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LIST OF AUTHORS IN VOL. I. 
 
 BIGGS, HERMANN M,, M. D. ; 
 BILLINGS, JOHN S., M. D., LL.D.; 
 CARMALT, WILLIAM H., M. D. ; 
 CONNER, PHINEAS S., M. D.; 
 COUNCILMAN, WILLIAM T., M. D. 
 DENNIS, FREDERIC S., M.D.; 
 GERSTER, A. G., M.D.; 
 NANCREDE, CHARLES B., M. D. ; 
 SMITH, STEPHEN, M.D.; 
 WARREN, J. COLLINS, M.D.; 
 WELCH, WILLIAM H., M.D.; 
 WOOD, HORATIO C, M. D. 
 
SYSTEM 
 
 OP 
 
 SURGERY. 
 
 EDITED BY 
 
 FREDERIC S. DENNIS, M.D., 
 / 
 
 Professor of the Principles and Practice op surgery, Bei.levue Hospital Medical College; 
 
 Visiting Surgeon to the Bellevue and St. Vincent Hospitals ; Consulting Surgeon to 
 
 the Harlem Hospital and the Montefiore Ho.aie, New York; President of 
 
 the American Surgical Society ; Graduate of the Royal College 
 
 OF Surgeons, London ; Member of the German 
 
 Congress op Surgeons, Berlin. 
 
 ASSISTED BY 
 
 JOHN S. BILLINGS, M. D.; 
 
 LL.D. Edin. and Harv. ; D. C. L. OxoN. ; Deputy Surgeon-general U. S. A. 
 
 Vol. I. 
 
 THE HISTORY OF SURGERY-PATHOLOGY-BACTERIOLOGY- 
 
 INFEOTIONS -ANAESTHESIA- FRACTURES AND 
 
 DISLOCATIONS-OPERATIVE SURGERY. 
 
 PROFUSELY ILLUSTRATED. 
 
 PHILADELPHIA: 
 LEA BROTHERS & CO. 
 
 1895. 
 
< ! 
 
 h / 
 
 Entered according to Act of Congress in the year 1895, by 
 
 LEA BROTHERS & CO., 
 
 in the Office oi" the Librarian of Congress, at Washington. All rir^hts reserved. 
 
 WESTCOTT & THOMSON. 
 ELECTROTYPERS, PHILADA. 
 
 WILLIAM J. DORNAN. 
 PRINTER, PHILADA. 
 
PREFACE. 
 
 This System of Surgery is intended to meet a growing want created 
 by the great progress which Surgery has made during the past few 
 years. It is with a view to i'ulfil this object tliat men of recognized 
 authority in their respective branches have consented to contribute in 
 order to present to the profession a comjilcte review of the domain of 
 modern Surgery — a domain whicli has so wonderfully enlarged its bound- 
 aries through the achievements rendered possible by the systematic 
 employment of antiseptic and aseptic methods of procedure. The task 
 has been most onerous, but the labors of an eminent corps of contribu- 
 tors have enabled the Editor to oiFer to the profession a concise and 
 complete work, presenting the most advanced opinions upon the new 
 problems involved in modern surgery, as well as the practical details 
 which conduce to success in treatment. In accomplishing this it is 
 gratifying to be able to announce that the whole has been the work 
 of American surgeons, and that it may be fairly said to represent the 
 most advanced condition of American Surgery. 
 
 The Editor takes this occasion to acknowledge his obligations to the 
 contributors, each one of whom is a teacher of Surgery or a director in 
 some large surgical clinic or hospital, and who, for this reason, is capable 
 of speaking with clinical authority from an experience based on the 
 study and observation of a large number of cases. Each department 
 is thus treated by an acknowledged master of the subject, who is able to 
 present the most modern and advanced views in the most cogent and 
 demonstrative way. 
 
 The Editor trusts that he will be found to have succeeded in the 
 endeavor to present a work of the scope and breadth that this great 
 subject demands, and that an appreciative reception will be accorded to 
 the results given by the contributors, who, though busy men, have con- 
 sented to offer the fruits of their labors for the benefit of the medical 
 profession. 
 
 The Editor especially, desires to acknowledge, with sincere thanks, 
 the great assistance accoi'ded to him by Dr. John S. Billings, through 
 whose valuable services and co-operation he has been enabled to bring 
 before the profession this work in its present comprehensive and at 
 the same time compact form. 
 
 Xo. .542 Madisos Avenue, New Yoek. 
 March, 1895. 
 
 5 
 
CONTENTS OF VOLUME I. 
 
 PACE 
 
 THE HISTORY AND LITEBATURE OF SURGERY 17 
 
 By John S. Billings, M. D., LL.D., Edinburgh and Harvard ; D. C. L. Oxon. ; 
 Deputy Surgeon-general, U. S. A. 
 
 SURGICAL PATHOLOGY', INCLUDING INFLAMilATION AND THE 
 
 REPAIR OF WOUNDS 145 
 
 By WiLLL\:vt T. Councilman, iM. D., Professor of Pathology, Harvai-d Med- 
 ical School, Boston. 
 
 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS 249 
 
 By William H. Welch, M. D., Professor of Pathology, Johns Hopkins 
 University, Baltimore. 
 
 SYMPTOMS, DIAGNOSIS, AND TREATMENT OF INFLA]MMATION, 
 
 ABSCESS, ULCER, AND GAN(4RENE .S35 
 
 By Charle-s B. Nanceede, A. M., M. 1 )., Professor of Surgery and of Clinical 
 Surgery, jNIedical Department of the I'niversity of Michigan, Ann Arlior. 
 
 SEPTICEMIA, PY45MIA, AND POISONED WOUNDS 383 
 
 By William H. Carmalt, M. D., Profes.sor of Surgery, Department of 
 Medicine, Y'ale University, New Haven. 
 
 TRAUMATIC FEVER, ERYSIPELAS, AND TETANUS 415 
 
 By' J. Collins Warren, M. D., Professor of Surgery, Harvard Medical 
 School, Boston. 
 
 RABIES; HYDROPHOBIA; LYSSA 433 
 
 By Hermann M. Biggs, M. D., Professor of Therapeutics and Clinical Medi- 
 cine, formerly Professor of Pathology, Berevue Hospital Medical College ; 
 Visiting Physician Bellevue Hospital, New York. 
 
 GUNSHOT WOUNDS 445 
 
 By- Phineas S. Conner, M. D., Professor of Surgery and of Clinical Surgery, 
 Medical College of Ohio, Cincinnati, and also in Dartmouth Medical College, 
 Hanover, N. H. 
 
 7 
 
8 CONTENTS. 
 
 PAGE 
 
 FRACTURES AND DISLOCATIONS 515 
 
 Ev Frederic S. Dennis, M. D., Professor of the Principles and Practice of 
 Surgery, Bellevue Hospital Jleilii'iil College ; Surgeon to the liellevue and 
 St. Vincent Hospitals, New York. 
 
 ANvESTHESIA 645 
 
 By Horatio C. Wood, M. D., LL.D., Professor of Materia Medica, Pliarniacy, 
 and General Therapeutics, I'Miversity of I'ennsylvania, PliihuU-liihia. 
 
 THE TECHNIQUE OF ANTISEPTIC AND ASEPTIC SURGERY 077 
 
 By Arpad G. Gerster, M. D., Professor of Surgery in the New York 
 Polyclinic ; Surgeon to the German and Mt. Sinai Hasjiitals, New York. 
 
 OPERATIVE SURGERY 729 
 
 By Stephen Smith, M. D., Emeritus Professor of Clinical Surgery, I^niver.sity 
 of the City of New York ; Visiting Surgeon to St. Vincent, and Consulting 
 Surgeon to Bellevue Hospital, New York. 
 
THE HISTORY AND LITERATURE OF 
 SURGERY. 
 
 By JOHN S. BILLINGS, M. D. 
 
 In this sketdi of the development of Surgery during the last three 
 thousand years a brief account is given, mainly in chronological order, 
 of the chief discoverers, improvers, and inventors in the art, and also of 
 the principal teachers of it. The original in\-entor may or may not have 
 been a lecturer or author, and the date of the first improvement in a 
 method of treatment or in the performance of a new operation was often 
 long prior to that general knowledge of such improvement which is 
 necessary to constitute true development. Some account is also given 
 of the trade, guild, or craft associations or corporations of surgeons, and 
 of their relations to education and to legislation. A few illustrations of 
 the state of the art at diflFerent periods, in the shape of the recommenda- 
 tions of different writers with regard to methods of treatment of certain 
 injuries or diseases, are presented ; but no attempt is made to trace the 
 history of the growth of knowledge with regard to each particular form 
 of disease or oj:)eration, this being left to the writers of monographs on 
 these particular subjects. 
 
 It requires leisure, patience, and access to a large library to make 
 historical studies really interesting, and the most I can hope to accom- 
 plish in this paper is to furnish to the physician who has little time, 
 taste, or opportunity for consulting the original documents the means of 
 ascertaining the periods and places in which the leading surgeons of the 
 world have done their work. The jirinted literature of surgery is vast 
 in quantity, and the great majority of it is obsolete and practically use- 
 less : even for statistical ])urposes the records of operations performed 
 prior to 1870 have now lost much of the value which they possessed 
 at that date ; yet in many respects the old surgical monographs, col- 
 lections of cases, and systems are the most definite and interesting of all 
 ancient medical literature. 
 
 To really enjoy the history of surgery it is necessary to consult the 
 original documents — to get the flavor of the quaint phraseology of the 
 older writers. No discourse about the surgical kno\\ledge of Hippoc- 
 rates, however eloquent" and eulogistic it may be, can give such an idea 
 of his teachings as is to be obtained from a perusal of his writings. 
 
 It is not to be expected that a man who is familiar with the resources 
 of the surgery of the present day will he al)le to discover in the ancient 
 records anything of much practical utility in his daily work which will 
 be new to him ; nevertheless, if he desires to compare his experience in 
 a particular case or class of cases with tliat of his predecessors — to obtain, 
 
 Vol,. I.— 2 17 
 
18 THE HISTORY AM) UTKnATrUK OF SUltOKRY. 
 
 as it were, a sort of "parallax in time" of the views wliieli liave been 
 held on tlie subject whieia occupies him — he will often not be able to do 
 this from the (current text-books. It will be neeessarv that he should 
 go back to the old masters, road, comi)are, and think ; and whenever he 
 does this it is safe to say that his eonclusions will be broader, wiser, 
 estal)lished on a firmer foundation, and more interesting to those to 
 whom he imparts them, than they ^\■ill be if derived solely from his own 
 experience. 
 
 In the history of the development in civilization of nations and 
 peoples, surgery almost necessarily precedes internal medicine with regard 
 to accurate observation of lesions of the human body and of their results. 
 Speculations about humors and fluxes, Idack bile and medical constitu- 
 tions, vital spirits and the doctrine of signatures, did not much occupy 
 the minds of the men of old in their attempts to note and describe the 
 signs of different forms of fractures and dislocations, the danger of 
 wovmds in diti'erent localities, the different varieties of tumors, or the 
 treatment of a calculus in the bladder or of a hernia. Of the many 
 remedies in the form of drugs, sahes, embrocations, and jjlasters M'hich 
 are described at length in the ancient medical books which have come 
 down to us, hardly more than twenty are now in ordinary use ; the 
 ancient physiology and pathology are, for the most part, now considered 
 as being merely curious illustrations of human error; and it is only a 
 portion of the anatomy and siu'gery of the ancients that remains as an 
 essential part of the foundation of the art cif medicine as it exists to-day. 
 
 The history of surgery is inextricably mingled with that of medicine, 
 and the best literature on the subject is to be found in some of the larger 
 formal treatises on the history of medicine. It has, however, been treated 
 of as a special branch of the art in a goodly number of Ijooks and essays, 
 the titles of a portion of which fill se\'en pages of volume xiii. of the 
 Index Catalogue of the Librarv of the Surgeon-General's Office at Wash- 
 ington. 
 
 The earliest records in our possession which relate to surgical opera- 
 tions come from Egypt. It is true that human skulls have been found 
 belonging to the Neolithic or Polished Stone Age, which have had por- 
 tions removed — being examples of the so-called jjrehistoric trephining 
 which is suj)posed to have been performed in cases of headache, epilepsy, 
 etc. — and the age of these relics is unknown ; but it is not at all probable 
 that it extends to the time of the pyramid-builders in the valley of the 
 Nile, when circumcision had been established as a religious rite and an 
 official system of medicine was in process of construction. 
 
 The Papyrus Ebers, written 1552 b. c. — that is, at least a century 
 bef(Sre the exodus of the Israelites — is a comj)ilation of receipts and 
 directions for the treatment of various diseases, many of which formulae 
 it refers to as being then ancient. Among these is a short section on 
 tumors near the surface of the body, in which it is said : " If this tumor 
 goes and comes under your finger, trembling even when your hand is 
 still, say, ' it is a fatty tumor,' and ti'eat it with the knife, after which 
 treat it as an open wound." From the Papyrus Ebcrs we learn that 
 there were physicians in Egypt who were not priests, and the same may 
 be iiiferred from the statement in Genesis (eh. 1. 2) that " Joseph com- 
 manded his servants the physicians to embalm his father, and the phy- 
 
THE HISTORY AM) LITERATURE OF SURGERY. 19 
 
 sicians embalmed Israel." The word in this text wliieh is translated 
 "phvsieians" is rephaiin, and it is sometimes translated as "dressers of 
 wounds " — /. c. surueons. The embalmers probably had a little more 
 anatomical knowledge than the physicians of the time ; but the Egyjit- 
 ians had a treatise on anatomy which, according to Manetho, was attrib- 
 uted to Ath(itliis, the son of Menes, who reigned 5241 B. c. 
 
 The few allusions to medicine scattered through the books of the 
 Old Testament indicate that the general belief was in accord with that 
 usually found prevailing among savage tribes — viz. that most diseases 
 are punishments intlicted by divine power, and to be removed by sacri- 
 fices and special ceremonies ; whence it follows that the priests were the 
 chief medicine-men. That there were other physicians is probable from 
 the grimly sarcastic account of King Asa, who " in his disease sought 
 not to the Lord, but to the physicians. And Asa slept with his fathers ;" 
 and also, perhaps, from Exodus xxi. 19 : "And if men strive together, 
 and one smite another with a stone, or with his fist, and he die not, 
 .... then shall he that smote him pay for the loss of his time, and 
 shall cause him to be thoroughly healed ; " or, as the Sef)tuagint has it, 
 " and shall pay the physician's fees." 
 
 The medicine of the Bible has been the subject of several learned 
 essays, but it does not appear that medicine was regularly studied among 
 the Jews as a separate profession until the rise of the Alexandrian 
 School, nor does either the science or the art of medicine owe anything 
 to this nation until after this period. The often-quoted chapter xxxviii. 
 of Ecclesiasticus about the physician is of late date, and was probably 
 written under Greek influence. 
 
 Some specimens of Jewish surgery prior to 200 A. d. are to be found 
 in the Talmud. The ralibis were acquainted with sutures for wounds, 
 with the method of freshening the edges of an old wound to obtain 
 reunion, with the employment of the uterine sound to learn whether the 
 blood came from the uterus or vagina, the operation for imperforate anus, 
 and also with an;esthctic substances with which they used to diminish the 
 jwin of a surgical operation or capital jtunishment.' Thev understood 
 the application to the body of artificial jjarts, as for supplying the loss 
 of substance of the trachea and replacing the loss of substance of the 
 cranial bone ; they knew artificial teeth, wooden legs, as also various 
 forms of apparatus for the unfortunates who were deprived of the use 
 of their lo«er exti'emities. 
 
 The first allusions to surgical subjects in Greek literature are found 
 in the poems of Homer, which may be accepted as dating from about 
 1000 B. c, whatever may be thought as to the reality of the siege of 
 Troy or the identity of Homer himself. In these poems mention is 
 made of ^Escnlapius, not as a god, but as a well-known and distinguished 
 physician, and of his sons INIaciiaon and Podalirius as surgeons and war- 
 riors. The works of Homer have been carefully examined and analyzed 
 by ^lalgaigne and Darcmberg with reference to medical and surgical 
 matters, and their conclusions may be briefly stated as follows:^ 
 
 ' Rabbinowicz : Ixi Medecine {hi Thdhnu/l, etc., Paris, 1880, p. xliii. 
 
 ^ " Essai sur I'Histoire et rOrganisation de la Chirurgie et de la M^decme grecqiies 
 avant Hipjiocrate,'' par M. Malgaigiie, Jour, de Med., iv. 303, Paris, 1846 ; La Medecine 
 dans HomSre, par Ch. Daremberg, 8°, Paris, 1865. 
 
20 THE HISTORY AND LITKRATVRE OF SUIiGERY. 
 
 Among tlie Greeks were certain surgeons whose knowledge and skill 
 were highly esteemed ; many of the warriors knew how to dress and 
 bandage wounds, and some of the Grecian women had the same skill, 
 corresponding to that possessed by the wives of tlie noi)ility in Western 
 Europe in feudal times. The dressings aj)plied to the wounds a|)pcar to 
 have been for the most part simple emollients : the effused blood was 
 pressed out, the surface was washed with warm water, certain crushed 
 roots or bruised leaves were applied to check hemorrhage. Over forty 
 Mounds in different parts of the body are described with more or less 
 detail, and in such a way as to indicate that Homer gav(> the residts of 
 actual observation and experience ; and in the course of these descriptions 
 a nomenclature is used which, anatomically, is much the same as that 
 employed by Hippocrates. The different effects of Avounds in different 
 parts of the body are referred to, and a curious illustration of this occurs 
 in the description of the injury of one of the horses of Nestor by an 
 arrow from the bow of Paris (viii. 81-86). The wound was on the top 
 of the head, penetrating to the brain, and it is said that the injured animal 
 was convulsed and turned round and round the pole. This, as INIalgaigne 
 points out, corresponds to the modern discovery that such movements of 
 rotation are produced by an injury of the cerebellum. 
 
 The anatomical terms used by Homer relate mainly to the exterior 
 of the body, and do not imply any greater knowledge of internal struc- 
 ture tlian is possessed by every butcher ; but his allusions to the fatality 
 of certain wounds embody tlie results of considerable experience. There 
 is nothing of surgical interest in Greek literature between the time of 
 Homer and that of the Hippocratic Writings, unless it be the passage in 
 Aristophanes in which the slave of Lamachus calls for hot-water com- 
 presses, etc. with which to dress the sprained ankle of his master. 
 
 In the fifth and sixth centuries B. c. there were in Greece and Great 
 Greece between fifty and sixty temples of ^sculapius, all of which were 
 probably resorted to by the sick, but those which became specially cele- 
 brated were those of Rhodes, Cyrene, Cnidos, and Cos. Those at Ciiidos 
 and Cos gradually became the most famous, and their so-called " schools " 
 occupy a prominent jjlace in the history of medicine. 
 
 By the term "medical schools" as applied to Cos and Cnidos it is not 
 meant that these were places for the jiublic teaching of medicine, but 
 rather that they Avere j)laces where certain medical families had settled, 
 and in each of which certain peculiar theories and methods of treatment 
 prevailed, the phrase " school " being used nuich as we Mould noM' speak 
 of the "French" or the "Munich" school in painting. 
 
 In the vicinity of these temj)les there seem to have collected physi- 
 cians M'ho Mere not priests, and M'ho belonged to an association or bro- 
 therhood, the members of which either claimed to be descendants of 
 ^sculapius or M'ere admitted to the guild by ad()ption M'ith sjjecial cere- 
 monies. These were knoM'n collectively as the "^Esclepiadje," and much 
 confusion has arisen from the erroneous ajjplication of this term in later 
 times to those M-ho ministered in the temple. There is no doubt that the 
 ]iricsts of the temj^le gave medical ad\ice, but, if Me are to judge from 
 the specimens preserved to us in the forms of inscriptions and memorial 
 tablets, it M'as not the sort of advice of Mhich any use is made in the 
 medical treatises of the Hippocratic school. 
 
THE HISTORY AND LITKRATVEE OF SURGERY. 21 
 
 It is probable that the real or lay physicians kept records which were 
 handed down from father to son, and were jireserved as a valnable family 
 heritage. That medicine was thus hereditary we know from the ilip- 
 pocratic oath, and from the genealogies which are given of many of the 
 celebrated physicians of Greece. According to Bertrand, this custom has 
 come down to the present time. On one of the slopes of Pindus there 
 are still five or six villages the inhabitants of which are supposed to be 
 born phvsicians and surgeons, each family having its own specialty and 
 its inherited tradition. If a son is wanting, the child of a stranger is 
 adopted. 
 
 There is no evidence that those who visited the temples seeking mirac- 
 ulous cures were examined or treated by lay physicians, but there were 
 certain attendants called zacoroi who received the patients and assigned 
 them to ])laces beneath the porticos; and from tlie information collected 
 by them it is possible that the priest who impersonated the god, appearing 
 in the night-watches, may sometimes have formulated his prophecies and 
 instructions. 
 
 The doctrines of the schools of Cos and Cnidos were committed to 
 writing, the first work of the kind coming from the school of Cnidos, 
 being what is known as the " Cnidian Sentences." Of this treatise there 
 were at least two editions, and it was in existence in the time of Galen. 
 A portion of it has been preserved to us in what are known as the Second 
 and Third Books of Diseases, and in the Treatises on Internal Affections 
 contained in the Hippocratic collections. 
 
 In this portion four diseases of the kidneys are described. In the first 
 there is acute ])ain in the loins, groin, and the testicle of the affected side 
 (renal colic) ; there is frequent urination, with gradual suppression of urine 
 and passage of .sand, causing pain in the urethra. A2>ply warmth and 
 purge with scammony. If the pain is great, use large euemata of warm 
 ■water ; if a tumor forms, make an incision over the kidney and evacuate 
 the pus. Such incision gives a chance of recovery ; without it death 
 will follow. 
 
 In the second form of disease of the kidney there are violent pains, 
 as in the preceding form. The patient passes blood with his urine at the 
 commencement of the disease, which is followed, after a time, by pus. 
 If he preserves a strict rest, he will be cured rapidly, but if he makes 
 effort, the pains will become sharper. When the kidney is filled with 
 pus it swells out near the spine ; in this case make, over the swelling, an 
 incision, generally deep, into the kidney. If you succeed in the incision, 
 you will cure the patient at once ; if you fail, it is to be feared that the 
 wound will not close, and the borders of the wound will contract and the 
 cavity of the kidney will be filled with pus ; if this passes inward and is 
 evacuated by the rectum, there is a chance of health ; but if it affects the 
 other kiduev, death is to be feared. Evacuants are to be used, and the 
 same regimen as for the preceding case. Very often this disease termi- 
 nates by a renal phthisis. 
 
 The school of Cos followed with its collection of maxims, the " Prse- 
 notiones CoaciB." Its doctrines will be best considered in the work of 
 its most illustrious disciple, Ilipiiocrates, who was born at Cos about 460 
 B. c. His father, Heraclidcs, and his grandfather were physicians, and 
 he received his earlv education at tlie school of Cos, after which he went 
 
22 THE HISTORY AND LITERATURE OF SURGERY. 
 
 to Athens and continued lii.s studios, re(rivin<:, the liest echication which 
 the Golden Age of Greek civilization could furnish. 
 
 The collection known as tiie "Hippocratic Writiuirs" dates from a 
 period about the time of Aristotle. Only a jxd'tion of these writinj^s are 
 the works of Hippocrates himself; several are probablv of more ancient 
 date — two at least appear to belong to the Cnidian School, and some are 
 by his disciples. On the otlier iiand, some of those which once belonged 
 to this collection have been lost. 
 
 The books in the Hijjpocratic collection which treat more especially 
 of surgical affections and o]x'rations, and which are accc2)ted bv most 
 commentators as having been written eitiier by Hippocrates himself or 
 by one of his immediate pupils, are those on injuries of the head, on 
 fraetui'es, on the articulations (/. e. on dislocations), Mochlicns (on the 
 bones and their injuries and displacements, and on apparatus), on M'ounds 
 and ulcers, on fistulfe, on hemorrhoids, and on the latrium or the Physi- 
 cian's Establishment, or the Surgery. 
 
 The book on injuries of the head liegins witli a description of the 
 sutures of the cranium and of the bones ol" the skull, in which it is stated 
 that the number and position of the sutures varies with the form of the 
 head ; that the coronal suture is wanting when there is no anterior pro- 
 tuberance of the skull, and the lambdoid suture is wanting when there 
 is no posterior protuljerance. As this does not agree with the oI)serva- 
 tions of modern anatomists, the commentators have much troul^le to 
 explain it, since they are unwilling to atlmit that Hippocrates made a 
 mistake in observation, or even that he generalized from insufticicnt 
 data ; which last is the most probable explanation. 
 
 He divides injuries of the bones of the skull into five classes — viz. 
 simple fissures, contusions without fracture or depression, fractures with 
 depression, indentations of the outer tabic, and fractures at a distance 
 from the place of injury, or fracture l)y coutrc-coup. AVith regard to 
 this last he says : " There is no remedy, for vhen this mischief takes 
 place there is no means of ascertaining by any examination whether or 
 not it has occurred, or on what part of the head." He then goes on to 
 say : " Of these modes of fracture the following require trepanning : the 
 contusion, whether the bone be laid bare or not ; and tiie fissure, \\hether 
 
 apparent or not ^V bone depressed from its natural jiosition 
 
 rarely requires trepanning, and those which are most jjressed and broken 
 require trepanning the least." 
 
 It will be seen that this is quite different from the rules of modern 
 practice. 
 
 For wounds of the head he forbids the application of any liquors or 
 cataplasms or tents, unless the wound is on the forehead or the part 
 which is bare of hairs or about the eyebrow and eye. The wound is to 
 be extended by incisions for the purpose of examining tiie bone when- 
 ever it is suspected that this is injured ; and it is remarked that these 
 incisions may be practised with impunity except on the temjile and the 
 parts above it, where there is a vein that runs across the temple, in which 
 region an incision is not to be made ; " for convulsions seize on a person 
 who has been thus treated ; and if the incision be on the left temple, the 
 convulsions seize on the right side ; and if the incision be on the right 
 side, tlie convulsions take place on the left side." 
 
THE HISTORY AXD LITERATURE OF SURGERY. 23 
 
 Tho books on fractures and on the articulations, together with the 
 book called " Mochlicus," contain sketches of the anatomy of the bones 
 and of the joints, and accoiuits of various forms of dislocations of the 
 diti'erent joints, with detailed instructions as to reduction and as to the 
 mode of bandaging in cases of fracture. Special attention is given to the 
 subject of injuries affecting the knee-, the elbow-, and the ankle-joints. 
 
 The paragraph on disk)cations of the knee does not correspond to the 
 experience of modern surgeons. It is as follows : " Luxations and sub- 
 luxatitins at the knee are much milder accidents than subluxations and 
 luxations at the elbow ; for the knee-joint, in proportion to its size, is 
 more compact than that of the arm, and has a more even conformation, 
 and is rounded, while the joint of the arm is large and has many 
 cavities 
 
 " Owing to their configuration, the bones of the knee are indeed fre- 
 quently dislocated, but they are easily reduced, for no great inflanniiation 
 
 follows nor any constriction of the joint They are displaced 
 
 for the most part to the inside, sometimes to the outside, and occasion- 
 ally into the ham. The reduction in all these cases iS not difficult, but 
 in the dislocations inward and outward the patient should be placed on 
 a low seat, and the thigh should be elevated, but not much. Moderate 
 extension for the most part sufficeth, extension being made at the leg and 
 counter-extension at the thigh. 
 
 " Dislocations at the elbow are more troublesome than those at the 
 knee, and, owing to the inflammation which comes on and the config- 
 uration of the joint, are more difficult to reduce if the bones are not 
 inuuediatcly replaced. For the bones at the elbow are less subject 
 to dislocation than those of the knee, but are more difficult to reduce 
 and keep in their position, and are more apt to become inflamed and 
 ankylosed." 
 
 Some of the older surgeons concur with Hippocrates in speaking of 
 dislocations of the knee as comparatively fre(pient, whereas at present 
 they are very rare. Dr. Adams supposes that the wrestlers at the public 
 games, who furnished Hippocrates with a Uu'ge proportion of his cases 
 of fractures and dislocations, may have been especially liable to this 
 accident. Hippocrates says that he knows of but one way in which the 
 shoulder-joint is dislocated — namely, that into the armpit ; but he does 
 not deny that the head of the humerus might be dislocated upward, out^ 
 ward, or forward. The methods of reduction are fairly described, and 
 are substantially those which are used at the ])reseut day. 
 
 He has much to say in various places about congenital dislocations, 
 some of which may be reduced to their natural condition, and especially 
 those at the ankle-joint. 
 
 In cases of compound dislocations he forbids reduction, as a general 
 rule. For example, in" speaking of dislocation at the ankle-joint com- 
 plicated with an external wound, he says you are not to reduce the parts, 
 but let any other physician reduce them if he choose ; " for this you 
 should know for certain, that the patient will die if the parts are allowed 
 to remain reduced, and that he will not survive more than a few days, 
 for few of them pass the seventh day, lieing cut off" by convulsions ; but 
 
 sometimes the leg and foot are seized witii gangrene But if not 
 
 reduced nor any attempts first made to ri'(hice them, most of such cases 
 
24 THE HISTORY AND lATERATURE OF SURGERY. 
 
 recover. The leg and foot are to lie arranged as the patient wishes, only 
 they must not be ])iit in a dependent jiosition nor moved ahout." 
 
 In speaking of these eomj^nnnd dislocations he makes no allnsidii to 
 cutting ofl' the protruding end of the bone, but in another section he 
 remarks that " complete resections of bones at the joints, whether the 
 foot, the hand, the leg, the ankle, the forearm, the wrist, for the most 
 part are not attended with danger, unless one be cut oif at once by de- 
 li([uiiun animi or if eontiiuial fevers supervene on the fourth day." 
 
 Hippocrates knew nothing about amputation of lindjs as an o])eration 
 through living parts or with a view to forming a stump of a particular 
 shape. In cases of gangrene due to the crushing of the blood-vessels, or 
 following fractures when the bandages have been applied too tightly, he 
 remarks that the most of such patients recover, even when a portion of 
 the thigh conies away or of the arm, and when the forearm and leg drop 
 oif the patients rapidly recover. 
 
 The sui'gical part of the Hippocratic collection is much more in 
 accordance with modern views than the medical part ; but there are 
 certain characteristics of all the books generally considered to have been 
 written by Hippocrates himself which are worthy of special attention in 
 connection with the high repute in -which they ha\e been held by med- 
 ical men for over two thousand years. In the first place, it is evident 
 that one of his special aims was to be entirely honest and truthful in his 
 statements. He reports no marvellous cures, no sjiecimens of extraor- 
 dinary success in diagnosis where others had failed; fatal cases are given 
 as well as recoveries, and there are no hints that the former were not seen 
 in time or that they had been improperly treated by others. He seems to 
 have written mainly for the purpose of telling what he himself knew ; 
 and this motive — i-ai-e among all writers — is especially rare among 
 writers on medicine. 
 
