaneously divided, care must be taken that the two ends of the same 
 tendon are united. 
 
 Tendon-suture may be done also in old cases of rupture or wound, 
 even when extensive dissection is required to find and free the w idely-sej)arated 
 ends buried it may be in a mass of scar tissue. If the freshened fragments 
 
DISEASES AND INJURIES OF THE MUSCLES, ETC. 343 
 
 ~ I I " nil .11 ijiiTii^iiBifiril^iii^^ 
 
 ;^**-^ 
 
 Czerny's Method of Tendon-suture when the Ends cannot 
 be Approximated. 
 
 can \)v applied to each other, t-itlior end to end or overhippinj.', tlie}'^ should be 
 stitched together, the sutures bein<i drawn only sulHciently ti;^ht to maintain 
 the apposition without making undue constriction of the included parts. If 
 there has been too great loss of substance to permit such direct attachment, 
 but the sheath ends can be united, this should be done, as redevelopment of the 
 tendon will occur in the canal thus formed ; or long catgut stitches may be used 
 which will serve as a framework \i\)on which the new formation can take place; 
 or one of the pieces of the tendon may be longitudinally split for the necessary 
 distance nearly to the end, and 
 
 the detached half turned down • ^ig. 122. 
 
 and united to the other part of 
 the tendon, the ultimate result 
 being the formation of a tendon 
 sufficiently strong fully to per- 
 form its physiological function 
 (Fig. 122). Where this can- 
 not be done, transplantation 
 may be effected, either of an- 
 other tendon from the same 
 individual when there has been extensive injury of the part, or of one taken 
 from a lower animal: .in the latter case usually, if not always, the graft is 
 absorbed and its place taken by a new formation. When only one end can 
 be found and separated from the surrounding cicatricial tissue, it may with 
 advantage be united to an adjoining uninjured tendon having the same general 
 anatomical course ; as, for example, the flexors or extensors of the hand and 
 fingers or those of the foot and toes. In all cases of tendon-suture much 
 advantasje will be derived from the use of the Esmarch bandao-e durino; the 
 operation, which will prevent the blood from obscuring the field of operation. 
 DiSPLACEMEXT OF Texdoxs. — Unassociated with fracture or dislocation, 
 displacements of tendons are of rare occurrence. Consequent upon sudden 
 muscular action or extreme violence the tendon is forced from its normal posi- 
 tion, is quickly and spontaneously replaced, or remains luxated until returned 
 by manipulation. The tendons of the peroneal muscles are those most usually 
 affected, especially that of the brevis, which is not very seldom found thrown 
 out of its bed behind the external malleolus and carried forward so as to be 
 readily felt and easily moved upon the malleolus. Slight pressure will return 
 it to its proper place, but it is held there with much difficulty and only imper- 
 fectly as a rule. The parts should be immobilized and a retentive dressing 
 kept on until repair of the torn sheath or lateral ligament has taken place, if 
 this can be secured. An aseptic suture or two may assist in retaining it in 
 place. The late Dr. James R. Wood devised and carried into effect an opera- 
 tion for the relief of dislocation of the tendon of the peroneus, viz., tenotomy 
 followed by fixation with plaster of Paris. Dislocation of the tendon of the 
 long head of the biceps flexor cubiti occurs occasionally ; AVhite has reported 
 and figured a case. 
 
 SECTION III.— AFFECTIONS OF BUES^. 
 
 In connection with some tendons and in close relation with most joints there 
 are to be found bursge, which are either normally present or acquired. The 
 former are present at the time of birth or soon after ; the latter are devel- 
 oped later in life in consequence of muscular action and friction. They 
 may be superficial or deep-seated ; many of the latter communicate directly 
 
344 iiX AMKRICAX TEXT-liOOK OF Si'RGKRY. 
 
 with neighboring artienhitions, especially in adults. As the result of injury 
 and of diathetic aft'eetions these bursii? are frecjuently the seat of disease, 
 giving rise to simple excess of fluid ; to suppurations ; to deposits, tuber- 
 cular, syphilitic, or malignant; to thickenings; and to fibrous and cal- 
 careous degenerations. 
 
 Bursitis. — The inflammations are acute, subacute, and chronic, the last 
 at times succeeding to the second, but generally such from the beginning. 
 "When it is one of the superficial pouches that is aflected, the prognosis is 
 ordinarily good, though at times, because of neglect of proper treatment, 
 extensive and destructive cellulitis results : when a deep-seated bursa is 
 affected the prognosis is much more grave, since there is danger of the exten- 
 sion of the inflammation to the joint as the result of the affection itself or of 
 the measures adopted for its relief. 
 
 Acute bursitis, due ordinarily to injury, at times to over-use, when super- 
 ficially located, is indicated by pain or at least tenderness, skin-redness of vary- 
 ing intensity, and, particularly, by swelling, coming on rapidly and consequent 
 upon excess of secretion, and, oftentimes, blood in considerable quantity. The 
 peculiar location in relation to a tendon and the limited extent and globular 
 form of the swelling serve to distinguish the disease from an ordinary cellulitis. 
 The associated general symptoms may be of high grade. If suppurative, unless 
 promptly arrested there is strong probability of extension to the connective 
 tissue outside the bursa, with resulting increase in the severity of symptoms 
 local and general. The deep-seated inflammations will often be mistaken for 
 those of the joints near by : and, indeed, in a considerable proportion of cases 
 they actually become articular after a little time, the bursa and the synovial 
 sac either directly communicating or being separated by a thin wall that 
 soon breaks down. Many of the extra-articular inflammations also doubt- 
 less originate in bursal disease. 
 
 The local treatment is at first by rest, elevation, pressure, and cold appli- 
 cations ; later, if the eftusion does not rapidly diminish and the inflammatory 
 symptoms do not subside, the sac should be aspirated, or, if pus is present, freely 
 laid open, disinfected by pure carbolic acid, and dressed antiseptic-ally until oblit- 
 eration of the cavity has been secured. If the patient is rheumatic, gouty, or 
 syphilitic, the ordinary general treatment of the particular diathetic state 
 should be employed. 
 
 Chronic bursitis, of much more frequent occurrence than the acute variety, 
 generally gives rise to little or no distress, and is characterized chiefly by swell- 
 ing, due to sac distention, or to this combined with much thickening of the 
 wall. At times the swelling is solid and of fibrous character, it mav be. though 
 rarely, bony. A very common locality is on the front of the knee, the prepa- 
 tellar bursa being the one usually affected (Fig. 123). It is due to long-con- 
 tinued pressure and irritation, as in those who kneel much, and is known as 
 housemaid's knee, as a similar affection of the olecranon bursa is spoken 
 of as miner s eJboiv. The enlargement of the prepatellar bur.sa is median in 
 position, is globular, usually fluctuates, and, unless it has become acutely 
 inflamed, is painless or nearly so, though some weakness of the knee is often 
 complained of. The subligamentous bursa is sometimes diseased, when the 
 swelling shows itself on the sides of the ligament, the tension of which causes 
 a central depression. 
 
 The treatment of the prepatellar enlargement is by aspiration or free 
 incision ; the latter, when aseptically done and when the resulting wound is 
 aseptically treated, gives the best result. Instead of a median cut, small open- 
 ings may be made on the sides and a drainage-tube carried through. When 
 
DISEASES AND IXJURIES OF THE MUSCLES, ETC. 346 
 
 Fig. 123. 
 
 K-i^ 
 
 suppuration lias occurred lateral incisions low down are to be preferred to a 
 central one, as they much more certainly secure drainajfe of the pockets on the 
 sides where the bursa overlaps the 
 inner and outer edges of the pa- 
 tella. If the sac has very thick 
 walls or the mass is solid, it should 
 be dissected out, care being taken 
 in the removal to keep as close as 
 possible to the outer surface of the 
 swelling. 
 
 The deeper subligamentous 
 bursal swelUny will ordinarily be 
 treated by rest, together with pres- 
 sure or the application of small 
 blisters, and relief may be ex- 
 pected only after considerable 
 time. The likelihood of existing 
 communication with the knee- 
 joint makes aspiration the pref- 
 erable form of operative treat- 
 ment. 
 
 Occasionally the bursa beneath 
 the semimembranosus tendon is 
 diseased, and when it has enlarged 
 so much as to cause marked swelling, not only, as at first, near the inner border 
 of the knee, but well out to or beyond the median line, the affection may easily 
 be mistaken for an intra-articular one or for an aneurysm. The very general 
 connection of this pouch with the synovial cavity, at least in adults, as a gen- 
 eral rule contraindicates any operation other than aspiration. 
 
 As the result of abnormal pressure combined with malposition of the articu- 
 lating surfaces there is frequently observed a bursal tumor over the metatarso- 
 phalangeal articulation of the great toe, much less frequently over that of the 
 little toe or over one of the other toe-joints. This is known as a " bunion " 
 (Fig. 139). It may cause but little inconvenience, but almost always there is 
 some tenderness in the part, and it is quite likely to become acutely inflamed. 
 Then the pain is decided — and it may be excessively severe — the skin is red- 
 dened, the fluid in the sac much increased, and walking becomes difiicult, and, 
 it may be, impossible. When suppuration occurs the pus may break through 
 the wall and cellulitis be developed, or a joint inflammation be excited and 
 cause more or less destruction of the articulating surfaces. The treatment is 
 that of acute bursitis in general — rest, cold, discutient lotions, tapping, or 
 incision and prompt evacuation of pus. If either the surrounding connective 
 tissue or the underlying joint has become infected, free incision should be 
 made and the wound dressed antiseptically. Should the bone have become 
 diseased, it must be removed by the sharp spoon or the gouge forceps, and the 
 previous malposition of the toe corrected during the period of healing. 
 
 Double Housemaid's Knee (original). 
 
346 
 
 AX AMERICAN TEXT- HOOK OF SURGERY. 
 
 CHAPTER V. 
 
 ORTHOPEDIC SURGERY. 
 
 Orthopedic surgery lias to do, properly, with tlu- treatment oi deformitieB 
 and contractions, especially by some form or other of mechanical aj)pliance, 
 though of late its field has been somewhat extended so as to include the con- 
 sideration of many deformity-producing joint affections. 
 
 Torticollis, or avky-xeck, is a contracted state of one or more of the mus- 
 cles of the neck, producing an abnormal position of the head. As ordinarily 
 observed it aftects, either wholly or chiefly, the sterno-cleido-mastoid muscle 
 (Fig. 124), though the deep muscles are at times at fault, and in long-standing 
 cases they are apt to be in greater or less measure involved. It is occasionally 
 
 acute, and is then commonly due 
 Fig. 124. to either cold or trauma. But 
 
 it is more commoidy chronic, 
 and is then spastic in character 
 and dependent upon nerve-irri- 
 tation. It has been produced 
 by an habitual malposition of 
 the head, assumed because of 
 existing ocular defect. It is 
 noticed coninionly in young 
 children : thougli rarely, it may 
 be congenital and due to ver- 
 tebral deformity or to injuries 
 received at time of birth. If 
 it first appears in adult life, as 
 it does occasionally, though for- 
 tunately not often, instead of 
 being spastic it is intermittent, 
 spasmodic, and generally affects 
 one or more of the muscles in- 
 nervated by the spinal accessory nerve. When acute it generally passes away 
 under the influence of rest, heat, and time, or it may become chronic and per- 
 manent. The spasmodic variety may disappear without treatment or after the 
 employment of baths, friction, and massage, electricity, tonics, quinine (for it 
 may be of malarial origin), change of locality, etc., or it may remain until 
 stretching, section, or removal of a portion of the spinal accessory nerve be 
 done ; and even these operations may leave the patient little or no better than 
 before. 
 
 The diagnosis of the commonly observed spastic contraction of the sterno- 
 cleido-mastoid nniscle is easy : the head is turned to the opposite side, the chin 
 is extended, the ear of the affected side is drawn downward toward the shoulder, 
 and the muscle is in strong relief and abnormally firm. At times only one of 
 the divisions of the nmscle, and that more commonly the sternal, is markedly 
 contracted. When the disease has been of long duration there is often decided 
 atrophy of the corresponding side of the face. The posterior rotator muscles 
 of the neck are probably involved, together with the sterno-mastoid. Pain is 
 not usually present. Rectification of the malposition can often be effected, at 
 
 Torticollis (original) 
 
ORTHOPEDIC SURGERY. 347 
 
 least to a considerable extent, voluntarily or by manual pressure, but at once 
 recurs when the pressure is removed. When the deeper muscles are diseased 
 there may be a question as to the existence of caries of the cervical spine, but 
 the history of the case, the absence of bilateral rigidity, and the character of 
 the deformity will generally suffice to indicate the nature of the trouble. 
 
 Having no tendency to get well of itself, the sp antic form should always be 
 treated either mechanically or by operation, followed l)y the apjdication of 
 proper retentive apparatus. Collars and braces of various kinds have been 
 devised with the intention of holding the head in the improved position secured 
 by forcible manipulation, and the plaster-of-Paris bandage over head, neck, 
 and shoulders has been used for the same purpose. Often in the milder cases 
 relief of the deformity may, in time, be secured by such appliances, but Avhen- 
 ever the muscular contraction is well marked the tendon and the adjacent 
 fascial bands should be cut, either subcutaneously or through an open wound. 
 Until recently the former method was almost uniformly employed, being much 
 safer and leaving but a very slight scar; but, aseptically made, the open wound 
 is attended with little or no risk, and has the advantage of permitting a more 
 complete division of the contracted tissues. The subcutaneous method will, 
 however, often be preferred. The head being so held as to render the tendon 
 tense, a small incision is made low down over its internal border; through 
 this a blunt-pointed tenotome is carried to and along the under surface of 
 the sternal portion, its cutting edge turned forward, and section made, after 
 which, in the same manner, the clavicular portion may be divided if necessary. 
 At times the sternal tendon can be cut upon the bone, thus avoiding the 
 danger of wounding the anterior jugular vein as it passes behind the muscle 
 a short distance above the sterno-clavicular articulation — an accident, how- 
 ever, of little moment, as the hemorrhage can be easily controlled by pressure 
 and the clot will soon be absorbed. The internal jugular vein has been 
 wounded, the knife having: been carried too far back in the first stasje of the 
 operation. 
 
 As has been stated, for the relief of spasmodic lory-neck, affecting the 
 sterno-cleido-mastoid muscle, the spinal accessory nerve may be stretched, cut, 
 or in part removed, the latter being much the most promising procedure. To 
 expose the nerve an incision may be made along the posterior edge of the 
 sterno-cleido-mastoid muscle at its middle or along the anterior edge, begin- 
 ning at the mastoid process and carried downward for about three inches : the 
 muscle being drawn aside, the nerve can be readily lifted and a piece of it 
 cut away. Exsection of one or more of the upper cervical nerves when the 
 posterior muscles are affected necessitates careful dissection and somewhat exten- 
 sive division of the trapezius and complexus muscles, and will not often be per- 
 formed. 
 
 Contractures. — As has already been stated, there are at times observed 
 in adults, as late phenomena of hemiplegic paralysis, contractures of the muscles 
 of the arm, forearm, and hand, especially of the flexors : such contractures 
 increase in intensity in proportion as the parts to which the muscles are sup- 
 plied are farther removed from the trunk. As commonly seen, the arm is 
 adducted, firmly held against the side (though occasionally it is abducted), the 
 forearm is flexed upon the arm, the hand upon the forearm, and the fingers 
 upon the palm ; these flexions cannot be entirely overcome by either passive 
 or active movements in extension. The deformity produced is proportionate 
 to the degree of contracture, and ordinarily is not relieved by any treatment. 
 Traumatic contractures due to wounds, not seldom to burns, and those conse- 
 quent upon extensive cellulitis with loss of tissue and the formation of strong 
 
348 
 
 .I.V A mi: UK AX TEXT-IK K>K OF SURGERY. 
 
 cicatricial adhesions, are so variable in locality, extent, and force that each 
 case must be treated accordin;^ to its special indications, mechanically or opera- 
 tively, by the use of apparatus or by stretching, rupturing, dividing, or by the 
 plastic insertion of healthy tissue taken from a near or a remote part of the 
 body or fmm a lower animal. At times the disability consequent uj)on the 
 irremediable deformity is so great that amjiutation is done. For the treatment 
 of contractures by lengthening of the tendon, see p. oSo (Fig. IIH). 
 
 CoNTKACTlMX OF TlIK PALMAK FaSCIA {T)u]>Uj/trc7l' h rO)ltr(n'fi<>n) (Figs. 
 12") and 126), producing permanent Hexion of a finger or fingers, is at times 
 
 Fi(i. 125. 
 
 Fkj. 126. 
 
 Dupuytren's Contraction of the Palmar Fascia (Keen). 
 
 The Same Hand afler Opt' ration (Keen). 
 
 met -with, generally in individuals beyond the middle period of life, much more 
 frequently in men than in women. It affects indifferently either hand, some- 
 times both. The ring or the little finger or both are most frequently flexed ; 
 next the middle finger: the thumb and the index more rarely. The ilegree of 
 flexion varies with the case and the length of time that tlie disease has existed. 
 It is not the flexor tendons that are contracte(L as was formerly believed to 
 be the case, but the palmar fascia and its digital prolongations, together with 
 the fibrous bundles uniting the fascia and the overlying skin, which latter is 
 involved only late and secondarily if at all. Beginning usually a^ a small hard 
 nodule at or near the line of the nietacarpo-phalangeal articulation, the disease 
 extends more or less slowly both downward and upward, with corresponding 
 drawing down of the affected finger or fingers, until in very severe cases the 
 finger-tip is strongly and steadily held against the palm. Its occurrence has 
 
ORTJKH'KDIC SURGERY. 349 
 
 been attributed to the action of various causes, — slight traumatisms frequently 
 repeatotl, the rheumatic or gouty diatlicsis, rcHex nervous irritation, etc. ; but 
 which of these is its real cause, or whether it depends upon any single cause, 
 has noi been determined. It certainly seems to be most frequent in those who 
 are rheumatic or gouty. A recently-reported cure by hypnotic suggestion, as 
 far as it goes, gives support to the nervous theory. 
 
 The diagnosis is easily made: the thickened elevated band in the palm 
 extending to the sides of the finger, the marked flexion resisting strong efforts 
 at extension, the absence of pain, the slow development of the condition, the 
 age of the individual, the non-existence of cerebral or spinal disease, or of 
 injury of the extremity followed by loss of substance and resulting scar-con- 
 traction, — all taken together render it impossible to mistake the nature of the 
 affection. 
 
 Treatment. — Left to itself, the palmar contraction always gets worse, and 
 it can be relieved oidy by operation. The skin should be divided by a linear 
 wound or reflected in a V-shaped flap, base downward, and the contracted 
 tissue dissected out, an operation which of late years has been freijuently 
 done with success. The hand and forearm are placed upon a palmar splint 
 for a few days. 
 
 Club-Haxd (Fig. 127) may occur congenitally as the result of de- 
 fective osseous development, or later because of wounds attended with 
 
 Fig. 127. 
 
 Double Club Hand original). 
 
 much loss of substance in the soft parts or the bones of the forearm 
 or carpus, or of paralytic contractions. There is a deviation, lateral, an- 
 terior, or posterior (very rarely the latter), similar to that in the lower 
 extremity constituting club-foot, and hence known as club-hand. Gen- 
 erally the hand is drawn over in flexion and toward the radial side. It is 
 often present at birth, or has followed extensive resection of the lower part 
 of the radius or ulna or of the carpus. Little or no relief can usually be afforded, 
 though early and persistent manipulation, with the use of a retentive dressing, 
 plaster or instrumental, has occasionally been followed by decided improvement 
 in the position and usefulness of the hand. Always after bone-removal, espe- 
 cially of the lower end of the radius, care must be taken for many months to 
 prevent the deflection of the hand, otherwise likely to occur, by passive and 
 active movements, and, if necessary, by the employment of a suitable apparatus. 
 Tenotomy ordinarily has done little good, and at times has done harm. 
 
 Webbed Fixgers (Syndactylism) is a congenital affection. It may affect 
 two or more fingers on one or both hands, the union extending to any point, 
 even to the tips. There may be a wide web of skin with but little connective 
 tissue within, or a narrow and thick one, or the phalanges of the two fingers 
 may be in close apposition. Frequently the deformity is a family peculiarity, 
 running back through three, four, or more fjenerations. If onlv two fingers 
 are united, they are usually the ring and middle ones. The strength and use- 
 
350 
 
 AX AMKIilCAN TKXT-liOOk' OF SURGERY. 
 
 Fig. 128. 
 
 fulness oftlir liaiul art' ot'tni hut little im|iaire(l. Siiii|ilc division of the web 
 rarely gives other than teiniiorary relief, the web re-lbniiin^f iVoiu the bottom 
 as the wound heals. To prevent such re-tbrmation a tlap of skin may be fixed 
 in the angle between the sepa- 
 rated fingers (see Fig. 128), or 
 a small hole may at first be 
 made at the level of the edge 
 of the normal web, in which 
 a thread or a button may be 
 placed and retained until the 
 edges of the cut have healed, 
 after which the remainder of 
 the web may be cut through. 
 The most satisfactory op- 
 eration is Didot's, in which a 
 flap the length of the finger 
 and half its width, with the 
 added width of the web, is 
 taken from the dorsal surface 
 
 Agnew's Operation for Webbed Fingers 
 
 of one finger and the palmar surface of the other (thus splitting the web and 
 separating the fingers), and each carefully applied over the denuded portion 
 of the finger to which it is attached, securing a normal skin covering of the 
 surfaces that are to be in apposition (Figs. 129, 130). 
 
 Supernumerary Digits (Polydactylism) are also congenital, are not 
 infrequent, and, like webbed fingers, in many cases are hereditary. They 
 
 are generally svmmet- 
 FiG. 129. Fig. 130. j-jcal, and often pres- 
 
 ent on both hands and 
 feet. Usually there is 
 but a single digit in ex- 
 cess, commonly on the 
 side of the little finger 
 or little toe ; though 
 not rarely the thumb, 
 much less often the 
 great toe, is double. 
 The development may 
 be complete, even to an 
 extra sui)porting meta- 
 carpal or metatarsal 
 bone, or it may be more or less imperfect, so that the supernumerary digit is 
 scarcely more than a rudimentary nodule connected with the side of a phalanx. 
 When perfect it is most often attached at a greater or less angle to the broad- 
 ened end of the metacarpal or metatarsal bone of the normal finger or toe, 
 though at times the normal and extra digit are very closely apposed, or even 
 fused, and held in a common envelope of skin. At times the connection with 
 the hand or foot is by a fibrous band of varying length and firmness. It may 
 be amputated at any time, but if not closely fused with the adjoining digit it 
 is best to remove it very soon after birth : and even if so fused, it should be 
 taken aAvay while the child is still quite young, to lessen the resulting deformity. 
 If there is a completely formed hand or foot, Avith an extra metacarpal or meta- 
 tarsal bone and corresponding digit, no operation need, or indeed should, be 
 done. 
 
 Didot's Operation for W'ebbed Fingers 
 (Walter Pye). 
 
 Transverse Section, showing 
 flaps before and after suture. 
 
< ) R Til OPE Die 8 UR GER Y. 
 
 351 
 
 Fig. 181. 
 
 Genu Valgum, or Knock-Knee (Bradford 
 and Lovett). 
 
 Genu Valgum, oit Kn(ick-Knee (Fig. 181). — This is the result of over- 
 growth of the internal condyle and curving inward of the shaft of the femur 
 in its lower part, with associated relaxation 
 and elongation of the internal lateral liga- 
 ments of the knee-joint. These changes pro- 
 duce an abnormal inclination of the interar- 
 ticular line, more or less close approximation 
 of the knees, and more or less Avide separation 
 of the feet, the individual in standing being 
 unable to bring the heels together. 
 
 It usually manifests itself in early childhood, 
 soon after the child begins to walk, but may 
 not do so until about the ])eriod of puberty, 
 or even, though rarely, much later in life. 
 In the former case it is a rhachitic manifesta- 
 tion ; in the latter, it is consequent upon an 
 occupation requiring long-continued standing 
 by a person of feeble muscular and ligament- 
 ous development. Often there is associated 
 flat-foot, which, indeed, at times may be the 
 primary and causative lesion. It may affect 
 one or both knees, may be so slight as to escape detection except upon very 
 careful examination, or so severe as to cross the knees, separate the feet very 
 widely, and render locomotion difficult and the gait wabbling. In children 
 other evidence of the existence of rickets will commonly be found. 
 
 The diagnosis is made on sight, except in the mildest cases. 
 
 Left to itself, when not severe it often spontaneously improves as the 
 rhachitic state passes away and the general strength increases. This favorable 
 termination is common in the static knock-knee of adolescents. 
 
 The earlier, however, that treatment, general and local, is begun, 
 the speedier will be the recovery and the less the resulting deformity. The 
 ordinary medicinal and hygienic treatment of weak and rhachitic subjects is 
 the appropriate one for young children. The local treatment is mechanical, 
 supplemented by baths, frictions, massage, electricity, and preceded, in the 
 severer cases, by osteotomy. 
 
 If the rickets is still active and the bones are soft and yielding, standing 
 and walking should be forbidden, the limb should be straightened as much as 
 possible by manipulation, and maintenance of the correct position should be 
 secured by an outside splint and bandage. Later, when the bones have become 
 firmer, great benefit often follows the use of such a splint with a counter-press- 
 ing pad on the inside, the resulting change in the relative positions of the 
 articular surfaces of the femur and tibia permitting the increased growth of 
 the external femoral condyle Avith restriction of that of the internal. Plaster 
 of Paris is an excellent material for this splint, or the limb may be completely 
 enveloped in it. 
 
 Immobilization w^ith the leg flexed at a right angle wnth the thigh is, by 
 many, preferred to that in the straight position, as the deformity is much less- 
 ened by the flexion. Forcible rectification followed by immobilization has often 
 been followed by great improvement, there being produced in the rapid straight- 
 ening an epiphyseal separation of greater or less extent or a laceration of the 
 external lateral ligament. But if sufficient force to produce such condition is 
 required, it is better instrumentally to break the thigh at a determined level 
 or to divide the bone with saw or chisel, especially as severe injury to the soft 
 
:}52 Ay AMK/i'lCAX ThWr-JiOOk' OF .SURGERY. 
 
 parts and the joint structures has at times been produced by the former method. 
 Braces of various kinds have l)et'n devised, all intended to correct the deformity 
 and allow the patient to go about, and many of them are of much service in 
 very young children. 
 
 If the knock-knee is great and the bones are firm, no material change for the 
 better can be ett'ected without operation, either fracture (osteoclasis) or section 
 (osteotomy), of which the latter is to be preferred, fracture requiring the use 
 of a special apj)aratus, and not always being produced at the desired ])lace. 
 Section nuiy be so done as to separate the internal condyle or divide the lower 
 portion of the femur, which latter is the operation ordinaril}" performed. A 
 small lontfitudinal incision beinff made down to the bone, half an inch or a little 
 more above the adductor tubercle, the osteotome is introduced, turned at a right 
 angle, and by successive blows of the hammer driven toward the outer side, 
 being so moved uj)\vard and downward as to secure division of the entire thick- 
 ness of the bone for three-quarters or four-fifths of its transverse diameter, the 
 uncut portion being readily broken by moderate force. The limb is then to be 
 straightened, an antiseptic pad applied, a layer of cotton put on, and immo- 
 bilization made by plaster of Paris. Little or no reaction ordinarily follows: 
 in about a month the dressing may be taken off, and after two or three weeks' 
 additional rest the patient is allowed to walk. Though the operation is not 
 altogether devoid of danger, since there may be serious hemorrhage from a 
 divided popliteal or anastomotica magna artery, or from the bone itself, or a 
 resulting aneurysm or gangrene, causing death or necessitating amputation, or 
 damage inflicted upon the external popliteal nerve, yet the likelihood of these 
 accidents is verj^ slight, and may be practically disregarded in deciding upon 
 the advisability of making the section. (See Osteotoni}''.) 
 
 Genu Varum, or Bow-Legs (Fig. 132), the opposite of genu valgum, is a 
 deformity usually affecting both limbs, in which the knees are more or less widely 
 
 separated, the joint surfaces are in such relation to 
 ^'^- ^^'■^- each other that the angle between them points outward, 
 
 and the chief pressure is between the internal con- 
 dyles. Except in a very few cases there is outward 
 curvature of the femur and tibia, or of the tibia alone, 
 with at times an anterior bend of the latter bone. 
 The curves of the tAvo legs together may form 
 an almost complete circle. A line drawn from the 
 center of the femoral head to the ankle is internal 
 to the knee. The disease l)egins in early childhood 
 and is of rhachitic origin, and the deformity is the 
 direct result of the weight of the body and muscular 
 action. Inspection at once reveals its existence, 
 which is further indicated by the turning in of the 
 feet and the rolling walk. In elderly persons suffer- 
 ing from osteitis deformans there may be a bow- 
 cienu vurum. or Bow-Legs lagged condition whicli is a part of the general bone 
 (Bradford and Lovett) disease, and is irremediable. 
 
 Treatment. — Spontaneous correction sometimes occurs, much more fre- 
 quently than in genu valgum ; but if the case is at all severe and the child so 
 young that the bones have not become firmly set in the abnormal curves, 
 mechanical treatment should be employed to bring the limbs in toward the 
 median line. This may be by plaster or braces, according to circumstances. 
 In older patients the bones are too strong to yield to any such pressure, and 
 correction of the deformity can be made only after fracture or section. Though 
 
ORTHOPEDIC SI ^RGKR Y. 
 
 353 
 
 osteoclasis by the aid of one or other of the instruments now employed gives 
 better results than in cases of genu valgum, yet osteotomy is the operation 
 that is generally done, linear division being effected at such levels as the con- 
 dition of the individual case may indicate. The method of operating and the 
 after-treatment are the same as in knock-knee. 
 
 Turning in or turning out of the knee conseciuent upon paralysis or 
 vicious union after fracture requires no special consideration. Each case must 
 be treated according to its cluiracter, medically, mechanically, or operatively. 
 
 Antero-posterior Curvature of the Legs is another of the deformities 
 due to rickets which in its aggravated form can be relieved only by operation. 
 When slight and detected early, it may be expected to disap})ear, either with- 
 out treatment or more probably under rest and appropriate fixation dressing ; 
 but in neglected cases, in some of which there is excessive bowing, linear or 
 often cuneiform osteotomy must be done on one or both bones according to 
 circumstances. In the performance of the latter the summit of the curve in 
 the tibia is freely exposed by a longitudinal incision of sufficient length. By 
 a saw or chisel a wedge, with its base anterior, is cut out of tlie tibia, after 
 which, if necessary to the straightening of the leg, the fibula is broken or 
 instrumentally divided. Tenotomy of the tendo Achillis also is generally 
 needed. Proper adjustment having been made, the limb is immobilized and 
 quietude maintained until repair and consolidation are completed. The ope- 
 ration and dressing must be done aseptically, that suppuration may not take 
 place, Avhich will always materially lengthen the period of treatment. There 
 is a risk, but not a great one, of wounding the anterior tibial vessels or nerve. 
 
 Club-Foot, or Talipes, is a non-traumatic deviation of the foot in the 
 direction of one or other of the four lines of movement — extension (T. equmus, 
 Fig. 133), flexion (T. calcaneus, Fig. 134), adduction (T. varus), and abduc- 
 
 FiG. 133. 
 
 Fig. 134. 
 
 Talipes Calcaneus (Albert). 
 
 Talipes Equimis (Albert). 
 
 tion (T. valgus), — or of two of these combined, as in equino-varus (Fig. 135). 
 It is due either to under- or over-action of muscles or to abnormal position, 
 
 2.3 
 
3o4 
 
 AX A.\fi:in('AX TEXT-r.ooK or surgery. 
 
 Double Equino-varus loriijiual i. 
 
 shape, or relations of one or more parts of the skeleton of tlu- foot. It may 
 be either congenital or accjuired, in tiie latter case being generally devel- 
 oped in early childhood and the result of infantile paralysis (acute anterior 
 poliomyelitis). 
 
 In the congenital variety the displacement is almost ahvays one of adduc- 
 tion, with commonly some elevation of the heel (Talipes Eqlino-vakus, 
 
 Fig. 185). Generally affecting 
 Fiu. 135. t)oth feet, it may be confined to 
 
 one, the right oftener than the 
 left. The inner border is raised, 
 the sole turned toward the median 
 line of the body, the heel more 
 or less lifted, the distal part of 
 the foot flexed upon the ])ro.\imal 
 part at tiie mid-tarsal articulation. 
 The degree of deformity varies 
 from that which is ])ut little in 
 excess of the natural inclination 
 of the foot of the new-born infant 
 up to so great rotation that the 
 weight in the erect posture is borne upon the ujtper and outer ])art of the 
 dorsum. At the time of birth and for some months afterward the deformity 
 can usually be easily corrected by manipulation, but later, if left to itself, it 
 becomes in greater or less measure fixed, in consequence of muscular contraction 
 and developmental clianges in the shape of the bones. 
 
 As to its cause, there has been much question. It has been attri])uted to 
 uterine pressure, to intra-uterine disease of the cerebro-spinal axis with result- 
 ing paralysis and arrests of development (it is not seldom associated with 
 malformations of the head, the face, the spine, the abdominal wall, or the 
 pelvis), and to persistence of the earlier foetal position of the foot, the later 
 normal rotation of the leg and foot, or at least of the latter, not having taken 
 place — an explanation that seems, at present, the most likely to be correct. 
 In a considerable number of cases it is a family peculiarity, either in the 
 ascending line or affecting several children of the same parents. 
 
 The diagnosis is easy, and the prognosis good if proper treatment is 
 promptly adopted and steadily maintained for a sufficient length of time, though 
 even under the m.ost favorable circumstances the ultimate development of the 
 foot is not what it would have been had the deformity not existed. 
 
 The treatment must be either manipulative or mechanical, or l)oth. In 
 those cases — and they are the majority — in which at birth and soon afterward 
 the foot can readily be brought into proper position by hand-pressure, such 
 pressure, could it be steadily maintained, would in time relieve the 
 deformity. As this cannot be done, some substitute for it must be found, and 
 that is best which most nearly apjiroaches it in evenness and gentleness of 
 pressure. Simple bandaging or the application of adhesive straps has been 
 used, and, at times, with success, but immobilization of the foot and leg by 
 plaster of Paris or gutta-percha is very much better, the parts being ju-otected 
 by cotton and the dressing carried sufficiently high up to prevent its ready 
 displacement. Frequent removals and reaj)])lications of the plaster will be 
 required'. Very rarely in these young subjects is there such tendon contrac- 
 tion as to necessitate section. The earlier the deformity is corrected and the 
 foot held in right position the better. If the case has been neglected and 
 nothing done until the child has begun to stand and walk, the malposition may 
 
onriloPEDlC SURGERY. 355 
 
 still be coi-rected by iiKinipiibition and overcome by immobilization, but with 
 much more difficulty. Decided retraction of the heel may often in this way 
 be relieved, but considera])le time will be required— time which may be saved 
 bv tenotomy. The tenotome is introduced by the side of the tendo Achillis 
 (rendered as tense as possible by flexion of the foot), carried underneath it, its 
 cutting edge turned against it, and division made by pressure and a slight saw- 
 in*^ motioii! There are but two dangers in this operation, that of wounding 
 tlie posterior tibial artery, and that of freely dividing the skin, neither of 
 which is likely to occur if care is taken. If either accident does happen, it la 
 usually a matter of no great importance. Pressure will stop the flow of blood, 
 and under antiseptic treatment the open wound will (quickly close without 
 inflammation. Elastic traction has been employed with much benefit. 
 
 Upon far the larger number of these patients club-foot shoes are applied. 
 They should be either solid or jointed opposite the middle tarsal articulation to 
 permit of any re(iuired lateral movement of the parts in front. The side-pieces 
 should be carried nearly up to the knee. If properly made, adjusted, and watched, 
 if it overcomes the deformity and maintains the correction, such mechanical 
 appliance is of great service. But as very often used it is of little or no bene- 
 fit, frequently a positive injury, since it is put on by an instrument-maker or 
 dealer uninformed in anatomy or pathology, and makes uneven pressure, 
 produces callosities and ulceration, fails to hold the foot in proper position, 
 frefjuently breaks and gets out of order, thus necessitating expense that can 
 be ill aff"o^i-ded, and is often worn long after it should have been thrown away 
 and a new one applied. Much better results will be secured by the average 
 practitioner, and especially among the poor, by plaster-of-Paris immobilization 
 than bv the use of a club-foot apparatus. 
 
 Before a proper mechanical appliance can be put on, forcible correction under 
 anesthesia may have to be made, together wdth tenotomy of the tendo Achillis, 
 of the tibial tendons, anterior or posterior or both, and of the plantar fascia. 
 In the aggravated long-standing cases in which there has taken place marked 
 change in°the shape of the bones, in the length and position of the ligaments, 
 and in the connective tissues of the foot, rectification cannot be effected except 
 after operation upon the bones or soft parts or both. A wedge-shaped piece 
 may be taken out of the tarsus (cuneiform osteotomy), or the cuboid, the 
 scaphoid, or the astragalus may be removed, or a free transverse incision may 
 be made through all the soft parts of the sole of the foot, which has been done 
 many times of^late and with great benefit (A. M. Phelps). Removal of the 
 astragalus gives an excellent result, preferable to that secured by osteotomy. 
 Always after operation a proper retentive apparatus must be applied and its 
 use continued for a long time. 
 
 Non-congenital Talipes, as has been stated, is almost always of paralytic 
 origin. It mav aff"ect one foot or both, and when double, unlike what is true 
 of the congenital variety, the deviation may be in opposite directions. It may 
 be noticed^as soon as tlie child begins to walk, or may appear later, according 
 to the time at which the spinal disease occurs. There is usually decided ele- 
 vation of the heel, with less lateral deviation than in the congenital cases, or, 
 it may be, none at all, and passive movements at the ankle and middle tarsal 
 joints are readily made until spastic contractures of the muscles limit or pre- 
 vent them. This freedom of movement, together with the coldness of the parts 
 and marked atrophy of the leg and foot, and at times the associated paralytic 
 or paretic state of the upper extremity, serves to differentiate the affection from 
 the congenital form. The prognosis is less favorable than in the latter, because 
 of the causative muscular paralysis. 
 
356 
 
 AN AMERICAN TEXT- HOOK OF SURGERY. 
 
 The treatment is mucli the same : rectification of the lualpositiou by 
 manipuhition, gentle, forciljle, or after tenotomy according to circumstances; 
 and maintenance of tlie proper position by immobilization or by apparatus. 
 The latter has the advantage of permitting the employment of massage, the 
 douche, electricity, and supplementary elastic traction ; all of \vliich should 
 be combined with the operative and mechanical treatment. 
 
 Talipes VAL(iUS, generally non-congenital, is characterized by flatness of 
 the foot, abduction of its anterior part and more or less elevation of its outer 
 border, from yielding of the arch. It occurs ordinarily in feebly-developed 
 persons, especially children, being the result of weight coming upon a foot 
 unable to sustain it, and may be associated with rickets, spinal curvature, 
 knock-knee, or badly united fracture. In the aggravated cases decided displace- 
 ment of the tarsal bones occurs, especially of the astragalus and the scaphoid, 
 toorether with changes in the ligaments unitinj; the os calcis, the astragalus, and 
 the scaphoid. In children pain is commonly absent, but in adults it is often 
 complained of after long standing or walking, and upon pres.sure there is 
 generally found to be tenderness in front of the inner malleolus, over the junc- 
 tion of the astragalus and scaphoid, and over the proximal ends of the inner 
 and outer metatarsals. The treatment is both general and local, consisting 
 of tonics, gymnastics, frictions, massage, and the douche, and especially the use 
 of a supporting steel plate as a substitute for the normal arch. Under such 
 treatment the prognosis is good. When there is present simply a weakness of 
 the ankle, support should be given either by a leather or steel anklet or a 
 brace shoe. 
 
 Talipes Calcaneus (Fig. 134) is not seldom seen as the result of infantile 
 paralysis, and occasionally at the time of birth. It consists of a deviation in 
 the direction of flexion, the patient walking upon the heel with the anterior 
 part of the foot raised, with or without some associated abduction. Relief may 
 often be afforded by manipulation alone, and generally by fixation by bandages, 
 
 a shoe, or a shoe and brace. 
 Tenotomy Avill seldom be re- 
 quired. In a few very severe 
 cases a portion of the tendo 
 Achillis has been removed and 
 its shortening thus secured. 
 
 Pes Cavus, or Hollow 
 Foot. — As the result of contrac- 
 tion of the peroneus longus or of 
 the deep muscles of the foot, or 
 of paralysis of the calf muscles, 
 marked exaggeration of the arch, 
 Avith approximation of the heel 
 and the heads of the metatarsals, 
 is occasionally produced. This 
 is known as pes cavus (Fig. 136) 
 — a condition which may be some- 
 what relieved by a steel sole-plate 
 with counter-pressure over the 
 dorsal prominence. In the com- 
 paratively few cases in which the 
 deformity is the result of disease or 
 injury w^ith subsequent contraction, cicatricial or otherwise, the deviation 
 varies with the cause, and may require for its relief the use of some mechanical 
 
 Fig 
 
 I'es Cavus (Albert). 
 
oirnioriihic surgery: 
 
 357 
 
 appliance or operative ti-eatiiicnt — tenotoiuy, section of tlie plantar fascia, free 
 incision, resection, or amputation. 
 
 Pes Planus, or Flat-Foot is due to an obliteration of the nornial arch 
 of the foot, and is therefore the opposite of pes cavus. The diagnosis of 
 these two conditions is fj;enerally easily made, not only by observing the 
 arch of the foot, but also by wett"ing the foot-sole with a colored solution and 
 makino- the patient step once squarely on a piece of white paper. In the normal 
 J" foot-sole (Fig. 137) the broad impression of 
 
 ^'•'- ^•^'- ^^'"- '"* • the ball of the heel and that of the balls of 
 
 ^9 J& A *^^® ^'^^"'^ ^^ connected by a moderately wide 
 
 w m M^ ^/^ isthmus along the outer border of the foot. 
 
 In pes cavus this isthmus disappears, and in 
 pes planus (Fig. 138) it is greatly broader 
 than it ought to be. The condition is often 
 associated with talipes valgus and lateral 
 curvature of the spine. 
 
 The cause is usually general weakness, 
 combined, as a rule, with long-continued 
 standing, as in mill-girls. Walking, unless 
 very excessive, rarely produces it, as this 
 tends to strengthen the foot. The chief 
 symptom is pain, which is produced and 
 is aggravated by standing, and often makes 
 this posture impossible for any length of time. 
 The best treatment is a general constitu- 
 tional tonic treatment, looking to greater 
 vigor of frame, less by drugs than by hy- 
 gienic means. Locally, a steel artificial arch under the sole, with an internal 
 lateral offshoot, will generally give much relief, and may even cure. 
 
 Hysterical Club-Foot is at times observed, and the possibility ot its 
 existence should be kept in mind when the age, sex, and neurotic temperament 
 of the patient are such as to favor its occurrence. 
 
 A moderate degree of equinus, the pointed toe, is frequently met witli 
 just after recovery from a fracture of the lower extremity, 
 and care should be exercised to prevent its development by 
 keeping the foot at a right angle with the leg during the 
 period of treatment, although the deviation ordinarily soon 
 disappears after the patient begins to walk about. 
 
 Hallux Varus, or Valgus. — Displacement of the great 
 toe may be either aAvay from or toward the other toes {S. 
 varus or ff. valgus (Fig. 139), respectively), most frequently 
 the latter. It is present to a slight degree in the majority 
 of adults, and has been observed at times even m young 
 children ; but troublesome hallux valgus is met with, as a 
 rule, only in persons beyond middle age, and in advanced 
 life is often associated with chronic rheumatoid arthritis. 
 Because of the wearing of a too narrow^, too short, too 
 pointed, or badly-fitting shoe, or not seldom of a similarly 
 faulty stocking, the great toe is crowded over upon the others 
 and inclined at a more or less obtuse angle with the inner bor- 
 der of the foot. As a result, the normal relations of the bones 
 of the metatarso-phalangeal joint are disturbed, and the pres- 
 sure of the shoe causes bunion and periosteal irritation, and may even give rise 
 
 I'liiit of a Normal Print of a Flat 
 
 Foot-sole. Foot-sole. 
 
 (Albert.) 
 
 Fio. 139. 
 
 Hallux Valgus and 
 Bunion (Bradford 
 and Lovett). 
 
358 
 
 AX J. 1/ /•;///( VI .V TKXT-IiOOK OF SCRGERY. 
 
 to destructive inflammation nf tlic suit parts and bono. I'ain ami disturbed 
 locomotion arc cnimnon in the more severe cases. 
 
 The treatment is either mechanical or operative. In the first case an ap- 
 paratus is applied to draw the toe to its ])roper plaee and hold it there, and at the 
 same time protect the bunion from pressure; in the second the articular extremi- 
 ties of one or both bones are removed with the saw or the cutting forceps — i. e. 
 complete exsection of the joint. Another plan of treatment which often gives 
 good results is division of the metatarsal bone, often the only satisfactory 
 method of treatment. A properly-shaped and well-fitting slioe should always 
 be worn afterward. The use of such a shoe from childhood on will prevent 
 the production of the deformity. 
 
 Hammer-Toe. — There is observed at times a permanent angular flexion of 
 one or more of the toes, especially the little and second, at the first phalangeal 
 
 articulation, the third ])ha- 
 FiG. 140. lanx being either in line 
 
 with the second or in exten- 
 sion or flexion on it. The 
 first phalanx is usually ex- 
 tended. Thickening over the 
 phalangeal joint is generally 
 present, bunion may be de- 
 veloped, and partial luxa- 
 tion often occurs (Fig. 
 140). This is known as 
 hammer-toe, and is the re- 
 sult of contraction of the 
 plantar fibres of the lateral 
 ligaments of the joint 
 Beginning 
 
 5 6 
 
 Hammer-Toe : A, a diagram of the position of lines in hammer-toe: 
 
 ammer-ioe : a, a aiagram oi me pusuiou ui iiiies lu utiuiiiici-njc: ,^-, -, s 
 
 1, metatarsal line ; 2, head of the first y)halanx; slight groove cor- (^onattUCKj 
 
 responding to position of dorsal border of second phalanx ; 3, 4, „e,,„l1„ ;„ Ufpr pbildbnnd 
 5, callosities due to boot pressure; 0, bursa over contracted joint; "suaiiv lu laiei uiuiuiiuuu, 
 7.8, shoe (the arrow indicates the direction in which the pres- ond oftenpst in bovs the 
 sure of the upper leather tends to force downward the head of the '*"^ uiieue&i m uu_)., luc 
 metatarsal line toward the sole); B, dissection of first interpha- deiormity IS the CaUSC 01 
 langealjoint in hammer-toe ; C, the same preparation after section , . *' . -i . 
 
 of plantar fibres of lateral ligaments (Anderson). mucn inconvenience, and at 
 
 times of actual suff'ering. 
 
 Relief is afforded only by operation. The lateral ligaments have been divided, 
 
 and subcutaneous and open division of the soft parts on the under surface of the 
 
 first phalanx done, but, as a rule, without satisfactory result. Either the toe 
 
 should be removed or, what is better, the joint excised. A similar disorder 
 
 exists in the hand, known as hammer-finger. 
 
 CONGENITAL DEFORMITIES BY EXCESS AND DEFICIENCY. 
 
 In both the upper and the lower extremities there are occasionally observed 
 errors of development producing abnormal enlargement of a part or the whole 
 of a limb, or, more frequently, deficiency, due either to arrested growth or 
 absence of an anatomical segment, or both combined, the result being a mal- 
 formation aff*ecting the functional value of the extremity in any degree from 
 the slightest to the most extreme. The hypertrophies other than of a finger 
 or toe are not amenable to treatment. The use, if necessary, of a raised shoe 
 may overcome the asymmetry in length of the lower extremities. The finger 
 or toe of excessive size, in which generally not only the bones but also the soft 
 parts, especially the blood-vessels and lymphatics, are aff'ected. should be removed 
 at as early a time as practicable. Deformities from non-development, interest- 
 
SURGERY OF THE NERVES. 359 
 
 ing as they may be anatomically and teratologically, arc surgically of interest 
 onlv when ('nuii<!;h of the limb has been developed t(» j)erniit of the application 
 of some form of prothetic aj)paratiis, or when one of the two bones of the fore-' 
 arm or leg is either entirely wanting or so defective as to permit of deviation of 
 the hand or foot from muscular action, in which case a supporting and restrain- 
 ing apparatus is of much value. 
 
 CHAPTER VL 
 
 SURGERY OF THE NERVES. 
 • SECTION I— GENERAL CONSIDERATIONS. 
 
 The larger nerves, like the blood-vessels, as a rule, lie in the protected 
 parts of the body, so that happily they often escape injury. Thus in the neck 
 the nerves lie deeply, protected in front by the collar-bone and laterally by 
 the muscles of the neck. In the arm they lie in the armpit, on the inner side 
 of the upper arm, and on the flexor aspect of the forearm. In the trunk and 
 the pelvis they lie on the posterior wall of these cavities, and in the leg, 
 chiefly on the posterior aspect of the limb, while those on the anterior aspect 
 are, as a rule, very deeply situated. 
 
 If we examine a nerve of any size, we find that it has on its exterior a 
 sheath, called the perineurium, between which and the nerve proper is a narrow 
 lymph-space. The perineurium sends offshoots into the interior of the nerve, 
 making partitions which enclose similar bundles of primitive nerve-tubules, the 
 partitions themselves constituting the endoneurium. Nerves are also supplied 
 with blood-vessels and with 7iervi nervorum. 
 
 It will be seen, therefore, that, however small, each nerve has within it all 
 the elements necessary for inflammatory changes, and in the connective tissue 
 of the perineurium and endoneurium all the possibilities for such new growths 
 as may be derived from this tissue. Waller has called attention to the degen- 
 erative changes which follow section of a nerve, and which constitute the 
 "Wallerian degeneration." It follows the course of the nerve-current. Hence, 
 if a sensory nerve be cut, the Wallerian degeneration will start at the point of 
 of section and travel toward the spine ; while if a motor nerve be cut, the 
 degeneration will extend from the point of section toward the periphery. This 
 process begins within a day or two after the section and becomes complete in 
 two or three weeks. It consists in the destruction of the myeline, and even- 
 tually of the axis-cylinder, with multiplication of the nuclei of the sheath. In 
 addition to this there is more or less atrophy with other degenerative changes, 
 which extend not only toward the spinal cord, but even into it ; in some cases, 
 for instance after amputation, such changes have been traced all the w'ay to the 
 brain. The muscles supplied by such a divided motor nerve soon show the 
 "reaction of degeneration." By this term is meant a peculiar change in the 
 response of the muscles to the galvanic current. In the normal condition it 
 will be found that the kathodic closure contraction (KCC) — that is. the contrac- 
 tion which follows closure of the electrical circuit by the application of the nega- 
 tive electrode (kathode) — is greater than the anodic closure contraction (ACC) — 
 that is, the contraction following the similar application of the positive electrode 
 
360 AK AMKnrcAX Ti:XT-]iOOK OF sri:(ii:L'Y. 
 
 (anode) — a condition which is expressed by the forniuhi K€C> ACC. If the 
 muscle have its motor nerve destroyed, the ACC (juitklv increases until KCC=* 
 ACC, and finally KCC<ACC. 
 
 After division of a nerve, even in cases in which the two ends have not been 
 brought into apjxjsition, reunion with true regeneration of the nerve-structure 
 will often take place, the axis-cylinder iiaving been redevelojK-d and the myeline 
 also, in varying amounts. If, however, the nerve-ends are united, this process 
 is not only hastened, but is also much more apt to be permanent than where no 
 such union has been eft'ected. 
 
 SECTIOX II.— NEUKITIS, OR INFLAMMATION OF A NERVE 
 
 Causes. — A neuritis may be idiopathic ; that is. arising from no percepti- 
 ble cause. By fiir the commonest cause is exposure to wet or cold. Gout, 
 rheumatism, syphilis, typhoid fever, diphtheria, and the exanthemata may also 
 give to rise such an inflammation. Of course it follows wounds and injuries 
 of nerves. Occasionally. l»ut rarely, it assumes the dangerous fonn known as 
 multiple neuritis, or, better, diffused neuritis, which may even cause death. 
 
 Neuritis may be either acute or chronic. In acute neuritis there will be a 
 marked increase of the connective-tissue elements of the nerve, with oedema 
 of the sheath from the exudation. The nerve-tubules become softened as a 
 result of granular and fatty changes, as well as from the inflammatory exudate, 
 and in some cases even pus may be present. Occasionally there will be hem- 
 orrbase into the nerve substance. 
 
 In chronic neuritis there is apt to be sclerosis from the development of 
 the connective tissue of the endoneurium with pressure on the tubules, which, 
 as a nde. results in their atrophy. In such a nerve the fibrous tissue may be 
 so developed as to make the nerve almost as tough as a tendon. In spite, 
 however, of such complete changes, there may almost always be seen single 
 nerve-tubules, which are perfectly normal, associated with others in every stage 
 of degeneration. It is very important to observe that a neuritis may extend in 
 both directions along the trunk of the nerve. Such a progressive neuritis is 
 called either an ''ascending " or a "descending neuritis."' as the case may be. 
 Its commonest pathway, however, is upward toward the spine, and hence if, for 
 example, the ulnar nerve be the seat of the neuritis, the inflammation may creep 
 upward till it reaches the brachial plexus and there involves another branch of 
 the plexus by continuity of stnicture. On the other hand, it is a remarkable 
 fact that a nerve may lie in the midst of inflamed tissues, and even be surrounded 
 bv pus for a long time, without any inflammatory change extending to the nerve 
 itself. 
 
 Symptoms. — The fii"st symptom of neuritis, as a rule, is an aching pain, 
 which follows the course of the affected nerve, and often prevents sleep. This 
 pain is apt to be remittent, is markedly worse at night, and is increased by 
 motion of the limb or by pressure or friction over the nerve. Not uncommonly 
 it will extend, it is thought by a reflex action, to neighboring nerves or to 
 corresponding nerves upon the other side of the body ; for instance, we are 
 all familiar with the fact that a carious tooth sometimes causes pain in the 
 corresponding tooth on the opposite side. With the pain there are apt to be 
 headache and fever, and occasionally even rigors. The nerve if superficial 
 can be traced as a thick cord which will present a continuous or an interrupted 
 swelling, and its course is .sometimes marked by a red line, as in phlebitis or 
 angioleucitis. The local temperature will sometimes rise. There may be sen- 
 sations of numbness or tingling in the area supplied by the sensory filaments. 
 
SURGERY OF THE NERVES. 361 
 
 This will very likely give rise to a mai-ked hyperesthesia, but if the neuritis 
 persists and is followed by atro])hy of the nerve, hyperesthesia will give place to 
 anesthesia. The motor filaments also will be affected, producing twitching and 
 tremors of the muscles, very soon followed by j)aresis, and finally by complete 
 paralysis, and, as a consequence of this, by muscular wasting. A good exam- 
 ple of these symptoms is often seen following inflammation of the seventh nerve 
 as it ]):isscs through the canal of Fallopius. 
 
 Diagnosis. — From rheumatism a neuritis can be recognized most readily 
 by the fact that the pain occurs in the track of a nerve, and later it can also 
 be differentiated by the sensory, motor, or trophic changes which set in. In 
 ordinary neuralgia the pain is of a very different order, being sharp and shoot- 
 ing and more diff"used over the affected area. There is no rise either of the 
 general or of the local temperature, nor is there apt to be any muscular spasm, 
 though occasionally this is seen in neuralgia of the fifth nerve. 
 
 Treatment. — The most important remedial measure is absolute rest — not 
 by putting the arm in a sling and the i)atient on a lounge or in bed, and enjoin- 
 ing rest, but by enforcing rest by the application of a splint. This should be used 
 in all cases unless absolutely impossible. With this, of course, there should 
 be elevation of the part, with the application of heat or cold, whichever is the 
 more grateful to the patient. Sometimes blistering, or even the actual cautery, 
 over the course of the nerve, w^ill be found of value. The constant galvanic cur- 
 rent is an excellent remedy. Deep injections of morphine, atropine, cocaine, or 
 chloroform, especially in cases of sciatic neuritis, have proved of great value, 
 wdiile morphine by the mouth may be exhibited in sufficient quantities to give 
 reasonable sleep. But it is precisely in these cases of chronic neuritis that the 
 greatest care must be exercised lest we form and encourage the morphine habit. 
 If anesthesia sets in instead of hyperesthesia, the application of the faradaic 
 current by the electric brush on a carefully dried and dusted skin is the best 
 treatment. Of course the general health must be looked after, with attention to 
 diet, the state of the bowels, sleep, habits, and exercise when this latter is 
 permissible. If the patient is of a rheumatic, gouty, or syphilitic constitution, 
 appropriate treatment must be used for whichever of these conditions may be 
 found. Meantime the muscles must be kept in good trophic condition until the 
 neuritis subsides and the nerve resumes its normal function of conveying the 
 stimulus to the muscles. This is best eff"ected by hot and cold douches, massage, 
 and electricity, continued in many cases for weeks or even months, until the 
 nerves resume their abandoned work. Sometimes, especially in sciatic neuritis, 
 stretching the nerve gives good results when all other means have failed. 
 
 SECTION III.— NEUEALGIA. 
 
 Neuralgia may be described as an acute paroxysm of pain in the area of 
 distribution of a nerve, not uncommonly radiating from this as a center to 
 neighboring parts. The ordinary forms of neuralgia are medical rather than 
 surgical, but they often require treatment by surgical means. 
 
 Cause. — The disorder is apt in most cases to follow debility, and especially 
 anemia caused by conditions that aff"ect the constitution, such as fever, neuras- 
 thenia, long-continued lactation, etc. Hence neuralgia has w^ell been called 
 "the prayer of the nerves for blood." Malaria, gout, rheumatism, and occa- 
 sionally syphilis, wnll often be found at the bottom of it. Persons of neurotic 
 temperament, and especially those coming from a neurotic family, often fall 
 victims to it. Not uncommonly in such patients the joints suffer; and in 
 young women, especially if the menstrual function is disordered or if there is 
 
;3(j2 AX AMF.i^'fcAX Tr.xr-nooK of smaERY. 
 
 any uterine trouble, there may be a serious neuralgia of the breast, which i& 
 chiefly annoying by reason of the pain and the freciuent suggestion of malignant 
 disease. Local conditions also may occasion it. A cari(nis tooth is often the 
 cause of a severe neuralgia, Avliich, it must be remembered, will manifest itself 
 not uncommonly in the corresponding tooth either (jf the opposite side or of 
 the other jaw. An aneurysm of the aorta or any other tumor which may press 
 upon an intercostal or other nerve will cause it, and disease of the kidney is 
 often attended with neuralgia of the testicle. The variety of the causes which 
 give rise to neuralgia will suggest to us that a most careful examination should 
 be made of the personal and family history in order to determine the appro- 
 priate treatment. 
 
 The neuralgias Avhich are most frequently brought to the attention of the 
 surgeon are that form of neuralgia of the fifth nerve known as trifacial neu- 
 ralgia or tic douloureux, sciatica, and the neuralgia of stumps and scars. 
 
 Tic douloureux is so called to distinguish it from ''tic convulsif," or 
 spasm of the facial muscles, which is sometimes painless and sometimes a 
 symptom of tic douloureux. 
 
 Cause, — As the disease manifests itself most commonly in the face and 
 teeth, if no cause is found in the face it is apt to be attributed to the teeth. 
 It is not uncommon for patients to be brought to the surgeon who have already 
 lost most or even all of their teeth in the vain hope of arresting the 
 relentless pain. As a rule, as soon as one tooth in which the neuralgia has 
 seemed to be worst has been removed another immediately assumes the 
 prime importance, and so tooth after tooth is needlessly sacrificed. The cause 
 must be sought in the condition of the nerve or its blood-vessels. Microscopical 
 examination will often show a neuritis accompanied even with hemorrhage into 
 the substance of the nerve, but more commonly it Avill reveal a marked senile 
 sclerosis (Putnam, de Schweinitz, and Horsley). This is in accordance with 
 the fact that the disease rarely attacks persons before middle life, when the 
 changes incident to age have begun. Dana has recently published some 
 investigations which seem to indicate that the cause is not to be sought so much 
 in the connective tissue of the nerve-trunk as in its vessels which have been 
 subject to obliterating arteritis, itself the result of advancing years. Carless 
 has called attention to the fact that the foramen ovale differs greatly in 
 size from nearly a circle seven or eight millimeters in diameter to a mere 
 slit not more than two millimeters broad. This narrowness of the foramen and 
 a similar contraction of the lumen of the infraorbital and inferior dental canals 
 may easily exert increasing pressure as the patient grows older, and so cause 
 a progressive neuralgia. In view of the influence of age as a cause of tic 
 douloureux, it is not surprising that very frequently after an operation on the 
 nerve has given relief for a time, the disease, whether due to sclerosis or to 
 obliterating arteritis, will recur in the nerve stump and require another and 
 more radical operation. Similar alterations have been traced in some cases 
 even to the Gasserian ganglion. Cold and dampness are also factors in the 
 production of the disease. 
 
 Symptoms. — Scarcely any disease, except possibly tetanus, is more 
 calculated to arouse the sympathies of the attending surgeon than severe tic 
 douloureux. The pain is usually described as burning, boring, cutting, or 
 darting. It is evoked by the slightest cause : a breath of air. mastication of 
 the simplest food, attempts to speak or to laugh, even the lightest touch or a 
 slight noise, will produce the most fearful paroxysm of pain, in which the 
 patient Avill suddenly protect rather than grasp his face with his hands, and 
 will writhe about, moaning or crying aloud with the fierce pain. Each meal 
 
SURGERY OF THE NERVES. 363 
 
 costs him frightful suffering. Only liquid food can be taken, for the slightest 
 attempt to masticate brings on a paroxysm of pain ; even the swallowing 
 of li<[ui(l is endured only because of the imperious demand of the body for 
 food and drink. While his days are days of misery, his nights are nights of 
 sleepless agony. Sometimes he Avill be free from the pain, it may be for days 
 or even weeks, but it is sure to return, at longer or shorter intervals, until life 
 becomes a burden. 
 
 The diagnosis is easy, for there is nothing with which such a terribly 
 painful disease can be confounded. 
 
 Sciatica, or neuralgia of the sciatic nerve, often from a true neuritis, is 
 not unusual. Its symptoms are obvious, and the diagnosis, as a rule, is easy. 
 
 Neuralgia of StUiMPS and Scars. — Sometimes after an amputation or an 
 operation the stump or the scar will become the seat of severe neuralgic pains. 
 AVhile not so severe as those of tic douloureux, they are sufficient to render life 
 miserable. The wearing of an artificial limb is sometimes made impossible, as 
 even light touching of the stump will produce severe pain. Gradually increas- 
 ing pressure is often better borne than light pressure. In stumps it is the 
 general rule that the cut ends of the nerves become bulbous — that is, develop 
 neuromata (Fig. 141) — and it is believed that these are probably the cause 
 of the pain. In scars the entanglement of small terminal filaments of the 
 nerves is thought to be the cause. Occasionally in either case a true neuritis 
 is set up. 
 
 Treatment of Neuralgia. — The first thing to determine is the cause, if 
 this be possible. If the patient be the subject of malaria, quinine in full doses, 
 up to 20 or even 30 grains a day, and in anemia iron, quinine, and cod-liver oil 
 generously given will often be of use. If these fail, arsenic may be pushed to 
 its physiological effect, while strychnine and gelsemium will be found of value. 
 If the patient be subject to gout or rheumatism, colchicum, the alkalies, the sali- 
 cylates, or the iodide of potassium will be indicated, and in syphilis the iodide 
 of potassium, and sometimes mercury, will give relief. Locally much can be 
 done to benefit the patient. If the nerve itself be tender, sometimes leeching 
 will bring relief. Heat or cold, whichever is more grateful to the patient, 
 even the application of freezing mixtures over the nerve, especially at the 
 tender spots, may be useful. The application of the ointment of belladonna 
 or veratrine, the menthol pencil, the application of croton chloral, and occa- 
 sionally the Paquelin cautery, will be of use. The long-continued daily use 
 of the constant galvanic current has often done good. Of course ihe whole 
 system should be built up by the best and most easily digested food, with 
 regulation of the bowels and the secretions and attention to the habits of the 
 patient. In women the menstrual function and the condition of the uterus 
 and ovaries should be ascertained and any necessary treatment be adopted. 
 Occasionally, however, the patient may be more benefited by a change of climate, 
 surroundings, occupation, etc. than by treatment with drugs. There is a great 
 temptation in rebellious cases to resort to the use of alcohol or morphine, 
 either by the mouth or hypodermatically, but these remedies are dangerous, 
 and the "latter too often makes the patient the victim of the morphine habit, 
 the consequences of which are worse than the disease for which relief is 
 sought. 
 
 In neuralgia of the joints, absolute rest by means of a splint, or more 
 commonly exercise, massage, the hot and cold douche, and electricity in some 
 of its forms, are the best remedies. In neuralgia of the breast it is very im- 
 portant to calm the patient's fears as to malignant disease. Nervous tonics 
 and sedatives, such as valerian, the bromides, asafetida, strychnine, iron, arse- 
 
.■5()4 AiX AM ERIC AX TEXT- HOOK OF SIIHIERY. 
 
 nic, and quinine, will ])e found usefid, as will also gentle massage with any of 
 the sinipli'V oiiitmciits. 
 
 I. Surgical Treatment of Tic Douloureux. — Most of the drugs above 
 mentioned will jjrobably have already been tried. If not, they should be used 
 fearlessly, eonibined, as a rule, with heat or cold and the constant current or 
 other form of electricity. The extraction of the teeth, as a rule, is to be con- 
 demned. Ordinarily all that is left f)r the surgeon to do is to proceed at once 
 to operation. 
 
 The operation for the removal of the nerves will be described later. 
 Though sometimes permanent, the relief obtained by such an excision, as a rule, 
 will be only temporary ; yet it is such a boon to the exhausted sufferer that it 
 should always be given when other means have failed. One, two, or three years 
 after the operation the patient will return with his neuralgia almost or quite as 
 bad as before. But the case is by no means hopeless. Sometimes internal 
 remedies or local applications, especially of the constant current, will again 
 give relief, and if not, a second operation can be done for the removal of the 
 stump of the nerve. In some cases where there is no stump of the nerve left, 
 simply the seizing of the fibrous tissues at the point of the former excision and 
 their avulsion will bring a prolonged freedom from pain. This may be repeated 
 more than once. If the entire trunk of the superior maxillary has been removed 
 far back in the orbit, the second operation will consist in the removal of Meckel's 
 ganglion. Recently Rose, Hartley, and others have gone even farther back 
 and removed the Gasserian ganglion itself. (See Operations on Nerves.) 
 
 II. Surgical Treatment of Sciatica, Neuralgia of the Brachial 
 Plexus, etc. — In cases of inveterate neuralgia — for instance, of the brachial 
 plexus or its branches or of the sciatic or other nerves — the remedies and 
 drugs above described are first to be employed. "When these have failed, 
 surgery still offers relief. Nerve-stretching (neurectasy) has been adopted in 
 very many cases with excellent results. (See Operations on Nerves.) Even 
 when this has failed we are not at the end of our resources. In a few csises 
 where the pain has resisted all other means of cure the spine has been opened, 
 the cord has been exposed, and the posterior or sensory roots of the implicated 
 nerves have been exsected, by Abbe and others. (See chapter on the Spine.) 
 But the number of cases is as yet too small and the time that has elapsed too 
 short for the expression of any final opinion as to the advisability of the opera- 
 tion. The pain in such cases is so severe, however, that any operation that 
 holds out even a slight prospect of cure should be deemed admissible unless 
 further experience should show it to be unwise. 
 
 III. Surgical Treatment of Neuralgia and of Scars and Stumps. 
 — If a known nerve is caught in a scar an incision should be made and the 
 nerve liberated from the cicatrix. If mere incision and liberation bring no 
 relief, a second operation should be done for the excision of the nerve. If no 
 known nerve is involved, but the pain probably comes from a small unnamed 
 filament entangled in the meshes of the irregular scar following, for example, a 
 lacerated wound, a burn, or a scald, the entire scar should be excised. The 
 linear scar which replaces the irregular and contractile cicatricial tissue of the 
 original scar is much less likely to give rise to such neuralgia. 
 
 In stumps two methods of treatment may be adopted, of course after the 
 medical means above described have been exhausted. The cicatrix of the 
 stump should be excised and the bulbous ends of the nerves be sought for, 
 drawn down, and severed with a clean cut of a sharp knife. If this does not 
 give relief a re-amputation should be done. Sometimes, as, for instance, after 
 amputation of the distal phalanx of the thumb, where the part is supplied by 
 
SCRGERV OF THE NERVES. 
 
 365 
 
 known nerves, a portion of each of these nerves should be exsected ; if this 
 does not relieve, as is too often the ease, a re-ainputation may be required. Not 
 uneonnnonly, however, such secondary stumps themselves will be i)ainful, and 
 the resources of the surgeon will be taxed to the utmost to effect a cure. It is 
 very likely that in these cases an ascending neuritis has been developed, and if 
 this can be diagnosticated a portion of the painful nerve may be exsected in its 
 continuity as high up as the tenderness is traced, unless such high excision of 
 the nerve would produce results so serious as to contraindicate operation. 
 
 Fig. 141. 
 
 SECTION IV. TUMOKS OF NERVES. 
 
 A distinction must be drawn between tumors which are in a nerve and 
 tumors which are ow or attached to a nerve, for some tumors are developed in the 
 nerve-fibrils which make up the nerve, while others are mere extrinsic growths. 
 The first class cannot, as a rule, be removed without entire excision of the nerve 
 itself. Those developed on the outside of the nerve may be removed without 
 injury to the nerve. If, however, severe neuralgic symptoms have continued 
 after removal of the growth, it will be best, as a rule, to exsect the portion of the 
 nerve to which it is attached, stretch the two ends of the nerve, and reunite them. 
 
 Tumors developed in the nerves them- 
 selves are called neuromata (Fig. 141), 
 True neuromata, other than the bulbous ends of 
 cut nerves, made up of nerve-fibers themselves, 
 are very rare. They are usually made up of 
 amyelinic fibers — i. e. fibers which have no mye- 
 line within the sheath. After the division of a ^ 
 nerve, either by exsection of a portion of it 
 or in an amputation, the proximal ends almost 
 always become bulbous : so frequently does this 
 occur that it may be regarded as a rule, e 
 These tumors have been called false neuromata 
 — i. e. tumors not made up of nerve-tubules, but 
 of fibrous tissue ; but Bowlby has shown that at ' 
 least in some cases a number of true nerve- 
 fibers are found in them. The neuromata oc- 
 curring in the trunks of nerves are generally 
 composed of fibrous tissue. Occasionally they 
 are sarcomata or cysts. While they are usually 
 single or exist in very small numbers, instances 
 have been recorded in which even hundreds 
 existed. 
 
 Symptoms. — When occurring in the course of a nerve such a tumor fre- 
 quently gives rise to no symptoms Avhatever, and may even be unsuspected 
 until revealed by a post-mortem. More commonly, however, it excites such 
 neuralgic pains as to lead to an examination of the part, and if the nerve lie 
 superficially the tumor may be detected. If not, it causes spasms from irrita- 
 tion or paralysis from pressure, while trophic lesions of the muscles, skin, and 
 other parts supplied by the nerves are often seen. (See Injuries of Nerves.) 
 
 Treatment. — If such neuromata produce no pain or other serious symp- 
 toms, they should not be interfered with. If any serious symptoms arise, the 
 tumor, with the portion of the nerve in which it is developed, should be removed. 
 If the two ends can be approximated by stretching, immediate suture should 
 be practised, but if they cannot be brought together the gap may be supplied 
 
 J 
 
 Neuromata in a Stump after Amputa- 
 tion of the foot : a, posterior tibial 
 artery ; ft, posterior tibial nerve ; c, 
 flat "neuroma of internal plantar 
 nerve ; d, round neuroma of same 
 nerve ; e, another small neuroma ; 
 
 /, cicatrix of stump (Duplay and 
 
 Reclus). 
 
:V)() AX AMi:i!I('.\X TEXT-llOOK OF sriiOERY. 
 
 by the transplantation of a suitable portion of a nerve from one of the lower 
 animals or from a nt-wiy-aniitiitated limb. It is even possible, when the ends 
 cannot be approximated, that if tlicv can be sutured together with catgut threads, 
 thus bridging the interval between the two ends, the nerve may be regenerated. 
 Van Lair makes use of a cylinder of decalcified bone to carry the catgut between 
 the ends. In the painful neuromata which develop in nerves after their 
 section or in stumps after amputation, after exhaustion of the medical means 
 the part should be opened, the nerves dissected out, and the bulbous extremi- 
 ties resected. 
 
 Painful Subcutaneous Tubercle. — A peculiar fonn of tumor con- 
 nected with a nerve is known by this name. It is generally single ; as its 
 name indicates, it is small, often about the size of a pea; it lies immediately 
 under the skin and is connected with a sensory filament of a cutaneous nerve. 
 It is usually made up of fibrous tissue. One symptom which distinguishes it 
 from all other tumors is its excessive tenderness and pain. This pain extends 
 up and down the limb, and is sometimes generalized, occasionally accompanied 
 with spasm of the muscles. The pain appears in paroxysms of greater or lesser 
 duration. The treatment is excision of the tumor, together with the portion 
 of nerve-twig in Avhich it grows. The resulting anesthesia will disappear in 
 time. 
 
 SECTION v.— WOUNDS AND IN.JUEIES OF NERVES. 
 
 These are not uncommon. They are seen more frequently in the upper 
 extremities than in the lower, the nerve-trunks being anatomically more exposed 
 in the arm and also more frequently subjected to violence. Contusion and 
 compression are the most frequent injuries. "Wounds may be either clean-cut 
 incised wounds or more or less extensive lacerated or contused wounds, such as 
 those caused by missiles of war, those which result from railroad and machinery 
 accidents, punctured wounds, and the like. 
 
 I. Contusions and Compression of Nerves. — Nerves suffer from con- 
 tusions, occasionally from direct blows, as on the ulnar nerve at the bend of 
 the elbow or on the brachial plexus in the neck. In addition to this, disloca- 
 tions, especially of the head of the humerus in the axilla, often produce serious 
 contusions and compression, as Avill also, though more rarely, the attempt at 
 reduction by placing the unbooted heel in the axilla. Dislocations, and espe- 
 cially fractures near the elbow, are liable to produce contusions and sometimes 
 laceration of the ulnar or musculo-spiral nerves. In fracture of the humerus 
 the musculo-spiral nerve is apt to be contused, compressed, or wounded, and the 
 brachiiil ])lexus may be similarly injured in fracture of the clavicle. Fracture 
 of the pelvis through the sciatic notch has resulted in like injury to the sciatic 
 nerve at its point of emergence. There are also some forms of steady or repeated 
 compression which produce trouble. Sometimes, though rarely, the excessive 
 growth of callus has been thought to cause the pressure. Tumors cause it not 
 ver}' uncommonly, especially thoracic aneurysms. The use of crutches, espe- 
 cially if not well padded, produces a form of palsy known ns ''crutch palsy." 
 This will be more cmnmon. of course, in heavy persons. Lying in peculiar posi- 
 tions, especially with one or both arms under tlie head, particularly in the deep 
 sleep of drunkards, will sometimes give rise to a similar palsy. The pressure 
 of the forceps on the seventh nerve during delivery sometimes produces facial 
 palsy in the child, and in addition to this the pelvic nerves of the mother may 
 be injured from prolonged pressure by the foetal head in delayed deliveries. 
 In all these cases the nerve suffers mechanically to a greater or lesser extent, 
 and the fibers are apt to be torn or pressed together ; occasionally hemorrhage 
 
srn(,'i:in' or the xmvES. 3G7 
 
 uito the substance of the nerve occurs, ^vhile the niyelinc Is niore or less 
 mechanically disturbed. In severe cases of contusion or compression there 
 will be of course entire mechanical destruction of the nerve. 
 
 Symptoms. — These will vary in accordance with the severity of the 
 injury. If it be slight the symptoms will resemble the common phenomena 
 produced when the ulnar nerve is struck at the elbow, which is known as strik- 
 ing the "crazy bone" or the "funny bone." This is generally attended with 
 tingling and a sense of "pins and needles" in the ulnar distribution. Loss 
 of function is not apt to follow immediately unless the contusion lias been violent. 
 Occasionally, however, apparently a severe neuritis will follow, with pain in 
 the distribution of the nerve and possibly palsy of the muscles supplied, and 
 trophic alterations in the skin and its appendages. 
 
 Treatment. — This will depend on the cause. If it be tiie pressure by a 
 tumor or by the dislocated head of the humerus or from a fracture, first of all 
 the cause must be removed if possible. The next most important indication is 
 that the nerve shall have absolute rest, — not rest merely by non-use of the 
 part, but rest by means of a splint, and, if the contused nerve be in the lower 
 extremity, rest in bed in addition to the splint. In cases of moderate injury this 
 perhaps is all that will be required, with possibly the local abstraction of blood 
 by means of leeches and cups. If the injury be more severe, the injection of 
 morphine, with or without atropine, or its administration by the mouth, in order 
 to quiet the pain, is generally indicated. Arsenic is sometimes of value, and 
 the repeated application of galvanism in obstinate cases may give relief. The 
 remote symptoms, motor, sensory, and trophic, are to be treated as is described 
 under the head of Wounds. 
 
 II. Wounds of Nerves. — Formerly division of the small nerves at the 
 bend of the elbow Avas very common from the promiscuous bleeding then in 
 vogue. At present by far the commonest Avounds of nerves are from glass — 
 as, for instance, from thrusting the hand through a pane of glass or from the 
 breaking of a glass bottle — and from knives, scythes, etc., Avhile the ordinary 
 accidents of civil life, such as punctured Avounds by needles, scissors, and splint- 
 ers, and the more extensive lacerated AVOunds foUoAving railroad and machinery 
 accidents, are of frequent occurrence. In military practice and occasionally in 
 civil life the nerves are implicated in gunshot Avounds. The damage done to 
 motion and sensation is most severe after Avounds of the larger nerve-trunks ; 
 but the reflex symptoms from such Avounds are more commonly seen Avhen the 
 smaller filaments are implicated, and more often after laceration or puncture 
 than after a clean cut. 
 
 Symptoms. — The symptoms of a nerve Avound are not distinctive of the 
 nature of the injury, Avhether it be a contusion, a clean incision, or a lacerated 
 or gunshot AA-ound. The immediate symptoms are both local and constitutional, 
 and vary to the greatest possible degree in their severity. The pain may be so 
 slight in some cases that the Avound Avill escape notice, or at most the patient 
 Avill imagine he has been struck by a stick or stone. In other instances the 
 pain even from the AVound of a small nerve Avill be so severe that he Avill lose 
 consciousness from it. This condition of shock will sometimes be very great, 
 especially in gunshot wounds. It need not be described here, for it resembles 
 the shock of other Avounds. 
 
 In one respect, hoAvever, a further statement is necessary, — namely, as to 
 the so-called "reflex palsies." In a number of instances it has been noted 
 that the AVOund of a small nerve (for it is more common in a small nerve than in 
 a large one), for instance, on the right side of the neck. Avill produce a palsy of 
 the left arm or left leg or of both; or a Avound of the thigh may produce paral- 
 
;i(i8 AiY AMh:ni('A.\ TEXT- HOOK OF SURGERY. 
 
 ysis of the arm or leg of the opposite side of the body, or sometimes of all four 
 limbs. This has been explained by Brown-Sd((uard on the theory of reflex 
 j)aralysis or spasm of the vessels of the paralyzed limb or limbs themselves, 
 but the theory advanced by Mitchell, Morehouse, and Keen, that it is due to 
 exhaustion of the nerve-centers of motion and sensation, seems to be the better 
 explanation. 
 
 Shock and pain, ^vith , loss of motion or of sensation, or of both, are then 
 the immediate symptoms of nerve wounds. Such wounds are of course attended 
 with more or less hemorrhage, and are subject to the same danger (»f infection 
 and intlammation that attends wounds elsewhere or of other organs. 
 
 It is, however, the remote symptoms and results of nerve wounds that are 
 by far the more important and interesting and constitute their peculiarity. 
 They were first carefully studied in our late civil war by Mitchell, Morehouse, 
 and Keen. Sensation and motion are sometimes e([ually affected; but sensation 
 is apt to be less affected than motion, and if both are affected, sensation, 
 as a rule, will return earlier than motion. If the nerve be a motor or a mixed 
 nerve and its function be destroyed, the muscles which it supplies will soon 
 show marked wasting, together with increasing feebleness of action, or not 
 uncommonly complete palsy ; and as a later result contracture of ths muscles 
 will follow, giving rise not only to inability to use the part, but also to serious 
 deformity. Combined with the motor disturbances there will be marked altera- 
 tions of sensation, and the skin supplied by the nerve will become anesthetic 
 or freciuently liyperesthetic and painful. 
 
 A third series of changes in the nutrition of the parts supplied by the nerve 
 follows, usually at a considerable time after the sensory and motor changes. 
 These trophic changes do not take place at the seat of the wound, but at a dis- 
 tance from it, in the area to which the nerve is distributed. They manifest 
 themselves first in a curious appearance of the skin, which looks as if it were 
 varnished. It is usually red and is very apt to be dry, though sometimes it will 
 be bedewed Avith perspiration, which is often acid and foul-smelling. Along 
 with this there is sometimes developed a burning pain, which Mitchell has 
 named "causalgia." Frequently even to point at the injured hand of such a 
 patient will evoke such a paroxysm of pain that he will draw his hand away in 
 fear. In many cases he obtains relief from Avetting the injured hand or foot, 
 and may even wear a cotton glove which he will constantly wet, or may pour 
 water into his boots in order to keep the burning foot in even moderate com- 
 fort. The hair is commonly greatly diminished in amount. The nails become 
 strangely curved, both in the axis of the limb and transversely, shoAving furrows 
 and ridges, and very often ulceration of the matrix occurs. Sometimes gan- 
 grene of the terminal phalanges of the fingers and toes Avill set in. and may 
 extend more Avidely, but not often beyond the fingers or toes. There is often 
 also an eruption like chilblains or eczema. Sometimes the larger joints will 
 become inflamed, SAvollen, and tender after a Avound of the main nerve or nerves 
 of a limb. These neural arthropathies folloAv not only Avounds or other lesions 
 of nerves, but also injuries to the central nervous system, either in the spine 
 or in the brain. They resemble rheumatic arthritis to a marked degree. 
 
 Diagnosis. — (1) As to Motion. — In making a diagnosis of the loss of 
 motion that folloAvs injury to any nerve it is only necessary to determine Avhat 
 muscles have lost their function and to compare these muscles Avith the nerves 
 wliich supply them. In order to test the strength of the muscles of the fore- 
 arm as a Avhole, the dynamometer must be used. This is simply an oval spring 
 with a graduated disc and a movable pointer. On grasping it the registration 
 by the pointer on the graduated scale shows the relative strength of the two 
 
SUUGERY OF THE NERVES. 369 
 
 arms. There should be simihir instruments to test the force of tlie motions at 
 the elbow, wrist, shoulder, and le^, but none such have been devised. 
 
 (2) As to Sensatiuii. — Here the problem is a much more difficult one, not 
 only because the nerve-supply of the skin is by no means so constant as that 
 of the muscles, but also because the methods involVed require greater atten- 
 tion. The loss of sensation in the skin varies considerably in its character. 
 In a certain area there will be absolute loss of sensation, or anesthesia. Between 
 this and the area of normal sensation is a zone of irregular outline in which 
 sensation is not absent, but perverted. This is the region of dysesthesia or 
 paresthesia, and will vary much in different cases. It must be remembered 
 that there is also what has been called "supplementary sensation." By this 
 is meant that the entire area ordinarily supplied by a certain nerve, which 
 should be entirely anesthetic after division of its nerve, is still found to possess 
 a more or less complete sensation after such division. Whether this is from 
 anastomoses of neighboring nerves or not is a problem which is as yet not 
 solved. To aid in its solution, in all cases in which a nerve has been pur- 
 posely cut or has been divided by accident the areas of full sensation, pares- 
 thesia, and anesthesia should be carefully mapped out by the methods described 
 below and the areas . indicated, that of total anesthesia by dark shading, that 
 of paresthesia by lighter shading. Only by collecting and comparing numerous 
 reports of such cases can the physiological anatomy of the nerves be determined. 
 
 In determining the areas of anesthesia and paresthesia the surgeon should 
 be careful not to rub the part nor adopt any other rude method of testing, for 
 any displacement of the skin is perceived readily at a distance. The best 
 methods are as follows : First, by a light pencil, or in some cases a feather or 
 bristle or any other means of delicate touch, the area, for instance, of anes- 
 thesia is determined from point to point, and is mapped out. Sometimes for 
 still more delicate determination the mere touching of the hairs that grow so 
 plentifully over most of the body can be used. An additional means is the 
 ability of the patient to recognize the points of a pair of compasses as tAvo points 
 or as one. The pair of compasses is fitted with a graduated scale indicating the 
 distance between the two points, either in inches or centimeters, and is called 
 an esthesiometer. The best are now provided with a small knobbed point and 
 a sharp point to each arm of the compasses. An ordinary pair of compasses 
 and a graduated ruler, however, Avill answer. In using them it is important 
 that the test be made alternately on the two corresponding limbs under the same 
 conditions and Avitli the same number of repetitions, and that, for proper com- 
 parison, it be done in each limb either transversely or in its long axis,, for the 
 ability to distinguish the tw^o points varies Avith the number of repetitions and 
 with the placing of the points transversely or lengthwise. It is especially need- 
 ful to see that the two points touch the skin simultaneously, for two successive 
 touches would of course be appreciated as two points, even when if touched 
 simultaneously they would be perceived as only one. All these examinations 
 should be made with the patient blindfolded, so as to prevent the assistance of 
 sight, and he should not be allowed to move the fingers, toes, or other parts in 
 order to assist sensation by the muscular sense. It must be remembered also 
 that normally many persons cannot distinguish well between adjacent toes, 
 especially the third and fourth. Where sensation has been lost to ordinary 
 touch it will still be retained to certain other stimuli, as, for example, electricity, 
 and these also may be used as a means of diagnosis. The electric wire brush 
 will evoke sensation in many cases where all other means fail. The sense of 
 temperature should also be determined b}' dipping the hands or feet into water 
 of a known temperature, or by applying mops dipped in th^ water, in many 
 
 24 
 
370 
 
 .i.v ^^fl•:li^<^^^' text- hook of smaKiiv. 
 
 cases using alternatt'ly liot and cold water. As a nilo, it will he ioiiiid that 
 while sensation and motion may be equally lost at the time of injury, sensation 
 will return, sometimes shortly, sometimes at a longer interval, before motion. 
 Generally also the irritability of the muscles to the constant galvanic current 
 is lost some time after their response to faradaic electricity, the return of electro- 
 muscular contractility being in the reverse order. Voluntary control over the 
 muscles is, as a rule, lost before response to electricity, and returns in reverse 
 order. 
 
 DIAGNOSIS OF LESIONS OF SPECIAL NERVES. 
 
 I. Fifth or Trifacial Nerve. — Figure 142 shows the cutaneous distri- 
 bution of the three branches of the fifth nerve (V,, Vg, and Y3) in different 
 
 shadinf^s. From a determination of 
 
 Fig. 14.']. 
 
 Fi(i. 142. 
 
 Distribution of the Cutaneous Sensitive Nerves 
 upon the Head : wna, omi, the oceiynt. niaj. and 
 minor (from the N. cervical. II. and III.); am, N. 
 auricular, magn. (from N. cervic. III.) ; cs, N. cer- 
 vical, sunertic. (Yrom N. cervic. III.); \\, first 
 branch ol the lifth {so, N. supraorbit. ; st, N. supra- 
 trochl. ; it, N. infratrochl. ; e, N. ethmoid.; I, N. 
 lachrymal.); I 2, second branch of the fifth (sjh, 
 N. subcutan. make sen zygomaticus) ; V3, third 
 branch of the fifth (at, N. auricuh)-tempor. ; b, N. 
 buccinator; to, N. mental.) ; B, posterior branches 
 of the cervical nerves (Seeligmiiller). 
 
 Paralysis of Left Facial Nerve, the face being in 
 repose (original). 
 
 the region of hyperesthesia or anesthesia the particular branch involved can 
 be ascertained. 
 
 II. The Facial Nerve may be injured in gunshot wounds, in fracture of 
 the middle fossa, or in neciosis of the petrous portion of the tem])oral bone, and 
 may also be divided by the surgeon in the removal of tumors from the parotid 
 and neighboring regions. If the injury be far enough back to involve the 
 chorda tympani, taste Avill be impaired. The palsy which follows injury of 
 the facial nerve is pathognomonic. The eyebroAv cannot be raised or wrinkled 
 horizontally, and the eyelids can be only ])artially closed. But the ))atient soon 
 learns to roll the ball up under the upper lid in order to wet the cornea and 
 preserve its translucency. The ala of the nose on the ])aralyzed side does not 
 move in respiration nor by volition, and control of the angle of the mouth is 
 lost, saliva and other liquids dribbling from it. The patient cannot pucker his 
 mouth to whistle. The entire face on the side of the lesion has an expression- 
 less stare. AVhen'the patient attempts to laugh or to close the eyes tightly, only 
 
SURGE/n' or THE NERVES. 
 
 371 
 
 the un])araly/e(I side of the face is Avrinkled, tlie other remains smooth. The 
 facial bein^ purely a motor nerve, no change of sensation occurs. 
 
 III. The Pneumogastric and its Recurrent Laryngeal Branch. — 
 In a very fe\v eases in tying the carotid or in the extir])ation of tumors the 
 pneumogastric luis eitlier been divided or ligated, and in the excision of goitre 
 one of the chief dangers is tiie division of the recurrent laryngeal. Either lesion 
 produces hoarseness and altered voice from paralysis of the vocal cord on that 
 side, and if in the excision of goitre the nerves ])e cut bilaterally instant tracheo- 
 tomy must be done to prevent suffocation. Except alteration of the voice, the ef- 
 fects of section of the pneumogastric or its ligation seem to be extraordinarily slight. 
 
 IV. The Ulnar Nerve. — This is cut most frequently just above the 
 wrist. It may also be divided at the elbow or in the upper arm. The motor 
 paralysis Avill affect the flexor 
 carpi ulnaris, the inner half 
 of the flexor profundus in the 
 forearm, and in the hand the 
 whole group of hypothenar 
 muscles, the two ulnar lum- 
 brical muscles, all the inter- 
 ossei, the adductor pollicis, 
 and half of the flexor brevis 
 pollicis. The appearance and 
 action of the hand in ulnar 
 paralysis are therefore very 
 characteristic. Besides the 
 wasting of the ulnar muscles 
 in the forearm, the hypothenar 
 eminence is wasted and may 
 become even hollowed, and 
 there is partial wasting of the 
 thenar eminence. The inter- 
 osseous spaces also are fur- 
 rowed from the wasting of 
 these muscles. If an object 
 be placed in the palm and the 
 patient be told to grasp it, 
 he will first flex the last two 
 phalanges of the fingers by 
 the common flexors, and then 
 by the further contraction of 
 these muscles will roll the 
 flexed fingers into the palm, 
 but he will not be able to 
 grasp an object by placing 
 the tips of the fingers on the 
 
 Anterior Surlatf. Posterior Surface. 
 
 Distribution of the cutaneous nerves to the shoulder, arm, and 
 
 thenar and the hvpothenar 
 
 , n • ' 1 JJistriDunon oi lue cutaneous nerves lo me soouiaer, arm, and 
 
 eminence by llexion at tne hand. The region of the N. radialls is represented by the 
 knuckle, as can be done unl^^oken. hatched Une,. that of the. N.ulnaris by the bfoken 
 
 in the normal hand. More- 
 over, as the interosseous and 
 lumbrical muscles extend the 
 last two phalanges of the fin- 
 gers, these joints of the fingers will remain constantly in semiflexion, while 
 
 hatched linos, a, anterior, 6, posterior surface : sc, Nn. supra- 
 scapular, (plexus cervicalis) : ax. chief branch of X. axillar. ; cps, 
 cpi. Nn. cutanei post. sup. and inf (from N. radialis) ; ra, termi- 
 nal branches of X. radialis: cm, d, Nn. cutanei medius (also to 
 the plexus) and lateralis (chiefly to the N. medianus) : cp, N. 
 cutan. palmar., N. rad. ; cmd, N. cutaii. medialis; me, N. media- 
 nus ; «, N. ulnaris; epu, N. cutan. palm, ulnaris (Henle). 
 
372 
 
 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 tlic first phalanges will be piilltMl bac-kwanl in marked extension by the now- 
 unopposed common extensor. 
 
 As a result of this the "claw hand" is jiroduced, and all the more delicate 
 motions of the hand are lost. Fig. 145 shows an extremely bad case. The 
 
 scar of the wound of the 
 Fig. l4o. ulnar nerve is seen, at A. A 
 
 lesion of this nerve is there- 
 fore of very serious import- 
 ance to any patient, whether 
 he be laborer, artisan, or in 
 the higher classes of life. 
 
 Sensation. — As a rule, 
 
 the ulnar nerve supplies the 
 
 ,g ulnar portion of the skin 
 
 Paralysis of Ulnar Nerve from Wound at A; contracture of com- of the hand both front and 
 mon extensor with posterior luxation of first phalanges ; B, bead y,rtn\r fVio ontivo littlo -finrror 
 cf metacarpal bone (Duchenne). oacK, tue eniue nine nnger, 
 
 and the ulnar half of the 
 ring finger ; but at the tip of the finger the median nerve invades somewhat 
 
 Fig. 146. Fig. 147. 
 
 Loss of Sensation on anterior and posterior surfaces of hand after division of the ulnar nerve (BowlbyV 
 
 the otherwise mathematical distribution of the ulnar. There are, however, in 
 this region marked diftVrences in different patients. 
 
 V. The Median Nerve also is most frequently divided ju-^t above the 
 wrist, where it is comparatively superficial, the flexor tendons being often 
 involved in the injury. It may be injured also higher up on the forearm or at 
 any point in the arm. 
 
 Motion. — The motor symptoms will depend on the point where the nerve 
 is injured or cut. If the median be divided above the elbow, all the flexors 
 and pronators of the arm, with the exception of the flexor carpi ulnaris and 
 the ulnar half of the flexor profundus, will be paralyzed. All the muscle? of 
 the thumb, except the adductor and half of the flexor brevis pollicis, will be 
 
SURGERY OF THE NERVES. 
 
 373 
 
 ])aralyzi'(l. In botli this and in ulnar paralysis flexion of the wrist is lost on 
 the radial or ulnar side respectively, but remains on the opposite side of the 
 forearm. The hand cannot be pronated except by its own wei;j;ht. Flexion 
 of the thumb is lost in the distal phalanx and weakened in the proximal, and, 
 what is still more important, the thumb cannot be opposed to the other fingers. 
 The last two j)lialanges of each of the fingers cannot be flexed, while flexion 
 at the knuckles still remains by the action of the interosseous muscles. If the 
 injury be at the wrist, the nmscles of the forearm Avill escape, the fingers can 
 be flexed, but the thumb still cannot be opposed to the other fingers, and hence 
 small objects can neither be picked up by the thumb and the tips of the fingers 
 nor be well grasped and retained. The appearance is again typical. Wasting of 
 the forearm is more marked than in ulnar paralysis, and the hand is in partial 
 flexion to the ulnar side, with extension of the wrist and fingers. While the 
 hypotlienar eminence is not wasted, the thenar eminence is almost gone. This 
 too, it will be seen, is a very serious accident in any station in life. 
 
 Sensation. — On the palmar surface the area of anesthesia or paresthesia 
 includes the radial half of the palm and the palmar surface of the thumb, index, 
 and middle finger, and the radial side of the ring finger, including the major part 
 
 Fig. 148. Fig. 149. 
 
 ^ K J 
 
 I' l/i 
 
 'V 
 
 Section of Median Nerve: areas of anesthesia 
 (heavy shading) and of dysesthesia (light shad- 
 ing) on palmar surface of hand (Bowlby). 
 
 Section of Median Xerve: regions of anesthesia 
 and dvsesthesia on dorsal surface of hand 
 (BowlbV). 
 
 of its tip. Posteriorly, nearly the whole of the fore and middle %gers becomes 
 anesthetic, and the radial side of the ring finger, but little or none of the dor- 
 sal surface of the hand. 
 
 YI. Radial Nerve. — This is divided occasionally as it passes over the 
 front of the forearm to the back of the hand just above the wrist. No mus- 
 cles are supplied by it. The region supplied by it with sensation, and there- 
 fore anesthetic after its section, is a portion of the skin over the metacarpal 
 bones and first phalanges of the thumb and the forefinger. 
 
 VII. The IVIusculo-spiral Nerve. — This is most frequently injured by 
 gunshot wounds or fracture of the humerus involving the musculo-spiral groove. 
 
374 
 
 ,1,V AMKincAX TEXT- HOOK OF SVIidKIiY. 
 
 Fk;. 150. 
 
 Paralysis of Musculo-spiral Nerve after Frac- 
 ture of the Humerus (•' wriBt-drop''; ; but 
 when fingers have been flexed into palm, 
 a, they can be extended b. at first inter- 
 phalangeal jnints by lumbricals and inter- 
 ossei. which are supplied by the ulnar and 
 median nerves (Erichsen). 
 
 Motkni. — If the nerve is paralyzed below the hraneh going to the supinator 
 longus, this muscle escapes paralysis and its function as a flexor of the forearm 
 
 becomes very marked. If the nerve is 
 injured above the origin of this branch, the 
 suj»inator longus is paralyzed, and flexion and 
 supination are impaired, though not lost, for 
 the biceps acts as a marked supinator as well 
 as flexor, and is aided by the supinator brevis. 
 Extension of the wrist and fingers is lost, 
 and there is distinct wrist-drop, with inability 
 to extend the fingers at the knuckle (Fig. 
 150). The last two phalanges, however, can 
 still be extended by the interosseous and 
 lumbrical muscles. Atrophy of the exten- 
 sors is very marked. 
 
 Sensation. — The loss of sensation will 
 differ, depending on the level at which the 
 nerve is injured. 
 
 Several of the above nerves may be 
 injured at one time, or the brachial plexus itself may be ruptured in accidents 
 and occasionally in surgical operations. 
 
 A^III. The Great Sciatic Nerve. — Since it is so well protected, the trunk 
 of the sciatic is not often injured or cut by accident, except in gunshot wounds, 
 but its external popliteal branch is sometimes divided in tenotomy of the 
 biceps muscle or accidentally just below the head of the fibula. 
 
 Motion. — The importance of this branch lies in the fact that it supplies the 
 anterior flexor muscles of the foot, and that its injury or division is followed 
 hj foot-drop, so that the foot drags in walking and the wearing away of the 
 boot-sole under the great toe is very marked. If the main trunk of the sciatic 
 is divided or injured, all the muscles below the knee are involved in the 
 paralysis. The patient can walk, because, as a rule, the muscles of the thigh 
 are not involved, but the leg is, as it were, flung forward from the hip at each 
 step. 
 
 The loss of sensation (Fig. 151) is generally less extensive than the loss of 
 motion, onlv the foot and the outer ]iart> of the leg being entirely anesthetic. 
 
 Prognosis after Injuries of Nerves. — This is more or less grave 
 in accordance with the importance of the nerve involved, the extent of the 
 injury, and the time that has elapsed without proper treatment. It is, however, 
 possible, after a lapse of months or sometimes even of years, to do much in the 
 way of restoration, sensation being, as a rule, more under control than motion. 
 If the time has been long and the injury severe, good results can be attained 
 only after treatment covering weeks or months, and in many cases can scarcely 
 be hoped for. Hence the especial need for the early correct treatment of these 
 injuries. 
 
 Treatment of Wounds of Nerves. — The fact that there is a lesion of 
 a nerve will not modify the primary treatment of the wound unless the ner\e 
 be amenable to suture, as described below. This should always be done at the 
 time of the accident. The wound should be treated in othev respects precisely 
 as any ordinary case. The treatment of the remote results due to nerve injury 
 are, however, somewhat peculiar, and are now to be considered. 
 
 Treatment of the Remote Effects following Nerve Injury. — 1. 
 Motion. — Un<iuestionably the agent which gives us the best promise of relief 
 from a destructive motor lesion is electricity. "When a motor or a mixed nerve 
 
s'ri?r;/:/n' or tjtk xervks. 
 
 875 
 
 lias been dividtMl, as has already been stated, the muscles which have been 
 paralyzed very soon indicate de-jjenerative changes affecting tlieir nutrition and 
 producing a permanent shortening. This degeneration can be prevented to a 
 large extent by the daily or almost daily use of electricity, wliich will keep 
 the muscles in their normal condi- 
 tion, ready to resume their natural '''" ^■''• 
 function by volition on the rehabili- 
 tation of the nerve-trunk, which may 
 then take the place of the electric 
 stimulus. If the nerve responds to 
 faradism, this is undoubtedly the 
 best form to use. If, however, so 
 much time has elapsed that the 
 muscles do not respond to faradism, 
 galvanism should be employed and 
 the effect of faradism re-tested from 
 time to time, and as soon as the 
 muscles respond to faradism this 
 should be used in preference. An 
 important adjunct to this is system- 
 atic daily massage of the paralyzed 
 limb, which should be persistently 
 employed with the same object as 
 the use of electricity. The hot and 
 the cold douche should also be used, 
 too;ether with such oreneral measures 
 as will best keep up the general 
 health. If muscular spasms occur, 
 the injection of yi-g- of a grain of 
 atropine deep into the substance of 
 the muscle is the best means of over- 
 coming the spasm. If deformities 
 have resulted, tenotomy is often indi- 
 cated and will result beneficially. 
 If the joints have become ankylosed 
 or otherwise diseased, the adhesions 
 must be broken up under anesthesia, 
 very often repeatedly, and the joint 
 stimulated to return to its normal 
 condition by passive motion, friction, 
 douches, massage, etc. These efforts 
 must not be relaxed until the lapse 
 of months or even of years has proved 
 that the lesion is beyond relief. 
 
 2. Sensation. — Anesthesia. — The 
 best means of stimulating the skin, 
 apart from the measures already 
 indicated, massage, friction, douche, 
 etc., is the electric brush. This is best applied with the faradaic current, the 
 skin having first been dried with flour. 
 
 Pain. — The pain varies so much in degree that the treatment must be cor- 
 respondingly varied. Sometimes the simple application of cold water is sufiB- 
 cient. Occasionally the injection of small amounts of morphine will answer 
 
 Anterior Surface. 
 
 Posterior Surface. 
 
 Distribution of the cutaneous nerves of the lower 
 extremity, n, N. ilio-inguinal. (plex. lumb.); li, 
 N. lumbo-inguinal. (to the genito-crural, plex. lum- 
 bal.); se, N. spermat. ext. < to the genito-crural.); ep, N. 
 cutan. post. (plex. ischiad.); c/, N. cutan. lateral. 'plex. 
 lumb.) ; cr, N. crurali.s (plex. lumbal.) ; oht, N. obtura- 
 tor, (plex. lumb. J ; sa, N. saphen. (plex. lumbal.); 
 cpe, N. commun. peron. (N. peron. tibial.) ; cti, N. 
 commun. tibial. ; per' . per", N. peronsei ram. superfic. 
 et prof.; cpm, N. cutan. post. med. (plex. ischiad.) ; 
 cpp, N. cut. plant, propr. (N. tib.) r plm, pll, N. plan- 
 tar, medial, et lateral. (N. tib.) (Henle). 
 
376 AN AMERICAN TEXT- HOOK OF SriiGEIiV. 
 
 the purpose, and often rest -svill do nuicli, l»nt in cases of severe pain, especially 
 tliat named by Mitchell "Oausal^ia," all means employed will sometimes he futile. 
 The patient who is a victim of such pain soon learns the value of cold water 
 and keeps the part constantly wet, wearing a wet glove or pouring water into 
 his boots. The most useful remedy in these cases i» repeated blistering over 
 the course of the nerve, and in many instances this will give even complete 
 relief, ^lorphine should be given by the mouth or by injection, but care must 
 be taken lest the morphine habit be formed. If the pain resists these remedies, 
 especially when com])ined with those already mentioned, the nerve involved 
 should be stretched, divided, or exsected. Sometimes even amputation is 
 required. 
 
 SECTION VI.— OPERATIONS ON NERVES. 
 
 These are four in numt^er: I. Nerve-Suture and Nerve-Grafting; II. 
 xNeuiectasy, or Nerve-Stretching; III. Neurotomy, or Division of a Nerve; 
 and ly. Neurectomy, or the Excision of a Part of a Nerve. 
 
 I. Nerve-Suture and Nerve-Grafting. — Primary Suture. — The old 
 view^s of the dangers of sutures as applied to nerves are entirely exploded, and 
 numerous cases in which suture of a nerve has been practised immediately 
 after the injury prove that recovery of function is greatly facilitated by such 
 suture. Hence, precisely as is the case Avith a tendon, a nerve should always 
 be sutured immediately if possible, even if the section of the nerve is only 
 partial. Supposing first that the nerve is merely divided, without loss of 
 substance, and hat the ends can readily be approximated, two or three sutures 
 should be passed not merely through the sheath of the nerve, but through its 
 substance. These should be preferably of fine silk, and inserted by sewing- 
 needles. The part then should have absolute rest on a splint, so that the nerve- 
 ends should not be torn asunder by motion of the limb. Catgut, kangaroo 
 tendon, etc. may also be used, of course with antiseptic precautions. In one 
 case in which no such means were at hand an ordinary hare-lip pin Avas inserted 
 obliquely through the two ends of the ulnar nerve and a loop of fine silk thrown 
 over its "point, brought out through the wound, and secured to the head of the 
 pin. At the end of three days the pin Avas withdraAvn, thus loosening the silk, 
 which Avas easily removed. The result Avas in every Avay satisfactory. If the 
 ends are so far separated that they cannot be readily approximated, one or both 
 ends of the nerve may be stretched until they can be placed in contact, and 
 the same process then carried out. While failure has occurred in a good 
 many cases, the results have been surprisingly successful in others. In a very 
 fcAv instances apparently primary union has taken place and sensation has been 
 restored in tAvo or three days, or even less : but more frequently one, tAvo, or 
 more Aveeks Avill elapse, and Ave should not despair of such a nerve until months' 
 or even years have passed. BoAvlby has analyzed 81 cases of primary suture, 
 of whicli 32 Avere entirely successful, 34 were partially so, and only 14 Avere 
 failures, the result in one case not being recorded. It is especially important 
 to remember that Ave should not be hasty in our conclusions as to results. The 
 early results may be disa])pointing, but time must be allowed for union, 
 degeneration, and regeneration of the nerve before avc can expect return of 
 function in most cases. Even the gravest of trophic changes should not make 
 us despair of the ultimate result. Sensation Avill return, as a rule, before 
 motion, and, in vieAV of the time that elapses before the nerve Avill be able to 
 carry the stimulus of volition to the muscles, the value of electricity in keeping 
 the muscles in good condition must especially be borne in mind. 
 
SURGE JiV or TIIK XKliVES. .377 
 
 Secondary Suture. — Within the hist few years, in a number of cases 
 weeks, months, or even a number of years after tlie injury, when the 
 muscles have been paralyzed for a long time and sensation has"^ been altered 
 or destroyed, the secondary suture of such divided nerves has been followed 
 by success. This operation, like all others, must be strictly antiseptic. 
 An Esraarch bandage may be applied, the nerve exposed, and the two ends 
 loosened from their attachments. The i)roximal end will, as a rule, be bulbous 
 and be found with ease. It is often more difficult to find the wasted distal end, 
 and sometimes it is best to cut down on the nerve beyond the site of the injury 
 at a point where the nerve lies in its normal relations, and then follow up the 
 trunk till we come to the cut lower end. The whole of the bulbous extremity 
 of the proximal end should be removed, but only a small portion, usually not 
 over a quarter of an inch, of the distal end. The two ends should then be 
 approximated by stretching, and the nerve sutured as before. In some cases — 
 ('. (T/., of injury with loss of substance of the musculo-spiral — it may be needful 
 to resect a portion of the bone in order to bring together the widely-separated 
 ends of the nerve. Bowlby's table of 7o cases of secondary suture of the nerves 
 gives successful results in 32, partially successful in 26, and failure in only \~). 
 
 Nerve-grafting. — If, after stretching, the ends of the nerve cannot be 
 api)roximated, two methods are open to us : partially splitting the nerve for a 
 certain distance, turning over what may be called the flap of nerve (Fig. 152), 
 
 N \ ' ^^ ^^^^Xcr-J' ' ~^^'" 
 
 Suture of a Nerve by Splitting the Ends (Beach). 
 
 and uniting it to the other cut end ; or flaps may be made" from both ends 
 (Beach). The results of this method of treatment have not, however, been 
 very satisfactory. Possibly the transplantation or grafting of nerves will 
 give better results. If a nerve can be removed from an amputated limb 
 (the two operations of amputation and nerve-suture being simultaneous), a 
 portion of human nerve can be transplanted. If it be impracticable to obtain 
 a portion of human nerve, a suitable portion of a nerve from one of the lower 
 animals can be removed, placed in its proper position, and sutured at both ends 
 to the cut ends of the nerve. It is probably a matter of indifference whether 
 this nerve be a motor, sensory, or mixed nerve, the nerve-tubules being simply 
 subservient to the transmission of the nervous impulse in either direction. The 
 suggestion of Von Bergmann that the entire limb shall be shortened by resec- 
 tion of a portion of the bone has been done a few times with success. 
 
 In all cases after secondarv suture the use of galvanism, and later of 
 faradism, together with massage, etc., should be employed for a year or more 
 before relinquishing the hope of a successful result. 
 
 II. Neurectasy, or Nerve-Stretching, was first introduced by Nuss- 
 baum in 1872. Vogt has shown by experiment that a nerve can be stretched 
 
37.S AX J.l//.7.'/r.LV 7V;A"/-/;00A' O/' S(Il(;i:i!Y. 
 
 one-twentieth of its length, and that it yiekls most at its spinal extremity, the 
 amount of elongation diminishing as \ve ajiproach the perij>hery, where it 
 becomes almost nothing. In order to guide us as to how much force we can 
 ap|)ly, it is important to know what force will ruj»ture the nerve. Marshall 
 gives the following result of experiments on difl'erent nerves: 
 
 Cohesion of Human Neixes after Death — Breaking Strain in Pounds. 
 
 Lbs. 
 
 Supraorhital 6 
 
 Infniorl.ital 12 
 
 Mental 5i 
 
 Brachial plexu.s 50-64 
 
 Ulnar 58 
 
 Musculo-spiral fil 
 
 Median 84 
 
 Crural . . • • 83 
 
 Internal popliteal 114 
 
 Great sciatic — vSvmington 86-17fi 
 
 fillaux 118-127 
 
 Gillette 165 
 
 Trombetta 82-288 
 
 Ceccherelli 154-220 
 
 It must be remembered that the force necessary to produce rupture is probably 
 somewhat greater in the living than in the dead subject. The nerves most 
 commonly stretched are the facial, the spinal, and the sciatic, especially the 
 latter. It should be noted that the facial nerve, which is not included in Mar- 
 shall's table, will bear a strain of from seven to twelve pounds, and that therefore 
 the head can be almost lifted from the table, and in some cases entirely so, 
 •without rupture of the nerve-trunk. The surgeon generally feels the rupture 
 of some strands, which will warn him of the impending rupture of the entire 
 trunk. The great sciatic nerve has ruptured in various subjects at a minimum 
 of 82 pounds and a maximum of 288. It is therefore, as a rule, absolutely safe 
 to lift the leg or even the pelvis by traction upon this trunk. "Whether nerve- 
 stretching produces any traction upon the cord has been much dis])uted. But 
 Tarnowski has shown experimentally in rabbits that while slight traction on the 
 sciatic nerve was followed by a passing hyperemia, when the traction was consid- 
 erable hemorrhages in the gray matter and inflammatory exudations were 
 caused, followed by sclerosis and atrophy of the nerve-cells : and marked effects 
 have been noted after stretching of the brachial plexus. Moreover, inasmuch 
 as there are on record at least eleven cases of death from lesion of the spinal 
 cord after nerve-stretching, such deleterious influences can scarcely be denied. 
 The eftects of nerve-stretching are more or less hemorrhage and destruction 
 of the nerve-tubules, differing in amount with the force used, with later cell- 
 proliferation in the neurilemma. This tearing of the nerve-tubules is followed 
 by degeneration precisely as after section of the nerve, followed in turn, how- 
 ever, by a much greater regeneration. In the cord the changes are usually 
 inflammatory, from a slight hyperemia up to a definite myelitis followed by 
 atrophy. The direction of the stretching is not a matter of indifference, for, 
 as shown by Tutschek, if a nerve be stretched by drawing it in a direction 
 away from the cord, the sensory fibers are more dulletl than the motor, but if 
 the traction be toward the cord the motor filaments suflTer more than the sensory. 
 We should therefore stretch the nerve in diff'erent direction^ for the relief of 
 pain and of spasm. If the stretching be very severe, it may be followed by 
 trophic changes, just as after a lesion of the nerve produced in any other way. 
 Various theories have been adduced as to the mode of action of neurectasy : 
 
sri;(;i:i!V or Tin: seiivks. ;i7y 
 
 the probability is, however, that its benefit results from some obscure change 
 in the nutrition of the nerve, in its separation from adhesions either to neigh- 
 boring parts such as cicatrices, etc., or to its own sheath, and in many cases 
 undoubteiUy to absolute rupture. 
 
 Two methods may be adopted. Ftrat, hij operation. The ti imk of the 
 nerve is exposed and loosened from tlie surrounding parts. It is then stretched 
 either by hooking it up by the fingers, or in a small nerve such as the 
 seventh nerve by a common pocket button-hook or similar instrument, or 
 by Horsley's saddle-shaped hooks for the larger nerves. The second or 
 bloodless method is applicable only to the great sciatic nerve. The patient 
 is etiieri'/ed, the leg kept extended at the knee, and the entire lower extremity, 
 being then used as a straight, stiff lever, is carried into marked and forceil flex- 
 ion at the hip. The results of the last method seem to have been very good in 
 a number of cases, but it must be borne in mind that in adults at least there 
 must be considerable rupture of the bellies of the hamstring muscles, and there 
 have been reported two cases of death after this metliod. 
 
 Conditions to which Neurectasy is Applicable. — The largest num- 
 ber of operations of this kind have been done for ataxia, and often with at least 
 temporary benefit ; but usually there has been only slight relief, and in many 
 cases none. In spinal disorder of all kinds, such as paralysis, myelitis, paralysis 
 agitans, athetosis, epilepsy, and tetanus, little good has been accomplished. In 
 " tic convulsif," or spasm of the facial muscles, the facial nerve has been stretched 
 in over twenty cases. In a very small number the relief has continued for 
 months, and in Southam's case even for five years, but in most instances relapse 
 has followed. The relief is so great, however, that the patient is generally will- 
 ing to submit to repeated operations, and the operation is undoubtedly to be 
 recommended. Neurectasy has also been used for Avry neck, in a few cases with 
 cure or benefit. Anesthetic leprosy has also been so treated with improvement. 
 In all cases where nerve-stretching has failed to relieve it is possible to do a 
 later neurotomy or neurectomy ; hence very often neurectasy should precede 
 these more severe operations. 
 
 III. and IV. Neurotomy and Neurectomy. — These two operations of 
 simple section of the nerve and exsection of a portion of it may be considered 
 together, as they differ only in the treatment of the nerve. As a rule, neurec- 
 tomy is to be preferred to simple neurotomy. They are done occasionally for 
 muscular spasm, but most frequently by far for neuralgia. Either may be 
 done as a primary operation or secondary after neurectasy. Neurotomy can 
 sometimes be done subcutaneously, as, for instance, in the supraorbital or the 
 infraorbital nerve. When several nerves lie close to each other, as in the arm- 
 pit, and there is doubt as to which is the nerve sought for, faradizing each 
 exposed nerve in turn will differentiate them. Once the nerve is exposed it 
 can be stretched, divided, or a portion of it exsected as may be desired. The 
 following nerves are those most commonly operated on : 
 
 1. The supraorbital nerve emerges on the face through the supra- 
 orbital foramen or notch. If it is a notch, it can usually be felt, but if a foramen 
 it can also be readily found, as it lies at the junction of the inner and middle 
 thirds of the eyebrow. A simple curvilinear incision one inch in length, which 
 if made in the eyebrow will be hidden by the hair, is sufficient to disclose the 
 nerve. 
 
 2. The Superior Maxillary Division of the Fifth Nerve. — A line 
 drawn from the supraorbital notch downward between the two lower bicuspid 
 teeth intersects the infraorbital and mental foramina. The infraorbital nerve 
 emerges at the former foramen. Simple section of this nerve, which was 
 
380 J.V AMF.IilCAX TKXT-IK K )K OF SURGEItY. 
 
 formerly done for neuralgia, has been very properly abandoned. A curved 
 incision an inch and a half long is made just below the lower border of the 
 orbit. AVliere this incision intersects the line above mi'ntione<l the nerve will 
 be found under the levator labii su])erioris, lying much deeper from the skin 
 than would be supposed. The nerve having been found, a silk thread is 
 passed under it by means of an aneurysm needle, and the thread is tied in 
 order to identify and make traction on the nerve. The upper border of the 
 incision is now raised by a spatula or retractor, and with a grooved director or 
 other instrument the periosteum covering the floor of the orbit is lifted and held 
 up by the spatula. Even if not at once seen, the canal for the nerve is readily 
 found and broken in by pressing on the floor of the orbit with the grooved 
 director. By a small sharply-curved hook the nerve is lifted from its bed and 
 divided far back in the orbit by means of curved scissors. Traction on the 
 anterior end will now pull out the entire nerve. Moderately sharp bleeding 
 usually follows the division of the nerve in the orbit, but is readily arrested by 
 packing with a little gauze. The bleeding of the external wound is controlled 
 by hemostatic forceps. 
 
 3. Removal of Meckel's Ganglion. — Sometimes after removal of the 
 superior maxillary division as above described, or better as a primary opera- 
 tion. Meckel's o^ancrlion and the nerve are removed. This is done bv Carno- 
 chans method, or better by Chavasse's modification of it. It consists of a T 
 incision below the eye, the horizontal part reaching from canthus to canthus, 
 and the vertical one nearly to the mouth, but without entering this cavity. 
 The infi-aorbital nerve is found, and as before is tied with a piece of silk. 
 The anterior wall of the antrum is then perforated by a three-quarter-inch 
 trephine or a chisel, including the infraorbital foramen. A half-inch trephine 
 or a chisel is applied to the posterior wall of the antrum, care being taken 
 merely to penetrate through the bone and not to wound the internal maxillary 
 artery, which lies close behind it. The nerve is next divided on the cheek, 
 and, after breaking through its groove in the floor of the orbit, the nerve is 
 drawn down through the trephine opening. By this method the nerve is pre- 
 served and utilized as a guide to the ganglion. The nerve, being made tense, 
 is now traced into the spheno-maxillary fossa and to the foramen rotundum. and 
 is divided just below the foramen with long delicate curved scissors. To con- 
 trol the hemorrhage iodoform gauze and small sponges on sponge-holders are 
 best, and it is almost essential that an electric light or forehead mirror be used 
 to illuminate the deep parts of the wound. Abbe has recently recorded two 
 cases in which he removed the nerve by a single horizontal incision one inch 
 and a quarter in length, breaking down both the anterior and posterior walls 
 of the antrum with a simple gouge. After removing the nerve he packed the 
 wound licrhtlv with strips of iodoform jrauze, and did not suture it until he 
 removed the gauze, forty-eight hours after the operation. Sensation being 
 paralyzed, no pain is caused by the late sutures. 
 
 Instead of trephining through the antrum, Horsley, after exposing the 
 nerve, lifts the contents of the orbit with the periosteum of its floor, lays open 
 the canal by sharp-pointed bone forceps, and then follows the nerve to the 
 foramen rotundum. Often the antrum Avill not be opened. Luecke resects 
 the zygoma, turns the temporal muscle up, and so gains access to the ganglion. 
 
 4. Inferior Dental Nerve. — Several operations have been devised for 
 this, but the best are as follows : 
 
 (1) Bij External Incision. — An incision two inches long is made along the 
 lower border of the jaw, beginning slightly behind the angle. This is better 
 than a vertical incision, which is almost certain to divide some branches of the 
 
SURGKIiV OF Till-: XEliVES. 381 
 
 seventh nerve, and may paralyze the muscles of the mouth. The incision, 
 bein^ well under the horiler of the jaw, is entirely hidden in men by the 
 beard and partly hidden in women by the jaw. The upper edge is displaced 
 upward on the vertical ramus, and after scraping away the masseter muscle a 
 half-inch trephine is applied an inch and a quarter above the angle. This 
 exposes the nerve at its entrance into the inferior dental foramen. Tlie nerve, 
 having been brought to the surface by a small sharply-curved hook, is first 
 stretched, and then as much of it as possible is exsected. If desired, the incision 
 can be prolonged above and parallel to the edge of the jaw, and the canal for 
 the nerve be laid open all the way to the mental foramen. Commonly rather 
 copious hemorrhage is caused by the division of the inferior dental artery if this 
 is involved in the cut. Packing will usually control it, but occasionally a liga- 
 ture is necessary. By this same incision the nerve may be removed without 
 trephining by separating the parts behind the jaw instead of in front of it, 
 scraping the internal pterygoid muscle instead of the masseter loose from the 
 jaw, and finding by the finger the sharp point of bone which marks the inferior 
 dental foramen. The nerve can now be brought to the surface as before and 
 be stretched and exsected. 
 
 Horsley has recently proposed a new method by a vertical incision through 
 only the skin and fat, beginning just above the zygoma, extending to the 
 angle of the jaw, and then following its lower border as far as the facial artery. 
 This flap is lifted without cutting the branches of the facial nerve. Between 
 the upper branch of the nerve and Stenson's duct the masseteric fascia is 
 divided, and the opening widened to three centimeters in diameter. The 
 parotid is now retracted toward the ear and the posterior border of the jaw 
 defined. Next the posterior two-thirds of the masseter are divided and the jaw 
 cleaned, so that the sigmoid notch is well seen. By drilling several holes and 
 by a small trephine the bone is removed, so that the sigmoid notch is prolonged 
 downward twelve to fifteen millimeters to the border of the inferior dental 
 foramen. Division of the periosteum on the inner surface of the jaw then 
 discloses the inferior dental nerve. This can be followed to within a centi- 
 meter of the foramen ovale and exsected. The lingual nerve lies half an inch 
 deeper and somewhat in front of the inferior dental, and may also be exsected. 
 The bleeding is free, but controllable. The internal maxillary artery may 
 have to be ligated and divided. An electric light is essential. 
 
 (2) The nerve can also be reached through the mouthy as follows : The 
 mouth being held open as widely as possible by a gag on the opposite side, the 
 mucous membrane is incised along the anterior border of the ramus of the 
 lower jaw between the last molar teeth of the two jaws. The finger can now 
 be inserted between the internal pterygoid muscle and the ramus of the jaw. 
 The muscle being separated from the bone, the same sharp projection of bone 
 at the opening of the inferior dental foramen before referred to is found and the 
 nerve broucrht to the surface with a hook. The long internal lateral ligament 
 of the jaw must not be mistaken for the nerve. Hemorrhage was very profuse 
 in two instances on record, and gave considerable trouble. 
 
 5. Removal of the Gasserian Gang-lion. — In not a few cases after the 
 above operations, especially on the superior maxillary and inferior dental nerves, 
 the neuralgia returns, and in order to remedy the pain Rose, Andrews, and others 
 have removed the Gasserian ganglion itself. This ganglion lies, it will be re- 
 membered, on the anterior surface of the petrous bone underneath the dura, 
 but above a layer of the periosteum which lies between the ganglion and the 
 base of the skull. Mr. Rose's later method is as follows: The eyelids are first 
 sewed together to protect the ball, the sutures being removed on the fourth 
 
3S2 
 
 j.v AMiJUc.w Ti:\"r-ii<)()K or sri:<;i:in'. 
 
 Fui. 15:?. 
 
 "»■— «»asfirftssaiai3(^E»o-i^ 
 
 day. A ciirvod iiuMsion is iiiailr tVom liall" an inch below tlie external an;^n- 
 lar ])rocess along the zygoma to its posterior extremity, then downward to the 
 angle of the jaw, and finally along the lower border of the jaw to the facial 
 artery. The flap is then dissected forward without wounding the facial nerve 
 or Stenson's duct. The zygoma is first drilled and then divided, and turned 
 downward with its attached masseter muscle. The coronoid j>rocess is simi- 
 larly divided, and displaced upward with its attached temporal muscle, and 
 later is removed. The internal maxillary artery is then ligated and divided. 
 The external pterygoid muscle is separated from the great wing of the sphe- 
 noid and the external ])terygoid plate. A long-handled half-inch trephine is 
 
 next api)lied a little ante- 
 rior and external to the 
 foramen ovale, the edge of 
 the trephine just impinging 
 on the edtje of the foramen. 
 The trunk of the nerve is 
 used as a guide to the gan- 
 o;lion, which is then re- 
 moved by small, sharply- 
 curved hooks, one of which 
 has a cutting concave bor- 
 der. Hemorrhaiie gives con- 
 siderable trouble. An elec- 
 tric forehead light is essen- 
 tial in working at such a 
 depth. The results of the 
 first case after twenty-two 
 months were entirely favor- 
 able so far as the nerve was 
 concerned, but the eye was 
 destroyed and had to be re- 
 moved — a calamity happily 
 avoided by the improved 
 techni(iue of later cases, all 
 of which, at least so far, 
 have remained free from 
 pain. 
 
 Recently, the osteoplas- 
 tic method of resection of 
 AVagner-Wolff (p. 499) has 
 been applied to this opera- 
 tion. In 1892, Hartley, 
 and a few months later 
 Krause, published independently identical methods of opening the skull by 
 an osteoplastic resection. The usual horseshoe-shape<l incision is made 
 through the scalp directly down to the bone, but the fla)) is not lifted from 
 the bone. The vertical and horizontal extent of the incision is usually about 
 three inches. The base (Fig. 153) thus marked out is much smaller than the 
 remainder of the flap, and terminates in front of the ear and behind the 
 external angular process of the frontal bone. A groove is then cut in the 
 bone with a chisel, and the inner table entirely divided by an osteotome, after 
 v.hich two or three periosteum elevators are inserted into the groove, and the 
 flap, consisting of bone and scalp together, is lifted to such an extent as to 
 
 Intracranial Neurccturay of the Fifth Norve (Hartley); A, manner 
 of holding; the ohisel in cutting the groove through the bone; 
 B, llai) lifted and turned down, exposing the dura mater and 
 middle meningeal artery. 
 
SUMGERY or Till': NERVES. 383 
 
 flap, consistin<^ of buiu- and M^alp together, is lifted to such an extent as to 
 snap the bone on a line between the ends of the incision. The niiildle menin- 
 <H'al arterv is unavoidably torn if it runs through a canal in the anterior infe- 
 rior angle" of the ])arictal bone, and even if not it is often torn by the small 
 branches passing directly from it into the bone. 
 
 The dura is not opened. The temporo-sphenoidal lobe is then lifted from 
 the middle fossa of the skull until the second and third divisions of the nerve 
 are recognized. Just behind their junction lies the ganglion. The nerves 
 are then cut as close as possible to their foramina of exit and the ganglion is 
 broken up, or if possible is removed. In several cases the bleeding on lifting 
 the temporo-sphenoidal lobe has been so profuse as to re(iuire packing by 
 iodoform gauze. This has been removed after three days, and the ganglion 
 and nerves then resected. An electric forehead light is almost essential in 
 the operation. Tiffany has collected one hundred and eight cases, of which 
 twentv-four died and eighty-four recovered. To these Carson has added one 
 hundred a<lditional cases, with only twelve deaths— a most encouraging 
 improvement. 
 
 Mixter of Boston has devised an o])eration for resecting both the second 
 and the third divisions of the nerve at the foramina rotundum et ovale, which 
 has been done several times successfully. He advises a curved incision through 
 the origin of the temporal muscle, beginning and ending over the zygoma, 
 which fs sawed through at each end, care being taken not to go back of its 
 tubercle, as the articulation would then be opened. The temporal and pterygoid 
 muscles being separated and turned down with the zygoma, both nerves may 
 be reached at the foramina. This incision was previously described by Salzer 
 as a method of reaching the foramen ovale. 
 
 6. The Lingual Nerve. — This has occasijonally been operated on lor tiie 
 relief of pain in cancer of the tongue. A suture is passed through the tongue 
 on the side of the operation. Pulling the tongue forcibly toward the opposite 
 side makes the lingual nerve tense, and it can be felt in the floor of the moutla 
 as a firm band beneath the mucous membrane. An incision is made through 
 the mucous membrane and a hook passed under the nerve, which is then 
 stretched or exsected. If the tongue is fixed by the growth, the nerve may 
 be exposed where it lies in contact with the lower jaw-bone just under the 
 mucous membrane beneath the first molar teeth. 
 
 7. The Seventh Nerve. — One of two methods may be adopted to reach 
 the nerve. First, the method of Baum, which is the best, as the nerve is 
 readily found and the scar is hidden by the ear. A vertical incision two and 
 a half inches long is made behind the ear, with a slight angle at the apex 
 of the mastoid. The posterior border of the parotid is the first landmark. 
 Displacing this forward, the shining aponeurosis of the sterno-cleido is the sec- 
 ond Clear the interspace between these two to a depth of one to one and a lialt 
 inches, when the prevertebral muscles and their fascial covering are the next 
 mark. The nerve lies in front of this fascia, crossing the deep and narrow 
 space between the mastoid and the vertical ramus of the jaw. ihe electric 
 liaht and the forehead mirror are very great helps. To find just where the 
 nerve crosses this space, place a moist sponge electrode on the cheek ; the nerve 
 will be found by touching the tissues at successive points with a tine wire 
 attached to the other cord of the battery. The current should be very 
 
 In Haters method the vertical incision is made in front of the ear. One 
 of the two main branches of the nerve will be exposed in the parotid gland, 
 and is to be followed back to the main trunk. In this method the trunk of 
 the nerve is apt to be reached in front of the point where it gives oft its 
 
384 ^iV AMERICAN TEXT-BOOK OF SURGERY. 
 
 branches to the occipito-frontal and tlie orbicularis, and these branches may 
 escape biin;; opcM'atCMl on. 
 
 8. The Spinal Accessory Nerve. — This has been operated on espe- 
 cially for wry neck. The nerve pierces the sterno-cleido-mastoid niuscle. and 
 then passes to the trapezius, supplyin;^ both of these muscles. It may be ope- 
 rated on before or after its passage through the sterno-cleido-mastoid: (A) If 
 operated on before it enters this muscle, the incision is made along the anterior 
 border of the muscle downward from the lobule of the ear for two or tiiree 
 inches. The muscle being exposed and turned outward, the nerve is discov- 
 ered a little above the level of the hyoid bone where it enters the muscle. 
 (B) To reach the nerve after it has emerged from the sterno-cleido-mastoid 
 muscle the incision is made along the posterior border of the muscle two 
 inches long, the center of the incision corresponding to the center of the muscle 
 vertically. The nerve will be found a little above the center of the wound, 
 and should be traced upward to its point of emergence from the muscle and 
 exsected. The former operation is the better one. 
 
 0. Division of the Nerves of the Posterior Cervical Muscles for 
 Wry Neck. — Keen has described an operation for the exsection of the poste- 
 rior divisions of the first three cervical nerves, which may be done either inde- 
 pendently of the operation on the spinal accessory or as an adjunct to it. 
 Noble Smith and Powers have since done similar operations. 
 
 10. Cervical Plexus. — The branches of the plexus may be reached by 
 means of an incision along the middle of the posterior border of the sterno- 
 cleido-mastoid muscle. 
 
 11. Brachial Plexus. — The brachial plexus may be readily exposed just 
 above the clavicle by the horizontal incision for the ligation of the subclavian 
 artery. The plexus is reached immediately under the deep fascia. The nerve- 
 trunks are easily recognized, and one or more of them may be operated on as 
 is deemed best. Care is required not to mistake the lowest cord for the artery. 
 
 12. Median Nerve. — In the arm the median nerve is readily reached by 
 the incision for ligation of the brachial artery, at the inner border of the biceps 
 muscle at its middle. The nerve usually crosses in front of the artery from 
 without inward. In the forearm the nerve can best be reached just above the 
 wrist-joint by an incision two inches long at the inner side of the tendon of 
 the palmaris longus. It lies immediately under the deep fascia. Its branches 
 to the thumb and fingers are easily reached by an incision along the inferior 
 border of the thenar eminence. It lies just under the edge of the palmar 
 fascia. 
 
 13. Ulnar Nerve. — In the middle of the arm the ulnar nerve can be 
 reached by an incision similar to that for finding the median nerve, but slight- 
 ly farther back. Behind the elbow it can be exposed by an incision directly 
 over it as it runs in the groove between the internal condyle and the olecranon. 
 A little above the wrist it is exposed by an incision on the radial side of the 
 tendon of the flexor carpi ulnaris. In the two ])ositions first described the 
 nerve lies immediately under the deep fascia. Just aliove the wrist it lies 
 more deeply under a second layer of the deep fascia. 
 
 14. Musculo-spiral Nerve. — This can be readily found in the musculo- 
 spiral groove by an incision corresponding to the groove between the biceps 
 and supinator longus muscles. The deep fascia having been divided, the 
 nerve is found in the interspace between these muscles, and can be felt as a 
 cord rolling between the finger-tips. 
 
 15. Radial Nerve. — This branch of the musculo-spiral can also be easily 
 found by a longitudinal incision on the outer border of the forearm, about three 
 
SURGEIiV OF JOINTS. 385 
 
 inches above the wrist-joint, just where the nerve passes under the tendon of 
 the supinator h^nrjns to tlie Ijack of the hand. 
 
 10. Great Sciatic Nerve. — The patient shouhl be phaced upon liis abdo- 
 men and an ineisi(»n about four inches lonti; sliouhl be made in tlie middle line 
 of the le<:, be<;innin<!; just below the <iluteo-fenioral crease. As soon as the 
 deej) fascia is cut through, the belly of the biceps will be found, and on tearing 
 throutrh the connective tissue at its outer border the trunk of the great sciatic 
 will be found with ease. 
 
 17. Tibial Nerves. — The anterior and posterior tibial nerves may be 
 exposed by the same o))erations as for ligation of their resj)ective arteries. 
 The posterior tibial may also be exposed by a curved incision Ijehind the 
 internal nuilleolus and the heel. It lies just posterior to the artery. 
 
 CHAPTER VII. 
 
 SUEGERY OF JOINTS. 
 
 SECTION I.— GENERAL CONSIDERATIONS. 
 
 Like the other structures of the body, the joints are subject to injury and 
 disease. All the articulations have an anatomical construction -Nvhich should 
 be kept in mind because of its influence upon the nature and course of the 
 pathological processes that are observed. The more or less expanded ends of 
 the bones, in each of the larger joints, are covered with an incrusting cartilage. 
 They are bound together by a capsular ligament, Avell developed in the ball-and- 
 socket joints, imperfectly so in the hinge joints, with re-enforcing bands as may 
 be required ; such ligamentous structures being firmly attached to the bones and 
 closely connected with the periosteum. The joint-cavity, except over the artic- 
 ulating cartilages, is lined by a synovial membrane, which is either a closed sac 
 or communicates with adjacent bursse. It is sufficiently lax to permit of the 
 free movement of the bones upon each other, and consequently is more or less 
 folded and fringed, and holds and covers larger or smaller masses of fat. intended 
 to lessen shock. Outside the capsule and supported by connective tissue are 
 the muscles moving the joint, their bellies, or more generally their tendons, 
 often running in well-formed sheaths. These muscles are always innervated 
 by branches of the same nerve that sends filaments to the joint structures 
 proper, and from the same trunk come the fibers distributed to the fasciae 
 and the skin over the insertions of the muscles. The blood-vessels, each arising 
 from the nearest large trunk, quickly break up into many small branches run- 
 ning among the fibers of the ligaments in the subsynovial connective tissue 
 and in the synovial membrane ; the incrusting cartilages being nourished by 
 imbibition. 
 
 Inflammations of varying intensity are of frequent occurrence : they may 
 be due to traumatism, to rheumatism or gout, to the presence and chemical 
 products of micro-organisms, or to disturbances of innervation. They may be 
 slight or severe, acute or chronic. They may terminate in resolution, in per- 
 manent new formations more or less deforming and disabling, or in destruction 
 of the articulation. They may originate in the joint structures proper, espe- 
 cially in the synovial membrane, or they may extend from contiguous parts, 
 the cancellous bone-ends, the overlying tendon-sheaths, or the periarticular 
 
 25 
 
SS6 Ai\ AM 1:1^ 1< AX TKXT- HOOK OF SlJidFJiY. 
 
 connoctivo tissues. Tliev inav be lar'rrlv roiiliiuMl to a sin<:le structure, the 
 synovial membrane being the part ordinarily aftccted, or they may involve the 
 Avhole of the joint. 
 
 The usual inflammatory changes in blood-supply, in cell-development, 
 and in function are all present. Vascular fulness is observed chielly in the 
 acute affections and in the synovial membrane, which becomes re<ldene(l, it 
 may be intensely so, especially in its fringes. Effusion of serum takes place 
 in the membrane, in the connective tissue beneath it, in tiie interspaces of the 
 ligaments, and particularly into the joint-cavity. The endothelial cells pro- 
 liferate unduly and are thrown off, even to the extent at times of rendering the 
 synovial fluid milky or purulent in appearance. Fibrinous exudations occur 
 on the free surface and in the membrane and capsule. New cell-growtli takes 
 place in excessive amount in certain of tlie infhinnnations — e.(j. tlie tubercular. 
 Extravasations of blood may occur into or beneath tlie synovial membrane or 
 into the cavity. The articular cartilage may undergo no material change, or 
 may become softened and absorbed under pressure or by the action of the new- 
 formed granulation-cells, or be separated in large flakes, or undergo atrophy, 
 or become hypertrophied around its edge. The ligaments also may be essen- 
 tially unaffected, or they may split up and degenerate in part or wholly, their 
 place being taken by a lardaceous new formation. In all cases function is 
 impaired, either as a whole with reference to movement or as respects the 
 synovial membrane and its secretion of synovia, which latter may become very 
 al)undant and very watery, or very scant, not enough to lubricate the surfaces, 
 which grate as they rub against each other. 
 
 SECTION II.— SYNOVITIS. 
 
 Except in acute attacks, mainly due to injury, an inflammation lighted up 
 in the synovial membrane does not remain confined to it, but affects the other 
 parts of the joint, and is an arthritis and not a synovitis, altliough not seldom 
 even in very chronic cases the synovial affection is the chief one. 
 
 As the result of an aseptic wound, of a subcutaneous injury (contusion or 
 sprain), of the irritation produced by a floating cartilage, or of exposure to 
 cold and dampness, simple inflammation may attack the synovial membrane. 
 The part becomes congested, cliiefly around the edges of the cartilage and in 
 the fringes, which because of their undue vascularity and the associated oedema 
 are somewhat elongated. At times the whole membrane is highly injected and 
 cedematous. The synovial secretion is more or less increased in amount accord- 
 ing to the nature and intensity of the inflammation. In character it may 
 remain normal or may become watery. Because of existing fibrinous exuda- 
 tions it may be flocculent. 
 
 The symptoms are unmistakable. The joint is painful, especially upon 
 motion, often severely so, and particularly at night. It is swollen and tense, 
 it may be fluctuating. At the knee the patella is floated up from the condyles, 
 upon which it can readily be depressed, to rise again when pressure is taken 
 off. By the muscular contraction of the flexors the joint is held in that posi- 
 tion which permits of greatest distention and is therefore the most comfortable. 
 The part is never in full extension, the production of which much increases 
 the suffering. Each joint has its position of greatest ease, which is sponta- 
 neously and quickly assumed when inflammation occurs. The swelling is most 
 marked in the spaces between the ligaments and where the capsule is not 
 crossed by firm tendons. The local heat is decidedly raised, but the skin, 
 while it is very sensitive to pressure, perhaps only at certain points, is neither 
 
SURGERY or JOINTS. 387 
 
 tliickciUMl nor reddened. ('i»iistiliiti<iii:il syniptoniH if present ai'c only moderate 
 in d('i!;ree. After a few hours, or at most days, tlu^ intensity of the symptoms 
 suhsides, tlie pain lessens, the swellinjf diminishes as the effusion and extrav- 
 asated blood are absorbed, the lind> takes its natural ])osition, and recovery 
 quickly folloAvs. If there has been much hemorrhage into the cavity, there 
 may be afterward some restriction of motion in consequence of organization 
 of a part of the clot and its adhesion to adjacent sides of the folded synovial 
 membrane. 
 
 In the treatment the joint should l)e placed at rest. Cold may be locally 
 applied by an ice-bag or a coil of rubber tubing (Leiter) or by continuous 
 irrigation ; or hot applications may be made, simple or medicated, the lead- 
 and-opium lotion being perhaps the best ; or equable pressure as firm as can be 
 comfortably borne may be employed, the affected region being enveloped in a 
 thick layer of cotton or wool, and a bandage, preferably of rubber, put oif. 
 The cotton or avooI next the skin nuiy be moistened with the hot lead-and- 
 opium wash, and the advantages of both heat and pi*essure be secured ; or the 
 joint may be at once immobilized in plaster of Paris. Pressure will ordinarily 
 prove most satisfactory. Unless the serous distention of the joint is extreme 
 or there has been a large extravasation of blood into the cavity, the fluid will 
 not need to be draAvn off, but may be left to the action of the absorbents. If 
 aspiration is done, every precaution must be taken to prevent sepsis. 
 
 Chronic Synovitis. — As already stated, a synovial inflammation, Avhat- 
 ever its intensity, cannot long continue without extension of the morbid pro- 
 cess to other structures of the joint and the development of an arthritis ; yet 
 not seldom the affection of the synovial membrane, so far as disturbance of its 
 function is concerned, remains so prominent a clinical feature that the case 
 may be very properly viewed as one of chronic synovitis. The active conges- 
 tion that belongs to the acute stage, of which the chronic is usually the sequence, 
 largely disappears, leaving the membrane but little changed in appearance from 
 the normal. There is, however, an undue amount of fluid in the cavity, and 
 the membrane itself is oedematous. Later, if the disease does not subside, the 
 membrane and the articular structures become irregularly thickened by plastic 
 exudation and the formation of fibrous tissue, ■with intervening patches where 
 there have been degeneration and softening. The folds of the membrane are 
 not seldom fastened together by adhesions resulting from the organization of 
 blood-clots or from an exudation thrown out between them ; and at times from 
 the fringes and villi there are developed, it may be in great number, growths 
 larger or smaller, often pedunculated, that push into the cavity. There is little 
 or no change in the temperature of the part. Though the joint is weak, it is 
 not specially painful except upon pressure, and may not be so even then. 
 Movements, especially in extension,' are restricted, and generally, as the 
 effused fluid has become absorbed, are attended by some grating or creaking. 
 It is the presence of an undue, often an excessive, amount of fluid in the joint 
 that is alone to be here considered, all the other conditions being those of long- 
 standing arthritis dependent upon diathetic, suppurative, or infective causes. 
 The symptoms of such accumulation of fluid are well marked. The joint if a 
 superficial one (and it is the knee that is by far the most frequently affected) is 
 evidently distended, perhaps very much so. There is fluctuation upon palpation. 
 The muscles in the vicinity are wasted, it may be considerably, making the 
 articular enlargement the more prominent. With the hypodermatic needle 
 fluid may be drawn off which will ordinarily be straw-colored or a little darker, 
 somewhat viscid, occasionally flocculent, and at times more or less blood-stained. 
 
 The treatment varies with the amount of fluid present and according 
 
388 .I.V AMERICAN TKXT-lUtOK OF SinidEliY. 
 
 to the type of tlie arthritis; for it must lu- rciiicniljcrctl that siijierahimflance 
 of fluid in a joint is not in itself a disease, but a symptom of a traumatic, 
 a rheumatic, a tubercuhir, or a deformini:; artliritis, or even (jf s<une local or 
 general disturbance of the circulation. When the aft'ection is not of h»ng 
 standing and the articular fulness is not very great, rest and pressure may be 
 all that will be required to produce absorption, the joint being enveloped in 
 cotton and bandaged (the elastic bandage being the best) or preferably immo- 
 bilized with plaster of Paris. Baths, frictions, massage, electricity, blisters, 
 mercurial ointment or plaster, each has often been found of service. Simple 
 aspiration followed by immobilization may bring about recovery, or if, as is 
 apt to be the case, reaccumulation of fluid takes place, it Avill l»e in nnich 
 diminished quantity and will very likely be readily absorbed. When the affec- 
 tion is of long standing and the joint is much distended, with associated marked 
 impairment of its usefulness, in the condition which may properly be called 
 hjldrarthrosls or lijfdrops articuU. when the methods of treatment already 
 spoken of have been thoroughly tried and have proved useless, very excellent 
 results may be secured by aspiration and injection of a 3 per cent, to /> per 
 cent, solution of carbolic acid. The parts having been thoroughly disinfected, 
 the fluid is aspirated (every care being taken to have the needle aseptic), the 
 cavity is irrigated with freshly boiled water until the fluid comes out perfectly 
 clear, and then the 1 to 2 per cent, carbolic solution is injected, after which 
 the joint is immobilized. This method of treatment should not be adopted 
 so long as there is any inflammation in the joint, and the o})eration must be 
 done with the most scru])ulous precautions as to asepsis. 
 
 SECTION III.— ARTHRITIS. 
 
 Inflammation of a joint as a whole may be either acute or chronic. It may 
 be consequent upon the presence of pyogenic cocci, of infection by the bacilli 
 of tuberculosis, or of the micro-organisms of any one of the acute infectious 
 diseases, or of gonorrhea ; upon rheumatism or gout or the rheumatoid con- 
 dition, whatever may be its nature ; upon syphilis ; and upon lesions of the 
 nervous system, especially tabes. 
 
 (A) Tubercular Arthritis. — The great majority of cases of chronic joint 
 disease are tubercular, the bacilli being primarily deposited in the ])one. the 
 synovial membrane, or the capsule and periarticular structures ; most frequently, 
 especially in children, in the bone. In this osseous variety of joint tuberculosis 
 the secondary infection of the soft parts takes place after destruction of the 
 cartilage over a carious area or over a wedge-sliaped tubercular infarct in the 
 epiphvsis. with resulting opening of the joint-cavity : or through a siinis extend- 
 ing to the synovial membrane outside the cartilage or reaching the capsule 
 farther out ; or, which is of comparatively rare occurrence, from the tubercu- 
 lar periarticular structures, the ligaments and the synovial membrane becoming 
 infected by the extension of the morbid process. When the synovial membrane 
 is aff'ected, whether primarily or secondarily from a neighboring focus in the 
 bone it matters not, the developed granulation-tissue is usually abundant and 
 soon extends to and involves the capsule and the structures outside of it. The 
 parts become thickened, a'dematous, and of a gelatinous or lardaccous appear- 
 ance, little or no fluid being present in the synovial sac. Occasionally the 
 membrane is thickly studded with small tubercules, and is highly vascular; there 
 is little new formation of tissue, but an abundant serous eff"usion into the joint 
 takes ])lace. In other cases the inflammation is a plastic one, the outgrowths 
 being few and large or papillomatous and very numerous. In the ordinary 
 
SURGERY OF JOINTS. 389 
 
 fun<^ous variety (the '* gelutiiiif'orm " or " gelatinoid dcgeneriition " of many 
 writers), as the result of the new growth and the oedcmatous infiltration, a 
 marked eliange soon takes place in the size, shape, and appearance of the 
 articulation. The natural elevations and depressions disappear, the softened 
 ligaments oft'ering little or no resistance to the pressure of the gi'owing granu- 
 lation-nuisses, with which before long they become incorporated. 
 
 The contour of the joint is globular or, more properly, spindle-shaped, 
 because of the decided atrophy of the parts above and below and the swelling 
 of the periarticular structures. The skin, as the result of obliteration of the 
 vessels and oedematous infiltration, is white, thick, and firmly attached to the 
 fascia beneath. A few large superficial veins can generally be seen. Palpa- 
 tion may and often does develop pseudo-fluctuation, because of the abundance 
 of fluid in the tissues, and true fluctuation in the exceptional cases in which 
 there is a large serous accumulation in the synovial sac or when the joint is dis- 
 tended with the so-called tubercular pus, which is not pus, but the milky fluid 
 of the li(|uefying caseated masses. Pain is, as a rule, but slight in the strictly 
 synovial variety ; in the osteal form it is decided, and may be very severe. 
 It is always to be elicited by pressure, although perhaps only over a limited 
 space. When the originally synovial disease has extended to the adjacent 
 epiphysis, pain will be present, even if previously absent. The heat of the 
 part is always increased; but often the elevation of temperature is so slight as 
 to be detected only by careful use of the thermometer. 
 
 Deformity is a constant accompaniment of the disease ; its degree is greater 
 or less according to the joint aff'ected, the amount of disease present, and the 
 treatment pursued. It is due to (1) the natural tendency of the parts to take 
 the position of greatest ease ; (2) the softening and destruction of the liga- 
 ments ; (3) muscular contractions induced by reflex irritations. These causes 
 often result in permanent vicious attitudes, assumed and maintained by the 
 patient through a long period of time. 
 
 Caseation and liquefaction of the fungous masses take place here as else- 
 where, giving, it may be, no evidence of their occurrence when the disease is 
 of limited extent, but indicated generally by the formation of so-called abscesses 
 and sinuses. The opening of these sinuses is almost certain to lead to pyogenic 
 infection unless the latter is prevented by antiseptic treatment. When it occurs 
 it results in a marked aggravation of the general and local morbid state. Very 
 frequently in the history of a tuberculous joint, extending over months or years, 
 a number of openings will successively arise, the sinuses which communicate 
 with these limited degenerations of fungous masses, carious patches, or sequestra 
 of small size alternately opening and closing. 
 
 The diagnosis of joint tuberculosis is easy, difliicult, or impossible accord- 
 ing to the extent, the character, the location, and the duration of the aff'ection. 
 If of the fungous variety in a superficial joint, advanced to the stage of decided 
 deformity, still more to that of abscess and sinus, there can ordinarily be no mis- 
 taking the nature of the trouble. Syphilitic disease has points in common, but 
 it is of comparatively infrequent occurrence, and generally there will be in the 
 history of the individual or in the condition of other parts of the body evidences 
 of a pre-existing specific infection. But if the disease is osteal, has advanced 
 but little, has caused only a slight impairment of the articular motions, hardly, 
 it may be, more than an unwillingness fully to use the joint, is attended with 
 little pain and no appreciable swelling or atrophy, if the muscular rigidity is so 
 little as to make it doubtful whether it exists, and if finally the joint is a deep 
 one, the disease very likely will be overlooked. At best the diagnosis is but a 
 proljable one. In all such cases, even when there is only a well-grounded suspicion 
 
390 AX AJfEnifAy TEXT- BOOK' OF STRGERY. 
 
 of the existence of tubercular disease, the patient should be given the benefit 
 of the doubt and treated for a time as though the disease was un(|uestionablv 
 present. 
 
 What is called '* pannous synovitis" is rarely met with. In this form 
 the tubercles are small and in great number, the vascularity of the membrane 
 intense, new formation of very limited extent, and the ligaments and jjcriar- 
 ticular structures but slightly affected. The great serous accumulation in the 
 synovial sac will almost certainly be regarded as non-tubercular in character 
 until after aspiration and examination of the fluid. 
 
 The prognosis depends upon the extent of the disease, the general con- 
 dition of the patient, and especially upon the treatment employed. In a few 
 cases, doubtless, the tubercular area is so small, the extension of the morbid 
 process so easily arrested, the new formation so slight, and the adhesions and 
 bands developed in its cicatrization so limited, that after recovery has taken 
 place there will be little, it may be practically no impaimient of the motions 
 of the joint. But in the great majority of cases this does not occur. The 
 cartilages are more or less extensively destroyed, intra- and extra-synovial 
 bands are foraied. and the size of the joint-cavity is diminished. In propor- 
 tion as there has been damage to the component structures of the articulation 
 must the functional value of the joint be lessened, all the more when there has 
 been displacement of one bone upon the other. The restriction of motion may 
 be absolute. Ossification of the granulation-tissue uniting the surfiices of the 
 epiphyses, which have been deprived of cartilage and eroded by caries, may 
 have taken place (true bony ankylosis), progressing sometimes to the extent of 
 complete fusion of the two bones ; or the same result may have been secured with- 
 out ossification, short, firm fibrous bands existing within the capsule, the action 
 of which is further reinforced by ligamentous and periarticular contractions 
 and adhesions (false, fibrous ankylosis). At times, though recovery has been 
 in a great measure secured, a sinus or sinuses will long remain because of the 
 presence of a limited amount of carious or necrosed bone or of the tuberculi- 
 zation of the sinus wall. Even where all morbid action seems to have been 
 arrested, and the patient for months, it may be for yeai-s, has been free from all 
 indications of disease, the joint may again become the seat of tubercular inflam- 
 mation, either because of the setting free of primarily encapsulated organisms 
 or because as a place of least resistance it most readily becomes the field of a 
 new infection. During the necessarily long period that must elapse before 
 recovery can take place there is an ever-existing danger of the development 
 of visceral or general tuberculosis. Caseation, if extensive, is associated with 
 constitutional disturbances of greater or less severit}'. When sinuses have 
 opened, septic infection of the diseased parts is almost certain to occur unless 
 prevented by antiseptic treatment, and the resulting suppuration exposes the 
 patient to the added risks of exhaustion, amyloid disease, and septicemia. 
 
 The treatment is that of tubercular disease in general. The indications 
 are to prevent, or, as far as possible, to limit, the multiplication of the bacilli 
 and the extension of their action ; to favor the condensation and cicatrization 
 of the non-tubercular new-formed granulation-tissue ; failing in this, to remove 
 the infected part. For the fulfilment of the first, rest is of the utmost import- 
 ance, since it lessens irritation and diminishes the blood-supply and the rapidity 
 of its flow. It may be secured by splints and muslin or rubber bandages, but 
 best by immobilization. The joint having been enveloped in a thick layer of 
 cotton, the plaster-of-Paris bandage is to be firmly but not too tightly applied 
 (that the beneficial effects of pressure may also be secured), not only over the 
 joint, but also nearly to the levels of the joint above and that below, care 
 
SURGERY OF JOINTS. 391 
 
 bciii- taken that the joint is held in a position of ease .luvin- the setting. Such 
 immobilization must be continued for .veeks, often for months, new bandages 
 bein.^ applied as the size of the joint diminishes. 11 this is employed at an 
 earlf peri^od and the affected limb is kept quiet, recovery may be expected in a 
 ZxX proportion of cases of joint tuberctdosis. Instead of the plaster-of-Paris 
 banda-e. a fixation or a traction-and-fixation splint may be employed, and is 
 by m.my regarded as preferable, but in general the plaster bandage Avill be 
 fomid t(; secure more complete rest of the joint. Accumulations of fluid, either 
 intra- or extra-articular, may very properly be removed by aspiration, provided 
 a thorou<.hlv aseptic needle is used, but in the ordinary cold abscesses conse- 
 quent ui;.n>in/ inflammation if the disease is thoroughly treated the abscesse 
 m^Y safilv be left to take care of themselves. If they are tapped they should 
 also be Avell irrigated, preferably with an oil or glycerin so ution of lodofoi-m 
 ?5 to 25 per cent! of the former ; 5, or better 10, per cent, of the latter). For 
 the relief of pain and localized tenderness ignipuncture or penetration into 
 the bone with the thermo-cautery has been used with advantage. 
 
 When the case is one of tubercular dropsy, aspiration should always precede 
 the application of the immobilizing dressing, or, better, aspiration followed by 
 the iodoform injection. ^ 
 
 Much attention has of late been given to the discovery and employment of 
 agents that will condense and favor the cicatrization of the new tissue outside 
 of the tubercular area and bring about the destruction or encapsulation of the 
 bacilli Chloride of zinc and iodoform are the remedies most m favor liiey 
 are iniected into and around the tubercular masses, and their employment 
 has certainly proved of service. In using the zinc solution only a few drops are 
 thrown in— three to five drops ordinarily, at times as high as twenty. Ihe tend- 
 ency seems to be, of late, to increase both amount and strength. Ihe lU per 
 cent solution of iodoform in glycerin or oil has been much more largely used 
 and unquestionablv in some cases it does both destroy the organisms and 
 favor the condensation of the new tissue. It may be injected once a week 
 or once a fortnicrht, and continued until the case is evidently well advanced 
 toward recovery or until it becomes certain that no good is being accom- 
 plished. This can usually bedetermined in the course of a month. V\ hen 
 used in the treatment of abscesses or of joints containing much fluid tbe in- 
 iection shoukl always be preceded bv thorough irrigation with freshly-boiled 
 water or a boric-acid solution (3 to 5 per cent.). Instead of either of tbe 
 remedies mentioned, the balsam of Peru may be used to advantage. 
 
 Of course, whatever local treatment is adopted, care must be taken to secure 
 for the patient as far as possible those general hygienic conditions which are 
 so strongly demanded by the subjects of tubercular disease, no matter where 
 located ^and the ordinary constitutional remedies should be employed. 
 
 When the extent of the disease and the local and general eflects produced 
 by it are such as to make it certain, or at least probable, that recovery cannot 
 take place under the treatment indicated, or, if it may, that it will be only at 
 great risk to life or after a long time, and then with a bmb far fi-om service- 
 able, conservative treatment must give place to operative. The tubercular tis- 
 sue must be thoroughly removed, by erasion, by excision, or by amputation. 
 These operations and the indications for the adoption of one rather than another 
 are treated of elsewhere (see Operations on Joints), and need not be considered 
 
 here 
 
 TUBERCULAR DISEASE OF SPECIAL JOINTS. 
 
 Hip- JOINT Disease.— Hip-joint disease {morbus eoxarius, morbus coxce) 
 is very much more common in children than in adults. In the former at least 
 
3i)2 AX AMERICAN TEXT-IKX tK OF SURGERY. 
 
 it is generally bony in origin, the tubercular deposit being in the majority of 
 cases at first in the femoral epiphysis, a region naturally subject to the action 
 of repeated shocks and slight traumatisms. In not a few patients the acetabulum 
 is first aftected, and primary infcctidn of the soft structures of the articulation 
 is probably by no means so infreijuent, even in early life, as is often supposed. 
 Whether in the beginning osteal or synovial, the disease naturally presents 
 three stages : first, that of deposition of the bacilli and the early irritations 
 and new formations consequent thereupon ; second, that of fully-developed 
 arthritis, with its eftusions and fungous masses; third, that of breaking down 
 of the infected tissues and greater or less disorganization of the joint, followed 
 by repair, which is usually slowly effected and fur from perfect, or by death. 
 Each stage has its distinguishing symptoms. Because of the most apparent 
 symptom, the second is often spoken of as the stage of lengthening, the third 
 as that of shortening. 
 
 In the first stage the disease is very apt to be overlooked or misunder- 
 stood for a considerable time, because of the doubtful or slight character of the 
 symptoms, though occasionally it is indicated at the very outset by well-marked 
 signs. Slight lameness, generally little more than stiffness, is noticed at times 
 — as a rule in the morning rather than later in the day after considerable exer- 
 cise has beev taken. The child is more or less indisposed to play, and quickly 
 tires. Rigidity of the muscles about the joint, especially of the adductors, 
 though not very decided, may be discovered on palpation. The muscles of 
 the thigh are a little atrophied. If the disease is primarily synovial, slight 
 fulness will perhaps be observed over the joint, in front or behind the trochan- 
 ter, or be recognized on pressure. At times, almost wholly in the osteal variety, 
 pain is complained of, about the hip, in the thigh, or most frequently at the 
 knee, but usually the patient suffers but little. It is not until the epiphysis 
 has become extensively diseased, especially on the side of the incrusting car- 
 tilage, that pain l)ecnmes a symptom of importance. 
 
 In the second stage the disease has ])rogressed so far that the symptoms 
 are decisive. The child limps, unquestionably ; the atrophy of the thigh is 
 positive, it may be great ; the adductor rigidity is marked. If, as is probable, 
 effusion has taken place into the joint, the fulness can be felt, if not seen, 
 and the hip will be evidently broadened sidewise. The affected extremity is 
 advanced and more or less abducted and everted, due to tilting of the pelvis, 
 the weight of the body in standing and walking being thrown on the sound 
 side (Figs. 154, 155). Occasionally, though rareh', the limb is adducted. The 
 gluteo-femoral crease is more or less lowered and shortened, and the lines of the 
 sulcus between the nates and, in girls, that of the vulva, are inclined. The 
 limb is apparently lengthened, but only apparently. Pain will be present sooner 
 or later. It will be located usually in the anterior and lower part of the thigh 
 and the antero-internal surface of the knee in the course of the obturator nerve. 
 It is often " starting " in character, and most severe at night or felt only at that 
 time. But pain of itself is an unreliable symptom, and its absence should never 
 be regarded when other indications of joint disease are present. The hip move- 
 ments are restricted, chiefly, as a rule, in full extension and abduction. These 
 symptoms are due to various causes : the muscular tension and distant pain, to 
 reflex nervous irritation ; the position of the limb, to involuntary muscular action, 
 and, in a measure perhaps, to distention of the joint when effusion has taken 
 place ; the starting pains, to sudden forcing of the articular surfaces together. 
 These pains occur chiefly at night, Avhen the protecting muscles about the joint 
 are less under control, aiid generally indicate more or less extensive destruction 
 of the articular cartilage. The effusion within the joint is slight in the osteal 
 
srnnEiiv OF joints. 
 
 393 
 
 variotv of tlio disease so lonji; as it is simply osteal, but is usually considerable 
 when "the soft structures are attected, whether such aftection l)e primary or sec- 
 
 FiG. 154. 
 
 F'lo. 1 •")"). 
 
 Position in Coxalgia (Albert). 
 
 Position in Coxalgia (Albert). 
 
 ondary. Not seldom it becomes very great, and causes marked swelling in front 
 of the trochanter major, and still more behind it. Because of the resulting intra- 
 articular pressure the pain is likely to be severe, and the malposition of the extrem- 
 ity in flexion and abduction with seeming elongation to be much increased. 
 
 The constitutional symptoms are often severe. 
 
 Even when large in amount the eifusion may spontaneously disappear to 
 a greater or lesser extent, but not seldom the pressure upon the weakened 
 diseased capsule is so great that rupture occurs, and the fluid is poured out into 
 the periarticular tissues, which it tuberculizes. Abscesses and sinuses will 
 probably follow (Fig. 156). Both local and constitutional symptoms are, as a 
 rule, for a time much lessened in severity as soon as the tension is relieved. 
 As the intra-articular fluid disappears, by absorption or after rupture, the joint 
 surfaces come in contact. The irritated muscles act more directly upon the 
 already damaged head and perhaps the acetabular rim, the bony parts are 
 crowded together and more or less rapidly broken down and worn away, and 
 progressively increasing flexion, abduction, and shortening result, sometimes 
 
 ^^^"The^ so-called third stage is now thoroughly established. The femoral 
 head is often much deformed, and is progressively pushed upward and out- 
 ward as erosion of the acetabular rim takes place. Actual luxation rarely 
 occurs the head ordinarily remaining within the capsule, which attaches 
 
394 
 
 AN AMEBIC AX TEXT- HOOK OF SURGERY. 
 
 itself farther and farther out on the bone (Fi<,'. I.'jT). The flexion of tlie thi<rh 
 
 upon the pelvis, which has been ))resent in greater or lesser degree from the 
 
 very commencement of the disease, is now decided and 
 
 1- j(i. 156. fixed. When the limb is brought down in extension so 
 
 ^j that the posterior surface of the thigh and that of the 
 
 W. knee rests upon the bed or table, the lumbar spine is 
 
 carried forward, and a marked lumbar curve is at once 
 
 develiiped. which di8a])pears as soon as the knee is 
 
 raised. To determine this point, which is one of great 
 
 Fig. 1o7. 
 
 
 Common Site of Hip Abscess 
 (Bradford and Lovett). 
 
 Intra-acetabular Luxation in Coxalgia (Tillmannsi. 
 
 importance, the patient should be stripped and laid on the floor or a firm table. 
 The sound leg can be flexed and extended at both the knee and the hip 
 without any influence upon the lumbar spine (Fig. 158, A). But Avhen the 
 diseased leg is extended the lumbar curve becomes so marked that there is 
 often space for the arm of the surgeon to be thrust under it (B). Flexion of 
 this leg and hip is followed by the disappearance of the curve. The reason 
 for this is that the femur and pelvis are held so rigidly together by the muscles 
 that they move as if ankylosed, and the tilting of the pelvis in the extension of 
 the thigh necessarily produces the lumbar curve. The adduction of the limb 
 which in this stage succeeds to the abduction of the second stage is commonly 
 not very great. As the result, however, of neglect of treatment it may reach 
 an excessive degree, the thigh in such cases beintj usuallv very stronglv flexed 
 and carried across that of the sound side. The whole extremity, including the 
 gluteal region, is greatly atrophied. 
 
 AVhen the so-called abscess has opened or been opened, secondary septic in- 
 fection is almost certain to take place unless jirevented by antiseptic treatment. 
 At times, though rarely, when there has been no perforation of the skin, the 
 pyogenic cocci find access to the part by the blood-stream. Upon the occur- 
 rence of such mixed infection the parts suppurate, with more or less increase 
 of local heat and tenderness and manifestation of the general symptoms of the 
 "hectic" state. The later symptoms vary greatly according as the case pro- 
 gresses favorably or otherwise. When recovery takes place, the discharge, 
 
SURGERY OF JOINTS. 
 
 395 
 
 if there has been any, lessens, the sinuses, or at least some of them, close, the 
 patient is wholly or 'in a great measure free from j.ain, and the general health 
 
 B f 
 
 Effects on the Lumbar ^piue of Flexing and Extending the Diseased Leg in Hip Disease (Albert). 
 
 improves. Partial or complete ankylosis of the joint takes place, and is either 
 fibrous or bony. In time the weight of the body can be borne on the limb 
 with comfort, the inevitable shortening being made good by a thick sole or a 
 raised shoe. When, on the other hand, the case does badly, new abscesses and 
 sinuses form, the discharge increases, the deformity becomes greater and greater, 
 the constitutional symptoms are graver, and there are very likely clear indica- 
 tions of the existence of visceral tuberculosis or of amyloid disease. _ 
 
 The prognosis depends largely upon the treatment. If the disease is 
 recognized early and properly treated, recovery will generally follow in children, 
 though it is a well-established fsict that a majority of the patients are likely to 
 die from some form of visceral tuberculosis before reaching full maturity. 
 In adults the chances of recovery are decidedly less. The disease may be 
 arrested at any point in its course, and the earlier this is efi"ected the more 
 nearly perfect will be the recovery. The three stages, it should be remem- 
 bered, are not always regularly passed through ; and if they are, the transition 
 from one to the other may be either slow or very abrupt. From the nature 
 of the cause the disease must be one of long duration, and at whateve^r point it 
 is arrested, recovery will often be apparent rather than real, and will be fol- 
 lowed by relapses, it may be, after many years. The future usefulness of the 
 limb will be in proportion to the adhesions that have formed and the amount 
 of damage done to the articulation. Even in the third stage, if favored by 
 fair hygienic surroundings and a tolerably good state of health, under proper 
 treatment, local and general, the patient, especially if a child, may be expected 
 to recover, though only after months or even years, and with a hip ankylosed at 
 a more or less vicious kngle and a limb decidedly and, it may be, greatly short- 
 ened. The ankylosis may be fibrous or bony or mixed. In a comparatively 
 small number of cases, after long-protracted disease, the fusion of the femur 
 and the innominate bone is so complete that it is impossible even upon section 
 to determine exactly the line of union. Fig. 159 shows a case of ankylosis 
 of both hips at such an angle that the patient could not stand erect. 
 
 As respects treatment, the earlier it is instituted the sooner and more 
 perfectly may the patient be expected to recover. The prime indication is to 
 secure rest, as absolute as possible, of the diseased part. When the disease is 
 
396 
 
 AN AMEBIC AN TKXT-ltOOk' OF SURGERY. 
 
 recognized early, in the great majority ofcasos prolonged recumbency, especially 
 if combined ^vitll extension by weight and pulley, -will arrest its progress. A 
 
 Fk;. l.")i). 
 
 Double Aiikykisis from Hiji joint Disease (original 
 
 very simple yet efficient apparatus for securing the desired rest is the gas-pipe 
 frame of Bradford (made of \ in. gas-pipe joined at the four corners by 
 " shoulders "), which serves at once as a stretcher upon which the patient may 
 be carried and a fixed frame to Avhich a fixation or traction apparatus may be 
 attached. Care must always be taken to make the extension in the line of 
 the deformity ; that is, in the line of the flexed and abducted or adducted 
 thigh, which is to be lowered and the abduction or adduction corrected as the 
 progress of the case may permit. 
 
 All the varieties of mechanical treatment that have been used — and they 
 are many — have for their immediate object the securing of fixation or traction 
 or a combination of the two. In the first class are to be placed the ])laster- 
 of-Paris dressing, the wire cuirass of Bonnet, the "plaster breeches" of 
 Sayre, the leather splint of Vance, the long splint of Thomas, etc. Thomas's 
 splint (Fig. 160), without doubt the most useful of the fixation appliances, is, 
 in brief, a bar of malleable iron about \ in. wide, extending from the inferior 
 angle of the scapula to the lower third of the leg, so shaped as to accommo- 
 date itself to the curve of the buttock, and held in position by three hoop- 
 iron bands, the upper encircling three-fourths of the chest, the second two- 
 thirds of the thigh on a level an inch or two below the perineum, and the 
 third two-thirds of the calf. The apparatus is held in place by bandages and 
 straps, and if the ])atient is going about, the sound foot is raised by a patten 
 
SURGERY or JOfXTS. 
 
 397 
 
 to a lieight ^vlli(•ll i.rcvciits the toes of the foot of the diseased side touch- 
 iiitr the^i^roimd, and compels the use of two crutches in Avalking (Fig. 160). 
 
 Fk;. 161. 
 
 Fio. 1G2. 
 
 Fio. 163. 
 
 Thumas's Splint. 
 
 Phelps's Splint. 
 
 Taylor's Splint. 
 
 Lovett's Splint. 
 
 Recognizing the fact that fixation cannot be absolute, and that it does not 
 overcome muscular contraction with the resulting injurious pressure between 
 the head of the femur and the acetabulum, the great majority of American 
 surgeons are employing some form or other of traction splint, a more or less 
 extensive modification of the Davis splint of forty years ago, early improved 
 upon by Sayre and Taylor. In these splints opportunity is afforded for 
 alterino- their length at will by drawing away the sliding lower rod of the 
 apparatus from the upper, or by acting upon the foot-piece through the aid 
 of a windlass, the counter-force through the perineal bands preventing the 
 body from following (Fig. 162). Pressure-symptoms are thus prevented or 
 relieved and recovery correspondingly promoted. When by the use of one 
 of these splints fixation is not sufficiently secured (which is comparatively 
 seldom), a combined traction and fixation splint may be employed, many 
 useful forms of which have been devised, among them those of Phelps and 
 Lovett (Figs. 161, 163). . , , , 
 
 General treatment, if called for by an enfeebled and tubercular state, is 
 indicated, but local medicinal treatment is of no value, except that which will 
 secure the destruction of the bacilli and the condensation and cicatrization of 
 the newly-formed granulation-masses, such as the injection into and around the 
 joint of iodoform, chloride of zinc, or acid phosphate of lime. When the cap- 
 sule is much distended or there is large extra-articular accumulation, aspiration 
 of the fluid will give great relief. In a few cases the bone has been tunnelled 
 through the trochanter and neck and a permanent drain established. When the 
 so-called abscess is nearing the surface, whether it shall be opened or be left to 
 itself to undergo absorption, as many times happens, or be spontaneously emp- 
 tied, will depend upon whether or not it is causing much local distress. If it is, 
 it should be aseptically opened and drained, the after-use of iodoform injections 
 being of much service. If it is not, careful attention to the maintenance of 
 quietude is all that will be necessary. If spontaneous opening is imminent, it is 
 
398 
 
 ^liV AMi:iU('AX TEXT- HOOK OF Si' liO Eli Y. 
 
 Fi<i. 104. 
 
 bettor to anticipate it liy iiunsion, as the danger of infection by pyogenic organ- 
 isms will be thus done away with or reduced to a minimum. In the more severe 
 <3ases, when the tuberculosis of the bone and joint is extensive, excision or era- 
 sion may be done, either early by choice or late from necessity, that which is done 
 €arly giving, of course, the best result. Though such operative interference, 
 because of its aseptic or antiseptic character, is now not attended with much 
 dan<Ter to life, and may be expected to lessen decidedly the period of treatment, 
 yet it does not materially diminish the lial)ility 
 to the occurrence of other or general tubercular 
 disease ; recovery is almost always with con- 
 siderable shortening, and the functional value 
 of the extremity is often no better than that after 
 spontaneous cure, and at times not so good. The 
 resulting deformity can, if necessary, be well 
 iind easily corrected by osteotomy through the 
 neck of the femur, or better below the lesser 
 trochanter (Fig. 164). 
 
 Fortunately, if the case is seen early and 
 properly treated, the necessity of deciding the 
 question Avhether or not operation shall be done 
 Avill seldom arise, and excision is called for 
 much less frequently now than it was a genera- 
 tion ago. When performed, a splint or some 
 protecting apparatus should be Avorn for a long 
 time afterward until the parts have become firm. 
 Many if not most of the early relapses are due 
 to neglect of such mechanical after-treatment. 
 
 Knee-joint Disease. — Of the larger 
 joints, the knee, next to the hip, is the one most 
 frequently aifected with tubercular disease. In 
 children the disease is as a rule primarily 
 osteal, beffinnins: in the femur oftener than in 
 the tibia, very rarely in the patella. In adults, 
 however, in more than half the cases it shows 
 itself first in the soft parts. The arthritis is so generally and so typically 
 fungous that the term ''white swelling," used without qualification, is always 
 understood to mean tubercular disease of the knee. 
 
 The symptoms in the osteal form are at first ill defined. There is 
 usually slight laiiu'iicss, with pain in the region of the affected epiphysis, more 
 severe at night, but often oidy tenderness on pressure, generally over a limited 
 space — by preference the internal condyle of the femur. Later there is expan- 
 sion of the condyles. The tendons about the joint are somewhat tense, and 
 there is some atrophy, especially of the parts just above the joint on the anterior 
 surface of the thigh'. Attempts fully to extend the leg are resisted and cause 
 pain. As soon as synovial inflannnation has been set up, the resulting effusion 
 produces fulness of the joint, most noticeable on the sides of the ])atolla and of 
 its ligauient. When this is infected ])y extension from the ei)i))hysis or by 
 primary location of the bacilli in the soft structures in the joint itself, the symj)- 
 toms become more marked, and soon unmistakable. There are rigidity and 
 atrophy of the part, and lameness, but in many cases this is accompanied with 
 so little pain that the patient continues for a long time to run about. The leg is 
 decidedly flexed, and the flexion steadily increases. But especially and cha- 
 racteristically there is swelling, the firm spindle-shaped enlargement of fun- 
 
 Ke>ult after Double Subcutaneous 
 Osteotomy of the Femur in the 
 Case in Fig. 154 (original^ 
 
SURGERY OF JOINTS. 
 
 399 
 
 gous disease, in wliifli tin- natural contour of the joint is lost and the skin over 
 it is pale. Because of this swelling the disease is not likely to he mistaken for 
 anything else, at least in children, though in adults osteo-sarcoma has not so 
 very rarely been regarded as tubercular disease. This error of diagnosis should 
 not occur, certainly if the case has been seen from an early day, since the 
 mali'i-nant aft'ection at first and often for a long time causes enlargement not of 
 
 Fio. 165 
 
 Fig. 167. 
 
 Ankylosis and Contractures 
 in Tuberculosis of the 
 Knee-joint (Tillmanns). 
 
 Subluxation in Knee-joint 
 Disease (Schreiber). 
 
 inKyiOSlS Ol iviiee-juilll, . mc Liuia la uio- 
 
 placed backward (Mutter Museum," Col- 
 lege of Physicians, Philadelphia). 
 
 the joint, but of. the parts just above or below it. Caseation and liquefaction 
 of the tubercular tissue give rise to so-called abscesses, which in time undergo 
 absorption, or, more often, open spontaneously or are opened by the surgeon. 
 Through the resulting sinus diseased bone may frequently but not always be 
 felt. Not seldom the leg is drawn back to and beyond a right angle (Fig. 165), 
 and pathological lu.xation is often produced in badly-treated cases (Figs. 166, 
 167), after which, as a rule, the severity of the symptoms markedly diminishes. 
 Such a luxation may occur also in spite of treatment. 
 
 According to its'intensity, and still more to the thoroughness of early treat- 
 ment, the disease terminates in one or other of three ways : (1) There may be 
 recovery, with more or less deformity and impairment of function, secured after 
 a few weeks or more often months, or, not uncommonly, only after years of 
 discharge, with the elimination of dead tissues both hard and soft, and the 
 destruction of the articulation. (2) Disorganization follows either slowly or 
 rapidly, and if extensive and accompanied with grave constitutional symptoms 
 may compel operation, followed by recovery, which may be speedy or slow, 
 complete or partial. In the latter case sinuses remain, which will continue 
 to discharge for a long time or even for the rest of life. (3) The patient dies 
 from exhaustion, from tuberculosis of other parts, from amyloid disease, or 
 from septic infection, whether an operation has or has not been done. When 
 the case is recognized early and properly treated for a sufficient length of 
 time, recovery with a useful limb may be expected. 
 
 The treatment is that of joint-tuberculosis in general. Rest must be 
 secured by thorough immobilization— by plaster of Paris or by some form 
 of splint securing fixation or both traction and fixation, as in Sayre's 
 knee-splint. No physiological use of the joint should be permitted. 
 
400 .l.Y AMERK'Ay TKXT-llOOK OF SUIlGETiV. 
 
 If the patient must walk, he shouhi do so onlv with crutches, tl»e sound foot 
 having been sufTiciently raised by a high shoe to prevent that of the diseased 
 extremity from coming in contact with the ground. If abscesses form, they 
 shoiihl be opened if the local and constitutional symptoms are decided. 
 Iodoform and chloride-of-zinc injections at times are of great service, but 
 are not required in the majority of cases coming under early observation. 
 
 If non-operative treatment fails, the tubercular tissue must be removed by 
 erasion, excision, or amputation. No absolute rule can be established as to the 
 time at which and the conditions for which operation should be done, but at the 
 present day, as the mortality attending erasion or excision is but slight, opera- 
 tions are done earlier than before and in much less desperate conditions of the 
 joint, and the results therefore are better. Though every case must be a law 
 to itself, it may be said in a general way that operation is indicated, (1) when 
 the disease has been of relatively rapid development : (2) when in spite of rest 
 and the ordinary constitutional remedies, employed for a reasonable length of 
 time, the tuberculization of tissue is extending and the tubercular masses are 
 softening and breaking down, and the patient is steadily losing strength and 
 weight: (oj when the disorganization of the joint is extensive, as indicated by 
 grating on movement, by abnormal freedom of motion from destruction of the 
 ligaments, by abscesses and sinuses, and by profuse suppuration. Whether 
 erasion or excision is the better operation, especially when the patient is a child, 
 has not as yet been determined. Theoretically erasion is preferable, since it 
 takes away only diseased tissue, and by sparing the region of the epiphyseal 
 line does not interfere with the after-growth of the femur in length. But it is 
 by no means easy thus to get rid of all the infected tissue, and unless this is 
 done recurrence will certainly take place. Even when the joint is excised 
 tubercular foci (PI. XI, Fig. 2) may not seldom be left in the bone outside the 
 line of section. 
 
 Amputation is called for only in those cases of extensive disorganization in 
 which there has long been marked enfeeblement of the general strength becau.se 
 of pain and suppuration, or when excision or erasion has failed to arrest the 
 local extension of the tuberculosis. In the former, especially in adults, removal 
 of the limb is more likely to save life and enable the patient afterward to earn 
 a living, and the operation is really conservative. Xot seldom it ha.s happened 
 that though by removal of the joint the limb has been saved, it has proved 
 only an encumbrance. 
 
 Ankle-joixt Disease. — Disease of the ankle-joint, if primarily of the 
 articulation, is more frequently of synovial than of bony origin : if bony, the 
 starting-point is more frequently in the astragalus than in the bones of the leg. 
 Not very seldom it is in a malleolus, the outer rather than the inner. In many 
 cases it is secondary to tuberculosis of the tarsus, and at times to disease of the 
 sheaths of the tendons crossing the joint. 
 
 If synovial, the symptoms observed early are, interference with the free 
 movement of the articulation and more or less well-marked fulness on the ante- 
 rior surface outside the flexor tendons and on the sides of the tendo Achillis. 
 If osseous, besides the intermitting inability or at least unwillingness fully to 
 flex and extend the foot, there will be present for a time only the pain, spon- 
 taneous or elicited by pressure, which belongs to osteitis, following which expan- 
 sion of the bone and intra-articular eff'usion will cause noticeable swelling. 
 When the disease is well established the region of the joint has the globular 
 contour with associated atrophy of adjacent parts that is so characteristic of 
 fungous arthritis, and the foot is held in decided extension. The skin is pale, 
 or deeply colored from congestion. Sinu.ses are developed comparatively late. 
 
SURGE in' or JOIXTS. 401 
 
 That the disease is not in the os calcis or in and about the middle tarsal articula- 
 tion will be indicated by the locality of the swelling, below or in front of the 
 ankle region. 
 
 The prognosis is that of tubercular arthritis in general, grave or not 
 according to the age and constitutional state of the patient, and especially to 
 the period of its recognition and the thoroughness of treatment. 
 
 Treatment. — As soon as the diagnosis is made, walking upon the foot 
 should be sto{)ped and the joint immobilized, care being taken in the applica- 
 tion of the plaster-of-Paris bandage to place the foot at a right angle with the 
 leg. The bandage must be renewed as often as the swelling subsides. After 
 a time, if the disease still progresses, iodoform or zinc injections may be used 
 with advantage. When the joint structures become disorganized, erasion or 
 excision, typical or atypical, is indicated, and should be done without delay. 
 Even when the tarsus has become extensively diseased and the tibia and fibula 
 are infected beyond the epiphyseal line, removal of the tubercular tissue, both 
 in the bone and in the soft parts, may be followed by recovery with a firm and 
 useful limb. But such removal must be thorough, all diseased tissue being 
 removed from the medullar}^ cavity of the leg-bones, the tendon-sheaths, the 
 meshes of the connective tissue outside the joint, — wherever it may be. If this 
 cannot be accomplished, amputation should be done or the osteoplastic resec- 
 tion of WladimirofF-Mikulicz. If the medullary canal is opened by amputa- 
 tion, all of the infected marrow must be thoroughly scraped out and the canal 
 disinfected and drained. 
 
 Shoulder-joint Disease. — The shoulder is much less frequently the seat 
 of tubercular disease than might be expected from its range of movement and 
 its exposed position. Children are at times attacked, but disease of this artic- 
 ulation is rare in them as compared with disease of the hip, knee, or elbow. 
 Young adults are the more common subjects, though it is at times met with, 
 and as a rule in a very destructive form, in persons w^ell advanced in life. 
 Any of the varieties of the disease may be seen ; and caries sicca more often 
 attacks this joint than any other (Fig. 61, p. 272). 
 
 The symptoms vary according to the form, though impairment of func- 
 tion is common to all. In other than the dry variety the affected region is 
 enlarged and of globular shape, firm to the touch when fungous masses are 
 present, fluctuating if there is intra-articular fluid in excess or if a periarticular 
 abscess has formed. Such an abscess may point in the axilla, or, following 
 the course of the muscles, on the anterior surface of the arm, on the side of the 
 chest, near the posterior axillary fold, or over the scapula. Pain to a consid- 
 erable degree may be present, and is often very severe in the ordinary dry 
 variety when suppuration occurs. In caries sicca, except in those rare cases 
 in which abscess is developed at a late period, there is no abnormal fulness of 
 the region ; on the contrary, the parts are greatly atrophied. Because of the 
 destruction of the head of the humerus, unattended by excessive new formation, 
 a hollow is produced under the acromion process which may excite a suspicion 
 of luxation, all the more because of the existing undue prominence of the 
 coracoid process. Movement, especially in adduction, is resisted, and even 
 under an anesthetic is found to be much limited. 
 
 The diagnosis in any of the varieties and at any stage is often diflScult 
 and uncertain, the aff'ection being confounded with bursal disease, with chronic 
 rheumatism, or with hysteria, especially the last two. The history of the case 
 and examination of the aspirated fluid will probably indicate the non-existence 
 of bursitis. Chronic mono-articular rheumatism is not likely to be present 
 in a young adult, and it is at such period of life, as a rule, that ca7'ies sicca 
 
 26 
 
402 AN AMERICAN TEXT-BOOK OF smOERV. 
 
 IS found. Iji an hysterical Joint tlicro is no restriction of motion when tlic 
 patient i.s auL'stlietized. 
 
 The prognosis is favorable in the majority of cases, particularly of the 
 dry variety, t'S])t'cially if the parts are early jnit at rest and kejit so. 
 
 Immobilization is essentially the only treatment requiretl so long as 
 abscesses do not form. When they have formed and the suppuration is free 
 the head of the humerus Avill usually have to be excised. Tlie final result of 
 excision is ordinarily excellent, the new joint being firm and quite movable; 
 sometimes it is very loose (flail-joint, dangle-joint), liut even then it may prove 
 serviceable. 
 
 Elbow-joint Disease. — The elbow is tubercular much more often than 
 either of the other large joints of the upper extremity. The disease shows 
 itself usually in children, and is of synovial origin in the majority of cases. 
 When osteal the primary focus is more likely to be in the epiphysis of the 
 humerus than in that of the ulna or of the radius ; in the latter it is rarely 
 seen. Even when the joint disease is extensive the tubercular bone affection 
 may be only on one side of the interarticular line, in which case the bone or 
 bones on the other side will ordinarily be found docidcdly rarefied. 
 
 iKi. ins. 
 
 Tubercular Disease of Elbow (original). 
 
 The symptoms here, as elsewhere, are not well marked in the beginning, 
 especially in the osteal variety. Spontaneous pain may or may not be present, 
 but pain can always be caused by pressure. There is some stiffness of the joint, 
 and the forearm is somewhat flexed. As soon as effusion occurs into the joint 
 or new formation to any decided degree takes place, fulness will be noticed on 
 
SURGEIiV or JOISTS. 403 
 
 the sides of the olecranon process and above it ; not until much later on the ante- 
 rior surface, because of the firm resistance of the overlying muscles and fasciae. 
 When the disease is well developed the region is markedly spindle-shaped, the 
 arm and forearm much atrophied, the flexion permanent at an angle of about 
 140°, the hand pronated (Fig. 108). Increase of local heat may occasionally 
 be recognized by touch. All movements are painful. If abscesses form they 
 will probably open through the posterior surface of the joint. 
 
 Treatment. — As soon as the disease is detected the joint should be immo- 
 bilized in flexion, the rectangular position being secured as soon as it can be 
 tolerated — from the beginning, if it is not too painful. If abscesses form and 
 open, the dressing must be so fenestrated as to permit of free discharge. Iodo- 
 form injections should be made through the sinuses into the abscess-sac or the 
 opened joint-cavity; such injections or those of chloride-of-zinc solution may 
 be made subcutaneously before sinuses have formed. After weeks or usually 
 months of fixation of the joint, especially if it was commenced early, recovery 
 may be expected ; in the more fortunate cases it may be with quite complete 
 preservation of the motions of the articulation, but much more often with 
 ankylosis. It is because of the likelihood of the occurrence of a stiff joint 
 that the parts should be fixed at a right angle, or even less — i. e. the angle at 
 which the extremity will be most useful. AVhen the joint has become exten- 
 sively disorganized, erasion or excision should be done without delay. The 
 result of such an operation at this joint is as a rule very satisfactory, excellent 
 motion being often secured. Very rarely amputation of the arm will be required. 
 
 "Wrist-joint Disease. — Except in connection with the same disease of 
 adjacent parts, especially of the carpus, tuberculosis of the wrist-joint is rarely 
 seen. Though it may be primary and synovial, it is commonly secondary to 
 caries of the bones of the wrist, or, much less often, to fungous teno-synovitis. 
 It attacks both children and adults, even persons beyond middle age. If primary, 
 ordinarily it soon extends to the bones beyond the wrist, and even when first 
 seen the case presents the symptoms of carpal disease. The joint motions are 
 restricted and painful. The affected region is enlarged, especially on the dor- 
 sum, the forearm and hand being decidedly, often greatly, atrophied. The 
 fingers are extended, seemingly lengthened. Disorganization takes place at a 
 comparatively early period. 
 
 The treatment, as in like disease of other joints, is by immobilization and 
 injection, by preference of the iodoform emulsion. Ignipuncture has been 
 successfully employed by a few surgeons. If commenced early and steadily 
 followed up, in a large proportion of cases treatment will effect a cure, though 
 the wrist will almost certainly be a stiff one : but the time required is often 
 very great, measured, it may be, by years. Because of this length of time and 
 of the much-crippled or entirely useless hand that so often remains, it is as a 
 rule wise to operate by erasion or excision if after several months of conserva- 
 tive treatment marked improvement in the local condition has not been secured. 
 
 Sacro-iliac Joint Disease. — Disease of the sacro-iliac articulation 
 (sacro-coxalgia) is of infrequent occurrence. It is very much more common in 
 young adults than in children, and seldom appears in individuals over thirty- 
 five years of age. It is likely to be mistaken for hip-joint disease. As a rule 
 it pursues an unfavorable course. Its pathological changes are essentially the 
 same as those of tubercular disease of other joints. There are the usual effu- 
 sions (which if intra-articular are necessarily limited) and exudations, abundant 
 new formation of infected granulation-tissue, destruction of cartilage and bone, 
 and the development of cold abscesses, internal or external. The fluid of such 
 abscess, if internal, may pass down behind the rectum into the ischio-rectal 
 
404 AX AMElilCAN TEXT- BOOK OF SURGERY. 
 
 fossa or by perforation into the bowels, or, following the muscular planes, may 
 reach the neighborhood of the sciatic notch, of Poupart's ligament, or the 
 upper part of the thigh, or may pass along the sciatic nerve to the region 
 behind the greater trochanter ; if external, the abscess will probably be found 
 over the joint near the edge of the ilium. If an abscess does not form, recovery 
 may be expected, with an ankylosed joint ; if an abscess does form, especially 
 an internal one, the probabilities are very strong that the patient will die, 
 though he may even yet recover after extensive bone destruction and later 
 fusion of the sacrum and ilium. When the affection has occurred in early 
 childhood it may be the cause of pelvic distortion, of much importance in the 
 female. 
 
 The symptoms are ill or well defined according to the stage of the 
 disease. At an early period there will be discovered scarcely more than a little 
 stiffness, discomfort in standing or walking for any length of time, and pain, which 
 is neither constant nor severe, in the region of the joint or sometimes in the 
 thigh. Later, at a time when the case is most likely to come under observation, 
 pain is decided when any motion is made, and may be present when the patient 
 is lying down. This will certainly be the case sooner or later when an attempt 
 is made to rest upon the affected side. Crowding of the ilia together will 
 always cause suffering. The pain is not simply in the region of the joint, but 
 as a rule radiates in various directions, according to the course of the nerves that 
 pass in close proximity to the articulation, especially the sciatic, the anterior 
 craral, the obturator, and the genito-crural. The thigh is more or less flexed 
 upon the pelvis, with tension of the psoas, and the patient throws his weight 
 upon the sound side. The affected limb seems elongated, or there may be 
 quickly alternating apparent lengthening and shortening. The patient walks 
 with a decided limp. The soft parts over the joint posteriorly may be swollen 
 or flattened. Usually after a considerable time the pus will show itself beside 
 the anus, in the outer part of the groin, behind the trochanter, or near the 
 iliac crest posteriorly: and before very long, if not opened by the knife, it 
 will be spontaneously evacuated. True suppuration is very apt now to occur 
 because of an added infection by the pyogenic cocci, with corresponding 
 increase in the gravity of the previously existing constitutional symptoms due 
 to the tuberculosis. 
 
 The disease is likely to be mistaken for neuralgia of the joint, for lumbago, 
 for vertebral or sacral caries, for sciatica, and especially for hip-joint disease. 
 The location, limitation, duration, and character of the pain will serve to dis- 
 tinguish it from the various neuralgic and myalgic affections. There will be an 
 absence of the ordinary local signs of spinal caries. If there is caries or necrosis 
 of the sacrum or ilium away from the articulation, there will probably be a 
 history of severe injury, with the after-symptoms of bone contusion or wound. 
 From hip-joint disease the differential diagnosis may not be readily made. The 
 attitude of the patient, the flexion and apparent elongation of the limb, the 
 pain, which, if present, will be located in front of or behind the hip. or even at 
 the knee, — are all much like what is observed in morbus coxarius. But careful 
 examination will show that the motions of the hip are unrestricted ; pressure 
 over the joint and crowding the head of the femur against the acetabulum will 
 cause no pain if the ilium alone is steadily fixed ; there is no adductor rigidity; 
 if the expanded wings of the ilia are pressed together severe pain is produced, 
 as it is by any motion of the limb the action of which is continued upward 
 through the pelvis; there is steady pain in the region of the sacro-iliac junc- 
 tion ; the anterior superior iliac spine on the affected side is more prominent 
 and upon a lower level than that of the sound side. 
 
SURGERY OF JOTXTS. 405 
 
 Tlie treatment will vary according as tliere is or is not an abscess. In the 
 latter case rest and counter-ii-ritation are of extreme value. The first is secured 
 by fixation of the whole pelvis and the limb of the affected side by apparatus 
 or plaster of Paris ; the last by the application of the actual cautery. If this 
 treatment fails and abscesses have formed, they should be evacuated and injected 
 with the iodoform-glycerin emulsion, or freely opened if possible, curetted, and 
 kept thoroughly drained. When the pain in the joint is very severe and the 
 formation of an abscess is strongly threatened, free opening of the joint should 
 be made, if necessary with the trephine. Of course all these operations must 
 be done aseptically and the Avound and cavities protected from septic infection ; 
 and rest, as absolute as possible, should be maintained until healing is complete. 
 
 Besides the tubercular affection, this joint is the seat also of rheumatic, 
 gonorrheal, and septic inflammations. The first two are comparatively mild, 
 and are usually recovered from, occasionally without ankylosis. The septic 
 arthritis, very generally of puerperal origin, is almost certain to destroy life 
 in a short time, in spite of any treatment, local or constitutional, that can be 
 adopted. 
 
 (b) septic arthritis. 
 
 Infection by the bacteria of suppuration, chiefly the staphylococcus aureus 
 and the streptococcus pyogenes, produces an acute arthritis which, if not prompt- 
 ly and actively treated, and sometimes in spite of treatment, results in destruc- 
 tion of the part and not seldom in loss of life. The infection may be produced 
 in one of several ways : (1) directly through an open wound made by a dirty 
 instrument, or one in which there is lodgment of a foreign body carrying the 
 pyogenic cocci, or through a later infection of an originally aseptic track ; 
 
 (2) by an opening of a joint-cavity in the progress of an osteo-myelitis or by 
 the extension of suppurative disease of the articular or periarticular structures ; 
 
 (3) through the transmission to and deposition in the synovial membrane of the 
 micro-organisms present in the blood of a pyemic patient. However produced, 
 if the infecting organisms are many and the case is left to itself, a high grade 
 of inflammation of the joint structures is rapidly developed, with an abundant 
 formation of pus. Exudation occurs into the synovial membrane, the subsv- 
 novial connective tissue, and the capsule, all of which soon become disorgan- 
 ized. The articular cartilages break down, either quickly in masses of consid- 
 able size, or more slowly at many points, through erosion by granulations. The 
 ligaments soften to such an extent, it may be, as to permit of undue motion of the 
 bones upon each other or of their complete luxation. The periarticular struc- 
 tures are filled with newly-formed infected granulation-tissue, in the breaking 
 down of which abscesses form extending in various directions above and below 
 the joint, and soon an opening through the skin takes place. 
 
 The symptoms are such as might be expected from the intensity of the 
 joint inflammation. The pain is very severe, generally worse at night: the 
 swelling is great ; the skin is red and hot ; fluctuation is distinct ; the parts 
 above and below are oedematous. The joint is flexed to the angle at which 
 intra-articular tension is least. Any attempt at motion much increases the 
 suffering. The constitutional symptoms are always grave, and are proportionate 
 to the extent and rapidity of development of the local disease. There is gene- 
 rally an initial chill, or at least well-marked chilliness. The temperature quickly 
 runs up several degrees, remaining high, with no very great fluctuations, or show- 
 ing a well-defined septic curve. The pulse, strong and full it may be at first, 
 soon becomes rapid and weak. The "• typhoid " state, more or less complete, 
 quickly sets in. In the very acute cases death from septicemia mav occur 
 
406 AX AMERICAX TEXT-BOOK OF SURGERY. 
 
 within a few days. Ordinarily with the opening of the abscesses and the 
 resulting relief of tension decided improvement, at least for a time, takes place 
 in the symptoms, both local and general. In those cases in which the joint 
 affection shows itself in the course of a pyemia the chief local symptom is 
 swelling ; the joint, or not infrequently several joints simultaneously affected, 
 becoming greatly distended with pus in the course of a few hours, the synovial 
 membrane and the articular structures in general showing upon examination 
 little or no evidence of being inflamed. 
 
 In the treatment, as in that of similar disease of bone, safety lies only 
 in prompt opening up of the suppurating area, followed by thorough disinfec- 
 tion and subsequent free drainage. In some of the milder cases aspiration of 
 the joint with antiseptic irrigation will arrest the progress of the disease; 
 but, as a rule, it is much better to incise the capsule and thus secure the 
 complete evacuation of the pus. Most rigid antiseptic treatment should be 
 pursued until the parts are entirely healed, and the joint must be thoroughly 
 immobilized, care being taken to correct as far as possible any existing displace- 
 ment. Recovery is generally by ankylosis, often bony and complete ; but 
 occasionally, because of early and thorough treatment, the articular motions 
 are preserved. 
 
 . The constitutional treatment is that of suppurative disease in general — care- 
 ful feeding and stimulation, quinine, and. later, such tonics as may be required. 
 If the suppuration continues in an exhausting degree despite the local treatment 
 adopted, and the joint is extensively disorganized, operative interference is 
 demanded. Erasion may be done, or, better, atypical resection. Often the 
 joint and the neighboring structures are so widely destroyed and the general 
 condition of the patient is so bad that only by amputation can it be hoped to 
 save life. The pyemic joint is commonly but a symptom of a constitutional 
 state that will cause death in a few hours, or at most in a few days, and the 
 arthritis demands no treatment. When the affection is of but moderate inten- 
 sity, the articular complication should be treated in the ordinary way. 
 
 (c) INFECTIVE ARTHRITIS. 
 
 Very similar to the suppurative arthritis just described is that met with in 
 connection with an acute infectious disease, such as small-pox, measles, scarlet 
 fever, typhoid fever, or erysipelas. It is due to one or, in many cases, to both 
 of two causes — viz. the presence in the joint of the ordinary septic bacteria, 
 or the pyogenic action of the specific micro-organism of the existing disease, that 
 of erysipelas being very closely akin to, perhaps identical with the streptococcus 
 pyogenes. The svmptoms, prognosis, and treatment are the same as those of 
 the ordinary septic joint inflammation. In the typhoid arthritis of the hip, 
 which joint is especially likely to be attacked, spontaneous dislocation occurs 
 in a number of cases. It is often produced spontaneously, sometimes by 
 movements of the patient or by careless handling of the limb at a time when 
 the capsule is largely distended with fluid and the femoral head consequently 
 is to some extent lifted out of the acetabulum, and when the ligaments and 
 muscles are greatly weakened. 
 
 But the suppurative is not the only form of arthritis found associated with 
 the diseases mentioned, nor even the most common. Not very rarely during 
 the height of the affection, more often in the period of subsidence and conva- 
 lescence, a joint or joints (polyarticular involvement being usually a result of 
 scarlatina or small-pox) will be found swollen, hot, and painful, as if affected 
 with rheumatism. Such inflammation may be attributed in part to the affection 
 
srh'(;i:/n' of joints. 407 
 
 of the nervous system belonging to the disease, and in part to the irritative 
 action upon the synovial nionibrane of blood containing the specific organisms, 
 but still more to their chemical products. Resolution ordinarily takes place in 
 the course of a few days, and no treatment is required other than keeping the 
 parts quiet, enveloping them in cotton secured with a bandage, or making hot 
 applications, simple or medicated. 
 
 (d) goxokhhkal arthritis (gonorrheal rheumatism, post-gonorrheal 
 
 arthritis). 
 
 Joint affections of several kinds are freciuently found associated with gonor- 
 rhea. There may be often only a more or less severe intermittent arthralgia, 
 "which soon passes away ; or there may be a chronic inflammation with abundant 
 effusion into the joint-cavity (hydrarthrosis), chiefly that of the knee; or an 
 acute sero-plastic arthritis ; or a suppurative inflammation, which is compara- 
 tively rare. 
 
 For a long time the disease was called gonorrheal rheumatism, and even 
 now it is generally so named. The joint affection, whether characterized by 
 intra-articular effusion, by articular and periarticular exudations, or by the 
 presence of pus, is not rheumatic, though a patient with gonorrhea may have 
 rheumatism, and a rheumatic joint because of such antecedent disease may be 
 more susceptible to the toxic action of the gonococcus or of the mixed gonor- 
 rheal and pyogenic infection. The more carefully the gonococcus of Neisser 
 has been sought in the fluids and tissues of the afi"ected joints, the more 
 frequently it has been found, and in cases in which it cannot be detected there 
 is good reason for believing that its ptomaines are the exciting cause of the 
 metastatic arthritis. When joint disease of somewhat similar character is 
 developed in non-gonorrheal urethral fever, as, e. g., after the passage of a 
 catheter or sound, it is possibly due to the taking up from the injured mucous 
 membrane of the urethra of the common pyogenic cocci, or it may be due indi- 
 rectly to their chemical products. The affection very rarely attacks women. It 
 may appear at any period in the course of the urethritis, but occurs much more 
 often in the third and fourth week than later, especially in its acute form. Any 
 articulation may be its seat, though in nearly one-half of the cases it is the 
 knee, and in about two-thirds the knee, the ankle, or the joints of the fingers 
 or toes. Generally it is mono-articular; rarely more than two or three joints 
 beinfj attacked either at the same time or in succession. 
 
 The symptoms vary according to the form of the arthritis. In the chronic 
 variety attended with abundant intra-articular effusion there is impairment of 
 function, and, of course, marked swelling, but the joint is not painful or is but 
 slightly so, except duringthe time of an acute exacerbation, which is occasionally 
 observed. In the acute form the suff"ering is intense, persistent, worse at night, 
 and much aggravated by movements, even slight ones. The parts are swollen and 
 hot, the skin is red, and the joint is held in the position of greatest ease. Atro- 
 phy of the structures above and below is quickly produced. There are decided 
 elevation of temperature and acceleration of pulse, and. because of the fever 
 and suffering, rapid loss of strength and weight. When suppuration occurs, 
 which is seldom, the local and general symptoms are intensified. The disease 
 terminates in resolution, in ankylosis, or in destruction of the joint ; most fre- 
 quently by far in ankylosis (fibrous) either partial or complete, due to organiza- 
 tion of the plastic exudations both articular and periarticular. The serous 
 accumulation in the joint, in spite of any treatment, will often remain unchanged 
 for many weeks, or it may be months. 
 
408 AN AMERICAN TEXT- HOOK OF SURGERY. 
 
 In the treatment of gonorrheal as in tliat of other forms of arthritis rest 
 is of prime importance. As long as there is any inflammation present the joint 
 sliouhl be kept immobilized. Blisters, mercurial a])i»lieations, fomentations, 
 cauterizations, all of which liave been employed again and again, can accom- 
 plish but a fraction of the good that results from the quietude and equable 
 coinpression secured by the plaster-of-Paris bandage. But immobility of the 
 joint must not be maintained for too long a time, lest ankylosis, to which, as 
 has been stated, there is a strong natural tendency, be established ; if on 
 the other hand passive motion is too early resorted to, the inflammation will be 
 lighted up again. The only safe rule to adopt is to keep the parts quiet until 
 all inflammatory symptoms seem to have subsided, and then gently to move the 
 joint. If the pain Avhich follows disappears spontaneously within a few hours, 
 twenty-four at the outside, no harm has been done, and the motions may be 
 continued and increased. If the pain continues, the parts should be again im- 
 mobilized for a time. An existing hydrarthrosis may be aspirated and car- 
 bolic-acid injections used. If suppuration occurs, aspiration and thorough 
 antiseptic irrigation may be employed, and the joint then immobilized Avitli a 
 fair prospect of success. If such treatment is not quickly followed by marked 
 amelioration of the symptoms, the cavity must be opened and drained as in 
 suppurative arthritis due to other causes. Absorption of exudations and dis- 
 appearance of adhesiojis, Avhen not very close or strong, will be much iavored 
 by the employment of massage, baths, and douches continued for as long a 
 time as may be necessary after the removal of the immobilizing dressings. If 
 ankylosis has taken place, it must be broken up or the joint excised ; such ope- 
 ration, however, will seldom be found necessary. 
 
 (e) rheumatic arthritis. 
 
 Rheumatic articular affections are common, and are both acute and chronic. 
 In the acute variety the joint inflammation is very rarely mono-articular. 
 One or several joints may be attacked at first, and other joints are apt to be 
 quickly aff"ected, with at times rapid and complete subsidence of the inflamma- 
 tion in the articulations in which it was primarily located. 
 
 The symptoms are those of acute synovitis, pain, extreme sensitiveness 
 to pressure, and heat and swelling due in part to effusion into the periarticular 
 structures, but chiefly into the cavity. Suppuration never occurs unless there 
 has been a mixed infection. As the arthritis is but a part of a general disease 
 which is medical and not surgical, and ends Avith very few exceptions in resolu- 
 tion, leaving, jtt least after a single attack, no changes in the structures or the 
 functional value of the articulation, it need not be here considered. 
 
 The chronic variety may be such from the start or may be the result of re- 
 peated acute attacks, each of moderate severity. The inflammation often causes 
 no material alterations in the joint structures, the synovial membrane being only 
 a little thickened and its vascularity diminished, with a diminution in the amount 
 of synovial secretion and the production of a grating or creaking on motion as 
 a consequence. On the other hand, there is occasionally an excess of fluid in 
 the joint. At times the arthritis is decidedly plastic, the membrane, the cap- 
 sule, and the periarticular structures being much thickened, with the formation 
 of bands and adhesions restricting motion even to a considerable degree. The 
 cartilages are usually unaffected, but may be irregularly thickened and thinned. 
 
 Treatment consists in the prevention of acute or more often subacute 
 exacerbations which serve to increase the weakness and stiffness of the affected 
 joint, and in the securing of absorption of the exudations and resulting adhe- 
 
SURGERY or JOINTS. 
 
 409 
 
 sions to such an extent as may be possible. The first is to be accomplished by 
 avoidance of the excitini; causes, cold and dampness, and by the proper protection 
 of the joint by wann woollen clotliinj^ ; the second by the employment of hot 
 baths, frictions, and massage and due use of the joint, together with the inter- 
 nal administration of the ordinary anti-rheumatic remedies — the salicylates, the 
 iodide of potassium, the salts of lithium, etc. Partial ankylosis should be 
 broken up under ether, and followed by massage, the douche, and active and 
 passive motion. Mucii attention lias lately been directed to the employ- 
 ment of dry heat of high degree (270° to 380° F., 132° to 165'" C.) 
 applied by means of special apparatus (Fig. 169). Very decided allevi- 
 
 Apparatus for the Employment of Hot Air in the Treatment of Arthritis. 
 
 ation of pain and increase of movement of partialh^ fixed joints have 
 been secured ; but the treatment, while serving a most excellent purpose 
 in relieving pain, cannot be regarded as curative. It has been found of 
 more service in rheumatic and gouty cases than in those of osteo-arthritis. 
 The immediate local results of the application of the hot air are marked 
 hyperemia, free sweating, and relaxation of contractions and adhesions ; 
 there is also some general increase of temperature and pulse-rate. Care 
 must be taken to avoid setting fire to the patient's clothing. An appa- 
 ratus heated by electricity has recently been devised. 
 
 (f) gouty arthritis. 
 
 Whatever may be the essential nature of gout, its most constant manifestation 
 is in the joints, in the smaller much more often than in the larger — e. g. those 
 of the fingers, and especially the metatarso-phalangeal articulation of the great 
 toe. Deposits of the urates, chiefly sodium urate, occur in the connective 
 tissue of the joint ; they produce destruction of the cartilages, unless it be true, 
 
410 .liV AMFJUCAX TKXT-noOK OF SURGERY. 
 
 as has been maintained by sonic, tliat tlic deposit can take place only in carti- 
 lafje that is in a state of" necrosis. As a result ot" the irritation consequent 
 upon the presence of the abnormal salts, there is overf!;rowth of the connective 
 tissue, ■with later contraction of the new-formed fibrous tissue, followed by altera- 
 tions in the shape of the joint and impairment of its motions. Repeated attacks 
 of acute inflanimation occur, of jjreater or lesser intensity according; to circum- 
 stances. Frequently the urates form masses of considerable size in the affected 
 joint (chalk-stones, tophi), which may lon^ remain without excitiiiff any i)articu- 
 lar disturbance, may <;ive rise to the formation of an abscess, or may often 
 cause ulceration of the skin and exposure of the chalk-stone. As is the case 
 in rheumatism, the joint affections of gout are but symptoms of a diathetic 
 state, the consideration of which belongs to the physician rather than to the sur- 
 geon, except so far as they may produce disabling contractions and deformities. 
 
 (g) OSTEO-ARTIIRITIS (chronic rheumatoid ARTrtRITIS, RHEUMATIC GOUT, 
 
 ARTHRITIS deformans). 
 
 For many years a disease in certain respects much resembling rheumatism, 
 in others resembling gout, has been recognized. As a rule having few excep- 
 tions, it is very chronic; goes steadily on from bad to worse; often produces 
 extreme deformities; and disables its subjects, even to the extent of altogether 
 preventing motion in the affected joints. Of the many names that have been 
 given to it, that of osteo-arthritis is to be preferred. It is occasionally acute, 
 when the patient is generally a young woman, though this form of the affection 
 may be met with in children. The disease is ordinarily seen in middle or 
 advanced life, even up to extreme old age. Women are more often attacked 
 than men. Of the smaller joints those of the hands and feet, of the larger the 
 hip and knee, are the ones usually diseased ; as a rule, two or three of the larger 
 joints are affected at a time ; when mono-articular it is most frequently located 
 in the hip or knee. 
 
 Its assumed causes are many. As predisposants there are heredity, a rheu- 
 matic or gouty family or personal history, long-continued hard work, mental 
 worry, an occupation or residence favoring exposure. The exciting cause has 
 been found in cold, in dampness, in injury, in the wretchedness of poverty, 
 and in a trophic neurosis of undetermined origin, at times doubtless septic. 
 It is one of the earlier degenerative affections, and anything that will impair 
 the general strength may be a cause, especially anything weakening the nervous 
 system. The poor are very subject to it, but perhaps no more so proportion- 
 ately than the well-to-do, the privations of the one class being offset by the 
 nervous strains of the other. A curious illustration of the possible causative 
 effect of dampness and want of sunlight may be afforded by the fact that the 
 disease has been found in five out of sixteen skeletons of gorillas examined in 
 various European museums, the native home of the gorilla being in the depths 
 of the African forests ; although more probably in this case the true cause is 
 to be found in the abnormal and depressing effects of captivity. 
 
 The advocates of the neural theory of causation believe that " the articular 
 lesions are peripheral manifestations of a degenerative change in the center for 
 joints situated in the medulla oblongata." 
 
 The articular cartilages are first affected. There occurs a fibrillary degen- 
 eration of the intercellular substance, with abundant new growth of the cartilage- 
 cells, and soon a breaking down and disappearance of both, leaving the surface 
 eroded and velvety, or, less often, smooth and thinned. By pressure of the 
 adjoining bone marked central thinning is produced, the extent and precise 
 
SURGFAiY OF JOINTS. 
 
 411 
 
 location of which are detorniiiKMl by the ])ressure. Later tlierc arc coinplete 
 disappearance of the cartilage and exposure of the underlying bone. This in 
 its turn wastes aAvay, with resulting changes in its shape. Not seldom the 
 external layer becomes sclerosed, even of ivory-like hardness, and by pressure 
 is worn down uniformly or in grooves. While the central part of the articu- 
 lating surface is weai-ing away, the peripheral is increasing in thickness, and 
 
 Fig. 170. 
 
 Advanced Osteo-arthritis of the Elbow, with eburnated and grooved articular surfaces and enormous 
 
 lips of bone (Moullin). 
 
 grows out into lips hanging over the edge, which later partly or wholly ossify 
 (Fig. 170). 
 
 The synovial fringes enlarge, new ones form, and outgrowths are devel- 
 oped. The original cartilage-cells of the membrane proliferate greatly. 
 Adhesions of adjacent sides of the fringes take place. Many of the out- 
 growths become pedunculated, and some of them may be detached, consti- 
 tuting one variety of "floating cartilage." 
 
 The capsule and ligaments, at first only congested and oedematous, 
 after a time as a rule undergo fibrous degeneration, with later the formation 
 of adhesions and contractions. They seldom ossify. Occasionally, instead of 
 becoming harder and firmer, they soften and permit undue movement of the 
 joint surfaces, even to the extent of the production of luxation. The irritated 
 periosteum over the end of the aflfected bone throws out new bone, the oste- 
 ophytes at times being numerous and of considerable length. The interior 
 of the joint is generally dry, but occasionally contains fluid in large quantity 
 (hydrarthrosis). Hernia of the synovial membrane may be produced, or a 
 communication established with a neighboring bursa. Muscular atrophy occurs 
 early. The tendons passing over the joint may harden and contract, may ossify, 
 may become detached from the bone, or may soften and disappear. At the 
 shoulder the long head of the biceps is commonly destroyed. 
 
 As the result of changes in the shape of the articulating surfaces, of new 
 growths upon their edges, and of degeneration of the synovial membrane, the 
 
412 AX AMERICAN TEXT-HOOK OF SURGERY. 
 
 ligaments, the muscles, and the tendons, deformity and restriction of movement 
 soon follow and become greater and greater. In the hand, where the disease 
 so commonly manifests itself, jironation occurs, with the fingers strongly in- 
 clined to the ulnar side and held in flexion or extension. On the sides of the 
 finger-joints, especially the distal ones, there may generally be found small, hard, 
 pea-like nodules (the nodosities of Heberden). In certain very mild cases the 
 knobbed condition of the fingers may be almost the only observed indication 
 of the existence of the disease. Several of the vertebrte or all of them may 
 be tied together by a bridge of bone, often said to be produced by an ossifica- 
 tion of the anterior common ligament, but really by a new formation in place 
 of the ligament, which has undergone absorption. In a few cases almost every 
 joint in the body has been found firmly fixed, the patient being incapable of 
 movement. While all these changes are going on in the joint there are very 
 slight or even no constitutional disturbances present. Suppuration does not 
 take place either in or about the joint, except in rare cases. 
 
 The symptoms of the chronic variety, when the disease is well developed, 
 are unmistakable, the only other affections likely to be thought of being chronic 
 rheumatism and gout. The coexisting enlai-gement and distortion of several 
 joints; the grating and creaking on movement; the slow progress of the 
 malady ; the long continuance of the ability to go about and attend to business ; 
 the absence of severe pain ; the normal temperature and pulse ; the want of 
 the proper symptoms of rheumatism and gout, — all these taken together render 
 the diagnosis easy and certain. In the acute variety, occurring generally in 
 children and young adults, the intensity and rapid development of the disease, 
 the symmetrical joint involvements, the articular enlargements, and the early 
 manifestation of muscular atrophy indicate the nature of the affection. When 
 only a single joint is affected — and this is, as has been stated, far more often 
 the hip — the diagnosis for a time may be uncertain. Like the other varieties, 
 it is generally seen in old persons {inalum coxoe senile), but is occasionally met 
 with in young subjects. It frequently follows contusion, as from a fall on the 
 trochanter. Nothing specially abnormal may be noticed for a time, but after 
 a number of weeks or even months the limb will be shortened and the joint 
 motions much restricted. Such a case has often been mistaken for an old 
 unrecognized fracture of the neck of the femur. Long ago it Avas described 
 by Bell as an "interstitial absorption" of the neck, but in such cases not 
 simply an interstitial but a general and extensive absorption of both head and 
 neck has taken place, with the formation of new bone along the neck in sub- 
 stitution of that taken away. The destructive and formative changes about 
 the joint are in no material respect difterent from those observed in the ordinary 
 polyarticular variety. 
 
 Of late Spender has called attention to certain symptoms that are developed 
 early, before any distinct evidence is afforded of articular changes. These are 
 (1) rapidity of the heart's action and increased arterial tension, due to dis- 
 turbance of the inhibitory action of the pneumogastric ; (2) the appearance of 
 bronzed and discolored patches upon the skin; (3) clamminess of and atrophic 
 changes in the skin because of vaso-motor disturbances ; (4) pain in the muscles 
 of the ball of the thumb or along the inner side of the wrist. The importance 
 of these symptoms, if they prove to be constant ones, is very great, as only at 
 an early stage is the disease curable. When joint changes to any considerable 
 extent have taken place, the damage is irreparable, and, probably, further 
 progress of the malady cannot be arrested. 
 
 The treatment must l)e l)y the removal as far as possible of all depressing 
 causes, the improvement of the general nutrition, and the administration of 
 
SURGERY OF JOINTS. 413 
 
 drugs and tlio emplovinont of measures tliat Avill i)romote absorption. Cod- 
 liver oil is rf much value, as is arsenic in tlie early sta^^'es ; later on arsenic 
 has proved to be decidedly injurious. The iodides, especially that of iron, are 
 beneficial, as are electricity,' baths, douches, and massage. Various thermal 
 and sulphur springs have enjoyed considerable reputation as affording relief. 
 Blisters and other strong counter-irritants, especially the actual cautery, have 
 been em])loved, but it is very doubtful if they ever do much good. If 
 hydrarthrosis is present, compression or better aspiration and carbolic injections 
 should be employed. Here is the one great exception to the rule of securing 
 rest to a diseased joint. Immobilization is not indicated, but active and 
 passive movements should be employed as long and as freely as possible. 
 
 (h) neuropathic arthritis, or tabetic arthropathy (CHARCOT'S disease). 
 
 Since it was first described by Charcot in 1868 a peculiar ost-eo-arthritis in 
 patients affected with locomotor ataxia has been frequently observed. The j omt 
 chan<Tes are in the main those of osteo-arthritis in general, but there are certain 
 differences of importance. The disease is much more acute, and affects chiefly 
 the larcre joints, particularly the knee. There is little or no pain, and constitu- 
 tional disturbances are absent. Without any injury having been received, the 
 ioint suddenly swells, and soon a large intra-articular effusion occurs, which alter 
 a time disappears through absorption or organization. Extensive and at times 
 very rapid ulceration and wearing down of cartilage and bone take place. 
 New formations are as a rule very limited, though an hypertrophying variety 
 is sometimes met with. The lesion often extends some distance up the shatt 
 and pieces of bone are separated as though there had been a comminuted 
 fracture. Marked grating and crackling even on slight movement are per- 
 ceived earlv. The ligaments quickly break down, with resulting great mobility, 
 it may be in every direction. Dislocation, or characteristic deformity without 
 complete luxation, occurs. Great atrophy of the affected limb is soon observed. 
 All these changes may take place while the patient is confined to bed, proving 
 conclusively that the rapidity and extent of the lesions are not due to over-use 
 of an osteo-arthritic joint the sensibility of which has been greatly diminished 
 or practically altogether lost because of the existing tabes. Ordinary osteo- 
 arthritis may occur in a tabetic patient, but it does not run the acute course 
 that is so characteristic of tabetic avthropathy proper. That the disease does 
 not depend upon degeneration of the peripheral nerves is shown by the absence 
 in a considerable proportion of cases of any marked changes m such nerves. 
 Everything seems to indicate that the disease is a peculiar one, depending upon 
 changes tlmt have taken place in the spinal cord, perhaps in the anterior horns. 
 The treatment is practically confined to protection of the affected joints 
 from injury, and to limitation of the abnormal movement by position or by 
 apparatus. ' If dislocation of a joint in the lower extremity has occurred, it 
 will probably be necessary for the patient to keep his bed. In a few cases 
 excision has been done, but the results have not been satisfactory. 
 
 (l) HYSTERICAL JOINTS. 
 
 More than half a century ago Brodie directed attention to cases of seeming 
 articular disease in which no joint lesion was present, and which were only 
 manifestations of hysteria. Since then such cases have been found to be of 
 frequent occurrence. In the great majority of instances the patients are 
 women, especially young women. Generally they are well educated, m easy 
 
414 ^l.V AMERICAN TEXT- HOOK OF SURGERY. 
 
 circumstances, and hij^hly impressionable, often the subjects of some ovarian 
 or uterine disturbance. Tbe knee and liip are tbe joints commonly affected ; 
 tlie trouble may come on sudiU'nly and -without known cause or after a sligbt 
 injury, or folhjw a mihl arteritis wliich has ((uickly disa))peared. Tbe patient 
 imagines that she has serious disease which causes great local distress and 
 decidedly or entirely prevents passive motion except at the cost of much suffer- 
 ing. Active motion may seem as impossible as though tbe muscles were 
 paralyzed, or, as is usually the case, may be executed w ithout special difficulty, 
 but in a rather feel)le way. The ])arts are generally normal in size and aj)pear- 
 ance except as affected by a slight amount of atrophy from disuse, or are at 
 times somewhat swollen and a little reddened, commonly l)ecause of the appli- 
 cations that luive been made. There is great hyperesthesia of the skin, the 
 least touch causing pain, much more than that produced by firm pressure. 
 There may be an api)arent rigidity of the muscles about the articulation, but 
 this at once and completely disaj)poars when the patient is anesthetized. The 
 joint may from the first 1)0 held fixed in extension or flexion, but will rarely 
 be found at that angle of flexion which secures the greatest ease and which is 
 characteristic of a true arthritis. Very often the position of the limb varies 
 from time to time, the change, it may be, occurring suddenly. 
 
 The local temperature is normal, or even subnormal, because of the sluggish 
 circulation, though transient and variable increase of heat may be noticed that 
 may even appear quite regularly at certain hours of the day. It is of the 
 highest importance that the true nature of the affection should be determined 
 at an early period. Tiiese cases are often misunderstood, and the patient is 
 treated for actual articular disease, traumatic, rheumatic, or even tubercular, 
 and in consequence becomes a permanent cripple. 
 
 The diagnosis is to be establislied by observing, first, the marked dispro- 
 portion existing between the subjective and the objective symptoms, a dispro- 
 portion so characteristic of all manifestations of hysteria ; second, the intense 
 hyperesthesia ; third, the absence of any evidence of degeneration of the tissues ; 
 fourth, the com})lete relief of symptoms Avhen the attention of the patient is 
 directed from herself and her malady ; and fifth, the entirely normal outline 
 of the joint and complete freedom of its motions during the anesthetic sleep. 
 It should not be forgotten that in any case of suddenly appearing disease of 
 the knee or hip in a young woman, especially if she is of a neurotic tempera- 
 ment, the antecedent probabilities are ail in favor of the hysterical nature of 
 the affection. But before concluding that it is of such nature care must be 
 taken to make sure that there are not in and about tbe joint evidences of an 
 organic lesion. Tbe extreme difficulty at times of learning the real character 
 of the disease and the deceptive character of this neuro-mimesis or nerve- 
 mimicry are shown by the fact that in some cases surgeons have connnenced an 
 excision or amputation only to find upon exposure of the joint structures that 
 there was nothing the matter with them. 
 
 The treatment is constitutional, supporting, and tonic, and directed to 
 any existing visceral disease. Moral treatment is esj)ecially needed. Unless 
 the confidence of the patient is gained and she realizes tbe truth of the state- 
 ment made to her that she has no joint disease, she will not get well. Of local 
 treatment the less the better. Electricity, frictions, batlis, massage, all are 
 very apt to keep the attention of the patient fixed upon her affection. The 
 joint should never be immobilized, and no brace of any kind should be apjdied, 
 as fixation of the articulation will almost certainly cause the formation of dis- 
 abling adhesions. Hypnotic suggestion has been found curative in certain 
 cases. 
 
SURGERY OF JOTXTS. 415 
 
 SECTION IV.— NEURALGIA OF JOINTS, 
 Neuralgic pain in a joint may be due to constitutional or to local causes — i. e. 
 to disease of the brain or spinal cord; to neurasthenia; to malaria; to syphilis; 
 to nerve injury; to pressure upon the main trunk high up or upon branches 
 near the articulation by a tumor or an inflammatory new growth ; to affection 
 of organs more or less remote, as in the hip in cases of uterine or ovarian 
 disease. Like similar pain elsewhere, it is intermittent and variable in 
 intensity, and is unassociated with any apparent permanent change in the 
 articular or periarticular structures. It is to be treated in the ordinary way, 
 by improvement of the hygienic surroundings, by regulated exercise, and by 
 the therapeutic or operative removal of the existing cause. In a few cases it 
 has been asserted that there has been a neuralgia, generally located in the knee, 
 so intense and so persistent that it could be relieved by nothing short of nerve- 
 stretching, neurectomy, or amputation. It may well be questioned if some or 
 even all of these cases were not really hysterical aff"ections instead of arthralgias. 
 Occasionally peripheral neuritis consequent upon traumatism, the pressure of 
 a tumor, or' disease of bone has given rise to arthritis that has ended in anky- 
 losis and deformity. 
 
 SECTION v.— WOUNDS AND INJURIES OF JOINTS. 
 
 Wounds of joints are of two classes, non-penetrating and penetrating. The 
 former are of little importance as long as they do not suppurate, but when they 
 suppurate there is danger of extension of the inflammation to the joint. If 
 attended with loss of substance, the resulting cicatricial contractions may more 
 or less interfere with articular movements. However slight such a wound may 
 be, it is wise to stop all motion of the joint, to clean and close the opening; 
 and to apply an antiseptic compress. In a few days complete repair may be 
 expected. 
 
 Penetrating ivoiinds, on the other hand, are always serious accidents. If 
 they are properly treated recovery follows in a large proportion of cases ; if 
 improperly treated or neglected they are almost certain to result in local destruc- 
 tion, not seldom in loss of life. Aside from compound dislocations and com- 
 plicated fractures, which are considered elsewhere, they are generally produced 
 by gunshot, by stabs, or accidentally by tools of trade. In a few cases in 
 originally non-penetrating injuries communication with the joint is established 
 later, often through a bursa. 
 
 The symptoms vary according to the nature of the vulnerating body, 
 the joint opened, and the extent of the injury, though there will be always 
 observed a discharge of synovia more or less mixed with blood, and in a 
 short time swelling of the parts from hemorrhage and intra-articular eff"usion. 
 The discharge of synovia in small quantity, however, is not pathognomonic, 
 since it may come from an unconnected bursa ; but if synovial fluid to any 
 considerable amount is poured out, penetration of the joint should be accepted 
 as a fact. In large wounds the articulating surfaces can be seen or felt. 
 Pain and bleeding are always present in greater or less degree, but are not 
 indications of penetration, as they are equally associated with wounds that 
 do not open the cavity. If protected from septic infection, the opening in the 
 capsule readily closes, the efl'used serum and extravasated blood are absorbed, 
 the synovitis quickly subsides, and recovery takes place with little or no impair- 
 ment of the functional value of the part, though some weakness and a slight 
 restriction of motion are apt to continue for a time. When such a wound is 
 
416 AN AMERICAN TEXT- BOOK <)E SURGERY. 
 
 made by an unclean instrument, or if at any time before healing it becomes 
 septic, the symptoms are very different and the prognosis is grave. By the 
 end of about the third or fourth day after the receipt of the injury, or at such 
 period as infection of a primarily aseptic wound may occur, the symptoms of 
 suppurative synovitis, already described, become manifest. If promptly and 
 vigorously treated, the joint may and generally will be saved, though prob- 
 ably in a decidedly damaged condition. It is not in the fact that the wound 
 involves an articulation, but in the risk of its becoming septic, that the great 
 danger lies. Here, as elsewhere, every effort must be directed toward prevent- 
 ing this occurrence. 
 
 By far the most dangerous of the joint wounds are those produced by 
 gunshot. In military surgery until recently, whether the articulation was 
 extensively crushed by the passage into or through it of a large ball or piece 
 of shell or opened by Assuring of the extremity of the wounded bone, unless 
 amputation or excision was primarily performed a suppurative arthritis was 
 developed within forty-eight or seventy-two hours, and quickly proved fatal, 
 or was recovered from only after weeks or months, and that with a greatly 
 damaged limb. When only the joint was injured there might be produced an 
 articular empyema, or the pus, travelling along the connective-tissue planes or 
 the tendon-sheaths, widely infected the soft parts. How far under the peculiar 
 circumstances attending the receipt and early treatment of joint wounds in 
 war it may be possible by "first aid'' and after antiseptic treatment to pre- 
 vent such wounds from becoming septic is a question as yet unsettled, though 
 the limited experience of a few surgeons in late wars renders it highly probable 
 that very much may be accomplished. 
 
 But in civil life, in which the wounds are commonly produced by pistol- 
 balls, it has been clearly shown that under proper treatment the joint injury 
 in the great proportion of cases may be conducted to a safe termination, even 
 to the extent of preservation in large measure of the articular movements. 
 
 Treatment. — Such a wound should never be examined with dirty fingers 
 or a dirty probe. The track of the ball and the probable extent of the damage 
 done should be determined only with an aseptic instrument or a thoroughly 
 cleaned finger. As a rule having very few exceptions, a piece of cloth carried 
 in with the ball can be detected only by the finger, and the presence of such a 
 foreign body is almost absolutely certain to infect the wound. The opening 
 and the track being enlarged if necessary, all foreign bodies and all com- 
 pleted detached pieces of bone should be removed and the wound carefully 
 disinfected as after compound fractures. A drainage-tube should then be intro- 
 duced, through and through drainage being secured if required. Antiseptic 
 dressings should then be applied and the joint immobilized. "When the bone 
 injury has been so extensive as to necessitate operation, atypical rather than 
 typical resection should be done. 
 
 As in the larger wounds in war, so in the smaller ones in civil life, the fate 
 of the part if not of the wounded man himself is in the hands of him who first 
 sees him ; in other words, if septic infection is prevented a good recovery may 
 be expected. If the wound becomes septic the cavity and the suppurating 
 tracks about must be opened up and thoroughly cleaned, sequestra removed as 
 they become separated, and proper general treatment pursued. Ankylosis 
 of the joint, frecjuently complete, is the ordinary termination if part and life 
 are saved. 
 
 Sprains. — By far the most common joint injury is sprain. This is pro- 
 duced bv a sudden wrench or twist of the articulation, and is experienced most 
 frequently in the ankle and wrist, in the former because of a misstep or a fall 
 
SURGERY OF JOTXTS. 417 
 
 upon tilt' ioot, ill thelatterbecauseof a fall iiix.ii the hand. Its degree may vary 
 from that wliieh is so sliglit tliat its eifects (|uickly subside to tliat which is asso- 
 ciated with luxation or fracture or both. The line of disidaceiiient may pass 
 through any section of the investing capsule, according to the mode of produc- 
 tion of tlie injury, but it most often is through that part in which motion is 
 physiologically least : hence in the hinge-joints it is lateral. By the abnormal 
 movement the synovinl membrane is unfolded on one side and compressed on 
 the other, and when the normal limit of such cliange is reached the membrane 
 is torn and crushed. The ligaments, though their fibers cannot stretch, do 
 elont^ate somewhat as a change is produced in their structural reticulations (as 
 illustrated in the Indian puzzle), but the limit is quickly reached, and further 
 extension produces laceration. The degree of tearing varies according to the 
 severitv of the wrench, from that of only a few fibers to that of the entire liga- 
 ment, to its detachment from the bone, to the production of fracture or disloca- 
 tion, and to rupture of distant muscles. Laceration of the vessels and slight or 
 extensive hemorrhage into the joint-cavity, the meshes of the articular structures, 
 and the connective tissue outside necessarily occur. Intra-articular extravasa- 
 tion to any considerable amount is indicative of severe injury and adds greatly 
 to the gravity of the case. The accident is most common in young and middle- 
 aged adults, is most likely to affect a joint that has previously been sprained, 
 and is much more easily produced in a deformed limb or one in which the mus- 
 cles are feebly developed and the ligaments relaxed ; hence its frequency in the 
 weak-ankled. 
 
 The symptoms are well marked, the only question, as a rule, being 
 whether or not the case is a simple sprain or whether there is an existing luxa- 
 tion or, more often, fracture. Pain is instantly produced, and is always severe. 
 Not very rarely the patient faints. After the first sharp attack there occurs 
 a period of comparative ease, followed, either quickly or more commonly 
 after the lapse of some hours, by a return of suff'ering. due to tension and in- 
 flammation. Before long the parts become swollen. If there is much hemor- 
 rhage into the joint-cavity, the fulness may be observed within a very short 
 time, but ordinarily only after a few hours ; it is then due in part to extravasa- 
 tion, but chiefly to efi'usion into the cavity of the joint and the periarticular 
 structures. The swelling is especially noticeable in those parts of the articula- 
 tion in which there is least pressure exerted by tendons and ligaments. Move- 
 ment of the joint is arrested either wholly or in large measure. If the ankle or 
 the knee is affected the patient cannot walk at all, or can walk only with a limp. 
 After a time, usually several days, subcutaneous extravasations are seen, wdth 
 resulting color-changes in the skin. If in a hinge-joint a lateral ligament has 
 been completely torn across, the gap may commonly be felt, and an abnormal 
 movement of the joint can always be effected. Laceration of a muscle can be 
 detected by touch, as also can a fracture with or without separation of the frag- 
 ments, as in the lower end of the radius or through a malleolus. In the ankle, 
 as pointed out by Callender, " sprain fracture " may occur. This is a fracture 
 of a part of the articular surface. Its existence cannot be discovered by touch. 
 This accident explains many of the cases of ankylosis of the ankle following 
 what is apparently a mere sprain. 
 
 The prognosis varies with the joint affected, the extent of damage done, 
 and especially the promptness and efficiency of treatment. When there has 
 been a large hemorrhage into the cavity, blood-clots often remain for a consid- 
 erable time; occasionally their organization and fusion with the adjacent syno- 
 vial membrane result in adhesions which decidedly restrict the after movements 
 of the joint. 
 
 27 
 
418 AN AMERICAN TEXT- HOOK OF SURGERY. 
 
 The treatment has for its object, as far as possible, tlie prevention ortlie 
 limitation of the inflammation in and about the joint. In the niihler cases rest, 
 with cold or, much better, hot applications, may be all that will be re({uired. 
 Compression is of decided service, a layer of cotton or wool being wrapped 
 around the joint and held in place by a moderately tight bandage of flannel or 
 rubber. After the active inflammation has subsided, massage is of great value, 
 and its early employment is advised by many surgeons. Free active and pas- 
 sive motion of the joint from the first, as has been strongly advised by some, 
 is painful, and cannot be otherwise than injurious when the sprain is a severe 
 one. By far the best treatment, as a rule, is immobilization of the joint by 
 the application of a plaster-of-Paris bandage. If applied soon after the acci- 
 dent has occurred, it will very much lessen congestion, hemorrhage, and effu- 
 sion, and diminish the time of confinement. If there has been a large amount 
 of blood poured out into the joint, it should be withdrawn through an aseptic 
 aspirator needle before the dressing is applied. One great advantage of this 
 method of treatment is that it will permit of the patient's going about and 
 attending to business if necessary — on crutches if the sprain is of the knee or 
 the ankle, Avith the arm in a sling if the affected joint is of the upper extremity. 
 Immobilization applied at once and maintained for a number of weeks, espe- 
 cially if the patient is kept quiet and the limb elevated, will in great measure 
 prevent the occurrence of the weak, swollen, painful, and crippled condition of 
 the joint that so often follows a severe sprain treated in other ways. Even if 
 there has been a fracture or a dislocation, this method of treatment is the best 
 that can be employed. 
 
 Ankylosis. — As the result of cicatricial contractions of new-formed granu- 
 lation-tissue in and about a joint, its motions are restricted, and the articulation 
 is said to be ankylosed. Limitations of movement due to loss of substance in 
 the skin and underlying soft parts consequent upon severe injuries, or due to 
 contractions of muscles and tendons, are not, properly speaking, cases of anky- 
 losis, though they are at times associated with the ankylosing effects of articular 
 and periarticular inflammation, and, it may be in marked degree, increase the 
 disability due to such inflammation. 
 
 That ankylosis may be produced, there must have been (1) a blood-clot adhe- 
 rent to the folds of the synovial membrane which later has become fused with 
 them ; or (2) the organization of an exudate within the joint commonly attached 
 to eroded parts of the articular cartilage, though at times deposited only in an 
 interosseous ligament; or (3) similar change in an exudate in the subsynovial 
 and interligamentous connective tissue ; or (4) degeneration of ligaments, with 
 after-contraction of the substitution granulation-tissue and the formation of 
 adhesions to the adjacent parts; or (5), what most often occurs, a combination 
 more or less extensive of two or more of these conditions. Until a few years 
 ago it was believed that simple disuse of a joint would be followed by ankylosis, 
 but this is now known to be an error, at least as to the larger joints. Without 
 inflammation of some form or other, ankylosis cannot take place. The restricting 
 band or bands may be of limited extent outside the cavity and of considerable 
 length within, or they may be very extensive in and about the capsule and very 
 short between the ends of the bones. The inflammation may terminate, as it 
 commonly does, in the formation of fibrous tissue, or may go on to ossification, 
 partial or complete. When the latter change has taken place within the joint- 
 cavity, where osseous union is generally found, there must have been a prior 
 opening up of the cancellous tissue of both the articulating bones. If the bone 
 deposit is external, it may occupy the place of a degenerated ligament and adja- 
 cent connective tissue, having started from the periosteum and passed over the 
 
SURGERY OF JOINTS. 
 
 419 
 
 Fig. 171. 
 
 joint as a natural splint altogetlior preventing any movement ; or it may be in 
 patches, larger or smaller, in the parts outside the synovial membrane. 
 
 According to the degree of organization of the new-formed tissue, ankylosis 
 IS fibrous or bony ; as respects the extent of restriction of movement, it is ^;ar- 
 tial or complete. 
 
 Except when, as after certain fractures and in cases of osteo-arthritis, the 
 ankylosis is due to displaced fragments and stalactitic outgrowths, or when there 
 has been but a limited bone deposit in the periarticular structures, bony anky- 
 losis is a complete one. It is not, however, by any means always associated 
 with entire obliteration of the joint-cavity, for, as has already been stated, 
 there may be only an outside bridge ; and when the union is an internal one 
 very often there will remain for years or through a long life a small synovial 
 cavity. The fusion of the articulating bones is seldom so complete that the 
 line of junction is not recognizable on section, but occasionally it is impossible 
 to find where one bone ends and the other begins, even the medullary cavities 
 being so directly continuous as to constitute but a single one. 
 
 Bony ankylosis is commonly a termination of septic (often an osteo-myelitic) 
 or tubercular inflammation, while fibrous ankylosis, which may be met with after 
 any form of joint inflammation, is very generally due to a traumatic, a gonor- 
 rheal, or a rheumatic arthritis. 
 
 In the fibrous variety the adhesions may be so extensive and short as prac- 
 tically to prevent all motion at the joint, or so lax as to interfere but little with 
 the ordinary movements ; or, as is more commonly the case, they may be sufficient 
 decidedly to limit the use of the limb. In the cases in which this variety most 
 strongly resembles the bonv, even when motion 
 at the articulation cannot be recognized, its 
 fibrous nature is proved by the pam attending 
 manipulations and the manifestation within 
 a fcAV hours of the symptoms of irritation or 
 inflammation, especially a local rise of tem- 
 perature. 
 
 The ill effects of an ankylosis are propor- 
 tionate to the resulting interference with the 
 physiological use of the joint ; they depend, 
 therefore, not only on restriction of motion, 
 but also, and to a greater extent, on the an- 
 gle of fixation. A knee completely anky- 
 losed in the straight position is much better 
 than one held in permanent flexion or one 
 which is movable and yet cannot be fully ex- 
 tended (Fig. 171). An ankylosis of the elbow 
 that prevents the forearm from being flexed 
 at a riorht anjile with the arm is much more 
 crippling than one in which extension cannot 
 be carried beyond a right angle. At the 
 shoulder, ankle, and hip loss of motion is 
 often compensated in a great measure by the 
 free movement of the scapula, at the knee, 
 and at the sacro-iliac junction respectively. AVhen ankylosis occurs in a young 
 child more or less interference with the after-growth of the bone may be expected. 
 
 The treatment will depend upon the variety, the angle, and the joint 
 affected. When the nature and extent of an articular inflammation make it 
 probable that ankylosis will occur, such inflammation should be limited as 
 
 Angular Ankylosis nf the Knee 
 (Bradford aiiil Lovett). 
 
420 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 mucli ;is possible, especially by rest : c.iro, liowever, must ])o taken not iiiiduly 
 to prolon<^ innnobilizatioii, particularly in cases of rhcunnitic origin, in Avhich 
 after a time regular passive motion should be made. In certain fractures, nota- 
 bly those about tiie elbow, it has been advised by many practically to disregard 
 the fracture after a few days, and by passive motion prevent the joint from liecom- 
 ing stiff; but it is better to treat the fracture in the ordinary way, remembering 
 that immobilization most thoroughly limits inflammation, and that the adhesions 
 are duo to inflammation. Both at the elboAV and at the knee (after fractui'e of 
 the patella) a resulting flbrous ankylosis, if forcibly broken u]), will commonly 
 be (juickly reproduced, hut with active use of the joint will generally spon- 
 taneously disappear in the course of a few months or at most in a year or two. 
 When the ankylosis is bony and the position a good one, no treatment should 
 be pursued, unless it be at the elbow, where by excision, partial or complete, a 
 serviceable movable joint may often be secured. When the angle is a vicious 
 one, excision should be done or the malposition corrected by osteotomy ; at the 
 hip the latter is much the preferable ojjeration. Forcible breaking down of 
 bony adhesions should never be done ; destructive inflammation of the part is 
 very likely to follow, the original disease having been almost certainly septic or 
 tubercular ; and if it does not, the surfaces will unite again by bone. 
 
 By massage, by frictions, by baths, by regulated movements, by the use 
 of electricity, especially by massage and movements, much may be accomplished 
 in the removal of periarticular exudations and adhesions. 
 
 But in the majority of cases a fibrous ankylosis will require for its removal 
 either a forcible rapid breaking up of the adhesions and straightening of the 
 limb or a slowly-effected correction of the deformity by continuous or inter- 
 mittent traction, by weight-extension, or by apparatus. As a rule, the former 
 method is to be preferred. If the tendons about the joint are contractured, 
 they should be divided a few days before the straightening is to be done, so 
 that the little wound of the skin may be entirely healed, as otherwise it may 
 be a starting-point for an extensive laceration. Very generally the tendons 
 are only contracted, and that more apparently than really, and will yield readily 
 enough when the limb is extended. When it is the knee that is the seat of 
 the difficulty, as is so often the case, the patient may be upon his back or 
 prone; in the latter position leverage can more readily be exerted. The limb 
 being grasped above the ankle and above the knee, firm, steady movements in 
 flexion and extension are to be made until the leg can be fully and easily 
 extended upon the thigh, Avhen the whole limb is to be enveloped in cotton and 
 immobilized by plaster of Paris, the dressing being kept on for two or better 
 for three weeks. During the straightening the rupture of the adhesions can 
 be both felt and heard, ^fhe operation is usually free from danger and folloAved 
 by little or no local or constitutional disturbance. 
 
 But accidents, and serious ones, may occur. The main vessels may have 
 become shortened and adherent, and may be ruptured when the limb is straight- 
 ened; or there may be laceration of one of the ])0])liteal nerves, with result- 
 ing paralysis; or the skin and adherent fascia may be extensively torn ; or long- 
 encapsulated pyogenic cocci may be set free and develop extensive suppuration 
 in the leg or thigh. No one of these accidents is to be expected ; any one of 
 them may happen. Because of the danger of setting free the infecting organ- 
 isms and producing destructive inflammation of the joint and structures out- 
 side, forcible breaking up of ankylosis following either septic or tubercular 
 disease should not be done. By the employment of weight-extension or by an 
 apparatus permitting of a gradual widening of the abnormal angle the deformity 
 can usually be corrected after a time. 
 
SURGERY or .lOTNTH. 
 
 421 
 
 Nodules of Fibro-carlilages, 
 some attached by elongated 
 pedicles and some loose 
 (Cruveilhier). 
 
 SECTION VI.-LOOSE BODIES IN JOINTS. 
 Loose bodies sometimes occur in the larger joints, in nine cases out of ten 
 in the knee. Thev consist of fibrous, bony, or cartilaginous tissue or a mixture 
 of them. So commonly are they cartilaginous that they are otten called by 
 the general name of "floating cartilages." They are 
 sometimes free in the cavity of the joint, orlessjrequently 
 attached by a long or a short pedicle (Fig. 1T2). (Occa- 
 sionally they are multiple, but more commonly there are 
 only one, two, or three. In size they vary from that of a 
 pea or bean up to that of the last joint of the thumb. 
 When multiple they are usually very small. They arc 
 developed in several ways, originating (T) from villous 
 outf^rowths from the synovial membrane, wliich are more 
 and°more crowded off from the surface, the contained car- 
 tilage-cells growing, and after a time often ossifying in the 
 center; (2) from detached osteophytes of osteo-arthritis ; 
 (3) from outgrowths from the articular cartilage ; (4) from 
 detached pieces of cartilage, with or without a bony sub- 
 stratum, which have been separated either by sudden vio- 
 lence or slowly by " quiet necrosis ;" (5) from blood-clots, 
 either in the cavity itself or much more probably in the sy- 
 novial villi ; (6) from fibrin poured out in an acute inflam- 
 mation, or, much more often, in a rheumatic subject, over 
 a limited space under the synovial membrane, which it 
 pushes inward until pedunculation and later separation of the nodule take place; 
 (7) from overc^rowth of the cartilage-cells normally contained in the synovial 
 membrane; (8) from detached tuberculized fringes or small parts of the infectea 
 membrane. The first is by far the most common origin, the others being rare, 
 most of them (3, 5, 6, 7) very rare. By many it has been denied that the 
 floating cartilage ever is a piece chipped off the articulating end of the bone, 
 but sufficiently numerous specimens prove that this accident occasionally occurs. 
 However produced, they usually undoubtedly follow traumatism, which is 
 often sli^^ht, or else are associated with a rheumatic or osteo-arthritic diathesis. 
 They are found in adults under middle age as a rule, and m men far oftener 
 than in women. When very small and numerous they are not usually attended 
 by other symptoms than those of chronic arthritis. When there are but one 
 or two, and these of considerable size, they demand treatment because of the 
 pain and disability produced by them. Occasionally by pressure they produce 
 absorption and erosion of the bony surface with which they are in contact. 
 
 Symptoms.— Sooner or later the presence of such a body is followed by 
 a sli-ht weakness and fulness of the joint, the patient at times feeling the 
 nodule at various parts of the joint, oftenest in the neighborhood of the pate la. 
 Occasionally the cartilage will be caught somewhere between the femur and the 
 tibia. Instantly pain is experienced, so intense, it may be, as to cause nausea 
 and faintin-. Motion of the joint is arrested, and the patient perhaps falls. 
 The inabilitV to flex or extend the joint continues until the loose body is dis- 
 lodged by various movements. Moderate or often considerable effusion into 
 the'ioint-cavity soon occurs, but is quickly absorbed, the joint then resuming 
 its previous condition. Similar attacks follow one another with increasing f^^- 
 quencv, and after each the recovery is progressively es.s complete, until finally 
 the effusion becomes permanent, and the joint is markedly weakened. 
 
 The diagnosis is, as a rule, easy. A small body which shps away from 
 under the finger can be detected first in one and then m another pai't of the joint. 
 
422 AN AMERICAN TEXT- HOOK OF SURGERY. 
 
 "When it cannot be felt its presence can only be inferred from the .siuhh-n 
 attacks of disability. The only affection witji which it can be confounded ia 
 the so-called " internal deran<,'enient of the knee-joint," which is caused bv the 
 slipping or dislocation of one of tiie semilunar cartilages. 'J'his also causes a 
 sudden, intensely painful arrest of motion at the knee, followed by acute syno- 
 vitis ; but the joint is more likely to be held in the locked condition, and after 
 the effusion has subsided an irregularity can usually be detected just above the 
 border of one of the tuberosities of the tibia. This is the edge of the semi- 
 lunar cartilage, dislocated forward or backward. 
 
 Treatment. — When such a sudden attack of pain and disability occurs, 
 the loose cartilage nuist l>e displaced by forced flexion and extension at the 
 knee, under an anesthetic if necessary, after which the joint should be immo- 
 bilized for a number of days. The only radical treatment is removal of the 
 loose body by opening the joint. Modern antiseptic methods have made the 
 operation a perfectly safe one, in marked contrast to the ver}^ serious results 
 which formerly followed the opening of this joint. The loose" body is first to 
 be fixed, if possible, either by the fingers or by a steel pin thrust into it, often 
 a procedure of great difficulty owing to its density. An incision is then made 
 directly into the joint, as near the cartilage as possible. This is pressed out, 
 or if any difiiculty is experienced the finger or a blunt hook or forceps is 
 passed into the joint and the cartilage seized. The edges of the wound in the 
 synovial membrane are to be united by buried catgut sutures, and the cutaneous 
 wound is closed and dressed as usual. The leg should be immobilized either 
 by a plaster-of-Paris dressing or a splint. 
 
 SECTION VII.— DISPLACED SEMILUNAR CARTILAGE. 
 
 This has long been termed "internal derangement of the knee-joint," 
 but is now known to be due to the slipping or displacement of one of the semi- 
 lunar cartilages, mo.st frequently the internal. It may occur in health, the 
 coronary ligament being torn away ; but it is commonly associated Avith chronic 
 synovitis or osteo-arthritis, in which diseases the attachments of the cartilages 
 are relaxed and more easily torn. The cartilage may be merely slipped between 
 the ends of the bones, or it may be rolled upon itself and entirely detached 
 from the tibia. Having once occurred, the accident is liable to be freijuently 
 repeated. 
 
 The symptoms are sudden and severe pain, with inability to stand or 
 walk, the leg being partially flexed and the joint locked. Swelling follows 
 quickly, but subsides after displacement of the cartilage. When the luxation 
 has occurred ftxMjuently, however, the effusion is more permanent and the limb 
 weak. 
 
 Treatment. — At the time of the accident replacement of the cartilage is 
 effected by flexion and extension with rotation of the knee, if necessary under 
 an anesthetic. Sometimes the patient will execute this maneuver himself bet- 
 ter than the surgeon. Occasionally replacement is impossible. When the 
 cartilage has been replaced the joint quickly resumes its normal condition, an 
 elastic knee-cap being often employed to steady and assist it. If the disability 
 is very great or reduction impossible, the joint should be opened and the 
 cartilage seized and Ijrought back to its normal position, where it should be 
 fixed by sutures carried through the periosteum of the tuberosity. It has been 
 removed with excellent functional results. Absolute asepsis is re(iuir('(l. 
 
DISL OCA TJOX^. 423 
 
 CHAPTER VIII. 
 DISLOCATIONS. 
 
 Defixitioxs. — A dislocation is a ])ennanent, abnormal, total, or partial 
 displacement from each other of" the articular portions of the bones entering 
 into the formation of a joint. 
 
 A temporarji displacement, followed immediately by a return to place, con- 
 stitutes a sprain. 
 
 When the oj)posin(^ articular surfaces are completely separated or touch each 
 other only by their edges, the dislocation is complete; lesser forms of displace- 
 ment are termed partial or incomplete, or subluxations. In the ball-and- 
 socket joints the dislocation is said to be complete Aviien the center of the 
 globular head rests outside the rim of the concave socket. 
 
 A coexisting wound of the soft parts that establishes communication between 
 the outside air and the cavity of the joint makes the dislocation compound ; 
 and the coexistence of other important lesions that seriously affect the treat- 
 ment and prognosis makes it complicated. 
 
 When the corresponding joints of a bone symmetrically placed on both 
 sides of the median line of the body, as the lower jaw or a vertebra, are dislo- 
 cated, the dislocation is said to be bilateral. It is total when both ends of a 
 bone, as the clavicle, are dislocated, or when a small bone having several joints, 
 as a carpal or a tarsal bone, is widely displaced. Dislocations are double when 
 symmetrical on both sides of the body, as of both shoulders. Dislocations are 
 said to be multiple when two or more bones are simultaneously dislocated, as 
 two or more fingers, a shoulder, and a hip. Both these last two terms are some- 
 times used in the sense of total. 
 
 Ordinarily a dislocation is traumatic, and occurs abruptly in a normal joint 
 as the result of external violence or of the sudden contraction of the patient's 
 muscles upon the bones forming the joint, but occasionally it takes place grad- 
 ually (or suddenly) without recognizable violence in joints that have been so 
 altered by disease as to facilitate the displacement ; such dislocations are com- 
 monly known as spontaneous or patholoyieal. Congenital dislocations are 
 those that occur during intra-uterine life, and are usually the result of defect- 
 ive development. 
 
 Nomenclature. — As a general rule, the distal member of the joint is the 
 one said to be dislocated ; thus we speak of a dislocation of the humerus, and 
 not of the scapula, when the scapulo-humeral joint is dislocated; an almost 
 universal exception to this rule is the term dislocation of the outer end of the 
 clavicle, used instead of dislocation of the acromion or of the scapula. Some- 
 times the name of the joint or of the region is used, as dislocation of the 
 shoulder, hip, elbow. Terms indicating direction correspond to the change in 
 the position of the distal segment of the joint, as backward dislocation of the 
 elbow, meaning that the upper ends of the radius and ulna ai-e displaced back- 
 ward. Special names indicative of the new relations of the displaced bones 
 are applied to some of the commoner varieties, as subcoracoid dislocation of 
 the shoulder, iliac or dorsal dislocation of the hip. 
 
 Statistics. — Dislocations are less frequent than fractures in the proportion 
 of 1 to 10 ; {hose of the shoulder are the most frequent, those of the elbow 
 
424 AX A.VFJUCAX TEXT-IIOOK OF SURGERY. 
 
 next. Tlio |)i()))Ovtioiis vary in diftercnt statistics, but in general terms it may 
 be said that dislocations of the shoulder consUtutc from one-half to two-thirds 
 of all dislocatio)is. 
 
 Age. — Dislocations may occur at any age from the very moment of birth ; 
 the absolute frequency is greater between the ages of twenty and thirty ; the 
 relative frequency, computed according to the number of people living at the 
 different ages, is greatest in the three decades between forty and seventy. 
 Below the age of twenty years dislocations of the shoulder are rare, those of 
 the oll)ow frequent; above that age those of the elbow are rare, those of the 
 shoulder frequent. It has been pointed out that dislocations of the elbow are 
 produced in childhood by the same violence — i. e. falls upon the outstretched 
 hand — that produces fracture of the humerus in adults, and dislocations of the 
 shoulder in adults by that which produces fractures of the clavicle in children 
 — i. e. falls upon the shoulder. 
 
 ETIOLOGY AND MECHANISM. 
 
 The causes are {a) pj'edisposing, and (b) immediate or detei-mining. 
 
 (a) Predisposing Causes. — Normal predisposing causes are found in the 
 conformation of certain joints which diminishes the area of contact of the 
 opposing ai-ticular surfaces in certain positions or establishes conditions of lev- 
 erage favorable for the rupture of opposing ligaments, as in hyper-extension of 
 the elbow ; or which avoids the opposition of ligaments, as in the movement 
 forward of the condyles of the lower jaw; and also in the greater exposure of 
 certain joints to external violence. Normal freedom of motion is more of a 
 protection against dislocation than a predisposing cause thereto, because the 
 necessary rupturing strain is not ordinarily put upon the opposing ligaments 
 before the limit of motion has been reached. A predisposing cause at the 
 elbow is found in the outward deviation of the forearm from the long axis of 
 she arm. Pathological predisposing causes are distention of the joint by an 
 effusion, destruction or softening of the ligaments by violence or disease, and 
 the fracture of bony processes or of one of a pair of parallel bones. 
 
 {h) Immediate or Determining Causes. — These are external violence 
 and muscidar action. External violence may be exerted directly upon the end 
 of the bone that is displaced, as in a dislocation of the head of the humerus by 
 a fall or a blow upon the prominent part of the shoulder; or indirectly through 
 and parallel to the shaft of the bone; or in a more complex manner by moving 
 the limb beyond the normal limit of the range of motion, so as to rujjture the 
 ligaments, and then forcing the liberated bone out of its place. 
 
 Muscular action dislocates by communicating a momentum to the limb 
 which acts in the same manner as external violence when the limit of the 
 range of motion is reached, or by acting directly upon the end of the bone 
 to draw it out of its socket. Thus a woman dislocated her shoulder by raising 
 her arm quickly to strike a blow, a man dislocated both shoulders by drawing 
 himself upward by his hands, another by raising his arm to paint a ceiling, 
 others during epileptic convulsions; dislocation of the lower jaw may be pro- 
 duced by yawning. Some individuals can voluntarily dislocate certain joints 
 by the contraction of certain muscles or groups of muscles ; in others a lia- 
 bility to dislocation of some one joint by slight causes exists (recurrent or 
 habitual dislocation) as the result of a primary traumatic dislocation, or of the 
 paralysis of certain muscles, or of other pathological conditions. 
 
DISL O CA TIONS. 425 
 
 PATHOLOGY OF RECENT DISLOCATIONS. 
 
 Except in very rare instances, one or more of the ligaments of a joint and 
 its capsule are torn during a dislocation; in the ball-and-socket joints the rent 
 in the capsule is on the side toward which the round head of the distal bone is 
 displaced ; in other joints the ligaments on either side or on both sides may be 
 torn, the position and extent of the injury varying with the mode of production 
 and the range of displacement. There is reason to think that both the capsule 
 and the ligaments escape rupture in the simpler dislocations of the lower jaw, 
 and a few^ cases have been reported in which those of the shoulder have similarly 
 escaped. In joints relaxed by paralysis of the corresponding muscles or by 
 an effusion within the capsule, dislocation habitually occurs without laceration. 
 
 Attached muscles that are put upon the stretch may be ruptured or torn 
 from their attachments, perhaps bringing Avith them in the latter case the scale or 
 apophysis of bone to which they are attached. Opposing prominences of bone 
 or portions of a prominent articular edge or rim may be broken off, as the cor- 
 onoid process of the ulna or the edge of the head of the radius in a backward 
 dislocation of the elbow, or the rim of the glenoid or cotyloid cavity. One 
 articular surface may be deeply indented by impact against the edge of the 
 other surface. 
 
 Associated injuries of adjoining parts may exist as complications. 
 The shaft of the dislocated bone or of a parallel bone may be broken ; the 
 dislocated end may be split ; the neighboring blood-vessels or nerves may 
 be ruptured or bruised; adjoining organs may be lacerated or compressed; 
 the soft parts and the integument may be torn. Fracture of the shaft or of 
 the neck of the dislocated bone may constitute a serious, perhaps an insurmount- 
 able, obstacle to reduction, because of the difficultv of communicating the 
 necessary movements to the dislocated end ; the commonest example is frac- 
 ture of the surgical neck of the humerus in combination with dislocation of 
 the shoulder. Fracture of the articular end of the dislocated bone is rare, 
 although there is reason to think that limited bruising of the head of the 
 humerus by impact against the edge of the glenoid fossa is not very uncom- 
 mon. Partial fracture of the rim of the socket of an enarthrodial joint or 
 avulsion of an apophysis is common, and does not ordinarily constitute an 
 important complication. Rupture of neighboring blood-vessels is most frequent 
 at the shoulder, where it usually consists in rupture or avulsion of the subscap- 
 ular or circumflex artery. Of injuries of nerves the most common is that of 
 the posterior circumflex at the shoulder. At the knee and the elbow the main 
 arterial, venous, and nerve trunks are occasionally torn. Injuries of adjoining 
 viscera are rare. In backward dislocation of the sternal end of the clavicle 
 the trachea or oesophagus is sometimes pressed upon ; and in one reported case 
 the dislocated humerus Avas forced through the wall of the chest, the bone retain- 
 ing its new' position and the patient surviving many years. 
 
 In uncomplicated cases reduction is habitually followed by repair of 
 the torn capsule and ligaments, but complete restitution to the normal condition 
 may be prevented by faulty repair of some of the lesions, by periarticular 
 thickening, by subperiosteal formation of bone in the young, or by more or 
 less persistent sensitiveness of the joint. Thus at the shoulder the ruptured ten- 
 don of the supraspinatus and the upper part of the capsule may fail to reunite, 
 and the patient be thereby exposed to frequent recurrence of the dislocation, 
 or the fracture and retraction of the greater tuberosity may annul or weaken 
 the powder of active external rotation, or injury to the circumflex nerve may 
 result in more or less prolonged paralysis and wasting of the deltoid. At the 
 
42G 
 
 AX A.VERrCAX TKXT-IlOOk' OF SURGERY 
 
 Fkj. 17:^. 
 
 elbow the stripping up of the periosteum from the posterior aspect of the external 
 condyle may load to such thickcnina; of the bone as will limit extension. 
 
 In dislocations that remain unreduced the displaced and lacerated con- 
 nective tissue becomes thicken('(l and c(jndenscd about tiie head of the bone, 
 
 sometimes uniting directly with it. some- 
 times forming a new capsule al)out it 
 which is more or less broadly continuous 
 with the old one ; the torn ligaments and 
 muscles contract new adhesions which 
 serve to fix the bone in its new position 
 and limit its motion. The untorn por- 
 tion of the capsule is drawn across the 
 other articular surface (e. g. the glenoid 
 fossa), and, if the contact is close, unites 
 permanently with it ; if the contact 
 is not close, the cavity of the socket 
 fills up with fibrous tissue of new for- 
 mation. The dislocated head comes to 
 rest against an adjoining surface of 
 bone, and under the influence of its 
 pressure the bone and the periosteum are 
 stimulated to the production of new bone 
 about tiie point of contact, and thus 
 is formed a bony rim. a veritable new 
 socket, possibly covered Avith fibro-car- 
 tilage (Fig. 173). The ossifying process 
 may extend to the adjoining soft parts 
 and produce large and irregular masses 
 of bone continuous with one and possibly 
 with both of the members of the joint. 
 A very important feature is the occasional binding fast of neighboring large 
 vessels or nerves to the dislocated bone. The result of all these changes is 
 that the dislocated bone becomes permanently fixed in its new position, and its 
 return to its former one can be eflected only with lacerations similar to, and 
 usually much more extensive and serious than, those which accompanied its 
 first displacement; furthermore, the socket from which it Avas displaced has 
 been shut off" by the adherent capsule or filled up with new tissue. 
 
 Old Supracotyloid Dislocation of tlie Femur, with 
 very complete new acetabulum (Kninleiii). 
 
 SYMPTOMS. 
 
 Deformity, including in this terra changes in contour and attitude, is always 
 present, and is frequently so marked as to be almost diagnostic on inspection 
 alone. The one demonstrative sign of dislocation is the recognized presence 
 of the head of the bone in an abnormal positon ; and this sign should always be 
 sought for in preference to others that are less demonstrative, but perhaps more 
 easily recognized. It is obtained by palpation of the region, by systematic 
 exploration of the bony prominences, and by the identification of abnormal 
 prominences or of those abnormally situated, by means of gentle movements 
 communicated to the limb. Thus in the common anterior dislocation of the 
 shoulder the finger recognizes the absence of the normal bony resistance offered 
 by the head of the humerus beloAV the acromion in front, and finds a new one 
 below or to the inner side of the coracoid process. Avhich shares in rotatory 
 
DISLOCATIONS. 
 
 427 
 
 
 A' 
 
 Diagrams to show the effect of attitude \\\n>n the meas- 
 ured length of the arm (A) in dislocation of the right 
 shoulder, and (A') when the bones are in normal posi- 
 tion; B, W , the acromion (original). 
 
 moveraonts coiunmnii-atiMl to the anii ; and the surgeon also notes that the axis 
 of the limb if })roloiio;e(l upward passes throu<i:h this proniiiienee. 
 
 ^leaifureiiioitx. — Many eonfusing statements concerning shortening or 
 elongation of the limb in different dislocations have been made. Error may 
 arise through failure to place the compared limbs in symmetrical positions, con- 
 tradiction through the choice of different lines of measurement. It may be 
 positively stated that, -with one or two extremely rare exceptions, such as dis- 
 location forward of both bones of the forearm, s/iorteiihiq can always be found 
 if the measurement is made on the proper side and with the limb in a suitable 
 attitude. The proper side is the 
 
 one away from which the head of ■ Fir;. 174. 
 
 the bone has been dislocated : the 
 suitable attitude is the one in which 
 the limb is inclined toward this 
 side. Thus, at the shoulder the 
 measurement should be made from 
 the tip of the acromion to the ex- 
 ternal condyle of the humerus, and 
 the arm should be in abduction. 
 Fig. 174 illustrates the sources of 
 error and contradiction. A repre- 
 sents an anterior dislocation of the 
 right shoulder seen from in front ; 
 A', the same shoulder with the 
 bones in place. Measured in abduction, B C is shorter than B' C or B JJ 
 or B' D' ; measured with the arm alongside the chest, B I) h as long as, 
 perhaps longer than, B' I)' . 
 
 In typical dislocations, those in which certain ligaments and portions.of 
 the capsule remain untorn, the attitude of the limb is characteristic, because 
 of the limitation of movement imposed by the untorn bands : thus in the 
 common anterior dislocation of the shoulder the elbow is held away from the 
 side ; in the common dorsal dislocation of the hip the thigh is flexed and 
 adducted. 
 
 As the consequence of this opposition of the untorn ligaments, the normal 
 range of motion is restricted in certain directions while it is unaffected in others. 
 In the hinge joints the normal range of motion is restricted and abnormal 
 lateral mobility exists. The statement is frequently made that mobility is 
 increased in fracture and diminished in dislocation. In that form the state- 
 ment is entirely misleading : ordinarily the mobility that is found in fracture is 
 wholly abnormal and exists between two parts of the same bone; the mobility 
 whose absence or restriction is noted in dislocation is mobility between two 
 separate bones. Normal mobility may be restricted, both in fractures and in 
 dislocations, by the opposition of the muscles aroused by fear of pain. In 
 dislocation of the elbow^ backward abnormal lateral mobility exists, just as it 
 does in fracture of the lower end of the humerus. 
 
 The production of the dislocation is usually accompanied by severe pain^ 
 which may persist for some time or may promptly give place to a feeling of 
 soreue.ss, with pain when the member is moved or the region handled. Per- 
 sistence of severe pain appears to indicate that some of the soft parts are not 
 torn, but are kept forcibly stretched. 
 
 Treatment. — As a rule, a recent dislocation should be reduced at the 
 earliest practicable moment. The conditions which may make delay advisable 
 are great inflammatory reaction and swelling and great shock, due usually to 
 
42« 
 
 i.v A^fI:RI('Ay text-book of surgery. 
 
 7yf ^ 
 
 Piagram to show the effect of the position of a limb upon the tension 
 of a ligament (original'). 
 
 associated injuries, which may contraindicate the infliction of pain or the use 
 of anesthetics. 
 
 The choice of a suitable method of reduction (l(.'i)eiids upon the reco*'- 
 nition of tlie obstacles to reduction. In most cases these are of two kinds: 
 the contraction of the muscles, excited by pain or the fear of pain, and the 
 resistance offered by untorn ligaments or portions of the capsule to move- 
 ments of the limb in certjiin directions. Other obstacles are the interposi- 
 tion of a portion of the capsule, common in certain dislocations {e. g. 
 the metacarpo-phalangeal), but rare in others, and unusual relations to 
 certain adjoining muscles created by a wide movement of the dislocated 
 bone. 
 
 In "typical" dislocations, those in which the limb assumes and retains a 
 characteristic attitude, -which has been shown to be due to the action of untorn 
 ligaments or portions of the capsule in resisting movement in certain directions, 
 
 it is essential that the 
 ^^^- 1"'5- limb should be placed 
 
 in a position and moved 
 only in a direction in 
 which the opposition of 
 these untorn structures 
 will not be encountered. 
 Fig. 175 shows diagram- 
 matically the position 
 {A) in which the liga- 
 ment {L) opposes and 
 that (J5) in which it per- 
 mits the movement of 
 the- limb in the direction indicated by the arrow, and by which the head would 
 be restored to its socket (.V). In "atypical" dislocations the laceration of the 
 ligaments and capsule is .so extensive that they offer little or no opposition to 
 movement in any direction. In the typical forms, therefore, certain well-defined 
 manipulations are needed whether anesthesia is or is not employed to remove 
 the opposition of the muscles : in the atypical forms reduction is usually very 
 easy by moderate traction and coaptation, without special attention to the 
 attitude of the limb during the manipulation. 
 
 Reduction by manipulation is a term applied to a succession of gentle 
 movements communicated to the dislocated limb by which the sides of the rent 
 in the capsule are separated from each other and the head of the bone is rolled 
 back into place by the aid of the untorn ligaments. The method is applicable 
 only to typical dislocations, and the best-known examples are Kocher's method 
 for the reduction of anterior dislocations of the shoulder, and Bigelow's for 
 that of dorsal dislocations of the hip, the details and mechanism of which 
 will be described in the appropriate places. 
 
 The opposition of the muscles, by which is meant a persistent contraction 
 of those attached to the dislocated bone wliich prevents its movement toward 
 its socket, ma}" be annulled by anesthesia, or overcome by forcible or per- 
 sistent traction, or avoided by momentarily distracting the patients attention. 
 The use of anesthetics has made the reduction of most dislocations very easy. 
 It should be pushed to the point of complete muscular relaxation: this is some- 
 times obtained during the short period of primary anesthesia which usually 
 precedes by some minutes the condition of complete anesthesia, and in the 
 simpler cases reduction may be then obtained : but if the manipulations are 
 likely to be at all prolonged, or if the patient is feeble or diseased or suffering 
 
DISL O CA TIONS. 429 
 
 f'roiii sliock, it is safV-r to wait for complete general anesthesia. The proportion 
 of cases in wliich dcatli lias followed the use of an anesthetic in the reduction 
 of dislocations is exceptionally hu-ge, and seems probably to be due to its timid 
 and insufficient use ; the anesthesia not being complete, the reduction causes 
 dangerous shock by pain. Such, at least, appears to be the explanation of the 
 disproportionate fatality of minor but painful operations under an anesthetic. 
 Ether is safer tlian chloroform for the purpose. 
 
 The use of pulleys, which formerly was general, is noAV rare in the reduc- 
 tion of recent dislocations, having been replaced by anesthetics or by the pro- 
 longed application of moderate traction, the muscles yielding gra'dually to 
 fatigue. This gradual traction can be made by a weight and pulley or by- 
 india-rubber, or, in some cases, by the weight of the dependent limb in a suit- 
 able position. Even without anesthesia, if the attention of the patient be 
 diverted the muscles will sometimes be seen to relax, and then by a sudden 
 sharp blow the bone may be replaced. 
 
 In cases in which reduction is prevented by the interposition of a portion 
 of tiie capsule, as at the metacarpo-phalangeal joint, or of a muscle or 
 tendon, as occasionally at other joints, an open arthrotomy may be necessary. 
 Under the protection of antiseptics this operation is reasonably safe, but the 
 risk appears to be least, in the case of the larger joints, if it is done while the 
 injury is fresh, on the first or second day, or, failing this, if it is postponed to 
 a much later period, after the reaction has subsided and the extravasated blood 
 has been reabsorbed, about the third or fourth week. 
 
 In old dislocations the manipulations used in recent ones will sometimes 
 succeed after the adhesions that bind the dislocated bone in its new position 
 have been ruptured by forcible movements of the limb, but usually strong 
 traction is also required to draw the bone to its place. Interference in such 
 cases is unavoidably blind and uncertain ; more extensive lacerations are neces- 
 sary to free the bone than those occasioned by the original dislocation, and the 
 changed relations of important vessels and nerves are such, and their fixation 
 by cicatricial tissue is so firm, that serious injury may be done. It seems much 
 safer, therefore, in many cases to resort to a cutting operation if the attempt is 
 to be made to restore the bone to its place. Furthermore, the structural 
 changes, are occasionally so great that even if the dislocation is reduced the 
 condition of the joint will fall far short of the normal, and the limb, in such 
 cases, will be no more useful than while the dislocation existed. Hence in 
 some instances it is as well to let the dislocated bone remain unreduced. 
 
 The accidents that may follow attempts at reduction are numerous and 
 varied. The skin may be torn by excessive and improperly applied traction, 
 the bone may be broken, vessels and nerves may be ruptured, suppuration may 
 be excited, and death may folloAv through the agency of the anesthetic or the 
 shock of the manipulations. 
 
 Fracture of the bone may occur, and may involve the shaft, the neck, or 
 the bony prominences, the fracture of the olecranon in old backward disloca- 
 tions of the elbow being the commonest example of the latter. It has been 
 noted that the bones of a dislocated limb sometimes show exceptional fragility, 
 apparently the result of interstitial changes provoked by disuse or altered con- 
 ditions of nutrition consequent upon the primary injury. 
 
 Injuries of vessels are most frequent and important in the common forms 
 of anterior dislocation of the shoulder, and of these the commonest appears 
 to be the rupture of the subscapular or circumflex artery or its avulsion from 
 the axillary. The axillary artery itself has been torn completely across, or its 
 inner and middle coats ruptured; the axillary vein has rarely been injured. 
 
430 Ay A.u/:/:/(A\ ri:xT-]i(>f)k' of si^nanm'. 
 
 llupture of an artcrv at the slioulder is followt-il l»y rajdd extravasation of 
 blood in the axilla ; pulsation at the wrist may ])ersist. The condition i.s a 
 grave one: of 47 cases 31 ended fatally (Stinison). Methods of treatment 
 that iiave proved snccessfiil are digital pressure, ligature of the subclavian, 
 and disarticulation at the .shoulder. Double ligature at the point of injury 
 has been uniformly fatal. 
 
 Injuries to main nerrcs are more rare : the roots of the brachial plexus 
 have been torn out in reducing a dislocation of the shoulder ; in some cases 
 paralysis of the limb lias f)llowed reduction. 
 
 Sijnrope and sH'llen <h'at1i have also followed reduction in a very few cases: 
 iti some of them it was probably due to rupture of a vessel or of large nerves ; 
 in one case fat embolism of the lungs wjis found. 
 
 After-treatment. — After reduction of a dislocation no other treatment is 
 usually renuired than immobilization of the limb for a few days in a suitable 
 position, and the subsequent avoidance for a few weeks of attitudes which would 
 favor recurrence. In dislocations of some joints (clavicle), and in certain forms 
 of dislocations of others, the tendency to recurrence is so great that special 
 measures are requisite to prevent it. Passive motion if made at all should 
 be kept within a painless range. 
 
 The condition of habitual dislocation can hardly be relieved except by- 
 operation. 
 
 CONGENITAL DISLOCATIONS. 
 
 Under this term are included certain dislocations which do not appear or are 
 ■not recognizable until after the lapse of some months or years, but the causes 
 of which — faulty development of the joint, paralysis, etc. — are supposed to 
 have existed at birth. From it are excluded those traumatic dislocations which 
 are prodnced in ufero or durinsf deliverv. 
 
 Congenital dislocations of the hip (Fig. 176) are by far the most 
 frequent, about !'<) per cent, of all : they are much more common in females 
 than in males, the proportion, according to different statistics, varying from 60 
 to 90 per cent. One or both joints may be involved. The typical congenital 
 dislocation of the hip is due to a defective development of the acetabulum as 
 carried on by the Y cartilage, which permits the head of the femur to pass, 
 under the influence of the weight of the bodv or of the contraction of the 
 muscles, upon the dorsum of the ilium. Exceptional cases in which it pa.sses 
 upon the pubes or into the obturator foramen have occurred, but they are 
 very rare. Usually the head of the femur is smaller than normal and the neck 
 short. As the child begins to walk, the changes increase, the displacement is 
 finally arrested, and compensatory changes in the attitude of the pelvis and 
 spine appear, the upper part of the pelvis being tilted forward, and the lumbar 
 spine showing a marked curvature forward. If only one hip is involved, the 
 child limj)s in walking ; if both are involved, there is no limp, but the attitude 
 of the body and the gait are peculiar. The tilting of the pelvis disappears 
 when the child is recumbent or when the thighs are flexed: the shortening 
 of the thighs can sometimes be overcome by traction. 
 
 Of the reduction of such a dislocation, in the usual sense of the term, there 
 can of course be no (piestion, for the normal structure of the joint does not 
 exist, and the most that can be attained is to diminish the deformity and func- 
 tional disability. Much has been gained in some cases by traction continued 
 for many months, by which the head of the femur has been drawn'nearer the 
 acetabulum and fixed there by condensation of the tissues about it. and per- 
 haps by the growth of a new bony rim or .socket on the ilium. Palliative 
 
DISIJX'A rioNS. 
 
 431 
 
 Fio. 171; 
 
 measures have also been iiscriilly ciuploye.l in the form of firm corsets of felt 
 or leather which kept the pelvis from tilting. In some unilateral cases the 
 aftected limb has been kept fixed in abduction, so 
 as to make it relatively longer in walking. Opera- 
 tive measures, usually the creation of a socket by 
 chiselling, liave of late been resorted to with a fair 
 measure of success. Ilotta performs the follow- 
 infT operation: An incision is made similar to 
 Langenbeck's incision for resection of the hij)- 
 joint. The head of the femur is separated from 
 the i)elvis, and all of the short muscles connecting 
 the upper end of the femur and the pelvis are cut. 
 The acetabulum is gouged out and the dislocation 
 is reduced. The head of the bone is held in 
 place while the thigh is slowly extended to 
 strctcli tlu- muscles which are parallel to the 
 femur. 
 
 In Loren/Zs operation an incision is made 
 between the tensor vaginae femoris and sartorius 
 muscles and the joint is opened. Gouge out the 
 acetabulum, and if necessary pare down the head 
 of the femur. The short muscles are not cut. 
 The bone is drawn into place by mechanical 
 means if necessary. In bad cases the hamstrings 
 are cut with a tenotome. The thigh must be 
 maintained in extension and slight abduction. 
 
 Among the rarer forms of dislocation of the hip 
 found at birth or appearing shortly thereafter are those due to dropsy of the 
 joint in utero, and those succeeding paralysis of one of the groups of muscles. 
 In such cases a reduction may perhaps be eifected, and the surgeon's efforts 
 must then be directed to preventing its recurrence. Congenital dislocations at 
 the shoulder appear also to be due to defective development of the glenoid 
 
 Among congenital dislocations of the knee, the most frequent is that in 
 which theleg is in extreme hyperextension, the foot sometimes resting against 
 the abdomen'! They have usually been easily corrected. 
 
 Double Congenital Dislocation of 
 the Hip (Stimsoii;. 
 
 SPONTANEOUS DISLOCATIONS. 
 
 Under this term are included those in which the dislocation occurs, usually 
 without external violence, as the result of predisposing changes in the articular 
 surfaces or in the ligaments or of the unopposed action of certain muscles, 
 others being paralyzed. Those due to destruction of the bones are incidents 
 of the diseases that produce the destruction, and will not be considered here. 
 Those due to dropsical distention of the joint are of more importance, for they 
 are capable of reduction and may easily escape notice at first. They occur in 
 the course of the eruptive fevers,"less frequently in that of the continued fevers 
 (Keen) or of articular rheumati.sm, and are most common at the hip. The 
 effusion in the joint makes the occurrence easy; the habitual attitude in bed. 
 the patient's position, resting on his side with the thighs flexed and the upper 
 one adducted, is also favorable, and the contraction of the muscles usually 
 does the rest. 
 
 Paralytic or " myopatliic " dislocations are most common at the shoulder. 
 
432 ^^V AMJJinCAX TEXT- HOOK OF HUUiiKRY, 
 
 The weight of the limb being unopposed by the scapular muscles, the head of 
 tiie humerus sinks and is easily disphice<l forward or backward. 
 
 SPECIAL DISLOCATIONS. 
 DISLOCATIONS OF THE LOWER JAW. 
 
 These constitute about 4 per cent, of all dislocations, are more frequent in 
 women than in men, and may be unilateral or bilateral. The displacement is 
 forward, the condyle resting in front of the eminentia articularis at tiie root of 
 the zygoma. This forward displacement is an exaggeration of the normal 
 forward movement of the condyle in opening the mouth. The interarticular 
 iibro-cartilage may accompany the condyle or may remain behind, its anterior 
 attachment to the condyle being torn. 
 
 Dislocations backward are very exceptional, a few cases having been re- 
 ported in Avhich, by a blow upon the chin, one or both condyles have been 
 driven backward, breaking through the anterior wall of the external auditory 
 meatus. By a similar blow very rarely the condyle has been driven into the 
 cranial cavity. In what follows only the forward dislocations are considered. 
 
 The usual cause of forivard dislocation is the wide opening of the mouth, 
 either voluntarily in laughing, yawning, or introducing some large object, or 
 in manipulations about the mouth, as by a dentist. Fixation is due to the pas- 
 sage of the condyle in front of the line of the lateral ligaments, the attach- 
 ments of which to the jaAv are exceptionally low. The internal pterygoid and 
 masseter aid in the fixation, partly by maintaining the elevation of the angle 
 of the jaw and partly by opposing the backward movement that would aid 
 reduction. The engagement of the coronoid process of the inferior maxilla in 
 front of the malar bone, which has been alleged to be a cause of the fixation, 
 rarely occurs, if ever. 
 
 The symptoms are inability to close the mouth, some projection of the 
 lower jaw, and the presence of the condyle in advance of its normal position. 
 In unilateral dislocation the chin is deviated to the opposite side and the inter- 
 ference with function is less. 
 
 Theoretically, the dislocation should be most easily reduced by opening 
 the mouth more widely to relax the lateral ligaments, and then pressing the 
 jaw backward; but the involuntary contraction of the muscles, unless the 
 patient is anesthetized, will be a serious obstacle. A fiiirly successful method 
 is by forcible pressure with the thumbs downward and backward upon the 
 lower molar teeth. In bilateral dislocation it is sometimes easier to make 
 reduction on each side separately. 
 
 The liability to frequent recurrence which sometimes ensues has been com- 
 bated by opening the joint and suturing the meniscus to the periosteum at the 
 margin of the articulation. The injection of tincture of iodine into the joint 
 has also been proposed. 
 
 DISLOCATIONS OF THE STERNUM. 
 
 Dislocation of one of the normal segments of the sternum from another is a 
 rare injury, and one not ahvays to be distinguished clinically from a fracture. 
 We describe dislocation of the body from the manubrium, and of the ensifoim 
 process from the body. 
 
 Dislocation of the Body from the Manubrium. — The lower border 
 of the manubrium is on a line joining the sternal ends of the second costal 
 cartilages, which articulate with both segments. Dislocations forward and 
 
DI8L O CA TIONS. 433 
 
 backward have been observed, the former being the more common. Forward 
 dislocation has been caused by direct violence (a blow upon the sternum), by 
 indirect violence (compression of the sides of the chest), by nmscular action 
 (the eftbrt made in exercising on parallel bars), and possibly by forced dorsal 
 flexion of the trunk. It may be complete or incomplete. In the complete 
 form the lower fragment may override the upper one as much as an inch, 
 the anterior fibro-})eriosteal envelope being torn and the posterior one being 
 stripped from the second segment. The costal cartilages retain their attach- 
 ments to the manubrium. Backward dislocations appear to have been caused 
 only by direct violence received upon the second segment. Either form is 
 frequently associated with dislocation or fracture of the ribs or of the costal 
 cartilages. 
 
 The general symptoms, interference with respiration and circulation, may 
 be very severe. The diagnosis is made by recognition of the change in the 
 anterior aspect of the sternum and of the relations of the line of separation to 
 the second costal cartilages. In forward dislocation the shallow depressions at 
 the upper corners of the body for articulation with the second costal cartilages 
 may be recognized. The well-known gravity of the injury appears to depend 
 mainly on associated lesions. 
 
 Reduction is made by forcible dorsal jflexion of the trunk and direct pres- 
 sure on the projecting fragment. In one or two instances it has been aided by 
 the coughing of the patient or by his making a deep inspiration. In some 
 cases in which the dislocation has remained unreduced it has caused no dis- 
 ability. 
 
 Dislocations of the Ensiform Process are very rare ; the apex may be 
 directed either forward or backward. The most prominent symptom in some 
 cases has been persistent vomiting, relieved by draAving the apex of the pro- 
 cess forward with the fingers or with a sharp hook introduced through the skin. 
 
 DISLOCATIONS OF THE RIBS AND COSTAL CARTILAGES. 
 
 Dislocation of the Head of the Rib. — Nine cases, several of them 
 verified by autopsy, have been reported, the head of the rib having been 
 thrown forward by a blow upon the rib from behind. In one the head had 
 been forced through the pleura into the lung. 
 
 Chondro-costal Separation. — A half-dozen examples of this injury 
 are on record ; the causes have been external violence and prolonged or vio- 
 lent coughing. The treatment is the same as that of fracture of the rib or 
 cartilage. 
 
 Chondro-sternal and Chondro-chondral Dislocations. — A few cases 
 of dislocation of the costal cartilages from the sternum or from each other have 
 been reported, besides those associated with fracture or dislocation of the ster- 
 num. The causes have been external violence received upon the chest and 
 muscular action exerted through the pectoralis major. Both forward and back- 
 ward displacements have been observed ; the former were easily reduced by 
 pressure, but readily recurred. 
 
 DISLOCATIONS OF THE CLAVICLE. 
 
 The clavicle may be dislocated at either end or at both ends simultaneously. 
 
 Sternal End. — The joint possesses an intra-articular fibro-cartilage which 
 has its strongest attachment above to the upper edge of the end of the clavi- 
 cle, and below to the cartilage of the first rib. The clavicle may be dislocated 
 forward, backward, or upward, in this order of frequency. 
 
 28 
 
434 AA^ AMKRICAX TEXT- BOOK OF SURGERY. 
 
 Dislocation forward appears to be most frequently caused by forcible 
 movement of the shoulder downward and backward, in which the center of 
 the clavicle comes to rest upon the first rib, and the inner end is thus thrown 
 forward as the outer one is lowered and carried backward. In cases of habit- 
 ual dislocation the bone slips out of place when the arm is raised beside the 
 head or when the shoulder is thrown back as in puttin<^ on a coat. In a case 
 reported by Stimson the liability to displacement was gradually developed in a 
 youth of nineteen years, so that it occurred whenever the elbow was raised to 
 the height of the shoulder, the bone returning to its place as the arm was low- 
 ered. The dislocation may be complete or incomplete : in the former the end 
 of the bone rests upon the front of the sternum to the inner side of or below 
 its normal position. Occasionally a piece is broken from the end of the clavi- 
 cle or the eilge of the articular surface of the sternum. 
 
 The symptoms consist in the marked projection and abnormal position 
 of the end of the clavicle, with local pain, sinking of the shoulder downward 
 and inward, and inability to use the arm. 
 
 Reduction is effected by drawing the shoulder backward and by suitable 
 pressure on the end of the clavicle ; and recurrence is prevented by immol>ili- 
 zation of the shoulder. This is the difficult part of the treatment, and many 
 plans have been tried, such as a figure-of-8 bandage about the two shoulders, 
 the turns crossing on the back ; prolonged rest in bed upon the back to avoid 
 the influence of the weight of the arm in reproducing the displacement; moulded 
 caps of leather or gutta-percha fitted to the end of the clavicle and held in 
 place by straps about the chest ; and direct pressure by a hernial truss the pad 
 of which rests upon the end of the clavicle while the spring passes to the back 
 under the axilla of the uninjured side. 
 
 The liability to recurrence may be extremely troublesome. In Stimson's 
 case it was overcome by three injections of a dram of alcohol into the peri- 
 articular tissues at intervals of a fortnight, the arm being meanwhile confined 
 to the side of the body. The same condition subsequently developed in the 
 other clavicle of the same patient, and was cured by a single injection. 
 
 DiSLOCATiox BACKWARD may be caused by direct violence received upon 
 the front of the inner end of the bone or by the forcing of the shoulder forward 
 and inward ; it may be complete or incomplete, and in the former case the dis- 
 placement is also inward or inward and downward, so that the bone presses 
 upon the trachea and oesophagus and causes dyspnea or dysphagia. 
 
 Symptoms. — The dislocation is to be recognized by the absence of the end 
 of the bone from its normal position and its presence in its new position, which 
 may be determined by palpation or by attention to the direction of the access- 
 ible portion of the bone. The shoulder hangs somewhat forward and inward. 
 
 Reduction is effected by drawing the shoulder outward and backward, 
 and recurrence is prevented by maintenance of the shoulder in this position. 
 In a number of cases in which the dislocation remained unreduced it was borne 
 without inconvenience, but in one in which the displacement was subsequently 
 increased by progressive distortion of the spine the interference with deglutition 
 was such that it became necessary to excise the end of the bone. 
 
 Dislocation upward has been caused by the forcible depression of the 
 shoulder: in a case reported by Stokes it was gradually produced on both sides, 
 apparently by the action of the sterno-cleido-mastoids "in forced inspiratory 
 efforts produced by great dyspnea due to ascites." The end of the bone is 
 displaced inward as well as upward, passing behind the sternal head of the 
 sterno-cleido-mastoid, and resting in the episternal notch. Reduction is 
 made by drawing the shoulder outward and by direct pressure on the end of 
 
DISLOCATIONS. 
 
 435 
 
 Fig 
 
 Upward Dislocation of Acromial End of 
 Right Clavicle (original^. 
 
 be overcome by drawing the 
 
 the bone. ^laljiaisne's hooks, devised f<n- the treatment of fracture of the 
 patella, have been used to prevent recur- 
 rence, one being fixed in the clavicle, the 
 other in the front of the sternum. 
 
 Acromial End. — The common disloca- 
 tion is upward or upward and outward, so 
 that the end of the clavicle overlaps the 
 acromion (Fig. 177). Fracture of the edge 
 of the articular surface of either bone may 
 accompany the dislocation. The cause is 
 usually a blow or fall upon the shoulder. 
 
 In the great majority of cases the end of 
 the clavicle simply rises more or less above 
 the level of the acromion without overriding 
 it, and can be easily pressed down into place 
 if the arm is at the same time pressed up- 
 ward ; but the displacement recurs as soon as 
 the pressure is removed. The manipulation 
 may be accompanied by crepitus if there has 
 been fracture of the edge of the articulation, 
 but the injury can be readily distinguished 
 from a fracture of the outer part of the clav- 
 icle by attention to the relations of the pro- 
 jecting bone to the acromion and by com- 
 parative measurements of its length. If it 
 overrides the acromion, the overriding can 
 shoulder outward. 
 
 Retention of the bone in place after reduction has presented so many 
 difficulties that some have taught that it is not worth while to attempt it, 
 especially since the persistence of the dis- 
 location ordinarily causes no loss of func- 
 tion ; but the method recommended by 
 Stimson is so simple and efficient that it 
 should always be tried (Fig. 178). A 
 long strip of adhesive plaster three inches 
 wide is placed with its center under the 
 point of the flexed elbow and its ends 
 carried up in front of and behind the arm, 
 crossed over the end of the clavicle, and 
 secured to the front and back of the chest 
 respectively while the bone is held in place 
 by pressure upon the clavicle and elbow. 
 Recurrence can be readily detected through 
 the plaster by the finger or the eye. For 
 additional security the forearm should be 
 supported in a sling and the arm bound to 
 the chest. 
 
 Subacromial Dislocation. — A few 
 cases have been reported in which the end 
 of the clavicle was displaced downward and 
 engaged under the acromion, the causes 
 being respectivelv direct violence upon the ,, . „, ^ .. „ ^ r.- , 
 
 ^ i. ^ ■ , 1 r> 1 1 Adhesive Plaster Dressing for L pward Dislo- 
 
 Upper surface Ot the outer end OI the ClaV- cation ofAcromial End of clavicle (original). 
 
 Fig. 178. 
 
436 ^l.V AMERICAN TEXT- BOOK OF SURGERY. 
 
 icle, a fall upon the shoulder, and muscular action while the arm was raised. 
 Reduction was easily made })y drawing the shoulder outward, and a tendency to 
 recurrence was observed in only one case. 
 
 SuBCORACOiD Dislocation. — Two surgeons have reported cases of this 
 singular dislocation, in which the clavicle is displaced forward and downward 
 below the coracoid process, but the reports are viewed with some suspicion. 
 
 Simultaneous Dislocation of both Ends of the Clavicle has been 
 reported in about a dozen cases, the cause usually having been extreme violence 
 by which the shoulder was pressed inward; in all the sternal end wa5 dislocated 
 forward, the acromial end upward. 
 
 DISLOCATIONS OF THE SHOULDER. 
 
 These are as frequent as all other dislocations taken together ; they are 
 rare in youth and old age, and much more frequent in men than in women. 
 The frequency is readily accounted for by the formation of the joint and by 
 its exposure to external violence. 
 
 The glenoid fossa looks forward as well as outward, and the head of the 
 humerus in leaving it laterally passes forward and inward or backward and 
 outward ; it may also pass downward or, in very rare cases, upward. The 
 secondary displacements succeeding to these primary ones are numerous and 
 varied, and are commonly produced by subsequent changes in the attitude of 
 the arm. Four principal groups may be made according to the primary dis- 
 placement, and subdivided according to the points at which the head of the 
 bone comes to rest or according to other clinical features, as follows : 
 
 ( Subcoracoid ; very common. 
 Anterior ..... -^ Intracoracoid ; exceptional. 
 
 (^ Subclavicular. 
 
 {Subglenoid ; uncommon. 
 Erecta ; very rare. 
 Subtricipital. (?) 
 
 T, , • f Subacromial ; rare, 
 
 rosterior . . . . • ^ c v. • 
 
 ( Subspinous ; very rare. 
 
 Upward ..... Supraglenoid ; very rare. 
 
 In the anterior dislocations the displacement is also more or less downward 
 (also of course inward), and in the downward ones it is usually also forward 
 and inward, and consequently the two merge into each other without a sharp 
 line of division ; as the term is used here, the anterior include in the subcoracoid 
 subdivision many of those known in the older terminology as subglenoid. The 
 latter term is correspondingly restricted to include only those in which the 
 head of the humerus lies very low. 
 
 ANTERIOR dislocations. 
 
 These present two varieties, the subcoracoid and the intracoracoid, accord- 
 ing to the distance to which the head of the humerus is displaced inward : an 
 extreme form of the latter is sometimes called the subclavicular. 
 
 Subcoracoid. — In this, the commonest form, the head of the humerus lies 
 beneath the coracoid process, in contact with it or at a variable distance, a finger- 
 breadth at the most, below it. The extent of displacement inward also varies, 
 from just suflBcient to keep the head balanced on the anterior edge of the glen- 
 
DISLOCATIONS, 
 
 437 
 
 oid fossa to that in which three-fourtlis of the diameter of the head lies to the 
 inner side of the coracoid process ; greater displacements inward are termed 
 intracoraeoid. 
 
 The injury may be caused by direct violence, as a blow or fall upon the 
 shoulder; indirect violence, as a lUll upon the hand or the elbow: forcible abduc- 
 tion or outward rotation of the limb ; or muscular action. Muscular action can 
 produce a dislocation either by directly pulling the head out of its socket, as 
 in convulsions, or, much more frequently, by im{»arting a sudden movement to 
 the limb which creates conditions of leverage and impulsion similar to those of 
 indirect violence. 
 
 The capsule is torn at its inner and lower portion, the rent extending for a 
 greater or lesser distance along the margin of the glenoid fossa. Exceptionally, 
 there may be no rent in the capsule. In " typical " cases the outer and upper 
 portion of the capsule remains untorn and aids in determining the attitude of 
 the limb and the limitation of its movements. The subscapularis muscle may 
 be pushed inward or torn for a variable distance upward from its lower margin. 
 The interposition of its untorn portion between the head of the humerus and 
 the coracoid process accounts for the interval between these bones observed in 
 some cases. The supraspinatus may be ruptured or torn from the humerus ; 
 also, but less frequently, the infraspinatus, and rarely the teres minor. Avul- 
 sion of a portion of the greater tuberosity may take the place of this rupture. 
 The head of the humerus may rest against the edge of the glenoid fossa or far- 
 ther inward against the side of the neck of the scapula ; its articular surface is 
 occasionally bruised by impact against the edge of the fossa. The tendon of the 
 long head of the biceps is occasionally torn from its attachment, and when the 
 greater tuberosity has been broken off it may slip to the outer side of the head. 
 
 Symptoms. — The elbow hangs a little away from the side, the outer aspect 
 of the deltoid is flattened, and the anterior and outer fulness of the shoulder is 
 lost (Fig. 171*). Viewing the arm from Fig. 179. 
 
 in front, the axis of the humerus is seen 
 to pass to the inner side of the glenoid 
 fossa, and the anterior fold of the axilla 
 is lowered. On palpation the normal 
 bony resistance below the front and 
 outer side of the acromion is absent, 
 and an abnormal one is found below 
 the coracoid process which shares in 
 slight rotatory movements communi- 
 cated to the arm. In the higher forms 
 the head can be felt only indistinctly, 
 if at all, in the axilla. Voluntary 
 movements are usually lost ; passively, 
 the arm can be easily abducted, but 
 cannot be so far adducted as to bring 
 the hand upon the opposite shoulder 
 and the elbow to the front of the 
 cliest (Dugas' sign). Measurement 
 from the acromion to the elbow while 
 the arm is abducted shows the distance to be less than on the opposite side 
 with the arm in the same position. 
 
 In making a diagnosis every effort should be used to determine the 
 position of the head of the bone and its continuity with the shaft. In very 
 fat patients this may be difficult or even impossible without the aid of an 
 
 Double Subcoracoid Luxation of Both Shoulders 
 (original). 
 
438 
 
 ^iV^ AMERICAN TEXT-BOOR' OF SURGERY. 
 
 Fig. 180. 
 
 anesthetic. "Where there is associated fracture of the anatomical neck, a 
 rare complication, the only means of diagnosis if the patient is fat may be 
 the shortening of the abducted limb. 
 
 In intracoracoid dislocation the head of the humerus is displaced farther 
 inward, either by the prolonged action of the dislocatiiig violence or, more 
 
 commonly, by a greater primury 
 displacement downward by which 
 the subscapularis is widely torn, 
 and then on lowering the elbow 
 the head of the humerus passes 
 upward and inward. The rent 
 in the capsule is correspondingly 
 greater. In a case reported by 
 Stimson the head of the hume- 
 rus had passed below and to the 
 inner side of the untorn subscap- 
 ularis, the tendon of which thus 
 formed an insuperable obstacle 
 to reduction and made arthrot- 
 omy necessary. 
 
 The symptoms are sim- 
 ilar to those of the subcoracoid 
 form ; the elbow is more widely 
 abducted, the deltoid more flattened, the head of the humerus easily recog- 
 nizable in the subclavicular fossa. Occasionally the arm is fixed in complete 
 horizontal abduction. 
 
 Treatment. — Reduction is usually easy, but occasionally, as in the case 
 just mentioned, may be impossible except by operation. 
 
 Fig. 182. 
 
 Fig. 181. 
 
 Kocher'.s ML'thnd cif UciliutidU by Manipuliition. First 
 movt'iueiit, (lutwaril rotation (<'op])i). 
 
 Kocher's Method of Reduction. Second movement, 
 elevation of elbow (Ceppi). 
 
 Kocher's Method of Kednction. Tliird 
 niovenient, inward rotation and lower- 
 ing of elbow (Ceppi). 
 
 Kocher's metliod is very successful in the higher forms of subcoracoid dis- 
 location, but frequently fails in the lower and in the intracoracoid. It may be 
 employed with or without the aid of anesthesia. The elbow is Hexed at a right 
 angle and pressed closely against the side ; then the forearm is turned as far as 
 
DISLOCATIONS. 
 
 439 
 
 Fk;. 183. 
 
 possible away t'lvmi the tn-uiik (external rotation of the arm) (Fig. 180). Unless 
 the head of the humerus rolls outward in front of and below the acromion dur- 
 ing this movement, the attempt will fail. Then, while the external rotation is 
 maintained, the elbow is carried well forward and upward (Fig. 181), the arm 
 rotated inward, and the elbow lowered (Fig. ]8ii). Sometimes it is useful to 
 have an assistant })ress the head outward with his fingers or by a band in the 
 axilla during the later steps. 
 
 Traction outward is also a very useful method, although it involves a cer- 
 tain degree of risk to the axillary vessels, especially in the aged. The patient 
 is laid on his back on the floor, and the surgeon, seated beside him, placing 
 one foot against his chest, seizes the arm at the elbow, and draws it steadily 
 outward in full abduction. If this does not bring the bone into place, an 
 assistant may press its head upward with his fingers, his thumbs resting on 
 the acromion. Or, the patient lying on the bed, the surgeon makes traction 
 on the arm for a few moments, and then, while maintaining the traction with 
 one hand, swings the arm toward the side over his closed fist in the axilla. 
 This is similar in action to the old method of the unbooted heel in the axilla, 
 but is less dangerous. 
 
 Occasionally reduction can be made by taking the patient unawares. He 
 is made to stand up, and the surgeon, standing beside him, holds his wrist, 
 with the elbow flexed at a 
 right angle, and gently moves 
 the arm and engages him in 
 conversation. Little by little 
 the deltoid is seen to relax, 
 and then a smart blow down- 
 ward upon the fold of the 
 elbow with quick external ro- 
 tation of the arm will eff'ect 
 reduction in a considerable 
 proportion of cases (Cole). 
 
 In intracoracoid disloca- 
 tions traction outward should 
 be used. 
 
 In older cases foi'cible ro- 
 tation is needed to break up ad- 
 hesions, after which Kocher's 
 method may succeed or forci- 
 ble traction may be required. 
 
 The cases in which com- 
 plete reduction is prevented 
 by the interposition of a por- 
 tion of the capsule or of a 
 tendon are very rare. 
 
 Subglenoid Iti^lnciUuii ^^unison) 
 
 DOWNWARD DISLOCATIONS. 
 
 This class includes those rare ones in w hich the head of the humerus rests 
 below the glenoid fossa on the tendon of the long head of the triceps, and those 
 more common ones in which it lies somewhat higher and to the inner side 
 under the lower and anterior edge of the glenoid fossa. The name by which 
 they are commonly known is subglenoid. The class also includes a rare form, 
 the lutatio erecta, and a doubtful one, the suhtricipital. 
 
 The cause is forcible abduction of the arm, by which the capsule is torn 
 
440 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 at its lower part, followed by rotation or impulsion wliich engages the head 
 bevond the edge of the fossa. The lower part of the tendon of the subscap- 
 ularis may be torn, and the greater tuberosity appears habitually to be in part 
 broken off by the traction of its attached muscles. 
 
 The syrnptoms are similar to those of subcoracoid dislocation, but more 
 marked. The elbuw is abducted, the shoulder flattened, the acromion prom- 
 inent, and the head of the humerus can be readilv felt in the axilla (Fig. 
 
 183). 
 
 Treatment. — Theoretically, the best method of reduction would be to 
 raise the elbow as far as possible and then to make traction, but as this in- 
 volves some ri.sk to the a.xillary vessels it is better to use an anesthetic and 
 reduce by traction in moderate abduction, with direct pressure upward and 
 outward upon the head of the humerus. 
 
 Luxatio Erectd. — In this rare form the arm is held vertically, the forearm 
 resting on the top of the head and held there by the patient to escape the 
 pain caused by lowering it. In the half-dozen cases reported the cause ap- 
 pears to have been forcible elevation of the arm. Reduction was easily 
 made by traction upward without changing the attitude of the limb until 
 after the head had been drawn into its socket. 
 
 Suhtriripital Dislocation. — Of this only a single case has been reported. The 
 head of the humerus was thought to have passed, after dislocation downward, back- 
 ward behind the tendon of the long head of the triceps, and then to have been 
 raised to a higher level behind the glenoid fossa by the lowering of the elbow. 
 
 POSTERIOR DISLOCATIONS. 
 
 These include two varieties, the subacromial and the subspinous, which dif- 
 fer only in the extent of the displacement. Some English writers make only 
 one class and give the name subspinous to all. The dislocation is infrequent, 
 and the subacromial variety is much the more frequent of the two. 
 
 The cause appears to be pressure of the head of the humerus outward and 
 backward, either directly or through the elbow, aided by adduction and internal 
 rotation of the arm. 
 
 Autopsies and experiment upon the cadaver show that the capsule is torn on 
 its outer side and above and below, the lesser tuberosity is sometimes broken 
 off, the supraspinatus ruptured or torn away with its facet of insertion, the teres 
 minor and triceps are sometimes torn. In the subacromial variety the head of 
 the humerus lies below the projecting outer portion of the acromion, with its ana- 
 tomical neck resting on the outer edge of the glenoid fossa and its articular sur- 
 face directed outward. In the subspinous variety the head is displaced farther 
 backward below the spine of the scapula, and perhaps separated from it by the 
 interposed infraspinatus. 
 
 Symptoms. — The arm hangs by the side in inward rotation, with the 
 elbow directed slightly forward. The fulness of the shoulder is lost in front 
 and increased behind. The absence of the head of the humerus in front and 
 its presence behind can be recognized by palpation : the coracoid and the ante- 
 rior part of the acromion are abnormally prominent. Voluntary movement is 
 lost, passive motion restricted and painful. 
 
 Treatment. — Reduction appears to be easy in both recent and old cases 
 by traction forward upon the arm or by direct pressure forward upon the head 
 of the humerus, but recurrence is frequent, presumably because of the loss of the 
 support of the subscapularis. "When the dislocation has remained unreduced 
 the disability has been greater than is usual in anterior dislocations. , 
 
DISL O CA TIONS. 44 1 
 
 UPWARD DISLOCATIONS. 
 
 The possibility of the occurrence of this very rare form l'^*- 1^4. 
 
 has been proved by a few clinical cases and two autopsies. 
 Amono; the causes were a fall upon the elbow, a blow down- 
 ward upon the acromion while the arm was raised, and an 
 epileptic convulsion. In one case certainly, and possibly in 
 two others, the coracoid process was broken. 
 
 The head of the humerus lies in the interval between the 
 acromion and the coracoid, closely in front of the clavicle 
 and usually above its level. The arm hangs by the side, the 
 elbow directed somewhat backward. Active and passive 
 movements arc greatly restricted (Fig. 184). 
 
 Reduction was effected in three cases by traction, and 
 by elevation of the elbow in one, but the dislocation at once su^7i^,iiKr^(i DiJ- 
 recurred in the latter. In three old cases reduction failed. location (Albert). 
 
 COMPLICATIONS OF DISLOCATION OF THE SHOULDER. 
 
 Compound dislocations are very rare, and are usually caused by extreme 
 violence, which is associated with extensive laceration of the soft parts in the 
 neighborhood of the dislocation, and inflicts other, and perhaps fatal, injuries at 
 the same time. The wound in the skin is commonly in the axilla. The gravity 
 of the condition arises either from associated injury done to the arteries of the 
 axilla or from the extent of the laceration of the soft parts and the probability 
 of suppuration. Infection is likely to take place before treatment can be begun, 
 the extravasated blood favors its rapid spread, and the extent and irregularity 
 of the laceration make subsequent cleansing almost impossible. Nevertlieless, 
 some very satisftictory recoveries have been reported. The treatment calls 
 for the thorough antiseptic cleansing of the parts, the reduction of the disloca- 
 tion, renewed cleansing, and thorough drainage of the cavity of the joint. 
 Probably in most cases it would be best not to close the wound in the skin, 
 but instead to pack rather deeply with the iodoform gauze for a few days. 
 Excision of the head of the humerus may be advisable to favor drainage and 
 oppose ankjdosis. 
 
 Fractures. — These may involve any of the prominences of the humerus 
 or scapula or the anatomical or the surgical neck of the humerus. The upper 
 part of the greater tuberosity is sometimes, perhaps frequently, torn off" by trac- 
 tion through its attached muscles in anterior dislocation ; the periosteal attach- 
 ments may persist and the displacement consequently be slight, or the piece 
 may be entirely detached, and may even lodge in the glenoid fossa and consti- 
 tute a serious obstacle to reduction. The fracture may be recognized by local- 
 ized pain and crepitus and by loss or diminution of voluntary outward rotation. 
 
 The lesser tuherosity has been found broken off' only in backward disloca- 
 tion by traction through the attached subscapulars. The acromion has been 
 broken by a blow upon it from above, which, continuing, has then dislocated 
 the humerus doAvnward and forward. 
 
 The coracoid process has been rarely broken ; once certainly in connection 
 with supracoracoid dislocation! The glenoid fossa is probably often broken 
 at its edge, and the fragment may be large enough to interfere seriously with 
 the maintenance of the humerus in its socket. 
 
 Fracture of the Anatomical or of the Surgical Neck of the Humerus. — The 
 former is a much rarer complication than the latter: it appears to be caused after 
 the head has left its socket by impact against the anterior edge of the glenoid 
 fo.s.sa, which acts like a wedge along the anatomical neck and splits off" the head. 
 
442 ^l^V AMERICAN TEXT-BOOK OF SCRGERY. 
 
 It is (lilluMilt (if rcc'(»^Miition. The diagnostic points an' the recognition of the 
 head in its abnormal j)ositi()n beneatli the coracoid process and its failure to 
 move with the shaft, the normal or nearly normal position of the greater tube- 
 rosity, the direction of the axis of the humerus toward the glenoid fossa, and 
 the absence of the limitation of passive movements peculiar to dislocations. 
 Possibly crepitus may be obtained. 
 
 In fracture of the surgical neck the recognition of the dislocation is easier, 
 because the greater tuberosity remains out of place together with the head ; 
 there is the same absence of characteristic limitation of motion and the same 
 normal direction of the axis of the humerus ; the tuberosity fails to move with 
 the shaft, and crepitus is almost certainly to be felt. 
 
 The small almost hemispherical head may sometimes, after fracture of the ana- 
 tomical neck, be pressed back into place with the fingers, and may even resume 
 its ])roper relations to the shaft and reunite with it. In dislocation with frac- 
 ture of the surgical neck the dislocation may sometimes be reduced under 
 an anesthetic by direct pressure upon the head and traction on the arm. 
 McBurney effected reduction in one case by cutting down through the deltoid 
 upon the lower end of the upper fragment, drilling a hole in it, and inserting 
 into this hole a strong right-angled hook, by means of which he made forcible 
 traction and rotation upon the fragment. This failing, the choice lies between 
 attempting reduction after the fracture has been united or establishing a false 
 joint at the seat of fracture. 
 
 Injuries to the Blood-vessels and Nerves. — The axillary artery or 
 one of its branches, especially the circumliex and subscapular, may be ruptured 
 in a dislocation, but of the reported cases of such injury the majority appear to 
 have been caused by attempts to reduce. The accident is to be recognized by 
 the rapid extravasation of blood into the axilla and down the arm and over 
 the chest. The radial pulse may persist, for the injury is more frequently of 
 an arterial branch than of the artery itself. The pressure of the extravasated 
 blood seriously interferes with the circulation, and operative interference may 
 be required because of the persistent hemorrhage or because of the imminence 
 of gangrene. The various methods of treatment have been pressure, ligature 
 of the subclavian or of the axillary artery, and disarticulation at the shoulder. 
 The resultant rate of mortality is high. 
 
 The posterior branch of the circumflex nerve appears very frequently to be 
 bruised or stretched, with consequent temporary, or possibly permanent, loss 
 of sensibility in the skin covering the deltoid, and of voluntary control of the 
 deltoid muscle. It is Avell, before attempting reduction, to test the sensibility 
 of the skin in the indicated region, in order that the loss of power in the 
 deltoid Avlien subsequently recognized shall not be wrongly attributed to the 
 means enq)loyed in reduction. 
 
 The after-treatment rarely calls for more than immobilization of the 
 joint for a fortiiiglit and the avoidance of abduction for a week or two longer. 
 
 The prognosis is good in respect both of reduction and of complete restora- 
 tion of function. The cases in which an uncomplicated dislocation cannot be 
 reduced are extremely rare. The subsequent usefulness of the limb may, how- 
 ever, be impaired by persistent stiffness and tenderness, especially in the old 
 and rheumatic, by paralysis of the deltoid, or by a liability to recurrence. 
 
 When the dislocation remains unreduced the arm is ordinarily fiiirly useful, 
 the lost mobility of the joint being compensated for in part by increased 
 mobility of the scapula, but occasionally it happens that the pressure of the 
 displaced head causes so much j)ain or the immobility is so marked that an 
 operation is called for to relieve it. 
 
DISLOCATIONS. 
 
 44;i 
 
 Treatment of Old Unreduced Dislocations. — If tlic dislocation can- 
 not be reduced by the usual uietliods after freely breakinff the adhesions by 
 forcible rotation and traction, the surgeon has bis choice bet-ween reduction by 
 open arthrotomy and excision of the head of the humerus. The former has 
 furnished a few good results, but it has more often proved impossible to make 
 reduction or the usefulness of the limb has not been increased. The method 
 of open arthrotomy is by an anterior incision. Excision of the head, through 
 an anterior incision or through one in the axilla, relieves pressure and gives a 
 movable joint ; but, as the division of the bone is made below the tuberosities, 
 active rotation is lost. Subcutaneous division and also open division of the 
 periarticular tissues have been employed a few times successfully, as has also 
 intentional fracture of the surgical neck to improve the position or to create a 
 false joint. 
 
 Habitual dislocation, that is, the liability to recurrence of the disloca- 
 tion on certain movements of the arm, has been successfully relieved in two cases 
 by Ricard by an operation which consisted in exposing the front of the joint by 
 an incision along the line between the deltoid and pectoralis magnus, and a 
 second one running from the upper end of the first outward along the margin 
 of the acromion ; through this the anterior portion of the deltoid is detached 
 and turned back. Then without opening the joint the lengthened and thinned 
 portion of the capsule .on the inner side is pinched up in a transverse fold, 
 which is made permanent by two or three vertical silk sutures which include 
 part of the tendon of the subscapularis below and the unchanged thick upper 
 portion of the capsule above. 
 
 DISLOCATIONS OF THE ELBOW. 
 
 These are second in order of frequency, and are much more common in 
 persons under twenty-five years of age than in others. They present a great 
 variety of forms, for the radius and ulna may be displaced together backward, 
 forward, inward, or outward, or the two bones may be displaced each in a 
 different direction, or either may be dislocated alone, the other remaining in 
 place. The following table is taken from Stimson : 
 
 Dislocations backward : 
 
 Backward and outward. 
 
 Backward and inward. 
 Lateral dislocations : 
 
 Incomplete {™^J;j_ 
 
 Complete outward. 
 Forward dislocations : 
 
 Incomplete, or first deo;ree. 
 
 Complete, or second degree. 
 
 With fracture of the olecranon. 
 Divergent dislocations : 
 
 Antero-posterior. 
 
 Transverse. 
 
 Dislocations of the forearm 
 (both bones) on the arm. 
 
 Dislocations of the ulna 
 alone . . ... 
 
 Dislocations of the radius 
 alone .... 
 
 Congenital and pathological 
 dislocations. 
 
 upward. I J- Ipcomplete, or first degree. 
 
 1,2. Backward and uuvYtuu. T o n Ti. ■ j i -- 
 
 ' ^ [1. Complete, or second degree. 
 
 3. Backward and outward, behind the radius. 
 
 1. Backward. 
 
 2. Outward. 
 
 3. Forward. 
 
 4. By elongation, or the subluxation of children. 
 
 5. Associated with fracture of the ulna. 
 
444 
 
 AN AMERICAN TEXT-llOOK OF SURGERY. 
 
 ¥iG. 1S5. 
 
 Dislocation of both Bones Backward. — This is the most common of 
 the dislocations at the elbow : two varieties, showing additional displacement 
 inward or outward, are noted, but the variation from the displacement directly 
 backward has no practical importance (Fi^. 185). 
 
 The cause is usually a fall upon the outstretched hand, and the mechanism 
 in such cases is either hyper-extension of the elbow, with the formation of an 
 am^le opening backward, or an increase of the normal outward deviation of 
 the forearm, followed by a twist which brings the coronoid process below and 
 then behind the humerus. The theory of dislocation by hyper-extension finds 
 some additional support in the api)arent relation between the frequency of the 
 injury in chiMren and the fact that in most young people the limb can be 
 easily extended beyond the straight line. In either case, as experiment shows, 
 the internal lateral ligament is torn, and the external one is either ruptured or 
 torn away from the bone, perhaps retaining its connection with the periosteum, 
 which is stripped off the back of the external condyle as the head of the radius 
 passes backward. The capsule is torn in front, the internal epicondyle (epi- 
 trochlea) is sometimes broken off, apparently by traction exerted through the 
 flexor muscles attached to it, and sometimes instead of this the muscular 
 
 attachments are ruptured. The coronoid process 
 is occasionally broken, as may also be a portion of 
 the head of the radius, the cause in each case being 
 pressure against the condyle ; both fractures are 
 rare complications, and probably occur only in 
 cases in Avhich the dislocation is caused by great 
 violence while the joint is in partial flexion. 
 
 Symptoms. — The elbow is jjartly flexed ; the 
 region is swollen ; if the thumb and middle finger 
 are placed on the internal and external epicondyles, 
 and the forefinger on the olecrantjn. the displace- 
 ment of the latter is readily recognized, and then 
 if the head of the radius is sought for it will be 
 found behind the external condyle as a bony 
 prominence Avhich rotates when the hand is pro- 
 nated and supinated. Passive flexion and exten- 
 sion arc possible within a narrow range, and in 
 full extension abnormal lateral mobility can be 
 recognized. If the swelling is not too great, the 
 tendon of the triceps can be felt or seen curving 
 backward to the olecranon when the joint is 
 flexed. The trochlear prominence of the humerus 
 is sometimes recognizable in the flexure of the 
 elbow, and may be very prominent. 
 Treatment. — Reduction in recent cases is generally very easy, especially if 
 the opposition of the muscles is overcome by anesthesia; it is then usually possi- 
 ble to slip the bones into place by pressure upon their projecting ends or by trac- 
 tion at the wrist. A plan that is often remarkably easy and successful without 
 anesthesia is that in which the elbow is slightly over-extended and the bones 
 then drawn into place by traction upon the forearm. There are cases in which 
 the dislocation can be thus reduced and reproduced at will with the greatest 
 ease and without causing any pain. The method by forcible flexion of the 
 elbow about the surgeon's knee placed in the fold of the joint, while at the 
 same time the forearm is forcibly pressed away from the arm by the knee, 
 has been in use for centuries, and is generally successful, although theoretically 
 
 Dislocation of the Elbow Back- 
 ward fStimson). 
 
DISL O CA TIONS. 44o 
 
 faulty. It is likeiy to tail whenever one or the other lateral ligament is insuf- 
 ficiently torn. If sufficient time has passed to have permitted the formation 
 of strong adhesions, they must first be broken by forcible flexion, and Ity this 
 manipulation it may happen that tiie olecranon j)rocess will be broken. 
 
 (Jompomid didocationa are to be treated according to the principles govern- 
 ing in such injuries, and they often yield very satisfactory results. The choice 
 lies between excision of the end of the humerus and deduction with ample 
 provision for drainage. The former may be expected to give a movable but 
 comparatively weak joint; the latter carries the greater chance of dangerous 
 suppuration with ultimate ankylosis and a strong but stiff limb. 
 
 The after-treat nic lit calls only for immobilization of the limb for about 
 three weeks. Passive motion to prevent ankylosis is not required, and is likely 
 to do harm ; the stiffness that exists Avhen the arm is removed from its dressings 
 will gradually disappear under the natural use of the limb. Massage and hot 
 and cold douches can be used Avith advantage at an earlier date. In children 
 there is the chance that the irritation of the injury, and especially the stripj)ing 
 up of the periosteum from the humerus, may result in an abnormal production 
 of bone that will mechanically limit the mobility of the joint; but passive mo- 
 tion will not prevent this result. 
 
 Lateral Dislocations of the ELBOw^ — The radius and ulna may be 
 together dislocated incompletely to either side, or completely to the outer side, 
 the coronoid process generally remaining anterior to the humerus. It would 
 appear from the observations of some surgeons that incomplete dislocations, 
 especially to the inner side, are tolerably frequent and often pass unrecog- 
 nized, being mistaken for backward dislocation or for fracture of the humerus. 
 
 The cause is usually a fall upon the outstretched hand, and the mechanism 
 appears to be an exaggeration of the outward angle of the elbow, by which the 
 internal lateral ligament is torn and the ulna moved directly downward away 
 from the trochlea, the radius and capitellum remaining in contact by their 
 edges ; a gliding lateral movement follows, by which the forearm is moved 
 either inward or outward to produce one or the other form. 
 
 Incomplete Inward Dislocation. — The sigmoid cavity of the olecranon 
 lies below and embraces the internal epicondyle, and the radius lies in front of 
 and somewhat below the trochlea, the sharp inner edge of the latter being inter- 
 posed between it and the coronoid process. Both lateral ligaments are torn. 
 
 The forearm is pronated and slightly flexed; its axis is parallel to and a, 
 little to the inner side of that of the arm. The olecranon and external con- 
 dyle are prominent, the internal epicondyle masked, the head of the radius to 
 be felt below and to the inner side of its normal position. Flexion and exten- 
 sion appear to be easy and not very painful. 
 
 Heduction is made by traction upon the extended forearm and direct lateral 
 pressure at the elbow. In cases that have remained unreduced the usefulness 
 of the limb appears not to have been much impaired. 
 
 Incomplete Outward Dislocation. — The radius and ulna are dis- 
 placed outwardly so far that at least the central longitudinal ridge of the sig- 
 moid cavity of the olecranon has passed beyond the outer rim of the trochlea ; 
 the radius lies partly below or entirely beyond the external condAde. Both 
 lateral ligaments are torn, and in a considerable proportion of cases the epi- 
 trochlea is broken off, and even displaced so far downward and outward that 
 it lodges in the groove of the trochlea. The elbow is more or less flexed, and 
 the forearm pronated and either parallel to the arm and somewhat external 
 to it or abducted. The internal condyle is prominent and the skin tightly 
 stretched over it; the external condyle is masked by the projection of the 
 
446 
 
 AX AMERICAN TEXT-BOOK OF SURGERY. 
 
 Fig. 186. 
 
 head of the radius. The olecranon is j)roniincnt. and the tendon of the tri- 
 ceps curves sharply backward and outward to it : tla- head of the radius can 
 be easily felt (Fig.' ISC). 
 
 The first indication for treatment is to disengage the ridge of the sigmoid 
 
 fossa from the gro<jve between the troch- 
 lea and capitellum, which may be done 
 by traction, or by hyper-extension, or by 
 abduction of the extended ft»rearm if the 
 radius still rests against the external con- 
 dyle so as to furnish a fulcrum ; then the 
 bones must be i)ushed laterally into place 
 by pressure ujjon the head of the radius. 
 If the broken epitrochlea is lodged in 
 the groove of the trochlea, it may seri- 
 ously oppose reduction, and in some 
 cases it has prevented it. 
 
 Complete Outward Dislocation. 
 — There are three varieties, according 
 to the extent of the displacement. In 
 the first the radius and ulna are moved 
 directly outward so far that the inner 
 edge of the sigmoid cavity of the olec- 
 ranon lies against the outer surface of 
 the external condyle, and the radius is 
 still farther to the outer side or has been 
 moved upward by pronation of the fore- 
 arm. In the second (sometimes called 
 subepicondylar) the forearm is flexed 
 and rotated inward ninety degrees, so 
 that the anterior surface of the ulna looks inward and its sigmoid cavity 
 embraces the outer aspect of the external condyle, the radius lying above it 
 and in front of the supracondylar ridge. In the third (supra-ei)icondylar) 
 
 the bones are moved still farther 
 up along the outer border of the 
 humerus, and sometimes also back- 
 ward so that the coronoid process 
 and the head of the radius lie be- 
 hind the suj)in:i tor ridge (Fig. 1H7). 
 The cause is a fall ujton the 
 hand or elbow or a blow upon the 
 inner side of the forearm near the 
 elbow. 
 
 The diagnosis is made by 
 recognition of the j)rominent ends 
 of the bones, the broadening of 
 the elbow, and the direction of the 
 bones of the forearm. In the first 
 variety the elbow is more likely to 
 be extended ; in the two others it 
 is flexed. 
 
 Reduction is usually easy because of the extensive laceration of the liga- 
 ments. In cases in which reduction has not been made the limb has been 
 very useful and motion at the elbow free. 
 
 Outwar.l -ui.iM-cijicondylar) Dislucatiou of the 
 Elbow (original). 
 
 Fig. 187. 
 
 Complete Outward Dislocation of the Elbow : A, radius ; 
 B, olecranon ; C, internal condyle (Hamilton). 
 
DISLOCATIONS. 447 
 
 Forward 1)I^^L0(•.\TI().\ of the Elbow. — Of this rare injury twenty 
 cases have been rej)<)rte(l, seven of wliieh were eonipound, and six of these 
 seven were further eoniplieated by fraeture of the oleeranon. In most of the 
 cases the cause was violence received upon the back of the flexed elbow. When 
 the olecranon is l)roken its tip remains in place, and the ulna and radius are 
 displaced upward u}>ou the anterior surface of the humerus. The cases not 
 cc)m])licated by this fracture present two varieties or degrees : first, that in 
 whieh the upper end of the olecranon rests against the under surface of the 
 humerus; seeond, that in whieh it has passed to the anterior surface of the 
 humerus : in the latter the triceps always appears to have been torn away from 
 the olecranon. Reduction was made in all but one of the simple cases, and in 
 that one the nature of the injury was not recognized and the limb was am])U- 
 tated. Of the seven compound cases, four suppurated ; two of these came to 
 amputation, and one recovered Avith a stift' joint. 
 
 Divergent Dislocation of the Radius and Ulna. — Of this two 
 varieties have been observed : the aniero-jjosterior (11 cases), in which the ulna 
 passed up behind, and the radius in front of, the humerus ; and the transverse 
 (1 case), in Avhich the olecranon lay behind the epitrochlea and the radius on 
 the outer aspect of the external condyle. The cause in several of the cases 
 appears to have been forcible abduction of the forearm, by which the internal 
 lateral ligament was ruptured, followed by internal rotation of the forearm. 
 In two cases reduction failed, and in one, only the ulna could be replaced. 
 
 Dislocation of the Ulna Alone. — This is very rare. The ulna is 
 displaced backward and more or less outward behind the radius by internal 
 rotation of the forearm upon the head of the radius as a center, and then car- 
 ried upward far enough to engage the coronoid process behind the humerus by 
 adduction of the forearm. The mode of pi'oduction appears to be hyper-exten- 
 sion or abduction of the extended forearm until the internal lateral ligament 
 ruptures, and then internal rotation (pronation) and adduction. 
 
 The forearm is usually in full extension and adducted ; flexion is very 
 painful, rotation free. The trochlea is prominent in front, and the olecranon 
 is prominent behind ; the head of the radius is in place. 
 
 Dislocations of the Radius Alone. — Four forms are recognized, — back- 
 ward, outward, forward, and downward ; but the character of the latter is still 
 iisputed. 
 
 Backward. — The head of the radius is displaced backward, and some- 
 times carried a little upward behind the humerus by abduction of the fore- 
 arm or by the aid of an associated fracture of the ulna or rupture of the inter- 
 osseous ligament, which permits the radius to move upward independently of the 
 ulna. The mode of its production is not understood. The orbicular liga- 
 ment ha» been found torn, and also the external ligament at its posterior part. 
 Reduction has been easily effected in recent cases by direct pressure forward 
 on the head of the radius, but in some instances the interposition of the orbicular 
 ligament has prevented reduction. 
 
 Outward. — This form is very rare, and most of the reported cases Avere 
 of long standing when reported ; in some of them the inner portion of the 
 head of the radius had been broken off. The diagnosis is made by the recog- 
 nition of the head of the radius outside of its normal position and of the ulna 
 in its proper place. 
 
 Forward. — This is more common than the two preceding forms, and a not 
 infrequent accompaniment of fracture of the shaft of the ulna by a fall upon 
 the hand. The head of the radius is displaced forward, and perhaps upward 
 by abduction of the forearm or by a total movement of the radius in that 
 
448 .l.V AMERICAN TEXT-BOOK OF SURdKRY. 
 
 direction, so that it rests, wlit'ii the elbow is flexed, against tlie anterior sur- 
 face of the external eondyle above its normal position. The orbieular liga- 
 ment and outer portion of tiie anterior li<^anient are torn. Tiie limb can be 
 abducted; full extension and liexion to a ri<fht angle are possible: suj)ination 
 is limited. The head of tiie radius can be felt in the fold of the elbow in 
 front of its normal position. Keduction has been sometimes easy, sometimes 
 difficult or impossible. The best method of reduction appears to be adduction 
 of the extended forearm, followed by direct pressure upon the head of the 
 radius. In cases of fracture of the shaft of the ulna this dislocation should 
 ahvays be looked for. 
 
 Downward, i»r Dislocation by Elongation, or Subluxation of Young 
 Children. — This, though of fretiuent occurrence, is observed almost exclu- 
 sively by the family practitioner or the dispensary surgeon. The theory of its 
 nature which is most widely held is that oifered by Duverney in 1751 — namely, 
 a displacement of the head of the radius downward so far that it engages under 
 the lower border of the orbicular ligament. 
 
 The clinical history is characteristic : a child, usually under three years of 
 age, is pulled by the hand ; it cries out with pain, and refuses to use the limb, 
 which hangs by the side, partly flexed at the elbow and pronated. There is 
 sensitiveness on pressure over the head of the radius, and a slight interval can 
 sometimes be felt between the latter and the condyle. Passive motion is free 
 in every direction except supination. On forcible supination a slight click is 
 sometimes felt, and the child at once begins to use the arm. 
 
 Old Unreduced Dislocations. — The solidity of the adhesions that unite 
 the displaced olecranon to the back of the humerus is such, and the production 
 of new bone by the irritated and loosened periosteum in the young is so prompt, 
 that dislocations early become irreducible by ordinary methods. If the limb 
 is extended and stiff", the position can be improved by forcible flexion, with or 
 without fracture of the olecranon, or resort may l)e had to open arthrotomy 
 with division or removal of the obstacles, or to excision. If open arthrotomy 
 is done, the incisions must be so planned that the adhesions on the inner and 
 outer sides of the humerus can be divided, and the sigmoid cavity freed of the 
 fibrous tissue which usually fills it. The choice lies between two lateral incis- 
 ions and a posterior transverse or U-shaped incision, through Avhich the triceps 
 is divided close above the olecranon and the joint freely opened from behind; 
 the first-named method is generally preferred. 
 
 DISLOCATIONS AT THE WRIST. 
 
 Dislocation of the Lower Radio-ulnar Joint. — By general usage 
 the ulna is spoken of as the dislocated bone. The dislocation may boiforward 
 or backward. 
 
 In the backward variety the cause has been exaggerated pronation, either 
 voluntary, as in wringing clothes, or by external violence. The end of the 
 ulna forms a marked prominence on the back of the Avrist, and sometimes over- 
 laps the radius slightly. Reduction by direct pressure is easy. 
 
 In the forward variety external violence is the common cause. The ulna 
 projects anteriorly, and sometimes overlaps the radius as in the backward vari- 
 ety. Reduction by direct pressure is easy. 
 
 Dislocation of the Carpus from the Radius. — This may take place 
 backward or forward, and in two cases was outward ; it may be complete or 
 incomplete, and may be accompanied by fracture of the anterior or the posterior 
 lip of the radius. The cause is forcible flexion or extension of the wrist or 
 
DfSLOCATrOXS. 
 
 449 
 
 direct violence. lu the incom])lete forms the cuneiform maintains its relations 
 with the triangular fibro-cartilage, while the scaphoid and semilunar are dis- 
 placed from the radius ; in one case the semilunar remained attached to the 
 radius, while the rest of the carpus was displaced backward. 
 
 The common Colles's fracture of the lower end of the radius was long 
 thought to he a dislocation of the wrist backward. The differential diagnosis 
 IS to be made by attention to the position of the styloid process of the radius, 
 to its relations with that of the ulna and with the proj^ecting mass on the back 
 
 Fig. 188. 
 
 Diagrammatic, to indicate the deformity in [A) dislocation of the wrist backward, and 
 (B) Colles's fracture of the radius (Stiinson). 
 
 of the wrist, and with the metacarpus. Fig. 188 shows the deformity in the 
 two injuries. 
 
 In dislocation forward the carpal bones form a rounded prominence on the 
 front of the wrist, and the lower end of the radius presents as a sharply-defined 
 line posteriorly, with a well-marked depression below it corresponding to the 
 prominence in front. Reduction is easy by traction and direct pressure. 
 
 Spontaneous suhJuxation fortvard has been recently described by Made- 
 lung. It occurs gradually in adolescents or young adults, and is characterized 
 by the absorption or arrest of growth of the anterior portion of the articular 
 surface of the radius, with corresponding displacement forw^ard and upward of 
 the carpus. The end of the ulna projects markedly, and the antero-posterior 
 diameter of the wrist is much increased ; dorsal flexion is limited. 
 
 Dislocations of the Carpal Bones.-»-A very few cases of dislocation of 
 the second row of the carpus backward or forward from the first have beeu 
 reported. 
 
 Isolated dislocation of every one of the bones of the carpus except the 
 cuneiform has been reported. The semilunar is the one most frequently dis- 
 located, the injury having been compound in half the cases reported, and the 
 displacement forward in all but one. 
 
 Carpo-metacarpal Dislocation. — The metacarpal bone of the thumb is 
 the one most frequently dislocated, the displacement being usually backward 
 and more often incomplete than complete. The cause in backward dislocation 
 is eithef forcible flexion of the member or direct violence. The base of the 
 metacarpal bone can be seen and felt as a prominence between the tendons of 
 the extensor primi and extensor secundi internodii. Reduction is usually easy 
 by direct pressure, but there is often a marked tendency to recurrence, which 
 must be opposed by a splint or by maintaining the member in abduction and 
 extension for one or two weeks. Dislocations forward and outward of the 
 same bone have been observed. 
 
 Isolated dislocations of the second and third metacarpals have also been 
 observed, and dislocation backward of the four inner and forward of all five 
 metacarpals. 
 
 Dislocations of the Thumb and Fingers. — Dislocation of the metacarpo- 
 phalangeal joint of the thumb is quite common, and has received much atten- 
 
 29 
 
450 
 
 ^.V AMEUrCAX TEXT- HOOK OF SURGERY. 
 
 Backward 
 
 I-'lu. ISi). 
 
 tion because of the (lilliculty fVe(iuently experienced in reduction of the back- 
 ward variety — a diHiculty the cause of whicli is now generally believed to be 
 the interposition of the anterior or glenoid ligament, with its included sesamoid 
 bones. 
 
 lislocation of the tluuub presents three forms: incomplete, 
 complete, and comjilex. The first is a form which can be 
 voluntarily produced by many persons b}' contraction of 
 the extensor of the first joint. The first phalanx moves 
 backward and stands at a right angle to the metacarpal 
 bone, from which position it can be returned with(jut 
 difficulty to its place by the action of the flexors. 
 
 In the coinplete form the phalanx is carried back- 
 ward and upward on the dorsum of the metacarpal, 
 usually by forced extension, the anterior ligament is 
 torn away from the metacarpal bone and drawn back- 
 ward witli its sesamoid l)ones along, and even past, tiie 
 articular surface of the head, while the tendon of the 
 long flexor slips to one side of the head, usually the 
 inner, although it may exceptionally remain in ])lace, 
 stretched along the head of the metacarpal. The first 
 phalanx is in extension at a right angle, the terminal 
 phalanx in flexion, the head of the metacarpal is promi- 
 nent in the thenar eminence (Fig- 18'J). 
 In the complex form, a form produced from the comjilete by forced flexion 
 of the thumb, the glenoid ligament is turned upward so as to lie between the 
 phalanx and the head or dorsum of the metacarpal. The thumb is in straight 
 
 Simple ComjiletL' Disloca- 
 tion of Right Thumb. 
 The long flexor tendon is 
 displaced to the inner 
 side (Fiiriihevif ). 
 
 Fk;. 190. 
 
 Complete Dislocation of the Thumb, outer side. The hook raises the periosteal continuation of the 
 lateral ligament, exposing the reflected sesamoid bone (Farabeuf ). 
 
 extension, parallel and posterior to the metacarpal ; its base can be felt as a 
 prominence ])eliind, and the head of the metacarj)al in front (Fig. 190). 
 
 The essential point in reduction is to avoid the transformation of the 
 complete into the complex form. The extension must be maintained or even 
 increased, and then the thumb should be pressed bodily downward until the 
 anterior edge of its base overlaps the articular surface of the metacarpal, when 
 it can be turned into place by flexion ; in this way the glenoid ligament and 
 the sesamoid bones are pushed before the phalanx. If this fiiils, the surgeon 
 can sometimes succeed by combining rotation of the thumb with pressure down- 
 ward, so as to free first one side and then the other — a sort of unbuttoning of 
 the head of the metacarpal from the grasp of the glenoid ligament and the 
 attached heads of the short flexor. In the complex form the same method 
 must be employed, but it is necessary to use more force, so as to ])ring the 
 
DISLOCATIONS. 451 
 
 tliuinl) fiirtluT (lowinvanl and free the e(l<,'e of the li;,faiiU'nt wliicli has been 
 turned up^vard. 
 
 It' manipulation fails, a longitudinal incision should be made, aseptically 
 of course, on the palmar aspect of the joint, cutting directly down upon the 
 head of the metacarpal; by tlrawing the edges of the incision apart the glenoid 
 ligament is exposed, and its free edge should then be nicked at its center and 
 lifted }»nst the head of the bone. 
 
 In forward dislocation, usually due to forced flexion, the base of the 
 phalanx lies anterior to, and perhaps a little to one side of, the head of the 
 metacarpal, and the posterior and lateral ligaments are torn. It is recognized 
 by the projection of the head of the metacarpal on the dorsum, and of the 
 base of the phalanx in front. It is easily reduced by direct pressure aided by 
 traction, or by increasing the flexion and then pressing the phalanx bodily 
 downward as in the dorsal form. 
 
 Metacarpo-phalangeal Dislocation of the Fingers. — These joints 
 have a glenoid ligament similar to that of the thumb, and sometimes a sesamoid 
 bone is developed in it. There is the same difficulty in reduction of the back- 
 ward dislocations. It is due to the same cause and is to be met by the same 
 measures. 
 
 Dislocations of the Phalanges. — These may be forAvard, backward, or 
 lateral. Reduction is • usually easy, although it is possible that the thick 
 anterior ligament may become interposed as at the metacarpal joint. 
 
 dislocations of the pelvis and coccyx. 
 
 The bones of the pelvis may be dislocated from each other or from the 
 sacrum at the pubic or sacro-iliac symphysis, but the lesion is commonly asso- 
 ciated with fracture of the pelvis, to which the reader is refen-ed. 
 
 Dislocation of the coccyx is a rare injury, more common in women 
 than in men, and is accompanied by symptoms of pain, disability, and nervous 
 disturbances that are present also in cases in which there is no dislocation or 
 fracture. 
 
 Forward dislocations have been caused by violence received upon the region 
 of the coccyx. The pain is severe and radiates through the trunk and limbs, 
 and is increased by any movement. The finger in the rectum recognizes the 
 coccyx flexed forward, and if it is pressed backward into place the pain ceases. 
 The tendency to recurrence is great, and if it is manifested the surest method 
 of treatment would probably be to excise the bone — an operation that is very 
 successful in the allied cases in which there is no dislocation. 
 
 dislocations of the hip. 
 These form, according to different statistics, from 2 to nearly 10 per cent, 
 of all dislocations ; they have been observed at all ages from six months to 
 ninety-one and a half years, and are much more frequent in men than in 
 women. The head of the femur may be primarily displaced in any of the four 
 principal directions, and may undergo a number of secondary displacements. 
 The "typical" cases, as shown by Bigelow, are those in which the Y-ligament 
 remains untorn in whole or in part and imposes a definite attitude upon the 
 limb. This ligament has the form of an inverted Y ; the base of the A is 
 attached to the anterior inferior spine of the ilium and the surface of the bone 
 immediately external to it and above the edge of the acetabulum, and its fibers, 
 diverging downward, form two strong bands, the inner and outer, which are 
 
452 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 attached respectively to the iiuier iuul outer ]>ortioiis of tlic imtfi'ior inter- 
 trochiiiiterie line. 
 
 Coiiijjound dislocations are very rare. 
 
 Dislocation of" the liip-joint may occur durin;^ or especially after typiioid 
 and occasionally after other eruj)tive fevers. The dislocation is due to over- 
 distention of the capsule and elongation of the ligaments which follow a 
 suhacute synovitis. The assumption of an hahitual attitude may prove a 
 factor in the production of a dislocation. The exciting cause of dislocation 
 is a slight force (turning in hed — lifting the patient). Keen helieves that in 
 many cases muscular contraction is the cause. The dislocation takes place 
 upon the dorsum of the ilium and is seen almost exclusively under twenty 
 years of age. Freciuently the dislocation is not discovered at the time of its 
 occurrence, but is noted some time afterward. If the dislocation is discov- 
 ered soon after its occurrence reduction can he readily effected ; hut if it is 
 not discovered for some time reduction may be impossible. 
 
 In the most conniion form the head of the femur passes backward out of 
 the socket while the thigh is flexed, adducted, and rotated inward ; if tlie 
 flexion is in great part maintained, the head remains close behind the ace- 
 tabulum, but if the flexion is diminished the head rises. The head may also 
 pass directly to this higher position by leaving its socket when the thigh is 
 but slightly flexed. The earlier writers made two classes of these two forms, 
 calling the former "dislocation into the ischiatic notch," and the latter "dis- 
 location upon the dorsum of the ilium," and supposed the latter to be the more 
 frequent. Later investigations, notably those of Malgaigne and Bigelow, 
 showed that the difference was generally due to a secondary displacement, the 
 head most frequently leaving the socket at the lower point, and rising in the 
 higher cases in consequence of the lowering of the knee. This has led to a 
 general abandonment of the division, and to the grouping of all the cases as 
 "dorsal," or "backward." The following classification, taken from Stimson, 
 resembles that used for dislocations of the shoulder ; the names of the principal 
 classes indicate the direction of the primary displacement, and those of the 
 varieties indicate either the place at which the head comes to rest or some 
 marked clinical feature : 
 
 Dislocations backward 
 
 Dislocations downward and 
 inward 
 
 Dorsal, comprising the "iliac" and the "ischiatic," or those 
 " upon the dorsum ilii" and "into the ischiatic notch" of 
 older writers. 
 
 Anterior oblique. 
 
 Everted dorsal, comprising the "supraspinous" and some of 
 the " supracotyloid." 
 
 Obturator. 
 
 Perineal. 
 
 Dislocations forward and ] o v I t) i • 
 
 upward . . . } Suprapubic j Pubic. 
 ^ . ■' [ Intrapelvic. 
 
 Dislocations directly upward (supracotyloid or subspinous). 
 Dislocations downward on the tuberosity of the ischium. 
 
 BACKWARD DISLOCATIONS. 
 
 In this class the head of the femur passes over the posterior lip of the ace- 
 tabulum, and lodges close behind it, or behind and above it, in the common 
 "dorsal" form in which the limb retains the attitude of flexion, adduction, 
 and inward rotation Avhich it had when the dislocation occurred. Occasionally, 
 
DISLOCATIONS. 
 
 4o3 
 
 but very rarely, the head un(lern;ocs furtlier disphvcement forward and iriAvard 
 by outward rotation of tlie linil), with ahihiction, and extension — the "everted 
 dorsal " variety ; and IJij^elow has described a still more rare variety in which 
 outward rotation is combined Avith Ilex ion and marked adduction, the head 
 rests above the acetabulum, and the lower part of the neck lies at its upper 
 and posterior margin — the "anterior oblique" variety. 
 
 1. Dorsal Dislocation. — This is by far the most common form ; it 
 includes those described as dislocations "upon the dorsum ilii," "into the 
 sciatic notch," "iliac," "ischiatic," "dorsal," and "dorsal below the tendon" 
 of various writers. The head of the femur leaves the joint posteriorly at a 
 higher or lower level ; it may pass below the tendon of the obturator internus, 
 or between it and the pyriformis, or above the latter ; it usually rests close to 
 the margin of the acetabulum, seldom if ever reaching the great sciatic notch, 
 but occasionally passing up to the dorsum of the ilium. 
 
 The cause is external violence acting from below upward in the direc- 
 tion of the long axis of the femur, and tending to push the knee toward 
 the pelvis while the thigh is flexed, adducted, and rotated inward, or exag- 
 gerated adduction and inward rotation combined with flexion. It may be 
 produced by transformation of a thyroid dislocation by flexion, adduction, 
 and inward rotation. 
 
 The capsule is irregularly torn in its posterior and lower portion, and is 
 occasionally detached from the femur, or, more rarely, from the acetabulum. 
 In the regular or typical cases the Y-ligament is untorn. The ligamentum 
 teres is torn away from the femur or ruptured. The quadratus femoris and the 
 gemelli are usually ruptured, and the tAvo obturators and the pyriformis may 
 be more or less torn. 
 
 It seems to have been satisfactorily shown that in the greater number of 
 cases the head leaves the socket at a relatively low point (the so-called ischiatic 
 form), and then rises, as the knee 
 
 is lowered, behind the obturator T^tg. 192. 
 
 internus (Fig. 191), or pushes that 
 muscle upward ; less frequently 
 it leaves the socket at a higher 
 point (the primary iliac form) and 
 remains in front of the obturator 
 
 Fig. 
 
 Pyr^f' 
 
 Odl.Ext. 
 
 m.Inl. Ei 
 
 Dislocation below, and then Ijehind and above, 
 the Obturator Internus (Stimson). 
 
 MacCorniac's Specimen of Recent Dorsal 
 Dislocation. The head of the femur 
 lies just behind the acetabulum, be- 
 low the pyriformis and above the ob- 
 turator internus and the torn gemel- 
 lus muscles (MacCormae). 
 
 internus (Fig. 192). The lowest point at Avhich it has been known to lodge is 
 the base of the spine of the ischium, the highest (possibly with rare exceptions) 
 a point on the ilium in front of the highest part of the great sciatic notch. 
 
4r,4 
 
 .i.v jj//;/.'/r.Lv Ti:xr- HOOK or sinoKin'. 
 
 Fig. 103. 
 
 The edge of the acetahuhmi may be chi|)j)0(l or even extensively hroken; the 
 head of tlie trnnir has l)een l)roken onee or twiee. 
 
 The symptoms are marked: tlie liml» is aihhicted, rotated inward, and 
 more or less Hexed (Fig. 1!>8), so that its knee rests upon the front of the 
 opposite thigh when the patient is reeumbent, its toes on the dorsum of the 
 other foot when he is upright. Flexion may be masked by the tilting of the 
 pelvis, in which case marked lordosis of the lumbar s])ine can be recognized 
 by passing the hand under the patient as he lies on his back. The upper 
 and outer part of tlie thigh is broadened, the troclianter rises above a line 
 'drawn from the anterior superior spine of the ilium to the tuberosity of the 
 ischium (Nelaton's line), and the head of the femur may be obscurely felt in 
 the buttock. 
 
 Voluntary movements are lost, but passive flexion and adduction are 
 possible; extension, abduction, and outward rotation impossible. 
 
 Because of its adduction the limb appears much shortened ; actual short- 
 ening will be found on measurement if the other limb is symmetrically placed, 
 but this is not usually needed to make the diagnosis. The 
 symptoms and the whole appearance of the limb are so 
 characteristic that the nature of the injury can hardly 
 fail to be recognized ; a much more common error is to 
 mistake a fracture of the neck of the femur for a disloca- 
 tion. 
 
 2. Everted Dorsal Dislocation. — As the name 
 indicates, this exceptional form differs from the common 
 one in the substitution of outward for inward rotation of 
 the limb, a substitution that is made possible by rupture 
 of the outer branch of the Y-lig^™eiit. If the head of 
 the femur remains behind the socket, flexion and some 
 adduction persist, but if it has moved upward and for- 
 ward to a position near to and above the anterior inferior 
 spine of the ilium, there will be extension and slight ab- 
 duction. 
 
 3. Anterior Oblique Dislocation. — In this, of 
 which there appears to be only one recorded case, the 
 limb crosses the opposite thigh, everted, and with the 
 knee extended. 
 
 Treatment of Backward Dislocations. — The es- 
 sentials in making reduction are to relax the untorn por- 
 tions of the cai)sule and the Y-ligJ^nient ; then to bring the 
 head of the bone, if necessary, opposite the rent in the cap- 
 sule, and to lift it into place by traction or manipulation, or by abduction and 
 outward rotation, Avhich accomplishes the same end through the agency of the 
 remaining ligaments. The patient is placed flat on his back, the pelvis steadied 
 by downward pressure of the surgeon's foot or of an assistant's hand upon the 
 anterior superior spine of the corresponding ilium ; the knee is flexed at a right 
 angle, the thigh rotated farther inward, flexed to a right angle (sometimes even 
 beyond), and then lifted bodily upward and rotated outward and lowered in ab- 
 duction. The lifting can be made easier by making a long loop of a bandage and 
 passing it over the Surgeon's shoulders and under the hollow of the patient's knee. 
 Or the patient may be laid on his face on a bed or table in such a way that 
 his thighs extend beyond its margin. The sound limb is held horizontal by an 
 assistant, and the dislocated one allowed to hang vertically down, the knee 
 flexed, and the ankle held by the surgeon. While the surgeon gently swings 
 
 Dorsal Dislocation of the 
 Femur (Cooper). 
 
DISLOl'ATIONS. 
 
 45r> 
 
 the limb tVuui side to side and diverts the patient's attention the niiiseles will 
 be seen to relax, and the bone will often slip into place without further manip- 
 ulation or with the aid only of a slij^ht (juiek pressure downward upon the calf. 
 
 Occasionally these methods fail, the head seeming to bo firmly caught by 
 some opjHising bony projection. After several failures another repetition, of 
 the attempt uuiy instantly succeed, or traction made by an assistant in the 
 direction of the axis of the slightly Hexed and adducted thigh while the sur- 
 geon presses inward against the great trochanter nuiy be successful. Anesthe- 
 sia is a great help. 
 
 Occasionally the manipulation transforms the dislocation into a thyroid one; 
 it can be restored to its original form by reversing the movement : flexion in 
 abduction and outward rotation, followed by adduction and rotation inward. 
 
 The everted dorsal and anterior oblique are reduced by first converting 
 ihem into the dorsal form and then treating them as such. 
 
 Fig. 194. 
 
 DISLOCATIONS DOWNWARD AND INWARD. 
 
 The head of the femur escapes at the lower or lower and inner part of the 
 socket, and either lodges in the obturator foramen, obturator or tlnjroid disloca- 
 tion, or passes farther inward to the perineum, perineal dislocation. The limb 
 is flexed, abducted, and. rotated outward. 
 
 1. Obturator Dislocation. — This is commonly caused by violence re- 
 ceived upon the back of the pelvis while the thigh is somewhat flexed and 
 abducted, but it may be produced by forced abduction alons. As the Y-liga- 
 ment is untorn and the head is displaced downward and inward, the limb is 
 held in abduction and flexion, and cannot be extended or adducted ; after flex- 
 ion it can be adducted. If the patient stands upright the injured limb is held 
 forward and appears to be lengthened in consequence of the lowering of that 
 side of the pelvis. If a comparative 
 measurement is made while the thighs 
 are well flexed, shortening will be 
 found. The trochanteric region is 
 flattened, the adductors tense. If 
 the patient is thin, the head of the 
 femur may perhaps be felt on deep 
 pressure through the adductors. 
 
 It has been stated on excellent au- 
 thority that a number of patients have 
 been able to walk immediately after 
 the accident and have not sought 
 treatment until after several days. 
 
 Reduction is made by flexion of 
 the hip to a right angle, traction while 
 making adduction, and then rotation 
 inward while lowering the knee ; fur- 
 ther outward instead of inward rota- 
 tion in the last step may also succeed. 
 2. Perineal Dislocation. — As 
 the head of the femur in this form is 
 displaced farther inward, the flexion 
 and abduction of the limb are much 
 
 Perineal Dislocation of Hip (original). 
 
 more marked, more so than can be together obtained in a normal limb. I here 
 is half an inch shortening, perhaps more. The cause is forcible extreme ab- 
 duction, and the laceration of the soft parts must be extensive (J^ig. 194). 
 
4o(j .i.v ami:ju<a.\ 'nixT-iiooK or surgery. 
 
 In two cases reported ])y Stiiiisoii reduction was easily made under ether 
 by flexion, traction, adduction, and lnwerinj: of the limit. 
 
 DISLOCATIONS Ul'WAUI) AND FOKWAki) AND INWAKI) AND FOJiWAKD 
 
 (SUPRAPUBIC). 
 
 The liead of tlie fenmr may rest u))on the upper ramus of tlie pul)es at tlie 
 ilio-])ectineal eminence or farther inward near tlie symphysis, Jn tlie latter 
 case it is thought to have reached this position by risint; from the obturator 
 foramen, a transformation of an obturator into a suprapubic dislocation ; in the 
 former it leaves the socket at its upper and inner part by hyper-extension or 
 abduction and outward rotation of the limb. The psoas and iliacus muscles 
 are stretched across the neck,. and the femoral vessels are usually raised by the 
 head. 
 
 The ilio-pectineal is the more common form ; in it the limb is markedly 
 everted and slightly abducted. The head of the femur can be readily felt in 
 the groin. The outer and posterior aspects of the hip are flattened. 
 
 Reduction is made by traction in the axis of the limb as it lies, in order 
 to bring the head down past the pubic ramus; then flexion while pressure is 
 made against the head to prevent it from moving upward again ; and finally 
 rotation inward. 
 
 DISLOCATIONS DIRECTLY UPWARD (SUPRACOTYLOID). 
 
 In this form of dislocation, of which only a very few cases have been reported, 
 the head of the femur is displaced upward and lodges below and a little to the 
 outer side of the anterior inferior spine of the ilium. The cases are too few to 
 permit much generalization, but it can be said that the limb is always everted 
 and sometimes abducted ; the trochanter is moved upward and backward, and 
 the head may be felt on deep pressure. Some of the patients have been able 
 to walk with a limp and have not sought treatment until after several days. 
 
 There is a close resemblance between these cases and those in which the 
 head of the femur is brought above the acetabulum, but at a higher level, by 
 adduction after a suprapubic dislocation or by eversion after a dorsal one (everted 
 dorsal). 
 
 DISLOCATION DOWNWARD UPON THE TUBEROSITY OF THE ISCHIUM. 
 
 This form also is very rare, since the head can easily undergo secondaiy 
 displacement upward and backward, transforming the dislocation into a dorsal 
 one, or forward by abduction and eversion, transforming it into an obturator 
 one. The limb is sharply flexed, and may be somewhat abducted and everted 
 or inverted. 
 
 Reduction has usually been easy by traction in flexion. 
 
 COMPLICATIONS OF DISLOCATION OF THE HIP. 
 
 Compound dislocations are very rare, are produced by great violence, 
 and are usually fatal. The complication has been observed only once in a dor- 
 sal, and two or three times each iji anterior and obturator dislocations. 
 
 Injury of the femoral vessels has occurred only in suprapubic and 
 obturator dislocations. 
 
 Fracture of the neck of the femur has occurred a number of times 
 during attempts to reduce a dislocation. It is of much importance, for it 
 makes reduction practically impossi])le. and if the fracture is at the narrow 
 
J)JSL OCA TJONS. 457 
 
 part of the neck, necrosis of the head is likely to follow. The most that can 
 be done is to put the liinb in a favorable position, or to excise the head and 
 neck in young patients in tlic lioju' of getting a iii()va1)h' joint. 
 
 TREATMENT OF UNREDUCED DISLOCATIONS. 
 
 Attempts that have been made to reduce old dislocations of the hip by 
 arthrotomv have mostly been unsuccessful, either through failure to effect 
 reduction,' through necrosis of the head of the femur, or through the death 
 of the patient ; the only successes (two cases) were obtained by the late Dr. 
 Parkes of Chicago. Excision of the head, or of the head, neck, and tro- 
 chanter, and subtrochanteric osteotomy, have been resorted to with consider- 
 able success in diminishing the disability. In many cases a fairly useful limb 
 will ultimately result even without any operative interference. 
 
 PATHOLOGICAL DISLOCATIONS. 
 
 These may occur as the result of rhachitic changes in the bones, of paraly- 
 sis of some of the muscles, of articular inflammations in the course of various 
 specific fevers, and may occur even in a normal joint as the result of prolonged 
 maintenance of the limb in flexion and adduction. It may occur gradually and 
 painlessly, and perhaps escape observation until it is too late to remedy it. 
 
 Allis's Researches. — Allis classifies all possible dislocations of the upper 
 end of the femur into <lislocations inward—/, e., upon the pubo-ischiatic 
 plane ; and outward—/, c., upon the ilio-ischiatic plane. The method of re- 
 duction is similar in all cases. It consists of two steps. By means of the 
 first the liead is drawn or lifted to a point near the socket ; by the second, 
 the head is pried into the socket through a fulcrum furnished by the hands 
 of an assistant. To make the best use of this method the pelvis should be 
 securely strapped to the floor. In recent cases the pelvis may be held fairly 
 secure by a strong assistant bearing down upon the anterior superior spines. 
 The surgeon slwidd never put forth more strength than would be required to 
 lift a weight equal to that of the patient's leg. 
 ' Dislocation of the Right Femur Inward.— V\^CQ the patient upon the 
 floor. The first"assistant presses down upon the spines of the ilium. I he 
 suro-eon flexes the thigh to a right angle and makes traction outward by the 
 beiit knee. The second assistant now presses deeply with the thumbs or 
 finger-tips at a point opposite the pubes and at the junction of the thigh with 
 the trunk. The surgeon, now regarding this pressure as a fulcrum, raises 
 the knee— but at the same time continuing the traction— and carries it 
 obli(|uely inward toward the pubes. Reduction will take place with a slight 
 iar perceived by both assistants. , . , . ^ i i. 
 
 Dislocation 'of the liiqht Femur Outward.— 'Y}ie pelvis being fixed as be- 
 fore, the surgeon makes traction upward by the bent knee. V\ hen the head 
 of the femur rises upon the pelvis below the socket the surgeon bends tor- 
 ward as if he would draw the head into it. At this moment the second 
 assistant ^rasps the base of the thigh with his two hands, forcing his thumbs 
 deeply in^'at a point just beyond the great trochanter; and the surgeon, 
 reo-ardin.T this pressure as a fulcrum, and still continuing his traction, brings 
 the limb'downward in extension. In case of failure in either case, strap the 
 pelvis to the floor and proceed as before. 
 
 Allis asserts that dislocations of the femur (inward or outward), when 
 accompanied bv fracture of the shaft of the femur below the great trochanter, 
 can be as readi'lv and easilv restored by the above methods as when no com- 
 
458 AX AMi:h'J(AX TEXT- 1 look' or St'RGERY. 
 
 plications exist. ( )m' tliiiiir, liowovor, is alisoliiti'ly iiccossary — viz., the 
 patient's pelvis must be strapjied tu the tloor. 
 
 DI.SLOCATION OF TilE KNKK. 
 
 Dislocsitions of tlie knee are infrequent, and aic divided into the fonvard, 
 backward^ outward, iniiuird, smd bji rotation, oeeurrin"/; in that order of fre- 
 quency. The dislocation is frequently compound, and often complicated by 
 injury of the popliteal vessels, which may consist in complete rupture or in 
 such bruising that a thrombus will form and lead to gangrene. Either popli- 
 teal nerve may also be injured. These possibilities add greatly to the gravity 
 of the prognosis in all the severe forms of di.slocation, and even the return of 
 pulsation in the arteries at the ankle after reduction is not proof tliat the artery 
 is uninjured and gangrene not to be feared. 
 
 Dislocation forward may be complete or, more commonly, incomplete. 
 The cause is hyper-extension of the knee or direct violence received on the front 
 of the thigh or the back of the leg near the knee. AVhen complete, the tibia 
 lies in front of the condyles and may be displaced upward a considerable dis- 
 tance, — four inches in one recorded case ; the laceration of the soft ])arts is 
 extensive. In the incomplete form the articular surfoces of the tibia and femur 
 are still partly in contact, and the laceration is much less. If the dislocation if 
 compound, the wound in the skin is posterior and transverse. The character 
 of the injury is readily recognized by inspection and palpation, and reduction 
 is easily made by traction and direct pressure. 
 
 Backward Dislocation may be complete or incomplete, and is most fre- 
 quently due to violence received upon the front of the leg or the back of the 
 thigh. The muscles behind the knee may be freely lacerated, and the patella is 
 sometimes dislocated outward. The leg is usually in full extension or hyper- 
 extension, and is sometimes deviated to one side. 
 
 Reduction is easy by traction and direct pressure. In a few cases in 
 which reduction was not made the limb was fairly useful. 
 
 Lateral Dislocations are much more infrequent than either the forward 
 or the backward ; they may be outward or, more rarely, inward, complete or 
 incomplete, but the complete variety is extremely rare. The common cause 
 of the incomplete dislocation is forced abduction of the leg for the outward, 
 and forced adduction for the inward variety. The injury is recognized by the 
 lateral projection of the head of the tibia on one side, and of the condyle of the 
 femur on the other; the patella is usually deviated toward the side of the dis- 
 location. Reduction has ordinarily been easy by traction and direct pressure. 
 The importance of obtaining firm union of the ruptured lateral ligaments makes 
 it advisable to keep the limb immobilized and unused for several weeks. 
 
 In Dislocation by Rotation the leg is rotated about its long axis or about 
 an axis parallel with it and passing through the center of one of its upper con- 
 dylar surfaces. The dislocation is termed outward or inward according to the 
 direction in which the toes are turned. In rotation aliout the central axis both 
 condylar surfaces are displaced, one forward, the other backward, and the dis- 
 location is said to be complete ; in the other form the cond^dar surface which 
 corresponds to the axis of rotation remains in place, and the other is displaced 
 forward or backward, constituting incomplete dislocation. The injury is rare, 
 and almost all cases have been of outward rotation. Additional backward or 
 outward displacement may be associated with the rotation. Reduction appears 
 to have been easily effected. 
 
DISLOCATloys. 459 
 
 DISLOCATION OF THE SKMIMNAIi CARTILAOES. 
 
 Either .seniilnn;ii- fartila^e may he (h'taclu-d at either eii<l or peripherally, 
 ami displaced toward the intereondyloid notch or to the outside, or it may be 
 laceiated. The injury may he i)ro(luced duriii<^ a dislocation or a sprain or hy 
 rotation of the leg or flexion of the knee. The internal cartilage is the one 
 more commonly affected. 
 
 The symptoms are very like those excited by a loose cartilage in the joint: 
 sudden, painful locking of the joint, usually occasioned by some definite move- 
 ment, and recurring with greater or less freciuency. Attention has been espe- 
 cially directed to the injury of late, and our knowledge has been increased by 
 the data supplied by several operations undertaken for its relief. The displace- 
 ment of the cartilage may sometimes be recognized by palpation along the 
 upper articular edge of the tibia in front. 
 
 The locking of the joint can be relieved Avithout much difficulty by various 
 manipulations, such as extension followed by sudden flexion, rotation of the 
 leg, or pressure upon the projecting cartilage. To prevent recurrence, various 
 pads and braces have been recommended the object of which is either to oppose 
 the displacement directly or to prevent the amount of flexion of the knee which 
 is a necessary preliminary to the occurrence. The operation that has been most 
 done of late consists in opening the joint by an incision along the side of the 
 patella, exploration through it to determine the exact nature of the lesion, and 
 then such treatment of the cartilage as may seem proper, usually excision of 
 the whole or of a part, or fixation to the tibia along the peripheral border by 
 suture. 
 
 DISLOCATIONS OF THE PATELLA. 
 
 The patella may be displaced to the outer or to the inner side, or may be 
 more or less rotated about its longitudinal axis, "edgewise" or "vertical" dis- 
 locations, or the two forms may be combined in varying degrees (Fig. 195). 
 Displacement upward or downward after rupture 
 of the ligamentum patelh^ or of the tendon of the 
 quadriceps respectively will not be here considered 
 as a dislocation. (See Rupture of Tendons.) 
 
 Displacement to the outer side is very much 
 more frequent than displacement to the inner side. 
 The causes and mode of production of the various 
 forms are much the same, either muscular action or 
 external violence acting directly on the patella 
 Gradual dislocation outward may result from 
 hydrarthrosis of the knee or from genu valgum. 
 
 Outward Dislocation. — This may be com- _ 
 
 plete or incomplete. In complete outward disloca^- ^.^^^^^^,,_ ,_,. ^,^^. variuus^Blli^a- 
 tion the patella rests against the outer surface of tions of the FateUa (Stimson). 
 the external condyle either by its inner border, or, 
 
 more commonly, by its posterior surface, or by its anterior surface, its outer 
 border being directed forward (Fig. 195, 1, 2, and 3). It may reach this posi- 
 tion either while the knee is extended or while it is flexed at about a right 
 angle. The internal lateral ligament of the patella — i. e. the fibrous expan- 
 sion at the attachment of the vastus internus — is ruptured longitudinally, the 
 rent sometimes extending several inches upward into the muscle, and this may 
 be torn away from the patella. 
 
 The nature of the injury is easily recognized, for the patella can be felt 
 in its abnormal position : when rotation of the patella is combined with out- 
 
4()() Ay AMEh'/CA.y TEXT-J'.OOK OF SURGERY. 
 
 ward dislocation it may be mure difficult to determine Avhether it.s outer or its 
 inner border is directed forward. 
 
 Reduction has usually been readily made by direct pressure, after the 
 quadricej)s has been relaxed by extension of the knee and flexion of the hip. 
 In a case seen by the writer simple extension of the knee reduced the dis- 
 location. 
 
 Incomplete dislocations are those in which, the knee being extended, the 
 patella rests above and partly to the outer side of the articular surface of the 
 femur, and those habitual dislocations in which, during flexion of the knee, 
 the patella moves outward and its outward border turns backward. 
 
 Outward Edgewise or Vertical Dislocations. — In these the patella is moved 
 outward and turned upon its longitudinal axis in such a wav that its inner 
 border rests in the groove of the trochlea, its outer border projects forward, 
 and its articular surface looks outward. The degree of rotation mav varv from, 
 say, 45° to 100° or 110° (Fig. 195, 4 to 7). Its fixation in this position is 
 due to the tension of the overlying soft parts. Reduction has usually been 
 effected by extension of the knee and direct pressure on the patella. ' 
 
 Complete reversal, the outer border passing in front to the inner side, has 
 been reported in only two cases. 
 
 Inward Dislocations are the same, mutatis mutandis, as the outward, 
 but they are very much more rare. 
 
 Congenital and Pathological Dislocations. — Congenital dislocations 
 appear to be very rare, most of the cases reported as such being actually habit- 
 ual or permanent dislocations developed during infancy or childhood. The 
 causes of these habitual dislocations are not always clear : in some the dis- 
 placement seems plainly to depend upon a defoimity of the limb, genu valgum, 
 but in most it can only be said that the affection develops gradually, the patella 
 usually slipping outward as the knee is flexed. The use of the limb is more or 
 less interfered with by pain, and sometimes by diminution of voluntary control. 
 The treatment consists in measures designed mechanically to oppose the occur- 
 rence of the displacement, such as a knee-cap or a splint that limits flexion. 
 In a recent case benefit was obtained by excision of a portion of the internal 
 lateral ligament of the patella : in another by pinching up a longitudinal 
 fold and securing it bv a continuous suture. 
 