 A second characteristic of the Hijipocratic Writings is the special 
 attention given to those symptoms which indicate the effect which the 
 disease is producing upon the body as a whole, including such phenomena 
 as fever, debility, delirium, restlessness, and so-called critical discharges 
 of various kinds ; while the special diagnostic signs of particidar forms 
 of disease of particular organs are given much less attention. 
 
 The aphorism of Hippocrates concerning the efficiency of fire — 
 namely, " that diseases which are not cured by medicines are cured by 
 iron ; those which are not cured by iron are cured by fire ; those not 
 cured by fire are incurable " — has been the cause of an enormous amount 
 of suifering and of bad surgery to nearly the present centuiy. 
 
 Surgery of India and China. 
 
 In the literature of India the first definite hymns, invocations, and 
 charms connected with medicine are foiuid in the fourth (or Atharva) 
 Veda. The oldest existing medical work is the Charaka-samhita, of 
 which the Sanscrit text has been published in 1877, and of which an 
 English translation is now in course of publication. Somewhat later, 
 probably, is the Susruta, of which two Sanscrit editions have been pub- 
 lished ; also a Latin translation by Dr. F. Hessler, published at Elrlangen 
 in 1844. English translations are in progress of publication, and a sum- 
 
THE HISTORY AXD LITERATURE OF SURGERY. 25 
 
 marv is given bv Dr. Wise in his history of Indian medicine. Botli 
 Charaka and Susruta profess to be, and are commonly said to be, commen- 
 taries on the Aynr-Veda — /. e. the Veda of Life — but, in tact, there is no 
 such work as the Ayur-Veda distinct from and preceding Charaka and 
 Susi'uta. 
 
 The date of composition of these works is unknown, and is variously 
 estimated at from 1000 B. c. to 700 A. D. Recent authorities consider that 
 the later date is the more probable one, and that the work took its jiresent 
 form under the influence of ideas derived from the Alexandrian School 
 and the early Arab writers. It was certainly known in tiie ninth century 
 A. D. Nevertheless, it shows little trace of a knowledge Iw the author of 
 the Hippocratic Writings or of the discoveries of the Alexandrian anato- 
 mists and surgeons, and it contains a number of things peculiar to itself 
 and probably derived from ancient Indian traditions. 
 
 The translation of Susruta by Anna Moreshvar Kunte, of which the 
 first numbers were published in Bombay in 1877, begins as follows : 
 
 "Salutation to Brahma, Prajapati, the twin Asvins, Iiulra, Dhan- 
 
 vantari, Susruta, and others. 
 " Now, hereafter, we .shall narrate the chapter named the descent of 
 knowledge (of medicine) just as it was taught to Susruta by the \enerable 
 Dhanvantari. Aupadhenava, Vaitarana, Aurabhra, Paushkalavata, Kara- 
 virya, Gopura, Rakshita, Susruta, and his other friends in earnest 
 addressed the venerable Dhanvantari, the respected of gods (then 
 known by the name of Divodasa), the descendant of Kasiraja, who was 
 leading the life of a hermit, surrounded by a number of sages : ' Sire ! 
 we arc moved with compassion, seeing human beings, though protected 
 (by their kings), yet quite helpless, being afflicted with numerous bodily, 
 mental, natural, and accidental maladies. We wish to be instructed in 
 the Science of jNIedicine for the sake of jiublic good, for earning our 
 livelihood, and for allaying the sufferings of mankind desirous of health. 
 Earthly and heavenly bliss depends upon it. Hence, Sire, we have come 
 to you to become your pupils.' 
 
 " To them said the venerable man : ' Ye are welcome. All of you, 
 my lads, shall be taught and made to meditate. Ayur-Veda is an Upanga 
 of the Atharva-Veda. The Self-born, after creating the universe, com- 
 posed it in a thousand chapters, containing a hundred thousand verses. 
 But, knowing the brevity of human life and the limitedness of human 
 understanding, he reduced it to eight divisions. These are : 1. Shalyam, 
 splinter (extraction) surgery ; 2, Shalakyam, iiKpiiry into the disease of 
 organs situated above the clax'icles ; ."3, Kayachikitsa treats of diseases 
 affecting the whole body ; 4, Bhutavida treats of diseases of mind jiro- 
 duced by demoniacal influences ; 5, Koumarabhrityam, care and treatment 
 of children ; 6, Agadatantram, doctrine of antidotes ; 7, Rasayanatantra, 
 doctrine of elixirs ; 8, Vajikaranatantram, rules for increasing the gen- 
 erative jKiwers. Which of tliese do you wish to be taught"?' — 'Sire,' 
 said they, ' teacli us all, but begin with surgery first.' — 'Be it so,' said 
 he. — Tiiey again requested liim, saying, ' Susruta, after consulting us all, 
 shall ask you for explanations (in matters of doubt), and whilst he is 
 made to understand we shall also try to do the same.' — ' Well, then, my 
 pupil, Susruta,' said he, ' the Science of Medicine has for its object the 
 emancipation from disease of tliose who are afflicted by it, and the jires- 
 
26 THE HISTORY AXD LITERATUnE OF SI'ROERY. 
 
 ei'vation of the health of tliose wlio possess it. Ayur-Veda is so called 
 hecaiise Ijy it health is gained or it hrin<i;s health. The best portion of 
 it I explain to you : try to follow me and judge by the four criteria of 
 judgment — namely, inference, comparison, testimony, and perception. 
 It is the best, because the first inflicted wound was healed (by its know- 
 ledge), and the head of Yajna was united to his trunk. It is said that 
 when Rudra cut of the head of Yajna the gods went to the twin Asvins 
 and said to them, " Yon two are of a higher rank amongst us. We 
 entreat you to join together Yajna's head and trunk." They complied 
 witii the request. For their sake the gods ]u-o])itiated Indra and allowed 
 them a share in his sacrifice. They forthwith joined the head and trunk 
 together. Of all the eight parts of which the Ayur-Veda is composed, 
 this is the best, from the speediness of its operations, from its including 
 the use of appliances, surgical instruments, caustics, cauteries, and from 
 its being ccjnuuon to tlie otlier parts (of the science). Thus it is eternal, 
 merit-giving, divine, leading to renown, longevity, and prosperity. 
 
 " ' The great god Brahma announced (the knowledge of medicine) 
 first ; Prajapati learnt it from him ; the twin Asvins got it from Prajajiati ; 
 from them Indra ; and from Indra have I learnt it. I am going to 
 impart it to anyI)ody who seeks it for tiie sake of public good. 
 
 " ' On the preliminary preparations (rules to be observed before, dur- 
 ing, and after the completion) of surgical operations : 
 
 " ' Every action (to be successi'ul) involves three stages — viz. 1, 
 the prejjaratory stage ; 2, the predominant stage ; 3, the succeeding 
 stage. We shall point out that the treatment of diseases has these 
 three stages. 
 
 " ' In this science the use of edged instruments is considered to 
 be predominant. Hence we shall begin our description with it and 
 its accessories. Edged instruments are used for eight purposes — viz. 1, 
 amjDutating ; 2, opening ; 3, scarifying ; 4, puncturing ; o, exploring ; 6, 
 drawing ; 7, evacuating ; and 8, sewing. A surgeon contemplating to 
 operate in any of tiie above ways should first have ready the following : 
 blunt instruments (forceps, etc.), sharp instruments, potential cauteries, 
 virtual cauteries, catheters, horns, leeches, a dry gourd, a cauterizing 
 needle, stufiing materials, strings, board, bandage, honey, ghee, fat, milk, 
 oil, soothing decoctions, injections, lotions, fan, cold and warm water, a 
 frying-pan, aljle, steady, and attached servants. 
 
 " ' Then on a good day, having a good lunar influence and the 
 auspicious influence of stars, after invoking blessings from the Brah- 
 mans and medical men, and propitiating the sacred fire with honey, rice, 
 and water, let the patient be seated, who has taken very little food, 
 oifered sacrifices, and made ablutions, with his face toM'ard the east. 
 The surgeon should stand with his face toward him, and plunge his 
 instrument after the ]iroper incision imtil matter comes out, and with- 
 draw it, avoiding vital j^arts, vessels, muscles, articulations, l)ones, and 
 arteries. In the case of a large collection of matter the incision may 
 be of the breadtii of two or three fingers even. 
 
 " ' Incisions ar'e either long, wide, even, or uneven. An incision, 
 whether long, broad, clean, or dependent, is always to be extolled when 
 it suits (the purpose and) the occasion. Boldness, rapidity of action, 
 sharp instruments, operation without trembling, fear, or doubt, are always 
 
THE HISTORY AND LITEEATUBE OF SURGERY. 'll 
 
 praiseworthy of the sur^-eon operating Tlie operations for moles, 
 
 ascites, piles, calculus, fistula, and mouth diseases are to be performed on 
 
 an empty stomacli Tlie instruments sliould be so made that they 
 
 siiould be of a good finish, strong, clean in api)earance, with good handles, 
 wiiether they be sharp or blunt. 
 
 " 'Among these the Svastika instruments ought to be about nine inches 
 long ; their mouths should be respectively like those of a lion, tiger, 
 wolf, hyena, bear, elephant, cat, hare, antelope, crow, heron, dog, jay, 
 vulture, falcon, owl, kite, cock, crouch, the bee, rat, mouse, or bullock, 
 each half being united to the other by a nail of the form of a lentil- 
 seed, being bent inward at the handles like the elephant-driver's hook. 
 These forceps are recommended for the extraction of splinters lodged in 
 bones. 
 
 " ' The tubular instruments are of a variety of kinds, having various 
 uses, open at one end or both or having several foraminje. They are 
 used for removing olistructions from the great canals of the bodv, or for 
 examination of diseases, or as suction-tubes, or for the easy application 
 of remedies. Their lengths are always determined by the apertui-e 
 of the canal whence the obstruction is to be removed or by the use to 
 which they are to be ajiplied. 
 
 " ' The diffei-ent tubular instruments which are used in fistula, hemor- 
 rhoids, polypi, sores, urethral injections, enemas, retention of urine, 
 ascites, inhalation for cough and dyspncea, and obstruction of bowels, 
 together with the bottle-gourd and the horns, shall be described hereafter 
 in their proper places. 
 
 " ' The probe-like instruments are of various kinds and serve a variety 
 of purposes. Their magnitudes differ according to the uses they are 
 applied to. Among them the earthworm-like probe, the arrow probe, 
 the serpent-hood probe, and the hook j^robe are each of them two in 
 numljer. They have l)een recommended for sounding, separating, loosen- 
 ing, and extracting (foreign bodies). Probes having lentil-seedlike ends 
 are two. They are slightly curved inward at their extremities, and are 
 used for the extraction of foreign bodies from the large canals. There 
 are six prolies wliit'h are capped with cotton wool, and are used for 
 cleaning and wiping purposes. Tliere are three which are ladle-like and 
 mortar-like, and are used for application of caustics. Three others there 
 are which have their ends like a jambul-seed. Three others, again, resem- 
 bling the elephant hook. These six are used for cauterizing purposes. 
 There is a nasal-polypus probe which resembles the kolasthi. There is 
 the inunction probe, whii-h at its both extremities has a knob like the 
 pea-seed, resembling an ojion liud. There is the urinary catheter, which 
 resembles the stalk of malati- [Jasnuninin gh(n<iiJior((~\ flower, and its 
 length varies according to purpose 
 
 " ' The lion-mouth forceps is for foreign bodies that can be seen, while 
 for covered ones there is the heron forceps and others of its kind. These 
 should be used gently, the foreign body being removed in accordance 
 with surgical precepts. 
 
 " ' The heron forceps is the best of all forceps, since its use never leads 
 to accidents. It enters easily and is very easily drawn back. It lays a 
 firm hold on splinters and removes them easilv.' " 
 
 Xo allusions are made to the use of the ligature, but amputations of 
 
28 THE HISTORY AND WrERATURE OF SURGERY. 
 
 tlic limbs were performed, the lieiiiurrluige being elieeiietl by tiie cautery, 
 by boiling oil, and by pressure. 
 
 The operation of lithotomy is described, being that of " cutting on 
 the gripe," the incision Ix'ing made on either the left or the right side of 
 the perineum, the breadth of a liarley-coru from the central line and an 
 inch from the anus. 
 
 The sui)ra})ubic o])cration was also known, rhinoplasty is described, 
 and herniotomy is referred to. Manual skill was to be acquired by the 
 student by making jiunctures and incisions on gourds and other fruits or 
 on dead animals. 
 
 Fractures and dislocations are described with considerable detail of 
 classification, and the bamboo sjilints recommended are still in use. The 
 most original thing in the work is the part which relates to plastic sur- 
 gery, and especially to rhinoplasty. 
 
 Of the history of surgery in China almost nothing is knoM'n. Hwa 
 T'o, who is supposed to have lived in the third century a. d., is ordinarily 
 considered to have been the father of surgery in China. He is said to 
 have performed abdominal section for the local treatment of diseased 
 viscera ; to have laid bare the scapula of a certain great military hero 
 and scraped from it certain poison, possibly carious bone ; also to have 
 relieved by acupuncture an affection of -the brain of another famous 
 general of his time. It does not appear that tiiis was entirely successful, 
 however, for he subsequently proposed trejiliining for the surgical cure 
 of this disease, on which the indignant general is stated to have declared 
 him a traitor who was plotting his death, and to have had him beheaded. 
 
 Ch'iin Kwei in the sixth century A. D. is also said to have successfully 
 removed certain diseased viscera by incision through the abdominal wall. 
 
 These stories rest upon no definite foundation. Acupuncture, counter- 
 irritation, and various forms of shamjxioing seem to have been the only 
 forms of surgical treatment practised in this nation, and opei'ative surgery 
 is now, as it probably always has been, practically unknown among the 
 Chinese. 
 
 After the time of Hippocrates there is very little of interest from a 
 surgical point of view recorded in Greece itself. His sons, Thessalus 
 and Draco, and his son-in-law, Polybius, were also physicians, and are 
 supposed to be the authors of some of the books in the Hip]iocratic col- 
 lection. Aristotle gave a strong stimulus to the study of anatomy, and 
 is said to have written two books on medicine, which have been lost. 
 Through the influence of his pupils the fomous library, museum, aiid 
 schools of Alexandria were formed, and the headquarters of medical 
 knowledge for the time being passed to Egypt. The Alexandrian School 
 is famous for the advances in the knowledge of human anatomy which 
 were made there as a result of the authority which was, for a short time, 
 granted for the dissection of human bodies. The numerous writings of 
 the anatomists of this school have been lost as distinct works, but prob- 
 al)ly all their important discoveries and teachings have been preserved 
 for us in the \\orks of Celsus, Galen, and Oribasius. Herophilus (about 
 300 B. c.) was perha]is the most famous of these anatomists, and many 
 of the names of parts which he gave are in use to-day, such as the 
 choroid, the retina, the dura and pia mater, the calamus scriptorius, the 
 duodenum, and the prostate. Erasistratus, his contemporary and rival. 
 
THE HISTORY AXD LITERATURE OF SURGERY. 29 
 
 was also a famous anatomist, but we know oven less of his work than we 
 do of that of Herophilns. Galen says that he invented the catheter, l)nt 
 it is probable that tiiis instrument was known both in Egypt and in 
 India long before. 
 
 The advances in surgery made by the Alexandrian School prior to 
 the Christian era ai'e practically summed up in the first treatise on sur- 
 gery written in Latin which has come down to us — namely, that of Celsns, 
 or, moi'c properly, of Aulas Cornelius Celsus. Of the personality of 
 this writer we know nothing jxisitively, but he probably lived at Rome 
 about the beginning of the Christian era, and was not a physician by 
 profession, medicine at that time being almost exclusively practised by 
 Greeks. He is quoted by Pliny as an author as distinguished from a 
 physician, and ids work was not referred to by any medical writer for 
 over a thousand years after his death. His book was a sort of encyclo- 
 ptedia of the arts and sciences of his time, intended for educated men, 
 but not specially for physicians, and the medical portion consists of 
 eight books or sections, wiiich, in the original, followed the five books 
 of the treatise on agriculture — the first book of the " De re Medica " 
 being in the oldest Vatican manuscript entitled " Aidi Cornclii Celsi 
 liber sextus, idemqne mediciiife primus." After the invention of jirinting 
 the " De re medica " of Celsus was one of the first books that issued 
 from the press, having been published in 1478, since which date there 
 have been over sixty Latin editions and translations into most modern 
 languages. 
 
 Most persons not familiar with the history of the art are accustomed 
 to jilace C-elsus with Hijipocrates and Galen as one of tiie three great 
 Fathers of Medicine ; but he was really only a compiler, altliough a 
 compiler whose conciseness and clearness of style have gained for iiim the 
 title of " the Medical Cicero." As Greek Mas the professional language 
 of his day, he could find no Latin equivalent for many of the technical 
 terms, and was obliged to use either a descriptive periphrasis or to give 
 the Greek word, intntduced by the piirase " the Greeks call it." He was 
 also troubled by the fact that in writing in Latin on tlie subject of hernia 
 he was compelled to use what was considered to be a very immodest and 
 improper word, for which he duly apologizes ; and this is one of the 
 numerous pi'oofs that his work was not intended for physicians espe- 
 cially, but for the educated public. 
 
 A compiler without practical experience is sure to make some mis- 
 take ; and a good illustration of this is found in the remarks of Celsus 
 upon dislocation of the liip, as pointed out by Broca. Dislocation of 
 the hip-joint, prior to the discoveiy of anassthetics and the introduction 
 of Reid's method, was often very difficult to reduce ; but after it had 
 once been reduced there was no special difficulty in keeping the head of 
 the femur in its proper jdace. Celsus had probably never seen a case, 
 but he had heard that one of tiie great dangers is that when reduceil it 
 may slip out again, this idea having probably arisen from confounding 
 fracture of the neck of the femur with dislocation of its head ; so he 
 argues as follows : " Some maintain that it always does so [i. e. slips out 
 again], but Hippocrates, Diocles, Philotinus, Xileus, and Heraclides the 
 Tarentine, very celebrated authors, iiave asserted tliat they have effected 
 a perfect cure. Xeitlier would Hippocrates, .Vndreas, Xileus, Xympho- 
 
30 THE HISTORY AM) LITERATUnE OF SUROERY. 
 
 dorus, ProtarcliUf^, Hcnu'lideH, and also a certain nicclianician liave 
 invented so many kinds of machines for extending tlie feninr in this 
 
 case if it had been to no purpose Therefore it must be attempted." 
 
 The logic is excellent, but the point which he supposes to be in dispute is 
 wholly imaginary. 
 
 Sonic of the details of surgical practice given by Celsus will be con- 
 sidered in connection with those found in otiier writers next to be referred 
 to. Of these the chief is Claudius Galen, who was burn at Pergamus 
 l;jl A. u. He studied medicine at the schools of Smyrna, Corinth, and 
 Alexandria, and returned to Pergamus at the age of twenty-eight, when 
 he was ai)pointed to the medical charge of tlic athletes of the gymnasium 
 connected with the temple of ^lllscidapius. Four years later he went to 
 Rome, where he soon became celebrated. He finally returned to his 
 native country, where he died when about seventy years old. He is 
 said to have written five hundred treatises on medicine, but a lai'ge 
 number of these have been lost, and a number which exist in manuscript 
 have not been printed. 
 
 The medical system of Galen is happily compared by Daremberg 
 to a tissue of which the Hippocratic Writings are the woof and those 
 of Aristotle the ^\•arp. His anatomy is mainly contained in his treatise 
 " De usu partium," the purpose of which treatise is to prove that all the 
 organs of the body are arranged in the best possible manner and show 
 the \\-isdom and care of Nature. After a few jjreliminary definitions he 
 begins his third section as follows : " As man is the wisest of all animals, 
 so the hands are the instruments which belong to a wise being. For 
 man is not the wisest of animals because he has hands, so says Anaxa- 
 goras, but he has hands because he is the Avisest, as says Aristotle, who 
 judges very judiciously. In fact, it is not by his hands, but by his 
 reason, that man has learned the arts. The hands are an instrument, as 
 the lyre for the musician or the pincers for the blacksmith." 
 
 Between the time of Celsus and that of Galen there were three 
 writers whose names should be mentioned in a sketch of ancient sur- 
 gery, although their works have for the most part been lost — namely, 
 Soranus of Ephesus, about 79-138 A. D., and Rufus of Ephesus, and 
 Heliodorus, about the beginning of the second century. The treatise 
 of Soranus on the diseases of women, edited and translated into Latin 
 by Ermerius, was published in 1869, and his " De signis fracturarum " 
 was published by Cocchius, with a translation, in 1754. A considerable 
 part of his medical writings form the books ordinarily attributed to 
 Cielius Aurelianus. Such M'orks of Rufus as have been preserved were 
 edited and translated into French by Daremberg, and published in 1879. 
 Heliodorus lived at Rome in the time of Trajan, about the beginning of 
 the second century a. d., and wrote a treatise on surgery, the fragments 
 of \\hich, preserved for us by Oribasius, indicate that he nuist have been 
 a skilful surgeon, well acquainted with anatomy and with various modes 
 of operating which have been proclaimed as marvellous in later days, 
 such as the torsion of arteries, a particular mode of operating for the 
 radical cure of hernia by excision of the sac, the excision of stricture 
 of the urethra, etc. 
 
 After Galen, probably about the end of the third century, came a 
 surgeon named Antyllus, who seems to have been a skilful operator and 
 
THE HISTORY ASD LITERATVEE OF SURGERY. 31 
 
 ail original writer, luit of wliose works wu \va\q only fragments preser\-ed 
 in the writings of Orihasius, a native of Pergainus, who was the physi- 
 cian and friend of the emi)eror Julian almut tiie middle of the fourth 
 century. Oribasius wrote a huge medieal eyeloptedia, whieh formed 
 seventy books, of which over two-thirds have been lost, but what 
 remains is of much interest in an historical point of view, because he 
 copied literally, or nearly so, the text of the authors from whom he 
 compiled, often giving their names, and in tliis way has preserved frag- 
 ments of many works of which we have no otlu'r means of knowledge. 
 
 The next in time of the great medieal compilers and encyclop;edists 
 is iEtius Amidenns, who lived in the early part of the sixth century, 
 studied medicine in Alexandria, and practised at Constantinople, where 
 he became famous. He wrote a work in four books, each containing four 
 .sections, which is known as the " Tetrabiblos." There are no translations 
 into modern languages. It is an important work in the history of sur- 
 gery, containing extracts from previous authors not found elsewhere, and 
 it supplements, to some extent, what remains to us of Oribasius, as it 
 contains copies of some of the lost sections of that writer. He describes 
 charms and amulets, in which lie had full faith, and he has been supposed 
 to have been a Christian, because in extracting a bone he recommends 
 the use of the following word-charm : " Bone, as Jesus Christ caused 
 Lazarus to come out of the grave, as Jonah came out of the whale's 
 belly, come out !" 
 
 Following aEtius, about the middle of the sixth century was Alex- 
 ander of Tralles, a Lydian, who practised at Rome, and wrote a \\-ork on 
 medicine in twelve l)Ooks, the Greek text of which was first published at 
 Paris in 1548. He was a Christian, and made use of amulets and incan- 
 tations, of which he gives several specimens. 
 
 Paul of uEgina (Paulus ^Egineta), the last of the Greek writers ou 
 medicine, lived in the early part of the seventh century and studied at 
 Alexandria. His seven books are among the most famous of medical 
 classics, and form a compend and abridgment of the medical literature 
 of his day carefully selected and concisely expressed. His main source 
 of information appears to have been the works of Oribasius. He does 
 not pretend to any originality, as will be seen by the following extract 
 from his preface: "It is not because the more ancient writers had omitted 
 anything in the art that I have composed this work, but in order to give 
 a continuous course of instruction ; for, on the contrary, everything is 
 handled l)y them properly and without any omissions, whereas the 
 moderns have not only in the first place neglected the study of them, 
 
 but have also blamed them for prolixity To remember all the 
 
 rules of the healing art and all the particular substances connected with 
 it is exceedingly difficult, if not altogether impossible. On this account 
 I have comjiiled this brief collection from the works of the ancients, and 
 have set down little of my own, except a few things which I have seen 
 and tried in the practice of the art." I'he sixth book is a system of 
 operative surgery, the most complete of any which have come to us from 
 before his time, and the source of most of the surgical treatises of Arabian 
 authors. In it he never refers to Celsus, but often to Galen. 
 
 Having thus given a brief account of the principal Greek and Latin 
 writers on surgery whose works are known to us, we may now consider 
 
32 THE HISTORY AND LITERATURE OF SURGERY. 
 
 tlie progress in the art wliich lincl l)con made between tlie time of Hi])])oc- 
 rates and tliat of Paul of ^'Eo-ina, a period of ahout one tlionsand years. 
 
 First, as to hemorrhage from recent wonnds, and more especially 
 arterial hemorrhage. Upon this snbject the Hijjpocratic Writings contain 
 nothing. C'elsus says (lib. v. cap. xxvi.) : "If we fear the hemorrhage, 
 the wound is to be filled with dry pledgets of lint, and a sponge squeezed 
 out of cold water is to be applied and eom])res,sed with the hand. If the 
 blood still issues, the lint must be changed frequently, and if dry lint 
 does not succeed, it should be moistened with vinegar. Caustics slaould 
 not be used, except in urgent cases, on account of the inflammation 
 which follows their use. If compression, cold, and vinegar fail to stop 
 the bleeding, the vessels which pour out the bhxtd are to be seized and 
 tied with two ligatures, one on each side of the wounded ])art, after which 
 the vessels are to be di\'ided between the ligatures, that tliey may retract 
 and still have the openings closed. If the case does not admit of this, 
 the actual cautery may be used." Celsus makes no reference here to any 
 distinction between arterial and venous hemorrhage. In speaking of 
 castration he says : " The veins and arteries nnist be secured by a liga- 
 ture at the groin and divided behind it." This is the first mention of 
 the ligature of blood-vessels in published literature : it was an invention 
 of the Alexandrian School, and is said to have been introduced at Rome 
 by Euelpistus, who lived a short time before Celsus. 
 
 Galen refers in several places to the use of the ligature, but treats 
 more especially of hemorrhage in the fifth book of the Alcthodus Medendi. 
 He directs that the finger be placed gentlv upon the mouth of the bleed- 
 ing vessel, extending and compressing it. If the wounded vessel lies 
 deep, the surgeon must thus learn its position and size, and then, whether 
 it be a vein or an artery, lift it with a hook and twist it a little. If'this 
 does not answer and it is a vein, styptics, such as roasted rosin, fine 
 flour, gypsum, etc., are to be tried ; but if it is an artery, it must be either 
 ligated or entirely divided. Sometimes the veins must also be ligated 
 and divided ; but it is safer to do both — that is, to ligate the proximal 
 end of the vessel and also to divide it beyond the ligature. Oribasius 
 says nothing about the ligature, but advises the cautery if the bleeding 
 cannot be checked otherwise. Paulus ^Egineta copies Galen almost 
 literally, but says, in addition : " You may know whether it is a vein or 
 an artery that pours fortii the blood from this, that the bloixl of an artery 
 is brighter and thinner and is evacuated by pulsations, whereas that of 
 the vein is blacker and without pulsation." 
 
 While it is thus evident that the use of the ligature was known from 
 the beginning of the Christian era, it is curious that it seems never to 
 have been employed to check hemorrhage from vessels divided in ampu- 
 tations. 
 
 Celsus remarks that in cases of gangrene of an extremity the incision 
 is to be made between the sound and the corrupted part, but says nothing 
 about details. Galen's advice is the same as that of Hippocrates. Paulus 
 says : " Leonides properly directs us not to divide all the parts at once 
 unless they are completely mortified, but first to cut the part where not 
 many nor \-ery large veins or arteries are known to be situated, down to 
 the bone quickly ; then to saw the bone as rapidly as j)0ssible, applying 
 a linen rag to the parts which have been cut, lest they be torn by the 
 
THE HISTORY AND LITERATURE OF SURGERY. 33 
 
 saAving and cause pain, and then, havinti' out tlirougli what remains, to 
 apply red-iiot irons to the vessels, and stop the lieim)rrhage thereby with 
 compresses of lint." The Leonides referred to here was an Alexandrian 
 surgeon who lived about the beginning of the third century a. d. Prior 
 to this, however, Archigenes, a celebrated physician mIio lived at Rwme 
 al)out the beginning of the second century A. D., and Heliodorus, had 
 given more details as to methods of ami)utation, as appears from the 
 fragments of their works preserved in the collection of Nieetas, ])ublisiied 
 bv Cocchius in 1756. Archigenes apjicars to have connnenccd tiie opera- 
 tion in some cases by a preliminary ligature of the blood-\'essels supply- 
 ing the parts ; the incision was a circular sweep down to the bone. The 
 red-hot iron was used to check hemorrhage. The method of Heliodorus 
 is substantially the same as that of Leonides. 
 
 Aneurism is not mentioned by Hippocrates or by Celsus. Galen 
 describes it in his work " De tnmoribus," saying that it may arise 
 either from simple dilatation or from a wound of an artery, and is 
 recognized by its pulsation. The only treatment he refers to is com- 
 pression by means of sponge. 
 
 The following is an extract from the treatise of Antyllus on aneurism, 
 as given by Oribasius : " There are two kinds of aneurysm. In the first 
 the artery has undergone a local dilatation ; in the second the artery has 
 been ruptured. The aneurysms which arc due to dilatation are longer 
 than the others. The aneurysms by rupture are more rounded. To 
 refuse to treat any aneurysm, as the ancient surgeons advised, is unwise ; 
 but it is also dangerous to operate upon all of them. We should refuse, 
 therefore, to treat aneurysms which are situated in the axilla, in the 
 groin, and in the neck, by reason of the volume of the vessels and the 
 impossil)ility and danger of isolating and tying them. We should not 
 touch an aneurysm of large volume even when it is situated in some 
 other part of the body. We operate in the following manner ujjon 
 those which are situated upon the extremities and the head : If the 
 aneurysm be by dilatation, make a straight incision through the skin in 
 the direction of the length of'the vessel, and, drawing open by the aid of 
 hooks the lips of the wound, divide with precautions the membranes which 
 cover the artery. With blunt hooks we isolate the vein from the artery, and 
 lay bare on all sides the dilated part of this last vessel. After having 
 introduced beneath the artery a probe, we raise the tumor and pass along 
 tlie probe a needle armed with a double thread in such a manner that 
 this thread finds itself placed beneath the artery ; cut the threads near 
 the extremity of the needle, so that there will be two threads having 
 four ends ; seizing, then, the two ends of one of these threads, we bring 
 it gently toward one of the two extremities of the aneurysm, tying it 
 carefully ; in like manner also we bring the other thread toward the 
 opposite extremity, and in this place tie the artery. Thus the whole 
 aneurysm is between the two ligatures. We open then the middle of 
 the tumor by a small incision : in this manner all which it contains will 
 be evacuated, and there will be no danger of hemorrhage. 
 
 " To tie, as it has l)cen advised, the artery on both sides the vein, and 
 then to extirpate the dilated part which finds itself between, is a dan- 
 gerous operation ; frequently, in fact, the violence and tension of the 
 arterial pneuma push off the ligatures. 
 
 Vol. I.— 3 
 
34 THE HISTORY AND LITEIiATUllK OP' SURriERY. 
 
 "If" the aiu'iirysm owes its origin t(j tlie ni|)tiii'C' ni' tlio artery, we 
 isolate witii tlie fingers as much of the tumor as we can, inckiding the 
 skin, after wliich we jiass uiiderneatli the isolated part the needle Mith 
 the double thread and proceed as before ; after which the tumor may be 
 opencil at its summit and tlie supcrflnous jiortion of the skin cut away." 
 
 Upon injuries of tlic skull and trepliining C'elsus s])eaks at consider- 
 able lengtli, (|Uoting fully from Hippocrates. To distinguish a fissure 
 from a suture he advises the pouring of ink (jn the part and then scraping 
 the bone ; if there is a fissure, the ink will mark it. He says that if 
 blood is extravasated beneath the cranium, tiie overlying bone will be 
 pale. If no dangerous symptoms come on, he would defer o])erating on 
 the bone for five days. All depressed l)one is to be removed, but no 
 more is to be taken away than is necessary. Galen preferred the use of 
 small gouges, and of an instrument called a lenticular, to that of the 
 trephine. He says that all greatly bruised (and depressed) bone is to be 
 removed, but that simple fissures do not require operation. Paulus co])ies 
 Galen. It will be seen that the Greek and Roman metliods did not differ 
 greatly from those of the present day. 
 
 In fractures of the spine Paulus says that, " having first given warn- 
 ing of the danger, w'e must, if possible, attempt to extract by an incision 
 the compressing bone," and that the same is to be done in case of frac- 
 ture of one of the spinous jirocesses. 
 
 Celsus (lib. v. cap. xxviii.) describes carcinoma as usually occurring 
 about the face, and in the Ijreasts of females, but says that it may also 
 occur in the liver or spleen. It is the seat of some lancinating pains, is 
 tumefied, immovable, and unequal, and the veins about it are swollen 
 and tortuous. It commences by what the Greeks call cacoethes, then 
 proceeds to carcinoma or scirrhus without idceration, then to an ulcer 
 which becomes fungous. " None of these can be removed except the 
 cacoethes ; the rest are aggravated by every method of treatment, and 
 
 the more energetic the remedies the more irritable they become 
 
 None were ever treated successfully with medicine ; . . . . after excision, 
 though a cicatrix has been formecl, they have returned again and carried 
 
 off the patient But no one can distinguish a cacoethes, which is 
 
 curable, from a carcinoma, which is incurable, except by time a'nd 
 experiment." 
 
 Galen describes cancer at greater length, Init adds nothing to the 
 means of tliagnosis : the only chance of cure lies in excision, but if this 
 be performed the arteries must not be tied. 
 
 Paulus merely abridges Galen's description, says nothing about an 
 operation, and advises external applications. A hard tumor which is 
 wholly insensible is incurable. 
 
 Cystic tumors, including atheroma, meliceris, and steatoma, are briefly 
 but cleai-ly described by Celsus (lib. vii. cap. vi.) ; they are to be removed 
 by incision : in steatoma the cyst must be divided, in the others it may 
 be removed entire. Antyllus gives a more detailed description, which 
 is quoted by Oribasius (lib. xlv.). 
 
 The Hijipocratic oath requires that litliotomy be left to those who 
 make a special business of it. The first author ^\•ho describes the opera- 
 tion is Celsus (lib. vii. cap. xxvi.). He says it should only be performed 
 in the spring, and on children Ijetween the ages of nine and fourteen, and 
 
THE HISTORY AND LITERATURE OF SURGERY. 35 
 
 in urgent cases when metlieines have failed, althongli he admits that a 
 rasli operation now and then succeeds. The toleration described is that 
 which is commonly known as "cutting' on the gripe," or, in modern 
 times, as the " Celsian t)peration." The description given by Celsus is 
 detailed, and in most points is very clear (lib. vii. cap. xxvi.). The essen- 
 tial principle is to force the stone down into the neck of the bladder and 
 hold it there by two fingers introduced into the rectum, after wliich a 
 lunatcd incision is to be made through the skin of the perineum imme- 
 diately over and extending to the neck of the bladder, and a second 
 incision in the convex part of the wound, so as to open the neck of the 
 bladder freely ; and the wound should be a little larger than the calculus, 
 for those who dread a fistula make too small an opening, and are after- 
 ward I'educed to the same inconvenience with still greater danger, because 
 the calculus when forced will make a passage unless it find one; and this 
 is even still more injurious if the form and inequalities of surface have 
 contributed in any way to this effect. If the stone is so large that it 
 cannot be extracted without lacerating the neck of the bladder, it must 
 be split according to the method of Ammonius, who was known as Lith- 
 otomus, the stone-cutter. It is done in this manner: A crotchet is intro- 
 duced to the calculus, so as to hold it fast while being struck, lest it 
 shoukl recoil backward ; then an ii'on instrument of moderate thickness 
 is to be employed, the one extremity of which is thin, but blunt, and 
 being ajiplied to the stone and struck at the other extremity, splits it, 
 great care being taken that neither the instrument itself nor any frag- 
 ment of the stone should injure any part. 
 
 There is practically nothing to add to this description by other Greek 
 writers until we come to the time of Paulus, whose description is much 
 the same as that of Celsus. He says that children up to the age of four- 
 teen are the best subjects for the operation : old men are difficult to cure, 
 because ulcers of their body do not readily heal, and intermediate ages 
 have an intermediate chance of recovery. The stone is to be brought 
 down I)y the fingers in the rectum, as described above; then "we take 
 the instrument called a lithotome, and between the anus and the testicles 
 — not, however, in the middle of the perineum, but on one side, toward 
 the left buttock — we make an oblique incision, cutting down direct upon 
 the stone where it protrudes, so that the external incision may be wider, 
 but the internal not larger than just to allow the stone to fall through it. 
 Sometimes, from the pressure of the finger or fingers at the anus, the 
 stone starts out readily at the same time tliat the incision is made, with- 
 out requiring extraction ; but if it does not start out of itself, we must 
 extract it with the forceps called the stone-extractor." . ..." If the 
 stone, being small, fall into the penis and cannot be voided with the urine, 
 we may draw the prepuce strongly forward and bind it at the extremity 
 of the glans. We must next ajiply another ligature round the penis behind 
 the menil)er, making tlie eonstriction at its extremity next the bladder, 
 and then make an incision down upon the stone, and, bending the penis, 
 we eject the stone, and undoing the ligatures we clear away the coagula 
 from the wound. Tiie posterior ligature is applied lest the calculus 
 should retreat backward, and the anterior in order that, when untied 
 after the extraction of tlie stone, the skin of the prepuce may slide back- 
 ward and cover the incision." 
 
36 THE HISTORY AM) I.ITKnATVRE OF SURGERY. 
 
 Aftei' the capture of Alexandria by tlie newly-risen Mohaniniedau 
 power, about 640 A. D., the Arabians became the inheritors and preservers 
 of the science of the Greeks. The first notions of medicine obtained by 
 the Arabs were proliably derived from Persia, if we may judge by the 
 names of a great number of tlieir drug;s, and the medical knowledge of 
 Persia came in part from India and in j)art from Greece. 
 
 The first Arab physician of note was Hareto Ben Coladoh, who lived 
 about the middle of the sixth century, and who seems to have studied 
 medicine under the Nestorians, a Christian sect dating from the early 
 part of the fifth century and occupying the ancient countries of Assyria 
 and Persia. The Nestorian physicians appear to \vA\e been very zealous 
 in collecting and ])rcserving all the medical works which could be found 
 at that time, including those of the Hippoci'atic collection and the 
 writers of the Alexandrian School. In the mean time, after the destruc- 
 tion of Jerusalem, certain Jewish physicians and teachers had settled in 
 Alexandria, and after the fall of that city we find some of these Jewish 
 physicians taking somewhat jirominent positions and being collectors 
 and translators of the medical literature of the Greeks. The so-called 
 " Arabic books on medicine " were largely compends and summaries of 
 the works of Greek writers which had been translated into Syriac or 
 into Hebrew, and thence into Arabic, or, in some few cases, directly into 
 Arabic. There are very few of these which contain any matter of interest 
 to the history of surgery. 
 
 The most famous of their writers was Avicenna (980-1036 A. D.), a 
 native of Persia, who for five hundred years rivalled Galen as an authority, 
 and, like him, was called the Prince of Physicians. The medical works 
 of Avicenna, known as " The Canon," are a sort of encyclopaedia, in 
 which the opinions of the Greeks and of Galen ai'e mingled M'itli Oriental 
 philosophy, forming a very jirolix and in many places obscure treatise 
 upon all subjects connected M'ith medicine. It was translated into Latin 
 by Gerard of Cremona, and became for a time the principal guide for 
 European jjhysicians, its high repute being probably due in part to the 
 diflieulty of imderstanding it. 
 
 The most celebrated writer on surgery of the Arabian School was 
 Albucasis, also known as Bulchasis, Abulcasis, or Alsaharavius, and 
 properly as " Khalaf Ibn 'Abbas (Abu Al-Kasim) Al-Zahrawi." He 
 was born at Zahra, near Cordova, and died about 1105 A. D. His great 
 work, Al Tesrif or Tasrif — /. e. the collection or encyclopaedia — included 
 thirty books upon all branches of medicine, but of these only a part have 
 ever been published. The three books of his works on surgery, forming 
 a special treatise (book xxx. of Al Tesrif), were published in Arabic and 
 Latin under the editorship of John Channing at ()xford in 1778, and 
 this is the best printed edition which is available, although in some 
 respects it is obscure and unsatisfactory. A translation into French A^'as 
 made l)y Dr. Leclerc and puldished in the Gazette iiifdicale de rAlr/erie 
 in 1858-61, and afterward issued as a rejn'int (Paris, 1861); and this is 
 the most convenient edition to consult for most purposes. 
 
 The work is divided into three books. The first is devoted to the 
 actual cautery and the use of caustics, with elaborate descriptions of the 
 instruments Avhich are figured. In fiict, Albucasis is the first author 
 whose works have come down to us who has given figures and good 
 
THE HISTORY AXD LITERATURE OF SURGERY. 37 
 
 descriptions of surgical instruments. The second book relates to incisions 
 of all kinds, bloodletting, scarification, treatment of wounds, and the 
 extraction of arro\vs and missiles, and the third is devoted to the treat- 
 ment of fractures, luxations, sprains, etc. 
 
 The treatise in general is a clear and comparatively concise statement 
 of methods of treatment. A large part of it is evidently derived from 
 Paul of ^Egina or from the original authorities from which Paul of 
 ..Egina copied, and it is hard to say how much of his work is really 
 original ; but it was the highest authority on the subjects of which it 
 treats during the period of the revival of letters in Western Europe, 
 and is a very important work for the student of the history of surgery 
 or of surgical operations. The following are some specimens of his 
 teachings : 
 
 In speaking of the operation of arteriotomy upon the temporal 
 arteries he directs that a portion of the vessel be cut out, so that the 
 t\\o ends may separate in order to prevent hemorrhage. If the artery 
 is large, it is necessary to tie it in two places — at two points — with a 
 strong double thread of silk or of the cord used in instruments of music 
 (catgut), in order that it may not alter before cicatrization takes place, 
 which would bring on a hemorrhage. This ligature sliould be double, 
 and the operator is to take away the intermediate part, either at the 
 time or later. 
 
 In speaking of the operation on scrofulous tumors of the neck he 
 says : " The tumor must be removed little by little, great care being 
 taken not to cut the blood-vessels or the nerves. If a vein or an artery 
 is injured, so that the hemorrliage is troublesome or hinders the operation, 
 put into the w(.)und some vitriol in powder or some kind of haemostatic 
 l)i)wder; bandage the wound, and leave it until the inflammation lessens 
 and the wound tends to putrefaction. Then the hemorrhage will cease 
 and you may go' on to complete your operation." 
 
 He says : " The ancients have spoken of opening the trachea, but 
 I have not known any one in our country who has practised this opera- 
 tion. If the operation has lieen decided upon, the incision should be 
 made below the third or fourth ring of the trachea transversely between 
 the two rings, so as not to injure the cartilages, but only to divide the 
 membrane between the rings. I have seen a slave who had cut his 
 throat with a knife. On examining the wound a little blood escaped, but 
 I found that neitlier the jugular vein nor the artery had been injured. 
 Tiie air came out by the wound ; I dressed it and he was cured, and 
 only a little hoarseness of voice followed. I feel, therefore, authorized 
 to say that incision of the trachea is without danger." 
 
 In speaking of aneurism he says: "As to the tumors which result 
 from the enlargement of tlie calil^re of the artery, a longitudinal incision 
 should Ije made over the skin. Eidarge the opening with hooks, dissect 
 the arterv, free it from- the meinl)i'anes which surround it, and lay it 
 completely l)are ; then introduce below it a needle with a double thread 
 and make a double ligature of the vessel, as we have recommended for 
 the excision of the temporal artery ; then plunge a knife into the part 
 of the vessel included between the two ligatures, and press out all the 
 l)l(iod which is contained therein, until the tumor has disappeared, 
 employing after this the treatment which leads to suppuration until 
 
38 THE HISTORY AND LITKRATURE OF SURGERY. 
 
 tlie ligatures fall." It will be swii tliat this is a cojiy ul' the description 
 of the operation of Antvlhis. 
 
 In speaking of the removal of (X'rtain fungoid abdominal tumors 
 resembling mushrooms he directs that a leaden wire be used to strangle 
 the growths, the wire being drawn tighter and tighter from dav to day, 
 so as gradually to penetrate the root of the tumor, so that it mav fall 
 without difficulty. He says: " Refrain from attempting to excise tumors 
 which are of a livid color, of slight sensibility, and of an irregular aspect, 
 for these tumors are cancerous." Elsewhere he says : " If the cancer is 
 situated in a region from which it can be entirely removed, such as the 
 breast, the thigh, etc., and, above all, if it has had its conunencement 
 little developed, one may operate on it ; if, on the contrary, it is large 
 and old, it is necessary to refrain. For my pai't, I have never been able 
 to cure a single one. I have never seen any one who has succeeded." 
 
 His description of the operation of the removal of calculus of the 
 bladder is substantially the same as that given by Celsus. 
 
 In the case of a vesical calculus in a woman he says that if you are 
 obliged to treat such a case, you must find a woman \\'\i\\ some skill in 
 medicine, but there are very few of them. If you cannot find such, it 
 is necessary to take a midwife, or, at all events, a woman who knows a 
 little something about the matter. This woman is to perform the opera- 
 tion under the direction of the surgeon, according to the method which 
 he gives in detail. 
 
 While the arts and sciences were more or less prosperous and pro- 
 gressive in the countries under Mohammedan rule, and especially in 
 Spain, throughout the rest of Europe medicine was substantially in the 
 condition in which it exists in barbarous tribes. With the rise of the 
 monkish orders, and especially of the order of St. Benedict, the priests 
 became the practitioners, and all progress or improvement was practi- 
 cally at an end. Relics, exorcisms, and prayers were more and more 
 relied upon ; the teachings of Hijipocrates and Galen were for the most 
 part forgotten. The great majority of the monks read nothing but 
 simple formularies and receipt-books. The kings and the great nobles, 
 including some of the bishops, resorted to Hebrew physicians, who 
 during the tenth and eleventh centuries were almost the only jiersons 
 who possessed medical learning or who wrote u|)on nu'dical subjects. A 
 Jewish physician in those days was a sort of contraband luxury. On 
 account of his religion he could only be possessed by those who had suf- 
 ficient power to protect him from mobs and monks ; but both Catholic 
 and Mohammedan rulers resorted to him when anything like scientific 
 knowledge was recpiired. Rabbi Isaac was the medical adviser of Pope 
 Boniface VIII. , and the physician of Saladin was Rabbi Ben-]\Ioosa, 
 better known as Moses Maimonides, \\ho was one of the most celebrated 
 authors of his race and time (1136-1209 A. D.). It should be noted that 
 the preference was for Jewish jihysicians as being Jews. For instance, 
 Francis I., being sick, wrote to Charles V. for an Israelite who was 
 an imperial physician. Accordingly, the doctor was sent to Paris, but 
 Francis, finding that he had been conyerted to Christianity, lost all con- 
 fidence in his skill and advice, and applied to Solyman II., who sent him 
 a true, original, hardened Jew, follo\ving whose advice he drank asses' 
 milk and recovered. 
 
THE HISTORY Ayi) LITERATURE OF SURGERY. 39 
 
 Surgery was for the most part abandoned to barbers, bathers, and 
 seventh sons, and fell into disrepute. These barbers and bathers were 
 considered to be of inferior caste, and an artisan would not take an ap- 
 prentice of a family of barbers, bath-keepers, she])herds, or butchers. 
 The operators were often peripatetic and were sulnlividcd into specialists. 
 For instance, one operated for hernia, another foi- calculus, a third for 
 cataract, etc., the knowledge being handed down from father to son, as 
 among the Greeks. 
 
 There were no European writers upon, or teachers of, surgery until 
 the time of the rise of the universities in Italy in the thirteenth century. 
 The ScIkioI of Salernum was probably in existence in the ninth century, 
 the ancient legend being that it was founded by four men — a Jew, a 
 Greek, an Arab, and an Italian — each of whom gave lessons in his own 
 language. 
 
 About the ycai- 1060 A. D. there came to this school a certain Constan- 
 tine, generally known as " Constantinus Africanus." Constantine was a 
 native of Carthage, and had studied in Arabia, India, and Egypt, after 
 Avhich he travelled extensively for over thirty years. Returning to Car- 
 thage and bringing with him copies of all the works of the Greek and 
 Arab writers which he had been able to obtain in his travels, he fell under 
 the suspicion of knowing more than it was at that time considered proper 
 for any man to know, and it was with some difficulty that he escajied the 
 jiunishment then in vogue for such criminals. He fled for refuge to 
 Salernum, where he was received with honors, which, however, he put 
 aside, and retired to the neighboring monastery of Monte Casino, where 
 he spent the rest of his life in translating and annotating the medical 
 works which he had collected. These translations became the text-books 
 of the Salcrnitan doctors, and in the next century the school was resorted 
 to from all parts of Eurojie by those who had heard of these long-lost 
 and forcrotten treasures of learning, which at that time were far in advance 
 of the existing knowledge of the ordinarj- practitioners.' 
 
 The doctrines of the school liecame more and more Arabic, and it had 
 lost its importance in the fourteenth century, having lieen superseded by 
 the schools of Xaples, Bologna, Paris, and Montpellier. 
 
 At the beginning of the thirteenth century comes the first writer on 
 surgery in the West — namely, Roger of Parma, whose work was first 
 printed at Venice in 1490, and is included in several editions of the 
 works of Guy de Chauliac. The Surgery of Roger is substantially the 
 sixth book of Paul of ^Egina. Following him came his pupil and com- 
 mentator, Roland, who was also of Parma. His w<irk is a copy of that 
 of Roger, with notes and some references to Hippocrates, Galen, and 
 Avicenna which do not appear in the work of his master. 
 
 The story of the Four Masters, as told by Quesnay, is a romantic 
 one — /. e. that they devoted their lives to the care of the sick poor in 
 Paris, their residence being a sort of surgical dispensjuy ; that they made 
 many discoveries and improvements which they described in a book 
 which was known to Guy de Chauliac, but lias been lost ; etc. Several 
 
 ■ For a full aiul interesting discussion of the writings of Constantine and tlie authors 
 copied and abridged by him, considt " Constantinus Africanus und seine Arabischen 
 Quellen," von M. Steinschneider, Archiv f. path. Anat. (Virchow), 1866, vol. xxivii. p. 
 361. 
 
40 THE HISTORY AND LITERATURE OF SURGERY. 
 
 manuscript copies of this worlv are now l^nown to exist, and in 1859 one 
 of these was edited by Daremhcrj;; and ])ul)lislR'd. 
 
 The history of surgery in Eurojie tlius begins in Italy at Salernum, 
 and in Bologna, where Hugo of Lucca flourished during the first half 
 of the thirteenth century, and was followed by William of Salicet. 
 We have no writings from Hugo, but the Cyrurgia of William remains 
 to us. The first edition of the original Latin was published at Placentia 
 in 1476, and this, with other editions, including French translations 
 (Lyons, 1492, and Paris, 1507) and an Italian translation published at 
 Milan in 1504, is in the Army Medical Library at Washington. 
 
 William of Salicet was the most celebrated .surgeon of his century ; 
 he M'as an educated physician, who gives some of his own observations 
 and his own conclusions, hardly citing previous authors, although it is 
 evident that he was familiar with the works of Avicenna and of Galen. 
 It is a pity that the Ci/riirf/ia has never been translated into English. 
 
 The next noted surgeon of this period is Lanfranc of Milan, a j^upil 
 of William of Salicet, to whom he refers as his "master of goodly 
 memory." Lanfranc also received a university education, and was a 
 physician as well as a surgeon. Political troubles having caused his 
 banishment from Milan, he went first to Lyons, where he wrote an 
 epitome of surgery, and finally in 1295 to Paris, where he gave, at 
 the School of Medicine, a course of lectures which were probably em- 
 bodied in his great Surgery, which he completed in 1296. He was thus 
 the introducer of the new Italian ideas into France. His large work 
 was first published at Venice in 1490 under the title Pracfica <juce dis- 
 cifur a)-s complda totiu^ Chirurgi(r." In the same year a French trans- 
 lation by Guillaume Yvoire was published at Lyons, and of this there is 
 a copy in the Bibliotheque Nationale at Paris. 
 
 After Lanfranc came Henri de Mondcville, a native of Normandy, 
 of whose early life nothing is known except that he studied at Mont- 
 pellier, and at Paris under Jean Pitard, who will be referred to hereafter, 
 and that he was one of the four surgeons of the court of Philip the Fair 
 prior to 1301. In 1306, at the request, as he says, of Bernard de Gordon, 
 a distinguished professor of Montpellier, he began to ^yrite, and to read 
 to his numerous pupils, a systematic treatise on surger>', which he did 
 not complete, although he lived until about 1318. This treatise, of 
 which several manuscripts exist, was finally edited and printed by Dr. 
 Julius Leopold Pagel of Berlin in 1892, forming an octavo volume of 
 660 pages having the title of Die Chinoyir (h\<^ Heinrich von Mondeville 
 {Hennondaville), etc., and has been translated into French and published 
 in 1893 by Professor Nicaise of the Faculty of Medicine of Paris. His 
 practice is much the same as that of Lanfranc, and of his successor, Guy 
 de Chauliac, who often quotes him. He describes the method of ligating 
 a wounded artery, recommending a peculiar kind of slipknot, but says 
 nothing of ligating the vessel in amputations, and refers to the use of the 
 ansesthetic sponge described by Guy. 
 
 Here may also be mentioned the Surgery of Master Jean Yperman, 
 a native of Flanders, who was born in the latter part of the thirteenth 
 century and studied under Lanfranc in Paris. The manuscript of his 
 book, dated 1351, Ayas first described, and in part published, by Dr. 
 Carolus in the Annales de la Sociefe de Medecine de Gand (vol. xxxii. 
 
THE HISTORY ASD LITERATURE OF SVRGERY. 41 
 
 1854) ; also jniblished separately as a re])rint. He refers to Roger and 
 Roland and the Four Masters, and frequently to Lanfranc, beyond \vh(ise 
 teaehings he seldom ventures to go, although he does give some cases of 
 his own. 
 
 The great French surgical author of the fourteenth century was Gui 
 (or, as it is more usually given, Guy) de Chauliac, " Guido de Chauliaco," 
 born aliout 1300 A. D. He received the university training of the cler- 
 ical profession and studied medicine at Paris, after wliich he continued 
 this study at Montpellier and Bologna, so that he had tlie lienelit of the 
 three greatest universities of that time — Paris being especially celebrated 
 for its surgery after Lanfranc had reached it ; Montpellier being the 
 centre for medicine ; and Bologna for anatomy, of which Bertrucius was 
 then professor. After extensive travels, and practice in different places, 
 including Lyons and Montpellier, he ^\•ent to Avignon and became the 
 physician of Pope Clement VI. and of liis successors. Innocent VI. and 
 Urban V. His chief literary work was liis Chinur/in, written at Avi- 
 gnon in 1363, and first published at Lyons by Nicholas Panis in 1478. 
 
 The " Great Surgery " begins with a special introductory chapter, 
 the chapilrc singuUer. He says : " Up to the time of Avicenna all 
 writers were both physicians and surgeons (/. e. well-educated men), but 
 since that time, either because of the fastidiousness or the excessive 
 occupation of the clerics, surgery has become a separate branch and has 
 fallen into the hands of the mechanics. 
 
 " The sects which have existed in my time among the operators of 
 this art, besides the two general ones of the Logicians and the Empirics, 
 have l)een five. 
 
 " The first was the school of Roger, Roland, and the Four Masters, 
 who treat all wounds and abscesses alike with cataplasms and poultices, 
 on the ground of the fifth aphorism, ' Lax things are good, and crude 
 bad.' 
 
 " The second was the school of Bruno and Theodoric, which treated 
 all wounds alike with wine, basing their practice exclusively upon the 
 maxim, ' The dry is nearest to that which is sound, and the moist to that 
 which is not sound.' 
 
 " The third sect was that of William of Salicet and of Lanfranc, who 
 wished to pursue the middle course, covering and dressing all wounds 
 with ointments and soft plasters, founding this practice on the fourteenth 
 maxim of the Therapeutics — that curation has one sole method ; tliat the 
 treatment should be gentle and without pain. 
 
 " The fourth sect is composed of all the military men, or German 
 chevaliers and others following the army, who, with conjurations and 
 potions, oil, wool, and cabbage-leaves, dress all wounds, basing their 
 practice on the maxim that God has given his virtue to herbs and to 
 stones. 
 
 " The fifth sect is of women and of many fools, who refer the sick of 
 all diseases to the saints solely, saying, ' Le Seigneur me I'a donnee ainsi 
 qu'il luy a plfl ; le Seigneur me I'ostera quand il luy plaira ; le noni du 
 Seigneur soit benit. Amen.' " 
 
 It will be seen that Guy is quite trenchant in his summaries and crit- 
 icisms, which, however, appear to be on tlie whole fair and justifialile. 
 
 The teachings of Guy were the chief authority in surgical matters 
 
42 THE HISTORY AXD LITERATURE OE SURGERY. 
 
 for over two litiiulri'd years, iuul wcri' tl:i' basis df iHiiiicrous abstracts, 
 odinpemls, and commentaries. He contributed little that was orij^inal, 
 although he gives some of his own observations. Follin remarks that a 
 sort of canulated sound, the dressing of ulc^ers with sheet lead, and some 
 jM'culiarly-shajx'd cauteries are his chief inventions ; l)ut his book is one 
 of the monuments of surgical literature. 
 
 The tSermo ■■^cjitiiiiiis dc cyruryla et dc dn'orafionc of Nicholas Faleu- 
 tiiis, of which the Washington Library has an edition printed at Florence 
 in 1507, is a huge folio volume compiled from the works of Arab writers, 
 with references to Roger and Roland, but not to Guy de Chauliac, so far 
 as I have found. His formula of words is " Dixit Haly," or " Avicen," 
 or "Albucasis," witliout attempt at conuneiit. 
 
 In the days of J^anfranc and (tuv de Chauliac surgery in AVestcrn 
 Europe was distinct from medicine, and was looked upon as a trade or 
 handicraft degrading to and unworthy of physicians, who claimed to 
 belong to the nobility. The physicians \vere of the priestly class and 
 abhorred the shedding of blood, and their traditions were adhered to long 
 after medical teaching in the universities had passed into the hands of 
 laymen. The barl)erswerc the ordinary surgical operators, and the reason 
 for this is given by Dr. Gardner ' as follows : " The monks, as all the 
 Avorld knows, recpxired to have their heads regularly shaved, but it is not 
 by any means so well known that they had to be bled at stated ]icriods. 
 3Iinu(u>i ed was the form of words descriptive of one who had undergone 
 the operation, the meaning being that he had been minntus xidu/uine — 
 i. e. deprived of blood. In the monastery of St. Victor at Paris there 
 was an order which prescribed such minution five times a year : ' Prima, 
 est Scptembri ; secunda, ante Adventum ; tertia, ante Quadrigesimum ; 
 quarta, post Pascha ; quinta, post Pentacosta.' The monks, therefore, 
 required to have about them those mIio could lioth shave and bleed, and 
 it was very natural that they should prefer that one antl the smne person 
 should ])erform both these operations." 
 
 In France, however, at an early date there were a few persons whose 
 business was the performance of surgical operations, and who were not 
 ordinary barbers, although they may have served an ajiprenticeship as 
 such. The Cor]ioration of Barbt'rs in the middle of the thirteenth cen- 
 tury was divided into two classes — the ordinary or lay barbers, afterward 
 known as "barber surgeons" or "surgeons of the short robe," and the 
 " clerk barbers " or " surgeon barbers," " the surgeons of St. Come," or 
 " surgeons of the long robe ; " and these last sought to be independent 
 of the ordinary barbers, to monopolize surgical operations, and to raise 
 their association from the position of a trade guild to that of a profes- 
 sional oryanization. The Guild of the Snry-eon Barbers was organized in 
 1268 by an order of the provost of Paris, selecting six surgeons who 
 were to examine and license those who wished to practise, more esjiecially 
 the barbers. Possibly one of these masters was the celebrated Jean Pitard, 
 but if so he must have been very young, for he was still living in 1326. 
 In 1311, Pitard obtained a decree from King Phili]) the Fair, in which, 
 after reciting that all sorts of quacks are infesting the city, it is ordered 
 that " no male or female shall practise surgery in Paris who has not been 
 
 ^ Gardner (John) : Sketch of the Early Ilislonj of the Medical Profession in Edinburgh, 
 Edinb., 1864, p. 6. 
 
THE HISTORY AND LITERATURE OF SURGERY. 43 
 
 exaniinod liy our sworn surgeons of Paris named and called togetlior for 
 tliat purpose by Jean Pitard, our sworn surgeon of the C'liiitelet, or his 
 successors." 
 