 DISLOfATIONS OF THE FIBULA. 
 
 Upper End. — The upper end of the fibula may be dislocated outward and 
 forward, or backward or upward. The injury is a rare one, even if those cases 
 are included in which it is associated with fracture of the tibia. 
 
 Outward and Forward. — In the seven reported cases the occasion has 
 been a fall, and the production of the di.slocation appears to have been associ- 
 ated with forcible depression and inversion of the front part of the foot, so 
 that it has been suggested that the immediate cause was traction exerted through 
 the extensor muscles that are attached to the front of the fibula. The displace- 
 ment is easily recognized, and reduction is readily effected by direct pressure 
 upon the head of the fibula. 
 
 Backward. — In three of the five reported cases the cause appears to have 
 been the forcible contraction of the biceps. Reduction was generally easy, 
 but in two the dislocation recurred, and persi.sted in one of them. 
 
 Upward. — There are three reported cases, but in only one of them is the 
 diagnosis beyond question. In this one (Boyer) the patient appears to have 
 also suffered a dislocation outward at the ankle or a lesion resembling a 
 Pott's fracture, in which, however, the fibula instead of being broken was 
 
1> ISL OCA TJONS. 4(j 1 
 
 pushed upward. The restoration of the foot to its place corrected the upper 
 dislocation. 
 
 Lower End. — A very few cases have been reported in wliich the lower 
 end of the fibula has been forced from its attachment to the tibia and the foot 
 and has been dislocated backward. In a unirjuc case observed by Stimson the 
 lower end of the iibula had been dislocated backward from the tibia, but had 
 preserved its connection with and its relations to the foot; the injury occurred 
 while the patient was wrestling with another lad, and was apparently produced 
 by forcible abduction of the front of the foot. 
 
 DISLOCATIONS OF THE FOOT. 
 
 TiBio-TARSAL DiSLOCATiOXS. — Four principal groups are made, according 
 to the direction in which the foot is displaced : backward, fortvard, outward, 
 and inward. 
 
 Backward. — The cause is commonly extreme plantar flexion, by which 
 the lateral ligaments are torn, when the liberated foot slips backward and the 
 astragalus is fixed behind the tibia Avhen the plantar flexion is relieved. Frac- 
 ture of the external malleolus, less frequently of the internal, may coexist. 
 Incomplete dislocation is a frequent accompaniment of Pott's fracture. The 
 foot appears shortened in front and the heel lengthened, but if there is some 
 swelling the dislocation may easily pass unrecognized unless a careful examina- 
 tion and comparison with the other foot are made. 
 
 Forward. — This form is very rare. The injury may be caused by exag- 
 gerated dorsal flexion or by direct pressure forward upon the heel. The foot 
 appears lengthened in front, the heel shortened ; the body of the astragalus 
 can be felt in front of the tibia. 
 
 Inward. — There are two varieties: in one, by supination and adduction 
 of the foot, the astragalus is turned down out of its mortise so that its upper 
 articular surface lies beloAv and in front of the external malleolus ; in the other 
 (thought to be secondary to a backward dislocation) the toes are turned more 
 or less directly inAvard, the foot lying nearly or quite in the transverse plane. 
 Reduction has always been easy. 
 
 Outward. — Most, if not all, of the cases described under this title appear 
 to have been Pott's fractures, either typical or with unessential variations. 
 
 SUB-ASTRAGALOID DISLOCATIONS. 
 
 The other bones of the foot may be dislocated from the astragalus hacJc- 
 ward, forward, outivard, or inward and backward. The first two forms are 
 very rare : the outward and inward are more common, and are produced by 
 forcible eversion and inversion of the foot respectively. Fractures of the 
 astragalus and of the external malleolus have been observed as complications. 
 Of 55 reported cases of all kinds (Stimson), 24 were compound. Of 24 simple 
 cases in which reduction was attempted, it was eff'ected in 14 and the ultimate 
 result was good; of the remaining 10 cases and the 7 in Avhich reduction was 
 not attempted, secondary amputation was done in 4, and secondary excision of 
 the astragalus in 4 ; in 5 the functional result was good notwithstanding the 
 persistence of the displacement. Of the compound cases, primary amputation 
 was done in 3, and excision of the astragalus in 10. 
 
 DISLOCATION OF THE ASTRAGALUS. 
 
 This is a more common injury ; the cause is usually a fall from a height, or 
 
4()2 Ay AMI'JilCAy 'IllXT-llOOK OF SlUdEliY. 
 
 forcible twisting of the foot. The varieties are very numerous : they niay be 
 grouped as forward, backward, outward and foi'ward, itnvard and forward, 
 and by rotation. In the first four groups more or less rotation of the astragalus 
 about either of its axes is frequently associated. 
 
 Outward and Forward. — This is the most frequent form. The head of 
 the ;istr:iu;ilus rests on tlic outer cuneiform and the cuboid bones, or even on 
 the fifth metatarsal, and its ])Osterior ])art is still in contact Avith the articular 
 surface of the tibia. The foot is adducted and inverted, the external malleolus 
 prominent. If the dislocation is compound, the head of the astragalus presents 
 in the wound. Reduction in cases not complicated by rotation of the astra- 
 galus is sometimes very easy by traction downward on the foot and pressure 
 backward on the head of the astragalus. 
 
 Inward and Forward. — The astragalus lies in front of or below the 
 internal malleolus, its head well depressed toward the sole ; the foot is abducted 
 and everted. Sometimes the head passes beyond the tendon of the tibialis 
 anticus, which then tightly embraces its neck and prevents reduction. 
 
 Forward. — Only a very few cases, presenting no common features, have 
 been reported. 
 
 Backward. — The displacement may be directly backward, or backward 
 and to either side. Stimson has collected IG cases, in 7 of which the bone 
 was broken at the neck and only the posterior fragment was dislocated. The 
 body of the astragalus can be felt behind the ankle, and the absence of its head 
 from its normal position may be recognized. In 3 of the reported cases per- 
 sistent flexion of the terminal phalanx of the great toe was present. Reduction 
 was effected in only one-third of the simple cases. 
 
 Dislocation by Rotation. — Only those cases are here considered in 
 which the astragalus remains in its mortise. The rotation may take place 
 about the vertical or transverse axis (and it is then associated with more or less 
 dislocation forward and inward, so that the separation from this class is arbi- 
 trary), or about the antero-posterior axis, without other displacement. Four 
 cases of the latter kind have been observed and verified by direct examination, 
 either post-mortem or during operation ; in three of them the u])|)er surface of 
 the astragalus was directed outward ; in one the bone was turned completely 
 over, 180 degrees. 
 
 DISLOCATIONS OF THE TARSUS AND METATARSUS. 
 
 Dislocations of one or more of the other tarsal and of the metatarsal 
 bones have been observed — namely, of the medio-tarsal joint, of every tarsal 
 bone separately except the outer cuneiform, and of the metatarsal bones sep- 
 arately and in various combinations. The metatarsus as a whole has been dis- 
 located in each of the four principal directions. 
 
DISEASES AM> IXJinJi:s OF LYMPHATICS. MW 
 
 CHAPTER IX. 
 
 DISEASES AND INJURIES OF LYMPHATICS. 
 
 GENERAL CONSIDERATIONS. 
 
 The lymphatic vessels pervade every tissue and organ in the body: the 
 delicacy and transparency of their walls and the very close adhesion of these 
 walls to surrounding tissues render it impossible to identify them under ordinary 
 circumstances. In their anatomy and general properties, however, they bear a 
 close resemblance to the veins, and the results of injuries to them and the dis- 
 eases to which they are subject are analogous to those of the venous system. 
 By reason of their function as absorbents they are the great agents of the intro- 
 duction into the general circulation of the products of local septic infection. 
 From their open mouths during the first hours following the receipt of a wound 
 comes much of the serous flow to dispose of which drainage is necessary, and 
 some of which, doubtless, later plays an important part in facilitating the active 
 cell-changes upon which the hesiling process depends. All wounds involve 
 lymphatics, but under ordinary conditions these vessels call for no special atten- 
 tion from the surgeon. . Their walls collapse and become closed by the plastic 
 exudate that is formed for the purpose of general repair. The superficial 
 lymphatic plexuses of the skin are not only exceedingly numerous, but are also 
 so superficially placed that they are readily influenced by antiseptic solutions 
 applied to the surface of the skin ; hence the value of external antiseptic 
 lotions and fomentations in inflammation of the superficial lymphatics and of 
 the somewhat deeper vessels into which they immediately empty, and the 
 caution, likewise, with w^hich solutions which may be toxic, as carbolic acid 
 and corrosive sublimate, should be applied for any length of time to extensive 
 surfaces of skin. Any consideration of the aflections of the lymphatics will 
 include those of the lymphatic glands, Avhich are scattered along their course 
 and form a part of the lymphatic system. In explanation of the greater fre- 
 quency of aff"ections of the lymphatic glands in youth, it must be remembered 
 that the quantity of lymph in circulation is greater then than in later years, 
 and that the lymphatic glands are, during that period of life, more largely 
 developed and more active. Figs. 196-200 show the lymphatic glands ac- 
 cording to the careful researches of Leaf. They should be consulted in con- 
 nection with operations in the neck, the axill?e. and the groin. 
 
 INJURIES OF LYMPHATICS. 
 
 Rupture of the Thoracic Duct. — This main lymph-duct, although so 
 much protected by its anatomical position, may nevertheless, under excep- 
 tional circumstances, be w^ounded or ruptured. Of 17 such cases collated by 
 Kirchner, 2 Avere due to contusions of the chest ; 1 each to a puncture, a cut, 
 and a shot wound ; 3 to erosion from suppuration. In the remaining cases 
 the account failed to assign a definite cause. The wound in these cases 
 resulted in chylothorax in nine instances ; in chylous ascites in six in- 
 stances ; in one (doubtful) in exudation into the mediastinum ; while the 
 remaining case was an instance of operative injury of the duct near its 
 mouth. In a case reported by Krabbel, the patient on the fifth day after 
 being run over by an empty coal-car died from sufi'ocation due to an efi'u- 
 sion into the right pleural cavity, which on post-mortem examination was 
 found to be chyle and to have come from a rent in the thoracic duct opposite 
 
464 
 
 ^^V AMERICAN TEXT-BOOK OF SURGERY. 
 
 the ninth dorsal vertebra, ^vhich had been transversely fractinod. In one of 
 Kirchner's eases a girl of nine years had been violently j>ushed against a win- 
 dow-sill, striking the front of her chest opposite the third rib; a gradual and 
 increasing dyspnea developed after some days, with signs of pleural effusion, 
 
 KiG. 190. 
 
 Lhit edge of skin 
 Submaxillary 
 salivary glaml 
 
 Inferior cunstricto 
 
 Omo-hyoid- 
 
 !>terno-thyroi(t 
 
 Internal jugular i-ein 
 
 Sterno-hyoiil 
 
 Sterno-masfni'l—/^ 
 
 
 Cltirirlf 
 
 Smnll occipital nerte 
 
 'osterior belly of digastric 
 lylo-hyoid 
 
 (turiculiir nerve 
 
 r anguli scapulx 
 
 accessory nerre 
 apezius 
 
 ftrending branches of 
 cervical plexus 
 
 ^'^ 
 
 Lymphatic Glands f>f the Head and Neck (after Leaf). 
 
 which on aspiration proved to be chyle ; relief followed the aspiration, but 
 dyspnea again became marked after some days ; a proposed repetition of the 
 aspiration was deferred on account of a spontaneous improvement which then 
 took place ; the dyspnea subsided, the signs of effusion gradually disappeared, 
 
 A Fio. 197. 
 
 The dotted line indicates'i 
 junction of Scarpa's fas- 
 cia with fascia lata. 
 
 Saphenous ^^■ 
 opening—^ 
 
 Femoral vein 
 
 Long saphenous 
 
 rein 
 Fascia lata 
 
 Superficial 
 fasciii 
 
 Ant. femonil 
 
 cutaneous 
 
 vein 
 
 Long saphenous 
 rein 
 
 Lymphatic (Hands of the Groin : a, superficial glands ; b, deep glands (after Leaf). 
 
 and ultimately full health returned. Two American cases have recently been 
 reported (Eyer, 1891 ; Manley, 1894). In the first a young man suffered 
 a severe S(|ueeze of his thorax, having been caught between a railroad-car 
 and an engine. No bones were broken, and for some days a traumatic 
 
1)Isi-:asI':.s and injuries of lAWfriiATics. 
 
 465 
 
 pneumonia of the rio;ht lung Avas the chii'f apparent result of tlie injury; 
 on the seventeenth day, however, a fluctuating swelling was detected in the 
 
 Fi(i. lys. 
 
 f<kin reflected 
 PcctoraiiK major 
 Central (jriiKp of (iliituls 
 
 Cilihnl'iC rein 
 
 Central (Superficial) Lymphatic filaiuK ot tin \xilla lafttr I eaf) 
 
 right inguinal region, which on being opened gave exit to much offensive 
 
 Fi<i. 199. 
 
 Oino-hyoid 
 
 Clavicle 
 
 SHbclaTius 
 
 Sitxpenaort/ ligament 
 
 Pccfuralis minor 
 Axillary fascia 
 
 Clavicular porliov of 
 pectorulin major 
 
 Infernal portion of 
 pectorulis major 
 
 Subscapular Lymphatic Glands in Section (after Leaf). 
 
 gas and a foul feculent discharge. After two or three days this discharge lost 
 
 Fig. 200. 
 
 Cephalic 
 
 Axilla 
 
 Glands snrrou ndi 
 subscapular 
 
 Latissimns dor 
 Teres maj 
 
 Biceps 
 
 ■s—Pectoralis minor 
 Pectoralis major 
 
 ^uhscapularis 
 '^erratus magmcs 
 
 rectonil (Dn.])) L\mj li Uil ( 1 iiid^ (after Leaf) 
 
 its offensiveness and became opaque and milky : rapid emaciation followed, 
 resulting in death on the thirty-eighth day from the original injury. Post- 
 so 
 
466 AN AMERICAN TEXT- HOOK OF SlJUaEI!Y. 
 
 mortem examination revealed a rupture of the tlioraeic duet at the point ^vhere 
 it passes through the aortic opening of the diaphragm ; the escaping chyle had 
 burrowed behind the peritoneum and had become superficial at the groin ; in 
 addition to this, some of tlie chyle had become diverted above the diaj)hragm 
 and had dissected up the pleura from the posterior chest-\vall on the right side 
 so as to form a post-})leural cavity, lilled with chyle, extending up as high as the 
 apex of the thorax. In the second case the escaping chyle likewise burrowed 
 behind the peritoneum and ])resented a superficial swelling at the groin which 
 was incised, and gave vent for ten days to an abundant chylous discharge. The 
 discharge then ceased, and the conijdete recovery of the patient followed. 
 
 There are no symptoms indicative of this rare injury until a sufficient accu- 
 mulation of the escaping chyle has occurred to call for its evacuation surgically. 
 The character of the evacuated fluid is the first indication that a wound of the 
 thoracic duct has occurred. According to the location of the wound, the effused 
 fluid may find its Avay into the peritoneal cavity or into the connective tissue 
 behind the peritoneum, into the pleural cavity or into the connective tissue 
 behind the pleura, or into the posterior mediastinum. The particular symptoms 
 which the eftusion will provoke nmst depend upon its location and extent. 
 Rapid emaciation wall result from the inanition due to the failure of the chyle- 
 current to reach its destination. 
 
 Death from inanition is to be expected after rupture of the thoracic duct. 
 The case already cited Avhich recovered shows, however, that exceptions may 
 occur, possibly due to the existence in a particular instance of a double duct 
 or other al)normality whereby a collateral circulation is possible. Experiments 
 on animals show that small recent wounds of the thoracic duct may heal spon- 
 taneously and quickly. 
 
 A wound of the thoracic duct is beyond surgical treatment. When, 
 however, such a wound is demonstrated or suspected, the suggestion of Agnew 
 is eminently rational that, instead of feeding the patient, no food should be 
 given, in order that the walls of the duct may remain as much as possible in a 
 state of collapse, and thus favor any attempt Avhich nature may make toward 
 closing the opening. Meanwhile, the possibility of introducing milk directly 
 into the venous circulation suggests its utility as a method of nourishment 
 during the period that must intervene before the ordinary processes of diges- 
 tion and absorption can be resumed. 
 
 The thoracic duct may be wounded near its termination at the base of 
 the left side of the neck in the course of operations for the removal of deep- 
 seated growths in that region, especially Avhen, as is sometimes the case, 
 irregular terminal branches reach somewhat high into the neck. Keen has 
 reported four instances of this accident. In two of these cases the fluid that 
 exuded was unmistakably chyle; in the other two it was serous in charac- 
 ter, but in all its abundance was great, and such as to make it extremely 
 probable, even in the latter cases, that its source was the thoracic duct. In 
 two of the cases the flow was controlled by a tampon, in one by a pressure 
 forceps, and in one by a suture. Three of these cases recovered, having sus- 
 tained no detriment from the injury to the thoracic duct. One died, but 
 its fatal result was not especially influenced by the Avound of the duct. 
 
 Lymphangitis. — Certain areas of lymi)hatic radicles, or the larger con- 
 tinuous lymphatic trunks, may become inflamed as the result of retention 
 within them of irritants. To the first form the term reticular h/mpJiangitis, 
 to the second the term tubular lymphangitis, as proposed by Bellamy, may 
 well be applied. In the vast majority of cases the irritants in question con- 
 sist of septic material absorbed from an infected wound. 
 
DISEASES AND lyJUIilES OF LYMPHATICS. 467 
 
 Reticnhtr b/)iij)han(/itis is seen in many cases of circumscribed skin inflam- 
 mation attended with'inore or less oedema. It is present in the condition 
 described as '^ erysipeloid " by Rosen])ach, a term applied by that investigator 
 to certain patches of superficial skin inflammation Avhich slowly spread from a 
 point of primary infection, usually on the fingers, the point originally aff'ected 
 returning to a condition of health, while the inflammation extends at the 
 periphery, until at the end of from one to three weeks the disease has 
 exhausted itself and entirely disappears, having possibly extended over the 
 back of the hands as far as to the wrist. Rosenbach found the cause 
 of this affection to be the invasion of the lymphatics by a specific thread- 
 formin^^ spore-bearing micro-organism derived from decomposing animal 
 matterf Ordinary erysipelas presents a typical form of reticular lymphangitis 
 in which the inflammation is produced by the invasion of the lymphatic chan- 
 nels by the streptococcus of erysipelas. (See Erysipelas, p. 66.) In the rapidly- 
 extendin<T inflammations which attend certain poisoned wounds the infection 
 is propa<nited along the lymphatics, which share in the general inflammatory 
 condition that prevails, 'both types of lymphangitis being present m a 
 marked degree. A lymphangitis of less virulence often develops in connection 
 with injuries of hands or feet that are neglected and subjected to motion and 
 irritation, or with scratches and abrasions that are brought into contact with 
 decomposing material. This inflammation may at first be limited to a small 
 area of the'immediately contiguous lymphatic rootlets ; if still further aggra- 
 vated, the larger trunks leading away from the part become involved, and 
 when seated iS the skin are seen as red and tender streaks running in the 
 direction of the lymph-current. 
 
 Tubular lymphangitis is invariably the result of the entrance mto the 
 affected duct of bacteria and bacterial products of more than usual viru- 
 lence. Long before the agency of pathogenic micro-organisms in its pro- 
 duction was "recognized, the affection was appreciated as of serious import 
 and demanding active treatment to subdue it. The entrance of septic mate- 
 rial into lymphatic channels must always attend infected wounds, but it is 
 exceptional that a spreading inflammation of these channels results. A pre- 
 viously existing state of general debility upon the part of the patient predis- 
 poses to it. Frequent irritation of the infected wound and the confinement 
 of septic secretions in it are often exciting causes. The infection of trivial 
 wounds, as a prick or scratch, with virulent septic material, as in dissection- 
 wounds and snake-bites, not infrequently causes it. Cases have been recorded 
 in which the bathing of the hands, without any wound of the skin, m putrid 
 fluid for some time has been followed by lymphangitis. The tender and some- 
 what cord-like minute red streak that is formed by the inflamed lymphatic 
 vessel results from the blocking up of its lumen by a coagulated exudate infil- 
 trating also the ensheathing connective tissue which shares in the inflammation, 
 this attendant cellulitis being of variable extent and intensity according to the 
 intensity of the primary lymphatic irritation. 
 
 To the ordinary inflammatory swelling of the affected part a certain amount 
 of oedema is added from the 'interruption of the lymph-current along the 
 thrombosed lymph-vessels. The extent and persistence of this oedema will 
 depend upon 'the number of the lymphatic trunks involved and the freedom 
 of the anastomosing communications. 
 
 Inflammation of the glands into which the affected lymphatics empty 
 speedily ensues upon a primary lymphangitis. For the production of glandular 
 trouble' it is by no means ne'ces'sary that any extensive inflammation of the 
 ducts leadintr ifrom the seat of infection to the gland should exist, for infective 
 
40S AX AMERICAN TEXT-JiOOK OF SURGERY. 
 
 matorial is often carried tlirou<rh the lyiiii»liaties without ])ro(luciiig any reac- 
 tion until it has become arrested in a <^hind, wliere its irritative effects are devel- 
 o|)ed. LikcAvise a second <rrou|) of ^dands may heconie involved by transmission 
 of infection from the first, without any disturbance of the connecting' ducts. 
 
 Symptoms and Course. — In addition to the local signs of lymphatic 
 inflammation that have already been described there are present constitutional 
 conditions dependent upon the extent and severity of the septic infection. 
 Rigors are not unconnnon. Fever, usually marked, but of variable severity, 
 develops. The more aggravated cases ra[)idly display the effects of jjrofound 
 septicemia. "When the source of irritation is less virulent and is transient or 
 is overcome by treatment, the inflammatory reaction soon subsides, the exu- 
 date liquefies and is absorbed, and the affected vessels readily return to their 
 normal state. If pyogenic organisms in sufficient number and activity have 
 formed a part of the infecting virus, suppuration along the course of the 
 inflamed vessels or in the glands into -which they empty results. In this pro- 
 cess of suppuration the surrounding connective tissue becomes invaded, result- 
 ing in abscesses. This is true both of gland suppuration and of suppuration 
 along the course of the vessels themselves. 
 
 Diagnosis. — Superficial lymphangitis is not likely to fail of recognition. 
 The tender red streaks indicative of the tubular variety are pathognomonic ; the 
 diffuse redness of the reticular variety, with its attendant sui)erficial ccdema 
 and its pain, and the general fever, distinguish it from ordinary erythema or 
 dermatitis. Some cellulitis accompanies all lymphangitis, and some lymphan- 
 gitis, on the other hand, attends all cellulitis. Which is the preponderating 
 element may sometimes be a matter of uncertainty. Practically, however, 
 the question is an unimportant one. Phlebitis is closely related to lymphangitis 
 in its symptoms, but a thrombosed vein forms a deeper-seated, coarser cord 
 than a similarly affected lymph-vessel, the cutaneous redness is not so vivid, 
 the pdin is less acute, the general fever is not so intenFc, and the tendency 
 to glandular involvement is less. Inflammation of the deep lymphatics is not 
 easily differentiated from ordinary cellulitis. If in a case of deep-seated 
 inflammation there is early involvement of the neighboring lymphatic glands ; 
 if lymphatic oedema can be detected ; if patches of superficial reticular lymph- 
 angitis appear at points of anastomosis with deeper trunks, — the existence 
 of inflammation of the deep lymphatics can be assumed. 
 
 Prognosis. — The course of a lymphangitis will depend upon the virulence 
 the amount, and the persistence of the infective cause, and the constitutional 
 vigor of the patient. The milder attacks upon the withdrawal of the cause 
 and the institution of proper treatment speedily subside; when suppuration 
 has occurred it may be limited in amount, and upon the evacuation of the 
 abscess or abscesses a steady return to health ensues. In the more virulent 
 forms successive groups of glands may become involved and suppurate ; exten- 
 sive abscesses develop ; septic absorption, with or without the formation of 
 metastatic abscesses in distant parts, imperils life ; and if recovery finally takes 
 place, it is after a prolonged illness ; not rarely death from exhaustion is the 
 inevitable end. In a certain class of cases lymphangitis assumes an insidious 
 and chronic form, affecting large areas of vessels and ])ro(lucing such Avide- 
 spread obliteration of them as to block up permanently the flow of lymph fnmi 
 a considerable territory and to entail a permanent lymphocdema of the affected 
 part. (See Elephantiasis or Lymphocdema.) 
 
 Treatment. — The recognition of the septic cause of the lymphatic inflam- 
 mation at once gives direction to the treatment that is to be employed. Prompt 
 and thorough disinfection of the original wound from which the infection has 
 
i>isi:asi:s axd injuries of lymphatics. 469 
 
 proceeded should be done. The aftected limb should be put at rest and elevated. 
 Tension, wherever present, should be relieved l)y free incision, without waiting 
 for suppuration to take place. The whole aftected territory should be covered 
 with compresses kept wet with a 1 : 2000 acjueous solution of corrosive sublimate 
 until the inflammation has fully subsided. All foci of suppuration should be 
 freely incised, evacuated, disinfected, and drained. The constitutional treat- 
 ment must be conducted in accordance with the general principles of support 
 and elimination. Pain may recjuire opiates, but, as a rule, all the secretions 
 should be promoted. Stimulants and nutrients should be fireely administered 
 in the more severe cases. Persistent oedema remaining after the subsidence 
 of the inflammation is to be overcome by bandaging and massage. 
 
 Lymphadenitis. — Lymphatic glands are prone to inflammation. Their 
 function as reservoirs, to which the lymphatics hurry whatever material they 
 gather, renders them certain to become places of arrest for whatever irritants 
 may have gained access to the lymphatic circulation. The extent to Avhich they 
 become involved in attacks of lymphangitis has been mentioned in the preced- 
 ing paragraphs, as well as the fact that they are aff"ected by absorption from sep- 
 tic wounds Avithout involvement of the trunks that transmit the septic matter. 
 The amount of inflammatory reaction which they display may be of every grade 
 from a slight transient tumefaction and tenderness to a rapid necrosis and sup- 
 puration, or to chronic enlargement and induration — according to the character 
 of the irritant acting upon the gland and to the local and general resisting 
 power of the individual. Syphilis, tuberculosis, carcinoma, glanders, are all 
 characterized by specific glandular inflammation, for the peculiarities of which 
 reference must be made to the sections devoted to these several alfections. 
 
 Exposure to cold and over-exertion are often accessory causes of ordinary 
 gland inflammation. They act as local depressants, favoring the activity of 
 infective organisms that otherwise Avould have been inert. A state of general 
 debility predisposes to glandular inflammation. The glands of the neck, axilla, 
 and groin are more frequently affected than those of other localities, which is 
 the natural result of the many sources of infection continually arising through 
 affections of the mouth, throat, and extremities. 
 
 The degree of inflammation excited often falls short of suppuration, in 
 which case either complete resolution and rapid return to the normal state 
 occur, or, what is by no means uncommon, some induration and enlargement 
 of the gland persists for some time. Suppuration is a very common event. 
 In cases of adenitis of sufficient intensity to entail suppuration, the surround- 
 ing connective tissue usually becomes involved in the inflammation and sup- 
 puration, and the resulting abscess when opened displays a pus-cavity in the 
 connective tissue enclosing the more or less thoroughly destroyed gland. 
 
 Symptoms. — Pain, heat, and swelling are the characteristics of an inflamed 
 gland. The swelling is nodular, and may be either well defined or diffused, 
 according to the amount of periadenitis. The degree of heat will depend upon 
 the intensity of the congestion. The location of the gland and the looseness of 
 the tissue in which it is imbedded will largely determine the amount of pain 
 attending the attack, although tenderness on pressure is always present. The 
 constitutional reaction is likew^ise variable ; in the more acute attacks consider- 
 able pyrexia is developed, with rigors on the occurrence of suppuration. 
 
 Distinct fluctuation may not be discernible for some time even after suppu- 
 ration has begun, since the gland which is breaking down is likely to present 
 more than one focus of suppuration, and for this reason w ill give at first only a 
 boggy feeling to the touch. This, again, will be rendered indistinct by the peri- 
 glandular congestion. If the surgeon waits to obtain well-defined fluctuation 
 
470 AX AMERICAX TEXT-BOOK OF SURGERY. 
 
 before deciding that suppuration has occurred, lie will find it only alter conj^id- 
 erable destruction of tissue has taken place. 
 
 Treatment. — The sources of infection should be removed or receive ade- 
 quate antiseptic treatment if possible. The part in -which the gland is located 
 should be kept at rest and free from irritation. From the onset of the glandular 
 symptoms cold should be kept apj)lied if practicable. Injections of five to ten 
 minims of a 3 per cent, solution of carbolic acid into the substance of the 
 inflamed gland, if made early, may suffice to prevent suppuration. If from any 
 cause it seems best to encourage suppuration, warm fomentations may be kept 
 applied. When pus has formed, the pus-cavity should be freely incised, all 
 necrotic tissue should be scraped away, and the cavity after having been 
 cleansed should be stuffed with iodoform gauze. On the third day this tam- 
 pon should be removed. In many cases healthy granulating surfaces will 
 already have formed, the adhesion of which may now be secured by the appli- 
 cation of an absorbent compress. In other cases a more prolonged use of the 
 iodoform tampon may be recjuired before the desired healing surface of the 
 cavity is produced. If sinuses have formed, they must be followed up, opened 
 freely, and treated in the same way as the original cavity. If the healing pro- 
 cess is sluggish, free applications of naphthaline and Peruvian balsam will serve 
 to stimulate it, due attention being paid to the general health. 
 
 Chronic Adenitis is, with rare exceptions, either tubercular or syphilitic 
 in its nature. In the exceptional cases not referable to these specific causes 
 nor beloncrino; to the malignant degenerations, inunctions of iodine, blisters, 
 and compression will be of service. Interstitial injections of a few minniis of 
 tincture of iodine, or of alcohol alone, will promote absorption. If the mass 
 resists these measures and its presence is a cause of functional disability or a 
 serious disfigurement, it may be excised. Very extensive operations are now 
 often practised in the removal of tubercular glands, especially in the neck, and 
 with great advantage. The operation should be very thorough. Every gland 
 that can be found should be removed. The wound, if made antiseptically, 
 usually heals in a short time, even in the most serious cases. Every measure 
 calculated to promote the general health should be resorted to, in addition to 
 the local means named. 
 
 Lymphangiectasi? and Lymphangioma. — The lymphatic vessels, like 
 their congeners the veins, are subject to dilatations and varicosities, which may 
 be of every degree and extent. To such dilatations in general the term 
 lymphancfiectasiH is applied, but when these dilatations by their size, their 
 confluence, or their aggregation form distinct tumors, the term lymphangioma 
 may be substituted (Fig. 201). 
 
 Dilatations of the cutaneous lymph-radicles may be recognized as soft trans- 
 parent sacs or vesicles filled with lymph, situated manifestly in the substance 
 of the skin, and not on its surface. They occur most frecjuently on the inside 
 of the thigh, on the genitals, and on the anterior wall of the abdomen, localities 
 rich in superficial lymphatic plexuses. They are usually superficial outcrop})ings 
 of a deeper, more extensive chain of lymphatic dilatations due to obstructive 
 changes in distant trunks. Rupture of these vesicles is not infrequent, and 
 is liable to be followed by a flow of lymjdi of variable amount and duration. 
 This is known as Lymphorrhagia. 
 
 Rupture of a dilated lymphatic along the urinary tract and the consequent 
 lymphorrhagia produce Chyluria — an intermittent accumulation of chylous 
 lymph in the urinary bladder. Similarly the tunica vaginalis testis may be 
 the seat of a lymphorrhagia, and Chylocele result. 
 
 A group of dilated lymphatic radicles may be present in the shape of many 
 
DISEASES AM> IXJURIES OF LYMPHATICS. 
 
 ■171 
 
 closely-aggregated vesicles of varying size; or if the enlargement extends along 
 the course of the ducts, cylindrical and tortuous cords, Avith nodular swellings 
 
 
 
 Fk; 
 
 20]. 
 
 
 
 
 
 
 
 
 a^^^ 
 
 MH^Ha.^ 
 
 
 
 /" 
 
 
 ■ 
 
 1 
 
 f^ 
 
 \ky^ 
 
 •a. 
 
 / 
 
 f 
 
 
 1 
 
 ■ 
 
 i 
 
 : 
 
 Lymiiliaiigiiinia Circumscriptum i'>riginal 
 
 at the site of the valve, are produced. The two varieties may coexist ; or still 
 greater dilatation at various points may have taken place, so that the varicos- 
 ities are converted into cystic tumors. Such varicose swellings in the inguinal 
 region may be confounded Avith hernia. Ectasi?e or dilatations of the blood- 
 vessels may coexist with those of the lymphatics, producing a tumor of mixed 
 character. Such mixed growths have been noted in the tongue, producing an 
 enlargement of it known as Macroglossia, and in the lips, Macrocheilia. 
 
 Etiology. — In a large proportion of cases of lymphatic dilatation the con- 
 dition is congenital in its origin ; it may be due to an essential vice of develop- 
 ment of unknown character, or more likely to obstructions to the lymph-stream 
 of a mechanical or an inflammatory nature arising during embryonic life. 
 In the acquired variety inflammation and thrombosis are the chief agents Avhich 
 are active in the production of the condition, the direct result being dilatation 
 of the radicles and of the primary channels, with lymph-stasis and oedema of 
 the tissues within the area from which the narrowed or occluded vessels are 
 supplied. Occlusion may also result from cicatricial contraction, from the pres- 
 ence of tumors, and from the blocking up of the lymphatic channels by tuber- 
 cular or cancerous material. The presence in certain lymphatic vessels of a 
 minute parasitic worm, the filaria sanguinis hominis, has been demonstrated to 
 be the cause of lymph-thrombosis and inflammation in a large class of cases 
 most frequently occurring in tropical regions. 
 
 Causes and Symptoms. — The cystic and tubular enlargements of the 
 lymphatics which have been described are observable only when they are situ- 
 ated superficially or when they form circumscribed swellings that are distinguish- 
 able as distinct tumors. A very marked and surgically important series of 
 symptoms may arise Avhen in the substance of a limb or part there is a diffused 
 dilatation with lymph-stasis. Such a condition results when there is obstruc- 
 tion of so large a number of the ducts converging to the root of the extremity 
 or part that but little relief through collateral trunks is possible. The affected 
 
472 
 
 AN AMHIUCAX TKXr-JiOOK OF sriidKRy 
 
 part becomes swollen by a lianl, compact, luawiiy tedi'iiia. Lymphoedema, 
 which is not readily reducible either l)y position or pressure. Attacks of diffuse 
 lymphangitis are prone to recur, each successive attack causing an aggravation 
 of the local condition. Thickening and induration of the skin and connective 
 tissue take jdace. Dilatation and niultii)lication of the blood-vessels keep 
 pace with the general connective-tissue hypertrophy. The muscles waste. In 
 the more advanced and aggravated cases of this class an enormous deformity 
 results; the skin becomes coarse and hypertrophied, with a tendency to eczema 
 and seborrhea ; papillary excrescences are numerous and the development of 
 ulcers is frequent ; the swollen limb presents lobulated masses heaped up at 
 different parts, separated from one another by deep sulci, which are especially 
 marked at the flexures of the joints. If the scrotum is the part aff'ected — a not 
 uncommon occurrence — it may form a huge tumor reaching bblow the knees or 
 even to the ground. This constitutes the disease known as Elephantiasis 
 Arabum. While it is more common in certain intertropical countries (Bar- 
 badoes, India, Cayenne, etc.), where its frequent dependence upon the presence 
 in the lymphatics of the filaria sanguinis hominis has been demonstrated, occa- 
 sional instances of it are met with in all climates. The accompanying illustra- 
 tion (Fig. 202) shows the condition of the limb of a girl of twenty-one years 
 of age, the subject of lymphoedema, five years after the inception of the dis- 
 ease. The changes in the limb were as yet moderate. The photograph from 
 
 Fig. 202. 
 
 Lymphitdeinu of left leg live years after its ouset (original). 
 
 which the cut was made was taken in 187o. At the present time, seven- 
 teen years later, the case presents the typical condition of the worst form of 
 elephantiasis. Repeated attacks of lymphangitis have occurred during this 
 period, each producing an aggravation of the previous condition. The leg 
 below the knee has become enormously deformed by the production of the ele- 
 phantoid masses; the outer side of the thigh remains healthy, but the skin of 
 the inner side has developed so as to form a very large and pendent lobulated 
 
DJSEA.'SES AM) ISJClilKS OF LYMI'HATICS. 
 
 47;] 
 
 Fig. '20.3. 
 
 nia^^ A similar eon.liticn has bo^un to develop in the other k-g, uhieh now 
 i. about in the fon<liti()n of the first as shown in the figure. Fig. 203 show.s 
 an example of tlir ehan-es produced by this disease in its most aggravated 
 
 form. , . , 1 1 ^ 
 
 Treatment.— Circumscribed dilatations and isolated cystic enlargements 
 
 m?v be extirpated with the knife. In the diftu.sed dilatations and a'dema due 
 to' persi«.tent obstructive causes, in cases in which collateral channels may in 
 time become sufficieiitlv <leveloped to relieve the stasis, relief will be given by 
 massa'^e, elastic baiulagini:, and support in an elevated position. In the 
 absence of the possible relief of the stasis all such attempts will be fruitless. 
 Ligation of the main artery of supply of the limb in a few recorded cases has 
 been followed bv rapid improvement. In others no benefit has resulted. A 
 resort to it wouhl be justifiable when other means had foiled. A\ hen the dis- 
 ease is confined to an" extremity and causes serious disability, amputation may 
 be done. Similar tumors involving the genitals should be excised. In the lat- 
 ter cla.ss of cases attempts should be made to preserve the penis and testas by 
 dissecting them out of the hypertropiiied mass in which they are imbedded. 
 The chief difficulty attending the ablation 
 of the growths is the prevention of hemor- 
 rhage ; but this has been greatly fiicilitated 
 by the use of the elastic bandage for con- 
 stricting its base. 
 
 Lymphadenoma. — Under this head 
 are to be classed lymph-gland tumors, in 
 which the essential change is purely a 
 hyperplasia of normal gland elements. 
 Simple overgrowths aff"ecting one or per- 
 haps two or three adjacent glands, with- 
 out a tendency to local degeneration or the 
 development of constitutional cachexia, 
 have been described, but it is probable 
 that in most of such cases, if not in all, 
 either foci of tubercular infection would 
 be found in them, if a sufficiently thor- 
 ough examination Avere made, or they 
 would in time show^ themselves to be the 
 precursors of a more generalized process. 
 Enlargement of lymphatic glands con- 
 sisting of hyperplasia of the normal struc- 
 ture is an important element of leukemia. 
 Single glands may attain the size of a 
 man's fist in this disease, and sometimes 
 all the lymph-glands of the body beconae 
 involved. Associated with the lymphatic 
 tumors are enlargements of other glands, 
 notably the spleen, thymus, and liver. 
 Changes in the marrow of the bones ac- 
 company these glandular changes. The 
 resulting alteration in the blood — namely, 
 the great incvease of the white corpuscles 
 and the diminution of the red — affords a 
 certain means of identifying this form of glandular disease, which has a place 
 more properly in internal medicine than as a surgical aff'ection. 
 
 Lymphoedema in its Later Stage (original). 
 
474 J.V A.UERICAX TEXT- HOOK OF SURGERY. 
 
 Malkixaxt Lymphoma. — Differing from these trlantlular tumors of leuke- 
 mia chiefly in the absence of the blood-changes are the cases of diff'use gland- 
 ular enlargement to which the term Malignant Lymphoma (Tlodgkhi's dis- 
 ease, Pseudn-Uukemia) is applicable (PI. IX. Fig. 2). In this aftection there first 
 appears a moderate painless swelling of one or more glan<ls. most fre(juently 
 in the neck, more rarely in the axilla, groin, or mediastinum. After a time 
 other glands enlarge, until great tumors may result, producing much dishgure- 
 ment. For a time no disturbance of the general health is observed. The 
 glands, if removed, show simply great hyperplasia of the normal elements. 
 Gradually groups of glands in other parts of the body become similarly 
 enlarged, until finally almost all the glands of tlie body are affected. Some 
 enlargement of the spleen may now be discernible, but it is not constant. 
 Coincident with this generalization of the swellings the health begins to suffer; 
 emaciation declares itself; progressive anemia develops, which, unless death 
 from some accidental complication occurs, becomes extreme ; dropsies arise ; 
 diarrhea sets in ; and finally collapse and death terminate the case. 
 
 The etiology of malignant lymphoma is totally unknown. It attacks 
 young adults most frequently. During its early history it is impossible to 
 distinguish it with certainty. The element of time is required to develop its 
 malignancy. When the swellings have become generalized and the constitu- 
 tional symptoms have declared themselves, the diagnosis is plain. The cha- 
 racteristics of the glands of lymphoma are these : they preserve their proper 
 shape ; they do not soften and degenerate, as do tubercular glands ; they do 
 not become fused together or adherent to surrounding parts by inflammatory 
 adhesions ; they have a certain elasticity when compressed, different from the 
 board-like hardness of unsoftened tubercular glands. 
 
 The prognosis is hopeless. Its course varies in its rapidity, usually 
 extending over about one year, although a more prolonged course is not infre- 
 quent. Pressure of the enlarged glands upon the trachea, oesophagus, or 
 important nerve-trunks may precipitate the fatal termination. 
 
 Treatment. — There is little to be gained from surgical interference except 
 when pressure-symptoms call for relief. The internal use of arsenic, com- 
 bined with its parenchymatous injection, has appeared to exercise a favorable 
 effect on the disease in some cases ; in others it has been inert. It should be 
 tried in all cases, and pushed to the maximum of toleration. Its administration 
 should be persevered in for a long period, and resumed whenever evidences of 
 rencAved glandular hyperplasia appear. 
 
 Sarcoma of Lymphatic Glands, Lympho-Sakcoma. — A lymphatic gland 
 mav be the seat of a primary sarcoma. In the early history of such a tumor 
 it will be impossible to distinguish it positively from other varieties of glandular 
 hypertrophy. As it continues to develop it will, after a time, display its special 
 malignant features as it involves the adjacent tissues and becomes attended by 
 secondary deposits in various internal organs, as the lungs, liver, kidneys, brain, 
 and bones. (See the chapter on Sarcoma.) 
 
 Treatment. — Soon after its development, if not already veiy large, it 
 should be thoroughly extirpated, the incision going wide of the gland. If it 
 returns, amputation should immediately be done if the tumor be on an 
 extremity. 
 
DISEASES OF THE SKIN AM) ITS APPENDAGES. 475 
 
 CHAPTER X. 
 
 SURGICAL DISEASES OF THE SKIN AND ITS APPENDAGES. 
 
 Co.MEDO. — This is a disease of the sebaceous glands occurring chiefly 
 about the face, neck, chest, and back, resulting from accumulation of the altered 
 sebum, producing small yellowish or Avhitish elevations marked by a central 
 black spot, due to staining by dirt of that portion of the retained secretion 
 occupying the orifice of tlie duct. Pressure "will express a small plug of 
 inspissated sebum mingled with epithelial cells, popularly called a "worm." 
 Partly due to idiosyncrasy, and usually a disease of puberty, it is apt to coin- 
 cide with dyspepsia and constipation, and in young women with chlorosis and 
 menstrual irregularities. 
 
 Treatment. — Frequent bathing with hot water and stimulating ointments 
 rubbed in at night (such as sulph. prsecip. 3j to ung. aquae rosie 5j), or Aveak 
 alkaline ointments (such as borax, grs. xx to .5J), may be tried. To remove 
 the comedones apply night and morning the following paste — aceti 3ij, glyceringe 
 jiij, kaolini giv, — after which gentle pressure by a watch-key applied over the 
 spots will dislodge the plugs. 
 
 Milium. — This appears as small, rounded, pearly, superficial elevations in 
 the skin, occurring chiefly on the face and genitals ; they are not painful, and re- 
 sult from the accumulation of sebum from obliteration of a small secondary duct. 
 
 Treatment. — Each elevation must be opened, the cheesy matter squeezed 
 out, and the interior touched with tincture of iodine or a nitrate-of-silver point. 
 
 Sebaceous Cysts or Wens. — These form variously-sized firm or somcAvhat 
 soft, rounded tumors, usually seated in the skin or subcutaneous tissue of the 
 scalp, face, back, or scrotum, although they occur elsewhere. The superjacent 
 integument is unaltered. If injured they may inflame and ulcerate, or, in the 
 old, degenerate into epithelioma. Although usually originating from obstruction 
 of a duct, they often have no opening, but at times one persists, admitting a 
 small probe. Their contents are cheesy or milky, and are often fetid. 
 
 Treatment. — Excision should be performed either by carefully dissecting 
 out every particle of the cyst, or, after transfixing this and the overlying skin, 
 seizing and tearing out each half of the cyst-wall with a pair of forceps. 
 
 MoLLUSCUM CoNTAGiosuM vel EpiTHELiALE is characterized by small, 
 semiglobular, or conical, whitish, sometimes translucent elevations, from the 
 size of a pin's head to that of a pea, with a central dark spot or depression, 
 which is the aperture of a duct. They occur chiefly upon the eyelids, cheeks, 
 chin, neck, breast, and genitalia, and are not painful, although terminating by 
 disintegration and sloughing of the masses. The question of contagiousness 
 is still a mooted point. It is liable to be confounded with molluscum fibrosum, 
 but may be distinguished from it by the absence of the central black opening 
 in this latter aff"ection and the more general dissemination. 
 
 Treatment. — Thorough inunctions with white precipitate or sulphur oint- 
 ment will sometimes suffice ; if not, each tumor should be opened, its contents 
 squeezed out, and the cavity cauterized with nitrate of silver. 
 
 Dermatitis Venenata. — Tincture of arnica and the wearing of garments 
 colored by aniline dyes containing arsenic will sometimes produce dermatitis, 
 but it usually results from the rhus venenata or rhus toxicodendron. Owing 
 to the volatility of the poison, actual contact with the plants is not necessary. 
 
47(j AJV AMKlilCAX TF.XT-IIOOK OF sriidEnV. 
 
 After a iew hours or c-vcii days of iiu-uhatioii, in cliildrcii trt'tfiilncss or sli;^bt 
 fever may be noticed, but ordinarily the h>cal symptoms first appear — viz. heat 
 and iteliing, probably of the face and hands, with surface redness and some 
 subcutaneous oedema. Eczematous vesicles now appear, usually first between 
 the fintjers ; next the genitals are apt to be attacked in the male, wlience the 
 eruption may spread to other parts. The infiame<l portions of the skin are 
 intensely red, somewhat ocdematous, and covered by groups of i)apules or vesicles, 
 these latter being often confluent, while from scattered excoriations a clear, 
 yellowish, gummy fluid exudes, forming a soft crust on drying. The eyelids, 
 lips, nose, ears, and genitals are sometimes enormously swollen, and exude 
 large quantities of serum. Sometimes the constitution sympathizes, as is shown 
 by fever, coated tongue, and constipation. The burning, stinging pain is 
 occasionally so severe as to deprive the patient of sleep, when anodynes will 
 be required. The disease remains at its height for several days, but usually 
 in a week the acute symptoms have subsided, although the disease may recur 
 from time to time. 
 
 The diagnosis, especially from erysipelas, nmst depend on the history of 
 exposure, on the appearance of the vesicles first between the fingers, next on 
 the dorsum of the fingers and hands, finally on the palms ; the eruption is more 
 scattered than in eczema ; the vesicles usually do not pass through the papular 
 stage, as is common in eczema, but often spring directly from the skin. The 
 disease is not contagious, although in recent cases the poison itself may be con- 
 veyed from person to person or to other parts of the same individual, as from the 
 hands to the genitals. 
 
 Treatment. — Cloths kept wet with black-wash, provided the extent of sur- 
 face be not too great, or w ith weak solutions of sulphate of zinc, or fluid extract 
 of grindelia robusta in the proportion of 3ij-3iv to the pint of water, keeping 
 the cloths just damp with the solution, are very useful ; for the face, when the 
 patient cannot remain confined to the house, equal parts of starch and precipi- 
 tated carbonate of zinc may be dusted over the parts. 
 
 Furuncle, or Boil. — This is a disease, probably due to mi<'robic infec- 
 tion, in which one or more small, circumscribed, acuminated, dusky-red, firm, 
 painful spots form in the skin, the result of localized inflammation, the cen- 
 tral portion of skin dying, forming a slough or "core" around which suppu- 
 ration takes place, ending in the separation of the "core," the subsidence of 
 the inflanmiation, and the healing of tlie cavitv bv granulation. The matu- 
 ration of each boil takes about a week or ten days : sometimes no suppuration 
 occurs, when the condition is called a " blind boil." The pain is throbbing, 
 and often quite severe until suppuration and loosening of the slough have 
 occurred, when it subsides. Although any portion of the integument may be 
 attacked, the face, ears, neck, back, axilla, buttocks. ])erineum, scrotum, labia, 
 and legs are the favorite sites; the nearest lyni])h-glands may become enlarged, 
 and sometimes constitutional disturbance results. Ei-i-oneous hygiene and diet 
 even in the robust, overwork, nervous depression, impro])er food, irregularity 
 of the bodily functions, and certain atmospheric conditions prevalent in spring 
 and autumn are predisposing causes. The diff"erences from carbuncle, with 
 which alone a boil is likely to be confounded, will become clear when the for- 
 mer disease is described. 
 
 Treatment. — The cause should be ascertained and removed. The diet 
 must be regulated and varied. Exercise in the open air, (juinine. iron, and 
 strychnine are useful in debilitated patients. Arsenic, with or without iron, is 
 at times of benefit. The sulphite or hyposulphite of sodium, grs. xv-xxx 
 ■every three hours, sulphide of calcium, \ gr. every two or three hours, and 
 
J ) IS i: ASKS OF THE SKIN A A J) ITS A I'/'hWDA (,' h'S. nlJ 
 
 projior (loses of sulphur iiitorniilly have been thouiiht to do good at times, but 
 there is no speeifie. When a hair oceupies the center of the boil its avulsion; 
 will sometimes abort the furuncle. Locally a. 10 per cent, salicylic-acid oint- 
 ment, or ichthyol combined Avith an erjual (piantity of collodion, -will prove bene- 
 ficial. White has reported a series of cases of furunculosis in which the obstinate 
 recurrence of boils was arrested by the administration of bichloride of mercury 
 in full doses. It is possible that this acts through its bactericidal properties, 
 the origin of the condition being perhaps microbic. 
 
 Carbuncle. — This is a circumscrilx-d, deep-seated inflammation of the skin 
 and subcutaneous tissue, terminating in a slough. Constitutional disturbance is 
 usually marked, the disease being ushered in by a chill followed by fever. The 
 skin becomes hot, painful, and dusky red, and a flattened, fairly circumscribed 
 inflammatory induration of the subcutaneous tissue forms; the pain is usually 
 burning. Steadily progressing and extending, until it may be from three to six 
 inches in diameter, by the end of from ten days to two weeks the mass begins to 
 soften, and the skin ulcerates at numerous points, which are usually filled with 
 yellow sloughs, whence issues sanious pus. The sieve-like appearance pre- 
 sented by the skin surface, due according to Warren to pus in the column9& 
 adiposjB, is characteristic, but in most large carbuncles the overlying integu- 
 ment sloughs away sooner or later, leaving a large, slowly-healing ulcer. 
 Carbuncle lasts for from four to six weeks, is usually single, and its favorite 
 sites are the back of the neck, shoulders, back, and buttocks : it is especially 
 dangerous Avhen occurring on the scalp, abdomen, and upper lip ; in these 
 locations, occurring as it does in the young, it runs an acute course and is 
 apt to terminate fatally from pyemia. It is a serious disease when extensive 
 and attacking the elderly, especially if complicated Avith Bright's disease or 
 diabetes, wdiich latter affection stands in a causative relation to it. The causes, 
 other than diabetes, are probably the same as those of boil. The possibility 
 of microbic origin should be remembered. The size, flatness, multiple points 
 of suppuration, and extensive slough distinguish carbuncle from furuncle. 
 
 Treatment. — Large amounts of easily digestible, nourishing food should 
 be given, but stimulants only when distinctly indicated. Quinine and tincture 
 of iron in large doses, with anodynes to procure rest, are requisite. Diff"erent 
 plans of local treatment may be adopted : one, of doubtful utility, is compres- 
 sion by the concentric application of adhesive straps, limiting the spread of the 
 inflammatory exudates and seeming to lessen the destruction of cellular tissue ; 
 another and far better plan is applicable even in the early stages, before the 
 skin is seriously damaged, and consists in making under anesthesia multiple 
 crucial incisions or one long incision — after freezing the parts to render them 
 friable — and thoroughly curetting away all dead or dying cellular tissue, care- 
 fully disinfecting, suturing, and draining, as in an incised Avound. This is done 
 upon the theory that the spread of the disease is due to the micro-organisms 
 flourishing in the sloughs. Or warm moist antiseptic dressings covered Avith 
 oiled silk, early removal of loose sloughs, and the free use of iodoform may be 
 employed, but poultices should be avoided. 
 
 Burns and Scalds. — These two classes of injuries may be conveniently 
 discussed together. Scalds are apt to be more extensive, because the clothing 
 diff'uses the fluid over a greater area and the hairs remain, Avhile in burns 
 these are destroyed and the tissues are often more deeply involved ; the efl"ects 
 of concentrated acids and alkalies resemble burns rather than scalds. The 
 old classification of Dupuy tren needs revision since the introduction of modern 
 methods of Avound-dressing, so far as prognosis goes, although if asepsis is not 
 secured and maintained, in the more severe cases the old rules will still hold 
 
478 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 good : moreover, the ability rui»iill_v to remove the drain of free sujijmration 
 and relieve pain by Thiersch's method of skin-grafting lessens the secondary 
 mortality of extensive burns or scalds. For practical purposes only three 
 classes of burns and scalds need be made, viz. : (1) those presenting ervthema- 
 tous inflammation of the skin without vesication ; (2) those in -which the inflam- 
 mation of the skin results in the formation of vesicles and bullae ; (3) those in 
 ■which partial or complete carbonization of the part results, or in which from the 
 secondary effects of inflammation more or less extensive and deep sloughs form. 
 
 Deatii, when it occurs, results early fi-om shock ; after reaction, from con- 
 gestion of internal organs produced by reflex vaso-motor paresis, or from these 
 congestions going on to actual inflammation of the pulmonary or gastro-intes- 
 tinal mucous membrane, of the serous membranes, etc. ; after suppuration is 
 established, exhaustion, erysipelas, pyemia, septicemia, and tetanus may end 
 life. (Edema of the glottis from scalds of the mouth is a very fatal complica- 
 tion, while perforating ulcer of the duodenum sometimes occurs. 
 
 The prognosis depends upon the extent and depth of the injury; thus 
 mere reddening of two-thirds of the cutaneous surface will almost inevitably 
 result in death, Avhile destruction of one-third of the skin will probablv pro- 
 duce the same result ; yet most burns of the first and second classes of the 
 extent commonly met with in practice will recover ; in burns of the third 
 class the region affected, the depth to which the tissues are destroyed, the 
 age, sex, and previous health of the patient, Avill determine the result ; thus 
 even slight burns of the third degree may be fatal to the young or old. 
 
 Symptoms. — These are local and constitutional. The local vary with the 
 depth of the injury, from mere reddening and swelling, up through vesication, 
 excoriation, and partial destruction, to charring. The pain may be of every 
 grade, from moderate burning up to intense agony, the most painful variety of 
 burns being that in which the outer layers of the skin are destroyed, exposing 
 the nerve-endings, less pain being complained of when total destruction of the 
 skin has taken place. The constitutional symptoms vary from slight fever in 
 burns of the first class to profound shock in the deeper forms, followed by reac- 
 tion, and this succeeded by congestion or inflammation of the viscera. Thus 
 death may result from cerebral coma ; later, the exhaustion incident to sup- 
 puration, pain, or hemorrhage, with the inflammation of the kidneys or 
 nervous centers liable to set in at this stage, is apt to carry off the patient. 
 
 Local Treatment. — In slight or moderate burns and sunburn nothing 
 else relieves the [)ain so well as wrapping the part in clotlis wet with a saturated 
 solution of bicarbonate of sodium or ordinary ''baking soda," or a weak dilu- 
 tion. 1 : 8, of phenol sodique. 
 
 In severe burns remove the clothing with great care, lest the cuticle be torn 
 off; relieve the tension in the blisters by pricking them with a needle; avoid 
 exposure to cold during the removal of the clothing and during the after-dress- 
 ing ; disinfect the parts with warm boric acid or boro-salicylic lotions; dress the 
 parts so as to exclude the air and keep them antiseptic by boric acid, iodoform — 
 in reasonable amounts — oil of eucalyptus, or other non-poisonous drugs, and by 
 enveloping the parts in cotton rendered aseptic by prolonged heating. Swath- 
 ing the parts in gauze wet with aseptic normal salt solution is an excelic-nt 
 dressing. Subsei|uent dressing should be done only when absolutely necessary 
 on account of the })ain. the sloughs being carefully removed or trimmed away, 
 and the most unirritative germicidal solutions employed for cleansing the sur- 
 faces. Where destruction of tissue has occurred, splints, elastic traction, and 
 position must be employed to prevent or overcome cicatricial contraction, 
 while early attention must be paid to the condition of the granulations, with 
 
DISEASES OE THE SKIN AND ITS APPENDAGES. 479 
 
 free skin-grafting — either from human sources or from the lower animals — 
 after Thiersch's method. ^Veak solutions of copper sulphate, or of chloral, 
 grs. X Cc/ 5J, to stimulate the formation of granulations, and repression of the 
 same by the solid nitrate of silver and pressure when Habhy or redundant, will 
 suffice in many cases to ensure healing, and should precede the skin-grafting. 
 
 Constitutional Treatment. — If shock is severe, stimulants, such as 
 ammonia and alcohol, with warm coverings, hot bottles, etc., and opium inter- 
 nally, should be used ; later, fluid nourishment, regulation of the bowels and of 
 the cutaneous and renal secretions, with iron, (juinine, and treatment calculated 
 to su])p()rt tlie system under the drain of ])rolonged suppuration, and treating 
 ■ such comjdications as pneumonia, pleurisy, peritonitis, enteritis, or hemorrhage 
 on general principles, constitute all that can be done. 
 
 The scars resulting from burns and scalds are almost certain to contract more 
 or less for a long time afterward, and produce in bad cases most terrible deform- 
 ities. These are to be prevented as far as possible by position, splints, active 
 and passive motion, etc., and later by operative measures. (See Orthopedic 
 Surgery, Surgery of the Face, and Plastic Surgery.) 
 
 LiGiiTNiXG-STROKE. — Instantaneous death or only temporary unconscious- 
 ness may result. Sometimes superficial or deep burns, or paralysis of the spe- 
 cial nerves or of those of general sensation and motion, may be occasioned. 
 
 Treatment. — The application of external warmth, artificial respiration, 
 and stimulants are indicated during the stage of shock ; later, galvanism and 
 strychnia internally may aid in the restoration of the paral}' zed nerves. The 
 local lesions must be treated in the same manner as burns of the same class. 
 
 Frost-bite. — This term is used to designate the local results of cold, the 
 destructive eifects being either direct or more usually indirect from inflamma- 
 tion. The depressing eff'ect of cold upon the circulation of the part is such 
 that this ceases, and the part may be actually frozen. With due care the vital- 
 ity may yet be restored ; but even when actual congelation of the part has not 
 occurred, unskilful treatment will determine gangrene. 
 
 Symptoms. — First numbness and tingling, then loss of power, usually 
 commencing in the fingers and toes, and a sense of weight, are complained 
 of; finally, absolute loss of sensation is noted, and the parts are bleached, 
 "white, and icy cold to the touch. Those parts which are hopelessW frozen, at 
 first white, cold, and insensible, after reaction either become swollen and dis- 
 colored, or may shrivel up and contract. Gangrene does not usually set in for 
 some little time, it being not unusual for the parts to look quite well for some 
 days, then to become discolored, bluish, next dark-blue, and finally black. A 
 line of demarcation forms, evidenced by inflammation in the contiguous living 
 tissues, and then a line of separation — i. e. ulceration — sets in, resulting event- 
 ually in the separation of the dead tissues. 
 
 Treatment. — As the result to be dreaded is partial or total death of tis- 
 sues the vitality of which has been seriously lowered by cold, and as undue 
 reaction will either determine the immediate death of the parts or give rise to 
 such a degree of inflammation as will destroy them by the compression exerted 
 by the exudates upon the feeble circulation, the indication is clear — viz. grad- 
 ually to induce a return of the heat-producing power of the parts. The tran- 
 sition must be slowly progressive ; thus, gently rubbing the parts with snow or 
 employing friction Avhile they are immersed in iced water is advisable, this being 
 done in a room where the temperature is low ; even the warmth of the bed has 
 been known to set up inflammation, which tends, as has been shown, to run on 
 into gangrene. Of course anything like approach to a fire must be avoided. 
 As soon as the general bodily temperature and that of the part have become about 
 
480 AX AMKincAX ri:xr-r>()(>K of scuuKin'. 
 
 normal, .stimulating friction with soap-linimcnt, alcoliol, and water or s])irit of 
 camphor, -with elevation of the parts, should be tried, after which, the air of 
 the room havinf; been gradually Avarmed, exposure to the air for a time is advis- 
 able ; then cover the parts with cotton : as reaction progresses, stimulants and 
 warm drinks may be cautiously administered. If excessive reaction takes 
 place, evaporating lotions of equal parts of alcohol and water are indicated. 
 Should gangrene set in, the treatment must be such as is proper for this 
 condition. 
 
 CoNSTiTUTioxAL EFFECTS OF CoLD. — This is first stimulating, the circula- 
 tion being increased in force and frequency : then pain and uneasiness super- 
 vene : general numbness and coldness, with drowsiness, inducing an almost 
 irresistible desire to sleep, are finally experienced, which if yielded to means 
 death from congestion of the viscera, the slowing respiration and failing nervou? 
 power and circulation making up a complexus of symptoms like those of 
 apoplexy. Sudden chilling produces death by cerebral anemia, slow prolonged 
 exposure to cold kills by cerebral congestion, Avhile sudden exposure to warmth 
 produces a fatal result from embolism : partial freezing usually causes fatal 
 congestion or sometimes anemia, both induced by capillary embolism. 
 
 Treatment. — In addition to the local means advised to prevent sudden 
 reaction, artificial respiration should be tried, and the temperature of the apart- 
 ment must be raised even more gradually than when dealing merely with a 
 frozen member. 
 
 Chilblain or Pernio. — This results from the sudden application of cold 
 to any exposed part, as the nose, ears, lips, fingers, or toes, of debilitated per- 
 sons. Moderate exposure to dry cold, or even to cold, damp air, followed by 
 the sudden increase of temperature induced by approach to the fire, is a pro- 
 lific cause of the slighter forms, especially in children and those with feeble 
 circulation. 
 
 Symptoms. — These may be only a slight degree of redness, swelling, 
 heat, and itchiui:, which subside almost Avithout treatment : or a more severe 
 condition may exist, marked by considerable swelling, such deep congestion as 
 often to produce a bluish tinge of the skin and very annoying heat, pain, and 
 itching. Although usually a favorable termination is to be expected, cases 
 occur where the inflammation runs higher, and vesicles form, which rupture 
 and leave obstinate ulcerations. If neglected, these ulcers may degenerate 
 into foul sores, even the bones becoming bared and carious ; but such results 
 are decidedly exceptional, the variety characterized by slight local conges- 
 tion, tenderness, and itching being that usually seen. 
 
 Treatment. — This should be prophylactic as well as curative. Persons 
 once attacked are liable to relapses upon slight provocation. Warm woollen 
 socks, gloves, and proper muflSers for the ears and face should be worn. As 
 a feeble circulation favors pernio, frictions of the parts to stimulate the circula- 
 tion, Avith general tonics, are advisable. Avoid any sudden a]iproach to the 
 fire after exposure to cold. In mild acute chilblains gentle frictions with snow 
 and the application of iced Avater, with rest and the use of lead-Avater and laud- 
 anum, usually suflSce. In the more chronic forms, when the skin is unbroken, 
 stimulant and astringent applications to the locally sluggish circulation, such 
 as tincture of iodine, alcohol, camphorated soap-liniment, oil of turpentine, oil 
 of peppermint pure or diluted up to even six parts of glycerin, and numerous 
 other similar applications, have all been successfully employed ; in especially 
 chronic or recurring cases the constant galvanic current has proved serviceable. 
 AVhen ulcers form they must be treated upon general principles. 
 
 Callosities. — These are flattened, irregular, translucent, yclloAvish, dense 
 
DISEASES OF THE SKJX AND ITS APPEND AGES. 481 
 
 thickenings of the cuticle, ■which are developed by prolonged pressure and fric- 
 tion, and are usually seated over bony prominences. According to their situa- 
 tion and cause their appearance varies ; thus various mechanical trades will 
 show thickenings on the hands differing in situation and appearance. The 
 soles and sides of the feet are common situations. So long as the exciting 
 cause persists, the thickening will remain, but usually when this has ceased to 
 act for a considerable time they gradually disappear, either exfoliating en masse 
 or more gradually desciuamating. The only troubles to which they give rise, 
 beyond slight diminution in sensibility and freedom of movement of the parts, 
 are the tendency to form fissures over the flexures of the joints, and the occa- 
 sional excitation of pain, heat, and suppurative inflammation from irritation 
 of the subjacent tissues. 
 
 Treatment. — Except in the event of the last two contingencies, treatment 
 is rarely needed. For fissures the application of softening ointments, as diachy- 
 lon spread upon lint, unirritating warm antiseptic washes or fomentations, and 
 quiet of the parts if the cracks be deep, secured by firm coaptating strapping 
 with adhesive plaster, are usually sufficient ; if abscess forms, treat it as such. 
 
 Clavus, or Corn. — A corn is a circular, flattened, hemispherical, circum- 
 scribed thickening of the horny layer of the epidermis, extending in the form 
 of a cone below the normal level of the corium, constant pressure having pro- 
 duced some localized absorption of this structure. Corns result from pres- 
 sure or friction either of the shoes or of adjacent surfaces, as those of con- 
 tiguous toes ; in the latter situations, from the constant moisture, the usually 
 yellow, horny, epithelial masses being substituted by soft, whitish collections 
 of epithelium (soft corns), which, being removed, leave a slightly elevated margin 
 of white, sodden cuticle with a central reddened depression — i. e. the deepest 
 layers of the epidermis — through which is seen the congested corium. Pressure 
 always produces pain by driving the conical mass of epithelium down upon the 
 sensitive corium, while,*^ from constant irritation, inflammation and even sup- 
 puration are not uncommon. 
 
 Treatment. — Since pressure from improperly-shaped shoes is the usual 
 cause, these must be improved in form, pressure must be taken off" by felt rings, 
 and after prolonged soaking in warm water containing washing-soda the outer 
 layers of the corn should be gently scraped away with a sharp knife — this is 
 better than digging them out with the point ; the tender surface should be pro- 
 tected by a little patch of salicylic rubber plaster. Or the reverse process may 
 be employed — i. e. hardening "^by applications of tincture of iodine or nitrate 
 of silver at night, and in the morning removing with the knife the hardened 
 tissue. The following prescription, painted on at night and scraped off in the 
 morning, is excellent : 
 
 I^ Acid, salicylici, 3iss ; 
 
 Ext. cannabis indicse, grs. x ; 
 
 Collodii, Ij. 
 M. Sig. — Paint on daily. 
 
 Soft corns should have the softened epithelium gently removed, and be 
 desiccated by keeping the surfaces separated, at the same time removing 
 pressure by proper disposition of pads of absorbent cotton, preceded by free 
 dusting with equal parts of boric acid and oxide of zinc. Inflamed corns 
 must be treated by rest, and warm, moist antiseptic dressings, the pns being 
 let out when formed, remembering that in the old, in whom senile vascular 
 changes have occurred, erysipelas and gangrene not infrequently result from 
 trimming a corn too closely. 
 
 31 
 
482 ^.V AMERICAN TEXT-BOOK OF SURGERY. 
 
 IIoRXS (CoHNU Cutaneim).— TLesc are solid, wrinkled, dry, hypertropliic 
 outgrowths of the skin ; they may be twisted, elongated, flattened, or miisli- 
 room-shaped, and are brownish-yellow, gray, or black in color. They varv 
 from the size of a mustard-seed to several inches in length, may be single or 
 more rarely midtiple, have flattened or concave bases attached to normal or 
 inflamed skin, and, while found on any part of the body, are most common 
 upon the face. Elderly persons are most liable to this affection, the young 
 being rarely attacked. Of slow growth, and painless uidess injured, tbev 
 sometimes drop off. a new horn sj)ringing from the shallow ulcerated base. In 
 structure they consist of hyperplasia and cornification of the epidermic cells, 
 with hypertrophy of the papilhe ; or, again, they may spring from the interior 
 of a sebaceous gland, an old ulcerated sebaceous evst being often their starting- 
 point. Warty growths may also be the origin of horns, and the bases of all 
 forms may undergo epitheliomatous degeneration. 
 
 Treatment. — <.)wincr to their tendency to re-form, the base from which 
 they spring must be freely dissected out. or destroyed by chloride of zinc, 
 caustic potassa. or the thermo-cautery. 
 
 Warts (\'erruc.e). — Warts are circumscribed, elevated hypertrophies of 
 both the papillary and epidermic layers of the skin. The common variety ( V. 
 vulgaris) most commonly appears upon the hands of children, but may occur 
 on other parts and at anv age. forming flattened or seiniglobular projections, 
 varying in size from that of a pin-head to half an inch in diameter. Primarily 
 of the same color as the surrounding skin, they become darker and harder after 
 a time, and the elongated papillse, covered Avith cornified epithelial cells at first, 
 may become partially denuded of these and present the appearance of a numbej 
 of projecting points, with a circuravallation of thickened cuticle: this is popu- 
 larly termed a "seed-wart."' Warts may be single or multiple, may rapidly 
 attain their full size, may last indefinitely or spontaneously disappear at any 
 stage, and are not contagious : if picked or wounded, they bleed freely, being 
 often very vascular. The filiform wart, occurring in narrow lines along the 
 free edges of the nails or elsewhere in patches, is formed by excessive elonga- 
 tion of the papillae, without the surrounding epidermic rim of the ordinary 
 form. The flat wart ( J \ plana) is never much raised above the surface, retains 
 its outer layer of epidermis, and therefore possesses a smooth surface. Warts 
 may occur upon the scalp singly or in small numbers, and consist of numerous 
 projections, compressed at their bases, but standing out at the j>eriphery; they 
 are often very vascular. Anatomically they consist of hyperplasia of the 
 papillae, of the blood-vessels, and of both the rete and the horny layer of the 
 epidermis. A form a])pearing congenitally, or even later in life, apt to be 
 pigmented and to become hairy, is called ncerns verrucosus. When such pig- 
 mented hairy growths occupy considerable portions of the surface and coincide 
 with the courses of important cutaneous nerves, they are called papilloma 
 neurotieum. and cause great disfigurement. 
 
 Treatment. — Painting the growths with the juice of the milk-weed, with 
 tincture of iodine, or with a solution of perchloride of iron, or applying moistened 
 powdered chloride of ammonium, will often cause their disappearance. If these 
 means fail, or if time is an element, free painting with bichloride of mercury, gr. 
 XXX to fej of collodion, touching once or twice with one of the strong mineral 
 acids, or repeated applications of glacial acetic acid, may be resorted to : care 
 must be exercised when employing any of these agents over superficial joints, 
 lest they penetrate too deeply. Excision by the knife, snipping them off with 
 curved scissors, or curetting them away when soft, is of course the quickest 
 means of removing warts. Hypodermatic injections of cocaine will avoid pain. 
 
DLSEASLS OF THE SKJX AXD ITS APPEyDAGES. 483 
 
 DISEASES OF THE NAILS. 
 
 Although chronic inflammatory aft'ections of the neighboring skin often pro- 
 duce changes in the form, color, and thickness of the nails, these so rarely call 
 for surgical interference that they will not be described here. 
 
 lii'PEiiTRui'HY. — This Can result only from hyperplasia of the papillae of the 
 matrix, the thickening of the nail occurring at the base, front, lateral edges, or 
 over its whole extent, according to the parts diseased. The nail may be evenly 
 thickened or variousl}' curved or twisted, Avhile its structure becomes brittle, 
 opaque, and discolored. Removal of the most projecting portions of the nail 
 will reveal the papillae elevated far above the normal level of the matrix. The 
 change is slow, progressive, and when pronounced is usually permanent. The 
 causes are not well understood : pressure, however, seems to be an exciting 
 cause, this being more efficient in the nails of the toes, especially those of the 
 great and little toes. The old, whose epithelial structures tend to overgrowth, 
 are more liable to hypertrophy of the nails than the young. "When attacking 
 the fingers, beyond the blunting of the tactile sensibility and the deformity, no 
 special trouble arises, unless painful cracks form from the splitting of the brittle 
 nails. When aff"ecting the feet, however, it is difficult for the patient to wear 
 shoes, the pressure leading to inflammation of the adjacent soft parts. It is 
 thousht that mere abnormal broadening of the nail is one of the causes of 
 "ingrowing toe-nail." 
 
 Treatment. — When the deformity seriously interferes with the appearance 
 or use of the foot, the nails must be reduced to normal dimensions by strong 
 scissors, with the knife or a fine saw, removing at the same time as deeply as 
 possible the elongated papilla?, which may be cut across during the operation, 
 and then cauterizing with perchloride of iron. When lateral hypertrophy 
 without thickening or incurvation is present, before inflammation has been 
 excited, frequent trimming of the anterior margins and corners of the nail has 
 been recommended. When actual ulceration of the lateral fold has occurred, 
 removal of an elliptical portion of the hypertrophied fold, suturing of the 
 wound, removal of a strip of nail, including the matrix underlying it, followed 
 by the use of wide-toed shoes, are the measures best adapted to cure the dis- 
 ease. Thinning the nail by scraping a groove with a piece of glass, and pack- 
 ing a little cotton beneath the buried edge of the nail, if persevered in, aided 
 by repression of the granulations by dusting with nitrate of lead, touching with 
 nitrate of silver, etc., will eventuate in the cure of a certain number of cases. 
 
 Inflammatiox of the Matrix (Onychia). — As a result of traumatism 
 in unhealthy individuals inflammation and suppuration sometimes occur at the 
 »"00t of a finger-nail and in the contiguous portion of matrix ("run-around"), 
 and often stubbornly continue unless the loosened, sharp edge of the buried 
 nail be carefully trimmed away from time to time and a little iodoform cotton 
 be emplo3'ed to press back the inflamed tissues. From lateral hypertrophy 
 of a toe-nail the .sharp lateral edge of the nail becomes imbedded in the lateral 
 fold, or from improper lateral compression of the toes the same portion of soft 
 tissues is forced up against the margin of the nail, in either case causing 
 inflammation, suppuration, and ulceration, resulting in the formation of red, 
 exuberant, excessively painful granulations, constituting the condition called 
 ingrowing toe-nail, though more correctly, in most instances, it should be 
 termed "up-growing pulp." Sometimes both edges, or even the whole matrix, 
 become involved, producing pain on any movement of the member. When 
 inflammation and ulceration of the whole matrix occur, especially where a 
 finger is involved, the condition is termed "onychia maligna:" it attacks 
 only those in depressed health. 
 
484 
 
 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 Treatment. — The treatment suggested for hypertrophy of the nail is 
 indicated for all inflaniination of the matrix, so far as removal of the portion 
 of nail producing irritation is concerned, but in onychia maligna the whole 
 nail usually requires removal under anesthesia, with destruction of the matrix 
 by caustics, or, better, dressing with powdered nitrate of lead or iodoform, and 
 the internal administration of iodide of iron, cod-liver oil, etc. 
 
 TUMORS OF CICATRICES. 
 
 Hypertrophied Scars. — Commonly these are masses of dense fibrous 
 tissue resulting from prolonged cicatrization due to extensive losses of sub- 
 stance. Hypertrophied scars assume a nodular, stellate, and reticular band or 
 bridle form, either by the time cicatrization is completed or shortly afterward 
 from further contraction ; or, again, long subse^iuently to the healing, appa- 
 rently normal, non-elevated sears take on this hypertrophic process, resulting 
 in the formation of tumors presenting the most varied appearance. No cause 
 can be assigned for these secondary fibroid alterations of scars, which some- 
 times attack those resulting from small linear incisions. The condition diifers 
 from keloid chiefly in the disarrangement of the component bundles of fibrous 
 tissue and the entire absence of the papillary layer of the skin. The vascular 
 supply, free at the outset, diminishes as the scar contracts. 
 
 Treatment. — Excision, followed by a plastic operation, is all that can be 
 recommended, and that for exceptional cases only, because the resultant scarring 
 will ofnecessitybegreaterthanthatoftheoriginal trouble, and too often the new 
 cicatrix undergoes hypertrophy ; doubtless some of the cases are closely allied to, 
 if not a variety of, keloid. In some cases reported by White thyroid extract 
 seems to have done some good. 
 
 ¥\c.. 204. 
 
 ill (uriginal). 
 
 Keloid. — This is a connective-tissue neoplasm arising in a scar, and may 
 develop single or multiple tumors (Fig. 204). 
 
 Symptoms. — Commencing usually as a small elevated nodule, as it slowly 
 enlarges it tends to assume an elongated oval form with irregularly radiating, 
 well-defined projections, presenting a rude resomlilance to a crab ; or, again, it 
 may affect a linear form. The growth — generally devoid of hair — is a smooth, 
 firm, elastic, pale-red, elevated, cicatrix-like mass, usually painless, but some- 
 
DISEASES OF THE SKIN AND ITS APPENDAGES. 485 
 
 times, especially on ])ressurc, the reverse ; more rarely itching is complained of. 
 Its favorite site is over the sternum, but it is met with over the mammae, on 
 the neck, ears, arms, and elsewhere. In those rare instances where it becomes 
 inflamed, keloid may present a temporary appearance of malij^nancy, but this 
 condition usually subsides spontaneously. The course may be either rapid 
 or slow, but, having reached a certain point, a keloid is apt to remain sta- 
 tionary for a time or for life, although it sometimes disappears. Although it 
 is stated that keloid can arise spontaneously, it usually starts from some trauma 
 of the skin, as the scars of burns, cuts, floggings, or the perforations in the 
 lobes of the ears for ear-rings. The colored race is decidedly more liable to the 
 development of keloid than the white. Microscopically, the growth consists 
 of dense fibrous tissues involving the corium and extending especially along 
 the adventitious tissue of the vessels. 
 
 Prognosis. — Although, as has been stated, keloid sometimes disappears, 
 the outlook is not very favorable ; temporary arrest in growth may continue 
 for years, yet the groAvths may again enlarge. 
 
 Diagnosis. — This is easy, the only condition with which it can be con- 
 founded being a simple cicatrix, which difliers in color, outline, elevation, and 
 consistence ; moreover, scars do not increase in size. 
 
 Treatment. — This is unsatisfactory. Removal by the knife or caustics 
 should never be undertaken while the growth is enlarging ; if any caustic is 
 used, the best is potassa fusa. Repeated scarifications (see Lupus) or multiple 
 electrolytic punctures may succeed. Anodyne liniments or morphine hypoder- 
 matically may be required to relieve pain. Thyroid extract has been tried 
 with success in a few cases. 
 
 LUPUS. 
 
 As lupus vulgaris is the variety of chief interest to the surgeon, lupus erythe- 
 matosus will be merely incidentally described under the head of differential diag- 
 nosis. Lupus vulgaris is a chronic new-cell growth, due to the bacillus tubercu- 
 losis, which forms variously-sized reddish or brownish masses consisting of an 
 aggregation of papules or tubercles, the usual termination being ulceration fol- 
 lowed by cicatrization. 
 
 Symptoms. — The disease commonly begins in youth as small, yellowish or 
 reddish-brown points beneath the skin, which increase and coalesce, forming 
 irregular roundish or serpiginous, ill-defined patches ; papules usually form and 
 enlarge until they become tubercles ; the lesions vary from the size of a pin- 
 head to that of a pea, and are covered with ill-formed epidermis. They may 
 be either firm or soft, and are painless. One of two changes follows : viz. 
 retrogression by absorption of the lesions takes place, leaving a thin cica- 
 tricial tissue covered with desquamating epithelium ; or ulcerative destruction 
 of the infiltrated skin occurs, with subsequent cicatrization, producing much 
 disfigurement. While the limbs and trunk may be attacked, the nose, cheeks, 
 and ears are the favorite sites ; it destroys the nasal and palpebral cartilages, and 
 even the eye when attacking the face, sometimes also extending into the mouth. 
 The extremities are frequently attacked, especially the fingers, the disease then 
 often resulting in serious deformity. It is never congenital, is rarely heredi- 
 tary, is uncommon among native Americans, and usually attacks only debili- 
 tated, underfed persons of the lower classes. 
 
 Diagnosis. — Syphilitic lesions most closely resemble those of lupus, and 
 the distinction must depend chiefly on the history, in conjunction with the fol- 
 lowing facts : lupous ulcers are relatively superficial and less extensive ; syphi- 
 litic ulcers are deep, excavated, and extensive ; the numerous spots of ulceration 
 in lupus tend to become confluent ; syphilitic ulcers usually remain distinct, and, 
 
486 A.X AMERICAN TEXT- HOOK OF SUliaEi:)'. 
 
 moreover, liave sharply-defined inar;_nns; tin- secretions of lupous ulcers are 
 thin, brownish, scanty, and inodorous, while those of syjdiilitic ulcers are thick, 
 often greenish, abundant, and offensive ; lu])Ous ulceration is slow, taking years 
 to reach the same size that a syphilitic ulcer would attain in the same number 
 of weeks; the lupous scar is yellowish, liard. and distorted; that of syphilis is 
 smooth, thin, whitish, and small compared to the extent of the original ulcera- 
 tion ; finally, a history of other syphilitic manifestations is often obtainable in 
 syphilitic ulceration. (See p. lt>3.) Lu|)us erythematosus usually appears after 
 puberty, beginning as an erythema ; the orifices of the sebaceous glands are 
 often gaping and distended with hardened sebum ; ulceration never occurs, 
 and after the disease disappears a cicatricial appearance of the skin is left. 
 Epithelioma is more localized, is painful and circumscribed ; induration exists ; 
 epithelial ulceration usually extends from one point, while that of lupus has a 
 multiple origin ; finally, epithelioma is rarely a disease of youth. 
 
 Prognosis. — If limited, the prognosis is fair, but when the disease is ex- 
 tensive it is very stubborn and results in marked scarring and deformity. 
 
 Treatment. — In the early stages thyroid extract and cod-liver oil, com- 
 bined w ith iodine and phosphorus, should be fiithfully tried. Avith stimulating 
 absorbent applications, such as e(|ual parts of tincture of iodine and glyce- 
 rin, mercurial plaster, tar ointment, or the ointment of red iodide of mercury. 
 Repeated linear scarification, making numerous parallel cuts which must be 
 crossed at various angles by others similarly disposed, is often very successful, 
 leaving eventually a healthy scar ; or the galvano-cautery may be employed 
 under anesthesia. When milder measures fail, recourse must be had to caustics, 
 of which chloride of zinc and pyrogallic acid are the best. Caustic potassa, in 
 stick form, should be bored into the diseased parts, and be promptly neutral- 
 ized by dilute acetic acid or vinegar. The papular and tubercular masses can 
 sometimes be successfully treated by Avorking a stick of nitrate of silver into 
 them, while the patches should be repeatedly painted over with a saturated 
 solution of the same : this is said not to leave scars. One dram of pyrogallic 
 acid to the ounce of ointment, applied thickly on lint twice daily, often does 
 well. Freezing the parts with rhigolene or ether and curetting with small, 
 sharp curettes, supplemented by applications of pyrogallic acid, is an excellent 
 measure ; or still better the patient may be etherized and thorough erasion of 
 the patches be done with the sharp spoon. AVhere the patches are of suitable 
 size and in a favorable position, excision is proper. Koch's lymph, especially 
 in the modified form, has seemed to be of more service in lupus than in any 
 other form of tuberculosis. 
 
 PERFORATiNa Ulcer OF THE FooT. — This is often a misnomer, no true 
 ulcer being present, but an opening communicating Avith a sinus, the orifice 
 being perhaps surrounded Avith granulations, and the neighboring skin only 
 slightly inflamed ; sometimes, hoAvever, the skin is extensively ulcerated : the 
 opening may be in the center of a corn. The usual position is over the meta- 
 tarso-phalangeal joint of the great or the little toe, although other parts may be 
 aflfected and several points at the same time ; one or sometimes both feet may 
 be attacked. The discharge is generally slight and sanious, and the opening 
 is found by probing to be the orifice of a sinus leading doAvn to diseased bone. 
 There is marked insensibility of the diseased part, and a varying amount of 
 anesthesia exists over an irregular area, extending sometimes to just beloAv the 
 knee; the toes are especially anesthetic. The local temperature is usually 
 reduced ; during the early stages abnormally free SAveating occurs, and later, 
 owing to organic changes in the tendons, distortion of the toes follows : the nails 
 areyelloAv, cracked, and tAvisted laterally. Increasedepithelial formation occurs 
 upon the sole and dorsum of the foot, Avhile the hairs and the depth of color of 
 
/>/,s7.AlX/vV OF THE SKIN AND ITS APPENDAGES. 
 
 487 
 
 the skin are increased. Dissections show the foot to he traversed by sinuses 
 eadi " o ctrious bone, inflamed buvsa>, and opened jomts w.tli eroded carti- 
 a'e " These ehan^es result from thickening of the endoneuruun with com- 
 pre ion and destruction of the sensory nerve-fibers. ^^^-^--^ ;;\ ';J7^^i 
 injurin- a peripheral nerve may cause perforating ulcer, or the neivc lesion 
 
 "^y^ioLi^^nuf is doubtful, owing to the liability to recurrence from 
 the persisteuc-e of the nerve lesions, even if healing should occur after re t 
 
 Treatment.-In its early stages prolonged rest m bed, or even the use of 
 an art'hml limb attached to the bent knee, will often secure temporary heal- 
 ii?; but 1 most cases, as soon as the member is used again the sore recurs. 
 Exci ion of the ulcer is useless, nothing short of a Syme or a P-ogoff amput^^ 
 Son availing. These measures are usually successful, for, a though the whole 
 an thetic ai^ea is not removed, experience shows that the ^^- ;! ^f^^^^ ^^^^^ 
 ■Mo to be-u- the pressure without ulceration ; occasionally amputation beloNv the 
 k^es^nist? beyond which point the anesthesia probably never extends. 
 Ch pa It hLs reported five cases in which entire recovery resu ted after stretch- 
 in t plantar nerves below the internal malleolus, and no failures. If further 
 experience demonstrates its efficacy, this should be the operation of choice. 
 MALIGNANT DISEASES OF THE SKIN. 
 
 Epithelioma may be either superficial or deep-seated, the former appear- 
 inff as small yellowish-red papules or flattened aggregations of the same, situ- 
 ated in the upper layers of the skin, which eventually crack or become excori- 
 ated, giving vent to a scanty watery or viscid secretion drying into thin brownish 
 c us s^; the^patch enlarges by additions to its periphery, and finally breaks down 
 into a supeiificial, spreading, rounded or irregular ulcer ^^^^^^rder usually e^^^ 
 vated into a "pearly ridge," although this may be leve with the ^1^^^, with a 
 sloping or sharply defined edge: the base is infiltrated hard, bleeds readdy, 
 and secretes a scanty viscid fluid. Pain is rarely complained of, and involve- 
 ment of the Ivmphatic glands seldom occurs. Unless the disease develops into 
 the infiltrating variety, the ulcer when once formed remains almost unchanged 
 
 in extent for a long time. , n ■ ^ r ■ «+ 
 
 Rodent UlceI, a variety of epithelioma, m this superficial form is most 
 frequently situated at the inner canthus or upon the side of the nose, it is 
 a disease of late adult life. It commences as a thickening of the skin which 
 continues to extend as a flattened nodule, and, becoming centrally abraded, 
 degenerates into an ulcer, at first of a rounded form, later irregular m out- 
 line. The base and margins are indurated, the latter being somewhat abrupt 
 or rounded, firm, and slightly elevated. The surface of the uIcct is smooth 
 or slicrhtly granular, glossy, dry and of a pinkish-red color. Progressing 
 slowly and attended with but little pain, although cicatrization may occur at 
 spots: the disease is never spontaneously arrested, everything in its course 
 being destroyed, including the bones, until the orbits, nose and mouth may 
 form one crater-like opening; in advanced cases severe hemorrhage from 
 ulceration of large vessels is not uncommon. 
 
 Deep-seated Epithelioma begins as a small reddish tubercle or warty 
 growth involving the whole skin and subcutaneous tissue, with an indurated, 
 fnfi trated base ^ usually within a few months, from failing ^l^tn-n ulcera- 
 tion begins at the older portions, producing an irregular ulcer with a foul, bleed- 
 incr, indurated base. Pain is often severe, lymphatic mvolvemen occuis 
 soSner or later, and death results from exhaustion due to pam, discharge, and 
 septic absorption. The most common sites are the lips, tongue, nose, eyelids, 
 forehead, scalp, penis and scrotum, and labia. Chronic ulcers, old cicatrices 
 
488 AN AMERJCAX TEXT- HOOK OF SVRGERY. 
 
 which have hecome irritated, and psoriasis may all degenerate into epithelioma, 
 and chronic irritations, such as those caused by a jagged tooth, by pruritus ani, 
 etc.. may give rise to the disease. 
 
 Diagnosis. — This must depend upon the points already given, upon the 
 rapid growth iiml early ulceration of" a flattened tubercle or wart, induration 
 of the base of the ulcer, age over forty years, and involvement of the lymphatics. 
 
 The treatment is free removal, including an area of healthy tissue. The 
 knife, galvano-cautery, or caustics such as potassa fusa or pyrogallic acid, after 
 freezing and curetting, may be employed. 
 
 Carcinoma. — This occurs in three forms : 1. The lenticular or scirrhous 
 fonn commences as slowly-growing, smooth, shiny, brownish-red, flat, dissemi- 
 nated papules or tubercles, which later become confluent ; these are painful, 
 ulcerate, involve the lymphatics, and recur after removal, finally destroying life. 
 2. The tuberous form occurs as firm, hard, flattened, raised, rounded, or oval 
 nodular masses, varying in size from that of a pea to an inch or more in diame- 
 ter, involving the skin and the underlying tissue. They are dull red, multiple, 
 discrete, or confluent, and terminate by ulceration, lymphatic infection, and 
 death. 3, Melanotic carcinoma commences as small, multiple, rounded or 
 oval, soft or moderately firm papules, finally becoming confluent. They are 
 brownish, purplish, or black, ulcerate, often forming gangrenous fungating 
 ulcers, involve the lymphatics, and eventually cause death : this variety usu- 
 ally commences in a mole or pigmented wart on the hands or feet during early 
 adult or middle life. 
 
 Cancerous ulcers differ from simple ulcers as follows : The malignant ulcer 
 is excavated, with elevated, everted, knobby, sinuous margins. The base is 
 nodular, infiltrated, and therefore fixed, often readily bleeds when touched, 
 is granular, livid, or covered with yellowish or grayish sloughs, and e.xudes a 
 profuse offensive ichorous or sanious discharge, which usually excoriates the 
 surrounding skin. The ulcer tends to spread continuously in extent and 
 depth, involving all the tissues, even bone, in its path. The breaking down 
 is preceded by a nodular irregular infiltration of the tissues and skin, the 
 latter often presenting a livid-red or violaceous, glazed appearance. Here 
 and there nodular or tubercular cancerous infiltrations are often seen, situated 
 some distance from the ulcer, with comparatively or — to the eye — absolutely 
 normal skin intervening. Again, much of the surrounding skin may be 
 more evenly infiltrated and fixed to the subjacent parts, presenting the 
 Avell known " hog-skin " appearance. 
 
 Treatment. — The same as for epithelioma. 
 
 Sarcoma occurs as small single or multiple, variously-sized discrete tuber- 
 cles or tumors, which may or may not be pigmented. Smooth, firm, elastic, 
 slightly tender on pressure, the non-pigmented tumors are reddish. ])uri)lish, 
 or brownish red. The multiple pigmented sarcoma is described as invariably 
 commencing on the plantar and dorsal surfaces of the feet. Sarcoma occurs 
 toward middle life and pursues a malignant course. Ulceration of sarcoma 
 of the skin does not usually produce much destruction of ti.ssue. "When 
 involvinrr the deeper parts or organs, as the breast, and ulceration occurs 
 late, secondarily attacking the skin, and extends rapidly, the ulcer presents 
 a foul, fungous appearance, the margins are not indurated to any extent, and 
 the discharges are abundant, often bloodv, and sometimes offensive. Free 
 hemorrhage is not uncommon. 
 
 Treatment. — Fowler's solution diluted with two parts of distilled water, 
 given hypodermatically twice daily, commencing with two drops and increasing 
 to its physiological limit, seems to be the only remedy which has proved succes.s- 
 ful. Early amputation is to be done where possible. 
 
BOOK III. 
 
 EEGIOJ^AL SURGERY. 
 
 CHAPTER I. 
 
 DISEASES AND INJURIES OF THE HE.4D. 
 I.— GENERAL CONSIDERATIONS. 
 
 Injuries of the head are peculiarh- important from the fact that they may 
 not be limited to the external soft parts and the bones, but may involve the 
 brain, the great nervous center on the integrity of which life itself depends. The 
 brain is well protected against ordinary injuries by moderate violence. Not 
 only is the head covered with the dense^ fibrous scalp, but the brain is further 
 encased and defended by the hard, bony skull, which is practically a closed 
 box, the thickness of which varies in different persons and in different regions. 
 This bony case is arched on its upper surface, so that blows which would 
 otherwise fracture and penetrate the skull glance from this curved surface and 
 do but little harm. Moreover, the bones are distinctly resilient and elastic, 
 yielding before a blow, but springing back to their former position without 
 fracture unless the violence be too great. Its elasticity of course diminishes 
 from youth to age. It is made up also of a number of bones united edgewise 
 at the"^ sutures, which to some extent diminish and dissipate the violence inflicted 
 upon the skull, although a fracture often crosses the sutures. Moreover, a 
 blow of sufficient violence may produce a fracture either at the point where it 
 is inflicted, or, occasionally, though rarely, at a point opposite that at which 
 the blow was received. This last form of fracture is called fracture by contre- 
 coup, or counter-stroke. It should be observed that injury by counter-stroke 
 is much more frequent in the brain than in the skull. There are a number 
 of instances on record where a blow received on one side of the head has pro- 
 duced laceration of the brain, and even of the middle meningeal artery, on the 
 opposite side. It will be seen, therefore, that in such cases if an operation is 
 done, the question on which side of the skull it shall be done is to be deter- 
 mined by localizing brain symptoms rather than by the external evidences 
 of injury. 
 
 Inside of this bony case lies the brain surrounded by its membranes, and 
 more or less steadied and protected by a small amount of fluid normally exist- 
 ing in the skull, both on the outside of the convolutions and in the ventricles 
 themselves. Not uncommonly there is a distinct area of oedema in the pia 
 which undoubtedly acts as a buffer in fending off a blow, but in spite of this the 
 brain must be looked upon as a soft mass of tissue more or less easily lacerated 
 by commotion or shaking from blows and falls, even without any fracture of 
 the bones. 
 
 Both the brain and its membranes are subject to inflammation, which is 
 followed by irritation and later by exudation, swelling, and pressure, and the 
 exudate cannot escape through the thick skull and scalp except a means of 
 4sy 
 
490 Ay A^fERICAN TEXT-llOOK OF SURGERY. 
 
 exit be offerctl l)y the surgeon. Hence the frecjuent need for trephining. The 
 pressure of this e.xu(hite may be relieved to some extent by tlie escape of some 
 of the intracranial bh)od and of some of the cerebro-spinal fluid into the spi- 
 nal canal ; but if the pressure increases, the functions of the brain must be 
 interfered with and become altered or even abolished, while the irritation may 
 cause an exaltation of function. This alteration or abolition may apply to 
 the intellectual, the sensory, or the motor functions of the brain, so that there 
 may be mania or coma, hyperesthesia or anesthesia, and spasm or paresis or 
 paralysis. 
 
 Moreover, the interference with function may be general, or if the pressure 
 be local the alteration or abolition of function will be local, at least at the 
 beginning, so that there will be paresis or paralysis of an arm or a leg, or 
 of half the face ; alteration or abolition of speech, either sensory or motor ; 
 hemianopsia if one cuneus be involved ; and, if there be inllannuation of or 
 pressure on the optic nerves or tracts, optic neuritis Avill develop. Sometimes 
 the alteration will be obscure, and functional rather tlian organic, so far as we 
 can discover, and will produce headache, epilepsy, or insanity, without any 
 perceptible change in the brain substance. When pressure is produced by a 
 blood-clot, caused by a blow with or without fracture, and followed not 
 uncommonly by a cyst, epilepsy is a not infrequent sequel. It seems also to be 
 probable that the scar resulting from laceration of the brain tissue, even in 
 simple fracture or contusion, may be followed by epilepsy. 
 
 While the o;eneral anatomical facts here stated have been of course long 
 known, yet the localization of function in various parts of the brain has been 
 proved and accepted only in the last thirty years, while cerebral surgery 
 founded upon it practically began only in 1884. Broca in France, Goltz, 
 Fritsch, and Ilitzig in Germany, and Ferrier and Horsley in England, have 
 done the principal work in solving the neurological ])roblem. while Macewen 
 and Horsley in England have created a new department in surgery. Fntil a 
 few years ago the skull was regarded as a region so dangerous that Dante's 
 motto might have been an appropriate warning : " Abandon hope, all ye who 
 enter here;" and though there were occasional accounts of extraordinary and 
 unexpected recoveries from accident, yet purposeful interference with the 1)rain 
 and its membranes was never to be thought of except where compound fracture 
 with serious brain symptoms made it absolutely needful, and then it was under- 
 taken with reluctance and fear. This was due, first, to our ignorance of the 
 localizing value of the different parts of the brain, which differ from one 
 another in function as much as the different viscera of the abdomen inter se ; 
 and secondly, to our ignorance of the fact, now amply proved, that if we em- 
 ploy the rigid antiseptic details practised by Macewen, and fully formulated 
 by Horsley so late as 1886 and 1887, we can invade the skull-cavity with 
 far less danger than was formerly thought possible. Inflammation and sup- 
 puration should rarely follow, provided antiseptic precautions are strictly fol- 
 lowed. These precautions are given in detail under the head of Technique. 
 They must be observed to the letter in every operation, no matter how slight, 
 which can possibly involve the brain-cavity. 
 
 This revelation of the function of the various parts of the brain, and the 
 similar revelation of the operative possibilities, have exercised a marked influ- 
 ence upon recent surgical practice. The aim of the present text-book will be 
 to place the surgeon abreast of the most recent experience; but, where treat- 
 ment is of doubtful or as yet unproved value, a proper conservatism will be 
 advocated; for it must still be recognized that any o))eration involving the 
 brain is a very serious one and may be attended with danger to life. 
 
DISEASES AND lyjL'RIKS OF THE HEAD. 
 
 491 
 
 II.— TOPOGRAPHY OF THE BKAIN IX ITS SURGICAL RELATIONS. 
 
 The situation ot" the chief fissures and convolutions of the brain, and 
 therefore of the various ascertained cortical centers, has of late assumed the 
 gre-itest importance, and they have frequently been mapped out on the exterior 
 of the skull with almost absolute accuracy, without any other guide than the 
 rules given below. Fig. 20o shows the points named by Broca on the skull, 
 
 Skull showing the Points named by Broca. 
 
 Ai. asterion (junction of the occipital, parietal, and temporal bones) ; Basion, middle of anterior wall of 
 foramen magnum ; £, bregma (junction of the sagittal and coronal sutures) ; G, ophryon (on a level 
 with the superior border of the eyebrows, and corresponding nearly to the glabella, the smooth swell- 
 ing between the evebrows) ; g, gonion (angle of the lower jaw) ; /, inion (external occipital protuber- 
 ance) : L, lambda "(junction of sagittal and lambdoidal sutures) ; N, nasion (junction of the nasal and 
 frontal) ; Ob, obelion (the sagittal suture between the parietal foramina) ; P, pterion ^ point of junction 
 of great wing of sphenoid and the frontal, parietal, and squamous bones. This may be H-shaped or 
 K-shaped, or " retourn^," in which the frontal and temporal just touch) ; S, stephanion (or, better, the 
 superior stephanion, intersection of ridge for temporal fascia aud coronal suture) ; S', inferior ste- 
 phanion (intersection of ridge for temporal muscle and coronal suture). 
 
 and Figs. 206, 207, and 208 show the chief fissures and convolutions of the 
 brain. 
 
 The fissure of Bichat between the cerebrum and the cerebellum corre- 
 sponds to a line drawn from the inion to each external auditory meatus. The 
 median fissure between the two hemispheres is slightly to the right of the 
 median line, the left hemisphere in right-handed persons being slightly larger 
 than the right, and vice versd in left-handed persons. The two lines just 
 given also correspond respectively to the lateral and superior longitudinal 
 sinuses. 
 
 The other three leading fissures which it is important to be able to locate 
 on the exterior of the skull are, 1, the fissure of Rolando ; 2, the fissure of 
 Sylvius ; and 3, the intraparietal fissure ; especially the first two. 
 
 1. The Fissure of Rolando (Figs. 206, c, and 2<>7, e), as Thane has shown, 
 starts from a point which lies back of the glabella 55.7 per cent, of the distance 
 from the glabella to the inion, and runs downward and forward at an angle of 
 67°, its average length being 3f inches. The lower third of the fissure changes 
 to a somewhat more vertical direction. Practically, the fissure of Rolando 
 
492 
 
 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 commences half an inch behind the mid-point between the glabella and the 
 inion. Mr. Horsley states that in a head with a cranial index of 75' the fissure 
 
 Fifi. 2or,. 
 
 s. - 
 
 — -P 
 
 View of the Brain from Above (Ecker). 
 
 A, anterior central or ascending frontal convolution ; B, posterior central or ascendin? parieUl convo- 
 lution ; c. central fissure or fissure of Rolando ; cm, calloso-marrinal sulcus ; F, frontal lobe ; / , , upper, 
 F,, middle, F3, lower fronUl convolution; /,, superior frontal sulcus ; /,, inferior frontal stJcus ; /,, 
 vertical fissure (sulcus pr!ecentralis) ; jp, intraparietal sulcus ; O, occipital lobe; o', sulcus occipitalis 
 transversus; 0,, first occipital convolution; 0.„ second occipital convolution ; P, parietal lobe; po, 
 parieto-occipital fissure; Fy, upper or postero-parietal lobule: P^, lower parietal looule, constituted 
 oy P-^< gyrus supramarginalis, andiP2't gyrus angularis ; S, end of the horizontal branch of the fissura 
 Sylvii; <,, upper temporal fissure. 
 
 runs at an angle of 69°, the angle increasing or diminishing one degree for 
 every two degrees of increase or decrease in the cranial index. In all ordinary 
 cases, however, the fixed angle of 67° will be found sufficient. 
 
 Chienes Method. — Mr. Jolin Chiene of Edinburgli has proposed a method 
 of fixing the position and length of the Rolandic fissure which is at once sim- 
 ple, ingenious, and always available. He folds a square piece of paper once 
 ^Fig. 209, ABCD). on the diagonal line AC. The angle BAG is then evi- 
 dently 45°. The angle DAC (45°) is then halved (22.5°) by folding the 
 paper again on the line AE. The sum of the angles BAG and GAE is 
 evidently 67.5°, which is near enough for all practical purposes to the angle 
 of the fissur'i of Rolando. The side AB is tlien applied to the middle line 
 of the head, the point A being placed half an inch behind the mid-point 
 between the glabella and the inion, when the line AE will correspond to the 
 fissure of Rolando. 
 
 1 The cranial index is found by dividing the transverse diameter of the head by the antero- 
 posterior diameter. 
 
DISEASE,^ AND INJURIES OF THE HEAD. 
 
 Fig. 207. 
 
 49a 
 
 Outer Surface of the Left Hemisphere (Ecker). 
 
 A antPrior ppntral or ascending frontal convolution : B, posterior central or ascending parietal convo- 
 ' Intion • ^sulcus centrX of fissure cf Rolando ; cm, termination of the calloso-marginal fissure ; F. 
 frontal lobe- F superior F. middle, and F3, inferior frontal convolutions: /„. superior, and/,, infe- 
 rior f^onta^su^lcusT °ucus p^^^ ?p, sulcus intra-parietalis; O, occipital lobe ; O, first, O,, 
 second O third ocdpifaconStions ; oi sulcus occipitalis transversus ; o„ su cus occipitalis longi- 
 ?,Xaii?infS P EtaK^^^ po, parieto-occipitaf fissure ; P.. superior parietal or postero-parie- 
 tel lobule pT inferior parieta^^^^^^^^ P,. gyrus supramarginalis ; P^-F^us annularis; & fis- 
 sfirP of svl'vhis «' horizontal S" ascending ramus of the same ; T, temporo-sphenoidal lobe ; 1 „ first. 
 TrsecoDd. TstVhiVd tem^^^^ coVolutions ; t,, first. U, second temporo-sphenoidal flssurea. 
 
 Fig. 208. 
 
 Inner Surface of Right Hemisphere (Ecker). 
 
 -ispiii^iiiilSl^ 
 
 l^me=-'o'"cuneu "ff ^arS\\a?lob^ 
 
 Mdpito-t4mpomUs lateralis globulus fusiformis) ; T.„ gyrus occipito-temporalis medialis (lobulus liu- 
 
 gualis) ; U, uncinate gyrus. 
 
494 
 
 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 The length of the fissure being ^l inches, Mr. Cliiene suggests that 
 every man who has seen his mother measure her tape on her right fore- 
 finger should know what point on his own right forefinger corresponds to 
 3| inches in length. This will give the length of the fissure of Rolando on 
 
 tlie line AE. 
 
 Fio. 20y. 
 
 V 
 
 
 ■T - 1 - 
 
 B 
 
 l\\ 
 
 
 / / 
 
 
 
 
 ' / 
 
 
 1 \ 
 
 V 
 
 \ 
 
 '^ 1 
 
 
 1 \ 
 
 V ,> / /o 
 
 
 1 
 
 Vv>:-\ 
 
 /€ 
 
 
 1 
 
 \ y 
 
 \ 
 
 
 1 
 1 
 
 1 
 
 
 \ 
 
 \ 
 \ 
 \ 
 
 \ 
 
 
 1b 
 
 e\ 
 
 \ 
 
 Chiene's Method (jf Fixing Position of Rolandic Fissure (original). 
 
 Mr. Horsley has devised an instrument made of metal or of two strips 
 of parchment paper, as shown in Fig. 210, the antero-posterior arm being 
 14 inches long, and the lateral arm being placed at an angle of 67°. The 
 scale of this instrument starts from the zero point (half an inch in front 
 of the lateral arm), and runs both forward and backward. To determine 
 the fissure of Rolando, place the antero-posterior arm in the middle line 
 in such a position that the glabella and the inion will each mark the same 
 distance from the zero point on the scale; for instance, each six or six and 
 a half or seven inches. The laternl arm will then correspond to the fissure 
 of Rolando, except in the lower third, where, as already stated, the fissure 
 
 Fk;. 210. 
 
 rTr,.^i.,.ii.ii.i..ii.^i.i.f.i,f,iT,i,p,,,r,i.r,i,r,i,F,i,i 
 
 Horsley's Cyrtonieter (as modified by Dr. Morris .1. Lewis). 
 
 becomes slightly more vertical. To admit of its use on both sides of the 
 skull the lateral arm should be made reversible right and left, or the whole 
 instrument may be reversed from side to side if it is graduated on both 
 sides. In children below nine years of age the fissure is much more obliijue 
 (even down to 02°), and lies farther forward on account of the slighter 
 development of their frontal lobes. 
 
 Kriinlein has recently proposed a .'dimple and accurate method of- locating 
 the fissures of the brain as follows (Fig. 211): (1) The base-line. ZJ/, runs 
 horizontally at the lower border of the orbit and the upjier border of the 
 auditory meatus. (2) Parallel with this, on a level with the supra-orbital 
 ridge, another horizontal line {KK') is drawn. (3) An anterior vertical line 
 
DISEASES AND IXJ CRIES OF THE HEAD. 
 
 495 
 
 {ZK) is drawn from the middle of the zygoma to the supra-orbital line. 
 (4) A middle vertical line is drawn from the articulation of the lower jaw A, 
 and })roloiiged to R. (5) A posterior vertical line is drawn from the posterior 
 ])order of the base of the mastoid [MK') and ])rolonged to 1*. the middle line 
 of the skull. (6) Draw a line from K to I*. Between the points li and P' it 
 corresponds to the fissure of lUjlando. (7) Bisect the angle PKK' by the 
 line KS. This line corresponds to the fissure of Sylvius from its bifurcation 
 
 Fh;. 211. 
 
 Supra-orbital line (upper horizontal) 
 
 Auriculo-orhital line (lower horizontal^) 
 
 Kronlein's method of locating the fissures of Rolando iHP') and of Sylvius (KS): Kronlein's points of 
 trephining for hemorrhage from the middle meningeal (KK') : and von Bergmann's region for tre- 
 phining for abscess of the temporo-sphenoidal lobes (AaK'M ). 
 
 to its posterior end. The point K is over the bifurcation of the fissure of 
 Sylvius. K and K' are the points for trephining to reach the anterior and 
 posterior branches of the middle meningeal artery. The method applies 
 equally to all varieties in the shape of the head. 
 
 The importance of fixing the fissure of Rolando will be especially appre- 
 ciated in observing the motor centers which cluster around this bv far the 
 most important of the cerebral fissures. 
 
 ^ This lower or '" German horizontal " is the same as " Reid's base-line." 
 
496 
 
 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 FR 
 
 POFi 
 
 2. The Fissure of Sylvius (Fig. 207, S, S', S", and Fig. 212, SF and 
 A). — To fix this fissure, draw a lino from EAP (Fig. 212), the external angu- 
 lar process, to Ol'r, by 
 Fig. •IVl. the siiortest route between 
 
 these points. This usually 
 passes at about haltan inch 
 above the meatus. The 
 fissure of Sylvius begins 
 one and one-eighth inches 
 posterior to the exter- 
 nal angular process on 
 this line, and from this 
 point the main line of the 
 posterior branch of the 
 fissure of Sylvius (Fig. 
 212, SF) runs in a direct 
 line toward the parietal 
 eminence, PE. The as- 
 cending or anterior limb 
 of the fissure corresponds 
 closely to the squamoso- 
 sphenoidal suture in its 
 entire length, and is con- 
 tinued upward in the same 
 line for half an inch or 
 more (Fig. 212, A). The 
 middle meningeal artery 
 is shown in the same fig- 
 ure in its relation to the 
 Sylvian and Kolandic fis- 
 sures. 
 
 The pre - central 
 sulcus, or, as it is often 
 called, the vertical sul- 
 cus (Fig. 207, P) is of 
 great importance, as it limits the pre-Kolandic convolution anteriorly. It is 
 sometimes joined by the inferior frontal sulcus (Fig. 207, /^). It runs parallel 
 to and just behind the coronal suture, at the width of one convolution in front 
 of the fissure of Rolando. Its upper end does not extend as far as the superior 
 frontal sulcus. The pre-Rolandic or ascending frontal convolution bends around 
 the lower end of the pre-contral sulcus forward and forms a crescentic convo- 
 lution which lies in the hollow of the two limbs of the fissure of Sylvius and 
 is continuous anteriorly with the third frontal convolution. It is called the 
 operculum, and in it, especially in its anterior portion (the base of the third 
 frontal convolution), is Broca's center for speech. 
 
 There are two frontal sulci, the superior and inferior, which divide the 
 frontal lobe into three convolutions: the superior, middle, and inferior, or first, 
 second, and third, frontal convolutions. The Hiipe7'ior frontal sulcus (Figs. 
 20() and 207, /^) starts from the pre-Rolandic convolution about midway 
 between the fissure of Rolando and the line of the pre-central sulcus. The 
 inferior frontal sulcus (Figs. 200 and 207,/^) starts from the vertical sulcus 
 and runs forward parallel Avith the superior frontal sulcus. It lies about on a 
 level with the superior temporal ridge or superior stcphanion (Fig. 20"), S). 
 
 Head, Skull, and Cerebral Fissures (adapted from Marshall 
 by Hare). 
 
 B corresponds to Broca's convolution : EAP, external angular pro- 
 cess ; FK, fissure of Rolando : I F, inferior frontal sulcus ; TPF, in- 
 traparietal sulcus ; MMA. iniddli' ineninKcal artery ; OPr, occipital 
 protuberance; PE, parietal eniiiii'ncf ; POF, parieto-occipitai fis- 
 sure : SF, Sylvian lissure : A, its aseendiuK limb ; TS, tip of temporo- 
 sphenoidal lobe. The pterion (to tlie left of B) is the region where 
 three sutures meet, viz., those bounding the great wing of the 
 sphenoid where it joins the frontal, parietal, and temporal bones. 
 
JJ/SJJASI'JS AND IX.nillF.S OF Till': UFA I). 
 
 497 
 
 Fig. 213. 
 
 3. The Intraparietal Fissure (Figs. 20(5 and 207, iij) lies posterior to 
 the fissure ot" liulamlo, and is the posterior boundary of the motor region. It 
 begins opj)osite the junetion of the nii(hlle and inferior thirds of the fissure of 
 Kohmdo. I'assing upAvard, it lies midway between the fissure of Rolando and 
 tile parietal boss. It then diverges from the fissure of Rolando posteriorly, 
 antl thus widens the upper end of the post-llolandic convolution to such an 
 extent that the upj)er end of this convolution is known as the Hiqyerior j)arietal 
 Ivhuh' (Figs. 20(), 207, and 20^, P"). In the middle of its course the intraparietal 
 fissure runs about parallel to the great longitudinal fissure and midway between 
 it and the parietal boss. Farther back it passes by the parieto-occipital fissure 
 and downward and backward into the occipital lobe. Below its curve, at the 
 ends of the Sylvian and first temporal fissures respectively (S' and ^\ Fig. 207), 
 are the supramarginal (P,) and angular (V^') gyri. Once these fissures are 
 determined from tlie outside of the skull and the brain exposed, the latter can 
 be faradized, and the exact localization of the motor cortical centers can be 
 determined by the movements produced by faradization. This has been done 
 in a number of cases with unexpected accuracy. 
 
 For a more minute localization of the other fissures and convolutions of 
 the brain the reader is referred to the American edition of Gray's Ar^atomy 
 for 1887, p. 681, and to the article on " The Surgery of the Brain," Buck's 
 Reference Handbook of the Medical Sciences, vol. viii. p. 201. 
 
 Figs. 213 and 214 show the position of the chief motor areas in the 
 brain of the monkey, as determined by Horsley and Schafer, which correspond 
 closely, as has frequently 
 been shown, to the same 
 cortical centers in man. 
 Roughly speaking, the 
 upper third of the con- 
 volutions in front of and 
 behind the fissure of Ro- 
 lando corresponds to the 
 center for the movements 
 of the leg ; the middle 
 third corresponds to those 
 for the arm (beginning 
 at the upper end with the 
 shoulder center, the 
 middle part the elbow 
 center, and the lower 
 the hand center). In 
 the lower third lie the 
 face center and the 
 center for the mouth and larynx. The centers for the face, leg, and trunk, 
 it will be noticed in Fig. 214, are largely situated on the median surface of 
 the hemispheres as well as on their external surface. Broca's center for 
 speech lies just in front of the end of the fissure of Rolando, and in the 
 angle formed by the main trunk and the anterior limb of the fissure of 
 Sylvius. 
 
 The center for vision is situated chiefly in the cuneus (Fig. 208, Oz), a 
 lesion of which produces blindness of the corresponding (right or left) half of 
 both retinse. The supramarginal and angular gyri are also probably- 
 concerned to some extent in vision. These same convolutions (supramargi- 
 nal and angular) are the seat of certain mental processes, the abolition of 
 
 32 
 
 Motor Areas on tlie Outer Surface of the Brain of the Monkey 
 (Horsley and Schafer). 
 
498 
 
 AX AMKJilCAX TEXT-liOOK OF SVlidERY. 
 
 Motor Areas on the Median Surface of tlie Brain of the Monkey 
 (Horsley and Schafer). 
 
 wliicli piuducL'S .sensory 
 apliasia, alexia, agraphia, 
 apraxia, etc. ; for the de- 
 tails of which see page 
 r>4(j. '{"lie cfiitcr for 
 hearing is pi-oljably sit- 
 u:itc(l in the luitldle mikI 
 jtosterior |)arts of tiie 
 first tempore -sphe- 
 noidal coiivolittioii (Fig. 
 :i')7, T'j. The center for 
 smell is pi-obaldy situ- 
 ated in the uncus, near 
 the lower part of the 
 hippocampus major (Fig. 
 208, U). 
 
 III.— TECHNIQUE OF CEKEBRAL OPERATIONS. 
 
 We owe this chiefly to Mr, Horsley's brilliant papers. It is always of the 
 utmost importance that the head should be shaved. This will often reveal 
 scars, etc. hitherto unsuspected, and no definite diagnosis should over be reached 
 or an operation determined on without this procedure. The fissures, so far 
 as is necessary, may be marked out on the shaven scalp by means of an aniline 
 pencil, which is itself antiseptic. Of course, after being shaved, the patient 
 should be protected against catching cold by a silk handkerchief or cap around 
 the head. The day before the operation the head should be shaved anew if 
 need be, scrubbed with soap and water, next cleaned with ether, and then 
 covered with a sublimate dressing, the three or four inner layers of which may 
 be wet with a sublimate solution 1 : 2000, as a 1 : 1000 solution might vesicate. 
 This dressing should be retained in place until the operation, when the disin- 
 fection should be repeated. There is no need for the spray. Of course all the 
 ordinary operative precautions described elsewhere, as to the thorough cleansing 
 of the finger-nails, hands, and arms of the operator and liis assistants, should be 
 carried out Avith scrupulous care. 
 
 Ether or chloroform may 1)0 used, and it is better to operate with the patient 
 in the seml-recumbent position rather than lying flat, in order to diminish 
 the amount of hemorrhage. It is important to mark three points on the bone : 
 viz. the place at which the center pin of the trephine is to be applied, and 
 the upper and lower ends of the fissure of Rolando at points just outside the 
 flap, in order that the fissure may be recognized after the flap has boon raised. 
 This is best done by using the center pin taken out of another trephine, by 
 means of which a little triangular point can be marked on the bone, using the 
 rongeur forceps, for example, as a hammer, or a very small gouge will nick the 
 bone sufficiently to enable it to be recognized. 
 
 The flap to be raised should be of a horseshoe shape, with a diameter of 
 about three inches. As a rule, the base of the flap should be below, on account 
 of tlie more favorable l)lood-supply. The flaj) of periosteum should be raised 
 with the scalp. The hemorrhage is best controlled by seizing the edge of the 
 flap at the bleeding points with hemostatic forceps. 
 
 The trephine opening, Avith rare exceptions, should be large, not less 
 than \\ inches. Once tlie trephine opening is made, it can be enlarged by the 
 rongeur forceps (Fig. 216) to any extent desired. Before enlarging it the dura 
 
J)Lsi:a.ses axi) ixjcuies of the head. 
 
 499 
 
 slioiild be separated from the bone by Ilorslcy's diiral separator (Fig. 215), 
 by means of Avhieli also tlic inner surfaee of the skull can be explored, and 
 any irregularities detected, two inches or more from the trephine opening. 
 
 Fkj. '_'!"). 
 
 Horsley's Dural Separator. 
 
 Osteoplastic Resection. — In 1889, Wagner, following an earlier 
 suggestion of Woltt", proposed to make a temporary osteoplastic resec- 
 tion by chiselling loose the piece of bone to be removed, except at one 
 portion where it was fractured and turned back on the scalp as a hinge. 
 The scalp is incised down to the bone, the flap not being loosened from it. 
 By mallet and chisel the bone is then nearly cut through at every point 
 excepting its base, the separation being completed by an osteotome. It is 
 then lifted by means of elevators, the base being fractured, a window, so to 
 
 Fig. 216. 
 
 Fig. 211 
 
 Hopkins' Rongeur Forceps, as modified by Weir. 
 
 Osteoplastic Restction of SLull b\ the Wagner- 
 WolU Method (Lsmarch and Kowalzig;. 
 
 Fig. 218 
 
 Keen's Rongeur Forceps 
 
 speak, being opened by turning back the flap (Fig. 217). By this means 
 access can be had to a very large area of the brain-cortex ; even three, four, 
 or five inches have been thus exposed. When the operation is terminated 
 the opening is closed by replacing the flap, which is sutured in place as usual. 
 In chiselling such a piece loose it is best to chisel it obliquely, so that the 
 opening in the inner table will be a little smaller than that in the outer, the 
 inner table thus forming a shelf on which the flap rests. The base of the 
 
500 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 llaj), wliioh serves as a hinge, should alwavs be in that part of the Ikip having 
 the Largest blood-suj)j)l\-. 
 
 The surgical engine with a special drill, an electrical motor vith a saw, 
 and the Gigli -wire saw have been also used in place of the chisel. 
 
 " Trephining " in the remainder of this chapter >vill be used in the sense 
 of opening the skull to obtain access to its interior, irrespective of whether 
 the opening is made by the trephine, the chisel, or any other means. 
 
 As a rule, the dura should be opened. The additional danger is very 
 slight, and the additional information may be very great. With rare excep- 
 tions, if we trephine at all the brain itself should be examined by sight and 
 touch. The opening in the dura is best made parallel with the edge of the 
 bone and a quarter of an inch away from its margin. Care should be taken 
 not to wound the large and troublesome veins of the brain immediately 
 beneath the dura. This can best be avoided by lifting the dura Avith rat- 
 toothed forceps while making the first incision by a knife, and then by using a 
 blunt-pointed pair of scissors. 
 
 If hemorrhage occurs from any branch of the middle meningeal, it may 
 be arrested by passing a ligature through the dura under the vessel Ijy means 
 of a fine semicircular needle, the finest Hagedorn being the best. For check- 
 ing hemorrhage in the brain the chief reliance must be placed on catgut (non- 
 chromicized). Some of the larger arteries can be tied directly, but in many 
 cases it is better with the fine semicircular Hagedorn needle to pass a ligature 
 through the brain substance and around the vessel, and tie it with great gentle- 
 ness, care being taken to see that the traction on the two ends of the ligature 
 is exactly even, in order not to tear the vessel. The knot must not be tied too 
 tightly, or it will cut through the fragile vessel. Pressure continued for a few 
 minutes by gauze or sponge and hot water at 105° to 115° will often serve a 
 good purpose. Sometimes, especially in hemorrhage from the sinuses, the hem- 
 ostatic forceps may be left for from thirty-six to forty-eight hours. Usually, 
 however, pressure upon the sinuses or plugging them is the best means of con- 
 trolling such hemorrhage. A lateral ligature may be used if the wound is small, 
 or the entire sinus may be ligated if need be. 
 
 After opening the dura the first point to be observed is whether the brain 
 bulges into the trephine opening, for if it does there is a pathological increase 
 in the intracranial pressure, due to tumor, abscess, internal hydrocephalus, etc. 
 Next observe the color. Lividity or a yellowish tinge will indicate a probable 
 tumor beneath the cortex. An old laceration will usually show a dirty yel- 
 lowish-brown. (Edema of the membranes is not uncommon, even to such an 
 extent as in great measure to obscure the sulci and convolutions. The serum 
 will escape on nicking the membranes, and the sulci and convolutions may 
 then be recognized. Absence of pulsation in the brain usually indicates a 
 large tumor, abscess, or cyst. The density of the brain can best be deter- 
 mined by touch. 
 
 If the brain tissue be abnormal, the whole abnormal portion ought to be 
 removed. In doing so we can cut much more freely antero-posteriorly than 
 vertically without doing damage, as in the vertical direction other centers than 
 the one we seek are more quickly encroached upon than by excision antero- 
 posteriorly. (Compare Fig. 213.) When the brain is exposed, if we wish 
 to recognize any motor center by faradization, no antiseptics should be used, 
 as they all dull the reaction of the cortex to electricity, but only sponges or 
 sterilized gauze wrung out of hot water. For faradization of the brain the 
 ordinary faradaic battery suffices. The current should not be too strong, lest 
 it do harm to the cortex. A current sufficient to stimulate the thenar muscles 
 
DISEASES AND IXJURIES OF THE HEAD. 601 
 
 is that usually emijloyed. A doiilile Ijraiii olectroile*(Fig. 211t) may be used 
 
 Fui. 219. 
 
 Double Brain-electrode (Keen). 
 
 with advantage. The points should be sterilized and the handle wrapped in 
 antiseptic gauze. By applying the electrodes to various parts of the cortex 
 the motor centers can be readily determined in most cases, even without 
 opening the dura. Notes should be taken of the phenomena following each 
 application, and the situation of the points stimulated should be determined 
 bv exact measurements. A stenographer should be present to take the dic- 
 tation of the observed phenomena rapidly and exactly. As a rule, it is better 
 not to drain after cerebral operations, but occasionally, especially in cysts, 
 drainage is a matter of importance. In abscesses, gunshot wounds, hemor- 
 rhage, etc. it is of course a necessity. Rubber tubing is the best means. 
 
 Not uncommonly the hone can be replaced. Even a l|-inch button of bone 
 will retain its vitality and re-establish its connection with the skull if properly 
 cared for. In all cases, therefore, where there is a possibility of the replace- 
 ment of the bone, the moment it is removed it should be placed in a bowl con- 
 taining a 1 : 2000 sublimate solution, and the bowl be placed in a basin of hot 
 water the temperature of which is kept at 105° to 100° F. This should be 
 the sole care of one assistant. Instead of replacing it in one large piece, it 
 may be bitten into small pieces by bone forceps. The pieces bitten away by 
 the rongeur forceps may be similarly utilized. Sometimes Senn's decalcified 
 ox-bone can be better used than the bone which has been removed. Of course 
 if the bone be diseased or very compact, or it be desired to change the intra- 
 cranial pressure, as in cases of headache, insanity, etc., the bone should not be 
 replaced. In this case a small disk of tin can be advantageously secured to 
 the inside of a skull-cap to protect the brain. To prevent adhesion of the 
 brain disinfected gold-foil has been inserted. Fraenkel has recently filled the 
 opening by a disinfected celluloid plate. Kiinig has proposed to fill the gap 
 of an old fracture by chiselling a neighboring piece of the outer table away 
 with a flap of scalp, sliding it into the opening, and covering the wound thus 
 made by transplanting skin by Thiersch's method. Instead of this, 
 pieces of the outer table of the neighboring bone may be chiselled 
 away and scattered thickly over the dura. They are held in place by 
 the replaced flap of scalp. If the dura has been removed, and it is still 
 desired to replace the bone in one large piece, this may be perforated 
 and secured to tlie under surface of the flap by catgut, then preferably 
 chromicized. 
 
 After the operation on the brain is completed the dura should be sutured 
 by interrupted or continuous catgut sutures as is desired. The scalp should now 
 be replaced and secured by the ordinary interrupted sutures, and an abundant 
 sublimate dressing, of which the inner lavers may be again Avet with a solu- 
 tion of the strength of 1 : 2000, should be applied. This should be covered 
 with rubber dam, and be retained in place by a bandage and, especially in 
 children or in restless adults, by a night-cap. As soon as the dressing is 
 moistened to its margin b}' serous or bloody discharge the wound should be 
 redressed. If a drainage-tube has been used, it should be removed at the 
 end of from twenty-four to forty-eight hours, except in cases of abscess, etc., 
 
502 AX AMElilCAX TEXT-IKJUK OF SURGERY. 
 
 •when it .should remain for some days. In ease no drainage has been provided, 
 if too mueh bh>od and serum or cerebro-sj)inal fluid aeeumulates under the 
 flap, as shown by its marked bulging and possibly by paralysis, the uound- 
 fluids can be evacuated by inserting a probe or a pair of forceps between two 
 stitches. As a rule, by the fifth or sixth day about half the stitches may be 
 removed, and all of them usually by the seventh or eighth day. Absolute 
 «|uietude, both of mind and of body, should be insisted upon, esi)ecially for 
 the first week. Xo letters, visitors, or other causes of excitement should be 
 allowed for some time. Though sometimes less severe restrictions may be 
 required, yet this course should be enforced for two weeks, and in some cases 
 even for months, after the operation. 
 
 Operation in Two Stages. — The severe shock in serious operations on 
 the l)rain has led llor.-^k'y and other surgeons to modify the procedure by 
 dividing it into two stages. The first stao;e consists in merely effecting an 
 opening into the skull. This is then closed by a few temporary sutures. 
 After an interval of from three to six days the wound is reopened and 
 the operation completed. This method is especially applicable to opera- 
 tions for brain-tumors and occasionally in the removal of the Gasserian 
 ganglion. 
 
 Secondary operations are not uncommonly recjuired when the brain, its 
 membranes, and the bone will all be adherent, and must be dissected free from 
 one another with great care. Some of the brain tissue will of necessity be torn 
 away, and more or less pronounced paresis of the centers corresponding to the 
 interference may be produced. After removal of a motor center there is of 
 course entire paralysis of the part supplied by this center ; and the pressure 
 caused by the blood-clot which accumulates and the later cell-proliferation is 
 apt to cause widespread paralysis, amounting even to a hemiplegia. After 
 some wxeks this invariably disappears to a greater or lesser extent, leaving, 
 however, the affected muscles, it may be. somewhat paretic. 
 
 If any portion of the dura has been removed, and especially if this 
 is followed by removal of the brain substance, there is a marked tendency to 
 proliferation of the cerebral tissue, with danger of a fungus cerebri forming. 
 This may be prevented by taking a bit of the pericranium from the under sur- 
 face of the scalp, turning the osteogenetic surface upward, and attaching it to 
 the dura by interrupted sutures. The pericranium will very quickly contract 
 adhesions to the dura, and the gap will be closed (Keen). 
 
 The limits of operative procedure are constanth' being enlarged. 
 Once the skull is trephined, we can explore the inner surface of the skull 
 over a wide area by the dural separator or probe. If the dura has been 
 opened, the finger can be gently inserted between the brain and the dura and 
 the .surface of the brain explored for at least an inch all around the opening 
 in the dura. The brain can be readily depressed by the finger or the knife- 
 handle used with gentleness, and the eye can see for an inch beyond the dural 
 opening. If the opening be toAvard the base of the brain, the brain may be 
 lifted either with or without the dura and the base of the skull explored for a 
 considerable distance. The cerebellum can be lifted and the finger and the eye 
 can reach to the foramen magnum. The sinuses can be safely uncovered and 
 separated from the skull, and the frontal lobe lifted far enough to discover the 
 anterior clinoid process, while laterally the surfaces of the petrous bone can be 
 explored. The brain can be punctured almost with impunity, especially if a 
 blunt instrument like a grooved director be used, so as not to wound the large 
 vessels, and the ventricles can be tapped. 
 
DISEASES AND IXJIRIES OF THE HEAD. 503 
 
 IV.— DISEASES INVOLVING THE SCALP. 
 
 1. Inflammation of the Scalp. — This is a frequent sequence of wounds, 
 and will be referred to later. It is often caused by the poison ivy or poison 
 oak and by erysij)t'las, and is described under these heads. 
 
 II. Tumors of the Scalp. — 1. The most frequent of all are the Seba- 
 ceous Tumors, or Wens. The pathology of these tumors will be found in the 
 chapter on Tumors. Their diagnosis is easy. They are frequently multiple, 
 are of slow growth, vary in size from that of a pea to that of a small egg, 
 are painless, and have an elastic, cystic feel. Occasionally, especially near the 
 angle of the eye, they are dermoid in character, having a number of hairs inter- 
 mingled with the sebaceous contents. Sometimes they ulcerate. 
 
 The treatment is extirpation. In removing them it is not necessary to 
 shave the scalp, but the hair should be neatly parted over them, all grease 
 removed from the scalp, which is next thoroughly disinfected with a bichloride 
 solution. An incision is then made down to the wall of the tumor, when it 
 can usually be enucleated without difficulty. It is very important to leave 
 none of the cyst-wall behind, or the tumor will be reproduced. A simple 
 bichloride dressing and a bandage complete the operation. Unless the tumor 
 is large, neither drainage nor sutures are necessary. Usually the wound will 
 be entirely well in three or four days. 
 
 2. Fatty Tumors occur rarely in the scalp, and are very difficult to diag- 
 nosticate from the sebaceous, as they resemble them in almost all respects. 
 They are apt, however, to be somewhat flatter and less globular, and also to 
 be situated more deeply than the sebaceous tumors, not uncommonly being 
 next the pericranium. An error in diagnosis is of no importance, however, as 
 the treatment is identical — extirpation. 
 
 3. Congenital Cysts and Fibromata may occasionally occur in the 
 scalp. The diagnosis is perfectly clear, and the treatment equally so — entire 
 removal. 
 
 4. Warts and Horns are not uncommon. Horns should be removed by 
 the knife. Warts, when they are inconspicuous and non-irritating, may be 
 disregarded, but if they show the least tendency to grow they should be removed 
 by the knife, as they sometimes become malignant. 
 
 5. Moles are a local hypertrophy of the skin. There are two forms : 
 first, the hairi/ mole, covered with more or less stiff, bristle-like hairs, and 
 without discoloration of the skin ; and, second, the pigmented mole, in Avhich 
 the skin is discolored and of a brown or black tint. Sometimes they are of 
 sufficient size to become serious disfigurements, and must then be removed by 
 the knife after local anaesthesia by cocaine. If very large, sometimes either 
 transplantation of skin or a plastic operation may make good the defect pro- 
 duced by their removal. 
 
 6. Pneumatocele, or a tumor filled with air, is very rarely met with. 
 Treves states that only ten cases are on record. It is most frequently a result 
 of spontaneous atrophy of the osseous tissue producing a communication with 
 the mastoid cells. The air then escapes under the pericranium, forming a 
 tumor which may vary in size up to that of a pigeon's egg. It is painless, 
 elastic, smooth, and tympanitic to percussion. Pressure will ordinarily oblit- 
 erate the tumor. The treatment is usually compression after emptying the sac 
 of its air by pressure or by the needle of a hypodermatic syringe. 
 
 III. Arterial Varix, or Cirsoid Aneurysm. — This is a peculiar dila- 
 tation of the arteries resembling the varix of varicose veins, but as it exists in 
 arteries it is called arterial varix. It occurs most frequently in the scalp and 
 
504 AN A. U /■:/,'/(■ A. \ TKXT-noOK OF SlltdKliV. 
 
 the liand. The arteries becoiiu- dihitrd, the uiiddlo coat es])ecially underf^oing 
 atrui)liy, and are elongated and tortuous, like ordinary varieosc veins. True 
 aneurysmal jmuches as large as the last joint of the linger or tlnnnb are felt at 
 various points. The whole mass pulsates synchronously uith the heart, and a 
 marked bruit is heard with the stethoscope (sec P'ig. ')•>). 
 
 There is no difficulty in making the diagnosis, Imt the treatment is 
 much less satisfactory. Ligation of one or both carotid arteries has been done, 
 but only occasionally has it been satisfactory. Excision has occasionally been 
 resorted to, and is perhaps the best method, but it should be done oidy by an 
 experienced surgeon, as it is apt to be very bloody and difficult. Hypoder- 
 matic injections of tincture of chloride of iron and of pure alcohol have both 
 been successful, as has also galvano-puncture. Direct ligation all around 
 the periphery by multiple ligatures tied over compresses of gauze has also 
 proved successful. The ligature should be inserted by means of a curved 
 Hagedorn needle, and should go all the way to the bone, in order to include 
 the dilated deep branches. Subcutaneous ligature has been tried, the so- 
 called Barwell's scarless method, by a curved needle carrying the thread from 
 point to point, being inserted anew at each point of exit and carried to the 
 next point. This method can be adapted to the ligation of the aneurysm in 
 sections, or if small the entire mass can be secured by one ligature. If not 
 increasing and not a source of annoyance, it may well be let alone. 
 
 IV. Capillary Varix, Naevus, or Mother's Mark. — These are of two 
 varieties : 1. One made up of capillary vessels of good size, presenting a small, 
 straivherry-like tumor, somewhat elevated above the skin. Naevi of this variety 
 are very apt to increase steadily in size until they become a serious danger 
 from hemorrhage. They should be removed early in life, especially if they 
 show any tendency to enlarge and invade the surrounding healthy skin. If 
 they are small, the best way is to put a pin underneath them and strangulate 
 them by means of a silk ligature, tied tightly under the pin, which prevents 
 its slipping off. It is very important that ' the whole of the nsevus shall be 
 included in the ligature, and if it is too large to be thus included by the liga- 
 ture and a single pin, it is better to insert two pins at right angles to each 
 other ; or a double ligature may be passed under a single pin, each half of the 
 ligature being tied separately. Excision will sometimes answer the purpose 
 where the naevi are small. When very large, however, they, must be ligated 
 in sections. 
 
 2. The Port-wine Mark is a naevus with very small capillary vessels, which 
 very rarely tends to enlarge, but may in itself be a serious deformity by its 
 color and its original large size. Its name describes very well its appearance. 
 The best treatment is excision, and, as the tissues of the face are very elastic, 
 such a naevus, even of considerable size, may easily be removed, leaving only 
 a linear scar. If too large for this method, it may sometimes be destroyed by 
 passing through its substance parallel threads of silk soaked in a tincture of 
 chloride of iron or Monsel's salt. Or the nrevus may be frozen a part at a 
 time, cross-hatched with a cataract needle or knife, the hemorrhage arrested 
 by steady pressure with blotting paper, this process being repeated from time 
 to time. This is practically painless and leaves no appreciable scar. Escha- 
 rotics and the cautery have also been successfully used. None of these methods, 
 however, is as good as excision, since most of them leave unsightly scars. 
 
 V. Lupus, the tubercular origin of which is noAV certain, is not so frequent 
 on the scalp as on the face. It is a persistent ulcer, following tubercular 
 infiltration of the skin, which gra<lually invades the surrounding sound struc- 
 tures and makes wide havoc. If small it may be excised: Koch's lymph 
 
DISEASES AND TXJURIES OF THE HEAD. 505 
 
 seems to have luul a heneiirial iiilluciice in a muiiber of cases. It may also 
 be cured sometimes by t]iorouo;h cauterization by ra(iuelin's cautery. 
 
 v.— DISEASKS AND M A LFOKM AT( »NS I N VoLV I N( ; llli: SKIF.L. 
 
 T. Periostitis, Ostitis, Caries, ami Necrosis all occur in the bones 
 of the skull as elsewhere. They very often follow injuries, are rarely tuber- 
 cular in origin, and still more rarely may follow typhoid fever. V>y far their 
 commonest cause is syphilis, Avhich may make extensive ravages and destroy 
 large parts of the skiill. The dura seeins in these cases to resist with singular 
 power the extension of inllannnation as a meningitis. Lai-gc portions of 
 necrosed bone may lie on a bed of granulations sjjringing front the dura, the 
 inllannnation being absolutely local and without any tendency toward a general 
 meningitis. There will usually be either the history of an injury or the plain 
 history of constitutional syphilis, with evidences of its existence in other parts 
 of the body. 
 
 The treatment of all these conditions is the same as elscAvhere. If pus 
 accumulates, it must be evacuated as early as possible. If sinuses form, they 
 must be opened speedily and be scraped and disinfected thoroughly. If caries 
 exists, the bone must be laid bare and all carious bone removed with sharp 
 spoon, gouge, and chisel. Necrosis may affect only the outer table or the entire 
 thickness of the bone. • The sequestrum and necrosed fragments must be en- 
 tirely removed. In no part of the body is it more important to insist on fre- 
 quent dressings, absolute cleanliness, and the securing, so far as possible, of an 
 aseptic condition ; otherwise the odor becomes almost intolerable. Corrosive 
 sublimate, carbolic acid, iodoform, aristol, peroxide of hydrogen, and pyoktanin 
 are all of use in attaining these ends. 
 
 II. Hypertrophy of the Bones of the Skull, with sclerosis and dis- 
 appearance of the diploe, is a not uncommon result of osteitis deformans, and 
 especially of hereditary syphilis, but usually recjuires no treatment. A local 
 and sometimes widely-spread enormous thickening of the skull occurs, known 
 as leontiasis ossium. If not too extensive, it is to be removed by the 
 chisel and rongeur. Permanent recovery has been reported in several cases. 
 
 III. Atrophy of the Bones of the Skull is often seen as a simple 
 senile change. All the bones of the skull become thin and light, and even the 
 base of the skull may become translucent or may be perforated as a result of 
 the gradual thinning and absorption of the bones. When occurring in early life 
 it was formerly thought to be especially the result of rickets, but later researches 
 have shown it to arise more commonly from hereditary syphilis. The cranial 
 bones may become so thin that they will crackle like parchment under very 
 slight pressure. It is sometimes called craniotabes, and especially affects the 
 occipital bone. A similar thinning sometimes occurs from brain-tumors. 
 
 The general treatment for inherited syphilis, together with cod-liver oil and 
 the hypophosphites of lime and soda, etc., will sometimes produce speedy and 
 very happy recovery. The child must be carefully protected from blows, falls, 
 and other mechanical injuries. 
 
 lY. Tumors of the Skull. — 1. Exostoses sometimes occur as a result 
 of injury, and if on the forehead become serious deformities. More commonly 
 they are the result of syphilitic gummata, occurring therefore in the tertiary 
 stage. They may arise on either the outer or the inner surface of the skull. 
 If external,"^ they are called exostoses; if internal, enostoses. 
 
 The treatment is that for syphilis of the bones. If external and a seri- 
 ous annoyance, they may be removed by the knife and chisel. If internal 
 and productive of any serious lesion of the brain, the skull should be trephined 
 
506 .l^V AMKRK'AX TKXT-noOK OF SURGERY. 
 
 and the mass removed. The diflRculty lies in locating the tumor. Not uncom- 
 monly the development on the inside of the skull corresponds to a similar 
 growth on the outside. Failing this, the only other indication of the internal 
 tumor is the localizing symptoms in brain disease which are described later. 
 
 2. Sarcoma affects the bones of the skull in all of its three forms, round- 
 celled, >pi)idk'-celled, and giant-celled. It may arise in the periosteum, the 
 diploe, or the dura. If it develops to any size, it is accompanied with great 
 deformity and in all cases with great danger. 
 
 The only proper treatment is excision by tlie knife, chisel, and saw, but 
 this is usually unavailing in preventing relapses, and the operation itself 
 involves such' danger as often to be fatal, especially when, as is sometimes the 
 case, the superior longitudinal sinus is involved. Except in very favorable 
 cases, therefore, as a rule no operation should be attempted. 
 
 Sarcoma arising from the dura perforates the cranium and spreads some- 
 times widely under the scalp, and finally perforates it externally. It was known 
 to the older writers a.^ fungus of the dura mater. The diagnosis is best made by 
 discovering the opening in the bone by touch and by the evidences of pulsation 
 of the mass, its partial or complete reducibility, generally accompanied with 
 symptoms of pressure, and the optic neuritis which often results from it. It 
 may occasionally be removed, but will always recur, and is a fatal disease. 
 
 3. Epithelioma is occasionally seen, and is to be treated on the same prin 
 ciples as stated under Sarcoma. 
 
 VI.— DISEASES AND MALFORMATIONS INVOLVING THE BEAIN. 
 
 I. Meningocele, encephalocele, and hydrencepbalocele are allied malforma^ 
 tions of the brain which are fortunately not common. 
 
 1. Meningocele consists in the protrusion of the membranes of the brain 
 through an aperture in the bones of the skull, the sac formed by the membranes 
 being distended to a greater or lesser extent by fluid which is extra-cerebral. 
 
 2. Encephalocele consists in the protrusion of a portion of the brain itself, 
 as well as of the membranes, usually with a smaller amount of fluid in it, the 
 fluid again being external to the brain substance. 
 
 3. Hydrencephalocele consists in the protrusion of the brain substance 
 itself as well as of the membranes, but in this case the interior of the mass 
 communicates directly with the ventricles, and is often filled with a large 
 amount of the ventricular fluid, so large in some cases that the layer of brain 
 substance enclosing the fluid is reduced to a very thin film. 
 
 All three forms of the disease arise in intra-uterine life, and are therefore 
 congenital. The most frequent is unfortunately the gravest form — viz. hydren- 
 cephalocele — and the least frequent is meningocele. As a rule, they are apt to 
 be fatal early in life. Their commonest situation is first in the median line, 
 especially in the occipital region ; next, the fronto-nasal ; and lastly, the sides 
 of the skull or about the base. Of 93 cases collected by Ilouel, 68 were occip- 
 ital, 16 fronto-nasal. and at the sides and base. 
 
 Diagnosis. — They have been mistaken for abscesses, nsevi, sebaceous cysts, 
 etc. The following points of diagnosis will generally enable the surgeon to 
 reach a proper conclusion : 
 
 All of them are congenital, commonly median, and especially occipital 
 in position. Meningocele is usually cystic in its feel, is translucent, fluc- 
 tuates, rarely pulsates, is more or less pedunculated, generally becomes tense in 
 forced expiration, and is easily reducible. Encephalocele is usually small, is 
 opaque, does not fluctuate, pulsates distinctly, has a wide base, becomes more 
 tense in forced expiration, and symptoms of pressure are produced on attempt- 
 
DISEASES AX J) IXJi'llIES OF THE HEAD. 5U7 
 
 ing to reduce it. JTj/ih'enccphalocele is generally large, is lobiilated, is partially 
 translucent, fluctuates distinctly, pulsates but rarely, is usually pedunculated, is 
 made only slightly more tense in forced expiration, and is not reducible. • 
 
 All three forms are apt to be combined with other deformities, and paraly- 
 sis often accompanies hydrencephalocele. 
 
 Treatment. — As a rule, hydrencephalocele is not amenable to treatment. 
 The child, fortunately, dies early. The other two forms hold out more hope, 
 especially if they are small. Sometimes an encephalocele by retrograde devel- 
 opment may be changed into a meningocele, and occasionally by gradual 
 concentric ossification, resembling that of the fontanelles, the bony aperture is 
 lessened and may even be closed. The intracranial communication with the 
 interior of the sac may be narrowed and finally obliterated, thus partially or 
 completely eS'ecting a spontaneous cure. Until the late improvements in cere- 
 bral surgery nothing was usually recommended in the way of treatment, cer- 
 tainly not unless there was danger of rupture. A number of successful cases 
 of excision, however, have been recently reported, and, unless the size of the 
 tumor or the condition of the patient forbid, this should be attempted, of course 
 with all the antiseptic care bestowed on all other brain operations. Enough 
 scalp should be preserved to make sufficient flaps to close the opening. If 
 operation be thought inadvisable, electrolysis may be used as a substitute. 
 Pressure and the injection of Morton's fluid (iodine gr. x, potass, iodid. gr. 
 XXX, glycerin oj) may be tried, but with little prospect of benefit. 
 
 II. Hydrocephalus, or dropsy of the brain, exists in two forms: 1. 
 Acute hydrocephalus, which is usually the result of meningitis, especially 
 of tubercular origin. It consists in an accumulation of fluid which is occasion- 
 ally extra-ventricular, but more commonly is in the ventricles themselves. There 
 will usually be headache, fever, more or less stupor or delirium, with symptoms 
 of pressure, producing strabismus, rigidity of the muscles of the neck, twitch- 
 ing of the muscles of the face or of the extremities, and convulsions, followed by 
 paresis or paralysis of one or more members. As a rule, optic neuritis will be 
 present. Generally nothing will check the progress of the disease. Tapping 
 of the ventricles has been done in several instances, but without success except 
 in one non-tubercular case of Mayo Robson's. Success must necessarily be 
 rare, but every life saved is one rescued from otherwise certain death. 
 
 2. Chronic hydrocephalus is entirely different in its origin and course. 
 It is usually congenital, although it may not be observed until some months 
 after birth. The first symptom is enlargement of the cranium, which goes on 
 until the bones become separated from one another. The protuberant forehead 
 gives a characteristically strange facial expression. The child very rarely 
 becomes able to walk or to talk. The sight is often affected, intelligence is 
 absent, and convulsions are common. The post-mortem will show enormous 
 distention of the ventricles, so that the brain consists merely of a soft bag of 
 cerebral substance distended with cerebro-spinal fluid. Fortunately, most such 
 defectives die early, but occasionally they live even to adult life. 
 
 The treatment is unsatisfactory and usually unsuccessful. Pressure does 
 but little good. Tapping has been done by two different methods. First, by a 
 fine trocar the ventricle has been punctured through the widely-dilated anterior 
 fontanelle. This puncture should be made away from the middle line, so as not 
 to puncture the superior longitudinal sinus. Not more than two or three ounces 
 of the fluid should be evacuated, for the removal of large quantities, and very 
 often even of small ones, is followed by convulsions and death. Occasionally 
 larger quantities have been removed successfully. In this case pressure must 
 be carefully maintained during and after the operation. Second, when the 
 
508 
 
 vkV AMKIilCAy TEXT- HOOK OF SURGERY. 
 
 Vertical Section of Base of Skull immediately to the 
 right of the Merlian Line: 'i, basal subarachnoid cav- 
 ity and its relation to the cerebellum : h. fcjurth ven- 
 tricle; r, site of trephine aperture ! Parkin). 
 
 ossification of tlio skull is complete, ta|»])ing tlie lateral ventricles has been 
 donOi but so far with but a single success. 
 
 Lumbar Puncture. — Quincke has recently proposed the tapping of the 
 theca of the lumbar spinal cord, thus draining the ventricles at a distance, 
 
 while pressure is inadeontheskull. 
 ^^'' ■ The theca of the spinal eord may be 
 
 punctured and some of the cerebro- 
 spinal Huid withdrawn for diagnos- 
 tic or therapeutic purposes. When 
 a patient is recumbent the cerebro- 
 spinal Huid is under a pressure of 
 20 to 40 mm. of water (Quincke), 
 and this pressure is (juite sufficient 
 to force the fluid out of a tube which 
 has been inserted. The lumbar re- 
 gion is selected for puncture. No 
 anesthetic is re(juired. The pa- 
 tient is placed upon his side. The 
 legs are drawn up and the back 
 strongly arched. In order to per- 
 form the operation a hollow needle 
 is employed, which is filled with a 
 stilet. The fluid is caught in a graduated glass. "^ The space between the 
 second and third lumbar vertebrae is determined and the lower edge of the 
 spinous process is the guide. In children the trocar is entered in the middle 
 line directly below the spinous process, the point of the needle being directed 
 upward; in adults the instrument is entered 5 mm. to the right of the middle 
 line, but is made to enter the dura in the middle line. 
 
 If the bone is struck, the needle is withdrawn a little and again pushed 
 upward and forward. AVhen the instrument enters the dural sac its point 
 can be moved freely. The stilet is then Avithdrawn. As soon as the fluid 
 begins to flow the rubber tube is attached to the needle and the fluid is 
 caught in an aseptic glass tube. It is not advisable to use a syringe for 
 suction purposes. 
 
 Lumbar jjuncture may give valuable aid to diagnosis, the character of the 
 fluid being altered, the (juantity being increased, and the pressure being ex- 
 aggerated. In acute inflammation of the brain and in brain tumor pressure 
 is greatly increased. In cases of acute inflammation sugar is absent. In 
 brain tumor albumin is increased. In tubercular or septic cases the fluid 
 may contain micro-organisms. If there is any obstruction in the channel of 
 communication between the fourth and the third ventricles, the diagnostic 
 value of lumbar puncture is impaired. The therapeutic utility of this oper- 
 ation is very doubtful. 
 
 Parkin has suggested in ]jlace of lumbar puncture to substitute jjuncture 
 of the subarachnoid space under the cerebellum. He reports 4 cases with 2 
 recoveries, and Ord and ^Yaterhouse record another recovery from an almost 
 certain tubercular meningitis. The occipital bone is treidiined. The dura 
 is opened, the cerebellum lifted, and the subarachnoid space jMincturcd by a 
 grooved director or other similar instrument (Fig. 220). 
 
 VII.— INMriUKS OF THE HEAD. 
 
 I. Cephalhematoma, or Caput Succedaneum, is a soft tumor usually 
 in the parieto-occipital region in new-born e)iildren. It consists of an accumu- 
 
DISEASES AND INJURIES OF THE HEAD. 509 
 
 lation of blood and seruiu under the scalp, the result especially of prolonged 
 labors and consequent mechanical injury to the scalp. Generally no treat- 
 nu'iit is necessary, as the mass is, as a rule, absorbed within a few days after 
 
 birth. 
 
 II. Wounds of the Scalp. — These differ in no respect from wounds 
 elsewhere in the body, excei)t that wounds of the scalp are more prone to 
 erysipelatous inflammation and abscesses than wounds of the skin in other parts 
 of the body, unless the greatest care is taken in their proper treatment. 
 
 The blood-supply of the scalp is so abundant that even a slight pedicle of 
 attachment is suflicient to ensure the vitality of a large flap. Hence in lace- 
 rated wounds an attempt should be made to save most of the torn pieces unless 
 absolutely detached. In any Avounds, except very small ones, in order to 
 ensure disinfection the scalp should be shaved over a very Avide area. Even 
 in women appearance must give Avay to safety. It should then be thoroughly 
 disinfected by the removal of all dirt and other foreign matters by rubbing in 
 sweet oil, then washing well with soap and water, following this by a thorough 
 scrubbing with a bichloride solution 1 : 1000, trimming off the infected edges 
 if the wound is lac.erated, and lastly by accurate suturing. The bleeding vessels 
 will require ligation only when exceptionally large, provided the hemorrhage 
 has been arrested by crushing the vessels in the jaws of hemostatic forceps. 
 The forceps may seize the entire thickness of the scalp with impunity. If 
 these precautions are taken, usually no drainage will be necessary, but should 
 there be necessity for it a few strands of disinfected horsehair will answer the 
 purpose. These should be removed in a day or two. Silkworm-gut interrupted 
 sutures may be used. A large sublimate dressing may then be applied and 
 retained in place by an ordinary recurrent bandage. The most important 
 point in such Avounds is the careful and Avide disinfection. They Avill then 
 follow the usual aseptic course of other wounds. If this be neglected, even 
 small Avounds have a large reserve of danger. 
 
 III. Abscess of the Scalp is first a consequence of inflammation, often 
 of an erysipelatous character, and occasionally it is a sequel of typhoid fever ; 
 secondly, it is a sequel of contusions ; and thirdly, it often follows wounds the 
 edges of Avhich have been closely coaptated without sufficient preliminary dis- 
 infection. Very often such patients are first treated in drug-stores, where 
 usually a very elaborate stellate dressing of adhesive plaster is put on Avithout 
 any attempt at disinfection. All such dressings should be removed at once 
 and the wound re-dressed after proper disinfection. 
 
 Abscess is accompanied usually with pain of a throbbing character and 
 inflammation of the scalp, which is almost ahvays erysipelatous in appearance, 
 though it may not be caused by the microbe of erysipelas. Not uncommonly 
 there' is marked oedema of the surrounding parts, which if it extends to the 
 eyelids produces blindness mechanically by the swelling of the lids. There is 
 almost alwavs pitting on pressure. The constitutional symptoms are marked 
 and sometimes verv severe, the fever running high and being accompanied not 
 infrequently with delirium. The chief dangers here are that the pus may bur- 
 row widely; if under the aponeurosis of the occipito-frontal muscle it wdl be 
 limited by the attachments of this muscle and its aponeurosis, and the location 
 of the effusion can thus be readily diagnosticated ; and if it be under the peri- 
 cranium, and sometimes even if 'it be more superficial, that the inflammation 
 may extend to the brain through the vascular perforations in the skull and 
 cause meningitis. Occasionally it may produce necrosis of the bone. 
 
 The treatment is very clear. As soon as the abscess is diagnosticated 
 a free incision should be made at Avhat will be the most dependent point in 
 
51 U AN AMERICAN TEXT-BOOK OF SURGERY, 
 
 the recumbent posture, •\s\\\\ disinfection of the wound as far as possible, and 
 drainage. 
 
 1\ . Contusions of the Head are very connnon as a result of falls, 
 blows, etc. TIk'V may l)e slight or severe. After a slight contusion the 
 patient is more or less stunned, and swelling veiy quickly follows, due chiefly 
 to hemorrhage under the scalp. This hemorrhage is very apt to give the 
 impression of depressed bone, and may mislead one into supposing that there 
 is a fracture, the hard ridge on the curved edge of the swelling being mistaken 
 for the edge of the depression. But after a simple contusion this ridge is ele- 
 vated considerably above the general contour of the head, the edges are rounded, 
 and pressure will not uncommonly cause pitting. If there be fracture with 
 depression, the edge is usually about on a level with the surrounding skull or 
 below it, and the margin is sharper, more irregular, and less circular. 
 
 Ordinarily pressure, with perhaps some cooling lotion, as simple tincture 
 of arnica or lead-water and laudanum, will cause the major part of the swell- 
 ing to disappear within twenty-four hours. Rather rarely, however, abscess 
 will follow. 
 
 If the contusion be somewhat more severe, the bone may become involved, 
 producing sclerosis as a result of the chronic inflammation, or if the blow be 
 sufficiently severe to destroy its vitality even necrosis may follow, although 
 this is a comparatively rare result. Severer contusions may involve the brain 
 itself. These are described under the next head. 
 
 V. Concussion or Laceration of the Brain. — The term "concus- 
 sion " of the brain is an unfortunate one, as it conveys the idea of a functional 
 rather than an organic lesion. While there may be slight injuries of the brain 
 that mav in this sense be properly called concussions, it is far better to consider 
 concussion as usually equivalent to laceration of the brain tissue. 
 
 The brain may be injured either by direct or by indirect force. A blow on 
 the head is an example of direct force ; an instance of indirect force is a fall 
 in which the patient lights fully upon his feet or sits down upon his buttocks. 
 AVhat happens in such cases is best explained by an experiment made by 
 Felizet. lie filled a skull with parafiine and dropped it on the floor. On 
 opening the head no fracture was found, but at the point of impact the bone 
 had been driven down upon the paraffine and flattened it, and, while the bone 
 had sprung back to its original position without fracture, the flattening of the 
 contents remained. Had the skull been living and filled with brain tissue, the 
 same depression and temporary compression of the brain would have taken place; 
 and we can scarcely imagine that such an amount of mechanical disturbance of 
 the brain can occur without more or less laceration of brain tissue and rupture 
 of blood-vessels, followed by some slight hemorrhage. Moreover, as Duret has 
 showm, the wave in the cerebro-s])inal fluid created by a blow produces what is 
 often its maximum effect on the opposite side of the skull from the point struck, 
 tearing the vessels of the pia and the cortex. This undoubtedly explains 
 injuries of the brain by so-called contreconp. or counter-stroke. Miles has 
 shown experimentally that at the point of impact there is a ''cone of depres- 
 sion," accom])anied by a " cone of bulging '" at the opposite })ole, thus con- 
 firming Duret"s observations. If the cone of bulging is sufficiently ample, a 
 fracture may be produced. 
 
 The patient who has received such an injury, if it be slight, will perhaps 
 lose his balance and fall, become pallid, confused, and giddy, and may be 
 nauseated and even vomit, but after a period of rest he will gradually recover. 
 If, however, the injury be more severe, there may be grave laceration of the 
 brain or of its membranes, or of Itoth. and the patient will fall and lie quietly, 
 
DISEASES AND IXJVIilES OF THE HEAD. oil 
 
 with a feeble, fluttering heart, cold, clammy skin, and apparently be uncon- 
 scious, lie can usually, however, be aroused by shouting and loud (|uestioning, 
 but will reply in monosyllabic answers or unintelligible sounds. He will not 
 be paralyzed, but may move the extremities, which will not have lost entirely 
 their sense of feeling. Not uncommonly urine and feces will be passed invol- 
 untarily. The pupils Avill vary, being either contracted or dilated to a mode- 
 rate extent, and possibly unequally, but, as a rule, they will react to light. 
 Occasionally convulsions occur. As he reacts he will very probably vomit. 
 Usually within twenty-four hours or more his condition as to consciousness 
 will become better, but he will suffer from considerable headache, lassitude, 
 and indisposition to exertion. After partial recovery, and sometimes for a 
 long period, he will suffer more or less with vertigo, headache, and indisposi- 
 tion to mental exertion. Occasionally more serious results will follow, even 
 after a long interval, and abscess of the brain should be especially watched for. 
 Sometimes epilepsy or insanity may follow. If the patient, instead of recover- 
 ing, grows Avorse, either coma will set in or the symptoms of meningitis or 
 encephalitis as described below. 
 
 Prognosis. — The uncertainty as to the degree and even the character 
 of the cerebral injury should make us especially careful as to prognosis and 
 treatment. Any contusion which has been severe enough to produce uncon- 
 sciousness should be considered a serious injury, for we may be sure that there 
 has always been such an amount of laceration as to make serious danger a pos- 
 sibility and often a probability. 
 
 Treatment. — As soon as possible the patient should be placed in bed 
 without any pillow, and his body surrounded with hot-water bags or hot-water 
 bottles suitably protected. He should be kept quiet and as free from the 
 excitement of conversation or business as possible, and restful sleep should be 
 encouraged. Aromatic spirit of ammonia during the period of shock is better 
 than alcohol, for the excitement of alcohol, which is quickly felt in the brain, 
 should be avoided. Hot water or ice water, as may be most agreeable to the 
 patient, may be given. A careful diet, with occasional purgatives, and atten- 
 tion to the general hygiene are necessary for days or weeks. 
 
 In case inflammation of the brain supervenes, surgical opinion is at present 
 somewhat divided as to the proper course to be pursued. Many surgeons, per- 
 haps the majority, would treat it as an Encephalitis (see p. 530) and not tre- 
 phine ; others, on the contrary, believe that if serious symptoms arise, indi- 
 cating intracranial mischief, especially if this be localized, a semicircular flap 
 of scalp should be raised over the seat of the injury and the bone inspected. 
 If an unsuspected fracture is discovered and the symptoms are serious, show- 
 ing meningitis or encephalitis, an exploratory trephining should be done and 
 the dura opened. Once such inflammation with its attendant proliferation and 
 exudation has begun, it is essential in their view that a means of escape for 
 the exudate be provided before the inflammation shall have proceeded so far as 
 the production of dangerous pressure or even of suppuration itself. In other 
 words, they would treat contusion followed by symptoms of serious intracranial 
 mischief precisely as they would treat such injuries in other parts of the bodv ; 
 always remembering that in the brain there is no possible means of escape for 
 the hemorrhage or exudate without surgical assistance, because of the bonv case 
 in which it is retained ; but remembering also that while trephining is equivalent 
 to incision down to the injury in any other part of the body, yet that it is 
 always a grave operation and never to be undertaken without earnest reflection 
 and good reason. 
 
 In many cases of severe contusion it is proper immediately (with all the 
 
512 AN AMEUIfAX TEXT-BOOK OF SUIiOKnY. 
 
 antiseptic precautions so often insisted on) to raise a liorseslioe-slia{)e(l fla}) in 
 order to determine at once the <[uestion of frac-ture, as the swellini^ of the 
 scalp if this be thick or very dense makes it difficult Avithout such an incision 
 to ascertain whether fracture exists or not. The objection that if a simple 
 fracture exists by such an incision we convert it into a compound one no longer 
 holds good, for a simple incision through the scalp is not attended with grave 
 danger in these days of antiseptic surgery, and the very slight dangers of the 
 wound are as nothing compared to a certain diagnosis and suitable treatment. 
 
 After the patient has recovered from a severe contusion or laceration of the 
 brain he should not be allowed to return to business or other occupation for at 
 least a numl)er of weeks, or even for a longer period ; and if at any time he 
 shows indications of hebetude or is attacked by headache, especially if accom- 
 panied with little or no rise of temperature or even a somewhat suljnormal tem- 
 perature, an abscess should be suspected and its symptoms watciied for, (See 
 Abscess.) 
 
 After severe concussion of the brain the patient sometimes passes, in the 
 course of a few hours or more, into a peculiar condition well termed by Mr. 
 Erichsen cerebral irritahility. Instead of recovering consciousness, he is apt 
 to lie on his side, w^ith his eyes closed, his legs drawn up, and his back curved. 
 The pupils are contracted, but respond to light. If disturbed, he is restless 
 and irritable or may even show some delirium. He may answer questions 
 sometimes in a vexed way, or may refuse to respond. There is sometimes no 
 rise of temperature, either general or local, and it may even be subnormal. 
 The pulse is weak and slow. Not uncommonly the bowels and bladder are 
 evacuated involuntarily, though sometimes the patient will indicate his wants. 
 Recovery Avill usually take place slowly, with no recollection of his condition 
 or conduct. Occasionally, however, the mental faculties will not recover. 
 The treatment for this irritability must necessarily be a symptomatic one. 
 
 VI. Compression of the Brain. — The surgical causes of compression 
 of the brain are intracranial hemovrliage, tumor, depressed fracture, foreign 
 bodies, and the products of inflammation. Hemorrhage and inilammatory 
 exudate produce the symptoms of compression almost immediately when they 
 are sudden and severe, but if the blood or exudate accumulate gradually, the 
 compression symptoms will arise as soon as the amount of blood or pus becomes 
 large. In very slight but steadily increasing hemorrhage or a slowly-forming 
 abscess the brain accommodates itself for a time to the gradually increasing 
 pressure. Even considerable depression of the bone may for some time be 
 followed by no symptoms of compression. 
 
 Symptoms. — In compression unconsciousness is complete. The patient 
 lies supine and does not move, or if he moves it will be an occasional restless 
 change of place of an arm or a leg. He Avill not respond to any questioning 
 or to the loudest shouting in his ear. The pupils are dilated and do not 
 respond to light, the breathing is slow and stertorous, with a peculiar jiuffing 
 respiration, due to expiratory distention of the cheeks and lips, the facial 
 muscles being paralyzed. The skin is usually hot rather than cold, and is 
 covered with a profuse perspiration. The pulse is slow, full, and often 
 irregular. The bladder and bowels are, as a rule, paralyzed : hence the urine 
 is not voided until the bladder becomes over-full, when the incontinence of 
 retention sets in. Sometimes the Avhole body is paralyzed, though hemiplegia 
 is more common. If the lesion is limited and not too large, the paralysis will 
 be limited, for example, to a monoplegia, that is to say, paralysis of one arm 
 or one leg or one side of the face, if the cause of the compression is limited to 
 one of the cortical centers supplying these regions. The significance of such 
 
DISEASES AND INJURIES OF THE I IK A I). 513 
 
 a localized paralysis is extrcmelv valuable in the diagnosis of the seat of the 
 lesion; and if the paralysis l)eiiins in (ine j)art of the l)ody and spreads to other 
 parts, the cortical centers of Avhich are adjacent to the center for the part 
 first paralyzed, the diagnosis may be regarded as positive. 
 
 If the cause of the compression is hemorrhage in the interior of the brain 
 — e.g. from the lenticulo-striate artery, the "artery of cerebral hemorrhage" 
 of Charcot — unconsciousness usually occurs instantaneously or almost so. If 
 it is from a rupture of the middle meningeal artery, a point of the greatest 
 importance in the diagnosis is that after the reception of the blow there is 
 a period of consciousness corresponding to the period of time necessary for 
 the escape of a sufficient quantity of blood to produce unconsciousness from 
 pressure. If a small branch of the middle meningeal is ruptui'ed, the period 
 of consciousness may be comparatively long, even several hours, occasionally 
 a day or more; but if the main trunk is injured, the blood pours out so 
 rapidly that only a few minutes may pass before unconsciousness supervenes. 
 
 If caused by fracture or foreign bodies, the symptoms of compression usually 
 follow immediately upon the reception of the injury, but occasionally they may 
 be delayed for some hours. If caused by inflammation and the formation of 
 pus, the symptoms of course will develop only when the pus accumulates in 
 sufficient quantity to produce serious pressure. This development of pressure 
 symptoms in these cases is usually gradual, the mental dulness deepening into 
 coma, but sometimes it is, as it were, by a sudden explosion. If tumor is the 
 cause, the brain may accommodate itself for some time to a slowlv-crrowing 
 tumor, but if it grows rapidly symptoms of compression will set in at an early 
 date. Optic neuritis will generally develop at an earlier or later date. 
 
 Diagnosis. — The principal conditions which must be diagnosticated from 
 injuries of the brain producing compression are alcoholic intoxication, opium- 
 poisoning, apoplexy, and uremia. If a man is picked up in the street by the 
 police and is carried to a hospital without any previous history, the surgeon 
 must be on his guard lest he mistake any one of these four conditions for a 
 serious injury to the brain. In cerebral injuries there will usually be an evi- 
 dence of the accident in a bruise or cut, though of course the man may have 
 fallen when intoxicated or have been suddenly attacked by apoplexy and in 
 falling have received a more or less serious wound. In intoxication the acci- 
 dent will usually be comparatively slight. Possibly his appearance, giving 
 evidence of intemperate habits, may be some guide to diagnosis, but this may 
 easily mislead us. His breath may be alcoholic, but it must be remembered 
 that alcohol may have been given to the man to revive him after serious brain 
 injury. A drunken man, although stupid, is not unconscious, nor is he para- 
 lyzed or hemiplegic. His pupils are not dilated as in compression, but are more 
 commonly contracted, dilating when any attempt is made to rouse him. The 
 temperature is generally subnormal. 
 
 In apoplexy there are absolute unconsciousness, stertor, and hemiplegia or 
 complete paralysis. In opium-poisoning the pupils are contracted to pin-points 
 and will not dilate, and there is no paralysis. In uremia paralysis and stertor 
 are absent, unless there is apoplexy, and there is apt to be oedema of the legs, 
 and if the urine be examined there will be found undoubted evidences of 
 albumin. The eye-ground should be examined in all cases, as it may throw 
 considerable light on the nature of the case. If, after all, the case is doubtful, 
 it should always be treated as one of cerebral injury. 
 
 Prognosis. — If the compression is caused by extravasated blood, the 
 patient has a fair chance of recovery after trephining, evacuation of the clot, 
 and arrest of the hemorrhage. If it is caused by depressed fracture, and the 
 
 3.3 
 
514 .l.V A.}fK/!/<'AX TEXT-BOOK' OF .SfJiC'EIi V. 
 
 proper operative relief is aflbrdeil. his chances of life will vary with the de^^ree 
 of severity of the injury. In cases of foreij^n body in the brain the j)rof];nosis, 
 as a rule, must be unfavorable; and the same may be said nf tumors and 
 inflammation Avith internal hydrocej»halus. 
 
 Treatment. — 'J'he diairnosis of compression havin<^ been established, the 
 treatment will vary with the cause. If it is from hemorrhage, the treatment 
 must be the speedy relief of the jiressure by evacuation of the clot and arrest 
 of further bleeding b}' ligature, as mentioned in the next section. If it is 
 from depressed bone, trephining should be done at once with all the pre- 
 cautions heretofore described, and the bone elevated or removed as may be 
 found necessary. If from foreign bodies, these .should be removed, with the 
 limitations stated in the section treating of that lesion. If from an abscess 
 in the brain, trephining should be done and the abscess evacuated and drained. 
 (See Abscess of the Brain.) If serum has accumulated either in the ventricles 
 or in the subarachnoid space, trephining should be done and the exudate 
 drained, even by i)uncture of the ventricles if necessary. If the compression 
 is from tumor, the tumor should be removed if the case is suita])le. 
 
 In all cases the utmost care must be observed as to the later treatment by 
 rest, the most restricted liquid diet, attention to the bowels and bladder, and the 
 general precautions mentioned in connection with Meningitis and Encephalitis. 
 
 YII. Intracranial Hemorrhage. — This may be either spontaneous or 
 traumatic. Tluxigh there is at least one case of apparently spontaneous rup- 
 ture of the middle meningeal arteries, yet as a rule spontaneous hemorrhage into 
 the brain occui's in connection with the lenticulo-striate artery distributed to the 
 ganglia at the base. The clot usually forms either in these ganglia or in the 
 white substance of the centrum ovale, and produces the familiar forms of apo- 
 plexy, the consideration of which belongs to medicine rather than to surgery. 
 Richardiere has shown that one of the most frequent causes of the death of new- 
 born children very shortly after delivery is meningeal hemorrhage from the rup- 
 ture of the vessels at the moment of birth as a result of traumatism to the foetal 
 head in its passage through the pelvis. 
 
 HemorrJiage from Traumatism may occur in three positions: it may be 
 (a) extradural, that is, between the dura mater and the bones ; {h) subdural, 
 that is, between the dura and the brain ; (c) cerebral, that is, into the brain 
 tissue itself. 
 
 {a) Extradural Hemorrhage. — This is almost always caused by the rup- 
 ture of the middle meningeal artery or its branches. The violence which may 
 rupture this artery is, as a rule, considerable, although it may be so slight as to 
 leave no bruise. Fracture will frequently exist, though in a considerable per- 
 centage of cases there may be no fracture whatever; but commonly it is pres- 
 ent, and extends not only over the vault, but also to the base of the skull. It 
 will be remembered that the middle meningeal arises from the internal maxil- 
 lary and enters the cranium at the foramen spinosum, quickly dividing into an 
 anterior and a posterior branch. The anterior branch, after running ii> the 
 groove in the wing of the sphenoid, reaches the parietal bone at its anterior 
 inferior angle, whence it passes upward toward the middle line. The poste- 
 rior branch, after running over the posterior part of the sijuamous portion 
 of the temporal bone, also reaches the parietal bone. The main trunk of the 
 artery is rarely ruptured ; the two branches are far more frequently the site 
 of this lesion (Fig. 221). 
 
 The symptoms of such hemorrhage are of great importance, for while 
 formerly in these cases the surgeon stood by with his arms folded and watched 
 his patient die, the last few years have taught us that a large proportion of such 
 
DISEASES AXD IXJrUIES O/' yv//-; HEM). 
 
 515 
 
 Fig. 221. 
 
 cases inay be saved by pruiiij)t interference. The accident may stun the patient 
 and niav prochiee a brief" jieriod of unconsciousness. Fi"oni this he recovers 
 only to rehipse anew into unconsciousness. This i>eriod of conariousucss 
 between the acci(U'nt and the appearance of the persistent coma is of tlic great- 
 est importance and worth all the other symptoms put together. It is due to the 
 fact that a certain amount of time must elapse before the quantity of blood 
 which escapes is sufficient to produce unconsciousness from pressure. If 
 the main trunk or one of the larger branches is ruptured, the blood escapes 
 raj)idly, and this period of consciousness will be very brief; but if one of the 
 smaller branches is ruptured the interval 
 may be one of hours or even days before 
 a sufficient clot accumulates to produce it. 
 The possible existence of this interval of 
 consciousness should therefore be inijuired 
 into in all cases, and if there be other 
 signs of intracranial hemorrhage the diag- 
 nosis will be clear. These other signs may 
 be, (1) Hemiplegia, on the side opposite to 
 the hemorrhage. The hemorrhage, AvliiK- 
 usually on tlie same side as the injury, 
 may take place upon the o])posite side, 
 in which case the hemiplegia and the 
 wound will be on the same side. More- 
 over, the paralysis is apt to be progress- 
 ive, extending from one part of the body 
 to another, as the widening clot produces pressure on one cortical center after 
 another. For instance, the clot may begin over the face center, producing 
 paralysis of the face ; then it extends upward to the arm center, and the arm 
 
 Hemorrhage from the Middle Meningeal Artery 
 (Jacobson). 
 
 Fig. 222. 
 
 Site of Trephine Opening to reach Clot in Hemorrhage from Middle Meningeal Artery (Kronlein) : a, b, 
 horizontal line through the meatus : c, d, on a line with the eyebrows ; e, f, vertical line 3 to 4 cm 
 behind the ext. ang. process ; g, h, at the posterior border of tlie mastoid process, a, the point to 
 reach the anterior, and b, the posterior branch (Esmarch and Kowalzig). 
 
 Avill be paralyzed; and finally, as it reaches the leg center, the leg will be para- 
 lyzed. Rarely the artery may be ruptured on both sides. (2) If the clot, 
 instead of extending upward, gravitates toward the base, the pupil on the 
 side of the clot will be dilated and immobile, and if on the left side aphasia 
 
516 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 will appear. (3) The pulse becomes frequent. (4) Respiration is slow and 
 stertorous. (5) The temperature Avill probably rise to 101° to 103°, or even 
 104° F., especially on the side opposite the clot. (6) In a compound (espe- 
 cially in a gunshot) fracture, with a perforation of the skull and the meninges, 
 blood may escape in such quantity and with such rapidity as continually to 
 force the l)rain-substance out of the wound. 
 
 Treatment. — As soon as the diagnosis is well established, operative treat- 
 ment should be resorted to as quickly as possible. Wiesmann has best shown 
 the importance of this, for of 147 cases treated expectantly, 131 (89.1 per 
 cent.) died, while of 110 cases operated on, only 36 (-32.7 per cent.) died, and 
 in the majority of the fatal cases the extravasation was not reached and the 
 clot therefore not removed. In operating we should determine the question 
 which side of the skull should be trephined, not by the site of the irijnry, but 
 by the localising symptoms. In far the greater number of cases, as shown by 
 Krbnlein, the clot will be best reached by trephining one inch and a quarter be- 
 hind tlie external angular process at the level of the upper border of the orbit 
 (Fig. 222, a). If the clot be not revealed by this opening, immediately tre- 
 phine again, just below the parietal boss, on the same level as the former open- 
 ing (Fig. 222, B ; see also Fig. 211). By the anterior opening the main trunk 
 and the anterior branch of the middle meningeal artery may be reached, and 
 by the posterior opening the posterior branch. In many cases, of course, it is 
 very doubtful which branch is ru])tured ; hence the need for the second open- 
 ing if the first does not disclose the clot. The clot should now be removed, 
 either opening being enlarged, if need be, by the rongeur forceps in order to 
 gain access to it. If the pupil is dilated, and evidence given therefore that 
 the clot is gravitating toward the base, the trephine opening should be made 
 near the first point, but about half an inch lower. The clot should be scooped 
 out very gently, and the cavity in which it has lain should be well washed out 
 with sufiiciently cooled boiled water. If the artery is still bleeding, a catgut 
 ligature should be passed through the dura, under the artery, and out again 
 through the dura on the other side of the artery, by a semicircular Hagedorn 
 tieedle, and the artery tied. Drainage should be carefully provided, and the 
 wound then treated as usual. If the first trephine opening does not answer 
 well for drainage in the recumbent posture, a second one should be immedi- 
 ately made. 
 
 (b) Subdural Hemorrhage. — This hemorrhage will occur most fre- 
 quently as a result of dej)ressed fracture and rupture of a number of small 
 vessels, or it may be of one large vessel (especially the middle cerebral), the 
 contents of which pour out under the dura. The symptoms will be much the 
 same as those mentioned in connection Avith hemorrhage from the middle menin- 
 geal, and at present there are no means of distinguishing between hemorrhage 
 from the middle meningeal and that from the middle cerebral. It is, however, 
 of no great pi-actical importance to distinguish between them, for the treat- 
 ment is the same. The anterior trephine opening before referred to, especially 
 if enlarged upward and backward, will give access to the middle cerebral, and 
 if the evidences point to intracranial hemorrhage, and on trephining no clot is 
 found under the bone, the dura should be opened and the clot searched for on 
 the surface of the brain itself, following the direction of the fissure of Sylvius, 
 in which the middle cerebral lies. If this be the source of the hemorrhage, 
 the bleeding point must be found and the artery ligated. More commonly, 
 however, subdural hemorrhage is caused by the rupture of a number of vessels 
 under a depressed fracture, and the consequences, unless the case is properly 
 treated, are most deplorable. Not uncommonly the patient will die as a result 
 
DISEASES AXD IXJLIIIES OF THE HEAD. oil 
 
 of the injury to tlie brain ; but sliould he recover the course of events is usually 
 as follows : The clot, having produced more or less extensive paralysis, is grad- 
 ually absorbed, but the brain may not expand to its former position, being per- 
 manently depressed, for the site of the injury is sometimes occupied by spongy 
 connective tissue the meshes of -which are filled with cerebro-spinal fluid, resem- 
 bling a series of cysts. The paralysis will gradually lessen and may almost 
 entirely disappear. Aft^r a varying interval, from a fcAV months up to two or 
 three years, the patient may, however, become subject to epileptic or other 
 cerebral disturbances, and if so he will lead a miserable existence so long as 
 he may live. The importance, therefore, of evacuating the clot, removing 
 the pressure, and thus preventing the disastrous later effects, is evident. 
 Hence all cases of marked and localized depressed fracture should be tre- 
 phined, the bone lifted, and the clot evacuated and treated as has been 
 described. 
 
 Hemorrhage from Pachymeningitis Interna. — A few^ cases have been 
 reported of subdural hemorrhage from pachymeningitis interna. These are 
 amenable to the same treatment, by trephining, evacuation, and drainage. 
 Even so long as two months after the accident Ceci has been able to rescue 
 his patient from a condition of complete coma and palsy, with almost total 
 restoration of function.- 
 
 ((?) Hemorrhage into the Brain Substance. — Severe traumatism 
 may rupture the vessels in the interior of the cerebrum, and even produce 
 hemorrhage into the ventricles. The symptoms in this case will resemble 
 those of ordinary apoplexy in every respect except the cause. The diag- 
 nosis is based upon this resemblance and this difference. As a rule, little can 
 be done in such cases, for the injury to the brain substance is generally so 
 extensive that even if the clot be evacuated the patient will usually die from 
 the injury. 
 
 {d) Wounds of the Sinuses of the Brain. — Occasionally in ope- 
 rations, but more commonly from severe and usually compound fracture, the 
 superior longitudinal or the lateral sinuses of the brain may be injured. It is 
 always a serious and often a fatal accident. The blood pours out so furiously 
 that the patient may die in a few minutes from the shock of the injui-y ; for 
 undoubtedly rapid loss of blood from the brain itself is more fatal than the 
 loss of an equal amount of blood from any other part of the body. Hence 
 all operations in the neighborhood of the sinuses should be conducted with 
 great care. If necessary to trephine in their neighborhood, the edge of 
 the trephine should be at such a distance as to be perfectly safe. With the 
 .dural separator or a grooved director or probe, and then the finger, the dura 
 may be separated and the sinus entirely detached from the skull ; and then the 
 original trephine opening can be safely enlarged at will by the rongeur forceps. 
 If necessary, a portion of the sinus may be removed by first exposing it in the 
 manner indicated, and then ligating it on both sides of the proposed incision. 
 Should the sinus be ruptured either in an operation or by a fracture, the hem- 
 orrhage usually can be controlled by instant packing with iodoform gauze. 
 Sometimes the margins can be seized by one or more pairs of hemostatic for- 
 ceps, which may be removed on the second or third day. Of course great care 
 should be taken lest they be displaced in the tossing of the head by the patient. 
 Lateral ligature and suture of the sinuses have also been employed. 
 
518 ^l^V AMERICAN TEXT-BOOK OF SURGERY. 
 
 VIII.— FRACTURES OF THE SKULL 
 
 Fractures of the skull are considered with injuries of the head rather than 
 ■with other fractures, for the reason that the fracture y^cr se is of comparatively 
 small moment. My far the most important factor in such injuries is the injury 
 to the brain or to its membranes, or to both. A violence that will break the 
 bones of the head is such that, even thou<:h there is no depression, very often 
 the brain itself suffers serious injury ; and if fragments are depressed or broken 
 off and driven into the brain, the injury becomes even more severe and often 
 fatal. The treatment of such fractures, therefore, is based on the injury, either 
 actual or possible, to the brain itself, rather than on the injury to the skull. 
 The history of such fractures and of their treatment is almost like that of 
 abdominal diseases and injuries. The hesitation to interfere Avhich })revailed 
 in the past has been happily replaced by positive action of the most radical 
 character, so that the treatment of such fractures has been almost entirely 
 changed within the last ten years. The danger is now perhaps in the opposite 
 direction — that surgeons may go too far and do harm rather than good by a 
 rash interference instead of a wise conservatism. 
 
 Fractures of the skull are very frequent as a result of falls, blows, either 
 from falling bodies or in personal encounters, and similar accidents. They are 
 often extensive and involve wide areas of the skull in multiple fractures ; or, on 
 the contrary, they may be limited to a very small area, as in punctured frac- 
 tures made, for instance, by a knife-blade or a nail, in which, as a rule, there 
 lurks even more danger than in the more extensive fractures, because they are 
 so apt to be improperly treated. The same varieties that are found in frac- 
 tures elsewhere obtain in the skull. The fracture may be either simple or 
 compound. If simple, the fracture in the bone does not communicate with the 
 external air ; if compound, it does, usually through the lacerated scalp. But 
 attention is especially called to the fact that a fracture of the skull which 
 extends into the nose, ear, or mouth is just as truly compound as a fracture of 
 the vault, and even more dangerous, because the feet that it is a compound 
 fracture, and therefore liable to infection, is so often overlooked. Such frac- 
 tures, again, may be impacted. They may also be partial ; that is, the outer 
 table may not be broken, yet fragments may have been broken off from the 
 inner table, wounding either the meninges or the brain itself. 
 
 Fractures of the skull are best discriminated by their position as fractures 
 of the vault and fractures of the base of the skull. Fractures of the vault are 
 usually the result of direct violence, while fractures of the base result either 
 from the extension of fractures of the vault from the side to the base of the 
 skull, or from indirect violence, such as a fall in which the person may alight 
 upon the feet or the buttocks, in which case the blow is delivered through the 
 spinal column, and sometimes even a fall on the vertex, in which, either with 
 or without fracture of the vault, the base is fractured in a similar manner by 
 the Aveight of the body. The base has also been fractured l)y violence received 
 through the lower jawbone, the condyles having even been forced within the 
 cavity of the skull. 
 
 Fracture of the skull sometimes, but very rarely, occurs at a point opposite 
 that at which the blow is received. This is called fracture by cantre-conp, or 
 counter-stroke. Rupture of the meningeal vessels and of the brain itself 
 certainly does take place at such a point not uncommonly, and its mechanism 
 has already been explained (p. 510). 
 
FRACTURES OF THE SKULL. 
 
 Plate XI IL 
 
 1. Linear fracture of vault of skull. 2. Depressed fracture of vault (from within). 3. Depressed 
 
 fracture of vault (from without). 
 
DISEASES AND INJURIES OF THE HEAD. 519 
 
 1. FRACTURE OF THE VAULT. 
 
 This may be a mere fissure, like a crack in a cliina plate (PI. XIIT, Fig. 1). 
 The fissure may not he limited to one bone, but may cross a suture and extend 
 quite widely. When compound, such a fracture may catch dirt or even a single 
 hair, which, unless it is removed and the part disinfected, may become a source 
 of serious or even fatal infection. Instead of a fissure the bones may be broken 
 into several pieces, a comminuted fracture, either with or without depression of 
 the fraixnients (PI. XIII, Figs. 2 and 3). If depression takes place, there is usu- 
 ally a funnel-like hollow. There is no separation of the fragments, save what 
 has been produced mechanically, for there are no muscles inserted on the skull 
 to cause displacements similar to those which occur with most other fractures. 
 
 Symptoms. — If the fracture be a fissure, it can.usually only be suspected, 
 but may possibly be recognized in some cases by a "cracked-pot'' sound. 
 This may be elicited by percussion, best with, but sometimes even with- 
 out, a stethoscope. It may be heard by the surgeon or by the bystanders, 
 or may be perceived only by the patient himself. The same curious sound 
 may be similarly elicited in hydrocephalus with beginning separation of the 
 bones. If the fracture is much depressed, however, the depression, as a 
 rule, may be easily felt by the finger. Care must be taken not to mistake for 
 a fracture the circular effusion of blood which is so common after contusion. 
 If there has been any destruction of the scalp, it is very possible to mistake an 
 old depressed scar from this loss of tissue for an old depressed fracture of the 
 skull. Occasionally there may be rupture of the dura even with simple frac- 
 ture, and the cerebro-spinal fluid escaping under the scalp Avill cause a partially 
 translucent, pulsating swelling, which becomes tense, especially with expiratory 
 efforts such as sneezing, coughing, etc. It is a very rare but a positive sign 
 of fracture. Still more rarely the fluid may come from the ventricles. 
 
 If the fracture be compound, its extent can be determined both by eye and 
 by touch, but care must be taken not to mistake the ordinary sutures, and espe- 
 cially those of the Wormian bones or a slit in the pericranium, for linear frac- 
 ture. The dark line of blood which marks a fissured fracture cannot be 
 sponged or washed away, while the coagulated blood in an unbroken suture 
 can be readily removed. This is a valuable means of differential diagnosis. 
 The tooth-like character of the sutures is also a valuable aid. If cerebro- 
 spinal fluid or brain tissue escape, the evidence of course will be positive. 
 
 Fracture of the inner table alone, which is very rare, can also only be sus- 
 pected, but if there have been marked violence followed by symptoms of intra- 
 cranial irritation or inflammation, the possibility that such an injury has occurred 
 is increased; and if the symptoms be of localizing value — for instance, if there 
 be a palsy of speech or of the right arm, or both of these symptoms, and if the 
 blow have been received above and in front of the left ear — the possibility will 
 become strong enough to warrant immediate operative interference. 
 
 The prognosis depends almost entirely on the amount of injury done to 
 the brain rather than to the bone. As to the fracture itself, repair will take place, 
 and the amount of callus thrown out in the skull is, fortunately, but little. 
 Were it great, pressure on the brain would be the rule even in simple fissurea 
 fractures. If the fracture be compound, with loss of any fragments of bone, 
 the loss will not usually be made good by new bone, but by fibrous tissue 
 
 Treatment. — The conservative treatment of the last seventy-five years, 
 which inculcated rest, antiphlogistics, sedatives, cold, and watching and Avaiting 
 until the patient recovered or died, is curiously preceded and followed by a bold 
 and active interference. Even pre-historic trephining, which was largely praC" 
 
520 AX AMi:in(A.\ Ti: XT- HOOK or sruarjiY. 
 
 tiscd as a religious rite, niust liave been comparatively liarniless, judging from 
 the large lunuher of skulls discovered -with trephine openings healed before 
 death. Prior to the earlier part of the nineteenth century the trepliine was 
 very frequently used: it is said that Chadborn trci)hined Philip of Nassau 
 for epilepsy twenty-seven times, and instances of even a far larger number 
 of o])erations on a single individual are known. The use of the trephine, 
 however, was gradually abandoned, and for the last three-quarters of a century, 
 almost disappeared until modern methods made the operative surgery of the 
 brain so much safer that a return to frequent trephining and other similar ope- 
 rative interference has been a very notable fact within the last few years. 
 Especially is this true since jNIacewen and Horsley have established the proper 
 technicjue of such operations. At present, therefore, trej)hining with a view 
 to the relief of innnediate symj)tonis, and also quite as much for the ])reven- 
 tion of later ill effects, is not only justifiable, but in many cases is demanded. 
 
 There are two forms of danger from such fractures :. (1) the immediate 
 dangers, which are first the injury to the brain, and secondly septic inflamma- 
 tion ; and (2) the later dangers of severe continuous heachiche or of epilepsy 
 and insanity, which are worse than death. For instance, even in a case of 
 simple fracture there may have been a rupture of the dura and more or less 
 laceration of the brain tissue, Avith effusion of a large or a small clot. If the 
 clot be small, it will be absorbed before long, and healing of both the brain 
 and the dura will take place by the ordinary cicatricial tissue of a lacerated 
 wound. The skull, if it have been depressed, may even recover its vaulted 
 contour (especially in children), but the scars which remain in the brain and 
 dura are sometimes remotely the cause of epilepsy, insanity, and other compli- 
 cations of like character. Such a fracture, especially if compound and the 
 result of a localized violence, may be attended with a clot, producing all the 
 symptoms of compression of the brain. This clot and the brain tissue more 
 or less intermingled with it may gradually be absorbed, but the brain is some- 
 times left permanently depressed, witli spongy connective tissue, the meshes of 
 which are filled with cerebro-spinal fluid; this sort of multiple cyst may keep 
 up the palsy originally produced by the clot, and epilepsy, insanity, and other 
 serious consequences may follow even if the patient recovers. The journals 
 of the last few years have recorded a number of such cases, and the lesson to 
 be derived from them is a most important and practical one. The doubt often 
 expressed as to the wisdom of converting a closed fracture into an open one by 
 an incision into the scalp has little weight, provided the surgeon observes the 
 modern antiseptic precautions, without which methods no surgeon should touch 
 a fracture of the skull. 
 
 Moreover, it is important to observe the great difference that should attend 
 the treatment in cases in whicli a sinqde fracture occupies a limited area as a 
 result of a localized violence — e. g. a blow from a hammer, and one in Avhich 
 the "bursting" force of a diffused injury produces long fissures in the bone 
 and widespread injury to the brain. In tlie former such an exploratory 
 incision may be entirely proper, in the latter in most instances it would be 
 inadvisable. 
 
 If tlie fracture of tJievauU be simple, ivitliout depression and without cere- 
 bral symptoms, or if moderate cerebral symptoms have been ptresent, but are 
 abating, or if a fracture be only suspected, the case should be treated expect- 
 antly, but if any serious symptoms of intracranial mischief arise trephining 
 should be done. In simple fracture with marked depression immediate jire- 
 ventive trephining should be done, even if there be no signs of encephalic 
 mischief. Any violence sufficient to break a bone and depress it, there is good 
 
DISEASES AND INJURIES OF THE HEAD. 521 
 
 reason to believe, may have lacerated the brain substance and probably the 
 dura, aiul may be follo\ved either by speedy infUunmation or later in many 
 cases by epilepsy, etc. if the depression remain. It is, however, but just to 
 add that many surgeons still reject trephining until some symptoms of a lesion 
 of the brain have manifested themselves. 
 
 In all compound fractures of the skull it is far better to shave the entire 
 scalp rather than a small area, as is so often done. The removal of the hair 
 even from a nu^derate area becomes very conspicuous, and it is better, even 
 from an esthetic ])oint of view, that the entire head should be shaved, so that 
 the new crop of hair shall be of a uniform length all over the head. More 
 than this, it is impossible to observe rigid asepsis without wide shaving, which 
 thus becomes obligatory, even in women. 
 
 Compound fractures should always be explored by a large incision in the 
 scalp. If the fracture be a mere linear fissure, it must be most carefully 
 disinfected, and if it be impregnated with dirt or even if a single hair be 
 caught in it, the outer table must be carefully chiselled away, turning the 
 fissure into a V-shaped groove. The reason for this is that the danger lies far 
 more in the probable infection than in the mere fissured fracture. If much 
 depression exist even without symptoms showing that serious injury to the 
 brain has been done, trephining should be done at once. It is still more 
 strongly indicated if there be localizing symptoms which point to an injury of 
 any of "^the cortical centers Avithin easy reach, Avhether the fracture be simple 
 or compound. 
 
 Punctured tvounds of the brain are of course always compound fractures 
 of the most fatal kind. In these the rule has long been absolute to trephine 
 whether there be any brain symptoms or not. 
 
 If the surgeon sees that symptoms of intracranial mischief, such as local 
 paralysis, epileptic seizures, beginning choked disks, etc., arise in any case of 
 fracture of the skull, even after a considerable interval, his proper course is 
 immediate operation. The longer the operation is delayed, the longer the 
 "epileptic habit" has had a chance to form and the organic changes in the 
 brain to become fixed, the less the probability of benefit from any operation. 
 If, however, as in a case reported by Horsley, an old depressed compound 
 comminuted fracture with laceration of the brain tissue, which caused in the 
 first thirteen days of the patient's stay in hospital 2870 fits, could be cured 
 by the removal of the scar tissue, we should not be deterred from attempting to 
 relieve even the apparently most hopeless cases. 
 
 To sura up the matter, in any fracture of the vault, simple or compound, 
 in which there are symptoms of intracranial mischief it is proper to incise the 
 scalp and trephine. If there are no symptoms pointing to intracranial mis- 
 chief, but there is marked localized depression from which we should infer the 
 probability of either immediate or remote ill consequences, we should trephine. 
 In all cases of punctured fracture the rule is absolute to trephine, open the dura, 
 and disinfect. If, however, in a simple fracture there be no decided depres- 
 sion and no brain symptoms, the expectant plan may be pursued ; but if the 
 fracture be compound, it must be carefully disinfected, as has been described. 
 
 In giving these directions to operate it is of course understood that not 
 only is the bone to be trephined, but if there is any reason whatever the dura 
 must be incised and the brain inspected. Any further steps must depend on 
 what is found. In 81 cases of compound fracture of the skull treated, as above 
 described, by primary trephining the mortality was 1.23 per cent., while in 12 
 cases treated secondarily the mortality was 33.5 per cent. (Wagner). That is 
 to say, later trephining, which should have been done at the time of the acci- 
 
522 AX A ME RICA X TEXT-BOOK OF SURGERY. 
 
 (lent, caused an initial mortality nearly thirty times as great as simple primary 
 trephining, to say nothing of later dangers. 
 
 2. FRACTURES OF THE BASE. 
 
 As has been already stated, fractures of the base (PI. XIY, Fig. 1) cither 
 result from the extension of fractures of the vault to the base, or arise from 
 indirect violence received through the spinal column or rarely through the 
 lower jaw. 
 
 In addition to these cases a punctured fracture of the base may take place 
 through four cavities at the base of the skull, the orbit, the nose, and the 
 mouth, or a fissured fracture of the ear. It is not very uncommon to see 
 fractures of the base, with wound of the brain, caused by umbrellas, canes, 
 knives, small sticks of wood, etc., which enter the orbit above the eyeball or 
 gain access through the nose by piercing the cribriform plate of the ethmoid, 
 while gunshot fractures are often the result of attempts at suicide by dis- 
 charging a pistol into the mouth. All invite infection from without. 
 
 The fracture of the base may exist either in the anterior, middle, or pos- 
 terior fossa of the base of the skull, the middle fossa suffering most frequently. 
 Often more than one fossa is involved. Fracture of the posterior fossa has 
 double the fatality of fracture of the other two. 
 
 The symptoms of fracture of the base are usually inferential, depending 
 on the violence of the blow, and not uncommonly on our ability to detect 
 extensive fracture of the vault probably extending to the base. In fractures 
 through the orbit or other of the cavities just mentioned the evidence may be 
 very clear, but, on the other hand, it may be very difficult to arrive at a posi- 
 tive conclusion. Not a few cases have occurred in which a thrust into the nose 
 has produced severe bleeding, but in which the evidence of puncture of the 
 base of the skull and injury to the brain has been very doubtful. This is 
 equallv true of the orbit, where a slight wound may be hidden in the folds of the 
 upper lid. Large splinters of wood which have entered the cranial cavity either 
 through the orbit or through the nose have been discovered at post-mortem 
 examinations, their presence having been unsuspected during life. Of course 
 the escape of brain substance through the ear, mouth, nose, or orbit is posi- 
 tive evidence. In fracture through the nose and mouth there may be vomit- 
 ing of blood which has been swallowed. 
 
 The commonest sign of fracture of the base, especially in the middle 
 fossa, is the escape of blood or cerebro-spinal fluid from the ear. Sometimes 
 there will be bleeding from the ear, followed by the ordinary serous discharge 
 from a Avound, which may exist without any fracture of the base, but this 
 bleedinrr will usuallv continue for onlv a short time. Lonji-continued bleed- 
 ing, or, still more, the continuous discharge of a watery fluid, from the ear, if 
 abundant, and especially if it is aff"ected by the position of the head and is 
 increased by any violent expiratory effort, such as sneezing, coughing, blow- 
 ing the nose, etc., is almost positive evidence of such fracture, and especially 
 if the watery fluid possess the chemical characteristics described below (p. 505). 
 The patient may be directed to make these expiratory efforts with a view 
 to testing the result. But in order that there shall be the escape of blood or 
 cerebro-spinal fluid from the ear externally, the drumhead itself must also 
 have been ruptured. The fact, therefore, must not be overlooked that there 
 may exist fracture of the base without the escape of blood or cerebro-spinal 
 fluid, on account of non-rupture of the drumhead. These fractures, however, 
 are still compound, because they communicate with the external air through 
 the Eustachian tube and the naso-pharynx, and their danger is all the greater 
 
FRACTURES OF THE SKULL. 
 
 Plate XIV. 
 
 1. Fracture of base of skull, 2. Gunsbot fracture of lower jaw and cranium. 
 
J)LsJ':a<sl\s a.xj) ixjiuiks of Tin-: head. wi?y 
 
 because of" their insidious character. Another evidence of" fracture ol" the base 
 is paralysis of the cranial nerves, especially of the optic, facial, and auditory 
 nerves. Deafness and facial palsy, therefore, are very significant of fracture 
 of the petrous bone, and if either or both of them accompany discharge of 
 fluid from the ear and other evidences of fracture of the base, the diagnosis is 
 assured. Optic neuritis also sometimes occurs, especially in fracture of the 
 posterior fossa (Battle). Its advent is usually not till toward the end of the 
 first week, and may be delayed even till three or four weeks have passed. 
 
 When the orbital plate of the frontal bone has been fractured, even with- 
 out puncture, there is another symptom of considerable value — namely, after 
 a day or two blood will appear first under the conjunctiva of the ball of 
 the eye, and later in the lids. In fracture of the posterior fossa, which is 
 especially fraught with danger, the mastoid region should be examined for 
 ecchymosis. This is easily overlooked, as its existence is often hidden by the 
 ear, the pillow, and the hair. As shown by Battle, it appears first anterior to 
 the tip of the mastoid process, usually some time after the reception of the 
 injury, and spreads chiefly upward and backward with a crescentic border. 
 The reason for these peculiarities is that the blood cannot reach the skin below 
 the occiput on account of the dense cervical fascia, but follows the muscular 
 planes sidewise, first reaching the surface anterior to the tip of the mastoid by 
 the loose tissue around the posterior auricular artery. 
 
 The temperature during the shock following the injury is subnormal. 
 This is succeeded by a rise to 100° or 101° F., followed often by a second fall 
 somewhat below the normal. It will then remain subnormal or rise to the 
 normal. If the temperature rises to any notable degree, we may suspect sup- 
 puration and meningitis. If soon after the initial fall it rises quickly to 102° 
 or in some cases 106°, 108°, or even 110°, we may be sure there has been 
 some serious laceration of the brain, with almost certainly a fatal issue. 
 
 The prognosis in fracture of the base had always been an unfavorable 
 one until of late years. The danger of infection was especially great, because 
 the points through which septic infection may penetrate are hidden, and there- 
 fore were generally overlooked. These sources of infection are chiefly, as has 
 been pointed out, the ear, mouth, nose, and orbit (if punctured) ; all of them 
 are more or less inaccessible, difficult to disinfect, and likely to be overlooked. 
 But the last few years have seen immense improvement in our methods of treat- 
 ing such fractures. The urgent necessity for disinfection of these dangerous 
 cavities has been recognized, and as a result fractures of the base are much, 
 more amenable to treatment and their danger has been greatly reduced. A 
 sudden, and especially a high, rise of temperature, as has just been stated, is 
 a most unfavorable symptom. 
 
 Treatment. — In case of fracture of the base the fluid which escapes from 
 the ear, nose, etc. ought to be collected, and examined to determine whether it 
 be cerebro-spinal fluid. If it be, it Avill contain a small amount of albumin and 
 a large amount of chlorides, and will sometimes give the reaction for sugar with 
 Fehling's test. Next the cavity or cavities involved must be carefully disin- 
 fected. The ear should first be mechanically cleansed of w^ax, dirt, blood-clot, 
 etc., and then should be most carefully disinfected by a stream of warm sub- 
 limate solution, 1 : 2000, or hydrogen peroxide, till it is absolutely clean. It 
 may then be filled with sublimated cotton, iodoform gauze, or some similar dis- 
 infectant, and a sublimate dressing be applied externally. In the orbit the 
 same rule must be carried out, and if the fracture be a punctured one, carry- 
 ing infection into the brain, the wound must be enlarged and thoroughly dis- 
 infected ; as a rule it is best to trephine or remove by the gouge and chisel 
 
o24 .l.V AMKlllVAy TEXT-liOOK OF Sl'RiiKRY. 
 
 sufficient of the roof of the orbit to inspect the duni and l)rain itself if need 
 be, and then after liaving disinfected the parts to drain them. 
 
 In the nose and mouth this proceeding nnist be modified, inasnnich as cor- 
 rosive-sublimate solution would be dangerous from the jjussibility of its being 
 swallowed. The parts, however, should be thoroughly washed with water as 
 hot as can be borne, and then with a boric acid s^jlution. which in the mouth 
 must be fre([uently repeated by gargling, and in the nose by Thudichum's 
 douche or bv spraying. The nose should then be lightly packed with subli- 
 mate gauze'or sublimate cotton, which will not only sterilize the air that may 
 enter by the anterior nares, but also, by obstructing the passage of the air 
 through the nose, tend to prevent infection by the posterior nares. Iodoform 
 or boric acid may be insufflated into the naso-pharynx, and thus reach the 
 orifice of the Eustachian tube. Of course it is recognized that the nose and 
 mouth cannot be made absolutely aseptic, but only approximately so. But 
 even this partial asepsis has resulted most hopefully in treatment. In rare 
 cases drainage-tubes may be inserted into the cranial cavity through the nos- 
 trils, if need be by puncture of the cribriform plate. Similarly, for draining 
 the middle fossa the skull may be trephined above and behind the auditory 
 meatus. Thoroughness of disinfection and of drainage must be an absolute 
 rule. To attain these ends the operative interference may have to be consider- 
 able, but they must be attained at whatever cost. If a fracture of the base is 
 extensive, the head may be shaved and a plaster cap applied so as to immobilize 
 the fragments. Of course the utmost quiet both physical and mental is neces- 
 sary, with restricted diet, attention to bladder and bowels, and treatment by 
 drugs to combat the symptoms as they arise. 
 
 IX. WOUNDS OF THE BRAIN. 
 
 These are produced by severe falls, by kicks, by the penetration of knives, 
 nails, swords, bayonets, rifle-balls, etc., and may be received either on the 
 vault or sides of the cranium or through the orbit, nose, or mouth. With 
 the exception of such wounds in children through the open fontanelles. or jios- 
 siblv in adults through a large parietal foramen, they are necessarily accom- 
 panied by fracture of the skull. In many cases they are punctured fractures 
 of the most dangerous kind. They must all be more or less septic in character, 
 with laceration of the brain substance by the vulnerating instrument, with not 
 uncommonly fragments of bone, hair, cap, etc. carried into the brain, and they 
 are always attended by more or less severe hemorrhage. Recovery after a 
 severe wound of the brain sometimes follows almost miraculously ; as, for instance, 
 in a recent case where a would-be suicide deliberately drove four nails through 
 the skull into the brain, one being driven through the occipital bone. Knife 
 wounds have been repeatedly recovered from, the blade of the knife having 
 remained in the brain for many days or even years. Not uncommonly pistol- 
 balls have remained in the brain for years before producing any serious symp- 
 toms, and sometimes the foreign body has been discovered only at the post- 
 mortem, no symptoms whatever having arisen. The celebrated Vermont 
 '* tamping-iron ctise," in which a patient recovered after being wounde<l by a 
 tamping-iron which passed entirely through the brain from below upward, is 
 too well known to require repetition in detail. Loss of brain substance is by 
 no means invariably fatal, although of course always serious. 
 
 The symptoms in such cases are occasionally surprisingly slight and long 
 delayed, but more commonly are immediate and severe and in proportion to the 
 extent of the injury received. Usually, even if the injury be moderate, head- 
 
DISEASES AA^n INJURIES OF THE HEAD. 525 
 
 aclie soon sets in, with all the symptoms of a developed encej)halitis, followed, 
 if not soon relieved, by coma and death. Very often there may be localizing 
 symptoms of the greatest value Avhicli will enalde us to discover an otherwise 
 hidden injury. For instance, if a knife-ldade have penetrated the speech 
 center above and in front of the left ear, and have been broken off and hidden 
 by the scalp and hair, the motor aphasia which follows will guide us to the 
 region where we should search for the injury. If word-blindness or apraxia 
 occur, the injury will be more apt to be above and behind the ear; if there 
 be hemianopsia, the region of the cuneus should be examined ; while palsy of 
 the face, arm, or leg will point to their respective cortical centers as the prob- 
 able site of the injury. In all such cases the entire head should be shaved, in 
 order that the surface of the scalp may be examined with minute care. The 
 vulnerating body also, if possible, should be examined, to see whether any part 
 has been broken off and possibly left in the brain, and the evidence of eye- 
 witnesses to the accident is alw-ays to be carefully weighed. In all cases which 
 may involve a trial at court or a coroner's inquest careful notes should be made 
 at the time. The question of foreign bodies in the brain will be treated presently. 
 Treatment. — The head should be shaved, and then Avith the greatest 
 care the parts should be made as aseptic as possible, and all foreign bodies on 
 the outside should be washed away or removed with forceps. Foreign bodies, 
 fragments of bone, etc. which have been driven into the brain should all be 
 removed and the depressed bone elevated ; the cavity in the brain should also 
 be disinfected. Hemorrhage should be arrested by ligature, by hot water, or 
 by pressure. The dura, if not lacerated beyond repair, should be sutured, and 
 possibly its place may be supplied by a bit of the pericranium. Drainage 
 should be provided, best by rubber tubing, and then the flap of scalp should 
 be replaced and sutured, and an ample sublimate dressing applied. The after- 
 treatment before indicated should be carried out. Secondary abscess will be 
 very apt to follow in many cases, and should be watched for, and the pus evac- 
 uated as soon as possible. 
 
 X. GUNSHOT WOUNDS OF THE HEAD. 
 
 These are frequently more sei'ious than they appear to be at first. A 
 glancing rifle-ball, and still more a larger shot, impinges with such force 
 that while only the scalp may seem to ha-ve been injured, in reality the 
 bone may have received sufficient injury to produce necrosis, and even the brain 
 and its membranes may be or may become involved. The outer table may be 
 only fissured, or, if it apparently have escaped, a fragment of the inner table 
 may have been broken off. The scalp not uncommonly sloughs to a consider- 
 able extent. In other cases the most frightful and extensive injuries of the 
 brain and the skull ma}' be produced, as is shown on Plate XIV (Fig. 2). 
 
 Gunshot wounds directly involving the brain may be either perforating or 
 penetrating. A penetrating w'ound is one in which the missile enters and doe? 
 not emerge, and a perforating wound is one in which it passes entirely through 
 the head. The injury to the skull or brain may vary from a comparatively slight 
 wound to one which inflicts immense and widespread injury both to the skull 
 and to its contents. The difference between the wound of entrance and the^ 
 wound of exit is apt to be far more marked in the skull than in the soft 
 parts. At the wound of entrance the aperture in the external table may be 
 no larger than the ball itself, or may even have been reduced to a simple 
 slit, whereas the inner table may be quite extensively fractured. At the 
 wound of exit the reverse is true. The outer table will be more extensively 
 
526 
 
 .l.V AMKIUCAy TEXT- BOOK OF SURGERY. 
 
 Vui. 
 
 fractured than tlie inner, and in addition the entire ajierturc at the wound 
 of exit, as the ball strikes on the concave surface of the skull, is ajit to be 
 much larger than the wound of entrance (Fig. 2i!8). 
 
 The symptoms are very much the 
 same as those in any other wound of the 
 brain, with the exception that, owing to 
 the widespread injury, there is less prob- 
 ability of limited localizing symptoms, 
 though these may exist. 
 
 Treatment. — The recent advance in 
 cerebral surgery again has materially 
 changed our treatment of such wounds. 
 The difference between the modern treat- 
 ment of gunshot wounds of the brain and 
 the older methods is due to the applica- 
 tion of antiseptic methods and the con- 
 sequent boldness with which we inter- 
 fere, to the use of the aluminium gravity 
 probe, and to our knowledge of the facts 
 that drainage of the brain is not only 
 feasible but essential, and that for the 
 pur])0se both of searching for the bullet 
 and of removing it we should often make 
 a counter-opening by the trephine. The 
 details of the treatment may be stated 
 briefly as follows: (1) Shave and disin- 
 fect the entire scalp. (2) Disinfect the 
 entire track of the wound from the wound of entrance to the wound of exit, if 
 onf be present, or to the certain or probable site of the ball if there be no wound 
 of exit. (8) If there be any serious hemorrhage, the wound of entrance or the 
 wound of exit or both must be freely enlarged by the rongeur forceps or the 
 trephine, and the vessels secured by ligature, or occasionally the hemorrhage 
 may be arrested by pressure or by hemostatic forceps. (4) The bullet or other 
 missile must be removed if possible. For this purpose, if necessary, a counter 
 trephine opening must be made. (5) Free drainage must be secured, again if 
 need be by a counter-opening. For this purpose the drainage-tube may have 
 to traverse the entire brain. (6) Apply antiseptic dressings, and continue the 
 subsequent treatment on the principles already laid down. Most of the points 
 above enunciated have already been considered, but some re(iuire a few words. 
 The removal of tlie hall has always been one of the principal difliculties in 
 gunshot wounds. Fluhrer has introduced a probe of great value (Fig. 224 j, made 
 
 Perforating Gunshot Wound of the Brain, in- 
 volving the cuneus and i)roducing hemian- 
 opsia. Tlie wound of entrance is marked by 
 a small linear sear below and to the right oi" 
 the wound of exit, wliieh produced the large 
 excavated scar (Thomson and Keen). 
 
 Fig. -224. 
 
 Fluhrer's Aluminium Gravity Probe (natural size, except the length, which is IJ inches). 
 
 of aluminium, with large conical ends of different sizes. The material is so 
 light that if the head be so placed that the track of the ball is vertical, the 
 probe if allowed to enter by its own weight will not produce a false passage, 
 but will follow the track of the ball. If the ball is near the wound of 
 entrance, it may be extracted through this Avound, but if it has penetrated so 
 far as to be more accessible from the opjiosite side of the skull, a counter- 
 opening should be made at the point at which the probe would emerge if it 
 
DISEASES AND ISJLRIES OF THE HEAD. 
 
 52; 
 
 were carried througli the head. It is iin|)ortaiit, tliorffore, in using the probe 
 to measure its length, and when the probe has readied the ball to measure the 
 protruding portion, which will give us the dejtth at which the ball lies from the 
 Avouud of entrance. Then, pushing the probe farther on just to the counter- 
 
 FiG. 22o. 
 
 Fig. 212, A, B.— Method of Determining the Point lor Counter-trephining: a, the protruding end of the 
 probe ; 6. its axis continued to the counter-point d ; c, similar lines all converging to d, the place for 
 the counter-opening. These lines are fixed by regarding the skull in various planes : first from above, 
 then in front, etc., and following the line of the protruding part of the probe to the opposite side of 
 the slcuU (Bryant). 
 
 opening, and again measuring the part which protrudes from the wound of 
 entrance, we ascertain the depth at which the ball lies from the counter-opening. 
 Two strands of antiseptic silk are now attached to the extremities of the probe 
 and are drawn through the wound by the withdrawal of the probe. To one 
 of these strands a No. 9 (French) gum catheter is attached. This must be 
 jiew and well disinfected, especially in the interior, and made rigid by a disin- 
 
528 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 fected straight stylet. A ])air of forcoj)S is now tethered to the eatlieter by a 
 loop of silk around one of its arms, and the ball is searched for at its known 
 de])th, first above, then l)elow, to the ri^rht and to the left of the catheter 
 guide. The forceps should not be swept around the catheter, but should be 
 withdrawn and reintroduced for each search. The object of this is, of course, 
 to avoid unnecessary injury of brain substance. The ball, if found, having 
 been removed, the second strand of silk is utilized to draw a drainage-tube 
 directly through the wound. In Fluhrer's remarkable case the ball entered 
 the forehead, struck the occiput, and rebounded in a track determined first by 
 the natural angle of reflection and secondly by the influence of gravity. He 
 made a counter-opening, and found the wound made in the meninges by the 
 ball on striking the inner surface of the occiput, and from this as a new point 
 of departure made another search in the manner above indicated, with the 
 result not only of removing the ball, but also of saving his patient. 
 
 Dr. Girdner has devised a very ingenious instrument which may aid in 
 locating the ball, viz. the " telephone probe." One end of the probe is attached 
 to a telephone receiver which is held to the ear. The other cord attached 
 to the telephone receiver has a metal handle which is moistened and 
 placed in the patient's closed hand or against some other part of his 
 bare skin. If the probe touches the ball, a grating sound peculiar to the 
 contact of the probe with a metallic substance is heard through the tele- 
 phone receiver. By means of the .T-rays a ball within the cranium may 
 now be accurately located. To accomplish this two skiagraphs must be 
 taken, one in the antero-posterior plane and a second at right angles 
 to this. Formerly balls lodged in the brain were allowed to remain unless 
 they were quite superficial and readily found. The idea was that any med- 
 dlincr with the brain with a view to the removal of foreijxn bodies was unwar- 
 ranted. Modern brain surgery has changed all this. Antiseptic disturbance 
 of the brain, though of course to be deprecated unless essential, we now know 
 is not so dangerous as the retention of the foreign body. Wharton has shown 
 by an analysis of 316 cases of foreign bodies lodged in the brain, occurring 
 even in the pre-antiseptic days, that in 106 in which removal was eff'ected 34 
 (32 per cent.) were fatal ; whereas in 210 cases in which the missile was 
 not removed 122 (58.1 per cent.) died, and of those who recovered 10 suc- 
 cumbed ultimately from the effects of the retention of the missile, and many 
 others suffered from epilepsy and other physical and mental troubles. Brad- 
 ford and Smith have analyzed 89 recent cases of similar Avounds of the brain, 
 with a mortality of 33.3 per cent, following removal of the ball, and 54 per 
 cent, when the ball Avas not removed. If the bullet cannot be found by the 
 wound of entrance without undue interference with the brain, thorough disin- 
 fection of the wound should be made, followed by drainage by a rubber tube 
 reaching the entire 'depth of the wound. If a counter-opening have been 
 made, disinfection and through-and-through drainage should be employed. 
 The head should then be placed so as to favor drainage, the wound covered 
 with antiseptic dressings, and the after-treatment carried out as before. 
 
 XI.— FOREIGN BODIES IN THE BRAIN. 
 
 The treatment of foreign bodies in the brain has already been practically 
 considered under the head of Compound Fracture and especially under that 
 of AVounds and Gunshot Wounds, and the reader is referred to these subjects. 
 
 XII.— FUNGUS CEREBRI, OR HERNIA CEREBRI. 
 The former is the better term, as there is not commonly a true hernia of 
 the brain. It is usually a growth from connective tissue (the neuroglia), and 
 
DISEASES AND INJURIES OF THE HEAD. 
 
 529 
 
 ravel V contains much true brain substance (F.g. 22b). lungus cerebri, of 
 course, cannot take place unless the dura has been opened, and in fact even in 
 this case it is not likely to occur unless the brain substance itselt has been 
 Avounded. Sei)tic Avounds by their failure to close early involve far greater 
 Fk;. 22ii. Fig. 227. 
 
 Removal of a Large Fibroma from the Brain 
 (original): fungus cerebri soon after ope- 
 ration 
 
 Depression in tlie Head, seven years after ope- 
 ration (same ease as Fig. 226; original). 
 
 dan<Ter of fungus cerebri than the aseptic wounds of modern surgery, which 
 close by immediate union, because the neuroglia is softened and the intra- 
 cranial pressure is markedly increased. Hence trephining ^^ /^o^%™ 
 modern precautions involves but little danger of such a growth. Jiven 
 if the dura has been opened, if it be closed either by interrupted or by 
 continuous sutures there will be scarcely any risk but the moment that 
 any brain substance is removed the general risk of the operation, and the 
 especial risk of fungus cerebri, are very much increased. If, therefore, in any 
 operation it is necessary to remove any of the dura, and still more if any of the 
 brain substance is removed, the suggestion made by Keen may be carried 
 out, that a piece of the pericranium should be entirely detached from the 
 under surface of the flap of scalp, turned upside down so that the osteogenetic 
 surface shall be uppermost, and secured to the dura by a few mterrup ed sutures. 
 Such a piece of the pericranium will retain its vitality and close the opening 
 which otherwise would exist in the dura, and thus prevent a fungus cerebri. A 
 fungus cerebri is usually more or less rounded and its surface lobulated, ot a 
 grayish dirty-white appearance, and soft to the touch ; it produces no pam, and 
 may pulsate with the heart. It is often the site of moderate or considerable 
 discharge, and there may be escape of cerebro-spmal fluid even from the mte^ 
 ri^r of the ventricles. It is apt also to bleed. The intelligence of the patient 
 frequently remains good. The diagnosis, of course, is easy. 
 
 Treatment.-As a rule, the best treatment is to let the fungus alone or 
 to dress it once or twice daily with simple antiseptic dressings. If it heals 
 slowly skin-o-rafting may be resorted to. Pressure by sponges or by dressing, 
 though sometimes useful, is often followed by symptoms of mti-acranial pres- 
 sure or by convulsions, and then has to be abandoned. If cut off" by the knite 
 or destroyed by the cautery, it almost always sprouts anew. It is a cunous tact 
 that as soon as such a fungus has cicatrized there is a sudden subsidence, so 
 that instead of a bulging mass of tissue there is a marked depression, which 
 is always permanent, and may be even one and a half inches deep. (See 
 Figs 223 and 227.) The latter shows the result seven years J^^er removal 
 of a large brain-tumor followed by the fungus cerebri shown mJ^ig.^-b. 
 An important lesson can be taught by such a depression m the brain 
 If the patient lies down, or even bends over, the hollow is immediately 
 
630 AN AMERICAN TEXT- HOOK OF SURGERY. 
 
 effaced. So too in violent expiratory efforts, such as sneezing and couf^liing, 
 the same effect will be ])roduced. Such a case shows very clearly the rapid 
 chan<i;es effected in the intracranial circulation and the cerebro-spinal fluid 
 either by position or by violent expiratory efforts. Q^his explains why when 
 suffering from headache we walk on tiptoe in order to avoid any shock to the 
 brain, anil also why it is unwise to do any operation for cataract or other opera- 
 tion involving an incision into the ball of tlie eye when there exists cough 
 from bronchitis or other similar cause. 
 
 XIII.— INFLAMMATION OF THE BRAIN AND MEMBRANES FROM TRAUMATISM. 
 
 Various terms are used to indicate inflammation of different parts of the 
 brain and its membranes. The terms encephalitis and eet'ebritis are used indif- 
 ferently for inflammation of the cerebrum, and cereheUitis is occasionally used 
 for inflammation limited to the cerebellum. 3Ie)ii)i</ifis means inflammation of 
 the meninges of the l)rain, and arnchnitiH inflammation of the arachnoid itself. 
 Two forms of meningitis also may be distinguished pathologically: pacht/men- 
 ingitis, or inflammation of the hard membrane or dura, and leptomeninf/itis, or 
 inflammation of the arachnoid and pia considered as one. The differential 
 diagnosis between these two forms can be made only on the post-mortem table; 
 clinically they cannot be distinguished. Moreover, inflammation of the brain, 
 of the pia and arachnoid, or of the dura is sure sooner or later to extend to 
 either or both of the others, and the consecjuence in any form may l)e the pro- 
 duction of suppuration, abscess, effusion into the ventricles, and softening of 
 the cerebral tissue if the brain itself is involved. 
 
 Causes. — These are usually traumatic, such as contusions or laceration? 
 of the brain, fracture of the skull, etc. Caries and necrosis of the bones of 
 the skull, and occasionally pyemia, may also be the starting-point of such 
 inflammation. Caries and necrosis of small portions of the skull not infre- 
 quently may cause a localized and limited meningitis, which is far less danger- 
 ous than the diffused form resulting from contusions or similar traunuitisms which 
 shake the brain as a whole and are followed by the most intense forms of dif- 
 fused inflammation. Very often a piece of necrosed bone will lose its vitality, 
 either from localized injury or from syphilis, and its removal ■will disclose a 
 layer of granulation-tissue under it extending somewhat beyond the layer of 
 necrotic bone ; yet in this case the rest of the membranes and the brain itself 
 may entirely escape. 
 
 Meningitis and encephalitis are either chronic or acute, and it is necessary 
 to distinguish the two forms. Encephalitis will be used as a type of all these 
 forms of inflammation. 
 
 1. Acute Encephalitis. — Symptoms. — These usually arise within a 
 day or two after the injury, and with distinct symj)t()ms, such as pain in the 
 head, which is apt to be general, photophobia, intolerance of noise, and rapidly 
 rising fever until the temperature is 103° or 104°, with flushed face, full, bound- 
 ing pulse, contracted pupils, and a rise of surface temperature at the site of 
 the injury. The bowels will be constipated and the patient sleejdess and rest- 
 less. Delirium is apt to set in early, with twitching and strabismus, followed 
 by drowsiness which deepens into coma, and as the symptoms deepen there 
 will be paralysis with involuntary evacuation of urine and feces, and the 
 patient will die in a typhoid state. The ophthalmoscope will rarely show- 
 choked disk. At the post-mortem the dura will be found inflamed and red- 
 dened, the arachnoid usually whitish and opalescent, and if the inflammation 
 have progressed far enough the hemisi)heres will be covered with a greenish- 
 yellow layer of pus. The brain substance itself will be softened and vascular, 
 
DLSEASKS AN J) JXJURIES OF TlIK HEAD. 531 
 
 and verv likely :i layer of pus will lie at the base of the brain. The ventri- 
 cles Avill be iilled with turbid serum. 
 
 It is very important to distinguish between such inflammation of the 
 brain and uremic coma. In uremia the fundus of the eye will probably show 
 patches of albuminuric retinitis, while the urine will contain albumin and 
 tube-casts, and there will be very likely coexisting (jcdema, especially about 
 the ankles and the face. Not uncommonly also there may be chills at the 
 beginning of the suppurative process in encephalitis, which are generally 
 absent in uremia. 
 
 Treatment. — The patient should be placed in a (juiet, dark room, Avith 
 the head raised and the entire scalp shaved. The bowels should be quickly 
 purged, but not innnoderately, lest tiie patient be weakened by it as well 
 as by the physical efforts necessitated by such purgation. The bladder 
 should be carefully looked after, and retention of urine relieved by the cath- 
 eter. Cold should be applied to the head, either by an ice-bag or by a coil 
 of tubing for cold water. Occasionally, but not often, bleeding from the arm 
 may be of value, but if so it will ])e only in the robust and at the beginning 
 of the attack. Leeching or wet cups applied to the mastoid region and nape 
 of the neck are better, as they directly withdraw venous blood from the lat- 
 eral sinus through depletion of the radicles of the mastoid veins. Large 
 doses of bromide, up to 100 grains, or even more, per diem, aconite, calomel 
 guarded by opium up to the point of beginning ptyalism, and hj^pnotics, such 
 as hydrobromate of hyoscine, chloral, paraldehyde, etc., should be given to 
 procure sleep. In the early stages alcohol in any form is to be avoided, as an 
 additional excitant, but in the later stages, when exhaustion and especially the 
 typhoid state develop, it may be of value. In the stage of exudation, when 
 pressure symptoms begin, blisters to the nape of the neck and occasionally to 
 the scalp, with mercury and iodide of potassium, are the best remedies, if any 
 remedies can be said to be best in a disease which is so often hopeless from the 
 start. Should the patient recover, as he occasionally will, the most careful 
 after-treatment is essential. Convalescence must be conducted very watchfully 
 as to diet, exercise, and occupation. No physical exertion, even of the mild- 
 est character, should be allowed until the convalescence is well established. 
 Absolutely no mental effort should be allowed, especially that involving any 
 excitement, worry, or over-study, for many weeks, or, better still, months, 
 after the attack. 
 
 2. Chronic Encephalitis. — The causes of chronic encephalitis are the 
 same as those of acute, but usually the initial traumatism is less severe and 
 the inflammation follows after a longer interval, but it is always much more apt 
 to result in the formation of pus, either extradural, subdural, or cerebral. Dis- 
 tinct accumulations of pus will be considered under the head of Abscess. 
 
 Symptoms. — The patient ha's received probably a blow on the head, 
 followed by the lighter symptoms already described under Contusion. From 
 these he will recover more or less rapidly, and will apparently be again a well 
 man ; but days, weeks, or even months, after the injury he will begin to suffer 
 with vague symptoms of cerebral trouble, especially headache, which very fre- 
 quently will be localized at or about the site of the injury. He will be unable 
 to attend to business or study for any length of time. There will be more or 
 less mental dulness and irritability of temper. Without any change in his 
 acuteness of vision, if the eyes are examined choked disk will be found. Not 
 long afterward there will very likely be a chill, followed by a localized paresis 
 or paralysis, and if the case terminate fatally the drow^siness will deepen into 
 coma, and he will die with the same symptoms as those of acute encephalitis. 
 
532 .LV AMERICAN TEXT-BOOK OF SURGERY. 
 
 Treatment. — The same care should be giveu to the patient as before 
 in the matter of mental quietude, physical rest, diet, moderate purgation, 
 and watching the bladder if necessary. Blisters to the back of the neck and 
 cold to the head are useful. Internally calomel and opium in the earlier 
 stages, and mercury and iodide of potassium in the later, will ])e found most 
 useful. Care must be taken not to confound the dulness caused by the opium 
 with the coma which may arise in the course of the disease, and, conversely, 
 the coma must not be mistaken for opium narcosis. If the patient recover, 
 the same Avatchful after-treatment that has been above described must be strin- 
 gently carried out. No one has better described the need for such rest after any 
 concussion or inflammation of the brain than Mr. Hilton, in Lecture III. of 
 his book Rest and Pain. 
 
 3. Operative Interference in Meningitis and Encephalitis. — Very 
 naturally, in view of the boldness of modern cerebral surgery, the question 
 will arise whether operative interference will not give a better chance for 
 relief than the treatment above indicated. As yet, it is too early to be dog- 
 matic on this point, for there is little experience to guide us. But as inflam- 
 mation in the brain as in other parts of the body is followed by exudation and 
 suppuration, and this exudate or pus, not being able to escape, produces rapid 
 tissue-changes and symptoms of pressure, and as the bony skull cannot be 
 perforated by the serum or pus, and so allow it to escape and relieve the 
 pressure, as is the case in the soft parts, it seems reasonable that we should 
 interfere surgically and afford a means of escape for the exudate l)y trephining, 
 opening the dura, and draining. All surgeons would be agreed upon the pro- 
 priety of this treatment when there is localized suppuration, but there is still 
 a difference of opinion as to its propriety in the early stages when the exudate 
 is only serous. It is, however, possible that just as when exudation or sup- 
 puration occurs under the dense periosteum, we incise it and give exit to the 
 fluid ; and when increased intraocular pressure occurs, an incision relieves it 
 and saves the eye ; or in an orchitis an incision relieves the pain and saves the 
 testicle ; so in inflammation of the brain future experience may show that it 
 will be wise to trephine for drainage of the effused fluids before they have 
 gone on to the stage of suppuration or abscess and done irreparable damage to 
 the brain. In that case we shall be able hereafter to cope with the dangers 
 of cerebral inflammation far better than we have been in the past, and our 
 mortality records Avill be immensely improved. Very little has been done in 
 this direction, however, and hence these views are put forward tentatively. 
 
 Mr. Horsley has already urged this course of treatment, and very prop- 
 erly his opinion carries great weight. In cases of chronic encephalitis prob- 
 ably such operative interference will be more likely to be followed by .«uccess 
 than in the acute form, for in chronic encephalitis the symptoms often indicate 
 localized pressure on a single cortical center or on more than one neighboring 
 center. In this case the indications Avould be clearly in favor of trephining, 
 incising the dura, or, it may be, puncturing it, with a view to the relief of the 
 pressure. AVhether acute or chronic, those cases afford the greatest probabil- 
 ities of cure in which there is evidence of localized rather than diffused, and 
 especially of basilar, inflammation, and in Avhich tlii^re is a local production of 
 serum or of pus. One remarkable acute case has been reported by Mr. A. E. 
 Barker, in which there is reason to believe that he evacuated an ounce of odor- 
 less pus from the fissure of Sylvius, Avith good result. While a single case like 
 this does not establish a rule, it at least suggests a possibility Avhich must be taken 
 into account and acted upon, especially in so fatal a disorder. In any such ope- 
 ration Ave must be guided absolutely by our present knoAvledge of the localizing 
 
DLSEAUKS AXI> IXJClllKH OF THE HEAD. 533 
 
 more doubttul. 
 
 XIV.-ABSCESS OF THE BRAIN. 
 ^ ^o Npnrlv 50 per cent, of the cases of abscess of the brain arise 
 
 simple fracture it a splintei is uiukc contusion, 
 
 ^^r^fnot e'^^Vrrbl'vtr^^^^^^^^ rLveryappa 
 
 ^vhich ^^^y^'^^J\f^;^^;'Jf'' Weeks or months after such an injury and 
 rently may have taken place. ^^^^' " . , f ^i.^ y^r^in has been 
 
 :," ^^rer^k^L^n-TmerHrron hS 'epted *e cse of a boy fifteen 
 
 tt^fwhJr:;?'d ateveve Mow on ^^it^^^t^t^ :^^. 
 
 from a pair of tongs, ihree days alter ^^^'^ ^ ^ ^j^ g^^j^e 
 
 set in. beginning in the rigU arm and ^P^'^f ^^^^ *Xrton t^^^^^^^ him, not 
 
 '''"bII's sucTam-:i rnd'tXmatic cases, cevebral abscess sometimes follows 
 
 Besides ^"'^ ™^', ™ ulcerative endocarditis, and in pyemia mul- 
 
 ?rp^rabtres°oVtt S ^oVurcommomy exist. Occasionally tubercular 
 
 "^'p^thor^ioarinatomy—The site of the abscess may be between the 
 
 X^duJIl-^btsfSl ^^e no means 
 
 °^' -nrilJ:tfht tt^c^^rS =i Ti-s .-ally situat^ ^^ 
 site of the injury, to which we ■^l'^^^^ ^^^^'^t,^l^JT\^ -^o^^-^ 
 as already stated, -^f ™^\™/"tinT aused by the TacerTtion of the brain, 
 on the opposite side of the head, being "^"f ^ 7^°° , ^^ determined 
 
 as already explained, by contre-coup. Its f "»^' ;'™£ ^^,t„ ^^ for 
 much mo^e by the loc^Mng sympt^^^^^^^^^ ,^ifH\hrabLls: wTi/ Brocas 
 instance m a case repoUed bj J Tnflrio'r frontal at its posterior end-and the 
 convolution— that is, tne miru ui lu ohsppss will vary, from a cavity 
 
 cicatrix was on the forehead The size ^^^^^^^^^^ of the 
 
 containing a dram or two of pus up to ^^^^^J^ ^^^°».^^J'°,gP ^here it is 
 
 result. 
 
534 .l.V AMEIUVAX TKXT-BOOK OF .SL'UaFli V. 
 
 Symptoms. — Those may be divided into three classes: (1) tliose due to 
 tlie sii)>j)urative process; {-) tliose due to pressure; (•]) the focal or localizing 
 syiujitoins. 
 
 (1) Si/mptons due to tJic ,Su/>j)uratii'c J'roccss. — Usually a rise of" temper- 
 ature is significant of suppuration in other parts of the body, but it is espe- 
 cially noteworthy that in cerebral abscess the temperature, as a rule, is either 
 normal or subnormal, even when the other symptoms indicate tlie gravest peril. 
 Occasionally there will be an initial rise, followed by a fall to normal or 
 below it, and then toward the end of the disease there will be another rise, 
 often accom])anied by delirium, and the temperature again subsides, only to 
 rise after an interval if life is sufficiently prolonged. The local temperature 
 over the abscess, it is stated, rises, even if the general body temperature be 
 subnormal. If, therefore, in any case following a traumatism symptoms of 
 serious intracranial jiressure set in, w^ith the botly temperature normal or sub- 
 normal while the local temperature rises and the pulse is slow, the first thought 
 of the surgeon should be that he has to deal probably Avith abscess of the 
 brain. A chill not uncommonly occurs, but may be absent. Of course ano- 
 rexia, vomiting, general malaise, etc. are present. Somerville has stated that 
 when there is pus in the brain the urinary chlorides Avill be below normal and 
 the phosphates will be above. 
 
 (2) Sjjmptoms due to Pressure. — Headache is one of the most important, 
 and is almost always present, and not infrecjuently of a severe character, so that 
 the patient will moan constantly. Should the temperature rise the headache is 
 often aggravated, and sometimes is located distinctly over the lesion, but very 
 commonly it is first general and then focal. The pulse is always slow, and may 
 even fall to 80 or 40. Respiration is often of the Cheyne-Stokes type. The 
 mind soon becomes clouded, and the dulness gradually deepens into coma, and 
 the bowels and bladder are evacuated involuntarily. Epileptoid convulsions 
 often occur, but if the abscess arises from ear disease and is situated in the 
 temporo-sphenoidal lobe, the patient may be free from them. Sensation 
 is not usually impaired to any extent. Choked disk may be present 
 or absent, and may be unilateral or bilateral. If bilateral, it is commonly 
 more marked on the same side as the abscess, though occasionally this is 
 reversed. Sometimes ptosis may be present, and occasionally the entire third 
 nerve is paralyzed, while the sixth escapes, though this is sometimes reversed. 
 The pupil on the side of the lesion is usually dilated and more or less immo- 
 bile. The patient's general condition fluctuates remarkably as to these symp- 
 toms of pressure, giving us hope sometimes of spontaneous recovery, and then 
 becoming worse than before. 
 
 If the abscess is cerebellar.^ the diagnosis is even more obscure. There 
 may be occipital headache and muscular rigidity of the neck. If it be in the 
 middle lobe, there will be muscular incoordination, and especially a drunken, 
 unsteady gait. Vertigo and vomiting are fre([uent and persistent. There will 
 sometimes be tenderness on pressure and pain on percussion over the cerebel- 
 lum. Choked disk is commonly absent. 
 
 (3) Foc(d or Localizing Si/mptoms. — If the abscess is situated in the left 
 temporo-sphenoidal lobe, it may press on Broca's convolution, and this will pro- 
 duce motor aphasia. If it involve or press upon the lower part of the Rolandic 
 motor region, it will produce paresis or paralysis of the opposite side of the face, 
 followed by paresis or paralysis of the arm, and finally of the leg as the pus 
 creeps upward in the motor region. Sometimes there will be distinct squint, 
 from paralysis of the sixth nerve. Should the abscess arise in the frontal lobe 
 from contusion or fracture of this region or from nasal disease, localizing symp- 
 
DISEASES AXD IXJl'IUES OF THE HEAD. 535 
 
 toms are apt to be absent, since the frontal lobe is a latent region ; and the 
 same statement applies to the occipital lobe unless the abscess involves the 
 cuneus, when hemianopsia of the same half — that is, right or left — of each ret- 
 ina will follow. If the angular or su|)ramarginal gyrus is involved, there may 
 be monocular Argyll-Kobertson jnipil,' as pointed out by Oliver. The 
 local temperature of the two sides of the head should be taken, though it 
 must be interpreted with care ; and it must be remembered that the left side 
 is normally of a slightly higher temperature than the right. Pressure on the 
 skull and percussion, like the local temperature, may be of value, but must 
 not bo relied u|>on absolutely. Ferrier states that pain which is not sponta- 
 neously complained of, but is elicited by percussion, is of greater value than 
 mere tenderness on pressure. As a means of diagnosis between cerebral and 
 cerebellar abscess this is of some value so long as the mental condition of the 
 patient is sufficiently clear. 
 
 Differential Diagnosis. — 1. Meningitis. — Meningitis and abscess are 
 very often extremely difficult to differentiate, but we may be helped in the diag- 
 nosis by the fact that meningitis is apt to develop Avithin the first three or four 
 days, whereas an abscess does not usually form earlier than the end of the first 
 week. In meningitis also there are apt to be early dulness, deepening into coma 
 and actual delirium, photophobia, and contraction of the pupils, with high gen- 
 eral temperature and marked rigidity of the cervical muscles. 
 
 2. Mastoid Disease, following suppurative disease of the middle ear, some- 
 times occasions serious cerebral disorder Avithout abscess. Trephining the 
 mastoid, which should generally be done at an early stage, will eliminate this 
 as a factor in the problem. Mastoid disease will ordinarily be accompanied 
 with swelling, oedema, and pain in the mastoid region. It must be remem- 
 bered also that a cerebral abscess and mastoid disease often coexist. 
 
 3. Extradural Abscess may be distinguished from cerebral abscess by the 
 symptoms given later. 
 
 4. Thrombosis of the Lateral Sinus and Pyemia. — Commonly the internal 
 jugular vein, as well as the lateral sinus, will be invaded by the thrombus, 
 and will be hard and cord-like, and the veins of the face are apt to be swollen. 
 Pressure and percussion over the lateral sinus will be painful. The tempera- 
 ture will fluctuate violently, rising far above the normal, and there will be 
 rigors, sweating, and general prostration, and eventually suppuration in the 
 joints, Avith pyemic symptoms referable to the lungs and liver. Usually also 
 the intellect is much clearer than in abscess, at least in the early stages. 
 
 5. Tumor. — A tumor is ordinarily slow in its growth, and often attended 
 with distinct localizing symptoms at a comparatively early stage, Avhile abscess 
 usually pursues a much more rapid course. There are in abscess commonly the 
 history and often the evidence of distinct injury or of disease of the ear or nose. 
 Choked disk is almost ahvays present in tumor, and is generally double and 
 much more frequent than in abscess. Moreover, abscess is far more com- 
 mon in the temporo-sphenoidal lobe or in the cerebellum, especially from ear 
 disease, while tumor is rare in these situations. In other parts of the brain, on 
 the contrary, tumor is more common than {ibscess. The temperature is not apt 
 to rise in tumor, but should there be any marked and rapid fluctuation, and 
 especially any prolonged subnormal temperature, it would be strong evidence 
 of abscess ; if the patient is syphilitic, he is more apt to have tumor than abscess. 
 
 ^ The Argyll-Eobertson pupil is one which is more or less contracted, but the iris does not 
 contract when light is thrown upon the retina, although it varies with accommodation and con- 
 vergence. If this peculiarity exists in one eye only, it is called monocular Arg}dl-Robertson 
 pupil. 
 
536 .l.V AMERICAN TEXT-BOOK OF SURGERY. 
 
 Treatment. — A few early attempts to evacuate an abscess of the brain, by 
 Dupuytrtn. I)etnioM. an<l others, are on record, but it is only since cerebral 
 localization has enabled us to diagnosticate with comparative accuracy the lo- 
 cation of an abscess, and within the last few years, since cerebral sur;:ery has 
 advanced with such rapid strides, that surgeons have been emboldened to inter- 
 fere in an operative way in cases of such abscess, and in very many instances 
 with the happiest results. When the abscess is located, the head should be 
 shaved and disinfected, as already describerl. If the localizing symptoms 
 point to the region of the scar, we should trephine at that point, but if they 
 indicate another region we should always trephine in accordance with the 
 doctrines of cerebral localization rather than by the indication or the history of 
 the lesion. Of course if there be a fistula discharging pus, we should trephine 
 at the mouth of the fistula and follow it up to the abscess. 
 
 The dura having been opened, if there be an abscess the brain substance 
 will probably bulge markedly through the opening. The normal pulsations 
 of the brain will be absent. For exploration the grooved director is the best 
 instrument to use. The hypodermatic needle and the knife have been used, 
 but there is considerable danger of wounding the vessels, whereas the grooved 
 director is safe in this respect, and as soon as the abscess is reached it will 
 allow the pus to flow through its groove. The director should be forced gently 
 and carefullv straight forward into the brain in the probable direction of the 
 abscess, and may be safely introduced to the depth of two to two and a half 
 inches if the abscess be not reached more superficially. If the abscess be not 
 reached, the director should be withdrawn exactly in the line in which it 
 entered, and the brain similarly punctured in another direction. As soon 
 as the abscess-cavity is reached, the knife should be used to open the abscess, 
 and the opening may be enlarged by a pair of hemostatic forceps, introduced 
 closed and drawn out expanded to a reasonable degree, so as to aflbrd a free 
 opening for the pus. The granulation-tissue lining the walls of the abscess- 
 cavitv should then be removed by the sharp spoon, care being taken not to do 
 unnecessary damage to the neighboring parts of the brain. The cavity should 
 next be very crentlv washed out. best with a horic acid solution, and a drain- 
 af^e tube inserted. ' This should be either of rubber or of silver. A buttonhole 
 opening should be made in the scalp through which the tube may emerge, and 
 the tube should be secured to the scalp by a silk thread. The bone should not 
 be replaced. If the abscess is large and the first trephine opening does not 
 drain it well in the recumbent posture, a second opening should be made, and 
 the tube may pass through this or through both openings. An abundant sub- 
 limate dressing should then be applied. After two or three days the drainage 
 tube may be gradually shortened until it can be dispensed with. Should there 
 be reaccumulation of pus after apparent healing, the wound must be reopened, 
 the pus evacuated, and the cavity washed out and treated as before. Some- 
 times such reaccumulation will occur two or three years after the first abscess. 
 
 If the first trephine opening does not disclose any abscess, and it is possible 
 that one mav exist at another point, a second, and if need be a third, trephine 
 opening should be made at the possible point of suppuration. The dangers of 
 additional trephining are nothing as compared with the dangers of an abscess, 
 which is necessarily fatal unless evacuated. 
 
 In cerebellar abscess the upper edge of the trephine should be well below 
 a line from the inion to the external auditory meatus (the line of the lateral 
 sinus), and midway between the tip of the mastoid and the inion. The gouge 
 may often replace' the trephine to advantage, especially in children. It must 
 be remembered that the skull is thin and quickly penetrated in this region. 
 
DISEASES A XI) INJURIES OF THE HEAD. 537 
 
 The rongeur may be used to enlarge the opening if need be. The flap in the 
 dura shouUl have its base upward, to guard the sinus. The grooved director 
 may be used again to penetrate the cerebellum, and even should the abscess 
 exist on the opposite side of the cerebellum, it may be reached by an oblique 
 puncture, care being taken not to injure the superior vermiform process. 
 
 XV.— DISEASES OF THE BRAIN ARISING FROM SUPPURATIVE DISEASE OF THE EAR. 
 
 If Ave look at the base of the skull on the inside, we will be struck by the 
 position of the petrous bone as a boundary-line between the middle and poste- 
 rior fossaj of the skull. The upper edge forms a sort of watershed, with a 
 moderate declivity in front toward the middle fossa, in which lies the temporo- 
 sphenoidal lobe, and a sheer declivity at the l)ack toward the posterior fossa, in 
 which lies the cerebellum. The wall of bone between the tympanum and the 
 middle fossa especially is very thin, and we can easily understand, on noting 
 the anatomical relation of the temporo-sphenoidal lobe and the cerebellum to 
 the petrous bone, how^ disease of the ear may readily break through the thin 
 osseous barrier and produce inflammation of the meninges, thrombosis of the 
 petrosal or lateral sinus, and involvement of either the temporo-sphenoidal lobe 
 or the cerebellum itself. This explains the frequency of cerebral disease as a 
 result of disease of the ear. 
 
 Barker estimates that there are not far from 2000 deaths annually from ear 
 disease in Great Britain, with a population of but little more than one-half that 
 of the United States. Of all these a very large proportion are caused by cere- 
 bral disorder resulting from ear disease. Of 43,730 cases of ear disease tabu- 
 lated by Biirkner, 66.9 per cent, were disease of the middle ear, and 20 per 
 <;ent. were suppurative middle-ear disease. Four-fifths of these were chronic, 
 among which are to be sought the greater number of brain lesions. We are 
 very apt to imagine that the excessively fetid discharges which often accompany 
 ■ear disease are far more dangerous than those without such odor ; but Rohrer 
 has shown that the non-fetid discharges are the causes of the most dangerous 
 ■cerebral sequels, since fetor is due to bacilli which are not pathogenic, but 
 merely saphrophytic. Therefore the presence or absence of odor in the dis- 
 •charge is no test of its danger. Of all the discharges, the inspissated pus 
 that is found in the ear in many cases is the most dangerous, being filled with 
 pathogenic micro-organisms. 
 
 Primary acute inflammation of the ear rarely causes cerebral trouble: it is 
 in the chronic cases that the danger lurks. In these, the mucous membrane 
 being destroyed, the bone is bare and often carious and the seat of septic dis- 
 charges and also of septic foci. Hence if we attack an ear the seat of such 
 chronic discharge, and possibly of such inspissated pus and septic foci, we 
 should be very careful to do it thoroughly and Avith the strictest antisepsis, or 
 we may light up new and dangerous septic processes, giving to the inactive 
 micro-organisms ncAv life by the moisture supplied to them by opening the ves- 
 sels and lymph-channels, and spreading them by breaking down the barriers to 
 their introduction into the system. 
 
 It is a curious fact that aural disease may produce an abscess an inch or 
 more from the inferior surface of the brain, the intervening cortex remaining 
 perfectly normal. This may occur, according to Barker, in one of two ways : 
 •either a thrombus may extend into the lateral or the petrosal sinus, and from 
 this through the veins that empty into the interior of the brain, especially as 
 these veins have no valves ; or, secondly, the blood-current may be reversed in 
 these veins by reason of the thrombus. 
 
538 J-V AMi:i!i(AX Ti:xr-Ji()()k' of sriKiKUV. 
 
 Aural ilist-ase may causr ineiiingitis, jiljlcljitis, throiuljo.sis of the lateral and 
 petrosal sinuses, extradural abscess, or cerebral or cerebellar abscess. Of 
 these, meninfritis, pyemia, and abscess are the most frecjuent. 
 
 I. The Meningitis from aural disease differs in no respect from that aris- 
 ing from other causes, except that it is more likely to be localized and may be 
 more fre<iuently relieved by operation, as has already been indicated under 
 that head. 
 
 II. Cerebral Abscesses from Ear Disease are almost always situated 
 in the teniporo-spliLUoidal hjbe between two vertical lines, of which the anterior 
 is drawn through the tragus, and the posterior two inches back of the tragus. 
 Nine-tenths of them lie in a region covered by a circle of one inch and a 
 quarter radius, the center of which is one inch and a fjuarter above and behind 
 the meatus. This is well named by Barker the '"dangerous region." They 
 may be encapsulated or diffused. In other respects they do not difTer from the 
 cerebral abscesses already described. 
 
 Diagnosis. — The ear discharge from which they arise is almost always 
 chronic, and may have existed for years. While the general health is good, 
 there may be a sudden cessation of the discharge, with a rise of temperature, 
 nausea and vomiting, and a dull ache in tlie mastoid region, the temples, and 
 the neck ; the pulse becomes frequent, the tongue foul, and very often there 
 is diarrhea ; that is to say, the symptoms of acute septic infection are engrafted 
 on the existing chronic saprogenic sup])uration. The headache and tender- 
 ness are often general or frontal, and not located at the site of the lesion. The 
 temperature after the initial rise is again subnormal, and is in especial con- 
 trast to that of pyemia, with its acute fluctuations, which bear no relation Xo- 
 the ordinary morning fall and evening rise, or to the presence or absence of dis- 
 charge, and may be accompanied with rigors. It is again in contrast to the high 
 temperature of meningitis, which has not the abrupt oscillations of pyemic tem- 
 perature. The intellect is dull and sluggish and deepens into coma. The bowels 
 are apt to be constipated, the breath fetid, and the skin muddy, and there is- 
 marked emaciation. Optic neuritis, if present, is of value, but is often absent. 
 Convulsive twitchings or paralysis are of great value, if present, by their local- 
 izing indications. The state of the pupil is not commonly to be relied upon. 
 
 Treatment of Abscess from Ear Disease. — The treatment of abscess 
 arising from ear disease is the same in princi])le as that of cerebral abscess in 
 any other region or from any other cause. Prevention of the cerebral disease 
 is vastly better than treatment after its onset. Hence if after chronic ear dis- 
 ease persistent headache, vomiting, and mental dulness, without rise of tem- 
 perature, occur, the mastoid should be opened as indicated below. Not seldom 
 this will avoid the later necessity for graver operations. If, however, when first 
 seen the intracranial symptoms have already arisen and the mastoid process has 
 not already been opene<l, with few if any exceptions the first step should be 
 to open the mastoid and thoroughly wash it out. In doing this as practised by 
 Horsley and Barker a vertical curved incision should be made a ipiarter of 
 an inch behind the meatus in the axis of the mastoid from its base to its tip, 
 about two inches in length, the ear being drawn well forward. The mastoid 
 antrum and cells should then all be thoroughly laid open by the gouge and 
 chisel, and the posterior wall of the meatus be chiselled away to the cavity 
 of the middle ear (Fig. 228). All the inspissated pus which is often found 
 both in the mastoid antrum and in the mastoid cells, and which cannot begot 
 rid of by simple syringing, should be removed by a small sharp spoon or a 
 gouge and chisel, care being taken not to wound the lateral sinus. In order 
 to reach the antrum the opening is best made from one-third to one-half of an 
 
DISEASES AND INJURIES OF THE HEAD. 
 
 539 
 
 inch boliind and the sanic distance above the center of the meatus (Fig. 221), x ). 
 T(t find the mastoid antrum Macewen has directed attention to the value of 
 
 Opening the Mastoid Antrum (Esmarch and Kowalzig). 
 
 the " suprameatal triaiigle " which is formed by the posterior root of the 
 zygoma above (dotted line. Fig. 230), 
 
 the upper and posterior segment of the ^'^^- 230. 
 
 osseous external meatus in front (broken 
 line, Fig. 230), and an imaginary nearly 
 perpendicular line uniting these two 
 (short nearly vertical line. Fig. 230). 
 Within this triangle and toward its 
 base the opening into the mastoid an- 
 trum may be made with safety. The 
 
 A, A, Reid's Base Line : fi, the meatus ; c, the point for tre- 
 phining to reach an abscess in the temporo-sphenoidal 
 lobe or to puncture the lateral ventricle 1'4 inches back 
 of the meatus and 1'4 inches above Reid's base line ; 
 i", the mastoid vein ; o, the point for trephining to reach 
 an abscess in the cerebellum ; v, the point for trephin- 
 ing the mastoid antrum (Barker). 
 
 Surface Guides for the Sigmoid Sinus and 
 the Suprameatal Triangle (Macewen): 
 artificial lines drawn upon the skull in- 
 dicating the following: (1) The short 
 vertical line from the posterior border 
 of the external auditory meatus to the 
 posterior root of the zygoma marks the 
 base of the suprameatal triangle (a) ; the 
 broken line indicates the anterior border 
 of the suprameatal triangle, its base being 
 the dotted line marking a part of the root 
 of the zygoma. This broken line also in- 
 dicates the course of the fiicial nerve. 
 (2) The second vertical line, extending 
 from parieto-squanio-mastoid junction 
 to tip of mastoid ; the upper two-thirds 
 of its length indicates the position of the 
 sigmoid sinus. (3) The oblique line pass- 
 ing from asterion to upper limit of ex- 
 ternal auditory meatus indicates the pos- 
 terior two-thirds of the sigmoid sinus 
 from its commencement to its knee. 
 
 perforation is made slightly forward to avoid opening the sigmoid sinus (the 
 curved part of the lateral sinus in the mastoid portion of the temporal bone, 
 
640 AN AMKlili'AX 'JllXT-JiOOK OF sriiGKIiY. 
 
 Fi". 22H). When the surtroon luis pcnt'trated to tlic depth of half an inch, 
 he must be eareful not to injure the facial nerve, the cour.se of which is indi- 
 cated by the broken line in Fig. 280. To avoid this he should " keep close 
 to the floor of the middle fossa and nearer the posterior border of the ojicning, 
 toward the posterior superior angle of the suprameatal triangle "' (Macewen). 
 The near approach to the nerve is often preceded by twitching of the facial 
 muscles. The face should therefore be exposed, and an assistant be re- 
 (juested to observe any such phenomenon. 
 
 Of course the external meatus should also be well cleansed antiseptically. 
 There is no objection here to the use of the 1 : 1000 sublimate solution, 
 which, however, should not be used in washing out the cavity of the cerebral 
 abscess itself. After having cleansed the ear it is well to inject the cavity 
 with an emulsion of iodoform and to apply boric-acid fomentations, which are 
 to be freiiuently changed. 
 
 Should this not relieve the symptoms very speedily, we must search for 
 the abscess itself, which will probably lie in the "'dangerous region." The 
 best point to apply the trephine is one and a quarter inches behind and the 
 same distance above the external auditory meatus (Fig. 229. <■). One great 
 advantage of this position is that it is far enough away from the ear to avoid 
 septic infection from any aural discharge in case no abscess is present. It is 
 better to use for the exploratory operation a small trephine, one-quarter or 
 one-half inch, enlarging the opening, if need be, with the rongeur forceps 
 or by a larger trephine. 
 
 The dura having been opened by a simple crucial incision, the grooved 
 director should be inserted downward, forward, and inward in the direction of 
 the opposite wing of the nose, as this is the axis of the temporo-sphenoidal 
 lobe. Should the abscess not be reached, punctures may be made in other 
 somewhat similar directions, and the cavity when found should be treated in 
 the manner already described. Sometimes pus in the groove for the lateral 
 sinus will ooze out through the opening for the mastoid vein (Fig. 229, i), which 
 should be examined by turning back the scalp sufficiently to expose it. If 
 found, of course the groove must be opened and the pus evacuated. The 
 groove for the lateral sinus can safely be exposed to a large extent by means 
 of the rongeur, gouge, and chisel. Of course great care must be taken not to 
 wound the sinus, but should it be wounded it can be plugged and the hemor- 
 rhage, as a rule, readily controlled. Whenever it is necessary to expose the 
 sinus, strips of gauze for plugging it should be within easy reach. In some 
 cases it is desirable to open it deliberately. (See p. 541.) 
 
 III. Cerebellar Abscess. — Abscess of the cerebellum sometimes arises 
 in connection with ear disease. It is usually situated in the anterior part of the 
 lateral lobes where these are in contact with the petrous bone and the groove 
 for the lateral sinus. 
 
 The general diagnosis for such an abscess is based on the same symptoms 
 as that of cerebral abscess, except that the temperature may be high from com- 
 plications, and choked disk is, as a rule, absent. Tenderness over the cerebel- 
 lum, especially on percussion, and occipital headache if present, are both of value, 
 but our mean's of positive diagnosis for cerebellar abscess are at present lamenta- 
 bly deficient. The point at which to trephine, as already indicated (Fig. 229, o), 
 is midway between the tip of the mastoid and the inion, and well below a line 
 drawn from the meatus to the inion. which line corresponds to the lateral sinus; 
 or, in general terms, an inch and a half behind the meatus and one inch below 
 Reid's base line — a line drawn from the lower border of the orbit through 
 the middle of the external auditory meatus (Fig. 229, a, a). The surgeon 
 
DISEASES AXP IXJVRIES OF THE HEAD. 541 
 
 must reraembor that the occipital bone is very thin. A gouge may often 
 
 '■^■''Tbc treaS'enTof the abscess when once fo«n<l is the same as that of 
 cereb'al ^^'^^ 1" punctunng the cevebeUum care must be taken not to 
 
 "J'lV • Exr;Sdt;;'A;sc:ss'iT;rbscess tb„„ing between the ,lu,, ana the 
 -^\;:^qni^'t:^JXS.cereb*r^^^^^^ 
 
 Di-es^ure are sometimes seen in extradural abscess. 
 
 ^Treatment -If the mastoid has not already been opened, it f ould be 
 
 "^Zt^ q4 -^en of cou.e not to -™a the latera srnus.^ K a 
 
 ^^^^ious bone rem^ov.^, -^^^f, r^S nS'the diagnosis was only 
 
 Hoffman gives - 'f ^^^°/^/^tIf we d agnosticated durin=g life, of which 
 
 r'eXXr-opSot^ri: hamiy necessary to comment upon such 
 
 Statistics. . . , ^tf^ral Sinus. — Until recent- 
 
 V. PyetT^la and Throt^bosis o he L t ^^^ ^^^^ 
 
 :t:n?ryX:rtto^]elnrth\rsu,;geonssL^iIhe^^^^^^^^^^^^ 
 
 toms and with its treatment, especutlly ^'°<='^f ';,;°!' j^f "°^„Ve i^^ pvemia 
 
 rinrCthe curved j^nion tf th^ lateral s.nus running in the groove of the 
 
 "-s::^~:Tb^ii^t.bh.d.^^ 
 
 soon softens -'l -JX^tty become detacb-ed and pass into the lungs ; or the 
 
542 .l.V AMlJilVAX TEXT-llOOK OF .SL'L'd K/H'. 
 
 Tlie symptoms uill be a prt'coding history of chronic otorrhea, followed 
 by headache aiid luiin in the region of the sinus, vomiting, distinct and 
 repeated rigors, followed by profuse sweating, violent oscillations of tempera- 
 ture, tenderness and local oedema over or behind the mastoid, and all the 
 ordinary sym|>toms of pyemia. As the clot usually extends both in the 
 course of the lateral sinus and soon into the iiiterjial jugular vein, there will 
 be tenderness over the course of the lateral sinus — that is. in a line Irom the 
 external auditory meatus to the inion — and also in the neck over the course 
 of the internal jugular vein, which may feel like a tense, tender cord or may 
 even have been destroyed. Choked disk will very likely be present. 
 
 The treatment should be prompt and positive. First, the mastoid should 
 be opened and cleansed. If the internal jugular vein is involved, it should 
 then be exposed in the neck, and the vein should be followed down until a 
 point below the thrombus is reached, which can usually be determined by 
 touch with comparative ease. The vein should next be ligated, to prevent 
 extension of the septic thrombus downward to the heart and lungs, and it 
 should then be washed out and made as aseptic as possible. Next the sinus 
 should be exposed, and if there be any pus in the groove for the sinus, it 
 should be washed away. If the sinus be thrombosed, it must l)e opened and 
 thoroughly cleansed even to the torcular Herophili. Should it not be closed 
 by the clot, and hemorrhage be very free, this may be controlled by instan- 
 taneous plugging with strips of iodoform-gauze, which should be ready at 
 hand. Although from the nature of the case perfect asepsis cannot be ob- 
 tained, yet the results have been such as highly to commend the treatment. 
 Recovery has taken place in 56 out of 84 cases — 6G.7 per cent. — that have 
 been operated on and reported. Without operation death is almost inevit- 
 able. Hence every case should be submitted to operation the moment the 
 diagnosis is established. 
 
 The petrosal sinuses may also be thrombosed, but without local symptoms 
 to guide ur-. 
 
 Sometimes the cavernous sinus is thrombosed, rarely from disease of the 
 ear, but more frequently from infective inflammation about the orbit, the 
 jaws, or the throat. If so, there Avill be hyperemia of the retinal veins and 
 oedema in the region of the frontal vein and in the eyelids, with exophthal- 
 mos from retrobulbar oedema. The opposite eye is often in turn aftected 
 from extension of the thrombus to the opposite side. There may also be 
 neuralgia of the first division of the fifth nerve and paresis or paralysis of 
 the muscles supplied by the motor oculi (third), the abducens (sixth), or the 
 pathetic (fourth) nerve, all of which run in the sinus. 
 
 The treatment of these latter forms of sinus-thrombosis and of pyemia 
 from ear disease, without thrombosis, must unfortunately be limited to the 
 general treatment of pyemia. 
 
 XVI.— SURGERY OF THE L.\TERAL VENTRICLES. 
 
 Until a few years ago it Avas supposed that any injury involving the lateral 
 ventricles was necessarily fatal. This, however, is disproved by a number of 
 cases in which the lateral ventricles have been opened by injury, such as simple 
 fracture of the skull, of which there are at least o ca.ses reported in^children, 
 of whom 3 recovered. In addition to these there are also recorded 7 cases of 
 compound fracture with secondary implication of the ventricles, 4 of which 
 recovered, and 2 of primary rupture of the ventricles by compound fracture, 
 both of which recovered. Sometimes also in cases of fungus cerebri a com- 
 
DISEASES A XI) IXJllilKS OF THE HEAD. 
 
 543 
 
 iiiiinieation is established -with the hiteral ventricles, followed by continuous 
 discharge of corebro-spinal fluid from the ventricles, in which recovery has 
 taken place. Besides this, Keen has shown that puncture of the lateral ven- 
 tricles through the brain substance can be done accurately, and that a drainage- 
 tube mav be introduced into the ventricles and remain several weeks without 
 inflammation of the brain or its meml)ranes, and that even irrigation of the 
 ventricular cavities from side to side after bilateral tre}»hining can be done 
 without discomfort to the patient. In very many modern cases the ventricles 
 have been successfully tapped as a deliberate procedure. Therefore in fract- 
 ure involving the ventricles we should not infer that the patient must die and 
 that we must do nothing, but should treat the case on the same antise})tic 
 principles and by the same methods that we should emi)loy had the ventricle 
 not been invaded, and with a very reasonable hope of recovery. 
 
 If the ventricles are to be tapped, the lateral route is the best. A half-inch 
 trephine opening should be made one and a quarter inches behind the external 
 
 Fig. 231. 
 
 Puncture of the Lateral Ventricle by the Lateral Route at A (Keen). 
 
 auditory meatus and the same distance above Reid's base line (Fig. 231, A). 
 Then the grooved director or a small tube (caliber No. 5 of the French cathe- 
 ter scale or a little larger) should be thrust carefully and steadily into the 
 brain in the direction of a point H vertically two and a half to three inches 
 above the opposite meatus. If the lateral ventricle be of normal dimensions, 
 it will be reached at a depth of two to two and a quarter inches, but if dis- 
 tended it will be reached at a less depth. The entry into the ventricle will 
 be recognized by the instant diminution of resistance and by the escape of 
 cerebro-spinal fluid. Drainage may then be eff"ected, either by inserting a 
 small bundle of horsehair doubled like a hairpin, wdth the rounded ends 
 inserted first, and passed through the tube, or by carrying a rubber drainage- 
 tube of the same size into the ventricle. 
 
 The operation has been done several times for chronic hydrocephalus, 
 without, however, up to the present time, a single cure ; but in acute hydro- 
 
544 AN AMERICAN TEXT-BOOK OE SURGERY. 
 
 eeplialiis the result lins been slij^litly more j)roinising. ^Ir. Mayo Hobsoii 
 has reported one case in which undoubtedly life was saved. Dennis has 
 reported one case of evacuation of a clot in the lateral ventricles, but the 
 laceration of the brain was such that the patient died soon afterward. A 
 number of successful cases of operation for increased intracranial pressure 
 have been reported. 
 
 Of course if the ventricles are tapped the asepsis should be absolute, or 
 the result will necessarily be fatal. 
 
 XVII.— INTRACRANIAL TUMORS. 
 
 I. Their cause cannot, as a rule, be determined. Occasionally they arise 
 from injury ; in which case they are apt to be sarcomata, although they may be 
 fibromata or other varieties of tumor. Sometimes they are parasitic in origin, 
 from the echinococcus or from the ray fungus (actinomycosis), and tumors of 
 both of these varieties have been operated on successfully. Much more fre- 
 quently, however, they arise from no assignable cause. Hale White and Bern- 
 hardt have gathered the statistics of 580 tumors, which are tabulated by Seguin 
 and Weir, as follows : 
 
 Number. Per cent. 
 
 Nature of tumor not stated 133 22.9 
 
 Tubercular tumors 137 23.0 
 
 Glioraata 76 13.0 
 
 San'omata (including cysto-sarcomata) 75 13.0 
 
 Hydatids, cysticerci, and echinococci 30 5.0 
 
 Cysts 27 4.6 
 
 Carcinomata . 24 4.0 
 
 Gummata 21 3.6 
 
 Glio-sarcomata 14 2.2 
 
 Mvxomata (including myxo-sarcoraata) 12 2.0 
 
 Ostenmata 6 +1.0 
 
 Neuromata 4 — 1.0 
 
 Psammomata 4 — 1.0 
 
 Papillomata 4 — 1.0 
 
 Filjromata 3 
 
 Cholesteatomata 2 
 
 Lipomata 2 
 
 Erectile or vascular tumors 2 
 
 Dermoid cysts 2 
 
 Enchondromata 1 
 
 Lympliomata 1_ 
 
 Cases 580 
 
 On looking at this table we see that the number of tubercular tumors exceeds 
 twofold that of tumors produced by any other one cause. The sarcomata and 
 gliomata, which are practically all sarcomata, taken together slightly exceed 
 tubercular tumors. Of the 580 tumors in this table, the nature of 447 was 
 known. The tubercular and these two kinds of sarcomata numbered 288, 
 leavinf', therefore, only 159 for all the other known kinds of tumor. Tuber- 
 cular tumors are most frequent in early life. Three-fourths of them occur 
 before the twentieth year, and one-half before the tenth, according to Gowers. 
 On the contrary, the various forms of cancer, including sarcoma, are more 
 common from twenty to forty years of age. 
 
 II. Location. — Of 687 intracranial tumors tabulated by Gowers, 297 
 were situated in the cerebral hemispheres, excluding the central ganglia, 179 
 in the cerebellum, 59 in the pons, 48 in the central ganglia, 31 in the medulla, 
 13 in the corpora quadrigemina, and 10 in the crura cerebri. Starr found 96 
 tumors of the cerebellum in 300 cases of intracranial tumors in children only. 
 
DISEASES AM) I XJ CRIES OF THE HEAD. 
 
 545 
 
 ITT Infiltration.— Some tumors are definitely limited either by a distinct 
 TN-all as in a wcll-.kHned cvst ; in others, as in a fil.roma or an osteoma the 
 limits of the tumor, though" without any such wall, are definite and abrupt ; but 
 mali-nant, and to a less extent tubercular, growths of the brain, as of othei- 
 nartrof the bodv, are more apt to infiltrate the surrounding tissues without 
 inv wcll-<lefined margins. This, however, is not always the case. When 
 infiltration exists, the need for removal of more tissue than that which constitutes 
 the tumor itself is very apparent. The probability of recurrence is also much 
 
 greater in such cases. • -i j. ^i, c 
 
 IV The symptoms of tumor are in many respects similar to those ot 
 
 other lesions. They niav be caused either by irritation or destruction of the 
 
 cerebral substance or by" pressure upon the brain. They are either diffused or 
 
 localized. , ^.^. , ^ 
 
 1 Headache is, as a rule, early, constant, and severe. V\ hen the tumor 
 is superficial the headache is apt to correspond to the site of the disease. 
 While, like all the other symptoms of tumor, it may be absent, yet m the 
 great majority of cases it is present, and is usually one of the most annoying 
 and painful symptoms. As a rule it is diffused, but even if it is localized we 
 must not depend upon it too much as an indication of the site of the tumor. 
 
 2. Pain is almost -always present, and may either be spontaneous or be 
 evoked by pressure or percussion. As a localizing symptom, pam, like head- 
 ache, is not of great value. Pain, however, which is not spontaneously com- 
 plained of, but \ produced by percussion, is of more value than spontaneous 
 pain or pain upon pressure. 
 
 3. Vertigo is a common symptom, although not constant, but is more 
 marked probably in cerebellar tumors than in cerebral. If the tumor is in 
 the cerebellum, the vertigo is apt to be present in the recumbent posture as 
 
 well as in the erect. . , , , . -r> v. i 
 
 4. Vomiting, if cerebral in origin, is of considerable value. Uy cerebral 
 vomitin.' is meant that variety Avhich has no relation either to the ingestion 
 of food°or to a furred tongue, constipation, diarrhea, or other evidences of 
 
 disturbed digestion. ■ c ra • ^ 
 
 5 Epileptic convulsions usually set in as soon as the tumor is ot sutfacient 
 size to produce pressure. They are often general in their distribution but 
 occasionally they are localized, and if so they are of great value ; for if the 
 attack begins always in the same arm or on the same side of the face or m the 
 same le«',''they point with reasonable accuracy to the location of the tumor. 
 
 6. Another of the pressure symptoms is choked disk, which in tumor is 
 nearly always double. It sets in'^probably as soon as the tumor has reached 
 any size, but while its existence is of value, as indicating the presence of a 
 tumor, it gives no indication of the position, character, or size of the tumor. 
 If it be m'onocular— that is, in one eye only— the tumor is most likely to be 
 in the opposite hemisphere, but if optic neuritis and choked disk exist m both 
 eves, as is almost always the case, the site of the lesion is probably the side on 
 w'hich the least swelling occurs ; and this may be especially inferred if the other 
 symptoms point in the same direction. Strange to say, it does not interfere with 
 the acuity of vision until secondary atrophy of the nerve has taken place. 
 
 7. Other Eye-sgmptoms.—PaiYesh of any single muscle or any group of 
 muscles f^eneral'ly indicates either pressure from a coarse lesion m the cortex 
 which supplies this muscle, or true infiltration of pathogenic material into the 
 meshes of the nerves themselves. Unless, however, associated with other symp- 
 toms, it is of little value. Spasm of any of the muscles is of more value than 
 paresis or paralysis, and indicates more positively a lesion in the motor centers 
 
 35 
 
.54') ^l.V AMKIUi AX rEXr-liUOK OF SllidKin'. 
 
 of sufli inusclos. Homonymous liomiaiiopsia is of j^reat value, since it jrenerally 
 indicates a lesion of the cuneus on the same side. 'JMie term hemianopsia denotes 
 acontlition in which, each retina bein^ divided by a vertical line into two halves, 
 the rijxht half of each retina is insensil>le to vision, and therefore objects in the 
 left half of the visual field .ire not seen ; or. r/Vv vrrsd, the left half of each 
 retina is blind, and then the rinjht half of each visual field is not seen. If the 
 riflht cuneus is involved, the right halves of the retinae will be blind and the 
 left halves of the visual fields not be seen, and vice versd. 
 
 The pupils are not unconnnonly unequally dilated or contracted. Their 
 condition is of little value in pointing out tumor in contrast with any other 
 intracranial disease. 
 
 Focal Symptoms. — 1. Hemianopsia has already been mentioned. 
 
 2. Aphasia. — If the tumor be located in the third frontal convolution, on 
 the left side in right-handed persons, and on the right side in left-handed per- 
 sons, as a rule, motor aphasia will be marked. 
 
 3. Paresis or Paralysis. — If the tumor be located so as to press directly 
 upon the fiice center, arm center, or leg center, or if it be even some distance 
 from these and yet large enough to exercise distant pressure upon them, there 
 may be paresis of the arm or leg or even a partial or complete hemiplegia. 
 
 4. Anesthesia. — Unless the internal capsule is involved, anesthesia is rare; 
 yet it sometimes does occur. Tumors pressing upon the olfactory or any other 
 nerve or involving the nucleus of any nerve or nerves will produce at first 
 irritation and afterward destruction of the function of such nerve or nerves. 
 
 Mental Disturbances. — As a tumor increases in size, stupor, and finally 
 coma, almost always precede death. Earlier in the history of the disease, how- 
 ever, there are mental disturbances, such as hallucinations and delusions, and 
 in most cases there is a general loss of mental acuteness, with loss of memory 
 and more or less childishness. Resemblance of the symptoms to hysteria 
 should not lead the surgeon to overlook a possible organic disease. Among 
 other mental disturbances, the following .should be mentioned : 
 
 1. Word-deafness, or, as it is often called, sensory or amnesic aphasia, is 
 the loss of memory of the sound of a word. For instance, a spoken word, such 
 as "cat," would not convey its proper meaning to the patient. AVord-deafness 
 generally indicates a lesion in the posterior half of the first temporal convo- 
 lution on the left side. 
 
 2. Word-blindness, alexia, is the loss of memory of the appearance of a 
 written or printed word. For instance, again, a written or printed word " cat " 
 would be unintelligible to the patient. This defect usually indicates disease 
 of the lower posterior portion of the parietal lobe on the left side, and espe- 
 cially the angular and supramarginal gyri. 
 
 3. Agraphia is the loss of memory of the muscular movements made in 
 writing, so that the patient has lost the faculty of writing, though he still 
 retains control of the muscles involved in this act. It usually indicates a 
 lesion beneath the motor speech center (Broca's convolution), or possibly of 
 the posterior part of the second frontal convolution. 
 
 4. Again, there may be loss of perception of the use. odor, color, or taste 
 of any object presented to the mind. This general symptom is often termed 
 apraxia, and of course has as many varieties as there are avenues by which 
 the mind may be reached ; for instance, sight, touch, smell, taste, hearing 
 for language, hearing for music, etc., any of which may be lost, producing 
 mind-blindness, mind-deafness, etc. The patient in mind-blindne.ss will be 
 unable to recognize an object by sight, but may still be able to recognize it by 
 touch. All these various conditions should therefore be examined. Apraxia 
 
DISEASKS AM> I^JUniES OF THE HEAD. 547 
 
 will <;oiior;illy iTidicatc a k'sioii in the sii|)raiiiar;^inal or angular gyrus in the 
 left lieniisj)lici(' in rigjit-lianded persons, and vice vcrsd. 
 
 V. Diagnosis. — That there is need for more exact means of diagnosis is 
 very evident when Ave rememher that in a numher of eases an operation has 
 been undertaken for a tumor su])posed to he loeated at a certain point, without 
 finding the tumor, and the post-mortem has shown either that the tumor existed 
 elsew here or that there was no tumor Avhatever. Time is enabling us, however, 
 gradually to become more accurate in our diagnosis. There are six questions 
 (Weir and Seguin) to which, if possible, we must obtain answers in any sus- 
 picious case : 
 
 1. Doi's a Tumor exist? — The symptoms, briefly stated, Avill be headache, 
 pain, possibly vertigo, cerebral vomiting, convulsions either general or local- 
 ized, and paresis or paralysis to a greater or less extent, choked disk, possibly 
 stupor toward the end of certain cases, hemianopsia, and apraxia or aphasia, 
 with or without anesthesia. While all these will not be present in any one 
 case, if there be a reasonable number of them the probabilities of tumor will be 
 very strong. The difterential diagnosis between tumor and abscess has already 
 been given on page 535. In Bright's disease, and sometimes in lead-poisoning, 
 there may be headache, vomiting, convulsions, and choked disk, but the exami- 
 nation of the urine and the usual dropsy in Bright's disease, and the wrist-drop 
 and condition of the gums in lead-poisoning, together Avith other symptoms of 
 both disorders, should put us on the right track. 
 
 2. What is the Location of the Tumor- ? — This question must be answered 
 by the localizing symptoms above given, if they exist : for it must be remem- 
 bered that in certain parts of the brain a tumor may exist without any local- 
 izing symptoms, but with only the general symptoms of headache, vomiting, 
 choked disk, and convulsions. These latent zones are especially the anterior 
 portion of the fi-ontal lobes, the temporo-sphenoidal lobe except on the left 
 side in part, a considerable part of the parietal and occipital lobes, and to 
 some extent the cerebellum. Sometimes even a very large tumor may exist 
 and give no signs of its presence, but if it be in certain localities where the 
 centers for the special senses are located, or in the cortical centers for motion, 
 or in the paths of distribution of the nerves from these centers, we may be able 
 in most cases to locate it with reasonable accuracy. If in the history a num- 
 ber of centers have been successively involved, this fact is very important, as 
 the history of the march of the paralysis or the irritation is of the greatest 
 value in enabling us to locate the tumor. Rapidly-produced blindness is 
 usually due to tumors, especially in the cerebellum or pons, which obstruct 
 the veins of Galen or the straight sinus or the iter e tertio ad quartum ven- 
 triculum, and so produce an internal hydrocephalus, pressure on the optic 
 tract, choked disk, and later blindness. 
 
 3. At tvhat Depth does the Tumor lie — that is, is it cortical or subcortical? 
 — A tumor in the cortex may be diagnosticated possibly by tenderness to pres- 
 sure over the area of the tumor, possibly by a local rise of temperature, and 
 also by considering the number and relations of the centers involved by the 
 tumor and the absence of anesthesia. 
 
 4. Is the Tumor Single or Multiple ? — As a rule, if multiple, operation 
 will be contraindicated ; but if single, its removal may be attempted unless 
 specially contraindicated. If single, the localizing symptoms should be referred 
 either to one center if the tumor be small, or to several adjacent centers if it 
 be large. If the centers involved are multiple and far apart, the probabilities 
 are against a single tumor and in favor of a multiple ; or if single, the tumor 
 will be very large. 
 
548 AN AMERICAX TKXT-llOOK OF SURdEIiY. 
 
 5. What is the Size of the Tumor. ^ — Tii a few cases this lias been diag- 
 nosticated. Tlie tumor is probably small if only a restricted area of the 
 brain is involved, as shown by a limited paresis or paralysis, if with time no 
 adjacent centers have become involved, and if tlie symptoms of intracranial 
 pressure are either slight or absent. A large tumor can be diagnosticated by 
 the involvement of a large numl)er of neighboring centers and marked symp- 
 toms of pressure. Often this diagnosis, however, cannot be made Ix'fore ope- 
 ration. Even if the tumor be large it may be removed succossfnlly. Thus 
 Horsley has removed a tumor weighing over four ounces, and Weir and Keen 
 have removed two others but little short of this weight ; and two of these three 
 patients recovered. We should therefore hesitate before refusing to operate, 
 even if the tumor be probably of large size, liefusal means Avitli practical 
 certainty a fatal termination. Operation, it is true, may be followed by death, 
 but this would only be anticipating by a little time the natural termination of 
 the disease, and it gives the only hope. If the tumor is found to be too large 
 for removal, the surgeon will of course terminate the operation, and, as shown 
 by a number of cases, the patient may be decidedly the better by reason of the 
 interference, especially from the relief to the headache, blindness, vertigo, and 
 vomiting. In one of Ilorsley's cases, in which for inoperable cerebellar tumor 
 he removed half of the occipital bone, the relief to the dyspnea, headache, and 
 rotary convulsions Avas so great that the patient requested the removal of the 
 other half, and his life was prolonged for two years in relative comfort. 
 
 6. WJiat is the Nature of the Tumor? — If the patient has suffered from 
 cancer, tubercle, or syphilis and the symptoms of intracranial tumor are present, 
 it is most likely that the cerebral tumor is of the same nature as the disease 
 already existing elsewhere. We can always make a guess based upon the facts 
 that before twenty years of age tubercle is much more frequent than any other 
 disease, and that betAveen twenty and forty glioma and sarcoma are more fre- 
 quent than other tumors ; but such a guess is hardly one upon Avhich Ave should 
 act. Hale White and A^on Bergmann have both opposed operation in syphi- 
 litic tumors, but the vicAv of Seguin is tliat if the antisyphilitic treatment has 
 been inefficient, including the administration of increasing doses of the iodides 
 up to half an ounce a day, operation should be attempted. Horsley limits such 
 trial of internal remedies to six weeks, after Avhich he Avould proceed to opera- 
 tion. A gumma Avhich has undergone a fibrous change and has resisted such 
 vigorous specific treatment is practically a permanent tumor, and Avhether it 
 shall be attacked or not must be determined on precisely the same grounds as 
 any other tumor. Tubercular tumors are more ajjt to be multiple than any 
 other variety, and Ave should therefore hesitate someAvhat more as to them. 
 
 VI. Prognosis. — If an intracranial tumor be not operated upon, it is 
 almost necessarily a fatal disease, Avith the exception of those syphilitic groAvths 
 which yield to the iodides. It is possible that life may be very much prolonged 
 in some fcAV cases, but in the majority a feAv months or a year or tAvo is all that 
 can be expected. Hence, as it is so almost uniformly fatal, and as operation 
 has given very fair results, it is proper that avc should operate, unless the 
 multiplicity, depth, size, etc. present positive contraindications. If Ave operate, 
 the prognosis varies much, first as to immediate recovery, and secondly as to 
 ultimate recovery. 
 
 1. Ah to Immediate Keeovery. — v. Bergmann's statistics (1898) include "273 
 operations for intracranial tumors, of Avliich l<il» (<il.!> ]ier cent.) recovered, 
 and 104 (38.1 per cent.) died. Of these, 157 Avere exjtloratory or ])alliative 
 operations, of Avhich 82 (52.2 per cent.) recovered and 75 (48.4 per cent.) 
 died. The chief reason for the fatality of this last condition has been prob- 
 
niSF.ASES A XT) IXJlliTES OF THF. HEAD. 549 
 
 ably too extensive exploration in search of the tumor or for its removal. If 
 no tumor is found after cautious search by knife, grooved director, and the 
 gentlest use of the little finger, or if, being found, it is not removable, the 
 operation should be terminated at once, especially if there is much bulging, 
 indicating a large tuuu)r. In 14 cases in which trephining was done for the 
 relief of the increased intracranial ])ressure caused by the tumor, recovery 
 followed in all. Probably time, by perfecting both the diagnosis and the 
 operative methods, will enable us to improve upon these results. At the 
 same time, it must always be recognized that an operation for cerebral tumor 
 is a very serious one, not to be undertaken lightly nor Avithout explaining the 
 entire matter carefully at least to the family: the mental condition of the 
 patient may be such that it would be unwise or useless to explain it to 
 him. 
 
 Another important reason for the mortality has been the delay in operating. 
 Physicians, who almost always see these cases first, postpone consulting a surgeon 
 for an unreasonal)ly long time, in the vain hope of improvement. It cannot be 
 too strongly insisted on that we should treat tumors of the brain just as we treat 
 tumors in other parts of the body — as a rule, remove them at the earliest pos- 
 sible moment. In the brain the reasons for early operation are even more 
 cogent, for the soft tissue here is more easily injured, it cannot escape from 
 pressure as do the soft parts not enclosed in such a bony case, and the growth 
 of the tumor is insidious and not easily perceived, as it is when accessible to 
 the eye and the finger. We can only infer its growth from the symptoms. 
 When a tumor is diagnosticated and located with reasonable certainty, if it be 
 probably amenable to operation, its removal by operation should be attempted 
 as soon as drugs have been fairly tried and proved of no avail. The limit 
 for this "fair trial" Horsley, as stated above, puts at six weeks, and cer- 
 tainly this is enough. After that it is but wasting time and imperilling life 
 to wait longer. . Further time only allows of increase in the size of the tumor, 
 with wider infiltration of brain tissue or wider destruction by pressure, and the 
 operative dangers and difiiculties increase with each week or month of delay. 
 If the tumor is not removable, the opening in the skull should not be closed 
 by replacing the bone. This partial operation will often be an immense com- 
 fort. In tumors of the cerebellum operation for their removal has been followed 
 by a fatal result in 15 cases out of 23. Their proximity to the fourth ven- 
 tricle, the tubercula ({uadrigemina, and the pons, Avith the important and vital 
 centers lying there, makes operations in such cases peculiarly hazardous. But 
 great relief can be given by wide removal of the bone, as already stated. 
 
 2. As to Ultimate Result. — If the tumor be malignant, it will return, as a 
 rule. In tubercular or syphilitic tumors the probability of a permanent cure is 
 good. In benign growths recurrence is not to be expected. In estimating the 
 future of such patients it must be remembered that the tumor during its growth 
 has done a certain amount of damage, just as a bullet that has lodged has 
 inflicted a certain amount of injury in its pathway to its resting-place. The 
 removal of the bullet or of the tumor will not affect the damage already done. 
 Hence if an optic neuritis, for instance, has continued long enough to be fol- 
 loAved by atrophy of the optic nerve, it is hopeless to expect that the blindness 
 Avill disappear, though vision may improve greatly even if the tumor has existed 
 for years. So also the paralysis of an arm or a leg from pressure on its center 
 may remain, though in the majority of cases the motor function has been to a 
 great extent restored. If the epileptic habit has been formed, the removal of 
 the tumor will probably modify and may possibly cure the attacks, but they 
 will often persist, though they may be less frequent and milder. 
 
550 AN AMERICA. \ ri'.XT- IK K )k' O/' srL'(;i:i{Y. 
 
 \\\. Treatment. — When it has been decided that the tumor exists in a 
 given locality, and that it is amenable to operation, the o))erative proeedure 
 may be very briefly descrii)ed. 
 
 1. A large semilunar llaj) is made, with the center corresponding to the 
 site of the tumor. 2. A large opening from two to four inches in diameter 
 is made in the skull, the best method being by a large osteoplastic flap. 8. 
 The dura should be opened. 4. The tumor, having ]>een recognized, 
 should be enucleated, if possible, by the ii)igci-. This will very rarely be 
 practicable. If not, the knife, the scissors, the sharp spoon, or the handle 
 of an ordinary teaspoon may be used to remove it, either as an entire 
 mass or piecemeal. 5. If the tumor be subcortical, an incision should be 
 made in the brain and the little finger inserted Avith great gentleness to 
 recognize the resistance, size, etc. of the tumor. When found it is to be 
 removed as before described. 6. If the tumor be so large that it would be 
 unwise to remove it, the operation should be immediately terminated and the 
 dura and llap secured, the bone not being replaced. 7. The operation is 
 often best done in two stages (p. 502). 8. The method of dealing with 
 hemorrhage and the other steps of the operation differ in no wise from those 
 described under the head of Techni((ue. 
 
 XVIII.— EPILEPSY. 
 
 From a surgical point of view cases of epilepsy are either traumatic or 
 non-traumatic. 
 
 I. Epilepsy following Traumatism. — As a rule, the epileptic attacks 
 do not make their appearance until some months or even years after the acci- 
 dent, and the earlier attacks are not only less frequent than the later ones, but 
 are often unattended at first by loss of consciousness (petit mal), and only after 
 a time become fully-developed epileptic attacks. There is reason to believe 
 that even slight accidents may sometimes produce epilepsy, presumably through 
 the agency of a cicatrix in the dura or in the brain. Very often in such cases 
 there will be lesions of motion and sometimes of sensibility, perhaps dating 
 back to the time of the accident. It is probable also that if after compound 
 fracture any portion of bone remains depressed, it may irritate the underlying 
 cortex and cause epilepsy. Similarly, in some cases apparently by reason 
 simply of the presence of the resulting cicatrix, epilepsy may follow. Hence 
 one argument for the radical treatment of such injuries at the time they are 
 received, as has been advocated in preceding pages. The numerous cases 
 reported in the periodical literature of the last few years constitute a very 
 strong reason for the propriety of thus interfering in the way of prevention of 
 the epilepsy, rather than allowing it to set in and then trying to remedy it. 
 
 Sometimes the cicatrix in the scalp is tender or is tlie seat of radiating 
 pains and sometimes of the aura. Pressure on it may produce a fit, although 
 most frequently it will not. Very rarely there will arise from a tramnatism a 
 sarcoma, fibroma, or other form"' of tumor which itself will cause epilepsy. 
 Apparently mere alteration in the texture of the cortical tissue from fatty or 
 other degenerative changes following traumatism may itself give rise to the epi- 
 lepsy. Sir. Ilorsley especially has shown not only that such brain scars, scars 
 in the dura, cysts, fragments of bone, etc., are presumably the cause of such epi- 
 leptic attacks' but also that their removal has resulted in relief and even in cure. 
 In cases of epilepsy arising from traumatism, if the trauma is .'^liown by 
 a scar or by evidence of injury to the bone without a scar, the injury may 
 be, fir-st, over Avcll-known centers, motor or otherwise ; or, secondly, it may lie 
 over the so-called latent zones of the brain. 
 
/> AS AM, SAW A\/> IX.JriilKS OF THE HEAD. 551 
 
 In those cases in •\vliicli tlic lesion lies over well-hiotvn centers and the 
 ei>/Ic/>f/i! Jit is limited to the viKscles corresjxmditiji to these motor centers, 
 the inference is that they stand in tlie relation of cause and effect. But 
 it must always lie remenihered that the irritation of the scar in the scalp 
 is sometimes sufficient to cause the epileptic attacks, and hence, as a rule, the 
 proper course of procedure is to prepare for a complete trephining with the 
 same minute care that has heretofore been described as necessary in cerebral 
 operations; l)ut if an exploratory incision exposing the bone under the scar 
 shows no injury sufficient to make us think the brain is certainly injured, ■\ve 
 should limit the operation to the excision of the scar. Especially Avill this be 
 proper if the scar be the site of tenderness on pressure and of the epileptic 
 aura, or if pressure on the scar produce a distinct fit. In a moderato number 
 of cases now reported in which there existed no fracture of the bono, but only 
 a sear in the scalp, the excision of the scar has been followed by cure. 
 
 Moreover, we must remember such cases as the one related by Briggs, in 
 which a girl had both an old depressed fracture of the skull and necrosis of 
 the tibia. He very wisely first operated on the tibia, and after five years 
 the fits had not recurred, showing that their origin was not in the depressed 
 fracture of the skull, Avhich prima facie was the probable cause, but in the 
 irritation of the tibial disease. We should not, however, be too hopeful if the 
 fits cease immediately after the excision of the scar or after any other ope- 
 ration. It is a strange fact, to which White has recently called renew^ed and 
 especial attention, that any operation, even though trivial, is apt to cause the 
 cessation of the fits for weeks or months ; and hence after removal of the scar 
 we cannot be certain that the epilepsy is cured until at least three years have 
 elapsed without the return of the attacks. The surgeons of the largest expe- 
 rience are probably the most cautious in drawing too favorable conclusions. 
 
 If excision of the sear does not cure the patient, and the scar lies over the 
 motor center which corresponds to the initial muscular spasm, and still more 
 if there is evidence of any depression of the skull or of an old compound 
 fracture, a second operation should be done and the patient be trephined. 
 The lesion rarely will be a splintering of the inner table, sometimes with a 
 depressed fragment of bone ; sometimes a cyst following a blood-clot, or not 
 uncommonly simply a brain scar, with generally a corresponding cicatrix in 
 the dura. Occasionally, hoAvever, nothing more than thickening and eburna- 
 tion of the bones of the skull will be found. 
 
 After trephining the skull, the dura should always be opened, even 
 though it be sound, in order to inspect the brain. If there be a scar in the 
 dura, it must be excised, and if there be one in the brain, it should also be 
 excised down to the white tissue. In such cases it is of the utmost importance 
 to remember that all the damaged brain tissue must be removed. It is better 
 even to trench somewhat upon apparently healthy brain tissue, for the removal 
 of a little more tissue than is necessary is preferable to the opposite error of 
 removinof less than is necessary, with possible retention of the epileptic fits. 
 In effecting this removal it is important also to remember that we can extend 
 our incisions in the antero-posterior direction much more freely than we can in 
 the vertical direction, for extension in the vertical direction means involve- 
 ment of other motor centers, whereas extension antero-posteriorly will prob- 
 ably merely add to the completeness of the removal of the injured center. It 
 is not, as a rule, necessary to go deeper than the gray substance, unless we 
 find evidence of a scar or other lesion at a greater depth. Care must be 
 taken to arrest the hemorrhage, as has been already mentioned in the section 
 on Technique, the ligature being the chief reliance, and pressure and hot 
 
552 -l.V J.l//;A'/r.i.V THXT-ltnOK OF srUdFUY. 
 
 water coming next in efficiency. Lai<re veins should be lijrated before 
 division, or, better still, should be avoided, as is often possible, by going 
 around them or by lifting them and working under them. If any of the dura 
 has been removed, its place should be supjilied. as has been suggested, by a 
 bit of the pericranium. This is especially important in cases where the brain 
 has been incised, so as to avoid a fungus cerebri. Drainage, as a rule, may 
 be omitted. The bone should not be replaced if it would probably product 
 pressure on the brain. (Otherwise it may be put back, not only the large 
 piece removed by the trei)hine, V»ut a number of the small pieces as well. All 
 these should have had the cai-e described in the section on Technique, in order 
 to preserve their vitality. If the bone is diseased, of course it should not be 
 replaced, nor if it is irregular and would produce irritation or pressure. Pos- 
 sibly experience may show that it is best not to replace it at all ; this is yet an 
 open question. 
 
 In those cases in which the lesion does not lie over well-known centers 
 of motion, special senses, language, etc., but over the latent zones, the scar 
 should still be excised as above advised, but the surgeon should always be 
 prepared to do a complete brain operation as well as simple excision of the 
 scar, for he can never tell how far it may be wise to extend the operation until 
 after he has lifted the scalp an<l inspected the bone. If excision of the scar, 
 as before, does not effect a cure, and there is distinct evidence, as above stated, 
 either of fracture or of irregularity of the bone, or if the scar is tender or the 
 seat of an aura, or if a fit follows pressure upon it, trephining should be 
 done. Once the bone has been removed, the dura should be opened, and then 
 what is to be done either to the dura or to the brain must depend on what is 
 found. Any dural scar, brain scar, altered brain tissue, or cyst should be 
 treated by excision. Sometimes in cases of compound fracture trejdiining will 
 have been done at the time of the accident and yet epilej)sy will develop later. 
 In such cases, whether the lesion be over the motor or other well-known cen- 
 ters or over the latent zones, as a rule it will be proper to lift a flap of scalp, 
 enlarge the bony opening if necessary, and examine the brain. Trimming the 
 thickened bone away from the edges of the opening left by a compound frac- 
 ture or a former trephining, or the removal of any of scar tissue, will often eff"ect 
 a great improvement, and in some cases even a cure. Secondary operations of 
 this kind have sometimes proved very successful. In all such operations as 
 this it must be remembered that if we undertake an operation at all it must.be 
 done thoroughly. A large trephine may be used, one and a half inches in 
 diameter, or else several small trephine openings should be made, and enough 
 of the bone between them be removed to enable us to see the brain tissue well. 
 Timidity in this respect will often result in a fruitless operation where a bolder 
 course might have achieved success. In operations on the brain it is always 
 important to have plenty of room for inspection of the brain, for determination 
 as to what should be done, and for facility in dealing with hemorrhage. 
 
 In all cases of epilepsy it is important that the operation should be done at 
 an early date, in order to prevent secondary sclerosis and the formation of the 
 epileptic habit, a point on which Sachs has laid especial stress. 
 
 II. NON-TRAUMATIC EPILEPSY. 
 
 1. Jacksonian Epilepsy. — This term is applied to tho.?e cases of epilepsy 
 in which there is spasm of a certain limited group of muscles u'ithout loss of 
 co7isciousness. and in which, therefore, the discharging lesion seems clearly to 
 be limited to the center corres]K)nding to the muscles involved. In a number 
 
DISEASES A\l> IXJf'lilES OF THE HEAD. 553 
 
 of sucli eases these centers liave been exposed, then recognized by the battery 
 as already tiescril)ed, and tlic entire area excised. The time has not yet come 
 when a definite opinion can be expressed as to tlie value of these operations. 
 The dan<:er to life is not very great. A large number of the cases iiave not 
 been bettered, but in many great relief has followt-d both in diminished severity 
 and diminished frequency of the attacks. 
 
 Some cases have been reported in which momentary faradization of the 
 coi'tical centers which are evidently diseased has produced a fit entirely analo- 
 gous to the typical ej)ileptic fits to which the patient has been a victim. Such 
 momentary faradization of a normal cortex should produce only a single move- 
 ment of the part supplied by that portion of the cortex. Whether this will 
 be of value in determining that a cortical centre which appears to the eye and 
 touch to be healthy is really diseased, is a matter to be decided by.a larger 
 experience. 
 
 The question naturally arises whether this excision will not ])roduce palsy 
 of the muscles supplied by this center. Complete j)riniary paralysis of these 
 muscles always follows such removal, and not uncommonl}* the pressure of the clot 
 or of the exudate formed after the operation will paralyze neighboring centeis, 
 so that there may be complete hemiplegia in many cases resulting from simple 
 excision, for instance, of the arm center. But it is an invariable rule that this 
 hemij^legia is but temporary. After a few Aveeks tlie patient will begin to re- 
 gain control over the muscles, and eventually he will regain motion in its entire 
 ranore, but usually with some lessened muscular strength : that is, there is a 
 certain paresis remaining. Whether this regain of muscular control is due to 
 the cortical center on the opposite side of the brain taking up the work of the 
 lost center (as the left hand may take up the work of the right after amputa- 
 tion), or to a regeneration of brain tissue, is at present in doubt, with perhaps 
 a preponderance of testimony against regeneration of the cerebral tissue. 
 Experimental transplantation of brain tissue itself from one animal to another 
 has been done with good results from an operative point of view. Whether 
 this can ever be applied to man is unknown. 
 
 One precaution is very essential in these cases. Many patients will describe 
 A fit of the Jacksonian type (without of course using this term), which descrip- 
 tion a closer observation will show to be wholly erroneous. In fact, so ab- 
 sorbed are the relatives of an epileptic in seeing that he does not injure him- 
 self, and in sympathetic care for him, that in most cases they are the worst pos- 
 sible witnesses as to the character of the attacks. Hence no patient should be 
 operated on for epilepsy unless his attacks have been seen either by the surgeon 
 himself or by a competent and trained nurse — if possible, one who has been 
 accustomed to observe such fits. Members of the family, moreover, are not 
 trained observers, and for scientific accuracy such training is essential. It is 
 essential that the nurse should be instructed by the surgeon to do absolutely 
 nothing but observe and immediately record the phenomena observed in each 
 fit. Cold, hard, scientific facts are what we want, not sympathetic statements. 
 In true Jacksonian epilepsy the patient himself, if a reasonably careful observer, 
 can give much help, because he does not lose his consciousness. 
 
 The observations above referred to should cover, first, what muscles are first 
 involved, and, secondly, the march of the fit ; that is to say, the fit having 
 .started at such and such a point, whether it extends to other points in any 
 definite order, and whether this order is the same in difi'erent fits. Thirdly, 
 the state of the pupils should be very carefully observed, Avhether dilated or 
 contracted, whether equally so, whether responsive to light stimulus, etc. 
 Lastly, as soon after an attack as the patient is capable of using the dyna- 
 
554 A\ A. \/ /:/:/< A. \ ■iiixr-iKKtK of srn(;r:in\ 
 
 monieter it should ])e iMiiployed to (letennino tlie comparative .stron(;tli of the 
 muscles, especially of those first involved, which in such cases are apt to be 
 paretic in conserinoncc of oxhaustion from the spasmodic motion. 
 
 2. Focal Epilepsy. — In a certain number of cases in which llicrc has 
 been no lesion of which there was evidence by scar, depressed bone, or other 
 3if];ns, in which there were unconsciousness and general epileptic spasm instead 
 of monospasm [e. //. of an arm or a le;:), but the attacks always began in a certain 
 set of muscles, as if they always had their orin;in from the cerebral center 
 dominating these muscles as a focus, from which they radiated to other centers, 
 an attempt has been made to prevent their recurrence or extension by removing 
 the center corresponding to the muscles in whicli tlie fits start. In these cises, 
 even more possibly than in those of the Jacksonian type, it is necessary to 
 have reliable and repeated observation of the attacks before deciding to operate. 
 Even with the diminished dangers of modern cerebral surgery, exposing the 
 brain, and especially excising a cortical center, is not a trifling operation, but 
 a serious one, which must not be undertaken without the best evidence of its 
 necessity. No member of the family, no friend, no one but a trained observer, 
 must be trusted to determine these facts. The testimony of the family may be 
 taken as a corroboration, but not as a foundation. Moreover, it has been Veil 
 pointed out by Putnam that the value of spasms starting in the bands is not sa 
 great as where the spasm begins in a less easily disturbed part, as the elbow or 
 the shoulder. The finger motions are highly specialized, and therefore tlieir 
 equilibrium is much more easily disturbed than, so to speak, the more phleg- 
 matic, coarser, better-balanced muscles of the larger joints like the shoulder. 
 If, therefore, in focal epilepsy the muscles of the shoulder are those first 
 involved, the spasm extending from the shoulder finally over the whole body, 
 such a case is far better suited to operation than one in which the more easily 
 unbalanced mtiscles of the hand, thumb, etc. are the site of the initial spasmodic 
 movement. In other words, the equilibrium of the hand is more easily disturbed 
 than that of the shoulder, and is therefore of less value as a factor in determining 
 us in favor of operation. Results seem thus far to indicate that in a small per- 
 centage of cases, which can scarcely as yet be stated numerically, a cure may 
 possibly be effected. In a number of cases, much larger than in the last class, 
 considerable improvement will follow ; in an equal or still larger number no 
 betterment Avill follow. The operation, however, does not seem ever to produce 
 an increase in the number of attacks. The percentage of deaths in the reported 
 cases is not large, yet danger is a factor in the decision of the question wliether 
 an operation shall be done or not, which must on no account be omitted in the 
 statement of the case to the patient and the family. Epilepsy is so direful a 
 disease that there are few parents or patients who would not be willing to face 
 a large risk to life for the reasonable probability of betterment, and still more 
 if there be a chance of cure, however small: and tliey are all the more willing 
 when there is but slight cliance of death and none of beinsr made worse. 
 
 In these cases it is especially important always to make a large opening in 
 the bone, in order, if possible, to recognize the convolutions. When the brain 
 is exposed, no antiseptics should touch it until the battery has well defined the 
 center which is to be identified and removed. In faradizing the brain the cur- 
 rent required is about that which is necessary to call the muscles of the thumb 
 into action, and stronger currents should be avoided : although no serious 
 injury to the brain has thus far been reported as a result of such faradization, yet 
 its possibility should lead us to use as gentle a current as will effect our object. 
 The faradization should not be repeated any oftener than is necessary. 
 
 Horsley has especially insisted here on thoroughness of excision. If any 
 
j>/s/:as/:s .im> /.v./ r /.•//•>• or ////■: jihad. o5r> 
 
 of the ceiitor be It'ft, the operation -will probably prove a failure. "When the 
 center sought for lias been found and its limits determined, any large veins 
 involved in its excision should first be tied, and then the center limited by 
 incisions made with a sharp knife held vertically to the surface. This should 
 penetrate to the white substance. The cortex may then be removed either by 
 scissors or by knife. Sometimes "vvo can strip off" or push away the pia and its 
 vessels from the underlying convolutions, and so avoid wounding any large 
 vessels. It will rarely, if ever, be necessary in cases of focal epilepsy to 
 remove any of the dura. After the excision, therefore, this should be care- 
 fully re])laced and secured ])y sutures, and the operation terminated as hereto- 
 fore described. 
 
 Unfortunately, the large majority of cases of epilepsy belong rather to 
 so-called general epilepsy than to focal, Jacksonian, or traumatic. Such 
 cases are evidently unsuited to any operation, and in our new-born boldness, 
 begotten of success in cerebral surgery, Ave should not overstep the limits of 
 prudence and operate indiscriminately and unwisely. Each case of epilepsy 
 must be studied by itself for days, and sometimes even for weeks, before we 
 reach a definite conclusion that it is wise to operate. The surest way to dis- 
 credit cerebral surgery is to practise unwise cerebral surgery. Hence, while 
 advocating a more radical treatment than that formerly thought to be wise, we 
 must be careful not to proceed to the opposite extreme of indiscriminate opera- 
 tive interference. A progressive conservatism, if the term is allowable, should 
 be our rule. 
 
 XIX.— TREPHINING FOR INVETERATE HEADACHE, INSANITY, AND ARRESTED 
 
 DEVELOPMENT. 
 
 I. Inveterate Headache. — Occasionally headache will be fixed in its 
 locality and of an excessively severe type, so that it will interfere seriously 
 Avith the patient's health and happiness, and may even make any occupation 
 impossible. The cause of such a headache is often traumatism, resulting in 
 disease of the bones. The possible existence of hysteria, gout, or syphilis 
 should always first be considered, and the family and personal history there- 
 fore should be investigated Avith great care. As a rule, especially in the case 
 of a hysterical Avoraan, we should refuse to undertake an operation until a 
 thorough trial of all the remedial means at our command for such diseases has 
 been carefully made by a competent neurologist. If then no relief has been 
 afforded, in view of the very small risk to life involved in simple trephining it 
 is proper that it should be done. Trephining having been done, it is better, 
 usually, to open the dura and inspect the brain, even if nothing further be 
 attempted. It is not Avise, as a rule, to go so far as to trephine a patient and 
 then neglect the information which may be derived from the simple opening 
 of the dura. Properly done, this adds practically little to the risk and may 
 add immensely to our knoAvledge. If nothing is found, the dura should be 
 sutured in place, Avithout replacement of the button of bone. 
 
 II. Insanity and other Mental Disturbances. — The most remarkable 
 case in Avhich a psychical disturbance has given a clue to the diagnosis is 
 reported by Macew'en. The man had been injured, and a year later suffered 
 from melancholia and a tendency to homicide. There Avere no motor phe- 
 nomena Avhatever, but it Avas discovered that for tAvo Aveeks after the accident 
 he had suffered from the form of apraxia called mind-blindness. Vision was 
 perfect, but Avhat he saAV conveyed no impression to him. His NeAv Testament 
 was recognized by touch, but on opening it the printed words had no mean- 
 
556 .l.V AMKHIVAX TEXT-IK )(>K OF Sl'liCERY. 
 
 ing for him. A lesion in tlie angular gyrus was diagnosticated, and on ope- 
 rating it was found that a portion of the inner table had been detached and 
 was pressing on the suj)rauiarginal and angular convolutions. 1'lie man made 
 a good recovery. This case is cited es])eeially as an indication of how a 
 minute, painstaking investigation of the history of an injury and its sequels 
 may prjve to be of the greatest value in locating, and therefore in relieving, 
 the disorder. The number of cases of insanity after injury is very consid- 
 erable, and operation is certainly justifiable in such cases if in any, provided 
 there be reasonable indications not only of an injury, but also of such connec- 
 tion between the injury and the insanity as would show that the injury stood 
 in a causal relation to the mental disturbance. It would be folly, for instance, 
 to trephine for an injury received after the insanity began unless there were 
 independent reasons for doing so, such as paralysis, etc., as a direct result of 
 the injury. Mr. Claye Shaw has recently trephined also in cases of general 
 paralysis of the insane, but the number of cases is too small and the time since 
 the operations too brief to give any data for an opinion Avhether the operation 
 is wise and will do any good. 
 
 III. Arrested Development. — If the cause of the arrest of develop- 
 ment be traumatic, something may be done with a hope of relief, as in a remark- 
 able case of Dr. Felkin and Mr. Hare in Avhich a girl of seventeen had sustained 
 fracture of the skull at the age of ten months, followed by pai-alysis and im- 
 perfect development of the right arm and leg. A cyst was found two inches 
 in depth, Avith an osteophyte half an inch long. This existed outside the dura, 
 which was not opened. The operation Avas followed by marked improvement. 
 
 Where, however, the arrest of development is congenital, the cause has 
 undoubtedly arisen during intra-uterine life, and there is serious doubt whether 
 any good will follow operation in such cases. As has already been indicated 
 under the head of Microcephalus, it is possible that a certain number of cases 
 of general arrest of development of the brain itself in size may be benefited by 
 a linear craniotomy. As a rule, however, in cases of arrested development of 
 intra-uterine origin, with the exception perhaps of microcephalus. it is undoubt- 
 edly wiser not to operate, as operation simply exposes the patient to danger with- 
 out any reasonable hope of improvement. 
 
SURGERY OF THE SPINE. 557 
 
 CHAPTER 11. 
 SUEGERY OF THE SPINE. 
 
 The general anatomical considerations in relation to the spine whicli 
 influence the diagnosis and treatment of its various diseases and injuries may 
 be briefly summarized as follows : 
 
 It supports the weight of the head, connects the bones of the thorax with 
 those of the pelvis, forms a bony canal for the reception of the spinal cord, 
 gives a basis of support and attachment for the ribs, and, owing partly to its 
 curves and partly to the fact that it is made up of so large a number of 
 bones with the intervertebral disks interposed between them, it lessens in a 
 very remarkable manner the effects of shock transmitted to it from various 
 parts of the body. 
 
 The normal curves of the column are three in number, and are all antero- 
 posterior. In the cervical region the normal curve is convex in front ; in the 
 dorsal, the convexity is posterior ; in the lumbar, the convexity is again ante- 
 rior. These curves'^ are maintained largely by the varying thicknesses of the 
 intervertebral disks and partly by the diff"erences in the vertical thicknesses of 
 the bodies of the vertebrse. 
 
 On each side of the spine are powerful muscles which run longitudinally, 
 the tendons of which are inserted into the processes of the vertebrse. These 
 muscles maintain the body in an erect position, and when in a condition of 
 health preserve the vertical position of the spine by preventing it from 
 inclining to one side or the other. The spinal cord, which is usually about 
 seventeen or eighteen inches in length, does not fill the spinal canal, but is 
 separated from the walls of the latter first by its investing membranes, and 
 then by some loose connective tissue containing a plexus of large veins. It 
 extends in the adult from the upper border of the first cervical vertebra to the 
 lower border of the first lumbar vertebra, where it ends as a slender prolonga- 
 tion of gray substance extending into the filum terminale. 
 
 The membranes of the cord consist of the pia mater, or vascular membrane 
 closely embracing the surface of the cord itself, the arachnoid, separated from the 
 pia mater by an interval known as the subarachnoid space, and the outermost 
 membrane, the dura mater, separated from the arachnoid by an interval known 
 as the subdural space. The arachnoid and dura mater are here and there con- 
 nected by areolar tissue, but for the most part are simply in contact, the cerebro- 
 spinal fluid keeping the arachnoid in close relation to the under surface of the 
 dura. The cord is steadied in the spinal canal largely by means of the nerves which 
 find exit through the intervertebral foramina on each side of the spinal column. 
 The anterior or motor roots are the smaller of the two ; the posterior roots, 
 which are sensory, are composed of finer filaments, and each root bears a gan- 
 glion which is situated in the intervertebral foramen just external to the point 
 where the nerve perforates the dura. The roots of the spinal nerves on leaving 
 the cord do not pass out directly at the same level, but run obliquely downward, 
 
55 ^i 
 
 JT AAf/./>'/(A.\ Ti'.xr-iiooh' or sf /,'(;/■: /i'v 
 
 so that the point at which a particiihir nerve emerges fVom the coid is r<,u. 
 siderahly higher than the point :it whicli it emerges from the s|)i:ial column, 
 this (lifierence of level increasing from ahove downwarfl. For exanijde. the 
 eighth dorsal nerve emerges from the spinal cord opposite the seventh dorsal 
 vertehra, hut from the spinal coluuui hetwcen the eighth and ninth dorsal 
 vertehr;e. These anatomical and ])hysiological facts will serve to make 
 somewhat clearer the descriptions of the various diseases and injuries of 
 the spine and of spinal operations. 
 
 r()N(iENITAL DEFOliMlTIES. 
 
 Spina Bifida. — The chief congenital deformity associated with the spine 
 is due to an arrest of development, owing to which the symmetrical halves of 
 the spinal column fail to unite, leaving a more or less considerahle space be- 
 tween them. The gap may extend completely through the bodies of the ver- 
 tebr;v\ or may be limited to the arches and the spinous processes; the latter 
 
 Kio. 232. 
 
 Spina Hifida (original). 
 
 is the more common. The lum))ar portion is the part chieHy affected, 50 per 
 cent, of all cases occurring in this region. 12 per cent, in the lum))o-sacral. 
 and 27 per cent, in the sacral. As the result of this deficiency the mem- 
 branes of the cord are pressed through the opening, forming a tumor 
 known as spina bifida (Fig. 232), on account of the condition of the 
 spine which gives rise to the deformity, and as hydrorhachis, on account 
 of the fluid contained in this tumor. The latter varies in size from that 
 
srnaKnv or Tin: spixk. 559 
 
 of a walnut or of a closed fist to tliat of a child's iicad. It is s(jiiiotimes 
 covered with skin nonnal in color and aj)})earance, but oftener the skin is thin 
 and translucent, or it may he entirely absent, in which case the tumor will 
 have a raw, florid a])pearance. The true sac of the tumor consists of the mem- 
 branes of the cord blended to«^ether and enclosing a liquid which is ordinarily 
 the cerebro-spinal fluid. It usually comnmnicates directly with the brain, as 
 in the normal condition, through the opening in the pia mater at the lower 
 border of the fourth ventricle. Pressure on a tumor of this variety w ill there- 
 fore sometimes cause stupor by increasing the pressure upon the brain. The 
 cord is variously situated as regards the sac, being sometimes in front, some- 
 times behind, and sometimes spread out as a thin layer upon its internal 
 surface. When the protrusion consists only of membranes and fluid, it is 
 called a spinal meningocele; Avhen it contains a portion of the cord also, 
 it is called a meningo-myelocele. When the central canal of the spinal 
 cord is dilated, forming the cavity of the sac, the tumor is called a syringo- 
 myelocele or syringo-myelia. The second of these is by far the more 
 common. 
 
 The diagnosis of this condition may be made by observing the follow- 
 ing points : 1. The tumor is congenital. 2, It occupies a central position, a 
 peculiarity which characterizes most tumors of intraspinal origin. 3. It may 
 probably be reduced by gentle pressure, or at least greatly diminished in size, 
 the diminution being attended with increased tension of the fontanelle, and 
 sometimes with stupor, convulsions, or other nervous symptoms. 4. The bony 
 margin of the gap in the spine can often be felt at the base of the tumor. 5. 
 The tumor becomes more tense when the child cries or coughs. 6. It is often 
 translucent, and when so an opaque band or bands, consisting of the spinal 
 cord and nerves, may sometimes be seen upon the inner surface of its wall. 
 7. It is apt to be associated with other deformities, such as hydrocephalus or 
 talipes, or with paraplegia, vesical or rectal paralysis, etc. 8. The cutaneous 
 covering of the tumor is often absent. 
 
 Occasionally some of these symptoms may exist and not others. We may 
 have a congenital tumor situated over the middle of the spine, fluctuating and 
 with thin and translucent Avails, but not perceptibly afiected by the coughing or 
 crying or straining of the patient, and not associated with hj^drocephalus or club- 
 foot or paraplegia. In this case the tumor is probably a meningocele, in which 
 the communication wnth the spinal canal has been shut off". The usual course 
 of such cases is toward death, which commonly occurs within six or eight 
 months ; spontaneous cure occasionally, but rarely, happens, the vertebral arches 
 growing and developing, and the neck of the sac correspondingly contracting, 
 and finally becoming shut off" from its communication with the canal. Oftener, 
 however, the integuments and membranes over the tumor ulcerate, the con- 
 tents of the sac escape, and frequently the child dies in convulsions or will 
 perish soon afterward from a septic meningitis following infection through the 
 ulcerated tract. 
 
 Treatment. — If the tumor is small, covered with sound skin, and not 
 growing rapidly, it should be enveloped in raw cotton and supported by a very 
 loosely-fitting elastic bandage ; or gutta-percha may be used as a binder ; or a 
 layer of cotton brushed over with collodion may be applied to its surface. There 
 is a chance by this method that the tumor may shrink and disappear. The out- 
 look is seldom encouraging, as even in the most favorable cases the child is small, 
 poorly nourished, and, as -has been said, is apt to have paralytic compli- 
 cations. 
 
 A number of successful cases of excision have been reported, and recently 
 
nnO AX AMKIUCAX TEXT- HOOK OF SVUdKliy. 
 
 Bayer has rcviowetl tlio whole subject, and rejects the use of the seton, 
 the injection of iodine, and the excision of a part of the sac, as being at the 
 same time unsatisfactory and dangerous. lie urges tliat the condition is one 
 anah»g()us to liernia and should be treated in a somewhat similar manner; 
 that the danger of meningitis in the one case is no greater than tlie dan- 
 ger of peritonitis in tiie other ; and that, as compared with the operation 
 above mentioned, it is both safer and more radical. In one case he operated 
 in the following manner : Two lateral flaps were made from the skin covering 
 the tumor and were dissected down to its pedicle, and the sac of the meningo- 
 cele was opened. The cauda equina was seen flattened out on the posterior 
 wall of the sac. It was loosened after dilatation of the incision, and was 
 replaced in the spinal canal. The sac of the meningocele was then removed, 
 leaving oidy tw'o lateral flaps of the dura, Avliicth were sewed together after 
 thorough antiseptic cleansing of the wound. The muscles and skin were after- 
 ward brought together separately. The case was successful. In some 
 instances the rudimentary arches of the defective vertebr.c have been divided 
 at their bases l)y bone-forceps or a chisel and mallet, and displaced toward 
 the middle line so as to close the bony defect. IJobroff accom])lislied the 
 closure of a defect in tlie sacral region by chiselling loose a ])ortion of the 
 adjacent ilium, and turning the fragment over as upon a hinge to cover the 
 opening. 
 
 Ilildebraml has collected 87 cases of excision with 23 deaths, a mortality 
 of 26.4 per cent. Unquestionably, operative measures, especially in men- 
 ingocele, are gaining ground in the estinjation of surgeons. 
 
 Should the case be unsuitable for excision, the injection of Morton's 
 fluid may be tried as follows: the sac being cleaned, a syringe which will 
 hold about 2 drams of an iodo-glycerin solution (iodine, 10 grains; iodide 
 of potassium, 1 dram; glycerin, 1 ounce) is chosen, and a moderately fine 
 trocar. The puncture in the swelling should })e made well to one side, 
 obli(|uely through healthy skin, and not through the membranous sac-wall, 
 the objects being to avoid wounding tlie cord or nerves and to diminish 
 the risk of leakage of the cerebro-spinal fluid. Unless the sac is very large, it 
 is probably better not to draw off" much, if any, of the fluid on the first occasion. 
 The child should be laid upon its side. About a dram is the quantity recom- 
 mended to be injected. Care must be taken to prevent escape of the cerebro- 
 spinal fluid, because any leakage may lead to septic meningitis and death. When 
 the needle is withdrawn the tissues should be pressed around it and the little aper- 
 ture immediately painted with collodion and iodoform and covered by a dressing 
 of dry gauze secured with collodion. A little chloroform may be given, to pre- 
 vent any crying and straining at the time. The child should \)Q kept as (juiet as 
 po8sil)le afterward, on its side, and an assistant should make sure, for the first 
 hour at least, that no leakao;e is ffoinjf on. Shrinkin<x of the cvst, settint; in 
 ra{>idly and continuing steadily, shows that all is well. If the injection fail 
 altogether or cause only partial obliteration of the sac, it should i)e rejjcated 
 at intervals of a week or ten days (Jacobson). 
 
 SPINAL TUMOES. 
 Congenital tumors other than spina bifida are found chiefly in the sacral 
 region, and may be of various kinds. Lipomata sometimes here attain a 
 very large size, and occasionally spring from the interior of the spinal canal. 
 Dermoid cysts, containing the usual contents, hair, sebaceous matter, etc., 
 are not infret^uent, and may communicate with the rectum or the bladder. The 
 
SmOKRY OF THE SPINE. 561 
 
 so-called congenital sacral tumor is a large mass occurring in the region 
 of the coccyx, .sonictinies peilunculated and made up of cysts of various sizes, 
 often lined with columnar ej)itlieliuni and filled Avith a viscid, gelatinous mate- 
 rial. Foetal tumors of all sizes may ))c found in the sanu' region, and may 
 contain iiicrclv masses of the different tissues or a considerable and Avell-devel- 
 oped portion, a limh or a trunk, of the foetus incorporated with the individual 
 who bears it. 
 
 All these growths may be treated by excision, although, as their extent is 
 often uncertain 1)efore operation, great caution should be exercised. 
 
 Tumors of the spinal cord itself may be either intra-medullary or extra- 
 medullary, and are of great variety. The diagnosis will usually be made by the 
 neurologist rather than by the surgeon, but it is proper to give a brief outline 
 of the general diagnostic points which it will be necessary to bear in mind 
 before deciding upon or rejecting operative interference. In the first place, it 
 will be re([uisite to determine whether the symptoms are due to pressure on the 
 cord or to inflammatory or other changes involving primarily the structure of 
 the cord itself. If, in a case of paraplegia, there is the history of a very 
 gradual onset beginning with pain and followed first by motor paralysis and 
 then by sensory paralysis ; if the symptoms are irregularly unilateral ; if the 
 pain has first seemed to be neuralgic or rheumatic and burning and shoot- 
 ing in character ; if the anesthesia and pain in the lower limbs ascend grad- 
 ually from the soles of the feet toward the trunk ; and if at the same time 
 there is a constant dull ache in a distinct segment of the spinal column, accom- 
 panied by a feeling of weakness at that point, much heightened by fatigue, — 
 we have a group of symptoms pointing strongly in the direction of a neo- 
 plasm. In addition, it would be found that at first the reflexes,^ both deep and 
 superficial, were much exaggerated, becoming gradually lost as destruction of 
 the cord with descending degeneration and wasting grew more marked, the 
 abolition of the reflexes beginning, as in the case of the pain and anesthesia, 
 in the plantar region and passing gradually upward. 
 
 Later in the disease we have the development of spasms with clonus, which 
 are most marked in the intradural cases, as is also the symptom of rigidity. 
 Local nutrition is not usually impaired ; tenderness of the spine on percussion 
 when it occurs in the dorsal region appears to be lower than the tumor pro- 
 ducino; it : in the cervical region this si;eneralization does not seem to hold so 
 closely. The feeling of stiffness and weakness Avill usually be found to corre- 
 spond to the position of the tumor. Lateral curvature of the spine is a 
 secondary result of the tonic spasm of the spinal muscles, and therefore the 
 concavity of the bend is on the same side as the growth. The pupils are not 
 affected, except when the cord is pressed upon above the level of the second 
 dorsal nerve. 
 
 The age of the patient, judging from Mr. Horsley's tables, throws but little 
 light upon the diagnosis of tumor, as we find lipomata occurring at an average 
 age of two and a half years, sarcomata at eighteen years, echinococcus at thirty- 
 four years, tubercle at thirty-nine years, scirrhus and myxoma at forty-eight 
 and fifty-three years. These figures apply to extradural growths. In the case 
 of intradural groAvths we have tubercle at eighteen and a half years, myxoma 
 at forty-three yeai's, fibroma at forty-four years, sarcoma at forty-one, psam- 
 
 ' By a " reflex " is meant an involuntary muscular response to certain irritations of the skin 
 (superficial reflex) or of the muscles (deep reflex), or, as it is often called, " tendon-reflex." The 
 commonest example of a superficial reflex is the movement of the leg upon tickling the foot- 
 sole ; the best instance of a deep reflex is the " knee jerk," or sudden extension of the leg fol- 
 lowing a tap on the ligamentum patellae. 
 36 
 
502 AN AMi:ni(AX TEXT-nOOK OF SVRCEIiV. 
 
 Uioma at fifty-one years. It will be seen, therefore, that while a<!;e may be of 
 use in excluding certain forms of growth, as, for example, tubercle in intra- 
 dural growths in persons beyond thirty years, it is of but little value in de- 
 ciding the general (juestion as to the j)resence or absence of a neoplasm. 
 
 Tins sketch of the ])rincij)al symj)toms makes a tolerably distinct clinical 
 picture, but one which is, nevertheless. lial)le to great variation, and therefore 
 difficult to difll'rentiate from that of certain conditions of the cord, some of 
 which are due to causes quite beyond the reach of operation. The chief of 
 these are — spinal hemorrhage, extra-medullary or intra-medullary ; pachymen- 
 ingitis externa, from caries ; chronic transverse myelitis ; jjriniai-y lateral 
 sclerosis or spastic ])araplegia ; hypertro{)hic cervical meningitis. 
 
 Having decided in any given case that the symjjtoms arc ])robubly due to 
 tumor, the interesting question, whether it is within or outside the membranes, 
 will still remain to be settled. The best general guide will be found in the 
 fact that the symptoms of intra-medullary growths are chiefly those of motor 
 and sensory impairment, while the extra-medullary growths produce much more 
 markedly irritative effects, as, for example, pain, spasms, etc. In the j)resence 
 of a paralysis of gradual development, preceded by long-continued signs of 
 nerve-irritation and w ith a distinct unilateral element, the transference of paral- 
 ysis from one to the opposite limb having been effected slowly and after a 
 considerable interval, the diagnosis of compression of the cord by some cause 
 outside of its own structure would seem warranted. Aneurysm might be 
 excluded in the absence of the characteristic physical signs and of evidence 
 of erosion of the spinal column ; gumma would be accompanied by a history 
 of syphilis, would often be associated with other and recognizable specific 
 lesions, and would possibly yield to the use of iodide of potassium : a new growth 
 (cancer or tubercle) in the bodies of the vertebrae themselves generally causes 
 a perceptible deformity. By attention to the points which have been men- 
 tioned a tolerably correct opinion may be arrived at. 
 
 Prognosis. — All the evidence which we now have points to extraordinary 
 reparative power on the part of a cord which has simply been suffering from 
 compression, and to an almost equally remarkable tolerance to operative inter- 
 ference. The material for finely differentiated prognosis can hardly yet be 
 said to exist, but in a general way it is safe to say that the diagnosis of 
 tumor (if it be non-malignant) carries with it a reasonably favorable prog- 
 nosis, which is strengthened if, in addition, the tumor is thought to be extra- 
 medullary. 
 
 As a result of these considerations it seems proper that every case of focal 
 spinal lesion thought to depend on a tumor, and not distinctly a malignant and 
 generalized disease, should be regarded as amenable to operative interference, 
 at least of an exploratory character, no matter how marked or how long con- 
 tinued the sym])toms of pressure may have been. The operation is ]»racti- 
 cally identical with tiiat of resection of the laminte. (See p. 585.) 
 
 Neuralgia. — In some cases of intractable brachial neuralgia, and in others 
 of spasms with violent neuralgic pains in the region supplied by the lumbar and 
 sacral nerves, intraspinal section of the posterior roots has been performed. The 
 operation has been done in five cases, in two of them with some improvement, 
 in the others without much success. It should certainly for the present l)e 
 reserved for cases in which it is desired to verify a doubtful diagnosis, or for 
 those in which the pain is so great and so little aff'ected by other treatment as 
 to justify so serious an operation. It may be performed by following the direc- 
 tions for resecting the arches and opening the dura in the manner described on 
 page 585. 
 
SURGEIiV OF THE SPIXK. 
 
 563 
 
 SPINAL CURVATURES. 
 The more common pathological curvatures of the spinal column are three 
 
 in nil 
 
 niber 
 
 Fig. 233. 
 
 Scoliosis, or lateral curvature ; Kyphosis, or Excurvation, an 
 antero-posterior curve "svith the convexity backward ; and 
 Lordosis, or Incurvation, an antero-posterior curvature Avith 
 the convexity forward. 
 
 Lateral Curvature. — In scoliosis the spine describes 
 two or more lateral curves with their convexities on oppo- 
 site sides of the longitudinal axis of the back (Fig. 233). 
 The vertebrae of the region involved are also otherwise 
 changed in their relations to the same axis, being rotated 
 so that their spinous processes point toward the concavities 
 of the lateral curves (PI. XY, Figs. 3 and 4). 
 
 Varieties. — The most common curvatures are those in 
 the upper part of the dorsal region with the convexity to 
 the right side. The second or compensatory curve is in 
 the lumbar region with its convexity toward the left (PI. 
 XY, Figs. 1 and 2). In marked cases a third, also com- 
 pensatory, may form in the cervical region, and will also 
 have its convexity on the opposite side from the original 
 curve. Occasionally four or five curves may exist, recip- 
 rocally compensating one another. 
 
 The intervertebral disks in the region of the curve are 
 unequally compressed, becoming wedge-shaped, with the 
 base of the wedge toward the convexity of the curve. 
 The rotation of the bodies of the vertebrse (Fig. 234) is often so extreme 
 that their anterior surfaces point directly toward the convexity and the spines 
 
 Primary and Secondary 
 Lateral Curvatures 
 (Agnew). 
 
 Fig. 234. 
 
 >^,r?^ 
 
 Torsion in Lateral Curvature (Bradford and Lovett;. 
 
 toward the concavity of the curve. This tends to bring the spines back again 
 into the median line, although sometimes in these cases the twist is so great 
 
564 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 that the angles of the ribs and the transverse processes of the vertebrte occupy 
 exactly the position of the spinous processes. 
 
 The ribs on the convex side are widely separated, and are more horizontal 
 than they normally should be ; their angles become prominent, and the scapula 
 is carried forward with them, making a large "hump" in the dorsal region. 
 On the concave side the obliquity of the ribs is exaggerated, and in bad cases 
 thev may even touch the crest of the ilium. The thorax is therefore generally 
 distorted, and viewed anteriorly will nresent an abnunnal prominence of the left 
 breast (PI. X^^ Figs. 8 and 4). 
 
 Causes. — PredisiJOHiny causes are general weakness, prolonged ill health, 
 rickets, rapid growth, struma, etc. The excitiny causes are all those conditions 
 which in such a subject produce for long periods an undue inclination of the 
 spine to one side or the other. The typical cases are accordingly seen in deli- 
 cate girls between twelve and twenty, whose muscular strength and develop- 
 ment do not keep pace with their growth, who sit for hours at a desk with no 
 support for their backs, and who carry a heavy weight in the shape of school- 
 books to and from school, and usually on the same side of the body. Any 
 habitual one-sided position of the body will have the same effect. Other causes 
 are obliquity of the pelvis, produced by unequal length of the lower limbs ; uni- 
 lateral muscular atrophy due to central changes when the seat of the trouble 
 is in the spinal cord; unilateral muscular hypertrophy, from over-use of one 
 side; or spas7n from central disease will draw the column toward the side of 
 the enlarged or contracting muscles. Sacra-iliac disease, by causing the 
 patient to lean away from the aff'ected side to relieve pressure, empyema, 
 through the resulting contraction of the thorax, and morbid groivths of the 
 sides of the trunk or pelvis, by their weight, may produce the same result. 
 
 Symptoms. — The earliest development of this trouble is often insidiotis. 
 The first complaint of the patient, if a boy, may be that the suspenders on one 
 side slip off" his shoulder, or in the case of a girl it may be first noticed by the 
 di'essmaker, who may wish to pad out one of her shoulders. Examination will 
 show a slight prominence of one scapula, and perhaps of the opposite iliac crest, 
 and if the spinous processes are followed down the back by one finger with firm 
 pressure, the resulting red line on the skin Avill show the curve unmistakably. 
 
 In severe cases the " hump " on one side, usually the right, the elevation of 
 the right shoulder, the projection of the ilium on the left side, the prominence 
 of the left breast, and the ea^sily recognized curves of the spine, constitute an 
 unmistakable group of symptoms, the majority of which are always present. 
 
 In hysterical distortion of the spine the curvatures disappear on making 
 the patient bend forward until the fingers touch the ground. In caries of the 
 vertebrae with lateral instead of antero-posterior curvation the characteristic 
 symptoms of Pott's disease will be present. (See p. 5(37.) 
 
 Treatment. — Perhaps the most important advice to be given to the gene- 
 ral practitioner in relation to the treatment of this condition is a caution against 
 the use of braces, corsets, jackets, and other mechanical appliances which, by 
 confining the movements of the chest and supplying an artificial support in 
 place of the muscles which it is most desirable to develop, actually do great 
 harm to many patients instead of good. 
 
 Careful attention to the general health, a rigid observance of all hygienic 
 rules, properly directed exercise both active and passive, and massage, consti- 
 tute the essentials of the only treatment likely to be of service. 
 
 The exercise should be prescribed by the physician. The patient should 
 walk a certain time daily carrying a light weight balanced on tlie head ; should 
 several times daily swing for a few minutes by the hands from a cross-bar; and 
 
SURGERY OF THE SPINE. 
 
 Plate XV. 
 
SURGERY OF TIT?: SPINE. 
 
 565 
 
 Fig. 235. 
 
 should sit on a scat raised some inches on the side corresponding to the con- 
 vexity of the himhar curve, so that the spine may he strengtliened during the 
 efi'orts to produce a curve compensatory to the ohliquity of the pelvis produced 
 by the slanting seat. A high sole on the shoe on the same side has a similar 
 effect. 
 
 The patient should be taught to hold the back in the position in which the 
 surgeon finds the curves to he least perceptible, as in that position the weak 
 muscles must act most vigorously and will gradually be strengthened. A form 
 of exercise which has been advocated by excellent authorities consists in 
 placing the patient face downward on a table, bringing 
 the shoulders and trunk over the end, and then, while he is 
 held on the table by an assistant who embraces the legs and 
 thighs, causing him alternately to flex and extend the body 
 at the hips while the surgeon or masseur resists his efforts. 
 Massage of the weak muscles, electricity, "muscle-beating," 
 etc. are valuable adjuncts. In very severe and long-stand- 
 ing cases with marked deformity and great weakness, the 
 use of a spinal jacket (Fig. 235), preferably of leather, but 
 it may be of plaster or steel, may be absolutely necessary. 
 Carefully directed gymnastics with the use of special appa- 
 ratus are often beneficial. 
 
 Posterior Curvature, or Kyphosis, as a distinct dis- 
 ease, is met with in infants as a result of rickets, or of hav- 
 ing been nursed in a sitting posture, or encouraged to sit up 
 straight at a very early age : at puberty it is usually found 
 in the same class of patients as the subjects of scoliosis, and 
 arises from the same cause; i. e. it develops in weakly girls 
 from long continuance in a bad position, such as they often 
 assume in practice on the pianoforte or at a school-desk : in 
 adults it may also be caused by employment that necessitates 
 constant stooping over, especially if this is associated with 
 poor food and bad hygienic surroundings. It is accordingly 
 seen in rag-pickers, miners, cobblers, tailors, etc. Oftener 
 it is symptomatic of some other disease, as spondylitis defor- 
 mans, or is caused by an unconscious effort to relieve certain symptoms, as 
 dyspnea in asthma and emphysema, tenderness in metritis and chronic peri- 
 tonitis, pain in muscular rheumatism or in chronic rheumatic arthritis. 
 
 Pathology. — In the slighter forms of the disease there is merely relaxa- 
 tion of the vertebral ligaments, with separation of the laminae and spinous 
 processes. In others there is absorption of the anterior portions of the inter- 
 vertebral disks and of the bodies of the vertebrae. 
 
 Diagnosis. — It requires to be diagnosticated only from the deformity of 
 Pott's disease, which may be easily done by noting the absence of muscular 
 rigidity, of pain or tenderness, of abscess, of complications of the spinal cord, 
 etc. The curve of kyphosis is extensive and is a true curve, not an angular 
 projection of one portion of the spine. The disease occurs more frequently in 
 the aged than in children. 
 
 The treatment consists in removing the cause and in developing the weak 
 spinal muscles by appropriate exercise and massage. In young persons aban- 
 donment of the vicious posture, with the use of proper exercise, will generally 
 effect a cure. In adults, and especially in the aged, the condition is apt to be 
 permanent, and if very pronounced may require the use of some form of spinal 
 brace. 
 
 Leather jacket and 
 jury-mast (Sayre). 
 
5<JG -l.V AMERJCAX TEXT-BOOK OF SURGERY. 
 
 Anterior Curvature, or Lordosis, is often congenital, and may be due 
 to rickets or to disease affecting the posterior ])ortioiis of the vertebral bodies, 
 but is commonly compensatory and secondary t(» the deformity of Pott's disease. 
 It may be produced by ankylosis of the hip-joints in partial tlexion. 
 
 It is usually found in the lumbo-dorsal region, and consists in a marked 
 forward curvation of the lumbar spine, throwing in the loins so that a deep 
 concavity exists in the lumbar region, making the sacrum and the hips promi- 
 nent, depressing the pubes. and causing a protuberance of the abdomen. 
 
 Treatment. — As a rule, it requires no surgical interference, but occasion- 
 ally, wiien it depends upon caries of the vertebrte, some artificial appliance 
 will be needed. 
 
 Spondylitis Deformans is a term which, though etymologically applicable 
 to an inflammatory disease of the vertebrae producing deformity, such as Pott's 
 disease, is employed clinically to denote chronic rheumatic arthritis of the 
 vertebral column (Treves). It is a disease of old persons, as a rule, though 
 occasionally it is seen in middle life. It is attended with the same changes that 
 characterize arthritis deformans everywhere (see section on Diseases of Joints), 
 and is marked by absorption of the intervertebral disks, by the formation of 
 osteophytes upon the bodies of the vertebrae, and finally by firm bony anky- 
 losis of several vertebra. The disease begins with pain in the back, followed 
 by rigidity and the development of kyphosis. The curve increases, the ribs 
 become fixed and the thorax immobile, so that respiration is abdominal. AVhen 
 it comes on in middle-aged or elderly persons, and is moderate in extent, it does 
 not seem greatly to influence the expectation of life. 
 
 Treatment is of little or no avail, but may be conducted on the general 
 principles applicable to chronic rheumatic arthritis elsewhere. 
 
 TUBERCULOSIS OF THE SPINE. 
 
 Pott's Disease, Spondylitis. — Cause. — Tubercular inflammation of 
 the bodies of the vertebrae is a disease usually found in childhood, afiecting 
 more frequently delicate children between the ages of three and ten years, of 
 poor parents, and especially those of tubercular families. No age or class is 
 exempt, however, and occasionally no family history of struma or of tubercle 
 can be elicited. Usually the affection is ascribed to some slight traumatism ; 
 this may be the exciting cause in many instances, but the tubercular diathesis 
 or soil is essential to the production of the typical disease. 
 
 Pathology. — The inflammation begins in the cancellated structure of 
 the vertebral bodies, which undergoes the changes characteristic of tubercular 
 ostitis elsewhere, the extent and rapidity of the process being proportionate to 
 the number and activity of the bacilli on the one hand and to the vitality of 
 the tissues and of the individual on the other. The results of the rarefying 
 ostitis thus set up may accordingly be threefold : 1. Resolution ; 2. Caseation ; 
 3. Liquefaction. 
 
 1. When resolution takes place, after a certain stage has been reached, tha 
 normal cells get the mastery, the bacilli disappear, the inflammation slowly sub- 
 sides, the exudation is reabsorbed, and the parts return to their original condi- 
 tion. This result is rare. 
 
 2. Far oftener the process of disintegration and caseation advances, the body 
 of the vertebra breaks down, usually at the anterior border first, and masses of 
 fungous granulations replace the osseous cancelli and invade the intervertebral 
 spaces, causing absorption of the disks. Even at this stage, however, repair 
 may begin ; ankylosis may follow the transformation of the granulations into 
 
SURGERY OF Till-: SPIXE. 567 
 
 sound filirous tissue, and a return to health uitli little or no deformity or func- 
 tional disability may ensue. This is the result aimed at by the surgeon, and as 
 a rule his successful cases belong to this group. 
 
 3. In the third class the destructive process is of greater activity : the case- 
 ous masses formed in and between the bodies of the vertebrae licjuefy and become 
 collections of so-called *• tubercular pus ;" the anterior surfaces and adjoining 
 edges of the affected vertebrae disappear, as do the intervertebral disks ; 
 the whole vertebral body may be absorbed, or more rarely may practically 
 become converted into a large sequestrum lying in a caseous abscess filled 
 with a serous exudation mixed with minute particles of bone, necrotic frag- 
 ments of connective tissue, and cheesy ddbris, which together give its contents 
 a milky appearance. 
 
 Still later, this collection of fluid finds its way toward the surface by one 
 of several channels and becomes a so-called spinal abscess, often, if it breaks 
 spontaneously or is opened carelessly, undergoing infection with pyogenic germs 
 or Avith germs of putrefaction or with both. During this time the disap- 
 pearance of the bodies of the diseased vertebrae, permitting the undue approx- 
 imation of those above and below them, has caused a change in the shape of 
 the spinal column, a falling forward of the segment above the diseased area, a 
 backward projection of the spinous process of the vertebra nearest the area 
 of disease, and the formation of a distinct prominence, which is known by the 
 unscientific name of "angular curvature" (PI. XVI). This most commonly 
 occurs in the dorsal region. A compensatory lordosis often follows in the 
 lumbo-dorsal region. This occurs, though very rarely, as a primary deformity 
 resulting from disease of the posterior portion of the vertebrae. It is, as has 
 been said, more often congenital and hereditary or associated with rickets. 
 Caries in the cervical or lumbar region first causes the disappearance of the 
 normal backward concavities of the spine in these regions, so that straightness 
 of the spine in the neck and in the loins has the same significance as a mode- 
 rate projection in the dorsal region. During this time a slow thickening of 
 the connective tissue betAveen the dura and the walls of the canal is going on, 
 a so-called external pachymeningitis, which is the chief cause of the paralysis 
 occasionally seen in this disease. This inflammatory growth is oftenest ante- 
 rior, and by its pressure produces motor paralysis ; fi'equently, however, it is 
 also posterior, and then there is paralysis of both motion and sensation. Occa- 
 sionally, but rarely, the bodies of the displaced vertebrae impinge upon the 
 cord. Still more rarely there occurs a transverse myelitis of the cord itself. 
 In both these latter cases there would, of course, be paralytic symptoms. 
 
 Symptoms of Pott's Disease. — These vary with the stage and extent 
 and situation of the inflammatory process, but observe approximately the fol- 
 lowing order in their development : 
 
 1. The child will complain of pain in the region supplied by the nerves aris- 
 ing from the affected segment of the cord. If the disease is lumbar, the pains 
 are abdominal and are apt to be associated with vesical irritability ; if dorsal, 
 the pains are epigastric or intercostal, and respiration is sometimes irregu- 
 lar and hurried from the failure of the respiratory muscles to take their full 
 share in the work ; if cervical, neuralgic pain or numbness in the arms and 
 hands, a tickling cough, and difficult deglutition are the prominent symptoms. 
 It is to be noted that the pains are apt to be symmetrical. 
 
 2. Increase of pain upon movemerit, and especially upon jumping or upon 
 flexing or rotating the spine, is extremely significant. If the child can jump 
 painlessly from a chair to the floor, it is almost certain that no inflammation 
 of the body of a vertebra exists. If the vertebrae be crowded together by 
 
568 
 
 jy AMi:iiicAy tkxt-hook of sriicKiiV. 
 
 pressure on the head or shoulders wliile the patient sits or stands or while he 
 lies face downward across the knees of the surgeon, the pain will be nmcli 
 increased. Conversely, if while erect the patient be gently lifted by the hands 
 under the chin and occiput, or if in the prone position on the surgeon's lap the 
 latter's knees be separated so that the spine is elongated, pain will be relieved. 
 Pain may be increased by percussion of the spinous processes, and sometimes 
 the skin over the spinal gutter and the neighboring muscles is tender to the 
 touch; but these signs are of slight value if present, and are by no means 
 constant. 
 
 3. Involuntary immobilization of the spine, a result of this pain upon 
 movement, is a very characteristic symptom. If the child is asked to look at 
 something behind him, he turns the whole trunk. If he is requested to pick up 
 something from the floor, he stoops by bending the thighs upon the trunk and 
 the knees upon the thighs, never by flexing the spinal column in the usual 
 way (Fig. 23<j). In walking he moves as though on ice, sliding or shufliing 
 along so as to avoid the jar of successive steps. In standing he fixes the upper 
 portion of the column by the aid of the trapezii and the other scapular muscles. 
 
 Fig. 237 
 
 Fig. 236. 
 
 Manner of Picking up an Object in 
 Pott's Disease (Agnew). 
 
 Standing Position in Pott's 
 Disease (Agnew). 
 
 the action of which at the same time raises the shoulders and throws the arms 
 out from the side (Fig. 237). 
 
 4. In standing or sitting there is also an invohintari/ transference of the 
 weight of the head and shoulders and parts above the diseased area to the 
 pelvis by means of the upper extremities. The hands are often placed upon 
 the hips and the arm muscles are tense. In walking about a room the little 
 patient will support himself upon articles of furniture, going from one to an- 
 other with great care, losing no opportunity to lay hold of a chair or a couch. 
 
SURGERY OF niK SPINE. 
 
 Plate XVI. 
 
 Pott's disease of the spine (spondylitis). 
 
SURGERY OF THE SPIXE. 
 
 569 
 
 5. The deformity Avill usually be charcicteiistic, and lias already been 
 described. As a rule, the diagnosis by means of the above symptoms should 
 be possible before any material change in the contour of the spine occurs. 
 
 6. Spinal abscess occurs later, and ^vill vary in its position according to 
 the seat of tlic cjiries. a. In disease of the cervical vertebra? the abscess is 
 apt to be retro-pharyngeal. A fluctuating swelling appears in the pharynx, 
 usually to one side of the median line. If it shows externally, it does so 
 behind the angle of the jaw. Sometimes it follows the oesophagus into the 
 mediastinum, or it may pass between the longus colli and scalene muscles and 
 point on the neck in front of or behind the sterno-mastoid. 
 
 h. In dorsal caries the fluid collects along the front and sides of the dorsal 
 vertebra; in the posterior mediastinum. Thence it may pass between the trans- 
 verse processes to the back, constituting dorsal 
 abscess ; or may descend to the diaphragm, pass 
 under the outer arcuate ligament, and point in 
 the ilio-costa! space as a lumbar abscess; or 
 go under the inner arcuate ligament to form a 
 psoas abscess (Fig. 238). The latter, being 
 prevented from spreading inward or backward 
 by the spine and the last rib, and having its 
 progress forward checked by the ligament, is 
 impelled downward by gravity and by its in- 
 crease in size, finding its way most easily into 
 the space between the two origins of the psoas, 
 gradually causing absorption of that muscle, 
 and usually pointing in the groin below Pou- 
 part's ligament and to the outer side of the 
 femoral vessels. It may, however, point above 
 Poupart's ligament, on the inside of the thigh, 
 or even below the knee. 
 
 c. In lumbar caries the fluid remains out- 
 side of the sheath of the ilio-psoas and occupies 
 the iliac fossa, forming an iliac abscess, which 
 is apt to occupy the angle at the junction of 
 the iliac and transversalis fascia and to point on the abdominal wall just above 
 the outer end of Poupart's ligament ; or it may gain access to the true iliac 
 space W'ithin the sheath of the ilio-psoas, which will then guide it below the 
 ligament to the upper part of the thigh outside the vessels. 
 
 As variations from these routes, which are the most frequent, we may have 
 abscesses passing between the ribs to the side of the chest, or opening into the 
 pleura or bronchi, or going through the great sacro-sciatic notch to appear 
 under the gluteal muscles, or through the thyroid foramen to point on the 
 upper and inner part of the thigh. 
 
 7. Paralysis, always motor at first and often not affecting sensation at all, 
 is the result chiefly of the external pachymeningitis which has been described. 
 
 Diagnosis. — The above symptoms will usually enable the disease to be 
 recognized and easily differentiated from thoracic or abdominal aneurysm, 
 hysteria, renal disease, rheumatism and neuralgia, empyema with subdiaphrag- 
 matic abscess, etc. The most important symptom in the early stages is, per- 
 haps, the rigidity of the spine ; later the deformity is easily recognizable. 
 
 Treatment. — The indications for treatment in Pott's disease are, 1. To 
 endeavor to secure resolution of the tuberculous ostitis ; 2. To limit the destruc- 
 tion of tissue and the resulting deformity as much as possible ; 3. To promote 
 
 Psoas Abscess (Albert) 
 
570 
 
 .l.V AMKRirAX TEXT- HOOK OF SVRGERY. 
 
 Extension in the Recumbent rositioii (Reeves). 
 
 ankylosis ; 4. To evacuate pus ; o. To remove a sequestrum or tlie focus of 
 carious bone ; 6. To relieve the cord from pressure by pus, bone, or, most com- 
 monly, by the products of an external })achynieningitis. 
 
 The first three may be considered together, and are efjually mot by the 
 application of the same principles. 
 
 Rmt is always the most important consideration. In very young children, 
 in patients of all ages "where there is very active and progressive disease, and 
 in all cases in which the ostitis or caries is situated in the cervical or upper 
 
 dorsal region, confinement to 
 l-iG. 239. bed in the recumbent ijoaition 
 
 is almost imperative. In cer- 
 vical caries the head and neck 
 should also be fixed by sand- 
 bags laid one on each side, 
 secured in position by tapes, 
 and extending from the vertex 
 to the shoulder. Extension in 
 bad cases with beginning pres- 
 sure symptoms may be applied 
 from the chin and occiput, the 
 head of the bed being suifi- 
 ciently elevated, or from the 
 lower limbs by raising the foot of the bed and applying adhesive strips with 
 weight and pulley, as for fracture of the femur, to both legs ; or the twa 
 methods may be combined. To prevent excoriation of the skin by the adhe- 
 sive strips, the legs may first be bandaged and the plasters applied over the 
 bandages. 
 
 Whenever the patient's circumstances make it practicable and the general 
 health can at the same time be maintained, recumbency with limitation of all 
 but slight and necessary movements should be continued until all symptoms 
 have disappeared, or, if the disease has already reached the stage of caseation, 
 or liquefaction, until complete consolidation has taken place. 
 
 This is not always possible, nor will the child always bear such pro- 
 longed confinement to bed. It is, however, so valuable as a method of 
 treatment that every efibrt should be made to secure its thorough trial. The 
 bed should be wheeled into the sunlight, or, at the proper seasons of the year, 
 into the open air. There should be gentle massage and frictions of the limbs 
 and of the abdominal and pectoral muscles. Alcohol baths, and sometimes in 
 very young children inunctions with cod-liver oil, are useful. The food should 
 be nutritious and as abundant as digestion and assimilation Avill permit. Much 
 of the success of treatment will depend upon the care and judgment shown in 
 the feeding, and the surgeon cannot too closely scrutinize the details of diet. 
 A large variety of tonics have been employed in these cases, but three are te 
 be especially recommended : viz. a well-made and digestible emulsion of cod- 
 liver oil ; the phosphates, which may often be contained in the same emulsion ; 
 and iodide of iron in doses to suit the age and the stomach of the patient. 
 
 When consolidation has occurred, which will be after a period represented 
 by months rather than weeks, and is accompanied by a disappearance of symp- 
 toms and an increase in the general strength and well-being, the patient should 
 be allowed to sit up, cautiously at first, and if the deformity has been marked 
 should wear some light form of spinal jacket. The higher the caries in the 
 vertebral column, the greater should be the caution in permitting the erect 
 position. 
 
SURGERY OF THE SPINE. 
 
 571 
 
 Rest of the aifected region wlieii the disease is below the mid-dorsal verte- 
 bra3 and is not too acute or extensive, and Avliere the patient is ohl enough, may 
 be satisfactorily obtained by the use of some form of spinal jacket, by means 
 of -which the weight of the parts above the disease may be transferred from 
 the spinal column to the curves and bony prominences of the pelvis and hips. 
 
 The simplest of these jackets is that known by the name of Dr. Sayre, who 
 devised it. It may be applied as follows : The patient is stripped, and a closely- 
 fitting woollen undershirt, reaching below the nates and provided with shoulder- 
 straps, is put on. He is then placed beneath a tripod, and a leather headgear 
 
 Fig. 240. 
 
 Fig. 241. 
 
 Tripod for the suspension of the patient 
 
 (yayre). 
 
 Patient in position for the application 
 of the plaster jacket (Sayre). 
 
 embracing the occiput and chin is adjusted, and in older children or adults 
 axillary bands are added (Figs. 240, 241). 
 
 By means of pulleys the patient is then elevated {a) so that the toes just 
 touch the floor ; (A) or so that the heels are about two inches from the ground, 
 the " fore-pads " of the feet being in contact with the floor ; (c) or so that the 
 heels are merely raised from the ground. These various degrees of extension 
 are to be applied according to the age and weight of the patient and the extent 
 of the disease, the first mentioned being suitable for the youngest and lightest 
 children and the least extensive disease, the last applying to adults and to more 
 severe forms of the trouble. 
 
 While the patient is held in this position the woollen shirt is kept drawn 
 well down, pads of cotton avooI are applied over the iliac spines and other bony 
 
572 
 
 AN AMERICAN TEXT-IKXJk' O/' SlJItGERY 
 
 Fig. 242. 
 
 ]»r(>iiiinonocs, tlio spiice hetwet-n tlio breasts in wcmiicii is Ullctl witli a tcinpo- 
 vary pad, and a wedge-shaped pad is ])laced over the lower part of" the ah(h)nien 
 
 under the shirt, with the base of the wedge upward, 
 enclosed in a towel to admit of its ready removal. 
 This is the so-called "dinner-pad," intended to leave 
 a space after its withdrawal which will allow for the 
 physiological distention of the abdomen after eating. 
 Plaster bandages are then applied, rollers 2-^ to 3 
 inches in width and 6 yards in length being used. The 
 first turns are made midway between the trochanter 
 and the crest of the ilium, and they are tlien carried 
 regulaily and smoothly up to the axilla, each turn 
 overlapping the preceding turn about one-third (Fig. 
 242). About three layers are recjuired. An assist- 
 ant with a basin of dry plaster and a wet sponge may 
 strengthen the dressing here and there if rcfiuired, 
 and can keep it smooth. The jacket should be left 
 on until the plaster has set, usually about fifteen or 
 twenty minutes, and the patient should then be taken 
 under the arms and carefully laid upon a hard mat- 
 tress, where he should remain about an hour. He 
 may then be allowed to dress and go about. The 
 temporary pads should be removed. 
 
 If the jacket has been well apjjlied it Avill usually 
 give relief or comfort. It should never be worn con- 
 tinuously longer than ten or twelve weeks. When 
 removed, the parts can be inspected and abrasions or 
 excoriations treated Avhile the patient is recumbent. 
 A new jacket may then be put on in the same man- 
 ner as before. The advantages of the plaster jacket 
 are its cheapness and the readiness with which it 
 can be applied. Its disadvantages are its weight, its 
 liability to exert uneven pressure, and its conceal- 
 ment of the parts beneath it for so long a time. 
 Some of these may be removed by cutting it down 
 the front after it has hardened, springing it off the 
 patient, and making holes at a short distance from 
 its two edges, after "binding" them with a broad 
 strip of adhesive plaster, so that it may be laced. 
 It should not be used in very young children, in 
 early and acute disease, in the presence of cardiac or 
 pulmonary complications, over abscess which is pointing, or in extremely feeble 
 and anemic patients. In all these cases recuml)ency, with proj)er attention to 
 diet and hygiene, is preferable. A jacket of half-tanned leather (Fig. 235), 
 such as has been recommended by Agnew, can be made by a good surgical 
 cutler from a mould taken in plaster as just described, and is much lighter and 
 more comfortable. A jacket of poro-plastic felt is also recommended, and can 
 be readily applied. Corsets of various sizes are made of this material. The 
 patient is suspended, wet cloths are wrajjped around the body, and a corset of 
 the proper dimensions is momentarily dipped in scalding water and is then 
 moulded to the figure. After it "sets," it can be made to lace doAvn the front, 
 and is easily removed and reapplied. 
 
 In cases of disease above the mid-dorsal region the "jury-mast " (Fig. 235) 
 
 Plaster applied, and slit up in 
 order to prepare plaster east. 
 
SURGERY OF TIIK sriXK. 573 
 
 must be ;i])|)li(.'(l ill addition. It consists of a vcr'iical bar fitted to the curve 
 of tlie l)ark and neck, extendin<^ above the head, and carrying the occipito- 
 mental leather a])paratus. The jury-mast removes injurious pressure on tlie 
 softened vertebral bodies by sup])orting the weight of the head and of the por- 
 tion of the trunk above the diseased vertebrte on the chin and occiput. The 
 lower end of the bar is hehl in the plaster by a cross-piece or is riveted to the 
 poro-j)lastic or leather jacket. In cases wliere the jury-mast is thought unsafe, 
 a breast-plate and collar for the same cases have been nuide by Edumnd Owen; 
 but such cases are far better treated bv rccumbenev. 
 
 The Treatment of Spinal Abscesses varies somewhat with their situ- 
 ation, but the rule should be to open them freely as soon as they are accessible. 
 Aspiration is usually a failure. Tapping and irrigation with antiseptic fluids, 
 or the injection of an emulsion of iodoform, or the swabbing out of the cavity, 
 followed by the use of iodoform and the treatment of the cavity as a simple 
 wound, have all been tried with more or less success. The results from any 
 of them are vastly better than Avere obtained by any of the older methods, but 
 their precise comparative value is as yet uncertain. 
 
 Retro-pharyngeal abscess if pointing in the pharynx should be opened 
 promptly, to avoid the danger of suifocation which attends its spontaneous 
 and unexpected evacuation. Of late, the tendency of surgeons is toward 
 reaching these abscesses by external incision, instead of through the mouth, 
 in order to secure asepsis. The incision is made at either border of the 
 sterno-cleido-mastoid muscle and the abscess reached by a careful dissection, 
 especially in the neighborhood of the vessels. 
 
 Psoas abscess may be opened either in the loin or in the groin or in both 
 localities. If only one is selected, the former is beyond all doubt to be pre- 
 ferred. A vertical incision at the outer edge of the erector spinge should be 
 carried down through the external oblique, internal oblique, and transversalis 
 muscles and the lumbar fascia until the edge of the quadratus lumborum is 
 seen. Then a transverse division of the fibers of that muscle and of the trans- 
 versalis fascia on the level of the tip of the second or third lumbar transverse 
 process avoids the lumbar arteries, which are above and below the process, 
 and gives access to the finger, Avhich in lumbar abscess will go at once into 
 the abscess-cavity, and in psoas abscess will easily pass through the attenuated 
 sheath and the few remaining fibers of the psoas into the collection of pus (Treves). 
 
 A second opening made below Poupart's ligament by cutting on the end of 
 a long probe introduced through the loin will permit of through-and-through 
 irrigation by means of a large drainage-tube, which later may be replaced by 
 two tubes, to be gradually shortened so that the abscess-cavity may contract in 
 the middle. 
 
 With proper antiseptic precautions the opening of a spinal abscess should 
 not be attended by the development of the hectic fever, the emaciation, and the 
 rapid failure which so commonly followed this operation in earlier days. It 
 was then thought to be due to the removal of the internal pressure of the pus 
 from the vessels in the walls of the " pyogenic membrane," but undoubtedly it 
 was the result of infection of a tubercular cavity with pyogenic organisms. 
 
 The lumbar operation is also to be preferred, as enabling us in a certain 
 number of cases to meet another indication — namely, the removal of the focus 
 of carious bone. In so-called "posterior vertebral disease," i. e. in cases in 
 which the osseous lesions are localized in the transverse or spinous processes or 
 the laminte, operation is of course both easy and satisfactory, and seven out of 
 eight recorded cases have given excellent results. Posterior vertebral disease is, 
 however, extremely rare. When the bodies of the vertebrae are diseased, as is 
 
574 AX AMERICAX TEXT- HOOK OF srUdKin'. 
 
 usually the case, altove the twelfth dorsal thoy are ])raeticallv inaccessible, 
 except in very unusual cases associated with extensive caries of the ribs. At 
 and below that point, however, an operation such as the one described above 
 may be of great use. Fourteen such operations have been followed by 
 eight cures, five cases improved, and one death Avhich had no relation to the 
 operation itself. They have shown that the solidity of the spine is not affected 
 by either the curetting or the removal of a sequestrum, and have demonstrated 
 that the costo-iliac space in proper cases {i. e. in those where only one or two 
 .•ertebn\2 are affected and there is l>ut slight angular projection with a curve of 
 large radius) is ample for the work to be done. For these reasons it is safe to 
 say that the search for the focus of bone disease in caries of the lumbar verte- 
 bme is indicated with sufficient frequency to give the matter a real surgical 
 interest. The seat of disease may be sought in exceptional cases even before 
 the appearance of an abscess, and in the presence of an abscess may often be 
 reached with great ease and certainty. The bodies of the lumbar vertebrre are 
 accessible by Treves's operation even when no abscess which is appreciable clin- 
 ically is found. If an abscess exists, therefore, even when it points anteriorly 
 it is proper to open it by the lumbar route and seek the focus of disease. This 
 permits us, if the abscess depends on vertebral disease, to reach the twelfth dor- 
 sal vertebra without wounding the pleura. The benefit to the patient in suc- 
 cessful cases is as definite and unmistakable as that following the removal of a 
 focus of tubercular ostitis and caries in any other region. 
 
 The last indication for operative interference, viz. the existence of paralvsis 
 thought to be due to pressure upon the cord, is to be met in various ways. 
 
 It should be clearly recognized that such cases, especially in children, fre- 
 quently recover under careful hygienic treatment, when the abscess, if any 
 exists, can be evacuated and the treatment by extension and a spinal jacket 
 employed. It has been shown conclusively by Weir Mitchell that no case 
 of Pott's paralysis ought to be considered desperate without the trial of sus- 
 pension, Avhich has succeeded after the failure of other accepted methods, 
 such as continued rest in bed, with the administration of tonics and frequent 
 cauterization with the hot iron ; that the pull probably acts more or less directly 
 on the cord itself, and the gain is not explicable merely by the obvious effects 
 on the bony curve ; that the methods of extension to be used in these cases 
 may be various, provided only that we do get active extension : and that the 
 plan and the length of time of extension must be made to conform to the needs, 
 endurance, and sensation of each individual case. 
 
 Extension may be employed by making the bed an inclined plane, or more 
 forcibly with the patient in a sitting position. In either case the stretching is 
 done through traction from the chin and occiput by means of a collar resem- 
 bling that used in swinging the patient for the application of a plaster jacket 
 (Fig. 239). When this form of extension can be borne (and it generally can 
 be) it is very effective. It must be the method used in high dorsal and cervical 
 caries. In other cases the extension may be made either from the upper portion 
 of a spinal jacket applied in the usual way or from both the jacket and the 
 occipito-mental collar. This distributes the pull and renders it a little less 
 severe, although if suspension from the head is done gently and the amount of 
 the pull is increased slowly, very few patients complain of it. If the extension 
 is to be made from a spinal jacket, loops of bandage, like the straps of a girl's 
 dress, should be carried up over the shoulders during its application, their loose 
 ends being imbedded in the plas'^er. In all cases the extending force is the 
 weight of the patient's body. 
 
 The apparatus may be improvised by having the collar made of quilted 
 
SURGERY OF THE SPINE. 575 
 
 canton flannel, the foot of the Ited ])eing raised if the use of an inclined jdane 
 is indicated, and the cord attached to the cross-bar, or, if vertical suspension 
 is desired, a gallows can be made by a carpenter to straddle the bed and to 
 carry the cord and pulley. The pulley may be fixed at the end of an iron sup- 
 port resembling that used in the "jury-mast" extension for Pott's disease. 
 This may be fastened to the back of a reclining chair, so that it curves out 
 over the head of the ])atient, ■who can then, if he is old enough, regulate for 
 himself the amount of i)ull which he can sustain with comfort. Tliis admits 
 of very delicate gi'aduation of the extending force, by suspending the patient 
 from a spring balance attached to the jury-mast. 
 
 This method of treatment should be persevered in for weeks or months 
 if there is the least indication of improvement, and will sometimes produce 
 remarkable results in apparently hopeless cases. Of course the most careful 
 attention to hygiene must be combined with this as with any other form of 
 treatment employed. Electricity and massage to keep up muscular nutrition, 
 good food, iron, and cod-liver oil, pure air and sunlight, are as important as 
 they always are in tubercular disease. 
 
 In cases in which all this has been tried unsuccessfully, or in those in which 
 the disease is slowly but steadily progressing to an unfavorable termination, 
 when with more or less complete loss of motion and sensation below the level 
 of the lesion there are incontinence of urine and feces and the development of 
 bed-sores, and especially when acute s^^mptoms threaten life, resection of the 
 arches and laminae of the affected region becomes justifiable. 
 
 When the tubercular process affects the arches and there is paraplegia, we 
 may sometimes operate in the hope, not only of freeing the cord, but also of 
 removing at the same time the focus of disease. This double indication may 
 also be fulfilled in those cases in which, Avithout bone disease, there is a posterior 
 pachymeningitis or a tuberculoma occupying the canal. Here again, however, 
 time and careful attention to hygiene, including change to sea- or mountain-air, 
 often work wonders. If the lesion of the bodies of the vertebrae is in the lum- 
 bar region at a point where these bodies are accessible, it may be possible in 
 certain cases to expose the cord from the back by removal of the laminae, with 
 the object not only of removing pressure, but also of reaching and taking away 
 the diseased bone and tubercular granulations. In tuberculosis of the body of 
 a vertebra and compression of the cord by anterior pachymeningitis we can fulfil 
 only one indication, i. e. liberate the cord from pressure. We should operate 
 only in grave cases in which acute compression, the appearance of respiratory 
 complications, and the rapid development of degenerative processes force us to 
 interfere, or in which the course of a chronic case is steadily toward a fatal 
 termination, although no advanced visceral tubercular lesions are present. 
 