 It was evidently impossible to enforce this order, for it was repeated 
 in 1352, and again in 1364, with penalties of Hues on the erring barbers, 
 half of the fines to go to the surgeons' guild, the Brotherhood of 8t. Come. 
 The organization of tiiis brotherhood was by no means pleasing to the 
 medical faculty, the memljcrs of which desired to retain control of all 
 branches of the art, and discredited surgery as a mere mechanical handi- 
 craft only to be exercised under the direction of a physician, whose dig- 
 nity forbade him to soil his hands. The statutes of the facidty in 1360 
 recpiirc the candidates to make oath that they will not practise surgeiy 
 in the sense of performing operations or' making applications by the 
 hands, including the treatment of five classes of affections — viz. wounds, 
 ulcers, fractures, dislocations, and tumors. 
 
 The lay barbers were employed by the physicians, and also sometimes 
 as assistants by the surgeons, and at last, in 1372, the barber of the king, 
 being the master of the guild of barbers by virtue of his position, induced 
 Charles V. to issue an edict which permitted them to treat wounds 'and 
 sores and forbade the surgeons to interfere \vith them. The relative 
 standing in the eyes of the public of the three kinds of practitioners — 
 viz. the physicians, the surgeons, and the barbers — may be inferred from 
 an order issued during an epidemic of the pest in 1383, which directed 
 that there shall be selected to visit the sick four physicians, two sur- 
 geons, and six barbers, and the fees of tii(^ doctors shall be three hundred 
 livres, of the surgeons one lunidred and twenty livres, and of the barbers 
 eighty livres. 
 
 The so-called College of Surgeons of Paris was not in the least a 
 surgical school or an association for mutual discussion and improvement : 
 it was })urely a trade guild, and the students were simply apprentices to 
 the master surgeons, becoming, after 1370, bachelors, licentiates, and 
 finally masters. The surgeons had a free dispensary, where they treated 
 the poor once a week, and perhaps the apprentices saw there something 
 of the jtractice of other masters besides their own. 
 
 The medical faculty, thinking that its rights, privileges, and monopoly 
 of treating the sick were being encroached upon by the surgeons, 
 encouraged the barbers in their controversies, and as one means of 
 doing this undertook to teach them anatomy. As the barbers did not 
 understand Latin, which was the only dignified and proper language to 
 be used in teaching in those days, a compromise was necessary, and this 
 was effected partly by the use of a sort of dog-Latin, of French words 
 with I^atin terminations, and partly by reading Guy de Chauliac in Ijatin, 
 but with comments in French, wiiile the assistant barber made tlu' 
 incisions in the cadaver and pointed out the ])arts as tiie reader named 
 them. In 1505 the bai'bers came moi-e formally under the protection 
 and jurisdiction of the faculty, and assumed the name of the Guild of 
 the Barber Surgeons, and a few years later the surgeons of the long 
 robe, having opposed this movement with very little success, and luu'ing 
 failed to become a separate faculty in the university, submitted to also 
 receive instructions from the physicians. Almost all the medical officers 
 attached to the French armies came from tlie Corporation of Barber 
 
44 THE HISTORY AND LITERATURE OF SURGERY. 
 
 Sui'creons, and finally <mc of tiieni, Ambrose Par^, acqnired so much 
 reputation and influence as to considerably increase the respectability 
 and standing of the guild. As a sample of surgical associations in the 
 provinces we may take the surgeons of Bordeaux, who in 1519 formed 
 a society composed of bcjaunes (yellow beaks or young birds — /. e. 
 aspirants) and companions. They had a password and special secrets ; 
 instruction was given in the winter at 5 A. M. in the form of commen- 
 taries on Guy de C'hauliac, and in the course of one hundred and sixty- 
 nine years five bodies were dissected.* 
 
 There is little of importance in the history of surgery during the 
 next hundred years after the death of Guy de Chauliac. Peter of 
 Argelata, lecturer on surgery at Bologna about the beginning of the 
 fifteenth century and dying in 1423, was the principal surgeon of his 
 time. His six books on surgery, edited by Maretus, first pul)lished at 
 Venice in 1480, are largely derived from Paulus and Guy. He was an 
 operator as well as a theoretical teacher, jierformed lithotomy and her- 
 niotomy, embalmed Pope Alexander VI., practised craniotomy of the 
 f'wtus in difficult labors, etc. A copy of his books was annotated on 
 the margins by Marcellus Cumanus, a surgeon in the Venetian army 
 in 1495, and these observations were finally published by Velschius 
 (G. H.) in his Sylloge Vurationum (Aug. Vindel., I(j68). Cumanus 
 found nothing in Argelata about the treatment of gunshot wounds, and 
 he noted a formula for this purpose consisting of a mixture of oil of 
 roses, galbanum, and asaf'oetida, to be applied hot. 
 
 Gunj)o\\-der was used in warfare at least as early as 1338 ; the English 
 employed it at the battle of Crecy in 134(), l)ut it was a longtime before 
 any surgeon published an account of gunshot injuries and their treatment. 
 The first Italian surgeon to do this was John de Vigo (1460-152-), sur- 
 geon of Pope Julius II. in 1503, whose Pracfica in Arte Vhintrgica 
 Copiosa was first published at Rome in 1514. This book had twenty- 
 one editions in thirty years, and was translated into Italian, French, 
 English, Spanish, Dutch, German, and Portuguese. The great success 
 of the book was due partly to the fact that it was the first complete 
 system of surgery issued after that of Guy de Chauliac, partly to the 
 fact that it contained an account of gunshot wounds and a section on the 
 new disease, syjihilis, and also, probably, to a considerable degree, because 
 it was a book which specially suited a practitioner who knew nothing of 
 anatomy and feared or disliked to make use of the knife. It is essen- 
 tially a surgery of plasters, ointments, and embrocations, and the name 
 of the author is best known to-day in connection with the " emplastrum 
 de Vigo." 
 
 The part relating to gunshot wounds is brief. He says they are con- 
 tused and burned, and therefoi-e need moist applications, but that they 
 are also jioisoned by the powder, and therefore need desiccation ; hence 
 thev are hard to cure. They are to be cauterized with the actual cautery 
 or with boiling oil of elder, " for cauterization kej^eth the wounde from 
 putrefyinge." 
 
 His chapter on syphilis begins as follows (I use the English transla- 
 tion of 1543): "In the yeare of our Lord 1494, in the moneth of 
 December, when Charles the Frenche kynge toke hys jorney into the 
 
 ' Sous (G.) : Bnnkaux medicale, 1877, p. 49. 
 
THE HISTORY AND LITERATURE OF SURGERY. 45 
 
 partes of Ytaly to recover the kyiiiidome ot' Xaples, tliere appeared 
 a certaiue dysease tliroughout al Ytaly of unknowen nature, whicli 
 sondre nations hath called by sondry names. The French men call 
 it the dysease of Naples, because the souldyours brought it from thence 
 into France. The Neapolitanes call it the Frenche dysease." 
 
 Controversies as to whether syphilis existed prior to the fifteenth cen- 
 tury have been many, and the literature on the subject is voluminous ; 
 but no positive and convincing proofs of such existence have yet been 
 found, although it is probable that it did occur before that time. One 
 of the theories of its origin, advanced first by Leonard Schmaus in the 
 preface to his little pampidet, Lucubratiuxcula dc morbo ynJllco et cam 
 (JKS noritcr rrpcrta cum li(/iio iiulico (sm. 4°, Aug. Vindel., lolS), is that 
 it was brought from the AVest Indies by the sailors who returned with 
 Columbus after his first voyage, and attempts have been made to furnish 
 positive evidence of this from human bones showing evidence of disease, 
 and antedating the Columbian discovery ; but none of these have been 
 convincing to skilled pathologists. Schmaus says in his preface that he 
 learned of its American origin from merchants and sea-captains ; but it 
 is probable that this idea was first suggested by the use of guaiacum in 
 this disease. Guaiacum came from America, and it was a common idea 
 that the bane and the antidote belonged together and were to be found 
 in the simie vicinity. It is certain that the disease existed in America 
 soon after the second voyage of Columbus. 
 
 After John de Vigo came Alexander Benedictus (14o ?-l o25), who was 
 professor of anatomy at Padua, an army surgeon, and who operated for 
 hernia and calculus. He is the author of treatises on anatomy and on 
 the pest, and of De omnium a verfiee ad plantam morborum signis, 
 etc. (Venice, 1535; Basil, 1594), which contains his surgical recom- 
 mendations. 
 
 Jacobus Berengarius Carpensis (147?-1560), professor in Bologna, was 
 the author of a celebrated treatise, Tracfatus de fractura cah'oriae seio 
 cranei (Bologna, 1518, quarto), of which a number of editions were 
 jiublished. This also contiiins a few remarks on the ti-eatment of gun- 
 sliot wounds, which he supposed to be burned or more or less poisoned. 
 He acquired a great fortune at Rome by his treatment of syphilis with 
 mercurial inunctions, of which he is reported to have been the inventor. 
 
 Alfonso Ferrius (1500- ?) of Naples, the physician of Pope Paul 
 III., wrote Dc Sclopetorum sive Archibusorum Vulneribus, librl tres 
 (Rome, 1552, quarto), in which he maintains that gunshot wounds are 
 poisoned and must be treated accordingly. 
 
 Bartholomieus Maggius (1516-62) of Bologna wrote De Vulnerwn 
 Hclopctorum et bombardonoii globidis Ubitorum, etc. (Bologna, 1552, 
 quarto), of which there Mere numerous later editions. 
 
 Leonardo Botallo (1530- ?) wrote De Ciirandis ^'ulneribus Sclope- 
 torum (Lyons, 1 580, octavo), in which he opposed the views of De Vigo 
 and Ferrius as to the poisoned condition of gunshot wounds. 
 
 Joh. F. Rota, who lived in the middle of the sixteenth century, wrote 
 De bel/iconim toniientorum vidnerum uatura et cundione liber (Bologna, 
 1555, quarto). 
 
 One of the wisest of the Italian surgeons of this period appears to 
 have been Michael Angelo Blondus (Biondi) (1497-15?) whose little 
 
40 THE lUSTonV AMI I.ITEHATrUE OF KUROERY. 
 
 treali.su J>c jMtrtibiia irtn srcti-s, tir.st j)Liblirihud in U'A'2, and wiiich is 
 contained in the Gesner Collection and also in Utfenbach's Thesaurus, 
 strongly urges the use of simple wat(>r and Avetted lint in the dressing 
 of Wduntls. Nevertheless, he was a ])artisan of the aneients, and two 
 of iiis sayings have l)econie historical as illustrating the university sjjirit 
 of tile age— viz. " It is more honorable to err with (Jalen and Avicenna 
 tiian to at'cjuire glory with others ;" and, " It is better to die l)y a regular 
 j)hysieian than to live by a quack." 
 
 One of the most celebrated Italian surgeons of the sixteenth century 
 was Gaspar Tagliacozzi, l)etter known as Tagliaeotius (.1546-09), who 
 was professor of anatomy and surgery in tiic University of Bologna, and 
 wrote tlie hrst special ti'eatise on ])lastie surgery, and more particularly 
 on the o])eratiou of rhinoplasty, with which his name is especiall)' asso- 
 ciated. The title of his book is De Curtorum Chirurgia per insiiionem, 
 libri duo, of which two editions wei'e published at Venice in 1597. One 
 of these, a large folio jiulilished by Ga.sjiar Bindonus, is celebrated for 
 the beauty of its plates,- the quality of the paper, and its typography, 
 being a splendid specimen of book-making ; the other edition of the 
 same date and place, jiublished by Robert Meiettus, is also a folio, but 
 a much poorer specimen of the printer's and engraver's art. There is 
 also a small octavo edition of Frankfort (1598), and one was published 
 in Berlin so late as 18.'U. He does not name the iierson from whom he 
 had learned his method, but it was probably from some one of the Inc-isors 
 of his day who had ac([uired his knowledge from a jnipil of one of the 
 Sicilian Brancas, who were celebrated for operations of this kind in the 
 middle of the fifteenth century. The elder Branca took his flaps for a 
 new nose from the skin of the face, being the Indian method ; his son 
 made use of the skin of the arm, and extended the method to repair of 
 nuitilated lips and ears, as we are informed by Bartholomeo Fazia. 
 
 The first notice of Tagliacozzi's method is givi'n by H. Mercurialis 
 in his Dc decorafione liber (4°, Venet., 1585, fol. 23). Two of his 
 pupils describe the methods and the results obtained, and acquired 
 repute by their performance of the operation — viz. Thomas Fienus of 
 Antwerp, and Jo. Bapt. Cortesius, who succeeded Tagliacozzi as pro- 
 fessor at Bologna ; but the practice fell into disuse among surgeons, 
 and little was heard of it until the beginning of the nineteenth century. 
 A curious use of plastic surgery is mentioned by Fortunatus Licetus — 
 viz. the making of double mon.sters for show purposes by grafting two 
 boys together by the back, nates, or arms, upon which he says : " Aver- 
 runcct Deus e severe puniant principes tales sicophantes." Victor Hugo 
 refers to the work of these " monster-makers" in his L' Homme (jni rit. 
 
 Marianus Sanctus Barolitanus (1490-154?), a native of Naples and 
 a special pupil of John de Vigo, wrote a treatise entitled Compendium 
 in Chyrurgia Utilissimum Volentibuti ipsas exercere, which was first pub- 
 lished at Rome in 1516, and subsequently appeared in connection with 
 the works of De Vigo. It is also in the Gesner Collection of 1555. 
 Neither Haller nor Malgaigne knew the date of the first edition, which 
 is jirobablv rare. The copy in the Washington Libi'ai'v is a small quarto 
 of fifty leaves, unnuml)ered and unpaged, and is a fine specimen of black- 
 letter printing. It contains three small rude figures of cauterizing irons, 
 and the last nine pages are occupied with his Traetatus de Capite. Mari- 
 
THE HISTORY ASD LITERATURE OF SURGERY. 47 
 
 anus Sanctus is best known by his treatise Dc LaphJc c.v resica per iiicis- 
 ionem e.vtrahenda, in which was, tor the tirst time, pulilished the method 
 of John de Romanes for lithotomy with a grooved staff, upon which an 
 incision was made into the membranous portion of the urethra, after Mhich 
 instruments were introduced to dihite or rupture tlie prostatic portion. 
 This is ivnown as " the metliod ^vith the great apparatus," from the num- 
 ber of instruments required, and also as the " Marian operation," from 
 the name of the person ^\•\\o tirst pul)lished the description. The first 
 edition of this treatise appeared at Venice in 1535. It is contained in 
 the Gesner Collection of 1555 and in Uflenbach's Thesaurus of 1610. 
 
 The " Gesner Collection," also known as the " Geneva Collection," 
 is a beautifully printed folio with the title Chiruryin. De chirurf/ia 
 licriptoreti optiini <jui<jue reteret^ et irceHtiorex, etc. (Tiguri, 1555). It was 
 edited by Conrad Gesner, and contains the principal surgical works of 
 Tagaultius, Hollerius, Marianus Sanctus, Bologninus, Blondus, Maggius, 
 Ferrius, liangius, and others, forming a valuable book of reference. 
 
 The first collections of the works of different writers on surgery were 
 published at Venice, the first being a small volume issued in 1490, and 
 again in 1497, containing the Chirnrgia parva of Guy, the Surgery of 
 Albucasis, and the commentary of Bertapaglia on Avicenna. A nuich 
 more complete collection is the Venice folio of 1498, which contains the 
 ■works of Guy de Chauliac, Brunus, Theodoricus, Lanfranc, Roger, and 
 Bertapaglia. Of this the Venice editions of 1499 and 1519 are in the 
 Washington Library; also the edition of 1546, which is the best and 
 contains also the treatises of Roland and of William of Salicet. 
 
 From very early times there were to be found througliout Western 
 Europe — in France, in Italy, in Germany, and in England — a certain 
 number of surgical practitioners known to the writers of that time as 
 " The Cutters " or " Incisors." Those who operated for lithotomy, her- 
 nia, etc. were of the first class. They travelled about from place to 
 place, and maintained more or less secrecy as to their methods, which 
 were held as a special family property, being handed down from father 
 to son. Among these may be mentioned tiie two Brancas, to whom 
 reference has been made in speaking of Tagliacozzi. 
 
 Another group of these travelling operators was known under the 
 name of Xorsini. These devoted themselves j)rincipally to operations 
 for hernia and to lithotomy. Fabrice d'A(iuapendente mentions Horace 
 of Norsia as a skilled operator in hernia. Sylvaticus in 1601 complains 
 that tile operation of lithotomy was abandoned to ignorant persons, like 
 the Xorsini. In 1633, Cortesi writes that at Messina he had seen Ulysses 
 of Norsia treat hernia by the application of caustic, followed by incision 
 of the eschar; and still later, in 1672, Bernardino Genga says that the 
 Norsini had some experience in the treatment of diseases of the urinary 
 organs. 
 
 To this class of Cutters belongs probably the unkuo\\'n surgeon men- 
 tioned by Senarega, who in his history of Genoa says that there died 
 there in 1510 a surgeon very skilled in removing calculi. He intro- 
 duced into the penis an iron rod, \\hich entered tiie body until it met 
 the stone which he was seeking, and wliich he then removed by a perineal 
 incision. It is supposed by some that tliis unknown Genoese taught 
 his method to John de Romanes of Cremona, who is ordinarilv credited 
 
48 THE HISTORY AND LITERATURE OF SURGERY. 
 
 witli the iuvontion of tlie fjrodvetl stniJ' for lithotomy, and who taught 
 his metliod to his assistant, Marianus Sanctus. 
 
 The most famous of the Incisors was Pierre Franco, a native of 
 Provence, horn ahout 1500, who operated in Provence, Burgundy, and 
 Switzerland, finally settling in Lausanne for a considerahle period, and 
 in 1501 living at Orenge. His I'dit trdite contciKiiit line den particx 
 principaUes de chiruiyie laquelle lea chirurgienn hernih-es exercent was 
 jjublished at Lyons in 1556. In this he describes and figures the 
 " Algalie " sound for detectmg stone in tlie bladder ; says that the 
 calculus is sometimes encysted so that it cannot be felt by the sound ; 
 describes the old operation of "cutting on the gripe," which he says he 
 formerly used; the operation with a grooved sound and gorget, of both 
 of which he gives figures, as also of forceps for crushing the stone if it 
 is large ; and concludes that if the stone does not present itself when the 
 incision is made, it is best to wait a day or two before attcm])ting to 
 remove it. He describes a case in a child ten years old in which, being 
 unable to extract the stone through the perineal incision, he performed 
 the suprapubic operation, removed the stone, which was the size of an 
 egg, and the patient recovered. This is the first recorded case of the 
 high ojjeration for stone. He says, however, that he does not advnse 
 this in ordinary cases. In his description of amputation he does not 
 mention the ligature, but advises the actual cautery, and gives figures of 
 the sickle-shaped knife, the saw, and the cautery-iron. In 1561 he pul)- 
 lished at Lyons his Truite dcs hernicn conk'nant une ample declaration 
 de toutes leiirs esp^cc>< & autres e.rcellentes parties de la chirurgie, assavoir 
 de la pierre, des cataractes des yeux, & autres maladies, desquelles comme 
 la cure est perilleuse, aussi est elle de peu d'hommes bien excrcee. This is 
 a small octavo of 16 preliminary leaves, 554 pages, and 1 leaf of errata. 
 It contains all the matter of the preceding book, and much more, with 
 figures of new instruments, and is really a small manual of surgery. 
 The part relating to lithotomy remains substantially the same. Next to 
 the works of Pare, this is the most valuable contribution of the century 
 to surgical literature. 
 
 The history of the Colot famil}' is curious and interesting, but is 
 wrongly given by most of the biographers : the best is that given by 
 Dr. E. "Turner in the Gaz. Hebd. de MM. et de Chir. (Paris, 1880, xvii. 
 2' ser. pp. 33, 49). 
 
 The story that a certain Germain Colot, a French surgeon, learned 
 the details of the methods of some of the Incisors about 1460, and then, 
 returning to Paris, operated on an archer who had been condemned to be 
 hung, but whose sentence was changed by the king to be operated on by 
 Coli>t, is probably without foundation. The original account, given in 
 the Chronique scandaleuse, does not mention the name of the operator, 
 and Malgaigne says that there is not even a presumption that there ever 
 was a surgeon named Germain Colot. 
 
 There was, however, a Laurent Colot or Collot, who lived at Tresnel, 
 near Troyes, in the middle of the sixteenth century, and who learned 
 the method of John de Romanes — or what is called the IMarian opera- 
 tion — from an itinerant lithotomist named Octavien da Villa. He kept 
 the method a secret and had great success, being called to Paris in 1556, 
 and was appointed lithotomist of the Hotel Dieu. The secret and the 
 
THE HISTORY AND LITERATURE OF SURGERY. 49 
 
 office remaiiK'fl in the family, the grandson Piiilijjpe (1593-1650) lieing 
 called to all parts of Europe to operate. His son Fran(,-ois (1630-1706) 
 wrote an aeeount of the niethoil, which was published after his death 
 under the title Traitii dc rope rat ion de la taillr, etc. (Paris, 1727). In it 
 he refers to the above-mentioned story about Germain C'ohrt, but does 
 not give his name, and asserts tiiat the operation ])erformed on the archer 
 was a nephrotomy and not a lithotomy. That the so-called family secret 
 could have been preserved until the beginning of the eighteenth century, 
 after the publication of the method by Marianus Sanctus in 1535 and by 
 Franco in 1556, illustrates tlie education of the surgeons of those days. 
 We now come to an epoch-making surgeon, Ambrose Pare (1517-90), 
 who was apprenticed to a provincial barl>er when he was about nine 
 years old. In 1532 he came to Paris, where he was probably again ap- 
 prenticed to a barber surgeon and attended the lectures of the doctor of 
 the Faculty of Medicine of Paris, whose business it was to explain to 
 the voung Ijarber surgeons those parts of the surgery of Guy de Chauliac 
 which relate to tumors, wounds, and ulcers. Very soon after his arrival 
 at Paris he had the good fortune to obtain a position as resident a})pren- 
 tice and dresser in the great hospital of the Hotel Dieu. Here he had 
 opportunities for dissections, for making post-mortem examinations, and 
 for the study of disease, of which he was not slow to avail himself. In 
 his preface to the reader he says : " You must know that for the space 
 of tliree j-ears I have lived in the Hotel Dieu of Paris, where I had the 
 means of seeing and knowing (in consequence of the great variety of 
 diseases brought there) all which can be of alteraticm and disease in the 
 human body, and to learn from an infinite number of dead all that can 
 be said of anatomy." 
 
 At the end of this service, when he was but nineteen years old, he 
 became body-surgeon to Mareschal Monte Jan, and went with him in the 
 army which Francis I. opposed to that of Charles V. in the invasion of 
 Provence in 1536. Gunshot wounds were supposed to be poisoned, and 
 the recognized means of destroying the venom was that prescribed by 
 John de Vigo — namely, cauterization by boiling oil. But in one battle 
 the supply of oil was insufficient, and our conscientious youth could not 
 sleep that night for thinking of the horril)le fate that was in store for the 
 poor fellows who had not been cauterized, (jreat was his astonishment 
 and delight the next day on finding that those who had not been burnt 
 were much more comfortable than those who had been treated sceundam 
 artem, and that recovery was prompter and more certain in their case. 
 But, while Pare had the sense and the independence to refuse to give 
 unnecessary pain, although commanded to do so by the highest surgical 
 authority of his day, he could not free himself from the notion that some 
 special treatment was recpiired for gunshot wounds, nor accept the plain 
 teaching of his own experience. He decided that the best thing to be 
 done was to use a secret remedy which- was the stock in trade of a certain 
 surgeon in Turin, and to learn the composition of this remedy he assidu- 
 ously courted the good graces of this surgeon for over two vears and a 
 half, and finally obtained the se(>ret for a round price, ])romising not to 
 divulge it. It was an oil of ])uppies, not much different from lard— a 
 simple protecting soothing application. No sooner had Pare learned the 
 secret than he hastened to publish it, deliberately breaking his promise 
 
 Vol. I.— t 
 
50 Tllf': HISTORY AXI) LITERATURE OF SURGERY. 
 
 on the crniind tliat siioli nn important matter should not be one man's 
 priviletic 
 
 The areat ini])rovem(iit made l)y Pare in snrti^erv was the use of" the 
 ligature to close bleeding arteries after amputation in place of scaring 
 them with red-hot irons, as had been done down to his time. 
 
 In the edition of his works published in 15(34, Dix Hvreft ck Chlni/r/ic, 
 he first describes and recommends the application of a ligature to lilccd- 
 ing vessels in amputations, and abandons the use of the cauteiy. His 
 account is as follows: After alluding to the j)assage in Galen which 
 states that "the vessels must be tied toward their roots, which are the 
 liver and the heart, to staunch the great flow of blood," he says : " But 
 having many times used this means of closing the veins and arteries in 
 recent wounds where there was a hemorrhage, I thought it might also be 
 done in amputating a member. Therefore, having conferred with Esti- 
 ennc de la Iviviere and Francois Kasse, both surgeons at Paris" [in 
 later editions the name of Rasse is struck out and in place is read " other 
 sworn surgeons of Paris "], " we agreed that we would make the trial 
 upon the first patient which offered, although we would have the cau- 
 teries all ready to use if the ligature failed." A few days afterward the 
 ligature was applied with success in a case of amputation of the leg. 
 
 Pare was a good anatomist, by far tlie greatest surgeon of his time, 
 the confidential friend of four successive kings, and is said to have been 
 the only Protestant in I'aris v.\w was spared the massacre of St. Bar- 
 tholomew, which was due to the direct action of the king. Malgaigne's 
 argument against the truth of this story cannot outweigh the direct state- 
 ments of Sully and of Brantome. 
 
 Catherine de Medici one day asked Pare whether he hoped to be 
 saved in the next world. " Yes, certcs, madame," said he, " because I 
 do what I can to be a brave man in this world, and because the mercifid 
 God understands all languages, and is as well satisfied with a French 
 prayer as with a Latin one." 
 
 To properly appreciate the \\ritings of Pare, they should be compai'ed 
 with those of other teachers of, or writers on, surgery of his day. His 
 treatise upon gunshot wounds may be compared with several small trea- 
 tises on surgery pul)lished in the latter half of the century, thirty or 
 forty years after the appearance of his treatise on this subject, and written 
 in French for the benefit of the barber surgeons. Take, for example, the 
 Traitte des arcbumdes of Joubert, published at Lyons in 1574. Laurens 
 Joubert (1529-83) was a distinguished physician of Mont])ellier, ]>ro- 
 fessor of medicine in the university and dean of the faculty. He had 
 served in the royal army in the campaign of 1569, where he ought to have 
 heard something of Pare's methods of treatment, but he makes no allu- 
 sion to them, unless it be where he speaks of the oil of puppies as an 
 anodyne. His Surgery is that of John de Vigo, written in a diffuse, 
 pedantic style, which was probably impressive to the barbers in jiropor- 
 tion to their inability to understand the meaning of his words. At one 
 time he was called in as an uni))ire in an argument between a physician 
 (Veyras) and the surgeon of the king of Navarre (Guilhemct) as to 
 whether gunshot wounds are contused and should be treated by poultices, 
 etc. or by desiccatives, as by washing with wine. The arguments on 
 both sides and Joubert's decision were published in a curious little book 
 
THE HISTORY AND LITERATURE OF SURGERY. 51 
 
 entitled Tracite dv Vhiinirgie, contcnant i-raye methode de r/ucrir plai/es 
 d\irquebumde, etc., par ]M. Jaeqiies Vtyras, docteur en Medecine, & M. 
 Tannequin Guilhemet, Chirurgien du Eoy de Navarre (Lyon, 1581, 8°). 
 Jonbert's decision was, upon the whole, in favor of the views of the 
 plu'sician, as was to be expected. He refers to Pare as " homme digne 
 foy," not with reference to his treatment of wounds, but to his statement 
 that bones may be fractured by the wind of a cannon-ljall — this lieiug 
 precisely one of the points on which Pare was wrong. 
 
 The lirst teaching in French given to the barbers and surgeons was 
 by a physician, Jean Canape of Lyons, physician of Francis I., who in 
 the first half of the century gave public lectures to them, and for the 
 same purpose translated into French a compend by Guy de Chauliac 
 (Lyons, 1538, 12° ; also 1563-71), some anatomical treatises of Galen 
 (Lyons, 1541), and several other small treatises. 
 
 Pierre Tolet (1502-8?), a surgeon of Lyons, in 1540 published a 
 translation into French of the sixth Book of Paulus ^gineta. In his 
 prefatory letter to this, addressed to the French surgeons, he refers to 
 Jean Canape as a man to whom surgery owes more than to any man who 
 has written since (Jalen. 
 
 In 1570, .Taeipies Dalechamps, pliysician and reader in surgery at 
 Lyons, published Vhlrurgie Framjoise as a manual for the barber sur- 
 geons. It consists of the sixth book of Paul of ^Egina, Hippocrates on 
 fractures and dislocations, and extracts from Celsus, Albucasis, etc., 
 witii the annotations of Dalecliamps, and a brief treatise on operations 
 by Jean Girault, master surgeon in Paris. 
 
 In 1583, Esaie le Lievre, surgeon, published a little book entitled 
 Ojfieinne et Jurdin de Chirurc/ie mUitaire contenant les instrumentz et 
 pinnies tves necessaires a tous Chinur/ieiw, etc. The general style of 
 this work may be seen in the following sentence : " Nous disons I'har- 
 quebnzade on jilaye faicte par harqucbuze ou canom ; estre une aiFection 
 contrc nature, portant de foy plusienrs especes d'accidens ; a scavoir 
 extreme contusion, combustion, diruption, dilaceratio, concution, frac- 
 tion, fracation, j)uis repercution, abolitions, destructions, extinctions, ou 
 mortifications, selon plus ou moings, des espritz tant vitaux, animaux, que 
 naturels : de laquelle complication assemblee, selon la nature tt noblesse 
 des parties offensees, se forme une indisjiosition tendant a reudre ladite 
 partie, consequement tout le subiect en cadaver." 
 
 The Sclopetarim of Quereetanus (Du Chesne) (Lyon, 1576) is a 
 wortliless book by a notorious charlatan. It was translated into Eng- 
 lish and published at London in 1590 by a certain John Hester, who 
 offered for sale the Arcana prescribed therein. Care is taken to give 
 two sets of remedies — one for the injuries of the common soldiers, the 
 other " to be used for the rich." For advertising purposes the same 
 John Hester published .1 .S7(o/-/ TH.^cmirs of the e.rccUent Doctour and 
 Kiiif/lit, ma'ifiter Leonardo Fhiorcircuiti, Bolognese, uppoii Chirurgerie 
 (London, 1580), advertising at the end that he is pi'epared to furnish 
 various salves, philosoj)hical oils, and other preparations recommended 
 in it. Phioravanti explains that "the reason why white of egg is to be 
 used in mixing ajiplications for wounds is because the white is that ])art 
 which produces the flesh, the skin, and the feathers of the hen, while 
 the yolk engendereth only the intestines. Therefore the white is like 
 
62 THE THSTORY AND LITERATURE OF SURGERY. 
 
 unto flcsli, aiKl its special business is to produce it." He says also that 
 the most perfect remedy for a great flux of blood from a wound is to 
 stitcli it close, and then take dry human blood-[)o\\dcr and lay it upon 
 the wound. This is tiie same as the mummy of I'aracelsus. 
 