 Operation having been decided upon for any or all of the above reasons, 
 the prognosis will be favorable in proportion to the youth and strength of the 
 patient, the absence of generalized tuberculosis, and the nearness of the lesion 
 to the base of the spine 
 
 In 1893 Chipault suggested the advisability of forcibly correcting the 
 deforuiity of Pott's curvature of the spine. The suggestion was not new 
 with Chipault. as Ambroise Pare in 1650 advocated forcible correction by the 
 use of an instrument of his invention. Chipault accomplished correction 
 while the patient was anesthetized, and subsequently immobilized the spinal 
 column by wiring the spinous processes of the adjacent vertebrae to each 
 other and aj3plying plaster of Paris. Calot is a strong advocate of rapid 
 correction. He advises that the patient be anesthetized, and be placed prone. 
 One assistant supports the chest and upper abdomen, another assistant the 
 
570 A^' AM ERICA X TEXT- BOOK OF Sr^ROKin'. 
 
 jH-lvis and lower abdomen. Wliile one assistant makes traction upon the 
 arms and another upon the legs, the surgeon makes downward pressure upon 
 the projection. Plaster of Paris is applied so as to include the head, neck, 
 chest and pelvis, while tractitin an<l pressure are maintained. In .<ome cases, 
 before the defornuty can be corrected, it is necessary to excise some of the 
 spines and lamin;\>. Some surgeons claim that what is practically a cure 
 can be obtained by this method. Others condemn it as highly dangerous. 
 The operation is not very dangerous — in fact, it is safe if violent force is not 
 used. It is always better to use moderate force on several occasions than to 
 use violent force at once. Forcible correction may cure paraplegia, may for 
 a time appear to cure deformity ; but, as Bradford has shown, it will not cure 
 the disease Avhich caused the deformity, and the correction may be only tem- 
 porary because bony repair may not occur. Calot and Ducrotjuet, on the 
 evidence of skiagraphs, maintain that bony repair does occur. This method 
 of correction should not be employed if the tubercular process has not ceased, 
 because an inactive process may again become active under the influence of 
 injury. 
 
 INJURIES OF THE BACK. 
 
 Sprains. — Sprains of the spine are of all degrees of severity. The struc- 
 ture of the vertebral column is so complex and its relations are so numerous and 
 varied that a great variety of .symptoms may follow a sprain according to the 
 extent of the damage which is inflicted. In the mildest degree of sprain the 
 muscles alone are involved, and we then have merely a temporary stiffness and 
 a little local tenderness over a limited area. In more serious accidents, as 
 those occurring during railway collisions, the -ligaments may also be involved 
 and are sometimes actually torn. When this happens in the case of the liga- 
 menta subflava, there may be immediate and severe extradural hemorrhage, 
 followed by temporary paraplegia. The symptoms which are never absent are 
 pain and stiffness. Occasionally there is a little local swelling, but this is not 
 constant. The pain is referred to the extremities of the injured nerves, some- 
 times shooting down the limbs, occasionally, when the injury is at the lumbo- 
 dorsal junction, being referred to the pubic region. The skin over the injured 
 part is apt to be exceedingly tender. The stiffness produces a degree of rigid- 
 ity of the spine which resembles very much that seen in Pott's disease, the 
 patient involuntarily immobilizing the vertebral column and avoiding rotation 
 and flexion as carefully as possible. When the injury is unilateral this mus- 
 cular rigidity is very marked on the injured side, and is a valuable means of 
 distinguishing real from asserted injury, especially in medico-legal cases, as it 
 cannot be simulated. 
 
 The diagnosis of severe sprains followed by great helplessness and by 
 some degree of paralysis will .sometimes be difficult, as the condition may 
 closely simulate that of fracture. In the latter, however, the paralysis is more 
 absolute, the disability more complete, the tenderness over the spine less dif- 
 fuse, and there is often an irregularity in the line of the spinous processes 
 which will serve at once to indicate the more serious character of the injury. 
 
 Treatment. — This does not differ in its general principles from that of 
 sprains elsewhere. Rest of the part, counter-irritation by dry cups or by some 
 rubefacient, gentle frictions with a liniment containing belladonna, followed 
 later by massage of the affected part, constitute the essentials of treatment. 
 It should always be borne in mind that there may be retention of urine. The 
 use of laxatives is freijuently indicated. 
 
 The later symptoms of spinal sprains are, after all, the most serious and 
 
l^URGEh'V OF Till': SITNE, bll 
 
 annoyinor. At the time of the accident there may ho the form of general 
 nervous depression which we know as shock, wliich may even deepen into its 
 graver variety of collapse ; or in neurotic patients there may occur the more 
 localized disturbance of cerebral origin known as acute hysteria, but this, as a 
 rule, will disajipear within a short time. Later, however, two forms of serjuelse 
 may occur which take a chronic character, and wliich are classified by Thorburn 
 in his excellent book on this subject as neurasthenic and traumatic hysteria. 
 In the former condition there is a general defect in the nutrition and nerve- 
 power, which when it follows a traumatism is manifested by weakness, loss 
 of memory, mental confusion and irritability, insomnia, headache, eye-strain, 
 photophobia, irregular and frequent pulse, dyspepsia, etc. These symptoms 
 occur in patients who have had mild shock at the time of the accident, and 
 they will generally pass away after rest and tonic treatment. They are very com- 
 mon, and are often associated with those belonging to traumatic hysteria, which 
 Thorburn describes as a functional affection of the nervous system resulting 
 from an injury, due probably to a change localized in some portion of the cere- 
 bral cortex, and manifested by well-defined and localized symptoms. He adds 
 that it has no known organic basis, is not reflex in origin, and is neither shock 
 nor neurasthenia. It is an affection of middle life, three times as common in 
 the female as in the male, occurring especially in persons of a neurotic temper- 
 ament or in those addicted to the excessive use of alcohol. It is favored by 
 great fright or by horrible surroundings at the time of the accident which 
 produces it. 
 
 The symptoms may be either psychical, including epileptiform attacks and 
 hysterical insanity ; motor, including paralysis and contractures of the limbs 
 and special effects upon such organs as the larynx and the bladder ; sensory, 
 in which case there is anesthesia, hyperesthesia, or paresthesia of the general 
 or special sensory nerves ; or lastly, there may be vaso-motor, secretory, or 
 trophic trouble.^ 
 
 As to its essential cause, the theory of Charcot, that traumatic hysteria is 
 frequently identical with the conditions produced by suggestion during hypnotic 
 sleep, is the most plausible which has yet been advanced. In lightly hypno- 
 tized persons a slight blow on an extremity is often followed by motor and 
 sensory paralyses if these are forcibly suggested by the operator : the same 
 symptoms may follow even without suggestion. The trifling traumatism 
 evokes from the cerebral cortex in its unaltered state the idea of severe 
 injury, and this is promptly followed by the loss of power and sensation which 
 might really follow a genuine injury. In traumatic hysteria the nervous shock 
 replaces the hypnotism, and the abnormal sensation caused by the injury gives 
 rise, as in the above instance, to the "auto-suggestion " which replaces sugges- 
 tion by the operator. 
 
 The treatment should consist in isolation, and in endeavoring to obtain 
 control over and influence upon the patient, and should conform to the prin- 
 ciples which govern the treatment of neurasthenics fey the rest cure. 
 
 Concussion as applied to injuries of the spinal cord is a term which may be 
 retained for convenience, but which has no accurate pathological signification. 
 When it is remembered that the cord does not entirely fill the spinal canal, 
 that it is connected Avith it only at those places where the nerves pass through 
 the intervertebral foramina and by the ligamentum denticulatum, that it is 
 closely embraced by its pia mater, that it is surrounded by fluid, and that the 
 canal and its contents are protected in the most thorough manner imaginable 
 
 ^ For a detailed description of thif5 condition, with illustrative cases, the monograph of 
 Thorburn on the Surgery of the Spinal Cord sliould be consulted. 
 
 37 
 
578 ^l.V AMKl^Kwy TKXT-HOOK OF sriidKin. 
 
 from tlio effects of violeiiee tiaiisniitted tluoii^li surrouiidiii;! stnictines. it is 
 evident tliat a trauniatisni Avliicli Avitliout eausiii;i some jiross lesion uoiild ))ro- 
 duee a condition of the cord justifying the use of the term "concussion "" must 
 be of rare occurrence. As a matter of fact, it is probable that some actual 
 lesion in the substance of the cord occurs, possibly a rupture of delicate nerve- 
 fibers, possibly a capillary hemorrhage, or, it may be, merely a vaso-motor 
 disturbance with slight serous exudation. In any event, the sym|»toms are 
 those which attend a moderate degree of shock ; that is, a tendency to syncope, 
 pallor of the face, nausea and vomiting, cold perspiration, etc., superadded to 
 ■which are the special symptoms which arise from the cord, such as numbness or 
 tingling or loss of power in the lower extremities ; or hiccough, wry-neck, tem- 
 porary paralysis of the arms, a sense of constriction of the thorax, or similar 
 symptoms if the upper portion of the cord suffers. The treatment appropriate 
 to sprains of the spine applies to injuries of this character. 
 
 Contusion of the sjjinal cord may result from severe sprain, but usually 
 occurs as a consequence of forced flexion of the vertebral column. It is 
 accompanied by hemorrhage into the substance of the cord — hematomyelia — 
 which usually occupies the gray substance, and may extend to a considerable 
 distance. It is accomj^anied by motor and sensory paralysis and a diminution 
 of the reflexes. It may be followed by acute myelitis and all the phenomena 
 attendant upon degeneration or destruction of the substance of the cord. It 
 is obviously difficult to diagnosticate from a fracture in which no deformity 
 exists. The prognosis is, however, more favorable, and in cases of contusion 
 of the cord of moderate severity the improvement which occurs at the end of 
 the first or second week will serve to show the character of the lesion. 
 
 Wounds of the spinal cord are comparatively rare. From in front the cord 
 is obviously inaccessible, except to injuries otherwise fatal; from behind, the 
 oblique downward direction of the spinous processes serves as a protection. 
 The most exposed region is between the occiput and atlas and the atlas and 
 axis. Of course if the vulnerating body takes an upward direction it may 
 reach the cord in the dorsal region, and in cases of gunshot wound the cord 
 may be wounded by the ball or by fragments of bone, just as in other fractures. 
 As a rule, wounds of the cord are fatal, especially those which are inflicted in 
 the upper segments, and if the wound be in the cervical region above the ori- 
 gin of the phrenics, death will follow almost immediately. 
 
 Compression of the Spinal Cord. — {a) From blood. Spinal hemor- 
 rhage may occur as a conseijuence of injury, and may proceed from the vessels 
 contained in the substance of the medulla or from those between the latter and 
 its membranes, or from the large plexus of veins found in the space between 
 the dura mater and the walls of the spinal canal. The symptoms of extra- 
 Tnedullary hemorrhage as given by Gowers, Mills, and others are as follows : 
 1, sudden and violent pain in the back, more or less diffused ; 2, pain along 
 the course of the nerves passing through the membrane near the extravasation ; 
 3, abnormal sensations, tingling, etc., and hyperesthesia, referred to the same 
 parts ; 4, spasm involving vertebral and other muscles supplied by affected 
 nerves, and also sometimes the muscles su{)plied by the cord below the seat of 
 the hemorrhage ; 5, general convulsive movements ; 6, spasmodic retention of 
 urine ; 7, consecutive paralytic symptoms, but not usually complete paralysis. 
 
 Some points of differential diagnosis between meningeal hemorrhage and 
 extravasation into the substance of the cord should be borne in mind. Symp- 
 toms of irritation, such as pain, hyperesthesia, and spasm, in meningeal hemor- 
 rhage usually arise immediately or very early, and may precede ])aralysis, 
 "vvhich is commonly not complete. In hemorrhage into the substance of the 
 
scnai:!!)' of 77//; srixi:. 579 
 
 cord j)iiralysi.s may be complete at first or may rapidly become so, and symp- 
 toms of irritation may be very largely wanting. Hemorrhage may, and not 
 infre(|uently does, involve not only the membranes, but also the substance of 
 the cord, giving rise to complex symptoms. 
 
 The symptoms of hitra-nwdullarii hemorrhage are as follows : The onset is 
 sudden : there is a history of traumatism or of disease associated with profound 
 blood-changes ; the symptoms are bilateral : there is pain in the back, with 
 disappearance of the reflexes connected with the affected segment ; spasms, 
 rigidity, and paralysis come on rapidly, as does also the girdle symptom. 
 Bed-sores, incontinence of feces, and retention of urine develop very early in 
 the case, which runs a rapid course and is often fatal. 
 
 The treatment of spinal hemorrhage will dejiend upon the severity and 
 the persistence of the symptoms. The presence of rapidly-extending paralysis, 
 thought to be due to extra-medullary hemorrhage and threatenino; life through 
 involvement of important centers, might justify an immediate resort to opera- 
 tion. Persistent paraplegia with the development of bed-sores and the occur- 
 rence of cystitis, these symptoms extending over some weeks in a case in which 
 the lesion is believed to have been one of hemorrhage, might also warrant a con- 
 sideration of the propriety of operation. The prognosis will be the more favor- 
 able, either with or without operation, the lower the seat of the compression of 
 the cord. The most favorable cases will be those in which a clot occupies the 
 lowest portion of the canal, pressing upon the lumbar cord or the cauda equina. 
 
 {h) Compression from lymph. — Meningitis may result from any one of the 
 forms of injury which have been considered, and may be accompanied by an 
 exudation of inflammatory lymph, which in many cases is sufficient to cause 
 grave compression symptoms. The most common form of this is the external 
 pachymeningitis of Pott's disease, already described. More rarely a meningi- 
 tis becomes transformed into a myelitis which involves a certain portion of the 
 cord transversely, and is accompanied by progressive paralysis, pain in the back, 
 the girdle symptom, increased reflexes, ankle clonus, etc. 
 
 As to the diagnosis of these various forms of injury, the time which 
 elapses between the accident and the development of the symptoms is one of 
 the most important factors. (1) If the symptoms occur instantaneously after 
 a grave injury, the cord has probably been compressed by a displaced vertebra, 
 and the case has been one of fracture or luxation or of the common lesion 
 which combines them both, the so-called fracture-dislocation. (2) If the symp- 
 toms have not made their appearance for some time, possibly hours, after the 
 injury, the cause is probably hemorrhage, paralysis not having been produced 
 until a sufficient amount of blood had accumulated to cause the necessary pres- 
 sure. If the hemorrhage is intra-medullary, less time will elapse than if it 
 occurs between the membranes and the walls of the canal. (3) If the symp- 
 toms of paralysis do not appear until a period varying from a week to one or 
 two months, they are probably due to pressure by inflammatory lymph the 
 result of an external pachymeningitis. 
 
 FEACTUEES OF THE SPINE. 
 
 As compared with other fractures, those of the vertebrae are rare, constitut- 
 ing only 3.3 per cent, of nearly 52,000 fractures treated in the London Hospital 
 during thirty-five years. Gurlt's table shows that fractures of the cervical and 
 dorsal vertebras are almost equally frequent, those of the lumbar vertebrae 
 much less common; that the vertebriB most frequently broken are the fifth 
 and sixth cervical, the last dorsal, and the first lumbar ; that is, those which are 
 
580 
 
 AX AMERICAX TEXT-IKX tK OF sriidKin'. 
 
 situated at tlio junction of the more niovay>le ^vitll the more fixed portions of 
 the spinal column. More than one vertehra is usually l)roken when the injury 
 involves the upper portion of the column. The cervical fractures are by far 
 the most fatal. The great majority of spinal fractures occur during middle 
 life. They are found more frequently in males than in females, probably 
 owing to the greater exposure of the former to injury. The body of the 
 vertebra is the portion fractured in the majority of cases, constituting, accord- 
 ing to Gurlt. about two-thirds of all fractures in the cervical region and seven- 
 eighths of all in the dorsal region. Fracture of the arches is found in about 
 one-half of the cases of cervical fracture, one-seventh of those in the dorsal 
 region, and one-eighth of those affecting the lumbar vertebrae. There is rea- 
 son to believe that the frequency of fracture of the arches has been somewhat 
 under-estimated. Stimson remarks that it does not seem improbable that some 
 of the severe sprains of the lower portion of the back which leave a more or 
 less permanent weakness or sensitiveness of the part may be fractures of the 
 arch without displacement and possibly without union. Certainly when the 
 fracture occurs from direct violence, which is comparatively rare, the arches 
 are especially likely to be broken. In 81 cases of resection of the spine for 
 fracture and luxation White found a record of fracture of the laminae or arches 
 in no less than 45 per cent. Of course, as he remarks, this does not represent 
 the actual frequency of this form of fracture, as doubtless in many of these 
 cases it was recognized previous to the operation and constituted one of the 
 principal indications therefor. The most common cause of fracture of the spine 
 is forced flexion, the head and neck being bent fonvard upon the chest, or the 
 thorax upon the pelvis. This occurs commonly in accidents in which embank- 
 
 Fio. ?43. 
 
 Fracture of Spine, with I-aceration sf the Cord (Shaw). 
 
 ments cave in or scaffoldings fall, and probably enters into those forms of 
 fracture in which the patient falls upon the feet or the sacrum or the head 
 from a considerable height. In all these cases we have associated with the 
 fracture, as a rule, tearing of muscles, laceration of ligaments, crushing of 
 the cancellated tissue of the body of the vertebra, hemorrhage into the spinal 
 canal, and commonly some displacement. The portion of the sjdne above 
 the fracture slips forward and pinches the spinal cord between the arch of 
 
FRACTURES OF THE SPINE. Plate XVII. 
 
 Fracture of the spine. 
 
SURGERY OF THE SPINE. T>?>\ 
 
 the vcrtt'hra iinmodiately above ami the e(l<^e of" the body of the broken 
 vertebra (IM. X\'II. and Fig. 243). Oecasionally a piece of bone is driven 
 into the sj»in:il cniial and compresses the cord. 
 
 'JMie symptoms common to all fractures of the vertebrte are pain, in- 
 creased on motion, tenderness on pressure, ecchymosis, and more or less 
 extensive paralysis of motion or of sensation or of both. 
 
 Subsidiary symptoms found in the majority of cases are deviation of 
 the spinous processes and occasionally angular deformity of the spine, phos- 
 pliatic urine, and disorders of the sexual organs, shown in the male by 
 priapism. 
 
 The prognosis in all cases is unfavorable, both as to recovery of func- 
 tion and as to great prolongation of life, becoming more serious in direct 
 proportion to the higher situation of the fracture, the severity of the injury 
 which causes it, and the amount of crushing or of dislocation. 
 
 Fractures of the Lower Three Lumbar VERTEBRiE. — These are not 
 very common, and are frequently unattended by serious symptoms. Owing to 
 the fact that the cord terminates at the level of the second lumbar vertebra 
 and that the long roots of the cauda equina surrounded by a firm fibrous mem- 
 brane slip smooths one upon the other, and thus slide out of the way of fragments 
 of broken bone, they often escape injury altogether. On account of the less- 
 ened rotation in the lumbar portion of the spine and of the large muscular 
 masses that surround the vertebrae there is apt to be no crepitus, deformity, 
 or preternatural mobility, and in the absence of paralysis the only symptoms 
 are local pain and tenderness and a feeling of weakness and instability Avhen 
 the patient attempts to stand. As this, however, would obviously accompany 
 a severe contusion of this region, it is evident that a positive diagnosis is 
 scarcely possible. In exceptional cases paralysis and other symptoms of frac- 
 ture are present. As a rule, the prognosis is favorable as to life, and, in fact, 
 complete restoration to strength and to functional ability often follows. 
 
 Fractures between the Second Lumbar and Tenth Dorsal Ver- 
 tebra. — These fractures are followed by paralysis of the portions of the 
 body which receive their nervous supply from the lumbar and sacral plexus. 
 Paralysis of the lower limbs and of the bladder and rectum is exceedingly 
 common. Sensation is sometimes not so completely abolished as motion, but, 
 as a rule, the paralysis of both motion and sensation is absolute. There is at 
 first retention of urine, which as the bladder becomes distended is imperfectly 
 relieved by a slight overflow or dribbling, the so-called "incontinence of reten- 
 tion." This, in cases which are neglected or in those in which septic instru- 
 ments are used for catheterism, or, in many cases, in spite of the greatest care, 
 is folloAved by a violent cystitis, with phosphatic and ammoniacal urine. The 
 retention of feces which at first occurs is due to a paralysis of the muscular 
 walls of the intestine ; as these gradually recover their pow'er to some slight 
 extent, the contents of the bowels are passed on toward the lower intestine, 
 and, owing to the paralysis of the sphincter, escape involuntarily. When the 
 motions are solid, this takes place at long intervals ; when they are liquid, they 
 flow away continuously, the patient having neither control nor knowledge of 
 their escape. The nutrition of the paralyzed parts is feeble; the skin becomes 
 coarse and branny and covered with desiccated epidermic scales. The muscles 
 waste, points exposed to pressure become red or purplish, and unless the 
 greatest care is exercised gangrene follows, producing bed-sores which tend 
 to extend, rapidly involving in such cases the entire thickness of the soft 
 tissues down to the bone and spreading in every direction. 
 
 The prognosis in these cases is distinctly unfavorable, although some 
 
582 .l.V AMKRlCAy TEXT-liOOK OF smcEliY. 
 
 undoubted instances of recovery have been recorded. Life is usuallv pro- 
 longed for from six months to two years. The patients die finally from exhaus- 
 tion or from the septic eft'ects of the bed-sores or the cystitis. 
 
 Fractures of the Dorsal A'ertebr.e. — In frattures between tiie tenth 
 and second dorsal vertebra^ tliere are all the above-mentioned symptoms, with 
 the addition of marked paralysis of the abdominal muscles, distention of the 
 intestines with gas. giving rise to tympany, and difficulty in respiration, which 
 will be greater the higher the position of the fracture, owing to the involvement 
 of a progressively larger number of the intercostal muscles. In addition to 
 the causes of death already mentioned, such patients may die from hypostatic 
 congestion, or from pneumonia which gradually follows the plugging up of the 
 air-vesicles and the bronchi with mucus, which the patient is unable to dislodge 
 by coughing or expectoration. The expectation of life is distinctly less than 
 in the dorso-lumbar fractures. 
 
 Fractures in the Ceryico-dorsal and Cervical Reoions. — There is 
 in these fractures, of course, paralysis of sensation at a much higher level than 
 in those already considered. A want of symmetiy in the sensory paralysis 
 is often observed at first, but disappears as degenerative changes occur in the 
 cord. Occasionally there is a hyperesthetic area immediately above the upper 
 limit of anesthesia, due probably to the congestion and irritation of the region 
 just above the seat of injury. If the fracture involves only the first or the 
 second dorsal, but one cord of the brachial plexus will be involved and the 
 paralysis of the upper extremities will be incomplete. If, however, it runs 
 through the lower cervical vertebra, there is likely to be absolute motor and 
 sensory paralysis of both arms. It is important to remember that the seat of 
 the compression of the cord will in the great majority of cases be higher than 
 that of the anesthesia or paralysis by the length of the course of the nerves 
 involved within the spinal canal, and that it will usually be caused by the for- 
 ward luxation of the vertebra above the seat of fracture. For example, the 
 nerve which supplies the interosseous muscles and the intrinsic muscles of the 
 hand is the first dorsal. Its root in the spinal cord is, however, on a level 
 with the seventh cervical vertebra. Therefore if, in a case of fracture, we 
 had marked prominence of the spinous process of the first dorsal vertebra, we 
 would understand that the cord was probably injured by the dislocation for- 
 ward of the vertebra immediately above it. and that the highest level of the 
 paralysis which would follow would be indicated by the distribution of the 
 first dorsal nerve. 
 
 Thorburn's tables, which are probably approximately correct, but require 
 confirmation, give the distribution of the most important nerves as follows : 
 
 Fourth cervical nerve supplies the supra- and infraspinatus. 
 
 Fifth " " " " biceps, brachialis anticus, deltoid, and supina- 
 
 tors. 
 
 Sixth " " " " subscapularis (this appears to be the highest), 
 
 pronators, teres major, latissimus dorsi, tri- 
 ceps, pectoralis major. 
 
 Seventh " " " " extensors of the wrist. 
 
 Eighth " " " " flexors of the wrist. 
 
 First dorsal " " " interossei and intrinsic muscles of the hand. 
 
 This is very well illustrated by one of Thorburn's cases, in which there was 
 a fracture-dislocation of the seventh cervical and first dorsal vertebnie, the first 
 dorsal having been fractured while the seventh cervical was displaced forward, 
 carrying with it the fragment of the first dorsal. The cord was compressed at 
 that level, and was softened for a short distance above and below the site of 
 
suRciKny OF Tin-: spfne. 
 
 583 
 
 Fig. 244. 
 
 Fracture-dislocation of the Seventh 
 Cervical and First Dorsal Vertebrae 
 (Thorburn). 
 
 compre.s.'^ioiK its centre Lein;:; occupied by an effusion of l)loo(l reaching; as liijrh 
 as the fifth cervical nerve-roots in the form of a narrow cone ( Fig. 244). In this 
 case the injury was at the extreme lower part 
 of the cervical region, and must at first have 
 involved the region of the first dorsal nerve, 
 and probably to some extent that of the eighth 
 cervical. At first there was paralysis only of 
 the intrinsic muscles of the hand and the inter- 
 ossei, but thereafter from day to day it was 
 possible to watch the extension upward of the 
 myelitis, the motor power failing in the fol- 
 lowing muscles in the order named : (1) flexors 
 of the wrist ; (2) extensors of the wrist ; (3) tri- 
 ceps and pectoralis major; (4) latissimus dorsi ; 
 (5) teres major and subscapularis ; (6) deltoids, 
 flexors of the elbow, supra- and infraspinati. 
 
 In the majority of cases of fracture of the 
 spine in which life is prolonged for any time a 
 similar series of phenomena will be observed. 
 
 Fracture of the Atlas and Axis. — In 
 fractures above the fourth cervical vertebra 
 when the cord sustains damage the injury is 
 either immediately fatal, or more often the 
 patients survive for a period o£ time varying 
 from a few hours to two weeks. In one case 
 (Hilton) the patient lived fourteen ^^ears, and 
 in another (Shaw) for fifteen months. Frac- 
 tures of the upper two cervical vertebrse, however, are especially dangerous, 
 on account of the close relations between these vertebrae and the medulla 
 oblongata, and also from their position above the roots of the phrenic nerves 
 and of the nerves supplying the external muscles of respiration. 
 
 The symptoms of fracture are complete paralysis of all the parts below^ the 
 seat of the fracture, rigidity of the neck, pain in the neck or occiput, and 
 sometimes distinct crepitus. These symptoms, however, result also from 
 dislocation, and a differential diagnosis is frequently impossible. The axis is 
 more frequently broken than the atlas, and the odontoid process is sometimes 
 broken alone. The structure of the body of the axis is more spongy than that 
 of the atlas, and its weakest point is about one centimeter below the neck of 
 the process, which explains the seat of one of the most common fractures. In 
 cases of fracture of the odontoid process with accompanying dislocation, the 
 head is rigidly maintained in a fixed position, and in cases of unilateral dis- 
 placement is turned to the opposite side. There is often an unusual prominence 
 of the larynx, and the posterior wall of the pharynx may be pushed forward 
 by the body of the dislocated vertebra. 
 
 The treatment for such an accident should consist in gently straightening 
 the spine and placing the patient in a supine position, w^ith fixation of the head 
 if the fracture involves a cervical vertebra, by applying sand-bags to each 
 side. The character of the bed upon which the patient is placed is of great 
 importance. The water-bed is preferable to any other, but in cases Avhere this 
 cannot be procured an ordinary mattress covered with mackintosh may be em- 
 ployed, and air-cushions and rubber rings may be used to protect the most 
 salient points. The bladder should be emptied every six hours by means of a 
 N^laton or Mercier catheter, Avhich should be kept scrupulously aseptic. If 
 
hSi AX AMEJi'/(A.\ TKXT-JiOOK OF SURGERY. 
 
 cyi'titis occurs in spite of tliis, it is sonictiincs useful fo wasli out tlie bladder 
 with solutions of boric acid, jieroxidc of hydro<^en, etc. If tlie constipation 
 which ininu'diately follows the accident is ])ersistent, it is well t») <rive a cathar- 
 tic. The <xreatest care must be exercise<l in cleansiiif^ the j)arts after any 
 dribbling of urine has occurred or after there has been an action of the bowels. 
 The patient should be washed daily and turned gently from side to side, so that 
 the laps, the sacrum, and all ))ortions of the back may be rubbed with alcohol 
 or soap liniment, and afterward anointed with zinc ointment containing enough 
 carbolic or salicylic acid to ])revent decomj)osition of the secreti«»ns. The bed 
 must be ke])t smooth and the drawsheets and other bed-clothing al»solutely 
 without wrinkles. If bed-sores form in spite of these precautions, the affected 
 regions must be immediately relieved from all pressure by the use of rubber 
 rings, and the sores themselves cleansed and dressed antiseptically. In this 
 way the greatest amount of comfort may be obtained while carrying out a 
 purely palliative and expectant treatment. It is obvious, however, that the 
 case is being left during this time to the unaided efforts of nature, the results 
 of which in the great majority of cases are, as has been seen, most unsatisfac- 
 tory. The tendency of modern surgery is toward rather more active interfer- 
 ence with these cases, and it is probably safe to say now that in the nuijority 
 of spinal fractures in which there is recognizable deformity immediate rectifica- 
 tion of the abnormal position is thought to be indicated, just as in any other 
 fracture. This in many cases can be done by the usual methods of extension 
 and counter-extension with manipulation. The lower limbs may be gently 
 drawn upon by one assistant, while the head is,firmly held in position by another 
 with his hands upon the chin and occiput. The surgeon can often under the.se 
 circumstances press the displaced bones into position while the patient lies either 
 upon his face or upon his back. If the fracture is high and the abdominal 
 muscles and external res])iratorv muscles are paralyzed, great care must of 
 course be observed in turning the patient on his f^tee not to interfere with the 
 action of the diaphragm by pressing upward the abdominal contents, as this has 
 been known to cause fatal asphyxia. 
 
 If the deformity cannot be relieved in this way, extension on an inclined 
 plane may effect the same pur|)ose. and a fixed dressing can be applied at the 
 same time by slipping beneath the u})per portion of the trunk of the patient, as 
 he lies supine upon a mattress, a many-tailed bajulage made of stout flannel and 
 then three to six layers of crinoline plaster bandages. The ordinary suspension 
 collar used in Potts disease should then be applied to the chin and occiput, and 
 the head of the mattress or of the bed gradually raised so as to use the weight 
 of the patient's body as an extending force, the collar being fastened to the 
 head-piece of the bed or being hehl very firmly by an assistant. The layers 
 of bandage may then be moistened and brought into position, a strip of ordi- 
 nary bandage being interposed between their anterior extremities, so that the 
 jacket may be easily opened and removed if it seems desirable. Extension 
 from the shoulders in cases of dorso-lumbar fracture, or from the chin and occi- 
 put in cases of fracture at a higher level, may then be c^uitiously applied daily, 
 or in some ca.ses may even be made permanent during the process of consoli- 
 dation. 
 
 The results in a number of cases in which this method or some modification 
 of it has been adopted are suflBciently encouraging to warrant its trial in a 
 much larger proportion of fractures of the spine than heretofore, ten cases 
 out of sixteen reported by Burrell having been greatly benefited. In many 
 cases, however, no results follow, and of course the method is open to the objec- 
 tions that there are some risks of increasing pressure on the cord in rectifying 
 
SURGERY OF THE SPINE. 585 
 
 tlic (Icfonnitv. and. furtlu-r, that it is dinicult to avoid unpleasant pressure effects 
 in spinal (."isos in ^vliicli a fixed dressini; of" this sort is used. Kenienibcring, 
 however, the e.xtreuiely unfavorable outlook in cases of fractuix's of the spine 
 treated expectantly, it seems worth while to run these or even greater risks 
 if in a fair proportion of cases the ])atients can be benefited. Of late years 
 resection of portions of the spine has been em])loyed with increasing fre- 
 quency in those cases in which the expectant treatment or tlie treatment by 
 extension had obviously failed, and in some cases has been resorted to imme- 
 diately after the fracture. The observations are now sufficiently numerous to 
 show that even extensive resections of the laminae do not greatly or perma- 
 nently weaken the spine, that under antiseptic methods the risk of consecutive 
 infiannnation of the cord or membranes is practically very slight, and that 
 danger from hemorrhage or from loss of cercbro-spinal fluid is not to be feared. 
 They also show that it happens not infVe([uently that the cord is directly com- 
 pressed by fragments of the lamina; themselves. The operation is therefore 
 one which should no longer be rejected on the sole remaining ground that we 
 cannot be certain in any given case as to the exact amount of damage which 
 has been done to the tissues of the cord. On the contrary, in the light of 
 experience this would seem rather to favor operation than to contraindicate it. 
 Whites statistics show that thirty-seven operations for fracture performed during 
 the antiseptic era have resulted in 6 complete recoveries from the operation and 
 injury, 6 recoveries with benefit, 11 recoveries unimproved, and 14 deaths, a mor- 
 tality of 38 per cent. Those cases in which the lesion occupied the lumbar region, 
 and especially those in which only the cauda equina were involved, were, as might 
 be expected, especially favorable. So, too, those cases in which fractures of the 
 arches or lamiucTe existed gave on the whole good results, while the prognosis, 
 just as in the expectant treatment, became unfavorable in direct proportion to 
 the severity of the injury and the height of the fracture. It is safe to say, 
 however, that the results of recent operative interference in properly selected 
 cases of fractures of the spine are encouraging, and are likely to lead to the 
 more frequent employment of resection of the posterior arches or laminne (a) in 
 all cases in which depression of those portions, either from fracture or from dis- 
 location, is obvious; (h) in some cases in which after fracture rapidly progressive 
 degenerative changes manifest themselves ; (c) in all cases in which there is 
 compression of the cauda equina from any cause, whether from anterior or poste- 
 rior fracture or from cicatricial tissue ; (tZ) in the presence of characteristic 
 symptoms of spinal hemorrhage, intra- or extra-medullary. 
 
 Operation is contraindicated by a history of such severe crushing force as 
 would be likely to cause disorganization of the cord. What will remain in 
 doubt previous to operation will usually be the extent of damage done to the 
 cord and the possibility of its reparative action. As to this, the safest rule is 
 that which has been formulated by Lauenstein — namely, that if after the lapse 
 of six or ten weeks there is incontinence of urine with cystitis or incontinence 
 of feces, and especially if there are also the development and spreading of 
 bed-sores, but little is to be hoped for from the unaided efforts of nature. If, 
 however, these symptoms be absent, and if there be the least improvement in 
 either sensation or motion, it will be proper for the surgeon to delay operative 
 interference still lono-er. 
 
 The operation itself — laminectomy — may be done in the following man- 
 ner: The patient is placed in a prone position, a gentle curve having been given 
 the spine by means of a firm small pillow placed under the lower ribs. A long 
 incision should be made directly doAvn to the tips of the spinous processes, the 
 middle of the incision being opposite the seat of the fracture. The muscles 
 
■;-!(] AX AMi.nrcAX Ti: XT- HOOK or smoERY. 
 
 slidulil lie frcclv scpMvatcd IVdiii the sides of the spinous processes iind the 
 ])()steri()r suvtacos of the hiiniiKO. The periosteum may Ix- reflected by mak- 
 iii<i; an incision tlirough it ah)n,i:; the angle between the sjtinous processes and 
 the himinnc, turning up its edge at this point Avith the help of dissecting 
 forceps, and then scraping the surfaces of the vertebral arches Avith a curved 
 periosteal elevator. This should be done neatly, so as to leave as little ragged 
 muscular tissue as possible, since this may become necrotic and produce later 
 troul)le. Then the periosteum is similarly reflected on the opposite side. 
 Retractors of moderate size, not large or clumsy enough to be in the -way, 
 are all that is needed to keep the muscular masses from interfering Avith the 
 sul»sequent procedures. This being completed, the hemorrhage should be ar- 
 rested by hemostatic forceps, by packing hot sponges between the spinous pro- 
 cesses and the detached muscular mass, and by ligatures. The next step con- 
 sists in the division of the spinous processes close to their bases by means of 
 laro-e, strong bone forceps set at an obtuse angle. This adds nothing to the 
 severity of the operation, while it aff'ords much freer exposure of the laminae, 
 Avhich are the next parts to be attacked. They can be expeditiously and safely 
 divided by the rongeur forceps or by a pair of strong bone forceps, either 
 straight or having a large obtuse angle as may be preferred by the operator. 
 The vertebra at the center of the incision or the displaced vertebra should be 
 selected, and the vertebral spaces above and below its laminre should be recog- 
 nized with the tip of the finger. The lamina? should then be cut through by 
 successive short nips of the bone forceps, the line of section being as close to 
 the transverse processes as possible. This gives the greatest exposure of the 
 cord and of the membranes. 
 
 The color of the dura should be noted, particularly with the vicAV of deter- 
 mining in cases of traumatism Avhether it is or is not necessary to open it. If 
 it be dark or purplish from the presence of exuded blood beneath it, or yelloAv- 
 ish from the presence of pus, it Avill, of course, be proper to incise it in order 
 to empty and to explore the subdural space. If it is determined to open it, it 
 mav be picked up in the median line and at the middle of the incision with a 
 pair of delicate toothed forceps, nicked Avith a knife or the scissors, and then 
 divided either upon a director or Avith a pair of blunt-pointed scissors to any 
 required extent upAvard and doAvnAvard. It can be easily and gently retracted 
 to either side, so as to expose the Avhole posterior surface of the cord to both 
 inspection and palpation, permitting the gentle insertion of the tip of the finger 
 betAveen its inner surface and the lateral aspect of the cord, and permitting 
 also, if need be, the investigation of the anterior and antero-lateral subdural 
 spaces by means of a blunt curved instrument, such as a pedicle needle or an 
 aneurysm needle. The inspection having been comjjleted, or it having been de- 
 termined after removal of the cause of compression that no iuditation for further 
 operation exists, the incision in the dura should be stitched up Avith fine inter- 
 rupted catgut sutures. These may be introduced very readily and speedily by 
 means of a pair of staphylorrhaphy or Hagedorn needles, the one not in use 
 being threaded by an assistant Avhile each stitch is being put in place ; the 
 stitches should be inserted at intervals of about one-eighth to one-sixth of an 
 inch, and Avhen all are in place can be easily tied, the ends being cut oft' short. 
 A small rubber drainage-tube and a dozen strands of chromicized catgut should 
 then be laid throughout the entire length of the wound, the umscles being 
 united above them by means of buried chromicized catgut sutures, after 
 Avhich the skin and aponeurosis are brought together by silk or silver Avire as 
 may be preferred. It is hardly necessary to say that the most rigid antiseptic 
 precautions should be observed from first to last. 
 
SURGEL'V OF Tin-: srfNE. 
 
 687 
 
 Autero-lateral View of a Cervical Dislocation, slMiwiii_' the 
 prominence of the upper vertebra, and at x a displaced artic- 
 ulating process (KoeniK). 
 
 Fig. 24tj. 
 
 DISLOCATIONS OF THE VERTEBRiE. 
 
 These, as lias been said, are eominonly associated with fracture, but a 
 number of cases have been reported and verified by post-mortem examination 
 in which uncomplicated dis- 
 location has occurred. They Fifi. 24o. 
 Avere nearly all of the cervical 
 region. A few dorsal dislo- 
 cations have been noted, the 
 majority of them aft'ecting the 
 twelfth dorsal vertebra. Only 
 three or four cases of dislo- 
 cation of the lumbar verte- 
 bi'ie Avithout serious fracture 
 have been recorded and con- 
 firmed by autopsy. 
 
 Vertebral dislocation may 
 be caused by forced flexion 
 or extreme extension. AVhen 
 j)roduced by such forces they 
 will uniformly be bilateral and 
 either forward or backward 
 (Figs. 240 and 246). They may 
 also be produced by extreme 
 lateral motions of the spine 
 or by excessive rotation. In 
 either of these cases they may 
 be unilateral, either forward or 
 backAvard, and may be incom- 
 plete, that is, the articular sur- 
 faces may remain in contact 
 at their edges ; or complete, in 
 which case the inferior process 
 of the upper vertebra passes 
 farther forward and sinks into 
 the notch between the body 
 and the superior articular process of the loAver vertebra (see Fig. 247). 
 It is usual in treating of dislocations of the vertebr.Te to speak of the upper 
 one as the vertebra that has been dislocated. Of course, there are the usual 
 
 associated lesions, including 
 ^^^- rupture of ligaments, mus- 
 
 cles, and blood-vessels, in- 
 juries to nerves, and often 
 laceration of the interverte- 
 bral disks. In the absence 
 of deformity the symptoms 
 will be the same as those 
 of fracture of the vertebree. 
 Crepitus and preternatural 
 mobility are not ahvays ob- 
 tainable in fracture, and in- 
 deed cannot wdth propriety 
 
 Complete Unilateral Dislocation by Rotation or Abduction of a \^q sOU^ht for in the maioi'itV 
 cervical vertebra (Koenig). <• P t i ' • 
 
 01 such cases. In the cervi- 
 cal region it may be possible to recognize the change in the relations of the 
 
 Anterior View of Figure 2-15 (.Koenig). 
 
588 
 
 AX AMK/.'JCAy Ti:XT-li(}OK OF ,S I '/,'(,' /■:/,')■ 
 
 transverse processes, the Ixxly of the disldciitcil vcrtclmi may ])e felt rlmniirli 
 the ]»h:innx, and the absence of the e()n('sj)()ii(lin<r spinoiis jirooess niav he 
 noted on the hack of tlie neck. The rigidity and the attitude in which" the 
 neck is held will often be very suggestive (Fig. 248), but may be closely 
 simulated by the muscular contraction and pain due to contusion of muscles 
 or to inflammation of the intervertebral joints. The paralysis will dej)end 
 upon the extent of the displacement and the corres))onding damage to the cord, 
 
 and may vary from a very slight pare- 
 sis to extensive para])legia. Usually 
 motor paralysis is more marked and 
 extensive than sensory paralysis, and 
 both kinds are apt to be less abso- 
 lute in dislocation than in fracture. In 
 some cases of dislocation paralysis has 
 been entirely absent. 
 
 Although many surgical authorities 
 have objected to any effort lacing made 
 to reduce luxation, on the ground that 
 the attempt may cause the immediate 
 death of the patient, especially if the 
 luxation is in the upper cervical region, 
 it yet seems proper in the majority of 
 cases in which dislocation is diagnosti- 
 cated to attempt to replace the part by 
 means of traction aided by flexion or 
 rotation. It is right that the patient 
 and his friends should ])e informed of 
 the risk of immediate death during this 
 procedure, but the surgeon may con- 
 scientiously and urgently advise that 
 this risk be accepted. The manocuvers will depend upon the seat of the dis- 
 location, but, as a rule, no special method can be indicated. If in a cervical 
 luxation an unnatural prominence in the pharynx can be felt, reduction may 
 be facilitated by making backward pressure with the finger through the mouth 
 •while at the same time traction is kept up from the chin and occiput. When 
 the displacement is unilateral, rotation should be used in addition to exten- 
 sion and counter-extension. The head, which is apt to be inclined to one side, 
 should be carried still farther in that direction, so as to disengage the processes 
 of the luxated vertebra, after which it should be gently rotated and bent toward 
 the opposite side, extension and counter-extension being kept up during the 
 whole of this procedure. In the lower segments of the spine the methods 
 already described for rectifying the deformity in fractures apply equally to 
 luxations. In the majority of cases the operator will be in doubt as to 
 whether or not a fracture coexists. 
 
 The prognosis is, of course, more favoral)le in uncomplicated luxations 
 which have been reduced than in fracture, but the injury in all cases must 
 be regarded as a very serious one. Even after reduction paralysis often per- 
 sists, and death ensues on account of the injury to the cord. 
 
 Luxation of the Fifth Cervical Vertebra (Blasius). 
 
suRGKin' or Tin: RrsriitATonv organs. 589 
 
 CHAPTER III. 
 
 SURGERY OF THE RESPIRATORY ORGANS. 
 
 section i.— the nose and nasal cavities. 
 
 Congenital and other Deformities of the Nose. 
 
 The nose varies naturally within wide limits in shape and size, and has 
 been studied alike by the artist and the surgeon, but outside of the natural 
 limits of variation we occasionally see more or less conspicuous deformity. This 
 may be either a failure to develop properly or an unusual width of space 
 between the nasal processes of the upper jaws. A few instances are on record 
 where the nose was totally lacking at birth. On the other hand, a supple- 
 mentary nose of such size as to cause the individual to be regarded as having a 
 double nose is not unknown. The fissure between the lower lateral cartilages 
 has been known to remain so conspicuous as to cause the individual to display 
 a bifid nose. Monks has recently remedied this by a vertical incision and 
 suture of the separated cartilages. Failure to develop in length along the 
 dorsal aspect may give rise in a prominent degree to that condition com- 
 monly known as snub-nose. That peculiarities in conformation of the nose 
 arc particularly likely to be transmitted by heredity is well illustrated 
 in the Jewish race. The subjects of inherited syphilis fre(juently present 
 noses which have little or no bridge, or which are so flattened between the 
 orbits as to be unpleasant to regard. Fractures often result in such a depres- 
 sion as to cause the deformity known as "saddle-shaped" nose. This too 
 has recently been successfully remedied by the insertion of a silver gilt or 
 celluloid plate through a small incision at the side or under the tip of the 
 nose. Strict asepsis is needful for success. The plate remains indefinitely 
 in situ. 
 
 But the most common deformities of the nose or nasal cavities are not those 
 which appear externally or which leave more than a slight external sign, but 
 those which produce variations of contour within the nasal foss?e. Perhaps the 
 most common of these is deviation of the nasal septum, which, though often 
 acquired, is most often of congenital origin. This may be slight in extent or 
 may be so marked as to lead to the virtual occlusion of the nasal passage on one 
 side. Furthermore it frequently happens that the pressure of such a bulging 
 septum against the turbinated bone produces various reflex irritations which 
 are at times quite severe. AVhen the degree of deviation is slight there is but 
 little evidence of it, but when it is extensive there is usually irregularity of 
 external configuration. 
 
 The nostrils are occasionally contracted from birth, and rarely are com- 
 pletely occluded by more or less tough membrane. When this membranous 
 occlusion is met with later in childhood, in the majority of instances it will be 
 
r.iio .i.v AMi.h'icAX Ti:xT-i:()()k' or ,sri:(; i:in\ 
 
 found to result from cicatricial tissue followinp; ulceration about the anterior 
 narcs. Such nostrils may be enlarged by a slow process of dilatation ; or a 
 combination of incision and stretching, which latter must extend over a long 
 period of time, may be practised. When the nostrils are completely occluded 
 or obliterated a combination of incision and dilatation is absolutely necessary. 
 
 A form of elepliantiasis occurs rarely in middle or later life. It has been 
 known to attain enormous ])roportions. It can be treated only in one way, 
 if at all ; that is, by excision of the affected tissue and proj)er closure of the 
 wound, — if necessary, by some plastic method. 
 
 A diseased condition much ros(>m1)]ing the above, but due to a very differ- 
 ent cause, is that known as rhinoscleroma. This is described by Ilebra as 
 an affection of the nose, the nostrils, and even the upper lips and the adjoining 
 parts. It is characterized by the a])pearance of hard swellings or tumors, — in 
 other words, of cutaneous nodosities, — sometimes almost polypoid in shape, iso- 
 lated or confluent, sometimes of a darker color than the adjoining parts. 
 These nodosities are more or less separated by fissures from which exudes a 
 yellowish fluid. The growths themselves may present cartilaginous hardness. 
 They distort the nostrils and make hideous the nose, and invade even the parts 
 about the mouth. Rhinoscleroma is due to the presence of n bacillus in the 
 tissues. Stepanow has been able to reproduce the disease in animals by inocu- 
 lation. It is amenable to but one form of treatment — that is, free excision 
 during its early stages. 
 
 Rhinophyma is a hypertrophic form of acne rosacea confined to the 
 nasal region, and is characterized by much vascular new growth. 
 
 Fissures of the Nose. — These are almost always connected with defects 
 of development and failures to close at or near the middle line, and are nearly 
 always confined to cases of cleft palate and hare-lip in Avhich the fissure extends 
 up into the nasal fossaj. Their proper consideration and treatment are connected 
 with the surgery of the mouth and face. It has happened once to the writer 
 to see a fissure of the septum, the effect of which was that there appeared to 
 be three nostrils. Under chloroform the thickest portion of this divided septum 
 was cut away and the third nostril abolished. 
 
 Asymmetry. — Asymmetry of the nasal portion of the face has been studied 
 especially by Zuckerkandl and Allen. While it may be of congenital origin, 
 in the majority of cases it is due to pre-existing stenosis of one nasal fossa, 
 which is thereby deprived of its proper nutrition and does not develop sym- 
 metrically with its fellow. This view is corroborated by the result of ex- 
 cluding the entrance of air into one nostril of vounsr animals. A variety of 
 experiments and clinical experiences makes it certain that obstruction of the 
 respiratory canals by enlargement of tonsils, hypertrophy of mucous membrane, 
 and adenoid vegetations in the pharynx occurring early in life is the principal 
 exciting cause of developmental defects in the nose. 
 
 Synechia, or adhesion or fusion of parts within the nasal fossje, is not 
 care, although those cases in which it is properly of congenital and develop- 
 mental origin are rare, since it is usually the result of some previously exist- 
 ing ulceration. 
 
 Diseases and Displacements of the Septum. 
 
 Abscess. — Abscesses in the septum may be acute or chronic. Acute abscess 
 comprises those forms which follow local traumatism, /. r. the purulent trans- 
 formation of a clot beneath the mucous membrane, as well as those abscesses 
 consecutive to furuncle, in the vicinity of a foreign body, or to adjoining ulcera- 
 
SURGERY OF THE RESPIRATORY ORGANS. 5i>l 
 
 tion. Corainonly the s\\t'lliiig of the septiini can l)e noticed by inspection 
 through the nostrils. It feels warm and is extremely ])ainful to the touch. Not 
 unfreiiuently perforation of the septum or loosening of its bony or cartilaginous 
 margins results. AVhen due to spread of septic influences from the neighbor- 
 hood this affection may be unilateral. ^JMie local treatment consists of early 
 and sulliciently free incision. 
 
 Chronic abscess is a more progressive and slowly destructive condition, with 
 minor or no inflammatory signs and few if any acute symptoms. It has been 
 mistaken for polyp and for a malignant disease. It is usually either of syphilitic 
 or of tubercular origin. When cither of these forms of intranasal disease is 
 primary, it may be followed by erysipelas of the face, by more or less local 
 destruction of tissue, or even by deep ])hlebitis and meningitis. 1'hey are 
 quite likely to be followed by loss of the septum and consequent deformity of 
 the nose. 
 
 Acute Coryza. — This is an acute inflammation of the Schneiderian mem- 
 brane, affecting, at least at first, that portion of it which covers the septum 
 and the lower turbinated bone, an<l is that condition known to the laity as 
 severe "cold in the head." A similar condition met with in the new-born or 
 in very young infants is a not uncommon sign of inherited syphilis. Except 
 for the distress which it sometimes causes or its reflex efi'ects, it is scarcely 
 of surgical interest, unless it occurs in those who have already some patho- 
 logical changes in these parts. The influence of cold and wet is predomi- 
 nant in its causation, since a slight chilling of the body is often enough to 
 produce it. It may also be caused by irritating vapors, e. g. of bromine, by 
 certain animal or vegetable products, such as pollen, by the odors of certain 
 flowers in susceptible individuals, by various foreign bodies, including polyps, 
 by traumatism, or by eczema or other eruptions within the nose. It may also 
 be attendant upon periostitis, upon furuncle or carbuncle, upon severe con- 
 junctivitis, or it may appear in the course of certain general diseases, like 
 measles, diphtheria, the grippe, etc. In certain individuals it appears so con- 
 stantly with attacks of asthma as to indicate something more than mere coin- 
 cidence. The young and those of a tubercular diathesis seem to be more fre- 
 quently affected. 
 
 Its local signs are those of profuse discharge of nasal mucus, with extreme 
 susceptibility and irritability of the Schneiderian membrane, and so much 
 obstructive swelling as to impair or make impossible nasal respiration. A 
 peculiarly uncomfortable and tickling sensation within the nose and a tend- 
 ency to sneeze on little or no provocation are its most marked symptoms. 
 So tumefied does the mucous membrane become as not merely to prevent that 
 passage of air through the nose which distinct speech requires, but even the 
 quality of the voice is changed. When the disease is severe the frontal and 
 maxillary sinuses are affected by extension, and the pain and discomfort are 
 thereby considerably increased. Often pharyngitis will further complicate the 
 disease, in which case there will probably be more or less implication of the 
 Eustachian tube, with its attendant complaints. In proportion to its severity 
 the sense of smell is impaired or temporarily lost. 
 
 An uncomplicated case of this character will ordinarily last five or six days. 
 If anterior and posterior rhinoscopy be practised an excellent demonstration 
 of the cardinal signs of inflammation will be afforded. 
 
 Treatment. — Acute coryza is virtually a self-limited disease, but its course 
 may be shortened by local and general treatment. The administration of a 
 brisk cathartic, followed by foot-baths at night, a sedative and antipyretic 
 mixture internally (phenacetin and quinine with small doses of morphia), the 
 
592 ^l^Y AMERICAN TEXT-BOOK OF SURGERY. 
 
 inhalation of steam from boiling water into wliicli a little ])(t\v(lciiMl camphor 
 has been tlirown, and the use of antisejitie alkaline spray to wliit-h \ to 1 jicr 
 cent, of coeaine and •} to o per cent, of antipyrine are added, will be found to 
 give very great relief. A snuff" eontaining menthol is often of great value. 
 When the watery discharge is ])rofuse the aildition of one-tenth of 1 ))er cent, 
 of atropine to the spray will materially diminish its excess. If local distress 
 be very great, a triturate may l)e ordered of 1 part of morj)hia with 25 parts 
 of bismuth subcarbonate or subnitrate, and the insufflation of a few grains of 
 this will have a ha]»))y effect. Avoidance of exposure to draught and cold is 
 of course an important adjunct in the treatment. 
 
 Ozena. — This is a term applied to a condition of fetid ulceration commonly 
 due to syphilis or other disease of the Schneiderian membrane, or else to an 
 atrophic form of inllaiuniation of the same commonly knoAvn as atrophic rJii- 
 nitin. The ulcerative form gives rise to discharges of a mixed muco-sanguino- 
 purulent character, with expulsion of crusts and scabs, and imparts a most 
 unpleasant and fetid odor to the breath. In the atrophic form of the disease 
 there is little or no ulceration, but so much lack of moisture as to lead to the 
 partial evaporation, decomposition, and drying of what discharge there may 
 be, with more or less disposition to the same characteristic odor of the breath. 
 Some writers include under this term disease of the adjoining sinuses and cel- 
 lular cavities, which undoubtedly frequently occurs, though not necessarily. 
 Practically, the term is applied to those cases of intranasal disease which give 
 rise to fetor of breath rather than any one distinctive pathological condition. 
 
 In every such case careful rhinoscopy should be practised, the treat- 
 ment depending upon the condition found. In most cases before such exami- 
 nation can be satisfactory nasal douches must be repeatedly given, and crusts 
 and liardened masses washed away by means of a spray with a compressed- 
 air force of from ten to fifteen pounds. Not until the nasal cavity has thus 
 been thoroughly cleansed and the immediate congestion caused by this inter- 
 ference subdued, either by waiting a little or by the application of a very weak 
 solution of cocaine, can an exact estimation of the condition be made. In 
 ulcerative forms small, ragged, more or less unhealthy ulcers may be found 
 in almost any part of the cavities, though these occur more commonly in parts 
 most easy of examination. More than this, it often happens that small or 
 relatively large areas of spongy bone will be found neerosed and loose or easy 
 of detachment, or that a necrosed area of cartilaginous or bony septum will be 
 discovered. Patients will sometimes present small portions of bone which have 
 been expelled spontaneously, which will be very suggestive. 
 
 Ulcerations in the nose which produce this condition may be of the follow- 
 ing varieties: 1, simple, which may have been originally of traumatic origin, 
 due to the finger-nail of the individual, to the presence of some foreign body, 
 or to the eff'ect of some caustic previously applied ; 2, tubercular, in which case 
 the general condition of the patient will be extremely significant : 3, syphilitic, 
 where there are almost sure to be other evidences of secondary or tertiary dis- 
 ease, the examiner having probably to look no farther than the mo.uth of the 
 patient in order to corroborate his diagnosis. 
 
 In all these forms of ulceration diseased or dead bone may occur, but this is 
 relatively infrequent in the first. The entire turbinated body, or one or more 
 of the turbinated bones, along with the septum, may be thus destroyed, and 
 even exfoliated extrrnally, and many a sunken bridge of the nose is evidence 
 of the destruction which has gone on beneath, due for the most part to the rav- 
 ages of tertiary syphilis. 
 
 The treatment of this variety of ozena consists in the main of removal 
 
SURGERY OF THE RESPIRATORY ORGANS. 
 
 593 
 
 of diseased bone, cauterizalion of the ulcer proper and its conversion into 
 healthy granulating tissue, and such measures as may be appropriately di- 
 rected toward cleanliness and antisepsis. If necessary, operation may be 
 undertaken, with cocaine or general anesthesia, for removal of set^uestra. Dur- 
 ing the treatment the general condition of the patient should not be neglected, 
 and in syphilitic cases a vigorous antispecific and tonic treatment will effect 
 almost as much benefit as do the measures instituted locally. 
 
 In that form of ozena due to atrophic rhinitis there is frequently necessity 
 for general and constitutional treatment, while the local treatment is directed 
 first toward cleanliness and freedom from the presence of decomposing crusts, 
 and secondly toward gentle stimulation of the nmcous membrane in order to 
 favor healthy secretion. The jiowders or sprays that are used for this pur- 
 pose contain substances which are mildly stimulating, such as preparations of 
 benzoin, to Avhicli menthol may be added. 
 
 Perforating Ulcer of* the Septum. — Under this name there has 
 recently been described an ulcerative process occurring usually along the 
 border of the cartilaginous septum, which' determines later its perforation, and 
 presents characteristics which apparently entitle it to separate description, inas- 
 much as it is independent of syphilis, tuberculosis, or lupus. The ulcer is round 
 or oval, and when oval has its long diameter placed antero-posteriorly. The 
 mucous membrane appears to be first affected. Local destruction advances 
 more and more deeply; finally the ulceration thus formed usually tends to 
 general cicatrization about its borders. It appears to attack old men oftener 
 than others. Histologically, the lesion seems to consist of an infiltration with 
 epithelial cells, as well as their subsequent multiplication. 
 
 Concerning its intimate cause we are yet ignorant. In some respects it 
 seems to correspond to perforating ulcer of the foot. It calls for little save 
 antiseptic treatment. 
 
 Deviation of the Septum. — Deviations of the nasal septum are very 
 common (Fig. 249), and constitute the most important abnormalities of the 
 nose. Mackenzie, for in- 
 stance, in examining 2152 Fig. 249. 
 individuals, found devia- 
 tion in 77 per cent., and 
 of a total of 34-46 cases 
 examined by several ob- 
 servers there was deviation 
 in about 60 per cent. 
 
 Deviation toward the 
 left appears to be more common than toward the right. It varies in amount and 
 character from a simple warping of the septal plate to complete displacement. 
 The causes of the deviation are by no means clear. In the infant the nasal 
 fossae are small and simple in conformation. The sinuses are not yet formed, 
 and the plates of the ethmoid are still cartilaginous. The cribriform plate is 
 even membranous and continuous with the falx cerebri and the dura mater, and 
 is thus flexible at a time when the vomer is already ossified. At the age of 
 two the frontal and ethmoidal sinuses, as well as the antrum, have begun to 
 form. The development of the turbinated bone is also tardy, and relative 
 activity of growth of these parts is a somewhat late manifestation. The 
 posterior or free boundary of the vomer is seldom misshapen, since it is 
 thick and strong, but its anterior portion is very liable to displacement, of 
 which traumatism is a frequent cause. Thus it appears that the vomer, occu- 
 pying the middle of a cavity with walls more rigid than itself, frequently 
 as 
 
 Varieties of Deflection of the Nasal Septum (Roberts). 
 
594 ^-V AMERICAN TEXT-BOOK OF SURGERY. 
 
 bends in the direction of least resistance, owing to injury or to unequal develop- 
 ment of surrounding parts. Deflections of the cartilaginous sections are most 
 common, next those of the bony parts, and finally those of the entire septum. 
 The cartilage may be bent upon itself vertically or horizontally, presenting 
 along the line of deflection a bulging sufiiciently prominent to occlude the 
 nares. Horizontal bending is much more common. The deep concavity of 
 the opposite nostril often corresponds with the convexity of the bend. It may 
 cause serious obstruction to the respiration. AVhen the warping is but slight 
 it ordinarily gives rise to no symptoms and calls for no interference. It not 
 unfreciuently happens that we have to deal with an enlargement of the middle 
 turbinated bone corresponding with the deflection of the septum, and second- 
 arily with a greater obstruction. 
 
 Another form of deformity of the septum is caused by development, near 
 the sutural line of the vomer and the palatal process, of a bony or cartilag- 
 inous ridge which constitutes a spur, as it is usually called, and which is in fact 
 an exostosis or ecchondrosis, and may extend horizontally for some distance. 
 It may be met with on one or both sides ; it helps to obstruct the inferior mea- 
 tus, always leads to thickening of the overlying mucous membrane, and should 
 alwavs be removed when met with. When the septum exhibits a double curve, 
 being warped first to one side and then to the other, it is described as repre- 
 sentinor a sigmoid flexion. This mav meet and touch the inferior turbinated on 
 one side and the middle turbinated on the other. 
 
 As might naturally be supposed, when the septum is markedly deflected we 
 frequently find the hard palate to be very high-arched or Gothic in contour. 
 Its transverse diameter is short, and the alveolar arch may be much more 
 oval or relatively smaller, by which the front teeth are thrown forward and a 
 characteristic expression given to the face. Delavan calls attention to the fact 
 that this condition is frequently associated with the habit of mouth-breathing, 
 and that it is often a family peculiarity. 
 
 Treatment of Deviated Septum. — For the rectification of this deform- 
 ity a large variety of operative methods have been suggested, depending in their 
 conception and for their successful performance upon the degree of deflection. 
 It is of some interest to know that this particular branch of surgery is one of 
 quite recent origin and development, and that almost all the operations prac- 
 tised for this purpose have originated within comparatively few years, although 
 the proceeding itself, after a rude fashion, is of great antiquity. By a few sur- 
 geons, Adams for instance, it was suggested to seize the crooked sei>tum between 
 the two blades of strong forceps and fracture it sufficiently to allow of resto- 
 ration to its normal outline. To keep it in the desired position head-bands 
 with pads and screws, or masks with adjustable pads, or intranasal apparatus 
 of more or less elaborate form. Avere called into requisition. Then it was 
 suggested to cut out of the septum, with a punch (Fig. 250) fashioned after 
 a conductor's punch, smaller or larger pieces of .shape according to the fancy 
 
 of the operator, by which the 
 septum would be so weak- 
 ened as to be easy of replace- 
 ment. This method is open 
 to the objection of leaving an 
 opening where nature did not 
 intend one to exist, and fur- 
 
 , „ ^ thermore leaves the septum so 
 
 Jams s Puuch. , , • i j 
 
 weakened as sometimes to lead 
 to subsequent falling in of the bridge of the nose. A much more successful 
 
SURGERY OF THE RESPIRATORY ORGAIiS. 
 
 595 
 
 application of tins tbrm of instrument is that by whi h a s^Ha^ mc^^ 
 n ade in the septum, yet without removal of any of it. ih.s ^^^^^'^'^^ens ^ 
 that it can he sprung' back into position, and yet leaves no perforation , but this, 
 le all otlier procedures where nothing is removed requires the «ubsequen u e 
 for a considerible k.^th of time of plugs by which the partition shall be held 
 S p^=^until Its tendency to warp is overcome. The saine oUl-;^on o^ le^g 
 a perforation often obtains against the use of the nasal saw (tig. 2.)1), which 
 
 Fig. 2.-)1. 
 
 Park's Nasal Saw. 
 
 Otherwise is a very useful instrument. Its especial range of usefulness is in the 
 ?emoTao outgrowths from the turbinated bones or of spurs or bridges from the 
 se rm It will be spoken of again later. A very simple method for uncom- 
 pl cated cases is that of incision through the protuberance along its long axis 
 Kwhich the septum is forcibly replaced by means of the finger in the nos- 
 t 1 Its elasticit} being thus temporarily overcome, it is held in place by 
 packin.. the previously obstructed nostril with plugs of antiseptic gauze oi of 
 mbber^or other suitable material. These are removed daily, and the parts 
 carefully cleansed, after which the plugs are replaced. If necessary, any re- 
 dundant portion can be pared with a knife or removed with a saw. 
 
 ingals has modified Ibis plan by incisions through the mucous membrane 
 its detachment from the underlying cartilage, and the removal of a triangular 
 portion of the latter, the base of the triangle being at Jhe^floor of the nose Of 
 CO u^e the membrane on each side of this piece should be detached Robe ts 
 ha dev^^ed an ingenious and very eifective way of overcoming septal deformity. 
 If there L angular deflection, he makes an incision from front to back ; if the 
 deflection is alrooved one, he splits the cartilage along the most prominent por- 
 tn aid cuts iSto the rest of the septum repeatedly until it has lost ^ts resiliency^ 
 An; small portions that protrude at the lower margin are removed ^^^^h knife or 
 saw If onlv small fragments of the entire thickness are cut a.^^y the 1 ttle 
 perforations thus caused^ubsequently heal. The septum is now held m place 
 by steel pins made for the purpose, which may be in- 
 serted through the nostril or from the outside (tig. 
 25-'^) The point is thrust through the inferior por- 
 tion of the septum, which is then placed in the desired 
 position, after which the pin is thrust still farther 
 onward and its point buried deeply in the firm and 
 untouched tissues at the back part of the nasal cham- 
 ber Two or more pins may be used for this purpose ; 
 they should be left a few days in sM. By this 
 method the use of plugs is avoided, and antiseptic 
 douches, powders, or sprays can be used as frequently 
 as desired. When ridges or projections of mucous 
 
 Fig. 252. 
 
 Pins inserted for Deviation of 
 Septum in Roberts's method 
 of operation. 
 
596 ^l^V AMERICAN TEXT-BOOK OF SURGERY. 
 
 membrane are the cause of the obstruction, or even Avhen this is composed 
 of soft cartihige. Jarvis recommends to transfix them with a needle and then 
 remove them with his steel wire snare. 
 
 Besides the methods thus briefly described (for more information concerning 
 which the reader is referred to special text-books), it has been proposed to 
 remove the offending cartilage or bone by rapidly revolving burrs or trephines 
 operated by the dental engine, by hand power, or by small electric motors, or 
 to attack them with fine chisels and gouges, the force being applied either with 
 the hand or with a small inallot. When properly performed, any or all of these 
 methods are admissible, and all are capable of afibrding relief In almost every 
 instance, however, there is necessity for long-continued care to preserve the 
 septum in its proper place and prevent it from again warping while still 
 weak. 
 
 Almost all these cases are complicated, however, by more or less hyper- 
 trophy of the mucous membrane of opposing surfaces, and it is relatively 
 seldom that attention to the septum alone will suffice. This brinf^s us to the 
 consideration of the causes which produce this other condition. 
 
 Hypertrophic and Atrophic Nasal Catarrh. — The complicated struc- 
 ture and character of the Schneiderian membrane, as well as the fact that, 
 especially in its lower portions, it is studded with large numbers of minute 
 glands Avhose function it is to secrete the nasal mucus, must not be overlooked 
 in accounting for this condition. These, being true glands, partake of the 
 usual adenoid-tissue arrangement. Evidently, then, irritations which affect 
 the membrane will also involve the glands, and the hypertrophy of one 
 without a corresponding aff'ection of the other is out of the question. This 
 membrane is more exposed to external influences than any other. Thus 
 it happens that repeated attacks of acute inflammation or the continuous 
 action of relatively trifling irritations lead to, first, a chronic congestion, and 
 second, tissue new-formation. This process, once begun, rapidly increases 
 in extent and severity. The new growth is very likely to occur along 
 that inferior turbinated bone which comes most closely in contact with a 
 deviated and protruding septum, and. as a rule, the structures over the lower 
 turbinated bone are much more commonly and extensively involved than those 
 over the other bones. This diseased tissue is usually more or less spongy or 
 erectile in character, and is composed of such a mixture of glandular and paren- 
 chymatous elements as to be commonly termed adenoid, the one form or the 
 other predominating according to the type of the structure first attacked. Hy- 
 pertrophy of the mucous membrane over the posterior portions of these turbi- 
 nated bones is more frequent tlian of that over the anterior portions. The ste- 
 nosis caused by these conditions may be partial or complete and temporary or per- 
 manent. Many individuals have just so much thickening as to suffer from alter- 
 nate stoppage and patency of the nostrils according to the condition of the weather 
 and their freedom from congestions due to colds. Anything which favors flow of 
 blood to the parts will occasion stoppage. Hence some persons complain of ina- 
 bility to breathe in bed through that side of the nose which is lowermost. Others 
 enjoy freedom of respiration in dry weather, while because of the hygrometric 
 condition of the atmosphere they suffer inconvenience during damp weather, and 
 some operators even take advantage of this latter circumstance ia order to seize 
 these growths when their increased size makes them easier to attack. 
 
 But interference with respiration is by no means the only trouble j)roduced 
 by this kind of hypertrophy. AVhen the stenosis is posterior, and especially 
 when the adenoid tissue of the naso-pharynx is involved, pressure is made upon 
 the orifice of the Eustachian tube, with the result of more or less impairment 
 
SURGERY OF THE RESPIRATORY ORGANS. 
 
 597 
 
 of heavin-. It is very important to boar this in niina, since not a few cases of 
 deafness iil one ear, or in both ears, depend primarily not upon disturbance m 
 the middle ear, but upon this conditi<.n of the naso-pharynx. iherefore in 
 treating patients for diafness an examination of the throat and nose is as essen- 
 tial as an examination of the meml)rana tympani. 
 
 After having made a careful examination and having recognized so far as 
 possible, the condition above described, there is considerable range of choice as 
 \o methods for obviating the difficulty, the choice being mainly between he rad- 
 c-il method of extirpation of the obstructing mass and that of its partia destiuc- 
 on y caustics or the actual cautery, trusting to the resulting cicatricial contrac- 
 io produce the desired diminution in size. The choice must be governed 
 to a certain extent by the occupation and the personal and constitutional habits 
 of die patient, and the means at hand. In either case local anesthesia can be 
 u.uallv accomplished with solutions of cocaine varying in strength from 2 to 
 8 ner cent usin- the stronger only when the weaker fail. Ihese may be 
 appHed fii!;; by the spray, tlfen by contact of small plugs o cotton saturated 
 ki e solution, or rarely, when necessary, by its injection mto the tissues with 
 tL fine neelof the ordinary hypodermatic syringe The operator must ahvays 
 expect the deeply colored and turgid appearance ot these growths to be modified 
 bv the constriniig effect of the cocaine. Small crushing forceps and scissors 
 have been devised with which those parts of the nasal cavity most subject to 
 thTs condition can be reached, and the hypertrophy when distinct or peduncu- 
 lated can sometimes be most easily removed by their aid 
 
 But some form of wire snare or ^craseur is perhaps the favorite instru- 
 ment for this purpose, and of the vanous forms of this ^^f "^^.^;;^.^7p^:f ^^3^.* 
 in this country, is more popular than that suggested by Jarvis (Fig. 253). 
 
 Fig. 253. 
 
 Jarvis's Snare. 
 
 Its wire loop is passed within the nose, and by the aid of artificial illumination 
 is lod-ed around the base of the mass which it is proposed to remove after 
 which" the loop is slowly tightened, and the fine wire cuts its way through 
 the tissue so slowly that, vessels being crushed across, the operation is almost 
 bloodless. In the attack upon posterior hypertrophies the manipulation is 
 sometimes quite difficult and requires the skill of an expert. It is made more 
 difficult by the sensibility of the part and by the reflex motions of the palate 
 and pharynx, which are usually beyond the possibility of voluntary control. 
 These are in some measure obviated by the use of palate retractors, or by the 
 introduction of tapes through the nostrils into the pharynx and bringing them 
 out through the mouth and tying them in front of the upper lip. By their 
 aid not onlv is the palate retracted and its movements controlled, but illu- 
 mination of"^tlie parts is also possible. These masses are sometimes removed 
 with a peculiar burr attached to some revolving mechanism, by which removal 
 is made as effective, though much more bloody. 
 
 The other method of treatment, by the use of caustics, avoids some ot the 
 unpleasantness of an operation, but usually produces much more pain and dis- 
 comfort, while snaring off a mass of adenoid tissue with the wire loop causes 
 frequently very little pain. 
 
598 
 
 .l.V AMERICAN TEXT- BO OK OF SURGERY. 
 
 An even more effective and commonly less painful method, certainly one 
 which leaves fewer unpleassant immediate consequences, is the use of the gal- 
 vano-cautery : the parts being prepared as above, the galvano-caustic knife or 
 point is applied as was the caustic, and is made to burn more or less deeply 
 and widely according to the effect desired. The resulting sloughs separate in 
 about the* same length of time, antl the after-treatment in each instance con- 
 sists mainlv in local cleanliness and antisepsis. The final benefit may not be 
 obtained until after the lapse of a number of weeks. This latter procedure of 
 course implies the possession of a suitable cautery or storage battery and the 
 necessary electrodes or cautery points, all of which are expensive. But when 
 it is applied with skill the result is usually very satisfactory. 
 
 A collection of adenoid tissue seldom exceeding 7 or S mm. in diameter 
 has been described by Luschka as the pharyngeal tonsil. This is found at the 
 vault of the pharynx, and may become enlarged under the same conditions as 
 those which give rise to hypertrophy or as those which produce adenoid tissue 
 in the nose. 
 
 The pharyngeal tonsil is itself of interest, since along with another col- 
 lection of similar tissue spread out at the base of the tongue it constitutes 
 what has been called the ring of adenoid tissue around the pharynx, the 
 principal portions of this ring being of course formed by the faucial ton- 
 sils. When this tissue in the pharynx is involved in hypertrophic changes, 
 it must be removed, either with spoons fashioned for the purpose or with cut- 
 ting forceps with somewhat dulled edges (Fig. 254). When diseased it may 
 
 Fig. 254. 
 
 Raynor's Naso-pharyngeal Scissors. 
 
 produce various reflex disturbances of about the same character as those men- 
 tioned under Neuroses of the Nose. 
 
 The Lingual Tonsil. — Completing the circle of glandular tissue around 
 the oro-pharynx there is more or less of lymphoid and adenoid structure 
 across the base of the tongue, which, described together, has l»cen known as 
 "the lingual tonsil." The principal difference between it and the faucial is 
 that the adenoid tissue here is disseminated in small groups over a consider- 
 able surface. There are here no glands, properly speaking, nor excretory 
 ducts nor outlets, but small enclosures, three or four lines in diameter, of 
 adenoid material covered by mucous membrane. These follicles much resem- 
 ble Peyer's patches in the intestines. They exist in the normal condition, 
 
SURGERY OF THE RESPIRATORY ORGANS. 599 
 
 but they become nmcb hyi^crtrophied, and of about the size attained by 
 lesions of adenoid tissue in the otlier parts of the ])barynx. They are 
 located between the circunivallate paj)ill£e and the epiglottis, and are incon- 
 spicuous except when enlarged. 
 
 Normally, there is a free interval between the base of the tongue and the 
 epiglottis, but this is more or less encroached upon when this tissue is hyper- 
 trophied, and sometimes tlie tip of the epiglottis may seem almost buried in 
 a mass of tonsillar structure. This hypertrophy may even extend laterally 
 to a considerable extent. When carefully viewed these masses will be seen to 
 form an aggregation whose component parts may be distinctly distinguished. 
 When these tissues are hypertrophied, there is sometimes complaint of pain 
 shooting up toward the ears, or there may be reflex discomfort in the larynx 
 or along the course of the pneumogastrics ; and when inflammation compli- 
 cates the hypertrophy there may be actual sharp pain. The voice is more or 
 less altered, and fatigue in speaking and singing is a common symptom. In 
 certain cases the voice is made uncertain and unreliable. Most patients suffer 
 from more or less reflex cough, either violent, spasmodic, or incessant, or else 
 of a hacking character. Part of this cough is due to friction between the 
 tongue and the glottis. It is ([uite likely that the so-called "globus hyster- 
 icus " is in many instances a sign of value, and due to the presence of 
 enlargements of this lymphoid tissue. Dyspnea and even asthma may occur 
 in patients with enlarged lingual tonsils. The only radical treatment con- 
 sists in the removal of the hypertrophies by caustics or mechanical measures. 
 The latter will consist either of the wire snare or of the sharp spoon in some 
 of its modifications. The galvano-cautery is often resorted to, and is prob- 
 ably the most satisfactory method of treatment. These operations can usually 
 be made by aid of cocaine without pain. 
 
 Atrophic Catarrh. — This is to a large degree a result of the previous 
 form, which when untreated has gone on to such complete formation of new 
 connective-tissue elements that the glandular portion has disappeared. The 
 result is now not so much the impediment to respiration as the dryness of the 
 parts, by which the patient's comfort in breathing is very materially dimin- 
 ished, and he has probably by this time, if not before, become changed from 
 a nose-breather into a mouth-breather. Still, with all this, there may be 
 such relics of previous hypertrophic obstruction as to call for purely surgical 
 relief by one or another of the methods above described. This form of disease 
 is likely to be more offensive than the previous, since the dried and thickened 
 mucous membrane is covered with crusts of desiccated secretion, which may be 
 more or less advanced in decomposition or which may cover over actual 
 ulceration in the tissues beneath. In this way we may have to deal with a 
 combination of atrophic catarrh and ozena. On account of the length of time 
 required to bring about this condition these cases pursue a very stubborn 
 and chronic course. Their treatment is, first, local cleanliness ; second, the 
 removal of any actual obstruction ; third, applications to whatever ulceration 
 may exist ; and finally, the endeavor to stimulate the long-disused remain- 
 ing glands into greater activity ; in other words, the restoration of the natural 
 secretion. This is to be accomplished mainly by stimulating and antiseptic 
 sprays or other applications, fluid or dry. It will require daily attention at 
 least by the patient himself, and often by the surgeon, and is a process so 
 slow as often to lead to discouragement and disappointment. Nevertheless, if 
 carefully persisted in, it may be productive of great good, if not of complete 
 restoration of the normal condition. 
 
ooo ^i.v AMi:iiu\{y Ti:xT-Ji<)()K oi srn(;i:iiy. 
 
 NASAL CATAKIMl. 
 
 Besides the acute and clin»nic tonus of inllainination of tlie Rchneiderian 
 membrane already referred to under the headings of (joryza and Adenoid 
 Thickenin«^, there is another form of chronic intiammation which is as com- 
 mon perhaps as anv, and which deserves consideration by itself under the 
 term of chronic catarrhal inflammation. This may bejLiin almost as a chronic 
 condition, or may be secondary to acute inllammations. As a rule, the 
 more chronic the' condition the more it involves the posterior nasal surfaces 
 alon<T with those of the pharynx, and we have practically to deal with a retro- 
 nasal or naso-pharyngeal catarrh. Narrowness of conformation may exert 
 some predisposing influence. Nevertheless, the condition prevails in all coun- 
 tries an<l climates ; l)ut it appears to be most frequent where atmospheric 
 chan'^es are most sudden. For the treatment of this condition, which is in the 
 main medical, the reader is referred to special text-books. 
 
 ULCERS. 
 
 Ulcers and ulcerations within the nasal cavities may be of the following 
 types: 1. Catarrhal ; 2. Tubercular (and Lupous) ; 3. Syphilitic ; 4. Leprous ; 5. 
 Malignant. It seems hardly necessary here to go into a description of each of 
 theseforms. Their nasal characteristics in no wise differ from those which the 
 same forms of lesion display elsewhere. Among the first must be reckoned 
 the kind of ulceration which one may see where two surfaces which were not 
 intended to touch each other have come into contact, or which the surface of 
 a nasal polypus, for instance, may exhibit. Tubercular ulceration of any- 
 thing like long duration will probably be accompanied by caries or necrosis 
 of the underlying bone. The same is true of the syphilitic form. Leprous 
 ulceration cannot be considered apart from general leprous disease, nor can it 
 so occur. Malignant ulcers are simply expressions of degeneration of malig- 
 nant neojdasms. and, while they may be regarded as among their disagreeable 
 phases, the ulcer itself is of little consequence as compared with the primary 
 disease, unless it produce frequent hemorrhages. 
 
 In the above statement no note is made of two or three other specific vari- 
 eties of ulcerations which may occur in the nose, such as those accompanying 
 glanders, actinomycosis, rliinoscleroma, etc. These are so rare in this country 
 as to deserve only mention. 
 
 The treatment of each of these forms must be obvious. The catarrhal 
 ulcer needs only cleanliness, freedom from irritation, and proper restoration to 
 a condition of healthy granulation, in order rapidly to heal. The tubercular 
 form mav rec^uire removal of diseased bone, and certainly should be thoroughly 
 cauterized or scraped, after which it can be coaxed to heal by simple measures, 
 unless the systemic infection be too pronounced. The treatment of the syphi- 
 litic form is inseparable from that of constitutional syphilis, and calls for anti- 
 specific medication. When one has to deal with a malignant ulcer in these 
 parts, the question is in the main whether the primary disease can be removed 
 by operation, no matter how severe, or not. If it appear that it can be, no 
 time should be lost in practising it. If, on the other hand, the case appear 
 inoperable, much nuiy be done by repeated curetting, or destruction of neo- 
 plastic tissue with the actual cautery, or its removal, or at least the removal 
 of so much of it as is accessible, with the scissors, knife, or snare. In this 
 way, without thought of radical cure, life may frequently be prolonged or 
 made less offensive both to the patient and to those around him. 
 
SURGERY OF THE RESPIRATORY ORGANS. 601 
 
 EPISTAXIS. 
 
 The term epistaxis originally denoted bleeding from any point aljout the 
 nose, but is now generally limited so as to mean hemorrhages frcjm the nasal 
 and connecting cavities. It may occur either as the result of trifling or severe 
 injury or spontaneously, and it may be active or passive. No mucous mem- 
 brane in the body is so naturally disposed to bleed both by liability to insult 
 and by character of construction as tliat which lines the nose. Hyperemia is 
 very easily ])roduced, and the l)lood- vessels of tlie part have little or no natural 
 support outside of their own walls. The traumatic form folhjws various inju- 
 ries, not necessarily applied directly to the nose. Falls of all kinds will fre- 
 quently produce it, and especially falls or blows upon the head. It is known 
 to occur frequently in connection with fractures of the skull, especially of the 
 base. It may occur from picking the nose or from rude introduction of some- 
 tliing into the nostrils, and occasionally follows explosions of some violence ; 
 thus men handling heavy pieces of artillery, especially within small compart- 
 ments, are frequently annoyed with it. When slight causes give rise to it, 
 there is nearly always some local or constitutional predisposition, usually in 
 the so-called full habit of body, or, in the aged, extreme fragility of vessels, or 
 a more or less varicose condition of the parts, in those who have this condition 
 elsewhere. The so-called spontaneous form may arise from inhalation of irri- 
 tating vapors ; from over-filling of the capillaries, due to violent over-action of 
 the heart or to too severe exercise ; from some act like coughing or sneezing ; 
 from previous ulceration ; from the presence of foreign bodies or parasites ; 
 or from the presence of tumors ; in fact, from anything which tends to produce 
 a filling of arteries and obstruction to venous return. It is common in pleth- 
 oric children and adults. It is frequently the precursor of apoplectic lesions 
 in the brain and eye. It occurs often in passage from dense to rarefied air or 
 the reverse, as in balloonists or those working in caissons. In such cases, in 
 fact, it is to be regarded as an apoplexy of the Schneiderian membrane. It 
 is a symptom of several acute diseases, for instance of typhoid, and accompa- 
 nies scurvy, purpura, chlorosis, etc. 
 
 It may be of a vicarious character, and may then occur from suppression 
 of menses, urine, or perspiration, or even of hemorrhages from varicose veins 
 or malignant tumors. Children approaching the age of puberty seem to be 
 liable to it, and some pregnant women frequently suffer from it. Extremes of 
 heat and cold upon the surface seem often to favor it, and psychical impres- 
 sions ai-e occasionally sufficient to excite it. In degree and extent it may 
 vary from the escape of a few drops of blood to a hemorrhage so violent as 
 to endanger life or even terminate it. It usually comes from one nostril, 
 sometimes from both, and may escape through the naso-phai-ynx into the 
 mouth, whence it may be expectorated or swallowed. The presence of blood 
 which has thus entered the stomach may excite the act of vomiting, by which 
 still further hemorrhage may be favored. As a rule, it escapes from some point 
 in the anterior nares, perhaps more often upon the septum than elsewhere. 
 
 The diagnosis seldom offers the slightest difficulty ; only in some cases of 
 grave constitutional disease where blood runs down the trachea or oesophagus 
 without the knowledge of the patient can uncertainty arise. While in general 
 epistaxis is to be checked at once, there are circumstances which may make this 
 inadvisable. If, for instance, it appear to be a relief of supercharged intra- 
 cranial vessels, it should be regai'ded rather as an advantage than otherwise, 
 and checked only in case it become excessive. Many congestions of the brain 
 and important parts within the skull have been relieved by this spontaneous 
 
(;()2 .(.V AMERK'AX TEXT-BOOK OF SURGERY. 
 
 venesection. J>ut, as a rule, it is sonictliin<f Avhicli should Ite clicfkcd as soon 
 as practica1tk\ especially if collapse threaten. 
 
 Treatment. — To I)ogin with, if possible, the cause should be ascertained 
 and removed. Removal, however, is seldom ])racticable, and treatment must 
 depend upon the exigencies of the case. First of all, position and rest should 
 be attended to. Naturally the higher the head the better, and patients should 
 not be allowed to lie down unless they be very weak. All pressure of clothing 
 about the neck and thorax should be removed, and patients should ])c cautioned 
 against cougliing and sneezing, as also particularly against constant efforts to 
 blow the nose and thus expel the blood, since by this act the formation of a clot 
 is prevented. It has been found that extension and elevation of the arms above 
 the head produce, by reflex vaso-motor mechanism, contraction of the nasal ves- 
 sels, as does also sometimes pressure at the root of the nose or about the nasal 
 region of the face, and these measures are to be recommended as worthy of trial. 
 Pressure against the bone upon either side of the ala nasi Avill often check epis- 
 taxis occurring from the anterior portion of the nose, as the lateral nasal ves- 
 sels supply the mucous membrane of this portion of the nasal cavities. Pres- 
 sure upon the carotid would also be indicated were it not that the jugular 
 vein is obstructed at the same time. The application of cold to the back of 
 the neck, ice-water enemata, and similar measures may also produce reflex vas- 
 cular spasm within the nose. If these measures be found inefficient, astrin- 
 gents may be employed by the nasal douche, such as ice-water or water as hot as 
 can be borne, or solutions of alum, tannin, etc. The stronger the astringent, 
 however, the more disagreeable the general effect, and if the bleeding point can 
 be localized it will be much better to apply some dry astringent directly to the 
 part. It has been a common practice to employ tents within the nostrils or 
 to pack the anterior naris with some material like cobweb, which not only 
 acts as a styptic, but also serves to entangle tlie blood and favor coagulation. 
 For cases of moderate severity or for hemorrhage following ordinary intranasal 
 operations the writer has found a solution of antipyrine, of 5 to 10 per cent, 
 strength, the most serviceable and the least disagreeable. Its effect upon the 
 blood-vessels is like that of cocaine, only more lasting, and it makes a very 
 serviceable styptic for general surgical purposes, since to its astringent proper- 
 ties is added that of being antiseptic. 
 
 AVhen hemorrhage is alarming, however, it is better not to waste time with 
 measures of the above character, but to proceed at once to plugging the nasal 
 passages. If the hemorrhage be anterior, the introduction of tampons through 
 the nostril may be quite sufficient. A series of these should be tied to a single 
 piece of stout silk, by means of which all are under control. If, however, this 
 be not enough, the posterior naris may be occluded by a very simjile procedure 
 which gives rise to no particular pain. The most serviceable instrument for 
 this purpose is the little canula devised by Belloc(i (Fig. "l^y^i) ; but in the 
 
 absence of this an ordinary 
 Fig. 25.'i. silk catheter may be armed 
 
 with a piece of stout silk or 
 twine by threading one end 
 of a piece, 15 inciics long, 
 through its eye. This cathe- 
 ter is now passed in along the 
 floor of the nose until it is 
 Benocq's canula. deflected downward by the 
 
 posterior wall of the pharynx. 
 So soon as its point is seen behind the uvula the silk thread may be caught with 
 
SUMGERY OF THE R ESP Hi A TORY ORGANS. 003 
 
 a toniU'uluin or iurcops and thawii out tliroii;;li tlie inuutli, while the catheter is 
 withdrawn from the nose. One end of the thread is now hanging from the nos- 
 tril, the other from the mouth. The middle of the latter is firmly tied around 
 a |)l(Ml(Tet of cotton or of sponge, which is then drawn backward and upward 
 by pulling on that portion which hangs from the nose, guiding the tampon 
 with the index finger of the other hand over tlie tongue into the pharynx and 
 then up and behind the soft ))alate. It is an advantage if the portion which 
 still hangs out from tlie mouth have been left so long that, a day or two 
 later, when it is desired to remove the tampon, this may be done by pulling 
 downward again hy means of this portion rather than having to dislodge the 
 plug Avith curved forceps in the pharynx or to push it backward by something 
 introduced again within the nose. If this end be left long enough for this 
 pitrpose, it may be brought out of the mouth and knotted to the other end, so 
 that by means of this continuous loop perfect control of the tampon is afforded. 
 After plugging the nostril posteriorly, anterior plugs may be inserted in case 
 the other be found insufficient. This method is usually very effective, and 
 if the plugs be not left so long in place that decomposition takes place, 
 it is quite safe. Posterior plugging without means of control by attached 
 threads is by no means free from danger, since death by suffocation during 
 sleep has been known to occur from its spontaneous dislodgment. Such a plug 
 should never be left in place for more than two days. If there be necessity 
 for longer protection it should be renewed. Plugs inserted through the nostril 
 should be tied successively to a single piece of stout silk, so that later they may 
 be easily dislodged and withdrawn by pulling gently upon its anterior end. 
 
 FOREIGX BODIES. 
 
 The ears and nose alike are exposed to the introduction of foreign bodies 
 either by accident or by design. This occurs naturally most frequently in 
 children who have not yet reached the age of reason. A list of possible 
 foreign substances would include almost everything of size not too large to 
 enter the nostril, and no attempt need be made to catalogue them. Introduced 
 nearly always from without, it may be possible for them to enter from the 
 naso-pharynx, as Avhen a substance is taken into the mouth and almost swal- 
 lowed, being finally expelled, not into the mouth again, but upward into the 
 posterior nares. These substances are by no means necessarily always inert, 
 since insects not infrequently effect an entrance into the nostrils. A small 
 particle is usually expelled by a reflex act as soon as introduced, but if it 
 remain long it may gather about it sufficient tenacious mucus to retain it in 
 place or even enable it to resist expulsion. On the other hand, a mass which 
 is large enough to be introduced with some difficulty or one which by imbibi- 
 tion of moisture may expand may give rise to a great deal of trouble in its 
 removal. 
 
 The signs and symptoms of foreign bodies in the nose are usually 
 unmistakable. Little children will sometimes not give evidence of their pres- 
 ence until decomposition or bleeding or profuse discharge attracts attention. 
 
 Treatment. — When the foreign mass is visible with ordinar}^ artificial 
 illumination, it can usually be grasped with forceps and removed or be dragged 
 out after the insertion of a small hook or tenaculum point, and ordinarily there 
 is nothing difficult about this manoeuver; but young children are frequently 
 so uncontrollable that the assistance of an anesthetic is necessary, and the 
 surgeon can accomplish in a few seconds by the aid of chloroform that 
 which would require a long struggle without it. At times when the mass is 
 
()04 AN AMERICAN TEXr-JiOOK OF SURGERY. 
 
 located too i'ar back within tlic iiilV-rior meatus for easy witli(lr;i\val it will be 
 foiintl much easier to pass in some sim])le instrument and ])usb it backward so 
 that it shall drop into the naso-jiliarynx, whence it should be removed by the 
 surgeon himself in order to avoid further complications. Sometimes sudden 
 forcible blowing into the other nostril by means of a tube over the end of 
 which the nostril is closed will expel the foreign body. Only when some sim- 
 ple procedure of this kind fails — and tliis will ])e very rarely — will anything 
 in the nature of an operation be rcijuired. If it be a piece of metal or some- 
 thing rigid which has been already lodged in a position not permitting with- 
 drawal, then it may be necessary to cut away some portion of the turbinated 
 bone or make some atypical operation according to the exigencies of the case. 
 
 EIIIXOLITIIS. 
 
 These are calculi or calculous concretions varying in size from 1 mm. to 2 
 or 3 cm., which are formed, much as are those in the bladder, by the deposition 
 of alkaline salts, mainly phosphates, around a foreign particle within the nasal 
 passages. This foreign particle may be a small mass of desiccated mucus. They 
 are usually unilateral, and commonly lie against the septum or Avithin the infe- 
 rior or the middle meatus. The general congestion or inflammatory changes 
 around them may give rise to symptoms alrendy doscri])ed. 
 
 AVhen the rhinolith, as such, produces symptoms, they are much like those 
 produced by any other foreign body. Nasal discharge and obstruction to res- 
 piration, with accompanying alteration in tone and voice, and perhaps anosmia 
 (loss of smell), will be the most common results. If any portion of such a con- 
 cretion presents to the view, it will probably be discolored and perhaps almost 
 black, appearing much as necrosed ])one in the same location often does, and 
 may be mistaken for it. Furthermore, its gritty surface may increase the liabil- 
 ity to error ; but it is very seldom that diseased bone alone will give rise to so 
 much fetor as accompanies an aggravated form of rhinolith. Careful examina- 
 tion of the nasal cavities after approved methods will enable a diagnosis to be 
 made, after which it Avill probably be an easy task with suitable dressing for- 
 ceps or a small spoon to dislodge and remove the concretion. If necessary, and 
 if no tissue around it calls for removal, the rhinolith may be broken into pieces, 
 being usually very friable, and removed piecemeal. 
 
 PARASITES. 
 
 The parasites which infect the nasal passages are mainly insects and 
 worms. In this country they are very rare. In the tropics such cases are 
 frequent, and sometimes of serious character. Danger comes not so much from 
 the adult insect as from the larvae which it may deposit, and Avhich may be aspi- 
 rated into the deeper cavities with inspiratory movements. Almost the only 
 parasite found in this country in the nose is the maggot. In certain catarrhal 
 and ozenous affections there is sometimes such fetor of discharge as to attract 
 flies, which penetrate the nasal cavity during sleep, deposit eggs there, and 
 leave them to be hatched as maggots, their incubation being favored by sur- 
 rounding warmth and moisture. Bv anv of these larv{\i the mucous membrane 
 may be destroyed, and the cartilage and the bones become necrosed. 
 
 The principal symptom is an itching in the nose which sometimes becomes 
 intense, with various ill-defined but well-located disagreeable sensations, which 
 in nervous and susceptible children may precipitate convulsive attacks. Almost 
 always there will be reflex headache, especially in the frontal region. Hemor- 
 
SURGERY OF THE RESPIRATORY ORGANS. 605 
 
 rhai^es may otx-ur tlu-rt' purely as tlie result of ulceration or of violent expulsive 
 eftorts. Sonietinics a cellulitis of the nasal region of the face may be set up, 
 and swelling may be so severe as nearly to close the eyelids. In the tropics the 
 condition may be fatal within a few hours, from local and general disturbance. 
 Antiseptic douches and inhalations of chloroform vaj)or or of a solution of iodine 
 in chloroform will be efiective in destroying the ])arasite8. 
 
 rOLYl'I AND TUMORS. 
 
 The principal neoplasms of the nasal cavities are myxomata and myxo- 
 fibromata, which usually occur in polypoid form, vascular tumors, adenomata, 
 exostoses and osteomata, enchondromata, and the malignant tumors, including 
 various forms of sarcomata and carcinomata. Of these the polypi, which are 
 usually adenomata or forms of myxomata, are the most frecjuent. They are 
 composedof very soft tissue of gelatinoid consistence, varying a little in firmness 
 according to the amount of fibrous tissue which they contain. They are usually 
 P3'riform in shape and pedunculated, of a pale flesh tint, almost translucent, vary- 
 ing in size from that of a pea to that of an almond, and annoy mainly from the 
 discomfort which they cause and their obstruction to respiration. The causes 
 of nasal polypi are very obscure. Certainly it cannot be chronic inflammation 
 alone, otherwise they would be met with in a large majority of individuals. 
 Men are more liable to them than women, and children usually escape. They 
 are met with sometimes singly ; at other times they occur by dozens and form a 
 cluster, several of which may perhaps be removed at one time. Some of these 
 are throughout of the same consistence, others have a cystic interior ; they are 
 covered with epithelium, and have very few vessels, if any, and no nerves at all. 
 The ordinary mucous polypi do not adhere to the bone. Those which spring 
 from parts beneath the mucosa must be largely fibrous in their structure. If 
 they grow rapidly they cause more disturbance than Avhen of slow growth. 
 
 So far as their location is concerned, they grow most frequently from the 
 middle turbinated body, next from the superior turbinated bone and meatus. 
 They rarely spring from the lower turbina1;ed bone and meatus ; in other words, 
 they will usually be found in the upper and more anterior portions of the nose. 
 They almost never spring from the septum. While they may extend backward 
 into the naso-pharynx or occasionally into the sphenoidal sinus, they never 
 fully escape spontaneously from the nostrils. When of considerable size they 
 may adhere at different points, so that the determination of their pedicle is 
 difficult. It is stated that the pear-shape forms arise from sharp prominences, 
 while those wnth broad bases arise from flat surfaces. 
 
 Symptoms. — These are at first insignificant and vague. The patient 
 usually complains of copious secretion from the nostrils and of difficulty in 
 breathing through one or both of the nares. Later comes complaint of some 
 discomfort, and the patient will frequently snuflf in the endeavor to free the 
 nostrils from some obstruction. After a while the secretion becomes muco- 
 purulent, with perhaps unpleasant odor, and the voice acquires a peculiar twang 
 which is always indicative of nasal obstruction. Perhaps the occurrence of 
 epistaxis may be the means of directing especial attention toward the nose. 
 The symptoms are augmented by humidity of atmosphere, since mucous polypi 
 are very hygrometric. Respiration may become audible, accompanied by a 
 Avhistling sound. These signs and symptoms will vary, of course, with the 
 extent of the disease. Aside from these purely local features, there occur 
 more or less frequent reflex disturbances, among which should be mentioned 
 asthma, cough — often distressing — hemicrania, facial and cranial neuralgia, 
 
<;(ii; 
 
 Ay AMiJncAX TEXT- HOOK OF srilOKHY 
 
 A, Mucous Polypi in the Nose ; B, anterior view of 
 same, normal size (Sajous). 
 
 vertigo, an<l even epilepsy. ^\ hen the nasal eavity is fille<l with polypi, the 
 nose often becomes more prominent and distended (Fig. 25Gj. 
 
 It is of course taken for granted that any complaint of nasal obstruction 
 will lead to a careful examination of the nose. Nasal polypi can scarcely be 
 
 taken for anything else save possibly 
 adenoid and catarrhal hypertrophy 
 of the mucous membrane. When 
 cocaine solutions are applied to the 
 former, they are not at all affected, 
 while the latter at once shrink and 
 retract under their influence. It 
 will be found also that a probe 
 carefully manipulated may be 
 passed under or around the ordi- 
 nary polypus, so that it can per- 
 haps be moved, or as it were 
 swung, from its stem, while it may 
 often be seen to sway or move 
 in a current of expired air. Aside from the local reflex annoyance which 
 it causes, tbe condition can scarcely be considered dangerous. There is a 
 great liability to recurrence after removal, which is due undoubtedly to failure 
 to make extirpation complete and to cauterize and destroy the surface or base 
 from which each polyp has sprung. Moreover, when the condition is multiple, 
 minute or incipient polypi may elude observation, develop later, and take the 
 place of those which were removed. Furthermore, the very causes which 
 operate in the first place to produce them may continue so to act. 
 
 While polypi may be spontaneously expelled, their proper treatment is 
 always surgical. Formerly the endeavor was made to inject into them some 
 escharotic, such as acetic, chromic, or carbolic acid, or some powerful 
 astringent ; but safer and more dexterous manipulations have taken the place 
 of these rude attempts, and measures for their removal now include avulsion, 
 excision, and the galvano-cautery. By avulsion is meant the use of forceps of 
 suitable device by which the polypus is seized as firmly as may be, and with as 
 little force as is necessary twisted off from its base. If the operator know 
 thorou^hlv his anatoniv and can make out the exact location of the jrrowth, 
 he will work much less in the dark than according to the old-fashioned way of 
 practically tearing away with the forceps whatever they may seize. This latter 
 method is painful and bungling, and likely to produce copious bleeding, where- 
 as the former is satisfactory so far as it goes. The naris should be illuminated, 
 and when the polyp can be neatly grasped it is better to twist it off by revolv- 
 ing the instrument until it is dislodged than rudely to tear it away. In this 
 as in the other operations cocaine solutions give the greatest aid. not only by 
 obtunding sensibility, but also by causing retraction of surrounding tissue and 
 better exposure of the growths. 
 
 For excision or abscission a most serviceable instrument is that form of 
 ^craseur devised by Jarvis, by which pedunculated growths can be blood- 
 l^ssly and almost painlessly removed (Fig. 253). Some dexterity and prac- 
 tice are necessary for its skilful manipulation, yet these may be easily 
 acquired. The base of the growth is caught by the wire loop, and its size 
 rapidly or slowly diminished according to the amount of discomfort cau.sed. 
 After removal of the polyp its base should be cauterized with some chemical 
 caustic or the galvano-cautery. Of course both indications are carried out 
 when the galvano-caustic loop is employed. The principal objection to this 
 
SURGERY OF rilE RESPIRATORY ORGANS. 607 
 
 method is tlie number of" re))etition.s usually necessarv to secure entire removal 
 of myxomatous tissue. Almost ahvays alter thus operating some local treat- 
 ment Avill be found necessary in order to overcome the condition of chronic 
 hyperemia or inilaiiimation consequent upon it. 
 
 Naso-pharyngeal Polyp. — A denser and more fibrous form of polypoid 
 growtli, composed of mixed mucous and fibroid tissue, occurs farther back in 
 the nose, and occasionally ])olypoid tumors of nearly pure fibromatous character 
 S])rin*i:ing from the jieriosteum or the bone at the base of the skull or the 
 adjoining facial bones Avill be found projecting into the pharynx. These be- 
 come of more serious nature in proportion to the amount of fibrous tissue they 
 contain, since the latter will prove a pretty accurate index of their vascularity. 
 
 When these spring from the septum or turbinated bones, they can usually 
 be removed by the ex])ert with the snare or the galvano-caustic loop, but a 
 genuine fibroid growing from the base of the skull and projecting downward 
 into the naso-pharyngeal cavity is an afi'air of a most serious nature. For 
 the removal of such growths operations of the greatest magnitude have been 
 undertaken, with varying success. The upper jaw of one side has been re- 
 sected, or the roof of the mouth cut away, or both upper jaw^s so far loosened 
 from their connections as to be temporarily depressed, an incision being made 
 clear across the face, by means of which extensive operative procedure access has 
 been gained to the naso-pharynx. Even after this has been done the removal 
 of the growth is by no means an easy matter, and the writer has seen in one 
 case a patient perish on the table from hemorrhage from one of these growths 
 during such an operation, which even the skill of a celebrated surgeon could 
 not check. Langenbeck's osteo-plastic resection of the upper jaw consists in 
 an incision from the inner angle of the orbit to the malar bone, and a second 
 from the nostril to the malar bone, joining the first. The soft parts are left 
 adherent to the bone. The bone is then sawn through both incisions to the 
 retro-maxillary fossa, which is exposed, when the bony flap thus made hinging 
 on the central line of the nose is thrown over on the opposite cheek. This 
 lays open the whole naso-pharyngeal cavity and retro-maxillary space. The 
 parts are then returned to their normal position after removal of the tumor. 
 
 VASCULAR AND OTHER TUMORS. 
 
 Angeiomata in the nose are rare. They are to be sharply distinguished 
 from a simple varicose condition of a limited area of mucous membrane, which 
 is quite common. They occur mostly in males during adolescence. Of the 
 symptoms, epistaxis is the most frequent and most prominent, the bleeding 
 being most profuse and persistent. 
 
 Adenomata. — Enough has already been said to show that a multiple 
 adenomatous affection of the mucous glands is very common, and such enlarge- 
 ments constitute the principal type of adenomata occurring in the nose. As a 
 rule, they are inseparable from hyperplasia of the surrounding tissue. Trans- 
 formation from adenoma into carcinoma, though infrequent, is well known to 
 occur. When met with, the tumor must be removed after the approved fashion 
 with the cold or hot wire loop. 
 
 Exostoses and Osteomata. — Outgrowths of bone which after a fashion 
 simulate physiological or normal protrusions are to be considered as exostoses, 
 while those which bear no such resemblance are termed osteomata. These are 
 sometimes of cancellous bone, but more often of compact bony tissue. They 
 are not common, are most often met with in the young, and at times may attain 
 large size. The symptoms which usually attract attention are increased dis- 
 
COS AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 charge ul' mucus, lu'inorrhai^e, a feeling of obstruction and of disconifoi-t or 
 itcliing, sometimes severe neuralgic pain, and perhaps loss of smell. Proper 
 examination will reveal the obstruction, and the probe or other instrument 
 must be used in order to determine by its hardness and rigidity whether it be 
 composed of soft tissue, cartilage, or bone. If of long duration there may 
 be ulceration and even necrosis. If the latter have taken place tliere will 
 be a fetid discharge which Avill certainly attract attention. In size and shape 
 they vary very much. Fortunately, it is usually easy to separate them fron) 
 the bone from which they spring. This removal may be effected with the wire 
 loop, with stout scissors adapted to the purpose, or with one of the forms of 
 intranasal saw. In a few instances when the growth was large and firm it 
 has been found necessary to lay open the nose so as to expose well the nasal 
 cavity of one side ; but such operations are done much more often in Europe, 
 since American ingenuity has devised the dental engine or its substitutes, by 
 means of which a rapidly-revolving trephine or burr may be made to cut away 
 even firm osseous tissue with little shock and with no necessity for external 
 incisioTis. 
 
 Enchondromata. — These are much more rare than bony tumors, al- 
 though an ecchondrosis corresponding exactly to the idea conveyed by the 
 term exostosis is a very frequent occurrence in the nose, forming a cartilag- 
 inous spur or projection often seen on the septum. Their detection and 
 removal in no wise differ from those of bony growths, and need no further 
 description here. 
 
 Malignant Tumors. — Although the nose is fre([uently involved in can- 
 cerous growths, they are rarely of primary origin in this locality. Even with 
 all the irritations to which the Schneiderian membrane is exposed, primary 
 epithelioma is very uncommon. Sarcomata arise more frequently from the 
 septum, while epitheliomata are perhaps equally common upon the septum and 
 upon the turbinated bones. While thorough extirpation here as elsewhere is the 
 only serviceable method of treatment, this may be done perhaps better by the 
 actual cautery operated through the natural passages than with more formidable 
 cutting operations. If complete destruction can be accomplished safely by some 
 chemical means, such as lactic acid, there is no reason why it should not be as 
 effective as removal by operation. In proportion as these growths affect the 
 parts nearer the pharynx they become less accessible, more likely to infiltrate 
 and affect the surrounding lymphatics, and both more difficult and more danger- 
 ous to attack by operation. Still, whatever good is to be accomplished in such 
 cases must be achieved either by use of instruments or by the galvano-cautery. 
 
 AFFECTIONS OF THE SINUSES. 
 
 Frontal Sinuses. — Injuries. — These occur, as a rule, from direct vio- 
 lence upon the forehead, Avhich may cause either sim])le, compound, or commi- 
 nuted fracture of its walls. Simple fracture, Avitli absence of cerebral symp- 
 toms, is common. It may be complicated by emphysema of the surrounding 
 soft parts, which may occur through the escai)e of air from the nose. If 
 there be depression of the outer table, it should be elevated to prevent 
 deformity. Compound and comminuted fractures may be complicated by the 
 lodgment of a foreign body. They are made more serious when the posterior 
 wall is also broken and the dura exposed. Operative interference is always 
 indicated in such a case. They are known to have been followed sometimes by 
 fistulous openings through which air may pass, and plastic operations have beea 
 made for their closure. 
 
SURGERY OF THE RESPIRATORY ORGANS. 609 
 
 Foreign Bodies an; either introduced from above or make their way 
 upward from the nose. The hitter are usually insects which creep up and may 
 either die there or deposit larvio which hatch and live. It is said that centi- 
 pedes have been found witliin the frontal sinus. These parasites, if they cause 
 any trouble at all, will usunlly set up an acute inflammation which will termi- 
 nate ])y abscess. 
 
 Inflammation. — This may be acute or chronic. When the latter, it is usu- 
 ally due to tuberculosis or syphilis. Inflammation may be the result of exten- 
 sion from the mucosa of the nose or from the surrounding bone. According 
 to its intensity will be the severity of its symptoms, which consist in the main 
 of pain and headache and a sense of weight and fulness in the forehead, with 
 usually the symptoms of acute coryza. The local signs are swelling and ten- 
 derness, more or less fever, rigors, and even delirium in the most acute cases. 
 When pus has formed and has escaped from the sinus proper into the cranial 
 cavity, it may produce various pressure-signs. An erysipelatous blush of the 
 overlying skin sometimes occurs. AVhen the disease is of syphilitic origin 
 there wnll be other signs of the constitutional condition. When of tubercular 
 origin it will probably be accompanied by caries or necrosis of the enclosing 
 bone, with other local manifestations. 
 
 A collection of pus in the frontal sinus is often spoken of as empyema 
 of the same, which, if old, will have produced marked change in the external 
 contour of this part of the face. The roof of the orbit is sometimes depressed, 
 and even the globe of the eye altered in position. When long existent the 
 bony wall may have so far disappeared by absorption as to yield a kind of 
 parchment crepitation upon pressure, with fluctuation underneath. This puru- 
 lent collection tends to evacuate itself spontaneously in the direction of least 
 resistance, which may be either externally into the nose or orbit or internally 
 into the ethmoid cells or the cranial cavity. 
 
 When signs of inflammation first present themselves here, leeching will 
 often aiford relief. This may be combined with whatever other treatment is 
 suggested by the condition within the nose ; but just so soon as 'signs of pus 
 are present or of cerebral disturbance or any other serious condition, no time 
 should be lost in perforating the external surface with a small trephine or other 
 instrument and cleansing and draining the cavity. In spite of the resulting 
 scar, it is wiser to do this by external incision rather than by operating 
 through the nose, as many have done in time past. 
 
 Cystic Dilatation or Dropsy of the Frontal Sinus has been described 
 by various writers, as well as hematomata and hydatid cysts. It is enough 
 here to mention the possibility of their occurrence, referring the student to 
 the larger treatises for their further description. 
 
 Tumors also occur within this sinus, both benign, like myxoma and 
 fibroma, and malignant, such as sarcoma and scirrhus. If considered suitable to 
 attack, they must be removed by external incision. The entire thickness of 
 the frontal bone has been more than once removed in order to extirpate growths 
 of this kind, and, providing the condition of the patient be at all favorable, no 
 operation can expose to so much damage and danger as does such a tumor. 
 
 Ethmoidal Cells. — The ethmoidal cells are liable to affection by direct 
 extension from the Schneiderian membrane, by which they are occasionally 
 involved in catarrhal thickening, polypoid growths, and even caries with per- 
 foration of the bones of the skull, accoi'ding to Virchow. Diphtheritic disease 
 has also extended as far as these cells, and it is stated that a frequent cause 
 of ozena is to be found here. 
 
 Sphenoidal Sinus. — W^hat has just been stated with reference to the 
 
 .39 
 
fJlO Ay AMKIUCAX TF.XT-liOOK OF SURGERY. 
 
 ethmoidal cells holds good also with relerence to this sinus, hut witii this 
 difterence, that disease here is more favorahly located for surgical relief. 
 Escape of cerebro-spinal fluid has been observed after injuries of this sinus. 
 Furthermore, by virtue of its intimate relation with the internal carotid and the 
 cavernous sinus, injuries to these vessels have followed wounds to this bony cav- 
 ity, and pulsating exophthalmos has been known thus to result. Caries and ne- 
 crosis of the body of the sphenoid may produce lesions of the nerves above men- 
 tioned, separation of fragments of l)one, hemorrhage which nuiy be fatal, retro- 
 pharvngeal abscess, thrombosis of the cavernous sinus, and perforation of the 
 baseof the skull. We may also have an empyema of this cavity from causes 
 similar to those mentioned before, the signs and symptoms of which would 
 include headache and spasmodic and sympathetic affections of the nerves in 
 intimate relation with it ; for example, photophobia and blepharospasm. The 
 sinus has been operated upon in recent years by three different paths: through 
 the naso-pharynx ; through the orbit after enucleation of the eye; and by the 
 nose, which seems to be the preferable route. 
 
 Tumors of the same character as those which involve the frontal sinus may 
 also be met with here, although much less amenable to operative relief. 
 
 The Antrum of IIigiimore, or the Maxillary Sinus. — The outer 
 wall of this cavity is t|uite exposed, and is liable to simple fracture by a blow, or 
 to compound injury with perforation by a weapon or other foreign substance. 
 The entire cavity is sometimes perforated by a foreign body, such as a bullet. 
 When the outer wall is depressed by injury or comminuted, it may perhaps be 
 elevated bv instruments introduced directly or from within the mouth or nose. 
 Swelling of the overlying soft parts, which may occur very frequently and 
 very <iuickly, will sometimes mask a depression of the bone. Mistake can be 
 best avoided by exploration with the finger in the mouth. 
 
 The antrum is sometimes filled with blood, either as the result of injury 
 from without or as the result of epistaxis. Almost always after plugging the 
 nose blood will force its way into the cavity. Ordinarily it Avill be easily and 
 quickly resorbed, but decomposition may result and abscess ensue. Insects 
 and foreign bodies may also exceptionally be found in it. 
 
 The most common affection of the antrum is inflammation with subse- 
 quent abscess. This may be the result of a propagation of the inflam- 
 matory lesion from the nose, or not infrequently of disease following up the 
 roots of the teeth, which sometimes project a little distance into this cavity. 
 As to the former, it may be said that the average size of the opening of the 
 antrum into the middle meatus of the nose is 4 by 8 mm. A second opening 
 rarely exists, and has l)een ascribed by Giraldes to a rarefying atrophy. When 
 we remember the ease of communication from one cavity to the other, the 
 ■wonder is that abscess does not occur much more frequently than is the case. 
 Not a few cases have followed attacks of the grippe in which the nasal symp- 
 toms were especially severe. The presence of polypi appears to be some- 
 times the exciting cause. The second form appears to be an extension by an 
 alveolar periostitis which is the result of dental caries; and a third form may 
 arise from purely traumatic causes. 
 
 Whatever the cause, the symptoms are about the same, consisting of local 
 pain radiating in various directions, especially toward the nose, swelling of the 
 overlying soft parts, and thinning of the bone so that sometimes it gives rise 
 to a parchment-like crepitation. If the nasal outlet be still patulous and pus 
 be present in the antrum, it will be found that in certain positions of the head 
 it Avill floAV into the nose, passing either anteriorly or posteriorly. When 
 this pathognomonic symptom is present the pus is very frequently offensive. 
 
siR(;i:iiy of tiik UKsriRATijuy org Ays. Gil 
 
 With the nasal specuhim it may jierhaps be seen trieklin^f into the nose. 
 AVhen the symptoms are very severe there may occur an expansion of the 
 •whole jaAv with elevation of the malar bone, displacement of the eyeball, 
 extreme alveolar tenderness, and extension of trouble along various nerve- 
 sheaths, with spontaneous perforation in some direction if timely relief be not 
 afforded. Percussion over the two antra will reveal a dull sound on the side 
 of the abscess. Attention has been called to the possiliility of derivin<r infor- 
 mation from the use of an electric light in the mouth, l;ut Zeim does not think 
 the diagnosis of suppuration in the antrum can be luade with any certainty by 
 this means. Between long-existing abscess, cystic degeneration, and tumor 
 within the antrum there may be some difficulty of diagnosis, but the presence 
 or absence of early signs of inflammation Avill aid as between the first two, while 
 as between cystic degeneration and tumor the existence of cachexia or of local 
 signs of inflammation will be most significant. 
 
 The treatment of inflammation previous to the formation of an abscess 
 may consist in leecliing and hot applications, with appropriate general measures. 
 When pus has already accumulated, a free opening for its evacuation is essential. 
 If the disease has extended upward from a tooth, the old method of removal 
 of the tooth and the perforation of the antrum at its base will l>e proper. But 
 when the teeth are sound, it is a pity to sacrifice one of them for this purpose, 
 and it is preferable to perforate the antrum at the point of election, which is 
 above the point of the root of the second bicuspid, about an inch above the 
 border of the gum. The mucous membrane of the buccal fold may be incised 
 at this point and the thin wall of bone perforated Avith a trocar or a delicate 
 gouge Avith the exertion of very little force. By this means a free opening 
 can be made with drainage into the mouth. More perfect drainage, however, 
 may be obtained by making a counter-opening into the inferior meatus of 
 the nose, ^'. e. on a level Avith the floor of the antrum; and if this be done a 
 drainage-tube may be drawn through from the mouth into the nose and left 
 protruding at the nostril for a fcAV days. This permits such thorough irriga- 
 tion as to ensure reasonably rapid recovery from the empyemic condition without 
 making the operation in any sense more severe or more serious. Daily irriga- 
 tion should be practised, and one or both openings should be kept patulous Avith 
 a proper packing or suitable device so long as any pus is discharged. 
 
 Tumors. — Morbid groAvths Avithin the antrum are by no means uncommon, 
 originating less frequently from the alveolar border than from the muco-perios- 
 teum. Of 307 cases tabulated by Weber, 133 Avere carcinomata, 84 sarcomata, 
 32 osteomata, 20 cysts, 17 fibromata, and the remainder miscellaneous ; in other 
 words, on the average tAvo-thirds of the tumors of the antrum are malio;nant. 
 Their general character as to benignity or malignity must be judged by their 
 rapidity of groAvth and by the general condition of the patient. Their earlier 
 stages are marked by fcAV if any symptoms, Avhile their later symptoms are 
 almost identical. If aftection of the neighboring lymphatic glands can be 
 detected, the probability is that they are malignant, although it must be said 
 of cancer of the antrum that, as a rule, the external lymphatics are slow to 
 become involved. If a tumor be recognized in this location, a decision as to 
 Avhether to operate must be formed partly upon the age and general state of 
 the patient, and partly upon the absence or presence of signs of involvement 
 of the adjoining and especially the surgicalh' inaccessible parts. To this end 
 careful examination of the nose and naso-pharynx should be made, vision should 
 be tested, and all the nerves of special sense, as well as the motor and sensory 
 nerves of this region, should be studied in order to recognize signs of involve- 
 ment of any of them. It having been decided to operate, the operation is 
 
612 ^.V AMERICAN" TKXT-r.OOK OF SURGKJiV. 
 
 practically that of removal of the ujjjter jaw, which is described in aiKjther 
 place. If the trouble be malignant, the surgeon cannot be too thorough in 
 removing tissues M'hich are even suspicious. If the neoplasm be benign, it 
 may be enough to lay open the cheek by the usual incision for the more for- 
 midable procedure, and then to expose the interior of the antrum by cutting 
 away its anterior wall. This will permit the easy extirpation of polypi, fibro- 
 mata, cysts, etc. 
 
 INJURIES OF THE NOSE, 
 
 Fractures and Dislocations of the nasal bones are considered elsewhere. 
 
 Wounds of the nose may be contused, incised, or lacerated. They de- 
 mand care in treatment mainly for the prevention of deformity. Accurate 
 coaptation of edges, readjustment of parts in proper position, and reduc- 
 tion by suitable means call for a high degree of surgical skill. Some in- 
 ternal support, as from a rubber or glass tube or an antiseptic plug, may 
 be advisable, and externally the collodion dressing reinforced by a few cot- 
 ton fibers will be found atlmirable. When a portion of the nose has been 
 actually carried away, some plastic operation for its repair becomes neces- 
 sary. Experience has also shown that when the nose has been partially or 
 even completely detached it is possible for complete union to occur if it be 
 immediately restored to its proper position and suitably held in place. Foreign 
 bodies, of course, should be immediately removed. Burns and scalds of the 
 nose are of particular importance, because of possible cicatricial contraction 
 and consequent deformity. This is bad enough at any part of its surface, but 
 is worst of all when occurrinj^ around the nostrils. It is to be fruarded against 
 by the utmost care during the healing process. an<l perhaps by some artificial 
 intranasal support, which must be worn steadily for some time and after a 
 while may be Avorn only during the night. (See also Deformities.) 
 
 Surgical Emphysema of the Nose. — This occurs quite commonly after 
 any injury by which a lesion of the mucous membrane is produced, especially 
 after fracture and dislocation. The term implies a distention or blowing up of 
 the cellular tissue by air, especially during the expiratory act, and is particularly 
 likely to take place when clots of blood fill up the nasal cavity and by their 
 presence excite the patient to frequent involuntary efforts to expel them. The 
 condition varies from the slightest recognizable puffiness of the skin about the 
 bridge of the nose to a most marked swelling of the soft parts about the face, 
 eyes, and forehead, b}' which the patient's features may be made almost unrec- 
 ognizable. When the palpating fingers are placed upon the distended tissues 
 a very fine bubbling crepitation is at once detected. This condition, though 
 terrifying to the laity, is one by itself of no serious importance. Only in case 
 germs of decomposition enter and set up a septic cellulitis will any trouble 
 follow. Should this result, the phlegmonous cellulitis might be serious or 
 even fatal. It would call for constitutional treatment and free incisions. 
 
 EHINOPLASTY. 
 
 The tenn rhinoplasty includes all operations having for their object the 
 restoration or repair of the nose. They are called for: 1st, for correction 
 of congenital deformity; 2d, to repair effects of injury; and 3d, for restora- 
 tion from the ravages of disease, the latter being malignant or ulcerative, 
 with or without caries or necrosis of the bone. No operation of the kind 
 should be performed until the destructive process lias been positively checked 
 or all actually diseased tissue removed by excision or ablation. These ope- 
 
SURCTEMY OF THE RESPIRATORY ORGANS. 613 
 
 rations date back to the earliest days of surgery, and seem to have been suc- 
 cessfully practised at a time when o])erative surgery in general was very 
 crude. Kliiiioplasty is divided into total and partial. For the relief of par- 
 tial deficiencies, such as defect of one of the ahe, a flap may be taken from 
 the upper side of the nose or from the tissues of the cheek ; usually only 
 when it requires to be very large will it be necessary to take it from the fore- 
 head. These flaps are almost invariably made by the process of transplantation, 
 leaving a pedicle for vascular supply, which should not be twisted too tightly, 
 lest this su])))ly be cut off". After the flap is fii-ndy im])lanted in its new posi- 
 tion, say in from ten to fourteen days, the pedicle may be divided, or, if neces- 
 sary, a redundant portion exsected. An extreme condition of pug-nose has 
 been remedied by cutting transversely across the nose, drawing the tip down 
 to the desired position, and then transplanting flaps from the cheeks to fill the 
 wedge-shaped defect. A new columna nasi is sometimes formed from the upper 
 lip by exsecting a small part at the middle line and then turning the strip 
 upward, the inside of the tip of the nose l)eing freshened for its reception. 
 The wound in the lip is then closed, as in the case of hare-lip, with pins or 
 sutures. For the relief of fistulous openings on one or both sides it is neces- 
 sary cleanly to excise the ulcerated or cicatrized margin, and then to slide or 
 transplant a flap fi'om the adjoining cheek. 
 
 For restoration of the entire nose two quite diff'erent methods have been 
 suggested, both of which are old. The procedure is as follows : First of all, 
 it is necessary to have an idea of the amount of skin to be transplanted. 
 In order to do this, a pattern is made with a piece of oiled silk by fash- 
 ioning it over the normal nose of some other individual, or by building up 
 on the face of the patient with wax, clay, or dough a model of a nose which 
 shall suit the other features. The pattern thus made will be rudely pyriform, 
 and it will be seen that a peculiar projection is to be arranged for at the dis- 
 tal border, from which the columna or septum is to be formed. This pattern is 
 to be used on either the forehead or the arm of the patient, according to 
 the selection of the operator. 
 
 The Tagliacotian method (Fig. 257), named from Tagliacozzi, a famous 
 Italian surgeon of the sixteenth century, comprehends the use of a flap of skin 
 raised usually from the left arm of the patient. This flap is marked out upon 
 the arm by means of the pattern already referred to, 
 allowing one-third on every side for shrinkage, since Fig. 
 
 the human skin may be always expected to shrink to 
 about this extent after the division or raising of a flap. 
 The original procedure includes the detaching of this 
 flap except its pedicle, and leaving it for about two 
 weeks in order that it may become more vascular and 
 thickened and its lower surface covered with granula- 
 tion. After two weeks the stump or remains of the orig- 
 inal nose are pared, and all surfaces to which it is in- 
 tended that the new flap shall unite are freshened with 
 scissors or knife, and then the arm is brought up to 
 the head, the flap trimmed to the exact necessary shape, 
 and fastened in its new position by numerous sutures, 
 after which the hand is placed upon the top of the head, 
 and hand and forearm suitably bandaged thereto by a ■svarreu's Apparatus for re- 
 somewhat complicated combination of slings and band- MetL'wi. ^^ Tagiiacozzi's 
 ages : a substitute for the original apparatus may be 
 made of plaster of Paris. As soon as the flap is supposed to be firmly ad- 
 
G14 
 
 AN AMERICAN TEXT- HOOK OF SURGERY. 
 
 Indian Method of Rhinoplasty (Prince). 
 
 berent, say in ten or twelve days, its pedicle is divided and trimmed as may be 
 necessary. Tbe columna is su1)se(iucntly made from tlic upper lip. Tlie orig- 
 inal operation contemplated tbat tbe flap sbould he made from tlie arm. Mod- 
 ern operators liave modified it by takin<r it from tlie forearm, but tbe necessary 
 confinement of bead and arm is so irksome tbat tbe operation is at present 
 scarcely ever done, altbougli in certain cases it oflfers good prospect of success, 
 provided tbe subject be patient and acquiescent. 
 
 Tbe otber operation, now generally practised, is tbat commonly known as 
 tbe Indian metbod, and was brought to Europe from Ilindoostan. Tbe model 
 and tbe pattern are made as before, l)ut tbe flap is now taken from tbe fore- 
 head, still alloAving one-tbird for siirinkage, tbe pattern l^eing applied either 
 perpendicularly or obliquely, depending much upon its contour (Fig. 258) and 
 
 the distance between ttie eyebrows 
 FifJ- '-•"'^- and tbe hair. Tbe incision is car- 
 
 ried down to tbe periosteum, begin- 
 ninii at the ri^bt marjiin of tbe 
 defect and terminating at tbe upper 
 end of tbe left superciliary ridge, tbe 
 pedicle of tbe flap being about two 
 centimeters wide. It is necessary 
 not to interfere with tbe angular 
 artery, since upon it depends tbe 
 nourishment of tbe flap, but the flap 
 thus outlined is dissected off and is 
 made to include tbe frontal aponeu- 
 rosis. Sometimes tbe periosteum is 
 raised, at least over the lower part of 
 the flap. Koenig has suggested to raise along with the periosteum tbe outer 
 table of tbe skull or at least its superficial portion, especially along the cen- 
 tral and lower portion, in order that a firm bony bridge of the nose may be 
 produced. If this be done — and tbe writer has practised this with success 
 and urges its performance — the integument sbould in no wise be raised from 
 that portion of the periosteum and bone which it is intended to utilize. Ex- 
 cept in the very young it will be impossible to detach this bone with the chisel 
 or any otber instrument in anything like a continuous layer: the bone-flap will, 
 in fact, be more like a series of thin flat chips which cling to tbe periosteum. 
 By virtue of the osteoblasts which abound on the outer surface of the bone 
 and in the deeper layer of the periosteum, perfect osteogenetic power is pre- 
 served, and tbe result will be the same. As soon as hemorrhage has subsided 
 tbe flap is rotated into its proper position, and tbe process of attachment with 
 fine and rather numerous sutures begun. Tbe abie and nostrils are formed by 
 an inward duplication of tbe lateral parts, and the septum is formed from tbe 
 appropriate portion and stitched down to tbe outer portion of tbe upper lip, in 
 which a groove sbould be made for it. The more perfect the apportionment 
 of amount tbe more ornamental tbe result. Tbe defect in tbe forehead will at 
 first be larger than the size of tbe flap, since the edges will retract. It will 
 be worth while to dissect the tissues loose from the frontal bone for an inch or 
 two all round this defect, in order that by sliding and by the tension of silk 
 sutures the size of the defect may be reduced at least by one-half. Some- 
 times it will be worth while to extend tbe incisions upon tbe scalp, so that 
 by rearrangement of tbe flaps the defect may be still further covered. Tbe 
 portions which cannot thus be protected must be allowed to heal by granula- 
 tion, or it may be possible to accomplish a good deal by skin-grafting after 
 
SURGERY OF TJIE RESPIRATORY ORGANS. 61-5 
 
 Tbier.ch-s methu.l. The .omul upon the fV.rehe.Hl is best .Ivessed ^vith i.Kh> 
 form ana careen silk protective underneath the or.l.nary asepf c . ressmc,.. i e 
 nAv nose ulv need oine artificial support, ^vhich can be lurnished ;;xtorna ly 
 i ha Ires in. of cotton or collo,li,.n,.vhile internally t.e nostnls ai^ kept patu- 
 ou an I 1 e tl^p supported by the introduction of rubber tubes It is be t to 
 m^ke c hp apparintlv too larj^e, since the new organ, which seems dispro- 
 n,n-donlZ TaiJ a first, will in the course of months shnnk and perhaps 
 CT^^V^ont because not large enough. Noses, thus ^-^^^ i.p are 
 often very sitisfactory, and leave but little evidence of the somewhat extensive 
 disturbance by which they were first produced. is referred 
 
 For more exact descriptions and variations in methods the leadei is reterrea 
 to the special works on plastic surgery. When from one cause or another it 
 m.y iXi mp acticable to repro^duce this organ by plastic surgery, much 
 " ' - be^h eln^plastic art in another direction, and artificial noses are now 
 ^:^pared f^m ce luloid or similar materials, which are kept firmly m p ace by 
 Ce tacl - ms, as if the patient were wearing glasses. These can be made with 
 sSi accuracy and worn with such exactness and comfort as almost to defy 
 detection except on close inspection. 
 
 SECTION II.-DISEASES AND INJURIES OF THE LARYNX AND TRACHEA. 
 
 Congenital Deformities and Defects. 
 Congenital absence of one or more of the laryngeal cartikges ha^ been 
 
 The.o.teon™oneongennala™^^^^^ 
 
 and fistul?e. ihese aie to oe aiuiuu fourth branchial 
 
 "' ra'-'VJfe'fexHen:: " in * 'fo rci t Opening ^o.U be unilat- 
 
 the middle line. Fissure of the epiglottis ''f^ »^''',.^f °„7'JJ/^e so minute 
 fistuh. are the lea«t uncommon of -^^^l'^^^^'^^^^ dSw discharge of 
 as to elude ordinary exammat.on /!'« f ,3*7' f 'le oriS''''" i" ""^ °^ *" 
 two or three drops of muco-purulent fluid from %™'"''t« ""°f ' . ^ i. 
 
 LARYNGITIS. 
 Larvngitis may be either acute or chronic, and may be catai-rh-l- croup- 
 
 ^rat^hl^gmors', sav': .^"r circu^crihed, .hen we have an abscess of 
 
 """ i'P'.t^ r.tarrhal Laryngitis mav be primary or the result of extension 
 
 Acute Catarrhal ^ary ngii j f - , j jjopathic it is usually 
 
 from the pharynx above o. fiom '^^\f^^^^^^.^^^^^ i„,uced by over-use of the 
 
 the result of exposure, it may a so oe mecu . i,.j.i,.;tion of noxious 
 
 ^d^:^^^TZZI^l^:Z^^ of^s;r.on and to 
 
01(j AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 fre(iuent violent and cvrii suflociitin^ attacks of eou;^liiii;^, with ]taitial or com- 
 plete loss of voice. U]>on laryu^oscopit: insjieotion tlic imicoiis iiiciiibranc will 
 be found conj^ested and swollen, the swelling being usually symmetrical. Accu- 
 mulations of mucus at various points may simulate ulceration, and will be found 
 especially on the vocal cords. Should the symptoms be very severe, oedema 
 of the larynx may ensue. 
 
 Tiio treatment consists in the removal of the cause when recognized ; fur- 
 thermore, in iiihalaiions of steam impregnated with sedative and astringent 
 substances, as well as in the administration of aperients and sedatives and the 
 continuous application of cold wet compresses or else the employment of leeches 
 over the larynx. Weak solutions of cocaine will give the same relief here 
 that they do in similar affections in the nose, but are usually to be avoided for 
 the reasons already given. There is danger in the application of strong astrin- 
 gents, such as nitrate of silver, etc., that they may produce sudden and serious 
 oedema. The medicinal treatment of croup and of diphtheria is not considered 
 here. 
 
 Chronic Laryngitis. — This, too, may be idiopathic or secondary. The 
 former may be the result of repeated attacks of acute inflammation or of 
 extension of similar trouble from above. The latter is almost always an 
 extension of similar trouble elsewhere, and may occur in arthritis (gout), 
 tuberculosis, syphilis, lupus, and cancer. The chronic variety is attended with 
 thickening of mucous membrane, more or less constant irritation, and usually 
 with hypersecretion. Erosions are unusual. A peculiar vai'iety of chronic lar- 
 yngitis called laryngitis sicca occurs principally in females ; it involves espe- 
 cially the mucous glands, the viscid products of which adhere to the mucous 
 membrane, wliere they dry into crusts which are sometimes fetid. These are 
 detached by violent coughing-spells, and leave behind them excoriations which 
 may bleed. The result of this is an atrophic and dry condition of the mucous 
 membrane. These affections are to be treated after about the same manner 
 as the similar condition in the naso-pharynx, namely, careful dislodgment by 
 the alkaline antiseptic spray of mucus and crusts, and then the application of 
 stimulating and antiseptic solutions. 
 
 (EDEMA OF THE LARYNX. 
 
 The most violent and serious sequel of inflammation of the larynx is the 
 condition known as oedema, which is sometimes incorrectly spoken of as oedema 
 of the glottis. This is an infiltration of fluid into the submucous connective 
 tissue of the larynx or that of the epiglottis or the mucous membrane immedi- 
 ately adjacent. This is less often a mere passive accumulation of serum than 
 an active inflammatory fluid exudate, the fluid being sometimes sero-sanguino- 
 lent or sero-purulent. In certain cases this occurs with great rapidity, espe- 
 cially when serous, and may destroy life by suffocation Avithin a very short 
 time, an amount of infiltration which elsewhere would be trifling serving at this 
 point to obstruct the passage of air thi'ough the narrowest portion of the air- 
 channel. So serious is it as to call usually for the promj)test surgical interfer- 
 ence. In time past this condition was confused with that of croup. The deaths 
 of General Washington and the empress Josephine were due to oedema, and not, 
 as has been ordinarily stated, to croup. Of course the oedema is owing to impedi- 
 ment to free circulation, whether from purely inflammatory process, mechanical 
 obstruction by tumor, or perhaps vaso-motor ])aralysis. It has often followed 
 wounds, sometimes even of the neck when the larynx has not been imj)licated. 
 It has been noted also in aneurysm, erysipelas, typhoid, glanders, whooping 
 
SUliGERY OF THE RESPIRATORY ORGANS. G17 
 
 cougli, j)nounioiii;i, septicemiii, etc. A death from this cause occurred on the 
 baseball fieUl a few years ago, due to fracture of the larynx. 
 
 Tlie symptoms are sonietiiiies so sudden that even with aid close at hand 
 the jiaiient dies before it can reach him. The princijial symptoms are local 
 discomlbrt, increasing perhaps to agony, stridor in breathing, especially in 
 insj)iration, cough, impulsive and violent, loss of voice, dysphagia and dyspnea 
 in fatal cases, rapidly increasing to apnea and death by suffocation. Along 
 "Nvith these of course go intense agitation, flushing of the face, then lividity, 
 and then cyanosis, protrusion of the e^'cballs, gasping respiration, and flicker- 
 ing pulse. The ])icture above presented is that of a fatal case. In a mild 
 degree it may be imitated during the recurring attacks of oedema which accom- 
 pany acute or chronic laryngitis. 
 
 The prognosis must depend on the predisposition and exciting cause. 
 The principal danger is that of suffocation ; if this is avoided, much, if not 
 everything, may be accomplished by treatment. 
 
 Treatment. — AVhen the case is not too acute, the best treatment consists 
 in nniltiple punctures into the tumid mass of swollen mucous membrane, which 
 may be made with a sharp curved bistoury, the blade of which is protected 
 nearly to the point with adhesive plaster. If possible, this should be done with 
 the aid of the laryngoscopic mirror. These punctures should not be made in the 
 interior of the larynx, but upon the swelling exposed to vieAv by means of the 
 mirror, since, although we desire free hemorrhage, we Avish to avoid entrance of 
 blood into the air-passages. AYhen hemorrhage is insuflicient it may be encour- 
 aged by gargling with warm water or by inhalations of steam. The punctures 
 may have to be repeated at intervals of a foAV hours or days. Should the case 
 be too violent to permit the time necessary for this kind of relief, intubation 
 or tracheotom}' will be indicated. The very condition which makes suffocation 
 threaten will make intubation at least difficult, while appiopriate tubes are not 
 usually at hand. Tracheotomy can always be done with the simplest instru- 
 ments, and a patient should not be allowed to die of suffocation from this cause 
 if a reasonably sharp penknife be at hand. Indeed, as a precautionary meas- 
 ure, if the patient threaten to require tracheotomy at any moment, it will be 
 far better and safer to perform it deliberately than wait to be called to do it 
 hastily with the chance of arriving too late. The serous infiltration usually 
 rapidly subsides after the performance of this operation. 
 
 ABSCESS OF THE LAEYNX. 
 
 This may be intra-, peri-, or retro-laryngeal. It is almost invariably a 
 secondary affection, most frequently resulting from disease of the cartilages. 
 Still, phlegmonous and traumatic laryngitis, tuberculosis, syphilis, glanders, 
 smallpox, pyemia, and the exanthemata have been mentioned as determining 
 causes. The inferior surface of the epiglottis, the internal aspect of the aryte- 
 noid cartilage, and the false vocal cord are the most frequent seats of circum- 
 scribed abscess not resulting from injur3^ The local symptoms are pain, dys- 
 phonia, dyspnea, dysphagia, and cough. The patient may even be threatened 
 with suffocation. 
 
 The diagnosis must be made by means of the laryngoscope, though it 
 may be impossible on account of swelling above ; but ordinarily the lesion can be 
 recognized as a swelling the base of which is red and the apex yellowish. The 
 principal danger is from suffocation either by the condition spoken of or by 
 oedema. Spontaneous evacuation usually occurs if surgical relief be not pre- 
 viously afforded. The treatment, of course, is incision with a properly curved 
 
G1.S J.V AMHlilCAX TEXT-BOOK OF SURGERY. 
 
 and <5iianl(Ml kiiifi'-])(>iiit. >i;iii<U'(l l»y ilie l:iryiigoscoj)C. Should this not bf feasi- 
 ble or should sufibeation threaten, a preliniinarv tracheotomy sh(»uld always be 
 made. Extra-larynixeal abscess is recognizable by the common signs of this 
 complaint, and should be treated in accordance with the ordinary rules. 
 
 PERICHONDKITIS AND CllONDIMTIS. 
 
 The latter is always preceded by the former, which itself may be traumatic 
 or secondary to previous disease. Idiopathic perichondritis is nearly if not 
 quite unknown. The most common causes of disease of the cartilages are 
 syphilis, tuberculosis, cancer, ty])hoid fever, and the exanthemata; more rarely 
 chronic laryngitis. Pathologically distinct, clinically the two conditions are 
 indistinguishable. The cricoid and arytenoid cartilages are those commonly 
 involved. When there is suppuration beneath the perichondrium, necrosis of 
 the cartilage proper occurs, and tlien an abscess forms which often discharges 
 spontaneously, following which there is usually cicatricial contraction, while 
 stenosis is the final result. Sometimes the arytenoid cartilages are thus dis- 
 charged entire. The route of pus from such a source to the surface is some- 
 times very indirect, while fistula often results and extensive emphysema may 
 take place. 
 
 The symptoms are those of more or less severe laryngitis, with pain on 
 motion or ])ressure and sometimes during deglutition or phonation. Later ap- 
 pear hoarseness, cough, and dyspnea with paroxysms of stridor: with an attack 
 of unusual severity there nuiy be spontaneous evacuation followed by marked 
 relief. By suitable external and internal examination a pretty accurate diag- 
 nosis of the location of the disease may be made, especially if an abscess has 
 already formed and broken. 
 
 Treatment. — In the earlier stages antiphlogistic measures are indicated, 
 with the ordinary local treatment and such constitutional medication as the 
 condition of the patient may call for. Should swallowing become impossible, 
 nourishment by stomach-tube or the rectum will be necessary, while when 
 local symptoms are severe, tracheotomy or laryngotomy, with cleaning out of 
 the abscess-cavities, is the only rational course. 
 
 ULCERS OF THE LARYNX. 
 
 These may be catarrhal, tubercular, syphilitic, or malignant. Only the 
 catarrhal will l)e referred to here, the other forms being described under their 
 respective headings. Of this we may have all degrees, from the most smiple 
 erosion to an ulcer of large extent. They are, as a rule, the result of chronic 
 processes, but possibly of injury, especially by lodgment of foreign bodies. The 
 mucous membrane around the periphery is usually slightly altered and some- 
 times infiltrated. They may be found at almost any point, but most commonly 
 are in the neighborhood of the vocal cords or upon them ; at times they are 
 even excavated. They may vary in size from that of a pin-point up. Some- 
 times in laryngoscopic examination we find cicatrices showing where old ulcers 
 have been healed. 
 
 The symptoms of ulceration are scarcely distinctive, and are included 
 under those of infiammation. When the vocal cords are involved their func- 
 tion is correspoiulingly impaired, and there is partial or complete loss of voice, 
 usually with irritating cough and severe laryngeal irritation. When the larynx 
 is in this condition there is always danger of oedema. 
 
 Treatment. — This consists in the ordinary methods of combating inflam- 
 mation and in the local application of some stimulating substance, which is 
 
SURGKIiY OF THE JiKSrUiATORV ORGANS. 619 
 
 usually praetisi'tl by means of a laryngeal ])i'obe upon whose tip a little nitrate 
 of silver is fused. Perfect rest sliouhl l»e insisted upon, and constitutional 
 treatment, such as the exliiltitioii of tonics, etc., is coninionly recjuired. 
 
 STEICTUEE OF THE LARYNX AND TRACHEA. 
 
 This is usually sj)oken of as stenosis, and may arise from causes within or 
 without these parts. One or both may be implicated, and sometimes there is 
 more than one stricture. AVhen produced from without it is called compres- 
 sion stenosis, and may l)e the result of abscesses, of tumors of the thyroid or 
 thymus or lym])li-glands or elsewhere about the neck, of cicatrices, or of aneu- 
 rysm. Sometimes the stricture is produced simply by the deflection of the re- 
 spiratory tube, sometimes by pressure and occlusion. Stricture from within, or 
 occlusion stenosis, may be due to congenital causes, to foreign bodies, to tumors, 
 to cicatricial contraction following ulceration, and to paralytic or spasmodic 
 affection of the intrinsic muscles ; also to oedema, to submucous hemorrhage, to 
 the presence of false membrane, to inflammatory adhesions, and to the result 
 of suicidal attempts. The constriction may occur at any point, the amount 
 varying within the extremest possible limits. Even complete obliteration is 
 known. Its most common situation is naturally at a point where the channel 
 is narrowest, namely, at- the glottis; and here, of course, it assumes an import- 
 ance begotten of anatomical location. 
 
 It will be seen, then, that constriction may be temporary or permanent, 
 slight or most serious, and implies various degrees of organic and tissue 
 changes. In proportion to the amount of stenosis there will be dyspnea, espe- 
 cially on inspiration and exertion, by which the voluntary muscles of inspi- 
 ration are called upon to an unwonted degree. Loud breathing merges into 
 stridor, and this later into an agonizino; suffocative and stridulous choking 
 respiration. In extreme cases the face is anxious and cyanotic, the pulse be- 
 comes small and frequent, and the muscular effort to breathe is most painful to 
 witness. The symptoms are about the same no matter Avhat may be the cause. 
 There is always danger that in a severe case of cicatricial stenosis there may' 
 be added, at the last, an oedema of the parts which will hasten the termination. 
 
 When time and opportunity afford, a careful study of the case should be 
 made in order to locate the stricture and determine its character, suitable meas- 
 ures then being decided upon. On the other hand, when the case is extreme 
 the trachea should be opened as low as convenient, profiting by the fact that 
 most of these lesions are located above the lowest accessible portion of the 
 windpipe. It may be that a large tumor or abscess so occupies the inferior 
 and middle portions of the neck that even tracheotomy will be impossible. 
 When there is time for careful study and deliberation, the relief must depend 
 upon the cause. At one time it may be dilatation of a cicatricial contraction, 
 at another the removal of a polyp or other tumor either by intra- or extra- 
 laryngeal methods, at another the performance of a tracheotomy, or possibly 
 a still more radical operation, such as removal of the larynx. At all events, 
 tracheotomy is often the temporary and almost always the final expedient. 
 Sometimes an artificial larynx is re(|uired, perhaps permanently. 
 
 SYPHILIS OF THE LARYNX. 
 
 Syphilis of the larynx may be acute or chronic. There is an acute form 
 which corresponds to the congestion and inflammation of the pharynx met with 
 in the early portion of the secondary stage, which may give rise to temporary 
 hoarseness and even to other signs of laryngeal irritation. When seen with a 
 
ii'2(> AX AMERICAN TEXT-BOOK OF SURGERY. 
 
 laryngoscope the interior of the larynx will present the .same livid and tume- 
 fied aj>))earance that -sve recognize in the pharynx. The treatment for this 
 form .should be vigorous and constitutional, with such local measures as may 
 be necc.s.sary to subdue irritation. 
 
 A chronic form of syphilitic laryngitis is cominf>n, and is marked by infil- 
 tration and inflexibility of mucous membrane, which, with time, go on to the 
 formation of mucous patches or extensive granulomatous tissue-formation, or to 
 extensive ulceration Avith destruction even of underlying cartilage, and in any 
 event to more or less reduction of caliber, or sometimes to the formation of 
 serious stenosis or even to complete occlusion. 
 
 Aside from mucous patches, extensive ulceration and even gummatous infil- 
 tration, or possibly formation of distinct gummata, may take place. About 
 these ulcerations there is usually a symmetry of location which is one of the 
 points of differential diagnosis between them and tubercular ulcerations. 
 Ulceration of the epiglottis especially is a common manifestation of the ter- 
 tiary stage. Such ravages as these seldom go on within the larynx without such 
 external or other manifestations of syphilis as to leave scarcely a doubt con- 
 cerning the nature of the lesion. 
 
 While local treatment is not to be excluded, the constitutional is the more 
 important of the two, save when immediate consequences threaten. 
 
 TUBEECULOSIS OF THE LARYNX. 
 
 Primary tuberculosis of the larynx is rare. Although these cases are 
 seen mostly by specialists, there is no reason why the general practitioner 
 should not be able to recognize their characteristics. In the first place, 
 there ai'e the ordinai'y evidences of chronic laryngitis with thickening of 
 the mucous membrane, Avhich goes on to the formation of multiple ulcer- 
 ations, ordinarily at first minute, coalescing later, accompanied by more or 
 less hacking cough or alteration of the voice. There is no part of the larynx 
 which is exempt from attack, but the most marked manifestations occur 
 about the arytenoid cartilages, the vocal cords, and the epiglottis. The nat- 
 ural outlines of the larynx as seen in the mirror become blurred, and there 
 is commonly an intumescence of the glotto-epiglottic folds and bands ; later 
 there occurs not only ulceration as such, but also the development of gran- 
 ulations, which, as a rule, are elevated above the surface, and which, when 
 on the posterior wall and in the middle line, are by many authorities 
 regarded as pathognomonic of the condition. This condition is usually sec- 
 ondary to pulmonary tuberculosis, but may be, as above mentioned, purely 
 primary. 
 
 AVhen the disease is of the primary type it requires usually to be differen- 
 tiated from .syphilis on the one hand and malignant disease on the other. 
 Asymmetry of ulceration, Avith the peculiarity of granulation spoken of above, 
 is always at least suggestive, Avhile the absence on the one hand of evidences 
 of .syphilis elsewhere, and the existence on the other of a family history of 
 consumption, or of a history of progressive emaciation, or of elevation of tem- 
 perature, especially in the evening, will greatly aid in diagnosis. Tiie crucial 
 test, Avhen it can be established, is the presence of tubercle bacilli, either in 
 the infected tissue or in the sputum. 
 
 Between tubercular and malignant disease of the larynx it is at times in 
 the early stages excessively difficult to determine, and it is necessary to watch 
 for a time before making an ab.solute diagnosis. A study of family history, of 
 temperature range, of constitutional conditions, will be of great aid. Malig- 
 nant disease is more likely to have a more definite origin and limit, around 
 
SUBGEllY OF THE RESPIRATORY ORGANS. 621 
 
 ■which healthy or nearly healthy tissue will be met with. Tubercular disease, 
 on the other hand, is likely to leave its marks in almost every portion of the 
 larynx, as well as to cause more local irritation, while there will be little if any 
 such infdtration as to cause fixation of the larynx upon the outside or involve- 
 ment of the lymphatic glands in the vicinity. More will be said on this topic 
 when speaking of Cancer of the Larynx. 
 
 In time past primary laryngeal tuberculosis was supposed to be irre- 
 trievably fatal, but, while it is still to be regarded as of extreme giavity, 
 nuich can be effected by treatment. This consists in both constitutional 
 and local measures, the latter being those indicated in tubercular disease, 
 and consisting of frequent applications of lactic acid to the ulcerated pas- 
 sage, and insufflation of iodoform or aristol or of some other dry anti- 
 septic material by which tissue-changes are influenced, as well as of some 
 anodyne poAvder, such as one containing very small portions of cocaine and 
 morphia, com})ined perhaps with menthol, bismuth subnitrate, and sugar of 
 milk. In aggravated cases absolute rest of the larynx as enforced by a 
 tracheotomy is sometimes of great benefit. If we could be assured that the 
 disease was purely local, it might be justifiable to extirpate the organ; but 
 patients thus far have proved unwilling to submit to this extreme measure at 
 a time when it promised them any abiding benefit. 
 
 TUMORS OF THE LARYNX. 
 
 Most laryngeal tumors involve the interior surface, although they may 
 rarely develop on the exterior, whence they may perforate. 
 
 Benign Tumors. — The majority of laryngeal tumors are non-malignant, and 
 of these two-thirds are probably papillomata. Their origin is always obscure, 
 though they are usually referred to local irritation. They are rarely multiple, 
 and the anterior portions of the larynx are most often involved. Males are 
 much more liable, and children frequently present this condition, even young 
 infants. Nearly all, if not all, of the so-called benign tumors have been met 
 with within the larynx. They vary in size from that of a small seed to 
 masses sufficient to protrude beyond normal laryngeal limits. They occur prob- 
 ably with greatest frequency in the vocal cords. It must never be forgotten 
 that the transformation of benign into malignant tumors occurs more typically 
 here than perhaps anywhere else in the body. This would include the change 
 of papilloma into epithelioma, of fibroma into fibro-sarcoma, and of adenoma 
 into carcinoma, this transformation taking place usually in elderly adults at 
 that period when age predisposes to such changes in various parts of the body. 
 
 Symptoms. — The symptoms of laryngeal tumor are uniform, no matter 
 what its histology. They vary only according to its size and location. Hoarse- 
 ness or dyspnea occurs when the action of the vocal cords is interfered with, 
 but seldom at other times. Preceding this condition, however, is one of un- 
 certainty of voice, with alteration of timbre and of tone limits. What is known 
 as double voice, or diphthonia, has followed symmetrical growths dividing the 
 glottis into two portions. Finally, complete aphonia may result. Dyspnea 
 occurs in proportion to the amount of obstruction of the respiratory channel. 
 When the growth is slow there appears to be a compensatory arrangement of 
 the parts by which even a large growth will cause but little obstruction. Dys- 
 phagia is rare unless the growth occupy some portions of the pharyngeal aspect 
 of the larynx. Cough and pain are late symptoms. 
 
 The final diagnosis is made with the laryngoscope: Avhen this is imprac- 
 ticable, as in children, the finger-tip inserted as far as may be carefully done 
 
<;22 
 
 .l.V AMERICAN TEXT- BOOK OF SURGERY. 
 
 v,'\\\ sometimes aid. After making out the presence of the tumor in the larynx, 
 a fine curved laryngeal probe should be introduced in order to determine its 
 exact location and fixation. Papilloma and fibroma are usually pedunculated 
 (Figs. 2r)!>, '2(>()), the latter more often so than the former, and^are commonly 
 
 Fk;. 260. 
 
 Fi(i. 2ri9. 
 
 Polyp of Laryii 
 
 PapiUoma of larynx (Stoerck). 
 
 easily seen. Angeiomata are usually dark in color and seated upon the vocal 
 cords. Cysts occupy, as a rule, the ventricles or the epiglottis. Enchondro- 
 mata occupy merely the posterior portion of the larynx, especially the arytenoid 
 cartilages. With the presence of these tumors there may or may not be signs 
 of irritation or inflammation of the surrounding parts. The principal dangers 
 which tliey cause are those of suffocation, and not a few deaths have been thus 
 induced. 
 
 Treatment. — "When removal is possible it should be accomplished with 
 the smallest necessary disturbance. They may be removed by the natural 
 channel or after external incision. The intra-laryngeal method includes cauter- 
 ization, incision, excision, crushing, snaring, and avulsion. Very small and 
 accessible papillomata may be attacked with chromic or nitric acid or with 
 the galvano-cautery. These are all to be used with extreme caution, for fear of 
 resulting oedema. The instrument-makers supply cautery points by means of 
 which, guided by the laryngoscopic mirror and a steady hand, the action of the 
 cautery may be limited to the desirea point. Incision is resorted to only in 
 cases of cysts. Excision is performed Avith curved scissors or guillotine knives. 
 When crushing is resorted to, it is with a hope of destroying vitality and caus- 
 ing a slough. The ^craseur has also been employed for intra-laryngeal snaring 
 of tumors, but is difficult to operate. Avulsion, or rudely tearing away the 
 growth by forceps, is perhaps the most common procedure. Pedunculated masses 
 are thus readily removed, and sessile growths can be torn away en masse. All 
 these instruments can be guided by the mirror. They require special dexterity 
 and considerable practice, and such operations are mainly relegated to special- 
 ists. Great facility has been acquired in this direction by a few, and the 
 intra-laryngeal method in the hands of an expert offers better possibility of 
 success than does a clumsy incision at the hands of a general practitioner. 
 
 A\ hen, however, it appears necessary to open the larynx, the operation is 
 known as thyrotomy or thyroid laryngotomy, an<l consists in incision in 
 the middle line, with sijlitting of the thvroid cartilage beneath the line where 
 the two aire join, and the exposure of the interior of the larynx to sight and 
 to more radical operative attack. The thyroid being so intimately connected 
 with the cricoid below and the hyoid above, it will be usually necessary to divide 
 the former as well as the membrane both above and below. After whatever 
 
SURGEllV OF nil-: HKSrillATORY ORGANS. 
 
 G2;i 
 
 Fig. 2(51. 
 
 growth is present has thus heeu removed, the cartihiginous rin<2;.s may be united 
 by suture of the periehonch-ium, or even thi'oufjli tlie cartihijiie itself. It Avill be 
 ■wise to extend the incision downAvard thr()u<ih the lirst and second tracheal 
 rings and to insert a tracheal tube, since the laryngeal wound will heal much 
 more kindly if thus placed absolutely at rest. 
 
 Malignant Tumors. — These arc composed of various forms of sarcoma 
 and carcinoma (Fig. 261). The epiglottis is perhaps the most common seat 
 of sarcoma, Avhich may be met with in rela- 
 tively young patients. The large ])roportion 
 of true carcinomata will be found to have 
 resulted from generations of previously benign 
 tumors. 
 
 Symptoms. — So fiir as symptoms are 
 concerned, they are those of benign tumors 
 already considered, plus sensations as of 
 foreign bodies, greater dysphagia, pain, 
 often shooting upward toward the ears, and 
 emaciation and lymphatic involvement. Sar- 
 coma is much less likely to be ulcerated. That 
 it is not always possible even for experts to 
 settle these questions of difference of diag- 
 nosis is evidenced by the case of the late Em- 
 peror Frederick of Germany. The prog- 
 nosis is always bad unless the disease can be 
 arrested by radical operation. An encourag- 
 ing percentage of cure has resulted from operations involving complete or 
 partial removal of the larynx. One case lived nearly six years after the extir- 
 pation, and then died of an acute disease. 
 
 Treatment. — The treatment of cancer of the larynx is addressed, accord- 
 ing to circumstances, either to alleviation or to radical cure. The former consists 
 in local astringent and anodyne applications, with perhaps the occasional removal 
 of projecting masses or the application of the actual cautery, by which the 
 growth may certainly be temporarily checked in many instances. When in 
 time the laryngeal symptoms become so severe as to harass the patient, trache- 
 otomy Avill give a respite of several Aveeks or months. On the other hand, 
 when the disease is apparently local and no trace of it can be found outside of 
 proper laryngeal confines, and when the general condition and fortitude of the 
 patient warrant so severe an operation, partial or complete extirpation of the 
 organ may be proposed, and, with the consent of the patient, carried out. 
 Laryngotomy and laryngectomy will be described with other operations. 
 
 Carcinoma of the Larynx (Stoerck). 
 
 TUMORS OF THE TRACHEA. 
 
 Every variety of tumor has been found within the windpipe, although tumors 
 arise more frequently from the membranous than from the cartilaginous portion, 
 and are more common nearer its upper portion. These tumors are often, but by 
 no means necessarily, associated with others elsewhere. Male adults are the most 
 often affected. The causes are absolutely obscure. A considerable number of 
 these cases are now on record, and the condition is one which can ordinarily be 
 recognized with the laryngoscope. The benign tumors are usually peduncu- 
 lated, the malignant seldom so. The symptoms are SDmewhat indistinct, and 
 do not vary much from those of laryngeal tumor, save that respiration is more 
 permanently aff"ected and phonation much less so, if at all. The main sign is 
 
624 J.Y AMERICAN TEXT-BOOK OE SURGERY. 
 
 dyspnea, which should always lead to laryngoscopic inspection. In almost every 
 instance a tracheotomy will be called for, and according to circumstances it may 
 or may not he possible to remove the tumor through the same incision, which 
 may be prolonged to the necessary extent. The operation of resection of the 
 windpipe has been suggested, but not yet made feasible. 
 
 TRACHELOCELE. 
 
 This term is applied to a hernia of the mucous membrane of the trachea 
 between two of its rings or through a congenital defect. The tumor thus 
 formed on its exterior consists of a cyst of mucous membrane, the contents of 
 which, instead of being fluid, consist of air. It may be anterior or lateral, 
 and may vary in size from that of a pea up to that of a hen's egg. Usu- 
 ally unilateral, it is sometimes bilateral. It is most common in the adult 
 male. The symptoms are dyspnea, altered voice, sometimes even aphonia. 
 Externally there will be found a compressible gaseous tumor, which mav be 
 distended when the patient makes forced expiration with closed mouth and nose. 
 It may come on slowly or suddenlv. 
 
 The treatment should consist at first in pressure, although radical opera- 
 tion may be necessary for its cure. 
 
 WOUNDS AXD INJURIES OF THE LARYNX. 
 
 These may be of external or internal origin. Those from within are caused 
 usually by foreign bodies, those from without in various ways. The most com- 
 mon of the latter are contusions, and incised wounds made in suicidal or 
 homicidal attempts. The average would-be suicide is too ignorant to make his 
 incised wound on the side of the neck, where the great vessels would be more 
 easily divided, but makes usually an extensive gash in front, at a point where 
 he most commonly divides the thyro-hyoid or sometimes the crico-thyroid 
 membrane, and the violence exerted is expended before the region of the 
 great vessels is reached. This constitutes the ordinary form of cut-throat, 
 many instances of which occur every year. Sometimes the epiglottis is par- 
 tially, perhaps completely, separated, and the incision may even involve the 
 posterior wall of the pharynx. While the wound thus inflicted opens widely 
 by a retraction of tissue, and presents sometimes a horrible aspect, it is not 
 nearly so dangerous as it would appear to be, the majority of these cases recov- 
 ering if early and properly treated. 
 
 Treatment. — If seen early, the treatment should consist in approxima- 
 tion of all the divided tissues, the deeper parts being united with catgut, while 
 for the integument catgut or silk may be used according to fancy. In certain 
 cases local rest should be ensured by performance of a low tracheotomy, and 
 where feeding is difficult or impossible the stomach or rectal tube may be 
 employed so long as necessary. Aside from such injuries, punctured wounds 
 and gunshot wounds of the larynx or trachea may occur, and call for much or 
 little treatment according to circumstances. 
 
 Wounds of internal origin are produced mainly by foreign bodies, such as 
 fish-hooks, needles, fish-bones, pieces of glass, etc. These may tear or punc- 
 ture according to their size and location, and may excite mild or intense symp- 
 toms of laryngeal irritation with inflammation and oedema or abscess. Similar 
 substances frequently excite spasm of the glottis, which may necessitate trache- 
 otomy or may even kill before such aid can be rendered. In all such cases the 
 condition should be investigated with the laryngoscope if possible. If urgent 
 gymptoms arise, tracheotomy must be performed ; if seen at once, the foreign 
 
SURGERY OF THE RESPIRATORY ORGANS. G25 
 
 body can often be located and removed with suitable forceps. If not seen for 
 some hours or days, it may be so hidden by tumefaction or by exudate and 
 membrane as to be invisible. In such a case considerable local treatment 
 which shall be astringent, antiseptic, and ano<lync may be necessary before 
 it can be discovered. Sometimes after such injuries hemorrhage occurs by 
 which alarming or fatal results may be brought about. In such cases, when 
 the patient survives, there is always a possibility of secondary hemorrhage. 
 Should bleeding be alarming, it can be best checked by a tracheotomy, with 
 plugging of the windpipe by a tampon above the tracheal tube. To wait for 
 its arrest by syncope is to take very much more risk than is involved in mak- 
 ing an early incision. 
 
 Fractures of the larynx are known, although fjuite infrequent. The 
 fracture is usually limited to the thyroid and cricoid cartilages. Such injuries 
 are produced usually by blows from without. In elderly individuals in whom 
 senile calcification has occurred such lesions may be produced with much less 
 violence than in the young. The most common cases are blows with the fist 
 or some blunt weapon, or received from balls in athletic games, attempts at 
 choking — accidental or premeditated — and falls upon hard objects with crush- 
 ing violence. 
 
 The symptoms must vary somewhat with the cause of the injury and its 
 extent. A blow on the larynx Avhich does not fracture it will often produce 
 unconsciousness, as has been seen upon the cricket field. In 1889 a death 
 occurred upon the baseball field, where the player was struck in the throat by 
 a swiftly-thrown ball which fractured the larynx. He fell unconscious, and 
 died in a few moments of oedema, timely tracheotomy not having been per- 
 formed. Pain, dyspnea, cough, ejection of frothy blood and mucus, dysphonia 
 or aphonia, and dysphagia, are the common symptoms in cases not quickly 
 fatal. They may be followed in a short time by emphysema spreading more 
 or less widely, and by oedema of the larynx, always serious, sometimes fatal, 
 as above. The prognosis is most serious Avhen the cricoid has been broken, 
 only two cases of recovery from this injury being on record. 
 
 Treatment. — The most timely and life-saving measure that can be prac- 
 tised is a tracheotomy, by which at least security from suffocation will be 
 afforded. This still leaves an injury unattended to. It has been found 
 inadvisable to try to suture broken cartilages in these cases, even though the 
 fracture be compound. Perfect rest, such coaptation as external support may 
 afford, and intralaryngeal medication to some extent, will bring about the best 
 results. 
 
 Dislocation of the laryngeal cartilages is known, but is very rare. The 
 most common form is luxation of an arytenoid cartilage from the cricoid upon 
 which it rests. This may be associated with fracture. A pathological form 
 of dislocation is known resulting from cicatricial contraction from within or 
 without. Complete separation of the trachea from the hirynx, the result of 
 an accidental hanging, has been seen. 
 
 The treatment must depend on the urgency and permanency of the symp- 
 toms. Intubation or tracheotomy will probably be called for if anything be 
 required, while in the pathological form measures for dilatation of the stricture 
 will be indicated. 
 
 FOREIGN BODIES IN THE AIR-PASSAGES. 
 
 The entrance of a foreign body into the air-passages is one of the common- 
 est of accidents. Ordinarily the substance is at once expelled in a violent and 
 reflex fit of coughing. Natural expulsion may be aided by inverting the 
 
 40 
 
626 A.\ AMERICAN TEXT-BOOK OF SURGERY. 
 
 patient, often a child, and slapping somewhat freely upon the back. These 
 foreign bodies are most commonly introduced in a sudden inspiration, volun- 
 tary or involuntary, while the substance is in or close to the mouth. The 
 greatest variety of substances are thus introduced, among the more common 
 being artificial teeth, material rejected from the stomach during the act of 
 vomiting, including curdled milk and particles from the alimentary canal or 
 the respiratory passages above, fragments of teeth dislodged during attempts 
 at extraction, particles of cork or sponge, broken instruments, necrosed bone, 
 toys, etc. On the other hand, foreign bodies enter from the outside by direct 
 puncture, as gunshot missiles, or through previous wounds, like that described 
 when speaking of cut-throat. Fluids of all kinds, blood, pus, etc., also have 
 easv access to the larvnx and trachea in manv instances. When inorganic 
 these materials are not likely to undergo change, but when animal or vegetable 
 they may absorb moisture and increase in size or macerate. When retained 
 for long periods they may become covered with mucus or even calcareous mat- 
 ter. They are most likely either to be entangled at a point between the epi- 
 glottis and the level of the glottis, or to pass down and become impacted in a 
 bronchus. It frequently happens that a very small particle will cause a pro- 
 digious amount of irritation. 
 
 The usual symptoms are spasmodic cough, spasm of the larynx, and a 
 feeling of suftocation. At times the symptoms are violent, and the patient may 
 become unconscious from deficient oxidation of the blood. Foreign bodies 
 ai"e also the cause of some cases of prolonged and chronic laryngeal symptoms, 
 ulceration, or abscess, in Avhich the actual cause is either unsuspected or can- 
 not be detected. Inspection is always necessary, and the laryngeal probe will 
 be of great assistance. Endeavors to locate and appreciate accurately the body 
 are always necessary, save where urgency does not warrant any delay. In not 
 a few instances, however, suffocation occurs within the moment during which 
 there is no one at hand with sufficient knowledge to render any assistance. 
 Thus the writer has known of two young men who were (juickly suffocated by 
 pieces of meat within the entrance to the larynx, and more than one death which 
 has been ascribed to anesthetics has been caused by plugging of the parts with 
 masses of undigested food rejected from the stomach during the reflex act of 
 vomiting. This affords a most cogent reason for insisting upon an empty stom- 
 ach before beginning anesthesia, as well as turning the patient upon one side 
 or upon the face whenever vomiting occurs during this condition of loss of 
 voluntary control. 
 
 The prognosis should be always guarded, as a foreign body, which to-day 
 causes no distress and scarcely any symptoms, months or years later may kill 
 by a slow process of ulceration, necrosis, or something equally disastrous. 
 
 Treatment. — Excej)t in the severest emergencies the first endeavor should 
 be to dislodge the substance by the simplest possible manoeuvers, which con- 
 sist, perhaps, in inverting the body and slaj>]iing the ])atient on the back or 
 chest. Many substances, like those of a mineral nature, may l)e thus easily dis- 
 lodged and expelled. If it ])e a body of some size, the presumption is that it 
 has lodged within reach of the finger, in which case the mouth should be widely 
 opened, if necessary held so, and the index finger pushed deeply into the 
 pharynx and swept beneath the epiglottis and down toward the glottis. If 
 there be any substance there which the finger alone cannot dislodge, it may be 
 aided with anything at hand wliicli will serve the ])urpose. It is often well 
 in these cases to seize the larynx from the outside with the other hand, and 
 raise it well up toward the lower jaw, by which it is l)rought within better reach 
 of the inside finger. Effort of this kind failing, artificial light and the laryn- 
 
SURGERY OF THE RESPIRATORY ORGANS. 627 
 
 goscopic mirror must be brout^ht into play, aud, accordin<^ to the substance at 
 fault and the ingenuity and dexterity of the surgeon, the foreign body when 
 seen may be grasped and removed uith more or less readiness. Various kinds 
 of forceps and otlier means for removing foreign bodies have been devised, 
 and may be used as recjuired. Finally, in cases where there is every reason to 
 think that some foreign body is present, although it cannot be seen, the better 
 way will be to wait, making repeated examinations, accustoming the patient to 
 laryngoscopic methods, and cultivating the throat to tolerate the mirror. It 
 may be possible, after a process of schooling of this kind, to see and withdraw 
 the intruding substance. While the medical attendant should be ever ready 
 to operate by intubation or by tracheotomy, these procedures should be held 
 in reserve so long as there is no urgent necessity for them. 
 
 One point which the student should always bear in mind is that symptoms 
 of laryngeal irritation sometimes exist long after the expulsion of the substance 
 which caused them, and that patients will sometimes insist that they have not 
 yet been relieved Avhen it is certain that the foreign body has been expelled. 
 Moreover, the irritation of foreign bodies is often successfully imitated in hys- 
 terical individuals. 
 
 BURNS AND SCALDS OF THE LAEYNX AND TRACHEA. 
 
 These are practically never dissociated from similar injuries to the parts 
 above, and perhaps to the oesophagus. Burns are produced by the inhalation 
 of hot steam and superheated air. Scalds are commonly produced by hot and 
 caustic fluids. Caustic fluids taken internally are not always swallowed, but 
 often "go the wrong way." The consequence of these injuries is a very acute 
 laryngitis, which supervenes at once, with excessive intumescence and oedema. 
 In proportion to the extent and severity of the lesion will be the amount and 
 depth of the tissue-destruction. Following the first violence of the lesion a 
 membranous exudate is formed which separates by sloughing, and, if the 
 patient survive, may undergo extensive cicatricial contraction. These cases 
 are often complicated with bronchitis of a most serious and even a fatal 
 <;haracter. 
 
 The symptoms produced by burns are immediate and violent; those pro- 
 duced bv caustics may come on much more slowly. 
 
 So far as treatment is concerned, immediate death by suffocation can 
 easily be averted by tracheotomy, though it may not avail to save the patient 
 from secondary lesions. Scalds produced by caustic acids or alkalies are 
 usually seen too late to admit of any antidote or to avert their destructive 
 effects. The symptoms must be treated as they arise, and while the introduc- 
 tion of a trachea-tube will make respiration easier, the probability is that the 
 attendant will have to treat a comjilicated case of lesion of the mouth and 
 larynx, if not of the oesophagus, which will finally baflle his most persist- 
 ent and well-directed efforts. Iced and mucilaginous drinks, antiseptic 
 mouth-washes and gargles, and anodynes under the skin or by the rectum, 
 with rectal nourishment, sum up the principal indications in the way of 
 treatment. 
 
 TRACHEOTOMY. 
 
 Under the general term tracheotomy are included all those operations by 
 which the respiratory channel is opened from without at any point between the 
 thyroid cartilage and the sternum. To be more exact, we speak of laryngotomy 
 when the incision is through the crico-thyroid membrane or thyroid cartilage ; 
 
628 
 
 AN AMERICAN TEXT- BOOK OF SURGERY. 
 
 of laryngo-tracheoUnny when tlie cricoid and upper rin^rs of the trachea are 
 divided ; and of trneheotomif proper, or, a-s it is sometimes improperly called, 
 bronchotomy, when the trachea itself is opened. One or another of these opera- 
 tions i.s done, partly according to the choice of the operator and partly according 
 to the necessities of the case. They are undertaken for, first, croup and diph- 
 theria ; second, for oedema or acute inflammatory affections: thir<l, in sy[)hili8 
 and tuberculosis of the larynx in order to give it rest ; fourth, for malignant 
 disease in order to relieve obstructions to respiration ; fifth, in certain rare spas- 
 modic affections or strictures ; and sixth, for the removal of foreign bodies. 
 Many of the indications for tracheotomy have already been discussed. We do 
 not deem it wise here to go into the question of indications in cases of croup 
 and <liphtheria, beyond this remark, that a large projiortion of fjital cases are 
 
 KiG. 202. 
 
 Carutis inter na et txterna 
 
 Vnin fiicialin ruiiimiinis 
 
 R. ,le.v,l. S. XII. 
 
 Vpiiii jiiiinlnrix interna 
 
 Vena thyreoid, unper 
 
 S. fthren 
 
 ficnieiiiis iiiif 
 
 o-(ieitlo- inaxtoideHM 
 fa rill I is rmiimnnix 
 eo-lii/oiil mnsile 
 hi/oiil mnxrie 
 
 rnii-hyiiid 
 
 liiiio rri-oidea 
 
 npezius 
 
 Hiiperfirintis 
 .[rttrin trnnKrersiilix i-olli 
 Arteria tmiixrerxnliM xrnpitlir J ^ 
 I'eiin jiit/ntiirix externa 
 
 Vena thyreoid, inferior. 
 
 Omo-hyoid 
 Arteria xnhrlaria 
 Steruo-rleido-inaxtoideiis 
 Clarirnla 
 Isthmns fjland. thyroid. 
 
 The Structures of the Nefk iiiflcr Ilciikei. 
 
 the apparent result of operations postponed too long, and that it is very unfair 
 to the operative procedure to speak of it as having terminated fatally. It 
 should rather be said of it that it failed to save life because too long delave<l. 
 The interests of surgery and of humanity alike dictate that operation should 
 be done at the earliest moment after the indication has arisen. Euthanasia 
 may be a desirable achievement after a late operation, but the rescue of a 
 human life usually depends upon early operative interference. 
 
 Operation being decided upon, the operator is next to elect at Avhat point 
 he will open the windpipe. This will depend in some measure upon the time 
 which he feels can be devoted to it, or, in other words, upon the urgency of 
 the case. When patients are in the last gasp of dyspnea, everything else mtist 
 give way to the nece.ssity for opening the trachea at once, and even if the 
 isthmus of the thvroid be <livided or some larire vein be cut. one may be sure 
 
sunaERV OF Till-: liEsrinAronv <>n<iAXs. <)2i> 
 
 that hemorrhage ean be ehecked within a few seconds, and that even if bh)od 
 goes into the traehea, air will go in with it. 
 
 In these circumstances the trachea will be opened wherever it can be 
 first reached. On the other hand, when the operator is afforded plenty of 
 time he may select his point of attack, according to the age of the patient, 
 the relative 'thickness and length of the neck, and the purpose for which he is 
 operating. The two points most commonly chosen are the cricoid cartilage 
 and the first ring of the traehea, by which we gain access above the thyroidal 
 isthmus, or the tracheal rings immediately below it. This istlimus of the 
 thyroid is rather a bugbear to young operators than an actual detriment, since 
 when met with it is but the work of a moment to slip a double ligature under- 
 neath it, tie in two places, and divide it between them, or even to catch and 
 divide it between two pressure forceps. In young children with very short, 
 plump necks one works with greater ease if he keeps near the larynx. On the 
 other hand, -when the trachea lies near the surface and the neck is long, and 
 when also the light is good, the opening can be made lower down. 
 
 Tracheotomy is simple upon the cadaver, and perhaps the easiest import- 
 ant operation which can be there made. In a living patient, under certain 
 circumstances, it may l)e equally easy, but when in the presence of a desperate 
 emergency, Avith poor light and'untrained assistants and a windpipe moving up 
 and down because of the violent efforts at respiration, it may be one of the most 
 trying ordeals which even a skilled operator has to face. Two anatomical con- 
 ditions especially serve to embarrass the operator or even endanger the patient's 
 life. The first is the plexus of veins which sometimes, but not always, is 
 spread over the anterior surfiice of the trachea. In the ideal normal condition 
 these are arranged in such a way as not to involve the middle line, but, as is 
 often the case, they may cross it irregularly and often, and sometimes a vein of 
 good size will present at just that portion of the tube which we have exposed 
 for incision. When this condition is met with, these veins may be pushed aside 
 or may be deliberately ligated or caught with forceps, or, if exigency require, 
 they must be divided without these precautions. They are, under these cir- 
 cumstances, usually engorged in connection with the very congested condition 
 of all parts of the head and neck. As soon as a few inspirations have been 
 taken and oxygen has had access to the blood, a restoration of equilibrium 
 takes place and this congestion quickly subsides. Consequently, the vein 
 which bleeds viciously for the instant may almost entirely collapse a few moments 
 or seconds later. It' will comfort young operators if they remember this fact. 
 The other principal anatomical danger is an adventitious or abnormal 
 artery which arises occasionally from the arch of the aorta, or sometimes from 
 one of the large arteries at the base of the neck, and takes its course upward 
 along the trachea, in rare instances to its full length. It is known as the thy- 
 roidea ima, and may lie directly in the track of the incision. When met with 
 it is to be dealt with as any other artery would be. It must also be borne in 
 mind that the innominate' artery sometimes courses as high as the seventh 
 tracheal ring. Lower in the neck the trachea is deeper and smaller, and is 
 consequently less accessible. In young children the thymus gland may also be 
 an obstacle"^; consequently with them it is always desirable to work on the 
 upper portion of the respiratory tube. 
 
 Whether in child or in adult, the head and neck should be stretched over a 
 pillow or sand-bag, and an anesthetic should always be given, unless the patient 
 be already unconscious or cocaine be used. The middle line is always the line 
 of safety.' and in this line the incision is made, ordinarily from the cricoid for 
 five to seven centimeters downward. After cutting through the skin and pla- 
 
G30 ^^V A mi: Jiff 'AN TPJXT-BOOK OF SURdFJtV. 
 
 tysraa the endeavor sliould l»e made to separate or cut between the pairs of 
 pre-tracheal nniseles. The traehea is steadied with the left hand of the operator, 
 and the incision iind dissection are continued, stoppin<j only for arrest of the 
 heniorriia)^e, until the cartilages are felt. Fortunately, these are unmistakable, 
 and so long as the operator can feel them or can find them he need have no 
 fear of going wrong. After they have been exposed and the bleeding has been 
 checked, a tenaculum is used to hook up the trachea, in order to bring it well 
 to the front before incision, and to steady it. When this is once secured it 
 should not be let go until opened. The opening is made with a pointed knife 
 and two or three rings are divided, or the cricoid cartilage and one ring, accord- 
 ing to circumstances. At once there is a rush of air accompanied with violent 
 and irregular respiratory motions. During inspiration blood, if present, will be 
 sucked into the trachea, and during expiration blood and mucus, and perhaps 
 false membrane, will be expelled, probably into the face of the operator, a 
 danger to be carefully guarded against, especially in diphtheria. ^ If there be 
 only a hissing of air, without free play, it may be known either that the open- 
 ing is not large enough or that it is plugged with some shred of tissue or with 
 false membrane or some foreign body. In the former case it must be carefully 
 enlarged ; in the latter case it should be dilated, while Avith forceps or probes 
 the membrane or foreign body is removed. 
 
 It will sometimes happen that just at the most critical moment the patient, 
 usually a child, will entirely cease to breathe. This may occur just before or just 
 after making the opening. In this emergency the tracheal wound, if made, 
 must be quickly searched, to learn if it be plugged ; if, on the other hand, it 
 appear to be open, the most promising procedure will be to suspend the patient 
 by the heels and to slap vigorously on the back, or while in this position to 
 make artificial respiration by compressing the thorax by the arms and then 
 raising them in order to expand it. 
 
 It is advisable to insert into the trachea, on each side of the incision, 
 a silk suture, which is ordinarily passed through the skin as well. This 
 should be tied and the ends left hanging long. In this way a permanent 
 and most serviceable retractor is provided, by means of which the surgeon 
 and the nurse have absolute control of the trachea. Indeed, so simple and so 
 effective is this manoeuver that one need never hesitate to practise tracheotomy 
 even though he have no trachea-tube at hand, since by means of an elastic tied 
 around the neck or extemporized hooks fastened into the suture and then con- 
 nected with an elastic tape back of the neck, every purpose of the operator can 
 be complied with. This is the so-called operation without tubes, which every 
 practitioner should understand and be able to make in an emergency. 
 
 Trachea-tubes (Figs. 26-5, 264, and 2(>r>) are made of hard rubber, as 
 well as of silver and aluminum. The rubber tubes are heavy and thick, 
 and those of aluminum are always preferable. They are made double, in 
 order that the inner tube may be taken out and cleansed or freed from 
 dry mucus as often as is necessary. When cleansing them it is much better 
 to use an alkaline solution, by which the mucus is more readily removed. 
 The outer tube has a little shield which is held in place by a tape passed 
 around the neck. The largest tube which will comfortably enter the trachea 
 should be used. In cases of obstruction from false membrane it is advisable 
 sometimes to remove both tubes, and with a small probang firmly fastened to 
 a handle or with a little cotton tightly wrapped around a wire (juickly and 
 dexterously to pass this down through the opening, and as quickly withdraw 
 it, by which means membrane is dislodged and expelled by coughing. Even 
 this procedure, however, is itself dangerous, and should not be practised 
 
SURGERY OF THE RESPIRATORY ORGANS. 
 
 631 
 
 oftener than inav seem to l.e re.iuired by the trachea filling up Avith that 
 
 wliich cannot be expelled. 
 ^'"*- '-''•' The after-treatment of cases 
 
 -where traciieotoniy has been per- 
 formed recpiires to be almost as judi- 
 ciously carried out as the operation 
 itself. Inasmuch as air enters directly 
 into the lungs, it should be properly 
 
 Fig. 2G5. 
 
 I'ark's Divided Trachea-Tube. 
 Fig. 264. 
 
 Keen's Trachea-Tube. 
 
 Johnson's Modified Durham's Trachea-Tube. 
 
 warmed and moistened : the room should be kept at a temperature of 80 F. if 
 possible, and the air kept moist with steam. Most of the conditions which neces- 
 sitate tracheotomy are those which produce profound depression, and tonics ana 
 stimulants are essential. Of these strychnia and alcohol are the most desir- 
 able. The nutrition and the excretions should be carefully looked after, along 
 with such internal medication as the surgeon may select. No rule can be 
 given as to how long the tube should remain ; this must depend upon the sub- 
 sidence of the indication for which it was performed. If for a foreign body, usu- 
 ally one or two days ; if for croup or diphtheria, five to ten days or longer ; it tor 
 rel'ief of ulceration or stenosis, perhaps for a month or months and even years ; 
 and if for temporary relief in case of cancer, until death terminates the case. 
 Sometimes a mass of granulations develops around the tracheal wound alter a 
 few days, and causes considerable trouble either in reintroduction of the tube 
 or in producing obstruction to respiration after its removal. Rarely they lead 
 to cicatricial contraction later, and to what is known as granulation stenosis 
 of the trachea. When present, if possible, these should be removed with caus- 
 tics, with scissors, or with galvano-cautery. Other dangers connected with the 
 operation are secondary hemorrhage, sloughing around the wound, emphysema, 
 and ulceration and abscess. When the latter results, pus may burrow down- 
 ward into the mediastinum and cause death. Cellulitis is probably the least 
 common untoward sequel of the operation. It must be treated upon general 
 principles. 
 
():}2 
 
 A.y AMERICAN TEXT- HOOK OF SURGERY. 
 
 INTUBATION OF THE LARYNX. 
 
 This is a distinctively American improvement upon the ohl operation of 
 tracheotomy which we owe to tlic ingenuity and patience of O'Dwyer : not that 
 previous efforts in this direction had not hcen made, but that he first made it 
 practicaljle. Enough time has elapsed since its intnxluction to make it very 
 plain that it constitutes a large addition to our means of affording instru- 
 mental relief, and to give it a dignity and importance which perhaps no other 
 operation of equal simplicity possesses. The indications for the operation are, 
 in the main, the same as those for tracheotomy. It is performed mainly in cases 
 of diphtheria and croup, and occasionally for relief from symptoms produced by 
 burns and scalds, by foreign bodies, and by pressure of tumors, especially those 
 located outside the larynx ; also fjr certain cases of ulceration and stenosis, the 
 tube in this instance acting as a permanent dilator. 
 
 In the ordinary cases of obstruction it is obvious that the sooner it is 
 performed the better, since by delay the patient is more exhausted and his 
 blood more loaded with deleterious products. The originator of the operation 
 considers that the most pressing indication for intubation is recession at those 
 parts of the chest which yield to external air-pressure, with continued restless- 
 ness due to insufficient oxygenation, as well as feebleness of respiration. The 
 two great advantages which intubation possesses over tracheotomy are the speed 
 with which it can be performed and the bloodlessness and lack of shock follow- 
 ing it. The principal disadvantage is that the necessary instruments must be 
 at hand, while tracheotomy can be performed with almost any instruments. 
 
 As ordinarily sold, the set of intubation instruments comprises five tubes (Fig. 
 266, a), of sizes suitable for children from the earliest weeks of infancy up to the 
 age of twelve. A metal gauge or scale (B) has marked upon it the lengths of the 
 tubes and the ages for which each is suitable. Selecting the proper tube, a fine 
 silk thread is passed through a small hole near the anterior angle of its upper 
 opening. This is for the purpose of retracting it if it should be lodged in a wrong 
 
 Fig. 266. 
 
 O'Dwyer's Intubation Instruments. 
 
 8-12 
 5-7 
 
 .'3-4 
 
 2 
 1 
 
 .*,;, 
 
 position. Each tube is supplied with a separate obturator, which is screwed 
 into the handle by which it is introduced. The patient is held upright upon 
 
SURGERY or Till-: JIESPIRATORV ORGAXS. 633 
 
 the lap of au assistant, the head ujioii the assistant's left shoulder. The arms 
 should be secured, either by wrapping a towel or sheet around the patient's 
 body or by being grasped below the elbows and held firmly against the body 
 until the tube is inserted and the thread removed. Unless the hands are thus 
 secured the patient nuiy seize it and jerk the tube out of place. The mouth-gag 
 (C) which accompanies the set is then inserted at the left angle of the mouth well 
 back between the teeth, opened and clamped in such position that the mouth is 
 open to its natural limit. Another assistant stands behind the patient with his 
 hands firmly grasping the head, steadies it, and at the same time with his left 
 hand keeps the gag in place. The patient should be so held that body, neck, 
 and head are ke})t naturally in a straight line. The operator then, keeping the 
 thread looped around his right little finger, holds the introducer (D) in the right 
 hand while, inserting the index finger of the left, he seeks with the tip of it for 
 the epiglottis, which he raises with it, thereby uncovering the glottis. By the 
 time this is done the lower extremity of the tube has been passed down by a 
 manoeuver much resembling that by which the laryngoscopic mirror is put in 
 place ; the index finger is now the guide by which it is passed downward into 
 the larynx. This manoeuver is the most difficult of those by which intubation 
 is performed. The tip of the tube must be kept in the middle line and close 
 under and in contact with the epiglottis, which has been raised into a vertical 
 position. At the same time the index finger must be shifted to the patient's 
 right, in order not to take up that space in the pharynx in the middle line which 
 the tube must now occupy as it is passed downward. As the tube is lowered by 
 raising the other end of the handle, the introduced finger must also ascertain 
 that it is not being passed into the oesophagus ; on the contrary, that the pos- 
 terior wall of the larynx can be felt behind the' tube. When it is ascertained 
 in this way positively that the tube is in the larynx, no time should be lost 
 in sending it home to its proper position, and at the same instant dislodging 
 it from the obturator by pushing the slide upon the handle with the thumb 
 of the right hand. If the upper end of the tube is not by this means sent low 
 enough down, it can be pressed home by the finger which is still in the pharynx. 
 It is recommended also, while the finger is still in the throat, to make sure by 
 palpation that the tube is in place, which can be done by inserting its tip into 
 the oesophagus and from that point feeling it in the larynx. With practice 
 such dexterity is obtained that the entire little operation requires but a very 
 few seconds from the time the finger is first introduced. The writer advises 
 that, the arms of the child being still firmly held, the gag be for a few moments 
 removed in order to make sure that there is no necessity for removing the tube 
 at once, as well as that it is in place and affording the desired relief; theii that 
 the gag should be introduced for an instant while the finger is once more well 
 introduced, and pressed down upon the upper end of the tube to hold it in place 
 during the fraction of the second required to catch hold of one end of the 
 thread and pull it out from the hole in the tube. Then the gag and the 
 restraint are removed and the patient allowed perfect freedom. The instan- 
 taneous relief afforded by this operation is among the most cheering spectacles 
 which the surgeon ever meets. There is usually some coughing, often with 
 expulsion of membrane, and rarely expulsion of the tube as the result of vio- 
 lent cough. It is ordinarily best to reinsert the tube should it be thus expelled, 
 using perhaps the next larger size. 
 
 The dangers of intubation are few. One danger is suffocation from too 
 large a finger or one held too long in the larynx ; consequently several rapid 
 attempts are better than one prolonged effort. Another danger is that of 
 pushing down membrane ahead of the tube in quantity sufficient to produce 
 
634 AN AMERICAN TEXT- HOOK OF SURGERY. 
 
 obstructioTi ; but tliis liappens very rarely. Should it occur, tlie tul)c must 
 bo (juickly removed by the string, and then reintroduced as soon as the mem- 
 l)rane has been expelled. Small pieces of membrane are usually coughed up 
 and driven through the tube. Tubes when expelled from the larynx are rarely 
 Bwallowed, but are ejected through the mouth. The only danger of losing 
 the tube into the stomach is from not placing it properly in the larynx, or 
 else from leaving the thread to be subseijuently swallowed and draw the tube 
 after it. Even if swallowed the tube will usually pass without trouble. These 
 tubes are to be retained on an average for six days. Sometimes they may be 
 removed sooner, or if coughed up may not need to be reintroduced. It must 
 be remembered that they rest upon the false vocal cords, and not upon the 
 true, and consequently the loss of voice which is apparent after their removal 
 is not likely to be more than very temporary. Of course while the tube is 
 in place the child can only whisper. 
 
 One positive disadvantage which these tubes entail is difficulty of degluti- 
 tion, especially during the time they are worn. This is to be overcome in two 
 or three different ways : First, by feeding the child only so small an amount 
 of fluid that even if a part of it enter the trachea through the tube it can 
 cause no serious irritation. Secondly, by putting the child in such position 
 that the force of gravity will prevent this accident. This is done either by 
 turning the child well over on its side, or, better still, by putting it in a position 
 where the head is lower than the body while drinking or feeding. This can 
 be easily done in spite of theoretical objections. Thirdly, by giving it food 
 which is of semifluid consistency, and for this purpose ice-cream is often found 
 to be soothing, palatable, and nutritious. During the time that the tube is 
 worn the air in the room should be kept warm and moist, while such medical 
 and local applications are continued as to the surgeon may seem fit. 
 
 Finally, after a few days comes the question of removal of the tube. This 
 is sometimes solved by its expulsion by the patient ; at other times it has to 
 be removed by a manceuver quite similar to that by which it was introduced, 
 the patient being held in the same way, and the left index finger being again 
 the guide by which the point of the extractor (E) is carefully guided into the 
 opening in the metal. The point being engaged in the caliber of the tube, 
 the blades are sprung apart by the thumb of the right hand acting on the 
 shank of the instrument, and the tube is, as it were, hooked out and withdrawn. 
 This procedure is usually more difficult than the introduction of the tube, but 
 practice, especially upon the cadaver, Avill quickly make perfect. These tubes 
 are of metal plated with gold, with an expansion at their middle, and are 
 purposely made heavy in order to prevent their spontaneous expulsion. 
 After use in one case they must be carefully cleaned, sterilized over the flame 
 or by boiling, and thus may be used over and over again. They may also be 
 replated from time to time. 
 
 Intubation is also a measure which may be resorted to for the treatment 
 of syphilitic or cicatricial stenoses of the larynx, and this simple method can 
 be made to take the place of the more painful and less serviceable dilatations 
 of the larynx recommended by various, especially foreign, surgeons. In a 
 case of this kind it answers every purpose to let the patient wear an intuba- 
 tion-tube for a few hours, or a day or two, at a time, (|uieting reflex excita- 
 bility, if necessary, by local applications of cocaine or by morphine or other 
 opiates internally. The advantage of the continuous dilatation lasting for 
 several hours over a momentary dilatation by an instrument like Schroetter's 
 will be apparent at once. 
 
 The systematic practice of intubation has been a distinct advance in the 
 
SURGERY OF THE RESPIRATORY ORGANS. 635 
 
 surgery of the windpipe and larynx, and a larjjer proportion of lives can be 
 saved by this measure tlian by anything else that we know of When the 
 question of operative relief is raised, it slionld therefore be decided, if prac- 
 ticable, in favor of intubation early performed. 
 
 One practical hint in the after-treatment of cases either of tracheotomy or 
 intubation seems of great importance, and that is not to lose sight of the fact 
 that many of these little patients, especially those suffering from diphtheria, 
 are in a state of profound systemic poisoning, with the heart muscle very much 
 weakened, and that part of the secret of after-success lies in recumbency, in 
 proper nourishment, and in appropriate tonic and stimulant treatment addressed 
 to the heart, for Avhich purpose alcohol and strychnia seem especially indicated. 
 
 LARYNGECTOMY. 
 
 Resection or extirpation of the larynx is one of the modern operation.^ 
 conceived of on theoretical grounds and proved feasible by experiment upon 
 animals. It is performed especially in cases of malignant tumor located with- 
 in the larynx, with little or preferably no involvement of adjoining tissue. 
 The operation has also been performed for stenosis, for lupus, for necrosis, 
 and once or twice for tuberculosis. A few operators have not hesitated to 
 extend the field of operation beyond the larynx proper, and in one case Lang- 
 enbeck extirpated the larynx along with the hyoid bone, the base of the tongue, 
 the submaxillary glands, and a part of the pharynx and oesophagus ; during the 
 operation he was compelled to tie both the external carotids. The operation 
 is alwavs one of grear gravity, the amount of which neverthless depends in an 
 appreciable degree upon the condition of the patient. Nevertheless, its results 
 have been so conspicuously successful in cases otherwise absolutely hopeless 
 that one need never hesitate to advise it when the general condition outside 
 of the larynx is favorable. 
 
 When the patient's general condition is bad from the long-continued dys- 
 pnea it is a great advantage to make a preliminary tracheotomy one or two 
 weeks before the operation, as it accustoms the patient to breathing through 
 the tube and improves the aeration of his blood. In fact, most operators per- 
 form tracheotomy either as the first step of the laryngectomy, or a week or 
 two beforehand. Keen has recently described a method of operating which 
 seems to simplify the operation very much and to lessen its dangers. He avoids 
 tracheotomy entirely. His method of operating is as follows : first, the pre- 
 liminary preparation extends over at least two or three days. The teeth are 
 first thoroughly cleaned by a tooth-brush ; every two hours, when the patient 
 is awake, each nostril and the mouth are sprayed Avith boric acid and listerine 
 or other similar disinfectant. Chloroform is administered in the horizontal 
 position. All of the usual antiseptic precautions being taken, an incision is 
 made in the middle line from a little above the hyoid bone nearly to the 
 sternum, and is deepened until the thyro-hyoid membrane, the larynx, and 
 two or more rings of the trachea are exposed. The isthmus of the thyroid 
 gland is divided, and if necessary is ligated. If there is any doubt as to 
 whether unilateral or total laryngectomy should be performed, the thyroid 
 cartilage is split precisely in the middle line so as not to injure the cords. 
 The two halves of the larynx are drawn well apart by retractors and the 
 interior is carefully examined. The amount of blood lost up to this time is 
 exceedingly slight. If total laryngectomy is decided upon, the soft parts 
 attached to the larynx are dissected away by the knife, scissors, raspatory, 
 or Allis's blunt dissector. Care must be taken to adhere very closely to the 
 larynx. If the disease is found to have extended beyond the larynx, the 
 
G'Mi AX .l.l//.7.'/r.LV yAA'/W/OOA' or srii(ii:iiV. 
 
 operation should be abandoned. This docs not apply, liowever, to cases in 
 which the only extension is by glandular infection. All such glands are to 
 be removed before the operation is terminated. The soft parts are separated 
 from the larynx on each side until the (esophagus is reached. All vessels 
 are immediately clamj»ed and tie<l witli catgut. I5v this dissection the larynx 
 is entirely freetl, excepting jtosteriorly and at the upjier and lower ends. 
 
 The patient is now placeil in the Trendelenburg ])osition, and the trachea 
 is divided horizontally at such a point as will extirpate the entire disease. It 
 is also important that this division should be below the level of the beard in 
 men. lest the hairs grow into the trachea. The u)»|)er end of the trachea is 
 (piiekly secured to the skin by three sutures. Into the open end is inserted an 
 ordinary tracheotomy caiiula. the outer tube of which has a caliber of 12 mm. 
 This is secured around tiie neck by disinfected tapes; into it is passed a 
 metal tube which connects by rubber tubing with a funnel covered with flan- 
 nel, through which the chloroform is subse(juently administered. Of course, 
 the tracheotomy tube and the rubber tubing will have been carefully disin- 
 fected. The upper end of the trachea is now pulled forward and the larynx 
 is carefully separated from the oesojihagus by the finger, aided by Allis's 
 dissector, and occasionally the knife or scissors. If the oesophagus is acci- 
 dentally buttonholed, the opening should be closed immediately by ordinary 
 Lembert sutures. When the upper border of the larynx is reached the soft 
 ])arts are divided transversely in front and behind, and at the sides. The epi- 
 glottis is now drawn down through the wound and removed; the anterior wall 
 of the resoj^hagus is next attached to the tissues just below the hyoid bone by 
 silk sutures placed close together. The advantage of this step is. that it pre- 
 vents food and anv secretions of the mouth gaining access to the wound left 
 by the removal of the larynx and infecting it. The tracheotomy tube is now- 
 removed from the upper end of the trachea, and what little chloroform is 
 needed is administered on a pledget of cotton covered with gauze held by a 
 pair of forceps over the opening in the trachea. The external Avound is 
 entirely closed by silkworm sutures, the space formerly occupied by the larynx 
 being suitably drained for twenty-four hours. The parts are dressed with 
 aseptic gauze above and below the tracheal opening, which is protected by 
 any framework, such as a pill-box with the top and bottom removed, covered 
 with gauze to prevent dust from entering. The patient is |)laced in bed 
 without bolster or pillows and the foot of the bed elevated on a chair. This 
 Trendelenburg position is maintained for one or two days. By the third day 
 the patient is encouraged to sit up in bed, or even out of bed. For one or 
 two days food is administered entirely by enemata. By the third day the 
 patient can swallow eitlier liijuid or sometimes solid food. Entire healing 
 per primam may be expecte<l. Any tendency to contraction of the tracheal 
 opening is met by intermittent use of a tube. 
 
 The Trendelenburg position, not only during the operation, hut after- 
 ward, is intended to prevent the access of infection to the lungs. The imme- 
 diate closure of the entire wound, and the separation of the laryngeal wound 
 from the cavity of the mouth and from the end of the trachea, and the absence 
 of any tracheotomy wound, reduce the amount of infected fluids which can 
 obtain access to the lungs to those from the cut end of the trachea. Another 
 advantage of this method is that it dispenses with the use of any tampon 
 canula, which has many dangers. If the surgeon however decides to use one 
 ot these, that of Gerster is to be preferred. The disadvantage of attaching 
 the cut end of the trachea to the skin and of uniting the oesophageal wall to 
 the hyoid is that it prevents the use of an artificial larynx ; but this at the 
 
SURGERY or Till-: REsrihwronv organs. g:57 
 
 best is a poor substitute, and in the frreat inajority of cases is not used at all. 
 In (V)lien"s woll-known case. tlH)u<:li no coninninifation existed between the 
 trachc;! Mild the nioutli, tlit' |iaticiit had audil)le voice. 
 
 Unilateral laryngectomy is a modification of tlie foregoin;^ wliich 
 includes the removal of a lateral half of the larynx, luiturally for disease lim- 
 ited to one side. It is performed upon the same general principles as the com- 
 plete extirpation, but while less formidable in theory and in description, it is 
 perhaps a more difficult operation, inasmuch as the mechanical details have to 
 be carried out in a restricted space. The ))artial operation has been successful 
 in about one-half of the total number of instances, and the complete operation 
 in something like "25 or 30 per cent. 
 
 SECTION III.— INJURIES AND DISEASES OF THE CHEST, PLEURA, AND LUNGS. 
 
 Pleuritic Effusions. — Serous effusions into one or both pleural cavities 
 may be the result of acute or chronic inflanmiation of the pleura or lungs, or 
 both, also of the presence of tumors or foreign bodies. The tumors need not 
 involve the pleura, but may cause passive effusions by obstructing the return 
 circulation. The large majority, however, of cases of hydrothorax Avith which 
 we have to deal are the result of so-called pleui'isy with effusion. These cases 
 become of special surgical interest, naturally, when the collection of the fluid 
 assumes such magnitude or such permanency as to call for mechanical measures 
 for its removal. 
 
 The signs of the presence of fluid in a pleural cavity are virtually the 
 same whether this fluid be serum, blood, or pus. In brief, they are these : 
 The patient is apt to lie on the affected side, by which the sound lung is afforded 
 better play. On inspection there will be found limitation of motion of this 
 side, and the intercostal spaces may bulge or at least be level with the surfaces 
 of the ribs. The apex of the heart, too, will be dislocated to one side or to 
 the other in proportion to the quantity of fluid present. Its displacement to 
 the left is never so great as that to the right. The liver may be displaced 
 downward. On palpation there is no friction ; fremitus and vocal fiemitus are 
 diminished or lost over the fluid. When the chest wall is oedematous the con- 
 tained fluid is purulent. By measurement the affected side will be found larger 
 than the Avell side. Upon percussion there will be dulness over the lower and 
 posterior surface of the chest, giving place to flatness, and, as fluid is increased 
 in amount, accompanied by a sensation of increased resistance under the percuss- 
 ing finger. This dulness will have a certain level, which in all probability 
 will alter with the position of the y»atient, while there will be pulmonary reso- 
 nance just above this line. When the amount of fluid is very great, flatness 
 may extend upward to the clavicle. Over the sound lung there is exaggerated 
 vesicular resonance upon auscultation ; the respiratory murmur is w^ak or 
 absent over those portions (jccupied by fluid, while, as the lung is compressed, 
 the breathing takes on a bronchial character. In mild cases friction sounds 
 are sometimes heard. 
 
 When these signs are found, one may be quite sure of the presence of 
 fluid. In order positively to prove the diagnosis, if such conviction be required, 
 the needle of a hypodermatic syringe or of an aspirator may be introduced ; 
 through this thin serum will always flow. It may be possible, however, for a 
 small needle to become clogged by a fragment of blood-clot or of fibrin or of 
 caseous pus, so that while the discovery of fluid with a fine needle is always 
 positive evidence, failure with the same needle to get fluid is not necessarily 
 the reverse, and only with the large-sized needle can this question be settled. 
 
638 .l.V AMERK'AX TKXr-HOOK OF SURGERY. 
 
 EMPYEMA. 
 
 This term is applied to a collection of pus in any cavity, but by common 
 consent, unless some other cavity is specified, it is understood to refer to that of 
 the pleura. Pus may be found here as the result of the same causes that bring 
 about serous effusion, plus the contamination ))y organisms from the lungs or 
 more remotely through the systemic circulation. In cases of penetrating 
 injury of the pleura, when air has entered this cavity it is not unlikely 
 that collections of blood or serum will become thus directly contaminated, 
 and empyema be the result almost from the outset. As a rule, however, it is 
 the result, perhaps the termination, of a chronic process. In recent cases the 
 pleura does not have time to become very much thickened; but in long-stand- 
 ing cases, especially those in which spontaneous perforation has occurred, the 
 pleura becomes infiltrated and altered, so as to lose all resemblance to its 
 original structure, and to be found sometimes a centimeter thick. Under these 
 conditions it is more like leather than like a living tissue. A collection of pus 
 having occurred within the pleural cavity from any cause, several possibilities 
 exist for it : its fluid portion may be gradually absorbed and its soli<l material 
 remain to cement the pleural surfaces together and to caseate, and finally to 
 disappear ; or it may excite further production of fluid of the same character, 
 which will produce such urgent symptoms as to necessitate relief; or it may 
 evacuate itself either by rupture into a bronchus or bronchiole and escape by 
 the mouth or by perforation elsewhere in any one of various directions. Thus 
 it has been known to burrow down around the external intercostal muscles which 
 terminate under the intercostal cartilages and to appear at various points about 
 the thorax, or to perforate or burrow around the fibers of the diaphragm and 
 cause perhaps a subdiaphragmatic abscess, or to take some other unusual 
 course. It has, for instance, been known to perforate behind the mammary 
 gland, and, pushing itself forward, to assume enormous size as a retro- 
 mammary abscess ; or to separate the diaphragm, and then the peritoneum, 
 and to make such a dissection of it from the abdominal wall as to appear in 
 the pelvis and in the abdominal wall as an enormous extra-peritoneal abscess. 
 But these are unusual cases, and it ordinarily gives rise to the same character 
 of disturbance as a collection of serous fluid, with the addition of the consti- 
 tutional signs of the presence of pus, such as chills, irregular high temper- 
 ature, emaciation, hectic, etc. 
 
 I. The idiopathic forms of empyema may be thus classified : 
 
 a. Staphylococcus and streptococcus form of infection of pleuritic ex- 
 udate. 
 
 h. Diploeoccus form, from Frankel's diplococcus pneumonia?, probably 
 originally the result of a pleuro-pneumonia, the pneumonic lesion 
 having cleared up. 
 
 c. Tubercular form, the result of tubercular pleurisy, which may be con- 
 
 taminated with pyogenic cocci. * 
 
 d. Secondary and embolic form, due to a suppurative focus elsewhere 
 
 (e. g. retro-pharyngeal abscess, perforating peritonitis, pyemia, etc.). 
 
 e. Putrid form, from contamination by saprophytic bacteria. 
 
 II. The traiunatic form must be regarded as comj)rising cases of — 
 Simjde and mixed infections from burns, wounds, foreign bodies, etc. 
 The surgical treatment of empyema — and it scarcely permits any other — 
 
 is by paracentesis, i. e. aspiration, or free incision and drainage. In simple 
 cases the former may be first tried, as described above. Serious or long- 
 standing cases should not have time thus wasted upon them, but should be 
 subjected at once to some form of thoracotomy (p. G40). 
 
SURGERY OF THE 11 EXPIRATORY ORGANS. 639 
 
 HEMOTHORAX. 
 
 By this term is meant a collection of blood in tlie pleural cavity. It is 
 almost always of traumatic ori«;in, altlioun^li the possiljility of spontaneous hem- 
 orrhage cannot be excluded. We meet with it most often in cases of fractured 
 ribs, where a sharp fragment of bone has scraped the surface of the lung dur- 
 ing respiration until the lung is removed from harm's w^ay by the presence of 
 serum or blood pressing it away. Furthermore, it is seen in cases of gunshot 
 or stab wound where an intercostal artery or some vessel in the lung has been 
 divided, and where blood, even to fatal amount, has collected. The general 
 physical signs already given in some detail will point to the presence of fluid, 
 and the history of the case or of the injury, with aspiration, if necessary, will 
 enable the surgeon to decide which condition he has to deal with. 
 
 OPERATIVE TREATMENT OF FLUID COLLECTIONS IN THE PLEURAL CAVITIES. 
 
 Paracentesis. — The indications for removal of fluid from the pleural 
 cavities, without reference to the stage of the disease, in moderate eff'usions are 
 dyspnea and distress, and the recognition of the presence of large amounts of 
 fluid, whether other symptoms and signs are violent or not ; furthermore, 
 the failure of nature or art to cause resorption within reasonable time, on the 
 average thi-ee weeks ; .spontaneous perforation into the lung ; the presence of 
 fever, perhaps with chills, and bulging of intercostal spaces, with oedema of 
 the overlying skin, which are supposed to indicate the presence of pus ; or the 
 certainty from the history and physical signs that blood has been poured out 
 and has not been resorbed. There are other reasons than the mere necessity 
 to obtain immediate relief why evacuation should be secured. By the pres- 
 ence of fluid the lung is naturally compressed and its integrity impaired, with 
 a pro.spect of permanent injury to its function if it be not permitted to resume 
 its former shape and size within a reasonable time. We may also be sure that 
 the longer it has been compressed the less elastic it is and the more difficult 
 will be its expansion. 
 
 Paracentesis Thoracis. — The term paracentesis is applied to evacuation 
 of fluid from any cavity, the particular cavity being specified in the name of 
 the operation. To Bowditch of Boston is due the credit of having first applied 
 suction for the evacuation of fluid effusions, a method which has now become 
 so general as scarcely to call for comment. For this purpose there are needed 
 a hollow needle or fine ti'ocar, some flexible tubing, and some mechanical 
 device for suction. In the absence of all other mean.s, siphonage may be 
 practised through a yard or more of rubber tubing first filled with aseptic 
 solution and its lower end kept constantly under water; or a Davidson syringe 
 may be used, or one of the more elegant forms of aspirator, or the Allen sur- 
 gical pump, although if the emergency be very dire an ordinary trocar, or even 
 the puncture of a tenotome blade, may be resorted to. The two main indica- 
 tions are to withdraw the fluid and to prevent the admission of air. If air can 
 be kept out, the lung must necessarily tend to expand in order to take the place 
 of the fluid which is removed. Inasmuch as this should be anything but a rapid 
 process, the needle should be only large enough to permit fluid to run ea.^ily 
 through it and carry perhaps Avith it fine flocculi of fibrin, otherwise pulmonary 
 hemorrhage, or at least violent intrathoracic distress, might ensue. Before 
 using it the needle should be cleaned and polished and then sterilized by pass- 
 ing it through the alcohol flame. Unless patients are too w-eak to sit up, they 
 are placed in a sitting posture. It is well to give a little stimulant before and 
 perhaps during the operation. The needle is inserted in an intercostal space 
 
640 AX AMKincAX ri: XT- BOOK OF smoKity. 
 
 eitlier just below the lower angle of the scajiula at the back, or at the side just 
 in front of the latissinuis dorsi muscle. Before introducing the needle the skin 
 should be scoured and made aseptic ; and it should be inserted quickly. It is 
 perhaps well to guard the needle with the finger, lest by too forcible a plunf^e 
 it be inserted too far. There is always a possibility with a too fine needle that 
 some particle of fibrin or clot or caseated pus may obstruct it so that nothincr 
 will flow out. Most of the aspirat(»r needles are provided with wires which 
 may be inserted into them after being cleansed, and with which they may be 
 cleared out. Should fluid still refuse to come, especially if the anterior end of 
 the needle appear to work freely as if in a cavity, it is better to withdraw it to 
 see that it is clear, and then to introduce a larger one. The withdrawal of 
 a needle should be done as quickly as its introduction ; after which the punc- 
 ture is sealed with plaster or collodion. 
 
 Sometimes patients becon)e so weak or faint that it is necessary to put 
 them in the recumbent position or even to stop the aspiration for the time. 
 The sudden expansion of the previously compressed lung certainly does often 
 cause a most disagreeable sensation, while the withdrawal of the fluid perhaps 
 allows the heart ((uickly to return to its normal position, by which its action 
 may be temporarily disturbed. I*erfect rest should be enforced for a number 
 of hours after the operation. 
 
 Should the lung persistently refuse to re-expand after repeated tappings, it 
 is scarcely worth while to make many efforts. Constitutional treatment with 
 tonics will probably do more for these cases than surgery. However, should 
 it be necessary after prolonged effort to do something, it would have to be 
 in the line, probably, of excision of ribs as described below. It has been 
 recently found tliat empyema, following pneumonia, is occasionally cured by 
 tapping. When, therefore, the pneumococcus is found tapping should first 
 be done. 
 
 When the effused fluid is purulent the prognosis after simple aspiration 
 is not nearly so good. In rare instances, esjit-cially in children, and in 
 pneumonic empyemas, one or two tappings may suffice, but a condition of 
 empyema or pyothorax differs but little from any other large abscess, save 
 that it has a bony and unyielding wall, and it calls for incision and drainage 
 after the same fashion. 
 
 THORACOTOMY. 
 
 Thoracotomy, or 0})ening the wall of the thorax for evacuation of collec- 
 tions of fluid, consists sim|)ly in an incision, jierhaps two inches long, throuL'h 
 the skin over an intercostal space, the opening througli the pleura Ix'ing an 
 inch or half an inch in length. When peiforming this operation the skin 
 should be cleansed, as well as the operator's hands; the skin may then be 
 slid upwanl for an inch or more above the point at which the opening is to 
 be made, in order that when it returns to its place it shall exercise .somewhat 
 of a valve-like action. This will be of little use so lonj; sis the draina'^e- 
 tube IS in use, but may be of service later. To avoid a mistake it is well 
 before finally dividing the jdeura to insert a needle or fine trocar to see if 
 pus be underneath. If found, no hesitation need be felt in perfi»rating the 
 pleura, being careful only not to push the knife too far in ; or in allowing the 
 pus to escape, which it will probably do by jets because of the patient's breath- 
 ing or coughing. The best point at which to )»uncture is at the side just in 
 front of the latissimus dorsi muscle, certainly not lower than the eighth inter- 
 space, and perhaps even as high as the sixth, ileic the jileura is near the sur- 
 face, and we gain the advantage of gravity in draining the chest, while drain- 
 
scnai:nv of tiii: lucspinAToiiv organs. G41 
 
 age-tubes at this point cause little discomfort. Of course air enters the chest 
 through the external opening, the air-pressure on each side of the lung is 
 e([uali7A'd. and there is no fear of distress from too rapid expansion of the lung. 
 The ])us from these cases is freciuontly fetid, l)ut the fetor will usually disap- 
 pear in a short time. Some surgeons advise washing out the pleural cavity, by 
 •which means pus-clots are removed and fetor of discharge is subdued, but when 
 there is neither fetor nor debris discharged it is perhaps as well to omit irriga- 
 tion. When this latter is practised we may use strong or saturated boric solu- 
 tions or solutions of mercuric chloride, 1 : 5000, followed by boiled water or 
 dilute Labarracjue's solution. Through the incision one or, preferably, two 
 good-sized stout drainage-tubes are inserted and f;\stened by silk sutures to the 
 skin. They should be just long enough to reach from without fairly into the 
 pleural cavity, and are introduced partly for purposes of washing and drainage, 
 and partly to keep the opening from healing too quickly. 
 
 In some instances the ribs are so close together that any tube will be col- 
 lapsed by their pressure upon it. AVhen this is the case a section of rib, prob- 
 ably of the seventh, about an inch in length, should be removed. After the 
 complete evacuation of an empyemic cavit}^ a large quantity of antiseptic and 
 absorbent dressing should be placed outside the wound, and over all this some 
 impervious covering such as rubber dam. Outside this an. elastic bandage 
 around the chest will be of advantage, provided it be not too uncomfortable. 
 This dressing should be renewed the following day. and after that every second 
 day. As soon as the discharge becomes serous, and has diminished to a very 
 small amount, one drainage-tube may be removed, and the second when the 
 amount is no greater than would be caused by the presence of the tube. Wlien 
 the chest has thus been opened, expansion of the collapsed lung is finally at- 
 tained in many cases. 
 
 Excision of Rib. — In certain cases it is evident at the outset, and in 
 other cases it becomes patent later, that mere incision with insertion of ilraiii- 
 age-tubes will not afford large enough and permanent enough vent. In such 
 cases it is a common practice to remove a section of one or two ribs through a 
 single external incision, the bony pieces being from one to two inches long. 
 This makes a somewhat more formidable operation than the foregoing, and is 
 advisable mostly in cases of longer standing. Whenever it is necessary to 
 incise the chest for this purpose, we must expect to find the pleura altered 
 from a thin parchment-like membrane into one which seems more like leather, 
 and which may be correspondingly tough. 
 
 THOEACOPLASTY (ESTLANDER'S AND SCHEDE'S OPERATIONS). 
 
 Finallv, the surgeon is called at times to cases where the empyemic con- 
 dition has existed for a long time, or where an encysted collection has 
 formed, or where spontaneous perforation has occurred, so that he has to 
 deal with a thoracic fistula, discharging at times a small, at times a large, 
 amount of pus. In these instances the pleura has become so rigid and inflex- 
 ible, and the lung so fixed in its abnormal position, that even if the cav- 
 ity be widely opened by the ordinary method it is impossible for it to heal, 
 since the lung cannot expand from within nor can the chest-wall collapse 
 from without. The ribs now act like parallel hoops, and serve to preserve 
 a cavity which we urgently desire to obliterate. This may be somewhat 
 diminutive in size, or may be almost commensurate with the entire space nor- 
 mallv occupied by one lung. It is in these cases that the thoracoplastic method 
 devised by Estlander has rendered the most signal service. It is based simply 
 
 41 
 
042 
 
 • I.V AMFJilCAX TEXT-IK K>K OF SCUdFin' 
 
 Oil the theory that inasmuch as tlie inner wall of the cavity cannot (•\j)an(l to 
 meet the ribs, the ribs must be so divided as to iierniit them to fall toward and 
 meet the lung tissue. It offers a prosjject of final cure for cases which are otlier- 
 ■wise beyond such possibility. The smaller the cavity the simpler the operation, 
 though one may not be deterred from resorting to it in exti-eme cases. Before 
 deciding to operate, however, it would be well carefully to examine the patient 
 and the urine, in order to recognize such signs of amyloid changes as would 
 make it unwise to give anesthetics or perform any sevei-e operation. 
 
 Inasmuch as it is usually necessary to attack several ribs, we must jilan our 
 incisions in such cases according to the size of the cavity and the amount of 
 collaj)se desirerl. In the im^-e simjile cases it is enough to make a long incision 
 from the axilla downward, and simply to divide or perhaps remove pieces from 
 the third to the eighth or ninth rib. At other times an incision is made both in 
 front and behind, and posteriorly at the inner border of the scapula, bv which 
 three or four ribs may be divided in front and from three to seven behind. 
 Such an operation as this is very severe, and leaves the patient witii a large 
 passage clear through the chest. 
 
 When performing this operation, if the patient's strength hold out, it i.s well 
 to do more than simply divide the ribs and the enormously thickened pleura. 
 This pleura is practically the wall of an immense abscess, and from it shreds 
 of membrane and disorganized tissue may hang like stalactites from the roof 
 of a cavern. These cases are also usually tubercular, and such membrane 
 is fraught with danger. It is advisable, therefore, to scrape and cut away from 
 both pleural surfaces as much of it as can be safely removed without excitincr 
 too serious hemorrhage. No fear need be felt from the intercostal arteries, 
 since it is a simple matter to check the hemorrhage with catch forceps and to 
 pinch the bones sufficiently to compress the arteries. The altered pleura, as a 
 rule, is not vascular, and it is surprising how so formidable an operation can be 
 made with so little loss of blood. No attempts should be made to suture or 
 close the wound, but it is left as widely open as possible, and perhaps packed 
 in order to keep it so. As granulations spring up on the freshened pleural 
 
 surfaces we have a gradual process of healing 
 by second intention or adhesion of granu- 
 lating surfaces, by Avhich the lung will be 
 gradually drawn outward and the chest 
 drawn inward. Considerable restoration of 
 function also occurs. 
 
 iSchcde's Operation. — In old cases, in which 
 the pleura may be an inch thick, Schede has 
 devised a still more radical operation. An 
 incision (Fig. 267) is made from the level of 
 the axilla in front to the second rib behind, 
 the convexity of the incision reaching to the 
 lowest limit of the pleura. The large flap 
 is dissected loose down to the ribs, the scap- 
 ula being lifted from the trunk. The ribs, 
 from the second downward, from the costal 
 cartilages to the tubercles, and the entire 
 muscular chest-wall and the pleura, are 
 then removed by large scissors or bone- 
 forceps and the flap is replaced on the lung 
 Any bleeding arteries are tied. Healing gen- 
 
 liicision for Schede's Operation of Tho- 
 racoplasty (Esmarch and Kowalzig). 
 
 after thorough curetting. 
 
 erally takes place by first intention. 
 
srii(;i:in- or riii: j:i:si'ii:A'r<tin- onaANS. 643 
 
 (JAXdKKNi: OF THE LUNGS. 
 
 This may bo oitlicr idiopathic' or traumatic. It is more coiniiioii in the 
 h)\vt'r than in tlio u])))cr h)hi's. 'I'hore are a (liffusc and a circiiniscrihed form. 
 Tlie ("ormer is usually of the emljolie variety. (ianL^ronc here, as elsewhere, 
 is the result of bacterial invasion and putrefaction. The lungs may be invaded 
 from -within by foreign bodies taken in by inhalation or by " swallowing the 
 wrong way." It occurs in marasmic patients, in the insane, in those that can- 
 not swallow well nor cough, and in those witli bulbar paralysis. It may also 
 result from necrotic ])rocesses in the pharynx or larynx ; also from perforation 
 of septic foci from other tissue, as through the j)leura or dia])hragm, or from 
 carious vertebnxi or infected bronchial glands. It develops secondarily also 
 from such conditions as fetid bronchitis or croupous pneumonia or bronchial 
 dilatation ; also by embolic processes from gangrenous bed-sores, puerperal 
 septicemia, etc. It furthermore occurs as the result of injuries, such as 
 lacerations, compound fractures, gunshot and stab wounds, etc. ; or as the 
 result of severe contusions with cerebral concussion by which respiration 
 is interfered with and venous stasis encouraged ; or by such injuries as cause 
 endocarditis. 
 
 The clinical signs of gangrene of the lungs much resemble those of fetid 
 bronchitis. The sj)utum as well as the breath has a most repulsive odor, and 
 if the former be collected in a glass it forms usually three layers, the lower one 
 consisting almost wholly of pus and debris. When of traumatic origin we have 
 intense local and prolonged pain, severe initial chills, pyrexia, and, later, fetid 
 expectoration. If the gangrene is localized in the lungs, ulceration may take 
 place ; when the pleura is involved it is fatal. By physical examination we 
 can sometimes easily map out the extent of the gangrenous condition. Some- 
 times we get even the signs of a cavity. If such be near the surface, we may 
 be sure of adhesion between lung and chest-wall, and may see here a plain 
 indication for surgical interference. 
 
 This may be rapidly and successfully performed by free incision down to 
 the pleura, with resection of one or more ribs if necessary, and then the open- 
 ing of the gangrenous pulmonary cavity, which is usually performed with the 
 cautery knife. The danger of the operation can be scarcely as great as that 
 of the condition if left unrelieved. 
 
 SUEGERY OF THE LUNG. 
 
 Modern experimental methods have shown that in certain cases and in certain 
 ways it is not only possible, but judicious, to attack the human lung. Centu- 
 ries of clinical observation have made it clear that the entrance of air into the 
 pleural cavity either from within or from without is by no means fatal, but may 
 be an incident quickly recovered from. So long, then, as air has access, it mat- 
 ters little whether it be through a small opening or through a large one ; that is 
 to say, if necessary, we can expose the lung by a large incision. Thus far, 
 the lungs have been attacked in cases of wounds, especially for the relief of 
 hemorrhage, of gangrene, of abscess Avhether due to gangrene, dilated bronchi, 
 or tubercular disease, for the drainage of cysts, for the removal of solid tumors, 
 for the excision of foci of tubercular disease ; and they may properly be 
 attacked in certain cases for the removal of foreign bodies. We may distin- 
 guish between simple incision, or pneumotomy, and exsection of a portion of 
 lung tissue, or jynt'ianectomif. 
 
 Experiments on animals have shown that two-thirds or more of one lung 
 can be removed through an incision in the thoracic wall with almost perfect 
 
044 .4.V AMERICAN TllXT-lK X )K OF SURGERY. 
 
 impunity- So much as this of a human hni;^ has as yet never heen safely 
 removed, but small portions have. Vivisection teaches us that although one 
 pleural cavity be opened and its lung collapsed and made temporarily useless, 
 the animal can get sufficient oxygen by respiring uith the other lung, and 
 that in case oxygenation be deficient or respiration suddenly sto])ped, it may 
 be continued by artificial means almost indefinitely. Consequently, if the 
 human patient must be subjected to some such ordeal as this, the surgeon 
 should have at hand a irachea-tube and bellows or means for inducing arti- 
 ficial respiration. In the operations recorded, however, it has seldom been 
 necessary to resort to them. 
 
 PxEUMOTOMY in the presence of disease consists ))ractically in the measures 
 described above for opening gangrenous cavities. This is where we expect to 
 find the lung adherent to the chest-wall. Should we fail to find it thus fixed, 
 the lung should be drawn up toward the surface and snugly fastened there by a 
 row of sutures. Within a few hours adhesion will have taken place, and the 
 cautery may be used for penetrating deeper, as above mentioned. This would 
 presumably be the Jjetter method for dealing with a foreign body in the lungs, 
 provided we can locate it, and if it cannot be located it will be inadvisable to 
 operate unless the chest has been already widely opened and the lung collapsed. 
 In one instance after a stab wound of the chest a man was allowed to die 
 because it was held that a large vessel in his lung had been wounded and that 
 his condition was consequently helpless. It was found later, however, that 
 the bleeding all came from an intercostal artery, through which the man had 
 bled to deatli into his own chest. In this case the result might have been 
 very different had free incision been made and the source of the hemorrhage 
 sought for. 
 
 Pneumectomy may be done in a similar way, as when a hernia of the 
 lung, recent or old, is excised ; or it may be forced upon a surgeon when in 
 operating upoji a malignant tumor of the chest he finds the lung adherent 
 behind it and involved in the disease. Success has been obtained in such 
 cases, the wound in the luni; tissue beino; closed according; to usual methods. 
 Or it may be done with deliberation, as in the case where an Italian surgeon 
 resected a tubercular lobe from one lung of his Jiancie, and later committed 
 suicide because of the fatal effect of his operation. 
 
 IIemourha<;k Folloavixu Wound of the LrN<;. — In a case recently re- 
 ported by J. Chalmers Da Costa, secondary hemorrhage into the pleural 
 cavity occurred eleven days after the infliction of a gunshot wound of the 
 lun,g. Several ribs were resected, and the lower lobe of the lung was found 
 to be lacerated, sloughing, and bleeding violently. It Avas impossible to arrest 
 the hemorrhage by ligatures or forceps. On attempting to pack gauze against 
 the bleeding surface, the lung was simply pushed away. The entire pleural 
 sac was filled with sterile gauze in order to afford a base of support, and 
 iodoform gauze was then packed against the bleeding lung. The hemor- 
 rhage was arrested and the patient recovered. 
 
 INTRATHORACIC TUMORS. 
 
 Intrathoracic tumors may spring either from the thoracic wall or from the 
 thoracic viscera. Of the former, the most common are exostoses and enchon- 
 dromata, which may develop in pedunculated form or as extensive sessile masses 
 involving several bones or cartilages. Malignant tumors, the most common of 
 which are sarcomata or mixed tumors, also develop in the same way. Tumors 
 springing from the thoracic wall, whether developed internally or externally, 
 
SLH(li:iiy OF TllK RKSl'HiATOHV OlidAyS. 
 
 645 
 
 constitute lo-Mtiinat.' sul.jocts for consideration ;vith reference to operative re lef, 
 the (lecision'lK'in- gn.m'.ae.l upon their cliaracter, extent, and probable adhe- 
 sion to the viscera of the thorax. Operations by Avhich portu.ns of several 
 ribs involved in such tumors are excised have been performed Avitli success, as 
 weil as operations for the removal of the sternum when that is the primary 
 seat of tlie disease. Thev are extensive and most severe, and should never be 
 made without a statemetlt of their dangers to the patient and his assumption 
 of risks. In most if n«.t all of them the costal pleura at least will be so 
 involved that free opening of the pleural cavity, with collapse of the lung is 
 inevitable. There would be no object in attacking such growths were the 
 overlvin<T integument so involved as to prevent its preservation for covering 
 the defect. When, however, the tumor simply involves one or two ribs only, 
 and is of an osseous or cartilaginous nature, it is quite possible in most cases 
 to remove it, subperiosteally, without opening the pleura. But little danger 
 
 attends such cases. ,. ^ ^ 4. f ^„*^ 
 
 Tumors involving the contents of the thorax lie, for the most pait out- 
 side the present domain of operative surgery. Nevertheless a few ot them 
 demand operative measures. Such, for instance, are substernal dermoid cysts, 
 hvdatid tumors of the lung, actinomycotic masses, and possibly others ot non- 
 malignant character. The sternum may be freely resected m ^^-^er to reach 
 thenf Even sarcoma" of the sternum has thus been successfully eiadicateri. 
 The diagnosis is made largely by a process of ex-clusion, as well as by 
 symptoms of pressure upon nerves and vessels and by a study of physical 
 sicrns The microscopic study of the sputum may also yield valuable evi- 
 de'nce. If a solid tumor in any way could be recognized as involving a cir- 
 cumscribed part of one lung, it might be warrantable to remove the affected 
 po t on. It has very recently been suggested to open the thorax from behind 
 bv resectincr ribs from a line near their angles to the inner side of the scap- 
 u a by whfch reasonable access is permitted to the posterior mediastinum 
 and tlfe root of the lung. Some such procedure as this -ay be made ser- 
 viceable in selected cases. Possibly also certain aneurysms within the tho- 
 rax may be attacked in this way. 
 
 INTRA-THORACIC CYSTS. 
 Although in America they are very rare, the most clearly defined, and in 
 some countries the most common, intra-thoracic cysts are hydatid or echino- 
 coccus cysts within the pleural cavities. They may develop as free cysts oi 
 more commonly in connection with the lungs or with the thoracic wall. Those 
 which have primarily formed within the liver sometimes perforate the diaphragm 
 Tnd involve^ the pleura or even the lungs. For the most part they contain 
 dauc^hter cysts within themselves, and may attain a size even as large as that 
 of a child's head. They cause usually considerable pain, which is increased 
 on Wing upon the aifected side, and are accompanied by dyspnea. Lnless 
 thev suDDurate the course of the disease is feverless. The veins over the 
 Sn Tp^minent, the chest-wall may be pushed forward, and the intercostal 
 paces widened and fluctuating; the liver and the heart may be displaced. 
 The aspirator needle will give the most positive results, the fluid withdrawn 
 beincT free from albumen and sometimes containing hook ets. 
 
 While puncture will afford temporary relief, and ^^Jeetion of iodine may 
 possibly re ult in cure, the most satisfactory result is afforded by ^ee mcision 
 if neceLry with resection of ribs, and packing the cavity with gauze, by which 
 free drainage is aff"orded. 
 
G4«i .l.V AMi:RIiAy TEXT-HOOK OF SCJK; KllY. 
 
 CONTUSIONS OF THE CHEST. 
 
 These may occur in a fireat variety of ways, as by the passage of vehicles 
 over the chest, by severe blows, by being caught between cars, etc. The chest 
 is constructed in a wonderfully elastic way. and it is surprising what contusions 
 it will coniinonly resist without serious injury. Mild contusions give rise to 
 ecchynioses and Itruiscs from which sloughing rarely mav occur. Even abscess 
 following such injuries is rare. Fractures of ribs are the most common serious 
 lesions ; these are discussed under their own heading. The chief symptoms 
 attendant upon such injuries are pain, which sometimes is (juite severe, and 
 such soreness as effectually for the time being to dis(|ualifv the muscles from 
 acting. Consequently, patients insensibly adopt the abdominal method of res- 
 piration, while such involuntary efibrts as coughing and sneezing give intense 
 pain. They assume a characteristic attitude, usually on the back, lying far 
 enough upon the injured side to rest it and give freer play to the other 
 side. 
 
 The treatment of these conditions is mainly the enforcement of rest, with 
 such compression of the chest-wall as will limit its motion. This is best carried 
 out by a snug bandage, by a broad binder, or by a broad piece of adhesive plaster 
 drawn nearly or quite around the thorax. This should be omitted only in case 
 it adds to the patient's discomfort instead of relieving it. Such local treat- 
 ment as may be appropriate may be instituted either by anodyne applications 
 beneath the bandages or by hot or cold applications outside. 
 
 Contusions involving the Thoracic Viscera may be of the most 
 complicated character. The amount of damage done within the thorax with- 
 out visible external evidence in certain cases is astonishing. This includes 
 rupture of vessels of the lung, rupture of the heart or pericardium, or such 
 minor lacerations as lead to hemorrhagic or inflammatory results. The heart 
 appears to experience results of concussion in many respects analogous to those 
 from concussion of the brain ; indeed, fatal results have followed such injuries 
 where even on autopsy no alteration was discovered. In the more severe 
 injuries blood may be thrown out in quantity beneath the pleura or into the 
 lacerated lung substance, by which many of the signs of circumscribed pneu- 
 monia will be caused ; in ftict, also, pleuritis and pneumonia of acute form are 
 not infrequently met with and sometimes run a fatal course. One sign of rup- 
 ture of the lung is the existence of emphysema, beginning either at the base 
 of the neck or in the epigastric region and extending thence upward or down- 
 ward. It is worth while to bear in mind that such emphysema may occur 
 "without any fracture of the thoracic wall. 
 
 Rupture of the lung may be quite extensive, and occurs in military as well 
 as in civil practice, such an injury, for instance, as a blow on the chest by a 
 spent cannon-ball having caused it. Rupture of the lung of course implies 
 extensive hemorrhage, with expectoration of blood or bloody mucus, and effu- 
 sion of blood into the chest in case the surface of the lung be torn. While 
 recovery is not impossible, it wmII be accompanied by serious inflammatory dis- 
 turbances, with permanent impairment of function. The heart and pericar- 
 dium have been also thus ruptured, and the heart has been completely separated 
 from its attachments, without more serious injury to the chest-wall than a tri- 
 fling abrasion of the cuticle. In all cases of rupture of the pericardium the 
 tear has been of large size, and for the most part the injury has been accom- 
 panied by fracture of the ribs or the sternum, or of both. A case is also on 
 record where the wadding of a small cannon struck a man in the chest with- 
 out injury to its wall, and the heart completely burst the pericardium. 
 
scnaEnv or the hespirat(jry oitoAys. 647 
 
 WOUNDS OF THE CHEST. 
 
 These may be divided into the non-penetratin<; and the penetrating. There 
 is practically no limit to the amount of possible laceration of the soft parts 
 about the chest. The immediate danger attending them is from hemorrhage, 
 while septic disturbances, including erysipelas, gangrene, and tetanus, are 
 among their possible consequences. The possibility of pleurisy and pneumo- 
 nia as immediate sequels must not be overlooked. In rjire cases also peri- 
 tonitis or a pericarditis or endocarditis develops in an unlooked-for mariner, 
 which is to be explained probably upon the theory of septic embolism. In such 
 wounds, whether incised or lacerated, the routine should be as elsewhere : first 
 hemostasis, then removal of all foreign material, and, if the parts are rudely 
 lacerated, excision of all torn and ragged tissue, careful suture with or without 
 drainage, and finally an antiseptic di'essing. 
 
 Penetrating Wounds of the Chest. — These may be of the most vary- 
 ing character, from the sliglitest perforation Avith a minute instrument or 
 weapon or the smallest bullet up to the most frightful loss of substance. They 
 are dangerous in proportion, first, to the amount of hemorrhage which they 
 produce, and, secondly, to the amount of air and especially of any foreign or 
 septic material which has been introduced or permitted to enter. 
 
 The first mentioned is the most immediate danger, and its relative extent is 
 to be judged of at the time by the direction of the penetrating substance, if 
 known or if it can be ascertained, and by the general condition of the 
 patient. 
 
 Inasmuch as wounds of the heart are elsewhere considered, we shall speak 
 here for the most part of injury to the lungs. If the patient expectorates 
 blood, the existence of a wound of the lung may be instantly recognized. 
 If air can be heard entering the chest or if the lung on one side is evidently 
 collapsed, it is a sign at least of perforation of the pleura upon that side. If 
 collapse is extreme and if death rapidly ensue, in all probability a large vessel 
 has been injured. If the diaphragm is paralyzed, it implies injury of the 
 phrenic nerve ; if the heart is tumultuous in its action, there has been injury 
 either to it or to the pericardium, or else to its nerve-supply. If the external 
 wound bleeds freely, the blood probably comes from one of the intercostal or 
 mammary arteries. If a weapon has been used, much information as to depth 
 of perforation, etc. may be obtained by examining it. 
 
 But no such conclusions can be drawn in cases of bullet wounds unless 
 there be a wound of entrance and none of exit, which implies of course that 
 the bullet is somewhere within the tissues. A bullet, under these circum- 
 stances, is not likely to be arrested by the lung, although it may be by the 
 substance of the heart. Consequently, if the lung has been thus injured 
 it has probably been perforated. Careful search for a wound of exit should 
 always be made, since there have been instances in which careless prac- 
 titioners probed and hunted for bullets which had passed completely through 
 the body, the Avounds of exit being found upon simply turning the patient 
 over. Nevertheless, it is necessary to ascertain, if possible, when two bullet 
 wounds are found, whether one or two shots have been fired. It is not 
 every bullet or stab wound of the chest that will cause perforation of the 
 pleura. A bullet or the blade of a knife may be deflected by the ribs or the 
 scapula in such a way as to pass perhaps a long distance through the tissues 
 without entering the thoracic cavity. 
 
 Emphysema is another evidence of perforation, at least of the costal 
 pleura, which Avill increase with time, and which may not exist at the moment 
 
648 Ay AMKincW TEXT- HOOK OF Sl'JiaKliY. 
 
 of first exaniiiiatioii if it bt' iiiadc iiniiicdiatflv after iiijiirv. lit rnia of the 
 lun^ of coiirsc is positive cn itlciicc of jterfuiation of the cliest-valh 
 
 The treatment of peiietiatin^r wounds of the cliest must necessarily (lei)enJ 
 in large measure upon their character and extent. Injuries to the large ves- 
 sels are usually rapidly fatal, and for these surgery as yet has little to offer ; 
 but when no such innnediate danger threatens the surgeon should seek first to 
 check hemorrhage, enlarging the wound by free incision, and ligating vessels 
 or tissues en masse according to circumstances. Although intercostal vessels 
 are protected by the groove in the lower border of the ribs in which they lie, 
 it is nevertheless not difficult either to wound or to secure them. A bleeding 
 internal mammary vessel is much more difficult to secure, and yet its course, 
 parallel to the border of the sternum and a short distance from.it, though 
 inside the thorax, is well known, and should other measures fail a large stout 
 needle carrying a strong silk ligature should be passed into the chest under it 
 and out again in such a manner as to include it within the loop. Should other 
 measures tail, bleeding ma}' be checked by a compress of aseptic gauze plugged 
 tiffhtlv into the wound. 
 
 Above all things, it is needful to warn against useless exploration, espe- 
 cially with the probe, in cases of bullet wound, since with the probe nothing is 
 ascertained which could not otherwise be learned, Avhile by its use protective 
 blood-clot is broken up and septic matter is frcfjuently introduced. Hemor- 
 rhage being checked and the region of the wound being thoroughly cleansed, 
 aseptic occlusion is probably the best course, at least for the average practi- 
 tioner, to pursue. The day has come when the thorax may be opened for 
 access to the wounded lung, pericardium, and heart by experts. The experi- 
 mental results of Block and others warrant this course : but the time has not 
 yet arrived when a general recommendation of this course is justifiable. Such 
 blood as is poured int(j the pleural cavity ordinarily coagulates rapidly and is 
 subsequently absorbed. If it still be liuid. or if later it should liquefy, or if 
 serous effusion or purulent degeneration takes place, its effects may be over- 
 come by aspiration or by incision and drainage. 
 
 COMPLICATIONS OF CHEST INJUEIES AND THEIR SEQUEL.E. 
 
 These have been in the main already considered ; still one or two of them 
 deserve distinct consideration. 
 
 Pneumocele, or IIerxia of the Lung, is a rare result of incised or 
 lacerated wounds which penetrate the thorax. It may be ])rimary or second- 
 ary. The former may occur in oblicpie wounds, the margins of which act as 
 valves to prevent the ingress of air, while they permit a small portion of one 
 lobe to be expelled by violent efforts in coughing. In another class of cases 
 the lung may escape at the time of the infliction of the wound. The second- 
 ary hernijB of the lung are those in which the wound is of large size and the 
 lung escapes some time after the infliction of the injury, or in which it occurs 
 during the removal of fragments or during the cicatrization of the wound. 
 When the protruding portion is not adherent it should be thoroughly cleansed 
 and restored to its proper cavity ; when fixed in place, ligature or excision is 
 to be recommended. 
 
 E.MPHY.SEM.\. — This has already several times been mentioned. By this 
 term is meant the escape of air into the cellular tissue outside of the thorax 
 proper. Usually, when present, emphysema extends to a distance of several 
 inches around tlie wound, and sometimes involves the entire neck and trunk. 
 After compound fracture of the ribs, for instance, it has extended as high a,s 
 
SURGERY OF THE RESPIRATORY ORGANS. 649 
 
 the scalp and as low down as the thighs. It is in no wise dangerous, except 
 that it may be so excessive as to interfere with respiration, or that the air may 
 bo infected, in which case cellulitis, erysij)elas, a1)sccss, or even gangrene, 
 may be the result. Ordinarily the air is taken up into the blood-vessels by 
 osmosis and disappcai-s within a few days. Should it give rise to great dis- 
 turbance, multiple punctures in the skin will facilitate its escape. 
 
 The other sequehie of chest injuries are mainly septic or inflammatory, and 
 are to be dealt with according to their nature and upon generally accepted 
 principles. Cicatricial contraction may cause deformity, or injuries of special 
 nerves may lead to vague or peculiar muscular, sensory, or trophic disturb- 
 ances, which, however, can hardly be considered here. 
 
 MEDIASTINAL ABSCESS. 
 
 This may be idiopathic, secondary, or traumatic. As a purely idiopathic 
 condition it is extremely rare. The secondary form may be consequent upon 
 abscess in the neck, burrowing down behind the deep cervical fascia, or upon 
 tubercular trouble either in the neck or within the thorax. The traumatic 
 variety may follow contusions, but has been most common after fractures of 
 the sternum or gunshot wounds. Such abscesses are characterized by a sense 
 of weight in this region, by pain on coughing, drinking, sneezing, etc., by a 
 sense of being out of breath, by more or less cedema over the sternum, and 
 by the constitutional signs of the presence of pus. When these signs are 
 present the proper course will be to trephine the sternum, enlarge the open- 
 ing freely by the rongeur forceps, explore carefully with the hollow needle, 
 and, if pus be found, to open, wash out, disinfect, and drain the cavity. Even 
 abscesses of the posterior mediastinum have been reached by a posterior 
 operation. 
 
 SURGICAL AFFECTIONS OF THE DIAPHRAGM. 
 
 This muscle constitutes the natural septum between the thorax and abdo- 
 men, and has fixed attachments to the spine and to the lower portion of the 
 thoracic wall. It is capable of considerable displacement upward and down- 
 Avard ; in forced expiration it rises to the right third cartilage, and in forced 
 inspiration descends to the right fifth intercostal space. On the left side it is 
 one or two ribs low^er. In cases of enormous abdominal distention it has been 
 found as high as the second rib, and in cases of enormous pleural effusion as 
 low as the false ribs. It, however, never loses its convexity. Most of its 
 upper surface is covered by pleura, and most of its lower surface by peritoneum ; 
 these two membranes therefore come into very close relation here. Still, there 
 is a small surface where the liver comes into actual contact with it, and at this 
 point a ball penetrating from behind at about the tenth dorsal vertebra might 
 enter the liver without Avounding the peritoneum. 
 
 Congenital Defects. — The sternal portion of this muscle is sometimes 
 wanting, and absence of other portions is occasionally seen, a case being on 
 record of a child which lived ten days in whom the left half was entirely want- 
 ing. Through such openings the abdominal viscera, most commonly the 
 stomach, may protrude into the thorax, constituting a diai^liragmatic hernia 
 (q. v.). Various muscular additions have also been observed, but these anom- 
 alies are rare. 
 
 Paralysis. — Paralysis of the diaphragm may occur in the course of 
 pleurisy, diphtheria, disease of the spinal cord, or lead-poisoning; or it may 
 be hysterical, or due to injury of one or both phrenic nerves, or to the destruc- 
 
Gr)() .Lv AMi:ni('A.\ riixr-iiooK of surgery. 
 
 tion i)t" their roots in riipidlv asfciuliii^ (lcgeii(.i;iii«-ii i'lKiii injiirv to the c'ord 
 in cases of fracture or dislocation of the spine. It may be unihiteral or 
 luhiteral. and eonijilete or jjartial. It is cliaracteri/e(l liy diflieulty in ])reath- 
 in<r, the abdoiiieii sinkini; (hiring inspiration and ]»econiin<: iuller in expiration, 
 thus reversin<; the natural order. All eflVtvts wliieh recjuire fixation or con- 
 traction of the diajjliraizni, sueh as cou<rhing, talking, etc., are made difficult or 
 impossible. 
 
 The prognosis must depend upon the cause, and treatment must be 
 directed to the removal of the same. In idiopathic or non-surgical cases the 
 faradic current, Avith one pole applied over the ])hreiiic nerve in the neck, the 
 other over the diai)hragni, is said to have given good results. 
 
 Hernia. — See Hernia. 
 
 Wounds. — Wounds of the dia})hragm are inseparable fi'om those of the 
 abdomen or chest, and are of impoa-tance according as the viscera on either 
 side of it have been injured. It is occasionally torn by the jagged end of a 
 fractured rib. Perforating wounds of the diaphragm, however, are not neces- 
 sarily fatal, and manN' patients have recovered who have been shot in such a way 
 that the bullet has first entered the abdominal cavity, passed through the dia- 
 phragm, and traversed the pleural cavity, or the reverse. The prognosis of such 
 wounds, therefore, is not necessarily bad, although they are always of the most 
 serious nature. 
 
 The diaphragm may be perforated as the result of abscess, of tumor, especi- 
 ally cystic, or of fatty degeneration. It is not an uncommon thing for it to 
 give way before advancing pus in cases of abscess of the liver, profuse adhe- 
 sion of the lung above it having taken place in such a way that pus is evacu- 
 ated through the bronchial tubes and the mouth. The same is true of sub- 
 diaj)hragmatic (subphrenic) abscess. 
 
 Rupture. — T'his may occur as the result of contusions either of the abdo- 
 men or of the chest, and occurs more frequently upon the left side, the presence 
 of the liver upon the right apparently affording protection. Through such rup- 
 tures diaphragmatic hernire frequently occur. When the rent is small, it is 
 usually the intestine which passes through ; when large, the stomach, or per- 
 haps both stomach and bowel. The consequence of this is sometimes immediate 
 strangulation of the bowel, at other times great embarrassment of respiration, 
 with vomiting. 
 
 The diagnosis of this condition is too often only made pnst-murtem. 
 When, however, it is made probable by the character of the injury, and when 
 the condition of the patient will warrant it, it is proper to open the abdomen 
 and explore. Still, in consequence of anatomical conditions this procedure, 
 coupled with that for repair of the damage, would be so difficult and prolonged 
 as to deter most operators, though it has been done successfully. 
 
 A question of medico-legal interest has been raised about these injuries, 
 whether such a hernia could be proved to have resulted directly from such 
 inj ury or to have antedated it. The presence or absence of a hernial sac will 
 settle this question. 
 
J > /SILASES AND J XJ lit IKS OF THE NECK. 651 
 
 CHAPTER IV. 
 
 DISEASES AND INJURIES OF THE NECK. 
 
 A roiNT in the anatomy ot" the neck to which too little attention is ironc- 
 rally directed is the constitution of the so-called branchial folds and clefts. 
 Very early in f(Vtal life there are found on each side of the head, behind the 
 rudimentary aural cavity, four fissures Avhich communicate with the upper end 
 of the future alimentary caruil. In the human embryo the third and fourth of 
 them should have disappeared by amalgamation about the sixth week, and the 
 second by the tenth. Only the first remains persistent, and appears as the 
 Eustachian tube, tympanic cavity, and auditory meatus. Between these clefts 
 develop the so-called branchial arches or folds. From the first of these is devel- 
 oped Meckel's cartilage, whieh hel])S to form the lower jaw; from the second, 
 two of the small bones of the ear, the styloid process, the stylo-hyoid ligament, 
 and the lesser cornu of the hyoid bone. Its great cornu and body develop 
 from the third. Of the fourth branchial arch there seem to be no permanent 
 remains. Most of the congenital tumors and fistulfe about the neck are to be 
 explained by the persistence or defective development of these early foetal 
 remains. (Cf. p. 664.) 
 
 CONGENITAL MALFOKMATIONS OF THE NECK. 
 
 Those Avhich will be considered here are for the most part cysts and 
 fistula. They have been termed branchial cysts, deep dermoid or deep 
 atheromatous tumors, congenital hydrocele of the neck, hygromata, ath- 
 eromatous cysts of lymph-nodes, etc. The preferable term, however, is 
 branchial cysts, and they may be divided into mucous, atheromatous, 
 serous, and sanguineous. They may be very small or may attain very large 
 size. They are most common in the region of the second and third clefts, ^. e. 
 the vicinity of the pharynx and larynx, and are in intimate relation with the 
 sheaths of the large vessels. They occur more frequently on the left side ; are 
 always globular or ovoid, and always fluctuate, fluctuation being detected by 
 bimanual palpation. They are lined with the same epithelium which originally 
 lined the clefts. They should not be confounded with the pure dermoid cysts, 
 which may be found at various points on the scalp, face, or neck, and are to 
 be distinguished from them in that they contain only epithelial products and 
 no hair or sebaceous or sudoriparous material, since the branchial clefts close 
 before such material is formed. 
 
 To the first class belong many of the so-called ranulae or cysts about the 
 base of the tongue. The second form is most common about the region of the 
 hyoid bone, and contains atheromatous material not of dermoid origin. The 
 third or serous form has very thin walls, and is that sometimes known as 
 hydrocele of the neck (Fig. 30). They may be single or multiple. The san- 
 guineous cysts may originally have been connected with the anterior jugular 
 vein. Their contained fluid is discolored b}^ admixture of blood. There is 
 but one variety of these, including those which still communicate with the 
 interior of the cranium. This form may be emptied by pressure, but will 
 quickly refill. They will be diagnosticated mainly by the character of the 
 fluid withdrawn upon aspiration. All these tumors lie so near the vessels, 
 and so transmit their pulsations, that they may be easily mistaken for 
 aneurysms. They lack free expansile pulsation, and they are common in 
 
()52 Ay AM ERICA X TEXT-liOOK <JF SlUdKliY. 
 
 youth, wlifii aneurysm is rare. No bruit is audible in tbeni, and expbjr- 
 atorj puneture gives widely different results. A final dia^^nosis of dermoid 
 cyst is perhaps to be made only by post-operative examination, but usually 
 a dermoid cyst will have a thicker wall. From cystic degeneration of one of 
 the retro-tracheal lymph-glands they will be distinguished jjartly by position 
 and partly by the fact that (juite early in their history the latter give rise to 
 considerable pain and difficulty in swallowing. They are to be explained as 
 the result of renewed activity, often due to pul>erty, at a point where there was 
 originally a tubular passage lined with epithelium which has failed to be com- 
 pletely obliterated — ''obsolete canals." Concerning the causes which call 
 into activity the inherent developmental forces remaining in these histological 
 relics we are profoundly ignorant. For such cysts the best line of treatment 
 practicable is their extirpation. When for any reason this is not feasible the 
 next best method consists in antiseptic incision, packing with gauze, and 
 drainage. 
 
 Congenital Fistulje. — These fistulae are due to the same primary causes 
 as those which give rise to the branchial cysts above described, being simply 
 persistent relics of the branchial clefts, one or both of whose extremities have 
 failed to close. They may open interiorly into the pharynx or externally upon 
 the neck. In the former case secretions may collect Avithin them, causing 
 trouble by suppuration, by producing cellulitis, or by giving rise to constant 
 discharge. They are not to be confounded with congenital fistulae of the 
 trachea, which are usually found in the middle line of the neck. The 
 former commonly open, Avhen external, in the lower third of the neck, along 
 the inner border of the sterno-mastoid. In rare instances the fistulae have 
 been complete from the neck to the pharynx. If they are capable of treat- 
 ment at all, it must be by cauterization and exciting granulations, with or 
 without division or dilatation of their external openings. 
 
 Cellulitis. — This may be primary or secondary, and superficial or deep. 
 The primary form iS usually the result of exposure to cold or to one of the 
 infectious diseases, e. g. scarlatina, while the secondary form may be consequent 
 upon trifling or severe injury, or the extension of inflammation from already 
 affected teeth, bones, lymph-glands, etc. The general signs and symptoms 
 of cellulitis of the neck are the same as those of cellulitis of other parts, 
 modified, if at all, only by anatomical disposition. 
 
 Any condition of this kind which terminates by resolution is apt to be 
 only annoying; but, on the other hand, such cases are serious just in pro- 
 portion as pus forms deeply and causes damage in the endeavor to evacuate 
 itself. The presence of pus in these cases is to be made out both by local 
 and by general signs. Of course fluctuation, when easily recognizable, 
 will dispel all doubt. On the other hand, most cases of cellulitis will be 
 accompanied by such brawny induration, and perhaps by such oedema, as to 
 mask the ordinary local signs of the presence of pus. In these cases the occur- 
 rence of symptoms of embarrassment of respiration, or of extending deep pres- 
 sure, or of chills or septic symptoms, will make it wise to institute a careful 
 search even at some depth for the suspected pus. This may be done with the 
 exploring needle, but it will be much more satisfactory and effective to anes- 
 thetize the patient and make free incisions over the suspected area, their posi- 
 tion and direction being guided by anatomical knowledge, taking the pre- 
 caution already mentioned of dissecting with extreme care and avoiding all 
 deep small punctures for fear of displaced important vessels or nerves. "When 
 the collection of pus has been reached, the opening should be enlarged suflS- 
 ciently to admit at least a finger, by which the cavity may be explored, in 
 
DISEASES A XI) INJURIES OF THE NECK. 653 
 
 order to ascertain wlietlicr a coiiuter-opeiiiii;^ is necessary, and, if so, to indi- 
 cate the point where such may be made with the greatest safety. 
 
 A special form of cellulitis is that known as Luchvig's anrjina, or 
 infectious submaxillan/ angina, an acute form of this disease involving the 
 areolar tissue around the submaxillary glands. After three or four days of 
 local discomfort the neck becomes swollen and i)ainful ; the condition extends 
 to the tongue, which becomes fixed and swollen ; there is great difficulty in 
 opening the mouth ; the anterior portion of the mouth is distended ; there is 
 great salivation ; and dyspnea and dysphagia are caused by pressure and fixa- 
 tion. The disease may be accompanied by very high temperature with septic 
 symptoms, and fre({uently terminates fatally. Sometimes the disturbance to the 
 circulation is so great that local gangrene is the result. It is an unusual form 
 of cellulitis of the neck, but one which may assume a terrible importance. 
 
 Abscesses and Consequent Fistula of the neck are virtually always 
 the result of a previous cellulitis. Abscesses have just been dealt with. 
 Fistulfe are best treated by enlargement of their external openings and a 
 thorough scraping of their wall with a sharp spoon, but when tortuous, or 
 when they divide, counter-openings or perhaps extensive incision and split- 
 ting may be necessary. The majority of fistulte of this kind will be found 
 connected Avith existing tubercular foci in lymph-glands or with the incom- 
 pletely healed results of operations for their removal. In either case they 
 are to be treated after the same fashion. 
 
 Cicatrices. — These are always the result of previous lesion of the skin. 
 They may be trifling in size, like the irregular, wrinkled scars which show 
 where tubercular lymph-glands hg^ve broken down and have caused more or 
 less destruction of the overlying skin, or where syphilitic disease has resulted 
 in the same condition ; or they may be extensive and disfiguring, being the 
 result of more or less widespread burns of the parts. (See Deformities of the 
 Mouth.) 
 
 Small and attached or depressed scars can be excised and replaced by scars 
 which are much more presentable. For the relief of the extensive cicatriza- 
 tion which folloAvs burns some one of the various plastic methods must 
 in whole or in part be adopted. This may consist in a division of the con- 
 stricting bands, or in the formation of flaps of dissected skin and their rear- 
 rangement by sliding or by transplantation, or recourse may be had to the 
 Indian method after a fashion much like that described in the formation of a 
 new nose, by which a flap of skin is raised from the arm to be sewed on to the 
 defect in the neck, while the arm is fastened to the head or thorax until the 
 flap can be safely detached ; or, lastly, one or other of these methods may be 
 combined with Thiersch's method. 
 
 The disappointment which may ensue after these eflbrts comes partly from 
 a failure of some part of the flaps to unite as w^e desire, and partly from 
 the formation of keloid tissue along the lines of union. This frequently 
 occurs in spite of all care and in consequence of unknown causes, and serves 
 sometimes to undo half of that which we appear at first to have accomplished. 
 When this tendency to keloid is once recognized, further efforts should usually 
 be discontinued, since it cannot be overcome. 
 
 INJUEIES OF THE NECK. 
 
 Contusions. — Contusions of the neck may be so violent as to cause insen- 
 sibility, or even death. The reputation Avhich a " blow upon the jugular " has 
 among the laity is an evidence of the severity of many of these injuries. 
 
G54 AN AMi:i!I(Ay TEXT- HOOK OF SlP^dKUY. 
 
 The results of siu-li ])l<)vs may be fracture of the livoid oi- of the caitihtt^es 
 <'f tlie hivynx, or a rupture of the mucous meuihraiic. lollowcd l)v a deep 
 (•mj)hysema. Aspliyxia may repeatedly tlircateii, and ior this tradieotomy 
 may be re(|uired. Aside from these lesions there may be bloody effusions or 
 acute inflamnuitory swellings. Avith all their suppurative possibilities, while from 
 some abrasion or eruption of the skin an erysij»elas even of the phle<_rnionou8 
 variety may develop. 
 
 Open wounds of the neck may be of all sizes, and be incised, punctured, 
 or lacerated in character. A wound by wliicli the ilccp fascia is divided niay 
 be called a deep wound, and will usually involve blood-vessels and nerves 
 of inii)ortance. The frequency with which the vessels escape, especially when 
 the trachea is divided in cases of suicidal attempt, has already been spoken of. 
 The extent and character of these wounds when not at once apparent to 
 sight must be recognized ])artly by the nature of what escapes, as air, arterial or 
 venous blood, mucus, or ])ossib]y food, as well as by a study of im])aired func- 
 tions, as of respiration or deglutition, by the occurrence of emphysema, and by 
 a consideration of whatever can be learned concerning the direction of the 
 wound and the weapon which inflicted it. If bleeding is profuse, the natural 
 inference is that an important vessel has been divided, although serious hemor- 
 rhage may result from wound of the thyroid body. If the carotids are 
 wounded, death will proba])ly ensue raj)idly. Ndlaton is said to liave remarked 
 that it takes four minutes for a man to bleed to death from the carotid, while 
 two minutes are sufficient to tie it. Wounds of the large veins are dangerous, 
 not simply from risk of loss of blood, but also of the admission of air. Jileed- 
 ing here is generally favored by free anastomosis. If seen in time, compression 
 can almost always be successfully a])plied to a bleeding wound in the neck, and 
 this may be continued until means are at hand for operative relief. In case 
 of a perforating wound into the larynx, patients may suffocate by the entrance 
 of blood into the air-passages. 
 
 Besides bullets, foreign bodies like arrow-heads or splinters of wood are 
 sometimes imbedded in the structures of the neck. Modern teaching with 
 regard to bullet wounds inculcates the wisdom of primary antiseptic occlusion, 
 without removal of the bullet, but other foreign bodies should be removed as 
 soon as detected. 
 
 Such Avounds as are not quickly fatal are usually recovered from. Danger 
 comes from complications rather than from the injury itself. The first indi- 
 cation in treatment is absolute hemostasis, followed by rigid asepsis or anti- 
 sepsis and closure of the wound, with or without draiiuige according to circum- 
 stances. In case of a deep wound it would be better to close it by two or 
 more tiers of sutures, if necessary for complete approximation. If the irsopha- 
 gus be opened, it may be sutured if conveniently situated, otherwise it w ill be 
 better to leave at least a portion of the wound open and pack it with gau/.e. 
 Untoward results of such w^ounds differ in no wise from those of injuries 
 generally, and are to be dealt with as they may arise. 
 
 Emphysema. — In deep wounds of the neck perforation of the air-passages 
 is probable. The possible extent of this condition has l)een already spoken 
 of (see Wounds of the Chest), the anatomical condition being virtually the 
 same. If it be practicable to close the tracheal opening of an emphysematous 
 wound, it should be done, but the external wound should not be completely 
 closed or sealed. 
 
DISEASES Ayi> JNJritlES (jF THE NECK. 655 
 
 TUMORS OF THE NECK. 
 
 Of tumors proper we find nearly every known variety occurring in and 
 about the neck. The benifrn tumors are usually of slow growth, movable, and 
 ])uinless, and give rise mostly to nu'chanical annoyance. They may be mis- 
 taken for cvsts, and indeed such tumors may be of mixed character. Malignant 
 tumors of the neck are not infreciucntly of rajiid growtii, proceeding often to 
 ulceration (PI. IX, Fig. 1), and sometimes to the condition of fungus luema- 
 todcs. In almost all instances of carcinomatous growths the lymph-glands in 
 the vicinity will be involved. This is less likely to occur in cases of sar- 
 coma. Malignant tumor being diagnosticated, the principal question is as 
 to whether it can be removed, and secondly whether operation is advisable. 
 Shoidd the tumor extend so deeply or Avidely as to involve vital parts, it is 
 unlikely that radical extirpation can be made with safety. This is especially 
 true of tumors at the base of the neck, Avhere the large vessels and perhaps the 
 thoracic duct are involved. In a certain class of tumors, also, where it may 
 seem that extirpation is still possible, yet, knowing the frequency with which 
 they return, one may well stop to ask whether it is worth while to expose the 
 liatient to the risk of operation when the probability of recurrence amounts 
 almost to a certainty. This is a matter which may be best submitted to an 
 intelligent patient for his own consideration and decision. Circumstances at 
 times make it expedient thus to gain a temporary respite, while at other times 
 t!iey render it more important than usual not to jeopard life. If a surgeon 
 decides to attack such a growth, he must be prepared to sacrifice everything 
 that is involved ; otherwise it is better not to operate. Even the pneumogastric 
 nerve under these circumstances in a few instances has had to be removed 
 with the rest of the contents of the carotid sheath. The phrenic nerve 
 should nevertheless be spared if possible. Death is not the inevitable, but it 
 is the common result of division of the phrenic, but not of the pneumogastric 
 nerve in the human being. 
 
 Infectious Granulomata of the Neck. — These comprise the actinomy- 
 cotic, glanderous, syphilitic, leprous, and tubercular forms of infection, which 
 nearly always are located in the lymph-glands. The actinomycotic and gland- 
 erous infections almost always first appear about the submaxillary and the cer- 
 vical glands, as the reader will perceive by refei'ence to these subjects. Leprous 
 disease is even less common in this country than are the other two, and is 
 marked by equally characteristic lesions in other parts of the body. The 
 same is true to a large extent of syphilitic aifections of the neck. Of these 
 granulomata, therefore, the surgeon has to deal with two forms mainly : tuber- 
 cular infection and enlargement of the lymph-glands, and syphilitic gummata, 
 which may develop at almost any point. This latter condition is usually cha- 
 racterized by such unmistakable evidences that doubt in diagnosis will scarcely 
 arise. Unless pus be present, these cases are hardly suitable for the knife, but 
 should be treated vigorously by anti-syphilitic remedies, operation being post- 
 poned until these have proved themselves insufficient. Should free pus be 
 present, a simple incision of the abscess, possibly combined with scraping and 
 cauterization of its walls, should be made at once. 
 
 Local Tubercular Disease. — The most common of all neoplasms in the 
 neck which call for surgical measures are those produced by tubercular disease 
 of the lymph-glands. These were formerly included under the term scrofula or 
 scrofulous glands or swellings, but in the light of modern pathological know- 
 ledge they should always be spoken of in their true character, as tubercular. 
 Thev are most common in childhood, but may occur at any age, and a distinct 
 
G5G AX AMKIUCAX TKXT-llOOK OF SURGERY. 
 
 senile form is known. In these cases we have to (U'al ■with a true tuhercular 
 infection, eitlier priniarv or, )>erliaj)S more often, secondary. In a majority of 
 instances some port of entry for infection will be found al)0ut the head or neck 
 of any individual thus sutfering. It may be a diseased tooth, an ulcer in the 
 mouth, nose, or oro-pharynx, a diseased tonsil, a suppurative lesion in the 
 middle ear, a chronic eczema, ulcerative disease of the skin or scalp, chronic 
 conjunctivitis, or something of this kind. The prime source of trouble is 
 more often concealed from ordinary observation, but can in almost all cases be 
 found if searched for witli suflicient care. One gland or several may be in- 
 volved. At times a chain of enlarged glands may be detected extending from 
 that behind the ear to those at the root of the neck, whence the disease seems 
 to extend into the thorax. The most common course for these lesions to pursue 
 is slow but steady enlargement, perhaps with periods of rest, W'hile the slow 
 development of caseous changes is often interrupted by a sudden suppurative 
 activity. Calcification and other changes are much more rare. As these 
 masses become larger and press nearer the skin, they not infrecjuently perforate 
 it by a process of granulomatous infiltration. On reaching the surface these 
 break down, and we have to deal with a sluggish fungoid ulcer overlying a 
 distinct hard mass. These changes are always accompanied by more or less 
 periadenitis or cellulitis about the principal focus, by which masses originally 
 quite movable become planted in their places and impossible of easy extirpa- 
 tion, being so fixed that it is necessary to dissect out the entire mass. Further- 
 more, when the masses are multiple the original chain of lymph-glands becomes 
 altered, and merges into what is much more like a columnar mass of infected 
 and infiltrated tissue, always lying near and often adherent to the sheaths of 
 the large vessels, and making complete extirpation always difficult and some- 
 times impossible. In such a mass of tissue we usually meet with foci of soften- 
 ino; and defjeneration. 
 
 This constitutes a form of disease often met with in individuals of tuber- 
 cular history and diathesis and of "scrofulous" appearance. The milder and 
 limited manifestations of such tubercular disease sometimes fade away and 
 disappear spontaneously, probably by atrophic processes, leaving few or no 
 traces. Even those cases in which spontaneous perforation has occurred will 
 sometimes slowly cicatrize, leaving unsightly and adherent scars, but the per- 
 manent and more agtirressive forms are most troublesome to surgeons. Sum- 
 ming up in few words the results of centuries of experience with regard to 
 their best treatment, we may say that save what may be done by general con- 
 stitutional measures, and by local applications in the way of promoting absorp- 
 tion of the peritubercular infiltration, no treatment has proved so effective as 
 thorough extirpation, which, as mentioned above, is often a most formidable 
 measure. In these cases, as well as in the so-called malignant diseases, both 
 surgeon and patient must be prepared for recurring manifestations of the dis- 
 ease which may call for a second or a third operation. Such cases, however, 
 are not so destitute of hope as are recurring cancerous cases. 
 
 The results of the injection of Koch's tuberculin are still suh Jiidice. 
 It is only just to say that in some cases the treatment has yielded very 
 encouraging results. 
 
 The injection of a solution or emulsion of iodoform into tlie infected 
 tissue is a measure which often giv^s more or less satisfactory results. The 
 amount must, of course, depend upon the size of the mass into which it is 
 injected. Most gratifying results have been obtained by the internal use 
 of guaiacol, of which eight or ten drops in milk are given after each meal, 
 though the more palatable form of essentially the same drug in the shape 
 
DISEASES AND INJURIES OF HIE NECK. 657 
 
 of bcnzosol is fireferable, of which five grains are given at a dose three or 
 four times a day. It may be put in capsule and made perfectly tasteless and 
 inoffensive. 
 
 Malignant Lymphoma. — Under this term are included the local mani- 
 festations of Ilodgkin's disease, or malignant lympho-sarcoma (PI. IX, Fig. 
 2), This is more specially a general disease, but its local manifestations 
 sometimes cause extreme symptoms of dyspnea, dysphagia, etc. It is spoken 
 of here only because it occasionally calls for operations on the neck, sometimes 
 of an exacting character. In one such case where the glandular manifestations 
 were extreme, tracheotomy was re((uired some months before the patient finally 
 succumbed, and toward the end the size of the glandular enlargements became 
 a barrier against the changing of the trachea-tube, since if removed it was 
 almost impossible to replace it. In these cases operation is advised only for 
 relief of urgent symptoms. 
 
 LiPOMATA occur very frequently in the neck. As a rule they can be easily 
 removed by enucleation. Sometimes they require deep and careful dissection, 
 exposing the vessels and nerves. 
 
 THE SALIVARY GLANDS. 
 
 The parotid gland occupies a position where it is quite exposed to inju- 
 ries, both contusions and open wounds, which are of importance not so much 
 on account of the glandular tissue itself, as because of the vessels and nerves 
 which pass through or near it. Septic disturbance following such wounds is 
 not uncommon, as well as paralysis of the facial nerve, which latter may result 
 from its division or from the pressure of inflammatory products. If it is purely 
 from the latter cause, the prognosis is not so bad ; if from division, there is little 
 to be hoped for in the way of restoration of function. Fistula occasionally 
 occur as the result of injury to the gland or to Stenson's duct. Fistulse of this 
 duct are usually the result of operation or accident, and are difficult to heal. 
 A variety of plastic operations have been suggested for their closure. Perhaps 
 the most feasible plan is that suggested by AgneAv, which consists in passing from 
 within the mouth a threaded needle around the duct posterior to the fistula, 
 entering and emerging as nearly as possible at the same point and including 
 the duct, but not the skin, in the loop. This ligature is tightly drawn and 
 knotted. Its immediate eff"ect is to produce ulceration wdthin the cheek, while 
 the suture, working its way loose, separates after a few days, leaving a new 
 and artificial fistula bv which saliva is again conducted into the mouth. 
 
 Parotitis. — While a diphtheritic form of this aff"ection is not unknown, 
 by far the most common form is that known generally as mumps, in 
 which one gland is aff'ected. sometimes both, chiefly in young males and dur- 
 ing adolescence. It should be classified with the specific infectious diseases. 
 It may be ushered in by chills, nausea, and fever, with considerable consti- 
 tutional disturbance, and causes local swelling which may be extensive, and 
 by which mastication and deglutition are interfered with. The disease often 
 assumes an endemic character, frequently spreading in schools. The pathology 
 of the disease is still obscure. Metastasis from the parotid to the mammae, 
 ovaries, or testes occurs in perhaps 3 per cent, of cases, or often enough to 
 deserve the recognition which it enjoys among the laity. When this occurs in 
 the male, we have to deal with a true form of orchitis, and this form is seldom 
 met with as a primary aff'ection of the part under any other circumstances. 
 Mumps is a self-limited disease, disappearing usually spontaneously, and leav- 
 ing no bad results except in a very limited number of cases in which suppura- 
 
 42 
 
658 AN AJfERICAX TEXT-BOOK OF SURGERY. 
 
 tion occurs. Ordinarily it needs l)ut little treatment, saline laxatives and 
 jxTJiaps mild anodyne apjdieations being usually enough. In severe cases 
 leeches may be applied Avith benefit. 
 
 Suppurative Parotitis. — This may be the result of mumps, or may occur 
 as a secondary and mixed infection in debilitated or susceptible subjects after 
 such infectious diseases as erysipelas, typhoid, scarlatina, variola, pueiperal fever, 
 etc. Abscesses are also often found in the parotid in cases of pyemia. The 
 parotid, being provided with a strong capsule and being contained m ithin a firm, 
 deep fjiscia, we must expect severe pain and much general disturbance when pus 
 thus forms within it. The only exception to this rule will be found in some 
 of the adynamic fevers. When the ordinary signs indicate the presence of pus, 
 or even the probability of it, an incision should be made as early as possible, 
 if necessary under an anesthetic, in order to check the course of the disease, as 
 well as to give it a direct path toward the surface, since if left to itself it may 
 cause disaster in various directions. Most frequently it opens into the auditory 
 meatus, but in exceptional cases it may pass downward to the chest, or upward 
 along the carotid sheath to the skull, or behind the pharynx, or into the neigh- 
 boring maxillary joint. If the pus be superficially located, the incision should 
 correspond with the course of the facial nerve; but if a deep incision is neces- 
 sary, it should be made in front of the line of the external carotid. Often, 
 however, it is much better to make a free incision and careful dissection with- 
 out reference to future scar. In these cases we must expect involvement of the 
 surrounding lymph-glands, along with a periadenitis or even an erysipelatoid 
 condition. Pus from such a source often has a bad odor. 
 
 TUMORS AND OTHER AFFECTIONS OF THE PAROTID. 
 
 Salivary Concretions or Calculi may form within the parotid or ob- 
 struct its duct. They have been found as large as a hen's egg. By such 
 obstruction they may cause retention of saliva, with inflammatory phenomena, 
 and these latter may proceed to abscess and to spontaneous evacuation, with 
 salivary fistula. 
 
 A positive diagnosis can best be made by the insertion of a probe along 
 Stenson's duct or by puncture of a needle from without. It may be impos- 
 sible to remove a small stone by dilatation of the canal. A large one must 
 be removed by incision, always, if possible, from within the moutii under 
 cocaine. 
 
 Cystic Dilatation of the duct or of the gland itself may occur from 
 simple inflammatory or cicatricial obstruction, and suppuration may finally 
 occur in such a sac. Incision from within the mouth, aijain, must be made, 
 along with, possibly, extirpation of the sac-wall. 
 
 It is especially in the carotid region that the different blastodermic layers 
 come into intimate relations with one another, which will account for the fact 
 that most of the tumors of the parotid are of a mixed character. Among 
 the benign forms are adenoma, chondroma, and fibroma, in which nearly 
 always myxomatous elements will be found. (.)f the malignant tumors, sar- 
 coma and carcinoma are almost eijually common. Just within the parotid 
 gland itself lies a lymphatic gland which sometimes develops into a tumor 
 from tubercular or sarcomatous degeneration and is generally easily removed. 
 
 A diagnosis of tumor of the parotid is easy, but the determination of its 
 exact character is often difficult. The distinction between the l)enign and 
 malignant forms, which is the most important, is made ))artly by considering the 
 age of the patient, the rapidity of the growth of the tumor, the relative fixity 
 
DISEASES AND INJURIES OF THE NECK. 659 
 
 of the neoplasm, and tlie involvement of the neighborinfj lymphatics. Benign 
 tumors which are causing inconvenience or worse may be excised, especially if 
 sujjerficial. Concerning the advisability of removing malignant tumors in this 
 region there is room for wide ditlerences of opinion. It is questionable whether 
 a cancer involving all or nearly all of the gland can be so radically extirpated 
 as not to invite speedy return of the disease. Still, in many instances opera- 
 tion has been followed by temporary relief, extending over such a space of time 
 as am]>ly to reward the patient for the suffering it has caused. 
 
 Treatment. — There are some tumors of the parotid which can be removed 
 with but little disturbance of the facial nerve. In such cases operation should 
 be advised without the slightest hesitation. But operation for the entire 
 removal of the gland is always difficult, and always followed by complete paral- 
 ysis of that side of the face, with accompanying inability to close the eyelid 
 and constant irritation of the eye itself, and is not only severe for the 
 patient, but frequently trying for the operator, that portion of the gland which 
 is Avrapped around behind and concealed by the lower jaw being very difficult 
 of access, while the danger of recurrence comes from the inadvertent leaving 
 of some fragment in this location rather than from any other source. The 
 incisions for this purpose may be made parallel to the borders of the jaw, the 
 operator being constantly on his guard against injuring the carotid sheath, and 
 being prepared, if necessary, to tie the external, perhaps even the common, 
 carotid. 
 
 THE SUBMAXILLARY GLAND. 
 
 This is much more protected from injury than the parotid, but resem- 
 bles it in other respects. It has a complete capsule, which has the same sur- 
 gical importance as that of the parotid. Its duct, named after Wharton, may 
 be obstructed by calculi, the presence of which when large may be detected by 
 one finger in the floor of the mouth and another beneath the jaw. The gland 
 is sometimes inflamed, and often participates with the parotid in cases of 
 mumps. Cysts of benign character and malignant tumors may arise primarily 
 within it, and often it is secondarily involved, even early, in cases of cancer 
 of the jaw. When involved in any of these aff"ections it should be removed 
 without hesitation, the only neighboring vessel of importance being the facial 
 artery, which is easily tied, while the lingual, and the hypoglossal and lingual' 
 nerves, are easily avoided. 
 
 The same remarks apply to the sublingual gland, which, however, is 
 seldom the seat of any primary surgical aff'ection. 
 
 THE THYROID BODY. 
 
 This is normally developed as a bilobed organ, the two portions of which 
 are separated by a narrow bridge of similar tissue, called the isthmus, which 
 lies normally near the second ring of the trachea. The lobes are of nearly 
 the same size under ordinary circumstances, although they may vary a little 
 within normal limits. The thyroid body is quite likely to be accompanied by 
 accessory masses of similar tissue, which may be connected with it, or may 
 lie behind the trachea, or beneath the base of the tongue, or elsewhere about 
 the middle or anterior portions of the neck, and which may assume con- 
 siderable surgical importance, since they seem quite likely to undergo 
 changes that may lead to errors in diagnosis. Thus when these little masses 
 are enlarged they may be mistaken for enlarged lymph-glands. 
 
 Thyroiditis is a rare form of aftection of this body, which when met with 
 
(!()() AN AAfK/ilCAN Ti:X'r- li()< >k' OF SUIid i: IIY. 
 
 occurs usually durin;^ typhoid and other iut'cctious diseases. It is accoiupanieil 
 by fever, pain, swelling, and perhaps serious venous obstruction, by which 
 headache, vertigo, epistaxis, or cyanosis may be caused. It may possibly go 
 on to suppuration. If this occurs, free incision should be made as early as 
 possible. Its treatment is for the most ])art anti))hlogistic. It is jirobably 
 of the same general character as the tttrunu'tis which occurs so often in cases 
 of goitre, and consists in more or less inflammatory disturbance in the pre- 
 viously diseased or enlarged thyroid tissue. Some authors have seen in such 
 cases evidences of a constitutional predisposition. It is easy to understand 
 how in such affected tissues hemorrhages, thrombi, and retrogressive metamor- 
 phoses, often with tissue-necrosis, may prepare the way for inflammation 
 on slight pi-ovoeation. Under these circumstances even a slight injury, or 
 a hemorrhage, whether apoplectic or traumatic, or an irritating injection, or 
 the introduction of an unsterilized needle, or the occurrence of some general 
 infectious disease, may bring about an inflammation in this focus of least 
 resistance. The symptoms of strumitis are similar to those of thyroiditis, save 
 that they are usually more severe because of the greater size of the organ, are 
 less (|uickly relieved, and often prove fatal. Free evacuation of pus, or trache- 
 otomy, or possibly extirpation of the organ, will be called for in such cases, 
 usually as emergency operations. 
 
 GOITRE, BRONCHOCELE, OR STRUMA. 
 
 This is a terra generally applied to an hypertrophy and hyperplasia of the 
 thyroid body; more common on the right side than on the left; involving at 
 times only a portion of the organ, at other times its entire mass. While it may 
 occur anywhere, its worst forms are met with in the mountain regions and 
 valleys of Asia and Europe, as well as in Chile and Mexico. Its hereditary 
 character is not clearly established. Its true cause has not been discovered. 
 Many conditions of climate and surroundings have been described as etiolog- 
 ical, but it is not likely that they alone are suflficient to produce it. It 
 is essentially a chronic disease. It occurs oftenest in women, and rarely 
 before the tenth year of age. Several different forms are described. Thus 
 we speak of hypertrophic or parenchymatous forms, in which the entire mass 
 seems to be made up of tissue identical or nearly so with the original. The 
 follicular form is that in which there is a minimum of stroma with a large 
 proportion of mucinous or glandular elements. The fibrinous form is the re- 
 verse of this, may be, in a measure, of irritative or inflammatory origin, and 
 may assume at times almost a sclerotic type. The vascular form is that in 
 which the normal vessels of the part are more or less dilated, and in which 
 frequently new vessels are formed. In fact, this form often assumes such a 
 phase as to entitle the mass to be considered as a cavernous tumor of the 
 thyroid. The vessels thus affected are for the most part the venous, but an 
 arterial form is known. 
 
 The cystic form is the most common. It consists in the development of 
 one or numerous small or large cysts, which may attain almost any size, and 
 may be filled with fluid of various degrees of consistency. The fluid is 
 always rich in soda-albumin, and may be more or less mucinous. It may also 
 contain cholesterin in rich proportion, as well as the products of fatty meta- 
 morphosis, together with the residue of recent or old hemorrhages. 
 
 A goitre may be of any dimensions, from the slightest perceptible increase in 
 size of the normal thyroid up to a tumor which will interfere with motions of 
 the head, and which may even overhang the chest and reach as far as the navel. 
 
DISEASES A XI) EXJilUES OF THE XECK. 661 
 
 Mild forms of goitrous enlartroinent are mot with sometimes in pregnant 
 women, and it will often be noted that a goitre will increase in size with each 
 succeeding pregnancy. This is but an expression of the sympathy between 
 this organ and the female pelvic organs which in many women is shown during 
 or succeeding each monthly jieriotl. 
 
 The goitrous tumor is usually not difficult of recognition. As a rule, it is 
 chronic in its course ; it rises and falls in the act of deglutition, is painless, is not 
 adherent to the oveidying skin, under which it moves freely, and has no attach- 
 ment to the jaw or to the clavicle beneath. The larynx moves with it, but it 
 is not adherent to any other parts in the neck. It is usually covered by promi- 
 nent veins. It is often an impediment to respiration, sometimes to deglutition ; 
 when large, or when developed in the direction of the recurrent nerves, it may 
 cause alteration or loss of voice. It may also distort the trachea or push it to 
 one side and displace the large vessels. Its original location is almost con- 
 stant, and a bilobed or symmetrical swelling of the neck is nearly always a 
 goitre. Some of the vascular forms give rise to a murmur which upon aus- 
 cultation will yield a marvellous blowing or rushing sound. About the only 
 difficulty in diagnosis which can arise will be with reference to the innocent or 
 malignant character of the swelling, since tumor of almost every other portion 
 of the neck is easily excluded. 
 
 Treatment. — Internal remedies are of little or no use, save as they may 
 serve to build up the debilitated individual. This, however, is not true of thyroid 
 extract, which, in the hands of Kocher and others, has greatly ameliorated 
 many cases and apparently cured a number. Iodine in some form has enjoyed 
 a certain reputation in time past, but is little given at present. All kinds 
 of local treatment have been resorted to. Iodine, again, has been the most 
 satisfactory medicinal application. In India an ointment made of red iodide 
 of mercury, rubbed in for ten minutes every morning, has given good results. 
 After its application the neck is exposed to the heat of the sun. But the only 
 treatment which can be recommended is surgical. Cysts may be tapped, and 
 perhaps drained. This should be done with aseptic precautions. A favorite 
 method of treatment has been the injection into the substance of the organ of 
 a watery dilution of tincture of iodine. In the soft parenchymatous or cystic 
 form this may be of some service, although accompanied by danger. In old 
 or hard goitres it is useless. Electrolysis has yielded good results in many of 
 the softer forms, one or more needles connected with the negative pole being 
 inserted into the substance of the tumor, while the positive pole is applied by a 
 large sponge or clay electrode in the vicinity. The current should be measured 
 with a galvanometer, and should not be strong enough to cause severe distress. 
 Such applications may be practised once or twice a week, and in severe cases 
 will often be followed by diminution in size of the mass, but scarcely ever by 
 its total subsidence. 
 
 Of more formidable operative procedures, ligature of the thyroid arteries 
 is perhaps the least severe, but is difficult. This, too, will sometimes give good 
 results in the vascular and parenchymatous cases. When dyspnea is caused 
 by pressure, a simple division of the isthmus will sometimes relieve it. 
 
 Enucleation or Partial or Total Extirpation of the mass (thyroid- 
 ectomy) is the radical ami final operation, which, especially in the Swiss 
 and German clinics, is done with a death-rate of about 1 per cent. The 
 operation is serious mainly on account of the dangers from hemorrhage. The 
 most successful method appears to be that of incision of the fascial capsule, 
 and shelling out of the tumor or tumors from within the fibrous investment, 
 which usually can be done without great difficulty. The parenchymatous 
 
CG2 .l.V AMi:i:i( AX TKXr-HOOK OF srudKHY. 
 
 form is to \\q dealt \s\\\\ l>y partial (.'xtirpatioii. The n-curreiit laryngeal 
 nerves must be carefully avoided. A'essels must be tied as they are encoun- 
 tered, and the base of the growth may be ligated en mmsxe. Bose and Pop- 
 ]»ert have recently practised a "bloodless " method by lifting the gland from 
 its bed sufficiently to encircle the pedicle witii elastic tubing before enucle- 
 ating the cysts. The expi-rience of Swiss surgeons shows that thyroidectomy 
 and enucleation are best <lone by a large curvilinear incision with the con- 
 vex side downward and without ether or chloroform. Eucaine, cocaine, or 
 Schleich's fluid may be used to deaden the pain of the skin incision and 
 (liminish the hemorrhage. By engaging the patient in conversation any 
 threatened injury to the recurrent laryngeal nerves may be instantly de- 
 tected by hoarseness or aphonia. 
 
 The principal danger of thyroidectomy is not so much the risk of immediate 
 disaster as of a peculiar constitutional change which seems to be inherently 
 connected with the loss of function of this organ ; a subject concerning which 
 we have ample clinical demonstration, with very little knowledge of its cause. 
 It is known as cachexia strum ipriva, and corresponds almost exactly with 
 the idiopathic condition known as myxoedema. The development of this 
 cachexia is, however, a matter of time. re(iuiring several weeks or months. 
 A more acute form of changes of the same general character results in the 
 condition known as tetany, which is a spasmodic nervous affection, in some 
 respects resembling tetanus, but having no infectious condition underlying it. 
 It has been shown by recent researches, both on animals and in man. that total 
 removal of tlie thyroid is very likely to bring about the acute or chronic form 
 of cachexia strumipriva, whereas the danger of the same amounts to little or 
 nothing when a portion of the organ, even so small as one-fourth or one-fifth 
 of its total mass, is allowed to remain. The inference from these experi- 
 ments, which is amply borne out clinically, is that the greatest, though sec- 
 ondary, danger of total removal of the thyroid is a series of tissue-changes 
 throughout the organism by which the body and the mind of the patient are 
 materially altered for the worse, while partial thyroidectomies are accompanied 
 by little if any such danger. While, then, total extirpation is an operation to 
 be avoided if possible, no hesitation need be felt about removing a large por- 
 tion of a goitrous thyroid ; in other words, so much as will afford relief from 
 most of its unpleasant features. Especially when the condition is unilateral 
 or largely so, no hesitation need be ielt in recommending operation. Several 
 surgeons have lately transplanted the thyroid gland of the slieep, and placed 
 it in the connective tissues or in the abdominal cavity ; others have injected 
 hypodermatically the juice of the gland. Both methods have met with encour- 
 aging results. The secre^of these changes is very probably connected with 
 the problem of the distribution of mucin and other waste products of the 
 system. Much benefit often accrues from the internal administration of thy- 
 roid extract, now easily j»rocured. It has considerable influence in reducing 
 the size of many parenchymatous goitres, and is of value in certain other 
 conditions, such as obesity. It may be given in doses of five to ten grains 
 thrice daily. 
 
 EXOPHTHALMIC <;OITRE (gRAVES's OR BASEDOW'S DI.^EASE). 
 
 In these cases the enlargement of the thyroid gland is usually accom- 
 panied with rapid juilse and prominent eyeballs, though any one or even two 
 of these symptoms may be absent. Often a systolic bruit may be heard over 
 the thyroid region, and the eyelids may be retracted and they do not follow 
 the eyeballs in the downward excursion (von Graefe's sign). Various ner- 
 
DISEASES AND INJURIES OF THE NECK. 663 
 
 vous symptoms are apt to accompany the disease, and polyuria, albuminuria, 
 ami dyspnea are fre(|uent concomitants. The cause of the disease is uncer- 
 tain, l)ut it is probably due to the toxic action of the thyroid internal 
 secretion. 
 
 Treatment. — Thyroid extract is to be avoided. The supra-renal extract 
 has done good in some cases, as has also electricity. Digitalis and measures 
 looking to the improvement of the general health have met with most success. 
 When properly directed internal treatment has failed surgical measures 
 should be instituted. Upon the plausible thcf)ry that the disease is due to 
 an excess of thyroid secretion, normal or abnormal, circulating in the sys- 
 tem, the most effective method of diminishing it would certainly be to remove 
 a portion of the gland. In 1896, Starr had collected 190 cases of thyroid- 
 ectomy for exophthalmic goitre. Of these, twenty-three were promptly fatal, 
 apparently from acute poisoning, induced perhaps by unavoidable handling 
 of the thyroid during the o[)eration. Death may also have been hastened by 
 ether, as that is a notably dangerous anesthetic to use during this operation. 
 Seventy-four cases were reported as entirely cured, and forty-five cases as 
 improved. In some instances the rapid pulse-rate has diminished even dur- 
 ing the course of the operation. Exophthalmos is the last feature of the dis- 
 ease to disappear. 
 
 These operations are often made difficult by friability of the capsule and 
 the vessels. As substitutes, have been proposed ligation of the thyroid 
 arteries — always difficult in these cases; exposure and suture to the skin of 
 the surface of the gland (Jaboulay), with the expectation that it will contract ; 
 and bilateral exsection of the entire cervical sympathetic nerve (Jonnesco). 
 None of these, however, have given the positive results attained by thyroid- 
 ectomy. 
 
 TUMORS OF THE THYROID. 
 
 The principal tumors proper of the thyroid are malignant, being sarcoma 
 or carcinoma according to the tissue primarily involved. All forms of these 
 growths are met with here, the soft forms of round-celled cancer being perhaps 
 no more frequent than the varieties of sarcoma. They are all characterized 
 by rapidity of growth, by great pain, by distinct pressure symptoms, by inva- 
 sion of the surrounding tissues, by involvement of neighboring lymphatics and 
 other tissues, by the general appearance of cachexia, and by the other ordinary 
 unmistakable signs of cancers generally. They run a course by which they 
 are soon distinguished from the innocent enlargement of the thyroid body, a 
 course which is frequently rapidly malignant from the outset. 
 
 The prognosis is always bad. If the disease be apparently still limited 
 to the thyroid proper and radical operation be not considered too fonnidable 
 for the strength of the patient, it should perhaps be performed, if only for the 
 relief of pressure symptoms ; but, unfortunately, it often happens that by the 
 time such a case reaches the surgeon's hands for any operative purpose it has 
 exceeded the limits of legitimate hope or even perhaps of possible performance. 
 
(>64 
 
 .l.V AMKIil<'A\ TEXr-llOOK OF SlliCKRY. 
 
 CHAPTER V. 
 
 SURGERY OF THE DIGESTIVE TRACT. 
 
 Fig. 268. 
 
 PART I.— DISEASES AND INJURIES OF THE MOUTH, TONGUE, JAWS, AND 
 
 PHARYNX. 
 
 Malformations and Deformities of the Cheeks and Lips. — As 
 many of the dcfonnities and luiilfdniiations of the cheeks and lii)s are due 
 to. retarded or arrested devehipment, which a study of the embryology of these 
 parts will alone make clear, it will be necessary in the first place to give a short 
 
 account of the development of the face. 
 
 At a very eai'ly period of foetal life a series 
 of clefts appear on each side of the cejdialic 
 extremity, separated by rods of tissue called 
 hrancliial arches. The clefts communicate 
 with the alimentary canal. 
 
 The first branchial cleft is between the 
 mandibular and hyoid arclics. The mandib- 
 ular arch, wliich is afterward developed largely 
 into bone, consists of a Hxperior maxUhu'i/ por- 
 tion, Avhich does not unite with its fellow in the 
 median line, but has the fronto-nasal process 
 interposed, and an inferior maxillary portion, 
 which early unites in the middle line and 
 forms the lower jaw. Between the superior 
 maxillary and inferior maxillary processes of 
 the mandibular arch is the buccal cleft. This 
 is closed early, except where the aperture re- 
 mains for the mouth (Fig. 268). These various clefts have usually coalesced 
 about the ninth or tenth week of foetal life, but occasionally this coalescence 
 fails or is incomplete. This leads to various deformities, the chief of whicii are 
 cleft palate and hare-lij). In rare cases the orbital cleft remains open, and in 
 still rarer cases the mamlibular arch is undeveloped. 
 
 The palate, which is in two parts, is formed by the growth of a horizontal 
 septum backward, which shuts off the nasal cavity from the mouth. This, of 
 course, is in two parts. The median union, which commences from before 
 backward, is not complete until the tenth week. Imperfect coalescence of the 
 parts produces cleft palate and hare-lip. 
 
 Jfare-lip is produced by the non-union of the mesial nasal process with 
 the superior maxillary process. The non-union may involve only the soft 
 parts or it may be complete, there being a fissure between the intermaxillary 
 and superior maxillary bones. This may occur on one or both sides, pro- 
 ducing the deformity of single or double hare-lip. 
 
 If the superior maxillary bones do not unite at the palatine cleft, which is 
 in the median line, we have the deformity of cleft palate. Hare-lip is always 
 to one or the other side of the median line following the direction of the naso- 
 maxillary fissure between the superior maxillary and intermaxillary bones. 
 Hare-lip. — Hare-lip may be single, double, or complicated, or may involve 
 
 Head of an Kmbryo : pr. p!ob., plobular 
 extremity of the mesial nasal process : 
 nw, maxillary process: j/;;;, mamiibn- 
 lar arch : hy, hyoidean arch ; 6c', first 
 branchial arch (Quain). 
 
SUROERV OF Tin: DTaKSriVK TRACT. 
 
 G»Jo 
 
 only the soft parts, or the hard ami soft parts at the same time. In about 
 one-tenth of the cases hare-lip is double, and when double it is not unfre- 
 (juently complicated with cleft palate and failure of union of the intermax- 
 illary bones. In such cases the intermaxillary bones will project, covered 
 by a small jiortion of skin, and attached to the sejttuni of the nose or even to 
 the tip itself (Fi^. 'iOy). Some cases have been reported of hare-lip coexist- 
 ini^ with congenital fissure of the cheek (Fig. 271). Single hare-lip is by far 
 the most common defect, and is said to occur more often on the left than on 
 the right side (Fig. 270), and more often in males than in females ; the gap 
 is usually flattened to the outer and rounded to the mesial side. It is occa- 
 sionally seen in the negro (Fig. 272). 
 
 Age for Operation. — There is considerable difference of opinion as to 
 the proper age at which the operation should be performed ; nearly all are 
 
 Fig. 269. 
 
 Fig. 271. 
 
 Double Hare-lip, with cleft of the hard palate 
 and protruding intermaxillary bone (Koenig). 
 
 Fig. 270. 
 
 Slight Hare-lip, with fissure of the lower 
 eyelid (Kraske). 
 
 Left Hare-lip extending into the nose (Koenig). 
 
 agreed that some time previous to dentition is the best ; some say between the 
 third and sixth months; others advocate its early performance. Fergusson 
 and others advocated performing the operation about the sixth week after 
 birth. Probably from the sixth week to the third month is the most suitable, 
 as the child's vitality is then usually good and operation is well borne. Of 
 course, the more severe operations are not so well borne in early infancy as 
 those for single hare-lip, but, as Holmes remarks, simple cases cannot be 
 operated on too early. In some cases of double hare-lip, when the child can- 
 not take the breast and has to be fed, early operation is often desirable should 
 the child be strong. At this earl}'^ period the operation is not Avithout danger, 
 for very young infants bear hemorrhage very badly. 
 
 Operation. — The operations for the cure of hare-lip are numerous (Figs. 
 273-276). Some are very ingenious, but very complicated, and while look- 
 
GG)J 
 
 .l^V AMKRIL'AN TEXT-JIOOK OF ^SCJiC'h'Uy. 
 
 in<j: well in a (lia^rain arc not easily carried out in practice. In operatinf^ 
 for liare-lip tiierc arc certain points to ])e kej)t in view. Fir.st, it is necessary 
 to olttain union l»y Hrst intention, and in oi'der to accomplish this the ed^es 
 of tlie cleft must he accurately hrou<^ht together and tiiere must he no tension 
 of the parts. It is also of imf)ortance that the red line of the lips shouhl he 
 even ; and when one side of tiie cleft is shorter and flatter than the other 
 this is by no means easy to accomplish. The edges of the cleft should he 
 pared freely, and the lip separated from its attachment to the gum. The 
 free separation of the lij* from the gum is a most important proceeding, for 
 it enables the edges of the cleft to be brought together without tension. The 
 best materials for sutures are silk-worm gut and horse-hair. The advantage 
 of silk-worm gut is that it is easily sterilized and can be left in situ a 
 week or more without giving trouble. The sutures should be introduced 
 about a (juarter of an inch from one edge of the cleft and brought out 
 
 Fio. 272. 
 
 Fi.;. 273. 
 
 Simple Hare-lip with Equiliiteral Sides. 
 
 Fig. 274. 
 
 Hare-lip in a Negro (original). 
 
 Methofl of Clemont or Malgaigne (N<!'lnton). 
 
 at the same distance from the opposite edge ; they should be placed deeply 
 enough to prevent hemorrhage from the coronary artery, but should not 
 penetrate the mucous membrane. Intermediate sutures of horse-hair are 
 very useful, and before finishing the operation the lip should be turned 
 lip and the mucous membrane sutured with horse-hair or catgut. This 
 has the effect of keeping the saliva out of the wound and so preserving its 
 asej)ticity. 
 
 Mr. Owen advocates a method introduced by Mirault of Angers (Fig. 
 27.')) many years ago, whereby the flap on one side of the cleft is preserved 
 and brought across the middle line and applied to the raw edge of the gap at 
 the lower part of the opposite edge of the cleft. Any redundancy of flap 
 can be removed after the sutures are introduced ; the flap should be left on 
 the side on which there is most tissue. In order to take the tension off the 
 stitches it is always well to apply a strip of rubber adhesive plaster to each 
 
SURGERY OF TllK DKiKSTlVE TRACT. 
 
 667 
 
 cheek and make the ends meet over the lip. Tlie part attached to the cheek 
 ^houhl be ])road, but the strip should narrow as it approaches the lips, ihc 
 two mesial ends may be perforated, and then laced together like a shoe. By 
 this means the cheeks are brought forward and the central parts of the lips 
 relaxed. If such a simple arrangement be applied, there is no necessity for 
 more complicated and expensive trusses. , • j 
 
 To describe the operation more in detail : The child, having been etherized, 
 is wrapped up in a towel or pillow-case to confine the arms, and is held by 
 an assistant in a convenient position. The surgeon, with a sharp, narrow- 
 bladed scalpel, transfixes one edge of the cleft and cuts a strip of tissue from 
 the mar.nn of the gap. going well up in the angle and paring freely and 
 cleanly. ^ lioth sides should be pared, and the strips may be cut away entirely 
 or left attached as the ingenuity of the surgeon may suggest, they being often 
 made use of, as the accompanying figures show, to make up for deficiencies in the 
 lip The incision on each side should be curved, the concavity being toward 
 the median line, so that when the two curves are brought together there will 
 be a slicrht projection of the prolabium instead of a notch. The strips from 
 the margins of the fissure may also be adjusted, so as to prevent the occurrence 
 of the notch at the point of union of the flaps. There is much less danger ot 
 
 Fig. 27-5. 
 
 Fig. 276. 
 
 Method of Mirault (NC'laton). 
 
 Operation for Double Hare-lip (original). 
 
 cutting too little from the edge of the cleft than of cutting too much. Only 
 sufficient pressure should be used to control hemorrhage, as too great press- 
 ure mav easily cause a slough. The frenum of the lip and all connections 
 between the lip and the gum are now freely divided. This Avill often cause 
 smart hemorrhage, which soon stops when the cut edges of the clett are 
 broucrht together and strapping is applied to the cheeks. The dressing ot 
 the wound should be as simple as possible ; it should be dusted over with 
 iodoform or painted with an iodoform paint. If sutures are used, they should 
 be removed about the fourth or fifth day, but the strapping should be left on 
 for a week or ten days longer. As the strapping gets loose it may be tight- 
 ened bv lacing the 'two sides together with silk or other strong materia 
 Union 'should be complete at the end of the second week, and often will 
 be so before. Should a portion of the wound fail to unite by first intention, 
 careful approximation by strips of plaster may be followed by union ; if this 
 fails, we must repeat the operation later. 
 
 In double hare-lip the operation is the same, except that it is done on 
 both sides, and both clefts should be closed at the same operation. When the 
 central portion is short, the portions cut from the gaps should be united m the 
 median line below the central portion. In some cases where the central por- 
 tion is narrow it is better to take it away altogether and treat the resulting 
 fissure as a single hare-lip. 
 
 Hare-lip complicated with Protrusion of the Intermaxillary 
 Bone.— This is a much mere difficult case to treat. In the first place, before 
 closing the clefts it is necessarv either to remove the projecting wedge of bone 
 or forSbly bend it back into position and hold it there by sutures or strap- 
 
GG« J.V AMEIUVAy TEXT-BOOK OF SL'UUKllY. 
 
 ping, and then proceed to tleal witli the hare-li|». In cases where the project- 
 ing bone is riulimentary an<l attached to the tip (jf tlie nose, it shoidd he 
 removed. Fergusson many years ago stated that if the intermaxilhiry l;one 
 be forced back, as the child develops the incisor teeth will grow backward 
 into the mouth and thus prove a source of annoyance. Hence he always 
 removed the projecting bone. But in many cases excellent results may be got 
 by forcing back the projecting bone and suturing it in ])lace after paring the 
 edges of the gaj) in the gums. The l)one is usually fractured, and can be 
 replaced without the rotation spoken of by Fergusson. 
 
 AFFECTIONS OF THE LIPS. 
 
 Inflammation of the lips is quite a common affection in winter, and is 
 due to cold. "Cracked" or "chapped" lips are troublesome and often very 
 painfid, bleeding on the slightest provocation. The fissure or crack is usually 
 in the median line, and, if treated early by the constant application of simple 
 or rose-Avater ointment and a strip of the more durable form of court-plaster 
 on muslin, gets well quickly. Should the fissure persist, it may need cauter- 
 ization with a sharp point of nitrate of silver to relieve the pain. 
 
 In early life such fissures are sometimes neglected and leave deep furrows, 
 which are very disfiguring. These gaps can be easily remedied by paring 
 the edges and bringing them together. Cracks may occur in the upper 
 or lower lip; in children they are seen most frequently in the lower, and are 
 indicative of a strumous diathesis. These children usually have enlarged 
 lymphatic glands of the neck. Such cases must be treated by attending to 
 the general health. If the fissures are painful, they should be brushed over 
 with a solution of nitrate of silver. Cocaine should be used first, so as to avoid 
 pain. When fissures or ulcers occur about the corners of the mouth in chil- 
 dren, they should be carefully inquired into, as they are often indicative of a 
 syphilitic taint. They leave scars which persist throughout life. 
 
 Many severe inflammations of the lips are caused by injuries, bites of 
 insects (bees, wasps, mosquitoes, etc.), and should be treated by the applica- 
 tion of evaporating lotions. The inflammation usually subsides rapidly. 
 Should it go on to suppuration, an early and free incision should be made. 
 
 Herpes of the lips occurs as "cold sores" or "fever blisters." Occa- 
 sionally in weakly individuals intense inflammation accompanies herpes of the 
 lips, and it is very apt to recur. It may be checked on its first appearance 
 by t)ie application of a little nitrate of mercury ointment. 
 
 TUMORS OF THE LIPS. 
 
 Epithelioma. — This form of carcinoma most frequently aftects the lower 
 lip, and is most common in males. It is essentially a disease of advanced life. 
 As a rule, its growth is slow and the glands are not early involved. It may 
 commence as a warty growth, as a mere excoriation, or as a fissure or ulcer 
 which will not heal. Sometimes it commences as a small indolent tubercle, 
 which soon ulcerates and is covered by a thick scab. This, when picked off 
 by the patient, grows again. Soon the ulcerated surface enlarges, deepens, 
 and is surrounded by a mass of induration : although not very painful, it is a 
 source of great discomfort, especially when eating. 
 
 Diagnosis. — Although the diagnosis of cancer of tlie lip may appear very 
 simple, yet it is occasionally mistaken for chancre, or rather chancre is mistaken 
 for it. Chancre of the lij) more frequently occurs in females, and may occur ;it 
 
SURGEnV OF THE DKiESTIVK TRACT. 
 
 669 
 
 all a-es; cancer occurs in males, as a rule, and after lorty-five The lymphatic 
 glands are involved very early in chancre, late in cancer. J lie progress of 
 cancer is usually slow and lasts many months. Chancre lasts a few weeks only. 
 Cancer never loses its har.l base and never heals completely. Chancre is sooner 
 or later accompanied by other manifestations of syphilis, as sore throat, secondary 
 nsh etc Cancer does not improve under treatment. Chancre improves rapidly. 
 Treatment.— There is but one method of treating epithelioma of the lip, 
 and that is by early and free excision. If the growth can be excised freely 
 before the submaxillary lymphatic glands become involved, there is a very good 
 chance of non-recurrence— more than in any other form of ciincer. Caustics 
 ^llould be avoided ; they only temporize with the disease and delay thorough 
 extirpation by the knife, often causing the operation to be postponed until the 
 cervical crlands are involved; the case is then comparatively hopeless and ope- 
 ration merely palliative. Sores on the lip which will not heal readily occurring 
 in i)ersons over forty-five should be excised. . ., v • 
 
 Operation.— the removal of an ordinary-sized epithelioma of the lip is a 
 simple matter. It is usual to employ a V-shaped incision with the base up- 
 ward, care being taken to cut well away from the growth, ihe edges of the 
 incision may be brought together with hare-lip pins or deep sutures of silk- 
 worm crut. The wound if properly closed heals by first intention withm a 
 week "when the disease is extensive the greater part or the whole of the lip 
 may have to be sacrificed and a new lip made by a plastic operation, fehould 
 the lower law be involved in the disease, a portion may have to be removed. 
 As a rule, it is best to remove the contents of the submaxillary triangle ot 
 the same side, including the submaxillary salivary gland, m which are em- 
 bedded several lymphatic glands. Even in the thinnest necks infected 
 enlarged glands may easily escape detection by palpation 
 
 n'evi are not infrequently seen on the lips (Fig. 32, p. 227). At first they 
 are usually small, and may be ligatured, or treated by pin-points of the thermo- 
 cautery or electrolysis. If the growth is deeper and larger, it may either be 
 dissected out or th^ lip excised as in epithelioma. The latter proceeding is 
 the easier, but care should be taken to cut into healthy tissue. Subcutaneous 
 licrature may also be used with advantage m many cases. ,. , , 
 
 "^ Cysts of the Lip.— These generally occur in the lower lip, and are due 
 to the blocking up of the mucous follicles in the inside of the hp ; they often 
 grow to a larSe size and appear as tense, semi-transparent, shmmg swellings 
 containing a viscid or clear mucus. They are always innocent. 1 hey should 
 be freely laid open, dried out with lint, and the inside painted with strong 
 nitric acid or cauterized with a thermo- or electro-cautery. 
 
 Horny growths are occasionally seen on the lips, and should be excised. 
 Hypertrophy (Macrocheilia) is commonly seen in strumous children, 
 and may occur in one or both lips. In some cases the hypertrophy is so great 
 that an operation is asked for to relieve the deformity. The removal of an 
 elliptical portion of the mucous membrane and submucous tissue m a horizon- 
 tal direction does much toward remedying the unsightliness of this affection. 
 
 WOUNDS OF THE LIPS. 
 These should be treated in the same manner as wounds of any other part. 
 Thev should be thoroughly cleansed and the edges brought accurately together 
 with deep sutures. If there is much hemorrhage from the coronary arteries, 
 they may be tied, but, as a rule, the hemorrhage ceases on tightening the sutures, 
 which should go down to the mucous membrane and so include the arteries. 
 
G70 
 
 ^l.V AMERJCAX TEXT-BOOK OF smaKHY. 
 
 MAI.I'OKMATIONS OF TUE Mv)UTII. 
 
 Congenital contraction or com- 
 plete closure of the mouth may 
 sometimes be seen as tlie result of 
 over-closure of the buccal fissure. 
 This is called microstoma. Ma- 
 crostoma, or lar^e mouth, is due 
 to the buccal fissure not closinor 
 completely, and in such cases the 
 mouth may actually extend to the 
 ear. 
 
 Of course the most common mal- 
 formations of the mouth are the dif- 
 ferent forms of hare-lip, which 
 have already been described. Me- 
 dian fissure of the lower lip is a rare 
 condition, so rare that its occurrence 
 has been doubted, but recently cases 
 have been reported and figured. 
 These are easily explained by the 
 non-union of the mandibular arch 
 in the central line. Median fissure 
 of the upper lip has also been occa- 
 sionally seen. 
 
 Deformities from Burns 
 and Scalds. — Deformities of the 
 lips the results of burns are not in- 
 
 Fir;. 278. 
 
 Results of Operation in the Same Case (original). 
 
 Deformity from the Cicatrix following a Burn (original), 
 
 frequently seen, and when se- 
 vere cause frightful disfigure- 
 ment. They, of course, in- 
 terfere with speech, and saliva 
 constantly dribbles from the 
 mouth. They are usually com- 
 plicated with contraction of the 
 face and protrusion of the lower 
 jaw. In some cases the lower 
 lip is so much everted that its 
 lower margin niay be attached 
 to the upper ])art of the ster- 
 num. A new lip may be made 
 after the manner recommend- 
 ed by the late Mr, Teale of 
 Leeds. Figs, 277 and 278, 
 from a case recently operated 
 on, well illustrate the deform- 
 ity and the hap})V residts of 
 oj)eration, the details of which 
 are as follows : 
 
 Cheilop I asty. — * The 
 everted lip is divided into 
 three parts by two vertical 
 incisions three-uuarters of an 
 inch long and carried down to 
 
SURUKllV OF THE DIUESTIVK TRAi'T. 
 
 671 
 
 the hone. These incisions are so phmned that the nii«hllc portion between 
 them occupies one-half the li}) ; from the hiwcr entl of each incision the knife 
 is carrie<l outward to a point one inch beyond the angle of the mouth. The 
 two flaps thus marked out are freely and deeply dissected up. The lateral 
 flai)S are now raised and united by twisted sutures in the mesial line, and 
 supported as on a base by the middle flap, to which they are also attached by 
 a few points of suture, leaving a triangular even surface to granulate." This 
 is a most satisfactory operation and always gives good results. 
 
 Salivary Fistula is usually seen in the line of Stenson's duct, and is the 
 result of injury, operation, or abscess following obstruction. Should Stenson's 
 duct from any cause be opened externally, saliva trickles out of the open- 
 ing and a fistula is the result. It may follow suppuration of the parotid after 
 injury or fever. It is one of the most troublesome of affections, causing great 
 inconvenience to the patient during mastication, when the flow of saliva is 
 much increased. The first point in the treatment is to establish an opening in 
 the mouth. This may be done by passing a probe through the external fistula 
 into the mouth in the direction of the duct, and then cutting down on it from 
 within and passing a probe daily. As soon as a free internal opening is estab- 
 lished, the fistula may be closed by touching it with a thermo- or electro-cautery. 
 Another method of treatment is to pass a seton through the fistula into the 
 mouth, bring it out of the mouth, and tie the two ends. In a few weeks a per- 
 manent internal opening is established, when the seton may be withdrawn, and 
 the external opening will soon close (cf. p. 657). When the fistulous opening 
 is small it may be at once closed with a fine point of an electric cautery. In 
 certain cases plastic operation is required to close the fistula. 
 
 Cancrum Oris. — This is a form of sloughing phagedena which occurs in 
 ill-fed, sickly children who are recovering from some of the exanthemata, espe- 
 cially measles and scarlet fever. A similar disease aff'ects the pudenda of 
 female children. It commences as a phlegmon of the cheek and lips, and is 
 
 often first seen as a dusky red spot on 
 
 the outer surface of the cheek. The 
 
 child opens its mouth with difficulty, 
 and if the surgeon looks in the inside 
 
 he will see a deep, sloughy, unhealthy 
 
 ulcer opposite the dusky spot. Large 
 
 portions of the cheek and lips may 
 
 become gangrenous, and the sloughing 
 
 process may even extend to the bone, 
 
 for it spreads with great rapidity. The 
 
 disease, Avhich is attended by consider- 
 able fever and great depression, is very 
 
 fatal, the patient usually dying from 
 
 exhaustion. "When recovery does take 
 
 place the deformity resulting from the 
 
 sloughing process is great (Fig. 279). 
 Treatment. — The food should be the 
 
 most nourishing possible, and stimulants 
 
 should be freely administered. When 
 
 the disease is first recognized the child _ . 
 
 should be put under ether and the parts freely cauterized with strong nitric 
 
 acid. Afterward they should be kept clean by antiseptic washes of Condy's 
 
 fluid, creoline. etc. . j ut 
 
 Stomatitis, or inflammation of the mouth, usually occurs m the debili- 
 
 Fk;. 279. 
 
 Cancrum Oris (Albert). 
 
(IT-J 
 
 AX AMFJilCAX TEXT- BOOK OF SURGERY. 
 
 tated wlien tlie (li<:;t'stivc organs are out of order. The simjilest cases are 
 merely an inflammation of the mucous membrane, and may be caused by any 
 irritant, as smoking, carious teeth, hot food, etc. This condition is easily 
 treated by awash of borax or ciilorate of potassium. In some cases the inflam- 
 mation runs into aphthous ulceration. This is often painful, and has to be cau- 
 terized by the solid stick of nitrate of silver preceded by cocaine. Where there 
 are recurrent attacks of a])hthous ulceration the general health should be im- 
 proved by tonics and nourishing food. 
 
 Mercurial Stomatitis and Mi'rcurial Glossitis are not uncommon in the 
 trades in Avhich mercury is used, and as a result of mercurial salivation from the 
 internal administration of the drug. The cause should be removed, and potas- 
 sium iodide avoided, as it increases the salivation. Ordinary washes of borax 
 should be employed, with cooling lotions. Ice is sometimes agreeable to the 
 patient, though it has no influence on the disease. 
 
 Fi(i. liSO. 
 
 MacToglossia (original). 
 
 MALFORMATIONS OF THE TONGUE. 
 
 Tongue-tie, or shortness of the fnenum lingune. The tongue is bound 
 down and cannot be [)rotruded beyond the incisors. This is a congenital defect 
 which is not uncommon, and when it exists to a high degree it prevents the 
 child from suckling, and later may interfere with articulation. In such cases 
 it is necessary to divide the tightened bands ; this should be done with a pair 
 of scissors with blunt points. The points should be directed to the floor of 
 the mouth to avoid wounding the ranine arteries. Cases are on record of fatal 
 henK)rrhage occurring from accidentally cutting these vessels. In dividing the 
 fnionum only a small cut is necessary, and then the rest may be torn through 
 with the fingers. Even this is generally unnecessary, for the child, in crying, 
 still further frees the tongue. The frienum may be congenitally too long, and 
 cases of death from suffocation have been recorded owing to this condition, the 
 patient '' swallowing " the tongue. 
 
SURGERY OF THE DKlESTIVE TRACT. 
 
 673 
 
 Macroglossia is a congenital hypertrophy of the tongue analogous to 
 elephantiasis. It is of slow growth, and as it enlarges causes great trouble, 
 tTL-. size intertVring with deglutition and speech. The tongue may 
 p otrude over the chin and reach even as far as the sternum. The subjects 
 r Is affection frequently suffer from epilepsy. The great enhvrgemen 
 causes deformity of the teeth and jaws, especially the lower jaw Ihe teeth 
 mav become carious and fall out, and the lower jaw has been known to be 
 di ioc^ited or distorted bv the pressure. There is constant dribb hng of 
 saliva and the protruded' tongue is much altered in appearance, indurated, 
 swoUen a d pui4lish in color T later, nodes, irregularities, and fissures appear 
 on its m-f^.ce\ aid occasionally the tongue ulcerates. On puncturing it there 
 L not much bleeding, but there is oozing of large quantities of serum. Tie 
 disease is not, as a rule, noticed for the first two years, as^sucking appeals to 
 delay the growth of th; organ by continuous pressure. The pathology of this 
 di else waS first elucidated by Virchow: he found that there was an overgrowth 
 ofTnterstitial connective tissue, with a remarkable infiltration of the whole organ 
 wih white cells collected here and there in a delicate network and foi'ming true 
 rvmphoid tissue. The disease, no doubt, is due to congenital defect aggra- 
 vated by frequent attacks of glossitis. 
 
 ThItreaLent consists in the removal of the protruded portion of the 
 toncue. In some cases the removal of a V-shaped portion will give the best 
 resuls. Ligature of the portion of tongue protruded has been successfully 
 p'^ctised bSt nothing is so safe or simple as removal with knife, galvano- 
 cauteiT, or ^craseur. The hemorrhage usually is not great, and the result is 
 almost^ nvanably satisfiictory. When bleeding is feared in young children, 
 remova by the ecraseur shodd be preferred, but in adults the knife or scissors 
 setter as its use is not followed by sloughing. The tongue should be drawn 
 fL-wad by means of ligatures passed through its substance, and the mcision 
 houW be^made in such a manLr that the tongue is left somewhat pointed ; 
 the bleeding vessels should be tied as cut. The after-treatment is the same as 
 that used for partial removal of the tongue for any other cause. 
 
 Wounds.— Usually wounds of the tongue are not serious, but Jiiyant 
 mentions a case where death followed a wound of the tongue ma small child 
 from trickling of blood down the larynx, the child dying asphyxiated. Wick- 
 ham Lec^g rebates cases of death following biting of the tongue m persons the 
 subjects of hemophilia. Wounds of the tongue may be produced in various 
 way^, but most commonly the wound is caused by the teeth. Epileptics not 
 infrequently bite the tongue during a fit. The tongue may be severely wounded 
 by a fall on the chin o? by a violent blow on the jaw when the tongue is 
 protruded. The protruded portion of the tongue may be completely bitten oil 
 
 or one side only be injured. . ^^ i 
 
 The hemorrhage resulting from injury to the tongue is seldom dangerous^ 
 and is usually easily controlled by hot water, ice or exposure to the^ir. bhouid 
 the hemorrhage be profuse, its source should be sought for and the bleeding 
 vessel, usually the ranine artery, tied. Oozing from the wound is genemlly 
 arrested by bringing its edges together with sutures. In certain cases where 
 the wound is far back, it may be necessary to pass a ligature through the tip 
 of the tongue, draw it out, and examine the wound thoroughly ; if the wound be 
 small, it should be enlarged and the bleeding vessel secured In some cases it 
 may be necessary to use the cautery to arrest the nemorrhage ; its use, how- 
 ever, interferes with primary union. Sutures are not necessary if the wound 
 be small, but if it be large and a portion of the tongue be hanging loose 
 the sides of the wound should be carefully brought together with deeply-placed 
 
674 Ay J.l/AV.'/r.LV THXT-JiOOK OF SlUdFJ;)'. 
 
 silk or catgut tiuturt's. The'.se must be tied with more than the iiMial care, or 
 they will loosen from the moisture and constant movements of tlie tongue. 
 The after-treatment of wounds of the tongue is similar to that of other wounds 
 of the mouth. Tlie mouth should he washed out frcijuently with weak Condy's 
 fluid, or a ])aiiit of iddofonu and alcohol may be used. 
 
 Foreign Bodies. — Wounds of the tongue may be caused by foreign bodies, 
 such as the stem of a tobacco-pipe, crochet-needles, splinters of w'ood, etc. 
 Foreign bodies are occasionally driven into the tongue in cases of gunshot 
 wounds ; these consist of teeth, portions of the jaw. etc. A bullet mav also 
 lodge in the tongue. "When a wound of the tongue does not readilv heal, or 
 when there is secondary hemorrhage, or, again, if a sinus exists and an indo- 
 lent swelling remains, a foreign body may be suspected. When it is removed 
 the wound usually heals. But its removal does not always bring about .so 
 happy a result ; in more than one case this procedure has been followed by 
 hemorrhase which has caused death. 
 
 TUMORS OF THE TONGUE. 
 
 Naevi are occasionally found in the tongue. If superficial, they may be 
 treated by nitric acid or by puncture with thermo-cautery needles. When the 
 growth is prominent and can be isolated it may be excised with scissors or 
 treated with ligature. In excision the cut should be made all around in 
 healthy tissue, the hemorrhage then being inconsiderable. The thermo-cautery 
 knife also may be used. When the growth is large and more diflfuse, excision 
 by the wire ecraseur is a valuable method of treatment ; the ^craseur should 
 cut through healthy tissue. Ligature is seldom necessary in such cases, but 
 when used should be passed deeply into the substance of the tongue and tied 
 very tightly. 
 
 Papillomata, or Warty Tumors, occur on the dorsum of the tongue, and 
 consist merely of hypertroiihied papilhe. The diagnosis is easy when the 
 affection occurs in early life, but when it exists in old people it is sometimes 
 difficult to diagnosticate from epithelioma. 
 
 Treatment. — Removal by scissors is the simplest and best mode of treat- 
 ment when the growths are small ; when large, ligature is more satisfactory. 
 If there be any induration at the base or the slightest suspicion of the growth 
 being malignant, to ensure complete removal the healthy tissue around should 
 be excised as well as the growth. Butlin rightly states that '' the treatment 
 of the larger and doubtful warts in persons over forty years of age by caustics 
 and other similar measures cannot be too strongly deprecated." 
 
 Ran u la is a large cystic tumor which is seen under the tongue on one or 
 the other side of the friv?num lingute. The tumor is semi-translucent, soft, and 
 has coursing over it large dilated veins. It occurs oftener in adults than in 
 children, and is usually painless, but the sense of fulness and the discomfort 
 induce the patient to consult a surgeon. It contains a clear, glairy fluid, 
 mucoid in appearance, but rarely saliva. The exact cause of the swelling has 
 given rise to much discussion. There is no doubt that it may be due to dilata- 
 tion of the ducts of the salivary glands, as well as to obstruction of those of 
 the sublingual mucous glands. 
 
 The treatment is not so satisfactory as would at first sight appear. If the 
 sac is emptied, it soon fills again, and to prevent the return of the disease it is 
 necessary to destroy the lining membrane of the cyst by caustics, after having 
 excised a portion of the cyst-wall. Sometimes the injection of 15 minims of a 
 mixture of tincture of iodine 10 parts, water 10 parts, and iodide of potassium 
 
SUIiGERY OF THE DIGESTIVE TRACT. (wo 
 
 1 part will avail. Tlie solid stick of nitrate of silver applied to the interior 
 of the sac ;xives the most satisfactory results. Butlin and Bryant recommend 
 the old method of treatment l)y a seton of strong silk, left for a week. Should 
 this fail, a Hap of the cyst-wall may be stitched back. 
 
 Salivary Calculus. — A calculus may form in the ducts of the salivary 
 glands. It has been seen in Stenson's duct and in the ducts of the sublingual 
 glands, but Wharton's duct is its more frequent situation. The calculus is 
 composed chiefl}' of calcium carbonate and phosphate, and magnesium phosphate. 
 It forms slowly, Jind may have been growing for years before it gives trouble. 
 Suddenly inflammation may be set up, and the patient consults the surgeon for 
 a large inflammatory mass between the tongue and the floor of the mouth. The 
 submaxillary gland is usually enlarged, and a fistula may form below the jaw. 
 The diagnosis is not commonly difficult, for the hard mass can generally be felt 
 with the finger. Cases are reported in which the inflammatory changes produced 
 by the calculus have been mistaken for malignant tumor. The treatment is 
 removal by free incision over the tumor. This is made inside the mouth. 
 Cocaine anesthesia is sufficient, as a rule. As soon as the cause is removed 
 the swelling and inflammation disappear. 
 
 Sublingual Cysts. — These are usually congenital, and are rather infre- 
 quent. Being situated between the tongue and the lower gum, they are often 
 mistaken for ranulie. They grow slowly, and the surgeon is never consulted 
 until they are of considerable size, and either interfere with deglutition or pro- 
 ject externally into the submaxillary space. They are painless, and are situ- 
 ated between the muscles on the under surface of the tongue. They have been 
 seen only in adults under twenty-five. These cysts contain a thick putty-like 
 material, made up of epithelium, cholesterin, and fatty matter, and have been 
 described by some writers as sebaceous cysts, but they are really dermoids, and 
 may contain hair, teeth, and bone. The contents are sometimes semi-purulent 
 and very offensive. They may grow to a considerable size, but generally are 
 about the size of a small orange. The sac is often tough and fibrous, though 
 sometimes it is very thin and easily broken, and its dissection is a matter of 
 some difficulty. 
 
 A sublingual cyst is not difficult of diagnosis. It appears as a smooth, 
 rounded swelling beneath the tongue, and often in the submaxillary space, but 
 it has none of the translucency so characteristic of ranula. Instead of being 
 actually fluctuating, the swelling has a doughy feel and is inelastic. They may 
 be multiple or single, central or lateral. The explanation of their occurrence 
 is simple. During development a portion of the epiblast gets folded in and 
 shut off from connection with the external surface. It remains as a sac lined 
 with epithelium, increases with the growth of the individual, and is apt 
 suddenly to take on rapid growth if anything stimulates the epithelial cells. 
 The involution of the epiblast occurs between the genio-hyo-glossi muscles or 
 between the genio-hyo-glossus and the mylo-hyoid, Avhich explains the central 
 and lateral situation of the cysts respectively. 
 
 The treatment is by excision, and this may be performed either from within 
 the mouth or externally in the submaxillary space. The latter operation is 
 preferable, as the region of the wound can be kept aseptic and the surgeon can 
 more easily see Avhat he is about. A vertical incision is made in the median 
 line between the muscles below the chin, and when the sac of the cyst is reached 
 it is pulled out gently and freed with occasional touches of the knife as it pro- 
 trudes. If care be taken there is but little danger of hemorrhage. Should 
 the cyst be large, the contents should first be evacuated. Many recommend 
 the removal of these cysts through the mouth, especially in females, as thus 
 
G70 .l.V AMi:i;UA.\ TKXT-liOOK OF SURdKUY. 
 
 a scar is avoided in the subniaxillarv space. It is simple in small cysts, but 
 when lar<;e it will be found a difficult j)roceedin<r. 
 
 Acute Glossitis, or parenchymatous intlammation (tf the ton<:ue, is a 
 somewhat rare afl'cction. It is much UKire common in adults than in children, 
 and more fre([uently attacks males than females. It sometimes follows specific 
 fevers, or may be due to injury, cold, septic conditions of the mouth, bites of 
 insects, etc. These, however, are special forms ; ordinary spontaneous glossitis 
 is said to be caused by cold and dnnip, and is looked uj)on by some as a 
 catarrhal affection. 
 
 At the onset of the affection the paticjit complains of tenderness of the tongue 
 while uuisticating solid food. The organ begins to swell rapidly, and within 
 twenty-four hours it becomes twice its natural size and protrudes from the mouth. 
 The portion of the tongue within the mouth is livid and shiny, but the part pro- 
 truding is dry, cracked, and brown. Pressure of the teeth causes its edges 
 to become indented, articulation is impossible, and difficulty in swallowing is 
 always present. Fre([ucntly there is dyspnea. There is also a ])rofuse secre- 
 tion of saliva, which continually dribbles away from the mouth. The termina- 
 tion of the disease is usually by resolution in four or five days ; there may be 
 small superficial sloughs on the surface which leave ulcers ; these, however, 
 heal rapidly. Occasionally the inflammation is so acute that gangrene super- 
 venes. One of the rare terminations of this affection is suppuration. Some- 
 times life is threatened by suffocation, and it may be necessary to perform 
 tracheotomy. Constitutional symptoms, as fever, etc., are always present. 
 Ilemiglossitis is a much rarer and a much less severe form of the affection 
 than the preceding, and usually occurs on the left side. There is not so much 
 difficulty in deglutition, and there is never any dyspnea. 
 
 Treatment. — The nuijority of cases get well in five or six days without 
 much treatment. A saline purge, a chlorate of potassium wash, and the suck- 
 ing of snudl pieces of ice form the proper treatment in the milder cases ; but when 
 the symptoms are urgent and the distress great, surgical interference becomes 
 necessary. A deep and long incision should be made in each side of the ra])h^ 
 near the root of the tongue, and free bleeding should be encouraged. The 
 bleeding is rarely severe, and the relief following free incision is immediate, 
 the tongue in a few hours resuming its natural size. After incision suppuration 
 is much less likely to occur. 
 
 Syphilis of the Tongue. — The most common manifestation of syphilis 
 in the tongue is in the shape of jisHures. These usually indicate a tertiary 
 period of the disease. Fissures are sometimes seen in the secondary stage on 
 the side of the tongue, and are often aggravated by the sharp edge of a carious 
 tooth. The syphilitic fissure is usually very sensitive to the touch and a source 
 of annoyance, though not surrounded by an inlianimatory condition, as other 
 fissures are. It may be single or multiple. The diagnosis is generally easy, 
 for there are manifestations of syphilis in other parts of the body. It should 
 be treated by the ordinary antisyphilitic remedies ; if secondary by mercury, 
 and if tertiary by potassium iodide. IJutlin recommends }>ainting the fissures 
 with a ten-grain solution of chromic acid, which he says, in coml)inati{)n with 
 mercury, heals them with great rapidity. When heale(l they leave scars. Ter- 
 tiary fissures may be produced by the breaking down of several small gummata, 
 and are of some depth and length. They may plough up the dorsum of the 
 tongue in every direction, and heal under treatment very slowly. 
 
 Ulceration commonly occurs during the secondary stage along the edges of 
 the tongue. The ulceration is superficial, and a white patch on the mucous 
 membrane of the cheek corresponding to the ulcer on the tongue will usually 
 
sriwEjn' or tiik dkikstive tract. 
 
 G77 
 
 },e foniul. Mhoohs tuberrlr.^ mav also ai)i)ear on the tip and l)or(ler.s of the 
 ton^nie durinj: the secondarv stage, hut at the same time they are seen m other 
 phiJes • thev are oval, grayish-colored masses covered with partly macerated 
 ep'ithelhim/ Gnmwata arc seen, and may he superficial or deep, multiple or 
 siiVde Thev mav he ahsorhed or hreak down. The deejJ syjihihtie ulcer m 
 cauled hy the hreaking down of a gumnia. and is nsnally situated on the 
 dorsum o"f the tongue. It has sharp-cut edges and an indurated hase. 
 
 It must also he borne in mind that the primary lesion of syphilis— c/iawcre 
 -mav occur on the tongue ; it presents the appearance of primary sores in 
 other \3arts, but its specific character may easily be overlooked on Jiccount ot 
 its rarity. The submaxillary lymphatic glands are usually enlarged from tlie 
 
 first • n 
 
 Tubercle of the Tongue.— When tubercle attacks the tongue it usually 
 manifests itself in the form of an ulcer, though tubercular fissures are some- 
 times seen on the tip and borders. They are most often single, and may be 
 
 stellate in shape. „ , ^ i xi, 4.:^ ,f +v.^ 
 
 The tubercular ulcer is seen most frequently on or toward the tip ot the 
 tono-ue, and when extensive it may be easily mistaken for cancer. I he ulcer 
 is irregular, with sharply-cut edges and pale, flabby granulations at the base; 
 there i1 little surrounding induration ; in its advanced stages it may eat deeply 
 into the toncTue. It is acutely painful, so much so that the lingual nerve has 
 been divided to ease the sufferings of the patient. It may be a primary mani- 
 festation of tubercle, but this is rare. It much more commonly occurs as a 
 secondary lesion. The diagnosis is often exceedingly difficult The tongue 
 has been excised for tubercular ulcer in mistake for cancer The prognosis is 
 quite as unfavorable as that of cancer, the patient succumbing to the disease 
 in from a few months to two years. . r^ ...,. ,• ^ if 
 
 Cancer of the Tongue is always of one variety, viz. Epithelion^a. it 
 commences as a small crack, nodule, or ulcer usually on the side of the tongue, 
 though no part of the tongue is exempt. The posterior half is much less com- 
 monly affected than the anterior. It occurs more frequently m men than 
 in women in the proportion of 247 to 46 (Barker). It will be found, on 
 examining the various statistics, that cancer of the tongue occurs most tre- 
 quently between the ages of forty-five and fifty-five. 
 
 There is no doubt that smoking predisposes to cancer of the tongue, as 
 many cases are preceded by leucoma or the so-called psoriasis of the tongue. 
 This^ condition may be produced by dram-drmkmg, smoking, and also syphilis. 
 In 80 cases 16 were preceded by leucoma (Butlin). The psoriasis and scars 
 produced by syphilis, injury, or any other cause will P.^'^^ispose to cancer ; any 
 irritation, such as a sharp tooth, the stem of a tobacco-pipe, a badly-fitting tooth- 
 plate, etc., will in some persons excite ulceration which may take on a cancer- 
 ous action. There is no doubt, however, that cancer of the tongue may orig- 
 inate without any pre-existing disease or irritation, but in ^l^e majority of cases 
 some form of irritation is the exciting cause of the disease. Many practitioners 
 who are consulted by elderly people for ulcers of the tongue are in the habit 
 of cauterizing the sore repeatedly with nitrate of silver or other caustic. Ihis 
 is a most pernicious custom, and one which, while it can do no good may do 
 infinite harm ; for, should the ulcer be cancerous, it only aggravates it, and in 
 an ulcer which is of a simple, non-malignant character it may excite cancer by 
 the continued irritation. Again, it does harm in cancerous ulcers by causing 
 operative measures to be put ofl" until a period when operation can be of but little 
 use, by soothing the patient with the idea that somethin| is l^emg done for 
 him. Ulceration of the tongue in people over forty years of age should always 
 
678 A^'' AMERICAy TEXT-liOOK <JF SClidKin'. 
 
 be regarded with suspicion, and if there he any doiiljt us to its nature flic uk-er 
 and 11 portion of healthy tissue around it should he excised. No donht many 
 cases of leueophikia terininate in e|)ithelionia. When the cancerous ulcer is 
 well developed or the induration at its hase is marked, the diaj^nosis is not so 
 difHcult. hut if there l)e any douht a portion should he excised, and the niicro- 
 sco])e will usually establish the character of the disease. 
 
 When the ulcer commences on the border of the tongue, it rapiilly infiltrates 
 not only the tongue, but also the floor of the mouth and the gums, and finally 
 the jaw-bone itself is affected. The tongue becomes fixed, and its motion is 
 so lin)ited that it cannot be protruded. Should the disease begin farther back, 
 the ulceration or infiltration extends to the pillars of the fauces, the soft palate, 
 and the tonsils. When the disease has advanced thus far, the glands in the neigh- 
 borhood become enlarged. First, there is tenderness in the submaxillary 
 region, with pain which shoots up to the ear ; later, the glands may be felt, 
 small and hard, but movable ; as they increase in size they become fixed. If 
 the glands are affected early, the case is unfavorable, especially so when there 
 is early involvement of the cervical glands innnediately outside the angle of the 
 jaw. As the disease progresses, deglutition and speech becoiae difficult, there 
 is profuse salivation, and a horrible fetor of the breath. Patients may die 
 from hemorrhage due to the growth ulcerating into some large vessel, or there 
 may be frecjuent hemorrhages from smaller vessels, which may hasten the end. 
 The usual mode of death, however, is from exhaustion due to pain, sleepless- 
 ness, starvation, sloughing, etc. The average duration of the disease in 
 patients who have had no operation is from a year to eighteen months. Many 
 cases succumb in less than a year, and few live longer than two years. 
 
 Diac/nosis. — In the advanced stages of cancer of the tongue the diagnosis 
 is not difficult ; the foul, deeply excavated ulcer with everted ragged edges and 
 widely infiltrated base, Avith large granulations protruding fiom it, the pain, 
 the fixation of the organ, and the induration of the submaxillary glands, stamp 
 the affection unmistakably as carcinoma. At this stage operation is not very 
 hopeful. 
 
 The diseases with which carcinoma of the tongue are most likely to be con- 
 founded are : 1, syphilitic ulceration, primary and tertiary ; 2, tubercular 
 ulcer ; and 3, simple ulcer. 
 
 From Syphilitic TJlceration. — The situation of the ulcer and the history of 
 the case will enable one to form an opinion. Syphilitic ulcers are usually jire- 
 ceded by induration or the existence of a lump at that point. In cancerous 
 ulcers the induration does not precede but follows the ulcer. There may be 
 two or more gummata on the tongue. Cancerous ulcer is always single. Can- 
 cerous ulcer occurs chiefly on the side of the tongue, syphilitic ulcer on the 
 dorsum. In the ulcer of tertiary syphilis the lymphatic glands are rarely 
 enlarged ; in cancerous ulcer which has existed for simie time they are always 
 enlarged. Many cases occur in which the diagnosis can be satisfactorily settled 
 only by the microscope. Every doubtful case should be submitted to a thor- 
 ough trial of antisyphilitic treatment. Even this is sometimes at fault and 
 sometimes dangerous, for cases of rapid spread of the disease have been ob- 
 served as the result of the cutting out of pieces of the growth for purposes 
 of diagnosis. 
 
 From Tubercular Ulcers. — In both the lymphatic glands are involved. 
 The age of the patient and the extensive induration would point to cancer. 
 In cases of tubercular ulceration we can usually get a history of tubercle in 
 the patient's family. Of course tubercle bacilli should always be sought for, 
 and if they are found all question as to the nature of the affection is set at rest. 
 
siuaimv OF the diukstivi: tjiact. ()79 
 
 From Siniiilr Ulcer. — Tf simple ulcer he suspected, a cause, such as a 
 carious tooth, traumatism, <flossitis, etc., should be looked for. Simple ulcers 
 have rarely uiuch induration about the base, but cancerous ulcers are remark- 
 able for the deep infiltration of the surrounding parts. Should the ulcer not 
 heal readily in a man over forty-five, it should be excised. 
 
 PrognoHiif. — Cancer of the tongue, like cancer of other parts, if not ope- 
 rated on, proceeds- invariably to a fatal termination. It is of the utmost 
 importance that tlie disease should be recognized in its early stages, when it 
 is a purely local affection. At this period, if removal of the tongue be under- 
 taken, the chances of the patient's remaining free from the disease are greater, 
 and should the disease recur the interval of freedom is much increased. 
 
 Treatment. — There is but one method of treatment of epithelioma of the 
 tongue, viz. removal by surgical operation. AVith regard to other methods of 
 treatment, by caustics, pastes, etc., they are not only useless, but hurtful. It 
 cannot be too strongly insisted on that the treatment of cancerous ulcers by 
 caustics is bad treatment, and that the only chance the patient has of cure is 
 early removal of the disease by surgical operation. The latest statistics pub- 
 lished by Butlin (1898) give encouraging results: out of ^'o cases in which 
 the tongue was entirely or partially removed, in 18 there was local recur- 
 rence, 28 died from glandular involvement, and 20 (30 per cent.) remained 
 well more than three years after operation. 
 
 OPERATIONS ox THE TONGUE. 
 
 In operations on the tongue, jaws, palate, tonsils, and larynx, the advan- 
 tage of the Trendelenburg position is often very great. In this position the 
 head is lower than the body, and the blood escapes by the nostrils and mouth, 
 instead of into the lungs and stomach. The danger of an aspii'ation-pneumonia 
 from the septic fluids of the mouth entering the lungs is greatly lessened. 
 
 Removal of a Portion of the Tongue. — Should epithelioma of the 
 tongue be confined to the tip or a very small part of the border of the anterior 
 half of the tongue, and should the submaxillary glands not be enlarged — in 
 other words, if the ulcer be early recognized as cancer — the removal of only 
 a portion of the tongue is justifiable, and gives a fair chance to the patient Avith- 
 out submitting him to the much more formidable operation of excision of the 
 whole organ. But the complete removal of the tongue is usually the better 
 operation, unless the ulcer is very small, for the chance of recurrence is much 
 less than when only part of the organ is taken away. Partial removal of the 
 tongue may be performed with galvanic ^craseur, wire ^craseur, knife, or scis- 
 sors. The knife is to be preferred when it is necessary to remove only a small 
 part of the tongue. The method recommended by Mr. Barker is very simple 
 and efficacious. A gag having been introduced, the tongue is draAvn out by 
 means of two ligatures placed one on each side of the median line of the 
 tongue near the tip. The tongue is then split down the middle, and the diseased 
 half is freed from the floor and side of the mouth with scissors. Needles are 
 now passed through the tongue behind the disease, and the loop of the ecra- 
 seur is placed behind them, tightened, and the affected half removed. The 
 loop of the ecraseur should be of wire or whip-cord. The objection to the 
 use of the galvano-cautery is the troublesome slough which follows. 
 
 Removal of the Entire Tongue. — In cases where the cancerous ulcer 
 involves the posterior half of the organ or is at all extensive it is necessary to 
 remove the whole tongue. In removing the tongue one of the chief dangers 
 is hemorrhage, and before proceeding farther it may be well to mention a 
 
680 
 
 A\ AM Kim A y TEXT-llOOK <)1 Sllidl.h') 
 
 very simple and reiidy method of anvstiiit: liciiKMiliage occurring either 
 accidentally during operation or afterward. This method -was introduced by 
 Mr. Heath of London, and has been adopted l)y most surgeons. It is this: 
 '* Tiie forefinger, )»assed well down to the cjiiglottis, is made to book forward 
 the hyoid bone and drag it up as far as ])raoticable toward the symphysis nienti. 
 The eiVect of this is to stretch the lingual arteries so as to completely control 
 for a time the How of blood through them, and in this way portions of the 
 anterior part of the tongue may be cut off almost bloodlessly." 
 
 The points to be kept in view in operations on the tongue for malignant 
 disease are: (1) The removal of all the disease, including all the infected 
 lymphatic glands; (2) the prevention of hemorrhage: (8) the avoidance of 
 the entrance of l)loo(l into the air-j)assages, especially by jdacing the patient 
 in the Trendelenburg position, or occasionally by ])reliminary tracheotomy ; 
 and, after operation, (4) the preservation of an aseptic condition of the mouth 
 and secretions until healing is complete. 
 
 The various operations which have been practised for the removal of the 
 entire tongue are very numerous. The most popular operation with English- 
 speaking surgeons at the present da}^ is that known as Whitehead's, viz. 
 removal of the tongue by scissors ; this may be done with or without pre- 
 liminary ligature of the lingual arteries. A few years ago nearly every surgeon 
 employed the galvanic or wire dcraseur, but the occurrence of secondary 
 hemorrhage when the slough separated was so frequent that the ^craseur has 
 been supplanted by the scissors. 
 
 Whitehead's Operation. — The operation for the removal of the tongue 
 is thus described by Mr. Whitehead : The head being placed in a good 
 light and a gag introduced, the tongue is drawn well forward by a liga- 
 ture through its tip: with a pair of sharp scissors the frfenum is then divided, 
 and, strong traction being made on the tongue, its attachments are gradually 
 freed by a series of short snips carried as far back as possible. The lingual 
 arteries may be secured as they are cut. The stump should be kept under 
 control as regards hemorrhage by a strong silk ligature passed through the 
 remains of the glosso-epiglottidean fold, and retained for twenty-four hours. 
 Mr. Whitehead states that he has never seen any trouble from hemorrhage. 
 
 Kocher's Operation (Fig. 281). — Kocher has performed complete excision 
 of the tongue 104 times, with 20 deaths. These deaths were chiefly in cases 
 complicated with extension of the disease to the floor of the mouth, tonsil, and 
 lower jaw. In QQ uncomplicated cases the mortality was only 3 (4.5 percent.). 
 
 This is the only operation for the removal of 
 the tongue which aims at preserving the 
 parts in a thoroughly asej)tic condition. 
 Tracheotomy is first performed and a well- 
 fitting canula introduced. The pharynx is 
 then packed with a carbolized sponge with 
 a cord attached, so that it can be easily re- 
 moved when necessary. An incision is now 
 made, commencing a little below the tip of 
 the ear and extending down the anterior 
 border of the sterno-mastoid' muscle to about 
 its middle, then forward to the body of the 
 hyoid bone, and along the anterior belly of 
 the digastric muscle to the jaw. The re- 
 sulting flap is turned up on the cheek, and 
 the lingual artery is ligatured as it passes under the hyoglossus muscle. The 
 
 Fig. 281. 
 
 Kocher's Incision for Removal of the 
 Tongue. 
 
SURdERY OR THE DlLiESTlVE TRACT. 081 
 
 fiioial artery and any veins that may be in the way are also secured. Com- 
 mencing from behind, all the structures in the submaxillary fossa are removed, 
 viz. the' lymphatic glands, the submaxillary, and. if necessary, the sublingual 
 glands. The opposite lingual artery is now tied by a separate incision if the 
 •whole tongue is to be removed. The mucous membrane along the jaw and the 
 mylo-hyoid muscle are then divided, and the tongue drawn out through the 
 incision and removed with scissors or galvano-cautery ; the latter is preferred 
 by Kocher, as there is less liability to after-oozing. The after-treatment is 
 m'ost important : if the operation be an extensive one, the external wound 
 should not be closed. Kocher's endeavor is to avoid the two great after- 
 dangers of excision of the tongue, pneumonia and general septicemia. To pre- 
 venf the discharge from causing infection, the whole cavity of the mouth and 
 pharynx is plugged with carbolized sponges and iodoform gauze. The patient 
 is fed partly by the rectum, but chiefly by the throat with a tube, twice a day, 
 when the dressings are changed. Thus, if all the minute directions are 
 enforced, the wound remains aseptic throughout, and no food or discharge from 
 the wound can possibly enter the air-passages. There is one thing that the 
 operator cannot guard against, and that is vomiting : should the patient vomit, 
 as is so often the case after the administration of anesthetics, ^the elaborate 
 preparations against sepsis may come to naught. In Kocher's hands this 
 operation has been most successful. 
 
 Removal of the Tongue after Dividon of the Lower Jaw.— This operation 
 was introduced by S^dillot of Strasburg. and afterward practised by Syme of 
 Edinburgh. It consists in making a vertical incision in the lower lip, sawing 
 throutrhlhe inferior maxilla at the^symphysis. separating the two sides of the 
 jaw, and drawing out the tongue and removing it by scissors, ^craseur, or 
 knife. The divided portions of the jaw are afterward wired together. It is 
 best to drill the holes for the sutures before dividing the jaw. This ope- 
 ration answers well when the floor of the mouth is involved in the disease. 
 
 Results of Operation.— The immediate results following excision of the 
 tongue are fairly good, considering the severity of the operation. Whatever 
 operation is practised, the mortality in a series of cases is about the same, and 
 the method has less influence upon the mortality than the after-treatment, in 
 219 cases collected by the writer from the tables of Agnew, ^unneley, Barker, 
 Whitehead, Langenbeck, and Kocher there were 26 deaths (11.87 per cent.). 
 The chief causes of death are septic pneumonia, pyemia, shock, and exhaus- 
 tion. When the tongue alone is excised the risk is much less : the iatal cases 
 occur most frequently when other parts are involved, as the tonsil, jaw, floor 
 of the mouth, glands, etc., such conditions requiring more severe operations. 
 Operation always relieves, if it does not cure, cancer of the tongue, recur- 
 rence bein<^ the rule. In all cases where the glands are involved these should 
 be removed before amputation of the tongue. Butlm recommends that alter 
 removincT part of or the whole tongue, as the case demands, the surgeon 
 should wait three or four weeks, and then in every case by a separate opera- 
 tion remove the glands in the cervical (carotid glands), submental and sub- 
 maxillary recrions. An incision is made along the anterior border ot the 
 sterno-m'astoid muscle from the mastoid process to below the thyroid carti- 
 lage, and a second incision from the symphysis menti to the flrst incision 
 ab°out the level of the upper border of the thyroid cartilage ; the flap is litted 
 up from below and all the glands in this region thoroughly removed, and the 
 flap replaced and neatly sutured. The duration of life in cases not operated 
 on is about a year; in 'those operated on about nineteen months, a clear gain 
 of seven months. 
 
(i82 AiY AMKRICA.X TEXT-HOOK OF SiUGKliY. 
 
 Bangers of Excision. — ITemorrliage formerly was niucli dreaded in tlicse 
 operations, but "with modern methods of arresting it this fear has vanished. 
 Seconthiry liemorrliage also is much less frequent now that the ecraseur has 
 been almost discarded. 
 
 The greatest danger connected with excision of the tongue is without doubt 
 septic })neumonia or other lung affections, produced by direct infection from 
 the fetid discharges of the decomposing wound. In some cases there is gan- 
 grene of a portion of the lung or a number of small, foul, circumscribed ab- 
 scesses ; in others, a condition of broncho-pneumonia. 
 
 After-treatment. — The most important jjoint in the after-treatment is to 
 preserve a condition of asepsis in the wound, for, as has been shown above, the 
 greatest danger is due to direct septic infection from the wound itself. Again, 
 the swallowing of blood at the time of operation tainted with the foul discharges 
 of the cancerous ulcer should be carefully guarded against by having the mouth 
 thoroughly and frequently Avaslied out with some antiseptic solution, as Condy's 
 fluid, carbolic acid, etc., before o}»eration, and during operation avoiding a con- 
 dition of too profound anesthesia, and by posture as far as possil)le. After 
 operation the wound in the mouth should be packed with sticky iodoform gauze, 
 as recommended by Billroth, painted over with alcoholic solution of iodoform 
 and resin, or at least dusted with iodoform crystals. Whitehead recommends 
 a varnish made of the ordinary constituents of Friar's balsam, substituting a 
 saturated solution of iodoform in ether for the rectified spirit. It is well to 
 feed the patient as freely and early as possible by the mouth : the results of 
 this procedure are as good as, if not better than, when, as was formerly advo- 
 cated, the patient is fed for the first few days by the rectum. For feeding by 
 the mouth a verv srood arrannement is a soft catheter with a piece of rubber 
 tubing attached to it, and to this again is attached a glass funnel : by ])Ouring 
 li(iuid food into the funnel the patient can be easily and comfortably fed. 
 Should any fetor appear in the wound, the mouth should be frequently washed 
 out with a solution of Condy's fluid (potassium permanganate 1 : 500), car- 
 bolic acid, or potassium chlorate. Whitehead says that instead of keeping 
 the patient in bed, he should rather be encouraged to sit up the day after the 
 operation, or even to go out if the weather be fine ; in this way discharges 
 of Idood from the wound are less liable to get into the air-passages. 
 
 DISEASES OF THE JAWS. 
 
 Congenital Deformities. — In the description of the development of the 
 face the various deformities of the jaws have been alluded to. These include 
 cleft palate, arrest of development of one or both sides of the lower jaw, non- 
 union of the two halves of the lower jaw, with median fissure of the lower lip, 
 and non-union of the premaxillaries, with median fissure of the upper lip. With 
 arrest of development of the lower jaw is sometimes associated a congenital 
 dislocation. All these deformities of the jaws, Avith the exception of cleft 
 palate, are extremely rare. 
 
 Acquired Deformities of the jaws are not uncommon. Hypertrophy of 
 the tongue may result in deformity by constant pressure. Chalk ref)orts a case 
 of dislocation produced by it. Sucking the thumb has a very marked influence 
 on the position of the teeth, and if persisted in may cause considerable deform- 
 ity of the jaw. Cicatrices outside the mouth may produce deformities. Burns 
 in childhood may be followed by deformities, such as binding the lower lip to 
 the sternum, and hence ])ulling forward the lower jaw to a considerable extent. 
 
 Abscess of tine Gums and Jaw, or "gum-boil," is a very common 
 affection, and is due to irritation from decayed teeth. Sometimes it is (juite 
 
SURGERY OF Till-: DKJ LSTIVE TRACT. G83 
 
 su})erficial and can be cured by puncture, but at otlier times, Avhcn connected 
 "with the diseased root of a tooth, it is inucli deeper and is accompanied by a 
 considerable swcllin<f of the face and severe pain. In such cases exit may be 
 found for the abscess along the surface of the tooth and temporary relief be 
 afforded, but the affection recurs, and nothing short of careful treatment by a 
 competent dentist, and sometimes removal of the tooth, will benefit the patient. 
 When the abscess breaks externally it may give rise to an external fistula, 
 ■\vhich Avill close ■when the offending tooth is cured l)y the dentist. In certain 
 cases the abscess, when untreated, may lead to necrosis of bone. The treat- 
 ment then is early and free incision of the gum and extraction of the diseased 
 tooth, unless it can be saved by the dentist. 
 
 Necrosis of the jaw may be the result of very different causes. It may 
 follow one of the zymotic diseases, or be produced by injury, ostitis, periostitis, 
 exposure to the fumes of phosphorus, or mercury. A carious tooth may be the 
 commencement of a necrosis of the jaw if not properly treated. The predis- 
 posing causes are struma, syphilis, and lowered conditions of the system from 
 disease or from deficient food. Necrosis occurs nearly as often in the upper 
 as in the lower jaw, and is seen at any age. It is always preceded by intense 
 and deeply-seated pain and inflamed and swollen gums ; the teeth become 
 loose, and soon sinuses form in every direction, giving exit to pus. On passing 
 a probe, dead bone is easily felt. Soon the health of the patient deteriorates 
 and a supporting treatment is necessary. The bone is bathed in pus, becomes 
 loose, and is easily removed through an incision in the gums, followed by deter- 
 gent mouth-washes, as noted above. 
 
 Phosphorus Necrosis frequently exists without the patient's at first 
 being aware of it. It is very rapid and involves a large extent of bone. The 
 symptoms are those of other forms of necrosis. The necrosed bone is usually 
 porous and is of a dirty gray color. 
 
 Treatment. — The dead bone should be quite loose before removal is under- 
 taken, as tearing out a portion not yet fully separated may lead to serious acci- 
 dents, such as wounds of vessels and fracture of the new bone. It is better, 
 if possible, to remove the sequestrum from the inside of the mouth, and Avhere 
 the necrosis involves the upper jaw this can usually be easily done, for, as a 
 rule, the alveolar process only is involved. But in necrosis of the lower jaw 
 the surgeon hiust be guided by the situation and direction of the sinuses, which 
 often point externally. The necrosed bone in such cases may often be more 
 easily removed by an incision along the line of the lower jaw. 
 
 Epulis. — This is a term Avhich is applied to various tumors of the gums. 
 They are really not connected with the gums at all, but Avith the periosteum of 
 the alveolar process and sockets of the teeth. Two forms are usually described, 
 viz. simple or fibrous epulis and malignant or myeloid epulis. 
 
 Simple Epulis is seen as a smooth, rounded growth, red in color, elastic, 
 and appearing much the same as the gum. It soon ulcerates and a sero-puru- 
 lent discharge exudes from its surface ; or it may ossify. 
 
 Malig7iant or Myeloid Epulis is a much more serious affection, and is 
 generally connected with the socket of the tooth. It is very vascular, of a 
 purplish color, grows rapidly, and soon presents a large fungating mass, which 
 protrudes between the teeth and bleeds easily ; it never ossifies. 
 
 Treatment. — Early and free removal is the only treatment for both ; not 
 removal of the growth alone, but extraction of the tooth and removal of the 
 alveolar process with the socket of the tooth. It is better to make two verti- 
 cal cuts with a Hey's or other saw, and then with a strong pair of cutting 
 forceps remove the portion of bone mapped out. In this way only will a 
 
084 ^^V AMKlilCAX TEXr-lloOK OF SilUiKliY. 
 
 succossful result ciisiu'. Without icmhivmI of Iiouc llic ilisease will ncMily 
 alway.'^ roturu, even in siinjilc cases. 
 
 Hyperostosis is a very rarr afVcction. l^cuiarkahle cases have heeli 
 rejiorteil i'roui time to time. The cxcitiiif^ cau.se of this atVeeticni may he a 
 hlow ou the face. The suj)erior maxilhe, as well as the other hones of the 
 hcail. are sometimes the seat of hypertrophy in the condition known as leon- 
 tiasis ossium. ^\ hen this is a local affection, o])erati<)n has been uiuler- 
 takeii for its relief with entire success. 
 
 Dentigerous Cysts are found in both the uj)per and the lower jaw, and 
 usually arise from permanent teeth as a result of some form of irritation. 
 They are frequently mistaken for solid growths. In these cysts, from 
 some unknown cause, the teeth remain undeveloped Avitbin the jaw or may 
 be inverted. The cyst-wall is generally very thick and lined by a vascular 
 membrane. The tooth may or may not project through this membrane. 
 
 Dia<i)iosis. — When a slow-growing, painless, solid tumor of the jaw is seen 
 in a young person, the surgeon should always examine the teeth. He will prob- 
 ably find a tooth absent or a temporary tooth where a permanent one ought 
 to be. Jaws have ])ecn removed for this affection under the supposition that 
 the tumor was malignant. It is better, therefore, in a young person, even if the 
 disease is not looked upon as a dentigerous cyst, to cut into the tumor before 
 mutilating the patient by the removal of the whole or a portion of the jaw. 
 
 Cysts of the Lower Jaw. — A limited portion of the lower jaw may be 
 expanded gradually by a single cystic growth. Such a cyst grows slowly, its 
 wall becomes thinner and thinner, and the tumor distinctly fluctuates. The 
 bone becomes so thin that it crackles on pressure. It is said that these cysts 
 originate in connection with the teeth. Sometimes a small cyst is connected 
 with the root of a tooth, and Powers considers that they are of inflammatory 
 origin. 
 
 Multilocuiar Cysts. — These cysts are nothing but a late stage of solid 
 tumors, this condition being due to cystic degeneration of sarcomata and epi- 
 theliomata. There is often a development of bone in the interior of the cyst. 
 They sometimes grow' to large size and are of years' growth. Frequently they 
 are painless. Excision of the jaw is the only legitimate method of treatment. 
 
 TUMORS OF THE JAWS. 
 
 Tumors of the jaws may be divided into non-malignant and malignant. 
 
 The noi} -malign nnt are — (1) Fibroma : (2) Enchondroma ; (3) Osteoma. 
 
 Fibroma. — Fibrous tumors of the jaws are not uncommon, and resemble 
 other fibrous tumors as regards their clinical history and appearance. They 
 grow from the periosteum, especially of an alveolus, and resemble epulis: 
 or they may grow from the endosteum and expand the jaw by their growth. 
 Such tumors usually make their waj into the antrum or nasal fossie. They 
 may occur in early life. Their growth is slow, but they persistently increase. 
 They seldom attain very large size nowadays, because being in an exposed 
 part of the body they are usually removed early. They are ])ainless and non- 
 maligiumt when compared with cancer. 
 
 Treatment. — Removal of the tumor and of the entire portion of the jaw 
 which gives attachment to it is the only form of treatment of any avail. 
 These tumors not infrequently return after an apparently complete removal. 
 
 Enchondroma is a rather rare form of tumor of the jaw. It is some- 
 times of immense size, and in certain ca.ses has killed the patient by suffocation. 
 Enchondroma usually appears in early life as a tumor of the antrum or body 
 
sriwiJKy OF Tin: J>iui:sTiyE tuavt. o«5 
 
 f tl lou-.r i-tw is verv hanl, sonunvhat ncxlular, and -rows more rapi.Uy 
 l::'fil!:::;:L^ O^c^s^^^ly .t l.^... ^n^...^^.^^ a., very apt to recur 
 localW wlien removed. ,.„ consist simply 
 
 :,'„,:'rothet a';:..;: l.-o'lf r^e Un>e,i.oa ......... TI. ^iy treatment .s 
 
 • ^ ' if k unfortuuatelv, by no means uncommon, and may occur in the 
 ^'-h tVlllrl -U iZi" aJt'tbu"; llingnishable from 
 
 mXLnr— fc:'tn afte/vomoval bcng L rule. Unless remove,. ,n 
 *^ iT'T?e:Sst™sTs:rco^ata, such as cystic myeloid fibrous, and 
 spiidlcelleraT^Ik the jaw, and should be t-t^l 7 -Ij -„ ,a 
 (]pe.-ation is rarely permanently «''«=<'^^f''''^^P'1r;f "^ ™X grow from the 
 even when the whole lower jaw is '■'r™°'«>„,, J''7^,"^^^^'Lvy be mistaken 
 periosteum. In the early stages a rapnlly-giowmg sarcoma may 
 
 for an abscess. 
 
 DISEASES OF THE TEMPORO-MAXILLARY ARTICULATION. 
 
 Tubercular disease of this joint is very --ly -™ ' ^^^^h^tides'TTs 
 affection is Rheumatic Arthritis wh.ch may fff<= ' 7^^,.°f,X^a ttlage and 
 a painful affection, and produces absorption of he mto^^ g 
 
 ±TZl::!^:::^^^]^^^ S:t»o oL s.de . on^ly one 
 XtdaHon is involved. It does not lea^'o osseous ankylos,^^^ 
 
 ...Thi: pr,?sibrL^^e;!r^ -^-^i^z^ ^rz 
 t^t:t^:z :i ^:j:^z.'^lI^^-^^ p«s forms 
 
 it should be evax^natecl early phenomenon met with in certain 
 
 Noisy Mastication.— ihis is a peculiar I mastication are 
 
 individuals, m whom some ^^vemeiits of the ^^l^^nl^ .^ instances is 
 accompanied by a snapping or cracking ^p/' ^^^^^.y^'^ i^ ,,hom this is 
 so loud as to be heard even -^^^^ ^/.^f [j^StVing becom so accustomed 
 noted are usually quite unconscious «.f ^^^^^J^^^ ^j^^^^i,^^ nse to it is one 
 
 to it as not to notice it themse ves. ihe ^^^^^^^^^J^^^^^^^ joint, and 
 
 ^? rratbtgLnignE^ r ::^v 'h,- 
 
 account of its etiology it .s almost ■•»P°^^'''ly'> <";'^^- ,„ylVlv and'to get 
 rlrtt Sit'of Tee in! T ru^^'^^ofTeVawt ^ kSd of tension wh?ch 
 ;:;in ;t:vent ke poslbil,ty of too sudden contact of articular surfaces. 
 
(;s<) A.\ AMKliHAS TKX'l'-HOOK OF sriHilJiV. 
 
 • 
 
 Ankylosis of the Jaw is usually confiiK'<l to one side, but may affect 
 both, ami may be bony or fibrous. It is not in{V('(|ucntly tlif result of siij)))U- 
 ration. Its reco«^niti(>n is easy. 
 
 Operations for the relief of this affection have been devised by Jlumijhry of 
 Cambridge, Esmarch, Kizzoli, and others. These operations all consist in simple 
 division of the neck of the jaw or in division Avith removal of a portion of bone. 
 Esmarch advises the formation of an artificial joint by the removal of a wedge- 
 shaped piece of bone through an incision in front of the massetcr, and Hi/.zoli 
 advocates cutting through tlie jaw with forceps introduced through the mouth. 
 Some of these cases after operation do well and have free movement of the 
 jaws for a time, but many relapse and movement becomes again limited. 
 
 Closure of the Jaws. — This may be merely temporary^ due to some 
 hysterical condition or to some reflex irritation of the muscles of mastication. 
 The exciting cause may be the cutting of a wisdom tooth or the failure to cut 
 one. This may be due to malposition or want of room. In such cases the patient 
 should be put under ether, the jaw thoroughly examined, and an incision made 
 over the affected tooth, or the next tooth extracted. Sometimes it may be neces- 
 sary to extract the wisdom tooth or to chisel away the surface of bone over it. 
 
 Permanent Closure of the Jaivs may be due to ankylosis, which has been 
 described above, or more commonly to cicatricial contraction from ulceration and 
 sloughing the result of gangrenous stomatitis in earl}^ childhood. The slough 
 not infrequently involves the whole thickness of tlie cheek, and hence the 
 resulting cicatrix is very extensive and unyielding, and the cheeks are blended 
 with the gums so that movement of the jaw is impossible. Division of the 
 cicatricial bands has been followed by no good results, and plastic operations 
 that have been devised have proved almost useless. The best treatment is 
 division of the jaw as for ankylosis and the forming of a false joint in front 
 of the cicatrix. Heath speaks highly of Esmarchs operation for the relief 
 of this condition. 
 
 DISEASES OF THE TEETH. 
 
 Dental Caries. — This is a very common affection, few persons reaching 
 adult life without having suffered from it. It is a decay on the surface of the 
 tooth which causes the tissues slowly to soften and disintegrate until the pulp- 
 cavity is reached. It may commence in the enamel or in the dentine beneath 
 the enamel. When the enamel is attacked, it becomes opaque and soon is dis- 
 colored ; when the dentine is reached, the progress is more rapid. The dis- 
 eased portion may be nearly black, but it is usually of a dark brown. The 
 deeper the stain the slower the decay. Carious dentine has a smell ])eculiar 
 to itself. The much-disputed question of the active cause of dental caries has 
 been finally settled by Miller, an American dentist, now in Berlin, who has 
 conclusively shown that dental caries is due to the bacteria in the mouth, of 
 which there are a large number. 
 
 The predisposivr/ causes of caries are (1) some defect in the enamel, so that 
 the dentine is exposed to the action of decomposing food and the bacteria in the 
 mouth ; (2) injury due to the too great crowding of teeth, the pressure causing 
 absorption of the enamel and thus exposing the dentine ; (8) the accumulation 
 of decaying substances between the teeth. In certain diseases, such as fevers, 
 etc., decay is more liable to occur. Pregnancy and the various forms of ill 
 health, by deranging digestion, are frequent predisposing causes. Imperfect 
 calcification of the teeth and hereditary conditions may also predispose to 
 caries. 
 
 The Exciting Causes of Caries. — (1) The acids which are the products of 
 
sunaKRY OF Till-: 1)Ii;kstive tuact. 687 
 
 fermontation and clieinical decomposition of food and other mattors in the 
 mouth, also acid niiicus secreted by the gums ; (2) when the dentine is 
 exposed, certain organisms, such as the Leptothrix bucvalis, appear and per- 
 vade the dentine and grow at its expense. When the pulp-cavity is reached, 
 severe pain is experienced. Owing to the pulp l)eing confinod within 
 bony walls, it cannot expand under the iniluence of iiitiamiiiation ; hence 
 great pressure is the result, and conse(i[uently intense pain. The pul}) recedes, 
 the inner surface of the cavity is attacked, and the disease proceeds from 
 within outward. Certain teeth are more liable to decay than others. This 
 is particularly true of the "sixth-year molar," or the first of the permanent 
 teeth to appear. Surgeons ftxMjuently overlook this tooth. The same tendency 
 to decay exists in the " wisdom " teeth. The surgical importance of dental 
 caries lies in the fact that the lymphatic glands beneath the lower jaw are so 
 frequently infected by tubercle and other germs that gain access through 
 diseased teeth. 
 
 Treatment. — The treatment of caries comes more within the province of 
 the dentist than within that of the surgeon, and consists in the removal of 
 the decayed tissue, so that a healthy surface is left, and then filling the cavity 
 with gold-leaf, amalgam, or other suitable material. The preventive treatment 
 consists in preserving. perfect cleanliness by toothbrush and antiseptic pow- 
 ders and maintaining a good condition of health. 
 
 Dental Periostitis. — The periosteum lining the sockets of the teeth is 
 liable to become inflamed, a diseased tooth being very frequently the cause. 
 The affection may be acute or chronic. When it goes on to suppuration an 
 alveolar abscess, or gum-boil, is the result. The tooth is very tender, espe- 
 cially on pressure, and feels as if it were too long ; it afterward becomes 
 loose and protrudes from the socket. This affection must not in its first 
 stages be confounded with inflammation of the pulp. In this latter, although 
 the pain is intense, still the tooth is not tender and does not feel as if it were 
 too large for the socket. The results following a neglected alveolar abscess 
 have been described above under Abscess of the Jaw. 
 
 Treatment. — Removal of the cause is the proper treatment, viz. extraction 
 of the diseased tooth. If left, the inflammation recurs, and in the end the 
 tooth has to be sacrificed. 
 
 SypFiiiitic Teeth. — The peculiar teeth which occur in children with inher- 
 ited syphilis, first described by Mr. Hutchinson, have already been mentioned 
 in the chapter on Syphilis. 
 
 Extraction of Teeth. — The extraction of the temijorary teeth is a sim- 
 ple matter, as in the natural course of events the roots are absorbed and the 
 crown of the tooth is shed from the gum. 
 
 The permanent teeth, however, frequently give some trouble, and unless 
 the operator uses judgment and care in the extraction serious damage may 
 be done. The surgeon must remember that skill is more requisite in the 
 extraction of a tooth than strength. The best instrument for extraction is 
 the forceps, of which there are many difterent kinds, but for all practical 
 purposes two or three pairs are all that the surgeon will require, for the upper 
 jaw a bayonet-shaped forceps with straight handles, and for the lower the 
 Universal lower molar forceps. The first two molars of the upper jaw and 
 the canines are the most difficult to extract, the easiest being the incisors and 
 bicuspids. In extracting a tooth with a single root it may be first loosened 
 by rotating it before pulling, but this procedure is useless in the bicuspids and 
 molars ; here the fjings are flat and cannot be rotated, but by a swaying move- 
 ment, first outward, then inward, for the upper teeth, and inward and then 
 
outward for the lower molars, the tooth is loosened and conies away easily. The 
 tooth should be seized as near to the root as j)ossible. Care is to he taken 
 not to break oft" any jiortion of the alveolar process, for, thouL'h serious results 
 rarely follow, yet sometimes necrosis occurs. For the removal of stumjis of 
 teeth special force])s are re(iuir('d. 
 
 Irregularities of the Teetin are comparatively common, and exist usually 
 in the ])ennanent set alone. Thumb-sucking is a frecjuent source of irregu- 
 larity, causing all the front teeth to protrude ; crowding of the teeth also is 
 often seen, and is relieved by extraction of one or more t«eth, thus giv- 
 ing room for the others to develop. Too early extraction of the temporary 
 canines of the upper jaw may cause the premolars to encroach on the territory 
 of the permanent canines, and thus produce deformity. Teeth which when 
 first erupted apjjear very irregular, as development proceeds often get into 
 line, and are finally quite regular in appearance. Su])ernumerary teeth not 
 infre(iuently aj»i)ear. The treatment of irregularities is purely mechanical, 
 and is fully described in works on dentistry, and surgeons would do well to 
 refer such cases to dentists for treatment. 
 
 Toothache. — Usually this is a symptom of dental caries, the ulceration 
 having exposed the pulp. It may also be due to intlammation of the peri- 
 osteum covering the root, ossification of the pulp, or exostosis of the root. 
 Healthy teeth may be aff'ected with severe pain from a neighboring diseased 
 tooth, in the same way as in some cases of hip-joint disease the pain is in the 
 knee. In doubtful cases it is always advisable to examine the teeth very care- 
 fully in order to see w^hich one is the source of trouble, and so to prevent 
 extraction of the wrong tooth. Occasionally the toothache may be due to 
 ■neuralgia. In cases of exposed pulp pain may be relieved by the oil of cloves, 
 creasote, carbolic acid, chloroform, aconite, and other remedies, applied on 
 absorbent cotton wool. Painting the gums with equal parts of tincture of 
 aconite and tincture of iodine sometimes affords relief. Extraction should 
 never be undertaken except as a last resort. 
 
 Hemorrhage after Extraction of a Tooth. — ]>leeding occurs in all 
 cases, but it is generally slight, and even if the oozing goes on for some time 
 there is usually but little danger. In cases of hemophilia or purpura hannor- 
 rhagica the extraction of a tooth is a serious matter and may be fatal. Slight 
 hemorrhage may be arrested by cold. In severe cases the cavity should be 
 cleansed of the blood-clots and carefully and tightly packed with cotton or strips 
 of lint with tannin rubbed into the meshes, and over this a plug of lint, and 
 pressure made by closing the jaws on the plug and fixing them with a four- 
 tailed bandage. It is only in the most severe cases that the plug has to be 
 soaked in perchloride of iron or the cavity touched with the actual cautery. 
 
 Odontomes, or Tooth Tumors. — Broca first described these tumors in 
 1807. They consist of very greatly hypertrophied dental tissue. Malformed 
 teeth and teeth with warty excrescences are sometimes included in this 
 group. A true odontome is usually encysted, has no attachment to the sur- 
 rounding structures, and rarely gives rise to much irritation. One variety 
 occurs in the lower jaw and contains the formative elements of one or two 
 molars. It grows irregularly and bears no resemblance to a tooth in shape. 
 This tumor, which grows slowly and expands the bone, may be mistaken for a 
 true tumor of the lower jaw, and portions of the jaw may be unnecessarily 
 removed. It is important, therefore, especially in all cases of tumors of the 
 lower jaw, that the surgeon before sacrificing a part of the jaw should bear 
 in mind the possibility that the tumor may be an odontome. ^Vhere tooth 
 tumors are attended by inflammation it is possible to mistake the case for one 
 
SVRGKny OF THE DIUKSTIVE TJiALT. 
 
 689 
 
 of necrosis. Son., oaonton.c-s aftct all the tissues <^ the teeth ; ^^he s aflect the 
 .n3 Or the dentine only. S..n.etin.es there is a fistulous conimunieation ^Mth 
 
 he exte naf^^^^ e^^ the cheek. The treatn.ent is suflRciently snnple. If 
 e 'n Xs . n and is mc^rely unsightly, it may be removed, but m cases 
 
 n .1 con of a large mass of'^dental tissue in.bedded in the Ja.^• an 
 
 nclo sh,.ul be made ovJr the growth, and then with a bone elevator or 
 forceps the tumor can be easily enucleated without serious damage to the 
 
 jaw. 
 
 AFFECTIONS OF THE PHARYNX, TONSILS, ANI> PALATE. 
 
 CoN.iENiTAL Malformations of the Pharynx -These are not common 
 Fistul"^ occur in rare cases and communicate with the pharynx, trachea, or 
 ^^,a a^us. They are due to persistence of the branchial clefts Pharyngeal 
 fistillle usually occur as minute orifices on one or both sides of the neck be ow 
 the cdottis, their direction being upward to the pharynx and oesophagus. 1 he> 
 occm- in the line of the old bSnchial clefts, the lowest being near the sterna 
 end of he clavicle, the next opposite the thyroid cartilage and the highest 
 betNveen the thyroid cartilage and the hyoid bone Paget) ^^ hen two in num- 
 ber they are Jften symmetrical. They vary in length from half an mch to 
 one and a half inches, and barely admit a probe, though the diameter of the 
 fistula is always greatei' than that of the external opening. The internal open- 
 in^ of the fis ula is found in the lateral wall of the pharynx, behind the cornu 
 of'th hyoid lone, or in the pharyngo-palatine side The fistula are lined by 
 a smooth membrane, which secretes a mucous fluid. They may be cured by 
 cauterization with the actual cautery. -^ i • r 
 
 Diverticula from the pharynx and oesophagus which are congenital indi- 
 cate also incomplete closure o"f the branchial clefts and occur in the same 
 re-ions as the fistuU^ ; occasionally they are not congenital, but acquired. 
 In" several instances they have been successfully excised and the margins 
 united by Lembert sutures. , . ■ n .• „ ^f 
 
 Tonsillitis (Quinsy, Cynanche tonsillans).— Acute inflammation ot 
 the tonsils sets in very suddenly with such symptoms as severe rigor, high 
 fever, headache, and general malaise. The tonsils soon become swollen, red 
 and painful, rendering swallowing difficult. The glands beneath and behind 
 the an.rle of the jaw enlarge and become very tender on pressure. One tonsi 
 is usually affected first, and in a day or two there is a fresh onset of fever and 
 the opposite one becomes similarly inflamed. When both tonsils are simulta- 
 neously attacked it is generally an indication of septic infection The patient 
 has -reat pain during swallowing, not only in the throat, but in the ear and the 
 side'of the neck. Articulation is difficult, and both hearin- and the sense of 
 taste are impaired. The temperature may go as high as 104 -lOo 1. Ihe 
 inflammation most frequently terminates in resolution m the course ot a tew 
 days, but occasionally it goes on to suppuration, ^\hen suppuration occurs 
 the swellincr in the tonsil increases rapidly and extends toward the sott palate, 
 the toncrue^becomes swollen and foul, the breath fetid, and swallowing very 
 difficult." The patient sits up in great pain and feels a sensation of suffocation. 
 In some cases pus forms rapidly, in others slowly. Some hold that the sup- 
 puration is always peritonsillar, and that incisions are useful only when made 
 in front of or behind the tonsil, where the pillars of the fauces are m con- 
 nection with it, and where pus is formed in the connective tissue around the 
 
 *'''' The causes of tonsillitis are many. A strumous diathesis predisposes to 
 
 44 
 
690 AX ami: HI (AX text- hook or surgery. 
 
 it, and also an arthritic diathesis, as well as exposure to cold, impure air, sewer 
 gas, worry, sexual excitement, etc. One attack predisposes to subseijuent ones. 
 The tendency to tonsillitis has been considereil hereditary by some. The sever- 
 ity of the fever, which may reach 10.5° F., and tlie great prostration often leave 
 the patient very weak for some time, especially if the inHammation has gone 
 on to suppuration. Some hold that all the severe forms of tonsillar inflam- 
 mation are due solely to septic infection. This view has not yet b^en fullv 
 accepted by the profession. 
 
 Treatment. — For ordinary tonsillitis, after administering a brisk purge, 
 nothing is better than a mixture of tincture of muriate of iron with chlorate 
 of potassium and glycerin, taken every hour or two, with occasional applica- 
 tions of a paint made of sodium bicarbonate, applied with a brush, or of silver 
 nitrate gr. Ix (a f.^j. Guaiacuni, salicylic acid, aconite, and many other rem- 
 edies have been recommended from time to time. Ten grains of Dover's pow- 
 der administered at bedtime give great relief. Should suppuration ensue, earlv 
 incision is the only treatment: scarification may relieve, but will do so only 
 temporarily. The abscess should be opened with a sharp-pointed bistoury 
 or tenotomy knife. Incision should be from within out and a little in front 
 of the tonsils. If a sharp-pointed bistoury is used, its edge should be guarded 
 by wrapping plaster round it to within an inch of the point ; in this way the 
 surgeon runs no risk of wounding tlie mouth. 
 
 Hypertrophy of the Tonsils. — Chronic enlargement of the tonsils is a 
 common aftection in strumous children. It is caused l)y a chronic catarrhal 
 inflammation or may be a simple hypertrophy without any inflammation. 
 Repeated attacks of acute tonsillitis not infrequently lead to^ this condition. 
 Boys and girls before the age of puberty are most frequently aff'ected, but as 
 the patient gets older the disposition to tonsillar inflammation decreases. The 
 enlarged tonsils appear in some cases almost entirely to fill the throat, the 
 uvula occupying the space between them. Xasal respiration is interfered with, 
 the child sleeps with its mouth open and its rest is broken. It is important 
 for the surgeon to understand that enlarged tonsils are very frequently the 
 cause of impaired general health, as nearly all the functions are' interfered Vith. 
 The condition is apt to be hereditary. 
 
 Treatment. — There is only one method of treating hypertrophy of the 
 tonsils eff'ectually, and that is by excision. It is best performed with some 
 form of tonsillotome or guillotine, after carefully separating all adhesions to 
 the arches of the palate, as wounds of these structures often cause severe 
 hemorrhage. No forceps are needed. The head should be held by an 
 assistant, who with his fingers presses in the tonsils : as much of the gland 
 should be removed as can be pressed into the tonsillotome. The enlarge- 
 ment of the tonsil being usually downward, the tonsillotome .should be 
 hooked over the projecting tonsil from below up. The tonsil may also be 
 removed with a probe-pointed bistoury, the tonsil at the same time being 
 pulled out with a tenaculum, but the u.se of the guillotine is advised in 
 preference to that of the knife, as being more expeditious, safe, and easy, 
 when the tonsil projects well toward the median line. Jarvis' snare (Fig. 
 2.53) is also an excellent instrument. Bleeding after tonsillotomy is some- 
 times severe, and from time to time fatal cases have been reported, chiefly in 
 patients suff'ering from hemophilia. Hemorrhage is generally easily controlled 
 ty pressure from within and from without. If everything' else fails, tie the 
 external carotid. The bleeding usually comes from a'«livided tonsillar branch 
 of the facial. 
 
 Caseous and Calcareous Concretions may be developed in the 
 
sunarjiY of the dtgestive tract. G91 
 
 crypts of the tonsils. Tliey are sometimes of large size, and give rise to 
 a considerable amount of inflammation, fetid breath, and general discomfort. 
 Gruening states that all tonsillar concretions are of parasitic origin and com- 
 posed of I('i>totIin/.r elements. The treatment consists in removal of the con- 
 cretion, and, if tJie tonsil is enlarged, removal of a portion of it. 
 
 Malignant Tumors. — Both mrroma and carciiKima occur in the tonsil. 
 The form of sarcoma is lympho-sarcoma, and that of carcinoma is epithelioma. 
 Sarcoma is more frequent than carcinoma. Both affections are equally malig- 
 nant. Sarcoma forms a distinct prominent tumor projecting into the fauces, 
 which finally ulcerates, and if untreated usually proves fatal by hemorrhage. 
 Sarcoma has been observed in persons under twenty. Epithelioma of the 
 tonsil is rarely primary. The tonsil may be secondarily involved by the 
 extension of the disease from the tongue and pillars of the fauces. Epithe- 
 lioma of the tonsil rapidly ulcerates and very early infiltrates the cervical 
 glands. It is more common in men than in women. 
 
 Treatment. — Epithelioma of the tonsils, if seen early, may be removed, 
 but in advanced cases, Avith infection of the glands, removal does not give 
 satisfactory results and is attended by not a little danger. Sarcoma of the 
 tonsil, owing to the fact that it occurs as a prominent tumor and does not so 
 early infiltrate or ulcerate, is more frequently attacked by the surgeon than 
 epithelioma. The removal may be effected through the mouth, or from the 
 outside by an incision in the neck, as recommended by Cheever of Boston. 
 
 Removal through the Mouth. — This is sometimes performed by means of 
 the ^craseur, galvano-cautery, or thermo-cautery. There is usually very little 
 hemorrhage. Sarcomatous tumors in their early stages are usually encapsu- 
 lated, and may be cut down upon within the mouth and easily enucleated 
 (Butlin). Unfortunately, they are very apt to recur. 
 
 Removal hy Incision through the Neck. — This operation is more suitable 
 for retro-pharyngeal than for tonsillar tumors. It consists in making an incision 
 about three or four inches in length along the anterior border of the sterno- 
 mastoid muscle from the ear to below the level of the tumor. A second 
 incision, joining this, runs along the lower portion of the inferior maxilla, and a 
 careful dissection is made down to the tumor, which is then removed (Cheever). 
 
 Czerny and Mikulicz have each devised a very radical operation for the 
 removal of growths of the tonsils. Both these operations require a preliminary 
 tracheotomy, and also division of the lower jaw in the region of the molar 
 teeth. The external incision in Czerny's operation reaches from the angle of 
 the mouth to the anterior border of the masseter muscle, and thence down- 
 ward to the level of the hyoid bone, and in Mikulicz's operation it reaches 
 from the mastoid process to the cornu of the hyoid bone. 
 
 Retro-pharyngeal Abscess. — This affection occurs chiefly in the young, 
 and may be due to various causes. It is usually met with in strumous children, 
 and may be an evidence of caries of the cervical vertebrse. In some cases it 
 folloAvs scarlatina. It may be glandular in its origin or due to extension of 
 inflammation from other parts, or it may be idiopathic. The abscess is situated 
 in the cellular tissue between the bag of the pharynx and the cervical vertebrae, 
 and projects forward in the throat, causing difficulty in swallowing. In cases 
 which have lasted some time the pus may extend laterally and cause a bulging 
 of the neck, usually behind the sterno-mastoid muscle, or it may travel toward 
 the posterior mediastinum. On examining the throat the diagnosis is easy : a 
 tumor is seen projecting into the pharynx, which on palpation is distinctly 
 fluctuating and does not disappear on pressure. The situation of the abscess 
 is in most cases to one side of the median line. 
 
692 ^l.V AMKKIVAy TEXT-BOOK OF SURdKRY. 
 
 TrentuH'nt. — As soon as dia^^'iiosticiited, the pus should lie evacuated by 
 incision cither in the mouth or through tlie neck. It may he tapped through the 
 mouth by a large trocar and canula, and after the first evacuation of the pus, 
 and when all danger of suffocating the patient by too free an escape of pus is 
 past, the abscess should be freely laid open with the knife. AVhilst evacuat- 
 ing the abscess the child's head should be held forward. The opening through 
 the neck was first recommended by the late Mr. Hilton. The incision may 
 be made eitiier behind or in front of the sterno-mastoid through the deep 
 fascia. The abscess is reached by a careful dissection, especially in the 
 neighborhood of the great vessels. The cavity is then thoroughly curetted 
 and either drained or closed. In cases in which the abscess is due to disease 
 of the cervical vertebrae large portions of bone have been discharged into the 
 pi larynx. 
 
 Tumors of the Pharynx. — These are of rare occurrence. Papillomata 
 of small size are occasionally seen. Fatty and fibrous tumors have also been 
 met with. Fatty tumors have been seen of large size, and are pedunculated, 
 some being reported as hanging over the oesophagus. Fibrous tumors originate 
 more often in the vault of the pharynx, and perhaps should be described as 
 naso-pharyngeal tumors. When of large size they may hang down into the 
 pharynx. Pulsating tumors of the pharynx may be due to aneurysm of the 
 internal carotid. 
 
 Carcinoma of the pharynx is of rare occurrence. 
 
 Retro-pharyngeal Tumors occur in connection Avith the lateral (jr the 
 posterior wall of the pliarynx. If left to themselves, these tumors will ulcerate 
 and necrose, and probably the patient will ultimately die of exhaustion from 
 repeated hemorrhages. They may in some cases be removed by incision 
 through the mouth, but of radical operations that by external incision, with 
 or without division of the loAver jaw. as described above in the paragraph on 
 Tumors of the Tonsils, is the best. 
 
 Congenital Deformities of the Palate may involve the uvula and the 
 soft and hard palate. The mildest form is where the uvula is bifid. Again, the 
 cleft may extend through the soft palate ; or the soft palate and a portion of 
 the hard palate may be fissured : or the separation may involve the Avhole of 
 the soft and hard palate and extend forward between the intermaxillary bones 
 and the superior maxilla. When this occurs the deformity is always accom- 
 panied by single or double hare-lip. In rare cases a circular or oblong open- 
 ing is seen in the center of the palate, the rest being closed. In the descrip- 
 tion of the development of the face and mouth it was shown that these deform- 
 ities are produced by an arrest of development of the parts and persistence of 
 an early foetal condition. 
 
 Cleft Palate. — AVhen the severe forms of this malformation occur they 
 give rise to great trouble : fluids pass freely into the nose, and unless the child 
 is carefully fed by hand (preferably with the mother's milk) it will soon die, as it 
 is quite unable to suck. In the less severe forms the child soon learns to swal- 
 low prof)erly, but as he learns to speak his articulati(»n is faulty and his voice 
 very nasal. For this reason early operation is advisable, not so early as for 
 hare-lip, but certainly before the child has learned to speak well, say between 
 the ages of three and four, when faulty articulation may be overcome by suc- 
 cessful closure of the cleft. When undertaken late, even if the operation be 
 successful, the patient will not be able to overcome the bad habits of articula- 
 tion acquired in his childhood. 
 
 Operation. — The operation is performed under an anesthetic, with the 
 mouth held open by a gag. The patient should be placed in the Trendelen- 
 
SUliaEIlV OF TllK DliSKSTIVE TRACT. 
 
 693 
 
 buro; posture to fiieilitate the escape of blood. The best age for the operation 
 is from two to five years; 
 
 biter, as a rule, in closure of Fig. 282. 
 
 the hard palate than in clos- 
 ure of the soft. 
 
 Staphylorrhaphy, or 
 the operation lor the closure 
 of a cleft in the soft palate, 
 has been practised for nuiny 
 years. To J. Mason Warren 
 belongs the credit of improv- 
 ing the operation by intro- 
 ducing a procedure Avhich 
 lessened the tension on the 
 flaps and so promoted union. 
 This was the division of the 
 levator and tensor palati mus- 
 cles of each side. Billroth 
 has recently introduced a new 
 
 procedure, which is to chisel away the lower part of the pterygoid process, so 
 as to relieve the tension produced by the tensor palati and palato-pharyngeus. 
 
 Operation. — The patient having been anesthetized and a gag introduced, 
 the end of one half of the cleft palate is seized with a pair of tenaculum for- 
 ceps and the edge freely pared with a thin-bladed knife (Fig. 283). The 
 same is done on the other side, especial care.being taken to freshen the upper 
 angle of the cleft. The parts are now ready for the stitches. These should be 
 of wire, horse-hair, or silkworm gut, preferably the last. All these materials 
 may remain some days Avithout causing trouble, as may also catgut and silk. 
 Various methods have been devised for passing sutures, such as a needle with the 
 
 Whitehead's Gag (Koenig). 
 
 Fig. 283. 
 
 Fm. 284. 
 
 The edges of the cleft are being pared with a 
 finibe-pointed t)istoury after passing the su 
 tures. It is t)etter to pare the edges before 
 paring the sutures (Bernard and Huette) 
 
 Method of Rink: The sutures dd and cc in place, the 
 third, b. being inserted from behind forward by a 
 curved needle and needle-holder, a: the lips are held 
 tense with the forceps (Bernard and Huettej. 
 
 eye at the point (Fig. 284), or a tubular needle. Special needles for right and 
 left side, in handles, are often useful. Should none of these appliances be at 
 hand, an ordinary sharp-pointed aneurysm needle or a half-circle Hagedorn needle 
 and a needle-holder will be sufficient. On one side the suture should be double 
 
«{>4 
 
 J.V AMKliU'AN TEXT-iiOOK OF SURGERY 
 
 and the other sinjL'lc : throujili the h»(»j) of the (hdihh- suture tlie single one is 
 iiassetl, the h)Oj» of the douliK' li^jjature withdraw ii, and tiie stit(di is /// aitu. 
 Tiiis procedure is necessary only when tlie needle cannot he pushed throu;.di 
 both sides at once. After tlie stitches have been tied (not too ti«:litly) and 
 the wound closed (Fig. 285), the palatal muscles may he divided by pushing 
 a tenotomy knife through the soft palate, immediately internal to the hamular 
 process, and cutting u))ward until the muscles are cut through (Fig. 280), 
 Clutton advises that the pillars of the fauces should be divided on both 
 sides, as low down as possible after the cleft has been closed. The chisel- 
 ling away of the lower end of the hamular process may serve a similar |)ur- 
 
 FiG. 285. 
 
 Y\(\. 286. 
 
 Tightening of the Ligatures by a Serre-Noeud, 
 a (Bernard and Huette). 
 
 The sutures being fastencil. the lateral incisions o b are 
 made to relieve teiisidii Ijv division ol' the tensor pahiti 
 muscles (Bernard and lluette). 
 
 pose. Should there be very little tension this procedure may be omitted. The 
 hemorrhage, which at first is quite brisk, soon ceases when pressure is well ap- 
 plied. The wound should be thoroughly irrigated Avith boric or salicylic acid 
 solution, and then painted over with an iodoform paint, as described in opera- 
 tions about the tongue and mouth. The patient should be fed on licjuid food 
 for three or four days, and afterward on soft food until the sutures are removed; 
 the less the mouth is opened the better. The stitches should be removed 
 about the sixth or eighth day, and the wound by that time should be com- 
 pletely healed ; frequently, however, a small point remains unhealed, and has 
 afterward to be closed by touching it with the thermo-cautery or a stick of sil- 
 ver nitrate. Care should be taken to see that the child before operation is in 
 good health and has not been exposed to any infectious disease. 
 
 Uranoplasty. — The ojieration for closure of cleft of the hard ])alate is 
 one of difficulty, and in cases where the cleft is very wide it is (|uestionable 
 whether it is not better for the surgeon to transfer the case to a dentist, so that 
 the aperture may be closed by some form of obturator. 
 
 Operation. — The most satisfactory mode of operating will l)e found to be as 
 follows : The edges of the cleft are first pared with a narrow-bladed knife ; then 
 all the soft tissues are raised from the hard palate by means of a })eriosteal ele- 
 vator, avoiding the tearing of the vessels which run thiough the anterior and 
 posterior palatine canals. The soft palate posteriorly should be freely separated 
 from the horizontal plate of the palate-bone by a cutting instrument, as tearing 
 freijuently causes sloughing of the parts. The sutures should now be introduced 
 in the same way as in staphylorrhaphy, and be of silver wire, horse-hair, or silk- 
 worm gut. They should not be tied until the incisions have been made on each 
 side midway between the alveolar border and the sutures. These incisions should 
 
SURGKRV or Till': DKiKSTIVi: TRACT. 695 
 
 be contiimod back into the veluiii. If tlicre bo nnicli tension, tbe muscles of 
 the ));ilate slioubl lie divided as described in Sta|)h_vlorrhuphy, or tbe end of tbe 
 internal pterygoid plate should be chiselled through, as recommended by Bill- 
 roth. (See ante.) Chiselling through the hard palate on each side of the 
 cleft has been recommended to relieve tension, but this procedure is rarely 
 necessary. Tt has been held, iiowever, that if the uiuco-])eriosteuui be fully 
 sejtarated from the posterior edge of the palate-bone, the muscles will be 
 paralyzed and no further cutting will be necessary. Some surgeons advise 
 that these lateral incisions should be made first ; but in some eases they are 
 not reipiired. and this Ave cannot tell until the edges are pared and sutures 
 iiitr()duce(l. Tu this way, also, hemorrhage is postponed until all the imjior- 
 tant steps of the operation have been completed. It is a good plan to tie the 
 sutures in the soft ])alate first. The first suture should be placed at the 
 junction of the hard and the soft palate. 
 
 Free hemorrhage sometimes occurs during the operation, but this usually 
 can be controlled by pressure made posterior to the incisor teeth. In some 
 cases of severe hemorrhage from the palatine arteries the palatine foramina 
 have been stopped with wooden plugs (Marsh). Secondary hemorrhage 
 occasionally occurs. In this operation anesthetics are always used. The 
 after-treatment is the same as after closure of the soft palate. Wyeth has 
 fractured and advanced the maxillary process in very young infants with 
 harelip and cleft palate, where the cleft was a Avide one. This procedure very 
 much simplifies the subsecjuent closure of the hard palate by lessening the 
 width of the defect. 
 
 Ulceration of the palate is usually tbe result of syphilis or of struma. 
 SypliiUtic ulceration may occur in the form of mucous patches with superficial 
 ulceration, or of deep ragged ulcers with sloughy bases. They generally heal 
 under specific treatment, but not seldom perforate the roof of the mouth. Local 
 treatment by astringents and nitrate of silver is sometimes beneficial. Strumous 
 ulceration is seen only in the young and feeble, and should be treated by tonics 
 and stimulants, and locally Avith antiseptic washes of boric acid, iodine, salicylic 
 acid, etc. 
 
 Abscess of the Palate is a rare occurrence. When seen anteriorly it 
 is usually connected Avith some disease of the teeth. Abscesses of the lateral 
 part of the soft palate may foIloAV tonsillitis. The proper treatment is early 
 and free incision. 
 
 Necrosis of the Palate. — The bone exfoliates very slowly, and occasion- 
 ally leaves a perforation in the hard palate. It is nearly ahvays the result of 
 syphilitic disease, although it may be the result of operative, gunshot, and 
 other Avounds. Plastic operations for fissures folloAving necrosis are of little 
 benefit, and the aperture should be closed by an accurately-fitting obturator. 
 
 Tumors of the Palate may be cystic or solid. Warty groAvths are occa- 
 sionally seen arising from the mucous membrane ; also fibro-sarcomata and cysts 
 containing glairy fluid. Sebaceous cysts are sometimes found in the substance 
 of the soft palate. They are recognized by their yelloAvish-Avhite color. Car- 
 cinomatous tumors of the palate are ahvays of the epitheliomatous type, and 
 are rarely primary, usually spreading from the tonsil or the tongue. Removal 
 of all these groAvths is the proper treatment. 
 
 PART II.— DISEASES AND INJURIES OF THE OESOPHAGUS. 
 
 Malformations. — These consist of fistulie, diverticula, and cystic growths, 
 such as have been described in the section on the Malformations of the Pharynx, 
 
696 ^l^V AMt:i:irAN TKXT-JiOOK OF SURGERY. 
 
 and are due to incomplete closure of the hrandiial clefts. In some cases there 
 mav be a con«:ciiital thickeninf; of the <e.soj)ha<rus in the situation of a hraiu-hial 
 cleft. This may cause some narrowin;^. The tube may be closed by a mem- 
 brane, or the whole tube may be dilated; large diverticula may jiroceed from 
 it, or it may be double or absent. Its absence is incompatible witii life unless 
 gastrostomy be performed. 
 
 Dilatation and Sacculation. — Dilatation may involve a large part of the 
 tubf or may be localized. When localized it is called a sacculation or diver- 
 ticulum. It is sometimes of immense size, but usually is small. Some form 
 of narrowing of the (lesophagus precedes dilatation, ami it is this that must be 
 treated. The dilatation (when not congenital) is usually caused by the arrest 
 of food at the point of stricture, the continuous endeavors to force it onward 
 producing a dilatation or pouching by putting the parts on the stretch. At 
 the junction of the pharynx with the oesophagus a "' pressure pouch " may form 
 on the i)o<terior aspect of the tube. This pouch or diverticulum has been 
 successfully removed through an incision in the neck by Butlin. Bergmann, 
 Kocher, and others. The operation appears to be neither very difficult nor 
 dangerous. After removal of the pouch the opening in the oesophagus is 
 closed with sutures. 
 
 Stricture. — This is the most common form of disease affecting the oesoph- 
 agus, and is due to various causes. Strictures of the rjesophagus may be divided 
 into — 
 
 Organic — Cicatricial or simple ; cancerous or malignant. 
 
 Non-organic — Spasmodic or hysterical. 
 
 Strictures may also be produced by the pressure of tumors, such as enlarged 
 thyroids, aneurysms, etc. 
 
 Cicatricial Stricture. — This may be produced by any injury to the tube, 
 such as ;i wouml. by the swallowing of corrosive fluids, or by syphilitic ulcer- 
 ation. The most common cause is the swallowing of corrosive li(juids, such as 
 lye, acids, etc., in early childhood. The stricture comes on slowly, and there 
 is nearly always a history of injury. If the stricture occurs in a young person, 
 it is probable that it is due to cicatricial contraction. The usual site is at the 
 beginning of the oesophagus opposite the cricoid cartilage. 
 
 Cancerous or Malignant Stricture. — Cancerous disease is a very com- 
 mon cau.-e of stricture. It may l>e engrafted on a simple stricture. It occurs 
 more often in men than in women, and usually at an age over forty-five. The 
 variety of carcinoma is nearly always epithelioma, and it most frequently attacks 
 the lower third of the tube. The symptoms are very plain, viz. gradually 
 increasing difficulty in swallowing, especially solid food, in individuals over 
 forty : regurgitation of food, with .sometimes a slight discharge of blood and 
 pus. and gradually increasing emaciation. 
 
 Spasmodic Stricture. — This form is associated with a hysterical condi- 
 tion, and is usually seen in the young, but it may occur at any age. It is 
 more common in women than in men. The previous history of the patient 
 will help to diagnosticate this affection. At times swallowing is quite ea.sy, 
 an<l suddenly the patient professes to be unable to swallow anything, the 
 attempt producing a severe spasm. The patient often com])lains of a con- 
 striction or the feeling of a lump in the throat (i/Iohiia hyHf*'rii-us). The 
 affection then appears suddenly and disappears as suddenly. The single pas- 
 sage of an cesophageal bougie often suffices to cure the stricture. When the 
 bougie is first used considerable opposition is offered to its passage, but on con- 
 tinuing the pressure this soon gives way and the bougie slips easily down the 
 tube. The condition of the linsual tonsil should always be examined 
 
SUROJ'JRy OF TJIK DIHEHTIVE TRACT. G97 
 
 n- .-. f ^trirfuri' — 'n.o fact tl.at a person has difficulty in s^vallo^ving 
 
 1 ;?Z -u a i en Ic atin! ' u.Ut to be sufficient to n.ake one suspect stne- 
 
 :;r^^ td t;;:: ;lined so,ne hours and t|-;l.-e,u^at. , espe- 
 
 .i.^11v if the ocsonhacrus ahove the stricture l)e inucli dda ed lain is not a 
 
 stricunc being easiyveco^.a^c.^^_pa^^t;cv^^^^^^^^^^^^^ 
 
 i„g hen,onhage; ^ut -ually the ,^,cnt d,cs of . an o^^^ ^^^^ ^^^^^^ ^^^^ 
 Jitnr^pltrofrte:; )7^T.UU^^y^ Las a n,ost disagreeable s.eU, 
 
 The patient usually gags, and may vomit, io obtain a 
 
 the patient should be anesthetized. ^^^,^ ^ .^^^^ 
 
 Beems to have some great advantages. A flexible gum-elastic 
 
fIflH J.V AMERICAN TEXT-llOOK ()F srilCERY. 
 
 four to six inches long is introduced into tlie strictuic and jiorniancntlv 
 retained there. Tlie upper end of the tulje is e.\f)anded into a funnel vhich 
 rests on the stricture. The lower end is closed somewhat like a catheter, 
 having an eye of large size a quarter of an inch from the end, through 
 which Ii(|uid food passes. For the purpose of withdrawing the tube, a piece of 
 plaited silk thread is passed about three-eighths of an inch below the rim of the 
 funnel in a single thread, and the portion inside the tube drawn out and tied to 
 the side pieces about two inches above the funnel. After ascertaining the exact 
 size of tlie stricture, the tube is placed in position by an instrument called an 
 introdunr, made of whalebone covered with gum-elastic. Symrtnds has left the 
 tube in without removal for two months. In the 17 cases of stricture treated by 
 this method, 9 died from the progress of the disease, but the stricture remained 
 patent and the patient was able to swallow to the last. In some cases where 
 there is cough on deglutition, Symonds recommends that the short tube be 
 rey)laced by the long tube of Krishaber of Paris, which proceeding renders the 
 operation of gastrostomy unnecessary ; or, better still, a piece of red-rubber 
 tubing cut oblicjuely at the end and sewed, an eye then being made as in a 
 catheter, should, with the aid of the introducer, be passed through the stricture 
 and left in situ. 
 
 Sir Morell Mackenzie, in his work on Diseases of the Xose and Tliroat^ 
 figures a long permanent oesophageal tube which he has used with success in 
 cases of absolute aphagia. The tube is left in five or six days at a time. 
 Senator of Berlin dilates the stricture with a laminaria tent attached to a 
 string and left in for from half an hour to an hour. The most suitable 
 strictures for this treatment are the non-malignant. 
 
 Wounds of the oesophagus are of rare occurrence. In cases of cut- 
 throat the oesophagus may be wounded or severed, and it may be wounded 
 by stabs of a knife or a bayonet or by a bullet. AVhen this occurs in the 
 thorax, the injuries to the neighboring organs are so great that this injury is 
 ordinarily overlooked. It is extraordinary how few cases of wound of the 
 (Esophagus are on record. But one case is noted in the Medical and Surgical 
 History of the Civil War. and that was found post-mortem. Foreign bodies 
 may wound the oesophagus from within. The passage of a bougie may wound 
 this tube, and even perforate it, causing hemorrhage, pain, and emphysema. 
 \^ hen the oesophagus is wounded in the neck the patient may recover. The 
 wound should, if possible, be sutured, and the patient fed by the rectum for 
 several days. A fistula may remain after the healing of the wound. 
 
 Foreign Bodies. — The impaction of foreign bodies in the oesophagus is 
 of comparatively common occurrence. Food niay be arrested here. viz. por- 
 tions of bones, fish-bones, meat ; also artificial teeth, coins, pins; in fact, nearly 
 every imaginable substance has been found in the oesophagus. The foreign 
 body when large is usually arrested at the narrowest part, viz. the commence- 
 ment of the oesophagus opposite the upper border of the cricoid cartilage ; but 
 there are two other points at which the body may be arrested, viz. where 
 the nesoj)hagus is crossed by the left bronchus and where it passes through the 
 diaphragm. Small and sharp bodies may lodge at any part of the tube. 
 Should the foreign body be arrested high up, there will be dysphagia and pain. 
 Some cases have died suddenly of a.sphyxia, so great is the spasm. After a 
 time the patient may get used to the foreign body and the symptoms almost 
 disappear. Should the substance swallowed be sharp, there will be more pain 
 and sometimes hemorrhage. In these cases the diagnosis of the exact position is 
 diflRcult, the sensations of the patient being a very poor guide. Even after the 
 foreign body has been removed or has passed down, the sensation of one being 
 
SURdKUy OF THE DIUESTIVK TUAi'T. 
 
 699 
 
 lod.'cd in the frullet remains, and it is sometimes hard to convince tlie patient 
 that it is not there. Larjre bodies, especially when they l)lock iij) the i)assafre 
 and prevent swallowincr, if not removed within a reasonal)le time, are incom- 
 patihle with life. If untreated, the foreifin body may ulcerate into nei^4i- 
 borin<r structures, such as the trachea, pleura, and pericardium. Not a lew 
 cases '•ire on record where a foreign body has ulcerated into the aorta and has 
 caused death bv heiiiorrliajre. , i i • i * 
 
 The ih'<u(uosis of these cases is aided, of course, greatly l)y tiie liistoiy, but 
 this cannot be obtained from children, lunatics, or determined suicides. Exter- 
 nal palpation, or the presence of a bulging in the neck, may serve to detect a 
 hir.re body, but a probang catheter or an esophageal bougie will otten satis- 
 factorily solve the problem. Small objects have been detected with the aid of 
 the oesophacroscope. Maiiv foreign bodies can now be accurately located by 
 means of th? skiagraph or tluoroscope. Interesting cases have been recorded 
 which afford the most convincing proof of the value of this new au to diag- 
 nosis in these cases. If any uncertainty exist, no examination should be 
 considered complete which does not include a good skiagraph of that portion 
 of the chest through which the oesophagus passes. 
 
 TreatnH'tit —^houU the object be round and smooth, it may be pushed 
 down with a probang, and if high up may be grasped with a pair of oesopha- 
 geal forceps (Fig. 287) and extracted. Pins, pieces of bone, etc. may be 
 
 Fig. 287. 
 
 Forceps in position to remove a foreign body from the gullet (Fergusson). 
 
 fished out with a horse-hair probang or Griife's coin-catcher. Vomiting will 
 sometimes displace a foreign body. ^ . , ^ ^ , . ., ^..^^^.f 
 
 In a certain number of cases the foreign body cannot be extracted except 
 bv cutting down on it. If the body has passed below the level of the supra- 
 sternal notch, it cannot be removed safely by external incision, and the .(ues- 
 tion of effecting its removal after performing gastrotomy must be considered 
 
 Csee p 700). 
 
 Operations on the (Esophagus.— External CEsophagotorny is per- 
 formed for the removal of foreign bodies and for cases of stricture high up in 
 the gullet. The incision is made on the left side of the neck, on account ot 
 
700 AN AMi:ni<'AX text-book of surgery. 
 
 tlic inclination of the (L'sopliajjus to that side. 'I'he incision is between the 
 larvnx and trachea on the insi(h' and tlie sheath of tlie vessels externally. 
 For ri'nioval of foreign bodies the center of the incision should be o))pi)site 
 the cricoid cartilage: by i)ullin<f the trachea and thyroid gland to the inside 
 and the vessels to the outside, and )»ulling aside or dividing the omohyoid 
 muscle, the oesophagus can easily be reached and incised longitudinally. If 
 the operation be i)erformed for the removal of a foreign body, this is extracted, 
 and the wound in the (Cso|»hagus closed witli catgut sutures, and the rest of 
 the wound partly closed and |)acked with ioiloform gauze. 1'he j)atient for 
 the first three or four days after oj)eration should be fed by eneinata, or 
 through a small gum-elastic catheter or rubber tube passed beyond the wound 
 before closing it. In cases where this operation is performed for relief of 
 stricture a pi-rmanent fistula is desired, and so a rid)her tube is left in the 
 wound. This operation is called (mop/iar/ostoini/. 
 
 Internal CEsophagotomy. — Instruments which are enlarged copies of 
 those used in the urethra, have been devised for cutting oesophageal strictures. 
 This operation is dangerous ; one-third of the cases have succumbed. It is 
 suitable only for certain cases of annular stricture. 
 
 Strictures have been incised through the opening made in tlie oesophagus, 
 and foreign l)odies seized as low down as the upper part of the stenmni by the 
 oesophageal forcej)s. 
 
 Gastrotomy and Digital Exploration of the CEsophagus. — M. II. 
 Richardson has devised an operation for the removal of foreign l)odies impacted 
 low down in the oesophagus. He performs gastrotomy, introduces his hand 
 into the stomach, and with his fingers explores the lower part of the oesophagus. 
 In this way he removed a plate containing four teeth which had been lodged in 
 the oesophagus near the cardiac end for eleven months. The man made a per- 
 fect recovery. W. T. Bull removed by gastrotomy a peach-stone from a child's 
 oesophagus, which was arrested some six or seven inches from the cardiac end 
 and had failed to be dislodged by other means. In this case, a small incision 
 having been made into the stomach, the finger was introduced, which guided a 
 bougie through the cardiac orifice, whence it was pushed u])ward until it pro- 
 jected from the mouth. Attached to the bougie was a double silk thread to 
 which Avas tied a s])onge. This Avas drawn uj) through the oesophagus, and 
 brought with it the peach-stone. The patient made a rapid recovery. In cases 
 where foreign bodies are situated at a distance of thirteen inches and over from 
 the teeth, from numerous experiments on the cadaver Richardson recommends 
 searchins for them from below throuj^h the stomach. 
 
 CEsophagectomy. — Excision of a portion of the (X'sophagus for malig- 
 nant growths has been performed several times. Czerny of Heidelberg is the 
 only surgeon who has operated with any degree of success. Five months after 
 operation his patient was living, without return of the disease, but within a 
 year she died of recurrence of the growth. The operation is performed in 
 the same way as oesophagotomy, but with a larger incision. A portion of the 
 oesophagus is resected, and the lower end fixed to the external wound. 
 
 'i'he iiKop/iai/dscopc is now not infreiiuently used for diagnosticating diseased 
 conditions of the oesophagus and the detection of foreign bodies. It is an 
 instrument which is illuminated by reflected light or electric light, and requires 
 considerable skill to handle. As yet but little progress has been made in the 
 diagnosis by this means of affections of the oesophagus. 
 
DISEA^SE.S AND INJURIES OF THE ABDOMEN. 701 
 
 CHAPTER VI. 
 
 DISEASES AND INJUKIES OF TPIE ABDOMEN. 
 PART I.— WOUNDS OF THE ABDOMEN. 
 
 The division of wounds of the abdominal wall into penetrating and 
 non-penetrating is now universally adopted. Irrespective of the nature of 
 the implement wliicli infiicts the wound, this division is important in reference 
 both to prognosis and to treatment. A large wound which does not implicate 
 the peritoneal cavity is not nearly so dangerous an injury as a small perfora- 
 tion made by a bullet or a small knife-blade and complicated by a visceral 
 injury. The differential diagnosis between non-penetrating and penetrating 
 wounds of the abdomen must be made in every case in which the surgeon is 
 called upon to treat a wound in this locality, as an approximately reliable 
 prognosis and a rational course of treatment must necessarily rest on a correct 
 diagnosis. 
 
 Non-penetrating Wounds. — In large incised or lacerated wounds of the 
 abdominal wall it is not difficult to determine whether or not the peritoneum 
 has been injured, as the deepest portion of the wound can be made accessible 
 to visual inspection and digital exploration. A wound of the abdominal wall 
 should never be explored for diagnostic purposes without proper antiseptic pre- 
 cautions, as the neglect of these is often the direct cause of the introduction of 
 septic material into the abdominal cavity in cases in which the parietal perito- 
 neum has been punctured, torn, or incised. The wound and its vicinity must 
 be rendered aseptic in the usual manner, and digital or instrumental explora- 
 tion must be done under the strictest antiseptic precautions. If after a care- 
 ful examination it is found that the injury is limited to the tissues outside of 
 the peritoneum, the wound is to be treated upon general principles, but with 
 due regard to restoring the resisting capacity of the abdominal wall by accu- 
 rate suturing of the incised or lacerated tissues. 
 
 A large and deep wound of the abdominal wall, unless treated with especial 
 care, is very liable to become subsequently the seat of a ventral hernia. 
 In order to prevent this later and often distressing condition, it is necessary 
 to obtain healing of the wound by primary union and to unite the different 
 layers by deep or buried sutures. After careful arrest of hemorrhage, and 
 cleansing and disinfection of the wound, the divided muscular layers must be 
 brought accurately together with a sufficient number of catgut sutures, but before 
 these are tied the superficial silk sutures are put in place in such a manner as 
 to embrace all the tissues, including the skin. After the margins of the 
 wound have been carefully coaptated by the tying of all the sutures, a few 
 superficial sutures are applied to bring the margins of the skin in accurate 
 approximation. Tubular drains should be avoided in such cases, as the space 
 occupied by the drain may become subsequently the starting-point of a ven- 
 tral hernia. If drainage is recjuired, this can be established by the insertion 
 at one or more points of an absorbable capillary drain composed of a small 
 bundle of catgut threads, or strips of iodoform gauze. 
 
 External support is furnished by a compress of hygroscopic antiseptic 
 gauze and absorbent cotton, retained in place by strips of adhesive plaster, 
 which must embrace at least two-thirds of the circumference of the body. 
 Next to imperfect suturing the most frequent cause of the formation of a 
 ventral hernia after an accidental or intentional wound of the abdomen is the 
 
702 .I.V AMi:i:i('AX TEXr-llOOK OF SURGERY. 
 
 too early active use of the tissues involveil in the injury. Ileiic-e the patient 
 shouM not he aHoweil to leave the hed until the |)roeess of repair is completed, 
 which will require at least from three to four weeks. If the erect position is 
 assumed before tiiis time, the increased tension in the abdominal wall may make 
 such an amount of traction upon the wound that the new tissues will yield to 
 the traction force, and o;ive way sufficiently for the parietal peritoneum to 
 bulge at the point oft'ering the least resistance. In the after-treatment of large 
 wounds of the alxlominal parietes it is necessary to maintain external support 
 by a well-fitting bandage for several months, the ])atient being cautioned not to 
 eniiaiie durini: this time in anv violent exercise which miirht brincr about a- sub- 
 cutaneous separation of the different muscular layers at the line of suturing. 
 
 Penetrating Wounds. — If in cases of incised and lacerated wounds of 
 the abdomen the peritoneum is laid open and the viscera protrude, their con- 
 dition must be observed, and if they are not wounded they must be care- 
 fully cleansed with warm sterilized water, or normal salt solution, dried, and 
 returned. Hlood-clots and other foreign botlies when present must be removed. 
 If the intestines have escaped through such a wound, and have become 
 strangulated and cannot be readily reduced, the surgeon should enlarge the 
 wound rather than resort to any violence in perhaps fruitless attempts at 
 reduction. In the closure of such wounds it is advisable to suture the peri- 
 toneum separately, after which they are dealt with in the same manner as non- 
 penetrating wounds. 
 
 The penetrating wounds of the abdomen most frequently met with in prac- 
 tice are punctured, gunshot, and stab wounds. These must again be divided 
 into those Avhicli have opened the peritoneal cavity without being complicated 
 by any serious injury of the abdominal organs, and those in which the great 
 danger consists in the fact that the missile or implement which produced the 
 wound has caused at the same time visceral injuries of a serious character. A 
 simple penetrating stab or gunshot wound of the abdomen is a more serious 
 injury than a much larger non-penetrating wound, yet is frequently followed by 
 recovery without active surgical interference ; but penetrating wounds compli- 
 cated by visceral injuries of important organs with few exceptions |)rove fatal, 
 unless the surgeon is able to prevent this termination by timely operative 
 interference and treatment of the visceral lesions. 
 
 In cases of gunshot and stab wounds of the abdomen the first duty of the 
 surgeon is to determine whether or not the abdominal cavity has been entered. 
 This part of the diagnosis may be easy or difficult according to circumstances. 
 If the bullet has passed through the body and the wounds of entrance and exit 
 occupy such positions that a direct line connecting them will necessarilv pass 
 through the abdominal cavity, there can be but little doubt that the bullet has 
 traversed that part of the peritoneal cavity interposed between them, and con- 
 sequently that there has been injury of the viscera occupying that locality. In 
 fat persons the exact outlines of the peritoneal cavity cannot be located with 
 absolute accuracy, and on this account some doubt may remain, in case two 
 bullet wounds, made by a single bullet, are found over the anterior or lateral 
 aspect of the pendulous abdomen, whether the peritoneal cavity falls in the 
 track made by the bullet. The existence of emphysema in the tissues around 
 the track of a bullet or stab wound is not positive evidence that penetration has 
 taken place, as it may be caused by the entrance of air from without. In stab 
 wounds prolapse of the omentum into the wound is of frecjuent occurrence, and 
 when this condition is present it is a positive evidence that the knife li;is pene- 
 trated the abdominal cavity. If a large bullet has entered the i)erit()neal 
 cavity by the shortest possible route through a thin portion of the abdominal 
 
DISEASES Ayi> INJURIES OF THE ABDOMEN. 703 
 
 vail, tlie fact that i)eiietrati()ii lias taken place often becomes evident in the 
 
 same manner. 
 
 In the majoritv of cases of penetratinn; wounds exi)lovation ot the wound hy 
 a careful dissection is the only positive and reliable procedure in determining 
 that the bullet or knife-blaile has entered the peritoneal cavity. Digital 
 exploration of small wounds should never be relied upon in ascertaining the 
 deptli and course of the Avound, as this measure is not infallible in making a 
 correct diagnosis, and in case the bullet has penetrated the abdominal cavity 
 the finger may push before it and into the peritoneal cavity infected foreign 
 substanc'es. The use of the probe should be discarded in tlie examination of 
 punctured and gunshot wounds of the abdomen for diagnostic purposes. The 
 wound-canal is often so tortuous from displacement of the tissues forming its 
 walls that it cannot be followed with a probe without risk of making false pas- 
 sages an occurrence which could not fiiil to lead to erroneous conclusions in 
 
 reference to the extent and course of the wound and in regard to the presence 
 of visceral complications which might demand prompt operative interference. 
 The only safe plan to pursue is to enlarge the wound by an incision at least two 
 inches in length, which should intersect the external opening through its center 
 and in the direction of the principal muscle involved by the injury. Before 
 this is done all the preparations for a laparotomy should have been completed, 
 everything required in the treatment of visceral wounds should be on hand, 
 and the consent of the patient and his friends obtained to do whatever may 
 become necessary in case it is found that the peritoneal cavity has been invaded 
 and that visceral injuries dem.and surgical interference. 
 
 It is often a difficult task to follow the track of a bullet with the scalpel 
 through a thick abdominal wall. The best method of procedure is to insert a 
 grooved director as far as it will pass without resistance, and then divide the 
 tissues layer after layer, catching bleeding vessels with hemostatic forceps as 
 fast as they are cut, in order to keep the field of operation as nearly as possible 
 in a bloodless condition. The bullet frequently discolors the tissues, and these 
 discolorations are often important landmarks in following the wound. When 
 the point of the director is reached, it becomes necessary to make a close in- 
 spection, and under no circumstances should the knife be used until the wound- 
 canal can again be identified and followed with the eye or the director. The 
 dissection is to be made carefully and slowly until the opening in the peritoneum 
 is reached, which alone establishes beyond a doubt the existence of penetration. 
 Quite recently the assertion has been made by several prominent surgeons 
 that laparotomy should be done in all cases where it can be shown that a punc- 
 tured Avound extends into the abdominal cavity, for the purpose of treating 
 intra-abdominal lesions. It must, however, be admitted that, in the absence 
 of serious visceral lesions, penetrating wounds of the abdomen are injuries from 
 which the patients are very likely to recover without operative treatment, and 
 that when such patients are subjected to laparotomy death may occur solely in 
 consequence of the operation. It is undoubtedly true that in most cases of 
 spontaneous recovery after punctured wounds of the abdomen the favorable 
 termination has been due to the absence of serious visceral lesions, which some 
 hold to be invariably present in such cases. In two out of six cases of pene- 
 trating gunshot Avounds of the abdomen which came under the observation of 
 Senn the absence of visceral injuries of the gastro-intestinal canal w^as demon- 
 strated by the use of the hydrogen-gas test, and both of these patients recovered 
 Avithout resort to laparotomy. The same absence of visceral lesions has been 
 also demonstrated during an operation or at the post-mortem. During the 
 Grf«co-Turkish Avar several cases of gunshot wounds of the abdomen recov- 
 
7(14 J.V AMKIiH'AX TEXT- HOOK OF SURGERY. 
 
 ert'd under a consorvative plan of treatment. In nearly all of these cases 
 the hiilk't entere<l the ab(h>nien above the level of the umbilicus, the most 
 favorable h)cati«»n for the escape of the intestines from the penetrating 
 projectile, the patient being in a standing position. Clinical ex|)erience 
 and the result of experiments show conclusively that laparotomy should 
 not be performed simply because a bullet or a knife-blade has entered the 
 al»dominal cavity, but that its performance should be limited to the treatment 
 of intra-abdominal lesions which, witliout operative interference, wouhl tend to 
 destroy life. Stab wounds are not as often complicate*! by visceral injuries as 
 are bullet wounds. A bullet which passes through the lower part of the abdo- 
 men from side to side or obliquely is almost sure to produce from four to four- 
 teen perforations of the intestines, while absence of dangerous visceral wounds 
 may be inferred with some degree of probability if it crosses the abdominal 
 cavity in an antero-posterior direction at or a little above the umltilical 
 level. 
 
 Symptoms. — The general symptoms in cases of penetrating punctured 
 wounds of the abdomen, with the exception of those due to profuse hemor- 
 rhage, furnish absolutely no reliable information in the differentiation between 
 simple penetrating wounds and penetrating wounds complicated by visceral 
 injuries. Severe shock may attend even a non-penetrating wound, and it may 
 be absent, or at least not well marked, in cases of multiple perforations of the 
 intestines. It is not an uncommon occurrence for a patient who has received 
 a penetrating wound of the abdomen to walk several blocks, or even a number 
 of miles, without a great deal of suffering and without showing any symptoms 
 of shock, and vet for a number of intestinal perforations to be revealed at a 
 subsequent operation or post-mortem. Vomiting takes place as frequently in 
 wounds of the abdominal parietes and in simple ])enetrating wounds as when 
 the viscera have been injured, ^'omiting of blood indicates the existence of 
 a wound of the stomach. 
 
 Pallor is present in all penetrating wounds of the abdomen soon after the 
 receipt of the injury, and it is only more pronounced when produced, at lea.st 
 in part, bv sudden and severe internal hemorrhage. Pain is a very unreliable 
 and ofren misleading svmptom. as it may be moderate or almost completely 
 absent soon after the injury has been inflicted, even when multiple perfora- 
 tions are present. The pulse at first is slow and compressible in all cases, 
 and nothing characteristic in its qualities is observed even if the stomach or 
 intestines have been injured. Hemorrhage caused by wounds of any of the 
 large organs, as the spleen, liver, or kidneys, gives rise to progressive acute 
 anemia, small, rapid pulse, cold, clammy perspiration, dilated pupils, yawning, 
 vomiting, and. in extreme cases, syncope and convulsions. 
 
 The local symptoms are of no more value in determining the existence of 
 visceral injuries in penetrating wounds of the abdomen than are the general 
 symptoms just enumerated. External hemorrhage is slight or entirely wanting 
 unless an artery or a vein in the abdominal wall has been injured. The bleed- 
 insr from visceral wounds jrives rise to accumulation of blood in the iieritoneal 
 cavity: this can be recognized by physical signs which denote the j)resence of 
 fluid in the free abdominal cavity and by the general symptoms indicating pro- 
 gressive anemia: increasing pallor of the face an<l of the visible mucous mem- 
 branes, small, feeble pulse, and dilated pupils. Wounds of the stomach often 
 give rise to hemorrhage into this organ and hematemesis. Blood in the stools 
 seldom follows hemorrhage into the bowels from intestinal wounds sufficiently 
 early to be of any diagnostic value. 
 
 Circumscribed emphysema in the tissues around the track made by a bullet 
 
1)IsI':ases axj) lyjuiUKS of ihe abdomen, 705 
 
 has been reo-ar.lod as an important si-n of the existence of intestinal perfora- 
 tion. This^'syn.ptom is n.isk-u.lino- and absolutely .levoid of diagnostic value 
 as this condition has frequently been observed in non-penetrating wounds ot 
 
 the abdominal Avall. . ^ • ^i -4.1 
 
 'Phe accumulation of any considerable quantity of gas in the peritoneal 
 cavity sometimes can be recognized by the disappearance of the nonnal liver 
 dulness, cause<l bv the presence of gas between the surface of the liver and 
 the chest-wall. This condition has been sought for m cases of perforating 
 T^ounds of the abdomen as a diagnostic point, and if found has been laid down 
 as a sure indication of the existence of visceral wourids of the gastro-intestinal 
 canal This is not, however, always the case. Adhesions between the liver 
 and chest-wall may have existed before the injury was received, or the 
 amount of gas present may be insufficient to give rise to this sign. 
 
 The escSpe of the contents of the wounded stomach or intestines through 
 the external wound is a rare occurrence, and is possible only when the exter- 
 nal wound is sufficiently large and straight and when it is located directly 
 opposite the visceral wound, or when there are pre-existing adhesions between 
 the abdominal wall and the injured portion of the gastro-intestinal canal. 
 It occurs more frequently in wounds of the large than of the small intestine. 
 When this symptom .is present it is conclusive proof of the existence of a vis- 
 ceral wound of the gastro-intestinal canal, and the character of the materia 
 which escapes will furnish a reliable indication as to what part of this tract 
 has been iniured. With the exception of the last-mentioned symptom and 
 the indication pointing to the necessity of arresting internal hemorrhage, 
 there is nothing about the local or general symptoms in cases of penetrating 
 wounds of the "abdomen that would enable the surgeon to decide with any 
 de-ree of positiveness, even after the injury was received, whether visceral 
 injuries existed or not. and, conse.iuently, whether celiotomy should or should 
 
 not be performed. i ^ ,i v i • i 
 
 Diagnosis.— It has already been urged that the fact that the abdominal 
 cavity has been opened should rest upon unmistakable evidence, such as pro- 
 lapse of the omentum or intestines, or the escape of the contents of the gastro- 
 intestinal canal, and in the absence of such evidence it must be established by 
 followin^r the track of the wound down to the opening in the parietal peritoneum. 
 After it'has been ascertained that the wound is a penetrating one, the course to 
 be pursued must vary according to circumstances. If the local signs and gen- 
 eral symptoms point to the existence of dangerous internal hemon-hage, no time 
 should be lost in further efforts to make an accurate anatomical diagriosis, as 
 sufficient evidence has been obtained to warrant a laparotomy for the purpose 
 of preventing death from hemorrhage by the direct surgical treatment of the 
 visceral injirries. If no such urgent indication presents itself, it is desirable 
 that the existence of visceral lesions demanding surgical interference should be 
 ascertained before the patient is subjected to the additional risks incident to a 
 laparotomy. Since a simple penetrating wound of the abdomen is an injury 
 from which a large majority of patients recover without operative treatment, 
 and since visceral wounds of the gastro-intestinal canal are attended by such 
 frio-htful mortality without surgical interference, the practical value and import- 
 ance of a correct diagnosis before deciding upon a definite plan of treatment 
 become obvious. It is apparent that if some reliable diagnostic tes could be 
 applied in cases of penetrating wounds of the abdomen which would indicate 
 to the surcreon the presence or absence of visceral lesions of the gastro-intes- 
 tinal canal, the indications for aggressive or conservative treatment would 
 become clear. 
 
 45 
 
7(»(j J.V AMi:i!irAy TKXT-noOK Ol SI UCEliV. 
 
 Senn lias shown by his exjieriraents on animals, and later by his clinical 
 experience in the treatment of six cases of gunshot wounds of tlie abdomen, 
 that rectal insujflation of hi/droin'n (/as can be for the most part relied upon 
 in demonstrating the existence of intestinal perforations before ojiening the 
 abdomen, lie has demonstrated conclusively that if the abdominal muscles 
 are completely relaxed under the inHuence of an anesthetic, hydrogen gas or 
 filtered air can be forced from the anus to the mouth if no perforations exist; 
 and if such are present the gas as a rule will escajjc into the peritoneal cavity, 
 where its presence can be easily iiscertained by tlie physical symptoms char- 
 acteristic of a free tympanites, or by the escape of the gas through the exter- 
 nal opening. 
 
 The use of hydrogen, while it has failed in a few cases, and in others has 
 made the return^ of the boAvels into the abdominal cavity more difficult, is 
 nevertheless occasionally a valuable addition to our means of diagnosis and 
 treatment. Many, perhaps the majority of, surgeons, however, hold that 
 the difficulties and possible dangers it creates more than offset its apparent 
 advantages. 
 
 Prognosis. — Penetrating wounds of the abdomen without serious visceral 
 injuries and without the presence of a septic foreign body in the abdominal 
 cavity are frequently followed by recovery without resort to intra-abdominal 
 treatment. Penetrating wounds complicated by visceral injuries giving rise to 
 profuse internal hemorrhage are serious injuries and call for prompt surgical 
 interference. Penetrating wounds complicated by wounds of the stomach 
 or of any portion of the intestinal tube large enough to permit the escape of 
 the contents of the injured organ must practically be regarded as mortal injuries. 
 In the former instance death usually follows in a short time from hemorrhage ; 
 in the latter, from septic peritonitis. In exceptional cases, where all the con- 
 ditions are favorable for such a termination, a spontaneous recovery may take 
 place by the wounded portion of the stomach or intestine forming speedy adhe- 
 sions with adjacent serous surfaces, thus protecting the peritoneal cavity against 
 infection. One of the most important conditions for such a favorable termi- 
 nation to take place is that the wounded organ should be empty at the time 
 the injury is inflicted and should remain so until the peritoneal cavity has 
 been shut off by adhesions. These cases, however, are exceptional : ex- 
 travasation, septic peritonitis, and death are the usual results of such 
 injuries. 
 
 Treatment. — The propriety of surgical interference in cases of pene- 
 trating wounds of the abdomen will depend on one of two things : 
 
 1. Dangerous internal hemorrhage. 
 
 2. "Wounds of the stomach or intestines large enough to permit of 
 extravasation. 
 
 The rational treatment of penetrating wounds of the abdomen originated 
 in this country, and its development to a life-saving and legitimate surgical 
 procedure has been brought about almost exclusively by the researches and 
 clinical work of American surgeons. Among those who contributed most 
 toward the advancement of this branch of abdominal surgery may be men- 
 tioned Gross, Sims, Kinloch, McGuire, Parkes, McGraw, Bull. Dalton, Ber- 
 nays, Cabot, Barrows, Keen, Stimson, and Senn. The most recent statistics 
 show that about 30 per cent, of the cases operated on have recovered, thus 
 fully sustaining the expectations of those who urge not only the propriety but 
 also the necessity of treatment by laparotomy in all cases in which penetrating 
 wounds of the abdomen are complicated by -serious visceral injuries. 
 
 1. Preparation of the Patient. — A patient suffering from a perforating wound 
 
I)IsI':asi:s asp l\j('uii:s of the ajwomkx. tot 
 
 of the abdonirn should be ])ro|)erly prepared before he is subjected to lapa- 
 rotomy. If the stomach is filled with food, a salt-water emetic should be given 
 for the purpose of evacuating the stomach, or, better still, it may be emptied 
 by a stomach tul)e. The rectum and colon should be emptied by a copious 
 enema of lukewarm Avater to which may be added a taldespoonful of common 
 salt. A hypodermatic injection of gr. J- of morphia and gr. -^-^ of strychnine 
 should be given shortly before the anesthetic is administered, as these drugs 
 in the doses specified assist the action of the anesthetic, secure rest for the 
 intestines, and sustain the action of the heart. If the patient is much pros- 
 trated, two ounces of whiskey diluted with four ounces of warm water should 
 be irivcn bv the rectum. ]>odv heat should be maintained and increased, and 
 the embarrassed circulation aided by the use of external dry heat. The 
 external wound and the whole abdomen must be thoroughly disinfected. 
 
 2. Operating Room. — The room in Avhich the examination is to be made, 
 and possibly laparotomy performed, should be prepared as directed in the sec- 
 tion on Operative Surgery. 
 
 3. Incision. — Great diversity of opinion still prevails in regard to where 
 the incision should be made. In the majority of cases the median incision 
 affords advantages which give it the preference. It should always be selected 
 in cases of gunshot wounds of the stomach, and where the wound of entrance 
 is located near the median line, and where it is known that the bullet has 
 taken an antero-posterior course. A median incision affords most ready access 
 in the treatment of wounds of the small intestine. 
 
 If the hydrogen-gas test is used, it may sometimes prove of value in decid- 
 ing the location of the incision. If in gunshot wounds of the upper portion of 
 the abdomen direct inflation of the stomach through an elastic tube reveals the 
 existence of perforation of this organ, the median incision should be selected. 
 If rectal insufflation yields a positive result before the gas has passed the ileo- 
 ciecal valve, the incision should be made over the wounded portion of the 
 colon, which is usually indicated by the course of the bullet. A wound in the 
 transverse colon can be found and dealt with most efficiently through a median 
 incision, perforation of the caecum or of the ascending colon calls for a lateral 
 incision directly over the wounded organ, Avhile a lateral incision on the left 
 side is indicated if from the direction of the bullet it is evident or probable 
 that the colon below the splenic flexure is the seat of the visceral injury. In 
 the treatment of gunshot wound of the colon a lateral incision should be made 
 sufficiently long to facilitate the finding and suturing of the perforation and to 
 enable the surgeon to search for and treat additional injuries. The external 
 wound is closed with several rows of buried sutures : there is but little danger 
 of the occurrence of a ventral hernia. 
 
 Laparotom}^ performed for the arrest of dangerous hemorrhage should 
 alwavs be done bv making a long median incision, which will afford the most 
 direct access to the different sources of hemorrhage. Very often it will be 
 advisable to make the incision in the line of the wound of entrance, more 
 especially in cases where a lateral incision is indicated from the location of the 
 wound, from the course of the bullet, and perhaps from the results obtained by 
 application of the hydrogen-gas test. 
 
 4. Arrest of Hemorrhage. — In penetrating wounds of the abdomen pro- 
 fuse hemorrhage is more frequently of parenchymatous and venous than of 
 arterial origin. Gunshot wounds of the liver, spleen, kidneys, and mesen- 
 tery give rise to profuse and often fatal hemorrhage. After opening the peri- 
 toneal cavity it is often very difficult to find the bleeding points, as the blood 
 accumulates as rapidly as it is sponged out, and it becomes necessary to resort 
 
708 .liV^ AMERICAN TEXT-BOOK OE ^LROERW 
 
 to special iru'ims in order to arrest the |)rofiise bleeding sufficiently to find the 
 source ot" heiiiorrliage. 
 
 One of two means should be employed: (1) digital compression of the 
 aorta ; (2) packing the abdominal cavity with a number of large sponges. 
 Digital compression of the aorta below the diaphragm can be readily made by 
 an assistant introducing his hand through the al>doniinal incision, which in 
 such a case must be larger than under ordinary circumstances. Compression 
 of the abdominal aorta immediately below tiie diapliragm will promptly arrest 
 the hemorrhage from any of the abdominal organs for a sullicient length of 
 time to enable the surgeon to find the source of hemorrhage and carry out the 
 necessary treatment for its permanent arrest. 
 
 Hemorrhage from a perforated, lacerated kidney may demand a nephrec- 
 tomy. A similar wound of the liver is sutured with catgut, cauterized with 
 the actual cautery, or tamponed with a long strip of iodoform gauze, one end 
 of which is brought out of the external Avound. A wound of the spleen, if the 
 hemorrhage cannot be arrested by the antiseptic tampon, necessitates splenec- 
 tomy. Very troublesome hemorrhage is often met with from wounds of the 
 mesenteric vessels. 
 
 When multiple perforations of the mesentery and visceral wounds of the 
 stomach or intestines are the source of hemorrhage, it is a good plan to pack 
 the abdominal cavity with a number of large sponges or gauze compresses to 
 each of which a long strip of iodoform gauze is securely tied, these strips being 
 allowed to hang out of the wound in order that none of the sponges may be 
 lost or forgotten in the abdominal cavity after the completion of the opera- 
 tion. The sponges or compresses make sufficient j)ressure to arrest paren- 
 chymatous oozing as well as venous hemorrhage if they are placed at different 
 points against the mesentery and between the intestinal coils. The sponges 
 are removed one by one from below upward, and the bleeding points secured 
 as fast as they are uncovered. 
 
 The ligation of mesenteric vessels, both arteries and veins, should be done 
 by applying the ligature en masse. Thornton's curved hemostatic forceps is 
 the most useful instrument for this purpose. Troublesome hemorrhage from 
 a large visceral wound of the stomach and intestines is best controlled by 
 hemming the margin of the wound with fine silk. If hemorrhage is profuse, 
 this must be attended to before anything is done in the way of finding or 
 suturing the visceral wounds. 
 
 5. Search for Perforations. — If the hydrogen-gas test has been employed 
 with a positive result before the abdomen was opened, there Avill be no dif- 
 ficulty experienced in finding the first opening. If the stomach was inflated 
 directly through an elastic tube, and the test has shown the presence of a per- 
 foration, a median incision is made from the tip of the ensiform cartilage to 
 the umbilicus and the stomach drawn forward into the wound. If no perfora- 
 tion is found in the anterior wall, the insufflation is repeated, and the escaping 
 gas will direct the surgeon to the perforation. After closing the perforation 
 the stomach is again inflated, and if a second perforation exists it is readily 
 detected by this test. The possibility of the existence of a third perforation 
 should be remembered ; consequently a third inflation may become necessary. 
 A second and a possible third perforation can also be detected by inflating the 
 stomach directly through the first or second perforation. 
 
 In searching for intestinal wounds by the aid of inflation further inflation 
 should be suspeniled as soon as the lowest perforation has been found. If 
 possible, the perforated ])ortion of the intestine should now be brought for- 
 ward into the wound, and after emptying the intestine below the perforation 
 
DLSEASKS AM) LXJililES OF THE ABDOMEN. 709 
 
 as far .ns possiMc of its fjas, tlie bowel is coinprossed })elow tho perforation by 
 an assistant and tho intestine bi^dier up is inllated tliron^rli the wound. As 
 a matter of eourse, a ])erfectly aseptie rrlass tube shoubl be inserted into the 
 rubber tube in pLaee of employing the tube which was used in the rectum. 
 The inflation is now carried as far as the second opening, when the first open- 
 ing is sutured, and after disinfecting an<l emptying the intervening portion 
 of its gas the intestine is replaced in tho alHlominal cavity. Further infla- 
 tion is now made through the socon<l opening, and if a third one is found the 
 second is sutured, and so on until the entire intestinal canal has been thor- 
 oughly subjected to the test. By following this plan extensive eventration 
 is rendered superfluous and the overlooking of a perforation is made abso- 
 lutely impossible; at the same time intestinal distention is guarded against 
 and the subsequent suturing of the wound greatly facilitated. I ndiscov- 
 ered perforations and external eventration in the search for perforations 
 figure largely as the causes of death in gunshot wounds of the abdomen 
 treated by laparotomy, and both of these sources of danger are avoided by 
 a thorough and systematic employment of the hydrogen-gas test. 
 
 There is good reason to think that quite as many lives have been lost by 
 prolongation of the search for perforations as by overlooked perforations, and 
 most surgeons now hold that the search should be made with the aid of inflation 
 and by I'apidly running over the movable portion of the intestines, and only so 
 much of the fixed portion as lies in the track of the bullet. 
 
 6. Suturing of Wounds of the Stomach and Intestine. — Trimming the 
 margins of the visceral wounds is not only superfluous, but absolutely harm- 
 ful, as it requires a useless expenditure of time and may become an additional 
 source of hemorrhage. The same can be said of the Czerny-Lembert suture. 
 All that is required in the treatment of a visceral wound of the stomach and 
 intestine is to turn the margins of the wound inward and bring into apposition 
 healthy serous surfaces by the continuous Lembert or by interrupted sero-mus- 
 cular sutures, which should always be made to include fibers of the submucosa. 
 Fine aseptic silk should be used, and from four to six sutures to an inch are 
 sufficient. If possible, wounds of the stomach should be sutured in a line paral- 
 lel with the loner axis of the organ, and wounds of the intestine should be closed 
 transversely, with a view of preventing constriction of the lumen. Defects an 
 inch and a half in length on the convex border can be closed in this manner 
 without fear of causing intestinal obstruction, while much smaller defects on 
 the mesenteric side often necessitate a resection, not only because the vascular 
 supply in the corresponding portion of the intestine would be inadequate, but 
 also because a suflficiently sharp flexion might be produced at the seat of sutur- 
 ing to become the immediate mechanical cause of intestinal obstruction. 
 
 7. Enterectomy. — Enterectomy is often indicated in cases of double per- 
 foration and in marcfinal wounds of the mesenteric border. If in cases of 
 multiple perforations it becomes necessary to make a double enterectomy, 
 and the intervening portion of the small intestine is not more than two or 
 three feet in length, it is best to resect the intervening portion itself, as the 
 immediate effect of the single operation will be less severe than that of a 
 double resection with a corresponding double enterorrhaphy. The mesentery 
 corresponding to the portion of intestine to be removed should be tied in 
 small sections with fine silk before the bowel is excised. Strips of gauze 
 are preferable to clamps in preventing extravasation during the operation. 
 The gauze strip is passed through a small buttonhole made with hemostatic 
 forceps in the mesentery near the intestine and tied Avith sufficient firmness 
 to prevent escape of intestinal contents. 
 
71U AX AMKJilCAX TllXT-HOOK OF SURdEllY. 
 
 8. Oinental Graftin<:f. — If tlie bowel at the seat of suturing shows evi- 
 dences of contusion, the line of suturing and the damaged portion of the 
 bowel should be covered by an omental graft, which is fastened in its place on 
 the mesenteric side by passing two catgut sutures in the line of the mesenteric 
 vessels through both ends of the graft and the mesentery and tying them 
 loosely. Before the graft is planted the surface of the bowel and the surface 
 of the graft which is to be brought in contact with it are scarified with the point 
 of an aseptic needle. 
 
 9. Irrigation of the Abdominal Cavity. — This is necessary only if fecal 
 extravasation or escape of stomach contents has taken place, an accident which, 
 if it has not occurred before the abdomen was opened, should be carefully 
 avoided during the manipulation of the wounded intestines. Flushing the 
 peritoneal cavity with normal salt solution, not only clears it of infectious 
 material, but acts at the same time as a stimulant to the Hagging circulation. 
 After completion of the irrigation the patient is placed on his side, and in 
 this manner the fluid contents of the abdominal cavity are poured out. The 
 cavity is then rapidly dried with largo sponges wrung out of a weak sublimate 
 solution (1 : lO.OOn) or Thiersch's solution. Some surgeons have practically 
 abandoned flushing of the abdominal cavity, and rely almost exclusively on 
 sponging in removing pus and extravasated fecal iuaterial. 
 
 10. Drainage. — Cases which require irrigation usually necessitate drain- 
 age. Other indications for drainage are visceral wounds of the liver, pan- 
 creas, spleen, and kidneys, where extirpation of the wounded part of the 
 organ or of the whole organ is deemed unnecessary, and the existence of 
 parenchymatous hemorrhage which cannot be remedied by any of the differ- 
 ent hemostatic measures. A combination of a tubular and gauze drain is 
 most advantageous. A glass drain reaching to the bottom of the pelvis 
 loosely packed with a strip of iodoform gauze answers an excellent purpose. 
 Occasionally multiple drains are indicated. The Mikulicz drain may be 
 used in arresting surface oozing. 
 
 11. Closure of the External Incision. — Incisions through the median line 
 are rapidly closed by one row of silk sutures which include all the tissues of 
 the margins of the wound. Incisions made in any other place are to be closed 
 in the same manner, or by two or three rows of buried catgut sutures and a 
 superficial row of silkworm-gut sutures including all the tissues except the 
 peritoneum. 
 
 12. After-treatment. — Absolute rest must be strictly enforced. Opiates 
 must be given in doses sufficient to quiet the peristaltic action of the intestines. 
 No food should be given by the stomach for at least forty-eight hours. During 
 this time a mixture of brandy and water, in small doses frequently repeated, is 
 agreeable to the patient, as it quenches thirst and exerts a favorable influence 
 upon the circulation. If more active stimulation is required to overcome shock 
 and the eff"ects of hemorrhage, whiskey, strychnine, ether, musk, or camphor 
 can be injected subcutaneously or by the rectum, while the perij)heral circu- 
 lation is restored by applying dry heat to the extremities and trunk. The subcu- 
 taneous transfusion of one to two pints of normal saline solution is an excel- 
 lent restorative and of special therapeutic value in cases where the vital forces 
 are depressed and life is in danger from the effects of hemorrhage. Should 
 symptoms of peritonitis set in, a brisk saline cathartic should be given at the 
 end of forty-eight hours, as at this time the intestinal wounds will have become 
 sufficiently united to resist the peristalsis provoked by the cathartic, while the 
 removal of the intestinal contents and the absorption of septic material from 
 the peritoneal cavity thus attained are not only the most efficient means of 
 
J)/,Sj:A,Sh\S AXl) lyjL'RIKS OF THE ABDOMEN. 711 
 
 avertiii<^ a fatal disciise, but also of placiug the wounds in tlie most favorable 
 condition for rapid repair. 
 
 If the case progresses favorably, liijuid food by the stomach can be allowed 
 at the end of the second day, and digestible solid food at the end of the first 
 veek. Under ordinary circumstances no effort is made to move the bowels 
 until the end of the third or fourth day. If early feeding becomes necessary 
 in marasmic or exsanguine patients, this can be done by rectal alimentation. 
 Patients should not be allowed to leave the bed until the external wound has 
 firmly united throughout, as any imprudence in this direction is liable to be 
 followed l)y the formation of a ventral hernia. The sutures are removed on 
 the eighth day, and the patient is directed to wear an abdominal supporter for 
 several months after he has left his bed. 
 
 PART II.— DISEASES AND INJURIES OF THE STOMACH. 
 
 Wounds and Contusions. — The stomach, when of normal size and in its 
 natural location, is so Avell protected by the chest-wall and the surrounding 
 organs that it seldom becomes the seat of injury from blunt force. Contusion, 
 partial laceration, and complete rupture may occur from a severe blow or kick 
 applied over the organ when distended with food. A partial laceration and 
 contusion will give rise to circumscribed pain at the seat of injury, followed 
 by a limited inflammation which usually results in the formation of adhesions 
 between the injured part and the adjacent surface. Evidences of circum- 
 scribed peritonitis in the region of the stomach after an injury are suggestive 
 of the existence of a traumatic lesion of this organ, and should warn the surgeon 
 to secure rest for the injured part by placing the patient on an absolute diet for 
 four or five days, withholding indigestible food until all danger of perforation 
 has passed. 
 
 As the peritoneal investment is less elastic than the muscular and mucous 
 coats, partial rupture of the organ necessarily implicates most frequently the 
 external or peritoneal coat. In complete ruptures and in lacerations involv- 
 ing the mucous coat hemorrhage takes place into the stomach ; and if the 
 patient vomits blood, the existence of a serious injury of this viscus may be 
 .fairly assumed. A rupture of the stomach large enough to permit the escape 
 of its contents into the peritoneal cavity is usually attended by additional seri- 
 ous injuries which still further complicate the case. Extravasation of food into 
 the peritoneal cavity causes severe pain and symptoms of shock, which, if the 
 patient rallies, is followed by diffuse septic peritonitis and death within forty- 
 eight hours. In cases of this kind the existence of a complete rupture can be 
 readily demonstrated by inflating the organ with hydrogen gas or filtered air 
 through an elastic stomach-tube. If the rupture is incomplete^ the stomach 
 will be dilated and its contour can be mapped out on the surface of the abdo- 
 men by inspection and percussion ; if a complete rupture has taken place, the 
 organ cannot be distended, as the gas will escape through the visceral wound 
 into the ai)dominal cavity, where its presence can be recognized by the physi- 
 cal signs wliich characterize a free tympanites. 
 
 In the treatment of a complete rupture of the stomach no time should be 
 lost. The abdomen should be opened by an incision from the xiphoid cartilage 
 to the umbilicus. If the visceral wound is located where it cannot be readily 
 found, it can be quickly pointed out by repeating the inflation. If extravasation 
 has taken place, the peritoneal cavity should be carefully cleansed by flushing 
 with normal salt solution and moj)ping Avith a soft aseptic sponge. If the 
 stomach has not been emptied by vomiting or by the escape of its contents 
 
712 .liV JJ/A/.'/rj.V TllXr-llOOK OF srii(ii:L'Y. 
 
 through the rupture, it should be evacuated completely through the wound 
 before this is closed with sutures. After careful arrest of hemorrhage the 
 rent in tiie stomach is closed by applying two rows of silk sutures: the first 
 row. to embrace the muscular and mucous coats, is cut short, and buried by the 
 second row, which is made to include the peritoneum and enough of the mus- 
 cular coat to give each suture a firm hold. Some surgeons employ only a 
 single row. If the peritoneal cavity has been contaminated by extrava.sation 
 for a considerable length of time, it is advisable to resort to drainage. As an 
 operation for such an injury necessarily requires a considerable length of time, 
 the circulation should be maintaine<l by a judicious use of external heat and of 
 stimulants administered by subcutaneous and rectal injections. As heart stimu- 
 hints, camphorated oil, digitalis, and strychnia, injected subcutaneously, are to 
 be relied upon. Whiskey or brandy diluted with Avarm water should be given 
 by the rectum. The patient is to be nourished exclusively by rectal alimenta- 
 tion for at least three or four days. 
 
 Gunshot and Stab Wounds of the Stomach are much more frequent 
 than lacerated wounds. The existence of a visceral wound of this organ in 
 connection with penetrating wounds of the abdomen is often made evident by 
 hematemesis, and less frequently by the escape of the contents of the stomach 
 through the external wound. If such positive indications are wanting, as is 
 usually the case in gunshot wounds, the diagnosis may be made by resorting 
 to insufflation with hydrogen gas or filtered air. 
 
 A number of cases have been reported where the stomach had been perfo- 
 rated by a small bullet, and recover}^ followed without operative interference. 
 Such a favorable termination can be hoped for if the visceral wound is small and 
 if the organ was empty at the time the injury was inflicted. Under such circum- 
 stances the wound is temporarily closed by the bulging of the mucous mem- 
 brane, w^hich forms a perfect plug until by a speedy process of repair the wound 
 on the peritoneal side is permanently sealed by new tissue. 
 
 In the surgical treatment of wounds of the stomach it is important to 
 remember that if the Avound is located near the cardiac orifice of the organ or 
 in the posterior wall, it is difficult of detection and not readily accessible to 
 direct treatment. In gunshot wounds of the stomach, unless the bullet grazes 
 one of the bordei^s, it is the rule that the organ is perforated at two points. If * 
 only one perforation is found, this should never be closed until search has been 
 made for additional perforations by inflating the organ through the perforation. 
 This diagnostic test prevents the possibility of leaving an undiscovered and 
 unsutured perforation. Two cases may be mentioned, in each of which one 
 perforation was overlooked and the patient died of peritonitis which could be 
 traced to the unsutured wound. In one of the cases the bullet passed through 
 the cardiac extremity of the stomach in an antero-posterior direction. The per- 
 foration in the anterior wall was readily found and sutured, and, as no other 
 visceral injuries could be found, the operation was terminated. The patient died 
 of septic peritonitis on the second day. The necropsy revealed a second per- 
 foration in the posterior wall of the stomach and a septic peritonitis which had 
 plainly developed from this source, as the large opening had remained patent, 
 establishing a free communication between the interior of the stomach and the 
 peritoneal cavity. The second case is of great interest, as it shows that one 
 bullet can produce three perforations in the stomach. The bullet passed trans- 
 versely through the upper part of the abdominal cavity. Abdominal section 
 was made, and two perforations in the stomach, one near the cardiac extremity, 
 the other near the pylorus, were easily found and sutured. The surgeon had 
 every reason to believe that he had found and treated all the perforations. 
 
DISKA.SES AND INJURIES OF THE ABDOMEN. 713 
 
 The patient died of septic jieritonitis, wliicli, as the post-mortem showed, was 
 caused by an overlooked j)erfbration in the small curvature of" the stomach. 
 Gunshot and stab wounds of the stomach are sutured in the same manner as 
 lacerated wounds, care being taken to cover the perforation some distnnce 
 beyond the margins of the wound by applying the superficial or Lembert 
 sutures at least half an inch beyond the margins on each side. The same 
 care must be exercised in the after-treatment of such cases as has been 
 detailed in describing the treatment of lacerated and ruptured wounds of this 
 organ. 
 
 Foreign Bodies. — Foreign bodies which traverse the pharynx and oesopha- 
 gus usually pass through the entire length of the gastro-intestinal canal and escape 
 in a day or two with the fecal evacuation. Coins, buttons, fragments of bone, 
 pins, and other small foreign bodies are usually disposed of in this manner. 
 The popular belief tliat the passage of a foreign body through the alimentary 
 canal is facilitated by the administration of purgatives is erroneous, as every 
 measure directed toward increasing peristalsis will tend to increase the risk 
 of its arrest and impaction. It has been advised to restrict such patients to 
 an exclusive diet of bread and milk for a number of days, to be followed by a 
 gentle laxative. Quite recently the so-called "Vienna treatment," consisting 
 in an exclusive diet of mashed potatoes, has received a great deal of attention 
 and has been employed to good advantage in such cases. 
 
 The dietetic treatment of foreign bodies in the alimentary canal is 
 founded upon the fact that during appropriate feeding the foreign body be- 
 comes, as it were, encrusted or buried, and is thus rendered less dangerous, and 
 its passage through the pyloric orifice of the stomach and along the intestinal 
 canal is facilitated. If the foreign body, such as a knife, fork, etc., either 
 from its great size or on account of its shape, cannot pass through the pyloric 
 orifice, it acts as an irritant to the Avails of the stomach, causing catarrhal 
 inflammation, ulceration, and even perforation. It is now possible, by means 
 of the skiagraph, to determine from day to day whether the foreign body re- 
 mains impacted or whether it is being passed onward Avith the fecal current. 
 Bodies retained in the stomach may sometimes be shown by the use of the 
 gastrodiaphane. Under such circumstances it becomes the duty of the sur- 
 geon to resort to the operative removal of the foreign body before it has in- 
 flicted irreparable damage. 
 
 Gastrotomy for the removal of foreign bodies is one of the oldest 
 and most successful of all abdominal operations. The first operation of this 
 kind was performed by Florian Mathias of Prague in 1602. The stomach is 
 reached through a median incision, and, if possible, the foreign body is located 
 before the incision for its removal is made. If this cannot be done, the ante- 
 rior wall of the stomach is brought forAvard into the Avound and retained in this 
 location Avith volsellum forceps, and a vertical incision made large enough to 
 admit one or tAvo fingers for digital exploration of the interior of the vis- 
 cus. After the foreign body has been located, it is grasped Avith a pair of 
 strong polypus forceps in such a manner as to extract it Avithout inflicting 
 additional violence. The visceral wound is closed in the usual manner 
 with Czerny-Lembert sutures, and after carefully cleansing the exposed parts 
 the organ is replaced and the external Avound sutured. Absolute diet must 
 be enforced for at least three or four days after the operation, the time re- 
 quired for the formation of firm adhesions betAveen the margins of the visceral 
 wound. 
 
 Ulcer. — Until recently ulcer of the stomach had no interest for the sur- 
 geon, as treatment for this affection Avas regarded as the exclusive pi'ovince of 
 
711 .i.v AMi:iii('A\ 77;.\"/-y;ooA' or sri:(n:i:y. 
 
 the physician. Recurring hemorrhage? from an ulcer of tliisorgan liave brought 
 nianv patients to tf»e brink of the grave, and not infre(|uently death has resulted 
 from this cause alone, while in many other cases the cicatricial contraction occur- 
 ring during the healing of an ulcer iias given rise to remote evil conscrjuences 
 beyond tiie range of successful treatment by internal medication. For these 
 reasons during the last few years ulcer of the stomach has become the subject 
 of surgical interest and operative interference. Perforatingulcerof thestomach 
 and duodenum follows circumscril)ed necrosis of the walls of these organs caused 
 bv a diminished arterial blood-supply of a limited vascular district. That many 
 of these ulcers are of vascular origin is shown by their funnel-shape and their di- 
 rect relation to a terminal artery. The defect is in the form of a cone, of which 
 the base is directed toward the lumen of the viscus. and the apex correspomls 
 with a small artery which must have been partially or completely obstructed be- 
 fore the necrosis occurred. These ulcers are sometimes multiple, and in the stom- 
 ach they are found by )»reference along the lesser curvature. After interru j)tion 
 of the arterial circulation the wedge-shaped, ischemic, necrosed portion is 
 removed by the action of the gastric juice and the ulcer is formed. As per- 
 forating ulcer of the stomach or duodenum never occurs in cases of ulcerative 
 endocarditis, and as it selects in preference young females, the causes of vascular 
 obstruction must be of a local nature. The sphacelus shows molecular decay, 
 but no trace of inflammation. The more fi-equent occurrence of perforation is 
 prevented by circumscribed plastic peritonitis, which seals the defect or estab- 
 lishes permanent adhesion between the affected j)ortion of the organ and an 
 adjacent serous surface. 
 
 The principal symptoms of ulcer of the stomach are a fixed pain, a cir- 
 cumscribed area of tenderness, and vomiting soon after eating. If in the 
 absence of the usual symptoms of carcinoma the patient vomits blood, the 
 diagnosis is almost positive. 
 
 The surgical treatment of ulcer of the stomach has for its object one of 
 three things : (1) arrest of hemorrhage ; (2) e.xcision of the ulcer ; (3) 
 suturing of a perforation. If a positive diagnosis of the existence of an 
 ulcer of the stomach, which threatens life from recurring attacks of hemor- 
 rhage or which has resulted in perforation, can be made, treatment by lapa- 
 rotomy sliould be resorted to without delay. The stomach is reached by 
 a median incision. The existence of a perforation, if not easily seen, can be 
 readily demonstrated by insufflation with hydrogen gas through an elastic 
 oesophageal tube. If no perforation is present, the seat of the ulcer can 
 sometimes be located by a circumscribed patch of peritonitis which corre- 
 sponds with the location of the ulcer within the viscus. As ulcers are 
 most frefjuently found in the smaller curvature and in the region of the car- 
 diac and pyloric orifices, these localities should be carefully inspected. If the 
 ulcer involves the upper posterior wall of the stomach, it can be found and treated 
 only through an incision in the anterior wall. If the ulcer is located in the 
 anterior wall, it can be readily excised and the resulting wound united in the 
 usual manner. The closure of the wound made by excision of an ulcer of the 
 posterior wall must be done in such a manner that the superficial or Lembert 
 sutures are inserted and tied before the deep stitches are made, which are tied 
 last and cut short. The woun«l in the anterior wall is then closed in the 
 ordinary manner. As in all other operations on the stomach, the patient is 
 placed on an absolute diet for a number of days. Rydygier was the first to 
 subject an ulcer of the stomach to surgical treatment, and since his time a 
 number of successful cases have been reported. Excision of an ulcer followed 
 by gastrorrhaphy will undoubtedly prevent the remote consequences which 
 
j>/sj:a.sj:s a.\/> ixjuries of the ajii>()M1-:x. 715 
 
 would follow the cicatrization and spontaneous licaling if the disease were 
 allowed to i)ursuc its own course. 
 
 Cicatricial Stenosis. — Cicatricial stenosis of either ot the two ontices 
 of che stomach, the cardiac and the pyloric, freciuently follows as a remote 
 sequel the healing of an ulcer or a traumatic defect in these localities. If it is 
 located at the cardiac orifice, the stricture interferes with the introduction of 
 food into the stomach ; if it involves the pyloric orifice, it interferes with the 
 escape of chyme into the intestinal canal. The development of the stenosis is 
 a slow process, as it depends upon the formation and contraction of cicatricial 
 tissue which is formed at the site of the former trauma or ulcer. The forma- 
 tion of an excessive amount of granulation-tissue in a surface wound or ulcer 
 of the stomach takes place in consequence of the continual irritation caused 
 by the food and digestive fluids ; and it is on this account that cicatricial con- 
 traction so often follows the healing of a wound of the mucous membrane or 
 
 ulcer of this organ. . . , . , , 
 
 Diagnosis.— At the cardiac orifice a cicatricial stricture develops most 
 frequently after destruction of the mucous membrane by the action of caus- 
 tics or throucrh the injury caused by the lodgment of a foreign body or by rude 
 attempts to remove it, whereas ulcer constitutes the most frequent cause of cica- 
 tricial stenosis at the pyloric orifice. A cicatricial stricture at the cardiac orifice 
 of the stomach may be suspected if the patient has experienced a gradually 
 increasing difficulty in swallowing solid food. As the stricture grows nar- 
 rower, the oesophagus above it becomes dilated and solid food is regurgitated 
 soon after it is swallowed, while liquids still enter the stomach through the 
 constricted orifice. If the patient has not reached the age at which carci- 
 noma may be suspected, and if the clinical history points to an antecedent 
 pathological condition which is known to produce a stricture, it is almost certain 
 that a stenosis of a benign nature exists. The presence of the stricture and its 
 exact location are determined by the use of an olive-pomted oesophageal bougie 
 (p 697). A cicatricial stenosis of the pyloric orifice of the stomach gives rise 
 to obstruction at this point, retention of food, and dilatation of the stomach. 
 Such patients are usually treated for months or years for dyspepsia or mdiges- 
 tion, until finally a careful examination of the stomach reveals the existence 
 of tiie obstruction and great distention of the organ. 
 
 The diacrnosis of stricture of the jjylorus must be based on the history ot 
 the case, the use of the siphon stomach-tube, and inflation of the orgaj. Ihe 
 clinical historv will usually reveal the existence of disturbed digestion lor years 
 previously, incident to the presence of an unhealed ulcer, and more recently 
 caused by the obstruction. For a time compensatory hypertrophy balances the 
 mechanical difficulties caused by the stricture, but when this is no longer pos- 
 sible the walls of the stomach become attenuated and the cavity ot the organ 
 is enormously increased in size, containing remnants of food which have been 
 retained for days and often for weeks. Through the elastic siphon tube the 
 stomach is evacuated and irrigated, and the quantity of fluid which it holds 
 furnishes important information in reference to the size ot the organ. Air 
 can be forced through the stomach-tube after the organ has been thoroughly 
 emptied and irrigated, and the contour of the stomach then becomes visible 
 externally and its outlines can be accurately fixed by percussion, ^eidlitz 
 powder can be used for the same purpose, the two portions being dissolved 
 separately, the bicarbonate solution being swallowed at once, the tartaric acid in 
 divided doses. It is not uncommon to find the greater curvature of the stom- 
 ach considerably below the umbilicus if dilatation has progressed to any con- 
 siderable extent. The absence of a tumor in the pyloric region is indicative 
 
71<) AX A.]//:/:/(:\y Ti:xT-iiO(jk' or sfnaKRY. 
 
 of a cicatricial stenosis, but docs not precliule the possiltilitv of" malignant dis- 
 ease. A cicatricial stricture of either orifice of the stomach is certain to lead to 
 a fatal termination from marasmus unless the mechanical difliculty is remedied 
 hy sur<fical interference, as a jjatient suft'erinii; from a stricture of the cardiac 
 ■orifice dies from starvation on account of his inability to inti'oduce food into the 
 stomach, and a pyloric stricture leads to permanent and complete obstruction to 
 the passage of food, the patient finally succumbing to the combined effects of 
 inanition and the retention of putrefying and fermented food in the stomach. 
 
 Treatment. — Cicatricial stenosis of the cardiac orifice of the stomach 
 should be treated by gradual dilatation in all cases ■where it is possible to pass 
 even the finest filiform bougie through the stricture. The different kinds of 
 urethral bougies answer often an excellent purpose in the early treatment of 
 narrow strictures. Dilatation should be carried out gradually, but persistently, 
 until the normal size of the lumen of the orifice has been restored, and the 
 largest dilating instrument used should be employed every Aveek or two for a 
 long time subsequently, in order to prevent recurrence of the stricture. If the 
 stricture proves impermeable to the different kinds of dilating instruments, the 
 only course left is to resort to a gastrostomy, both for the purpose of establish- 
 ing a new route for the introduction of food into the stomach and in order to 
 afford another opportunity to make an attempt to dilate the stricture from 
 below. Abbe has recently devised a new method of treatment in cases of 
 oesophageal stricture. Afcer opening the stomach through an external in- 
 cision, he passes with an instrument a string through the stricture, and, bring- 
 ing one end out through the mouth and the other through the opening in the 
 stomach, divides the stricture by placing the string on the stretch and moving 
 it rapidly upward and downward until the stricture is divided. After the 
 oesophagus has been rendered permeable in this manner the visceral and ex- 
 ternal incisions are closed, and recurrence of the stricture prevented by the 
 frequent introduction of oesophageal bougies. 
 
 The operative treatment of a cicatricial stricture at the pyloric end of the 
 stomach consists in dilating the stricture forcibly through a wound in the 
 stomach (Loreta), or through a gastric fistula (Treves), in the formation of a 
 partly new pylorus by the Heineke-Mikulicz pyloro-plastic operation, or in 
 establishing a new outlet from the stomach into the upper portion of the small 
 intestine by making a gastro-enterostomy. (See p. 724.) 
 
 Dilatation of the Stomach without Mechanical Obstruction. — As 
 a rare pathological condition Ave occasionally find an enormously dilated stomach 
 without a mechanical obstruction at the pyloric orifice. The cause of dilata- 
 tion in such cases is a chronic catarrhal infianimntion of the mucous membrane, 
 which results in a Aveakenino; and attenuation of the muscular coat and gradual 
 yielding of all the tunics. If under dietetic and ap])r(i])iiate medical treat- 
 ment, including systematic evacuation of the stomach through the rubber 
 siphon tube and the application of the galvanic current directly to the interior 
 surface of the stomach through an insulated oesophageal tube, the function 
 and normal size of the organ cannot be restored, a " tuck " may be taken in 
 the stomach by scAving the greater curvature to the lesser by several roAvs of 
 stitches, as Bircher and Weir have done in four cases ; or a ncAv outlet from the 
 stomach into the small intestine may 1)0 made by a gastro-enterostomy (p. 7*24). 
 Bircher has recently recommendecl in such cases redujilication of the anterior 
 Avail of the stomach, with suturing of the fold by numerous catgut sutures, 
 and has reported several successful cases. Weir and others have resorted to 
 this procedure Avith satisfactory results. 
 
 Carcinoma. — MA-o-fibroma and other beniirn tumors of the stomach are 
 
DISt:ASE,S ASn lyjLIilES OF Till-: ABDOMEN. 717 
 
 extremely rare, and when present seldom necessitate surgical interference. 
 Sarcoma as comj)ared Avith carcinoma is so extremely rare that it is necessary 
 only to speak briefly of carcinoma as a tumor of the stomach which interests 
 the surgeon. It a})pears that in the stomach the general law is observed that 
 this disease develops in preference at points where two kinds of epithelial cells 
 meet. It is a well-known clinical fact that in the stomach the disease has its 
 primary starting-point most fre((ucntly at the pyloric or the cardiac orifice, and 
 of these two regions the pyloric is the more fre(iuently aflTected. 
 
 Carcinoma in either of these localities gives rise to a combination of clinical 
 symptoms which suggest the existence of ulcer and stricture. As soon as 
 the surface of the carcinoma ulcerates, hemorrhage into the stomach is of fre- 
 quent occurrence, and the tumor, by narrowing the orifice, at the same time 
 gives rise to obstructioi:^ ^^ tlie same manner as a simple stricture. It is not 
 always easy or even possible to ascertain the existence or exact location of a 
 carcinoma of the stomach by any of the known physical signs. A carcinoma 
 at the cardiac orifice, from its deep location, may attain a considerable size 
 before its presence can be demonstrated by palpation or percussion. In 
 the majority of advanced cases of carcinoma of the pylorus, however, a dis- 
 tinct tumor can be felt in the pyloric region, but often the weight of the 
 tumor has carried that part of the stomach in a downward direction, and the 
 tumor may be found as low as the level of the umbilicus. The size of the 
 stomach is greatly diminished in carcinoma at the cardiac orifice, while if the 
 disease is located in the opposite extremity the organ is often found enormously 
 distended in consequence of the long-standing obstruction. It is sometimes 
 not easy to differentiate between a carcinoma of the pyloric extremity of the 
 stomach and a retro-peritoneal tumor in that locality. Inflation of the stomach 
 is the most reliable diagnostic procedure in such cases. If the tumor is retro- 
 peritoneal, it becomes covered by the distended stomach ; if it belongs to the 
 stomach, though it may be displaced downward, its position relative to the 
 anterior wall of the abdomen remains unchanged by the inflation. The exist- 
 ence of a carcinoma at the cardiac orifice can be shown by the oesophageal 
 bougie, and the degree of contraction at this point is ascertained in the same 
 manner. A carcinoma of the stomach may be suspected if a patient more 
 than forty years of age gives a history of disturbed digestion dating back for 
 several months or a year, combined with evidences of cardiac or pyloric steno- 
 sis. The chemical examination of the contents of the stomach, so much relied 
 upon during the last feAv years in making a differential diagnosis between 
 benign and malignant affections of this organ, is not always reliable, but will 
 often yield valuable diagnostic information. Free hydrochloric acid is not 
 infrequently found in the stomach contents in carcinoma, and it may be ab- 
 sent in catarrhal gastritis and non-malignant pyloric obstruction. Hematemesis 
 in persons beyond middle age, and enlargement of the cervical glands, indi- 
 cate malignant disease. A tumor affecting the anterior wall of the stomach 
 can usually be demonstrated by the gastrodiaphanoscope. 
 
 The surgical treatment of carcinoma of the stomach consists either in the 
 removal of the mechanical obstacle which interferes with the introduction of 
 food into the stomach or with its escape from it, according to the location of the 
 tumor, or in the removal of the disease. In carcinoma of the cardiac orifice life 
 can be prolonged by keeping the strictured portion patent by the careful intro- 
 duction of oesophageal tubes. Liquid and finely divided food can be introduced 
 in this manner. If the stenosis has reached such an extent that it is 
 difficult to introduce stomach-tubes, a small rubber tube should be passed 
 through one of the nasal passages and into the stomach, to be retained in 
 
718 .i.v AM /:/:/( A. y ri:xT-JiooK of sunaKRV. 
 
 pliit-e, and tlirough this licjuid food can be injected into tlie stomach. If this 
 method of feedini: is no lon<;er possible, a pistrostomy is indicated. A limited 
 carcinoma of the pylorus, if it has not resulted in secondary infiltration of the 
 lymphatic glands behind it, furnishes a legitimate indication for a radical ope- 
 ration. (See Operations, p. 725.) If, however, the disea.se has extended 
 beyond the walls of the stomach, pylorectomy is contraindicated. and the sur- 
 geon must be content to establish a new outlet from the stomach into the upper 
 portion of the small intestine. In pyloric carcinoma life is greatly prolonged 
 and much suffering prevented by placing the patient on a carefully selected 
 diet and bv resorting to irrigation of the stomach as often as the retention of 
 the undigested food may render it necessary. 
 
 Gastric Fistula. — An external gastric fistula may form as one of the 
 results of a perforating ulcer of the stomach if adhesions between the anterior 
 surface of the stomach and the abdominal wall have shut out the peritoneal 
 cavity before perforation occurred. It may also develop after a })erforating 
 wound of the stomach if peritonitis is prevented by a speedy union between 
 the margins of the visceral and parietal wounds. An intentional gastric fistula 
 may require surgical treatment for its closure if the object for which the fistula 
 was made has been accomplished, as when it has been undertaken with a view 
 of dilating a cicatricial stricture of the cardiac orifice or the lower portion of 
 the cesophagus. 
 
 Treatment. — If the fistula is short and leads directly into the stomach, 
 an effort should be made to close it without opening the peritoneal cavity. 
 The abdominal wall should be incised to the extent of at least two inches down 
 to, but not through, the peritoneum. This Aviil expose the opening in the 
 stomach. The lining of the fistulous track is now freely excised, special care 
 being taken to vivify that portion of the fistula which corresponds to the wall 
 of the stomach. In closing the fistula the line of sutures must be applied in 
 the direction off'ering the least traction. The first row of sutures is made with 
 fine silk, and should embrace the mucous and submucous coats. The remain- 
 incr coats of the stomach are broujrht together with strong catgut sutures. The 
 margins of the wound corresponding to the abdominal wall are united Avith a 
 deep row of catgut and a superficial row of silk sutures. An antiseptic compress 
 retained with long strips of adhesive plaster constitutes the dressing. Nothing 
 should be given by the stomach for at least four or five days. Thirst is quenched 
 with fragments of ice, and food is administered exclusively by the rectum. If 
 this operation shouM fail, and in cases where it is not applicable, the abdo- 
 men must be opened, the stomach separated from the abdominal wall, and the 
 fistulous opening closed in the same manner as a visceral wound of this organ. 
 Wherever it is possible to cover with peritoneum that part of the Avail of the 
 stomach Avhich has been separated, this should be done, as this Avill secure a 
 more speedy and certain union of the sutured parts. As an additional precau- 
 tion it might be advisable to fasten the sutured part of the stomach to the 
 inner surface of the abdominal wound Avith a few catgut sutures, and drain the 
 external Avound Avith an iodoform gauze tampon d(»wn to this ])oint. Avhieh Avould 
 eff'ectually protect the peritoneal cavity against extravasation should the visce- 
 ral Avound fail in healing by primary intention. 
 
 OPERATIONS ON THE STOMACH. 
 
 Gastrotomy. — The term gastrotomy Avas used for a long time synony- 
 mously Avith abdominal section or laparotomy, as Avell as to designate the ope- 
 ration of temporarily opening the stomach for the removal of a foreign body, etc., 
 
DISEASES AM> IX/i'Ji/ES OE THE A Ji DOMEX. 
 
 71 'J 
 
 but is now restricted to the latter operation, while the opening ot the i)eritoneal 
 cavity is designated as abdominal section, laparotomy, or, as has recently been 
 proposed by Harris, coeliotomy. As compared with the operation whicli will be 
 described as gastrostomy, the wound in the stomach, irrespective of its purpose, 
 is always closed ; that is to sav, gastrotomy is always followed by gastron-haphy. 
 Gastrotomv is performed for the removal of foreign bodies which have become 
 lod-ed in the stomach, or for tiie rem-.val of a gastrolith (Thornton, Schon- 
 born, and others), or for the purpose of treating lesions withm the stomach. 
 ITnder the last heading mav be mentioned the localization and direct treat- 
 ment by excision of ulcers and the digital divulsion of cicatricial strictures ot 
 the pvloric or tbe cardiac orifice. The stomach should be washed out with a 
 weak'aiitiseptic solution, such as salicvlated water or boric-acid solution, im- 
 mediately before the anesthetic is administered, in order to prevent extrava- 
 sation in the vicinity of the wound after making the incision. 
 
 In the majority of cases it will suffice to make an incision tlirough tlie 
 abdominal wall from the ensiform cartilage to the umbilicus, and if more room 
 is required a small transverse incision can be added on the side of the median 
 line where it will be most needed. The anterior wall of the stomach is now 
 broutrht well forward into the wound, which, if the organ is normal in size, 
 can ^eadilv be accomplished without inflation. The peritoneal cavity is then 
 protected by packing sterile gauze around the exposed portion of the st/^m- 
 ach. The incision is always made transversely to its long axis. The best 
 method of opening the stomach is to cut down to the mucous membrane with 
 a sharp scalpel, and then open the organ between two catch-tooth forceps and 
 enlarr'e the incision to the reiiuisite extent with blunt-pointed scissors. After 
 the foreign body has been extracted, or the visceral lesion remedied, the wound 
 is closed^ in the manner described below. Stomach-feeding should not be 
 commenced for at least four days, Avhen small quantities of liquid food are to 
 be given at short intervals. Up to this time thirst is allayed by allowing 
 small fragments of ice to dissolve in the mouth and by enemata of salt solu- 
 tion, and%he strength of the patient is sustained by rectal alimentation. 
 
 Gastrorrhaphy.— Gastrorrhaphy signifies the closure of a woundof the 
 stomach by suturing. It is done in the same manner as in enterorrhaphy. 
 After careful hemo?tasis, the deep or buried sutures are first applied. These 
 should consist of fine aseptic silk, are made to include all the coats of the 
 stomach with the exception of the peritoneum, and are cut close to the knot. 
 About four sutures to an inch will be required The superficial sutures of fine 
 silk should include the peritoneum and enough of the subjacent tissue to give 
 them a firm hold. An ordinary sewing-needle is inserted about a quarter of 
 an inch from the margin of the wound, and is brought out near, but not at, 
 the margin, re-entered on the opposite side at a similar point, and brought out 
 at the same distance from the wound on the opposite side. As the superficial 
 sutures are being tied the peritoneum is gently inverted. It is thought by 
 some surgeons (Senn) that slight scarification of the peritoneum hastens the 
 process of repair ; and on this account they deem it advisable, before the super- 
 ficial sutures are tied, to subject to this treatment the peritoneal surfaces which 
 are to be brought into apposition. Others are of the opinion that scarification 
 adds nothing to the rapidity of union between such opposed serous surfaces. 
 Gastrostomy. — Gastrostomy is an operation for establishing a fistulous 
 opening in the stomach through 'the anterior abdominal wall. A resort to this 
 operation is indicated in cases of malignant or cicatricial stenosis of the oesoph- 
 a^rus or cardiac orifice of the stomach advanced to such an extent that the 
 introduction of food per viam naturalem or by the use of tubes is no longer 
 
720 A A AMi:m( A.\ I i:xr- HOOK o/' sr 1:01:1: v. 
 
 possible. Tlie results of this operation in malignant dist-ase have tlius far not 
 proved verv satisfactory, as it lias seldom been jx-rfonueil before the patient 
 had reached an extreme dejz;ree of marasmus ^vhi^•h in itself proved the great- 
 est source of danger. As the object of the operation is to establish a <fastric 
 fistula through which food can be introduced into the stomach, it is evident 
 that the opening in the stomach sliould be made as near as possible to the car- 
 diac orifice. In all instances in wliich the patient's strength warrants the per- 
 formance of the oj>eration in two stages, as was first suggested by Mr. Ilowse, 
 this method should be practised, as it is much safer than that by Avhich the 
 stomach is opened at once. 
 
 Forster, Durham, and Verneuil made the abdominal incision in the line of 
 the left linea semilunaris. Fenger's incision is the one which has been em- 
 ployed most fre(iuently. This incision, from three to four inches in length, is 
 made to the left of the rectus muscle, a little below and parallel to the left 
 costal arch. The tissues are divided, layer after layer, with a sharp scalpel 
 until the peritoneum is reached. This is incised between two forceps and the 
 opening enlarged to each angle of the wound. It is essential to protect the 
 muscular and connective tissues of the belly-wall against the action of micro- 
 organisms and the gastric juice ; hence the first thing to be done after opening 
 the abdominal cavity is to suture the parietal peritoneum to the skin with fine 
 silk or catgut stitches. If it is difficult to find the empty and contracted 
 stomach, the next step of the operation is to inflate the organ, which will 
 bring its anterior wall into sight, Avhen it can be drawn into the wound. 
 By this procedure the operation is greatly facilitated and the surgeon will 
 avoid the eiror of opening the colon in place of the stomach, as was done 
 by Maunder. The stomach should be drawn forward sufficiently to make 
 a small cone, and in this position it is fastened by suturing it to the sides 
 of the Avound. Langenbeck made use of two long steel needles in anchoring 
 the stomach more securely in the wound, the needles transfixing both margins 
 of the wound and the Avail of the stomach. The needles should not enter 
 the lumen of the stomach. 
 
 If the patient's strength can be maintained by rectal alimentation for four 
 or five days, the opening of the stomach sliould be postponed until that 
 time, as then the organ will have become firmly adherent to the abdominal 
 wound. If, however, the symptoms are very urgent and the delay of stomach- 
 feeding might endanger the life of the patient, a small incision is made at once in 
 the stomach, into Avhich a small rubber tube is fixed, and through this at short 
 intervals licjuid food and stimulants are injected. The opening in the stomach 
 should never be large, as there is nearly always a tendency to the escape of 
 food from the fistulous opening. That even five days will not always suffice to 
 prevent separation of the stomach from the abdominal wound is shown by a 
 case in which the needles were removed on the fifth day, and as the stomach 
 appeared to be firmly adherent it was opened and stomach-feeding commenced. 
 Two days later the stomach was found completely separated, and its contents 
 escaped into the peritoneal cavity, causing a rapidly fatal ])eritonitis. 
 
 A number of operations have recently been devised for the jmrjiose of 
 eflfectually i»revejiting leakage through the fistulous <)j)enings. The Ssabana- 
 jew-Franck method (Fig. 288) has j)roved satisfactory in many cases. The 
 stomach is first exj>osed by an incision parallel with the left costal margin, its 
 anterior wall seized and a cone drawn out. A second incision parallel with 
 the first is now made one inch al)0ve the costal margin, and the two made to 
 communicate by freeing the skin from the sulijacent muscles by blunt dissec- 
 tion. The portion of stonuich which had been seized is carried under this 
 
f)isi:ASEs Axi) ly.niur.s or riii: ahdomen. 721 
 
 bridge of skin and out of the secontl incision, wliere it is sutured. The 
 first incision is tiicn closed. The stonnich nuiy be opened at once, or at a 
 
 Fk;. 1>8S. 
 
 The Ssnbanajew-Franck Method of (instrostomy. 
 
 later time if there be no haste. By thus brincring the stomach out over the 
 border of the costal cartilages leakage is largely prevented. 
 
 E. J. Senn relies on a circular valve, which he forms by inverting and 
 ftisteninir witb sutures the tip of the cone in preventing the escape of the 
 food. The last-mentioned procedure has yielded excellent functional results 
 in the hands of a number of operators. 
 
 Witzel's Method of Gastrostomy : a, first stage-c, the rubber tube ; a, a', b, 6', two folds of the wall of 
 stomach with threads inserted ; d, hole in stomach for insertion of tube, b, second stage-tube buried 
 by tying the stitches, thus approximating a to h, and a' to b'. 
 
 Witzel has proposed a new method of performing gastrostomy which has 
 yielded excellent results, and has been quite generally adopted by the pro- 
 fession. The external incision is made to the left of the median line through 
 the rectus muscle. After bringing the stomach forward into the wound, an 
 opening is made at the desirable point in the anterior wall large enough to 
 permit'the insertion of a rubber tube a little larger than an ordinary lead- 
 pencil (Fig. 289 A, e). After the introduction of the tube two vertical folds, one 
 on each side of the opening, are made (a, a', b, h'\ which are united over the 
 tube by a number of muscular sutures to a distance of at least two inches 
 (Fig. 289 b). The distal end of the tube is brought out through the upper angle 
 
 46 
 
1-22 Ay AMK1U<JA.\ TKXT-JiOOk' <)l SI lid Ell Y. 
 
 )t" till' external incision, to which the stomach is securely fastened with a 
 number of sutures, after which tlie balance of the external wound is closed. 
 Food can be introduced at once throufjh the tube. The tube may sometimes 
 be removed after a permanent channel has been established, and reinserted 
 only for feeding purposes. The valvular construction of the internal opening 
 effectually prevents the escape of food. Keen and others have reported suc- 
 cessful cases by this method. 
 
 After the fistula has been well established the stomach-feeding is to be 
 managed in such a manner that the patient masticates all solitl food, which is 
 then injected through a rubber tube, or, if the opening and tube are large 
 enough, it is poured in through a funnel. The act of mastication satisfies at 
 least in part the sensation of hunger, which is not always the case if stomach- 
 feeding is exclusively relied on. Gross and Zesas have collected respectively 
 207 and 162 cases, with surprisingly different rates of mortality ; that of Gross 
 being only 29.47 per cent., while Zesas' mortality was GO per cent, for cica- 
 tricial stenosis and 84 per cent, for malignant cases. The operation should 
 not be made responsible for this bad showing, however, because we have reason 
 to believe that in most cases the disease would have proved fatal in a short 
 time without it. These unfortunate results should only remind us not to post- 
 pone the operation until the patient has not sufficient recuj)erative powers left 
 to rally from its immediate effects and to secure satisfactory repair. If gas- 
 trostomy is undertaken as a preliminary step in the treatment of impermeable 
 cicatricial strictures of the cardiac orifice or of the lower portion of the oesoph- 
 agus, the fistula is closed as soon as the patency of the normal channel has 
 been restored by rapid or gradual dilatation. 
 
 Digital Divulsiox of Cicatricial Strictures of the Pylorus. — In 
 1883, Loreta of Bologna introduced a new method of treating non-malignant 
 strictures of the pylorus, which consists in opening the stomach a little nearer 
 the pyloric than the cardiac extremity, and passing first the right index finger 
 through the strictured portion, and later also the left, and then separating them, 
 as he did in the first case, more than three inches. Considerabk force is usu- 
 ally required in dilating the stricture to this extent, and during such forcible 
 stretching there is always danger of tearing through the entire thickness of the 
 wall of the pylorus. The wound of the stomach is closed in the same manner 
 as after gastrotomy for other purposes. The stomach should be thoroughly 
 emptied by irrigation with a boric-acid solution before the operation, and dur- 
 ing the stretching process the visceral wound should be drawn well into the 
 abdominal incision. Notwithstanding the f^ict that a number of successful 
 operations of this kind have been reported, it is more dangerous and uncertain 
 in its results than the pyloro-plastic operation of Heineke-Mikulicz (see below). 
 To the immediate risks of Loreta's operation, rupture of the pylorus and hemor- 
 rhage, must be added recurrence of the stricture, which is certainly one of the 
 most common remote consequences following the treatment of cicatricial stenosis 
 by rapid or slow dilatation, wherever the stricture may b: located. In this 
 particular it can hardly be a.«sumed that stricture of the pyiorus constitutes the 
 sole exception. The same distinguished surgeon resorted to instrumental divul- 
 sion of cicatricial stenosis of the cardiac orifice through an incision of the stomach, 
 and the two cases which he treated by this method were reported as cured. 
 The dilatation was made with an instrument resembling that of Dupuytren for 
 lithotomy. 
 
 Forcible dilatation of strictures of the cardiac orifice is a far more difficult 
 operation than stretching of the pylorus, but, as from the inaccessibility of this 
 
JJISKASES AM) I.\jriiJi:s OF Till': AJiJXjMEN. 
 
 723 
 
 region no plastic operation can be performed, the operation will have a limited 
 field of usefulness in the surgery of this part of the stomach. 
 
 Pyloroplasty. — The operation for cicatricial stenosis of the pylorus 
 well deserves the name pyloroplasty, as it not only removes the mechanical 
 obstruction, but at the same time creates a new pylorus. This operation 
 was first devised by Ileineke of Erlangen, and eleven months later Mikulicz, 
 ignorant of lleineke's work, did the oj)eration in exactly the same manner. 
 The operation is done by cutting through the anterior wall of the pylorus 
 and extending the incision about an inch toward the stomach and the same 
 distance in the direction of the duodenum, as is shown in Fig. 290. This 
 incision divides the stricture, and the contracted pylorus becomes the pos- 
 terior wall of the new pylorus by retracting the margins of the wound on 
 each side at the center with a tenaculum and suturing the wound trans- 
 versely to the long axis of the stomach, as represented in Fig. 290. The 
 
 Fig. 291. 
 Fig. 290. 
 
 Pyloroplasty : theuxisof the incision is changed 
 Pyloroplasty: the incision. by traction from horizontal to vertical: su- 
 
 tures in position ; only one of the two rows 
 of sutures is shown. 
 
 new pylorus is made up of tissue taken partly from the duodenum and partly 
 from the anterior wall of the stomach, the posterior wall being composed of 
 the narrow, contracted pylorus. In suturing the wound it is advisable to tie 
 first from each angle of the wound, tying the central sutures last (Fig. 291). 
 Two rows of sutures are employed, the same as in closing a wound of the 
 stomach. Recurrence of the stricture is a physical impossibility, as the new 
 
 Fig. 292. 
 
 Pyloroplasty : aftt-r tying the sutures. 
 
 pylorus is composed mostly of healthy ti.ssue, and the danger attending the 
 operation is not greater than that which accompanies an ordinary wound of 
 the stomach. The results of this operation have been very satisfactorv, and 
 it is almost certain that it will take the place of all other operations in the 
 surgical treatment of cicatricial pyloric stenosis ia which the pathological 
 conditions permit of mobilizing tissue for the construction of the new pylorus. 
 
7:^4 ^l.V AMERICAN TEXT- HOOK OF SlJiaEIiV. 
 
 Gastro-extkhostu.mv. — This operation is intended to establish an anas- 
 tomotic openin<2; between the stomach and upper portion of tlie suiail intestine 
 in eases of malignant stenosis of the ftylorus. It was devised and first 
 practised by WiilHer. He made an incision about three inches in lenffth 
 m the anterior wall of the stomach at a safe distance from the carcinoma and 
 near the great curvature, and a similar incision in the convex side of the intes- 
 tines about thirty inches below the plica duodeno-jejunalis, and united these 
 two visceral wounds with sutures, thus establishing a direct communication be- 
 tween the stomach and the small intestine. In uniting the ppsterior margins 
 of the wounds the serous or superficial sutures should be first inserted and tied, 
 and then the inner or second row of sutures are tied and cut short to the 
 knot. J^ilk should be used exclusively as suturing material. It is advis- 
 able to insert and to tie securely the posterior row of Lembert's sutures 
 before the . visceral incisions are made. In Wolfler's operation the move- 
 ments of the intestine at the point of juncture are in a direction opposite 
 to the peristaltic action of the stomach, a condition which must be unfavor- 
 able to the easy escape of the stomach contents into the intestinal canal — a 
 circumstance which led Rockwitz so to modify the operation that he turns the 
 intestinal loop one-half around its axis and unites it with the stomach in this 
 position, and thus brings the two organs in such a relative position that the 
 peristaltic wave of both is in the same direction. Yon Hacker has modified 
 the operation still further, and establishes the communicating opening in 
 the posterior instead of the anterior wall of the stomach. This is the opera- 
 tion of choice. The portion of intestine which should be united with the 
 stomach is that which lies from twenty-four to thirty inches below the pylorus. 
 Operators have experienced a great deal of difficulty in finding this place 
 without too great loss of time and unnecessary handling of the intestines. 
 Luecke advises to seize and unite with the stomach the first intestinal loop 
 that presents itself in the wound, and gives it as his opinion and the result 
 of his experience that in doing so the anastomotic o])ening will invariably be 
 made near the desirable point and not distant from the duodenum. This 
 advice has led to serious mistakes. In one case in whicli this direction was 
 followed, the post-mortem revealed that the opening had been made eight 
 feet below the pylorus, and in one of Lauenstein's cases the opening was 
 found near the ileo-Ciecal region, conse(|uently nearly the entire lengtli of 
 the small intestine had been excluded from participation in the processes of 
 digestion and absorption. 
 
 In searching for the upper portion of the small intestine it is not always 
 easy to find the plica duodeno-jejunalis. The following plan of search may be 
 recommended. The first loop that presents itself is brought forward into the 
 wound, and is held in this position by an assistant, while the surgeon follows 
 the intestine in one direction, observing carefully its color and the thickness 
 of its walls as loop after loop is examined. If the intestine leads in an 
 upward direction, the color becomes paler and the walls thicker, and the duo- 
 denum will soon be reached. If he is tracing the bowel in an opposite direc- 
 tion, the intestine becomes gradually smaller, its walls thinner, and the color 
 is more of a bright red. Should this be the case, the loops of the intestines 
 are returned, and the examination is made from tlie loop held by the assistant 
 in an opposite direction, which will soon lead to the part that it is intended to 
 unite with the stomach. As soon as the desirable loop is reached, it should be 
 turned around, and held in this position by an assistant until the anastomosis 
 has been completed (Fig. 2'.t8). According to Keen, from 1891 to 1806, 401 
 gastro-enterostoraies had been reported, with a mortality of 33.91 per cent. 
 
DISEASES A XI) IXJllilES OF THE ABDOMEN. 
 
 725 
 
 Fio. 293. 
 
 Gastro-enterostomy (Rockwitz). 
 
 Mikulicz lias oj)erate(l on 74 cases with 24 deaths (32.5 ])er cent.). Carle 
 i-t|)ort8 27 ^astro-enterostoniies for non-malignant stricture, with but two 
 deaths, and one of these was due to 
 hemorrhage from an ulcer of the stom- 
 ach, and not to the operation. The 
 mortality is due to the deldlitnted con- 
 dition of the patients operated on and 
 to the great length of time required 
 to unite the visceral wounds. Unnec- 
 essary loss of time is a source of great 
 danger in the class of cases in which 
 it becomes necessary to make a gastro- 
 enterostomy. 
 
 Senn has modified Wolfler's opera- 
 tion by securing apposition between 
 the stomach and the intestine by means 
 of perforated decalcified bone plates, 
 which he asserts greatly shortens the operation and brings the parts into a 
 more favorable condition for speedy union. This procedure and its modifica- 
 tions are fully described in the chapter on Intestinal Obstruction. The 
 approximation plates are reinforced by a number of superficial sutures in the 
 same manner as in establishino; an intestinal anastomosis. The serous sur- 
 faces interposed between the plates must be scarified. As the mucous mem- 
 brane of the stomach shows a great tendency to turn out, it should be fastened 
 in the middle of the wound on each side with a fine catgut suture before the 
 viscera are approximated. A gastro-enterostomy with the aid of approxima- 
 tion plates can be completed in half an hour. At the present time the Murphy 
 button has superseded most of the other mechanical devices for approximating 
 the stomach and intestine, as well as different portions of the intestine. 
 
 The tendency of many surgeons, however, is to abandon mechanical aids 
 of all kinds and to rely on suturing exclusively in performing gastro-enter- 
 ostomy and entero-anastomosis. 
 
 Patients with carcinoma of the pylorus who survive a gastro-enterostomy are 
 relieved of much suffering and live in comparative comfort for from three months 
 to a year or more. The operation proves most beneficial in cii-cular car- 
 cinoma of the pylorus with great distention of the stomach. It is contraindi- 
 cated if the disease has become diffuse and the organ is not much dilated. The 
 operation is also not applicable if the general strength of the patient is so much 
 reduced that death is likely to result from the immediate effects of the pro- 
 cedure, or if the disease has extended to other important organs and death 
 would ensue in a short time from this cause. In well-selected cases gastro- 
 enterostomy is a legitimate operation which is destined to relieve suffering, 
 prolong life, and reflect credit on the achievements of modern surgery. 
 
 Pylorectomy. — Excision of the diseased pylorus is called pylorectomy. 
 This operation, first done on animals, was suggested by Winiwarter and Gussen- 
 bauer as a remedy for carcinoma of the pyloric end of the stomach, but the first 
 operation on the human subject was done by Billroth. The mortality in 
 cases with extensive adhesions is 72.7 per cent., while it is but 27.2 per 
 cent, in those free from the adhesions. Of 84 cases in the practice of 
 Kocher, Kronlein, Czerny, and Mikulicz, there were 75 per cent, of suc- 
 cesses. Of those that survived the immediate effects of the operation, all 
 but one died in a period varying from four to eighteen months. Gastro- 
 enterostomy can show a much lower mortality and a prolongation of life of 
 
■2(j 
 
 AN AMJ'JJilCAX TEXT- HOOK OF SlIidKnY. 
 
 the survivors of from two months to a year and more. Pylorectoniy .should Ite 
 limited to cases of circumscribed annular carcinoma of the pylorus in -which 
 the disease has not extended beyond the wall of the viscus. Adhesions of the 
 pylorus to other organs and the presence of infected lymphatic glands are abso- 
 lute contraindications. As a positive diagnosis of carcinoma of the pylorus 
 cannot usually be made suflSciently early to justify this operation, the surgeon 
 ■will generally find, after he has opened the abdomen and ascertained by direct 
 inspection ami palpation the extent of the disease, that he is forced to abandon 
 the original intention, and Avill complete the operation by making a gastro- 
 enterostomy. In the absence of regional metastasis and extension of the dis- 
 ease by contiguity to adjacent organs, a radical operation is indicated, provided 
 the patient's strength is sufficient to warrant its performance. It is to be hoped 
 that future research will enable physicians to make a sufficiently early diagnosis 
 to bring all cases of pyloric carcinoma within the reach of successful radical 
 surgical treatment. 
 
 Preparatory to the operation the stomach should be placed in a ccndition 
 of absolute physiological rest for at least two days, during whicli time it should 
 be washed out' daily through an elastic siphon tube with a weak antiseptic solu- 
 tion, such as salicylated water or a solution of boric acid, and for the last time 
 this should be done immediately before the anesthetic is given. If no contra- 
 indications are present, chloroform should be given in preference to ether, as it 
 is less liable to be followed by retching and vomiting. In opening the abdo- 
 men Billroth prefers a transverse incision made over the middle of the tumor, 
 if such is present, and sufficiently long to secure ready access to the seat of 
 operation. Bleeding must be carefully arrested before the peritoneal cavity is 
 opened. The pylorus is now brought well forward into the wound with vol- 
 sellum forceps, and the peritoneal cavity is protected against infection during 
 the operation by packing aseptic or iodoform gauze around the parts to be 
 
 Fig. 294. 
 
 Fi(i. -290. 
 
 Oblique Division of the Stomach and Duod- 
 enum in Pylorectomy (EJsmarch and Kow- 
 alzig). 
 
 Duodenum united to the 'irvatir Curvature: upper por- 
 tion of incision throuf,'h the stomach sutured before 
 the section was completed lEsmarch and Kowalzin). 
 
 excised. The omentum below the pylorus is tied in small sections and divide<l 
 between two silk ligatures. The other connections are dealt with in a similar 
 manner. As soon as the pylorus is isolated it can be drawn farther forward into 
 the wound, and a small compress of gauze or a sponge is placed underneath it ; 
 in either case the precaution should be taken to attach a forceps to guard 
 against losing the compress or sponge in the abdominal cavity. If the stom- 
 ach has been washed out thoroughly, there is no danger of perit(mitis from 
 extravasation, as the small quantity of fluid which it contains can be removed 
 with a sponge as it escapes when the organ is incised, or it is taken up by the 
 underlying gauze. The incision through the duodenum and stomach should 
 be made at least an inch from the border of the tumor (Fig. 294). As the 
 
4 
 
 DISEASES AND INJURIES OF THE AHDOMEN. I'll 
 
 incision thvongli the stomach will be much larger than that through the duo- 
 denum, Billroth commences at the upper border, and follows the knife by 
 suturing until the remaining length of the incision will correspond with the 
 section through the duodenum, wdien the section is completed, the duodenum 
 divided, and the part removed. The duodenum should always be attached to 
 the larger curvature of the stomach, as shown in Fig. 21>r>. 
 
 In uniting the duodenum with the stomach fine aseptic silk sutures are 
 inserted by a round needle in a holder, first at the cut edge of the stomach 
 between the mucous and muscular coats, so as to include the muscular coat 
 and the ])eritoneum ; then inversely through the same layers of the duodenum; 
 and finally brought out between these layers and the mucous membrane at the 
 cut edge of the duodenum. After tying the posterior sutures the anterior por- 
 tion of the wound is closed in the usual manner. In bringing the cut sur- 
 faces together, care must be taken to avoid the formation of folds. Billroth 
 warns not to attach the duodenum to the lesser curvature of the stomach, 
 as the location of the new pylorus in that locality is unfavorably situated for 
 the free escape of the contents of the stomach into the duodenum. Any weak 
 points in the line of suturing should be reinforced by superficial sutures. In 
 some cases Billroth sutured the incision in the stomach completely, and 
 implanted the duodenum into a slit in the anterior wall of the stomach near 
 the greater curvature. In some instances it may be found advantageous to 
 close both incisions and follow the pylorectomy by a gastro-enterostomy, a 
 method of operating which has recently been brought prominently to the atten- 
 tion of the medical profession by Bulfof New York and Tuholske of St. Louis, 
 the first of whom reports two successful cases. The abdominal incision must 
 be carefully closed by several rows of buried sutures and by superficial sutures, 
 and tension relieved by at least two button sutures. The after-treatment, as 
 in all other operations on the stomach, consists in withholding food by the stom- 
 ach for several days, relying during this time exclusively on rectal feeding and, 
 if need be, on the hypodermatic administration of stimulants. After two or 
 three days small quantities of liquid food frequently repeated are allowed, but 
 solid food must be strictly excluded from the diet until the visceral wound is 
 healed. Should flatulency occur, it is relieved by a turpentine enema. 
 
 Gastrectomy. — Gastrectomy literally signifies the excision of the entire 
 stomach, but as the term has been used in surgery until recently it means the 
 removal of only a part of this organ. In pylorectomy a partial gastrectomy 
 is always made ; but if a portion of the stomach is removed Avithout excision 
 of the pylorus, the operation is known as a partial gastrectomy. In the sur- 
 gery of the stomach this operation may come into use in the excision of an 
 ulcer or the removal of a limited carcinoma in the anterior Avail of the stom- 
 ach or the greater curvature. In removing a portion of the wall of the 
 stomach for either of these indications the incisions should be made in 
 such a manner that the resulting wound can be safely sutured with the 
 least possible tension and without reducing the lumen of the organ more 
 than is absolutely necessary for the complete removal of the disease. 
 
 When the entire stomach is removed the operation is called total ga^strec- 
 tomy. The first complete excision of the stomach for malignant disease 
 was performed by Schlatter, of Zurich, during the winter of 1897. The 
 patient, a Avoman, greatly debilitated by the disease, recovered and lived for 
 fourteen months. Digestion and assimilation seemed to be but little impaired 
 by the loss of the stomach. A few other similar cases have been reported by 
 Brigham. Richardson, and others, Avith some successes. Complete gastrec- 
 tomy has necessarily a very limited legitimate application in surgery. 
 
728 J.v AMi:i;i(Ay riixr-iiooK oy srnai.uy 
 
 PART irr.-DISEASE8 AND INJITRIES OF THE INTESTINES. 
 
 Wounds and Rupture of the Intestines. — Gunshot and stab wounds 
 of the intestines have been described in a previous chapter, and it is only 
 necessarv here to refer verv briefly to tlie subject of contused and hicerated 
 wounds caused by external violence, but not attended by a perforatiiit; wound 
 of the abdomen. Contused and lacerated wounds of the intestine result usually 
 froni a kick or blow or from the passage of a carriage-wheel over the abdomen. 
 
 In a contusion of the intestine all the coats may be injured without 
 fecal extravasation taking place. Such an injury is followed by more or less 
 inflammation of the injured part and circumscribed })eritonitis. If the injury 
 is not extensive, adhesion to an adjacent serous surface takes place, and the 
 patient recovers. If, however, the inflammation is severe, gangrene, perfora- 
 tive peritonitis, and death ai'e almost sure to follow. Rupture of the intes- 
 tine varies in extent from a few lines to complete division of the bowel. The 
 size of the wound in partial rupture and of the lumen of the intestine in com- 
 plete laceration is diminished by bulging of the mucous membrane. As in 
 cases of stab and gunsiiot wounds of the intestines, contusion and laceration 
 of the intestines are injuries which are seldom diagnosticated before the abdo- 
 men is opened or before the diseases to which they give rise make their appear- 
 ance. In rupture of the intestine extravasation and hemorrhage often cause 
 symptoms resembling shock, but these are not invariably present and are by 
 no means pathognomonic. It is possible that in the future the hydrogen-gas 
 test will yield valuable diagnostic information in the differentiation between 
 contused and lacerated wounds. If there be an opening in the intestine, the gas 
 will escape through it and produce a well-marked free tympanites. The prob- 
 able diagnosis must rest on the manner in which the injury was inflicted, the 
 degree of force applied, and a careful study of the local and general symptoms. 
 
 Treatment. — Patients who have received an injury of the abdomen 
 should be kept in bed on an absolute diet for several days if the symptoms 
 are such as to make a rupture of the intestine improbable. Under this treat- 
 ment a contusion of the intestine will be followed by recovery, as a rule. If 
 the symptoms point to the probability of a rupture of the intestine, immediate 
 laparotomy should be performed, as by following this course the chances for a 
 favorable result are much better than if the 0})eration is postponed until symp- 
 toms of peritonitis set in. 
 
 The external incision should be made through the linea alba. If intra- 
 peritoneal hemorrhage has taken place, this demands the first attention. If 
 the laceration is not readily found, rectal insufflation of hydrogen gas or filtered 
 air will point out and locate the visceral injury at once. Immediate enteror- 
 rhaphy deserves the preference over the formation of an artificial anus, as it is 
 not attended by any greater immediate risk to life and does away with the 
 remote dangers incident to a secondary operation. Lacerated wounds of the 
 intestine are closed in the same manner as incised wounds, only that perhaps 
 the margins of the wound should be more inverted, in order to secure apposi- 
 tion between healthy serous surfaces. If the lacerated wound presents contused 
 margins, it may become necessary to cover the contused area with an omen- 
 tal graft in order more effectually to guard against the occurrence of sub- 
 sequent perforation. If the mesentery is torn it also must be sutured. As 
 some extravasation always takes place in lacerated wounds of the intestines, it 
 is necessary to flush the abdominal cavity with normal salt .-olution before 
 the external wound is closed, and to make ample provision for drainage. The 
 after-treatment consists in stimulation to counteract shock and in securing rest 
 
DISK ASKS AM) IXJllilKS OF THE ABDOMEN. 729 
 
 for the injured iute.stine by w ithhuldiug food by the stoiuacli for several days 
 and by the administration of opiates. 
 
 Pkufokatiox from Typhoid Fever. — Typhoid fever is one of the causes 
 of perforation of the intestine. The mortality due to perforation is shown 
 by Fitz's table to l)e 6. AS per cent., figures Avhich i)ractically represent the 
 freijuency of the condition. It is most apt to occur during the third week 
 of the disease. A perforation is often preceded by marked leucocytosis, and 
 occasionally by pronounced localized tenderness. When perforation occurs 
 the individual passes into a state of profouiul shock. In this state he may 
 die; but he usually rallies, the rally being generally followed by se))tic 
 peritonitis and death. After perforation, as a rule, the liver dulness dis- 
 appears. There is no (piestion that it is the duty of the surgeon to operate 
 in such cases. He should not operate during early shock ; but must wait — 
 but only a reasonable time — for the rally, hurrying the reaction as much as 
 possible by hot enemata, the hypodermatic injection of strychnia, wrapping 
 the patient in hot blankets, hy])odernioclysis, etc. The most favorable time 
 to operate is within the first twelve hours. After twenty -four hours opera- 
 tion is almost hopeless. In 83 cases tabulated by Keen there were IG re- 
 coveries. When a fair degree of reaction is obtained open the abdomen, the 
 incision being over the seat of perforation if any signs point to it ; otherwise 
 in the linea alba. When the point of perforation is found the opening is 
 closed by Lembert sutures of silk. It is not necessary to excise the edges 
 of the ulcer. The abdomen is irrigated with plenty of hot salt solution. 
 Wipe with care betw-een the liver and diaphragm and in the recto-vesical 
 pouch. Insert drainage-tubes, suture the abdominal wound or wounds, apply 
 dressing, and adopt proper means for the treatment of shock. 
 
 INTESTINAL OBSTRUCTION. 
 
 Definition and Classification. — Intestinal obstruction, occlusion, 
 strangulation, and ileus have been used as synonymous terms. Some authors 
 wish to draw a line of distinction between cases of intestinal obstruction and intes- 
 tinal strangulation upon an etiological basis, including under the former term 
 all instances where the obstruction is caused by a tumor, enterolith, or intussus- 
 ception, while internal hernia, volvulus, and constriction by a band are included 
 under the head of strangulation. For practical purposes such a distinction is 
 superfluous, as any cause which mechanically interferes with the passage of 
 intestinal contents produces the symptoms characteristic of intestinal obstruc- 
 tion, and if it cannot be removed by ordinary means should be treated by 
 abdominal section. The classification into true and false obstruction, from a 
 surgical standpoint, should also be abandoned, as operative interference is indi 
 cated only in cases of obstruction due to the presence of mechanical obstacles, 
 such as foreign bodies, tumors, intussusception, or to compression of the lumen 
 by tumors, flexion, twisting, and bands of constriction. Inflammation of the 
 tunics of the bowel and diftuse peritonitis may give rise to symptoms resem- 
 bling those of obstruction, and the indications for treatment are to combat 
 the inflammation and to restore peristaltic action, combined with mechanical 
 means to relieve the abdominal distention. 
 
 A more important classification remains to be mentioned, in which all cases 
 of true intestinal obstruction are divided into acute and chronic. This distinc- 
 tion must be maintained for many reasons. In chronic obstruction the 
 symptoms usually develop very slowly as the occlusion becomes more complete. 
 During the early part of the affection the intestinal wall above the seat of 
 
7:50 ^.v .i.i//;A7r,LV TExr-iiooK or srnarnv. 
 
 obstruction uii(k'r^of.s compensatory liypcrtropliy, (li):itati(»n taking place very 
 slowly unless the chronic suddenly merges into the acute form — an event which 
 is always announced by a coniplexus of symptoms characteristic of acute or 
 subacute obstruction. Chronic obstruction is more frequently met with in 
 persons advanced in years, and tlie seat of the obstruction is usually located 
 in some ])art of the laruje intestine. The acute form is caused by ])atho- 
 logical conditions which suddenly narrow or oI)literate the lumen of some por- 
 tion of the intestine, usually above the ileo-ciccal valve, and often, without any 
 premonitory symptoms, give rise to a group of acute symptoms almost patJiog- 
 nomonic of this affection. The sudden arrest of the fecal circulation is fol- 
 lowed by violent jieristaltic action of the bowel above the seat of obstruction 
 in a vain attempt to clear the intestinal tract, which, from muscular exhaustion 
 and the increased pressure from within due to the accumulation of intestinal con- 
 tents, finally gives rise to paresis and the.textural changes which accompany 
 great congestion in relaxed and exhausted tissues. In the treatment of such 
 acute cases prompt action constitutes an essential element of success, as in a 
 few hours or days the patient ])ecomes utterly prostrated, and the bowel at and 
 above the seat of obstruction will have undergone irreparable i)athological 
 changes. 
 
 Surgical Resources in the Treatment of Intestinal Obstruction. 
 
 Evacuation and Irrigation or Lavage of the StOxMach. — Accumula- 
 tion of intestinal contents above the seat of obstruction acts deleteriously in 
 several Avays : 1. It causes violent peristaltic action of the intestine above the 
 seat of obstruction ; 2. It exhausts the patient's strength by causing persistent 
 retching and vomiting ; 3. It is one of the causes which produce distention 
 of the intestine above the obstruction ; 4. It favors fermentative and putre- 
 factive changes in the intestinal contents. 
 
 Kussmaul has introduced a new and exceedingly valuable measure in the 
 treatment of intestinal obstruction by the use of the soft-rubber stomach-tube. 
 By the siphon action of the tube, gas and the fluid contents of the stomach and 
 upper portion of the intestinal canal are evacuated, and thus abdominal dis- 
 tention is relieved and the hydrostatic pressure in the intestine above the 
 obstruction diminished. In inserting the tube into the stomach the patient 
 should be asked to make swallowing movements, which will convey the tube 
 along the oesophagus without causing much gagging, which often prevents the 
 forcible introduction of the tube. After the stomach has been evacuated it 
 should be washed out with a weak solution of salicylic or boric acid, a pro- 
 cedure which cannot fail to diminish the fermentative and putrefactive pro- 
 cesses in the retained intestinal contents. 
 
 Distention of the Colon with Fluids. — For evacuation of the colon 
 copious rectal injections are resorted to almost instinctively in every case of 
 intestinal obstruction. This procedure has also been employed quite exten- 
 sively with the intention of utilizing the hydrostatic pressure as a means for 
 the correction of the mechanical difficulties which have given rise to the 
 obstruction. For the former pur|)ose they should never be omitted ; for the 
 latter indication they should never be used, as fluids cannot usually be forced 
 beyond the ileo-ciecal valve, and in the treatment of mechanical obstruction 
 below this point it is far inferior to insufflation of air or gas. 
 
 Rectal Insufflation of Hydrogen Gas or Filtered Air. — The em- 
 ployment of hydrogen or filtered air in the diagnosis and treatment of some 
 forms of intestinal ol)struction is occasionally valuable. The inffation i& 
 
DiiSEASES A.\/> ixjrniKs or the J/.'/^o.I/A.V. 7ol 
 
 made in the same iiianiicr as in tlic diagnosis of intestinal wounds. By its 
 use the seat of obstruction beh»\v the ileo-cecal valve can be located with 
 accuracy, and above this point at least approximately. The inflation will 
 distend the bowel below the obstruction, and the air or gas will not j)ass be- 
 yt»nd it. It is an extremely useful resource in the treatment of invagination, 
 and in describing this form of intestinal obstruction it will again be referred 
 to as a therapeutic measure. 
 
 Taxis and Massage. — Abdominal taxis, so nmch lauded by Mr. Ilutcii- 
 inson as a means of treating intestinal obstruction, is not only unscientific and 
 useless f(jr this purpose, but is attended by great risk to life. Taxis and mas- 
 sage, scientitically })ractised, have a limited range of application in the treat- 
 ment of intestinal obstruction, but they are a])plicable oidy to cases where the 
 obstruction is due to the presence of a foreign body, a fecal accumulation, or 
 an enterolith, and should only be resorted to before these causes have devel- 
 oped inflammatory changes at the se'at of impaction. 
 
 Uniform and Uninterrupted Compression of the Abdomen. — In all 
 cases of intestinal obstruction, but more particularly in the chronic form, uni- 
 form support of the abdomen affords relief to the patient, and is one of the 
 best means of preventing rapid distention of the intestine above the seat of 
 obstruction. Fixation and equable compression are resorted to in other parts 
 of the body as the best known means of controlling muscular spasms. Uniform 
 compression of the abdomen is best secured by padding the iliac regions with 
 absorbent cotton and then enveloping the body from the pubes to the tip of 
 the sternum with broad strips of adhesive plaster, which should be made to 
 overlap one another. 
 
 Puncture of the Intestine. — Advanced cases of intestinal obstruction 
 are always attended by great distention of the bowel above the obstruction, a 
 condition Avhich causes increased intra-abdominal pressure. The distention 
 may be so great as to destroy life by the suspension of important functions 
 from mechanical pressure. It also aggravates the mechanical difficulties which 
 interfere with the passage of intestinal contents, as the distended bowel under 
 such circumstances forms numerous flexions which constitute additional obstruc- 
 tions. If life is threatened by the distention, and more efficiejit surgical aid, 
 for any reason, cannot be rendered, puncture of the intestine may prove bene- 
 ficial. Puncture of a distended paretic intestine is always attended by some 
 risk of extravasation, and on this account the needle puncture should be made 
 obliquely through the wall of the intestine, in order to reduce this source of 
 danger to a minimum. The best instrument for this purpose is one of the 
 smaller needles of an aspirator. Care should be taken to render the needle 
 aseptic before it is used. The puncture should be made at the most prominent 
 point, and the instrument pushed boldly forward in an oblique direction until 
 resistance ceases. 
 
 Enterostomy. — The formation of a fecal fistula above the ileo-csecal valve 
 by operation should be called enterostomy, and not enterotomy. This opera- 
 tion was done by N^laton for the first time in 1840. The mortality of the 
 operation has been nearly as great as that of laparotomy with removal of the 
 cause of obstruction, and on this score alone its further application should be 
 limited to exceptional cases Avhere a radical operation is inadmissible on account 
 of the nature of the obstruction or the enfeebled condition of the patient. The 
 operation, which can be made without anesthesia, is performed by making an 
 incision not more than two and a half inches in length in the right iliac region, 
 above and parallel to the outer half of Poupart's ligament, and all hemorrhage 
 should be arrested before the peritoneal cavity is opened. The parietal peri- 
 
732 AiY AMKRIL'AS TEXT-BOOK OF SLRUFAlY. 
 
 toiRMun is now sutured to the skin. Almost witliojit exception a distended 
 knuckle of intestine, readily recognized by its size and color, presents itself 
 in the wound, and is drawn forward sufliciently for a surface the size of a 
 quarter of a dollar to be united with the margins of the wound with fine silk 
 sutures closely placed. An incision large enough to admit the tip of the index 
 finger is now made in the center of the united part transversely to the long 
 axis of the bowel, and after the escape of intestinal contents and disinfection 
 of the surface of the wound the margins of the visceral wound are separately 
 stitched to the skin by a single suture on each side, in order to secure patency 
 of the opening. On incising the bowel the surgeon is often disappointed at 
 the small amount of gas and fluid which escapes, and it is frecjuently several 
 hours before a free escape takes place and the abdominal distention begins to 
 diminish. In exceptional cases an enterostomy is followed by a permanent 
 cure bv the spontaneous correction of the mechanical difficulties which caused 
 the obstruction; in other cases a radical operation is to be done later; while 
 in a third class the fistula is allowed to remain permanently in case the cause 
 of the obstruction cannot be removed. 
 
 Colostomy. — The term eolotomy has been used to designate the operation 
 of forming a fistulous opening in any part of the colon. But this word, lite- 
 rally, onh'means cutting into or incising the colon for the purpose of making 
 a temporary opening, as in gastrotomy, enterotomy, etc. Hence the operation 
 of making a more or less permanent fistula in the colon should be known and 
 described as colostomy, corresponding to (/astr ostomy^ enterostomy, etc. This 
 operation will always retain its place in operative surgery as a palliative and 
 life-prolonging procedure in the treatment of carcinomatous stenosis of the 
 lower portion of the colon and in cases of inoperable carcinoma of the rec- 
 tum and in cases of extensive cicatricial stenosis beyond the reach of more 
 conservative measures. The modern operation of colostomy is made by 
 opening the peritoneal cavity in the right or left iliac region, or even in 
 the epigastrium, according to the location of the obstruction, and one 
 of its principal objects is to interrupt the fecal circulation completely at 
 the artificial anus, so as to procure absolute physiological rest for the 
 portion of bowel below it — a condition not attainable by the lumbar 
 operation. Inguinal colostomy was first practised by Littre. In early 
 times the mortality was even higher than in lumbar colostomy, being 
 from 46 to 53 per cent. This was the consequence of opening the 
 peritoneal cavity without antiseptic precautions. The introduction of an- 
 tiseptic methods here, as in all other intra-abdominal operations, reduced 
 the mortality to the neighborhood of 5 per cent. Kiinig has reported 
 20 cases with only 1 death, from peritonitis ; Cripps, 26 cases with only 
 1 death. 
 
 A number of operations have been described for making an inguinal colos- 
 tomy. The one devised by Maydl is done as follows : He makes an incision 
 about four inches in length over the portion of the colon wliich is to be opened, 
 and in the direction of the fibers of the external obli(iue muscle, and draws the 
 bowel forward until its mesenteric attachment is on a level with the external 
 incision. Through a slit in the mesocolon close to the gut is inserted a glass 
 rod with a Hange at each end, iodoform gauze being wrapped around the 
 ends to prevent displacement (Fig. 296). The rod prevents the return of 
 the bowel into the abdominal cavity before adhesions have formed. By means 
 of a row of sutures ])laced on each side of the prolapsed gut. including the 
 serous and muscular coats, the two limbs of the flexure, so far as they 
 lie in the abdominal .wound, are stitched together beneath the support. 
 
DISEASES AND INJURIES OF THE ABDOMEN. 
 
 733 
 
 The base of the prolapsed intestinal loop is sutured to the ])arietal perito- 
 neum with a few points of suture to shut off the peritoneal cavity and pre- 
 vent ])rotrusion of the small intestine if the patient should vomit or cough 
 after the operation. The wound around the base of the intestine should 
 
 Fk;. 2%. 
 
 Maydl's Operation for Inguinal Colostomy, show'ing the flanged bar, and at one end the iodoform gauze : 
 a is the line of the later incision (modified from Esmarch and Kowalzig). 
 
 be sealed with strips of iodoform gauze and collodion. If the intestine is 
 to be opened immediately, which should be done only Avhen the symp- 
 toms are such as to demand prompt relief, it is stitched to the parietal 
 peritoneum of the abdominal incision, and the latter is protected by iodoform 
 
 Fi<i. 297. 
 
 Artificial Anus after the Maydl Operation (from a photograph) : the patient has excellent control of the 
 
 bowels (original). 
 
 collodion. If incision of the bow^el can be postponed for a few days until 
 firm adhesions are formed, the intestine is stitched to the peritoneum and 
 surrounded by iodoform gauze packing around and beneath the support. If 
 the artificial anus is made for lesions incapable of subsequent removal, a 
 
734 Ay A MK lire AX TEXT-BOOK OF SUIidKltY. 
 
 transverse i)j»enin;i. including one-thir<l of tlie ])erij»lierv <>f the Itowcl. is made 
 bv the thermo-cautery, drainage-tubes are inserted into the two luinina. and 
 the intestine is carefully washed out. 
 
 If it is the intention to establish a permanent artificial anus and the prog- 
 ress of the case is satisfactory, the bowel is cut through completely in two 
 or three weeks, the support serving a useful purpose as a guide in making this 
 incision. A few sutures will serve to secure the cut ends to the skin. If the 
 direction of muscles has been regarded in making the abdominal incision, the 
 patient is provided with so eflBcient a sphincter that a large drainage-tube is 
 required to keep the opening patulous. Should the artificial anus be only a 
 temporary one, the incision in the intestine is made in a longitudinal direction. 
 When it has become desirable to close the artificial opening, the rubber sup- 
 port is removed, after which the bowel retracts, and the opening often closes 
 without any further treatment. If the adhesions are too firm for this, they 
 are removed, the bowel is sutured and returned into the peritoneal cavity, and 
 the external wound is closed. 
 
 The modern operation of inguinal colostomy is indicated in cases of con- 
 genital atresia of the rectum when the blind end of the bowel cannot be 
 readily reached through the perineum; also in cases of carcinoma of any por- 
 tion of the colon and rectum not amenable to a radical operation. Finally, 
 the operation might become necessary in irreducible invagination of the colon 
 in which, for anatomical reasons, resection or anastomosis cannot be done. 
 
 Abdominal Section', or Cceliotomy. — In making an enterostomy or colos- 
 tomy the abdominal cavity is opened, but these two palliative operations are 
 not classed under abdominal section in the treatment of intestinal obstruction, 
 as this expression in this connection is reserved for those cases in which the 
 abdominal cavity is freely opened for the purpose of finding and removing the 
 cause of the obstruction.* A radical operation in the treatment of intestinal 
 obstruction embraces — 1. The detection and removal or rendering harmless the 
 cause of the obstruction : 2. The immediate restoration of the continuity of the 
 intestinal canal. 
 
 To meet the first indication the cause of obstruction must be found, its 
 nature determined, and, whenever advisable or practicable, removed — a step 
 in the operation which may be very easy or may be a most formidable and 
 serious undertaking, more especially in cases where the pathological conditions 
 which have given rise to the obstruction are of such a nature as to constitute 
 in themselves an imminent or remote source of danger, as, for instance, malig- 
 nant disease or gangrene of the bowel from constriction. Abdominal section 
 in the treatment of intestinal obstruction has so far been attended by a fearful 
 mortality, owing to the fact that most operations were performed at a time 
 when the patients were in collapse or when the parts involved in the obstruc- 
 tion had undergone advanced and often irreparable pathological changes. 
 
 Schramm has collected 190 cases of intestinal obstruction treated by lapa- 
 rotomy, and of this number 64.2 per cent, died, the mortality before antisep- 
 tics were employed being 73 per cent., and since that time 08 per cent. Curtis 
 has collected the cases of intestinal obstruction treated by abdominal section 
 since the year 1873, consequently since the antiseptic treatment of wounds was 
 introduced ; the whole number of cases, 328, show a mortality of 68.9 per cent. 
 A more careful study of these statistics shows the value and importance of 
 earlv operations, as sometimes delay of only a few hours will bring complica- 
 tions Ashich not only necessitate more time in their removal, but will at the 
 same time necessitate a resection or anastomosis which, had the operation been 
 performed earlier, might have been avoided. Abdominal section in the treat- 
 
DL'SEA.^ES AMJ I.XJCRIKS OF THE ABDOMEN. 735 
 
 ment of intestinal obstruction, both acute and chronic, is one of the most for- 
 midable operations in surgery. Tlie surgeon ^ho undertakes it should be per- 
 fectly familiar Avith the anatomy of the abdominal cavity and its contents, and 
 conversant with all the pathological conditions which may give rise to obstruc- 
 tion ; at the same time he should have a full knowledge of the technical details 
 of the different operations, and be supplied with the necessary instruments and 
 a])pliances. Keen's " Operation Blank and List of Instruments required in 
 Various Operations" is an excellent aid in making the necessary preparation, 
 not only for this but also for all other operations. 
 
 The first and most important rule is to make use of the strictest precau- 
 tions in securing an aseptic condition of everything that will be brought in 
 contact with the wound or the peritoneal cavity. This includes the room, 
 patient, operator, and assistants, instruments, sponges, ligatures, table, blan- 
 kets, towels, wash-basins, etc. Where the cheapest and most efficient antisep- 
 tic— heat— cannot be emploved for this purpose, the disinfection is done with 
 warm water, potash soap, and an antiseptic solution (1 : 20 solution of carbolic 
 acid or 1 : 2000 corrosive sublimate). The operator must satisfy hiraseit ot 
 the aseptic nature of everything which is used inside of the peritoneal cavity. 
 As soon as the abdomen is opened, boiled water or sterile normal salt solution is 
 substituted for antiseptic solutions. To secure the proper temperature boiling 
 water is cooled by adding cool pre-boiled water, not by freshly-drawn cold water. 
 If the patient is much prostrated, 3V of a grain of strychnine and 4 ot a 
 irrain of morphia should be given subcutaneously, and four tablespoontuls ot 
 brandy in four ounces of warm water by the rectum, before the anesthetic is 
 given Irrigation of the stomach should always precede inhalation ot the 
 tnesthetic. If no contraindications are present, chloroform should be given 
 until the patient is fully under its influence, when the narcosis can be con- 
 tinued with ether. , , • i • • • 
 
 If the obstruction has been located beforehand, the abdominal incision 
 should be made as near it as possible : when it is in the caecum or the ascending 
 colon, it is to be made on the right side ; when in the descending colon, on the 
 left side ; in all other cases, and in all instances where the seat of the obstruc 
 tion cannot be determined beforehand, a median incision is indicated. Ihe 
 first incision should at least be large enough to admit the hand. It may be 
 stated as a rule that the ease of diagnosis increases with the size of the incis- 
 ion, and the danger which attends searching in the dark for the obstruction 
 more than overbalances the slight increase of risk incident to a large incision. 
 It must be borne in mind that in nine out of ten cases the obstruction is located 
 in the lower portion of the abdominal cavity, below the umbilicus, and that in 
 the great majority of these cases it will be found in one or the other of the 
 iliac" regions. If evisceration is not decided upon, the best plan to pursue is 
 to explore first the lower segment of the abdomen, more especially the ileo- 
 csecal region, the sigmoid flexure, and the pelvis, and if the obstruction can- 
 not be detected, a systematic search for it must be instituted. Any distended 
 loop of the intestine that may present itself in the wound is an evidence that 
 the obstruction is located lower down. The loop is withdrawn and is held by 
 an assistant while the operator examines in one direction, and if this does not 
 lead to the obstruction, the portion examined is returned, and the bowel is then 
 explored in the opposite direction. As a rule, the intestine is more dilated and 
 congested the nearer the obstruction. If the assistant's hands are too much 
 in the way, the bowel can be fixed in place with a strip of gauze passed through 
 a slit in the mesentery, which can be held by an assistant until the obstruction 
 is found. 
 
736 Ai\ AMERICAN TEXT-BOOK OF SCRGERY. 
 
 If a lonf^ iiK'dian iiicisioti is made, the small intestines will escape at once; 
 these should he caught in warm, moist, aseptic compresses, su])]»orted in this 
 position by the hands of one or two assistants, and ke{)t warm by pouring 
 on warm boiled water from time to time. Some operators j)refer warm, dry 
 compresses or towels for this purpose. The surgeon is now able to examine 
 rapidly and accurately every portion of the intestinal canal with a view of 
 locating the obstruction, with little or no risk of inflicting injury during the 
 examination. The greatest objection that has been urged against this method 
 is the difficulty of replacing the distended intestines ; but the proper way to 
 effect this is, instead of making direct compression, to resort to protection 
 of the intestines by covering the whole mass with a warm, moist, aseptic com- 
 press, the margins of which are tucked in under the abdominal incision. In 
 this Avay the bowels are protected against the injurious effects of irregular 
 direct pressure, and are guided back into the abdominal cavity as the wound 
 is closed by tying the sutures, already in place, from above downward. If 
 uniform, diffuse, gentle pressure fails in replacing the intestines, the margins 
 of the abdominal incision should be lifted with blunt hooks and the pelvis 
 raised (Trendelenburg's position) — expedients which render material aid in 
 effecting replacement. Should the obstacles be so great as to frustrate all 
 gentle attempts at reduction, it is better to resort to incision and evacuation 
 of the most distended portion of the prolapsed bowel. In cases where after 
 evisceration it is not possible to find the obstruction by examination of the 
 distended visible portion of the intestine, the contracted empty portion below 
 the obstruction can be brought into sight by rectal insufflation of hydrogen gas 
 or filtered air, and a searcli made for the obstruction from below upward by ex- 
 amining the bowel as it becomes inflated until the seat of obstruction is reached. 
 This method of examination will also reveal additional obstruction should such 
 exist below the one which has arrested the passage of intestinal contents. 
 
 Operative Treatment of the Obstruction. — Intestinal Anasto- 
 mosis. — This operation consists in establishing a communication between the 
 intestine above and that below the obstruction, thereby permanently excluding 
 from the fecal circulation the portion of the bowel which has become impermeable. 
 The idea of making such an anastomosis originated with Maisonneuve, and the 
 procedure was studied experimentally by A'^on Hacken. Billroth resorted to it, 
 and Senn modified it by substituting for the sutures perforated decalcified bone 
 plates. Various substitutes have been proposed for the latter. Senn made 
 numerous experiments on animals, and he and others have repeatedly per- 
 formed the operation on the human subject with results that have proved most 
 satisfactory. 
 
 In suturing the two visceral wounds together in establishing the continuity 
 of the bowel by the old end-to-end method, a great deal of valuable time is lost 
 and only very limited areas of serous surfaces are brought in contact. Lateral 
 anastomosis by absorbable perforated plates can be made in a much shorter 
 time, and large areas of serous surface are interposed between the clamps, and, 
 being held in uninterrupted contact, soon become firmly adherent. 
 
 The plates are now made and used in three sizes, according to the age of 
 the patient and the part of the intestinal canal to be operated upon. They 
 are made of decalcified bone, are oval in shape, and the central perforation 
 should correspond in size with the opening that is to be established. The 
 plates are to be kept ready for use fastened between two pieces of glass and 
 immersed in a solution composed of equal parts of water, glycerin, and alcohol. 
 To the margins of the perforation are fastened four double silk sutures ; the 
 lateral or fixation sutures are armed with round needles ; these strings are fast- 
 
I) TS EASES A.\J) lyjrniES OE THE ABDOMEN. 737 
 
 cnoil to tlu' jdate w itii a lock stitch (Fi;^. 'IW). As substitiitci^ for the bone 
 plates, cat<i;iit rings and mats have been devised by Abbe, Matas, Davis, and 
 Brokaw. Robinson uses untanned leather as material for the plates, and 
 Stamra lias had o;ood results with cartilage-jdates made of the scapuhe of 
 calves. Baracz has substituted for the absorbable animal substances plates made 
 of the Swedish turnij), and Dawbarn has used j)lates made of raw potato. 
 The portions of the intestine between which it is intended to establish a com- 
 munication should be brought well forward into the wound and surrounded 
 on the sides with aseptic gauze. The incision is made on the convex surface 
 of the bowel opposite the mesenteric attachment and in the direction of its 
 long axis. In length it must correspond with the greatest diameter of the 
 plate. The plate is inserted endwise, and as soon as it is in the lumen of 
 the bowel it is brought into proper position by making traction on the four 
 strings. The serous surfaces corresponding to the size of the plate are freely 
 scarified. In operating for intestinal obstruction the proximal part of the 
 bowel will be found distended, and its contents must be freely emptied through 
 the incision before the plate is inserted. After thorough evacuation and irri- 
 gation of the interior of the bowel, further extravasatim is prevented by an 
 
 Fig. 298. 
 
 Senn's Decalcified Bone Plate (original). 
 
 assistant, who compresses the bowel above the place where the incision is to 
 be made. This can also be done by passing a rubber band or strip of gauze 
 through a slit in the mesentery and tying it over the bowel, or by catching 
 it with a pair of lock forceps at the point of crossing after tightening it. 
 The lateral sutures are now passed through the margins of the wound near 
 the border and equidistant from its angles (Fig. 299). 
 
 Before approximating the parts, the surfoces are well cleansed, and if neces- 
 sary, disinfected. The superficial sutures behind the plates (Fig. 299, r) are 
 inserted and tied before the plate-sutures are tied. An assistant now holds the 
 intestine in such a manner that the two visceral wounds are brought together 
 when the surgeon approximates the visceral Avounds by tying the plate-sutures. 
 In tying the threads attached to the plates the posterior pair of the middle or 
 fixation sutures are tied first, and the threads cut short to the knot. During 
 the tying of all tlie sutures the plates are to be held in apposition. The tying 
 is done Avith sufficient firmness to bring the parts in accurate apposition, with- 
 out endangering the tissues interposed betAveen the plates. After tying the 
 first pair of sutures the end or apposition sutures are tied, and finally the 
 anterior pair of fixation sutures. Care must be exercised to interpose the 
 
 47 
 
738 
 
 AX AMKRICAX TKXT-IK )<)K OF sriidKUY 
 
 maro;ins of the viscrral wounds accurately l)et\veeii the plates. After this 
 has been done, a few stitches of the continued suture are made at the border 
 
 Fir;. 299. 
 
 Ileo-colostomy with Decalcified Bone Plates, sho\vin<r plates in position, one in the ileum, the other in 
 the colon : a a! a', lateral or fixation-sutures passed through the margins of the wound, a' to be tied 
 to a' ; 6 6 6' 6', end or apposition-sutures, to be tied 6 to 6 and 6' to 6' ; c, posterior or sero-museular 
 sutures (original). 
 
 of the plates anteriorly, in order to reinforce the ])lates and bring in appo- 
 sition a maximum area of serous surfaces (Fig. 300). 
 
 Intestinal anastomosis should take the place of an artificial onus in all 
 cases where the patient's strength warrants the procedure ; and a radical oj)era- 
 
 Showing thf .\nterior CoriiiiiuiMl SiTo-iiiusculur Suture as the final step in ileo-colostomy (original i. 
 
 tion is contraindicated by the general condition of the patient or by the char- 
 acter and extent of the local disease which has caused the obstruction. 
 
DISKASHS AM) IXJURIES OF TllK ABDOMEN. 
 
 7;i9 
 
 Fkj. 301. 
 
 The Murphy button (Fi<^s. SOl-303) has been (juitc extensively used as 
 a means of a|)])r().\iniati()n in aniistoniosis. While this button has been very 
 successfully used in a large number 
 of cases, its employment is attondod 
 with several dangers in that part of 
 the intestinal canal above the ileo- 
 cecal valve. The orifice of the button 
 may become plugged, and the button 
 itself has fallen into the stomach, or 
 has been retained in the intestinal 
 canal. These dangers, however, have 
 not been so frequent as to prevent its 
 general use. 
 
 Laplace's Forceps for Intes- 
 tinal Anastomosis. — As -will be seen 
 by referring to the accompanying il- 
 lustrations, these forceps resemble two 
 pairs of hemostatic forceps, held in 
 apposition by a clasp (Fig. 304). The 
 blades of each half are semicircular in 
 shape, so that -when thev are placed 
 
 , .1 ,1 /• ' 1 i 1 I 1 Murphy Button (fuliirged I : A, open; B, closed. 
 
 together they form a complete double ^ 
 
 circle or oval, between which the portions of intestine to be united are held. 
 
 Fig. 302. 
 
 Fig. 303. 
 
 End-to-end Union of Intestine bv means of the End-to-end Union with the Murphy Button 
 
 Murphy Button : the two portions of the button. shown in section, 
 
 held in position by purse-string sutures, are ready 
 to be pressed together. 
 
 Encl-to-end Anastomosis. — The two ends of bowel to be united are brought 
 together by four .sutures, the first at the mesenteric attachment, the second 
 
 Fig. 304. 
 
 Laplace's Forceps for Intestinal Anastomosis. 
 
 exactly opposite this point, and one on either side midway between. The 
 forceps are then to be introduced between any two of these sutures and both 
 
740 
 
 AN AMERICAN TEXT-BOOK OF sriiGERY 
 
 sides opened simultaneously, so that one of the circles is within either extrem- 
 ity of the intestine. The forceps are 
 Fig. 305. then clamped. If the serous surfaces do 
 
 not tend to invert over the blades as 
 the forceps are closed, they should be 
 
 End-to-end Intestinal Anastomosis by Laplace's For- 
 ceps: by detaehinp the clamp the two blades are 
 successively removed as before and the remaining 
 small opening sutured. 
 
 Gastro-enterostomy by Laplace's Forceps : forceps 
 inserted. 
 
 adjusted so that this result will be accomplished. A continuous or inter- 
 rupted suture may then be applied according to the preference of the opera- 
 tor. Laplace uses two running sutures.' Having completed the line of 
 suture, the clamp is removed, and first one-half of the forceps is slightly 
 
 Fig. 307. 
 
 Sutures inserted ; forceps still in position. 
 
 opened and removed, the handle describing a semicircle, and then the other 
 half is removed in the same manner. One or two stitches to close the 
 point occupied by the forceps complete the operation (Fig. 305). 
 
 Lateral Anastomosis, Gastro-enterostomy (Figs. 306-808), Entero-entvros- 
 
nisi: ASKS AND INJUR FES OF THE ABDOMEN. 
 
 741 
 
 tomij, etc. — The ])ortioii.s of the two viscera that are to be united are placed side 
 by side and held between the thumb and forefinger of each hand by the assist- 
 ant, or the oi)erator may hold one part and the assistant the other. xV sharp- 
 pointed knife is then thrust tlirou<,fh all the coats of the viscus and an incis- 
 ion made, correspondin<;- in len^'th with the width of the forceps to be employed, 
 and a similar incision is made in the other viscus. The forceps are opened, 
 one blade is inserted into either opening, and, after ascertaining that the 
 adjustment is accurate, they are closed. The sutures are then applied and 
 the forceps removed as above described. In performing lateral anastomosis 
 between two portions of intestine the divided ends must first be closed by 
 sutures. For this purpose Laplace uses forceps with long and slender 
 blades. The divided extremity of the intestine is grasped between the 
 blades of these forceps and invaginated; a running Lembert suture is then 
 applied, the forceps unlocked and withdrawn, and one or two sutures com- 
 
 Vvi. .SOS. 
 
 Removal of first blade of forceps. 
 
 plete the operation. This method has the advantages, that do not obtain 
 with those heretofore employed, of permitting rapid and accurate suture, 
 without leaving behind any*^ non-absorbable mechanical device. 
 
 The use of all artificiaraids to anastomosis has of late been abandoned 
 by .some surgeons, Avho have returned to the old method of suturing, an opera- 
 tion recently described by Abbe. His method, which has given excellent 
 results, is as follows : After resection and closing the two ends as usual, he 
 lays these ends alongside of each other and applies two rows of continuous 
 Lembert sutures a quarter of an inch ajjart and an inch longer than the pro- 
 posed cut (Fig. 309). Each thread (24 inches long) is left at the end of its 
 row, being still threaded. The bowel is then opened for four inches a quar- 
 ter of an Tnch from the sutures, both rows being to one side of the cut. The 
 vessels are temporarily caught Avith hemostatic forceps. The opposite portion 
 of the bowel is then opened in the same manner. The two adjacent cut edges 
 are now united by an overhand suture, the needle piercing both the mucous 
 
742 
 
 AN AMERICAN TEXT- BO OK OF SURGERY. 
 
 and the serous coat, and so securing the bleeding vessels (Fig. 310). The 
 forcejts are removed as they are reached. The two free cut edges are sim- 
 ilarly whipped, after which the serous surfaces on the opposite sides of the 
 
 Kui. :}0y. 
 
 Fig 
 
 Suturing Intestines in Apposition before Incision 
 (Abbe). 
 
 Showing the Four-inch Incision and the Sewing 
 of the Edges (Abbe). 
 
 Opening are approximated and secured by tw^o rows of continuous Lembert 
 sutures, the first two threads serving this purpose. It is asserted that this 
 method recjuires little, if any, longer time than that with plates or rings of 
 any kind, and is free from many of their disadvantages. 
 
 Maunsell's Method of Intestinal Anastomosis. — After the divided 
 ends of the intestine are cleansed two temporai-y sutures are employed to make 
 a preliminary approximation. One suture is introduced at the point of attach- 
 ment of the mesentery and includes all the coats of the intestine and both 
 layers of the former, the other suture is placed directly opposite and also 
 includes all the coats (Fig. 311). These are then tied and the ends left 
 long. A longitudinal incision an inch and a half long is next made in 
 the larger segment of intestine, opposite the mesentery, and tAvo inches 
 from the divided extremity. This may be made by picking up the wall of 
 
 Fig. 311. 
 
 
 MaunseU's Method for Longitudinal Section of Gut : n, peritoneal coat ; 6, muscular coat ; c, mucous 
 coat; d, temporary sutures passed into the bowel and out through the longitudinal slit made in the 
 larger intestinal segment; e, mesentery. 
 
 the intestine by the thumb and finger, transfixing at the base of the cone, 
 and cutting outward. Through this opening a pair of forceps is passed, the 
 free ends of the sutures caught, and the cut ends of the bowel brought out 
 at this point (Fig. 312). The two temporary sutures are held by an assist- 
 ant, while the ends of the intestine are united by through and through su- 
 tures (Fig. 313) — about twenty being introduced. The temporary sutures are 
 removed, the invagination reduced, and the edges of the longitudinal incision 
 closed by Lembert sutures (Fig. 314). A V-shaped section of the mesentery 
 
DISEASES AND IXJVIinCS OF THE ABDOMEN. 
 
 743 
 
 should first be removed corresponding to the amount of intestine excised, 
 bleeding ))oints ligated, and the two surfaces united by sutures, as in other 
 methods of anastomosis. 
 
 Intestinal anastomosis is indicated — 
 
 1. In cicatricial stenosis of the intestines. 
 
 2. In inoi.erable carcinoma of the intestine if the disease is located 
 
 Fui. 312. 
 
 TeritoneaJ. cvaJ 
 
 
 tJ-j^.M' 
 
 -J- 
 
 ^.31^^0Tfy^eraon^^ co^-^ 
 
 lon 
 
 Mflunsoirs Method for Longitudinal Section of Intestine, showing relative position of the peritoneal 
 * coats of bowel invaginated at the longitudinal opening (Wigginj. 
 
 sufficiently high up in the colon to permit the formation of an opening 
 
 below it. a- ^ 
 
 3, In irreducible volvulus and invagination uhen the parts aitected pre- 
 
 FiG. 313. 
 
 Fig. 314. 
 
 Maun^elTs Method: the needle passed 
 through both sides of the bowel and 
 through all the intestinal coats : one 
 passage of the needle places two su- 
 tures. 
 
 Maunsell's Method : intestine after completion of the anasto- 
 mosis and reduction of the invagination : «, point of union 
 between the ends of the bowel, showing that the peritoneal 
 coat is well turned in, and that the sutures and knots are 
 all inside the gut; 6, longitudinal slit in bowel, closed by 
 Lembert sutures. 
 
 sent no external evidences of gangrene, and resection is impracticable on 
 account of unfavorable general or local conditions. 
 
 4. As a substitute for circular enterorrhaphy when the lumina of the 
 resected ends differ greatly in size. 
 
 5. In congenital atresia of the intestine. 
 
 The use of bone-plates in gastro-enterostomy has been referred to in the 
 chapter on Injuries and Surgical Diseases of the Stomach. 
 
 Laparo-enterotomy. — Incision of the bowel for the removal of obstruc- 
 tion durincT laparotomy is indicated when the obstruction is due to the presence 
 of a foreign body, a concretion, an enterolith, a gall-stone, or a pedunculated 
 benign polypoid tumor ; also in cases in Avhich the bowel has become paretic 
 by distention from the accumulation of gas and feces. In the removal of a 
 foreign body, a concretion, a gall-stone, or an enterolith not amenable to 
 removal by submural crushing or fragmentation with a needle, the incision 
 
741 AX AMEh'K'AX TEXT- HOOK OF SURGERY. 
 
 for extraction should not bo made (tver the seat of impaction, as this part of 
 the intestine has undergone changes unfavorable to the satisfactory healing 
 of the visceral wound. It is much better in such cases to make the incision 
 opposite to the attachment of the mesentery, in a healthy j>art of the intes- 
 tine, an inch or two below the impaction, and then crush the foreign ])ody 
 by instruments introduced through the incision. The removal of a non- 
 maliiTuant pedunculated polypoid tumor is to be accom])lished by making an 
 incision on the convex side of the bowel large enough to admit of the drag- 
 giniz of the tumor through it, after which the base of the pedicle is trans- 
 fixeil with a needle armed Avith a stout ligature which is tied on each side, 
 the tumor cut ott", and the Avound closed in the usual manner. Incision of 
 the bowel for overdistention is indicated when the intestinal wall has become 
 paretic from distention or inflammation. A transverse incision at least an 
 inch in length on the convex side is preferable to puncture. Through such an 
 incision tiie intestinal contents can be forced out from both sides and several 
 feet of intestine can be unloaded in this manner. After evacuation the inci- 
 sion should be closed in the usual manner. Cases may present themselves in 
 -which it is advisable to make more than one visceral incision. For the pur- 
 pose of stimulating the paretic intestine McCosh recommends the injection 
 of a solution of magnesium sulphate through the incision before suturing the 
 wound, a practice which seems to have been attended by excellent results. 
 
 Enterectomy. — The indications for excision in injuries of the intestine 
 have been already discussed. In the treatment of intestinal obstruction this 
 operation becomes necessary when the obstruction is due to a malignant tumor 
 if it is possible to remove the disease completely, also for the removal of benign 
 tumors which cannot be excised by enterotomy, and in all cases in which gan- 
 grene has been caused by constriction, comj)ression, or over-distention. 
 
 In incomplete enterectomy only a portion of the circumference of the bowel 
 is excised. This can be done with safety only on the convex surface of the 
 bowel, as partial enterectomy on the opposite side, by cutting off' the blood- 
 supply, might cause gangrene or result subsequently in intestinal obstruction 
 from flexion. In making a complete enterectomy not more than three or four 
 feet of the small intestine should be removed, as resection of a larger portion 
 is likely to give rise to progressive marasmus should the patient recover from 
 the operation. The intestine on each side of the proposed section should be 
 tied with a rubber band passed through a slit in the mesentery. The mesentery 
 is tied in small sections with fine silk ligatures before the bowel is excised. 
 After excision enterorrhaphy or lateral anastomosis is done. 
 
 The mortality of this operation thus far has been very great. In a series 
 of 35 resections of the large intestine for obstruction which Weir collected, 
 it amounted to 100 per cent. Reichel has also shown that resection of the 
 small intestine for conditions giving rise to obstruction gave a mortality of 
 75 per cent., whereas in secondary resection for artificial anus the mortality 
 is reduced to 37 per cent., a statement which is supported by Makins in his 
 report of 13 deaths in 3!> resections for artificial anus. 
 
 Enterorrhaphy. — The closure of a wound of the intestines with sutures, 
 and also the joining of the ends of the intestine by sutures after resection, is 
 called enterorrhaphy. End-to-end restoration of the continuity of the intestinal 
 canal after resection is termed circular enterorrhaphy. 
 
 The appalling mortality after intestinal resection is due principally to the 
 fact that, as a rule, the operation is delayed too long ; besides, the inunediate 
 effects of so grave an operation are serious and often result in death from 
 shock, while many cases have proved fatal from leakage at the ])lace of sutur- 
 
DISEASES AXI> IXJIRIES OF THE A B DOMEX. 
 
 7-15 
 
 Fig. 315. 
 
 Lembert's Suture : u. .-ierous coat : 6, muscular coat; 
 c, submucous fibrous layer. 
 
 ing. Suturing of an intestinal wound is a verv delicate operation, and every 
 studenti of surgery should prepare himself carefully by working on the intes- 
 tines of dead and living animals and the cadaver. 
 
 The subject of the suturing of intestinal wounds is one of tlie most 
 bewildering topics of surgery, as hardly a year passes without the descrip- 
 tion of some new suture. It will be well, therefore, to limit our study 
 
 to the two kinds of suture now al- 
 most universally employed, the super- 
 ficial and the deep, or, as usually 
 termed, Lembert's and Czernys 
 sutures. Lembert was the first to 
 point out that in order to obtain 
 union of an intestinal wound it is 
 absolutely necessary to bring the 
 serous surfaces in contact ; accord- 
 ing to his teachings, it is only 
 necessary to include in the suture 
 the peritoneal coat, but later it 
 was suggested to include enough 
 of the muscular coat to give the 
 suture a safe hold. Halsted has 
 clearly pointed out that it is unsafe 
 to rely on the serous and muscular 
 coats in giving the necessary hold to the sutures, and insists that the needle 
 should penetrate more deeply and catch some of the fibers of the firm sub- 
 mucous coat, which he has so well de- 
 scribed. In applying the Lembert suture 
 the edges of the wound are turned in a 
 little, and the folds sewed together with 
 a fine round sewing-needle carrying a 
 fine aseptic silk thread. The stitches are 
 placed at intervals of about one-eighth of 
 an inch (Fig. 315). 
 
 In order not only to approximate these 
 serous surfaces more perfectly, but also to 
 bring together accurately the margins of 
 the mucous membrane, Czerny reinforces 
 the Lembert suture by a row of deep su- 
 tures (Fig. 816). These sutures to serve 
 their purpose best should not, as Czerny 
 advised, include all the coats, as it is much 
 better to make this stitch extraperitoneal 
 :ind cut the threads short to the knot. 
 The deep row of sutures is then buried 
 by the Lembert sutures. In circular 
 
 enterorrhaphy the double or Czerny- Lembert suture should always be 
 employed. 
 
 If time is an object, the Lembert suture can be applied in the form of the 
 continued suture, but when this element does not enter into consideration the 
 interrupted suture should be invariably employed. In circular enterorrhaphy 
 the greatest difficulty encountered is at the mesenteric attachment, where the 
 bowel for a small space is not covered by peritoneum. It is necessary either 
 to cover this space with peritoneum by stitching the two peritoneal layers of 
 
 Fig. 316. 
 
 Czerny-Lembert, or Double lutestiual Suture, 
 
746 AX AMKRICAX TEXT-BOOK OF SURGERY. 
 
 the mesentery over it with a fine catgut suture, or carefully to r.djiist the mes- 
 entery on each side with the licmhcrt stitch. The safety of a circular r-nteror- 
 rhaphy is increased by covering the line of suturing with a strip of omentum, 
 which is fastened on the mesenteric side of the bowel with two fine catgut 
 sutures passed through the mesentery. Although completely detached, such 
 omental grafts retain their vitality and become firmly attached to the serous 
 surface of the bowel within from twenty-four to forty-eight hours, thus form- 
 ing an additional safeguard against subsecjuent leakage at the seat of suturing. 
 
 Conditions may present tliemselves after excision of the intestine, more 
 especially the colon, which do not admit of bringing the resected ends together. 
 In such circumstances it may become necessary to establish a permanent arti- 
 ficial anus ; but if it is possible to establish the continuity of the intestinal 
 canal by lateral anastomosis, this method of treatment should be adopted. It is 
 possible that, in the future, experimental research will prove the practicability 
 of restoring such defects by a plastic operation, consisting of transplantation 
 of a corresponding portion of the small intestine between the separated ends, a 
 procedure which would necessitate circular suturing at three different points. 
 Until it has been shown that some such plan is feasible, the surgeon must con- 
 tent himself with establishing an anastomosis between the proximal and the dis- 
 tal end by lateral apposition by any selected method. If the two lumina of 
 the intestine after resection do not correspond in size, and do not diU'er so 
 much as to render circular enterorrhaphy impossible, the section of the 
 smaller end should be made oblicjuely at the expense of the convex side of 
 the bowel, which will increase the surface to be united. Madelung in resect- 
 ing the bowel always makes his incisions somewhat obli(|uely in the same 
 direction, for the purpose of guarding more effectually against gangrene on 
 the Convex side of the bowel. If the mechanical difficulties cannot be over- 
 come in this manner, the convex surface of the smaller intestinal end is incised 
 longitudinally to the requisite extent, which will then enable the surgeon to 
 unite the ends without the remotest fear of causing a mechanical obstruction. 
 
 Lateral Implantation. — If for any reason circular enterorrhaphy is out 
 of the ([uestion restoration of the continuity of the intestinal canal is secured 
 either by closing both ends and establishing between the bowel above and 
 that below the site of resection an anastomotic opening, or by implanting the 
 smaller end into an incision on the convex surface of the larger end an inch or 
 two above the sutured end, and fixing the implanted portion in its place by 
 Lembert sutures. Billroth has resorted to this expedient with good success in 
 several cases of excision of the caecum for malignant disease. In two similar 
 cases Senn obtained excellent results by intestinal anastomosis. 
 
 Direct Treatment of Obstruction or Strangulation by a Band or 
 Diverticulum, Flexion, or Adhesion of Intestines. — Ligamentous 
 bands as a cause of intestinal obstruction usually indicate an antecedent at- 
 tack of peritonitis. Such bands when found are either divided or, preferably, 
 extirpated, and if the strangulated loop has not suffered gangrene, this simple 
 procedure answers the indications for which the abdominal section was under- 
 taken. If the constricting band is a diverticulum, this appendage should not 
 be divided, but extirpated, and the opening in the intestine carefully sutured. 
 If an adherent long appendix is the cause of the obstruction, it is dealt with 
 in the same way. If flexion of the bowel has produced tlie obstruction, the 
 flexed part, which is almost without exception adherent, should be separated, 
 and the flexion corrected by straightening the bowel or by excising the apex 
 of the flexion by a V-shaped excision and closing the resulting wound with 
 sutures in the usual manner. When intra-abdominal hemorrhage is followed 
 
DISEASES AND /X./CRIES OF THE ABDOMEN. 747 
 
 bv a complcxiis of synijitoms indicative of the presence of intestinal obstruc- 
 tion, the ab(h)iiieii shi)uhl be o])ene(l ami the coagiihited l)loo(l removed by 
 spon<fin_i!; and Hushing tlie peritoneal cavity with norinal salt solution, and 
 the recurrence of the same condition prevented by arresting further hemor- 
 rhage. If a mass of intestinal coils has become firmly adherent and has 
 caused the obstruction, it is often impossible to unravel them, and in such 
 cases the whole mass is excised, as was done successfully by Baum and Koe- 
 berl(?, followed by circular enterorrhaphy ; or if this cannot be done, an anas- 
 tomosis is established between the portions of the intestines above and below 
 the seat of obstruction. 
 
 Von Hacker has advised, in cases of intestinal obstruction caused by 
 conditions which do not admit of resection, to exclude the affected part of 
 the bowel from the fecal circulation by dividing the bowel above and below 
 the obstruction, closing both ends by suturing, and restoring the continuity 
 of the bowel by circular enterorrhaphy or lateral anastomosis. For the pur- 
 pose of preventing the harmful effects of secretions or pathological products 
 which might accumulate in the excluded portion of the bowel, this procedure 
 has been modified by stitching the ends of that portion to the corresponding 
 aniiles of the external incision. 
 
 Toilet of the Peritoneal Cavity. — If everything that has come in con- 
 tact Avith the abdominal cavity during a laparotomy for intestinal obstruction 
 has been rendered aseptic by the most absolute antiseptic precautions, and 
 the local conditions found have caused no infection, and no soiling of the 
 peritoneal cavity with intestinal contents has taken place during the operation, 
 the abdominal cavity is aseptic, and can be safely closed after the removal by 
 gentle sponging of any blood that may have collected. If, however, infection 
 from any source has occurred, the peritoneal cavity should be flushed with 
 normal salt solution. In such cases drainage is a necessity. A large glass 
 drain inserted into the bottom of the pelvis and loosely filled with strips of 
 iodoform gauze best answers the purpose. In some cases multiple drains are 
 necessary. An aseptic napkin or a small compress of gauze should protect 
 the intestines during the time required for the introduction of the sutures. 
 The omentum should be drawn downward sufficiently to line the whole in- 
 cision. When the sutures are all in place they are tied from above down- 
 ward. If tension is considerable, it is necessary to add two or more button 
 sutures, which are passed down to, but not through, the peritoneum, and are 
 to be removed as soon as the tympanites disappears. 
 
 After-treatment. — Food bj the stomach is not to be allowed for at least 
 two days. Thirst is quenched by small fragments of ice, and stimulants and 
 liquid food are administered during this time by the rectum. Hypodermatic 
 injections of camphorated oil and strychnine are exceedingly useful in counter- 
 acting the immediate effects of the operation. The abdominal walls should be 
 well supported with strips of adhesive plaster and a bandage applied over the 
 dressing. Greig Smith states distinctly that " no case of operation for intestinal 
 obstruction is properly concluded until the distended bowels are relieved of their 
 contents." One of the most favorable symptoms after a successful operation for 
 intestinal obstruction is a spontaneous action of the bowels, as it not only proves 
 that the cause of the obstruction has been removed, but is also an evidence that 
 peristaltic action has been restored. The retention of fecal material in the 
 distended paretic intestines after operations of this kind not only retards 
 recovery, but is in itself a grave source of danger. Mr. Tait has taught us 
 the value of saline cathartics in the prevention of peritonitis after abdominal 
 operations. It appears reasonable that the same treatment would be useful in 
 
748 .l^V AMKIUCAX TKXT-liOOK OF Sl'llCEllY. 
 
 tlic manuixeinent of cases after oj)eratioiis for intestinal ol)struction. Exami- 
 nation of the intestine above the seat of obstruction will satisfy the sur<reon 
 that it will respond slowly but surely to mechanical irritation, and it is only 
 loi^ical to conclude that the same effect would be produced by the administration 
 of a brisk saline cathartic. Its use, however, should be delayed until after 
 the intestinal wound is well united — till the third day if possible. Dangerous 
 as the use of cathartics must be before the ol)struction is removed, their judi- 
 cious emi)loyment may be beneficial after the continuity of the intestinal canal 
 has been restored by operative treatment. Stimulating rectal enemata should 
 be given to assist the action of the cathartics if the seat of operation has been 
 above the ileo-ciBcal valve. Opiates should be given only to relieve pain, and as 
 sparingly as possible, so as not to impair the ])eristaltic action of the intestines. 
 
 Anatomico-pathological Forms of Intestinal Obstruction. — IJefore 
 considerin"' tlie special forms of intestnuil obstruction, it nnist be understood that 
 clinically they all belong either to tlie acute or to the chronic variety of ob- 
 struction. 
 
 The forms which give rise to ACUTE symptoms, and terminate in a few days 
 either in death or in recovery, are those in which the mechanical difficulties that 
 interfere with the passage of the intestinal contents arise suddenly, or at least in 
 a short time. As illustrations of acute intestinal obstruction may be enumerated 
 the sudden blocking of the lumen of the intestine by a gall-stone or other foreign 
 body, invagination, the incarceration of an intestinal loop under or over a con- 
 stricting band, and volvulus. In all such cases the lumen of the intestine at the seat 
 of obstruction becomes impermeable, completely arresting the passage of feces. 
 
 The most conspicuous clinical symptoms of acute intestinal obstruction are 
 absolute constipation, the fecal diseliarges. if any take place after the obstruction 
 has occurred, consisting of intestinal contents from below the seat of obstruc- 
 tion ; vomiting, which, as a rule, appears early and is most distressing if the 
 obstruction is high up in the small intestine ; and tympanites, Avhich is most 
 marked if the obstruction is low down in the intestinal canal. Peritonitis 
 frequently gives rise to the adynamic form of intestinal obstruction by arrest- 
 ing the peristaltic action of the bowels, and it is often difficult to differentiate 
 between the inflammatory or adynamic and the mechanical form of obstruction. 
 
 As important diagnostic points it may be mentioned that peritonitis is 
 attended by more severe and continuous pain, tenderness, and rigidity of the 
 abdominal' muscles and a more decided rise in temperature, as a rule, from the 
 very beginning, than is obstruction due to mechanical causes, in which the 
 pain is paroxysmal, tenderness is either absent or less marked, the aljdominal 
 muscles are not rigid, and the temperature in the beginning is either normal 
 or only slightly increased. 
 
 Acute intestinal obstruction, unless treated by surgical interference, with 
 few exceptions results in death in from tw^o days to two weeks. Spontaneous 
 recovery in such cases is the exception, death the rule. If recovery takes jdace 
 unaided by surgical interference, the mechanical o])struction is removed or 
 corrected, as when an impacted gall-stone becomes dislodged and is forced into 
 a larger portion of the intestinal canal, when a twist of the bowel is corrected 
 in volvulus, when an intussusceptuni sloughs and is eliminated, or when 
 spontaneous reduction of a strangulated intestinal loop is effected. 
 
 In the treatment the administration of cathartics is absolutely contra- 
 indicated in such oases, as they invariably aggravate the symptoms and local 
 conditions which have caused the obstruction. Absolute diet, and the use of the 
 rubber stomach-tube, combined with irrigation of the stomach and ^mall doses 
 of opium to diminish the violent peristalsis, are the measures wdiich should be 
 
DISEASES A XI) IXJUniES OF THE ABDOMEN. 749 
 
 relied upon in assisting the tendencies to recovery, and to hridge over the time 
 until it is deemed necessary to interfere surgically. 
 
 In CHRONIC cases of intestinal obstruction the clinical history usually 
 points to a gradually increasing stenosis of the intestine ; an increasing diffi- 
 culty in procuring a normal passage by the usual laxatives ; frequently diar- 
 rhea, owing to a catarrhal inflammation of the nmcous membrane above tiie 
 seat of obstruction ; colicky })ains, caused by increased peristaltic action; and, 
 finally, a gradually increasing tympanites and vomiting. 
 
 Chronic obstruction is caused most frequently by malignant disease of the 
 bowel at or below the ileo-csecal valve, cicatricial stenosis affecting the same 
 portion of the intestinal canal, fecal impaction, and chronic, slowly-progress- 
 ing invagination. Spontaneous recovery in such cases is possible only if the 
 obstruction is due to non-maligiiaut causes and an intestinal anastomosis is 
 established between an intestinal loi>p below the obstruction and the intestine 
 above it by ulceration. It is not uncommon in cases of chronic obstruction 
 for acute symptoms to develop suddenly, and the primary condition is usually 
 found only after opening the abdominal cavity in search for the cause of the 
 acute obstruction. 
 
 Treatment. — With the exception of chronic invagination, which some- 
 times can be reduced, the causes which give rise to chronic obstruction make 
 it necessary to perform either enterectomy or intestinal anastomosis, or to 
 establish an artificial anus. 
 
 ExTERO-LiTiiiASis. — Entcro-lithiasis is due in the majority of cases to the 
 impaction of a gall-stone or the formation of an enterolith, the nucleus of 
 which is frecjuently a gall-stone, in the lumen of the bowel. 
 
 Biliary Calculus. — Rokitansky asserted that a calculus the size of a 
 hen's egg may pass through the bile-ducts. It is now generally believed that, 
 as a rule at least, such large concretions can escape from the gall-bladder only 
 by ulceration through its walls, and that a gall-stone of smaller size, after it has 
 passed through the bile-ducts, subsequently becomes larger by the formation 
 of concentric concretions during its retention in the intestinal canal. Leich- 
 tenstern has found that out of 1541 cases of intestinal obstruction from different 
 causes, tabulated by himself, 41 were produced by gall-stones. Of 51 cases of 
 intestinal obstruction caused by the impaction of a gall-stone, collected by 
 Wising, 38 died. In some of these cases the calculi were of great size. In 
 the cases reported by Smith and Fagge they measured four and a half by two 
 and a half inches in circumference. The calculus may become impacted in 
 any portion of the small intestine from the duodenum to the ileo-ctecal valve, 
 but most frequently it becomes lodged in the duodenum or the lower portion 
 of the ileum and just above the ileo-ctecal valve. * 
 
 The clinical history of such cases points to a previous attack or passage 
 of gall-stone, or. if the calculus has gained entrance into the intestine by ulcer- 
 ation, to an antecedent attack of circumscribed peritonitis in the region of the 
 gall-bladder. If the calculus has become impacted in the duodenum or the 
 upper portion of the jejunum, scanty urine, obstinate vomiting, and the ab- 
 sence of tympanites indicate that the obstruction is located high up in the 
 intestinal canal. If the impaction has taken place in the lower portion of the 
 ileum or above the ileo-caecal valve, the symptoms will be the same as in 
 obstruction from other causes in these localities. The administration of pur- 
 gatives even in this form of intestinal obstruction is exceedingly hazardous, 
 as the foreign body in a short time produces textural changes at the seat of 
 impaction which render dislodgment impossible by this method of treatment. 
 
 Treatment by laparotomy should not be postponed until irreparable path- 
 
750 .4.V AMKIilVAX TEXT-liOOK OF Si'RGEltV. 
 
 ological changes liave been produeeil by the foreign body. After the abdomen 
 has been opened and the seat of impaction located, an eft'ort shouhl be made to 
 crush the stone by pressure, provided the wall of the intestine is in such a con- 
 dition as to warrant such an attempt. If this does not succeed, enterotomy is 
 indicated. The stone should never be attacked at the seat of impaction, but 
 should be pushed in an upward or downward direction, and then removed, if 
 possible, by breaking it up by manual pressure, or, if this fail, the method 
 suggested by Tait, of passing a stout steel needle obliijuely thn)ugh the in- 
 testinal wall and attacking the calculus, may be tried. After the stone has 
 been crushed and the debris within the gut has been pushed into a healthy 
 segment of bowel below, the puncture in the serous coat should be closed by 
 drawing the peritoneum over it with a fine superficial suture for the purpose 
 of guarding against leakage. If the stone cannot be displaced and has to be 
 removed by enterotomy, the site of operation after suturing should be covered 
 by an omental graft. If the intestine at the seat of impaction presents evi- 
 dence of gangrene, it must be resected and the continuity of the intestinal 
 canal restored by circular enterorrhaphy. 
 
 Intestinal Concretions. — "We have already seen that a small gall-stone 
 when retained for a sufficient length of time in the intestinal canal mav become 
 the nucleus of an intestinal concretion, which by the addition of concentric 
 layers gradually increases in size until it fills the lumen of the bowel, and 
 after its impaction gives rise to intestinal obstruction. Enteroliths causing 
 obstruction have been described in which a variety of foreign bodies have been 
 found as nuclei. According to the analysis made by Virchow of two entero- 
 liths, the concretions are composed principally of phosphate of ammonia and 
 organic substances, especially of the derivatives of the biliary acids known as 
 dysUsin. In one case Langenbuch removed an enterolith by enterotomy from 
 the jejunum, but the patient died a few hours later, and at the post-mortem a 
 second mass, still larger, was found in the pyloric region of the stomach. The 
 surgical treatment of intestinal concretions is the same as that of impacted 
 gall-stones. 
 
 AscARiDES. — Halina, Saurel, Pockels, Stepp, and others have reported 
 cases in which intestinal obstruction was produced by masses of ascarides 
 becoming impacted in the small intestine. The patients were invariably 
 children. "When the surgeon is called upon to treat a case of intestinal 
 obstruction in a child, such a cause should be borne in mind, as in a case of 
 tjiis kind a timely anthelmintic remedy, followed by a brisk cathartic, may 
 prove efficient in removing the cause of obstruction. If such treatment should 
 prove unavailing, no time should be lost in resorting to operative treatment 
 by abdominal section, which should be conducted in the same manner as in 
 operations for intestinal concretions. 
 
 Fecal Obstruction. — This is almost without exception met with only in 
 the large intestine, and, in preference, in the caecal region or in the sigmoid 
 flexure. Cases have been reported where a congenital dilatation of some part 
 of the colon predisposed to this affection. The acquired form of dilatation 
 which attends all cases is the result of prolonged over-distention, resulting in 
 paresis of the distended segment of the bowel. Impaction of feces sometimes 
 gives rise to dangerous complications. Ulceration, and even perforation, may 
 take place from this cause. Distention of the bowel often takes jilace to an 
 enormous extent. Cruveilhier found on making a necropsy on an old man the 
 transverse colon so dilated that it measured 35 cm. in circumference, and the 
 crecum had attained the size of a child's head. One of the most important 
 diagnostic points is to give an anesthetic and make pressure over the swelling. 
 
DISEASES AM) IXJURIES OF THE ABDOMEX. 751 
 
 when the fecal masses can he indented, tlie pressure leaving a permanent de- 
 pression. Patients who have once suffered from fecal impaction are very prone 
 to suffer from a recurrence of tlie same condition at intervals. 
 
 If the impaction is within reach, its removal should be accomplished by 
 the use of a scoop, assisted by copious injections. If the bowel at the seat 
 of impaction has lost its contractility, cathartics are useless, and, if it is in 
 a state of inflammation, positively hurtful. In such cases massage and high 
 injections are indicated. After the mechanical removal of the fecal accumula- 
 tion a recurrence should be prevented by the administration of extract of 
 belladonna, gr. ^, with an equal dose of extract of nux vomica, combined with 
 half a grain of aloes and a grain of sulphate of iron in pill after each meal. 
 Massage and electricity will render material assistance in restoring normal 
 peristalsis. Perforation and suppurative inflammation in the connective tissue 
 or the peritoneal cavity must be met by prompt surgical treatment. In cases 
 where all ordinary measures fail to remove the fecal accumulation and the 
 symptoms of obstruction continue unabated, it would be not only justifiable, 
 but good surgery, to cut down upon the distended bowel and break up the 
 mass within the gut, and push it along to a portion of the intestine below, 
 where peristaltic action has not been suspended. In cases where the patho- 
 logical conditions contraindicate such a course of treatment it mav become 
 necessary to resort to colotomy and remove the fecal mass through the wound, 
 and, according to circumstances, either close the visceral wound by suturing or 
 establish a temporary artificial anus in the corresponding inguinal region. 
 
 Invagination or Intussusception is that form of intestinal obstruction 
 caused by the telescoping of one section of the bowel into another. A trans- 
 verse section through an invaginated portion of the bowel reveals three intesti- 
 nal walls, of which the outer, or sheath, is called the intussuscipiens, and the 
 two inner the intussusceptum. The usual form of invagination is when 
 the intussusceptum is directed downward, when it is called a descending invagi- 
 nation, to distinguish it from a rare form in which the intussusceptum is directed 
 upward, which is called ascending invagination. It is estimated that 30 per 
 cent, of all forms of intestinal obstruction, exclusive of hernia and congenital 
 malformations, are cases of invagination. 
 
 The direct causes of invagination are not well understood. Some main- 
 tain that descent of the bowel takes place into a paretic section below it, 
 while others assert that the intussusceptum is drawn into the intussuscipiens 
 by active peristaltic action of the latter. The cause of a chronic invagination 
 is often a tumor att-ached to the inner surface of the bowel. In more than 50 
 per cent, the patients are under ten years of age. Invagination, according 
 to Heusner, is the cause of obstruction in three-fourths of all cases of intesti- 
 nal obstruction in children. The disease, as a rule, is more acute in children 
 than in adults, and the mortality is correspondingly greater. The average 
 mortality without surgical interference is more than 80 per cent. Death is 
 caused by exhaustion or gangrene and perforation at or near the neck of the 
 intussuscipiens. Spontaneous recovery is possible only if reduction takes place 
 or if the intussusceptum sloughs away after the bowel above has become firmly 
 adherent to the neck of the intussuscipiens. In this way patients have event- 
 ually recovered after the elimination of several feet of gangrenous intestines. 
 In the ileo-colic and colic varieties it is not uncommon for the apex of the 
 intussusceptum to descend as far as the rectum, where it can he discovered 
 by digital examination, and sometimes the bowel is protruded some distance 
 beyond the anus. 
 
 In the diagnosis of this affection the greatest weight should be placed on 
 
752 .I.V AMEIUCAX TKXT-IiOOK OF SURaKIiV. 
 
 the existence of an elongated cylindrical swellinf;;, tenesmus, eoliekv )»ains. and 
 the jtrescnce of niueus and Mooil in the discharges from the rectum. Another 
 important symi)t<»ra wliich distinguishes invagination from other mechanical 
 causes which jiroduce acute obstruction is the al>sence of complete constipa- 
 tion, gas and licjuid feces finding escape through the narrow lumen of the 
 intussusceptum. 
 
 The first indications in the treatment (d' invagination are to withhold food 
 by the stomaeh and to administer opiates to diminish the jx-ristaltic action of the 
 bowel above the seat of obstruction, after wh-ich no time should be lost in effect- 
 ing disinvagination by mechanical measures. The simplest, safest, and most 
 efficient of these is distention of the bowel below the obstruction with hydrogen 
 gas or filtered air, which is done in the same manner as rectal insufflation for 
 diagnostic purposes. Before insufflation is made, the colon should be thor- 
 oughly washed out with a high enema by Hegar's method, in which an ordinary 
 enema nozzle connected with a funnel by a rubber tube about two feet long is 
 inserted in the rectum. Warm water is then poured into the funnel and fills 
 the rectum and colon. From two to four quarts may be injected. This should 
 be done without an anesthetic, so that jtain may warn us when to desist. Insuf- 
 flation must always be practised while the patient is thoroughly under the influ- 
 ence of an anesthetic and with the jiatient nearly or completely in the inverted 
 position. In recent cases of invagination below the ileo-cwcal valve this method 
 of treatment will frequently succeed in effecting reduction. If reduction cannot 
 be accomplished in this way, operative treatment must be resorted to at once. 
 In patients too mucli prostrated to bear a laparotomy, an enterostomy or colos- 
 tomy should be performed, according to the location of the invagination. Lap- 
 arotomy is indicated after rectal insufflation has been faithfully and thoroughly 
 tried with negative result, in all instances in which the general condition of the 
 patient is such as to justify this procedure. Treves gives the mortality in 183 
 recorded radical operations for invagination as 72 per cent. ; when reduction 
 was easy it was 30 per cent., and when difficult 91 per cent. The difference 
 between the mortality of early and that of late operations is the most con- 
 vincing argument in favor of early operative interference. 
 
 As a rule to which there should be few exceptions, the incision should be 
 made in the median line, as it furnishes the most ready access to the invagina- 
 tion and enables the operator to apply the various surgical resources with the 
 greatest facilit}'. For special indications a second lateral incision may be made 
 later. In recent cases the difficulty encountered in reduction consists in an 
 (Edematous condition of the intussusceptum, and on this account the invagi- 
 nated bowel should be firmly compressed between both hands of the operator 
 before direct attempts at reduction are made. Reduction is then trie<l by mak- 
 ing gentle traction on the bowel with one hand above the obstiniction, while 
 with the other the bowel is compressed below at a point corresponding with the 
 apex of the intussusceptum. in such a manner as to force this in an upward 
 direction, while the intussuscipiens is at the same time drawn in a downward 
 direction. Reduction is sometimes facilitated b}' assisting the traction from 
 above by elastic pressure from below, made by rectal insufflation of hydrogen 
 gas or filtered air. If adhesions exist, they can be separated by inserting and 
 passing around the bowel Kocher's director or a small probe. If reduction 
 has been accomplished, the necessary precautions should be taken to prevent 
 reinvagination, consisting in shortening the mesentery at the point of invagi- 
 nation by folding it upon itself in a direction parallel to the bowel and 
 securing it in this position by a few catgut sutures. Should repeated attempts 
 at reduction fail, one of three methods of treatment may be pursued : 1. The 
 
J>/S/JASES AND rXJiJIilKS OF THE ABDOMEN. 753 
 
 formation of an anastomosis between the bowel above and below the intussus- 
 ceittion: 2. Keseetion of the invaginated portion, to be followed by eircular 
 enterorrha|)hy ; 3. Formation of an artificial anus ; 4. Resection of intussus- 
 ceptum. Partial resection of the invaginated portion of the bowel by the 
 removal of the intussusceptum is advisable in the absence of gangrene of the 
 intnssuscipiens. The intussusceptum is removed through a longitudinal 
 incision in the intnssuscipiens near the neck after preliminary ligation near 
 its base. The opening is utilized in making an anastomosis between the 
 boAvel above and below the neck of the invagination, as in Maunsell's method. 
 
 Volvulus. — Volvulus, or the tAvisting of a loop of intestine around its 
 axis, constitutes a well-defined form of intestinal obstruction. This pathological 
 condition can occur only where the mesentery of the bowel is of considerable 
 length, and is therefore most frequently met with in the lower portion of the 
 ileum and at the sigmoid flexure of the colon. The condition, as compared 
 with some other forms of intestinal obstruction, is quite rare. The immediate 
 cause of the volvulus has been ascribed by Grawitz to accumulation of intesti- 
 nal contents above a constricted portion of bowel, while Nieberding has traced 
 it in a few cases to adhesions of an omental stump to an intestinal loop. 
 
 The symptoms of volvulus will vary to some extent according to the 
 location of the twist. If it affects the small intestine, early and persistent 
 vomiting is the most important symptom. This symptom appears later, and is 
 less persistent if the sigmoid flexure has become twisted around its axis. Wahl 
 has called attention to a condition which he considers almost pathognomonic 
 of volvulus — a circumscribed area of tympanites corresponding to the location 
 of the twist and caused by gaseous distention of the twisted loop. 
 
 Treatment. — Of all forms of intestinal obstruction, volvulus leads most 
 rapidly to a fatal termination. This fgict alone is a sufficient warning to lose no 
 time in temporizing measures. We have reason to believe that a volvulus after 
 it has caused symptoms of obstruction is very seldom reduced without direct 
 surgical interference. On the other hand, it mav be stated as a fact that if an 
 early laparotomy is done the prognosis Avill be more favorable than in almost 
 any other form of intestinal obstruction. It is necessary to make a long median 
 incision, for the purpose of both detecting and correcting the volvulus. The 
 untwisting in recent cases can be done without difficulty; where adhesions 
 have become firm and numerous it may be impossible. If the bowel can 
 be untwisted, a recurrence of the same lesion and at the same place can be 
 prevented by shortening of the mesentery, which is to be done in the same 
 manner as has been described in the operative treatment of invagination. If 
 the untwisted bowel shows evidences of gangrene, resection becomes a necessity. 
 If no such changes have taken place, but reduction is found impossible, the 
 distended twisted loop is incised, emptied, and washed out with a mild anti- 
 septic solution, the wound sutured, and an intestinal anastomosis established 
 between the intestine above and that below the volvulus. 
 
 Flexions and Adhesions. — Flexions and adhesions as a cause of intes- 
 tinal obstruction are almost without exception the remote consequences of a 
 previous peritonitis. An adherent intestinal loop may gradually become flexed 
 by the cicatricial contraction of the inflammatory material deposited between 
 the bowel and the adjacent serous surface. Immobilization of a section of the 
 intestinal tube in a mass of inflammatory exudation may cause intestinal ob- 
 struction by arresting peristaltic action of that part of the intestine. The 
 obstruction may remain incomplete for an indefinite period of time, until the 
 compensatory hypertrophy of the intestinal wall on the proximal side of the 
 obstruction can keep pace no longer with the increasing mechanical difficulties, 
 
 •48 
 
7o4 AiX AMi:in<A.\ i'i:xr-ii()()K of ,si'ii(,'i:in'. 
 
 wlu'U syuiptoms of acute obstruction set in, wliicli may be tlie first intimation 
 of the existence of an old-standing obstruction. 
 
 Treatment. — If abdominal section is undertaken for the correction of 
 such patholo^^ical conditions, an effort should be made to preserve the con- 
 tinuity of the intestinal canal by isolating the adherent loop or loops and 
 .straightening out the tube, and, if possible, displacing it in such a manner a.s 
 to prevent it from subsequently resuming the same relations. Wherever it is 
 possible to cover a raw surface by stitching over it the surrounding healthy 
 peritoneum, this should be done to prevent a recurrence of the adhesions and 
 malposition. If a section of the intestine is so firmly imbedded that it cannot 
 be liberated without great violence or perhaps rupturing its wall, it should be 
 allowed to remain and tlie fecal circulation be restored by establishing an anas- 
 tomotic opening between the bowel above and that below the adherent portion. 
 The same can be done in case a flexion has caused the obstruction and is simi- 
 larly imbedded in a plastic exudation. If the flexed portion can be easily 
 separated, the flexion is removed by the excision of a V-shaped piece, which, 
 after suture of the wound, leaves the intestine in a straight and permeable con- 
 dition. 
 
 Strangulation by Ligamentous Bands or Diverticula. — Ligament- 
 ous bands resulting from old adhesions are usually found in those parts of the 
 abdominal cavity which are most frequently the seat of peritonitis, viz. in the 
 pelvis and the ileo-caecal region. Their formation can generally be traced to 
 a broad parietal adhesion which by the movements of the free portion of the 
 intestine has become elongated and often narrowed to a delicate cord. It 
 becomes a cause of obstruction when the migrating or free end forms an at- 
 tachment to some fixed point, which then renders the band tense and unyield- 
 ing. In case a loop of intestine becomes ensnared underneath it, strangulation 
 takes place in the same manner as in strangulated hernia, the constricting cord 
 by its pressure causing venous engorgement below the constriction and retention 
 of intestinal contents in the afferent limb of the loop. As in hernia, an intes- 
 tine may have become adherent and fixed underneath such a band for an indef- 
 inite period of time without strangulation taking place, so long as the immediate 
 causes of strangulation are absent. Any cause which disturbs the mechanical 
 relations still further in such a case, as a fall, lifting, coughing, the administra- 
 tion of an active cathartic, etc., may bring on an acute attack of intestinal 
 obstruction. A displaced neck of a hernial sac may cause obstruction in the 
 same manner as a ligamentous band. A band of constriction can also be 
 formed by the margins of an opening in the mesentery or omentum, through 
 which a loop of intestine may pass and become strangulated. An adherent 
 portion of omentum in the course of time may become drawn out into a narrow 
 twisted cord which may become a cause of internal strangulation. Another 
 frequent location for bands is in the umbilical region, where the remains of the 
 umbilical artery may cause constriction. 
 
 A considerable number of cases of intestinal obstruction are on record in 
 %vhich the obstruction was caused by a Meckel's diverticulum, and in several of 
 these the strangulation was successfully treated by laparotomy. To the same 
 category belong bands the remains of obliterated omphalo-mesenteric vessels. 
 Diverticula are found most fre(iuently in the lower portion of the ileum, and 
 are supplied with a mesentery when they spring from the lateral aspect of the 
 intestine or near the mesenteric attachment. Diverticula on the convex sur- 
 face of the bowel are free, and are supplied with vessels from the intestinal wall. 
 From a surgical standpoint the appendix verraiformis must be regarded as a 
 diverticulum. This appendage may become a cause of obstruction when it is 
 
i>isi:a>ses AM) jy.Ji JUEs of riii: aiuxjmex. 755 
 
 of abnormal lencrtli and supplle*! with a long mesentery, and when at the same 
 time it is transformed into an unyieldintr band by fixation of its free extremity 
 to some firm ])oint by adhesive inflammation. 
 
 Treatment. — The operative treatment of the obstruction in this form of 
 intestinal strangulation is usually not attended by any difficulties, provided the 
 operation is not postponed until the strangulation has produced gangrene. The 
 band of constriction, whatever its location or mode of origin may be, is traced 
 to both the fixed points of attachment and excised between two ligatures. 
 The excision of the constricting band not only relieves the strangulation, but 
 also prevents a possible recurrence of a similar attack from the same cause. If 
 gangrene has occurred, it will become necessary to make a partial or complete 
 enterectomy acconling to the location and extent of the gangrene. In oper- 
 ating for obstruction caused by an elongated adherent appendix vermiformis 
 or a diverticulum it is necessary to remove these appendages near their attach- 
 ment to the intestine and to prevent extravasation by carefully inverting the 
 margins of the wound and closing it by suturing. If this cannot be done, 
 a ligature is applied near the attachment, and after amputating the appen- 
 dage the stump is buried by suturing the peritoneum over it. Bands com- 
 posed of remains of the omphalo-mesenteric vessels are divided or excised 
 between two ligatures : if this precaution of ligating them is omitted, trouble- 
 some hemorrhage may be encountered. 
 
 NON-MALIGNANT STENOSIS. 
 
 Congenital Stenosis. — Congenital narrowincr of the bowel varies in 
 degree from a slight contraction to complete atresia. If the stenosis is com- 
 plete or sufficiently well marked to prevent the passage of intestinal contents, 
 symptoms of intestinal obstruction will develop soon after the birth of the child. 
 Even if the narrowing is considerable, the bowel remains permeable and no 
 serious symptoms are produced until some foreign body becomes lodged above 
 the seat of constriction and causes obstruction from fecal arrest. The surgical 
 treatment is the same as in the next form. 
 
 Acquired or Cicatricial Stenosis. — Cicatricial stenosis is one of the 
 remote consequences of deep ulcerative lesions, such as are caused by dysen- 
 tery, typhlitis stercoralis, tuberculosis, and typhoid fever. The most frequent 
 cause of cicatricial stenosis is tubercular enteritis. The tubercular intestinal 
 ulcer is usually circular, and in the event of healing the cicatricial contractions 
 result in the formation of a circular stricture. Strictures from such a cause 
 are not infrequently multiple. They are found most commonly in the ileo- 
 cecal region and lower portion of the ileum, and are often complicated by 
 tuberculosis in other organs, notably the lungs. The cicatrix which forms 
 during the reparative stage of the ulceration contracts slowly and causes ste- 
 nosis and chronic intestinal obstruction. As in cases of congenital stenosis, 
 the obstruction often becomes complete and gives rise to acute symptoms 
 when a foreign body or solid feces become impacted above the seat of con- 
 striction. Xot infrequently the causes which have led to cicatricial stenosis are 
 located at the same time or appear successively in different parts of the intes- 
 tine, producing consequently multiple strictures. Cicatricial stenosis of the 
 small intestine is caused most frequently by tubercular ulcers ; the same con- 
 dition in the colon results commonly from dysentery, while stricture of the 
 rectum often appears as a syphilitic lesion. 
 
 The clinical history of cases of cicatricial stenosis must be traced to the 
 primary lesions which produced the stricture, and terminates with the well- 
 
7oG AN AMAJiJCAA TKXT-IiUUK OF SL'UL! KliY. 
 
 known symptoms characteristic of chronic oh.stniction. It is not uncommon 
 in these cases to see the ohstruction assume siuMenly an acute form. 
 
 Treatment. — Enterectomy should be performed only if the bowel at the 
 seat of obstruction presents pathological conditions which necessitate this ope- 
 ration, otherwise the continuity of the intestinal canal is restored by an entero- 
 plasty or by intestinal anastomosis. Enteroplasty is performed in the same 
 manner as pyloroplasty, and is applicable in narrow circular strictures. If the 
 stricture is wider, and especially if several strictures are close together, an 
 intestinal anastomosis is safer and much more easily executed than enterectomy 
 and circular suturing. 
 
 Intestinal Tumors. — A tumor can give rise to intestinal obstruction in 
 different ways, according to its location and anatomico-pathological character. 
 A tumor or swelling outside of the intestinal tube may cause obstruction by 
 compression. A polypoid groAvth springing from the mucous or sul)mucous 
 tissue interrupts the fecal circulation either by blocking the lumen of the bowel 
 by its size or by causing an invagination or flexion. A circular carcinoma 
 produces a stenosis which leads to chronic obstruction, but is also frequently 
 the indirect cause of acute intestinal obstruction. 
 
 Benign Tumors. — Benign polypoid tumors seldom attain sufficient size to 
 give rise to intestinal obstruction unless they cause additional mechanical dis- 
 turbances, such as invagination or flexion, conditions wdiich have already been 
 described. If the tumor alone is the cause of obstruction, it is to be removed 
 by laparo-enterotomy. If the tumor has caused invagination or flexion of the 
 intestine, its operative removal must be preceded or followed by removal of 
 the mechanical difficulties to which it has given rise. Buchwald and Kulen- 
 kampff have reported cases of intestinal obstruction caused by cysts of a 
 benign character which had evidently originated in the intestinal wall and had 
 caused obstruction by flexing the bowel at an acute angle. If in such cases 
 the cyst cannot be enucleated without opening the lumen of the bowel, and 
 with a prospect that the flexion will be corrected by its removal, resection and 
 circular enterorrhaphy will become necessary. 
 
 Malignant Tumors. — Malignant stenosis of the intestine mav be caused 
 either by a sarcoma or by a carcinoma, of which the former is more frequent 
 above, and the latter below, the ileo-csecal valve. A sarcoma of the intestine 
 always has its starting-point in the wall beneath the mucous membrane, while 
 carcinoma commences either in the mucous membrane or in its glandular 
 appendages. 
 
 A sarcoma, as a rule, does not give rise to glandular infection, but to 
 extensive regional infection in the course of the blood-vessels and connective- 
 tissue spaces, and obstruction is caused more frequently by flexion than by 
 circular constriction of the bowel. As a sarcoma of the intestine usually gives 
 rise to symptoms of obstruction, and consequently comes under surgical treat- 
 ment, usually after extensive infiltration of the mesentery and retro-peritoneal 
 tissues has taken place, it is questionable if it is prudent to attempt a radical 
 operation, as in case the patient recovers from the operation an early recurrence 
 is almost inevitable. If a sufficiently early diagnosis were possible, resection 
 could be made with a fair prospect of a permanent result ; but if infection 
 has extended to the tissues around the bowel, it is more judicious to leave the 
 sarcoma and to exclude the obstruction by an intestinal anastomosis. 
 
 Carcinoma is found most frequently in the region of the sigmoid flexure, 
 the cjtcum, and the rectum. The disease either appears as a circumscribed 
 circular affection, in which case the lumen of the bowel is narrowed gradually, 
 giving rise to symptoms indicative of chronic obstruction ; or diffused infiltra- 
 
/)/s/:asks a.xi) injuries of the abdomen. 7^7 
 
 tioii of the intestinal wall takes place at an early stage, in ^vliicli case obstruc- 
 tion sets in later and the symptoms are less marked. A malignant stenosis 
 may have existed for montiis without symptoms, when suddenly symptoms of 
 acute obstruction set in. In cases of acute intestinal obstruction in elderly 
 people, where no cause for it can be found in the abdomen, a thorough rectal 
 examination should never be neglected. While sarcoma may occur in chil- 
 dren, carcinoma is seldom met with in persons under thirty-five years of age. 
 Carcinoma at an early stage is attended by regional infection in which the 
 mesenteric and retro-peritoneal glands arc principally involved. If the tumor 
 has attained considerable size, it can be felt through the abdominal wall, and 
 its location and relations to surrounding organs can be accurately determined 
 by rectal insufflation of hydrogen gas or atmospheric air. If ulceration has 
 taken place, hemorrhage into the bowel may occur, and this symptom when 
 present should be taken into careful consideration in the differential diagnosis. 
 Catarrhal inflammation of the raucous membrane above the scat of obstruction 
 is an almost constant occurrenci, and constipation alternates with diarrhea. 
 
 In malignant stenosis of the small intestine resection with circular enteror- 
 rhaphy can be done with comparative ease. While excision of a corresponding 
 portion of the mesentery is not only unnecessary, but even harmful in enterec- 
 tomy for non-malignant lesions, this should never be neglected in malignant 
 cases, as by it the mesenteric glands, Avhich arc most liable to become infected 
 first, are removed. In resection of the caecum the retro-peritoneal glands 
 should be removed as far as possible, and the continuity of the bowel restored 
 either by circular suturing or by making an intestinal anastomosis a few 
 inches above the closed ends of the ileum and colon, or by implanting 
 the resected end of the ileum into a slit in the ascending colon a few- 
 inches above its closed end. If after resection of the lower portion of the 
 colon it is found impossible to approximate the two ends of the bowel, 
 and the distal end is not sufficiently accessible to make an intestinal 
 anastomosis, it should be closed and dropped into the abdominal cavity, 
 while the proximal end is brought out through a wound in the left groin, 
 where it is secured by deep and superficial sutures, making thus a per- 
 manent artificial anus. If on account of the extent or location of the 
 carcinoma it is found impossible to make a radical operation, one of two things 
 may be done. If the bowel below the obstruction is accessible, an intestinal 
 anastomosis is made, or the ileum is divided just above the ileo-caecal valve, the 
 distal end invaginated and closed with sutures, and the proximal end implanted 
 into the bowel below the seat of obstruction. If on account of the location of 
 the obstruction either of these operations cannot be done, an artificial anus 
 should be established in one of the inguinal regions according to the location 
 of the carcinoma, and if the first incision was made through the middle line, 
 this is closed and dressed separately. 
 
 Retroperitoneal Tumors. — Tumors and sAvellings in the retroperitoneal 
 space present to the surgeon many points of diagnostic and operative inter- 
 est. In the diagnosis of such pathological conditions it is important to con- 
 nect the tumor with its anatomical starting-point. The retroperitoneal loca- 
 tion of a palpable tumor can sometimes be definitely ascertained by rectal 
 insufflation of air. If the tumor is in contact with the anterior abdominal 
 wall, the area corresponding with its circumference will be dull on percus- 
 sion. If the colon is distended with air, the dulness disappears if the tumor 
 is retroperitoneal, as the distended colon separates it from the abdominal 
 wall ; if the tumor is intraperitoneal, it is often displaced by the distended 
 colon, but the disappearance of the tumor and dulness is less marked. 
 
758 Ai\ ami:l'i<'AX 'nixr-iiooK of sunaj:in\ 
 
 Tumors in the retropcritoiu'al space, uitli lew exceptions, are of niesoblastic 
 origin. Dermoids in tliis locality are exceedingly rare. Inflammatory 
 swellings take their starting-point most frequently in the bodies of the verte- 
 brne, lymphatic glands, and connective tissue. 
 
 The operative treatment of retroperitoneal tumors is attended by much 
 more risk to life than the removal of intraperitoneal tumors. 'J'he surgeon's 
 eftbrts fretfuently cease with an exploratory laparotomy. 
 
 Fatty tumors develop most frc(iuently in connection with tlie j»ararenal 
 cushion of fat along the ilio-psoas muscle and in the obturator foramen and 
 crural canal. Usually they do not reach large size; in a few cases they have 
 attained an enormous size. They often undergo sarcomatous degeneration. 
 Their growth is slow% and the symptoms which they produce are due almost 
 exclusively to pressure. Their removal is effected through a median abdomi- 
 nal incision by splitting the peritoneum over the center of the tumor in a 
 vertical direction, followed by enucleation. After careful arrest of hemor- 
 rhage the peritoneal incision is sutured before closing the abdominal incision. 
 
 Retro-peritoneal Struma. — This tumor, of a malignant or semi-malignant 
 nature, has its origin in the supra-renal gland or foetal rests of this gland. 
 Such a tumor is closely allied to or almost identical with sarcoma histolog- 
 ically and clinically. It is rapid in growth and soon infects tlie kidne3^ A 
 number of successful radical operations have been recorded ; but unless thor- 
 oughly removed speedy recurrence is certain to take place. 
 
 Sarcoma in the retroperitoneal spaces springs either from one of the 
 bodies of the vertebras, the pelvic bones, lymphatic glands, or the connective 
 tissue. Lympho-sarcoma of the retroperitoneal glands fre((uently appears as 
 the result of regional dissemination of sarcoma of the testicle. As a primary 
 and secondary affection of the lymphatic glands it presents itself in the form 
 of a multiple rapid-growing tumor. Fascial, periosteal, and bony sarcomas are 
 characterized clinically by a rapid-growing tumor in the retroperitoneal space. 
 
 Serous cysts have been found in the retroj)eritoneal space that originated 
 from remains of either the Wolffian body or Miiller's ducts. Cysts of such 
 histoo-enetic origin have thin walls and contain a clear fluid in which albu- 
 min, chlorides, and traces of urea and uric acid can be found. In some of 
 these cases the kidney on the corresponding side was either absent or in a 
 rudimentary form. In a foAV cases retroperitoneal serous cysts in the renal 
 region have successfully been removed through a lumbar incision. 
 
 Tubcrrulosis of the retroperitoneal I//mj)/iatic glands is frei[uently one of 
 the remote results of a similar affection of the testicle. By an extraperito- 
 neal incision a chain of tubercular glands extending from the internal 
 inguinal ring to the bifurcation of the common iliac artery have been 
 removed. Progressive extension is one of the typical clinical features of 
 glandular tuberculosis in this as well as in other regions. Caseation and 
 abscess-formation occur if life is sufficiently prolonged. The abscess usually 
 points above the crest of the ilium. 
 
 Chronic abscesses which develop in the course of tubercular spojidylitis 
 often appear as retroperitoneal swellings, and have freiiuently been mistaken 
 for pyonephrosis and paranephric abscess. A careful study of the clinical 
 history, combined -with a painstaking examination to locate the swelling 
 properly, aided, if necessary, by an exploratory puncture in the lumbar 
 region, Avill usually enable the physician to make a correct diagnosis. Retro- 
 peritoneal tubercular abscesses of glandular or osseous origin, accessible 
 through the lumbar region, should be treated by tapping, followed by injec- 
 tion of a 10 per cent, iodoform-glycerin emulsion. 
 
DISEASES AND INJURIES OF THE ABDOMEN. 759 
 
 Adynamic Intkstinal Obstruction caused by Arrest of Peri- 
 stalsis. — A number of pathological conditions are known to produce 
 symptoms which so closely resemble those of intestinal obstruction due 
 to mechanical causes that the abdomen has been repeatedly opened in 
 such cases with the expectation of removing the cause of obstruction, yet 
 no occlusion of any kind could be found. These are the cases that have 
 caused the t^rejitest difficulty in diiignosis, and have often brought dis- 
 appointment and reproach upon the surgeon. The obstruction in these cases 
 is not caused primarily by a narrowing of the lumen of the intestine, but by 
 suspension of the forces which propel the intestinal contents, and which results 
 in the accumulation of feces and gases in the paralyzed portion of the bowel ; 
 this is followed by distention of the intestines, constipation, and obstinate 
 vomiting, which in rare cases may become fecal. Circumscribed or diffuse 
 paresis of the intestines is often caused by an inflammatory affection, such as 
 peritonitis or enteritis, which produces suspension of muscular contractions in 
 the same manner as when an inflammatory process in any other organ affects 
 directly the muscular tissue ; or the tunics of the intestines may be in an intact 
 condition, and paralysis result from reflex causes. In either case the most 
 striking symptom is an extensive tympanites. While in obstruction from 
 mechanical causes the peristaltic action of the intestines can sometimes be 
 seen on the surface of the abdomen, paralysis from over-distention not having 
 taken place, in the paralytic form the abdominal surface is smooth and the 
 outlines of the intestinal coils are not perceptible. In this form of obstruction 
 expulsion of gas and the passage of intestinal contents are prevented by the 
 formation of numerous flexures, owing to the great distention of the intestines, 
 which is followed by compression of some parts of the intestines by the dis- 
 tended loops. 
 
 The diseases which cause adynamic intestinal obstruction are rapid accumu- 
 lation of gas from fermentative or putrefactive processes in the intestines, peri- 
 tonitis, and catarrhal and ulcerative enteritis. A paretic condition of the bowels 
 has also been observed following prolonged laparotomies, especially when 
 evisceration has been necessary. 
 
 In rare cases the intestinal paresis is caused either by embolism of 
 branches of the mesenteric arteries or thrombosis of the mesenteric veins. 
 In either case the impaired circulation is almost sure to give rise to gangrene 
 or sloughing of the intestine, to an extent corresponding with the vascular 
 district affected. 
 
 if a positive diagnosis of adynamic obstruction can be made, the treat- 
 ment consists in relieving the distention by puncturing the bowel, external 
 support by enveloping the abdomen with strips of adhesive plaster, tubage of 
 the colon, a rigid diet, and the administrat;jon of such remedies as naphthaline 
 to procure an aseptic condition of the intestinal canal. If under such circum- 
 stances a laparotomy is made upon the supposition that a mechanical cause 
 exists, the intestine should be emptied through one or more incisions at least 
 an inch or more in length, which are at once sutured, the intestines returned, 
 and the external wound closed, after which a treatment is adopted which is 
 directed toward the removal of the primary cause and the prevention of the 
 production of gas in the intestines. 
 
 APPENDICITIS. 
 
 Appendicitis, or inflammation of the appendix vermiformis, is now a well- 
 recognized surgical lesion, and is regarded as the primary lesion in the cans- 
 
7(io ,i.v AMi:i:i( A.\ TKxr-iiooK or suhgery. 
 
 ation of the ruiiiiorous loriiis (»t" inllaiiiiuatiun in the ileo-civcal re;:;iun known 
 !vs typhlitis, perityphlitis, paratyphlitis, and appendicular peritonitis. 
 
 Etiology. — As re«:ar<ls etiology, we may first consider (<?) the predisposing 
 causes. The exjilanation of the great fre(|iien<y with which the ap]»endix 
 becomes the seat of inHanmiatory and tlestructive lesions as compared with 
 the other jiortions of the digestive tract is undoubtedly to be found in its 
 embrvologv and in its anatomical relations. There can be no question that 
 those' structures which remain to us as functionless vestiges of parts once 
 useful in our prehistoric ancestors are possessed of low vitality and but feeble 
 resistant powers. This is as true in the life of the race as in that of the indi- 
 vidual. It doubtless explains in part the special su.sceptibility of the appen- 
 dix to inflammation, as it does that of the uterus and the female brea.st to 
 cancer during the post-sexual ])eriod of life. 
 
 In addition, its dependent position, its communication by an orifice, often 
 more or less narrowed, with that portion of the intestine in which inspissation 
 of intestinal contents first occurs, Avhile at the same time it is removed from 
 the direct fecal current — all appear to be conditions so markedly predisposing 
 to inflammatory attacks that we need look no further for a suflicient explana- 
 tion of the extraordinary frequency of appendix trouble. 
 
 (h) ExciTiNU Causes. — Putting aside the comparatively rare cases in 
 which tubei'cular or other general disease localizes itself in the appendix, we 
 have two chief classes of exciting agencies, clinical differentiation of which 
 is to be earnestly aimed at : the mechanical and the bacterial or infective. 
 The latter comes into play usually, perhaps almost constantly, as a sequel of 
 the former, which may, however, exert its action alone from first to last in a 
 given instance, and does so in some cases. 
 
 ^ 
 
 Sections of two Appendixes, showing Obstruction of ilie l.uiuen. 
 (Original.) (Richardson.) 
 
 The following anatomical points must be remembered : The location and 
 direction of the appendix are variable. In the majority of cases the base of 
 this organ is situated at or near McBurney's point ; but it has been found in 
 exceptional cases in the left side and beneath the diaphragm. Its direction 
 may be upward, downward, or to either side. Its length varies from one to 
 six inches or more. The appendix is commonly found curved upon itself, 
 because its mesentery, derived from the inferior layer of the mesentery of 
 the ileum, is too short for it. In the fnetal type of the cecum and appendix 
 the latter has a mesentery which runs to its tip : but in the majority of adults 
 it ends about the center of the appendix or at the junction of its middle and 
 distal thirds. Along the free concave border of the mesentery runs a single 
 vessel, a branch of the ileo-colic, and from this branch the appendix, as a 
 rule, derives almost its entire blood-supply. Another peritoneal fold runs 
 from that part of the ileum most remote from its mesenteric attachment and 
 is united with the mesentery of the appendix. It carries no blood-ves.<?els. It 
 is the remains of the true mesentery of the appendix (Treves). It is inter- 
 esting to note the fact that in the different types of cecum found in our 
 species those which involve its disproportionate growth show that it derives 
 its peritoneal covering partly at the expense of the mesentery of the appen- 
 
APPENDICITIS. 
 
 Plate XVTIT. 
 
 r.. K ■= 
 
 <^ —. a: 
 
 *n a; :;■ 
 3 f= j" 
 
 :^ 
 
 
 x' £. ? 
 
 c s - 
 
 — X "" 
 
 
DISEASES AM) fXJURIES OF THE ABDOMEN. 761 
 
 <li.\. wliii-h becomes more an<l more scanty and more vertical in dircc-tion the 
 larger the rehitive size of the cecum. 
 
 We here have the factors Avhich enter into the production of a large number 
 of cases of appendicitis. Distention of the ileum with gas or of the caput coli 
 with 'ras or fecal matter will cau.se dragging on one or the other of these 
 folds. '^ilready too scanty, increase the torsion of the appendix, interfere with 
 the blood-suYplv through its single vessel, and. according to the degree of 
 torsion, produce congestion and tumefaction, catarrhal iiiHammation. ulcera- 
 tion, or gangrene, with the clinical symptoms that belong to each. The 
 anatomical conditions are so simple and easily understood, and explain so 
 completelv various well-known types of the disease, that we may assume 
 them to be sufficient in many cases to account for all the symptoms. 
 
 It seems ])robable that the bacterial cause of appendicitis is. as a rule, the 
 bacterium coli commune. It is almost invariably to be found in the intestinal 
 tract, and seems in the presence of sound mucous membrane to have little or 
 no power for evil ; but it is equally well demonstrated that if the epithelium 
 is once dcstroved, it has both pathological and pyogenic properties. 
 
 Ex])eriments have shown that even a moderate degree of constriction of 
 the intestinal canal may be followed by the [lenetration of its walls by this 
 bacterium, and also- that its virulence is much increased by the presence of 
 irritative conditions, such as exist in advanced constipation or marked 
 diarrhea, even when produced experimentally by tartar emetic. 
 
 Other micro-organisms are exceptionally associated with acute appendi- 
 citis, but the most reliable observations seem to show that in 82 per cent, of 
 infective cases this bacterium is the active agent (Tavel and Lanz). 
 
 Barbacci found that in perforative peritonitis cultures from the exudate 
 yield onlv one microbe in the vast majority of cases, the bacillus coli com- 
 munis. Fowler, who has studied the bacteriology of appendicitis on an 
 extensive scale, almost invariably found this bacillus, but in many cases asso- 
 ciated with other microbes such as the streptococcus pyogenes, diplococci, 
 micrococcus Havus liquefaciens, etc. 
 
 A third class of causes which may be regarded as both predisposing and 
 exciting must be made to include fecal concretions and foreign bodies. The 
 latter, once thought to be the chief factors in producing the disease, are now 
 known to be of great rarity, occurring in only about 4 per cent, of operative 
 <3ases (Matterstock. Fowler). Fecal concretions are found in 15 to 20 per 
 cent, of such cases, and there is evidence to show that they may occasionally 
 by their presence give rise to the lesion of the mucous coat which precedes 
 infective processes ; but they are so often absent in cases of all grades of 
 severity, and so often preseiat in autopsies on persons who have died from 
 other diseases, that they should not be considered of primary importance. 
 
 Catarrhal appendicitis may be caused by an extension of catarrh of the 
 cecum bv continuity of the mucous membrane into this structure; in a few 
 oases traumatism has been thought to have caused the disease. 
 
 The effect of age 'must be taken into account in summing up the 
 etiological factors. It is certain that the two extremes of life are nota- 
 bly exempt, but the explanation of this fact is thus far purely theoretical. 
 It'is asserted that in very early life the funnel-shaped appendix, apex down- 
 ward, offers fewer opportunities for the formation and retention of masses 
 of inspissated feces, while in old age atrophy of the mucous membrane 
 about the cecal orifice of the tube again widens it ; but we lack positive 
 knowledge upon these points. The very existence of the fold of mucous 
 membrane known as the valve of Gerlach is disputed, and in any event it is 
 so imperfect mechanically as to be presumably of slight importance. 
 
702 ^l^V AMERICAN TEXT- HOOK OF SI IK! Ell Y. 
 
 The disproportion between the sexes re(iuires explanation. If we accept 
 the usual description of tlif anatomy of the parts concerned, there seems to 
 be no good reason Avhy api)endicitis should be found in men four or five times 
 morefrei(uently than in women; but if future observations confirm the asser- 
 tion of Clado, that a fold of i)eritonenm passes from the right ovary to the 
 meso-appendix — the appcndiculo-ovarian ligament — and if this fold carries a 
 blood-vessel, an obvious and sufficient exj)lanation has been found. It has 
 been shown (Bryant) that the male appendix is four-tenths of an inch longer 
 than that of the female ; that its caliber is slightly larger ; and, possibly as 
 a result of the latter fact, that it contains fecal concretions in a larger per- 
 centajje of cases. But these circumstances do not seem to throw much li<:ht 
 on the subject. 
 
 The manner in which constipation or diarrhea and digestive disturbances 
 generally favor the development of appendicitis is now evident. We have a 
 vestigial structure of relatively poor vitality and low resistant power, so situated 
 mechanically that its one source of blood-supply is greatly interfered with by 
 twisting or dragging, and connected by short or scanty folds of serous mem- 
 brane with portions of the digestive tract especially liable to changes of form 
 and size, which thus easily produce such torsion or tension. Furthermore, a 
 micro-organism, capable of great virulence if epithelial exfoliation occurs or 
 if any area of lessened resistance exists, is almost constantly present. 
 
 Pathology. — In an appendix the seat of inflammation, the mucous 
 membrane is usually very vascular and considerably tliickened, and as the 
 opening into the cecum is narrowed by the same cause, accumulation of a viscid 
 or muco-purulent product takes place, which distends the lumen of 
 the appendix. The ulcers, which are often multiple, present sharp, well- 
 defined, infiltrated margins, and in depth vary from a slight superficial 
 abrasion to complete perforation of the appendix. The examination of 
 cadavers made with special reference to determine the relative fre- 
 quency of disease of the appendix, by Kraussold, Toff"t, Tiingel, Fer- 
 gu.sson, Ransohoff", and others shows that almost always a jtrimary appen- 
 dicitis precedes an attack of perityphlitis or paratyphlitis. From the ana- 
 tomical structure of the appendix and its relations to the peritoneal cavity 
 we have reason to believe that the peritoneal cavity is implicated more or less 
 in almost ever^^ case in which appendicitis leads to perforation. A diffuse cel- 
 lulitis or pldegmonous inflammation of the connective tissue behind the cjvcum, 
 without participation of the general peritoneal cavit}^ will occur if before 
 perforation takes place that part of the appendix has become firmly adherent 
 to the parietal peritoneum, the perforation in such cases not opening into 
 the peritoneal cavity, but into the loose retro-peritoneal connective tissue, and 
 leading to a localized extra-peritoneal abscess. Such an abscess may present 
 itself near the anterior superior spine of the ileum, above Poupart's ligament, 
 or even in the lumbar region, in the latter instance simulating a ])erinephritic 
 abscess, or it may dischai'ge its contents into the caecum, an adjoining adherent 
 loop of the small intestine, the bladder, the vagina, or even the rectum. In 
 cases of this kind a localized peritonitis always precedes the phlegmonous inflam- 
 mation and suppuration. In other cases perforation takes place into the peri- 
 toneal cavity, but the extension of the infection is limited by the formation 
 of an abscess-wall composed of loops of the small intestine which liave become 
 firmly adherent by plastic exudation, and the resulting abscess is the pro(hu;t 
 of a limited suppurative peritonitis. The gravest form of appendicitis is deter- 
 mined if the whole appendix becomes gangrenous or if the ])erforation com- 
 municates with the free peritoneal cavity. Total gangrene is usually the 
 inevitable conseijuence of thrombosis of the princii)al artery or thrombo- 
 
1)Isi:asI':s axd jnjuries of the audomiix. liv.i 
 
 plilchitis ot" the veins of the ineseiiterioliini [or iii('S()-;n)j)cii(li.\], or of" siiiiul- 
 tanooiis or consecutive thrombosis of both sets of vessels. If no .ittempt at 
 localization occurs, the sej)tic material, becoming diffused over the whole peri- 
 toneal cavity, gives rise to a diffuse septic peritonitis which results in death 
 within two or three days. Identical conditions with the same result follow 
 the rupture of a limited paratyplditic or })erityphlitic abscess into the peri- 
 toneal cavity. In a considerable )»ereentage of cases a perityphlitis or ])!ira- 
 typhlitis docs not terminate in suppuration, but the inflammatory swelling 
 disappears within a few Aveeks. This, the most favorable termination of 
 appendicitis, is most likely to folloAv if perforation does not occur or if the 
 perforation is small and tlu> appendix surrounded by a mass of plastic exu- 
 dation. Rupture of an abscess into the cecum is tisually, but not always, 
 followed by permanent relief. In recurring a])i)endicitis a limited swelling 
 forms in the region of the appendix, and disappears after the acute symptoms 
 subside, to reappear later. In this form of appendicitis flexions and stric- 
 tures are almost constantly found. 
 
 Symptoms. — Let us suppose that we have a case in which constipation, 
 which is usually present, or diarrhea, or at least some digestive derange- 
 ment, has caused intestinal distention with fecal matter or with gas, or 
 irregular and excessive peristalsis in the ileo-cecal region. The meso-appen- 
 dix is dragged upon, the torsion of the appendix increased, the return of 
 blood interfered with ; the arterial supply, more difficult to disturb than the 
 venous current, is but little affected. If we could see such an appendix, we 
 would undoubtedly find swelling and congestion, hypersecretion, nerve-irrita- 
 tion. It seems theoretically unreasonable to suppose that in every such case 
 there is necrosis even of epithelium or infection even of low grade. It is 
 probable, however, that there is, even in the mildest cases, an exudate under 
 pressure into the submucous and muscular coats of the wall of the appendix, 
 and a slight adhesive peritonitis of very moderate extent. The post-mortem 
 findings, which show that in one person out of every three there has been 
 some pathological condition present in the appendix, are so out of propor- 
 tion to the clinical percentage of frequency, large as that is, that it seems 
 evident that some such minor attacks must take place, and often with phe- 
 nomena so slight that they scarcely attract attention. 
 
 The usual symptoms of such a case as we are considering are : pain, at 
 first general and diffused over the abdomen, because the superior mesenteric 
 plexus of the sympathetic, Avhich supplies the appendix, also largely supplies 
 the intestines, and because irritative nerve-pain is apt to be referred to the 
 peripheral extremities of nerves ; next and within a very short time it is felt 
 in the umbilical region, because as such pain increases in intensity it is often 
 referred to the nearest nerve-centre, and the great sympathetic ganglia of the 
 abdomen are situated in that region. 
 
 The pain at this time is often colicky in nature, and a discussion has 
 arisen as to whether or not the circular muscular fibers in the appendix have 
 actually been observed in alternate spasm and relaxation when exposed in a 
 wound (Morris); but it seems unimportant, as appendix irritation may result 
 in colicky spasm of neighboring portions of either small or large intestines. 
 
 After a few hours the pain is felt in the right iliac fossa, because then a 
 neuritis has developed of sufficient grade to cause tenderness on pressure. 
 It is a localized tenderness in all the varieties of appendicitis, because while 
 the appendix itself is movable, it always arises from the same part of the 
 cecum, and the mobility of the latter is much more restricted. The point 
 of pain on pressure known as McBurney's point, situated about two inches 
 from the anterior superior spine toward the umbilicus, indicates, therefore. 
 
li]\ A\ AMEIiK'AX TEXT-IiOOK O/' sr IK ! Eli Y. 
 
 vitli iiioiU'vate accuracy tlic l)asc, not the ti]i. of the M])|»('ii(|i.\. and is rarclv 
 absent even in ganj^reiious cases, because that jiortion of the a]»j)en(li\ is 
 usually the last to be atlectcd by interference with the blood-supplv. 
 
 Vomitino; coniinonly follows, with little relation to gastric conditions, and is 
 ordinarily reHex and due to reversed peristalsis, as the ejeeta show a degree of 
 digestive change correspontling to the time which has elapsed since the last meal, 
 "^ Moderate fever (lt0.5° to 101° F.) and slightly increased pulse-rate (90 to 
 110) are usually present, and are doubtless due to the same sort of absorption 
 of intestinal ])roducts as gives rise to the same symptoms in constipation or 
 in true bilious colic, for which cases of this kind are sometimes mistaken. 
 
 There is slight rigidity of the right rectus muscle, and later of the abdom- 
 inal muscles over the right iliac fossa, often, but perhaps not necessarily, due 
 to peritonitis, and in any event arising from the fact that those muscles re- 
 ceive their nerve-supply from the seven lower intercostals, while the suj)erior 
 mesenteric plexus gets its splanchnics from the same seven intercostals. 
 
 As long as the disease is limited to the appendi.x the swelling is not 
 distinct, and if the appendi.x is located behind the cecum it often eludes 
 detection. 
 
 The swelling sometimes increases ({uite rapidly within a few days, and 
 varies in size according to the extent of the disease and the character of the 
 tissues involved. It appears early, and attains considerable dimensions as 
 soon as the connective tissue behind the cecum is extensively involved in the 
 inflammatory process. Even if a large abscess has formed, fluctuation is 
 generally absent or indistinct, on account of the rigidity of the abdominal 
 wall covering the inflamed area. 
 
 Diagnosis. — As to the diagnosis of the mild class of cases tending to 
 recovery, it is to be made chiefly from stercoral typhlitis, a condition which 
 has been so overshadowed during the advance of our knowledge in regard to 
 appendix disease that we are in danger of acting as if it were non-existent. 
 In some elaborate reviews of the diagnosis of appendicitis it is hardly men- 
 tioned, and yet a very moderate clinical experience ought to convince any 
 careful observer that it is occasionally present. It has many features in com- 
 mon Avith appendicitis, and it is quite possible that to some degree this is 
 present in most cases of stercoral typhlitis, but the independent existence of 
 the latter condition has apparently been shown both at autopsies and at 
 operations, where it is asserted that severe forms of typhlitis and perityph- 
 litis have been found to be dependent on stercoral ulcers of the cecum, and 
 the appendices were normal. Some surgeons of large experience have never 
 seen this condition, and there is still much diff'erence of opinion about it. 
 It is true that in the vast majority of cases of severe inflammation and 
 suppuration in the right iliac fossa the appendix is at fault, but it should 
 not be forgotten that in many of them the original trouble is a constipation, 
 associated with distention of the cecum by fecal masses often containing 
 undigested food, and exciting both mechanical and chemical irritation. The 
 relation of the mild attacks of appendicitis to digestive derangement is unmis- 
 takable, and it is not very uncommon to find in relapsing aj)pendicitis that 
 one particular article of food is the especial exciting cause of an attack. 
 
 If in many cases fecal distention of the cecum is the starting-point of 
 appendicitis, it is reasonable to believe that in some of them the trouble does 
 not pass beyond the cecum, and it is important to recognize these cases, 
 because the prognosis is so much more favorable, and operative measures need 
 not, as a rule, be thought of. 
 
 They occur chiefly at the times of life when appendicitis is less common, 
 and more especially in children. They can be recognized with certainty 
 
DISEASES AND INJURIES OF THE A 11 DOM EX. 
 
 7G5 
 
 only l.v thu initial presoiue of a tloughy, sausage-shaped swelling in the cecal 
 re.Mon". assoc-iatt-d with the usual symptoms f.f appendicitis ina modified form. 
 The localized tenderness is not so great ; the fever is very moderate ; vomit- 
 ing is rarelv a prominent svmptom ; constijiation is almost invariable, thougli 
 occasionally a spurious diju-rhea (analogous to the " incontinence of reten- 
 tion " in bladder cases) may make its appearance. 
 
 The discovery of a swelling at the very beginning of an attack ot apparent 
 appendicitis of obviously mild type would, perhaps, justify the diagnosis of 
 stercoral typhlitis, but in the absence of that sym])tom it would be safer to 
 consider doubtful conditions as almost certainly indicating appendicitis. 
 
 A differential diagnosis between an inflammatory lesion m the ileo-cecal 
 retrion and intestinaf obstruction in the same locality is sometimes difficult. 
 Appendicitis is almost always attended by a rise of temperature from the very 
 becrinnin«^ while an intestinal obstruction uncomplicated by inflammatory 
 lesions is^iot attended by fever. The history of the case is often valuable in 
 making an early and correct diagnosis, as it is well known that a person who ha& 
 once sufteredfrom appendicitis is prone to subsequent attacks unless the primary 
 cause is removed by operative measures ; hence if a patient has passed through 
 an attack of appendicitis at some previous time, however remote this may be, 
 if he airain presents • evidences of iBflammation in the ileo-cecal region it is 
 very probable that he is suff'ering from a recurring attack of appendicitis. If 
 durincr the course of an attack of appendicitis the patient experiences a sudden 
 diffuse pain and presents evidences of shock, frequent, small, and wiry pulse, 
 and a subnormal or high temperature, it is almost certain that an ulcer of the 
 appendix or a peritvphlitic or paratvphlitic abscess has ruptured into the peri- 
 toneal cavitv. Incomplete intermission of symptoms, especially pain and 
 tenderness, is almost a sure proof of the existence of a mechanical obstruction 
 in the appendix in the form of stenosis or flexion, or a combination ot both. 
 Hepatic colic is to be distinguished from appendicitis by the history of pre- 
 vious attacks and of jaundice (if obtainable), in conjunction with the symp- 
 toms which are : Sudden, severe, cutting pain in the upper right half ot tfie 
 abdomen, which extends to the back or shoulder of the same side; there may 
 or may not be jaundice. In many cases the patient has a chill, and vomiting 
 is the rule. There may be tenderness over the gall-bladder, and an absence 
 of signs in the right iliac fossa. 
 
 In renal colic the pain, as in the preceding disease, is intense and unre- 
 mittincr: it extends to the genitals ; the bladder is apt to be irritable ; the 
 testicle of the aff-ected side is usually drawn up toward the external abdom- 
 inal ring. The urine almost invariably contains blood, which may be de- 
 tected bv the microscope if not by the naked eye. Fever and the board-like 
 tension of the abdominal wall on the right side are absent, and vomiting is 
 exceptional ; there may be a previous history of renal colic. 
 
 Acute indiqestion mav closely simulate a beginning appendicitis. Any 
 doubt will be' removed speedily, however, as the symptoms of the former 
 rapidly disappear under rational treatment. 
 
 In women the discrimination between fi/^o-ovanVm disease and appendi- 
 citis is frequently necessary. This usually may be done by a very careful 
 attention to the previous historv and to the manner of onset and progress ot 
 the symptoms. Vaginal or rectal examination may establish the diagnosis. 
 In rare cases the appendix lies in contact with the tube and ovary, and in- 
 flammation of any one of these structures will naturally spread to all and 
 give rise to symptoms more or less confusing. • , i ■ 
 
 Other intra-abdominal surgical conditions are to be distinguished m tlie 
 same manner, by a minute study of the history and the individual symptoms. 
 
7<)6 AX J j//;/.'/r.LV rr.x'j'-JKjoK or sina i:nY. 
 
 Prognosis. — Tin- moitality of appendicitis and the attendin^r jxTit yplditi.s or 
 paratyphlitis is about one out of seven or eight cases. Witliout ])ronipt surgi- 
 cal interference death is almost sure to ensue if the general peritoneal cavity is 
 invaded. Life is in great peril if the resulting abscess opens into the pleural 
 cavity or the bladder. The prognosis is favoral)le if the peritonitis is of the 
 plastic type, as in such cases the disease remains circumscribed and the general 
 peritoneal cavity is protected against infection. In recurring appendicitis the 
 danger to life increases with each successive attack, as every subsequent attack 
 bv aggravating the local lesion may give rise to perforative peritonitis. 
 
 Treatrnent. — The medical treatment of appendicitis should aim at the 
 prevention of ])erforation and at giving the peritonitis a plastic character. 
 During the incipient stage it would be advisable to administer saline cathar- 
 tics in such doses and at such intervals as to secure an early and free evacua- 
 tion from the bowels, and in this manner remove the fecal accumulation in 
 the cecum which is so frequently present in these cases. A warm-water 
 enema containing an ounce of magnesium sulphate should be given for the 
 same purpose. Externally, hot antiseptic fomentations and the use of mus- 
 tard or turpentine relieve pain, and at the same time rather favor a plastic 
 peritonitis. Onlv li([uid food in extremely small amounts is to be given 
 (luring the acute stage. The use of blisters and other potent counter-irri- 
 tants is more harmful than beneficial. About 80 to 85 per cent, of all cases 
 recover under such treatment. 
 
 In a large majority of cases judicious surgical treatment will become neces- 
 sarv if the inflammation does not yield to the treatment detailed above. Ulcer- 
 ative, gangrenous, and jterfora ting ap))endicitis are surgical affections, and should 
 be treated as such. The propriety of surgical intervention in acute suppurative 
 appendicitis was first established by AVillard Parker of New York in 1867. The 
 treatment of recurring catarrhal and ulcerative appendicitis by laparotomy and 
 removal of the appendix, either during an attack or after the acute symptoms 
 have subsided, has been placed on a sound surgical basis by McBurney, Treves, 
 Senn, KUmmell, and others. As it is often necessary in these cases 
 to open the abdominal cavity, the strictest antiseptic precautions must be 
 observed. The abdominal incision may be made directly along the outer 
 border of the rectus muscle from the level of the umbilicus nearly to the 
 middle of Poupart's ligament, or it may be a curved incision nearer the 
 spine of the ilium with its center on the omphalo-s])inous line, or in the 
 presence of a tumor it may be directly over the most ])rominent ])art of the 
 swelling. McBurney's plan of incising the abdominal wall has found much 
 favor with the profession. It consists in dividing the muscles in the direction 
 of their fibers ; that is, the external oblique and internal oblicjue are divided 
 in opposite directions, more by tearing than by cutting. Retractors become 
 necessary to keep the wound open during the operation. After the operation 
 the opening is closed by the muscular fibers resuming tlieir former position, 
 the resisting power of the abdominal wall is but little imj)aired, and the 
 occurrence of a ventral hernia is more effectually prevented than by cutting 
 in one direction through the muscular plane of the abdominal wall. The 
 margins of the wound are retracted by an assistant, and prolapse of the 
 small intestine is prevented by packing the abdominal cavity around the 
 cecum with a compress of antiseptic gauze. If the ajipendix cannot readily 
 be found, the anterior longitudinal band of the cecum is taken as a landmark ; 
 if, as is frequently the case, the appendix is located behind the cecum, this 
 must be lifted forward and the band followed to the appendix. Tiie appen- 
 dix is then freed from all adhesions, ligated with aseptic silk or catgut close 
 
DISEASES AND INJURIES OF THE ABDOMEN. 767 
 
 to the cecmn, aii-l cut oH' below the ligature. The stump is buried with a few 
 Leinbert sutures. The mucous meml)raiie of the cut surface should be disin- 
 fected with the cautery or pure carbolic acid. Subserous amputntion of the 
 appendix is now generally practised when this method is applicable. A tew 
 lines from the cecal end of the appendix a circular incision is made through 
 the peritoneum, wliicli is reflected in the form of a cuff. The denuded part 
 of the appendix is then tied with a fine silk ligature and cut off a line or two 
 below, after which the mucous membrane is cauterized with pure carbolic acid, 
 the stump iodoformized, and the peritoneal cuff sewed over it with fine cat- 
 gut sutures. As in all lateral incisions, the external wound is to be closed 
 by deei) and superficial sutures. 
 
 ' If an ulcer of the appendix or an abscess in its vicinity has perforated into 
 the free peritoneal cavity, a lateral incision, such as has been described, should 
 be made, as it affords better access to the parts which retiuire direct surgica 
 treatment than a median incision. In such cases the abdominal cavity should 
 be freely irrio-ated with warm sterilized water or Thiersch's solution (salicylic 
 acid o-r'. xivf and boric acid, gr. Ixxxiv (a), Oj of water) before the appendix 
 is reinoved, and the flushing repeated after the removal has been effected. 
 Adenuate provision for drainage is an absolute necessity in all cases where 
 pus or fecal matter has obtained access to the abdominal cavity. 
 
 If the appendicitis has resulted in the formation of a circumscribed abscess 
 in the ric-ht iliac fossa, a slightly curved incision from four to six inches in 
 lencrth, commencing just above the middle of Poupart's ligament and extend- 
 inAoward the anterior superior spine of the ilium, will answer m the majority 
 of^cases. The deeper tissues are divided and retracted m the same manner as 
 thoucrh the operator were about to ligate the external iliac artery. This incis- 
 ion leads down to and behind the ctecum, the most frequent location ot an 
 incipient abscess resulting from appendicitis. The use of the exploring needle 
 as a means of locating the pus before the operation is to be condemned. ±.x- 
 ploratory puncture made at the time of operation is attended by less danger and 
 may give valuable information in regard to the location of the abscess, it tlie 
 peritonitis has become limited, it must be the great object of the surgeon to reach 
 the abscess and to remove its primary cause without invading the general peri- 
 toneal cavity, and on this account the utmost care must be exercised not to 
 penetrate the abscess-wall on the peritoneal side during the search for the ap- 
 pendix and its removal. As soon as the abscess is reached its contents should 
 be washed out with a weak antiseptic solution, and gentle search made for lec^il 
 concretions and foreign bodies if the appendix is found to be perforated. In 
 some cases the appendix will be found completely detached from the cjBcum 
 and adherent to the surrounding tissues or lying m the abscess as a gan- 
 grenous slough. It will generally be impossible to cover the stump witfi 
 peritoneum in these cases. In many cases of circumscribed abscess, and espe- 
 cially in those in which the appendix is bound down by adhesions m the 
 depth of the wound, the surgeon should be content with evacuation, irrigation, 
 drainao-e, and packing with iodoform gauze. Persistent search for the appen- 
 dix and attempts at its removal in these cases are attended with such danger 
 of opening the general peritoneal cavity that they are not to be recommended. 
 When it is impossible to enucleate and remove the appendix, it may sometimes 
 be laid open by an incision in its long axis and drained, as advised by lait. 
 If the abscess presents anteriorly underneath the abdominal wall, it is opened 
 by an incision which will afford the best drainage, and after flushing it with 
 an antiseptic solution it is well drained and the drainage maintained until the 
 surgeon is satisfied that healing is taking place from the most remote portions 
 
7«J8 A.\ A.)fi:in<'AX ri.xT-nooK or si'iiaEHV. 
 
 of the abscess. The too early removal ol" drains is often followed by recun-fiiee 
 of the abscess. If the abscess does not heal, it is a sicrn either that sinuses 
 have formed, which nnist then be scraped out with a sharp spoon and tiior- 
 ou^'hh^ disinfected, or that a perforated appendix has to be removed, which can 
 be done either by enlarging the sinus Avhich leads down to it f)r through the 
 peritoneal cavity. 
 
 Ohmtekatixg Appendicitis; Appendicitis Obliterans is a name 
 recently given by Senn to a form of appendicitis in which the lumen of 
 the appendix at difierent points is gradually obliterated by cicatricial contrac- 
 tion. The obliteration begins as a stricture which may appear at any point in 
 the lumen of the appendix, and leads to its complete closure. Occasionally 
 the entire appendix is transformed into a solid cord, in which event the symp- 
 toms disappear completely and a permanent spontaneous cure is the result. 
 
 Recurrent Appendicitis. — A patient who has had even a mild attack 
 of appendicitis is more prone to others, and these may vary in type from the 
 mildest to the most severe. It is probable that after a second attack opera- 
 tion during the interval would be recommmended by most surgeons as offer- 
 ing less risk than further delay. But it cannot be denied that many persons 
 who have had several such attacks have recovered under judicious medical 
 treatment. If the condition in the first instance was at all serious as regards 
 danger to life, or if the second attack was distinctly of a graver type, there 
 would be practically no difference of opinion among surgeons, operation 
 being certainly indicated. 
 
 Chronic Relapsing Appendicitis. — In chronic relai)sing appendicitis 
 the case is somewhat different. The interval then is not one of entire 
 health ; there are digestive disorders, flatulence, constipation or diarrhea, 
 and pain in the right iliac fossa, aggravated by motion or exercise or 
 fatigue. The attacks themselves are of a higher grade of severity, are 
 accompanied by the appearance of a tumor, which often never entirely disap- 
 pears, and by distinct evidence of localized peritonitis. The general health 
 suffers severely, and the patient is apt to be anemic and emaciated. 
 
 In the majority of these cases which finally require ojteration, especially 
 in those in which the persistence of the local symptoms during the interval 
 is marked, pus is present in small (quantity and is surrounded by thick, firm 
 adhesions. 
 
 The diagnosis may usually be made by the history, the localized pain, 
 the variable tumor, etc. Not infreijuently, especially where the early stage 
 of a malignant neoj)lasm is suspected, the only possible diagnosis is by 
 exploratory incision. 
 
 Even these cases do not invariahlji require operation. Treves, who 
 originally proposed the operation in 1877, has thought it necessary to call 
 attention to the fact that it has been performed recently without proper 
 discrimination, and adds: " The circumstances which would justif\- an opera- 
 tion in these cases must be precisely defined, and it cannot be too em])hat- 
 ically stated that, in a fair proportion of instances in which the trouble has 
 relapsed, no surgical interference is called for. I am aware of many cases 
 in which a patient has had three or more attacks of typhlitis, and has then 
 ceased to be troubled with any further outbreaks. In some examples of the 
 relapsing form much can be done by medical means, by diet, by attention to 
 the bowels, and by placing the patient under conditions more favorable to a 
 state of peace Avithin the abdomen." 
 
 There is good reason for believing that the mortality of the operation in 
 skilful hands will be a low one. If the indications for operation are clear, 
 
DISEASES AND INJURIES OF THE ABDOMEN. 769 
 
 the (luestion as to wliether it shall be done between or during attacks must 
 be unhesitatingly decided in favor of the period of quiescence, the operative 
 difficulties being tlien much less, especially as regards the important question 
 of possible general infection. In the recurrent type, if operation is to be 
 considered at all, it might be well to take the risk of waiting for another 
 attack, which may never come. 
 
 In the chronic relapsing cases, however, if the surgeon, in deciding upon 
 operation, limits himself to the following indications formulated by Treves, 
 he had far better take advantage of the interval. Operation is indicated 
 when — 1. The attacks have been very numerous. 2. The attacks are 
 increasing in frequency and severity. 3. The last attack has been so severe 
 as to place the patient's life in considerable danger. 4. The constant 
 relapses have reduced the patient to the condition of a chronic invalid and 
 have rendered him unfit to follow any occupation. 5. Owing to the per- 
 sistence of certain local symptoms during the quiescent period there is a 
 probability that a collection of pus exists in or about the appendix. 
 
 White has recently summarized his conclusions upon the general subject 
 of appendicitis, which must be regarded as one still open to discussion : 
 
 1. The explanation of the great frequency of inflammation of the appen- 
 dix is to be found in the following facts : 
 
 (a) It is a functionless structure of low vitality, removed from the direct 
 fecal current ; it has a scanty mesentery, so attached to both cecum and ileum 
 that it is easily stretched or twisted when they become distended ; it derives 
 its blood-supply through a single vessel, the caliber of which is seriously 
 interfered with or altogether occluded by anything which produces drag- 
 ging upon the mesentery. 
 
 (6) In addition, there is almost always present a micro-organism — the 
 bacterium coli commune — capable of great virulence when there is constric- 
 tion of the appendix or lesions of its mucous coat or of its parietes. 
 
 2. The symptoms in a case of mild catarrhal appendicitis — general 
 abdominal pain, umbilical pain, localized pain, and tenderness on pressure in 
 the right iliac fossa, vomiting, moderate fever, and slightly-increased pulse- 
 rate — cannot at present with any certainty be distinguished from the symp- 
 toms, apparently precisely identical, which mark the onset of a case destined 
 to be of the very gravest type. 
 
 3. It must be determined by future experience Avhether or not operation 
 in every case of appendicitis, as soon as the diagnosis is made, would be 
 attended by a lower mortality than would waiting for more definite symptoms 
 indicating unmistakably the need of operative interference. At present such 
 indication exists in every case if the onset is sudden and the symptoms mark- 
 edly severe, and Avhenever in a mild case the symptoms are unrelieved at the 
 end of forty-eight hours, or, a fortiori, if at that time they are grow'ing worse. 
 
 4. It must be determined by fut?ure experience whether cases seen from 
 the third to the sixth day, which present indications of the beginning cir- 
 cumscription of the disease by adhesions, and which tend to the formation of 
 localized abscesses, will do better with immediate operation with the risk of 
 infecting the general peritoneal cavity, or with later operation when the cir- 
 cumscribing wall is stronger and less likely to be broken through. At pres- 
 ent operation is certainly indicated whenever a firm, slowly-forming, well- 
 defined mass in the right iliac fossa is to be felt, or, on the other hand, when 
 a sudden increase in the sharpness and the diffusion of the pain and tender- 
 ness points to gross perforation of the appendix or breaking down of the 
 limiting adhesions. 
 
 49 
 
77<i J.v amj:i;i<a.\ ti.xt-iiook or sii:(u:i:y. 
 
 o. In the bei^inniiifr of general .suj)|)urative peritonitis operation offers 
 some hoj)e of siieces.s. In the ])resence of general jieritonitis with septic 
 paresis of the intestines operation has thus far been useless. 
 
 6. Recurrent apj)en(licitis of mild type, like acute appendicitis, frefjuently 
 results from digestive derangements. Several attacks may occur followed by 
 entire and permanent recovery, but it is as yet impossible to diff'erentiate 
 these cases accurately from those which do not tend to spontaneous nire. 
 Operation is certainly indicated whenever the attacks are very fref|uent. 
 
 7. Chronic relapsing appendicitis is characterized by the persistence of 
 local symj)toras during the intervals and by more or less failure of the 
 general health. Operation is usually to be advised in these cases. 
 
 8. It is well for surgeons to be slow in recommending oyioration in all 
 cases in which during tlie first attack an abscess formed and discharged into 
 the cecum. It is in such cases that a spontaneous recovery occurs very fre- 
 (juently. 
 
 Fecal Fistula. — A fecal fistula is a communication between any portion 
 of the intestinal tract and the external surface of the body or some hollow 
 internal organ through which gas and the solid or liquid contents of the intes- 
 tine escape. In the majority of cases the external opening will be found in 
 one of the inguinal or lumbar regions. The pelvic organs through which an 
 outlet is most frequently established are the bladder, uterus, and vagina. An 
 artificial anus made for tlie purpose of relieving an intestinal obstruction becomes 
 a fecal fistula if the cause of the obstruction is not removed subsequently, either 
 spontaneously or )jy operative interference. Fecal fistulae are established spon- 
 taneously most frequently after strangulated hernia where the strangulation has 
 resulted in gangrene of the bowel, or in case of perforation of an intestine or 
 of the appendix vermiformis by an ulcer after the inflamed part has become 
 adherent to the abdominal wall or some of the internal organs, or they may 
 result from the rupture of an abscess into an intestine, the external opening 
 being established later. An intestinal fistula may also be caused by a malig- 
 nant tumor located in the intestinal wall or reaching it from an adjacent organ. 
 Traumatic fecal fistula caused by a perforating gunshot or stab wound of the 
 abdomen generally heals without surgical interference. In the history of a 
 number of these cases it has been noticed that the openings have closed once 
 or twice and opened again before the final closure has taken place. 
 
 Anatomically and from a practical standpoint it is important to divide 
 fecal fistuloe into two varieties. In the first variety the perforated intestine 
 has become or will become adherent to the abdominal parietes or to an adjacent 
 organ over a considerable surface, while the affected segment of the gut remains 
 straight ; consequently the lumen of the intestine is not diminished and the 
 fecal circulation is not impaired. For these reasons only a small quantity of 
 intestinal contents escapes through the fistula, while the rest passes per viam 
 naturalem (Fig. 317). A fistula of this kind often heals without operative 
 treatment. 
 
 In the second and more troublesome variety the opening in the gut is larger, 
 und, in case a whole loop of the intestine has sloughed, represents the entire 
 circumference of the lumen of the bowel, the afferent and efferent tubes lying 
 side by side like the parallel tubes of a double-barrelled gun (Fig. 318). The 
 feces are, in consequence, diverted toward the external opening incessantly and 
 w^ith force, renderinj; the case incurable so long as this condition remains. If 
 the bowel has not been destroyed in its entirety, but has suffered a lateral 
 defect of considerable dimensions, the affected loop becomes flexed, the apex 
 of the flexion corresponding with the opening in the gut : the wall opposite 
 
j)/s/:asks a\/> ixjriui:s or the abdomen. 771 
 
 the oiu'iiiiiu^ is thru thrown into :. projection technically called a septum ov 
 snur. which directs the contents of the intestine toward the opening, and 
 
 KiG. 317. J''^- ='!«• 
 
 IntestinalFistuhawithoutLinin.M.f MUCOUS Mem- Artittciul -^""« ■ «-^^^»'- = /„-/^«^""" ''' ''"'■^ 
 
 brane: a, abdoiiiinal wall; /-, intestinal wall; current isenn;. 
 
 c, mucous membrane ; (/, listnla (Senn). 
 
 according to the length and direction of this spur a large part or the whole 
 of the contents escape through the fistula. 
 
 The len<Tth of the fistulous tract from the external opening to the intes- 
 tine varies fT-om half an inch to eight or more inches, its direction often being 
 circuitous and difficult to follow. This is especially the case if the intestine has 
 become adherent to the floor of the pelvis and the perforation has given rise to 
 extensive phlegmonous inflammation, the formation of an abscess, and finally 
 a fecal fistula. °The location of the fistulous opening in the intestinal canal is 
 often not easily determined. If the perforation exists below the ileo-caecal 
 opening, the discharge consists of feces ; if it is above this point, the discharge 
 is more fluid, is devoid of off"ensive odor, and on closer examination is found to 
 be not feces, but chvle from the small intestine. Rectal insuflftation of hydro- 
 gen gas may be an "important aid in locating the intestinal opening. If it is 
 below the ileo-csecal valve, the gas will escape from the fistulous opening under 
 slight pressure, without much distention of the abdomen, and prior to the sound 
 indicating that the gas is passing through this valve. 
 
 No specific rules can be laid down for the surgical treatment of intestinal 
 or fecal fistula. The treatment must necessarily vary according to the location 
 and size of the opening in the gut, the length of the fistulous tract, and the 
 condition of the intestine at the seat of perforation. If the opening in the 
 bowel is small and no obstacle exists to the passage of the intestinal contents, 
 healincr frequently takes place without surgical interference. A spontaneous 
 cure is^hastened in such cases by clearing out the intestinal canal thoroughly 
 by cathartics and injections and placing the patient subsequently for several 
 weeks on a liquid diet, with rest in bed. The fistulous tract should at the 
 same time be rendered as nearly aseptic as possible by the use of the curette 
 and peroxide of hydrogen, and the external opening protected against intec- 
 tion from without by an antiseptic hygroscopic compress. If the intestine has 
 become adherent to the abdominal wall, and if the opening m the gut can be 
 easily reached by an incision through the abdominal wall without opening the 
 peritoneal cavity, an attempt should be made to close it by suturing, ihe 
 fistulous tract is excised carefully and the whole wound closed by at least four 
 rows of sutures. The first row of fine silk sutures should embrace the mucous 
 and submucous coats of the bowel, while the second row approximates the 
 remaining coats, after which the abdominal wall over the intestine is carefully 
 closed by two rows of sutures. If the external fistulous opening communicates 
 with an abscess-cavity interposed between it and the intestinal perforation, the 
 abscess should be treated before an attempt is made to close the opening in the 
 bowel. If several external openings are present, these should be united by 
 incisions which will expose the suppurating or granulating cavity between the 
 
772 AN AMERICAN TEXT- BOOK OF SURGERY. 
 
 bowel iind the external surface for effective treatment, and at lea.'^t tninsfoim 
 the abscess into a simple fistulous tract, if the fistula is not closed, as will be 
 the case occasionally. Treves has successfully dissected out the entire fistulous 
 tract with its walls, sewed up the opening into the gut, and closed the abdomi- 
 nal wound. 
 
 In the second variety a cure is impossible without removal of the mechan- 
 ical obstruction to the fecal circulation at a point opposite the opening in the 
 bowel. The introduction of a rubber tube, as suggested by Banks, for the 
 purpose of gradually forcing the spur out of the way, has not yielded satisfac- 
 tory results. Dupuytren sought to destroy the septum by an instrument which 
 he devised and which he called an " enterotome." This consists of a couple 
 of steel forceps-like blades, which, being introduced into the canals, are made 
 to compress the septum by the action of a screw. For the sake of safety it is 
 necessary that the instrument should be made to cut its way through the tis- 
 sues very slowly, so that union may take place between the apposed serous 
 surfaces before the section is completed. In the hands of careful surgeons the 
 use of this instrument has been followed by good results, but its employment 
 is not devoid of danger, neither does the fistula always close after the septum 
 has been divided. Senn has described a method of dealing Avith fecal fistulte 
 and artificial anus in cases in which the mucous membrane of the intestinal 
 opening is continuous with the skin, which greatly diminishes the danger of 
 peritonitis and increases the certainty of the result. It consists in closing 
 the intestinal opening by a row of sutures placed transversely to the long 
 axis of the bowel. After this preliminary closure of the wound the field of 
 operation is thoroughly disinfected. As no intestinal contents escape, the 
 abdomen can be opened and the intestine separated without fear of producing 
 peritonitis. The preliminary sutures are then buried by Lembert sutures, 
 the intestine reduced, and the external incision closed throughout. In four 
 cases complete closure of the intestinal opening and satisfactory primary 
 healing of the external wound were secured. If the intestine is completely 
 detached, the spur will soon disappear spontaneously after this method 
 of operating. The treatment of intestinal fistula by laparotomy, resec- 
 tion, and enterorrhaphy under strict antiseptic precautions has been most 
 encouraging. Unless special indications are present, the abdomen is to be 
 opened in the middle line for fistulix; communicating with the small intestine, 
 and laterally for fecal fistulas. The adherent perforated portion of the bowel 
 is then separated, special care being taken to prevent fecal extravasation dur- 
 ing this step of the operation. If no spur is present and the opening is small, 
 it can be closed by suturing. If the opening is large and a spur has formed, 
 and especially if the adherent loop is much flexed, enterectomy and circular 
 enterorrhaphy or a lateral anastomosis will be necessary for the cure of the 
 fistula and the restoration of the continuity of the intestinal canal. 
 
 PART IV.— INJURIES AND DISEASES OF THE PERITONEUM, OMENTUM, AND 
 
 MESENTERY. 
 
 The peritoneal cavity is anatomically and physiologically a large lymph-sac 
 which is noted for its capacity of absorption. Large amounts of absorbable 
 aseptic fluid and solid substances are removed from it in this manner in a 
 remarkably short time when the peritoneum is in a healthy condition. During 
 the pre-antiseptic period this cavity was a noli me tangerc to the surgeon, as 
 it was well known that open wounds usually gave rise to fatal peritonitis. 
 Recent researches have shown that the peritoneum is not so susceptible to 
 the action of pathogenic microbes as many of the other tissues, provided 
 
DISEASES' AND INJURIES OF THE A B DO 31 EN. 773 
 
 the abdoiniiuil cavity can be kept free from fluids which serve as a nutrient 
 medium for ])athogenic micro-organisms and the peritoneum itself is in a healthy 
 condition. 
 
 Wounds. — Wounds of the peritoneum heal with remarkable rapidity if the 
 peritoneal surfaces are kept in uninterrupted contact by mechanical means. 
 Within a few hours firm adhesions will take place by the interposition of 
 plastic material, and the definitive healing is often nearly completed within 
 a week or two. Tlie process of repair may be hastened by scarification. 
 Wounds of the peritoneum should always be closed by suturing wherever this 
 is possible, as otherwise it is very prol)able that organs })rought in contact 
 with them will become permanently adherent, and unsutured wounds of the 
 parietal peritoneum might become the starting-point of a ventral hernia. In 
 the treatment of all visceral wounds of the abdominal organs it is important 
 that they should be made as nearly extra-peritoneal as possible by suturing 
 the peritoneum over them after uniting separately their deeper portions. If it 
 is deemed necessary that the operation should be completed as speedily as pos- 
 sible, this can be done by the continued suture. Wounds in the mesentery 
 should be closed, for if this is not done a loop of intestine may become 
 ensnared in the rent, causing acute intestinal obstruction. 
 
 Foreign Bodies. — The tolerance of the peritoneum to the presence of 
 aseptic foreign bodies is remarkable. It has been shown by experiments on 
 animals that large fragments of aseptic tissue are removed by absorption within 
 a short time. Aseptic fluids, such as blood, serum, and saline solutions, are 
 promptly removed by the same process. Aseptic metallic and other substances 
 incapable of removal by absorption become encapsulated and remain harmless 
 in the peritoneal cavity. Bullets should be removed only in case they can be 
 found without extra loss of time and can be extracted Avithout involving addi- 
 tional risk. If the patient recovers from the injury, the bullet becomes encysted 
 and seldom causes further mischief. 
 
 In the treatment of penetrating wounds of the abdomen by laparotomy 
 it is essential to search for and remove septic foreign bodies, as fragments of 
 clothing, splinters of wood, etc., w^hich, if allowed to remain, will become 
 the cause of septic peritonitis; but no time should be lost in search for bullets 
 and other small projectiles. 
 
 PERITONITIS. 
 
 For good reasons the existence of primary or so-called idiopathic peritonitis 
 is considered more than doubtful by most modern surgeons, and it has become 
 the routine practice to search for a local cause in every instance, with a view 
 of adopting a rational course of treatment. The pathology, prognosis, and 
 treatment of peritonitis vary according to the causes which produce it. The 
 most favorable cases are those in which the inflammation is produced by an 
 aseptic cause, such as a trauma or the action of a chemical irritant, and an 
 inflammation of this type is termed plastic peritonitis. 
 
 Plastic Peritonitis is a purely regenerative process, and should not be 
 classed with the inflammatory affections. It is produced by aseptic causes, 
 remains limited to the seat of trauma or chemical irritation, and does not extend 
 much beyond the surface-area to which the stimulus was applied. The general 
 febrile disturbance which accompanies it is caused by the introduction into the 
 circulation of the products of coagulation-necrosis or metabolic tissue-changes. 
 A plastic peritonitis attends every healing of an aseptic wound of the perito- 
 neum or subcutaneous injury of this structure unattended by infection. The 
 existence of this form of peritonitis is indicated by circumscribed pain and 
 
771 .l.V AM/:/i'/(A.\ TEXT- HOOK OF sriUlKRY. 
 
 tenflerncss and ri^xidity of the abdominal wall correspondinfT to the inflamed 
 area. It leads to the formation of firm adhesions, whieh, however, in the course 
 of time may tlisapj)ear in j)art or completely. The proL^iosis is favorahle. In 
 the treatment rest and opiates to relieve pain, and a limited diet, are of the 
 greatest importance. Hot fomentations are more agreealde to the patient tlian 
 the use of cold, and have a favorable influence in limiting the disease. 
 
 Septic Peritonitis. — All forms of progressive peritonitis can be said to 
 owe their origin to a septic cause, but the adjective septic is here used to desig- 
 nate a form of peritonitis which destroys life before the peritoneum has under- 
 gone any serious pathological changes. Death results in a short time, sometimes 
 within twelve hours, from the absorption of septic material from the peritoneal 
 cavity. The peritoneum in such cases, aside from increased vascularity, pre- 
 sents no well-marked macroscopical changes. This disease is well known to 
 obstetricians as the most virulent form of puerperal fever, resulting from infec- 
 tion through the lymphatic vessels of the uterus. It is also frequently caused 
 b}' perforation of an intestinal ulcer or an abscess into the free })eritoneal cavity, 
 and by gangrene of an intestinal loop caused by internal strangulation and 
 after abdominal section. It is ushered in by a chill or symptoms resembling 
 those of shock ; the pulse runs up to from 140 to 160 beats per minute within 
 a few hours, and remains constantly high. The temperature is often subnor- 
 mal, and remains so during the whole course of the disease. Retching and 
 vomiting are prominent and distressing symptoms. Abdominal distention is 
 often well marked ; in other cases it is completely absent. In perforative sep- 
 tic peritonitis (from appendicitis) the pain is usually very intense and diffuse, 
 but in the septic form of peritonitis after abdominal section, and when the dis- 
 ease occurs during the puerperal state, it is not unfrequently entirely absent. 
 Delirium and dry tongue are almost always present. The duration of the dis- 
 ease seldom extends beyond a week. Death is caused by toxemia. Patients 
 are often pulseless for twentj^-four hours, with cold, livid extremities and 
 bathed in a clammy perspiration before death. 
 
 As this form of peritonitis almost uniformly proves fatal, the treatment 
 should be prophylactic rather than curative. As it is caused by infection with 
 pus-microbes, it can be prevented only by guarding against their entrance into 
 the peritoneal cavity through a Avound, and by the early removal of suppura- 
 ting foci Avhich threaten to rupture into the peritoneal cavity. After the dis- 
 ease has once become fully developed, even flushing of the abdominal cavity is 
 powerless to check its progress. The treatment must be purely sym])tomatic. 
 If septic material has accumulated in the abdominal cavity, it should be removed 
 by flushing with Thiersch's solution of salicylic acid, and reaccumulation pre- 
 vented by securing drainage. The heart's action is to be kept up by alcoholic 
 stimulants, champagne or brandy, up to a point just short of intoxication, and 
 by subcutaneous injections of camphorated oil or strychnine; in short, life 
 should be supported until elimination of the septic micro-organisms can be ac- 
 complished through the excretory organs, while the surgeon assists the system 
 in the process of elimination by drainage and flushing of the abdominal 
 cavity. 
 
 FiBRiNO-PLASTic PERITONITIS. — This is a combination of plastic perito- 
 nitis and septic peritonitis, and was first accurately described by Mikulicz. 
 An attempt at localization takes place by the formation of numerous adhesions 
 between the intestinal coils and between them and the parietal peritoneum and 
 adjacent organs. It results from the same causes as septic jieritonitis, only 
 that probably the quantity of septic micro-organisms introduced is less or that 
 the resisting powers of the peritoneum or the system are greater. If life is suf- 
 
DISEASES AND INJURIES OF THE ABDOMEN. lib 
 
 ficientlv prolonged, the disease oltm tcnirmiitcs in a circiiniseribed suppura- 
 tive peritonitis. 
 
 In sueli cases mnltiple a))seesses are often found, a pathological condition 
 wliich must be remembered wlieJi an operation is perforincd, as it is necessary 
 to find, open, and drain the ditterent foci of suppuration. 
 
 Suppurative Pkritonitis. — Etiologically,se[)tic peritonitis and .sui)j)ura- 
 tive peritonitis are identical; clinically, they differ in so far that septic perito- 
 nitis is generally diff'use and leads to a rapidly fatal termination, while what is 
 known as suppurative i)eritonitis is more fre(|uently circumscribed and n)orc 
 amenable to surgical treatment. Both forms are caused by infection with pus- 
 microbes. The microbe most fre(i[uently found in the inflammatory product 
 of suppurative peritonitis is the bacillus coli communis, when the disease 
 occurs as a secondary aff'ection to perforative appendicitis. In the purely 
 septic variety death results from sepsis before suppuration has occurred, 
 wliile in su])]iurative peritonitis the pyogenic microbes are either fewer in 
 number or meet with conditions less favorable to the production of a fatal 
 dose of ptomaines, or, finally, the peritoneum is in a condition which is un- 
 favorable for the entrance of pyogenic microbes or their ptomaines into the 
 circulation. 
 
 Experimental research has demonstrated that in the causation of suppura- 
 tive peritonitis two conditions must be present at the same time: 1, the pres- 
 ence of pyogenic bacteria ; 2, a wound of the peritoneal surface or an ante- 
 cedent pathological condition which diminishes the absorptive capacity of the 
 "peritoneum. The microbic cause is the essential etiological factor, as Avithout 
 it the other conditions would not result in this form of peritonitis. Serum or 
 blood in the peritoneal cavity prevents the speedy removal of pyogenic microbes 
 by absorption, and if they remain they multiply and produce their specific 
 pathogenic effect on the peritoneum. 
 
 In suppurative peritonitis pain, as a rule, is more pronounced and constant 
 than in the septic variety, and the disease is usually attended by a rise in the 
 temperature to 102° or 104° F. Rigidity of the abdominal muscles is a con- 
 stant symptom in all forms of acute peritonitis. Vomiting and obstinate con- 
 stipation are often such prominent symptoms that it becomes difficult to make 
 a differential diagnosis between peritonitis and intestinal obstruction. Arrest 
 of the fecal circulation may be caused by tympanites alone, while perforative 
 peritonitis is attended by a local and general shock, causing intestinal paresis 
 by the inhibitory action on the sympathetic nerves. In differentiating betw'een 
 these two conditions it must be remembered that in the absence of a swelling 
 absolute constipation and fecal vomiting are the most characteristic symptoms 
 of obstruction, and that in most cases of peritonitis the pain is severe and con- 
 tinuous, with diffuse tenderness, tympanites, and absence of visible intestinal 
 coils. In mechanical obstruction of the bowels the temperature is usually not 
 above normal unless complications have set in, while in peritonitis a rise in 
 temperature is the rule, although in some of the gravest cases the temperature 
 is subnormal. Many cases of alleged recovery from intestinal obstruction 
 without operation undoubtedly were cases of adynamic obstruction, and the 
 recovery was either entirely spontaneous or facilitated by means which assisted 
 in the restoration of peristaltic action. 
 
 In perforative peritonitis and peritonitis with putrefaction the presence of 
 gas in the free peritoneal cavity gives rise to an important physical sign. 
 In tympanites from peritonitis without perforation and intestinal obstruction 
 the distended intestines push the liver in an upward direction ; hence on per- 
 cussion the liver dulness remains, but is transferred higher up. But under 
 
776 AN AMJJi'/CAA y/.A 7-/.'OOA <JJ' Sl'iaiKIiY. 
 
 the circuinstanccs mentioned above the gas in the free al)(loininal cavity occu- 
 pies the space between the liver and the chest-wall ; conse(|uently the liver 
 dulness has disa]>peareil and the whole rijiht side of the chest is tympanitic on 
 percussion. Tympanites is often a most distressing symj)tom in circumscribed 
 peritouitis, but may be entirely absent in the most fatal form of this disease. 
 In suppurative peritonitis the presence of pus in consideriil)le quantity is indi- 
 cated by the physical signs arising from the accumulation of fluids either 
 in the free peritoneal cavity or in a circumscribed ])ortion of it. If the pus is 
 not confined by adherent intestines and plastic exudation, it will gravitate 
 toward the most depeiulent portion of the peritoneal cavity, and on this account 
 the area of dulness will vary according to the position of the patient. In circum- 
 scribed suppurative peritonitis (peritoneal abscess) the pus is confined in a limited 
 space by adherent abdominal organs and fibrinous exudation, and Avill then pre- 
 sent all the signs and symptoms of a deep-seated abscess. 
 
 Treatment. — For years it was the universal practice to resort to the use 
 of opium in the prevention and treatment of peritonitis, until Tait showed the 
 fallacy of this treatment and recommended saline cathartics in threatened cases 
 of peritonitis. The explanation of the beneficial eftect (jf this treatment con- 
 sists in the fact that a brisk saline cathartic promotes the absorption of fluids 
 from the peritoneal cavity, and by so doing removes the indirect cause of peri- 
 tonitis and at the same time favors the elimination of pyogenic microbes. 
 Intra-abdominal wounds and dead tissue of all kinds favor the development 
 of jieritonitis in the same way as blood or serum. 
 
 The proper prophylactic treatment of peritonitis, therefore, consists in 
 guarding against the ingress into the peritoneal cavity of pyogenic microbes 
 by following the strictest antiseptic precautions in all operations which neces- 
 sitate abdominal section, and by preventing the accumulation of putrescible 
 material in the abdominal cavity by a careful toilet of the peritoneal cavity 
 after the completion of the operation; and, when the conditions are such that 
 reaccumuiation is likely to ensue, by establishing free drainage. 
 
 In perforative peritonitis cathartics are absolutely contraindicated, as 
 increased peristalsis would aggravate the existing conditions by increasing 
 the extravasation and by preventing limitation of the infection. Of the 
 beneficial eflect of the use of such drugs in the prevention and treatment dur- 
 ing the early stage of septic and suppurative peritonitis from other causes 
 mention has been made above. In perforative peritonitis opium should be 
 administered to diminish the peristalsis, to relieve pain, and to diminish shock- 
 Unless the location of the perforation can be ascertained beforehand, the incis- 
 ion should be made in the median line. If on opening the peritoneal cavity 
 the jjcrforation cannot be readily found, rectal insufHation of hydrogen gas 
 may be resorted to, and will probably show not oidy that a ])erf()ration 
 exists, but also its exact location. The perforations are treated in the same 
 manner as an incised wound. Care must be taken to suture the oj)ening in 
 a direction that will interfere the least with the lumen of the intestine. After 
 suturing the perforation the abdominal cavity is washed out freely with warm 
 sterilized water or Thiersch's solution. Drainage in these cases must never 
 be omitted, as the operator has no assurance that the peritoneal cavity has 
 been rendered perfectly aseptic. A threatened septic peritonitis after lapa- 
 rotomy ,can often be aborted by giving half an ounce of magnesium sul- 
 phate, dissolved in a glassful of water, upon the appearance of the first 
 symptom. The action of the saline cathartic can be hastened and its bene- 
 ficial effects increased by the administration of a turpentine enema. After 
 the bowels have been thoroughly moved, a minute (pumtity of opium may be 
 
DISEASES AND INJURIES OF THE ABDOMEN. 777 
 
 <riven l)ut only to relieve severe pain. If the symptoms do not subside under 
 Tlii^ treatment", the abdominal wound should be opened sufficiently to permit 
 free irri>;ation with salicylated or sterilized water, a Keith dram, loosely 
 packed witii iodoform jra"u/.e, inserted, and a copious antisei)tic hyjrroscopic 
 dressing applied. In -eneral suppurative peritonitis -au/e drains may be 
 passed between the coils of intestine in diftcrent directions, l^inney has had 
 excellent results from systematic wiping of the bowel with gauze sponges. 
 
 In oi)enin^ the abdiimen for the evacuation of pus the surgeon must look 
 for a primary'^lesion ; but he will not always find it, as it is not invariably 
 present. If the primary cause is found, it should be removed, if possible ; and 
 if this cannot be done,' free drainage from the primary focus must be estab- 
 lished. If the intestinal disturbance is great, the bowel should be emptied 
 bv makino- one or more transverse incisions on the convex side. To do this 
 safelv the" patient must be placed on the side, and the intestinal loop to be 
 incited brought well forward into the wound. After evacuation the visceral 
 wound is sutured in the usual manner. Localized sui)purative peritonitis 
 broutrht about by curable causes is amenable to successful surgical treat- 
 ment*! An operation is always indicated as soon as tlie presence of pus is 
 ascertained. Delay is dangerous in these cases, as the delicate walls, com- 
 posed of plastic exudation, may yield to the pressure, and the extravasation 
 of pus infect a new portion of the peritoneal cavity or perhaps its entire 
 extent. In circumscribed suppurative peritonitis the incision is to be^made 
 ^t a point where the pus is in contact with the abdominal wall. If, on 
 cutting through the peritoneum, no pus is found and the free peritonea 
 cavity has been opened, it is not safe to evacuate the pus until the peritoneal 
 cavit'y has been shut out by gauze pads or by suturing the abscess-wall to 
 the parietal peritoneum or packing the wound for a few days with iodoform 
 gauze, postponing the opening of the abscess until firm adhesions have formed 
 between the margins of the wound and the surface of the abscess-wall. 
 This method of operating in two stages must be frequently resorted to m the 
 treatment of pelvic and visceral abscesses. All operations for suppurative 
 peritonitis are to be conducted upon rigid antiseptic principles, and antiseptic 
 measures are to be followed without relaxation during the entire after-treatment. 
 As patients suffering from peritonitis are always greatly debilitated from the 
 effects of the disease, as well as from lack of solid food, which for obvious 
 reasons must be withheld, every effort should be made to sustain strength by 
 the systematic administration of liquid nourishment, by nutritive enemata, and 
 by alcoholic stimulants. Absolute rest must be enforced, for the purpose of 
 limiting the extension of the disease and with a view of aiding the process of 
 
 repair. . . „ , 
 
 Tubercular Peritonitis.— Tubercular peritonitis occurs as one of the 
 lesions of acute general tuberculosis, with chronic pulmonary phthisis, with 
 tubercular inflammation of the genito-urinary tract, and as a local inflamma- 
 tion. The form of tubercular peritonitis which interests the surgeon is the local 
 form, in which the disease occurs in the peritoneal cavity as a primary lesion. 
 Klimmell regards this form as a purely local aff"ection, amenable to surgical 
 treatment in the same sense and to the same extent as a tuberculosis of joints. 
 The source of infection in these cases is the intestinal canal. Undoubtedly, 
 in manv instances of this kind the peritoneal aff"ection is preceded or attended 
 by tubercular ulceration of the intestines. A considerable number of such 
 cases have been permanently cured by abdominal section : in one of the first 
 cases operated upon by Sir Spencer Wells the patient remained in perfect 
 health for twenty-six^ years after the operation. The effect of the bacillus 
 
778 A\ AMi:ni(.\.\ rr.xr-iinoK of srucEiiv. 
 
 (if tubcM'cuIosis on \\w pcritoiiemii is not uniform, and the- conditions found 
 in peritoneal tuberculosis are variable : as a result a number of forms of 
 loeali/.i^l tuberculosis of the peritoneal cavity liave been ilescribed. Of tliese 
 till' followino; may be mentioned : but only the first variety of tubercular peri- 
 tonitis here described is amenable to successful surf^ical treatment. 
 
 Tuhfrcular Ascites. — In this form the peritoneum is tliickene<l, hyper- 
 emic. and stud<led with masses of tubercle-tissue in the form of miliary 
 nodules. If the effusion is general, occupying the whole peritoneal cavity, the 
 adhesions are few and slight. If the fluid is encapsulated, the walls of the 
 cavity are formed by intestinal loops which are adherent among themselves 
 and to the surrounding structures. The circumscribed form usually takes its 
 origin from the floor of the pelvis, and often gives rise to a swelling which 
 simulates an ovarian cyst to perfection. The fluid which causes the dropsy is 
 either a clear, transparent serum or serum in Avhich small flocculi are suspended, 
 or which has become slightly turbid from the admixture of the products of retro- 
 grade tissue-metamorphosis. Coagulation-necrosis and caseation of the nodules 
 appear to be retarded for a mucli longer time than in cases of glandular tuber- 
 culosis. The amount of fluid may vary from a teacupful in the circumscribed 
 form to from four to six gallons in diffused tubercular ascites. Secondary infec- 
 tion is found most frequently in the spleen, pleura, and lymphatic glands. 
 
 Fihrino-plastie Tubercular Peritonitis. — In this variety of tubercular peri- 
 tonitis no serum is found in the peritoneal cavity. The peritoneal surfaces, 
 which are studded with miliary tubercles, are covered by a thick layer of gelat- 
 inous fibrin which cements together all the adjacent serous surfaces, so that 
 the whole abdominal cavity api)ears to be filled witli a large, boggy mass com- 
 posed of all the viscera adherent to one another, and with the interspaces filled 
 ■with fibrin. 
 
 AdJtesice Tubercular Peritonitis. — In this form the i)rimary inflammatory 
 exudation is slight, but the endothelial cells proliferate and form new tissue, 
 which undergoes cicatrization, giving rise to firm and extensive adhesions. 
 The plastic peritonitis may be so extensive as to cause intestinal obstruction 
 from perfect immobilization of a large portion of the intestinal tract. In this 
 35 well as in the foregoing form of tubercular peritonitis ulceration of the intes- 
 tine may take place, resulting in the formation of a bimucous, internal fistula 
 if the openings in two adjacent loops correspond, or in the formation of a fecal 
 abscess, terminating later in an external fecal fistula. 
 
 Diagnosis. — the diftuse variety of tubercular drojtsy of the peritoneal cav- 
 ity might be mistaken for ordinary ascites or for a large single cyst of the ovary 
 or some other abdominal organ. Ordinary ascites is usually caused by cirrhosis of 
 the liver, malignant disease of the omentum or peritoneum, and valvular di.sease 
 of the heart : and if these conditions are absent there is good reason for suspicion 
 that the effusion has resulted from a tubercular inflammation of the jieritoneum. 
 The circumscribed form of tubercular ascites might be simulateil by a small 
 ovarian cyst, pregnancy, pyosalpinx or hydrosalpinx, pyonephrosis or hydro- 
 nephrosis,*^ cyst of the pancreas, a distended bladder, an enlarged gall-bladder, 
 and pelvic abscess. All of these conditions must be kept in view in making a 
 differential diagnosis. An exploratory incision may become necessary before 
 rendering a jiositive opinion. 
 
 Treatment. — Abdominal section with drainage has proved most useful in 
 arresting the disease if the dropsy is circumscribed. After evacuation of the 
 fluid the parts .should be well dried and dusted lightly with iodoform. The 
 abdominal cavity must be drained with a Keith's large glass tube loosely packed 
 with iodoform gauze : the capillary action of the gauze transfers the fluid, which 
 
DISEASES Axn ixJi'inEs OF nil': ahdomex. 779 
 
 is secreted eonstaiitly, into tlie livgroseopic antiseptic dressinj;. 'Die drain is 
 allowed to remain as long as fluid escapes, wliich is often the case for several 
 weeks and sometimes for months. If reaccnmiilation of fluid takes place, 
 the same j)rocedure can be repeated after an interval of two weeks. In ope- 
 rating for cireimiscrilx'd tubercular ascites it is verv important to exercise 
 great care in o]>ening the abdominal cavity, as a looj) of adherent intestine 
 may be found at tlie ])oint where the incision is made. 1'he peritoneum must 
 be recognized and carefully divided, in order to avoid wounding of the bowel 
 should such a condition be met with. If any caseous foci are found, they 
 should be removed with a sharp spoon, or they can be destroyed or reiulered 
 harndess by ignipuncture and thorougli iodoformization. A tubercular sal- 
 pingitis calls for removal of the affected appendage. 
 
 J\n'ace}it(i<i!< (iMominin, or tapping the abdomen, is re(|uired in certain 
 cases of ascites, tubercular or otherwise. It is performed by introducing a 
 trocar and canula through the abdominal wall, in the middle line, between 
 the umbilicus and the pubes. The patient should be propped up, the blad- 
 der emptied, and the line of dulness determined by percussion on the front 
 of the abdomen. The trocar must be introduced below the level of dulness. 
 The puncture is dressed with aseptic gauze. During the withdrawal of the 
 fluid the patient's pulse should be carefully observed, and the process stopped 
 if any sign of cardiac weakness becomes manifest. An abdominal binder 
 adds to the patient's comfort after the fluid has been withdrawn. 
 
 DISEASES OF THE OMENTUM. 
 
 The omentum being only a duplicature of peritoneum, between the layers 
 of which more or less fat is found, and being in contact with the parietal and 
 visceral peritoneum, it is not surprising that this structure almost without 
 exception participates in all the acute and chronic inflammatory affections of 
 the peritoneum. It is a well-known pathological fact that in injuries and cir- 
 cumscribed inflammatory lesions of nearly all the abdominal organs the omentum 
 becomes adherent to the affected region, and in this manner furnishes a valu- 
 able protection for the peritoneal cavity against extravasation through small 
 intestinal wounds and perforations. 
 
 Cysts. — Cysts of the omentum of non-parasitic origin and non-malignant 
 in character are exceedingly rare." They can be readily removed by enuclea- 
 tion or extirpation. In the latter case it is necessary to guard against hemor- 
 rhage by tying in small sections the part of the omentum which has to be cut 
 through with fine silk ligatures before the division is made. Solitary echino- 
 coccus cysts are extremely rare. Disseminated echinococcus cysts from rup- 
 ture of a mother-cyst in the liver or its vicinity are occasionally met Avith, 
 but their removal by operative procedure is usually impracticable. An iso- 
 lated echinococcus cyst of the omentum is to be treated in the same manner 
 as when the cyst is located in the liver ; that is, by an operation in two stages. 
 
 Malignant Tumors. — Primary carcinoma of the omentum does not occur, 
 as the essential matrix for carcinoma, epithelial cells, is not found in the omen- 
 tum. A primary malignant tumor which springs from the omentum is always 
 a sarcoma. When the tumor has attained considerable size it is easily recog- 
 nized, as it is located immediately underneath the abdominal wall, and adhe- 
 sions to surrounding surfaces do not take place at an early stage of the disease, 
 and consequently the tumor remains movable for a long time. If the tumor 
 has attained a large size and involves the omentum over its whole extent, it is 
 flattened out and feels under the abdominal wall very much like the back of a 
 
780 AN AMERICAN TF.NT-llOOK OF Sl'HGERY. 
 
 large turtle. Not long ago one operator reinoveil .such a tumor that weighed 
 forty pounds. Sanguineous tumors of the omentum have been described by 
 Reamy, Doran, Thornton, and Gardner, but these are only a vascular variety 
 of sarcoma. If primary malignant disease of the omentum could be recognized 
 before the disease had extended to adjacent organs, a i-adical ojteration for its 
 removal could be done with a fair prospect of a pernument cure. In such cases 
 it would be necessary to divide the omentum some distance from the tumor 
 between ligatures, or between ligatures and clamp forceps on the tumor side. 
 
 CYSTS AND TUMORS OF THE MESENTERY. 
 
 Cysts. — Cysts between the peritoneal layers of the mesentery containing 
 serum or a sanguineous fluid have been successfully removed by operative 
 treatment. Chylous cysts, resulting from the obstruction of a chyle-duct and 
 the retention of secretion behind the seat of obstruction, sometimes attain the 
 size of an adult's head. Carson of St. Louis cured such a case by abdominal 
 section and drainage. Extirpation of a cyst of the mesentery should not be 
 attempted, as it is attended by troublesome hemorrhage, and the obliteration of 
 a number of mesenteric vessels might be followed by gangrene of the intestine. 
 These cysts can be dealt with successfully by incision and drainage. It is 
 preferable to make the operation in two stages. The incision in the abdominal 
 wall is made over the most prominent portion of the swelling, and the cyst-wall 
 is stitched to the incised parietal peritoneum and the wound packed with iodo- 
 form gauze. In about five days the dressing is removed, and the cyst incised 
 and drained. It is important that strict antiseptic precautions should be 
 observed, not only before and during the operation, but until the cyst is oblit- 
 erated, in order to prevent suppuration in the interior of the cyst, an event 
 which Avould indefinitely postpone recovery or even endanger life. 
 
 TUxMORS. — The only tumor of the mesentery which deserves mention is 
 lipoma. Lipoma of the mesentery has been subjected to operative treatment 
 by Ellis, Homans, Terillon, and others. The I'emoval of such tumors when 
 they are of large size, as in the two cases reported by Ilomans, is an exceed- 
 ingly difficult and dangerous operation, and unless they give rise to serious 
 symptoms it is best to be content with the exploratory laparotomy should the 
 relations of the parts indicate great difficulties in eff'ecting enucleation. 
 
 PART v.— DISEASES AND INJURIES OF THE LIVER, GALL-BLADDKR, 
 SPLEEN, AND PANCREAS. 
 
 SECTION I.— THE LIVEK. 
 
 Hydatid Cysts of tin-; LtVRH. — Hydatids are found in connection with 
 the liver more frequently than with any other organ. The cysts vary greatly 
 in size, and are usually single, but may be multiple (Fig. 311*). They are 
 found in every part of the liver — in the center, at the upper border, where 
 they may project into the thorax, and on the lower surface, where they escape 
 from under the free border of the liver and may even fill the greater part of 
 the abdomen, and be mistaken for cysts of the ovary. 
 
 Symptoms. — A tumor is present in the right hyj)ochon(lriac or ejiigas- 
 tric region ; it is painless and does not interfere with the general health. A 
 hydatid fremitus has been noted by some, but this sign is uncertain. If the 
 tumor is behind the liver, it may push it forward and increase the area of 
 liver dulness. When enlargement is great, symptoms such as oedema of the 
 lower extremities may arise from pressure on the inferior cava. The tumor 
 
DISEASES AND INJURIES OF THE ABDOMEN. 781 
 
 in some cases is liable to enlarge very rapidly, and to become inflamed and 
 sui.i)urato, or rupture mav take i)laee into the abdominal cavity. It is often 
 a most diflicult affection to diagnosticate from cancer or other tumor ot tfie 
 liver, and when suppurating it is not readily distinguished from abscess ot 
 the liver. The pus of a hydatid tumor has a peculiar odor, ihe diagnosis 
 
 Vui. ;51D. 
 
 Fig. 320. 
 
 Hydatids enclosed in a common cyst (Gross). 
 
 Echinococci (Gross). 
 
 may often be cleared up by the aspirator. Should the fluid evacuated con- 
 tain booklets and scolices (Fig. 320), all doubt as to the character of the 
 tumor is at an end. Konig condemns preliminary aspiration, considering it 
 dano-erous. He prefers to open the abdomen at once in doubtful cases and 
 examine the tumor. Should the case not prove to be one of hydatids, the 
 operator >vill be in a position immediately to remove the tumor if prac- 
 ticable. , ., . 11- • J_■^.^ 
 
 Treatment. — Although the existence of hydatids in the liver is compatible 
 with a fairly comfortable existence, and most medical authorities advise non- 
 interference when there are no distressing symptoms, still the success of opera- 
 tive treatment has been so great that it is advisable when hydatids have been 
 diagnosticated to proceed at once to operation. Simple aspiration has been 
 successful in many cases, but more recent authorities state that by this method 
 of treatment the mother cyst has not been removed, and that relapses fre- 
 quently occur after apparent cure. When suppuration has set in, some sur- 
 geons yet advocate the employment of a large trocar and canula and the fre- 
 quent washing out of the cyst with iodine, Condy's fluid, carbolic acid, or other 
 antiseptic ; but operative measures have proved so safe that most modern sur- 
 geons do not hesitate to recommend them. The operation may be performed 
 in either one or two stages : i i • i 
 
 Operation in One Stage. — Lindemann was the first to recommend this mode 
 of operating, and Landau and Konig both practise it in preference to Volk- 
 mann's operation in two stages. Tait also advocates performing the operation 
 in one stage. All antiseptic precautions having been taken, as in other opera- 
 tions on the abdomen, an incision is made over the most prominent part of the 
 tumor down to the peritoneum. This is then carefully opened and the edges 
 packed round with sponges. The tumor is incised, the contents are evacuated, 
 and the edges of the cyst sewed to the abdominal wound, the sponges being 
 withdrawn as the stitches are introduced. Silk or catgut may be used. A 
 large drainage-tube should be introduced into the cavity and the wound dressed 
 antlseptically. In cases where the cyst is covered by a considerable thickness 
 of liver, an'aspirating needle should first be introduced to make sure of the 
 character of the contents, the liver incised, and the finger thrust through the 
 
Ts-j .i.v AMKRK'AX 'n:xT-ii<)()h' or sf/:(;/:/n: 
 
 opening to prevent hemorrhage, which can usually he controlled hy sponge 
 pressure. The eilges of the opening in the liver should next he stitched to 
 the ahdoniinal wound, and a large drain introduced into the cyst and a dress- 
 ing applied. The stitches in the liver usually hold well. Tait, in a case where 
 he accidentally opened a large sinus, arrested the hemorrhage easily hy pass- 
 ing a thread down on one side of the sinus and up on the other and tying it. 
 Landau before incising the liver recommends the passing of deep sutures par- 
 allel to the a.xis of the wound at each angle. These sutures should be of strong 
 silk, and should include the abdominal wall as well as the cyst-wall. 
 
 Operation in Two iStai/rs. — This operation, which was first recommended 
 by Volkmann, is easily performed. An incision is made along the lower mar- 
 gin of the ribs over the cyst down to the peritoneum: all bleeding having been 
 arrested, the peritoneum is incised the whole length of the wound, and then the 
 wound is dressed with iodoform gauze or other antiseptic dressing. Adhesions 
 between the parietal peritoneum and that covering the tumor are usually pretty 
 firm in five or six days, when the tumor may be incised, the contents evacu- 
 ated, the cavity washed out with antiseptic solution, and a drainage-tube intro- 
 duced. This operation has been most successful, and is, perhaps, safer than 
 the operation performed in a single stage. Some cases of hydatids of the upper 
 surface of the liver have been successfully attacked through the thorax by 
 resecting the ribs. All other methods of treating hydatids of the liver, such 
 as acupuncture, electrolysis, caustics, parasiticide injections, have been super- 
 seded by the more scientific operative procedures above described. After ope- 
 ration for hydatid tumor of the liver a biliary fistula sometimes results. 
 
 Simple Cysts, and also dermoid cysts, are occasionally found in the liver. 
 These should be treated in exactly the same Avay as hydatid cysts. 
 
 Tumors. — Carcinoma, sarcoma, gumma, lymphoma, adenoma, and erectile 
 tumors are seen in the liver, but usually they are not amenable to surgical 
 treatment. Cases of excision of cancerous and gummatous nodules have been 
 reported, and also of tumors formed by hydatid cysts. Excision of cancerous 
 nodules would usually be of little avail, as, when the liver is affected with car- 
 cinoma, it is, as a rule, secondary and the organ is studded with nodules. Car- 
 cinomatous tumors of the liver have, however, been successfully removed by \'on 
 Eiselsberg and others, and Hochenberg, in a case of carcinoma of the gall- 
 bladder, removed the diseased and the neighboring portion of the liver. Simple 
 tumors of the liver have not infreiiuently been successfully removed of late, 
 cases being reported by Liicke, Von Bergmann, and Keen. The latter, in a 
 paper, gives a table of 50 cases of liver resection, 42 of which occurred in 
 females ; of the 59 cases. 48 recovered. The tumor may be removed by repeated 
 small touches of the cautery — all large vessels bein<]j tie<l. In tliis wav hemor- 
 rhage is ])revented. In 6 of the cases above mentioned the stump was sutured 
 to the abdominal wound ; in the others it was returned into the abdominal cavity. 
 
 Abscess of the Liver. — This affection may follow contusions, wounds, etc. 
 It is much more common in tropical than in temperate climates, and is associated 
 fre<iuently with dysentery. Acute hepatitis may terminate in abscess. It may 
 follow operation on the rectum, being due to septic phlebitis. It has followed con- 
 finement, with jihlebitisof the uterine veins. It is an occasional result of pyemia. 
 Hydatid cysts, by taking on suj)purative infiammation, may result in abscess, 
 and abscesses have been excited by the invasion of lumbrici. The predisposing 
 causes are exposure, drinking, irregular habits, and residence in tropical climates. 
 
 Symptoms. — The patient usually has had freipient attacks of illness, has 
 an unhealthy look, a rapid pulse, elevation of temperature, vomiting, a furred 
 tongue, and an anxious countenance. He may occasionally have a rigor, or 
 
DISEASES AM) IX.Ii'lilES OE THE A li DOM EN. 7.S3 
 
 merely shivering fits. There is :i <lull. aching pain felt in the liver and some- 
 timo/in the ri.'ht shoulder, and tenderness over the liver ; sometimes fluctuation 
 mav he made T)ut. When the ahscess has attained any size there are fulness 
 and hulcrincr in the right hvpochon.lrium. Jaundice is rare. Should the ahscess 
 be on the upper surfiice of the liver, it may push up the diaphragm and cause 
 shortness of breath : occasionally it may inflame the diaphragm and adjacent 
 pleura and iiive rise to severe pain. n ■ a ^ a 
 
 Diagnosis. It is sometimes difficult to diagnosticate trom inflamed ana 
 
 distended gall-bladder, hydatids, cancer, malaria, pneumonia, etc. The intro- 
 duction of an aspirating needle will frciiuently clear up the case. These 
 abscesses may burst into the pleura, lung, or pericardium, may point exter- 
 nally or may^pen into the intestine or the general cavity of the peritoneum, 
 the connection of liver-abscess with the amceba coU has been carefully 
 worked out by Kartulis. Councilman, and Lafleur, and they have proved be- 
 yond a doubt" that amreke are the cause of the large single liver-abscess. In a 
 'person suspected of liver-abscess, whether or not there be enlargement of the 
 liver, exploratory asjjiration is indicated ii' ama-hce coli be found in the stools. 
 Aspiration is best performed bv introducing the needle in the mid-axillary line 
 between the seventh and eighth ribs : too small a needle should not be used. 
 When a liver-abscess bursts into the pleura it may be mistaken for em- 
 pyema. The character of the pus is, however, distinctive, for it is of a 
 brown-red color and contains amoehce. Again, the pus may perforate the lung 
 and be coughed up: here the same reddish color and the presence of the amoeba 
 coli would enable the surgeon to distinguish the aff"ection from simple empyema. 
 The prognosis of liver abscess is usually grave. Septic cases are almost 
 universally fatal, surgical treatment being of no avail. 
 
 Treatment.— In tropical abscess surgical treatment is not infrequently fol- 
 lowed by success. In some cases the abscess has been cured by aspiration, but 
 if the abscess has been definitely located it should be treated like an abscess 
 anywhere else, viz. by incision and drainage. The incision should be made 
 along the edge of the ribs, near the subcostal angle, and when the liver is 
 reached it sh'ould be stitched to the abdominal wound, incised, the abscess 
 evacuated, washed out if fetid, and drained : in fact, treated much in the same 
 way as a hydatid cyst. Some have advised operation in two stages, but in one 
 stage with aseptic' precautions the operation has been eminently successful. 
 Abscesses which form on the upper surface of the liver frequently discharge 
 through the lung. They have been successfully attacked through the lower 
 part of the thorax by excising one or two ribs, incising the diaphragm, and 
 draining. It is advisable to sew the parietal and phrenic pleura together before 
 incising the liver through the diaphragm. 
 
 Rupture of the Liver. — An injury sufficient to cause rupture of the 
 liver usually causes equally serious eff"ects in other organs, so that surgical 
 interference' ordinarily is of no avail. Still, if not immediately fatal, the 
 abdomen should be opened and the wound brought together. Wounds of the 
 liver substance heal rapidly, and hemorrhage is generally at once arrested by 
 approximating the torn edges. In one case reported by H. E. A^ alton there 
 was rupture o^ both liver and kidney. The liver rupture was so far back that 
 it could not be sutured, so was packed with iodoform gauze. The patient made 
 a rapid recovery, going out of hospital well in five weeks. 
 
 Wounds of the Liver.— These may occur accidentally during an opera- 
 tion or be produced bv stabs, bullets, etc' Many cases of recovery after punc- 
 tured and incised wounds of the liver are reported by Otis in the Medical and 
 Surgical History of the War of the Rebellion. Cases of recovery are reported 
 
784 
 
 A.\ AMi:incAX TEXT- HOOK OF SVlidKRY. 
 
 after a bullet Imd ]»;isso(l conijiletcly tlir«»u<^li the liver. Should tlic case be 
 complicated by Avoiind of the stoiiiach, spleen, kidney, or <:reat vessels, it is 
 very unfavorable. In cases of incised or gunshot -wounds of the liver the 
 proper course is to open the abdomen and suture the wounds. In suturing 
 the liver it is important to place the sutures at some distance from the edge 
 of the wound. No doubt in the future a quicker resort to laparotomy in 
 wounds of the viscera will save many lives, and surgeons will no longer be 
 willing to stand by and see the patient die without attempting some form of 
 surgical relief. 
 
 Resection of Portions of the Liver. — Portions of the liver have been 
 of late successfully excised both by the knife, by the thermo-cautery, and by 
 the elastic ligature applied externally after suturing the liver to the margins 
 of the abdominal incision. Langenbuch records a case in which he successfully 
 removed the greater part of the left lobe in a woman aged thirty. The lobe 
 had been extensively deformed by tight lacing, and caused serious inconveni- 
 ence. There was considerable hemorrhage, but the vessels were secured and 
 the woman made a good recovery. Portions of the liver, the seat of hydatid 
 cysts, have also been successfully removed by the thermo-cautery and elastic 
 ligature. Nodules of cancer and gummata have been excised, but with no 
 great permanent benefit to the patient, the operations having usually been 
 based on mistaken diagnoses. Portions of the liver have extruded from 
 
 the abdominal wound, and 
 Fig. 321. have been removed success- 
 
 fully. Free hemorrhage 
 sometimes occurs in ope- 
 rating on the liver, which is 
 usually rapidly arrested by 
 tamponing with iodoform 
 gauze and securing the 
 bleeding vessels. 
 
 Floating Liver. — In 
 this rare malady the liver 
 forms an abdominal promi- 
 nence which can be moved 
 about, which is apt to trans- 
 mit aortic pulsations, and 
 which changes its situation 
 as the patient shifts her atti- 
 tude. This condition usually 
 arises from a lax abdominal 
 wall following repeated preg- 
 nancies. Fig. 321 exhibits 
 a typical case verified by a 
 post-mortem. 
 
 The only treatment that 
 is needed in some cases is 
 the use of an abdominal belt. 
 If this should fail to relieve 
 the symptoms, an oi)eration 
 may be undertaken, with the 
 view of suturing the liver 
 Treves and others have reported successful cases 
 
 Floating Liver (original). 
 
 in its proper position, 
 of hepatopexy. 
 
DISEASES AND INJURIES OF THE ABDOMEN. 7S5 
 
 GALL-f^TONES AND DISTENTION OF THE GaLL-IJLADDER. Gall-StoneS, or 
 
 biliary calculi, occur more f'recjuently in wonion than in men. They are rare in 
 infiincy and childhood. Tifi;ht lacing, by obstructing the flow of bile, and 
 hence leading to its inspissation, is one of the causes of gall-stones. High 
 living and want of exercise also favor their formation. They occur of all 
 sizes, from that of a grain of sand to that of a hen's egg. Gall-stones are 
 most fre({uently multiple, and arc then faceted by reciprocal pressure — a valu- 
 able point in diagnosis when a stone has been passed and found in the stools — 
 but when of large size they are usually single or double. When small they 
 occur in large numbers, several thousands having been found in one person 
 (Otto). When small and numerous the patient frequently passes them, and 
 they may be found in the stools. The passage of gall-stones from the gall- 
 bladder to the duodenum is attended by vomiting and intense pain, which is 
 relieved only by full doses of morphine, administered preferably hypoder- 
 matically. After an attack of biliary colic, jaundice, to a greater or less 
 extent, is observed. If the urine be examined, bile-pigment Avill often be dis- 
 covered in it, even if there be no jaundice. 
 
 The conditions which call for surgical interference may be caused by the 
 arrest of the gall-stone in its passage to the intestine, either in the cystic or in 
 the common duct. When arrested in the common duct there is obstruction to 
 the outflow of bile and consequent jaundice, and the gall-bladder becomes 
 enlarged, and may be felt as a rounded, pear-shaped tumor under the edge 
 of the right lobe of the liver. The contents are not usually bile, but may 
 be mucous, muco-purulent, or purulent fluid, Avhen the cystic duct is 
 occluded. A greatly distended gall-bladder has been mistaken for ascites, and 
 has been tapped for ovarian tumor, hydatids, etc. The bile-duct may become 
 obstructed also by the pressure of tumors involving neighboring organs, as the 
 stomach, pancreas, or liver, or it may become occluded by the spread of cancer- 
 ous diseases commencing in the contiguous organs. Gall-stones are not infre- 
 quently the accompaniment of cancer of the liver, as obstruction to the flow of 
 bile favors their formation. Obstruction of the common duct is always accom- 
 panied by jaundice, but the cystic duct may be occluded and give rise to grave 
 symptoms without there being any trace of jaundice or any history of biliary 
 colic. Not a few cases of enlarged gall-bladder thickened and altered bv in- 
 flammation are difficult of diagnosis, owing to the downward displacement of 
 the liver from tight lacing or other causes. Such tumors have been mistaken 
 for diseased or floating kidney, malignant disease of the bowel, etc. On the 
 other hand, cancerous nodules in the liver have been mistaken for diseased 
 gall-bladder and the abdomen opened. In many cases there is no distention 
 of the gall-bladder, but, on the contrary, it is small and surrounded by thick 
 adhesions produced by the presence of the calculi. 
 
 Rupture of the Gall-bladder. — Several cases of this accident have 
 been successfully treated by incision and drainage (Lane) or by aspiration (I. 
 Bell). In these cases large quantities of bile escaped into the abdominal cav- 
 ity. Peritonitis does not necessarily folloAv, as the bile is usually aseptic. 
 
 Suppuration of the gall-bladder not infrequently occurs, and this adds much 
 to the seriousness of the case. The obstruction in these cases is nearly always 
 situated in the cystic duct. In some cases the gall-stones may ulcerate through 
 the gall-bladder into the stomach, duodenum, or colon, and in this way large 
 stones have escaped from the gall-bladder and afterward have produced ob- 
 struction of the bowels. For the relief of the conditions of the gall-bladder 
 above described two operations have been devised, viz. cholecystotoniy and cho- 
 lecystectomy. 
 
 50 
 
786 AN AMNincAS TKXr-JiOOK OF SUlKiFAiY. 
 
 Cholecystotomy is porfonnt'd lor tlie relief of distention of the gall- 
 bladder from obstruction of the cystic or common duct and for the re- 
 moval of calculi. This operation has been very successful. It is essen- 
 tially of American origin, iiaving been first done by liobbs of Indiana})oli8 
 in 181)7, and its establishment and practical perfection being due to Marion 
 Sims in 1878. Tait in 54 cases had -VJ j)erlecl recoveries. In 170 cases 
 of ojierations in gall-bladder bile-ducts perfoi-med by Mr. Mayo Kobson 
 10 patients died, in 1>8 patients operated on without jaundice all recov- 
 ered ; the deaths occurred among the remaining 77 cases with jaundice. 
 Of 115 cholecystectomies, 5 died; of 6 choledochotomies, 1 died. Murphy 
 of Chicago collected 201 cases of cholecystectomies, with a death-rate 
 of 19 per cent. The operation is performed by making an incision over 
 the tumor, if it l)e present; if not, a vertical incision in the right semi- 
 lunar line. If more room be needed, an incision at right angles to the 
 first may be made Avith advantage. Then the distended gall-bladder, if 
 very much distended, is aspirated. It then should be carefully packed 
 around with aseptic j)ads before it is opened and the stones removed. 
 The cut edges of the gall-bladder are now stitched to the deeper parts 
 of the wound (not to the skin), a drain introduced, and the skin-incision 
 closed as far as possible. If the gall-bladder is stitched to the skin, an 
 incurable fistula often results. Bile flows freely from the tube for some time, 
 but after its removal the fistula usually closes in from two to four weeks. 
 Occasionally it remains open and there is a permanent biliary fistula. In 
 such cases the common duct is probably occluded by gall-stones. There 
 is often great difficulty in removing stones impacted in the ducts. A long- 
 handled scoop, something like a uterine curette, will be found useful for remov- 
 ing stones from the gall-bladder and cystic duct. Some surgeons have succeeded 
 in piercing the stone with a needle, thus breaking it up and pushing the frag- 
 ments into the duodenum ; others (Tait) break up the stone by using padded 
 forceps from outside the duct ; others again have oi)ened the duct, removed 
 the stone, and afterward sutured the duct successfully. In cases where the 
 stone is lodged near the duodennl opening of the duct, McBurney has suc- 
 cessfully removed it by incising the duodenum, slitting up the duct, and thus 
 reaching the stone. Abbe has performed a somewhat similar operation for 
 obstruction of the common duct, but in his case the obstruction was due to a 
 cancerous nodule. In perfi)rming the operation of cholecystotomy. Sir 
 t'j)encer Wells, after evacuating the distended gall-bladder and removing the 
 • stones, stitches it up ;igain by continuous suture and returns it. In these 
 cases the gall-bladder is first carefully packed around with carbolizcd sj)onges, 
 aspirated, and then drawn out of the wound before being incised. By 
 this means the necessary manipulations are carried on without any danger of 
 the contents of the gall-bladder getting into the peritoneal cavity. In many 
 eases the operation of cholecystotomy, or incision of the gall-bladder, is an 
 easy one, but the operation may present unusual difficultii-s when the gall- 
 bladder is small and shrunken and cannot be brought to the abdominal wound. 
 In such a condition it may be sutured and returned into the abdomen, as 
 recommended by Kuster, or a drain packed around with iodoform gauze may 
 be inserted. 
 
 Van Hook recommends air-distention in operations upon the bile-tracts, 
 as the operator may thus readily identify these structures, locate obstructions 
 if present, or determine that they are absent. It also serves to test the 
 accuracy of sutures of the duct walls. He has devised a s])ecial ai)i)aratus 
 for infiating the ducts; but some other form of pump can easily be devised. 
 
DISEASES AND INJURIES OF THE ABDOMEN 787 
 
 Tlic first step is tlio iutroductiou of a suitable canula into the gall-bladder, 
 which is held firmly by a purse-string suture in the latter. No danger is to 
 be apprehended from the use of this measure. 
 
 Cholecvstotomv is tlie proper operation in cases where the common duct is 
 blocked, ami also in eases where gall-stones exist in the gall-bladder, giving rise 
 to repeated attacks of biliary colic. ,,,,,, . . .1 
 
 Cholecystectomy, or excision of the gall-bladder, was hrst practised 
 bv Lan-eubuch of Berlin in 1880. His method is as follows: An incision is 
 made iifthe right hypochondrium, parallel to the lower border of the liver 
 an.l is ioiued by a second incision running along the outer border of the right 
 rectus "imiscle. The abdomen having been opened, the transverse colon and 
 small intestine are pushed aside by a large sponge; the liver is then ele- 
 vated, so as to bring the lesser omentum into prominence, ^^^e gall- 
 bladder is easily separated from the liver by a few strokes of the knile, 
 and the cystic duct freed and ligatured in two places with silk. Atter 
 removal of the gall-bladder the wound in the abdomen is closed and the 
 operation is completed. , • 1 
 
 Cholecystectomy is also advocated in cases where there is degeneration 
 of the .ndl-bladder and there is no chance of restoring its function, or where 
 the cralf-bladder is small, contracted, or perhaps suppurating so that it can- 
 not be fixed to the abdominal incision. Excision of the gall-bladder is also 
 indicated in cases of gangrene, phlegmon, or cancer. If the common duct 
 is not patent, this operation is contraindicated. 
 
 Cholecyst-enterostomy, or the formation of a communication between the 
 intestines and the gall-bladder, has been successfully performed. ihis ope- 
 ration endeavors to avoid the formation of a biliary fistula; but, ot course, 
 the danger to the patient is much greater, and the opening is liable to 
 
 contract. , ^ i 1 r i.r 
 
 This operation has of late been frequently performed by means ot the 
 smallest-sized Murphy's button. It is a rapid, easy, and comparatively sate 
 method of forming a communication between the gall-bladder and small 
 intestine. In cases in which, after the operation of cholecystotomy, the 
 fistula persists and discharges large quantities of bile, it may be taken 
 for ^ranted that the common duct is occluded and cholecyst-enterostomy 
 shoutd be undertaken, the opening in the gall-bladder closed by Lem- 
 bert's sutures, and then the gall-bladder should be returned into the 
 abdominal cavity and the abdominal wound closed. It would be well to 
 keep in a drain for a few days, in case any leak should occur in the gall- 
 bladder. ^ ,. „ . . ,, 
 Gall-stones in the Common Bile-duct— According to Courv-oisier, gall- 
 stones are in the common duct in about 4 per cent, of all cases of cholelithi- 
 asis In 67 per cent, of the cases the stone is found in the duodena end ot 
 the common duct, according to Mayo Robson. Jaundice with distended gall- 
 bladder not due to gall-stones is presumptive evidence of malignant disease. 
 Jaundice without distended gall-bladder favors the diagnosis of cholelithiasis. 
 Courvoisier found that in 35 operations performed for obstruction m the 
 common duct, in 18 the obstruction was due to causes unconnected with ga - 
 stones— e^. g., cancer, tumor, stricture— and in all these 18 cases the gall- 
 bladder was dilated. ^^ i e 
 If there is no enlargement of the gall-bladder with frequent attacks ot 
 pain, each attack accompanied by an increase in the jaundice, which is never 
 wholly absent; if there are loss of weight and feverishness during the attack, 
 and pain in the epigastric region, then we may conclude we have a stone in 
 
788 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 the common duct. A'arious methods of getting rid of the stone have been 
 mentioned above ; but the best method by far, when possible, is the operation 
 of choledochotomy, or removal of the stone by incising the duct. After se)ia- 
 rating ndhcsions and making an assistant retract the parts well, the duct will be 
 made out along the free border of the lesser omentum. A finger introduced 
 into the foramen of Winslow should j)ush the duct and contained stone into 
 prominence ; then an incision is made over the prominence and the stone 
 removed. A probe should now be introduced to see if there are any more 
 stones. The incision should be closed by a double row of sutures, the outer 
 layer a continuous Lendjert of fine silk. A drainage-tube, packed around 
 with gauze, should be left in the abdomen. The gauze should reach the in- 
 cision in the duct. The mortality in the operation of choledochotomy is 
 about 25 per cent., and the difficulties are great. In some cases stones have 
 been removed from the hepatic duct with success. 
 
 SECTION II.— THE PANCREAS, 
 
 Notwithstanding the fact that the pancreas is the most inaccessible of all 
 the abdominal organs, it has been a number of times successfully subjected to 
 operative measures. 
 
 Cysts. — This affection has been fully described by Senn, who comes to 
 the conclusion that all cysts are retention cysts, and are due to cylindrical con- 
 traction or obliteration of the common duct or its branches, or to impacted cal- 
 culi. Cysts are more frequently met with in men than in women, and often 
 follow injury. The cyst usually grows rapidly and is situated above the 
 umbilicus. Gastro-intestinal disturbances, such as vomiting and diarrhea, are 
 common symptoms. The skin has an unhealthy, muddy look, and the pain is 
 sometimes considerable. 
 
 The tumor itself is generally well defined and has an elastic feel, as if very 
 tense. If aspirated, the fluid has a brownish color, is alkaline in reaction, digests 
 fat, and turns starch into sugar. The skin about the sinus which is left after 
 operation is often raw and sore. A considerable number of cases are now scat- 
 tered through medical literature, and not a few have been diagnosticated before 
 operation. 
 
 Pancreatic Cysts. — (Jf 12 cases of extirpation of the cyst, 5 died ; of 
 31 cases treated by incision and drainage of the sac, 2 died; but 10 of those 
 who recovered had more or less permanent fistulse. Simple tapping has 
 proved fatal in 2 cases. The cyst has been mistaken for hydatids, ovarian 
 cyst, tumor of the kidney, etc. 
 
 Treatment. — An incision is made over the tumor down to the cyst, which 
 is then aspirated, pulled gently out of the wound, and incised. After evacu- 
 ating the contents the cyst should be stitched to the parietal wound and the 
 cavity drained. A fistula may persist for some time. 
 
 Abscess of the pancreas is sometimes seen, and usually ends fatally, nearly 
 all the reported cases having been found only post-mortem. Should a diagno- 
 sis be arrived at, the proper procedure would be to incise and drain. 
 
 Wounds of the pancreas have been recorded from time to time. Rupture 
 of the pancreas has been seen from severe contusions. Many cases of gunshot 
 wound of the organ are reported, also stab wounds from a knife or other instru- 
 ment. In such cases portions of the pancreas have protruded from the wound 
 and have been cut off, with subsequent recovery of the patient. Dargan 
 reports a case where the pancreas was successfully replaced in the abdominal 
 cavity. In cases of severe abdominal wounds where the pancreas is injured the 
 
DISEASES AND INJURIES OF THE ABDOMEN. 789 
 
 lesion ^Y()uld be diseovered in performing abdominal section for the treatment 
 of wounds of other organs. It would be quite justifiable to excise portions of 
 bruised or injured pancreas. . , • • 
 
 Cancer of the pancreas is so insidious that when diagnosticated it is 
 usually too for advanced for operation. 
 
 Portions of the pancreas have been removed during operation on neighbor- 
 mcr orf^ans for carcinomatous tumors or other diseases, without bad results. 
 
 SECTION III.— THE SPLEEN. 
 
 Cysts of the Spleen.— These may be simple, dermoid, or hydatid, and 
 are very difficult to diagnosticate positively without opening the abdomeii. 
 Hydatids may be recognized by the fremitus or by an examination of the 
 aspirated fluid. Usually these cysts should be treated like those of the liver, 
 viz. by abdominal incision over the tumor, fixing the cyst-wall to the abdom- 
 inal wound, incising, evacuating, and then draining. 
 
 Carcinomatous and Sarcomatous Tumors of the spleen do not otter 
 
 any hope of being treated surgically with success. . . , . , 
 
 Abscesses may follow injury or be the result of septic infection, and 
 
 should be incised and drained with strict aseptic precautions. They are not 
 
 usually recognized until they approach the surface and fluctuate freely. 
 
 Rupture produced by "kicks, blows, or other injuries is usually fatal. 
 When accompanied by an external wound the spleen may protrude, and the 
 sur^reon may find it necessary to remove it wholly or partially. 
 
 "Stab or Gunshot Wounds.— If the patient be seen m time, it will be 
 proper to perform abdominal section and endeavor to arrest the hemorrhage by 
 tamponing with iodoform gauze, by ligature of vessels, or even by excision ot 
 the spleen if the injury be great. ^ , x. e 
 
 Splenectomy, or excision of the spleen, has been performed a number ot 
 times. Vulpius has collected 117 cases of splenectomy with a death-rate of 
 50 per cent. ; if, however, from these cases those suff"ering from leucocy- 
 themia, lardaceous spleen, spleno-megaly, in which the operation should not 
 be done, be deducted (32), the mortality in the remaining cases (85) is re- 
 duced to 33 per cent. The indications for the operation are tumors and 
 cysts, wounds, and movable or dislocated spleen. In leukemia the operation 
 has been invariably fatal from hemorrhage, which is the great danger of 
 splenectomy. Hypertrophied spleens have been successfully removed, but 
 for the most part these cases are not suitable for operation. 
 
 Operation. — An incision is made in the left semilunar line, the perito- 
 neum freely opened, and the hand introduced to explore the tumor. All adhe- 
 sions are separated, and ligated if necessary, and the spleen delivered through 
 the wound, the lower extremity, first. Great care should be taken not to twist 
 or drag on the pedicle. The vessels entering the hilum should be clamped, 
 the spleen removed, and tLen each vessel ligated separately some distance from 
 its extremity. Some advise cutting the pedicle away piecemeal between 
 pressure artery forceps and then securing the vessels. The after-treatment is 
 the same as after ovariotomy. 
 
 PART VI.-DISEASES AND INJUEIES OF THE RECTUM. 
 
 Surgical Anatomy. — The rectum in the male is in relation in front 
 with the trigone of the bladder and the seminal vesicles, and in the female 
 with the vagina and uterus. The lower three or four inches are uncovered 
 
790 A.\ AMhJi'JCAA Ti:XT-ll()Uh' OF .SI /,'(; J./n'. 
 
 bv peritoncnin. It is freely supplied l»y blood-vessels, eliieHy iVom the supe- 
 rior heinorrhoidiil braueh of the inferior mesenteric artery. This artery passes 
 down in the niesorectuiu. and divides into two branches, each of which forms a 
 loop on the side of tiie bowel, about five inches above the anus. From these 
 loops a number of vessels are given oft" which pierce the muscular coat and run 
 down immediately beneath the mucous membrane to the anus. There is a branch 
 in each column of the rectum. These arteries anastomose freely with one another, 
 and are connected by lateral branches, but they do not anastomose with the 
 middle and inferior hemorrhoidal arteries, which supply the skin about the 
 anus. From a knowledge of the development of the rectum it will be easily 
 understood that the lower end descends a considerable distance to meet the 
 involution of the skin at the anus, and in descending carries with it its own 
 vessels, the superior hemorrhoidal. The veins have much the same anatomical 
 arrangement as the arteries. 
 
 Iseliio-reetal Fossa. — On each side of the rectum is a fossa called the 
 iscbio-rectal. It is two or three inches in depth, pyramidal in shape, ami filled 
 with fat. There are very few blood-vessels in this fossa, and it is the common 
 seat of fistulse and ischio-rectal abscess. 
 
 Congenital Malformations. — These are not infrequent, and are very 
 various. In early foetal life the bowel and urogenital sinus end in a common 
 cloacal opening ; later, separation between the bhulder and urethra and the 
 rectum takes place, and there are two distinct orifices. But occasionally this 
 separation does not occur, and the lower end of the rectum opens into 
 the bladder (Fig. 322), or, more commonly, if the child be a male, into 
 the membranous portion of the urethra ; or into the vagina if the child be 
 a female. 
 
 Imperforate Anus and Imperforate Rectum, — The lower one and a 
 
 Fig. 322. Fig. 32o. 
 
 Rectum opening into Bladfler: a, penis; ft, bladder; A, Depression for aniil jmce of n-ctum; R B, 
 
 c, rectum opening into bladder (Owen). bladder ; M, Meckel's diverticulum ; CE, future 
 
 cesophagus; I', pharynx ; T, urachus lOwen). 
 
 half to two inches of the rectum are not formed from the hypobla.st. as is the 
 rest of the alimentary canal (with the exception of the mouth), but by an 
 involution of the epiblast or skin which meets the end of the alimentary canal 
 formed by the hypoblast (Fig. 823). Occasionally this involution does not 
 occur, and there is no union with the lower end of the alimentary canal. This 
 is called imperforate anus. Again, a simple cul-de-sac may exist at the anus, 
 and the bowel may terminate at some distance above, and either end by a blind 
 extremity or open into the membranous urethra or the vagina. In such a case 
 
DTSEASKS AND INJURIES OF THE ABDOMEN. 
 
 791 
 
 the involution ot" the skin oecurred nornuilly, but the rectum above was not 
 sufficiently (levelo])e(l to meet it, and the result is a deformity called imper- 
 fonitc rectum (Fig- 324). Im- 
 perforate anus and imperforate Fio. 324. 
 rectum may exist together. The ^^.. 
 term imperforate anus is often 
 applied to either condition. In 
 some cases the involuted por- 
 tion of skin meets the end of 
 the large intestine, but a sep- 
 tum remains between them still 
 unabsorbed, and occludes the 
 bowel. This may be easily di- 
 vided, and the child will then 
 have a free exit for feces. Some- 
 times the anal opening, though 
 present, is so small as to admit 
 only a fine probe, and the sur- 
 geon is compelled to nick the 
 edges with a narroAV-bladed knife 
 and then dilate with his finger. 
 
 Diagnosis. — The fact that 
 the child has had no motion of 
 the bowels is usually noticed at 
 an early period by the nurse : 
 even if there should be a well- 
 formed anus, an intelligent nurse 
 will inform the doctor that there 
 has been no passage through the 
 bowels, and an examination will 
 soon reveal the condition. Should the bowel communicate with the vagina 
 or the urethra, the passage of meconium from these orifices will soon be 
 detected. 
 
 Treatment. — In cases where there is imperforate anus the bowel usually 
 lies close to the skin, and a simple incision into the bulging anal region will 
 reach the lower end of the rectum distended by meconium. The edges of the 
 bowel should be fixed to the external opening, and the mother should be 
 instructed to pass her little finger daily into this opening, so as to prevent 
 contraction. 
 
 In some cases, ow ing to deficiency of the rectum, no fulness can be felt, 
 and the bowel cannot be reached through an anal incision, even though a deep 
 exploration be made. In such patients the abdomen should be opened in the 
 left groin, as in inguinal colostomy, and the end of the bowel searched for. 
 Sometimes the sigmoid flexure is absent, and other portions of the large bowel 
 must be secured and brouo;ht to the abdominal wound. Some surgeons, when 
 the bowel cannot be reached thi'oun;h the anal region, advocate leaving the case 
 alone, saying that a child is better dead than with a false anus in the groin, 
 but the fact remains that individuals have grown to full maturity in comfort 
 with such openings, and have even married and lived to an advanced age. 
 
 Operation is especially necessary when the bowel ends in the urethra or 
 vagina, for here the bowel usually terminates in a narrow canal and cannot 
 be reached from the perineum. These cases, if left alone, do not die in three 
 or four days, as do the others described above, but live on very uncomfortably, 
 
 Imperforate Rectum (Holmes). 
 
792 AN AMERICAN TEXT- BOOK OF SURGERY. 
 
 j)assing feces through tlie urethra ami vagina. In such cases inguinal colos- 
 touiv is a very necessary operation, and one which gives great relief to the 
 little patient. 
 
 Mode of Examining the Anus and the Rectum. — In all cases of ordinary 
 external examination the patient should lie on the side or hend over the back 
 of a chair ; of course, previous to the inspection the lower bowel should have 
 been washed out with an enema. In some cases where the anus is deeply sit- 
 uated, placing the patient in the position assumed when at stool will cause some 
 ]>r«)lapse of the mucous membrane, and thus hemorrhoids, polypi, and fissures 
 can easily l>e diagnosticated. For ordinary purposes of examination, the 
 fin^rer well covered w ith vaseline is the most valuable instrument ; it should 
 be slowly and cautiously insertetl, and any tumors, indurations, or internal 
 o])e!iings of fistulse should be felt for. Malignant and other ulcerations 
 of the lower three or four inches can be made out, especially if the patient 
 strains whilst in the squatting position. Strictures can also be felt. For a 
 
 Fig. .325. 
 
 Kelly's Urethral Specula. 
 
 liigher and more thorough examination other means are required, such as 
 soft, flexible bougies and specula. In any case of doubt the ])atient should be 
 placed under other, the sphincter should be forcibly dilated, and then a com- 
 plete and thorough examination made. For purposes of high exploration 
 Kelly of Baltimore has devised a series of cylindrical specula of various 
 lengths (Fig. 325). The examination is made with reflected light, the patient 
 being in the knee-chest po.«ition. Anesthesia is not always necessary. "The 
 patient kneels on an ordinary kitchen table, with the elbows spread out at 
 the sides so as to bring the chest as close to the table as possible, while the 
 thighs are perpendicular to it, supporting the pelvis as high as possible " (see 
 Fig. 326). A number of specula of different sizes and lengths are used, the 
 one for diagnosis of the sigmoid flexure being as much as 14 inches long and 
 1^ of an inch in diameter. Each speculum is provided with a blunt obturator 
 with a stout handle ; before introduction the speculum is well coated with 
 vaseline. " The buttocks are drawn apart and the blunt end of the obturator 
 is laid on the anus, which is also coated with vaseline. The direction of the 
 
DISEASES AND INJURIES OF THE ABDOMEN. 
 
 793 
 
 instrument should be Hrst downward and forward, and, wlicn tlic splnnctcr is 
 well passed, up under the sacral promontory. The moment the speculum 
 clears the sphincter ani and the obturator is withdrawn air rushes in audibly 
 and distends the bowel." Kelly has introduced the longest instrument as 
 much as 12 inches, and has diagnosticated stricture ^ inches up; owing 
 to the distention of the rectum with air the mucosa is plainly seen and the 
 valves recognizable. By moving the instrument about m various directions 
 the condition of the different parts can be easily made out • il feces interfere 
 with the view, they can be removed with a special scoop, l^or inspection of 
 the lower end of the rectum a short (4 cm.), stout speculum is used (sphincter- 
 oscope) After introduction and removal of the obturator by slowly withdraw- 
 ing and pushing back a little the whole sphincter area is brought into view. 
 
 Fin. 326. 
 
 Examination of the Rectum by Reflected Liglit (Kelly) 
 
 Hemorrhoids, or Piles.— These may be defined as tumors which are 
 composed chiefly of varicose or dilated veins of the lower end of the rectum, 
 surrounded by infiltrated connective tissue. Fig. 327 shows the rectal veins. 
 
 Causes.— The chief predisposing causes of piles are man's erect position 
 and the absence of valves in the hemorrhoidal veins. Heredity also influences 
 their formation, as it does that of varicose veins elsewhere. Pregnancy and 
 anything which obstructs the portal circulation predispose to piles, as do also 
 sedentarv habits, over-eating, over-drinking of alcoholic liquors, the excessive 
 use of purgatives, and, lastly, constipation, which is nearly always the exciting 
 cause of an attack. Piles are almost as common in women as m men, and are 
 oftenest seen in middle life. They rarely occur before puberty, though cases 
 occurring in infants and young children are reported. Piles are usually 
 divided Into external or blind piles, and internal or bleeding piles. 
 
794 
 
 ^l.V AMERICAN TEXT-BOOK OF SlUCEIiY. 
 
 External Piles. — The external are subdivided into venous and ciitaneons. 
 
 renous Piles. — These are due to a varicose condition of the external 
 hemorrhoidal veins. They appear about the margin of the anus as bliiisli, 
 soft, round tumors which, by pressure, can be easily emptied of the contained 
 blood. When thrombosed and intliuned they are filled with blood-clot iind 
 become hard, tense, and extremely painful, causing often much constitutional 
 disturbance. There is a great deal of tenesmus and a feeling as if a foreign 
 body were in the rectum. Defecation causes severe suffering. 
 
 Cutaneous Piles. — These are often a sequence of the venous pile, frequent 
 inflammations producing hyperplasia of the connective tissue around the 
 dilated veins, and thus small tags or tumors are formed, which, in some cases. 
 
 VH}f 
 
 VIIM 
 
 VHE- 
 
 Eectal veins seen from without ; Amp, rectal pouch or ampulla; P, skin at margin i>i anus reflected; 
 SE, external sphincter ; VHE, external or inferior hemorrhoidal vein ; VUI, internal or superior 
 hemorrhoidal vein; VHM, middle hemorrhoidal vein (Dnret). 
 
 are pedunculated. In other cases, however, the cutaneous pile consists of a 
 hypertrophied fold of skin about the anus, which Avhen inflamed becomes 
 (Edematous, infiltrated, and acutely painful. 
 
 External piles when quiescent give but little trouble, but when inflamed 
 they are excessively sensitive and cause much malaise in the most robust. 
 Suppuration occasionally supervenes, but usually the inflammation subsides in 
 a few days, and the pile remains as a somewhat larger tag of skin. Associated 
 vrith external piles is not infrequently seen a fissure or eczema of the anus. 
 External piles rarely if ever bleed. 
 
 Treatment. — Palliative treatment is unsatisfactory, yet when patients 
 refuse operative treatment it must be undertaken. It is most important to 
 
DISEASES AM) lyjl'lilES OF THE AJiDOMFN. 795 
 
 overcome the constipation which usually coexists, and this may he done by 
 the administration of confection of senna and sulphur, the compound liquorice 
 powder, cascara, or other laxative. Usually, to relieve pain an application of 
 equal parts of the extracts of belladonna and opium, or belladonna and ;^lyce- 
 rin, may be made to the part, and then a hot fomentation applied. If the in- 
 flammation is very severe, leeches often do good. 
 
 Operative Treatment. — For the venous pile immediate relief may be 
 obtained by incising the tumor and turning out the contained clot, and then 
 dusting the parts with iodoform. Before making the incision the part should 
 be painted over with an 8 or 10 per cent, solution of cocaine. A very small 
 bit of cotton should be placed betAveen the lips of the Avound if the pile be 
 of any size. The patient should be kept in bed for a day after the incision, 
 lest there be subsequent hemorrhage. For the cutaneous pile there is no rem- 
 edy so efficacious as excision, even when the pile is inflamed and oedematous ; 
 there is no bleeding Avhich is not easily controlled by pressure ; some advise 
 excision by dissection and afterward sewing up the skin. If the ulcer left 
 does not granulate rapidly, it may be stimulated by balsam of Peru or the 
 local application of sulphate of copper. The bowels should be confined for a 
 day or tAvo and the patient kept in bed. The wound should be dusted with 
 iodoform. In cutting away cutaneous piles care should be taken not to cut 
 into the anus, for stricture may follow too free excision. 
 
 Internal or Bleeding Piles are situated Avithin the sphincter, and are 
 much moi'e serious and troublesome than the external. They are conveniently 
 divided into venous, columnar, and ncevoid (Ball). ^\iQ internal ve7i02is pile 
 resembles the external one, except that it is covered with mucous membrane 
 instead of skin, and tends to bleed easily, especially during defecation. This 
 form is often seen in people with cirrhotic livers, in spirit-drinkers, and in 
 women who have borne many children. 
 
 The Columnar Pile is commoner than the venous, and " consists essentially 
 of hypertrophy of folds of mucous membrane surrounding the anal opening, 
 the so-called pillars of Glisson. They have a red, almost vermilion color, 
 elongated form, and contain within them one of the descending parallel branches 
 of the superior hemorrhoidal artery" (Hamilton). In these piles the arteries 
 can be frequently felt pulsating. 
 
 The Ncevoid Piles, or capillary hemorrhoids, are small, bright-red tumors 
 having a spongy, granular look, situated high up in the rectum. They are 
 rarely larger than a ten-cent piece, and bleed very easily ; in fact, the loss of 
 blood is continuous and is a serious drain on the system. They are composed 
 of hypertrophied connective tissue, plentifully supplied with both arteries and 
 veins, Avhich become thrombosed when the pile is inflamed. In fact, the blood- 
 vessels are so numerous that they look like ncevoid groAvths. 
 
 Symptoms. — Of course the symptom Avhich most attracts the attention 
 of the patient is the frequent and sometimes constant bleeding, Avhicli is much 
 increased by defecation. Hence the name bleeding piles. At first the patient 
 loses blood at stool only ; then for some time before and after. Later the 
 bleeding may occur at any time, exhausting the patient, and sometimes pro- 
 ducing extreme anemia. During defecation there is usually considerable pain, 
 or rather discomfort, and the piles have a tendency to protrude, dragging with 
 them the boAvel and causing prolapse. -Occasionally the pile tumors remain 
 protruded so long that they become strangulated, being caught by the sphinc- 
 ter, or they may inflame and become so congested that their great size prevents 
 their return. The pain in these cases is excessively great. If left to them- 
 selves, they sometimes become gangrenous and slough off. thus producing a nat- 
 
796 AN AMi:i!l(\{N TKXT-JiOOK OF SURGERY. 
 
 unil cure of the disease, though often not a complete one. In such cases, if the 
 consent of the patient can be obtained, it is better at once to proceed to the 
 radical cure by operation. The irritation of inflamed internal piles not unfre- 
 (juently produces urinary disturbance and even retention. In women these 
 piles are often the accompaniment of womb disease. If there be excessive 
 pain during and after defecation, an examination will probably reveal a fissure 
 of the anus. Small i)olypi also are sometimes seen in cases of hemorrhoids. 
 
 Treatment of Internal Piles. — Palliative treatment in the milder forms 
 of piles is sometimes successful, but in the severer forms, especially where there 
 is much bleeding, nothing but a radical operation will afford permanent relief. 
 The patient slujuld above all things avoid constipation. His bowels should be 
 kept regular by laxatives, such as the compound licjuorice powder, confection 
 of senna and sulphur, a pill of aloes (gr. 1|), belladonna (gr. \)^ nux vomica 
 (gr. 1^), aided by an enema or some mineral water in the morning. Next, the 
 patient should wash and grease the protruded piles after defecation, and then 
 carefully return them by gentle pressure. Regular exercise sliould be taken, 
 and over-eating should be avoided ; alcoholic liquors should be given up. The 
 piles may occasionally be anointed with some astringent ointment, such as the 
 unguentum gallae comp. 
 
 Operative Treatment. — The two chief methods of radically curing piles are 
 by the ligature and by the clamp and cautery. 
 
 Before any operation for the radical cure of piles the patient should be pre- 
 pared by the administration of a brisk purgative the evening previous to the ope- 
 ration, and immediately before the operation the rectum should be well washed 
 out with two or three large soap-and-water enemata. After an anesthetic has 
 been administered the sphincter should be stretched by the introduction of both 
 thumbs, and the tension should be kept up until the muscle is felt to give way. 
 By this means the rectum can be easily explored and the whole diseased area 
 brought into view ; in addition, there is much less pain after operation. This 
 procedure also enables the surgeon immediately to recognize the occurrence of 
 hemorrhage after operation, for all the blood flows externally instead of being 
 confined by the spasmodically contracted sphincter, as it would be if the 
 muscle were not stretched. The patient should be placed during operation in 
 the lithotomy position, the knees being kept apart by Clover's crutch or other 
 means ; or on the side with the thigh drawn up. 
 
 Ligature. — Each pile should be seized with a small volsellum forceps, 
 drawn down, and separated from the submucous and muscular tissue from 
 below with scissors. As the vessels enter the pile from above, there is no 
 danger in separating the lower end of the pile. The pedicle should now be 
 tied tightly with a strong silk ligature : that there may be no danger of the knot 
 slipping, three half hitches should be employed instead of the usual two. The 
 ligature should be cut off short, and also the pile beyond the ligature, enough 
 being left to prevent the knot from slipping. It is better to tie the piles from 
 below up. In the columnar pile it may be necessary to transfix the base with 
 a curved needle on a needle-holder armed with a double thread, and then the 
 muco-cutaneous border around the base of the pile should be incised, the pile 
 tied in two halves, and the superfluous portion cut off. 
 
 Clamp and Cautery. — The patient having been prepared as descri])ed 
 above, each pile is seized in a volsellum, brought down, and clamped tightly 
 with one of the numerous clamps, such as Smith's, Lee's, Yolkmann's, etc. 
 Smith's clamp without the ivory plates is as good as any. The pile should 
 now be cut off about an eighth of an inch in front of the clamp, and the cut 
 surface slowly cauterized several times with a Paquelin cautery heated to a 
 
DISEASES AM) IXJURIES OE THE ABDOMEN. 797 
 
 dull-red heat. The clamp should then bo relaxed slightly, and if there is any 
 bleedincr the pile should again be cauterized. The old-fashioned cautery, 
 althou.rh more troublesome, is quite as good as, if not better than, Paquelin s. 
 Some dispense Avith the cutting of the pile by scissors, preferring to trim it off 
 with the cautery. After both the above-described operations the parts should 
 be washed thoroughly with an antiseptic solution, then dusted with iodoform 
 and a morphia siTppository introduced. Absorbent cotton should be placed 
 over the perineum and kept in place with a T bandage. 
 
 After-treatment— Miex pile operations it is necessary to confine the bowels 
 for a few days, and this may most easily be done by giving a gram of opium 
 two or three*^ times a day. Bv this means also the pam is controlled. Un the 
 third mornin^^ the patient should have a dose of castor oil, and after that a 
 daily movement of the bowels. There is often difficulty in urination after 
 operations for piles. This may be overcome by applying hot fomentations 
 over the lower part of the abdomen and by encouraging the patient to make 
 a i^reat effort to urinate. If retention does occur, a catheter may have to be 
 used for a few days. Operation for piles by ligature or cautery is very sate, 
 the mortality being very slight indeed. i • i r- .-u 
 
 Other operations than those above mentioned have been devised tor the 
 cure of piles. Excision of the piles has been extensively practised by Mr. 
 Whitehead of Leeds, England. 
 
 Wldtehead's Operation.— l^he whole circumference of the mucous mem- 
 brane of the bowel is divided at the muco-cutaneous junction ; the mucous 
 membrane bearincr the hemorrhoidal tumors is dissected from the muscular coat 
 and brought do^^ below the margins of the anus. The mucous membrane 
 above the^iles is then divided transversely and attached by sutures to the tree 
 maro-in of the skin below. In this way the whole hemorrhoidal area is got rid 
 of ^The objections to the operation are that it is tedious, bloody, and apt^to 
 cause stricture if one does not get union by first intention ; m fact, it has few 
 advantages over the ligature or the clamp and cautery. • . /i im 
 
 Treatment by ignipuncture, crushing, the injection of carbolic acid (1 : lU), 
 all have their advocates, but none of these methods has given as satisfactory 
 results as the two first described, viz. ligature and the clamp and cautery. 
 
 Prolapsus— This is a descent or a protrusion of the mucous membrane 
 of the bowel only (prolapsus ani). or of the whole thickness of the bowel, 
 throucrh the Sinus\proIapsus recti) (Fig. 328). When the whole bowel pro- 
 trude? the tumor may reach the length of five or six inches. It is a rare 
 affection in adults, but is comparatively common m children, and it is usually 
 seen in those of slight resisting power and of relaxed fiber. Anything 
 which causes straining at stool will produce it, such as constipation, phimo- 
 sis, stone in the bladder, polypi, irritation from worms, etc. in elderly 
 people it frequently accompanies hemorrhoids, enlarged prostate, etc 
 
 Treatment—In children the cause should be removed if possible, and 
 the general condition improved by iron, tonics, and cod-liver oil, which will 
 help to keep the bowels regular. The stools should be passed with the 
 child Ivincr on its side, and when the bowels protrude they should be^ gently 
 pushed bJck and kept in place with a bandage. Broad strips of adhe- 
 sive plaster, applied so as to keep the buttocks together, are usef^il m young 
 children. In sime cases touching the protruded bowel m several longitudinal 
 strips with a solid stick of nitrate of silver or with nitric acid is beneficial 
 In adults palliative treatment is not so successful, and operation is frequently 
 demanded Many operations have been devised for the relief of prolapse of 
 the rectum. Some still believe the cautery is the best method of treatment. 
 
71>8 
 
 j.v AMi:i!i(A.\ ri:xr-i'>()()K of sri.'ai.m' 
 
 Crijips says four linos of (.-iiutery a (juarterof an inch wide sliouM bi" (|iiic'kly 
 drawn in the h)ng axis of the bowel at eijual distances; then the bowel is 
 
 Fu;. 328. 
 
 Prolapsus Ilt'cti (oriifiiial). 
 
 returned and a tube introduced some five or six inches. This is packed around 
 with cotton wool and iodoform. The bowels should be confined by opium for 
 ten days, and for at least six weeks the patient should pass his motions lying 
 on his side. In using the cautery the old-fashioned cautery-iron is better than 
 Paquelin's, as it does not cool so quickly. In the most inveterate cases a 
 V-shaped piece has, with good result, been excised from the sphincter and the 
 edges of the wound brought tog-ether. Roberts advocates the excision of 
 V-shaped portions of the sphincter and the entire posterior wall of the rectum, 
 having a common base at the back of the anal opening. Treves excises the 
 protruded mucous membrane and attaches the cut mucous mem])rane to the 
 skin. The sphincter is not divided. The removal of several of the vertical 
 folds ])y clamp and cautery is an operation which is often successful When 
 the patient refuses operation he should be directed to inject 5vij-viij of warm 
 water into the bowel before going to the closet, and after the motion has passed 
 an ounce of cold water should be introduced and allowed to remain. 
 
 To reduce a prolapsus the patient should be placed on his side; the tumor 
 should be well oiled, and then pressed back gently Avith a soft towel, or, if this 
 fail, the finger may be covered with lint and introduced into the bowel, gently 
 pressing up the tumor ; the finger can then be withdrawn and the lint left 
 behind. Occasionally the tumor, if allowed to remain out for any time, becomes 
 strangulated and gangrenous, and finally sloughs off, the affection thus under- 
 going a spontaneous cure. 
 
 Sphincterismus, or spasm of the sphincter, is nearly always avssociated with 
 ulcer or fissure of the rectum or an inflammation of some neighboring organ, as 
 the prostate, bladder, etc. In some very rare cases there is no discoverable 
 lesion. It is attended by considerable pain, and is liable to occur in women 
 who are hysterical. If due to fissure or ulcer this must be first treated. 
 Sometimes in hysterical cases a suppository of belladonna (gr. j of extract) 
 
DISILiSI'JS AX J) IXJllilES OF THE ABDOMEN. 71)5) 
 
 and the luhiiinistration of eneinatii Avill leuiovo tho spasm, bvit should these 
 means fail, forcible dilatation of the sphincter with the surgeon's fingers, under 
 ether, will surely cure. 
 
 Pruritus, or painful itching of the anus, is a most troublesome affection, 
 and due to many causes, such as thread-worms (oxyuris vermicularis), pediculi, 
 scabies, eczema, small external piles, etc. In some cases it is a pure neurosis, 
 and there is no local inflammation to be made out, the skin about the anus 
 having a dead-white, parchment-like look. These cases are the most difficult 
 to treat. 
 
 The irritation usually is worse at night after the patient gets warm in bed, 
 and then the itching is intolerable. Nervous patients who give way to 
 scratching often produce an eczema or excoriate the whole anus and its neigh- 
 borhood. Many patients who suffer from this troublesome affection are of a 
 gouty diathesis. 
 
 Treatment. — If due to thread-worms or eczema, these should be treated. 
 The eczema may be moist or dry. If moist, soothing applications, such as 
 liquor plumbi (1 : 40), linimentum calcis, etc., should be employed, but if dry, 
 then some preparation of tar, such as liquor carbonis detergens, oil of cade, 
 etc. It is a very important thing to keep the buttocks apart, and this may be 
 done by a pledget of marine lint (fine oakum), the tar with which it is impreg- 
 nated acting remarkably well as a local application. To get rid of the thread- 
 worms, cold water may be injected into the rectum, or salt and water, or infusion 
 of quassia, but it must be remembered that these parasites live chiefly in the 
 caecum, and that removing them from the rectum is a temporary measure, as 
 they will soon reappear. Purgatives often prove useful. 
 
 The neurotic cases are usually elderly persons and the most difficult to treat. 
 First, the patient should avoid scratching and should keep the bowels regular ; 
 should abstain from alcoholic liquors and smoking, especially cigar-smoking; 
 should live plainly and on a non-gouty diet. Marine lint locally applied is 
 useful, and in some cases a mercurial ointment, as the dilute citrine, oleate of 
 mercury, etc. Bathing in very hot or cold water or in solutions of cocaine 
 sometimes relieves. Painting the part with iodine or nitrate of silver may be 
 tried. In some cases, however, nothing seems to benefit. The actual cautery 
 has been used and the sphincter has been stretched with good result, but it is 
 very common to find that what will relieve one patient will have no influence 
 on another. 
 
 Foreign Bodies. — These are not infrequently introduced into the rectum 
 to arrest a diarrhea or from perverted sexual impulse or by the insane. A 
 great variety of these foreign bodies have been removed from the rectum — 
 jam-pots, stones, pieces of wood, soap, nails, bottles, etc. Sometimes foreign 
 bodies, such as fish-bones, chicken-bones, etc., that have successfully passed 
 through the rest of the alimentary canal become arrested in the rectum. 
 These may form the nucleus of concretions. It may severely tax the inge- 
 nuity of the surgeon to extract such foreign bodies. If the body be small, 
 it may be removed with forceps or thumb and finger; if larger, the patient 
 should be placed under ether, and, after thoroughly dilating the sphincter, 
 the body should be extracted. 
 
 Wounds. — These are sometimes produced by the rough use of an enema 
 syringe or the careless introduction of a bougie, and cases are recorded where 
 perforation of the bowel and entrance into the peritoneal cavity have occurred 
 and death from peritonitis has followed. Wounds caused by falling on sharp in- 
 struments may perforate the rectum and bladder. Punctured wounds are much 
 more likelv to lead to septic complications than free incised wounds where thei-e 
 
«UU A^y AMKIIIVAN TKXT-JKJOK OF SllidKltY. 
 
 is "00(1 tlraiua«a'. Tlie rectuin may be iiijiiicil (Imiiii: parturition and the recto- 
 vaginal septum completely torn through. Gunsiiot wounds of the rectum and 
 bladder may occur and yet the patient recover, but if the peritoneum be per- 
 forated the chance of recovery is not so great. In gunshot wounds pieces of 
 bone may be lodged in the rectum. Wounds of the rectum nuiy occur during 
 an operation for stone, and if discovered should be sutured innnediately. 
 