 Tiic reference made by Pare as to the value of the instruction whicli 
 he obtained in the Hotel Dieu is perhaps the tirst allusion to the imi)urt- 
 anee of hospitals as a means of furnishing instruction in surgery. Hos- 
 pitals had existed since before the Christian era in India, and those in 
 Persia under the Nestorians were really used for educational purposes 
 in connection with their medical schools. The foundations of many 
 European hospices and hosjiitals date from the tenth and twelfth cen- 
 turies, such, for example, as the San Spirito at Rome and St. Bartholo- 
 mew's and St. Thomas's in London, some of the impulse to the forming 
 of such institutions apparently having come from the need of providing 
 them for lejiers. 
 
 No surgical instruction appears to have been given in the hospitals 
 of the Middle Ages, exccjit that the surgeons connected witii them may 
 have employed some of their apprentices to assist them in the bandaging 
 and in the dressing of wounds ; but what we know as " clinical surgery " 
 was an aifair of nuich later date. 
 
 Of the immediate j)upils and followers of Pare, the most important 
 were Pierre Pigray (15o.j-161.j), whose published works are mainly 
 abstracts and translations of Pare; and Jacques Guillemeau (1550-1012), 
 surgeon of Charles IX., Henry III., and Henry IV., and surgeon of 
 the Hotel Dieu, who accjuired tame as a writer and teacher in surgery, 
 obstetrics, and ophthalmology. His La chirurgic fmnqolse (Paris, 1594, 
 folio) was translated into Dutch, and thence into English, and published 
 at Dort in lo!t7 under the title of The French < 'hin(r(/ci-ifc, i'orimng a, 
 beautifully printed and illustrated foliii, winch was much the best work 
 on this subject which had then appeared in English. Guillemeau Avas 
 unusually well educated for a surgeon of those days, having studied 
 under Riolan as well as under Pare, and he tried to harmonize the 
 statements of the latter and those of his op])onent, Gourmelin, by saying 
 that Galen recommends the cautery in amputation for gangrene, and aji- 
 proves the use of the ligature for hemorrhage when there is no corruption. 
 
 Par4 in advising the ajiplication of the ligature says it does not 
 matter if some other tissue besides the vessel is included in it ; but 
 Guillemeau says that a portion of such tissue is to be included : " prenant 
 quelquc portion de chair ensemble," evidently thinking that this is an 
 important feature of the o})eration. 
 
 His chapter on aneurism contains an account of a case of traumatic 
 aneurism at the bend of the elbow in which he applied a single ligature 
 above the swelling M'ith success. In this case the aneurism had ruptured, 
 and after ligating the artery he opened it further and turned out the 
 clots. This one ligature A\as j)laced three fingers'-breadth aliove the 
 tumor. Park's description of the operation also refers to the use of but 
 one ligature, and not to tlie operation of Antyllus. 
 
 There were no surgeons of repute in Germany prior to the middle 
 of the fifteenth century ; they were almost all barbers, who could 
 neither read nor write. In 1868 there Avas for the first time pub- 
 lished a manuscript treatise on surgery Avritten in German about 1460 
 
THE HISTORY AND LITERATURE OF SURGERY. 53 
 
 by Hc'inricli Pfolzju-iuidt, and entitled BiiinHh-Ertznei. This, the oldest 
 German work on surgery at present known, relates mainly to the treat- 
 ment of wounds, but it contains a remarkable chapter on the making 
 of a new nose from the skin of the arm after the method of Branca. 
 There is an allusion to the burning t)f wounds by powder, but no refer- 
 ence is made to lithotomy or to operations for hernia. It gives a receipt 
 for a narcotic mixture to be inhaled from a sponge similar to that men- 
 tioned by Guy de Chaidiac. The first German surgeons of repute whose 
 works have come down to us are Hieronymus Bnmschwig, and Hans 
 von Gersdorff, called Schylhans or Schieliians, both being surgeons at 
 Straslinrg in the last half of the fifteenth century. Erunschwig was 
 born about the middle of the fifteenth century, and published at Stras- 
 burg in 1497 a folio volume with the title Din id da-s biwh dcr Viruryki, 
 Ilmdwirck der Wundartzny von Hyeronimo brunschwig. Of this there 
 were eight other editions, the last at Augsburg (1539, quarto). The 
 Washington Library has the folio editions of 1508 and 1513 and the 
 quarto editions of 1533 and 1539 ; also the English translation of 1525, 
 and a Dutch translation in folio printed at Utrecht in 1535. The Eng- 
 lish translation is the first book on surgery in English, and its title-page 
 is a curiosity in itself. It begins as follows : 
 
 " The noble experyence of the vertuons handywarke of surgeri prac- 
 tysyd & compyled by the nioost expertc ]Mayster Jherome of Bruyns- 
 wyke borne in Stracsborowe in Almayne yi' whiciie hath it fyrst proved 
 and trewly foiuide by his awnc dayly exercysynge." 
 
 This title is the work of the unknown translator, who has also given 
 a short })rcfaci', in which he siiys that "it is oftentymes sene and dayly 
 chaunceth in small townes, borowghs and villages that dyverse people 
 hurt or dyseased for lacke of connynge men be taken in hande of them 
 tliat lie barbers or yonge maisters to whome this sciens was never dys- 
 closed, not thynkynge on the wordes of the olde lernyd men that say, 
 It is not wel possible to man that he sholde bryngt' well to a good end 
 the thynge wliiche ho never or hath but lytell seen." 
 
 Brunschwig's book was the first in which any definite statement is 
 made about gunshot wounds, or, as the English translation has it, " of 
 woundis sliot with a gone whereas the venym of the powder abydyth in." 
 To remove the venom he advises to pass a small cord of hair through 
 the wound and draw it back and forth, after which a tent is to lie placed 
 in the womid. 
 
 In amputation he advises either the actual cautery or boiling oil to 
 cheek hemorrhage. He has nothing to say about lithotomy, herniotomy, 
 aneurism, or tumors — the book biMug, in fact, a treatise on the military 
 surgery of those days. It is illustrated with large quaint wood-cuts 
 which are anifiiig the earliest sjiecimens of the art. Haeser says there 
 were two English translations — one published at London, and the other 
 at Soutliwark, but these are the same work. 
 
 Hans von Gersdorff was an army surgeon in 1476-77, and published 
 his book, Fcldthuch der Wundtarzucfi (in folio), at Strasburg in 1517. 
 Of this there were eight later editions and translations into Latin and 
 Dutch. The Washington Lil)rarv contains the first edition, and also 
 the Strasliurg editions of 1527 and 1540 and the Erankfort edition of 
 1551. Gersdorll" treats more fully of shot-wounds than docs Brunschwig. 
 
54 THE HISTORY ANT) LITERATURE OF SURGERY. 
 
 He docs not consider them to be poisonous, but gives detailed directions 
 for findiiiu' and extracting the bullet, with figures of instruments, and 
 advises tliat tiie powder be removed, after wliieh warm linseed oil is to 
 be poured int() the wound. He says: " I do not know of any l^etter or 
 milder remedy than this, which 1 have learned from Master Nicolaus, 
 called the Maulartzt, surgeon to Duke Sigmund of Austria." If ampu- 
 tation becomes necessary, he says : " First of all advise the jiatient to 
 resign himself to God, to confess his sins, to remember the suffering of 
 our Lord witli thanks, and the surgeon the same ; tJuis will God grant 
 him good foi'tune in his work. And when you will cut him have ready 
 by each other all your instruments and ap])aratus, such as scissors, knife, 
 saw, styptics, bands (lassbendel), bandages, pads, tow, eggs, and what 
 belongs to it, so that one follows the other in the order of the operation, 
 since there is need of this. And when you are ready to cut let some 
 one draw back the skin strongly and tie a band firmly around it, and 
 place another band in front so tliat a space of a finger-breadth be left 
 between the two bands that you may cut between them with tiie knife ; 
 then this cut is quite sui'e, easily made and makes a good stump. When 
 j'on have made the cut take a saw and divide the bone, and then remove 
 the band and tell some one to draw the skin over the Ijone and flesh and 
 hold it tight in front ; and you should have a bandage two fingers limad 
 and well wetted that it may lie smooth, and witli it bandage the thigh 
 down to the cut that the flesh may go in front of the bone, and leave it 
 thus bound. And you need not fear bleeding if you have done as above 
 described. Bind now over the styptic a good thick pad, take the bladder 
 of a bull, ox, or hog, one which is strong, cut the neck open so that it will 
 go over the pad and stumj), and the bladder should be wet but not too 
 soft ; draw it tlien over all, tie it hard with a band and you need have 
 no care about the bleeding." 
 
 The following is the styptic referred to : " Take of unslacked lime 
 two ounces, vitriol, alum, each, one ounce, of aloes to be calcined, gall- 
 nuts, colophony each a quarter of an ounce ; of the residuum in the 
 retort when you make aquafortis two and a half ounces, and the white 
 hair of the belly of a hare or deer chopped up, and mix all together 
 
 thoroughly. When you use it mix it with white of eggs But if 
 
 an artery rages and will not be staunched then burn it with a cautery." 
 Although he used no ligature in am]iutation, he does advise a double 
 ligature on a wounded blood-vessel. He has a chapter on leprosy, but 
 says nothing definite about syphilis. The plates in Gersdortf 's book are 
 especially interesting. 
 
 Walter Hermann Ryif was also a Strasburg surgeon of the first 
 part of the sixteenth century, and published a number of treatises in 
 German, his Gross Ckirurgci appearing in 1545, and his Kleiner 
 C'hirurr/i in 1551. This tendency to depart from scholastic methods 
 received a strong impulse from the sayings, doings, and writings of 
 Philippe Aureole Theophrastus Bombastes de Hohenlieini, lietter known 
 as Paracelsus (1493-1541). He was born in the village of Einsiedeln, 
 near Zurich, studied medicine with his father, travelled extensively, 
 studied chemistry and alchemy \\ith Sigismund Fugger, and served 
 as an army surgeon in eam]>aigns in Italy and the Netherlands. Of 
 unbounded self-assurance and ha\ ing a knowledge of some new rcme- 
 
THE HISTORY AND LITERATURE OF SURGERY. 55 
 
 dies, such as antimony, arsenic, and mercury, he soon acquired a great 
 reputation, and in 1526 was appointed professor of medicine in the 
 University of Basle. He is eliaraeterized by Dalton as "a rampant, 
 blatant, boasting, ignorant vagalionil, with a face of bi'ass and a tongue 
 like a race-horse," and, if the word " ignorant " be omitted, it is a true 
 picture. But he \v"as also a sort of genius, in a way a poet ; and, knave and 
 charlatan, and in his latter days drnidvard, though he was, his doctrines 
 were accepted by such men as Frobenius, Erasmus, and Van Helmont, 
 anil had a powerful influence throughout Europe for a century or more, 
 some of his pecidiar theories still surviving as the essence of modern 
 homceopathy. He wrote or dictated many works, of which the only 
 one that need be mentioned here is Der grotmen Wundartzney (15.36-37), 
 of which there were several editions, besides Latin and French transla- 
 tions. The second chapter begins as follows : " It is necessary to know 
 in the first place what is the efficient cause of the curing of wounds, 
 because this may of itself indicate the proper treatment. Know then 
 that the human body contains in itself its own proper radical lialsam, 
 born in it, and with it, and not only the body as a \vhole contains it, 
 but all its parts, such as flesh, bones and nerves, have each its own 
 
 peculiar juice competent to cure wounds It is not the surgeon 
 
 who cures wounds, it is the natural balsam (or juice) in the part itself." 
 Hence he inveighs against what he calls " the damnable precept which 
 teaches that it is necessary to make wounds suppurate." Elsewhere 
 he calls this animal juiee " la mumie," but he also meant by this a 
 special preparation made from certain parts of the human body — 
 something like the animal juices and extracts whicli have been re- 
 cently recommended as remedies, and which are quite Paracelsian in 
 character. 
 
 The ideas of Paracelsus were accepted by Felix Wurtz (1514-74) of 
 Basle, who studied under Ryft' at Nureml)erg, and was on terms of inti- 
 macy with Paracelsus and with Conrad Gesner, the most learned man 
 of his time. He acquired great reputation, and published his Practka 
 (ler Wauflarziiet/ in 1563. Of this about fifteen editions appeared during 
 the next hundred years, including an Euglisli translation by Fox, pub- 
 lished in 1656. He remarks that "skill in surgery is obtained with 
 great painfulness, for it is not gotten witii sitting on a cushion at home 
 and by reading and writing ; .... it is not enough to be full of talk, 
 and to say such and such and write so and so, — a patient is little the 
 better for it if the surgeon hath no skill to dress his wounds." The work 
 is almost entirely devoted to wounds and fractures and their consequences, 
 and contains nothing as to the teehni(]ue of surgical operations. The 
 treatment advocated is in the main sinqjle and sensible. Styptic powders 
 are condemned fi)r general use, as is also the cautery to suppress hemor- 
 rhage, except in amputation of the thigh. No allusion is made to the 
 ligature, and it is not probable that he had ever seen the works of Pare. 
 He objects to the probing of wounds, declaring tiiat it is filly to feel and 
 grope about them, and tliat some surgeons use the ]n'obe merely because 
 tiuy have seen it used and to show that they are doing something. Cat- 
 aplasms and poultices for fresh wounds are condemned, and the blood 
 is not to be washed or squeezed out, " for it is a right flesh glue and 
 hasteneth the healinar." He often refers to the conservative surgeons 
 
56 THE HISTORY AND LITERATURE OF SURGERY. 
 
 who say, "Old customs should not be abandoned," and says, " ThcrcCore 
 in sonic places the books of 'J'lieophrastus Paracelsus (to whom the best 
 and most fiuiious sur};-eons must give place) ai'c prohibited to be read ; 
 but in my simple judgment it is done vi'iy tbolishly." He objects to 
 drawing a cord through a gunshot wound, or to using hot oil, or to 
 treating such injuries otherwise than as simple wounds. The third part 
 of his book, being on the symptoms and complications of wounds, 
 including a description of the wound-fever or pyaemia, is the most 
 original and valuable part of the work. 
 
 The instruction of the barber surgeons' apprentices at the end of the 
 sixteenth century appears to have been based on the views of Jerome of 
 Brunswick, if we may judge from a little manual by Julius Holder, pub- 
 lished at Frankfort in 1592, entitled DialoguH, em Niltzliche niicl Warh- 
 (iff'tif/c Bcurlircihinu) dnes rcchtc Wundiniztti mind seiner Jleixferschtiff. 
 This is in the form of ijuestions and answers, Latin terms being curiously 
 intermixed with the (rerman. 
 
 Another good specimen of the sort of instruction given to apprentices 
 of German barber surgeons in the sixteenth century is the Wundartzney 
 zu alien gebrechen des gantzen Leibs, etc. of Joannes Charethanus (or 
 C'liaretanns), of which five editions appeared between 1530 and 155'5. 
 The edition of 15411, printed at Frankfort, is a small quarto of 20 
 leaves, giving directions for Itloodletting and tootli-pulling, and various 
 formula for salves and potions. It directs that wounds should be dressed 
 twice a day; that he who i.s wounded in the head shall not walk about or 
 move much ; that he shall avoid perspiring and talking, which inflame 
 or disturb the brain and make him insensible ; above all, he shall avoid 
 strong wine, which ])uts him in deadly peril; likewise the rays of the sun 
 and light and heat and indigestiljle meat and the society of woman, whom 
 he shall not even look upon. 
 
 If a large ai'tery is cut or opened, first secure the same carefully with 
 a silk thread to stop the bleeding ; then lay on the red powder and cover 
 with a red plaster. Let it remain for four days and heal it like other 
 wounds. 
 
 The Seventeenth Century. 
 
 The seventeenth century is more remarkable for the advances which 
 were made in jihysics and in physiology than it is for improvements in 
 surgery. It was the age of Francis Bacon (1561-l<)2(j), of (Jalileo (15(54— 
 1642), of Rene Descartes (1596-1650), of Pascal (1623-62), of Sir Isaac 
 Newton (1642-1727), and of Robert Boyle (1626-91), all of whom had 
 a powerful influence in developing the iatro-chemical and iatro-mechan- 
 ical theories which prevailed about the end of the ccnturv. This was 
 also the ago of Borelli (1608-79), of Thomas Sydenham (1624-89), 
 and, above all, of William Harvey (1578-1657), the pupil of Fabricius 
 d'Aquapendente, whose celebrated work, E.rercitatio Andtoniica de Jlofu 
 Cordis et Havgidnis, appeared in 1628. 
 
 At the commencement of this century the most distinguished Italian 
 surgeon was Hieronymus Fabricius d'Aquapendente (1537-1619), who 
 was a pupil of Fallopius and succeeded him as professor of anatomy at 
 Padua. He was the discoverer of the valves of the veins anil the teacher 
 of Harvey. His principal discoveries and writings relate to anatomy 
 
THE HISTORY ASD LITEEATURE OF SURGERY. 57 
 
 and embryology, Init lio was also professor of surgery, and his Pcniatcu- 
 chos Chinitr/icnm (f'rancof., 1582) and his Opera Chirurgka (Paris, 
 1613, in folio, and later editions) were important works of reference 
 during tiie next century. Fabrieius was learned and elocpient, and made 
 the University of Padua the nKjst important school for anatomy and sur- 
 gery in Europe. His surgery is mainly tiiat of Celsus, Paul of JEgina, 
 and Albucasis, to whom he gives full credit, carefully noting the sources 
 of his ([notations. No great advance in the art is due to him, but his 
 works contain manv accounts of cases and references to tiie metliods of 
 other surgeons, making them valuable historically, and they are far more 
 interesting as a piece of literature tiian is the corresponding work of John 
 de Vigo. In speaking of wounds of the intestines he refers to animal 
 sutures and to the insertion of a piece of the trachea of an animal to 
 preserve the lumen of the gut. He describes tracheotomy and urges its 
 performance in certain eases, and says tliat lie has seen one case of cancer 
 of the breast cured by excision, but has never performed the operation 
 himself. 
 
 Next to him came Cesare Magati (1579-1647), who became professor 
 at Ferrara in 1612 (or 1621?), and who gained much repute by his book, 
 De rara mcdieatlone rulnenim, fieu de vulnerihua raro fracfcaul ix (\\hr\ ii., 
 Venet., 1616, folio). In this he urged a simpler mode of treating wounds 
 tlian was then fasliionahlc, advising less fre<pient dressings, eondenniing 
 the use of tents, and maintaining that gunshot wounds are not poisoned. 
 His doctrines were specially urged and made prominent by Sancassini in 
 the early part of tiie eighteentli century. 
 
 Marcus Aurelius Severinus (1580-1656), professor at Na])les, one of 
 tile most celebrated teaciiers of anatomy and surgery of his time, is best 
 known by liis book De recondita abxcesnuuiii naficra (Naj)les, 1632, 
 quart(j), of wliich several later editions were publislied. 
 
 Giovanni Battista Cortesi (1554—1636), a barber's apprentice, after- 
 M-ard a pu])il of Tagliacozzi, whom he succeeded as professor at Bologna, 
 publislied a treatise on wounds of the head in 1632, and a manual of 
 surgery in 1633, wliicii are of little interest. 
 
 Gaspar Asellius, the discoverer of the lacteals, in 1623 was professor 
 of surgery and anatomy at Pavia, but wrote notiiing on surgery. 
 
 Spigelius (1578-1625), a native of Brussels, professor of anatomy and 
 surgery at Padua in 1605, \vas an operator, and is said to have trephined 
 the same jxitient seven times, but there is nothing surgical in his pub- 
 lished w(n-ks. Trephining was a common operation at this time, being 
 employed in cases of insanity, of severe lieadache, and of clironic diseases 
 of the eyes, as well as for injuries of the skull. 
 
 Pietro de Marchetti (1589-1673), professor of surgery at Padua, 
 published a collection of cases under the title Observafionnm medico- 
 chiruir/icanini xyllor/e (Padua, 1664, and later editions), whicii is of 
 permanent liistorical value. Among these cases is one of successful 
 trepiiining following a dagger-wound of the head two or three montiis 
 previous, and several cases of the same operation for headache. Here 
 also is the celebrated ease in which a pig's tail was forced into the anus 
 of a prostitute, and was removed by sli])ping a tube over it. Pietro was 
 succeeded in the chair of surgery in 1()62 l)y his son Dominique, wlio 
 accpiired great fame as a teacluu-, and is said to have performed neplirot- 
 
58 THE irrsTonv Axn litebatuhe of simoERY. 
 
 omy successfully without being guided by the jjresence of any tumefac- 
 tion of the ])art. 
 
 Filippo Masiero, a surgeon of Padua, was the author of the follow- 
 ing books: II chirunjo in j)ratfica, etc. (Venet., 1688, 4to ; 5th ed. 
 1749, 8°), // mgno chinur/iro (Parts I., II., Padua, 1697), and Opere 
 chiruir/isclic (Padua, 1707). 
 
 Carolus Musitanus, a physician of Najjles, published his ( 'liinirr/ia 
 theoretica practiea in 1698. Haller styles him " improbabiliuni histori- 
 aruni narrator." 
 
 In France there was little jn'ogress in surgery until near the end of 
 the century. The medical faculty finally triumphed over the surgeons 
 by obtaining a decree which united tlie barl)ers and the surgeons in one 
 corjwration, and the College of St. Come was no longer a jiower in the 
 land. Among the French works on surgery of this period may be men- 
 tioned Quelques traites des operalions de chirurgie, by Jean Girault (Paris, 
 1610) ; Obficrrations Medechiales et Chirurr/icales, etc., of Gul. Loyseau 
 (Bordeaux, 1617); Observations iatrocliirurgiqucs of Covillard (Lyon, 
 16."i9) and Le Vhiturgien Operatcur of the same author (1633 ?; 2d 
 ed. Lyon, 1640); Epintola de hiryngotomia of Rene Morean (Paris, 
 1646); La Cliirurgie Militaire of Leonard Tassin (Nimwegen, 1673); 
 Les opiratlons de la chirurgie of J. Bienaise (Paris, 1688); and Traite 
 des phij/es d'arquebusade of Scipio Abeille (Paris, 1695). 
 
 In 1696, M. de la Vauguion, a physician, published a Traite coinplet 
 des opendions de chirurgie (8°, Paris), which is the most complete man- 
 ual in French prior to that of Dionis, and of the English translation of 
 which at least three editions were published (1699, 1707, and 1716). He 
 names the tourniquet and describes its application in amputation and 
 in the operation for aneurism, and quotes frequently from Fabricius 
 Hildanus. 
 
 Nicolas de Blegnv (1652-1722), surgeon of the duke of Orleans in 
 1683, the founder of the first medical journal, published a treatise on 
 venereal diseases in 1673, and a treatise on the treatment of hernia, with 
 description of a truss of his invention, in 1676. He is also the author 
 of the first city directory. 
 
 Previous to the seventeenth century surgery had made little progress in 
 the Netherlands, and there are very few books to be noted. The work of 
 Ypermans has already been referred to. CVirolus Battus, a surgeon of Por- 
 dreeht, published in 1590 his Handtboeck dcr Chirurgijen, of which tliere 
 were six later editions. He also translated the works of Pare into Dutch. 
 
 In the middle of this century Holland became celebrated as a centre 
 of anatomical and surgical teaching through the labors of Tulp, Bar- 
 bette, Van Meekren, Van Home, Van Roonhuysen, Solingen, Verduyn, 
 and others, and the schools of Amsterdam and Leyden began to draw 
 students from all parts of Europe. 
 
 Paul Barbette (162?-7?), son of a Strasbui-g surgeon, studied in 
 Mont]jellier and Paris and settled in Amsterdam. He was a voluminous 
 writer, and his Chirurgie, first jiublished in Dutch in 1657, passed through 
 ten editions and translations, Ix'iug a pr)pular manual, while his Ojiera 
 omnia was issued twenty-two times in various languages. He first 
 described femoral hernia, suggested laparotomy in intestinal obstruc- 
 tion, and extirpation of the spleen, which he performed on dogs. 
 
THE HISTORY AyD LITERATURE OF SURGERY. 59 
 
 Job Janszoon Yan Meekren (■?-166(}), a native of Amsterdam 
 and a pupil of Tulp, was a celebrated operator. His book, Heel ni 
 genvexhonMiye uumiierkingen (Amst., 1(J(J8), was translated into German 
 and Latin. 
 
 Joh. van Home (1621-70), professor of anatomy and surgery in 
 Leyden, was a distinguished teacher, but his writings relate mainly to 
 anatomv, his 3IierofecIine id est brerissima Chiniir/iae Methothin (1(>()3) 
 being nierely a manual. There is an English translation of this (London, 
 1717). 
 
 Hendrik van Roonhuyscn (1625-6?), a surgeon of Amsterdam, also 
 well known as an obstetrician, published his Genees-en Heelkonstuje 
 aanmerfcingen in 1672. He operated for wry-neck and hare-lip, advised 
 Caesarean section, removed tumors, and seems to have been specially 
 skilled in his art. 
 
 Cornelis Solingen (1641-87), a surgeon at the Hague, wrote 3Ianuale 
 Operatien der Chirurgie (Amst., 1684), which Haller says is full of 
 original observations. 
 
 Peter A. Verduyn (162?-?), a surgeon of Amsterdam, is celebrated 
 for his treatise on the flap method of amputation. Diss, de nora artuidii 
 decitrtandonuii ratiorie {Am^t., 16i»6). He seems to have known nothing 
 of the similar methods of Lowdliam. (Sec p. ()7.) 
 
 Joannes Muys of Arnhcm and Leyden jniblished the first two parts 
 of his Pra.vis Chirurgiae rationalis in 1683, and the complete work in 
 1695. This contains accounts of one hundred and twenty cases, some 
 of which are curious and interesting. 
 
 Fabricius Hildanus (1560-1624) is sometimes called the "Father of 
 German Surgery," althougli this title belongs more properly to Hcister. 
 He was a Swiss by birth, and for the last twenty years of his life was 
 the city physician of Berne. He was a surgeon's apprentice who man- 
 aged to acquire a good classical education, and probably obtained good 
 practical training under Griffon, a surgeon of Geneva. He travelled 
 much, resided for some time at Cologne, and became widely known as 
 a bold and skilful i)]W'rator, and especially as a lithotomist. He was a 
 strong opponent of Paracelsus and his friend Wurtz, and was a volu- 
 minous writer, but his monographs are, for the most part, of little 
 interest, the best being his Lithotomia Vesicae (Basle, 1626), translated 
 into English and published at London in 1640. His most important 
 ])ublieation for readers of the present day is his Obserrationnin et Curn- 
 tioiiiiiii Vhirurgienrum Venfuriac, in wiiich he relates his experience in 
 a large number of siu'gical cases of the most varied character. He 
 advised amputation at an early stage in gangrene, and that the incision 
 should be made in the sound and not in the decayed flesh. 
 
 He used the cautery, and not the ligature, in wounds of the arteries, 
 and devised a number of complicated instruments, none of which are 
 of practical interest. His chief influence on surgery was through his 
 correspondence with German physicians and surgeons, and through his 
 urging u])on the German surgeons the necessity for the study of anat- 
 omy. His Opera omnia, of which several editions were published, 
 appears to have been a favorite book of reference for surgeons for 
 many years. 
 
 John Schultes, better known as "Scultetus" (1595-1645), a pupil of 
 
60 THE IITSTOnr AM) UTEUATVriE OF SURGERY. 
 
 Fal)riciiis (rA(|ii:ii)i'ii(lc'iit(', hccaiiu' city physician at Uini. His tjrcat 
 M'oriv, the AniKiiiKnitdriiun L'hirurgkmvi (Uhii, l()"j.'3, folio), passed 
 thi'oiigh many editions and was translated into many languages. 
 
 Joseph Schmidt (KiOl-?), an army surgeon, published Spenilmn 
 ( 'lilruri/lcinii (IJlin, KJTjfJ, quarto) and Kxatiwii C/iiriirf/icujii (Franeof., 
 
 The most celebrated (icrnum surgeon of tiie hitter part of this j)eriod 
 was Mattha'us Gottfried Purmann (l(j4'j-1711 ?), who was apprenticed 
 as a barber surgeon, became a medical oificer in the Brandenlnirg armv 
 in 1675, and city physician at Breslau in 1685. He was a voluminous 
 writer, and his (r/'o.s.scr vnd f/cuitz neu-f/ewuinJciier Lorbcer-Krantz, oder 
 Wi'i nd-Artsuci/ [Franc(){., 1692, 4to; also 1722), his Chirurgiii Curiosa 
 (Franeof., 1694, 4to; translated into English, Ivondon, 1706, fob), and 
 his Funftziy nondcr- uiid iruiidcrbahre /Schustswunden Curen (Franeof., 
 1721) are valuable works in the history of the art. He was a strong 
 advocate of the cure by the M'ea]ion-salve and the sympathetic powder, 
 and tells several stories of the successful use of these remedies. He used 
 styptics and bandages to control hemorrhages after amputations, objecting 
 to the eauterv, l)ut savs nothintr about the ligature. 
 
 Here may also be mentioned John von Muralt (1 645-1 7;33), a dis- 
 tinguished Swiss anatomist and surgeon, who was one of a celebrated 
 family of physicians of Zurich. He studied at Basle, Leyden, Oxford, 
 and Paris, and in 1761 returned to Zurich, where he soon became dis- 
 tinguished as an anatomist and surgeon. In 1677 he announced jjublic 
 lessons in anatomy, M'ith demonstrations on the bodies of criminals and 
 of persons dying of remarkable diseases in the hospitals, and in the 
 same year published his Vade Mecmn Anatomicmn, giving the date by 
 the enlarged letters in the motto of the book, " LVX et faX IMcDICi"- 
 nse." In the second edition of his surgical writings, published in 1711, 
 he describes a method of amputation by fla]> devised by Saborian in 
 Geneva, who first performed it in 1701, and this is by some claimed to 
 be the first mention of that method of operation, but it had already been 
 described by Yonge in 1679. (See p. 67.) 
 
 Other German surgeons of this period were Mathias Ludwig Glandorp 
 (1595-1636), whose iSpecidum Vhlrun/icitm appeared in 1619 ; Jessenius 
 a Jessen (1566-1621), author of Tnxfitutioncx Vhinirgicac (1601); Paul 
 Ammann (1634-91), author of Pntxix vuincrum lethaliiim (Franeof., 
 1690); Joh. Agricola (1589-164?), author of Chirurgia parva (Nurn- 
 bei-g, 1643); and John H. Jungken (1648-1726), author of Compendium 
 Chinur/icac Mantndix ahuofutum (Franeof., 1692). 
 