 In the treatment of wounds of the rectum free draituuje should be 
 obtained, even if the wound has to be made larger. This, with frequent 
 irrii^ation with antiseptic solutions and antiseptic dressings retained by a 
 T-bandage, ought to be sufficient. (For the treatment of puerperal lacerations 
 see the chapter on the Female Genito-urinary Organs.) 
 
 IiM FACTION OF Fkchs. — This most frequently occurs in elderly people of 
 sedentary habits who have been the victims of habitual constipation. In them 
 the rectum above the sphincter is dilated into a pouch in which feces collect 
 and become a hard, solid mass which the bowel is unable to expel. The 
 patient, of course, complains of constipation, distention, pain, etc., and the 
 presence of the mass of feces produces sufficient irritation to cause a spurious 
 or catarrhal diarrhea. In some cases acute obstruction supervenes, with vomit- 
 ing and symptoms of collapse. On attempting to administer an enema it is 
 found that but a small quantity of fluid can be injected, and the introduction 
 of the finger reveals the bowel packed with feces. The fecal mass should be 
 removed with the handle of a large spoon or a lithotomy forceps, aided by 
 copious injections of hot water and soapsuds. Many of these cases when 
 not examined have been treated as cases of diarrhea, with the result of aggra- 
 vating the condition of the patient. 
 
 Fissure, or Anal Ulcer. — This is a most painful and troublesome affec- 
 tion, which must not be confounded with the larger ulcerations occurring in 
 the bowel. It commences first as a mere excoriation or crack of the mucous 
 membrane, produced by the passage of a large, hard motion. This exposes 
 some of the nerve-filaments of the anus, and every motion increases the pain 
 and irritation until an ulcer is formed which will not heal. Fissure is always 
 accompanied by severe spasm of the sphincter. 
 
 The symptoms are severe pain during and after defecation, with the dis- 
 charge of a small amount of blood. The patient dreads a motion of the bowels 
 and postpones the act as long as possible, with the result of very much increas- 
 ing the pain, which is out of all proportion to the amount of disease. Fissure 
 is more common in women than in men, and women frequently refer the pain 
 to the vagina and womb, and have much unnecessary special treatment before 
 the cause of the trouble is discovered. On examination the fissure is found on 
 the posterior border of the anus, marked by a red oedematous fold of mucous 
 membrane which looks like an external pile, and which is very tender on pres- 
 sure. On separating these folds about the anus a fissure is seen leading to a 
 rather broad elliptical ulcer, which is often not so large as the nail of the 
 little finger. 
 
 Treatment. — If the case is a recent one, it may possibly be cured with- 
 out operation. The bowels should be opened daily with a mild laxative, and 
 afterward the parts should be well washed with soap and water, and some mer- 
 curial ointment applied, such as the ung. hydrarg. amnion, chlor. or dilute 
 citrine ointment,* etc. The ointment should be spread on a piece of lint and 
 
 ' Mr. AUingham recommends the following ointment: 
 
 Ilydntrfr. ohlor. mit., gr. iv ; 
 
 Piilv. o|'ii, 
 
 Ext. belladonna;, ad gr. ij ; 
 
 Ung. simpl., Sj* 
 
I)isi:ases and injuries of the abdomen. 801 
 
 carefully inti-odiicod into the amis, 'roucliing the ulcer with a sharp-pointed 
 stick of nitrate of silver or the actual cautery is excellent practice, but is so 
 painful that the previous application of cocaine is necessary. In the event 
 of the milder measures not being successful, the surgeon can promise a speedy 
 cure. Placing the patient under ether, the ulcer is exposed by means of a 
 speculum and is incised in its whole length, the incision reaching well into the 
 sphincter and partially dividing it. Many surgeons strongly recommend dila- 
 tation of the sphincter under ether as a curative measure, a procedure which is 
 now undertaken before performing most operations on the rectum. The after- 
 treatment should be rest in bed, Avith opium to confine the bowels, followed by 
 a dose of castor oil on the third day, and daily evacuation thereafter. 
 
 Rectal Abscess. — There are various kinds of abscess found about the 
 rectum. The commonest are the ischio-rectal and the marginal. We may 
 also have an intramural abscess of the rectum or a perirectal abscess ; these 
 two latter give rise to but few symptoms except fulness and weight, and are 
 usually first discovered by the exit of pus through the anus. 
 
 Ischio-rectal Abscess may be acute or chronic. The acute variety is 
 attended by very severe pain and often considerable constitutional disturbance- 
 It is more common in middle life in people who are run down in health ; it 
 may follow severe illness. It is felt on one side or other of the anus as a 
 prominent, hard, brawny mass, having as it softens a red surface. If not 
 opened it may burst externally or into the rectum. 
 
 Chronic Ischio-rectal Abscess. — This occurs in the broken-down and debili- 
 tated and in people of a phthisical diathesis. It commences insidiously, with- 
 out much if any pain, and the pus gradually collects and presents externally 
 or bursts into the bowel. It sometimes follows kicks and blows, or it may 
 be due to a tubercular or carcinomatous focus in the rectum which ulcerates 
 into the ischio-rectal fossa. 
 
 Treatment of Ischio-rectal Abscess. — Early and free incision in the 
 acute form is the proper treatment. The surgeon should operate as soon as the 
 hardness can be felt, and not Avait for fluctuation, which rarely appears. The 
 patient should be etherized and an incision made deeply into the fossa. The 
 finger or a sharp spoon should be introduced and all the loculi should be broken 
 down. If the pus has burrowed in any direction, it should be followed by free 
 incision. After thoroughly washing out the cavity with sublimate or other 
 solution, it should be stuffed Avith iodoform gauze. Some recommend dusting 
 the cavity with iodoform and introducing a large drain. Early and free incis- 
 ion will prevent in most cases the formation of a fistula. The treatment of the 
 chronic variety is similar to that of the acute, free incision and drainage. 
 
 The 3Iarginal Abscesses usually originate from a suppurating pile or an 
 inflammation of one of the anal mucous follicles, due possibly to some foreign 
 body, as a fish-bone, etc. These abscesses are often attended with great pain 
 and frequently end in fistula. Treatment by early and free incision under 
 ether spray or chloride-of-ethyl spray or cocaine is ahvays satisfactory. 
 
 Fistula. — This is a sinus going up the side of the rectum, and having 
 usually tAvo openings, one in the boAvel and one in the skin, and is the result 
 of ischio-rectal abscess. When a fistula folloAVS an anal abscess, it is not a 
 very serious matter, the extent of the suppurating tract being small and sub- 
 cutaneous, and the internal opening superficial to the sphincter and at the 
 ver2;e of the anus. The more severe forms of fistula are altogether outside 
 the sphincter, the internal opening being half an inch to an inch and a half 
 from the edge of the anus — that is, either between the external and internal 
 sphincter or above the internal — and the external opening may be anywhere 
 
 51 
 
802 AN AMERICAN TEXT-IiOOK OF SURGERY. 
 
 in the neighboihood of the :iii:il ri'^fion ; usually it is in the ischio-rcctal 
 fossa. There may be several external openings, and, in fact, the fistulous 
 tract may burrow in all directions ; occasionally a fistulous opening is seen on 
 each side of the gut. The more severe forms of fistula with sinuses proceed- 
 ing from them in all directions are not infreciuently connected with stricture 
 of the gut. In some cases the fistula is very tortuous and will not readily 
 admit a probe. 
 
 The usual division of rectal fistuhxi is into Complete and Incoinvlete. The 
 incomplete are again subdivided into Blind External and Blind Internal. 
 
 Complete Fistula. — This is the most common form. It has both an 
 external and an internal opening. The external o])ening is usually situated 
 within an inch of the anal verge, and is small ; it is distinguished by a little 
 projecting mass of granulation, and continually discharges a thin, purulent 
 fluid. The internal opening is generally within an inch of the margin of the 
 anus, most frequently immediately above the sphincter, and from this opening 
 a sinus may extend for some distance up the bowel. The escape of fluid feces 
 and flatus through a complete fistula is common, and the patient is subject to 
 repeated inflammatory attacks due to the fistula being blocked up with portions 
 of feces. This may lead to suppuration and the formation of new external o))en- 
 ings. The internal opening may be on the opposite side from the external, and 
 the sinus may almost encircle the bowel (" horseshoe fistula "). A single inter- 
 nal opening may communicate with several external ones. 
 
 Incomplete Flstul.e may be of two kinds, internal and external. When 
 a sinus leads up to the bowel from an external opening in the skin, but there 
 is no opening into the bowel, it is called a blind external fistula. When there 
 is only an internal opening, but no opening in the skin, it is called a blind 
 internal fistula. This is much more difiicult to diagnosticate than the blind 
 external. A blind internal fistula may be suspected when the patient gives 
 all the usual symptoms of fissure and yet no fissure can be found (Kelsey). 
 From time to time there will be swelling about the anus, which, after a dis- 
 charge of pus from the bowel, will disapj)ear. It is only by placing the ])atient 
 under ether, stretching the sphincter, and carefully examining the lower three 
 inches of the bowel with a speculum that the aff"ection can be satisfactorily 
 detected. If the sinus is of any size, it will betray it.self by induration, and 
 in this region the internal orifice should be searched for. 
 
 The diagnosis of an ordinary complete fistula is easy, for the patient is 
 usually already under the care of the surgeon for ischio-rectal abscess, or con- 
 sults him for some of the secondary attacks of suppuration which are so com- 
 mon in the severe forms of fistula. 
 
 Symptoms. — Where a fistula is Avell established, it may give rise to but 
 little trouble, but usually there are some tenesmus, a little blood in the stools, 
 the passage of flatus and pus through the external opening, and the incon- 
 venience and discomfort of stained linen. With fistula is often associated a 
 condition of hypochondriasis. To examine a patient with fistula he should be 
 placed on the side on which the disease is supposed to be, the buttocks brought 
 well over the edge of the examining table or couch ; a probe should now be 
 gently introduced into the external opening, and without force pressed onward 
 till it reaches the internal opening ; now the finger should be introduced and 
 the probe felt in the bowel. Should one attempt to ))ass a probe with the finger 
 in the bowel, the contraction of the sphincter would much distort the sinus 
 and make the passage of the probe difiicult. Should the sinus be tortuous or 
 the probe not pass easily, the finger may be introduced to feel for the internal 
 opening and the indurated track leading to it. 
 
DISEASES AXI> INJURIES OF THE ABDOMEN. «03 
 
 TrPatment-'Hie evening before operation the patient's bowels should 
 
 found, 01 t\^^\^^^^y^^3^^f;|,';fi,tula, instead of being cut through at once with 
 
 no unnecessary sacrifice ot iieaitny tissue. 
 
 ^""t:i,Lt:h: ™:i;°fi£.f crUas .e^ Cssected out and excsed^ the 
 
 only a Lgle straight cut should be made through the sphmc e.^ ^ - a'-aJ^ 
 
 """ho treatment by elastic ligature as a rule should be advised on^y in these 
 cases or .here the patient .ill -t subm>. to //-'^-^f ^ -^^.^X L tissue 
 cutting operat,on .s much -P-j™- ,. -, '°f;|, rsho,ufbe of solid India rub- 
 wtra'bouTr tenth '^'^1^ in^diameter. and after having passed. 
 
 ^S- r d^bSs:t:^:^^^^^^^-= — 
 
 '"'phthis::?"ar;fi;tula inanoare not ™f-<."»»'V-^reCr';:^Ti: 
 
 operafon m these ?f^' ' "^ '^Xre The operation should be followed by a 
 rrouinrpfnt o'SV ^Xlus track. Unless the lung trouble is very 
 
804 .l.V AJfKRICAN TEXr-BOOK OF SUlid i:i! Y. 
 
 result of abscess. Wouinl of the gut during the ojieration of hiteral lithotomy 
 has produced this form of fistula. The affection can be easily recognized by 
 the fact that urine is continually dribbling through the anus, causing excori- 
 ation and giving rise to an off'ensive urinous odor. When the o)»ening between 
 the rectum and bladder is of some size, as occurs in cancerous fistula?, feres 
 and flatus may be discharged through the urethra ; in such cases the opening 
 of coinmunication is usually high up. 
 
 Treatment. — In cancerous fistulae curative treatment is impossible : all 
 that can be done is to keep the parts clean, and if the amount of feces 
 escaping into the bladder be large, relief may be obtained by the performance 
 of colotomy. In fistula from other causes, if small, the application of the 
 thermo-cautery may prove successful, but in fistube of larger size the edges 
 should be freely pared and brought together with silkworm gut or horse- 
 hair sutures, the urine being drained away by a soft-rubber catheter intro- 
 duced into the bladder. In recto-urethral fistulce an old method of treatment 
 Avhich is often successful is to introduce a grooved staff" into the bladder and 
 cut on this through the sphincter ani, commencing the incision at the fistula. 
 In this way the rectal is converted into a perineal fistula. During the heal- 
 ing process the bladder should be drained by a soft-rubber catheter. 
 
 Recto-vaginal Fistula and its treatment are described elsewhere. 
 
 Syphilitic Ulceration. — This usually occurs near the anus during the 
 first year after the contraction of the initial lesion. The severer forms of 
 ulceration are met with in the later stages of the disease, and are due to the 
 breaking down of gummata. This form is most intractable. There is also a 
 form of ulceration about the anus in inherited syphilis which appears three 
 or four months after birth. 
 
 Tubercular Ulceration may occur as a primary lesion or be secondary 
 to disease in other parts. It is often very extensive, oval in shape, with ragged, 
 undermined edges. The long axis of the ulcer is parallel to that of the bowel. 
 It not infrequently leads to the formation of a fistula. Ulceration is occasion- 
 ally seen in connection with hemorrhoidal tumors. Multiple follicular ulceration 
 is sometimes seen, and in old people with chronic venous congestion about the 
 lower end of the bowel a varicose nicer may form. Cancerous ulceration of 
 the bowel has already been fully described. Ulceration following true epi- 
 demic dysentery is seen in countries Avhere this disease occurs. 
 
 Symptoms. — Ulceration of the rectum has been frequently mistaken for 
 dysentery, and not without reason, for pain, diarrhea, and discharge of bloody 
 mucus are the constant accompaniments of ulceration of the rectum. There is 
 a constant desire to go to stool, and when the desire is satisfied only a little 
 bloody mucus is the result. Ulceration about the anus is much more painful 
 than ulceration higher up. There may be extensive ulceration high up without 
 the patient's suffering any great degree of pain. The diagnosis is to be made 
 by digital examination and by the use of some form of speculum. Kelly's 
 method of examination is. in many cases, of invaluable assistance. 
 
 Treatment of Ulceration of the Rectum. — This is not very .satis- 
 factory. The earlier forms of f<_i/i>Jiih'fi(' nicer about the anus usually yield to 
 anti-syphilitic treatment and the application of some form of mercurial oint- 
 ment. The severer forms, which are more common in women, are difljcult to 
 treat. They lead to a form of inveterate stricture, and the only relief to l;e 
 obtained is either by excision or colostomy. 
 
 Patients the subjects of tubercnlar ulceration should be treated constitution- 
 ally with cod-liver oil and nourishing diet. The parts about the ulcer should 
 be kept clean by washing out the bowel morning and evening with warm water. 
 
DISEASES A.XJ) INJURIES OF THE ABDOMEN. 805 
 
 Occasional injections of starch f.lj) and tincture of opium (iTlxx) give much 
 relief. When the ulceration is situated low down and there is much spasm of 
 the sphincter, the ulcer should be incised. 
 
 TUMORS OF THE RECTUM. 
 
 Polypus. — This affection is not very rare in children. It frequently gives 
 rise to hemorrhage, for in children the polypi are more vascular than in adults. 
 Polypi are more often seen in patients under ten years of age. and may cause 
 intussusception, prolapsus, and hemorrhage. Frequent hemorrhages from the 
 bowel in children are nearly always due to a vascular polypus. These polypi 
 are from the size of a pea to that of a cherry, and are often attached by long 
 stalks to the bowel. If high up, the polypus is difficult to find, but when low 
 down the small red growth may protrude from the anus. If it cannot be seen, 
 an enema will bring down the bowel and the polypus with it. It may be felt 
 by the finger in the bowel. Removal is the only treatment. 
 
 Villous Growths. — These are comparatively rare, and, though innocent 
 at first, may develop malignant characters later on. The tumor is sessile or 
 has a short, broad pedicle growing into the bowel ; it is lobulated, and the sur- 
 face has a soft, velvety feel. When situated low down it may give rise to 
 straining and prolapse, and also to hemorrhage. There is no induration about 
 the base, as in cancer, and it is freely movable. On microscopical examination 
 it has all the characteristics of an adenoid polypus. Complete removal is the 
 only treatment. Recurrence is not uncommon. 
 
 Condylomata are met with about the anus, and are usually due to syphilis. 
 (See Syphilis.) 
 
 Warty growths are sometimes seen, and call for excision. They may be 
 of large size. 
 
 Sarcoma of the rectum is very seldom seen. 
 
 Caxcer. — The form met with in the rectum is nearly always cylindrical 
 epithelioma, and it commences in the epithelium of the follicles of Lieberkiihn. 
 Colloid cancer, as well as scirrhus, may affect the rectum, but both are very 
 rare. Colloid cancer is often a later stage of epithelioma. 
 
 There are two forms of the epithelial cancer. The first commences in the 
 mucous membrane, ulcerating and soon destroying it, and afterward invading 
 the submucous tissue. It extends more commonly laterally, often completely 
 surrounding the bowel by a ring of cancerous ulceration and having an indu- 
 rated base. This ulcer bleeds easily and increases by extending upward. In 
 the later stages a fungating mass may project into the bowel. 
 
 The second variety is first seen as a nodule beneath the mucous membrane, 
 projecting into the bowel, and may attain considerable size without ulcerating 
 through the mucous membrane. It increases equally in all directions, and 
 exists in its earlier stages more as a cancerous tumor than as a cancerous 
 ulceration of the bowel. Later, when the mucous membrane ulcerates, it 
 grows rapidly, presenting a huge fungating mass in the cavity of the bowel. 
 
 There are also various degrees of hardness in these cancers. In some, the 
 fibrous stroma being more abundant, the cancer grows and ulcerates slowly, 
 and bleeds less readily when touched. The softer varieties grow more rapidly, 
 quickly infiltrate surrounding structures, and soon involve the lymphatic glands. 
 Thev break down readily under the finger and bleed freely. In these forms the 
 glandular elements are more abundant, alveoli being numerous. The softer 
 varieties are not so favorable for operation as the slowly-growing, firmer cancers. 
 When cancer affects the anus it is always of the squamous form of epithelioma. 
 
 Symptoms. — Rectal cancer is a disease of middle life, usually occurring 
 
806 ^.V AMERICAN TEXT-HOOK OF SL'JidEltY. 
 
 in persons over forty. It often comes on very insidiously, and is not discovered 
 until the surgeon makes an examination. The symptoms may be first consti- 
 pation, pain, and bearing down, •with, at times, discharge of mucus and blood. 
 Blood alwavs appears sooner or later, and diarrhea occurs from time to time. 
 The pain occasioned by the feces passing over the ulcerated surface is very 
 severe, and the patient dreads a movement of the bowels. On examining the 
 rectum with the finger, at from three to five inches from the anus a hardened, 
 ulcerated mass will be met with, which has so contracted the bowel that the 
 finger can be passed through it with difficulty or not at all. The edges of the 
 stricture feel ragged and irregular. When the cancer is high up it ma}' be 
 difficult to reach unless the patient bears down strongly or is examined in the 
 standing position. In the late stages of the disease the patient suffers from 
 marked cachexia, the cancer having by this time invaded the neighboring 
 organs. Death occurs from extension of the disease, exhaustion, rupture into 
 the peritoneal cavity, etc. The stricture caused by the malignant disease fre- 
 quently leads to fistulje. which may open into the vagina, into the bladder, or 
 on the external surface, forming a sort of artificial anus. 
 
 The diagnosis of cancer rests between that of other tumors outside the 
 bowel and that of non-malignant stricture. In non-malignant stricture the dis- 
 ease is apt to extend to the anus, whereas in cancerous stricture there is usually 
 healthy mucous membrane between the disease and the anus. Xon-malignant 
 stricture has a smoother feel and is devoid of nodules, but often the diagnosis 
 is very difficult, and can be determined only by microscopic examination. 
 The diagnosis between malignant and non-malignant stricture is described in 
 the section on Stricture of the Rectum (pp. 800. 810). Tubercular ulceration 
 of the rectum, enlarged prostate and tumors of the prostate, and villous 
 tumors have been mistaken for cancer. 
 
 Tubercular Ulceration of the Rectum much resembles epithelioma, 
 and a microscopic examination is often necessary to clear up the case. But 
 the history of the individual and the fact that tuberculosis may exist else- 
 where are often conclusive. 
 
 In Enlarged Prostate and Tumors of the Prostate one always finds 
 the tumor on the anterior wall of the bowel and covered with healthy rectal 
 mucous membrane. The tumor itself is firm and smooth if the case be one 
 of simple hypertrophy of the prostate. 
 
 Villous Tumor. — This is a rare form of growth, which is soft and is 
 not accompanied by the deep infiltration of cancer. Villous tumor is always 
 covered by a viscid mucus, and, although it bleeds, does not do so readily. 
 The discharge may be blood-stained in villous tumor — in cancer the dis- 
 charge is always bloody. Villous tumor may exist for years without affect- 
 ing the general health; frequently, however, it ends by becoming malignant. 
 
 Abscess or Acute Inflammation has been mistaken for cancer, but the 
 history of the case and time will easily clear up the diagnosis. 
 
 Treatment. — Proctectomy, or Excision. — In all cases where there is 
 a possibility of entire removal of the growth its excision should be under- 
 taken. Should the growth be freely movable and should there be no great 
 involvement of the glands, while at the same time the general condition 
 of the patient remains good, the case is one in which extirpation by the peri- 
 neal or sacral method should be attempted. It was formerly advised that no 
 excision should be attempted unless, under anesthesia, the finger could reach 
 above the growth, but recently many successful cases of excision have been 
 reported where the growth was high up, as much as twelve inches of the lower 
 bowel being removed. In these cases Kraske's operation or some modifica- 
 
DISEASES AND INJURIES OF THE AEDOMEN. 
 
 807 
 
 tion of it is usually adcptcd. When tl.c sij^.noia il.xuvc .s mvolvoa, the gro^Uh 
 may be reached from aboye. The most fayorable cases tor operation are those 
 r vhich the disease occurs in the posterior Avail. When the anter.or v^xll .8 
 iuyolye.1 the bhulder an.l prostate in the male and the yagma m the female 
 are sure to be implicated early, rendering operation difficult and often inef- 
 fectual If the patient's geneVal condition is feeble and cachexia is present, 
 exci ion is contriindicated! The imn.ediate results are fayorable only from 
 10 to 15 per cent, succumbing from the operation. Of course in selected cases 
 the mortality should not be so high as this. . ^v, • , . 
 
 Z-mfA'l-The patient is prepared for the operation by haying the intes- 
 tines thorou-^hly emptied, and immediately before operation the rectum should 
 bedashed out with warm water and boric acid by means of a tube carried 
 wel7up1he bowel. He shouhl then be placed in the lithotomy position, with 
 The buttocks ra seel. The bladder should be emptied before operation, and 
 f the rectu B has to be dissected out, a sound should be placed in the bladder 
 for a Juide. If the cancerous nodule be small, movable, and on tbe poste- 
 rior wSl it may be excised by an elliptical transverse incision, and the cut 
 ed^esof the mucous membrane should then be brought together with sutures or 
 ?fe wound packed with iodoform gauze. When the disease is more extensive 
 an incisfon should be made from the anus to the coccyx in the median Ime ; then 
 the o^^n^art of the rectum should be separated from the tissues m front of he 
 sphin ter by two crescentic cuts, which go into the ischio-rectal foss^, and dis- 
 sS up quickly beyond the growth posteriorly, and more carefully m front, 
 wh "e he\ttachment is closer^nd the structures more important. B eeding 
 Thould be stopped by forceps, or the cut parts should be ightly packed w th 
 spon.es When the tectum has been separated to a point well above the gro..^h 
 k is cut off and any enlarged lymphatic glands are removed The upper end 
 of the c.ut should then be brought down as closely as possible to the lower end 
 and sutm-ed. The external woSnd should be well irrigated with sublimate solu- 
 tion and a drainage-tube packed around with strips of iodoform gauze intro- 
 duc;crabove the sStured g^t. The wound and bowel should be ^^^^^-^^J^^^ 
 crated twice a day. Some surgeons suture the external wound, but this method 
 I? nt^few a vantages, secre^tions being retained and the pam and discomfor 
 Tthe patient being much greater. Packing the wound -^ ^do -m g^^^^^^^ 
 a simple procedure and gives good results. Immediately after the operation 
 the Wis should be ke'pt confined by opium but later laxatives should be 
 given. After the second week bougies should be passed daily. 
 ^ Kraske^s Operation.-Y or cancer high up m the rectum Kraske of Frei- 
 burf has devised a very radical operation. The patient is placed on his left 
 sMet and In incision is 'made from'the second piece of the sacrum in he mid- 
 dle line to the anus. The soft parts are then dissected off on the lett side to 
 the edg; of the sacrum; then thi coccyx is excised and the attachment of the 
 sacro-sdatic ligaments divided close to the sacrum In this way the rectum is 
 exposed; but still better access is obtained by chiselling away a part of the 
 leffsideof the sacrum, commencing opposite the third lelt sacral foramen and 
 avoidincr the nerves passing through the foramina (line BA in J^ig. 6^\i). i^y 
 this operation the upper part of the rectum can be fully exposed and ex^ 
 led Sout iniurin ^he lower end. Should the peritoneum be injured m 
 frrefn^the recul^ it should be immediately sutured and, as a rule, no ill 
 S? will follow. Some surgeons deliberately open the peritoneum and t^rn- 
 T^on it with iodoform gauze or after operation leave a dram m it. Utliers 
 have removed even larger portions of the sacrum transversely, thus mvadmg 
 the spTnal canal and without any ill results. These various operations are 
 
808 
 
 AX AMERICAN TEXT-HOOK OF SURGERY. 
 
 shown in Fig. 321*. 
 
 Fig. 329. 
 
 Different levels of Resection of the Sacrum : KG, Kocher's 
 line : BA, Kraske's ; BU, Hochenegg's ; BD, Baidenheuer's ; 
 RS, Rose's (Maas). 
 
 It i.s well bct'ore exci.sing the diseased jxjrtion of howel 
 
 to slit the posterior wall of the 
 rectum down to the sphincter, 
 and then to make tlie trans- 
 verse cut behjw an<l above 
 the cancer. The advantage 
 of completely suturing the cut 
 edges of the rectum is doubt- 
 I'ld. The sutures do not hold, 
 and feces are apt to escape be- 
 tween them. Kraske now pro- 
 vides an artificial anus at the 
 line of suture, whilst Schede, 
 after making a complete suture 
 of the bowel, performs inguinal 
 colostomy. The sacral wound 
 should be left open and stuffed 
 with iodoform gauze. The 
 after-treatment is the same as 
 after other forms of excision. 
 Rydygiers Operation. — 
 The soft parts are incised on the left side, beginning at the posterior superior 
 spine of the ilium and extending downward to the tip of the coccyx ; from 
 here the incision proceeds in the median line to the anus. After division of 
 the sacro-sciatic ligaments the soft parts are separated from the anterior sur- 
 face of the sacrum. A transverse incision is now made below the third sacral 
 foramina and the bone divided along this line with a chisel. The flap of soft 
 parts and bone is then reflected to the right side, the rectum exposed, and the 
 diseased structures excised, the cut ends of the bowel sutured after excision ; 
 the flap of soft tissues and bone is replaced, the flap being retained in place 
 by silk or other sutures through the soft parts. Levy has devised a new 
 operation for exposing the rectum. He makes a transverse incision through 
 the soft parts and bone, half an inch above the cornua of the coccyx, four 
 and a half inches long, and from the ends of this incision vertical ones down 
 through the gluteus maximus on each side. lie then frees the connective tis- 
 sue on the anterior wall of the sacrum, and the bone and skin flap is turned 
 down and the rectum exposed ; after resecting and suturing the })()wel the flap 
 is replaced and the bone and skin sutured in position. In many cases excision 
 of the cancerous portion is much facilitated by a simple removal of the coc- 
 cyx in connection with the posterior incision. In cases unsuitable for excision, 
 and where the stricture has considerably reduced the lumen of the bowel and 
 obstruction occurs, inguinal colostomy should be performed. This frequently 
 gives great relief to the i)atient and prolongs his life. Ullmann in these 
 cases recommends the formation of an anastomosis of the bowel above the 
 disease and the lower end of the rectum by means of Kraske's incision. In 
 women the vaginal route has been adopted in a few cases with advantage. 
 
 When there is but little obstruction, or where operation is refused, the 
 patient's life may be made more bearable by a strict attention to diet. A 
 purely milk diet, with some form of meat juice, is often very satisfactory. 
 Cod-liver oil and milk laxatives give much relief, as does a daily enema of 
 warm water. It should be injected high up and beyond the disease by means 
 of a rubber catheter attached to the syringe, and afterward a small starch 
 injection with 20 to 30 drops of laudanum should be administered. The parts 
 
DISEASES AXI> J y JURIES OF THE ABDOMEN. 809 
 
 should be kept very clean, and, if the patient has much pain and is restless at 
 night, opium should be given. 
 
 STRICTURE OF THE RECTUM. 
 
 Stricture of the rectum may be either simple or malignant. The latter 
 has already been considered under Tumors. The simple stricture is fibrous, 
 and is fre(|uently the result of one of the forms of ulceration described above, 
 or is due to some form of chronic inflammation (as dysenteric), which leads to 
 the deposition and subsequent contraction of fibrous tissue normally arranged 
 circularly in the bowel. Pelvic cellulitis may lead to stricture of the bowel, 
 as ma}' also the various operations performed for prolapsus, piles, fistula, etc, 
 A stricture is occasionally found in young women which appears to be due to 
 partial persistence of the septum between the anus and the rectum : it grad- 
 ually grows narrower from irritation and recurring ulceration until it attracts 
 attention and requires relief. The fibrous stricture is divided into the annular 
 and tubular. Stricture involving less than an inch of the bowel is called annu- 
 lar. The strictures involvino; a larfrer extent of bowel are named tubular. 
 Fibrous stricture of the rectum is found from four to six inches from the anus 
 or immediately above that opening. Syphilitic stricture is usually found imme- 
 diately above the anus, and is most frequently seen in young women under 
 thirty. All forms of simple stricture ai'e more common in Avomen than in men. 
 When the stricture has lasted some time the bowel above becomes dilated and 
 often ulcerated. 
 
 Symptoms. — If due to ulceration, it will be preceded by symptoms of 
 that affection, but surcreons rarelv see stricture of the rectum in an early sta^e, 
 being first called in when symptoms of obstruction present themselves. The 
 patient has frequent attacks of diarrhea, followed by constipation. He will 
 often have difficulty in defecation, straining at stool and passing scybala or 
 motions reduced in size. Flat, ribbon-shaped motions are usually but not 
 always due to stricture, as they may be produced by an irritable sphincter. 
 After having passed a motion the patient will feel as if the bowel has not been 
 emptied, and when diarrhea exists it will compel him to go to stool very fre- 
 quently, passing each time only a little flatus and mucoid discharge, with a few 
 small scybalous masses. Later on, bloody mucus may be discharged and the 
 diarrhea is almost continuous. The patient spends most of his time trying to 
 relieve his bowels. Abscesses may now form in the neighborhood of the stric- 
 ture and result in fistula. Recto-vaginal fistula is a not uncommon sequence of 
 stricture. The parts about the anus become excoriated and raw, and the pa- 
 tient's condition is pitiable : his general health fails, he becomes hectic, has albu- 
 men in his urine, and death ensues, produced either by complete obstruction or 
 by peritonitis. This is the course of a severe form of stricture. Many cases of 
 annular stricture do not produce such severe symptoms and do not go on to a 
 fatal termination. Should the stricture be within three or four inches of the 
 anus, the diagnosis is easily made by the finger, but in strictures high up the 
 diagnosis is often very difficult ; the patient has diarrhea, alternating with 
 obstinate constipation. The detection of such strictures by the passage of a 
 bougie is uncertain, and may be dangerous because of the risk of perforating 
 the bowel. Bryant of London describes a condition of " balloonincr of the 
 rectum." which exists when the stricture is high up. The finger in passing 
 the sphincter will enter a cavity the walls of which are "ballooned" or 
 expanded. The surgeon will be able to move his finger freely, and the walls 
 of the rectum can be felt only when searched for. The high strictures may, 
 
810 AX AMERICA X TEXT-BOOK OE SlEdEEY. 
 
 of fourso, bo diagiiostieatod b_v tlio passage of the band into the rectum, as 
 recouiniended by Simon : it shoiibl be passed cautiously after dilating the 
 sphincter, and a small hand is necessary for this j>rocedure. The most def- 
 inite information will be obtained bv the use of one of the specula devised 
 by Kelly. 
 
 The diagnosis bet^vt'on malignant and simple stricture is not always easy. 
 The fact that the stricture has existed some time and is in a patient under 
 middle age will often determine the diagnosis. The peculiar sensation of 
 malignant stricture conveyed to the finger is almost unmistakable : masses of 
 new growth can be felt, and there is ulceration at some one point where the 
 growth is more pronounced. The sacral lymphatic glands are involved in the 
 later stages of rectal cancer. 
 
 Treatment. — If the stricture be of moderate extent and Avithin reach, the 
 patient may be made comparatively comfortable by proper diet and the use of 
 laxatives and enemata. Rectal bougies should also be passed daily and be 
 gradually increased in size. The bougie should be retained five minutes to an 
 hour — as long, indeed, as the pain is not severe. It is well at the conmiencement 
 to confine the patient to bed. After the stricture has been fully dilated the 
 patient should pass a bougie himself at least once a week. 
 
 If this treatment fails, the stricture must be divided. An annular stricture, 
 if low down, should be divided posteriorly and bougies passed as before. In 
 the severer cases proctotomy, as described below, with division of the external 
 parts, is by far the best procedure. This, however, cannot be practised when 
 the stricture is high up or of great extent ; here w^e must perform colotomy to 
 save the patient's life. In these cases it is a most satisfactory operation. 
 French surgeons have recently advocated and practised with success the extir- 
 pation of these severe forms of stricture (especially those which are syphilitic) 
 by means of Kraske's operation. The results, according to reported cases by 
 Qu^nn and Richelot, are excellent. 
 
 Proctotomy (Linear). — This is chiefly performed for stricture of the rec- 
 tum, and should be performed only when dilatation has failed. The contents 
 of the bowels having been thoroughly evacuated, the patient is placed in the 
 lithotomy position, the finger introduced through the stricture, and a sharp- 
 pointed knife inserted in front of the tip of the coccyx and pushed through 
 the tissues until the finger is reached; a blunt-pointed bistoury now replaces 
 the first knife, and all tlie tissues between the anus and tip of the coccyx are 
 cut through. Some perform this incision with a Paquelin cautery or dcraseur, 
 but a knife is the best and speediest. The wound should be packed with iodo- 
 form gauze, and the whole supported by a T bandage. The after-treatment is 
 the same as after excision of the rectum. This operation in simple stricture is 
 often curative, and as the wound heals power of retaining feces will gradually 
 return. 
 
 PAET VII.— HERNIA. 
 
 By Hernia is meant the protrusion of any viscus from its natural cavity 
 through normal or artificial openings in the surrounding structures. Thus 
 we have hernia testis, hernia of the lung, etc. But by the term hernia used 
 alone we mean the ]>rotrusion of a portion of the abdominal contents 
 through the parietes, and this is known by the popular term "rupture." 
 The commonest forms of rupture protrude through one of the natural openings 
 or weak spots in the abdominal parietes, as. for instance, the inguinal and 
 femoral canals. Hernia may occur at the umbilicus or even at the obturator 
 foramen. The contents of a hernia are bowel and omentum, separately or 
 
J) IS/: ASKS AX J) lyJCL'IKS OF THE A J: POM EX. 
 
 811 
 
 Fig. 330. 
 
 together. An omental lu-rnia i.^ called an epiplocele, and ii hernia of the 
 inte.>*tine an enterocele; a combination of the two is called an entero- 
 epiplocele. The bowel involved in a hernia i.s usually the lower {jortion of 
 tht' small intestine, but the large intestine is also found, even the whole caecum ; 
 also the bladder ((■//stocch'^), stomach [</astrocele), ovaries, gall-bladder, etc. 
 
 Anatomy. — Covering the bowel or omentum we have the sac ; this con- 
 sists of the protruded portion of peritoneum, which has been pushed gradually 
 through one of the canals (inguinal or femoral), or of the process of perito- 
 neum, which has been carried down by the testicle in its descent, and the con- 
 nection of which with the peritoneum of the abdomen still continues, not hav- 
 ing been obliterated, as it usually is, before birth. The former is called an 
 acquired hernial sac ; the latter is called a congenital hernial sac (Birket), and 
 is found only in inguinal hernia. After the hernia escapes from the canal 
 through which it passes it enlarges greatly, and is covered, of course, still by 
 its sac. This portion of the sac is called the body, the portion which lies in 
 the canal is called the neck, and the opening in the abdominal cavity is called 
 the mouth. The sac, taken as a whole, has somewhat the shape of a Flor- 
 ence flask (Fig. 330). In a hernia of long standing the sac becomes very 
 much thickened and often adherent to 
 the surrounding structures, so that even 
 should the contents of the sac be wholly 
 reduced the sac still remains, and is ever 
 ready to receive its contents agam on the 
 slightest provocation. The sac of a re- 
 cent hernia is thin and transparent, as it 
 is peritoneum, and is easily reduced with 
 its contents, no adhesions as yet binding 
 it to the surrounding structures. The 
 neck of the sac is thrown into pleats and 
 folds, owing to the constriction produced 
 by the narrow hernial opening. The parts 
 covering the hernia outside the sac vary 
 according to the situation of the hernia ; 
 they usually consist of various fascijie, 
 tendons of muscles, and even portions of 
 muscles themselves, and. lastly, super- 
 ficial fascia and skin. 
 
 Etiology. — Hernia is more common in 
 males than in females, and may occur at 
 any period of life. The majority of cases, however, occur before middle age, and 
 the largest number, according to Kingdon, during the first ten years of life, 
 owing to the non-closure of the process of peritoneum which is carried down 
 by the testicle. Frequently the hernia is congenital. Hernia is most fre- 
 quently strangulated between the ages of forty and fifty. 
 
 Hereditary predisposition to hernia exists without doubt in many. Mr. 
 Kingdon estimates that in about 34 per cent, there is an hereditary tendency 
 to hernia, many of these patients being born with it. 
 
 Occupation predisposes, people who have laborious occupation being most 
 liable to the acquired form ; some assert, however, that it is more commonly 
 seen in these individuals only because there are more of them. It is said that 
 persons with abnormally long mesenteries are, on that account, predisposed to 
 hernia. After abdominal section the patient is very liable to have rupture at 
 
 * This term is also applied to the bladder protruding or tending to protrude at the vulva. 
 
 Hernial sac. with contained bowel : X, neck of 
 sac ; S, sac ; B, bowel (original) 
 
812 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 the site of the wound, and stout women who have borne many ehihlren are 
 especially subject to rupture. Certain diseases, as bronchitis, whoojjing-cough, 
 stricture, and constipation, predispose to rupture by causing violent and pro- 
 longed use of the ab(h)minal muscles. These aflections occurring in old people 
 with relaxed tissues not infre((uently start a rupture. 
 
 Seat of IIkiinia. — This will be more fully discussed in treating of the 
 various kinds of hernia. The most common seats of hernia are the inguinal, 
 the femoral, and the umbilical regions, though occasionally protrusion occurs 
 through the diaphragm, obturator foramen, ischiatic notch, vagina, etc. 
 Out of every 100 cases of hernia, 84 are inguinal, 10 femoral, and 5 
 umbilical. According to Berger of Paris, in every 5 cases of inguinal 
 hernia 4 are of the double variety. In 10,000 cases 3.31 per cent, 
 had suffered some time or other from complications, as, for instance, 
 strangulation, etc. 
 
 DrA(JN0Sis. — Hernia is first noticed at one of the rings (inguinal, femoral, 
 umbilical) as a fulness or swelling, which is especially evident on standing. 
 Coughing, lifting heavy weights, etc. make the swelling more tense and elastic. 
 This swelling, which is smooth and uniform, will disai)pear on lying down, and 
 after long rest in bed may not immediately reappear on standing. The sur- 
 geon can usually, in recent hernia especially, easily reduce the swelling by 
 manipulation with the fingers (taxis). The bowel, as it is returned, often gives 
 a gurgling sound and slips in quickly. On placing the finger in the ring 
 through which the bowel has been pushed, and keeping it there when the 
 patient stands up, there is no return of the hernia. As soon as the finger is 
 removed, however, the tumor reappears. On making the patient cough the 
 tumor becomes tense, and there is a decided impulse which does not occur in 
 other tumors. Should the contents of the swelling be bowel, there will be a 
 tympanitic note on percussion, but if the contents be omentum, the tumor will 
 have a doughy feel, a dull note on percussion, and Avill lie reduced with much 
 greater difficulty. Hernial tumors which contain both boMcl and (mientum 
 may be tympanitic at some points, dull at others, and Avhen reduced give out 
 a gurgling noise. Persons with hernia are conscious of a weakness at the seat 
 of rupture, especially during exertion. There may also be uneasiness and 
 griping pain, which are attributed to constipation or other cause. 
 
 Prognosis. — Provided the hernia can be kept reduced by a truss placed 
 over the aperture of exit, the prognosi-s is favorable. The patient, however, 
 always runs the risk of strangulation of the hernia should the truss get dis- 
 placed during severe exertion or if it should fail through some defect to keep 
 the hernia entirely reduced. 
 
 The prognosis is not so favorable in a very large hernia, for it is difficult 
 to get a truss that will keep it in place, owing to the large size of the hernial 
 ring ; nor in irreducible hernise, as they tend to increase in size. In very 
 small hernine the danger of strangulation by the entrance of an additional 
 knuckle of gut into the sac renders the prognosis unfavorable. 
 
 In irreducible omental herniae, where there is an occasional descent of small 
 intestine, the prognosis is still less fixvorable, owing to the danger of the bowel 
 suddenly becoming strangulated at the orifice of tJie sac. 
 
 Palliative Treatment. — Every individual, young or old, who is the sub- 
 ject of a hernia which is reducible should wear* a properly-fitting truss. A 
 truss is an instrument composed of a pad which fits over the site of the her- 
 nia, and a belt which surrounds the pelvis or body and keeps the pad in place ; 
 the belt is often made to act as a spring. A properly-fitting truss should 
 keep in the hernia on all occasions without causing pain or discomfort. In 
 
DISH ASKS Ay I) lyJlRIKS OF THE ABDOMEN. 813 
 
 young infants a skein of Berlin wool may be made to Jo service for a truss by 
 doubling; and passin<:; it around the abdomen, j)lacing the loop directly over 
 the outer abdominal ring, and then passing the free ends of the skein through 
 the loop, thus making a knot opposite the site of the hernia: the ends which 
 are passed through are then carried down the upper part of the thigh between it 
 and the scrotum, brought round the external side of the thigh near the top of 
 the great trochanter, and there tied or fixed with a safety-pin to the band of 
 worsted already round the pelvis. The advantage of this truss is that it can 
 be easily washed and easily applied. 
 
 A truss should be worn all day, and should be j)ut on in the morning before 
 rising and taken off at night after going to bed. It should never be removed 
 except when the patient is lying down. Some individuals in whom the hernia 
 tends to come down even when in the recumbent position require to Avear a 
 truss night and day. The night truss need not be so strong as the day truss. 
 The wearing of a truss in the very young often results in cure by closure of 
 the neck of the sac, but even in these cases it is unwise to leave oflF wearing a 
 light truss, for it not unfrequently happens that on any sudden exertion the 
 bowel Avill descend in the old channel, become strangulated, and thus endansrer 
 the patient's life, especially should he happen to be beyond the reach of skilled 
 surgical assistance. Trusses are very difficult to adjust to the very fat, and 
 some forms of hernia are from their situation, etc. extremely troublesome to 
 fit with a truss — e. g. umbilical hernia. The pressure of the pad should always 
 be in the direction of the hernial canal, and should cover the aperture through 
 which the hernia protrudes. The pad should not be too convex, for this shaped 
 pad has the effect of distending the aperture and so increasing the size of the 
 rupture. The pad should be flat, and the shape should be suited to the form of 
 hernia for which it is used. Pads are made of various substances — vulcanite, 
 wood, india-rubber, etc. ; water-bags and sand-bags have been used, and all 
 have their advocates. The variety of trusses is innumerable. In some the 
 spring is formed by the belt which encircles the pelvis, and in others is situ- 
 ated in the pad itself. Some pads are fixed solidly to the encircling belt, and 
 others are attached by a ball-and-socket joint. The truss best suited to the 
 patient is one which keeps in place in all the various movements of the body, 
 and does not permit of the descent of the hernia whilst coughing, jumping, 
 or straining. One of the best tests is to make the patient stoop forward, 
 with his knees apart and his hands resting on his knees, and then direct him 
 to cough. If the truss stands this test, it is one which is suitable to the 
 patient. For the majority of cases it will be found that the circular spring 
 truss is the best. 
 
 To Measure for a Truss. — The size of the aperture, the kind of hernia, 
 and whether it is single or double, should be noted. The circumference of the 
 pelvis one inch below the crest of the ilium, the girth of the body opposite the 
 hernial aperture, and the distance of the hernial ring from the iliac spine should 
 all be accurately measured. Instructions should also be given the instrument- 
 maker as to the direction in Avhich the pressure should be made, forward, back- 
 Avard, or inward. 
 
 Radical Cure. — The radical cure of hernia has for years exercised the 
 ingenuity and talents of surgeons. Many operations have been devised, and 
 have for a time been popular, and then have been forgotten or have fallen into 
 disuse. The operation devised by Wiitzer is never practised noAv, and Wood's 
 elaborate operation is so difficult and complicated that no other surgeon has been 
 able to get such good results as the originator. These operations since the intro- 
 duction of aseptic surgery have been entirely superseded by that of open incision. 
 
814 .l.V AMERICAN TEXT-BOOK OF SUUdERY. 
 
 There have been other methods which have met with a measure of success — viz. 
 those which aim at the obliteration of the canal by the introduction into it of 
 some irritant and astrin>:ent, such as the fluid extract of oak-bark, alcohol, 
 iodine, etc. ; but here, again, the result is often unsatisfactory, and tlie method 
 is suitable for the cure of only the smaller varieties of hernia. 
 
 It is as well to state that, before recommending a so-called radical operation 
 for the cure of hernia, the surgeon should consider the position of the patient. 
 If he is a man past middle age or has a hernia that is not very large and is 
 easily retained in place by a properly-fitting truss, no operation should be 
 recommemled. Macready says that under twelve months of age 08 per cent, 
 of congenital ruptures are cured by truss ; from one year to five years, 1<> per 
 cent. : and after that no cures occur. Up to fifteen years of age only 5 per 
 cent, of acifuired herni;« are cured by a truss. It is also, in most ca.ses, unwise 
 to attempt a radical cure of hernia by operation in very young infants. But 
 if the hernia is .strangulated or very large or irreducible, or such that a truss 
 will not keej) it in place, or. perhaps, if the patient is desirous of entering 
 some public .service for which a strict physical examination is demanded, or 
 desires to be rid of the .serious annoyance of a truss, it is justifiable to recom- 
 mend an operation for the radical cure of the hernia. In deciding this ques- 
 tion it must also be remembered that a hernia which in youth is easily retained 
 and gives little trouble may become a very serious source of annoyance and 
 danger in later life. 
 
 The principles of the modern operations for the radical cure of hernia are 
 much the same in all — viz. to di.ssect out the sac and excise it and to en- 
 deavor to close the hernial canal by sutures. There are many diff'erent opera- 
 tions for effecting this purpose, and it would be impossible in a work of this 
 kind to describe them all. The operation practised by Czerny, Banks. An- 
 nandale, and others is very simple and one which gives good results. It is 
 mo^t important in order to secure a permanent and satisfactory result after 
 the radical operation that three conditions be fulfilled: (1) Complete extir- 
 pation of the sac; (2) closure of the canal; and (3) imme<liate union of 
 the Avound. This latter is by far the most important. The most com- 
 mon form of hernia is the infiuinaL and it is for this variety that the 
 operation for a radical cure is mo.st frequently performed, and for which 
 it is most suitable, though it is also done in cases of umbilical and femoral 
 herniie. 
 
 Inguinal Hernia. — An incision is made over the tumor and the parts 
 carefully divided until the sac is reached. This, if old, is known by its white 
 appearance. The sac should then be dissected out carefully, and cautiously 
 separated from the spermatic cord. The bowel shoubl be reduced before the 
 sac is opened ; but if it contains omentum which is adherent, the sac should 
 be opene«l and the omentum tied and cut off. The sac should now be pulled 
 down and a ligature of silk or catgut, preferably the former, applied to the 
 neck as high up as possible, and the sac removed. Xext the canal is closed 
 by sewing the pillars of the ring together, or, better still, if the hernia be 
 inguinal, suturinij the conjoined tendon of the internal oblique and transver- 
 sal is to Poupart's ligament by means of three or four sutures of kangaroo 
 tendon. The external wound is closed by several intorrujjted sutures and a 
 drain place<l at the lower end. It should be dressed like any other wound, 
 the object, of course, being to get union by first intention. 
 
 Macewen's Operation. — Macewen of Glasgow preserves the sac and re- 
 turns it within the abdomen, where it is retained in a j»uckered-up condition 
 by ligatures (Fig. 331), and acts as a pad placed against the abdominal aspect 
 
I > IS EASES AND INJURIES OF THE ABDOMEN. 
 
 815 
 
 by suturing the 
 Fig. 332. 
 
 of the intonial ring (Fig. •J'52). He also closes 
 conjoined tendon to I'oujjart's ligament (Fig. 
 333). 
 
 Ball of Dublin, after dissecting out tlie 
 sac, reeonuuends torsion or twisting before 
 suturing and cutting off the sac. 
 
 Barker of Lonilon dissects out only tlic 
 neck of the sac, ligatures it, and cuts it off 
 half an inch below the ligature, but does not 
 dissect out the lower scrotal portion. The 
 neck of the sac is fixed to the abdominal wall 
 by the ligatures that close the internal ring; 
 the canal is closed by several sutures, the 
 wound dressed with dry dressing, and no 
 drainage used (Fig. 334). 
 
 Hahted of Baltimore divides the mus- 
 cles of the abdominal wall nearly as far as 
 the level of the anterior superior spine ; the walls of the sac are sutured 
 by (quilted sutures at as high a level as possible, and then the lower por- 
 tion cut away. The spermatic cord is now lifted and the divided muscles, 
 including the aponeurosis of the external oblique, are stitched with very deep 
 quilted sutures in layers. The veins of the cord, excepting one, are then 
 
 excised and the cord is placed directly 
 Fig. 333. under the skin. The skin wound is 
 
 Fig. 302.— Macewen's Operation; the sac 
 transfixed and drawn into folds. 
 
 Fig. 303.— The sac as a pad covering the 
 abdominal aspect of the internal ring 
 in Macewen's operation (Tillmanns). 
 
 Fig. 334. 
 
 Macewen's Operation : the threads ready 
 for tying (original). 
 
 Barker's Operation for the Radical Cure of Hernia : aa, 
 skin incision ; b, spermatic cord ; c, r, hernial sac ; d, 
 suture for the sac ; e, sutures for drawing the walls 
 of the canal together. All the sutures are represented 
 in situ, ready to be drawn close and knotted (original). 
 
 then closed with buried skin sutures. The dressing consists of a small pad 
 of sterilized gauze, held in place by a bandage which has been soaked in 
 alcohol, and the whole covered with celluloidin. 
 
 BassiHis Operation (Fig. 335). — Bassini of Padua has devised the fol- 
 lowing operation, which is now' largely adopted by surgeons : The aponeurosis 
 
SIG 
 
 ,i.v AMKRK'Ay Ti:x'r-r,o<)K of surgery. 
 
 Fio. 335. 
 
 A-c, Bassini's Operation for the Cure of 
 Inguinal Hernia (Esmarch and Kow- 
 alzig). 
 
 of the external obli(iue and the pillars of the ring are first exposed, and then 
 the canal is slit up, the aponeurosis of the external oblique being dissected 
 
 from the tissues below so as to form two 
 flaps. The cord is now drawn out and sepa- 
 rated from the neck of the sac, the sac dis- 
 sected out, opened, and its contents reduced. 
 The neck of the sac is then ligatured after 
 twisting, and the sac cut oft" below the liga- 
 ture. The cord is held up and kept in the 
 upper angle of the wound, whilst the border 
 of the rectus and edges of the internal ob- 
 liffue, the transversalis. and transversalis 
 fascia are united by a continuous suture to 
 Poupart's ligament underneath the held-up 
 cord, thus forming the posterior wall of a 
 new canal. The divided aponeurosis of the 
 external obli(jue is now sutured over the 
 cord, thus forming the anterior wall of the 
 new spermatic canal. The wound in the 
 skin is closed in the usual way, a drainage- 
 tube being used only in cases of very large 
 hernijfi. 
 
 BuJJ and Coley of New York report 250 
 cases of operations on children under four- 
 teen years by this method, with three deaths and four relapses : since those 
 statistics have been published Coley has operated on 230 consecutive cases 
 in children without a death. 
 
 Kochers Operation. — Instead of slitting up the aponeurosis of the exter- 
 nal oblique, a buttonhole opening is made through the aponeurosis over the 
 internal ring. A pair of artery forceps is then passed through the slit and 
 brought out at the external ring, and the sac, which has previously been 
 isolated, is seized by the forceps, drawn out through the slit, and drawn 
 down so as to lie over the aponeurosis. Here four or five sutures are passed 
 through " the obliijue fibres of the aponeurosis, external obli(iue muscles and 
 underlving muscle fibres of the internal oblique and transversalis, through 
 the sac itself and the ligament of Poupavt beneath it. These sutures bring 
 together the pillars of the external ring to which the lower end of the sac is 
 fastened." 
 
 Many other operations have been devised, but these are the chief. After 
 every operation for the radical cure of hernia it is well to keep the patient in 
 bed, so that the wound should be perfectly and soundly healed before it is sub- 
 ject to any great tension. The wearing for a time of a light truss is advisable, 
 but a truss that compresses the parts strongly should be avoided, as it tends to 
 reproduce the previous condition by promoting the absorption of the cicatricial 
 tissue. With strict antisepic precautions the immediate results of the operation 
 have been good, especially in small hernia in young adults. Still, the operation 
 is not without risk, especially in stout, old people with large hernise and who 
 are perhaps the subjects of chronic bronchitis. As to the curative results of 
 this operation, many operators report wonderfully successful series of cures 
 after six months, a year, and even two to three years, by some special form 
 of operation, but recent investigations by impartial observers of the average 
 number of permanent cures of hernia by direct method of incision give the 
 proportion of permanent cures as about 60 per cent. Cas^s may relapse after 
 
DISEASES AND INJURIES OF THE ABDOMEN. 817 
 
 even five years of ;i|iiiareiit cure. Most of our stati-tic-s are based on insuf- 
 ficient (lata, series of cases having been reported within six months to a year 
 after the operation. 
 
 In femoral hernia the operation may consist simply in dissecting out and 
 removing the sac, no attempt being made to close the ring. Gushing of Bos- 
 ton after returning the gut fastens the sac as a pad in the femoral ring, doubling 
 it on itself, as in INIacewen's operation, and sewing it -by ligatures which at the 
 same time pass through Poupart's ligament and the pubic portion of the fascia 
 lata, thus closing the ring. The saphenous opening is also closed by slipping 
 the pubic fascia under the iliac fascia and suturing them together. Salzer 
 removes the sac and then closes the external orifice by a flap formed by the 
 fascia covering the pectineus muscle. Watson Cheyne closes the crural canal 
 with a flap taken from the pectineus muscle itself. 
 
 Bassints Metliod. — The patient is placed on the back, with the pelvis 
 raised, so as to bring the hernial tumor prominently forward. An incision 
 should now be made directly over the tumor and parallel with Poupart's liga- 
 ment. After cutting through the superficial structures and ligating all 
 bleeding vessels, the sac is exposed, isolated, and opened. Any adhesions 
 of bowel or omentum are broken down and the bowel returned : then the 
 neck of the sac is lighted, the sac cut ofi", and the stump returned into the 
 abdomen. AVith a curved needle threaded with strong, moderately large 
 silk the posterior and under portion of Poupart's ligament is sewed to the 
 pectineal aponeurosis (pubic portion of fascia lata) close to its origin from 
 the pectineal line, with three sutures. The first suture perforates the ligament 
 immediately external to the pubic spine; the second is placed half a centi- 
 meter outside of this, and farther out still is placed a third. These sutures 
 are left untied until the next are in position. Three or four sutures now are 
 passed through the falciform border of the fascia lata and the corresponding 
 part of the pectineal fascia, and over the internal saphenous vein. All the 
 sutures are now tied ; the upper ones draw Poupart's ligament backward to 
 the pectineal line, and thus close the mouth of the crural canal ; the other 
 sutures close the saphenous opening. The skin is next sutured and no 
 drainage is used. 
 
 Bassini had operated (when his paper was written) on 54 cases, and 
 forty-one of them he had kept under observation for from two to nine years, 
 and so far had observed no relapses. 
 
 In umbilical hernia the edges of the hernial opening may be pared and 
 Iwought together, and the sac itself used as a plug to stop the opening. 
 
 Radical Cure in Congenital Hernia. — In congenital inguinal hernia the 
 sac, being continuous with the tunica vaginalis, cannot be dissected out and 
 removed in its entirety. It should first be separated from the surrounding 
 structures in the inguinal canal, and then divided transversely without injuring 
 the cord. The lower part is left behind and forms the tunica vaginalis ; the 
 upper part should be freed from the cord by splitting it up behind and the 
 cord carefully separated. The sac itself should now be pulled down and liga- 
 tured high up, and cut ofi" as in other forms of hernia. 
 
 C^ECAL Hernia. — Hernia of the cnecum alone is seldom or never seen, 
 for in nearly every case in addition to the caecum we find the vermiform 
 appendix, a portion of the ileum, and a portion of the ascending colon. 
 According to the most recent observations, a ceecocele with an incomplete sac 
 is rare. The sac is usually complete, and the caecum and other portions of 
 the intestines accompanying it are free within the lumen of the sac, and the 
 walls of the sac are not reflected around any part of the intestine (Lock- 
 
 52 
 
818 AN AMl'.incAX TEXT-IIOOK <)l' SC /,'(.■ K/n'. 
 
 wood). CV)ii<^enital ciococele is the most coiuuion variety, and is usually eauscd 
 by the descent of the testicle, which pulls down the ciecum, apjtendix, and 
 ])ortions of the ileum with it. This is due to the existence of a fold of peri- 
 toneum (plica vascularis) reaching from the globus major of the testicle to the 
 ci«cum, appendix, ileum, and mesentery, and which contains the sj)ermatic ves- 
 sels and gubcrnaculum testis. In accpiired ciecoccle thoc has usually been 
 an antecedent hernia of the small intestines, but in some cases where the 
 cfecum with the ascending colon float freely in the abdomen, owing to the 
 large and small bowel liaving a common mesentery, hernia of the caecum may 
 occur in the same way as does hernia of the small intestines. 
 
 SkjmoU) Hkrxia is very much like c:ocal hernia, and in the same way 
 may be divided into congenital and ac([uired, with an incomj)lete or complete 
 sac. The sigmoid Uexure, like the c;ecum, has connected with it the fold of 
 peritonenm (plica vascularis), which contains the spermatic vessels, and in 
 fetal life connects the testicle with the sigmoid flexure. During the 
 4lescent of the testicle the sigmoid flexure may be carried down with it, but 
 on the other hand nniy be the cause of keeping the testicle from descending. 
 
 Irreducible Hernia. — A hernia is said to be irreducible when the pro- 
 truded bowel cannot be returned into the abdominal cavity, and this without 
 any symptoms of strangulation or obstruction. Irreducible herniaj are usually 
 of long standing and large size. This condition is often caused by careless- 
 ness in the patient and neglect to keep in a reducible hernia with a truss. 
 There is always a large amount of omentum in the sac, and this it is which 
 cannot be returned, the gut often sli])ping in without difliculty. The reason 
 why the hernia cannot be reduced is that adhesions have formed between the 
 omentum and sac and also between the omentum and the bowel itself. As 
 time goes on, the neck of the sac thickens and becomes narrower, while the 
 mass of omentum becomes larger. The hernia sometimes reaches an enormous 
 size, preventing the patient from following any occupation. Even if it be 
 small, it gives rise to much discomfort, and the ])atient is always in danger of 
 strangulation of the rupture. 
 
 Treatment. — The reduction of an irreducible hernia can be satisfactorily 
 accomplished by performing the operation for radical cure. The sac should 
 be opened, the excess of omentum tied off with catgut or silk, and the bowel 
 returned ; then a radical cure should be performed. Should the individual be 
 old and fat, the operation, even when performed with the strictest aseptic pre- 
 cautions, is not without danger. In very large hernije in stout people it is 
 well to prepare them by keeping them in bed for a couple of weeks or more, 
 feeding them on a diet which will not make ftit, such as lean meat and vege- 
 tables, and giving them no fats, sugar, starch, or alcohol. By this means the 
 patient's size is reduced, and the bowel, which has perhaps not entered the 
 abdomen for years, may sometimes be reduced without much difficulty. In 
 some of these cases, where the ring is of large size, the radical cure may be 
 made much more certain by the removal of the testicle and the cord of the 
 affected side. Some surgeons advise attempting reduction without operation 
 by keeping the patient in bed, with hips raised, ice to the scrotum, and on low 
 diet. Taxis should be employed daily, and occasional saline purgatives should 
 be given. By this means the fat is absorbed and reduction has been accom- 
 plisheil after a few weeks. "Where operation is refused or is inadvisaltle owing 
 to age, etc., this method may be tried. Trusses with a large concave pad 
 have been devised for the support of this form of hernia. 
 
 Incarcerated Hernia. — By this term is indicated an irreducible hernia 
 in old people, which becomes obs^tructed with gases, feces, or undigested food, 
 
I)Isi:asi:s am) lwhiuks of the AnnoMiiy. «19 
 
 and lioiico the ])ass:i(ro tliroiiirh the Ixnvels is ])l(icki'tl. It is most common in 
 umliilical licniia. Tlieiv may be eructation of ^as and slitrlit vomiting, with 
 constipation, but there is no tenderness or tension of the hernial tumor and 
 all the symptoms are subacute. Impulse on coughing is well marked. It is 
 necessary in these cases to give large enemata of sweet oil with a little turpen- 
 tine. Taxis may be tried, and in this way the gases and feces may be made to 
 move on. Tiie local application of ice or of hot fomentations aids in relieving 
 this condition. A full dose of castor oil may be given after the above means 
 have been tried. 
 
 Inflamed Hernia. — This is generally the result of violence or may be 
 produced by pressure of a badly-fitting truss. The part is hot, red, painful, 
 and tender, but there is not much tension ; there may be increase in the size 
 of the tumor. Pyrexia is always present, and there are all the symptoms of 
 a local peritonitis. There may be vomiting and constipation, but no great 
 constitutional depression, as in strangulated hernia, and there is still impulse 
 on coughing. Irreducible hernia are the most liable to become inflamed, 
 especially irreducible femoral epiplocele. 
 
 Treatment. — Rest in bed, with the local application of an ice-bag, relaxa- 
 tion of the parts by position, and if there is much pain opium should be given. 
 Should the condition go on to suppuration, an incision should be made and the 
 pus in the sac evacuated. The effects of the inflammation are seen in the sub- 
 sequent firm adhesions of the gut or omentum to the sac. 
 
 Strangulated Hernia. — A rupture is said to be strangulated when it is 
 so tightly constricted at its neck that it cannot be returned into the abdomi- 
 nal cavity and its circulation is interfered with ; thus there is not only obstruc- 
 tion to the passage of feces, but also an arrest of circulation in the protruded 
 portion of bowel Avhich, if not relieved, results in gangrene and death. It 
 occurs more often in old than in recent hernias, and more often in conjrenital 
 than in acquired. 
 
 Mechanism of Strangulation. — It is usually due to the descent of an 
 additional fresh knuckle of bowel into an old hernial sac, or, in a case in 
 which there has been no prior hernia, to a sudden descent of a knuckle of 
 bowel during some violent exertion through some of the natural apertures of 
 the abdomen. This sudden forcing of the bowel through a narrow aperture 
 causes constriction, which, if it continues, is followed by strangulation. It 
 does not always occur during violent effort, but may be produced by increased 
 peristaltic action of the bowels in a patient who has been suffering from diar- 
 rhea, constipation, or what is commonly called '"bowel complaint." At first 
 there is merely constriction at the hernial ring : this leads to congestion of the 
 part and arrest of return of venous blood, which results in engorgement and 
 swelling of the protruded portion of gut. This swelling increases the con- 
 striction, strangulation ensues, and, if it is very severe, death of the part 
 rapidly follows. In some cases where the strangulation is not so extreme 
 the . circulation is not entirely arrested ; the progress of the disease is not 
 so rapid, and ulceration of the constricted portion may be the result. This 
 is followed by perforation, escape of feces into the peritoneum, and general 
 peritonitis. 
 
 The seat of stricture may be at the hernial orifice or in the neck of 
 the sac itself It is most fre([uently outside the neck of the sac at one of the 
 hernial rings. When it occurs at the neck of the sac, it is due to thickening 
 at that point and the fusing together of the various pleats and folds into 
 which a large sac is thrown where it passes through a small opening. The 
 seat of stricture may be in the sac itself, produced by bands of adhesions 
 
b-20 A.\ AMERICAN TEXT-BOOK OF SLUUEUY. 
 
 which stretch across it. Cases are on record where the straiif^ulation has been 
 proihiced by the twistin<^ of a h)oj) of tlie protruded bowel in tlie sac. 
 
 Local Changes the Result of Strangulation. — First. congeHtion 
 occurs in the protruded j)arts, j)r(jduc-ed by the arrest of circuhition through 
 the veins, but not the arteries ; then engorgement and swelling occur, and the 
 bowel has first a dark-red, then a ])urplish, appearance. At the same time 
 there is effusion of serum into the sac, and now the circulation is completely 
 obstructed and the bowel becomes almost black, and soon becomes gangrenous. 
 When the obstruction to the circulation is not complete and has laiited some 
 time, the effects of inflammation are seen : the bowel becomes dark in color, loses 
 its glistening appearance, is covered with flakes of lymph, and becomes soft 
 and less elastic, and the serous coat is covered with ashy-gray spots. Omen- 
 tum, when strangulated, has first a dark -purplish, and afterward a yellowish- 
 gray, color. In a hernia that has been strangulated for some time there are 
 always evidences of inflammation. As the gangrene advances, gas is generated 
 and the parts crackle, the gut ruptures, and fecal matter is extravasated. The 
 fluid in the sac, which was at first clear, becomes reddish, turbid, and finally 
 off'ensive. It is sometimes very difficult to tell positively whether the gut is so 
 damaged as to be beyond recovery. It may be very dark colored and yet be 
 sufficiently alive. The best test is the condition of the peritoneal coat, which 
 peels off" easily when it has lost its vitality. If the bowel is flaccid and in- 
 elastic, then, without doubt, gangrene has set in. The bowel may be ulcerated 
 at the line of stricture and perfectly healthy elsewhere. Perforation may result 
 and feces escape into the abdominal cavity, leading to general peritonitis and 
 death. Suppuration of the sac may occur as the result of strangulation, but 
 this is rare. Gangrene of the intestine is more frequent in femoral than in 
 inguinal hernia, but ulceration of the line of stricture is more common in 
 strangulated inguinal hernia. 
 
 Symptoms. — In cases in which there is sudden and complete constipation 
 with perisistent vomiting a strangulated hernia should always be suspected, and 
 the various apertun's through which a hernia might ])rotrude should always 
 be examined. If at the site of a hernia is found a tumor which is tense, hard, 
 and painful and irrreducible, there will not be much difficulty in making a 
 diagnosis. 
 
 The symptoms of strangulated intestine are always the same, whether the 
 strangulation occurs in the abdomen or outside of it — viz. faintness, collapse, 
 severe abdominal pain, chiefly referred to the umbilical region, complete con- 
 stipation, so that flatus ceases to pass, then vomiting, at first of food, then of 
 bile-stained fluid, and finally of fluid with a fecal odor. The tongue is dry and 
 brown and the pulse rapid. In strangulated hernia there are ivi addition, at 
 first, pain at the seat of rupture, a greater degree of tension, the tumor having 
 increased in size, dulness on percussion over the hernia, and absence of impulse 
 on coughing, with the fact that the tumor is irreducible. 
 
 If unrelieved, the abdomen becomes much distended, retching is more fre- 
 quent and thirst intense, hiccough sets in, the urine is much diminishea in 
 quantity, and the patient gradually sinks from exhaustion in eight or nine 
 days, though in very acute cases he may die in forty-eight hours. The bowel 
 by this time has become gangrenous or there is general peritonitis. With the 
 onset of gangrene there is often a cessation of the more urgent symptoms, as 
 vomiting and pain. The severe collapse, pain, and vomiting which set in early 
 in a case of strangulation are due to the profound impression produced on the 
 abdominal sympathetic plexuses by the pinching of the gut. This also 
 accounts for the diminished excretion of urine. 
 
J)/.s/:asI'Js a XI) i\.iii!ii':s or rni: MinoMrx. 821 
 
 Often the symptoms are not so severe as described above, especially in 
 femoral hernia, where the patient may be unaware for some time that strangu- 
 lation exists or even that he has a hernia. In recent hernise the symptoms are 
 much more acute than in old herniiie, and they are not so urgent when omen- 
 tum is protruded witli the bowel or when the tumor has for some time been 
 irreducible. In cases of obturator or sciatic hernia it may be impossible to 
 discover the tumor even by the most careful examination. A small knuckle 
 of bowel may become strangulated behind a piece of omentum and be out of 
 the reach of the surgeon : there is no impulse on coughing, not much tender- 
 ness, and the tumor may feel soft and lax. A knuckle of gut may become 
 strangulated inside the sac of a large hernia, and yet the hernia as a whole 
 may give no evidence of strangidation. Again, a hernial tumor may have 
 all the symptoms and appearances of strangulation, and yet not be the seat 
 of the obstruction. All these possibilities of error emphasize the need of ex- 
 ploratory operations, either herniotomy or abdominal section, in any case in 
 which life is seriously endangered and the exact cause obscure. 
 
 Richter's Hernia (P.arti.al Exterocelk). — This was formerly de- 
 scribed as the constriction of a pre-existent diverticulum in a hernial orifice, 
 but the name is now applied to that form of hernia where only a part of the 
 circumference of the bowel is constricted by the margin of a hernial opening. 
 This artificial diverticulum looks like a nipple, and protrudes from the con- 
 vex surface of a loop of bowel. On relieving the strangulation the nipple, 
 as a rule, disappears, leaving a deeply indented ring of a dark-blue color in 
 strong contrast to the rest of the bowel. It occurs most frequently at the 
 femoral ring, only a few cases having been seen elsewhere. The symptoms 
 are not so severe, on the whole, as when the whole circumference of the 
 bowel is involved. The vomiting is not so persistent, and feces and flatus 
 may continue to pass. The tumor itself is often so small as to be overlooked, 
 and if the patient is stout even the most careful examination will fail to make 
 it out. 
 
 The proper treatment of Richter's hernia is either herniotomy or, if 
 there be every symptom of hernia and no tumor present, an abdominal 
 section. 
 
 Littre's Hernia. — This term is applied to a hernia which contains a 
 Meckel's diverticulum. It is vei'v rare, and when strangulation takes place 
 the symptoms closely resemble those met with in partial enterocele. 
 
 Strangulated Omental Hernia. — When omentum alone is strangulated, 
 as sometimes occurs, the symptoms are similar to those of strangulation of the 
 bowel, but not so severe ; the pain is less, vomiting not so persistent, and con- 
 stipation not so complete. In fact, the symptoms are those of Littre's hernia, 
 and some suroreons assert that in all cases of so-called strangulated omental 
 hernia there is an error in diacrnosis. and that a small stranfjulated knuckle of 
 gut behind the omentum has been overlooked. 
 
 Diagnosis of Strangulated Hernia. — Usually the diagnosis of stran- 
 gulated hernia presents but little difiiculty. It may, however, be confounded 
 with incarcerated or inflamed irreducible hernia. 
 
 In incarcerated hernia there is impulse on coughing and absence of tender- 
 ness ; vomiting, when present, is not severe. Constipation exists in both, but in 
 this form yields to treatment. In inflamed hernia the local inflammation is very 
 marked, and elevation of temperature always exists ; constipation is not com- 
 plete, flatus and fluid feces readily passing, and there is no vomiting. When 
 hernia is double, it sometimes requires a careful examination to determine 
 which one is strangulated. Various tumors, glandular and others, have been 
 
822 .l.V AMElilVAX TKXT-Ji(J(Jh' OF SL'IH; Kin'. 
 
 mistaken for strangulated lieniia and operated on. The loeal evidence of 
 tumor Avould serve to diagnosticate strangulated hernia from iiitestinal 
 obstruct t'loi. 
 
 Prognosis. — If unrelieved by reduction or operation, the prognosis is bad. 
 In very acute cases the patient will die in forty-eight hours if the hernia is not 
 reduced. Some cases which have been " left to nature " have lived a fortnight, 
 and in others the bowel has become gangrenous and the sac and skin have 
 sloughed, thus exposing the opening in the bowel. Recovery with an artificial 
 anus may result. 
 
 Treatment. — JS^o deJay is permissible, for unless the strangulation be 
 relieved the patient will surely die. There are only two methods of treatment 
 — first, td.vis : second, lierniotomy. 
 
 Taxis. — This is the reduction of the bowel into the abdomen by means of 
 manipulation with the fingers. When seen very early the hernia may be 
 returned without the administration of an anesthetic ; indeed, the patient him- 
 self frequently returns the hernia by assuming the recumbent position and 
 pressing in the protruded bowel. If the patient is seen later and there is con- 
 siderable tension of the part, an anesthetic should be administered before taxis 
 is attempted. It is remarkable how simple the reduction of many herniae 
 becomes under ether or chloroform. A rupture that would not previously yield 
 to taxis often goes in under anesthesia with the slightest amount of manipu- 
 lation. 
 
 Method of Performing Taxis. — When fully under the influence of the 
 anesthetic, the patient is placed on his back with the pelvis raised, and the thigh 
 of the affected side flexed and rotated inward if the hernia be femoral or inguinal. 
 Indeed, it is important that everything should be done to relax the parts about 
 the hernial ring. The neck of the sac is then seized with the thumb and fin- 
 gers of one hand, and thus fixed, while with the other hand the surgeon endeav- 
 ors to return the strangulated gut by gentle pressure in the proper direction. 
 In femoral hernia this is at first downward, to bring the gut opposite the 
 saphenous opening, then backward, and then upward. In inguinal hernia it 
 is usually slightly upward and outward. The part which protruded last, pre- 
 sumably at the neck of the sac, is that first to be returned. The bowel should 
 be coaxed rather than forced in. A kneading and squeezing movement or 
 gently pulling the tumor from side to side or downward often proves .success- 
 ful, the gut returning Avith a sudden gurgle or rush, a sensation which is quite 
 peculiar to hernia. Too prolonged or violent manipulation is strongly to be 
 condemned, and may do an infinite amount of injury. If by moderate and 
 gentle taxis for from five to ten minutes the surgeon fails to overcome the 
 strangulation, he should waste no further time, but proceed at once to the per- 
 foriiumce of hcrniotornif. 
 
 When Taxis is Contraindicated. — Taxis should not be employed when 
 it is suspected that the gut is already gangrenous, in cases where the hernial 
 tumor is inflamed by previous manipulation, Avhere stercoraceous vomiting has 
 set in, or in many of the later stages of strangulation. If the strangulation 
 occurs in an old irreducible hernia, herniotomy should be at once performed. 
 The older methods of treatment by opium, ice-bag, or hot bath should be tried 
 in those cases only where the symptoms are not urgent or the patient refuses 
 operation. 
 
 Strangulation after Reduction. — It occasionally happens that after the 
 reduction of a hernial tumor symptoms of strangulation persist, and when such 
 an occurrence takes place it is due to one of the following conditions : (1) the 
 return of injured or gangrenous bowel ; (2) paralysis of the bowels, existing 
 
DISEASES Ayj> jyJLJ:iES OF THE ABDOMEN. 823 
 
 as the result of freneral ]»eritonitis; (3) tlie presence of a second strangulated 
 hernia ; and (4) the reduction of the hernial tumor en ma»se or en bloc. 
 
 The trt'atnient of all these conditions is the same — viz. abdominal section 
 and the immediate examination of the condition of affairs. If the bowel is 
 jraiiirrenous, an artificial anus should be established, or, if the patient's condi- 
 tion warrants it, a resection and lateral anastomosis of the affected bowel should 
 be performed. In the other cases the surgeon should be guided by the condi- 
 tions found on opening the abdomen. 
 
 If the sac and its contents are returned, still strangulated, into the abdom- 
 inal cavity, the condition is known as reduction en masse. The tumor disap- 
 pears without any gurgling sound, and the constitutional symptoms are still 
 unrelieved. Immediate incision should be practised, either in the median line 
 or over the site of the hernia. This accident occurs most frequently in the 
 inguinal variety of hernia. 
 
 In certain rare cases the sac is ruptured and the gut makes its escape into 
 the subserous connective tissue, the protruded bowel still remaining strangu- 
 lated. Treatment by herniotomy should be performed for the relief of the latter 
 two conditions. 
 
 Remote Consequences following Reduction of a Strangulated Hernia. — 
 Intestinal obstruction may ensue some time after a reduction of hernia : (1) 
 owing to the formation of bands of adhesion ; (2) from a displaced hernial 
 sac : (3) from cicatricial stenosis, due to some sloughing of part of the 
 injured bowel. 
 
 In all these cases exploratory laparotomy is called for. and in the last- 
 mentioned resection of the stenosed portion of the bowel. 
 
 After-treatment. — After a strangulated hernia has been reduced the 
 vomiting ceases and the patient feels greatly relieved. He should be kept in 
 bed for some days, and fed on nutritious fluid diet until the bowels act sponta- 
 neously. It is well to fix a pad over the hernial ring by means of a properly- 
 applied bandage, to prevent the return of the hernia. 
 
 Herniotomy. — Should taxis fail or the case be one where the conditions 
 are adverse to taxis, the surgeon must at once proceed to perform herniot- 
 omy. Having shaved the parts and carefully cleansed them antiseptically, 
 an incision about two inches long should be made over the tumor and the 
 various structures carefully divided down to the sac. It is often very difficult 
 to recognize the sac, it varies so much in character, sometimes bein^r thick and 
 fibrous, and at other times thin and translucent. It is often hard to distin- 
 guish it from bowel or omentum. Most commonly, in recently strangulated 
 cases which have been previously reducible, it looks like a cyst, fluctuating 
 and having a bluish color. When reached it should be pinched up between two 
 artery forceps and divided ; immediately there is an escape of fluid often hav- 
 ing a fecal odor, and the bowel is seen lying within the sac. The constriction, 
 which is usually at the hernial ring, should now be relieved by cutting. To 
 effect this the finger is introduced up to the constricting point, a blunt-pointed 
 bistoury pushed along it. and the constriction divided cautiously in the proper 
 direction suitable to each form of hernia. The bowel should then be exam- 
 ined : if healthy and full of vitality, as evidenced by its elasticity and capacity 
 to transmit its contents (the strangulation having been relieved), it may be at 
 once returned into the abdomen with the omentum. If the protruded omen- 
 tum be large in amount or adherent, it is better to tie it with silk or catgut in 
 sections and then remove it. Any adhesions that exist should be freed and, 
 if vascular, cut between two ligatures. The sac should then be treated as in 
 operations for the radical cure of hernia, and the neck of the sac ligatured as 
 
824 AN AMKinCAN TEXT-llOOK OF srUdERY. 
 
 hiirh up as possible. If the sac be small, it should be dissected out and cut 
 off lialf an inch below the ligature at its neck ; but if it be large, it may be 
 left, after cutting it througli or excising a small part of the upper portion. 
 The canal is closed, as in the radical cure of hernia. If the hernia is actjuired, 
 as is most commonly the case, the conjoined tendon should be sutured to Pou- 
 part's ligament with three or four stout silk sutures. The external wound is 
 closed in the usual way with silkworm-gut or silk sutures, and the ordinary 
 antiseptic dressings applied, maintained in place by a firmly-applied spica 
 bandage. 
 
 The patient should have no iluiil or food of any kind for twenty-four hours : 
 there is, hoAvever, no objection to the administration of a small dose of mor- 
 phia hypodermatically if there be much pain. The bowels may be allowed to 
 act of their own accord, and if, at the end of a Aveek, they are still constipated, 
 they may be relieved by enemata, castor oil, and salines. If there be much 
 distention previous to this, salines often prove beneficial. 
 
 Abdominal Section to Reduce Strangulated Hernia. — Tait has 
 recently proposed to treat strangulated hernia by abdominal section and 
 reduction of the hernia by traction from within the belly, aided by pressure 
 from without, instead of the usual method of external herniotomy. In excep- 
 tional cases this may be commended ; as, for instance, in a case of evident 
 acute intestinal obstruction from a femoral hernia so small as not to produce 
 any perceptible tumor externally, or in a pre-peritoneal hernia ; but it will 
 hardly replace herniotomy as a routine practice. 
 
 Gangrenous Intestine and its Treatment. — When on opening the sac 
 the intestine is found to be gangrenous, what should be done? There are seve- 
 ral methods advocated : (1) To resect the gangrenous gut, suture the cut ends, 
 and return the bowel into the abdomen. (See Enterotomy.) (2) To fasten it 
 outside the abdomen and open it at once. The patient recovers with an arti- 
 ficial anus or a fecal fistula, Avhich can be treated at a later period when he has 
 regained his strength. (3) If only a small portion of the bowel be gangrenous, 
 to return it within the abdominal cavity, anchor it Avith a suture just inside the 
 ring, and introduce a large drain through the ring in close proximity to the 
 bowel. (1) Resection of the gut, owing to the Aveak condition of the patient, 
 may not ahvays be advisable. In such cases the use of Murphy's button, or 
 some other means of rapidly uniting the ends of the divided bowel, is recom- 
 mended. The second method is perhaps the safest for the general prac- 
 titioner Avho has ha-d no practice in resecting intestine. His patient Avill have 
 a better chance of recovery, and later operative procedures for closing the fecal 
 fistula can be undertaken. A method advocated lately by llelferich of 
 GreifsAvald is Avorthy of mention — viz. to make an immediate alxlominal sec- 
 tion and establish intestinal anastomosis betAveen the part of the intestine 
 above the gangrenous gut and the part beloAv it. The gangrenous gut is 
 alloAved to remain outside the hernial opening. By this means peristalsis is 
 obtained from the first, and later the gangrenous gut may be resected Avith- 
 out danger, the anastomosis favoring the early closure of the fecal fistula. 
 
 Seqnehe to Herniotomy. — (1) Tiie Avound may not unite by first intention, 
 and if the sac has been very adherent the disturbance of the cellular tissue 
 mav cause some sloughing. In such cases the Avound should be reopened and 
 stuffed with iodoform gauze. 
 
 (2) Diffuse general peritonitis may set in ; this is known by the persistence 
 of the vomiting, the continuance of the pain, distention, and tenderness of the 
 abdomen, Avith elevation of temperature. This may be due to leakage from a 
 j>erforation, to a gangrenous condition of the boAvel, or to the introduction of 
 
DISEASES AND INJURIES OF THE ABDOMEN 
 
 825 
 
 septic matter from will.out at tlie time of operation, as in any other alxlominal 
 section. Immediate laparotomy should be done. 
 
 (3) The reduced j^it, ^vhicli has been returned as suspicious, may become 
 gancrrenous and obstruction of the bowel still continue. If this condition be 
 su^lKH'ted. the abdomen should be opened and the <rancrrenous bowel sought 
 for, and either resected or incised, and kept outside the abdomen with the 
 object of forming an artificial anus. 
 
 ' (4) The bowel may not be gangrenous, yet be so injured that it may not be 
 able to resume its proper functions, and the patient may die in consequence if 
 not relieved bv a laparotomy. 
 
 (5) The bowel may be temporarily paralyzed by local inflammation so as 
 not to be able immediately to resume its functions, though alter some days it 
 may recover completely its normal condition. In such cases there is obstinate 
 constipation, without vomiting or other signs of peritonitis. 
 
 (G) Cases of acute mania have followed the operation tor strangulatea 
 hernia, some of which have proved fatal (Shepherd). 
 
 SPECIAL HERNIiE-INGUINAL HERNIA. 
 
 This is the commonest form of rupture. More than two-thirds of the cases 
 4ipplying to the London Truss Society for trusses suffered f'-^m inguinal hernia. 
 Accordmcr to Bercrer, as the result of the examination of 10,000 cases ot 
 hernia, 9G per cent, of the males had inguinal hernia, and 44.6 per cent. 
 
 of the females. , . , . . , ^ ^ ^^ .^ ■ 
 
 By inguinal hernia is meant a rupture which is situated wholly or partly in 
 the inguinal canal or in the inguinal canal and scrotum. 
 
 Ino-uinal hernia may be oblique, or external, and db'ect, or internal. 
 An Oblique Inguinal Hernia is one which passes through the spermatic 
 canal, having the same course as the spermatic cord— viz. through the internal 
 rin.. aloncr the inguinal canal, and through the external abdominal ring to the 
 scrStum. ''in its course it passes to the outer side of the epigastric artery, and 
 hence is also called external mguinal hernia. Oblique inguinal hernia consists 
 of two forms, congenital and acquired. 
 
 Direct or Internal Inguinal Hernia passes directly through the abdom- 
 inal walls to the external abdominal ring, and thence to the scrotum. It pushes 
 in front of it or passes through the conjoined tendon, and is i7iternal to the epi- 
 gastric artery, passing through a triangle bounded internally by the rectus 
 abdominis, externally by the epigastric artery, and below by Poupart s liga- 
 ment (HesselhacK s triangle). . 
 
 Congenital Inguinal Hernia.— The tubular process of peritoneum which 
 accompanies the testicle in its descent to the scrotum becomes obliterated at its 
 upper part durino- the later months of foetal life. The lower part remains, 
 envelops the testicle, and is called the tunica vaginalis. The previous connec- 
 tion of the tube with the peritoneum is marked by a dimple at the internal 
 rino- Occasionally this obliteration does not take place, and the tube remains 
 con'tinuous with the abdominal peritoneal cavity, so that a hernia may suddenly 
 descend in this tube to the scrotum. The hernia is in the tunica vaginalis, 
 which forms its sac. This is the form of hernia which is named congenital 
 (Ficr .3.36) It is said to occur most fref|uently on the right side. 
 
 Iviethod of Obliteration of tlie Tubular Process.— There are two 
 points at which the obliteration takes place— viz. at the internal ring and a 
 little above the epididvmis (Fig. 337). The obliteration begins first at the 
 higher point and takes place later at the lower point, thus leaving a serous 
 
826 
 
 .l^V AMERICAN TEXT-BOOK OF SURGERY. 
 
 tultc bftwt'on them. 
 
 Fi(i. 33ti. 
 
 Tbis tubt' .sodu .shrinks into ;i Hla-ous curd; but on the 
 other hand the process of obliteration ujay not go 
 on, and while the two ends are closed the tube re- 
 mains patent, and in it a hydrocele of the cord may 
 subseipieiitlv form. 
 
 Infantile or Encysted Hernia. — In certain 
 cases the tubular process of peritoneum closes only 
 at the upper end, thus leaving only a thin layer of 
 membrane between the peritoneal cavity and the 
 tunica vaginalis. "When a hernia occurs, as it some- 
 times does, even in adult life, suddenly, the hernial 
 sac is pushed into the tunica vaginalis, carrying the 
 septum before it. and hence in front of the gut there 
 will be three layers of peritoneum (Fig. 338). Oc- 
 casionally the septum is ruptured, and the gut may, 
 as in true congenital hernia, descend into the sac of the tunica vaginalis. 
 
 Congenital Hernial Sac 
 (original). 
 
 Fig. 337. 
 
 Fig. 338. 
 
 Fig. 339. 
 
 Infantile Hernial Sac, 
 first stage (original). 
 
 Infantile Hernial Sac, sec- 
 ond stage (original). 
 
 Funicular Hernial Sac 
 
 (original). 
 
 Hernia into tlie Funicular Process. — When the tubular prolongation 
 of peritoneum closes at the loiver point only, there is a funicular process of 
 peritoneum which passes through the internal ring, down the canal, and into the 
 scrotum. The gut gets into this process, and. as in congenital hernia. pas.ses 
 down into the scrotum, but the testicle remains quite distinct from the rupture 
 (Fig.SlOj. 
 
 Congenital hernia, as its name implies, appears at birth or soon after, devel- 
 oping suddenly ; at once descending into the scrotum, it envelops the testicle. 
 This form of hernia is much more liable to strangulation than the acquired^ 
 and is very difficult to reduce when strangulated, because the neck of the sac 
 remains long and narrow (Fig. 309). 
 
 Congenital inguinal hernia is almost the only form of hernia seen in female 
 children. The bowel protrudes into the canal of Xuck, a process of perito- 
 neum which descends along the round ligament in the female foetus. 
 
 Acquired Inguinal Hernia (Plate XIX, Fig. 1). — This fonn is rarely 
 or never seen before jjuberty, and is more common in men than in women. It 
 may be either oblique or direct. 
 
 The oblique form descends along the inguinal canal to the outer side of the 
 epigastric artery, and is the most common variety of hernia. Its coverings 
 from within out are the peritoneum, infundibuliform process of the transver- 
 salis fascia, cremaster muscle, intercolumnar fascia, superficial fascia, and skin. 
 As it emerges from the external rinir and enters the scrotum it becomes much. 
 
HERNIA. 
 
 Plate XIX. 
 
 1. Femoral hernia. 2. Inguinal (scrotal) hernia. 
 
J) IS i: ASKS AM) lyjrniKs of the abdomen. 827 
 
 larger, and in some cases is of enoniioiis size (Plate XX, Fig. 1). In the 
 female it enters the laliium majus (Plate XX, Fig. 2). 
 
 In old eases of ae(|uired ()bli([iie hernia the rings l)ecome much enlarged 
 and are approximated, so that the internal ring lies directly behind the exter- 
 nal. This, of course, has the effect of shortening tlie neck. Whilst an oblique 
 hernia is in the inguinal canal it is called a bubonocele. It always forms 
 sloAvly, and in this is very different from the congenital form. It is always in 
 front of the s])ermatic cord, and when it reaches the scrotum the testicle is 
 always below and distinct from the hernia. 
 
 In acquired direct inguittal hernia the hernial sac protrudes directly through 
 the external ring to the scrotum. It either passes through the conjoined tendon 
 or to the outer side of it, and there is no long neck, as is the case in the oblique 
 variety. When reduced, tlie fino;er can be puslied directly throujih the exter- 
 nal ring nito the abdominal cavity, whereas in the oblique form the finger passes 
 along the inguinal canal to the internal ring and then into the abdominal 
 cavity. In old hernige, however, as mentioned above, where the rings are 
 large and opposite each other, the contrast is not so marked, and in fact a 
 diagnosis cannot always be made. 
 
 Direct hernire are never congenital. 
 
 Diagnosis between Congenital and Acquired Inguinal Hernia. — 
 Congenital hernia occurs suddenly at birth or soon after, passes at once to the 
 scrotum, and envelops the testicle, rendering its recognition difficult. Acquired 
 hernia comes on slowly in adult life, and has the testicle below and quite dis- 
 tinct from the hernial sac. 
 
 Diagnosis of Inguinal Hernia from Other Tumors. — Usually a 
 hernia is recognized by the history of the case, the impulse on coughing, 
 the tympanitic note on percussion, and its reducibility. The intestine always 
 returns with a gurgle. The swelling occupies the inguinal canal, and its upper 
 limit cannot be reached. The testicle in the acquired variety is situated at the 
 bottom of the sac, and the spermatic cord is obscured. There is always an 
 impulse on coughing, even in an irreducible hernia. When the sac contains 
 omentum it is dull on percussion, has a doughy, knotty feeling, and returns 
 without a gurgle. 
 
 Hydrocele. — History of a tumor, beginning below and extending upward ; 
 is dull on percussion, pyriform in shape, gives no impulse on coughing; is 
 translucent ; the testicle is behind and at the middle. 
 
 Hematocele comes on suddenly after injury ; is dull on percussion, gives no 
 impulse on coughing ; is opaque, with a doughy feel. 
 
 Congenital Hydrocele. — Is translucent, dull on percussion, gives an im- 
 pulse on coughing ; the testicle is behind the tumor ; the tumor disappears 
 when the patient lies down, and returns slowly on standing, and fills from 
 the bottom, whereas in hernia the tumor is opacjue and reappears quickly on 
 standing. When hernia and hydrocele coexist the diagnosis is not so easy. 
 
 Hydrocele of the Cord. — This appears as a tense, fluctating swelling in the 
 inguinal canal, having distinct limits above. On pulling the cord it moves 
 with it. (See Diseases of the Spermatic Cord.) 
 
 Varicocele. — Is dull on ])ercussion, but may have an impulse on coughing; 
 feels like a bag of worms. It can be reduced by pressure, but returns even if 
 pressure be made on the ring sufficient to retain any hernia. 
 
 Undescended Testicle. — In every case of inguinal swelling the surgeon 
 should examine the scrotum to see if it contains two testicles, and then he 
 cannot mistake an undescended testicle for a hernia, as has been frequently 
 done. 
 
828 AN AMERICA X TEXT- BOOK OF SURGERY. 
 
 Treatment. — The treatment by trusses has already been described. In 
 some eases of congenital hernia a cure is not infrequently effected in a year or 
 two by a properly-fitting truss, but in the acijuired variety it is very rarely safe 
 to leave off the truss. 
 
 Taxis. — In reducing an inguinal hernia the pressure in the o])li(|ue variety 
 should be in the direction of the canal, -whereas in the direct variety and in 
 old oblique herniae the pressure should be directly backward. Before employ- 
 ing taxis the thigh should be adducted and flexed. 
 
 Herniotomy. — In performing herniotomy for strangulated inguinal her- 
 nia the only vessel in danger of being wounded is the deep epigastric, and to 
 avoid tliis the incision of the constriction should be directly upward. In 
 oblique hernia the constriction is usually at the internal ring, and in direct 
 hernia the conjoined tendon is the cause of the strangulation. 
 
 The treatment of the various forms of irreducible, inflamed, obstructed, 
 and inguinal hernine must be based on the principles already laid down when 
 treating of hernia generally. The radical cure of inguinal hernia has been 
 sufficiently described. 
 
 FEMORAL HERNIA (PLATE XIX, FIG 2). 
 
 Femoral or crural hernia occurs when the bowel escapes from the abdom- 
 inal cavity under Poupart's ligament, passes through the femoral ring, and 
 enters the femoral or crural canal. 
 
 The femoral canal commences at the femoral ring and ends at the 
 saphenous opening in the fascia lata. It is about half an inch long, and 
 wider at its termination than at its commencement. The peritoneal sac in 
 femoral hernia is always acquired, never congenital. The hernia first of all 
 passes through the femoral ring, pushing in front of it peritoneum and the 
 septum crurale (Cloquet's fascia); then it descends along the femoral canal, 
 lying on the pectineus muscle and covered by the sheath of the vessels and 
 fascia lata ; finally, it reaches the lower border of the saphenous opening, 
 passing outward under the falciform border, and pushes in front of it the crib- 
 riform fascia. When it escapes from tliis opening it passes upward beneath the 
 loose superficial fascia and over Poupart's ligament, and becomes very much 
 larger. So its direction from within outward is first downward, then forward, 
 and then upward. A fully-developed femoral hernia has somewhat the shape 
 of a retort. From without inward the coverings of a femoral hernia are : skin, 
 superficial fascia, cribriform fascia, sheath of the vessels, septum crurale, and 
 peritoneum. The neck of the hernia is always situated at the femoral ring, 
 which is bounded externally by the femoral vein, internally by Giinl>eniat's 
 ligament, above by Poupart's ligament, and below by the pubes covered by the 
 pectineus muscle. "When strangulated the stricture is usually at the femoral 
 ring, the sharp edge of Gimbernat's ligament being the constricting point. 
 
 To the outer side of the neck of the sac we have the epigastric artery, and 
 above the spermatic cord. In about one in three and a half cases the obtura- 
 tor artery arises from the epigastric and passes down to the obturator foramen. 
 In 10 per cent, of such cases it ])asses to the inner side of the femoral ring, 
 and would be in danger of being wounded when the edge of Gimbernat's 
 ligament is cut to relieve a strangulation. 
 
 About Q.Q per cent, of all cases of hernia are femoral in males. Femoral 
 hernia is much more common in females (37.1 per cent.) than in males. It 
 rarely occurs before adult life. It is much more liable to become strangulated 
 than inguinal, it being not uncommon to find a femoral hernia strangulated 
 
HERNIiE. 
 
 Plate XX. 
 
DISEASES AND INJURIES OF THE ABDOMEN. 829 
 
 at the time of its first descent. The lieinia is rarely of large size, and its 
 contents consist usually of a portion of the ileum. Omentum is never found 
 in large (juantities, but is fre({uently irreducible. 
 
 Diagnosis. — It is not always easy to distinguish femoral from inguinal 
 hernia in stout females when it has mounted above Poujjart's ligament. 
 Femoral hernia can always be pushed to the outside of the spine of the pubes, 
 Avhilst inguinal hernia always lies to the inner side. In stout people the spine 
 can always be felt by abducting the thigh, and thus bringing into prominence 
 the adductor longus tendon, which arises immediately below the pubic spine. 
 To assist in the diagnosis the line of Poupart's ligament should always be 
 marked by a string, and not by the eye. 
 
 Femoral hernia as usually seen is a small, tense, round tumor situated in the 
 groin, inside the vessels and outside the pubic spine. In some rare cases it 
 has been seen outside the vessels. 
 
 Diagnosis from Other Tumors. — Psoas Abscess. — This is very apt to 
 simulate hernia, as it has an impulse on coughing and partially or wholly dis- 
 appears on the patient's lying down, though without the gurgle of a hernia. It 
 is always situated to the outside of the vessels, and is accompanied, usually, by 
 some angular deformity of the spine. 
 
 Fatty Tumor has a lobulated feeling, no impulse on coughing, is dull on 
 percussion, and irreducible. 
 
 Varix of the Saphena Vein may simulate hernia, but on reducing it and 
 asking the patient to stand whilst the finger presses on the ring, it will always 
 return, while a femoral hernia will not. 
 
 Enlarged Lymphatic Grlands, when inflamed, have sometimes been mis- 
 taken for strangulated femoral hernia and operation has been performed. In 
 some cases the crural branch of the genito-crural nerve has been found 
 stretched tightly over an enlarged and inflamed gland, giving rise to such 
 reflex symptoms as vomiting and constipation. A strangulated hernia and an 
 enlarged, inflamed gland may coexist. In some cases the diagnosis cannot be 
 made without incision. 
 
 Cysts in the Femoral Canal are very diflScult to diagnosticate ; they are 
 always irreducible and have no impulse on coughing. 
 
 Treatment of Femoral Hernia. — When reducible, a properly-fitting 
 truss should be worn. A truss will never cure a femoral hernia, and in some 
 cases cannot be made to keep in the hernia. 
 
 When strangulated, taxis should first be employed, the thigh of that side 
 being flexed, adducted, and rotated inward. In this way the margin of the 
 saphenous opening is relaxed. If the hernial tumor has reached above Pou- 
 part's ligament, it should be lifted and drawn downw'ard before pressure is 
 employed. Not the slightest violence should be used, and if taxis fail, resort 
 should be immediately had to herniotomy. 
 
 Herniotomy. — The parts having been shaved and rendered aseptic, an 
 incision should be made over the inner side of the tumor in the direction of 
 its long axis, and the tissues cautiously divided until the sac is reached. It is 
 often very difficult in femoral hernia to distinguish the sac, owing to its altered 
 appearance from the pressure of a truss or from the accumulation of fluid out- 
 side the sac. In most cases there is no fluid in the sac, and the sac is often 
 opened before the surgeon is aw^are of the fact. It may be recognized by its 
 smooth lining and the presence of bowel. The sac having been opened, the 
 seat of stricture, which is usually the sharp edge of Gimbernat's ligament, is 
 sought. The finger is introduced into the sac, the pulp facing inward, until 
 the edge of the ligament is felt ; a hernia knife or a blunt-pointed bistoury is 
 
s:M) a\ amhl'K'ax text-book of srnoERY. 
 
 passed along the finger with its edge down and gently insinuated heneath the 
 ligament, and then the edge, turned inward, nicks a few of the constricting 
 fibers until the stricture is relieved. Tlie stricture having been relieved, the 
 bowel is examined, and if normal is reduced with omentum. If the omentum 
 is adherent, it should be tied and removed. If the condition of the patient 
 is good, the sac should next be dissected out and its neck ligatured as high 
 up as possible. It is then cut off a little below the point of ligature. In some 
 cases it is wise to fix the neck of the sac at the femoral ring by ligatures. 
 The wound should be closed with silkworm-gut sutures and a small drain 
 introduced at its lower angle. The dressings should be carefully applied, so 
 that they will not be soiled by contact with urine or feces. 
 
 The results of this operation are usually remarkably good. A radical cure 
 does not always take place, but the life of the patient is saved and recovery is 
 generally rapid. In case an abnormal obturator artery is wounded, it would 
 be well to enlarge the incision upward and look for the bleeding point. The 
 artery when cut completely through usually retracts to such an extent that it 
 is most difficult to secure. In some cases a needle has been successfully ])laced 
 beneath it and the hemorrhage arrested. Wounding of the obturator is an 
 accident which will rarely happen if the knife is dull and the incision is not 
 too free. (For the radical cure of feiuoral hernia see p. 817.) 
 
 UMBILICAL HERNIA. 
 
 This form of hernia occurs in 5.46 per cent, of all cases in males, and 
 27.34 in females. It is congenital in nearly all cases in males and in the 
 majority in females (Berger). 
 
 There are three forms of this hernia — viz. (1) congenital; (2) infantile; 
 and (3) adult. 
 
 (1) Congenital Umbilical Hernia occurs most frequently in female 
 children, and is due to an arrest of development whereby the abdominal walls 
 do not properly close. It is sometimes of large size, and contains not only the 
 intestines, but various organs, as the spleen, liver, etc. In some monsters all 
 the abdominal contents are contained in the hernia. This form of hernia may 
 be small, and is seen as a tumor at the root of the umbilical cord. The sac 
 protrudes into the cord, and cases are on record where the bowel has been in- 
 cluded in the ligature applied to the cord at birth. In some cases where oidy 
 a small diverticulum of gut is included recovery may proceed uninterruptedly, 
 but in others a fecal fistula may result. If a large amount of intestine is in- 
 cluded, a fatal issue is inevitable 
 
 As a rule, the coverings of the hernia are so thin that the contents of the 
 sac can easily be seen. 
 
 Treatment. — 'V\\e hernia should be returned and kept in place by strips 
 of plaster encircling the abdomen, so as to bring the recti muscles close together; 
 over this a tight binder should be applied. A flat cork pad the size of a silver 
 dollar under the strapping is sometimes advised. Occasionally um))ilical hernia 
 has ])een operated on successfully. 
 
 Infantile Umbilical Hernia. — This form is very common, and comes on 
 after separation of the umbilical cord, and is caused by the stretching or yield- 
 ing of the cicatrix at the umbilicus. It never reaches a large size, and tends 
 to undergo a spontaneous cure. 
 
 Treatment. — The hernia can be easily reduced, and kept so by the appli- 
 cation of adhesive or porous plaster. Plaster is objectionable, however, because 
 of its tendency to produce troublesome oczema on an infant's skin. A truss 
 may be applied. Infantile umbilical hernia never becomes strangulated. 
 
DISEASES AND /XJ CRIES OF THE ABDOMEN. 831 
 
 Adult Umbilical Hernia. — This form of hernia very rarely commences 
 in infancy : it is almost always acquired rather late in life. It is seen most 
 commonly in stout women who have borne many children : also in men with 
 pendulous bellies. It sometimes reaches a lar<re size, but usually is not 
 larger than the closed fist. The contents are commonly the transverse colon 
 and omentum. The stomach has been found in hernia? of very large size, and 
 even the gravid uterus. Umbilical hernia is very liable to become obstructed 
 or inflamed, but is rarely strangulated. It is often irreducible. 
 
 Treatment. — When reducible, it should be kept in place by a belt sur- 
 rounding the abdomen. "When irreducible, a cup-shaped pad kept in position 
 by a belt or bandage should be applied. Trusses or belts are very difficult to 
 fit so as properly to retain this form of hernia, and the stouter the individual 
 the more difficult it is to apply a suitable truss. 
 
 Should the hernia become strangulated, taxis should first be employed, and 
 it often succeeds ; but should it fail, herniotomy should be performed without 
 delav, as crancrrene sets in verv rapidlv. It is well to remember that the skin 
 and the sac in this region are very thin, and the operator may open the sac 
 before he is aware of it. The contents also are commonly adherent. The 
 patient is frequently old and feeble, and perhaps suffers from a chronic bronchitis. 
 Altogether, the subjects of strangulated umbilical hernia are not usually in a 
 very favorable condition to bear well a severe operation. 
 
 After reaching the sac, it should be carefully opened and the hernial ring 
 divided at its lower border, and if necessary at one or two other points. The 
 gut should be examined, and if in good condition returned ; the adherent omen- 
 tum separated, ligated, removed, and the stump also returned. The sac should 
 now be dissected out, the neck drawn down a little, and either sutured with a 
 continuous suture and amputated half an inch below, or ligatured with stout 
 silk and removed, as in other forms of hernia. The pillars of the ring should 
 be freshened a little and sutured with strong silk. The wound should then be 
 closed and a drainage-tube inserted. If the gut be gangrenous, an artificial 
 anus should be established. 
 
 In cases of strangulated umbilical hernia where the assistance is poor and 
 the condition of the patient is unfavorable, no time should be wasted in sepa- 
 rating large intestine from its adhesions or in ligaturing omentum ; the recently 
 descended intestine which has become strangulated should be returned as 
 quickly as possible, and the operation completed without delay. 
 
 The radical cure of umbilical hernia may be undertaken and fairly good 
 results as to permanent cure may be obtained ; that is, if the hernia be not 
 too large. In performing the operation the neck of the sac should be well 
 separated from the surrounding structures, the bowel returned into the abdo- 
 men, and the sac tied off. The pillars of the ring should then be brought 
 together with silkworm gut or strong silk sutures ; the external wound 
 closed with horsehair or silkworm gut and the dressings applied. In many 
 cases, owing to the protruded omentum having an attachment to the sac, it is 
 necessary to open the sac and tie off the protruded omentum in sections. The 
 sac is afterward lioratured and cut off. Some surgeons recommend that the 
 hernial ring should be dissected out (omphalectomy) and the new ring brought 
 together with deep sutures of catgut and silkworm gut. By this more radical 
 operation it is held that cure is much more likely to be permanent. 
 
 Ventral Hernia. — This term is applied to any hernia coming through 
 the abdominal walls in regions not the usual sites of hernise. It is frequently 
 seen in the scar following operations for ovarian tumors, appendicitis, etc. It 
 may also follow injury or abscess in the abdominal walls. Ventral hernia is 
 
«;52 AN AMERICAN TEXT-liOOK OF SURGERY. 
 
 usually large, and rarely or never becomes strangulated, owing to the size of 
 the opening. Most of the cases are found in the linea allm. 
 
 Treatment. — The application of a suitable abdominal belt or truss ia 
 generally all that is required, but in some cases, where the protrusion causes 
 great discomfort and inconvenience, and the general condition of the patient 
 is good, reoj)ening the wound and suturing afresh may be advised. In cases 
 not due to operation the sac has been dissected out, ligatured, and removed 
 with success. 
 
 Lumbar Hernia. — This variety is very rare. The rupture occurs through 
 a triangle bounded by the external oblique, latissimus dorsi, and crest of the 
 ilium (Petit's triangle). Lesshaft states that the triangle is constant only in 
 women, and is not seen in young children. Before reaching this triangle the 
 sac passes through the lumbar fvscia near the outer border of the (juadratus 
 lumborum muscle. It may follow wounds, contusions, strains, or abscesses. In 
 (il<l people it may come on without any apparent cause. It is easily reduced, 
 antl never attains a large size. Cases are on record where it has become 
 strangulated. This form of hernia has been mistaken and incised for tumor, 
 abscess, hematoma, etc. Males and females are e((ually liable to lumbar her- 
 nia. A well-made abdominal belt is usually sufficient to retain it properly in 
 position. 
 
 Perineal Hernia. — This form descends in front of the rectum, and is most 
 often seen in females. The protrusion escapes between the fibers of the leva- 
 tor ani muscle. It may be due to traumatism, and in males to constipation. 
 Ebner thinks that perineal hernise are congenital. The prominence may appear 
 in males in the perineum near the anus or scrotum, and in females may 
 descend into the labium majus (pudendal hernia). When this hernia appears 
 in the vagina or labium, it may be mistaken for mucous cyst, but it is always 
 reducible. In females it may contain the bladder. 
 
 IscHiATic Hernia. — This is a protrusion of gut through the great sacro- 
 sciatic foramen, most commonly above, but sometimes below, the pyriformis 
 muscle. It has over it the gluteus maximus muscle, but may escape beneath 
 its lower border. When small and strangulated it may be overlooked, owing 
 to its great depth. It is one of the rarest forms of hernia. 
 
 Obturator Hernia. — This also is rarely seen, and still more rarely 
 recognized before death. The gut protrudes through the obturator foramen, 
 usually at its upper part, where the canal is situated. It pushes before it the 
 obturator fascia, and perhaps a j)ortion of the obturator externus muscle, and 
 is covered by the pectineus muscle. It is internal to the femoral vessels. 
 The neck of the sac is deeply situated in the obturator canal, and may have 
 the obturator artery to its outer or inner side. It is rarely recognized unless 
 strangulated, and even then it is often overlooked. There is a prominence to 
 the inner side of the vessels in the region of the pectineus muscle. When 
 strangulated, in addition to the usual signs of strangulated hernia, there is a 
 tender, hard swelling at the upper and inner part of the thigh, and severe pain 
 down the inner side of the thigh as far as the knee in the course of distribution 
 of the obturator nerve. It is most common in females, rarely occurs before 
 fifty, and may be mistaken for femoral "hernia. 
 
 Treatment. — Taxis is not usually successful, bur should be tried with the 
 thigh tlexed. adducted, and rotated outward. Herniotomy should be performed 
 if the seat of the strangulation be recognized. The stricture is always at the 
 neck of the sac, and should be relieved by cutting down^^^ird. The saphena 
 vein may give trouble. In some cases the hernia might be easily reduced by 
 performing median abdominal section, thus relieving rapidly and safely the 
 
DItiEASES AND INJURIES OF THE ABDOMEN. 833 
 
 strarifijnlated gut by traction from above. This lu'riiia has sometimes been 
 recoii;nizo<l by vaginnl examination. 
 
 Diaphragmatic Hehxia. — There are two forms of this hernia, congenital 
 and traumatic. 
 
 Tlie confieuitaJ form is due to the defective devehjpment of the diaphragm, 
 whereby it is ini])erfectly closed, and thus some of the abdoiuinal contents are 
 protruded into the tlioracic cavity. The stomach is the viscus most often dis- 
 jdaced, next tlie coh)n, and then the small intestines. The spleen and liver 
 have also been found in the thoracic cavity. The deficiency nearly always 
 occurs on the left side. 
 
 The traumatic form is due to rupture of the diaphragm by violence or to 
 stab Avounds. It occurs most commonly on the left side, and the stomach is 
 the organ most frequently displaced. It is rarely recognized before death. 
 Of 250 cases collected by Leichtenstern, only 5 were diagnosticated. After 
 severe crushing injury Bryant of London refers to excessive thirst as a promi- 
 nent symptom. 
 
 Hernia into the Foramen of Winslow occasionally occurs, and gives 
 rise to symptoms of intestinal obstruction. It can be recognized only by 
 abdominal section or after death. 
 
 Properitoneal Hernia is a form of hernia which occupies an abnormal 
 position within the abdominal or pelvic wall and in front of the peritoneum. 
 It may lie between the parietal peritoneum and the muscles, between the planes 
 of the abdominal muscles, or outside of them and just beneath the skin and 
 superficial fascia. The first of these varieties is the true properitoneal 
 hernia. 
 
 As a rule, these cases are originally inguinal hernife : they are usually con- 
 genital, and are apt to be associated with an undescended and more or less 
 atrophied testicle. After they have for a time occupied the inguinal canal the 
 resistance to their descent offered by the testicle forces them out during a mus- 
 cular effort on the part of the patient into the connective tissue between the 
 peritoneum and the muscles or into one or other of the spaces above men- 
 tioned. 
 
 The cause of this peculiarity in the congenital form, according to Trende- 
 lenburg, is the persistence of a cavity which must exist at a certain stage in 
 the descent of the testes — an instance of arrested development. In acquired 
 cases, according to Kronlein, the cause is mechanical, the pressure of a badly- 
 fitting truss or repeated attempts at taxis forcing the internal away from the 
 external ring, and dilating the sac or canal into a pouch between the layers 
 of the parietes. 
 
 Properitoneal herniae are found just above Poupart's ligament and are par- 
 allel with it, extending upward and outward as far as the anterior spine. Some- 
 times the}^ are large and overlap Poupart's ligament, extending doAvnward to the 
 upper portion of the thigh. There is apt to be thinning of the abdominal wall 
 at the seat of sw'elling. 
 
 In case of strangulation taxis may be apparently successful, and yet the 
 abdominal pain Avill become more intense and the symptoms will not disappear. 
 The tumor will not go back with the characteristic gurgle, and the symptoms 
 will continue unabated, or even aggravated, by attempts at reduction. If the 
 scrotal tumor or that occupying the canal disappears, the swelling above Pou- 
 part's ligament will become more tense and increase in size. Upon operation 
 the loops of gut lying in the scrotum cannot be reduced as usual, or if reduced 
 persistently descend again or lie fixed in close proximity to the internal abdom- 
 inal ring. 
 
 53 
 
834 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 The treatment should consist in a free incision, such as wouhl ])e proper 
 in a stran^iuhited inguinal licM-nia, followed by dilatation with the finger or by 
 division of the ring through which the hernia ])rotrudes ; or Trendelenburg's 
 method may be adoj)ted and an incision made tinough the linea alba, and repo- 
 sition of the bowel effected by traction from within. 
 
 Rktro-I'KRITOxXEAL Hernia (Mem-nti'n'c Hernia of Cooper). — This rare 
 form of hernia is caused by the lodgment of small intestine in the fossa duo- 
 deno-jejunalis.' The intestine pushes its way onward, forcing the fold of 
 peritoneum forming the fossa before it. In time there is quite a large sac 
 filled with bowel behind the posterior layer of peritoneum. In one case Sir 
 Astley Cooper found the whole of the small intestines, with the exception of 
 the duodenum, hidden from view, occupying a large sac in the middle of the 
 abdomen and surrounded by large intestine. As a rule, these cases are only 
 diagnosticated post-mortem. On opening the abdomen and entering the peri- 
 toneal cavity, a second sac containing the small intestine is found. This sac 
 is clear and free from blood-vessels, being composed of mesentery which haa 
 been pushed forward by the herniated bowel. 
 
 The symptoms in extreme cases have been severe pain, vomiting, weak- 
 ness, and cullupse. 
 
 Treatment. — By opening the abdomen the condition could be easily 
 recognized, and the intestine might be pulled out of the enlarged fossa duo- 
 deno-jejunalis. No successful cases of treatment have been reported. 
 
 1 This fossa is seen if the transverse colon be thrown upward and the small intestine drawn 
 to the right. It is formed l\v a fold of serous membrane passing from the parietal peritoneum 
 to the left of the terminal part of the duodenum (Treves). 
 
SURGERY OF THE GENITO- URINARY TRACT. 
 
 835 
 
 CHAPTER VII. 
 
 Fig. 340. 
 
 SURGERY OF THE GENITO-URINARY TRACT. 
 
 PART I.— DISEASEvS OF THE KIDNEYS AND URETERS. 
 
 Surgical Anatomy. — The kidneys are seated in tlio lumbar and liypo- 
 chondriac regions. Their lower levels are sonieAvhat above the umbilicus. The 
 
 right kidney is three-quarters of 
 an inch lower than the left. Their 
 upper borders are about on the 
 level of the interval between the 
 eleventh and twelfth dorsal spines. 
 The lower edge of the left kidney 
 is about two inches above the 
 crest of the ilium ; of the right 
 kidney, one and a quarter inches. 
 The hilum is on the level of the 
 first lumbar spine, and is two 
 inches from the middle line (Fig. 
 340). 
 
 The kidneys are only par- 
 tially covered with peritoneum. 
 Portions of the anterior surface 
 are in relation Avith the back of 
 the ascending and descending 
 colon, some cellular tissue inter- 
 vening, and with the duodenum 
 and pancreas. The posterior sur- 
 face is uncovered. The external 
 border is sometimes partially cov- 
 ered with peritoneum. The kid- 
 neys are usually surrounded with 
 a large quantity of fatty tissue 
 poorly supplied with blood-ves- 
 sels. The ureters are about 14^ 
 to 16 inches in length and of the 
 caliber of an ordinary goose-quill, narrowing where they pass through the 
 bladder-walls. Their walls are compar- 
 atively thick and muscular, but are sus- 
 ceptible of great dilatation without rupture 
 when the dilating force is gradual. They 
 are entirely retro-peritoneal (Fig. 341). 
 
 Anomalies. — The kidneys may oc- 
 cupy a position in the pelvis in front of the 
 spine, or the one on the left side may rest 
 above the spleen. They may be altered 
 in shape and size by arrest of develop- 
 ment, or one kidney may be entirely 
 absent, in which case the remaining 
 organ is apt to be of unusual size. 
 Occasionally they are united at their 
 extremities'^ (usually the upper) and form the "horseshoe" kidney. 
 
 Diagram of the Relations of Kidney to Viscera, Spine, and 
 Surface Points (original). 
 
 Fig. 341. 
 
 Kidneys, Ureters, Ascending and Descendtag 
 Colon from behind (original). 
 
836 AN AMElilCAN TKXT-BOOK OF .SURGERY. 
 
 Floatiiifi Kldnei/. — Eitlur kidney, especially the ri^flit, may lie uiiiiat- 
 urally inoval)le and constitute the " Hoating kidney. " 'I'he kidneys are held 
 in phiee normally by the connections of the peritoneum ^\■ith the j»erine|diric 
 fat. If the latter is absorbed during acute disease or from long-continued 
 ill health, the organ can move more freely, and by its weight elongates the 
 peritoneal folds, which in other cases are abnormally long and lax. The 
 kidney may also be dislocated by traumatism, and become a floating kidney. 
 
 Movable kidneys are most common in poorly-nourished fenuiles who have 
 borne children, the scarcity of the fat and tlie relaxation of the abdomiiuil 
 walls following pregnancy acting as predisposing causes. 
 
 Symptoms. — The symptoms may vary from a slight uneasiness referred 
 to the lumbar or the hypochondriac or sometimes the umbilical region, to agon- 
 izing pain, which when paroxysmal has been supposed to be due to a strangu- 
 lation by twisting of the renal nerves and vessels. The length of the latter 
 limits the degree of mol)ility of the kidney, which can only describe the seg- 
 ment of a circle of which the vessels are the radius. 
 
 Physical examination may show undue lumbar resonance (a fallacious and 
 uncertain symptom), or may reveal a movable tumor in the hypochondrium or 
 in the umbilical or even the iliac region. The depression of the hilum, and 
 sometimes the pulsation of the renal artery, may be recognized, and if the 
 tumor on manipulation plainly recedes toward the loin and is of the size and 
 consistence of the kidney, the diagnosis becomes reasonably certain. Malig- 
 nant omental growths, solid tumors of the ovai'ies, growths of the abdominal 
 wall, beginning enlargement of the spleen, and distention of the gall-bladder 
 may usually be easily excluded. 
 
 Treatment. — When the symptoms are moderate in degree, the use of a 
 compress attached to a broad, neatly-fitting elastic bandage will often suffice 
 for their relief. When of greater severity, the operation of nephrorrhapliy 
 should be considered, but only after the treatment by belt and compress has 
 failed, and after thorough attention has been paid to the general health and 
 condition of the patient. 
 
 Nephrorrhaphy or Nephropexy. — The operation is as follows: Place 
 the patient in the })rone ])osition, with a cylindrical ])ad beneath the abdomen, 
 the ilio-costal space on the side of operation being turned upward and made 
 prominent. Define carefully the position of the twelfth ril), so that accidental 
 opening of the pleura may be avoided; make an incision parallel to it and about 
 half an inch below it, and four inches in length, beginning two and a half 
 inches from the spines of the vertebniB (Fig. 342, A). Divide the latissimus 
 dorsi, the external oblique, the internal oblique, the transversalis, and the lum- 
 bar fascia; separate the perinejiliric fiit, which will bulge into the wound, with 
 the fingers, or Avith two pairs of dissecting forceps, and thus ex])0se the cap- 
 sule of the kidney. Up to this point the operations of nephrorrhaphy, neph- 
 rotomy, ne])hro-lithotomy, and nephrectomy are identical. In the case of 
 nephrorrhaphy the surgeon next proceeds to pass by means of curved needles 
 four to six sutures of medium-sized plaited or twisted silk through the capsule, 
 including a portion of kidney tissue, and then through the adjacent lumbar 
 fascia and muscles, knotting them and cutting them off short. If there lias 
 been but little disturbance of the fat, the wound may be closed without drain- 
 age ; otherwise it is well to leave in a rubber drainage-tube for a day or two. 
 
 The ultimate results of this operation have been favorable in most of the 
 reported cases. There is no means of estimating, however, the unsuccessful 
 cases not reported. Performed with proper antiseptic precautions, the mortality 
 should be very trifling. 
 
SVL'(li:in- OF THE GIJXITO- URINARY TRACT. 
 
 837 
 
 Nephralgia. — The urine, as a consecjuence of overwork, of error.s in diet, 
 of the rheumatic or jj;onty diathesis, etc., may become a positive irritant and 
 give rise to various forms of nej)hritis, more appropriately considered in text- 
 books on medicine. If it is persistently acid, it may give rise to nephralgia, 
 a deep-seated unilateral lumbar pain, of a dull aching character, with exacerba- 
 tions of sharper pain extending along the course of the ureters toward the 
 groin or into the testicle. The best time to test the urine in making the diag- 
 nosis of this condition is about two hours after a meal, preferably breakfast, 
 when it is normally mildly alkaline. This pain may be diagnosticated from 
 that accom])anying the more serious conditions of renal calculus, pyelitis, dis- 
 ease of the bladder or prostate, etc. by the absence of the symptoms character- 
 
 FiQ. 342. 
 
 |lf*"^y #^^>^''//'^^ 
 
 Anatomy of Renal Region to illustrate Operations on the Kidneys (after Esmarch and Kowalzig): A, 
 usual incision midway betweeia twelfth rib and crest of the ileum for operation on the kidney ; B, 
 Kouig's incision; J/c, trapezius ; J/W, latissimus dorsi ; 8p, erector spina- ; Q^, quadratus lumborum; 
 oe, obliquus externus : oi, obliquus internus ; Tr, transversalis abdominis ; Fid, lumbar fascia ; 
 C, descending colon ; R, kidney ; xi, xii, ribs. 
 
 istic of those ailments and by the relief afforded by attention to the general 
 health, to the diet, and to the hygiene of the sexual organs. Alkalies, such as 
 potassium citrate or potassium acetate, Vichy, or, if there is constipation, Fried- 
 richshail water, regular baths followed by friction, great moderation in the use 
 of meats, sweets, and alcohol, are clearly indicated. 
 
 The very similar pain due to myalgia of the lumbar muscles is generally 
 rheumatic or gouty, and may be cured by the use of belladonna in ointment 
 or liniment, and by the administration of the salicylates. 
 
 Phosphatic Urixe, in which the opposite condition of over-alkalinity 
 prevails, is found most commonly in nervous, overworked persons of sedentary 
 habits and feeble digestion. It is associated with general lassitude, occipital 
 headache, and depression of spirits. In young males it is a constant source 
 of sexual hypochondriasis, the patient referring his symptoms to early mastur- 
 bation or to sexual excess, and often mistaking the milky deposit of phosphates 
 for seminal losses. Dilute mineral acids, strychnia, a regulated diet, and rest 
 or chanare of scene will effect a cure. 
 
838 AX AMElilCAN TEXT-BOOK OF SURGERY. 
 
 UXALURIA is often an unsuspected cause of a variety of genito-urinary 
 symptoms. It may be found in young persons, overfed, of indolent habits, 
 with ungratified sexual desires, or may follow sexual excesses, especially in 
 gouty or rheumatic ])ersons. In the latter case it is fre(juently the cause of 
 persistent and distressing sexual feebleness or even of entire imjiotence. It is 
 always well in patients with the vague genital symptoms, ill-defined lumbar or 
 hvpogastric pains, mental depression, etc. so constantly found in sexual hypo- 
 chondriacs to examine the urine for the octahedral or dumb-bell crystals of 
 calcium oxalate, with which will often be found an excess of uric-acid crys- 
 tals, and of amorphous phosphates or urates. 
 
 Here, again, the mineral acids in infusions of vegetable tonics, and a rigidly 
 restricted diet, with an occasional course of sodium phosphate (20 grains four 
 times daily) in some alkaline diluent, such as Vichy or Lithia water, will 
 cause a rapid disappearance of all the annoying symptoms. Change of air 
 and scene will often effect a cure when drugs alone have failed. 
 
 Gravel. — When the crystalline substances naturally held in solution in 
 the urine are deposited in the uriniferous tubules or elsewhere, the condition 
 known as gravel exists. It is due to too great concentration of the urine, 
 caused by lack of exercise, high living, excess of meats and sugars in the food 
 and of malt or sweet effervescing liquors in the drink. It is due also to the 
 gouty diathesis, to excessive sweating, and much more frequently than is sup- 
 posed to an insufficiency of water in the daily diet, a common but often unsus- 
 pected cause of many chronic kidney diseases. The deposit may be uric acid, 
 urates, or calcium oxalate, the relative frequency corresponding to the order 
 of mention. The symptoms of gravel are those of hyperacidity of the urine, 
 with marked vesical and urethral symptoms superadded, increased frequency of 
 micturition and ardor urinre being especially noticeable. The treatment is the 
 same as that for nephralgia or oxaluria. 
 
 Renal Calculus. — If the crystalline particles or the amorphous powder 
 deposited become glued together by colloid material derived from mucus or 
 blood-clot, they form a nucleus on which further depositions of salines from the 
 urine occur, and constitute a calculus, which may soon attain a size that pre- 
 vents its passage through the ureter. It may, and most frequently does, con- 
 sist of uric acid ; next in frequency is calcium oxalate, and much more rarely 
 the stone is composed of calcium carbonate or of the mixed jihosphates. Cal- 
 culi may form in the tubules or in one of the calyces, and may vary in num- 
 ber from one to hundreds. 
 
 When the stone finds its way into the ureter it may exceptionally escape 
 almost unnoticed, but as a rule its entrance into and pa.ssage through that duct 
 give rise to a group of symptoms known as nephritic colic, which are as 
 follows : A person who has been entirely comfortable and in ])erfect health is 
 seized instantaneously with a violent pain, felt first in the luml)ar or hypo- 
 chondriac region, but at once extending down the line of the ureter toward the 
 scrotum and the end of the penis. The testicle is strongly drawn upward by 
 spasm of the cremaster. The pain follows the branches of the lumbar plexus 
 into the groin, thigh, and hypogastrium. The patient is apt to prefer a sitting 
 position, stooping over so as to relax the ilio-psoas and lumbar muscles — those 
 in closest relation to the ureter. Vesical irritation and tenesmus are fre(iucnt. 
 Faintness, cold sweating, and even collapse are not uncommon accompaniments 
 of such an attack. It may cease as suddenly as it began, but the relief is not 
 permanent until the stone has either receded into the pelvis of the kidney or 
 more luckily has passed onward into the bladder. In the latter case no further 
 attacks may follow. If the former event has occurred, the next paroxysm 
 
SURGERY OF THE GENITO-URINARY TRACT, 839 
 
 and atropia in small doses, wann Datiis, and uiuici 
 
 other kidney be aiseasta; uiui i,,!.,^ tk^no of the Ion, ffivmj? rise to 
 
 ulceration, the stone escapes ™/» '^^« ^'i"^; ,' H, n cS>n ca^ le esublished 
 a l.nnbar or pdv.c aWs. " *' ™f "fean now be done by an expert in 
 :;':'',.::^o/r:.-";S itfthS »c. the urete. operation ,s elcar.y 
 
 cated^'ra Lti^ctly localized ar.. of tenderness .n^t^^^^^^^^^ 
 
 'thTs method was employed have recent^ ''^'HZl^t, curved incision on 
 
 If the calculus .8 m the upper P«' ''"Vf *^, "" ,ffth rib, then directed 
 
 a line beginning just below ami parallel to he '^f j;'j,,j j^^ external 
 
 Sacted if thVSf though a^tgin^al incis.on which opens neither the 
 bladder nor the peritoneum. ' incision 
 
 on ir::ryt\tit:r;rr:irvaT^^^^^^^^^^ ^vith^i. cocey. 
 -Ai:errr:^r::LTir?^^^^^^^ 
 
 /. ^ • ^ fi.o ,irPtPr it will <^ ve rise to some or all ot the toliowing symp 
 from entering the uietei, it will ^ive ^■cc^.,,^,., cases- lumbar pains and 
 
840 AN AMKIiK'AX TKXT-liOOK OF SUJiGERY. 
 
 hematuria is tlie most valuable. There is often a history of personal or family 
 predisposition to oxaluria or to litheraia. 
 
 Direct exploration with a needle will sometimes reveal the existence of 
 stone, and if done with care is not a dangerous procedure. Rarely in emaci- 
 ated ])ersons and in cases of excessively large stone it may be recognized by 
 direct l)inianual palpation. 
 
 Diagnosis. — Early tubercular jryelitis will be associated with an excess 
 of j)us, a slighter hematuria, a strumous rather than a lithemic history, bacilli 
 in the urine, etc. Spinal caries may be associated with a degree of renal irri- 
 tation that is misleading, especially where the abscess is close to or presses upon 
 the kidneys. Usually the deformity or tenderness of the spine will suffice to 
 differentiate the condition. Nepliralgia^ lithiasis, oxaluria, hi/dronephrosis, 
 and pf/onepJirosis should be carefully eliminated. 
 
 Nephro-lithotomy, — Operation should be decided upon when the diag- 
 nosis is reasonably certain, the patient is disabled by pain or exhaustion, pre- 
 vious treatment has failed, and there is no reason to fear grave organic disease 
 of the other kidney. A moderate amount of albumin, with casts, is to be 
 expected, and in the face of distinct symptoms of stone should not deter the 
 surgeon, as the results without operation are so unpromising. The preparatory 
 treatment should consist in the free use of diluents, restricted diet, the admin- 
 istration of a laxative and of an enema, and rest in bed for some days. 
 
 The position of the patient and the incisions until the kidney is exposed are 
 the same as in the operation of nephrorrhaphy. (See page 836.) If more room is 
 needed, the edge of the quadratus may be incised. Firm counter-pressure 
 should be made on the anterior surface of the abdomen by an assistant while 
 the lower ribs are elevated by another. The diff'ercnt surfaces of the kidney 
 should then be examined by the finger of the surgeon and compressed between 
 the finger and thumb, and if no stone is disclosed an exploring needle or long 
 acupressure pin may be inserted in several directions. Howse has compared 
 the sensation given to the finger by a stone imbedded in the kidney to the out- 
 line of the last joint of a finger; Morris, to the uncut end of a pencil. It 
 varies, of course, with the size and shape of the stone and its distance from the 
 surface. Instances have been recorded of large stones so situated that they 
 could not be felt even Avhen the kidney was removed and was lying on a table, 
 and were disclosed only when it was laid open. If the above means fail, there- 
 fore, in a case with well-marked symptoms, a linear incision may be made large 
 enough to admit the end of a finger, the pressure of which usually stops the 
 hemorrhage, which is apt to be free at first. For the purpose of obtaining a 
 better opportunity of examining the kidney in operations involving this 
 organ than has hitherto been possible, Edebohls has devised an inflatable 
 cylindrical rubber bag. The patient should be in the prone position and the 
 bag inflated and placed under the abdomen transversely. After the usual 
 incision has been made and the kidney exposed and thoroughly separated 
 from its fatty capsule and any adhesions that may exist, the )»atient is to be 
 grasped by the feet and drawn toward the foot of the table. The cylindrical 
 pad is thus brought under the costal margin, and the kidney, in most 
 cases, can be entirely extruded through the wound. If a stone is found, it 
 may be shelled out with the finger-nail, or if very large and branched, with 
 light adhesions, it may be broken by forceps and the fragments removed with 
 the finger and curette. The cavity should be syringed forcibly with antiseptic 
 lotions, sponged with fine small sponges, and packed with iodoform gauze around 
 a drainage-tube. The operation may be a very difficult one, OAving to the thick- 
 ening and adhesion of all the perinephric tissues, to hardening of the kidney 
 
SURGERY OF THE GENITO-URINARY TRACT. 841 
 
 itself, to the small size of the stone, or to its situation near the anterior surface 
 of the kidney. Death may result from hemorrhai^e, septicemia, or uremia. 
 
 In some cases anuria (suppression of urine) follows this operation. The 
 freijuent existence of stone in both kidneys then justifies the immediate 
 exploration of the other kidney. 
 
 Nephrectomy. — Before deciding upon this operation the presence of 
 the second kidney sliould be ascertained, for very rarely there is but one — a 
 "horse-shoe" kidney — the removal of which would be necessarily fatal. 
 This may be done either by an independent lumbar incision on the opposite 
 side, which is immediately closed when the presence of this kidney is ascer- 
 tained ; or the hand may be introduced through the original abdominal in- 
 cision and the presence of the other kidney be proved by pal{):ition. 
 During an operation begun for the removal of a stone it may be thought 
 advisable to take away the kidney itself, on account of its disorganiza- 
 tion, the existence of multiple abscesses, or the impossibility of taking 
 away all fragments of the stone. As a rule, hoAvever, a free nephrotomy with 
 thorough drainage gives tlie patient the best chance for recovery from the 
 immediate danger of the condition and operation. This will leave the patient 
 with a urinary fistula, which, if it does not close spontaneously in two or tliree 
 months, may necessitate a secondary nephrectomy. Eemoval of the kidney 
 may also be indicated in tubercular or calculous pyo-nephrosis, or even hydro- 
 nephrosis, nephrotomy and free drainage having first been tried. 
 
 Nephrectomy for malignant disease in both adults and children has been 
 thus far a very fatal and a very unsuccessful operation. The best results have 
 been obtained in nephrectomies for sarcoma in adults, but even in these the 
 mortality has been very large. The kidneys may also require removal for 
 wounds, ruptures, tears of the ureter, and occasionally for movable kidney, 
 after failure of nephrorrhaphy. 
 
 Catheterization of the ureters is performed in the female with moderate 
 ease, and is possible, but far more difficult, in the male. It may enable the 
 surgeo-n to advise or reject nephrectomy in a given case by demonstrating the 
 presence or absence of a functionally active and sound kidney on the opposite 
 side. 
 
 The lumbar operation is performed through the same incisions as those 
 already described (p. 836), special care being taken to secure sufficient room. 
 Incision of the quadratus and a vertical slit downward, making the orig- 
 inal cut irregularly T-shaped, will often be required. Konig's method (Fig. 
 342, B) may be needed in cases of exceptionally large or very adherent 
 kidneys. The soft parts are divided vertically along the border of the erector 
 spinse ; the incision is then continued anteriorly in the direction of the umbili- 
 cus, ending at the outer border of the rectus ; the muscles are divided down 
 to the peritoneum, which should be pushed forw^ard. Or the kidney may be 
 reached by direct incision along the outer edge of the rectus, or through the 
 linea alba^ both methods, as a rule, opening the peritoneal cavity ; sometimes 
 the peritoneum can be stripped oflF the abdominal wall and the kidney be 
 removed without opening the abdomen. The lumbar incisions are to be pre- 
 ferred, except in cases of neoplasms of large size. When the kidney is reached 
 it should be enucleated from its capsule, or, if the latter is adherent, should be 
 separated with it from the perinephric fat and surrounding tissues. The ureter 
 should be tied separately and the stump curetted and disinfected. The vessels 
 should be tied by one stout silk ligature, or, better, in two bundles, by passing 
 a pedicle needle carrying a double ligature between them, tying the two halves 
 separately, and then " tying back " around the whole mass. 
 
842 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 The pedicle should then be cut through uith scissors at least a half-inch 
 from the ligature. Further hemorrhage may be arrested, if serious, by hemo- 
 static forceps left in situ, or, if moderate, by plugging with iodoform gauze 
 around a drainage-tube. 
 
 INFLAMMATORY AND SUPPURATIVE AFFECTIONS OF THE KIDNEYS. 
 
 Interstitial Nephritis as a surgical affection is due either to some 
 inflammation or ulceration of the urinary tract below the kidney or to some 
 reflex irritation, such as that from catheterism, acting upon a kidney which 
 has already long been subjected to pressure caused by anterior obstruction, 
 such as urethral stricture or prostatic hypertroj)hy. A rigor may usher in 
 the attack if it is acute and follows instrumentation, or the symptoms may be 
 very insidious in the subacute variety due to associated chronic obstruction or 
 irritation. In either case there are likely to be moderate fever, thirst, ano- 
 rexia, dry tongue, and gradual exhaustion. In the absence of inflammation 
 of the bladder, prostate, or urethra the urine contains merely a trace of albu- 
 min. Hyaline casts are present, but may be scanty. As a rule, this condition 
 runs into suppuration of the kidney, or, if it has arisen acutely from catheter- 
 ism with a septic instrument, is associated with a suppurative pyelitis or iryelo- 
 nepltritis. These conditions have the same causes as the non-suppurative affec- 
 tion, with the additional factor of infection by the pyogenic bacteria. 
 
 A patient who has had chronic inflammation or atony of the bladder, or 
 prostatic disease with residual urine, or an old tight stricture with occasional 
 retention, or who has recently had an operation upon the urethra or the blad- 
 der, or who has a renal calculus, or tubercle or carcinoma of some portion of 
 the urinary tract, may suddenly develop a high temperature, drowsiness, a dry, 
 furred tongue, a sallow color, and rapid loss of flesh ; or such a case may run a 
 more chronic course, with pain in the back, frequent micturition, evening rig- 
 ors, quotidian or tertian, and a variable quantity of pus in the urine. Often 
 the lumbar pain and the fever are in inverse proportion to the percentage of 
 pus while it accumulates in the dilated and often sacculated kidney ; tension 
 and pain are great, septic absorption and fever are marked. The discharge 
 of the pus is followed by a subsidence or temporary disappearance of these 
 phenomena. 
 
 Pyo-nephrosis. — If a considerable accumulation takes place, the kidney 
 becomes converted into a mere sac or bag containing pus, and forming a 
 tumor most prominent in the ilio-costal space posteriorly, moderately tender 
 to the touch, diminishing sometimes in size coincidently with an increase of 
 pus in the urine, obscurely fluctuating, and dull on percussion ; on the right 
 side its dulness may be separated from that of the liver by a line of resonance 
 over the colon, but this is not constant, as the kidney and liver may have 
 become adherent at various points. 
 
 This condition of pyo-nephrosis is most apt to occur when, in addition to 
 the usual causes of pyelo-nephritis, the^'e is some anterior obstruction, as stric- 
 ture or enlarged prostate, or still more constantly if the obstruction is in the 
 ureter, as from contraction of its vesical orifice, or from an impacted stone. 
 
 In women, as has been demonstrated by Kelly, it is possible to catheter- 
 ize separately the two ureters, and in this manner determine from which kid- 
 ney the pus or blood may come. Harris of Chicago has devised an instru- 
 ment which, by means of a blunt blade inserted in the rectum in men and in 
 the vagina in women, will raise the posterior floor of the bladder into a ridge 
 in the middle line, thus forming two lateral pouches into which the two 
 ureters deliver the urine of the two kidneys separately, and from which the 
 
SURGERY OF THE G EN ITO- URINARY TRACT. 843 
 
 urino of each kidiiev can be drawn tlirouf^'Ii separate tubes. This instru- 
 ment has been successfully used by a number of surgeons, and bids fair to 
 be of some use in differentiating tlie condition of the two knlneys. 
 
 llYDiiu-NEPiiKusis when not congenital is due to similar conditions. 
 Althouc^h the cause of hydro-nei)hvosis is always mechanical and obstruc- 
 tive, itis congenital in a large proportion— nearly one-third— of the cases, and 
 is tiien due to various pathological conditions of the ureter, such as twists or 
 kinks or stenosis, or to its compression from some abnormality of surrounding 
 structures, or to obstruction at its point of emergence from the kidney or at 
 that of its entrance into the bladder. 
 
 Among the causes which exert their influence later in hie, malignant dis- 
 ease of the pelvic viscera is one of the most common. Then, of course, the 
 hydro-nephrosis is merely a symptom altogether secondary in importance to the 
 uiiderlyinc^ disease, but it may serve as an important aid to diagnosis in doubt- 
 ful cases m the rather exceptional instances where it forms a distinct lumbar 
 swellincr. Impaction of a calculus in the ureter, which has been found m 40 
 per cent of acute cases, is of much more practical significance, and may require 
 operative interference by the method already described. An accumulation ot 
 urine in the kidney. from obstruction in floating kidney may also be the cause 
 of ac((uired hydro-nephrosis, which is then intermittent. 
 
 It should not be forgotten that frc(iuent micturition is in itself a compe- 
 tent cause for the production of hydro-nephrosis, acting through the oft- 
 repeated interference with the escape of the urine from the vesical ends of tbe 
 ureters. Hydro-nephrosis may aftect either kidney, and in about 15 per cent, 
 of the reported cases both kidneys have been involved. 
 
 Symptoms.— While the case is a simple one of hydro-nephrosis— z. e., 
 before infection with pyogenic microbes has occurred, there may be almost no 
 evidence of disease of the kidney until a distinct swelling is apparent m the 
 loin, or, more rarely, in the abdomen. In children frequency of urination may 
 be the only noticeable symptom, and may lead to an ineffectual search for ves- 
 ical calculus and to circumcision. In adults it is even more difficult of early 
 recognition, on account of the greater thickness of the abdominal walls. 
 
 It should not be forgotten that the frequency with which hydro-nephrosis 
 causes a visible or palpable tumor in the loin or abdomen is very slight, com- 
 pared with the great number of cases found at autopsies. In advanced cases 
 the concomitant disturbance of the renal function may give rise to thirst, to 
 nausea or vomiting, to persistent headache, to dryness and sallowness of the 
 skin ; yet these are symptoms common to many affections of the kidneys. If 
 there is a rapid rate of growth, lumbar aches, obscure abdominal pains, and 
 frequent micturition may be added to the symptoms, and if the disease is bilat- 
 eral there may be intermittent anuria of varying degrees, followed by uremia. 
 Constipation from pressure on the descending colon is an occasional symptom. 
 When the swelling appears, it will present the characteristics which distinguish 
 growths involving the kidneys ; i. e. it will first show in the flank, and will 
 have the colon in front of it, and often the small intestine also. It will, in 
 addition, be dull on percussion, more or less distinctly fluctuating, and rounded 
 or irregularly lobulated. A history of a lumbar tumor varying in size is 
 almost pathognomonic, but it should be remembered that patients with other 
 cystic swellings, and even with solid tumers, will often innocently make very 
 misleading statements as to changes in size which they imagine they hare 
 noticed. If, however, the variation was unmistakable, and especially if a 
 diminution in size was associated with an increased outflow of urine, the diag- 
 nosis may be made with much positiveness. The symptoms of pyo-nephrosis, 
 
844 JiV AMKRIVAN TEXT-BOOK OF SLUUKUY. 
 
 which niav at any tiiiu' supervene in such a case, will he easily recofi;nized. 
 The development of ritjors, fever, .sweating, and increased local pain and ten- 
 derness, together with the appearance of pus in the urine, will often clear up 
 the case at once. If these syniptonis are wanting, as they sometimes are, the 
 diagnosis may be impossible. 
 
 Ilydro-nephrotic tumors have been mistaken for ovarian growths with con- 
 sideral)le fre(iuency, a number of cases having been submitted to laparotomy 
 before the error was recognized. If an accurate history is obtainable, the direc- 
 tion of the growth of the swelling, its association with some renal symptom, the 
 relation to the colon, and the negative results of vaginal and uterine examina- 
 tion will usually clear up all doubts. 
 
 It might be thought that an examination of a small portion of the fluid 
 withdrawn by means of an aspirator would be conclusive, but such is not inva- 
 riably the case. It is never })ure urine, but usually contains urea, with acid 
 and a little albumin. Sometimes, however, these ingredients are wanting, and 
 the tapping may simply furnish a thick, ])urulent, putrid fluid, which could 
 scarcely be distinguished from that of a perinephric abscess (9-. v.). 
 
 Prognosis. — The prognosis varies with the cause. If that is not malig- 
 nant or in itself necessarily fatal, if the tumor is of but moderate size and is 
 stationary, if only one kidney is affected, and if the lower urinary organs are 
 not the seat of suppurative disease, there is but little risk to life. If both kid- 
 neys are involved, uremia commonly results. 
 
 Treatment. — The administration of drugs is of no avail. Frictions and 
 manipulations have seemed to be successful in a few cases, all of them young 
 children, but obviously little dependence can be placed on such methods, which 
 might even be dangerous if vigorously employed. Tapping is folloAved by cure 
 in a certain proportion of cases, but usually has to be repeated a number of times. 
 It is better to use a small needle and to remove the fluid by aspiration. If the 
 right kidney is affected, the best point for the insertion of the needle is halfway 
 between the last rib and the crest of the ilium, and about two and a quarter 
 inches posterior to the anterior superior spine. On the left side the absence 
 of the liver makes it safe to go a little higher, and a spot just below the last 
 intercostal space may be selected. 
 
 A simple aspiration may effect a complete cure, either by the relief of tension 
 or by permitting the unfolding of a twist of the ureter. If repeated tappings 
 fail to bring about a cure, nephrotomy, stitching of the edges of the cyst to 
 the parietal wound, and drainage and irrigation should next be employed. 
 Nephrectomy should be used only in cases in which a permanent fistula 
 with offensive purulent discharge indicates great disorganization of the renal 
 tissue and threatens the development of sepsis. If ai the first tapping the fluid 
 is found to be distinctly purulent, nephrotomy should be done either at once 
 or as soon as the tumor re-forms. 
 
 Weir has suggested that in cases of acute septic invasion of the kidney an 
 exploratory incision on one or both sides mijjht relieve the acute interstitial 
 invasion, and, if a large and well-defined focus of pus were found, might do 
 still more good, lie did a nephrectomy successfully in one case of septic 
 pyelo-nephritis, but the frequency with which both kidneys are involved in 
 such cases makes it improbable that the operation would often result favor- 
 ably. 
 
 Perinephritis. — Inflammation in the loose connective and fatty tissues 
 surrounding the kidney is of very fre(iuent occurrence. It is most frequently 
 found in adults, and is not uncommon in children. 
 
 Etiology. — Perinephritis may be simple and idiopathic, or may be the 
 
SURGERY OF THE GENITO-URINARY TRACT. 845 
 
 result of an aftectioM of" the kidney itself. Occasionally its exciting cause is 
 to be found in some noiglil)oring or remote organ or structure, or it may be 
 due to traumatism. 
 
 Symptoms. — When it is not the result of infection, it has but little 
 importance from a surgical point of view. The symptoms are vague, the 
 most noticeable being localized tenderness and pain, relieved somewhat by 
 flexion of the thigh upon the abdomen ; stiffness of tlie spinal column ; incli- 
 nation of the trunk toward the affected side ; inability to bi'ing the ham to 
 the surface on which the patient lies su])ine, or at least inability to do so with- 
 out much pain. There is also fever, sometimes quite marked. 
 
 Diagnosis. — This condition is often mistaken for coxalgia or for Pott's 
 disease in the early stage. Perinephritis should be recognizable by the locali- 
 zation of the tenderness, the absence of the characteristic deformities of either 
 the spine or the lower extremity, and the failure to elicit pain or tenderness by 
 pressure on the trochanter or by crowding together the vertebrae. Occa.sion- 
 ally pain in the knee increases the resemblance to coxalgia. 
 
 Treatment. — Rest is most important. Stimulating liniments applied 
 with deep friction may be useful ; leeches or wet cups followed by hot stupes 
 have been employed with apparent benefit. Laxatives are indicated, and 
 small doses of opiates and of belladonna, by relieving the spasm of the psoas, 
 may be of much value. The case may terminate in resolution, but much more 
 commonly runs on to suppuration. 
 
 Perinephric Abscess. — The infective inflammation in these cases may 
 extend to the loin from any portion of the urinary or intestinal tract in rela- 
 tion by contiguity or continuity with the retro-peritoneal connective tissue. 
 Thus it has been known to follow lithotomy, internal urethrotomy, castration, 
 prostatic abscess, appendicitis, etc. It may result from perforation of the 
 diaphragm by an empyema. In many cases it is secondary to suppurative 
 pyelitis, usually calculous in its origin. Actual, or at least demonstrable, per- 
 foration of the capsule of the kidney is not a necessity in these cases, the 
 inflammation appearing to spread by contiguity, although doubtless all such 
 cases indicate true microbic infection of the area secondarily invaded. 
 
 Symptoms. — The indications of the formation of pus in a case of peri- 
 nephritis are similar to those which accompany deep-seated suppuration any- 
 where. Rigors, sw^eats, high temperature, etc. are apt to be marked. If the 
 abscess is consecutive to disease of the kidney and the result of the escape of 
 urine through a renal fistula, the debilitated condition of the patient and the 
 putrescible and highly poisonous character of the extravasated fluid are factors 
 which give the case peculiar gravity ; an intense primary septic intoxication 
 (sapremia) immediately resulting, often soon followed by Avell-developed septice- 
 mia. In other instances the case runs a slow course, the constitutional symp- 
 toms being vague and ill defined. In these cases the following group of local 
 symptoms will be of chief diagnostic importance : deep-seated, paroxysmal 
 lumbar pain extending into the thigh and the hypogastrium, sometimes into 
 the groin and scrotum ; tenderness on direct, and especially on bimanual, pres- 
 sure upon the loin, one hand being in front, the other behind ; increased re- 
 sistance and fulness in the lumbar region, followed by brawniness of the skin 
 and later by oedema ; lameness, flexion of the thigh upon the abdomen, incli- 
 nation of the body toward the affected side, are, as in simple perinephritis, of 
 great value ; oedema of the lower limb on the same side is of frequent occur- 
 rence ; the formation of a distinct fluctuating swelling, vague in its outlines, 
 would ordinarily be conclusive as to the character of the case, but if doubt 
 remains the use of a hollow needle will resolve it. 
 
846 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 Diagnosis. — Nephralgia and renal calculus lack the inflaniinatory and 
 constitutional symptoms which accompany abscess ; lumbago could be recog- 
 nized by the absence of fever, of flexion of the thigh, and of lateral bending 
 of the trunk ; hip disease and vertebral caries, by the characteristic deformities 
 and by the gait of the patients ; aj)pendicitis and periciecal altsco.ss, by the site 
 of original pain and by the concomitant intestinal and abdominal symptoms; 
 psoitis and psoas abscess, by the situation of the pain, which is apt to be 
 anterior to a line draAvn from the front border of the axilla to the crest of the 
 ilium, while in perinephritis and perinephric abscess the local symptoms are 
 apt to be posterior to such a line (Morris). 
 
 Prognosis. — The proba])ility of entire recovery of course varies greatly 
 with the cause. In simple cases treated by early incision recovery is prompt 
 and complete. In cases dependent upon suppuration along the urinary or 
 intestinal tract, extending to the retro-peritoneal connective tissue, early ope- 
 ration is likewise followed by cure in the great majority of instances. In 
 cases secondary to pyelo-nephritis, renal calculus, etc. fistula often follows, and 
 the final outcome is greatly influenced by the character of the renal disease. 
 
 Treatment. — In all cases operation should be resorted to as soon as 
 the condition is recognized, or even as soon as there are distinct localizing 
 symptoms showing the presence of an acute inflammation with no tendency 
 to disappear by resolution. An incision on the outer edge of the quadratus, 
 in the costo-iliac space, vertical or oblique, and opening up the post-renal space, 
 is of no gravity whatever. Delay may mean extensive burrowing, perfora- 
 tion of the diaphragm with consecutive empyema, and opening of the abscess 
 into some of the contiguous viscera or into the peritoneal cavity. An explora- 
 tion by means of a hollow needle should certainly be made, therefore, when- 
 ever the earlier symptoms of perinephric inflammation are followed by fulness, 
 hardness, and tenderness, and especially if in addition there are heat and red- 
 ness of the skin. Failure to find pus in this manner may warrant further 
 delay, but a persistence of the same symptoms would certainly justify a free 
 incision long before fluctuation could be felt through the thick abdominal 
 parietes. Six pints of pus were found and evacuated in one such case, although, 
 owing to the thickness of the subcutaneous fat, no fluctuation could be made 
 out. 
 
 After evacuation of the pus the finger should explore the kidney, and if 
 a renal fistula is found it should also be probed. If there are grounds for 
 believing the disease to be of calculous origin, the kidney should be carefully 
 palpated, or even pierced with an exploring needle or probe, in the endeavor 
 to locate a stone. If one is found, nephro-lithotomy may be proceeded with 
 at once if the condition of the patient warrants it. As a rule, nephrectomy 
 even in cases of real disorganization of the kidney should be postponed, as 
 statistics show a much lower mortality after secondary operations for removal of 
 the kidney than after those done at the time the loin is opened for abscess or 
 to permit of the extraction of a stone. 
 
 The cavity should be thoroughly and forcibly sponged out, so as to remove 
 all shreds of necrosed connective tissue, the ddbris of the abscess, and much 
 of the infected granulation-tissue. If it is limited in extent, it may be well 
 to curette the walls. Free irrigation with sublimate solution, the insertion of 
 a drainage-tube, the inner end of which may be carried directly into the open- 
 ing in the kidney if there be one, and the packing of the wound with anti- 
 septic gauze, complete the operation. Only a few sutures at each angle of the 
 wound are allowable. Nutritious food, tonics, and often stimulants, are urgently 
 needed by the patient during convalescence. 
 
SURGERY OF THE GENITO- URINARY TRACT. 847 
 
 Tuberculosis of the Kidney is usually associated with evidences of 
 tul.crcular disease elsewhere, and occurs chiefly in hroken-down persons, often 
 of middle aj^e or younger. It has been differentiated into "scrofulous kid- 
 ney" and "miliary tuberculosis of the kidney," etc., but there is no important 
 clinical or pathological distinction between the varieties, which differ only in 
 the extent of the renal involvement. If the tuberculosis assumes the miliary 
 or disseminated form, it is apt to affect both kidneys, and as a rule, reveals an 
 intense de^rree of constitutional infection. The other form is a tubercular 
 pyelo-ncphntis, sometimes local and primary, oftener secondary to other vis- 
 ceral tuberculosis, and more especially to ulcerating tubercular disease of the 
 bladder or prostate. The symptoms are those of pyelo-nephritis plus the evi- 
 dences of general tubercular disease. The patient often has a strongly marked 
 family history of tuberculosis. i i x-^ ^i of 
 
 It has been said that vesical irritation is the most usual, and often the most 
 prominent and distressing, symptom. Dickinson asserts that m a case contain- 
 in<^ pus from the kidneys the absence of bladder symptoms excludes renal 
 tuberculosis. It is more probable, however, that the frequent micturition anu 
 vesical tenesmus depend on a beginning tubercular deposit about lie lower end 
 of the ureter or in the bladder itself. There may not be a lumbar tumor, ihe 
 prominence of the vesical symptoms and the coexistence of tubercle elsewhere 
 are most to be depended on for diagnosis. 
 
 The prognosis is unfavorable. ^ . 
 
 The treatment in advanced cases should be palliative. In primary cases 
 which have gone on speedily to suppuration and to the production of pyo- 
 nephrosis or perinephric abscess, and in which the condition of the kidney is 
 therefore discovered during the operation for these conditions, and before the 
 general health is much affected, operation may be considered, it but one or 
 two caseous foci are found and the kidney is not much enlarged or nodulated, 
 incision, curetting, and drainage may suffice. In more extensive disease 
 nephrectomy offers the only hope of cure. . -, t .i, ^ »ooo 
 
 Cysts of the Kidney may be congenital or acquired. In the former case 
 they are sometimes of enormous size, and may even interfere with delivery. 
 These are thought to be due to defective development of the tubules, as in 
 such cases there are often other imperfections arising from developmental iail- 
 nre In the adult they are often found in large numbers scattered through 
 the parenchyma of the organ or sometimes occupying chiefly the cortex, ihey 
 cannot be diagnosticated during life, as they produce no distinctive symptoms 
 and often no symptoms at all. ^^+:^^ 
 
 More rarely, however, simple or serous cysts form and constitute a notice- 
 able tumor. They begin in the cortical portion of the organ aad grow toward 
 the surface, the rest of the kidney remaining normal. The precise origin of 
 these cysts is uncertain. They grow toward the loin increase slowly and at 
 first painlessly, and have the usual characteristics of renal tumors: as they 
 enlarge the cyst-wall thins, and a tumor which at first may have been mistaken 
 for a solid growth becomes evidently fluctuating. Hemorrhage may take place 
 into the cavity of the cyst, or it may become the starting-point of a malignant 
 
 ^^""Thrdiagnosis is difficult, and it is often impossible to distinguish such a 
 cyst from one of the spleen, liver, pancreas, omentum, or mesentery, or indeed 
 from any other intra-abdominal growth. .i, • ^ p „^ ^;^h 
 
 Prognosis.— If unrelieved, death may result from the interference with 
 nutrition caused by the immense size of the growth and its pressure upon other 
 
848 A.y AMKIUCAX TEXT-noOK OF SURGERY. 
 
 parts, or may be caused by exhaustion from repeated hemorrhages into the 
 cyst-cavity. 
 
 Treatment. — Frequent tapping -will often effect a cure. If it fails to do 
 so. the cyst sliould be cut down upon and oj)ened and its edges attached to those 
 of the j)arietal wound. Complete collapse and cure often follow. If a per- 
 sistent fistula is left, nephrectomy will offer the only prospect of cure, but 
 the fact that the kidney is probably healthy and functionally active must 
 weigh strongly against operation if there be the least reason' to doubt the 
 condition of the opposite kidney. 
 
 Hydatid Cysts are found in the kidneys more frequently than in anv other 
 organ except the liver and the lungs. They are sometim&s secondary to 
 hydatids of those organs. They give rise to the same general symptoms a's do 
 other renal cysts, but, owing to their tendency to rupture into the pelvis of the 
 ureter and to discharge their contents by that route, the prognosis is more 
 favorable. In 52 out of 53 cases collected by Roberts the cysts were evacuated 
 in this manner, and there is no authentic case recorded in which such a cyst 
 emptie<l itself through the loin. 
 
 The diagnosis can be made with certainty only when the vesicles or 
 booklets are recognized in the urine, or after removal through a trocar. Their 
 passage along the ureter excites the usual symptoms of renal colic. 
 
 The treatment should consist in incision, suture of the edges of the cvst 
 to the parietal wound, and drainage. Daily irrigation and dressing will be 
 required for a long time. Tapping may be employed previous to incision, but 
 is usually unsuccessful. 
 
 Solid Tumors of the Kidney. — Most of these are malignant, and the 
 majority are carcinomatous. The greater number, again, are secondary to 
 cancer of the testicle or to cancer of some other organ. The most frequent 
 form of renal cancer is the soft, or medullary, which is oftenest found in 
 young children or in persons of advanced age. 
 
 Hematuria and pain in the loin, succeeded by the development of a hard, 
 nodulated tumor attaining an extremely large size in a comparatively short 
 time, and occurring before the age of five or after that of sixty, would consti- 
 tute a group of symptoms justifying the diagnosis of renal cancer. Occasion- 
 ally the passage t^f small cancerous masses per urethram admits of a positive 
 microscopical diagnosis. If this were made very early, nephrectomy would 
 offer some chance of cure, otherwise the treatment must be palliative. Butlin 
 reports 2 cases out of 18 free from recurrence at the end of three years after 
 operation. 
 
 Sarcoma presents the same clinical symptoms. It occurs chiefly in the 
 young. The only chance of cure lies in the early extirpation of the organ. 
 
 INJURIES OF THE KIDNEY. 
 
 SuBPARiETAL INJURIES. — Injuries of the kidney without wound of the 
 abdominal parietes may result from direct violence, as from crushes and blows 
 upon the loin or upon the ilio-costal region of the abdomen, or from indirect 
 violence, as in falls from a height, accompanied by sudden bending of the 
 trunk at the time of alighting. They are by far the most fretiuent of all forms 
 of injury to the kidney. The}" may be very severe up to rupture or even 
 actual pulpefaction of the organ, or may consist of an extremely slight con- 
 tusion with few symptoms. 
 
 Symptoms. — The history of an accident or traumatism sufficient to have 
 produced the injury, lumbar pain and tenderness shooting down toward the 
 
SURGERY OF THE GENJTO-URINARY TRACT. 849 
 
 groin, testicle, or tlii^ijli, fV(M|ueiit and pninfiil micturition, and hematuria, are 
 the symptoms most commonly present. In severe cases with extensive lacera- 
 tions of the substance of the kidney there are superadded the constitutional 
 symptoms of hemorrhage and shock, and sometimes of collapse. As to the 
 hematuria, which is perhaps the most distinctive sign of injury of the kidney, 
 it must not be forgotten that it may be marked in a case of strain or simple 
 contusion in which there has been a sudden congestion in some portion of the 
 urinary tract, or may be absent in cases of laceration of the kidney in which 
 the ureter is plugged and occluded by a coagulum. 
 
 Prognosis. — In simple contusions the prognosis is favorable, and even in 
 injuries attended Avith a certain degree of laceration there is a larger propor- 
 tion of recoveries than after rupture of other abdominal viscera. If death 
 occurs speedily, it is usually due to hemorrhage or collapse; later, to perito- 
 nitis or to diffuse suppuration in the loin, with septicemia or pyemia, or, if the 
 opposite kidney happens to be diseased, to uremia. 
 
 Treatment. — The patient should be kept absolutely at rest ; the diet 
 limited to liquids; gallic acid or ergot or opium and lead administered if 
 hematuria is extreme. Strapping the affected region so as to limit the move- 
 ments, as in cases of fractured rib, will often give great relief from the pain. 
 Enemata may be given at first if required. Purgatives should be avoided. 
 Vomitino-, by encouraging hemorrhage, is especially dangerous. If persistent, 
 the patient should for a time be fed entirely by enemata. The chief difficulty 
 often consists in the accumulation of blood-clots in the bladder, followed by 
 vesical tenesmus and by retention of urine. If the blood-clots are small, they 
 will probably be spontaneously evacuated. If they are somewhat larger, 
 causing retention and tenesmus, a large catheter with two good-sized lateral 
 openings should be introduced and the bladder injected wijth some non-irritating 
 antiseptic solution with moderate force. If this fails, one of the evacuating 
 tubes used in litholapaxy may be inserted and connected with the evacuator, 
 and fluid thrown into and drawn out from the bladder by that means. 
 
 Occasionally all these methods fail, and in such cases a median urethrotomy 
 is indicated, both to evacuate clots and to relieve retention, and also to avoid 
 decomposition of the blood and urine and the subsequent pyelo-nephritis from 
 which many such patients have died. In cases of profound shock with or with- 
 out hematuria, but with an increasing tumor in the loin, an incision should be 
 made as if for lumbar nephrotomy or nephrectomy ; the kidney should be thor- 
 oughly examined, and if torn across or pulpefied should at once be removed. 
 Resection of a portion of the kidney in such cases has been proposed, but 
 seems likely to be attended with a larger mortality than nephrectomy. 
 
 Penetrating Wounds of the Kidney. — A wound extending through the 
 soft parts to the kidney may be either extra- or intra-peritoneal. In extra- 
 peritoneal Avounds of the kidney the posterior surface of the organ is involved, 
 and the wound extends through the tissues of the loin. Exploration with an 
 aseptic finger is proper and Avill often establish the diagnosis. The appear- 
 ance of urine in the wound would of course be conclusive, but its absence 
 does not disprove the existence of a renal wound, as the latter may involve 
 only the cortex, neither the pelvis of the ureter nor a renal calyx having 
 been opened. Hematuria may be due to coincident contusion, but it always 
 points strongly to involvement of the kidney. Perinephric abscess is a com- 
 mon sequel. 
 
 If the wound is on the anterior surface and is intra-perito?7eal, the symp- 
 toms will include those due to extravasation of blood or urine into the peri- 
 to^neal cavity, 
 
 54 
 
8.50 
 
 .-l.V AMi:iiirAy TEXT- HOOK <Jl' SLRdKHV. 
 
 Prognosis. — In the latter class of cases the profrnosis is very unfavor- 
 able, hut ill extra-peritoneal Avound? of the kitlney. uneoniplicated hy injury 
 to other structures, recovery niav he expected in the majority of cases. 
 
 Treatment. — In extra-peritoneal wounds, rest, low diet, ergot, and small 
 doses of opium, and thorough antisepsis in and around the wound, are clearly 
 indicated. Hemorrhage may be arrested by packing, accompanied, if neces- 
 sary, hy enlargement of the wound, so as to prevent urinary infiltration. 
 Drainage should be secure<l bv the introduction of a larji-e rubber tube down 
 to the wounded surface. 
 
 In iiitra-peritoneal wounds abdominal section, with nephrectomy, will almost 
 always be required. 
 
 WOUNDS OF THE UEETERS. 
 
 There are very few recorded instances of uncomplicated wounds of the 
 ureters. In the historic case of the archbishop of Paris, who was shot in 
 the loin during the revolution of 1848, and who died in eighteen hours, the 
 ureter was divided close to the pelvis, but there were also fracture of the third 
 lumbar vertebra and division of the cauda equina. 
 
 The ureter has been Avounded during the removal of uterine, ovarian, and 
 other abdominal tumors. Occasionally it has been divided purposely on 
 account of its incorporation Avith a malignant groAvth (Morris). 
 
 A''an Hook, Avho has studied the surgery of the ureter extensively, advises 
 against the use of sutures in longitudinal wounds of this 
 Jig. 343. duct. For cases of complete division of the ureter he has 
 
 devised the folloAving method of anastomosis (Figs. 343, 
 344). If the division of the ureter is 
 Fig. 344. sufficient to exclude the chance of suc- 
 
 cess by suturing, but not complete, it 
 should be made so. The free extremity 
 of the distal portion is then ligated 
 with silk or catgut one-fourth to one- 
 half inch from the point of division. 
 Then make Avith fine, sharp-pointed 
 scissors a longitudinal incision in the 
 ureter, beginning one-quarter of an 
 \\ / /J^ \ I j h ^1 X / inch beloAv the ligature, and twice as 
 
 ^F Im^ a I \ \ Ai^ ^^^^c, ^^ ^^^^ diameter of the ureter. 
 
 Next make an incision Avith the scis- 
 sors, one-quarter of an inch in length 
 ( i \ 5^^vf ( (r^ ^^^~Vn ^" *^^ ^''^^ ^^^ "^ ^^^® proximal por- 
 
 ) \ \/j^'^M\ V I (y7^^'a\c \ ^^^^' ^^""^ ^^^y small cambric needles, 
 
 V threaded on the same piece of catgut, 
 are passed through this end from witliin 
 outAvard. one-eighth of an inch from 
 the free end. and one-sixteenth to one- 
 eighth of an inch apart. The needles 
 are then carried through the slit in the 
 lower portion of the ureter and doAvn 
 the tube for half an inch. Avhen they 
 are pushed througli the Avail of the 
 duct side by side ; the upper portion 
 of the ureter is draAvn into the lower by traction on the suture, and secured 
 by a knot. The ureter is then carefully enveloped Avith peritoneum. 
 
 Van Hook's Method of Uretero-ureteral Ana.<!t(>- 
 mosis: Fig. 343 shows the ureter rtividid. and 
 the lower end tied aijd split on one side, ready 
 to ref-eive the upperend. whieh is drawn down 
 into it bvtwo traction lii:atnres: Fifr. :M4shr>ws 
 the ureter held in place by the traction liga- 
 tures, which have been tied. The five untied 
 sutures unite the entering ureter to the cut 
 edges of the intussuscipient ureter. 
 
SURGERY or THE GENITO-URINARY TRACT. 851 
 
 Fowler has recently reported a method of iinidaiitatioii of the ureters 
 into the rectum in exstrophy of the bladder (see below), by which the abdo- 
 men is opened in the median line, the patient being in the Trendelenburg 
 position : the ureters are identified, exposed, and cut away from the bladder 
 wall, and then placed in the anterior wall of the rectum through a valve-like 
 opening. He has had a good result in one case. 
 
 Stricture of the Ureter is of very rare occurrence, except as a result 
 of compression from without by pelvic or abdominal new growths. 
 
 Watson of Boston has, however, reported two cases of stricture, in both 
 of which a ureter was nearly or quite obliterated by a dense mass of connect- 
 ive tissue. In one case there was a doubtful history of the passage of a renal 
 calculus years previously. The condition Avas associated with pyo-nephrosis in 
 both instances. He has collected four other cases from medical literature. 
 
 PART II.— DISEASES AND INJURIES OF THE BLADDER. 
 
 Congenital Deformities. — Occasionally, but rarely, the bladder is absent, 
 and in that event the ureters may open directly into the urethra, rectum, or 
 va^dna, or upon the surface of the body in the middle line. The condition 
 is usually associated -with other abnormalities, such as undescended testicles, 
 imperforate anus, etc. 
 
 Supernumerary bladders are also rare forms of congenital deformities, 
 most of the reported cases having been really examples of multilocular or sac- 
 culated bladder. A few^ authentic instances exist, how^ever, in one of which 
 there were said to be five separate bladders. 
 
 Cystocele, or hernia of the bladder, is usually secondary to obstructive dis- 
 ease. The dilatation of the organ, the thickening and weakening of its coats, 
 and the straining during the frequent efforts to evacuate the urine constitute 
 powerful factors in bringing about a protrusion of the viscus. This is also 
 favored by weakness or relaxation of the abdominal walls, as from ascites or 
 senility, or by the existence of a broad cicatrix followdng abdominal section. 
 The bladder in these cases will protrude in the line of the linea alba, but in 
 others it may follow the track of the cord or of the great blood-vessels 
 through the walls of the abdomen, and appear in the inguinal or femoral or 
 obturator region. In the female prolapsus frequently takes place into the 
 vagina, the bladder protruding between the labia. 
 
 Symptoms. — The presence of a rounded fluctuating tumor in any of the 
 above situations, increasing in size during the intervals of urination, markedly 
 reduced in size by catheterization or after micturition, and lacking the charac- 
 teristic signs of epiplocele or enterocele, should serve to establish the existence 
 of a hernia of the bladder. In case of doubt a grooved needle or an aspirator 
 will remove all difficulty. It should not be forgotten that in a case of cysto- 
 cele, especially if it be irreducible, the interference with the evacuation of the 
 urine tends to favor the formation of calculi, and that one or several may 
 exist in the protruding pouch and may be mistaken for nodules of malignant 
 growths. 
 
 Treatment. — When the tumor is reducible, a truss should be worn to 
 retain it in place. When it is irreducible, a support or truss with a concave 
 pad may be used to prevent its increase. Operative treatment has, as a rule, 
 been unsatisfactoiy, except sometimes in vaginal cystocele. 
 
 Exstrophy is the most frequent of all the congenital defects of the bladder. 
 It occurs in males in from 80 to 90 per cent, of all cases. It results from an 
 arrested development of the lateral portions of the uro-genital cleft, which fail 
 to come together to form the front of the bladder and the anterior parietes of 
 
852 ^^V AMERICAJS^ TEXT-BOOK OF SURGERY. 
 
 the abdomen. The pubic symphysis is absent. The posterior wall of the 
 bladder, covered with mucous membrane. Imlges forward through the unnatural 
 opening, and is usually covered with tenacious vesical mucus. The penis is 
 the subject of complete epispadias. The prostate is rudimentary. There is 
 usually complete double inguinal hernia, the presence of which in the two 
 halves of the scrotum, already separated by the unnatural interval between the 
 pubic bones, causes the parts to resemble the labia of the female. If the scro- 
 tum is absent, the testes are found in the inguinal canal. 
 
 A similar condition in tlie female causes a separation of the labia and 
 nymph?e and converts the vagina into a shallow fissure, but the disability pro- 
 duced is not so great as in the male. 
 
 Patients with exstrophy are usually found with marked cystitis from expo- 
 sure of the mucous membrane to the air and from its friction against the cloth- 
 ing. The urine is fetid and ammoniacal ; the skin of the abdomen, thighs, 
 perineum, and buttocks is excoriated or eczematous. The general nutrition is 
 often affected, and the child is apt to be feeble and sickly. 
 
 Treatment. — Appliances intended to collect the urine and protect the ex- 
 posed surface of the bladder have thus far been entire failures. Some opera- 
 tive procedure is necessary as a preliminary. Of the many methods which 
 have been devised. Wood's operation, which consists in turning down a flap 
 from the abdomen above the opening (between it and the umbilicus) and cover- 
 ing it by two others taken from the inguinal region, is perhaps the most gene- 
 rally applicable. In the male, Roux's operation as modified by Maury of Phila- 
 delphia is often most useful, and sometimes has the advantage of curing at the 
 same time any inguinal hernia which may coexist. It consists in turning up a 
 large convex flap from the scrotum, the groin, and the perineum, slipping the 
 penis through a small opening near the base of the flap, and sliding the edge 
 of the latter beneath a second flap raised from the tissue above and to each 
 side of the opening. The flaps are held in place by the " tongue-and-groove 
 suture." 
 
 Successful operations for exstrophy greatly diminish the annoyance of the 
 condition, concentrating the outflow of the urine at a single point, and thus 
 permitting the use of a urinal and preserving the surrounding skin-surfaces 
 from irritation. Of course in the case of the male sexual potency is never 
 acquired, the penis always remaining rudimentary. 
 
 GENERAL CONSIDERATIONS IN THE DIAGNOSIS OF GENITO-URINARY DISEASE. 
 
 Pain. — The pain of gen i to-urinary disease may be considered in relation 
 to the region in which it is felt and the time at which it is felt. In regard 
 to the first subdivision, it may be remarked that the region to which the pain 
 is referred should not be considered -as, necessarily the seat of the trouble. A 
 stone in the bladder causes pain which is felt at the under surface of the penis 
 a short distance back of the meatus ; disease of the kidneys constantly gives 
 rise to pain which is felt chiefly in the groin, down the thigh, or in the testi- 
 cle ; while disease of the testicle in its turn produces pain radiating along the 
 inguinal line. In the majority of instances, as in those mentioned, reflex pain 
 is due to the irritation of a nerve-trank, the abnormal sensation being 
 referred to the point of termination of the nerve : pain, however, may, of 
 course, be felt at the seat of trouble itself, as, for example, in urethritis, 
 where the pain is felt in the inflamed urethra ; in retention of urine, where it 
 is referred directly to the bladder and hypogastric region ; or in prostatitis, 
 where it is felt in the rectum and perineum. In some cases of the last-men- 
 tioned trouble the pain is duplex in character, being both localized and 
 
SURGERY OF THE QENITO- URINARY TRACT. 853 
 
 referred, a patient witli a tlireatencd prostatic abscess having rectal pain and 
 urethral ])ain at the same time, the latter closely resembling that produced by 
 vesical calculus. 
 
 The second subdivision in regard to pain refers to the time at -which it is 
 felt. Pain during micturition may be due to cystitis, prostatitis, or urethritis, 
 or to the passage of gravel, or to a small calculus. Pain before micturition, 
 which is relieved by that act, may be due to cystitis or to retention of urine. 
 Pain -which is increased at the end of micturition may be caused by vesical 
 calculus or by acute prostatitis ; if it is markedly increased during defeca- 
 tion, it points to the latter trouble ; if relieved by rest and much increased by 
 movement, it indicates the former condition. 
 
 Frequency of Micturition. — Increased frequency of micturition is a 
 diagnostic sign Avhich is of value only when considered carefully in its relation 
 to other symptoms. Normal micturition depends upon the healthfulness of a 
 certain nerve-tract, which, beginning in the peripheral extremities of the 
 nerves distributed to the genito-urinary apparatus, extends to a certain por- 
 tion of the lumbar enlargement of the spinal cord, and thence along other 
 nerves to the muscles of the bladder and urethra. If the sensory nerves are 
 unduly irritated, frequent micturition results. This is seen in phimosis, con- 
 tracted meatus, urethral stricture, urethritis, cystitis, prostatitis, and vesical or 
 renal calculus. If, on the other hand, the stimulus to these sensory nerves 
 remains normal, but the spinal center becomes irritable, the same effect is 
 produced as in cases of sexual excess or spinal concussion. The nerve-supply 
 may remain normal, and yet frequent micturition be produced either by an 
 excessive secretion of urine, as in diabetes, or by such contraction of the blad- 
 der as renders it disproportionately small, so that it is over-distended by even 
 a normal amount of urine. Or, again, micturition may be too frequent from 
 some obstructive cause, such as hypertrophy of the prostate, or when from 
 weakness of its muscular walls the bladder fails entirely to empty itself, always 
 retaining several ounces of urine. A condition which seems to combine the 
 hypersecretion of urine with intolerance of the bladder is that known as 
 "nervousness," or in its most aggravated form as hysteria. 
 
 It is evident, therefore, that we know but little which is of value so long 
 as we simply know that the patient urinates too often. Further light, however, 
 may be thrown upon the subject by a question as to whether or not the fre- 
 quency is increased by movement or by rest. If the former, a stone in the 
 bladder or a pedunculated growth of the bladder may account for it. If the 
 latter, it may result from retention of urine due to atony or to an enlarged 
 prostate. The patient with these last-mentioned troubles will find that he 
 urinates at shorter intervals at night than in the daytime. 
 
 There are other points in relation to this act which will help in arriving at 
 a conclusion. If the size of the stream is diminished, it suggests the existence 
 of a stricture, a contracted meatus, or an inflammatory swelling somewhere 
 along the urethral tract. If the force of the stream is diminished, it suggests 
 obstruction, as from stricture or prostatic disease, or muscular weakness, as in 
 atony. If the time required for the act of urination is increased, it likewise 
 suggests obstruction or weakness. 
 
 Hematuria. — Bloody urine may result from a solution of continuity at- 
 tended Avith hemorrhage and affecting any portion of the genito-urinary tract. 
 
 When the blood is derived from the kidneys, there will usually have been 
 a history of renal disease and coexisting evidence in the shape of albuminous 
 urine, granular or hyaline casts, oedema, retinal degeneration, etc. Or there 
 may be the characteristic symptoms of renal calculi, or the symptoms of wound 
 
854 AN AMFAilCAN TEXT- HOOK OF sriHlFHY. 
 
 or contusion of tlio kidnev, or of tumors, or tubercle of that oriran may be 
 present. In tlie majority of cases the blood wliicli is derived from the kidneys 
 is found when the urine is passed to be uiiiloinily distributed throu^^li it. jrivin^ 
 it a dark smoky hue, but in cases of wounds or of malignant growths of the 
 kidnev it is passed out in such quantities that it may fill the bladder with 
 clots (p. 841'). Long, narrow cylindrical ureteral clots will often be voided. 
 
 Hemorrhage from the ureters is almost always the result of the presence 
 or passage of a calculus, and is attended with all the symptoms of that occur- 
 rence, intense pain in the back and loins extending into the testicle on the 
 affected side, retraction of the testicle, vomiting, cold sweat, and profound 
 prostration. 
 
 Hemorrhage from the prostate, if non-traumatic, is usually the result of 
 tubercular or carcinomatous ulceration, and is attended with marked enlarge- 
 ment of that gland and with the usual symptoms of obstruction to urination. 
 Hemorrhage from the urethra is rare, except as a result of instrumentation. 
 In botli urethral and prostatic hemorrhage the blood is discharged in clots, 
 sometimes tubular or cylindrical in shape, which precede the stream of urine. 
 
 Hemorrhage from the bladder may be suspected whenever the symptoms 
 do not point to any of the above conditions, and, of course, may be recognized 
 with certainty when its immediate cause can be discovered. A vesical calculus 
 or tumor (usually a papilloma), a tubercular or carcinomatous ulceration, may 
 be recognized by the sound, the presence of fragments of the neoplasm in the 
 urine, the cystoscope, etc. 
 
 In acute cystitis or prostato-cystitis the symptoms of frequent and painful 
 urination, with tenesmus, will point to the cause. Obstructive disease in the 
 form of hepatic enlargement or abdominal tumors by pressing on the vena cava 
 may give rise to a degree of congestion in the vesical plexus which results in 
 hemorrhage. 
 
 Certain drugs, as cantharides and turpentine, in full doses produce the 
 same conditions. Diseases attended by profound alteration of the blood, as 
 purpura, scurvy, and occasionally some of the exanthemata, may be accom- 
 panied by vesical hemorrhage. The invasion of the coats of the bladder by 
 the Bilharzia hcamatohia is a possible cause of hematuria in some Eastern 
 countries. All these conditions are easily recognized by their concomitant 
 symptoms. 
 
 Treatment. — Of course when the cause can be definitely ascertained it 
 should be removed. In moderate hemorrhage without great distention of the 
 bladder, and Avith no serious interference with urination, the clots may safely 
 be left to the processes of nature if the bladder is a non-infected one. They 
 will gradually become disorganized and will pass out in shreds or dissolved in 
 the urine. If, however, they fill up the entire bladder and become obstructive, 
 or if such bleeding occurs in a case in which there is already ammoniacal and 
 fetid urine, it will be necessary to wash them out and to irrigate the bladder 
 with antiseptic and hemostatic solutions. , A full-sized catheter with very 
 large eyes should be used, and boric-acid solutions should be injected and 
 drawn out again by suction. The evacuating tube and washing bottle used in 
 litholapaxy will be found very serviceable in such cases. After the bladder 
 is free from clots, nitrate-of-silver solutions, from 1 : 10,000 to 1 : 500, may be 
 carefully employed with great advantage. In case of failure with the catheter, 
 a cystotomy, suprapubic or perineal, is indicated. In the majority of cases 
 the former is preferable, as permitting at the same time a more satisfiictory 
 exploration of the bladder, and possibly the removal of the cause of the 
 hemorrhage, as by excising a tumor, curetting a tubercular ulcer, etc. 
 
SURGERY OF THE GENTTO- URINARY TRACT. 
 
 855 
 
 RETENTION OF UKINi:. 
 Tlie l)la(l(ler inav fail to empty itself on account of various causes : 
 (1) OiKstnicthe ntuscs arc found in urethral stricture, spasmodic or organic ; 
 hvpertrophied prostate or acute prostatitis : impacted calculus ; tumors of the 
 urethra and bladder: congenital atresia of the urethra or of the preputial 
 orifice; constriction by a string tied around the penis; pressure by the gravid 
 uterus ; or fecal impaction. 
 
 (•2) DctWtice e.rj>uhirc force mav result from paralysis; from disease or in- 
 jury ; from atonv ; from reflex inhibition, as after the ligature of hemorrhoids ; 
 from shock or great muscular weakness in low fevers, etc. ; or from the toxic 
 action of drugs, as belladonna, opium, or canthandes. 
 
 Symptorns.— In either event the symptoms of retention are easily rec- 
 ocrnized. The local signs are the gradual formation of a hypogastric tumor 
 ri'sinc' into the abdomen and sometimes extending above the umbilicus. The 
 elonSition of the vesical fascia caused by this rise of the viscus is accompanied 
 by a° similar elongation of the urethra, so that, as in prostatic hypertrophy, 
 ail ordinary catheter may not be long enough to reach the bladder. 
 
 The tuinor is rounded in outline, and in thin persons can be seen through 
 the abdominal walls. . It is most prominent when the patient is erect. It is 
 dull on percussion and fluctuates; the flanks are resonant. 
 
 Fi<T 345 shows the swelling caused by a distended bladder. Ihis has not 
 
 Distended Bladder mistaken for an Abdominal Tumor (original). 
 
 seldom been mistaken for an abdominal tumor. A catheter will instantly 
 
 clear up any doubt. . ^ ..i 
 
 The subjective symptoms vary with the cause. In acute retention the 
 desire to micturate is extremely urgent, the distress an<l anxiety great ; the 
 patient makes constant efforts to empty the bladder, with violent straining, 
 often accompanied by escape of the contents of the lower bowel, it the reten- 
 tion is complete, th^se symptoms continue with increasing severity until the 
 patient passes into a condition of toxemia, with rigors, fever, failure of circu- 
 lation, dry brown toncrue. delirium, hiccough, stupor, and finally death it 
 the retention is incomplete and the distention of the bladder is fairly relieved 
 by the escape of a few drops of urine from time to time, these symptoms may 
 be slower in making their appearance, and the case will run a more chronic 
 but very similar course. 
 
856 AN AMERICAN TEXT- BOOK OF SURGERY. 
 
 The most insidious cases, however, are those in which eitlier from paralysis 
 or from the very gradual production of the condition it is not attended with 
 auv unusual sensations, the patient often com])lainiiig only of the drilthling of 
 urine, which is almost constant, and which results iVoui the overliow from a 
 hladder already distended to its fullest capacity when fresh drops of urine enter 
 it from the ureters. This dribbling — the "incontinence of retention " — is too 
 often carelessly or ignorantly regarded as evidence that the bladder is empty- 
 ing itself, and many fatal cases have resulted from this mistake on the j)art of 
 j)atient, nurse, or physician. The condition is most fre(iuent in cases of pros- 
 tatic enlargement, of vesical |)aralysis, and of old stricture. The secondary 
 efl'ects of retention of urine in such cases are those of obstructive disease 
 already described. (See section on Diseases of the Kidneys.) If long contin- 
 ued, it results in disorganization of the secreting structure of the kidneys from 
 the backward pressure. If acute and complete, it may produce fatal suppi-es- 
 sio7i of urine from tlie same cause. 
 
 Treatment. — The management of a case of retention of urine will depend 
 upon the cause and the acuteness and urgency of the symptoms. When cathe- 
 terism is possible, it is the surgical procedure obviously appropriate to the great 
 majority of cases. In urethral or vesical spasm occurring during acute ure- 
 thritis, or in the retention due to a gonorrheal prostatitis, a short delay may 
 be justifiable, during which warm baths, opium, enemata, leeching to the peri- 
 neum, etc. may be tried, but even in these cases the catheter should be resorted 
 to promptly if the symptoms are at all urgent. The special treatment appli- 
 cable to the other conditions before mentioned will be found described under 
 their respective headings. 
 
 In some cases, however, catheterism is found to be impossible, and it is 
 evident that immediate relief should be given the patient. Three routes for 
 entering the bladder have been described and employed : (1) suprapubic ; 
 (2) perineal ; (3) rectal. 
 
 Of these, the first is to be preferred in the vast majority of cases. The nee- 
 dle of an aspirator, or a small trocar and canula, should be inserted in the 
 median line just above the symphysis and the urine withdrawn. The usual 
 antiseptic precautions, including shaving of the pubes, should be taken : the 
 operation requires no skill in its performance and is attended with reuuirkably 
 little danger. The small puncture should be closed at once with iodoform and 
 collodion. 
 
 (2) The perineal route has l)een advocated by Ilowlett, and also by Harri- 
 son, in cases of enlargement of the prostate (q. v.), but is not to be recom- 
 mended simply for the relief of retention. 
 
 (3) Rectal puncture, by which the bladder is opened by a large curved trocar 
 and behind the base of the prostate, has been employed in many instances, 
 but is even less desirable than the perineal route. 
 
 INJURIES OF THE BLADDER. 
 
 The bladder may be wounded directly, as in stabs, gunshot wounds, etc., 
 through the hypogastrium, the vagina, or the rectum, or even from the pos- 
 terior aspect through the sacro-sciatic foramen ; or it may be punctured by 
 one of the pelvic bones, usually the pubic, in cases of fracture of the pelvis ; 
 or it may be involved in the rent occasioned by a violent disjunction of the 
 symphysis pubis. 
 
 When there is a wound communicating with the surface of the body 
 through the abdominal wall, the diagnosis is usually easy. The escape of 
 
SURGERY OF THE GENITO-URINARY TRACT. 857 
 
 bloody urine in some cases, or in others the diffital exploration of the wound, 
 will at once reveal the character of the injury. But in cases arising from 
 fractures or in those in which the bladder is ruptured, the recognition of the 
 condition may be much more difficult. In cases where a violent compressing 
 force is applied during distention, as where a wheel of a heavy wagon passes 
 over the lower part of the abdomen, the healthy bladder, if distended at the 
 time, may be ruptured. An atrophied or atonied or ulcerated bladder may 
 give way under a much more insignificant force, such as involuntary contrac- 
 tion of the abdominal muscles during vesical tenesmus. 
 
 In the former class of cases the rent in the bladder is usually in the pos- 
 terior wall, running downward from the urachus ; in the latter it occurs at the 
 region of greatest weakness, sometimes involving a sacculus or diverticulum 
 (Plate XXI, Fig. 1) consisting only of mucous membrane and cellular tissue 
 and protruding between the muscular ridges of an hypertrophied bladder, 
 sometimes passing through a spot which has been thinned by the pressure of 
 a calculus or infiltrated by tubercular, sj^philitic, or carcinomatous deposits. 
 
 Symptoms. — If there is a history of a severe fall or of the application 
 of a comj)ressing force during distention of the bladder, followed by collapse, 
 with inability to micturate, wound or rupture of the bladder should be strongly 
 suspected. The introduction of a catheter will usually be followed by the 
 escape of only a little blood or bloody urine. If a known quantity of a 
 warm boric-acid solution be injected Avith moderate force into the bladder, the 
 gradual rise of that viscus from behind the pubes into the abdominal region, 
 which should occur when it contains from eight to ten ounces of liquid, does 
 not take place, and on permitting the escape of the fluid through the catheter a 
 diminished quantity will be found to have returned. Filtered air can also be in- 
 jected into the bladder by an ordinary Davidson s^'ringe over the outer end of 
 which cotton has been tied. If the bladder be intact, it will become distended 
 as a suprapubic tympanitic tumor, and the air will escape through the cathe- 
 ter ; if it be ruptured, the air will distend the general peritoneal cavity and 
 will not escape through the catheter to any extent. If the rupture is extra- 
 peritoneal, emphysema of the cellular tissue will be produced. 
 
 In the presence of this group of symptoms it will be certain that there is a 
 wound or rupture of the bladder, but it must not be forgotten that a minute 
 perforation or puncture, followed by leakage, may exist and be of grave 
 importance, while none of the above phenomena can be elicited, and that occa- 
 sionally, though rarely, the opening in the vesical Avail has been valvular in 
 character, and has permitted the bladder to contain a considerable quantity of 
 urine under pressure, though alloAving it to trickle through when the organ 
 has collapsed. 
 
 The two chief varieties of wounds or ruptures of the bladder are : (1) the 
 extra-peritoneal ; (2) the intra-peritoneal. , 
 
 In the first variety the urine escapes into the pre-vesical connective tissue 
 or into the vesico-rectal or vesico-uterine space. If not removed by operation, 
 cellulitis and sloughing follow, involving the neighboring parts and often 
 extending to the anterior wall of the abdomen or opening the rectum or vagina. 
 The patient dies from septicemia. 
 
 In the second variety (the intra-peritoneal) there may be one or even two 
 days during which no special symptoms manifest themselves. The more 
 nearly normal the condition of the urine the longer the interval, but sooner or 
 later general peritonitis occurs, and the patient dies quickly Avith a distended 
 abdomen and symptoms of shock. Intra-peritoneal rupture may be suspected 
 in the interval if on catheterization the instrument seems to enter a large 
 
858 ,1-V A.yfERICAX TEXT-IK X )K OF SURGERY. 
 
 cavity, like a capacious bladder, and can be moved freelv. and yet little or 
 no urine can be withdrawn. 
 
 Treatment. — Whenever there is good <:round for suspecting a wound or 
 rupture <>f the bladder, operative interference is imperative. An incision 
 should be made through the hypogastrium. as in suprapul)ic lithotomy, the 
 rectal bag having first been introduced and distended, cus in that operation. 
 The peritoneum should be gently rolled up, with the pre-vesical fat, and 
 the parts carefully inspected. If a rent is visible or if an extravasation 
 of blood and urine leads to one, it may be sewn up and the surrounding 
 region irrigated and drained. If the edges are much lacerated or contused, it 
 would be better to put a large drainage-tube into the bladder. If the urine 
 has found its way into the scrotum or perineum, free incisions must be made 
 in those regions to give it exit. If the rent is not discovered by inspection 
 and palpation, it is well to open the bladder and explore its inner surface with 
 the finger. 
 
 If an intra-peritoneal opening is found, the abdominal incision should be 
 extended upward, the peritoneal cavity opened and the wound in the bladder 
 closed by means of Lembert sutures, fine silk being the best material and 
 the stitches being inserted through only the muscular and peritoneal coats, and 
 not through the mucous membrane. They should be about one-eighth of an 
 inch apart. They may be tested by distending the bladder before the abdomi- 
 nal Avound is closed. The peritoneal cavity is then irrigated, and if there is 
 any peritonitis a drainage-tube is inserted, ^^ome modifications are advised 
 by different surgeons, but on the whole it may safely be said that prompt 
 operative interference, suture of the bladder, antiseptic irrigation, and drain- 
 age have greatly lessened the mortality after injuries of the bladder. The 
 adoption of Trendelenburg's position simplifies these procedures. 
 
 The results of laparotomy for intraperitoneal rujnure of the bladder, 
 as shown in the cases of MacCormac, Holmes. Ilalstrom. Grant, Blum, and 
 others, are in the highest degree encouraging. 7 out of ItJ cases having recovered, 
 while in 8 of the 9 fatal cases the average time between the operation and the 
 injury was twenty-eight hours, and in the ninth case the vesical sutures were 
 faulty. In Blum's case recovery ensued, though the operation did not take 
 place until forty hours after the rupture. 
 
 ATONY OF THE BLADDER. 
 
 The condition known as atony of the bladder is by no means uncommon, 
 and may even be said to exist in a minor degree in almost all persons past 
 middle age. Every male adult who will carefully observe his own experience 
 will in all probability find that he is unable to eject as forcible a stream of 
 urine from the bladder as when he was a bov ; and the slig-ht enfeeblement 
 increases very distinctly when middle age is past. This form of atony may 
 be said to be physiological. 
 
 There is another variety, which is a true muscular paresis, an actual loss of 
 tone, as the name implies, in the muscular walls of the Idadder, and which is 
 dependent upon well-recognized causes. There is a distinct thinning and 
 ■weakening of the muscular coat of the bladder, associated sometimes with fatty 
 degenei'ation of the muscular fibers, sometimes with a fibroid change resulting 
 in contracture precisely similar to that which occurs in disused muscles else- 
 where. In the one case the bladder is a mere flaccid pouch capable of disten- 
 tion to a large extent, but quite incapable of completely emptying itself. In 
 the other it will hold only a few ounces of urine, but cannot completely evac- 
 uate that quantity. 
 
SURGERY or Till-: (iKXiro-rinxAin' thact. 859 
 
 Bftwt'cn these two exticines and a foiulition of lioaltli there are all 
 degrees of atony. A common cause of these retrograde changes in the blad- 
 der, apart from senility, is over-distention, which may be chronic and de- 
 pendent upon some obstructive condition, such as enlarged prostate, vesical 
 tumor situated near the neck of the bladder, tight urethral sti-icture, etc. ; or 
 it may have resulted from true paralysis of the bladder, which is very apt 
 in neglected cases to be followed by secondary atony ; or it may have been 
 due to persistent neglect of the calls of nature on the part of the patient, 
 whose occupation or whose pleasures were so preoccupying as to lead him 
 habitually to postpone the emptying of the bladder until the need of doing so 
 became imperative. Or the cause may liave been acute over-distention hap- 
 pening on some one occasion when for a long period it was impossible for the 
 patient to find an opportunity to urinate. In these instances the over-stretch- 
 ing of the muscular fibers is probably the active factor. In any event, the 
 result is that the patient is unable to void his urine, and that a certain quan- 
 tity is retained after eacli act of micturition. 
 
 It is this "residual urine," as it is called, Avhicli, both in cases of prostatic 
 disease and in vesical atony, constitutes at the same time a serious difficulty 
 and a guide to the proper treatment. If allowed to accumulate, it will sooner 
 or later result in over-distention of the bladder, or it may decompose and set 
 up a troublesome cystitis. It should always be evacuated by regular catheteri- 
 zation, which should be performed two, three, or four times daily according to 
 the quantity of residual urine. This is, of course, a form of retention of urine, 
 but that expression is usually associated with the idea of complete retention 
 the result of obstructive disease of the urinary tract or of an absolute paralysis 
 of the bladder-wall. When this is acute, it is readily recognized by the history 
 of non-evacuation of urine and by the presence of the characteristic hypogas- 
 tric tumor, which soon becomes abdominal if no relief is afforded. But there 
 is a partial retention of urine w^hich, though not so immediately dangerous, is, 
 by reason of its greater frequency, a far more important surgical condition. 
 In its lower grades it is often not recognized, and the symptoms of frequent 
 micturition, loss of force in the stream, dribbling of urine, etc. are referred to 
 cystitis and treated accordingly. Of course there may be a combination of 
 various conditions associated with atony and with partial retention ; in other 
 words, the original lesion may have been a stricture of the urethra or an acute 
 prostatitis or a prostatic growth or an impacted urethral calculus, or it may 
 occur after certain operations, particularly those upon the lower end of the rec- 
 tum, as the ligation of hemorrhoids, when there is often a reflex inhibition of the 
 micturition-center of the spinal cord, followed by retention of urine. But in all 
 these cases it is the over-distention and atony which constitute the most efficient 
 cause of partial retention of urine, and this is true even in cases of prostatic 
 enlargement in which there is a permanent obstacle to the free passage of urine. 
 
 The methods of treatment which are worthy of trial may be grouped under 
 four heads, it being premised that if there is marked c^^stitis a preliminary 
 course of treatment may be necessary before the other methods can be fairly 
 put into application : 
 
 (1) Catlieterization. — The patient should be instructed in the use of a 
 catheter, and should also be told how to keep that instrument aseptic, and, 
 for greater precaution, how to disinfect it before each insertion. In cases 
 where four ounces of urine are retained he should use it twice daily, night and 
 morning ; if the residual urine reaches six ounces, he should use the catheter 
 once every eight hours ; and if it amounts to eight ounces, catheterization 
 should be employed every six hours. (2) Irrigation of the bladder with cold 
 
860 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 boric-acid solutions, beginning at a temperature of 90° to 100° nnd gradually 
 reduced, or potassium permanganate, in the strength of one to three grains 
 to a pint of sterile water, will sometimes be found of great use. (3) Elec- 
 tricity is often of considerable benefit, and may be applied in the manner lonw 
 ago suggested by Sir Henry Thompson. An* insulated electrode is carried 
 into the bladder and the other moistened electrode placed over the hvpogas- 
 trium, a weak current being passed directly through the walls of the blad- 
 der. The strength is gradually increased until slight sensations of discom- 
 fort are experienced. The application may be varied occasionally bv putting 
 the other electrode in the rectum. In mild cases which come under care im- 
 mediately after the occurrence of over-distention this is of much benefit, and 
 in later and more serious cases it may be a useful adjuvant. (4) Strychnin 
 is the only drug which produces beneficial results in these cases, and even 
 upon it but little dependence can be placed. It may be given in combina- 
 tion with ergot, cantharides, or tincture of the chloride of iron. 
 
 URINARY CALCULUS. 
 
 The normal urine is a watery solution of various organic and inorganic 
 materials dissolved in water, the latter constituting about 90 per cent, of the 
 whole. The important organic constituents are urea and uric acid ; the inor- 
 ganic consist of the bases, chiefly sodium, potassium, and magnesium, with 
 which the uric acid unites. Other acids, especially phosphoric and sulphuric, 
 form salts with the same bases. These with the chlorides make up the bulk 
 of the inorganic substances contained in urine. 
 
 There is. of course, also mucus derived from the kidneys and bladder, and 
 a certain amount of renal and vesical epithelium. When urine is entirely 
 normal and has been recently passed, it shows no sediment except a little of 
 this mucus containing a few epithelial cells. After fermentation various forms 
 of amorphous urates form and settle, and the urine becomes turbid from the 
 presence of the products of decomposition. 
 
 Uric acid, although normally present in the proportion of only about 
 1 : 1000 in the urine, is of great importance in the formation of calculi, and 
 with the urates, especially those of sodium and ammonium, makes up the bulk 
 of most urinary deposits. 
 
 Oxalic acid is sometimes found in the urine in combination with lime in 
 the shape of octahedral or of dumb-bell crystals. 
 
 The phosphatic deposits in the urine are composed of admixtures of the 
 alkaline phosphates, those of sodium and potassium, with the earthy phosphates, 
 the bases of which are calcium and magnesium. In fermenting urine in which 
 the urea has been decomposed into ammonium carbonate the phosphoric acid 
 unites with the ammonium, and deposition of the triple phosphates takes place, 
 the sediment containing the ammoniaco-magnesium phosphate and calcium 
 phosphate. The alkaline phosphates, being soluble, do not occasion deposits. 
 
 Cystine is found rarely among urinary sediments, and is in the form of 
 hexagonal crj'stals, smaller than those of uric acid. It contains a large amount 
 of sulphur (25 per cent.). It is never found anywhere else in the body, and the 
 mode of its formation and the circumstances which favor it are unknown. 
 
 The general conditions which favor the formation of an excess of urinary 
 deposits do not vary greatly for these different forms. They indicate, as a 
 rule, defective digestion and assimilation, insufficient oxidation, disproportion 
 between the solid and the fluid constituents of the diet, excess of meats, fats, and 
 sugars, insufficient exercise, etc. But, while these are important factors, they 
 do not of themselves, as a rule, bring about the formation of calculi. The 
 
SURGERY OF THE QENITO- URINARY TRACT. 801 
 
 presence of the colloids is necessary, and these are furnished in the shape of 
 mucus and inuco-j)us whenever any catarrhal condition of the urinary tract is 
 superadded to the excess of solids contained in the urine. In addition to these 
 chief predisposinji; causes there are others of minor importance, such as age, 
 sex, race, etc. These may be briefly considered : 
 
 Age. — Children are especially liable to the formation of uric-acid calculi 
 (primary calculi) ; old persons, to the development of phosphatic stones 
 (secondary calculi). In the former the uric acid, which is in feeble combina- 
 tion witii the alkaline bases, is liberated })y an excess of acid of any sort in 
 the urine, and the uric acid crystallizes in the presence of the renal mucus or 
 of the vesical mucus, which binds the crystals together, forming a concretion 
 which makes the nucleus of a stone. The same process takes place in the 
 majority of cases whenever stone forms in acid urine, the stone growing by 
 fresh accretion of uric acid or of the urates. Oxalate of lime may in the 
 same manner crystallize and be deposited in either of its forms. 
 
 In old persons, especially in old men with enlarged prostates, residual 
 urine, and cystitis, the urine, which has become alkaline from fermentation 
 and decomposition of urea into ammonium carbonate, contains all the materials 
 for the formation of stone around a given nucleus of any sort. Sometimes, espe- 
 cially in gouty or rheumatic individuals, the nucleus is a small uric-acid con- 
 cretion descending from the kidney ; sometimes it consists simply of a number 
 of phosphatic crystals glued together by the thick, stringy vesical mucus ; 
 sometimes it is a blood-clot, a spicule of bone, a piece of bougie, or a foreign 
 body introduced into the bladder by the patient. In any event, continued 
 precipitation of the phosphates in the alkaline urine goes on, and secondary 
 stone-formation occurs. 
 
 Sex. — Owing to the shortness of the female urethra, its large caliber, the 
 absence of obstructive disease, and the comparative infrequency of vesical 
 disease in women, they are very rarely the subjects of stone. It is estimated 
 that only about 5 per cent, of all cases of stone are seen in females. 
 
 Race. — Negroes seem especially free from the liability to urinary calculi. 
 Statistics show that in this country less than 4 per cent, of the cases operated 
 upon for stone occur in negroes. 
 
 Constitutional disease, particularly gout and rheumatism and the associated 
 condition known somewhat vaguely as lithemia, favors the formation of calculi, 
 especially of the uric-acid variety. 
 
 Local Disease. — As already stated, prostatic hypertrophy with consecutive 
 bladder-changes is a common cause of secondary stone-formation. Urethral 
 stricture is much more rarely a cause, probably because the expulsive power 
 of the bladder is unimpaired. Atony of the bladder favors the retention of 
 small fragments of gravel or of urinary deposits of any description, and thus 
 often leads to the development of calculi. Any disease of the kidney pro- 
 ducing excessive secretion of renal mucus, and indeed any catarrhal disease 
 of any portion of the urinary tract, will favor the formation of calculi. 
 
 Varieties of Urinary Calculi. — Stones may be classified either 
 according to their chemical composition or with relation to the circumstances 
 attending their formation. 
 
 Those forming in acid urine (the mucous membranes of the urinary tract 
 being usually unaffected by disease) are chiefly, in the order of frequency, the 
 uric-acid calculi, the oxalate-of-lime calculi, the urates, and the rarer forms of 
 cystine, xanthine, indigo, etc. Those forming in alkaline urine (secondary to 
 catarrhal disease of the kidneys or of the bladder) are the phosphate or car- 
 bonate of lime, which usually originates in the kidney, and tiie phosphatic cal- 
 
862 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 culi — the amiuoniaoo-inaguesian variety — formed only in anniioniaeal urine, 
 and therefore almost always originating in the bladder. 
 
 The majority (probably two-thirds) of all stones have nuclei of uric acid; 
 of the remainder, a considerable proportion have nuclei or crystals of oxalate 
 of lime or of the urates ; others contain lumps of inspissated mucus or blood ; 
 and in addition an endless variety of foreign bodies introduced by accident, 
 findintc their war into the bladder from disease of neighborino; bones or cav- 
 ities (as -after ulceration of a dermoid cyst, or after the formation of vesico- 
 rectal fistula), or foreign substances, such as portions of whip-lashes, shoe- 
 strings, pen-holders, etc., which have usually been introduced by the patient 
 under the influence of morbid erotic desire. Such patients are commonly 
 either boys at about the age of puberty or old men with waning sexual powers. 
 
 The form, size, and density of a calculus depend upon its chemical com- 
 position, the condition of the bladder, and the length of time during which 
 the stone has been growing. Usually, however, it may be said that stones are 
 either oval or rounded in shape, flattened on several surfaces, and, if there are 
 other calculi in the bladder, presenting facets worn by attrition of one stone 
 against the other. The surface of a calculus may be very rough and irregular 
 or may be smooth and uniform. 
 
 In size it may vary from that of a bird-shot or a pea to one measuring 
 many inches in circumference and weighing several pounds. In this country 
 the largest stone extracted without fragmentation, without sloughing of the 
 parts, and with recovery of the patient, weighed nine and a half ounces and 
 measured eight and a half inches in circumference (White of Philadelphia). 
 
 Symptoms of Vesical Calculus. — In many cases before the develop- 
 ment of vesical symptoms the descent of the nucleus from the kidney will 
 have been announced by the characteristic phenomena already described under 
 the head of Nephritic Colic. (See p. 838.) A history of this soi't is therefore 
 an important indication in cases of suspected stone, and if cleai- and unmistak- 
 able should lead the surgeon to repeated examinations if the further group of 
 symptoms now to be detailed, or the majority of them, be present. The most 
 important of these symptoms of vesical calculus are as follows : 
 
 (1) Frequent urination, more marked by day than by night. The patient 
 is obliged to empty the bladder at intervals varying from two or three hours to 
 every few minutes. The desire to do so is irresistible and sudden. It is much 
 increased by active motion, as on walking or riding over rough roads or streets. 
 It varies with the size and shape of the stone, and is often greater when the 
 stone is of small size than when it is large, as in the former case the degree of 
 motion imparted to the calculus during movements of the body is greater than 
 when the stone is of large size and has made for itself a place in the bas-fond 
 of the bladder. Freijuent urination is also more marked if the stone has an 
 irregular surface than if it is smooth and uniform. A stone may be of very 
 considerable bulk, but if pa»tially encysted or if held in ])lace by bands of 
 organized lymph it may give rise to astonishingly little disturbance. Fre- 
 quency of urination is more marked in young than in old persons. In the 
 latter there is often some prostatic enlargement, and the stone is apt to lie in 
 the bas-fond of tlie bladder, removed from contact with its most sensitive por- 
 tion. In these cases the usual nocturnal frequency of urination will continue 
 unmodified by the presence of the calculus. It is for this reason that in every 
 case of enlarged pi'ostate a careful examination for stone should be made even 
 when special symptoms of its presence are not to be noticed. 
 
 (2) Pain. — The characteristic pain of stone is darting and burning in cha- 
 racter, is felt during micturition, but is most severe at the termination of the 
 
SUBOERY OF THE GENITO-UBINARY TRACT. 863 
 
 act, .ho„ .... n-ntau... o,- i„.,a„.ea -->- .r,:;!™;'; .It^a^ S St 
 
 r t l„ \ft cm1k,v ,... existed for some time, it may gradually lesser, m 
 food o '•'"'';• J;;'^'" ;-Ji,,^,,,,ear. In these cases the stone has probably 
 
 wr «r] - ;f f "^ t™Su:; 'C;. 
 
 /eVpnW -This -symptom is often absent in adults, and of course ,s 
 rari!n o^d TrsL. It is 'of Lnsiderable diagnostic value m young children^ 
 it s due to^ongestion of the vessels of the^prostato-ves.eal region. In boys 
 • 1 1 + f^o fr^vmntinn of the habit of masturbation. 
 
 " TtI M« ;t «? n Snt par:? the body may be associated .Uh stone 
 
 (g lUJltx iHuni> m ui» 1 rectum or m the perineum 
 
 In many cases these pains will be fdt ^^^^^ J^J^^^^^^ f^.^^ tlfe seat of 
 sometimes however^ m ^f^^ppei xtrl'id:s/trb\ck, thighs, stomach, 
 
 TT'^'^^ortrrfrelent y'in he neigtborhood of the ball of the great 
 F„e f mav ext nd ovTr the^ hole sole of the foot, and is apt to be asso- 
 
 bv symptoms which more or less closely simulate those of stone. The d.f- 
 ^.entTatLHs not difficult in many cases, but m others >t .s tmposs.ble. 
 
<S64 .l.V AMERICAN TEXT- BOOK OF smai'Jn'. 
 
 The existence of tlie entire group of symptoms given above cannot justify 
 a positive diagnosis of vesical calculus unless a further examination is made and 
 the stone found and touched by the surgeon. Even then its presence must be 
 made evident to the sense of hearing, as under no other circumstances can all 
 possibility of error be eliminated. In doubtful cases the presence or absence 
 of stone may usually be determined by means of the ./-rays. This may be 
 the only method by uhich an encysted stone can be detected. 
 
 Different forms of the vesical sound have been recommended, but the best 
 and simplest has a straight steel shaft, with a short curve near the tip and a 
 smooth flattened handle. Two forms should be used habitually, one with a 
 very slight curve, and the other with a short abru])t curve, permitting it to be 
 carried into the pouch behind the prostate. They should be about twelve 
 inches in length, and of a caliber of about 13 of the French scale. In using 
 these sounds the patient should be in a recumbent or semi-recumbent position, 
 the abdominal muscles well relaxed by slight elevation of the shoulders, the 
 knees drawn up, and the thighs somewhat separated. During the exploration 
 the bladder should be moderately distended with water. The sound is well 
 warmed and oiled, and is introduced in the same manner as a catheter, remem- 
 bering, however, the fact that its curve does not correspond with the normal 
 curve of the fixed part of the urethra, and that therefore it is especially import- 
 ant at the time that the point of the sound is made to traverse this region that 
 downward pressure should be made with the fingers at each side of the root- 
 of the penis near the pubes, so as to elongate and straighten out the urethral 
 curve. It will be found that strict attention to this will greatly facilitate the 
 introduction of the instrument. Once in the bladder, the cavity should be 
 explored in a systematic manner. The sound should be partially withdrawn 
 and reinserted in a straight line, the handle being slightly raised and depressed 
 from time to time. The beak of the sound should then be turned toward one 
 side of the bladder, and should be made to traver.se the arc of a circle sweeping 
 transversely through the bladder from above downward. It should then be 
 turned to the opposite side and the same mananiver repeated. If the stone is 
 not found in this manner, the searcher should again be introduced to its full 
 length, and the tip turned gently toward the floor of the bladder and then 
 rotated from side to side, while the instrument is gradually withdrawn until it 
 comes in contact with the vesical neck. If the stone is not detected with the 
 first instrument, the second one, of diff'erent curve, should be introduced and 
 the search repeated. Some surgeons prefer a hollow searcher, so that during 
 the exploration the urine can be withdrawn or water injected (Fig. 346). 
 
 Various plans may be adopted for increasing the thoroughness of this exami- 
 nation. The surgeon may press down the anterior wall of the abdomen, so as 
 to bring the upper wall of the bladder well Avithin the reach of the tip of the 
 instrument. With the finger in the rectum the bas-fond of the bladder may 
 be elevated, so as to be brought more closely in contact with the searcher. 
 The patient may be instructed to stand upright, and the fluid from the bladder 
 gradually withdrawn through the hollow searcher, the tip of which is at the 
 same time gently turned from side to side and brought from the base toward 
 the vesical neck. This is an excellent plan for discovering small fragments 
 which elude the ordinary method. In cases of enlarged prostate the stone 
 may often be more easily discovered if the buttocks are raised so as to roll 
 back the stone toward the fundus. 
 
 Some diff'erence of opinion exists as to the degree of evidence which is 
 necessary before an operation is undertaken. A few surgeons consider it suf- 
 ficient to feel the stone with the tip of the instrument. The majority prefer to- 
 
SURGERY OF THE GENITO- URINARY TRACT. 865 
 
 demonstrate its presence by eliciting the characteristic click. The latter is 
 certainly by far the most definite and satisfoctory symptom it is possible to 
 obtain, and, althoii^^h even tliat docs not entirely exclude the possibility of 
 error, it reduces it to a. minimum. 
 
 Now and then a papilloma or other growth will become encrusted with uri- 
 nary deposits, and will give a most deceptive sensation both to touch and to hear- 
 ing. Occasionally a small scale of calcareous matter will form, Avhich can be 
 felt or heard once by the sound and cannot again be found. With these excep- 
 tions, however, the click which is elicited by the touch of the sound upon the 
 calculus is pathognomonic, and may serve as a basis for a positive diagnosis. 
 The statement that " if the surgeon's hand is not delicate enough to detect the 
 contact of his searcher with the stone Avithout the aid of hearing, it will be 
 wiser for him not to attempt to deal further with surgery of the bladder," is 
 misleading. We prefer rather to accept the teaching of Agnew, who states 
 that too much importance cannot be attached to the testimony furnished by 
 the ear, which is far more reliable than the sensation communicated by touch ; 
 and he is certainly quite within reason when he adds that if all the circum- 
 stances attendant upon the errors of diagnosis in consequence of which patients 
 have been cut without a stone being found in the bladder could be learned, it 
 would doubtless be found that the operators proceeded more on Avhat was felt 
 than on what was heard. 
 
 A fasciculated condition of the bladder will sometimes cause a very decep- 
 tive sensation to be communicated to the hand of the surgeon as the tip of the 
 instrument sweeps over the ridges of the organ, and occasionally bony growths 
 developed from the pelvis, tumors, fecal impaction in the rectum, undue promi- 
 nence of the promontory of the sacrum, etc. have given rise to similar error. 
 In all these cases, however, no sound is elicited. 
 
 Sources of failure in the detection of stone may be enumerated as follows : 
 (1) a more or less completely encysted condition of the calculus, leaving little 
 or nothing of its surface exposed to the immediate touch ; (2) the presence of a 
 diverticulum containing the stone and communicating with the bladder by a 
 small aperture, the calculus in such a case being practically extra-vesical ; (3) 
 the stone may be suspended by a thread of lymph from the summit of the 
 bladder, or may even be fastened to the anterior wall of the bladder by fibrin- 
 ous adhesions ; (4) the surface of the calculus may be so covered with blood- 
 clot or with lymph as to prevent the characteristic sound from being elicited. 
 In the majority of these cases, however, the symptoms will be such as to war- 
 rant at least an exploratory operation, when the true character of the case 
 will be revealed. In doubtful and obscure cases never less than two examina- 
 tions should be made before the surgeon gives a positive opinion, and if there 
 is much pain or spasm excited by the necessary manipulations on the first 
 examination, the second should be conducted while the patient is anesthetized. 
 The various plans suggested of approximating the walls of the bladder should 
 be carefully tried, and the patient put in different positions with the object of 
 dislodging the stone and bringing it Avithin the reach of the searcher. The 
 bladder should be kept fully distended during the examination, and the 
 urine should be gradually withdraAvn later. In some cases straight sounds 
 will prove more useful than those with even a slight curve ; occasionally a 
 very small stone can best be detected by means of the Bigelow evacuating 
 tube connected Avith a Avash-bottle, as in evacuation of the bladder after 
 litholapaxy. 
 
 The size of the stone may be estimated if a Thompson's searcher (Fig. -346) 
 is used by slipping the collar on the stem of the instrument to the meatus after 
 
 55 
 
86<j AX AMEIilCAX TEXT-BOOK OF SURGERY. 
 
 the stone is first touched, and tlieii marking tlie |)oint at whicli the sound ceases 
 to come in contact witli it as it is slowly withdrawn, gentle tapping being kept uji 
 
 Fig. 34(j. 
 
 Thompson's Searcher. 
 
 during this procedure. The measurements on the scale of the searcher between 
 the collar and the meatus will then indicate approximately the diameter of the 
 stone. In females the search for stone should be conducted Avith a straight 
 sound, and, if there is any doul)t remaining, the urethra should be dilated and 
 the little finger of the surgeon inserted for digital ex])loration. 
 
 Some idea of the composition of a calculus may often be obtained from the 
 fragments passed during urination, and more definitely from those adhering to 
 the blade of a lithotrite if the latter is introduced for the purpose of measure- 
 ment previous to selecting the form of operation. Frequently, however, the 
 urinary deposit, and even the superficial layer of the calculus, are phosphatic 
 and derived from the sediment of the ammoniacal urine of cystitis, Avhile the 
 nucleus and the bulk of the underlying stone may be of uric acid or of oxa- 
 lates, and very dense. 
 
 The Treatment of Vesical Calculus. — The non-operative treatment 
 of vesical calculus is of chief importance in its relation to prophylaxis. The 
 attempt to procure solution of a stone already in the bladder has been perse- 
 vered in by the profession since the earliest days, but Avithout practical result. 
 Neither drugs by the mouth nor vesical injections can be used in sufficient 
 strength to exert any material influence upon a calculus. It is conceivable 
 that a verA'^ small and very soft phosphatic stone might be aff'ected by acid 
 solutions weak enough to permit of their being thrown into the bladder, but 
 litholapaxy for sucli stones is so immensely superior in safety and certainty 
 and promptitude of cure that no other method need be considered, least of all 
 one of such doubtful utility. 
 
 When it comes to the prevention of sto«ie, hoAvever, the case is diffierent. 
 The advice given to a litheraic patient who has perhaps had one or more 
 attacks of renal colic, or who is habitually passing urine of high specific grav- 
 ity containing an excess of uric acid, is of the utmost importance. With such 
 a patient it is essential to regulate the diet, the exercise, and the mode of life 
 generally. The free use of water as a beverage both at and betAvecn meals, 
 and especially on going to bed and on rising, should be insisted upon. The 
 particular sort of Avater to be used is a matter of minor importance, as the 
 results are equally good Avhether ordinary cistern- or rain-Avater or distilled 
 water, or Poland. Bedford, or any other of the still spring-Avaters, is employed. 
 The dilution of the urine, and the consecjuent increased solvent poAver, seem 
 to be secured as Avell by one as by the other, provided only that a sufficient 
 quantity be taken. Many other beneficial effects folloAv the habitual use of 
 large quantities of Avater. In persons Avhose general strength is beloAv the 
 average, and particularly in thin or emaciated patients with imperfect digestion, 
 milk may to a large extent take the place of Avater. It should be used ahvays 
 with special care as to the effect upon the gastro-intestinal tract, and may have 
 to be peptonized or skimmed, or diluted Avith plain Avater or Avith lime-Avater 
 to meet the needs of the particular patient. In the majority of persons Avho 
 
SURGERY OF THE GENI TO- URINARY TRACT. 867 
 
 habitually pass concentrated urine it Avill be found to be in some shape the 
 best of all articles of diet, and a persevering effort to secure its employment 
 should bo made even when, as is so frequently the case, the patient protests 
 that milk does not agree Avith him. 
 
 As to the general dietary, the most important articles to cut off are the 
 sugars and fats, and the most important to restrict are meats and alcohol. Such 
 patients should be directed to eat meat but once daily, and then sparingly ; to 
 take a minimum of sugar and of butter or other fats ; to drink little but water 
 or milk or Aveak tea, or if wine be taken to select a light claret or white wine 
 and drink it largely diluted. Green vegetables, salads, and fruits, bread, eggs, 
 and light fish, with a little poultry, may be said to constitute the staple of the 
 diet in these cases. 
 
 The occasional use of a mild laxative or of small doses of calomel and soda 
 in patients who are inclined to torpidity of the liver and defective bile-secre- 
 tion will be found advantageous, but the prolonged use of the saline purga- 
 tives, such as Epsom or Glauber salt, or of the waters containing them, Fried- 
 richshall, Carlsbad, Hunyadi, etc., is distinctly contraindicated, favoring rather 
 than preventing concentration of the urine. 
 
 Moderate exercise is extremely beneficial, especially if it can be taken in 
 the open air and systematically. Excessive exercise to the point of great 
 muscular fatigue and profuse sweating should be avoided. 
 
 As to drugs, it may be necessary to use either alkalies or acids, according 
 to the reaction of the urine and the character of the sediment. In acid urine 
 with excess of uric acid and of the urates, phosphate of sodium in full doses, 
 taken with a large quantity of fluid, often seems to be of great benefit, but 
 occasionally has no effect whatever. The magnesium salts have been recom- 
 mended, especially the boro-citrate, where the indications for alkalies were 
 persistent. If the oxalates or phosphates are the predominent elements in the 
 urine, or are intermingled, which is often the case, the mineral acids, especially 
 muriatic and nitro-muriatic, and to a less extent phosphoric, are of extreme 
 value ; and this is increased if they are given in conjunction with nerve-tonics 
 and with bitter stomachics. In these cases special attention must be paid to 
 the surroundings of the patient, to securing proper hygienic conditions, plenty 
 of exercise and fresh air, absence of mental strain or overwork, and, more 
 important still, avoidance of worry and trouble as far as possible. Attacks 
 of stone are sometimes coincident with a certain degree of nervous break-down 
 attributed to the pain and distress of renal colic and of the vesical irritation, 
 but are rather to be regarded, in many cases, as a precedent etiological factor 
 of much importance. 
 
 In the preventive treatment of stone of whatever variety the avoidance 
 of catarrhal conditions of the urinary tract is of the greatest importance. In 
 the absence of the colloids, the crystalline deposit of even the densest urine 
 will remain in the shape of fine dust or sediment, and will have little or no 
 tendency to adhere or consolidate in large particles. The formation of stone 
 depends in the great majority of cases upon the presence of agglutinating 
 material binding together the urinary deposits. This is found in the vesical 
 mucus, which is in great excess in all chronic catarrhal diseases of the bladder, 
 and the production of which is favored by the existence of stricture or of 
 hypertrophied prostate or vesical atony with residual urine. 
 
 The treatment of these conditions and of the chronic cystitis which so 
 often accompanies them is therefore of the utmost value in the prophylaxis 
 of vesical calculus. 
 
 A stone having once formed, the operative treatment applicable for its 
 
868 ^^V AMElilCAX TEXT-BOOK OF .SlliaEIiY. 
 
 removal varies according to a number of factors, chief among which are — 1, the 
 size of the stone; -. its composition; -3. the condition of the kidneys: 4, the 
 presence or absence of obstructive disease, as urethral stricture ; o. the con- 
 dition of the prostate and bladder ; 0, the age of the patient. . 
 
 The possible methods of removing a given stone from the male bladder 
 are — 1. perineal lithotomy, a, lateral, h, median : 2, suprapubic lithotomy ; 3, 
 litholapaxy. The remarkable change brought about in the treatment of cal- 
 culus by the introduction of the last-named method has greatly reduced the 
 field of the first two. The limitations of their emjdoyment since the develop- 
 ment of litholapaxy, and especially since its extension to children, may well be 
 indicated by the experience of Thompson, who in former days found it neces- 
 sary to cut one in every four patients with calculus, and who now cuts but one 
 in thirty. 
 
 It is safe to say that in adults perineal Utlwtomy should be done chiefly 
 under the following circumstances : 1. In cases of deep urethral stricture rebel- 
 lious to dilatation, in which by selecting the median method the stricture may 
 be divided at the same time. 2. In cases of stones of moderate size and of 
 such hardness and density as to make too great demands on the strength of the 
 lithotrite or of the operator. This condition occurs very rarely, o. In cases 
 of atony of the bladder where there is little or no expulsive power, where 
 there is already a chronic cystitis, and where the stone is of medium size. In 
 some cases a preliminary crushing of a few minutes' duration may make the 
 operation the preferable one even when the stone is of considerable size. 
 
 Suprapubic lithotomy should be selected — 1, when the stone is an unusually 
 large one, and at the same time is believed to be of exceptional hardness ; 2, 
 in cases of marked prostatic hypertrophy with pouched bladder, chronic cys- 
 titis, and large stone : and 3, sometimes w hen the kidneys are diseased. 
 
 Litholapaxy is the method appropriate to nearly all other cases, though a 
 few exceptions to the above rules may result from the presence of such compli- 
 cations as advanced renal disease, vesical tumor, etc. 
 
 Preparatory Treatment. — Whatever operation is to be performed on a 
 patient with vesical calculus, certain preliminary examinations and preparations 
 are invariably necessary. The general health of the patient, especially in 
 regard to the condition of the kidneys, should be carefully looked into. The 
 quantity of urine passed daily should be measured for some days. The pres- 
 ence of albumen, of blood or pus, of fetor, etc. should be carefully noted. 
 Both the choice of operation and the prognosis and post-operative treatment 
 will be influenced by the results of this inquiry. 
 
 The patient should be put to bed for two or three days previous to opera- 
 tion, to reduce as much as possible the irritation of the bladder produced by 
 motion. If the urine is extremely fetid and ammoniacal, as in old cases of 
 atony or of enlarged prostate, it is well to draw it every eight hours and irri- 
 gate the bladder with strong boric-acid or weak nitrate-of-silver or potassium- 
 permanganate solutions. At the same time salol or boric acid in five-grain 
 doses four times daih* should be administered by the mouth. A milk diet is 
 advisable, though light meals may also be allowed, especially in old persons. 
 
 The pubes and perineum should be shaved, no matter which operation is to 
 be performed, as it reduces the risk of infection even during a litholapaxy, 
 permitting thorough asepsis of the parts that have to be handled during the 
 introduction and manipulation of the instruments. A laxative should be given 
 the night previous to. and an enema about four hours before, the operation. 
 
 These various methods may now be described. 
 
 Perineal Lithotomy. — 1. Lateral Lithotomy. — This operation, popular- 
 
SURGERY OF THE GENITO-URTNARY TRACT. 
 
 809 
 
 i/,cd about the end of the seventeenth century by Frerc Jacques, and placed on 
 an enduring scientific basis by the labors of Cheselden in the early part of the 
 eighteentli century, is still the operation of ])reference in certain cases in adults 
 and with some surgeons in almost all children. In ])erforming it the incision 
 is made in the left side of the perineum, extending through the left lobe of the 
 prostate to the neck of the bladder. 
 
 The following anatomical points bear upon the performance of all forms of 
 perineal lithotomy : The perineum is a lozenge-shaped space, the four angles of 
 which are at the symphysis pubis, the tuberosities of the ischia, and the tip of 
 the coccyx. The anus is in the middle line between the tuberosities, and its 
 center is about one inch and a half from the tip of the coccyx. Midway be- 
 tween the perineo-scrotal junction and the center of the anus is the "perineal 
 center," which corresponds to the middle of the lower edge of the triangular 
 ligament. The bulb with its artery lies in front of the point. The middle 
 
 Fig. 347. 
 
 Curved Stone Forceps for Lithotomy. 
 Fig. 348. 
 
 Straight Stone Forceps for Lithotomy. 
 Fig. 349. 
 
 5*1 
 
 Lithotomy Staff. 
 
 line of the perineum is not crossed by any vessels, and, like the median 
 line of the neck and abdomen, is comparatively bloodless. The pelvic fascia 
 and the levator ani muscles separate the perineal space from the cavity of 
 the pelvis. The distance from the skin to the floor of the pelvis represents 
 the depth of the perineum and varies with the amount of subcutaneous fat. 
 It varies also with the point of measurement, being from two to three inches in 
 the posterior part and less than one inch in the anterior part of the perineum. 
 In an adult of ordinary size the distance from the skin to the bladder Avhen 
 the limbs are in the lithotomy position is from two and a half to three 
 inches. The membranous urethra is about three-fourths of an inch below the 
 symphysis. 
 
 The instruments needed in the performance of lateral lithotomy are a 
 
»70 
 
 .4.V AMERICAN TEXT-BOOK OF SURGERY. 
 
 Fig. 350. 
 
 lithotomy knife, a grooved staff, a ])robe-pointe(l bistoury, litliotomy forceps 
 (Figs. 347, 348), scoop, a large-sized gum catheter, and a catheter en cJiemise 
 (Fig. 350). The staff should have a large curve with a lateral groove, 
 and should be of moderate size, so as not to interfere with the introduction 
 of the finger (Fig. 349). Various forms of knife are preferred by different 
 operators. 
 
 A lithotrite should be at hand in case an unexpectedly large stone is met 
 with. The patient having been placed upon a narrow table and fully anesthe- 
 tized, a searcher is introduced into the liladder and the presence of the calculus 
 demonstrated by eliciting the characteristic sound. The bladder is emptied and 
 washed out with warm boric-acid solution, six to eight 
 ounces of Avhich are left in it. The thighs are flexed 
 on the abdomen and the legs on the thighs, the lower 
 limbs being then given in charge of two assistants, 
 who steady them in that position, keeping the median 
 line of the perineum exactly vertical. The grooved 
 staff is then introduced and entrusted to an assistant, 
 who holds it steadily with his right hand, keeping the 
 handle nearly vertical, but inclined a little toward the 
 right groin, while the concavity of the staff is brought 
 firmly up against the arch of the pubes. With the left 
 hand the assistant draws up the scrotum. The ope- 
 rator then takes his place kneeling or sitting with his 
 face opposite to and on a level Vith the patient's peri- 
 neum, lie steadies the integument of the perineum 
 with the fingers of the left hand, and then with the 
 knife makes an incision from a point to the left of the 
 raphe and about one inch and a quarter in front of the 
 anus to a point about midway between the tuber ischii 
 and the anus, a little nearer the tuberosity than the 
 gut. so as to avoid wounding the rectum. 
 This incision is deepest at its anterior extremity. It divides the skin, 
 superficial fascia, transverse perineal muscle, nerve, and vessels, the lower 
 edge of the anterior layer of the triangular ligament, and the lower or exter- 
 nal hemorrhoidal vessels and nerves. 
 
 The surgeon now introduces his left forefinger into the depths of the wound, 
 feeling for the staff and pressing the rectum backward. When the groove in 
 the staff is found, the knife is carried along the finger-nail, which should rest 
 against the inner lip of the groove of the staff (Fig. 351). When it is certain 
 that the point of the knife is safely lodged in the groove, it is pushed along 
 it with the blade inclined so as to be parallel with the external wound, and is 
 made to enter the bladder. This will usually be announced by a gush of 
 urine. As the knife is Avithdrawn, the incision in the neck of the bladder 
 and in the prostate, which is directed obliquely downward and outward, is 
 gently enlarged. By this cut the membranous and prostatic portions of the 
 urethra are opened and the compressor urethr«>, the posterior layer of the 
 triangular ligament, a few of the anterior fibers of the levator ani, and the 
 left lobe of the prostate are divided. 
 
 The surgeon now carries the left forefinger along the groove of the 
 staff into the bladder and feels for the stone. When the finger is in con- 
 tact with it, and not before then, the staff is taken out, the forceps are 
 introduced alongside of the finger, and the stone is seized and withdrawn. 
 The latter portion of this operation, the seizing and extraction of the 
 
 Catheter en chemise. 
 
SURGERY OF THE GENITO-URTNARY TRACT. ^71 
 
 stone, should be done systematically, the forceps being fully introduced 
 before they are opened, and the blades then separated and closed while a 
 rotary motion is given to them. If they fail to grasp the stone after they 
 have been gently swept from one side of the bladder to the other, it may 
 
 Fig. 351. 
 
 Lateral Lithotomy (Tillmanns). 
 
 be soucrht behind the prostate by withdrawing the forceps slightly, raising the 
 handle? and then opening and closing them. When the calculus is grasped, it 
 should be withdrawn slowly and gently and by traction in the axis ot the pel- 
 vis—that is, in the recumbent position, upward and forward. it there is 
 much resistance from the tissues near the neck of the bladder stretched over 
 the stone, they may be pushed back with the finger or may occasionally re- 
 quire further division by a light touch of the knife. 
 
 If possible, the calculus should be extracted without fragmentation, as it it 
 crumbles or breaks into pieces the operation is prolonged by the necessity tor 
 the use of the scoop and for repeated washing out of the bladder. ^ Alter the 
 stone has been removed the bladder should be carefully explored with the fan- 
 ger to make certain that it does not contain a second calculus. A gum or solt- 
 rubber catheter should be introduced through the wound into the bla<lder, and a 
 stream of warm boric-acid solution sent through it forcibly a few times until it 
 comes back clear. If there is no hemorrhage, the patient may then be put in 
 bed with the hips and knees flexed, and the wound lightly covered with anti- 
 septic absorbent cotton frequently changed or with a large soft sponge wrung 
 out of warm carbolic solution. The slight hemorrhage which invariably tollows 
 this operation, coming from the transverse perineal and hemorrhoidal vessels, 
 usually ceases spontaneouslv. If they bleed very freely, they are seized with 
 pressure forceps as soon as the stone is extracted, and upon their removal when 
 the patient is prepared for bed the hemorrhage will usually be found to have 
 ceased permanentlv. If not, they can readily be tied. Hemorrhage from the 
 artery of the bulb' may cause considerable trouble, but will usually admit of a 
 ligature, or at least of arrest by forceps, which may be left in position for a day 
 
872 
 
 .4.V AMERICAN TEXT-BOOK OF SURGERY. 
 
 Fifi. 352. 
 
 or two. The internal pudic, altliou<rli protected by tlie lip of the tuberosity 
 and the margin of the ramus of the ischium, has occasionally been wounded as 
 the result of carrying the incision too far externally. It may be seized with 
 forceps, which are left in position, or, better, ligated by means of a strong awl- 
 shaped needle with an eye near the point of the needle carrying a strong 
 thread. The needle is passed along the inner side of the ramus of the ischium 
 half an inch in front of the tuberosity, and brought out on the inner side of 
 the artery, the point of the needle being directed toward the surface, so that 
 the thread may be disengaged from the eye. The needle is then withdrawn 
 and the thread tightened. This would also command the circulation through 
 the artery of the bulb. In case of venous hemorrhage it may be necessary to 
 pack the wound. This may be done either by the catheter en chemise (Fig. 350) 
 or bv the air tampon of Buckston Browne. The former is made by cutting 
 an opening in a stjuare of muslin or stout linen, passing a gum catheter through 
 it, and fastening them together at a point about three inches from the end of 
 the catheter by a thread. The projecting portion of the catheter is then passed 
 into the bladder, and the space between the instrument and the inner portion 
 of the muslin is packed with antiseptic gauze. The Buckston Browne tampon 
 
 consists of a central tube acting as a cathe- 
 ter surrounded by a soft-rubber bag. which 
 admits of distention with air or water (Fig. 
 352). 
 
 Other accidents may occur during the 
 operation. "Wound of the rectum is usu- 
 ally the result of the knife not being suf- 
 ficiently lateralized, or is sometimes the 
 consequence of sloughing following the 
 withdrawal of an exceptionally large cal- 
 culus. In either case it ordinarily heals 
 spontaneously, but sometimes a fistula is 
 left. The urethra has occasionally been 
 missed altogether, and still oftener in chil- 
 dren has been torn completely across. In 
 them the bladder is higher and more mo- 
 bile than in adults. The connective tissue 
 of the region is delicate and easily lace- 
 rated. The wound is necessarily a small 
 one, and during the effort at introduction 
 of the finger, therefore, it has happened 
 even to very skilful lithotomists that the 
 urethra has been torn across and the 
 finger has been pushed onward into the loose cellular tissue of the recto- 
 vesical space, where by its pressure an artificial cavity is formed which is 
 then mistaken for the interior of the bladder. This accident is likely to be 
 followed not only by immediate failure of the operation, but )»y pelvic cellu- 
 litis, peritonitis, and death. It may be avoided by making the incision into the 
 urethra sufficiently large at first, and by observing that as the finger is passed 
 through it is tightly grasped by the prostatic urethra and the neck of the 
 bladder, giving a sensation very different from that experienced if it is in the 
 loose, unresisting tissue of the recto-vesical space. When the mistake is made 
 and is recognized in time, it can be remedied by withdrawing the finger, rein- 
 serting the knife into the groove of the staff", and carefully enlarging the incis- 
 ion toward the neck of the bladder. If, however, the latter has been pushed 
 
 Buckston Browne's Tampon. 
 
SURGERY OF THE GENITO-URINARY TRACT. 87;^, 
 
 oft' the staff, so that it cannot be reachod, it Avould bo proper to perform 
 at once a suprapubic litliotoniy, to pass a catheter from tlie bhidder out 
 through the perineum, and to phice a small drainage-tube in tlie recto-vesical 
 space alongside of it. The accident can be avoided in the majority of cases if 
 the plan fre(i[ucntly followed by Agnew in very young children with entire suc- 
 cess be adopted — namely, to (lis])ense with the introduction of the finger and 
 to carry a pair of small force})s directly along the groove of the staff after 
 the incision has been made into the bladder. When it is clearly recognized 
 that they have grasped the stone, the staff may be withdrawn and the extrac- 
 tion completed. The same result can be attained by passing the finger along 
 the concavity of the staff — i. e. along the roof, the more fixed portion of the 
 urethra. In a few instances the urethra has been missed altogether and the 
 bladder opened beliind the prostate, and in others the knife has been carried on 
 so far tliat the posterior wall of the bladder itself has been wounded. Both of 
 these accidents are likely to result fatally from extravasation of urine, pelvic cel- 
 lulitis, and peritonitis. Death may occur after lateral lithotomy from any of the 
 causes which have been mentioned ; from septicemia following sloughing or ab- 
 sorption of the wound products or of decomposing urine ; or from suppurative py- 
 elo-nephritis, especially in cases in which the kidneys are already much diseased. 
 
 Median Lithotomy. — This operation is performed by means of an incision 
 made through the raph^ betAveen the scrotum and the anus. The patient is 
 placed in the same position as for lateral lithotomy, and a grooved staff is in- 
 troduced and held carefully in the median line well up under the arch of the 
 pubes. An incision is then made in the line mentioned, and deepened until 
 the membranous part of the urethra is reached. This is freely opened on the 
 groove of the staff for the space of about three-quarters of an inch. The 
 finger is then introduced, and carried with a boring or rotatory motion onward 
 through the prostatic portion of the urethra to the bladder. When the stone 
 is touched the staff is Avithdrawn and a pair of forceps introduced, or a director 
 may be first passed along the groove of the staff into the bladder and the staff 
 withdrawn, and the finger then passed along the director as a guide. This 
 has the advantage of allowing more room for the finger and of permitting it 
 to follow the upper wall of the urethra, which is more firmly fixed than the 
 lower, and therefore less liable to be torn across. The parts divided in this 
 operation are the skin, superficial fascia, sphincter ani, perineal center, the 
 lower edge of the triangular ligament, the compressor urethrae, the membranous 
 urethra, and the apex of the prostate. The advantages claimed for it are the 
 slight amount of hemorrhage, as there are no vessels of any size in the line 
 of the incision, the avoidance of the risk of wounding the ejaculatory ducts, 
 the lessened probability of urinary infiltration from disturbance of the recto- 
 vesical fascia, and finally the simplicity of the operation itself. It must be 
 remembered, hoAvever, that at the anterior end of the incision the knife is 
 necessarily in close proximity to the bulb, and at the posterior end is very 
 near the anterior wall of the rectum. 
 
 Suprapubic Lithotomy. — Anatomical Points. — The peritoneum is 
 attached to the bladder at its summit, extending upon the anterior surface 
 as far as the insertion of the remains of the urachus. Posteriorly it descends 
 betAveen the bladder and the rectum to a loAver level. It is attached firmly 
 to the anterior surface and summit of the bladder, but ver}^ loosely to the 
 abdominal parietes at the level of reflection of the membrane, thus enabling 
 it to folloAv the various changes in the size and position of the bladder. 
 When empty that organ is flattened, is triangular in shape, and lies 
 against the anterior Avail of the pelvis, between Avhich and it is a quantity 
 
874 
 
 J.V AMERICAN TEXT- BOOK OF SURGERY 
 
 Fig. 353. 
 
 of loose connective tissue containing fat. ^VLen the blatlder and rec- 
 tum are entirely empty the peritoneal fold on the anterior .surface is a 
 little below the upper edge of tlie .symphysis. "When the .>^uniniit of the 
 bladder is two inches above the pubes and the organ is pre.«sed again.st the 
 
 abdominal wall, the reflection of perito- 
 neum is about three-quarters of an inch 
 above the .symphysis. Distention of the 
 bladder alone will elevate the fold of peri- 
 toneum from one-half to three-quarters 
 of an inch. Distention of the rectum 
 alone will elevate the ba.se of the blad- 
 der, but will have little or no effect upon 
 the reflection of peritoneum. It ^>rovides, 
 however, a firm basis for the fundus of 
 the ])ladder. prevents the latter when 
 dilated from extending toward the peri- 
 neum, and pushes the whole organ for- 
 ward against the anterior abdominal wall. 
 Under these circumstances the same quan- 
 tity of fluid wliich if injected into the 
 bladder when the rectum is empty would 
 raise the pre-vesical fold three-quarters 
 of an inch, has been shown to increase 
 the elevation to from one and a half to 
 three and a half inches (Fig. 353.) The 
 vesical veins which run from the apex 
 of the bladder and pass under its fun- 
 dus are compressed when the rectum is distended. 
 
 These preliminary anatomical points are of great importance in the operation, 
 which is conducted as follows: The patient is prepared as for lateral lithotomy; 
 an empty rectal bag (Fig. 354) is oiled, introduced into the rectum, and passed 
 well above the sphincter. The bladder is then emptied by means of a soft 
 catheter and washed out with a warm solution of boric acid. The rectal bag 
 is then distended with about eight or ten ounces of fluid when the patient is 
 an adult : larger quantities have been u.sed, but occasionally Avith serious 
 results from laceration of the mucous membrane or the peritoneum. In 
 children, as the bladder is already an abdominal organ, the distention of 
 the rectum can often be dispen.sed with altogether. The next step con- 
 sists in the injection of the bladder, which can usually be sufficiently di.s- 
 tended in an adult by the injection of ten to twelve ounces of liquid, and in a 
 child under five years of age by the use of about three ounces. Keen and 
 others prefer to distend the bladder with air filtered through cotton, which i.s 
 tied over the end of a Davidson syringe, instead of fluid. The catheter is 
 then withdrawn and a soft india-rubber drainage-tube tied around the penis to 
 prevent the escape of the fluid from the bladder. An incision three inches long 
 is then made in the middle line, beginning half an inch below the upper edge of 
 the pubes. The line between the recti or pyramidales having been found, 
 the muscles may be separated with a few touches of the knife and the han- 
 dle of the scalpel, but on no account should any forcible or vigorous tearing 
 of the parts be employed. It is better, if the intermuscular interval is not 
 apparent at once, to carry the incision directly through whatever muscular 
 fibers make their appearance in the wound, adhering to the median line and 
 deepening the incision until the transversalis fascia is reached. Ttis is 
 
 LiftiiiL' up the Peritoneum by Rectal and Vesi- 
 cal Distention ; JI, bladder : H, rectum dis- 
 tended by the Petersen bag; A', peritoneum 
 (Hotter). 
 
SURGERY OF THE GENITO- URINARY Th'ACT. 
 
 875 
 
 tlioii divided, and if the <Ml(rcs of" tlic \vr)iiii(l ;irc licld asunder bv retractors, 
 a layer of" loose connective tissue and fat, freijuently containing large veins, 
 will become apparent. This lies directly over the wall of the bladder and 
 conceals it. It may also be divided with light touches of the knife, aided 
 occasionally by sej)aration with the handle or the fingers, the same pre- 
 
 Petersen's Iltrtal i;i.>lii<_-uryiitL'r, modified by Guyon 
 
 caution being observed not unnecessarily to tear or break up the connective 
 tissue in this region, as rough manipulation may result in sloughing or in uri- 
 nary infiltration after the operation. A portion of the fat may be gently 
 pushed upward with the forefinger, and will usually carry with it the fold of 
 peritoneum if the latter descends to this level. It is, however, not often seen 
 during the operation. There may be at this stage profuse bleeding from the 
 veins running in the connective tissue lying upon the front of the bladder. 
 All bleeding should be checked by the use of hemostatic forceps, but no time 
 need be lost in applying ligatures, as the bleeding is almost entirely venous, 
 and Avill usually cease promptly when the rectal bag is emptied. 
 
 The anterior surface of the bladder having been recognized by its color, 
 by the presence of the muscular fibers, and by its fluctuation, it should be 
 transfixed with a sharp hook inserted transversely near the upper angle of 
 the wound. The surgeon, holding this in the left hand or entrusting it to an 
 assistant who fixes the bladder, opens the organ by thrusting a scalpel verti- 
 cally through the wall just below the hook, and precisely in the median line, 
 and cutting downward toward the pubes. The edges of the opening may then 
 be seized with tenacula, or loops of silk may be passed and given to assistants 
 to hold so as to steady the organ. The hook may then be withdrawn and the 
 surgeon may introduce the right forefinger into the bladder. The wound 
 should be large enough to admit easily of two fingers, which may be employed 
 instead of lithotomy forceps, or the latter may be introduced and the stone 
 extracted. The rectal bag is then emptied and withdrawn. The India-rubber 
 tube encircling the penis must not be forgotten. If the bladder is healthy 
 
<S7G AN AMJJRICAy TEXT-BOOK OF SlliOEUY. 
 
 and iminfoctod, and ospocially if the operation has been carried out in a cliild 
 or in a healthy adult, suture of the bladder may be employed. The wound is 
 brought ^vitllin reach of the surgeon by two blunt liooks, one inserted at cacn 
 of its extremities. With them it is brought forward to the surface and the 
 margins of the incision kept steady and parallel with each other. Very fine 
 ehromicized catgut should be employed. The sutures should be interrupted, 
 should not include the mucous membrane, should be introduced by means of a 
 curved needle in a holder, and should be very closely applied. Many methods 
 have been devised, but this appears to be the best (Treves). A small drainage- 
 tube is introduced into the lower part of the wound in the parietes, and the 
 rest of the wound is then closed. In such a case the after-treatment is con- 
 ducted in the same manner as after any abdominal section. 
 
 If the case is one which does not permit of suture of the liladder, a few- 
 stitches may be placed at tlie two extremities of the wound in the aljdominal 
 wall, including all the tissues which have been divided. It is thought import- 
 ant by some surgeons to stitch the slit in the bladder to the fascial and deeper 
 €dges of the wound, two or three sutures being placed on each side, and one 
 below at the lower end of the incision, so as to shut oft" the tissue behind the 
 pubes. It is said greatly to lessen the danger of urinary infiltration. A large- 
 sized tube also is introduced into the bladder and retained for from thirty-six to 
 forty-eight hours. Others dispense with both these procedures, which thev con- 
 sider useless, and employ no form of drainage-tube, using a catheter introduced 
 through the urethra if there is retention of urine. During the after-treatment 
 the patient may turn upon his side from time to time so as to lessen the exco- 
 riation of the parts. The skin in the neighborhood should be protected by 
 antiseptic ointment, the edges of the wound should be frequently lightly 
 dusted with iodoform, and a pad of antiseptic absorbent cotton, or, better, a 
 soft, clean sponge, should be lightly fastened over the wound itself. The 
 patient Avill require constant attention to prevent troublesome excoriation, but 
 may be allowed a considerable range of motion, and should be encouraged to 
 sit up comparatively early. 
 
 LiTHOLAPAXY. — ^fhe Operation of lithotrity, by which the stone was crushed 
 usually at several sittings and the fragments were left for unaided evacuation 
 
 Fig. 355. 
 
 Bigelow's Litliotrite. 
 
 by the patient, has Iteen completely supplanted ])y the modern o])eration of 
 litliola])a\y, in which the crushing and the removal of the fragments are both 
 :'ompleted at one sitting. This, Avhich is the greatest advance in the treatment 
 of vesical calculus which has been made in the history of surgery, we ow-e to 
 an American surgeon, Professor Bigelow of Boston, who in 1878 proposed the 
 method and described the instruments which after long experimentation and 
 careful study he had devised. These consist of lithotrites for crushing the 
 stone and evacuators for removing the debris. The litliotrite is made in a 
 variety of forms, the two most useful being those which are represented in 
 Figs. 355, 856. The surgeon may use the kind which he prefers, but in 
 all cases should be certain that the instrument has been made by a thoroughly 
 
SURGERY OF THE GENITO-URINARY TRACT. 
 
 877 
 
 careful and rc'lia))k' maker, and that it lias tlic strength requisite for the great 
 strain to which it is often subjected. The evacuators are also now of great 
 
 Fig. 356. 
 
 Fig. 357. 
 
 Thompson's Lithotrite. 
 
 variety. That of Dr. Bigelow is represented in Fig. 3o8, and in the opinion 
 of many surgeons has not yet been improved upon. It consists of a large 
 elastic bulb with a detachable glass bot- 
 tle at its lower end, and with a stop- 
 cock at the summit for the purpose of 
 filling the bulb, and one at its lower ex- 
 tremity for connection with the evacuating 
 tube. A perforated tube which extends 
 from the lower stopcock into the center of 
 the bulb is so made that the area of the 
 fenestra in its walls is greater than the 
 area of its transverse section. Therefore, 
 during the process of evacuation of the 
 debris, Avhen the bulb is compressed the 
 current of fluid flowing back into the 
 bladder tends to go through the small 
 openings in the walls of the perforated 
 tube rather than through its main chan- 
 nel. In this way any fragments floating 
 in the reservoir, which have not yet set- 
 tled in the glass receiver at the bottom, 
 are arrested, and are less likely to be 
 thrown back into the bladder. The 
 coiled tube, figured in the cut, connects 
 with the stopcock at the summit of the 
 bulb, and, by dropping the sinker at the other end into a basin of warm anti- 
 septic solution, may be used to increase the quantity of water in the bulb 
 whenever desirable. 
 
 The patient should be prepared as for the other operations for stone. The 
 bladder should be emptied and washed out several times before the operation 
 if it is infected and contains fetid urine, and in any event at the time of 
 operation, after which about six to eight ounces of boric-acid solution should 
 be injected and retained. The surgeon should ascertain that the urethra will 
 admit full-sized instruments. The patient should lie upon the back with the 
 shoulders slightly elevated and the thighs somewhat separated. 
 
 The lithotrite should be gently introduced, as in catheterism, until the beak 
 reaches the bulbous portion of the urethra. The shaft will then be perpendic- 
 ular. If it is held for a few seconds in that position, the penis at the same 
 time being drawn upward, the blades will pass through the narrow orifice of 
 the membranous urethra, and if then the handle be gently and slowly depressed 
 the instrument w^ll pass through the prostate and enter the bladder. The blades 
 should be allowed to slide down the inclined plane of the trigone until they 
 touch the posterior wall of the viscus. They should rest there for a few 
 seconds until all currents in the contained fluid have subsided, and then the 
 
 Beak of Bigelow s Litbutritt, c 
 
 pen. 
 
878 
 
 AN AJflJIilCAN TEXT-BOOK OF SURGERY. 
 
 male blade should be gently drawn out until a very slight resistance from its 
 contact with the neck of the bladder is observed. After another pause of a 
 
 Fi«. 3o8. 
 
 Bigelow's Evacuator. 
 
 few seconds it should be pressed back, and in many cases the stone will be 
 found in the grasp of the instrument. If it is not, the blades should be rotated 
 first to the left, then to the right, the shaft of the instrument remaining in the 
 median line, and the same manoeuver repeated. The degree of rotation may 
 be varied if need be, or if there is a post-prostatic pouch the blades may be 
 turned directly toward the floor of the bladder. This may be done most easily 
 and safely by depressing the handle of the lithotrite so that the shaft is hori- 
 zontal instead of directed upward. All these movements should be gentle. 
 The rule laid down by Thompson is an excellent one : viz. that the more 
 powerful the lithotrite — that is, the longer and larger its blades — the less 
 ready should we be to adopt the reversed positions of the blades, and the more 
 fluid is it desirable to have in the bladder. 
 
 The stone having been seized, the instrument is then to be partly with- 
 drawn, so that its blades occupy the center of the cavity of the bladder ; the 
 screw is then turned, gradually at first, so that if the calculus is hard it may 
 not fly out from between the blades. As it becomes apparent that it is firmly 
 grasped the power is increased, and continued until the stone is felt to break, 
 usually into several fragments. The male blade is screwed home so as to 
 pulverize the smaller fragments, and the process of seizing and crushing is 
 repeated until no large pieces can be felt. This should usually occupy from 
 fifteen to thirty minutes, according to the size and hardness of the stone. 
 The lithotrite is then withdrawn, of course with the blades well closed, and 
 an evacuating tube introduced. For an adult, one of the caliber of 28 to 30 
 (French) will do in the majority of cases. It is connected with the bulb, the 
 stopcock turned, and then gentle compression of the rubber l»all made with 
 the right hand while the evacuating tube is steadied with the left hand. 
 Firm pressure may be made, followed by a delay of three or four seconds 
 
SURGERY OF TIIK GENITO-URINARY TRACT. 879 
 
 after expansion of tlio l)ull) is completer (Thompson), or compression may be 
 made more (juickly and trcMiuently and less forcibly (Bigebjw). 
 
 If there is much debris in the ))ladder, the end of tiie evacuating tube 
 shouhl not be inserted as far as the fundus, but as the quantity diminishes it 
 may be h)wered so as to pick up the hist fragments. 
 
 Sometimes the tube will become suddenly blocked by a fragment and the 
 bulb will cease to expand. Quick, forcible pressure will generally dislodge the 
 obstructing body. Sometimes the bladder wall will come in contact with the 
 eye of the tube, giving a peculiar sensation not urdike the nibbling of a fish 
 at tlie end of a line, and hence called by Bigelow the " fish-bite." It indi- 
 cates that the bladder is not sufficiently distended and that more fluid must be 
 thrown in. This can be done by using the rubber tube (Fig. 808), dropping 
 one end in a basin of warm boric-acid solution ; then, after slowly compressing 
 the bulb, the way to the bladder being open, the stopcock of the evacuating 
 tube is closed and that communicating with the rubber tube is opened. On 
 relaxing pressure the bulb will promptly refill from the boric solution outside. 
 When no further pieces of stone can be heard or felt, it is well to withdraw the 
 lithotrite, introduce a vesical sound, and make a final exploration of the blad- 
 der. If a fragment is found, a smaller lithotrite may be used to crush it, and 
 the debris then extracted in the usual manner. Auscultation over the hypo- 
 gastrium while the bulb and evacuator are in place may aid in determining the 
 presence of a final fragment. 
 
 The only complication of the operation worthy of mention is the possible 
 clogging of the blades of the lithotrite, so that they cannot be approximated 
 sufficiently to permit of their safe withdrawal. In such an event (which is 
 naost unlikely to occur if the fenestrated lithotrite be used) the blades must be 
 made to protrude in the perineum or above the pubes, and then cut down upon 
 as in median perineal lithotomy or suprapubic lithotomy, freed, and withdrawn, 
 the remainder of the calculus being extracted as in the above operation. 
 
 Rest in bed on the back, milk diet, warm fomentations to the epigastrium, 
 boric acid or salol by the mouth, and moderate doses of quinine, constitute the 
 essentials of the after-treatment. 
 
 In children the principles governing the selection of the form of operation 
 for stone have lately undergone marked change. Until comparatively recent 
 times the very low mortality of perineal lithotomy in children in the hands of 
 skilful operators made it seem a work of supererogation to seek for a better 
 method of operation : a safer could scarcely be found. A high rate of mortal- 
 ity after lithotomy was almost always due to deaths among elderly adults. Fer- 
 gusson long ago said that it would be difficult to name any single operation of 
 magnitude which was more successful on young subjects than lithotomy, quot- 
 ing a series of 105 cases operated on at the Norwich Hospital, with only 3 
 deaths, as evidence of the correctness of his statements. Brodie said : " In 
 boys under the age of puberty lithotomy is so simple and so generally success- 
 ful that we ought to hesitate before we abandon it for any other kind of ope- 
 ration." These opinions were reiterated by surgical teachers almost without 
 exception from those days until some six or seven years ago. Velpeau enu- 
 merated as the objections to lithotrity before puberty "the want of develop- 
 ment of the sexual organs, the small diameter of the urethra, the indocility of 
 the patients, and the extreme sensibility of the parts." In 1884. Surgeon- 
 Major Freyer, an accomplished lithotritist and a lithotomist who had cut for 
 stone in boys 132 times consecutively without a single death, repeated Vel- 
 peau's assertions almost in the same words, objecting to the crushing of stone 
 in boys on account of the undeveloped condition of the geni to-urinary organs, 
 
880 .l^V AMERICAN TEXT-BOOK OF SURGERY. 
 
 the smallness of the bladder, tlie narro\vnes.s of the urethra, and the liability 
 to laceration of the vesical and urethral mucous membrane, lie added that 
 no instruments had boon invented by which lithola|)axy could be performed 
 with safety in male chihhcn. 
 
 Other objections have liccn advanced from time to time, maiidv. however, 
 relatin<^ to the same anatomical points and (before the introduction of lithol- 
 apaxy) to the difficulty of getting rid of the fragments. As late as 1888, 
 Keyes wrote that, on account of the limited proportions of the male urethra 
 before puberty, the excessive sensibility of the child's bladder, and the want 
 of docility and self-control at that time of life, lithotomy is to be preferred in 
 male children under the age of fourteen. He made exception in favor of 
 very small stones. 
 
 Many similar expressions could be quoted from the writings of surgeons 
 of all degrees of experience, but they emphasize chiefly the same points, the 
 majority of which are now, in the light of the modern improvements in lithot- 
 rity, without applicability. Anesthesia has made the "extreme sensibility" 
 of the parts and the '' indocility " of the patients of little moment. Otis has 
 shown that in children, as in adults, the "small diameter of the urethra" may 
 be greatly increased with entire safety ; antisepsis during and after the opera- 
 tion has minimized the danger of laceration of the mucous membrane ; instru- 
 ments have been made which-are at the same time small enough to permit of 
 their introduction into the urethra and bladder of young infants, and strong 
 enough to deal with very large and very hard calculi ; Bigelow has overcome 
 the difficulty of getting rid of the fragments ; and the argument from .statistics 
 is at least neutralized by the records of Keegan and Freyer, the former having 
 performed 59 litholapaxies in children with but 1 death ; the latter, influenced 
 by his colleague's results, having adopted the operation and performed 49 con- 
 secutive litholapaxies without a death. 
 
 In the fjice of these undisputed facts there is but one argument remaining 
 which has any weight as urged against the operation of lit]iola])axy in children, 
 and that is the alleged greater probability of recurrence. As regards the two 
 great classes of operative procedures for the removal of calculus, the cutting 
 and the crushing operations, all forms of lithotomy as compared with all forms 
 of lithotrity, and at all ages, there can be little doubt that the statistical evi- 
 dence in relation to recurrence is at present in favor of lithotomy. But it 
 should not be accepted without reservation. Many of the tables, notably those 
 of Sir Henry Thompson and Mr. Cadge, are based on an experience extending 
 over many years and antedating the introduction of litholapaxy. Those tables 
 make the proportion of recurrence after lithotrity about 1 in 7 or 1 in 8, and 
 after lithotomy about 1 in 20 ; but, like so much of the statistical matter which 
 our text-books and journals contain, they are useless or misleading at the pres- 
 ent day. The two principal causes which lead to recurrence are: a. the failure 
 to remove every portion of stone at the first operation ; h, the new formation 
 of stone in the kidney and its descent into the bladder. In the tables of 
 Mr. Donald Day, based on the records of the Norwich Hospital, the first class 
 includes two-thirds of all the cases of recurrence. But circumstances have 
 altered. The employment of a large-sized evacuating tube, the immediate and 
 thorough emptying of the bladder, the minute pulverization usually possible 
 with completely fenestrated lithotrites, the increased knowledge of the great 
 tolerance of the bladder to prolonged manipulations if they are gentle and 
 skilful, have all combined to place the question of recurrence upon a very 
 different level, and to make the collection of a new set of statistics ab.solutely 
 necessary before venturing to draw any positive conclusions. 
 
SUItGERY OF THE GEXJTO-URINARY Tit ACT. 881 
 
 But if, for the sake cif argument, we investigate existing statistics on this 
 subject, we find that the great majority of cases of relapse or recurrence have 
 taken place in patients past middle life, and especially in very old persons with 
 eidarged prostates and feeble or atonic bladders. It will be recognized at 
 once that these conditions do not prevail in children. The prostate is unde- 
 veloped ; the bladder is almost an abdominal organ ; no pouch exists at the 
 fundus ; sacculation is nearly or (juite unknown ; cystitis is a comparatively 
 manageable complication ; the ex])ulsive power is proportionately greater than 
 in the male adult, in whom a ''physiological atony" is not at all infrequent. 
 In addition to these reasons for not anticipating the formation of new calculi 
 in children around nuclei of vesical origin, it may be reasonably expected 
 that the conditions favoring the development of renal calculi will be more 
 easily treated and controlled in children than in adults. Certainly among 
 well-to-do people who can carry out a proper system of diet and medication it 
 is fair to suppose that the lithic diathesis, of whatever variety, will be more 
 readily combated in children, whose diet and drugs and mode of life can be 
 rigidly ordered, than in adults with fixed and often very prejudicial habits. 
 
 For these reasons, while admitting that the question of recurrence is still 
 %uh judiee^ there is little probability that there will be enough difference 
 between the proportions of relapses in children after lithotomies and after 
 litholapaxies to justify any decided preference on that ground alone. 
 
 The position of litholapaxy as applied to children is moreover strengthened 
 by a review of the history of lithotomy, which, unlike the operation with which 
 we contrast and compare it, has undergone but little change for many years. The 
 improvements in suprapubic lithotomy have, it is true, rendered it applicable 
 to a much wider range of cases, and it is equally true that its most favorable 
 results have been attained in children ; but thus far the statistics of supra- 
 pubic lithotomy in children do not compare favorably with those of either 
 litholapaxy or lateral lithotomy. This is probably due to the fact that in a 
 large proportion of cases the operation was selected only after litholapaxy had 
 been attempted and failed, or else was originally chosen on account of the 
 unusual character of the calculus. It will probably always be employed in 
 preference to lateral or median lithotomy in cases of extremely large or excep- 
 tionally hard stones ; but when we remember that Freyer has removed by lithol- 
 apaxy a calculus weighing 808 grains from a boy of nine, and Keegan one of 
 TOO grains (and of uric acid) from a boy of nine and a half, it is evident that 
 neither size nor hardness offers an insuperable bar to the latter operation. 
 
 Median lithotomy in children, although advocated by some surgeons, is 
 objectionable on account of the great danger of wounding the bulb or the rec- 
 tum, and the difficulty in obtaining space through which to pass the finger into 
 the urethra and the bladder. It is indeed true that the passage of the finger 
 is not absolutely necessary, although it has always been one of the time-honored 
 rules of lithotomy not to withdraw the staff until the finger is in contact with 
 the stone. Agnew's method (p. 873) avoids this difficulty, and Mr. Cadge 
 recommends almost precisely the same method as both safe and efficient. It must 
 be remembered, however, that its adoption places the surgeon in almost the same 
 situation, in regard to the possibility of leaving debris or unnoticed stones in 
 the bladder, that he occupies after litholapaxy. If the stone is soft and breaks 
 down under the forceps, or if there are multiple calculi, he will be dependent 
 on the touch and sound elicited by the vesical explorer, just as after the other 
 operation. If, then, the introduction of the finger be dispensed with in either 
 median or lateral lithotomy in children, these operations lose one of their 
 alleged advantages — viz. the assurance of the absolute removal of all calculous 
 
 o o 
 
 56 
 
882 .l.V AMERICAN TEXT-BOOK OF SURGERY. 
 
 fragment?. If it be insisted upon, it constitutes in a small proportion of cases 
 an unavoidable source of both difficulty and danger. Sir William Fergusson, 
 Keith, Thompson, Cadge, and many others have recorded occasional trouble 
 with this step of the operation. 
 
 niese facts and the other special dangers of lateral lithotomy in children 
 have already been described, but one further possible contraindication should 
 not be lost sight of. If the incision be prolonged a little too far backward, the 
 left ejaculatory duct can hardly escape division and subsequent obliteration, 
 an<l, although this may not be a serious accident in cases in which the integ- 
 rity of the opposite half of the genitalia, the testicles, duct. etc.. is unimpaired, 
 yet it leaves the patient entirely dependent on that one side for fertility, if not 
 for potency. Mr. Teevan has reported four cases of sterile husbands among 
 lithotomized patients. Langenbeck and Sir William MacCormac have called 
 attention to the same danger, and Keegan believes the lateral operation to be 
 frequently followed by emasculation. Dennis quotes Dr. Charles Leale in rela- 
 tion to several cases coming under his own observation in which such patients 
 grew up with shrill voices, atrophied testicles, absence of hair upon the face, 
 etc. ; in fact, with all the characteristics of eunuchs. The evidence as to this 
 point is as yet fragmentary and inconclusive, but is of sufficient importance to 
 deserve careful consideration. 
 
 These objections to perineal lithotomy in children are at least as weighty 
 as any that have been urged against litholapaxy. Most recent writers, basing 
 their opinion on the foregoing facts, express the conviction tliat the field of lith- 
 olapaxy in children is likely to be considerably enlarged in the near future. It 
 seems probable that the following statements will be generally accepted as cor- 
 rect : In every case of calculus in male children litholapaxy, on account of 
 ease of performance, low mortality, speedy recovery, and absence of danger 
 of emasculation, should be the operation of predilection, division of the meatus 
 being freely resorted to if that portion of the urethra offers an obstacle to the 
 introduction of instruments. The lithotrite and evacuating tube should be of 
 a size which can be inserted into the bladder without much effort or over- 
 distention, and great gentleness should be observed in passing these instru- 
 ments. They should be withdrawn and reintroduced as seldom as possible, the 
 stone being finely pulverized before the lithotrite is taken out at all. In seek- 
 ing for or attempting to seize the stone, care should be taken to avoid such wide 
 separation of the blades as would bring the male blade in frequent contact with 
 the vesical neck. The crushing should invariably be done only after rotating 
 the blades into the center of the bladder. Every particle of the resulting 
 debris should be evacuated. Rest in bed. milk diet, and sterilization of the 
 urine by boric acid or salol, given internally both before and after the opera- 
 tion, are valuable adjuncts. During the operation every antiseptic precaution 
 should be observed. The exceptional cases of calculi which are both large and 
 hard may be best treated by suprapubic lithotomy, but neither unusual size nor 
 a moderate degree of density should of itself alone be thought positively to con- 
 traindicate litholapaxy. 
 
 Perineal lithotomy in chihlren has now a much more limited field than 
 heretofore, and should be employed chiefly in those cases of stones thought to 
 be of small or medium size in which no lithotrite, however small, can be intro- 
 duced with safety. 
 
 Vesical Calculus in Females. — The rarity of vesical calculus in the female 
 is due to the shortness and dilatability of the urethra and to the comparative 
 infrequency of vesical disease in that sex — conditions which favor the sponta- 
 neous escape of small stones descending from the kidneys, and which do not 
 
SURGERY OF THE GENITO-rinXARV TIIM'T. 883 
 
 furnish the agglutinatincr material in the form of vesical mucus necessary to 
 the development of calculi from urinary sediments. The proportion ot calculi 
 in females as compared with males is about as one to twenty-two. 
 
 The causes, symptoms, and methods of diagnosis are essentially the same. 
 
 The treatjnent of stone in women is at the present time confined to three 
 
 procedures : , i i .1 • ^ 
 
 1 If the stone is quite small, the urethra may be stretched to the required 
 extent first by suitable dilators, then bv the little finger, and then Ijy the fore- 
 fin.-er. If this is done slowlv, there will be but little laceration of the mucous 
 membrane, and the incontinence that follows will be of short duration, ihe 
 stone may be extracted with the finger or by means of a scoop or a pair ot 
 forceps 2 If it be too large to extract in this manner, the dilatation ot the 
 urethra should be carried to a sufficient extent to permit of the introduction of 
 a lithotrite : litholapaxv should then be performed in the usual manner. Ji. it 
 the stone is at once extVemely large and exceptionally hard, suprapubic lithot- 
 omy should be employed, but is very rarely necessary. 
 
 *The same rules are applicable to cases of stone m female children, although, 
 of course, the dilatation of the urethra cannot be carried to the same extent. 
 Incision of the urethra and neck of the bladder should not be employed in 
 any case, on account of the risk of permanent incontinence Vaginal lithot- 
 omy, while it still has its advocates, is inferior to the methods above described. 
 
 CYSTITIS. 
 
 Inflammation of the bladder may be acute or chronic. 
 Acute cystitis mav result from injury, as in the rough use of sounds ; trom 
 the use of drucrs, as cantharides ; from the presence of a foreign body, as a cal- 
 culus • from the extension of urethral inflammation, as m cases of stricture ; 
 from 'infection with micro-organisms, as with the gonococcus or the pyo- 
 genic staphylococci in specific urethritis, or with the bacillus tuberculosis ; or 
 from new Growths, as epithelioma. In the milder degrees of acute cystitis 
 the vesicaf mucous membrane is congested, thickened, and swollen, the epi- 
 thelium detached in places, leaving raw or abraded surfaces. In the more 
 severe forms the bladder is lined with tough, tenacious lymph ; there may be 
 ulceration and occasionally even sloughing. The submucous connective tis- 
 sue and sometimes even the entire thickness of the bladder-wall, are infiltrated 
 with pus. Occasionally organization of the exudate covering the mucous sur- 
 face takes place, and large fragments, or even casts, of the interior ot the blad- 
 der are passed per uvethrain (membranous cystitis). 
 
 Cystitis if lon<? continued or of the severer grades, is very apt to spread 
 by continuity along the ureters, and to involve the kidney, producing first a 
 pyelitis, and'^then'^a pyelo-nephritis, not infrequently fatal. 
 
 Symptoms.— Increased Frequency of Urination.— "IXws is one ot the 
 earliest symptoms, often preceding the development of actual pain by some 
 hours ihe desire to void urine occurs with increasing frequency until in 
 bad cases it becomes almost constant. The relief aff-orded by passing a few 
 drams of urine continues for but a few moments, or the urine may be passed 
 in quantities not exceeding a few drops, and with no relief whatever to the 
 distressing and urgent desire. Tenesmus.-'&iv^mmg is extremely severe. 
 The patient will lean over the vessel or urinal, quivering with the muscular 
 eifort. Often the bowels are involuntarily evacuated at the same time, and 
 hemorrhoids are not infrequently developed as a complication. Pa?'«.— The 
 pain may be referred to the neck of the bladder, to the hypogastrium, or to 
 
884 ^l.V AMERICAN TEXT-BOOK OF SURGERY. 
 
 the perineum, and may radiate into the loins or down the thighs. It dimin- 
 ishes as the acuteness of tlie attack subsides. C/nDif/es in tlw urine take phice 
 soon after the development of the attack. It becomes turbid, with a heavy 
 deposit of mucus, then scanty, then blood-tinged. Pure blood in lesser or 
 greater quantities will often follow the expulsion of the last fcAv drops of 
 urine. Constitutional JJisturhance. — This is often slight in comparison with 
 the intensity of the local symptoms. Occasionally a marked febrile movement 
 occurs and persists during the heiglit of the attack. 
 
 Chronic Cystitis. — The causes of chronic inflammation of the bladder 
 are all those which have been enumerated as producing acute cystitis, though 
 the latter is not necessarily a precedent condition in every case of chronic 
 cystitis. The latter is more apt, however, to result from a combination 
 of mechanical and chemical causes, such as enlarged prostata', stricture, new 
 growths, stone, or atony or paralysis of the bladder accompanied by retained 
 or decomposing urine. Obstructive disease alone or mere loss of expulsive 
 power may continue for a long time without causing an appreciable degree of 
 inflammation. They produce, however, a chronic congestion of the mucous 
 coat and degenerative changes in it and in the muscular wall of the bladder, 
 and if subsequently, by the use of a catheter or other instrument not per- 
 fectly sterile, microbic infection occurs, the field is prepared for an obstinate 
 and often incurable inflammatory process. 
 
 The changes in the walls of the bladder may result in atony or atrophy, 
 with thinning of the mucous membrane, fatty degeneration of the muscular 
 fibers almost to the point of disappearance, and great distention of the 
 organ, or may be followed by hypertrophy of the muscular coat, the fibers 
 forming ridges or fasciculi standing out in the interior of the bladder and 
 separated by lozenge-shaped spaces, the organ itself being contracted, so that 
 its cavity can contain but a few drams of fluid. Sometimes between these 
 muscular bars pouches- of mucous membrane protrude, forming distinct sacculi 
 communicating with the interior of the bladder by narrow mouths and re- 
 maining permanenL Occasionally they contain calculi. 
 
 Symptoms. — The phenomena due to acute CA'stitis are present in a modi- 
 fied fonn. Urination is not so frequent ; tenesmus is much less or is absent ; 
 pain is frequently very slight ; and the constitutional symptoms are marked only 
 when consecutive renal changes have occurred or when sapremia has followed 
 absorption of the products of urinary decomposition. The urine is not apt to 
 contain blood, but becomes loaded with a thick, tenacious mucus which is some- 
 times one-half its bulk, and which has jriven rise to the term catarrh of the 
 bladder which is often used synonymously with chronic cystitis. It is almost 
 always more or less ammoniacal, and is apt to be fetid and to contain a great 
 excess of phosphates. 
 
 Treatment. — Removal of the causes, when possible, is of course indicated. 
 A cystitis due to calculus or to new growths or to a retained catheter can be 
 but little influenced by treatment until the stone or the tumor or the instru- 
 ment is removed. 
 
 If the cystitis be due to the administration of cantharides or tincture of 
 the chloride of iron or other drug, withdrawal of that article and the substitu- 
 tion of an alkaline diuretic will effect a prompt cure. In cases of cystitis 
 following rough instrumentation, but in which no infection has taken place, 
 rest in bed, restricted diet, anodynes or opiates to relieve tenesmus, and the 
 administration of diluent and alkaline drinks will usually bring about a return 
 to health. 
 
 When microbic infection has occurred, however, the case is apt to be much 
 
SURGE in' or nil-: arxiro-rRixMiv thact. 885 
 
 more serious :ind prolonged. The treatment then Avill depend on the duration 
 of the attack. In the stage of ncutc intiamniation the plan above mentioned 
 should be rigidly followed out. The diet for some days should consist almost 
 exclusively of milk : the patient should remain in bed with the hips elevated*, 
 the bowels should be moved by salines and enemata ; opium by suppository 
 should be used to control spasm and tenesmus ; an alkaline mixture may be 
 administered with advantage. Ordinai'ily, the intensity of the symptoms will 
 subside under this treatment in a few days, and sometimes recovery will then 
 be complete. 
 
 Often, however, the condition passes into the cl ironic for in ^ which is more 
 intractable and obstinate. The same symptoms continue in a somewhat les- 
 sened degree. The urine becomes loaded with mucus and is voided Avitli in- 
 creased frequency, but with lessened tenesmus as compared with the acute 
 variety of the disease. The treatment should consist at first in removal of the 
 cause. If this is mechanical — that is, resulting from calculus, urethral strict- 
 ure, prostatic hypertrophy, tumor, etc. — the treatment of the cystitis includes 
 that of the condition which originated it. The treatment of vesical calculus, 
 of stricture, of enlarged prostate, and of new growths of the bladder will be 
 found elsewhere. 
 
 For a chronic cystitis which persists after the removal of a calculus or of a 
 neoplasm, or after the dilatation of a stricture, or the careful Avitlidrawal of 
 residual urine in cases of atony or prostatic hypertrophy, a great variety of 
 methods of treatment may be employed, and may be classified under (1) the 
 administration of remedies by the mouth ; (2) the use of vesical injections or 
 irrigations. In the former class are included the Avell-known balsams of 
 copaiba and cubebs and the large class of terebinthinates. with buchu, uva ursi, 
 triticum repens, etc. Under this head should also be included the adminis- 
 tration of antiseptics, which, when excreted through the kidneys, sterilize the 
 urine and prevent or retard the development in it of micro-organisms. The 
 most useful of these are salol and boric acid in five-grain doses three or 
 four times daily. Among the materials which Avill be found valuable for vesi- 
 cal irrigation may be included solutions of nitrate of silver, J to 2 per cent., 
 or stronger according to the sensitiveness of the patient ; peroxide of hydro- 
 gen, from 25 per cent, to full strength ; permanganate of potassium, from J to 
 3 or 4 per cent. ; boric acid, from 2 to 10 per cent. ; creolin, from 1 to 5 per 
 cent. ; corrosive sublimate, from 1 : 15,000 or 20,000 to 1 : 5000 ; carbolic acid, 
 1 : 500 ; and many others, chiefly belonging to the same class of antiseptics. 
 It is useful to employ the weaker solutions in large quantities, and to precede 
 their introduction by irrigation of the bladder with boiled Avater, or, in the case 
 of the silver and permanganate salts, by distilled water. In cases which fail to 
 yield to these methods of treatment, and in which frequent urination and pain- 
 ful tenesmus are prominent symptoms and are accompanied by gradual failure 
 of the general strength, a perineal cystotomy followed by permanent drainage 
 will often be required, and will usually give marked relief, and occasionally 
 result in entire cure. It permits not only of the constant drainage which is 
 so important in endeavoring to overcome sepsis, but also of the freer use of the 
 irriorations above described. 
 
 TUMORS OF THE BLADDER. 
 
 The benign tumors of the bladder include the fibromata, the fibro-myxo- 
 mata, and the papillomata. The latter are by far the most frequent, and 
 indeed all vesical growths tend to assume a papillomatous character, although 
 
886 
 
 ^.V AMEI^ICAX TKXr-BOOK OF SUJiUERY. 
 
 there are no ].a]iill{« in tlie mucous membrane. It has been suggested that 
 this occurrence may be exphiined by the embryonic relation of the bladder 
 and allantois, the foetal villi being partially dependent on the latter. 
 
 Fibromata smiX lihro-myromata grow from the submucous coat of the blad- 
 der, are either sessile or pedunculated, and are covered by unaltered mucous 
 membrane or by villi. 
 
 PapiUomata spring from the superficial layer of the mucous membrane, and 
 constitute red vascular masses, sometimes with long pedicles, occasionally ses- 
 sile ; their surface is soft, smooth, and rounded, and is often indistinguishable 
 by touch from the healthy mucous membrane ; they sometimes bleed very 
 freelv. Occasionally they undergo ulceration, and there is reason to believe 
 that a growth originally purely papillomatous may become malignant in its 
 later stages. 
 
 Malignant Tumors of the Bladder may be sarcomatous, but the epithelio- 
 mata are bv far the most frequent. They originate in any portion of the blad- 
 der, grow with great rapidity, and are soon followed by ulceration of the mucous 
 surface, and often by involvement of the entire thickness of the bladder-wall. 
 Enlargement of the pelvic glands and secondary deposits in other viscera are 
 common. 
 
 Symptoms of Tumors of the Bladder. — The chief symptoms are 
 vesical irritability and hemorrhage. Either may precede the other. In papil- 
 lomata profuse bleeding may be the very first indication of disease. In the 
 fibromata and carcinomata there is apt to be a period during which the symp- 
 toms are those of cystitis, but at first without marked alteration of the urine. 
 Later hemorrhage occurs, and still later the urine becomes fetid and ammoniacal. 
 Diagnosis. — The recognition of new growths in their early stages is often 
 verv difficult. The most valuable diagnostic symptom is the hemorrhage, 
 which, when free and spontaneous and recurring at intervals, the urine in the 
 mean time remaining clear, is extremely suggestive. Free hemorrhage after 
 gentle sounding, the symptoms of cystitis in the absence of stone or of any 
 infective cause, severe vesical pain radiating to other regions, are all valuable 
 aids to diagnosis. 
 
 Certainty can be reached only by the recognition of the villi of a papilloma, 
 detached portions of a fibroma, or cell-nests and small sloughs from an epithe- 
 lioma, or by the aid of the 
 Fig. 359. cystoscope, which is here of 
 
 the greatest usefulness. 
 
 This instrument, as im- 
 proved by Leiter, consists of a 
 Ions hollow shaft of larcje cal- 
 iber, with an obtuse angle a 
 short distance from its extrem- 
 ity. At the angle is a pris- 
 matic window, so arranged that 
 the rays of light entering it are 
 reflected along the shaft to the 
 eye of the surgeon, and near 
 the end of the beak there is 
 another window covering in a 
 small incandescent electric lamp (Fig. 359). The tube contains magnifying 
 lenses. Adjustable ends carry windows on the concavity or convexity of the 
 curve, so that either the anterior surface of the bladder or the bas-fond and 
 trigone may be conveniently observed. 
 
 Leiter's Cystoscdy 
 
 liiial section; a, metal tube; 
 
 b.openinc for light iroin the small electric lamg^; d, loop of 
 current from c; II, enlargement of extremity of tube 
 
 (Tillmanns). 
 
SURGERY OF THE GENITO- URINARY TRACT. 887 
 
 In using the instrument it should be lubricated with glycerin ; the bladder 
 should be washed out and filled with a clear li(|uid ; the current should not be 
 turned on until the instrument is in position. If the inspection has been at 
 all prolonged, so tliat the lamp may have become hot, the precaution shouhl be 
 taken to turn off the current a half-minute to a minute before the instrument 
 is withdrawn, so that there may be no risk of burning the urethra. 
 
 The value of the cystoscope in the recognition of new growths is unques- 
 tioned, but is as yet confined within narrow limits. Such growths may undoubt- 
 edly be seen in many cases by its help, and their exact size and site outlined, 
 but often an almost equally accurate diagnosis of location can be made with 
 the vesical sound, and a far more precise knowledge of the character of the 
 growths can be obtained by microscopic examination of fragments removed by 
 forceps or passed spontaneously. The presence of foreign bodies unsuited for 
 litholapaxy and requiring lithotomy has been demonstrated by the cystoscope. 
 The determination of the side from which renal hemorrhage is taking place 
 can also be made in some instances in this way. 
 
 Extravagant claims have been made as to the usefulness of the instrument, 
 and are not likely to be fully realized, but it has taken an assured place in the 
 armamentarium of genito-urinary surgeons. Its congener, the electric urethro- 
 scope, is of far less value, and has been much abused by novices and over- 
 eager investigators, who have thus far added but little by its means to our 
 knowledge of urethral conditions. 
 
 Treatment. — The operative treatment of tumors of the bladder should 
 be by means of either a perineal or a suprapubic incision. 
 
 The former is preferred by some surgeons, but is applicable only to single 
 small pedunculated tumors situated near the neck of the bladder. The latter 
 is equally useful in these growths, and permits of the free exposure and inspec- 
 tion of all tumors and of comparatively ready access to them. It is the opera- 
 tion of preference in by far the larger number of cases. 
 
 If the perineal route is for any reason selected, the bladder is opened just 
 as in the operation of median lithotomy. (See p. 873.) The finger of the 
 surgeon having recognized the situation and limitations of the groAvth, a pair 
 of forceps is introduced, the tumor seized, and partly bitten, partly twisted off. 
 Too much direct traction should not be made, for fear of injuring the bladder- 
 wall, nor should the manipulations with the forceps be carried out while much 
 suprapubic pressure is being made, as a double fold of the bladder-wall might be 
 thus included with the growth in the grasp of the forceps and gravely injured. 
 The risk of this taking place is much increased if the tumor is sessile. 
 
 In the suprapubic operation the bladder is opened as in suprapubic lithot- 
 omy. The following methods of dealing with the growth may be mentioned 
 (Treves) : The growth, when exposed and carefully examined by the finger 
 and also by inspection, may be dealt with in the same manner as like growths 
 in more accessible parts would be treated. A small electric lamp is of con- 
 siderable service. Growths with slender pedicles may be pinched or twisted 
 off. If the pedicle be stouter, it may be grasped and fixed close to the 
 bladder-wall by means of a pair of pressure forceps bent at a suitable angle. 
 The neck is then grasped by a straight pair of pressure forceps at a little 
 distance from the first pair, and is twisted off by rotating the instrument last 
 introduced. In other instances an ecraseur, carrying a cord or a fine wire, 
 may be employed. If the growth have a broader base, it may, if it be well 
 defined, be transfixed close to the bladder-wall by means of a rectangular 
 needle in a handle, and be then ligatured with silk in two segments. Some 
 of the softer and more diffused growths can be scraped away with the finger- 
 
888 
 
 AX AMERICAN TEXT- HOOK OF SURGERY. 
 
 nail or with a curetto or a sliarp sj)ooii. Others, of ^'rcater substance, can b 
 removed piecemeal ^vith Tiioiui)soiis forceps (Fig. 360) and the resulting stumi 
 
 ting stump 
 
 Fiii. aoo. 
 
 Thoiiii).>on's Vesical Forceps for removing Growths in Bladder. 
 
 then well scraped with Volkniann's spoon. This is the method which would 
 be applied to epithelioraatous growths. 
 
 After the removal of extensive growths the bladder mav l)e well rubbed 
 out with a Turkey sponge, which will remove all detached or partly-detached 
 fragments. Bleeding may be checked by the pressure of a firm piece of 
 sponge or by injections of either cold or hot boric-acid solution. The cases 
 must be few in which an appeal to the actual cautery is necessary. The pres- 
 sure of the rectal bag causes venous engorgement, and the sooner that appliance 
 can be dispensed with the better. Two fingers introduced into the rectum by 
 an assistant will often bring the growth more readily into view than will the 
 rectal bag. The after-treatment of the case is the same as is proper after 
 suprapubic lithotomy. 
 
 PAKT III.— DISEASES AND INJURIES OF THE URETHRA. 
 The normal male urethra is about nine inches in length, and is divided 
 into three portions. The spongy or penile portion is about seven inches long, 
 is contained within the erectile tissue of the corpus spongiosum, and extends 
 from the meatus to the posterior extremity of the bulb. "When the penis is 
 flaccid, it constitutes a curve the concavity of which is downward, but when 
 the organ is raised or is erect the curve is obliterated and becomes a straight 
 line. The memhranons urethra is found between the two layers of the tri- 
 angular ligament, about an inch below the under surface of the symphysis 
 pubis. It is a half to three-quarters of an inch in length, and is surrounded 
 
SURGERY OF THE GEXITO-rRTXARY TRACT. 
 
 889 
 
 by the compressor urethrjB muscle, which, taking its origin on each side from 
 the unner part of the descending pubic ramus, serves to support and, wlien it 
 contracts, to compress this portion of the urethra. The prontatic urethra runs 
 through the prostate ghmd at the junction of its upper an<l its middle third 
 It is from one and a half to one and three-quarters inches in length (tig. obi). 
 
 Fig. 3(51. 
 
 naS ifthe comm^^^^^ duct ; 16, prostatic plexus receiving 17, dorsal vein of penis ; 19, bulb , 
 
 20, Cowper's gland (Owen). 
 
 The urethra is narrow at the meatus, enlarges within the glans at the fossa 
 navicularis, has a variable caliber, with normal points of constriction in the 
 spongy portion, enlarges again in the region of the bulb, is narrow at the 
 bulbS-membranous junction and between the layers of the ligament, and again 
 widens as it penetrates the prostate, so that this portion of the urethra has 
 normally the largest caliber and is the most dilatable. • ■ d 
 
 The^fixed curve of the urethra— z. e. the curve assumed by the majority ot 
 adult urethrre— in a condition of rest is measured from just in front of the 
 triangular ligament to the neck of the bladder. It is that of a circle three 
 and a quarter inches in diameter, and is represented by an arc of such a cn-cle 
 subtended by a chord two and three-quarter inches m length (l^ig. db2). ihis 
 curve may be lessened somewhat by depressing the urethra by means ot a 
 fincrer at each side of the root of the penis: it is always lengthened in cases 
 of hypertrophy of the prostate or when the bladder is greatly distended. It 
 may be temporarily obliterated, as when a perfectly straight instrument is 
 introduced into the bladder. ^ ^^ .\ 
 
 Oatheterism.— The passage of a properly-made steel sound or silver cathe- 
 ter, the curve of which corresponds, as it should do, with that gn-en above, is one 
 of the minor operations of surgery most frequently required. For its pertorm- 
 ance the patient should, whenever possible, be placed in a recumbent position, 
 the head and shoulders slightly elevated, the knees a little separated, the mus- 
 
890 
 
 AX A ^^ ERIC AX TEXT-BOOK OF SURGERY. 
 
 Fig. 362. 
 
 ck'S relaxed. The surgeon, if riglit-lianded. stands at the left side of the 
 patient. The sound or catheter, tlioroughly sterilized, well warmed, and lubri- 
 cated with some aseptic oil or oint- 
 ment, is taken in the right hand, 
 the penis between the tliunib and 
 fingers of the left hand. 
 
 The organ is gently put on the 
 stretch, care being taken to keep the 
 dorsum facing the abdominal wall, 
 and to avoid any twists in the ure- 
 thra which would constitute obsta- 
 cles to the instrument, the point of 
 which is then engaged within the 
 meatus. At this time the shaft of 
 the sound or catheter should be par- 
 allel to the line of the groin. This 
 direction is important chiefly in 
 catheterism of persons with large 
 protuberant bellies, in whom, if it is 
 not followed, the point of the instru- 
 ment will be made to catch in the 
 upper wall of the triangular liga- 
 ment, owing to the elevation of the 
 handle necessitated by the protrusion 
 
 yd 
 
 )l';a 
 
 Instrument with faulty curve. O d fB6niqu6). Correctly-curved conical instrument, b. Leiifrth of natu- 
 ral curve of urethra,/ k. Length of cord of curve of sound, h 0, 2,^5 inches (Van Buren aixi Ktyes). 
 
 of the abdomen. The handle should in any event be kept low until the tip 
 of the instrument is about to enter the membranous urethra. The penis is 
 
 Fig. 363. 
 
 Faulty Curves (Van Bureu and Kcycs;. 
 
 drawn up with the left hand while the instrument is gradually pushed onward, 
 the handle being finally swept around to the median line, the shaft being kept 
 parallel to the anterior plane of the body and nearly touching the integument. 
 The instrument is now pressed downward toward the feet, while the left hand 
 still steadies the penis and makes slight upward traction. After four or five 
 inches of the shaft have disappeared witliin the urethra, it will be found that the 
 downward motion of the instrument is arrested (Fig. ;3G">). The fingers of the 
 left hand can then be shifted to the perineum, where the curve of the instrument 
 
SUBGERY OF THE GENirO-URINARY TRACT. 
 
 891 
 
 Fici. 3G4, 
 
 can bo felt ])(.'liiii(I tlie scrotmii. The liandle may then, and not until then, be 
 litt('(l from its close relation with the anterior 
 alxlominal "wall and swept gently over in the 
 median line, describing the arc of a circle, 
 while the left hand acts as a fulcrum over 
 which the curve of the instrument glides (Fig. 
 o()G). It often facilitates the final step in 
 catheterism if after the shaft has reached and 
 passed the perpendicular the handle is taken in 
 the left hand, and the index and middle finrjers 
 of the right hand are placed one on each side 
 of the root of the penis, making doVnward pressure, while the left hand, depress- 
 ing the handle, carries the point of the instrument through the membranous and 
 
 ^ 
 
 Proper Curve (\u.\i Buren and Keyes). 
 
 Fig. 365. 
 
 Passing a Catheter (to the membranous urethra): A, rectum: B. bladder; C, pubes: D, intestines: 
 E, scrotum : F, bulb ; G, prostate ; H, neck of bladder ; P, tip of catheter (Albert). 
 
 prostatic urethra into the bladder. Its entrance into that organ will be recog- 
 nized by the free motion that can be given the tip of the instrument when the 
 handle is rotated, and by the latter remaining exactly in the median line and 
 pointing away from the pubes when the hold upon it is relaxed. The whole 
 manoeuver should be done with gentleness ; no force whatever is necessary. 
 
 If there is spasm of the circular fibers of the urethra at any point, or, as 
 is often the case, of the compressor urethrae at the bulbo-membranous junction, 
 a little delay will be followed by relaxation. At this same region, where the 
 larore and movable bulbous urethra contracts as it passes through the ligament, 
 
892 
 
 ^.V AMERICAN TEXT- BOOK OF SURGERY. 
 
 the onward pressure of a bougie or catheter is more often arrested on account 
 of unskilfulness on the part of the operator than at any other point. If 
 
 Fig. 366. 
 
 Passing a Catheter into the bladder (Albert). (For references see Fig. 365.) 
 
 the handle be lifted too soon from the proximity to the abdominal wall, the tip 
 of the instrument catches in the subpubic ligament above the urethral orifice ; 
 if the handle is not raised at the proper time or if the fingers in the perineum 
 do not give the curve of the instrument the gentle upward pressure that it 
 needs, the tip buries itself in the loose and movable floor of the urethra below 
 the orifice. In either case the curve protrudes unnaturally in the perineum. 
 The withdrawal of the instrument for an inch or two and its gentle reintro- 
 duction, raising or lowering its tip as may be required, will usually suffice to 
 overcome this obstacle. 
 
 If the catheter is a small one and is used roughly and unskilfully, it may 
 be made to penetrate the wall of the urethra instead of following the canal 
 itself Such wounds leading into the peri-urethral or submucous tissues are 
 known as false passar/es. Tliey are most apt to occur in the bulbous and in 
 the prostatic regions, for obvious anatomical reasons. AVhen recent they are 
 attended by profuse hemorrhage, are often followed by chill and fever, and, 
 especially if the patient's kidneys are already diseased, may result fatally. 
 
 The introduction and retention of a catheter, frerjuent irrigation of bladder 
 and urethra with antiseptic solutions, and the administration of salol, boric 
 acid, and quinine are the essentials of treatment. If suppuration follows and 
 chill and fever are recurrent or persistent, it may be necessary to drain through 
 the perineum. 
 
 Old false passages are often sources of difficulty during catheterism. This 
 may sometimes be overcome by inserting into the abnormal channel one or 
 several filiform bougies, after which it often becomes easier to pass one into 
 the bladder. 
 
 In cases of enlarged prostate a catheter with a much longer shaft and 
 larger curve will be required, or a Mercier catheter will be found useful. 
 In stricture a large variety of sizes and shapes may be employed. If the 
 
SURGERY OF THE GEXITO-URINARY TRACT. 893 
 
 contraction is small an<l tortuous, the most useful instruments are the whale- 
 bone filiform bougies, which may be used straight, or, better, with a slight 
 
 Fig. 007. 
 
 Filiform Whalebone Bougies. 
 
 angle given them near the tip (Fig. -307), as the orifice of a stricture is usually 
 eccentric, i. e. not in the middle or center of the obstruction. It happens very 
 
 Fig. 3(38. 
 
 Gouley's Tunnelled Catheter. 
 
 rarely that one of these will not pass. The tunnelled catheter (Fig. 368) and 
 the ordinary steel sound are indispensable instruments in the treatment of 
 these cases. The indications for their employment will be found in the sec- 
 tion on Strictures. 
 
 Urethral Fever, Catheter Fever, Urinary Fever, Acute and Chronic. — 
 Following the introduction of an instrument, even when it has been done with 
 skill and care, the patient may, after an interval varying from a few moments 
 to several hours, have a chill, followed by a rise of temperature. In many 
 cases this is not repeated. Warmth to the surface, a full dose of quinine, and 
 the immediate administration of a urinary antiseptic are usually the only treat- 
 ment required. The patho^nesis is not certainly determined. In this form — 
 acute urinary fever — it may be that a nervous element enters to a considerable 
 extent into the causation of the chill ; but in the recurring form — chronic 
 urinary fever — we have a true toxemia, always dependent on bacterial infec- 
 tion, and often to be avoided by thorough instrumental asepsis and proper 
 preparation of the patient, When it does occur, the same line of treat- 
 ment as for any other form of infection of the urinary tract is appro- 
 priate. The more severe forms of urinary fever are, however, so apt to 
 terminate fatally that every possible prophylactic measure should be em- 
 ployed to prevent its occurrence. 
 
 INJURIES OF THE UEETHEA. 
 Ruptures of the pendulous portion of the urethra are rare, and are not 
 apt to be extensive, nor, although troublesome in regard to treatment and 
 cure, are they usually dangerous. In most cases the rupture occurs during 
 sexual intercourse, and has been accompanied by immediate pain and swelling, 
 followed by ecchymotic discoloration of the entire pendulous portion of the 
 penis and by more or less severe hemorrhage from the meatus. They usually 
 
894 ^l^y A^fKRICAX TEXT-JiOOK OF SURClKliY. 
 
 do well iiiuler the use of evaporatiiif^ lotions and rest, followed by gentle 
 catheterization after the blood has disappeared and the swelling subsided. 
 Ruptures affecting the deeper portions of the urethra are, however, much 
 more serious. Excluding those which result from instrumental violence — 
 that is, false passages — and those which result from the giving way of the 
 softened and distended urethra behind a stricture, which are described else- 
 where, they are caused almost invariably by some form of traumatism applied 
 to the urethra, most of the recorded examples having been the result of falls 
 astride of hard or resistant bodies. The mechanism of rupture of the urethra 
 has been variously explained. Franc, Velpeau, and Poncet have attributed 
 the urethral laceration to the crushing of the membranous portion of the 
 urethra between the offending body and the lower border of the pubic arch. 
 If the accident occurred with the patient in a leaning position, the body 
 directed forward, they believe that the posterior part of the spongy urethra 
 could be crushed against the pubes, and think that when the force which pro- 
 duces the injury acts in the lateral direction the urethra is more probably 
 pressed against the upper portion of the descending pubic ramus. Oilier 
 refers lacerations of the membranous urethra to the pressure of the canal 
 against the sharp edges of the subpubic ligament, Avhich in his experiments 
 seemed to have divided the upper wall of the urethra. Terillon believes that 
 when the body which is fallen upon is narrow the urethra is crushed against 
 the ramus of the pubes, and thinks the injury is likely to be found about the 
 region of the bulb ; and when the fall is upon a broader substance the urethra 
 is crushed against the anterior surface or inferior edge of the pubes, and the 
 lesion is found more anteriorly. Guyon says that in this accident, whether 
 the cause is a fall or a blow, the mechanism is the same : the urethra and the 
 soft parts which immediately surround it are pressed and crushed against the 
 resisting pubic symphysis, whilst the superficial tissues, more supple and more 
 elastic, escape or are scarcely involved. He believes, as does Terillon, that 
 such ruptures are frequently only partial, and that they are commonly situated 
 in the spongy portion of the urethra, an inch or less in front of the anterior 
 layer of the triangular ligament ; and in this opinion he is supported by Iver- 
 sen, who has recently analyzed twenty-nine cases of this accident. Duplay 
 thinks that in a certain proportion of cases the urethra is ru)iture<l by a tem- 
 porary dislocation of the symphysis pubis, the soft bones springing back into 
 their proper relation after the crushing force is removed, and leaving no trace 
 of the accident except the urethral lesion. He thinks that this ('' rupture by 
 traction ") may also occur in case of fracture of the pelvis with a displace- 
 ment of a portion of the pubic arch ; and it is of course evident that the 
 urethral Avail could be wounded directly by a fragment of bone after such a 
 fracture. 
 
 In attempting to diagnosticate a rupture of the urethra we must depend 
 chiefly upon — 1, the history of the accident; 2, the phenomena connected with 
 urination, which is usually difficult or impossible ; 3, the appearance of blood 
 either at the meatus or beneath the skin or in both situations ; 4, the develop- 
 ment of a swelling due to extra vasated urine. As in the majority of cases all 
 these symptoms are present, the diagnosis in general terms of a rupture of the 
 urethra can hardly be said to be difficult, but in exceptional cases, where one 
 or more are absent, it may be a matter of great uncertainty. So, too, the 
 recognition of the precise seat of the rupture may be comparatively easy if 
 the case is an uncomplicated one, or under some circumstances may be almost 
 impossible. The anatomical peculiarities of the part explain the usual course 
 of urinary extravasation. (See Stricture of the Urethra.) 
 
SURGERY OF THE GENITO-URINARY TRACT. 895 
 
 Treatment. — The important question of treatment in these cases may be 
 sinipliiifd by adopting a cUissification simihir to that employed by Guyon and 
 Duphiy, Avliich is based upon symptoms rather than u|)on the anatomical seat 
 of the injury. All cases may be divided into three classes — mild, moderate, 
 and grave. 
 
 In mild cases — i. e. in those where after such an injury there is an appear- 
 ance of blood at the meatus, with difficult urination or Avith retention, but -with 
 no evidence of extravasation and no general alarming symptoms, and in which 
 catheterization is easy — the surgeon may be content with regular evacuation 
 of the bladder by means of a soft instrument well greased with carbolized oil, 
 and with prescribing absolute rest, the patient being carefully watched for the 
 onset of fever or the appearance of local swelling. 
 
 In cases of a more severe type, in which, in addition to urethral hemorrhage 
 and retention of urine, there are evidences of extravasation, and in which cathe- 
 terism, though difficult, is possible, it is wisest to leave a full-sized catheter in 
 the bladder, and at the same time freely to lay open the perineum and scrotal 
 tissues or any which have been involved in the extravasation. 
 
 In cases of greater gravity, in which catheterism is impossible, careful peri- 
 neal section should at once be made, the rent in the urethra sought for, and a 
 catheter passed through it into the bladder. This is sometimes one of the 
 most difficult procedures in operative surgery, particularly if it has been delayed 
 until inflammatory change or local gangrene has altered the appearance and 
 relations of the parts involved. If persevering and careful search fails to 
 reveal the proximal end of the torn urethra, suprapubic cystotomy, for the 
 purpose of retrograde catheterization, is justifiable for that purpose, the distal 
 end of the torn urethra being almost always easily discoverable. Except as 
 to the latter point, surgeons, as a rule, are agreed upon the above-described 
 methods of treatment, and a number of them endorse the propriety of the 
 suprapubic operation in such cases. 
 
 In cases of complete rupture the following indications exist after the intro- 
 duction of the catheter : 1st, to open a large passage for the accumulating 
 fluids; 2d, to keep up a free flow of urine; 3d, to encourage rapid union of 
 the two ends of the urethra and the walls of the cavity formed by the extrav- 
 asation into the perineum ; 4th, to prevent the formation of a cicatricial stric- 
 ture of the urethra. Suprapubic aspiration (Lefort, Molliere) is palliative and 
 meets none of the indications. External urethrotomy (Guyon and others) 
 does not provide for prompt union of the canal and does not prevent consecu- 
 tive contraction. Antiseptic measures, carried out by allowing an elastic 
 catheter to remain in the perineal wound, which is tamponed, or by suturing 
 its borders, produce more rapid union, but are likewise followed by urethral 
 coarctation. The stitching of the proximal end of the urethra into the wound, 
 and catheterizing only after healthy granulations have formed, while reducing 
 risks to the life of the patient, is followed by the same results. 
 
 Suturing of the divided ends of the urethra has now been done in a suf- 
 ficient number of cases (Erasme, Guyon, White, Keyes, Barling, and others) 
 to justify its employment whenever they can be brought together. Catgut is 
 the preferable suture-material. The mucous membrane should not be included. 
 
 GOXOERHEA ( URETHRITIS j. 
 
 The word gonorrhea, although etymologically inaccurate as a designation 
 of the disease in question, is still so universally employed and so well under- 
 stood that it has been retained here for the sake of convenience. 
 
896 AX A.}f/JRICAN TEXT-BOO A' OF SURGERY. 
 
 Authorities are iioav practically a unit in the belief that the gonococcus 
 is the cause of gonorrhea. At the same time a urethritis niav be set 
 up by other causes — bacterial, chemical, mechanical, or constitutional. The 
 term "urethritis" ((ualified by the a])propriatc adjective, according to the 
 cause, is the proper one to designate these cases. Clinically, the two 
 forms may be indistinguishable ; but the microscope should make the sepa- 
 ration possible. The distinction is unimportant therapeutically, but may 
 assume great importance from the medico-legal standpoint.^ AVe may 
 assume, however, that in the majority of cases of acute urethritis gono- 
 cocci, the microbes of suppuration, and other bacteria -will be found inter- 
 mingled. 
 
 Inflammation of the male urethra may be thus either simple, in which 
 infection with only pyogenic microbes has taken place, or specific, in which 
 gonococci are also present. 
 
 Simple urethritis may be due to a great variety of causes. Authentic 
 cases are recorded of well-marked urethritis following accidental or experi- 
 mental exposure to leucorrheal discharges ; to the pus from a healthy abscess 
 or from a purulent bronchial catarrh ; to the secretion from an endocervicitis 
 or endometritis ; to the discharge resulting from ulceration or malignant dis- 
 ease of the uterus ; to the menstrual fluid or acrid vaginal discharges ; to 
 powerful injections ; to the passage of gravel ; to catheterism ; and to many 
 other undoubtedly non-specific causes. The condition thus evoked is often 
 indistinguishable clinically from that following sexual intercourse with a person 
 already having a similar disease, many severe and complicated cases of gonor- 
 rhea being derived from one or the other of these sources. As a rule, however, 
 it is somewhat less severe and less protracted than the specific variety, due to 
 infection with the gonococci, though great caution should be observed in draw- 
 ing any inference as to causation from the character of a particular attack, as 
 the variations observed in the different tirades of urethritis are no greater than 
 those which prevail among inflammations of other mucous passages, and which 
 are due to individual idiosyncrasy or to differences in the power of the original 
 irritant. 
 
 The facts that urethritis of either variety does not protect from subsequent 
 attacks, that its pathology is that of any catarrhal inflammation, and that 
 it may be reawakened or re|)roduced by local irritation, by indiscretion in 
 diet, etc., afforded strong ground for the assertion that it is not a specific 
 disease. 
 
 Late bacteriological discoveries have, however, as above stated, outweighed 
 these arguments, though for convenience we may still differentiate the varieties 
 of urethritis according to their clinical course, dividing them into (1) typical 
 or acute inflammatory gonorrhea ; (2) subacute or catarrhal gonorrhea ; (3) 
 irritative or abortive gonorrhea. 
 
 We may begin with a description of acute inflammatory gonorrhea, 
 "which is the variety most frecjuently encountered, particularly in those persons 
 who are for the first time affected. 
 
 The interval of incubation, or the time which elapses between exposure 
 and the development of urethral symptoms, is a variable one, extending from 
 a few hours to twelve or fourteen days. In the great majority of cases, how- 
 ever, the disease appears during the fii'St week. The patient notices a drop of 
 milk-and-watery-like fluid at the meatus, which is slightly red and puffed or 
 everted ; a tickling sensation is often felt in this locality, and the next act of 
 urination is attended with a feeling of warmth at the end of the canal or Avith 
 actual scalding. After this the symptoms increase rapidly in number and 
 
SURGERY OF THE GENITO- URINARY TRACT. 897 
 
 severity, so that within forty-eight hours, or even sooner, the disease may be 
 described as having passed into its first or " increasing" stage, the cha- 
 racteristic phenomena of ^v•hich, with their respective causes, are as follows : 
 
 Changes in the Meatus. — There are redness, eversion, and often erosion 
 of the lips of the meatus ; sometimes, but rarely, so much swelling as to 
 constitute a distinct obstacle to the passage of urine, w^hich escapes only 
 by drops. 
 
 Ardor Urince. — Scalding at each act of urination, or ardor urinae, is the 
 symptom which gives the disease in French its popular name of " chaude- 
 pisse." This is due partly to the distention of the inflamed and swollen 
 mucous folds of the urethra during the passage of the stream, but chiefly to 
 the contact of the salts of the urine with the inflamed surface. 
 
 Chordee. — Painful erection, or chordee, is present to a greater or less extent 
 in all such cases. It may occur at any time during the twenty-four hours, but 
 is most frequent after the patient has become warm in bed. He is awakened 
 or kept awake by an intractable, persistent priapism, which is associated with 
 pain felt along the under surface or often along the sides of the penis. In well- 
 marked cases the organ is bent or curved, usually in a downward direction, 
 more rarely upAvard or .laterally. The corpus spongiosum, situated beneath 
 and between the corpora cavernosa and surrounding the urethra, is more 
 directly involved in the inflammatory process than the other portions of the 
 penis. The urethritis extends by contiguity to the submucous connective tis- 
 sue, and thence continuously to the trabecule of the erectile tissue of the 
 spongy body. The lympL which is exuded in these localities blocks or fills 
 up the intertrabecular spaces or meshes containing the intricate venous plexus 
 which by its engorgement and distention furnishes the essential mechanical 
 element of normal erection. When the organ becomes erect, the ccfi'pora cav- 
 ernosa expand normally and fully, but the blood is unable to find its way into 
 the partially obliterated erectile tissue of the corpus spongiosum, which remains 
 rigid and inflexible. The pain along the sides is produced by the pressure on 
 the nerves caused by the unnatural position, and that along the under surface 
 by the attempted distention of the spongy body. 
 
 Frequent Urination and Vesical Tenesmus are other symptoms which 
 occur about this time in many cases. They generally indicate an extension 
 of the inflammation to the deep urethra, and are the most obvious diagnostic 
 symptoms between anterior and posterior urethritis, the latter term signify- 
 ing that the infective inflammation has spread to the region behind the com- 
 pressor urethrse muscle. The same symptoms may exceptionally be due to 
 reflex influence from a disturbance as yet localized at or near the meatus. In 
 either event the irritability of the neck of the bladder is shown by the in- 
 ability of that organ to retain more than a very small quantity of urine, the 
 urgency of the calls to evacuate it, the difficulty in starting the stream, and 
 the bearing-down, expulsive efforts Avhich accompany or follow the dribbling 
 of the last few drops. 
 
 The discharge during this period has been growing more and more pro- 
 fuse. At first thin and of a bluish-white hue, like city milk, it has become 
 white, then yellow, and then greenish or streaked with blood. 
 
 There are, then, certain conditions — ardor urinte, profuse purulent discharge, 
 chordee, and frequent urination — which characterize the first or increasing stage 
 of inflammatory gonorrhea. 
 
 The Complications of tFie First Stage. — Balanitis. — When the 
 inflammation, instead of remaining within the urethra or involving only the 
 lips of the meatus, extends over the surface of the glans penis, we have the 
 
 57 
 
898 
 
 AX AMERICAN TEXT- BOOK OF SURGERY. 
 
 condition known as balanitis. This is usually caused ))y a neglect of cleanli- 
 ness, but it occasionally occurs from extension of intlanunatory action by con- 
 tinuity and in spite of the greatest care. Its symptoms are those of superficial 
 inflammation — viz. heat, redness, burning or itching, and finally exfoliation of 
 epithelium, leaving an eroded or sometiuies a superficially ulcerated surface. 
 Not infre(iuently little crops of herpetic vesicles aj)pear, and may remain 
 discrete until tiiey desiccate, or may pustulate, coalesce, and leave an ulcer 
 which is sometimes mistaken for a chancre or chancroid. 
 
 The form of the initial lesion of syphilis known as the chancrous erosion 
 may be mistaken for a superficial balanitis. The period of incubation, the 
 absence of urethral discharge, the abrupt limitation of the erosion, the presence 
 at its base of "parchment" induration, the enlargement of the inguinal lym- 
 phatics, and the lack of an infiaminatory element are symptoms of the former 
 condition which should render it easily distinguishal)le from a solution of con- 
 tinuity due to balanitis. 
 
 Balano-postJdtis. — An extension of the inflammation from the surface of 
 the glans to the inner or mucous layer of the prepuce gives rise to what is 
 known as balano-posthitis. It has no special clinical significance, except 
 that it is almost invariably followed by, or associated with, an inability to 
 retract the foreskin so as to uncover the glans penis. This is due to an exten- 
 sion of the inflammation to the loose cellular tissue uniting the two surfaces of 
 the foreskin, which rapidly becomes oedematous, and in some cases is the seat 
 of an eff"usion of plastic lymph. 
 
 Phimosis (Fig. 369). — The phimosis thus produced is an extremely objec- 
 tionable complication, as it interferes with treatment, necessitates most vigilant 
 
 and unremitting care as to cleanliness, 
 Fig. 369. and obscures the diagnosis and prog- 
 
 nosis. If the case has not been watched 
 from the beginning, and the patient 
 comes under observation for the first 
 time witli a vague history and with an 
 oedematous, swollen prepuce, from the 
 orifice of which pus or pus and blood 
 exude, it is not always easy to deter- 
 mine the exact underlying condition. 
 An indurated chancre can generally be 
 discovered without trouble by its hard- 
 ness, and moreover is not often complicated in this manner. A soft or chan- 
 croidal sore, hoVever, or a balanitic ulceration may not be so readily recognized. 
 The main points of distinction may be tabulated as follows : 
 
 Phimosis from Gonorrli'ca (Cullcricr). 
 
 Phimosis from Gonorrhea. 
 
 No hi.story of sore on glans or prepuce. 
 Swellini;; in foreskin at first almost entirely 
 
 oedematous. 
 Discharge usually purulent. 
 No definite area more tender or harder than 
 
 the rest. 
 Chordee often present. 
 Ardor urinae extends along the whole length 
 
 of the canal. 
 
 Vesical symptoms not infrequent. 
 Bubo very rare. 
 
 Phimosis -with Subpreputial Chan- 
 croid. 
 
 History of sort;. 
 
 Swelling often due to plastic lymph around 
 the ulcer. 
 
 Discharge often sanguinolent. 
 
 A distinct spot usually discoverable by pal- 
 pation. 
 
 Never any true chordee. 
 
 Ardor urina? only when the urine comes in 
 contact with the inflamed or ulcerated 
 foreskin. 
 
 No vesical symptoms in uncomplicated cases. 
 
 Bubo common. 
 
SURGERY OF THE GEXITO- URINARY TRACT. 899 
 
 Paraphimosis (Fig. 870), a condition in uliich the prepuce, retracted and 
 caught behind the projecting corona glandis, cannot be brought forward, is a 
 less frequent but more annoying and danger- 
 ous conijdication. The tense and rather in- I^'^o- 
 elastic edge of the preputial orifice constitutes 
 the cause of the constriction, "which grows 
 tighter as swelling increases. The neighbor- 
 ing parts, at first oedematous, soon become 
 infiltrated with lymph, the return of blood 
 from the glans is interfered with, and, in ex- 
 treme cases, ulceration or even sloughing of 
 the head of the penis has occurred. The line 
 of constriction is situated a short distance be- 
 hind the glans, immediately back of which is 
 a furrow due to the normal depression existing 
 there, intensified by the surrounding oedema. Paraphimosis (Cuiierier). 
 Back of this is a swollen fold of mucous mem- 
 brane, which is the part of the inner layer of the prepuce normally in contact 
 with the posterior face and edge of the corona. Then is found a second and 
 very deep furrow, Avhich is the actual seat of the trouble, and behind this 
 another prominent collar of swollen integument. Paraphimosis is attended 
 with severe pain, which does not disappear until either the prepuce has been 
 replaced or the constriction has been relieved by division or by ulceration. It 
 is often productive of deformity from cicatricial contraction in those cases in 
 which surgical interference has been delayed or ineff'ective. These complica- 
 tions — balanitis, balano-posthitis, phimosis, and paraphimosis — are by far the 
 most frequent of those which make their appearance during this early period of 
 the disease, and have accordindv been described in their usual clinical order. 
 The first stage, or that in which there is a progressive increase in the severity of 
 the symptoms, is of variable duration, but under well-directed treatment com- 
 monly terminates in from five days to a week, after which, for a short time, the 
 condition appears to remain stationary. 
 
 Symptoms and Complications of the Second or Stationary 
 Stage. — The discharge is still profuse, and the ardor urinaj and chordee 
 marked and in some cases agonizing. Patients will complain bitterly that 
 their comfort during the day is interfered with by urgent calls to urinate, 
 which they resist to the last possible moment in a vain endeavor to avoid the 
 pain occasioned by it, and that their rest at night is disturbed by frequently 
 recurring erections, which are no less painful, and which often will not subside 
 until some means has been adopted for their reduction. During this period, 
 which may be said to extend on an average from the seventh or eighth day 
 to the end of the second week, the inflammation is gradually extending back- 
 ward and may give rise to other complications. 
 
 Follicular and Peri-urethral Abscess. — Dipping down from the urethral 
 membrane into the follicles which empty upon its surface, the inflammation of 
 gonorrhea occludes their mouths by causing swelling of their lining membrane, 
 and converts them into little bags or pockets of pus — follicular abscesses — which 
 appear as small, round, tender tumors along the under surface of the urethra. 
 They very often open internally, but now and then adhesion to the skin takes 
 place, pointing occurs outwardly, and they discharge upon the cutaneous surface. 
 Fortunately, they are not followed by urinary fistulse. If the suppurative pro- 
 cess involves the loose connective tissue around the urethra, a peri-urethral ab- 
 scess is formed. This is most frequent at precisely the points which on a priori 
 
900 ^l.V AMERICAN TEXT-UO(jK OF SUltGERY. 
 
 grounds would liave been selected — those at which frouorrhea is most persist- 
 ent, the fossa navioularis and the anterior j)art of the nieinhrftnous urethra. 
 
 Ljimphnntfith. — In a certain projjortiun of cases of gonorrhea a sinijjle 
 lymphangitis occurs as a result of infection with pyogenic microbes. It aflects 
 most commonly the lymphatics of the dorsum of the penis, and is almost inva- 
 riably associated with neglect of cleanliness and retention of the discharge 
 between the prepuce and the glans. This is what might be expected on ana- 
 tomical groun<ls from the group of lymphatics involved, those directly connected 
 with the urethra itself belonging to the deeper set, and running beneath the 
 pubic arch to join the deep lymphatics of tiie pelvis and to terminate in the 
 lumbar glands. The symptoms consist in a thickened, cord-like line of indu- 
 ration extending from the prepuce to the root of the penis, usually tender to 
 the touch, easily isolated from the surrounding structures, and often traceable 
 upon the surface by a faint red linear blush. 
 
 Gonorrheal Bubo. — Either with or without lympliangitis as a forerunner, 
 inflammation of one of the glands of the groin may be the result of gonorrhea. 
 The gland affected is usually one of the superficial set, lying just below' Poupart's 
 ligament, imbedded in the subcutaneous cellular tissue and above the foscia lata. 
 A small, painful tumor makes its appearance in the groin : it is at first freely 
 movable beneath the skin, but afterward contracts adhesions to the latter and 
 to the surrounding parts, and becomes doughy in feel and reddish or purplish 
 in hue. In the majority of cases, after reaching this condition, it wmII subside 
 under appropriate treatment, disappearing by resolution. In others, however, 
 suppuration ensues, the connective tissue which surrounds the glands liquefy- 
 ing first. Indeed, very often the glandular structure itself is not involved in 
 the suppurative action. 
 
 Another group of complications may be mentioned as possible occurrences 
 toward the end of the third week, some of them, however, often appearing 
 much later. They are cowperitis, prostatitis, and cystitis. 
 
 Cowperitis. — Inflammation of one or both of Cowper's glands is a result of 
 extension of the urethritis by continuity along their ducts, which empty into 
 the posterior portion of the spongy urethra. The fij'st symptom usually devel- 
 oped is pain in the perineum, much increased by pressure and rendering sitting 
 or walking markedly painful. The inflammatory SAvelling of the glands is 
 resistec" by the two layers of the triangular ligament between which they are 
 situated and by the deep perineal fascia, and this resistance, associated with the 
 determination of blood to the part by gravitation, imparts, as in other inflam- 
 mations where the same conditions exist, a throbbing element to the pain which 
 renders it peculiarly distressing. Suppuration in the periglandular tissue some- 
 times occurs, in w hich case the usual signs of the formation of pus are jiresent. 
 
 Prostatitis. — After gonorrhea has spread backward as ftn* as the prostatic 
 urethra, it may, and in some cases unavoidably does, involve the prostate gland 
 in spite of the best-directed treatment. The follicles and the glandular elements 
 of this body are primarily and chiefly affected, the muscular tissue which 
 composes the larger portion of its mass remaining in mild cases uninvaded. 
 The anatomical and physiological relations of the gland furnish a key to the 
 symptoms produced by its inflammation, the earliest of which will ])robably be 
 a feeling of weight and distention in the perineum and rectum. This is soon 
 followed by frequent urination, due to the inability of the bladder completely 
 to empty itself, the exit of the urine being interfered with by the engorged 
 gland. The end of the act is painful. Defecation is also painful, markedly 
 so if the feces are inspissated, and the finger inserted into the rectum feels the 
 anterior wall pushe<l into the center of the bowel, hot, unnaturally firm, and 
 
SURGKRV OF rill-: <;i:Nrn)-i'jiL\Mn' tract. 901 
 
 tender to the touch, while throii<fh it the outlines of the greatly enlarged 
 prostate ean be felt. As the disease progresses the pain increases, becomes 
 throbbing, particularly when tlie i)atient is erect or in the sitting posture, radiates 
 along the cords of the hypogastric plexus to all the n.eighl)oring regions, and 
 is very greatly aggravated by any evaetuition of the bladder or rectum. The 
 frecjueney and difheulty of micturition both increase, the latter sometimes pro- 
 ceeding to comj)lete retention. The disease may terminate by resolution, the 
 most frequent Avay, or by suppuration. If suppuration occurs, it is usually 
 due to the coalescence of several inflamed follicles, which, lying in proxim- 
 ity to one another, have broken down into a common cavity. The pus is 
 frequently discharged into the urethra, but occasionally pointing takes place 
 in the direction of the rectum. In either event evacuation gives great relief. 
 In most cases the prostate is left with some fibrous thickening — a hyperplasia 
 of its cellular tissue — which is often the groundwork for future trouble, but 
 which should not be confounded with the hypertrophy of the same tissue and 
 of the muscular elements which so frequently takes place in advanced life. 
 An acute prostatitis may run into a chronic condition, which is very annoying 
 and intractable. The same symptoms exist in a modified and much subdued 
 form : the pain is replaced by a sense of weight and fulness ; micturition is 
 rather too frequent and is feeble, the last drops dribbling from the meatus ; a 
 mucoid discharge like the white of raw egg, but occasionally milky, may be 
 squeezed from the urethra by deep pressure from behind forward, and the 
 same discharge appears at the meatus after every evacuation of the rectum. 
 By examination through the latter the gland is found to be somewhat enlarged 
 and slightly tender on firm pressure. 
 
 Cystitis. — A greater or less involvement of the neck of the bladder is often 
 a concomitant of acute prostatitis, and is indicated by increased urinary trou- 
 ble and by the appearance of a drop or two of blood at the end of micturition. 
 This prostato-cystitis, which is the form of vesical disease usually encountered 
 in gonorrhea, may subside under treatment or may pass into a well-developed 
 inflammation of the mucous membrane of the vesical neck. In this case (gon- 
 orrheal cystitis) there are certain well-marked symptoms, chief among which 
 are very frequent urination, the patient not being able to retain his water for 
 more than a few moments, and the desire to expel it becoming intense and 
 irresistible on the slightest delay ; excessive vesical tenesmus at the end of the 
 act, which is characterized by severe burning pain instead of a sense of relief, 
 blood and pus following the stream of urine, the latter part of which is turbid 
 or milky. There are few constitutional symptoms, little or no fever, no rigors, 
 and but slight deterioration of the general health unless the disease runs a pro- 
 tracted course. The diagnosis between prostatitis and cystitis, Avhich are the 
 only complications of gonorrhea likely to be confounded, may be made by 
 attention to the following points : 
 
 Prostatitis. Cystitis. 
 
 Perineal and rectal pain. Possibly a little tenderness of the perineum 
 
 on pressure, but no rectal pain. 
 Pain violent and throbbing, aggravated dur- Pain burning, not especially affected by def- 
 
 ing defecation. ecation. 
 
 Tenesmus not always present. Tenesmus constant and severe ; very charac- 
 
 teristic. 
 Stream of urine diminished in size. Size of stream not always affected. 
 
 Retention of urine common. Retention of urine rare. 
 
 Urine not much changed in appearance. Urine turbid and ropy, last drops mixed with 
 
 blood. 
 Rectal examination shows enlargement and No prostatic enlargement or tenderness 
 great tenderness of the prostate. recognizable on rectal examination. 
 
902 AX AMERICAX TEXT-BOOK OF SURGERY. 
 
 These complications belong in the majority of cases to the stationary period 
 of gonorrhea, wliich extends from one to two weeks, rarelv longer, ami during 
 
 C ■•'Co 
 
 which the acute symptoms of the first stage, the ardor urinre, chordee, etc., 
 remain nearly or tiuite unaltered. 
 
 At the termination of this stage that of subsidence begins, and in uncompli- 
 cate<l cases progresses rapidly until com))lete recovery has taken place. 
 
 Symptoms and Complications of the Third Stage, or that of 
 Subsidence. — Urination becomes painless and less frequent ; the discharge 
 grovvs thinner, becomes watery and scanty, or dries up altogether; erections 
 no longer occur with abnormal frequency, and do not give rise to curvation of 
 the penis or to pain. If any of the complications which have been described 
 has existed, the last vestiges of it fade away. 
 
 But until this stage is actually completed, as long as any of the symptoms 
 of urethritis are still evident there are yet certain dangers to be avoided and 
 serious difficulties which may present themselves. 
 
 JEpoUdt/niitis. — Chief among these, in respect to frequency of occurrence, 
 is epididymitis, or swelled testicle, which is a complication usually supervening 
 in the fifth or sixth week of the disease, sometimes coming much earlier, and 
 sometimes as late as the end of the second month or even in the third month. 
 In the great majority of instances it is obviously the result of the extension of 
 the urethral inflammation along the ejaculatory ducts and spermatic canal to 
 the epididymis itself. The first symptom is an aching, occasionally a neuralgic, 
 pain along the line of the groin, more frequently on the left side. If the cord 
 be taken between the thumb and finger and rolled gently, it will be found to 
 be tender on pressure. If the inflammation progresses and the epididymis ia 
 involved, this preliminary pain is soon followed by a feeling of weight and a 
 dull ache in the aff'ected testicle, which begins to increase in size and rapidly 
 becomes of great bulk and exceedingly painful. The nauseating quality pos- 
 sessed by this pain is peculiar to it, and serves greatly to aggravate its un- 
 pleasantness. The scrotum becomes purplish in color. 
 
 The patient, particularly if the testicle be not supported so that its weight 
 is withdrawn from the cord, will walk in a slightly stooping posture with the 
 legs apart. The dragging of the heavy tumor upon the spenuatic vessels 
 prevents the free return of blood from the testicle and serves to increase the 
 tension, and by additional pressure upon the nerves to add to the pain. Under 
 proper treatment the acute inflammatory symptoms subside by resolution in a 
 few days, but the enlargement disappears very gradually, a small portion of 
 the globus i»inor often remaining perceptibly indurated throughout life. In a 
 still smaller number of cases suppuration occurs in the subcutaneous cellular 
 tissue, and sometimes involves a large portion of the scrotum. Persistent indu- 
 ration of the globus minor, which consists of a single tube for the passage of 
 semen, may interfere with or entirely prevent the exercise of its function, and 
 if both testicles have been involved sterility more or less permanent may result. 
 There may be all the indications of virility ; there is no diminution in desire 
 nor in ability to perform the sexual act, which is accompanied by emission 
 of fluid derived chiefly from the prostate and the seminal vesicles, and is 
 attended by the customary amount of pleasure. In other words, the patient, 
 though sterile by reason of the absence of spermatozoa from the fluid which he 
 emits, is not by any means impotent. Time and suitable remedies will sometimes 
 remove this condition, but the prognosis in this respect should be guarded. 
 
 That the left testicle is aff'ected twice as often as the right is usually attrib- 
 uted to the fact that as a rule it hangs lower, and thus receives less support 
 from the scrotum. It is more probably, however, the result of the position of 
 
SURGERY OF THE GENITO-URINARY TRACT. 903 
 
 the left spermatic vein behind the sigmoid Ik-xurt', and also of" its indirect com- 
 munication -with the vena cava through the renal vein, ^vhich it enters at a 
 right angle, the right spermatic vein emptying into the cava at an acute angle. 
 These causes are sufficient to produce local congestion.^ a po^verflll predisj)Osing 
 cause of inflammatory attacks. As a result of pressure on the efl'erent vessels 
 by inflammatory products, or as a consequence of extension of the inflammatory 
 action itself, acute hydrocele may and often does complicate epididymitis, adding 
 to the size of the swollen organ and increasino; the feelin*' of tension to both 
 the patient and the surgeon. It requires no special treatment, and usually 
 subsides uhen the declining stage is reached. 
 
 Subacute or Catarrhal Gonorrhea. — This occurs most commonly in 
 persons >vho have had previous attacks of gonorrhea, and is an example of the 
 tendency manifested by all mucous structures to take on inflammation upon 
 slight provocation after having once been aff"ected. It is particularly notice- 
 able in the urethra for several reasons : the canal affords periodical passage to 
 a secretion, the urine, -which is especially liable, by reason of changes in its 
 constitution, to become an actual irritant; it is exposed at times of erection to 
 intense congestion of all its vessels, — the converse also being true, that a con- 
 gested or irritated spot along the urethra predisposes to erection ; gravitation, 
 the proportionately excessive supply of blood to the region, and the absence of 
 extra-vascular resistance, due to the loose character of the spongy tissue, all 
 favor the persistence of any congestion left after a first attack of urethritis ; 
 the approximation of the mucous surfaces of the urethral walls during the 
 intervals between the acts of micturition is here, as elsewhere, unfavorable to 
 the disappearance of granular or injected areas or other traces of inflammation. 
 For these reasons, among men Avho have had gonorrhea once, many have sub- 
 secjuent manifestations, a predisposing cause being usually present, although 
 some additional irritant, such as contact with menstrual fluid or with a leucor- 
 rheal secretion, is generally necessary to bring on marked symptoms. 
 
 Symptoms. — A patient with this variety of urethritis will present him- 
 self, after a suspicious or an unaccustomed connection, with a free muco- 
 purulent or purulent urethral discharge. He will complain of very little 
 pain, possibly only of a sensation of warmth during urination. Chordee is 
 absent or very slight, there is no vesical irritability, and complications are 
 infrequent. The only afl"ection for which this form of gonorrhea is likely to be 
 mistaken is urethral chancre, the possibility of which should never be forgotten.^ 
 Under treatment the discharge rapidly diminishes until only a drop or two of 
 muco-pus can be seen, and that chiefly in the mornings. This symptom is apt 
 to linger in spite of all efforts to remove it, and is perhaps the most persistent, 
 and by reason of its long continuance the most annoying, consequence of this 
 form of gonorrhea. There are, hoAvever, some complications which, although 
 they may likewise appear during an acute attack, are often associated with this 
 catarrhal condition of the urethra, and are of considerable gravity. These are 
 gonorrheal rheumatism, gonorrheal ophthalmia, and gonorrheal conjunctivitis. 
 
 Complications of Catarrhal Gonorrhea. — Gonorrheal Rheuma- 
 tism, or urethral synovitis, or Post-Gonorrheal Arthritis as it has been 
 better called, may appear at any time during the existence of a purulent dis- 
 charge from the urethra. It is much more common in men than in women. 
 It develops suddenly, and is usually accompanied by some abatement of the 
 discharge, more rarely by its entire disappearance. The disease has been 
 ascribed to various causes — metastasis, reflex agency, identity of gonorrhea 
 
 ' The diagnosis between infecting chancre of the urethra and gonorrhea may be found in 
 the chapter on Syphilis. 
 
904 .l.V AMERICAN TEXT- HOOK OF SURGERY. 
 
 und syphilis, development of a pre-existing rheumatic diathesis, and, finally, a 
 form of septicemic infection, the last hypothesis being the one now generally 
 accepted -as correct. 
 
 The symptoms of this complication come on rapidly, usually during the 
 later stages of either an acute or a catarrhal g(jnorrhoa. The j)atient, without 
 any premonitory signs, or perhaps after a slight chill or '' creep " and a little 
 febrile disturbance, notices pain and swelling in an articulation, commonly the 
 knee, ankle, wrist, or elbow, the degree of frequency being in the order of 
 mention. Within a few hours the swelling, due to synovial exudation, increases, 
 the joint becomes moderately red and hot and very tender, the suffering on 
 touch or movement being great. It may remain in this condition for some 
 time, may involve neighboring tissues, producing a general arthritis, or may 
 in a very few cases subside rapidly. There are few if any constitutional symp- 
 toms. The disease in a certain number of cases develops only vague travel- 
 ling pains in joints, bones, and muscles, and does not produce rt'ell-marked local 
 symptoms. Ordinary rheumatism is the only disease for which this form of 
 joint-affection is likely to be mistaken. The diagnosis should be based upon 
 the following points, which, for convenience' sake, may be tabulated thus : 
 
 Post-Gonorrbeal Arthritis or 
 Gonorrheal Rheumatism. Ordinary Rheumatism. 
 
 Associated with urethritis. Not associate.] with urethritis. 
 
 Very infrequent in women. Not very rare in women. 
 
 Constitutional symptoms transient and not Constitutional symptoms marked and pro- 
 severe, longed. 
 
 Very little fever. High fever. 
 
 No sweating. Profuse sweating. 
 
 Urine unaltered. Urine high-colored and loaded with urates. 
 
 Often associated with sclerotitis, bursitis, Not complicated with sclerotitis, bursitis, or 
 and teno-synovitis. teno-synovitis. 
 
 Cardiac lesions rare. Cardiac lesions frequent. 
 
 Inflammation remains fixed ; involves one or Inflammation jumps from one joint to 
 a few joints. another, involving many. 
 
 Local pains rather less than in true rheu- Pains always severe. 
 matism. 
 
 Efi'used fluid is absorbed very slowly. Eflfused fluid absorbed with comparative 
 
 rapidity. 
 
 Tendency to hydrarthrosis after acute stage Tendency to chronic hydrarthrosis less 
 has passed. marked. 
 
 Great tendency to relapse during subsequent Relapses have no association with urethral 
 gonorrheas. conditions. 
 
 Anti-rheumatic remedies are of little value. Artti-rheumatic remedies are evidently useful. 
 
 Gonorrheal Ophthalmia and Gonorrheal Conjunctivitis. — See 
 puruh'ut eijnjanctiviti.'i, p. lU-lT. 
 
 Irritative or Abortive Gonorrhea. — There remains to be considered 
 the third variety of so-called ''gonorrhea," the irritative or "abortive." Not 
 infrequently after a suspicious connection a patient will complain of a slight 
 pain on urination and a little itching at the meatus. An examination discloses 
 a reddening of the lips of that orifice, and a little transparent secretion coming 
 from the anterior half-inch of the urethra. These symptoms are very similar 
 to those of the earliest stage of an acute urethritis, and indeed are altogether 
 indistinguishable from them — a fact of importance in deciding as to the pro- 
 priety of "abortive" treatment. Instead, however, of increasing in inten- 
 sity, they remain stationary for some days, and then, if not aggravated by 
 improper treatment, subside entirely, the whole duration of the case not 
 exceeding a week or ten days. There are no sequelae and no complications 
 
SURGERY OF THK O EXITO-URIXARY TRACT. 
 
 905 
 
 associated with this c-ondition, Avhich is siin])ly one of mucous irritation and 
 consequent hypersecretion. 
 
 The three varieties of urethritis which have thus been described may be 
 contrasted as foHows, it being understood that such accurate clinical differentia- 
 tion does not invariably occur, but that in many cases the characteristics of 
 the different classes are intermingled. The tabular form will be useful in 
 enabling us to recognize at a glance the main points of difference : 
 
 Acute Inflammatory 
 Urethritis. 
 Usually a first attack. 
 
 Begins with a little redness, 
 |iouting, and tinglinii, itch- 
 ing, or smarting at the 
 meatus. 
 
 Rapidly develops free dis- 
 charge, ardor urinas, chor- 
 dee, and other symptoms. 
 
 Discharge thick, yellow, 
 greenish, or bloody. 
 
 Usual complications : prosta- 
 titis, cystitis, bubo, etc. 
 
 Treatment at first actively 
 sedative and antiphlogistic 
 or mildly antiseptic. 
 
 Catarrhal Urethritis. 
 
 Usually a second or subse- 
 quent attack. 
 The same. 
 
 Most of these symptoms, with 
 the exception of the dis- 
 charge, are absent. 
 
 Discharge milky or watery. 
 
 Most common complications : 
 rheumatism, ophthalmia. 
 
 Treatment may soon be 
 '■ anti-blennorrhagic :" cu- 
 bebs, copaiba, etc., with 
 injections. 
 
 Irritative Urethritis. 
 
 No relation to previous ure- 
 thral disease. 
 
 The same, but to a much les8 
 degree. 
 
 All these symptoms absent; 
 
 does not progress beyond 
 
 this point. 
 Almost no discharge. 
 
 No complications. 
 
 No treatment necessary. 
 
 Chronic Urethral Discharges. — As a direct continuation or prolonga- 
 tion of the acute affections of the urethra, or as more or less remote sequelae, 
 a number of chronic urethral discharges are met with. These may for con- 
 venience be divided into three classes : those due to a urethral catarrh, a con- 
 dition often left after the subsidence of an acute urethritis ; those dependent 
 upon a chronic gonorrhea, the inflammation having localized itself in some 
 portion of the urethra, producing a granular or even superficially ulcerated 
 surface : and those commonly known as gleet, which in almost every instance 
 will be found associated Avith urethral coarctations, often of the sort known as 
 "strictures of laro;e caliber." Nearly all chronic discharges arising from the 
 urethra proper will be found to fall under one or the other of these heads, and, 
 as it is a matter of much therapeutic importance to be able to distinguish them, 
 their chief diagnostic points may be briefly considered. 
 
 Urethral Catarrh, — In many cases of gonorrhea, for some time after 
 the disappearance of the last drops of muco-purulent discharge there will still 
 be found a condition of excessive secretion or of increased "urethral moisture,'' 
 which will often be a source of unnecessary anxiety to the patient and the 
 surgeon. The symptoms associated with this mucous catarrh vary from a mere 
 feeling of wetness about the meatus to the pos.sible production, by "stripping " 
 the urethra, of a drop or two of clear, albuminoid liquid, slightly tenacious and 
 resembling that resulting from a prostatorrhea, with which, indeed, it is often 
 associated. There is no subjective symptom, except a sensation of dampness 
 at the extremity of the penis. This is often so marked as to lead the patient 
 to useless examinations of the organ, or to induce the belief that a free dis- 
 charge exists, but is absorbed by the dressings or by the under-clothing. 
 Treatment of any sort, as a rule, serves only to aggravate, or at least to per- 
 petuate, this condition, which, in nineteen cases out of twenty, will subside 
 spontaneously in a few days or weeks. 
 
 Chronic Gonorrhea. — In other cases, after all marked symptoms have 
 
906 
 
 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 vanished there .will yet remain a milky, or rather creamy, droj), which can be 
 pressed out of the meatus whenever a few hours have elapsed after urination. 
 This may come from any portion of the urethra, but will usually be found to 
 proceed from the fossa navicularis or from the anterior membranous portion. 
 By "stripping" the urethra an inch or so at a time, gradually working back- 
 ward, or by proper use of a bulbous bougie, as will be described under the 
 head of Treatment, or by means of the urethroscope, a very definite idea 
 of the exact site of the trouble may be obtained. The meatus will be 
 found a little reddened or swollen ; there will be an undue warmth or even a 
 slight scalding on urination ; erections will be accompanied with a dull ache, 
 and all these symptoms will be much increased by venereal, alcoholic, or other 
 excesses, especially by prolonged and ungratified sexual excitement and by the 
 free use of spirituous liquors. There is no interval between this condition and 
 the last stage, or rather the preceding stage, of an acute urethritis. 
 
 Gleet. — In some cases, and especially in those in which the gonorrhea has 
 been of long continuance or has fre(|uently been repeated, there will occur 
 another group of symptoms, chief among which is a "gleety " or muco-puru- 
 lent discharge. In the mornings the lips of the meatus will be found glued 
 more or less tightly together, and on separating them a drop of opalescent, 
 whitish fluid will become apparent or may be squeezed out. The discharge 
 may be more profuse, but cannot usually be found during the day in sufficient 
 quantity to be made apparent at the meatus, owing to the frequent washing 
 out of the urethra by the stream of urine. There Avill often be found asso- 
 ciated with this discharge a dribbling of urine at the end of micturition, an . 
 increased frequency of the latter act, and a few vague lumbar or hypogastric 
 pains or aches — a group of symptoms which should always suggest the exist- 
 ence of a stricture of large caliber. 
 
 We may now bring together the main points of difference between the 
 various chronic urethral discharges : 
 
 Urethral Catarrh. 
 
 Follows immediately on sub- 
 sidence of ";onorrhea. 
 
 Discharge watery ; thin mu- 
 cus. 
 
 Chronic Gonorrhea. 
 
 Continuous with attack of 
 gonorrhea, often a first one. 
 
 Discharge creamy ; pus. 
 
 Not much afiFected by habits. Greatly aggravated by excess 
 
 in drink or by sexual ex- 
 
 Gleet. 
 
 Usually a variable interval 
 after subsidence of gonor- 
 rhea ; generally after sev- 
 eral attacks. 
 
 Discharge milky or milk-and- 
 w-atery ; mu co-pus. 
 
 Increased by the same causes, 
 but not to the same degree. 
 
 No subjective symptoms. 
 
 Affects no special portion of 
 the urethra. 
 
 Cause : loss of tone and dila- 
 tation of capillaries of part. 
 
 Prognosis : subsides without 
 treatment. 
 
 Expectant treatment. 
 
 With bulbous bougie urethra 
 is found to be normal. 
 
 citement. 
 
 Warmth or scalding on urin- Dribbling after urination \ 
 ation ; very slight tendency frequency of urination; 
 
 junc- 
 
 to chordee. 
 
 Lingers chiefly about the 
 navicular fossa and the 
 bulbo-membranous 
 tion. 
 
 Persistence of low grade of 
 inflammation. Circum- 
 
 scribed congestion with 
 small granulations. 
 
 Requires local treatment. 
 
 by local injec- 
 
 Treatment 
 
 tions. 
 
 Point of sensitiveness, from 
 which bougie brinirs nus. 
 
 hypogastric and lumbar 
 pains. 
 Source of Ww discharge 
 always back of the coarc 
 tation. 
 
 Submucous deposit around 
 urethra, interfering more 
 or less with its caliber. 
 
 If cause be not removed, 
 almost certainly grows 
 worse. 
 
 Treatment by dilatation and 
 injections. 
 
 Point of moderate resistance. 
 
SURGERY OF THE GEXITO- URINARY TRACT. 007 
 
 Prostatorrhea. — There is a form of discharge dependent upon chronic fol- 
 licular proHtatitix in Avhich tiie chief diaijjnostic points arc as foHows: 1. Undue 
 frecjuency of micturition, with pain felt in or near the end of the penis at the 
 termination of the act. The prostatic nerve-plexus, supplying the vesical neck 
 and the gland itself, becomes the cavernous plexus, and is continued to the end 
 of the penis, terminating at the proximal side of the fossa navicularis. This 
 nervous supply sufficiently explains the above symptom. 2. A feeling of 
 weight or of fulness in the perineum and rectum, sometimes amounting to 
 absolute pain, especially during the passage of hardened feces. The relations 
 of the pelvic plexus of the sympathetic, which supplies the rectum as well as 
 the skin of the buttocks, perineum, and external genitals, in addition to fur- 
 nishing the nerves for the mucous surfaces and muscular portions of the bladder, 
 prostate, and urethra, of course explain the occurrence of this symptom. 3. 
 Diminution in the force of the stream, associated with dribblino; toward the 
 end of the act. The frequency of this symptom shows that in the majority 
 of cases of this kind the inflammatory trouble does not remain localized in 
 the mucous membrane, but extends into the prostatic ducts, and even into the 
 substance of the gland itself. This is further shown by the fact that in the 
 great majority of such cases the volume of the prostate, as examined through 
 the rectum, is appreciably increased, while there is often slight tenderness upon 
 pressure. 4. The first portion of urine passed, if collected in a glass, will be 
 found more turbid than the second portion. This aids in diagnosticating the 
 condition under consideration from a primary cystitis, although the symptom 
 has not the practical value Avhich Ultzmann has attached to it. 5. The sedi- 
 ment in the urine will be found to consist of prostatic epithelium, muco-pus, 
 and a few mucous shreds. These are often associated with casts of the folli- 
 cles and prostatic ducts, which are sometimes deceptively like hyaline casts of 
 renal origin. This resemblance is most frequent in cases of chronic trouble. 
 6. There is often, but not invariably, associated with these conditions a certain 
 amount of sexual excitability, frequent erection, and premature ejaculation 
 during attempts at intercourse. 
 
 This group of symptoms is characteristic of follicular prostatitis or pros- 
 tatorrhea, and is not so apt to be found in uncomplicated cases of stricture of 
 the urethra, but the condition is frequently diagnosticated and treated as one 
 of gleet depending upon stricture. 
 
 TREATMENT OF GONORRHEA. 
 
 In determining the proper treatment for existing gonorrhea it is necessary, 
 in the first place, to understand clearly the character and stage of the case 
 with which Ave are dealing. The classification which has been given will be 
 found a good one for practical purposes, and nearly all cases can be assigned 
 to one or other of the three classes — acute, subacute, or abortive. 
 
 To take them up seriatim, we may suppose that a patient belonging to the 
 first or acute inflammatory class presents himself for treatment with the symp- 
 toms characteristic of the early stage : a red, swollen meatus, a little pain on 
 urination, and a muco-purulent discharge. The propriety of employing in 
 such a case the so-called " abortive " treatment at once suggests itself, but 
 should not be seriously considered. There is a strong practical objection to 
 the adoption of this method in the impossibility which exists of accurately dis- 
 tinguishing at the outset between the different varieties of urethritis ; one 
 of which, beyond question, would be greatly aggravated by this treatment. 
 As the most ardent advocates of the abortive treatment recommend it only 
 
908 ^.V AMERICAN TEXT-BOOK OF SrnaEIiV. 
 
 at the earliest appearance of symptoms, it is evident tiiat in manv cases a 
 slight local irritation, limited to the extremity of the urethra and likely to 
 subside spontaneously in a few days, -would be converted into a general 
 urethritis. This treatment, then, which consists in the injection once or twice 
 of a strong solution of nitrate of silver, or in the very frequent injection of 
 weaker solutions of the same salt or of some astringent such as tannin, need 
 not here be further described. The first care should be to remove as far as 
 possible all sources of irritation, chief among which are (1) the influence of 
 motion, friction, and gravitation in increasing the amount of blood in the part; 
 (2) the similar effect produced by sexual stimulus ; and (3) the character of the 
 urine, which must necessarily come in contact with the irritated surface. 
 
 (1) To overcome the first, rest in the recumbent position is obviously the 
 most important means at our command, and its power in limiting and sub- 
 duing the intensity of acute urethritis can hardly be over-estimated. The 
 patient should be told to avoid, in every possible numner, physical exertion, 
 to ride instead of walking, to sit instead of standing, and at such times as 
 may be convenient to lie on his back with his hips elevated. (2) The 
 patient should carefully avoid the companionship of women of any class, as 
 under the circumstances there is apt to be an exaltation of sexual impulse 
 which renders even the mere proximity of females more or less provocative 
 of erection, or at least of a very harmful hyperemia of the parts. (-3) In order 
 to render the urine as bland and innocuous as possible, rigid attention to cer- 
 tain dietary rules is indispensable. A skimmed-milk diet is beyond question 
 the one best adapted to this stage of the disease. A few farinaceous articles or 
 a little stale bread and butter may be added, but the more nearly the diet is 
 made to consist of skimmed milk the more likely is it that the patient will 
 escape the severe ardor urinjB and troublesome chordee of the first week or 
 two. In most cases, however, we are compelled to be content with a modifica- 
 tion of the ordinary regimen, and should instruct the patient to reduce his 
 animal food to the minimum, to avoid all greasy, fried, or highly-seasoned 
 articles, to abstain from the use of pepper, vinegar, salt, coffee, and tea. Salad 
 dressings, asparagus, acid fruits, tomatoes, strawberries, etc., pastry of all 
 kinds, and indeed any article of food difficult of digestion, should be strictly 
 prohibited, as should all malt, vinous, and spirituous liquors. The patient 
 should be expressly warned against the use of beer and champagne. Apolli- 
 naris, seltzer, and soda water are permissible drinks and may be taken in 
 large quantities, serving then the double purpose of diluting the urine and 
 at the same time of reducing the appetite, so as to render more easy the 
 observance of moderation in eating. Ordinary drinking-water may be taken 
 in the same way, to the amount of three or four (juarts daily, with great 
 advantage : and to meet the same indication, the reduction of the salts con- 
 tained in the urine, it is well to prescribe some alkaline hydragogue diuretic, 
 combining with it an arterial sedative and an anodyne directed especially to 
 the genital functions. 
 
 Instructions should next be given as to the best method of retaining such 
 dressings as will serve to collect and absorb the discharge. If the foreskin 
 quite covers the glans penis, the very best dressing consists of a little morsel 
 of absorbent cotton placed over the meatus and retained within the preputial 
 orifice. If it nearly covers the glans, but does not extend to the meatus, a 
 small aperture should be cut in the center of a piece of patent lint or old 
 linen, two and a half to three inches square ; this should be stretched gently 
 with the fingers until just large enough to slip over the head of the penis 
 and back of the corona. The ends should then be turned forward and the 
 
SURGERY OF THE G ENlTO-riUXARY Tit ACT. 909 
 
 foreskin brought in the same direction, when it will serve to hold the lint 
 or linen in place. If the glans penis be entirely uncovered, it will be 
 necessary to support the dressing in some other manner. A good plan 
 then is to take the foot of an old stocking or a bag of old muslin made large 
 enough to hold the organ comfortably, and pin it to the front of the under- 
 clothing. " Gonorrhea bags" of antiseptic wood wool constitute an excellent 
 dressing. 
 
 Tlie foregoing directions all ])ertain to the first visit of the patient. If 
 the case belong to the third (irritative or abortive) class, all the symptoms will 
 subside in a few days ; if to the second (subacute or catarrhal), the discharge 
 will become more profuse, but no marked subjective symptom will develop; if 
 to the first (acute inflammatory), the phenomena already described will make 
 their appearance with an intensity proportionate chiefly to the lesser or greater 
 strictness with which the directions given have been observed. In the first 
 case (irritative gonorrhea) no further treatment is required ; in the second 
 (catarrhal gonorrhea) we may at once begin with the use of such injections as 
 will be hereafter described as appropriate to the declining stage of inflam- 
 matory urethritis ; but if we are dealing with a case of the acute inflammatory 
 variety, w^e must continue to watch for and treat the symptoms. 
 
 Treatment of Ardor Urinae. — For the relief of the ardor urinae and 
 tendency to frequent urination such a diuretic mixture as that suggested 
 above is very useful, and should be persevered in or given in larger doses and 
 more frequently. In addition, the patient may be instructed to immerse the 
 penis in hot Avater during each urination, which is often followed by extraordi- 
 nary relief, probably due to the equalization of the blood-supply caused by it, 
 the temporary distention of the superficial vessels relieving, to a certain extent, 
 the congested and swollen mucous membrane, and thereby diminishing the 
 resistance to the passage of the stream of urine and the friction betAveen it and 
 the sensitive walls of tlie urethra. 
 
 Treatment of Chordee. — In the treatment of chordee attention must 
 be paid to the folloAving points, the first of which is the most important as a 
 prophylactic measure: Before going to bed the bowels should invariably be 
 evacuated. The bedroom must be cool and well ventilated, the mattress hard, 
 and tRe bed-clothing; light. No late meals should be taken, and anv tendencv 
 of the thoughts toward sexual matters should be resolutely combated. The 
 medicinal treatment of chordee has embraced a great variety of remedies, of 
 which none is at the present time generally recognized as of pre-eminent value. 
 Opium in the form of suppositories, used at bedtime, is very efiicacious, but not 
 without its disadvantages, the constipation induced by it being prejudicial. It 
 may be necessary to employ it, however, in which case the following formula 
 may be used : 
 
 I^ Pulv. opii, gr. vj ; _ 
 
 Pulv. camphorse, gr. xviij ; 
 
 01. theobromse, q. s. 
 
 M. et ft. suppositoria No. vj. 
 Sig. Use one at bedtime. 
 
 Camphor may be given internally in doses of a fluidram of the tincture or 
 in the form of the monobromide in from three- to five-grain doses. Lupulin 
 in fifteen- to twentv-grain doses and gelsemium in the dose of three minims or 
 more of the fluid extract, repeated every time the patient wakes with chordee, 
 have been extremely useful. None of these remedies are, however, so certain 
 
910 AX AMKIilCAX TEXT-llOOK OF SllidKliY. 
 
 i 
 
 in their effects as is bromide of potassium. Its employment as an alkali, as an 
 arterial sedative, and as an anaphrodisiac, is especially indicated in the early 
 stages of gonorrhea, and should never be neglecte<l even when the symptom of 
 chordee is absent. When that complication exists, the dose of bromide should 
 be increased until decided drowsiness is produced, and it should be given at 
 intervals during the day. with a double dose, combineil with ten or fifteen drops 
 of tincture of l)cllad()nna. at bedtime, and repeated if the patient awakes dur- 
 ing the night with chordee. Under this treatment, pushed vigorously, the 
 patient will rarely have any erections, painful or otherwise. If, however, in 
 spite of the free use of bromides, the employment of camphor and opium sup- 
 positories, and attention to the hygienic rules laid down, the chordee is per- 
 sistent and very painful, it is well to adopt more active measures for its repres- 
 sion, not onlv to free the patient from pain, but also because each recurrence of 
 chordee aggravates the tendency to inflammation, and, pio))ably, increases the 
 liability to subsequent stricture. In such cases nothing is so effectual as the 
 free abstraction of blood from the perineum by means of leeches. From a 
 healthy adult eight or ten ounces should be taken, and for the next day or two 
 he should occupy a strictly recumbent position with the hips elevated. 
 
 Urethral Injections in the Early Stage. — When the surgeon has 
 decided to begin the use of injections he should order for the patient a l)lunt- 
 pointed, hard-rubber urethral syringe large enough to hold three fluidrams. 
 At this stage the disease, although often extending a few inches backward, has 
 reached its greatest intensity at or near the fossa navicularis, a point at 
 which the nozzle of an ordinary syringe may act as a mechanical irritant 
 and serve to increase or perpetuate the inflammatory action. Having j)ro- 
 cured his syringe, the patient should be taught how to use it, and, although 
 it gives a little more trouble, it is always Avell personally to inspect this pro- 
 cedure at least once. In using the injection the patient should sit upon the 
 edge of a hard chair, the buttocks projecting slightly o¥er it, the feet separated, 
 and the thighs relaxed. In this way all pressure or tension upon the perineal 
 muscles is removed and the injected fluid finds its way backward to a sufficient 
 depth. In those cases in which the disease is clearly localized anteriorly, or 
 in which any injection reaching the prostatic urethra or the neck of the l)lad- 
 der gives rise to vesical irritability, the patient may sit upright, with a hand- 
 kerchief or towel rolled up and placed just back of the scrotum, thus occluding 
 the urethra at that point. The syringe, having been nearly <»r (juite filled 
 according to the depth to which it is thought necessary to throw the injection, 
 is held betAveen the thumb and middle finger of the right hand, the tip of the 
 index finger resting on the end of the piston. The conical extremity of the 
 syringe is then inserted from a quarter to a half inch within the meatus, 
 which is held open for that purpose by the thumb and fingers of the left hand, 
 and which is then drawn tightly around the syringe, the ])ressure being made 
 laterally, so as to narrow the aperture instead of broadening it as when it is 
 compressed in an antero-posterior direction. If this is done ])r()])erly while 
 the syringe is depressed so that the piston points toward the umbilicus and is 
 gently forced home, every drop of the liquid, to the amount of at least two 
 fluidrams, will be deposited within the urethra. The patient should then 
 use the injection in this manner after each urination, and should hold the 
 injected fluid within the urethra for two or three minutes before suft'ering it to 
 escape. It may be laid down as a rule that any injection which gives rise to 
 more pain than might be described as a very slight smarting is likely to do 
 harm rather than good, and should be diluted or discarded. 
 
 In selecting the drugs to be used by injection and by the mouth in the 
 
SURGERY OF THE GENITO- URINARY TRACT. 911 
 
 treatment of the form of urethritis avc are <loscribin;f — viz. recent anterior 
 specific urethritis — our description of its etiology should not be lost sight of. 
 As this form of gonorrhea is often an instance of mixed infection, the treat- 
 ment should be more or less thoroughly antiseptic. 
 
 The application of the principle of antisepsis to the treatment of 
 urethritis may be made for one of two reasons and in one of two ways. The 
 drugs employed may be given on account of their supposed action upon either 
 the microbes of suppuration or the alleged specific microbe of gonorrhea — the 
 gonococcus of Neisser. They may be used locally or may be administered by 
 the mouth, although even when given in the hitter way their action is largely 
 a local one. As to the reason for their employment, in the light of modern 
 pathology it is not necessary to believe in an invariable and essential relation 
 between the gonococcus and gonorrhea to see a clear indication for the use of 
 germicidal agents. The successful treatment of suppuration anywhere demands 
 the employment of some such agent, though it must be admitted that when the 
 pus is furnished by a mucous surface the difficulties of treatment — i. e. of suc- 
 cessful antisepsis — are greater than under most other circumstances ; and it 
 must likewise be admitted that those difficulties are much increased when the 
 suppurative process is established in a canal like the male urethra, the ana- 
 tomical peculiarities of which favor so markedly microbic growth or multipli- 
 cation. 
 
 While the employment of antiseptics in urethritis or a -belief in their 
 efficacy does not necessitate a corresponding belief in the gonococcus as the 
 sole cause of gonorrhea, yet a consideration of the rationale of such treatment 
 undoubtedly involves an inquiry into the natural history of that microbe, w'hich 
 is certainly present, whether as cause or as effect, in the large majority of cases 
 of acute gonorrhea. Unfortunately, the results of culture experiments and of 
 experiments as to the influence of germicides upon gonococci external to the 
 body do not afford satisfactory evidence as to the effect of the same agents when 
 applied to the same germs imbedded in the depths of an inflamed urethral mucous 
 membrane. Bumm's investigations appear to show that at first they multiply 
 by preference in the papillary layer, and find their way to the surface only dur- 
 ing the latter part of the purulent and during the subsiding (or muco-purulent) 
 stage, and Finger uses this as a theoretical argument against the early admin- 
 istrattion of either asti'ingents or antiseptics. Enough is knoAvn, however, to 
 enable us to state with certainty that the agents which are effectual against the 
 microbes of suppuration are not equally destructive of the gonococci, several 
 competent observers having noted the fact that antiseptic solutions, when 
 applied to gonorrheal secretions outside of the body, have seemed to exert 
 but little effect upon the gonococcus even when strong enough to destroy pus- 
 cells and the pyogenic microbes almost immediately. 
 
 Considering topical remedies first, and excluding a large number which 
 have little or no claim to occupy time or attention, we may divide the remainder 
 into three classes : 
 
 1. Those which when strong enough to exert a sufficient germicidal action 
 are locally so irritating as to be harmful or unbearable. This class includes 
 nitrate of silver, carbolic acid, chloride of zinc, iodine, chloral, potassium per- 
 manganate, salicylic acid, and creasote, all of which have been faithfully tried 
 in many cases and by competent surgeons, the concurrent testimony being that 
 when used in sufficient strength to sterilize the discharges they produce an 
 amount of irritation and swelling, ardor urinse, chordee, and even, exception- 
 ally, urethral ulceration, that far outweighs any advantage to be derived from 
 their antiseptic properties. 
 
912 AN AMKHICAX TKXT-BOOK OF SLRGERY. 
 
 2. Those which are such feeble aritisej)tic agents that they cannot be de- 
 pended upon to destroy all the bacteria found in urethi-ai discharges. Among 
 these may be mentioned resorcin, thallin, quinine, sulphate and acetate of 
 zinc, lanolin, sulphur waters, tannin, alum, hydro-naphtiio), and cadmium sul- 
 phate. The clinical evidence and the experimental evidence coincide as to 
 most of these drugs. Each has had its more or less enthusiastic advocates, but 
 when given a wider trial has been found disappointing, while bacteriologists 
 have shown that the germicidal action is either limited to a very few varieties 
 of bacteria or is slow and uncertain. 
 
 3. The third class includes a number of agents which, while open to the 
 same objection of too feeble or too limited antiseptic action, have the additional 
 drawback of insolubility in ordinary media, and of occasionally becoming 
 mechanically irritating from the formation of concretions. Among these are 
 iodoform, calomel, bismuth subnitrate, oxide of zinc, and other insoluble 
 powders. 
 
 It must not be supposed that this list is intended to be even approximately 
 complete. It might be increased literally a hundred-fold ; and nothing could 
 better demonstrate the absurdity of empirical methods than the dozens of 
 ridiculous formulae and the hundreds of useless drugs which have from time to 
 time been recommended for use in the various forms of urethritis. So far, 
 however, as they are antiseptics, they would be found in one or the other of 
 the above classes. 
 
 There are certain agents which have been purposely omitted from this 
 classification, but which, as ordinarily employed, might with considerable pro- 
 priety have been included. These are corrosive sublimate, sulpho-carbolate 
 of zinc, boric acid, peroxide of hydrogen, and salicylate of bismuth, which in 
 various combinations are of practical value in attempting by topical treatment 
 to secure asepsis in an inflamed urethra. They may be used in different pro- 
 portions and either singly or in combination. A useful prescription is as 
 follows : 
 
 I^ Ilydrarg. chlorid. corros., gr. -^^^ 
 
 Zinci sulpho-carholat., gr. xviij ; 
 
 Glyceriti boroglycerini (31 per cent, boric acid), f.^ij ; 
 Aquse rosse, foiv. — M. 
 
 S. Use locally; dilute if painful. 
 
 To this may be added from 18 to 24 grains of the watery extract of opium if 
 the urethra is especially irritable. 
 
 Argonin and protargol, new preparations of silver, are at ))resent on trial 
 by the profession. It is generally conceded that silver is one of the most 
 actively destructive agents to the gonococcus, and for these new compounds 
 the manufacturers claim the maximum germicidal power with the minimum 
 of irritation to the urethral mucous membrane. Either may be employed in 
 watery solutions of from 1 to 5 per cent. 
 
 The so-called blennorrhagics, of which cubebs and copaiba are the chief, 
 may be used with advantage very early in all cases except those of high inflam- 
 matory type. There can be little doubt that the beneficial action of these 
 drugs, as well as that of their congeners, gurjun, .sandal-wood, kava-kava, 
 eucalyptus, and the various terebinthinates, is chiefly due to their antiseptic 
 powers, which not only deprive the altered and partially sterilized urine con- 
 taining them of many of its harmful properties, but cause it to exert a posi- 
 tively curative eff'ect upon the suppurating mucous membrane. They may with 
 marked benefit be combined with salol, which by its decomposition into sali- 
 
SURGERY OF THK (iKNITO-imiNAllY TltACT. 913 
 
 cylic and carbolic acids, to be excreted through the kidneys, aids powerfully 
 in renderiiK-- the urine not only aseptic, but also antiseptic. 
 
 A usefuT prescription is for a capsule containing salol 5 grs. ; oleoresin ot 
 cubebs, 5 grs. ; l»ara balsam of copaiba, 10 grs. ; pepsin, 1 gr. ; four to six 
 capsules daily being given, 'riiesc are now prepared commercially and are 
 known as compound salol capsules. In cases where the irntation of the whole 
 urinarv tract is so great as to contraindicate the use of cubebs or copaiba the 
 salol may be given alone in ten-grain doses four times daily, or boric acid may 
 be administered in some such combination as the following: 
 
 ^ Acid, boric, 
 
 Potassii bromidi, ''^^ ^^'".1 ' 
 
 Tinct. aconiti, ^?"..^^j''^ 
 
 Liq. potass, citrat., f^vnj. — M. 
 
 S. One tablespoonful in water every two hours. 
 In certain cases where these preparations disagree or seem to lose their effect 
 it will be well to substitute sandal-wood oil in doses of ten minims four times 
 daily This amount may be dropped upon a lump of sugar and swallowed 
 with a little water, or it may be given in capsules. A commercial article is 
 sometimes sold by druggists which has not by any means the same thera- 
 peutic value as the genuine oil, being a decided irritant to both the genito-uri- 
 nary and the digestive tract. It may be known by its turbidity or cloudiness, 
 the pure oil being perfectly translucent and of a pale amber color. A little 
 later in any case an injection containing an insoluble sediment may be substi- 
 tuted for the antiseptic injection given above, as, for example, 
 
 Vf Zinci acetat., __ . 
 
 Acid, tannic, ^^ ^'\ 
 Acid, boric, |"J ; 
 
 Aquge hydrogenii dioxidi, fsvj. M. 
 
 S. For local use. 
 
 Sometimes, especially in the first few days, no injection can be borne 
 except an almost purely sedative one, and then the following may be tried: 
 
 Bi Acid, boric, 3iJ ? _ 
 
 Ext. opii aq., gr- xviij ; 
 
 Liq. plumbi subacet. dil., f5vj. — M. 
 
 While using the injections containing insoluble sediments the patient will 
 often be unable accurately to estimate the character and amount of his discharge. 
 After a time, therefore, it is well to substitute for them a watery solution ot 
 some simple astringent, preferably of sulpho-carbolate of zinc, beginning with 
 about two grains to the ounce, and combining it, if there be any lingering sen- 
 sitiveness or scalding, with morphine or dilute hydrocyanic acid, as in the 
 following prescriptions : 
 
 i^ Morphinse sulphat., gr. j ; 
 
 Zinci sulpho-carbolat., 9j I 
 
 Aquae rosae, f oiv. — M. 
 
 "B^ Zinci sulpho-carbolat., ^J ' .. 
 
 Acid, hydrocyanic, dil., gtt. xij ; 
 
 Aquifi roste, f^iv. — M. 
 
 58 
 
914 J.v AMi:nicA\ TKXT-nooK OF SI /:(i i:i:y. 
 
 In this, a.s in ;ill other c-iscs, it' tlie injection proves to be painful, it sliouhl be 
 diluted ; if painless and it" it does not entirely control the discharge, it should 
 be strengthened. 
 
 Under this treatment in many instances the discliarjie \vill disappear, and 
 no further symptoms manifest themselves, unless, as often occurs, treatment is 
 prematurely discontinued. The only safe rule to follow is to instruct the jiatient 
 gradually to sto]) the use of injections and to decrease the dose of medicines, 
 omitting first the mid-day portions, then those of the morning, and last of all 
 those taken just before going to bed; the whole process should extend over 
 ten days. lie should also be cautioned against frequent or vigorous "strip- 
 ping" of the urethra for purposes of inspection. 
 
 Irrigation with various antisejjtic solutions, usually thrown in by the aid 
 of gravity, are in much favor with some practitioners. It is probable that 
 their systematic use in large numbers of cases Avould show a reduction in the 
 average time of cure. A considerable proportion of private patients are, how- 
 ever, unable or unwilling to employ them at their homes. Recently the 
 method recommended by Janet has been given extended trial by a few genito- 
 urinary specialists. It consists in copious irrigations of the urethra with a 
 solution of potassium permanganate. If the anterior urethra only be atfected, 
 a fountain syringe, placed two feet above the patient's body and supplied 
 with sufficient rubber tubing to which is attached a meatus nozzle, is em- 
 ployed. If it is intended to irrigate the posterior urethra and bladder, the 
 reservoir is raised four and a half feet above the patient's body. The strength 
 of the solution should not be greater than 1 : 7000 or 1 : 5000 in beginning 
 the treatment; but may be gradually increased to 1 : 2000 or even 1 : 1000. 
 The irrigations are carried out once or twice daily. Distilled water should 
 be employed in making the solutions. 
 
 Some very favorable rejiorts upon this method have appeared in the jour- 
 nals ; but it has not received the approval of those most experienced in this 
 line of work. There are objections to its general ado})tion, and some sur- 
 geons believe they have observed harmful eflects following its use. 
 
 Treatment of Persistent Urethral Discharges. — If, in spite of the 
 injections above given, the discharge continue, recourse may be had to stronger 
 solutions, the sensibility of the urethra being taken as an index. In this way 
 five or six grains of zinc sulphate to the ounce will often effect a cure when 
 weaker injections have failed. Or acetate of zinc, tannin, sulphate of copjjcr, 
 nitrate of silver, alum, tincture of catechu, hydrastin, and various other drugs 
 may be employed occasionally with advantage. 
 
 Treatment of Urethral Catarrh. — If the characteristics of what we 
 have called urethral catarrh are present, a little attention to the general health, 
 fifteen drops of the syruj) of iodide of iron after meals, fresh air and moderate 
 exercise, a free diet, with an occasional glass of claret or burgundy at meals, 
 Avill usually be sufficient, without local treatment, to terminate the case. Per- 
 severance in the use of astringent injections and in the introduction of bougies 
 will sometimes hasten a cure, but quite as often seems to retard it. These con- 
 stitute the majority of those chronic urethral cases which are often reported by 
 patients as having been cured by honuxsopathic treatment, the negative charac- 
 ter of which leaves free play to that vis medicatrix naturce which is really all 
 that is needed. 
 
 Treatment of Chronic Gonorrhea. — In other cases, ])articularly when 
 the attack is the first one, the discharge persists, creamy or yellowish in appear- 
 ance, associated with a few mild subjective symptoms indicative of a localized 
 inflammation, which proves to be easily aroused into a state of activity ; a con- 
 
,s (/,'(,■ hh'y or THE (iKXiTo-i liiyAJiY ruArr. !)15 
 
 ditioii Avliicli it is convciiieiit to dt'si<fii:ite as chronic goiionlica. To (letcrniiiie 
 this beyond question, a bulbous bougie, three or four sizes smaller than the 
 normal caliber of the urethra, should be gently inserted into the bladder, the 
 surgeon noting as it goes in the exact situation of any point of unusual sensi- 
 tiveness, and looking for this or siniihir })oints during its Avitlidraval. He must 
 not be misled by the normal sensitiveness of the ])rostatic urethra. He should 
 look at the shoulder of the bulb, and oljserve •whether it Ijrings out any dis- 
 charge, and, if so, notice its character. The urethroscope may occasionally be 
 of use in these cases. If the symptoms and appearances which have been 
 described as characteristic of chronic gonorrhea are present, it may be assumed 
 that the sensitive spot corresponds to a small patch of granular urethritis to 
 which it is necessary to a])])ly appropriate remedies directly. For this purpose 
 the patient should be ordered a prostatic syringe of hard rubber having a long 
 curved nozzle with a bulbous tip. He should be instructed in what manner and 
 to what depth to insert this instrument, and the surgeon should himself admin- 
 ister the first two injections. For this it is well to use about one-half fluidram 
 of a 1 or 2 per cent, solution of nitrate of silver in distilled water, or, if this does 
 not give rise to pain on the first injection, a still stronger solution. The dis- 
 charge and pain may be increased for a short time after these injections, which 
 should then be followed by gradually strengthened solutions of sulpho-carbolate 
 of zinc, tannin, sulphate of copper, or some other astringent carried to the exact 
 spot in the same manner. If the discharge diminishes, but does not disappear, 
 the same process may be repeated; and this will almost invariably result in 
 permanent cure. It should never be forgotten that in certain cases the progress 
 of the injection backward may be cut off by spasmodic contraction of some of 
 the circular muscular fibers surrounding the urethra. This, occurring as soon 
 as the first drops of the injection reach the locality, will effectually prevent 
 the liquid from passing any farther, and thus from coming in contact with 
 the surface which is the source of the discharge. In these cases the use of 
 full-sized sounds is imperatively indicated, all other treatment being worse 
 than useless. 
 
 Irrigation of the urethra with various medicated liquids has been recom- 
 mended, and is a useful procedure in cases in which the foregoing treatment 
 proves ineffectual. A moderate-sized, short, flexible rubber catheter — preferably 
 a " N^laton " — with large bevelled eyelets, should be inserted nearly into the 
 bladder, and then connected with a syringe like the ordinary " Mattson " or 
 " Davidson " syringe. A pint or more of the preferred solution, usually of 
 one of the antiseptics or astringents above mentioned, may then be passed 
 through the urethra without withdrawing the catheter, the lotion finding its 
 way between the instrument and the Avails of the urethra and making its 
 exit at the meatus. In one or the other of these ways chronic gonorrhea is 
 always curable. 
 
 Treatment of Gleet. — In a case of true gleet, with a history of sev- 
 eral previous attacks of gonorrhea or one which has been very protracted, 
 with dribbling after urination, etc., we should carefully examine the ure- 
 thra with a bougie a boule, when we shall probably find the condition described 
 as indicative of the presence of a submucous deposit or a " stricture of large 
 caliber" or commencing stricture. The fact that in every normal urethra the 
 bulb of the instrument will meet with some resistance as it passes under the 
 posterior layer of the triangular ligament (White) seems worthy of reiteration, 
 as failure to recognize it has been a frequent source of error in diagnosis and 
 treatment. Another source of error, already referred to, is spasm of the mus- 
 cular fibers occurring at some point along the urethra and imparting to the 
 
916 AN AMEJiJCAN TEXT- BO OK OF SUItGERV. 
 
 bougie the precise sensation felt in passing a stricture. The possible associa- 
 tion of spasms of this character with strictures of large caliber situated ante- 
 riorly should not be forgotten. The treatment of gleet in the great majority 
 of cases thus becomes that of the stricture upon which it depends. (See section 
 on Stricture of the Urethra.) 
 
 Treatment of Complications. — Balanitis usually requires for its treat- 
 ment only perfect cleanliness and the use of some desiccant sedative powder, 
 such as opium Bj, lycopodium ^ij, and acid, boric. 3J. Three or four times 
 daily this should be dusted on the inflamed surface, which should be previously 
 washed and gently dried. Strips of dry lint inserted between the glans and 
 foreskin, and changed whenever they become moist from the discharge, will 
 often effect a cure. 
 
 Balano-posthitis, when accompanied by oedema of the prepuce, is best 
 reduced by a lotion of lead-water and laudanum continuously applied. The 
 dry dressing may be used with advantage after the swelling has subsided. 
 Good in both cases follows from painting over the inflamed glans and the inner 
 surface of the foreskin with a 30- or 40-grain solution of nitrate of silver. 
 
 Phimosis may be relieved by circumcision or by splitting open the fore- 
 skin along the dorsum, completing the operation at some later period ; but 
 both of these procedures are undesirable if it is possible to avoid them. In 
 nearly every case lead-water and laudanum externally, with subpreputial 
 injections of soap and water, followed first by clean water, and then by 
 lead-water and laudanum, will reduce the swelling, so that the glans may be 
 uncovered. 
 
 Paraphimosis (Fig. 370), if seen at first while the preputial swell- 
 ing is a'deraatous and not inflammatory in its character, should be imme- 
 diately reduced. 
 
 The ordinary procedure, which usually suffices, consists in oiling the parts, 
 locking the index fingers of the two hands above and behind the corona 
 glandis, and the middle fingers below and beneath it, and gradually com- 
 pressing the glans itself with the thumbs, emptying its congested vessels, and 
 finally forcing it backward while the fingers bring forward the swollen foreskin. 
 Or the body of the penis may be encircled with the thumb and index finger 
 of one hand while with the other the glans is gradually compressed and pushed 
 into the preputial orifice. It must be remembered that not only the glans but 
 also a ring of swollen mucous membrane is to be returned through that orifice. 
 When these means fail, or, indeed, in preference to them in many cases, the 
 method of Mr. Eddowes has been most satisfactory. It consists in wrapping 
 the glans and prepuce with a slip of wet lint two inches wide and extending a 
 little in front of the glans, and then winding around the glans from before 
 backward a piece of round elastic ligature. By the time the corona is reached 
 the glans will be reduced in size, and it will be often possible to slip the end 
 of a grooved director beneath the constricting band. Then, withdrawing the 
 ligature rapidly, the shrivelled glans may be pushed backward and the prepuce 
 drawn forward to its natural position. If the chief obstacle to reduction be the 
 amount of oedema, it will be proper to evacuate the serum by several minute 
 punctures with an exploring needle. 
 
 AYhen the paraphimosis has been of longer duration and an effusion of 
 plastic lymph is present, more permanent compression may be required, and in 
 that case the glans and foreskin should be " strapped " with pieces of adhesive 
 plaster. In twenty-four hours reduction usually becomes possible. If not, 
 the dressing should be removed. If all these means fail, we may divide the 
 constriction on the dorsum of the penis by inserting beneath the prepuce a flat- 
 
SURGERY OF THE GENITO- URINARY TRACT. 917 
 
 tenod sharp-pointed bistoury an.l then turnin- its edge and cutting upward ; 
 or the stricture may be cut down upon from without inward, always remen.ber- 
 in<. to look for it in the furrow which divides the mucous membrane from the 
 infe-ument, the first one behind the furrow of the cervix glandis. 
 
 Follicular Abscess often opens spontaneously into the urethra and 
 requires no surgical interference. When the skin becomes thinned and dis- 
 colored over such a swelling, it is well to incise it freely. 
 
 Peri-urethral Abscess should be evacuated more promptly--as soon, 
 indeed, as suppuration is established, as a spontaneous opening in these cases 
 Ly be followed by urinary extravasation. In their earliest stages these 
 Tbs^cesses may sometimes be aborted by the use of sedative lotions with 
 absolute rest in bed, moderate elevation of the organ, and free purgation. 
 
 Lymphangitis rarely requires any special treatment Evaporating and 
 sedative lotions and rest will usually relieve any pain which may be associated 
 
 ^'^ Bubo mav be aborted by the use of pressure or iodine, or, if these fail, may 
 be poulticed and opened as in any case of glandular suppuration. It is never 
 
 ' "cowperlSs'renuires rest, elevation of the buttocks, leeches to the 
 perin^:^ hof sitzlfhs, poultices, and prompt evacuation if suppuration 
 
 ''''''prostatitis, Prostaio-cystitis, and Cystitis must all be treated in 
 very much the same manner. Uoon the first development of the early symp- 
 toms-frequent urination, vesical tenesmus, etc.-the patient should be placed 
 at absolute rest in the recumbent position, with the hips elevated upon a hair 
 p How his diet for a few days should be limited to skimmed milk, of which 
 Te may take any desired quantity ; an alkaline diuretic --ture shou d be 
 fieely administered; three-ounce cnemata of hot water, or of hot staich- 
 waLr containing a few drops of laudanum, should be given every two or three 
 hours six or efght ounces' of blood may, with advantage, be taken by leeches 
 from the perineum, which should afterward be covered with hot fomenta ions ; 
 and finally opium, combined with belladonna or hyoscyamus, m suppositories 
 should be^edai bedtime and at intervals during; the night if t^e call to 
 urinate are frequent. Bromide of lithium in five-grain doses every three hours, 
 or dtrtte of caffeine in three-gram doses, may be added to the diuretic mixture 
 if the urine remain scanty and high-colored. j i ^i, ^-^^^ 
 
 All urethral injections should be immediately stopped, and the patient 
 should be instructed to resist as long as possible the desire to urinate, and also 
 the inclination to strain and bear down at the end of the act. 
 
 Retention of Urine.— If retention of urine should occur as an additional 
 complication, place over the hypogastrium a large, mushy, hot hop poultice 
 covered with oiled silk, and renew every two hours; give an enema of hot 
 water and soapsuds. If the symptoms of retention and of distention of the 
 bladder become serious, the urine should be drawn a.^y -^^h- J^^ ^r^rder" 
 eter usino- the greatest possible tenderness in its insertion. It must be under- 
 tood thaf the evils of the gentle introduction of a soft -*h^^7^;y- ^/^^^^ 
 as every six or eight hours, are less than those produced by the intense and 
 :imost Untinuous^enesmus. Of course, if a tight stnctui. - P--^ -d 
 there is difiiculty in introducing a soft instrument, other instruments must be 
 tried, and occasionally external urethrotomy or perineal section may become 
 
 ""'' Prostatic Abscess.— When during an attack of acute prostatitis the 
 patient suddenly has rigors, followed by increased fover and sweating, it is 
 
i)lS J.V yiMKIilCAN TEXT- HOOK OF smoKllY. 
 
 probable that suppuration has occurred in the ghind. If the abscess opens 
 into the urethra, as it usually does, no special treatment is necessary ; if it 
 points toward the rectum, however, or if, with unniistnkable symptoms of sup- 
 puration, the abscess shows no disposition to point in either of these directions, 
 it becomes necessary to evacuate it. An incision should be made in the 
 median line of the perineum nntil the pus-cavity is reached, care being taken 
 not to Avound either the urethra or the rectum. 
 
 Chronic Prostatitis. — When prostatitis becomes chronic the treatment 
 is difficult and prolonged. It may be summarized as follows : Kemoval of 
 stricture, contracted meatus, phimosis, or other predisposing cause ; restricted 
 diet ; avoidance of all liquors, except some form of light red wine ; careful atten- 
 tion to the bowels, cold-water enemata once a day being often of great service ; 
 daily cool hip-baths of a temperature and duration governed by the sensations 
 of the patient, and persisted in as long as they are followed by relief of sub- 
 jective symptoms ; counter-irritation to the perineum, preferably by iodine ; 
 normal exercise of the genital functions. Cauterization of the prostatic urethra 
 is unquestionably useful in many cases, but should be employed only after 
 the foregoing measures have failed. A few drops of a 30- or 40-grain solu- 
 tion of nitrate of silver should be deposited in the prostatic urethra, and the 
 immediate effect, which is a more or less marked inflammatory action, watched 
 and controlled by rest and appropriate remedies. The operntion may be 
 repeated if no benefit result from the first application. 
 
 In the form of urethral discharge dependent upon chronic follicular 
 prostatitis, which has been described (p. 907), attention to the following 
 rules of treatment Avill give the most satisfactory results in a large proportion 
 of cases : Limited diet, especially as regards nitrogenous articles of food ; absti- 
 nence from sexual excitement, particularly if ungratified ; great attention to the 
 condition of the rectum, which should never be allowed to contain, even for a 
 few hours, a mass of hardened inspissated feces. To avoid this, white wheat- 
 gluten suppositories or weak glycerin suppositories used at bedtime are most 
 satisfactory. A free application of a mixture of tincture of iodine and tincture 
 of belladonna should be made to the perineum, and repeated night and morn- 
 ing until the skin becomes tender, resuming it at once when the tenderness 
 passes away. This is better than the actual blisters recommended by Sir 
 Henry Thompson and others, on account of the long-continued irritation which 
 can be kept up in this manner. Careful attention should be paid to the condi- 
 tion of the urine. As a routine treatment a mixture of bromide and citrate 
 of potassium, with small doses of aconite, belladonna, and ergot, will be found 
 useful. 
 
 The prostate is so situated anatomically that congestions and inflammations 
 once occurring in it are powerfully favored by the influence of gravitation. 
 In nearly every position of the body it is at the lower extremity of a portion 
 of the circulatory system which is peculiarly apt, in bipeds, to suft"er from 
 chronic congestion and vascular dilatation. Hemorrhoids are chiefly, if not 
 exclusively, a disease of the human and anthropoid species, and prostatic 
 hypertrophy, simply as a result of advancing years, is found almost exclu- 
 sively in these species, and is possibly due to the same cause. In all ordinary 
 postures the blood which has entered the prostate must make its exit against 
 the attraction of gravitation. Whenever we find this mechanical condition in 
 the body, we are apt to find also dilatation of the blood-ve.ssels and hyper- 
 trophic tis.«uc-change. To prevent this, and to restore both the vessels and 
 the tissues to their normal size and caliber, there is no better remedy than the 
 application of cold, especially in the form of a jet or stream of water. In the 
 
.scA'aijRv Of Till-: aKMro-nuxAin' tract. mo 
 
 cases in question the persistent and thorough use of the hidct is of tlie greatest 
 benefit (White). The j)atient should use it for ten or fifteen minutes at least 
 twice daily, once after his usual evacuation of the howels and once before going 
 to bed. It is Aveil at ])oth tliese times to wash out the rectum witli tepid or warm 
 Avater, and to employ the cold jet directed against the perineum. The powerful 
 contraction of all the muscular and vascular structures in the neighborhood is 
 well shown in the effects of this treatment upon hemorrhoids, prolapsus ani, 
 and similar conditions, and is participated in by the vessels and muscular 
 structure of the prostate. 
 
 Epididymitis, at its onset, should be treated as follows: Put the patient 
 to bed in the recumbent position ; elevate the scrotum above the level of the 
 thighs. Apply directly over the painful testicle a piece of patent lint soaked 
 in the following lotion, with which it should be kept continually wet : 
 
 i^ Tinct. aconiti, 
 Tinct. opii, 
 
 Liq. plumbi subacetat. dil., ad fsj ; 
 Aqufe, f.si'j- — ^I- 
 
 Shave the hair from the groin on the affected side, and take about six ounces 
 of blood, by means of leeches, along the line of the cord. Administer a half 
 bottle of the effervescing citrate of magnesium, place the patient on restricted 
 diet, stop all urethral treatment, give him a drop of tincture of aconite and 
 five grains of bromide of potassium every two hours, or more frequently if 
 there be any febrile reaction. Often this treatment at an early stage will 
 prevent any further manifestations : the symptoms will subside, and in two or 
 three days the patient may be permitted to walk around, keeping the testicle 
 still enveloped in the lotion and well supported by a suspensory. When the 
 swelling, either in spite of treatment or in its absence, has progressed to a 
 considerable extent and the testicle presents a large solid mass, the pain hav- 
 ing become dull and aching, and severe only upon motion or in walking, great 
 relief may be obtained by the application of compression. 
 
 In strapimig a testicle the scrotum should be shaved, the testicle drawn 
 down as far as possible, and a strip of adhesive plaster about half an inch in 
 width made to encircle its upper extremity, so as to retain it in that position 
 in the form of a tense tumor, pear-shaped and purplish in color. This is then 
 tightly covered in with successive strips of plaster, placed first circularly until 
 the greatest circumference of the tumor is reached and they refuse to adapt 
 themselves neatly to the surface, and then longitudinally so as to cover in the 
 lower segment completely. The testicle may then be placed in a suspensory 
 bandage, and in most cases the patient is able to go about with little or no pain. 
 The dressing should be replaced every day or two, since it will loosen as the 
 swelling disappears. An ointment of belladonna and iodoform may then be 
 applied upon a piece of lint worn beneath the suspensory. 
 
 The induration of the epididymis Avhich remains after all inflammatory 
 action has disappeared is usually permanent and is not much affected by treat- 
 ment. It may, however, diminish under the use of belladonna and mercurial 
 ointment and the internal administration of iodine and a mercurial. In cases 
 of double epididymitis followed by sterility it is well to pursue this method of 
 treatment for a long period, as the re-establishment of the spermatic canal to 
 ever so slight a degree is then, of course, a matter of great importance. 
 
 Gonorrheal Rheumatism is considered to be a peculiarly obstinate and 
 intractable form of joint-trouble, and treatment is pronounced, by all author- 
 
920 j.v a.u/:r/('AX Ti:xT-iinoK of sr'narjn'. 
 
 ities on the subject, to be in the highest degree unsatisfactorv. It is due to 
 infection with the gonococci ; or, when it accompanies a simple urethritis, to 
 infection with pyoi;eiiic bacteria, or often, doubtless, to a mixed infection. 
 It is occasionally tlie local evidence of absorption of bacterial or chemical 
 products and their presence in the fluids and tissues of the joints. For the 
 symptoms and treatment see the section on the Arthritis of infective Disease 
 (p. 399). 
 
 GONORRHEA IN THE P^EMALE. 
 
 Gonorrhea in the female is not so frequent, so limited in its situation, so 
 protracted in its course, or so serious in its results as in the male. The ana- 
 tomical arrangement of the genito-urinary organs in women permits gonor- 
 rheal inflammation to develop in the vulva, vagina, urethra, or uterus, which 
 are involved with a frequency indicated by the order of mention. Vaginitis 
 is, however, described by some writers as the most common of these varieties 
 of gonorrhea. The uterus is insensitive, not prone to inflammatory action from 
 external irritants, and in a position where such irritants, especialh' when de- 
 rived from sexual intercourse, are not retained in contact with it for any length 
 of time. The delicate urethral mucous membrane is protected from frequent 
 contamination by its sheltered position and its situation above the genital canal, 
 fluids deposited in or flowing from the latter not necessarily coming in contact 
 with it. The vulva and vagina are obviously much more exposed to irritating 
 or traumatic agencies, any one of Avhich, whether a purulent secretion from the 
 male urethra, violence, inordinate masturbation, etc., is capable of exciting in 
 these parts a severe inflammation. 
 
 Vulvitis. — Causes. — A''ulvitis may be produced in any of the ways men- 
 tioned, may be secondary to a vaginitis, may be due to worms, to the secre- 
 tions of mucous patches, to uncleanliness and the accumulation of sebaceous 
 matter, to criminal violence, or to any traumatic or infective cause. It some- 
 times arises spontaneously in infants during dentition, and is said by Dupuy- 
 tren, who cites cases in proof, occasionally to ])e epidemic in very young chil- 
 dren. However caused, vulvitis begins with an itching sensation and a feeling 
 of heat and burning, soon followed by tumefaction of the parts, Avhich are 
 bathed in a secretion at first muco-purulent, then thick, yellowish or greenish, 
 acrid, and oftensive. If the i)arts be inspected a day or two after the onset of 
 the disease, the labia will be found red, abraded, and excoriated, and the nym- 
 phse sometimes swollen so as almost completely to occlude the entrance to the 
 vagina. The parts are sensitive to pressure and painful upon motion. The 
 vulva is often surrounded by an area of congestion which extends beyond the 
 vulvo-femoral folds and may be seen for some distance down the thigh. The 
 passage of the urine across the inflamed surfaces gives rise to an intense burn- 
 ing, which may be mistaken for the ardor m-'nvx of urethritis, and is often 
 quite as severe. 
 
 Complications. — Bnho. — The inguinal glands are apt to be enlarged and 
 tender, and sometimes suppurate. Bubo is, however, also less common in the 
 female than in the male, and when it does occur is almost always associated 
 with a vulvitis or a urethritis. 
 
 Vulvo-vaginal Abscess. — In some cases inflammation follows the ducts of 
 Bartholin's glands, and excites suppuration or abscess in these ])odies, which 
 are compound tubular glands, surrounded by a fibrous envelope, and situated 
 
suRd Eli y OF Tin: a i:m to- i /:/\. i // }' 7/.'. i ( t. 
 
 021 
 
 one on t'acli .side of the entrance of the vai^ina. In acute cases there are 
 heat, redness, and tenderness of the inflamed part; which signs, together with 
 the peculiar pyrifonn swelling, servo to facilitate the recognition of the condi- 
 tion. In the early stages the swelling can most readily he recognized hy put- 
 ting a finger in the vagina and pressing outward toward the ranms of the 
 isciiium. The ahscess will sometimes evacuate itself spontaneously through 
 the duct of the gland or at the inner surface of the nympluie, or the pus may 
 work its way hetween the layers of the ischio-pubic fascia and escape just 
 within the labium majus: but its cure can usually be hastened by a prompt 
 and free incision made through the mucous membrane at the inner and lower 
 aspect of the tumor. Suppuration in these glands has a peculiar tendency 
 to recur, and accumulation of i)us and the conse(iuent swelling will often take 
 place, after a first attack, without any marked symptoms of inflammation. 
 Under these circumstances — particularly if pressure on the tumor does not 
 cause the appearance of pus at the orifice of the duct — it is possible, in 
 exceptional cases, to mistake the condition for a pudendal hernia, for a cyst, 
 for a hydrocele of the round ligament, or for oedema of the cellular tissue of 
 the labium or vice versa. 
 
 The differential points in the diagnosis of vulvo-vaginal abscess from the 
 first three mentioned affections may be contrasted as follows : 
 
 Chronic Vulvo- 
 vaginal Ab- 
 scess. 
 
 History of previous 
 iutiammation. 
 
 Swellint^ pyriform ; 
 base downward ; 
 greatest swelling 
 inward. 
 
 Fluctuation. 
 
 Irreducible. 
 
 No impulse on cough- 
 ing. 
 Dull on percussion. 
 
 Most common in old 
 prostitutes. 
 
 Pudendal Hernia. 
 
 Sudden appearance. 
 
 Shape very similar, 
 but greatest pro- 
 jection outward. 
 
 Doughy or elastic. 
 
 Reducible by pres- 
 sure near ramus of 
 ischium. 
 
 Distinct impulse. 
 
 Cyst of the 
 bium. 
 
 La- 
 
 Slow, painless 
 growth. 
 
 More distinctly cir- 
 cumscribed; some- 
 times peduncu- 
 lated. 
 
 Elastic. 
 
 Irreducible. 
 
 No impulse. 
 
 Resonant if an enter- Dull. 
 
 ocele. 
 Seen at any age. Seen at any age. 
 
 Hydrocele of the 
 Round Liga- 
 ment. 
 
 No ))revious inflam- 
 mation. 
 
 General, diffused 
 swelling. 
 
 Doughy. 
 
 Partially reducible. 
 
 No impulse. 
 
 Dull. 
 
 Seen oftenest in 
 young persons. 
 
 (Edema of the vulva is usually symmetrical, and in nearly every case is 
 either a result of pregnancy or parturition or of the presence of an abdominal 
 tumor, or accompanies a vulvitis, and is then, of course, easily recognized by 
 the inflammatory symptoms. 
 
 Vaginitis. — Causes. — Vaginitis has for its most frequent cause a puru- 
 lent discharge from the male urethra. In other words, gonorrhea in the female 
 is usually due to direct infection by the male. It may, however, result from 
 violent or excessive copulation, from masturbation, from contusions, from 
 inflamed hemorrhoids, or in various other ways. Females already affected with 
 leucorrhea sometimes develop a vaginitis after protracted exertion. It may 
 result from an extension upward of a vulvitis, although the reverse is met 
 with quite as often. Children and young girls are especially subject to inflam- 
 mation of the vagina, which is sometimes found as a complication of dentition 
 or of the eruptive fevers, and sometimes as a sequel of the first approaches of 
 the male. Vaginitis, which is apt to be of a leucorrheal character, sometimes 
 occurs in the early stages of syphilis as a result of the extension of inflam- 
 
1)22 A.\ AMLL'KAy TEXT-liOOK OF SLUUKllY. 
 
 luation from mucous patches seated ujion tlic vulva or of cliaiiircs whit-li take 
 place in the os uteri. Tiie neck of the uterus is frcijuently the seat of certain 
 lesions in the secondary stages of sy}>hilis which may he the medium of propa- 
 gating inflammation to the vagina. 
 
 Symptoms and CompUcationsf. — Vaginitis following purulent infection 
 usually begins at the lower and posterior aspect of the canal. It is at first 
 attended with a feeling of weight and fulness, sometimes referred to the rec- 
 tum, and with a dry, glazed, congested appearance of the mucous membrane. 
 After the lapse of a few hours a mucoid discliarge appears, rapidly becomes 
 purulent, and. when the disease involves an increasing extent of surface, as it 
 generally does, is very profuse, soiling the posterior portion of the patient's 
 linen and trickling down her thighs and over her perineum uidess absorbed 
 bv suitable dressings. The subjective symptoms, although not often as marked 
 as in vulvitis, are occasionally very characteristic, and are due in the first 
 place to the proximity of the bladder and rectum to the inflamed canal, and 
 in the second to the nervous connections of the region, giving rise to certain 
 reflex phenomena. Under the first of these classes may be enumerated vesical 
 irritability and tenesmus, aching or throbbing pelvic or hypogastric pain, 
 hemorrhoids, dysenteric symptoms, prolapsus uteri, etc. : under the latter, 
 sciatic, crural, lumbar, and abdominal pains. Sometimes, when the inflam- 
 mation has been very intense and the discharge has been retained, extensive 
 though superficial ulceration of the vagina occurs, the pus becomes mingled 
 with blood, the pain is considerably increased, and the disease assumes a very 
 obstinate and rebellious form. 
 
 Chronic Vaginitis. — In the chronic variety of vaginitis the presence of 
 the discharge, tliickening of the vaginal mucous membrane, and enlargement 
 of its papilliie are almost the only symptoms met with. Now and then a ca.se 
 is seen in which the inflammation has become strictly localized, a small patch 
 of strawberry-red granulations being found, analogous to those seen in the 
 urethra in chronic gonorrhea, and on other mucous membranes, as the con- 
 junctiva, when iuflanmiation assumes this form 
 
 Cases of chronic vaginitis in young persons are observed in which the 
 vagina is hard and small, its ruga? well seen, yet evidently swollen, cedematous, 
 and with either no secretion or covered over by an old, grayish-white accumu- 
 lation of epithelial detritus. 
 
 Urethritis. — Causes. — Urethritis in the female is commonly classed as a 
 venereal aftection. and is unquestionably due in a majority of cases to extension 
 of inflammation from the vulva or vagina, but it is unsafe to assume that any 
 ■woman with a urethritis has necessarily acquired it by contagion and as a result 
 of exposure to the discharge resulting from a similar inflammation in the male. 
 It may be admitted, however, that the existence of a urethritis in a female 
 is presumptive evidence of impure connection, particularly in those cases in 
 which it exists independently of any vulvar or vaginal aft'ection. "When these 
 regions are involved the (juestion of original causation reverts to them, as their 
 inflammations almost invariably precede the urethral trouble. 
 
 Symptoms. — The shortness of the female urethra, its downward inclina- 
 tion from the neck of the bladder to the meatus, and the comparatively small 
 amount of mucous membrane involved prevent at the same time the formation 
 of any large amount of discharge and the development of any extremely pain- 
 ful symptoms. 
 
 Ardor in'mse does exist in nearly all cases, and is sometimes quite marked, 
 but is not comparable in severity to the same symptom as observed in the 
 male. The proximity of the inflamed area to the neck of the bladder ren- 
 
srnai:!!)' or riii: t; i:.\rri>-rh'i.\Mn' ruAcr. !)2:'> 
 
 ders some dej^ret' ot" iiivolvciiicnt of tliat viscus (juite coninion, but, although 
 urination may be much too tVecjuent, the degree of tenesmus and the associated 
 spasm and pain are less distressing than uhen cystitis occurs as a complication 
 of male urethritis. In many eases the spontaneous emptying of the urethra 
 by gravitation or its washing out by the stream of urine is so complete that to 
 obtain evidence of the existence of a discharge it is necessary to insert a finger 
 into the vaginal outlet and gently *' strip" the urethra from behind forward, 
 compressing it against the under surface of the pubic arch. This should be 
 done some time after urination. Occasionally the meatus will be found red, 
 pouting, or everted, and it is sometimes surrounded by a ring of vegetations. 
 
 Uterine Gonorrhea. — The form of uterine inflammation set up by gon- 
 orrhea is usually cndocervicitis. In nearly every case in which the upper por- 
 tion of the vagina is implicated in the disease the os uteri is bathed almost 
 constantly during the height of the inflammation in an acrid, irritating pus. 
 In many cases the irritation thus engendered, instead of limiting itself to the 
 production of congestion, abrasions, superficial ulcerations, and other changes 
 in the os, extends into the neck and sometimes into the body of the uterus, 
 producing in each instance its characteristic symptoms. 
 
 In the former case there will be seen upon examination with a speculum a 
 red, swollen, ulcerated os, from between the lips of which protrudes an albu- 
 minous, mucous, or muco-purulent discharge so viscid and coherent that it is 
 detached with difficulty. When the disease extends to the lining membrane or 
 to the body of the uterus itself, when it advances through the Fallopian tube 
 to the peritoneal cavity or to the ovaries, or when in other cases it extends 
 from the submucous connective tissue of the vagina to that which lines the 
 pelvis, it produces complications which are of extreme gravity. 
 
 A description of metritis, salpingitis, ovaritis, peritonitis, and pelvic celluli- 
 tis, when those affections result from gonorrhea, will be found in the chapter on 
 the Diseases of the Female Genito-urinary Organs. 
 
 TEEATMEXT OF GONORRHEA IN WOMEN. 
 
 Treatment of Vulvitis. — The speedy cure of a case of vulvitis depends 
 upon attention to the following points : 
 
 The patient should be placed at absolute rest, with the pelvis elevated : this 
 is more important in this than in any other variety of gonorrhea in the female, 
 gravitation and the friction produced by movement operating powerfully and 
 prejudicially if the patient insists upon walking. Perfect cleanliness and dr^-ness 
 of the parts are essentials of success in treatment. The labia should be gently 
 washed every two hours Avith a strong solution of bicarbonate of sodium, which 
 will dissolve and remove all accumulated sebum and mucus, and will at the same 
 time often prove to be, in itself, a very soothing application. In using this the 
 labia should be gently separated with the thumb and fingers of one hand, while 
 with the other a stream of the alkaline solution is squeezed out of a sponge 
 held a short distance above. After this operation is completed a soft old linen 
 rag should be held in contact Avith the vulva until all the fluid is absorbed, the 
 parts should be dusted Avith a fine poAvder of starch and oxide of zinc or of 
 opium and lycopodium, a piece of patent lint should be carefully interposed 
 between the labia, and absolute quiet should be preserA^ed until it is time to re- 
 peat the dressing. In certain cases the inflammation runs so high, and the swell- 
 ing, pain, and discharge are so excessive, that these gentle measures do not suf- 
 fice. It Avill then be necessary to purge, to employ prolonged, general hot-baths 
 — not sitz-baths — to folloAv them with a lotion of opium and lead-water kept con- 
 tinually on the inflamed region, or to paint the entire vulva with a forty -grain 
 
924 A^" AMi:in('AX TEXT- HOOK OF SURGERY. 
 
 solution of nitrate of silver. This last expedient may be adopted earlier, and 
 rarely fails to produce a fiood effect. Wlien tlio burning and tliroljbing are 
 very great, and particularly if there is .some constitutional disturbance, the ab- 
 straction of blood by leeches placed along the lines of the groins and on the 
 perineum is clearly indicated. The diet during this period should be restricted, 
 consisting chiefly of milk and farinaceous articles. 
 
 When it becomes apparent that a vulvo-vaginal gland is involved, timely 
 local bleeding may arrest the inflammation, but if it fail to do so suppuration 
 may be hastened by warm fomentations, cloths wrung out of hot water and laid 
 over the affected labium being preferable to poultices. The incision should be 
 made on the inner and lower aspect of the swelling, as in that manner it is pos- 
 sible to obtain the best drainage. In chronic, frequently-recurring abscesses 
 of this region, instead of dissecting out the capsule of the gland, as has been 
 recommended, or of putting in a seton, it will be sufficient to lay open the 
 cavity by a free incision, and, after curetting, to pack the wound with iodo- 
 form gauze. 
 
 Treatment of Vaginitis. — Vaginitis requires the same general manage- 
 ment as vulvitis, rest in bed, elevated buttocks, restricted diet, and attention 
 to cleanliness being all valuable adjuvants to treatment. The confinement to 
 bed is hardly so imperatively necessary as when the vulva is the seat of the 
 disease, and motion, through friction or in any other way, does not so greatly 
 aggravate the symptoms. The patient should, hoAvever, be particularly cau- 
 tioned against undue exercise and also against indulgence in sexual intercourse. 
 In markedly inflammatory cases this will not be necessary, as the pain induced 
 by attempts at intromission will be a sufficient preventive. In cases of acute 
 vaginitis Avith profuse purulent discharge, tumefaction of the mucous membrane, 
 etc., the routine treatment should be as follows : 
 
 The patient, being in bed with the buttocks resting upon a hair pillow or a 
 folded sheet, the bowels having been opened with a saline laxative, should be 
 instructed to wash out the vagina every two hours with an injection of a pint 
 or two of soap and water, or, if that prove irritating, with an alkaline solu- 
 tion ; to folloAV this with a pint of simple Avater ; and to conclude with the use 
 of a pint of some medicated solution, preferably at this stage one of acetate 
 of lead. 
 
 The materials used as injections are various, but belong chiefly to the classes 
 of astringents and antiseptics. In the great majority of cases it Avill be found 
 best to use at first the acetate of lead ; to folloAV this, as the pain subsides and 
 the inflammation becomes less acute, Avith alum or the acetate or sulphate 
 of zinc, or Avith sublimate solution 1 : 10,000 or 1 : 20,000, or Avith peroxide 
 of hydrogen in combination with sulpho-carbolate of zinc ; and, Avhen under 
 this treatment the pain has entirely disappeared and the discharge has become 
 Avatery, to pack the vagina Avith tannin or to use suppositories according to cir- 
 cumstances. In prescribing vaginal injections for Avomen it is ahvays Avell to 
 order the material in poAvder, telling the patient hoAv much to dissolve in a 
 given quantity of water. For use in a pint of water, for instance, she should 
 employ of 
 
 Acetate of lead, one teaspoonful = three drams ; 
 Acetate of zinc, tAvo teaspoonfuls = three drams ; 
 Sulphate of zinc, one teaspoonful = tAvo drams ; 
 Alum, one teaspoonful = two drams ; 
 Tannin, four teaspoonfuls = tAvo drams. 
 
 These should be diluted Avhen it is found that they occasion pain. 
 
SURGERY OF THE GENITO-URINARY TRACT. 925 
 
 The subsiding stage of a vaginitis Avill be best treated with vaginal sup- 
 positories, wliich may be used thrice (hiily, the sui)ine position being observed 
 for at least an hour after the introduction of each one. As examples of useful 
 formulne the following may be given : 
 
 ^, Ext. opii, gr. iij ; 
 
 Acidi tannici, 3J ; 
 
 01. theobroma?, q. s. 
 
 M. et ft. suppositoria No. xij. 
 
 "S^ Pulv. aluminis, 
 
 Cerat. plumbi subacet., da oiij ; 
 01. theobrorafe, q. s. 
 
 M. et ft. suppositoria No. xij. 
 
 In ordering these the patient should be informed that they will stain her linen 
 if the discharge is allowed to come in contact with it. 
 
 In some women w^ith whom oily applications prove objectionable, or in 
 those too poor to use suppositories, it will be well to pack the vagina with 
 strips of patent lint into the meshes of which tannin or powdered alum has 
 been rubbed. 
 
 Occasionally, Avhen the vagina remains irritable and raw, bleeding easily, 
 it will be Avell to apply to its surface very thoroughly a strong solution of nitrate 
 of silver, 40 to 60 grains to the ounce of water. This is best done by inserting 
 a cylindrical speculum, elevating its outer extremity, pouring into it two or three 
 fluidrams of the silver solution, and then gently withdrawing it. As the w^alls 
 of the vagina fall across the end of the tube they will be thoroughly bathed in 
 the liquid. 
 
 At night in all cases of vaginitis it will be found convenient to employ 
 little pledgets of absorbent cotton into which some medicated powder has been 
 rubbed. The patient should keep, on a chair or table beside the bed, two or 
 three of these little rolls, and on waking during the night should insert one 
 as far as the finger w^ill carry it, first, of course, withdrawing the previous one. 
 Lead, zinc, and tannin may be used in this way, the first-named usually with 
 the greatest advantage. 
 
 Treatment of Urethritis. — Urethritis in females, as a rule, runs its 
 course very rapidly and requires but little attention. Injections may be used 
 by the surgeon, their strength being carefully adapted to the sensibility of 
 the mucous membrane, and the probability of their entering the bladder being 
 remembered. The same principles of treatment hold good and the same solu- 
 tions are useful as in urethritis in the male. Copaiba, cubebs, and sandal- 
 wood oil may also be administered with advantage, acting as usual through the 
 urine. No mention has been made of their employment in speaking of the 
 treatment of other forms of gonorrhea in the female, as in them the anti-blennor- 
 rhagics are worse than useless. Occasionally it may be necessary, in chronic 
 cases, to wipe out the urethra with a probe wrapped in cotton and dipped in a 
 solution of from 20 to 40 grains of nitrate of silver, and in some instances the 
 solid stick has been employed. 
 
 Treatment of Uterine GonorrFiea. — The affections of the uterus pro- 
 duced by gonorrhea require no distinctive or peculiar therapeutic management. 
 Nitrate of silver for abrasions, leeches for congestion, tampons or suppositories 
 applied through a speculum and retained in contact with the os by elevation 
 of the hips, iodoform, iodine, and all the well-known articles of the gyneco- 
 logical armamentarium, are useful here as in other uterine affections ; and the 
 
f)26 AiY AMEJiJCAy TEXT- HOOK OF sriUiKllY. 
 
 same remark applies to the other pelvic and ahdominal trouhles ^vhit•h may 
 complicate or follu\r a vaginitis. 
 
 STRICTURE OF THE URETHRA. 
 
 To consider philosophically the treatment of urethral stricture Ave should 
 first have a clear idea of the exact pathological conditions which are to be 
 overcome. Definitions arc rarely at the same time comprehensive and precise, 
 but it is probably a close approximation to the truth to describe stricture as an 
 abnormal lessening of the caliber or of the dilatability of the urethral canal, 
 associated with changes in the mucous, muscular, or subnmcous structures con- 
 stituting its walls. This definition includes the following chief varieties of 
 stricture : (1) inflammatory ; (2) spasmodic ; (3) organic. 
 
 (1) The existence of Inflammatory Stricture has been denied by emi- 
 nent authorities, who assert that without congestion of the prostate, spasm of 
 the circular fibers, or pre-existent organic stricture no swelling of the mucous 
 membrane alone is competent to give rise to retention of urine. While this is 
 true, it cannot be disputed that occasionally in cases of acute anterior ure- 
 thritis, with no suspicion of previous stricture and with the prostate unaffected, 
 there is great diminution in the size of the stream of urine, manifestly fi'om 
 the unnatural approximation of the swollen urethral Avails. Although the 
 condition is almost ahvays of short duration and never goes on to retention, it 
 is often the first step in the formation of organic stricture. The treatment is 
 that appropriate to the form of urethritis in question. 
 
 (2) Spasmodic Stricture depends on a contraction of the muscular 
 fibers surrounding the urethra, either the unstriped or the compressor urethrse, 
 and is always due to some irritative cause, direct or reflex, often aided by such 
 predisposing causes as the uric-acid or oxalic diathesis, sexual plethora or 
 excess, etc. It sometimes depends upon and complicates organic stricture 
 situated in advance of the seat of spasm. The immediate treatment consists 
 in the use of a warm bath, the administration of morphia or atropia, preferably 
 by the rectum or hypodermatically, the use of diluent drinks, and, of course, 
 the removal of the exciting cause if it can bo discovered. The retention of 
 urine so common after operations \jpon the anus and rectum, as in cases where 
 hemorrhoids have been tied, and occurring more rarely from reflex irritation 
 from a greater distance, is the result of vesical inhibition rather than of ure- 
 thral spasm. 
 
 (3) Organic Stricture is always the result of some antecedent injury or 
 disease: in the vast majority of cases it is due to a previous urethritis, and is 
 especially apt to follow those cases in which the urethral inflammation has 
 reached an exceptionally high grade of intensity, oi", still more, cases which 
 have run a very protracted course. The pathological condition varies from an 
 induration and thickening of the mucous membrane, with connective-tissue pro- 
 liferation occurring in its depths, to the formation of a dense mass of cica- 
 tricial tissue occupying the submucous region and extending into the meshes 
 of the corpus spongiosum. The strictured portion of the urethra varies greatly 
 in extent, from a mere cord-like band, the so-called linear stricture, to one 
 slightly broader, annular stricture, and from that to a contraction which may 
 involve as much as two or three inches of the canal, converting it into a devious 
 irregular channel. This has been called the tortuous stricture. Many classi- 
 fications have been adopted, but this answers well for practical purposes. 
 
 The situation of a stricture also varies greatly, but there can be no doubt 
 that the great majority are to be found in the bulbo-membranous region, 
 
SURGERY OF THE GEXITO-rRIXA liY TRAi'T. 927 
 
 which includes a spnce from about one incli in front of the anterior hiyer of 
 the triangular ligament to the prostato-membranous junction. The next most 
 frequent seat is in the first two and a half inches of the urethra, and the 
 smallest number are found in the middle of the spongy urethra. These 
 remarks apply to the forms of stricture produced ]>y urethritis. Travimatic 
 stricture usually aftects the membranous urethra, and it is asserted that stricture 
 produced by masturbation is to be found, as a rule, in the same region. As a 
 matter of fact, however, strictures from this latter cause are exceedingly rare. 
 This is shown by the comparative infrequency of strictures among adult males 
 of any community as compared with the number who have at some period of 
 their lives been addicted to the habit of masturbation, and still more forcibly 
 by the history of persons in prisons, asylums, and hospitals for the insane, 
 who have been known to practise the habit to excess over long periods, but 
 in whom stricture is not unusually frequent. 
 
 If stricture is no more common in such patients than among their associates, 
 it may safely be assumed that, at least as ordinarily practised, masturljation 
 can only be productive of organic stricture with such rarity as to make it 
 scarcely worth considering as an etiological factor. The dictum of Sir James 
 Paget may still be said to express the view of the profession, namely, " that 
 masturbation does neither more nor less harm than sexual intercourse prac- 
 tised with the same frequency in the same conditions of general health, age, 
 and circumstance." 
 
 Strictures are further divided into irritable, when they are readily inflamed 
 and bleed easily upon the touch of an instrument, and resilient, when they are 
 elastic and contractile, returning with great rapidity to their former size after 
 being dilated. They are also divided into those of small caliber, which may 
 be arbitrarily assumed to include strictures which will admit only instruments 
 less in circumference than 15 millimeters, and those of large caliber, or strict- 
 ures which will take instruments from that size upward. 
 
 These preliminary remarks are necessary to a consideration of the proper 
 method of treating strictures, as is also some inquiry into the functional 
 importance of strictures of large caliber. That every urethral coarctation 
 following urethritis must at some time have been a stricture of larcre caliber 
 is self-evident, but just when such a stricture becomes an active pathological 
 factor and is able to give rise to symptoms is an unsettled point. Indeed, it 
 is not probable that it ever can be definitely determined in a mathematical 
 sense. The idea that any particular fixed caliber represents the normal con- 
 dition of the urethra has for a long time been abandoned, the observed varia- 
 tions of that canal being such that no special dimensions can be assigned to it 
 as representing the precise dividing-line between health and disease. The old 
 method of regarding the size of the meatus as an indication of the normal cal- 
 iber of the canal behind it is also unquestionably fallacious, it having been 
 conclusively shown that no more definite relation exists between them than 
 between any other mucous canal and its corresponding outlet, the mouth and 
 the oesophagus, for example, or the anus and the sigmoid flexure. That there 
 is a certain correspondence between the size of the urethra and that of the 
 flaccid penis is true, the caliber of the one increasing with the circumference 
 of the other, but that this ratio is present in any absolutely unvarying manner 
 has not yet been demonstrated. At most, the size of the penis may be said 
 to furnish a general indication of the urethral dimensions, but one which is 
 approximate merely. On the other hand, it has been shown that there are 
 usually certain normal variations even in the spongy portion, and that it is 
 often impossible Avith any of the means at our command to distinguish between 
 
928 AN AMERICAN TEXT- BOOK OF SURGERY. 
 
 these natural irregularities and coarctations of cfjual caliber due to incipient 
 stricture. 
 
 Those surgeons who follow the teachings of Dr. Otis of New York, whose 
 valuable work has added greatly to our knowledge of the subject in question, 
 accept his scale of the relation of the caliber of the urethra to tlie circumfer- 
 ence of the flaccid penis, any interference with which they regard as evidence 
 of the existence of stricture. The figures wliicli Dr. Otis gives, while they 
 doubtless represent accurately the distensibility of the male urethra, do not by 
 any means represent what can fairly be called its normal caliber, and fail alto- 
 gether to recognize the ftict that there are points of physiological naiTowing, 
 notably along the course of the pendulous urethra, where some of his disciples 
 find the greatest number of contractions. Sir Everard Home, De Camp, Rey- 
 bard, and others long ago demonstrated the variations in size and dilatability 
 of the different portions of the urethra, and Civiale observed that in the middle 
 of the spongy urethra there is a notable diminution of elasticity. Weir and 
 Sands of New York confirmed by casts of the urethra these older observations, 
 and there can now be no doubt of the existence of such ])liysiological points of 
 constriction or of diminished distensibility. Otis in effect assumes that the 
 urethra should be a tube of uniform caliber, at least anterior to the triangular 
 ligament. The ingenious instrument which he has devised, the urethrometer, 
 when used under the guidance of Otis's table, will detect apparent strictures in 
 the majority of normal urethras, and should be employed only in exceptional 
 cases. 
 
 The most valuable urethral instruments for the purpose of diagnosis are the 
 go-called '-bougies a boule." They may be made of metal, with slender stems, 
 having small expanded ends or handles, upon which the number of the instru- 
 ment may be marked, the opposite end being tipped with an acorn-shaped 
 bulb : this should represent in millimeters the circumference of the shoulder 
 of the bulb. More satisfactory instruments are the flexible gum bougies 
 a boule. The base of the acorn-shaped bulb should join the shaft at almost 
 a right angle, and not at the large obtuse angle often found in impro])erly- 
 shaped instruments. The size selected for exploration should be determined 
 approximately in the manner already mentioned by noting the circumference 
 of the flaccid penis. A scale which diff'ers from that published by Dr. Otis in 
 giving a lower grade of numbers is as follows : 
 
 A penis 3 inches in circumference at the middle of the spongy portion 
 indicates a urethra which should normally admit an instrument of about 26 
 to 28 millimeters in size ; when it is 3^ inches, the urethra should have a 
 caliber of from 28 to 30 mm. ; 3^ inches, 30 to 32 mm. ; 3| inches, 32 to 34 
 mm. ; 4 inches, 34 to 36 mm. ; beyond which size it is seldom necessary to gc 
 (White). 
 
 If the meatus be too small to admit of the introduction of a bulbous bougie 
 of the required size, it should be enlarged by incision. The penis should then 
 be grasped just behind the corona and held gently between the thumb and 
 first finger of the left hand, the foreskin, if redundant, having been retracted 
 The dorsum of the penis should ftice the abdominal wall. The bougie, well 
 oiled, should then be passed gently into the bladder. If arrested, the point on 
 the shaft corresponding to the meatus should be marked, the distance from that 
 to the bulb representing the position of the anterior fiice of the stricture. If 
 that instrument or a smaller size passes through, it should then, after a moment's 
 delay, be withdrawn, and if during its outward passage any contraction is found 
 other than at the triangular ligament (which has been shown to be normal), it 
 is probably due to stricture, though spasm, Avhieh often rehixes after a few sec- 
 
SURGERY OF THE GENITO-URINARY TRACT. 929 
 
 onds or shifts its position in the canal as measured from the meatus, may give 
 rise to errors in diagnosis. It cannot always be recognized with certainty. 
 
 By this smaller scale the probability of mistaking physiological narrowing 
 for stricture is greatly diminished, and cases which present definite symptoms, 
 such as gleety discharge, fre(|U('nt urination, dribbling at the end of mictu- 
 rition, etc., and in Avhicli sucli an examination discloses a distinct contraction, 
 may Avith propriety be considered as cases of organic stricture. This is not 
 unduly conservative, but represents fairly the views of the majority of modern 
 surgeons, including many of those who, from special study and experience, 
 have the right to speak with authority on- the subject of genito-urinary 
 diseases. 
 
 We may now consider the treatment appropriate to the different varieties 
 of organic stricture. 
 
 (1) Strictures of Large Caliber, tliat is, of more than No. 15 (French), 
 situated at or behind the bulbo-membranous junction. 
 
 The stricture having been located and measured by the bulbous bougie in 
 the manner above described, a conical steel sound a few sizes larger than the 
 bulb which has passed the stricture should be sterilized by heat or by a car- 
 bolic lotion, or at least thoroughly polished by friction with a clean towel, and, 
 after having been warmed to the temperature of the body and oiled with 1 : 40 
 carbolized oil, should be carefully introduced through the stricture. If the 
 instrument is used with ordinary care and gentleness and has been properly 
 sterilized, and if in passing it through the deep urethra the fingers of the left 
 hand of the surgeon are used as a fulcrum in the perineum, and the long end 
 of the lever is depressed with slowness, while the conical point representing the 
 short end is made to follow accurately the subpubic curve of the urethra, the 
 production of prostatitis, epididymitis, or urethral fever, the three most com- 
 mon complications of rough or clumsy instrumentation, will occur with extreme 
 rarity. In the majority of cases these complications are due to the use of force 
 in the introduction of the bougie (when it practically becomes a divulsor, and 
 is very objectionable) or to a slovenly disregard of antiseptic details in the use 
 of urethral instruments. 
 
 Sometimes a few drops of blood will follow the withdraAval of the instru- 
 ment. Usually the next act of urination will be slightly painful, and often the 
 gleety discharge which has caused the patient to seek treatment will increase 
 for a day or two. The use of an instrument in this manner is always followed 
 by a slight and transitory hyperemia of the region about the stricture, during 
 which condition in many cases, particularly recent ones, appreciable softening 
 and absorption of stricture-tissue occur. This period lasts for from three to four 
 days, and only when it begins to subside should the instrument be reintroduced. 
 Ordinarily, an advance of one or two numbers of the French scale may be 
 made each time, but occasionally the same instrument must be introduced at 
 several sittings before it can be exchanged for a larger one. This should be 
 determined by the degree of resistance experienced during its introduction, the 
 pain which it excites at the time and subsequently, and the presence or 
 absence of bleeding. Personal experience soon becomes the safest guide as 
 to the degree to which dilatation may be carried at any particular sitting. The 
 feelings of the patient should always be consulted. When the full size has 
 been reached (following the table given above as an approximate guide), 
 the symptoms will usually disappear, and after this it is necessary only to 
 carry on the dilatation at longer and longer intervals to maintain the cure. 
 Most surgeons have no difficulty in teaching patients of average intelli- 
 gence to use such an instrument for themselves, and the great majority of 
 
 59 
 
980 AX AMERICAN TEXT-JiOOK OF SURGERY. 
 
 patients do so Avitliout the least discomfort or inconvenience. A certain [iro- 
 portion of cases under this plan of treatment will get entirely Avell, so that 
 years afterward no trace of stricture can l)e discovered. Others, if the inter- 
 vals between the introduction of the sound are too long, will have slight recon- 
 traction, shown possibly by a recurrent gleet; l)ut the rule is that with ordi- 
 nary care a practical cure is attained by this method in the great majority of 
 cases. Its advantages are obvious, and have for many years held for it the 
 first place in the estimation of those surgeons whose aim is to effect a cure, or at 
 least to cause the disappearance of all symptoms, while they at the same time 
 minimize the danger and inconvenience to the patient, who even in those cases 
 in which an entire cure is not brought about remains by this method master of 
 the situation. 
 
 In contrast to this are presented the claims of internal urethrotomy, 
 the merits of which are somewliat extravagantly vaunted by its advocates, 
 while its undoubted dangers are sometimes ignored. We do not by this mean 
 the danger to life itself, although that exists in a definite percentage of cases, 
 but rather the curvation of the penis, the excessive hemorrhage, the defective 
 expulsive power causing dribbling after urination, etc., which not infrequently 
 follow extensive urethrotomy. 
 
 It must be remembered that no special advantage is claimed for this opera- 
 tion unless it is extensive, the figures of Otis being usually adopted by the 
 practitioners who habitually employ dilatating urethrotomy in stricture of large 
 caliber. We are justified in saying that as applied to the class of strictures 
 under consideration (those of the deep urethra) the operation is not believed by 
 the profession nor by the majority of those having special experience in genito- 
 urinary disease to be either safe or curative. 
 
 (2) Strictures of Large Caliber occupying the Pendulous Ure- 
 thra. — In this region all the risks of cutting operations are much reduced, 
 and, if scrupulous attention to antiseptic details be observed, need scarcely be 
 considered. The probability of permanent cure seems also to be correspond- 
 ingly increased. These statements are borne out by the experience of many 
 independent and unprejudiced observers, and the greatest difterences of opinion 
 which exist at present as regards these strictures have reference rather to their 
 diagnosis, the frequency of their occurrence, and their pathological importance 
 than to their treatment. The physiological variations in the caliber of the 
 normal spongy urethra are considerable; and this fact, taken in conjunction 
 with the excessive estimate of what constitutes normality, serves to explain the 
 extraordinary number of strictures found in this region and operated upon by 
 a few practitioners. 
 
 As to the diagnosis of strictures of large caliber, even the bougie a boule 
 may be misleading if used in the deep urethra, on account of the normal points 
 of obstruction both to its introduction and to its withdrawal which are there met 
 with, while the urethrameter is similarly misleading in the pendulous urethra, 
 especially if its revelations are interpreted according to an unnecessarily large 
 standard. In the latter region the normal variations account satisfactorily for 
 a certain proportion of the statements of a few writers on this subject who 
 find an extraordinary number of strictures in this region. In the deep ure- 
 thra it has been necessary for them to account for their frequent discovery 
 of strictures, even in cases without antecedent history of venereal disease, by 
 constituting masturbation an active etiological factor. Some years ago it was 
 demonstrated that the "deep-seated stricture usually of large caliber found at 
 the subpubic curvature and its vicinity," and descrii)ed as "an essential lesion 
 of masturbation," was in reality the point of normal resistance to the with- 
 
SURGERY OF THE GEXITO-UJilXA R V TRACT. 931 
 
 drawal of biillious bouizics ottered ])y the posterior layer of" the triaiiguhir liga- 
 ment (White). 
 
 The prostatic urethra being at once more movable and more dilatable than 
 the membranous ])ortion, the bulb slips smoothly along it until the point is 
 reached at -which this layer of fascia closely embraces the posterior part of the 
 membranous urethra and the outer surface of the prostate. Here, for obvious 
 reasons, it is arrested, and it is at this moment that the deceptive sensation 
 which may he considered indicative of the existence of organic stricture is 
 communicated to the hand. A series of observations and dissections u}»on the 
 cadaver have established this view, and eliminated the possibility of the resist- 
 ance being due to a spasm of the compressor urethrae muscle, which surrounds 
 the canal at this point. Arrest of the instrument occurs as invariably after 
 death as before. Avoiding these errors, then, and accepting the lower scale 
 which has been given, the existence of strictures in the region under consider- 
 ation may be determined in the usual way. 
 
 As to treatment, internal urethrotomy is to be preferred when a stricture 
 of the pendulous urethra is of long standing, distinctly fibrous in character, or 
 non -dilatable. Resiliency or resistance to dilatation is indeed the chief indi- 
 cation for a cutting operation on strictures at any portion of the urethral tract, 
 and is far more important in determining the choice of treatment than their 
 caliber, but internal urethrotomy in the pendulous urethra is particularly satis- 
 factory on account of the comparative freedom from danger which has already 
 been mentioned. As to the probability of eff'ecting thereby a permanent cure, 
 while, as has been said, it is much greater here than elsewhere, such a cure can 
 be expected in only a limited proportion of cases. It is not in accord with other 
 pathological observations to suppose that the mere division of a dense and old 
 contractile band of fibrous tissue will result in its absorption ; and the majority 
 of the true strictures of the spongy urethra which are cured by internal ure- 
 throtomy are those in which the division of the stricture is supplemented by the 
 use for some time of full-sized bougies. The relief of tension aftbrded by the sec- 
 tion of the stricture gives full play to " inflammatory atrophic dilatation," and 
 in a certain pi'oportion of cases retrograde metamorphosis and absorption take 
 place or at least a thinning and weakening of the fibrous band, which results 
 in its practical disappearance as a cause of obstruction. It is probable, how- 
 ever, on both clinical and pathological grounds, that the great majority of 
 so-called strictures of the pendulous urethra which are cut by the extremists 
 in urethrotomy are merely points of physiological narrowing, and the so-called 
 "cures" are merely illustrations of the fact that by a linear incision into its 
 long axis we can put in the normal urethra a longitudinal splice of fairly 
 healthy tissue which has but little tendency to contract afterward, and can 
 thus more or less permanently enlarge the urethral caliber. This fact also 
 explains the freedom from fiital results claimed by some surgeons who find 
 strictures and do urethrotomies in the great majority of their cases of chronic 
 urethral discharge. As there has been no real interference with the genito- 
 urinary functions, there has been no development of renal or vesical disease, 
 and the urethra can be operated upon and the "splice" introduced with com- 
 parative impunity. It is difficult to see, however, how such a splice would 
 prevent the steady contraction of a mass of old cicatricial tissue, such as occu- 
 pies the wall of the canal and the peri-urethral space in strictures of some 
 standing. 
 
 The proportion of cases in which true strictures of large caliber in the 
 pendulous urethra require internal urethrotomy varies largely with the character 
 of the patients among whom the surgeon practises. In hospital and dispensary 
 
932 AN AMERICAN TEXT-BOO A' OF SURGERY. 
 
 services, and among the poorer classes generally, strictures quite frequently 
 will be found to have been neglected, and almost always will be of long stand- 
 ing before the patient presents himself for treatment, even if they are not 
 of small caliber. They will, therefore, recjuire urethrotomy in a much larger 
 percentage of cases than will be found among private patients of good social 
 position. Among the latter perhaps not more than one in eight or ten needs 
 such operative measures, gradual dilatation, as above described, amply suf- 
 ficing in the remainder to cause the disappearance of all symptoms, and some- 
 times of the stricture itself when it is soft and of recent formation. Indeed, 
 even in older cases a notable amount of absorption of the indurated band con- 
 stituting the stricture can often be observed, and its diminution from dav to 
 day can be verified by the touch when the urethra is stretched over a full- 
 sized sound. 
 
 The exact time at which a urethral coarctation becomes of definite patho- 
 logical importance is, as has been said, still unsettled ; but that strictures of 
 large caliber are occasionally the cause, not only of gleet, frequent micturition, 
 dribbling, and other urinary symptoms, but also of reflex pains and of impo- 
 tence and other forms of sexual disorders, is certainly true. 
 
 The increased friction and resistance resulting from even a slight fibrous 
 peri-urethral deposit disturb the normal relations of the bladder, and by 
 rendering it irritable bring on the symptom of frequent micturition. The 
 imperfect closure of the tube, the muscular action of which at the point of 
 deposit is materially interfered with, causes the equally imperfect expulsion 
 of the last drops of urine and produces another characteristic symptom, drib- 
 bling at the end of micturition ; the retention and decomposition of these last 
 drops, together with the abnormal friction between the stream of urine and 
 the urethral walls, give rise to a subacute inflammation of the mucous mem- 
 brane, accompanied by a catarrhal or muco-purulent discharge, constituting 
 the condition of gleet ; by reflex irritation transmitted from the area of inflam- 
 mation pains in remote organs and situations are developed, notably in the 
 lumbar and hypogastric regions. 
 
 This relation of cause and eff'ect has been in the main accepted as correct 
 by the profession for many years. The difl"erences of opinion which now exist 
 are chiefly as to the amount of urethral contraction which is sufficient to pro- 
 duce noticeable eff'ects ; and here the evidence must rest upon clinical observa- 
 tions supported by the results of autopsies. 
 
 (8) Strictures of the Meatus and of the Neighborhood of the 
 Fossa Navicularis. — In this region dilatation is peculiarly unsatisfactory. 
 Owing to the intimate relation between the spongy tissue of the glans and the 
 urethra, to the exceptionally rich nerve-supply to the part, and to the extreme 
 sensibility characteristic of muco-cutaneous outlets, the stretching of the stricture 
 by means of sounds gives rise to pain, irritation, and inflammation. For these 
 reasons, and on account of the absolute safety of the procedure, it is better to 
 divide all such strictures than to attempt to dilate them. But while the cutting 
 of true strictures in the anterior urethra is good surgery, the division of every 
 narrower point at the meatus and in the first few inches, simply Ijccause those 
 points are (as they should be normally) of smaller caliber than other ]»oints in 
 the canal, is routine surgery of a very unprofitable sort. 
 
 The operation of meatotomy is best done with a probe-pointed tenotome 
 with the usual convex cutting edge. The incisio« should be made upon the 
 floor of the urethra, and should be sufficient to remove entirely all sense of 
 resistance upon the withdrawal of a full-sized Inilbous bougie. It should be a 
 little larger than the caliber which it is desired to establish permanently, so as 
 
SURGERY or TIU-: GEXITO-URIXARY TRACT. 933 
 
 to allow for subsequent contraction. Like all other operations upon the ure- 
 thra, it should be done with scrupulous attention to antiseptic details. A short, 
 straight, conical bougie, the so-called meatus sound, should be gently inserted 
 once in twenty-four hours during the healing process. Deeper troubles, unless 
 urgent in their character, should be ignored until healing is complete. Some- 
 times, but much more i-arely tlian is generally supposed, such troubles, although 
 previously thought to be organic, will be found to have disappeared. In those 
 cases they have probably been due to reflex irritation, but this condition never 
 occurs except in conjunction with a pinhole meatus or with a distinctly stric- 
 tured condition of the urethra in its vicinity. The production of deep urethral 
 spasm as a result of the so-called anterior stricture of large caliber, either at 
 the meatus or elsewhere, is open to grave doubt. 
 
 (4) Strictures of Small Caliber (less than 15 French) situated in 
 advance of the bulbo-membranous junction. — Strictures of this cal- 
 iber in this region, unless seen very early and found to be unusually soft and 
 dilatable, furnish the typical condition for internal urethrotomy, that in which 
 it is attended with the minimum of danger and with the greatest prospect of 
 effecting a permanent cure. The operation may be performed with the instru- 
 ment which the surgeon happens to prefer, the essentials to success being a 
 linear division in the roof of the urethra of every portion of strictured tissue, the 
 incision extending from. the normal parts behind to the normal parts in front 
 of the stricture. If the contraction is of very small caliber, a Maisonneuve 
 urethrotome may be passed through it over a filiform guide, and a preliminary 
 urethrotomy done, so that one of the various forms of dilating urethrotomes 
 may be passed through it and the stricture freely divided from behind for- 
 ward. A bougie a boule should then be used to demonstrate the complete 
 division of the stricture, a large-sized gum catheter passed and tied in the 
 bladder, and bleeding controlled, if necessary, by the application of a firm 
 bandage. The moderate risk attending this operation is reduced to its smallest 
 proportion by the employment of sterilized instruments ; the use of urethral 
 irrigation before, and, if necessary, after, the operation ; the administration 
 of internal remedies which tend to sterilize the urine ; and attention to the 
 various details of antisepsis as applied to genito-urinary surgery. 
 
 A few days after the operation a full-sized bougie should be gently passed, 
 and should be used afterward, as in cases of dilatation, for some weeks. Often 
 it will be necessary to pass it at intervals for a much longer period. In a 
 fair proportion of cases an apparent cure follows. 
 
 (5) Strictures of Small Caliber (less than 15 French) situated at 
 or deeper than the bulbo-membranous junction. — The diagnosis of 
 these strictures, which are surgically most important, can be made either by 
 means of a bulbous bougie, if it is possible to pass one through them, or by 
 introducing a sterilized sound, well warmed and oiled, down to the anterior 
 face of the contraction. They will usually be accompanied by gleet and 
 marked vesical symptoms, increasing in severity with the tightness of the 
 stricture. The choice of treatment lies between dilatation and some form of 
 urethrotomy. Divulsion is so clumsy, so uncertain, and so dangerous as to 
 have to-day almost no advocates, and to enter into argument against it would 
 be therefore a waste of time. 
 
 In beginning the treatment of such a stricture as we are considering we 
 should attempt, first, with great gentleness, to pass through it a steel sound, 
 provided its introduction re([uires no force Avhatever. Below 8 or 10 of the 
 French scale we should not go, as a rule, in the use of metal instruments, as 
 in the most skilful and experienced hands there is a distinct and unavoidable 
 
i>34 ^.V AMi:in<AX TEXT- HOOK OF SVllOEHY. 
 
 danger of laceration of tlie inHanictl an<l degenerated mucous membrane around 
 the strictured region, and of tlie formation of a ''false passage" — i. e. of per- 
 foration of the urethral wall. If a sound (jf whatever size is passed through 
 the stricture, it should be allowed to remain for from five to ten minutes and 
 then withdrawn. If it is the first ex|»erience witli the patient, it is best to 
 avoid further instrumentation for from twenty-four to seventy-two hours, in the 
 mean time administering five-grain doses of salol or boric acid four times daily, 
 with a full dose of quinine night and morning. At the next sitting it is 
 often well to recommence with the same instrument, after which one, two, or 
 three larger sizes may be used in succession if their introduction is easy and 
 is not accompanied by pain or followed by bleeding. Pain and hemorrhage are 
 unmistakable indications for lengthening the intervals and for proceeding with 
 greater slowness in the use of larger instruments. 
 
 Once fairly established, however, the treatment by dilatation is carried on 
 as described above, the full normal caliber being usually reached in two or 
 three weeks. If the stricture is not resilient or irritable or traumatic in its 
 origin, it will be found that all symptoms have disappeared, unless, perhaps, 
 the gleet persists for a time, but this, too, will finally subside. If the stricture be 
 a recent one, it also may undergo absorption, but in any event the occasional in- 
 troduction by the patient of a steel sound will always keep the case under control. 
 
 In the case of resilient, irritable, or traumatic stricture in this region, or 
 of stricture which for any reason, as the occurrence of rigors, is non-dilatable, 
 external ])eriiieal nrethrotomy is the operation of choice. 
 
 (6) Strictures of the Deep Urethra permeable only to Filiform 
 Bougies. — In certain cases no steel sound and no ordinary soft instrument can 
 be made to pass the stricture, but a persevering trial with filiform bougies made 
 of whalebone will result in the pa.ssage of one into the bladder. This trial 
 should be made persistently and patiently, and in the absence of retention of 
 urine may be repeated on successive occasions. At the first sitting, if a fili- 
 form having been passed down to the stricture refuses to enter it. it should be 
 withdrawn and bent to an angle of 45° bv Ijcnding it across the thumb-nail from 
 one-quarter to one-third of an inch from the end (Fig. 8(57). The orifice of a 
 tight stricture is frequently not in the middle of the obstructed urethi-a, but is to 
 be found at some point around its circumference ; and the little manoeuver above 
 described will often enable the surgeon to enter it when with a perfectly straight 
 filiform he cannot do so. If this does not succeed, several filiforms should be 
 passed by the side of the first one, so as to impinge upon the irregular ante- 
 rior face of the stricture at a number of points. By attempting to pass first 
 one and then another of these, the instrument bearing the right relation to 
 the orifice will often be found and passed into the bladder. If this fails, or if 
 one filiform can merely be engaged in the stricture, but cannot be made to 
 pass through it, it is proper, in the absence of retention, to tie it in jilace and 
 allow it to remain in situ for twenty-four hours. In the great majority of cases 
 at the end of that time it can be passed with comparative ease into the bladder. 
 There is no objection to still longer delay or to repeated trials if no urgent 
 symptoms be present. 
 
 After the first instrument is introduced in such a case, four courses are 
 open to the surgeon : (1) lie may allow it to remain in place, with the cer- 
 tainty that in one or two days others may be sli|)pe(l alongside of it, and may 
 be used as guides for the introduction, first, of a tunnelled catheter, and later 
 of the ordinary soft or steel bougies; (2) he may attempt to conduct a tun- 
 nelled catheter over it into the bladder at once, to be followed by gradual 
 dilatation ; (3) he may conduct over jt a tunnelled and grooved staff and pro- 
 
sc/!<; /■:/:)■ or ////■: (;/:\/To-r/u\A/n' t/^act. 935 
 
 ceed to tlie pcrfonnanof of external j»eriiieal iiietlircttdiuy ; (4) lie may use it 
 as a guide for a Maisonneuve urethrotome, an<l may immediately perform in- 
 ternal urethrotomy. 
 
 These procedures have hccii menti(»ned in the ftrder of preference and of 
 safety. If the stricture which is heing dealt with is not of traumatic origin 
 and is not known to be specially resilient or irritable, the first method will 
 lead up to the adoption of gradual dilatation, with the greatest degree of com- 
 fort and absence of anxiety to both patient and surgeon. Even if there has 
 been moderate retention, it is absolutely certain that the urine will pass with 
 increasing freedom by the side of the filiform, and that the danger of the case, 
 so far as retention is concerned, is at an end. If retention has been complete 
 for a long time and is threatening, and the need for immediate relief is marked, 
 it is well to adopt the second method and endeavor to catheterize at once. 
 Failing in this, the third procedure should be employed in all cases of urgency 
 and in all cases of traumatic, resilient, or irritable stricture, as well as in cases 
 in which there is a history of fre(iuent rigors after instrumentation. The ope- 
 ration is simple, is easily performed, and has a very small mortality. If the 
 median line of the perineum be rigidly followed, hemorrhage is insignificant, 
 and in no event is likely to be dangerous. The stricture is freely divided, 
 and, although not frequently cured, may be left, as in a successful dilatation, 
 entirely under the control of the patient and the surgeon, the urethra having 
 been restored to its full caliber. The fourth procedure should be employed 
 onlv in those cases in' which the patient refuses to have the external operation 
 performed. It is attended in the best hands with a distinctly larger mortality 
 than any of the other methods mentioned, and there is no reliable evidence 
 that it is followed by any larger percentage of permanent cures. 
 
 (7) Impassable Strictures of the Deep Urethra. — If the methods 
 of procedure which have been described are adopted, very few strictures will 
 fall into this class, but occasionally, in spite of the most persistent efi"orts, no 
 instrument can be made to enter the bladder. Sometimes the distended and 
 chronically inflamed urethra behind such strictures will have given way and 
 permitted the leakage of a greater or less quantity of urine into the surround- 
 ing structures. In either of these events the operation of perineal section 
 becomes imperatively necessary. 
 
 There has alwavs been more or less confusion in the nomenclature of the 
 perineal operation for the relief of strictures. The old '* houtonniere opera- 
 tion " of Desault (of which the so-called " Cock's operation " is a modifica- 
 tion) had for its object the establishment of an opening from the perineum 
 into the bladder, was usually effected by opening the urethra behind the 
 obstruction, Avas purely palliative, and, if it ever resulted in a cure, did it by 
 accident, as the procedure itself did not include of necessity any division or 
 enlargement of the strictured portion of the canal. It was an " external 
 urethrotomy," to be sure, but it was not related either in its purpose or in 
 its method to the other operations known by that name. Since Syme revived 
 and popularized the operation of external urethrotomy — the division of a 
 stricture upon a grooved staff pa.?sed through it into the bladder — more system 
 has been introduced into the terms employed, but there is still much objection- 
 able looseness. Hunter, Grainger, C. Bell, and others had, before Syme's 
 time, formulated the operation known as ^'■perineal section," which was also 
 an external urethrotomy, but which was then restricted to those eases in which 
 no instrument whatever could be made to pass the stricture. The term should 
 still be reserved for such ca.ses, and on account of its brevity is, perhaps, pref- 
 erable to its synonym, "external perineal urethrotomy without a guide." 
 
936 .l.V A.VERICAN TEXT-JIOOK OF SURGERY. 
 
 As to the symptoms of extravasation ^vllicll indicate the immediate 
 performance of this operation, the urethra may be divided into four re<rions. 
 In all that part from the meatus to the scrotal curve extravasation is accom- 
 panied by a swelling of the penis, greatest in the immediate neighl)orhood of the 
 point of escape. In the region included between the attachment of the scrotum 
 and the anterior part of the bull), the course of extravasated urine is governed 
 by the attachments of the deep layer of the superficial fascia or the fascia of 
 Colles. Extravasation of urine occurring through a solution of continuity in 
 the bulbous region of the urethra will first follow the space enclosed by this 
 fascia in front and below and by the anterior layer of the triangular ligament 
 posteriorly, and, as it cannot reach the ischio-rectal space on account of the 
 attachment of the fascia to the base of the ligament, and cannot reach the 
 thighs on account of the insertion of the fascia into the ischio-pubic line, it is 
 directed into the scrotal tissues, and thence up between the pubic spine and 
 symphysis until it reaches the abdomen. 
 
 Fig. 371. 
 
 
 A'i*" 
 
 
 The Fascia of the L'rethra, Prostate, and Bladder : r, rectum ; s, symphysis pubis ; b, bladder ; p, prostate 
 
 (Macalister). 
 
 If it escapes from the membranous urethra, the extravasated urine will 
 be confined to the region included between the layers of the triangular liga- 
 ment, and will gain access to other parts only after suppuration and sloughing 
 have given it an outlet, and the consecutive symptoms will then depend upon 
 the portion of the aponeurotic wall which first gives way. If the opening is 
 situated behind the posterior layer of the triangular ligament — i. e. in the pros- 
 tatic urethra — the urine either may follow the course of the rectum, making 
 its appearance in the anal perineum, or, as it is separated from the pelvis only 
 by the thin pelvic fascia, may make its way through the latter near the pubo- 
 prostatic ligament, where it is especially weak, and may spread rapidly through 
 the subperitoneal connective tissue. Fig. 371 shows the fascire influential in 
 dii'ecting extravasated urine. 
 
 Urethral Fistul.*;. — The extravasation of urine behind a stricture may 
 
SURGERY OF THE GENITO- URINARY TRACT. 937 
 
 be small in amount and may take place almost unol)serve<l by the patient. 
 At first a mere leakage of a drop or two of urine, it later causes suppuration 
 in the peri-urethral tissues, and there results an abscess, which, if it breaks 
 externally, causes, according to its location, a urethro-penile, urethro-perineMl, 
 or uri'thro-rcctaJ fistula. Other causes may operate to produce these condi- 
 tions, but stricture is by far the most common. The diagnosis is usually easily 
 made by observation of the exit of urine through the abnormal channel, and 
 by careful probing from without inward through the fistula while a steel sound 
 is in the urethra. The treatment when the stricture is passible consists, first, 
 in restoring the normal caliber of the urethra, and then curetting or laying 
 open the fistulous tract ; after which the urine should be drawn either by 
 means of a retained catheter or by regular catheterization. 
 
 Perineal Section. — In the presence of retention or extravasation of 
 urine in a case of stricture in which catheterization is impossible there can be 
 no doubt as to the proper procedure. Immediate perineal section is so evi- 
 dentlv the only operation which meets all the indications that no other can be 
 seriously considered. The steps of the procedure are obvious and beyond dis- 
 pute, except as to a few points which may be mentioned. 
 
 In all cases in which perineal section is performed for stricture impass- 
 able, but without other complications, the method of Mr, Wheelhouse of 
 Leeds seems to meet every indication. The passage of the staff" to the 
 stricture shows the exact site of the latter ; the insertion of the threads into 
 the divided urethra not only serves to hold it open and give an opportunity 
 for the discovery of the proximal portion, but also fixes the anterior end and 
 renders it easily recognizable during the operation. The least useful direction 
 which Mr. Wheelhouse gives is that of turning the staff" with the concavity of 
 the curve upward, so as to hook it into the upper portion of the urethral wound. 
 The instrument is sometimes in the way, has to be held by an assistant, and 
 does not aff"ord much help during the operation. 
 
 If persevering search fails to reveal the proximal end of the ui'ethra in 
 cases of traumatic stricture with practical obliteration of the canal, are supra- 
 pubic cystotomy and retrograde catheterization justifiable? This may be 
 answered affirmatively, though such failure should be very exceptional. If 
 the bladder contains urine, and particularly if it is distended, pressure on the 
 hypogastriura, or bimanual pressure with the fingers of one hand on the abdo- 
 men and of the other in the rectum, will often cause a jet of urine to issue 
 from the proximal end, and thus at once disclose its situation. Hemostasis in 
 the whole wound by very hot water will sometimes reveal the urethra by 
 emphasizing the difference between its color and the surrounding parts, the 
 urethra generally being much paler. The relation to the pubes and to the 
 lower edge of the triangular ligament should be most carefully borne in mind, 
 the search for the torn end in ruptures or for the portion behind the stricture 
 in those cases being frequently carried too near the pubes. The membranous 
 urethra in the adult usually runs through the ligament about one inch below 
 the symphysis and about three-quarters of an inch above the perineal center. 
 All guides, however, fail occasionally in certain of these cases, and it is then 
 that suprapubic cystotomy is warranted, as an operation with so small a mor- 
 tality that the slight additional risk is far outweighed by the advantages to 
 the patient of having even an imperfect restoration of the urethral canal. 
 
 Much difference of opinion exists as to the value of a retained catheter 
 after perineal operations opening the urinary tract. Many authorities advise 
 that in cases of section for stricture no instrument be employed, or that, 
 at most, a short perineal drainage-tube be used. Others direct that it be 
 
iK]H AX AMr.L'icAX TEXT-iujoK (jF sri:(;i:ny. 
 
 kt'j>t in fur forty-eight hours and then withdnuvn. The retained catheter is, 
 however, of great value in all operations connecting the bladder with the 
 surface of the body, not excepting certain cases of lithotomy witli purulent 
 cystitis. If Spence's caution is observed and it is not allowed to fjroject far 
 into the bladder, and if it is kept clean and sweet by regular antiseptic injec- 
 tions, it is of tlic utmost advantage in aiding in the prevention of urethral 
 fever, as has been shown by Keyes, Harrison, Diday, Shield, Davies, Hill, 
 White, and many others. Of equal importance is regular catiieterization at short 
 intervals, begun after the removal of the catheter first introduced. A decided 
 febrile movement after urethral operations will often disappear or reappear 
 in accord with the employment or the neglect of the catheter. The traumatic 
 urethritis to wliich the retained catheter or the frequent use of the instrument 
 is said to give rise will almost disappear from one's practice if antiseptic irri- 
 gation is employed in such cases, and particularly if especial attention is paid 
 to the sterilization of the urine by the internal administration of antiseptics. 
 The sterilization of urine by boric acid or by salol is of great in.portance in 
 the after-treatment of all these cases, and should never be omitted. These 
 remedies are more effective if combined with full doses of quinine, but either 
 of them is far more useful than quinine alone. They should be given with 
 more freedom and more regularity in urethral and vesical operations. 
 
 The conclusions as to the treatment of organic strictures of the urethra 
 may be summed up as follows : 
 
 1. Strictures of large caliber — tliat is, more than 15 French — situated at 
 or behind the bulbo-membranous urethra are to be treated, almost without 
 exception, by gradual dilatation. 
 
 2. Strictures of large caliber occupying the pendulous urethra are to be 
 treated by gradual dilatation wlien very recent and soft, and by internal 
 urethrotomy when of longer standing, distinctly fibrous in character, or non- 
 dilatable. It is to be I'emembered that the great majority of so-called strictures 
 of large caliber of the pendulous urethra are merely points of physiological 
 narrowing. 
 
 3. Strictures of the meatus and of the neighborhood of the fossa navicu- 
 lars should be divided upon the floor of the urethra wlienever it is evident 
 that they are real pathological conditions producing definite symptoms, and 
 not normal points of narrowing. 
 
 4. Strictures of small caliber (less than 15 French) situated in advance 
 of the bulbo-membranous junction, unless seen very early and found to be 
 unusually soft and dilatable, furnish the typical condition for internal ure- 
 throtomy, which should be done preferably with a dilating urethrotome, and 
 invariably Avith all possible antiseptic precautions. 
 
 5. Strictures of small caliber (loss than 15 French) situated at, or deeper 
 than, the bulbo-membranous junction should be treated Avhenever possible by 
 gradual dilatation. In a case of resilient, irritable, or traumatic stricture in 
 this region, or of stricture which, for any reason (as the occurrence of rigors), 
 is non-dilatable, external perineal urethrotomy is the operation of choice. 
 
 6. Strictures of the deep urethra permeable only to filiform bougies should 
 be treated by gradual dilatation when possible, the filiform being left in xitti 
 for some time, and followed by the introduction of others or used as a guide 
 for a tunnelled catheter. If the stricture be not suitable for dilatation, exter- 
 nal perineal urethrotomy should be performed. 
 
 7. Impassable strictures of the deep urethra always require the performance 
 of perineal section. 
 
suiKiEnv or Till': ajJXiTo-cjijyAny tract. 
 
 939 
 
 PART IV— DISEASES OF TIIP: PROSTATE GLAND. 
 
 Anatomy. — Tlio prostate, "whicli l)oth in structure and in function is rather 
 a muscle tluin a gland, is situated at the neck of the bladder and around the 
 first inch of the urethra. It is composed chiefly of unstriped muscular fibers, 
 the inner or circular layer of Avhich is continuous in front with those surround- 
 ing the membranous urethra, and behind with the muscular coat of the blad- 
 der. An outer layer beneath the fibrous capsule forms a sheath for the gland, 
 while between them the glandular structure is imbedded. This is composed of 
 a number of follicles lined with columnar epithelium and emptying by from 
 fifteen to twenty excretory ducts in the floor of the prostatic portion of the 
 urethra. It is divided into two lateral lobes by a deep notch behind and by 
 a furrcw at the upper and lower surfaces. The so-called middle or third lobe is 
 the portion which is between the tAvo lateral lobes at the under and posterior 
 part of the gland just beneath the neck of the bladder. The uretlira usually 
 passes through the gland at about the junction of its upper and middle thirds. 
 The ejaculatory ducts traverse it. Its chief function is genital and ejaculatory. 
 It contracts at the beginning of the sexual orgasm, after the semen has dis- 
 tended the prostatic sinus, and forces it out in jets or spurts. It is supported 
 
 Vertical Section of a Male Pelvis : a, rectus abdominis muscle ; h, bladder ; c, symphysis pubis ; d, suspen- 
 sory ligament of penis ; e, dorsalis penis vein;./', Cowper's gland; g, rectum; h, rectum; i, seminal 
 vesicle; k, ejaculatory duct; I, prostate; m, transverse perineal muscle; n. external sphincter ani; o, 
 internal sphincter ani; p, internal sphincter ani; q, external sphincter ani (Braune;. 
 
 and held in position by the posterior layer of the triangular ligament, the 
 deep layer of the perineal fascia, and the pubo-prostatic ligament. It is in 
 
IMO 
 
 ,i.v AMHL'K .\.\ riixr- HOOK OF sri:<;i:i:y. 
 
 fcliition \vitli till' j)ubt's in front and the rectiiiii bi'liind. It is iiljont tlic >i/.u 
 of ii liurse-cbe-stnut, iiiid weigLs a lialf-ounce (Fig. 'JT-j. 
 
 Vui. -MW. 
 
 Vertical Section of Pelvis in a Case of I'njstatic Hyijertrophy : P, firostatc ; D, openings of vesical diver- 
 ticula; I ', bladder (Koenigi. 
 
 Wounds of the Prostate are very rare. They occur occasionally in 
 penetrating wounds of the perineum or of the rectum, but are then usually 
 secondary in importance to more serious injuries. The gland is of course 
 wounded during the performance of lithotomy, but unless the incision extends 
 beyond its capsule no evil results follow. Whenever that is opened there is 
 great risk of pelvic cellulitis and peritonitis. 
 
 Atrophy of the Prostate has been said to occur after wasting disease, 
 after double castration, and as a result of old age. The condition has no 
 recognizable symptoms. 
 
 IIypertuophy of the Prostate. — In about one-third of all males who 
 have passed middle life some enlargement of the {)rostate has taken place. In 
 about one-tenth of all males over fifty-five this enlargement becomes of patho- 
 logical importance. 
 
 Pathology. — The hypertrophy varies in some of its features, but as a rule 
 consists of a general enlargement of the gland in all directions, together with 
 the development within it of separate tumors resembling uterine fil)ro-myomata. 
 The increase in size is due to overgrowth of the fibrous and muscular constit- 
 uents of the organ, the glandular elements remaining almost unaifected. The 
 
(JEMTO-rKlNAKY DISEASES. Pi.ATK XXI, 
 
 2. Hypertrophy of the median lobe of the prostate (Watson). 
 
SUnaKIiV OF THE iiKXlT()-l'RI.\'M:Y TliACT. i)41 
 
 size and shape of tlu- j)rostate gland itself" and of the tumors it contains vary 
 exceedingly. Either the lateral lohes or the median lobe may enlarge more 
 than the rest of the gland (I'l. XXI, Fig. 2, and PI. XXII) ; the latter may 
 constitute a bar extending up into the bladder and blocking the orifice; the 
 former may compress the urethra into a mere slit or chink, may elongate it so 
 that the prostatic portion measures three or four inches, or may twist and distort 
 it so thr t the most Hexil)le instrument can only with difficulty be made to traverse 
 it. Tne tumors may be no larger tlian a pea or may be of the size of a child's fist. 
 
 As the prostate grows certain changes in the bladder occur. The apex of 
 the prostate is held in place by the triangular ligament. As the gland enlarges, 
 therefore, it does so in a backward direction, carrying with it the neck of the 
 liladder. If the growth is uniform, the bladder simjdy falls into a pouch ante- 
 riorly between the prostate and the pubes, and into another and larger one 
 posteriorly, in front of the rectum. 
 
 If the growth is confined chiefly to the median lobe, it may act, as has 
 been said, as a valve, and serves to obstruct the internal orifice very consider- 
 ably (PI. XXI, Fig. 2). 
 
 In cases of sudden obstruction without much antecedent irritation the blad- 
 der is apt to undergo dilatation and atony : if the obstruction is of slow develop- 
 ment and has been accompanied, as it often is, by congestion of the vesical 
 neck, hypertrophy of the muscular walls takes place : they thicken, and the 
 bladder contracts, and- may become pouched or sacculated, as in the presence 
 of any other obstructive cause. 
 
 McGill classifies tlie various forms of the intravesical growth — tliat which 
 produces urinary symptoms — into (1) a projecting middle lobe, pedunculated 
 or sessile ; (2) an overgrowth of the middle lobe and of the two lateral lobes, 
 forming three distinct intravesical projections (Plate XXII) ; (3) enlargement 
 of the lateral lobes only ; (4) a uniform collar-like projection encircling the ori- 
 fice of the urethra. It is only in about 50 per cent, of cases of hypertrophied 
 prostate that urinary troubles manifest themselves. In the others, the growth 
 not belonging to one of the above varieties, there is but little interference with 
 the functions of the bladder. 
 
 Symptoms. — Often the earliest symptom of prostatic disease is the 
 increased frequency of urination, most marked at night. This may precede 
 anv enlargement appreciable through the rectum or recognizable during cathe- 
 terism. It arises from the congestion of the plexus of large veins at the neck 
 of the bladder, the return circulation through which is interfered Avith by the 
 prostatic overgroAvth. To this general congestion of the region of the prostate 
 may also be attributed the unusual and occasionally unnatural sexual desires 
 of old men. A patient with prostatic hypertrophy may not notice much increase 
 in the frequency of micturition during the day, but at night he Avill be com- 
 pelled to get up more and more often as the obstruction increases and as the 
 walls of the bladder gradually become less able to overcome it. After a time 
 a more or less considerable quantity of urine is always retained within the 
 bladder, and the patient is able only to pass that w^hich is in excess. This 
 retained or " residual " urine may remain stationary in amount, but more fre- 
 quently will gradually increase until in some cases, in which both the hyper- 
 trophy of the prostate and the atony of the bladder are marked, only an ounce 
 or two can be evacuate<l spontaneously, although catheterism will show that the 
 bladder contains possibly a pint or more. 
 
 From the same cause arises the characteristic enfeeblement of the stream, 
 w^hich, instead of being projected away from the body, will drop perpendicularly 
 toward the feet of the patient. 
 
942 .l^V AMr.h'K'AX TKXT-IK )()K O/' sriiCEUY. 
 
 Those symptoms contimie for :iii imlcfiiiitc |»(.'rio(l. ami in some cases, 
 after reaching a certain intensity, fail to increiuse in severity, especially if l)y 
 aseptic catheterism the residual urine is periodically withdrawn. In others, 
 however, a subacute prostate-cystitis supervenes, either froTu infection throii<rh 
 the urethra or by means of the catheter, and then tlie symptoms felt are most 
 distressinir. The desire to urinate is nearly constant, and the act is accompa- 
 nied with burning ])ain and tenesmus : it may be ff)llowed each time l)y a sliglit 
 hemorrhage; rest at night is interfered with ; the general strength fails from 
 the continual suflering ; the urine becomes fetid, animoniacal. and reduce<l in 
 quantity; pyelo-nephritis develops; general sepsis occurs; and the patient 
 dies uremic and comatose. 
 
 Diagnosis. — In determining the existence ami the degree of 'prostatic 
 enlargement a systematic course should be followed. The patient should 
 always lie recumbent, with the knees drawn up and separated. The rectal 
 examination may conveniently l)e made first. The under surface of the gland 
 is gently palpated, the outlines recognized, the degree of projection into the 
 rectum and tlie longitudinal enlargement estimated. It may be found regular, 
 rounded, and uniforndy increased in size, or it may be nodulated and uneven. 
 It will usually be enlarged in both directions, so that the lateral borders are 
 approximated to the pubic and ischiatic rami, and the finger fails to reacb the 
 base or upper limit of the gland. Ordinarily it is insensitive, but occasionally 
 there is tenderness on pressure. 
 
 After completing this examination, the patient, who should previously have 
 urinated, is catheterized. It will be found that there is a greater or lesser 
 amount of residual urine : tliat the shaft of the instrument enters the urethra 
 to an unusual depth ; and that the handle must be depressed between the thighs 
 more than ordinarily before the point of the catheter can be made to enter the 
 bladder. Sometimes an instrument of the usual length and curve will not 
 reach the bladder at all ; and this explains the occasional failure of attempts 
 at catheterism for retention due to enlarged prostate. 
 
 The symptoms due to acute proHtatitia have already been detailerl, and, 
 together with the history of urethral infection, will serve to differentiate the 
 two conditions. The age of the patient may also serve to exclude hypertrophy. 
 
 Malignant disease may be suspected if hemorrhage is a predominant symp- 
 tom and if the growth is especially irregular in shape and uniform in consistence. 
 
 Tulierch of the ])rostate is almost always associated with tuberculosis of 
 some other portion of the genito-urinary tract. By collecting the urine for 
 twenty-four hours, permitting it to settle, and carefully examining the sediment 
 the presence of bacilli can usually be demonstrated. 
 
 Treatment. — In most cases of prostatic enlargement the best two guides 
 to the surgeon are afforded by the degree of disturbance at night and the 
 amount of residual urine. If the patient sleeps well, is obliged to empty the 
 bladder only once or twice between evening and morning, and has but one or 
 two ounces of clear residual urine, the treatment should be hygienic and 
 general, and local interference should be avoided. Great care should be taken 
 to avoid chilling of the surface ; the diet should be light and digestible ; alcohol 
 should be used not at all or in great moderation ; malt liquors and champagne 
 should be interdicted ; the bladder should be emptied at regular intervals ; 
 constipation and straining at stool should be especially avoided. If. however, 
 the patient rises three or four or more times at night to urinate, and if the 
 residual urine amounts to several ounces, systematic catheterism should begin 
 at once. The evils of delay are greater than those associated with the use of 
 the instrument. The amount of residual urine will usually increase, as will 
 
dioxiTo-riMXAKN' i)isi:.\si<:s. 
 
 I>LATK XXII. 
 
 General Enlargement of the Prustate (White and Wood). The divided surfiiees of the supra-uretliral 
 portion and the large median lobe sliow well. Catheterization was possible in this case only with a 
 metal prostatic catheter, the point of which invariably turned to the patient's left on entering the blad- 
 der; profuse bleeding always followed the introduction of the instrument. A, point in middle lobe 
 against which the catheter impinged and from wliich tlie hemorrhage came ; B, verumontanum. 
 
sri!(ii:in' or the aKxiro-rniXAin' tract. 9t;3 
 
 the vesical atony, the risks ot" renal cvunjjlications are greater. an<l Avlien, 
 finally, the use ot" the eathetcr hcconies iiii|»('rative. tliere is far greater danger 
 than if it hud heen begun earlier. 
 
 The fretiueney with uhieh tlie catheter slutuld he used is ))ro|)ortionate 
 to the (juantity of residual urine and the urgency of the symptoms. As a 
 rule, where the urine does not exceed three fluidounces in amount and is not 
 turhid or bad-smelling, tlie use of the instrument at bedtime will be sufficient. 
 If, however, the urine is ammoniacal, or if it is of larger amount, or if the 
 patient urinates with some pain and greater frecpiency, it may be well to 
 cathererize two. three, or even four times daily. Experience and familiarity 
 with the special needs of each particular case must decide this question. No 
 drugs have the slightest effect upon the hypertrophy itself, but those which 
 render the urine aseptic will be found valuable adjuvants in these as in nearly 
 all other surgical diseases of the genito-urinary tract. It may be necessary to 
 combine Avith them in certain cases the bromides, belladonna, or small doses of 
 opiates, but tliese should always l)e regarded as necessary evils, to be used only 
 in exceptional cases or in times of emergency, and to be thrown aside as soon as 
 they can be dispensed with. 
 
 There are cases, however, in which catheterism fails to meet the indications. 
 Either in spite of it or because of it the symptoms increase in severity, the 
 general condition beconjes more alarming, and it is apparent that the patient 
 will die exhausted if further relief is not given ; or the same condition may 
 arise in cases of complete retention of urine with cystitis and with extremely 
 difficult or painful catheterism. Under these circumstances treatment may 
 still continue to be palliative, and may consist in opening the bladder through 
 the perineum by means of an incision like that for median lithotomy. 
 
 Occasionally it will seem wise to make drainage by means of a supra- 
 pubic puncture, and Hunter McGuire and others have shown that it is pos- 
 sible to do this by establishing a small, permanent fistulous opening running 
 obliquely upward, and to retain considerable power over the urine. The 
 suprapubic incision has the advantage also of permitting, better than that 
 through the perineum, the thorough exploration of the bladder and prostate, 
 and, if necessary, the employment of more radical methods. 
 
 Prostatectomij. — In selecting an operation for the more permanent relief 
 of the condition it is Avell to remember that the severity of the symptoms in 
 any case has no definite relation to the extent of the enlargement as felt 
 through the rectum, but depends rather upon the presence and the extent of 
 one or the other of the varieties of intravesical growths described on p. 941. 
 
 Such a growth having been diagnosticated, it may be approached and 
 removed in one of three ways (Treves) : 1. By perineal incision. The perineum 
 and bladder are opened as in median lithotomy (p. 873): the projection is 
 recognized with the fingers and enucleated with the help of a curette or seized 
 by a pair of forceps and twisted or torn away. Watson has shown that in 
 two-thirds of prostatic cases appropriate for radical treatment the intravesical 
 growth lies at a distance of three inches or less from the perineum, and that 
 therefore any one possessing an index-finger of the length of three inches may 
 be able to attack them successfully. This, however, leaves one-third of all 
 such cases which cannot be reached after the operation has begun — a weighty 
 objection to this treatment. In a number of instances pedunculated growths 
 or projecting portions of lateral lobes have been seized and removed during 
 the performance of perineal lithotomy. But these were accidents, and in most 
 of them the removal was incomplete so far as its effects upon the obstructive 
 symptoms were concerned. 
 
944 jy A.vr:ni('AX TExr-nooK or^ surgery. 
 
 2. By suprapubic incision. In this operation the bladder is readied and 
 opened just as in a suprapubic lithotomy- McGill has enumerated as follows 
 the special points of technique : (1) The (juantity of water thrown into the rec- 
 tal bag should be smaller than usual, rarely more than from six to ten ounces. 
 {'2) Preliminary irrigation of the bladder should be continued until the fluid 
 returns perfectly clear. (3) The (juantity of fluid left in the bladder varies 
 from ten to twenty ounces. (4) In cases where contraction of the bladder is 
 combined with Iiypertrophy of the walls the operation is contraindicated. (5) 
 A catheter left in the bladder until the latter is opened facilitates the opera- 
 tion. (6) The linea -alba is opened by an incision directly upon the symphy- 
 sis, and afterward divided upward u))on a director. (7) Before beginning 
 the removal of the prostate the Idadder must be secured by passing a suture 
 through each lip of the wound and stitching it to the wound in the abdominal 
 wall. A third suture between the lower angle of the vesical wound and that 
 of the abdominal Avound is thought to aid in preventing urinary extravasation 
 into the pre-vesical space. (8) In the case of a pedunculated middle lobe the 
 pedicle may be divided with curved scissors. A sessile middle lobe may require 
 in addition some avulsion by forceps. The collar ])rojection should be divided 
 into two lateral halves by passing one blade of a pair of scissors into the ure- 
 thral orifice and cutting the portion above it, repeating the procedure for the 
 lower segment, and then enucleating with the scissors and fingers. (9) When- 
 ever possible, enucleation with the finger should be preferred to cutting with 
 sharp instruments, the mucous membrane over the ])rojecting portion having 
 first been divided Avith scissors. (10) Hemorrhage should be arrested by irri- 
 gation with very hot (almost scalding) water. (11) The operator should ascer- 
 tain that the urethra is entirely patent at the end of the operation, by inserting 
 the forefinger as far as the first joint into the canal. (12) A large drainage- 
 tube should be left in the bladder for forty-eight hours. The wound should 
 be united above the tube by a deep and a supei'ficial row of sutures. (13) 
 Irrigation with boric solution may be required as part of the after-treatment. 
 
 5lcGill has removed portions of the prostate weighing in one case seven 
 ounces and in another two and a quarter ounces. White of Philadelphia 
 removed in one case a mass Aveighing three ounces. 
 
 In any case where, after a suprapubic prostatectomy, the urethral canal is 
 not ordinarily patent, the operation may be supplemented by median perineal 
 urethrotomy, by means of which growths in the prostatic urethra or in the 
 suburethral prostate can be dealt witii. 
 
 The results of experience thus far seem to show that the operation of 
 prostatectomy is justifiable in some cases of hypertrophied prostate in which 
 catheterism is difficult or impossible or excessively painful, and in which a 
 high grade of cystitis has developed and septicemia or uremia is imminent. 
 The prognosis is unfavorable in proportion to the duration of the obstructive 
 symptoms and the size of the mass which it is necessary to remove to secure 
 patency of the urethra, and is, of course, much influenced by the condition of 
 the kidneys. 
 
 Double Castration for Hypertrophy of the Prostate. — White's 
 Operation. — In June, iJ^U-j, White, as the result of researches begun a year 
 previously, suggested in a paper before the American Surgical Association 
 that castration might produce atrophy of the enlarged prostate, and might 
 thus be a valuable method of treatment. His theory had resulted from a con- 
 sideration of the apparent analogy between the uterine and prostatic fibro- 
 myomata, but was further based upon a series of experiments on dogs (which 
 showed rapid atrophy of the prostate folloAving castration), on some physiolog- 
 
SURQEEY OF THE GEXJTO-URINARY TRACT. 945 
 
 ical observations of" John Hunter on the lower animals (corroborated by 
 Griffiths), iiiid on some sciittored cases in surgical literature showing a shrink- 
 ing of the prostate after castration for various causes, and strengthening the 
 opinion previously formed. Since the publication of his paper many cases 
 have been reported, the large majority having been extremely successful. It 
 is too soon yet to speak with authority as to the precise limitations or the exact 
 risks of the operation. It may be said with much confidence, however, that 
 in a considerable proportion of all cases of enlarged prostate castration will be 
 followed by a rapid diminution in the size of the gland, and a coincident dis- 
 appearance of many — sometimes of all — the obstructive symptoms. More- 
 over, with the ability completely to empty itself the bladder has in a number 
 of cases regained a healthy state of the mucosa, previously the subject of 
 infective inflammation, and with the return of normal micturition all the symp- 
 toms of confirmed cystitis have disappeared. Sir Joseph Lister has noted the 
 fact that the rapidity with which relief has followed this operation has in 
 many of the reported cases been as remarkable as the degree of improvement 
 itself. 
 
 Griffiths, who eighteen days after double castration examined the enlarged 
 prostate of a patient who died of popliteal thrombosis and gangrene, has 
 shown that changes were then taking place which were obviously preliminary 
 to "the conversion of- the prostate into a small, firm, fibrous mass containing 
 only remnants of the tubules and but few traces of its muscular fibers." Kirby 
 has found the beginning of these changes in the prostate of a patient castrated 
 during an advanced stage of uremia, and who died within three days. Other 
 reports of similar character have been published. Moullin says : " Removal 
 of the testes is followed in a large proportion of cases, if not in all, by complete 
 and rapid absorption of the enlarged prostate. This has now been proved con- 
 clusively." The operation thus rests now upon a firm clinical and pathologi- 
 cal basis, and has certainly passed the theoretical stage. Experiments con- 
 ducted by White with the aid of Kirby and Wood seem to show — a, that 
 unilateral castration will be followed by a certain degree of prostatic atrophy 
 on the corresponding side, but that it is not certain that this will be either 
 prompt enough or complete enough to be curative in prostatic cases ; b, that 
 ligation of the cord is followed by prostatic atrophy, but usually only when 
 the testicles have first become functionless themselves, and that this atrophy 
 is also slow and somewhat uncertain ; c, that ligation of the vas alone has 
 little eff"ect on the testicle, but causes a decrease in the size and Aveight of 
 the prostate ; c?, that ligation of the nervous and vascular constituents of the 
 cord separately influences the prostate only by first producing disorganization 
 of the testicles, and that this result is neither prompt nor certain. 
 
 At present, therefore, double castration seems to be the operation which 
 comes into direct comparison with the various forms of prostatectomy, and it 
 may safely be said that it is likely in properly selected cases to have a lower 
 mortality, is far easier of performance, requires a much shorter period of 
 anesthesia, and Avhen fully successful secures a return to a condition more 
 closely resembling the normal than any of the other operations looking toward 
 a radical cure of the hypertrophied prostate. 
 
 The operation must be regarded as still on trial so far as accurate choice 
 of cases and precise prognosis are concerned, but the conclusions of Feziwick, 
 after an experience of nine cases, are, with some modifications, accepted by 
 White after a careful analysis of all reported cases, now numbering more 
 than four hundred. They are as follows: 1. There is no doubt that shrink- 
 age of the prostatic tissue in many of the forms of senile enlarged prostate 
 
 60 
 
94G AN A3IERICAN TEXT-BOOK OF SUliUERY. 
 
 ensues u})on double castration. Further experience must, however, decide as 
 to whether every Ibrni of prostatic growth is thus affected. 2. It is certain 
 that escape from catheter-life after castration depends largely upon the health 
 of the vesical muscle. The grade of the atony, therefore, should be most care- 
 fully estimated before any hopes of relief from catheterization are held out. 
 To promise a confirmed catheter case that orchectomy will do away with the 
 instrument may merely bring discredit on the operation and disappointment 
 to the patient. Even after prostatectomy we are unable to promise such relief 
 if the muscle is hopelessly atonic, and we cannot do so after castration. 3. 
 It is possible that castration, by diminishing the prostatic and vesical con- 
 gestion and removing the obstruction to urination will enable the more healthy 
 tissues to overcome the microbic infection of the inflamed senile prostate if 
 such infection be present, or to prevent it if not yet established, and thus 
 remove a constant menace to the integrity of the kidneys, for it will con- 
 trol the most prolific source of ascending pyelitis. 
 
 It appears that while double castration is likely to have a wide range of use- 
 fulness, the exact limitations of Avhich must be determined by longer experience, 
 it is now safe to say that it Avill prove of value in the following conditions : 
 
 1, in reducing bulky overgroAvth of the prostate : it may be found that the 
 small, tough, fibrous median or lateral vesical outgrowths will be better removed 
 by suprapubic prostatectomy ; 2, in controlling the distress and danger of an 
 inflamed senile enlarged prostate ; 3, in lessening the frequency or difiiculty 
 of introducing the catheter in advanced or confirmed catheter-life; 4, in avoid- 
 ing the mechanical difficulty of crushing a post-prostatic or a post-trigonal 
 stone, by levelling the base of the bladder, thus rendering the operation of 
 litholapaxy feasible in a condition in which before it was impracticable ; 
 5, in reducing chronic cystitis and recurrent phosphatic calculus in cases of 
 confirmed catheter-life. 
 
 Jacobson of London has summarized his viewg on the subject as follows : 
 " The cases in which, in my opinion, the operation is most called for fall into 
 two groups : (a) The more urgent, where (1) previous appropriate treatment, 
 cai-efully carried out, has failed ; (2) where there have been one or more 
 attacks of retention ; or (3) where hemorrhage has taken place — in either 
 case the peril of cystitis, too often fatal here, is enormously increased ; (4) 
 where there is inability to micturate, or where this is painful or frequent ; 
 (5) where the passage of the catheter is increasingly difficult, with the risks 
 of hemorrhage, formation of false passages, etc. ; (6) where the prostate is 
 soft and elastic, not densely hard and fibrous — in such cases marked relief 
 may be expected. Of course, the greater the power of voluntary micturition 
 which remains, the more natural the urine as to urea, specific gravity, albu- 
 min, and sugar, the greater the rallying power of the patient, and the clearer 
 the mind, the better the prognosis. (6) Less urgent cases. Here the opera- 
 tion is prospective and preventive. The patient is younger, the power of 
 voluntary micturition is still good, there is no cystitis; but palliative treat- 
 ment fails to relieve the frequent disturbance at night, and hematuria has 
 begun to occur at intei'vals. Here the surgeon is abundantly justified in 
 advising the operation as a preventive of worse things which are certain to 
 come. The operation will not be often accepted here, but it is in such cases 
 that it will give the best results. 
 
 ''As to the amount of relief which we can promise our patients, Ave shall 
 de well to be cautious while hoj)eful. deciding each case by itself very care- 
 fully, especially as regards these two factors: {a) The amount of voluntary 
 mictunition and control which this operation will restore must largely depend 
 
SURG Ell V OF THE GEmTO-URINARY TRACT. 947 
 
 upon the condition of the bhulder, how far long-standing cystitis or habitual 
 use of the catheter has damaged its walls, replacing the muscular with 
 fibrous tissue, and converting it into an inelastic thick-walled sac. (f)) The 
 state of the prostate. The more vascular, the softer, the more rich in gland- 
 ular tissue this is, the more decided will be the shrinking that follows castra- 
 tion. On the other hand, the denser and more fibrous tlie gland, the longer 
 delayed certainly, and, perhaps, the less marked will be the benefit." 
 PiiOSTATiTis may be acute or chronic, follicular or parenchymatous. 
 Acute Follicular Prostatitis is usually a complication of gonorrhea, and has 
 already been described. (See pp. 900, 917.) It may occur as a, complication 
 of stricture. The mucous membrane and the follicles which empty upon its 
 surface are chiefly affected. If abscesses occur, they are small, are apt to be 
 numerous, and almost invariably empty spontaneously into the urethra. 
 
 Chronic Follicular Prostatitis is often a sequel of an acute attack. It 
 sometimes follows an attack of gonorrhea in which there has been no evidence 
 of acute inflammation of the gland. Its symptoms, course, and treatment 
 have been described in connection with the subject of chronic urethral dis- 
 charges. (See pp. 907, 918.) 
 
 Parenchymatous Prostatitis. — In this form the inflammation affects the 
 whole substance of the gland, after causing great disorganization. It may 
 result from — «, traumatism; b, tubercle; or, c, gout. a. Injuries of the pros- 
 tate are chiefly those inflicted during the various operations for stone or during 
 operations upon the urethra or bladder ; occasionally the use of a large instru- 
 ment, especially in patients broken down in health or with a cystitis Avith fetid 
 and ammoniacal urine or with pyelo-nephritis, will bring about this form of 
 prostatitis. It is ushered in by a chill, with deep-seated perineal pain, and 
 swelling recognized by rectal examination. It is usually suppurative in such 
 cases, but if the symptoms are marked by the presence of vesical or renal 
 disease, or, especially, if there is already distinct enlargement of the prostate, 
 the character of the trouble may escape detection until it is far advanced. 
 The pus may escape through the capsule of the gland, penetrating the recto- 
 vesical fascia and setting up a fatal pelvic cellulitis, or it may point in the 
 perineum or even in the groin. 
 
 Free evacuation by means of a median perineal incision is ahvays indicated 
 when the diagnosis is assured, and such an incision should be made for pur- 
 poses of exploration when deep-seated parenchymatous suppurative prostatitis 
 is strongly suspected. This is markedly in contrast with the follicular variety 
 (gonorrheal prostatitis), in which operation is scarcely ever required. 
 
 b. Tubercular prostatitis is very rare as a primary affection. It occurs in 
 the course of tubercular disease of the bladder or kidneys ; occasionally, but 
 more rarely, as a sequel of tuberculosis of the testicle. Its symptoms in the 
 early stages are those of a high grade of chronic prostatitis or often closely 
 resemble those of vesical calculus, hematuria after urination and pain at the 
 end of the penis being often present. Later, the urine becomes filled with the 
 debris of the caseating masses, and tubercle bacilli may be found if the sedi- 
 ment from a considerable quantity of urine be collected and examined. 
 
 The cystoscope might show the existence of ulceration at or near the neck 
 of the bladder. 
 
 The prognosis is very unfavorable. 
 
 Treatment. — The general hygienic measures appropriate for tuberculosis 
 anywhere are applicable here, but have less than their usual effect. The local 
 use of emulsions or of suppositories of iodoform has been recommended, but the 
 bladder and urethra will not tolerate them of sufficient strength to be of much 
 
f)48 AN AMERICAN TEXT-HOOK OF SURGERY. 
 
 service. The direct application to the ulcerated region of silver nitrate (from 
 1 to 5 per cent., or stronger if it is well borne) is sometimes of much tempo- 
 rary benefit. If there .are no deposits elsewhere, and there is reason to believe 
 that the prostatitis is ])rimary, and especially if the kidneys are thout^ht to be 
 sound, perineal or suprapubic prostatotomy, and curetting and cauterization 
 of the aft'ected surfaces, would seem best to fulfil all the indications, but are 
 rarely applicable under these limitations. They may become justifiable as paU 
 liative measures for the relief of hemorrhage, pain, and vesical tenesmus, but 
 then a simple perineal cystotomy would probably be almost equally beneficial. 
 
 c. Grout jf Prostatitis is an irritative and congestive rather than an inflam- 
 matory condition of the gland, found in men at or beyond middle life who are 
 lithemic, who have been high livers, and who habitually indulge to excess in 
 malt liquors or sweet sparkling wines. The uric, or sometimes the oxalic, 
 diathesis Avill be found to coexist. The symptoms are those of prostato-ves- 
 ical irritation. The disease never runs on to suppuration, and is rarely 
 serious, but is very apt to recur if the original errors of diet or habits of life 
 are resumed. 
 
 The treatment is that indicated by the condition of the urine. It should 
 be largely hygienic. 
 
 Prostatic Calculi. — The prostate, like other glandular structures, is 
 occasionally occupied by concretions consisting of inspissated secretions. 
 These are often small and numerous at first, but later become coated Avith 
 secondary phosphatic deposits, and in some cases have been agglutinated by 
 mucous and fibrinous exudates so as to convert the whole prostate into one cal- 
 culous mass. They give rise tc symptoms very difficult to differentiate from 
 those of vesical calculus. It will be observed in cases of doubt that the stone 
 remains fixed, never changing its position with the different movements of the 
 body, as does a stone in the bladder. It may sometimes be felt between the 
 finger in the rectum and a sound in the urethra. If movable, the introduction 
 of a large sound will often displace it and push it back into the bladder. 
 When small and multiple, such calculi may often be seized by urethral forceps 
 and extracted. White has thus removed from the prostatic sinus ten calculi 
 weighing altogether two hundred and thirty grains. If larger and fixed, a 
 median perineal incision is the best method for their extraction. 
 
 Malignant Disease of the Prostate. — Both carcinoma and sarcoma 
 afiect the prostate. The encephaloid variety of the former is more common. 
 When the disease develops in a prostate already hypertrophied, the diagnosis 
 is very difficult. Originating in a prostate previously unchanged, it may be 
 recod^nized by the rapidity of the growth, the frequency and severity of the 
 hemorrhage, the associated cachexia, etc. Extension beyond the capsule of the 
 gland and involvement of neighboring parts, as the rectum and the vcsiculse 
 seminales, sometimes take place, and may be discovered by digital exploration. 
 
 Treatment is of but little avail. Suprapubic or perineal cystotomy for 
 drainage is sometimes indicated. A pedunculated growth might be twisted off 
 through either incision, and obstructive symptoms temporarily relieved. Death 
 usually occurs from exhaustion or from secondary deposits in other viscera. 
 
SURGERY OF THE GENITO- URINARY TRACT. 949 
 
 PART v.— DISEASES OF THE TESTICLES. 
 
 Congenital Deformities. — Occasionally both testicles are entirely want- 
 ing (cryptorchidisin) ; more coumionly one is lackinj^ (monorcliidisin). Supernu- 
 merary testicles have been reported, but are probably instances of detachment 
 of the globus major from the body of the epididymis (Agnew). 
 
 Retained Testicle (undescended testicle) is much more frequent. It is 
 usually unilateral, though occasionally both testicles fail to reach the scrotum. 
 The organ may be arrested during its descent within the abdomen beloAv the 
 kidney, in the inguinal canal, or just outside of the external abdominal ring. 
 In rare cases the testicle has been found in the perineum. If both testicles 
 are retained, the suspicion may arise that the individual is a cryptorchid, and 
 a microscopical examination of the fluid ejaculated during a sexual orgasm 
 may be necessary to decide the question. 
 
 A retained testicle, especially if it is situated in the inguinal canal, is liable 
 to inflammatory attacks and even to malio-nant chano;e. 
 
 Treatment. — Various operations have been devised for placing and retain- 
 ing such an organ in the scrotum ; but while they are frequently fol- 
 lowed by temporary improvement, they are apt to be finally disappoint- 
 ing. If the retained testicle gives rise to much trouble, and if the other 
 testicle is present and is sound, castration is often the most satisfactory 
 treatment. 
 
 Inflammation of the Testicle. — Under this head are usually de- 
 scribed both epididymitis and orchitis, which may exist either separately or 
 conjointly. 
 
 Acute Epididymitis is usually gonorrheal in its origin, though more rarely 
 it may follow perineal lithotomy, an injury to the perineum, lithotrity, cathe- 
 terization, etc. 
 
 The symptoms and treatment have been sufiiciently described in the 
 article on Gonorrhea. (See pp. 883, 900.) 
 
 Acute Orchitis may I'esult from the extension of an epididymitis, but this 
 is uncommon. It is usually caused by traumatism : metastasis in mumps may 
 give rise to a very acute orchitis. 
 
 When acutely inflamed the testicle swells rapidly, but retains its normal oval 
 form. The pain is dull and nauseating, radiates toward the groin, hips, and 
 loins, and is markedly lessened by support to the testicle. Acute hydrocele 
 is not so common an accompaniment as in cases of epididymitis. The exudate, 
 which during the acute stage occupies the connective- tissue spaces between the 
 seminiferous tubes, may break down, and suppuration may follow in persons 
 already in poor health and with feeble resistant powers. Infection in these 
 cases probably occurs through the blood rather than through the urethra and 
 vas deferens. More commonly reabsorption takes place, but the gland is apt 
 to be left softened or atrophied and predisposed to subsequent attacks. 
 
 Bilateral orchitis may result in impotence as a result of these atrophic 
 changes in the secreting structure of the glands themselves, while bilateral 
 epididymitis, in consequence of its obstructive sequelae, is far more apt to 
 cause sterility. 
 
 Treatment. — The patient should be put to bed, the scrotum elevated, and 
 iced lead-water and laudanum applied. If the cold is of itself a cause of suf- 
 fering, hot fomentations of the same lotion will often give relief. Laxatives 
 and febrifuges should be given, and during the height of the inflammation 
 enough morphia hypodermatically to control the acute pain. Aconite and 
 bromide of potassium in appropriate doses will be found of great use. Punc- 
 
1)50 .1-V A}ri:L'i(AX Ti:xr-no<>k' or srii(; i:i:y. 
 
 ture of the tunica vaginalis, and even j)unctuiv or incision of tlie tunica albu- 
 ginea, has been rcconmiended in cases in which the tension and swelling are 
 very great. The former is harmless, but usualh' needless. The latter is rarely 
 if ever justifiable. If the orchitis is of the rheumatic or gouty variety, the 
 salicylates and iodide of potassium, with lithia-water and a restricted diet, are 
 indicated. 
 
 Chronic Orchitis rarely follows an acute attack, but is more eonniioidy the 
 result of some constitutional infection. When it results from local causes it is 
 characterized by a slow enlargement of the gland, with only moderate pain 
 and with a loss of the testicular sensibility. If it continues for any length of 
 time, atrophy of the gland is sure to result. Frequently the inflammatory 
 exudate li(iuefies, the skin ulcerates, infection occurs, and the organ is riddled 
 with sinuses or disappears almost completely. 
 
 The treatment should consist in careful regulation of the general health, 
 the administration of tonics with alteratives, and the local use of eciuable pres- 
 sure by strapping, gentle at first, firm later if it is well borne. An ointment 
 of mercury, belladonna, and iodine, or one containing iodoform, often seems to 
 be useful. Castration will be required if there are several suppurating foci. 
 
 Tubercular Orchitis usually occurs in patients between the ages of twenty 
 and forty. There is often a family history of tubercular disease. The 
 epididymis is apt to be first involved. The disease is frequently bilateral. 
 It is insidious in its origin, giving rise to little or no pain, but beginning as 
 a hard, irregular enlargement at the lower and posterior aspect of the gland, 
 gradually increasing, and sometimes extending along the vas deferens. Later 
 the whole gland is involved and undergoes caseous degeneration. The skin be- 
 comes adherent, sinuses form, and purulent infection follows. Secondary tuber- 
 cular deposits in the seminal vesicles or in more remote regions are often 
 found. 
 
 Treatment. — If the diagnosis is reasonably clear or if multiple sinuses 
 have formed, and if the disease is unilateral, castration is clearly indicated, 
 both to secure local health and, even more urgently, to avoid general dissem- 
 ination of tubercle. If both glands are affected, however, the consequences of 
 castration are so unpleasant that palliation and symptomatic treatment should 
 be persevered in until there is unmistakable evidence of the complete destruc- 
 tion of the organ. Sinuses should be enlarged and curetted, abscesses should 
 be opened promptly, ulcers should be treated with nitrate of silver and dressed 
 antiseptically. and every attention should be paid to the general health and 
 strength of the patient. 
 
 Syphilitic Orchitis (syphilitic sarcocele) also begins painlessly, but, as a 
 rule, in the body of the gland ; like tubercular orchitis, it is apt to be bilateral. 
 It causes a dense, irregular, knotty induration, but not much increase in size. 
 These phenomena, together with the history and the results of specific treat- 
 ment, generally render its recognition easy. (For the differential diagnosis 
 from tubercular orchitis and from carcinoma of the testis see p. 169.) 
 
 Malignant Diseases of the Testicles. — Carcinoma of tjie Testis 
 usually assumes the soft or encephaloid form. It is an exception to the rule 
 that carcinomata develop most frequently after middle age. Of 67 cases col- 
 lected at random, 51 were in persons under forty, and 24 appeared before the 
 age of thirty. The disease is usually unilateral, and begins in the form of 
 one or more small nodules occupying the body of the gland and soon enlarging 
 so as to involve the epididymis. The swelling is at first smooth and uniform, 
 but as soon as the tunica albuginea breaks down it becomes irregular, with 
 areas which are soft and fluctuating, and grows with increased rapidity. The 
 
sri;(!i:in' ov the aENiTO-vniNAiiY tract. i»5l 
 
 veins of the scrotum are greatly enlarged ; the ^Vm hecoines adherent and ulcer- 
 ates; the crroAYth reaches a large size and is sometimes enormous; fungous pro- 
 trusions, insisting of granulations, and of sloughs of the connective tissue and 
 even of portions of the glan.l, make their a])pcarance and hleed upon the least 
 touch • the cord is thickene.l. and the inguinal and pelvic glands are involved. 
 The <n-ner:il health soon fails, the patient hecomes cachectic and emaciated, and 
 deatl'? usually results in from one to two years after the first appearance of the 
 
 growth. T 4. 
 
 Scirrhus of the testicle is very rare, and presents no features peculiar to 
 
 the locality. „ . ., , , ,. • • 
 
 Sarcoma of the testicle is found in all its forms. Several subdivisions 
 have been made of certain of these sarcomatous growths, and have somewhat 
 unnecessarilv complicated the study of the pathology of the testis. 
 
 The so-called Cystic Tes^tide, the "hydrated testicle" of Sir Astley Cooper, 
 is probablv almost always an early stage of sarcoma. It is of variable 
 duration, Imt is often slow in its development and is attended with a gradual, 
 painle^^ uniform enlargement of the whole gland, which retains its oval shape, 
 is smooth and elastic to the touch, and often fluctuates. It may reach an im- 
 mense size. It resembles hydrocele or hematocele in form and general appear- 
 ance, but is heavier than the former, is more ovoidal, and is opaque. Jrom 
 hematocele the diagnosis may be more difficult, and sometimes it can be made 
 in the later stages of cystic disease only by recognition of the enlarged veins 
 over the surface of the scrotum and by the general cachexia. In the earlier 
 stacres the introduction of a trocar will in either case often be followed by 
 bleedincT, but in hematocele the blood will be in greater quantity, and will be 
 darker and altered in appearance. In those cases in which the contents of 
 an old hematocele have undergone partial organization, leaving areas contain- 
 ing fluid blood, the diagnosis may be practically impossible, but it is less im- 
 portant, as in both cases castration is indicated. 
 
 Enclmidroma of the Testicle has been described as a benign growth, but it 
 is probable that it is almost invariably a form of sarcomatous disease. In some 
 cases it grows very slowly, and may then be recognized by its great weight 
 and density, and by the absence of pain and of involvement of the skm or of 
 neif-hborincT tissues. Even then, however, it is extremely apt to take on ma- 
 lignant chSnge, while in the more rapidly growing form it is found from the 
 outset in combination with cystic and sarcomatous disease. 
 
 Jacobson in this connection has appropriately called attention to the close 
 relations of cartilage to the other tissues of the connective-tissue type, and says 
 that when it is remembered how narrow is the dividmg-lme between these 
 tissues and the sarcomata, especially when, as a result of continued irritataon, 
 the former tend to recur to their embryonic form, it may well be doubted it an 
 enchondroma of the testicle ever really deserves the term " innocent." 
 
 Sarcoma proper may be of the round-celled variety, in which case it is met 
 with in an unmixed form, grows rapidly, reaches a large size, and is soon fol- 
 lowed bv secondary deposits having all the characteristics of extreme malig- 
 nancy. "^ Spindle-celled sarcomata are more frequently associated with other 
 structures of the connective-tissue group— viz. cartilaginous, myxomatous, and 
 adipose tissue— run a slower course, and are more difficult of recognition, but 
 sooner or later develop the usual phenomena of this form of malignant growth. 
 Diagnosis of Malignant Disease of the Testis.— In their early 
 stages both carcinomata and sarcomata are liable to be mistaken for enlarge- 
 ments due to chronic orchitis, as at this time they both have an oval shape, 
 a smooth surface, and are somewhat indurated. Later, as the growths soften, 
 
952 AN AMERICAN TEXT-BOOK OE SURGERY. 
 
 and especially when, as is often the case, there is fluid in the tunica vaginalis, 
 they may simulate an old hydrocele with a thickened, opaque tunic or a hema- 
 tocele w'ith thickened walls. The following points may be enumerated as of 
 chief diagnostic value (Jacobson): (1) continuously progressing solid enlarge- 
 ment without inllammation; (2) unc((ual resistance of the swelling at diflCcrent 
 parts; (3) entire absence of translucency ; (4) tendency to become adherent; 
 (5) increasing aches or painfulness; ((J) enlargement of the cord and, a fortiori, 
 of the lumbar glands. In doubtful cases additional information should be at 
 once sought for by an antiseptic tapping or exploratory incision. The latter 
 is preferable, as it gives more certain information, and is the best treatment in 
 those liematoceles which are liable to be mistaken for malignant disease. Punc- 
 ture of a malignant growth usually gives vent to blood-stained fluid which is 
 not large in amount, or to sero-mucous fluid which is not blood-stained. On 
 puncture of a hematocele there usually escapes either grumous altered blood 
 or fluid blood, which flows for some time, producing a distinct alteration in the 
 size of the SAvelling. 
 
 Castration. — The most recent review of the results of operation in ma- 
 lignant disease of the testicles is that of Butlin. In 99 cases collected by 
 him there were 4 deaths from causes directly connected with the operation. 
 Many of the patients were lost sight of, but there were 5 cases of sarcoma well 
 at the end of from twenty months to two years, and 2 cases of carcinomata 
 without recurrence at the end of forty-two months and one hundred and eight 
 months respectively. Mr. Butlin's conclusions as to this important subject 
 ai'e that castration for malignant disease is an o]ieration Avhich may be per- 
 formed with very small danger to life. The operation, whether for sarcoma or 
 for carcinoma, cannot be said to be attended with large success, so far as com- 
 plete cure of the patient is concerned, but there is a great lack of information 
 on this subject. There is, however, evidence that it may be attended with 
 permanent success, and there is still further evidence that the operation may 
 be an excellent palliative measure even if it fails in its primary object, cure. 
 There is comparatively little likelihood of recurrence in situ unless the cord is 
 thickened or the scrotum adherent at the time of the castration. There is no 
 prospect of success for operations for recurrent disease unless the recurrence is 
 in the scrotum. Castration may be performed for malignant disease of both 
 testes, if not with a reasonable prospect of permanent cure, yet certainly with 
 hope of temporary relief, and also with the hope of temporary relief in cases 
 of malignant disease in children. 
 
 The operation is performed as follows : The hair of the pubes, scrotum, 
 and perineum having been shaved and these regions repeatedly washed and 
 disinfected, and the possible jjresence of hernia in the scrotum or in the canal 
 being kept in mind, the skin of the scrotum should be steadied by the thumb 
 and fingers of the left hand of the operator Avhile an incision is made from a 
 point just below the external abdominal ring to the bottom of the scrotum. 
 This is gradually deepened, layer by layer, the tunic being recognized, when 
 it is reached, by its immobility. The testis and tumor may sometimes be 
 removed with the tunic by simply shelling out the mass from the scrotal tis- 
 sues with the fingers, aided here and there by touches of the knife. Usually, 
 however, it will be necessary to lay open the tunic either for ])ur{)oses of diag- 
 nosis, to lessen the bulk of the swelling, or because the tunic itself has con- 
 tracted inflammatory adhesions to the surrounding parts or has become incor- 
 porated with them during the progress of the disease. After the tumor is 
 freed from all attachments except that to the cord, traction is made upon 
 it so as to elongate the latter, which is then isolated by the finger. It may 
 
SURGERY OF THE GENI TO- URINARY TRACT. 953 
 
 then be secured by a clamp, divided below it, and the vessels secured sepa- 
 rately, or it may be encircled with a stout chromicized catgut ligature or a 
 fine strong silk thread, and then divided, the ends of the catgut or silk being 
 cut short and the cord allowed to retract into the canal after inspection of 
 the cut surface has shown that there is no hemorrhage. A small drainage- 
 tube may be carried up to the stump of the cord and left in place for a day or 
 two. All hemorrhage, even oozing from minute vessels, should be arrested by 
 ligature before the wound is closed. Otherwise very troublesome bleeding 
 may occur. During suturing the inversion of the edges of the wound by 
 the' dartos should be guarded against. The scrotum should be moderately 
 elevated and well supported by the antiseptic dressing. Special care should 
 be exercised to prevent infection from urine or feces. 
 
 Sterility, or incapacity to fecundate the female, may depend on some 
 defect in the spermatic fluid, such as alisence or enfeeblement of the sperma- 
 tozoa. I'll is may result permanently from disease, as any of the forms qf 
 orchitis, atrophy of the testicles, neoplasms, etc., or temporarily from sexual 
 excess or the general feebleness following an exhausting illness. It may also 
 be caused by the various forms of impotence, with the accompanying inability 
 to deposit the semen within the vagina, or it may result from obstruction of 
 the excretory ducts of the testicle, as in double epididymitis, tumor of the 
 seminal vesicles or prostate, stricture of the urethra, etc. The diagnosis can 
 best be made by microscopical examination of recently-ejaculated semen. If 
 live spermatozoa are found and if the individual has no form of impotence, 
 sterility may be excluded. 
 
 Impotence, or inability properly to perform the sexual act, may arise 
 from absence of the penis, malformation or diminutive size of that organ, or 
 disease or injury producing changes in portions of the erectile tissue and pre- 
 venting their participation in the act of erection, thus leaving part of the penis 
 flaccid. Various diseases and injuries of the cerebro-spinal axis, and especially 
 of the lumbar cord, are accompanied or followed by loss of potency. Urethral 
 stricture, especially when deep-seated and associated with hyperesthesia of the 
 prostatic region, often causes a certain degree of impotence by inducing pre- 
 mature ejaculation, in many cases the erection subsiding before an entrance can 
 be effected. Oxaluria is not infrequently a cause of very persistent and com- 
 plete impotence, which, however, disappears rapidly under appropriate diet and 
 drugs. The treatment of all these forms should be directed to the removal of 
 the underlying condition. 
 
 Pseudo-impotence is a form of sexual disability Avhich has its origin in the 
 imagination or in the fear of the patient. It is very common among young 
 men who have been unaccustomed to sexual indulgence and who have failed 
 at their first attempt, owing to nervousness, want of confidence, or possibly a 
 genuine distaste for the female. This sometimes happens during the early 
 period of married life, and gives rise to intense anxiety and distress on the 
 part of the husband. As a rule, all that is needed is a few words of advice 
 and encouragement, with the injunction to refrain from repeated attempts while 
 mentally perturbed. A placebo may be given, and these measures with time 
 will always work a cure. 
 
 Spermatorrhea is a condition in which there is escape or oozing of 
 semen, instead of erection or pleasurable sensation. In the sense of a con- 
 stant flow of semen it is extremely rare. When observed intermittently in 
 vigorous men who have suddenly become continent, it may almost be regarded 
 as physiological.' It is not infrequently associated with chronic posterior 
 urethritis or with strictures of large calibre. 
 
954 ^l.V AMKlilCAX TEXT- HOOK OF SL'llGEltY. 
 
 In bad cases it is accompanied by a very marked form of imjiotence Avith 
 loss of both desire and ])o\ver of erection. A microscopic examination of 
 tlie discharge is often necessarA' to distinguish it from catarrhal contlitions 
 of the uretliral tract. The treatment varies with the cause: but the pa- 
 tients will usually be morbid and difficult to manage. Their hygiene must 
 be rigidly attended to : locally, no two things do so much good, even wiien 
 they are used empirically, as tlie instillation of weak silver solutions into 
 the posterior uri'tiira and prostatic sinus and tlic use of the ccdd steel 
 sound. 
 
 Varicocele. — The veins of the spermatic cord may be divided into two 
 sets, an anterior, running with the spermatic artery and called the pampiniform 
 plexus, and a posterior, smaller set accompanying the deferential artery and 
 surrounding the vas deferens. The veins m the left cord are said to be always 
 larger than those of the right (Spencer). The arteries of the cord are the 
 spermatic, lying in front of the vas, the deferential, which runs w ith it, and the 
 cremasteric, which is more superficial. 
 
 Varicocele is usually an enlargement of the veins of the pampiniform 
 plexus only, but occasionally all the veins of the cord are involved. The 
 testicle on the affected side is apt to be smaller and softer than its fellow, and 
 the dartos structure is usually flabby and relaxed. 
 
 The condition occurs chiefly in young unmarried adults, and so rarely 
 develops before puberty or after middle age that it is evident that it has 
 some relation to the sexual function, being apparently favored by a lack of its 
 normal exercise. The mechanical conditions of the spermatic veins, their great 
 length, their tortuous course, and the absence of support from firm under- 
 lying or surrounding muscles, are said to predispose to varicocele ; but if these 
 were very important factors it would be much more common on the right side 
 than it is. Sir Astley Cooper, Agnew^ Marshall (who examined 30,000 
 recruits), and others state that they have never seen a well-marked case on 
 the right side. The entry of the left spermatic vein into the corresponding 
 renal vein at a right angle instead of at the acute angle at which the right 
 spermatic vein joins the vena cava, its passage behind tlie sigmoid flexure, 
 and its greater length, bave all been regarded as explaining the great pre- 
 ponderance of left-sided varicocele, and probably all share in bringing it 
 about. 
 
 Exciting causes are found in whatever determines an increased amount of 
 blood to the testicles, as heavy lifting, straining during defecation or urination, 
 excessive sexual indulgence, etc. 
 
 Symptoms. — The disease is easily recognized. The scrotum on the 
 affected side is filled with a tortuous mass of veins, giving a peculiar worm- 
 like feel to the touch. Their convolutions are often visible through the skin. 
 The scrotum is elongated and dusky or purplish in color. There is not much 
 pain, but occasionally a dull ache extending along the cord and into the loins 
 is experienced. Patients with varicocele are apt to be depressed and melan- 
 choly. They are often the subjects of pseudo-impotence, and if they have 
 once failed in an attempt at sexual intercourse, if they have masturbated when 
 younger, and especially if in addition there is a noticeable diminution in the 
 size of the testicle on the affected side, they become sexual hypochondriacs of 
 the most pronounced type. Occasionally, but rarely, genuine atrophy of the 
 testes results from the interference with the circulation produced by the en- 
 larged veins, but, as the other gland is usually normal, neither impotence nor 
 sterility is threatened. 
 
 The disease can scarcely be mistaken for any other condition, and the 
 
srn(;i:nY or the aEyiro-rinxAHV Thwrr. 
 
 9r,5 
 
 directions often given for its diagnosis fnuii scroliil licniia or congenital liydro- 
 eele seem umieces.sarv. 
 
 Treatment. — The ]ialliatii)n of a case <»f vaiicorck- may be attempted by 
 means of eold doudies, regidation of the bowels, avoidance of all exciting 
 causes, the use of a firm, well-iitting suspensory bandage, etc., but little or no 
 effect upon the already existing enlargement need be exjtected. 
 
 The radical cure may be indicated either by actual pain and disability, by 
 progressive atrophy of the testicle, or by the mental condition of the patient. 
 
 Excision of the affected veins is the operation which is most satisfactory. 
 The usual ])reliiiiinary shaving and cleansing of the region should be done, after 
 uliieli. while an assistant makes the tissue tense Ijy drawing the testicles and scro- 
 tum downward, an incision al)out two inches in length is made over the most 
 prominent part of the varicocele. The veins are exposed, but are not sepa- 
 rated from the fascia surrounding them and holding them together. The 
 vas with its venous plexus is recognized and avoided. An aneurysm needle 
 threaded with catgut is then passed under the veins at the upper end of the 
 
 Fig. 374. 
 
 w 
 
 k 
 
 Hydrocele (original). 
 
 incision and again at the lower end. The ligatures are tied, and in each 
 instance left with one long end. The intermediate portion of the veins is 
 then cut out Avith the scissors, and the stumps are brought into apposition 
 and held by tying the ligature ends together. This raises the testis to a 
 higher level and results in shortening the scrotum on that side. The results 
 have been excellent in large numbers of cases. 
 
 Hydrocele. — Hydrocele is a condition in which there is an abnormal quan- 
 tity of fluid in the cavity of the tunica vaginalis testis (Fig. 374). It occurs 
 with about equal frequency on both sides, and is usually unilateral. The acute 
 form of hydrocele accompanies some varieties of orchitis and many cases of 
 epididvmitis, and occasionally follows traumatism. Sometimes the cavity of 
 the tunic is divided into tw^o portions by the adhesion of its walls, in which 
 case the hydrocele is said to be bilocular. The causes of hydrocele, exclusive 
 of traumatism, are not often very easily traced. It has been attributed to 
 violent muscular efforts, to straining, etc., and is certainly favored by relax- 
 ation of the scrotum due to long-continued high temperature. Hydrocele is 
 therefore more frequent in tropical climates than elsewhere. 
 
 The fluid of a hydrocele is almost identical in composition with the serum 
 
966 A.y .1 . 1/ /•;/.' /r.LV Ti:XT-li()<)k' OF sritGERY. 
 
 of the blood. In the majority of eases it is transpurent and <jf a straw or 
 amber color. Occasionally, especially in traumatic hydroceles and in those 
 which are secondary to disease of the tunic, the fluid is dark-colored and 
 opaque, owing to the presence of the coloring matter of the blood-corpus- 
 cles which it contains. In old cases the tunic is often iiiucli thickened, and 
 this thickening may of itself render the hydrocele incapable <jf transmitting 
 
 In encifsted hydrocele the fluid is contained in the sac between the epi- 
 didymis and the tunic or between the tunica vaginalis and the tunica albu- 
 •rinea. In coiuienitaJ hydrocele the continuity between the cavity of the tunica 
 vaginalis and that of the peritoneum still exists, so that the serum from the 
 al)domen is free to pass downward along the track of the cord, and thus 
 produces a hydrocele. Infantile hydrocele may be of either of the above 
 varieties. 
 
 Symptoms. — The swelling in hydrocele begins at the low^er portion of 
 the scrotum, and is slow in developing : it is slightly pyriform, smooth, tense, 
 and fluctuating ; it is elastic on pressure, which does not alter the size of the 
 swelling ; it fluctuates distinctly, is dull on percussion, and is not accompa- 
 nied by pain, redness, or other alteration in the skin. A peculiarity of 
 hydrocele worthy of attention is that the tumor- instead of hanging downward 
 between the thighs, as in hernia, projects forward from the body, and, if pressed 
 back, springs again to its original position when released. The most charac- 
 teristic symptom of hydrocele is its translucency. This should be elicited by 
 examining the patient in a dark room while a candle is held close to one side 
 of the scrotum, which is made tense by the hand of the surgeon, the other 
 being placed in contact with the anterior margin of the swelling, so as to inter- 
 cept the rays of light. In ordinary hydroceles the translucency is easily 
 recognized. In those which contain an opaque or bloody fluid it cannot, of 
 course, be found, and the use of an aspirating needle may be required to estab- 
 lish the diagnosis. The test by transmitted light should always be em])loyed 
 in cases of supposed hydrocele, to exclude the possibility of a coexistent hernia 
 and to fix the position of the testis, which will generally be found posteriorly 
 just below the middle of the scrotum. Attention to the features of the condi- 
 tion which have just been described will usually render the diagnosis easy, but 
 in rare instances it is possible to be mistaken, as in cases of irreducible omental 
 hernia with redema of the scrotum and the subjacent tissues. 
 
 Treatment. — The treatment of hydrocele may be palliative or radical. 
 Palliative treatment consists in occasional tappings when the tunic becomes 
 fully distended. The patient should lie upon his back in a semi-recumbent 
 position ; the skin of the scrotum should be thoroughly disinfected and made 
 tense by the left hand of the surgeon, who with the other plunges a small 
 trocar into the anterior part of the sac in a direction upward and inward, 
 avoiding any large superficial vein which may be apparent. The dej)th to 
 which the trocar is plunged should be limited by keeping the thumb or finger- 
 nail in contact with the canula at the distance of an inch and a half or two 
 inches from the point of the instrument (Fig. 375). By observing this 
 precaution and by inserting the trocar in the proper direction all danger of 
 wounding the testicle is easily avoided, especially if its position has been 
 previously and accurately determined by the light test. The sac having 
 been emptied, the canula is withdrawn, and the little opening immediately 
 closed by a pledget of bichloride cotton held in place by iodoform and 
 collodion. 
 
 The radical treatment of hvdrocele mav be either by injection or by 
 
sunoEJ!)' or Tin-: <n:xrn)-URiNAiiv travt. 
 
 957 
 
 !"i<i. .S7'j. 
 
 ^H 
 
 Tapping a Hydrocele; testicle in usual 
 position: //</, cavity of hydrocele ; NH, 
 epididymis; i/o, testicle (Tillmanns). 
 
 Operation. In the former case tlic lliiiil is withdrawn as above described. 
 After the sac is emptied a (piaiitity of tlie undiluted offieinal tincture 
 of iodine proportionate to the size of the sac, 
 and varvino; from one to five or six drams, is 
 thrown tlirouirli tlic caiuda into the sac and 
 allowed to remain lli(>re. To prevent the 
 escape of any portion of the iodine, it is well 
 to withdraw the syringe and canula together. 
 The li(iuid is diftused over the entire surface 
 of the memhi-ane by lifting and gently rub- 
 bing the scrotum. The canula ])uncture is 
 closed with cotton and collodion, the scrotum 
 is elevated, and if it becomes very swollen and 
 sensitive is covered with dilute lead-water and 
 laudanum. In the course of twenty-four 
 or thirty-six hours the swelling will have 
 reached its original size or even passed be- 
 yond it. After tills it begins to subside, 
 and at the end of three or four weeks will, in 
 successful cases, have disappeared entirely. 
 The cause of failure in this simple ope- 
 ration is usually a neglect to use a suf- 
 ficient (juantity of iodine, or a failure to 
 empty the sac of the hydrocele, so that the 
 iodine which is injected is at once diluted 
 by the remaining fluid and does not set up an adequate degree of inflammatory 
 action. Sometimes, too, even when these precautions have been observed, a 
 considerable quantity of the iodine already injected is lost at the moment of 
 taking the syringe out of the canula. The great majority of all cases of 
 uncomplicated hydrocele are curable by this method when properly performed, 
 but if the tunica vaginalis be much thickened, injection however performed, 
 must fail, owing to the impossibility of absolute collapse of the sac. 
 
 In congenital hydrocele in adults the method of injection may be danger- 
 ous on account of the communication of the sac with the peritoneal cavity. 
 It would probably be better always to employ one of the methods yet to be 
 described. Carbolic acid may be used in place of iodine, and is preferred by 
 some surgeons. From ten to thirty drops of the pure acid, liquefied with the 
 least possible amount of water, are injected, or a dram of the 5 per cent. 
 solution in glycerin of the crystallized acid may be used. 
 
 Treatment hy Incision. — By this method a vertical incision from one and 
 a half to two inches in length is made through the disinfected tissues of the 
 scrotum and along the anterior and low^er portion of the sw^elling, and into the 
 tunica vaginalis. The margins of the tunic are then stitched to the edges of 
 the skin-Avound by a few catgut sutures, and a large drainage-tube is introduced 
 into the sac. The wound is dressed antiseptically and is washed out daily. 
 The drainage is shortened at intervals, and the sutures may be removed before 
 the end of the first week. Instead of using a tube, the cavity of the hydro- 
 cele may be packed with iodoform gauze. 
 
 Excision of the parietal layer of the tunic has been re-introduced by Von 
 Bergmann, and consists in dissecting it out from the tissues of the scrotum 
 and cutting ofi" portions, leaving sufficient to serve as a normal covering for 
 the testicle. A drainage-tube is inserted and the edges of the external 
 '••ound are sutured. This method is more severe than those just described. 
 
fi58 A.\ .i.i//;///r.i.v ri:xT-Jiouh' c/' sri^'aEiiv. 
 
 Iiiit may Ix; rcMjuired in c;i.sc.> of inveterate liy<lroccle in Avliich all other 
 methods fail. 
 
 Indieations for the selection of one or the other of the other two methods 
 are as folloAvs : In the great majority of simple cases in which no previous 
 operation has been tried the absence of a cutting operation or of an open 
 wound, the fact that no anesthetic is required, and the comparatively sliort 
 convalescence, together with the extremely favorable results, render the treat- 
 ment l)y iodine injection the method of choice. 
 
 The antiseptic incision should be selected {<i) in cases of previous failure 
 with iodine: (//) where the sac is very large or has very thick walls; {<■) where, 
 on account of ill-health or premature age, the risk of inflammation after iodine 
 injection is especially to be dreaded; {d) in cases of congenital hydrocele, 
 when a careful incision w ith antiseptic precautions will be safer than any other 
 method if the pressure of a truss for the obliteration of the peritoneal com- 
 munication cannot be persevered in ; {e) where the surgeon is desirous of 
 exploring the sac of the tunica vaginalis, as in cases where enlargement of the 
 testis of a doubtful nature coexists with hydrocele, and does not yield to ordi- 
 nary treatment ; (/) where two hydroceles coexist — e. g. vaginal and encysted 
 hydroceles ; ((/) in some cases of hydrocele complicated with' hernia — e. g. 
 where the bowel is irreducible, and where, especially in uniiealthy patients, 
 there is a risk of the inflammation set up by the iodine extending to the her- 
 nial sac (Jacobson). 
 
 Hematocele. — Hematocele is a collection of blood in the tunica vaginalis. 
 It is usually due to injury, but may be the result of disease aifecting the inner 
 surface of the membrane. It sometimes follows violent straining efforts, and 
 now and then is a se(|uel of the treatment of hydrocele by tapping. It consti- 
 tutes an ovoidal or globular tumor, witli its largest circumference below, non- 
 fluctuating, opaque, heavy, quite solid, and resistant to pressure. If these 
 symptoms are all present, the diagnosis is usually easy. In old cases the 
 thickening of the tissues is so great, and the density of the contents of the 
 tunic is such, that the swelling resembles a solid tumor, and its true character 
 can sometimes be recognized only by means of an exploratory incision. 
 
 Treatment. — In acute traumatic cases the scrotum shotdd be elevated 
 and wrapped in iced lead-water and laudanum. After the swelling has become 
 stationary or has begun to subside, absorption of the blood may be favored by 
 gentle and uniform compression, either by means of a narrow elastic bandage 
 or by strapping with adhesive plaster. If, in spite of these means, a hemato- 
 cele is very large, is increasing in size, and is accompanied by heat, pain, and 
 oedema of the scrotum, it is well to make a longitudinal incision into the sac, 
 evacuate its contents, irrigate the cavity, pack it with iodoform gauze, and 
 dress it antiseptically. If at this time disease of the testicle itself is discov- 
 ered, or if there is a marked amount of inflammatory change in the tunic, 
 accompanied by great pain and irritation, castration, with removal of the sac, 
 is the most satisfactory treatment. 
 
 DISEASES OF THE SPERMATIC CORD. 
 
 The cord is subject to a variety of growths, the most common of which, 
 however, are the lipomata. These may be single or multiple. They are 
 usually harmless and require no surgical treatment. Primary malignant 
 growths of the cord are exceedingly rare, although malignant disease is often 
 found to be secondary to similar disease of the testicle. 
 
 Diffused Hydrocele of the Cord. — The most important pathological 
 
,Si'R(JERy or THE GKNlTO-URlNAltY TRACT. 959 
 
 conditions of the spermatic cord are found in the various forms o-t hydrocele. 
 As the testicle descends from the loins to the scrotum it carries with it a 
 double layer of peritoneum, and this makes a serous sac extending from the 
 internal ring of the abdomen to the scrotum, one layer lying in contact with 
 the cord and the tunica albuginea, and the other with the inner surface of the 
 cremaster muscle and the scrotum. The space between that portion of these 
 two layers which surrounds the testicle constitutes the tunica vaginalis testis. 
 Usually, above the external ring the space between the two layers is oblite- 
 rated and they invest the cord as a single membrane. If they remain sepa- 
 rate between the internal and external rings, and if serum accumulates between 
 them, an elongated swelling forms, extending from a little distance above the 
 testicle to the internal ring, cylindrical while the patient is lying down, but 
 becoming pyriform when ho is standing up. The swelling is soft and iluctu- 
 ates : it may be made to appear below the external ring by pressure over the 
 course of the canal, and will disappear when that pressure is removed. It is 
 occasionally translucent by transmitted light. It is most likely to be mistaken 
 for an irreducible omental hernia, as when it is tense there is a very perceptible 
 impulse on coughing, and as the sac of such a hernia may contain a fluid which 
 resembles that of hydrocele. It may be treated by iodine injection or by the 
 introduction of the seton. 
 
 A similar condition, in which the two layers of the tunic investing the cord 
 have remained open at one or more places and are blended together at others, 
 gives rise to Encysted Hydrocele of the Cord, which is somewhat different 
 in shape from the form just described, but otherwise has the same characteris- 
 tics. Very rarely, the funicular process of the peritoneum contracts and becomes 
 adherent to the cord at the external ring, but remains open above, communi- 
 cating with the general peritoneal cavity. If this upper opening is large, it is 
 possible to have a hernia and a hydrocele coexistent, but usually the funicular 
 process adheres to the cord with sufficient closeness at the internal ring to per- 
 mit only of the entrance and exit of fluid. When the patient stands erect the 
 symptoms of this form of hydrocele are those of diffused hydrocele of the cord, 
 but when he assumes the recumbent posture the tumor disappears, on account 
 of its reducibility ; and, as it often has a distinct impulse on coughing, this 
 swelling is likely to be mistaken for hernia. It, however, disappears more 
 slowly than the latter affection and without the characteristic gurgle, is slower 
 in reappearing, and is often translucent. It should be treated by the applica- 
 tion of a truss, which, especially in young persons, will often be followed by 
 the closure of the peritoneal prolongation at the internal ring. 
 
 In congenital hydrocele in children^ and, indeed, in all forms of hydrocele 
 in infants, the treatment by the use of the seton is extremely satisfactory. 
 The sac is punctured by a sharp tenotome, and a needle threaded with aseptic 
 silk is passed along the blade of the instrument and brought out through the 
 skin of the scrotum. The silk is loosely tied ; the contents of the sac drain 
 away by the side of the thread, which soon sets up sufificient adhesive inflam- 
 mation to obliterate the cavity of the sac; it should be removed in two or 
 three days, and should be covered in during its retention by an antiseptic 
 dressing. 
 
 DISEASES OF THE SCROTUM. 
 
 (Edema of the scrotum deserves mention, as it is sometimes mistaken for 
 hydrocele. It may follow any acute inflammation of the parts or any trauma- 
 tism, but is oftener produced by the conditions which cause oedema of the lower 
 extremities, such as cardiac and renal diseases. It is an almost invariable 
 
9G0 ^l.V AMl'JRICAN TKXT-llOOK OF SURGERY. 
 
 symptom of extravasation of urine superficial to Colles' fascia, in wliicli case 
 it soon extends to the subcutaneous tissue of the penis and prepuce, and often 
 to that of the abdomen. It may usually be easily recognized by tiie pitting 
 on pressure, the semi-transparent, glazed, and sliiniiig appearance of the skin, 
 the disappearance of the normal scrotal folds, tlie doughy feel, and tlie uniform 
 character of the swelling, "which is almost always bilateral. 
 
 No special treatment is necessary except in cases where it arises from 
 retained pus or urine, or where the tension is so great that the vitality of the 
 skin is threatened. Under these circumstances free incisions extending well 
 into the subcutaneous tissues should be employed. 
 
 Elephantiasis of the Scrotum is a disease which is accompanied by an 
 enormous hypertrophy of the subcutaneous connective tissue, due probably to 
 a chronic inflammatory condition of the lymph-vessels, which, in its turn, may 
 be produced by the presence in tlie blood of the filaria sanguinis hominis. 
 (See p. 472.) ' 
 
 Epithelioma of the Scrotum, known as chimney-sweep's cancer, is a 
 disease which has the characteristics of epithelioma elsewhere, beginning as a 
 little warty growth, usually at the lower part of the scrotum, often covered Avith 
 a peculiar crust, ulcerating, and gradually extending until all the superficial 
 tissues are involved. Later, the inguinal glands are infected, and the patient 
 dies as in otlier forms of carcinoma. It is exceedingly rare in this country, 
 and its comparative frequency at one time in Great Britain was supposed to 
 be due to the soft coal which was so commonly used there, the soot or particles 
 of which, accumulating in the flexures of the scrotum of an uncleanly person, 
 were thought to give rise to persistent irritation, which later determined the 
 cancerous growth. The treatment is by early and thorough excision. 
 
 PART VI.— DISEASES AND INJURIES OF THE PENIS. 
 
 Hypospadias. — This is a congenital deficiency in the lower wall of the 
 urethra, which may terminate at the perineo-scrotal junction or at any point 
 anterior to it. The varieties of hypospadias are described in accordance with 
 the degree of arrest of development which has occurred. If this has been 
 extreme, the anterior orifice of the urethra may even lie in the perineum, the 
 two halves of the scrotum remaining ununited, and often consisting of two 
 separate pouches, which- arc empty when the testicles have failed to descend, 
 and Avhich therefore resemble strongly the external genitalia of the female. 
 In these cases the penis is atrophied and is closely applied to the fissure in the 
 scrotum. In the penoscrotal variety the opening is at the junction of the 
 anterior fold of the scrotum with the inferior surface of the penis, and the 
 latter is apt to be somewhat better developed, although still strongly curved 
 downward, owing to its being much shorter on its inferior than on its upper 
 surface. In the penile variety of hypospadias the urethral opening may be 
 at any point on the lower surface of the penis between the peno-scrotal junc- 
 tion and the corona glandis. In the so-called balanic hypospadias the opening 
 of the urethra is situated on the under surface of the glans ; the fraenum is 
 absent. There is often a little groove at the anterior extremity of the glans 
 which resembles the normal meatus, but which usually ends in a blind j)ouch. 
 When this disease is situated far back, the patient is usually sterile, though 
 not necessarily impotent if the organ is well developed. Often, however, 
 it is so rudimentary or so markedly curved upon itself that intercourse is 
 impossible. The glandular forms of hypospadias are of no physiological 
 importance. 
 
SURGERY OF THE (i KXITO-Uli IXA liV TRACT. 
 
 961 
 
 The operation which has been most successful in the relief of this condition 
 is that Avhich has been formulated by Duplay, and is performed in three stages: 
 
 Fig. 376. 
 
 A B 
 
 Duplay's Operation for Hypospadias (Duplay and Reclus). 
 
 Fig. 377. 
 
 (1) The penis is straightened by incising transversely the ridge which unites 
 the glans to the hypospadic opening, and cnrrying this incision as deep as is 
 necessary to obtain complete straightening of the penis. 
 A considerable delay should follow this step, often as 
 much as three or four months if the incurvation has 
 been considerable. 
 
 (2) The next step should consist in the restoration 
 of the meatus and the formation of a new urethral 
 canal from the extremity of the glans to the neighbor- 
 hood of the hypospadic opening, Avhich should be left 
 untouched to give exit to the urine. The meatus is 
 formed simply by freshening the two lips or by deep- 
 ening the latter by means of incision, and then uniting 
 the lips over a small gum catheter. The remainder of 
 the canal is formed by making on each side of the 
 ])enis and on its lower surfoce a longitudinal incision extending from the base 
 of the glans to near the hypospadic opening (Fig. 376, A, ah, a'h'). The 
 internal lip of this incision is dissected up slightly, while the external is dis- 
 sected freely, so as to make a large flap, taken from the skin of the lateral 
 parts of the penis. These flaps are then united by quilled sutures of silver 
 wire or silk, perforated shot being employed to fasten them, or the wire or 
 silk may be passed through small perforated leaden plates or tubes (Fig. 376, 
 B). These flaps are united over the catheter, which will thus have a cuta- 
 neous covering at its upper and lateral aspect and a linear granulating surface 
 
 Gl 
 
 Transverse Section of the 
 Penis after Operation : S, 
 the new urethra (Duplay 
 and Reclus). 
 
0G2 AN AMU HI CAN TKXT-nooK OF SURUKliV. 
 
 bcnoatli it (Fi<;. 377). Diiplay asserts that no contraction of the canal results 
 fron) the cicatrix thus fornied. 
 
 (8) The third stage consists in the freshening of the fistulous opening which 
 is left, and the union of its edges over the retained catheter by means of the 
 same form of suture. 
 
 In the second stage several operations may he rcfpiired to secure a com- 
 plete urethra. An operation based on that of Wood of London, in which a 
 transverse incision is made in the ledundant ])r('j)uce close to the coronal 
 groove in the dorsum, the glans slipped through the opening thus made, the 
 prepuce brought down. s|)lit, and stitched to raw surfaces made by dissecting 
 up lateral penile flaps, has recently been revived by White, who re|)orts satis- 
 factory results. 
 
 Epispadias is an absence of the vipper wall of the urethra, and is much 
 rarer than hypospadias. It is often associated with exstrophy of the bladder. 
 It may be extensive, in which case the opening of the urethra is close to the 
 pubes, or there may be a congenital absence of the pubic symphysis. An ope- 
 ration similar to that just described is employed for its cure, but is often more 
 troublesome and less successful than that used for hypospadias. 
 
 Wounds of the Penis are of no special importance unless they involve 
 the urethra or extend deeply into the spongy or cavernous bodies. They should 
 be treated on the general principles which apply to the treatment of all wounds, 
 but will require in addition, in the majority of cases, the introduction and 
 retention of a metal catheter in order to give a point of support for sutures 
 or dressings. Hemorrhage is sometimes very obstinate. 
 
 When the urethra has been divided, immediate sutures, extending to the 
 submucous tissue, and a retained catheter should be employed. 
 
 Fracture of the Penis has been known to occur during coition, and 
 consists in laceration of the corpora cavernosa, followed by extensive extrav- 
 asation of blood into the erectile tissue. It has also occurred from injury 
 inflicted accidentally or maliciously, but always when the organ was in a 
 state of firm erection. Hemorrhage must be arrested as soon as possil)le by 
 enveloping the penis in cold clotlis and tightly bandaging it. If the disten- 
 tion from the escape of blood into the spongy tissue is so great as to imperil 
 the vitality of the tissues or of the organ, one or more incisions should be 
 made for the escape of blood. An annoying sequel of the accident is the 
 tendency to lateral or upward or dow^nward curvature during erection. This 
 is sometimes so marked as greatly to interfere with coitus, and even to render 
 the patient permanently impotent. 
 
 Phimosis is a condition in which the prepuce is unnaturally elongated, 
 and at the same time its orifice is contracted so that it is difficult or impos- 
 sible to uncover the glans. It is generally congenital, although occasionally 
 acquired as the result of masturbation at a very early age. It is of more than 
 local importance, as in the young it keeps up a continual irritation which often 
 leads to masturbation or to vesical irritability. It frequently interferes with 
 the full growth and development of the organ. The balanitis and balano- 
 posthitis to which it gives rise are sometimes followed by grave nervous symp- 
 toms — chorea, epilepsy, and other diseases of a similar character. It also 
 favors greatly the contraction of venereal disease. 
 
 The operation of circumcision is indicated in every case in which the above 
 condition exists. No child is too young for its performance, and most adults 
 with hypertrophied foreskins with small orifices would be benefited by the 
 operation. In preparing for its performance the two layers of the prepuce 
 should be carefully washed with soap and water, and disinfected and rendered 
 
SURGERY OF THE G EX/TO- URINARY TRACT. 963 
 
 aseptic in the usual manner. The prepuce is then drawn forward, so that it can 
 be grasped in front of the anterior extremity of the ghms by a pair of forceps 
 the bhides of whicli are long enough to extend on either side beyond its edges. 
 These may be self-retaining or may be entrusted to an assistant.' The operator 
 then seizes the projeeting portion of the prepuce and removes it by means of a 
 sharp bistoury, cutting along the anterior edge of the forceps. These being re- 
 moved, it will be found that while the skin retracts to or behind the corona the 
 ghins is still covered by the hood-like mucous membrane. This should now be 
 divided in the median line up to the dorsum of the glans near the corona, and 
 then should be trimmed oft" at a distance of a sixteenth to an eighth of an inch 
 from the point of reilection, following the curve of the coronal edge, and either 
 going through the frjBnum or leaving it untouched, according to the amount of 
 hypertrophy present at that point. It should be remembered that the chief 
 cause of the not infrequent failure of young o])erators permanently to uncover 
 the glans penis by this operation is their neglect to cut this fold sufficiently 
 short. When it is left long enough to come forward in front of the meatus, it 
 brings with it the elastic and extensile skin: the cicatrix forms in that position, 
 and the phimosis for which the operation was performed recurs. By leaving 
 the strip of mucous membrane no broader than an eighth of an inch this 
 accident may always be prevented. If the frenal artery is cut during the 
 operation, it should be ligated with fine catgut. Torsion is not always reliable. 
 The edges of the skin and mucous membrane should be brought into appo- 
 sition by a few interrupted sutures, and the line of incision dressed wuth some 
 unirritating antiseptic. Some operators prefer an entirely dry dressing, and 
 Palmer of Louisville describes as follow^s a method by which he has had^dmi- 
 rable results : After stitching, a piece of dry aseptic gauze, four inches long 
 and half an inch wide, covered with iodoform and boric acid and spread on a 
 clean towel, is laid under the frsenum, brought up around the cut, right and left, 
 to the dorsum, and trimmed Avith scissors. Over this a strip of absorbent cotton 
 three-quarters of an inch wide, then a Maltese cross of dry gauze, with a 
 central hole for the meatus, and then a similar cross of rubber tissue, are 
 applied, and the whole bandaged snugly in place. A waist-belt, a jock-strap, 
 and a bunch of cotton to cover the glans, Avell dusted with boric acid, com- 
 plete a dressing that permits the subject to go to work at once at any ordinary 
 vocation. If the patient will retract the dressing on urinating and use a little 
 absorbent cotton to receive the final drops, this original dressing mav be left 
 on five days. When the stitches are removed the parts should be dusted with 
 boric acid, a loose pledget of cotton wrapped around them, and the patient 
 discharged. 
 
 Occasionally, owing to oozing of blood, it may be found necessary to make 
 additional pressure. In such a case an extra one-inch roller may be applied 
 over the dressing, to be removed some hours later without disturbing the dress- 
 ing proper. 
 
 Inflammation of the Penis is usually the result of extension either from 
 a severe infective urethritis or from a phagedenic chancre or chancroid. 
 
 Gangrene of the Penis is almost always the result either of mechanical 
 obstruction, as where, either for mischief or for purposes of sexual excitement, 
 foreiirn bodies have been tied around the organ, or of phagedena. It occasion- 
 ally follows unrelieved cases of paraphimosis. 
 
 Epithelioma of the penis and of the foreskin has the usual characteristics 
 of this disease elsewhere. It is favored by the presence of a long or contracted 
 prepuce and by accumulations of smegma, by concretions or calculi, or by any 
 other source of local irritation. If it is confined to the foreskin and is reco.y- 
 
964 AX A.VFRrf'AX TKXT-JIOOK OF Sr^RGKRY. 
 
 nized early, circumcision is sufficient treatment. But if, as is more commonly 
 the case, it has already extended to the glans, nothing short of amputation of 
 the penis will be of any value, and it is better in these cases to sacrifice the 
 larger portion of the organ. 
 
 The operation is a simple one : the hemorrhage may be controlled by the 
 grasp of the thumb and finger of an assistant close to the pubes or by sur- 
 rounding the root of the organ with a narrow rubber cord ; and a circular 
 stroke of the knife at a point well behind the uppermost limit of the disease 
 is sufficient for the removal of the organ. The vessels may be tied separately ; 
 the mucous membrane can be brought forward and stitched to the skin, or, if 
 the operation is modified and the corpus spongiosum containing the urethra is 
 left somewhat longer than the rest of the stump — the better plan — the urethra 
 may be slit up with scissors, and the lower wall attached by a suture to the 
 skin of the under surface of the penis, while the cut edges of the upper wall 
 are sutured to the corpora cavernosa. The retained catheter will be required: 
 an antiseptic dressing, preferably of iodoform, should be applied around it, and 
 if there occurs any moistening of the parts with urine, they should be irrigated 
 and dusted afresh with iodoform daily. The method of section by the ecraseur 
 is not to be recommended. 
 
 Amputation of the entire penis is sometimes required for malignant dis- 
 ease. The operation is as follows (Treves) : The patient having been placed 
 in the lithotomy position, the skin of the scrotum is incised along the whole 
 length of the raphe. With the finger and the liandle of the scalpel the halves 
 of the scrotum are then separated down to the corpus spongiosum. A full-sized 
 metal catheter is now passed as far as the triangular ligament, and the knife 
 is inserted transversely between the corpora cavernosa and the corpus spongi- 
 osum. The catheter having been withdrawn, the urethra is cut across. The 
 deep end of the urethra is then detached from the penis back to the triangular 
 ligament. An incision is next made round the root of the penis continuous 
 with that in the median line ; the suspensory ligament is divided, and the penis 
 separated except at the attachment of the crura. The knife is now laid aside, 
 and with a stout periosteal elevator or rugine each crus is detached from the 
 pubic arch. This step of the operation involves some time, on account of the 
 very firm union of the parts to be separated. Four arteries — the two arteries 
 of the corpora cavernosa and the two dorsal arteries — require ligature. The 
 corpus spongiosum is slit up for about half an inch, and the edges of the cut 
 are stitched to the back part of the incision in the scrotum. The scrotal 
 incision is closed by sutures, and a drainage-tube is so placed in the deep 
 part of the wound that its ends can be brought out in front and behind. 
 No catheter is retained in the urethra. 
 
SURGERY OF THE FEMALE GEXERATIVK ORGANS. 965 
 
 CHAPTER VIII. 
 
 SURGERY OF THE FEMALE GENERATIVE ORGANS. 
 
 Anatomical Memoranda. — Certain anatomical data are important to be 
 borne in mind by the surgeon in the investigation and operative treatment of 
 the generative organs of the female. 
 
 The peritoneum which invests the uterus descends in front only far enough 
 to cover the upper three-fourths of its surface (Fig. 378). Being reflected 
 
 Fig. 37S. 
 
 Diagrammatic Sagittal Section of the Female Pelvis: U, uterus; R, rectum: S, symphysis : P, perineal body ; 
 B is beneath bladder. This is the position of the uterus when the bladder is alniost empty (Skene). 
 
 thence upon the posterior wall of the bladder, usually at about the level of the 
 OS uteri internum, the lower segment of the uterus, anteriorly, is left in close 
 relation to the base of the bladder, being separated from it only by a thin 
 layer of loose connective tissue. Along the posterior surface of the uterus the 
 peritoneum descends somewhat below the level of the vaginal insertion before 
 it is reflected backward upon the rectum. The layers of the peritoneum which 
 extend laterally from the uterus to the sides of the pelvis, constituting the 
 broad ligaments, enfold the Fallopian tubes, the ovaries, the parovarium, and 
 the round ligaments, together with the cellular tissue, lymphatics, nerves, and 
 some muscular fiber. When tension is made upon the round ligaments from 
 without so as to draw them out through the internal abdominal ring, as in 
 
imC) 
 
 AX AMERICAN TEXT-HOOK OF SrUOEUY. 
 
 Fig. 
 
 operations to shorten them, their closely-attached ])eritoncal covering is drawn 
 out with them to some extent, and rec^uires to be carelully detached and re- 
 flected in order to make possible the extraction of the required amount of 
 the ligament. 
 
 The ovaries project upon tlie posterior surface of the broad ligaments, and 
 the fiTnbriated extremities of the tubes droop posteriorly toward the ovaries. 
 To this anatomical relation is due the fact that in inllanimatory affections of 
 the ovaries and tubes these organs tend to sink into and become adherent in 
 the posterior cul-de-sac, where they must be sought by the finger of the sur- 
 geon for the purpose of enucleation. The two layers of the broad ligaments 
 are loosely joined by connective tissue. They are easily separated to an 
 indefinite extent by hemorrhagic or inflammator}^ effusions or by the develop- 
 ment of new growths. The ovarian artery courses along the upper border of 
 the outer part of the broad ligament. If traction is made upon the ovary so 
 as to make tense and prominent the part of the ligament extending from the 
 ovary to the lateral pelvic Avail, the artery may be easily identified, and pre- 
 liminary ligation or compression of it may be readily done. 
 
 The uterine artery, leaving the lateral pelvic wall at a point just above the 
 ischial spine, reaches the vaginal wall at the level of the os externum, and 
 
 thence runs upward toward the 
 uterus (Fig. 379). Opposite the 
 junction of the vagina and uterus 
 it gives off a good-sized branch, 
 which with its fellow of the op- 
 posite side encircles the cervix. 
 Thence it runs tortuously up the 
 side of the uterus between the 
 folds of the broad ligament, giv- 
 ing off" frequent branches to the 
 uterus, and finally inosculates with 
 the ovarian artery above. Pre- 
 liminary ligature of this artery 
 may be readily done from the 
 vagina by pulling the cervix down 
 toward the vulva, and then pass- 
 ing a ligature by means of a well- 
 curved needle introduced deeply 
 at the side of the cervix through 
 the lateral vaginal pouch. The 
 needle, having described a curve 
 through the tissues, is brought out 
 a short distance behind its point 
 of entrance. The ligature which 
 thus introduced will have 
 
 379. 
 
 IS 
 
 Relations of TTreters and Uterine Arteries to the Cervix 
 V, uteni ; C, cervix ; la, vagina; Vt, ureter ; A U, uter 
 inc arteries (Pozzi). 
 
 passed around the artery, and 
 when firmly drawn and tied will 
 have closed it. The uterine artery 
 may also be tied from above within the pelvis, Avhen the pelvic organs have 
 been exposed by abdominal section, by drawing the uterus to the side opposite 
 to that upon which the ligature is to be applied, and then carrying a curved 
 needle, armed with a ligature, through the attachment of the broad ligament 
 to the uterus, so as just to engage the substance of tlie uterus ; then, having 
 penetrated both layers of the broad ligament, it should be carried back, per- 
 
SURGERY OF riJK FEMAJ.E G EXE RATI VE ORGANS. 9G7 
 
 forating the ligament again at a point about three-eighths of an inch to the 
 outside of the first perforation. The artery Avill be embraced by this loop, 
 which may then be tied. 
 
 The ureters in their course toward the base of the bladder approach later- 
 ally to within about half an inch of the uterus at the level of the os internum. 
 They preserve about this distance from the cervix as they pass onward to the 
 bladder, the opening of the ureter into the bladder being about half an inch 
 anterior to the cervico-vaginal junction (Fig. 879). The lower outlet of the 
 pelvis is closed in by a diaphragm of muscular and fascial tissue, the fibers of 
 which, having their origin from the lateral bony points, blend in the middle 
 line, where they converge to the outlets of the rectum and the vagina. By 
 the integrity and tonicity of the various parts of this complex diaphragm the 
 pelvic viscera are held in place. Additional support is received from the peri- 
 toneal reflections that envelop the pelvic viscera, and from the fibrous strands 
 and connective-tissue substance that bind them together. 
 
 By the extensibility, the contractility, and the mobility of its different 
 supports the widely-varying degrees of distention and of contraction which 
 the functions of the pelvic organs normally require are made possible. This 
 peculiarity of structure makes it possible for the uterus to be drawn down to 
 the vaginal outlet for examination and for operative attack, and facilitates 
 the introduction of specula and of the finger for purposes of exploration. 
 By the rupture or over-distention of important portions of this diaphragm 
 the pelvic organs, 'deprived of their proper support, tend to sink down perma- 
 nently from their proper positions and to protrude in varying degrees through 
 the outlets below. 
 
 METHODS OF INVESTIGATION. 
 
 Diagnostic investigations of the generative organs of the female include 
 examination by inspection, palpation, percussion, and exploratory puncture. 
 
 The bladder should always be evacuated, preferably by a catheter. 
 When distended with urine, it has been mistaken for an abdominal tumor. 
 (See Fig. 345.) 
 
 Inspection. — Inspection includes the careful observation of the hypogas- 
 trium and the pudenda, and the exposure of the cavity of the vagina and the 
 surface of the vaginal portion of the cervix uteri by proper specula. Micro- 
 scopic investigations may properly be classed as methods of inspection. 
 
 Inspection of the hypogastrium requires the supine position ; of the pudenda, 
 the same posture with "the knees drawn up and the thighs abducted. For intra- 
 vaginal inspection a retractor for the perineum is required ; for instance, the 
 well-known retractor of Sims. The patient, having been placed upon a table 
 of proper height, is made to lie upon her left side, the left arm behind the back, 
 the thorax fully prone upon the table, the right knee fully flexed and brought 
 up as far as possible under the body, while the left knee and leg are carried up 
 about half the distance. The pelvis is now brought to the edge of the table, 
 the retractor inserted into the vagina, and the perineum strongly drawn back. 
 The vagina is distended by the air which is thus admitted, and by properly 
 varying the depth to which the retractor is inserted and the direction in which 
 traction is made, together with elevation of the right labium and natis by the 
 hand of an assistant, the entire vagina and the vaginal portion of the cervix 
 uteri may be brought into view. Inspection may be still further facilitated by 
 elevating the anterior wall of the vagina by a suitable rod or speculum and by 
 drawing down the uterus with a tenaculum. 
 
 Palpation. — By the touch may be ascertained the rigidity of overlying 
 parts; the sensitiveness of the organs; their position, size, shape, and den- 
 
968 
 
 .l.V AAfL'h'/CAX TKXr-liOOk' OF sriidHh'Y. 
 
 sity ; tlicir iii()l)ility and tlit-ir relations to other oi'^ans : tlie presence of adhe- 
 sions, infiltrations, exudations, and tumors ; the character and extent of tumors 
 and other abnormal masses. 
 
 For the purpose of palpation that position should be secured which will 
 relax as much as possil)le the nmscular and fascial coverings that hide the parts 
 to be palpated. As a rule, the suj)ine position, with the knees drawn up on a 
 firm table of j)roper lieiji^ht, is the most favorable, (jreat differences exist in the 
 comi)leteness with which palpati(»n may be done uj)on dif!'erent individuals, owinj^ 
 to the varying degrees of rigidity and sensitiveness of tissues and of accumu- 
 lations of adipose tissue. The more relaxed and thin the tissues, the more 
 facile the palpation. The induction of relaxation by complete anesthesia is 
 often recjuisite to make satisfactory palpation possi))le. 
 
 Large pelvic tumors are readily detected and much valua])le information 
 about them is to be gained by simple hypogastric palpation. 'J'heir size, their 
 mobility, wlietlier solid or fluid, their shape, the readiness with which the 
 abdominal wall can be made to glide over them, may be ascertained with con- 
 siderable accuracy. The vaginal touch in such cases may supplement the 
 hypogastric, and is especially valuable in determining the relations of the 
 tumor to the uterus and the character of the deeper portion of the tumor. 
 
 Palpation of the ovaries, tubes, and uterus should always be done by the 
 combination of hypogastric pressure with the vaginal or rectal touch — bimanual 
 
 Fig. 380. 
 
 Bimanual ralpation (Pozzi). 
 
 palpation. The external hand should be placed above over the nonnal site of 
 the organ to be examined, and deep, firm pressure should be exerted in the 
 direction of the tip of the vaginal or rectal finger, so as to push the organ 
 down toward it and prevent its escape. The finger which is in the vagina 
 should at the same time press upward into the pelvis as far as possible. In 
 this way in favorable cases the organ can be balanced between the tAvo forces 
 and its examination satisfactorily effected (Fig. 380). Rectal examination 
 may be made more complete and satisfactory by simultaneously drawing down 
 the uterus toward the vulva by a tenaculum in the hands of an assistant. 
 The uterine sound is available as a means of ascertaining the depth and direc- 
 
SUliClKRY OF rill': FEMM.E (iKNKIiATIVK OlidANS. 969 
 
 tion of the uterine canal. It is practically a lengthened finger, and its use is 
 one form of jjalpation. It is rarely needed. 
 
 Pereu^min. — The relative dulness or resonan(;e ovci- the hypogastric region 
 gives valuahle infoniiation as to the |)resence and location of inflated intestine 
 and of solid or lluid tiniioi\s. It is chietlv valuahle in distinLrnishin<£ ascitic 
 fluid from cysts. 
 
 Exploratory Puncture. — Information as to the composition of an ohscure 
 swelling deep in the pelvis may be obtained by the use of a small trocar and 
 aspirating syringe. Its results cannot always be considered as certain, for a 
 swelling may be fluid at one part and solid at another, and the exploring ti-()car 
 may not reach the fluid part, and so conclusions ))ased upon the results of its 
 insertion mav be erroneous. Danf^er of woundin<i: other orj'ans or vessels or 
 ■of introducing or disseminating infection attends its use, so that it should rarely 
 be resorted to, especially as the information sought to be gained by it can gene- 
 rally be obtained by other means. Whenever it is resorted to it should be 
 with the most careful antiseptic precautions. 
 
 SURGERY OF THE VULVA. 
 
 Injuries of the Vulva are likely to be attended with special symptoms 
 from the rupture of some branch of the rich venous plexus with which it is 
 supplied. Penetrating wounds may occasion copious hemorrhage ; contusions 
 may produce extensive infiltrations of blood. These are to be treated on the 
 general surgical lines described in the chapter devoted to Wounds in general. 
 The more distinct blood-masses, hcematoma vulvce or pudendal hematocele, as 
 a rule disappear in time under simple rest and gentle pressure. When the 
 €ff"usion is so large as to cause decided pressure eff"ects. or when the distended 
 tissues threaten spontaneously to give way, it is better, with proper antiseptic 
 precautions, to lay the whole mass freely open by the knife, turn out the clots, 
 ligate or clamp any bleeding points, and allow the wound to granulate. 
 
 Inflammations of the Vulva. — The muco-cutaneous covering of the 
 vulva may be provoked to inflammation by the presence within its folds of 
 irritating foreign matter, of decomposing secretions, or of acrid discharges ; by 
 undue friction ; and by the extension of inflannnation of parts adjacent to it. 
 The inflammation may be diffuse and superficial, may extend to the deeper 
 layers of tissue, or may be limited to the muciparous or sebaceous follicles. 
 Diabetic subjects are prone to the development of an aggravated eczema of 
 the vulva, due to the irritation of fermenting saccharine urine which is per- 
 mitted to moisten the parts. By the infection of abrasions or wounds phleg- 
 monous suppurative inflammation may develop. Gangrenous inflammation of 
 the vulva — noma — occasionally occurs in persons whose resisting power has 
 been undermined by exhausting disease or constitutional cachexige. It has 
 most frequently occurred in badly-nourished children as a sequel to one of the 
 eruptive diseases. The ulcerations and eruptions (mucous patches) seated upon 
 the vulva, due to venereal infection, have been treated in the chapter devoted 
 to Syphilis. 
 
 Symptoms. — The parts are tender and congested, and more or less tume- 
 fied and covered with muco-purulent secretion. Raw patches due to exfolia- 
 tion of epithelium may be present. Pruritus is apt to be a source of com- 
 plaint. In the follicular variety minute red papular elevations may stud the 
 surface of the part. These are the congested orifices of the aff"ected follicles, 
 and give exit to an altered and increased mucous or sebaceous secretion. 
 Inflammation of the gland of Bartholin will declare itself by the appearance 
 
970 AN AMERICAN TEXT-BOOK OE SURGERY. 
 
 of a painful tense oval swelling Ioav down upon the inner aspect of tlie vulva 
 at the entrance of the vagina. In the phlegmonous forins of vulvitis increased 
 local swelling and pain and more marked constitutional reaction are present 
 Suppuration and gangrene are indicated by their usual signs. 
 
 Treatment. — The milder forms of vulvitis need little more tlian rest, the 
 removal of the exciting cause, and cleanliness. The parts ma}' be irrigated 
 with a warm solution of l)orax or boric acid, and the labia kept separated 
 by a fold of soft absorbent fabric, as absorbent gauze, saturated Avith oxide-of- 
 zinc cream, the latter being simply enough oxide of zinc stirred up in water 
 to form a creamy fluid, which may be extemporaneously prepared as often 
 as needed. Solutions of permanganate of potassium, sulphate of zinc, alum, 
 nitrate of silver, and otlier mildly antiseptic and astringent substances may 
 also be used to advantage for purposes of irrigation. When tlie inflammation 
 is more acute and painful, warm fomentations of lead and opium (lie}, plumbi 
 subacetat., ,lij ; tinct. opii, f§j ; aquae, Oij) are to be used until the acute 
 symptoms subside. Deep suppuration requires treatment by early incision, 
 as in other parts of the body. Gangrene should be attacked locally by the 
 free use of the actual cautery or of tlie knife, followed by a saturated solution 
 of chloride of zinc, so as to destroy the local infective poison, with subsequent 
 continuous antisepsis of the parts by iodoform tampons, while every possible 
 means to stimulate the general strength of the patient should be employed. 
 
 Pruritus. — The annoying itching which attends the various forms of 
 vulvitis may require special treatment for its relief while the measures required 
 for the cure of the conditions that cause it are being carried on. The vulvar 
 surfaces must be protected as far as possible from the contact of all irritating 
 discharge. The antiseptic washes used for the relief of the vulvitis may suffice 
 for this. Keeping the vulva well smeared with a bland ointment, as ungt. 
 zinci oxidi, will give relief. The use of a solution of corrosive sublimate in 
 emulsion of bitter almonds (1 : 500) Avill give the combined antiseptic and anti- 
 pruritic eifects of the mercurial and of hydrocyanic acid. It may be employed 
 twice daily. In diabetic cases the fermentation of the urine may be kept in 
 check by the free use of a 3 per cent, solution of hyposulphite of soda or of 
 chloral. In senile pruritus pudendi, in which there is atrophy of the nerve- 
 terminals, rather than inflammatory irritation, peppermint-water Avill sometimes 
 afford relief — five drops of oil of peppermint shaken up thoroughly in a pint of 
 hot Avater to Avhich a teaspoonful of borax has been added. The parts should 
 be bathed freely Avith this lotion. An 8 per cent, solution of cocaine pencilled 
 over the parts Avill also sometimes afford relief. In inveterate cases that have 
 resisted other treatment relief may possibly be obtained by pencilling the entire 
 affected surface Avith a mixture containing equal parts of carbolic acid and tinc- 
 ture of iodine. A superficial eschar is produced, Avith permanent change in the 
 sensitiveness of the nerve-endings. Certain cases resist all treatment and re(juire 
 the constant use of opiates to relieve the suffering Avhich the affection entails. 
 
 Tuberculosis Vulv^. — The labia are occasionally the seat of local tuber- 
 cular infection. The disease in its advanced ulcerative stages has been termed 
 lupus vulvae, and by the French esthiomene. The local infection first mani- 
 fests itself by the formation of superficial tubercles, Avhich coalesce. The moist- 
 ure and Avarmth of the parts favor early necrosis. The resulting ulcer grad- 
 ually extends peripherally, surrounded by a zone of infiltrate<l infected tissue. 
 The edges of the ulcer are thin, purple, and undermined, and its base is irreg- 
 ular and eroded, secreting a scanty, thin, puriform discharge. Cicatrization is 
 frequently present at one part while the ulcer is extending at other points. 
 The extent of the infiltration and the destruction of tissue may vary greatly: 
 
SURGERY or THE E EM ALE GENERATIVE ORGANS. 971 
 
 in some instances the inflammatory and tubercular infiltration of the parts is 
 sufficient to occasion great increase in their volume; in others, a predominating 
 ulcerative action, involving especially the skin and adjacent connective tissue, 
 may produce extensive dissections about the vagina, bladder, and rectum. 
 Erosion of blood-vessels may provoke repeated hemorrhages. The affection 
 is most freciueiit in the young, and is likely to be accompanied with tuber- 
 culosis of other portions of the body. Recurrence after apparent healing is 
 frequent. 
 
 Diagnosis. — The affection is to be distinguished from epithelioma and 
 from syphilitic ulceration : differentiation is not ahvays easy, but may usually 
 be made by attention to the following points: 1. The age of the patient: the 
 tubercular ulcer is most common in early life, epithelioma in later life. 2. The 
 history : antecedent syphilis ; tuberculosis in other parts of the body. 3. The 
 appearance of the ulcer : the epithelioma exudes a more abundant fetid secre- 
 tion ; its surface is mammillated, its edges are heaped up, and its base is more 
 extensively and deeply infiltrated. The syphilitic ulcer is crateriform, with 
 sharply-cut edges, in marked contradistinction to the flat, superficial eroded 
 tubercular ulcer with its undermined edges. 4. The effects of treatment : anti- 
 syphilitic treatment causes speedy improvement in the syphilitic ulcer ; is with- 
 out benefit in the other forms. 5. Bacteriological tests : the detection of the 
 bacilli of tuberculosis- by adequate tests suffices to establish the diagnosis. 
 
 Treatment. — Constitutionally, measures calculated to improve the general 
 health which are of proved value in dealing with tuberculosis in any part of 
 the body are to be vigorously resorted to. Locally, thorough curetting of the 
 base and borders of the ulcer should be done, scraping away all the somewhat 
 soft and degenerated tissue which may be present, and which will readily yield to 
 the curette. The remaining surfaces should then be cauterized with the thermo- 
 cautery or with a saturated solution of chloride of zinc. Tampons of iodoform 
 gauze or dressings of Peruvian balsam should be used in the after-treatment 
 till full cicatrization is accomplished. 
 
 Tumors of the Vulva. — The labia may become the seat of any of the 
 growths, benign or malignant, to which similar tissue in other parts of the 
 body is subject. Out of 10,290 neoplasms in females recently analyzed by W. 
 R. Williams, 420 had their initial seat in the external genitals, including the 
 vagina. Of these, 158 were epitheliomata ; 3 were sarcomata ; 17 were fibro- 
 mata ; 1 was a lipoma ; 167 were non-venereal papillomata, of which 148 were 
 urethral caruncles ; and 74 were cystomata. 
 
 Papillomatous Growths sometimes display much luxuriance, Avhich is 
 favored by the warmth, moisture, and friction of the parts. They should be 
 excised if pedunculated ; destroyed by caustic if broadly sessile. Small vas- 
 cular papillomata at the entrance of the urethra — urethral caruncles — are 
 common. They appear as bright-red, fleshy growths of small size, and are 
 often the source of much annoyance from smarting during urination and from 
 bleeding. They may be destroyed by cauterization or by excision, great care 
 being given to the absolute arrest of the bleeding. 
 
 Malignant Disease of the Vulva tends to rapid extension and early 
 involvement of the adjacent lymphatic glands. Excision to be of any avail 
 must be done early and with care to excise a wide area of the apparently 
 uninvolved tissues. 
 
 Dermoid and Sebaceous Cysts are met with, but the most common cys- 
 tic tumor of the vulva is a retention-cyst of the glands of Bartholin, 
 which presents itself as an ovoid, tense, elastic, painless tumor low down at the 
 vulvo-vaginal junction. It may demand no treatment, but if its size becomes 
 
972 AN AMERICAX TEXT-BOOK OF SURGERY. 
 
 inconvenient it should be dissected out. If it becomes inflamed, it should be 
 freely laid open and its sac dissected out. 
 
 Lymphcrdema, or Elephantiasis, occurs in the vulva next in frequency 
 to elephantiasis of the leg and foot. Extirpation with the knife is the only 
 remedy of any value. 
 
 YARirosE VEINS of the vulva are frequently met with. They may arise 
 spontaneously, or may be due to the pressure of a pregnant uterus or of a 
 pelvic turaorupon the venous trunks into which the vulvar veins empty, or to 
 occlusion of the latter. In the latter cases rest in the recumbent posture and 
 gentle support by a properly-adjusted compress is the most that can be done 
 by way of palliation. In other cases ligation and excision of the varicose 
 vessels are re(juired. 
 
 Adherent Labia. — Adhesion of the opposite surfaces of the labia minora 
 is not uncommon in infants as the result of slight vulvitis from defective clean- 
 liness. The adhesions are usually not very firm, and give way to traction. 
 If necessary, the knife may be used to accomplish their separation. The parts 
 should be kept separated by a suitable compress until the abraded surfaces of 
 the labia become healed. 
 
 More dense and extensive adhesions of the labia in later life may result 
 from ulcerative inflammation of these parts and their blending together in the 
 subsequent cicatrization. Such adhesions require the knife. 
 
 SUEGERY OF THE PERINEUM. 
 
 Rupture of the Perineum may be occasioned by accidental traumatism, 
 but is commonly the result of over-distention of the perineal body during 
 childbirth. Every degree of laceration may result from this latter cause, 
 from slight tears of the fourchette to extensive rents involving the sphincter ani 
 and a portion of the recto-vaginal septum. If the rent does not involve the 
 sphincter ani, it is termed an incomplete rupture ; if the sphincter is involved, 
 the rupture is said to be complete. In other and not infrequent instances 
 subcutaneous rupture of the muscular tissue and fasciie of the perineum takes 
 place, producing relaxation of the pelvic floor and loss of perineal support, 
 although the skin and mucous surfaces remain intact. Such injuries may be 
 termed concealed ruptures. 
 
 The chief disabilities determined by tears of the perineum depend upon 
 the greater or less loss of the muscular support to the pelvic viscera which 
 results. The injury, as a whole, is a combination in varying amounts of 
 separation, paresis, and atrophy, the eff'ects of over-distention and bruising as 
 well as of laceration, so that often the apparent tear gives little clue to the 
 extent of the real loss of support. 
 
 The symptoms are, first, a sense of Aveakness and of dragging down of 
 the pelvic organs from the sagging down of the pelvic floor and the resulting 
 undue stretching of the remaining supports ; and, secondly, actual prolapse in 
 varvinjr degree of the vajrina, bringino; with it the anterior wall of the rectum, 
 reetocele, and the base of the bladder, ci/stocele, and ultnnately the uterus, 
 procidentia uteri. These conditions of relaxation and prolapse are often greatly 
 aggravated by the imprudence of patients in leaving their beds within a few 
 days after delivery, before full involution of the uterus has taken place and 
 before the overstretched and semi-])aralyzed tissues of the pelvic floor have had 
 time to regain their tone. Rupture of the sfthincter ani adds to the above 
 symptoms those of incontinence of feces and of flatus. 
 
 Treatment. — Immediate suture of a perineal rent for the purpose of secur- 
 
SURGERY OF THE FEMALE GENERATIVE ORGANS. 973 
 
 ing primary union if possible should always be done. These tears are lacerated 
 and infected Avounds, and are to be nianajied in accordance with the general 
 principles governing the treatment of such wounds. Special care should be 
 taken so to place the sutures that perfect coajitation of the inuscular elements 
 of the perineum shall be secured. A strip of iodoform or oxide-of-zinc gauze 
 should be laid in the vagina, protruding from the vulva, to act as a drain for 
 the vagina, preventing accumulation of the lochia within it, and an abundant 
 absorbent compress sliould cover the perineum and vulva, and be changed as 
 often as saturated. The bowels should be kept loose, and the bladder relieved 
 by catheter during the first week. The sutures should remain in situ for ten 
 days, but should be removed at any time if evidences of deep suppuration 
 demand the abandonment of the attempt at primary union. The usual ten 
 days' recumbency observed after childbirth should be prolonged to at least 
 twenty-one. 
 
 I^erineoplasti/. — Plastic operations for restoration of the perineal body are 
 required when primary suture has failed or been omitted. They should not be 
 undertaken until from six to twelve months after the original injury, and a 
 time should be chosen when both the local and the constitutional conditions of 
 the patient are good. In the complete variety relaxation of the contracted 
 sphincter should first be secured by distending it twice daily for a Aveek or 
 more before the operation by inserting a finger into the anus and pressing 
 the parts firmly back toward the coccyx for five minutes at a time. 
 
 As an essential preliminary in all cases the bowels should have been thor- 
 oughly cleaned out by a course of laxatives, and the rectum finally Avashed out 
 by copious enemata before the operation. An hour before the operation a sup- 
 pository containing a grain of opium should be placed in the rectum. The 
 vagina and the vulva should have been subjected to repeated boro-salicylic or 
 hydro-naphthol douches for some days, and the parts about the field of ope- 
 ration should be shaved and Avell scrubbed immediately before beginning the 
 operation. 
 
 The instruments required are few and simple, including a sharp bistoury, 
 scissors curved on the flat, two pairs of mouse-toothed forceps and one of dis- 
 secting forceps, a dozen hemostatic forceps, a needle forceps, two or more large 
 full-curved needles, preferably Hagedorn's pattern, as many small curved 
 needles, and a pair of suitable retractors for holding back the labia. Silk 
 thread, sterilized by boiling or steam shortly before using, is to be preferred 
 for sutures — a coarser thread for the deep sutures, a finer one for superficial. 
 Catgut is to be used for ligatures, and occasionally will be best for sutures. 
 The patient should be put in the lithotomy position, with the pelvis elevated 
 on a hard pillow. Should operations upon the cervix uteri or upon the ante- 
 rior vaginal wall be required, they may be done at the same sitting before 
 beginning with the perineum. 
 
 The operative procedures will vary according as the laceration is of the 
 incomplete or the complete variety. The concealed variety are to be made into 
 the incomplete by transfixion Avith the bistoury and incision as the first step of 
 the operation. Much scope to the ingenuity and judgment of the surgeon Avill 
 be given in the effort to meet the varying conditions of different cases, while 
 he keeps in vicAv the primary indication of bringing together and securing 
 the reunion of the divided and separated muscular elements of the perineum. 
 These have retracted on each side toAvard the pubic rami, and a careful in- 
 spection of the parts when the labia are held asunder will usually discover 
 some lateral depresssion in the borders of the cicatrized laceration indicating 
 the site of these muscular stumps. A more marked dimpling on each side of 
 
974 
 
 ^.V AMFJUCAX Ti:X'r-r,(i()K OF SI' lid EH V. 
 
 tlio anus shows jdaiuly tlio sites of the retracted ends of tlie sphincter ani wlien 
 the laceration is a complete one. Whatever incisions are made must l>e planned 
 so as fully to denude these points, and the sutures must be placed so as to bring 
 and hold them in apposition till reunion has occurred. This may usually be 
 best done in the following manner: 
 
 I. Incomplete Laceration. — The labia being held apart, the sur- 
 geon, having noted the beginning of the cicatricial tissue on each side at 
 the base of the nym])lue, makes an incision through the skin along the outer 
 edge of the cicatri.x, from one to the other of these points (Fig. 8M1). The 
 vaginal end of this incision is now seized at its middle by a pair of forceps, 
 which retains its hold upon it until the close of the ojieration, lifting it uj) and 
 holding it out of the way as the work progresses. With the scissors the surgeon 
 
 Fig. 381. 
 
 Fig. 382. 
 
 Line of Incision in Perineoplasty (Pozzi). 
 
 Perineoplasty, the Vaginal Flap raised (Pozzi). 
 
 now works his way in between the rectum and the vagina for about an inch and 
 a half below and well into the base of the labia on each side. As the vajjinal 
 flap is raised up without removing any tissue, a broad and extensive area of 
 denudation is formed (Fig. 882). The splitting of the tissues should be car- 
 ried deeply into the lateral sulci, so as to expose the retracted muscular stumps. 
 At this ])oint there is likely to be free bleeding, for the control of which pres- 
 sure forceps, hot-water tampons, ligatures, and the after-pressure of the deep 
 sutures will suffice. Caution will often be re(juired in the course of tlie dis- 
 section to avoid opening into the rectum, but care to keep the dissection along 
 the plane of the loose submucous tissue between the vagina and rectum will 
 prevent such an accident. 
 
 Bleeding having been arrested, the sutures are to be placed. The deep 
 sutures are first in order. Beginning at the lower angle of the denudation, a 
 large strong needle, armed with a strong coarse thread, is introduced clo.se to 
 the margin of the incision, passed outward deeply into the tissues, and made to 
 sweep around so as to emerge in the center of the wound in its depth between the 
 vagina and the rectum, care being exercised not to penetrate into the rectum. 
 
SURGERY OF THE FEMALE (iFNERATIVE ORG ASS. 975 
 
 Having been brought out at tliis point, it is again inserted at the same point 
 anil passed on through the tissues of the opposite side, being thrust in deeply 
 at the side, so as to grasp an abun(Uint thiekness of tissue in its loop, emerging 
 tiirough tlie skin close to the border of the incision at a point opposite to where 
 it was introduced on the other side. A second, third, and possibly a fourth sim- 
 ilar suture are then introduced in like manner, proceeding from l^elow upward, 
 until sufficient have been placed evenly and firmly to close the wound. While 
 these sutures are being introduced, the tissues in the lateral sulci, which natu- 
 rally tend to retract, should be seized with the mouse-toothed forceps and drawn 
 strongly into the wound, so that the sutures shall obtain a deep grasp upon 
 them. The sutures are now tied seriatim, havino- been drawn sufficiently tij^ht 
 to bring the parts into coaptation. If they have been introduced in the way 
 described, the deeper parts will be fully and easily brought from each side 
 into contact, and a firm, competent perineal body will be restored. The ends 
 of each suture should be cut off an inch or tw'o from the knot, in order that 
 the suture may be easily found when it is desired to remove it later, for, as a 
 rule, the knot itself will have become somewhat imbedded in the skin. After 
 the tying of the deep sutures, as many points of superficial sutures may be 
 placed as may seem to be required fully to 
 coaptate the superficial portions of the edges 
 of the wound. The fold at the entrance to 
 the vagina made by the lifting of the center 
 of the flap, if too redundant, may be retrenched 
 to any degree and the edges sutured (Fig. 388). 
 
 The sutures having been applied, the parts 
 should be well dredged with powdered oxide 
 of zinc. Increased comfort will be given the 
 patient by the pressure of a soft absorbent pad 
 against the perineum, but it is not essential. 
 
 In the after-treatment especial care is to be 
 taken to guard the wound from the urine. The 
 patient should turn over upon her face to uri- 
 nate, and the parts should be Avell douched with 
 the boro-salicylic solution after each urination. 
 If the patient is unable to urinate in this way, 
 a catheter must be used, with every precaution 
 to avoid infection of the bladder and conse- 
 quent cystitis. The sutures should remain in 
 place for at least ten days. If they are not 
 causing much irritation, they should be left in 
 some days longer. The patient should be kept 
 in the reclining position for three weeks, and 
 not allowed upon her feet until four weeks have elapsed. 
 
 II. Complete Laceration. — If the rent extends up into the recto-vag- 
 inal septum for any distance, it is best to secure its repair down to the level of 
 the sphincter as a separate operation, reserving the repair of the latter and of 
 the perineum until a later period. 
 
 The operation upon the recto-vaginal rent is to be conducted as follows : 
 The edges and apex of the rent should first be split by a bistoury to the 
 depth of about three-eighths of an inch. Two rows of sutures are required, 
 rectal and vaginal. Beginning within the rectum at the apex of the rent, 
 fine silk sutures, at intervals of about three-sixteenths of an inch, are intro- 
 duced w^ith a small well-curved needle, so that each shall come out at the bot- 
 
 Perineoplasty, condition after Suturing 
 (Pozzi). 
 
076 AN AMERICAN TENT-BOOK OF SURGERY. 
 
 torn of the s])lit tliat has been made, thus embracing only tlie rectal half of 
 the denudation. These should then be tied in the order in wliich they were 
 introduced. A similar series of sutures, preferably of catgut, should now be 
 inserted along the vaginal line of the wound, each being tied as it is inserted. 
 In this way a broad surface of apposition is secured. In the after-treatment a 
 loose movement of the bowels should })e secured daily and the ordinary atten- 
 tion to cleanliness of the parts should be maintained. Further operation may 
 be delayed until after a period of at least six weeks, when the procedures 
 are the same as are now to be described for the ordinary complete lacer- 
 ation. 
 
 The first steps are the same as those that have been described for repair of 
 the incomplete form. Then the lateral incisions are to be prolonged backward 
 along the side of the anus sufficiently far fully to expose the retracted stumps 
 of the sphincter ani. A first set of sutures must now be introduced to bring 
 together the denuded fibers of the sphincter. The location of the stump of the 
 muscle on each side having been identified, the needle should be passed through 
 it so as to grasp its substance : the deepest suture should be placed first, being 
 entered well back by the side of the anus and directed forward toward the 
 perineum, emerging in the middle line, there to be reintroduced and carried 
 back on the other side in the reverse direction till it shall emerge on the 
 other side of the anus at a point symmetrical with that Avhere it originally 
 entered. Three such sutures should be introduced. The remaining sutures, 
 for the perineum proper, should be introduced as in the incomplete variety. 
 The parts are now brought into apposition and the sutures tied in tiie order of 
 their introduction. The dressings and the after-treatment are the same as 
 above described. 
 
 Not a few surgeons prefer, however, to remedy the entire defect at a single 
 operation. 
 
 SURGERY OF THE VAGINA. 
 
 Malformations of the Vagina may be congenital or acquired. The 
 former are vices of development, the latter the results of sloughing, adhesion, 
 and cicatricial contraction. A median longitudinal septum occasionally divides 
 the canal more or less completely into two, owing to the imperfect coalescence 
 of the ducts of Miiller of the embryo. The hymen may be imperforate. The 
 vagina may be rudimentary or altogether absent ; in which case there is usually 
 imperfect development or total absence of the uterus and ovaries. These con- 
 ditions call for surgical treatment only after puberty in those cases in which the 
 presence of the developed uterus has established menstruation and vaginal mal- 
 formation, or in which atresia causes retention of the menstrual fluid. 'J'he opera- 
 tive procedures required may vary from a simple puncture of a distendcil hymen 
 to a long and difficult dissection between the bladder and the rectum through 
 the connective tissue that has replaced the vagina. The practical difficulties 
 which attend efforts to keep open a long channel that has been estal)lished by 
 such a dissection are very great, so that in the cases where two or more inches 
 of the vagina are occluded the surgeon Avould be justified in removing the 
 uterus through a suprapubic abdominal incision rather than in attempting to 
 overcome the vaginal atresia. The evacuation of a (juantity of retained 
 vnenstrual fluid is attended with sjiecial danger from septic infection. 'J'o 
 guard against this, every possible antisejitic precaution should be observed. 
 The incisions should be free, the cavity should be thoroughly emptied and 
 irrigated with an antiseptic solution, a fold of iodoform gauze should be 
 
SURGERY OF TlIK FEMALE dENERATIVE ORGANS. 977 
 
 placed in tlio vai:^ina extending from tlie cavity of tlie uterus to the vulva to 
 act as a drain, and an abundant absorbent dressing should be jdaced over the 
 vulva, to be changed as oi'ten as it is saturated by the discharges. The irri- 
 gations may be re})eated daily until the distended parts have contracted to 
 their normal dimensions. 
 
 Vaginismus. — This term is applied to a spasmodic contraction of the mus- 
 cles of the vaginal opening upon any attempt at coitus, which renders marriage 
 unfruitful. The introduction of the finger for a vaginal examination may pro- 
 duce the same effect. 
 
 Its cause is sometimes the sensitive remains of the hymen, which, though 
 they appear to be normal, yet often contain enlarged nerve-filaments : some- 
 times there is erosion at the entrance of the vagina, and sometimes the affec- 
 tion is apparently entirely nervous in origin. 
 
 The treatment may with advantage be at first the application of a 5 or 
 10 per cent, solution of cocaine a few minutes before coitus. Whatever the 
 cause, this will often allay the pain and irritation and permit intercourse. If 
 this does not succeed, a careful examination should be made, and if ulceration 
 is found it should be treated with nitrate of silver or other suitable application. 
 If sensitive remains of the hymen are present, they may be excised. The 
 mere stretching of the vaginal orifice will often effect a cure. After excision 
 or stretching the vagina should be methodically dilated for some time, until 
 painless intercourse is possible. 
 
 Injuries. — Lacerated wounds of the vagina have occurred as the result 
 of a first coitus : they are not infrequent in connection with ruptures of the 
 cervix uteri or of the perineum. They may occur in the course of operative 
 procedures upon the uterus. The hemorrhage is likely to be abundant. 
 The treatment of such wounds should be in accordance with general surgical 
 principles, and should never be attempted without first fully exposing the 
 wounded point. Removal of clots and free admission of air to the vagina 
 will often secure hemostasis. 
 
 The injuries of the vagina which most engage the efforts of the surgeon 
 are those in which penetrations of the bladder or rectum are present and 
 degenerate into permanent fistulas. The most common cause of such fistulte 
 is sloughing from the prolonged pressure of the foetal head during a difficult 
 labor. The resulting opening into the adjacent viscus may vary greatly in 
 its size, form, and location. In rare instances the cavity of the uterus is 
 invaded. The two forms of fistula most commonly met with are the vesico- 
 vaginal and the recto-vaginal. 
 
 VESICO-VAGINAL FISTULA. 
 
 These fistulse range in size from minute openings, recognizable with diffi- 
 culty, to those where much of the septum is lost and the anterior wall of the 
 bladder prolapses into the vagina. Cicatricial contractions of the vagina are 
 frequent complications. 
 
 The symptoms are those of incontinence of urine, the external genitals 
 being continually bathed and irritated by the urine. 
 
 The diagnosis is usually at once determined by inspection after the 
 anterior vaginal wall has been brought into view. Confirmation may be had 
 by the use of a sound or probe if needful, and, in cases Avhere the orifice is 
 minute or hidden by a cicatricial fold, by the injection of colored fluids into 
 the bladder. 
 
 62 
 
978 
 
 AX AMFJUCAX TEXT-llOOK OF SURGEllY. 
 
 The prognosis is usually ^ood if" the case is ainciiahk' to i»la>tic (iiicration 
 for its closuro. 
 
 The treatment, cxecjit in cases of verv ininiitt' fistuhv, is hy jdastic fipera- 
 tion. When the openiiii!; is very small, it8 closure may ))ossil)ly he effected 
 by touching it with a cautery point and thus exciting adhesive inllammation. 
 During the after-treatment of such a case the bladder should be kej)t drained 
 of urine by a permanent catheter. In every case operation should be deferred 
 
 Vesico-vaglnal Fistukt exposed, edges of fistula being pared (Simon). 
 
 till the general health of the patient is well established and the local con- 
 ditions ai-e favorable for repair. All local inflammation must have been 
 subdued and excoriations healed. Cicatricial contractions of the vagina 
 must have been overcome by division or dilatation. The functions of the 
 bowels and of the kidneys must have been brought into a state of healthy 
 activity. 
 
 The fistula may best be exposed by putting the patient in an exaggerated 
 lithotomy position, the pelvis being raised upon a firm cushion and the vagina 
 widely opened by the use of suitable retractors, laterally, superiorly, and infe- 
 riorly. The uterus is now to be drawn down by a tenaculum so as to make 
 
siic(ii:ny nr the femaij-: (;exi:r.\tive ohgans. utd 
 
 the fistula still more acfc.s.siblo. The edges of the fistula are now freelv and 
 evenly pared by knife or scissors, the strip to he renioveil being held' by a 
 toothed tissue forceps or tenaculum, bevelling the edges niaiidv at the experise 
 of the vaginal portion, but taking care to remove all cicatricial tissue and to 
 extend the removal of tissue at the points which arc to be at the ends of the 
 suture line, so that there shall be no puckering when the sutures are tied. 
 AVhen tl)e tissues are thin and it is important to avoid the removal of tissue, 
 the edges of the fistula may be split instead of pared, and thus a sufficient raw 
 surface for coaptation secured. The rather free bleeding which follows these 
 incisions will be controlled by the sutures when api)lied,and need not delay, 
 their immediate ajiplication. For the sutures fine silk is the best- material.' 
 For the needles the liat, i)artly-curved needles of llagedorn are to be prefen-ed. 
 A needle forceps adapted to them will be required. The sutures should be 
 introduced, beginning at the most distant point, the needle entering near the 
 vaginal edge of the incision, sweeping outward into the tissues, so al to bring 
 within the suture loop an abundant portion of the thickness of the tissue^ 
 finally emerging at the depth of the wound just below the vesical mucous mem- 
 brane, to be then entered at a corresponding point at the opposite side of the 
 wound, and carried through its edge in a reverse direction into the vagina. 
 The sutures should be introduced at intervals of about three-sixteenths of an 
 inch, and care should be taken to have the two sides of the fistula penetrated 
 by the sutures at corresponding points to ensure accuracy in the subsequent 
 adjustment. If necessary to relieve tension — for no tension must be permitted 
 on the suture line — relaxing sutures may be inserted a little farther from 
 the wound-edges, and carried either below the vesical mucous membrane or 
 through it into the bladder if need be. When all the sutures are in place, 
 the bladder should be irrigated with a warm antiseptic lotion to remove 
 any blood-clot that may have accumulated within it. The sutures are then 
 tied. A few accessory points of suture finally may appear needful to secure 
 perfect apposition. A small tampon of gauze "impregnated with oxide of zinc 
 should be left in the vao-ina. 
 
 For ten days the patient should remain in bed, being allowed to assume 
 any position she may prefer. For the first forty-eight hours the urine should 
 be removed by catheter every four hours, and after that spontaneous micturi- 
 tion may be allowed as often as the patient desires. On the third day the 
 tampons may be removed and subsequent daily vaginal douches instituted. On 
 the eighth day the sutures may be removed. Vesical tenesmus, if present, is 
 to be relieved by morphia and hyoscyamus. After the tenth day the patient 
 may gradually resume her wonted duties. Daily free evacuations of the bowels 
 should be secured from the first. Should only partial success be secured by a 
 first effort, repetitions of the operations should be made at a later date till final 
 closure is secured. 
 
 For the partial relief of aggravated cases, in which the loss of substance is 
 too great for any plastic operation for the closure of the opening into the 
 bladder, closure of the vagina has been practised. In some instances this 
 procedure has, however, entailed such serious disorders from urinary retention 
 and decomposition in the unnatural reservoir that the vagina has had to 
 be reopened. In other instances a portion of the recto-vaginal septum has 
 been removed, so as to make the rectum a receptacle for the urine and men- 
 strual secretions after the urethra and vagina have been closed up, and com- 
 fort has thus been secured. Should these devices prove fruitless or inad- 
 visable, the ureters may be detached from the bladder and implanted into 
 
980 A\ J. 1/ /•;/.' /r.LV TKA'T- /!()() h' OF sri!(;i:iiv. 
 
 the V((.tiiiii, :is h;is hccii done witli success in cases of" exstropliv of the 
 bhidtler. 
 
 Kkcto-Yacuxal Fistula. — The metliods of exposino; and treating these 
 fi^tuhv are in <:eneral siinihir to those Just detailed. If the fistula is lii^^h up, 
 the sphincter ani should be paralyzed by thorough stretching before the ope- 
 ration is begun, and the movements of the bowels be restrained by opiates for 
 the first week thereafter. If the fistula is near the anus, the ti.ssues of the 
 perineum and anus should be divided into the fistula, and then the repair con- 
 ducted as described for complete lacerations of the perineum. 
 
 INFLAMMATIONS OF THE VAGINA. 
 
 The vaginal mucous membrane may be provoked to inflammation by the 
 presence of irritating foreign bodies, by the use of irritative injections or appli- 
 cations, by the contact of irritating secretions, by the irritation of excessive 
 coition, and by infection with the gonorrheal poison. The inflammation 
 provoked by the latter cause is not distinguishable from that due to other 
 causes, except possibly under the microscope by the detection of the gonococci 
 in the discharge. Vaginitis may be acute, subacute, or chronic. It is usually 
 attended with more or less vulvitis. The gonorrheal form is prone to extend 
 to the endometrium and thence to the Fallopian tubes, provoking ultimately 
 pyosalpinx and often pelvic peritonitis. 
 
 The symptoms of vaginitis depend on the acuteness and intensity of the 
 attack. Local lieat and pain, with some tumefaction, and altered secretion — 
 scanty at first, but soon becoming copious and muco-purulent in character — 
 are the chief symptoms. Inspection of the vaginal mucous membrane shows 
 that it is congested and bathed in muco-pus, often with patches of excoriation. 
 In the more intense forms an ulcerative process may become established, with 
 subsequent cicatricial contractions and adhesions. In the mildest cases nothing 
 may be complained of but the altered and excessive discharge or leucorrhea. 
 Every degree of severity betAveen the two extremes may occur. Its natural 
 tendency is toward cure, but in many instances the persistence of cau.sative 
 influences prolongs it indefinitely. In some cases a granular condition of the 
 mucous membrane is produced, constituting a very intractable and painful state. 
 The flowing of acrid discharges over the parts at the outlet of the canal often 
 produces excoriations and fissures at this point, which make coitus very pain 
 iul, even impossible. 
 
 Treatment. — During the acute stage of an attack, rest in bed. saline ape- 
 rients, and fre(iuent hot hip-baths are indicated. The vagina should be washed 
 out several times daily with a copious hot, mildly antiseptic douche, as of borax, 
 one dram to water one quart, or of licjuor jdunibi subacetatis, half a fluid- 
 ounce to water one quart. As soon Jis the symptoms have moderated somewhat 
 the cure will be expedited by keeping the walls of the vagina separated by a 
 fold of lint or gauze soaked in oxide-of-zinc cream. This should be carried 
 well up to the posterior fornix through a speculum and protrude between the 
 labia. It should be removed at the end of twenty-four hours, the vagina 
 douched, and the medicated lint again inserted. This treatment should be per- 
 severed in until the cessation of the symptoms indicates that the disease has 
 subsided. An occasional douche should be persisted in for a time thereafter, 
 to prevent recurrences. In the more chronic forms, if the use of the zinc 
 tampons is impracticable, recourse may be had to douches of sulphate of zinc, 
 one dram to the quart of hot water once or twice daily. In the more invete- 
 rate forms inspection will show certain parts which are especially affected to 
 
srRf;i:nv or riii-: femat.e (ikmiumivi: ouaAXS. osi 
 
 ■wbicli direct applications of nitrate of" silver or carbolic acid may be needful. 
 In all cases, as far as possil)le, tlie cxcitin<2; cause sbould be removed. Coitus 
 is to be forbidden. 
 
 If fissurfs ))ersist or are indicated by pain wlicn efforts to dilate tbe canal 
 are made, tbey sbould be sou^bt for, and treated by distention and cauteriza- 
 tion to their deepest point witb stick nitrate of silver. Sucb applications 
 sbould be made once a week till a cure is effected, tbe parts meanwbile being 
 kept protected by smearing them with oxide-of-zinc cerate. 
 
 TUMORS OF THE VAGINA. 
 
 Solid gi'owths are of rare occuiTence. Cases of lipoma and sarcoma have 
 been recorded, but are of extreme rarity. Myoma in tbe vafrinal wall has been 
 occasionally observed, (\ircinoma is rare as a primary disease, tboujrh frequent 
 by extension from the cervix uteri. Cysts are of more frequent occurrence. 
 They may develop from persistent embryonic canal-ducts of Muller or canal 
 of Gartner ; from dilated lymph-ducts ; or more commonly from closed and 
 distended mucous follicles. 
 
 Excision of all these growths should be done when practicable. In cases 
 of cysts, if the cyst-wall cannot be easily excised in toto, the portion left should 
 be freely cauterized to destroy its secreting surface and excite adhesive inHam- 
 tion thereof. 
 
 FOREIGX BODIES IN THE VAGINA. 
 
 The vagina has been made the receptacle of many foreign substances, which 
 become the subjects of surgical care through the inflammation and ulceration 
 which are excited by them. Their presence is detected in the course of the 
 explorations required for ascertaining the cause of the symptoms. They are 
 to be removed, and the inflammation, ulcerations, or fistulae produced by them 
 treated on the lines already laid down. 
 
 PROLAPSE OF THE VAGINA. 
 
 As the result of injuries to the perineum and loss of support from the pelvic 
 floor, an eversion of the vagina to some extent is common. As the posterior 
 wall rolls out it brings with it the anterior wall of the rectum, and produces 
 a swelling of varying size upon tbe floor of the introitus, to which the term rec- 
 tocele is applied. Similarly, the anterior vaginal wall in its eversion brings 
 with it the base of the bladder, constituting a cystocele. Both of these 
 conditions entail more or less functional disturbance of the organ involved. 
 Diminution of the expulsive power of the lower part of the rectum attends 
 rectocele. Pouchinor of the floor of the bladder, with retention and decom- 
 position of urine and cystitis, is the result of cystocele. For their relief it 
 is of prime importance that the pelvic floor be restored by perineoplasty. At 
 the same time, the following special plastic operations may be done upon the 
 walls of the vagina if the extent of the relaxation and prolapse seems to call 
 for them. 
 
 Anterior and Posterior Elytrorrhaphy. — These operations consist in 
 the removal of longitudinal strips of the vaginal mucous membrane of varying 
 length and width, and closing the gaps thus made by sutures, so as to narrow 
 or to reef in the relaxed membrane. The anterior wall of the vagina most 
 frequently calls for this retrenchment, which is a most valuable accessory to 
 the other measures instituted for renewing the supports of prolapsing pelvic 
 organs. The denudation in anterior elytrorrhaphy should be quite free, should 
 
082 
 
 A.X AMi:h'I(AX TKXr-l'.OUK OF SLlidKnY. 
 
 extend from Lalf an inch behind the raeatus urinarins cxt^rnns backward 
 nearly to the cervix uteri, and sliould lie trianguhir, or rather arrow-shajie<i. in 
 form, Avith tlie base of the trianjrle or arrow just in front of the cervix. The 
 elytrorrhaphy sliouhl be done before the perineophisty is proceeded with, and 
 after any operation on the cervix that may have been*re(juired. The piece to 
 be removed should first be marked out with the point of the scalpel, and then 
 with the tissue forceps and scissors the entire piece should be dissected away, 
 beginning behind and working forward, care being taken not to wound the 
 
 Fig. 386. 
 
 Cervix Uteri. 
 
 Shape of Flap to be Removed in Anterior 
 Elytrorrhaphy (original). 
 
 First Step in SuturiniEr the Wound of Anterior 
 Elytrorrhaphy (original). 
 
 bladder. In Fig. 385 the lines A B D C A indicate the shape and relations 
 of the denudation recommended. The application of the sutures is to be 
 made first to the barbs of the arrow, B F being sutured to B D, and C E to 
 CD, the sides of the lozenge DA (Fig. 386) then remaining to be sutured. 
 Silk is the best material for these sutures. They are to be removed in eight 
 or ten days. 
 
 SURGEKY OF THE UTERUS. 
 
 Hypertrophy of the Cervix. — A true overgrowth of the cervical por- 
 tion of the uterus, unaccompanied by inflammation, due to an as yet unex- 
 plained error in nutrition, occasionally occurs. The tissues of the cervix are 
 apparently normal in their character. The overgrowth assumes the character 
 
suRaKRv or Tin-: femali-: (n:xi:iiATi\'i': oiuians. 983 
 
 of" an eloii^^ation whit-li may fill the va<i;iiia. even to the extent of protruding 
 from the vulva (Fi^. oST). It is an att'ection occurring more freriuently in 
 
 Fio. 387. 
 
 Fig. 388. 
 
 Hypertrophy of the ("ervix Uteri (Skene). 
 
 the unmarried. It entails obstructive dysmenorrhea by the angulation or 
 bending of the uterine canal which it produces ; it is a source of sterility after 
 marriasre ; it irritates the vagina and is a cause of much local 
 discomfort. 
 
 The diagnosis is readily established by careful bimanual 
 examination, which will show the body of the uterus to be in its 
 proper place and of uoi*mal size, while the finger in the vagina 
 will trace the reflexion of its mucous membrane to the cervix 
 at its normal distance from the introitus, notwithstanding that 
 the elongated cervix fills the vagina. 
 
 The treatment is by amputation. The annexed figure, 
 388, shows the lines of incision adapted to obtain the best 
 resulting stump (Skene). Subsequent shrinking is to be ex- 
 pected, for which reason the stump should be made a little 
 longer than the normal cervix. 
 
 Wounds of the Uterus. — Lacerations of the cervix uteri 
 are a frequent complication of childbirth. If they are exten- 
 sive and are recognized at the time, immediate sutures should be 
 applied. If neglected, they heal by granulation, leaving often 
 permanent Assuring of the cervix, in many cases accompanied 
 with marked hyperplasia and eversion and erosion of the mucous membrane 
 of the cervical canal, a chronic inflammatory condition of the whole endo- 
 metrium, and subinvolution. 
 
 Diagram of the 
 Pieces re- 
 moved in Am- 
 putation of 
 H y p e r t r 0- 
 phied Cervix 
 (Skene). 
 
1)84 
 
 A.\ AM ERICA y rilXT-nOOK OF SLRtlKltY 
 
 Fig. 389. 
 
 Bilateral Laceration of Cervix Uteri of Moderate 
 Degree (original). 
 
 In manv instances these healed fissures jrivo rise to no synij)tonis, when 
 they shouM be let alone. More fre(|uently the constant e.\j)Osiii(' of" the 
 everted cervical mucosa to vaginal infections and irritations serves to per- 
 petuate and aggravate the co- 
 existent metritis and endome- 
 tritis, and re))air of the lacer- 
 ation hy a])|)i-oj)riate jdastic 
 o|»erati()n is necessary as a 
 part of the ti'eatment re(|uired 
 for curing the chronic uterine 
 inflainniation. 
 
 The operation for hin-r- 
 afcii crrrir is best done while 
 the patient is in the dorsal 
 ])osition, as for vaginal fis- 
 tula. (See Fig. 4()»j.) The 
 perineum being retracted and 
 the labia being separated on 
 either side, the cervix is 
 brought down to the intro- 
 itus by a tenaculum, and 
 held by a stout thread passed 
 through each lip for the more 
 convenient control of the 
 parts. With an ordinary 
 scalpel the cicatricial tissue at the apex of the fissure is now thoroughly 
 divided ; along the limits of the mucous lining of the canal a second 
 incision is carried, and the flaps thus marked out are dissected away, giving 
 broad raw surfaces for coaptation. If the fissure is bilateral, both sides should 
 be thus freshened before any sutures are introduced. Pretty free bleeding 
 may be expected from these incisions, but it will be fully controlled by the 
 tying of the sutures. Silkworm gut or stout silk thread is the best material 
 for the sutures, and a strong, well-curved Ilagedorn needle of small size answers 
 well for the;r introduction, a suitable needle-holder being essential. The 
 number of these sutures and the method of their introduction are governed 
 by the general principles applicable to all plastic work. The sutures should 
 be left in situ for ten days, during which time the patient should remain 
 recumbent. 
 
 Punctured Wounds of the Uterus assume ini])ortance when they are 
 the subjects of septic infection, as when inflicted by unskilful attempts at pro- 
 ducing abortion. Septic inflammation of the substance of the womb and of 
 the peritoneum may follow, with the gravest consequences. The treatment 
 indicated is, first, full dilatation of the cervical canal ; then thorough curetting 
 and repeated antiseptic irrigations of the uterine cavity, aided by continuous 
 drainage by a mesh of iodoform gauze placed within the uterine cavity and 
 protruding into the vagina. The extension of the infection to the Fallopian 
 tubes and to the pelvic peritoneum may call for abdominal section, ablation of 
 appendages, and intra-peritoneal irrigations and drainage. 
 
 Rupture of the Uterus, when occurring as a complication of difficult 
 childbirth, presents a lacerated wound of the body of the uterus, l)eginning 
 usually in tlie lower segment of the uterus and extending to a variable degree 
 both longitudinally and transversely from the point of beginning. The 
 symptoms of the accident include shock, heiiio! rhage, cessation of the ute- 
 
SURGJ'JRV OF Tin-: FKMALI': (SKXEUATIVK OUdANS. 985 
 
 vine contractions, and in most cases escape of the (a-tiis tliroii^'li the rent 
 into the abiloniinal cavity. 
 
 The treatment shoukl be by abdoiniiial section, ))recede(l, if" need be, by- 
 intravenous infusion of a (|uart or more of a (i : 1000 saline sohition to combat 
 the eftects of hemorrhai^e and shock ; the removal of the f(ctus and blood-clots 
 from the ])eritoneal cavity: the brin<;ing of the uterus out throujih the abdom- 
 inal wound, and the arrest of hemorrhage by an elastic cord drawn about the 
 cervix ; the cleansing and suturing of the rent in the uterus after the manner 
 advised in Cesarean section, or, if the condition of the lacerated tissues is such 
 as to render their subsecjuent kind healing uncertain, the total ablation of the 
 uterus, with vaginal drainage, as ])ractise(| after vaginal li vsterectoniy. 
 
 Incision of the Uterus for Removal of Foetus. — Cesarean Section. 
 — The necessity for incising tlie uterus for the delivery of a child that cannot 
 be delivered alive by other methods having been determined by the rules of 
 obstetrics, the operation is performed as follows : 
 
 Preliminanj Preparation. — Every possible antiseptic detail in the cleans- 
 ing and disinfection of the patient's abdominal surface and of the vagina is to 
 be carried out, as in all cases of abdominal section. In all the steps of the 
 operation the most rigorous precautions against sepsis are to be observed. 
 
 Tlie Operation. — The patient having been placed upon a proper table, 
 preferably a short one, with her knees at its edge and her feet supported on 
 a chair to facilitate access to the vagina, and having been anesthetized, an 
 incision is made through the abdominal wall in the median line over the most 
 prominent part of the tumor, beginning about three inches above the pubes 
 and extending upward above the umbilicus, being in all from five to six 
 inches in length. As the abdomen is opened the uterus projects into the open- 
 ing : an assistant now presses the abdominal walls on each side of the incision 
 down against the uterus, thus retracting the wound-edges and pressing the ute- 
 rus still more prominently into the wound-opening. At the upper end of the 
 incision a limited vertical incision is at once made into the presenting wall of 
 the uterus : if it does not quite perforate the uterine wall, the finger may be 
 used to complete the perforation. Then, the finger being pushed along as a 
 director, the uterine incision is to be lengthened downward to the full extent of 
 the primary incision, using preferably an angular scissors for the purpose. The 
 amniotic sac pouts into the wound, and is next to be equally freely divided, 
 unless, as may have happened, it has been already opened and divided with the 
 uterine wall. If the placenta should lie in the line of the incision, the fingers 
 should be insinuated between it and the uterine wall until its margin is reached, 
 when the membranes are to be ruptured as before. The hand of the operator 
 now, plunging into the uterine cavity, seeks the head of the child if it is acces- 
 sible, or otherwise the feet, and quickly extracts it. If the head has previously 
 become impacted in the pelvis, it should be pushed up by the hand of an assist- 
 ant in the vagina. The umbilical cord, having been double clamped by forceps, 
 is cut between them, and the liberated child turned over to a nurse. 
 
 Bleeding from the uterine incision, if free, should be controlled by direct 
 compression or by compression of the neck of the uterus by the hand of an 
 assistant. If spontaneous contraction of the uterus does not take place, a 
 hypodermatic injection of ergotine (gr. ij) should be given. The placenta 
 and membranes should now be withdrawn from the uterus. If not already 
 detached, the placenta should be grasped by the hand and lifted away by 
 compression from circumference to center. 
 
 The empty and contracted uterus may now be lifted out of the abdominal 
 cavity, resting upon hot, wet towels that are placed beneath it and over the 
 
98G J.V AM /•:/>•/< AX TKXT-noOk' OF SURGERY. 
 
 alxloiuiiial wound to facilitate the ap|)lieation of the sutures. Or it may be 
 sutured in i<lta if the conditions favor ready access to tlie wound in it. 
 
 Tlie suturin<r must be done Avitli jTreat care, for upon this detail, more tiian 
 on any other, dej)ends the after-course of the case. Two layers of sutures are 
 •required, a deep and a superficial. Silk is the most reliable material to use for 
 sutures. The deep sutures are first placed. A well-curved needle is intro- 
 duced about a quarter-inch from the wound-edge, made to sweep outward into 
 the substance of the uterus, and then brought out near to, but not through, 
 the mucosa. The number of these should be from two to three to the inch. 
 Care is to be taken that no suture shall penetrate into the uterine cavity. The 
 sutures are to be tied firmly, but not so tightly as to strangulate the tissues. 
 For the purpose of making the approximation still more perfect, if any defect 
 apjiears anywhere along the line a number of accessory sutures may be applied 
 betAveen the primary deep sutures wherever the need may appear. These may 
 include only about one-fourth the thickness of the uterine Avail. 
 
 A second superficial set of sutures is finally to be introduced, in number 
 about two to each deep suture, and of fine silk. A strip of the peritoneum 
 with a thin layer of muscular tissue, beginning just to the outer side of the line 
 of the primary sutures, is transfixed Avith a fine needle, Avhich is carried across 
 to the other side of the Avound-line. Avhere it again picks up the peritoneum as 
 at the beginning. By tying these sutures the peritoneum is aj»proximated over 
 the whole Avound-line and the primary sutures are covered in. The peritoneal 
 cavity is noAv to be cleaned by irrigation and sponging, the uterus replaced, 
 the omentum drawn doAvn over it, and the abdominal incision closed in the ordi- 
 nary manner. If at the time of the operation the uterus be found to be already 
 the subject of septic infection, it should be extirpated in toto. This is to be 
 done according to the technique for abdominal hysterectomy for other conditions. 
 
 The after-treatment of Cesarean section does not differ from that required 
 after abdominal section in general. 
 
 SymiJhyseotomy. — The necessity of resorting to Cesarean section for de- 
 livery of a foetus in cases of contracted pelves may be avoided in certain cases 
 by a section of the interpubic articulation at the symphysis and temporarily 
 drawing apart the pubic bones. It is practicable to carry such separation to 
 a distance of about three inches (seven centimeters) without serious injury to 
 the sacro-iliac articulation. AVhen the obstetrician has determined that the 
 space gained by such an amount of separation will enable the head of the 
 foetus to pass, symphyseotomy should be done. 
 
 The technique of the operation is as folloAvs : The pubes having been 
 shaved and cleansed, a sufficiently free incision is made in the middle line 
 through the soft parts doAvn to the bone, to expose the articulation. This in- 
 cision should terminate below or a little above the clitoris. The Avound-edges 
 having been retracted, the glistening fibers of the symphyseal ligaments are 
 clearly exposed by further light touches of the knife. By drawing upon the 
 clitoris the filaments of its suspensory ligament are made prominent, and by 
 a transverse cut these are severed and the subpubic space exposed. By push- 
 ing a finger or a blunt instrument like a periosteal elevator betAveen the recti 
 muscles above, the soft tissues can noAv be pressed back from the posterior sur- 
 face of the symphysis and guarded from injury, Avhile with an ordinary scalpel 
 the joint is divided from before backAvard. Much separation of the joint is 
 still prevented by the dense fibers of the triangular ligament or deep perineal 
 fascia. Rupture of this fiiscia, if it is caused by the uncontrolled crowding 
 doAvn of the foetal head from strong uterine contractions, may tear through the 
 venous plexuses about the neck of the bladder, and even lacerate the urethra 
 
SCRdKnv OF THE r EM ALE (iEXEnATlVK OJiOANS. 987 
 
 and vuiiina. Profuse liciuon-lia'ri', witli (lifliciilty controlled by tampons and 
 by mass ligatures, is the immediate result of such an accident, and sepsis and 
 fistuhc the later. Fatal results have eventuated from these causes. To pre- 
 vent these a systematic division of the deej) fascia from the arch of the pubis 
 on either side should be made at once after dividing the symphysis. A blunt- 
 pointed bistoury by closely hugging the bone on each side can readily and 
 s<ifely accomplish this. The full separation possible of the bones at the sym- 
 physis should be made, and tlie gaping Avound tem))orarily tamponed ^vith iodo- 
 form gauze, after \vhich the delivery of the child should be immediately ef- 
 fected. After delivery has been accomplished the external wound should be 
 sutured, except at its lower angle, in which a small strip of iodoform gauze as 
 a drain should be kept for the first forty-eight hours. The bones should be 
 approximated and supported by a broad adhesive bandage encircling the pelvis. 
 The patient should be kept recumbent for about four weeks. 
 
 Inflammations of the Uterus. — The mucous lining of the uterus, the 
 endometrium, is the chieffseat of inflammatory conditions affecting the uterus. 
 The submucous tissues share to a greater or less extent in the superficial i'nflam- 
 matory disturbances of the mucosa, and in certain acute affections complicating 
 the puerperal state a spreading septic lym])hangitis and phlebitis are excited, 
 which cause the whole substance of the uterine Avails to become acutely inflamed, 
 often with a fatal result. 
 
 Endometritis may be confined to the cervix or may involve the corpo- 
 real endometrium as well. Cervical endometritis is the most frequent variety. 
 The inflammation may be acute or chronic. In the acute form th-e mucous 
 membrane is congested and SAvollen : an abundant, viscid, rauco-purulent secre- 
 tion is poured out upon its surfiice {Jencorrhea). The submucous tissues are 
 congested and infiltrated with inflammatory exudates in a varying degree, de- 
 pendent upon the severity of the superficial inflammation. According to the 
 extent of the endometrium invaded, there will be swelling of the cervix only 
 or of the whole organ. The inflammation not infrequently extends along the 
 Fallopian tubes and may involve the pelvic peritoneum. More frecjuently the 
 affection is of gradual development and assumes a subacute form, with tendency 
 to chronicity from the beginning. In the clironie form the mucous membrane is 
 swollen and pulpy, oedematous, passively congested, prone to fungoid vegeta- 
 tions, easily provoked to bleed. The leucorrheal discharge is abundant and 
 acrid. The orifices of the mucous follicles of the cervix (glands of Naboth) 
 frequently become occluded, with formation of small retention-cysts as the 
 result. The os uteri is tumid, the cervix swollen, and, if the body of the 
 uterus is involved, the whole organ is enlarged, with an increase in the depth 
 of its cavity. Where lacerations of the cervix permit it, the SAvollen cervical 
 flaps become everted, with erosion of their epithelial covering. As the result 
 of long-existing congestion, proliferation of submucous connective tissue takes 
 place, with subsequent contraction, atrophy of glandular elements, and sclero- 
 sis. When the corporeal endometrium is more especially affected the cervical 
 appearances described will be absent. 
 
 Etiology. — A predisposition to endometritis may arise from a multitude of 
 causes, constitutional and local, which diminish the resisting power of the tis- 
 sues of the organ, interfere with its nutrition, and conduce to local blood-stasis. 
 Bad hygiene, overwork, improper clothing, uterine displacements, suppressed 
 menstruation, excessive coitus, abortions, subinvolution after parturition, and 
 cervical lacerations are among the predisposing causes that should be especially 
 mentioned. The exciting cause is always infection with pathogenic micro-organ- 
 
988 AN AMEIilcAX Ti:xr-IU)()K OF SC lid F.Ii Y. 
 
 isms. These may be derived from the vagina or cervix, the cavities of wliich 
 ahvavs contain pyojienic cocci in abundance, tlioufrh of little virulence : or they 
 niav be introduced from without by tiie finger of the surgeon or accoucheur, 
 a sound, a pessary, or other instrument, or the finger of the patient herself. 
 The puerjicral uterus presents conditions especially favorable to the full 
 activity of pathogenic micro-organisms, mf)st of all when organic d(^bris is 
 retained within the uterine cavity or when unhealed lacerations of its sub- 
 stance are present 
 
 The infection may be of gonorrheal origin, in which case, after the subsi- 
 dence of the acute vaginal symi)toms, the infection may persist in the cervical 
 follicles indefinitely, occasioning only slight symptoms until reawakened into 
 activity by some of the conditions named as jiredisposing, especially abortion, 
 parturition, and traumatism. Gonorrheal endometritis is prone to extend into 
 the Fallopian tubes and induce an inveterate salpingitis. 
 
 The symptoms of endometritis comprise dull pelvic pain and tenderness ; 
 aching, referred to the sacral and lower lumbar regions ; a sense of dragging 
 within the pelvis; more or less profuse leucorrhea. Menstruation is painful or 
 in the more chronic conditions is unduly frequent and prolonged : the bladder 
 is irritable; the bowels are torpid; inspection reveals a viscid discharge issu- 
 ing from the os externum ; the cervix is tumid and congested ; and epithelial 
 erosions, granular degenerations, and cystic enlargements, if present, are 
 detected at a glance. If the endometritis involves the body, the sound or 
 bimanual examination shows an enlargement of the organ, and the endome- 
 trium is tender and bleeds easily when touched with an instrument. In gene- 
 ral, the digestion is deranged, and the nervous system especially is the subject 
 of multiform disturbances. In many cases a condition of chronic invalidism 
 is establishe<l. In the more acute cases the attack may be ushered in with 
 rigors and fever, and may be attended with all the recognized signs of local 
 septic inflammation. 
 
 The prognosis must depend upon the extent of tissue involvetl. the pre- 
 vious duration of the affection, and the complications present, together with the 
 constitutional conditions of the patient. To these must be added the ability 
 and willingness of the patient to submit to the treatment refjuired. The disease 
 is sometimes rebellious to treatment, but. as a rule, may be expected to yield to 
 intelligent and thorough measures. A disposition to relapses characterizes the 
 affection, due to the lingering of infective material in the glandular recesses of 
 the endometrium and to the frequent repetition of the exciting cau.ses. 
 
 Treatment. — Minute inquiry must be made into the existence of predis- 
 posing ami the continuance of exciting causes, and especial care must be given 
 to their removal. Acute attacks require absolute rest in bed. the free use of 
 saline cathartics and warm enemata, hot fomentations to the hypogastrium. and 
 the administration of a copious hot vaginal douche twice daily, continued for 
 thirty minutes at a time, the patient being recumbent. 
 
 In subacute and chronic conditions constitutional treatment a.ssumes import- 
 ance. Anemia and neurasthenia must be combated : constipation must be 
 guarded against. The local treatment requires the correction of malpositions, 
 the restoration of support to the organ, and the avoi<lance of the irritation of 
 sexual congress. Frequent periods of rest in the recumbent position are 
 important. Hot vaginal douches, as described above, may be continued. In 
 the intervals between the douches, or as a substitute for them in part, may be 
 u.^sed wool or cotton tampons saturated with glycerin and tannin Oj-f.?j). 
 Of the highest value in treating persistent endometritis is the thorough scrap- 
 ing away of the altered superficial layers of the mucosa (curetting), followed 
 
siRdKin' or Till-: female aE^EU.\'riVE organs. 98D 
 
 1)V c'(|u;illv tlmroiiixli disiiil'cct ioii of" tlic rciii:iiiiiii<; |i(irti(m iiiid ;i<li'(|uate drain- 
 a^e tlioreatU-r. 
 
 (Jin'cff<((/<' of the ciKluiiictriitiii slioiild always Ix' <fiiaiilcd l)_v lull aiitiso[)tic 
 precautions. I*roliiiiiiiary scnibbiMjj:; and antiseptic irrigations of the vulva 
 and the vagina should he thoroughly made. Anesthesia is often re(|uired. 
 The dorsal position is to he chosen, the cervix expose*!, seized with the vol- 
 sella. and drawn down to the introitus. Preliminary dilatation of the cervi- 
 cal canal is usually necessary. A sharp uterine curette is to be selected, and 
 after the direction and depth of the uterine canal have been ascertained witli 
 a sound, is introduce<l to the bottom of the cavity, and with firm repeated 
 strokes is drawn over the whole endometrium until the superficial layer of the 
 entire mucosa has been removed. The curette is then withdrawn and the 
 interior of the uterus is thoroughly irrigated with a hot antiseptic solution. 
 A 10 per cent, emulsion of iodoform is now freely injected into the uterine 
 cavity through a glass catheter introduced to its fundus. The vaginal sur- 
 face of the cervix and the adjacent vaginal mucosa should be plentifully 
 sprinkled witli oxide of zinc powder. Recumbency in bed for one week 
 sliould follow. Should free bleeding from the endometrium persist, the cavity 
 of the uterus should be packed Avith iodoform gauze, which packing should 
 be removed on the fourth day afterward. 
 
 Lacerations of the cervix should be repaired as soon as the congestion of 
 the cervix is relieved'; mucous polypi should be scraped or twisted off: if the 
 cervix has become hypertrophied or remains persistently enlarged by passive 
 congestion and oedema, a portion of it should be removed with the knife, as 
 already described for Amputation of the Cervix. 
 
 DISPLACEMENTS OF THE UTERUS. 
 
 Normally the uterus lies in the pelvic cavity in a position of slight ante- 
 flexion, suspended among the other viscera of the lesser pelvis, by the uniform 
 pressure of which on all sides it is maintained in position. The direction of 
 its longitudinal axis varies, however, through a considerable arc, according to 
 the position of the body and the relative fulness of the bladder and the rectum. 
 Displacements to a degree that call for surgical intervention may occur for- 
 ward — anteversion and anteflexion ; backward — retroversion and retroflexion ; 
 and downward — prolapse and procidentia. The symptoms which arise in cases 
 of displacement are not due to the mere change of axis or place of the organ, 
 but are due to the tension upon the ligaments, the dragging upon adjacent 
 organs, and the nervous and circulatory reactions from coincident congestions 
 of the uterus and adnexa. Considerable displacement, in the absence of 
 these complications, may therefore exist without causing any symptoms or 
 disability. 
 
 Anteversion and Anteflexion. — Mere anteversion, a position in which the 
 uterus is inclined forward to an undue degree, causes no symptoms and calls for 
 no treatment. When it is due to subinvolution and chronic endometritis the 
 symptoms present are due to these conditions, and may be relieved by appro- 
 priate treatment. When it is a part of a more extended inflammation, and the 
 uterus is bound down by adhesions, the malposition of the uterus is a relatively 
 minor incident in the complex conditions present, and does not in itself con- 
 stitute an important indication for treatment. 
 
 In nntf'ficxion the uterus is bent forward u))on itself, the angle of flexion 
 being usually at the junction of the body and the cervix. (See Fig. 391.) 
 
990 
 
 AX .1.1/ /•;/.' /r.Lv TNXT-iiooK or scuaKin' 
 
 Such a flexion may ho duo either to defective deveh)|)niciit of the tissue of the 
 anterior wall of the uterus durin*:; the period of devel()i)inental aetivitv at 
 puhert}^ or it may be the result of later inllammatory conditions of the uterus 
 and adnexa l)y means of -which the cervi.x becomes h.xed by adhesions or the 
 utero-saeral bands arc shortened, while the swollen fundus is toppled over for- 
 ward, and is not infrequently fixed by adhesions to the anterior pelvic wall. 
 
 Stenosis of the uterine cavity at the point of bendin<f — the os internum — 
 is the immediate effect of the flexion. The retention of secretions and the 
 
 Fig. .390. 
 
 Normal I'ositiou of the Uterus (original). 
 
 altered circulatory and nutritive conditions that follow in turn induce a 
 chronic inflammatory state of the endometrium. Dysmenorrhea, and in the 
 married sterility, result. 
 
 The symptoms are chiefly those of dysmenorrhea. Pain, referable to 
 the uterus, precedes the ap])earance of each menstrual flux. It is paroxysmal 
 in character, varies much in its intensity, but is usually in proportion to the 
 acuteness of the flexion. As the flow becomes established the pain is relieved. 
 The attendant endometritis produces its own special symptoms, while it also 
 aggravates the stenosis. In some cases a considerable degree of anteflexion 
 fails to produce any symptom. 
 
 Diagnosis. — The globular mass of the fundus, pressing forward upon the 
 bladder, is at once felt by the examining finger when pressed uj) in front of 
 the cervix, and its continuity with the cervix and the angle at their junction 
 can readily be made out. B}^ combined manipulation, aided, if need be, by a 
 finger introduced into the rectum, the whole contour of the organ may be 
 ascertained. Some uncertainty may arise when the cervix is long and is 
 directed into the vagina, as if belonging to a retroverted uterus, and also when 
 a fibroid seated in the anterior wall of the uterus causes the anterior sur- 
 face to simulate that of an acute flexion. A sound introduced into the uterine 
 
SUBGJ'JRV or Till: rilMALE GENERATIVE ORGANS. ll!)l 
 
 canal uilKk'toriniMc the dia<,'iiosi.s by doinoiistrating the real direction of the 
 canal. To facilitate the introduction of the sound, the cervix, after having 
 been exposed, should be drawn downward and backward }>y a volsellum for^ 
 ceps, and the sound should be well curved. 
 
 The treatment consists, first, in the straiH;litening of the organ by 
 manipulation as just described; secondly, in the dilatation of the canal^ either 
 by a uterine dilator or by the introduction of sounds of successive graduated 
 sizes ; thirdly, in the curetting of the altered endometrium. These procedures 
 are to be accompanied with abundant antiseptic irrigations of the uterine and 
 
 Fig. 391. 
 
 uterus Anteflexed (original). 
 
 vaginal cavities and adequate disinfection of all instruments and appliances. 
 Whenever the tendency to recurrence of the flexion is marked, resort may be 
 had, fourthly, to the introduction of a stem-pessary of suitable length, which 
 may be Avorn for two or more months. An essential requisite of this pessary 
 is that it shall not interfere with the ready drainage of the uterine cavity. 
 The wire pessary of Outerbridge is recommended for this reason. 
 
 If, as is often the case, the projection of the anterior lip of the cervix into 
 the vagina is abnormally slight, it should be let down into the vagina by 
 making a free transverse incision through the vaginal mucous membrane at its 
 point of reflexion upon the cervix. By pulling the cervix backward this 
 transverse incision is converted into a longitudinal one by the approximation 
 of its lateral angles, Avhich should be secured by sutures. If there is an 
 excessive projection of the posterior lip, it may be shortened and the canal 
 made straighter by taking out a transverse wedge from its posterior surface 
 and suturing the raw surfaces. If the vaginal portion of the cervix, as a 
 whole, is long and conical, a portion should be amputated. 
 
J)W2 
 
 ,I.V AMKinCAX TKXT-IIOOK OF SriiCKUY. 
 
 lietrovcrsion and Ii<'tr()Jh'.n'on. — When tlie fiiiulus of tlie uterus habitu- 
 ally points toward the sacrum a rctrovcmwn of the organ exists. The degree 
 to which such tilting backward extends may vary much. It is usually asso- 
 ciated with some prolapse. In the great majority of cases which })resent 
 symptoms the uterus becomes also bent upon itself backward, constituting the 
 condition of retrojlexion. 
 
 Backward displacements of the uterus occur more commonly in women who 
 have borne children, being sequelae of accidents complicating childbirth ; and 
 as a result the uterine supports are relaxed, the swollen uterus, becoming more 
 or less prolapsed, is forced backward by the pressure of the abdominal organs, 
 and by the same process is flexed upon itself after the further descent of the 
 
 Fig. 392. 
 
 Uterus Retroverted and Retrollexed (-original). 
 
 cervix is arrested. In nulliparous women it is also met with. As predisposing 
 causes may be enumerated any condition that induces laxncss of the uterine 
 supports, such as general aneinia, debility from illness or fatigue, or natural 
 flabbiness of muscular or fibrous tissue ; improper posture in standing or sitting, 
 in which the pelvis is held in a position of lessened oblicjuity by an undue pro- 
 jection forward of the symphysis, and the weight of the abdominal viscera, 
 that should be supported by the lower abdominal wall and the pubic arch, is 
 directed into the pelvis upon the fundus and the anterior surface of the uterus; 
 habitual tight constriction of the abdomen, whereby intrapelvic pressure is in- 
 creased : increased weight of the organ, as during menstruation or as the 
 result of endometritis w myomatous tumors. 
 
 The immediate cause of a retroversion is intrapelvic pressure. This is 
 usually gradual in producing its effect, but occasionally produces acute symp- 
 toms during great strain, as in lifting or coughing or by a fall. Pelvic tumors 
 may crowd the uterus backward. 
 
SURGERY OF Till: FEMALE (IFXFUATIVI: ORGANS. 993 
 
 Backward displacements that cause symptoms have usually advanced to the 
 extent of flexion, and as rule arc complicated with chronic eiuloinetritis and 
 uterine hyperplasia, most extensive in the cervical portion. In many cases 
 these inflanimatory conditions antedate the displacement, and have contributed 
 to it, but after the displacement has developed they are perpetuated and aggra- 
 vated by it ; when previously absent they are produced by it. Not infre- 
 quently an intercurrent pelvic peritonitis produces adhesions which bind the 
 uterus in its malposition. 
 
 Symptoms. — The complex of symptoms which attend endometritis and 
 relaxation of the pelvic floor (see pp. 972 and 98S) indicate the presence of 
 those conditions. Dysmenorrhea and menorrhagia are common. The pelvic 
 discomfort is aggravated by walking or standing, and is often sufficient to 
 greatly restrict the following of any occupation or the enjoyment of any exer- 
 cise. Pressure upon the rectum renders defecation difficult, often painful, and 
 fosters the development of hemorrhoids. Backache, referred to the middle of 
 the sacrum, is the rule. Sterility is common. Cases vary much in the degree 
 to which particular symptoms are present. 
 
 The diagnosis is made by vaginal touch. The cervix is felt lower than 
 normal in the vagina and pointing somewhat forward. If retroversion only is 
 present, the posterior surfiice of the uterus is palpated by the tip of the finger 
 pressed into the posterior fornix ; if flexion exists, the rounded fundus is like- 
 wise detected, and the angle of the junction of the body with the cervix ap- 
 preciated. The diagnosis may be confirmed by the uterine sound and by 
 rectal palpation. Endometritis and other inflammatory complications declare 
 themselves by their own special symptoms. Adhesions are detected by the 
 resistance that is met with to attempts at the reposition of the organ. Peri- 
 metric bands and masses of exudate can sometimes be felt by the examining 
 finger. A small fibroid jutting out from the posterior wall of the uterus, an 
 enlarged ovary prolapsed into the cul-de-sac of Douglas, or masses of inflam- 
 matory exudate behind the uterus may be mistaken for a retroflexed fundus, 
 with which, indeed, they may coexist. By careful and thorough palpation of 
 all the pelvic contents the distinction may be made. 
 
 Treatment. — Complicating inflammatory conditions, if present, demand 
 first attention. The details of the treatment of such conditions are given else- 
 where. In particular, inflammation of the appendages and of the pelvic peri- 
 toneum should be relieved before any forcible attempts at reposition of the 
 uterus are made. But if the uterus is freely movable, though swollen from 
 endometritis, it may be replaced at once and supported by tampons charged 
 with boro-glyceride or ichthyol and glycerin (12 per cent, mixtures), applied 
 also for their primary depletive and antiseptic action. 
 
 Keposition of a retrodisplaced uterus, if it is jwt bound down by adhesions, 
 may be readily effected in many cases by introducing a properly-curved uterine 
 sound in:: ;.e uterine canal, with its concavity toward the sacrum, and then 
 slowly sweeping its handle around an arc of 180° until its concavity looks for- 
 ward. Then, by depressing the handle against the perineum, the uterus is 
 brought into anteversion. This maneuver should be done while the patient is 
 in the latero-prone position. It is then aided by the force of gravity, which 
 will also serve to retain the uterus in its restored position until suitable means 
 for its retention may be applied. This procedure should be done with the 
 greatest gentleness, and if the uterus does not readily follow the sound, the 
 procedure should at once be abandoned. Special repositors have been devised 
 to accomplish the same end. They are sounds so constructed that the portion 
 introduced into the uterine cavity is a lever that by mechanism may be moved 
 
 63 
 
9i*4 Ai\ AMKRIi'AX TEXT-IK >(JK OF srii<;i:in\ 
 
 so as to lift up tlie uterus and throw it over into anteversion. Tlie same result 
 can be obtained by placing the patient in the knee-chest position and then re- 
 tracting the perineum. The vagina is ballooned out by the atmospheric pres- 
 sure ; the intestines gravitate away from the pelvis, and the uterus, freed from 
 pressure, topples over forward. If the uterus is im})acted so as not to obey 
 the force of gravity, it may be loosened by drawing the cervix downward and 
 backward with a tenaculum, and pushing against the fundus witii a sponge 
 pressed up in the posterior fornix by forceps. 
 
 As a preliminary to these operations the clothing of the patient must be 
 loosened about the waist. 
 
 In patients with lax and thin abdominal walls the reposition may be 
 effected l)y conjoined manipulation : the uterus is first lifted u{) by two fingers 
 in the rectum or vagina, and then the fingers of the other hand, pressing the 
 abdominal wall deeply into the pelvis, insinuate their tips behind the fundus 
 of the uterus and tip it forward. 
 
 When the uterus is jixed in retroposition by adJwsions little success will 
 result from attempts at repositing it by the means above mentioned. If the 
 adhesion is limited to the anterior wall of the rectum, the rectal wall may be 
 temporarily pulled forward with the uterus, but as soon as the repositing force 
 is withdrawn the displacement recurs. Delicate adhesions may be ruptured, 
 but eftbrts to rupture any adhesions within the pelvis by force applied from 
 ■without involve possibilities of rupture of intestine or blood-vessels. Such 
 blind efforts should therefore never be made. Adhesions are best overcome 
 by the fingers introduced into the pelvic cavity through an incision in the 
 anterior abdominal wall. The gravity of this procedure will depend upon the 
 extent and density of the adhesions and the character of the organs involved. 
 Such adhesions may range from the presence of a few slender fibrous filaments, 
 readily ruptured, through every stage up to the very solid fusion of the uterus 
 in a mass of appendages and exudates. When adhesions are extensive or 
 dense they should be separately dealt with under the guidance of the eye after 
 full exposure of the pelvic cavity through a free incision of the abdominal wall, 
 with the pelvis elevated so as to secure gravitation of the boAvels out of the 
 pelvis toward the diaphragm. A uterus thus adherent is usually associated 
 with conditions of the appendages that call for the ablation of the latter. 
 Great care is often required to avoid wounding the intestine or bladder. After 
 full enucleation has been secured the uterus may present extensive denuded 
 areas on its surface that will invite fresh intestinal adhesions. A uterus 
 thus extensively denuded, and by the removal of its appendages made func- 
 tionally useless, may very properly be also entirely ablated. 
 
 Retention of the reposited uteriis in its proper position may recjuire means 
 of widely differing character. When there are no adhesions ; when no tender 
 prolapsed ovary makes pressure behind the uterus intolerable ; when no in- 
 flammatory conditions of the vagina, uterus, or adnexa are present ; when the 
 pelvic floor is intact and the tonicity of the uterine supports is sufficient to 
 prevent any marked degree of prolapse ; when the retro-displacement has been 
 the result of the relaxation caused by temporary anemia or by increased intra- 
 pelvic pressure caused by improper dress or habitual positions of the body, 
 which conditions may be remedied, — the reposited uterus may be kept in its 
 usual position by a properly-adapted, closed, double-lever pessary. (See Figs. 
 8i>8 ami 304.) Such a pessary acts by making tense the natural supports of 
 the uterus, especially the utero-sacral ligaments. If it is, as it should be, 
 somewhat conical, with the larger end lying behind the cervix, the contraction 
 of the vaginal wall upon it tends to crowd it upward, and thus to prevent the 
 
SURGERY OF Till': FEMALE GENERATIVF ORGANS. ;)!)5 
 
 uterus IVoni descending, while the cervix is forced backward. It should never 
 make undue pressure at any point, and its presence in the vagina should not be 
 appreciated by the patient exce{)t by the comfort experienced from it. It should 
 be adapted to the oajiacity of the vagina in which it is to be placed. Its length 
 should correspond to the distance from the j)osterior fornix to the upper end of 
 the uretlira ; its width, to the transverse diameter of the vagina measured 
 across the cervix. The depth of the posterior fornix should be the measure 
 of the posterior curve. Hard rubber is the best material from which a pessary 
 should be made. Immersion for a short time in boiling water will soften such 
 a pessary so that its shape may be readily altered as required. A temporary 
 
 Fig. 393. 
 
 Fig. 395. 
 
 Closed Double-lever I'essary. 
 Fig. 394. 
 
 Pessary, side view. 
 
 Pessary in Position (redrawn from Skene). 
 
 substitute for a pessary may be improvised by adjusting pledgets of cotton or 
 lamb's wool in the vagina so as to distend the posterior fornix and the canal. 
 Such tampons should be rendered antiseptic by charging them with oxide of 
 zinc or boro-glyceride and glycerin. They may be left in situ as long as a 
 week without becoming oifensive. 
 
 When a pessary is to be introduced, the patient should be in the latero- 
 prone position ; the uterus should first be reposited ; the pessary, after being 
 oiled, is seized by its narrower end, turned on its edge, introduced into the 
 introitus, and, by pressing the perineum strongly back, is pushed on into the 
 vagina. Here it is turned so that its broader end is transverse. Usually the 
 posterior bar comes in front of the cervix at first, and it is necessary that the 
 index finger be introduced to depress it and guide it past the cervix into the 
 posterior vaginal fornix. The removal of the pessary is accomplished by 
 grasping its lower end between the thumb and finger and steadily withdrawing 
 it, pushing the perineum strongly backward with it as it emerges. As long 
 as a pessary is in use the vagina should be douched with borax and hot water 
 daily. Should irritation or local tenderness in the vagina be caused by it, it 
 should be withdrawn. It is either imperfectly shaped for the case or further 
 treatment to relieve local inflammatory conditions is required. A properly- 
 fitted pessary may be left in the vagina for periods of two or three months at 
 a time. Should its prolonged use be required, it should be removed at inter- 
 vals of at least three months, and not be replaced for some days, preferably a 
 week. 
 
 From the limitations enumerated at the beginning of this section it is 
 plain that in a very large proportion of cases of retro-displacement of the 
 
99G ^.V AMKIUCAX TEXr-lK^OK OF SVRUFAlY. 
 
 uterus pessaries Avill either be inefficient or undesirable for maintaining the 
 organ in its proper phice after it has been reposited. They are ahvajs to be 
 regarded as temporary palliative agents to be dispensed with as soon as possi- 
 ble ; that is, as soon as the natural tonicity of the uterine supports has been 
 so regained that the uterus is held by them in normal position. 
 
 Sagging of the pelvic floor, which is a frecjuent complication, should in all 
 cases be remedied by the appropriate surgical procedures, perineorrhaphy and 
 colporrhaphy. Certain cases in which pessaries could not be used before the 
 restoration of the pelvic floor may then be employed. But, inasmuch as 
 much uncertainty must always exist in this respect, it is preferable that cases 
 Avhich have to be submitted to operations upon the pelvic floor should at the 
 same time be given the benefit of some additional measure to make more 
 secure the retention of the uterus in anteposition. Many operative procedures 
 have been devised for this end. Among these two are especially to be recom- 
 mended as practical and efficient — viz. first, shortening of the round liga- 
 ments ; and, second, suturing of the posterior surface of the fundus of the 
 uterus to the anterior abdominal wall. 
 
 Shortening of the Round Ligaments. — The proper function of the 
 round ligaments, to preserve the fundus of the uterus in slight anteversion, and 
 thus indirectly to aid in supporting the uterus in its normal position in the pel- 
 vis, depends upon the tonicity of its fibro-muscular structure. When from any 
 cause the uterus is chronically retroverted, and especially through lacerations 
 or over-distention of the pelvic floor, the uterus is also prolapsed, the tissue of 
 the round ligaments is prevented from contracting to its normal length, and a 
 condition of permanent elongation is induced which entirely destroys its func- 
 tion as a uterine support or guy. The retention of the uterus in its normal 
 position after the employment of other means required to restore the pelvic 
 floor and overcome subinvolution and endometritis will be much more certainly 
 ensured by so shortening the round ligaments that they again make sufficient 
 traction on the fundus of the uterus to bring it well up toward the symphysis 
 pubis. This is practicable only in cases free from adhesions. 
 
 The credit of establishing this procedure as a proper resource in suitable 
 cases is to be given to Mr. Alexander of Liverpool, with whose name the ope- 
 ration is often associated. 
 
 Technique of the Operation. — The field of operation should be cleansed 
 with the same care that has been directed in connection with abdominal sec- 
 tions, and rigorous antiseptic precautions should be observed in all particulars. 
 The location of the internal abdominal ring having been identified (at a point 
 midway between the anterior superior spine of the ilium and the spine of the 
 pubes and half an inch above Poupart's ligament), a two-inch incision through 
 skin and superficial fascia, parallel with Poupart's ligament, should be made 
 over the internal ring, about one-third of it being to the outer side of the ring, 
 ^ and the other tAvo-thirds running along the line of the inguinal canal. The 
 aponeurosis of the external oblique muscle being exposed, and the diverging 
 fibers of the roof of the inguinal canal being identified, the inguinal canal is 
 freely opened, so as to expose the internal ring. The overhanging fibers of the 
 internal oblique muscle are to be diawn upward, so that the tissues emerging 
 through the ring may be clearly identified. A little teasing of the connective 
 tissue that binds together the parts will soon make plain the outlines and the 
 structure of the round ligament as it runs forward along the floor of the canal. 
 As soon as it is identified it should be isolated, and with gentle traction drawn 
 out from the pelvis : as this is done the connective-tissue fibers that invest it 
 and hold it will have to be carefully strippetl from it by suitable forceps : as 
 
SURGERY OF THE FEMALE GENERATIVE ORGANS. 097 
 
 the cord is further drawn out, it will S(jon become apparent that a cuft' of peri- 
 toneum is being stripped back from it. A little inadvertence may easily tear 
 this peritoneal investment and the peritoneal cavity be opened — an accident, 
 however, wliieh has no serious significance. The pulling out of the ligament 
 is thus continued until it no longer emerges with any freedom through the 
 ring ; from two to three inches of the ligament may easily be drawn out ; the 
 uterus, meanwhile, should be lifted up from below by the finger of an assist- 
 ant in the varjina to facilitate the running; of the ligament and to determine 
 when the control over the uterus by the ligament has been regained. 
 
 A strand of gauze is now passed under the loop of the portion of the liga- 
 ment that has been brought out, and a temporary antiseptic tamponade and 
 covering of the wound applied, while the ligament of the other side is in the 
 same manner found and drawn out. 
 
 Beginning with the second ligament, suture of the ligaments is next to be 
 done. Silkworm gut is the best suture material to be used. AVhile the liga- 
 ment is strongly drawn out a needle is passed through the integument, and 
 each layer of the wound-edge in turn, down to the border of the internal ring 
 which it pierces, and then, transfixing the ligament, is made to pass out on the 
 other side in the same way. Similar sutures are passed at intervals of about 
 one-third of an inch along the course of the inguinal canal until the apposition 
 of the deep wound is secured and the fixation of the ligament is accomplished. 
 The slack of the ligament is tucked up under the aponeui'osis of the external 
 oblique muscle at the inner end of the wound. A few strands of silkworm 
 gut may be introduced at the outer angle of the wound down to the internal 
 ring for drainage, and enough points of superficial suture applied to bring the 
 wound-edges fully together. A proper protective and absorbent dressing is to 
 be applied. Primary union is to be expected. The patient should remain 
 recumbent for four weeks. The sutures may be removed at the end of two 
 weeks. The uterus should be supported by a lever pessary or tamponade of 
 the vagina for some months. 
 
 Hysteropexy,orSuturingof the Posterior Surfaceof the Fundusto 
 the Anterior Abdominal Wall. — Whenever the abdominal cavity has already 
 been opened for the separation of adhesions or for dealing with diseased appen- 
 dages, to antevert the uterus and suture it to the anterior abdominal wall is a 
 natural step when a retroversion has previously existed. The anteposition and 
 the security from prolapse obtained by such suturing seems more absolute and 
 more certainly reliable than even that obtained from shortening the round 
 ligaments ; for which reason surgeons Avho are able to so control their operative 
 conditions as to avoid all dangers of sepsis are warranted in opening the abdom- 
 inal cavity for the special purpose of thus securing the uterus. The time 
 occupied for this operation and the amount of operative traumatism inflicted 
 are very much less than in the operation for shortening the round ligaments : 
 for this reason, especially in feeble patients and in those in whom for any 
 reason prolonged anesthesia is to be avoided, utero-ventral suture would be 
 preferred. The adhesions which result from this procedure gradually elongate, 
 so as to give considerable play to the uterus, but not sufficient to permit of its 
 retroversion. Experience has shown also that the dilatation of the bladder 
 with urine is not embarrassed. Subsequent pregnancy may pursue a normal 
 course. 
 
 Technique of the Operation. — The preliminary preparations should be 
 those prescribed for an abdominal section for any other purpose. In all the 
 steps of the operation rigid asepsis must be observed. A general anesthetic 
 is required. A three-inch incision should be made in the middle line of the 
 
998 
 
 AN A3IERICAN TEXT-BOOK OF SURGERY. 
 
 abdomen, beginning just above the symphysis. Through this incision two 
 fingers are introduced, which lift up the fundus of the uterus and bring it into 
 view while the sides of the incision are held apart by retractors. As soon as 
 the fundus is exposed it is seized at its middle by vulsellum forceps, lifted 
 up and drawn forward against the symphysis. By these maneuvers the 
 uterus is anteverted and the posterior surface of the fundus is made to present 
 in the lower part of the abdominal incision, and the insertion of the sutures 
 required is made easy and safe. The sutures may be of silk or of silkworm 
 gut, preferably the latter. Three should be inserted at intervals of one-third 
 of an inch. A slightly curved needle, grasped by a needle-holder, is desirable. 
 The lowest suture should be introduced first, the point of introduction being 
 about an inch below the fundus where grasped by the vulsellum. The needle, 
 armed with a strand of gut, is carried transversely through tlie uterine tissue, 
 penetrating to the depth of an eighth of an inch, and emerging about three- 
 quarters of an inch from its point of entrance. The two other sutures are in- 
 troduced in the same manner, the last and highest passing underneath the 
 
 Fig. 396. 
 
 Position of Uterus after Suture of the Posterior Surface of the Fundus to the Anterior Abdominal Wall 
 
 (utero-ventral suture ; original). 
 
 prongs of the vulsellum. The free ends of the sutures on either side are 
 then each in turn threaded into a curved needle, and are passed through 
 the parietal peritoneum at a distance from the edge of the incision in it 
 equal to one-half the width of the included uterine area. A portion of 
 the rectus muscle and of the aponeurotic fibrous sheath of the" rectus is 
 also penetrated by this needle. When the three sutures have thus been 
 passed on the two sides, they are to be tied, the one nearest the symphysis 
 first, and the others in the reversed order to that in which they were 
 introduced. The ends of the sutures are then cut off close, and the su- 
 tures buried by the subsequent closure of the superficial portion of the 
 wound. In this manner the lower part of the peritoneal opening is 
 closed, and a broad and even apposition of the serous surfaces of the 
 uterus and parietes secured. Any slight bleeding which may have oc- 
 
SURGEin' OF THE FEMALE OENERATIVF ORGANS. 999 
 
 curved from the pricks of the uterus is at once arrested by pressure when 
 the sutures are tied. The cul-de-sac of Douglas should be sponged out, 
 and the entire wound then sutured as in any other abdominal section. 
 No tampon or pessary in the vagina is required. The after-care is the 
 same as in other simple abdominal sections. As a rule, the convalescence 
 is smooth. The buried sutures create no irritation. In a small proportion 
 of cases they may after a time excite a local irritation and the development 
 of a sinus, for the cure of Avhich the suture will have to be exposed and 
 removed. 
 
 Prolapse and Procidentia. — Any descent of the uterus below its normal 
 position in the pelvis is a prolapse. The association of the lesser degrees of pro- 
 lapse Avith retroversion has already been considered. When the prolapse becomes 
 so aggravated that the cervix tends to protrude at the vulva, or the uterus by 
 eversion of the vagina escapes in toto from the pelvic cavity (^procidentia), the 
 displacement assumes characters of its own requiring separate consideration. 
 To the same causes which unite to produce the lesser degrees of prolapse and 
 retroversion are due the more extreme degrees. A more marked weakening 
 of the pelvic floor, a greater relaxation of the uterine ligaments, an increased 
 or longer-continued abdominal pressure, suffice to urge farther downward the 
 sinking uterus, until it finally presents habitually at the introitus, or by an 
 eversion of the vagina presents as a tumor between the thighs. Usually pro- 
 
 FiG. 397. 
 
 Complete Prolapse of the Uterus, with Eversion of Vagina (original). 
 
 lapse of the vagina precedes that of the uterus ; the anterior vaginal wall 
 gives way most easily and brings with it the floor of the bladder. 
 
 In less degree, but with much frequency, the posterior wall rolls out, car- 
 
J 000 
 
 Ai\ J.i//;/.'/r.LV TllXr-llOOK OF sriiCEliY. 
 
 rvin<,' with it tlie anterior wall of the rectum (rectocele; see p. 972). An 
 apparent prolapse may be due to hypertrophic elonfjation of the cervix (Fig. 
 387, p. 983). Some hypertrophy of the cervix, often considerable, attends 
 real prolapse, and is the result of hyperplasia due to congestion and to the 
 dragging of the cervical attachments. Endometritis is always present. The 
 prolapse<l mucous surfaces are thickened and tougiiencd, often excoriated and 
 ulcerated. 
 
 The severity of the subjective symptoms produced is not necessarily 
 gauged by the amount of prolapse present. The lesser degrees are most 
 
 Fig. :W8 
 
 Uterus Prolapsed ; Complete Eversion of Vagina; extreme dragging downward of bladder (original). 
 
 frequently attended by pain and invalidism ; in the more severe types the 
 complaint is more from the mechanical inconveniences of the tender tumor 
 hanging from the vulva. 
 
 Treatment. — Palliation may be secured by the pressure of a perineal pad 
 attached to an abdominal bandage. The uterus having been pushed back 
 into place, a rubber ball may be introduced into the vagina and kept in place 
 by the perineal pad ; or a shalloAV cup, supported upon a stem bent to follow 
 the curve of the vagina, may be made to support the uterus, the stem being 
 held in place by a perineal band. Such supports are at best inefficient and 
 obnoxious, and should be advised only when the patient positively refuses 
 operative relief. 
 
SURGERY or rill-: i emalI'I GKNKHArn'i-: organs, looi 
 
 Via. 399. 
 
 To relieve prolapsus perniaiieiitly resort must be made to a eombination of 
 whatever procedures are required to restore the integrity and tone of the 
 pelvic floor and of the uterine supports, and in the most aggravated cases to 
 reinforce these natural su|)ports hy additional sources of support. As a pre- 
 liminary the size and weight of the uterus itself will first re(juire operative 
 interference. The degenerated and chronically inflamed endometrium should 
 be curetted and treated; the enlarged cervix will often re((uirc amputation,or 
 lacerations call for plastic repair ; the thickened and relaxed vaginal walls 
 should be retrenched by excising longitudinal strips from them ; to the opera- 
 tion on the anterior wall (described on p. 972j, for cystocele, being added the 
 excision of ovoid strips from the lateral walls, if need be. Tlie retrenched 
 vagina may be still more reinforced and its eversion prevented by a scries of 
 circular submucous ligatures inserted in the following manner (method of 
 Freund) : The vagina being everted and the cervix uteri protruding, a well- 
 curved needle, armed with a strand of silk- 
 worm gut, is inserted through the vaginal 
 mucosa, at a point about an inch and a half 
 from the vagino-cervical junction, and is car- 
 ried circularly about the vagina in the sub- 
 raucous tissue as far as the needle will con- 
 veniently go ; the needle then is brought out 
 through the mucous ?;urface ; after some inches 
 of the thread have been drawn out the needle 
 is re-entered in the same opening through 
 which it emerged, and made to traverse again 
 the submucous tissue farther around the vagina, 
 is brought out, reinserted, and again passed on 
 until it has made the complete circuit of the 
 vagina, and finally emerges at the needle-open- 
 ing first made. A second encircling suture is 
 placed in the same manner about an inch and a 
 quarter away from the first, and a third at about the same distance again away 
 from the second. The uterus is now pushed up, carrying with it the vagina. 
 As the vaginal walls infold and the line of the first applied suture is turned in, 
 the tAvo ends of the thread are draAvn out firmly until the lumen of the vagina is 
 narrowed so as to barely admit the tip of the finger. A knot is now tied, and 
 made to bury itself in the submucous tissue by cutting the ends short and 
 pushing the knot through the needle-opening out of sight. As the reposition 
 of the uterus is continued by the pressure of the finger, the second and third 
 sutures each are in turn treated in the same manner. The number of such 
 encircling sutures may vary with the exigencies of the particular case. They 
 act by interposing a mechanical barrier to the eversion of the vagina, and are 
 of special value during the early months after the operation, until the natural 
 tonicity of the parts has been regained. They may also, by their irritation, 
 provoke inflammatory deposits along their course, which may act as perma- 
 nent sources of vaginal constriction. They should be reserved for cases which 
 have passed the childbearing age. If at any time they ulcerate through into 
 the vagina at any point, they are easily removed. 
 
 The relaxed and lacerated perineum will require perineoplasty. These 
 measures should be still further supplemented by shortening the round liga- 
 ments or by anterior utero-ventral suture. If, despite the combination of 
 these measures, the prolapse recur, it would be justifiable to remove the uterus 
 as a part of an extensive plastic operation. 
 
 Showing Method of introducing Circu- 
 lar Submucous Sutures in the Vagina 
 for relief of Prolapse (Freund). 
 
1 002 
 
 .l.V AMinUCAy TEXT-BOOK OF SlHUERY 
 
 Inversion of Uterus ; 
 angles of inflection 
 
 INVERSION OF THE FTERUS. 
 
 The uterus may become turned inside out as the result of a force dragging 
 down upon the fundus while the cervix is relaxed and dilated. Such inver- 
 sion, which may be partial or complete, is a very rare accident. It has taken 
 place most fre(^uently as a coinjjlication of cliildbirth ; in other instances a 
 polypoid growth, attached to the fundus, but driven down by the uterine 
 contractions, has dragged with it the fundus. 
 
 The uterus when completely inverted forms a pear-shaped body distending 
 
 the vagina ; it may be associ- 
 V\(-- -l*^'**- ated with j)ro]apse to such a 
 
 / --^n/t degree that it projects through 
 
 the vulva as an external tumor. 
 The mucous membrane, tumid 
 and congested, bleeds easily. 
 In long-standing cases it may 
 by atrophy and cicatrization lose 
 much of its peculiar glandular 
 structure. 
 
 Tlie symptom most prom- 
 inent is hemorrhage. When 
 the inversion is sudden and 
 complicates childbirth, this 
 hemorrhage is severe, at times 
 uncontrollable and fotal. In 
 the more chronic conditions 
 every degree of metrorrhagia 
 may be present. The symptoms 
 of endometritis and prolapse will be added, according to the degree of each 
 which may be present. 
 
 Diagnosis. — Vaginal examination reveals the tumor filling the vagina. 
 By deep palpation of the pelvic cavity by the rectum, or from the abdominal 
 surfiice in thin subjects, may be made out the funnel-shaped depression formed 
 by the inverted peritoneal surfiice of the uterus, into which the Fallopian 
 tubes, the round ligaments, and in some cases the ovaries, are drawn. (See 
 Fig. 400.) 
 
 Treatment. — In recent cases reposition may be effected by a process of 
 taxis, the patient being anesthetized. The manipulations must be conducted 
 80 as to produce dilatation of the cervical ring and pressure upward of the 
 inverted mass. These manipulations should not be persisted in for more than 
 an hour at a time. In the event of failure, and from the first in more chronic 
 cases, some form of continuous elastic pressure must be devised. This will 
 consist of a suitable hard-rubber sliallow cup to embrace the presenting portion 
 of the tumor, to which a strong stem is attached that protrudes from the 
 vagina externally. To this elastic tapes are attached that lead in front and 
 behind to an abdominal bandage above. By means of these elastic bands the 
 requisite elastic pressure is exerted. Anesthesia is not required while such an 
 apparatus is in use. The process of replacement is slow in its progress, and 
 may require the pressure to be kept up for as long as forty-eight hours. In 
 the event of failure to reduce the inversion after a forty-eight hours" trial of 
 elastic pressure, it would be justifiable to open the abdomen above the pubis 
 and dilate instrumentally the contracted cervical ring from above, while pres- 
 sure is made from below on the vaginal tumor. In the event of final fail- 
 
 a, vagina; b. fundus uteri; c, c, 
 
 c, c, d, d. extent of uninverted 
 
 cervix ; e, vaginal wall ; /, the peritoneal cul-de-sac of 
 the inverted uterus ; g, g, Fallopian tubes passing down 
 into the inverted uterus ; h, h, ovaries ; i, i, broad liga- 
 ments ; k, k, round ligaments (Crosse). 
 
iiUIi(n:ilV OF TllK FEMALE GENERATIVE ORGANS. lOO.'i 
 
 urc to aet'oni])lish reposition Ity tliis means the total exeision of the uterus 
 shouhl be (h>ne. 
 
 TUMORS OF THE UTERUS. 
 
 FrRRO-MYOMATA. — Tumors composed of tlie unstriped muscular fibers and 
 of the connective tissue normal to the uterus are frcfjuently developed in the 
 walls of the uterus. The relative proportion of muscular and fibrous tissue 
 varies greatly : to those tumors in which the former preponderates the term 
 myomata is applied ; to the latter, fibromata. The class is best designated by 
 the compound term fihro-wyoinata. 
 
 The number of such tumors which may develop in a single uterus is 
 variable : often the growths are multiple, in some cases occurring in large 
 numbers, in others singly. They 
 
 may attain great size, and are liable ^^^^- ^'^l- 
 
 to degenerative changes. According 
 to the location of these tumors a 
 clinical subdivision of them is estab- 
 lished. Those which are near the 
 external surface of the uterus tend 
 to protrude under the peritoneum, 
 and in that case form the subserous 
 variety ; those which are more cen- 
 trally located in the wall of the 
 uterus are interstitial or intramural 
 growths ; those which grow toward 
 the cavity of the uterus form the 
 submucous group. (See Fig. 401.) 
 
 The tumor-mass is usually differ- 
 entiated from the surrounding uterine 
 tissue by a layer of loose connective 
 tissue that forms a kind of capsule 
 to it and facilitates its enucleation. 
 When the tumors protrude from a 
 free surface, their position tends to 
 luxuriant development, and as the 
 growth proceeds the bond of connec- 
 tion with the uterus becomes rela- 
 tively smaller, forming a distinct pedicle. A tumor floating in the peritoneal 
 cavity is apt to provoke irritation of the serous surfaces with which it comes 
 in contact, and to contract adhesions with them as a consequence. Such adhe- 
 sions are most frequent with the omentum and the intestines. Tumors orig- 
 inating in the tissues of the cervix may push outward between the layers of 
 the broad ligament or may protrude into the vagina. A general hypertrophy 
 of the whole uterus to some degree always attends the development of these 
 growths. The endometrium becomes hyperplastic and swollen, and is prone to 
 inflammatory changes with consequent menorrhagia. Fibro-myomatous growths 
 belong to the period of functional activity of the uterus. Their natural tend- 
 ency is to grow as long as menstrual life continues, while their presence tends 
 to delay the natural menopause. After the menstrual climacteric has been 
 passed they tend to undergo involution and atrophy, but in exceptional instances 
 their growth remains unchecked. 
 
 Fibro-myomata occasionally share in the process of involution following 
 an intercurrent pregnancy, and thus disappear. Defective nutrition, due to 
 
 Fibro-myomata Uteri (diagrammatic), showing (1> 
 submucous, ('_') intramural, and (3) subserous 
 growths (origiualj. 
 
1U04 A.y AMJ'JJiJCAA' TKXT-JKJOK OF SURGERY. 
 
 elongation or torsion of the pedicle or other interference with the hlood-supply, 
 may arrest growth or induce atrophy. In this shrinking a process of calcifi- 
 cation sometimes occurs. Defective nutrition of an overgrown myoma may 
 induce liquefaction of the growth at points in its interior, leading to the forma- 
 tion of spaces filled with fluid, cyHtic. degeneration., or to the permeation of a 
 portion of it with serous or mucoid fluid, (edematous or 'iiiijxo)natous degenera- 
 tion. Occasionally an enormous development of blood-vessels and blood-spaces 
 takes place, angio/natous degeneration. Such a change may also involve more 
 particularly the lymph-vessels and lymph-spaces, constituting a lymphangio- 
 matous degeneration. A fibro-myoma may become the seat of pyogenic infec- 
 tion, with abscess-formation. Sloughing is a not infrequent occurrence in sub- 
 mucous growths as the result of injury and infection, in which case spontaneous 
 elimination may occur, or if the necrotic masses ai"e retained the phenomena 
 of septic absorption in a high degree result. 
 
 The symptoms caused by fibro-myomata are variable and multiform, 
 being dependent upon the location and size of the growth, the changes pro- 
 duced in the uterus, and the complications that may arise. Interstitial and sub- 
 serous growths may attain considerable development without provoking especial 
 symptoms. Submucous growths, however small, determine at once marked 
 hemorrhages, uterine discharges, and the whole complex of symptoms attend- 
 ing chronic endometritis. The tendency to hemorrhage and the consequent 
 anemia are always marked accompaniments of this class. Menstruation is 
 usually painful as well as profuse, and the protrusion of these polypoid growths 
 into the uterine cavity is sufficient to occasion strong expulsive pains in the 
 organ. Growths imbedded within the pelvis, even though not very large, may 
 give rise to much suffering from pressure upon adjacent organs — e. g. the 
 bladder, the ureters, the rectum, the nerves, and the blood-vessels. Growths 
 which have ascended into the general abdominal cavity cause annoyance chiefly 
 by their weight, unless they have attained great size, Avhen renal, hepatic, and 
 cardiac lesions may result. The presence of adhesions may give rise to pain- 
 ful traction symptoms. 
 
 The diagnosis of fibro-myomata is to be established by bimanual palpa- 
 tion, by which the changes in the form and size of the uterus are appreciated. 
 If a distinct tumor is visibly pushing forward the abdominal wall, or upon 
 pressure may be felt within the pelvis, such manipulations and counter-pressure 
 are to be made as may be required to determine whether or not the tumor 
 springs from the substance of the uterus. When the abdominal Avails are 
 thin, and the case is otherwise also favorable for examination, the relations and 
 shape of the tumor in the pelvis may be mapped out with much distinctness, 
 especially under general anesthesia. In less favorable cases uncertainty may 
 arise as to whether a given mass is an outgroAvth from the uterus, or is distinct 
 from it, but closely attached to it. The depth and course of the uterine canal 
 give important evidence in settling this question, for it is always elongated and 
 often tortuous in cases of fibro-myoma. Careful palpation, both rectal and 
 vaginal, will usually enable the surgeon to detect the outlines and estim.ate the 
 volume of the uterus, and thus aid in differentiating tumors of tubal or ovarian 
 origin from those belonging to the uterus. (See the sections on Tubal and 
 Ovarian Diseases.) Even small nodules on the serous surface of the uterus 
 may be felt by the finger: small interstitial growths may be difl'icnlt or even 
 impossible to recognize, but may be inferred from the coni])lexus of sym])toms, 
 especially if the uterine canal is elongated and tortuous. In some cases of 
 interstitial growth in their earlier course it may be diflUcult to differentiate the 
 condition from pregnancy, but continued observation cannot fail in due time to 
 
SURi^ERV OF THE FEMALE GENERATIVE ORGANS. 1005 
 
 develop the distinj^uishing cliamcteristics of the latter eondition. Small sub- 
 mueous growths are to be detected by the sound, and even more ccrtairdy by 
 the curette in the course of the curettage to which the organ will be naturally 
 subjected for the relief of the persistent endometritic symptoms present. Pro- 
 truding polypoid masses are detected by the finger or exposed by the speculum. 
 
 Tlie prognosis of Fibro-myomata, as far as regards direct danger to 
 life, is in general favorable. Only a small proportion of such growths deter- 
 mine sym])toms of sulFicient gravity to bring them to the attention of the sur- 
 geon. Of these, the most atrophy and cease to become sources of suffering 
 after the menopause ; in rare instances of the submucous variety spontaneous 
 expulsion into the uterine cavity or gradual breaking down by sloughing and 
 escape through the vagina have occurred. In other instances, however, the 
 growth is so rapid or so uninterrupted even by the menopause as to entail 
 serious risks to life from the com})ression of other organs, from its interference 
 with the normal processes of life, from the pains and disabilities it entails, or 
 from the profound anemia caused by persistent and profuse hemorrhages. 
 When comparatively young women become the subjects of troublesome fibro- 
 myomata, the case assumes a serious aspect, for many years of invalidism and 
 of exposure to intercurrent complications are probable before the favorable 
 influence of the menopause can be expected. The occurrence of cystic degen- 
 erations destroys the hope of later disappearance by involution ; the occur- 
 rence of septic infection with suppurative and gangrenous processes immedi- 
 ately threatens life. Growths springing from the cervical portion and extending 
 between the layers of the broad ligament occasion early and severe symptoms 
 from pressure upon adjacent pelvic viscera. Submucous growths have a 
 special danger from the hemorrhages which they induce. Sarcomatous degen- 
 eration of fibro-myomata has been reported in a number of instances. It 
 must be acknowledged, therefore, that the prognosis of a growing fibro- 
 myoma is always a serious one. Such a growth possesses possibilities of death, 
 through the exhaustion consequent upon a complexus of sufferings; through 
 renal, cardiac, or digestive disturbances ; through the prolonged anemia and 
 consequent general nutritive failure and lessened power to withstand inter- 
 current maladies ; through thromboses originating in the sluggish current 
 of dilated blood-spaces in vascular growths ; or, finally, through septic or ma- 
 lignant changes in the tumor itself. Further than this, in a large proportion 
 of cases in which life is not directly threatened the presence of these growths 
 very greatly restricts the usefulness of the patient, prevents her from gaining 
 a livelihood, and entails upon her a prolonged condition of invalidism. 
 
 Treatment is called for only in cases in which troublesome symptoms 
 have arisen or are impending, and must be directed to the relief of symptoms, 
 the arrest and retrogression of the growth, if possible, and, lastly, the removal 
 of the tumor by operative measures. 
 
 Hemori'liage is to be combated by rest in the recumbent posture during the 
 menstrual periods ; by the administration of ergot and opium or cannabis indica 
 in full doses ; and by thorough curettage of the endometrium, followed by 
 gauze packing, or by the caustic action of a galvanic electrode introduced 
 into the uterine cavity, through which an electric current of sufficient power 
 is passed. In the event of these measures failing, the removal of the Fal- 
 lopian tubes and ovaries will induce an artificial menopause, and thus put a. 
 stop to the bleeding with rare exceptions. 
 
 Arrest of growth and retrogression of tumor may be secured in some cases — 
 1. Bg prolonged administration of ergot. This may best be given hypoder- 
 matically, from 1 to 2 grains of purified ergotin in an antiseptic solution (1 jiart 
 
lUOG JiV AMi:ilI('AX TKXT-noOK OF SURUEnV. 
 
 of or^otin to 10 parts of the monstrmini) being used for each injection twice 
 ilailv. If no iniprovenuMit is niaiiitV'st after two inoiitlis' continuanee of such 
 injections, they nniy be abandoned. Tiie best efteots of ergot may be expected 
 when the tumors arc of recent devehi])nient. are soft, and liave caused only 
 moderate symptoms. 
 
 2. Bii Eh'ctroli/slH. — A current of from 75 to 2;")0 milliamj)eres' strength 
 when j>assed tlirough the substance of a fibro-myoma, if continued for a suf- 
 ficient length of time or repeated often enough, has been demonstrated to be 
 capable of inducing in some instances rapid retrogression of the tumor. Sub- 
 mucous and interstitial growths of moderate size are the ones most likely to be 
 benefited by electrolysis. If possible, the uterine electrode should be intro- 
 duced into the cavity of the uterus, and each introduction should lie preceded 
 by thorough disinfection of the uterine and vaginal cavities and of the electrode 
 itself. When the introduction of the electrode into the uterine canal is imprac- 
 ticable, and the growth is readily accessible through the vaginal wall, a spear- 
 pointed electrode nuiy be thrust directly through the vaginal wall into the 
 substance of the growth, the most scrupulous antiseptic precautions being used. 
 The abdominal electrode should cover a broad surface and be closely in contact 
 with the skin over its whole extent. Experience has shown that the usefulness 
 of electrolysis for the dispersion of uterine fibro-myomata is much restricted, 
 since it not only fails favorably to influence a large proportion of such growths, 
 but also introduces risks of provoking septic and gangrenous complications, of 
 causing peritoneal irritation and consequent adhesions, and in some cases of 
 postponing needed operative interference, which has to be resorted to ultimately 
 under much less favorable conditions for success than would have been pres- 
 ent earliei". 
 
 3. Bji Removal of the Fallopian Tubes and the Ovaries, thus inducing arti- 
 ficially the menopause. The reported results of this procedure in suitable 
 cases are very uniform in their success. The largest number of cases reported 
 by one surgeon is that of Tait, who in 1891 reported 271 operations of the 
 kind for myomata. Of these, 6 (2.2 per cent.) died as the result of the opera- 
 tion ; in 8 no favorable efteet resulted, the patients having subsequently to 
 undergo hysterectomy or having died; in the remaining 257 cases complete 
 relief ensued, the troublesome symptoms ceased entirely, and the tumor either 
 disappeared or ceased to grow. The reported results of other surgeons are 
 equally favorable as regards the ultimate effects upon the tumor and the hem- 
 orrhages, but the rate of mortality has been greater. 
 
 Resort to the removal of the tubes and ovaries is indicated in all cases in 
 which growths or hemorrhages persist despite treatment, and in which the tech- 
 nical difficulties and dangers are less than would attend hysterectomy. Early 
 operation is more especially indicated when the patients are comparatively 
 young. In cases of very large tumors removal of the appendages is contra- 
 indicated on account of danger of inducing oedema and necrosis of the growth. 
 (For the technique of the operation see the sections on Diseases of the Tubes 
 and Ovaries.) 
 
 Removal of Fibro-myomata by Operative Measures. — Extirpatioyi 
 through the i^agina is feasible for groAvths occupying the vaginal portion of 
 the cervix, for polypoid growths springing from the body of the uterus and 
 protruding into the uterine cavity, and for moderate-sized submucous growths 
 which are being pressed into the cavity by violent uterine contractions. Dila- 
 tation of the cervix and bilateral division of it up to the vaginal junction may 
 be done when required to give sufficient access to the growth. The pedicles of 
 small polypoid growths may be twisted and cut with scissors. Irrigations with 
 
SURGERY OF Till-: FEMALE (iEXEHATIVE ()I{(JAXS. 1007 
 
 hot water and taiii]i()iia(lc with iodol'onii ^aiize will siiilico to contiol the laiiior- 
 rha«;e, or, if not, a suitalde clamp forci'j)S jiiay be left ap])lied to the .stump for 
 a few hours, Lar«fe polypoid growths which fill up the vagina require a pre- 
 liminary process of diminution by piecemeal excision until their volume is 
 Bufficiently reduced to make it ))()ssible to reach their ])edicles for final division. 
 
 iSubmucous fibroids of nn^derate size, not larger than a foetal head, which 
 are being expressed into the uterine cavity are susceptible of removal through 
 the vagina if the latter is roomy or distensible. The capsule is first split freely 
 with the knife and peeled back to each side, while the tumor, held and drawn 
 upon by suitable hooked forceps, is worked out by blunt-edged, spoon-shaped 
 enucleators, assisted by the scissors as required. The work is usually tedious 
 and laborious : attempts of this kind should be restricted to small growths or 
 to moderately large ones which have become spontaneously pressed down by 
 uterine contractions against the internal os uteri, with some dilatation of the 
 cervical canal. Care is to be taken to guard against hemorrhage, shock, 
 peritonitis, and septicemia, which have been the chief causes of the mortality 
 attending these operations. 
 
 Extirpation through Abdominal Incision. — Tumors which have persisted 
 in growing despite the intelligent use of the measures already described, and 
 are accompanied w'ith symptoms that threaten the existence of the patient, 
 or which seriously compromise the usefulness or the happiness of life, and 
 which are not accessible through the vagina, may be reached and extir- 
 pated through suitable incision in the abdominal wall. The character of the 
 operation will vary according as the tumor (a) projects freely into the peri- 
 toneal cavity and is attached to the uterus by a distinct pedicle ; {J>) is sessile 
 upon the peritoneal surface of the uterus, or, if imbedded in the wall of the 
 uterus, lies near the peritoneal surface and can be enucleated without opening 
 the cavity of the uterus ; (c) embraces so much of the substance of the uterus, 
 and has deformed it to such an extent, that the removal of the tumor requires 
 the removal of the uterus at the same time ; {d) when in addition to the latter 
 condition the tumor has developed low down beneath the parietal peritoneum 
 or into the folds of the broad ligament. 
 
 In varieties (a) and (h), after the abdomen has been opened and the tumor 
 and uterus exposed, the tumor is to be removed with the knife as if it were 
 upon any other part of the body, the character of the incisions being deter- 
 mined by the principles applicable to growths in general. Growths imbedded 
 in the uterine wall are readily enucleated as soon as they have been freely 
 exposed by incision of the overlying tissue. Bleeding, which usually is not 
 great, is to be controlled by ligatures to bleeding points and by the pressure 
 of the sutures ; ligatures in mass may be required. In cases of large pedun- 
 culated growths the pedicle may be yjrovisionally secured with an elastic liga- 
 ture, or by transfixion with a double ligature, or by strong compression forceps, 
 while the tumor is cut away. Apposition and suture of the wound-surfaces are 
 to be effected by fine silk passed deeply so as to bring the surfaces fully into 
 contact. When all bleeding has been fully staunched and the wound well 
 sutured, the uterus is allowed to resume its place in the pelvis, the abdominal 
 cavity is cleansed from blood, and the incision in the abdominal wall is 
 closed. These steps constitute the procedure of myomectomy. In varieties 
 (c) and {d) a portion or the whole of the uterus is removed with the tumor, and 
 the operation becomes one of supravaginal j^^rtial hysterectomy or of total 
 hysterectomy, as the case may be. For the purpose of gaining the required 
 access to these tumors, which are usually large and often complicated by adhe- 
 sions, the abdominal incision should be made free at the outset or should be 
 
1008 
 
 ^i.v .\Mi:in< A.\ Ti:xT-ii(K>K or sri:(;i:i;y 
 
 enlar<£e(l at once if the nece.ssarv iuaiii|)ulation.s are found to l)c lianijierod Vjy 
 the restricted length of the priiuarv incision. Care must be taken at the 
 lower angle of the cut not to wound the bladder, which is often carried up 
 much beyond its usual location upon the anterior face of the tumor. Adhe- 
 sions must be systematically searched for, and sej)arated as they are ex])Osed, 
 especial care bein;; taken to control hemoi'rhage from them, if they are vas- 
 cular, by doul)l(' li<^ature both upon the side of the tumor and upon that of 
 
 the surfaces to which it is adherent. 
 Ki(i. 402. Finally, the hand is able to slij) under- 
 
 neath the tumor, to dislodge it from 
 its bed, and to bring it out through 
 the abdominal incision. The further 
 manipulations within the pelvis will 
 be much facilitated by the elevation 
 of the pelvis, as shown in Fig. 402, 
 the position being known as Tren- 
 delenburg's position. 
 
 After the disengagement and de- 
 livery of the tumor immediate atten- 
 tion should be given to its relations 
 to the bladder, which often will be 
 found extensively attached to its an- 
 terior face. If so, it must be care- 
 fully detached well down to the neck 
 of the uterus. 
 
 The relations of the broad liga- 
 ment and the appendages to the tumor 
 next require attention. If the tumor 
 has developed laterally between the folds of the broad ligament upon one or both 
 sides, suitable incisions of these folds must be made to admit of the enucleation of 
 the tumor. This will be facilitated by preliminary ligation of the ovarian artery. 
 The denuded surfaces of the broad ligament left after enucleation or detachment 
 of the tumor should be brought into apposition, and complete hemostasis secured 
 by a row of sutures running from its upper free border down to the cervix uteri. 
 Where the broad ligament, though carried up on the tumor, still presents appre- 
 ciable normal folds, these are to be treated as lateral pedicles by tying them off 
 with successive double ligatures in mass, applied on the sides next the pelvis and 
 the tumor respectively, between which they are severed. Clamp forceps may be 
 substituted provisionally for the ligatures, especially upon the side next the 
 tumor, often Avith advantage in the saving of time. When the tumor has devel- 
 oped mainly in the fundus in such a manner that the broad ligaments have not 
 become involved with it, they demand no special attention from the surgeon, 
 except in cases of total extirpation, in connection with which procedure they will 
 again be referred to. In other cases they become engaged, to a greater or less 
 degree, in the constrictor which is thrown around that portion of the uterus 
 which is to constitute the pedicle, by the division of which the tumor is finally 
 completely detached and removed, together with the tubes and ovaries. 
 
 By the means now described the isolation of the tumor will have been 
 accomplished, and only a somewhat narrow ma.ss of uterine tissue will remain 
 to be divided, which will be drawn up to the abdominal wound. This, the 
 pedicle, will usually be composed of the cervical portion of the uterus. Its 
 treatment is a vital point in the operation, and may be conducted in various ways. 
 The pedirlf is at once to be strongly constricted. This may most quickly 
 
 Trendelenburg's Position : elevation of the pelvis 
 for facilitating intrapelvic manipulations. 
 
SURGERY OF Till': FEMALE (iENERATIVK ORGAXS. 1009 
 
 be tlone by an t'lastic cord, usin^ tor the |iiir|»oso strong rubber tubing or 
 solid cord of about one-quarter inch (0 mm.) diameter, which, -while strongly 
 stretche<l, is passed two or three times around the part and its crossed ends 
 secured by tying them with silk or by compressing them together with a 
 strong clamp forceps. Just above the ligature two large pins should be 
 thrust through the pedicle, in order to prevent slipping of the ligature when 
 the tumor is cut away. If the pedicle is very thick, it may be transfixed by 
 the elastic cord and ligated in two parts. Care must be taken in applying 
 this ligature that neither bladder nor intestine is caught in its bite. A differ- 
 ent but very efficient method of constriction may be found in the use of a wire 
 constrictor with a sliding bar forced down by screw pressure. The pedicle is 
 embraced by the two arms of a strong copper wire loop; the bar, pierced at 
 each end to receive these arms, is slid along them down to the pedicle, and 
 then by a screw attachment is powerfully pressed against it. Any amount of 
 constriction can thus be applied : the positiveness and certainty of the con- 
 stricting force have made this device a favorite with many operators. When 
 it is used, after suitable constriction has been effected the bar is secured in 
 position by a small set-screw, the main screwing apparatus is detached, and 
 the wire is left in place, resting on the surface of the abdomen, until the 
 strangulated mass shall slough off and set it free. 
 
 The pedicle having been constricted, the tumor is cut away at a sufficient 
 distance above the constrictor to ensure against its slipping off. The toilet of 
 the peritoneal cavity is noAv to be made, wnth close examination to discover any 
 bleeding points. Should much blood-clot or fluid have accumulated in the 
 peritoneal cavity, it should be freely Avashed out with warm water, 110° F., or 
 preferably with a normal salt solution (6 : 1000) poured into it. The sponges and 
 instruments should have been counted and their number written down before 
 the operation, and they should be now recounted to ascertain that none have 
 been left in the abdomen. The cavity having then been carefully dried, the 
 abdominal Avound is to be closed. At the loAver angle of the wound the pedi- 
 cle is first to be fixed by carefully suturing with catgut the adjacent edges of 
 the parietal peritoneum to the peritoneal surfaces of the pedicle just below the 
 constrictor ; then the remaining Avounded peritoneal surfaces are to be sutured, 
 followed by suture of the remaining abdominal planes. The superficial sutures 
 are not inserted for a little distance from the pedicle, but the parts are allowed 
 to gape a little to receive the disinfecting tampon with which it is best to sur- 
 round the pedicle while sloughing. Upon the cut surface of the pedicle is now 
 placed a thin pledget of cotton squeezed out of a saturated solution of chloride 
 of zinc ; the gutter about the pedicle is freely dusted with a drying and antisep- 
 tic powder (as tannin three parts and salicylic acid one part) and packed with 
 sterilized cotton. An abundant sterilized absorbent dressing is placed over all, 
 and may remain undisturbed for a Aveek or more. Subsequent dressings will 
 be made as required to meet the needs for cleansing and antisepsis which the 
 necrotic stump may present. During the second or third Aveek the separation 
 of the pedicle slough may be expected : when all necrotic tissue has cleared 
 away, a deeply-depressed granulating surface will be left, Avhich will rapidly 
 shrink and heal. 
 
 The delay, annoyance, and possible danger of infection from the sloughing 
 stump Avhen treated in the AA'ay described may be avoided by hollowing out the 
 cut surface of the pedicle Avith the knife, cauterizing well the accessible por- 
 tion of the cervical canal Avith the thermo-cautery, and scAving together the 
 opposite walls of the cup-shaped cut surface of the stump by, first, a series of 
 sunken catgut sutures to close the deeper parts, and then by a row of silver 
 
 64 
 
1010 .l.Y AMKIUCAS TEXT- HOOK OF Sillii III: Y. 
 
 sutures to close the more sujjerficiiil parts; the ends of tlie silver sutures are 
 to be left long, so that they may l)e brought out through the lower angle of the 
 abdominal wound, there to be fastened to a transverse bar or simply grasped in 
 the bite of a long-nosed clamp forceps laid across the abdomen, by which the 
 stump of the pedicle may be held up in contact with the anterior abdominal 
 wall. The suturing of the pedicle stump is to be done Avhile the elastic con- 
 Btrictor is still in place; then the uterine arteries are to be ligated below 
 the constrictor by a silk suture passed deeply into the lateral surface of 
 the cervix on each side and lirmly tied ; the rubber constricting cord is now 
 removed ; any oozing of blood from between the lips of the stump-wound is 
 to be controlled by tlie introduction of additional sutures so placed as to com- 
 press the sources "of oozing when tied tightly on its free margin. The toilet 
 of the peritoneal cavity is now to be made, as already described, the perito- 
 neum of the stump united on all sides by catgut sutures to the parietal peri- 
 toneum, and the abdominal Avound above closed in the usual manner, except 
 at its lower portion, where it is allowed to gape to expose the suture-line of 
 the attached pedicle stump. The silver suspensory sutures project through the 
 raping wound here, and are to be secured to a transverse support, as already 
 mentioned. Care should be taken in the original application of these wire 
 sutures to tAvist them all in one direction, and to give to all a certain recorded 
 number of turns in order to facilitate their later removal Avhen the points of 
 twisting will have become concealed at the bottom of a retracted granulating 
 pit. The suspension of \)a(i pedicle stump having been effected, a tampon of 
 iodoform or oxide-of-zinc gauze is gently crowded between the wires and the 
 adjacent wound-edges ; the general wound-line above is treated as usual, and 
 over all an abundant sterilized protective dressing applied (Kelly). By this 
 method the pedicle incision is for a time kept extra-peritoneal, and hemorrhage 
 or infection from it can be readily observed and treated. If no such compli- 
 cation occurs, the primary dressing may be left in place for a week, and by the 
 tenth day the suspensory sutures may be removed and the unclosed portion of 
 the abdominal wound be brought together by secondary sutures or allowed to 
 heal by granulation. In some cases enough of the peritoneum will have been 
 detached to allow of its inversion and suture. The pedicle is then dropped into 
 the abdomen. The canal should have been disinfected by the Paquelin cautery, 
 and will serve for drainage. 
 
 Total Hysterectomy. — Rather than leave any portion of the cervix behind, 
 whether treated as a pedicle fixed in the abdominal wound or as a stump 
 covered over by peritoneum and dropped back into the pelvis, it is better to 
 excise it totally whenever practicable. Usually this can be done quite as 
 readily and speedily as the partial excision. In every case the preliminary 
 disinfection of the vagina and of the cervical canal should be made prepara- 
 tory to total excision. For this purpose the patient, after anesthetization, 
 should be placed in the lithotomy position, the pudenda and the vagina 
 thoroughly scrubbed with soft soap smeared upon a sponge on a handle, the 
 cervix curetted and swabbed out with a solution of chlori(le of zinc, 1:10, 
 and tamponed with iodoform gauze ; copious antiseptic irrigations of the vagina 
 and pudenda should follow: then the cervix should be detached from the 
 vagina by an incision at the cervico-vaginal junction, which should be deep- 
 ened anteriorly suflRciently to detach the bladder from the cervix, and pos- 
 teriorly sufficiently to strip up the posterior peritoneal covering from the cervix 
 to an equal distance, or to open into the cul-de-sac of Douglas. The spaces 
 thus opened uj) should be packed with sterilized gauze, and the vagina l)elov- 
 should also be tightly stuffed with the same material to arrest the iienioi 
 
 ow 
 
SUBGEHV OF THE FEMALE GENERATIVE ORGANS. 1011 
 
 rliago. The i):itifiit should tlien be phiced in tlie usual dorsal position and 
 the abdouiiual incision made. After the peritoneal cavity has been opened the 
 pelvis should be elevated into the position of Trendelenburg, and the remainder 
 of the operation conducted with the patient in that position. The tumor 
 should now be lifted out of the abdomen through the incision, which should 
 have been made long enough to admit of its easy delivery ; all adhesions are 
 dealt with as they appear according to the methods elsewhere described. If 
 the ovaries and tubes appear diseased, they should noAv first be separately ex- 
 tirpated ; if they are healthy, they require no special attention. The relations 
 of the bladder to the tumor are then identified, after which an incision through 
 the peritoneum across the anterior face of the uterus should be made just 
 above the line of the vesico-uterine reflexion ; this incision should extend 
 laterally on either side to the broad ligament : this peritoneal flap is now 
 stripped from the uterus by blunt dissection ; soon the cellular interspace 
 between the uterus and bladder is entered, and the ready separation of the 
 bladder from the uterus is proceeded with until the wound-space previously 
 made below from the vagina is opened into. This is made more facile by the 
 way it has been distended and made prominent by the gauze packing. By 
 careful tearing of the connective tissue of the broad ligaments at either side 
 of the cervix, thus exposed from the front, the uterine vessels are identified and 
 partially isolated ; by means of a suitable ligature-carrier a catgut or silk liga- 
 ture is passed around them subperitoneally, and they are tied, first on one side 
 and then on the other, close down to the vaginal insertion. Care must be 
 taken not to include the ureters in this ligature. If the precaution is observed 
 to keep close to the cervix in passing the ligature, there is little danger to the 
 ureters, which have been carried well fa-ward with the bladder. The greatest 
 danger of such an accident attaches to cases in which, on account of growths 
 springing from the cervix low down and extending outward into the broad 
 ligament, the relations of the structures have been changed. In such cases 
 especial caution must be used in identifying and isolating the structures 
 about which ligatures are to be tied. The broad ligaments are next tied off, 
 outside the ovaries and tubes, by two or more catgut or silk ligatures on either 
 side. The chief vessels supplying the uterus have thus been tied, and the 
 tumor and uterus may now be removed in one piece between the ligatures : as 
 the section of the broad ligaments reaches their base, the tumor should be 
 carried forward upon the symphysis so as to expose the posterior face of the 
 uterus ; an incision through the peritoneum across the posterior face of the 
 uterus at about the juncture of the cervix and the body is now made, and a 
 posterior flap of peritoneum bluntly dissected down until the posterior wound- 
 cavity previously made from the vagina is entered. This posterior and the 
 anterior vaginal opening are now connected by cutting with scissors inside the 
 ligatures on the uterine vessels, and the whole mass, thus freed, is taken away. 
 Nothing but the most insignificant bleeding will have attended any of the steps 
 of the operation until the final section of the lateral connections. After the 
 last cut one or two small vaginal branches will probably spurt, but are readily 
 caught by hemostatic forceps and ligated. The pelvic cavity should now be. 
 carefully sponged out : after an assistant has withdrawn from below the pre- 
 liminary vaginal packing, a fold of iodoform gauze should be passed from 
 above through the superior opening of the vagina, so that it may be seized by 
 the assistant and drawn through until its end protrudes at the vulva, while the 
 upper portion of this gauze is left as a loose packing in the wound made by 
 the ablation of the uterus. Over this packing the peritoneal flaps are drawn 
 and sutured from side to side, so as to close off from the general peritoneal 
 
1012 ^.Y AMKRICAX TKXT-liOOK OF KrinnJiY. 
 
 cavitv the entire wound-Jirea with its lin:ature.s. Special care should be taken 
 to cover with a peritoueal fold the stump of the infundibulo-pelvic ligament 
 on either side. When this suturing is completed, the pelvic cavity is seen to 
 be closed below by a smooth peritoneal diaphragm which shuts off the wound- 
 cavity, which latter remains extraperitoneal and well drained through the 
 vagina bv the iodoform gauze previously inserted. The abdominal wound is 
 now closed in the usual manner. 
 
 In cases in which the tumor is too bulky to be readily handled, as required 
 for carrying out the technique as now described, an elastic rubber cord may 
 be cast about tiie cervix after the anterior peritoneal flap has been reflected 
 and the greater part of the mass amputated. The remaining stumj) may then 
 be removed in the manner described above, after disinfecting the exposed cervi- 
 cal canal by cautery. 
 
 During the after-treatment an antiseptic absorbent pad at the vulva re- 
 ceives the vaginal discharges. At the end of four days the iodoform-gauze 
 drain may be removed and the granulating cavity irrigated with an antiseptic 
 solution. A new light packing of iodoforai gauze is placed in the vagina. At 
 the end of another week this may be removed, and no further drain will be 
 required. A mildly antiseptic douche should be used daily as long as there is 
 any discharge. During the first four days after operation the bladder should 
 be emptied by catheter. After the first change of vaginal drains spontaneous 
 urination may be allowed. At the end of the third week the patient may be 
 allowed to gel up, and gradually thereafter to go about. 
 
 GENERAL CONSIDERATIONS PERTAINING TO ABDOMINAL SECTIONS FOR DIS- 
 EASES OF THE FEMALE GENERATIVE ORGANS. 
 
 The Preparation of the Patient. — Especial care should be given to 
 have the bowels empty. For three days or more beforehand the diet should 
 be of soft, easily-digested food. On the day before operation a saline purge 
 should be given, supplemented, if need be, by a simple enema. During the 
 same period a daily warm bath should be given and the skin of the abdomen 
 should be well scrubbed with soap and brush, especial care being taken with 
 the umbilicus. During the night preceding the operation the abdomen should 
 be kept covered with gauze saturated with the boro-salicylic solution, this to 
 be replaced in the morning Avith gauze saturated with corrosive-sublimate solu- 
 tion, 1 : 2000, after a final scrubbing and shaving of the pubes. The vagina 
 should be subjected to copious antiseptic douching twice daily, and if total 
 hysterectomy is contemplated the more thorough and vigorous sterilization 
 already described should be done. The patient should empty her bladder 
 voluntarily before being taken to the operating room ; the use of a catheter is 
 rarelv required. The antiseptic precautions which must be observed as to the 
 room, instruments, etc. will be found detailed in the chapter ujion this subject. 
 
 The Position of the Patient. — Large growths wliich have pushed up into 
 the general abdominal cavity and are readily accessible and removable without 
 requiring much manipulation in the true pelvis, and small pelvic masses which 
 are enucleable by the fingers alone without the aid of the eye and can readily 
 be brouorht up to and out of a small abdominal wound, may be satisfactorily 
 dealt with while the patient is in the ordinary horizontal dorsal position. 
 When, however, any of the steps of the operation are embarrassed by the pres- 
 ence of intestinal coils or where it is desirable to bring into sight the recesses 
 of the pelvis, the patient's pelvis should be raised sufficiently to place the trunk 
 at an incline of from 4.5° to 60° to the horizontal. (See Fig. 402.) 
 
 The Incision through the Abdominal Wall — The position and length of this 
 
SURGERY or tup: fkmalk generative organs. 1013 
 
 must be detcniiiiKMl l)y tlie special case, and are referred to in eonnection with 
 each condition treated of. In general, however, it should be midway between 
 the pubes and the umbilicus, and as short as is consistent with the accurate, 
 ready, and raj)id performance of the manipulations re(iuired for the exploration, 
 the separation, and the removal of the tumors. When the growths arc cystic 
 in character and free from adhesions, an incision from two to three inches in 
 length will usually suffice, whatever the size of the tumor, the collapsed sac of 
 Avhich, having been emptied by tapping, is readily drawn out of the relatively 
 small opening. The operator should not permit himself to be embarrassed by 
 an unduly restricted incision at any time, but should enlarge it with scissors at 
 once according to the needs of the case. 
 
 Adhesions. — The search for adhesions is usually to be reserved until in the 
 case of cysts these have been emptied of their contents, or in the case of solid 
 growths these have been freely exposed so that their attachments can be readily 
 recognized and dealt with. If the adhesions are soft and recent, they are 
 easily separated by the finger-tip or sponge. If they are firm and vascular, 
 they' should be secured by double ligatures or clamp forceps, and cut between 
 them. At times the adhesions to intestine or bladder will be so close and firm 
 as to prevent this double ligation ; in this case a portion of the wall of tlie 
 growth must be dissected away and left attached to the viscus. If possible 
 the raw surface thus left attached should be folded in upon itself and sutured 
 so as to leave a peritoneal covering exposed. Firm omental adhesions are to 
 be treated by tying the omentum in sections and cutting it away. If intestine 
 or bladder be lacerated in the attempts to separate adhesions, immediate suture 
 of the wound should be done, and the Avounded part, if possible, brought up and 
 secured in juxtaposition to the abdominal wound, and protected by a tampon 
 of iodoform gauze for some days until the possibility of fecal or urinary extrav- 
 asation has passed aAvay. 
 
 A7'rest of Hemorrhage. — The sources of hemorrhage are chiefly three — 
 adhesions, the pedicle, and raw surfaces left by the enucleation of non-pedun- 
 culated growths. The temporary use of clamp compression forceps, to be 
 later replaced by permanent ligatures if necessary, is of the greatest value 
 in expediting the removal of abdominal growths. The elastic ligature for 
 the compression of thick pedicle stumps has been already described. Mass 
 ligatures are often required, and can be resorted to freely with comparative 
 impunity in consequence of the fact that the tied-off parts do not necrose, but 
 soon become again vascularized after having been nourished for a time through 
 imbibition. Catgut, as a rule, is the best material for ligatures. Masses that 
 are too large to be included in a single loop may be transfixed and tied in sec- 
 tions, two or more as the case may require. Each succeeding loop should catch 
 the preceding one. Membranous edges or folds may be secured by a sort of 
 hemstitch or shoemaker's stitch. Broad oozing surfaces may often be best 
 treated by cauterization with the thermo-cautery. Cases occur in which none 
 of the methods described avail fully to arrest bloody oozing from a deeply- 
 placed raAV surface. For such conditions is reserved the use of an antiseptic 
 tampon by stuffing the cavity Avith iodoform gauze. For this purpose a pouch 
 of iodoform gauze of suitable depth and capacity may be carried doAvn upon 
 the bleeding surface and its cavity stuffed Avith long strips of sterile gauze, the 
 ends projecting through the loAver end of the abdominal incision. (See Fig. 
 403.) More positive compression may be exerted by stuffing successive layers of 
 a lono- strip of iodoform gauze into the cavity, and finally bringing the end of 
 the o-auze out through a glass drainage-tube, the end of Avhich is made to press 
 doAvn upon the tampon beloAv. Later, by raising the tube somewhat, the entire 
 
1014 
 
 AX AMKIiJCAX TEXT- HOOK OF SLRiUlUY 
 
 strip Clin readily be drawn out through it. Such a tampon shouhl he removed 
 after forty-eight or seventy-two hours, according to the amount of oozin". 
 
 Fig. 408. 
 
 Tamponade of the Peritoneal Cavity after Hysterectomy: a, a, pouch or tube of iodoform gauze : A thread 
 fastened to center of pad ; c, c, c, strips of iodoform gauze (Pozzi). 
 
 If the bleeding is too copious to be controlled by such a tampon, clamp 
 forceps may be applied and left in situ for from twenty-four to forty-eight 
 hours, their handles being brought together out throurrh tlie lower angle of the 
 abdominal incision. 
 
 Cleansing of the Peritoneal Cavity. — All blood and other fluids that have 
 escaped into the peritoneal cavity should be carefully removed before closing 
 the abdominal wound. If there is much such material to be removed, washing 
 out of the cavity should be resorted to by pouring into it, while the relaxed 
 parietes are held apart, several pitcherfuls of warm salt solution. 6 : 1000, and 
 110° F. in temperature. Most of this fluid at once escapes upon squeezing 
 the parietes together ; the rest is to be carefully sponged out. Finally, the 
 utmost caution is to be used not to leave in any of the recesses of the cavity 
 any sponge or instrument, a deplorable accident which has happened many 
 times, and to jruard airainst which it should be the invariable rule to bejxin such 
 an operation with a definite known number of sponges and forceps, all of which 
 should be accounted for before the incision is closed. 
 
 Drainage. — Whenever the separation of extensive adhesions has left behind 
 surfaces from which considerable sero-sanguinolent oozing is to be expected, 
 and especially if any suspicion of possible infection of such secretions exists, 
 provision should be made for drainage. If the question is a doubtful one, the 
 benefit of the doubt should be given to the drainage-tube, since it can be 
 
ISURGERY OF Till-: FEMALE GENERATIVE OlidAXS. 1015 
 
 removetl at an early day it* f'niiiKl siiitcrlliioiis. In eases where secondary hera- 
 orrha<;e is feared a drain sliould he eni))loyed until the period of reaction has 
 been fully established. " Folds of sterile gau/e are to be preferred for the 
 drainage of blood and serum ; when the area has been infected iodoformized 
 gau/.e is indicated; wlien heniostati(r tanijionade has been rcijuired the gau/.e 
 taui|M)n likewise acts as an energetic drain. One end of the gauze is laid 
 upon the area to Ite drained, the other is led out through the parietal wound; 
 over this projecting end is placed an abundant absorbent dressing, which is 
 chaniied as often as it becomes saturated with discharges. As soon as the 
 discharge becomes scanty the drain should be removed. In favorable cases 
 this may be done from the second to the fourth day. If upon the removal 
 of the drain the welling up of retained secretion should show that the drain- 
 age had been incomplete, a rubber tube drain should be inserted to the bottom 
 of the discharging cavity, and its after-care conducted on the general princi- 
 ples which govern the use of a drain in any part of the body. By many sur- 
 geons glass tubes have been used for abdominal drainage, together with fre- 
 (puMit careful aseptic syringe-suction to remove accumulating secretion, or a 
 gau/.e wick may be introduced into the tube." 
 
 The Closure and Dressin;/ of the Abdominal Wound. — The first precau- 
 tion is to secure union of the peritoneal edges: to ensure this, separate sew- 
 ing of the peritoneum may be done with a running suture of catgut. Many 
 surgeons deem this unnecessary. If a pedicle stump has been brought out 
 at the lower angle of the wound, the peritoneal edges adjacent to it should be 
 carefully sewed around the pedicle below the constrictor. If at the same 
 time a drainaore-tube has been inserted, it should be brought out an inch or 
 more above the pedicle and the intervening space sutured. By many opera- 
 tors all the remaining tissues along the wound-line are now brought together 
 at once by a series of interrupted sutures, silk or silkworm gut being used as 
 the material. A more perfect safeguard against subsequent hernia will be 
 obtained, however, by separate suture with catgut of the edges of the fibrous 
 structure of the linea alba or of the sheath of the rectus muscle, and this 
 should be done if the condition of the patient will warrant the slight addi- 
 tional delay which it may cause. Lastly, the superficial fascia and skin are 
 sutured. If a drain is used, one or two silkworm-gut sutures should be intro- 
 duced through the whole thickness of the edges at the place where the wound 
 must gape to receive the gauze. These sutures, having been loosely tied 
 when introduced, are to be draAvn tight when the gauze is removed, so as to 
 secure, if possible, immediate union also of that part of the wound. If dur- 
 ing the introduction of the peritoneal sutures the intestines tend to protrude, 
 they should be kept back by a sterile gauze pad placed over them until the 
 sutures have been introducetl, enough of the last introduced sutures being 
 left momentarily untied to admit of the final withdrawal of the protecting- 
 pad. The external dressing should be sterile, soft, and absorbent, and a 
 sufficient mass of it should be placed over the wound to protect it from 
 accidental infection. The wound may be still further protected by a layer 
 of iodoformized collodion (1 : lo) painted thickly over it, or by free dust- 
 ing with a powder of iodoform and boric acid (1 : 7) or with oxide-of-zinc 
 powder. The main dressing is to be kept in place by several broad strips of 
 adhesive plaster or by a suitable binder. 
 
 After-treatment. — Shock is to be combated upon general surgical prin- 
 ciples. Severe pain must be relieved by the hypodermatic use of morphine, 
 but the use of opium in any form is to be avoided as much as possible. Vomit- 
 incr, if persistent and distressing, is to be alleviated by small frequent doses 
 
101 <J AX A mi: IN (AX TEXT- lion K OF SVUCKIiV. 
 
 of hot water, by an ounce of stron<T infusion of coffee, or by cocaine in doses 
 of gr. \-\ every two hours, and by rectal feeding. The vomiting attendant 
 upon peritonitis, should that condition develop after sume days, is to be met 
 by the relief of the condition which ciiuses it. Tynij)anites is to be relieved bv 
 the introduction liigh up of a rectal tul)c and the occasional administration of a 
 turpentine enema or one containing half an ounce of tincture of asafetida and 
 twenty grains of bisulphate of (jiiinia. Peritonitis, if threatened, calls for 
 the ap))lication of an ice-coil to the abdomen and for the free use of .saline 
 purges. If uncheckeil by these, the wound should be reopened, collections of 
 septic fluids sought for and evacuated by free antiseptic irrigations, and thor- 
 ougi) drainage provided for. Hemorrhage into the ]>eritoneal cavity may 
 occur from a slipped ligature or from a vessel which, though not bleeding when 
 the wound was closed, has begun to bleed with the establishment of reaction. 
 Symptoms of progressive anemia and shock beginning to show themselves a 
 few hours after an operation indicate such bleeding, and call, at any risk, for 
 immediate reopening of the wound, exploration of the peritoneal cavity, and 
 arrest of the hemorrhage. 
 
 In general, cases of abdominal section which escape any of the complica- 
 tions named demand simply the ordinary attentions proper to a person seriously 
 ill. For the first twenty-four hours notliing should be introduced into the 
 stomach except an occasional sip of hot Avater. Thirst, if great, can be slaked 
 by enemata of hot water ; ice and the drinking of cold water should be avoided. 
 As soon as the nausea and vomiting have subsided, the administration of small 
 quantities of liquid food may be begun. Milk with lime-water or Yichy water, 
 thin gruels, beef-juice, and such-like ])reparations, are to be used. If the 
 patient will take it, peptonized milk is best of all. As the convalescence pro- 
 gresses, a gradual advance to a more solid and varied dietary will be made 
 according to the judgment of the surgeon in the particular case. If the irri- 
 tability of the stomach persists beyond the first forty-eight hours, feeding by 
 the rectum should be resorted to and continued until the stomach becomes able 
 to tolernte food. Peptonized milk, beef peptonoids, eggs beaten up with salt 
 and milk, are recommended for rectal feeding. The bladder should be emptied, 
 if possible, voluntarily, but if at the end of about eight hours spontaneous 
 urination has not occurred, a catheter should be used, every precaution being 
 taken against the introduction of septic matter into the bladder, the intro- 
 duction of the catheter being always preceded by a cleansing of the external 
 meatus with an antiseptic wash. The catheter should be passed at intervals 
 of eight hours until the power of normal urination is regained. The bowels 
 should be moved on the third day by an ordinary enema if they have not been 
 spontaneously evacuated before. 
 
 Re-dressing of the abdominal wound in an uncomplicated case will not be 
 required until the end of ten days or two weeks. At the end of this time, the 
 primary dressing having been removed, the wound will be found firmly healed 
 and the sutures may be taken out. If any stitch-hole abscesses should be dis- 
 covered, they will be treated on general principles ; otherwise a small protect- 
 ive pad is simply laid over the recent cicatrix and suitable strips of adhesive 
 plaster are applied to prevent any undue tension. During the third week the 
 patient may be allowed to sit up, and according to the more or less rapid 
 return of her strength may thereafter be allowed to resume her usual life. 
 A protective abdominal binder should be worn for at least six months 
 thereafter. 
 
 Jntestinal Adhesiotis, with consequent Angulation ayid Obstruction, consti- 
 tute a complication to be feared whenever extensive raw surfaces have to be left 
 
SURGERY OF Till-: FEMALE GENERATIVE ORGANS. 1017 
 
 within tlie peritoneal cavity. It is difticiilt t(» differentiate this accident from 
 general peritonitis, both conditions declaring themselves by obstinate vomit- 
 ing, constipation, and tympanites, and tending to speedy death. In either 
 case reopening of the wound and exploration are called for. If angulation is 
 found to be ])resent, the adhesions must be broken up and the intestine set free. 
 Ke-adhesion and renewed olistruetion should be j)revented Ijy the use of saline 
 purges to provoke peristalsis. Martin suggests anointing the raw surfaces that 
 are to be left behind with sterilized olive oil as a possible preventive of adhe- 
 sion. In any case, a cardinal rule is always to draw over every raw surface 
 as much of a' peritoneal covering as possible by sliding and suturing before 
 closing an abdominal wound. 
 
 CARCINOMA OF THE UTERUS. 
 
 According to the statistics of Williams, 31 per cent, of all cases of carci- 
 noma occurring in women have their seat in the uterus. The cervix is the 
 region most frequently affected primarily ; the body is, nevertheless, not rarely 
 the point of origin. It is rare for it to occur in women under thirty years of 
 age. About tAvo-thirds of all cases occur between the ages of forty and sixty. 
 In addition to the influence of age as a predisposing cause, there is much 
 ground for assigning a marked influence, as contributing to its development, 
 to chronic inflammatory conditions of the uterus, especially when combined 
 with neglected lacerations of the cervix. 
 
 Carcinoma of the Cervix Uteri may present itself primarily either as 
 an affection of the vaginal portion or of the mucous membrane of the canal, or 
 as a nodular infiltration of the wall of the cervix. The first form, the cancroid 
 of some authors, may remain for a long time limited to the vaginal portion. 
 Its further spread, as a rule, is particularly marked toward the vagina. 
 
 Carcinoma of the Corpus Uteri occurs as a primary disease more 
 rarely than that of the cervix. It originates in the glandular structures of 
 the endometrium, and thence extends as a diffuse infiltration with rapid dis- 
 integration. 
 
 In all forms of cervical cancer the vagina is frequently invaded early ; 
 extension upward to the body of the organ is, as a rule, slow. The vascular 
 and lymphatic streams tend outward from the cervix along the base of the 
 broad' ligament (Fig. 404) : hence the extension of the disease in this direc- 
 tion outward into the broad ligaments before the proper body of the uterus is 
 involved. The inguinal lymphatic glands become affected only after a wndely- 
 disseminated pelvic disease has been created. 
 
 As the infiltration characteristic of the disease increases, the contiguous 
 tissues and adjacent organs become involved; the bladder, uterus, or rec- 
 tum (Fig. 405) may become more or less seriously damaged, and the symp- 
 toms referable to their irritation or obstruction be added to those existing 
 previously. The early involvement of the connective tissue of the broad 
 ligaments thickens and shortens them and anchors the uterus firmly, while it 
 may cause compression of the pelvic vessels, giving rise to oedema of the lower 
 extremities and to pain along the involved nerve-trunks. A more or less 
 rapid disintegration of the new growth supervenes early ; the processes of 
 infiltration and ulceration follow close upon each other : as a result, the blad- 
 der or the rectum, one or both, may be opened into, and one great foul cloaca, 
 receiving urine, feces, and the debris and discharges from the uterus, be created. 
 A forerunning adhesive inflammation alone prevents the frequent opening of 
 the peritoneal cavity also. 
 
U»18 Ay AMKliUAy TEXT-noOK OF SLllUKllY. 
 
 TIk' symptoms in its earlier staf^es are indefinite and uncertain. Card- 
 
 ^'..y 
 
 Lymphatic Vessels of the Uterus: 1, lymphatics coming from body and fundus of uterus; 2, ovary; 3, 
 vagina; 4, Fallopian tube: 5, lymphatics coming from neck of uterus; 6, lymphatic vessels coming 
 from neck of the womb and going to the iliac glands ; 7, lymphatic vessels coming from the body and 
 fundus of the uterus and going to the lumbar glands; 8, anastomosis uniting the vessels of the neck 
 and body of the uterus ; 9, small lymphatic vessel situated in the round ligament and terminating in 
 the inguinal glands; 10, 11, lymphatic vessels of the Fallopian tube emptying into the great lym- 
 phatics of the body of the uterus; 12, ligament of the ovary (Pozzi;. 
 
 nomatous degeneration of the uterus may attain considerable proportions with- 
 out provoking any noticeable synip- 
 FiG. 405. toms, and may finally be detected only 
 
 by accident. More frequently the oc- 
 currence of vague pains, irregular hem- 
 orrhages, and a somewhat ])rofuse and 
 offensive vaginal discharge invites ex- 
 amination as to their cause. The ir- 
 regular and easily-provoked bleeding.s^ 
 which mark an invasion of carcinoma 
 when it occurs at the period of the 
 menopause are often attributed to the 
 menstrual irregularities which so fre- 
 quently attend it. The occurrence of 
 such bleedings at that period of life, 
 therefore, is to be considered a suspi- 
 cious circumstance and to call for care- 
 ful examination. The discharges that 
 attend a disintegrating carcinoma are 
 thin, watery, and dirty, often acrid 
 and mixed with shreddy debris, and 
 exceedingly offensive. 
 The diagnosis declares itself at once to the eye and to the touch, upon exam- 
 
 Cancer of both Lips of the Uterus (Skene). 
 
^cuajjjiv OF r/n: fhmalf (hixfaiative onaAXs. ioi9 
 
 ination, in cases that are well advanced in their development, hut in the earliest 
 stages it is impossihle, except hy the aid of" the inicroscope, to difterentiate the 
 disease from the indurations and erosions due to ordinary inflammatory con- 
 ditions. In all suspicious cases a small section of the affected tissue should 
 be removed and submitted to the examination of a pathologist. If the affected 
 part is high up, and hence not readily accessible, scrapings from the deeper 
 mucosa should I)e o))tained Avith a sharp curette for similar examination. 
 
 The prognosis is that which attends like malignant disease elsewhere. 
 The average prolongation of life when the disease pursues its natural course is 
 from twelve to eighteen months. The younger the patient the more rapid the 
 course of the disease. If the disease is detected early enough to admit of 
 the absolute removal of all affected tissue, j)ermanent cure may be expected. 
 The early extension of the disease outward along the lymphatic channels of the 
 deep pelvis, which for some time it may be impossible to detect, makes the 
 prognosis in any given case uncertain. In estimating the proportion of cases 
 in which permanent relief is obtained by extirpation, the consideration of all 
 cases in which the clinical diagnosis has not been confirmed or established by 
 the microscopical findings as determined by a competent pathologist must be 
 excluded. This is especially important in dealing with malignant disease of 
 the vaginal portion, for which simple inflammatory conditions are often mistaken. 
 The principles which govern the prognosis of carcinoma of the uterus are the 
 same as obtain in other organs of the body, modified by the special anatom- 
 ical relations of the uterus. Cure is to be expected only from operative meas- 
 ures that Avill secure the removal of a very considerable zone of apparently 
 healthy tissue around and beyond that Avhich is manifestly diseased. Since 
 carcinoma of the portio vaginalis is usually detected at an earlier period of 
 development, and naturally extends slowly at first, it will always present the 
 largest proportion of cures of any of the forms of the disease. 
 
 Treatment. — The prevention of the development of carcinoma of the 
 uterus has a practical side through the probable predisposing influence of 
 chronic endometritis, especially when accompanied with laceration and ero- 
 sion of the cervix. The proper treatment and early cure of such conditions, 
 therefore, assume importance in the prophylaxis of carcinoma. The occur- 
 rence of irregular hemorrhages or the development of leucorrheal discharges 
 in women who are approaching or have passed the menopause should be the 
 signal for immediate and thorough examination of the uterus. The presence 
 of carcinoma having been determined, its total extirpation is to be done at 
 the earliest possible moment if the disease appears to be still sufficiently 
 limited to afford ground for hope that its removal is practicable. 
 
 Carcinoma of the portio vaginalis, when detected in its earliest stages 
 while vStill superficial and circumscribed to a limited area, may be attacked 
 with some hope of permanent cure by a supra-vaginal excision of the cervix^ 
 followed by thorough cauterization of the wound surfaces exposed. The 
 usual preparatory treatment is first attended to. The cervix having been 
 draAvn down as much as possible, a preliminary ligature is first applied to 
 each uterine artery by a curved needle armed Avith a stout thread, intro- 
 duced dee])h^ in each lateral vaginal fornix ; the vaginal mucous mem- 
 brane is then divided circularly where it is reflected upon the cervix, and 
 the submucous connective tissue is bluntly dissected from the cervix, keep- 
 ing close to the cervix, separating the bladder from it in front, until the 
 end of the internal os is reached ; similarly the posterior surface of the 
 cervix is enucleated to the same height. Any accidental opening through 
 the peritoneum into the posterior cul-de-sac should be sutured. As the 
 
1()2(> 
 
 .4^V AMKIUCAS TEXT-nOOK OF SVIICKRY. 
 
 denudation is extended laterally, should any vessels sj)out they are ligated in 
 the wound. The denuded eervix is then split into an anterior and a poste- 
 rior half by lateral incisions, and each part cut oft" transversely at the highest 
 point accessible. The exposed stump is then thoroughly seared by a therrno- 
 or electric-cautery button, and a light tampon of" iodoform gauze ap]»lied. 
 The subse(juent treatment is simple: the eschar separates in due time, leav- 
 ing a granulating surface v hich heals rapidly, rec^uiring only the use of daily 
 antiseptic douches for cleansing purposes. For some time the parts should 
 be carefully watched, and the appearance of any susj»icious change should be 
 met by the [)rompt removal of the entire organ. 
 
 Total extirpation of tJie tifmfx is preferred by many surgeons to any jKir- 
 tial removal in all cases without reference to the apparent limitation of the 
 disease. AVhen done by the vaginal j»ath alone, and in the absence of infil- 
 trations of the broad ligament to restrict the movability of the uterus, the 
 
 Fig. 406. 
 
 Showing method of exposing uterus preparatory to operative attack upon it tliroURh tlie vagina. 
 
 total extirpation takes but little more time, and is attended with but little 
 if any more hazard to life than is the partial operation, and has the advantage 
 of leaving no uterine tissue to become the seat of recurring disease. 
 
 Vacfinal Jfi/sterctonit/. — As an immediate preliminary to the operation 
 the rectum and bladder should have been emptied, the pubes shaved, and 
 thorough disinfection of the external genitals and thighs made. For the 
 operation the ])atient should be placed upon her back with pelvis raised in an 
 exaggerated lithotomy position. (See Fig. 406.) 
 
 The labia and perineum having been retracted, the cervix is seized by a 
 suitable volsellum forceps and drawn as far down as possible; any excavation 
 in the cervix left by the curetting and cauterization is first well irrigated with 
 sublimate solution, 1 : 1000, and then filled with a tampon of iodoform gauze, 
 and its lips sewed as closely together as possible by a continuous suture. The 
 cervix is then lifted strongly forward, so as to put the posterior vaginal pouch 
 
SURGERY OF TU F FIlMALl-] dE^^FJlATIVE ORdANS. 1021 
 
 on tlie stretch. A transverse incision is next made just heliind the cervix 
 through the vaginal wall, opening into the sac of Douglas. A series of sutures 
 is then passed so as to control bleeding from the vaginal vessels severed by 
 the cut. 
 
 The cervix is now drawn strongly to one side, and a moderately large 
 curved'needle, armed with a strong thread, is thrust through the lateral reflec- 
 tion of the vagina as close as [)ossible to the uterus, deeply into the base of 
 the broad ligament, and after executing a sharp curve is brought out again 
 about a quarter of an inch from its point of insertion. This manoeuver may 
 be aided and guided by the forefinger introduced into the posterior incision 
 already made. The cervix having been permitted to drop back into its natural 
 position in the middle line, this ligature is tightly tied, and thus the uterine 
 artery encompassed by it is ligated. After the same manoeuver has been exe- 
 cuted upon the opposite side, the. cervix is further separated from the vagina 
 by prolonging the incision already made, laterally, inside the ligatures; the 
 cervix is separated from the broad ligaments on each side up to the limit of 
 the tissue grasped by the lateral ligature applied. If bleeding points present 
 themselves, they should be controlled by the insertion of additional sutures 
 from the vaginal surface. These hemostatic sutures, as, indeed, all ligatures 
 applied throughout the course of the operation, should be tied with great firm- 
 ness. The cervix is now drawn backward and downward so as to expose the 
 anterior vaginal pouch and put the bladder attachments upon the stretch. The 
 remaining vaginal attachment is now divided by a transverse incision in front 
 of the uterus and as close to it as possible. This incision should open into the 
 cellular interspace between the uterus and the bladder. By the finger, aided 
 by scissors if necessary, the bladder is stripped oif — great care being taken to 
 keep close to the uterus in the w^ork of separation, lest the bladder be injured — 
 until the peritoneum is reached. The extent of tissue to be worked through 
 before the peritoneum is reached will vary considerably in diff'erent subjects, but 
 the diminished sense of resistance communicated to the finger when the peri- 
 toneum is reached will suffice to indicate its presence, even though it be not rec- 
 ognizable by the eye. It may be at once opened, or its incision may be deferred 
 to a later stage of the operation, whichever may seem the more convenient. The 
 cervix has now become freed for some distance above the vaginal attachment : 
 its safe liberation from its broad-ligament attachments remains to be accom- 
 plished. Having been drawn down as much as possible, a ligature, by means 
 of a strongly curved needle upon a suitable handle (Deschamps' needle), is 
 carried upAvard close alongside the uterus, so as not to encompass too great a 
 portion of the lateral tissues still holding the uterus ; the thread, having been 
 brought out again, is securely tied, and the greater part of the tissue grasped 
 by it is cut. By a succession of ligatures thus applied, taking care to in- 
 clude in each ligature a portion of the tissue held by the preceding one, fol- 
 lowed by successive snips of the scissors, the broad ligaments are gradually 
 tied and cut off. The application of the higher ligatures may be facilitated 
 by retroverting the uterus by the help of a finger passed through the poste- 
 rior incision over its fundus, together with volsellum forceps to make trac- 
 tion, and pulling it down as far as possible. By this act the upper part of 
 the broad ligament, twisted upon itself, is made readily accessible. The 
 lateral attachments i)eing all finally cut, the anterior peritoneal reflection, if 
 not cut before, is now cut across and the uterus entirely liberated. 
 
 If at any time in the course of the manipulations the intestines tend to 
 protrude through the peritoneal opening, which is uncommon, they should be 
 crowded back by a sponge, to which a marked string is attached to identify 
 
102'2 AX AMERICA X TEXT- HOOK OF Sf /,'(//: J,' V. 
 
 it for siibsei|uent romoval. puissed into the pelvic cavity. 'I'lie sponirc tanijion, 
 if one has been inserted, liaving been Avithdrawn, and all bleedin<!; having 
 been absolntely controlled by ligatures, sutures, or clamp forceps, tlie parts 
 should be irrigated with a mild antiseptic douche, and finally dried uith 
 sjionges upon suitable liolders. The vaginal •wound mav be diminished in 
 extent by a suture apj)litMl at either lateral conimissure, but this is not 
 important. 
 
 A strip of iodoform gauze is next pushed up into the pelvic cavity for 
 drainage purposes, its lower portion being coiled up in the vagina. A sepa- 
 rate small piece of iodoform gauze should be stufted into the introitus, to be 
 frequently changed as retjuired by the exigencies of urination. An abundant 
 .*^oft absorbent pad is placed over the vulva, to be changed Avhcnever saturated 
 with the discharges. 
 
 The after-treatment is very simple, and is guided by general principles. 
 An easy convalescence, free from pain and constitutional disturbance, is usual. 
 At the end of the first week tlie long gauze drain is AvithdraAvn and the vagina 
 gently irrigated. After another week the patient may be allowed to sit up. 
 Careful vaginal douches may be given daily as required for cleanliness. After 
 three weeks, Avalking and gradual return to ordinary life may be begun. 
 
 Instead of tying off the ])road ligaments, as above recommended, it will 
 often be found practicable and more expeditious to clamp the broad ligaments 
 by suitable long-jaAved clamp forceps, which are left hi situ protruding from 
 the vulvar opening for from forty-eight to seventy-two hours, when they may 
 be gently loosened and removed without fear of further hemorrhage. If the 
 clamps are to be used, the posterior and anterior peritoneal pouches are to be 
 opened first, and through these openings the blades of the clamps are to be 
 adjusted close to the uterus. If the operation is embarrassed by rigidity and 
 narrowness of the introitus or of the vagina, the perineum may ])e incised so 
 as to obtain more room. The proper sutures to close the incision are to be 
 inserted after the uterus has l)een removed. 
 
 Hemorrhage, sepsis, ligature of a ureter, and wound of tlie bladder are 
 accidents against which the surgeon must be especially on guard. The liabil- 
 ity of some tissue to slip out from the jaws of a clamp when a large mass of 
 tissue is held in its grasp is an important objection to the use of clamps in 
 such a manner. In the application of ligatures, also, too great a mass of tissue 
 should not be embraced by the loop of a single ligature, for the same reason. 
 In any event, great care should be taken to see that perfect hemostasis is ob- 
 tained at each step of the operation. As to sepsis, the chief source of infec- 
 tion is likely to be the uterus itself, owing to defects in the attempts at steril- 
 izing it. Special care should be taken to make this preliminary Avork thor- 
 ough. The ureter is liable to be wounded or to be included in the grasp of a 
 ligature or clamp if care is not taken to keep close to the u*:erus in all the 
 manipulations involving the base of the broad ligaments. When such an acci- 
 dent happens, if not fiital, it results in a ureteral fistula. A tear of the blad- 
 iler is also possible during its separation from the cervix if the operator is not 
 careful to confine his dissections to the tissues close to the uterine substance. 
 If the bladder is torn, immediate suture of the rent should be done, and a soft 
 catheter retained in the bladder for five days. 
 
 Excision of Cdi'cinoniatoiis Uterus and Broad Lijiavwnt hy the Abdominal 
 Route. — Cases originating in the mucous membrane of the cervical canal, or 
 presenting much infiltration of the cervical substance, or involving any por- 
 tion of the corpus uteri, call for the total extirpation of the uterus, together 
 with the lymphatic vessels and glands of the broad ligaments, provided the 
 
iSU-BGEI^y or Tlfb: female aENERATIVE ORGANS. 1023 
 
 iuvolveint'iit of iH'i_i;lib()i'ing organs and the extension ot" tlie infiltration to 
 tlie pelvic walls are not manifestly such as to demonstrate that total removal 
 of the disease is impracticable. Even in the latter case it has been demon- 
 strated that by removal of the diseased uterus and ligation of the internal 
 iliac arteries the further progress of the disease may be much tlclayed and 
 a period of from one to two years added to the life of the individual. The 
 fiehl of justiHable o[)erative interference has thus become much extended. 
 The development of metastatic foci in the lymph nodes of the broad liga- 
 ment by transmission of infecting cells along the lymphatics takes place so 
 early and for a long period is so difficult of detection by any means of gross 
 examination, that it is better to regard all cases of uterine carcinoma when 
 discovered as having already developed such extension, and therefore to 
 resort to the widest possible removal of the circum-uterine tissue, together 
 with removal of the uterus itself, as soon as the diagnosis is clearly estab- 
 lished. Such radical excision can best be done by an attack by the com- 
 bined vaginal and abdominal routes. 
 
 Ti'cliiii'iue. — Preliminary thorough disinfection of the surface of the ab- 
 domen, of the pudenda, and of the vagina is to be done, followed by curet- 
 tage of the uterus, cauterization of any broken-down surface, stuffing the 
 uterine canal Avith iodoform ijauze, and suturino; the external os, and a final 
 <louching of the vagina. The ureters may now have a catheter introduced 
 into each, if the operator chooses, for the purpose of facilitating their iden- 
 tification in the later steps of the operation; but, as a rule, this is not 
 necessary. Then the mucous membrane of the vagina is to be separated 
 from the cervix, the bladder freed, and the posterior cul-de-sac opened, as 
 already described under vaginal hysterectomy. Finally, the spaces opened 
 up in front and behind the cervix are stuffed with iodoform gauze and the 
 field of attack transferred to the abdomen. The dorsal decubitus with ele- 
 vated pelvis is now required, and the abdomen is opened by a median supra- 
 pubic incision sufficiently free to give perfect exposure of and ready access to 
 the pelvic viscera. A ligature is now placed upon the upper part of each 
 broad ligament near the pelvic brim, and also upon each round ligament, and 
 those structures divided; next the vesico-uterine reflexion of the peritoneum 
 is incised transversely, and the bladder is separated from the uterus ; the in- 
 cision in the peritoneum is now prolonged on either side outward to join those 
 previously made, and by blunt dissection along the pelvic wall the trunk of 
 the internal iliac artery is exposed ; two ligatures, half an inch apart, are 
 applied to each artery and the vessel severed between them. The ureter 
 should then be identified under that portion of the peritoneum on the 
 inner side of the incision made for exposing the artery ; this is (juickly and 
 easily done, and the ureter should thereafter be kept in view throughout the 
 successive steps of the dissection, care being taken that no injury be in- 
 flicted upon it. On each side successively is now dissected out the tissue of 
 the broad ligament, with its vessels and glands, until the primary vaginal 
 incisions are opened into and the uterus is freed. Hemorrhage is much 
 restrained by preliminary ligation of the internal iliacs; but some venous 
 trunks on the outer wall of the pelvis, and some arterial twigs from the ob- 
 turator and the hemorrhoidal arteries, may require ligation. Careful search 
 for enlarged glands is to be made along the pelvic floor and the outer wall of 
 the pelvis, and any found are to be removed. All hemorrhage having been 
 arrested, the vaginal tampons are removed and a new strip of iodoform gauze 
 is thrust from above down into the vagina, while its upper portion is kept 
 loosely folded in the denuded area ; then the edges of the peritoneal flaps are 
 
1024 J.V AMKRiCAy TKXT-IKJOK OF SLnUKliV. 
 
 brought togetlier so as to cover over tlie raw area exce])t at tlie inidtUe of tho 
 suture line, wliere an opening sliouM be left into which an end ot" the gauze 
 drain shoubl be drawn. Should the ureters and the base of the bladder be 
 involved in the carcinomatous growth, it will be necessary to excise all the 
 diseased tissue, going through sound tissue wide of the disease, and after- 
 ward to suture the bladder and reinijdant the shortened uretei's into its 
 u])|>er part. Considerable time and a iair degree of technical skill are re- 
 (juired for the accomplishment of the ojieration thus described. The result- 
 ing shock is best combated by intravenous injection of* a saline solution 
 of three pints or more. The after-care does not differ from that already de- 
 scribed for abdominal operations in general. The mortality attending the 
 removal of the carcinomatous uterus, while necessarily iniluenced much by 
 tile technical skill and exj)erience of the operating surgeon, is dependent 
 still more upon the degree of exhaustion already caused by the disease, and 
 the extent and duration of tlie oj)erative steps required to eradicate outlying 
 aff'ected tissues in addition to the uterus itself. The removal by the vagina 
 of a uterus still movable and with disease limited to its own structure entails 
 but little hazard to life when done with ordinary care and skill. The more 
 extensive and prolonged the dissection retpiired. as in the procedures de- 
 scril)ed in the last paragraph, the greater the immediate danger from shock, 
 hemorrhairc. and prolonged anesthesia. The immunitv from recurrence de- 
 
 . * 11*1 
 
 pcnds upon the stage in the development of the primary growth at which 
 the radical extirpation«is done: the earlier in the history of the growth and 
 the less its apparent extension the greater the probability of future immu- 
 nity and the more easily and quickly are the most thorough procedures 
 accomplished, and the least are the immediate dangers to life that attend 
 them. 
 
 The ultimate results obtained in efforts at extirpation of uterine carci- 
 noma do not differ from those obtained by the removal of similarly diseased 
 organs in other ]iarts of the body. 
 
 Palliative Treatment of Advanced Cases. — Unfortunately, a large 
 proportion of cases of cancer of the uterus do not present themselves to the 
 surgeon until the disease has extended beyond the limits of the uterus, espe- 
 cially along the lymphatics of the pelvic connective tissue in the base of the 
 broad ligaments. This is indicated by the fixation of the uterus and by the 
 indurations perceptible to the finger in the parametric tissues. Disintegration 
 of the carcinomatous growth is also more or less advanced, hemorrhages are 
 frequent, and the discharges are copious and offensive. Such cases may be 
 temporarily much benefited by free curetting of the softening tissue, followed 
 by thorough cauterization, the curetting should be done with a sharp curette, 
 and should be radical in its extent. If the bleeding provoked by it is not 
 quickly checked by irrigations with hot water and compression with an iodo- 
 form tampon, hemostasis may be secured by deep sutures introduced so as to 
 encompass the bleeding points. When the bleeding has been stopped the 
 cauterization is to be done. For general use chloride of zinc is the most con- 
 venient and efficient caustic. The technique of its use is as follows : Small 
 pledgets of absorbent cotton, soaked and wrung out of a saturated solution of 
 zinc chloride, are stuffed into the cavity left by the curetting until it is filled 
 up. The adjacent surfaces of the vagina are smeared with an ointment of 
 bicarbonate of sodium and petrolatum, 1 : 3, and the vagina filled with a tam- 
 pon of absorbent cotton wrung out of a saturated solution of Idcarbonate of 
 sodium, the latter provision being adopted to prevent cauterization of the vagina. 
 On the third day the tampon and as much of the caustic packing as w ill easily 
 
SURGERY or Tin-: FEMALE dENERATlVE ORGANS. 102o 
 
 come away are to be removed. By the fifth (hiy all the packing will have 
 been removed. Between the fifth and tentii days the eschar will come away, 
 leaving behind a grannlating surface, which will to a large extent contract 
 and cicatrize during the subse<iuent weeks, while simple cleansing douches are 
 used. A notable amelioration of all symptoms at once occurs, and is main- 
 tained until the processes of infiltration and breaking down have again become 
 far advanced. 
 
 Malkinant Ai)1:noma of the corporeal endometrium is a transitional form 
 of disease between simple inflammatory hyperf)lasia of the glandular structures 
 of the endometrium and carcinomatous degeneration. It is characterized by 
 an abundant new formation of glandular tissue that tends to infiltrate the 
 deeper tissues. It is slow in its growth, possibly taking some years to develop 
 serious symptoms : its most prominent symptom is hemorrhage, which, if the 
 affection is developed before the menopause, is a menorrhagia ; if later in life, 
 is irregular in its attacks. If subjected to the curettings and cauterizations 
 efficient against simple inflammatory glandular hyperplasia, it quickly recurs, 
 and after a lapse of a more or less prolonged period, from three to five years, 
 develops into typical carcinoma, with involvement of adjacent tissues, metas- 
 tasis, and death. 
 
 The diagnosis is to be made by comparison of the histological findings 
 from microscopical examination of deep scrapings, with the clinical course. 
 The microscope shows the marked and irregular proliferation of the glands 
 with diminution of interglandular tissue, and the history of the case is charac- 
 terized by repeated recurrence after treatment. Such an assemblage of con- 
 ditions, particularly if a new development in a woman who is approaching or 
 has passed the menopause, is sufficient to establish the probable diagnosis of 
 malignant adenoma and to make radical treatment justifiable. 
 
 The treatment is the sam^ as for true carcinoma of the body of the 
 uterus — viz. total hysterectomy, by the vagina if possible. 
 
 Sarcoma of the Uterus is rare : it may occur at any period from child- 
 hood to old age ; its most frequent development has been noted as a degenerative 
 change in fibro-myomata. Its symptoms and cause are not essentially different 
 from those of other forms of uterine malignant disease, and its treatment is 
 the same. 
 
 THE fallopian TUBRS. 
 
 Inflammation of the Fallopian Tubes, or Salpingitis, is a frequent 
 condition, being secondary to inflammatory conditions of the endometrium. 
 Septic endometritis and gonorrheal endometritis stand in a direct causative 
 relation to nearly all cases of salpingitis. Tuberculosis occasionally develops 
 in the Fallopian tubes and determines its own type of inflammation. Cancer 
 of the uterus, as it disintegrates, is accompanied with secondary septic infec- 
 tions that may be propagated to the tubes and determine there inflammatory 
 complications of more immediate danger and suffering than the primary dis- 
 ease. Both tubes become affected in about one-half the cases. When but 
 one tube is diseased, the left tube is the one most frequently affected. 
 
 Pathology. — The changes in the muco.sa of the tubes are those common 
 to inflamed mucous membranes in general, and depend, as to their extent, 
 upon the intensity and depth of the inflammation. The tissues of the tube 
 become infected, swollen, and succulent ; the secretion is increased in 
 amount, and in the more severe cases is purulent. The tube elongates and 
 becomes somewhat convoluted. The most important changes are those which 
 result from the involvement of the peritoneum in the inflammatory processes. 
 
 65 
 
102G 
 
 A A AMEliKWy 'lEXr-liOOK OF SiJiiJJJliY 
 
 Local peritonitis may be excited either by extension of the infianunation 
 throujili the wall of the tube to its investing peritoneinn or by the escape of 
 infective secretions from the ojien abdominal end of the tube. Diftuse, raj)i<lly- 
 fatal ])eritonitis may result, but in general the peritonitis remains localized 
 within the pelvis, and by its exudate cements together to a varying degree 
 the pelvic organs. In the majority of cases the peritoneal inflammation is 
 limited to the immediate neighborhood of the abdominal end of the tube, 
 the fiml)ri;\} of -which become agglutinated and adherent to tlie ovary or other 
 adjacent structure. The minute uterine orifice of the tube early becomes 
 blocked by infiammatory swelling of the mucosa, so that the occlusion of the 
 abdominal opening determines an accumulation of its secretions within the 
 closed tube and its greater or less distention, forming a convoluted sausage-like 
 bodv hanginjx down bv the side of the uterus. (See Fiir- 407.) 
 
 Fig. 407. 
 
 Hydrosalpinx (Hennig). 
 
 If the retained fluid is purulent, the condition is that known as pi/osalpinz ; 
 if the secretion is mucoid and limpid, possibly chocolate-colored, a hydrosalpinx 
 is present. A bloody effusion constitutes hemafosalpiur. There is reason to 
 believe (Bland Sutton) that nearly all cases of blood-effusions into the Fallo- 
 pian tubes are results of a tubal pregnancy. 
 
 The ovary becomes involved early when the inflammation extends to the 
 peritoneum. Its capsule undergoes inflammatory thickening ; its follicles are 
 unable to discharge their contents and become converted into cystic dilatations 
 (Fig. 401>) ; the suppurative process may extend to one of these dilatations, 
 and an ovarian abscess result. 
 
 Pus enclosed in a Fallopian tube is practically an abscess within the cav- 
 ity of the pelvis, and has often been spoken of as pelvic abscess. If the in- 
 fection is active and the local conditions are favorable, the pus may continue 
 to accumulate until great distention of the tube has been produced; mean- 
 while, extensive adhesions to adjacent organs are formed, so that the ultimate 
 openinfi' of the abscess may be into intestine, vagina, or bjaihler. or it may 
 find its way to the surface in the inguinal region. Less frequently it bursts 
 into the free peritoneal cavity. In more favorable cases the obstruction at the 
 uterine orifice may be overcome and the tube discharge itself into the uterus ; 
 in other instances the active suppuration is arrested, the secretion becomes 
 inspissated, and a thickened, chronically inflamed tube, enclosing a limited 
 
SUBGERV Of rill-: ri:.UMJ: aKMlHATlVE OUGANS. 1027 
 
 amount of thick jms, rt'iiiains. A slow afcmnulatioii of serous lluid may take 
 place into such a cavity, convertinj; it into a hydrosalpinx. 
 
 Salpiui^itis may from the outset l)e less severe in its type than has })een 
 described, may never determine peritoneal comj)lications, and, like any other 
 mucous catan-Ji. may subside and leave no pei'maiii'iit daraa<fe Ix'hirid it. The 
 swellin<^ of the mucous lining of the tube leads to temporary obstiuction of the 
 uterine orifice, and to the production of the symptoms of tubal distention with 
 the increased mucous secretion. Under treatment the iiiHammation subsides, 
 the orifice a<xain becomes patent, and the retention is relieved by the escape 
 of the secretion into the uterus. Such attacks are liable to recur. 
 
 The symptoms of salpingitis will vary acconlini:; to the acuteness of 
 the attack, the virulence of the infection, the involvement of the peritoneum, 
 and the e.xistence of occlusion and distention of the tubes. Acute suppura- 
 tive salpim/itis is ushered in by rigors, fever, and pain in the lateral regions 
 of the pelvis. Pressure into the pelvis, either from above or from the vagina, 
 shows great tenderness. Conjoined mani))ulati()n makes evident to the finger 
 in the vagina or the rectum the more or less swollen tube. The involvement 
 of the peritoneum is signalized by a more diffused pain and tenderness, with 
 some tympanites. The pouring out of exudate into the pelvic pouch and the 
 cementincT t02;ether of the organs give to the examinin"; finijer a sense of a 
 hard mass filling up more or less of the pelvis, enveloping the uterus and 
 appendages, and immobilizing the uterus. The later general symptoms are 
 those of chronic septicemia attending pus-collections anywhere, leading to 
 exhaustion and death. 
 
 Chronic Salpingitis. — If the acute onset is limited in its invasion and 
 subsides into a chronic state, there will persist a dull pain in the pelvis, which 
 is aggravated by motion, as in walking, or by coition ; there is local tenderness ; 
 menstruation will be painful, the flow being increased in frequency and amount; 
 the enlarged tubes, more or less obscured by adhesion to adjacent viscera and 
 by inflammatory exudations, will be perceptible to the examining finger as elon- 
 gated swellings at the side of or behind the uterus. The patient is rendered a 
 chronic invalid by reason of continual pain and the aggravation of her suffer- 
 ings Avliich any attempt to engage in the activities of life produces. If the 
 aff'ection is bilateral, sterility results. 
 
 Catarrhal Salpingitis declares itself by pain, tenderness, and SAvelling 
 along the course of the tubes, which fall short of the more threatening and 
 severe symptoms already detailed. A sudden amelioration of all symptoms 
 may occur, with disappearance of what may previously have been a well-defined 
 tumor, as the inflammation subsides sufficiently to permit the tube to empty 
 itself into the uterus. 
 
 The diagnosis requires a careful comparison of the history of the case 
 with the symptoms and conditions evident to physical examination. The dif- 
 ferentiation of salpingitis from other pelvic conditions which may be confounded 
 with it is often difficult, and sometimes impossible, previous to operation. Doubt 
 may arise, more especially in cases of small ovarian and parovarian growths, 
 early tubal pregnancies, small pedunculated uterine fibro-myomata, exudations 
 into the substance of the broad ligaments, and even retroflexions of the uterus, 
 all of which may simulate closely the conditions of chronic salpingitis. A his- 
 tory of a labor or abortion complicated by the development of peritoneal symp- 
 toms as the beginning of the trouble in question, or of trouble developing 
 after some minor gynecological procedure, or of the previous existence of an 
 acute vaginitis and endometritis possibly or confessedly gonorrheal, creates a 
 strong presumption in favor of salpingitis. Pain, tenderness, and a definable 
 
1028 ^-l^V AMi:iU('Ay TEXT-nOOK OF sunaERY. 
 
 intrapolvic mass, all may attend tlic conditions cnuiru'ratcd as lialtlc to be con- 
 founded with salpingitis, Imt the characteristic history is likely to he hickin<^. 
 Ovarian affections form swellin<;s that are not so directly continuous with the 
 uterus as are tubal swellings; broad-li;^ament effusions, comparatively rare, are 
 lower down in the pelvis and depress the vault of the vagina; a retroflexion 
 of the uterus will escape recognition only through haste or lack of practice in 
 the examiner. Notwithstanding these academic distinctions, it is often the 
 case that adhesions and exudations and distentions so alter the relations and 
 contour of parts in the pelvis as to make their ])ositive identification impos- 
 sible to the most experienced examiner. Salpingitis may coexist with other 
 intrapelvic affections, another source of confusion being thus added to the 
 diagnosis. 
 
 Tubercular salpingitis may be suspected when, in young women whose life 
 is above susj)icion as regards gonorrheal or other common septic infection, the 
 usual signs of tubal inflannnation and enlargement develop. If tuberculosis 
 in other parts of the body coexists, the suspicion is strengthened. 
 
 The prognosis of the milder forms of salpingitis is good : even in cases 
 whose onset is acute and severe, under proper treatment speedy amelioration 
 and ultimate recovery may be hoped for. This occurs only when the disease 
 is arrested and subsides without having causetl occlusion of the abdominal 
 opening of the tubes. In some of these cases, however, the recovery is not 
 absolute, but a latent infection remains for an indefinite time that may be 
 reawakened into severe activity by some new exciting cause in after-years. 
 Under proper treatment decided amelioration, and occasionally entire recovery, 
 may at times be secured in cases that presented every evidence of occlusion of 
 the tube : in a large proportion of such cases, however, the condition persists 
 uninfluenced to any marked extent by treatment, and is to be relieved only by 
 extirpation of the tube. When the suppuration is frankly declared and is pro- 
 gressive, its spontaneous evacuation through the vagina or the rectum may be 
 followed by ultimate recovery or by gradual wasting from prolonged septic 
 absorption. The danger of the bursting of such an abscess into the general 
 peritoneal cavity, with rapid death, is always considerable. 
 
 The treatment in the acute stage requires, first of all, absolute rest in the 
 recumbent position. Hot fomentations should be kept applied to the hypogas- 
 trium ; copious hot vaginal douches at intervals of four or six hours sliould be 
 administered; the bowels should be freely moved by salines; pain, if severe, 
 should be controlled by opiates, but the amount given should be kept at the 
 minimum consistent with the relief of pain. As the acuteness 6f the symp- 
 toms subsides the fomentations are omitted, the douches are diminished in fre- 
 (juency, and a gradual restoration to activity is allowed. If with the subsi- 
 dence of the acute symptoms the evidences of permanent change, involving 
 intra-peritoneal inflammatory exudates, occlusion, and distention of the tubes, 
 persist, the further ado])tion for a time of means for promoting absorption 
 of inflammatory exudates is to be recommended. The iodides and saline 
 laxatives may be administered; the vault of the vagina may be painted 
 with tincture of iodine once or twice a week. A weekly insertion of a vag- 
 inal tampon charged with boro-glyceride may be resorted to. The regular use 
 of a copious hot vaginal douche twice daily for a prolonged period is to be 
 kept up. As long as improvement attends these measures they should be con- 
 tinued. In a fair proportion of cases a gradual return to health takes place: 
 many, however, remain rebellious, any temj)orary improvement being (juickly 
 overcome if the patient attempts to go about or to perform any work. Wlien 
 the disease has been demonstrated to be incurable by these means of treatment. 
 
SURGERY or Till-: FEMALE GENERATIVE ORGANS. 1029 
 
 extirpation of tlu' diseased tubes hv abdominal seetion sboubl be done. This 
 extirpation should not be deferred until the patient is worn out through h)ng 
 suffering, but should be resorted to as soon as the inefficiency of less radical 
 measures lias been uninistakal)ly demonstrated. The techniciue of the ojM-ra- 
 tion retjuired for removal of the tul»es will be considered in connection with 
 that re([uired for the extirj)ation of degenerated ovaries, with which they are 
 usually associated. 
 
 When the suppuration within the tube is abundant from the outset, and 
 causes the rapid accumuhition of a considerable amount of pus within the 
 dilated tube or in spaces outside of the tube shut in by adhesions, attended by 
 all the local and constitutional symptoms of an acute abscess, the pus-cavity 
 must be evacuated as speedily as possible by puncture from the vagina if it 
 tends to bulge into that canal and its fluctuation is appreciable there ; other- 
 wise by abdominal section and enucleation if possible : in any event, the cavity 
 must be opened and emptied, the contact of its contents with the general peri- 
 toneum prevented as far as possible, and free drainage provided for by means 
 of glass tubes reinforced Avith iodoform gauze tampons. 
 