 The oldest English medical book -which we have is perhaps the Leech- 
 book, written about 970 A. d., and printed in 1865 as volume ii. of the 
 Lecehdoins, Worfeiinning, ((»d l-itarcraff of Early England. This is maiidy 
 the receipt-book of a herbalist, giving the uses of common herbs, and 
 among other things the composition of various " wound-salves." But it 
 also contains matters taken from Paul of ^Fgina, and directs : " If thou 
 must carve off or cut off an unhealthy limb off from a healthy body, tlien 
 carve thou not it on the limit of the healthy body, Init much more cut or 
 carve in the hole and (juick body." The following is the best surgery in 
 the book : " For hare-lip, pountl mastic very small, add the white of an 
 egg, and mingle as thou dost vermillion ; cut with a knife the false 
 
THE HISTORY AND LITERATURE OF SURGERY. 61 
 
 edges of the lip, sew fast witli silk, then smear without and within with 
 the salve, ere the silk rot. If it draw together, arrange it with the hand ; 
 anoint again soon." 
 
 In the hook of The Pht/siciaiifs of Myddrni, which dates from about 
 tlie thirteenth century, there are a few references to surgical opera- 
 tions. Tile autlior says (page 40) : "A wounded lung is the physician's 
 third tlitiiculty, for he cannot control it ; but he must wait for the will 
 of God. By means of herbs a medicine may be prepared for any one 
 who lias a pulmonary abscess [empyema]. He should let out [the 
 matter] and support [the patient] as in the case of a wounded lung, till 
 lie is recovered. But most usually he will have died within eleven years 
 [or one year]." Page 44 : " A hard vesical calculus is thus extracted by 
 operation : Take a .staff and place it in the bend of the knee ; then fix 
 both arras within the knees, doubling them over the staff, and securing 
 both wrists with a fillet over the nape of the neck, the patient (being 
 placed on the back), his stomacii \\\^, witli some supjiort under both 
 thighs, and the calculus cut for on tlie left side of the urethra. Let him 
 subsequently be jnit in a water-bath that same day, also the day follow- 
 ing early, and after this he should be put in the kyfteitii. Then he 
 should be removed to his bed, and laid tiiere on his back, his wound 
 being cleaned and dressed with flax and salt butter. He should be kept 
 in the same temperature until it be known wliethcr he shall escape [effects 
 of the operation]. He should be kept without food or drink for a day 
 and a night previous to the operation, and should iiave a bath." 
 
 The following is the direction for an antesthetic (page 423) : " Take 
 the juice of orpine, eringo, poppy, mandrake, ground-ivy, hemlock, and 
 lettuce, of each equal parts. Let clean earth be mi.xed with them and a 
 potion prepared, tlieii without doubt the patient will sleep. When you 
 are prepared to t)perate upon the jjatient, direct tliat he shall avoid sleep 
 as long as he can, and then let some of the potion be poured into his 
 nostrils, and he will sleep without fail. 
 
 " When you wish to awake him, let a sponge be pounded in vinegar 
 and put in his nostrils. 
 
 " If you wish tliat he should not wake for four days, get a penny- 
 weight of the wax from a dog's ear, and the same quantity of pitch ; 
 administer it to the patient and lie will sleep. 
 
 " Wiien you would that he should awake, take an onion, compounded 
 with vinegar, and pour some into his mouth, and he will awake. Take 
 care that you keep him quiet, and warned of the operation, lest he should 
 be disturljed." 
 
 The first surgeon in England of whom we have any definite account, 
 and wliose writings still exist, was John of Arderne (or Arden), born 
 about l."]08, who practised in Newark until about 1370, when he went 
 to London. He wrote a treatise on surgery of which several manu- 
 script copies are in existence, but the- only work of his which has been 
 printed is ^1 trcuthc of the fixfuld in the fumhimenf, or other placet of the 
 bodt/, etc., which is included witli the translation of Arcffius on wounds 
 of the head, etc., printed in London in lo8S, liciiig a translation by John 
 Read. His operation itself consisted either of slitting up the fistula or 
 of passing a thread tlirough it, ^\•llich is to be drawn so as to cut through 
 the flesh graduallv. 
 
62 THE HISTORY AND LITERATURE OF SURGERY. 
 
 His dcscriptiiiii of caiu'cr of tlic rcctiini is a graphic one, and begins 
 as follows : 
 
 " Bubo is an Apostunie breding within the fundament in the longa- 
 tion with great hardness, but with little paine. This before his ulcera- 
 tion is nothing but a hid Cancer, which cannot in the beginning be 
 knowne by sight of the eye, for it is hid within the fundament, and 
 therefore it is called Bulio. For as an Owle hidctii her self in the dai'ke 
 places, so this griefe lurketh within in the beginning. 
 
 " Bnt after processe of time it is ulcerat and frettith and goeth out, 
 and oftentimes it frettith and ulcerith all the circumference of the funda- 
 ment, so that the excrements goeth out contimiallie without retencion, 
 and may never be staied unto the death, nor cured by the healpe of man. 
 And it is thus knowen. 
 
 " Put your finger within the fundament of the pacient, and if ye 
 finde within a thinge very harde, sometime on the one side, and sometime 
 on both, which hindreth egestion, than it is Bubo. 
 
 " And the manifest signs are these. The patient cannot abstaine from 
 stoole, for aking and priking, and that twise or thrise within an lionre, 
 and the excrementes seeme as it were mingled with watrie blond, and it 
 stinkcth very strongly, so that all the nnskilfull surgions and the patient 
 also thinketh they have Dissenterium, when truel}' it is nothing so, for 
 Dissenterium is with flux of the belly, but in Bubo there goeth foorth 
 hard egestion and sometime they may not goe out for straightnesse of 
 the Bubo, but are reteyned within the fundament straiglitly so that ye 
 may feele them with your finger and drawe them out, and in this case 
 glisters availeth much. 
 
 "And when they bee nigh their ende, they beginne to have lynger- 
 ing fevers, and to loose their appetite, tlie_y forsake all, and covet wine, 
 they eate little and covet everieday lesse and lesse, they sleepe bnt little 
 and unquietly, they are heavie as well in niinde as in body, and as they 
 waxe weaker and weaker, they covet their bedde and above all thinges to 
 drinke water, neverthelesse they can speake and move themselves to the 
 last breath. 
 
 " From these (I say) wash your handes if you have care of j'our credit, 
 unlesse it be in glisters as aforesaide to ease him." 
 
 At the beginning of the fifteenth century there was a great dearth of 
 surgeons in England, as it appears from Rymer's Fcedera that in 1417 
 Henry authorized " John Morstede to press as many surgeons as he 
 thought necessary for the French expedition, together with persons to 
 make their instruments.' With the army which won the day at Agin- 
 court there had landed only one surgeon, the same John Morstede, who 
 indeed did engage to find fifteen more for the army, three of whom were 
 to act as archers." 
 
 Of the English surgeons of the fifteenth and sixteenth centuries, those 
 whose names are best known are Vicary, Gale, Clowes, and Lowe. 
 Thomas Vicary (149?-1561), the first master of the Amalgamated Bar- 
 bers and Surgeons in 1541, and one of the first governors of St. Bar- 
 tholomew's, published in 1548 a work on anatomy in English. No copy 
 of this edition is known to exist, but the edition of 1577 was reprinted 
 by the Early English Text Society in 1888. Thomas Gale (1607-86), a 
 
 ' The Antiquary's Portfolio, by J. S. Forsyth, vol. i., London, 1835, p. 80. 
 
THE HISTORY AND LITERATVRE OF SURGERY. 63 
 
 native of London, served in the army of Henry VIII. in France in 1 544, 
 and nnder Piiilip II. of Sjmin in 1577, succeeded Vicary as master of 
 the Barber Surgeons Company in 1561, and in 1563 published \\is, Lwti- 
 tui'ion of Chirurfferie, with other treatises, one of whicii is Of icounds 
 made with Gonuetihof, in whicii lie opposes the views of Brunswiclv, De 
 Vigo, and Fcrrius as to the venomous nature of such wounds, and quotes 
 Maggius approvingly. He advises styptics in amputations — says that 
 his method is used in St. Thomas's Hospital, and gives cases to prove 
 that bullets may be left in the body without danger. 
 
 William Clowes (1540-1624) was at first a naval surgeon, and became 
 surgeon of St. Bartholomew's in 1581. He wrote A proved practise for 
 all young C'hirurcjions concerning buniingn with Gnnpowder and Woundes 
 made with Gunshot, etc. (London, 1 SOI ,'.S° ; 3d ed. 1637,4°). He refers 
 to Pare as a man worthy of admiration, and, like Gale, comments severely 
 on the ignorance of the so-called surgeons of his time. Peter Lowe 
 (155?-161?), a Scotch surgeon, practised for a long time in France and 
 Flanders and as an army surgeon. In 159(5 he \\as in London, where 
 he published his works on the Spanish Sickness and The Mliole Course 
 of Vhirurgerie. In 1598 he returned to Glasgow, and founded the Fac- 
 ultv of Phvsicians and Surgeons of Glasgow, which was chartered by 
 King James VI. in 1599. His book on surgery passed through four 
 editions, and is a good manual for its time. In amputation for gangrene 
 he used the actual cautery, but says : " In amputation without putrefac- 
 tion I finde the ligature reasonal)le sure ]irii\i(ling it be quickly done." 
 This is perhaps the first mention in Kuglisli of the ligation of arteries in 
 amputation. In hernia he advised the pricking of the intestines with a 
 needle to discharge the wind and lessen the bulk of the tumor. 
 
 About the middle of the sixteenth century there lived at JMaidstone, 
 Kent, a surgeon named John Halle, who published in 1565 a translation 
 of the ( 'hirurr/ia parva of Lanfranc, with some remarksof his own, entitled 
 An Historical Expostulation cdso against the beastly abusers, both of Vhy~ 
 rurgerie and Physiche in our tymc : With a goodly doctrine, and instruc- 
 tions necessary to be marked and followed of all true Chirurgies. 
 
 The history of surgical corporations in England begins with the bar- 
 bers' guild, which was at first a meeting for social and religious purposes, 
 originating probalily in the thirteenth century. These barbers soon 
 began to call themselves barber surgeons. There were, however, sur- 
 geons who were not barbers, some of whom had served in the army, and 
 in 1368 these surgeons formed a separate guild, which about 1421 com- 
 bined with the physicians.' The barbers obtained a eliarter of incorpora- 
 tion from King Edward IV. in 1462. 
 
 There is notiilng in the charter about bnrl)cry — that is, shaving and 
 hair-cutting — Iiut a good deal about the regulation of surgery. In 1492 
 arms were granted to the " Guild of Surgeons," whicii appears to have 
 been a small body of eight or ten men superior in social position to the 
 
 ' The details of the quarrels between the barbers and the surgeons, and of the organ- 
 ization and ])rogress of the guilds, will lie found in The Annals of the Barber Siirgeonx of 
 London, compiled by l^idney Young (a thick quarto volume published in 1S90), and in 
 The Ch-aft of Siirf/ery, by J, Flint South (published in 1886). The act of Parliament 
 passed in 1540, allowing the United Companies of Barbers and Surgeons to have yearly 
 four bodies of criminals, was the first law in the country for promoting the study of 
 anatomv. 
 
64 THE HISTORY AM) MTEUATURE OF SVIWKRY. 
 
 l)arber.s. In 1540, uikUt the rcitrn of Hciirv VIII., tlie barbers and 
 the surgeons were united and incorjiorated In- act of Parliament as the 
 Company of tiie Barber Surgeons, tiie first inastei' Ijeing Thomas Vieary. 
 
 lu the year 1542 an act was j)assed regulating the j)raetiee of surgery, 
 stating that "the Company and Fellowship of Surgeons of London, 
 minding their owne lucres, and nothing the profit or ease of the diseased 
 or patient, have sued, troubled, and vexed divers honest persons, as well 
 men as women, whom God hath endueed with the knowledge of the 
 nature, kind and operation of certain herbs, roots and waters, and the 
 using and ministering of them, to such as have been ]iained «ith custum- 
 able diseases, as women's breasts being sore, a pin and the web in the eye, 
 uncomes of the hands, scaldings, burnings, sore mouths, the stone, stran- 
 
 guary, saucelin, and morphew, and such other like diseases And 
 
 yet the said persons have not taken anything for their jiains or cunning. 
 .... In consideration whereof, and for the ease, comfort, succour, help, 
 relief, and health of the King's poor subjects, inhabitants of this his 
 realm, now pained or diseased. Be it ordained, etc. that at all time from 
 henceforth it shall be lawful to every person being the King's subject, 
 having knowledge and experience of the nature of herbs, roots and 
 waters, etc., to use and minister according to their cunning, experience 
 and knowledge, .... the tiforesaid statute .... or any other Act 
 notwithstanding." 
 
 The Barber Surgeons had public demonstrations of anatomy and dis- 
 sections in their hall, but it was forbidden that any of them should make 
 dissections or give lectures on anatomy at any place fithcr than said hall. 
 The reader in anatomy was for many years a ])hysician. 
 
 In l(i()4 the comjwmy was presented with five hundred copies of the 
 Tables (if Surf/er}! of Horatius Morns, a Florentine physician, translated 
 by Kichard Caldwell' (London, 1585, .32 pp. 8°). These books were 
 given by j\Ir. Caldwell to be distributed among the surgeons who were 
 freemen of the company. 
 
 In 1643, Edward Arris gave to the corporation the sum of two hun- 
 dred and fifty pounds for the pur^iose of having one human body pub- 
 licly dissected and six lectures thereupon read each year. 
 
 The Gale Lectureship was tbunded by Dr. Gale, the order being issued 
 in l(i98. These two bequests are now combined and the lectures in con- 
 nection with them are known as the Arris and Gale Lectures. 
 
 One of the lecturers before the Barber Surgeons was Alexander Read 
 (or Rhead), a Scotchman, who graduated in 1620 at Oxford. His Lec- 
 turei< on wounds were published in 1(534, those on tSiirc/ical operations in 
 1637, and all his works in 1650. Read taught that a bullet may be so 
 made that it will make a poisonous wound, quoting as authority Querce- 
 tanus. Speaking of ligature of the artery, he says : " Ambrose Parrey 
 ■would have this mean to be used after the amputation of a member, whom 
 you may read ; but in my judgment his practice is but a troublesome and 
 dangerous toy ; as he shall finde who shall go to make trial of it." 
 
 An important part of the business of the Corporation of Surgeons was 
 
 ' The Dr. Caldwell referred to was Richard Caldwell, a graduate of O.xford and a 
 physician, and president of the college in loT(l. Through his intlnence Lord Luniley 
 founded and endowed a lectureship on surgery, which is still known as the Lumleian 
 Bequest. 
 
THE HISTORY AXD LITERATURE OF SURGERY. 65 
 
 the examining and licensing of naval snrgcons, both for the royal navy 
 and for merchant ships. An account of such an examination is given by 
 Smollett in his novel Boderick Bandom. Oliver Goldsmith also pre- 
 sented himself for examination in 1758, and the minutes of the court of 
 examiners read as follows : " James Bernard, mate to an hospital ; Oliver 
 Goldsmith, found not qualified for dito." 
 
 In Scotland the University of Aberdeen was founded in 1494, and in 
 1505 had a professor of medicine. 
 
 King James III. is reported to have been "ane singular gude 
 chirurgian, and there was none of that profession if he had any danger- 
 ous cure in hand but would have craved his adwyse." His method of 
 obtaining practice must have been effectual, although it was an unusual 
 one. \ie find in the accounts of the treasurer for 1511 an entry as fol- 
 lows : " Item to one fallow, because tiie King pullit forth his tootht, 
 xiiii. 5." 
 
 The first charter of the Royal College of Surgeons of Edinburgh is 
 dated July 1, 1505. It directs that no person shall make use of the 
 craft of surgerv or of barber craft within this burgh unless he is freeman 
 and burgess of the same, and that he must be examined by the masters 
 of the same craft upon the following points — namely : The anatomy, 
 nature, and complexion of every member in man's body, and all the 
 veins of the same. Every year one executed criminal was to be given 
 to the college for anatomical purposes. No master of the craft shall 
 take any apprentice who cannot write and read. Probably the most 
 important provision was, that no person -within the burgli shall make 
 or sell any aqua vite except the masters, mcml)ers, and freemen of the 
 corporation. 
 
 By 1589 it had become the custom to admit barbers at a lower rate, 
 but tiiey had only the right to act as barbers, being specially forbidden 
 to practise surgery, and were to have " na signe of chirurgie in their 
 bughts or houses oppcnlie or privatlie." 
 
 In the early part of the seventeenth century the leading British sur- 
 geons were Clowes and Lowe, already referred to, and John ^^\)odall 
 (156?-164?), who had served as an army surgeon, and about 1612 was 
 elected surgeon to St. Bartholomew's Hospital and likewise surgeon-gen- 
 eral to the East India Com])any, which last gave him the ap])ointing of 
 surgeons and mates to all the company's ships. In 1G17 he published a 
 work entitled T/ir Suir/eoiifi Mate or Milifari/ i{- Doincstiquc Surgery. 
 Discoursing faithfully & plainly the method and order of the Surgeons 
 chest, the uses of the instruments, the vertues and Operations of the 
 Medicines, and the exact Cures of Wounds made by Gun-shott, etc. 
 In 1628 he published a work entitled Viatknim, Being fhe Bafh-Wcnj to 
 The Surgeotitt Chefit. Containing, Chirurgical Instructions for the 
 yongcr sort of Surgeons, imployed in the Service of his Majestic, or 
 for the Common-Wealth upon anjt occasion whatsoever. Intended 
 chiefly for the better curing of Wounds made by Gunshot.' His 
 
 ' These works were afterward pnblisheil together in folio in l()o9, 1G53, and 1658, a 
 separate tille-p.age being given to each work, but the pagination being oontinnons. The 
 second title-page is often transferred in place of the lirst one, which has been lost, lead- 
 ing, on careless examination, to the erroneous supposition that tliey are two entirely dis- 
 tinct works of the same date. 
 Vol. I.— a 
 
66 THE HISTORY AND LITERATURE OF SURGERY. 
 
 works arc not specially instructive, hut are in parts very good reading. 
 In ani|)utatiou he recommends tying large vessels, especially those of 
 the thigli, if it can be done, but he seems to think that the surgeon 
 will often fail, in which case, as well as for the smaller vessels, he 
 recommends buttons of astringent and caustic powders. 
 
 In gangrene Woodall urged amputation in the mortified instead of 
 the sound part — an old treatment which had then fallen into disuse. 
 He also' suggests amputating as low as the ankle for disease of the foot, 
 instead of just below the knee, as was usually the case. He had never 
 seen the actual cautery used in amjnitation. 
 
 In 1648, James Cook of Warwick published his MrUififliim Cliirur- 
 giae, or the Harrow of Surgery, a manual which seems to have been 
 j)opular, the sixth edition in 1717 being "licensed by the College of 
 Physicians and fitted for the use of all sea-surgeons." In his descrip- 
 tion of amputation no mention is made of the ligature of arteries. 
 
 The greatest English surgeon of the seventeenth century was Eichard 
 Wiseman (1622-76), sometimes called the English Pare. He was 
 apprenticed to a barber surgeon in 1637, served in the Dutch navy until 
 about 1644, when he joined the army under Charles I., and was admitted 
 to the Company of Barber Surgeons in 1651. He was a surgeon in the 
 Spanish navy for three or four years, and in 166(1 joined King Charles 
 II. and was appointed one of his surgeons. In 1672 he ])ublished A 
 Treatise of VVoundx in an octavo of 277 pages. In 1676 this was 
 enlarged and printed in a large folio volume under the title Severall 
 Chirurgieall Treatm's. There were eight of these treatises — viz. I. Of 
 tumors ; II. Of ulcers ; III. Of the diseases of the anus ; IV. Of the 
 King's evil ; V. Of wounds ; VI. Of gunshot wounds ; VII. Of frac- 
 tures and luxations; VIII. Of lues venerea. In 1686 this was pub- 
 lished in folio, having the words " the second edition " on the title-page, 
 although it was really the third, and the so-called " third edition " (folio, 
 1796), \vith the title Eight Chirurgieal Treatises, etc., was really the 
 fourth. Other editions appeared in 1705, 1719, and 1734, and there is 
 a spurious edition of 1692, which is really the original edition of 1676 
 Avith a new title-])age. 
 
 ^V^iseman used the complex dressings of the period, but knew that 
 simple measures produced equally good results. He used styptics and 
 cauteries, and not the ligature, but he included the end of the cut vessel 
 in one of the stitches through the lips of the Avonnd. Being a personal 
 friend of the king, he used his influence with him to promote the inter- 
 ests of the Barber Surgeon's Company. His Avorks Avere ncAcr trans- 
 lated, and Ayere A'cry little known on the Continent, lint they had a 
 decided influence on the improA'ement of the art in Englantl. 
 
 James Yonge (or Young) (1646-1721), a natiA'e of Plymouth and a 
 naval surgeon, published in 1679 a little book of 120 pages entitled 
 Currus Triumphalis, e Terebintho. Or an account of the many admirable 
 Vertues of Oleum Terebinthinae. 3Iore 'particularly, of the good effects 
 produced by its application to recent Wounds." .... And lastly, A 
 new Way of Amputation, etc. He objected to Pare's method of liga- 
 tures in amputations, saying that it is " a Avay ahyays tedious, often 
 successless ; and AvhateA'er A'aunts the Author makes of it, it cannot be 
 so secure as he pretends ; it being liable (sometimes from the slackness, 
 
THE HISTORY AND LITERATVUE OF SURGERY. 67 
 
 otherwise from the too great straightness of the thred ; sometimes from 
 its sinalhiess, cutting- through, or from its weakness, giving way) to a 
 new flux when not so tolerable to the Patient, or so easily cured by the 
 Artist as at first; moreover,, where two Vessels or more bleed in one 
 Wound (whit'h is very frequent), the one must be neglected, while the 
 Ligature is making on the other." But he says : " The ligation of an 
 Artery on other accounts, as in the Toothach, Epiphora, Aneurisma, &c., 
 is not hereby impugned." On page 30 is to be found, perhaps, the first 
 printed description of a tourniquet — "very useful in iVmputations, espe- 
 cially above the knee ; that is to say a wadd of hard linnen cloth, or the 
 like, inside the Thigh a little below the Inr/iicn, then ])assing a Towel 
 round the member ; knit the ends of it together, and with a Eattoon, a 
 Bedstalf, or the like ; twist it, till it compress the Wadd or Boulster so 
 very strait in the crural vessels that (the circulation being stopped in 
 them) their bleeding when divided by the Excision, shall be scarce large 
 enough to let him see where to apply his Restrictives." A similar tour- 
 niquet had, however, been used l)y John Morell in 1674 at the siege 
 of Besaiifon. The " new way of amputation " is by a single flap, and 
 is the first printed description of this method, which he says he learned 
 from Mr. C. D. Lowdhara of Exeter. 
 
 The Complmt Discourse of Wounds, . ... as also a Treatise on 
 Gunshot Wounds in General, by John Brown (surgeon to the king) 
 (London, 1678, 4to), is a pompous, diffuse, tedious book, containing 
 nothing of any impcu'tance. 
 
 Some curious illustrations of the English surgery of the middle of 
 the seventeenth century are to be found in the Diary of the Rev. John 
 Ward, Hear of Strntford-upon-Avon, extending from 16^8 to 1679, 
 edited by Charles Severn (London, 1839, 8vo). For example: "A 
 cancer in ]\Irs. Townsend's breast, of Alverston, taken off by two sur- 
 geons First they cutt the skin cross and laid itt Iwick, then they 
 
 workt their hands in ytt, one above and the other below, and so till 
 
 their hands mett, and so brought itt out There came out a gush 
 
 of a great quantitie of waterish substance, as much as would fill a flag- 
 gon. They jiut in a glass of wine and some lint, and so let itt alone 
 till the next day ; then they opened itt again, and injected myrrhe, aloes, 
 
 and such things, as resisted putrefaction, and so bound itt up againe 
 
 The way how and where itt should be cutt was niarkt with ink by one 
 Dr. EdWards." 
 
 " Gill told mee of a woman that had an apostheme about the side, 
 and his master intended to trc])an her on one of the ribs ; whether it 
 canne be ; — I suspected itt to Ix' a ly." 
 
 " The mountebank that cutt wry necks, cutt three tendons in one 
 child's neck, and hee did itt thus ; first by making a small orifice with 
 his launcet, and lifting upp the tendon, for fear of the jugular veins, 
 then by putting in his incision knife, and cutting them U])wards ; they 
 give a great snaj)p when cutt. The orifice of his wounds are small, 
 and scarce any blood fiillows." 
 
 " Gill said Jiis Mr. Day hath amputated five armes, three leggs and 
 somewhat else since he came to Oxford, and but two of all these died, 
 and one was a person of sixty years att least." 
 
 "John Phillips his child had a red swelling in the forehead, I sup- 
 
68 THE HISTORY AM) LITERATURE OF SURGERY. 
 
 pose ix varix or nacvuss and itt was taken off In- one of Coventry, by 
 tying a liair ahont itt, and oinlinii' itt liarder everv dav ; in two weeks 
 itt fotclit itt oif." 
 
 A curious episode in the history of surgery in the iirst ludf of the 
 seventeenth century is the controversy on the sympathetic or magnetic 
 cure of wounds. This was a doctrine of Paraeeksus, and in 1(508 one 
 of his foUovyers, (ioclenius, professor of medicine at ^larhurg, called 
 special attention to it by iiis \york, Trdddtun <Je 3I(ir/n<iica Vuratione 
 Vuliwrifi. His doctrines were objected to by the priests on religious 
 grounds. Van Hehiiont wrote in defence of the doctrine, and liis pam- 
 phlet was published without his knowledge in 1G21. This created great 
 excitement, and was translated into English by Walter Charleton, and 
 pul)lished in 15(!0 under the title ^1 ieniart/ of Parciclo.rex. The cure 
 was to anoint the bloody sword or other \ycaj)on which had inflicted the 
 injury, or a stone or cloth dijiped in the blood as it flowed from the 
 wound, with a special ointment, and put it away carefully, applying 
 nothing to the wound but a bit of wet lint. Goclenius thought the 
 cure was a natural process ; the priests thought it was due to magical 
 formula and the aid of the devil ; and Van Helniont tuidertook to 
 prove that both were wrong, and tliat the so-called " weapon cure " was 
 due to a certain mysterious sympathy precisely analogous to what, in 
 later times, was called "animal magnetism." 
 
 The priests' view that weapon-salve cures are magical and sinful is 
 given in the Hoplocri.wiasponr/as ; or a sponge to unpe away the weapon- 
 sa/re, by AV'illiam Foster, Parson, etc. (London, 1 G31), whicli was directed 
 mainly against the celebrated Rosicrucian Robert Flndd, who replied with 
 Doctor Fludds answer unto M. Foster, or the squesing of Parson Foster's 
 sponge, .... wherein the sponge-bearer's immodest carriage and be- 
 haviour towards his brethren is detected, etc. (London, 1631). Fludd's 
 book is much better reading than that of Foster. 
 
 Sir Kenehn Digby's discourse at IMontpellier, on the cure of wounds 
 by the jwwder of sympathy, puldishcd in l(j57, \yas a famous book in 
 its day. A less-known Init equally curious book, by C de Irvine, an 
 army surgeon, was printed at Edinburgh in 1656 under the title of 
 lledicina Magnetica, or the rare and wonderful art of curing by sym- 
 pathy, and several other controversial pamphlets of the period are 
 noted in the Index Catalogue of the Washington Library under the 
 heading " Symi)athy." 
 
 After the expulsion of the Moors from Spain there is little worth 
 noting in the history of sur'gery in that country until after the middle 
 of the sixteenth century. In 1488 it was ordered that those wishing to 
 practise surgery must be examined imder the direction of the Brother- 
 hood of St. Cosme and St. Damian at Zaragoza, to which association 
 was granted the privilege of dissecting the bodies of persons dying in 
 the hospital recently established in that city. The surgeons were for- 
 bidden to order or to dispense internal remedies. At the end of the 
 fifteenth century there were a few Spanish \yriters on syphilis, the best 
 known being Villalobos. 
 
 The first celebrated Spanish surgeon was Francis Arcfeus (1493- 
 157?), whose treatise, De recta curandorinn rulnerum, ratione, written 
 in his old age, was first published at Antwerp in 1574 and again at 
 
THE HISTORY AXD LITERATURE OF SURGERY 69 
 
 Amsterdam in 1658. This was translated into English by John Eead, 
 and published at London in 1588, and a Dutoh translation was published 
 in H)(i7. Arcitus recommends the use of the tre])hine in fractures of 
 tile skull, describes with some minuteness the operation for excision of 
 cancer of the breast and an apparatus for the treatment of club-foot, 
 and advises mercui-ial inunctions on the joints for syphilis. His treat- 
 ment of wounds is, in the main, that of John de Vig<:). 
 
 Another Spanish surgeon of the sixteenth century of some repute 
 was Bartoleme de Aguero (15;n-97), professor of surgery at Seville, 
 called by some the Spanish Pare, whose works were published in 1604 
 uuiler the title Tesoro (k la verdadcra cirujla, and in other editions in 
 1624 and 1654. 
 
 Dionisio Da^a Chacon (1510-159?), a surgeon in the Spanish army, 
 .serving in many countries and in the inuuediate service of Charles V., 
 Phili]) II., Juan of Portugal, Don Carlos, and Don John of Austria, 
 wrote his Pradica y teorica dc cirujic about 1580. This was the lirst 
 comprehensive work in surgeiy written in Spanish. He used the 
 cautery for checking hemorrhage in amputations, did not consider gun- 
 shot wounds poisonous, and abandoned the use of boiling oil in treating 
 them after 1544, at the suggestion of a certain M. Bartolomeo, proltably 
 Maggius. His interesting report on the injury of the head of Don 
 Carlos, in which he opposed \"esalius, ^vho advised the trepan, is given 
 with comments bv J. M. Guardia in the Gazette Med. de Paris, 1863, 
 p. 41. 
 
 Andreas Alcazar, professor at Salamanca, published in 1575, in folio, 
 his Chir>ur/iae, .... libri sex, and in 1582 his De vidneribus capitis. 
 
 Juan Fragosa, surgeon to Philip II., published Erotemas quirurgicos 
 (Madrid, 1570, 4to), De la Cirur/ia, etc. (Madrid, 1581, fob), Tratado 
 de cirtKjia saeado de la cirugia unieersid, a little manual of questions 
 and answers for students (1692), and Cirujia universal, .... Y ma.^ 
 otros tres tratados .... Una summa de jyroposiciones contraciertos 
 avisos de cirugia . . . . de la^ deelaraciones acerca de diversas heridas 
 y muertos . . . . de los AphorixmoK de Hi/ppoerates tocantes a cirugia 
 (Alcala, 1592, and several later editions). 
 