 Neoplasms of the Fallopian Tube are very seldom met with, and hardly 
 merit special attention. Descriptions of one or two isolated cases of myoma 
 and of primary carcinoma may be found in literature. According to Bland 
 Sutton, adenomata are not infrequent, being met with as papillomatous masses 
 springing from the tubal mucosa distending the tube and sprouting out into 
 the free pelvic cavity. They determine a copious effusion into the peritoneal 
 cavity, and are possible causes of some otherwise inexplicable cases ot obstinate 
 ascites. Tubes thus affected should be extirpated by abdominal section. 
 
 Tubal Pregnancy. — For details pertaining to the etiology and patho- 
 logical anatomy of tubal pregnancy reference must be made to treatises upon 
 obstetrics. Its diagnosis and treatment, however, engage in a special degree 
 the attention of the surgeon. When rupture occurs, in a great majority of 
 instances the immediate and bold intervention of the surgeon is re(|uired to 
 avert impending death. In the few instances in which the conditions after the 
 primary rupture of the tube make any further development of the embryo 
 possible, the ultimate intervention of the surgeon will be required, according 
 to the special conditions of the particular case, either to avert disaster from 
 a second rupture, to secure the removal of a sac filled with an infected mass of 
 decaying debris, to liberate a feeble or imperfectly-developed foetus, or to rid 
 the body of the encumbrance of the degenerated remains of a foetus that has 
 perished. All forms of extra-uterine gestation pass their primary stages in 
 the Fallopian tube. As the growth of the ovum proceeds, the structure of the 
 tube is such as to make inevitable one of the following events : 
 
 1. The vascular relations of the ovum may be so defective that after a few 
 weeks it perishes; an extravasation of blood from ruptured chorionic villi pro- 
 duces or attends this result ; the rapidly-increasing distention of the tube from 
 this hemorrhage may be so great as to cause its rupture, or, if not, there per- 
 sists a blood-tumor of the tube, a heviatomljnnx, which may rupture at some 
 later time or remain as, a source of local irritation, attended with pain and pro- 
 ducing disability. 
 
 2. If the ovum has become fixed in the outer third of the tube, it may 
 during the first eight weeks of its development become extruded into the peri- 
 toneal cavity through the still open ostium abdominale> Shock and hemorrhage 
 accompany this accident. This is the most frequent source of intra-peritoneal 
 pelvic hematocele. 
 
 3. If the ovum continues to grow, or if it is suddenly enlarged by a copi- 
 
1030 
 
 ^l.V AMKJUCAX Ti:XT-Ji()OK OF tSriidEHY. 
 
 s liomorrli;i<ie into its villi, rupture of the tube inevitably results (Fig. 408). 
 
 ich ruj)ture is tVe(iueiit between the third and tenth -weeks after impregnation, 
 and is rarely deferred beyond the twelfth week. If the site of tlie ovum is 
 along the middle third of the tube, the line of rupture may be through the 
 floor of the tube into the connective tissue of the broad ligament, but in th 
 
 OUS 1 
 
 Sue 
 an 
 
 Tubal Pregnancy, rupture at ew\ of second month: Td, ruptured luhe ; li, i^Wo. of rupture; Od, right 
 ovary; Xrc/, right round ligament : T^s left tul)e : Acs, left tube round ligument ; /'/', peritoneum ; Oj, 
 section of frozen specimen ; MR, Miiller's internal os ; Oe, external os (Handl). 
 
 or it may become the subject of infection and septic changes. If the primary 
 rent is too small to permit the escape of the ovum through it, recurrences of 
 bleeding are induced until fatal anemia results. 
 
 4. If the rent in the tube opens into the conneetive-tissue spaces of the 
 broad ligament, the hemorrhage becomes restrained by the resistance of the 
 tissues, and a more or less extensive hematoma or hematocele of the broad 
 ligament results. If the ovum is already dead, or dies as the result of the 
 rupture, it and the effused blood will in time become absorbed, and recovery 
 after a prolonged illness may result. If the ovum survives the accident, room 
 for its further growth for a time is provided for by the gradual opening up of 
 the broad ligament. 
 
 In the majority of cases the foetus, after a variable ]»eriod of feeble struggle 
 for life in its new relations, dies. If it escapes infection, it may be retained 
 for an indefinite time, undergoing mummification or saponification or becoming 
 
SURGERY OF THE FEMALE GENERATIVE ORGANS. 1031 
 
 encrusted Avitli limo-salts. Mure IViMjueiitly iurcctiou is tnuisniiticd to it 
 tlirough adjacent tissues, and the decomposition and suppuration resulting 
 produce a higlily septic pelvic abscess. If, however, the life of the foetus is 
 prolonged, its growth is attended by the formation of a sac by the stripping 
 up of the peritoneum from all the adjacent jtarts. Ruptui-c of this sac may 
 occur at any time : if the rupture shoidd involve the site of the placenta, pro- 
 fuse and rapidly fatal bleeding results ; otherwise the foetus may escape into 
 the free peritoneal cavity, and, being still nourished by its previous placental 
 attachments, continue its growth there ; again, rupture may never occur, but 
 the development of the f(etus may go on to term and spurious labor take 
 place, the foetus die, the liquor amnii be absorbed, and indefinite retention of 
 the degenerated fwtus follow. In any case in which abscess-formation takes 
 place the collection may find vent externally through the rectum, vagina, 
 bladder, or uterus, or may point through the abdominal wall. 
 
 The diagnosis of tubal gestation before rupture is very difficult. A 
 distinction is to be made from inflammatory conditions of the Fallopian 
 tube or of the broad ligament and from small ovarian growths. At best, 
 the decision can rarely, if ever, be a positive one. The early symptoms of 
 conception when the ovum is fixed in a tube do not differ so much from those 
 attending uterine pregnancy as to attract attention, so that it is not until rup- 
 ture takes place that suspicion of the presence of any trouble is awakened. 
 The symptoms that attend rupture are pain, shock, vomiting, and the signs of 
 internal hemorrhage. There is usually some bloody vaginal discharge, accom- 
 panied with shreds of decidual membrane from the uterus sufficient to suggest 
 abortion. The abdominal pain and general depression are like that attending 
 acute intestinal strangulation or perforation or axial rotation of the pedicle 
 of an ovarian cyst. The condition may be confounded with that due to the 
 passage of renal or biliary calculi. The analysis of the symptoms and the 
 attendant circumstances should, however, so strongly indicate the presence of 
 a progressive internal hemorrhage as to justify immediate opening of the abdo- 
 men, thereby to corroborate or disprove the diagnosis. If the rent is minute 
 and the hemorrhage slight, possibly frequently recurrent, the signs of acute 
 anemia are absent and the case resembles one of an inflammatory nature. 
 
 When the rupture takes place into the connective-tissue spaces of the broad 
 ligament, the pain and shock are considerable, but are less threatening of 
 immediate dissolution, and pass off after a time, Avhile to the touch an effusion 
 into the substance of the broad ligament is perceptible. If the embryo lives, 
 its further growth will cause a gradually increasing laterally placed tumor to 
 develop, in which in advanced cases the outlines of the foetus may become 
 perceptible. 
 
 The treatment of a tubal pregnancy should, if possible, consist in its 
 immediate extirpation 1?y abdominal section. The improbability of the con- 
 dition being recognized in its earliest stages will render operation for its 
 extirpation at that period, before rupture, very rare, although then it could 
 be done Avith facility. The comparative safety of abdominal section, the 
 clearing aAvay of obscurities that may have hung about the diagnosis, and 
 the definite removal of the disease which it secures combine to render such 
 operative interference desirable as soon as reasonable ground is found for 
 believing a gravid tube to be present, rather than the adoption of the electric 
 currents and interstitial injections which have been proposed for destroying 
 the ovum and leaving it in situ. 
 
 When rupture has occurred and dangerous hemorrhage is going on, the 
 abdomen must be opened at once by an incision several inches in length, free 
 
I0;i2 AN AMrJilCAX TKXT-liOOK OF SUIWERY. 
 
 enouirh to permit the easy inspection of tlie cavity of the pelvis: the ruptured 
 tube must he removed and perieet hemostasis be effected by suitable lifiatures, 
 after which all blood-clots and otlier effusions must be sponged out, followed 
 by copious flushings of the pelvic cavity with warm salt solution. In many in- 
 stances great advantage will be derived from a simultaneous intravenous infu- 
 sion of salt solution to the extent of a quart or more, to overcome anenua and 
 shock. If the o{)eration has been preceded by a more or less prolonged history 
 of recurrent hemorrhages, with formation of adhesions and infljimmatory exu- 
 dates, the cleansing of the peritoneal cavity must be imperfect, and drainage by 
 tube and gauze tampons will be required. If a secondary rupture of a broad- 
 ligament sac has taken place, after the peritoneal cavity has been cleansed the 
 rent in the sac, if possible, should be sewed into the abdominal wound, and the 
 cavity treated thereafter as an abscess-cavity till it becomes obliterated. 
 
 In cases in which ])rimary rupture into the connective-tissue spaces of the 
 broad ligament has been attended with the death of the embryo, no opera- 
 tive interference is called for. But if the embryo survives and continues to 
 grow, it should be removed without delay. Before the fifth month the gesta- 
 tion mass can be readily enucleated as a whole. From the fifth month onward 
 the involvement of neighboring parts by the expansion of the sac will have 
 become such as to prohibit enucleation. The sac must then be sewed into 
 the incision in the abdominal wall, and incised, the foetus removed, and the 
 placenta removed if it is detached; otherwise left for subsequent spontaneous 
 detachment, while the cavity of the sac is irrigated, tamponed with iodoform 
 gauze, and treated as an open abscess-cavity. Especial risks attend attempts 
 to remove a growing extra-uterine foetus of this class, owing to the possibility 
 of the placental site being at the place of incision; in which case a copious 
 hemorrhage will result, to be arrested only by compression of the abdominal 
 aorta. 
 
 Whenever infection of an extra-uterine foetal mass has taken place, the 
 decomposing suppurating collection must be dealt with according to the gene- 
 ral principles applicable to such abscesses. It is only in cases in which the 
 abscess tends to point into the vagina that attempts should be made to reach 
 it and evacuate its contents through that canal. 
 
 The hope of securing the ultimate delivery of a viable child should never 
 cause postponement of operative interference after a diagnosis of extra-uterine 
 pregnancy has been arrived at. since such children, if they arrive at term and 
 are delivered living, are gencrallv punv and malformed and rarelv survive manv 
 weeks, while postponement of operative relief is always attended with increas- 
 ing risk to the life of the mother. 
 
 SURGERY OF THE BROAD LIGAMENTS. 
 
 Parametritis or Pelvic Cellulitis. — Inflammation of the connective- 
 tissue substance of the broad ligaments is comparatively rare as a primary dis- 
 ease. Its general cause is sepsis conveyed through some abrasion or other injury 
 of the vault of the vagina or of the wall of the uterus, by means of Avhich an 
 infective inflammation is excited in the course of the veins or lymphatics of 
 the broad ligament. The resulting phlegmon may cause an inflammatory infil- 
 tration of varying extent of the pelvic subperitoneal connective tissue which 
 imbeds and fixes the uterus. The overlying peritoneum shares in the inilam- 
 mation, and adds its own exudates and adhesions to those caused by the changes 
 in the cellular tissue. The inflammation tends to terminate in supj)uratiun : 
 not infrequently a chronic non-sup})urating inflammatory condition is engen- 
 
SURGERY OF Till': FKMALI'J (lENERATJ VP: ORGANS. 1033 
 
 dered, which ])ro(liices infiltrations and contractions sufficient to cause perma- 
 nent disphiceinents and impairment of function in the pelvic viscera. 
 
 The symptoms do not difter from those already described in connection 
 with intlauimations of the endometrium and of the Fallopian tubes ; which con- 
 ditions are usually in some degree associated with the cellulitis itself. In the 
 more acute forms the ]»ain is severe : rigors and fever attend the onset of the 
 attack, and are continued by the establishment of suppui'ation. The pus may 
 discharge itself by way of the vagina, rectum, bladder, or abdominal wall, and 
 by the formation of imperfectly drained pus-cavities may give rise to a wasting 
 septicemia. 
 
 The diagnosis is to be made by careful bimanual examination, which will 
 show the existence of an infiltration into the spaces of the broad ligament, pro- 
 truding downward into the vagina, displacing, possibly, the uterus to one side, 
 and spreading upward and outward within the broad ligament to the brim of 
 the pelvis. If the peritoneal pouches can be felt to be empty and the ovaries 
 free, the diagnosis is corroborated. The existence of other inflammatory com- 
 plications will usually make all these conditions obscure. 
 
 The prognosis in recent cases, under proper treatment, is in general good, 
 but when by long-standing chronic inflammatory conditions permanent atrophy 
 of tissue, with displacement and adhesions, of organs, has developed, a state of 
 permanent invalidism is created Avhich at best can be only ameliorated. 
 
 The treatment is the same as that which has already been detailed 
 for other pelvic inflammations. An especially definite good result n)ay be 
 expected in these cases, when the acute symptoms have subsided, from the 
 use of local resolvents, as painting of the vault of the vagina with tincture of 
 iodine, prolonged and frequent hot vaginal douches, and the use of boro-glyce- 
 ride vaginal tampons. The prolonged and free use of saline cathartics is like- 
 wise of great value. 
 
 Pelvic Hematocele may be accepted as a general term for all blood- 
 effusions into the pelvis. Effusions into the free peritoneal cavity are desig- 
 nated by the term intra-peritoneal hematocele ; those into the connective- 
 tissue interstices of the broad ligaments, by the term hematoma of the broad 
 ligament. By far the most common source of intra-peritoneal blood-effusions 
 is tubal gestation, and they have already been considered in connection with 
 that condition. The production of hematoma of the broad ligament as the 
 result of rupture of a gravid tube has also been described. Such hematomata 
 may also be caused by the rupture of varicose veins situated in the tissue of 
 the broad ligament. Such accidents have commonly associated with them 
 the sudden arrest of the menstrual flow. 
 
 Extravasations of blood in considerable amount into the tissue of the broad 
 ligament are likewise among the common accidents from imperfect hemostasis 
 after operations for the removal of growths from that structure. The after- 
 course of these hematomata does not differ from that of similar effusions in 
 other parts of the body. The fluid portion is absorbed ; the residual elements 
 gradually disintegrate and are slowly absorbed ; and ultimately the effusion 
 disappears. In exceptional instances an accidental infection is introduced and 
 suppuration complicates the course of the case. 
 
 The occurrence of the hemorrhage is marked by sudden sharp pain in the 
 pelvis and well-marked shock, soon passing off with the rapid development of 
 a more or less extensive tumor within the layers of the broad ligament. In 
 the more aggravated effusions the pressure of the blood-mass dissecting into 
 the connective-tissue spaces about the rectum and bladder provokes marked 
 tenesmus of those parts, and in the rectum mechanical constipation. Local 
 
]0;J4 ^I.V AMHIilCAX TEXT-nOOK OF SCIidKRV. 
 
 exiiniination reveals to the touch a diflused tuiiHtr within the hroad liframont, 
 wliieh, wlien ot" sullicient extent, can be apfji-eciated hy abdominal j)al|)ation 
 as a mass rising up laterally from the pelvis, distinctly confined within mem- 
 branous barriers. This tumor is free from the extreme sensitiveness which 
 attends inflammatory effusions, an<l later will be observed to undergo gradual 
 contraction, finally to disappear. The suddenness of the attack and of the 
 development of the tumor and the absence of the characteristic signs of acute 
 inflammation will serve to diagnosticate a hematoma from an inflammatory 
 eflliision: the distinct limitation, the nodular feel, the lateral position, and the 
 speedy cessation of the constitutional signs of hemorrhage which attend hema- 
 toma will differentiate it from the soft, limitless, shifting mass, pushing down- 
 ward the posterior vaginal vault, which results from bleeding into the free peri- 
 toneal cavity — a form of henutrrhage which, if extensive enough to produce 
 marked symptoms, almost invariably goes on to a fatal end if not arrested by 
 operative measures. 
 
 Small or partly absorbed hematomata may be confounded with tumors of the 
 Fallopian tubes, with fibro-myomata of the uterus developing outward into the 
 folds of the broad ligament, and with cysts of the broad ligament : but careful 
 study and repeated observation of the later course which the pelvic mass pur- 
 sues should suffice for the distinction. 
 
 The treatment of hematoma of the broad ligament is purely expectant. 
 Intra-peritoneal hematocele requires abdominal incision, exposure, and ligation 
 of the bleeding point, involving the ablation of the distended and ruptured tube 
 and the cleansing of the peritoneal cavity from the effused blood. 
 
 SURGERY OF THE OVARIES. 
 
 Ovarian Hernia. — An ovary has occasionally been found in a hernial 
 sac, in which relation it may present itself as a tumor as far down as the labium 
 majus. Unless it becomes inflamed or the subject of other disease, such dis- 
 placement has no pathological significance and produces ho symptoms nor dis- 
 ability. Suspicion of the presence of an ovary in a hernia will be aroused if 
 a somewhat hard, elastic, ovoid body is detected in a la])ium or in the inguinal 
 canal, which resists pressure and temporarily swells during the menstrual 
 epochs. If upon examination the uterus is found to have its fundus tilted 
 over to the affected side, and a connection between the uterus and the ovoid 
 body can be established by mani])ulation, the diagnosis is rendered certain. 
 If the ovary can be reduced into the abdominal cavity, it should be done, and 
 its further escape prevented by a suitable truss : if the ovary is diseased and 
 the cause of suffering, it should be extirpated^ otherwise no treatment is 
 required. 
 
 Prolapse of the Ovary downward into the peritoneal pouch behind the 
 uterus, where it may readily be felt by the examining finger, is not uncommon. 
 It may be due to relaxation of the broad ligament from imiterfect involution 
 after labor or to increase in weight of the organ from disease. The pressure 
 of a fecal mass from above may have dragged it down, or the [trolapse may 
 be consecjuent upon the changes attending retroversion of the uterus. The 
 mere change in its position has no special significance and gives rise to no 
 sym))toms, but Avhen the ovary is enlarged and congested its presence in the 
 cul-(le-sac may expose it to such pressure during defecation, walking, or coition 
 as to cause pain and disability. When such symptoms are present, it is gen- 
 erally the case that the displacement of the gland is only an incident in in- 
 flammatory disturbances of the ovary, and the tube is often firmly bound by 
 
SURG Kin' or Till-: female generative organs. io35 
 
 adhesions in its j»l;icc. If tlic <tvary is iiKjviihk' and there is no coexistent 
 disease callin<; for its ablation, and yet the disability from its presence in the 
 ciil-de-sae is such as to call for relief, it may he lifted uj) by slutrtening the 
 round ligaments. 
 
 Inflammation ok the Ovauiks.— Three classes of inflammatory affec- 
 tions of the ovaries may be distinguished : 1. An acute sejitic inflammation, 
 tending to rapid disorganization, the organ l)eing implicated in an acute, 
 often fatal, spreading septic inflammation of the uterus, tube, and pelvic peri- 
 toneum. 2. An inflammation likewise excited by infection from a pre-existing 
 salpingitis of subacute or chronic type, in which first the capsule of the 
 ovary, and later the deeper structures of the organ, become involved. 3. A 
 slowly-developing, primary inllammation of the tissue of the ovary itself, 
 chronic in its tendencies, having its beginning in a chronic hyperemia of the 
 gland due to functional derangement and sexual excitation, and displaying 
 but little tendency to involve ailjacent organs. Between the first two of these 
 classes there is no distinct dividing-line: the difference is one of degree and 
 not of kind — one of clinical rather tlian of etiological or pathological import- 
 ance. In both classes the ovarian inflammation is an incident in, or a part 
 of, a widespread affection involving the endometrium, the appendages, and 
 the contiguous peritoneum. Tiie conditions attending the development and 
 extension of this septic inflammation, and the manner in which the ovary 
 becomes involved in it by infection, have already been described in the sections 
 devoted to Inflammations of the Uterus and of the Fallopian Tubes. 
 
 The changes which are produced in the ovary are those incident to gland- 
 ular inflammations in general. In the more acute and virulent attacks tissue- 
 necrosis and suppuration 
 
 quickly supervene, with de I^'i<i. 409. 
 
 struction of more or less of 
 the gland, and with subse- 
 quent history of pelvic ab- 
 scess in those cases in which 
 limiting adhesions form 
 early enough to shut off the 
 general peritoneal cavity 
 and to avert speedy death 
 from diffuse septic perito- 
 nitis. In the milder cases 
 the investing tunic of the 
 ovary is thickened by inter- 
 stitial proliferation and by 
 deposit upon it of plastic 
 j)eritoneal exudates, which 
 at the same time bind it 
 more or less extensively 
 and firmly to adjacent sur- 
 faces. The ovary is for a 
 time swollen by congestion 
 and inflammatory exudates 
 both into the follicular cavi- 
 ties and among the fibers 
 of its stroma. Later, this 
 enlargement gives place to atrophy and condensation through absorption of 
 eflfusion, organization and contraction of new-formed connective tissue, and 
 
 Chronic Ovaritis witli Multiple Cysts (Winckel). 
 
103(; AA AMi:iiicAy text-iujok or sinaiJiY. 
 
 general ])r()oe.ss of sclerosis of inflaiuinutory origin. This atropliy of the tissue 
 of the «i;lau(l may he more than ecjnijK'nsated for hy jtcrsistent ami increasing 
 cystic dilatation of altered follicles, hy hhjod-etVusions, and hy limited sui)|)H- 
 rativc foci, so that a very manifest enlargement of the organ may persist 
 indefinitely (Fig. 409). 
 
 Evervdegree of disease in respect to acuteness or chronicity, and to the 
 amount of tissue-damage inflicted, may he presented in different cases. Both 
 ovaries may ))e affected, or but one. When hut one ovary is affected, a later 
 affection of the other is prone to occur. 
 
 The prognosis will vary according to the character and extent of the 
 tissue-changes. Under favorable circumstances, with proper treatment, in 
 the less severe cases recovery may be secured with more or less atrophy 
 and loss of secreting structure. In many cases, indeed, there will be pre- 
 served sufficient normal structure to carry on the process of ovulation and 
 to make impregnation possiljle if the Fallopian tube is also patent. In the 
 more severe cases, when abscesses have formed, spontaneous evacuation may 
 occur, most frequently through the rectum, with subsequent contraction and 
 obliteration of the cavity, and gradual absorption of inflammatory exudates 
 and atrophy of the remnants (»f the destroyed organ. In a large proportion 
 of cases, however, the inflammation of the organ ])ersists for an indefinite 
 time, with alternations of remission and exacerbation of its symptoms, a con- 
 stant source of suffering and of disability. When the pus-cavities exist in the 
 ovarv thev may determine the signs indicative of retained pus, and when not 
 relieved by art or nature may lead to exhaustion and death from septic absorp- 
 tion, or in more favorable cases may undergo resorption. The prognosis in a 
 given case will ])e closely bound up with that of the complicating salpingitis 
 and perimetritic peritonitis, of Avhich account must always be taken. 
 
 The symptoms are not definite, being usually obscured and dominated 
 by those due to the pre-existing tubal and peritonitic conditions. Often a tube 
 and an ovarv are bound up together indistinguishably in a mass of inflamma- 
 tory exudate. Pain in the ovary is constantly present as a dull ache, rendered 
 worse by physical exertion or by local pressure or concussion, as in defecation 
 or coition. Violent pain is usually excited at each menstrual jjcriod : if the 
 loss of blood is profuse, the pain may be alleviated after the flow has become 
 well established. Multiform reflex pains are prone to be manifested in distant 
 parts, with marked emotional and neurotic disturbances of the most varied 
 character. The general health suffers, digestion is interfered with, and in the 
 chronic forms permanent invalidism is entailed. Sterility is the result of the 
 changes in the tubes and ovaries and of the impossibility of enduring the 
 marital approach by reason of the pain it produces. 
 
 In cases in which the surrounding disease is comparatively slight, or in 
 which its results have been modified by time and treatment, the enlarged, 
 nodulated, sensitive ovary may be isolated and recognized by the finger in the 
 vagina or the rectum with the help of bimanual palpation. 
 
 The treatment is that which has already been described as required for 
 inflammation of the Fallopian tubes — rest, purgation, local anti))hlogistic and 
 resolvent applications, general hygiene, and, finally, in default of recovery 
 under such measures, extirpation of the diseased organs by abdominal 
 section. 
 
 Chronic Ovaritis not due to direct septic infection is slow and gradual in 
 its development, being preceded for a prolonged period by simi)le hyperemia. 
 This long-continued congestion eventuates in degenerative changes, the more 
 aggravated cases presenting thickening of the investing tunic with degeneration 
 
SURGERY OF rili: FEMALE < i F.\ Fi:ATI V F OliOANS. 1037 
 
 of till' follicles into small cysts, and an increase in (piantity of the connective- 
 tissue stroma, ■with atropjiy of the proper ;:lan(iiilar tissue/ 
 
 Tile etiology of this (tvarian con<;estion and inllaniniation is ohscure : it 
 is apparently closely associated in many instances with deranged ovarian inner- 
 vation ; it develops most frecpiently with excitahle. unstahle, emotional natures; 
 it may be associated with un^natified, perhaps unrecognized, sexual desire, and 
 in some instances it is excited by unnatural sexual gratificati(»n. 
 
 The symptoms are pain in the region (»f the ovaries, aggravated at the 
 menstrual |)eriods ; menstruation tends to excess both in quantity and in fre- 
 quency ; the ovaries are tender and swollen ; backache and headache, with the 
 myria(i vague pains of neurasthenia and hysteria, are frecjuent attendants. 
 
 The diagnosis is to be made by bimanual palpation, by which the tender- 
 ness and the enlargement of the ovaries are directly ascertained and the signif- 
 icance of the syniptonis confirmed. 
 
 The prognosis is favorable, as a rule, under proper treatment. But when 
 profound structural changes have taken place in the ovaries, a less favorable 
 prospect is to be acknowledged, and in some cases nothing short of the ablation 
 of the diseased organs Avill bring relief. 
 
 In the treatment those measures which have to do with the regulation 
 of the general life play an important part. All occasions of emotional and 
 sexual excitation are to be removed. Moderate exercise, the avoidance of 
 everything likely to induce or aggravate pelvic congestion, regular hours of 
 sleep, rest in bed during the menstrual periods, regulation of t^e bowels, and 
 general tonics, are to be enjoined, combined with prolonged counter-irritation by 
 repeated blisters to the abdominal surface over the site of the ovaries. As a 
 last resort, when all measures have failed to afford relief, and chronic suffer- 
 ing and invalidism are unavoidalile, the affected organs may be extirpated by 
 abdominal section. 
 
 Ablation of the Uterine Appendages by Abdominal Section. — 
 The names of different surgeons are often attached to this jirocedure. and the 
 practice may possibly be convenient in the direction of brevity, but the above 
 simple descriptive term is much to be preferred. The term oophorectomy is also 
 in frequent use. This term, however, does not in itself include the idea of the 
 removal of a part or the whole of the Fallopian tube, which, as a rule, is as 
 important a part of the operation as the removal of the ovary. As a general 
 term, therefore, the designation "ablation of the uterine appendages." bein^r 
 brief, comprehensive, and descriptively correct, deserves to be used to the exclu- 
 sion of all others. 
 
 Ablation of the uterine appendages has been advised in the preceding pages 
 for the following con<litions : 1. Cases of uterine fibro-myomata attended with 
 serious menorrhagia; 2. Chronic inflammation of the Fallopian tube, with 
 retention of inflammatory products within the distended tube; 3. Chronic 
 and intractable inflammation of the ovary, attended with pain and disability; 
 4. Early tubal gestation. 
 
 In addition to these indications, the operation has been resorted to many 
 times for the relief of marked nervous disturbances of maniacal, epileptic, and 
 hysterical character, which were aggravated or elicited by each recurring men- 
 strual epoch. In a few instances marked improvement has followed the opera- 
 tion, but in so small a proportion of cases that at present the weight of authority 
 is against the operation in these neurotic cases unless distinct evidences of 
 disease of the ovaries can be obtained. In severe and intractable dysmenor- 
 rhea due to such arrested development of the uterus that the normal function 
 of the uterus in the processes of menstruation is imperfect, while the ovaries 
 
1038 AX AMi:iiI('AX TEXT-Ji(J(JK OF SL'liC'ERY. 
 
 are snfficientlv (Icvcloped to produce their refrular monthly niolimiriii, the 
 removal of the a|)j)i'ii(l;i<;es is the only treatment available, and is to he resorted 
 to without hesitation alter failure of j)i()loni:ed efiorts to stimulate the "growth 
 of the uterus. 
 
 Operative Teehniqiic. — The preparation of the patient and all the attendant 
 details for the prevention of septic infection are the same as have been elsewhere 
 described (]). 1012). The incision through the alxlominal wall is short, midway 
 between the unil)ilicus and the piibcs ; tlic opening in the j)eritoncum should 
 be simply lari»;e enou<fh to admit two fingers, which at once seek the fundus of 
 the uterus and thence trace the tubes outward to the ovaries. If there are no 
 adhesions, the conclusion of the operation is very simple, and is quickly accom- 
 plished by pulling the ovary up into the incision by the fingers or by suitable 
 forceps. The broad-ligament pedicle is transfixed by a needle or ]>ointed for- 
 ceps, which carries through a loop of strong silk thread with which the pedicle 
 is tied in two parts ; into the loop on the uterine side tiie tube is pulled, so as 
 to secure the removal of most of its length. The knots having been strongly 
 and securely tied, the pedicle is severed about a quarter of an inch beyond the 
 ligature, and the stump, after having been carefully inspected to detect any 
 possible hemorrhage, is dropped back into the pelvis. 
 
 In cases of uterine fibro-myoma. if the tumor is large and adherent, great 
 difficulties may be experienced in finding and removing the ovaries. The 
 situation of the ovary will vary greatly according to the site and direction of 
 growth of the tumor. The tumor must be pulled aside and each ovary sought 
 for after such enlargement of the abdominal incision as may be demanded to 
 secure ease and ])rccision of manipulation. If the difficulties in securing the 
 ovaries are found to l)e insurmountable, hysterectomy may be substituted. 
 
 AVhen the npj)endages are matted together or are glued by intlammatory 
 adhesions to adjacent structures, their enucleation and removal introduce com- 
 plications into the operation which demand time and the greatest amount of 
 patience and skill upon the part of the operator. Especial difficulty and 
 danger attach to adhesions to the urinary bladder and to the intestine. As 
 a rule, enucleation can best and most safely be accomplished by the fingers. 
 It is to be remembered that the ovary, swollen and heavy, naturally sinks 
 down into the posterior peritoneal pouch, where it becomes covered in by 
 inflammatory exudate. Here, therefore, it is to be sought by the linger, which 
 begins its work by breaking down adhesions at the lowest point of the posterior 
 pouch as it proceeds to dig out the ovary from its bed of exudate. Carefully 
 keeping close to the ovary, it is gradually enucleated; the swollen or thickened 
 tube may be identified as the enucleation proceeds, and is in turn liberated, 
 until finally the mass is sufficiently unfolded to be brought up into sight. 
 Should the broad ligament be so shortened and rigid as to prevent the forma- 
 tion of the usual pedicle, it will have to be sewed ofl", as has been described. 
 The arrest of bleeding from the bed out of which the appendages have been 
 enucleated, and the sul)sc(iuent use of drainage, are to be governed by the 
 principles })reviously laid down. 
 
 If the sense of sight is re([uired to deal intelligently with any complica- 
 tion that may be met with, the pelvis should be rMise<l into the Trendelenburg 
 position (Fig. 402), and the abdominal incision prolonged as needed to secure 
 the re(juired exposure. This is especially desirable if the tubes or ovaries are 
 distemled with pu-*, on account of the danger of rupture of the sacs. In 
 d'.'aling with such accumulations of pus the general ]>critoneal cavity should 
 be shut off bv sterile gauze i)ads before much manijiulation of the |)us-filled 
 sac is attempted. If the sac ruptures, the effused pus should be carefully 
 
SURGERY OF Till-: FKyTM.K CENERATIVE ORGANS. 1039 
 
 sponged out, mtlicr ilnin WMshcd (.iit. mid ili-.iiiia;:*' instituted. If there is a 
 large |iiis-eavity vliieli euniiot be eiiuclt'a(»'(l, tlic opcniiig into it slioid<l, if 
 possible, be sewn into tiie ubdonunal wound antl a drainage-tube be earried 
 through its bottom into the vagina. It" the abdominal walls cannot be de- 
 pressed sulliciently to reach the abi5cess-oj)ening, reliance will have to be placed 
 on iodoform-gauze packing and the usual glass drain. The toilet of the peri- 
 toneum, the question of drainage, the closure of the wound, and the subseciuent 
 care are to be governed by the jirinciples apj)licable to abdominal operations 
 in general. 
 
 The niiniaJitii following operations for aldation of the uterine appendages 
 depends much upon the skill and experience of the individual operator and 
 upon the character of the cases operated upon. It is susceptible of reduction 
 to a very small figure. Different surgeons have reported long series of cases, 
 amounting to hundreds, with a mortality of less than 5 per cent. 
 
 Ulthnate l\e>mlts. — The proportion of cases in Avhich restoration to health 
 is secured to the extent of freedom from pain and restoration to comfort and 
 usefulness is by no means commensurate with the proportion of recoveries 
 from the operation. In many cases, although the diseased appendages are 
 safely removed, there remain intrapelvic indurations and adhesions which 
 cause persistent pelvic pain, uterine congestions, and vesical and intestinal <lis- 
 turbances. Fatal intestinal obstruction from angulation of adherent intestine 
 is an occasional sequel. Immediate relief to pain is the exception. Usually 
 the pelvic pains persist for months, gradually but ultimately disappearing, pos- 
 sibly not until after the lapse of some years; in some cases the relief is never 
 perfect. A'^entral herniae, sinuses from retained infected ligatures, and fecal 
 and urinary fistuhu are among the occasional sequelae. 
 
 Mental disturbances sometimes occur after the removal of the appendages. 
 In most instances the lapse of time, the subsidence of pain, the improvement 
 in general health, and the influence of reassuring advice suffice to allay these, 
 although in certain instances an unstable mind is pushed over into confirmed 
 insanity. Such a remotely possible event should have no weight, however, in 
 determining in a given case whether the appendages should or should not be 
 removed. Fecundity has already been destroyed by disease, but the possibility 
 of marital congress is in most cases restored. The sexual appetite is, as a rule, 
 restored to its normal condition ; in some cases it is diminished, in some it is 
 increased. The menstrual function is generally quickly abolished, but occa- 
 sionally its arrest is delayed for months, and in about lO per cent, of all cases, 
 menstruation continues with its usual regularity. No changes in the tastes, 
 personal appearance, or sexual characteristics result from the removal of the 
 appendages of adult women, other than those resulting from the relief of dis- 
 ease and the abolition of pain. 
 
 OVARIAN TUMORS. 
 
 The ovaries are frequently the seat of new growths, especially of cysts. 
 Of 10,290 tumors examined by Williams, 80-4 had their origin in the ovaries, 
 including 87 more properly classifiable as cysts of the broad ligament. Of the 
 whole number, 752 were cysts, 27 were carcinomas, 24 were sarcomas, and 1 
 was a fibroma. Of the cysts, 30 contained dermoid elements. These figures 
 will give a clear idea of the relative frequency of the various neoplasms to 
 which the ovaries are liable. 
 
 OvARiAX Cystomata. — The pathology of cystic growths of the ovary can 
 be understood only by a study of their incipient stages. For what follows 
 
1040 
 
 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 given to Mr. IJlaiid Sutton, by whose work on Surcjical 
 Jvarks and Fallopinn Tubes much light on the pathology of 
 
 credit is to be 
 
 Diseases of the Oi ^ _ . 
 
 these affections has been shed. In Fig. 410 is given a diagrammatic repre- 
 
 FiG. 410. 
 
 ■'^s5lc5m8,o£11 
 
 Diagram retresenting the Cyst-regions of the Ovary : a, oophoron ; b, paroophoron ; c, parovarium ; k, 
 Kobelt's tubes; jf, Gartner's duct (from original drawing by Sutton). 
 
 sentation of the ovary and parovarium, showing its division into an egg-bear- 
 ing portion, tlie oophoron ; a region in which ova are not found, the paroopho- 
 
 FiG. 411. 
 
 "'i^!^^^^'"' 
 
 A incipient oophoriticeysf, /?. paroophoron ; /'.parovarium; F, Fallopian tube, natural size (from orig- 
 ' inal drawing by Sutton). 
 
 ron; and th« parovarium. Cysts developing in earh ..f these present dis- 
 tinctive features. .• ..1 
 
 Incipient oophoritic cysts are shown in Figs. 411 and 412, representing the 
 two clinical varieties, unilocular and multilocular cysts. 
 
 The development of the.se cvsts is due to changes in the normal ovarian 
 follicles In their earlier historv they are lined with epithelium, which later 
 disappears through the atrophic changes in the walls of the cyst caused by the 
 
SURGERY OF THE FEMALE GENERATIVE ORGANS. 1041 
 
 pressure of the accumulating fluid. As tlie cyst enlarges it causes rapid 
 absorption of the paroophoron. In size these cysts may vary from the smallest 
 appreciable follicular dilatation to a cyst containing gallons of fluid. The 
 
 Fio. 412. 
 
 Human Ovary in Section, showing a Multilocular Cyst in an early stage : A, oophoron ; B, paroophorrpn . 
 P, parovarium ; F, Fallopian tube (from an original drawing by Sutton). 
 
 contents may be a thin, colorless fluid or a thick, tenacious mucus. The fluid 
 may be grumous from admixture with blood. 
 
 Frequently in multilocular cysts the epithelium exhibits very active changes, 
 resulting in the development of glandular masses and the production of a com- 
 plex tumor, a cysto- adenoma. 
 
 Ovarian dermoids are cysts in whose walls skin elements occur in varying 
 degree. In such cysts hair, sebaceous glands, sweat-glands, teeth, mammae, horn, 
 nail, bone, unstriped mus- 
 cle, and brain-matter have ^^^- '^^^■ 
 at times been identified. 
 They contain a pultaceous 
 matter formed of shed 
 epithelium and epithelial 
 debris, sebum, and shed 
 hair, oil, and cholesterin. 
 
 Tumors arising from the 
 structure of the oophoron 
 occur at all periods of life. 
 In the foetus they are not 
 infrequent. A large pro- 
 portion of ovarian tumors 
 occurring in infancy are 
 dermoids. 
 
 Parooplioritic cysts are, 
 as a rule, unilocular, and 
 differ from cysts of the 
 oophoron in the following 
 particulars : 1. They do not affect the shape of the ovary until they have 
 attained an important size. 2. They always burrow between the layers of 
 the meso-salpinx, and when large between the layers of the broad ligament. 
 3. The interior is beset with warts (Figs. 413 and 414). The warts in such 
 cysts vary greatly in number. They may cause a general papillomatous infec- 
 
 66 
 
 \kv>" 
 
 Parooplioritic Cyst, showing its relations to tube, ovary, and meso- 
 salpinx (Dorau). 
 
1042 
 
 AN AMERICAN TEXT-BOOK OF SriiGERY. 
 
 tion of the peritoneum. They are rare before tlie twenty-fifth year, and are 
 paost common between the twenty-fifth and fiftieth years. 
 
 Fici. 414. 
 
 IV" 
 
 
 
 lt:^. 
 
 Ruptured Paroophoritic Cyst : F, Fallopian tube (from an original drawing by Sutton). 
 
 Papillomatous Cysts have also been noted as arising within the oophoron 
 and within the layers of the meso-salpinx entirely independently of the ovary 
 or parovarium. (See Figs. 415 and 416.) 
 
 Fig. 415. 
 
 Papillarv Cyst growing between the layers of the broad ligament, near the tubo-ovarian ligament: 
 A, ovary ; P, parovarium; F, Fallopian tube (from original drawing by Sutton). 
 
 Parovarian Cysts. — Cystic dilatations of the parovarium burrow be- 
 tween the layers of the meso-salpinx ; they are usually unilocular and filled 
 with a clear fluid of low specific gravity. The ovary is generally found 
 attached to one side of the cyst, and the Fallopian tube is stretched over the 
 cyst. (See Fig. 417.) They do not often contract adhesions. They are 
 almost unknown before puberty. 
 
 Ovarian cysts in general, in the great majority of instances, develop during 
 the period of greatest sexual activity in women, although they are not rare in 
 infancy and in old age. There are many observations of the occurrence of 
 
SURGERY OF THE FEMALE GENERATIVE ORGANS. 1043 
 
 Fig. 41 G. 
 
 Papillomatous Cj st of the Broad Ligament 
 (original; 
 
 the affection .simultaneously in both ovaries. Their rate of growth is variable 
 and uncertain. 
 
 The symptoms Avhich they provoke are due mainly to weight and pres- 
 sure and to accidental complications 
 Avhich may develop. Their earlier 
 history is often marked by the ab- 
 sence of noticeable symptoms, so that 
 not infrequently they are first dis- 
 covered by accident after they have 
 attained some size. Only Avhen the 
 free development of the cyst toward 
 the abdomen is hindered, as in some 
 broad-ligament cysts, are symptoms 
 referable to the bladder — e. g. irrita- 
 tion and tenesmus — likely to be pro- 
 voked early. In some cases vague 
 pelvic distress and sense of weight are 
 soon experienced in a sufficient degree 
 to invite examination and lead to de- 
 tection of a growth. Menstrual dis- 
 orders are comparatively rare, menor- 
 rhagia being the most frequently ob- 
 served symptom referable to the ute- 
 rus. When the cyst has emerged from the pelvis a spherical or irregular 
 tumor causes a visible enlargement of the abdomen. This enlargement may 
 
 become enormous, produ- 
 FiG. 417. cing distention and thin- 
 
 ning of the abdominal 
 walls and protrusion of 
 the umbilicus, while many 
 dilated veins marble the 
 cutaneous surfiice. This 
 SAvelling is flat on percus- 
 sion and is fluctuant ; pos- 
 sibly at its sides solid 
 masses can be felt, while 
 about it a zone of reso- 
 ^ nance will indicate the 
 presence of the displaced 
 intestines. As the tumor 
 becomes large enough to 
 distend the abdomen, a 
 train of pressure - symp- 
 toms is inaugurated, involving all the abdominal organs to a greater or less 
 degree. The digestive apparatus is disordered; secretion and excretion are 
 faulty ; emaciation and debility result. 
 
 By compression of the ureters the ready flow of the urine into the blad- 
 der is interfered with, and various renal disorders are engendered, resulting 
 finally in uremic and cardiac complications. (Edema of the lower limbs and 
 varicose enlargements of the leg and hemorrhoidal veins may be produced. 
 
 When the abdominal distention is .sufficient to embarrass the action of the 
 diaphragm, dyspnea, and later cyanosis, result. Adhesions between the tumor 
 and the viscera are prone to form, and by their traction to interfere with func- 
 
 ■"^^K 
 "i^'-^ 
 
 '%>-^- 
 
 A Cyst of the Parovarium, showing its relation to ovary and tube 
 two-thirds its natural size : A, oophoron ; B, paroophoron ; F, Fal 
 lopian tube (from an original drawing by Sutton). 
 
1U44 AN AMIliaCAS TKXT-JiOOK OFSlliUKRY. 
 
 tion and fause pain : with tlic gradual (Iev('lo|»nient of tlie condition.-; named 
 discomfort and j)ain are added ; sleep is interfered witli ; the emaciation and 
 cnfeeblement are })ro<:;ressive; a facial expression indicative of ])ain and mal- 
 nutrition ifafics oi'dridiui) becomes well marked; and finally death occurs 
 through exhaustion and uremia. 
 
 The accidental complications to which ovarian cysts are especially 
 liable are those of inflammation, twisting of the pedicle, and rupture. 
 
 lufiammation may be excited by infection derived from adjacent structures, 
 especially the Fallopian tube, the intestinal canal, and the urinary liladder, or 
 by defective antiseptic precautions during tapping. 'J'his inflammation may 
 be restricted to a limited portion of the cyst-wall, and result sim])ly in the 
 formation of circumscribed adhesions to neighboring structures, or it may dif- 
 fuse itself over the whole surface and produce universal adhesions which may 
 unite the sac to all the abdominal organs. In some instances the newly-formed 
 vessels in these adhesions are very numerous, and attain so great a size as to 
 dwarf those of the pedicle as a source of nutrition to the tumor. During the 
 process of organization of these adhesions, if the surfaces remain in apposition, 
 the adhesions will be close and sessile. But by movements while the inflam- 
 matory exudate is still soft this material may be stretched into bands of some 
 length and of varying width. 
 
 Suppuration in an ovarian cyst is not an uncommon accident, occurring 
 most frequently in smaller cysts lying low in the pelvis, especially 'dermoids. 
 The symptoms that indicate inflammation of an ovarian tumor are those of 
 acute circumscribed peritonitis, local pain and tenderness, possibly an initial 
 chill, followed by fever and general disturbance. The violent symptoms 
 gradually fading, a more or less prolonged local tenderness persists for a time, 
 but ultimately disappears. Repeated attacks of this nature may mark the 
 history of a case. AVhen suppuration of the sac occurs, the symptoms are more 
 severe and prolonged, and develop the type of hectic characteristic of deep- 
 seated acute abscess. Emaciation and exhaustion from septic absorption are 
 rapid, and, unless the pus finds exit, death soon follows. Such abscesses may 
 burst spontaneously into any of the neighboring cavities or hollow viscera or 
 upon the cutaneous surftice. The resulting sinuses in rare instances are ade- 
 quate to the full evacuation and obliteration of the cyst, with final cure, but 
 more often fail of such relief, while continued retention of ])us and septicemia 
 remain to prolong the sufferings of the patient and to determine an ultimately 
 fatal result. 
 
 Torsion of the Pedicle. — The stretching and elongation of the natural 
 ovarian attachments as an ovarian tumor develops serve finally to provide it 
 with a pedicle of varying length and breadth in Avhich many and large blood- 
 vessels run. Occasionally the cyst is caused to rotate upon its axis to such a 
 degree as to cause torsion of this pedicle. This accident occurs with marked 
 frequency wdien pregnancy has complicated the case, more especially after 
 delivery. When the torsion is sudden and close, the veins becoming first com- 
 pressed, a severe venous engorgement of the cyst is produced, with much exu- 
 dation of serum, blood-extravasations, distention of the cyst, and ultimate 
 necrosis of its tissue. When the torsion is more slowly effected its consequences 
 may be limited to diminishing the blood-supply, and thus to atrophy of the 
 tumor, unless new vascular connections through adhesions have been formed 
 sufficient for its nutrition independently of the pedicle. The symjitoms pro- 
 voked by the occurrence of torsion of the pedicle of an ovarian cyst are sudden 
 and violent pain in the abdomen and shock, with pot^sibly a noticeable rapid 
 increase in size of the tumor and alterations in its relative position in the 
 
SURGEh'V OF Till-: FKMALK dKNERATIVK ORGANS. l()4o 
 
 abdomen and in its ])rossnro-symptonis. To tlicse may 1)0 added the symptoms 
 of intiM-nal liomorrha^a* wlicn nuicli cfViision of hlood into the cyst-cavity has 
 taken phvee. The sinhh-n deveh)pmeiit of tliese symj)tonis in a woman known 
 to have an ovarian tiimoi- is sidlieient to estal)lish a probable diagnosis and to 
 call for inimeiliate abdominal section for its relief. 
 
 Bupturc of an ovarian cyst may be occasioned by a traumatism : it may 
 result s])ontaneously, as from erosion ])roduced by tiie pressure of intracystic 
 papillary growths, or from necu'osis owing to defective nutrition of a part of 
 the cyst-wall, or follow from the infhimniatory changes incident to supj)uration. 
 The rupture may be into the free peritoneal cavity, which is by far the most 
 frequent occurrence, or into any of the hollow viscera with which adhesions 
 have been formed. 
 
 When tlie ovarian fluid is clear and of low specific gravity, it is well tole- 
 rated by the peritoneum and is rapidly absorbed, provoking free diuresis. 
 When the fluid is colloid in character, it is irritating and provokes peritonitis. 
 Rupture of a cyst may result from the distention and neci'osis caused by tor- 
 sion of the pedicle, in Avhich case free, possibly rapidly fatal, hemorrhage from 
 ruptured vessels is likely to occur. 
 
 The diagnosis of ovarian cysts requires for its establishment a careful 
 examination of the physical characters and relations of a growth, taken in 
 connection with its history. In cases of doubt greater positiveness may be 
 arrived at by taking -advantage of the relaxation of the abdominal and peri- 
 neal tissues to be secured by anesthesia, while careful palpation and percussion 
 are made. In cases of great distention of the abdomen a preliminary tapping 
 will facilitate examination. 
 
 In its earliest stages an ovarian cyst is to be distinguished especially from 
 small pedunculated subserous fibro-myomata, from inflammatory swellings 
 of the appendages, and from tubal pregnancy. It is possible that these con- 
 ditions may coexist with ovarian cyst and thus obscure the diagnosis, so that 
 at times it may be difficult to make out positively the exact nature of an intra- 
 pelvic mass. The absence of the special symptoms that attend the various con- 
 ditions named (for which see the sections descriptive thereof) will serve to indi- 
 cate that a movable, clearly-outlined globular mass in the ovarian region, Avhich 
 is not especially tender to the touch and which is discernible by bimanual pal- 
 pation, is an ovarian cyst. 
 
 When the tumor has risen from the pelvis into the abdominal cavity, spe- 
 cial difficulties of diagnosis will present themselves, according as it still remains 
 as a distinctly-outlined growth partially filling the abdominal cavity, or has 
 attained a size sufficient to fill it to distention. In the first class of cases it is 
 to be distinguished from a distended urinary bladder, from normal and from 
 extra-uterine pregnancy, and from cystic degeneration of fibro-myomata. The 
 distinction will usually not be difficult if the possibility of the existence of 
 these conditions is borne in mind and their existence inquired into. A dis- 
 tended bladder collapses upon the introduction of a catheter : the common signs 
 of pregnancy Avill usually reveal themselves if sought for. Pregnancy and 
 ovarian cvst may coexist, and thus obscure, for a time, an exact appreciation 
 of the condition present. Amniotic dropsy may cause the distended uterus to 
 simulate for a time a fluctuating cyst, but careful examination will show the 
 tumor to be the distended uterus. In any case of doubt as to the existence of 
 presnancy a delay of a few months at most will determine the question. The 
 history of extra-uterine pregnancy and the character of the resulting tumor will 
 declare its existence if a sufficiently careful examination be made. A fibro- 
 cystic tumor of the uterus will reveal on examination the symptoms charac- 
 
1040 
 
 AN AMERICAN TEXT-JiOOK OF SURGERY. 
 
 Lateral View of Abdomen affected with Am 
 
 Ml.lTt). 
 
 teristic of uterine fibro-myomata — cnlarfjcment of tlic nfcriis, clonjratcd uterine 
 t-anal, continuity of structure of tumor aiul uterus, and Miciion-lia^fia. 
 
 When the ahchtniinal cavity is filled to distention, so as to obscure any 
 tumor within, the (juestion of ascites becomes important, and the dilleientia- 
 tion from it of an ovarian cyst a matter requirin<i care. The histoiT of the 
 case may give information: the former existence of a laterally placed movable 
 tumor indicates a cyst ; the existence of chronic disease of heart, liver, kid- 
 neys, or peritoneum would account for an ascites. The shape of the abdomen 
 is to be noted. If it is prominent, tending to protrude centrally, with its great- 
 est circumference below the umbilicus, which is not jtrominent, a cyst is indi- 
 cated ; if it flattens in front, with bulging in the ilanks as the jjatient lies on the 
 
 back, with a prominent 
 Fig. 418. umbilicus, at the level 
 
 of which the circumfer- 
 ence is greatest, ascites 
 is indicated. Figs, 418 
 and 419 illustrate the 
 difference. 
 
 Upon palpation in as- 
 cites the abdominal wall 
 is soft and lax unless the 
 distention is very great, 
 and the fluctuation is 
 most distinct from flank 
 to flank ; in a cyst the ab- 
 dominal wall is tense and 
 the fluctuation is most dis- 
 tinct in front. The area of dulness on percussion is a very im])ortant difleren- 
 tial indication. In ascites the abdomen is resonant in front, from the floating 
 
 of the intestines on the 
 Fi«- 419. fluid, and the flanks are 
 
 dull ; the area of dulness 
 will vary with change of 
 posture, the part lying 
 uppermost being always 
 resonant. In cystomata 
 the area of dulness is in 
 the front of the abdomen ; 
 changes of posture do not 
 affect its position ; its lim- 
 its are sluirply marked, 
 and it is surrounded by 
 an area of intestinal res- 
 onance ; even when the cyst is of large size resonance can usuallv ))e detected 
 in one or both flanks (Figs. 420 and 421). 
 
 The accumulation of dropsical effusions in cyst-like cavities formed by 
 intra-peritoneal adhesions in the course of cancerous and tubercular perito- 
 nitis mav form tumors that will simulate to some extent ovarian cystomata. 
 The history of their development and the absence of the special signs which 
 attend ovarian growths will indicate their nature. 01)esity may give rise to 
 suspicion of ovarian tumor, but careful examination will fail to elicit any signs 
 confirmatory of the suspicion. lU-nal and liver cysts, when enlarged to such a 
 degree as to extend down into the pelvis, may be confounded with ovarian cysts. 
 
 Lateral View of Abdomen affected will 
 
 Cyst (Albert). 
 
SURGERY or THE I1:M.\LI': aENERATrri': organs. 10I7 
 
 As long as a line oi" ivsoiiaiicc exists l.etween the timior and the piibes, per- 
 cussioirwill serve to (litVereiitiate tiiem. 'I'lie diilness of a liver cyst will also 
 
 Fig. 420. 
 
 Fig. J21. 
 
 Ana of Duluess (shaded) in Ovarian Cystoma (Barnes). Area of Dulness (shaded) in Ascites (Barnes). 
 
 usually be continuous with the ordinary liver dulness. That of a renal cyst 
 will extend up under the ribs and into the flanks around to the spine, Avhile 
 downward over its center may be traced the resonant colon Avhen distended 
 
 with gas. 
 
 The prognosis of ovarian cystomata is almost wholly bad unless they are 
 subjected to surgical interference. After they have attained sufficient size to 
 affect the general health, but a brief period of life, rarely exceeding two years, 
 is to be looked for. The tendency to death by malnutrition and uremia has 
 been already mentioned. Peritonitis and embolism also are frequent causes of 
 death. Papillomatous cysts are prone to malignant degeneration. In rare 
 instances spontaneous cures take place ; they follow rupture of the cyst, or 
 atrophy caused by defective nutrition through a gradually effected twist of the 
 pedicle. 
 
 The treatment required for ovarian cysts is, in all cases where possible, 
 their extirpation by surgical means — ovariotomy : palliative tapping is to be 
 resorted to only when symptoms of extreme pressure require immediate relief. 
 It should be done onlv'under rigorous antiseptic precautions. 
 
 Ovariotomy was first done in 1809 in Danville, Ky., by Dr. Ephraim 
 McDow^ell of "that village. The patient recovered. It was not until fifty 
 years later that the operation became at all common. Thanks to the know- 
 ledge of the principles of asepsis and antisepsis that has become general dur- 
 ino- the last quarter of the present century, early resort to the operation is 
 now universal, and the ratio of successful results following it is very large. 
 
 Technique of Ovariotomy. — The preparation of the patient, the anti- 
 septic precautions attending the operation, and the preliminary incision of the 
 abdominal wall are to be conducted as described on page 1012. The cyst hav- 
 ino- been exposed, a finger is swept over its anterior surface to note its imme- 
 diate relations and to detach any soft adhesions that may be present ; then, 
 while the abdominal wound is made to gape and the tumor to project into it 
 by proper pressure, a large canula is thrust into it, either through a small 
 opening made with a bistoury or by means of an attached trocar. As the 
 
104.S J.V AMKRICAy TKXT-JiOOK OF SCRaKRV. 
 
 fluid of the cyst is evacuated through the canuL'i, the cyst-wall, seized by 
 broad-bladed forceps, is drawn up and out through the incision, the abdominal 
 wall being kej)t applied to the collapsing cyst by the continued pressure made 
 by an assistant. If tlie contents of the cyst are too thick to run freely through 
 the canula, the patient is to be turned on her side and the opening in the cyst 
 enlarged sufficiently to permit the surgeon to introduce his hand and scoop it 
 out. Multijde secondary cysts may be broken down and emptied in the same 
 Avay if they are not reailily penetrated and evacuated by the canula through 
 the primary cyst. Adhesions as they are met with are to be overcome in 
 accordance with the principles specified on page 1038. The pedicle is to be 
 securely tied, the C3^st cut away, and the stump of the pedicle, after careful 
 inspection to make sure that the hemostasis is complete and secure, is dropped 
 back into the pelvis. Broad-ligament cysts which are sessile must, if possible, 
 be enucleated after proper incision of the layers of the broad ligament that 
 form the capsule. If this enucleation is found im])racticable, the edges of the 
 cyst and capsule are to be stitched to tlie abdominal wound and the cavity 
 drained. The same device may be resorted to in the case of universally adker- 
 ent cysts whose separation seems impracticable. The cleansing of the peritoneal 
 cavity, the closure of the wound, the use or not of drainage, and the after- 
 treatment are in accordance with the general princijiles specified on page 987. 
 
 BesuJts. — The removal of ovarian cysts uncomplicated by extensive or 
 dense adhesions is quickly accomplished, ordinarily occupying less tlian thirty 
 minutes in the hands of surgeons of average dexterity. The mortality in 
 such cases is between 5 and 10 per cent. In complicated cases the operation 
 is much graver in its prognosis, the death-rate rising to from 10 to 25 per 
 cent., being influenced much by the dexterity of the operator. Shock, hemor- 
 rhage, and sejjtic peritonitis are the chief causes of death. Intestinal obstruc- 
 tion from angulation of the bowel through adhesions is responsible for a mor- 
 tality of about 1 per cent. 
 
 Solid Tumors of the Ovaries. — The ovaries may be the subjects of 
 carcinoma, sarcoma, and fibroma, in relative frequency according to the order 
 in which they are here named. The symptoms which they present are not 
 characteristic at the onset. They are with difficulty distinguishable from 
 pedunculated subserous solid growths from the uterus. They early provoke 
 ascites. They should be extirpated without delay after recognition. 
 
 Tumors of the Broad Ligament. — Cysts of the broad ligaments have 
 been studied with ovarian cysts, with which they are clinically closely associated. 
 
 Papillomata of the Fallopian Tubes and Fibho-myomata of the tubes 
 and of the round ligaments, also Malignant Tumors arising primarily in these 
 structures, have been met with. ^Vhen recognized, they are, if possible, to be 
 extirpated by abdominal section. 
 
 Hydrocele of the Round Ligament. — Small cysts, containing serum, 
 are sometimes found within the peritoneal investment that ensheathes the round 
 ligament for a varying distance within the inguinal canal. They present them- 
 selves as ovoid, tense sacs within the inguinal canal or at its external orifice. 
 They are to be distinguished from herni;^. from glandular enlargements, and 
 from lymphatic dilatations. They may be extirpated with the knife if they 
 are the cause of any discomfort. If, as in some cases that have been described, 
 they communicate with the general peritoneal cavity, they are practically 
 hernial sacs, and require the same treatment of enucleation and tying off that 
 would be suitable to the latter condition. 
 
DISEASES AM> /.XJllUHS OF THE BREAST. 104:) 
 
 CIIAPTEll IX. 
 
 DISEASES AND INJURIES OF THE BREAST. 
 
 Surgical Anatomy. — Tt l)ehooves the suro;eon to Ito :i((|iiaiiito(l uith the 
 niinutor anatoiiiY of the niainnia, espooially tlie distrihution of its lyinph-vessols, 
 in oi(Un- correctly to diairiiosticatc and treat its diseases. Owing to tlie age and 
 the dift'ering functional changes to which it is subject, the size, appearance, and 
 consistence of the breast vary within wide limits, but the gland-structure 
 retains its normal relations with the circumjacent tissues, except perhaps when 
 the organ is unusually pendulous. The hoionhtrtrs of the breast are often ill 
 defined, portions of the gland-structure irregularly penetrating the surround- 
 ing adij)ose tissue, especially on the axillary side, and at times these glandular 
 masses appear to be totally dissociated from the mamma proper. It is of import- 
 ance to recall this when operating for carcinoma. The gland prope?', however, 
 is included within a firm fascial envelope, which, as a rule, strictly limits inflam- 
 matory infiltration ; thus an interacinous abscess, even when deeply seated, very 
 rarely becomes a post-mammary one, nor does the latter penetrate between the 
 gland-lobules, and by the directions thus compulsorily pursued by the pus in 
 neglected cases of these diseases the original seat of the trouble can often be 
 determined. Posteriorly, the fascia of the pectoralis major, serratus magnus, 
 and external oblique muscles is separated from the costal surface of the gland 
 by a loose layer of areolar tissue, through Avhich pass numerous blood-vessels 
 surrounded by very distinct perivascular lymph-spaces — a fiict to be borne 
 in mind when dealing with mammary carcinoma. Keaching from the third rib 
 above to the sixth or seventh below, the gland-tissue is thickest at its center 
 and toward the axillary side, in which direction it extends farthest, making the 
 long axis of the gland pass from the anterior axillary fold obliquely from above 
 downward and inward. The overlying integument, the circumference of the 
 fibrous gland-capside, and the superficial fascia — which is also attached to the 
 clavicle — are intimutel}^ connected with one another by fibrous bands, serving 
 to hold the gland in place, and explaining the dimpling of the skin — not the 
 depression of the nipple — over contracting neoplasms. 
 
 The nipple in some patients forms a w- ell-marked conical projection ; in others 
 it is small and depressed, with a constricted base : it may lie in an umbilicus- 
 like depression, or, again, it may be practically absent, being on a level with 
 the skin. The skin is wrinkled, numerous sebaceous glands opening in the sulci 
 thus formed ; it is covered with papilkie, and varies in color from a light pink to 
 a dark brown, according to the complexion of the individual, and to whether 
 pregnancy has existed or is now present ; in which event the nipple becomes 
 much darker — sometimes a deep blackish-brown in brunettes. Uterine tumors, 
 it is alleged, produce somewhat similar changes. The nipple is composed of 
 numerous blood-vessels, areolar tissue, the milk-ducts, and considerable un- 
 striped muscular tissue. The glandrStructure is composed of numerous minute 
 lobules aggregated into lobes, each lobule opening into a small duct, these 
 small ducts in turn joining larger ones, until finally the secretion is emptied by 
 fifteen or twenty milk-ducts opening upon the summit of the nipple, these large 
 ducts beneath the areola having first become dilated so as to form little sacs 
 (ampullce, milk-sinuses), but at the base of the nipple contracting into small 
 canals whose orifices admit only a stout bristle. Glandular epithelium lines 
 both the gland-vesicles and the ducts, continuous with that investing the nipple. 
 
 Arteries, Veins, Nerves, and Lymphatics of the Breast. — Blood reaches 
 
lOoO A.\ AMJ:U1LA.\ TEXT-noi)K OF SlRUKllY. 
 
 the ijland cliiefly through brandies of the long and superior thoracjc, inter- 
 nal inauiiiiarv, and intercostal ((rtcrics ; sometimes there is a special branch 
 from the axillary trunk. In a virgin breast these vessels are small ; during 
 lactation they are much enlarged, as well as Avhen the breast is the site of a 
 rapidly-growing neoplasm. For the most part the arteries enter the upper 
 and axillary borders of the gland, a point to be remembered when operating, 
 since the organ can be rapidly excised with but little loss of bhjod by dissect- 
 ing it \\\) toward the axilla, the deeper attachments in this region being divided 
 last. The blood is returned by veins generally ])ursuing a course similar to that 
 of the arteries, and chiefly emptying into the internal mammary and axillary 
 veins. The nerves are derived from the anterior and lateral cutaneous thoracic 
 nerves, and communicate with the cutaneous branches of the lower cervical 
 nerves. 
 
 Both the superficial and tlio deep lymphatics enter, in the main, the axillary 
 glands, passing in two directions — one to the glands internal to the vessels, the 
 other, more external, joining the lymphatics of the arm. Other routes must be 
 remembered, since they account for systemic infection when no enlargement of 
 the axillary glands has been detected. Thus the lymphatics of the nipple and 
 sternal side pass through the second intercostal space with the artery and vein 
 to the anterior mediastinum, there entering glands; others join the first in 
 the anterior mediastinum by penetrating the space between the fourth and 
 fifth costal cartilages ; and, finally, the deep absorbents of the costal surface 
 of the gland accompany the branches of the aortic intercostals on the axillary 
 side, reaching the thoracic duct in the posterior mediastinum. It is by the 
 passage of microscopic particles of the growth along these cliannels that carci- 
 nomatous disease enters the cnest, often producing growths m the pleura, with 
 consequent pleuritis, etc. ; again, by this route the system may be contami- 
 nated, the axillary glands escaping infection entirely or at least for a long 
 period, although the axillary route is the one almost always taken by the 
 infecting fragments. It is probable that more unusual routes are pursued by 
 the infected lynipli only in cases in which the axillary lym])liatic glands be- 
 come early blocked by secondary growths, or recurrence takes place in an 
 operation scar when the axilla has been completely emptied of all lynaphatic 
 structures. The lymphatic vessels of both sides of the chest freely inter- 
 communicate, and some, passing over the clavicle, enter the superficial cer- 
 vical glands. Lymph vessels also pass downward to accomjtany the superior 
 and deep epigastric vessels, to terminate in the inguinal glands, possibly pass- 
 ing through a lymphatic gland situated on the internal surface of the rectus 
 abdominis muscle near Douglas's fold. 
 
 CONGENITAL MALFORMATIONS. 
 
 Supernumerary Nipples and Mamm^, while usually situated in close 
 relation with the normal organs, sometimes occupy the axillary region, and rare 
 instances have been reported of these organs having been located upon the 
 back, over the acromion process, on the anterior abdominal wall, and on the 
 outer aspect of the thigh. This abnormality is not confined to women, but 
 occurs also in the male sex. The supernumerary nipple usually lies below and 
 to the inner side of the normally situated one ; it is sometimes well developed, 
 but is more usually small or lacking in one or more of the following peculiar- 
 ities : viz. the papillae, areola, follicles, or hairs. This abnormality occurs most 
 frequently upon the left side. These accessory glands are rarely functionally 
 active. 
 
/>/s/:as/:s a.M) ix.irini.s or riii: /:/,•/■: a sr. 1051 
 
 Treatment. — Sliould tliey cause ineiital or physical inconvenience, they 
 may be excised. 
 
 Absenck of the Mamm^-. — A few sueli cases are on recorcl, tlie light 
 ghmd being the one commonly al)sent ; in atldition, more or less of the mus- 
 cular and bony walls of the corresponding portion of chest-wall is also lacking. 
 
 DISEASES OF THE NIl'I'EE. 
 
 INFLAMMATION. — While this may result from any form of irritation, it is 
 hardly ever met with except in connection with lactation. The trouble is 
 rarely limited to the nipple, but extends to the surrounding skin, the red 
 swollen organ itself becoming excoriated and fissured ; ulcers form, these 
 latter at times extending so deeply as to destroy the skin around the base more 
 or less completely, leaving little else than the lacteal ducts as a connecting 
 bond for what is left of the body of the organ : constitutional symptoms are 
 sometimes present. Much smarting pain is felt, aggravated at each attempt 
 at suckling, at which times fissures are reopened, the scabs are torn oft", bleed- 
 ing follows, and the pain is so severe that the Avoman often abandons the 
 attempt ; the engorged gland is not relieved, and either from this, or more 
 commonly from septic lymphangitis spreading from the nipple, mammary 
 abscess results. Sometimes the nipple is destroyed by ulceration, leading 
 almost inevitably to extensive mastitis and recurring trouble at each succeeding 
 delivery. 
 
 Treatment. — The eifect of frequent applications of the infant to the 
 breast should be guarded against as far as possible by properly-constructed 
 shields, the nipple itself being always moistened before nursing and carefully 
 dried afterward : these measures, combined with washing Avith a tolerably strong 
 borax lotioij, will sufiice for the average case. Disinfection by non-poisonous 
 antiseptics (if the breast is being nursed from), and stimulating and astringent 
 applications, such as glycerole of tannin and sulphurous acid, equal parts, with 
 double the bulk of water, tannic acid (grs. v to f 5J of glycerin), aided in extreme 
 cases by touching the fissures or ulcers Avith a pointed stick of nitrate of sil- 
 ver, constitute the best means available ; but mechanical protection by some 
 form of shield is imperative in all severe cases. Sometimes the use of the 
 breast has to be abandoned, in which case gentle centripetal frictions of the 
 breast with hot camphorated oil, with occasional emptying of the gland by a 
 breast-pump or firm compression with strips of belladonna plaster may be 
 tried, both plans tending to suppress the secretion of milk. 
 
 Retracted Nipples. — This may be a congenital condition, or may be the 
 result of cicatricial contraction from badly-ulcerated nipples, from inflammation 
 of the gland, or from neoplasms. 
 
 Treatment. — Sometimes this condition appears to be benefited by the 
 application of suction by means of a breast-pump or a bottle Avith properly- 
 formed neck, the contained air having been rarefied by heat. Many Avomen 
 with retracted nipples can nurse their children by the use of some one of the 
 better forms of nipple-shield. 
 
 Paget's Disease. — This is a chronic destructive dermatitis of the papil- 
 lary layer of the nipple and areola, most frequently attacking individuals 
 betAveen forty and sixty years of age, although in one patient the disease 
 commenced at twenty-eight years. 
 
 Symptoms. — According to BoAvlby, this disease is not simply eczema. 
 First, a branny desquamation occurs, either on the nipple or areola, followed 
 by a slight watery discharge, Avhich may become very free, yellowish, and 
 
10.12 
 
 A.\ AMi:JiICAy TKXT-llOOK (iF sriKilJlY 
 
 sticky. Next small scales and crusts form, which, ])ocoming separate*!, leave 
 raw or excoriated, intensely reddened surfaces. The process extends periphe- 
 rally from the nipple as a center, with sharply defined inar^^ins, ncfither vesicles 
 nor pustules forming, until sometimes much of the skin covering the breast is 
 involved. The diseased surfaces are much redder than in eczema. During 
 the later stages the nipple becomes retracted, and in the more chronic cases is 
 not infreiiiiently destroyed by ulceration, which, extending to the areola, leaves 
 
 Fic. 42'2. 
 
 I'a^a't's disease of Hit; Nipple (original). 
 
 a circular or ovoidal ulcer with a papillated, granular surface. Tingling, 
 burning pain is complained of, but not severe itching. 
 
 Relation of Psorosperms to Paget's Disease. — Certain constantly- 
 found rounded or oval bodies occupying the deeper layers of the epidermis 
 liave been described by Darier, Wickham, Bowlby, and others. These have 
 never been seen in eczema, and have been considered by the above-mentioned 
 authors, as well as others, to be psorosperms standing in a causative relation 
 to Paget's disease. This claim seems more than doubtful, wliile none claim to 
 have detected tliem in the mammary tumors following the majority of reported 
 cases of Paget's disease — viz. 24 out of 35. 
 
 While some observations have been supposed to show that certain cases are 
 really superficial epitheliomatous disease of the orifices of the lacteal ducts, the 
 lesions have usually been of too long standing and yield too readily to simple 
 treatment to be anything except a form of dermatitis. Nevertheless, this con- 
 dition of constant irritation unquestionably predisposes to carcinoma mamma', 
 and if simple, soothing applications do not effect a cure, excision of the dis- 
 eased tissues should be done, including the whole breast, if any suspicious 
 indurations exist, with careful exploration of the axilla where the condition 
 of the mammary glands has demanded excision. 
 
 DISEASES OF THE BREAST. 
 
 Neurotic Conditions of the Breast are of common occurrence in young 
 unmarried women, but are never found in the aged. The most important a.s 
 
DISEASES AND IXJIINES OF THE BREAST. 1053 
 
 well as the most frequent is siniiile neuralgia, constant or periodic, severe lanci- 
 nating pain being complained of in the armpit, and perhaps extending down the 
 arm. The gland itself and the skin over it in many cases are exceedingly sen- 
 sitive when even gently handled (hyperesthesia), although nothing abnormal 
 can be detected. The patients are often greatly distressed by the fear of can- 
 cer. Ovarian disturbance frecjuently coexists, and probably stands in a causa- 
 tive relation to the local neurosis. 
 
 Diagnosis. — Where no tumor can be detected, the more severe the pain is 
 and the greater the sensitiveness the less need the practitioner be alarmed, and 
 the more confidently can he ascribe the trouble to its true cause. 
 
 Treatment. — As the mental and moral condition has much to do with the 
 development of the trouble, all local treatment must be avoided, while regular 
 hours for sleep, open-air exercise, tonics, cold bathing, and the avoidance of sen- 
 sational novels, with provision for healthy mental occupation, must be insisted 
 upon. 
 
 Atrophy may occur in the unmarried as well as in the married, either from 
 congenital defect inducing premature senescence or from ovarian disease, pre- 
 sumably always atrophy. Manifestly, no treatment can be of any avail. 
 
 Hypertrophy. — This is due to abnormal development of the constituents 
 of the breast, usually commences at puberty, and commonly afiects both 
 breasts. The general health may or may not be impaired ; the catamenia are 
 in all cases established, but are apt to be scanty or irregular. Occurring in 
 adults (usually before thirty years of age), the single and the married, the 
 prolific and the sterile Avoman, alike may be attacked. The course is slow 
 throughout, or rapid for a time and then perhaps stationary for life or for 
 long periods, but usually one breast outstrips the other in growth. Pain is 
 rarely complained of even upon handling, but the inconvenience from the 
 weight (tumors having been reported of even sixty-four pounds) is often 
 excessive. The breasts may be symmetrically enlarged or may be pendulous, 
 and are covered wdth normal skin. They feel soft throughout or as if each 
 lobule was uniformly enlarged, rendering the mass somewhat irregular, but no 
 circumscribed induration is detectable. When occurring later in life, while both 
 breasts are apt to be attacked, one may commence to enlarge before the other. 
 
 Diagnosis. — This depends upon the uniform, gradual, excessive enlarge- 
 ment — often commencing at puberty — without cutaneous or glandular involve- 
 ment, and the normal feel of the gland, which Avhen compressed between the 
 opened hand and the chest-wall gives no sensation of localized induration : 
 when both breasts are enlarged the condition can hardly be mistaken. 
 
 Treatment. — Attention to the general health and to the ovarian and ute- 
 rine functions is important, compression and support of the glands may be tried. 
 The excitation of lactation has proved successful in two cases, while the removal 
 of one breast has in one or two reported cases caused diminution in the size of 
 the other. When the Aveight becomes unendurable, amputation must be done. 
 
 Mammitis, Mastitis, or Inflammation of the Breast. — Of course from 
 traumatisms or other causes inflammation may attack the tissues over and in the 
 immediate neighborhood of the breast, and this may terminate by resolution 
 or suppuration : absence of the characteristic induration of the gland will 
 serve to distinguish this from mammitis, and the treatment must be conducted 
 upon general principles. 
 
 Mammitis may occur at any age and in either sex. Infants not uncom- 
 monly present evidences of mammitis within a few days after birth, especially 
 if the nurse has tried to ''break the strings of the breast " or "to rub aAvay the 
 milk :" because a milky or serous discharge sometimes exudes from the nipple. 
 
1051 j.v A^f/':/i'l('AX T/:.\'T- /!()() h' or atay/a'/.t. 
 
 Either S])ontanooiisly in those in somewhat feeble health, or from a })lo\v, 
 inflammation is not uncommon at or about puberty in boys as well as in girls, 
 although it is more common in females : resolution or suppuration may take 
 place. Between sixteen and twenty years of age a chronic enlargement of the 
 breast in a girl — although often a fibroma — is exceedingly apt to be either 
 a localized mannnitis or a chronic abscess the result of such a condition. 
 
 Acute mammitis, however, more often attacks nursinijr women durinii the 
 first week to a month after delivery, then being usually due to infective lym- 
 phangitis from "cracked nipples," especially when these organs are retracted 
 or the ducts are obstructed by recent or old inflammatory conditions, but is 
 often attributable solely to inability of the child to empty the breast. coml)ined 
 with exposure to cold. Both these conditions favor congestion, and therefore 
 predispose to mammitis, but the exciting cause is the entrance of germs, 
 either through an open surface or after lodgment in the deeper portions of 
 the milk-ducts, by their penetration into the periacinous connective tissue : 
 during the later stages of lactation, if the individual becomes run down in 
 health, trivial causes will induce mammitis. Abscess of the breast often 
 follows. 
 
 Symptoms. — At first only uneasiness and stiffness of the whole or part 
 of the breast are complained of; next a chill or slight rigor occurs, which is 
 followed by fever, with a tense, hot, swollen, painful condition of the breast, 
 one or all of the lobes being indurated and the overlying skin reddened. 
 The inflammation may terminate by resolution or suppuration, or may leave 
 chronic thickening of the gland. AVhen pus forms, it may be situated, first, 
 superficial to the gland ; secondly, in its substance, or rather between the 
 lobes (intramammary, interlobular); and, thirdly, between the gland and the 
 chest-wall (post-mammary). The first variety differs neither in symptoms 
 nor in treatment from any other superficial abscess, but often preludes the 
 second form. The interlobular form usually occurring during lactation may 
 be single or multiple, and presents the usual signs of deep-seated glandular 
 abscess. 
 
 Acute Post-mammary Ahscei<i<. — Although this may result from infection 
 of an ecchymotic collection following trauma, post-mammary abscesses more 
 commonly result from propagation of the inflammation from the deep lobes 
 of the gland. 
 
 Symptoms. — The abscess is often preceded by constitutional symptoms 
 of inflammation of the gland. Avith some deep-seated tenderness and indura- 
 tion. Rapidly the whole mammary and post-mammary regions become en- 
 gorged, producing a characteristic elevation of the whole breast, which is 
 unaltered in form. Although the skin is hot and traversed by enlarged veins, 
 it is not materially reddened unless the post-mammary phlegmon is secondary 
 to an extensive mastitis, which may coincide. The base of the gland early 
 becomes encircled by an oedematous ring of tissue. Examination shows an 
 elastic resistance when the gland is pressed against the thorax. Actual fluc- 
 tuation is difficult of detection, and can be best felt by placing one hand at the 
 periphery of the gland over the oedematous collar and suddenly pressing the 
 breast backward. The constitutional symptoms rajiidly increase in severity 
 until they fre(|uently assume rather alarming pro]iortions. 
 
 Treatment. — This should be directed against the formation of pus, and 
 must consist in the measures advised for fissured nipple, cessation of nursing 
 with the affected breast, the cautious use of the breast-pump, in robust indi- 
 viduals a saline purge, sometimes leeching, and attempts to arrest the secre- 
 tion of milk by extract of belladonna reduced to a plasma by glycerin, fre- 
 
DISEASES AND IXJURIES OF THE BREAST. 1055 
 
 qiient Imt fomentations if pus is forming, while tiie moment tliis is detected free 
 antiseptic incision and drainage must be employed, the cut or cuts passing. in a 
 radiating manner from the nipple to avoid division of the lacteal ducts. Sup- 
 port must be afforded to the breast by a proper sling or bandage, and the 
 arm kept in a sling or bound to the side. The post-mammary form requires 
 free incision, preferably at the lower, outer part of the swelling. Neglected 
 cases require free incisions, freshening of the sinuses with the Volkmann sharp 
 spoon, disinfection, and free drainage. More rarely, the gland must be par- 
 tially dissected back from the chest-wall, and the suppurating sui'faces freshened, 
 after which the breast must be sutured in position with catgut, carefully effacing 
 all cavities by means of buried animal sutures. Proper attention to diet, with 
 quinine, ferruginous tonics, and stimulants, is indicated if the patient's 
 health is deteriorated. 
 
 Cold {Tubercular) Post-mammary Abscess. — This may be secondary to 
 disease of the thoracic walls, when it will have been preceded by the symp- 
 toms of a deep-seated, slowly-progressing induration, posterior to the mamma. 
 This eventually softens and pushes forward the whole gland. The skin some- 
 where at the periphery of the breast becomes adherent, infiltrated, thinned, 
 and finally ulcerates; or pyogenic infection occurring, an approach to the 
 complexus of symptoms of acute i)ost-mammary abscess is presented. When 
 resulting from tubercular mastitis, a slowly-growing, infiltrating, semi-elastic, 
 ill-defined mass can be felt deep in the ghmd. The overlying skin becomes 
 adherent, and when situated beneath or near the nipple this becomes retracted. 
 While progressing anteriorly the post-mammary region is also invaded, when 
 the conditions gradually develop as described above. 
 
 Treatment. — This is such as is adapted to any tubercular process, neces- 
 sitating removal of all infected tissues. Amputation of the breast, evacuation 
 of the axillary contents, and resection of diseased ribs may be demanded. 
 
 Milk Fistula. — These result either from abscesses opening up the milk- 
 ducts or from the surgeon's knife, the secretion of milk serving to keep the 
 orifices patent, so that the abscesses degenerate into fistulous tracks. 
 
 Treatment. — Stimulating injections, as of iodoform, iodine, or chloride 
 of zinc, may be employed, with compression along the sinus tracks and general 
 support of the breast. Should these measures fail, the sinuses must be dilated, 
 curetted, antiseptically irrigated, and a drainage-tube inserted through their 
 whole extent, the tube being gradually shortened and compression applied in 
 its track as it is withdrawn. 
 
 Chronic Inflammation ; Chronic Abscess. — As a sequence of the acute 
 process or from certain constitutional causes (struma ?) in an otherwise healthy 
 breast, one or more portions may become the seat of chronic inflammation, 
 •evidenced by thickening and perhaps tenderness on pressure. This condition 
 may remain stationary, may gradually diminish, or may terminate in the forma- 
 tion of pus, Avhich is very slow to reach the surface. 
 
 Treatment. — Attention to the general health, support of the breast 
 amounting to pressure if it can be borne, counter-irritation from time to time, 
 and covering the part with a belladonna plaster or applying equal parts of 
 extract of belladonna and compound ointment of iodine. Avill generally hasten 
 resolution. If pus is suspected, the exploring needle or the aspirator must be 
 used, as it is of the utmost importance that these collections should be opened 
 at the earliest possible moment. The incisions should be made as directed for 
 acute abscess, but careful curetting of the cavity, thorough antiseptic irrigation 
 or irrigation with weak iodine-water, followed by light packing with iodoform 
 gauze around a drainage-tube if the cavity be of any size — the gauze to be 
 
lOoG J.V AM 1:111 VAX TKXT-BOOK OF SLIKiEIiV. 
 
 withdrawn in a day or two — will facilitate the liealinii; process. In the more 
 refractory cases cuneiform excision with careful suturing may become re(|uisite. 
 
 Chronic Lobular Inflammation (Irritable Mamma). — J'athologically, 
 this is a chronic interstitial mamraitis resulting in a small-celled infiltration 
 of the interlobular connective tissue, with some epitlielial proliferation. The 
 newly-formed connective tissue, contracting, obliterates the ducts and acini, 
 resulting in fatty degeneration of the epithelium. Some of the acini, by hav- 
 ing only their ducts compressed, may dilate, forming small cysts. The import- 
 ance of this aftection resides in its liability to be mistaken for carcinoma when, 
 occurring about the menopause. 
 
 Symptoms. — Either the Avhole or more commonly a part of the mamma 
 becomes indurated and tender — possibly even the latter, with but little of the 
 former — in young unmarried or in sterile married women, in these latter perhaps 
 more often about or after the menopause. Disturbances of the uterus, of the 
 ovaries, of digestion, with mental excitement or depression, are not uncommon. 
 
 Diagnosis. — This must depend upon the following facts : The growth does 
 not steadily increase as in neoplasms ; the pain and tenderness are greater ; the 
 benign tumor is more circumscribed, while scirrhus is much harder, the den- 
 sity appearing less — instead of greater, as would be true of scirrhus — if the 
 mass be examined by rolling the breast over the chest-wall with the flat of the 
 hand ; the swelling is wedge-shaped, with the apex toward the nipple ; the pain^ 
 is referred to the disti'ibution of one or more nerves, which, as Mr. Birkett long 
 ago pointed out, if pressed upon at their exit from the thorax, will give rise to- 
 severe pain, "sometimes confined to the branch distributed to the indurated 
 part, while the rest are unaffected;" the axillary glands if enlarged — a rare 
 event — are not indurated. In an exceptionally doubtful case a fragment can 
 be removed by antiseptic incision and subjected to microscopic examination. 
 
 Treatment. — This should be directed to the removal of the functional dis- 
 turbances mentioned : assurance should be given that the disease is not malignant 
 and is curable, and a belladonna j)laster should be applied, chiefly to j)revent 
 the patient's handling the part, Avhile small doses of iodide of potassium should 
 be given internally. If these measures fail, counter-irritation and compression, 
 or in severe cases free antiseptic incision, may be tried. Should the induration 
 persist or increase, with severe pain, despite appropriate treatment, in middle- 
 aged or older Avomen, amputation is indicated, because continued iri'itation may 
 result in the development of genuine carcinoma. 
 
 OmtiiNic CrRKHOTic Mastitis. Diffused Ciihoxtc Mastitis. — Owing^ 
 to the difficulty experienced in distinguishing this affection in the atrophic 
 stage from scirrhous carcinoma it demands a brief description. Commonest 
 near the climacteric and usually attacking one breast, the initial symptoms 
 are those of a subacute inflammation producing pain and swelling of either a 
 portion or the Avhole of the mamma. The tender area gradually becomes 
 indurated, the disease spreads until in advanced cases the Avhole gland, nipj)le, 
 overlyjng skin, and ])aramammary fat become involved. Pyrexia is absent 
 throughout. Still later, irregular contraction occurs, producing a nodulated 
 tumor Avith retracted nipple covered by adherent puckered skin. Rarely both 
 Avatery discharges from the nipple and enlargement of the axillary glands are 
 detectable. The disease ])ursues a chronic but irregular course, usually ter- 
 minating by resolution, leaving a permanently atroj)liie(l gland, although 
 calcification is a i)0ssible se({uel. 
 
 Diagnosis. — The history is im])ortant. The long duration Avithout infil- 
 tration of the ])ectoral muscle; the rarity of involvement of the axillary 
 glands; Avhen this is noted, its insignificance and the absence of fusion of all 
 
DISEASES AND rXJdiJES OF THE BR EAST. 1057 
 
 the axillary tissues Ciiusiiifi later ))aiii in and (cdema of the extremity; the 
 maintenanee of the <feneral health, the absenee of viseeral involvement, and 
 the tendency to resolution, should render a diagnosis possible in most cases. 
 
 Treatment. — Iodine, both internally and externally, or mercurial oint- 
 iiit'iit in conjunction with lirni ])ressure, will usually .suffice. If the enlarge- 
 ment continues to increase, amputation is indicated. 
 
 Tubercular Affections. — Secondary involvement of the l^reast, causing 
 induration or abscess and ulceration, may take place "when the neighboring 
 cellular tissue, lymphatic glands, or bones are the seat of primary tuberculosis. 
 Velpeau, however, has described certain instances where at numerous points 
 of the breast there were isolated masses whose centers had undergone case- 
 ous change. This condition is found in pale, delicate females, and coincident 
 strumous enlargement of the axillary and cervical glands is quite common. 
 The small masses are difficult to detect, because not sharply defined, and tend 
 slowly to enlarge, break down, and open externally by ulceration, leaving the 
 gland riddled with sinuses. 
 
 Treatment. — Early extirpation, including in the removal, as a rule, the 
 entire breast, is probably the best practice. Curetting, irrigation Avith weak 
 iodine-water, and packing with iodoform gauze may be successful. Tubercular 
 infection of the neighboring glands is common : if any enlarged glands are de- 
 tected at the time of operation on the breast, they should be removed then. 
 
 Syphilitic Affections. — As in tuberculosis, so in syphilis, secondary 
 trouble may result from specific disease in the contiguous cutaneous, cellular, 
 and osseous tissues. A primary affection of the gland, producing a more or 
 less uniform indurated enlargement of the organ, has been described as occur- 
 ring in syphilitics in the late secondary or early tertiary period. Either one 
 or both breasts may be attacked, producing a not very painful, hard, smooth 
 enlargement readily yielding to antisyphilitic treatment. 
 
 Treatment. — Iodide of potassium, either alone or combined with mercury, 
 aided perhaps by counter-irritation and pressure, is all that is requisite. 
 
 TUMORS OF THE BREAST. 
 
 Tumors composed of nothing but pure fibrous, fatty, myxomatous, cartilag- 
 inous, vascular, or nervous tissues are so rare that they will not be separately 
 considered here, the student being referred to the general chapter on Tumors. 
 
 For clinical purposes mammary tumors may be classed under the following 
 heads : 
 
 1. Those tumors resembling fully-formed connective tissue and 
 derived from it. Tumors belonging to this class are 7ion-viaI/</iiaut, and com- 
 prise the fibromata (fibrous tumors), the lipomata (fatty tumors), the myxomata 
 (mucous tumors), and the chondromata (cartilaginous tumors). 
 
 2. Those tumors resembling embryonic or transitional connective tis- 
 sue, and derived from the connective tissue of the gland : these neoplasms 
 are malignant. To this class the term sarcoma is applied. 
 
 3. Those tumors which more or less closely resemble glandular tissue 
 and are derived from the glandular epithelium. They are non-malignant^ 
 except when occurring in connection with sarcomatous elements. This class 
 comprises adenoma pure, or adenomatous tissue combined with fibrous tissue 
 (adeno-fibroma), with cysts (adeno-cystoma), or with atypical cells of the 
 connective-tissue type, round, spindle, or giant cells (adeno-sarcoma). 
 
 4. Those tumors composed of atypical epithelial cells, atypically re- 
 lated to the fibrous stroma of the gland. These tumors are malignant. The 
 term applied to this class is carcinoma. 
 
 67 
 
1058 AX ami: UK AX TEXT-IKX )K OF SURGERY. 
 
 5. Those tumors resulting from hypertrophy of such higlily specialized 
 tissues as blood-vessels, etc. They are non-malupinnt. This class emhraces 
 angeioma (vascular tumor) and neuroma (nervous tumor). 
 
 About 83 per cent, of all mammary tumors are carcinomata, ■while the remain- 
 ing 17 per cent, are sarcomata, adenomata — including its varieties — and cysts. 
 
 Adenoma. — In its pure form this is one of the rarest of mannnary neo- 
 plasms. Closely resembling the mammary tissue in the pregnant woman, the 
 epithelial elements are arranged in a purposeless -way, as it -were, a confused 
 mass of acini and ducts being seen microscopically. The cubical ejiithelial 
 elements may line "with a single or double layer the newly-formed acini, but 
 are more apt entirely to till tlieir lumen, only a mass of cells Ijcing discernible; 
 but. unlike carcinoma — Avliich presents a very similar picture — the cells are 
 separated from the surrounding connective tissue by a distinct basement mem- 
 brane; i. e. they do not infiltrate the connective tissue. 
 
 Diagnosis. — This must depend upon the detection of a tumor in the breast 
 of a -woman — usually married and prolific — from thirty to thirty-five years 
 of age: of slow growth, re([uiring many years to roach a size proiluctive of 
 annoyance ; movable, and bosselated on the surface. Neither retraction of the 
 nipple nor involvement of the axillary glands occurs, but where any portion 
 of the mamma is left there is sometimes a tendency to local " reproduc- 
 tion." 
 
 Treatment. — Free excision of the tumor or occasionally removal of the 
 entire breast. 
 
 Adeno-fibroma. — These are the commonest of all the benign mam- 
 mary neoplasms. They consist of bypertrophied connective tissue, mingled 
 with small portions of normal or altered glandular tissue. They occur as 
 freely-movable circumscribed, rounded, slightly nodular, usually painless 
 growths, about adolescence or at least under twenty years of age. When 
 no secondary cystic changes have taken place, they are firm and elas- 
 tic : when they have undergone cystic degeneration, over the more prom- 
 inent bosses they feel soft or even fluctuating, while dense elsewhere. Pain 
 is sometimes complained of by neurotic individuals. These neoplasms are 
 completely encapsulated, and their cut surfaces are dry, white, opaque, com- 
 pact, creak under the knife, and in some specimens the bundles of fibrous 
 tissue are concentrically disposed around numerous central ])oints which 
 project above the surface. In slowly-formed tumors dense adult fibrous tissue 
 is the main constituent : in more rapidly developing neoplasms interlacing 
 bands of young, wavy connective tissue form the bulk of the tumor, 
 producing a more succulent growth, which is glistening white or even 
 rosaceous on section. In those of most rapid growth abundant cellular 
 elements are present. Inflammation or supjmration of fibromata is very 
 rare, and in consequence fungous ])rotrusion through ulceration of the skin is 
 almost unheard of. Should this occur, the skin immediately around the open- 
 ing is normal, non-adherent, and of course not infiltrated. Cystic degeneration 
 from fatty or mucous change of the epithelium or myxomatous degeneration 
 of the interacinous tissue takes place in about 4 per cent, of all cases, and 
 even blood- or extravasation-cysts have been observed, while telangiectatic 
 change occasionally attacks the cystic variety, indicated in one-half the cases 
 by a bloody discharge from the nipple : such tumors are of rajtid growth. 
 
 Diagnosis. — Sometimes a small solitary adeno-fibroma so closely resem- 
 bles a cyst that only a resort to the hypodermatic syringe can decide the 
 point. The age of the patient, and the defined, circumscribed outline of the 
 tumor, serve to distinoruish it from both carcinoma and chronic lobular inflam- 
 
i)f.sEAs/:s .i.\/> i.\jrini:s or riii: r.nr.Asr. l()o9 
 
 Illation, while the ahsence of adhcsidii to the skin and ilccper parts, with the 
 iVeedom of the axilhirv jrhmds from involvement, still further distinnfuishes it 
 from carcinoma. Wliile usually siiiL'le, they are occasionally multiple. 
 
 Prognosis. — If removed they do not recur. 
 
 Adkxo-cystoma. — Since any adenonui consists of acini and ducts pos- 
 sessino; no normal outlet, cysts form either from accumulation of their secre- 
 tion or from l)ein<^ drawn asunder by the contraction of the periacinous and 
 pericanalicular tissue of the new o:i'owth. This condition is apt to obtain when 
 there is primarily but little hyperplasia of the connective-tissue elements of the 
 neoplasm, which would of course result in the hard form or ordinary adeno- 
 fibroma described in the last section, often called, from its excess of fibrous 
 tissue, a fibroma. The cysts are lined with round, cubical, or cylindrical 
 glandular epithelium. In many instances the pericanalicular interstitial tissue 
 projects as ingrowths into the cavities of the cysts — which they sometimes com- 
 pletely fill — forming many-shaped papillary, cauliflower, dendritic, or perhaps 
 pedunculated masses covered by epithelium. This variety of adenoma is called 
 "the proliferous mammary cyst," " endocanalicular " or " intracanalicular 
 mammary tumor," and comprises 86 per cent, of the cystic tumors of the 
 breast. Upon section they present a Avhite or cream-colored, lobulated surface, 
 with numerous cysts, some small, some large — some have been reported even 
 containing a quart — but usually of medium size, filled with a serous, mucous, 
 lactescent fluid, or one variously tinted by blood, rendering it brownish or san- 
 guinolent. A distinct capsule envelops the growth, which, it has been alleged, 
 is always attached by a pedicle to the gland tissue, and never infiltrates it. 
 
 Diagnosis. — This tumor is distinguished from an adeno-fibroma by occur- 
 ring later in life, from thirty to thirty-five years of age, and from carcinoma 
 by the fact that the latter, as a rule, appears later. While it is bard, it is mov- 
 able, somewhat nodulated, of slow growth, and in advanced cases from the large 
 cysts it is of unequal consistence, giving here and there, over the most promi- 
 nent bosses, a sensation of elasticity, perhaps of indistinct fluctuation. Some- 
 times, after growing slowly for many years, it will suddenly enlarge, when it 
 may produce ulceration of the skin, a fungating, bleeding mass protruding, 
 but the skin-opening is supple, wuth sharp-cut edges — hence not infiltrated with 
 the growth — and the axillary glands are not involved. Possibly from the 
 inflammation the glands may be, in rare instances, somewhat enlarged and 
 tender in these ulcerating cases, but they never present the characteristic 
 steady increase in size, with matting together of all the axillary tissues, termi- 
 nating in oedema of the arm from pressure on the veins. 
 
 Prognosis. — Visceral involvement never occurs, nor does local recurrence 
 take place after thorough removal. 
 
 Adeno-sarcoma. — In the preceding forms of adenoma the periacinous 
 and peritubular connective tissue, becoming hyperplastic, develops into a 
 permanent tissue more or less perfectly approximating the type of normal 
 fibrous tissue, but in adeno-sarcoma the proliferating elements tend to form, 
 not adult, but some variety of embryonic connective tissue. Thus it may con- 
 sist chiefly of small spindle-cells, mingled with a varying amount of mature 
 connective tissue, of large spindle-cells, of imperfectly organized fibrous tissue 
 infiltrated by numerous round cells, of stellate and fiber cells with anastomos- 
 ing processes, between which lies a mucoid substance ; or, finally, all these 
 varieties may be found in the same tumor, each in a different portion of the 
 growth or variously combined : scattered cysts are also frequently found. 
 Growths of this nature are believed to remain fjuiescent for long periods when 
 commencing in early life, but it is more probable in such cases that an origin- 
 
I0(j0 .i.v AMi:in(AX THXT-nook' OF .si'/i(.'/':/n'. 
 
 ally i)eiii<i:n growtli has luulerjioiie a secondary malignant (sarcomatous) cliange. 
 Originating in middle life, adeno-sarcomata always grow rapidly. 
 
 Diagnosis. — A tumor connnoncing in the breast of a woman from thirty 
 to forty years of age (perhaps older), covered by non-adherent skin, which is 
 heavy, movable, slightly nodulated, elastic, but of unequal consistence at its 
 more prominent points, and which grows with great rapidity without involve- 
 ment of the axillary glands, is probably an adeno-sarcoma : moreover, a tumoi 
 which has jiresented for years the symptoms given for adeno-cystoma, which 
 suddenly begins to enlarge, provided the enlargement is not due to one or more 
 cysts becoming distended, is probably a benign adeno-cystoma undergoing sar- 
 comatous change. 
 
 Prognosis. — The microscope alone can determine the degree of malignancy 
 of any given growth, the appearances varying from those of a tumor essentially 
 benign up to those characterizing one whose interacinous tissue is extensively 
 infiltrated with round cells or composed chiefly of spindle-cells, when the growth 
 is practically a round- or spindle-celled sarcoma, which is liable to recur both 
 locally and in distant parts. 
 
 Sarcoma. — For the specific histological appearances of the solid sarcomata 
 the reader is referred to the section on Tumors, p. 202. The round-, spindle-, 
 and giant-celled forms all occur, mingled with more or less adenomatous tissue, 
 but the large spindle-celled is by far the commonest. Sarcomata are liable to 
 become inflamed or to suppurate, and may undergo myxomatous, fatty, cystoid, 
 calcareous, and telangiectatic metamorphoses, the two former being the most 
 frequent cause of those large interstitial hemorrhages of such common occur- 
 rence in mammary sarcomata, sometimes converting them in Avhole or in part 
 into a grumous, semifluid material. More than half of all mammary sarco- 
 mata undergo cystic changes, and in about one case in seven discharge from 
 the nipple takes place. Sarcomata usually appear between the ages of twenty 
 and thirty-five years — one has been reported so early as the eighteenth year — 
 and when of very rapid growth there may be considerable local elevation of 
 temperature. They usually thrust aside, compress, and cause atrophy of the 
 gland, but in rare instances are only attached to it, and then merely by a ped- 
 icle. Their usual position is beneath or near the nipple or in the uj)per inner 
 segment of the gland. 
 
 Diagnosis. — Possessing a distinct capsule, they form rounded or ovoidal, 
 somewhat lobulated, usually single, firm, or soft and elastic, rapidly-growing 
 tumors. They are in consistence sometimes so difl^luent that they feel fluc- 
 tuant, so that surgeons have incised them, believing them to be chronic 
 abscesses. The veins of the overlying skin enlarge early, but the tumor 
 does not become adherent to it nor to the contiguous tissues (Plate XXIII, 
 Fig. 1). Later there is a distinct tendency to ulceration, but this is due to 
 inflammation and gangrene from pressure rather than to infiltration with 
 sarcomatous elements, and, as a rule, the surrounding skin is at first neither 
 discolored nor attached to the fungous protrusion which almost invariably 
 forms after the skin has given way. The ulcer is apt to be circular, and some- 
 times several exist, with intervening bridges of sound skin. The discharge 
 from the fungus is fetid and bloody, but may be purulent from inflammation. 
 
 Sarcomata usually develop with great rapidity, and the viscera, especially 
 the lungs, may become involved early, but the axillary glands do not enlarge 
 except in very rare instances, and then only from inflammatory irritation, not 
 from the lodgment of sarcomatous elements. The distinction between solid 
 and cystic sarcomata may perhaps be made by noting that the latter appear 
 earlier — before the thirty-third year ; that they are more apt to be located 
 
/>/s/:as/:.^ a.\/> i\./rnii:s or riii: r.in:Asr. lOGl 
 
 ne<ar tlie nipple; that tlicy ^row mow rapidly: that they suddenly increase 
 after (luicsconce or slow j^rowth lor Ioiil' periods; that they are more lobidated 
 and their consistence is more une((nal ; (hat disehari^e from the nijiple is «(iiite 
 fre(|uent; and that pain, usually harassin<:;, is e.\])erienced in more than three- 
 fourths of all cases. They must be differentiated from carcinoma by the earlier 
 age at which they occur, by their mobility, by their uneijual density, by the 
 absence of retraction of the nipple, of invasion of the skin, of induration of 
 the lymphatic glands, and of fixation to the chest-wall, and, when ulceration 
 exists, by the fact that in sarcoma fungous protrusion is apt to occur ii'lthont 
 infiltration of tlic skin, the characteristic thickened, infiltrated, everted mar- 
 gins of the carcinomatous ulcer being absent. 
 
 Prognosis. — Many of the sarcomata, especially those of the round-celled 
 form, which possess but little intercellular substance, are exceedingly malig- 
 nant. Both local recurrence and visceral imjdication are the rule, the former 
 being the commoner because the disease, although apj)arcntly remaining encap- 
 sulated, progresses along the adventitia of the blood-vessels external to the 
 capsule, which serve as points of departure for both the local recurrence and 
 the visceral contamination. 
 
 Treatment of Adenoma, Adeno-fibromata, and Sarcomata. — 
 Grasping the mass firndy so as to render the skin tense, an incision should 
 be made down to and through the capsule of an adenoma or a fibroma, 
 when it can readily be enucleated, requiring perhaps a few touches of the knife. 
 Adeno-cystomata, when involving much of the gland, require amputation 
 of the entire breast ; and the same treatment is indicated for cases of cysto- 
 sarcomata and pure sarcomata, with free removal of the superjacent skin. 
 
 Carcinoma. — Predisposing and Exciting Causes. — Heredity has 
 some but not a great influence, but traumatism and such lowering in grade and 
 vitality of the tissues as results from the chronic thickening and induration 
 left after acute mammitis or abscess seem not uncommonly to stand in causa- 
 tive relation to carcinoma. As has already been pointed out, the chronic 
 dermatitis of the nipple called Paget's disease sometimes precedes and un- 
 questionably favors the development of carcinoma. Any slight, prolonged 
 irritation, increasing the vascular supply to the epithelial tissues in a gland 
 which is senescent or old — which for the mamma means from thirty-five to 
 fifty years — may excite the disease in one predisposed to it, probably by some 
 inherited peculiarity of tissue. As a rule, the patient when attacked is in 
 good or even robust health. 
 
 The pathological anatomy of carcinoma has been so fully described else- 
 where that only a few general remarks will be made here. Carcinoma is an 
 atypical epithelial growth consisting of a stroma whose intercommunicating 
 spaces are occupied by polymorphous, spherical, or cubical epithelial cells, no 
 genuine intercellular cement substance being apparently present, and the inter- 
 communicating columns of cells — seen in cross-section they resemble alveoli, 
 and are hence so called — are not surrounded by a basement membrane, but 
 are in direct relation with the fibrous stroma, thus differing from adenoma, in 
 which a limiting membrane encloses the cell-masses, and which moreover are 
 often not solid, but possess a central space, exactly simulating a normal acinus. 
 
 Varieties of Carcinoma. — According to the relative proportions of the 
 fibrous and the epithelial elements, a given carcinoma is classed as hard or soft. 
 At one extreme is the fibrous, hard, or scirrhous carcinoma, in which the 
 fibrous tissue is in excess; at the other, the epithelial elements form the bulk 
 of the tumor, resulting in the soft, cellular, medullary, or encephaloid 
 carcinoma. 
 
IDC-J 
 
 ,LV AMi:i!icAy 'j'j:xr-ii<K)K o/- s (/:(.' /•j/n\ 
 
 Course, Symptoms, and Termination of Hard Carcinoma. — 
 
 Scirrlius ioniis an incuuliii-, nodulated, .^omculiat rounded, slony-liard, lieavy 
 mass, inseparable from the glandular tissue, jiossessing no defined outline, but 
 gradually merging into tlie healthy niannuary tissue, "with whieh it I'roely 
 moves (JPlate XXIII, Fig. 2). Soon it adheres to the skin, Avhieh becomes 
 dimpled, and later to the pectoral muscle ; thus at first being partially, 
 then immovably, fixed to the chest-wall. At the outset the tumor grows 
 slowly : the nipple gradually becomes retracted when the tumor is primarily 
 located close to or i)enoath the nipple, or when it spreads to this neigh- 
 borhood ; but the growth never attains a great size, as does the soft car- 
 cinoma. As a rule, the upper, outer (axilhiry) segment is attacked, but 
 scirrhus may originate close to the nipple or to the inner side of the 
 breast. Studying in detail cei'tain symptouis, it will be seen that while 
 the skin may adhere to subjacent inHamed tissues or benign growths, it 
 is then glazed, thinned, and stretched by mechanical pressure ; but in 
 carcinoma the conditions are diff'eront, for the fibrous septa, connecting the 
 skin and mammary fascia being infiltrated with young cells, new fibrous tissue 
 forms, which, contracting, pulls in isolated imtJiinncd portions of normal skin, 
 producing the characteristic delicately-j)itted "pig-skin" appearance. 
 
 Betraction of the nipple due to carcinoma differs from that seen occasion- 
 ally in benign growths, in that the nipple is actually di-awn in, and not buried, 
 by the projection of the tumor-mass ; and by pressing this back in the case of an 
 innocent growth, the nipple will be seen to be normal, having only been buried, 
 not retracted. Genuine retraction of the nipple results from the contraction 
 of the milk-ducts, the walls of which have been infiltrated with young cells 
 which have developed into fibrous tissue (Fig. 428), In proportion to the 
 
 propinquity of the growth to the 
 nipple is its retraction : a growth 
 occupying only the upper outer seg- 
 ment of the gland will not produce 
 this symptom. When present it 
 is valuable corroborative evidence 
 of the existence of a hard carci- 
 noma, but its absence under some 
 circumstances proves nothing. Very 
 rarely a small amount of thin dis- 
 charge exudes from the nipple when the growth is near it, but tliis discharge 
 differs from that characteristic of some forms of cystic adenomata. 
 
 Pain, usually believed to be characteristic of carcinoma, is al)sent in the 
 earlier stages, and becomes prominent only when the tumor is of some size. 
 The diagnostic significance of this symptom, which is relied upon by the 
 public and too often by the ]U'ofession until the best chance for cure has been 
 lost, cannot be too earnestly combated. Sometimes slight stinging pains 
 attract attention to the growth ; but it is more often accidentally discovered : 
 it is not tender. When fixed to the chest-wall and the axillary nerves are 
 compressed by the secondary lymphatic glandular tumors, the jiain is severe 
 and almost ceaseless. Its character is lancinating, darting, or cutting. 
 
 Cachexia is usually only present when ulceration has taken place and when 
 mental anxiety, prolonged pain, or profuse discharge has exhausted the patient; 
 but in nearly every instance the patient is in robust health when first attacked. 
 Moreover, if under the former circumstances the tumor is removed, and with 
 it worry, pain, and discharge, the patient promptly regains color and ffesli. 
 Age is an important point, since most hard carcinomata appear between the 
 
 Fto. 42.".. 
 
 Retraclion of the Nipple in Mammary Carcinoma 
 
 (Bryant). 
 
TUMORS OF rm: breast. Plate XXIII. 
 
 1. Sarcoma of the breast. '1. Scirrhus of the breast. 
 
DISEASES AXD IXJURTES OF THE BREAST. 1003 
 
 ages of forty and fifty years. A very few cases have been reported before 
 the thirtieth year, yet this is a rarity. A distinct percentage are under 
 thirty years of age. In one instance, now first reported, the tumor was de- 
 tected hite during the nineteentli year, the microscopic diagnosis being made 
 both of the ))riinary an<l axilhiry growths, after operation, (hiring tlie latter 
 half of the twenty-third year. Hence any mammary tumor presenting dis- 
 tinct symptoms of local malignancy with involvement of the lymphatic 
 glands must be considered malignant, despite the youth of the patient. 
 
 Scirrhus, left to itself, will involve the whole mamma, converting it, with 
 the overlying skin and subjacent muscular parietes of the chest, into one nod- 
 ular, stony-hard mass with retracted, buried nipple. The cancer-cells find 
 entrance into the perivascular lymph-spaces of the cutaneous blood-vessels, 
 forming; here and there smaller or larger nodules. When this condition 
 involves a large portion of the chest-wall, it is called cancer " ew cuirasse." 
 Owing to the contraction of the widely-spread and rigid neoplasm, the movements 
 of the chest are sometimes sufficiently embarrassed to produce distinct difficulty 
 in breathing. Usually the skin over the afi"ected area is decidedly reddened. 
 Ulceration may occur (Plate XXIY, Fig. 1), either superficial or deep, more 
 commonly the latter, producing deep, crater-like cavities with hard, tuberous, 
 irregular, and everted margins, the base being formed of unhealthy, sloughing 
 granulations or cancer-tissue covered with thin, ichorous, sanious, offensive dis- 
 charge : no fungus ever forms. Severe and repeated hemorrhages, readily 
 controllable, however, by pressure, are not uncommon. Early in the disease, 
 although often incapable of detection by the touch, the axillary lymphatic glands 
 become involved in fully 85 per cent, of cases supposed before operation to be 
 free from this complication : when the axillary fascia has been divided, the 
 glands are found to be carcinomatous. Indeed, such a condition will be 
 present in practically every case where the primary disease has existed even 
 so short a time as six months. These, forming masses behind and in 
 front of the brachial plexus and vessels, finally fuse together, steadily con- 
 tracting until the return circulation is markedly interfered with, as evinced by 
 oedema of the Avhole upper extremity, and most distressing neuralgic pain is pro- 
 duced. From the axillary glands the disease spreads to the supraclavicular 
 glands. By recalling the other routes by which the lymph is normally returned, 
 as described on page 1050, the surgeon will recognize that the anterior medias- 
 tinal glands, the pleura, and the viscera may all be involved, even although 
 secondary disease of the axillary lymphatics does not occur. Plate XXIV, 
 Fig. 2, shows the appearances in local recurrence after extirpation. After the 
 lymphatic glands the viscera become diseased, in order of frequency as fol- 
 lows : liver, lungs, pleura, and bones. Cysts, usually from retention produced 
 by obstruction of acini or ducts, are occasionally observed. 
 
 The Atrophic or Withering Scirrhus, from the fatty degeneration 
 and absorption of the epithelial cells (Fig. 424) — perhaps induced by the un- 
 usually abundant development of the fibrous stroma contracting so as to diminish 
 the blood-supply to the cells — leaves little more than a mass of fibrous tissue, 
 with here and there a few cells surrounded by granular debris. Although the 
 tumor is slower in its progress and rather diminishes in size than increases, 
 the malignancy is not thereby lost, the ultimate result being the same. 
 
 Diagnosis. — This depends upon the detection of a tumor most frequently 
 in the upper, outer seguientof the breastof a woman usually over forty yearsold, 
 heavy, stony-hard, Avithout definite outlines, covered by adherent '*pig-skiu " 
 intecrument, at first moving icitli the breast, and later adherent to the pectora- 
 lis major muscle, with enlargement of the axillary glands and retraction of the 
 
1()(]4 
 
 AN AJfK/i'/CAX TKX'f- /!()() h' OF SUIiilFJiy. 
 
 Fk;. 424. 
 
 nipple as the growth reaches its neigliborliood : if originating beneath or near 
 the nipple, retraction of that organ will be an early sign ; if the neoplasm is 
 examined when only one border of the gland is involved, this sym])tom will 
 be entirely absent. From sarcoma it is to be distinguished, in addition to 
 the difference in feel and absence of mobility, by the adherent and jx'ciiliar- 
 looking skin and the glandular involvement. 
 
 Soft Carcinoma. — This is a disease of earlier life, runs a more ra])id 
 course, and its capability of contaminating the system is much more pro- 
 nounced than that of scirrhus. Usually more deep-seated than scirrhus, it 
 forms at the outset a rounded, nodular, movable tumor, at ])oints elastic or 
 pseudo-Huctuant, growing with such rapidity that it may sometimes reach the 
 size of a child's head in a couple of months. Soon the skin adheres, reddens, 
 becomes glazed, and. the ap))earances closely simulating those of abscess, the 
 
 integument gives way by ulceration. By 
 this process and sloughing of masses of the 
 tumor large excavated sores are formed. 
 Tain is a late symptom, but cachexia sets 
 in early, as well as lymphatic and vis- 
 ceral metastases. Cysts are also formed 
 occasionally, as described when speaking 
 of scirrhus, Avhile abscesses have been 
 observed, especially in rapidly-growing 
 tumors developing during pregnancy. Col- 
 loid change likewise very rarely attacks 
 some of the firmer forms of soft carcinoma. 
 Diagnosis. — The resemblance to 
 round-celled sarcoma is great, the cardi- 
 nal point of distinction being that sar- 
 coma is an encapsulated, and therefore a 
 distinctly circumscribed growth, Avhile 
 soft carcinoma is a non-circumscribed, 
 infiltrating neoplasm. The rapidity with 
 which it attains a great size, the relative 
 softness of the mass, the late a])pearance 
 of pain, and the early constitutional in- 
 volvement distinguish it from hard car- 
 cinoma. Colloid carcinoma cannot be 
 diagnosticated before removal, but is of slow growth, and glandular infection 
 occurs late. 
 
 Prognosis. — Without operation carcinoma of both kinds terminates by 
 death ; the attending operation will be referred to later. 
 
 The average duration of life in the fibrous form is about thirty months, in 
 the soft about twelve months, although life may be greatly prolonged in the 
 former, while it may 'be much curtailed in the latter, especially if the disease 
 commences during pregnancy, when a few weeks sometimes comprise the whole 
 course of the affection. 
 
 Treatment. — Experience having proved that no internal remedy is of 
 the slightest benefit, the question resolves itself into allowing tlie disease to 
 pursue its course, relieving pain and making the patient as comfortable as pos- 
 sible, — the so-called palliative method; or resorting to the radical plan, mean- 
 ing by this the prompt extirpation of all the diseased tissues. • 
 
 Palliative Treatment. — This is often necessitated by the disease hav- 
 ing reached so advanced a stage when first seen that all opportunity for the 
 
 Atr(i|iliif Scirrhus (original). 
 
TUMORS OF THE BREAST. 
 
 Plate XXIV. 
 
J > IS i: ASKS AX/} i.\j( inKs or the breast. 1065 
 
 succes'?t"iil employment of tlie radical method has been lost. The parts must 
 be put to rest by carrying the arm in a sling ; corsets and tight clothing must 
 be interdicted-, but at the same time the diseased organ must be carefully sup- 
 ported. Local apj)lications of extract of belladonna with opium or conium at 
 first give relief, but the tVce use of mor|)hia with small doses of atropia soon 
 becomes requisite. The constant application of acetate of lead in the propor- 
 tion of grs. XV @ 3j will sometimes aflbrd relief when a rapidly-growing tumor 
 becomes reddened, hot, and tense, or ice-bags may be employed. When ulcera- 
 tion has taken place, deodorizing, unirritating dressings should be employed, 
 such as chloral, grs. v (a) 5J of vaseline, balsam of Peru, etc. The use of Es- 
 march's powder under these circumstances will often relieve the pain, check the 
 rapidity of growth, and decidedly diminish fetor. Its composition is arsenious 
 acid and muriate of morphia, each 0.25 part, powdered gum arable 12.0 parts. 
 Half a teaspoonful of this should be daily sprinkled over the surface of the 
 sore until a yellowish crust forms, which after separation leaves a healthy 
 granulating surface : this powder can be repeated when necessary. Hemor- 
 rhage can be stopped by pressure or by the local application of styptic cotton. 
 
 Operative Treatment. — The first question to be answered is. Can the 
 disease be totally eradicated ? If not, no operation should be attempted, unless 
 to remove a foul sore purely as a palliative measure. 
 
 While each case must be a rule for itself, the following conditions are posi- 
 tive contraindications to a radical operation: great enlargement of the supra- 
 clavicular glands, cancer en cuirasse, such a dissemination of small shot-like 
 bodies in the skin that a Avide margin of healthy skin cannot be left outside 
 of the smallest nodule, or such extensive axillary involvement that the thor- 
 ough clearing out of that space will be impossible. Again, the liver, lungs, 
 and other viscera should be carefully examined to eliminate the probability of 
 any metastases, because the discovery of any such is an absolute bar to opera- 
 tion. To reiterate, unless all local and glandular disease can be thoroughly 
 eradicated and presumptive proof exists that the viscera are free, no operation 
 should be done. Moi'eover, in very advanced life the disease often progresses 
 so slowly that the probabilities of prolonged life are sometimes greater without 
 than with operation. 
 
 When the skin is merely adherent and the tumor freely movable on the 
 deeper parts, with simple enlargement of the axillary glands, the surgeon should 
 urge the promptest and freest possible operative measures. It is the surgeon's 
 duty to endeavor to educate the public up to the recognition of the necessity for 
 early operation before extensive local and glandular infection has taken place. 
 
 The results of early radical operations performed by Konig, Kiister, Gross, 
 Banks, Estlander, and Gussenbauer show from 16.7 per cent, to 22.5 yier 
 cent, of permanent cures, the average being 20.08 per cent. According to 
 Curtis, Dennis, Weir, and Bull, the average of permanent cures is 20.87 
 per cent. 
 
 In Halsted's and Cheyne's cases somewhat over 50 per cent, have passed 
 the three-year limit without recurrence ; Mr. Cheyne's cases (1899) number- 
 ing 99 and covering a period of nine years. Similar good results are ex- 
 pected by the best operators, partly from the more thorough operations which 
 are now done, and also because both patients and the profession are learn iiig 
 the equally important fact that early operations, before systemic involve- 
 ment has occurred, are much more likely to yield favorable results than later 
 operations. 
 
 The mortality from the operation, which is a much more severe procedure 
 than was formerly adopted, has fallen, according to Williams, from 17.35 to 
 
10«() AN AMKIilVAX TEXT-BOOK OF SllHiKUY. 
 
 9.4 |>or cent. This latter percentat^e uiKiuestionably represents a much higher 
 ileath-rate than prevails in this country, which is only aliout "> per cent., and 
 in 4(J4 cases reported hy Jiidl. Dennis, Weir, iialsted, and Keen is onl}- O.iSG 
 per cent. Williams conclusively shows that where a cure is not effected life 
 is prolonged, those operated upon living upon an average 60.3 months, as 
 compared with those not operated upon, who survive for only 44.8 months. 
 From the data given by Iialsted, recurrence in the practice of Czerny, 
 Fischer, Gussenbauer, Kiinig. Liicke. and A'olkmann reaches 02.55 per cent., 
 but in his own practice, with a still bolder use of the knife, only 3 recurrences 
 were observed in 46 cases. 
 
 Method of Operating. — While no rules can be given applicable to every 
 case, in general every particle of diseased tissue must be removed, no regard 
 being paid to retaining . enough skin to cover in the Avound if this essential 
 indicatit)n will be thereby interfered with. The knife should sweep wide of 
 the apparent limit of infiltrated skin, making, if necessary, a cut encircling 
 the whole base of the gland. If it appears right to save any of the covering 
 skin, the outline of the incisions should include an ellipse embracing the cen- 
 tral portions of the growth, the long axis of the ellipse extending from just 
 below the anterior axillary fold downward, forw ard, and inward. The incisions 
 should be boldly made through the skin and paramammary fat down to the 
 pectoral aponeurosis, and the gland rapidly dissected oft' from below upward, 
 leaving the attachments toward the axilla uncut. Let an assistant compress 
 each spurting vessel by the finger-tips until hemostatic forceps can be applied. 
 The pectoral fiiscia, and any remaining portions of infiltrated muscles or out- 
 lying gland tissue, must be freely removed. 
 
 A complex network of lymphatic vessels lies on the outer surface of the 
 muscles and the upper surface of the fascijie. These vessels intercommuni- 
 cate, and the lymph-current is from the muscle toward the fascia, as demon- 
 strated by injections. The presence of these lymphatic networks shows the 
 necessity of removing the pectoral fascia with the underlying fat in all opera- 
 tions for carcinoma, and also explains the possibility of a carcinoma being 
 actually adherent to tlie fascia, while the muscle itself may remain free. 
 
 The axilla is to be opened by an incision parallel to and one inch below 
 the anterior axillary fold, and this space cleared of aU glands (Figs. 198. 200), 
 h'mphatic vessels, and fat by dissection. Careful use of the knife, with double 
 ligature of any tissues that may contain large vessels before dividing them — even 
 to the axillary vein if endangered — will render this a safe procedure. It is safer 
 to clear the vein first, and then proceed withw hat further dissection may be requi- 
 site. Having determined by careful search both in front of and behind the axil- 
 lary vessels and nerves that every gland, however minute, has been removed, the 
 skin should be freely loosened by the scalpel handle or its edge around the wound 
 until the margins can be approximated. To secure this without tension, either 
 completely or partially, relaxation buttons and sutures are sometimes requisite ; 
 these can be removed from the fifth to the seventh day. Finally, if thought 
 necessary, provide for drainage bypassing a perforated glass or rubber drain- 
 age-tube through the posterior axillary fold by an especial incision, thus drain- 
 ing the most dependent portion of the wound. The skin should then be 
 accurately apposed by superficial sutures, either interrupted or continuous. 
 If relaxation sutures will not enable the surgeon to coaptate thcAvhole wound, 
 the angles should be closed, leaving the central portion to heal by granula- 
 tion. Skin-grafting may be immediately adopted, provided the operation have 
 been done aseptically — /. c. without the use of antiseptics : or after granula- 
 tions have formed this procedure may be employed to close the whole gap 
 
DISEASES AXn I X.I TR FES OE THE BREAST. 
 
 1067 
 
 at one sittinji;. Aseptic sheets or towels should surround the field of opera- 
 tion, and when a prolon<;ed axillary dissection is re([uisite the hreast-wound 
 should be temporarily covere(l with aseptic fjauze to prevent shock and per- 
 haps ])neuraonia : antiseptic sponges or niojis of aseptic ^;iu/e should also ]>e 
 employed, avoiding as far as possible all wetting of tho patient. The ordinary 
 aseptic preliminaries and some one of the forms of aseptic dressings must be 
 em])loYed, and the arm confined to the side by a snugly-pinned binder. Shock, 
 wiiich is often very pronounced, must be combated by appropriate measures. 
 The mortality by this method of operating, although small considering the 
 magnitude of the operation, is slightly higher than by the older plan ; but 
 more cures will result, hence more lives will in the end be saved, 
 
 Halsted has insisted that all the pectoralis major muscle, excepting 
 possibly its clavicular portion, should be excised with the breast in one 
 
 Fro. 425. 
 
 Halsted's Operation for Removal of the Breast. 
 
 piece, including the axillary contents. Thus : Carry the incisions at once 
 through the fat, fully reflect the triangular skin-flap, and, dividing the 
 costal insertions of the pectoralis major, split the muscle between its costo- 
 sternal and clavicular portions up to about opposite the scalene tubercle on 
 the first rib ; divide the clavicular portions of the muscle with the overlying 
 skin close up to the clavicle, exposing the apex of the axilla ; draw upward 
 the cut clavicular portion of the muscle with a broad, sharp retractor and dis- 
 sect all loose tissue from it ; split the muscle out to the humerus, and cut it 
 through close to its attachment, making tension by means of traction upon the 
 loosened breast muscles, etc. ; strip everything away from the chest-wall, 
 including, when possible, the sheath of the pectoralis minor, clearing the exter- 
 nal border of the muscle, cut it transversely through its middle, dividing it 
 as far externally as possible, and then reflecting inward the cellular tissue 
 overlying the coracoid extremity of this muscle, which then draw upward with 
 a broad, sharp retractor ; dissect out and carefully ligate close to the axillary 
 trunks all the small vessels, chiefly veins, lying beneath and near to the mus- 
 cular insertion ; complete the extirpation of the axillary contents by dissecting 
 the vein, artery, and nerves clean of any loose tissue ; making traction upward 
 and outward, divide with the knife the fascia which binds the axillary fat to 
 the chest-wall; an assistant renders the triangular skin-flaps tense; dissect 
 the tissues away from the subscapular, teres major, and latissimus dorsi mus- 
 
1()<)8 
 
 j.v AMi.iucAX ri:.\i'-i>()()h oi SI i:(n:in\ 
 
 c-lcs. c'Xposiii;^ ami srciirin<j; before dividing tlic subscapular vessels, but spar- 
 iii;j: the suliscapnlnr nerves if possible; liaviiiL' cleared tliese. turn the mass 
 inward ami remove it by a cut along tlie l)ase of the triangle; apjtruximate 
 the wound by a buried purse-string suture, including only the base of the tri- 
 angular llaj), whose api'X is to )«• shifted lu a lower position, so as to secure a 
 loose lining for the axilla, maintaining contact between tlie flap and subjacent 
 tissues by carefully-applied dressings. Prolong the skin incision ujtward 
 over tlie clavicle and clear the sujira-clavicular s])ace of all eidarged lymjih- 
 atic glands, carefully avoiding the thoracic duct when operating upon the 
 left side. No axillary drain need be emi)loyed. the uncovered portion of 
 wound healing either by so-calleil organization of blood-dot or by granula- 
 tion. Little or no disability is said to be noticeable after this 0]>eration. and 
 what results comes from loss of skin, not loss of niuscle. and can sometimes 
 be rectified by skin-grafting. 
 
 Cysts. — The distinction must be made between these and ci/stic tiiinorif — 
 I. e. cystic degenerations of solid tumors — since all forms of mammary tumors 
 may undergo such changes, even the carcinomata; but the adenomata and the 
 sarcomata more frequently show these alterations. 
 
 Hyd.\tid Cysts. — This is the only parasitic disease of the breast, and is 
 of very rare occurrence. Only one cyst ha,s ever been found at a time, but it 
 may contain from one to four daughter cysts. Hydatid cysts grow .slowly, 
 attain a moderate size, are ])ainless, forming smooth, round, firm, elastic, some- 
 times fluctuating, movable tumors, adherent neither to the skin nor to the 
 chest-wall. They generally occur in the upper outer segment of the gland, 
 but are never found near the nipple. From secondary changes the skin may 
 become adherent or the axillary glands enlarged. 
 
 Diagnosis. — From other forms of cysts it will generally be impossible to 
 distinguish a hydatid cyst e.xcept by the use of the exploring needle or trocar, 
 thereby evacuating the characteristic watery fluid and perhaps daughter cysts 
 and booklets. From a lacteal cyst it can readily be distinguished, because 
 the latter appears near the nipple during lactation^ and is prominent, and of 
 rapid formation. 
 
 Galactoceles, or jNIilk Cysts. — These are rare, result from obstruction 
 and dilatation of the milk-sinuses or ducts, and in consequence are situated 
 close to the nipple or beneath the areola. Nearly always single, they appear 
 suddenly during lactation, increase rapidly and form soft, fluctuating, painless 
 swellings, sometimes pendulous, covered with unchanged skin containing 
 enlarged veins : sometimes milk can be expressed from the nipple by pres- 
 
 Fk;. 426. 
 
 r - \\ 
 
 Cystic 1' 
 
 •il<l). 
 
 sure on the cysts. The contents mav be unchanged milk, like cream, or con- 
 sist of a semi-solid, cheesy material, in Avhich case the history generally shows; 
 
/>/s/:as/:s a\/> i.wii i;fi:s of the biikast. uxii* 
 
 that Huctuation was iiotccl at the l)('Lriiniiii<r, and that the tumor <;ra<liially be- 
 came solid to the feel, and smaller: sometimes it ean be indented by the finger. 
 
 Glandular Cysts. — While these may be single, they are commonly mul- 
 tiple, sometimes being disseminated throughout tho gland. They originate in 
 the smaller rather than in the larger ducts, and in the acini, from their partial 
 or complete occlusion, the former being rather common, when their sero-sangui- 
 nolent contents may escape quite copiously from the nipple. The cysts vary 
 in size from that of a pin's head to cavities Avhicli may contain many ounces, 
 but are oftenest about an inch in diameter. Their interior is covered with a 
 layer of epithelial cells, papillomatous ingrowths from which, at times, com- 
 pletely fill up the cyst-cavity. The contents may be yellowish serum or may 
 be variously tinted red or brown from admixture of old or more recent blood. 
 
 Diagnosis. — They are prone to occur in patients from thirty-five to fifty 
 years of age, are smooth in outline, and are somewhat elastic, but fluctuation 
 is rarely detectable, the cysts when tensely filled being often mistaken for solid 
 growths. This must be remembered in any case of suspected carcinoma when 
 neither involvement of the skin nor adhesion to the deeper parts has taken 
 place, since cysts occur at tlie same age, so that when in (loubt the exploring 
 needle or an incision should be resorted to before sacrificing the breast : the 
 above points, with the absence of lym]iliatic glandular involvement an<l the 
 slow, benign course, distinguish doubtful cases of cysts from malignant disease. 
 
 Cysts resulting from Degenerative Changes (Involution Cysts). — 
 These mostly occur in women past the menopause, and are usually numerous, 
 and so small as to escape detection. Occasionally one or more may enlarge, 
 causing much embarrassment in diagnosticating them from carcinoma. No 
 involvement of the skin, deeper structures, or lymphatics, however, is found : 
 they pursue a slow% benign course, and exploratory incision will determine 
 their nature. 
 
 Lymphatic Cysts. — Certain serous cysts w^hich do not differ materially in 
 their symptoms, course, and treatment from the glandular cysts have been 
 ascribed by Birkett and others to accumulation of fluid in the connective-tissue 
 lymph-spaces, and have therefore been termed "connective-tissue cysts" or 
 "•lymph-space cysts:" they are lined Avith endothelial plates instead of epi- 
 'helial cells, and resemble — except for their contents — adventitious bursas. 
 
 Diagnosis. — This has been sufficiently indicated in the description of 
 each variety. 
 
 Treatment. — When thin-walled, incision, with antiseptic packing after 
 wiping out the cavity with iodine tincture or deliquesced carbolic acid, will 
 usually suffice. If thick-walled or numerous, excision of the diseased portion 
 is indicated, and if the disseminated form exists, nothing short of amputation 
 is worth considerinof. 
 
 Contusions of the Breast. — When the relation which traumatism bears 
 to the development of tumors in the female breast is considered, it will be 
 recognized that these injuries should be carefully treated by rest, confining 
 the arm to the chest or in a sling, and by evaporating anodyne applications, 
 while any induration should be removed, if possible, by the frequent prolonged 
 use of equal parts of compound iodine and belladonna ointments or mercurial 
 ointment in combination with belladonna. 
 
 Wounds. — These require the treatment which Avould be adapted to similar 
 injuries of other glands, remembering that if suppuration occurs it mav extend 
 throughout the cellular framework of the gland, producing widespread damage, 
 so that antisepsis, proper drainage, and fixation of the mamma by properly 
 applied bandages, and of the arm by confining it to the chest, are advisable. 
 
](»70 AX AMKlilVAX TEXT- HOOK OF SURGERY. 
 
 DISEASES OF THE MALE BREAST. 
 
 Occasionally the <,'lan(l becomes iiypertkopiiikd and functionally active, 
 the result of frequent applications of a nursing child to the breast. 
 
 Inflammation of the Male Breast. — This may result from injury, with 
 any of the usual conseciuences of inflammation, but sometimes the glands at 
 puberty become enlarged and tender irrespective of traumatism, these attacks 
 perha]is recurring from time to time. 
 
 Treatment. — Anodyne applications and protection of the parts from fric- 
 tion, with such treatment as has been indicated for the inflamed female breast, 
 should be instituted if suppuration is threatened or is present. 
 
 Tumors. — These may be either benign or malignant, examples of nearly 
 every variety of each having been observed. Of the former variety, cysts — 
 even galactoceles — and fibromata are the most common. Spindle-celled sarco- 
 mata and scirrhous carcinomata are the usual varieties of malignant growths, 
 carcinomata occurring in the proportion of about one male to forty-two females. 
 These neoplasms pursue the same local and constitutional course as in the 
 female. 
 
 Treatment. — This is precisely that recommended for the same affections 
 occurrincj jn women. 
 
BOOK TV. 
 OPERATIVE SURGERY. 
 
 CHAPTER I. 
 
 GENERAL PRINCIPLES. 
 
 Theke are certain general principles which must guide the surgeon in 
 the performance of every surgical operation. These principles require careful 
 consideration, and no operation either of small or great magnitude should be 
 undertaken without a full knowledge of their importance. 
 
 Dangers Common to all Operations. — It may be stated as an apho- 
 rism that no surgical interference is free from danger to life. This must be 
 borne in mind in the consideration of every surgical operation. The distinc- 
 tion, however, must be recognized between an operation performed for some 
 cosmetic effect and- one performed to relieve human suffering and to save life. 
 In the former case the danger should enter prominently into the consideration 
 of the propriety of the operation, while in the latter case the same danger 
 would have little weight. There are cases that may stand midway between 
 these two extremes, and under these circumstances each individual case must 
 be considered upon its own merits. 
 
 The first general danger is Hemorrh(ige. Some loss of blood must always 
 attend an operation, but the aim of the surgeon should be to sacrifice the small- 
 est amount consistent with the completion of the operation. The more blood 
 lost during an operation, the less rapid the healing process and the greater 
 the shock. The hemorrhage may occur during the operation, or it may ensue 
 shortly after its completion, or it may take place after the wound has nearly 
 healed. The time of its occurrence is of less importance than its results. 
 The methods of arresting hemorrhage are considered elsewhere. 
 
 Anesthesia is a second danger ; hence the administration of an anesthetic 
 is a most important part of an operation and requires the services of a thor- 
 oughly trained and experienced physician. 
 
 Shock is a danger common to all operations. By this condition is meant 
 a functional depression of the circulatory system. The degree of depression 
 depends upon the situation of the injury, the character of the operation, and 
 the idiosyncrasy and age of the individual. The nervous system is primarily 
 affected in shock, and secondarily the circulatory. This is evident, because 
 with a normal action of the heart shock is impossible. Age likewise is a factor 
 to consider in estimating the severity of shock, although age is a relative term. 
 The acred as well as children suffer greatly from shock. The important differ- 
 ence, however, must not be overlooked that the aged do not react from shock 
 as readily as children. Shock associated with traumatic delirium is a most 
 serious condition. No operation, except such as the arrest of hemorrhage or 
 the relief of a strangulated hernia, should be undertaken under these circum- 
 stances. The aged with healthy viscera suffer less from shock than the mid- 
 dle-aged with diseased viscera. 
 
 1071 
 
1072 ^l.V AMERICAN TEXT- BOOK OE SVRUERY. 
 
 The prognosis in shock (k'ltciids upon the natmc of the injury inflictt'<l, 
 the special organs involved, and the individual iiliosynrrasy. A tenij)erature 
 ])ersistently helow UG° F., or a feehle and I'reiiuent pulse and shallow hreathing 
 with sudden rise of temperature, indicates a raost grave condition. 
 
 Spkcial Dangers of Opkuation. — Entrance of air Into vcinif is a most seri- 
 ous accident occurring in very rare instances during an operation upon the 
 nock, where the cervical fascia holds the veins j)atent, or as a result of a 
 wound o\' -A vein in this region. The internal and external jugulars, the suh- 
 clavian, the veins at the root of the neck, the axillary, subclavicular, sub- 
 scapular, and thoracic veins, and the cerebral sinuses, are the vessels the 
 w()unds of which are most likely to be attended with entrance of atmospheric 
 air. A wound of the facial or of the femoral vein has given rise to this seri- 
 ous accident, and cases of sudden death after delivery have been ascribed to 
 the entrance of air into the uterine sinuses. Air in the form of ])utrid gas 
 has been sent to the heart and caused death in cases of ganiirene. 
 
 The way in which the entrance of air into veins causes death has been the 
 subject of much study and experimentation. If air enters through a wound 
 of one of the veins, it is carried by suction to the right auricle and ventricle, 
 where it becomes mixed with the blood in these cavities, forming aeriform 
 emboli. The right heart endeavors to force the blood and air through the 
 lungs, but fails, and as a consequence the left heart is collapsed from want 
 of blood, and, no blood being sent to the cerebrum, a fatal syncope follows. 
 Experiment upon animals has undoubtedly shown that they can live after the 
 direct injection of large quantities of air into the circulation (Hare), but the 
 clinical fact remains that patients have repeatedly died from the accident, and 
 hence it is to be carefully guarded against, especially in all operations about 
 the neck. 
 
 The symptoms of entrance of air into the veins may be constitutional 
 and local. The constitutional symptoms are syncope, feeble and frequent 
 pulse, irregularity of respiration amounting to cardiac dyspnea, and dilatation 
 of the pupils. Auscultation over the precordial region reveals the presence 
 of a churning sound synchronous with the ventricular systole and accompanied 
 by a violent and irregular action of the heart. These symptoms are usually 
 preceded by a gurgling noise, and in a few seconds convulsions and fatal col- 
 lapse ensue. 
 
 The local signs are the appearance of bubbles of air in the wound and a 
 patent condition of the veins. The mouths of the veins are prevented from 
 closing by the fascia which surrounds them, and the canalization exposes them 
 to this danger. 
 
 The treatment for entrance of air into the veins must be prompt and 
 bold. The head should be immediately lowered to prevent fatal anemia of the 
 brain. Hypodermatic injections of brandy or digitalis should be at once 
 administered, and artificial respiration resorted to without delay, in order to 
 re-establish the pulmonary circulation and thus convey more blood to the left 
 heart. Treves has suggested pouring water into the wound to prevent any 
 further ingress of air and at the same time to allow the air to bubble out of 
 the wound. The patent vein should be instantly closed by the finger, and 
 then immediately ligated. Elastic bandages can be applied to the upper ex- 
 tremities with a view of facilitating the afflux of blood to the trunk and heart. 
 The inhalation of oxygen gas has been recommended. Tracheotomy has been 
 suggested, with inflation of the lungs through the tube, in order to stimulate 
 the pulmonary circulation and thus force out the air emboli. In all opera- 
 tions upon the neck when the veins are likely to be interfered with the surgeon 
 
OPERATIVE SURGERY. 1073 
 
 should guard against the iiiti-.iiicc of ;iir into wounded veins by not cutting 
 tissues Avhen tensely streteiicd, and hy having an assistant ready to compress 
 the vein between tlie wound and tlie heart in ease of its division: he should 
 use the handle of the sealj)el in the separation of the deep tissues of the neck, 
 and should, when possible, tie the veins lying in the course of an operation with 
 two ligatures and cut between them. 
 
 Uonopldlia. — Operations upon persons the subjects of hemophilia — "Ideed- 
 ers " — are most dangerous, because, in spite of every possible human device 
 to arrest the hemorrhage, it will often persist. The pathology of the disease is 
 but little understood. Hemophilia may exist in several members of a family, 
 and there seems to he undoubted foundation for the opinion that the disease is 
 often hereditary. The slightest traumatism, such as a scratch or a laceration of 
 the gums with a toothpick, induces a hemorrhage. The hemorrhage may occur 
 idiopathically from the nose or from the rectum, or may appear as minute 
 extravasations under the skin. ^Vllen the hemorrhage occurs from a wound 
 either as the result of traumatism or in consequence of a surgical ojteration, 
 the blood oozes freely from the entire surface, and may not be controlled by 
 heat or cold, by styptics, by compression, by ligature, or by the cautery ; but 
 all these means should be tried. The bleeding continues until the patient 
 becomes anemic and exsanguine. Ergotine has been used to contract the ves- 
 sels, but its efficiency is doubtful. 
 
 Preliminary Examination of the Patient. — Before undertaking any 
 operation certain examinations should always be made and certain indications 
 and contraindications considered. 
 
 The mental state of the patient is of no little importance. A patient who 
 is in fear of a fatal result or a soldier who is depressed by defeat is always a 
 much poorer subject for an operation than one who is cheerful and bright or, 
 it may be, indifferent. Hence in this respect children, who are not subject to 
 gloomy forebodings, and for a similar reason the insane, are very good patients 
 surgically. 
 
 No patient should be operated on without a careful examination of the 
 heart and lungs. Any serious disease of the heart should make us hesitate, 
 and if an operation be contemplated for mere cosmetic purposes, it should be 
 abandoned ; if the necessity for it be absolute, it must be undertaken, but with 
 great caution, especially as to the use of the anesthetic. If the lesion be at all 
 pronounced, the patient and the fimily should be so informed, and deliberately 
 make a choice, Avith a full knowledge of the danger. The lungs also should 
 be examined, for in case of bronchitis an operation which could be deferred 
 should be postponed until the bronchitis has been cured, or, if the operation 
 must be done, chloroform should be used instead of ether. Operations, espe- 
 cially on the brain, on the eye, and on the abdomen, should not be done during 
 an attack of bronchitis, for the cough suddenly produces great intracranial, 
 intraocular, and intra-abdominal pressure which may do much harm. 
 
 Deformities of the Chest, such as are produced by Pott's disease, if moderate-, 
 offer but a slight objection to operations, and even if severe may result in no 
 disadvantage to the patient. The anesthesia, however, in these cases should be 
 as brief as possible, and that method of operation chosen Avhich is the shortest; 
 for instance, in stone in the bladder lithotomy instead of litholapaxy. 
 
 The urine should invariably be examined, and if there be Bright's dis- 
 ease caution should be exercised as to the anesthetic and the functions of the 
 kidney watched afterward. Surgical opinion is at present somewhat divided 
 as to whether ether or chloroform shouhl be preferred in Bright's disease, but 
 the weight of authority is in favor of the latter. If diabetes is found, no 
 
 68 
 
1074 AX AMERICAN TEXT-BOOK OF SURGERY. 
 
 operation siiould \>c dune unless the need is absolute, lor diabetics are markedly 
 predisposed to hemorrhage, suj)puration, erysipelas, and shock. 
 
 The jieneral ritaliti/ of" the patient should also be considered, ami in poor 
 states of health all operations should be postponed it" possible. On the other 
 hand, it nnist In? remembered that operations ior pathologic-al causes, such as 
 tumors, joint disease, etc., are borne tar better by teeble subjects than similar 
 surgical interference by the robust and hearty. A man in the prime of life 
 with all his functions active, whose leg is crushed to such an extent as to 
 need am))utation, runs two or three times the risk that a patient does who 
 has been bedfast for weeks in consecjuence of a joint disease, and the interrup- 
 tion to whose activities is far less than in the case of the robust and hearty 
 man, as there is also present the additional shock from the crush ( Fig. 2'I). 
 Very fat patients also are poor subjects for operation. Women, for instance, 
 with very large, fat breasts are apt after operation for cancer to suffer necrosis 
 of the fatty tissues, with development of butyric fermentation, accomjianicd by 
 al)undant discharge and very foul odor, even without infection from jiyogenic 
 bacteria: su]i)iuration itself often occurs. A very fat abdominal wall is also an 
 obstacle, not only by reason of the ready breaking down of the fat. but also 
 in a mechanical sense, as it renders access to the abdominal cavity ditficult. 
 
 Age. — Very young children do not bear operation well. Mr. Dents 
 statistics show that under five years of age the mortality after amputation was 
 12.5 per cent., between five and ten it fell to 3.3 per cent., and between ten 
 and twenty rose again to 16.1 per cent. ; so that children bear operation better 
 than infants or adults. One reason for this mortality is that very young 
 children bear shock badly ; pain is borne, if possible, still less well. More- 
 ovei', it is difficult to keep young children clean, and wounds below the waist 
 may especially easily become infected through the urine or feces. It is often 
 stated that children bear the loss of blood badly, but, while the loss of the 
 same quantity of blood is borne badly as compared with adults, yet if the 
 amount of blood lost be regarded in relation to their age and size, they prob- 
 ably bear it quite as well as adults. Old age is likewise a factor for evil. 
 After forty, patients bear operations increasingly less and less Avell as their age 
 advances, and if we add habitual intemperance we have the worst possible 
 patients for an operation. 
 
 jSex. — Women bear operations, as a rule, better than men, since they are 
 less active ])hysically, and usually are of a more ecjuable temperament. Ope- 
 rations, naturally, should not be undertaken during the menstrual period unless 
 necessary, nor during pregnancy ; but menstruation is not an absolute bar, and 
 many operations, even up to amputation at the hip-joint, have been done during 
 pregnancy without ill results. If sepsis occurs, abortion is sure to follow. One 
 rule should ])e absolute : never to operate on a breast during lactation, on ac- 
 count of its great vascularity. If operation is necessary, we should wait until 
 weaning is accomplished. 
 
 Disease. — Bright's disease and diabetes have already been alluded to. 
 Tubercular patients react well after operations, and especially tubercular 
 children. The same may be said of patients with accpiired syphilis, but 
 those subject to heretlitary syphilis, from the feebleness of their constitution, 
 stand operations poorly. 
 
 Synchronous operations — as, for instance, aiuj)ut;iti()n of two or three e.x- 
 tremities — are sometimes necessitated by multiple injuries. Of course there is 
 no choice in such a case, but they should be done with all speed, so as to dimin- 
 ish shock, and it is of advantage if they can be done sinndtaneously by two 
 operators. Hemorrhage in such a case should be especially guarded against. 
 
OPERArrVE SERVER V. 107r> 
 
 The Management of the Patient Before Operation. — The nianajie- 
 ment of the patient before an operation involves a knowledfre of liis tempera- 
 ment, habits, and constitution. If the patient is not in f^ood physical condition 
 and the circumstances of the case permit, the operation should he postjxmed for 
 a short time until, by the use of tonics, by i-est, and by nutritious diet, the gen- 
 eral health is improve<l. A study of the^ habits and temperament of the ))atient 
 is often of great benefit to the surgeon. Sometimes a patient is very nervous, 
 irritable, and restless on account of the dread of an operation, and in such a 
 case the surgeon should do all in his power to allay his fears, to assure him of 
 the safety of the operation, and to point out the fact that modern antiseptic 
 surgery can ofl'er relief or save life 'with but little sufl'ering as a rule. A 
 thorough examination should be made of the patients viscera, especially the 
 heart, lungs, kidneys, and liver, in order to have a comprehensive knowledge 
 of all the emergencies that might subsequently arise. The technique of ])rep- 
 aration of the patient is fully discussed later. 
 
 Hygienic Conditions which Surround the Patient. — These greatly 
 influence rapid recovery after a surgical operation, as well as often induce or 
 prevent death from se])tic causes. 
 
 The surgeon should perform an operation under the most favorable hygienic 
 conditions possible in the case. The room in which the patient is to be operated 
 upon, as well as the one he is to be placed in during convalescence, should be 
 large, exposed to the sun, well ventilated, and scrupulously clean. The bed 
 and bedding should be free of any contamination from prior exposure to 
 infectious disease, and all the appliances for dressing the wound should be 
 aseptic. The sanitary arrangements of the house should be perfect. Too 
 much importance cannot be placed upon the question of ventilation of the 
 sick-room. In the air of a room there are held in suspension particles of 
 organic matter, epithelium, and dust, also the exhalations from the lungs, des- 
 quamations from the skin, and floating particles derived from clothing and 
 other sources. Pasteur has pointed out the fact that an ill-ventilated room is 
 a source of great danger, because the dust held in suspension may act as a 
 carrier of septic germs and cause infection in a wound. It is thus evident 
 that a Avell-ventilated chamber is an important condition to ensure safety and 
 rapid recovery. An open fireplace is a safeguard, because it leaves no damp 
 surfaces upon which floating and germ-laden dust can settle, and also because 
 it produces a free outward draught from the room. 
 
 In the event of a serious operation the carpets should be removed, as well 
 as all the hangings and upholstered furniture. The ceilings and side walls 
 should then be brushed down with a towel saturated in bichloride. Papered 
 walls require a dry toAvel. AVhen the room is thus made empty and dusted, 
 the floor and all the woodwork and furniture should be well scrubbed and 
 washed with a solution of bichloride of mercury of the strength of 1 : 500. 
 A plain kitchen table is the best for an operating table. There should be 
 placed in the room four plain wooden or cane-seat chairs, a washstand, and a 
 table for instruments, medicines, etc. The operating table should have a rub- 
 ber under it. and a waste-water pail should be j)]aced under the table. Five 
 or six china washbowls and as many pitchers should be provided, two or three 
 of them filled with distilled or cooled boiled water. Plenty of boiling water 
 must be provided. 
 
 Two blankets should be placed on the bed instead of sheets, and ten well- 
 corked hot-water bottles or bags provided to place around the patient after the 
 operation. Three or four sheets and a dozen or more towels, wrung out of a 
 1 : 1000 sublimate solution and rough-dried the night before the operation. 
 
loTG .l.V AMKliK'AX TEXT- HOOK OF SURCiERY. 
 
 should lie provided. Many surgeons prefer to wet them in a liot solution at the 
 time of" the operation and then spread them all around the field of" operation. 
 
 TlIK I'UKPAKATION ()F TllK Patiknt. — If" possible, before the operation 
 the patient should rest in bed for a day or two. The nifiht before tiie opera- 
 tion he should have a mild la.xative, and an enema the morninr; of the opera- 
 tion. In certain operations antiseptic injections sliould l)e used in tiie va^^ina 
 and boiled water in the rectum. 
 
 Too much importance cannot be attached to the pn-liminary disinfection of 
 the field of oj)eration. Cheyne has pointed out the fact that there are more 
 patlio^jenic micro-or_<;anisms in a s«juare inch of the cutaneous surface tlian 
 would be found in the Avard of a well-ventilated hospital. This fact demon- 
 strates how ina<le<|uate is any attempt to disinfect the air in a ward, and at the 
 same time emphasizes the importance of disinfection of the field of operation as 
 well as of the hands of the operator, his assistants, and the nurse. The skin 
 is covered with des(juamate<l epithelium and filled with innumerable micro- 
 organisms. The day before the ojieration, therefore, the part must be ."haved, 
 and then the micro-orn;anisms be got rid of, first with soap and water, then with 
 ether or alcohol, and lastly Avith a sublimate solution, 1 : 1000, or in specially 
 dirty regions 1 : 500. Some surgeons advise the prior application of a soap 
 poultice to the skin with a view to separation of the effete material. A subli- 
 mate gauze dressing should then be applie<l and retained in place by a bandage 
 or binder, and allowed to remain until the operation is to be done. In opera" 
 tions about the male genitals the penis should always be wrapped round with 
 some aseptic gauze. Disinfection of the mouth, nose, and ear has been 
 described on page 512. The navel, the pubes, the scrotum, and the armpits 
 re(|uirc especial care, since they are peculiarly apt to harbor dirt. The same 
 is true of the scalp, and in operations on the head it is better, as a rule, to 
 shave the entire head. On the scrotum and head the sublimate solution should 
 not be stronger than 1 : 2000, lest pustulation or excoriation follow. In trau- 
 matic cases, where the patients are begrimed Avith the ordinary dirt of the 
 streets, oil and grease from machinery, etc., if sweet oil be well rubbed over 
 the parts the dirt will be much more readily removed by the soap and water. 
 In operations about the upper part of tlie l)ody the arms, and in operations 
 about the lower part of the body the legs, should be wraj)ped in bichloride or 
 sterilized sheets or towels, lest the patient contaminate the wound by touching 
 an unclean extremity to it. In operations about the chest, the neck, or the 
 face a bichloride or sterilized towel should always be Avrapped around the liair 
 and another around the inhaler. In operations involving much exposure or 
 great shock it is well to wrap the patients body, arms, and legs in a thick 
 layer of cotton, kept in place by bandage and binder, in order to maintain the 
 body-heat. This can be done also by hot-water bottles, or in some cases the 
 operation may be done on a hot-water bed. 
 
 Asepsis and Antisepsis. — The stage of controversy and of argument as 
 to the benefits of asepsis and antisepsu? is past. With the exception of a very 
 few superfluous laggards, the surgical world is at one as to the value of these 
 methods. Even those who oppose them practically apply the same principles 
 by difl'erent methods. Heat and carbolic acid in this regard are e<iuivalent 
 means. The bacteriological proof that suppuration, erysipelas, pyemia, and all 
 other similar dangers arise from pyogenic organisms is now practically absolute. 
 The clinical proof is ecjually strong. The statistics of all operations in the 
 pre-Listerian days, as contrasted with those of the la^t twentv vears. show that 
 all those septic diseases which were rife in private and especially in hospital 
 practice, and slew their thousands and tens of thousands, have almost disap- 
 
OPERATIVi: SVUCKRY. IO77 
 
 peared. Conipouml fVactiircs, wliicli then wci'c aiiioiifi the most dangerous 
 accidents, are now scarcely more (lan;:;eroiis than simple fractiii-es, and the 
 mortality-rate after amputation and abdominal section has fallen nearlv to 
 zero. 
 
 Two methods are employeil, the aseptic and the antiseptic. In the aarptic 
 method chemical antiseptics or heat, or both, are used for the purpose of obtain- 
 ing absolute surgical cleanliness, including in this the patient's person, the 
 hands of the surgeon and his assistants, all instruments, dressings, etc. ; and 
 after this no chemical antiseptic is used, but only such solutions, dressings, etc. 
 as have been sterilized and made germ-free by heat. In tlie antiseptic method 
 the same antiseptics are used for procuring cleanliness, and in addition chemical 
 antiseptic solutions and dressings impregnated with them are used during and 
 after the operation. One thing must be clearly understood : that either metliod 
 must be thorough or it is useless. 
 
 Antiseptics. — As an antise])tic the most universally valuable and availal)le 
 is heat. A temperature of 140° F. for ten minutes is fatal to all pathogenic 
 bacteria except the tubercle bacillus and anthrax spores, which require a moist 
 heat of 212° F. for at least four minutes (Sternberg). Moist heat is far more 
 efficient than dry heat ; e. g. the spores of the tubercle bacillus if exposed to 
 dry heat recjuire for their destruction a temperature of 284° F. for three hours. 
 It is especially well to remember that even in the country this method of abol- 
 ishing sepsis can always be used. Instruments and dressings can always either 
 be boiled or placed in an oven and thus be entirely sterilized at a moment's 
 "warning. It is not necessary that the surgeon should have all the appliances 
 of the modern hospital or drug-store. Old sheets can be prepared extempo- 
 raneously by heat, and will form excellent sterilized dressings. 
 
 Of antiseptic drugs there are a very large number Avitli more or less bacte- 
 ricidal power. Among them should be especially mentioned carbolic acid, 
 bichloride of mercury, biniodide of mercury, and hydronaphthol. Iodoform 
 is undoubtedly useful in many cases in tuberculosis and in inhibiting the 
 growth of pyogenic organisms, but it should itself be sterilized before being 
 used : b}' some surgeons, except in cases of tuberculosis or chronic suppuration, 
 it is entirely discarded ; by others it is depended upon in the permanent dress- 
 ings to the exclusion of all other antiseptics. 
 
 Peroxide of hydrogen has been largely used as an antiseptic, but its pre- 
 cise value has yet to be determined. The ordinary solutions are not invariably 
 germicidal. The bacteria of tetanus, for instance, have been grown under a 
 fifteen-volume solution (Kyle). Its antiseptic action seems to be dependent 
 upon its destruction of the albuminoid element upon which the bacteria live ; 
 hence it has a definite field of usefulness in .suppuration. Practically, carbolic 
 acid in solutions of 1 : 20 to 1 : 40, and bichloride of mercury in solutions 
 externally of from 1 : 1000—4000, and internally in solutions of from 1 : 5000 
 for the irrigation of joints to 1 : 10,000 for the peritoneal cavity, are the anti- 
 septics with which the modern surgeon has to deal. Most surgeons prefer 
 to use boiled water only in the peritoneal cavity. 
 
 Preparation of Surgeon, Assistants, and Nurse. — The surgeon and 
 his assistants may wear ordinary clothing, but should be in their shirt-sleeves, 
 ■with the sleeves rolled up well above the elbows. Partly for the protection of 
 the patient and partly for the protection of their clothing they can wear either 
 white coats or aprons, or else should be protected by a sheet folded several 
 times, so as to be about half a yard wide and five or six feet long. One end 
 of this can be turned in next the person over a bandage which is tied around 
 the neck, and another bandage is tied around the waist. This serves an excel- 
 
1078 AN AMERICAN TEXT- HOOK OF SritUERY. 
 
 lent purpose as an extemporaneous apron. ^Vllicllever is worn, coat, apron, 
 or slieet, it sliouM have been made aseptic by steriliziiif; by heat or by having 
 been dippetl tlie ni<;ht before in a liicliloride sohition and rougli-drie<l, but it 
 must be remembered tliat no iln/ materiiil is actively antiseptic, or even reliably 
 aseptic, if dust or dirt of any sort conies in contact with it. It is not uncom- 
 mon to see the sweat dropping from the head or chin of a surgeon during an 
 operation. This, of course, is excessively dangerous, since it carries the germs 
 of the face and hair directly into the Avound, the abdominal cavity, etc. Per- 
 sons who sweat ])rofusely, therefore, should tie a towel around the forehead and 
 head to absorb all this excess. On no account should they wipe it off with 
 their hands, since the hands are immediately infected ]>y such contact. A 
 sterilized towel must be used. The nurse should wear some wash-goods, such 
 as white muslin or a neat calico. If she assists at the operation otherwise 
 than with the sponges, she should wear an apron or a sheet. 
 
 Disinfection of the Hands. — When the antiseptic method was first intro- 
 duced, it was thought that the principal source of the germs of suppuration 
 was the air, and hence the use of the spray, which is now practically aban- 
 doned. Its abandonment has been due to the fact that surgeons have recog- 
 nized the fact that the three chief sources of infection are, first and foremost, 
 their own hands ami those of their assistants ; secondly, instruments not prop- 
 erly disinfected ; and thirdly, sponges and dressings. Hence, above all, the 
 hands and forearms of every person who is to touch the wound must be dis- 
 infected. The first means of cleansing the hands is that which commends 
 itself to common sense — viz. the removal of the dirt rather than its attempted 
 disinfection. Hence the hands and forearms should be washed with hot water 
 and soap and nail-brush continuously for several minutes. During this wash- 
 ing the nails should be very thoroughly cleaned by scraping under their free 
 ends and also along their sides and bases with a penknife, nail-cleaner, or 
 other similar instrument. This portion of the disinfection is most imjjortant, 
 since infection is carried more frequently by the hands than by any other 
 means. The nails should also be cut very short. The nail-brush, moreover, 
 should be aseptic. Especially in hospitals, where it is constantly used and is 
 apt to become foul, it should be always kept in a 1 : 40 carbolic solution 
 or in a 1 : 1000 sublimate solution, either of Avhich should be frequently 
 changed. One brush should be kept for the soap and water, and another 
 separate one for the disinfection. 
 
 Two methods are chiefly in vogue for disinfection of the hands. The first 
 one is the method of Furbringer, and is as follows : The forearms and nails 
 having been cleaned as just directed, they are dipped into absolute alcohol 
 for at least one minute, and then are plunged while wet into a hot subli- 
 mate solution, 1 : 1000, and well scrubbed with a nail-brush, the nails re- 
 ceiving extra attention. This antiseptic scrubbing should be continued for 
 not less than one minute. Whenever the hands or forearms touch any object 
 which has not been disinfected they should immediately be washed again in a 
 bichloride solution. Even when this method is scrupulously carried out, if 
 the bichloride is precipitated by sulphide of ammonium, numerous colonies 
 can then be grown by inoculating culture-tubes from the hands. In fact, 
 sterilization of the hands is a relative asepsis, and not an absolute one. For- 
 tunately, the human body does not provide a soil in which, as in the culture- 
 tubes of the bacteriologist, everything is favorable for the growth of the pyo- 
 genic or other micro-organism, else every accident would be followed by septic 
 infection. By phagocytosis, by the bactericidal action of the blood-serum, or 
 by other means the comparatively few germs which find access to the tissues by 
 
oi'KR. 1 Trvi: SI lid KJi y. i oto 
 
 liaiids thus prepared are, as a rule, destroyed rir ren<lered inert; but occasion- 
 ally, especially if the details ar<' not ri;i;idly ohserved. infection will occur. 
 
 "Weir recommends the followinj^ method for sterilizinf.' the hands : scrub 
 thoroujrhly with hot water and <;reen soa)». cleanse about and beneath the 
 nails; a scant tablcspoonful of commercial ehloride of lime is put in the j)alm, 
 then a piece of sodium carbonate, 1 inch wide and 1 .V inch thick; a little 
 water is added to make a thick cream ; this is rubbed into the palms, hands, 
 and arms until the roui^di j^rains of the chloride disappear or diminish, or 
 until there is a sense of coolness in the palms. It should also be rubbed 
 around and under the nails. The process takes three to five minutes. The 
 hands are then washed with sterile water. If any odor persists, it may be 
 removed by a dilute solution of ammonia water. 
 
 The other method is by means of the potassium-permanganate and oxalic- 
 acid solutions (Kelly). The three steps insisted upon are as follows : First, the 
 cleansing of the hands with soap and water, frequently changed, as before. 
 Secondly, immersion of the hands in a solution of permanganate of potassium 
 made by adding an excess of the salt to boiling distilled water, until every 
 part of "the hands and forearms is stained a deep mahogany-red or almost 
 black color. They are then transferred to a saturated solution of oxalic acid 
 until completely decolorized and of a healthy pink color. Thirdly, washing 
 off the oxalic acid in warm sterilized water. The chief objection to this 
 method is the annoying irritation of the skin, especially of the forearms, 
 which often follows. ^ This may be avoided by washing with lime-water after 
 using the acid. 
 
 In view of the difficulty of always securing an aseptic condition of the 
 surgeon's hands, Halsted first introduced the use of rubber gloves, and they 
 have been employed by many operators. While they have some inconven- 
 iences, the results of their use have influenced a nund^er of surgeons to em- 
 ploy them in most operations, especially those which do not demand the great- 
 est nicety of touch. Cotton gloves have been recommended by Mikulicz. 
 
 Disinfection of Instruments: — The best method by far is to boil the instru- 
 ments for ten minutes in a 1 per cent, solution of sodium carbonate. The so- 
 dium carbonate is added to prevent rusting. It is also a poAverful antiseptic 
 solution, destroying staphylococci in two or three seconds and anthrax spores 
 in two minutes "^(Schimmeibusch). When taken out of the boiler the instru- 
 ments should be placed in trays in water which has been boiled and allowed 
 to cool. If the instruments are not to be used at once, they should be placed 
 in carbolic solution, 1 : 20, which is to be diluted to 1 to 60, immediately 
 before beginning the operation. To this some boiling water may be added 
 in order to make it more agreeable to the hands. On no account should 
 the boiling water be cooled by freshly-drawn unboiled water, since, as this has 
 not been Serilized, it will contain many germs. As the instruments are soiled 
 thev should be cleansed by a nurse with aseptic hands in an aseptic solution and 
 replaced in the tray. Placing the instruments in a 1 : 20 solution of carbolic 
 acid for fifteen minutes will also sterilize them very well, and in case the 
 instruments have wooden handles it will be essential that this method be fol- 
 lowed, since boiling would loosen the handles. To prevent the roughening of 
 the hands the carbolic solution may be poured off just before the operation is 
 begun, and the trays, etc. filled with boiled water. When the operation is ter- 
 minated the instruments should be scrubbed with a nail-brush and carefully 
 dried, especially in the joints and serrations or teeth of forceps, etc., in order 
 to get rid of a*ll blood, fragments of tissue, etc. This cleansing is quite as 
 important as their disinfection prior to the operation. If the case has been 
 
1U80 
 
 .i.v AMi:i:n A.\ riixr-nooK of srnaiJiY. 
 
 a suppurating one, tlii' iiistniiiicnts .sliould be Ijoilcil after tlic opcratinn. in- 
 ilcpeiidi'iitly of the prej)arati(His for the next oiie. 
 
 I>i>ihif('cti<)n hi/ Minus of F<o'iiial)h/n/(h'. — The r.xpcriiiicnts of a luiiiilx'r 
 of writers seem to show that iorinahlehytle vapor is an ellicieiit agent in ster- 
 ilizing instruments. The accompanying illustration (Fig. 427) shows a con- 
 
 Fio. 427. 
 
 Af)7)aratus for use in Sterilization by means of Formaldehyde. 
 
 venient form of formaldehyde sterilizer, designed by Dr. H. 0. Reik of Bal- 
 timore, M<1. It is made of copper, and its dimensions are 7x12x12 inches. 
 The shelves are made of heavy, wide-meshed wire gauze. The upper shelf 
 extends entirely across the chamber; the other two shelves are but eight 
 inches long. A space eight inches high and four inches Avide is thus left for the 
 lamp used in vaporizing the paraform pastils. The instruments having been 
 placed upon the shelves, a five-grain paraform tablet is placed in the recep- 
 tacle at the top of the lamp atid the lamp lighted. The door is to be imme- 
 diately closed. Fifteen minutes' exposure suffices for thorough disinfection. 
 It is necessary that the sterilizing chamber should be absolutely air-tight, 
 otherwise the disinfection w ill be unreliable. Larger cabinets may be employed 
 for instruments that are too large to be received in the one here described. The- 
 quantity of paraform used in such a case should be correspondingly greater. 
 
 Spo\(iES. — Most surgeons have practically given up marine sj)onges. and 
 use small j)ads of sterilized or antiseptic gauze instead. 'I'hese answer admir- 
 ably, especially for the dry method of Landerer. In the abdomen, gauze pads 
 about 8 or 10 inches square may replace the large flat elephant's-ear sponges 
 to advantage. They are made of a number of folds of the ordinary gauze 
 used for surgical dressings, loosely hemmed at the margins, and then steril- 
 ized or made aseptic by sublimate solution. The edges should not be cut, 
 but should be folded over and hemmed so as not to have loose threads which 
 might be left in the abdomen. 
 
 Marine sponges should be first placed in a bag and beaten for a long time in 
 order to free them from the sand in their meshes. They should then be ^vashed 
 for some daj^s in water which is frequently changed, and best in water which 
 is slightly acidulated with hydrochloric acid. They must again be washed 
 in pure water in order to remove the acid. Different methods may be fol- 
 lowed in their disinfection : (1) They may be soaked for twenty-four hours or 
 less in a solution of ordinary washing soda, a pound of the so<la to a dozen 
 
OPERA Ti 1 7-; srna ku v. 
 
 1081 
 
 sponcres, and the soda then be removed by washing in clean water. The sponges 
 are ifext soake.l for twenty-four hours in a 1 : 20 carbolic solution, and <lried 
 bv moderate artificial he:."t. Thev are then well wrapped up and kept in a 
 d'rv place (2) After beating the sponges free from san<l and washing them m 
 the warm water, they should be soaked in a solution of potassium permanga- 
 nate half an ounce to the gallon, and if the pink color ot the solution is lost 
 more permanganate should be added. If this addition is necessary the sponges 
 should be takH'n out of the liquid, the permanganate dissolved, and the sponges 
 put back, for if the permanganate is put in upon the sponges it discolors 
 Ihem in spots. Thev are then washed in warm water and dipped for a vejy 
 few minutes into a solution of sulphite of sodium 3x and hydrochloric acid t5ij 
 to the gallon of water. If they are allowed to remain any length of time in this 
 solution tliev will not onlv become bleached, but very much softened. Ihey 
 are then thoroughly washe<l for twenty-four hours, after which they are kept in 
 glass jars in a carbolic solution, 1 : 40. (3) Borham's method is that adopted 
 bv Giei<^ Smith in preference to others. The sponges after being cleansed are 
 first soaked in a 1 per cent, solution of potassium permanganate (about . ograins 
 to the pint). The sponges, having next been washed repeatedly in boiled water 
 are placed in a gallon of water in which has been dissolved half a pound of 
 sodium hyposulphite for a dozen sponges. Four ounces of oxalic acid are 
 added, which bleaches the sponges and dissolves out any fibrin in their meshes. 
 They should remain in this solution not more than ten minutes, and are finally 
 
 placed in a carbolic solution. ,, , , i.- ii„ 
 
 ^ Ligatures and SuTURES.-For ligatures, silk and catgut are practically 
 the two' most employed. The silk may be either the plaited silk or, peHmps 
 better, the Chiies^ twisted silk. Ballance and Edmunds have recently 
 recommended for the ligation of arteries in continuity dentists floss silk, 
 wh~h re large vessels have to be tied, does not slip so easily as other 
 linds on account of the entanglement of its fibers. For sutures either silk- 
 worm gut or silk is the best. Silver and other wire sutures, formerly so 
 popular, are but little used nowadays. 
 
 ^ %he ,ilk is made of different sizes appropriate to the vessels or pedicles 
 to be tied. It is best prepare*! bv boiling after it has been wound on glass 
 spools which are thus disinfected at the same time. Another method consists 
 n puttin. three or four spools into an ordinary test-tube the mouth of which 
 has been" stopped with ordinary jewellers' cotton. Absorbent cotton is not 
 go d s nceXcomes of course very wet. The test-tube, thus prepared as for 
 bacteriolocTical use, is then placed in a sterilizer and exposed to steam heat foi 
 an hour o!- more. In order to carry these test-tubes they may be placed in 
 the ordinary tin tubes in which plasters are dispensed, the tube having been 
 of course properly cleansed, or holes of a suitable size and depth may be 
 borJm ; bh4 of wood by an auger and stopped with rubber -rks^ Just 
 before use the silk should be placed m a carbolic solution 1 : 20, and alcohol, 
 one- bird of the former to two-thirds of the latter Carbolic acid is better than 
 subl mate, as the needles may be threaded and placed m the same tray. The 
 alcohol is added so that if desired the catgut may be placed m the same tray 
 with the silk, and not undergo softening, which very quickly occurs when the 
 catfTut is placed in plain watery solutions. -, • i. ii q,^,!! 
 
 ^Simlnn gut ii that used by anglers, and is purchased in bundles Sma 
 round threads should be selected and the poor ones thrown away. The threads 
 should be soaked in a carbolic solution for fifteen minutes before -- T^ie dan^ 
 ger of its breaking while being tied can be obviated V niaking the first kn^^^^ a 
 double one and tying the second one very lightly or not at all (Gieig Smith). 
 
1082 ^l.V AMKIUCAX TEXT-IK K)K OF S( lidKI:)'. 
 
 Cat;/uf also can he used for sutures, and especially for ligatures. Raw cat- 
 gut, as ordinarily purchased commercially, has two «)l)jections : first, it has a 
 considerable »|uantity of fat in it : and secomlly. it is infected with germs from 
 its very source, heing made from the suhmucosa of the intestine of the sheep. 
 There are very many methods of sterilizing catgut; of these the following 
 may be named as reliable. The Jefferson Hospital method is as follows: The 
 catgut is first ))laced in ether for 48 hours to extract the fat; then in a mixt- 
 ure composed of corrosive sublimate gr, xx, tartaric acid gr. c, and ounces 
 of 0') per cent, alcohol. The smaller sizes are soaked in this solution from 
 .") to 7 minutes, the medium sizes from 1" to 1"> minutes, the largest sizes 
 from 20 to 8U minutes. It is then permanently kept in alcohol (95 per 
 cent ), to 8 ounces of which two drops of a solution of chloride of palladium 
 (gr. XV (a .^j) are addetl. If more is added, all the palladium precipitates. 
 At the University of Pennsylvania Hospital cumol catgut, as first devised by 
 Kn'iiiig. is emjiloyed. The process is as follows: Roll 12 strands in figure-of- 
 8 form so that it can be placed in a large test-tube; heat the catgut to 80° 
 C. and keep at this point one hour; place in cumol. which must not be above 
 100° C. ; heat to lGo° C. and hold at this point one hour ; pour off the cumol 
 and dry the catgut either over a sand-bath or in a hot-air oven at 100° C. for 
 two hours; transfer with sterile forceps to sterile test-tubes. In drying or 
 boiling suspend the catgut on slender wire loops or on cotton, to keep it from 
 touching the bottom or sides of the beaker-glass. It should be immersed in 
 sterile water a few moments before being used, or it may be put into bichlor- 
 ide solution instead of sterile water. Another method of sterilizing catgut 
 is by boiling it in alcohol. It can scarcely be used, however, outside of hos- 
 pitals, as it reijuires special apparatus. It may also be i)repared with forma- 
 lin. If it is desired to make the catgut less absorbable, it can be chrom- 
 icized in this manner : 200 parts of catgut by weight are added to carbolic 
 aci<l 200 parts, and water 2000 parts, with chromic acid 1 part. The catgut 
 should lie in this preparation for twenty-four or forty-eight hours. It may 
 then be preserved either in alcohol or in ether, as before. Catgut and silk 
 may be kept in (juantity in reel-holders, but these are generally objectionable 
 on account of the great difficulty of preventing their being soiled and infected 
 during an operation by the necessary contact with blood- or pus-covered fingers 
 and scissors. Robb and Ghrisky made a bacteriologicnl study of the sutures 
 removed in forty-five cases in which every antiseptic precaution had been fol- 
 lowed, and without exception they found them infected with a greater or less 
 number of bacteria. J>ilkworm-gHt was infected with f;ir fewer germs than 
 silk or catgut. Even silver wire was not exempt. Tension was a potent factor 
 in causing multi|)lication of the germs. Hence the greater safety of silk- 
 worm-gut is proved bacteriologically as well as clinically, and the importance of 
 approximating the wound-surfaces with the least possible tension is emphasized. 
 
 DRES.-^rXiJS. — Ordinary cheese-cloth is prepared in the following manner: 
 The grea.se is removed and the gauze made ab.sorbent by boiling it either with 
 soft soap or .soda, after which it is rinsed and dried. The gauze is then fohled 
 in suitable packages and sterilized in a steam sterilizer. If desire<l. it may then 
 be .soake<l in a .solution of bichloride of mercury, 1 : 1000. with twice as much 
 common salt as of sublimate. The object of the salt is to prevent the sub- 
 limate from turning into calomel. It can be kept either moist or dry in dis- 
 infected gla.ss jars. Sterilized gauze is first made ab.sorbent as ])efore. and 
 then is boiled for ten or fifteen minutes; or it may be placed in a sterilizer 
 an<l steame<l f.r the same length of time. The best iodoform gauze is made 
 as follows: Four ounces each, by weight, of iod<»form. glvcerine. and alco- 
 hol. an<l six grains of corrosive sublimate are well mixed and allowed to 
 
OPEUATIVE Sl'liCKRY. 1083 
 
 stand for three days. Moist bichloriilc ^Miizf is then saturated with the 
 emulsion, allowed to di-i)» till almost dry, and is then kept in sterilized cov- 
 ered glass jars. In iisiiiir suhlimate <rau/e it should he remend)ered that cer- 
 tain j)arts ot" the body — tor instance, the recently-shaven seal]) and the scro- 
 tum — are liable to be ))ustulated by a 1 : 1000 gauze, and it should therefore 
 be used of a strength of 1 : 2000 or 3000 on these parts. This can easily be 
 done with suificient accuracy extemporaneously by washing the ordinary sub- 
 limate gauze in sterilized water, and then in a solution of sublimate of the 
 desired strength. For making sublimate solutions the manufacturing chem- 
 ists now sui)ply tablets containing ~\ grains of bichloride of mercury and 37^ 
 grains of tartaric acid, the object of the latter being to prevent the decom- 
 position of the bichloride and the fornuition of the albuminate of mercury 
 from the blood-serum. One of these tablets added to one pint of water makes 
 a solution of 1 : 1000. Dressings are best held in place by bandages made 
 of gauze rolled on slender cylindrical sticks of wood to give stiffness to the 
 roller. These bandages do not easily slip. Of course, ordinary roller band- 
 ages may also be used. If pressure is desired at any point on the Haps, it 
 can be made either by placing a moist antiseptic sponge underneath the 
 dressing or by absorbent cotton, or, better, antiseptic wool, outside of it. 
 
 The Operation. — The surgeon should first of all see that absolutely 
 everything is ready ; not only that the patient has been ])roperly prepared, 
 the stomach and bowels attended to, the clothing ready for operation, instru- 
 ments, dressings, rubber dam, bandages, and all the drugs and antiseptic 
 solutions at hand, but that everything that can be needed, from the most 
 important to the least, is within reach. During the operation every detail 
 must be attended to " with a thoroughness as minute and definite as if that 
 detail wei'e the turning-point of success." The means for the prevention 
 of shock have already been described in part, but still further we must 
 remember that the time occupied by the operation and the duration of the 
 anesthesia influence considerably the amount of shock. Hence speed without 
 haste should be the rule for every operation. Of course the precautions should 
 be taken to remove false teeth, tobacco, or other foreign bodies from the mouth. 
 After the patient is etherized he is placed upon the operating table, and his 
 clothing so arranged that if possible it shall not be soiled. The body is pro- 
 tected by blankets, over which are laid sterilized or antiseptic towels or sheets. 
 
 The incision should always be sufficiently long. The question whether it 
 shall be an inch or two longer or shorter, as far as healing is concerned, i? 
 of little matter at the present day, but it is of great importance that it shall be 
 long enough to give ample room for the manipulations required. No feats of 
 dextrous manipulation Avithin narrow limits are allowable. Hemorrhage is 
 arrested as vessels are divided by placing the fingers upon them until they 
 can be clamped w^ith the hemostatic forceps, and later ligatured if required. 
 Heat and pressure by wads of gauze dipped in hot w^ater at 110° to 120° F. 
 will be most valuable aids, especially for arresting the bleeding from the smaller 
 vessels and any general oozing. 
 
 Irrigation during an operation is often employed. Normal salt solution is 
 the one most frequently employed. If bichloride of mercury is used, it should 
 usually be of the strength of 1 : 1000 to 1 : 3000. In the abdomen, the blad- 
 der, or a joint it should rarely be used, and not stronger than 1 : 10,000. 
 
 Landerer s dry method of operating is adopted by many surgeons. In 
 this, once the field of the operation, and therefore the wound, are aseptic, no 
 fluid whatever is allowed to touch the wound. Mops or pledgets of gauze 
 are packed in it as rapidly as the operation is completed at one part, and sub- 
 
10S4 J.v AMimrcAX ri.xr-iiook' or scucinn'. 
 
 sei|UiMitly, when tlio last part lias Ix-cii jiackcd. it will he foiiinl, if tlic woiiml 
 lit' a lariro oiio, that the ))art first packi'd is jicrfeetly bh^oillcss anil dry. 
 
 Ihudiuiiir. — Ik'forc the ('(lifcs of tho wound are approxiiiiatcd the (jiics- 
 tii»n of drainaj^o is to ho decided. The ))rinci])l('s upon which this must he 
 dctcnniucd are inciitiouod in various ))arts of this w<irk. We have here to 
 do only with the practical methods which arc most common and etlicient. 
 
 Carbolic acid and bichloride of mercury and other antiseptic solutions, 
 while they prevent suppuration, irritate the tissues to a certain extent, so that 
 provision must be made for the removal of serous exudation. Drainafre- tubes 
 shouhl bo brought out at the angle of the wound which will be lowest when 
 the jiatient is recumbent, or through an o))ening in the lower flap : and the size 
 of the tube should bo adapted to the character of the wound itself. 
 
 Drainage in a wound can be secured by tubes made of rubber, of glass, of 
 decalcified bone, or upon the principle of capillarity. The tubes should be cut 
 the proper length, and holes made upon the sides at short intervals, and then 
 the tube should be cut oft' nearly flush with the skin and held in situ by an 
 ase))tic safety-pin, or often bettor by a stitch through the skin and tube. The 
 lower angle of the wound should not constrict the mouth of the tube by hav- 
 ing the last suture too tight. If the tube projects much beyond the wound, 
 instead of being flush with the surface, the projecting part is compressed or 
 bent by the dressings, and it will fail to drain the wound. In a very long 
 wound it is better to phice two short drain-tubes, one at each end, rather than 
 one very long one. The rubber tube may be removed upon the first or second 
 day after operation unless more prolonged drainage be ref|uircd by reason of 
 prior su))|)uration, etc. If the wound has been made aseptic at the first dress- 
 ing, there is no occasion for a tube to remain longer than the third day ; it may 
 often be removed sooner, as its usefulness is over when it has drained the primary 
 al»un<lant secretion. Its longer retention will tend to cause a persistent sinus. 
 Glass tubes are used in abdominal cavities, but seldom in wounds of soft ))arts. 
 The capillary drainage is oftocteil by strands of catgut or horsehair. A dozen 
 strands a few inches in length are laid in the bottom of the wound, so as to 
 project beyond the angle of the wound, but not beyond the dressing. In 
 some wounds the drainage by rul)ber tube and by strands of catgut or horse- 
 hair can lie advantageously combined, both being inserted at the operation, 
 the tube removed in twenty-four to forty-eight hours, and the horsehair later. 
 
 Many wounds, if the hemorrhage is entirely arrested and the wound abso- 
 lutely aseptic and its walls in contact, may be entirely closed without drainage. 
 This is certainly the ideal toward which the surgeon should strive, as a drain- 
 age-tube is always a possible means by which infection may occur. But the 
 conditions stated must be first realized. 
 
 Methods of Suturing. — Sutures may be the continued or glover's, inter- 
 rupted, quilled, twisted, hare-lip, button, etc. 
 
 In the continued or glover n suture the needle is introduced about one-quar- 
 ter of an inch from the edge of the wound, and is carried first through one lip 
 ' ■ 1'-' of the wound, and then through the other at a 
 
 ^•. - .^ point one-quarter of an inch from the edge, and 
 
 .ifei^'- 'If^ ' "^^ '**" #-'• so on from one end of the wound to the other 
 ;■ , ,y^ , ■/ -/ y (i'^'g- 428). At the lower angle an opening suf- 
 
 \ .v,>-^ ^M .M. ^ ft,'] fit'icntly large to introduce a drainage-tube may 
 •^■--.:.^lj:^.^.-:^£'..~'"i^-^--'iB^ be left if necessary. The tube must not be 
 continmti ur <;iuv(t\ siitiiri; constrictcd. Otherwise it will not afford free 
 
 , Bernard «n,l n.atte). drainage. 
 
 The interrupted suture (Fig. 429) is made by approximating the edges of 
 
<h'i:i:a ti i v-; s( 'rokr y. 
 
 1085 
 
 ■f 
 
 Iiiicrruplcil >uturc UJi-riiard 
 and Huelte). 
 
 YlG. 430. 
 
 the Avouiid by iiitrodiu-iiii.' a suture in the luaniier ali-eady (h'scrihed. hut the 
 knot is tied and the ends cut off, and other fresh 
 sutures are intnxhu-ed in the same way. About 
 tliree <»r tour stitcht^ to the inch are used, accord- 
 ing to circumstances. The interrupted suture 
 must not be tied too tightly, as tension will pro- 
 duce a stitch abscess; only that tightness which 
 will bring the two edges of the wound into appo- 
 sition is desirable. In removing the interru[)ted 
 suture (whicli is the suture most commonly used) the stitch is lifted gently 
 from the skin sufficiently to introduce one point of a pair of scissors, which 
 should then cut the suture exactly at one of the points where it penetrates the 
 skin. The skin on the opposite side of the wound is then supported by the 
 blades of the scissors, one on each side of the stitch, while WMth tlie forceps it is 
 withdrawn. In situations where a prominent scar is objectionable an inter- 
 cuticular stitch in which the needle is introduced on the under surface of the 
 skin, emerging directly at its cut e<lge. and passing back and forth from side 
 to side, may be employed. It is made with silver wire, the ends beino; secured 
 by simply bending them. The result is an almost invisible scar. This suture 
 is especially adapted to exposed parts, as the face. The object of this method 
 is to avoid infection by the skin-coccus (staphylococcus epidermidis albus), 
 
 Avhich is constantly found in the ejjideruiis, 
 and may be carried through the stitch- 
 wound by the suture if the latter is passed 
 tlirough the skin from Avithout inAvard. 
 
 The quilled suture is indicated where 
 there is considerable tension (Fig. 430). The 
 needle is introduced half an inch from the 
 edge of the wound, carrying a double thread, 
 Avhich is passed and then unthreaded. The 
 quill is then caught in the loops upon one 
 side of the wound, and the two free ends are tied around a corresponding 
 piece of quill upon the opposite side. The length of the quill should exceed 
 the length of the incision, so 
 that the Avound will be evenly 
 and uniformly draAvn in appo- 
 sition. A fcAv superficial su- 
 tures may be passed through [ 
 the skin edges, if need"<l to • 
 
 m:ike more jjerfect approxi- ^ 
 mation. i 
 
 The twi-sted suture is some- I 
 times used in hare-lip cases. f 
 A steel pin is thrust tlirough 
 both lips of the Avound at a 
 distance of half an inch from 
 the edge. The edges are then 
 brought into accurate apposition; a silk thread is Avound over the ends of 
 the pin in an oval or figure-of-8 manner (Fig. 431); h shows the suture com- 
 pleted. Strips of gauze are placed under the heads and cut ends of the pins 
 to protect the skin. 
 
 The hutton suture (Fig. 432) consists of two lead buttons, to one of Avhich 
 
 (.^uiiiL-d >uuiii- (iiL-rii;ii(.i iiini Hiu-tte). 
 
 Fig. 431. 
 
 Twistt'd Suture (Bernard and Huette). 
 
lo.sn 
 
 .l.V AMFJill'AX TEXT-HOOK OF SURGERY 
 
 Fi<;. -l; 
 
 Huttoii Siitiiiv iHrvaiit). 
 
 Fig. 433. 
 
 The Quilted Suture (Bernard anil Huette). 
 
 is attached a silver wire. The button is phiccd about two inches from the edge 
 
 of the wound, and the wire is threaded to a needle 
 which is passeil throuirli under the tissues and across 
 tlie wound and out the other side at a point two inches 
 from the edge of tlie wound. 'iTie second button is 
 now placed at this point, and the silver wire is passed 
 through the perforated centre and wound across the 
 edges or wings of the buttons. The button suture is 
 used where the wound is extensive and there is a 
 tendency for it to gape from tension. After amputa- 
 tion of the breast the button suture is sometimes used with advantage as a 
 deep or relaxation suture in addition to 
 the sutures of the edges of the wound ('//>- 
 proriniatiou .suture). Such sutures can be 
 made extemporaneously also by perforated 
 glass beads or other similar objects, the 
 wire suture after passing tiirough the 
 beads being twisted on bits of disinfected 
 Avood. such as pieces of a match. Small 
 pledgets of aseptic gauze may be substi- 
 tuted for the buttons, one being caught in 
 the loop of the thread and the free ends 
 tied over the opposite pledget. In all forms of this suture care must be 
 taken that the tension is not too great, or it will favor suppuration. 
 
 The quilted suture {¥\^. 433) is often used to act as a sort of splint, and 
 to keep the edges of the wound quiet where there is a tendency for the lips to 
 gape or to contract, as in the scrotal tissue, where the action of the cremaster 
 prevents absolute quiet. 
 
 Suhcutayieous or Buried Sutures are often necessary in deep wounds. In 
 this case each layer of tissue beneath the skin must be sutured separately. A 
 divided tendon must be sutured to its other end, the fiber of a muscle must be 
 united to its other fibers : fascii^, aponeuroses, nerves, and any other structures 
 must be brought into contact each with its own divided part. Where we have 
 to deal with deep wounds from aponeurotic and muscular tissue, as in the 
 abdominal wall, buried sutures, either of catgut or silk, can be used. Different 
 layers should be united each to its fellow, and especial care be taken that the 
 aponeurotic structures of the abdominal wall are included in the sutures. As 
 Treves has Avell stated, the surfaees of the wound, and not only the overlying 
 skin, are to be approximated. 
 
 For details as to the sutures of nerves, tendons, muscles, and bones see the 
 articles on the surgery of those structures. 
 
 Seeondary Sutures are used in wounds which immediately after operation 
 have been packed with iodoform or other antiseptic gauze to secure complete 
 hemostasis or asepsis not obtainable by the usual methods. The packing is 
 withdrawn in two or three days, when the sutures which may have been inserted 
 and left long at the time of operation, or may be put in later, are tie<l in the 
 customary manner. Union by first intention can fretjuently be secured in this 
 way in wounds that would have been infected or distended by blood-clot if 
 closed immediately. 
 
 After the continuous or interrupted sutures have been applied, if no drain- 
 age has been used, the wound may often be sealed by covering it with small 
 strips of gauze painted over with iodoform collodion or with a mercurialized 
 solution of collodion, 1 : 30,000. 
 
OPKUATIVE SURGERY. 1087 
 
 If, although formal drainage is dispensed with, fiome oozing is to be 
 expected, it would be better to use interrupted sutures at wide intervals, 
 thus permitting of the escape of the fluids of the wound from between its 
 edges. 
 
 A dry method of dressmq icowuh is often employed. This is especially 
 adapted to small wounds. Iodoform, aristol, salicylate of bismuth, acetani- 
 lid, or some other innocuous but antiseptic powder which forms a thin film 
 over the surface of the wound, may be dusted upon it after it has been sutured, 
 and thus by inspissating the blood and serum a dry aseptic crust is formed 
 which when hard prevents putrefaction. As this fihn is exposed to the air, 
 it soon dries, and the hard, firm crust prevents the entrance of particles of 
 dust into the wound. Under this artificial scab the healing process rapidly 
 progresses. The scab thus formed should not be removed, but alloAved to 
 fall off after the part is healed beneath it. 
 
 An illustration of the usefulness of this method may be found in the plan 
 of treatment of compound fractures adopted by Treves, and, following him, 
 bv White. When the case is admitted to the hospital the wound and sur- 
 rounding parts are cleansed as thoroughly as Avould be done for an aseptic 
 operation, but no attempt is made to arrest the oozing of blood, Avhich in 
 the great majority of these cases is still going on. Iodoform is sjirinkled 
 in large ([uantities and at short intervals over the wound and adjoining 
 parts, and this is continued sometimes for two or three days. At the end 
 of that time a scab has formed, beneath which cicatrization and repair take 
 place aseptically. The infiltration of the muscles and connective tissue 
 which sometimes follows the sealing of the wound in compound fracture while 
 oozing is still going on, is thus avoided, and with the least possible disturbance 
 of the parts. During the entire course of the case the affected limb, with the 
 necessary fixation apparatus, is covered by sterile towels only and kept outside 
 of the covering of the bed. as the atmosphere Avhich surrounds such a part 
 beneath the bed-clothes is much more likely to be septic than the general 
 atmosphere of the ward. Results in a large number of cases justify confi- 
 dence in this method. 
 
 Healing beneath a Moist Blood-clot. — This method of healing is 
 adapted to those cases in Avhich there has been a loss of substance in the 
 soft parts and the edges of the wound cannot be brought into apposition. 
 It is also applicable in cases of resection of joints and of compound fracture 
 of the long bones, especially where there is slight separation of the fracture 
 due to the loss of comminuted fragments. In operation for removal of necrosed 
 bone it is also a method of repair that has many advantages. Schede has re- 
 introduced this method, and to him is due the credit of perfecting the technique 
 of a process of repair in cases in which the healing would never have taken 
 place, or, if it had taken place, would have done so very imperfectly. The 
 wound is thoroughly cleansed and made perfectly aseptic, and then blood is 
 allowed to fill up the cavity. The blood-clot thus formed affords protection to 
 the raw surfaces of the wound, and if the clot does not contract and desiccate on 
 the one hand or undergo decomposition on the other, it will form a nidus for 
 granulation-tissue w-hich develops and finally cicatrizes. In order to utilize 
 a blood-clot for the purpose of healing it is essential to keep the clot moist. 
 To provide for this, a small strip of rubber tissue or protective is placed over 
 the surface of the wound and made to overlap its edge. This fine rubber 
 tissue should be rendered perfectly aseptic and immersed in carbolic acid 
 before its application to the wounded surface. Over the protective a strip of 
 iodoform gauze may be placed, and over the iodoform gauze is placed loosely 
 
1088 .-liv^ AMi:iii<'A.\ ri:xr-i:<K)K of .sLiiuEnv. 
 
 an abuiulanc'o of l»iclil<>ri(lo <;auzo, Avhicli jjvovidcs ample drainai^e by absoi-ltintr 
 fioiii the uoiiml all sui|)lus serous and lieinoniiai^ie disehaiires. Tiie wounds 
 that are best adapted for this process of healiiii: are those in which the struc- 
 tures and tissues are highly vascular. Tendons, fasciic, and other tissues pos- 
 sessing a low grade of vascularity are not suitable for it. 
 
 Open Wounds can be treated on the same aseptic principles that govern 
 the surgeon in the management of closed wounds. If a wound is allowed to 
 remain oi)en, it can l>e kept aseptic if provision is made for fi-ee drainage and 
 oxvgen is admitted to the wounded surface. By free drainage is meant a pro- 
 vision to prevent any retention of discharges that may undergo ])Utrefaction. 
 A clean, healthy granulating surface is a barrier to the entrance of septic 
 germs into the circulation. Frequent irrigiation and the avoidance of the 
 retention of discharges afford immunity from sepsis in any wound. The small 
 amount of discharge from the granulation-tissiu^ left after irrigation under- 
 goes a sort of desiccation and concentration which renders the soil unsuitable 
 lor the growth of septic germs. Pasteur has demonstrated that germs will 
 not multiply upon a surface bathed in a concentrated discharge. The free 
 admission of oxygen to the o])en wound is in itself somewhat of a safeguard 
 against putrefaction. Many of the special germs concerned in the develo])- 
 ment of putrefaction are ofteti incapable of multiplication in the j)resence of 
 oxygen. 
 
 After-treatment. — As soon as an operation is terminated the patient 
 should be put to bed between blankets and surrounded, if necessary, with hot- 
 water bottles or hot-water bags, great care being taken that the patient is not 
 burned bv them — an accident which has often produced serious conse(iuences. 
 The room should be darkened for the first few hours at least, and the utmost 
 quiet, both of mind and body, obtained. No visitors should be alloAved, 
 except .perhaps either the husband or the wife. Very frequently for want of 
 this direction friends, and especially a number of members of the family, may 
 greatly disturb the patient by conversation. Not only should rest of the 
 body as a whole be insisted upon, but also and especially rest of the part. 
 For example, after an amputation of the breast the arm of that side should be 
 secured to the trunk by a ])inder or bandage. After an operation on or near 
 a joint the extremity should be placed upon a splint. In the early stages of 
 union of wounds, the fine connective-tissue fibers, which are developed and 
 bind the parts together, and the delicate slender vessels, should be preserved 
 intact by absolute rest of the part. 
 
 The patients comfort should be the chief object, and hence a change of posi- 
 tion may be allowed, not by the active eftbrts of the patient, but by the aid of 
 the nurse. All such little attentions as placing a pillow for proper support of 
 the part, or relaxing a bandage, or the insertion of a little cotton at a point 
 of undue pressure, or gentle friction applied to the back or extremities, suspen- 
 sion of an extremity, or its being placed on a double inclined plane, — all these 
 means and the many others which will suggest themselves to a thoughtful 
 nurse are to be employed for the comfort of the patient. ^loreover, we must 
 not forget that many patients are made uncomfortable by too heavy and too 
 warm bed-clothing. That amount of clothing which is the most conducive to 
 comfort is the best. For the treatment of shock external heat has already 
 been mentioned as one of the most important means. Sometimes, again, irri- 
 tation by nuistard for a short time to the abdomen or to the extremities may 
 be used. If the shock is due to great loss of blood, the foot of the bed should 
 be raised and pillows and bolsters removed, thus favoring the access of blood 
 to the brain by gravitation. Strychnine, digitalis, and enemata of hot, strong 
 
OPERATIVE ^SUIIGERY. 1089 
 
 coffee, Avhiskey — if" lu'iuorrha^^c lias been excessive, iioriiiiil salt solution by 
 intravenous injection or subcutaneously — one or all, may be used. 
 
 One of" the most annoying post-operation symptoms is ether-voiiutiny . This 
 usually occurs, and often continues for two or three hours, and sometimes as many 
 days. If vomiting continue for ovot' twelve to eighteen hours, some other 
 cause than ether-nausea should be sought for, especially peritonitis if the ope- 
 ration has been an abdominal section. The best treatment for ether-vomit- 
 ing is the administration of one-fourth of a grain of coca'ine every hour or two 
 until four or five doses have been taken, with small doses of brandy and finely 
 divided ice or champagne and ice. The ice is best pulverized by placing a 
 small lump in a loop of a clean towel and striking it, as if it were a hammer, 
 on a marble w'ashstand. Very hot water will often arrest the vomiting better 
 than ice. Mustard over the epigastrium is also found useful, and occasionally 
 lavage of the stomach by the stomach-tube, Avhich has been successfidly 
 employed in desperate cases of this character. The vomiting is usually 
 accompanied by marked thirst. This can be best relieved by a rectal enema 
 of six to eight ounces of warm Avater, to which may be added a little brandy 
 or whiskey. 
 
 Any other than a trifling operation is usually followed by some pain. 
 Since the introduction of antise})tics the amount of pain which patients suffer 
 has been greatly diminished. It is no uncommon thing nowadays, after an 
 amputation of an extremity or of a breast, to have the patient pass the entire 
 period from the operation to complete convalescence with practically no pain. 
 Occasionally, however, moderate, and sometimes severe, pain will be experi- 
 enced ; it is likely to occur if infection takes place. Formerly morphia was 
 practically the only remedy that was used to relieve this pain, but it evidently 
 had its disadvantages in the constipation, the furred tongue, and other digest- 
 ive disturbances which it induced. For severe pain morphine must still be 
 employed in doses of i to ^ grain, best given hypodermically. But in most cases 
 the moderate pain after an antiseptic operation, unless the remedy is contra- 
 indicated by great shock and a weak heart, can be controlled and sleep in- 
 duced by small doses (5 to 15 grains) of almost any on^ of the antipyretics, 
 all of which act as analgesics. Antipyrine, antifebrin, phenacetin, acetan- 
 ilid, etc. may be used, unless contraindicated by some cardiac weakness. 
 Opium is to be resorted to only if these fail. In operations on the abdomen the 
 pain, tenderness, and other symptoms of a beginning peritonitis are best met, 
 in the opinion of many surgeons, by repeated and fre(iuent small doses of a 
 saline aperient {h to 1 teaspoonful of RocheJle or Epsom salt every hour 
 until free purgation has been secured). 
 
 The bladder must be carefully attended to after an operation. Sometimes 
 the patient will be able to urinate voluntarily, but in many cases the catheter 
 must be used. This should be most carefully disinfected, as has already been 
 described. As a rule, it need not be passed before the patient feels the need 
 for it, from five to eight hours after the operation. 
 
 Food and Drink. — After any serious operation a patient may readily go a 
 number of hours, and even two or three days, without food by the stomach. 
 In operations on the stomach and intestines this should be a cardinal rule. 
 No food whatever is required for from four to six hours after the operation, 
 during which time the stomach may possibly right itself and retain small 
 quantities. If there is difficulty in retaining it, the patient should be fed by 
 rectal enemata of peptonized milk, beef-tea, etc. If given by the mouth, the 
 food should be at first in quantities of not more than two or three ounces every 
 two hours, the amount being increased and the intervals lengthened as the con- 
 
 G9 
 
1090 A.y AMKnuAy tkxt-iuxjk of ^^I'UGEny. 
 
 (lition of the stomach Avill warrant. As a rule, the bowels, which have been 
 thoroughly evacuated the morning before the operation, will not be opened the 
 <lay after it; but on the second day, or certainly on the third day, they should 
 be moved, either by an enema or by a gentle laxative. After the second or 
 third day they should be carefully seen to either every day or every second 
 day. Often after operations for hemorrhoids comfort will be attained better 
 by daily evacuations, which prevent the feces from becoming hard and defeca- 
 tion painful. The surgeon should be careful to direct that until the patient is 
 able to rise a bed-pan should be used, and on no account should he rise to use 
 the commode, still less to go to the water-closet. 
 
 After the first or second day the patient's comfort is greatly increased by 
 a daily sponge bath of hot water and alcohol, which should be done without 
 any exposure of the person. Careful notes should be taken by the nurse, 
 either on a printed blank or on one prepared extemporaneously by the surgeon. 
 
 Renewal of Dressings. — As a rule, the less frequently the dressings are 
 disturbed the better it will be for the patient, since even the gentlest renewal is 
 apt to cause some pain, and also since the handling of a wound always exposes 
 it to the possibility of infection. So soon, however, as the wound-fluids 
 have wet the dressings to their edge they must be reinforced, or, better still, 
 renewed ; in some cases this will be required within a few hours in con- 
 sequence of the free oozing. In other cases even a number of days may 
 elapse before the dressing is changed. If a drainage-tube has been inserted, 
 the dressings should be changed in from twenty-four to forty-eight hours in 
 order to take it out. Usually by the fifth or sixth day the sutures Avill cause 
 a little tension and produce stitch-abscess unless they are removed. These 
 abscesses are especially due to the skin-coccus, the staphylococcuH epidermidis 
 aUnis (Welch), which is constantly and normally found in the epidermis, and 
 certainly cannot be removed by any of the present methods of disinfection of 
 the skin. The renewal of dressings should be done with the same antiseptic 
 care as their first application : the hands of the surgeon and the nurse should 
 be disinfected with care similar to that exercised at the time of operati'in. 
 The instruments — usually a pair of scissors, dissecting-forceps. a probe, a 
 grooved director, and a pair of dressing-forceps are all that are required — 
 should be disinfected by being placed in a 1 : 20 carbolic solution for at least 
 fifteen minutes, and the new clean dressings should be ready for application 
 before the wound is uncovered. The bed-clothes should be turned down and 
 covered with antiseptic or sterilized towels. If the wound is in the abdomen, 
 the chest should be protected by a shawl also covered by a similar towel. 
 Great care should be taken not to chill the patient. If they have to handle 
 the body or bed-clothing, the binder or bandage, the surgeon and nurses should 
 again disinfect their hands. Soiled dressings having been removed, the wound 
 may be gently washed with an antiseptic solution, and after such attention to 
 the wound as seems necessary the dry clean dressings, followed by the binder 
 or bandage, should be applied. It is very important to change the position 
 of the patient from time to time, to prevent be<l-sores. 
 
 Bed-rests are often of great service during convalescence. They should, 
 however, be employed with judgment, as it is sometimes dangerous to allow a 
 patient to assume the upright position even in bed unless the heart's action is 
 sufficiently strong. One which enables a patient gradually to sit up after a 
 serious surgical operation and during the repair of a wound hastens recovery. 
 
 Air-cushions may serve as useful adjuvants by contributing to the comfort 
 of a patient during convalescence. These may be used to remove pressure 
 from parts which have shown a tendency to bed-sore formation, or they may 
 
OPERATIVE SURGERY. 1091 
 
 be employed to rest extremities upon, or to make uniform and equable pres- 
 sure upon certain parts of the body. 
 
 WaU'r-cushlons are often found to contribute to the comfort of a patient. 
 They can be used to afford support to the back, or can be filled with hot water 
 and serve as a conductor of heat to a part. Care should be exercised lest the 
 water be too hot and thus burn a patient who may ]>e in shock after an injury. 
 Sinqle and double inclined planes are indicated wlien it is necessary to place 
 one of the extremities in a position of flexion. In compound fracture of the leg 
 in which there is a tendency for the fragment to protrude through the wound 
 the double inclined plane relaxes the muscles and prevents the accident. A 
 single inclined plane is indicated in a fracture of the patella or a wound of 
 the^'quadriceps extensor muscle of the thigh, or in a case of cellulitis of the 
 forearm where elevation, compression, and fixation of the part are simultan- 
 eously required. 
 
 Suspension apparatus, especially for the lower extremities, is necessary 
 where a certain amount of movement of the body in bed must be allowed, 
 while at the same time it is necessary to secure physiological rest to the 
 wounded part itself. 
 
 Splints are often a necessity in wound-treatment. They serve to secure 
 absolute rest to the part until healing takes place. Whatever material is em- 
 ployed for the splint, it should be carefully and evenly padded with absorbent 
 cotton. If the padding becomes stained by the discharges, a new one should 
 be substituted, as it might be the means of carrying infection to a wound. 
 
 COxMPLiCATiONS AFTER OPERATION. — The most important danger is that 
 of septic inflammation. There will usually be a post-operation rise of tem- 
 perature to 100°, or occasionally to 101°, which will persist for from twenty- 
 four to forty-eight hours. If the temperature rises after this latter time, sepsis 
 should be suspected, the dressing be removed, and the wound inspected. If 
 sepsis has occurred, the wound should be disinfected through the drainage-tube 
 if one has been used, or in some cases it may be necessary to reopen the wound 
 by removing the stitches, and follow this by disinfection. If hemorrhage 
 has occurred and any considerable clot has formed, evinced by bloody oozing, 
 by swelling and tension, and by a rise of temperature to 101° or over, the 
 probabilities are that the clot is too large to be absorbed. One, two, or more 
 stitches should be removed and the clot completely evacuated, and any bleed- 
 ing vessels secured, followed by a redisinfection with scrupulous care. If this 
 is "done within from twrnty-four to forty-eight hours, very frequently the case 
 will still run an aseptic course. If in an abdominal case peritonitis arises, the 
 saline treatment should be instituted at once. Sometimes the bowels become 
 greatly distended with flatus, in which case great comfort may be obtained from 
 inserting a soft catheter or rectal tube, which may be held in place and secured 
 from loss within the bowels by a moderately long thread tied to its extremity. 
 If the distention does not yield, a saline laxative in repeated doses, or a tur- 
 pentine enema, will usually relieve it. 
 
 Not uncommonly, especially in hospital patients, delirium tremens Avill 
 occur after an operation : this must be treated in accordance with the prin- 
 ciples already laid down in connection with that affection. Occasionally in- 
 sanity follows surgical operations, especially those about the head, uterus, or 
 ovaries. The attack may often be only temporary, but in some cases it is 
 more or less permanent. 
 
 Causes of Death after Surgical Operations. — This may be due to 
 hemorrhage, either primary or secondary ; to the administration of the anes- 
 thetic, directly or indirectly, as, for, example, by choking from the entrance 
 
101)2 AN AMKRICAy TEXT- HOOK OF Si: HOE II Y. 
 
 nf vomited matter into the trachea; to sliock of tlie operution, due in part to 
 hemorrhage a-s wi-ll as narcosis, and also to the traiiinatisni calling for the ope- 
 ration ; to entrance of air into the veins; to sepsis from incomplete or im})erfect 
 antiseptic technique; to shock, either primary or secondary, from some organic 
 disease of one of the vital org-ans of the body ; to tetanus ; to persistent vomit- 
 ing ; to delirium tremens ; to the formation of emboli or thrombi ; to the devel- 
 opment of some intercurrent disease, as jjncumonia, peritonitis, bronchitis, or 
 some other affection which may be indirectly or directly attributed to the opera- 
 tion itself; to oedema glottidis, caused by an intlammation of the surrounding 
 tissues in the neck ; to an extension of an inHa^nmation from one organ or tissue 
 to another, as a surgical kidney from a cystitis the result of an operation for 
 removal of a calculus; to perforation of the bowel, owing to a slough caused 
 by tearing up adhesions during a l:ij)arotomy, or to the formation of a slough 
 produced by adhesive inthimmation between the intestine and bladder, for 
 example, when a fistulous communication was established ; or to over-stimu- 
 lation of the heart in an attempt to bring about reaction after operation. 
 
 CHAPTER II. 
 
 ANESTHESIA. 
 
 Anesthetics have contributed much to the present success of surgery. 
 The first recorded instance of a surgical operation having been performed 
 while the patient was under the influence of anesthesia was the removal 
 of a tumor from the neck by Dr. Crawford W. Long of Atliens, Ga., in 
 1842. No further attotnpt, however, was made to introtUice an anesthetic 
 until 1844, whcTi Dr. Horace ^Yells, a dentist of Hartford, Conn., first inhaled 
 nitrous-oxide gas, and had a tooth extracted without any sensation. With- 
 out doubt, the merit of introducing ether as an anesthetic belongs to Dr. Mor- 
 ton, who in 1846, at the suggestion of Dr. Jackson, a chemist, selected this 
 agent for the purpose of extracting teeth. Dr. John C. Warren, the senior 
 surgeon of the Massachusetts General Hospital in Boston, was applied to by 
 Dr. Morton in the autumn of 184(3, who informed him tluit he had discovered 
 a means of preventing pain in dental operations, angl wished to have an oppor- 
 tunity to try it in a surgical operation. The first operafion was {x^'formed by 
 Dr. Warren at the hospital on October IC, 1846, and consistoil in the removal 
 of a vascuhir tumor of the neck from a young man in the public operating 
 room. Dr. Morton administered the ether. In a few months anesthesia, 
 hitherto a dream, had become a reality throughout the civilized world. In 
 1847, Prof. James Y. Simpson of Edinburgh first introduced chlorof(M*m into 
 surgical practice. 
 
 Anesthetics act by p»oducing a p.aralysis of the cerebral and spinal nerve- 
 centers. There is first a stage of cerebral excitement, followed by a stage of 
 cerebral insensibility, then a loss of voluntary movement, followed by a loss 
 of reflex aetion. Consciousness is lost before the paralysis of the muscles 
 supervenes, and a patient is said to be fully anesthetized when the nerve-cen- 
 ters are paralyzed, with the exception of those presiding over the respiration 
 and circulation. 
 
 Ether is chemically the oxide of eihyl, with the formula (C2H5)20. It is a 
 
A NESTHESTA . 1 093 
 
 hi<:lilv volatile and clear li(|ui(l. with a piin^rent odor, a sharp taste, and a spe- 
 ciiic i«;ravity of .Too (at ^)AJy° F.), and boils at Ito^ F. It is highly inflanmiablo 
 and explosive. This fact shouhl always bo borne in mind, because during an 
 operation a lighted candle or gas-jet brought near the ether may cause a serious 
 explosion. Ether vapor, being heavier than air, always falls ; hence if a light 
 has to be used, it should be held above the ether to avoid the danger of such 
 an explosion. If an explosion occurs, the patient's face should instantly be 
 covered witii a towel or pillow to prevent l)urning ; the inhaler may be thrown 
 U]ion the floor, but in'iu'i- the ether-can or bottle, for fear of the spilling of the 
 ether and its catching fire. 
 
 Ether is prepared by the action of sulphuric acid upon strong alcohol 
 heated to a temperature of 260° to 300° F. A simple test as to the purity 
 of ether is to add a little oil of copaiba to it, when the mixture should remain 
 clear: if an emulsion forms, it indicates impurity of the ether from the pres- 
 ence of alcohol or water. 
 
 There are some contraindications to the use of ether as an anesthetic. In 
 cases of renal disease ether is generally thought to be less safe than chloro- 
 form, owing to the danger of suppression of the urine and shock, although 
 the opposite opinion is held by some surgeons. The presence of nephritis 
 certainly calls for care in the administration of either ether or chloroform. 
 The minimum (piantity should be administered. Chloroform is often well 
 borne when administered with pure oxygen. In atheroma of the vessels it is 
 not expedient to use ether, owing to the vascular excitement incident to the 
 primary stage, which might result in rupture of the vessels from increased 
 tension. In patients suffering from emphysema, asthma, or chronic bron- 
 chitis ether is unsuitable, owing to its irritation of the pulmonary and bron- 
 chial organs. Ether is also contraindicated in serious and prolonged operations 
 about the face and mouth where the patient cannot be kept constantly breath- 
 ing the vapor. Ether can be safely employed when it is necessary to use the 
 actual cautery or a lighted candle near the face of the patient by suspending 
 its administration for a few moments, and fanning away its vapor before 
 using the cautery. 
 
 Ether is best administered by means of Allis's inhaler. The latter should 
 be placed over the nose and mouth dry, and the ether put on it drop by 
 drop, increasing the amount gradually as the mucous membranes become 
 accustomed to the vapor. Cough, spasm of the larynx, etc. are thus 
 largely avoided. After a few inhalations the patient is bewildered, the face 
 flushed, the respiration rapid, and the pulse at first slightly accelerated and 
 somewhat stimulated. Then follows the period of ''primary anesthesia," 
 which continues for a brief time, and during which short operations, such as 
 opening an abscess, dilating the sphincter, etc., may be done without pain 
 and with almost instantaneous recovery. If during the earlier part of the 
 administration the patient is repeatedly directed to hold his arm up, its fall is 
 a good indication of the induction of this stage. Many surgeons, however, 
 consider this a dangerous practice. 
 
 A period of excitement soon supervenes, and it is often necessary at this 
 period to restrain the patient. After the stage of excitement the patient passes 
 into a state of muscular relaxation ; the respirations are regular, accompanied 
 often by snoring, and attended by a considerable secretion of mucus in the 
 mouth. The face is flushed and the skin soon becomes moist. During the 
 period of muscular rigidity which precedes that of relaxation the breathing 
 sometimes ceases, and artificial respiration must be resorted to at once. 
 
 While administering ether the fact must always be borne in mind that its 
 
105M AX AMI-J^CAy TKXT-naoK OF SiliiUim'. 
 
 vafior commonly kills by asphyxia, and nut by syncope; conseciuontly, the 
 j)uise usually keeps up lonji; after the patient has ceased to breathe, although 
 in rare cases the i'ailure of the heart is primary, the patient dying of syncope. 
 Hence, though the pulse is to be watched, the resjiiratioii should be the jirin- 
 cipal object of solicitude. 'I'he symptoms of asphyxia come on gradually, and 
 thus a warning is given, and the first appearance of dangerous symptoms must 
 be met with prompt and suitable remedies. There are certain patients who 
 take ether with great difficulty, and in whom its administration is attended 
 with some danger. Patients with cardiac obstruction and sluggish circulation 
 are very apt to take ether badly. If the face is florid or there is much capil- 
 lary stasis, the administration of ether is attended with especial difficulty. 
 
 The hypodermatic injection of -^ of a grain of morphine with -j-^ of a 
 grain of sulphate of atropine has been suggested as a valuable addition in 
 securing the anesthetic state. It should be given about fifteen minutes before 
 the ether is administered. 
 
 Chlokofoum (formula CIICI3) is a clear rK}ui<l. with a specific gravity of 
 1.407 at G2.5° F., with a sweetish taste and an ethereal odor. The drug 
 should not be allowed to stand exposed to the light, since the article thus 
 becomes impure by decomposing and forming hydrochloric acid and chlorine. 
 
 In admiyiistering chloroform a toAvel may be placed over the patient's mouth 
 and be kept moistened by chloroform drop by drop, or about a half teaspoonful 
 should be poured upon a napkin and held about an inch from the face, but never 
 allowed to touch it, on account of its irritant action on the skin. The patient 
 should be instructed to close the eyes, since the vapor may inflame the con- 
 junctivae. A little vaseline may be smeared over the face to prevent erythema 
 of the skin. After the patient has inhaled the chloroform a few minutes, con- 
 sciousness is lost, the conjunctivae become insensitive, and the breathing assumes 
 a stertorous character. During the inhalation the na])kin must be ke|)t at least 
 one inch from the patient's face, not only because if held nearer than this the 
 vapor might act as a vesicant, but also and especially because experiment has 
 shown that the vapor is inhaled under the condition just stated in the strength 
 of about 5 per cent, admixture with the air, which is a proper proportion. The 
 vapor must not be given too suddenly nor continued too long without alloAving 
 fresh air to be inspired. The patient should be always placed in the recumbent 
 posture, and never allowed under any circumstances to sit up erect. Before 
 the patient is fully anesthetized convulsive movements often take place and 
 the face becomes cyanosed. It is best in such case not to struggle with the 
 patient, but to discontinue the inhalation until the cyanosis has disappeared, 
 when the napkin can be replaced over the face. Occasionally, without con- 
 vulsive movements or lividity of the face, the patient passes ((uickly into an 
 unconscious state. The pupils should be closely watched to ascertain if they 
 respond to light or if they are dilated. Failure of the pupils to respond to 
 light, or their wide dilatation, is a sign of approaching danger, and the inha- 
 lation should be at once discontinued, the head lowered, the tongue drawn 
 well out of the mouth, the heart stimulated, and artificial respiration begun. 
 The loud stertor indicating the closure of the larynx by the epiglottis is a sign 
 of danger, and must not be mistaken for snoring, in which a patient often in- 
 dulges while profoundly under the influence of an anesthetic. 
 
 In beginning anew to place the chloroform over the face of a patient upon 
 whom its use has been discontinued on account of some serious signs, the vapor 
 should be carefully and slowly given, otherwise fatal syncope may follow in a 
 heart already aff'ected by a previous overdose. During the entire period of 
 taking chloroform the finger should be kept over the temporal artery, to detect 
 
ANESTHESIA . 1 095 
 
 immediately the slightest change in its' character or volume. Every respira- 
 tion should be watched. It is not enough to watch the movements of the chest, 
 because the glottis may be closed and the chest-wall move, and yet but little 
 air enter the lungs. Tlie hand may be placed over the mouth and the current 
 of air recognized. In case the glottis is closed and the vapor has filled the 
 pharynx, the patient becomes asphyxiated, and as soon as the glottis is open a 
 condensed volume of vapor instead of fresh air is drawn into the lungs. If the 
 patient is suffering from a weak and feeble heart, this sudden overdose may cause 
 a fatal termination. A patient may die either on account of asphyxia or from 
 heart-failure. The asphyxia may be due to the presence of a foreign body in 
 the larynx from vomited material, or to a too condensed form of vapor which 
 the patient has been allowed to inhale. Heart-failure is a frequent cause of 
 death during the administration of chloroform. The face becomes pale, the 
 finger-nails turn blue, the pupils become dilated, the pulse flickers, and the 
 heart's action is arrested. As a rule, this accident occurs only in a heart which 
 has undercrone fattv deereneration or in which mitral or aortic valvular lesions 
 exist. The respiration often keeps up even after the heart ceases to beat. Ilence 
 in giving chloroform the great importance of watching especially the pulse in 
 addition to the breathing. Death may occur from syncope during the first few 
 inhalations, or it may occur at the end of the period of anesthesia, but under 
 these circumstances some warning of impending danger is given by the gradual 
 onset of the symptoms. 
 
 Of course in giving any anesthetic it is highly important that the lungs as 
 well as the heart and the kidneys should be sound. The anesthetic is probably 
 never eliminated entirely by the lungs, but only with the aid of the excretory 
 organs crenerallv. If the lungs have a smaller area than usual on account of 
 disease, just so much more strain is thrown on the kidneys, and if, in addi- 
 tion, the latter are contracted or fatty, the danger is greatly increased, espe- 
 cially if ether is used. Chloroform usually kills by its depressing action on 
 the heart, and it seems highly probable that it often does this by the prop- 
 erty which it has been shown to have, of destroying the contractile power 
 of the cardiac muscle when it reaches it in a sufficiently concentrated form. 
 Various circumstances mav greatly affect the degree of its concentration in 
 the luTigs and the circulation, and thus increase or decrease the danger of its 
 employment. Of these the most important are those connected with the cha- 
 racter of the respiration of the patient and the circulation through the lungs- 
 For example, a given quantity of chloroform, say one dram, will exert its 
 greatest effect when the respiration is deep and quick, because the vapor 
 is then carried, in a given period of time, in larger quantity into the air- 
 spaces of the lungs. If, at the same time, the patient, being only partially 
 anesthetized, stops suddenly after breathing deeply — i. e. closes his glottis and 
 strains — he increases the rapidity of absorption of the chloroform vapor into 
 the blood ; or if the movement of blood through the lungs is exceptionally 
 slow, as shown by a dusky or congested appearance of the face, the opportunity 
 for absorption will likewise be greater, and the blood will reach the heart over- 
 charged with chloroform, and possibly produce its poisonou^ effect. 
 
 A combination of these conditions, therefore, should put the anesthetizer, 
 especially one who employs chloroform, on his guard. During the preliminary 
 stages of chloroformization at least it may be said that a patient who is suffering 
 from shock after injury or accident, who is only partially anesthetized, whose 
 face is dusky or congested, and who is struggling against the anesthetic, is in 
 the greatest danger. Manv deaths have occurred from chloroform under these 
 circumstances and in this first stage, or so-called "stage of excitement." 
 
101»6 .1-V A. V /:/.'/( AX TKXT-B(J()k' OF SlRdKIiY. 
 
 The secofiJ stage is the period of true anesthesia, during which conscious- 
 ness and sensibility are abolished, the muscles partly relaxed, the pulse weak, 
 the breathinj: often shallow and feeble: it is during this stage that operations 
 should be performed, and great care observed to limit the quantity of chloro- 
 form used to the least amount necessary to continue the condition without 
 causing it to pass into the third stage, or that of dangerous narcosis, in which 
 there are increasing weakness of the pulse, stertorous breathing, complete abo- 
 lition of the reflexes, and other indications of ]trofound involvement of the nerve- 
 centers. This is still more dangerous than either of the other stages. There 
 may be no premonitory symptoms of danger, or it may be indicated by either 
 great paleness or congestion of the face or by marked irregularity and failure 
 of the pulse. 
 
 It seems probable that the position of the patient during the administration 
 of chloroform has something to do in increasing or diminishing the risks of 
 respiratory or cardiac failure. It is said that during gynecological and obstetric 
 operations, in which the patients are kept lying on the left side, the pulse and 
 respiration have been more satisfactory during anesthesia from chloroform than 
 when the patients have taken it in the dorsal position. It may be that the view 
 which attributes special safety to the drug in obstetrical cases took its origin in 
 the fact that the customaiy obstetrical position in England and in this country 
 is upon the left side. Buxton thinks that the influence of position is unques- 
 tionably important, and is due to the fact that the condition of the heart, lungs, 
 tongue, and larynx is more nearly correct physically and physiologically when 
 a patient is placed in the left lateral position instead of on the back. In hip 
 opinion, the difference in the condition of the pulse and respiration of patients 
 chlorofonned in the dorsal and lateral positions has been so striking as grad- 
 ually to force on one the lesson of placing every patient, where it is possible, 
 on the left side while chloroforming him. 
 
 Poisoning from Ether and Chloroform. — In his address before the 
 Berlin Congress of 1800. Dr. II. C. Wood calle<l attention to the value of forced 
 artificial respiration, and to its superiority to the ordinary plans as practised 
 upon the human being. He stated that he had repeatedly taken dogs in which 
 both respiratory and heart movements had been absolutely arrested by chloro- 
 form or by ether, and had restored them to life by pumping air in and out of 
 the lungs. He further called attention to the fact that Dr. Fell of Buffalo had 
 demonstrated the extraordinary efficacy in man of forced artificial respiration 
 in severe morphine-poisoning, so that the methods of the physiological labora- 
 tory must be considered as applicable to human beings. Dr. Fell s a]iparatus 
 consists of a pair of foot-bellows, by which air is forced into a receiving cham- 
 ber, which is connected with an apparatus for warming the air. and a valve 
 ■which can be opened and shut by a movement of the finger. This valve, in 
 turn, leads to a trachea-tube which is inserted into the trachea of the narco- 
 tized subject. When the valve is opened, the air rushes through the chamber 
 into the lungs and expands them ; the finger is lifted, the valve shuts, the 
 lungs contract, and so the respiration goes on. Experiments upon the dead 
 body convinced Dr.' Wood that the trachea-tube is not necessary, and that a 
 closely-fitting face-mask, such as is employed for the inhalation of nitrous 
 oxide, will suffice in most if not all cases, and that an intubation-tube makes 
 a good substitute for the trachea-tube. All the apparatus that Dr. Wood 
 believes necessary is a pair of bellows of proper size, a few feet of India- 
 rubber tubing, a face-mask, and two sizes of intubation-tul>es (in case the face- 
 mask should not suffice) ; there should also be set in the India-rubber tubing 
 a metal tube with an opening similar to that commonly found in the tracheal 
 
A NESTHESIA . 1097 
 
 canula of the physiological laboratory, so that the operator can allow the escape 
 of anv excess of air thrown hv tlie bellows. 
 
 In using this apparatus the mask should ]>e first tried care being exercised 
 to see that1)y a thread passed through it the tongue is well drawn forward and 
 held in place, so that the epiglottis is kept up. If the lungs do not fully 
 expand, the intubation-tube may be employed. The lungs should be thor- 
 ouc^hlv but slowlv expanded bv each stroke of the bellows, and a respiratory 
 rat'e of about si.xteen to twentv a minute be steadily maintained. It is essen- 
 tial to free the lungs and bloo<l as rapidly as possible of chloroform by quickly 
 chaiK^ing the residual air of the lungs : but of course due care must be exer- 
 cised^'that no force sufficient to rupture the air-vesicles l)e employed. A\ hen 
 the symptoms are protracted and the body temperature fails, external warmth 
 must be used, and the temperature of the room, unless the air entering the 
 lun<TS be artificially heated, should not be less than 85° F. 
 
 Nitrous-Oxide Gas (formula NjO) consists of nitrogen and oxygen in chem- 
 ical union. The gas is made from nitrate of ammonium, which is heated in a 
 glass retort until at 226° F. the salt melts, and at 460° F. it gives off the gas. 
 This gas is stored for use in gasometers or in steel cylinder in whicli it has 
 been liquefied by pressure. This is the best form for surgical use. On turn- 
 in<T a key the gas escapes into a rubber bag (Avhich comes with the apparatus), 
 in°which it is instantly vaporized and from which it is inhaled. When the gas 
 is administered it enters the blood bv diffusion through the thin walls of the 
 air-cells in the lungs. The physiological eff"ects are diminution m the number 
 of the respirations! and the breathing also becomes shallow. If the gas is 
 pushed to a dangerous dose, the eff"ect is entire cessation of respiration, ihe 
 heart, however, pulsates until some time after breathing has ceased. It is 
 therefore of the greatest importance to watch carefully the respirations when 
 this anesthetic is administered. i -i v 
 
 The duration of unconsciousness is about one minute : hence, while this gas 
 is the safest of all anesthetics, its great drawback is the short interval of time 
 durin-T which anesthesia continues. Nitrous oxide can be administered, how- 
 ever bv one accustomed to giving it so that an operation occupying consider- 
 able' time can be performed. In over 400.000 recorded administrations of 
 the aas by Dr. J. D. Thomas of Philadelphia and the Colton Dental Asso- 
 ciation in New York, only one death has occurred, and it is not positively 
 certain that this death was due to the gas. 
 
 In adminhterinq the gas a cork or a piece of wood with a long safety-string 
 attached to it is placed between the molar teeth. The mouth-piece is then 
 inserted, the nostrils are closed bv the thumb and finger, and the pa- 
 tient be<-ins to inhale the gas. No mask should be used, as this prevents the 
 adminisfrator from observing the color of the face and lips. NNhen 
 the lun^rs are filled there is a slight cyanosis visible about the tace 
 and earl and the tips of the fingers. In a few seconds later the 
 patient be^rins to lose consciousness. During this time the room 
 should be l<?pt quiet, and no loud talking indulged in, as this is apt to dis- 
 turb the patient and bring him back to consciousness. ^^ ithm one minute from 
 the inhalation the pupils dilate, the face loses all its expression, and strabismus 
 is observed. In a very short time deep anesthesia supervenes, accompanied by 
 stertorous breathing and muscular twitchings : the conjunctiva become insensi- 
 tive to touch, and the eveball itself oscillates. The respirations soon become 
 slower and shallow. The pulse at this stage should be watched, and if there 
 is any change the inhalation of the gas should be immediately discontinued. 
 The stertor and cyanosis are the signs indicating that the patient is anesthe- 
 
1098 .I.V AMKincAX TEXT- HOOK OF SURGERY. 
 
 tize<l. The cessation of stertor, the disappearance of the cyanosis, and the 
 absence of convulsive movements indicate the return to consciousness, ■svhicli is 
 sometimes usliered in by a shriek or cry. Durinj: the stage of anestliesia pro- 
 duceil by nitrons-oxide gas there are no emerirencies which are ])eculiar to tliis 
 anestlietic, and none which are not fully covered by the rules laid down for the 
 manatrement of accidents during the administration of any anesthetic. 
 
 Rules for Giving Ether and Chloroform. — The patient should not 
 eat any solid food fur eight Imurs before taking an anesthetic, nor any fluid food 
 less than two hours before the operation. lie may take some brandy and 
 cracked ice ten minntes before inhaling the anesthetic. 
 
 The anesthetizer should always listen to the patient's heart, and at the same 
 time assure the patient that this act is a part of the routine treatment in giving 
 an anesthetic. If he is adroit, he can turn this to good advantage by assuring 
 the patient that his heart is free from any disease. 
 
 The patient should always assume the recumbent position, which facilitates 
 the circulation between the heart and the brain. Syncope is more likely to 
 occur when the patient is in the sitting posture. 
 
 All articles of dress should be loosened, so as to have nothing to impede or 
 constrict the respiration and the circulation, especially about the neck and 
 abdomen. 
 
 The urine should always be examined, especially before ether is given. 
 
 In giving chloroform apply vaseline over the face to prevent irritation and 
 excoriation of the skin by the vapor. The ej^es must be closed, so that a con- 
 junctivitis will not be produced. 
 
 False teeth must be removed, and tobacco or any other foreign body in 
 the mouth taken out, lest it might foil back into the pharynx or larynx. 
 
 In applying the towel or inhaler to the mouth allow at first a free admix- 
 ture of air Avith the vapor. Assure the patient that, though the first few 
 inhalations are disagreeable, they are free from danger. 
 
 Instruct him to take a fcAv full, deep inspirations in quick succession and 
 count out loud up to fifty. 
 
 Watch the number and character of the respirations, and also feel every 
 pulsation of the temporal artery from the beginning to the end. Clear the 
 mouth and throat from mucus whenever it seems to impede the free entrance 
 of air into the larynx. If mucus accumulates to any serious extent in the 
 bronchial tubes, inversion of the patient will get rid of it. 
 
 When the eyelids can be raised without resistance and the cornea is insen- 
 sitive, the patient is usually fully anesthetized. Do not begin an operation 
 until the patient is entirely under the influence of the anesthetic, as it is dan- 
 gerous to operate during partial anesthesia. 
 
 If vomiting occurs, turn the patient's head well to one side, open the mouth 
 widely, and clear the throat and pharynx. 
 
 Under no circumstances should an anesthetic be given unless the adminis- 
 trator has tongue forceps, a mouth-gag, the necessary cardiac stimulants, and a 
 hypodermatic syringe at hand. Tracheotomy instruments, the battery, and 
 an apparatus for forced artificial respiration should always be within reach in 
 a hospital. 
 
 3Iortality. — It is not surprising that any drug which is capable of depriv- 
 ing a patient of consciousness and of rendering him insensible to pain is not 
 entirely devoid of danger. Death from an anesthetic can often be traced to 
 some carelessness. When carefully watched and administered properly there 
 is, as a rule, but little danger. Sometimes, however, even with the best of 
 care, sudden death will occur. 
 
ANESTHESIA. 1099 
 
 Gurlt's statistics of 1897 cover over 330,000 cases. These show one 
 death in every 207;') eases from chloroform ; one in every 5112 from ether; 
 one in every 7()lo from (•hh)r()lorm and i-tlier to;^etiier ; one in every 3370 
 from tlie mixture of ak-ohol, cidoroform, ami ether; and one in every 5396 
 from etiiyl bronnde. Some deaths have resulted from the cases having need- 
 lessly been anesthetized in the sitting posture, often by incompetent persons, 
 and without the proper means at hand to meet the sudden emergencies that 
 may arise. More and more is it coming to be recognized that no anesthetic 
 should bo administered, unless in an emergency, by anyone but a |)ractised 
 and skilful anesthetist, and no operation of imj>ortance be done except in a 
 hospital which attbrds plenty of assistants and is suj)plied with everything 
 needful for every possible complication and danger. Every surgeon should 
 observe the above rules, and should inform himself in detail in regard to 
 every patient before an anesthetic is administered. 
 
 ACCIDENTS OCCURRING DURING THE ADMINISTRATION OF AN ANESTHETIC. 
 
 Death may occur suddenly from paralysis of the heart. This accident is 
 likely to happen when the vapor is administered in too concentrated a form to 
 a patient suftering from a fatty or enlarged heart. The respirations continue 
 after the heart has ceased to beat. In sudden syncope produced by an over- 
 dose of the anesthetic the patient's head should be immediately lowered almost 
 to the floor. 
 
 Death may occur by asphyxia due to a falling back of the tongue over the 
 epiglottis. The tongue in this case should be forcibly drawn well out of the 
 mouth. Death may also occur by a tetanic fixation or by relaxation of the res- 
 piratory muscles. In the two latter conditions the heart pulsates while the res- 
 pirations have ceased. Artificial respiration should be kept up, and nitrite of 
 amyl administered by inhalation in three-drop doses. 
 
 Death, again, may occur from coma on account of a violent congestion of 
 the brain. This accident is more likely to arise in patients addicted to the 
 alcoholic habit or in cases of renal disease or in epileptics. 
 
 Death may also be caused by entrance of vomited material into the larynx 
 and trachea. 
 
 Finally, death may occur from a combination of the causes already men- 
 tioned, associated with traumatic or surgical shock. In exceedingly nervous 
 patients tympanites of the stomach often irritates the pneumogastric nerve and 
 enfeebles the heart's action. Removal of the gas in the stomach is to be 
 secured if possible, in order to avoid danger. 
 
 When any of these conditions — which are likely to occur during anesthesia 
 from chloroform, but may also be produced by ether and other anesthetic 
 agents — are threatened, the duty of the anesthetizer should be the same in 
 every case. He should promptly take the following precautions : 
 
 1. Remove the anesthetic, and secure a plentiful supply of fresh air about 
 the head and face of the patient. 
 
 2. Place the fingers back of the angles of the inferior maxilla and press it 
 strongly forward, thus carrying with it the tongue. 
 
 3. Seize the tongue with forceps and draw it forward. 
 
 4. Lower the head of the patient, and, if the case is grave, raise the lower 
 limbs, pelvis, and trunk higher than the head and shoulders. 
 
 5. Use forced artificial respiration, or, if the apparatus for this is not at 
 hand, then begin the movements of artificial respiration, catching the arms at 
 the elbows and carrying them outward and upward until they almost meet in a 
 
1100 A.y AMKIUCAX TKXr-lif)<>K OF SURGERY. 
 
 line alx)ve the head, then bringing them down again until they touch the ante- 
 rior surface of the chest: at each movement moderate pressure should be made 
 upon the lower portion of the chest. These motions should be repeated not 
 oftener tlum sixteen or eighteen times per minute. 
 
 ^'). Dax'iJi alternately hot and cold water or ether on the front of the chest 
 and ab«lomen. 
 
 7. Give hypodermatic injections of strychnine, tincture of digitalis, or nitro- 
 glycerin. 
 
 8. Rub the extremities strongly toward the heart. 
 
 9. Compress the abdominal aorta. 
 
 The last two methods are intended to keep the blood in the region of the 
 heart and great nerve-centers, where, at least during the period of shock, its 
 presence is vitally imjxjrtant. 
 
 10. Faradize the diaphragm through the phrenic nerve, placing one pole 
 on the pit of the stomach and the other over the base of the neck at the 
 external border of the stemo-mastoid muscle. 
 
 11. Small lumps of ice, or "ice suppositories," inserted into the rectum, 
 will sometimes by reflex action bring about deep breathing, as Avill also forci- 
 ble dilatation of the sphincter ani. 
 
 12. As soon as the power of swallowing returns, use diffusible cardiac 
 stimulants — alcohol and ammonia, etc. 
 
 Choice of an Anesthetic. — The general conclusions may be formulated 
 as follow- : 
 
 1. As a rule, ether, as the safest of the more powerful anesthetics, is to be 
 preferred ; the lessene<l risk to life more than counterbalances its minor dis- 
 advantages. 
 
 2. Chloroform may be employed when ether has failed or cannot be pro- 
 cured, or when there is a distinct record of serious trouble during a previous 
 etherization. It is jx>ssibly safer in children than in adults, and it is said to 
 be exceptionally adapted for administration in obstetrical cases. It has some 
 distinct advantages over ether in cases of stenosis of the larynx or trachea, 
 and may be considered in those cases of emergency in which an operation has 
 to be performed a short time after a solid meal. As secondary- indications for 
 its employment the following may be mentioned : (a) protracted operations 
 about the mouth, jaws. nose, or pharynx which necessitate the mouth and 
 nose being uncovered ; {h) operations calling for the employment of the actual 
 cautery in the vicinity of the mouth, though ether may be used as above 
 directed ; (c) severe bronchitis, emphysema, or asthma ; {d) extensive renal 
 disease : {e) marked atheroma. 
 
 3. Nitrous oxide should be employed in operations which can be completed 
 in from two to five minutes. 
 
 4. Methylene, methylene ether, and the various anesthetic mixtures, such 
 as the A. C. E. mixture (yilcohol one part, Cliloroform two parts, and -Fther 
 three parts) are not so safe as ether alone, and have no decided advantages to 
 compensate for the increased risk. 
 
 Local Anesthesia. — It often is necessary to perfonn certain minor ope- 
 rations where it is undesirable to administer a general anesthetic. The open- 
 ing of a felon or an abscess, paracentesis thoracis, the removal of a toe-nail or 
 a Avart, the extraction of a splinter, are some of the minor operations where 
 local anesthesia is most valuable. 
 
 There are several ways to produce local anesthesia. One of the simplest 
 is to place over the part to be incised a small muslin bag containing some ice 
 pounded very fine, with salt, which must be kept in contact with the skin for 
 
A NESTHESIA . 1101 
 
 two or three ininiites or until tlie skin is l)lanclic(l. Another way is by spray- 
 inf; j»ure etlier or rhi^folene over the part by a hand-atouiizer. Recentlv the 
 sprays of ehhiride (»f" etliyl and anestile have been employed to advantage. 
 They are sold in small iilass tubes provided with means to deliver a fine jet 
 of the volatile Hiiid, whieh quickly chills or even freezes the surface with 
 which it comes in contact. In certain tissues, among which may be men- 
 tioned the scrotum, a slough may result from local anesthesia; judgment, 
 therefore, must be exercised in its employment. 
 
 FAhyl CJiloride is a local anesthetic Avhich possesses superior advan- 
 tages. It is made by the action of either hydrochloric acid or phosphorous 
 chloride upon alcohol. The great volatility has been overcome by the use of 
 glass bulbs upon one end of which is a capillary orifice to which is attached a 
 copper screw thread for the cap. The bulbs contain enough of the ethyl 
 chloride to produce anesthesia in at least a dozen cases. The action is very 
 rapid, and it is said to produce no local injury or any constitutional danger. 
 For such minor operations as opening abscesses or carbuncles, removal of 
 splinters, extraction of teeth, removal of small subcutaneous tumors and 
 ingrowing toe-nails, this local anesthetic is of great value. The thermo- 
 cautery can be applied to a surface upon which this local anesthetic is applied, 
 provided only the cautery iron does not approach the jet of spray and a suffi- 
 cient time has elapsed to permit of evaporation, Avhich requires but a few 
 seconds. A little vaseline smeared over the surface of the skin which is to be 
 anesthetized will prevent the transient redness. In order to produce local 
 anesthesia the bulb should be held in the palm of the surgeon's hand, and 
 then the cap unscrewed and the jet of spray directed to the spot, with the 
 nozzle about six inches from the s.kin. The integument almost instantly 
 becomes red, which is at once followed by a white color, which is indicative of 
 insensibility. The effect continues about two minutes. The action of the 
 drug can be hastened by blowing on the skin upon which the jet falls. 
 
 In dentistry a special bulb is prepared, and this jet is directed to the gum, 
 which has been previously dried and over which some vaseline has been 
 smeared. The rest of the gum and the teeth should be protected by a piece 
 of linen. 
 
 The Hydroclilorate of Cocaine, as suggested by Dr. Koller, is another means 
 of producing insensibility to pain. It can be best employed in parts where the 
 circulation can be confined within a limited area. In incision of a felon, for 
 example, a stout ligature should be placed around the finger, the cocaine in- 
 jected into the skin, and the drug allowed to remain in the finger, the blood 
 of Avhich is thus cut off from the general circulation by the ligature. The 
 use of the ether spray as a preliminary measure to the hypodermatic injection 
 will make the operation absolutely painless. In operations upon mucous sur- 
 faces the cocaine is found to possess remarkable anesthetic properties. The 
 solution need only be applied to the mucous membrane by a small swab of cot- 
 ton. Insensibility follows in about three to five minutes, and continues for 
 from fifteen to twenty minutes. Operations of considerable magnitude have 
 soMetimes been done under cocaine, using it first by hypodermatic injection, 
 and then dropping it in the wound from time to time. 
 
 The drug must be used Avith caution, especially about the head, as not a 
 few alarming cases of syncope, delirium, and paralysis or tetanic fixation of 
 the respiratory muscles have been observed. In those mild cases of cocaine- 
 poisoning which are characterized merely by pallor, tremor, restlessness, and 
 weak pulse, stimulants and recumbency are all that will be required. In 
 severe cases death may occur in two modes — by paralysis of the respiratory 
 
1102 j.v A^ff:^/(■A^' tkxt-hook nr scnai-jn'. 
 
 center and bv tetanic fixation of the respiratory muscles (Mosso). In those 
 which manifest respiratory failure the hypodermatic use of strychnia is atten<led 
 with the hest results. In those ca.«es in which tetanic fixation of the chest- 
 muscles occurs (as a part usually of ireneral convulsions) chloral by enema is 
 of great value. In convulsive cases inhalations of amyl nitrite or hypoder- 
 matics of nitro-glycerin are to be employed. When delirium is violent, if tiie 
 heart be not verv weak, chloral can be useil. or hyo.scine in small doses hypo- 
 demiatically. The patient when very delirious will require to be restrained. 
 The bladder should be emptied and the action of the kidneys stimulated. The 
 subsequent tendency to sleeplessness is to be antagonized by a hypnotic. 
 
 SvJdeich' Si iniiltration-inetliod i»f htcal aiu'>tht.r>ia is ba-st-il uj»un Liebreich's 
 discovery that the injection of water into tiie subcutaneous tissue pro<luces 
 local anesthesia by causing an artificial edema of the parts. Schleich 
 availed himself of this method and improved upon it by employing small 
 quantities of cocaine and morphine in a weak saline solution. The anes- 
 thesia is produced by causing artificial ischemia <lue to tension and pressure 
 in the tissues. The action of the drugs assists also in producing loss of 
 sensation. 
 
 The skin covering the field of operation, with the syringe and its needle, 
 should be made aseptic, and the solution injected under the integument. As 
 soon as the first injection is made, the second one should be made at the 
 extreme limit of the zone of anesthesia, and so on until the field of operation 
 is covered. The introduction of the needle at the beginning can be made 
 painless by the employment of the ethyl chloride spray. 
 
 This method of local anesthesia has a wide range of usefulness in minor 
 surn-erv. and has also been employed in some capital operations, such as 
 herniotomy, amputations, etc. 
 
 Schleich's formula are as fdlows: 
 
 Solution Xo. 1, strong, for inflamed tissues: 
 
 R Cocainfe hydrochloratis, 
 
 Morphine hydrochlor., 
 
 Sodii chloridi sterilisati. 
 
 Aquae destill. sterilisati. q. 
 
 M. et adde 
 
 Solut. formalini (40 per cent.). 
 
 Or Solut. acid, carbol. (oO per cent.), 
 
 Solution No. 2. for moderately hyperesthetic areas, is the same, except 
 that the quantity of cocaine is reduced to gr. iss. 
 
 Solution No. 3 is still Aveaker, the amount of^ cocaine being only gr. \ and 
 of morphine gr. yV- 
 
 All of these ingredients are sterilized individually, except the cocaine 
 and morphine, which, if pure, are practically sterile. These solutions should 
 be kept in a cool place, or they become inefficient. 
 
 In practice as many as 2o syringefuls of Solution No. 1. 50 syringefuls 
 of Solution No. 2, and 500 syringefuls of Solution No. o may be used. 
 
 Encn'ine, CjgHj^NO^. is a local anesthetic which is insoluble in water: but 
 a solution can be made by first dissolving the eucaine in a little alcohol and 
 then adding water. It has a special advantage over cocaine in that it does 
 not decompose nor lose its efficacy after boiling. This enables the surgeon to 
 use a sterile solution. A 2 per cent, to a 5 per cent, solution produces anes- 
 thesia of the conjunctiva and cornea in less than three minutes. Congestion 
 
 
 gr- 
 
 "j; 
 
 
 gr- 
 
 i; 
 
 
 gr. 
 
 "j; 
 
 s. 
 
 ad fsiiiss ; 
 
 
 gtt. 
 
 .j; 
 
 
 gtt- 
 
 j'j- 
 
A NESrilESIA . IK »3 
 
 of tlio (•(»iijiiiiftiv;i (Iocs Mot Inllou the apjdifatioii of the drug, as is the case 
 Avith cocaine. In optlitlialniological surgery eucaine is of special advanta<'e. 
 The pupil is not dilated and reacts to light during the application. From 
 doses as high as 30 grains, according to Kiesel, no toxic eflects have been 
 observed. The action of eucaine on the heart is to reduce the ninri])er of 
 beats, which is in marked contrast to the action of cocaine, uhich increases 
 the heart's fre(|U('ncv. To produce local anesthesia a subcutaneous injection 
 of a solution of from 1 |)er cent, to per cent, may be emi)loyed. From a 
 clinical point of view, eucaine produces just as rapid, profound, and lasting 
 anesthesia as cocaine, but is less dangerous. It also produces a larger area 
 of anesthesia than cocaine, and its effect lasts longer. Occasional] v, how- 
 ever, local gangrene, as a result of vasomotor constriction, has been observed. 
 Guaiacol has been used to relieve pain in acute neuralgia. A solution 
 can be prepared consi.sting of fifteen grains of guaiacol in five drams of alco- 
 hol. The solution is painted over the painful part with a camel's-hair brush. 
 It has also been used in the form of an ointment of the strength of five parts 
 of guaiacol to thirty parts of vaseline. This drug has also been emploved 
 hypodermatically in a solution, 1 : 10 to 1 : 20, of olive oil ; but the drug 
 used in this way is not free from deleterious effects. 
 
1104 AX AMERICAN TEXT-BOOK OF SURGERY. 
 
 CHATTER III. 
 
 PLASTIC SURGERY. 
 
 General Principles. — This branch of surgery includes all operations for 
 the repair of deficiencies of embryonal development, as hare-lip or exstrophy of 
 the bladder, for the replacement of parts lost by accident or disease, as lupous 
 or syphilitic destruction of the nose, and for the restoration of the function of 
 parts restrained by cicatricial contraction from injury or disease, as eyelids 
 bound down by scars, a joint fixed by the cicatrices left by a deep burn, etc. 
 The tissues employed are commonly those obtained from other portions of the 
 patient's body, or they may be transferred from a donor. The termination 
 '• plasty " is often appended to the name of the organ or part to be repaired or 
 replaced, and the word thus formed becomes synonymous with such restoration, 
 as •• cheiloplasty."' the formation of a lip. Retrenchment of abnormally large 
 noses or ears belongs to this branch of surgery. 
 
 Although bone, muscle, nerve, periosteum, and mucous membrane have all 
 been used in certain plastic operations, the skin with its subcutaneous tissue is 
 that most frequently employed. With the exception of bone and nerve, the 
 portions of tissue used must be about one-tliird larger than the defect to be 
 repaired, since they are sure to shrink both immediately and for many weeks 
 subsequently. Flaps should have their pedicles as broad as possible, fashioned 
 with curved outlines, thus admitting of greater stretching ; they should include 
 the larger vessels of the parts, with which their long axis should coincide ; and 
 they should never be subjected to either tension or torsion if these can possi- 
 bly be avoided ; indeed, when a choice exists between a simple operation involv- 
 ing one or both of these procedui-es and another more difficult and elaborate, 
 the latter should be chosen. 
 
 Favorable and Unfavorable Conditions. — xVs syphilis and lupus are 
 frequently the causes of deformities which require plastic operations, it is abso- 
 lutely essential in the first disease that some months shall have elapsed since 
 any manift-stations of syphilis were detectable, and that the patient shall have 
 been treated for a prolonged period with antisyphilitic remedies; while in a 
 patient who has suffered from lupus it is imperative that all the diseased tissue 
 shall have been long since destroyed, as shown by a perfectly sound cicatrix 
 which has remained healthy for some months. Hare-lip or cleft-palate opera- 
 tions must never be attempted when there is any disturbance of either the 
 gastro-intestinal or respiratory mucous membranes, for manifest reasons over 
 and above the distinctly increased risk to life. Rigid asepsis is far better than 
 antisepsis, and is essential if Thiersch's method of skin-grafting has to be em- 
 ployed to fill up the gaps left by deficient flaps or to close the surfaces from 
 which these have been dissected. 
 
 The^r«i atei) in any plastic operation must consist in the proper freshening 
 of the edges of the parts to be apposed or of the surfaces to which flaps are to 
 be transferred. This may be incidentally done when removing cicatricial tis- 
 sue, loosening up the bound-down alar cartilages of a partially destroyed nose, 
 or the surface may have to be specially freshened, as in the case of hare-lip. 
 The largest attainable raw surface must be secured wherever merely the edg^es 
 of flaps are to be apposed, provided that this does not entail such destruction 
 of tissue as will add a worse evil — viz. tension of flaps from lack of tissue, as 
 in cleft palate ; but the same end can often be secured without any removal nf 
 tissu^e — or at least with very little — by splittinij the edge of the cleft on one side 
 
PLASTIC SURGERY. 
 
 1105 
 
 and removing a strip of tissue on tbe other. It is rarely advisable to freshen 
 both surfaces by splittinj;, because proper coa])tation will then be difficult. 
 
 The second step must be the arrest of hemorrhage, otherwise })rimary union 
 may fail from the interposition of a clot. This should be done either before 
 
 Fig. V.'A. 
 
 ++ 
 
 % 
 
 ^ 
 
 ^ 
 
 Diagrams of Various Methods of Plastic Surgery. The shaded portions represent the parts removed. 
 The arrows indicate the direction in which the flaps are displaced. The second and fourtli columns 
 show the results of the operations represented in the first and third (Esmarch and Kowalzig). 
 
 coaptation or by using such methods of suturing as will secure this arrest after 
 closing the wound : this is peculiarly necessary when transplanting mucous 
 membrane. The tJdrd step is to adjust the parts with so little tension that the 
 sutures merely retain, but do not pull, the parts together : this is the secret of 
 success in operations for cleft palate. The foin-th step is, Avhen flaps from other 
 parts have been employed, to close the gap left by their transplantation. The 
 fifth step is to dress either aseptically or antiseptically in such a way as to 
 avoid motion or frequent handling of the parts. 
 
 70 f 
 
km; 
 
 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 Whore the rt'itair of" the doloct or the overcoming of a defonnity recjuires a 
 series of operations, as often happens, sufficient time should be allowed for all 
 shrinkage and readjustment of parts to have taken place before any further 
 operation is attempted. Sutures which it is desired should last for many 
 days must be of wire, or preferably of silk, both as fine as will hold. Where 
 extensive and deep wounds are to be apposed, buried sutures of catgut are 
 best, although fine aseptic silk will do. Sometimes coaptation with immobility 
 
 Mw'. ^ mm ymiii, 
 
 Plastic Operation for Extroversion of the Bladder (Ashhurst). 
 
 of the wound-surfaces and of the tissues for some distance around is best 
 secured by the "splinting" action of hare-lip pins with figure-of-8 ligatures. 
 An admirable means of removing tension from the wound-edges so that the 
 superficial sutures shall merely hold the margins together is the " relaxation 
 suture" in some one of its forms. Catgut is unreliable, and should be used 
 only in the form of " buried sutures," or perhaps in between silk sutures. 
 Classification of Methods. — Deformities and lesions are repaired by 
 one of four methods — viz. (1) approximation of parts; (2) interpolation of 
 flaps derived from contiguous or distant parts, a pedicle being left ; (3) trans- 
 plantation of flaps without pedicle ; (4) retrenchment of redundant parts. 
 Roberts' table, v/hich is here reproduced, slightly condensed, gives an admir- 
 able epitome of the whole subject : 
 
 Methods used in Plastic Surgery. 
 
 Displacement — stretching or sliding of tissues. 
 
 I. Simple approximation after freshening the edges, as in hare-lip, vesico- 
 vaginal fistulse, etc. 
 II. Sliding into position after transferring tension to adjoining localities, 
 as in V-shaped incisions for ectropion and cicatricial contraction of 
 joints after burns, and in linear incisions to allow stretching of skin 
 to cover large wounds and to relax contracted parts. 
 
PLASTIC SURGERY. 11<>7 
 
 Interpolation— burrowii.- material fVui.i adjacent regions, from a limb, or 
 from another person. 
 
 I. Transferring a flap with a pedicle. 
 
 A. Putting in place at once: 
 
 1. By rotating the flap and the pedicle in its own plane through 
 
 'one-fourrh or one-half of a circle, as in making an upper 
 eyelid or a nose from the forehead. 
 
 2. By twisting the flap on its pedicle, as in making the side of 
 
 nose from a lip. 
 
 3. By everting the flap entirely with the raw surface uppermost, 
 
 *as in covering exstrophy of the bladder by a scrotal flap. 
 
 4. By superimposing one flap' on another which has been everted, 
 
 *as in Wood's operation for exstrophy of the bladder. 
 
 5. By carrying the flap across an intervening portion of skin, 
 
 and fixing only its end to the part to be repaired— a 
 method rarely employed; when the flap has become 
 attached the pedicle is severed. 
 B. Gradually carrying a flap into its permanent position by a series 
 of partial sliding, transferring, or twisting operations— seldom 
 employed, and advisable only when there is nothing but cica- 
 tricial tissue in the immediate vicinity of the part to be 
 repaired. 
 
 II. Transplanting ivithout a pediele. 
 
 (a) By accurately suturing in position portions of tissues recently re- 
 moved from the part itself, from other regions of the patient's 
 own body, or from a lower animal ; e. g. replacing the bone 
 after trephining, interpolating pieces of nerve-trunks between 
 the freshened ends of divided nerves in secondary operations 
 where there has been loss of substance. 
 (5) By skin-grafting in some one of the forms presently to be 
 described.* . . 
 
 Retrenchment— removing redundant material and causing cicatricial con- 
 traction. 
 I. By cutting out elliptical or semi-elliptical pieces of tissue, as in ptosis, 
 
 cystocele, etc. r • ■ 
 
 II. By cutting out triangular or wedge-shaped portions of tissue, as in 
 'closing the vaginal aperture, decreasing the size of a lip, nose, etc. 
 Reverdin's° Method of Skin-grafting. — Strictly speaking, the term 
 "epidermic trraftinc^," by which Reverdin originally designated the procedure, 
 is the only correct one, since " the epidermis by itself, but the living epidermis, 
 that of the deep laver, is alone necessary for the success of the graft. lor 
 success the general health of the patient must be good and the granulations ot 
 the ulcer healthy ; moreover, when possible, complete asepsis should be secured 
 and maintained, because all antiseptics endanger the vitality of the grafts. If 
 antiseptics are requisite to secure asepsis of a freely suppurating ulcer, they 
 must be thoroughly removed by prolonged douching with sterilized normal salt 
 solution (6 : 1000). Small grafts about the size of a large pin's head will do 
 quite as well as large ones, and are far less painful to obtain from the donor. 
 When procured from another individual, it is imperative that all possibility of 
 specific trouble be excluded, and that the donor be young. 
 
 Amputated limbs— even the skin of recent cadavers has been used— may 
 
 * Readjustment of recently severed finger-tips, nose, etc. is sometimes incorrectly classed 
 among the plastic operations. 
 
1108 AX AMKIilCAX TKXT-IH K >K OF Sll^drJiV. 
 
 supply tlie grafts, since Martin has sliown that after many hours of exposure 
 in the open air at a temperature of nearly 32° F. grafts could be successfully 
 applied, but that at such temperatures as 82° F. exposure of from six to seven 
 hours destroyed their vitality, so that the limb of a healthy individual ampu- 
 tated for some accident may be utilized for grafting purposes for at least twenty- 
 four hours if kept cool — in a refrigerator, for instance. The skin of any of 
 the lower animals may be employed, especially that covering the abdomen of 
 the frog. In most instances some other portion of the patient's own skin must 
 be utilized. Much difference of opinion seems to exist as to whether grafts 
 from the skin of a black transferred to a Avhite patient will remain pigmented, 
 and vice vcrsd, so that it will be better always to graft ])lacks from blacks and 
 whites from whites. 
 
 Method of Performing the Operation. — Having rendered the ulcer, 
 the neighboring skin, and the part from which the grafts are to be taken asep- 
 tic, the point of an ordinary (aseptic) sewing needle should be thrust under the 
 epidermis, the skin elevated, and the graft shaved off by a sharp scalpel or cut 
 off with a pair of small curved scissors. To ensure obtaining the deeper, active 
 epithelial layers, a small portion of the derm should always be removed. The 
 graft must then be gently deposited, cut surface downward, upon the granula- 
 tions by means of the needle, avoiding any pressure such as will induce bleed- 
 ing. Having placed as many grafts as desired, very narrow strips of protective 
 or of thin pure rubber or gutta-percha tissue should be applied over the grafts, 
 extending for a couple of inches on each side of the ulcer, interlaced in such a 
 manner as to ensure retention of the grafts and at the same time allow of free 
 escape of any serous or purulent secretions. Over the protective a compress wet 
 with the salt solution must be applied. Next a piece of oiled silk or protective 
 must follow, then a pad of absorbent cotton and a gently applied bandage ; 
 sometimes a light plaster-of-Paris or silicate-of-sodium bandage is advisable, 
 especially on the limbs of children when the grafting is done near the joints. 
 In from twenty-four to forty-eight hours all dressings but the lattice-work of 
 protective should be removed, the parts gently irrigated Avith warm salt solu- 
 tion, and a dressing identical with the primary one applied, repeating this pro- 
 cedure from time to time, and at the end of a Aveek removing the protective 
 strips next the grafts and reapplying if necessary. In many instances the 
 grafts shed their cuticle, which floats off in the discharges, the operation 
 apparently having failed from loss of the entire graft, but at the next dress- 
 ing commencing growth of epidermis will often be shown by bluish-white 
 spots, not only where the grafts were supposed to have taken, but also 
 where they were thought to have been shed. As the grafts extend eccen- 
 trically, each capable only of producing an area of about half an inch of cica- 
 trix, and stimulating to healing the contiguous sluggish borders of the sore, 
 they should be placed about half an inch from one another and from the bor- 
 ders of the ulcer, or, when this is irregular in outline, rows of grafts should be 
 placed so as to cut the surface up into triangles and irregular figures, which if 
 skilfully planned will diminish the extent of surface each graft must cover, and 
 conseqiiently their number and the pain incident to their removal. If one 
 grafting will not suffice, the operation should be repeated. The spots from 
 which the grafts have been taken are best treated by dusting them over with 
 sterilized iodoform and covering them with dry absorbent cotton and a band- 
 age, the dressing not to be removed for about ten days. 
 
 Unfortunately, but little diminution of the cicatricial contraction is effected 
 by Reverdin's method, and, while healing is more rapidly secured, too often an 
 almost equally rapid breaking down of the new cicatrix results, either from no 
 
PLASTIC SURGERY. 1109 
 
 recognizulilc cause or iVom causes which wouhl be inadequate to produce such 
 a result in a scar formed by the ordinary processes of healing. 
 
 TiiiKKPcn's Method of Skin-grafting. — Thiersch contends that healing 
 of a granulating surface results, first, from a conversion of the soft, vascular 
 granulation papillnc — by contraction of some of their elements which have 
 developed into young connective-tissue cells — into "dry cicatricial papillae," 
 actually approximating the surrounding tissues, thus diminishing the area to 
 be covered by epidermis ; and, secondly, by the covering of these papillae by 
 epidermic cells. Contraction having gone on as far as the laxity of the tissues 
 will admit, and the capacity for developing new epidermic cells by the margins 
 of the wound being limited, the granulations of the unhealed central portion 
 remain stationary — i. e. vascular and soft: few if any of their component cells 
 having undergone development into connective tissue, the maximum of con- 
 traction has not yet been attained, but will be promptly reached if they are 
 covered in Avith epidermis. Moreover, any trivial mechanical or vascular irri- 
 tation will give rise to exudation from the soft subjacent papillye, resulting in 
 separation of the newly-formed skin. Still further, microscopically two layers 
 of granulation-tissue are discernible, the more superficial possessing vertically 
 disposed capillaries, the deeper containing a horizontal network of vessels, from 
 which the former spring, coursing through a structure more or less dense accord- 
 ing: to its age — i. e. stage of conversion into connective tissue. A free removal 
 of this upper, soft layer of granulations, yet capable of full contraction, must 
 be effected to prevent cicatricial distortion and the risk of separation of the 
 epidermis, these evils being avoided by laying the grafts directly upon the 
 layer of granulations with horizontally disposed capillaries, to which layer 
 the transplanted portions will become firmly adherent, and will remain so, 
 undisturbed by cicatricial contraction. 
 
 Favorable and Unfavorable Conditions. — Syphilis may prevent 
 the grafts from taking. The best results are attained when the granulations 
 are about six weeks old, are firm, and have reached this condition by repeated 
 cauterization and compression. Most careful disinfection of the hands, instru- 
 ments, and parts, with subsequent removal of all antiseptics, is essential, as is 
 complete arrest of hemorrhage. The salt solution should be freshly sterilized. 
 All portions of the wound must be covered with the grafts if possible, and they 
 in turn with the protective strips. After the second or third day, daily dress- 
 ings, with free irrigation, are imperative. Grafts applied to loose connective 
 tissue, to fascia, or to periosteum do not succeed so well as on freshened gran- 
 ulations, while on glandular and muscular tissues the results are only fair. On 
 cancellous bone or tendons the results are not permanent, while grafts will not 
 even primarily adhere to compact bone. 
 
 Metlnod of Operating. — Complete asepsis having been secured, as before 
 indicated, and all antiseptics washed away with the salt solution, the soft gran- 
 ulations are to be scraped away with the sharp spoon, including a small portion 
 of the newly-healed margins if they do not appear healthy, and the bleeding 
 surface irrigated, covered with protective, a»d compressed for a few minutes 
 to check all oozing. Any portion of skin relatively free from underlying fat 
 — that of the arm or thigh — having been pi-eviously sterilized and shaved, is 
 put upon the stretch by one hand while with the other a long wide razor or 
 microscopic section-knife is applied flatwise, and the upper layers of the skin 
 removed by a to-and-fro movement of the knife, which is kept flooded with the 
 salt solution. Mixter of Boston has devised an excellent apparatus which facil- 
 itates the cutting of these long grafts, and McBurney some hooks for lifting and 
 stretching the skin. Each graft should be as broad and long as possible, and 
 
1110 
 
 AiX AMKlili'Ay TEXT- HOOK OF SUROKHY 
 
 be immediately laid upon the prepared siiriaee, upon which it is floated from the 
 knife by salt solution, A probe may be used to facilitate this manccuver, draw- 
 ing the edge of the graft on to the wound-surface while slipping the blade away. 
 Subsequent correction of position may be effected by the probe or by a camel's- 
 hair brush. Each graft must l)e gently pressed into ])lace with a s[)atula, and 
 must be in contact with its neigiibor, better slightly overlapping its fellow and 
 the margins of the wound, otlierwise separation of the grafts is apt to occur, 
 commencing at the edges, or a spreading ulcerative destruction is liable to set in. 
 Skin from the abdomen or back of a living frog may be substituted for or used 
 to supplement human grafts : indeed, the hairless skin of the young of any of 
 the lower animals will do. The dressing should consist of the lattice-work of 
 protective strijis, a compress moistened with salt solution and covered in with 
 protective, outside dry cotton, and possibly the fixed dressing described for ordi- 
 nary epidemic grafting. Mayer has recently devised a better method (Fig. 
 430). The limb is encircled by two collars of sterilized gauze wet with the 
 
 Fig. 436. 
 
 Mayer's Dn'ssing for Thiersch's Method of Skin-grafting (from original photograph by J. M. Bertolet). 
 
 salt solution, one above and the other below the site of the grafts. These col- 
 lars should be an inch or more thick. Strips of sterilized wood covered with 
 gauze and long enough to reach from one collar to the other are laid in place 
 and fixed by gauze bandages. Over this "cage" are placed several gauze 
 pads wet with the salt solution. The whole dressing is then covered with rub- 
 ber dam and a bandage. A hot-water bag keeps the grafts in a warm, moist 
 chamber untouched by any dressing which might displace them. The outer 
 gauze dressing need only be wet once daily. After a few days, ■when the 
 grafts have taken, the whole dressing is removed and borated albolene oint- 
 ment is applied. When employed as an adjunct of a plastic operation, hav- 
 ing checked all hemorrhage by compression, the epidermic strips must be 
 placed and dressed as just directed, and will usually unite with the subjacent 
 tissues. Blood beneath a graft, indicated by a bluish tint, although endanger- 
 ing the vitality of the graft, does not necessarily cause its loss. A pink tint 
 at the close of a few days usually indicates success, while if the grafts be at 
 this time of a dead white they will probably exfoliate, although only the outer 
 layers may float away, while the deeper, active ones remain. Sometimes the 
 grafts are perforated by the granulations, and disappear for a time to reappear 
 as epidermic islets later on. The surfaces from which the grafts have been 
 removed must be dusted with sterilized iodoform, and dry cotton bandaged on, 
 this dressing to be left on for about ten days ; or they may be dressed precisely 
 like the grafts themselves. 
 
 Trauitplantation of Skin. — Krause has revived tliis practice. The granu- 
 
rLASTic srii(ii':iiY. ^^ 
 
 fivl'.lays, -vny epidennic blebs are punctured, and a dressing s.nulai to the 
 ^''VS^.PLANTATION OF Mucous Membka>- K—Where this measure is de- 
 
 the pait.— in ^^ f ^'*;"^^,,'' r", • . ^,^,^1^ yet Wblller has resected the cica- 
 success less in'obabie than m sKin-giaiuug, j^i^ > „;^^„iar .rraft 
 
 tridal tissue of uvetl,.-a,l strictures, ami, suturing .n position a c rcukr gratt 
 :'f'mir:nen,brai,e, has .oiiiicHt adiiere -'^f "^^ oT'^X e'' ^ie" „t 
 
 rthrrw^;;rVbt;*^df:m^^^^^^^^^^^ tu. »„«.,. the 
 
 o at" vb concerned or if the conjunetiva -^^'^'^r^ "^^ J^"^ 
 M . <^,~,f s mav be taken from the rectum ; again, the conjunctiva of the labbit 
 Z S"iemb™,e of the frog's stomach, of the esophagus ot the pigeon oi 
 
 ™^^'peTa\r:n -'m saml'::!:|S;";e^Hminre;, freshening of surfaces, ,oos- 
 
 Xirom' :un lu'bj^s and placed '^ ^^::^:tZt tl^ :^, 
 fV,^ wVinlA tbirkness of the membrane must be emplo\ea, ami me ^^^ y 
 
 tl ^olcf orr:ew":tth°\hrfiSLrsu..faces of the old tissues are 
 :a-rear:^FT'SE3 = ^^ 
 
 --'^;^^:t^rl:t-^t':ii:]^^ 
 ;te^^rcLr«»'»^^^^^^^ 
 
 and must be carefully fixed in position D} du ^^ be 
 
 s:iu !^;r =d| «^:^ - --^ . 
 
 aereTS^^'rn:!::^^^^^^^^^^^ 
 l^er:,:i''^ab:rrrroFrt^^^^^^^^^^^^^ "^' edge; from t.o to four 
 
1112 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 .sutures will be ie(|uir('d, aiul where there is a distinct sheath this had better 
 be separately secured by a couple of stitches. If the nerve-ends cannot be 
 readily approximated, careful but thorough stretching of both the proximal 
 and distal portions of the nerve -will often secure this end, but if not, a nerve 
 freshly removed from some lower aninud or from a recently amputated limb 
 should be carefully sutured in position. Either stretching the nerve or insert- 
 ing a graft is better than the interposition of a decalcified bone drainage-tube 
 or a bundle of catgut threads, as has been advised. 
 
 Bone-grafting. — The method depends somewhat upon whether the skull- 
 bones are concerned or one of the long bones. Thus, when trephining the 
 bone the button or fragments removed must be at once transferred to a warm 
 (100°-10">° F.) aseptic salt solution, and kept at that temperature until re- 
 placed. If the operation is for accident, any foreign matter must be re- 
 moved, even to paring with the bone chisel, and disinfection effected by 
 weak solutions of mercuric bichloride before placing in the warm aseptic 
 solution. When but little aseptic bone can be saved, the fragments may be 
 laid on an aseptic surface, minced into fragments with a chisel, and scattered 
 over the dura. 
 
 If a defect in a long bone, the continuity of which has not been destroyed, 
 requires repair, after exceptional precautions to render the part aseptic, prop- 
 erly shaped bone-grafts from a recently amputated limb or removed from a 
 living animal must be placed in situ, or bone chips may be packed in so as to 
 fill up the gap. When non-union results after compound fracture with short- 
 ening from loss of bone, after preparing a longitudinal sulcus in the tissues 
 between the ends of the bones — which must be carefully freshened — bone- 
 grafts, either human or from the lower animals, may be secured in position : 
 success has, as yet, been rarely attained. Shifting of bone has been done by 
 dividing a strip of the hard palate, covered w^ith its soft parts, parallel to the 
 fissure in cleft palate, but leaving unsevered the bony attachments in front, 
 and partially fracturing the pedicle, drawing the bony flaps together with 
 sutures ; or, when forming a new nose, turning down with the skin and perios- 
 teum the outer table of the frontal bone split off with a chisel after cutting a 
 groove around the part to be removed. 
 
 A modification of bone-grafting has been suggested by Senn. whereby 
 aseptic bone-cavities and defects left by trephining may be filled — in the first 
 case by chips, and in the second by decalcified-bone plates carefully fashioned 
 to fit the opening. 
 
 Method of Preparing Decalcified Bone. — Select the compact layer of the 
 fresh tibia or femur of the ox, remove all periosteum and medullary tissue, 
 divide into longitudinal strips about one-eighth of an inch Avide, and immerse 
 in a relatively large quantity of 10-1.5 per cent, watery solution of hydrochloric 
 acid, which must be renewed daily for from one to two weeks : then wash 
 thoroughly in water or a weak solution of caustic potash, cut into small chips, 
 soak for forty-eight hours in 1 : 1000 mercuric bichloride solution, remove and 
 store in a saturated solution of iodoform in ether. When about to be used, wrap 
 in aseptic gauze, dissolve out the excess of ether and iodoform with alcohol, 
 and put in 1 : 2000 mercuric l)ichloride solution until recjuired, when careful 
 drying with iodoform gauze should precede their implantation. For cranial 
 defects large plates must be sawn out of the compact tissue and decalcified, as 
 already described. 
 
 Operation. — Having cleansed, sterilized, and dusted the cavity with iodo- 
 form, it is to be carefully packed with chips until filled, a capillary drain intro- 
 duced at the most dependent part, and the periosteum and soft parts united by 
 
LIGATION OF ARTERIES. HI'' 
 
 buried ciitgut sutures : if a, delict of the soft parts exists, an iodoform gauze 
 tampon mjw be employed to keep the chips in position. Wlien an opening in 
 the skull is to be filled, the plate or plates should accurately fill the gap, but 
 must be perforated in numerous places to allow the wound-secretions to escape. 
 It is alleged that ordinary l)one-grafts undergo decalcification, and are only 
 then infiUrated with bone-forming cells, thus merely acting as a scaffolding, 
 for which purpose decalcified bone will do ef^ually well, requires no decalcifica- 
 tion, and is not only aseptic, but actively antiseptic. 
 
 CHAPTER IV. 
 
 LIGATION OF AKTERIES. 
 
 The Ligation of Arteries requires a precise knowledge of anatomy, 
 which can be acquired only in the dissecting-room. The technique of the 
 operative work must be learned by practice upon the cadaver. The region in 
 which the vessel is situated should be thoroughly prepared for an aseptic ope- 
 ration. (See p. 10-76.) t i, n u 
 
 The INCISION should vary in length from two to four inches. It should be 
 made from left to right, and from above downward, and at an angle of five de- 
 grees over the course of the vessel. The integument lying over the vessels should 
 be held firmly between the middle finger and the thumb of the left hand of the 
 suro-eon. The skin must not be stretched or pulled aside, otherwise the incision 
 will" not be over the underlying vessel. The knife should be held between the 
 thumb and index finger of the right hand of the surgeon. When, however, 
 the incision has been made through the superficial tissues, the knife may be 
 held for the deeper dissection in the same manner as a pen. When the ves- 
 sel is reached, the handle of the scalpel, an AUis' dry dissector, or the index 
 fincrer may be used to tear and gently push aside the loose connective tissue sur- 
 roimding die arterv. The depth of the skin-incision should be the same from 
 the begmning to the end, and not terminate obliquely at either extremity. 
 After cutting through the skin, the fascia should be raised and a small 
 opening made, through which a director is passed with the point constantly 
 turned upward. The. fascia is slit along the entire length of the wound. 
 Instead of a director, two pair of thumb forceps can be used in the fol- 
 lowing manner : The surgeon seizes with the forceps the fascia at a certain 
 point, and the assistant grasps the fascia at a point directly opposite ; then 
 both the surgeon and the assistant together lift up the fascia from the wound, 
 and the operator cuts between the two forceps. The surgeon then releases the 
 hold upon the tissue with the forceps, and the assistant follows his example, 
 and the same procedure is repeated. In this manner no structure of import- 
 ance can be cut when the fascia is lifted up from the wound. 
 
 The retractor should first be placed in the wound by the surgeon, and 
 when properly adjusted he requests the assistant to hold it in si^w just as he 
 has placed it. Two retractors are used, and in this way the wound is kept 
 well open, so that light enters into its depth. 
 
 The SHEATH of the artery is now reached, and great care must be used in 
 opening it. It should be seized by a pair of forceps upon the side opposite the 
 accompanying vein, lest that vessel be injured. A small aperture is cut or 
 
14 
 
 ^.y AMERICAN TEXT-BOOK OF SURGERY. 
 
 torn in the sheath only larfje enon<ih to admit the point of an aneurysm needle. 
 It is important to remember that the sheath should be disturbed as little as 
 possible, because the vasa vasorum lie in it. Any unnecessary disturbance 
 might be a cause of secondary hemorrhage. In passing the aneurysm needle 
 (Figs. 437, 438) around the artery it should be always passed away from the 
 
 Fig. 437. 
 
 Ordinary Aneurysm Needle threaded (MacCormao). 
 
 vein — i. e. inserted first between the artery and vein. The nerve must not be 
 included in the ligature. When the needle has been passed around the artery 
 
 Pig. 438. 
 
 Aneurysm Needles (MacCormac). 
 
 the vessel must not be lifted up from its bed. as 
 this act would be likely to set up some cellular 
 inflammation. Before the ligature is finally 
 tightened an examination should be made to 
 ascertain if any tissue besides the artery itself 
 is included in the ligature. The two thumbs 
 can be placed on top of the artery and the liga- 
 ture lifted by the two hands, so that the artery 
 is occluded by simultaneous pressure produced 
 by the thumbs above and the ligature below. 
 An assistant should now ascertain if pulsation 
 is lost in the vessel upon its distal side. The 
 ligature is tied with a reef knot in the manner 
 shown in Fig. 439. 
 
 The INDICATIONS for the ligation of arteries 
 are — 1, hemorrhage ; 2, aneurysm; 3, arrest of 
 
 Fig. 439. 
 
 Manner of Tightening Ligature (MacCormac). 
 
 malignant growths and control of acute inflammations. (For the discussion 
 
LIGATION OF ARTERIES. 
 
 1115 
 
 of these special indications and the contraindications the reader is referred 
 to each subject.) 
 
 LIGATION OF SPECIAL ARTERIES. 
 
 The Innominate Artery (Pis. XXV and XXVI) arises from the arch of 
 the aorta upon the right side, and at the sterno-clavicular articulation divides 
 into the right primitive carotid and right subclavian arteries. The artery 
 begins at a point about the middle of the manubrium and ascends to the 
 upper edge of the clavicle. As the clavicle is movable, the termination of 
 the artery may be slightly above or below the bone. The incision should 
 be made along the anterior margin of the sterno-cleido-mastoid muscle down 
 to the sternal notch. An incision at an angle to this should be made out- 
 ward along the upper border of the clavicle. The inner attachment of the 
 sterno-cleido-mastoid muscle is now divided in order to allow of more room to 
 reach the vessel. After tearing with the fingers the loose areolar tissue, the 
 surgeon must look out for the anterior jugular vein, and secure it between two 
 ligatures or else draw it out of the way with a blunt hook. The sterno-hyoid 
 and sterno-thyroid muscles must be divided. The pericardial cervical fascia 
 is now divided on a director, and the inferior thyroid vein must be ligatured 
 or drawn to one side. The bifurcation of the innominate can now be felt, and 
 the needle passed from beloAV upward so as to avoid wounding the pleura and 
 the innominate vein. The internal jugular vein must be carefully guarded, 
 and also the innominate vein which occasionally overlaps the artery. The 
 pneumogastric nerve and the phrenic must be held out of the way in passing 
 the ligature. Only two patients out of twenty-four have survived the opera- 
 tion. Banks's patient lived fif- 
 teen weeks, and Smyth's (of Fig. 440. 
 New Orleans), the first success- 
 ful case, lived ten years. 
 
 The COMMON CAROTID (Pls. 
 
 XXV and XXVI) is formed by 
 a bifurcation of the innominate 
 upon the right side and from the 
 arch of the aorta upon the left. 
 The artery extends from the 
 sterno-clavicular articulation to 
 the superior border of the thyroid 
 cartilage. It runs for the most 
 part just under the internal bor- 
 der of the sterno-cleido-mastoid 
 muscle. Its course is marked by 
 a line from the sterno-clavicular 
 articulation to a point midway be- 
 tween the angle of the jaw and 
 the mastoid process. It lies in 
 two triangles of the neck, the su- 
 perior and inferior carotid trian- 
 gles. The superior carotid tri- 
 angle, or the triangle of election, 
 is bounded behind by the sterno- 
 cleido-mastoid, in front by the 
 anterior belly of the omo-hyoid, and above by the posterior belly of the digas- 
 
 Position of the lines of incision for ligation of temporal, 
 facial, lingual, common carotid (above the omo-hyoia). 
 subclavian, axillary (first portion), and internal mam- 
 mary arteries (MacCormac). 
 
llli; AN AMF.RIVAN TEXT- HOOK OF SURGERY. 
 
 trie. The inferior earotid triangle, or the triangle of necessih/, is bounded in 
 front by tlie median line, above by the anterior belly of the omo-hyoid, and 
 below liy tiie sterno-cleido-niastoid. 
 
 The internal jugular vein is upon the outer side. Upon the right side, at 
 the root of the neek, the vein is separated from the carotid artery, forming two 
 legs of a triangle the base of which is formed by the subclavian artery. The 
 common carotid is ligated about the middle of its course, either just above or 
 just below the tendon of the omo-hyoid muscle (Fig. 440). In studying the 
 anatomy of the neck it is necessary to remember that the primitive carotid 
 terminates at the ui)per border of the thyroid cartilage, and is slightly over- 
 lapjted by the sterno-cleido-mastoid ; that the point of election for ligating the 
 artery is on a level with the cricoid cartilage ; that the omo-hyoid tendon 
 crosses in front of the carotid artery and upon a level with the cricoid car- 
 tilage ; that the inferior thyroid artery crosses behind the carotid upon this 
 same level: and that the pneumogastric nerve lies on a plane behind the 
 artery, between it and the internal jugular vein, upon its outer side. 
 
 In ligating the artery the patient's head should be turned to the opposite side. 
 The surface guide is the anterior margin of the sterno-cleido-mastoid muscle, 
 and the deep muscular guide is the tendon of the omo-hyoid muscle. An 
 incision (Fig. 440) about three inches long should be made parallel to the ante- 
 rior edge of the sterno-eleido-mjistoid muscle. The center of this incision should 
 be opposite to the cricoid cartilage. The skin and the two layers of the super- 
 ficial fascia between which is the platysma myoides should be divided. The deep 
 fascia attached to tlie border of the sterno-cleido-mastoid muscle is next divided 
 upon a grooved director. The tendon of the omo-hyoid muscle will now be 
 exposed. The tendon must be loosened, so that it can be pulled down or 
 raised upward in the wound by a blunt hook, according as the ligature is to be 
 applied to the carotid above or below the muscle. The index finger of the sur- 
 geon should be introduced into the wound for the purpose of exploring the dif- 
 ferent structures. The sheath of the carotid artery should be opened upon its 
 inner side, so as to avoid wounding the internal jugular vein, which might 
 overlap the artery during a deep inspiration. 
 
 The needle should be passed from without inward, so as to direct its point 
 between the two vessels and away from the vein. There are some important 
 structures that the surgeon must avoid wounding in ])assing the needle around 
 the carotid artery. In front there are three : the descendens noni nerve, the 
 sterno-mastoid artery, and the lobe of the thyroid gland. Behind there are 
 also three : the pneumogastric nerve, the sympathetic nerve, and the inferior 
 thyroid artery. Upon the outer side there is one, the internal jugular vein ; 
 and upon the inner side, likewise one, the lobe of the thyroid gland. 
 
 The Collateral Circulation is established in the following manner: 
 
 1. Internal carotid of one side with the internal carotid of the opposite side, 
 through the circle of Willis. 
 ' 2. Vertebral artery of one side with the vertebral artery of the opposite 
 side, through the circle of Willis. 
 
 3. Superior thyroid of one side Avitli the inferior thyroid from the sub- 
 
 clavian of the same side. 
 
 4. Arteria prineeps cerricis from the occipital with the profunda cervicis 
 
 from the superior intercostal of the same side. 
 
 5. Ophthalmic, from the internal carotid with the angular from the facial 
 
 of the same side. 
 
 6. Superior thyroid, lingual, and facial with corresponding arteries from 
 
 the opposite side. 
 
PLATE XXV. 
 
 -■■..cviZlC&t*^^^'?!'*^^^*'''^ 
 
 (Maclise.) 
 
 A. innominate artery at point ol bifurcation ; B, subclavian artery, crossed by vagus nerve : C, common 
 carotid artery, with vagus nerve at outer side, and descendens noni nerve on it ;"o, external carotid artery 
 E internal carotid artery, with descendens noni nerve on it; F, lingual arterv, passing nntUr the tibers of 
 the hyoglossus muscle : G, facial artery; H, teinporo-maxillarv arterv ; I, occipital arterv, crossing internal 
 carotid artery and jugular vein ; K, internal jugular vein, crossed bv branches of cervical plexus, which 
 join descendens noni nerve; L, spinal accessory nerve, which pierces sterno-mastoid muscle, to be distrib- 
 uted to It and trapezius ; M, cervical plexus of nerves, giving oil the phrenic nerve to descend the neck 
 on the outer side of the internal jugular vein and over the scalenus muscle; N, vagus nerve, between 
 carotid artery and internal jugular vein ; O, ninth or hvpoglossal nerve, distributed to muscles of tongue ; 
 P, P, cords of brachial plexus of nerves; Q, subclavian arterv in connection with brachial plexus of 
 
 mastoid muscle of right side; 3, scalenus posticus muscle ; 4, splenius muscle; 5, mastoid insertion of 
 steniomastoid muscle; 6, internal maxillary arterv; 7, parotid duct; S, genio-hvoid muscle- 9 mvlo- 
 hyoid muscle, cut and turned aside ; 10. superior thyroid arterv; 11, anterior half "of omo-hyoid muscle; 
 IJ. sierno-hyoid muscle, cut ; 13, sterno-thvroid muscle, cut 
 
LTGA TION OF A Ji TKR TES. 1117 
 
 The Internal Carotid (PI. XXV) Ijegins at the l)ifnrcation of the primi- 
 tive carotid, upon a level with the superior border of the tliyroid cartilage, 
 passes upAvard, and enters the skull through the carotid foramen in the petrous 
 portion of the temporal bone. As the vessel ascends in the neck it lies in 
 front of the transverse processes of the upper three cervical vertebrje. At the 
 beginning the internal carotid lies behind and a little external to the external 
 carotid anery. The surface guide is the sterno-cleido-mastoid. 
 
 The incision for ligature of the internal carotid artery is practically identi- 
 cal Avith that to be described for securing the external carotid. Having divided 
 the inte<mment, the two layers of the superficial fascia between which lies the 
 platvsmS mvoidos, and the deep fascia attached to the anterior border of the 
 sterno-cleido-mastoid muscle, the posterior belly of the digastric muscle and 
 the stylo-hyoid muscle are brought into view. The superior thyroid, lingua , 
 and facial veins, and also some lymphatic glands, are to be carefully avoided. 
 The hypoo-lossal nerve will be seen crossing the external carotid artery. Ihe 
 muscles and the veins are to be retracted and the small glands removed, and 
 the internal carotid will be fully exposed. In passing the ligature around 
 the vessel the needle should be carried from without inward, and the pneumo- 
 gastric nerve and the internal jugular vein should be carefully avoided in 
 the center of the wound and behind the vessel, and the pharynx upon the 
 
 inner side. , , , , .<. ,• i- ^u 
 
 The External Carotid (PI. XXV) is formed by the bifurcation ot the 
 primitive carotid, the division of which takes place upon a level with the supe- 
 rior border of the thyroid cartilage. The artery passes upward in the neck in 
 a curved direction, with its convexity forward, until it reaches a point midway 
 between the external auditory meatus and the condyle of the inferior maxilla. 
 In the upper part of its course it is imbedded in the substance of the parotid 
 gland. The surface guide is the sterno-cleido-mastoid. ^ , • f 
 
 The incision should begin at a point midway between the angle ot the inte- 
 rior maxilla and the mastoid process of the temporal bone, and extend down- 
 ward parallel with the anterior border of the sterno-cleido-mastoid muscle to 
 the upper border of the thyroid cartilage of the larynx. The integument, the 
 two layers of the superficial fascia between which lies the platysma myoides, 
 and the deep fascia which is attached to the anterior border of the sterno-cleido- 
 mastoid muscle are to be divided. The superior thyroid, lingual, aiid facial 
 veins, and also the lymphatic glands, are to be carefully avoided, ihe pos- 
 terior belly of the digastric muscle and the stylo-hyoid muscle are to be 
 retracted upward and inward, and the sterno-cleido-mastoid is to be drawn 
 outward. The hypoglossal nerve is now fully exposed to view as it crosses m 
 front of the external carotid artery, and must be drawn inward. A branch of 
 the artery should be sought and found in order to exclude the internal carotid 
 artery, which at this point lies close to the external carotid and might be mis- 
 taken for it. Unlike the external, the internal carotid gives ofi no branches 
 in the neck. At the bifurcation the internal carotid is the more external of 
 the two vessels, and lies on a plane posterior to it. The needle shi)uld now be 
 passed from without inward, and any branch that is given off from the external 
 carotid near the site of the ligature should be tied also, m order to ensure the 
 formation of a thrombus at the point of ligation. 
 
 The internal jugular vein sometimes overlaps the artery, and great care 
 must be exercised lest the vein be wounded during the necessary manip- 
 ulations. Before the ligature is finally tightened the operator should see the 
 effect upon the temporal by compressing the external carotid between the liga- 
 ture behind and the thumb upon the front of the vessel. The internal carotid 
 
1118 AX A}n:iM('AX TEXT-noOK OF sritCKllY. 
 
 must not l>o includt'd in tlic li^^ature. a mistake that niav <mciii- if the exter- 
 nal earotitl is tied close to the hi furcation. 
 
 The Sl'I'KKlou TllYROlli (IM. \\\') is the first hrancli <:ivcn r. IV from the 
 external carotid artery. This vessel arises from the external carotid by a 
 single trunk, while the lingual and facial often arise from a common trunk 
 which bifurcates to form these two vessels. The artery as it leaves its 
 parent trunk passes upward and forward quite superficially. This vessel is 
 irenerally injured in attempts to commit suicide, because it stands out promi- 
 nentlv uj»on the anterior aspect of the neck. The artery .><o(tn curves down- 
 ward, and runs deep in the neck to enter the thyroid gland. The surface guide 
 is an oblique line drawn parallel with the anterior border of the sterno-cleido- 
 mastoid muscle, while the muscular guide is the muscle itself. During the 
 operation the patient's head should be turned to the opposite side and the chin 
 be elevated. An incision should be made parallel to the anterior border of the 
 sterno-cleido-mastoid muscle, its center being at a point corresponding to the 
 superior border of the thyroid cartilage. The skin, the two layers of the super- 
 ficial fascia between which is the platysma myoides, and the fascia along the 
 anterior border of the sterno-cleido-mastoid muscle are next divided. This 
 will permit the latter muscle to be drawn outward. The superior thyroid artery 
 will now be visible crossing the floor of the superior carotid triangle. As it 
 crosses the triangle it is situated between the primitive carotid artery and the 
 lobe of the thyroid gland, into which it passes. The carotid sheath should be 
 brought fully into view, and the superior thyroid artery will be found along its 
 inner border. The surgeon must exercise care lest the superior thyroid, the 
 lingual, or the facial vein be Avounded. 
 
 The Lingual Artery (Pis. XXY and XXA^I). — This vessel is reached 
 by a curved incision beginning a little below and to the right or left of the 
 symphysis menti, and extending downward and outward to the greater cornu 
 of the hyoid bone (Fig. 440). This incision is then to be carried upward 
 toward the angle of the inferior maxillary bone, terminating at a point on a 
 level with the beginning of the incision, but short of the facial artery. The 
 integument is divided throucrliout the lenorth of the curvilinear incision; then 
 the two layers of the cervical fascia between which is the platys'.na myoides. 
 The apex of the submaxillary gland is now visible, which should be seized by 
 a tenaculum and drawn upward by gentle traction, at the same time tearing 
 carefully with the handle of the scalpel the loose connective tissue which binds 
 the gland to the subjacent parts. This dissection will expose Lesser s triangle. 
 The base of this is uppermost, and is formed by the hypoglossal nerve, while 
 the two sides lying beloAv are formed by the anterior and posterior bellies of 
 the digastric muscle. The floor of this triangle is formed by the hyoglossus 
 muscle, upon which lies the ranine vein just below the hypoglossal nerve. 
 Beneath the hyo-glossus muscle is found the lingual artery. The movements 
 of the hyoid bone during respiration can be controlled by holding the bone 
 steady with a tenaculum, as suggested by Thiersch. The lingual veins accom- 
 pany the lingual artery as a rule, but are of small size. The greater cornu of 
 the hyoid bone is also a very serviceable guide. 
 
 The Facial Artery (PI. XXV). — This vessel is secured at the point 
 where it crosses the inferior maxillary bone in a groove just in front of the 
 anterior border of the masseter muscle. To expose the artery, an incision 
 one inch in length should be made from the anterior inferior angle of the 
 masseter muscle in the line of the artery (Fig. 440), dividing the integument, 
 fascia, and platysma myoides. The vessel can be ligated just as it dis- 
 engages itself from beneath the submaxillary gland. Tlie facial vein is found 
 
PLATE XXVr 
 
 "^ ^ ^> If. \8 ' 
 
 (Maclise.) 
 
 A, root of common carotiri artery; B, subclavian artery at origin; C, trachea; D, thyroid axis of sub- 
 clavian artery; b, vagus nerve, crussing origin of subclavian artery ; F, subclavian artery at third division 
 of arch ; G. i».st-scapular brancli of subclavian ; H, transversalis humeri tiranch of subclavian ; I, traiis- 
 ver.sjilis colli branch of subclavian ; K, posterior belly of omo-hyoid muscle, cut : L, median nerve branch ; 
 M, iiiu.scul(i-s|.iral nerve; N, anterior scalenus muscle ; O, cervical plexus, giving off the phrenic nerve, 
 which talics tributary branches from brachial plexus of nerves ; P, upper part of internal jugular vein ; 
 Q, upper part of internal carotid artery; R, superior cervical ganglion of sympathetic nerve ; S, vagus 
 nerve, lying external to sympathetic nerve, and giving off <, its laryngeal branch; T, superior thyroid 
 artery; U, lingual artery," separated bv hyoglossus muscle from V, hypoglossal nerve; W, s.iblingual 
 glaiui ; X, genio-h void muscle ; Y, mvlo-hvoid muscle, cut and turned aside ; Z, thyroid cartilage ; 1, upper 
 part of sterno-hvoid muscle ; 2, upper part of omo-hyoid muscle; 3, inferior constrictor ol pharynx; 4, 
 cricoid cartilage'; 5, crico-thvroid muscle ; 6, thyroid body; 7, inferior thyroid artery of thyroid axis ; 3, 
 sternal tendon of sterno-mastoid muscle, turned down; 9, clavicular portion of sterno-mastiud muscle, 
 turned down; 10, clavicle; 11, trapezius muscle; 12, scalenus posticus muscle; 13, rectus capitis anticus 
 majnr muscle; 14, stylo-hyoid muscle, turned aside; 15, temporal artery; 16, internal maxillary artery; 
 17, inferior dental branch of fifth pair of cerebral nerves; 18, gustatory branch of fifth pair of nerves; 
 I"), external pterygoid muscle ; 20, internal pterygoid muscle ; 21, temporal muscle, cut to show the deep 
 icinixiral liranches of fifth yjair of nerves ; 22, zygomatic arch ; 23, buccinator muscle, with buccal nerve 
 and parutid duel ; 24, masseter uiUbclc, cut on the lower maxilla ; 26, middle constrictor of pharyr^x. 
 
LIGA TION OF AR TEBIES. 1119 
 
 upon the outer side. In niakinj^ the incision the skin should be drawn upward 
 over tlie bone, so that when the skin retracts the scar will not be visilWe upon 
 the face. 
 
 Middle Meningeal. — For a descrij)tion of the method of ligation of this 
 vessel see Intracranial Hemorrhage (p. r)14). 
 
 The Temporal Artery (Pis. XXV and XXVI) is found by a vertical 
 incision one inch in length made half an inch in front of the tragus and just 
 above the zygomatic arch (Fig. 440). After dividing the skin, the fascia, 
 and the dense cellular tissues, the finger of the surgeon can distinctly feel 
 the pulsation of the vessel. In order to avoid the temporal vein and the 
 auriculo-temporal nerve, the aneurysmal needle should be passed from behind 
 forward, as the temporal artery lies superficial to and in front of the vein and 
 nerve. 
 
 The Subclavian Artery (Pis. XXV and XXVI) springs from the innom- 
 inate artery upon the right side, and from the arch of the aorta upon the left 
 side. The vessel extends from the sterno-clavicular articulation to the lower 
 border of the first rib. It lies behind the scalenus anticus muscle in the second 
 part of its course. In the third portion it lies in the subclavian triangle, 
 which is bounded helow by the clavicle, on the outer side by the posterior belly 
 of the omo-hyoid, and on the inyier side by the posterior border of the sterno- 
 cleido-mastoid. 
 
 The artery is ligated in the third portion of its course, just outside of 
 the outer border of the scalenus anticus muscle. Ligation of the subclavian 
 behind, and upon the inner side of, the scalenus anticus has proved uni- 
 formly fatal. The surface guide is a line drawn parallel to and half an 
 inch above the clavicle, extending from the outer edge of the sterno-cleido- 
 mastoid muscle to the inner edge of the trapezius muscle. The muscular 
 guide is the outer border of the scalenus anticus muscle. The tubercle on 
 the first rib into which the scalenus anticus is inserted is the deep anatom- 
 ical guide. 
 
 In ligating the subclavian artery in its third portion the shoulders should 
 be lifted by a pillow, the head turned toward the opposite side, and the shoul- 
 der corresponding to the side upon which the artery is to be ligated drawn 
 downward. Before beginning the incision the external jugular vein should 
 be compressed and its course distinctly outlined, so that this vessel may be 
 avoided. The skin is now drawn down over the clavicle, and an incision is 
 made directly upon the upper margin of the clavicle and extending down to 
 the bone, and from the outer margin of the sterno-cleido-mastoid muscle to the 
 inner border of the trapezius muscle (Fig. 440). By drawing the integument 
 well down over the clavicle the external jugular vein is retracted under- 
 neath the clavicle, and thus escapes injury. When all the tissues are divided 
 to the bone the integument is allowed to assume its normal position, and the 
 line of the incision is found to be about half an inch above the clavicle and 
 directly over the course of the artery. The superficial structures having been 
 divided, the external jugular must be pulled to one side. The loose areolar 
 tissue, with the deep fascia which engages in its meshes the suprascapular and 
 transverse cervical veins, is separated with the index finger and the handle of 
 the scalpel. The tendon of the omo-hyoid muscle is exposed, and this must be 
 pulled upward with a blunt hook, and at the same time the suprascapular artery 
 must be avoided. The surgeon should now feel for the outer border of the sca- 
 lenus anticus muscle, and carry his index finger down along the edge of the mus- 
 cle until the tubercle on the first rib is felt. The subclavian vein lies in front 
 of this muscle and upon a lower plane {i. e. lower in the erect posture), while the 
 
1120 AN AMERICAN TEXT-HOOK OF SURGERY. 
 
 subclavian artery lies beliind tlio muscle. Tlic artery having been thus exposed 
 and its })ulsation clearly tV'lt with the tip of the sur<:eon's finger, the aneiirvsra 
 needle shouhl be passed from below upward and from before backward. In 
 passing the needle around the artery in the manner just described, the vein 
 and the pleura must be avoided below, and the cords of the brachial plexus, 
 especially the lowest cord above. 
 
 The Collateral Circulation is established by tiiree sets of vessels: 
 
 1. The sujirdscti^niliir and the posterior seupuhir from the transversalis 
 
 colli, with the dorsalis scapulce from the subscapular. 
 
 2. The internal mammary, the superior intercostal, and the aortic inter- 
 
 costals with the long thoracic and superior thoracic from the axillary, 
 and the dorsalis scapuhv from the subscapular. 
 
 3. Small branches given off' from the subclavian, anastomosing with unnamed 
 
 branches from the axillary artery. 
 
 The Inferior Thyroid Artery (PL XXVI) can be ligated by the same 
 incision that is employed for the purpose of tying the primitive carotid. 
 Having exposed the carotid artery and the internal jugular vein at a point 
 just below where the omo-hyoid tendon crosses in front of the carotid, the 
 sheath and its contents should be gently drawn outward and the tendon 
 upward by blunt retractors. The inferior thyroid artery will now be exposed 
 to view as it crosses behind the carotid, nearly upon the same level as that at 
 which the omo-hyoid tendon crosses in front of the carotid. The artery 
 enters the thyroid gland opposite to the fifth cervical vertebra. This vessel 
 crosses behind nearly on the level of the cricoid cartilage. Care must be 
 exercised by the surgeon not to include in the ligature the middle cervical 
 ganglion or the recurrent laryngeal nerve, nor to injure the oesophagus. If 
 the artery is tied low down, the thoracic duct must be carefully avoided. 
 
 The Vertebral Artery (PI. XXVI) is reached by an incision four inches 
 in length, beginning below the mastoid process and extending downward and 
 forward parallel with the posterior margin of the sterno-cleido-raastoid muscle, 
 terminating about one inch above the clavicle. The external jugular vein 
 must be avoided in making this incision. The transverse process of the sixth 
 cervical vertebra is the deep anatomical guide to the vessel. Having 
 exposed the posterior edge of the sterno-cleido-mastoid muscle by drawing it 
 toward the mesial line, the scalenus anticus muscle should become visible. 
 Upon this lie the phrenic nerve and the transverse cervical artery, which 
 should be protected from injury. The border of the scalenus anticus should 
 be made distinct, and in the interval between it and the longus colli muscle 
 the vertebral artery will be found, with its vein lying superficial to tlie artery. 
 The needle should be passed from without inward and from behind forward, 
 avoiding injury to the pleura and drawing aside the vertebral vein. 
 
 The Internal Mammary Artery may be tied in any part of its course, 
 according to the site of injury of the vessel. It lies just beyond the borders 
 of the sternum. In the upper t/co intercostal spaces the vessel lies upon the 
 pleura : and if the vessel is injured in this place, the pleura is most likely 
 to be injured also, and hemorrhage takes place into the cavity of the pleura. 
 If the vessel is wounded below the third intercostal space, the pleural cavity 
 is not necessarily opened, since the triangularis sterni muscle is between the 
 artery and the pleura. If the vessel is wounded below the third intercostal 
 space, the wound can be tamponed, as the triauiiularis sterni muscle is behind, 
 and pressure can be made against this muscle. Of course above the third 
 intercostal space strips of antiseptic gauze should not be introduced into the 
 wound. If the injury to the internal mammary artery is above the third 
 
PLATE XXVII, 
 
 r^^^:^t^ 
 
 "w^^^ 
 
 (Maclise.) 
 
 A, axillary vein, drawn from the artery to show the nerves lying becween both vessels. On the bicipi- 
 tal border of the vein is seen the internal cntaneous nerve ; on the trieipital border is the nerve of Wris- 
 berg, communicating with some of the intercosto-humeral nerves; a, the common trunk of the vena 
 coniiies, entering the axillarv vein; B,axillarv arterv crossed by one root of the median nerve ; b. basilic 
 vein, forming with a the axillarv vein, A ; C, c6raco-b"rachialis muscle ; D.coracoid head of biceps muscle; 
 E, pectoralis major muscle; F.pectoralis minor muscle; G, serratus magnus muscle, covered hy g, the 
 axillarv fascia, and perforated at regular intervals by nervous branches called intercosto-humeral; H, 
 conglobate gland, crossed bv nerve called " external respiratory" of Bell, distributed to the serratus mag- 
 nus muscle; I, subscapular arterv; K, tendon of latissimus dorsi muscle; L, teres major muscle. 
 
LIGATION OF ARTERTES. 
 
 1121 
 
 intercostal space, the symptoms of hemorrhage in general are present, and in 
 addition groat difficulty of respiration. In a wound of the internal mammary 
 artery both ends of the divided vessel should be tied, or return of the hemor- 
 rhage will take j)lace through the deep epigastric. Fig. 440 shows incisions 
 for reaching the internal mammary artery. 
 
 The Axillary Artery (IM. XXVll). — The surface guide to the axil- 
 lary artery is a line drawn })arallel to the anterior border of the axillary space, 
 at the junction of the anterior with the middle third. The artery extends from 
 the lower border of the first rib to the lower border of the tendon of the teres 
 major and latissimus dorsi nmscles, its three portions being respectively above, 
 behind, and below the pectoralis minor muscle. The deep muscular guide 
 is the lower border of the pectoralis minor. In operating on the third por- 
 tion the arm should be drawn outward at right angles to the trunk and 
 abducted (vide Fig. 441), and an incision made three inches in length along 
 the junction of the anterior with the middle third of the axillary space. 
 The integuments and fascia are to be divided along the inner border of the 
 coraco-brachialis muscle. The median nerve is to be drawn to the outer side 
 and the axillary vein to the inner side. The ulnar nerve lies upon the inner 
 side. 
 
 Collateral Circulation. — If the ligature is applied above the acromial 
 thoracic artery, the collateral circulation is the same as in ligature of the third 
 portion of the subclavian. If the ligature is applied to the axillary below the 
 acromial thoracic branch, then the subscapular and long thoracic anastomose 
 with the internal mammary, superior intercostal, and aortic intercostals. 
 
 The Brachial Artery (PI. XXVIIl). — The surface guide is a line 
 drawn from the junction of the anterior with the middle third of the axillary 
 space to a point midway between the two condyles of the humerus. The 
 muscular guide is the inner border of the biceps muscle. The artery lies 
 upon the triceps, coraco-brachialis, and brachialis anticus muscles. It is 
 overlapped in the upper part for a few inches by the biceps and coraco- 
 brachialis muscles. The deep anatomical guide is the median nerve, 
 which lies usually in front of the artery as it comes from the outer to the 
 inner side of the vessel. The incision should be made about the middle of the 
 arm obliquely along the inner margin of the biceps muscle (Fig. 441). Dur- 
 
 FiG. 441. 
 
 Lines of Incision Ibr ligation of tlie axillary (third portion), brachial, radial, and ulnar arterieg 
 
 (MacCormac). 
 
 ing the operation the arm should be rotated outward and placed at right angles 
 to the trunk, and the forearm supinated; the back of the arm should not be 
 allowed to rest upon anything; lest the triceps muscle push away the biceps 
 and the muscular guide be lost. After the integument and fascia have been 
 divided the median nerve will appear in view. The nerve is to be pulled out- 
 ward and the basilic vein and ulnar nerve inward with blunt hooks. The 
 71 
 
1122 AN AMKRK'AX rKXT-BOOK OF Si'RGERY. 
 
 arterv will be found directly under the nerve. The operator must avoid mak- 
 ing his incision too low down and too far internally, lest he mistake the ulnar 
 nerve for the median and liLMte the inferior profun<la artery for the brachial. 
 
 Collateral Circulation, — The superior profunda with the radial recur- 
 rent, the inferior profunda with the ulnar recurrent, and the anastomotica 
 magna with the interosseous recurrent. 
 
 The Radial Artery (PI. XXIX). — The surface guide is a line drawn 
 from a point midway between the two condyles of the humerus to a point lialf 
 an inch internal to the styloid process of the radius. The muscular guide 
 is the intermuscular space between the supinator longus and flexor carpi 
 radialis muscles. As the artery passes down the forearm it rests upon the 
 biceps tendon, supinator brevis, pronator radii teres, radial origin of the 
 flexor sublimis digitorum, flexor longus poUicis, and pronator quadratus mus- 
 cles. At the lower end of the forearm the artery rests upon the radius itself. 
 The nerve is upon the radial si<le in the middle of the forearm, but at the 
 wrist it has no relation with the artery, having passed to the back of the 
 forearm. 
 
 The incision should be made three inches above the wrist-joint, the forearm 
 being extended and supinated. It should be two inches in length, and between 
 the tendons of the supinator longus and flexor carpi radialis (Fig- 441). 
 
 Collateral Circulation. — The interosseous aiieries with the anterior and 
 posterior carpal arteries from the radial. 
 
 The Ulxar Artery (PI. XXIX). — The surface guide is a line drawn 
 from a point midway between the two condyles of the humerus to the radial 
 side of the pisiform bone. The artery in its course down the forearm lies 
 upon the brachialis anticus and flexor profundus digitorum muscles. The 
 flexor carpi ulnaris muscle is situated upon the ulnar side of the vessel. The 
 nerve lies to the ulnar side of the artery. 
 
 During the operation the wrist should be extended and the forearm supi- 
 nated. The incision should be three inches in length, its lower end termi- 
 nating about an inch above the wrist-joint (Fig. 441). The skin, the super- 
 ficial fascia, and the deep foscia lying above the ulnar artery are to be divided 
 upon a director or between forceps, and the artery Avill be exposed. The needle 
 should be passed from within outward, to avoid including the ulnar nerve in 
 the ligation. 
 
 Collateral Circulation. — The interosseous arteries with the anterior and 
 posterior carpal arteries from the ulnar artery. In case both radial and ulnar 
 arteries are ligated simultaneously, the collateral circulation is carried on by 
 the carpal arteries of both of these vessels, which anastomose with the iiiter- 
 osseoiis arteries. 
 
 The Superficial Palmar Arch (PI. XXX) may be ligated at the point 
 of injury. An Esmarch elastic bandage should be applied, so as to afford a 
 drv dissection of the parts. The divisions of the median and ulnar nerves, as 
 well as the tendons of the flexor muscles of the fingers, lie beneath the super- 
 ficial palmar arch, while the integument, palmaris brevis muscle, and palmar 
 fascia cover the vessel. 
 
 The incision to secure the superficial palmar arch should be made trans- 
 versely across the palm of the hand along a line drawn from the palmar border 
 of the root of the thumb, when hyperextended, to the ulnar border of the 
 hand (Fig. 442). To prevent the recurrence of hemorrhage both ends of the 
 divided arch should be ligated, as well as any branches of the arch that are 
 wounded. 
 
 The Deep Palmar Arch (PI. XXX) is formed by the radial artery and 
 
PLATE X X Vlll 
 
 iMaclise.) 
 
LIGATION OF ARTERIES. 
 
 1123 
 
 Fig. 442. 
 
 The Fiq;ure shows the position of the 
 .'^u])frficial ralniar Arch, and the 
 direction and jKjsition of the wound 
 which would liave to be made in 
 order to reach it (MacCormac). 
 
 a branch from tlie ulnar artery. The arch lies upon the interosseous muscles, 
 
 and likewise upon the bases of the metacarpal bones, and is covered by the 
 
 flexor tendons of the fingers and flexor brevis 
 
 pollicis. The deep arch if wounded can be tied 
 
 by a dissection, having first applied Esmarch's 
 
 elastic bandage. The wound in the palm of the 
 
 hand must form the guide to it. Injury of the 
 
 deep structures of the palm must be carefully 
 
 avoided. 
 
 The Intercostal Arteries are given off 
 from the posterior part of the aorta on each 
 side. Each artery divides into a posterior and 
 an anterior branch, the latter running forward 
 to supply the structures in its intercostal space. 
 The artery runs in a groove along the lower 
 border of the rib, Avhere it may be tied, a rib 
 being resected if necessary. If the pleural 
 cavity is filled with blood in consequence of a 
 hemorrhage from this vessel, the cavity should 
 be washed out with an antiseptic solution and 
 drained. 
 
 The AbdOxMINAl Aorta is a continuation 
 of the thoracic aorta, and extends from the last 
 dorsal vertebra to the left side of the fourth 
 lumbar vertebra, at which point it divides into 
 the common iliac arteries. The artery lies upon the front of the bodies of the 
 vertebrae. The stomach, transverse colon, and the small intestine, the pan- 
 creas and the splenic vein, the peritoneum, mesentery, and sympathetic nerve 
 plexus, lie in front of the artery, while behind it are found the left lumbar 
 veins, thoracic duct, receptaculum chyli, and the anterior ligaments connect- 
 ing the bodies of the vertebrie. To the right of the abdominal aorta lie the 
 inferior vena cava, the thoracic duct, and the vena azygos, while to the left 
 of the aorta no important parts are contiguous except the gangliated chain of 
 the sympathetic nerve. 
 
 The abdominal aorta can be ligated by an incision about four inches in 
 length, the center of which is opposite to the umbilicus and a little to its left 
 side. The skin, superficial fascia, aponeurosis of the external and internal 
 oblique muscles, the transversalis muscle, and the peritoneum are all divided. 
 The peritoneum should be held by two sutures to prevent its edges from retract- 
 ing out of reach. The patient is now turned upon the right side, so that the 
 abdominal viscera will gravitate to that side, and the peritoneum can be torn 
 through upon the left side of the artery. The aneurysm needle should be 
 passed between the vena cava and the artery, care being taken not to include 
 the sympathetic nerve. The abdominal aorta can also be reached by a lateral 
 incision, which begins at the tenth rib and extends downward to near the 
 anterior superior spinous process of the ilium. The skin, superficial fascia, 
 the aponeurosis of the external and internal oblique muscles and the trans- 
 versalis muscle and fascia having been divided, the peritoneum is carefully 
 stripped up from its attachment to the abdominal parietes, and the vessel 
 reached behind the peritoneum and without opening into the general peritoneal 
 cavity. The needle should then be passed around the artery in the same man- 
 ner as described in reaching the vessel by the median incision. 
 
 The abdominal aorta has been li orated eleven times, with eleven deaths. 
 
1124 
 
 AN AMERICAN TEXT- HOOK OE SURGERY 
 
 Fio. AV.\. 
 
 The Common Iliac Artkriks (1*1. XWi) are about two inches in length, 
 be<'in at the left side of the body of the fourth lumbar vertebra, and extend 
 
 to their bifurcation into the internal and 
 external iliac arteries at the sacro-iliac 
 synchondroses. 1'he right common iliac 
 artery is a trifle longer than the left, be- 
 cause the two common iliac veins join to 
 form the vena cava upon the right side of 
 the fifth lumbar vertebra. 
 
 The common iliac arteries may be li- 
 gated either by an incision which opens the 
 peritoneal cavity, or by a lateral incision 
 which reaches the vessel beiiind the peri- 
 toneum. The surface guide of the 
 common iliac arteries is a line drawn from 
 a little below and to the left of the um- 
 bilicus to a point midway between the 
 symphysis pubis and the anterior superior 
 spinous process of the ilium. An incision 
 is made six inches in length along the 
 linea semilunaris, beginning from the 
 lower border of the seventh rib and ex- 
 tending to nearly the spine of the pubes 
 (Fig. 443). Having divided all the tis- 
 sues, including the peritoneum, the intes- 
 tines are carefully removed and wrapped 
 in hot aseptic gauze, the peritoneum below 
 scratched through, and the needle passed 
 from without inward upon the right side, 
 and from within outward upon the left 
 side. In passing the needle in this way 
 the point is carried away from the vein. 
 The other method of reaching the common iliac artery is by a lateral incis- 
 ion and by stripping up the peritoneum, so as to secure the vessel without 
 opening the peritoneal cavity. The incisitm should begin from the eleventh 
 rib, and extend downward to a point two inches above the center of Poupart's 
 ligament; all the tissues are to be divided until the peritoneum is reached. 
 The subserous areolar tissue and the peritoneum are to be carefully stripped 
 upward and forward from the iliac fossa until the fascia covering the psoas 
 muscle comes into view. Just above the sacro-iliac synchondrosis and upon 
 the inner margin of the psoas muscle the common iliac artery is felt pulsating. 
 As the two vessels difier slightly in their relative anatomy, the needle must be 
 passed in a different direction in each case. In ligating the left common iliac 
 artery the needle must be passed from within outward, carefully avoiding the 
 superior hemorrhoidal artery, which must be pushed aside, together with the 
 mesocolon belonging to the sigmoid flexure. The ureter crosses the common 
 iliac below, and is generally raised with the peritoneum. In ligating the right 
 common iliac artery the needle must be passed from without inward, carefully 
 avoiding the iliac veins, which have crossed underneath the artery in order to 
 form the vena cava. The ureter, as in the case of ligating the left common 
 iliac, is usually raised out of reach, but if it is not lifted from the vessel with 
 the peritoneum it must be pulled downward by a blunt hook, so as not to be 
 included in the ligature. 
 
 Direction of the Common and External Iliac 
 Arteries, and the positions of the superficial 
 incisions adopted for their ligature. On the 
 right side is that for the external iliac, and 
 on the left side that for the common iliac 
 artery (MacCormac). 
 
PLATE XXIX 
 
 placlise.) 
 
 F 
 
 artery 
 
 municating 
 
 middle 
 
 io- 1 _A fascia covering biceps muscle ; B, basilic vein, with internal cutanemis nerve : C brachial 
 -."with veiiffi com'ites; D. cephalic vein, with external cutanwrns nerve; (?, mediaii nerve ; E. a cuin- 
 catint? vein, joining veme comites : F, median basilic vein; G, lymphatic gland ; H, radial arter> at 
 le • I radial arterv of the pulse ; K, ulnar artery, with ulnar nerve ; L, palmaris brevis muscle. 
 
 lomm subliniis: P, flexor pollicis longus ; Q. median nerve; R, lower end of radial artery ;S,lo\Ner end 
 of ulnar artery, in company with ulnar nerve ; T, pisiform bone; U, extensor metaearpi pollicis. 
 
LIGATION OF ARTERIES. 
 
 112;-) 
 
 The Internal Iliac Aktkries (IM. XXXI) arise at the bifurcation of the 
 common iliac near the sacro-iliac synchondroses. The internal iliacs run down 
 into the pelvic cavity to supply the pelvic organs. These vessels can be 
 ligated in either of the two ways already described for reaching the common 
 iliac arteries. After the abdominal cavity is opened or the peritoneum is 
 pushed aside by the lateral incision, the pulsation of the artery can be dis- 
 tinctly felt as the vessel descends into the pelvis upon the inner side of the 
 psoas muscle and along the sacro-iliac synchondroses. The needle used to 
 secure this vessel should be made with the curve at right angles to the shaft, 
 and one must be made for the right and one for the left internal iliac artery. 
 The ligature should be applied about one inch below the bifurcation, and the 
 needle passed from within outward and from behind forward. The ureter lies 
 in front of the artery, and the external iliac vein must be carefully avoided. 
 Dennis of New York has re- 
 ported three cases of ligation Fig. 444. 
 by the intraperitoneal ope- 
 ration. Two recovered ; the 
 third — in which both internal 
 iliacs were tied for the first 
 time — died. In lio-aturing all 
 the vessels in the abdominal 
 cavity, the bowels should be 
 thoroughly emptied by a ca- 
 thartic the night previous to the 
 operation, and by an enema a 
 short time before the opera- 
 tion. The bladder should also 
 be emptied, as in all abdom- 
 inal operations. 
 
 The Gluteal Artery is a 
 branch of the internal iliac ar- 
 tery, and emerges from the pel- 
 vis at the upper part of the great 
 sacro-sciatic foramen above the 
 pyriformis muscle. The gluteal 
 artery can be ligated at the 
 point where the vessel comes 
 out of the pelvis. The patient 
 should be placed upon his ab- 
 domen with the thigh extended 
 and the hip-joint rotated inward. 
 The surface guide is a line 
 drawn from the posterior supe- 
 rior spinous process of the ilium 
 to the middle of the trochanter 
 major. At the junction of the 
 upper with the middle third 
 of this line the artery emerges 
 from the pelvis (Fig. 444). 
 The muscular guide is the 
 upper border of the pyriformis 
 muscle. The gluteus raaximus muscle cavers the artery. An incision six 
 inches in length should be made along the course of the artery, as indicated by 
 
 Position and Direction of the Superficial Incisions which 
 must be made in order to secure the gluteal artery and the 
 sciatic and pudic arteries : j4, posterior superior iliac spine; 
 B, great trochanter ; C, tuberosity of the ischium ; D, ante- 
 rior superior iliac spine ; ^i?, ilio-trochanteric line, divided 
 into thirds. This line corresponds in direction with the 
 fibers of the gluteus maximus muscle. The incision to 
 reach the gluteal artery is indicated by the darker portion 
 of the line. Its center is at the junction of the upper and 
 middle thirds of the ilio-trochanteric line, and exactly cor- 
 responds with the point of emergence of the gluteal artery 
 from tlie great sciatic notch. AC, ilio-ischiatic line. The 
 incision to reach the sciatic artery and internal pndic is 
 indicated by the lower dark line. It also is to be made in 
 the direction of the fibers of the gluteus maximus muscle. 
 The center of the wound corresponds to the junction of the 
 lower with the middle third of the ilio-ischiatic line 
 (MacCormac). 
 
1 1 '2i] A N A M ERICA N TEXT-B O OK OF S UR GER Y. 
 
 the linear guide. Alter dividing the skin and fascia, the gluteus maximus 
 muscle will appear, the fibers of which, running parallel to the incision, can 
 be separated and held apart by retractors. The deep fascia beneath the mus- 
 cle is to be divided, and the artery will now be felt in tiie bottom of the wound 
 and at the upper ])art of the foramen above the tendon of the pyriformis. 
 The vena? comites must be separated and the needle j)assed around the artery. 
 
 The Sciatic Artery is a branch of the internal iliac artery, and leaves 
 the pelvis through the great sacro-sciatic foramen at its lower part and below 
 the tendon of the pyriformis muscle. The artery descends between the tuber- 
 osity of the ischium and the trochanter major. This vessel has close to it the 
 internal pudic artery. The patient is placed upon the abdomen with the thigh 
 extended and the hip-joint rotated inward. The surface guide is a line 
 drawn from the posterior superior spinous process of the ilium to the tuberosity 
 of the ischium. The muscular guide is the lower border of the tendon of 
 the pyriformis muscle. An incision is made along the linear guide already 
 mentioned (Fig. 444) : after division of the skin and fascia, the gluteus max- 
 imus muscle comes into view ; its fibers are separated by tlie handle of a 
 scalpel and held apart by retractors. Having divided the fascia beneath the 
 gluteus maximus, the sciatic artery can be felt pulsating just below the inferior 
 mar<^in of the pyriformis. The sciatic nerve accompanies the sciatic artery as 
 it emerges from the pelvis, and the internal pudic artery lies internal to the 
 sciatic artery. The course which the two arteries take will dispel any doubt 
 as to which vessel is the sciatic. The ligature is passed around the artery, 
 carefully avoiding the nerve, the internal pudic artery, and the venoe comites. 
 
 The Internal Pudic Artery. — This vessel may be tied either within 
 the pelvis in the perineum or outside of the pelvis as the artery emerges from 
 the greater sacro-sciatic foramen just below the pyriformis muscle. The vessel 
 can be tied by the same incision that has been already described to secure the 
 sciatic artery^ since the artery lies just internal to it at the lower part of the 
 greater sacro-sciatic foramen (Fig. 444). The internal pudic nerve accom- 
 panies the artery, which has venae comites. The artery enters the pelvis by 
 passing through the lesser sacro-sciatic foramen, and skirts along the outer side 
 of the ischio-rectal fossa lying upon the obturator internus muscle and covered 
 over with the obturator fascia. 
 
 The internal pudic can also be ligated in the perineum. The patient is 
 placed in the same position as for lithotomy, and an incision is made from a 
 point just beneath the symphysis pubis to the inner side of the tuberosity of 
 the ischium. The vessel can be felt pulsating an inch and a half above the 
 tuberosity. The skin, fascia, and tissues are divided, and the artery found 
 with its venae comites and the internal pudic nerve. The crus penis is liable 
 to be wounded in the upper part of the incision. 
 
 The External Iliac Artery (PI. XXXI) is formed by the bifurcation of 
 the common iliac, and extends from the sacro-iliac synchondrosis to Poupart's 
 ligament. The external iliac artery runs along the inner margin of the psoas 
 muscle, to which it is bound down'by a reflection of the fascia. The genito- 
 crural nerve lies upon the outer side of the artery, and near Poupart's ligament 
 the spermatic vessels cross it. The left external iliac vein lies upon the inner 
 side of the artery, but it is under the artery at its beginning upon the right 
 side. Just above Poupart's ligament the circumflex iliac vein crosses the 
 artery, and the vas deferens winds around the epigastric artery and descends 
 into the pelvic cavity upon the inner side of the external iliac artery. 
 
 The external iliac artery can X>e ligated by first performing a laparotomy 
 by an incision in the linea semilunaris, and then tearing through the posterior 
 
PLATE XXX, 
 
 "— <5S^ 
 
 (Maclise.) 
 
 vi^ 1 A r-i.Tifll artprv B median nerve: b,b,b, its branches; C, ulnar artery, forming F, sujier- 
 
 bone of the^humb^ tendons of extensor digitorum communis: A*, tendon overlying that of indicator 
 
 n?l^ttnsor earn radfalis brevier G, tendon of extensor carpi radialis longior : H, tendon of third ex- 
 ?en\or"of the th^umbTl tendon of 'second extensor of the thumb ; K. tendon of extensor minimi dig.ti. 
 joining a tendon of extensor communis. 
 
LIGATION OF ARTERIES. 1127 
 
 layer of the peritoneum in the same manner that has already been described 
 for tying the common or the internal iliac artery. The artery can also be tied 
 by a lateral incision about four inches in length about one inch above Poupart's 
 ligament. The incision should begin just external to the origin of the deep 
 epigastric artery, "which is about the center of Poupart's ligament, and con- 
 tinue outward and upward along the crest of the ilium internal to the circum- 
 flex iliac artery (Fig. 443). The incision made in this manner avoids wound- 
 ing these two brandies of the external iliac artery, and thus preserves a most 
 important collateral circulation. The skin, the superficial fascia, the aponeu- 
 rosis of the external oblique muscle, and the internal oblique and transversalis 
 muscles, are all divided to the full extent of the external incision. The trans- 
 versalis fascia is now severed upon a grooved director, carefully avoiding the 
 peritoneum. The peritoneum and the subperitoneal areolar tissue are next gently 
 stripped up from the iliac and psoas fasciae with the finger or the handle of the 
 scalpel, and with its contained viscera is pushed inward toward the umbili- 
 cus. The spermatic vessels and the ureter are usually adherent to the perito- 
 neum, and are thus pushed out of the way. The surgeon should exercise great 
 care in stripping up the peritoneum, as any rough manipulation would be likely 
 to favor the development of a purulent oedema or a pelvic cellulitis or pelvic 
 peritonitis. The finger should now be carried to the bottom of the wound, and 
 the inner margin of the psoas muscle felt, along the edge of which the artery 
 runs. The needle should be passed from Avithin outward, so as to avoid the 
 external iliac vein, which lies upon the inner side of the artery. The ureter 
 crosses the artery at its extreme upper end, and must be pushed upward if for 
 any reason it should cross lower down than usual. The genital branch of the 
 genito-crural nerve is seen lying upon the front of the vessel, and must not be 
 included in the ligature. The ureter usually is out of reach, but the possi- 
 bility of its presence, owing to its non-attachment to the peritoneal mem- 
 brane, must not be overlooked. 
 The Collateral Circulation : 
 
 1. The internal mammary wdth the deep epigastric artery. 
 
 2. The ilio-luonhar with the circumjiex iliac artery. 
 
 3. The gluteal with the external circumjiex. 
 
 4. The obturator with the internal circumjiex. 
 
 5. The internal pudic with the extertial pudic. 
 
 6. The sciatic with the perforating branches of the deep femoral. 
 
 7. The comes nervi ischiadici with the branches of the deep femoral. 
 
 The Deep Epigastric Artery is given off from the external iliac just 
 above Poupart's ligament, and runs upward toward the umbilicus. At its 
 beginning it lies just to the inner side of the internal abdominal ring, and in 
 its course runs between the peritoneum and the fascia transversalis. 
 
 The epigastric artery can be ligated by an incision beginning one inch 
 above Poupart's ligament and carried parallel to the ligament for three inches. 
 The center of the incision should be over the artery. The surface guide is 
 a line drawn from the middle of Poupart's ligament to the umbilicus. The 
 muscular guide is the transversalis muscle with the transversalis fascia. 
 The integument, two layers of superficial fascia, the aponeurosis of the ex- 
 ternal oblique muscle, and the internal oblique and transversalis muscles and 
 fasciae are to be divided, and when the transversalis fascia is reached it should 
 be cut upon a director and the artery exposed. The needle should be passed 
 in such a manner as to avoid the veins. 
 
 The Circumflex Ilii is another branch of the external iliac artery, and 
 takes a direction upward and outward parallel with Poupart's ligament and the 
 
1128 
 
 AN AMEincAX TEXT- HOOK OF SURGERY. 
 
 crest of the ilium. It runs close to the inner lip of the crest. The circum- 
 flex iliac artery can be ligated by the same incision that has been mentioned 
 for securing the opi^jastric artery, or the vessel may be tied by another iticis- 
 ion just above and parallel to l*ouj)art"s ligament and the crest of the ilium, 
 'riic diti'erent layers must be cut down upon until the transversalis fascia is 
 reached. The artery lies between this fascia and the peritoneum. 
 
 The Femoral Aktkry (PI. XXXI) is a continuation of the external iliac 
 vessel. It extends from a point midway between the anterior superior spinous 
 process of the ilium and the symphysis pubis to the opening in the adductor 
 magnus muscle, through which the femoral artery passes to become the pop- 
 liteal. The artery lies in a triangle known as Scarpa's triangle, which is 
 bounded as follows : the bane of the triangle is Poupart's ligament, the outer 
 side is the inner margin of the sartorius muscle, and the inner side is the 
 inner margin of the adductor longus muscle. The inner border of both mus- 
 cles must be taken as the boundaries of the triangle, which excludes the sarto- 
 rius from taking part in the floor of the triangle, but includes the adductor 
 longus. The femoral artery is covered by integument, superficial and deep 
 fasciae, and the sheath of the vessels. A branch of the internal cutaneous 
 nerve and the crural branch of the genito-crural nerve lie upon the sheath of 
 the vessels. The internal saphenous vein lies superficial to, as well as upon, 
 the inner side of the artery. 
 
 The ligation of the femoral artery is usually performed at the apex of 
 Scarpa's triangle, about five inches below Poupart's ligament. The surface 
 guide is a line drawn from a point midway between the anterior superior 
 iliac spine and the symphysis pubis to the adductor tubercle upon the inner 
 condyle of the femur. The muscular guide is the inner margin of the 
 sartorius muscle. The patient should lie upon his back, with the knee 
 slightly flexed and the hip rotated outward, the femur also being slightly 
 flexed and abducted. The incision should begin three inches below Poupart's 
 
 Fig. 445. 
 
 The lines indicate the incisions to be made for tlio ligature of the foniniiiii feinnnil. of the femoral in 
 Scarpa's triangle and in Hunter's canal, and of the posterior tiliiul in the calf and hehind the mal- 
 leolus (MaeCormae). 
 
 ligament (this should be a measured distance, or the incision will probably be 
 made too low), and be carried downward about three inches along the line of 
 
PLAT E XXXI. 
 
 --;:^'^~:c ■:-<CX^ 
 
 (Maclise.) 
 
 A, aorta at point of bifurcation ; B, anterior superior iliac spine; C. symphysis pubis; D. Poupart's 
 iigament, immediately above which are seen the circumflex iliac and epigastric arteries, with vas deferens 
 and spermatic vessels : E, E*, right and left iliac muscles, covered by peritoneum : the external cutaneous 
 nerve is seen through the membrane ; F, the vena cava ; G, G*, common iliac arteries, giving ort' internal 
 iliac branches on the sacro-iliac symphyses; gr, a, right and left ureters; H, H*, right and left common 
 iliac veins ; I, I, right and left external iliac arteries : each is crossed bv circumflex iliac vein ; K, K, right 
 and left external iliac veins; L, urinary bladder, covered by peritoneum; M,the rectum; N, profunda 
 branc'n of femoral artery ; O, femoral vein ; o, saphena vein ; "P, anterior crural nerve ; Q, sartorius muscle, 
 cut; S, pectineus muscle; T, adductor longus muscle ; U, gracilis muscle; V, tendinous sheath given off 
 from long adductor muscle, crossing vessels and becoming adherent to vastus internus muscle (forming 
 Hunter's canal y ; W, femoral artery. 
 
LIGATION OF ARTERIES. 1129 
 
 the femoral artery (Fig. 44')). Tlic integument, the superficial fascia, and the 
 fascia lata are all divided. The lymphatic glands, if they are in the field 
 of operation, must he pushed aside or removed. The internal saphenous vein 
 lies upon the inner side of the incision, and its position can be readily made 
 out by making pressure upon the vein near its entrance into the femoral. 
 The surgeon should now look for the sartorius muscle, the fibers of which run 
 downward and inward. The sartorius must not be mistaken for the adductor 
 longus, the fibers of which run downward and outward. Just under cover of 
 the sartorius muscle the sheath of the femoral vessels will be found. The 
 sheath should be opened upon the outer side, so as to avoid wounding the 
 femoral vein in the event of its overlapping a part of the artery. Upon the 
 sheath lies the crural branch of the genito-crural nerve. In passing the needle 
 around the femoral artery it should be carried from within outward. The 
 femoral vein in this situation is posterior as well as internal to the artery. 
 The long saphenous nerve must be avoided as it lies over the artery. 
 
 Collateral Circulation. — 1. The profunda femoris with the articular 
 bratu'/ti's of the jmpUteal and the tibial recurrent. 
 
 2. The arteria comes nervi ischiadici with the perforating branches of the 
 profunda femoris and the articular branches of the popliteal and tibial recur- 
 rent. 
 
 The Popliteal Artery (PI. XXXII) is a continuation of the femoral 
 from the opening in the adductor magnus muscle to tlie lower border of the 
 popliteus muscle. The artery as it runs obliquely downward lies at first upon 
 the posterior border of the condyloid surface of the femur, in its middle por- 
 tion upon the posterior ligament of the knee-joint,, and in its lower portion 
 upon the popliteus muscle. Behind the popliteal artery is the popliteal vein, 
 which is joined by the short saphenous vein from below, while the internal 
 popliteal nerve is superficial and a little external to the vein. The space 
 through which the artery runs is covered over by a dense fibrous fascia which 
 is a continuation of the fascia lata, and this binds down the vessels and nerves 
 and lymphatic glands. The lateral boundaries of this space are formed above 
 by the inner and outer hamstrings, and below by the divergence of the two 
 heads of the gastrocnemius muscle. 
 
 The ligation of the popliteal artery may be best accomplished in the upper 
 part of the space. The surface guide is a line drawn from a point about 
 one inch internal to the upper .angle of the space to the apex of the inferior 
 angle. The muscular guide is the external margin of the semi-membra- 
 nosus muscle. An incision should be made beginning at the upper part of the 
 space and continuing obliquely downward through the space, about four inches 
 in length. This incision should be just external to the outer margin of the 
 semi-membranosus muscle. The integument and superficial fascia having been 
 divided, the fibers of the semi-membranosus appear in view. This muscle 
 should be drawn inward with a blunt retractor. The space will be found to 
 contain loose areolar tissue, which must be carefully teased away with the 
 handle of the scalpel until the sciatic nerve is exposed. Just to the inner 
 side of the nerve lies the popliteal vein, while the artery lies slightly more 
 internal and almost covered by the vein to which it is closely connected. The 
 sciatic nerve and the popliteal vein must now be drawn to the Outer side by a 
 blunt hook, when the artery will be fully exposed to view. The aneurvsm 
 needle should be passed in a direction from without inward. 
 
 The Posterior Tibial Artery (Pis. XXXII and XXXIII) arises at the 
 bifurcation of the popliteal. It begins at the lower margin of the popliteus 
 muscle, and extends down the back of the leg to a point between the internal 
 
]];30 AN AMEIZICAN TEXT-BOOK OF SURGERY. 
 
 malleolus and the tuberosity of tlie os calcis, avIktc the artery divides to forra 
 the internal and the external ])lantar. The artery in its course down the leg 
 lies upon the deep layer of muscles of the calf and is covered in by the super- 
 ficial layer. The surface guide is a line drawn from the middle of the pop- 
 liteal space to a point half an inch behind the tip of the internal malleolus. 
 The muscular guide is the outer border of the flexor lon<^fus di^^itorum in 
 the lower part of its course, and the soleus muscle, beneath whicli it lies, in 
 the upper part of its course. It can be lifjated through an incision in the mid- 
 dle of the calf while the patient is lying upon the abdomen. This should be 
 made slightly to the inside of the median line of the leg, and be about six 
 inches in length in order to reach the artery at this depth and fully to expose 
 it. The muscles of the calf are then divided down to the deep fascia beneath 
 which the artery lies. This fascia being divided upon a director, the artery is 
 exposed, the nerve lying to its outer side. The artery is, however, more com- 
 monly ligated by an incision four inches in length parallel to the inner border 
 of the tibia and three-quarters of an inch behind it (Fig. 445). In dividing 
 the skin and the fascia the internal saphenous vein must be carefully avoided. 
 The thin tibial attachment of the soleus is next carefully divided throughout 
 the entire length of the incision. The ankle-joint is now^ extended, thus relax- 
 ing the soleus, which is lifted by a retractor, and the deep fjiscia comes into view. 
 The artery can be felt pulsating under it, near the external border of the tibia, 
 and is exposed by dividing the fascia upon a grooved director. The artery 
 needle should be passed from without inward to avoid the nerve. 
 
 The posterior tibial artery can be also ligated just behind the internal mal- 
 leolus. A crescentic incision is made with the convexity downward, the center 
 of which should be at a point midway between the tip of the internal malleolus 
 and the inner tuberosity of the os calcis (Fig. 445). Tlie skin, the superficial 
 and the deep fasciae, and the internal annular ligament having been divided, 
 the artery is exposed. The relations of the parts from above downward are as 
 follows : the tendon of the tibialis jiosticus, the tendon of the flexor longus 
 digitorum, the artery with a vena comes on each side of it, the posterior tibial 
 nerve, and the tendon of the flexor longus pollicis. 
 
 The Peroneal Artery begins about an inch below the popliteus muscle, 
 and passes obliquely down the leg parallel Avith and just posterior to the shaft 
 of the fibula. The incision should be about four inches in length upon the outer 
 part of the calf, while the leg is rotated so that, its inner surface rests upon the 
 operating table and its outer surface is turned upward. The skin, the fas- 
 ciae, the fibular origin of the soleus muscle, and the deep fascia separating this 
 muscle and the flexor longus pollicis, are all to be divided. The soleus and 
 flexor longus pollicis muscles can be relaxed by extending the ankle-joint, 
 and the cut fibers of the soleus can be retracted inward. The peroneal artery 
 will be found upon the inner side of the flexor longus pollicis : it has occa- 
 sionally been observed in the substance of that muscle. It lies close to the 
 fibula, and unless this fact is observed the posterior tibial might be tied in its 
 place. 
 
 The Anterior Tibial Artery (PI. XXXIII) is formed by the bifurca- 
 tion of the popliteal, and begins at the lower border of the popliteus muscle. 
 It passes between the tibia and the fibula just above the interosseous mem- 
 brane, and then runs down upon this membrane to the ankle-joint, from which 
 point the vessel is known as the dorsalis pedis. The anterior tibial artery in 
 the upper third of the leg lies between the tibialis anticus muscle and the 
 extensor communis digitorum ; in the middle third of the leg, between the 
 tibialis anticus and the extensor proprius pollicis ; in the lower third of the 
 
PLATE XXXII. 
 
 r^km^,.-^ 
 
 (Maclise.) 
 
 Fig:. 1 — A, tendon of gracilis muscle ; B, B, fascia lata : C, C, tendon of semimembranosus ; D, tendon 
 of semitendinosus, E, E, the two heads of gastrocnemius : F, popliteal artery: G, popliteal vein, joined 
 by short saphena vein; H, middle branch of sciatic nerve; K, posterior tibial nerve, continued from 
 middle branch of the sciatic, and extending to K*; L, posterior (short saphena vein ; M, M, fascia, cover- 
 ing gastrocnemius ; N, short (posterior) saphena nerve, formed by union of branches from peroneal and 
 posterior tibial nerves ; O, posterior tibial artery, appearing from beneath soleus muscle in lower part of 
 leg; P, salens muscle, joining tendo Aehillis; Q, tendon of flexor communis digitorum ; R, tendon of 
 flexor longus poUicis ; S, tendon of peroneus longus; T, peroneus brevis muscle ; U, U, internal annular 
 ligament, binding down vessels, nerves, and tendons in hollow behind inner ankle ; V, V, tendo Aehillis: 
 w, tendon of tibialis posticus muscle ; X, the venae comites of posterior tibial artery. 
 
 FisT. 2.— A, C, 0, E, F, G, H, I, refer to same parts as in Fig. 1 ; B, inner condyle of the femur; K, 
 plantaris muscle, lying upon popliteal artery; L.popliteus muscle; M, M, M.the tibia: N, N, the fibula; 
 O, O, posterior tibial artery ; P, peroneal artery ; Q, R, S, T, U, V, W. refer to same parts as in Fig. 1 : X, 
 the astragalus. 
 
LIGATION OF ARTERIES. 
 
 1131 
 
 Fig. 44G. 
 
 leg, between the extensor communis digitorum and tlie extensor proprius pol- 
 lici's. It has the anterior tibial nerve in the ujjper third of its course upon 
 the outer side, in tlie middle third anterior to 
 it, and in the lower third again upon the outer 
 
 side. 
 
 The ligation of the anterior tibial may be ac- 
 complished in the lower part of the upper third 
 of tlie leg. The surface guide is a line drawn 
 half an inch from the inner sitle of tlie head of the 
 fibula to a point midway between the two mal- 
 leoli. The muscular guide is the outer mar- 
 gin of the tibialis anticus muscle. The incision 
 should be made four inches in length along the 
 line indicated by the surface guide (Fig. 446). 
 The skin and superficial fascia are divided, and 
 then the deep fascia upon a grooved director. 
 The foot should now be strongly extended and 
 everted, in order to make tense the marginal 
 border of the muscular guide. This muscle 
 must be separated by retractors from the ex- 
 tensor communis digitorum. The artery will 
 be found lying upon the interosseous mem- 
 brane, with the anterior tibial nerve in front 
 of it or to its outer side. The two muscles are 
 to be widely separated, the nerve drawn out- 
 ward, the vems isolated from the artery, and the 
 aneurysm needle passed from without inward. 
 
 The anterior tibial artery can be ligated 
 also above the ankle-joint. The surface 
 guide is a line drawn in front of the ankle- 
 ioint midway between the two malleoli. The 
 muscular guide is the outer edge of the 
 extensor proprius pollicis. An incision is made 
 along the linear and muscular guides, dividing 
 the skin and superficial fasciae. The tendon 
 of the tibialis anticus is made taut by eversion 
 of the foot, and the extensors by flexion of the 
 toes and extension of the foot. The tendons of the two extensors are now 
 separated by retractors, and the artery is felt pulsating in the mtertendmous 
 space, with the anterior tibial nerve upon the outer side. The needle is to be 
 passed from without inward, avoiding the venpe comites and the nerve. 
 
 The DoRS\Lis Pedis Artery (PI. XXXIII) is a continuation of the ante- 
 rior tibial artery, and its course would be indicated by a line drawn from a 
 point midway between the two malleoli to the interosseous space between the 
 ^reat and second toes (Fig. 446). The linear guide to the artery is the pro- 
 loncration of a line indicating the guide to the anterior tibia , and the mus- 
 cular guide is the outer margin of the extensor proprius poUicis. 
 
 In licratincr the dorsalis pedis arterv the ankle-joint should be extended and 
 the toes%tron"gly flexed, which will bring out in relief the tendons ^liich are 
 to serve as a guide to the arterv. The skin and superficial fascia are divided 
 by an incision about three inches in length, and the above-mentioned tendons 
 are separated by retractors after dividing the dense fascia attached to the 
 extensor proprius pollicis. The artery will be felt pWsating at the bottom of 
 
 Position and direction of the incisions 
 which may be made to ligate the an- 
 terior tibial and dorsalis pedis arte- 
 ries (MacCormac). 
 
1132 AX AMERICAN TEXT-ROOK OF SURGERY. 
 
 the wound, witli the nerve lying u{)on the outer side and the venae comites 
 upon the two sides of the artery. The inner tendon of the extensor brevis digi- 
 torum erosses tlie dorsalis pedis artery, and this tendon must be retracted out- 
 ward in order fully to expose the dorsalis pedis artery. 
 
 CHAPTER V. 
 OPERATIONS OX BONES AND JOINTS. 
 
 Operations on bones and joints are numerous and of many kinds — the 
 enucleation of non-malignant tumors, the removal of sequestra, the wiring of 
 fragments after fracture, division for the relief of deformity, trephining, aspi- 
 ration, and incision to give exit to fluids, pus, blood, and excessive secretion, 
 or for the extraction of foreign bodies, etc. ; and especially the taking away 
 of a part or the whole of a bone or a joint for injury or disease — resection or 
 excision, for the terms are commonly used interchangeably. 
 
 Resection or Excision. — Whenever the condition of the diseased or 
 injured part is such that life will be seriously imperilled by the long contin- 
 uance of suppuration and protracted confinement that must be associated with 
 non-operative treatment, or when the functional value of the articulation or 
 limb so preserved Avill be but slight, or the resulting deformity will be great, 
 or the existing disease in all probability will extend to contiguous parts or 
 be carried to those at some distance, or when amputation is the alternative, — 
 then resection is indicated, provided the condition of the patient permits of its 
 performance. The danger of its execution is not excessive; the likelihood 
 of the complete removal of the disease is in many cases at least fair ; and 
 the part saved will be serviceable, or can be rendered so by the aid of some 
 apparatus. 
 
 The ItiHtrumnnts required for its performance are knives and scissors for 
 such laying open of the soft parts as may be necessary to uncover the bone or 
 joint and to remove infected tissues : retractors to keep the field of operation 
 exposed ; saws and cutting forceps for division of bone ; gouge forceps, sharp 
 spoons, chisels, and hammer for the removal of limited portions of bone; ele- 
 vators and periosteotomes for removing the periosteum ; drills and pins and 
 sutures of wire or other suitable material for the after-fixation of the parts 
 if this be necessary ; and the ordinary instruments and dressings for closing 
 wounds. Barker's sharp spoon, which permits the flushing of the field of 
 operation through its hollow handle, will often be found of niucli service. 
 The Esmarch bandage is generally useful, but in some of the operations it 
 cannot be employed, and in others is of doubtful value because of the great 
 amount of after-oozing. As immobilization of tiie limb will generally have 
 to be secured for a considerable length of time splints of special form may be 
 required. 
 
 Whenever practicable — and this is almost always the case — the operation 
 should be performed antiseptically and the strictest antisejitic after-treatment 
 employed, the mortality thus being reduced to a minimum, early union secured, 
 the general strength of the patient economized, and the inconvenience and risk 
 of frequent dressing saved to both operator and patient. Whenever it can be 
 done the periosteum should be lifted off the bone, not in shreds, but in as com- 
 plete a sheet as possible, and preserved, that regeneration more or less complete 
 
PLATE XXXIII. 
 
 
 (Maclise.) 
 
 Fi«.l.-A, tendon of t,,etibiaUsa„tiev.jnu^^ 
 alls posticus muscle; D the ">»•} ^''•J'\';, ""^\ 'V/il ^ q' 'leiis muscle: H, tendon of the plantans 
 ;;;S; r',^?^:f^r;;itnl^f i^;^'T^J^o^tS a^ryf\^L, posterior tibial nerve, 
 ""rt. 2.-A. tibialis anticusmuscle; a itstendon;Bexten^^^^^^^ 
 four tendons; C, extensor longus PoHicis miiscle D D the tu^m^^ ^ ^^.^^^. ^ 
 
 descending to the dorsum ot the toot. 
 
OPERA T/O AS ON HONES AND JOINTS. ll").'^ 
 
 accordin<:f to circuinstaiices may take jdat-f. Such subperiosteal resection 
 may coiiiinonly be done in cjuses of disease, but in cases of injury, especially if 
 recent, it will frecjuently, if not generally, be found impossible to effect it. 
 
 In all cases tlie least possible injury should be done to the soft structures 
 consistent with due exjiosure (»f the part to be ojterated upon, the muscles being 
 divided longitudinally rather than cut across, and important vessels and nerves 
 avoided or pushed aside. Hemorrhage should be temporarily controlled by 
 forceps, as, speaking generally, it is inadvisable to sj)end time in the applica- 
 tion of ligatures, as at the close of the operation many of them will be found 
 unnecessary. 
 
 When a portion (»f bone is removed, not liecause it is diseased, but in 
 order to get at deeper-seated j)arts, as in certain operations upon the Jaws 
 and in the skull, it should be sejjarated otilji in /xoi, to be later re])laced and 
 attached — the so-called osteoplastic resection. 
 
 When the excision is of a part of the shaft of a bone, it is one in con- 
 tinuity ; when of an articular extremity, in contiguity. Speaking generally, 
 operations in continuity are much less satisfactory than those in contiguity ; 
 and this is particularly true if they be done upon the femur and the humerus. 
 Non-union has not seldom been observed, and an ununited fracture of the 
 thigh is a great inconvenience — much more so, of course, than one of the arm, 
 though this is troublesome enough. Besides this, in the thigh the resulting 
 shortening may mucb disable the patient. 
 
 In the forearm and leg, when one bone only is operated upon and any con- 
 siderable piece is taken away, the ends of the fragments cannot be brought 
 together, and the re-formation necessary to fill in the gap is apt to be imper- 
 fect : often it is so in an extreme degree. Bone-grafting as now done prom- 
 ises something toward the filling up of such defects, but how much may be 
 accomplished by it the future must determine. Compensatory overgrowth of 
 the other bone may, and often does, render the limb a serviceable one, but 
 there has frequently been observed, especially in the forearm, a gradually pro- 
 duced deformity at once unsightly and crippling. It is much better in these 
 cases to cut out so much of the other healthy bone as will enable the operator 
 to bring the fragments of both bones into proper apposition. Very generally, 
 when the case is one of injury, informal removal of detached fragments, with, 
 if necessary, the cutting off of sharp ends of the others, gives a much better 
 ultimate result than resection in continuity. 
 
 When in an excision in contiguity the entire articulation is removed, it is 
 complete ; when the end of only one bone or a portion thereof, partial. At 
 times an entire bone is taken away. When the excision is done in a regular 
 way and after some established method, it is a formal or typical one ; when 
 partial and adapted to the peculiar condition of the particular case, informal 
 or atypical. If performed for inj»ry and within a few hours after its receipt, it 
 is primary; when in the period of local and general disturbance accompany- 
 ing and following reaction and before the occurrence of suppuration, inter- 
 mediary ; when, without regard to the nature of the cause, after suppuration 
 has become established, secondary. Under ordinary circumstances inter- 
 mediary operations should not be done. 
 
 When in a limited portion of the shaft a tumor is present, if non-malig- 
 nant it should be shelled out and the healthy bone preserved ; if malignant, 
 the entire hone should be resected or the limb amputated or the case left un- 
 operated upon, according to circumstances. 
 
 In joint rejections the question of partial or total excision will be settled 
 by the nature and extent of the cause and the probable functionaH'alue of the 
 
1134 AX A.VFRrr.lX TKXT-IlOOk' OF ST'Ra KRV, 
 
 limb after one operation or the other. If there has })een received an injury 
 nfteeting a part of tlie articuhition, that part only should be removed, provided 
 the ultimate usefulness of the joint will be as great as if complete resection 
 had been done. The rule to sacrifice nothing unnecessarily holds good, and 
 late experience of the results of improved wound-treatment has been favor- 
 able to partial excisions and those of informal character. 
 
 But if the case is one of disease almost certainly tubercular, \\'\\\ j)artial 
 removal get rid of the entire disease ? If the lesion is confined to one bone, 
 there is no reason for complete excision unless a better result functionally can 
 thus be secured; but it is generally the case, at least in the elbow, knee, wrist, 
 and ankle, that by the time the operation is warranted the tubercular deposit 
 is not thus limited, and complete removal in those Joints will usually be best. 
 Infected synovial and perisynovial tissues must always be thoroughly removed; 
 and it is in doing this that much of the difficulty of the operation often lies, 
 and the fiiilure to accomplish it is the frequent cause of relapse. 
 
 The prognosis has of late years become very good, certainly so far as 
 recovery from the operation is concerned. Until the introduction of antisepsis 
 the mortality was heavy from exhaustion, septic infection, amyloid disease of the 
 kidney or intestines, tubercular meningitis, or tuberculosis of the lungs, often 
 greatly aggravated by the resection and its direct results. At the present time 
 the patient is not likely to die if in any fit condition for operation and if properly 
 protected against the dangers of suppuration. 
 
 A thoroughly aseptic excision is almost certain to be followed by 
 prompt healing, even if rliere is coexisting tubercular disease in another 
 joint or bone or in the lung, and improvement, greater or less, of longer or 
 shorter duration, in the condition of such other part may be expected to fol- 
 low. If the tubercular deposit is not thoroughly removed, the recovery will 
 be incomplete ; sinuses will remain, necessitating reopening and scraping ; or 
 the apparently healed wound will reopen, or the disease will so extend in the 
 bone and soft parts as to compel amputation: or a general dissemination of the 
 bacilli, at times set free by the operation itself, may occur and speedily cause 
 death. The large number even of those successfully operated upon die before 
 many years, commonly of pulmonary tuberculosis. 
 
 AETHRECTOMY OR ERASION. 
 
 The ideal operation in cases of tubercular joint disease is one in which all 
 unhealthy tissue is taken away and all healthy tissue left undisturbed. This 
 cannot be the case when excision is done, since more or less unaffected tissue 
 must be removed : often the error will be in both directions, and some infected 
 tissue will be left. 
 
 Erasion is a better term than arthrectoray. The latter term should be 
 restricted to complete extirpation of tlie synovial membrane and diseased peri- 
 articular structures, leaving the bone untouched — an operation which is neces- 
 sarily of limited application. Erasion is intended exactly to satisfy the 
 requirements, to cut away and with sharp spoon to scrape away the tubercular 
 material present in membrane, ligament, and bone, and nothing more. 
 
 If it were possible to ascertain before or at the time of operation just 
 where the tubercular deposits were and their full extent, erasion would afford 
 complete relief, or at least relief as complete as can be effected in a case of 
 local tuberculosis, since there must always be a chance of operative dissemi- 
 nation or of coexisting tubercular disease in near or remote parts. It is not 
 possible, however, to do this, although much can be learned by inspection, by 
 
OPERATIOXS OX liOXES A XI) JOIXTS. ll.i") 
 
 pressure through the soft parts or directly upon the exposed bone (limited ten- 
 derness, which is often pathognomonic, being thus discovered), or by puncture, 
 diminished resistance indicating locali'/e<l softening, due, it may be safely con- 
 cluded, to disease. 
 
 15ut while it is true that erasion may not accomplish the desired object, the 
 considerable experience of many surgeons in various parts of the world in the 
 last few years has shown that both in children and in adults thorough cleaning 
 out by knife, scissors, and spoon will, in a large proportion of cases, be fol- 
 lowed by highly successful results, even to the preservation of the function of 
 the articulation operated upon. The operation may be done much earlier than 
 an excision is likely to be performed, it is less severe, an<l if unsuccessful the 
 major operation, typical resection, is still in reserve, can be readily executed, 
 is attended with no more risk than if primary, and if delayed by the erasion 
 until after full growth of the limb has been secured, the ultimate shortening is 
 much less. 
 
 In doing an erasion the joint must be fully opened, and that method of 
 incision is the best which most completely and with least injury to the parts 
 permits of thorough exploration, since success can be looked for only after 
 removal of all, or nearly all, of the diseased tissue, although without doubt 
 very small portions of tubercular material can be spontaneously got rid of 
 by degeneration and cicatrization or by encapsulation. 
 
 Most of the arth'rectomies have been done upon the knee-joint. The term 
 arthrotomy is at times, but improperly, employed as synonymous with erasion 
 or arthrectomy. If used at all, it should be in its proper sense, to indicate 
 simple incision of a joint, without regard to the purpose or extent of the 
 opening. 
 
 OSTEOTOMY. 
 
 Division of a long bone for the relief of deformity is, as a rule, easy of 
 performance, is attended with but little danger, and is satisfactory in result. 
 The section is ordinarily a linear one, but it may be cuneiform, a wedge being 
 removed (Fig. 447), or trochleiform, the section being a curved one. 
 
 Generally it is done subcutaneously, the incision down to the bone being 
 only large enough to admit of the ready passage of the saw or chisel employed, 
 or even this may be omitted and the chisel driven in ; but at times the portion 
 of bone to be operated upon is fully exposed, and with aseptic precaution this 
 open method is attended with little or no more risk than the other. Either 
 saw or chisel may be employed, the latter being generally preferred, as being 
 more under control, easier to use, and making no dust. Two or three chisels 
 of different sizes may be used in dividing the bone, or a single one, according 
 to the preference and habit of the operator. Of saws, the choice lies between 
 the chain saw and the narrow stiff one, and ordinarily the latter will be se- 
 lected. A sand-bag to rest the limb on will much facilitate the operation. 
 Complete instrumental division of the bone need not be made, as a thin por- 
 tion of the surface opposite the point of entrance can readily be broken, and 
 the risk of injury to the soft parts by the chisel or saw^ avoided. 
 
 The dangers are two — septic inflammation and wounding of important 
 nerves or blood-vessels, especially the latter. The former will be prevented 
 by antisepsis or asepsis during the operation and after-treatment ; the latter 
 by care at the time of the section, though the accident has happened in the 
 practice of even the most prudent and skilful operators. When it does occur, 
 the existing conditions will determine whether it is better to let the damaged 
 part alone or to cut down and suture the nerve or tie the vessel. The bone 
 
1136 
 
 ^.y AMERICAN TEXT-BOOK OF SURGERY 
 
 having been divided, rectification of the malposition should be effected at once, 
 an aseptic dressing with an abundance of cotton placed around the area of ope- 
 
 Viii. 447. 
 
 Diagram representing a Curved Tibia: ,-1, with a wedge removed on the convex side for the purpose 
 of straigiitening the bone ; B, the same with the bone straightened ; C, the same with a wedge 
 removed from the concave side and the bone straightened, thus necessarily leaving a gap in the 
 bone (after Little). 
 
 ration, and the limb immobilized by a plaster-of-Paris dressing or a splint for 
 a number of weeks — four to eight or more according to the age of the patient 
 and the kind and locality of the operation. Unless the wound becomes infected 
 there are not, at any time, constitutional symptoms of serious import. 
 
 Osteotomy for Genu VAL(iUM. — One of the most useful of these oste- 
 otomies is Macewen's supracondyloid osteotomy for genu valgum. The 
 patient lies recumbent, with the leg flexed upon the 
 Fig. 448. thigh and the abducted thigh flexed upon tlie pelvis, 
 
 and laid upon its outer side, on a sand-pillow. Mac- 
 ewen's description of his operation is as follows: "A 
 sharp-pointeil scalpel is introduced on tlie inside of the 
 thigh, at a point where the two following lines meet, one 
 drawn transversely, a finger's-breadth above the superior 
 tip of the external condyle, and a longitudinal one drawn 
 half an inch in front of the adductor magnus tendon. The 
 scalpel here penetrates at once to the bone, and a longi- 
 tudinal incision (Fig. 448, ,4) is made, sufficient to admit 
 the lar<:est osteotome and the finjrer, should the surgeon 
 deem it necessary. Before withdrawing the scalpel the 
 largest osteotome is slipped by its side until it reaches 
 the bone. The scalpel is withdrawn, and the osteotome, 
 which was introduced longitudinally, is now turned trans- 
 versely in the direction recjuired for the osseous incision 
 (Fig. 448, B). In turning the osteotome too much 
 pressure must not be exerted, lest the periosteum be 
 scraped oft". It is then convenient to pass the edge of the osteotome over the 
 
 Macewen's Operation 
 •■or Genu Valgum : A, 
 skin incision ; B. os- 
 teotome incision ; (', 
 epiphyseal line; D, 
 inner condyle (orig- 
 inal). 
 
OPERATIONS ON BONES AND JOINTS. 1137 
 
 bone until it reaches the posterior internal border, when the entire cutting 
 edge of the osteotome is a})|»lied, and the instrument is made to penetrate from 
 behind forward and toward the outer side. 
 
 " After completing the incision in that direction, the osteotome is made to 
 traverse the inner side of the bone, cutting it as it proceeds, until it has divided 
 the uppermost ])art of the internal border, when it is directed from before back- 
 ward toward the outer posterior angle of the femur. 
 
 " In cutting on these lines there is no fear of injuring the femoral artery. 
 The bone may be divided without paying heed to this order of procedure, but 
 it is better that the operator should have a definite plan in his mind, so that 
 he may be certain as to what has been divided and what remains to be done. 
 The writer is persuaded that accidents have happened by not paying heed to 
 this. In using the osteotome the left hand, in which it is grasped, ought to 
 give, after each impulse supplied by the mallet, a slight movement to the blade 
 — not transversely to its axis, but longitudinally — so as to prevent any disposi- 
 tion to fixity which it might assume. 
 
 "After the inner portion of the bone is divided a finer instrument may be 
 slipped over the first, which is then withdrawn ; and even a third, if necessary, 
 mav take the place of the second when the outer portion of the bone comes to 
 be divided. Whether one or more osteotomes be used depends much on the 
 resistance met with. If the tissue is yielding, one may sufiice ; if hard or 
 brittle, two or three will effect the division more easily and with less risk of 
 breaking or splitting the bone longitudinally. In the adult the dense circum- 
 ferential layer of bone resists the entrance of the osteotome at the outset, but 
 several strokes cause the instrument to penetrate this superficial dense portion, 
 ■when it will pass easily through the cancellated tissue, 
 
 •'After a little experience the surgeon recognizes, by touch and sounds 
 when the osteotome meets the hard layer on the outer aspect of the bone. If 
 it be considered desirable to notch or penetrate this outer dense part of the 
 bone, in doing so the osteotome ought to be grasped firmly by the left hand, 
 the inner border of the hand resting on the limb, so a^s to check instantly any 
 impetus which may be considered too great. It is better to snap or bend this 
 layer rather than cut it. 
 
 " When the instrument is to be altered in position, it ought not to be pulled 
 out in the ordinary way, as it is then liable to be removed from the wound in 
 the soft parts, as well as from the bone. Instead, let the left hand, with its 
 inner border resting on the limb, grasp the instrument, while the thumb is 
 pressed under the ridge afforded by the rounded head, and gently lower the 
 osteotome outward by an extension movement of the thumb. In this way the 
 movement may be regulated with precision. It is desirable to complete all the 
 work intended by the osteotome before removing it from the wound. 
 
 " When the operator thinks that the bone has been sufiiciently divided, the 
 osteotome is laid aside and a sponge saturated in 1 : 40 carbolized watery solu- 
 tion is placed over the Avound. While the surgeon holds the sponge he at the 
 same time employs that hand as a fulcrum, while with the other he grasps the 
 limb lower down, Hsing it as a lever, and jerks if the bone be hard, or bends 
 slowly if the bone be soft, in an inward direction, when the bon« will snap or 
 bend as the case may be. 
 
 " No drainage-tube is required, and sutures need not be employed. The 
 wound is dressed antiseptically, the extremity is put up in a splint which cor- 
 rects the deformity, and the case is treated like an ordinary compound fracture." 
 
 Osteotomy for Ankylosis of the Hip-Joint. — In certain cases of dis- 
 eases of the hip-joint ankylosis results, with faulty position (flexion) of the 
 
 72 
 
1138 
 
 AN AMERICAN TEXT-BOOK OF SURGERY. 
 
 Fig. 44y. 
 
 limb. Osteotomy may be required to correct the deformity and bring the limb 
 into a straiglit position. 
 
 The section of the bone may be made tlirough the neck or through the 
 shaft just behnv the lesser trochanter. 
 
 Osteotomy through the Neck of the Femur. — 1 With a saw 
 (Ada/ns's Operation). — Mr. Adams describes this procedure as follows : 
 
 " The left thumb is placed firmly so as to compress the soft tissues solidly 
 af^ainst the bone at a point situated at the center of the top of the great tro- 
 chanter and the breadth of one finger above it. 
 
 " At this point the narrow-bladed knife is pushed in till it reaches the neck 
 of the femur, at a right angle across the front of which it is then carried (Fig. 
 449, A). The knife is then gently moved to cut a 
 space for the easy insertion of the saw, which, travers- 
 ing the course of the knife, reaches the front of the neck 
 of the femur, and gradually cuts it completely through. 
 The surgeon cuts until he feels that the saw is free of 
 tiie bone, and moving it in the soft tissues only behind 
 the bone." The limb is to be at once straightened, and 
 in order to do this it will often be necessary to cut with 
 a tenotome, under strict aseptic precautions, the con- 
 tracted tendons. The wound is dressed antiseptically, 
 and the limb is maintained in extension by the exten- 
 sion apparatus of Buck or by the long external splint 
 of Desault. 
 
 " 2. With the Osteotome. — A longitudinal incision 
 is to be made, penetrating to the bone and about | inch 
 in length, in the axis of the femoral neck and just above 
 the summit of the great trochanter. The osteotome is 
 pushed in alongside of the knife, which is now with- 
 drawn, and the osteotome is turned so that its edge is at right angles to the 
 axis of the femoral neck. The neck is now divided by striking with a mallet. 
 The dressing is the same as al)ove indicated." 
 
 Osteotomy through the Shaft, just below the Lesser Trochanter 
 (Gant's Operation). — The osteotome should be employed in Gant"s operation, 
 though the saw can be used. A longitudinal incision is made over the outer 
 aspect of the femur at the level of the lesser trochanter (Fig. 449, B). the 
 osteotome is introduced and turned on its axis, as described in the previous 
 operation, and the bone is divided just below the level of the lesser trochanter. 
 The straightening and dressing are to be done in the same wav as after Adams's 
 operation. 
 
 SPECIAL EXCISIONS. 
 
 Upper Jaw. — The upper jaAv may be removed because of existing disease, 
 non-malignant or malignant, sarcomatous or carcinomatous, or to facilitate the 
 removal of retro-maxillary tumors. Though the operation is a bloody one, it is 
 remarkably free from danger, reunion of the soft parts is rapid, and the result- 
 ing deformity is slight and capable of much relief by the a])plication of a den- 
 tal plate. To avoid the annoyance of the blood collecting in the patient's 
 throat, the Trendelenburg posture may be employed, as recommended by 
 Keen. When done for sarcoma, a cure may often be effected or recurrence 
 may be long postponed ; and if for carcinoma, life may be made more com- 
 fortable, though perhaps not prolonged ; it may even be somewhat shortened. 
 
 The bone is best exposed by an incision over the infraorbital ridge from 
 
 for Ankylosis 
 , intrii-capsular, 
 iperation ; B, ex- 
 tra-capsnlar, Gaut's opera- 
 tion (original). 
 
(}/'/■: Jx' A T/OXS (>.\ liOXES AM> JOLXTS. 
 
 11:59 
 
 the malar lioiit- to near tlie internal cantlius. then aiun;^ the side of the nose 
 around the ala to the median line, and down through the central part of 
 the u{>])er lij) (Fig. 450, .1). Fig. 450, i>', shows the incision of Yelpeau, 
 ■which is carried throuijh the cheek from the angle of the mouth to the 
 
 I'm;. 4')(). 
 
 Excision of the Jaws; .4, by a median incis- 
 ion ; B, by Velpeau's metiiod ; C, excision 
 of tlie lower jaw (original). 
 
 Excision of the Upper Jaw: ^, by Lan^enbeck's 
 method; B, by Gensoul's method (original). 
 
 center of the malar bone. The flap so formed is drawn inward. Fig. 451, A, 
 shows Langenbeck's operation. This incision begins on the lateral aspect of 
 the nose at the junction of the nasal bone with the cartilage, and is terminated 
 by sweeping upward and outward to the middle of the malar bone. It forms a 
 U-shaped flap, with the convexity downward, reaching as far as the junction of 
 the cheek and upper lip. Fig. 451, .B, shows the incision of Gensoul of Lyons, 
 who was the first successfully to remove the upper jaw. The flap thus outlined 
 by any of the above methods is dissected off" the bone and the free hemorrhage 
 arrested by hemostatic forceps, pressure, and hot water. With a fine saw or 
 the cutting forceps, preferably the former, the malar bone itself is cut through 
 (Fig. 452, B), and later the ascending process close to its junction with the 
 frontal (Fig. 452, A). After median division of the mucous membrane of the 
 roof of the mouth back to the soft palate with the knife, and laterally between 
 the hard and the soft palate, the horizontal plates of the two maxillae are sepa- 
 rated from above downward with the saw or cutting forceps (Fig. 452, C). The 
 bone can then be removed with the lion forceps, the pterygo-maxillary union 
 readily yielding, or if, as not seldom happens in cases of malignant disease, the 
 posterior wall is left behind, it can be easily seized and brought away. When 
 not diseased, and when its removal is not required in order that sufficient room 
 may be secured for necessary further work, the orbital or alveolo-horizontal 
 plate may be left, the bone being sawn across just below the one or above the 
 other ; but it is generally necessary to take away at least the latter. 
 
 Bleeding vessels, if necessary, having been tied and general hemorrhage 
 stopped (in which the cautery is often very useful), the soft parts are to be 
 apposed as accurately as possible along the line of incision and secured by the 
 requisite number of fine stitches, the cheek-cavity filled with cotton or gauze 
 
1140 
 
 AN AMERICAN TEXT- HOOK OF SURGERY. 
 
 Fig. 4r,i>. 
 
 j»lu«;s, if rp(juiro(l t'itlier to prevent oozing or to support the flap, and antiseptic 
 gauze and cotton applied externally and secured by a li<;lit baiida^j^c. J*riinary 
 
 union usually takes place. When 
 onlv the lower part of the bone is 
 to be removed, the operation may 
 ordinarily be done through the 
 mouth. 
 
 If done to render possible or 
 easy the taking away of a pharyn- 
 geal growth, only the upper or 
 inner bony attachments (malar 
 and frontal, frontal and intermax- 
 illary) should be divided, and the 
 bone tui-ned downward or out- 
 ward, to be later replaced ; it w ill 
 almost certainly reunite. Fig. 
 4r)2 shows the long incisions for 
 the removal of nasal polypi by 
 the methods of Poeckel and Lan- 
 genbeck. (See NavSO-pharyngeal 
 Polyp, p. 607.) Such osteoplastic 
 resection, though somewhat more 
 difficult of performance, saves the 
 deformity and later application of 
 a plate, which are necessarily con- 
 nected with the ordinary complete 
 removal of the upper jaw. The 
 soft parts need not be removed 
 from the bone, but only incised at 
 the point. Where they remain 
 attached externally, they are util- 
 ized as a " hinge." 
 
 Lower Jaw. — Resection of 
 this bone may be in continuity, or of one half or of the whole, for injin-y or 
 for disease. If in continuity and on one side, it can often be readily effected 
 through the mouth, the soft parts being carefully cleared away and the bone 
 divided with the straight or chain saw% or in an informal way wnth the cutting 
 and gouge forceps. Extensive operations in continuity or involving a half or 
 all of the bone should be done through an external incision of sufficient length, 
 and just below the lower })order of the bone, with or without central division 
 of the lower lip and soft parts of the chin according to circumstances (Figs. 
 450, C, 452, G). If the middle portion is taken away, as all the attachments 
 to the genial tubercles are severed, dropping back of the tongue must be 
 guarded against by passing a ligature through it until sufficiently strong adhe- 
 sions of the soft parts luive formed to prevent the occurrence of such an 
 accident. 
 
 In resecting the half or the whole of the lower jaw, after separation of the 
 soft parts, external and internal, well back toward the angle, the bone is divided 
 in the middle line (Fig. 452, G), and firmly held off while the further separation 
 of the soft parts is continued up to and including the coronoid process, after 
 whii^h disarticulation can be readily effected, either by dragging or by a few- 
 cuts with knife or scissors kept close upon the condyle. When ])erformed for 
 disease the periosteum should be preserved as far as possible, unless the disease 
 
 Lines for Various Excisions of both Upper and Lovver 
 Jaws : A, B, C, excision of the upper jaw ; I), Poeckel's 
 operation (nasal polypus) ; EC, (JutJrin's operation 
 (partial excision) ; F, F, Langenbeck's operation (nasal 
 polypus) ; G, excision of lower jaw ; //, removal of 
 portion of alveolus ; /, Esmarch's operation, ankylosis 
 of lower jaw (original). 
 
OPERATIONS ON JiONKS AND JOINTS. 
 
 41 
 
 is malignant; and whoncvcv the object of tlio resection can he secured by saw- 
 ing through the body or at tiie bases of the processes, division at such level 
 should be made. 
 
 Clavicle. — A part or the whole of the clavicle may be removed for dis- 
 ease, generally sarcoma. Exposure is made by a longitudinal incision, the 
 soft parts dissected off carefully, but as rapidly as possible, the bone divided 
 internally to the aflected area or separated at the sternal junction, lifted up and 
 cleared posteriorly as far as may be necessary toward or to the scapular attach- 
 ment, and there sawn through or disarticulated. The hemorrhage, often very 
 great when operating for malignant disease, is to be temporarily checked as 
 the operation proceeds by the application of hemostatic forceps. By keeping 
 close to the bone and the diseased mass there is little danger of wounding the 
 important deep vessels and nerves. Provision for drainage having been inade, 
 the edges of the external incision arc to be brought together and sutured, an 
 antiseptic dressing applied, and the arm securely fastened to the side. If sep- 
 tic infection is prevented, death, if it follows, will be from shock or hemorrhage 
 or later from recurrence of the malignant affection. 
 
 When done for cause other than malignant and the periosteum has been 
 saved, regeneration, at times quite perfect, may be reasonably expected. 
 
 Scapula. — Removal of the shoulder-blade, partial or complete, may be 
 rendered necessary or advisable on account of necrosis following injury or of 
 the presence of a tumor benign or malignant, the latter cause indicating com- 
 plete resection, although occasionally a partial operation has not been followed 
 by recurrence. When done for necrosis the operation is comparatively simple 
 and easy ; when for osteo-sarcoma, it is not seldom difficult and dangerous. 
 
 In complete resection a single vertical incision may be made on a line a 
 little posterior to the middle of the spine, and the soft parts reflected forward 
 and backward (Fig. 453, ver- 
 tical line of 1); or, better, an Fig. 458. 
 incision along the whole pos- 
 terior border, inclined forward 
 at the upper end and forward 
 and upward for a short dis- 
 tance at the lower end, fol- 
 lowing the anterior border, 
 with usually an associated one 
 over the course of the spine. 
 Fig. 458 shows the incisions 
 of Syme, Langenbeck, and 
 Collier for extirpation of the 
 scapula, as well as the incision 
 for resection of the glenoid 
 cavity of the scapula. The 
 overlying soft parts having 
 been turned aside, and the 
 spinal muscles saved or left attached to the bone according as the resection is 
 not or is for malignant disease, the superior angle and adjacent upper border 
 is freed from its attachments, then the posterior border and inferior angle, the 
 knife being constantly kept as close as possible to the bone. Lifting up the 
 scapula, its anterior surface is cleared, and then the anterior border toward the 
 glenoid fossa, the dorsal and subscapular arteries being tied when reached. 
 The acromion process being freed, the attachments of the scapular muscles 
 divided close to the humerus, and the coracoid process separated from its liga^- 
 
 
 Extirpationof the Scapula : 1, after Syme ; 2, after Langenbeck ; 
 3, after Collier ; 4, incision for resection of the glenoid cavity 
 of the scapula (Tillmanns). 
 
1142 
 
 AN AMi:iilVAy TKXT-llOUK OF SVIHiEltV 
 
 Fig. 454. 
 
 ments and imiscles, only the region of tlie glenoid fossa remains to ])e cleared, 
 after which the hone is lifted out, hemorrhage arrested, drainage pntvided for, 
 the Ihips adjusted and united, and an ordinary compressing and retaining dres.s- 
 ing applied. By such method of operating control of hemorrhage is well 
 secured. 
 
 Shoulder. — Resection of the shouldei- — or rather, in the great majority 
 of cases, of the head of the humerus — has generally been for severe injury, 
 especially gunshot, rarely for the compound fractures of civil life, occasionally 
 for the relief of deformity, as that following unreduced lu.xation or hadly- 
 united fracture of the neck of the humerus, and at times, though but seldom, 
 for chronic joint disease, from which this articulation is in an extraordinary 
 degree e.xempt. Under the present method of wound-dressing purely conser- 
 vative treatment, with the informal removal of completely detached fragments 
 when necessary, may commonly be expected to give good results, better, indeed, 
 than those after typical excision. 
 
 It may be done by a single straight incision from above downward (Fig. 
 454, £), or by a flap raised from the anterior surface (Fig. 454, C), the former 
 
 method being much the better, as it inflicts 
 little damage upon the muscles, and leaves, in 
 consequence, a more useful arm, though occa- 
 sionally, because of the nature and extent of 
 the original injury, the deltoid has been so 
 wounded that little additional violence will be 
 done it in forming a flap. Generally the cut 
 is made directly down to the bone in a line 
 from the middle of the acromion to the center 
 of the deltoid insertion, separating rather 
 than cutting the muscular fibers, though it 
 may be carried from the inner (Fig. 454, A) 
 or outer point of the acromion along the in- 
 ternal or external border of the deltoid. 
 
 The capsule is then opened and the soft 
 parts separated from the tuberosities and the 
 upper part of the shaft, the knife being kept 
 close upon the bone, especial care being taken 
 to turn the long head of the biceps uninjured 
 out of its groove. The head of the bone 
 having been luxated through the incision, 
 division is made with the saw at the neces- 
 sary level, no lower down than is absolutely demanded, in order that the likeli- 
 hood of the occurrence of a "dangle" joint may be reduced to a minimum, for 
 although a "flail " arm is often far from being a useless one, either without or 
 with the aid of an apparatus, yet if recovery can be secured with close approx- 
 imation of the upper end of the humerus to the scapula, it is much better. 
 
 The operation may be done subperiosteally, the periosteum being divided 
 longitudinally and then transversely at the level of the section of the bone, 
 and turned aside, and the tuberosities chipped off", carrying with them the unin- 
 jured muscular insertions. In old luxations, as the vessels are pushed back- 
 ward and inward, the incision can safely be made along the border of the coraco- 
 brachialis muscle. 
 
 If necessary, though such is seldom the case, the glenoid fossa may be 
 removed by saw or forceps, the attachment of the long head of the biceps 
 being, if possible, preserved by separating a scale of bone or stripping off 
 
 Excision of the Shoulder: A, vertical in- 
 cision of Laiificnbcck : B, incision of 
 Baudens.lhictcr.and Oilier; C, Morel's 
 incision (after Tillmanns). 
 
OPERATIONS ON BONES AND JOINTS. 
 
 1143 
 
 Fig. 455. 
 
 the periosteum. The ordinary antiseptic dressing iiaving ])Con applied, the 
 parts are lioUl in place by a bandage, or, better, by an immobilizing i)laster 
 splint or casing, carried well up over the top of the shoulder and retained 
 by a bandage passed under the opposite axilla. 
 
 Elbow. — Resection of the elbow is called for in certain cases of compound 
 fracture, gunshot or other, of tubercular disease, of old unreduced luxation, or 
 of bony ankylosis. It may be done in various ways, all or nearly all, liowever, 
 modifications more or less diverse of tiie method by a single longitudinal in- 
 cision, central or lateral, with or without a transverse 
 incision (Fig. 455) ; or of that by two lateral incisions, 
 with a connecting cross-cut — H-shaped — the former being 
 generally preferred. Cutting down upon the posterior sur- 
 face of the joint in the median line from a point a couple 
 of inches above the articulation to one at or slightly 
 below the line of junction of the olecranon with the 
 shaft, or along the outer border of the triceps to the B- 
 level of the epicondyle, and then downward and inward 
 across the olecranon, the capsule is opened and the soft 
 parts dissected oft' on each side (subperiosteally, if pos- 
 sible) until the condyles have been well uncovered, special 
 care being taken to save uninjured the ulnar nerve. 
 This lies between the olecranon and the internal con- 
 dyle, and is to be avoided by dissecting close to the 
 bone in this situation. After flexion of the forearm 
 the lower end of the humerus is cleared (Fig. 456), 
 pushed out through the wound, and sawn off" (Fig. 
 457) ; and then the upper ends of the ulna and of 
 the radius are treated in like manner. Instead of Excision of the Elbow: a, 
 
 T ,. ,, (,, , p .-, ■ T 1 1 median vertical incision ; 5, 
 
 dissecting the soit parts irom the epicondyles and Listen's r-incision (after Es- 
 
 the upper edge of the olecranon, these bony surfaces ™^'"'^^)- 
 
 may be chiselled off' and turned aside with their muscular attachments un- 
 
 Fk;. 456. 
 
 Excision of the Elbow : the clearing of the humerus (original). 
 
 disturbed. If the amount of bone removed is so great that a movable 
 joint is not likely to be secured, the sawn surfaces may be Avired or pinned 
 
11 II 
 
 LV AMi:ui('Ay 'n:x r-iiooK of srii<ii:i!Y 
 
 tofjc'tlior. or a sort of inortiso and tonon mar be made ln-twccn the nln.-i ami 
 the liuiiierus. 
 
 If" tlicrc lias not been much of the liones excised, restoration of the func- 
 tions of the elhow to a "greater or less extent may be exjteeted, so conijdcte at 
 times as to pei-niit of the Imnd liciuir hiiil upon the shnulder. in a few cases 
 
 Vu.. 4-)7. 
 
 Excision of the Elbow : sawing of the humerus (after Farabeuf ). 
 
 in which years after the resection an examination of the elbow has been made^ 
 there have been found to be present bony down-growths from the sides of the 
 humerus, embracing between them and buttressing the upper end of the ulna 
 and radius, much as the malleoli do the astragalus. 
 
 When the portion excised has been considerable, unless close approximation, 
 is made and maintained a flail-like condition of the arm will be produced, capa- 
 ble, however, of being greatly improved by the use of proper prothetic appa- 
 ratus. At the completion of the operation immobilization should be made, 
 readily and fully effected by plaster of Paris, and maintained for six, eight, or 
 more weeks if ankylosis is sought for (always, of course, at a right angle, or a 
 little less, never in extension) ; but if motion is aimed at, passive movements 
 should be commenced by the end of the second Aveek. When done in the 
 hope of bony ankylosis, care should be taken that as much of the periosteum 
 as possible is preserved in the area of the future joint. 
 
 At times in these cases simple osteotomy, linear or trochleiform. will relieve 
 the ^lifliculty, but there is always danger that such operation will be followe<l 
 by fusion of the bones in spite of earlv and metho<lical passive motion. 
 
 Old unreduced luxations may be treated by complete or partial excision, 
 access to the joint being readily had through an incision across the back of the 
 joint with division of the olecranon at its base, this process being reflected with 
 
OPERATIONS ON BONES AND JOINTS. 
 
 1115 
 
 the soft parts and later replaced and wired. Oftentimes, after subcutaneous sec- 
 tion of the olecranon, reduction of tlie luxation can he effected, passive motion 
 securing a lax fibrous attachment of the separated process which later allows 
 of the ordinary movements of the joint. As is true of compound fractures of 
 all joints, treatment by resection after this injury at the elbow is now much 
 less frecjuently reijuired than formerly. 
 
 WiiiST. — Kesection of the wrist is occasionally done because of extensive 
 injury, mainly of the lower end of the bones of the forearm. Ordinarily, how- 
 ever, it is necessitated by tubercular disease, which always chiefly aff'ects the 
 carpus. The best method of operating must vary according as the excision is 
 for injury or for disease. In the former case lateral incisions carried but a little 
 distance, or perhaps not at all, below the joint level will give ready access to 
 the bone and permit of easy removal, with slight danger to the soft parts. 
 
 It is widely different with the operation for disease. The carpal bones can- 
 not thus be readily reached nor thoroughly extirpated without serious risk to 
 vessels and nerves. One of three methods will commonly be selected : a single 
 long dorsal median incision, or two incisions placed laterally over the back of 
 the wrist, or a transverse straight or curved division of the structures covering 
 the posterior surface of the carpus, the last affording readiest access to the dis- 
 eased bones, but objectionable because of 
 the necessary section of the tendons — an 
 objection, however, of much less weight 
 now than formerly, since after their suture 
 early and functionally perfect repair can be 
 secured. 
 
 The method by a single incision will 
 generally be preferred, being easier of exe- 
 cution and less disturbing to the tendons 
 than the others. A very convenient form 
 of the incision consists in carrying it from 
 the middle of the radial border of the meta- 
 carpal bone of the index finger upward be- 
 tween the tendon of the long extensor of 
 the thumb and that of the extensor indicis 
 
 Fig. 459. 
 
 Fig. 458. 
 
 Excision of the Wrist by OUier's incision 
 for radial side (original). 
 
 A. Excision of First Metacarpal Bone; B, Excision of 
 MetiicariMi-iilialaiiseal Joint of the Thumb; CC, Excis- 
 ion of IiiH"r]ihalan,t;eal .Joint of the Thumb; D, Excision 
 of Metaearpii-jihalangeal Joint (original). 
 
 to the dorsum of the radius between the extensor indicis and the short radial 
 extensor of the wrist, the soft parts covering the carpus being carefully lifted 
 and turned aside, subperiosteally as far as possible (Fig. 458). 
 
lui; 
 
 .4.Y AMERICAN TEXT-BOOK OF &UJiGEIiY 
 
 Fjg. 400. 
 
 In excising an interphalanffeal joint a lateral incision is made on the side 
 of the joint (Fig. 450. C). Tlie lateral ligament is divided, and the bones 
 protruded and i?awn. Two lateral incisions instead of one may be used (Fig. 
 4ol), C, C). 
 
 In excising a metacarpo-phalangeal joint a single lateral incision is 
 employed, and the operation is done as in the above case (Fig. 4')9, D and B). 
 Fig. 4">0, A^ also shows the incision for resection of XheJirHt metacarpal hone. 
 Ju'section in eontinuiti/ or comph'te removal of a bone of the upper extrem- 
 ity for injury, more often for disease, will be effected in the ordinary way, as 
 already mentioned in treating of such operations in 
 general, care being taken to fasten the ends firmly 
 together when this can be done, and to preserve the 
 periosteum as far as practicable, in order that regener- 
 ation may take place, thus lessening, or in the most suc- 
 cessful cases preventing, after-deformity. 
 
 Hip. — Resection of the head of the femur in civil life 
 is almost always required because of tubercular caries. 
 It is ordinarily done through an incision beginning about 
 midway between the anterior superior iliac spine and 
 the trochanter, and continued downAvard around the tro- 
 chanter or across its outer surface along the outer border 
 of the thigh for a sliort distance, the knife being carried 
 directly to the bone (Fig. 460). Figs. 4G1 and 4Gi* show 
 other incisions for excision of the hip-joint. The cap- 
 sule having been thoroughly opened, the periosteum is 
 divided transversely at the level of bone-section, and as 
 completely as possible separated from the femoral neck, the muscular attach- 
 
 Excision of the Hip-joint 
 (Tillinanns). 
 
 Fig. 461. 
 
 Fig. 402. 
 
 
 Excision of the Hipj : Luecke's incision 
 (original). 
 
 Excision of the Hip: Langenbeck's external incision 
 (original). 
 
 ment to the trochanters being severed, or, better, the bone-surfaces which secure 
 them being chiselled off, or the whole of the greater trochanter may be split 
 off and turned aside. It very often happens that the condition of the parts 
 is such that little or nothing can be gained by an attempt at preserving the 
 
orKHATioys o.v jkjxf.s axd joints. 
 
 11-17 
 
 Fig. 4(io. 
 
 periosteum, and iDuch time will bo saved and as <rood an ultimate result secured 
 by omitting it. The head of the femur is then forced out of the acetabulum and 
 the diseased bone sawed oft", any limited portion 
 of affected tissue being removed by gouge and 
 spoon rather than by a second sawing at a 
 lower level. To facilitate (lraina<:e, the tro- 
 chanter major is generally taken away, but 
 in most of the cases suitable for operation this 
 is not necessary. If the acetabulum is dis- 
 eased, it should be thoroughly scraped. In- 
 stead of luxatinti; the head and then dividing 
 the neck, the steps may be reversed, the neck 
 being first sawn through ; but the operation 
 thus done, as a rule, is not so easy of exe- 
 cution. Moderate extension may be em- 
 ployed after the operation. As soon as 
 the wound is sufficiently healed the patient 
 should be gotten up on crutches. 
 
 By a few surgeons an anterior incision is 
 preferred (Fig. 461), the knife being entered 
 half an inch below the anterior superior iliac 
 spine and carried downward and a little in- 
 ward for about three inches, passing between 
 the tensor vaginae and glutei muscles on the 
 outer side and the sartorius and rectus on the 
 inner. If the operation is done aseptically 
 and the parts protected against after-infection, 
 primary union may be secured. 
 
 Knee. — Resection of the knee is done 
 because of injury, deformity, ankylosis, or 
 especially disease. It is performed in seve- 
 ral ways, according to individual preference 
 and the facility and thoroughness of exposure 
 of the joint structures. These methods are a 
 curved incision across the front of the joint, with the convexity downward, 
 passing through the ligamentum patelh^ (Fig- 463), or with the convexity 
 upward above the patella, a straight transverse incision passing through the 
 patella, Avhich is sawn, with or without associated short longitudinal incisions 
 on the sides; or a single longitudinal incision, median or lateral, a method 
 inapplicable to cases of disease. 
 
 As ordinarily done, the curved or transverse incision is made from condyle 
 to condyle, opening the joint; the flap containing the patella is turned upward; 
 the limb is flexed, the crucial and lateral ligaments divided, great care being 
 used to avoid wounding the popliteal artery, the end of the femur is thoroughly 
 uncovered, and a slice of necessary thickness sawn off", the epiphyseal line 
 being, if possible, preserved in children. This is very essential, in order 
 that the ultimate shortening may be reduced to a minimum, as the chief 
 growth of the femur — and the point of greatest growth in the entire body — 
 is at its lower end. The saw should be carried in a slightly oblique direc- 
 tion from behind forward and in a plane parallel to that of the epiphyseal 
 line. The articulating surface of the tibia is then to be in like manner 
 removed, all diseased soft parts being cut or scraped away. The patella, 
 if diseased, as is usually the case, should be removed ; if not diseased. 
 
 Incieion for Resection of the Knee 
 (MaeCormac). 
 
114S AX AMKRFtWN TEXT-BOOK OF HURGFAIY. 
 
 it may l»r removed or left as preferred. The hone surfaces are then 
 apposed, drainage-tuhcs placed in position from side to side or ohliquely 
 from before backward, and brought out through counter-openings on the 
 posterior surface, the edges of the incision sutured, the parts antiseptically 
 dressed, and the limb immobilized by plaster of Taris or a suitable 
 
 Fig. 464. 
 
 InterruiittHi Splint (modified from Esmarcli mid Kowulzig). 
 
 bracketed splint. If the patella has been sawn through, its fragments 
 should be wired, or held together by stout catgut sutures through the fascial 
 enveloj^e. The femur and tibia may be sutured with catgut or wire or fas- 
 tened by nails or dowels. 
 
 Immobilization should be maintained for two, or better three, months, and 
 a posterior splint should be worn for many months longer, that firm union 
 in the position of nearly full extension may be secured. The drainage-tubes 
 should be removed in the course of a few days, as, although they have at 
 times been left for many weeks without harm, it is likely that their presence 
 may favor the formation of sinuses which may become tubercular and con- 
 tribute to the production of an unfavorable result. 
 
 Bony ankylosis -of the knee, as a rule, may be treated by osteotomy, 
 linear or cuneiform, rather than by resection. 
 
 In operating upon old luxations partial excision of the end of the femur 
 may usually be made. . 
 
 It is at this articulation that erasion is most frequently done, and the 
 relative value of such operation as compared with typical resection has yet 
 to be determined. When done for tubercular disease, an excellent method is 
 that of Miller of Edinburgh. An incision is made below the patella, deeply 
 curved downward toward the tuberosity of the tibia, and another straight 
 across the center of the patella, joining the ends of the first. The upper 
 flap is then reflected upward, the tendon of the rectus and adjacent 
 muscular fibers divided, and the entire anterior portion of the capsule, 
 together with the patella and an elliptical portion of skin, stripped downward 
 and removed en masse by cutting through the ligamentum patellae and the 
 tibial attachments. The remainder of the joint is then cleaned uj) and the 
 bones resected. 
 
 When the joint lesion is great, the destruction extensive, and the gen- 
 eral health much enfeebled, especially in poor patients not in hospital, 
 amputation often offers a much better chance of preserving life, and should 
 be performed. 
 
 Ankle. — For the resection-of the ankle-joint many operations have been 
 devised of late years — more than for the removal of any other articulation. 
 The methods are lateral, postero-lateral, and posterior, without and with asso- 
 ciated division of tendons and removal of the astragalus. 
 
 An excellent method is that in which an incision over the inner border of 
 the fibula, commencing an inch and a half or two inches above the tip of the 
 
OPERATIONS ON BONES AND JOINTS. 
 
 1140 
 
 external malleolus, is carried to and a little in front of the malleolus, and 
 another is made directly backward close under the malleolus to the external 
 
 Fni. 405. 
 
 \ i ] 
 
 Reseetion of Ankle-joint, after Langenbeck; incision over the lower end of fibula {a) and tibia (6) 
 
 (Tillmans). 
 
 border of the tendo Achillis, dividing the peroneal tendons (Fig. 467, li). The 
 flap thus outlined is dissected off" the lower part of the fibula, and the malleolus 
 sejiarated with chisel, saw, 
 
 or cutting forceps — removed yiq. 460. 
 
 if diseased, if healthy turned 
 back to be later reunited. 
 The astragalus is then freed 
 from its attachments and 
 taken away, and the foot 
 dislocated "^ inward, when 
 ready access is had to the 
 lower end of the tibia, which 
 is cut away to such extent 
 as is necessary. The dis- 
 eased tissues about the joint 
 are easily reached and re- 
 moved, and by extending _ — 
 
 the orip-inal incision alons; a, Excision of Astragalus (inner incision) : £, Excision of 
 LUC yjiiQ ID Ankle (inner incision) (original). 
 
 the outer border ot the loot 
 other bones of the tarsus, 
 if affected, can be got at 
 and taken away. The sev- 
 ered peroneal tendons are 
 then sutured, drainage-tubes 
 put in, counter-openings, if 
 thought advisable, being 
 made and through drain- 
 age thus secured, gauze and 
 cotton dressing applied, and 
 the leg and foot placed in a 
 splint or immobilized with 
 plaster. Figs. 465, 466, 
 and 467 show the various _^.,^_ 
 
 incisions for excision of the .-i, Excisionof Astragalus f outer incision^: 5, Exdsion of Ankle 
 , . (outer incision) ; C, Excision of Os Calcis (original). 
 
 The removal of the as- . , ,. , .• i, i 
 
 tracralus very much facilitates the extirpation of the diseased tissues, hard 
 and soft, and lessens but little if at all the later functional value of the 
 
 Fig. 407. 
 
1150 
 
 .l.V AMI'JRICAX TEXT-BOOK OF SUROKRY 
 
 limb. If it is desired to save uninjured the peroneal tendons, two lateral 
 incisions may be made, one as already described, the other (Fif^. 400. .1) 
 over the inner malleolus and forward internal to the tendon of the tiljialis 
 anticus, between which the structures in front of the joint can be lifteil 
 up, chiselled, or scraped out, or excised, as before, after reujoval of tjie 
 external malleolus and astragalus. When there is a compound luxation of 
 the astragalus a formal resection will not ordinarily be required, it being 
 usually possible to take away the bone through the existing wound or by 
 enlarging it. 
 
 Resections of the Foot. — Removals of the tarsal bones, largely atypical, 
 may be made through lateral incisions, or, better, by an incision across the 
 dorsum, the severed tendons being later sutured or allowed to make attachment 
 as they can in the course of the healing of the wound, the former procedure 
 being preferable. It has lately been advised to split the foot back between 
 the third and fourth metatarsals to the middle tarsal joint, and thus gain access 
 to the affected parts. The essential prerequisite to success is thorough removal 
 of the diseased tissues, and the end-result of complete excisions even of the 
 entire tarsus or of its anterior segment and the metatarsus in part or in whole 
 is often excellent, the functional value of the foot being but little impaired. 
 Figs. 466 and 467 show the incisions for removal of the astragalus, and Fig. 
 467 shows the incision for removal of the os calcis. 
 
 When the tarsus is largely diseased, and especially when the soft parts of 
 the heel and the posterior part of the sole have been destroyed or seriously 
 
 Fig. 468 
 
 Via. 4G9. 
 
 Osteoplastic Resection of the Foot : A, B, C, skin incisions ; D. E 
 and F, G, points at which the bones are to be divided ; shaded 
 parts to be exsected (original). 
 
 Result after Osteoplastic Resection 
 of the Foot (after Farabeuf >. 
 
 damaged, an osteoplastic operation (" Wladimiroff-Mikulicz operation") may 
 be done, a flap of the posterior tissues from the level of the malleoli to that of 
 the scaphoid tubercle being removed (Fig. 468, A, B, C), the articulating end 
 of the leg-bones and the posterior part of the scaphoid and cuboid sawn through 
 (Fig. 468, DE,FG), the intervening bone excised, the foot extended, the 
 sawn surfaces apposed, and the edges of the wound sutured, the weight of the 
 body being afterward supjjorted on the ends of the metatarsal bones, and the 
 under surfaces of the toes now bent at a right angle (Fig. 46l>). Except when 
 there is extensive ulceration or loss of substance at the heel, such osteoplastic 
 resection has no advantage over a large atypical tarsal excision, and is likely 
 to leave a less useful foot. 
 
AMPUTATIONS. 
 
 1151 
 
 Rejection in Continuity of Bones of the Lower Extremity. — Such 
 an operation should not be done upon the femur, because of the strong prob- 
 ability of non-union. Upon the 
 
 tibia or fibula it is more likely to Fio. 470. 
 
 be followed by a successful re- 
 sult, regeneration of the bone or 
 compensatory hypertrophy of the 
 untouched shaft freiiuently tak- 
 ing place. Care must be exer- 
 cised during the period of repair 
 to prevent deviation of the foot. 
 Upon a metatarsal or phalangeal 
 bone of the foot, as upon a cor- 
 responding one of the hand, it 
 may be readily and successfully 
 done, the necessary incision being 
 made over the inner or outer side 
 rather than the middle, to avoid injuring the extensor tendon (Fig. 473). 
 
 When in the hand a first or second phalanx cannot be subperiosteally 
 removed, the distal part of the finger should be allowed to drop back, the 
 resulting fibrous union often becoming short and firm and securing a useful 
 finger, failing which- amputation can be done. 
 
 Excision of First Metatarsal Bone (original). 
 
 CHAPTER VI. 
 
 AMPUTATIONS. 
 
 Indications. — It is impossible to do more than indicate in very general 
 terms the more important conditions calling for amputation. Injuries of similar 
 degree afiecting the upper or the lower extremity call for difi"erent treatment, 
 because of the much greater freedom of the collateral circulation in the former, 
 rendering gangrene less probable. Where conservative treatment or excision 
 would be proper in the upper extremity, amputation would be called for in the 
 lower limb. A broken constitution with damaged assimilative and eliminative 
 organs, as in the aged, in alcoholics, in chronic Bright's disease, or when tuber- 
 culosis of the lungs exists, often compels the sacrifice of the limb. Avulsion 
 of a whole or part of an extremity of course requires an attempt to place the 
 remaining portions in a condition to heal by amputating at a higher point, 
 or, if the whole limb is gone, by fashioning flaps out of what remains of the 
 soft parts, and approximating and dressing them. 
 
 Compound Fractures and Dislocations are the most common accidents 
 demanding amputation. Extensive comminution and loss of bone may demand 
 this in the lower extremity, because even if saved the limb will be useless as a 
 means of locomotion : when in the lower limb rupture of the main vessels is 
 
1152 ^.V AMERICAN TEXT-BOOK OF SURGERY. 
 
 added to this condition, amputation is indicated, but in the upper limb an 
 attempt should bo made to save it by securin<^ the vessel in the wound. In 
 the lower extremity secondary lu'iiiorrha<fe from the main arter^^ after compound 
 fracture usually calls for amputation ; but further trial of conservative treatment, 
 after arrest of the bleeding by ligature, is in exce[)tionally favorable cases justi- 
 fiable after a similar accident affecting the upper extremity. Great laceration 
 of soft parts, with extensive loss of skin, added to free comminution of bone and 
 wounded vessels, always demands amputation ; extensive flaying, which will ren- 
 der the member useless if saved, sometimes calls for its removal ; for instance, 
 destruction of the skin of the heel and sole of the foot will result in a cicatrix 
 which can never bear the weight of the body, and extensive burns of an entire 
 extremity may require amputation. Compound fracture involving the knee- 
 joint commonly calls for amputation, because of the great damage to the soft 
 parts. Similar injuries to the ankle may admit of conservatism if the parts 
 can be rendered aseptic ; or if the soft tissues are not much damaged, ex- 
 cision should be practised. This latter rule is also applicable to the shoulder 
 and elbow, but bad compound fractures of the wrist require amputation. 
 
 Compound dislocations of the ankle, elbow, shoulder, and hip, provided 
 only moderate injury has been inflicted upon the soft parts — where conserva- 
 tism is not indicated — should be treated by excision, as a rule. Owing to the 
 frequent damage to the popliteal vessels, and the destruction of most of the 
 vessels capable of carrying on the collateral circulation, amputation is the 
 safest course in compound dislocations of the knee. 
 
 Lacerated and Contused Wounds inflicted by the claws or the teeth of wild 
 animals, and the extensive shattering of bone produced by gunshot wounds, 
 often demand amputation. AVhile Avounds and lacerations of arteries rarely 
 call for amputation except for a traumatic or diff"used popliteal aneurysm or 
 similar conditions of the deep arteries of the leg, or for traumatic aneurysm of 
 the axillary, it is often required for secondary hemorrhage the result of pre- 
 vious wound of a vessel or following ligation of an artery in its continuity. 
 
 Gangrene the result of frost-bite, of burns, of traumatism, or of a wound 
 of an artery or of its gradual occlusion in the young, demands amputation well 
 above the limits of the disease, and even in the senile form, under favorable 
 circumstances, amputation of the leg or thigh is sometimes proper. The stu- 
 dent, however, should consult the section'on this disease for the special indi- 
 cations for and against operation. 
 
 Many destructive diseases of the hones a,m\ joints, where extensive implica- 
 tion of the soft tissues exists, demand amputation. 
 
 Malignayit Tumors of the extremities are best treated by amputation when 
 they affect the bones, and even when these tumors are free from bony attach- 
 ments their relations to other important structures may be such that they can- 
 not otherwise be safely removed. In this case the whole of the bone involved 
 should be removed ; that is, the amputation should be at or above the joint on 
 the proximal side of the disease. Very rarely, benign growths reaching such 
 a size as to render life burdensome require removal of the limb; or by their 
 ulceration, followed by profuse discharges, they may menace the patient's life 
 unless removed. 
 
 Tetanus, with the modern views as to its pathology, cannot be considered 
 an indication for amputation. 
 
 For Deformities, such as severe neglected club-foot, limbs rendered useless 
 by cicatrices, mal-union of fractures, etc., amputation is sometimes done in robust 
 young individuals, but these are usually operations of complaisance, not of 
 necessity. 
 
AM/'ITATKjXS. 11'>' 
 
 INSTRUMKNTS. 
 The instruments re(|uire.l for iun]mtations are those to arrest hemor- 
 rhac'e ilurin<- the operation, knives, saws, retractors, cutting bone lorceps 
 stro"ig (lion^jaw) forceps to liohl a bone fragment, tenacula, artery and 
 hemostatic forceps to secure the vessels, needles to sew up the Haps, scis- 
 sors, and dissecting forceps ; in addition, capillary or tube drains must be 
 provided, proper dressings, and a splint to fix the joint above the segment 
 
 amjjutated. 
 
 ToURNiQrKT. — The most commonly employed tournniuet at the present 
 time is the elastic band devised by Esmarch \iu<h' infra). Petit's was em- 
 ployed largely for many years ; it consists of two metal plates capaole ot 
 beim^ separated bv a powerful screw, and a stout strap with pad and buckle. 
 Othei" forms of instruments have been devised which press only on the vessel 
 and at a point directly opposite—/, e. horseshoe tourniquets, Hoey's clamp, 
 and Skey's tourniciuet, large sizes of the two latter being used to control the 
 
 abdominal aorta. ,,,17 j 
 
 EsM arch's Apparatus. — This consists of a broad rubber bandage and a 
 flattened rubber band with a hook at one end and a few links of chain at the 
 other. ApjjUcatioH.—'Yhe bandage is put on firmly from below upward, 
 without reverses, as high as is desired, when the band is carried well on the 
 stretch around the limb above, but close to the last turn of the bandage, and 
 is secured with the hook and chain or by tying the crossed ends : the rubber 
 bandacre is then removed. Do not draw the band too tight nor leave it on too 
 lonc^, fest paralysis from pressure on the nerves result ; again, never allow 
 the^member to be decidedly flexed or extended after its application, because 
 tearing of the muscles may result. The annoying oozing following the use 
 of the'^Esmarch bandage can be lessened by removing it as promptly as pos- 
 sible, thus lessening the vaso-motor paresis ; by maintaining elevation of the 
 part combined with the use of hot water; and by digital compression of the 
 main artery for a few moments. An amputation can be made practically 
 bloodless without the Esmarch bandage by elevation of the limb for a few 
 minutes just before operation, bv centripetal massage of the part, and 
 the use of the Esmarch band applied on the full stretch so that the main 
 artery is at once compressed. Thus, apply the mid-part of a portion of 
 the stretched band suddenly against the inner, anterior aspect of the upper 
 thigh, quickly encircling the limb with the band and rapidly passing other 
 
 tight turns. , • • 1 i 
 
 Amputating Knives. — Modern knives, having their points sharp and 
 double-edcred, are fitted for both the circular and the transfixion methods of ope- 
 rating. A breadth of from three- to five-eighths of an inch, and a length of 
 from six to nine inches of cutting edge, are proper dimensions for the blade. 
 Double-edged, sharp-pointed knives called catlins are employed by some ope- 
 rators in transfixion operations or to clear the interosseous space, but the point 
 of any amputating knife will do for this latter purpose. One metacarpal knife 
 with a three-and-a-half-inch blade, a slender bistoury with heavy back, and a 
 stout scalpel are all the knives absolutely requisite. 
 
 Saws. While many patterns of saws have been proposed, the best is 
 
 the ordinary flat-bladed one. but it is well to have a smaller instrument (meta- 
 carpal saw) with movable back. 
 
 Cutting Bone Ft>RCEPS are necessary to remove rough or splintered 
 edf'es which may be left by the saw or for dividing the metacarpal or pha- 
 langeal bones. 
 
11.04 J.v AMr.nicAX ri: XT- nook' or s('ii(;i:in\ 
 
 Fergusson's lion-jaw forceps are useful where in compound fractures only a 
 fragment of bone is left, rendering difficult such steadying (jf it by the hand as 
 will prevent splintering when sawing, or when retrenchment of bone is requisite 
 because the flaps have been cut too short. 
 
 A Tenaculum and Artery-, or Hemostatic Forceps are required to secure 
 the vessels, the last being all that are usually rerjuisite, except where a vessel 
 is imbedded in naturally dense tissues or those rendered dense by inflammation, 
 or when the vascular coats will not hold a ligature ; in all of which cjises it is 
 often necessary to take up with the vessel some of the surrounding tissues and 
 include them in the ligature. In these cases the tenaculum is the best instru- 
 ment, or a ligature may be carried through the tissues by a curved needle and 
 tied. 
 
 Lir.ATURES are made of silk, catgut, or some animal tissue of a size propor- 
 tioned to the vessels to be tied, properly asepticized and secured by a square or 
 reef knot : sometimes it is desirable to use the surgeon's knot, secured by a 
 second half knot, when including a mass of tissue with the artery. 
 
 The Ri:tk ACTOR consists of a piece of muslin or of several thicknesses of 
 gauze, six or eight inches wide, rendered thoroughly aseptic, and torn halfway 
 up into two or three tails. The latter form is used for the forearm or leg, the 
 center tail being passed through the interosseous space, the outer ones being 
 wound around the bone on each side, crossed over the soft parts, and. with the 
 untorn portion similarly disposed on the other side, drawn firmly upward by 
 an assistant. Where there is only one bone, the two tails are made to embrace 
 the bone, are crossed, and then held as above directed. 
 
 Sutures may be of wire, when they must be twisted and cut off, and 
 removed by a reversal of the process ; of chromicized catgut, when they should 
 be introduced in the form of interrupted sutures, tied in a reef knot ; or, best, 
 of silkworm gut or silk, employed as the interrupted suture, the stitches being 
 about one-third of an inch apart. 
 
 The Needles employed to pass the sutures should be either large, long 
 "saddlers' needles." or ordinary surgical needles with only their extremities 
 slightly curved, or the Hagedorn needle. The best needle-holder for the latter 
 is Abbe's with the spring catch. 
 
 Halsteds "gut wool " or "antiseptic wax "' for controlling undue bleeding 
 from the bone should be ready. The best formula for tlie latter is Horsley's, 
 viz. : beeswax seven parts, almond oil one part, and salicylic acid one part. 
 
 OPERATIVE METHODS. 
 
 These are all modifications (1) of the ^'' circular method " in which the skin 
 and superficial fascia, being divided in a circular manner, are dissected up for 
 a sufficient distance, the muscles cut circularly down to the bone, and this in 
 turn sawn at a higher point; and (2) of the "'flop method,'' in which a cover- 
 ing is provided for the bones by variously-shaped "flaps " of skin and fascia, 
 or of muscle in addition. 
 
 Circular Operation. — After shaving and antiseptic cleansing, hemor- 
 rhage having been ])rovided against by Esmarch's band, by the tourniquet, or 
 by digital ])ressure on the artery, the patient's limb must be made to project 
 over the edge of the operating table or bed, and the floor be protected from 
 the blood by an old blanket, a piece of oil-cloth, or a bucket. One assistant's 
 duty should bo to give the anesthetic, another must attend to the tourniquet, a 
 third should hold and manipulate the limb, while a fourth will manage the 
 retractor, assist with instruments, etc. The instruments should be arranged in 
 
AMJ'l'TATlONS'. 
 
 1155 
 
 Circular Amputation ; dissoctinj? up the skiu-tlap ( l-:smarch). 
 
 proper trays orliiid on an antiseptic towel conveniently near the surgeon's right 
 hand : unless the operator pj^ ^^j 
 
 be ambidextrous, he should 
 
 stand with iiis left hand to 
 Avard the patient's trunk. 
 Drawing the skin of the 
 limb upward with the left 
 hand and stooping slight- 
 ly, a long knife should be 
 carried by the right hand 
 beneath and around the 
 limb, so that its back pre- 
 sents to the operator's face 
 with its point drop])ed well 
 
 downward. The heel being i .t r v *v, 
 
 firmly pressed against the skin, the knife must be swept around the limb, the 
 operator gradually rising from his stooping posture, until the entire circuit ot 
 the member has been made. A few light touches of the knite as the skin is 
 firmlv pulled up will suffice to obtain enough flap for a thm limb ; but it is 
 usuailv requisite rapidly to dissect up and reflect a cuft" of skinm length about 
 half the diameter of tlie member, carefully avoiding scoring the subcutaneous 
 fat in which ramifv the cutaneous vessels, by directing the knife toward the 
 deeper tissues. A "longitudinal incision must often be made on one side ot the 
 cuff to admit of its reflection over a conical part, as the calf or a muscular 
 
 After the cuff has been evenly dissected high enough, the surgeon must 
 apply the long knife to the muscles and cut them as before with a circular 
 sweep of the knife down to the bone. The periosteum must be divided by a 
 circular cut and forced up with the muscles, either by the finger or by the 
 handle of the knife, for an inch or more : this is preferable to separating the 
 muscles from the periosteum up to the point where the bone is to be sawn, in 
 the le<^ or forearm, where tliere are two bones, the interosseous tissues must be 
 divided by the point of the knife, entered first in front, then behind rocking 
 it from side to side, or by a scalpel or narrow catlin similarly used. Adjusting 
 the retractor as before directed, the surgeon must force up the soft parts in 
 order to apply the saw as high as possible. , . , ^ , , -i •. 
 
 Holding the saw firmly and steadying its edge by his left thumb-nail, its 
 ed<Te must be drawn firmlV backward— from heel to point— cutting a groove, 
 wlRni a few even strokes will complete the division of the bone Theo- 
 retically, the saw should be held vertically to prevent the weight of the limb 
 from breaking the bone before its complete division ; but if carefully held by the 
 assistant so as neither to strain the unsawn portion nor bind the saw, the divis- 
 ion can be made in any way most convenient to the operator. In the leg it is 
 better to saw through the fibula before the tibia is completely divided, to avoid 
 strainintr the superior tibio-fibular joint; and the radius in the forearm, as it is 
 the more movable of the two bones. As soon as the limb is removed, all ves- 
 sels that can be detected are to be taken up with a tenaculum or forceps and 
 tied • the pressure on the artery is then to be relaxed, and any bleeding points 
 are to be caucrht first with forceps, and then every bleeding vessel, whether 
 artery or vein, is to be tied. Cut off with the bone forceps any uneven por- 
 tions of bone, draw out and remove with the scissors all large nerves, retrench 
 projecting tendons, and check capillary oozing with hot aseptic water. If 
 bleedincr persists from the bone, and the vessel cannot be plugged with a 
 
115G 
 
 .l.Y AMFJUCA.X TEXT-HOOK OF ^VimERY. 
 
 Fia. 472. 
 
 piece or twisted strand of catgut, a small pellet of antiseptic wax fastened 
 to a silk ligature must be pressed on the spot : this can be brought away 
 by the ligature along the track of the drainage-tube at a subsequent dress- 
 ing. This, however, is an expedient rarely demanded, as catgut plugging 
 or sewing of the periosteal flaj>s or the tissues over the bone, so as to exert 
 pressure, is better; or Ilalsted's "gut wool," or Ilorsley's "antiseptic wax " 
 may be used. Any bleeding periosteal vessel must be twisted, or tied by a 
 catgut thread passed by a small curved needle. The stump being now dry, 
 a drainage-tube should be placed so as to emerge at what will be the most 
 dependent angle, and the skin sutured by interrupted silkworm gut or silk 
 stitches so as to form a vertical or a horizontal line : an antiseptic dressing 
 must next be applied, such as will be described for flap operations, and a splint 
 bandaged on in amputations below the elbow or knee to keep the whole limb 
 at rest ; or it may be made comfortable on a pillow. 
 
 Flap Operations. — The flaps may consist of skin alone, or of muscle in 
 
 addition. When the latter is included, 
 there must be enough skin to cover the 
 muscle, enough muscle to cover the bone, 
 and the bone must be sawn above the 
 angle of junction of the flaps. The flaps 
 may be cut from without inward or from 
 within outward. The latter is spoken 
 of as transfixion. 
 
 Siiujh'-flap Operation. — This is ad- 
 visable only when from injury or disease 
 the tissues on one side are unfit to use, 
 while on the other they are sound. The 
 flap must be somewhat longer than the 
 transverse diameter of the limb at the 
 point wliere the bone is to be sawn ; 
 should as far as possible be rectangular 
 in outline ; must include skin, fascia, and 
 a good layer of muscle, and is best made 
 by cutting from the skin inward, the tis- 
 sues on the opposite side of the extremity 
 being divided transversely or by an in- 
 cision slightly convex downward ; and 
 the bone cleaned of tlie soft parts, and 
 sawn off" at least one inch above the base 
 of the flap, as directed for the circular 
 operation. 
 
 Douhle-jiap Operation (Fig. 472). — In addition to the general rules 
 which have been given above, the following directions will suflice, ex- 
 cept in certain instances where some special modifications — which will be 
 described — become requisite. In breadth each should be half the width of 
 the member ; in length they may be equal, or one may be longer than the 
 other, but the aggregate length must be somewhat more than the diameter of 
 the limb at the level at which the bone is to be sawn, especially in operations 
 for disease, where the muscles will not at once retract to their full extent, but 
 may do so to an unpleasant degree in the course of a few days. They may 
 consist of skin alone or of muscle also, while they may be lateral, antero-pos- 
 terior, or antero-lateral. While cut more rapidly by the transfixion method, 
 there is apt to be a redundance of muscle, so that a better stump can be made 
 
 The Flap Method by Transfixion (S(;'flillf>t). 
 
AMPUTATIONS. 
 
 1157 
 
 by cutting from the skin iinvurd, or one flap may thus ho made while the 
 other is eut by transfixion. The advantage of inuscuh)-eutaneous flaps is 
 that by buried animal sutures all s|)aces may be effaced, and thus all, except 
 perhaps ca|)illary, drainage can he dispensed with, which is hardly possible 
 with cutaneous flaps alone. 
 
 Mixed or Modified Circular Method — i. e. flaps of skin and cir- 
 cular of muscles. — The best is that of Syme, in which two semilunar flaps 
 are dissected up a short distance above the angles of juncture of the Haps, 
 the remainder of the operation being identical with the circular method 
 (Fig. 478). 
 
 Method of Closing and Dresshu/. — After first arresting all bleeding, 
 if the patient's condition will permit of prolonging the operation, a more 
 ideal result will be obtained by sewing the periosteum over the end of the 
 bone or bones, by closing the sheaths of nerves after they have been divided 
 as high as possible, and by sewing together the divided ends of the muscles. 
 In employing this method it is essential that the technique be consistently 
 aseptic throughout, as drainage must be dispensed Avith. Finally, the skin 
 must be united by interrupted silk or chromicized catgut or silkworm-gut 
 sutures, between each two of which three or four of the catgut drainage- 
 
 FiG. 473. 
 
 Mixed Method : skin-flaps and circular through muscles (Esmarch). 
 
 threads should pass. These are kept parallel and in contact with one another, 
 cut off square, and kept moist by «, piece of protective Avhich shall cover in 
 the wound and extend one inch beyond the cut ends of the drains. Some 
 surgeons use simply a rubber drain-tube for a day or two, with or without 
 capillary drainage ; suture the edges of the flaps, and secure apposition of 
 the surfaces of the flaps by deep sutures passed through and through or by 
 suitable compression by pads and bandages. Over the stump a voluminous 
 mass of gauze, Avith sufficient aseptic cotton or wood-wool to absorb the 
 bloody serum, must be applied and bandaged securely in place, the dressing 
 extending many inches above the extremity of the stump ; for instance, well 
 above the knee for an amputation at the middle of the leg. 
 
 Splints are indicated for amputations below the elbow-, knee-, and wrist- 
 joints. Should no hemorrhage, great rise of temperature, undue pain, or 
 soakage of discharges through the bandages demand it, such a dressing in an 
 aseptic operation may remain undisturbed for from tAvo to three weeks, when 
 if silk thread has been used the stitches must be removed; if catgut has been 
 employed, it may have disappeared ; in either case the stump will usually be 
 found soundly healed. When it is doubtful whether asepticism has been 
 secured, two short rubber drainage-tubes must be introduced, so that one 
 emerges at each angle of the wound, reaching doAvn to the bone, cut off 
 
1158 AN AMERICAN TEXT- HOOK OF SUIiaEliV. 
 
 nearly flush witli tlie surface, and secured by a safety-pin or stitcli : tliese 
 must be removed at the end of two or tliree days unless re(|uired for a 
 longer period. 
 
 Amputations in Continuity and in (Juntkjuity. — The first term is 
 used to indicate an amputation where a bone is sawn tlirough, wliile an 
 amputation in contiguity is synonymous with removal of a limb tlirough a 
 joint. 
 
 After-treatment and Compijcations. — As all dressings should be 
 conducted on aseptic principles, the student should consult the section devoted 
 to this subject. If the union is not firm, so long as the sutures are not irri- 
 tating the parts allow them to remain. Where additional support is needed, 
 strips of aseptic or antiseptic gauze fixed with collodion are better than adhe- 
 sive plaster; but if this latter is used, interpose a few layers of gauze between 
 them and the line of union. Spasm and retraction of the muscles must be 
 combated by firm circular bandaging, adhesive plaster, stirrup-extension by 
 weight and pulley, and splints, as must also the elevation of the heel some- 
 times following Chopart's operation. Antipyrine internally may also be 
 used. 
 
 Hemorrhage may occur a few hours after operation (consecutive or reac- 
 tionary, from small vessels overlooked, because not bleeding, during shock), 
 or days or weeks after operation from imperfect closure or giving way of 
 arteries (secondary hemorrhage). If consecutive and slight, firm bandaging, 
 elevation, and ice-bags over the stump should be tried. If these measures 
 fail, or if it is evident that a large vessel is bleeding when union has not 
 progressed far, the flaps must be opened and the bleeding points secured ; 
 but if union is nearly completed, use acupressure, or, better, tie the vessel 
 or vessels just above the stump. Painful enlargements of the nerves must 
 be excised, while caries and necrosis of the bones re(iuire the same treatment 
 as when arising from other causes, except that reamputation is more often 
 appropriate than primary amputation would be for bone disease. 
 
 Mortality. — Circumstances vary so much that only a few facts are beyond 
 reasonable dispute. Age influences the result: thus, operations in children are 
 usually successful, Avhile the reverse holds good for the aged, the death-rate 
 increasing with advancing years. Renal, hepatic, or other visceral disease 
 greatly increases the danger, as do bad hygienic surroundings. Amputations 
 for injury have a higher death-rate than those for disease, as do those for 
 malignant disease as compared with operations for caries, chronic suppurative 
 arthritis, etc.; moreover, amputations of the lower limb are more dangerous 
 than those of the upper ; again, the death-rate for the thigh is nearly twice as 
 great as for removals of the leg : the mortality of leg amputations is much greater 
 than that of amputations of the forearm ; and, in turn, those of the upper arm 
 are more dangerous than those of the forearm. Antiseptic surgery has enor- 
 mously diminished the mortality. 
 
 Primary Amputation means one done after injury, before the onset of 
 traumatic fever (if shock persists, this may mean after the lapse of even so 
 long a time as seventy-two hours). 
 
 Intermediary operations are those performed during the acute inflam- 
 matory stage — /. e. from two to four weeks, possibly less ; while Secondary 
 amputations are those performed after the subsidence of fever and the establish- 
 ment of suppuration. Amputations for accident should always, when possible, 
 be primary, but if this cannot be done, wait for the secondary period rather 
 than run the exceptional risks of an intermediary operation. 
 
AMPUTATIONS. 
 
 1159 
 
 Fig. 474. 
 
 Amputation of a Phalanx (after 
 Esmarch). 
 
 SPECIAL AMPUTATIONS. 
 
 Amputations of the Fingers. — From the importance of the hand, and 
 because this member possesses its peculiar powers in virtue of the pos.sibility 
 of the tip of each digit being apposed to that of the thumb, it is of paramount 
 importance to presci-vc even small ])ortions of a phalanx, especially of the thumb. 
 
 Amputation through a Phalanx can be done by two square ilaps fash- 
 ioned by making a circular cut down to the bone, supplemented by two vertical 
 lateral ones, or two semilunar flaps may be employed; the bone may be divided 
 by cutting forceps or by a small saw, and the digital arteries on each side 
 twisted or included in the stitches by which the flaps must be coa])tated ; tlie 
 other fingers and the wrist must be kept (juiet on a si)lint for about ten days. 
 
 Amputation through an Interphalangeai Joint may be done either 
 by a single palmar flap or by two semilunar flaps, the chief point to be re- 
 membered being that the joint in the last row 
 of phalanges is one-twelfth of an inch beyond 
 the most projecting part of the knuckles ; that 
 of the middle row, one-sixth of an inch beyond ; 
 and that of the metacarpo-phalangeal joint, 
 one-third of an inch beyond. Use a narrow, 
 sharp-pointed bistoury for these operations, 
 and cut the flaps from without inw^ard, after 
 which the lateral ligaments must be divided, 
 when the knife-edge should be entered on the 
 dorsal aspect of the joint, passed between the 
 bones, and made to cut doAvnward and forward, 
 severing the palmar ligaments, and completing the disarticulation (Fig. 474). 
 
 Amputation at the Metacarpo-phalangeal Joints. — This may be 
 done by double lateral flaps, or thus : With the patient's hand pronated make 
 a longitudinal half-inch cut over the head of the metacarpal bone ; carry the 
 knife obliquely from the lower end of this incision down on one side to the 
 interdigital web across the base of the finger on the palmar surface and 
 upward on the other side to the longitudinal cut, dividing the tissues down 
 to the bone ; cut the tendons and lateral ligaments, and complete the dis- 
 articulation. All the fingers may be thus separately removed, or to remove 
 them all together a transverse dorsal incision may be made, disarticulation 
 eff"ected, and a palmar flap made by transfixion from within outward, 
 and a palmar flap made from within outward. 
 
 AMPUTATION OF THE THUMB 
 
 through its metacarpal bone (Fig. 475) or with this bone, and amputation 
 
 of the little finger with 
 
 its metacarpal bone, can be F^*^'- ^'^'^^ 
 
 done best by the modified 
 
 oval method given for the 
 
 disarticulation of an entire 
 
 finger. 
 
 AMPUTATION OF THE META- 
 CARPUS. 
 
 Amputation of a por- 
 tion or of all of the meta- 
 carpus, with or without por- 
 tions of the carpus, must 
 usually be done by fashion- 
 
 Amputation of the Thumt) through the Metacarpal Bone 
 (original). 
 
ll»i(> 
 
 AN A.VEJiJCAX TPLXT-liOOK OF .SURGERY 
 
 ing tia}).s, not according to any given rule, but as the condition of the 
 tissues permits. 
 
 AMPUTATION AT THE WKIST. 
 
 Til is mav be effected bj the circular method, controlling the circulation 
 through the brachial artery. Make the incision from one inch to one inch 
 and a half below the radio-carpal joint, reflect the Hap, open the joint from 
 the radial side, and, having disarticulated, secure the vessels, about three or 
 four in number. A single oval or rectangular palmar flap cut from without 
 inward ni:iv iiiso be em|)b>ved. 
 
 AMPUTATION OF TH?: FOREARM. 
 
 The circular method does well here, but antero-j)Osterior musculo-cutaneous 
 flaps are preferable (Fig. 476), best made by cutting from without inward, 
 
 Fifi. 47«. 
 
 Anii>ut.iti(>n of tin' Forearm (I5ryaiit). 
 
 although they can be fashioned by transfixion : retrenchment of tendons is 
 re(iuisite. When possible saw the bones above the attachments of the pronator 
 radii teres to retain the power of pronation. 
 
 AMPUTATION AT THE ELBOW. 
 
 Elliptu'iil Method. — Semi-flex the arm ; enter the point of the knife about 
 one inch below the inner condyle, carry it up over the forearm nearly to the 
 joint in a curve with the concavity upward, thence carry the curvilinear 
 incision downward, passing one and a half inches below the external condyle ; 
 forcibly flex, and complete the incision by outlining an ellipse with the con- 
 vexity downward, extending at its lowest point about three inches below the 
 tip of the olecranon : reflect the skin ; divide the anterior nniscles half an 
 inch below the joint; disarticulate this from the outer side, cutting the ulnar 
 nerve well above the joint ; tie the brachial or radial and ulnar vessels, with 
 a few smaller branches ; close the wound transversely. 
 
 The F/ap Method of Guerin. — Hold the forearm semi-prone; introduce 
 the knife in the mid-forearm line one inch below the bend of the elbow; trans- 
 fix by skirting around the radius with the knife-point ; cut an external flap 
 two to three inches long: divide the tissues on the opposite side of the joint 
 by a curved incision carried from without inwards, convex downward ; dis- 
 articulate from the outer siile : close the wound vertically after tying the 
 vessels. 
 
 AMPUTATION OF THE ARM. 
 
 When operating near the shoulder there may not be space enough to apply 
 the tourniijuet. but by maintaining the arm at a right angle the compress can 
 be applied over the axillary artery so as to press this against the prominent 
 head of the humerus, the tourniquet plate being placed over the acromion pro- 
 cess ; again, compression of the subclavian against the first rib can be effected 
 by an assistant with a padded key, or by the use of Keen's method by a com- 
 
AMPUTATIONS. 
 
 n«)i 
 
 Fro. 477. 
 
 press above the clavicle, held in place by an Esmarch bandage passed alter- 
 nately between the thighs and in 
 the opposite axilla. 
 
 While the (.'ircular nicthod does 
 well in innjditatioii of tho arm, the 
 double antero-posterior flap 
 is the better operation, this being 
 ione either by transfixion or by 
 cutting from without inward (Fig. 
 477). As the l»iceps contracts moic 
 than the triceps, the anterior ila]) 
 should be the longer of the two, 
 and the bone must be especially 
 cleaned behind by a few extra 
 touches of the knife : the brachial 
 artery, the superior profunda, and a varying number of smaller vessels require 
 ligature. If the location of the disease or injury prevents the formation of 
 antero-posterior flaps variously disposed, single or double flaps can be made. 
 
 Amputatiiiii (if the Arm (Bryant). 
 
 Fig. 478. 
 
 AMPUTATION AT THE SHOULDER. 
 
 The Oval or Larrey's Method (Fig. 478). — Control the circulation by 
 compressing the subclavian against the first rib, or as above; enter the point of a 
 
 medium-sized knife below and just anterior to the tip 
 of the acromion process, making a three-inch longi- 
 tudinal cut; from just below the middle of this make, 
 first in front, then behind, slightly curved lateral 
 incisions with their convexities downward, extend- 
 ing respectively to where the anterior and posterior 
 axillary folds end in the arm tissues ; rapidly loosen 
 the edges of the wound ; while the bone is rotated 
 outward, forcibly sweep the point of the knife be- 
 neath the acromion process across the capsule, divid- 
 ing it, the long head of the biceps, and the subscap- 
 ular muscle ; then forcibly rotate in, cutting the infra- 
 and supraspinatus and teres minor muscles ; finally, 
 pass the knife behind the head and neck of the 
 bone, and while an assistant grasps the flap contain- 
 ing the vessels behind the knife, remove the limb by 
 cutting from within outward, so as to connect the 
 two lateral incisions by a transverse one ; tie the brachial and subscapular 
 arteries, the former occupying the first muscular interspace behind the anterior 
 axillary fold : suture the sides of the oval together, so that a linear wound 
 remains. 
 
 Dupuytren's Method. — Taking the same precautions against hemor- 
 rhage, with the patients arm well extended from the body grasp the deltoid 
 with the left hand; transfix, traversing the joint with the knife entered one 
 inch in front of the acromion process and emerging at the posterior axillary 
 fold, and form a large deltoid flap by cutting downward, backward, and out- 
 ward ; turn this aside ; disarticulate by dividing the muscles rendered tense by 
 outward and inward rotation ; slip the knife behind the bone and cut a short 
 inner flap from within outward, an assistant grasping the flap behind the blade 
 to control the artery ; secure the vessels and suture the wound. 
 
 Larrey's Amputation at the 
 Shoulder-joint (after Stim- 
 son). 
 
IK; -J 
 
 l.V AMKIilCAy TEXT-JIOOK Of S( /.'(, /:/:)'. 
 
 Wyeth's Bloodless Method.— See tliat tlie shoulder jn-ojects .sliglitly 
 bevonci the edge uf the taldc : j.hiee the arra at a right angle with the body ; 
 introduce one long steel {>in — a twelve-inch mattress needle will do — through 
 the pectoralis major tendon (Fig. 479) — /.<'.. the anterior axillary foM, enter- 
 ing it somewhat to the thoracic side of the middle of the fold : bring the point 
 out one inch internal to the tip of the acromion process, and guard it with a 
 sterilized cork. Pass a second pin through the tendon of the latissimus dorsi 
 
 Aminitation at Shoulder-joint 
 
 arked by a black 
 
 muscle — i. e., the posterior axillary fold, a little internal to the middle of this- 
 fold, causing the point to emerge posteriorly one inch internal to the tip of the 
 acnnninH process ; guard the point with a sterilized cork : tightly wind around 
 the axilla and shoulder, internal to the pins, a piece of black-rubber tubing 
 one-half inch in diameter : according to the muscular development of the 
 patient two or three turns may be made : disarticulate by any of the approved 
 methods ; secure the main vessels and any small ones visible ; remove the tub- 
 ing and pins : secure temporarily all bleeding points with forceps and tie them 
 off; complete as directed for each special method. 
 
 Caution. — It is essential that both pins emerge one inch internal to the tip 
 of the acromion: otherwise, when the humerus is disarticulated, the tulting 
 tends to slip down, thus drawing the flaps together, when the vessels nuiy 
 retract, severe hemorrhage then occurrincj, necessitating ligation of the sub- 
 clavian artery or removal of the tube to secure the vessels in the wound, this 
 latter only being possible of execution after severe loss of blood. 
 
 AMPUTATIONS ABOVE THE SHOULDER. 
 
 The flaps must be fashioned as the condition of parts left by injury or dis- 
 ease will allow ; the easiest plan is to disarticulate the arm first, tie the axillary 
 vessels, expose the scapula by a T-incision, the transverse arm of the T 
 roughly corresponding to the spine of the scapula', detach it from the thoracic 
 wall by cutting from below upward, and separate it from the clavicle or 
 divide this bone with a saw or forceps. 
 
A.U/'l /A y/o.vx. 
 
 1 1 <i;i 
 
 i-Ki. J so. 
 
 I.NThMtSC \l'l l.(i-T||u|! ACie A M ITT A I I" • \ ( |{ i;.M(»VA 1, n|t Till: WlluLK I'l-l'KH 
 
 ExTKii.MiTv), I'M), Hkkckk's Mktiiok ( Ki;,'. 4«0).— Iffli.- (-..iiditions <1<. not 
 forbid, a|)|)ly an K>in:iirli liaii(la;4(' tit the ii|i))t'r fx- 
 troiiiity as lar as the lower border uf the axilla; 
 make an incision extending fnttn the inner extremity 
 of the ehiviele outward to the toped" the sliouhler; 
 iineover and resect the niiddh' half of the clavicle, 
 thus exposin;^ the subclavian vessels, uhich must 
 next l)e tied — both artery and vein : it is better as a 
 rule to tie the artery first bv two ligatures, each about 
 one inch apart; divide the vessels Itetween the liga- 
 tures ; cut the axillary plexus with the scissors; 
 commence a second incision at the center of the first, 
 carryinir the knife directly across the anterior part 
 of the axilla and inner arm to the inferior angle of 
 the scapula; from the outer extremity of the first 
 incision over the clavicle carry the knife posteriorly 
 across the dorsum of the scajjula to its inferior an<!;le, 
 joining the termination of the second incision; 
 reflect the posterior flap thus made ; divide all muscular and ligamentous 
 attachments; secure all bleeding points, and suture the flaps. 
 
 Kcninviil i»f the Whole I'pper 
 Kxtifinity (Berserj. 
 
 AMPUTATIONS OF THE TOES. 
 
 These should not be removed through a phalanx, interphalangeal disarticu- 
 lation being preferable. y . ,^, 
 
 Amputations througfn the Interphalan- 
 geal Joints. — Open the joint transversely from 
 above, making an incision slightly distal to the 
 joint, disarticulate by dividing the lateral liga- 
 ments, and shave off a ])lantar flap by cutting 
 from within outwar<l. 
 
 Amputation at the Metatarso-phalan- 
 geal Joint. — This can be done either by lateral 
 flaps or by the modified oval, remembering that 
 the joint is higher than it seems, because the 
 web between the toes is about halfway between 
 this joint and the extremity of the toe. Make a 
 longitudinal incision, commencing on the dorsal /i. nisnrtifuiati,, nor the second pim- 
 
 '^ 1 • 1 f -11 1 • lanx of II Toe l)v the racket or oval in- 
 
 SUriace two-thirds OI an inch above the artlC- eision: iJ. disarticulation of the ^reat 
 1 .■ IT ii__ -liii t<x> bv the oval incision (original I. 
 
 ulation ; pass oblujuely down one sine to the 
 
 web, across the base of the toe on the plantar surface, and up on the opposite 
 side to the starting-point : dissect u)) the ])lantar flap, and disarticulate during 
 forcible flexion by dividing tendons, lateral and other ligaments. The oval 
 method (Fig. 481) may also be used for both these last amputations. 
 
 Amputation of the Toes may be done by opening the joints by an 
 incision extending across the dorsum of the foot convex downward, dividing 
 the tendons, disarticulating, slipping the knife behind the Ixmes. and shaving 
 off one large plantar flap. 
 
 Amputation of the Great or Little Toe with its Metatarsal Bone 
 can be done by the oval method, the preliminary longitudinal incision curving 
 somewhat upward over the base of the metatarsal bone to give more room. Two 
 or more toes with their metatarsals mav also be removed bv the same method. 
 
(M 
 
 I.V AMEIi/CAN TEXT-BOOK OF SUlKiEllY 
 
 coimiicnciiig the line of incision half an inch above the tarso-nietatarsnl joints. 
 and carrving it so as to embrace tlie toes to l)e removed. 
 
 AMPUTATION TIIHOUJH Till: MHTATAUSUS. 
 Cut from within outward by transfixion a short dorsal flap slightly convex 
 downward, and a long plantar one ; free these; saw the bones across ; suture 
 so as to make the line of union on the dorsum of the foot. 
 
 AMPUTATION THROU({H THE TARSO-METATARSAL .JOINTS. 
 Hey's Operation. — Make an incision commencing on the outer side of tlie 
 tuberosity of the fifth metatarsal bone at its upper end, carry it down to the line 
 
 * ,^., of the nietatarso-phalangeal joints, thence across the 
 
 tio. 482. , 1 ' 1 1 X! n 1 xi • 
 
 sole convex downward, and hnally up along the inner 
 
 side of the foot to the tuberosity of the scaphoid br)iK' ; 
 connect the two extremities of this incision by a dorsal 
 one. also convex doAvnward; dissect up both flaps, the 
 sole resting on the operator's palm ; disarticulate the 
 four outer metatarsals, and saw across the internal 
 cuneiform bone. The more common plan is to disar- 
 ticulate the first, third, fourth, and fifth metatarsals, 
 and saw across the base of the second metatarsal. 
 
 Lisfranc's Operation (Fig. 482). — For the right 
 side grasp the front of the foot with the left thumb on 
 the base of the fifth metatarsal bone, and the forefinger 
 about half an inch in front of the tuberosity of the 
 scaphoid bone ; make an incision, convex downward, 
 cutting to the bones between these two points ; reflect 
 the flap slightly ; disarticulate first the three outer 
 metatarsals, then the first, and finally the second, by 
 cutting upward between its base and the internal cu- 
 neiform for about half an inch (the cowp de main. 
 Figs. 483, 484) ; repeat this procedure on the outer 
 dotted liue'shows'tiie'piantar sidc, and Complete the separation by a transverse cut, 
 incision) (after GuurinV dividing the ligaments between the middle cuneiform 
 
 and the base of the metatarsal bone. The disarticulation of all the bones is 
 
 Lisfranc's Amjmtation (tlie 
 
 Fig. 483. 
 
 Ki.;. 484. 
 
 The Coup de Main in Lisfranc's Amputation : first 
 step (after Guerin). 
 
 The Coup de Main in Lisfranc's Amputation : second 
 step (after Gu(Jrin). 
 
 greatly facilitated by forcibly depressing the front of the foot. Finally, pass 
 the knife behind the bones and shave off" a long plantar flap, longer on its 
 inner side. 
 
AMP VTA TIOXS. 
 
 1165 
 
 Chopart's Aiuputation : .1, 
 line of disarticnilatiim ; 
 B, the dorsal, and C, the 
 plantar incisions. 
 
 AMPUTATION AT THE MEDlO-TAKSAL JOINT. 
 
 Chopart's Operation (Ki;;. 485). — As now pcrforuied, grasp the foot so 
 tliiit the tliimib and fori'liii^aT (according' to the side) are 
 Kifi. 48o. rcspectivelv alxmt half an inch behind the tuberosity of 
 
 the scaphoid and midway between the base of the fifth 
 metatarsal and the outer malleolus, the sole thus resting 
 on the operator's palm ; make a dorsal incision, curved 
 downward between these points; divide the extensor 
 tendons ; forcibly de])ress the anterior part of the foot ; 
 disarticulate by dividing the ligaments, uniting the 
 scaphoid with the astragalus and the cuboid with the 
 OS calcis ; slip the knife behind and then under the bones, 
 shaving ott" a long plantar Hap, longer on its inner side. 
 
 AMITTATIONS AT THE ANKLE. 
 
 Syme's Amputation (Fig. 486). — Hold the foot 
 at right angles to the leg; enter the point of a short 
 straight knife below the 
 center of the external mal- Fig. 48G. 
 
 leolus, and cut straight 
 across the sole to a corre- 
 sponding point on the other 
 side — not to the tip of the 
 internal malleolus; dissect 
 the tissues of the sole back 
 of the OS calcis, keeping close to the bone, until 
 the point of the heel is turned, and then cutting 
 the tendo Achillis ; unite the extremities of the 
 first incision by a transverse one across the 
 articulation; open the joint; divide the lateral ligaments and complete the 
 disarticulation ; finally, clear the tibia and fibula and saAV off the malleoli, 
 including a small slice of the articular surface of the tibia : pass a drainage- 
 tube through an opening made at the thinnest portion of the flap posteriorly ; 
 tie the anterior and pos- 
 terior tibial vessels. 
 
 Pirogoff's Ampu- 
 tation (Fig. 487).— 
 Make a plantar incision 
 obliquely forward from 
 the tip of one malleolus 
 to that of the other, 
 extending down to the 
 bone; dissect back half 
 an inch : unite the ex- 
 tremities of the first 
 cut by a second dorsal 
 one convex anteriorly, 
 exposing the ankle- 
 joint; disarticulate; 
 slip a saw back of the 
 astragalus and divide 
 
 Syme's Amputation of the Foot 
 (after E.smarch). 
 
 Fig. 487, 
 
 rirdfjoll .s Amputation : sawing the os calcis (Wyeth). 
 
 the OS calcis obliquely in the line of the first incision; remove the ends of the 
 tibia and fibula ; secure vessels ; suture the -svound so that the sawn bones are 
 
11 n<; 
 
 I X A MKIifC. I .V 'I'KXT- lUtOh' OF Sf 1!<; EJi y 
 
 in contact, and hold thcni there by two broad strij)s of adhesive phister, crossing 
 tlie end of the stump at ri;^ht angles over the dressing; secure the limb on a 
 posterior splint. 
 
 AMPUTATION OF THE LEG.' 
 
 The modified circular is the best for the lower third,^while the double ante- 
 ro-posterior flap method, the anterior one being the 
 longer, or S^dillot's, is better for the middle and upper 
 portions. 
 
 S^dillot's Method (Fig. 488).— Make a short lon- 
 gitudinal skin incision along the inner edge of the tibia; 
 draw the tissues to the fibular side, so that a narrow, 
 long knife can be passed to the outer side of the tibia 
 and fibula, transfixing the calf muscles; cut a broad, 
 rounded flap by a sawing motion ; divide the tissues 
 on the inner side of the limb by an incision convex 
 downward; clear the bones by a circular cut; divide 
 the interosseous membrane ; force the .soft parts up 
 so as to expose the bones one inch above the angle of 
 the flaps, Avhere they must be sawn. The anterior and 
 posterior ti))ial and ])eroneal arteries, with two or three 
 smaller branches, Avill require ligature : the line of 
 union will be vertical, one angle being dependent and 
 well fitted for drainage. In all leg amputations 
 removing half an inch more of the fibula than of 
 the tibia makes a better stump. The tibia should be 
 first sawn for an inch obliquely from above downward 
 and backward, and then by a fresh cut transversely. 
 This bevels the sharp tibial crest, which otherwise 
 sMiiiots Method (Wyeth). might perforate the flap. 
 
 AMPUTATION OF THE KNEE-.JOINT. 
 
 Flap Method. — Cut a long anterior quadrilateral cutaneous flap with 
 rounded corners bv commencing; near the back of one tuberosity 
 of the tibia and extending to the other, passing from one to three 
 inches below the tubercle of the tibia, according to the length 
 of the posterior flaps ; dissect this up until the ligamentum jiatelljfi 
 is reached ; divide this ; forcibly flex the knee ; cut the lateral 
 and crucial ligaments; slip the knife behind the joint and cut 
 outAvard, forming a short, s<|uare musculo-cutaneous posterior flap. 
 Unly the j)opliteal and a few small vessels will reciuire ligature. 
 Lateral Flap Method (Fig. 489).— Stephen Smith's 
 Operation. — With a large scalpel commence an incision one inch 
 below the tuberosity of the tibia ; curve it downward and back- 
 ward to the back of the leg, thence upward to the middle of the 
 popliteal space; repeat this on the other side; raise the flaps, 
 including everything down to the bone, until the joint is reached; 
 divide the patellar and lateral ligaments and complete the disar- 
 
 Fiap Mitbod ticulation ; the line of union is longitudinally median behind the 
 
 snuth*"^^^" condyles of the femur. 
 
 ' See page 1171 for point of election for :iiiii)iitatioii of tlie leg, umier tlie lii-ading "Arti- 
 ficial Limbs." 
 
 ''■ .See page 11.5') for "circular metiiod" (Fig. 471), page 1156 i Fig. 472i for "single-flap" 
 operations, :ind page 1157 (Fig. 473) for "mixed method." 
 
J. 1/ /'/'/'. I rinys. 
 
 Hi; 
 
 AMPUTATION ABOVE THE KNEE. 
 
 This may be done by either of the inothofls advised, by sawing off more 
 or less of the condyhjid end of the femur, but the antero-posterior Hap method 
 is the better. 
 
 Garden's Operation. — 'I'his is done by dissectin;^ up a large rounded 
 anterior cutaneous thip, dividing the tissues behind by a transverse incision, 
 and cutting the muscles in a similar manner down to the femur in front above 
 the patella, which is drawn downward by flexing the knee ; complete the ope- 
 ratiim by sawing tlirough the base of the condyles. 
 
 Gritti's Operation. — In tiiis a rectangular flap is raised from tlie front 
 of the leg and knee, leaving the patella in s/fii, a shorter posterior one fash- 
 ioned, the femur sawn across above the condyles, the cartilaginous surface of 
 the patella removed by a small saw. and the two freshened osseous surfaces 
 maintaiiie<l in apposition. 
 
 AMPl'TATION OF THE THIGH.' 
 
 At the lower tFiird cut from without inward an anterior semilunar flap in 
 length rather more than one-half the diameter of the limb at the point where tin- 
 bone is tobesawn,andin width half the 
 
 circumference: dissect this up, includ- I''i<'- -^'JO. 
 
 ing everything down to the bone (Fig. 
 490) ; reelect the flap, and, passing the 
 knife behind the femur, cut downward 
 and backward, forming a posterior 
 semilunar Ha)) fully equalling the an- 
 terior in length, since the posterior 
 thigh muscles will retract more than 
 the anterior, and thus will bring 
 the cicatrix behind the end of the 
 bone ; clear the bone by a few cir- 
 cular cuts of the knife ; force the 
 tissues, including the periosteum, up 
 with the knife-handle, and saw the 
 bone an inch and a half above the 
 angles of junction of the flaps. Seven or eight vessels will require ligature, 
 ]ierhaps more. 
 
 Middle and Upper Thirds. — In either situation the same operation is to 
 be recommended, as a rule cutting both flaps from without inward, not by 
 transfixion, lest they be too bulky, the posterior muscles being cut longer than 
 the anterior to allow for retraction. The modified circular operation is also 
 well ada))ted for operations at these points. In high thigh amputations there 
 is oftentimes no rooiu either for the tourni({uet or for Esraarchs tube : in such 
 case recourse must be had to either Wyeth's method, digital compression of 
 the femoral against the brim of the pelvis, the abdominal tournicjuet, or 
 Macewen's method of controlling the circulation through the abdominal aorta 
 (Fig. 494). 
 
 Amputation through the Trochanters, as being less dangerous than 
 exarticulation at the hip, may be performed for injury or even for malignant 
 di.sease. in which latter case, if on section the bone proves to be involved, 
 the remaining fragment can be dissected out of the joint. 
 
 ' For point of election, see Artificial Limbs, p. 1171. 
 
 .\inpulatioii of the Thigh (Bryant) 
 
1168 
 
 Ay AMERICAN TEXT-llOOK OF SVRCERY. 
 
 AMPUTATION AT TIIK IIIP-.TOINT. 
 Before an amputation at the liip-joint. as in some other similarly serious 
 operations, it is well to envelop the patient's body and the other three limbs 
 
 Ki<i. 49). 
 
 Wyeth's Bloodless Amputation at the Hip-joint : The pins and rubber tubing applied : circular and 
 longitudinal incisions for skin-flap. 
 
 with raw cotton secured by bandages, so as to diminish shock by preventing 
 the loss of body heat. 
 
 Fig. 492. 
 
 Wyeth's Bloodless Amputation at the Hip-joint : Cuff of skin and subcutaneous fat turned back, muscles 
 divided at level of small trochanter, bone partly stripped, and large vessels exposed for dcligation. 
 
 Of the many methods of performing this amputation (over forty-five have 
 been described) only a few will be given. 
 
AMPUTATIONS. 
 
 IKIi) 
 
 Modified Circular. — Tliis is useful when a tumor involves tlie muscles 
 higli u)). Cut sliort antero-posterior skiii-tia|ts; make a circular cut of the 
 muscles at the joint-level and disarticulate: after the Haps have been reflected 
 the femoral vessels can he tied, if desired, before they are divided by the cir- 
 cular sweep through the muscles. Macewen's method (p. 1170) of compress- 
 ing the abdominal aorta or digital compression of the aorta through an ab- 
 dominal incision, or some other means for controlling the circulation, must 
 of course be emj)loyed if the artery is not to be tied until after the anterior 
 skin-llaj) has been i'eliecte(l. 
 
 Wyeth's Bloodless Method of Amputating at the Hip-joint. — With 
 the hip well over the edge of the table, if the condition of the limb allows it, 
 apply an Esmarch bandage as high as possible; enter the point of a steel 
 mattress needle, three-sixteenths of an inch in diameter at its base and one 
 foot long, one inch below and slightly to the inner side of the anterior supe- 
 rior iliac spine, carrying the needle through the tissues, so that the point will 
 emerge directly opposite to and about three inches from the point of entrance; 
 
 Fk;. 493. 
 
 Listen's Amputation at the Hip-joint (Wyeth). 
 
 pass a second needle an inch below the level of the crotch internally to the 
 saphenous opening, through the adductors, so that the point will come out about 
 an inch below the tuber ischii (Fig. 491); cover the needle-points with corks; 
 pass a long piece of half-inch black — ?'. e. pure — rubber tubing, on the stretch, 
 tightly five or six times around the thigh above the fixation needles, and tie 
 or clamp it ; remove the Esmarch bandage ; six inches below the tourni(juet 
 make a circular skin incision down to the deep fascia; this is joined by a lon- 
 gitudinal incision commencing at the tubing and passing over the trochanter 
 major; reflect the cellulo-cutaneous cuff to the level of the trochanter minor; 
 by a circular sweep of the knife divide all the muscles at the same level (Fig. 
 492) ; remove the soft tissues from the bone for about four inches downward so 
 as to reach the vessels ; do not saw off the bone, but keep the entire limb for use 
 as a lever in dislodging the head of the bone ; secure all visible vessels ; loosen 
 the rubber tourniquet and tie all bleeding points; divide all the muscular 
 attachments of the upper portion of the femur, always keeping close to the 
 bone ; expose the capsular ligament and divide it in its circumference. Forci- 
 74 
 
117>) 
 
 J.V AMJ:JiJ(A.\ TKXT-llOOK OF SL lidKUY 
 
 blc ek'Viitiuii, abdiic-tion, and adduction of the tlii^di ])ermit tlic entrance of air 
 into the socket and at tlie same time rupture the liffamentum teres, and the 
 disarticulation is thus easily and rapidly efl'ectiMl. Secure any vessels cut by 
 the last incisions, and coaptate the flaps vertically. To obviate the danger of 
 infection from urine and feces, especially in women, place the drain well 
 externally and seal the inner end of the Avound with gauze or cotton and iodo- 
 form collodion. 
 
 Antero-posterior Flap Operations. — Liston's Operation. — With a 
 ten- or twelve-inch blade transli.x by eiitciing the jioinl niid\say l)el\\een the ante- 
 rior superior iliac spinous process and the trochanter major ; graze the front of 
 
 the joint, emerging in front of 
 I'K'- ^''^- the tuber ischii, carefully avoid 
 
 wounding the genitals or o))po- 
 site thigh, and i-apidly cut an 
 oval flaj) al)out five inches long 
 (Fig. 498); let an assistant re- 
 flect this ; open the capsule with 
 the limb strongly rotated out- 
 ward ; cut the ligamentum teres ; 
 slip the knife behind the hea<l 
 of the femur, dividing the rest 
 of the capsule ; have the femur 
 rotated somewhat inward, and, 
 cutting obli(|uely downward and 
 backward, form a posterior flap 
 ('(jualling in length the anterior 
 one; as each flaj) is cut an as- 
 sistant should sei/.e it and com- 
 press the whole surface with a 
 folded towel to control hemor- 
 rhage. The femoral, the pro- 
 funda, the comes nervi ischiad- 
 ici, with the gluteal and sciatic 
 and numerous l)ranches. includ- 
 ing some of those of the obtu- 
 rator artery, will require liga- 
 ture. 
 
 Guthrie's Method. — With 
 a four-inch blade cut a semi- 
 lunar posterior flap, commencing 
 a little above the trochanter 
 major, and passing in a curve 
 doAvnward across the back of 
 the limb to a point just in front 
 of the tuberosity of the ischium: map out a similar anterior flaf) ; divide the 
 jtosterior muscles and then the anterior obliquely from l)elow u])ward until 
 the joint is reached; then disarticulate. 
 
 Lateral Flap Method. — Larrey's Operation. — This will be described, 
 not because superior to the others, but because the injury or tumor for which 
 operation is recjuired may necessitate lateral flaps. Expose and tie the common 
 femoral vessels just l)eneath TV)U])art's ligament; transfix Avith a knife entered 
 in the incision perpendicularly between the muscles inserted into the trochanter 
 minor and the contiguous under suriace of the femur, and cut a short internal 
 
 Macewen's Method for Compression of the Abdominal 
 Aorta (original). 
 
AMPl'TATIOAS. 1171 
 
 Hup by directing the knife oblicjuely downwind :ind inward, whieli should be 
 retiected by an assistant ; Ireely incise the capsule as the femur is forcibly 
 abducted: divide the lignientuni teres: slip the knife between the head of the 
 femur and the acetabulum and cut a postero-external rounded lla]» by an incis- 
 ion directed downward and backward; ])ressure with a towel and the hand 
 must control bleeding until catch forceps can be applied to the bleedinji; jtoints. 
 Hemorrhage in Hip-joint Amputations. — As the chief immediate 
 danger in hip-joint amputation is that of hemorrhage, it is important to under- 
 stand hoAV to apply the abdominal tourniquet unless Wyeth's method be 
 emi)loyed. As this is one of the most efficient means, so it is also attended 
 with some danger if applied with too much force. The bowels nmst be well 
 emptied by a cathartic and an enema, and got out of the way by gently rolling 
 the patient upon the right side before applying the ])ad. 'I'iie ])ad should 
 then be adjusted, with a soft sponge interposed between it and the skin a 
 little to the left of the umbilicus: but as the aorta may be median, it is bet- 
 ter to feel for the pulsation of the vessel r;ither than to rely upon any arbi- 
 trary rule: either I'ancoast s (a large Skev's tourniijuet) or Listers (a large 
 Hoey's clamp) may be used, the pad being screwed down only hard enough 
 to control pulsation in the iliac; and not a moment should be lost in putting 
 catch forceps on every oozing point after ligating the main vessels, so that the 
 tourniquet may be promptly loosened. With a thin patient digital compression 
 of the aorta may be effected, while a firm pincushion secured over the vessel 
 by a few turns of an Esmarch bandage makes a good improvised tourni(juet, 
 the chief objection to this being that it interferes unduly with respiration. 
 An Esmarch bandage applied uj) to the lower limits of the tumor or injury and 
 allowed to remain during the operation is invaluable, because it drives into 
 the circulation, and thus saves, all the blood contained in the limb. Macewen 
 has effectively controlled the abdominal aorta by throwing the weight of the 
 body on the aorta through the closed right hand (Fig. 494) placed a little to 
 the left of the middle line, the knuckles of the index finger just touching the 
 upper border of the umbilicus. With the left hand the arrest of the blood- 
 current is ascertained by feeling the femoral at the brim of the pelvis. Only 
 enough weight to arrest the femoral pulse is required. If the patient vomits 
 or coughs, the pressure must be increased, lest the hand be lifted from the 
 aorta by the abdominal muscles. 
 
 ARTIFICIAL LIMBS. 
 
 As it is not possible for all patients who lose limbs to obtain artificial ones, 
 many of the methods of amputating described will still be practised : but Avhile 
 it is true that owing to the inefficiency of prothetic apparatus for the upper 
 extremity all that can possibly be saved should be here conserved, in the 
 lower limb an amputation at the junction of the middle and lower thirds of 
 the thigh, or one at the same point of the leg, renders artificial progression far 
 easier than is possible after knee- or ankle-joint amputations or partial ampu- 
 tations of the foot, and should always be adopted if possible. 
 
 The attempt to supply lost portions of limbs dates back to about the begin- 
 ning of the sixteenth century, and the present ''box-" or "peg-leg " is essen- 
 tially that described by Ambroise Pare. 
 
 Artificial Arms. — The simplest form of apparatus for amputations beloiv 
 the shoulder consists of a leather socket accurately fitting and ensheathing the 
 stump for several inches, secured to the part and to the body by proper straps ; 
 by means of light internal and external steel rods jointed at the elboAV, and a 
 
117J j.v AMKL'ic.w ri:xr-ii<j<jK or sf/,'(;/:/n: 
 
 coiicf.ileJ CD^ijred wheel ami ratcjitt manij)ulate«l b>- the other hand, movenieiit 
 with fixation at any desired angle can be obtained ; at a point corresponding 
 to the wrist is secured a wooden block with central iron socket, into which a 
 knife, fork, show-hand, or iron hook can be screwed. With the latter a man 
 can use the spade, drive. an<l indeed make a living by light manual labor. 
 
 A similar a})paratus with the socket fitting what remains of the forearm, 
 and secured by a broad laced band or straps above the elbow, serves an e.xcel- 
 li.*nt purpose for umjmtation below the elbow. When a cheaper arm for ampu- 
 tation above the elbow is desired, and flexion at the joint can be dispensed 
 with, a raw-hide moulded apparatus, curved according to Biggs's suggestion, 
 and stiffened by two lateral steel bands, fitted of course with the same terminal 
 wooden block and screw socket, both looks well and enables the patient to work 
 with consideraldc ease. 
 
 Many pages could be devoted to the consideration of the more complex 
 artificial limbs, but the attempt will be made here only to describe a few typi- 
 cal ajiparatns. while those desiring more explicit information in the English 
 language are referred to special treatises on this subject. 
 
 The power by which the anificial member is moved, if the amputation be 
 above the elbow, is often communicated by cords passing from the other arm, 
 but by Graefe s plan, which is employed in a modified way to-day, spontaneous 
 movement is effected by springs or catgut strings secured to a corset embracing 
 the shoulder and thorax, by the action of the shoulder and trunk muscles, un- 
 aided by the other hand, even in amputations of the arm proper. Where the 
 thumb remains, but tlie rest of the hand down to the metacarpus has been 
 removed, the best results are to be obtained by an artificial hand with 
 immovable, partly-flexed fingers secured by a moulded leather socket fitting 
 over the carpus and secured to the forearm. 
 
 For amputation through the forearm the following apparatus of Van Peter- 
 son, although old. is one of the best : A sheath of light wood enclosing the 
 stump is secured to the arm by two padded leather bands connected by vertical 
 straps ; the hand, movable at the wrist in flexion and extension, has the fin- 
 gers kept constantly flexed, with the thumb apposed to the tip of the fore- 
 finger by springs; from the encircling band just above the elbow is a strap 
 connected with a cord passing around a concealed pulley near the wrist, so that 
 when the arm is extended to seize an object the fingers are also extended, 
 while when the forearm is flexed to bring the object forward, the fingers close 
 by virtue of springs, grasping the object. The efficiency of this apparatus is 
 in proportion to the length and strength of the forearm stump 
 
 The loss of the arm at or above the elbow is also best remedied by Van 
 Peterson's adaptation of Graefe's ideas. This apparatus consists of an articu- 
 lated arm. forearm, carpus, and phalanges, the stump being received into a 
 socket which is secured to the shoulder and chest by a *' corset of that sort 
 which readily transmits to the artificial arm all the movements which are 
 made by the stump if he brings it forward, backward, upward, or downward." 
 Three catgut cords are fastened to the corset — one back of the sound shoulder, 
 one beneath the armpit on the side of amputation, and one near the shoulder 
 of the same side. These are so disposed that when the stump is drawn forward 
 the traction flexes the forearm : when it is carried back, the forearm is extended 
 and carried away from the body, in which position the fingers — held flexed by 
 springs — are opened. To seize anything, the patient need only carry the 
 hand thus opened to the object, and gently draw the stump toward the body, 
 when the springs will close the fingers upon, say a cup, which can now be car- 
 ried to the mouth by bringing the stump forward, this motion flexing the fore- 
 
AMi'i lA rioxs. 117;> 
 
 nnii iiiul l)nn_iring the liand to its (k'stination. The anus of Charrierc. Mathieu, 
 aiui InH'hard art^far inferior in usi-fiilness to that of Van Peterson. 
 
 Artificial Leus. — For jtavtial (imjnitntiaus of flu- foot a nietallic sole, 
 somewhat elastic at its fore part, with a raised niariiin around tlie In-el, should 
 be secured to two light lateral steel splints extending to just below the knee, 
 jointed opposite the ankle, and held in proper relation with one another and 
 the leg by two transverse padded seuiicircular metallic bands, to which straps 
 are att'iiched in front so as to secure the apparatus to the leg. A hollow wooden 
 or moulded raw-hide foot may be used to fill out the boot in front. 
 
 Bechard's modification of Martins apparatus— for the description of which 
 there is not space — is the best for the average C/iopart ntump. For a Syme 
 or subastragaloid amputation the simplest apparatus is a laced leather boot-leg 
 stiffened by lateral steel supports, with a heel composed of thick cork lined 
 with chamois leather. 
 
 For amputations beloiv the knee the peg or bucket leg employed since the 
 time of Pare may be used, consisting of a stout wooden peg with an expanded 
 lower extremity, "^attached by the other end to a socket composed of a conical 
 piece of lisht wood, with two lateral splints embracing the thigh, the inner of 
 which should extend onlv to the middle of the thigh, while the external reaches 
 to the iliac crest and is fastened around the pelvis by a padded belt: a strap 
 passed around the lower part of the thigh holds the inner short splint to the 
 outer. The front of the flexed knee rests upon a cushion between the two 
 
 splints. ■ • 7 
 
 When selecting a more elaborate apparatus certain general principles must 
 be kept in mind— viz. no pressure must be made on the end of the stump; the 
 points of support must be the thigh, the circumference of the leg, the inferior 
 border of the patella, the tuberosities of the tibia, and the tuberosity of the 
 ischium, one or all, according to the point at which the limb has been removed 
 or as the special requirements of the case demand ; moreover, where an arti- 
 ficial knee-joint is required the center of motion must be behind the long axis 
 of the lower extremity, and it is essential that the foot shall be capable of ever- 
 sion and inversion as\vell as of flexion and extension, so that the whole surface 
 of the bottom of the foot can rest upon the ground whatever may be the direction 
 of the artificial limb. Probably the best leg is that of Bly of Rochester, con- 
 sisting of a nroper socket and bearings with the center of movement of the knee- 
 joint "posterior to the axis of the limb, a foot with a metatarso-phalangeal joint, 
 and a tibio-tarsal articulation formed by a glass ball enclosed in a vulcanized 
 rubber sac, with four adjustable rubber muscles, which enable all the normal 
 movements of the foot to take place, while the eccentric position of the knee- 
 joint does away with the necessity of any thigh extensor when the limb has 
 been removed above the knee. The artificial limb of Myops may perhaps 
 serve a better purpose when the amputation has been made just above the 
 tibio-tarsal articulation, being constructed on the same principles as that of 
 Bly, but employing spiral springs instead of compressed rubber for muscles. 
 Marks's rubber^foot, constructed of a light piece of wood imbedded in a mass 
 of rubber of the shape of the foot, is immovably connected with the leg, but 
 the rubber, by virtue of its elasticity, is said to accommodate itself to all sur- 
 faces, thus compensating for the absence of the movements of the tibio-tarsal 
 joint. . 
 
 After amputations at the knee-joint, both in the peg leg and in the more 
 elaborate substitutes, the end of the stump— as in Hudson's limb— must rest 
 upon the distal extremity of the thigh armor. This in Hudson's apparatus 
 consists of a concavo-convex posterior splint laced on the thigh, with a lower 
 
1171 .l.V AMIJncAX TEXT-naoK OF SUHGKRY. 
 
 extreraity modelled so as to represent the femoral condyles, which- is secured 
 hv proper bolts and joints to a metal surface on the le<; section resemblinjr the 
 articular surfaces of the licad of the tibia. Artificial ligaments and muscles 
 favor the natural knee movements. 
 
 Sufficient has been already incidentally said about artififial limbs for //////// 
 amputations, except that the support ought to be taken from the tuberosity of 
 the ischium, the gluteal region, and the pelvis, and not through the medium of 
 the thigh armor, which will sooner or later create trouble with the stump. 
 
 Prothetic a|ij>aratuses for hip-joint amputations are so rarely required, and 
 are in general so unsatisfactory, that only a few words need be devoted to the 
 general principles involved in their construction, the student being referred for 
 further details to Watson on Amputations and tlieir Complications. (Acknow- 
 ledgment is here made to this source for many of the foregoing facts.) 
 
 Pelvic armor, moulded to the gluteal and iliac regions on the side of ampu- 
 tation and on as much of the opposite side of the pelvis as can be utilized, and 
 bearing upon the tuberosity of the ischium, must be firmly secured by circum- 
 pelvic strajis supported by suspenders: the artificial hip- and knee-joints can 
 flex only in the sitting position, this movement being permitted by the with- 
 drawal of bolts which are movable at will by means of a strap. The usual 
 means of progression is by undulatory movement of the body, projecting the 
 limb by a swing similar to that employed by the hemiplegic, although a strap 
 passing from the foot, secured over the front of the knee and obliquely encir- 
 cling the shoulder of the sound side and thorax, may be employed to impart 
 additional movement to the limb by the action of the opposite shoulder mus- 
 cles : it hardly again needs mention that during progression the artificial knee- 
 and hip-joints must be rigid ; a cane or even a crutch is usually needed. 
 
MINOR SrRGERY. 1175 
 
 CHAPTER VII. 
 
 MINOR SURGERY. 
 I.— SURGICAL DRESSINGS. 
 
 Any surgical wound-dressing should be absorbent, to admit of the ready 
 impregnation^^ ith medicinal substances and to absorb discharges. The sub- 
 stances in most common use are absorbent cotton, gauze, lint, tow, oakum, 
 jute, wood-wool, moss, peat, and })ine sawdust. 
 
 Lint, in the form of "patent lint," is well adapted for wet dressings and for 
 spread cerates; domestic lint is prepared from old linen, boiled in a weak alkaline 
 solution, freed from this bv washing, dried, and scraped on one side with a knife ; 
 this latter i)rocedurc may be dispensed with . Paper lint is moderately absorbent, 
 and can be used with fair satisfaction for the apidication of wet dressings over 
 unbroken surfaces. Absorbent gauze is ordinary cheese-cloth from which all 
 rrreasy material has been removed by boiling in a weak alkaline solution (r^ g. 
 washing soda or soft soap), thoroughly rinsing out in pure water, and <lrymg. 
 It can readily be impregnated with any medicinal agent, and freely absorbs dis- 
 charcre^ Tow, unless rendered aseptic, should only be used outside other dress- 
 ings as an absorbent or to pad splints; the same remark is applicable to oakum, 
 jute and the substance now to be considered. Absorbent cotton, made by a 
 process similar to that for preparing gauze, is an exceedingly useful material, 
 readily rendered antiseptic by impregnating it with antiseptics in solution or m 
 fine powder ; it can also be used for wet dressings. 3Ioss, long-fibred such as 
 abounds in the far South, cleansed and baked, is an excellent outside dressing, 
 as is wood-ivool, peat, or ;;me? saivdust sewn up in bags of proper size, feo tar 
 as possible, all these substances, even when made antiseptic by germicidal 
 drugs, should be previously rendered aseptic by proper heating. 
 
 Practically speaking, gauze rendered sterile by steam in the modern 
 pressure sterilizer, the antiseptic gauze prepared with corrosive sublimate 
 or carbolic acid, the sterile or medicated cotton, and the sublimated wood- 
 wool, prepared in sheets, are the dressings chiefly used in this country. 
 
 For various mechanical purposes surgical dressings are used m the form of 
 compresses, firm masses of different sizes and shapes, oblong, square, cylindri- 
 cal graduated, etc., made by folding up lint or muslin. Graduated compresses 
 ma'y1)e either pyramidal or wedge-shaped, and are formed by superimposing one 
 upon another, in proper relation, a series of square or oblong compresses of 
 aradually diminishing size. A square of lint or muslin cut from the angles 
 Toward its center forms a Maltese cross well adapted for snugly applying a 
 dressing over a projection, as a stump. Pledgets are compresses formed of 
 cotton,%ow, oakum, etc., in which the fibers are pulled longitudinally until 
 most are parallel, the ends folded and tucked in, and then formed by pressure 
 of the hands into various shapes : they are used externally to other dressings to 
 absorb discharges or to exert compression. Tents are small cylinders or cones 
 made by rolling strips of gauze or lint or by twisting masses of oakum into 
 the required shape : they are occasionally used to keep wounds open to per- 
 mit serum or pus to escape. If wet dressings are employed, especially where 
 warmth is desired, some covering impervious to heat and moisture must be 
 used, such as " rubber dam," oiled silk, paper passed through melted wax or 
 paraffin, or even stout paper thoroughly greased. 
 
llTfJ AN AMERICAN TEX I- HOOK OF SL'IKiFJiY. 
 
 11. HANDAiiKS. 
 
 RoLLKH Bandaoks (Platos XXXIV to XXXVII) consist of strips of 
 muslin, preferably unbleaclied or gauze, varying from one inch to four inches 
 in width and from one to twelve yards in length, which are rolle(l up 
 from one end so as to form cylindrical masses or '' single-headed " rollers, 
 or are rolled from both ends, constituting " double-headed " rollers. 
 Bandages are rolled either by the hand or with some kind of bandage- 
 roller. To roll by hand, fold one end for two or three inches sev- 
 eral times upon itself, then, forming this portion into a small mass, 
 roll the bandage up upon the thigh until a small cvlinder is formed. Next 
 seize this between the thumb and forefinger of the left hand, the unrolled 
 portion firmly held between the extended right forefinger and thumb, keeping 
 up moderate traction so as to tighten the cylinder, which is formed by first 
 supinating the left hand, then, loosening the grip, pronating the same hand to 
 gain a fresh hold, so that by supinating again the cylinder will be rolled around 
 its long axis from right to left: this rotation is kept up by a series of move- 
 ments of supination and ))ronation, the remaining fingers of the left hand aid- 
 ing in the revolution of the cylinder, while the extended right forefinger and 
 thumb revolve partly around the cylinder. A single-headed roller consists of 
 an initial or free end, a terminal one — i. e. that in the center of the roll — and 
 a body, the portion between the two extremities. In applying a single-headed 
 roller hold it between the thumb and fingers of one hand, pressing it firmly 
 into the palm by the fingers, and always place the external surface of the free 
 end on the part to be bandaged, to prevent its sudden unrolling: retain it there 
 by pressure of the fingers of the other hand until it can be fixed by one or two 
 circular turns. All bandages must lie smoothly and flat, each edge exercis- 
 ing the same pressure ; otherwise excoriation of the skin or interference with 
 the circulation may result. The tui-ns of a roller applied to a cylindrical 
 part may pass in a circular manner, each turn exactly covering the ]»receding 
 ones [circular bandage). 
 
 If the part be covered by causing the turns to ascend moi-e or less rapidly 
 in a spiral manner, each turn overlapping the preceding one about one-third, the 
 result is a s/}ir(fl handai/c. In most limbs the attempt to cover with a spiral will 
 result in only one edge of the bandage being in contact with the part, the other 
 standing freely off. To obviate this, adopt the following mananiver : hold the 
 spiral turn just made with the fingers of the left hand on the upper surface 
 of the limb, then with the roller held in the supinated right hand, four to eight 
 inches being unwound so as to form a dependent loop, pronate the hand ; carry 
 the bandage loosely beneath the limb until the opposite side is reached, when by 
 gentle, gradual traction the reversed turn will snugly apply itself to the part: 
 this is called a "reversed turn" or "making a reverse," and, combined with 
 the spiral turns, "a spiral reversed handafje.'' The secret of success is to 
 make the loop of bandage turn over without the slightest traction, this being 
 made only when the opposite side of the limb is reached. 
 
 When a projecting point is to be covered — the elbow, for instance — a series 
 of figure-of-8 turns, applied alternately above and below, will best secure this 
 end, each overlapping its neighboring turn by one-third of its width. Such 
 regions as the groin, axilla, shoulder, and breast can be best covered by what 
 are essentially figure-of-8 turns, each succeeding one ascending from below 
 upward, overlapping by one-third, foi'ming a figure like " the leaves of an ear 
 of corn," one member of the figure-of-8 encircling the thigh, for instance, the 
 next the pelvis, the next the thigh and groin, and so on : this bandage i-s 
 called a spica. 
 
BANDAGES. 
 
 Plate XXXIV. 
 
 
 Fig. 1.— Spiral reversed of tlie npi>er extremity. 
 
 Fio.2.— The gauntlet. 
 
 Fig. 3. — Spica of the thumb. 
 
 -.Spiral reversed of the lower ex- 
 tremity. 
 
 Fig. 4.— The demi-gauntlet. 
 
 Fig. 6. — Method of covering the heel. 
 
MINOR srnaiinv. 1177 
 
 T>an(la<xos placed on the cxtreiiiitics sliould he ui)])lied more h)0.sely as they 
 advance (■n)ni heh>\v upward, especially if the lind) he flexed, in order not to 
 interfere with the circulation. Until experience teaches the surj^eon how 
 firmly turns of a handa«^e can witii safety he drawn, they should l)e ai)plicd 
 loosely rather than tightly. When used to retain dressin<,'s or splints, a num- 
 ber of moderately firm turns, passing and repassing over one another, will 
 secure better fixation than a single layer drawn dangerously tight. All firmly- 
 applied dressings of the extremities should leave the fingers and toes exposed : 
 the patients should be seen within a few iiours, when, if the jiarts do not feel 
 easy, or if a duskiness of the exposed portions is seen, or nundjness of the fingers 
 or toes is complained of, the dressings should be loosened. If a pin secures 
 the end of a bandage, it should be introduced point downward. In bandaging 
 the arm to the chest, etc. a pad must be interposed to prevent chafing. Skin 
 must never be in contact with skin. 
 
 The special methods of applying certain bandages will now be given in 
 detail, by modifications of which any form of di-essing may be devised. 
 
 Spiral Reversed Bandage of the Upper Extremity. — AVitli the initial 
 end of a roller eight yards long, take two circular turns around the Avrist ; pas& 
 thence obliquely across the back of the hand to the extremities of the fingers ; 
 ascend the hand by three or more spiral turns to the metacarpo-phalangeal 
 joint of the thumb; cover this and the wrist by figure-of-8 turns, and ascend 
 the forearm by spiral turns, adding reverses when requisite until the elbow is 
 reached, Avhen, if the joint is to be flexed, it must be covered in Avith figure-of- 
 8 turns, after which continue the spiral or spiral reversed turns up the arm 
 (Plate XXXIV, Fig. 1). 
 
 Spiral of the Fingers. — By two circular turns around the wrist fix the 
 initial end of a roller one inch wide and one and a half yards long ; pass 
 obliquely across the back of the hand to the root of the finger ; descend to its 
 tip by very oblique turns, whence the bandage must ascend by a series of spiral 
 reverses ; "secure by splitting the bandage for a few inches and tying the ends 
 around the root of the finger, or ascend to the wrist by a spiral turn, terminat- 
 ing by a circular turn. All the fingers may be thus bandaged in succession, 
 the hand finally being covered in bv a series of figure-of-8 turns, forming the 
 gauntlet (Plate'XXXIV, Fig. 2). 
 
 The Spica of the Thumb is started by a circular turn around the wrist, 
 and a second turn follows to hold the first in position. It then sweeps across 
 the back of the hand and the back of the metacarpo-phalangeal articulation 
 under the middle phalangeal joint to the upper surface of the last phalanx of 
 the thumb : several ascending spiral turns are now made, and the ball of the 
 thumb is then covered by a series of ascending figure-of-8 turns. The spica 
 of the thumb is used to retain splints and dressings or to arrest hemorrhage by 
 pressure (Plate XXXIV, Fig. 3). 
 
 The Demi-gauntlet has but a limited field of usefulness, and, as it leaves 
 the fingers free, it must not be tightly applied. It is used to retain dressings 
 on either the dorsum or palm. If we desire particularly to cover the palm, 
 that portion of the hand is turned up, or if the dorsum, that part is made 
 superior. Take two circular turns around the wrist ; sweep to the root of 
 either the thumb or little finger ; pass it around the base of the extremity 
 and return to the wrist, and so progressively bandage each finger, and finally 
 run a series of ascending figure-of-8 turns, including the hand and wrist, 
 from the roots of the fingers (Plate XXXIV, Fig. 4). 
 
 Spiral Reversed Bandage of the Lower Extremity. — With the tip 
 of the patient's heel on the surgeon's knee or properly supported by an assist- 
 
117S j.v AMEiiirAX TKXT-iinoK OF srinnim'. 
 
 .int. Hx the initial extremity of a roller seven yards Ion;,' and two and a lialf or 
 three inches wide by circular turns just above the malleoli ; descend obliijuely 
 over the dorsum, under the sole, and back to the dorsum of the foot, up which 
 the bandage must pass by several spiral turns, covering in the instep : when| 
 this is reached, pass the bandage under the point of the heel, thence to thej 
 dorsum, then down beneath the sole, then along the outer surface of the heel, 
 next around the heel above its point to reach the instep, whence, passing to 
 the sole, a turn is made around and above the point of the heel on the inner 
 side, again to pass to the instep, when the roller must be carried by spiral and 
 reversed turns up to the knee. There it is finished off by a few circular turns. 
 If it is desired to extend the dressing above the knee, this must be covered by 
 figure-of-8 turns of a second roller, and the thigh ascended by spiral and 
 reversed turns. When the heel does not require covering, the turns beneath 
 and around the point of the heel must be omitted (Plate XXXIV, Fig. 5). 
 
 The method of covering the heel is shown in Plate XXXIV, Fig. 6. 
 
 The Spica of the Instep starts by a circular turn around the ankle, fol- 
 lowed by a second turn to hold the first ; the roller now sweeps across the 
 instep to the root of the toes under the sole of the foot, and ascends for a dis- 
 tance by several spiral or spiral reversed turns. From the instep a turn is made 
 across the point of the heel, another somewhat higher and another somewhat 
 lower to catch the free edge, and the bandage is ascended by figure-of-8 turns 
 around the ankle and instep (Plate XXXV, Fig. 1). 
 
 The Crossed or Figure-of-8 of One or Both Eyes. — Place the initial 
 extremity of a two-inch roller five yards long on one temple ; make two circu- 
 lar turns around the forehead and occiput from right to left for the right eye; 
 I'eaching the occiput, pass from under the right ear up over the right eye, across 
 the opposite temple, down to the occiput ; then, repeating two or more of these 
 oblique turns, finish off with a circular turn around the forehead. If both 
 eyes are to be covered, proceed as before until the third oblique turn over the 
 right eye has reached the left parietal protuberance, when, instead of descend- 
 ing to the nape of the neck, pass around the forehead, down over the root of 
 the nose, the left eye, left cheek, under the same ear to the nape of the neck, 
 thence to the right parietal protuberance, down again over the left eye, and, 
 making two more similar turns, finish off with a few circular turns around the 
 forehead (Plate XXXV, Fig. 2). 
 
 Barton's Bandage, or Figure-of-8, of the Jaw. — Place the initial 
 extremity of a roller two inches wide and five yards long on the nape of the 
 neck just beneath the inion ; pass over the right parietal bone to the vertex, 
 down over the left temple to the chin, beneath this up the right side of the 
 face and right temple to the vertex, down over the left parietal bone to the 
 starting-point at the nape of the neck, thence around the right side of and 
 along the jaw to the chin, across the front of which the bandage must pass 
 back to the nape of the neck : a repetition of these turns, with pins at their 
 points of intersection, completes the dressing (Plate XXXV, Fig. 3). 
 
 The Gibson Bandage starts with three vertical turns around the head and 
 jaw and in front of the ears. Just above the level of the ear, after the three 
 vertical turns have been made, the bandage is reversed and carried three times 
 horizontally around the head and forehead. As the bandage reaches the occi- 
 put after completing the third horizontal turn, it drops to the base of the skull, 
 and is run forward below the ear and around the chin back to the opposite side 
 of the head and neck to the starting-point. Three of these neck-and-jaw 
 turns are made. On completing the third turn the bandage is reversed and 
 carried from the occiput to the forehead over the vertex, and fastened with a 
 
BANDAGES. 
 
 Plate XXXV. 
 
 Fig. 1.— Spica of the instep. 
 
 ^^ ^.^^_^^^^^ 
 
 ^^^A ^-^Ski ^^H 
 
 
 
 Flu. 2.— Cruh.Mjd ur lif,'urc ul-s ul buUi eyes. 
 
 Fk;. ;;. — Barton's bandage, or ngure-of-8 
 of the jaw. 
 
 Fig. 4. — Gibson's bandage. 
 
 Fig. 5.— Oblique or crossed bandage of the 
 angle of the jaw. 
 
 Fig. 6.— Spica of the groin. 
 
MIXO n s r/.v ,' /.;/.' > '. J I 7 «) 
 
 ])iii. Pins are now introdiiccd at |»i»ints where the turns cross each other. 
 This bandaj^e is used in fracture or dislocation of the jaw (IMate XXXV, 
 Fig. 4). 
 
 The Oi$i-iQUE or Cuosskd Handacjk ok tjik Anclk of tiik Jaw is started 
 by a circuhir around tlie forehead, and a second turn to hold the first, running 
 toward the affected si<le. After the completion of the second turn the bandage 
 is carried around the head to the base of the skull, passes forward to tlie opposite 
 side, and is carried under the ear and Tinder the jaw to the front of the ear of 
 the injured side. A series of advancing turns are now^ made, in front of the 
 ear of the injured side and back of the ear of the sound side, until the parts 
 are sufficiently covered. The bandage is ended by carrying the last turn under 
 the ear of the injured side to below the occiput on the opposite side, and then 
 by a circular around the forehead and occiput (Plate XXXV, Fig. 5). 
 
 This bandage is used with a compress in fractures of or near the angle of 
 the lower jaw, and for retaining dressings on the chin, side of the face, and 
 vault of the cranium. It is a useful dressing, but is tight and uncomfortable, 
 and it makes so much pressure on the throat as to be rather unsafe for young 
 children or to apply to a person not entirely recovered from an anesthetic. 
 
 The Spica of the Groin or Figure-of-8 of the Pelvis and Thigh. — 
 With a three-inch roller ten yards long make two circular turns around the 
 pelvis, passing from right to left, and from before backward if for the right 
 groin, and the reverse if for the left. Reaching the front of the right groin, 
 pass over the inner side of the thigh, beneath and around it to reach the groin, 
 whence the bandage, crossing the first turn, ascends to the ilium of the oppo- 
 site side; beneath the back around the pelvis to the right groin as before, each 
 turn ascending the thigh and covering one-third of the previous one until by 
 their repetition the roller is exhausted. With a longer bandage by passing 
 every other turn around the opposite instead of the same thigh a spica of both 
 groins may be applied (Plate XXXV, Fig. 6). 
 
 Spica of the Shoulder. — Start a two-and-a-half-inch roller by one or 
 two spiral reversed turns around the upper arm, then pass up from behind over 
 the shoulder, over the front of the chest, beneath the opposite axilla, across 
 the back, over to the front of the arm, around which it must w ind to pass from 
 over the back of the shoulder to the front of the chest, the successive turns 
 advancing from below upward (Plate XXXVI, Fig. 1). 
 
 Figure-of-8 Bandages of both Shoulders (Plate XXXVI, Fig. 2), of 
 one or both Breasts (Plate XXXVI, Fig. 3), of the Neck and Axilla (Plate 
 XXXVI, Fig. 4), of the Ankle (Plate XXXVI, Fig. 5), or of the Elbow 
 (Plate XXXVI, Fig. (3), convey in their names the method of application, the 
 only advice requisite being to fix the initial end by circular turns around the 
 arm, leg or chest. 
 
 Velpeau's Bandage. — Place the palm of the hand of the injured arm on 
 the shoulder of the sound side, with padding between the arm and the chests 
 wall to prevent chafing ; place the initial extremity of a two-and-a-half-inch 
 roller ten yards loiig under the axilla of the sound side, pass up over the back, 
 over the clavicle, down the front and outside of the arm, under the outside of 
 the elbow, up over the chest to the sound axilla; repeat the first turn, but on 
 reaching the sound axilla the second time, pass around the chest and over the 
 injured arm to the same axilla, then make a turn over the clavicle and arm, 
 then a circular, the turns (tseendiiKj spica-Avise : pin the points of intersection 
 of the turns (Plate XXXVII, Fig! 1). 
 
 The Desault Bandage consists of three rollers, a pad, and a sling. The 
 first roller is to be applied while the arm of the injured side is extended at 
 
IISO .l.V AMKUK'Ay TEXr-IlOOK OF SJlidKIlY. 
 
 right angles to the body. A wodgc-sliaped pad with the base up is inserted 
 into the axilla, and this first bandage holds the pad. It is applied by ascend- 
 ing spiral turns around the chest, and is listened by carrying the roller obliquely 
 across the front of the chest, over the sound shoulder, under the a.xilla. over 
 the shoulder across the back to the pad. obli(juely over the lower portion of the 
 chest to opposite the lower portion f»f the pad. and then ascending spiral turns 
 are made to a level with the top of the jnid (Plate XXXA^II, Fig. '!). 
 
 The arm is now brought to the side over the pad. This pad is the fulcrum, 
 the arm is the lever, and the second roller of Desault is the force to correct the 
 inwanl displacement of the fracture of the clavicle. The second roller of 
 Desault holds the arm to the side by a series of ascending spiral turns, includ- 
 ing the arm and chest, starting just above the elbow and terminating just 
 below the shoulder of the injured side (Plate XXXVII. Fig. 8). 
 
 The third roller corrects the downward and forward displacement from a 
 fractured clavicle. It starts in the axilla of the sound side anteriorly, runs to 
 the top of the shoulder of the injured side, down the back of the arm to the 
 elbow, and from this to the point of origin. The roller is now carrie<l backward 
 under the axilla of the sound side, runs across the back to the shoulder of the 
 injured side, down the front of the arm to the elbow, and from this point across 
 the back to the point of origin. These turns give us two triangles, an anterior 
 and a posterior. Remembering that the third roller of Desault starts in the 
 axilla of the sound side anteriorly, its formula is : from axilla to shoulder, 
 from shoulder to elbow, from elbow to axilla, pass to the back ; and again 
 from axilla to shoulder, from shoulder to elbow, from elbow to axilla (Plate 
 XXXVII. Fig. 4). 
 
 After the application of the third roller the hand is hung in a sling. 
 
 Recurrent B.\ndage of the Head. — Fix the initial extremity of a six- 
 yard roller, two inches wide, by circular turns parallel to the supraorbital ridge. 
 When the middle of the forehead is reached, reverse, hold the reverse with 
 a finger of the left hand, carry the bandage over the sagittal suture to the 
 occiput, reverse here ; let an assistant hold the turn, carry back the roller 
 obliquely to the forehead, reverse, hold, carry back to the occiput, repeating 
 these turns, covering in one-third of each preceding one until the left half of 
 the head is covered from above downward to the circular turns ; then cover 
 in the right side by similar turns, fixing all by circular turns and careful pin- 
 ning (Plate XXXVII. Fig. o). The same bandage can be applied by a double- 
 beaded roller, the body placed over the occiput or forehead, circular turns made, 
 and then the recurrent turns by one head of the roller while the other is con- 
 tinued in a circular manner, fixing each recurrent turn as it is made. 
 
 Recurrent Bandage of Stumps. — This should be applied with a single- 
 headed roller of proper width precisely as for a recurrent of the head, com- 
 mencing by circular turns a few inches above the end of the stump, followed by 
 the recurrent turns covering the stump, and finishing off" bv circular turns 
 (Plate XXXVII. Fig. 6). 
 
 T-Bandages. — These consist of a strip of muslin long enough to encircle 
 the part once or twice, to the middle of which a second shorter strip, or some- 
 times two strips, are secured at a right angle : when one cross-strip is employed, 
 the bandage is called a single T. when two, a double T. 
 
 Double T of the Perineu.m. — Pass the transverse portion around the 
 body just above the iliac crests, with the vertical strips at the mid-point behind : 
 tie or pin ; then bring one vertical strip over the dressings between one thigh 
 and the genitals, and the other between the opposite thigh and the genitals,^ 
 securing both to the transverse portion. A single or a double T-bandage may 
 
BANDAGES. 
 
 Plate XXXVI. 
 
 Fig. 1.— Spica uf ihc sliuuldur. 
 
 Fig. 2.— Posterior flgure-of-8 of both shoulders. 
 
 Fig. 3.— Figure-of-8 of one breast. 
 
 Fig. 4.— Fiffure-of-8 of neck and axilla. 
 
 Fig. 5.— Figure-of-8 of the ankle. 
 
 Fig. 6.— Figure-of-8 of the elbow. 
 
MI.\<>n SURGERY. ll.Sl 
 
 be employed to retain dressings on the head, the transverse portion passing 
 around the eranial vault, the other passed over the dressings, boieath the 
 transverse strip, back again to it, and there pinned : a wide vertical piece, for 
 instance, may be used to cover in an ear. 
 
 Four-tailed Bandage. — This is useful to retain dressings on the chin, 
 etc., and is made of a strip of muslin three to four inches wide, long enough to 
 encircle the part and overlap somewhat ; turn down the middle of each end 
 toward the center. In ajyplying it to the chin, for instance, place the body of 
 the bandage over the point of the chin, pass the anterior or upper pair of tails 
 over the front of the chin, beneath the ears to the nape of the neck, and secure 
 them; then bring the other tails up beneath the chin to the back part of the 
 vertex ; tic or pin. 
 
 Handkekchief Bandages. — These consist of large handkerchiefs or pieces 
 of muslin about three-fourths of a yard square, one of which, folded once, forms 
 an oblong ; its diagonal angles being brought together, a triangle; by folding 
 a triangle from its summit to its base, a cravat is formed ; while a cravat twisted 
 is a cord. It would require many pages to describe all temporary or permanent 
 handkerchief bandages, and but three Avill be explained, premising that in 
 applying all forms the body of a cravat and the base of the triangle correspond 
 to the initial end of a roller bandage. 
 
 Fronto-occipital Triangle. — Place the base on the forehead ; carry the 
 apex over the vertex, letting it drop below the occiput ; bring the lateral angles 
 around the head over the apex of the triangle crossing them at the occiput 
 until they reach the temples or the forehead ; pin or tie : the summit is then 
 to be turned up and pinned behind to the body of the handkerchief. A hand 
 or a stump can be dressed in a similar manner. 
 
 Fronto-occipito-labial Cravat. — Place the body on the forehead, carry 
 the ends to the occiput, and cross them, bringing them forward to each side of 
 the lip and pin, or first pass one end through a slit in the other. 
 
 Figures-of-8, serving a similar purpose to that of Barton's bandage of the 
 jaw, or similar figures of the neck and armpit, the shoulders, the chest, sus- 
 pensories of the breast or of the testicle, can be devised by using more than 
 one triangle or cravat. 
 
 III. Fixed Dressings. — Such substances as glue and zinc oxide, glue 
 and chalk, paraffin, dextrin, and starch have all been employed, but the appli- 
 cation of plaster of Paris and silicate of sodium alone will be described, the 
 former being the one almost universally employed. 
 
 Plaster of Paris. — This must be of good quality (dental plaster is the 
 best), recently calcined, and may be applied in one of two ways : Bandages, 
 pieces of blanket or strips of other materials, are passed through a watery 
 mixture of plaster of the consistency of cream, loosely rolled, and rapidly 
 applied to the part, or the li(iuid plaster may be smeared over a bandage pre- 
 viously applied. Unless employed in the form of one or more thicknesses 
 of old blanket, cut into the shape of the re(|uired splints and soaked in the 
 li(iuid plaster, this method is undesirable. 
 
 Almost universally, some loose texture, as cheese-cloth, cross-barred muslin, 
 mosquito netting, or, preferably, crinoline, is cut into strips of a Avidth proper 
 for the part (two to three inches), and the meshes filled by rubbing in dry plas- 
 ter with the hand as it is loosely rolled up. Wrapped in w^axed paper and kept 
 in a warm, dry place, these rollers will be serviceable for some time, but are best 
 prepared just before using. Various special apparatuses have been devised for 
 preparing and rolling plaster bandages, but the hand will do equally well. 
 
 Mode of Application. — Cover the part with a woollen stocking, a flannel 
 
lisLi A\ AMi:i!i<\\.\ ri:xr-r,()Oh' oi' sri:<;i:i:y. 
 
 roUiT baiida^ic, <n' a knit uiidervest, act'ordiiig to the part, liimicrse a rolk-r 
 emhvi.se in a basin of warm water, and when all air-bubble.s have cca-^ed t<> 
 escape take out, S(jiieeze with the hand, and iipply as any roller bandage, but 
 mori' .sA^'^///, smoothing the turns with the other hand as they are made : three 
 or four thiekne.sses of bandage are usually sutficient. When the first bandage 
 is taken out of the water, put in another. A little drv plaster may })e used 
 to strengthen the dressing, sprinkled over the e.xterior and smootlied down 
 with the wet hands as it sets. A little mucilage, glue, or stale beer will delay 
 setting, while a little table salt or alum will hasten the process, which unas- 
 sisted takes from ten to thirty minutes. Some one of the plaster shears or 
 Hunter's saw is the best instrument for the removal of plaster dressings, but 
 a stout knife — a pruning-knife is the best — will do, while painting a strip 
 of the dressing with dilute hydrochloric acid will soften it so that an ordinary 
 knife or shears will divide it. 
 
 SiLiCATE-OF-SoDA DRESSING. — After protecting the part in the same way 
 as when applying a plaster dressing, bandage the limb loosely (because if un- 
 washed the bandages will shrink, thus constricting the parts) with ordinary 
 wet muslin rollers, painting each layer thickly with the silicate : from four to 
 six layers of bandage will suflice. Ordinary cheese-clotii folded in several 
 thicknesses and soaked in the sodium silicate can be more expeditiously 
 ajiplied. As water softens this material, the dressing is easily removed. The 
 disadvantage of the silicate dressing is that it refjuires many hours to dry 
 thoroughly, and that it becomes softened by discharges or wet dressings. 
 
 IV. Rubefacients. — These are agents which revulse by causing congestion 
 of the skin : a few teaspoonfuls of oil of turpentine sprinkled over a piece of 
 flannel wrung out of hot water, applied to the skin and covered with oiled silk 
 or dry flannel, form the turpentine stupe : twenty minutes is the maximum 
 for this application. Mustard flour (the black being the stronger), mixed 
 "with tepitl water into a paste, spread thinly on a piece of muslin or paper, and 
 covered with jjauze or thin cambric, is an excellent counter-irritant. Few 
 skins will bear pure black mustard for more than ten minutes. Diluted one- 
 half with wheat or corn flour, twenty minutes should be the maximum of appli- 
 cation, because blistering must be {^voided, that produced by mustard being 
 specially painful. After removing a mustard plaster, greased lint should be 
 applied. A mustard fnot-hafJi consists of one or two tablespoonfuls of pure 
 mustard in a bucket two-thirds full of water at 105° F. : the feet may be kept 
 in this for about twenty minutes, a blanket being thrown around the limbs 
 and including the bucket to retain the heat. Revulsives must be used with 
 caution in cases of shock or coma, lest impaired vitality or sensation to pain 
 result in extensive sloughing of the skin. 
 
 V. Vesicants are agents which cause a more permanent congestion of the 
 skin by producing inflammation, terminating in a serous effusion, elevating 
 the cuticle into vesicles or blisters. Rapid vesication can be effected by the 
 strong acjua ammoni?e of the Pharmacopeia, by wetting with it a piece of lint 
 of the desired size and covering with oiled silk ; or by a suitably shaped iron 
 (knife-blade, etc.) heated in boiling water. Spanish flif in the form of can- 
 tharidal cerate or collodion is the vesicant most often used, the cerate being 
 spread thinly on a piece of adhesive plaster, leaving a margin of from one- 
 half to three-fourths of an inch, which will serve to retain the blister in posi- 
 tion. The skin must be well cleansed before its application: six to eight 
 hours will usually suffice to produce incipient vesication, when removal of the 
 blister and the application of a poultice for a few hours will cause the " filling 
 up of the blister." If no further effect is desired, the serum should be drained 
 
BANDAGES. 
 
 Plate XXXVIT. 
 
 Fig. 1.— Velpeau's baiulatje. 
 
 Fig. 2.— Desault's bandage, first roller. 
 
 Fig. 3. — Desault's bandage, second roller. 
 
 Fig. 4.— Desault's bandage, third roller. 
 
 Fig. 5.— Recurrent bandage of the head. 
 
 Fig. 6.— Recurrent bandage of stumps. 
 
MINOR SURGERY. 1183 
 
 oft" by ii puiicturc at tlie most (lc'j>ou(lc'nt point, and an ointnient of oxide <)f 
 zinc be applied : but if a more persistent irritation is requisite, tiie cuticle 
 must be removed and the surface kept covered with some in-itating ointment, 
 as compound resin cerate. Cantharidal collodion, when of good quality, will 
 vesicate if painted on in several layers, but as found in the shops is an uncer- 
 tain remedy. Blisters must be cautiously employed in either the aged or the 
 voung, and especially in those suflfering from any low form of disease. 
 
 VI. The Actual Cautery is used in the form of variously-shaped irons 
 (hatchet-edged, round, or olivary) fitted into wooden handles and heated in a 
 charcoal furnace. As a counter-irritant the iron should be heated only to a dull 
 red heat, and be ((uickly drawn in parallel lines, about one inch apart, over the 
 skin, avoiding all bony" prominences: compresses wet with aseptic cold water 
 or with some antiseptic lotion may then be applied. 
 
 The Paquelin. Thermo-cmitery \^ a convenient form. It consists of hollow 
 platinum cauteries and a handle covered with wood ; a benzole reservoir; a 
 pair of rubber bulbs, like those for a hand-spray apparatus, connected by a 
 tube with the reservoir ; a long rubber tube to connect the cautery handle 
 also with the reservoir ; and a spirit-lamp with attached blowpipe. Screwing 
 on the desired point, the tube from the reservoir is slipped over the handle, the 
 point is heated in the lamp, is removed from the flame, and by compressing the 
 bulbs — previously connected with the reservoir — benzole vapor is -forced into 
 the point, which will heat up, and can be maintained at any temperature by the 
 rapidity with which the bulb is worked : if the point will not heat with the 
 simple "flame, attach the bulbs to the blowpipe on the lamp, and, compressing 
 them, heat the cautery to a bright-red heat, and then connect with the reser- 
 voir and proceed as before directed. 
 
 VII. Bloodletting. — Local depletion is effected by scarification, punc- 
 ture, cupping, and leeching. 
 
 Scarification consists in numerous small, parallel incisions made in the 
 long axis of the limb or part with a sharp-pointed knife, which, depleting the 
 capillaries of such parts as inflamed skin, the tongue, the tonsils, or the con- 
 junctiva, is often beneficial ; the length and depth of the incisions must vary 
 with the part. When employed to relieve tension of skin or fascia, by dis- 
 
 posing them as in the subjoined diagram, the maximum of yield- 
 
 _r-_-^2— ing will be obtained by the minimum of cutting. The flow of 
 -^' blood can be encouraged by warm aseptic fomentations, or. if ex- 
 cessive, packing with aseptic gauze will check the flow. Puncture is -dinodi- 
 fication, as when, for instance, a narrow bistoury is plunged into an inflamed 
 testicle to relieve tension. 
 
 Cupping may be dri/ or wet. Dry Cupping consists in employing an 
 exhausted receiver over the integument, whereby congestion of the included 
 skin is effected and sometimes serum is effused. When cupping-glasses with a 
 suction-pump are employed, the glasses must be firmly held in position and 
 the air exhausted ; but small tumblers or wineglasses will do. In using them, 
 moisten their interiors with a little alcohol or whiskey, light this, and at once 
 apply, holding firmly over the part : as the contained air cools the glass will 
 " suck," owing to contraction of the air. Always remove cups either by open- 
 ing the stopcock or by tilting them while pressing down the skin on one side. 
 
 " Wet Cupping.— Having congested the skin by a dry cup, make parallel 
 incisions with a lancet point, or apply the spring scarificator set to such a 
 depth as only to cut through the true skin ; spring the lancets, set, reapply 
 
1184 ^I^V AMA'Ji'/CAX TEXT-nOOK OF SURGERY. 
 
 at right angles, and spring again, and at once apply a cup : tlio second cutting 
 is not always necessary, and adds to the inevitable scarring. When the cups 
 have ceased to fill remove them, empty, apply, and exliaust again ; when 
 enough blood has been drawn, wash the parts with some mild antiseptic solu- 
 tion and cover with dry aseptic or antiseptic compresses. 
 
 Lekching. — Two varieties of leech are employed: the American, capable 
 of withdrawing one dram of blood, and the European or Swedish, abstract- 
 '\xi(T about half an ounce; but warm fomentations after the animals have 
 dropped off will in both instances increase the amount. Method of Applica- 
 tion, — Select the most vigorous, remove them from the water, in which they 
 should be kept one hour before using, dry in a soft warm cloth, and apply to 
 the part, previously shaved if necessary and thoroughly cleansed with warm 
 water and soap. A few drops of blood placed on the part or smearing it with 
 milk will induce the leeches to take hold. By a cone of paper a single leech 
 can be confined to one part, as the canthus of the eye, while for the cervix 
 uteri a cylindrical speculum must be employed. When a number are used on 
 external parts, they may be confined beneath a tumbler : if only one or two 
 are needed, they can be* taken one at a time between the thumb and forefinger 
 and held to the part until they bite. Such parts as the eyelids or the scrotum 
 should never be leeched, nor should the inflamed area itself, but only the cir- 
 cumjacent tissues. Never pull off a leech, but sprinkle salt on it if slow to 
 drop off: injecting a solution of salt will serve a similar purpose in the vagina. 
 Pressure usually checks all oozing, but if it should fail to do so. touching with 
 a pointed stick of nitrate of silver or with a red-hot knitting needle, or pass- 
 ing a fine cambric needle beneath the wound and throwing a figure-of-8 thread 
 around it. will check the bleeding. The artificial leech may be employed, but 
 is uncertain in action and produces raised, rounded scars. 
 
 Venesection, or Phlebotomy. — All the advantages, with none of the 
 risks, of arteriotomy, or of bleeding from the jugular vein, can be effected by 
 opening a vein in the arm : and this operation alone will be described. Ren- 
 dering the parts and instruments thoroughly aseptic (for septic phlebitis is the 
 only thing to be dreaded after phlebotomy), make a few moderately firm turns 
 of a narrow bandage or of a tape around the middle of the arm ; fi.x the me- 
 dian cephalic vein with the left thumb, and with a lancet or a sharp-pointed 
 bistoury open the vein obliquely to its long axis : few practitioners possess a 
 spring lancet, and if used on the median basilic vein it may wound the sub- 
 jacent brachial artery. If the vein does not become prominent, make the 
 patient firmly grasp a stick or merely close the hand forcibly ; alternate open- 
 ing and closing of the hand will promote the flow after opening the vein. 
 Having obtained the requisite effects as indicated by the pulse, remove the 
 tape, apply a dry aseptic compress, and, securing this by a few figure-of-8 
 turns of bandage around the elbow, place the arm at rest. The more rapidly 
 the blood is abstracted, the less will be required to lower the force of the cir- 
 culation, so that the sitting or standing posture is desirable where marked 
 effects are required and but little blood can be spared. 
 
 A'lII. Artificial Respiration. — Sylvester's, being that most generally 
 applicable, will alone be described : Lay the patient on a level surfjice ; clear 
 the pharynx of all mucus, etc. ; keep the tongue drawn forward by forceps or a 
 suture ; secure it to the lower jaw or let an assistant hold it out; remove all 
 constricting clothing from the chest and abdomen ; support the head and shoul- 
 ders slightly by a folded-up coat. Kneeling or standing behind the patient, 
 grasp the forearms near the fully-flexed elbows ; firmly compress the lower part 
 
MINOR suii<ii:ny. 1185 
 
 of the tlidiMX fur ;i few seconds by pressirif; the patient's elbows against the 
 front of the chest; then sweep the arms outward and upward alongside of the 
 head until the hands touch, pulling firndy upward for a few,.seconds to secure 
 thorough elevation of the thoracic walls {inspiration) ; then bring the arms 
 with flexed elbows down against the sides and lower part of the chest, firmly 
 compressing it as before, thus imitating expiration. l^e[)eat these procedures 
 from twelve to fifteen times a minute until voluntary respiration reconmiences, 
 when the movements must be eontinueil to reinforce the natural effort so long 
 as nature is unequal to assume all the labor. The efforts at resuscitation must 
 not be abandoned for an hour or more, meanwhile employing dry warmth, 
 warm frictions to the surface, and stimulants hypodernuitically, by the rectum, 
 or by the mouth when swallowing becomes possible ; carefully watch for sec- 
 ondary apnea, and promptly resume artificial respiration if it supervenes. 
 Fell's method of forced artificial respiration is described on page 1096. 
 
 IX. Transfusion and Hypodermoclysis with Normal Salt Solu- 
 tion. — Mikulicz has shown that in profuse hemorrhages the collapse is due 
 to the diminution of the arteria! pressure, and that if a solution is injected 
 into the body, which is of the same chemical composition as the serum of the 
 
 7k;. 495. 
 
 Or 
 
 Collin's Transfusion Apparatus. 
 
 blood, the solution will raise arterial pressure. The saline solution which is 
 used is as follows : 
 
 Sodii chloridi, 1 dram ; 
 
 Sodii bicarb., 15 grs. ; 
 
 Aquaj destill., 2 pints. 
 
 Calcium chloride, grm. 0.25 (grains 4) ; 
 
 Potassium chloride, grm. 0.1 (grains 1^); 
 
 Sodium chloride, grm. 9.0 (grains 135) ; 
 
 Sterilized water, 1000 c.cm. (1 quart). 
 
 Or in an emergency 1 dram of common salt to a pint of sterilized water. 
 
 This solution can be injected subcutaneously into the cellular tissue of 
 the body, notably over the abdomen, under the breasts, or in the axillae (hypo- 
 dermoclysis), with a carefully-disinfected funnel and five or six feet of rub- 
 ber tubing, or a similarly disinfected fountain syringe and a needle of large 
 75 
 
1186 
 
 .-l.V AMKRlCAy TEXT- HOOK OF S {/.'(; KJi' y 
 
 size or an aspirator needle. A pint or more lias been introduce*!. The skin 
 is to be rubbed constantly to help the diffusion of the solution. 
 
 For tmnfffufiio)!. the apparatus of Collin (Fi<j:. 4'.t5). or a most carefully 
 disinfected syringe or funnel connected with a hypodermatic needle by dis- 
 infected rubber tubing, may be used. After preparing the parts as for any 
 other operation, a vein at the bend of the elbow is laid bare and three cat<:ut 
 liiratures placed under it. The needle is introduced into the vein and held 
 in place by the middle litrature. r)ne or more pints of the solution at Ux.b'^ 
 F. are then slowlv introduced. The needle is then withdrawn, the middle 
 ligature removed, and the upper and lower ligatures tieil and cut short. The 
 wound is then closed and dressed as usual. During transfusion great care 
 must be taken to prevent entrance of air — e. g., by keeping the funnel con- 
 stantly full. 
 
 X. Aspiration. — The usual form of aspirator (Potain's. Fig. 4!»6) consists of 
 a hollow needle with a lateral eye (or trocar and canula with plunger to clear it if 
 
 Fir,. 496. 
 
 Aspirator and Injector. 
 
 I 
 
 blocked) : of a stopcock and joints, to which on one side is attached the needle 
 and on the other a long rubber tube having a short piece of glass tubing inter- 
 posed near the needle end ; of a rubber cork with two stopcocked tubes, one for 
 the tube connecting with the needle, the other for the short tubing connecting 
 with the pump ; finally, a wide-mouthed bottle must be provided. 
 
 Operation. — Having arranged the instrument as directed, secure the cork 
 in the bottle, turn off the stopcock on the side next the needle, and open that 
 on the pump side ; exhaust the bottle, turn off the exhaust cock, introduce the 
 needle until the lateral eye is buried ; then, turning the cock on the needle side 
 of the vacuum, pass the needle onward until the pus or serum appears in the 
 segment of glass tubing. When the reservoir is filled, turn the cock on the 
 needle side, remove the cork, empty, replace the cork, form a new vacuum, and 
 proceed as at first : should the needle become blocked, a few strokes of the 
 pump will clear it. If a trocar is to be used, screwing the canula on in place 
 of the needle, the trocar, with its properly-packed joint to render the canula 
 air-tight, is to be introduced, and the same connections made as before, but the 
 instrument must be thrust into the cavity and the trocar withdrawn until the 
 stopcock back of the canula can be turned off. then the cock between the can- 
 ula tubing and the vacuum is to be turned on. If the canula becomes blocked, 
 
Mixoh' s nun: in'. ii.s7 
 
 introduce the appropriate ])lun>!;er, tiii'ii on tlie eaiiula stopcock — the trocar 
 having been withdrawn — remove the phmger iind turn off the canula cock, all 
 with the vacuum connected. When tlie packed joint for both trocar and 
 plunger fits into the connecting joint, a groove on each instrument informs the 
 operator when it has been sufficiently pulled out to enable the stopcock to be 
 turned off; when the packed joint belongs to each trocar or plunger, these 
 instruments can be withdrawn only to a certain point, which will allow the 
 stopcock to be turned. After the canula or the needle has been withdrawn 
 the little puncture must be sealed with collodion or plaster. 
 
 XI, Hypodermatic Injections. — These are made with a syringe contain- 
 ing about thirty minims and having an adjustable hollow needle jioint, the cylin- 
 der being of metal, glass, or hard rubber. When not in use a fine wire should 
 be kept in the needle, which must always be cleansed and dried after using, 
 while the cap should be adjusted over the end of the syringe to prevent the 
 packing of the piston from drying : if iodine is employed, gold or platinum 
 points, instead of steel, and a hard rubber syringe should be used. 
 
 Operation. — As perfect asepticism is essential, it is better to boil the needle 
 in a little water in a spoon. Then draw up about twenty minims of the water 
 into the syringe and empty this into the spoon, having thrown out any of the 
 water left after having removed the needle ; drop into the fluid the powdered 
 drug or compressed pellet (as it is most commonly prepared for liypodermatic 
 use), aid its solution by stirring with the end of the syringe ; then charge the 
 instrument, attach the needle, and, holding it point upward, that all air may 
 rise to the top, slowdy force up the piston until the air is expelled, as shown 
 by the escape of a drop of fluid from the needle. While strychnine and ergot 
 are usually thrown into the muscles, morphia, atropine, and brandy are to be 
 injected into the subcutaneous cellular tissue. 
 
 There are two Avays of introducing the needle — one by pinching up a fold 
 of skin free from veins (usually over the outer anterior surface of the forearm 
 or thigh) between the thumb and first two fingers of one hand, while with the 
 other the needle is quickly thrust into the cellular tissue parallel with the fold : 
 the other method, far less painful, is to select an avascular portion of the skin, 
 render it tense by the thumb and finger of one hand, and quickly drive the 
 needle so obliquely through the integument as to reach the cellular tissue, 
 which it must penetrate — introduced in either way — for about three-fourths of 
 an inch ; the fluid must next be slowly injected, the needle withdrawn, and the 
 puncture compressed for a few moments by one finger, while with another gen- 
 tle friction is exercised over the projection formed by the fluid, to diffuse it over 
 a larger area. 
 
 XII. Vaccination. — This should be done immediately after birth if expos- 
 ure to variola has occurred or if an epidemic of that disease is prevalent ; but 
 about three months is the preferable age. Infjints suffering from any slight ail- 
 ment or from any form of skin affection should first be cured of such diseases. 
 Humanized virus in the form of lymph taken from a typical vesicle on a healtJiy 
 infant and of healthy parentage at the eighth or ninth day of the disease (arm- 
 to-arm vaccination) ; carefully pulverized fragments of dried human scab of 
 such a child free from all blood or pus, ground up between two clean glass plates 
 and mixed to a creamy consistence with tepid water ; and bovine or aiiimal 
 virus — i. e. the lymph from the eight-day-old vesicle of the inoculated natural 
 vaccine disease on the udders of young heifei's, allowed to dry on quills or ivory 
 points, — are all employed, but the safest plan is to use only bovine virus. 
 
118s AX j.v/./.'/r.i.y rr.xr-iiooK or scua i:i!V. 
 
 Operatiii)!. — I'rcpart' tlie skin as tor any otlicr ojteration. Witli an asep- 
 tic lancet, the skin over the insertion of the deltoid muscle, or. better, on 
 the leg, being rendered tense by the thumb and fingers of one hand, carefully 
 scrape away the epitlu^liuni over at least two small surfaces of skin about 
 one eighth of an inch square until a slight bloody serous oozing occurs, and 
 then with the lancet cover these spots with the drieil scab reduced to a creamy 
 consistence as just described, or thoroughly rub them with the (juill or ivory 
 point charged with bovine virus previously dipped in tepid water : any of 
 these methods is rendered more certain by tattooing the lymph into the 
 abraded surface by the lancet or ivory point. A more rapid and equally 
 effective plan is to make with the lancet or the previously moistened ivory 
 point three or four short parallel scratches very close together, crossing 
 these with others similarly disposed, and then applying the lymph as 
 directed. Arm-to-arm vaccination can be done by puncturing the vesicle 
 on the eighth day with the lancet point, and then entering the instru- 
 ment obliquely well into the cutis at one or more points. The exuded 
 blood and serum must be allowed to dry thoroughly before replacing 
 the clothing. The parts should be constantly protected by an aseptic 
 dressing until the inflammation has subsided and the crust is dry. Ex- 
 posure to cold and dampness must also be avoided. The indications for 
 revaccination can be found in medical treatises, the operation being like 
 the primary one. 
 
 XIII. Electricity. — This is used in the form of the in dueed current (farad- 
 ism) to exercise and improve the nutrition of muscles, and in the form of the coji- 
 stant current (galvanism) along the course of nerve-trunks to excite their con- 
 ducting power or act as a sedative in neuralgia : and the same current is used 
 to induce chemical decomposition (electrolysis) or to cauterize and destroy tissue 
 by heating an encircling wire or a galvanic knife. Franklinic or static elec- 
 tricity is also occasionally used. For electrolysis a galvanic battery of thirty 
 or more medium-sized cells is required, with needle electrodes insulated except 
 near their points. The operation consists in introducing into the aneurysm or 
 tumor two needles a short distance apart, each connected with a pole of the 
 battery ; then, commencing w ith a weak current, this must be cautiously 
 increased, the sitting lasting from a half-hour to one hour, after which the 
 needles are to be removed and the punctures sealed by collodion. 
 
 XIV. Galvano-caitery. — This requires a battery of a few large elements 
 closely coupled, and various curettes, knives, and ^craseurs fitting into an insu- 
 lated handle. The chief advantage of this form of cautery is the po.ssibility 
 of placing the instrument in position ivkile cold, and then heating it. Where 
 hemorrhage is undesirable, a dull red heat should be maintained, for at a white 
 heat the tissues are divided as if with a knife and bleeding follows. When 
 the ecraseur is used, needles must be passed at right angles through the healthy 
 tissues, the platinum wire placed behind these, and the wire — at a dull red 
 heat — slowly tightened. 
 
 XA'. Massage. — This is employed to stimulate the circulation in the part 
 mechanically, to loosen tissues bound down by adhesions, to diffuse inflammatory 
 exuilaies over a wider area, thus favoring their absorption, and to change the 
 rate of the circulation to a point compatible with rapid absorption and normal 
 nutrition. Four distinct varieties of manipulation are found to be most gen- 
 erally useful: viz. rubbing or stroking; kneading; tapping or percussion; 
 
MiMtL' s( n<;i:in'. 11x9 
 
 piis^ive and active inuvcnients. Strokimj coii^iists in ;j:;(.'nti(.' rubbing dii-ected 
 from the periphery upward, commencing the process above the inflamed part 
 and continuing it over tlic diseased area; the pressure at first light, but finally 
 firmer, will force the exudates into the tissues above, which have been emptied 
 by the prejjaratory rubbing. KncaiJiiKj means rubbing the part circularly 
 with the pulps of the fingers and the thumb or the palm of the hand, and is 
 best combined with pinching up of the skin or muscles singly or together and 
 gently rolling them between the fingers and palm. PercuHHian is effected by 
 tap]iing the surface over the diseased part with the tips of all the fingers held 
 on a level, or with the ulnar side of the hands, or, after covering the part with 
 a towel, three parallel }>ieces of stiff" rul)ber tubing fixed in a handle (a muscle- 
 beater) may be employed, gently striking the part transversely to its long 
 axis. Passive movements should be made at the close of each sitting if a joint 
 is concerned. Massage is sometimes advisable twice daily, but often once a 
 day or every other day is better; each sitting may last from fifteen minutes 
 to one hour. 
 
 XVI. Clinical Thermometers, — The best are straight self-registering 
 instruments, generally graduated in this country on the tube in degrees and 
 fractions of degrees of the Fahrenheit scale. Only "certified" thermometers 
 should be used. These have been tested as to their accuracy, and a certificate 
 of the error comes with each. No good thermometer ought to vary more than 
 ■^°. To use one, the register must be shaken below 95° by Jiohling the 
 instrument bulb downward and swinging it sharply at arm's length, or, holding 
 it in the same manner with one hand, jar it down by striking the lower side 
 of the hand grasping it against the wrist of the other hand : the bulb must 
 now be placed beneath the patient's tongue with the lips gently closed over 
 the stem, observing that this is directed upward, or in the axilla, the arm 
 being brought up and across the chest to maintain apposition of the axillary 
 surfaces with the bulb. The instrument must ordinarily be retained about 
 five minutes, but one-, two-, and three-minute thermometers are now made. 
 The same thermometer should always be used, and for the same length of time, 
 in any given case. Carefully cleanse the thermometer in water or with some 
 disinfectant immediately after removing, es])ecially if it has been in the mouth, 
 the vagina, or the rectum, where it is sometimes placed. 
 
 Thermometers should not be used in the mouth in young children, in the 
 insane, or in delirious patients, lest they bite them and injure their mouths 
 with the fragments of glass. 
 
 Surface thermometers, the bulbs of which are spiral or coiled, are some- 
 times employed for noting the diff'erence in temperature of corresponding parts 
 of the body, but the ordinary clinical thermometer, held in place by a grooved 
 cork, or covered with a layer of absorbent cotton, by the ends of which it is 
 held in position by the examiner's fingers applied at some distance, will often 
 suffice. 
 
 XVII. Applications of Heat and Cold. — Dry heat may be applied by 
 means of hot-Avater bags, hot sand- or salt-bags, heated bricks, or bottles or 
 cans filled with hot water: again, by coils of block-tin pipes arranged as caps 
 for the head or flat pads, a constant current of water at any temperature can be 
 employed. Always interpose one or more layers of flannel or clothing between 
 the skin and the heated applications, exercising great care lest the heat be too 
 great or leakage occur, because in either event serious burning or scalding may 
 result. Old hot-water bags should not be used, lest they burst. Moist heat is 
 
lino .LV .i.i//;/.'/r.i.v Ti.xr-iiooh' (H' srn<;i:in'. 
 
 emplovoil iu tlio funn of fonK'ntations as described below ; or by hot affusion 
 or the douche — that is to say. pourinjT it from a height ; or, finally, by l»ot 
 baths. When moist heat is to be applied to a joint, the best way is to extend 
 the limb and wrap the joint witii a lonii Hannel bandage ten or twelve inches 
 wiile. This is j>assed four or five times around the joint, the end han<^ini^ 
 down into a slop-jar or bucket to carry off the water. Very hot water may 
 then be poured over the flannel from a tablespoon or cup. the part beinj; thus 
 kept continuously at as high a temperature as can be borne. 
 
 Prolonged {hot) Baths may be of service in shock Avhere the injury will 
 admit of this, which is seldom. Locally, as for a sprained ankle, the tem- 
 perature must be as hi<;h as can be borne, and kept up for half an hour or 
 more by adding freshly-heated water. As a substitute for the relaxation bet- 
 ter effected by anesthesia, a general warm bath, prolonged until faintness is 
 induced, may be employed in strangulated hernia, while a warm hip-bath often 
 proves of value in cystitis, vaginitis, and in retention of urine, when the 
 patient should endeavor to pass his urine while in the bath. 
 
 Poultices are much less freijuently employed than formerly. While they 
 mav still be used occasionally when the skin is unbroken, if there is any 
 lesion of the skin antiseptic fomkxtations of gauze moistened with a hot 
 antiseptic solution, covered with rubber dam, and kept warm by a hot-water 
 bag, should be used instead, and in fact are always to be preferred. 
 
 JJrf/ cold, applied by means of crushed ice in bladders or rubber bags, or 
 ice-water passed through coils of tubing, is an important agent : several yards 
 of small rubber tubing coiled around and secured to a night-cap, one end of 
 the tubing being connected with an ice-water receptacle above and by the 
 other emptying into a vessel below, is a good substitute for the metallic coils, 
 while mats for the abdomen and other parts can also be similarly made. Moist 
 cold may be applied by compresses wet in ice-water, by irrigation, or by cold 
 affusions. Irrigation can readily be carried on by a constant current of water 
 conveyed from an elevated receptacle by the capillary attraction of a few nar- 
 row strips of lint, gauze, or lampwick extending from the reservoir to a moist- 
 ened clotb covering the diseased area. The alternate affusion or douche of 
 hot and cold water, poured from a height, is often serviceable by improving 
 the sluggish circulation in chronic joint affections,thus favoring the absorption 
 of exudates. 
 
 XA^III. Adhesive Plaster is cut or torn of appropriate width. Rubber 
 adhesive plaster does not require heat to make it adhere, but the old form of plas- 
 ter does. "When used to coaptate wounds, one end is fixed a short distance from 
 one side of the wound: the strip is firmly drawn across the wound, more or less 
 ataright angle to it, while the fingers on the opposite side exercise counter- 
 pressure : the free extremity must then be applied. Intervals must be left 
 between the strips for the escape of discharges, except when strapping ulcers, 
 where each strip should overlap its fellow by one-third. When removing strips 
 of adhesive plaster always loosen both ends, and draw them equally toward the 
 line of the wound, thus removing them without straining the union. 
 
 XIX. CoLLODiOX may be used to seal a puncture, either by' merely paint- 
 ing it on or by the application of a morsel of absorbent cotton soaked with it. 
 By fixing one end of a strip of gauze or a long shred of absorbent cotton by 
 collodion on one side of a wound it may be drawn together, the free end being 
 similarly fixed on the opposite side : this is excellent for scalp and face 
 wounds. 
 
USE or Tin: RONTGKN RAYS IN SURGIUIY. HDl 
 
 XX. Ointments sliould bo spread with a spatula or table knifo in a thin 
 layer upon lint or muslin, nicked liero and there to give exit to discharges. 
 
 CHAPTER VIII. 
 
 THE USE OF THE X OR RONTGEN RAYS IN SURGERY. 
 
 Thk llontgen method is, of course, in its infancy. It has, however, 
 reached already a degree of usefulness that makes it obvious that the neces- 
 sary apparatus will be an essential part of the surgical outfit of all hospitals, 
 and will be employed constantly in a variety of cases. Those to which the 
 method can now be applied with advantage may be summarized as follo\ys, 
 emphasis being placed on the fact that what is written to-day may require 
 revision or reversal tomorrow; so rapidly are improvements and discoveries 
 taking place : 
 
 1. Foreign Bodies Imbedded in any of the Tissues of tine Body. 
 — This is at once the most obvious and the simplest application of the skia- 
 graph to surgery. Hundreds of cases have already been reported. Bullets, 
 fragments of metal or of glass, needles, etc. are easily found, and even if 
 they are lodged in bone the varying density of the shadows cast by sub- 
 stances of different permeability or of different chemical constitution will serve 
 to define and locate them. It is desirable, if the foreign body be in a locality 
 containing important surgical structures, that skiagraphs be made from at 
 least two view-points, so that the depth from the surface and the exact rela- 
 tions of such body can be determined by measurement. A single skiagraph 
 of a piece of steel in the arm, for example, taken from the front shows 
 merely its relation to the inner or outer edge of the arm, not at all its 
 depth. A second view taken laterally would make the approximal situation 
 evident. 
 
 Various methods based on mathematical principles have been devised 
 Avhich, when employed with sufficiently accurate apparatus, make the precise 
 localization of even minute foreign bodies possible. 
 
 2. Foreign Bodies in Certain of thie Organs and Viscera are 
 likely to be discovered and located with a degree of accuracy that will vary 
 with the region or structure involved and with the thickness of the enclosing 
 tissues. It is obvious that extension of the method to the location of such 
 bodies in the trachea, bronchi, and other portions of the air-passages is sure 
 to come Avith further improvements in technique. In the digestive tract — 
 except, perhaps, the first third of the oesophagus — the difficulties are greater ; 
 but the presence or absence of foreign bodies can doubtless be determined, 
 although below the stomach it is questionable whether any definite informa- 
 tion as to exact situation can be obtained. In many cases, however, especi- 
 ally in children, it is a matter of grave doubt as to whether or not some 
 foreign body has been swallowed. As the most uncertain cases occur in the 
 youngest children, and as the ease of skiagraphy of the whole body is in 
 direct proportion to the thinness and softness of the tissues, we may expect 
 in )ust these cases to get the exact information which is so often lacking in 
 the history given by anxious parents or nurses. White has removed by gas- 
 
1192 A A AMi.iiicAX rr.xr-nooK or scuaKin'. 
 
 trotoiny from the thoracic portion of the (esoph;i«!;us of a chihl two years and 
 five months of age a "jackstone,'" which liad heen impacted there for twelve 
 days and which was detected and located by this method (JM. XXWIII.). 
 
 Manv cases have already been reported of tiie detection and removal of 
 bullets from within the cranium, while the detection, localization, and re- 
 moval of fragments of metal from the eye are of freipient oecurreiice. 
 
 3. Foreign Bodies Formed within the Organism Itself include 
 chiefly gall-stones and renal, vesical, and prostatic calculi. 
 
 Gall-stones skiagraphed without the body cast very faint shadows : cal- 
 culi of oxalate of lime, of i)hos])hate of lime, and of triple phosphate cast 
 shadows as dense as those of bone or metal ; uric acid calculi cast easily- 
 recogni/able but somewhat fainter shadows. 
 
 Kecent improvements in apparatus and technique have made discovery 
 of most of these calculi possible. Gall-stones have and probably will evade 
 detection, as they are surrounded by the bile and liver, both of which are as 
 opaque as these calculi. The yiresence or absence of renal and vesical cal- 
 culi can, however, be absolutely demonstrated. The Kfintgen discharge from 
 a low vacuum or " soft " tube will differentiate between the less dense tissues. 
 It has been found possible to jienetrate the lumbar region and differentiate 
 between the kidney shadow and surrounding structures. Where such detail 
 is possible it is absolutely certain that no calculus, no matter what its density, 
 can escape detection. Where no calculus is visible in a negative having such 
 detail it is certain that none is present. The negative as well as the ])0sitive 
 diagnosis can therefore be relied upon. 
 
 4. Inflammatory Swellings and New Growths (except Avhen l)ony) 
 have not yet been shown to offer any sj)ecia] features diagnosticating them 
 from normal structures. Bony tumors can plainly be seen, and as the 
 method improves it is to be expected that intracranial and intraspinal 
 osteomata may be discovered and located, and possibly even jx-riosteal thick- 
 enings due to' tubercular, syphilitic, or pyogenic infection. Dead bone has 
 frequently been differentiated from living bone and the approxinuite outline 
 of the diseased area shown, while sequestra can be detected in the cavities in 
 which they lie. Abscess in bone can be made out perfectly. 
 
 Comparison of the normal limb Avith that which is the subject of tuber- 
 cular or other chronic bone-disease w ill often reveal the full extent of the 
 latter better than any other method of exploration, and in a recent case led 
 to the perform n nee of an amputation through the hip-joint instead of through 
 the upper third of the femur, the condition found abundantly justifying the 
 procedure. 
 
 5. Fractures and Dislocations (PI. XXXIX.) at present ofter the 
 greatest field for the e very-day use of the Riintgen method. It is impossible 
 at this time to present exhaustively the conditions under which it should inva- 
 riably be used, or to separate them from those in which it is a matter of 
 interest rather than of necessity. But it is safe to say that it will be 
 ■wise to employ it, when possible : 
 
 {a) In all fractures in or about joints, either as a preliminary to the 
 reduction of deformity or as evidence that such reduction has been accom- 
 plished. These fractures are, for unavoidable reasons, often followed by 
 some limitation of motion and a more or less imperfect functional result. 
 They have therefore on innumerable occasions been the basis for suits for 
 malpractice. It will be both a satisfaction and a safeguard for the surgeon 
 if he can see that his work has been accomplished properly, and can retain 
 definite evidence of that fact. 
 
< 
 
 02 
 
 o: 
 
 < 
 
 o 
 
 i5 
 
 
 •o ^ 
 
USE OF THE l.'OXTdKy HAYS /\ .vrAV/A'A' )'. lii)3 
 
 {b) In doubtful cases or cases supposed to be of great rarity it will be 
 of inestimable value, both as aidiny; diay-nosis and as demonstratinir and 
 recording the conditions present. 
 
 ((') In cases of old injury in Avhich, as so frequently hajjjiens, no reliable 
 clinical history is obtainable and no accurate diagnosis can possibly be made 
 by the ordinary methods. 
 
 ((/) In cases of ununited fracture, both to show the exact position and 
 relation of tlie fragments prior to operation, the presence or absence of inter- 
 posing structures, etc., and also to show after operation the degree of efficacy 
 of the wire, or of the peg or screw, or of the splint or other retaining appa- 
 ratus. AVe may freciuently determine in such cases whether or not open oper- 
 ation is needed, union often being obtainable, where the fragments can be 
 brought into good position and nothing is interposed, by mere friction and 
 the reapplication of the splint or other dressing. 
 
 6. In cases of excision of joints at the time when — for example, in the 
 knee — it is desirable to demonstrate that bony union has been obtained, 
 and in the elbow that it has been avoided. 
 
 7. In cases of deformity of all sorts affecting the bones, their epiphyses 
 or dia])hyses, and requiring careful investigation before surgical interference 
 is declined or advised. 
 
 8. In many obscure cases of the type of metatarsalgia, in which the 
 demonstration of the cause of the nerve-pain and the indications for surgical 
 treatment are etiually clear and convincing. 
 
 The Apparatus. — The most practical form of apparatus and the method 
 of using it employed at present are described as folloAvs by Dr. Leonard, 
 skiagrapher to the hospital : 
 
 The apparatus consists of four parts. The first is a storage battery of 
 from four to twelve cells, arranged to give an electromotive force of from 
 eight to twelve volts. By combining the cells in series or in multiple arc 
 varying amounts of amperage and voltage can be secured, according to the 
 needs of the coil employed. The second part of the apparatus is a current- 
 inferrupter. The best type is represented by the automatic electro-magnetic 
 vibrator running on a shunt circuit of the main current by a separate electro- 
 magnet. The vibrator should be so constructed that the ratio between the 
 make and the break in the main current can be varied at will, as well as the 
 number of interruptions. The contact-points of the interrupter where the 
 break is made in the current are made of thick pieces of platinum, and on 
 either side are attached the terminals of a variable condenser, to take uj) the 
 extra current due to the self-induction in the coil, and thus help t(j make the 
 break more sudden. The third part consists of an inductorium of the Ruhm- 
 korff type, the primary coil of which is attached to the interrupted battery- 
 circuit. A coil to do efficient .r-ray work shoidd be capable of giving a 
 '' fat " spark of at least eight inches, while twelve or fifteen inches are proba- 
 bly a better length. The length of the spark is not the only essential. Its 
 efficiency is dependent upon its volume or amperage, which is recognizable 
 by the "fat" quality, which makes the spark look yellow and smoky, as if 
 fat were burning. This quality of amperage in a secondary spark is needed 
 in ;c-ray work, for without it it is impossible to produce a sufficient volume 
 of low vacuum discharge to penetrate masses of tissue, as the lumbar and 
 pelvic regions. 
 
 Before undertaking to use an .I'-ray tube the student should acquire com- 
 plete control of the coil he is using, for unless the coil is perfectly adjusted 
 and mastered the greatest efficacy cannot be secured from the tube. When- 
 
II!) I .i.v A y/:/:/(A.\ THxr-iiook' of sunaKRY. 
 
 over the ro if* any (leticiency in the (juality of the work prodiiccil hy the tiil)e 
 the coil shoiihl be tested by itself to see tiiat it is in jierfect condition. 
 
 The /to>if(/i'n Ray Tahr. — The necessity of prodncing shar]dy-defined 
 sluidows in the adaptation of the Kdntgen rays to surgical diagnosis lias de- 
 veloped a type of tube that is innch more eilicient than the Crookes' tube of 
 the type studied by Hilntgen. It Avas noticed at an early jieriod that as the 
 tube was employed its resistance to the passage of the current gradually in- 
 creased till it became impossible to pass the current through it, and it became 
 necessary to re-exhaust it. 
 
 Careful study of the qualities of the discharge fioni the tube during the 
 progressive raising of the vacuum shows that there was an equal variation in 
 the penetrating power of the discharge. The low vacuum or "soft"' tube 
 was found to be capable of differentiating between the less opaque structures, 
 while the power of penetration was found to increase with the vacuum, and 
 the higher the vacuum which can be overcome by the energy of the second- 
 ary current the greater will be the penetration. 
 
 Penetration is not, however, of the greatest value ; the property of differ- 
 entiating between all ranges of densities is of greater value. Differentiation 
 between the lesser as well as the greater densities is essential to the future 
 development of this method of diagnosis. In order, therefore, that a tube 
 should be most useful for diagnostic purposes, it should be capable of pro- 
 ducing and maintaining for any desired length of time any of the various 
 (jualities of the RiJntgen ray that the operator may desire to employ. 
 
 The self-regulating. a:-ray tube seems, at present, to fulfil most nearly 
 these requirements, as it can be made to produce any quality of Rlintgen 
 discharge whenever the operator desires. It consists of two parts — the main 
 bulb and an auxiliarv bulb, containing a regulating device that is connected 
 with a shunt-circuit outside the tube. The main bulb is exhausted to about 
 one-millionth of an atmosphere and has within it two terminals, the kathode 
 or negative pole and the anode or posi*^ive. The kathode is a concave alum- 
 inum disc of such radius of curvature that the discharge from its concave 
 surface is focussed upon the surface of a platinum plate which forms the 
 anode. This anode plate is inclined at an angle of about fifty degrees. The 
 Rbntgen rays originate on its surface at the focal point of the kathode dis- 
 charge, and its inclination permits them to be cast out at one side. The 
 rays radiate in all directions in straight lines from their point of origin. The 
 shadow of any body skiagraphcd is thus cast by a bundle of rectilinear 
 divergent rays. The image is thus always larger than the original object, 
 and the parts farthest from the perpendicular rays in the center of the 
 bundle are more or less distorted. These facts should be always remembered, 
 for in order to get least distortion in the part to be studied it should be 
 placed directly beneath the focal point on the jdatinum anode. 
 
 The auxiliary bulb contains a second kathode that heats a salt contained 
 in a conical bulb opposite it, and thus drives off' a gas that lowers the vacuum 
 in the main bulb. The action of this auxiliary kathode is governed by a 
 gap in a shunt-circuit outside the main tube. When the resistance of the 
 main bulb is greater than the shunt-circuit containing the air-gap and the 
 auxiliary kathode, the current |)asses through the shunt-circuit and heats the 
 regulating tube till the resistances are e((ualized or the main ])ulb is slightly 
 lower, when the r-rays are again produced in it. 
 
 To judge whether a tube is working properly, the ((uality of the current 
 that is energizing it must be considered. When Avorking regularly the tube 
 should have an apple-green color, while the platinum anode should be red 
 
o 
 
 0} 
 
 ;?; 
 
 c 
 
 w 
 
 H 
 
 o 
 a 
 
 1 
 
USE or THE RONTGEN HA VS IN SURGERY. 1 H>5 
 
 hot, with a white-heat spot at the center. Cure should be taken, however, 
 not to overheat a low or " soft " tube, or the platinum may be punctured. A 
 tube .should never be allowed to go so low that a pur])le color is seen about 
 the kathode. 
 
 Thi' PIioto;/ni/>/it'r Plat>\ — The photographic plate employed may be of 
 any make, and should be wrapped in light-proof black-an<l-nrange pai)er. 
 The specially prepared a;-ray plates seem, however, to give better results, and 
 come conveniently wrapped in light-proof envelopes, which protect them 
 from ordinary light while permitting the perfect action of the a:-rays. The 
 plate is placed with the .sensitive side next the i)art to ))e skiagraphed, pro- 
 tected in warm weather by waxed-paper, and may be conveniently held in 
 place by a gauze bandage to prevent motion and a consequent loss of defini- 
 tion. 
 
 The intensity and chemical effect of the rays seem to be governed by 
 the law of inverse squares, so that an exposure at double the distance must 
 at least be quadrupled if the same density in the negative is desired. The 
 tube is placed on the o])posite side of the part to be skiagraphed. Thus the 
 shadow of the part is cast upon the plate, the differentiation in density de- 
 pending on the relative opacity of the various tissues to the rays. The tube 
 should always be at least twelve inches from the plate. At this distance the 
 length of tlie exposure varies from one to fifteen minutes, according to the 
 condition of the tube, the quality of the current energizing it, and the result 
 that it is desired to produce. 
 
 The Fluoroserrpe. — The fluoroscope is made to protect the eyes from ordi- 
 nary light while observing the shadows cast upon the fiuoroscopic screen by 
 the more opaque tissues. The screen is an opaque cardboard, upon which is 
 a fluorescent salt, as calcium tungstate or barium platino-cyanide, which has 
 the property of fluorescing or glowing wlien acted upon by the .r-rays. 
 The fluoroscope is a necessity Avith every outfit. Its chief value consists in 
 detecting abnormal motion, although it may be employed to detect foreign 
 bodies and even to locate them Avhen used Avith a localizing tube. 
 
 Rontgen-ray Dermatitis. — Some time after the introduction of the Ront- 
 gen rays into surgical diagnosis it Avas found that under certain circum- 
 stances' a dermatitis Avas produced, which Avas erroneously described as a 
 burn caused by the :c-rays. For a long time the exact conditions 'that 
 would produce "it, its pathology, and the method of protecting patients from 
 it Avere unknoAvn. Investigations by experienced pathologists have proved 
 that this lesion is not a true burn, but a dermatitis which probably results 
 from the devitalizing action of the currents of electricity that escape into the 
 air about the tube. At least this much has been established : when these 
 currents are eliminated no " burns '" can be produced. They are readily 
 eliminated by introducing between the tube and the patient a .sheet of thin 
 aluminum or gold leaf spread on a card, and connected to the earth by a 
 •'•grounding " Avire, Avhich in practice can be conA^eniently attached to a gas-, 
 water-, or steam-pipe. Care, however, should ahvays be taken in operating 
 under new conditions till the phenomena connected with this dermatitis are 
 all knoAvn. 
 % 
 
INDEX. 
 
 Auuk's l)(ivv>tiiii<,' operation, TIT) 
 Al)doineii, (•<.)iii|ires.sioii of, in olistriictioii, 7ol 
 contusions of, 711, TliH 
 diseases and injuries of, 701 
 cnterectomy in wounds of, 709 
 gnnsliot wounds of, 702 
 incised wounds of, 701 
 lacerated wounds of, 701 
 laparotomy in punctured wounds of, 70o 
 uon-penetratinsi wounds of, 701 
 omental graftiutj in wounds of, 710 
 penetrating wounds of, 7Ul, 702 
 
 symptoms of, 704 
 punctured wounds of, 702 
 stab wounds of, 702 
 wounds of, 701 
 
 searcii fur perforations in, 708 
 
 treatment after operation, 710 
 Abdominal aorta, ligation of, 1123 
 cavitv, irrigation of, 710 
 drainage, 710. 1014 
 hysterectomy, 1007 
 section, 734," 1007, 1012. 1037, 1049 
 
 ablation of uterine appendages by. 1037 
 
 adhesions found in, 1013 
 
 after-treatment in, 1013 
 
 arrest of hemorrhage in, 1013 
 
 cleansing of peritoneal cavity in, 1014 
 
 closure and dressing of abdominal wound 
 in, 1015 
 
 for diseases of female generative organs, 
 1012 
 
 drainage in, 710 
 
 incision for, 1012 
 
 for intestinal obstruction from adhesions 
 and angulation, 1016 
 
 position of patient in, 1012 
 
 preparation of patient in, 1012 
 Abortion after syphilis, 181, 190 
 Abscess, acute, 44 
 of antrum, 610 
 of bone, chronic, 275 
 of brain, 533 
 
 treatment of, 536 
 of breast, chronic, 1055 
 Brodie's, 47, 275 
 cerebellar, 534. 540 
 cerebral. 533, 538 
 
 from ear disease, 538 
 cold, 45, 77 
 dorsal, 569 
 extra dural. 533, 541 
 follicular. S99 
 
 treatment of, 917 
 of gums, i)S2 
 hepatic, 47 
 
 from hip-joint disease, 393, 394 
 of hip-joint, opening of, 397 
 
 Abscess of iliac fo.ssa, 767 
 
 iscliio-rectal, 79(», 801 
 
 of jaw, 6.S2 
 
 of larynx, 617 
 
 of liver, 47, 782 
 
 lumbar, 46, 569 
 treatment of, 573 
 
 of lympbatic glands, 47 
 
 marginal, HOI 
 
 mediiLstinal. 649 
 
 metastatic, 60, 63 
 
 of neck, 47, 653 
 
 of nose, 590 
 
 of palate, 695 
 
 palmar, 47, 338 
 
 of pancreas, 788 
 
 perinephric, 47. 845 
 
 perinephritic, 47, 844 
 
 perityphlitic, 47, 762 
 
 peri-uretlirai, 899 
 treatment of, 917 
 
 of prostate, 917 
 
 psoas, 46. 569 
 
 treatment of, 573 
 
 of rectum, 801 
 
 retro-piiaryngeal, 47, 569, 691 
 treatment of, 573. 692 
 
 of scalp, 509 
 
 of space of Retzius, 47 
 
 spinal, 569 
 
 treatment of, 573 
 
 of spleen, 789 
 
 subdiapliragmatic, of subphrenic. 47 
 
 subdural, 532 
 
 of the teeth. 683 
 
 vulvovaginal, 920 
 A. C. E. mixture, 1100 
 Acetabulum, fracture of, 321 
 Acinous carcinoma, 211 
 Acne, syphilitic, 161 
 Acromegaly, 281 
 .Vcromion process, fracture of, 309 
 Actinomycosis, 137, 655 
 
 iodid of potassium in, 139 
 Actual cautery, 1183 
 .\cu pressure, 255 
 .Vcupuncture in aneurysm, 245 
 Adams' operation, 1138 
 Adenitis, 467, 470 
 
 syphilitic, 155, 156 
 
 tubercular, 80 
 Adenocystoma of breast, 1059 
 Adeno-fibroma of breast, 105^ 
 Adenoma of breast, 1059 
 
 malignant, of corporeal endometriiun. 1025 
 
 of nose, 607 
 Adenomata, 209 
 Adeno-sarcoma of breast, 1059 
 
 1197 
 
Jilts 
 
 JNDJ'LX. 
 
 Aillii'-sivc iMtlannnatiiin, 18 
 
 l)laster, 111)0 
 
 !,trii)s, 102 
 Al-robir hinit-riii, 2 
 AfTC relation of, to operation, 1074 
 Ajjnew's operation for webl»e<i fingers, 350 
 
 splint, .'527 
 Apraphia, 4t>S, o4f. 
 Air, enlranee of, into veins, 1072 
 
 filtered, reetal insufflation of, 730 
 Air-eiisliions, 1090 
 Air-passaijes, foreign bodies in, *i25 
 
 surgery of. aS*.) 
 Alcoholic, intoxication, differential diagnosis 
 
 of, 513 
 Alexia, 498, 546 
 Alexins, S'2 
 Allis on the hip, 457 
 Alopecia, 157 
 
 AiiKvba coli in liver abscess, 783 
 Anii)iill;o, 1049 
 Amputation, 1 151 
 
 for aneurysm, '245 
 
 at ani<le, 1165 
 
 in ankle-joint disease, 401 
 
 of arm, 1160 
 
 Berger's, 1163 
 
 (ardcn's, 1107 
 
 C'hopart's, 1165 
 
 circular method, 1154 
 
 after compound fractures and dislocations, 
 1151 
 
 in conliiruity, 1158 
 
 in continuity, 1158 
 
 for deformities, 1152 
 
 double-flap operation, 1156 
 
 Dupuytren's, at shoulder, 1161 
 
 at elbow, 1160 
 
 in elbow-joint disease, 403 
 
 of fingers, 1159 
 
 flap method, 1156 
 
 of forearm, 1160 
 
 for gangrene, 1152 
 
 of great toe with its metatarsal bone, 1163 
 
 Gritti's, 1167 
 
 after gunshot wounds, 120 
 
 hemorrhage after, 1158 
 
 Key's, 1164 
 
 at hip-joint, 1168 
 Guthrie's, 1170 
 Larrey's, 1170 
 Listoii's, 1170 
 Wyeth's bloodless, 1169 
 
 indications for, 1151 
 
 through interphalangeal joint, 1159 
 
 through interphalangeal joints of toes, 1163 
 
 interseapulo-thoracic, 1 163 
 
 above knee, 1167 
 
 at knee-joint, 1166 
 
 for knee-joint disease, 400 
 
 Larrev's, at shoulder, 1161 
 
 of leg! 1166 
 Lisfranc's, 1164 
 
 of little finger with its metacarpal bone, 
 1159 
 
 of little toe with its metatarsal lx)ne, 1163 
 
 for malii;nant tumors, 1152 
 
 at medio-tarsal joint, 1165 
 
 at metacarpophalangeal joint, 1159 
 at metacarpus, 1159 
 
 Am|tutation at metatarso-phalangeal joini, 1163 
 
 through metatarsus, llti4 
 
 mixed method, 1 157 
 
 mortidity after, 1158 
 
 f)f jienis, 9(»4 
 
 tiirough a |)halanx, 1159 
 
 PirogoH's, 1165 
 
 Sedillot's, 1166 
 
 above shoulder, 1162 
 
 at shoulder, 1 161 
 
 single-flap operation, 1156 
 
 special forms of, 1159 
 
 Stephen .Smith's, 1166 
 
 iSyme's, 1165 
 
 through tarso-metatarsal joint, 1164 
 
 for tetanus, 1152 
 
 of thigh, 1167 
 
 of thumb, 1159 
 
 of toes, 1 1 63 
 
 through the trochanters, 1167 
 
 of entire upper extremity, 1163 
 
 after wounds, lacerated and contused, 1152 
 
 at wrist, 1160 
 Amussat's operation (colostomy), 732 
 Anaerobic bacteria, 2 
 Anastomosis, intestinal, 736 
 
 without rings, 741 
 Anatomical tubercle, 77 
 
 Anderson's method of tendon-lengthening, 335 
 Anel's operation in aneurvsm, 242 
 Anesthesia, 1071, 1092 
 
 areas of, 369 
 
 in deformities of chest, 1073 
 
 local, 1100 
 Anesthetic, choice of, 1100 
 Anesthetics, accidents during administration 
 of, 1099 
 
 history of, 1092 
 
 mortal itv from, 1099 
 Anestile, I'lOl 
 Aneurysm, 229 
 
 acupuncture in, 245 
 
 amputation for. 245 
 
 Anel's operation for. 242 
 
 Antyllus's operation for, 242 
 
 arterio-venous, 248 
 
 axillary, 250 
 
 brachial, 251 
 
 Brasdor's ()j)eration for, 243 
 
 carotid, 249 
 
 causes of, 234 
 
 circumscribed false sacculated, 2:!2 
 
 cirsoid, 233, 503 
 
 coagulating injections in, 245 
 
 component parts of, 232 
 
 compression in, 239 
 
 advantages over ligation, 244 
 
 diagnosis of, 237 
 
 diffuse false sacculated, 232 
 
 digital pressure for, 241 
 
 dissecting, 232 
 
 duration ol", 23S 
 
 Esmarch's iiandage in, 241 
 
 extirpation of, 245 
 
 false sacculated, 232 
 
 femoral, 251 
 
 flexion of joint in, 241 
 
 foreign bodies introduced into sac in, 244 
 
 fusiform, 231, 238 
 
 galvano-puncture in, 245 
 
INDEX. 
 
 1199 
 
 Aneiirvsni, Hiintoriiin operation for. 'l\'-\ 
 
 idiopathic, 'I'M 
 
 iliai-. li.")! 
 
 instniiDoiital coinpri'ssinn in, 21U 
 
 Macfwi-n's method in, 'J-lfJ 
 
 nianipiilation in, 24-'> 
 
 lUH'.ile, 1114 
 
 popliteal, 'J-")l 
 
 pressure upon orj^ans by, 2;'.4 
 
 sacoMJated, 'IWl 
 
 .septicemia and pyemia in, 'I'.W 
 
 sifjns and symjitonis ot'. "io-j 
 
 spiiy>,Mno<rrapiiic judse-tracings in, 23() 
 
 spontaneous cnre of, 233 
 
 subclavian, ^l^^i) 
 
 traumatic, 24() 
 
 treatment of, 238 
 
 true sacculated, 232 
 
 tubulated, 231 
 
 varicose, 248 
 
 Wardrop's operation for, 244 
 .\neurysinal hernia, 232 
 
 sac, contractility of, 240 
 
 varix, 247 
 Angioleucitis. See Lymphangitis, 466 
 Angioniata, 202 
 
 cavernous, 228 
 
 of nose, 607 
 
 plexiform, 228 
 Angular gyrus, 497 
 Ankle, amputations at, 1165 
 
 excision of, 1148 
 Ankle-joint disease, 400 
 
 osteoplastic resection in, 401, 1150 
 Wladiinirofi'-Mikulicz operation for, 401, 
 1150 
 
 tuberculosis of, 400 
 Ankylosis, 418 
 
 in liii) -joint disease, 395 
 
 of jaw, 686 
 
 Esmarch's operation for, 686 
 
 after knee-joint disease, 400 
 
 l)artial, 419 
 Anthrax, 83, 128 
 
 bacillus of, 10 
 
 carbuncle, 129 
 
 cedenia, 129 
 Antisepsis, 1076 
 Antiseptic method, 1077 
 
 wax, Horsleys, 1154 
 Antiseptics, 1077 
 Antrum, abscess of, 610 
 
 of High more, 610 
 
 tumors of, 611 
 Antyllus, method of, in aneurysm, 242 
 Anuria, 841 
 Anus, artificial, 734 
 
 fissure of, 49, 800 
 
 imperforate, 790 
 
 ])rolapse of, 797 
 
 pruritus of, 799 
 Aorta, abdominal, ligation of, 1123 
 Aphasia, 497 
 
 amnesic, 546 
 
 sensory, 546 
 Apophysis, separation of, 283 
 Apoplexy, differential diagnosis of, 513 
 Appendicitis, 759 
 
 bacterial causes of, 761 
 
 bacterium coli commune in, 701 
 
 Appendicitis, catarrhal, 7f'il 
 ciironic relapsing, 768 
 iliagnosis of, 764 
 etiology of, 760 
 exciting causes of, 760 
 fecal concretions in, 761 
 foreign bodies in, 761 
 McBurney's j)lan of incising abdominal wall 
 
 in, 766 
 micro-organisms in, 761 
 olijiterans, 768 
 pathology of, 762 
 surgical treatment of, 766 
 symptoms of, 763 
 Appendix vermiformis, anatomy of, 760 
 
 inflannnation of, 759 
 Apraxia, 49.S, 546 
 Arachnitis, 530 
 Ardor urinaj, 897 
 Argyll-Robertson puiiil, 535, note. 
 Arm, amputation of, 1160 
 bandages for, 1177 
 cerebral center for, 497 
 Arms, artificial, 1171 
 Arrow-wounds, 121 
 Arterial varix, 230, 503 
 Arteries, atheroma of, 229 
 calcification of, 229 
 contusecL wounds of, 257 
 gunshot wounds of, 257 
 healing of, 33 
 incised wounds of, 257 
 inflammation of, 228 
 lacerated wounds of, 257 
 ligation of, 1113 
 
 for hemorrhage, 254, 255 
 punctured wounds of, 257 
 rupture of coats of, 258 
 special, ligation of, 1115 
 torsion of, for hemorrhage, 255 
 wounds of, 257 
 Arteritis, 228 
 
 Artery, axillary, collateral circulation after 
 ligation of, 1121 
 ligation of, 1121 « 
 
 wounds of, 260 
 brachial, collateral circulation after ligation 
 of, 1122 
 ligation of, 1121 
 carotid, collateral circulation after ligation 
 of, 1116 
 common, ligation of. 1115 
 external, ligation of, 1117 
 internal, ligation of, 1117 
 wounds of, 260 
 of cerebral hemorrhage, 514 
 circmnflex ilii, ligation of, 1127 
 dorsalis pedis, ligation of, 1131 
 epigastric, deep, ligation of, 1127 
 facial, ligation of, 1118 
 
 femoral, collateral circulation after ligation 
 of, 1129 
 ligation of, 1128 
 wounds of, 261 
 gluteal, ligation of, 1125 
 iliac, conunon, ligation of, 1124' 
 
 external, collateral circulation after liga- 
 tion of, 1127 
 ligation of, 1126 
 internal, ligation of, 1125 
 
12(J0 
 
 jyOEX. 
 
 Artery, innnininate, litjalion of, 1I1"> 
 
 inter^<>^ital, lieiiic>rilia;,'u from, 2(jl 
 ii^ntioii of, 1 1-."> 
 
 internal niaimnarv, lieiuorrliage from, 2fil 
 ligation of, I'VIO 
 
 lingual, ligation of, lllS 
 
 niiiiille meningeal, hemorrhage from, 'A\ 
 ligation of, 51G 
 
 peroneal, ligation of, 1130 
 
 p0|>liteal, ligation of, WIS} 
 \vi. mills of, 2(31 
 
 pudic, internal, ligation of, 112(5 
 
 radial, collateral circulation after ligation, 
 of, 1122 
 ligation of, 1 122 
 
 rupture of in fracture. 292 
 
 sciatic, ligation of, 112(5 
 
 subclavian, collateral circulation after liL'a- 
 tion of, 1120 
 ligiitiou of. 1119 
 woimds of, 26(J 
 
 temporal, ligation of, 1119 
 
 terminal, 59 
 
 thyroid, inferior, ligation of, 1120 
 superior, ligation of, 1118 
 
 tibial, anterior, ligation of, 1130 
 jiosterior, ligation of, 1129 
 
 ulnar, ligation of, 1122 
 
 vertebral, ligation of, 1120 
 wounds of, 2fi0 
 Arthrectomv, 1134 
 Arthritis, 386, 388 
 
 chronic rheumatoid, 409 
 
 deformans, 409 
 
 deformitv in, 389 
 
 forms <.f,"388 
 
 gonorrhceal, 407 
 
 gouty, 409 
 
 infective, 406 
 
 neuropathic. 413 
 
 post-gonorrheal, 407, 903 
 
 rheumatic, 408 
 
 septic, 405 
 
 of temporo-maxillary articulation, 685 
 
 tubercular, 388 
 
 urethral, 407 
 Artificiid arms, 1171 
 
 legs. 1173 
 
 limbs. 1171 
 
 respiration, 1184 
 
 forced, in poisoning bv ether and chloro- 
 form, 10H(5 
 Ascites, 1046 
 
 tubercular. 778 
 Asepsis, 1076 
 Aseptic fever, 34 
 
 methods, 1077 
 Asphyxia. 1095. 1184 
 Aspiration. 1 186 
 
 of hip-j(jini, 397 
 
 in joint-tuberculosis, 388 
 
 use of, in paracentesis thoracis, 639 
 Assistants, preparation of for operation, 1077 
 Asterion, 491 
 
 Asthenic inflammation, 18 
 Astratralus. removal of, 355 
 Atheroma, 229 
 Atony of bladder, 858 
 Atrophv of bone, 276 
 
 of breast, 1053 
 
 Atrophy of muscle, 336 
 
 Aveling's transfusion apparatus. 1185 
 
 P>A<lM,i:.s, 1 
 
 of anthrax, lo, 128 
 of glanders, 9, 135 
 of malignant odema, 9, 125 
 mallei, 9, 135 
 of noma, 9 
 of jKscudo-iidema, 9 
 pvocvaneus, 7 
 of syphilis, 9 
 of tetanus. 8, 70 
 of tubercle, 8, 74 
 Hack, injuries of, 575 
 
 sprains of, 575 
 I'acteria, 1 
 aerobic. 2 
 anaerobic, 2 
 of dental caries, iiN7 
 efTect of temperature on, 3 
 facultative, 2 
 
 number injected or dose of, 7 
 obligate, li 
 pathogenic, 2 
 pyogenic, 2 
 saprogenic, 2 
 saprophytic, 2 
 Bactericidal drugs, 4 
 Balanitis, 897 
 
 treatment of 916 
 Balano-posthitis, S98 
 
 treatment of, 916 
 Baldness from syphilis, 157 
 Ball's operation for radical cure of hernia. 8l4 
 Bandage, Barton'.s, 1178 
 circular, 1176 
 
 crossed, of angle of jaw, 1179 
 demi-gauntlet, 1177 
 Desault's, 1 199 
 double T of perineum, 1180 
 figure-of-8, 1176, 117s, 1179 
 
 of ankle, 1179 
 
 of elbow, 1179 
 
 of both eyes, 1178 
 
 of the jaw, 1178 
 
 of neck and axilla, 1179 
 
 of pelvis and thigh, 1179 
 
 of shoulders, 1179 
 four-tailed, 1181 
 fronto-occipital triangle, 1181 
 fronto-occipito-labial cravat, 1181 
 Gibson's, 1178 
 handkerchief. 1181 
 oblique, of ant;le of jaw, 1179 
 recurrent, of head, ll80 
 
 of stump, 1180 
 spica, 1176 
 
 of groin, 1 179 
 
 of instep, 1178 
 
 of shftulder, 1179 
 
 of thumb. 1 177 
 spiral, 1176 
 
 of fingers, 1177 
 
 reversed, 1176 
 
 of lower extremity, 1177 
 of upper extremitv, 1177 
 
 T, 1180 
 
 \'elpeau's. 1 179 
 Bandages, 1176 
 
INDEX. 
 
 12U1 
 
 Barker's operation for fractured patella, 328 
 for radical cure of hernia, 81,") 
 for transverse fracture of patella, 328 
 Bartholin's j;land, inHainniation of, 969 
 
 retention-cyst of, 971 
 Barton's dressing, 319 
 Basedow's disease, 062 
 Basion, 491 
 
 Bassini's operation for radical cure of femoral 
 hernia, SIT 
 of inguinal hernia, 815 
 Baths, hot, proloni^ed, 1190 
 Baiun's method of stretching facial nerves, 383 
 Bed after operation, 1088 
 Bed-rests, 1090 
 Bedsores, 48, 54 
 Bee-stings, 126 
 Bellocq's canula, 602 
 Berger's amputation, 1163 
 Bichat, fissure of, 491 
 
 Bichloride of mercury as an antiseptic, 1077 
 Bigelow's evacuator, 878 
 
 operation (lithola[)axy), 876 
 Bilharzia luvniatobia, 854 
 Biliary calculus, obstruction from, 749 
 Bites of lips, 668 
 
 and stings of insects and reptiles, 126 
 Bladder, absence of, 851 
 
 atony of, 858 
 
 attention to, after an operation, 1089 
 
 congenital deformities of, 851 
 
 diseases and injuries of, 851 
 
 exstrophy of, 851 
 
 fibromata of, 886 
 
 fibro-myxomata of, 886 
 
 hernia of, 851 
 
 inflammation of, 883 
 
 injuries of, 856 
 
 papillomata of, 886 
 
 rupture of, 857 
 
 stone in, 860 
 
 tumors of, 885 
 
 wounds of, 856 
 Bladders, supernumerary, 851 
 Blennorrhagia. See Gonorrhea, 895 
 Blennorrhagics, 912 
 Blisters, 1182 
 Blood, changes of, in inflammation, 12 
 
 extravasation of, in inflammation. 12 
 
 poisoning. See Septicemia and Pyemia. 
 
 transfusion of, 1185 
 Blood-plaques, 14 
 Blood-vessels, changes of, in inflammation, 11 
 
 diseases of, 224 
 
 wounds of, 260 
 Bloodless tissues, regeneration in, 30 
 Bloodletting, 1183 
 Bodies, foreign, i^ee Foreign bodies. 
 
 loose, in joints, 421 
 Boil, 476 
 
 Boiling water, effect of, on bacteria, 4 
 Bonds splint, 319 
 Bone, abscess of, chronic, 275 
 
 atrophy of, 276 
 
 chips, decalcified, 1112 
 
 chondromata of, 279 
 
 fibromata of, 278 
 
 fissure of, 283 
 
 inflammations of, chronic, 271 
 septic, 266 
 
 76 
 
 Bone, overgrowth of, 275 
 
 regeneration of, 31 
 
 replacement of, after trepiiining, 501 
 
 sarcomata of, 280 
 
 Senn's decalcified plates, 736, 737 
 
 separation of splinter of, 283 
 
 tul)ercn]osis of, 79, 272 
 
 tumors of, 277 
 malignant, 280 
 Bone-grafting, 1112 
 Bones and joints, operations on, 1132 
 
 jdastic operations on, 1112 
 
 syphilis of, 167, 184, 277 
 Bonnet's wire cuirass, 396 
 Bony tumors, 200 
 Bougies a bnnlr, 928 
 
 filiform whalebone, 893 
 
 oesophageal, 697 
 Bowel. See Intestine. 
 Bow-legs, 352 
 
 Brachial plexus, exposure of, 384 
 Brain, abscess of, 533 
 treatment of, 536 
 
 compression of, 512 
 
 concussion of, 510 
 
 diseases from ear disease, 537 
 
 electrode, 501 
 
 faradization of, for recognizing motor cen- 
 ters, 500 
 
 foreign bodies in, 528 
 
 gunshot wounds of, 525 
 
 removal of the ball in, 526 
 
 laceration of, 510 
 
 limits of operative procedure on, 502 
 
 and membranes, traumatic inflammation of, 
 530 
 
 motor areas of, 497 
 
 punctured wounds of, 521 
 
 secondary operations on, 502 
 
 topography of, 491 
 
 treatment of, after operation, 501 
 
 tumors, 544 
 
 diagnosis of, from abscess, 547 
 differential diagnosis of, 535 
 prognosis of, 548 
 symptoms of, 545 
 treatment of, 550 
 
 wounds of, 524 
 Branchial arches, 664 
 
 clefts, G51, 664 
 
 cvsts, 651 
 
 folds and clefts, 651, 664 
 Breast, abscess of, chronic, 1055 
 
 adeno-cystoma of, 1059 
 
 adeno-fibroma of, 1058 
 
 adenoma of, 1058 
 
 adeno-sarcoma of, 1059 
 
 amputation of, 1065 
 
 atrophy of, 1053 
 
 cancer of, 1061 
 
 carcinoma of, 1061 
 encephaloid, 1061 
 scirrhous, 1062 
 
 atrophic or withering, 1063 
 soft, 1064 
 
 chancre of, 148 
 
 congenital malformations of, 1050 
 
 contusions of, 1069 
 
 cvsto-sarcoma of, 1061 
 
 cysts of, 1068 
 
1202 
 
 INDEX. 
 
 Bre.i.^t, diseases of, 1052 
 
 diseases and injuries of, 1049 
 
 livpertrophy of, 1053 
 
 inHaiiiiiiation of, 1053 
 
 niak', diseaises of, 1070 
 iiillaiiiiiiation of, 1070 
 tumors of, 1070 
 
 neurotic conditions of, 1052 
 
 sarcoma of, 1060 
 
 surgical anatomy of, 1049 
 
 syphilis of, 1057 
 
 tuberculosis of, 1057 
 
 tumors of, 1057 
 
 wounds of, 1069 
 Bregma, 491 
 
 Bridle (linear) stricture, 926 
 Broad ligament, hematoiua of, 1033 
 surgerv of, 1032 
 tumors of. 1048 
 Broca, points of skull named by, 491 
 Broca's center for speech, 497 
 Brodie's abscess, 47, 275 
 Brokaw's rings, 737 
 Bronchial tubes, foreign bodies in, 625 
 Bronchocele, 660 
 Bronchotomy, 627 
 Browne's, Buckston, tampon, 872 
 Brush burn. 112 
 Bryant's triangle, 323 
 Bubo, gonorrheal, 900 
 in female, 920 
 treatment of, 917 
 
 syphilitic, ditlerential diagnosis of, 156 
 Buboes, chancroidal, 156 
 
 syphilitic, 155 
 Bubonic plague, 83 
 Buck's extension, 296 
 Bullet probes, 117, 526 
 Bunion. 345 
 Burn, brush, 112 
 Burns, 477 
 
 of larynx and trachea, 627 
 
 and scalds, deformities from, 670 
 Burs.-e, aflections of, 343 
 Bursitis, 344 
 Button suture, 1085 
 
 Cachexia, cancerous, 210 
 
 strumipriva, 662 
 Cadaverin, 2 
 Caxal hernia, 817 
 Calcification of artery, 229 
 Calculus, biliary, obstruction from, 749 
 of prostate, 948 
 renal, 838 
 salivary, 658, 675 
 vesical, 860 
 
 in children, operations for, 879 
 
 failure in detection of, 865 
 
 in females, 882 
 
 operative treatment of, 867 
 
 preparatory treatment for operation 
 
 868 
 prophylaxis of, 866 
 size of, 865 
 sounding for, 864 
 symptoms of, 862 
 treatment of, st;6 
 varieties of, 861 
 in Wharton's duct, 659 
 
 Callosities, 480 
 
 Callus, external, 31, 291 
 
 exuberant and painful, 292 
 
 intermediate, 31 
 
 internal, 31 
 
 provisional, 31 
 Cancer of breast, 1061 
 
 chimney sweeps', 960 
 
 en cubage, 1065 
 
 juice, 211 
 
 melanotic, 205 
 Cancerous cachexia, 210 
 
 ulcers of skin, 488 
 Cancrum oris, 55, 671 
 Caiiula, Belloc(i's, 602 
 Capillaries, changes of, in inflammation, 11 
 Caput succedaneum, 508 
 Carbolic acid as an antiseptic, 1077 
 Carbuncle, 46, 477 
 
 anthrax, 129 
 Carcinoma, acinous or spheroidal-celled, 211 
 
 of bre;ist, 1061 
 encephaloid, 1064 
 
 Ilalsted's method of treatment, 1067 
 mortality of, 1065 
 scirrhous, 1062 
 
 retraction of nipple in, 1062 
 soft, 1064 
 
 of cervix uteri, 1017 
 
 diagnosis of, 213 
 
 encephaloid, 212 
 
 epithelial, 213 
 
 extension of, 212 
 
 hard spheroidal-celled, 211 
 
 of intestine, 756 
 
 of jaws, 685 
 
 of larynx, differential diagnosis of, 172 
 
 medullary, 212 
 
 of pancreas, 789 
 
 of pharynx, 692 
 
 of rectum, 805 
 
 scirrhous, 211 
 
 of skin, 488 
 
 soft spheroidal-celled, 212 
 
 of stomach, 716 
 
 of testicle. 950 
 
 encephaloid, differential diagnosis of, 173 
 
 of tongue, 677 
 
 of tonsils, 691 
 
 treatment, 215 
 
 of uterus, 1017 
 
 palliative treatment of advanced cases, 
 1024 
 Carcinomata, 210 
 Carden's amputation, 1189 
 Carditis, traumatic, 223 
 Caries. 264 
 
 of bones of skull, 505 
 
 dental, 686 
 
 dry, 78, 271 
 
 fungous, 271 
 
 necrotic, 265 
 
 sicca, 76, 271 
 CarrKid triangle, inferior, 1116 
 
 superior. 1116 
 Cartilages, floating, 421 
 
 .semilunar, dislocations of, 459 
 displacement of, 422 
 Cartilaginous tumors, 199 
 Caruncle of urethra, 971 
 
INDEX. 
 
 1203 
 
 ( 'aseoiis degeneration, 7o 
 Castration, 9o'2 
 
 for hypertrophy of prostate, 944 
 Catarrii, atrophic nasal, 59fi, 59!' 
 
 nasal, COO 
 
 hypertrophic and atrophic, ■"iQG 
 
 of lirethra, 90") 
 treatment of, 914 
 Catsnt, 108-J 
 Catheter en chemise, 870 
 
 fever, 893 
 
 (Joulev's tunnelled, 893 
 Catheterlsm, 889 
 Catheterization, 859 
 Causal}j;ia, 574 
 Cautery, actual, 1183 
 
 galvano-, 1 188 
 Cell-division, direct, 29 
 
 indirect, 29 
 Cell-nests, 213 • 
 
 Cells, exudation, 27 
 
 formative, 27 
 
 wandering, 12 
 Cellulitis of neck, 652 
 
 pelvic, 1032 
 
 phlegmonous, 67 
 Center, cerebral, for arm, 497 
 
 for elbow, 497 
 
 for face, 497 
 
 for hand, 497 
 
 for liearing, 498 
 
 for leg, 497 
 
 for mental processes, 497 
 
 for mouth and larynx, 497 
 
 for shoulder, 497 
 
 for smell, 498 
 
 for speech, 497 
 
 for trunk, 497 
 
 for vision, 497 
 Cephalhematoma, 219, 508 
 Cephalic tetanus, 71 
 Cerebellar abscess, 540 
 Cerebellitis, 530 
 Cerebral abscess from ear disease, 538 
 
 center. See Center, cerebral. 
 
 hemorrhage, artery of, 514 
 
 injuries, differential diagnosis of, 513 
 
 irritability, 512 
 
 operations, color of brain in, 500 
 opening of dura in, 500 
 technique of, 498 
 
 syphilis, 170 
 Cerebritis, 530 
 Cerebro-spinal fluid from ear in fractures 
 
 base of skull, 522 
 Cervical plexus, exposure of, 384 
 Cervix uteri, carcinoma of, 1017 
 treatment of, 1019 
 hypertrophy of, 982 
 lacerations of, 983 
 Cesarean section, 985 
 Chalk-stones, 409 
 Chancre, 142 
 
 of breast, 148 
 
 diagnosis of, 145 
 
 diflerential diagnosis of, 148 
 
 extra-genital, 144 
 
 of hairy scalp, 146 
 
 of hands, 147 
 
 hard or Hunterian, 142 
 
 of 
 
 ("hancre, laliial, differential diagnosis of, 146 
 
 prognosis of, 151 
 
 soft (jr chancroid, 154 
 
 subpreputial, diflerential diagnosis of, 150 
 
 of tongue, 147 
 
 of tonsil, 147 
 
 treatment of, 151 
 
 uretiual, diflerential diagnosis of, 150 
 ( haiicroid, 154 
 
 treatment of, 155 
 Chapped lips, 668 
 Charbon, 128 
 Charcot's disease, 413 
 
 Cheeks and lips, malformations and deformi- 
 ties of, 664 
 Cheese-cloth for dressings, 1082 
 Cheiloplasty, ()70 
 Chetuotaxis, 13 
 Chest, contusions of, (546 
 
 injuries and diseases of, 637 
 
 injuries, complication of, 648 
 sequelae of, 648 
 
 non-penetrating wounds of, 647 
 
 penetrating wounds of, 647 
 hemorrhage in, 647 
 
 wounds of, 647 
 Chiene's method for fixing Bolandic fissure, 
 
 492 
 Chilblain, 480 
 
 Chimney-sweeps' cancer, 960 
 Chloride-of-ethyl spray, 1101 
 Chloroform, 1094 
 
 and ether, rules for giving, 1098 
 
 poisoning from, 1096 
 Cholecystectomy, 785 
 Cholecyst-enterostomy, 787 
 Cholecystotomy, 786 
 Choledochotomy, 788 
 Chondritis, 618 
 Chondroma of bone, 279 
 Chondromata, 199 
 Chopart's amputation, 1165 
 Chordee, 897 
 
 treatment of, 909 
 Chylocele, 470 , 
 Chyluria, 470 
 Cicatrices of neck, 653 
 
 tumors of, 484 
 Circulation, collateral. See Arlei-y. 
 Circumcision, 962 
 
 Clamp and cautery for internal piles, 796 
 Clap (gonorrhea), 895 
 Clavus, 481 
 Claw-hand, 339, 372 
 Cleft palate, 664, 692 
 
 production of, 664 
 Clement's operation for hare-lip, 666 
 Cloaca, 269 
 Club-foot, 353 
 
 hysterical, 357 
 
 shoes, 355 
 Club-hand, 349 
 Coagulation-necrosis, 19 
 Cocaine hydrochlorate, dangers of, 1101 
 
 as a local anesthetic, 1101 
 Coeliotomy, 734 
 Cold abscess, cocci in, 7 
 
 constitutional effects of, 480 
 
 sores, 668 
 
 in synovitis, 387 
 
1204 
 
 INDEX. 
 
 Colli, use of, 1190 
 
 Collateral circulation. See Artery. 
 
 Colics' y law in syphilis, 178 
 
 Collodion, 1190" 
 
 Colon, distention of, with fluids, 730 
 
 Colostomy, 732 
 
 iliac or inguinal, 732, 733, 734 
 Colotoniy, 732 
 Columnar epitheliomata, seats of predilection 
 
 of. 215 
 Coma, diagnosis of forms of, 513 
 Come<lo, 475 
 
 Complications after operation, 1091 
 Compound fractures. See Fractures. 
 Compresses, 1175 
 Compression of abdomen, 731 
 
 for aneurysm, 239 
 advantages of, over ligation, 244 
 
 of brain, 512 
 
 of spinal cord, 578 
 Concretions of tonsils, 690 
 Concussion of brain, 510 
 
 of spinal cord, 577 
 Conditions to which neurectasy is applicable, 
 
 379 
 Condylomata, 208 
 
 syphilitic, 183 
 Coiidy's fluid, 682 
 Congenital defects of diaphragm, 649 
 
 deformities of bladder, 851 
 of jaws, 682 
 of palate, 692 
 of testicles, 949 
 
 fistulic of neck, 652 
 
 malformation of breast, 1050 
 of pharynx, 689 
 of rectum, 790 
 
 sacral tumor, 561 
 Congestion in inflammation, 13 
 Constant current. 1188 
 Contractures, 347 
 
 from burns and scalds, 347, 479 
 
 of muscle, 335 
 Contre-coup, fractures by, 489 
 
 injuries of brain by, 510 ^ 
 Contusions, 87 
 
 of breast, 1069 
 
 of chest, 646 
 
 and compression of nerves, 366 
 
 of head, 510 
 
 of intestines, 728 
 
 involving thoracic viscera, 646 
 
 of larynx, 624 
 
 of neck, 653 
 
 of parotid gland, 657 
 
 of spinal cord, 577 
 
 of stomach, 7ll 
 Cooper, mesenteric hernia of, 834 
 Corn, 481 
 
 Cornu cutaneum, 482 
 Corpuscle, the third, 14 
 
 Corpuscles, white, numerical increase of, in in- 
 flammation, 14 
 Coryza, acute, 591 
 
 syphilitic, 182 
 Cotton, absorbent, 1175 
 Cowperitis, 900 
 
 treatment of, 917 
 (!owper's glands, inflammation of, 900 
 Cracked lips, 668 
 
 Cracked-pot sound in fissured fracture of skull 
 
 and hydrocephalus, 519 
 Craniotabes, 86 
 Crepitus, 290 
 Cripp's splint, 298 
 Croupous inflammation, 19 
 Crusta phlogistica, 14 
 C'ryptorchidism, 949 
 Cuneus, 497 
 Cupping, dry, 1183 
 
 wet, 1 183 
 Curettage of endometriun), 989 
 Curvature of spine, angular, 567 
 anterior, 566 
 lateral, 563 
 posterior, 565 
 Cut throat, 624 
 Cynanche tonsillaris, 689 
 Cvrtometer, Horslev's, 494 
 
 ■ Wilson's, 494 
 Cystic dilatation of Stenson's duct, 658 
 
 testicle, 951 
 Cystitis, 883, 901 
 
 treatment of, 884, 917 
 Cystocele, 811,851,972, 981 
 Cystomata, 217, 1039 
 Cystoscope, Leiter's, 886 
 Cystotomy, perineal, 868 
 
 suprapubic, 873 
 Cysts, atheromatous, 217 
 'blood-, 219 
 
 branchial, 651 
 
 of breast, 1068 
 
 compound proliferous, 219 
 
 congenital, 219 
 
 dermoid, 219, 560, 789, 971, 1041 
 
 extravasation, 218 
 
 exudation, 217 
 
 of gland of Bartholin, 971 
 
 hydatid, 220 
 
 intrathoracic, 645 
 
 of jaw, dentigerous, 684 
 lower, 684 
 multilocular, 684 
 
 of kidnev, 847 
 hydatid, 848 
 
 of lip, 669 
 
 of liver, 780, 782 
 
 of mesentery, 780 
 
 mucous, 218 
 
 of neck, 651 
 
 of new formation, 218 
 
 of omentum, 779 
 
 ovarian, 1042 
 
 of ovary, 1042 
 dermoid, 1041 
 
 of pancreas, 788 
 
 papillomatous, within oophoron, 1042 
 
 parasitic, 220 
 
 paroophoritic, 1041 
 
 parovarian, 1042 
 
 proliferous mammary, 1059 
 
 retention, 217 
 
 sebaceous, 217, 475 
 
 simple or serous, 218 
 
 of spine, dermoid, 560 
 
 of spleen, 789 
 
 sublingual, 675 
 
 of submaxillary gland, 659 
 
 of vulva, dermoid, 971 
 
INDEX. 
 
 1205 
 
 Cysts of vulva, sebaceous, 971 
 Czeriiy-Lenibert suture, 709, 745 
 Czerny's method of tendon suture, 343 
 
 Dactylitis, syphilitic, 170, 186 
 Death, causes of, after operation, 1091 
 Decubitus, 48, 54 
 Deformities, amputation for, 1152 
 
 (if chest, anesthesia in, 1073 
 
 congenital, 351, G51, 682, 692, 851, 949 
 
 of jaws, 684 
 
 of nose, 589 
 
 of palate, 692 
 
 of spine, 558 
 Deformity in arthritis, 389 
 
 in fractures, 28!) 
 
 silver-fork, 318 
 Degeneration, reactions of, 359 
 Delirium nervosum, 37 
 
 traumatic, 37 
 
 tremens, 38, 293 
 after fracture, 293 
 Demarcation, line of, 53 
 Dental caries, 686 
 
 periostitis, 686 
 Dentigerous cysts of jaw, 684 
 Dermatitis venenata, 475 
 Dermoid cysts. See CijMs, dei-moid. 
 Desault's bandage, 1179 
 Development, arrested, trephining for, 556 
 Diapedesis of leucocytes, 12 
 Diaphragm, congenital defects of, 649 
 
 hernia of. See Hernia. 
 
 paralysis of, 649 
 
 rupture of, 650 
 
 surgical affections of, 649 
 
 wounds of, 650 
 Didot's operation for webbed fingers, 350 
 Digestive tract, surgery of, 664 
 Dilatation of stomach, 715, 716 
 
 of urethra, 928 
 Diplococci, 1 
 
 Disease, relation of, to operation, 1074 
 Disinfection of field of operation, 1076 
 
 of hands, 1078 
 
 of instruments, 1079 
 Dislocations, accidents during reduction 
 429 
 
 after-treatment of, 430 
 
 of astragalus, 461 
 
 attitude of limb in, 426 
 
 bilateral, 423 
 
 of carpal bones, 449 
 
 carpo-metacarpal, 449 
 
 causes of, 424 
 
 of clavicle, 433 
 
 of coccyx, 451 
 
 complicated, 423 
 
 complications of, 312, 425 
 
 congenital, 423, 430 
 
 of costal cartilages, 433 
 
 deformity in, 426 
 
 double, 423 
 
 of elbow, 443 
 
 etiology of, 424 
 
 of femur, 451 
 
 of fibula, 460 
 
 of foot, 461 
 
 habitual, 443 
 
 of hip, 451 
 
 of. 
 
 Dislocations of hi|>, complications of, 45(1 
 compouixl, 456 
 
 congenital, 430 
 after typhoid, 452 
 
 fractures in reduction of, 456 
 
 pathological, 457 
 
 unreduced, treatment of, 457 
 of humerus, 436 
 
 with fracture, 442 
 
 McBurney's method of treatment, 442 
 
 habitual, 443 
 incomplete, 423 
 of lower jaw, 432 
 of knee, 458 
 
 of laryngeal cartilages, 625 
 measurements in, 427 
 mechanism of, 424 
 methods of reduction of, 428 
 mobility in, 427 
 by muscular action, 424 
 nomenclature of, 423 
 old, reduction of, 429 
 partial, 423 
 of patella, 459 
 pathological, 423 
 pathology of recent, 425 
 of pelvis, 451 
 
 predisposing causes of, 424 
 of radio-ulnar joint, lower, 448 
 of radius above, 447 
 
 by elongation, 448 
 
 and ulna, divergent, 447 
 reduction of, by manipulation, 428 
 repair after, 425 
 of ribs, 433 
 
 of semilunar cartilages, 459 
 shortening in, 427 
 of shoulder, 436 
 
 complications of, 441 
 
 compound, 441 
 
 fractures with, 441 
 
 luxatio erecta, 440 
 
 old, unreduced, treatment of, 443 
 
 reduction of, by Kocher's method, 438 
 
 treatment of, 438 
 
 vascular and nerve injuries in, 442 
 of spine, 587 
 spontaneous, 423, 431 
 
 in fevers, 431 
 of sternum, 432 
 subastragaloid, 461 
 symptoms of, 426 
 of tarsus and metatarsus, 462 
 of thumb and fingers, 449 
 traumatic, 423 
 treatment of, 427 
 of ulna alone, 447 
 unreduced, 426 
 of vertebrie, 587 
 of wrist, 448 
 Dissection wounds, 123 
 Diverticula of pharynx, 689 
 Double inclined plane, 296 
 Douche, alternate, hot and cold, 1190 
 Drainage, 102, 1083 
 
 of abdominal cavity, 710 
 Dressing, plaster-of- Paris, 1181 
 silicate-of-soda, 1181 
 wounds, dry method of, 1087 
 Dressings, 103, 1082 
 
1206 
 
 INDEX. 
 
 Dressings, changes of, 103, 1090 
 Hxed, 1181 
 renewal of, 1092 
 Dry cold, 1190 
 heat. 11S9 
 
 method of dressing wounds, 1087 
 of Landerer, 1083 
 Dugas' sign, 437 
 
 Dupuvtren's amputation at shoulder-joint, 
 1161 
 contraction of fingers, 348 
 splint, 332 
 I)ural separator, Horsley's, 499 
 Dura mater, fungus of, 50G 
 
 loss of, tilled in by pericranium, 502 
 opening of, in cerebral operations, 499 
 Dysesthesia, regions of, 369 
 
 £ab, cerebro-spinal fluid from, in fracture of, 
 base of skull, 522 
 
 disease causing meningitis, 538 
 cerebral abscess from, 538 
 
 suppurative disease of, causing brain dis- 
 ease, 537 
 
 syphilis of, 184 
 Ecchvmosis, 87 
 
 Echinococci, 220, 781, 848, 1068 
 Ecthyma, syphilitic, 161 
 Effusions, pleuritic, 637 
 Elbow, cerebral center for, 497 
 Elbow-joint disease, 402 
 
 tuberculosis of 402 
 Election, triangle of, 1115 
 Electric injuries, 122 
 Electricity, 1188 
 Electrode, double, for brain, 501 
 Electrolysis, 1188 
 
 in uterine fibro-myomata, 1006 
 Elephantiasis arabum, 472 
 
 of scrotum, 960 
 
 of vulva, 972 
 Elytrorrhaphy, 981 
 Embolism, 58, 292 
 
 fat, 96, 292 
 Embolus, 58 
 Embryonic tissue, 26 
 Emphysema, 647, 648 
 
 of neck, 655 
 
 surgical, of nose, 612 
 Empyema, 47, 638 
 
 of frontal sinus, 609 
 
 idiopathic forms of, 638 
 
 surgical treatment of, 638 
 
 traumatic, 638 
 Encephalitis, 530 
 
 operative interference in, 531 
 Encephalocele, 506 
 Encephaloid carcinoma, 212 
 
 of breast, 1064 
 Enchondroma of jaws, 684 
 
 of nose, 608 
 
 of testicle, 951 
 Enchondromata, 199 
 Endarteritis, 228 
 
 Endocanalicular mammary tumor, 1059 
 Endometritis, 987 
 Endometrium, curettage of, 989 
 Endotheliomata, 208 
 Enterectomy, 709, 744 
 
 in wounds of abdomen, 709 
 
 Enterocele, 811 
 
 I)artial, 821 
 Entero-epiplocele, 811 
 Entero-llthiasis, 749 
 Enterorrhai)liy, 744 
 Enterostomy, 731 
 Enterotomy, 732 
 Epiblastic tumors, 210 
 Epidermic pearls, 213 
 Epidermis, regeneration of, 30 
 Epididymitis, 902, 949 
 
 treatment of, 919 
 Epilepsy, 550 
 
 focal, 554 
 
 general, 555 
 
 Jacksonian, 552 
 
 non-traumatic, 552 
 
 removal of cortical center in, 551 
 
 traumatic, 550 
 
 trephining for, 551, 553, 554 
 Epiphysis of femur, separation of, 325 
 
 lower, of humerus, separation of, 315 
 
 separation of, 284, 311, 315, 325 
 
 upper, of humerus, separation of, 311 
 Epiphysitis, 267 
 
 acute, 267 
 Epiplocele, 811 
 Epispadias, 962 
 Epistaxis, 601 
 
 Epithelial carcinomata, 213 
 Epithelioma, 213, 487 
 
 columnar, 215 
 
 columnar-celled, 215 
 
 of jaws, 685 
 
 of lip, 214, 668 
 
 of penis, 963 
 
 of scrotum, 960 
 
 of skull, 506 
 
 squamous-celled, 213 
 
 of tongue, 166, 677 
 Epulis, 683 
 Equinia, 135 
 Erasion, 1133 
 
 in ankle-joint disease, 401 
 
 in elbow-joint disease, 403 
 
 of joint, 391 
 
 for knee-joint disease, 400 
 
 in wrist-joint disease, 403 
 Erectile tumors, 202 
 Erethistic granulations, 28 
 Ergot in uterine fibro-myomata, 1005 
 Erysipelas, 66 
 
 curative influence of, 69 
 
 facial, 68 
 
 of mucous membranes, 68 
 
 neonatorum, 68 
 
 phlegmonous, 68 
 
 streptococcus of, 7, 66 
 
 after wounds, 107 
 Erysipeloid, 467 
 Erythema, syphilitic, 158 
 Esmarcli's apparatus, 1153 
 
 bandage in aneurysm, 241 
 
 operation for ankylosis of jaw, 686 
 
 powder, 1065 
 Esthiomene, 970 
 Estlander's operation, 47, 641 
 Ether, 1092 
 
 administration of, 1093 
 
 and chloroform, rules for giving, 1098 
 
INDEX. 
 
 1207 
 
 Ether, contraindication to use of, as an anes- 
 thetic, 1093 
 
 poisoning iVoni, 1096 
 
 voniitinf,', 10S9 
 J:thnioi<l.ii ceils, f)09 
 Ethvl cliloride, 1101 
 Eucaine, 1103 
 Evacuation of sti>inach, 730 
 Evacuator of Higelow, S78 
 Examination of patient before operation, 1073 
 Excision. See Iit;gection, 1142 
 Excurvation of spine, 563, 565 
 Exostoses, 277, 505 
 
 of nose, 607 
 Exploratory puncture, 969 
 Exstr()f)l>y of bladder, 851 
 Extension apparatus, 296 
 Extravasation of urine, 935 
 Exudation cells, 27 
 
 Eace, cerebral center for, 497 
 Facies ovariana, 1044 
 Facultative bacteria, 2 
 Fallopian tube, fibro -rayomata of, 1048 
 inliainmation of, 1025 
 papilloniata of, 1048 
 surgerv of, 1025 
 tumors of, 1029. 
 malignant, 1048 
 False passages, 892, 934 
 Faradic electricity, 1188 
 Faradization of brain, in recognizing motor 
 
 centers, 500 
 Farcy, 135 
 Fat embolism, 296 
 Fatty tumors, 198 
 of scalp, 503 
 Faucial tonsils, 598 
 Fecal fistula, 770 
 
 impaction, 750, 800 
 
 obstruction, 750 
 Feces, rectal impaction of, 800 
 Felon, 47, 340 
 Femoral canal, 828 
 
 hernia. See Hernia, femoral. 
 
 ring, 828 
 Femur, osteotomy through neck of, 1138 
 through shaft of, 1138 
 
 separation of epiphysis of, 325 
 Fever, aseptic, 34 
 
 blisters, 668 
 
 catheter, 893 
 
 hectic, 36 
 
 secondary, 36 
 
 septic, 35 
 
 suppurative, 34-36 
 
 surgical, 34 
 scarlet, 37 
 
 traumatic, 35 
 
 malignant group of, 34 
 
 urethral, 37, 893 
 
 urinary, 893 
 Fevers, spontaneous dislocations in, 431 
 Fibrinous inflammation, 18 
 Fibroblasts, 30 
 Fibroma of bladder, 886 
 
 of bone, 278 
 
 of jaws, 684 
 
 of "uterus, 1003 
 Fibromata, 197 
 
 Fil)ro-myomata, uterine, 1003 
 electrolysis in, 1006 
 ergot in, 1005 
 
 extirpation through abdominal incision, 
 1007 
 through vagina, 1000 
 removal l)y f)i)('ratiou, 1006 
 
 of uterine appendages for, 1006 
 sul)mucous, 1003 
 sul)serous, 1003 
 treatment of, 1005 
 Fibro-myxomata of bladder, 886 
 Fibrous tumors, 197 
 Field of operation, disinfection of, 1076 
 Filaria sanguinis hominis, 471 
 Filiform wliaiel)oue Itougies, 893 
 Fingers, Dupuvtren's contraction of, 348 
 
 webbed, 349 
 First intention, liealing by, 25 
 Fissure of anus, 49, 800 
 of Bichat, 491 
 of bone, 283 
 
 of cheek, congenital, 665 
 intraparietal, 497 
 median, 491 
 
 of lower lip, 670 
 of nose, 590 
 ofEolando, 491 
 
 Chiene's method of fixing, 492 
 of Sylvius, 496 
 Fistula, 51, 801 
 in ano, 801 
 
 and phthisis, 803 
 tubercular, 78 
 blind, 802 
 complete, 802 
 of neck, 652 
 fecal,_ 770 
 gastric, 718 
 incomplete, 802 
 milk, 1055 
 of neck, 652 
 of parotid gland, 657 
 of pharynx, 689 
 recto-urethral, 804 
 recto-vaginal, 804, 980 
 recto-vesical, 803 
 salivary, 657 
 of Stenson's duct, 657 
 ureteral, 850, 1023 
 urethral, 936 
 vesico-vaginal, 977 
 Fixed dressings, 1181 
 Flail-joint after excision of head of humerus, 
 
 402 
 Flat-foot, 357 
 
 Flexion of joint in aneurysm, 241 
 Floating cartilages, 421 
 kidnev, 836 
 liver, 784 
 Fluhrer's aluminium probe, 526 
 Focal epilepsy, 554 
 Foetal tumors, 561 
 Follicular abscess, 899 
 treatment of, 917 
 Fomentations, antiseptic, 1190 
 Food and drink after an operation, 1089 
 Foot, perforating ulcer of, 486 
 Foot-drop, 374 
 Forcible correction in Pott's disease, 575 
 
1208 
 
 INDEX. 
 
 Foreign bodies in air-paRsages, 625 
 
 in brain. o'iS 
 
 in frontiil sinuses, G09 
 
 in nose, fiOS 
 
 in cesopliagns, 69S 
 
 in j)eritoneuni, 773 
 
 in rectum, 799 
 
 in stomach, 713 
 
 of tongue, 674 
 
 in vagina, 981 
 I'^ormaldehyde sterilization, 1080 
 Formative cells, 27 
 Fossa iiaviiMilaris, stricture of, 932 
 Fracture or Fractures, 282 
 of acetabulum, 321 
 of acromion process, 309 
 ambulant treatment of, 296 
 of astragalus, 333 
 of atlas and axis, 583 
 Barton s, 320 
 box, 294 
 
 of calcaneum, 333 
 of clavicle, 30G 
 of coccvx, 321 
 Col less, 318 
 comminuted, 285 
 complete, 283 
 
 complications and consequences of, 291, 312 
 compound, 276, 283 
 
 treatment of, 298, 299 
 of coracoid process, 309 
 of coronoid process, 316 
 of costal cartilages, 306 
 with crushing, 286 
 deformity in, 289 
 delayed union of, 300 
 dentate, 283 
 by depression, 283 
 by direct violence, 285, 289 
 with dislocations of shoulder, 441 
 
 of hip, 456 
 displacements in, 287 
 just above elbow, after-treatment of, 316 
 of external malleolus, 332 
 extracapsular, 285 
 faulty union of, 303 
 of femur, 321 
 
 extracapsular, 321 
 
 intracapsular, 321 
 
 lower end of, 325 
 
 neck of. 321 
 
 ill reducing hip dislocations, 456 
 
 shaft of, 324 
 fissured, 283 
 of foot, 333 
 of forearm, 317 
 
 frequency of, in different bones, 282 
 of glenoid fossa, rim of, 310 
 green-stick, 283 
 gunshot, 287 
 of hip, 322 
 
 measurements in, 322 
 of humerus, 310 
 
 with dislocation of bead, 312 
 
 lower end of, 313 
 
 shaft of, 31. S 
 
 upper end of, 310 
 of hyoid bone, 305 
 of ilium, 321 
 immediate causes of, 288 
 
 Fracture or Fractures, impacted, 285, 310, 322 
 incom]>lete, 283 
 bv indirect violence, 285, 289 
 intercondyloid, 284, 313, 325 
 intra-articular, 284 
 intracapsular, 285 
 of ischium, 321 
 of larvnx, 625 
 of leg,' 329 
 
 lower end of, 330 
 
 upper end of, 329 
 longitudinal, 283 
 of lower jaw, 304 
 of metacarpal bone, 320 
 of metatarsal bones, 333 
 mobility in, 427 
 
 abnormal, 290 
 multiple, 285 
 
 by muscular action, 285, 289 
 of nasal bones, 303 
 oblique, 283 
 of olecranon, 316 
 of patella, 326 
 
 operative measures for, 327 
 
 subcutaneous suture for, 328 
 pathological, 282 
 of pelvis, 320 
 of penis, 962 
 
 permanent dressings for, 293 
 of phalanges, 320 
 Pott's, 330 
 
 predisposing causes of, 288 
 of pubes, 321 
 of radius, lower end of, 318 
 
 shaft of, 317 
 
 and ulna, 316 
 
 upper end of, 317 
 reduction or setting of, 293 
 repair of, 290 
 of ribs, 305 
 of sacrum, 321 
 of scapula, 309 
 simple, 282 
 of skull, 518 
 
 base of, 522 
 
 compound, 521 
 
 by contre-coup or counter-stroke, 489 
 
 fissured, of vault of, 519 
 
 inner table of, 519 
 
 punctured, 521 
 of base of, 522 
 
 rules for trephining in, 520 
 
 vault of, 519 
 of spine, 579 
 spontaneous, 282 
 
 in cancer, 212 
 of sternum, 305 
 
 of superior maxilla and malar bones, 303 
 symptoms of, 289 
 toothed, 283 
 transverse, 283 
 treatment of, 293 
 T-shaped. 284 
 of ulna, shaft of, 317 
 ununited, 282, 300 
 
 treatment of, 302 
 varieties of, 282 
 of vertebrae, 579 
 V-shaped, 283 
 Fraenum linguae, shortness of, 672 
 
INDEX. 
 
 1209 
 
 Fragilitas ossium, 277 
 Fratiklinic electricity, 1188 
 Fruiiklinism, 1188 
 
 Frontal sinus, cystic dilatation of, 609 
 dropsy of, 009 
 empyenui of, 609 
 tumors of, 609 
 sinuses, foreif^n bodies in, 609 
 inHamniation of, 609 
 injuries of, 608 
 sulcus, inferior, 496 
 superior, 496 
 Frost-bite, 479 
 
 gangrene from, 55 
 Fungus cerebri, o28 
 of dura mater, 506 
 hi^matodes, 212, 655 
 Fiirbringer's method of disinfecting hands, 
 
 1078 
 Furuncle, 46 
 
 Galactocele, 218, 1068 
 Gallbladder, distention of, 784 
 
 rupture of, 785 
 Gall-stones, 784 
 
 intestinal obstruction from, 749 
 Galvanic electricity, 1188 
 Galvano-cautery, 1188 
 Gal vano- puncture iti aneurysm, 245 
 Ganglion, 341 
 
 compound, 340 
 Gangrene, 21, 52 
 
 amputation for, 1152 
 
 dry, 52 
 
 embolic, 60 
 
 ergot causing, 55 
 
 after fracture, 293 
 
 from frost-bite, 55 
 
 hospital, 57 
 
 idiopathic, 53 
 
 of lungs, 643 
 
 moist, 53 
 
 neuropathic, 55 
 
 of penis, 963 
 
 senile, 53 
 
 symmetrical, 55 
 
 traumatic, localized, 54 
 spreading, 54 
 
 treatment of, 55 
 
 after wounds, 107 
 Gangrenous emphysema, 125 
 
 inflammation, 19 
 
 intestine, 824 
 Gant's operation, 1138 
 Gartner's duct, 1040 
 Gasserian ganglion, removal of, 364, 381 
 Gastrectomy, 727 
 Gastric fistula, 718 
 Gastrocele, 811 
 Gastro-enterostomy, 724 
 
 Gastro-intestinal tract, disturbances of, in he- 
 reditary syphilis, 189 
 Gastrorrhaphy, 719 
 Gastrostomy, 719 
 
 Witzel's method of performing, 721 
 Gastrotomy, 718 
 
 and digital exploration of oesophagus, 700 
 
 for foreign bodies in stomach, 713 
 Gauze, absorbent, 1082, 1175 
 
 antiseptic, 1082 
 
 Gauze, bichloride, 1082 
 iodoform, 1082 
 sublimate, 1082 
 (ielatiniform or gelatinoid degeneration, 389 
 Generative organs, female, anatomy of, 965 
 methods of examination of, 967 
 surgery of, 965 
 Genitourinary disease, diagnosis of, 852 
 frequency of micturition in, 853 
 hematuria in, 853 
 pain in, 852 
 tract, male, surgery of, 835 
 tuberculosis of, 78 
 Genu valgum, 351, 1136 
 
 varum, 352 
 Gibson's bandage, 1178 
 Girdner's telephonic probe, 528 
 Glabella, 491 
 
 (iiand, prostate. See Prostate gland. 
 Glanders, 84, 135 
 
 bacillus of, 9, 135 
 Glands of Hartliolin, inflammation of, 969 
 retention-cyst of, 971 
 lymphatic, inflanunation of, 466 
 
 sarcoma of, 474 
 salivary, 657 
 tubercular, of neck, 655 
 Glandular tumors, 209 
 Gleet, 906 
 
 treatment of, 915 
 Glioma, 205 
 Glossitis, acute, 676 
 
 mercurial, 676 
 Glover's suture, 1084 
 Goitre, 660 
 
 exophthalmic, 662 
 operative procedures for, 661 
 strumitis in, 660 
 treatment of, 661 
 Gonion, 491 
 Gonococcus, 7, 896 
 Gonorrhea, 895 
 abortive, 904 
 ardor urinse in, 897 
 bubo in, 900 
 catarrhal, 903 
 
 complications of, 903 
 chronic, 905 
 
 treatment of, 914 
 in the female, 920 
 
 treatment of, 923 
 incubation interval, 896 
 irritative, 904 
 lymphangitis in, 900 
 subacute, 903 
 
 symptoms and complications of first stage, 
 897 
 of second stage, 899 
 of third stage, 902 
 treatment of, 907 
 
 urethral injections for early stage of, 910 
 of uterus, 923 
 treatment of, 925 
 Gonorrheal arthritis, 407 
 bubo, in female, 920 
 
 treatment of, 917 
 
 conjunctivitis, 904 
 
 treatment of, 920 
 
 ophthalmia, 904 
 
 treatment of, 919 
 
1210 
 
 jyiJEX. 
 
 Gononlical rlieiiniatism, 407, 877 
 
 treatment of, '.Ult 
 (ioulev's tunnelled catheter, 893 
 (iout, rlieuinatie, 409 
 (Toutv arthritis, 409 
 (iranulation and Granulations, 28 
 erethistic, 28 
 healing by, 27 
 -tissue, 2t) 
 Grannlomata, infectious, of neck, 655 
 Gravel, 838 
 ti raves' disease, 662 
 Grilled hand, 339 
 Grittis amputation, 1167 
 Guaiacol in treatment of local tuberculosis, 656 
 
 pain, 1103 
 Gum-boil, 682 
 Gumma, cerebral, 170 
 of tongue, 677 
 
 diflerential diagnosis of, 166 
 Gumniata, 163 
 Gummatous osteo-myelitis, 168 
 
 osteo-periostitis, 168 
 Gums, abscess of, 682 
 Gunpowder grains in skin, 121 
 Gunshot wounds, 112 
 
 of abdomen, 702 
 
 of brain, 525 
 
 of the head, 525 
 
 of joints, 416 
 
 of spleen, 789 
 
 of stomach, 712 
 Guthrie's amputation at hip-joint, 1170 
 Gyrus, angular, 497 
 supramarginal, 497 
 
 Hallux varcs, 357 
 
 Halsted's method in carcinoma of breast, 1067 
 
 Hammer-finger, 358 
 
 Hammer-toe, 358 
 
 Hand, cerebral center for, 497 
 
 Handkerchief bandages, 1181 
 
 Hands, disinfection of, 1078 
 
 Hare-lip, 604 
 
 Hartley's operation on the Gasserian ganglion, 
 
 382 
 Head, contusions of, 510 
 
 diseases and injuries of, 489 
 
 gunshot wounds of, 525 
 Headache, inveterate, trephining for, 555 
 Healing of arteries, 33 
 
 under a blood-clot, 29, 1087 
 
 by first intention, 25 
 
 by granulation, 27 
 
 by second intention, 27 
 
 of subcutaneous wounds, 29 
 
 by third intention, 28 
 
 of wounds, 25 
 Hearing, cerebral center for, 498 
 Heart, diseases of, 221 
 
 injuries of, 222 
 
 and lungs, examination of, before operation, 
 1073 
 
 over-distention of, 221 
 
 rupture of, 222 
 
 tapping the cavitv of, 221 
 
 wo\mds of, 222. 22:; 
 
 cause of sudden death in, 223 
 Heat as an antiseptic, 1077 
 
 and cold, ajiplications of, 1189 
 
 Heat, dry, 1189 
 
 eHect of, on sjwres, 4 
 
 moist, 11.S9 
 Heath's method of removal of entire tongue, 
 
 680 
 Hectic fever, 36 
 
 state, 394 
 Hematocele, 058 
 
 intraperitoneal, 1033 
 
 pelvic, 1033 
 
 pudendal, 9t)9 
 Hematomata, 87, 219 
 
 of broad ligament, 1033 
 
 vulva-, 969 
 Ilematomyelia, 578 
 Hematosalpinx, 1026 
 Hematuria in genitourinary disease, 853 
 Hemianopsia, 546 
 Hemophilia, 256, 1073 
 Hemorrhage, 91, 252, 1071 
 
 abdominal, laparotomy for, 707 
 
 in abdominal section, arrest of, 1013 
 
 after amputation, 1158 
 
 after-treatment of, 256 
 
 arrest of, 99 
 
 in penetrating wounds of chest, 648 
 
 arterial, 252 
 
 into brain-substance, 517 
 
 capillary, 252 
 
 cerebral, artery of, 513 
 
 in cerebral operations, 500 
 
 consecutive, 252 
 
 constitutional, 253 
 
 diagnosis of, 254 
 
 extradural, 514 
 
 extrameduilary, of spine, 578 
 
 in hip-joint amputations, 1171 
 
 from intercostal artery, 261 
 
 intermediary, 252 
 
 from internal mammary artery, 261 
 
 intracranial, 514 
 
 intramedullary, of spine, 579 
 
 ligation in, 255 
 
 local, treatment of, 254 
 
 from middle meningeal artery, 514 
 
 in operations on liver, 784 
 
 from pachymeningitis interna, 517 
 
 parenchymatous, 252 
 
 primary, 252 
 
 reactionary, 252 
 
 secondary, 253 
 
 spinal, 578 
 
 spontaneous, arrest of, 253 
 
 subdural, 516 
 
 from tooth socket, 688 
 
 torsion in, 255 
 
 transfusion after, 254 
 
 treatment of, rules for 256 
 
 in \iranoplasty, 695 
 
 venous, 252 
 
 symptoms of, 261 
 
 in woiuids of abdomen, 707 
 Hemorrhagic diathesis, 1073 
 
 inHammatif)n, 19 
 Hemorrhoids, 792 
 
 external, 794 
 
 internal, 795 
 Hemothorax, 639 
 Hepatopexy, 784 
 Hereditary syphilis, 176 
 
INDEX. 
 
 1211 
 
 Hiri'ditarv sypliilis, disttirliances of jjaslro- 
 
 intestiiial trat't in, IS'J 
 IIiTiua, SIO 
 anatomy ul", SI 1 
 
 Hassini's method of radical cure, .SI"), S17 
 of bladder, S')! 
 ciecal, 811, 817 
 cerebri, G'JS 
 
 conjienital, radical cure of, S17 
 of diaphragm, 8o3 
 diaphragmatic, 8o.> 
 encysted, 8*2(1 
 femoral, S'JS 
 
 into foramen of Winslow, 833 
 into funicular j)rocess, 826 
 incarcerated, 818 
 infantile, 82(> 
 inflamed, 819 
 inguinal, 825 
 
 treatment of, 828 
 irreducible, 818 
 ischiatic, 832 
 Littr^'s, 821 
 lumbar, 832 ^ 
 of lung, 648 
 of muscle, 334 
 obturator, 832 
 ovarian, 1034 
 
 palliative treatment of, 812 
 perineal, 832 
 properitoneal, 833 
 radical cure of, 831 
 retroperitoneal, 834 
 Richter's, 821 
 sigmoid, 818 
 strangulated, 819 
 umbilical, 830 
 ventral, 831 
 Herniotomy, 823 
 
 in femoral hernia, 829 
 in inguinal hernia, 828 
 in umbilical hernia, 831 
 Herpes of lips, 668 
 Hesselbach's triangle, 825 
 Heterologous tumors, 194 
 Hey's amputation, 1163 
 Highmore, antrum of, 610 
 Hip-joint abscess, aspiration of, 397 
 opening of, 397 
 disease, 391 
 
 abscess from, 393, 394 
 ankylosis in, 395 
 deposition of bacilli in, 392 
 first stage, 392 
 osteotomy for, 1137 
 prognosis of, 395 
 second stage, 392 
 stage of lengthening, 392 
 
 of shortening, 393 
 symptoms of first stage, 392 
 of second stage, 392 
 of third stage, 393 
 terminations of, 395 
 treatment of, 395 
 tuberculosis of, 391 
 Hodgen's splint, 299 
 Hodgkin's disease, 474, 657 
 Holla's operation, 437 
 Hollow foot, 356 
 Homologous tumors, 194 
 
 Hopkins' rongeur forceps, 499 
 Horns, 482 
 
 of scalp, 503 
 Horny growths of lips, 669 
 Horseshoe kidney, 841 
 Horsley's antiseptic wax, 1154 
 cyrtometer, 494 
 dural separator, 499 
 Hospital gangrene, 9 
 Housemaid's knee, 344 
 Howship's lacuna-, 2<)4 
 
 Humerus, separation of upper epiphysis of, 311 
 Hunterian oj)eration for aneurysm, 243 
 Hutchinson's teeth, 187, 6S7 
 li (iter's mctliod of reaching the facial nerve, 38:1^ 
 Hydatids, 220, 780, 848, 1068 
 Hvdrartlirosis, 388 
 Hydrated testicle, 951 
 Hydrenceplialocele, 506 
 Hydrocele, 955 
 encysted, 956 
 incision of, 958 
 infantile, 956 
 injection of, 956, 957 
 of neck, congenital, 651 
 of round ligament, 1048 
 of spermatic cord, 827, 958 
 symptoms of, 956 
 tapping of, 956 
 treatment of, 956 
 Hydrocephalus, 507 
 
 Hydrogen gas in intestinal perforation, /06, 
 70S, 728 
 rectal insufflation of, 706, 730 
 peroxide as an antiseptic, 1077 
 test in intestinal contusions and lacerations, 
 728 
 Hydronaphtol as an antiseptic, 1077 
 Hydronephrosis, 843 
 Hydrophobia, 84, 131 
 Hydrops articuli, 388 
 Hydrorrhachis, 559 
 Hydrosalpinx, 1026 
 Hygroma of neck, 651 
 Hymen, 976 
 Hyperostosis of jaw, 684 
 Hvpertrophv of bones of skull, 505 
 of breast," 1053 
 of cervix uteri, 982 
 of lips, 669 
 of muscle, 336 
 of nails, 483 
 of prostate, 940 
 scars, 484 
 of tonsils, 690 
 Hvpnotic suggestion in hysterical joints, 415 
 Hypoblastic tumors, 210 
 Hypodermatic injections, 1187 
 Hypodermoclysis, 95, 1185 
 Hypospadias, 960 
 Hysterectomy, abdominal, 1007 
 Cesarean, 985 
 supravaginal, partial, 1007 
 
 total. 1010 
 vaginal, 1019 
 Hysteria, traumatic, 577 
 Hysterical club-foot, 357 
 
 joints, 413 
 Hysteropexy, 997 
 Hysterorrhaphy, 986 
 
1212 
 
 INDEX. 
 
 IciioRors pus, 41 
 
 Ileo-oolostoiiiy, 738 
 
 lli:ic fossa, circumscribed alwcess of, 7<>7 
 
 Iiiipai'tiou, fecal, 800 
 
 Imperforate aims, 7!)0 
 
 rectum, 790 
 Impetigo, sypliililic, 161 
 Implantation, lateral, of intestine, 74ri 
 Impotence, 953 
 
 pseudo-, 9")3 
 Incision, length of, 1083 
 Inclineil jilanes, 1091 
 Incontinence of retention, 581, 95ti 
 
 of urine, 856 
 
 after fractures of the spine, 581 
 Incurvation of spine, 563-566 
 Indian method of rhinoplasty, 613 
 Inditierent cells, 26 
 Induced current, 1188 
 Infarction, 59 
 Infection, bio-chemical, 123 
 
 mixed. 123 
 Inflammation, 10 
 
 adhesive, 18 
 
 asthenic, 18 
 
 of bone, chronic, 271 
 
 of breast, 1 053 
 
 cardinal symptoms of, 10 
 
 chronic, 20 
 
 congestion in, 13 
 
 croupous. 19 
 
 diet in. 25 
 
 of Fallopian tubes, 1025 
 
 fibrinous, 18 
 
 of frontal sinuses, 609 
 
 gangrenous, 19 
 
 hemorrhagic, 19 
 
 interstitial, 18 
 
 of joints, 388 
 
 of lips, 668 
 
 of male breast, 1070 
 
 of nerve, 360 
 
 of nipple, 1051 
 
 of ovary, 1035 
 
 parenchymatous, 18 
 
 of penis, 963 
 
 phlegmonous, 19 
 
 of scalp, 503 
 
 septic, of bone, 266 
 
 serous, 18 
 
 sthenic, 18 
 
 suppurative, 19 
 
 terminations of, 20 
 
 treatment of, constitutional, 23 
 local, 21 
 
 of uterus, 987 
 
 of vagina, 980 
 
 varieties of, 18 
 
 vascular changes in, 11 
 
 of veins, 224 
 
 of vulva, 969 
 
 after wounds, 106 
 Ingrowing toe-nail, 483 
 Inion, 491 
 
 Injections, coagulating, in aneurysm, 245 
 hypodermatic, 1187 
 
 of rectum, 730 
 
 urethral, in earlv stage of gonorrhea, 
 910 
 Insanity, post-operative, 38 
 
 Insanity, trephining for, 555 
 Insect-bites and stings, 126 
 Instruments, disinfection of, 1079 
 Intestinal anastomosis, 736 
 without rings, 741 
 canal, tuberculosis of, 78 
 concretions, obstruction from, 750 
 fistula, 770 
 obstruction, 729 
 acute, 748 
 
 from adhesions and angulations, 1016 
 adynamic, 759 
 after-treatment of, 747 
 anatomico-pathological forms of, 748 
 from ascarides, 750 
 chronic, 748, 749 
 from concretions, 750 
 direct treatment of, from strangulation by 
 band, diverticulum, flexion or adhe- 
 sion of intestines, 746 
 from gall-stones, 749 
 from intussusception, 751 
 operative treatment of, 719, 730 
 surgical resources in treatment of, 730 
 perforation, after tvphoid, hydrogen gas in, 
 
 706, 708, 709 
 stenosis, non-malignant, 755 
 tract, syphilis of, 172 
 tumors, 756 
 Intestine and Intestines, carcinoma of, 756 
 cicatricial stenosis of, 755 
 congenital stenosis of, 755 
 contusion of, 728 
 diseases and injuries of, 728 
 exclusion of, 747 
 flexions and adhesions of, 753 
 gangrene of, 60 
 invagination of, 751 
 lateral implantation of, 736, 746 
 puncture of, 731 
 rupture of, 728 
 sarcoma of, 756 
 strangulation bv bands or diverticula, 
 
 756 
 suturing of wounds of, 709 
 to trace up or down, 724 
 woinids of, 728 
 Intracanalicular mammary tumor, 1059 
 Intra parietal fissure, 497 
 Intrathoracic cysts, 645 
 
 tumors, 644 
 Intubation of larynx, 632 
 
 in syphilitic stenosis of larynx, 532 
 Intussusception, 751 
 Intussusceptum, 751 
 Intussuscipiens, 751 
 Invagination of bowels, 751 
 Involucrum, 269 
 Involution cysts of breast, 1069 
 Iodoform as an antiseptic, 1077 
 gauze, 1082 
 
 in treatment of cold abscess, 46 
 Iritis, svphilitic, 183 
 Irrigation, 1083, 1190 
 of abdominal cavity, 710 
 of stomach, 730 
 Irritability, cerebral, 512 
 I schio- rectal abscess, 790, 801 
 chronic, 801 
 fossa, 790 
 
INDEX. 
 
 1213 
 
 Jacksonian epilepsy, 552 
 Jaw and Jaws, abscess of, 682 
 acqiiireil derurinilies of, 082 
 ankylosis of, GSG 
 
 Ksniarch's operation for, 686 
 oareinonia of, 685 
 closure of, 686 
 
 congenital deformities of, 682 
 dentigerous cysts of, 684 
 diseases of, 682 
 enchondroina of, 684 
 epithelioma of, 685 
 fibroma of, 684 
 hyperostosis of, 684 
 lower, cysts of, 684 
 uniltilocular cysts of, 684 
 necrosis of, 683 
 osteomata of, 685 
 phosphorous necrosis of, 683 
 sarcoma of, 685 
 tumors of, 684 
 Johnson's modified Durham's trachea-tube, 630 
 Joints, anatomical construction of, 385 
 ankylosis of, 418 
 
 partial, 419 
 erasion of, 391 
 excision of, 391 
 gunshot wounds of, 416 
 hysterical, 413 
 inflammations of, 386, 388 
 loose bodies in, 421 
 neuralgia of, 415 
 stiffness of, after fractures, 292 
 •surgery of, 385 
 tuberculosis of, 80, 388 
 
 aspiration in, 391 
 
 rest in, 390 
 
 treatment of, 390 
 wounds and injuries of, 415 
 
 Karyokinesis, 29 
 Keen's operation blank, 735 
 rongeur forceps, 487 
 trachea-tube, 630 
 Kelly's method of disinfecting hands, 1079 
 
 rectal tubes, 792 
 Keloid, 484 
 Keratitis, 187 
 
 interstitial, 187 
 Kidney, cysts of, 847 
 diseases of, 835 
 floating, 836 
 hydatid cysts of, 848 
 injuries of, 848 
 sarcoma of, 848 
 stone in, 838 
 surgical anatomy of, 835 
 
 nephrectomy in, 844 
 tuberculosis of, 847 
 tumors of, 848 
 wounds of, 848 
 Knee, turning of, in or out, 353 
 Knee-jerk, 561, note 
 Knee-joint disease, 398 
 amputation for, 400 
 ankylosis after, 399 
 erasion for, 400 
 excision for, 400 
 non-operative treatment of, 399 
 operative treatment for, 400 
 
 Knee-joint disease, subluxation in, 399 
 terminations of, 399 
 tuiierculosis of, 398 
 Knee-splint of Sayre, 398 
 Knock-knee, 351 
 Kobelt's tubes, 1040, 1041 
 Kocher's method of reduction of shoulder dis- 
 locations, 438 
 operation for removal of entire tongue, 6H0 
 for hernia, 816 
 Koch's tuberculin in tubercular lymphoma, 
 
 656 
 Kraske's operation, 807 
 Kronlein's method, 48 
 Kussmaul's tube, 730 
 Kyphosis, 86, 553, 565 
 
 Labia. See Vvlm. 
 Laceration of brain, 510 
 
 of the cervix uteri, 983 
 Lambda, 491 
 Laminectomy, 585 
 Landerer's dry method, 1083 
 Langenbeck's method of treating aneurysm, 
 
 238 
 Laparotomy. See Abdominal section. 
 for abdominal hemorrhage, 707 
 closure of external incision in, 710 
 in punctured wound of abdomen, 704, 707 
 Laplace's forceps, 739, 740 
 Larrey's amputation at hip-joint, 1170 
 
 at shoulder-joint, 1161 
 Laryngectomy, 635 
 partial, 637 
 unilateral, 637 
 Laryngitis, 615 
 
 sicca, 616 
 Laryngotomy, 627 
 
 thyroid, 622 
 Laryngo-tracheotomy, 628 
 Larynx, abscess of, 617 
 benign tumors of, 621 
 burns and scalds of, 627 
 cancer of, differential diagnosis of, 172 
 cerebral center for, 497 
 contusions of, 624 
 dislocation of cartilages of, 625 
 fractures of, 625 
 incised wounds of, 624 
 intubation of, 632 
 malignant tumors of, 623 
 cedema of, 616 
 
 phthisis of, differential diagnosis of, 172 
 syphilis of, 189, 619 
 ' differential diagnosis of, 172 
 and trachea, diseases and injuries of, 615 
 congenital deformities and defects of, 615 
 strictures of, 619 
 treatment of Avounds of, 624 
 tuberculosis of, 620 
 tumors of, 621 
 ulcers of, 618 
 
 wounds and injuries of, 624 
 Lateral implantation of intestine, 746 
 Lavage of stomach, 730 
 Lawn tennis arm, 334 
 
 leg, 334 
 Leeching, 1184 
 Leg, artificial, 1173 
 cerebral center for, 497 
 
J 21 4 
 
 INDEX. 
 
 Leio-mvoma, 202 
 Leiter's cystoscope, 886 
 
 tubes in nviiovitis, 887 
 I.enibert's .siilniv, 74") 
 Lei lilt iiL'^is (issitmi, 505, 684 
 Lepra, 655 
 Leptinneningitis, 530 
 Leptotlirix hueealis, 787 
 Lessor's triangle, 1118 
 Leiicoeytes, function of, 16 
 Leucoeytosis, 18 
 LeuconiaVnes, 2 
 Leucnrrliea, ".•S7 
 I^evis's splint, 819 
 
 ligament, roinid, hydrocele of, 1048 
 Lifjation, 255 
 
 of arteries, 1113.' See -.4r/eri/. 
 Ligature of arteries, 1113. See Arlerij. 
 
 for internal piles, 796 
 Ligatures. lOSl 
 
 material and disinfection, 1081 
 Lightning-stroke, 479 
 Lint, 1175 
 Lip, cysts of, 669 
 
 epithelioma of, 668 
 
 na»vi of, 669 
 Lipomata, 198 
 
 of neck, 657 
 
 of spermatic cord, 958 
 
 of spine, 560 
 Lips, affections of, 668 
 
 bites of, 668 
 
 chapped, 668 
 
 cracked, 668 
 
 herpes of, 668 
 
 horny growths of, 669 
 
 hypertrophy of, 669 
 
 inHanimation of, 668 
 
 tumors of, 668 
 
 wounds of, 669 
 Lisfranc's amputation, 1164 
 Liston's amputation at hip-joint, 1170 
 Litholapaxy, 876 
 
 in children, 880 
 Lithotomy, lateral, 868 
 
 median, 873 
 
 perineal, 868 
 
 suprapubic, 868, 873 
 Lithotrites, 876, 877 
 Littre's hernia, 821 
 Liver, abscess of, 47, 782 
 amoeba coli in, 783 
 
 dermoid cysts of, 782 
 
 disease and injuries of, 780 
 
 floating, 784 
 
 hydatid cysta of, 780 
 
 resections of portions of, 784 
 
 rupture of, 783 
 
 simple (;ysts of, 782 
 
 syphilis of, 184 
 
 tumors of, 782 
 
 wounds of, 783 
 Lockjaw, 70 
 
 Loose bodies in joints, 421 
 Lordosis, 86, 563, 566 
 
 compeaisatory, 567 
 Lorenz's operation, 431 
 Loreta's operation, 722 
 Ludwig's angina, 653 
 Lumbar abscess, 44, 569 
 
 Lumbar abscess, treatment of, 573 
 
 puncture, 508 
 Lum|iy jaw, 18S 
 Lung, hernia of, 648 
 
 rupture of, 646 
 
 surgery of, 643 
 Lungs, gangrene of, 648 
 
 injuries and diseases of, 637 
 Lupus, 76, 78, 485, 504 
 
 exedens, 76 
 
 hypertrophicus, 76 
 
 of pharynx, 78 
 
 of skin, 76 
 
 and syphilis, ditlerential diagnosis of, 485 
 
 of tonsil, 78 
 
 of velum, 78 
 
 vulgaris, 76, 163 
 
 differential diagnosis of, 163 
 
 vulva?, 970 
 Luxatio erecta, 440 
 Luxation. See Dislocation, 
 Lymph, 26 
 
 Koch's, 85 
 Lymphadenitis, 469 
 Lymphadenoma, 473 
 Lymphangiectasis, 470 
 Lymj)hangionia, 470 
 Lymphangitis, 466 
 
 in gonorrhea, 900 
 
 from gonorrhea, treatment of, 917 
 
 reticular, 467 
 
 tubular, 467 
 Lymphatic cysts of breast, 1069 
 
 glands, abscess of, 47 * 
 
 inflammation of, 466 
 tuberculosis of, 80 
 Lymphatics, diseases and injuries of, 463 
 Lymphcedema, 472, 972 
 
 of vulva, 972 
 Lymphoma, malignant, 474 
 
 of neck, 657 
 Lymphorrhagia, 470 
 Lymphorrhea, 470 
 Lympho-sarcoma, 205, 474 
 
 malignant, 657 
 Lyssa, 131 
 
 Macewen'.s method of amputating upper 
 third of thigh, 1167 
 in aneurysm, 246 
 of compressing the aorta, 1171 
 
 operation for radical cure of hernia, 814 
 
 snpracondyloid osteotomy, 1136 
 Macrocheilia, 471, 667 
 Macroglossia, 471, 673 
 Macrophages, 16 
 Macropluigocytes, 16 
 Macrostoma, 670 
 Malacosteon, 276 
 Malgaigne's hooks, 327 
 
 operation for hare-lip, 666 
 Malignant disease. See Carcinoma and Sar- 
 
 COllUi. 
 
 growths, protozoa in, 195 
 
 psorospermije in, 195 
 (edema, 125 
 
 bacillus of, 9 
 pustule, 129 
 Mallein, 84 
 Mai perforant, 48, 486 
 
iM)i:x. 
 
 1215 
 
 Maltese cross, 1 175 
 Mamma, irritable, 1056 
 
 tubereiilosis of, 78 
 Mamma', absence of, 10") 1 
 
 supernumerary, 1051 
 Manunary gland. See Breast. 
 Mammitis, 1058 
 Manipulation in aneurysm, 245 
 
 in rediutiou of dislocations, 428 
 Marginal abscesses, 801 
 Marjolin's ulcer, 214 
 Massage, 1188 
 
 abdominal, 731 
 Mastication, noisy, 685 
 Mastitis, 1053 
 
 chronic cirrhotic, 1050 
 Mastoid disease, ditierential diagnosis of, 535 
 
 diseases of, 535, 538 
 Mannsell's method, 742 
 Maxillary sinus, 610 
 Maydl's operation, 732 
 Mayer's dressing for Thiersch's skin-grafting, 
 
 1110 
 McBurney's point, 763 
 Measurements in fractures of hip, 322 
 Meatotomy, 932 
 
 Meatus, urinary, stricture of, 932 
 Meckel's cartilage, 6.51 
 
 diverticulum, 754, 790 (Fig. 323) 
 ganglion, removal of, 364, 380 
 Median fissure, 491 
 Mediastinal abscess, 649 
 Mediastinum, posterior, 645 
 Medullary carcinoma, 212 
 Melanosis, 205 
 Melanotic cancer, 205 
 Melon-seed bodies, 80, 339 
 Meningeal artery, middle, hemorrhage from, 
 
 514 
 Meningitis, 530 
 
 from aural disease, 538 
 differential diagnosis of, 535 
 operative interference in, 532 
 Meningocele, cerebral, 506 
 
 spinal, 559 
 Meningo-myelocele, 559 
 Mental processes, cerebral center for, 497 
 
 state of patient, 1073 
 Mercurial glossitis, 672 
 
 stomatitis, 672 
 Mercury, bichloride of, as an antiseptic, 1077 
 
 biniodide of, as an antiseptic, 1077 
 Mesarteritis, 228 
 
 Mesenteric hernia of Cooper, 834 
 Mesentery, cysts of, 780 
 
 injuries and diseases of, 772 
 tumors of, 780 
 Metastatic abscesses, 60, 62 
 Microbes, 1 
 Micrococcus, 1 
 Micro-organisms, 1 
 Microphages, 16 
 Micro-phagocytes, 16 
 Microstoma, 670 
 Micturition, frequency of, in genito-urinary 
 
 disease, 853 
 Mikulicz's osteoplastic resection, 401, 1150 
 Milium, 475 
 
 Milk cysts of breast, 1068 
 fistulae, 1055 
 
 Milk, sinuses, 1049 
 
 Milzbrand, 128 
 
 Mind blindness, 546 
 
 Miner's elbow, 344 
 
 Minor surgery, 1175 
 
 Mirault's operation for liare-lip, 667 
 
 Mixed infection, 45 
 
 Mixter's operation on fifth nerve, 382 
 
 Moles of scalp, 503 
 
 Mollities o.ssium, 276 
 
 Molluscum contagiosum, 475 
 
 epitheliale, 475 
 Monorchidism, 949 
 Morbus coxic, 391 
 
 coxarius, 391 
 Mortality from anesthetics, 1098 
 
 of carcinoma of breast, 1066 
 Morton's fluid, 507 
 Mother's mark, 228, 504 
 Motor areas of brain, 497 
 Mouth, cerebral center for, 497 
 
 closure of, 670 
 
 diseases and injuries of, 664 
 
 malformations of, 670 
 Mucous membrane, transplantation of, 1111 
 tuberculosis of, 77 
 
 membranes, erysipelas of, 68 
 
 papules, 183 
 
 patches, 159, 183 
 
 tubercles, 208 
 
 tumors, 201 
 Mumps, 657 
 Murphy button, 739 
 Muscle, atrophy of, 336 
 
 contractures of, 335 
 
 diseases and injuries of, 333 
 
 hernia of, 334 
 
 hypertrophy of, 336 
 
 ossification of, 337 
 
 plastic operations in, 1111 
 
 rupture of, 334 
 
 syphilis of, 167 
 
 tuberculosis of, 77 
 
 tumors of, 337 
 wounds of, 337 
 Muscle-grafting, 1111 
 Muscular fiber, striped, regeneration of, 30 
 Mustard foot-bath, 1182 
 
 plasters, 1182 
 Myalgia, 334 
 Myornata, 202 
 
 of uterus, 1003 
 Myomectomy, 1007 
 Myositis, 334 
 
 afrigore, 335 
 
 ossificans, 337 
 
 rheumatic, 335 
 Myxcedema, 662 
 Myxomata, 201 
 
 N^vi of lips, 669 
 
 of tongue, 674 
 Na^vus, 227, 504 
 
 verrucosus, 482 
 Nail, hypertrophy of, 483 
 
 inflammation of matrix of, 483 
 
 ingrowing, 49, 483 
 Nails, diseases of, 483 
 
 polypi, 605 
 Nasion, 491 
 
iL'lt] 
 
 jyi)i:x. 
 
 Xaso-pkarvngeal p<^>lvp, S07 
 Navel. S«»e Umbiliau. 
 Necessity, triangle of, 1116 
 Neck, abscess of, 658 
 cellulitis of. 652 
 cicatrices of, 653 
 coDgenital tistula of, 652 
 
 hydrocele of, 651 
 contusions of, 653 
 cysts of, 651 
 
 diseases and injuries of, 651 
 emphysema of, 654 
 fistulre of, 653 
 hygromata of. 651 
 infectious granulomata of, 655 
 injuries of. 651 
 lipomata of, 657 
 open wounds of, 654 
 syphilis of. 655 
 
 tuberculosis of lymph-glands of, 655 
 tumors of, 655 
 wounds of, 654 
 wr^•-. See Torticollis. 
 Necrosis, 264, 269 
 of bones of skull, 505 
 of jaw, 683 
 of palate, 695 
 phosphorous, of jaw, 683 
 Necrotic caries, 265 
 Necrotomy, osteoplastic, 272 
 N^laton's'line, 323 
 
 prol)e. 117 
 Neoplasms. See Tumors. 
 Nephralgia, 837 
 Nephrectomy, 841 
 
 in surgical kidney, 844 
 Nephritis, interstitial, 842 
 
 suppurative, 842, 843 
 Nephro-lithotomy, 840 
 Nepliropexy, 836 
 Nophrorrhaphy, 836 
 Nerve or Nerves, centers, syphilis of, 188 
 cohesion of, 378 
 
 contusions and compressions of, 366 
 facial, diagnosis of lesions of, 370 
 fifth, diagnosis of lesions of, 370 
 
 methods of reaching, 377 
 grafting, 376, 377, 1111 
 great sciatic, diagnosis of lesions of, 374 
 
 exposure of, 384 
 inflammation of, 360 
 injuries, prognosis of, 374 
 
 remote eflects following, treatment of, 374 
 lingual, stretching <(r eisection of, 383 
 median, diagnosis of lesions of, 372 
 
 e.x[>osure of. 373 
 musculo-spiral, diagnosis of lesions of, 373 
 
 exposure of, 384 
 operations on, 376 
 plastic operations on, 1111 
 pneumogastric, diagnosis of lesions of, 371 
 of posterior cervical muscles, division of, for 
 
 wry-neck. 3'<-i 
 radial, diagnosis of lesions of, 373 
 
 exposure of. 384 
 recurrent larvngeal, diagnosis of lesions of, 
 
 371 
 special, diagnosis of lesions of, 370 
 spinal accessory, exposure of, 384 
 stretching, 377 
 
 Nerve or Nerves, supraorbital, exposure of, 379 
 
 surgery of, 359 
 
 suture, 376 
 
 syphilis of, 188 
 
 tibial, ex|)fi6ure of, 385 
 
 tissue, regeneration of, 31 
 
 tumors of. 202, 366 
 
 ulnar, diagnf>sis of lesions of, 371 
 exjKjsure of, 384 
 
 wounds of, 367 
 
 and injuries of, 366 
 treatment of, 374 
 Nervous syphilis, 170 
 Neuralgia, 361 
 
 of brachial plexus, surgical treatment of, 364 
 
 of joints. 415 
 
 of scars, surgical treatment of, 364 
 
 of spine, 562 
 
 of stumps and scars, 363 
 
 treatment of, 364 
 Neurasthenic sequel* of spinal sprains. 577 
 Neurectasy, 377 
 
 conditions to which it is applicable, 379 
 Neurectomy, 379 
 Neuritis, 360 
 Neuromata, 365 
 Neurotomy, 379 
 Nipple and areola, 1049 
 
 diseases of, 1051 
 
 inflammation of, 1051 
 Nipples retracted, 1051 
 
 supernumerary, 1048 
 Nitrous oxide gas, 1048 
 Nodes, syphilitic, 168 
 Noma. 55, 969 
 
 bacilli in, 9 
 Nose, abscess of, 590 
 
 adenomata of, 607 
 
 angeiomata of, 607 
 
 asymmetry of. 590 
 
 atrophic catarrh of, 599 
 
 catarrh of, 600 
 
 deformities of, 5S9 
 
 enchondromata of, 606 
 
 exostoses and osteomata of, 607 
 
 fissures of, 590 
 
 foreign lx>dies in, 603 
 
 hypertrophic and atrophic catarrh of, 596 
 
 injuries of, 603 
 
 parasites in, 604 
 
 plugging of, 602 
 
 polypi of, 605 
 
 restoration of, 612 
 
 rhinoliths in, 604 
 
 septum of, diseases and displacements of, 590 
 
 surgery of, 589 
 
 surgical emphysema of, 612 
 
 tumors of. 607 
 
 ulcers of, 600 
 
 wounds of, 612 
 Nose-bleed. 603 
 Nostrils, deformities of, 589 
 Nurse, preparation of, for operation, 1077 
 
 Obeliox, 491 
 Obligate bacteria, 2 
 Obliterating appendicitis, 
 Obstniction, fecal, 750 
 intestinal. 729 
 acute, 743 
 
 r68 
 
INDEX. 
 
 1217 
 
 Obstnutioii, intestinal, adyiiiiinic, 7J0 
 arter-lrealinent of, 747 
 lioni ascariiles, 750 
 chronic, 741) 
 from concretions, 750 
 from gal I -stones, 749 
 operative treatment of. 730 
 in stran^Milation by hand, diverticnlnni, 
 tlexion, or adiiesion of intestines, di- 
 rect treatment of, 746 
 surgical treatment of, 730 
 Odontumes, C88 
 
 O'Dwyer's intubation instruments, 632 
 (Edema, antlirax, I'iU 
 
 of hirynx, 616 
 Gi^sophageal bougies, 687 
 CEsophagectomy, 700 
 tEsophagoscope, 700 
 (Esophagotomy, 697 
 CEsopliagus, dilatation of, 696 
 diseases and injuries of, 695 
 foreign bodies in, 69S 
 
 gastrotomy and digital exploration of, 700 
 malformations of, 695 
 operations on, 699 
 sacculation of, 696 
 stricture of, 696 
 wounds of, 698 
 Ointments, 1191 ' 
 
 Omental grafting in abdominal wounds, 700 
 Omentum, cysts of, 779 
 diseases of, 779 
 injuries and diseases of, 772 
 tumors of, 780 
 Omphalectomy, 831 
 Onychia, 483 ' 
 maligna, 4S3 
 syphilitic, 160 
 Oophorectomy, 1037 
 Oophoron, 1040, 1041 
 
 papillomatous cysts within, 1042 
 Operation cases, after-treatment of, 1088 
 Operations, dangers common to all, 1071 
 dangers, special, in, 1072 
 preparation for, 1076 
 Operative surgery, general principles of, 1071 
 Operculum, 496 
 Ophryon, 491 
 Ophthalmia, gonorrheal, 904 
 
 treatment of. 
 Opisthotonos, 70 
 
 Opium-poisoning, differential diagnosis of, 51: 
 Orchitis, 949 
 
 syphilitic, 173, 950 
 
 differential diagnosis of, 173 
 tubercular, 173, 950 
 Orrhotherapy, 81 
 Orthopedic surgery, 346 
 Osseous system, surgery of, 262 
 
 tumorsi^ 200 
 Ossification of muscle, 337 
 Osteitis of bones of skull, 505 
 rarefying, 264 
 simple acute, 266 
 
 syphilitic, differential diagnosis of, 169 
 tubercular, differential diagnosis of, 169 
 Osteo-arthritis, 410 
 Osteoblasts, 32 
 
 Osteoclasis in genu valgum, 353 
 Osteoclasts, 32 
 77 
 
 Osteo-malacia, 378 
 Osteomata, 200 
 of Jaws, 6S5 
 of nose, 607 
 Osteo-myelitis, 264 
 gummatous, 168 
 tubercular, 79 
 Osteoperiostitis, 263 
 gummatous, 16S 
 
 non-speiiiic, differential diagnosis of, 180 
 syphilitic, 168 
 
 diflereiitial diagnosis of, 186 
 Osteoplastic necrotomy, 272 
 resection of foot, 401, 1150 
 of skull, 499 
 (Jsteoporosis, 264 
 < )steo-sarconia, 280 
 Osteo-sclerosis, 264, 265 
 Osteotomy, 1135 
 
 for ankylosis of hip-joint, 398, 1137 
 (cuneiform) for talipes, 355 
 for deformity after coxalgia, 398, 1137 
 for genu valgum, 352, 353, 1136 
 through neck of fenmr, 1138 
 supracopdyloid, 1136 
 Otitis media, catarrhal, 1087 
 
 chronic purulent, intracranial sequela; of, 
 525 
 Ovarian cyst, 1042 
 
 diagnosis of, 1045 
 inflammation of, 1044 
 rupture of, 1045 
 suppuration of, 1044 
 torsion of pedicle of, 1044 
 cystomata, 1039 
 dermoids, 1041 
 hernia, 1034 
 tumors, 1039 
 Ovaries, surgery of, 1034 
 
 and tubes, removal of, 1037 
 Ovariotomy, 1047 
 
 technique of, 1047 
 Ovaritis, 1035 
 Ovary, cysts of, 1042 
 dermoid cysts of, 1041 
 inflammation of, 1035 
 prolapse of, 1034 " 
 tumors of, solid, 1048 
 Oxaluria, 838 
 Ozena, 592 
 
 PACHYMENINGXTIiS, 530 
 
 internal hemorrhage from, 517 
 Paget's disease, 1051 
 
 relation of psorosperms to, 1052 
 Pain in genito-urinary disease, 852 
 Painful subcutaneous tubercle, 366 
 Palate, abscess of, 695 
 
 cleft, 692 
 
 congenital deformities of, 692 
 
 necrosis of, 695 
 
 tumors of, 695 
 
 ulceration of, 695 
 Palmar abscess, 47 
 
 arches, ligation of, 1122 
 
 fascia, contraction of, 348 
 Palpation, bimanual, 968 
 Panaris, 47, 339 
 Pancreas, abscess of, 788 
 
 cancer of, 789 
 
1218 
 
 L\j)i:x. 
 
 Pancreas, cv.sts of, 7S8 
 
 diseases and injuries of, 780 
 wounds of, 78S 
 Pannous synovitis, oilO 
 I'apilloina neurotieuin, 482 
 Papilloniata, *J(»S 
 
 of bladder, 88(1 
 
 of Kallopian tube, 1048 
 
 of tongue, t!74 
 
 of vulva, 971 
 Papillomatous cysts within tlie oophoron, 1042 
 Pa(pielin's thernio-cautery, lls.'i 
 Paracentesis, <i89 
 
 abdominis, 779 
 
 auriculi, 221 
 
 pericardii, 222 
 
 thoracis, ().S9 
 Paralysis of bladtler, 858 
 
 of bowels, 759 
 
 muscular, 335, 355, 368 
 
 from nerve injuries, 370 et seq. 
 
 persistent, after fractures, 292 
 Parametritis, 1032 
 Paraphimosis, 899 
 
 treatment of, 910 
 Paratoloid, 81 
 Paratyphlitis, 760 
 Parenchymatous inflammation, 18 
 Paresthesia, region of, 369 
 Parietal lobule, superior, 497 
 Park's tlivided trachea-tube, 630 
 Paronychia, 340 
 Paroophoritic cvsts, 1041 
 Paroophoron, 1040, 1041 
 Parotid gland, contusions of, 657 
 cystic dilatation of, 658 
 fistula; of, 657 
 tumors of, 658 
 wounds of, 657 
 Parotitis, 657 
 
 suppurative, 658 
 Parovarian cysts, 1042 
 Parovarium, 'l040, 1041 
 Patella, fracture of, treatment of, 32G 
 Pathogenic bacteria, 2 
 Patient, examination of, before operation, 1073 
 
 hygienic conditions surrounding, 1075 
 
 management of, before operation, 1075 
 
 mental state of, before operation, 1073 
 
 preparation of, 1076 
 Pedicle in hysterectomy, treatment of, 1008 
 
 of ovarian cyst, torsion of, 1044 
 Pelvic abscess, 1026 
 
 cellulitis, 1032 
 Pemphigus, 182 
 Penis, an)pntation of, 964 
 
 diseiises and injuries of, 960 
 
 epithelioma of, 963 
 
 fracture of, 962 
 
 gangrene of, 963 
 
 inflammation of, 963 
 
 and urethra, relative sizes of, 928 
 
 wounds of, 962 
 Perforating ulcer of foot, 48, 486 
 
 of nasal septum, 593 
 Perforations, intestinal, search for, 708 
 Periarteritis, 228 
 Pericarditis, traumatic, 223 
 Pericardium, diseases of, 221 
 
 efliision into, 222 
 
 Pericardium, incision and drainage of, 222 
 
 injuries of, 222 
 Perichondritis, (118 
 Perineal lithotomy, 868 
 
 section, 937 
 Perineoplasty, 973 
 I'erinephric abscess, 47, 845 
 Perinephritic abscess, 47, 844 
 I'erineidiritis, 844 
 Perineum, rupture of, 972 
 complete, 972, 975 
 concealed, 972, 974 
 incomplete, 972 
 repair of, 973 
 
 surgery of, 972 
 Periostitis aibuminosa, 268 
 
 of bones of skull, 505 
 
 dental, 687 
 Pcri])hlel)itis, 225 
 Peritoneal cavity, toilet of, 747 
 Peritoneum, foreign bodies in, 773 
 
 injuries and diseases of, 772 
 
 wounds of, 773 
 Peritonitis, 773 
 
 adhesive tubercular, 778 
 
 appendicular, 760 
 
 librino- plastic, 774 
 
 plastic, 773 
 
 saline cathartics in, 710 
 
 septic, 774 
 
 suppurative, 775 
 
 treatment of, 776 
 
 tubercular, 777 
 Perityphlitic abscess, 47, 762 
 Perityphlitis, 47, 760 
 I'eri-urethral abscess, 899 
 
 treatment of, 917 
 Pernio, 480 
 Pes cavus, 356 
 
 planus, 357 
 Peteisen's rectal colpeurynter, 875 
 Petil's tourniquet, 1153 
 
 triangle, 832 
 Phagedena, 154 
 Phagocytes, 3, 16 
 Phagocytosis, 16 
 Pharyngeal tonsil, 598 
 Pharynx, afTections of, 689 
 
 carcinoma of, 692 
 
 congenital malformations of, 689 
 
 diverticula from, 689 
 
 fistuhe ot; 689 
 
 lupus of, 78 
 
 tumors of, 692 
 Phimosis, 898, 962 
 
 treatment of, 916 
 Phlebitis. 224 
 Phleboliths, 226 
 Phlclmtomy, 1184 
 Phlegmonous inflammation, 19 
 Phosphalic urine, 837 
 Phos|)horus necrosis of jaw, 683 
 Phthisis and fistula in ano, 803 
 
 of larynx, differential diagnosis of, 172 
 Piles, 792 
 
 bleeding, 795 
 
 external, 794 
 
 internal, 795 
 Pirogofl's amputation, 1165 
 Placenta, syphilis of, 180 
 
INDEX. 
 
 1219 
 
 Phuiter, adhesive, 1190 
 breeches, HIHJ 
 splint, 2'.»0 
 Plaster of-Paris bandage, 295 
 dressing, 1181 
 splints, 294 
 in synovitis, 387, 388 
 Plastic operations on bones, 1112 
 on muscles, 1111 
 on nerves, 1111 
 surgery, 1104 
 Pledgets, 1175 
 
 Pleura, injuries and diseases of, 637 
 Pleuritic efliisions, 637 
 
 operative treatment of, 639 
 Plexus, brachial, exposure of, 384 
 
 cervical, exposure of, 384 
 Pneumatocele, 503 
 Pneuniectomy, 643 
 Pneuniocele, 648 
 Pneumotouiy, 643 
 Polydactylism, 350 
 Polypus, nasal, 605 
 nasopharyngeal, 607 
 of rectum, 805 
 Port-wine mark, 228, 504 
 Potassium permanganate and oxalic acid for 
 
 disinfecting hands, 1079 
 Pott's disease of spine, 79 
 treatment of, 569 
 fracture, 330 
 Poultices, 1190 
 Powder in skin, 121 
 Precentral sulcus, 496 
 Pregnancy, extra- uterine, 1029 
 Preparation of patient for operation, 1076 
 of surgeon, assistants, and nurse for opera- 
 tion, 1077 
 Prepuce, 899, 916, 962 
 Pressure, digital, for aneurysm, 241 
 Primary syphilis, 142 
 Probe, Fluhrer's aluminium, 526 
 ^selaton's, 117 
 
 telephonic, of Girdner, 117, 528 
 Procidentia uteri, 972, 999 
 Proctectomy, 806 
 Proctotomy, 810 
 Prolapse of anus, 797 
 of ovary, 1034 
 of rectum, 797 
 of uterus, 999 
 of vagina, 981 
 Proliferation of cells, 15 
 Prostatectomy, 943 
 Prostate gland, anatomy of, 939 
 atrophy of, 940 
 calculus of, 948 
 diseases of, 939 
 hypertrophy of, 940 
 diagnosis of, 942 
 double castration for, 944 
 pathology of, 940 
 symptoms of, 942 
 treatment of, 942 
 
 castration in, 944 
 Wiiite's operation for, 944 
 injuries of, 940 
 
 malignant disease of, 942, 948 
 tubercle of, 947 
 wounds of, 940 
 
 Prostatic abscess, 917 
 Prostatitis, 900, 947 
 
 acute, 947 
 
 chronic, treatment of, 918 
 
 follicular, acute, 907, 947 
 chronic, 947 
 treatment of, 918 
 
 gouty, 948 
 
 parenchymatous, 947 
 
 treatment of, 917 
 
 tul)ercular, 947 
 Prostato-cystitis, treatment of, 917 
 Prostatorrhea, 907 
 Pruritus ani, 799 
 
 of vulva, 970 
 Psammoma, 205 
 Pseudarthrosis, 300 
 Pseudo-impotence, 953 
 Pseudo-leukemia, 474 
 Pseudo-oedema, bacillus, 9 
 Pseudopodia, 12 
 Psoas abscess, 46, 569 
 treatment of, 573 
 Pterion, 491 
 Ptomaines, 2 
 
 in traumatic gangrene, 9 
 Ptyalism, 672 
 Pudendal liematocele, 969 
 Puncture, 1205 
 
 of bladder, 856 
 
 exploratory, 949 
 
 lumbar, 508 
 
 of subarachnoid space, 507 
 Pupil, Argyll-Robertson, 535, note 
 Purulent infiltration, 42 
 Pus, 41 
 
 blue, 41 
 
 ichorous, 41 
 
 sanious, 41 
 
 tubercular, 76 
 Pus-corpuscles, 41 
 Pustule, malignant, 128 
 Putrescin, 2 
 
 Pyelitis, suppurative, 842 
 Pyelonephritis, 842 
 Pyemia, 63 
 
 in aneurj'sm, 234 
 
 after fractures, 293 
 
 and thrombosis of lateral sinus, 541 
 Pylorectomy, 725 
 Pyloroplasty, 723 
 
 Pylorus, cicatricial stricture of, digital divul- 
 sion of, 723 
 
 excision of, 725 
 Pyocyanine, 7 
 Pyogenic bacteria, 2 
 
 cocci, 6 
 
 membrane, 45 
 Pyo-nephrosis, 842 
 Pyosalpinx, 1026 
 Pyothorax, 638 
 
 Quilled suture, 1085 
 Quilted suture, 1086 
 Quinsy, 689 
 
 Rabies, 84, 131 
 
 Railroad injuries of spine, 576 
 
 Ranula, 218, 674 
 
 Ray fungus, 137 
 
1220 
 
 INDEX. 
 
 Kayiiaud's disease, 55 
 Keactions i)f degeneration, 35!) 
 Keetal oolpeurynler, .^75 
 
 insiilUatiou oi hydrgen gas (jr filtered air, 
 730 
 Rectocele, 1»72, 981 
 Recto-urethral fistnla-, 803 
 Recto-vaginal fistula, 804, 980 
 Recto-vesical fistula, 803 
 Rectum, abscess of, 801 
 
 cancer of, 805 
 diagnosis of, 806 
 
 condylomata of, 183 
 
 congenital malformations of, 790 
 
 examination of, 792 
 
 excision ot", SOG 
 
 foreign bodies in, 799 
 
 imi)erforate, 790 
 
 injuries and diseases of, 789 
 
 ojjening into bladder, 790 
 
 polypus of, 805 
 
 prolapse of, 797 
 
 sarcoma of, 805 
 
 stricture of, 809 
 
 surgical anatomy of, 789 
 
 syphilitic ulceration of, 804 
 
 tubercular ulceration of, 804 
 
 tumors of, 805 
 
 villous growths of, 805 
 
 warty growths of, 805 
 
 wounds of, 799 
 Reef knot, 255 
 
 Reflex, definition of, 561, note 
 Reid's base line, 540 
 Relation of psorosperms to Paget's disease, 
 
 1052 
 Relaxation suture, 1086 
 Renal absc§ss, 642 
 
 calculus, 838 
 
 fistula, 846 
 
 hemorrhage, 849 
 Rei)air, the process of, 25 
 Resection, 1132 
 
 of ankle, 1148 
 
 atypical, 1133 
 
 of bones of lower extremity, 1150 
 of upper extremity, 1145 
 
 of clavicle, 1141 
 
 in contiguitv, 1133 
 
 of foot, 1150 
 
 formal or typical, 1133 
 
 after gunshot wounds, 120 
 
 of hip, 1146 
 
 informal or atypical, 1133 
 
 intermediary, 1133 
 
 of interphalangeal joint, 1146 
 
 of jaw, lower, 1140 
 upper, 1138 
 
 of knee, 1147 
 
 of liver, portions of, 784 
 
 of metacarpo-phalangeal joint, 1146 
 
 osteoplastic, 1133 
 of foot, 1150 
 of skull, 499 
 
 primary, 1155 
 
 of ribs, 642 
 
 of scapula, 1141 
 
 secondary, 1133 
 
 of shoulder, 1142 
 
 of wrist, 1145 
 
 Residual urine, 859 
 
 Resolution, 20 
 
 Respiratory organs, surgery of, 589 
 
 tract, syphilis of, 172 
 Rest in joint-tuberculosis, 390 
 
 after operations, 1088 
 Retention cyst of gland of Bartholin, 971 
 
 of urine, 855 
 
 treatment of, 917 
 Retraction of nipple in carcinoma, 1062 
 Retractor for amputation, 1154 
 Retro-i)eritoneal tumors and cysts, 757 
 Retro-pharyngeal abscess, 509, 691 
 treatment of, 573 
 
 tumors, 692 
 Reverdin's method of skin-grafting, 1107 
 Rhalido-myoma, 202 
 Rhachitis, 85, 185, 276 
 Rheumatic arthritis, 408 
 
 of the temporo-maxillary articulation, 
 685 
 
 gout, 409 
 
 myositis, 335 
 Rheumatism, gonorrheal, 407, 903 
 treatment of, 919 
 
 muscular, 335 
 Rheumatoid arthritis, chronic, 409 
 Rhigolene spray, 1101 
 Rhinoliths, 604 
 Rhinophyma, 590 
 Rhinoplasty, 612 
 Rhinoscleroma, 590 
 Rhiziform bodies, 80, 339 
 Rice bodies, 80, 339 
 Richter's hernia, 821 
 Rickets, 85, 276 
 
 difierential diagnosis of, 185 
 Rings, Brockaw's, 737 
 
 Senn's 707, 738 
 Robb and Cihrisky's bacteriological study of 
 
 sutures, 1082 
 Rodent ulcer, 214, 487 
 Rolando, fissure of, 491 
 
 Chiene's method of fixing, 492 
 Rongeur forceps, 499, 505 
 Rontgen (X) rays, use of, in surgery, 1191 
 Roseola, syphilitic, 158 
 Rose's operation on the Gasserian ganglion, 
 
 381 
 Round ligament, hydrocele of, 1048 
 
 shortening of, 996 
 Rubefacients, 1182 
 Rupia, 162 
 Rupture, 810 
 
 of bladder, 857 
 
 of diaphragm, 650 
 
 of gall-bladder, 785 
 
 of intestines, 728 
 
 of liver, 783 
 
 of lung, 64(> 
 
 of muscle, 334 
 
 of ovarian cyst, 1042 
 
 of perineum, 972 
 
 of sphincter ani, 972 
 
 of spleen, 789 
 
 of stomach, 711 
 
 of tendon, 342 
 
 of urethra, 893 
 
 of uterus, 984 
 Rydygier's operation, 808 
 
JMu:x. 
 
 1221 
 
 Sat, lionual, Sll 
 
 Sacral tumor, congenital, ofil 
 
 SatTo-iliac joint disease, 403 
 
 tiiiiermlosis of, -lO.S 
 Saline cat liartirs in peritonitis. 710 
 
 transfusion, 95, 11 S5 
 Salivary concretions or calculi, doS, G75 • 
 
 list M lie, ()')7 
 
 Inlands, 657 
 Salivation, ti72 
 Salpini^itis, \(\2.h 
 
 Salt solution, transfusion of, 9o, 11 So 
 Sanious pns, 41 
 
 Saphenous vein, internal, varix of, 226 
 Sapreinia, (it), 61 
 Saprogenic l)acteria, 2 
 Saprophytic bacteria, 2 
 Sarcocele, syphilitic, 950 
 Sarcoma and Sarcomata, 202 
 
 alveolar, 205 
 
 bacillus i>rodigiosus in, treatment of, 207 
 
 of bone, 280 
 
 of bones of skull, 506 
 
 of breast, 1060 
 
 diagnosis of, 207 
 
 giant-celled, 205 
 
 of intestine, 756 
 
 of jaws, 685 
 
 of "kidney, 848 " 
 
 of lymphatic glands, 474 
 
 lymph 0-, 205 
 
 melanotic, 205 
 
 myeloid, 205 
 
 nest-celled, 205 
 
 prognosis of, 207 
 
 of rectum, 805 
 
 round-celled, 204 
 
 of skin, 488 
 
 spindle-celled, 205 
 
 subperiosteal, 206 
 
 of testicle, 951 
 
 of tonsils, 691 
 
 toxins of erysipelas in treatment of, 207 
 
 treatment of, 207 
 
 of uterus, 1025 
 Suyres dressing for fracture of clavicle, 308 
 
 jacket, 571 
 
 knee-splint, 398 
 Scalds, 477 
 
 of larynx and trachea, 627 
 Scalp, abscesses of, 509 
 
 diseases involving, 503 
 
 fatty tumors of, 503 
 
 horns of, 503 
 
 inflammation of, 503 
 
 moles of, 503 
 
 sebaceous tumors of, 503 
 
 tumors of, 503 
 
 warts of, 503 
 
 wounds of, 509 
 Scaritication, 1183 
 Scars, hypertrophied, 505 
 
 neuralgia of, 363 
 Schede's operation, 642 
 Schleich's method for local anaesthesia, 1102 
 Sciatica, 363 
 
 surgical treatment of, 364 
 Scirrhous carcinoma of breast, 1062 
 
 carcinomata, 211 
 Scirrhus, atrophic, 211 
 
 Scirrlni-i, atrophic, of breast, 1062 
 
 duration of life in, 21 1 
 
 of testicle, 951 
 
 withering. 211 
 of brea.st, 1063 
 Scoliosis, 86, 563 
 Scrofuloderma,, 77 
 Scrofulous abscess, 45, 77 
 Scrotum, diseases of, 959 
 
 elephantiasis of, 960 
 
 epithelioma of, 960 
 
 fcdema of, 959 
 Scurvy, 72 
 
 Sebaceous cysts, 217, 475 
 of scalp, 503 
 of vulva, 971 
 Second intention, healing by, 27 
 Section, abdominal. See Abdominal section. 
 S^dillot's amputation, 1166 
 
 method of removal of tongue, 681 
 Senn's bone chips, 1112 
 
 decalcified -bone plate, 737, 738 
 
 hydrogen test, 706, 708, 728 
 Separation of lower epiphysis of humerus, 315 
 Sepsin, 2 
 Septic infection, 60, 61 
 
 inflammations of bone, 266 
 
 intoxication, 3, 60 
 Septicemia, 60 
 
 in aneurysm, 234 
 
 after fractures, 293 
 
 temperature of, 61 
 Septum, nasal, deviation of, 593 
 
 perforating ulcer of, 593 
 Sequestra, 269 
 Sequestrotomy, 270 
 Sequestrum, 269 
 Serous inflammation, 18 
 Serpent-bites, 126 
 
 Serum-therapy, 81. See Orrhotherapy. ' 
 Sex, relation of, to operations, 1074 
 Shock, 92, 1071 
 
 Shoulder, cerebral center for, 497 
 Shoulder-joint disease, 401 
 excision in, 402 
 
 tuberculosis of, 401 
 Silicate-of-soda dressing, 1182 
 Silk, 1081 
 Silkworm gut, 1081 
 Silver-fork deformity, 318 
 Simple ulcer of tongue, 679 
 Sinus, 51 
 
 cavernous, thrombosis of, 542 
 
 frontal, diseases and injuries of, 608 
 
 lateral, pyemia and thrombosis of, 541 
 
 maxillary, 610 
 
 petrosal, thrombosis of, 542 
 
 sphenoidal, 609 
 Sinuses of brain, wounds of, 517 
 Skin, carcinoma of, 488 
 
 malignant di.seases of, 487 
 
 sarcoma of, 488 
 
 surgical diseases of, 475 
 
 tuberci.ilosis of, 76 
 Skin-grafting, Krause's method, 1110 
 
 Reverdin's method, 1107 
 
 Thiersch's method, 1109 
 Skull, atrophy of bones of, 505 
 
 caries of bones of, 505 
 
 epithelioma of, 506 
 
1222 
 
 iyi)EX. 
 
 Skull, hvpertrophv of bones of, 505 
 
 necrosis of bones of, 505 
 
 osteitis of bones of, 505 
 
 periostitis of bones of, 505 
 
 points named by Broca in, 491 
 
 sarcoma of bones of, 506 
 
 tumors of, 506 
 Sloughs, 54 
 
 Smell, cerebral center for, 498 
 Smith, Nathan R., anterior splint of, 298 
 
 Stephen, amputation of, 1166 
 Snake-bites, 84, 126 
 Sounding for urinarv calculus, 864 
 Spanish flv, 1182 
 Speech, Broca's center for, 497 
 Spermatic cord, diseases of, 958 
 hydrocele of, difbsed, 958 
 
 encysted, 959 
 lipomata of, 958 
 
 malignant growths of, primary, 958 
 Spermatorrhea, 953 
 Sphenoidal sinus, 609 
 Sphincter ani, rupture of, 972 
 Sphincterismus, 798 
 Spina bifida, 558 
 Spinal cord, compression of, 578 
 concussion of, 577 
 contusion of, 577 
 theca, tapping of, 570 
 tumors of, 561 
 wounds of, 578 
 
 hemorrhage, 578 
 
 jacket, 599 
 
 meningocele, 559 
 
 tumors, 560 
 Spine, access of, 567, 569 
 
 abscesses of, treatment of, 573 
 
 congenital deformities of, 558 
 
 curvature of anterior, 566 
 lateral, 563 
 posterior, 565 
 
 curvatures of, 563 
 
 dermoid cysts of, 560 
 
 excurvation of, 563, 565 
 
 extramedullary hemorrhage of, 578 
 
 incurvation of, 563, 566 
 
 intramedullary hemorrhage of, 579 
 
 lipomata of, 560 
 
 neuralgia of, 562 
 
 Pott's disease of. 566 
 
 sprains of, 576 
 
 surgery of, 557 
 
 tuberculosis of, 566 
 
 tumors of, 560 
 Spirillum, 1 
 Spleen, abscess of, 789 
 
 cysts of, 789 
 
 gunshot wound of, 789 
 
 injuries and diseases of, 789 
 
 rupture of, 789 
 
 stabs of, 789 
 
 syphilis of, 188 
 
 tumors of, 789 
 Splenectomy, 789 
 Splint, plaster, 296 
 Splinter of bone, separation of, 283 
 Splints, 1091 
 
 Gooch's flexible wooden, 294 
 
 moulded, 294 
 
 plaster-of-Paris, 294 
 
 Splints, wire-gauze, 294 
 
 wooden, 294 
 Spondylitis, 566 
 
 deformans, 566 
 S{H)nges, 1079 
 SjMjres, 2 
 
 effect of heat on, 4 
 Sprain, 416, 423, 576 
 
 of back, 576 
 Sputa, tubercle bacilli in, 5 
 Squint. See Strabismus. 
 Stab wounds of abdomen, 702 
 of spleen, 789 
 of stomach, 712 
 Staphylococci, 1, 8 
 Staphylococcus epidermis albus, 1085, 1090 
 
 pyogenes albus, 6 
 aureus, 6 
 citreus, 6 
 
 serum, 83 
 Staphylorrhaphy, 693 
 Static electricity, 1188 
 Stay-knot of Ballance and Edmunds. 33 
 Stenosis, cicatricial, of stomach, 715 
 
 of intestine, non-malignant, 755 
 Stenson's duct, cystic dilatation of, 658 
 
 fistulae of, 657 
 Stephanion, 491 
 Sterility, 953 
 
 Sterilization, methods of 1077 
 Sthenic inflammation, 18 
 Stomach, carcinoma of, 716 
 
 cicatricial stenosis of, 715 
 
 contusions of, 711 
 
 dilatation of, 715, 716 
 
 diseases and injuries of, 711 
 
 evacuation of, 730 
 
 foreign bodies in, 713 
 
 gunshot wounds of, 712 
 
 irrigation of, 730 
 
 lavage of, 730 
 
 operations on, 718 
 
 rupture of, 711 
 
 stab wounds of, 712 
 
 suturing of wounds of, 709 
 
 ulcer of, 713 
 
 wounds of, 711 
 Stomatitis. 671 
 
 mercurial, 672 
 Stone in the bladder. See CcUadus, urinary. 
 Strangulated heniia, 819 
 
 abdominal section in, 824 
 after-treatment of, 823 
 diagnosis of, 821 
 symptoms of, 820 
 treatment of, 822 
 Strangulation of intestine by bands or diver- 
 ticula, 754 
 
 local changes from, in hernia, 820 
 
 mechanism of, in hernia, 819 
 
 reduction after, 822 
 Streptococci, 1, S3 
 Streptococcus erysipelatis, 7, 66 
 
 pyogenes, 6 
 Stricture of larynx and trachea, 619 
 
 of oesophagus, 696 
 
 of pylorus, cicatricial, digital divulsioo of, 722 
 
 of rectum, 809 
 
 of ureter, 851 
 
 of urethra. 926 
 
INDEX. 
 
 1223 
 
 Struma, 660 
 
 Strumitis iu goitri-, 660 
 
 Strumous uUi-r of palate, 695 
 
 Stumps, neuralgia of, H63 
 
 Suliararhnoiil space, puncture of, 507 
 
 Subclavian artorv. Keen's metliod of compress- 
 
 inp, 1160 __ 
 Sublingual cysts, 675 
 
 gland, 659 
 Subluxations, 423 
 
 iu knee-joint disease, 399 
 Submaxillary angina, infectious, 653 
 
 gland, diseases of, 659 
 Sulcus, frontal, inferior, 496 
 superior, 4yt) 
 precentral, 496 
 vertical, 490 
 Supernumerary breasts, 1050 
 
 digits, 350 
 Suppuration, 36 
 
 acute, treatment of, 26 
 witb bacteria, 7 
 after wounds, 107 
 Suppurative inflammation, 19 
 Supramarginal gyrus, 497 
 Suprameatal triangle, 539 
 Suprapubic cystotomy, 873 
 
 lithotomy, 873 
 Surgeon, preparation of, for operation, 1077 
 Surgical fever, 34 
 
 kidney, nephrectomy in, 844 
 scarlet fever, 37 
 Suspension apparatus, 1091 
 Suture and Sutures, 102, 1081 
 buried, 1086 
 button, 1085 
 continuous, 1084 
 Czemy-Lembert, 709, 745 
 glover's, 1084 
 interrupted, 1084 
 Lembert, 709, 745 
 of nerve, primary, 376 
 
 secondary, 377 
 quilled, 1085 
 quilted, 1086 
 relaxation, 1086 
 secondary, 1086 
 subcutaneous, 1086 
 of tendon, 342 
 twisted, 1085 
 Suturing, methods of, 1084 
 Swedish turnip plaster, 737 
 Sylvius, fissure of, 496 
 Syme's amputation, 1165 
 Symphyseotomy, 986 
 Symphysis, pubic, separation of, 320 
 Synchronous operations, 1074 
 Syndactylism, 349 
 Synechia, 590 
 Synovitis, 386 
 pannous, 390 
 
 plaster of Paris in, 387, 388 
 tubercular, 80 
 urethral, 903 
 Syphilides, 157 
 palmar, 16© 
 papular, 158 
 papulo-squamous, 160 
 plantar, 160 
 pustular. 161 
 
 Syphilides, tubercular, 162 
 
 differential diagnosis of, 163 
 Svphilis, 139 
 "bacillus of, 9, 139 
 of bone, 167, 184,277 
 of breast, 1057 
 cerebral, 170 
 
 diagnosis of, 171 
 of ear, 184 
 general, 157 
 hereditary, 176 
 diiU-reiitial diagnosis of osseous lesions of, 
 
 1S5 
 intermediate period of, 184 
 pathology and symptoms of, 180 
 primary stage of, 181 
 secondary stage of, 181 
 treatment of, 192 
 inherited, diagnosis of, 189 
 
 prognosis of, 189 
 intermediate period, 141 
 of intestinal tract, 172 
 of larynx, 189, 619 
 
 differential diagnosis of, 172 
 of liver, 184 
 
 mercurial inunction in, 175 
 methods of transmission of, 141 
 of mouth, tertiary, 165 
 of muscles, 167 
 of neck, 655 
 
 of nerve-centers and nerves, 188 
 of nervous system, 170 
 period of primary incubation, 140, 141 
 of primary symptoms, 141 
 of secondary incubation, 141 
 of secondary symptoms, 141 
 of tertiary symptoms, 141 
 primary, 142 
 of respiratory tract, 172 
 secondary, 157 
 of spleen, 188 
 of teeth, 187 
 of testicles, 173, 189 
 transmissibility of, 177 
 
 to child, 179 
 treatment of, 174 
 vapor baths of mercury in, 155 
 Syphilitic buboes, 155 
 "orchitis. 950 
 
 differential diagnosis of, 173 
 osteojaeriostitis, 168 
 
 diflferential diagnosis of, 186 
 sarcocele, 950 
 teeth, 687 
 
 ulcers of palate, 695 
 
 of rectum, 804 
 
 of tongue, 676 
 
 Syphilodermata, 157 
 
 Syringo-myelia, 559 
 
 Syringo-myelocele, 559 
 
 Tabetic arthropathy, 413 
 Tagliacotian method of rhinoplasty, 613 
 Talipes, 353 
 
 calcaneus, 353, 356 
 
 congenital. 354 
 
 equino-varus, 354 
 
 equinus, 353 
 
 non-congenital, 355 
 
 valgus, 353, 356 
 
1224 
 
 jyjiKX. 
 
 TalijH^ variiis iio3 
 Tapping. See Ptuncfnttstis. 
 Taxis, 822 
 
 aUli^iuinnl, 731 
 
 when conlraindicated, S22 
 
 in femoral hernia, strangulated. 829 
 
 in inguinal liernia, strangulatetl, 828 
 
 methcHi oi }^>erforming, S22 
 
 in un)bilic:il ht-rnia, strangulated, 831 
 Teeth, diseases of, t>86 
 
 extraction of, 687 
 
 Hutihinson's, 187 
 
 irre<.MiIarities of, 6SS 
 
 syphilitic. 1S7 
 Telangiectasis. 227 
 
 Tenn)oro-niaxilL'ir_v articulation, arthritis of. 
 685 
 diseases of, 685 
 Tendon, reflex, 561, note 
 
 lengthening of. '^mo 
 
 regeneration of. 31 
 
 rupture of. 342 
 Tendon-sheaths, tuberculosis of, 80. 339 
 Tendon-suture, 342 
 Tendons, dise.nses and injuries of, 338 
 
 displacement of, 342 
 
 wounds of. 342 
 Teno-svnovitis. 338 
 
 chronic tubercular, 339 
 
 for talii>es equino-varus, 355 
 Tents, 1175 
 Teratomata, 216 
 Testicle and Testicles, carcinoma of, 950 
 
 iencephaloid>, diflerential diagnosis of. 
 173 
 
 congenital deformities of, 949 
 
 cystic, 951 
 
 dise.ises of. 949 
 
 enchondroraa of, 951 
 V hydrateil 951 
 
 inflammation of. 949 
 
 malignant disease of, 950 
 
 retaineil. 949 
 
 sarcoma of. 951 
 
 scirrhus of. 951 
 
 syphilis of, 173, 189 
 
 tuberculosis of, 78, 950 
 
 undescended. 949 
 Tetanus, 70 
 
 acute, 70 
 
 after fractures. 293 
 
 amputation lor. 1152 
 
 antitoxin. 72, S3 
 
 bacillus of, 8. 70 
 
 cephalic, 71 
 
 hydrophobicus 71 
 
 neonatorum, 71 
 
 traumatic, 70 
 Tetanv. 71 
 Theciti.*. 338 
 
 Thermocautery, r.-npielin's. 1183 
 Thermometers, cliniad. 1189 
 Thieriichs niethotl of skin-grafting, 1109 
 
 solution. 7o7 
 Thomas's long splint, 396 
 Thoracic duct, rupture of, 463 
 wound of, 466 
 
 viscera, contusions involving, 646 
 Thoracoplasty, 641 
 Thoracotomv, 640 
 
 ThromlK>-phlebitis. 226 
 Throml>osis, 58 
 
 of cavernous sinus, 542 
 
 of i>etrosal sinus, 542 
 
 and pyemia of lateral sinus, 541 
 
 white, 59 
 Thrombus, 58 
 
 white, cure of aneurysm by, 246 
 Thyroid IkhIv, 659 
 
 laryngotomy, 622 
 
 tumors of. 6(i3 
 Thyroidea ima artery, 629 
 Thyroidectomy. 661 
 Thyroiditis, 659 
 Thyrotomy, 622 
 Tic convulsif. 362 
 I douloureux. 362 
 Toe-nail, ingrowing. 483 
 Toilet of {>eritoneal cavity, 747 
 Tongue, cancer of. 677 
 
 chancre of. 147 
 
 epithelioma of. 165. 214, 215, 677 
 
 loreign bodies in, 674 
 
 gummata of, 165, 677 
 
 malformations of. 672 
 
 mucous tubercles of, 677 
 
 nsevi of. 674 
 
 oj^>erations on, 679 
 
 papillomata of, 674 
 
 parenchymatous int^ammation of, 676 
 
 removal of, entire, 679 
 partial, 679 
 
 swallowing of, 672 
 
 syphilis of, 165, 676, 678 
 
 tuberculosis of, 77, 677 
 
 tumoi^ of, 674 
 
 ulcer of, tubercular. 677 
 
 ulcerations of. diagnosis from chancre. 147 
 
 warty tumors of, 673 
 
 wounds of. 673 
 Tongue-tie, 672 
 
 Tonsil and Tonsils, calcareous concretions of. 
 690 
 
 carcinoma of. 691 
 
 caseous concretions of, 690 
 
 chancre of, 147 
 
 faucial. 59$ 
 
 hy|»erirophy of 690 
 
 lingual, 598 
 
 lupus of. 78 
 
 malignant tumors of, removal of. 691 
 
 pharyngeal, 598 
 
 san-oma of, 691 
 
 tumors of. malignant, 691 
 Tonsillitis, 689 
 Tooth, hemorrhage after extraction of, 683 
 
 tumors, 688 
 Toothache, 688 
 Tophi. 409 
 Torsion, 2-55 
 
 of pedicle t)f ovarian cyst, 1044 
 Torticollis, 346 
 Tourniquet of Petit, 1153 
 Toxemia, 60 
 Toxic infection. 3 
 Toxins, 2 
 Trachea, burns and scalds of, 627 
 
 tumors of, 623 
 Trachea -tubes, 630 
 Trachelocele, 624 
 
INDEX. 
 
 1225 
 
 Tiacheotomy, 627, 628 
 
 at'ter-treatiuent of, G31 
 
 in traotiire of larynx, 625 
 Transfnsion ol" salt solntion, 254, 1185 
 Transmission of liereditary syphilis, 177 
 
 of niii-robic disease, 3 
 
 of syphilis, 141 
 Traumatic anenrysm, 240 
 
 delirium, 37 
 
 epilepsy, 550 
 
 fevei-, 34 
 
 gangrene, 53 
 ptomaines in, 9 
 
 hysteria, 577 
 Trendelonhurg's position, 736, 1008 
 
 operation for varicose veins, 227 
 Trephining for arrested development, 556 
 
 for cerebral abscess, 536 
 
 in fracture of skull, rules for, 520 
 
 for insanity and other mental disturbances, 
 555" 
 
 for inveterate headache, 555 
 Triangle, carotid, inferior, 1116 
 superior, 1115 
 
 of election, 1115 
 
 Lesser's, 1118 
 
 of necessity, 1116 
 
 supramental, 539 
 Trismus, 71 
 
 nascentium, 71 
 Trunk, cerebral center for, 497 
 Truss, 812 
 
 how to measure for, 813 
 Tubal pregnancy, 1029 
 diagnosis of, 1031 
 treatment of, 1031 
 Tubercle, anatomical, 75 
 
 bacillus of, 74 
 
 miliary, 74 
 
 painful subcutaneous, 366 
 Tubercles, mucous, 208 
 Tubercular arthritis, 388 
 
 ascites, 778 
 
 fistula, 78 
 
 osteo-myelitis, 79 
 
 peritonitis, 777 
 adhesive, 778 
 
 synovitis, 80 
 
 ulcer of tongue, 677, 678 
 
 ulceration of rectum, 804 
 Tuberculin, 84, 656 
 Tuberculosis, 74 
 
 of ankle-joint, 400 
 
 of bone, 79, 272 
 
 of breast, 78, 1057 
 
 of elbow-joint, 402 
 
 of genito-urinary tract, 78 
 
 of hip-joint, 391 
 
 of intestinal canal, 78 
 
 of joints, 80, 388 
 diagnosis of, 389 
 prognosis of, 390 
 treatment of, 390 
 
 of kidney, 847 
 
 of knee-joint, 398 
 
 of larynx, 620 
 
 of lymphatic glands, 80 
 of neck, 6-53 
 
 ®f mucous membranes, 77 
 
 of muscles, 77 
 
 Tuberculosis of panniculus adiposus, 77 
 
 of sacro iliac joint, 403 
 
 of shoulder-joint, 401 
 
 of skin, 76 
 
 of the spine, 79, 556 
 
 of tendon-sheaths, 80, 339 
 
 of testicle, 78 
 
 of tongue, 77, 077 
 
 verrucosa, 77 
 
 of the vertebrie, 79, 566 
 
 of vulva, 970 
 
 of wrist-joint, 403 
 Tubes and ovaries, removal of, 1037 
 TiiiliieU's method in aneurysm, 238 
 Tumor albus, 80 
 Tumors, 194 
 
 of antrum, 611 
 
 of bladder, 885 
 
 of bone, 277 
 
 of brain, diagnosis of, 547 
 diflerential diagnosis of, 535 
 prognosis of, 548 
 treatment of, 550 
 
 of breast, 1057 
 
 of broad ligament, 1048" 
 
 cartilaginous, 199 
 
 causes of, 194 
 
 of cicatrices, 484 
 
 classification of, 196 
 
 diagnosis of, 196 
 
 epiblastic and hypoblastic, 210 
 
 erectile, 202 
 
 of Fallopian tube, 1029 
 malignant, 1048 
 
 fatty, 198 
 of scalp, 503 
 
 fibrous, 197 
 
 fcetal, 561 
 
 of frontal sinus, 609 
 
 glandular, 202 
 
 growth of, 195 
 
 intestinal, 756 
 
 intracranial, 544 
 
 intrathoracic, 644 
 
 of jaws, 684 
 
 of kidney, solid, 848 
 
 of larynx, 621 
 
 of lips, 668 
 
 of liver, 782 
 
 malignant, amputations for, 1152 
 
 of mesentery, 780 
 
 mesoblaslic or connective-tissue, 197 
 
 mucous, 201 
 
 of muscle, 337 
 
 muscular, 202 
 
 of neck, 655 
 
 of nerves, 365 
 
 of nose, 605-607 
 
 of omentum, 779 
 
 origin of, 194 
 
 osseous, 200 
 
 ovarian, 1039 
 
 of ovary, solid, 1048 
 
 of palate, 695 
 
 of parotid, 658 
 
 of pharynx, 692 
 
 of rectum, 805 
 
 retro-pharyngeal, 692 
 
 of scalp, 503 
 
 of skull, 505 
 
1226 
 
 INDEX. 
 
 Tumors, spinal, 560 
 
 of spinal conl, 561 
 
 of spleen, TS'.i 
 
 of siil)niaxillary gland, 059 
 
 of thyroid, 005 
 
 of tongue, 073 
 
 of tonsils, 091 
 
 tooth, 088 
 
 of trachea, 023 
 
 treatment of, 196 
 
 of litems, 1003 
 
 of vagina, 981 
 
 vascular, 202 
 
 villous, 208 
 
 of vulva, 971 
 
 warty, 208 
 Turpentine stupe, 1182 
 Typhlitis, 700 
 
 Ulcer and Ulcers, 48 
 acute, 49 
 of anus, 800 
 atonic, 49 
 callous, 50 
 
 cancerous, of skin, 488 
 chronic, 49 
 erethistic, 49 
 exuberant, 49 
 of foot, perforating, 486 
 healthy, 49 
 irritable, 49 
 of larvnx, 618 
 Marjo'lin's, 618 
 neuro paralytic, 48 
 of nose, 600 
 painful, 49 
 perforating, of foot, 48, 486 
 
 of nasal se{Uum, 593 
 phagedenic, 50 
 rodent, 51, 214, 487 
 simple, of tongue, 679 
 specific, 51 
 of stomach, 713 
 strumous, of palate, 695 
 syphilitic, of palate, 695 
 of tongue, 678 
 dee[), 677 
 tubercular, of tongue, 677 
 varicose, 49, 220 
 Ulceration, 48 
 
 of new growths, 210 
 
 of rectum, syphilitic, 804 
 
 tubercular, 804 
 syphilitic, of palate, 695 
 of tongue, syphilitic, 678 
 Uranoplasty, 694 
 
 Uremia, differential diagnosis of, 513 
 Ureter, catheterization of, 841 
 
 stricture of, 851 
 Uretero-lithotomy, 839 
 Ureterotomy, 889 
 Uretero- ureterostomy, 850 
 Ureters, 835, 067 
 diseases of, 835 
 wounds of, 850, 1022 
 Urethra, diseases and injuries of, 868 
 injuries of, 893 
 
 and penis, relative sizes of, 988 
 rupture of, 893 
 stricture of, 926 
 
 Urethra, stricture of, annular, 920 
 deep, impassable, 935 
 
 ])ermeable only to filiform bougies, 934 
 inllanunatory, 920 
 irritable, 927 
 of large caliber, 929 
 
 behind the bulbo-membranous junction, 
 
 933 
 of pendulous portion, 930 
 linear, 920 
 
 of meatus and fossa navicularis, 932 
 organic, 926 
 resilient, 927 
 of small caliber, 933 
 
 of small caliber, in advance of bulbo- 
 membranous junction, 933 
 deei)er than bulbo-membranous junc- 
 tion, 933 
 spasmoilic, 92<) 
 tortuous, 92() 
 Urethral arthritis, 407 
 caruncle, 971 
 catarrh, 905 
 
 treatment of, 914 
 chancre, 150 
 discharge, chronic, 905 
 treatment of, 914 
 persistent, treatment of, 914 
 fever, 37, 893 
 fistula, 936 
 
 injections in early stage of gonorrhea, 910 
 svnovitis, 903 
 Urethritis, 895 
 antisepsis in, 911 
 in female, 922 
 
 treatment of, 925 
 simple, 890 
 Urethrotomy, external, 935 
 
 internal, 934 
 Urinar}' calculus, 860 
 deposits, 837 
 fever, 893 
 Urine, bloody, 853 
 chylous, 470 
 
 examination of, before operation, 1073 
 extravasation of, 857, 894, 936 
 incontinence of, 581, 856 
 infiltration of, 893 
 phosphatic, 837 
 residual, 859 
 retention of, 855 
 
 treatment of, 856, 917 
 tubercle bacilli in, 5 
 Uterine ai)pendages. ablation of, by abdorainwl 
 section, 1038 
 removal of, ultimate results of, 1039 
 gonorrhea, 923 
 treatment of, 925 
 Utero-ventral suture, 997 
 Uterus, anteflexion of, 989 
 anteversion of. 989 
 carcinoma of, 1017 
 displacem«nt of, 989 
 fibro-myomata of, 1003 
 
 treatment of, 1005 
 inflammations of, 987 
 inversion of, 1002 
 myomata of, 1003 
 prolapse of, 999 
 punctured wounds of, 984 
 
INDEX. 
 
 1227 
 
 Uterus, reposition of, Dt'S 
 retrolU'xion of, {•'••2 
 retruvorsion ot", '.11)2 
 rupture of, '.>X4 
 sarcoiiKi III", 1025 
 surgery of, 1025 
 tumors of, 1001^ 
 wounds of, '.'SH 
 
 Vaccination, 1 1H7 
 Vacciuo-sypliilis, 147 
 Vagina, atresia of, i'7G 
 closure of, il7'.) 
 foreign luulies in, OSl 
 indaiuniation of, 980 
 injuries of, 977 
 malformations of, 976 
 prolapse of, 981 
 surgery of, 976 
 tumors of, 981 
 wounds of, 977 
 Vaginal hysterectomy, 1020 
 Vaginismus, 977 
 Vaginitis, 921, 980 
 chronic, 922 
 treatment of, 924 
 Varicocele, 954 
 Varicose aneurysm, 248 
 ulcer, 226 
 veins, 225 
 of vulva, 972 
 Varix, 225 
 
 arterial, 230,437 
 capillary, 505 
 
 of internal saphenous vein, 225 
 Vas deferens, wounds of, 959 
 Vascular tumors, 202 
 Vein and \'eins, axillary wounds of, 262 
 complications of wounds of, 261 
 diseases of, 223 
 entrance of air into, 1072 
 femoral, wounds of, 262 
 inflammation of, 224 
 jugular, wounds of, 262 
 subclavian, wounds of, 262 
 varicose, 225 
 
 of vulva, 972 
 wounds of, 261 
 Vein-stones, 226 
 Velpeau's bandage, 1179 
 
 dressing for fracture of clavicle, 337 
 Velum, lupus of, 78 
 Venereal disease, 139 
 Venesection, 1184 
 
 Ventricles, lateral, surgery of, 507, 542 
 tai)ping of, in hydrocephalus, 507 
 puncture of, 543 
 Verruca necrogenica, 77 
 Verrucae, 482 
 
 Vertebra^ tuberculosis of, 79, 566 
 Vertical sulcus, 496 
 Vesical calculus. See Calculus, Vesical. 
 
 forceps of Thompson, 888 
 Vesicants, 1182 
 Vesico-vaginal fietula, 977 
 Villous growths of rectum, 805 
 
 tumors, 208 
 Vision, cerebral center for, 497 
 Vitality of patient, relation ef, to operations 
 1074 
 
 Volkinann's sliding rest, 297 
 
 splint, 294 
 Volvulus, 753 
 Vomiting from ether, 1089 
 Von Hacker's method in intestinal oljstruc- 
 
 tion, 747 
 Vulva, dermoid cysts of, 971 
 
 elephantiasis of, 972 
 
 inflammation of, 920, 969 
 
 injuries of, "J(J9 
 
 lympliuiliMna of, 972 
 
 malignant disease of, 971 
 
 papilloma of, 971 
 
 pruritus of, 970 
 
 sebaceous cysts of, 971 
 
 surgery of, 969 
 
 tuberculosis of, 970 
 
 tumors of, 971 
 
 varicose veins of, 972 
 Vulvitis, 920, 969 
 
 treatment of, 923, 970 
 Vulvo-vaginal abscess, 920, 971 
 
 Wallerian degeneration, 369 
 Wardrop's operation for aneurysm, 244 
 Warts, 208, 482 
 of scalp, 503 
 Warty growths of rectum, 805 
 tumors, 208 
 of tongue, 674 
 Water, boiling, as an antiseptic, 1077 
 Water-cushions, 1091 
 Webbed fingers, 349 
 Wens, 475, 503 
 
 Wharton's duct, calculi in, 659 
 Wheelhouse's method of perineal section, 937 
 White's operation, 944 
 White swelling, 80, 398 
 Whitehead's gag, 693 
 
 operation for excision of piles, 797 
 for removal of entire tongue, 680 
 WhiUow, 47, 340 
 Wilson's cyrtometer, 494 
 Withering" scirrhus, 211, 1063 
 Witzel's method of performing gastrostomy, 721 
 Wool-sorters' disease, 128 
 Word-blindness, 546 
 
 -deafness, 546 
 Wound fever, primary, 34 
 
 secondary, 34, 35 
 Wounds, 89 
 
 of abdomen, 701 
 
 arrest of hemorrhage in, 707 
 euterectomy in, 709 
 non-penetrating, 701 
 omental grafting in, 710 
 penetrating, 911 
 diagnosis of, 705 
 incision in, 707 
 preparation of patient for operation in, 
 
 706 
 symptoms of, 704 
 treatment of, 706 
 search for perforations in, 708 
 treatment after operation, §10 
 after-treatment of, 106 
 arrow , 121 
 aseptic, 91 
 cleansing of, 100 
 coaptation of, 101 
 
1228 
 
 INDEX. 
 
 Wounds, complications of, 10() 
 constitutional treatment of, 10') 
 contused, !•(), 1](» 
 
 and lacerated, 1 10 
 dissection, 123 
 
 dry method of dressing, 1087 
 erysipelas after, 107 
 gangrene after, 107 
 gunshot, 00, 113 
 
 am|)utations after. 120 
 
 intermediary jieriod in, 120 
 primiry period in, 120 
 secondary })eriod in, 120 
 
 probing of, 117 
 
 resections after, 120 
 
 treatment of, 118 
 healing of, 25 
 hemorrhage after, 91, 99 
 incised, 90, 109 
 inflammation after, 100 
 of intestine, suturing of, 709 
 lacerated, 90, 110 
 
 and contused, amputations after, 1152 
 local treatment of, 104 
 open, 90 
 
 Wounds, open, treatment of, 118K 
 
 pain after, 91 
 
 penetrating, 90. See Ahdomen, Cluxi, i-ic. 
 
 perforating, 90. See Abdomen, Chest, etc. 
 
 poisoned, 90, 112 
 
 punctured, 90, 112 
 
 repair of, 97 
 
 septic, 91 
 
 of sinu.se8 of brain, 517 
 
 subcutaneous, 90 
 healing of, 29 
 
 suppuration after, 107 
 
 of tongue, 732 
 
 treatment of, 99 
 Wrist-drop, 374 
 Wrist-joint disease, 403 
 erasion in, 403 
 excision in, 403 
 
 tuberculosis in, 403 
 Wry-neck, 346 
 Wyeth's amputation at hiii-joint, 1109 
 
 A'- Rays, 1191 
 
 ZOOGLKA, 1 
 
 LIST OF INSTRUiAIENT-MAKERS' CUTS. 
 
 Acknowledgment is hereby made to the firms named below for the use of the 
 following cuts : 
 
 Geo. Tiemann »fe Co., New York : 
 
 Figs. 250, 251, 253, 254, 255, 263, 264, 265, 266, 347, 348, 350, 352, 354, 
 355, 356, 357, 358, 360, 367, 496. 
 
 J. H. Gemrig & Son, Philadelphia: 
 
 Figs. 215, 218, 240, 241, 242, 346, 349, 368. 
 
 W. F. Ford & Co., New York : 
 
 Figs. 41, 42. 
 Otto Flemming, Philadelphia : 
 
 Fig. 219. 
 E. A. Yarnall Co., Philadelphia • 
 
 Fig. 216. 
 Lentz &. Son, Philadelphia : 
 
 Fig. 169. 
 
CATALOGUE 
 
 MEDICAL PUBLICATIONS 
 
 W. B. SAUNDERS, 
 
 No. 925 WALNUT STREET, PHILADELPHIA. 
 
 Arranged Alphabetically and Classified under Subjects. 
 
 THE hooks advertised in this Catalogue as heing sold by subscription are usually to he 
 obtained from travelling solicitors, hut they will he 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 j)arts 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 pos'c- 
 ofhce 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 30, 31, for a List of Contents classified according to subjects. 
 
 LATEST PUBLICATIONS. 
 
 American Text-Book of Dis. of Eye, Ear, Nose, and Throat. Page 3. 
 
 American Text-Book of Genito-Urinary and Skin Diseases, Page 4. 
 
 American Text-Book of Diseases of Children — Rev. Edition. Page 3. 
 
 American Text-Book of Gynecology — Revised Edition. See page 4. 
 
 American Year-Book of Medicine and Surgery. See page 6. 
 
 Anders^ Practice of Medicine — Revised Edition. See page 6. 
 
 Vierordt's Medical Diagnosis — Fourth (Revised) Edition. See page 29. 
 
 Van Valzah and Nisbet^s Diseases of the Stomach. See page 28. 
 
 Church and Peterson's Nervous and Mental Diseases. See page 8. 
 
 Da Costa's Surgery — Revised and Enlarged Edition. See page 10. 
 
 Saunders' Medical Hand-Atlases. See page 2. 
 
 Griffith on The Baby — Revised Edition. See page 12. 
 
 Butler's Materia Medica and Therapeutics — Revised Edition. Page 8, 
 
 De Schweinitz' Diseases of the Eye — Revised Edition. See page JO. 
 
 Vecki's Sexual Impotence. See page 28. 
 
 Stoney's Materia Medica for Nurses. See page 28. 
 
 Penrose's Diseases of Women — Second Edition. See page J 8. 
 
 McFarland's Pathogenic Bacteria — Revised Edition. See page 17, 
 
 American Pocket Medical Dictionary. See page 10. 
 
 Stengel's Text-Book of Pathology. See page 26. 
 
 Hirst's Text-Book of Obstetrics. See page 13. 
 
 Graf Strom's Massage and Medical Gymnastics. Page \2. 
 
 Saunders' Pocket Formulary— Fifth ( Revised ) Edition. See page 24. 
 
 Stevens' Practice of Medicine— Fifth (Revised) Edition. See page 27* 
 
SAUNDERS' MEDICAL HAND-ATLASES. 
 
 The series of books included under this title consists of auiliorized translations into 
 English uf the world famous Lehmann Medicinische Handatlanten, which for sci- 
 entif c accuracy, pictorial beauty, compactness, ami cheapness surpass any similar 
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 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 must vaiual)le features of these atlases is that they offer a ready and satis- 
 factory substitute for clinical observation. To those unable to attend impoit.mt clinics 
 these books will he absolutely indispensable. 
 
 In planning this series ot books arrangements were made with representative publishers 
 in the chief medical centers of nhe world for the publication of translations of the atlases 
 into nine different languages, the lithographic plates for all these editions being made in Ger- 
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 reduced. Thus by reason of their universal translation and reproduction, tlie publish- 
 ers 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 
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 In view of the striking success of these works, Mr. Saunders has contracted with the 
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 In consideration of this enormous undertaking, the jniblisher has been enabled to prepare 
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 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 
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 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. 
 
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 Atlas of Internal Medicine and Clinical Diagnosis. By Dr. Chr. Jakob, of Erlangen. Edited 
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 With 107 colored figures on 44 plates, and 25 text-illustrations. Cloth, $2.50 net, 
 
 Atlas of Operative Surgery. Bv I>r. O. Zitckkrkandl, of Vienna. Edited by J. Chalmers 
 
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 Atlas of Pathological Histology. Atlas of Operative Gynecology. 
 
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 Atlas of General Surgery. Atlas of Diseases of the Ear. 
 
THE AMERICAN TEXT-BOOK SERIES. 
 
 AN AMERICAN TEXT=BOOK OF APPLIED THERAPEUTICS. 
 
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 By 65 Eminent Contributors. Edited by Louis Starr, M. D., Con- 
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 AN AMERICAN TEXT=BOOK OF DISEASES OF THE EYE, EAR, 
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 AN AMERICAN TEXT-BOOK OF GENITO-URINARY AND SKIN 
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 Bangs, M.D. , Late Professor of Genito-Urinary and Venereal Diseases, 
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 AN AMERICAN TEXT-BOOK OF LEGAL MEDICINE AND TOXI- 
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 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 Aledical Journal. 
 
 " As 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 
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 Illustrated Catalogue of the ''American Text-Books " sent free upon application. 
 
Medical Publications of W. B. Saunders. 5 
 
 AN AMERICAN TEXT-BOOK OF PATHOLOGY. 
 
 Edited by John Guitkkas, 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. 
 
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 AN AMERICAN TEXT=BOOK OF SURGERY. Second Edition. 
 
 By 13 Eminent Professors of Surgery. Edited by William W. Keen, 
 M.D., LL.D., and J. William White, M.D., Ph.D. Handsome 
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 ♦' Personally, I should not mind it being called THE Text-Book (instead of A Text- 
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 the Board of Examiners of the Royal College of Surgeons, England. 
 
 " If this text-book is a fair reflex of the present position of American surgery, we must 
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 London Lancet. 
 
 AN AMERICAN TEXT=BOOK OF THE THEORY AND PRACTICE 
 OF MEDICINE. 
 
 By 12 Distinguished American Practitioners, Edited by William 
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 Illustrated Catalogue of the "American Text-Books^' sent free upon application. 
 
6 Medical Publications of W. B. Saunders. 
 
 AN AMERICAN YEAR-BOOK OF MEDICINE AND SURGERY. 
 
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 and text-books of the leading American and Foreign authors and 
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 ' Jahrbiicher ' of Geraiany. " — London Lancet. 
 
 THE AMERICAN POCKET MEDICAL DICTIONARY. 
 
 [See Do/iaiur s Pocket Dictionary, page 10.] 
 
 ANDERS' PRACTICE OF MEDICINE. Second Edition. 
 
 A Text-Book of the Practice of Medicine. By James M. Anders, 
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 James C. Wilson, Professor of the Practice of Medicine and Clinical Aledicine, Jefferson 
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 ASHTON'S OBSTETRICS. Fourth Edition, Revised. 
 
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 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- Coinpends, page 21.] 
 
 " Embodies the whole subject in a nut-shell. We cordially recommend it to our read 
 
 ers." — Chicago Medical Times. 
 
 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 Smmders' Question- Compends, page 21.] 
 
 " 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. 
 
Medical Publications of W. B. Saunders. 7 
 
 BASTIN'S BOTANY. 
 
 Laboratory Exercises in Botany. By EnsoN S. Bastin, M.A., 
 late Professor of Materia Medica and Botany, Philadelphia College of 
 Pharmacy. Octavo volume of 536 pages, with 87 jjlates. Cloth, $2.50. 
 
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 " Tliere is no work like it in the pharmaceutical or botanical literature of this country, 
 and we predict for it a wide circulation." — American Journal of Pharmacy, 
 
 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 12 full-page plates. Cloth, $1.25 net. 
 
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 by leadii'ig German and American surgeons." — Birtningham (Eng. ) Medical Review. 
 
 "This little volume can be recommended to any wlio are desirous of learning the details 
 of asepsis in surgerj', for it will serve as a trustworthy guide." — Loiidon 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. 
 
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 our notice in a long time. The field embraced in the title is covered in a terse, interesting 
 way." — Yale Afedical Journal. 
 
 BROCKWAY'S MEDICAL PHYSICS. Second Edition, Revised. 
 Essentials of Medical Physics. By Fred J. Brockwav, 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 21.] 
 
 " The student who is well versed in these pages will certainly prove qualified to com 
 prehend with ease and pleasure the great majority of questions involving physical principles 
 likely to be met with in bis medical studies." — American Practitioner and News. 
 
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 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 Aledical Journal. 
 
 " It contains all that one need know on the subject, is well written, and is copiously 
 illustrated." — Medical Record, New York. 
 
 BURR ON NERVOUS DISEASES. 
 
 A Manual of Nervous Diseases. By Charles W. Burr, M.D., 
 Clinical Professor of Nervous Diseases, Medico-Chirurgical College, 
 Philadelphia ; Pathologist to the Orthopedic Hospital and Infirmary 
 for Nervous Diseases ; Visiting Physician to St. Joseph's Hospital, etc. 
 Jn Preparation. 
 
8 Medical Publications of W. B. Saunders. 
 
 BUTLER'S MATERIA MEDICA, THERAPEUTICS, AND PHAR- 
 MACOLOGY. Second Edition, Revised. 
 A Text-Book of Materia Medica, Therapeutics, and Pharma- 
 cology. By George i". 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, 860 
 pages, illustrated. Cloth, $4.00 net ; Sheep, ;g5. 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 Lecturer 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." — A^ezo York Alcdical 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. i2mo, 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." — Ne^u York 
 Medical Times. 
 
 CHURCH AND PETERSON'S NERYOUS AND MENTAL DISEASES. 
 Nervous and Mental Diseases. By Archihald Church, M. D., 
 Professor of Mental Diseases and Medical Jurisprudence in the North- 
 western University Medical School, Chicago ; and Frederick Peter- 
 son, M. D. , Clinical Professor of Mental Diseases, Woman's Medical 
 College, N. Y.; Chief of Clinic, Nervous Dept., College of Physi- 
 cians and Surgeons, N. Y. Handsome octavo volume of 843 pages, 
 profusely illustrated. Cloth, ;^5.oo net; Half Morocco, |!6.oo net. 
 
Medical Publications of W. B. Saunders. 
 
 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, ^6.00 net. 
 
 "The work must be considered a valuable addition to the list of available textbooks, 
 and is to be highly recommended." — Neiu York Aledical Joiirnal. 
 
 "Tliis 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. 
 
 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, 382 pages; 55 
 illustrations. Cloth, ^1.50 net. 
 
 [See Saunders' Question- Compends, page 21.] 
 
 " 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. 
 
 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. 200 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 of Nervous and Mental Diseases. 
 
 CRAGIN'S GYN/ECOLOGY. 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, ^i.oo ; interleaved for notes, 
 
 [See Saunders' Question- Compends, page 21.] 
 
 " 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. 
 
10 Medical Publications of W. B. Saunders. 
 
 CROOKSHANK'S BACTERIOLOGY. Fourth Edition, Revised. 
 
 A Text-Book of Bacteriology. By Edgak M. Ckookshank, 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- 
 ologj', 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 Ch.\l.\iers 
 D.^CosTA, 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 sui^ery in the English language which so well fulfils 
 the requirements of the modem student.'' — Medico-Chiruygical 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, ^LD., 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 clearlj' 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 Medical 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. 
 
 The American Pocket Medical Dictionary. Containing the Pro- 
 nunciation and Derivation of over 26,000 words and phrases, and a large 
 number of useful tables. Edited by W. A. Newman Borland, M. p.. 
 Assistant Demonstrator of Obstetrics, L'niversity of Pennsylvania : Fel- 
 low of the American Academy of Medicine. 518 pages; handsomely 
 bound in full leather, limp, with gilt edges. Price, ^1.25 net. 
 
 DORLAND'S OBSTETRICS. 
 
 A Manual of Obstetrics. By W. A. Newman Dorland, ^LD., 
 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 
 Medieal Rei'iew. 
 
 " 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. Saunde rs. 
 
 11 
 
 FROTHINGHAM'S GUIDE FOR THE BACTERIOLOGIST. 
 
 Laboratory Guide for the Bacteriologist. By Langdon Froth- 
 
 Tngham M D.V., Assistant in Bacteriology and Veterinary Science, 
 
 Sheffidd Scientific School, Yale University. Illustrated. Cloth, 75 cts. 
 
 .. It is a convenient and useful little work, and will more than repay the outlay neces- 
 
 am M<;fico-Sii?gic<jl Bulletin. 
 
 GARRIGUES' DISEASES OF WOMEN. Second Edition. Revised. 
 Diseases of Women. By Henry J. Garrigues, A.M., M.D , Pro- 
 fc for of Gynecology in the New York School of Clinical Medicine ; 
 Gy^roloSt to St^'Mark's Hospital and to the Gern.an Dispensary 
 New York City, etc. Handsome octavo volume of 728 pages ^Hus^ 
 trated by 335 engravings and colored plates. Cloth, ^4-00 net, 
 Sheep or Half Morocco, $5.00 net. 
 
 .. One of the best text-books for students and P-^titioners.^ich has been publ.^^^^^^ 
 the English language ; it is condensed e,ea;, and -^^^^^^^^ •„ | 
 
 ^t^l^n^dlnSv: t:^' t;:::S^^litionersto who^ expenenced^nsuUants 
 
 GLEASON'S DISEASES OF THE EAR. Second Edition, Revised. 
 Essentials of Diseases of the Ear. By E. B Gleason S.B., 
 MD Clinical Professor of Otology, Medico-ChirurgK:al College 
 ^;iUdelphia; Surgeon-in-Charge of ^1- Nose Throat, and Ear Dep^^^^ 
 ment of the Northern Dispensary, Philadelphia. 208 pages, ^Mth 
 114 illustrations. Cloth, $1.00 ; interleaved for notes, $1.25. 
 [See Saunders' Question- Compends, page 21.] 
 
 ramd^:'— Liverpool Medico- Chi rurgica I Joicrna I. 
 
 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 
 xhaXeLearch of medical literaUire from its -gin^o the p.esen 
 day, abstracted, classified, annotated, and indexed. Handsorne im 
 perial octavo volume of 968 pages, with 295 engravings ^^ he ^ex , 
 and X 2 full-page plates. Cloth, $6.00 net; Half Morocco, $7-00 net. 
 Sold by Subscription. 
 
 " One of the most valuable contributions ever made to medical literature. It is so far 
 as we kn^w absolutely unique, and every page is as f--"f ^"^ -.^rrTferenS^o all wt 
 the medical profession has this volume va ue: '^J'^^^Yco leeal tol^'-S^^^^^^^ Medical 
 are interested in general scientific, sociologic, or medico-legal topics. ^ 
 
 ^"7:This is certainly a most -arkable and in..sth^^oUn^ It -d. aU^j^ng 
 
 medical literature, an anomaly on anomalies m that there >s noumg n 
 
 medical literature. It is a book full of revelations ^^'Z^J'^.'^ MedS-S^I^^^^^ 
 
 but interest and sometimes almost homfy its readers. -American Meduo ^tirgic 
 
12 Medical Publications of W. B. Saunders. 
 
 QRAFSTROM'S MECHANO-THERAPY. 
 
 A Text-Book of Mechano-Therapy (Massage and Medical Gym- 
 nastics i. I*)y AxKi. \'. ('.KAi-sikoM, B. Sc, M. I)., laic Lieutenant in 
 the Royal Swedish Army ; late House Physician City Hospital, IJlack- 
 well's Island, Xew York. i2mo, 139 i)ages, 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. i2mo, 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 obser\'ing 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. 
 
 A convenient blank for keeping a record of the child's weight during the first two years 
 of life. Printed on each chart is a curve representing the average weight of a healthy infant, 
 so that any deviation from the normal can readily be detected. 
 
 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., late Professor of Principles of Sur- 
 gery and of Clinical Surgery in the Jefferson Medical College, and 
 A. Haller Gross, A.M., of the Philadelphia Bar. Preceded by a 
 Memoir of Dr. Gross, by the late Austin Flint, M.D., LL.D. In 
 two handsome volumes, each containing over 400 pages, demy octavo, 
 extra cloth, gilt tops, with fine Frontispiece engraved on steel. Price 
 per volume, §2.50 net. 
 
 "Dr. Gross was perhaps the most eminent exponent of medical science that America 
 has yet produced. His Autobiography, related as it is with a fulness and completeness 
 seldom to be found in such works, is an interesting and valuable book. He comments on 
 many things, especially, of course, on medical men and medical practice, in a very interest- 
 ing way." — The Spectator, London, England. 
 
 HAMPTON'S NURSING. Second Edition, Revised and Enlarged. 
 Nursing: Its Principles and Practice. Py Isadii, 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 jileasure 
 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. 
 
Mediciil Publications of W. B. Saunders. 13 
 
 HARE'S PHYSIOLOGY. Fourth Edition, Revised. 
 
 Essentials of Physiology. By H. A. Hark, M.I)., Professor of 
 'I'hcrapeutics and Materia Medica in tlie Jefferson Medical College of 
 rhilaciclphia. Crown octavo, 239 pages. Cloth, $1.00 net; inter- 
 leaved for notes, $1.25 net. 
 
 [See Saunders' Quesiion-Compends,^2igQ 21.] 
 " The best condensation of physiological knowledge we have yet seen."— Metrical 
 Record, New York. 
 
 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. "—A^rw 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 coxaxaenAeA.'"— Medical Record, New \ ork. 
 
 HEISLER'S EMBRYOLOGY. 
 
 A Text=Book of Embryology. By John C. Heisler, M.D., Pro- 
 fessor of Anatomy in the Medico-Chirurgical College, Philadelphia. 
 In Preparalion. 
 
 HIRST'S OBSTETRICS. 
 
 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 a number of 
 colored plates. Cloth, $5.00 net; Sheep or Half Morocco, $6.00 net. 
 This work 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 practical side of the subject, and to this end presents an unusually 
 
 large collection of illustrations, the majority of them original. 
 
 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- Ch irurgical Journal. 
 
 "The best student's manual which has appeared on the subject."— 5/. Louis Medical 
 and Surgical Journal. 
 
14 Medical Publications of W. B. Saunders. 
 
 JACKSON AND GLEASON'S DISEASES OF THE EYE, NOSE, AND 
 THROAT. Second Edition, Revised. 
 Essentials of Refraction and Diseases of the Eye. By I^dward 
 Jackson, A.M., M.U., Professor of Diseases of the Kye in the Phila- 
 delphia Polyclinic and College for Graduates in Medicine; and — 
 Essentials of Diseases of the Nose and Throat. By E. Bald- 
 win CiLEASON, M.D., Surgeon-in-Charge of the Nose, Throat, and 
 Ear Department of the Northern Dis])ensary of Philadelphia. Two 
 volumes in one. Crown octavo, 290 pages; 124 illustrations. Cloth, 
 $1.00; interleaved for notes, Si-25- 
 
 [See Saunders' Question- Compends, page 21.] 
 
 "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; Vice-President of the American Paediatric Society; Editor 
 "Cyclopaedia of the Diseases of Children," etc.; and Henry 
 Hamilton, Author of "A New Translation of Virgil's ^neid into 
 English Rhyme," etc.; with the collaboration of J. Chalmers Da- 
 Costa, M.D.. and Frederick A. Packard, M.D. With an Appendix 
 containing Tables of Bacilli, Micrococci, Leucomaines, Ptomaines; 
 Drugs and Materials used in Antiseptic Surgery; Poisons and their 
 Antidotes ; Weights and Measures ; Thermometric Scales ; New 
 Official and Unofficial Drugs, etc. One volume of over 800 pages. 
 Prices, with Denison's Patent Ready-Reference Index: Cloth, S5-oo 
 net; Sheep or Half Morocco, $6-00 net; Half Russia, S6.50 net. 
 AVithout Patent Index: Cloth, $4.00 net; Sheep or Half Morocco, 
 $5.00 net. 
 
 " I am much pleased with Keating"s Dictionarj-, and shall take pleasure in recommend 
 ing it to my classes." — Henry M. Lyman, M.D., Professor of the Principles and Practict 
 of Medicine, Rush Medical College, Chicago, III. 
 
 " I am convinced that it will be a very valuable adjunct to my study-table, convenient 
 in size and sufficiently full for ordinary use." — C. A. Lindsley, M.D., Professor of the 
 Theory and Practice of Medicine, Medical Dept. Yale University. 
 
 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 Paediatric 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, 1 2. 00 net. 
 
 " This is by far the most useful book which has yet appeared on insurance examination, 
 a subject of growing interest and importance. Not the least valuable portion of the volume 
 is Part II, which consists of instructions issued to their examining physicians by twenty-four 
 representative companies of this country. If for these alone, the book should be at the right 
 hand of every physician interested in this special branch of medical science. ' ' — The Medical 
 News. 
 
Medical Publications of W. B. Saunders. 15 
 
 KEEN ON THE SURGERY OF TYPHOID FEVER. 
 
 The Surgical Complications and Sequels of Typhoid Fever. 
 
 By Wm. W. Kkkn, M.D., LL.D., Professor of the Principles of Sur- 
 gery and of Clinical Surgery, Jefferson Medical College, Philadelphia; 
 Corresponding Member of the Soci^te 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 linglish 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." — 
 Amencan MeJico-Sitigicii/ Bulhtin. 
 
 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, containing blanks for fifty operations, 
 50 cents net. 
 
 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 ; Bacteriologist to the Philadelphia 
 Orthopedic Hospital, hi Preparation. 
 
 LAINE'S TEMPERATURE CHART. 
 
 Temperature Chart. Prepared by D. T. Laine, M.D. Size 8 x 13^ 
 inches. A conveniently arranged Chart for recordiiig 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. 
 
 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 Lifirmary, 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 Aledical Journal. 
 
16 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' Hosi)ital, Minneapolis, etc. Handsome octavo volume of 
 800 pages, profusely illustrated. Cloth, $5.00 net; Half Morocco, 
 $6.00 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 Netcs, New 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 book 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. Mallorv, A.!NL, ALD., Assistant Professor of Pathology, Harvard 
 University Medical School, Boston; and James H. Wright, A.^L, 
 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 glad 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., ^LD., 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 21.] 
 
 " 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. Sixth 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., RLD., Clinical Professor of Genito- 
 Urinary Diseases, University of Pennsylvania, etc. Crown octavo, 338 
 pages, illustrated. With an Appendix containing full directions for the 
 preparation of the materials used in Antiseptic Surgery, etc. Cloth, 
 Ji.oo; interleaved for notes, $1.25. 
 
 [See Sounders' Question- Compends, page 21.] 
 
 " Contains all necessary essentials of modem surgery in a comparatively small space. 
 Its style is interesting, and its illustrations are admirable." — Medical and Surgical Reporter. 
 
Medical Publications of W. B. iSautiders. 17 
 
 McFARLAND'5 PATHOGENIC BACTERIA. Second Edition. Re- 
 vised and (jreatly Enlarged. 
 Text-Bool< upcn the Pathogenic Bacteria, liy Jo^kih McKar- 
 i.AN'D, M. 1)., I'rolc'ssor ot" Pathology and Ha( tcriology in the Medico- 
 Chirurgical College ot I'hikulelphia, etc. Octavo volume of 497 pages, 
 finely illustrated. Cloth, $2.50 net. 
 
 " Dr. McFarland lias 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. H. Andkrson, M.D. , Professor of Patholoj^y 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. 
 
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 MORRIS'S MATERIA MEDICA AND THERAPEUTICS. Fifth 
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 Essentials of Materia Medica, Therapeutics, and Prescription- 
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 MORRIS, WOLFF, AND POWELL'S PRACTICE OF MEDICINE. 
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 delphia; with an Appendix on the Clinical and Microscopic Examina- 
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18 Medical Publications of W. B. Saunders. 
 
 MORTEN'S NURSE'S DICTIONARY. 
 
 Nurse's Dictionary of Medical Terms and Nursing Treat- 
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 A Text=Book of Diseases of Women. By Charles B. Penrose, 
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Medical Publications of W. B. Saunders. 19 
 
 POWELL'S DISEASES OF CHILDREN. Second Edition. 
 
 Essentials of Diseases of Children, liy William M. Powell, 
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 PYE'S BANDAGING. 
 
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 1. ESSENTIALS OF PHYSIOLOGY. By II. A. Hare, M.D. Fourth edition, 
 
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 2. ESSENTIALS OF SURGERY. By Kdward Martin, M.D. Sixth edition, 
 
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Saunders' 
 
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 Any of these Manuals will be mailed on receipt of price (see next page for List). 
 
Saunders^ New Series of Manuals^ 
 
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 PHYSIOLOGY. By Josrph 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, J?l.25 net. 
 
 SURGERY, General and Operative. By John Chalmkrs DaCosta, M.D., Clini- 
 cal Professor of Surgery, Jelferson Medical College, Philadelphia; Surgeon to the 
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 Octavo, gii pages, profusely illustrated. Cloth, ^4.00 net ; Half Morocco, $5.00 net. 
 
 DOSE=BOOK AND MANUAL OF PRESCRIPTION=WRITINQ. By E. Q. 
 
 Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Phila- 
 delphia. Illustrated. Cloth, $1.25 net. 
 
 SURGICAL ASEPSIS. By Car i. Beck, M.D., Surgeon to St. Mark's Hospital and 
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 MEDICAL JURISPRUDENCE. By Henry C. Chapman, M.D. Professor of Insti- 
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 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 
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 Cloth, ^2.50 net. 
 
 MANUAL OF ANATOMY, By Irving S. Haynes, M.D., Adjunct Professor of 
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 MANUAL OF OBSTETRICS. By W. A. Newman Dorland, M.D., Assistant 
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 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., P\R.C.S. Edin., Assistant Surgeon to Chelsea Hospital, 
 London. Handsomely illustrated. Cloth, ^2.50 net. 
 
 VOLUMES IN PREPARATION. 
 
 NOSE AND THROAT. By D. Braden Kyle, M.D., Clinical Professor of Laryn- 
 gology and Rhinology, Jefferson Medical College, Philadelphia ; Consulting Laryngolo- 
 gist, Rhinologist, and Otologist, St. Agnes' Hospital; Bacteriologist to the Philadel- 
 phia Orthopedic Hospital and Infirmary for Nervous Diseases, etc. 
 
 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 
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 Pamphlet containing specimen pages, etc sent free upon application. 
 
24 Medical Publications of W. B. 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. 
 
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 recommended." — British Medical Journal. 
 
 SAUNDERS' MEDICAL HAND-ATLASES. 
 
 This series of books consists of authorized translations into English of 
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 volume contains from 50 to 100 colored lithographic plates, besides 
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 SAUNDERS' POCKET MEDICAL FORMULARY. Fifth Edition, 
 
 Revised. 
 
 By William ^L 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, Formulae and Doses for Hypo- 
 dermic Medication, Poisons and their Antidotes, Diameters of the 
 Female Pelvis and Fcetal Head, Obstetrical Table, Diet List for Various 
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 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. 
 
Medical Publications of W, B. Saunders. 25 
 
 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. Lend., 
 Physician to the Northeastern Hospital for Children, Hackney, etc. 
 Crown octavo, 212 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 Saundefs' Question- Cojnpetids, page 21.] 
 
 " Should take its place among the standard volumes on the bookshelf of both student 
 and practitioner." — London Hospital Gazette. 
 
 SENN'S GENITO=URINARY TUBERCULOSIS. 
 
 Tuberculosis of the Genito-Urinary Organs, Male and Female. 
 
 By Nicholas Senn, M.D., Ph.D., LL.D., Professor of the Practice of 
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 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- 
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 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. " — Ne%v 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. Cloth, $6.00 net; 
 Half Morocco, $7.00 net. 
 
 " The most exhaustive of any recent book in English on this suljject. 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 of the American Medical Association. 
 
26 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.U., Clinical rrofessor 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, i86 pages; 48 original illustrations. Cloth, 
 $1.00 ; interleaved for notes, $1.25. 
 
 [See Saunders' Question- Compends, 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- Surgical 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. Formulae for the preparation of diluents and foods are appended. 
 
 STELW AGON'S DISEASES OF THE SKIN. Third Edition, Revised. 
 Essentials of Diseases of the Skin. By Hknrv \\ . 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, 270 pages; 86 illustrations. Cloth, $1.00 net; inter- 
 leaved for notes, S1.25 net. 
 
 [See Saunders'' Question- Compends, page 21.] 
 " The best student's manual on skin diseases we have yet seen." — Times and Register. 
 
 STENGEL'S PATHOLOGY. 
 
 A Text=Book of Pathology. By Alfred Stengei,, M. D., Physician 
 to the Philadeli)hia Hospital : Clinical Professor of Medicine in the 
 Woman's Medical College; Physician to the Children's Hospital; 
 late Pathologist to the German Hospital, Philadelphia, etc. Handsome 
 octavo volume of 848 pages, with nearly 400 illustrations, many of them 
 in colors. Cloth, $4.00 net; Half Morocco, S5.00 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 
 Physical 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 modem 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. '-^7 
 
 STEVEN5' PRACTICE OF MEDICINE. Fifth Edition, Revised. 
 
 A Manual of the Practice of Medicine. I.y A. A. Stkvens, A. M., 
 M.I)., Lecturer on 1 crminologv aiul Instructor in Physical Diagnosis 
 in the University of Pennsylvania ; Professor of Pathology in the 
 Woman's Medical College of Pennsylvania. Spe( ially intended^ for 
 students preparing for graduation and hosjjital examinations. I'osi- 
 octavo, 519 pages; illustrated. Flexible leather, $2.00 net. 
 "The frequency with which new editions of this manual are demanded bespeaks its 
 Donularilv It is an excellent condensation of the essentials of medical practice ^,r the 
 student, and may be found also an excellent reminder for the busy phy.Mc.an. -Buja/o 
 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., 
 U Sc lately Examiner in Physiology, University of Aberdeen, and 
 of the New Museums, Cambridge University ; Professor of Physiology 
 in the Western Reserve Universitv, 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. "—Z.'w^/ow Lancet. 
 
 "Of the many text-books of physiology published, we do not know of one that so 
 
 nearly comes up Jthe ideal as does Prof. Stewart's volume, "-^r^/^./. Medual Journal. 
 
 STEWART AND LAWRANCE'S MEDICAL ELECTRICITY. 
 
 Essentials of Medical Electricity. By D. D. Stewari, M.D., 
 Demonstrator of Diseases of the Nervous System and Chief of the 
 Neurological Clinic in the Jefferson Medical College; and L. S. 
 Lawrence, M.D., Chief of the Electrical Clime and Assistant Demon- 
 ^t?lr of bisease's of the Nervous System in the Jefferson Medical 
 College, etc. Crown octavo, 158 pages; 65 illustrations. Cloth, 
 $i.oo^ interleaved fornotes, ^1.25. 
 
 [See Saunders' Que stmt- Comp ends, page 21.] 
 .< Throughout the whole brief space at their command the authors show a discriminating 
 
 knowledge of their subject."— ^/^^?V«/ News. 
 
 STONEY'S NURSING. Second Edition, Revised. 
 
 Practical Points in Nursing. For Nurses in Private Practice. 
 
 Bv Emily A. M. Stoney, Graduate of the Training-bchool for Nurses, 
 Tawrence Mass.; late Superintendent of the Iraming-School for 
 Nu™ Carney Hospital, South Boston, Mass. 456 pages, illustrated 
 with 73 engra^vings 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 ox.^.^ -Therapeutrc Gazette. 
 
 This is a well- written, eminently practical volume, which covers the entire range of 
 1 his is a w^'.' . • u' ,1 from hosnital nursing, and nstructs the nurse how best to 
 
 private nursing as distinguished from hospital ""rsing, everything ordinarily 
 
 "'T,V;:'l *aX. .he physician can p„c. in >he hands of his ,.ri.a,e nurses »,.h ,he 
 assurance of benefit."— (^/^^c^ Medical Journal. 
 
28 Medical Puhlications of W. B. Saunders. 
 
 STONEY'S MATERIA MEDICA FOR NURSES. 
 
 Materia Medica for Nurses. I^y I<>mii.y A. M. Stonky, Graduate of 
 the 'rraining-School lor Nurses, Lawrence, Mass. ; late Superintendent 
 of the Training-School for Nurses, Carney Hospital, South 15oston, jMass. 
 Handsome octavo volume of about 300 pages. C'loth, $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 I'oison-emergencies, 
 Ready Dose list, Weights and Measures, etc., as well as a Glossary, detining 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."— /ourna/ 0/ /At 
 
 American Aleciiail Association. 
 
 THOMAS'S DIET LISTS AND SICK=ROOM DIETARY. 
 
 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.U., Demonstrator of Therapeutics, Jefferson 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." — Medical 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 
 (J. Veck.1, M.D. From the second German edition, revised and en- 
 larged. Demi-octavo, about 300 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 CJennan 
 book has received the highest consideration. This edition is more tlian a mere translation, 
 for, although based on the German edition, it has been entirely rewritten in English. 
 
Medical Publications of W. B. Saunders. 29 
 
 VIERORDT'S MEDICAL DIAGNOSIS. Fourth Edition, Revised. 
 Medical Diagnosis. By Dr. Oswald Vierordi', 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. Lindslky, M.D., Professor of the Theory and 
 Practice of Medicine, 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 circulatoiy 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. 
 
 Surgical Pathology and Therapeutics. By John Collins Warren, 
 M.D., LL.D., Professor of Surgery, Medical Department Harvard 
 University; Surgeon to the Massachusetts General Hospital, etc. 
 Handsome octavo volume of 832 i)ages ; 136 relief and lithographic 
 illustrations, 33 of which are printed in colors, and all of which were 
 drawn by William J. Kaula from original specimens. Cloth, ;^6.oo 
 net; Half Morocco, ^7.00 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. 
 
 " The handsomest specimen of bookmaking that has ever been issued from the American 
 medical press." — American Journal of the Medical Sciences. 
 
 " 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. Fourth 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, 218 pages. Cloth, $1.00; inter- 
 leaved for notes, $1.25. 
 
 [See Saunders' Questio7i-Compends, page 21.] 
 
 "The scope of this work is certainly equal to that of the best course of lectures ori 
 Medical Chemistry." — Pharmaceutical Era. 
 
CLASSIFIED LIST 
 
 Medical Publications 
 
 W. B. SAUNDERS, 
 
 925 "Walnut Street, Philadelphia. 
 
 ANATOMY, EMBRYOLOGY, 
 HISTOLOGY. 
 
 Clarkson — A Text-Book of Histology, 9 
 Haynes — A Manual of Anatomy, . . . 13 
 Heisler — A Text-Book of Embryology, 13 
 Nancrede — Essentials of Anatomy, . . 18 
 Nancrede — Essentials of Anatomy and 
 
 Manual of Practical Dissection, ... 18 
 Semple — Essentials of Pathology and 
 
 Morbid Anatomy, 25 
 
 BACTERIOLOGY. 
 
 Ball — Essentials of Bacteriology, ... 6 
 Crookshank — A Text-Book of Bacteri- 
 ology, 10 
 
 Frothingham — I.aboratory Guide, . . 11 
 Mallory and Wright — Pathological 
 
 Technique, 16 
 
 McFarland — Pathogenic Bacteria, . . 17 
 
 CHARTS, DIET- LISTS, ETC. 
 
 Griffith — Infant's Weight Chart, ... 12 
 
 Hart — Diet in Sickness and in Health, . 13 
 
 Keen — Operation Blank, 15 
 
 Laine — Temperature Chart, ... -15 
 
 Meigs — Feeding in Early Infancy, . . 17 
 
 Starr — Diets for Infants and Children, . 26 
 Thomas — Diet-Lists and Sick-Room 
 
 Dietary, 28 
 
 CHEMISTRY AND PHYSICS. 
 
 Brock way — Essentials of Medical Phys- 
 ics 7 
 
 Wolff — Essentials of Medical Chemistry, 29 
 
 CHILDREN. 
 
 An American Text-Book of Diseases 
 
 of Children, . . 3 
 
 Griffith — Care of the Baby 12 
 
 Griffith — Infant's Weight Chart, ... 12 
 
 Meigs — Feeding in Early Infancy, . . 17 
 
 Powell — Essentials of Dis. of Children, 19 
 
 Starr — Diets for Infants and Children, . 26 
 
 DIAGNOSIS. 
 
 Cohen and Eshner — Essentials of Di- 
 agnosis, 9 
 
 Corwin — Physical FJiagnosis 9 
 
 Macdonald — Surgical Diagnosis and 
 Treatment 16 
 
 Vierordt — Medical Diagnosis 29 
 
 DICTIONARIES. 
 
 Borland — Pocket Dictionary, .... 10 
 
 Keating — Pronouncing Dictionarj', . . 14 
 
 Morten — Nurse's Dictionary, .... 18 
 
 EYE, EAR, NOSE, AND THROAT. 
 
 An American Text- Book of Diseases 
 
 of the Eye, Ear, Nose, and Throat, . 3 
 De Schweinitz — Diseases of the Eye, . 10 
 Gleason — Essentials of Dis. of the Ear, il 
 Jackson and Gleason — Essentials of 
 
 Diseases of the Eye, Nose, and Throat, 14 
 Kyle — Diseases of the Nose and Throat, 15 
 
 GENITO=URINARY. 
 
 An American Text-Book of Genito- 
 urinary and Skin Diseases, 4 
 
 Hyde and Montgomery — Syphilis and 
 the \'enereal Diseases, ...... 13 
 
 Martin — Essentials of Minor Surgery. 
 
 Bandaging, and Venereal Diseases, . 16 
 Saundby — Renal and Urinary Diseases, 24 
 Senn — Genito- Urinary Tuberculosis, . 25 
 Vecki — S(-xual Impotence, 28 
 
 GYNECOLOGY. 
 
 American Text- Book of Gynecology, 4 
 Cragin — Essentials of Gynecology, . . 9 
 Garrigues — Diseases of Women, ... 11 
 Long — Syllabus of Gynecology, ... 15 
 Penrose— Diseases of Women, .... 18 
 Sutton and Giles — Diseases of Women, 28 
 
 MATERIA MEDICA, PHARMACOL- 
 OGY, AND THERAPEUTICS. 
 
 An American Text-Book of Applied 
 
 Therapeutics 3 
 
 Butler — Text-Book of Materia Medica, 
 
 Therapeutics and Pharmacology, ... 8 
 Cerna — Notes on the Newer Remedies, 8 
 Griffin — Materia Med. and Therapeutics, 12 
 Morris — Essentials of Materia Medica 
 
 and Therapeutics, . . 17 
 
 Saunders' Pocket Medical Formulary, 24 
 Sayre — Essentials of Pharmacy, . . 24 
 
 Stevens — Essentials of Materia Medica 
 
 and Therapeutics, ... ... 26 
 
 Stoney — Materia Medica for Nurses, . 28 
 Thornton — Dose-Book and Manual of 
 
 Prescription-Writing, ...... 28 
 
 MEDICAL JURISPRUDENCE AND 
 TOXICOLOGY. 
 
 An American Text-Book of Legal 
 Medicine and Toxicology 4 
 
 Chapman — Medical Jurisprudence and 
 Toxicology, .......... 8 
 
 Semple — Essentials of I^egal Medicine, 
 Toxicology, and Hygiene 25 
 
Medical Publications of W. B. Saunders. 
 
 31 
 
 Nervous and mental 
 diseases, etc. 
 
 Burr — Nervous Diseases, 7 
 
 Chapin — Coinpendiuin of Insanity, . . 8 
 Church and Peterson — Nervous and 
 
 Mental Diseases, 8 
 
 Shaw — Essentials of Nervous Diseases 
 
 and Insanity 26 
 
 NURSING. 
 
 An American Text-Book of Nursing, 29 
 
 Griffith — The Care of the IJaby, ... 12 
 
 Hampton — Nursing 12 
 
 Hart — Diet in Sickness and in Health, I3 
 
 Meigs — Feeding in Early Infancy, . . 17 
 
 Morten — Nurse's Dictionary 18 
 
 Stoney — Practical Points in Nursing, . 27 
 
 OBSTETRICS. 
 
 An American Text-Book of Obstetrics, 4 
 Ashton — Essentials of Obstetrics, ... 6 
 Boisliniere — Obstetric Accidents, Emer 
 
 gencies, and Operations, .... 
 Borland — Manual of Obstetrics, . 
 Hirst — Text-Book of Obstetrics, . 
 Norris — Syllabus of Obstetrics, . . 
 
 PATHOLOGY. 
 
 7 
 lo 
 
 13 
 
 18 
 
 Physi- 
 
 An American Text-Book of Pathology, 5 
 Mallory and Wright — Pathological 
 
 Technique, .... 16 
 
 Semple — Essentials of Pathology and 
 
 Morbid Anatomy, . . 25 
 
 Senn — Pathology and Surgical Treat- 
 ment of Tumors, 25 
 
 Stengel — Te.xt- Book of Pathology, . . 26 
 Warren — Surgical Pathology and Thera- 
 peutics, 29 
 
 PHYSIOLOGY. 
 
 An American Text-Book of 
 
 ology, 
 
 Hare — Essentials of Physiology, . . . I3 
 Raymond — Manual of Physiology, . . 19 
 Stewart — Manual of Physiology, ... 27 
 
 PRACTICE OF MEDICINE. 
 
 An American Text-Book of the The- 
 ory and Practice of Medicine, .... 5 
 
 An American Year-Book of Medicine 
 and Surgery, 6 
 
 Anders — Text-Book of the Practice of 
 Medicine, 6 
 
 Lockwood — Manual of the Practice of 
 Medicine, 15 
 
 Morris — Essentials of the Practice of 
 Medicine, 1 7 
 
 Rowland and Hedley — Archives of 
 the Roentgen Ray, 19 
 
 Stevens — Manual of the Practice of 
 Medicine, 27 
 
 SKIN AND VENEREAL. 
 
 An American Text-Book of Genito- 
 urinary and Skin Diseases, 3 
 
 Hyde and Montgomery — Syphilis and 
 the Venereal Diseases 13 
 
 Martin — Essentials of Minor Surgery, 
 Bandaging, and Venereal Diseases, . 16 
 
 Pringle — Pictorial Atlas of Skin Dis- 
 eases and Syphilitic Affections, ... 19 
 
 Stelwagon — Essentials of Diseases of 
 the Skin, 26 
 
 SURGERY. 
 
 An American Text-Book of .Surgery, 5 
 An American Year-Book of Medicine 
 
 and Surgery, 6 
 
 Beck — Manual of Surgical Asepsis, . . 7 
 DaCosta — Manual of Surgery, .... 10 
 
 Keen — Operation Blank, 15 
 
 Keen — The Surgical Complications and 
 
 Sequels of Typhoid Fever, 15 
 
 Macdonald — Surgical Diagnosis and 
 
 Treatment, 16 
 
 Martin — Essentials of Minor Surgery, 
 
 Bandaging, and Venereal Diseases, . 16 
 Martin — Essentials of Surgery, .... 16 
 
 Moore — Orthopedic Surgery, 17 
 
 Pye — Elementary Bandaging and Surgi- 
 cal Dressing, 19 
 
 Rowland and Hedley — Archives of 
 
 the Roentgen Ray, 19 
 
 Senn — Genito-Urinary Tuberculosis, . 25 
 
 Senn — Syllabus of Surgery, 25 
 
 Senn — Pathology and Surgical Treat- 
 ment of Tumors, 25 
 
 Warren — Surgical Pathology and Ther- 
 apeutics, 29 
 
 URINE AND URINARY DISEASES. 
 
 Saundby — Renal and Urinary Diseases, 24 
 Wolff— Essentials of Examination of 
 Urine, 29 
 
 MISCELLANEOUS. 
 
 Bastin — Laboratory Exercises in Bot- 
 any, 7 
 
 Gould and Pyle — Anomalies and Curi- 
 osities of Medicine, n 
 
 Grafstrom — Massage, ....... 12 
 
 Keating — How to Examine for Life 
 
 Insurance, ... 14 
 
 Rowland and Hedley — Archives of 
 
 the Roentgen Ray, 19 
 
 Saunders' Medical Hand-Atlases, . . 2 
 Saunders' New Series of Manuals, 22, 23 
 Saunders' Pocket Medical Formulary, . 24 
 Saunders' Question-Compends, . . 20, 21 
 Senn — Pathology and Surgical Treat- 
 ment of Tumors, -25 
 
 Stewart and Lawrance — Essentials of 
 
 Medical Electricity 27 
 
 Thornton — Dose-Book and Manual of 
 
 Prescription-Writing, 28 
 
 Van Valzah and Nisbet — Diseases of 
 the Stomach, 28 
 
In Preparation for Early Publication. 
 
 THE INTERNATIONAL TEXT-BOOK OF SURGERY. In two volumes. 
 
 By American ami liriiish authors. Edited by J. Collins Warren, M. D., LL.D., 
 Professor of Surj^ery, Harvard Medical School, Boston ; Surgeon to the Massachusetts 
 General Hospital ; and A. Pearck Gould, M. S., F. R. C. S., England, Lecturer on 
 Practical Surgery and Teacher of Operative Surgery, Middlesex Hospital Medical 
 School ; Surgeon to the Middlesex Hospital, London, England. 
 
 AN AMERICAN TEXT=BOOK OF PATHOLOGY. 
 
 Edited by John Guiteras, M.D., Professor of General Pathology and of Morbid 
 Anatomy in the University of Pennsylvania; and David Riesm.^n, M.D., Demon- 
 strator of Pathological Histology in the University of Pennsylvania. 
 
 AN AMERICAN TEXT=BOOK OF LEGAL MEDICINE AND TOXICOLOGY. 
 
 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. Hai.nes, M.D., 
 Professor of Chemistry, Pharmacy, and Toxicology in Rush Medical College, Chicago, 
 
 Illinois. 
 
 AN AMERICAN TEXT=BOOK OF DIAGNOSIS. 
 
 Edited by Alfred Stengel, M. D., Physician to the Philadelphia Hospital; Professor 
 of Clinical Medicine in the Woman's Medical College ; Physician to the Children's 
 Hospital ; late Pathologist to the German Hospital, Philadelphia, etc. 
 
 HEISLER'S EMBRYOLOGY. 
 
 A Text=Book of Embryology. By John C. Heisler, M.D., Professor ol 
 Anatomy in the Medico-Chirurgical College, Philadelphia. 
 
 KYLE ON THE NOSE AND THROAT. 
 
 Diseases of the Nose and Throat. By D. Braden Kyle, M. D., Clinical Pro- 
 fessor of Laryngology and Rhinology, Jefferson Medical College, Philadelphia; Con- 
 sulting Laryngologist, Rhinologist, and Otologist, St. Agnes' Hospital ; Bacteriologist 
 to the Philadelphia Orthopedic Hospital and Infirmary for Nervous Diseases, etc. 
 
 PRYOR— PELVIC INFLAMMATIONS. 
 
 The Treatment of Pelvic Inflammations through the Vagina. By W. R, 
 
 Pryor, M. D., Professor of Gynecology in the New York Polyclinic. 
 
 WEST'S NURSING. 
 
 An American Text-Book of Nursing. By American Teachers. Edited by 
 Roberta M. West, late Superintendent of Nurses in the Hospital of the University 
 of Pennsylvania. 
 
COLUMBIA UNIVERSITY LIBRARIES 
 
 This book is due on the date indicated below, or at the 
 expiration of a definite period after the date of borrowing, &s 
 provided by the Hbrary rules or by special arrangement with 
 the Librarian in charge. 
 
 DATE BORROWED 
 
 DATE DUE 
 
 DATE BORROWED 
 
 DATE DUE 
 
 ..4^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 C2a 1 lO- S3 ) lOOM 
 
 
 
 
1899 
 
 ERSITY LIBRARIES (hsI.sU) 
 
 1899 C.1 
 
 )2144360 
 
 toerioan text 'i^,^^r'7.j>~f~