 Cristobal ]\Iontcmayor, surgeon of Kings Phili]) II. and III., wrote 
 Medici nia y cirur/ia de rulnerihus co^;///.s' (Valladolid, 1613; Saragossa, 
 1664). 
 
 Pedro Griigo de Vadillo, a .surgeon of Lima, published at Madrid, in 
 1632, Discursos de verdadera cirugia y censura de ambar vias, y eleccion 
 de 1(1 primera intcncion curatira, y unicion de las heridas, of which a 
 third edition appeared in 1692. 
 
 Eighteenth Century. 
 
 At the beginning of the eighteenth century the only city in which 
 there were any special o])portunities for the study of surgery was Paris. 
 There was no place for the barbers or the barber surgeons in the univer- 
 sities of P^urope, and they had no institutions of their own in which any 
 teaching worthy of the name could be obtained. Many of them had 
 learned something in the camp or on the battle-field, which was the 
 great practice school for the surgeons, as it had been for three centuries, 
 
70 THE HISTORY AND LITEUATURE OF SURGERY. 
 
 and there were hut few surgeons of the time in Enghind, I*' ranee, or 
 Germany wlio failed to gain experience therein. Nevertheless, this 
 military experience contributed little to the advancement of surgery. 
 Haeser says that tlie cliief cause of tiie supremacy of French surgery in 
 the seventeenth and eighteenth centuries was the wars undertaken by 
 Louis XIV. and his successors, and that streams of German blood con- 
 tributed in some degree to the foundation of the mastt-i'ship of the 
 French in tlie <lomaiu of surgery. There is a grain of truth in this 
 statement, but it does not explain why the German and the English 
 surgeons, who also saw more than enough of military surgery at this 
 period, did not make the ssime ])rogress as tlu; French. jVrmv service 
 gives valuable exjierieni-e to the man who has suitable preliminary 
 training and is well grounded in anatomy, but for the barbers and barber 
 surgeons of the eighteenth century such service increased their knowledge 
 but little. It is true that the surgeons had learned something. They 
 knew that shot-wounds were not poisonous and did not require cauteriz- 
 ing, and a large number of them probabl}- also knew that ordinary wounds 
 not involving the bones really required very little treatment. Never- 
 theless, they kept on prescribing and using their oils, ointments, plasters, 
 vulnerary drinks, etc., the formula' for which fill a considerable space in 
 the surgical treatises of the day ; and there is one special reason for this 
 which the modern surgeon and historian usually does not fully appreciate. 
 This reason was, that the charges of the surgeons in those times were 
 based upon these ap])lications, and this was also true for the ordinary 
 practitioners of medicine : they compounded and dispensed their own 
 remedies; their charges were nuulc for the remedies and not ibr the 
 visits ; and hence the fees were in proportion to the number of the 
 mixtures, draughts, unguents, etc. which were ordered for a particular 
 case. The surgeons at the beginning of the eighteenth century, as a 
 rule, used styptic powders and compression to check hemorrhage. Those 
 who knew anything about the use of the ligature apjjcar to have been 
 afraid to trust it, and to have jireferred the actual cautery. It was sup- 
 posed to be necessary, or at all events desirable, to include a portion of 
 the surrounding tissues with the artery to be ligated, for fear that the 
 ligature might cut through the coats, and for the same reason the cord 
 was often tied over a small pad instead of being made directly to encircle 
 the vessel. In the army the surgeons necessarily practised medicine, but 
 in civil life they were, as a rule, forbidden to use or prescribe the internal 
 remedies, that being the business of the physician, who claimed exclusive 
 rights in this respect. 
 
 Atthe beginning of the eighteenth century the leading surgeons in Paris 
 were Georges Mareschal (1(358-1736), surgeon of tiie Gharite and first sur- 
 geon of Louis XIV. in 1703; Jean IMery (1645-1722), first surgeon of 
 the Hotel Dieu and the deviser of the operation of suprapubic puncture of 
 the bladder; and Pierre Dionis (U)5?-1718), who had commenced teach- 
 ing anatomy at the Jardin du Roy in 1673, and in connection with his 
 lessons gave demonstrations of surgical operations on the cadaver. He 
 had many pupils, and his Couis d'operations de Chirurgie, first published 
 at Paris in 1707, went through many editions and was translated into 
 English, Dutch, and German, being a popular manual for fift}' years. 
 He advises the ligature of arteries in amputations, but .says that at the 
 
THE HISTORY AND LITERATURE OF SURGERY. 71 
 
 Hotel Dieu the vitriol button is used instead. He advises the Marian 
 operation in lithotomy, but says that he does not believe the high opera- 
 tion to be so dangeriius as is supposed, and that he is assured tliat AI. 
 Bonnet has often practised this operation at the Hotel Dieu with iiapjiy 
 success. He tells at leugtli tiie story of Frere Jacques up to that date, 
 and apparently very fairly, showing the ignorance of the man, but saying 
 tiiat a surgeon who is a good anatomist may succeed by his method ; Avhicli 
 was true prophecy. 
 
 This Frere Jacques — Jacques de Beaulieu (1651-1719) — was an 
 ignorant peasant who for a time was a servant of an Italian Incisor 
 named Palloni. He became a monk, or, as Dionis says, a sort of a 
 monk, and came to Paris in 1697, as he said, to show the surgeons how 
 to perform lithotomy in a particular way. He was successful at first, 
 and acquired great reputation, but soon had many deaths and left Paris, 
 going ill 1704 to Holland, where he tauglit his method to Rau, who 
 improved it into what is generally known as the lateral operation. 
 Frere Jacques himself improved iiis methods greatly after his visit to 
 Paris, and spent the rest of his life as a wandering lithotomist, chiefly 
 in Austria and Italy. 
 
 There is mucii good reading in Dionis : he does not confine himself 
 to a mere description of the operations, but gives anecdotes which furnish 
 a picture of his times and surroundings. 
 
 Gabriel le Cierc, a surgeon of Lille, ]iublished at Paris in 1092 a 
 little book called La chirurgie complete, being a sort of quiz-coinpend 
 with questions and answers. This became a popular manual, passing 
 througii eighteen editions and translations. He mentions the Hotel-Dieu 
 method of stopping l)leeding arteries by vitriol buttons, and says that it 
 is the custom of the Hotel I)ieu to em])loy a ])erson to keep on the 
 dressing with the hand for twenty-fi)ur hours after the ojieration. 
 
 B. Haviard (1656-1702), surgeon of the Hotel Dieu, published in 
 1702 iiis Nouccau vccn.eU (V observations chirurgieales, which was trans- 
 lated into English and published at London in 1740. This is a valuable 
 collection of cases, containing a description of the tourniquet (using that 
 name) as ap])lied at the Hotel Dieu in 1688 in a case of successful liga- 
 tion of the femoral for a wound of that vessel. He refers to the per- 
 nicious atmosphere of the Hotel Dieu and its eifects on wounds, gives an 
 interesting note on Frfere Jacques, describes a case of dermoid cyst of tiie 
 ovary and one of congenital absence of the penis, and gives details of 
 some remarkable cases of litiiotomy. It is a book worth ha\'ing. 
 
 Rene Jacques Croissant de Garengcot (1 688-1759) publislied his Trctite 
 des operations <ie chirurgie in 1720 (2d ed., 3 vols., in 1731). He was 
 one of the best anatomists and surgeons of his time, and introduced 
 many methods in details of operations for nasal polypus, hare-lip, stran- 
 gulated hernia, etc. 
 
 Alexis Littre (1658-1726), whoso name remains connected with the 
 form of hernia first described by him, was a surgeon who devoted him- 
 self largely to pathological anatomy, and wiiose papers are contained in 
 the Memoirs of the Academy of Surgery. He first proposed the opera- 
 tion of colotomy in 1710. 
 
 Nicolas Andry (1658-1742), dean of the medical faculty of Paris in 
 1724, is known in the history of surgery by his U Orthopedic, ou Vart de 
 
72 THE JITSTORY AND LlTEllATVRE OF SURGERY. 
 
 pvh-enif et de corrir/cr <1>i)is /cs niftinx Irx (llfforiiiiih du corps (Paris, ] 741), 
 being tlie first work in wiiicli tiic word (irtlidpu'ilia is used. It is a ])i)j)- 
 idar treatise on the eare of children, and has very little to do with oi-tlio- 
 piedia as that word is now understood. 
 
 The most distinguished surgeon of the first half of the eighteenth 
 century was Jean Louis Petit (1674-1750), who entered the army at the 
 age of eighteen. In 1700 he settled at Paris and commeneed giving a 
 private eourse of lectures in anatomy and surgery. He invented tiie 
 screw toui'niquet, an appliance of ahnost as nuicii importance as tlie liga- 
 ture to tlie surgeon who iias to ani[)utate with unskilled assistance, devised 
 herniotomy without opening the sac, and made an improvement in tiie 
 circular method of amputation l)y cutting successively the skin and tiie 
 muscles, instead of dividing them at (jne stroke according to the old 
 method. This was carried still further by Desault, who divided the 
 muscles on two levels. To Petit also is due the credit of having first 
 demonstrated the mechanism of the occlusion of arteries in wounds, 
 showing the chief process to be the formation of a clot, a part of which 
 surrounds the end of the vessel and a jiart of which is a plug oceujjying 
 the cavity ; and of giving the first account of moUities ossium. 
 
 After the triumph of the medical faculty over the surgeons and l)ar- 
 ber surgeons in tiie middle of the seventeenth century, the College of St. 
 Come continued to give instruction, although it could not grant degrees, 
 and in 1690 the number of the students was greater than the number of 
 students in medicine, being over seven hundred. It was by no means 
 poor, and in 1691 it began the construction of a new amphitheatre, which 
 was completed in 1694.' In it were given lessons on anatomy and sur- 
 gical operations, and similar teaching was given by a few ambitious young 
 surgeons as a private enterprise. To lieconie a member of St. Come the 
 aspirant must have been an apprentice for at least six years before he 
 could present himself to perform his " grand chef d'ceuvre," which, if 
 successful, would make him a master surgeon. This "grand chef 
 d'teuvre" was a long process of examination. The Washington I^ibrary 
 contains a manual of preparation for it, in the form of a neatly-written 
 manuscript, bound in four volumes, 8vo, " par C. Caulay, recu chirurgien 
 jure le 24 judlet, 1737." 
 
 Fran9ois de Lapeyronie (1678-1747) was a surgeon of Montpellier 
 and demonstrator of anatomy in the School of Medicine. He came to 
 Paris in 1714, soon became surgeon of the Charite, and first surgeon of 
 the king in 1736. He was wealthy, and spent his money freely for the 
 benefit of the Royal Academy of Surgery, which was organized in 1731, 
 increasing in fame and jjrosperity for the next forty years, and through 
 the agency of which, to a considerable extent, Paris became the great 
 surgical centi-e of the world. J. L. Petit became the first director of 
 theacademy, and Sauveur-Francois Morand (1697-1773) its first secre- 
 tary. Morand was an ingenious surgeon. He proposed amputation at 
 the hi])-joint and ovariotomy, and performed the high o])eration for 
 stone, but he was an uneducated man, and Mas unable satisfactorily to 
 perform the duties of secretary of the academy, which post he resigned 
 in 1739. He was succeeded' by Autoine Louis (1723-92), to Avhom 
 the success of the academy and its marked influence on the progress of 
 ' Corlieii : La France Med., 1878, xxv. p. 481. 
 
THE HISTORY AND LITERATURE OF SURGERY. 73 
 
 surgery are to a great extent due. He was professor of physiology, and 
 in 1757 became surgeon of tlie Ciiarite, l>ut he was not so much an 
 •operator or inventor as he was a learned historian, editor, and critie. 
 
 An indispensable work for the student of the history of surgery in 
 France at this period is the collection of eulogies pronounced by Louis 
 upon deceased members of the academy, published with notes and 
 appendices by E. F. Dubois in 1859. These so-called Mo(/cs are judi- 
 cial, critical, historical essays whicli are unt'cpiallcd in surgical luograjiiiy. 
 .A.t the conuneucement of liis eulogy on Le Cat lie remarks that tiiese 
 memoirs will form a part of the liistory of the ^^cademy to be read in 
 years to come, and tliat the truth must be told ; and in this he was a 
 true prophet. His (EVcre.s diccrM's de chlrurgic were published in 1788. 
 
 Of the earlier members of the academy, besides those already named, 
 the most distinguisiied were Le Dran and Le Cat. Henry Fran9ois le 
 Dran (1685-1773), the son of a surgeon, was educated in Paris, and 
 became a master in surgery at the age of twenty-two. In 1724 he was 
 appointed one of the four surgeons of the Charite, and established an 
 anatomical school there, and in 1730 published his Parallele des diffe- 
 rentf'K mnni^re de tirer la pierre hors de la vessie, which gaye him much 
 reputation. In 1734 he was sent as chief surgeon to the army, and pub- 
 lished the result of his obseryatious in 1737 in his Traitc .... ■mr Ics 
 j)l(ii/cn d'armcft a feu, which went througii several editions. In 1742 he 
 j)ublishcd a treatise on operative surgery. Le Dran made no great con- 
 tribution to surgery, but he was a celebrated teacher and had many 
 ])upils from Germany, through whom his method became popular in 
 that country. 
 
 Claude Nicolas le Cat (1700-68) was a surgeon of Rouen, wiio 
 l)ei'ame surgeon-in-chief of tlie Hotel Dieu of that city as the result 
 of concoiu's in 1729. He won many prizes from the Academy of Sur- 
 gery in Paris, being specially skilled in " prize-essay writing," became 
 professor of anatomy and surgery in the school established at Rouen in 
 1736, and attracted many students. He was a voluminous ^vriter, l)ut 
 his papers wiiich relate to litiiotomy are tiie only ones of any special 
 A'alue. His rejnitation was greater abroad than it \vas at home. 
 
 Otlier surgical writers of this period are (Tuillanmc Mauquest de la 
 Motte (1655-1737), whose Trade complet de chirurr/ie (3 vols., Paris, 1 722) 
 was a very popular text-book ; Georges de la Faye (1699-1781), whose 
 Priiicipes de rhirure/ie (Paris, 1739), an elementary handbook, passed 
 through many editions and translations; and Elie Col de Villars (1675- 
 1747), whose ('ours de ehirun/ie a])peared in 173.S. 
 
 Dominicjue Anel (1678-1725 ?), a native of Toulouse, was a pupil of 
 J. L. Petit, a surgeon in the French and Austrian armies, and a wan- 
 derer over Europe. In 1710 he ligated the brachial artery of a priest 
 in Rome for traumatic aneurism, and tliis is claimed as a triumph of 
 Frencli surgery preceding the metiiod of John Hunter. In fict, it was 
 tiie operation performed and dcscril)ed long bef )re by Guillemeau. In 
 Genoa, in 1712, he devised his operation for lachrymal fistula and the 
 syringe \vhich still bears his name. In 1716 he was practising as an 
 eye surgeon in Paris. 
 
 George Arnaud de Ronsil, a French surgeon, went to London prior 
 to 1748, and remained there until his deatii in 1774. His Dissertation 
 
74 THE HISTORY AND LITEUATUBE OF SURGERY. 
 
 on Hernia (London, 1748) was a ])a))t'r of niiioli importance. His 
 Memoires de chirurf/le (London, 1702, 2 vols. 4to) cdntains matter of 
 permanent value, and a curious paper, " Inconveniens des Descentes par- 
 ticuliers aux Pretres de l'£glise Komaine," with reference to Leviticus 
 xxi. 20. In 1732 he excised the caecum and a part of the colon and 
 ileum in a case of hernia. 
 
 Jean Baseilhac (1703-81), better known as Frere Come, was the son 
 of a surt;eon and was educated as such. In 1729 he became a monk, 
 but continued to practise surgery among the poor, and invented the 
 lithotome cache. He published anonymously in 1751 an account of 
 his operation, and in 1779 published a paper on the high operation. 
 He was a skilful surgeon, and obtained greater success with his instru- 
 ment than any other person has been able to do. 
 
 Pierre Brasdor (1721-97) was professor of anatomy and operative 
 surgery in the College of Surgeons of Paris, and contril)uted to the 
 Memoirs of the Academy of Surgery. His name is remembered in con- 
 nection with his suggestion to treat certain aneurisms by ligation of the 
 artery on the distal side of the tumor ; which was first done by Wardrop. 
 
 Francis G. Ijcvacher published in the Memoirs of the Academy of 
 Surgery, in 17(j9, a paper on gunshot wounds, in which lie, for the tirst 
 time, showed that what were sujiposed to be the effects of the wind of a 
 ball were really due to the ball itself. 
 
 Hugues Ravaton, a surgeon of the French army, published in 1750 
 the best treatise on gunshot wounds which had yet appeared. His 
 Chinirgie rVarm^e was issued in 17(j7, and his Pratique moderne de la 
 ehintrgie in 1770. He was the first to practise amputation by the 
 double-flap method. 
 
 Jean Joseph Sue (1710-92), son of a Paris surgeon, and often men- 
 tioned as "Sue le jeune," was a teacher of anatomy, and in 1761 one of 
 the surgeons of the Charite. He published £lemenh de chirurgie (Paris, 
 1755), Traite des bandages (Paris, 1761), and Dictionnaire posifif de 
 chirurgie (Paris, 1779). 
 
 Jean Louis Belloq (1730-1807), a professor of anatomy in Paris, 
 devised a number of instruments, among which was the canula for 
 plugging the posterior nares still known by his name. 
 
 In the latter part of the century the leading surgeon in Paris was 
 Pierre Joseph Desault (1744-95), who became surgeon of the Hotel 
 Dieu in 1788, and soon had a crowd of students following his public 
 clinic, the like of which had never been seen before. He was a pupil 
 of Louis and of Morand, and surgeon of the Charite in 1782. He 
 ■was the first teacher of surgical anatomy in the modern sense of the 
 term, made many improvements in the treatment of fractures, and con- 
 tributed largely to the perfecting of surgical technique. He wrote 
 almost nothing, but his pupil, Bichat, gave the substance of his teach- 
 ings in the CEuvres chirurgimles (3 vols., 1798-1803). In 1792, Desault 
 was arrested on the charge of having poisoned the wounds of some of the 
 revolutionists who had been brought to the Hotel Dieu. It was then but 
 a step from the prison to the scaffold, and his pupils formed themselves 
 into a deputation to defend him before the tribunal, their spokesman 
 being Jean Pierre Maunoir, a young Swiss, afterward a celebrated sur- 
 geon in Geneva, whose pleadings prevailed and Desault was released. 
 
THE HISTORY AND LITERATURE OF SURGERY. 75 
 
 The Hotel Dieu of Paris was the " oldest, largest, richest, and worst 
 hospital in Europe." In the latter part of the eighteenth century it con- 
 tained over twelve hundred l>eds, and sometimes over three thousand 
 patients, having four or five in one bed. The first distinct mention of 
 surgeons in the Hotel Dieu occurs in the records of the year 1539, in 
 which it is ordex-ed that the surgeon Jocot la Normand shall be retained 
 to serve as surgeon in the Hotel Dieu in place of George Barbas at a 
 salary of about one hunilred antl eighty francs. By declai'ation of the 
 managers in 1(505 the surgeon nuist call a physician to see all the opera- 
 tions of surgery which he shall make witliin the Hotel Dieu. 
 
 In 165-1, Jacques Petit, master of surgery in Paris, was named sur- 
 geon of the Hotel Dieu. This was an invasion, for up to that time the 
 surgeons had been chosen from among tlie surgeons of the hospital. 
 This Jacques Petit gave a course of anatomy to the pupils in the hos- 
 pital, commenced the collection of instruments of surgery, and gave a 
 sort of course of surgery at the liedside. Tliis was tiie beginning of 
 clinical surgery in this hospital and in France. He entered the hotel 
 at the age of thirteen, studied sui'gery there, and filled the place of sur- 
 geon-in-chief until 1705. The story was that he was more than sixty 
 years in the house without putting his foot outside of it. 
 
 He was succeeded in 1 705 by Mery, one of the most celebrated of 
 the surgeons of this period. Mery was succeeded in 1722 by Thibault, 
 he by Pierre Boudou, and he by Moreau, who was succeeded by Desault 
 in 1786. Desault was succeeded by Pelletan in 1795. 
 
 The records of the Hotel Dieu which escaped the fire of 1871 have 
 been published by the Bureau of Public Assistance under the title Col- 
 lection ill' ilocHincnis pour acvrir <), I'hixfoire des hopitaii.v de Paris (Paris, 
 18S1-S7). In the second of these volumes, pul)lished in 1883, are given 
 the deliberations of the governors of this hospital for the years 1768 to 
 1791, at the time when the hospital was badly overcrowded and com- 
 plaints were being made by the surgeons of the management of the 
 institution. Among other things, it contains a copy of the memoir of 
 the Sisters in charge of the hospital, who in 1 789 made a complaint 
 against Desault to the effect that he was bringing pupils from tiie out- 
 side into the amphitheatre, which should be reserved for the pupils of 
 the hospital alone, that the dressing of wounds was being interfered 
 with, and that from two to three hundred strangers were admitted every 
 day to hear iiis lectures. To this there is a long reply by Desault, show- 
 ing that tlie complaints were in part ill founded, and urging that it is 
 contrary to the public good to confine clinical instruction to the pu))ils 
 resident in the house. The matter was investigated and the decision 
 was given in favor of Desault. A very interesting description of the 
 old Hotel Dieu, showing the arrangement and character of the beds and 
 furniture, overcrowding, etc., is given by Dr. J. B. Tenon (1724-1816) 
 in his Mciiwires stir les hopitau.v dc Pari.i (1788, 4to). 
 
 Francois Chopart (1743-95) became professor in 1771, and in 1780 
 published, with Desault, the Traite de.s maladies chirurgicales et des 
 operations, etc., which contains some of Desault's views, but which was 
 wholly written by Chopart. His name remains connected with a form 
 of partial amputation of the foot first described in 1792. 
 
 Raphael Bicnvenu Sabatier (1732-1811) was a pupil of Petit, and 
 
76 THE HISTOllY AM) LITERATURE OF SURGERY. 
 
 hceanie professor of anatomy in the Royal College of Surgery. His 
 princi])al work was his Dc hi m/'rhrinc ojjeratoire (ti voh., 1 7!).S-1S10). 
 
 J. Fr. l>('S('hanip.'< ( 1740-1X24), a ])M|)il of Moreau and surgeon of 
 till' diarite, l)rought tiie Hunterian ojteration for aneurism into notiee 
 in France, and published an interesting historical treatise on lithotomy 
 in 1796. 
 
 Francois Quesnay (l(;fl4-1774), secretary of the Academy of Surgery, 
 wrote a work on the iiistorv of surgery in I'^'auce wliich is full of errors. 
 
 Antoine Portal (1742-18;52), professor of anatomy in the Royal Col- 
 lege of France, is the author of Hidoire dc P anntomie et de la chirurgie, 
 etc. (7 vols., Paris, 177()-7o), which is a useful book of reference. 
 
 Jean Rene Sigault studied surgery at Paris, and was received as mas- 
 ter in the school in 1770. In 1768 he presented a memoir to the Royal 
 Academy of Surgery proposing to substitute the section of the symphysis 
 of tiie pubis for the Ctesarian section. The proposal was not aj)j)roved, 
 but he performed the operation in 1777 with success, and, as he had 
 become a doctor of the Faculty of Medicine, his new operation was 
 received with great enthusiasm by the members of the faculty. He 
 ])ublislied his Memoire [xur la section de la sipnphyse des os pubis, 
 pratiqia'c sur la femme Soiu-hot'\, lu aii.r assemblees dii 3 d du 6 decembre, 
 1777 (16 pp. 4to, Paris, 1777), and Discours sur les avanfar/cs de la 
 section de la symj^lujse (8vo, Paris, 1778). 
 
 Georg Fischer, in his Chirurgie vor 100 Jahrcn (Leipzig, 1876), has 
 given a graphic picture of the condition of surgery and surgeons in 
 Germany in the eighteenth century. The great mass of the ]>eople 
 <H)nld only obtain surgical treatment from local liarbers or from wander- 
 ing charlatans. The barber's apprentice could hardly write or even 
 read German. He learned how to shave, and then ^\•ent from house 
 to house to serve his master's clients. He was also taught how to 
 sharpen knives, sjiread blisters, and make lint. He performed the most 
 menial duties in the house, and occasionally one of the unhappy youths 
 ran away and was duly advertised as a sort of runa\\ay slave. The 
 people were grossly ignorant and intensely superstitious, lielieving in 
 charms and magic ; and the supply of this kind of medicine was not 
 wanting. The cutters for stone and hernia, the cataract-operators, the 
 bone-setters, and the travelling charlatans flourished everywhere, and 
 the repeated edicts and ordinances issued by kings, nol)les, and city 
 autiiorities to remove the complaints made by the physicians and to settle 
 the ditticulties merely prove the condition of the times and seem to have 
 had very little etfect. Even the executioners competed witli the sur- 
 geons. They were supposed to have special dealings with the powers 
 of evil, and in consequence to have special knowledge of the means of 
 curing diseases considereil to be due to witchcraft. A part of their busi- 
 ness was to dislocate joints l)y the rack or to break bones ujxm the wheel, 
 and hence it was supposed that they had special skill in the repair of 
 fractures or of dislocations. 
 
 The practice of medicine was forbidden to the executioners in Prussia, 
 but in the year 1744 Frederick the Great granted to them permission to 
 treat fractures, wounds, and ulcers, and \\\\q\\ the Berlin surgeons com- 
 plained of this he issued an order saying that he had not ]>ermitted all 
 executioners, Init only the skilful ones, to practise, and if tlie surgeons 
 
THE HISTORY AND LITERATURE OF SURGERY. 77 
 
 are as skilful as they pretend to be, every one will rather trust them than 
 go to an executioner ; but if the surgeons are ignoramuses, the public 
 must not sutfer, but must submit to be treated by the executioner rather 
 than to remain lame and crippled. 
 
 In Germany the first surgeon of importance in the eighteenth century 
 was Lorenz Heister (1683-1758), a native of P'rankfort-on-the-Maiu. 
 After studying medicine for four years at Giesseu and other German 
 universities, he went to Amsterdam in 1706 to study anatomy and sur- 
 gery under Ruysch and Ran, and took his degree at Leydcn in 1708. 
 He gained experience in the army hos])itals at Brabant and Flanders, 
 made a tour into Great Britain, and in 1710 became professor of anatomy 
 and surgery in tiie University of Altdorf Here he lectured in Latin, l)ut 
 found the students and young surgeons so ignorant that he determined to 
 print his system of surgery first in German, which he did at Nuremberg 
 in 1718, as he states in his preface to later editions, and as given in bibli- 
 ographies. I have, however, never been able to see a copy of this date, 
 the earliest edition in the Washington Library having the imprint " Niirn- 
 berg, bey .loluuin Hoffmanns seel. Erbeu, im Jahr nidcexix." The work 
 was a very ])i)pular one, and M'as translated into Latin, and thence into 
 English under the title of A general Hystem of surgery (1743; 7th ed. 
 1759), forming a thick quarto which is still excellent reading for a 
 surgeon. Sharp saj^s, in the preface of his Critical enquiry (1750), 
 " Heister's Surgery is in every body's hands, and the character of 
 Heister is so well established in England, that any account of that 
 work is needless." 
 
 The other German university professors of surgery in the first half 
 of the eighteenth century who are worthy of note are Haller, Platner, 
 Mauchart, and Bass. 
 
 xVlbrecht von Haller (1708-77), a native of Bern, a pupil of Boer- 
 haave, and one of the greatest physicians wlio ever lived, was professor 
 of anatomy and surger}' in the University of Gottingen from 17.36 to 
 1753, and exerted a powerful influence on the development of anatomy, 
 jihysiology, and surgery through his \vritings and his pupils, who came 
 to him from all parts of Europe. He never performed a surgical opera- 
 tion on the living body, and his teaching in stu'gery was therefore purely 
 theoretical. His Bihliofbcca chirurgica (2 vols., Berne, 1774-75) is the 
 most valual)le work on the history and literature of surgery that has ever 
 been published. He placed on a firm foundation the experimental method 
 in dealing with surgical problems wdiich was a little later so successfully 
 employed by .Tohu Hunter, and which has contributed so much to our 
 kno\vle(lge during the present century. 
 
 Johann Zacharias Platner (l()!t4-1747) was ])rofessor of auatomv and 
 surgery in the University of Leipzig from 1724 until his death. His 
 Iniiiitutiones chirurgice rationales turn medica', etc. (Leipzig, 1745) jiassed 
 through several editions and was trn-islatcd into German and Dutch. 
 
 Burchard David Mauchart (1696-1 751) studied at Tiibingen, Altdorf, 
 and Paris, and became professor of auatoiuv and surgcrv in the Univer- 
 sity of Tiibingen in 1726. He devoted himself chiefly to the anatomy 
 and diseases of the eye, and left no systematic treatise, but published a 
 nund)er of dissertations, which were collected after his death and pub- 
 lished in three volumes (Tubingen, 1783-86). 
 
78 THE IIISTORY AND LITERATURE OE SUROERY. 
 
 Hi'inric'li Bass (1670-1754) bccamo professor of surgery in the Uni- 
 versity of Halle in 1718, and in 1720 ])ul)lislK'(l his (irihullirlier Bfrivht 
 von Ji<iii(1ii</('ii, which was a favorite text-hook for the next fifty years. 
 
 The <;reat ditht'iilty experieneed liy the trovernnient in providinfr 
 eom])etent surgeons for the troops led to tiie organization in 1724, at 
 lierlin, of a niedieo-ehirurgical college, the Friedrieh Wilhelnis Institut. 
 In 1727 the Charite Hospital was fonnded by King Friedrieh Wilhelni I., 
 mainly to furnish clinical instruction to the students of this college. The 
 supply, however, was not equal to the demand, for Frederick 11. in his 
 Silesian campaigns found an urgent need for skilled surgeons, and sent 
 some of his young officers to Paris and Strasburg to perfect tlieir educa- 
 tion and to fit themselves to instruct others, and in 1743 he engaged 
 twelve French surgeons and assistants for the benefit of his troops. The 
 results were not altogether satisfactory, because surgery M'as generally 
 considered to be distinct from and inferior to medicine ; those who were 
 destined to it were usually apprenticed to barbers, and the young sur- 
 geons were, as a rule, men of an inferior class and of little education. 
 Finally, in 1795, as the result of urgent appeals from Gorcke, the sur- 
 geon-general of the Prussian army, the college was reorganized under 
 the name of the Pe]>iniere, and was devoted exclusively to the education 
 of medical offic'ers for the army, retaining a special connection with the 
 Charite.' An institution similar to the Pepiniere, and for the same pur- 
 pose, was organized in Dresden in 1748 as the "Collegium Medico- 
 chirurgicum." - 
 
 The three German military surgeons of chief repute during this period 
 were Schmuckor, Bilguer, and Theden. 
 
 Johann Lebrecht Schmucker (1712-86) was educated at the Pepiniere, 
 and sent to Paris for two years by the king to study under Le Dran. 
 He became the surgeon-general of the army, and pnljlished the results 
 of his experience in his Chirurgischc Wahntchmungcn (2 parts, 1774) 
 and Vermisohte chirurgische Schriften (3 vols., Berlin, 1776-82). His 
 observations on wounds of the head and trephining and on amputations 
 are the most valuable of his writings. 
 
 Joh. Ulrich Bilguer (1720-96) studied at Strasburg and Paris, and 
 entered the army in 1741. In 1757 he became the second surgeon- 
 general. In 1761 he published his />(■ mernhrorum ampufatione rarissime 
 administranda, etc., which passed through numerous editions. In this he 
 opposed the excessive tendency to amputation of his time, which was 
 rather encouraged by Schmucker, and went to the other extreme. His 
 Chinirglsche Wahrnehinungrn (Berlin, 1763; translated into English, 
 London, 1764) is his most important work. 
 
 Joh. Christ. Anton Theden (1714-97) was educated as a barber sur- 
 geon, entered the army in 1737, and became third surgeon-general in 
 1758 and first surgeon-general in 1786. His Neue Bemerkungen mid 
 Erfahrungen zur Bcrcichcriing der Wundarzneykunst mid 3Icdicin (pub- 
 lished in 1771 and later editions, also in a French translation) contains 
 accounts of some remarkable cases and surgical methods — so remarkable, 
 
 ' For details consult Das Konigl. preus. Med.-chir. Friedrieh Wilhdms Institut, von D. 
 E. Prenss, Berlin, 1819, 8vo. 
 
 ' For the history oi^ this see Das Kom'glich scichsische Collegium Medieo-chirurgicmn, von 
 Dr. H. Fr51ich, im Der Feklarzt, AVien, 1877, No. 9. 
 
THE HISTORY AND LITERATURE OF SirROERY. 79 
 
 in fact, as to excite some suspicion. For tlie ligature of arteries in am- 
 putation he substituted graduated compresses and tiie use of a certain 
 wonderful lotion, the " arquebusade," composed of vinegar, alcohol, sugar, 
 and dilute sulphuric acid, with some salt of lead. He strongly advocated 
 methodical bandaging of the extremities, claiming by its use to have 
 cured aneurism, varix, etc' 
 
 In the last half of the century the two chief German surgeons were 
 Von Siel)old and Richter. 
 
 Carl Casper von Siebold (1736-1807), the son and apprentice of a 
 surgeon, served for a time in French hospitals, and studied in Paris 
 under Morand and in I^ondon under Pott and Bromfield. In 1769 lie 
 became professor of anatomy, surgery, and obstetrics at AViirzljurg, and 
 soon acquired great reputation as an operator and clinical teacher. He 
 was succeeded as professor and as surgeon of the Julian Hospital by his 
 son. Job. Barth. Siebold (1774-1814), who founded a journal called 
 Chiron, devoted to surgery. 
 
 August Gottlieb Richter (1742-1812) became professor of surgery in 
 Gottingen in 1766, and gave a new impulse to the study of that art in 
 Germany, l)eing the tirst to jilace it on a scientific basis. He was the 
 best teacher of surgery in Germany in his day, had travelled extensively, 
 was familiar with the good work then going on in France and England, 
 and was an excellent writer. His Ahhandhmg von den Bruehcn 
 (1777-79) was the best book on hernia up to that date, and is still 
 a classic. His history of surgery, Anfaiu/.'^;/ri'in<1e den WundarzncifkiDist 
 (7 vols., 1782-1804), is a model in arrangement and style, but is not 
 complete. His journal, the Chirurgische Bibliothck (15 vols., 1771-96), 
 did more to develop surgery in Germany than any previous agency. 
 
 In Austria there is little worthy of note in the history of surgery 
 until the latter part of the century. Gerard van Swieten (1700-72), a 
 pui>il and friend of Boerhaave, went to Vienna in 1745 and introduced 
 clinical instruction, but the only surgeon of repute there in 1780 was 
 Ferdinand von Leber, who is principally known by the investigation 
 which he made upon the use of torture in jurisi)rudenee. In 1785 the 
 Military Medico-Chirurgical Akademie was founded by the emperor 
 Joseph II. and placed under the direction of Brambilla, the object being 
 the «nne as that of tlie Berlin Pepiniere. It was connected with a hos- 
 pital of twelve hundred Ix'ds, and received one hundred pupils, of whom 
 twenty-four were residents in the house. The course of study was two 
 years, and after passing the examination the student received the degree 
 of doctor in surgery and the first vacant position in a regiment. 
 
 Giovanni Alessandro Brambilla (1728-1800) was an Italian who had 
 studied in Pavia, and liecame a surgeon in the Austrian army and a special 
 favorite of the emperor. He pi-epared the Insfnikiion fur die Profes- 
 soren der k. h. chirurf/isriioi Militurakademie (Wien, 1784, 4to) and the 
 Instrukfiun fur das k. k. Jlilitdrnpital zu Wicn (Wien, 1784, 4to), which 
 are curiosities in literature. The subjects and the order of the subjects 
 to be taught are scheduled for each professor. He also published a 
 large atlas of engravings of surgical instruments and a history of dis- 
 coveries made by Italian anatomists and physicians, and exerted a power- 
 
 ' For details as to the military surgery of these times see Die Krieys-Chiruryie der 
 letzcn ISO Jahre in Preussen, von Dr. E. Gurft, Berlin, 1876. 
 
80 THE JirSTORY AND LITERATURE OF SURGERY. 
 
 fill iiillucncc upon tlic j)i'()trress of surfriciil education, ;iltli()ii;;li ho made 
 no special imj)rovenients himself. A proteg6 of Branil)illa was Joh. 
 Nejionuik Ilunezovsky (1752-98), a barber's apprentice, who in 1781 
 was ap])(>inted professor in the military medical school at (iumpendorf, 
 and published a compendium of surgical operations in 178'), of which 
 there were three later editions. 
 
 iVt the commencement of the eiffhteenth century Holland was a great 
 centre of medical instruction : Boerhaave had introduced clinical teach- 
 ing at Leyden, where Bidloo was also lecturing ; Ruysch and Rau were 
 teaching in Amsterdam, and all who desired a complete education in 
 surgery visited these schools. 
 
 Frederik Ruysch (Ki.'^iS-l 731 ) commi'nceil teaching anatomy in Ley- 
 den in l()(j(), and became famous for the jicrfection of his anatomical 
 preparations, and especially for his injected prejiarations. His collection 
 was purchased by the czar, Peter the Great, but a part of it was lost 
 before it reached St. Petersburg. His numerous essays relate chiefly to 
 anatomy, iiut contain some surgical observations. 
 
 Joh. Jac. Rau (l()(iS-1719), a native of Baden and an a])])rentic.e of 
 a barber surgeon in Strasburg, studied at Leyden and Paris and settled 
 in Amsterdam, where he gave lessons in anatomy and surgery, to the 
 great dissatisfactiou of Ruysch. Having learned from Frere Jacques 
 his method, he improved ujion it and acquired great fame as a lithoto- 
 mist, but kept secret the details of his method, which was p7-ol)ably the 
 lateral o]teration. He wrote nothing of importance, but had many dis- 
 tinguisiied pupils. 
 
 To this period belong Abram Titsingh (1685-?) of Amsterdam, city 
 surgeon, surgeon of the admiralty, and master of the Surgeons' Guild, who 
 wrote works on lithotomy, spina l)itida, venereal diseases, etc. which 
 were valuable in their day; Joh. Daniel Schlichting (1703-?), a lecturer 
 on anatomy and surgery in Amsterdam in the middle of the century, 
 said to have been the first to perform neurotomy for neuralgia of the 
 fifth pair; Jos. Monnikhof (1707-87), appointed herniotomist of Am- 
 sterdam in 1752, who in 1775 published statistics of one thousand cases 
 of hernia, the first collection of this kind which had appeared ; and 
 Charles Faudacc] (1691-175 ?) of Namur, who studied in Paris under 
 Petit, and published Rtlftcxiom sur lex ]j/ai/cx, etc. (Nanuir, 1735), and 
 Noarcau traite dcs pinics crarmcs-d-fci( (Namur, 174(i). 
 
 In Ghent the leading surgeon was Joh. Palfyn (l(i5O-1730), educated 
 in Paris, master of the Barber-Surgeons' Comj^any in Ghent in 1698, and 
 professor of anatomy and surgery in 1708. He is best known by his 
 Anatomic Chirun/ienlc, first published at Paris in 1726, and the first 
 treatise with the title of " Surgical Anatomy." 
 
 In the last half of the century the most celebrated teacher in Hol- 
 land was Peter Camper (1722-89), a native of Ijeyden, who became pro- 
 fessor of anatomy and surgery in Amsterdam in 1755 and professor in 
 Groningen in 17(33. He was one of the most learned men of his time, 
 and a voluminous writer on anatomy, pathology, and medical jurispru- 
 dence. His treatise on calculus (1782), his dissertation on fracture of the 
 patella and olecranon (1789), and his Irones hcrniarum, ])ublished after 
 his death by Soemmering, are valuable contributions to surgical literature. 
 
 Among the Italian surgeons of the eighteenth century the best 
 
THE HISTORY AXD LITERATURE OF SUROERV. SI 
 
 known are Benovoli, tlu' two Xannonis, Lancisi, A^alsalva, Tacconi, 
 ami Bertrandi. 
 
 Antonio Jiencvoli (1(385-1756), a surgeon of Florence, discovered in 
 1722 that eataract is an opacity of the lens, and published his I>l-tcorsi 
 (U chirurr/id in 1750. He discovered the principle of treating stricture 
 of the urethra by dilatation. 
 
 Angelo Xannoni (1715-90) studied in Florence under Bcnevoli, and 
 afterward in Paris and Rouen, and became chief surgeon of the hos- 
 pital Santa Maria Xuova in Florence, attaining great rejiutation. His 
 principal works are Trattafo chirtdr/ico sopru la ficiDpHcita del iiiedicnre 
 i malt d'aftenenza della chirurgia (1770) imd Jlemorie sopra aleani ca-d 
 rnri di chirurqia (1776). 
 
 Lorenzo Nannoni (1749-1812), son of Angelo, studied under his 
 father, and became surgeon to the Hospital of the Innocents in Flor- 
 ence, where he g-ave clinical teaching. His ])rincipal work is Trattafo 
 delle malcric cliirinr/ichc, tie. (2d ed. •'} vols., 1793-94). 
 
 Giovanni ilaria Lancisi (1654-1720), professor of anatomy at Rome 
 and physician to Popes Innocent XL and XII., is best known as an 
 anatomist, but in his De molu cordis et aneurt/smatihiis, first published 
 after his death in 1728, and in four later editions, he first clearly pointed 
 out the difference between true and false aneurism. 
 
 Antonio Maria Valsalva (1666-1723) studied at Bologna, graduating 
 in 1687, and became professor of anatomy in the university and sur- 
 geon to the Hospital of the Incurables in 1697. His chief work was 
 De awe humana tractatus (1705). 
 
 Gaetano Tacconi (1689-1782), a native of Bologna, succeeded Val- 
 salva as professor, and was surgeon to the hospital Santa Maria. He 
 wrote Kofizia dclla fcrifa e della ciira chlrurglca seguita, etc. (1738), and 
 De rarls qnihuftdatn hcrniis, etc. (1751). 
 
 Giovanni Ambrogio Bertrandi (1723-65), son of a surgeon, studied at 
 Turin and Paris, and in 1758 succeeded Lotteri as professor of surgery 
 at Turin. His principal work is his Trattato delle operazioni di chi- 
 rurgia (2 vols., 176."?), which ]iassed through several editions and was 
 translated into French and German. His collected works, Opere 
 an(doiiiiche e ccrusiche, w'ere published after his death in fourteen 
 volumes (1786-1802). 
 
 At the beginning of the eighteenth century there were few edticated 
 surgeons in London, and still fewer in the provincial towns ; there was 
 no special instruction in siirgerv to be obtained except through appren- 
 ticeship ; and the facilities for studying anatomy were extremely limited.' 
 When the monasteries were broken up by Henry VIII. the hospitals, 
 which had previously liclongcd to the Church, became the proj)erty of 
 the government. St. Bartholomew's was refounded in 1544, and placed 
 under the superintendence of Thomas Vieary. This hospital had one 
 physician and three surgeons, and these allowed tlieir pupils and appren- 
 tices to attend and witness the practice. In 1()62 there is mention of 
 the presence of such students, hut no formal system of lectures or teacli- 
 ing seems to have existed until after 1734, when leave was granted for 
 
 ' See The present state nf chyrurgeri/, by T. D. (Loniion, 1703i, in wliicli, amoiif; otlier 
 charlatans, reference is made to "The Unborn Doctor who cut off a vast number of 
 women's breasts without loss of blood.' 
 Vol. I.— 6 
 
82 THE HISTORY AND LITERATURE OF SURGERY. 
 
 any of tlic surgeons or assistant snrfjcons to road lectures in anatomy in 
 the dissecting-room of the hospital, and in 17(j.3 a course of lectures on 
 surgery was commenced by Percival I'ott. 
 
 At St. Thomas's Hospital tlie first mention of an ap])rentiee in the 
 books is in 1561. The Barber Surgeons' Company was diss;itisfied with 
 the teaching in St. Bartholomew's and St. Thomas's hospitals, as it was 
 losing money thereby, and in 1695 it made a special investigation into 
 the complaints as to the manner of teaching in these hosjMtals, tlie sur- 
 geons to which declared that they had never taken an ajjprentice for a 
 less term than seven years, but that some of the apj)rentices of other sur- 
 geons were allowed at times to witness their practice. In 1702 the gov- 
 ernors of St. Thomas's Hospital took the matter of teaching into their 
 own hands, and passed a law forbidding ])U])ils or surgeons to dissect 
 without permission of the treasurer. In 1703 it was resolved that 
 no surgeon should have more than three " Cubbs ;" in 1758 this term 
 was altered to that of " Dressers." Lectures on anatomy and surgery 
 began with C'heselden about 1720, and the Anatomical School may be 
 said to have been fairly established about 1780.' 
 
 At the London Hospital the entry of the first student was in 1742, 
 two years after the commencement of the hospital, and the Medical 
 School was fully organized upon the model of the Edinburgh Faculty 
 in 1785. 
 
 In the Orders of St. Bartholomew, dated 1633, it is directed " that no 
 cliirurgeon, or his man, doe trepan the head, dismember, or j)erform any 
 great oper'con, but with the approbation or by the direction of the doc- 
 tor." Special operators were appointed to cut for the stone at the hos- 
 pitals, a Mr. Mullins doing this for St. Bartholomew's and St. Thomas's. 
 
 The ^ledical School of Guy's Hospital dates from 1769, in which 
 year a resolution was jiassed by the governors that all surgeons of the 
 hospital should occasionally give lectures to tlie pupils. It is also noted : 
 " No persons are to be entertained as pupils but such as have served five 
 years to a regular Surgeon or Apothecary." At this time the schools of 
 Guy's and of St. Thomas's were united, the surgical lectures being given 
 at St. Thomas's and the medical at Guv's, and the two M-ere known as 
 the "United Hospitals." ^ 
 
 The ill-assorted union of sury-eons and barl)ers formed by the act of 
 1540 was by no means harmonious, but the surgeons were unable to get 
 rid of the barbers imtil 1745, when they agreed with Mr. Ranby, Serjeant 
 surgeon to the king, that he should procure the act of Parliament desired, 
 and that in return lie should be made a member and be elected as master. 
 The act of 1745, incorporating the "Masters, Governors, and G(aiinion- 
 alty of the Art and Science of Surgeons of London," pro^•ided that it 
 should be governed by a " court of assistants, composed of twenty-one 
 members, whose office was for life, and who filled their own vacancies 
 by election from the freemen of the comjiany." Ten of this court of 
 assistants were to be " examiners," whose office was also for life, and it 
 was a penal offence for any one to practise surgery in London or within 
 seven miles of the same without having been duly examined and licensed, 
 
 ' See Prospectus, 1877-78, p. 11. 
 
 '' See A Biographical History of Guy's Hospital, hy S. Wilks and G. T. Bettany 
 (London, 1892). 
 
THE HISTORY AXD LITERATURE OF SURGERY. 83 
 
 except tliat the rights of members of the College of Physicians to do so 
 were not to be interfered with. The surgeons on their separation from 
 the barbers took nothing witii tliem except the Arris and Gale becpiests ; 
 tiie iiall, HItrary, and plate remained with the barbers, and the new com- 
 pany had to i)rovide a building lor itself. 
 
 The condition of the company in 1790, as stated by ISIr. Gunning, 
 the master of the company, in his address at the close of his term of 
 office, was as follows : " You have a theatre for your lectures, a room for 
 a Library, a connnittee-room for your Court, a large room for the recep- 
 tion of your committees, together with the necessary accommodation for 
 
 your Clerk Your theatre is \\ithout lectures, your library room 
 
 without books is converted into an office for your clerk, and your com- 
 mittee room is become his parlour, and is not always used even in your 
 common business, and when it is thus made use of it is seldom in a fit 
 and proper state." The next thing tliat appears in its history is a charter 
 by George III., dated 1800, for consolidating tlie Royal College of iSur- 
 geons of London, in the preamble of which it is stated that "we are 
 informed tiiat the said Corporation of Masters, Governors, and Com- 
 monalty of the Art and Science of Surgery of London hath become 
 and is now dissolved." This charter of 1800 simply reiterates the act 
 of 1745. 
 
 Turning now to Scotland, we find tiiat, in 1694, Dr. Archibald Pit- 
 cairn returned to Edinburgh from Leyden and endeavored to establish a 
 medical scliool, which lie intended, if possible, should surpass tiiat of 
 Leyden ; and his first step was to induce a surgeon named Monteith to 
 apply to the town council for a grant of dead bodies. As soon as the 
 other surgeons heard of this, tiiey also applied for tiie .same privilege. 
 The privilege granted to the surgeons had a clause to the eftect " that 
 the petitioners shall before the term Michaelmas, 1697, build, repair, and 
 have in readiness one anatomical theatre, M'here tiiev shall once a year 
 (a subject ottering) have one public anatomical dissection, as much as 
 can be shown upon one body, and if the ftulzie, this presents to be void 
 and null." This condition was complied witli, and as the grant required 
 that the body should be buried within ten days, tiie surgeons selected 
 ten of their number, termed " operators," each of wiiom lectured one day 
 on certain specified parts. In 1705 this .system was changed, and one 
 surgeon performed the duty, wiiile the town council made this same sur- 
 geon professor of anatomy in the university. This was the commence- 
 ment of the Medical School, altliough it was not until 1726 that it was 
 fully formed througli the influence of John Monro, an army surgeon 
 who had settled in Edinl)urgli in 1700. 
 
 The leading surgeon in England in the first half of the eighteenth 
 century was William Cheselden (1688-1752), a pupil of William Cowper, 
 who began to lecture on anatomy in 1711 in his own house, and continued 
 his teaching afterwairl at St. Thomas's Hospital, to which he was 
 ap[)ointed assistant surgeon in 1718 and surgeon in 1719. In 1723 
 he published his Treatise on the high operation for the fitoiie. Soon after 
 he gave up this and perfected liis "lateral operation for the stone," an 
 improvement on tiie method of Frere Jacques and Ran, whicii soon 
 became famous. He publisiied a paper in the Philosophical Transactions 
 on the formation of artificial pujiil, wiiicli operation he was the first to 
 
84 THE HISTORY AND LITERATUltK OF SURGERY. 
 
 ]icrf()rm. In 1733 he became surgeon to St. George's Hospital at its 
 loiiiidation, retired from St. Thomas's in 1738, and was one of the hist 
 wardt'Ms of tlie 15arher 8ui'geoiis' ('ompany immediately before the sepa- 
 ration of the surgeons and liaiiiei-s, whieii took place in 1744-45. 
 
 His pupil, Sanuiel Sharp (1700-78), was elected surgeon to Guy's 
 Hospital in 1733. His Treatise on the ojxrations of surgery (London, 
 1739 ; lOtli ed., 1782) and his Critical inquiry into the present state 
 of sinyery (London, 1750 and 1761, and translated into French, S])anish, 
 and German) were celeljrated in tiieir day, and the Critical iia/niry is 
 still a most interesting book to the surgeon. He devised the cylindrical 
 form of the crown of the trephine at jiresent used, and contributed to 
 the knowledge of the anatomy of hernia. 
 
 William Bromfield (1712-92), surgeon to St. George's Hospital and 
 surgeon to the king, published his L'hirurgical observations and cases, in 
 two volumes, in 1773. These contain a number of valuable improvements 
 in surgical methods, particularly as to bilateral lithotomy and the com- 
 pression of the subclavian artery above the clavicle on the first rib. He 
 also clearly points out the proper manner of ligating the artery in ampu- 
 tations, using the tenaculum to draw out the vessel, so that the nerve and 
 other tissues should not be included, but he used a flat ligature. That 
 he was a cool operator is shown in a case of lithotomy which he reports 
 in the second volume at ])age 266, in which the intestines protruded into 
 the bladder, and in which he first extracted three stones and then returned 
 the intestines, with result of a perfect cure. 
 
 William Beckett (1684-1738), a London surgeon, wrote Practical 
 surgery illustrated and improved : being chirurc/ical observations .... made 
 at St. Thomas's Hospital (London, 1740, 8vo), also A collection of chirur- 
 gical tracts (London, 1740, 8vo), including a paper on new discoveries 
 relating to the cure of cancers, published by him in 1711. 
 
 Benjamin Gooch, a surgeon of the Norfolk and Norwich Hospital in 
 1771, published a volume of Cases and praciical remarks in surgery 
 (London, 1758), and a collective edition of his works appeared in three 
 volumes (London, 1792). He taught that in case of a wound of an 
 artei'v ligatures must lie apjilied both aliovc and below the wt)und. 
 
 John Douglas (?-1743) was a Scotch surgeon who gave private lec- 
 tures on surgery and anatomy in London about 1720, and in the 
 same year published an account of the performance of the high opera- 
 tion for the stone under the title of Lithotoniia Donglas-fiana. He was 
 conceited and quarrelsome, and jniblished two alnisive pamphlets on 
 Cheselden, by whom he was com])letely overshadowed. 
 
 His l)rother, James Douglas (1675-1742), was a jihysician who settled 
 in London about 1700, and was a distinguished anatomist and obstetrician. 
 He puljlished a Description of the peritoneum (London, 1730, 4to), in 
 which he described the fold of the peritoneum which is still known by 
 his name. 
 
 To the first half of this century lielongs one of the greatest itinerant 
 quacks known to history — viz. .John Taylor (1708-67), who styled him- 
 self " Chevalier, ophthalmiater pontifical, imperial, and royal." He was 
 born in Norwich, and in 1727 published a pamphlet on the mechanism of 
 the eye and on cataract. This he dedicated to Cheselden, from whom he 
 acknowledges that he had learned all that he knew about the matter, and, 
 
THE HISTORY AND LITERATURE OF SURGERY. 85 
 
 ■while tlie work was boastful, yet it was not more so than some otluT jmlj- 
 lieations of that day. Soon after this period lie ai)pears to haye giyen up 
 all idea of respectable practice, and tnvyelled far and wide oyer Europe, 
 advertisin<r himself extensiyely in eyery place that he came to, and 
 publishing for the same purpose a large number of pamijhlets referring 
 to his wonderful cures. His autobiography, published in three yolunies 
 (Loudon, 1762), is one of the curiosities of literature. 
 
 The principal English surgeon in the middle of the century was 
 Perciyal Pott (1713-88), who became assistant surgeon of St. Bartholo- 
 mew's Hospital in 1745 and surgeon in 1749. His eontril)utions to 
 .surgery were numerous and im])i>rtant, especially those on hernia, 
 injuries to the head, hydrocele, and the disease of the spine still known 
 l)y his name as " Pott's disease." His Treatise on ruptures was pub- 
 lished in 175(3, his Practical remarks on the hi/drocelc, in 1762, and his 
 Beniark.s on that kind of palst/ of the hirer linihs irliich is frequentljj found 
 to accompany a curvature of the spine, in 1779. His Chirurgical works 
 appeared in 1771, and there were four later editions, besides German, 
 French, and Italian translations. 
 
 Alexander Monro (1697-1767), a pupil of Cheselden and of Boer- 
 haaye, became the first professor of anatomy in the Uniyersity of Edin- 
 burgh in 1725; he also lectured on surgery and made great use of com- 
 paratiye anatomy. He founded the Royal Infirmary and gaye clinical 
 lectures on surgery, and was one of the best surgeons of his time. His 
 writings relate chiefly to anatomy, but he also wrote important papers on 
 aneurism, cataract, hernia, etc. He first tried to cure hydrocele by the 
 injection of wine. His son, Alexander Monro [secundus] (1733-1817), 
 succeeded him as professor of surgery, and held the chair until 1810, 
 when he gaye it oyer to his son of the same name, Alexander Monro 
 [tertius] (1773-1859), who resigned in 1846, the professorship haying 
 thus been held by the three Monros for one hundred and twenty-one 
 years. Although the chair was thus, after a fashion, hereditary, the 
 talent did not descend to the third generation. 
 
 The next name to be mentir)ued is that of a man whose works mark 
 an epoch in the deyelopment of surgery — -John Hunter (1728-93), the 
 yiituigest son of a Scotch fjirmer. His brother William, ten years older 
 than himself, haying receiyed an excellent education according to the 
 l)attern of that time, settled in London and began to lecture on anatomy 
 •and surgery in 1746. In 1748, John Hunter, a rough, ignorant youth, 
 decidedly addicted to low company and amusements, and not haying 
 shown the slightest taste for study, joined his brotiier, and was employed 
 by him as an assistant in the dissecting-room which he had just estab- 
 lished. He soon showed that he had found his proper field of actiyity, 
 and after one year's experience was able to take charge of the pupils 
 and to direct their work. William Hunter was a good classical scholar 
 and a cultiyated and 'polished mm of the world, being in all these 
 respects a complete contrast to his brother, who decided in fayor of 
 -surgery as a career, and studied under Cheselden and Perciyal P<itt. 
 
 The brothers entered into partncrshij) in 1754, John deyoting him- 
 self mainly to anatomy and to physiological experimentation. He also 
 began to deliyer lectures, but he was by no means attractiye as either 
 a writer or a speaker, and in the latter capacity his audience neyer 
 
86 THE IIISroRY AND LITKRATURE OF SURGERY. 
 
 aniountcd to twenty persons. In ]7()1 lie joined the army, jjoint;' to 
 tlie Spanisli l*eninsnhi, and remained witli it until 17(j3, durinfj; w iiieii 
 time he colk'eted the observations contained in his treatise on ^runsliot 
 wonnds. On his return lie began to teaeh anatomy and snrjiery to 
 private pupils or apprentices, in which undertakinjj he was aided by his 
 election as sure;eon to St. Georij;e's Hospital in 17(j<S. The remainder of 
 his life was sjient in this work, in investigations, and in the formation 
 of the splendid museum which is now under the charge of the lloyal 
 College of iSurgeons of Ijondon. 
 
 The name of John Hunter is familiar to all surgeons mainly through 
 his recommendation that in cases of aneurism due to disease t)f the artery 
 the artery should be tied in the sound parts between the aneurism and 
 the heart ; and aside from this and his great museum, very few persons, 
 except those who have ])reparcd Hnntcrian orations or studied them, 
 could probably state with any clearness what it was that he did to 
 acquire the reputation which he possesses. His work on comj)arative 
 anatomy was the result of the dissection of over five hundred species 
 of animals, in the course of which he made innumerable discoveries and 
 anticipated many comparatively recent observers ; and in comparative 
 physiology it was even greater, being so far in advance of his times that 
 it was not comprehentled. 
 
 The treatise on Blood, InJJaimnaiion, and Gunnhof Woundti is usually 
 considered Hunter's greatest work and as embodying the results of the best 
 part of his researches. This work was completed and given to the pi'ess 
 during the last year of Hunter's life, and was not puldished until 1794. 
 
 The merit of Hunter's operation for aneurism does not, as Guthrie 
 remarks, lie in the operative process, but in the ))rinciples upon which 
 it is founded. The dangers arising from the aj)j)licati()n of the method of 
 Antyllns to aneurisms produced by disease of the artery were in part due 
 to the danger from hemorrhage w'hen the artery, in a state of disease, is 
 ligated, and in j)art to the sup]niration and ulceration which follo\^'cd the 
 opening of the sac. But Hunter, reasoning upon e.\])eriments made by 
 him in removing portions of the coat of arteries, and also upon the 
 results which he had observed with regai'd to the establishment of a 
 collateral circulation in cases where an artery had been obstructed, said : 
 " If the artery, however, cannot be tied above the aneurism in the ope- 
 ration, whore can it be tied if the limb be amputated? \Miy not tie it 
 up higher in the sound parts, where it is tied in amputation, and pre- 
 serve the limb ?" 
 
 He first performed this operation in 1785, placing four ligatures on 
 the artery with various degrees of tightness. The patient was cured of 
 the aneurism, but died of other complications fifteen months afterward. 
 In the second operation he applied only one ligature. Hunter prfibably 
 was not aware of the full scope and value of his suggestion. He con- 
 sidered that the arteries which would admit of the operation were the 
 carotids above the sternum, any of the branches of the external carotids, 
 the subclavian after having passed the scalcni muscles, and the crural 
 after having passed Poupart's ligament and given oif the large muscular 
 artery. He did not think the subclavian should be tied in axillary 
 aneurism, because he would doubt as to the soundness of the artery, 
 and the simie with the femoral where it passes under Poupart's ligament. 
 
THE HISTORY AND LITERATURE OF SURGERY. 87 
 
 His plan was opposed by Pott and Bromfield, the latter of whom said : 
 " An extravagant proposition has been snggested by some people to tie 
 up the prineipal trunk of an artery in the extremities. I once saw an 
 attempt of this kind in a true aneurism of tlie ham, in which I shall 
 only remark that the patient died ; and I tlo Itelieve that the embarrass- 
 ments which occurred, as well as the event of the operation, will deter 
 the gentleman who performed it from making a second attempt in a sim- 
 ilar ease." Hunter, after quoting this, says : " Now, unfortunately either 
 for Mr. Bronitield or myself, this is the very case from which I have 
 formed favorable ideas of the success of future operations of a similar 
 nature." ' Pott, writing in 1777, said : " As far as my observation and 
 experience go, the operation for aneurism in the femoral and popliteal 
 arteries, however judiciously performed, will not be successful ; that is, 
 will not save the patient's iife. I have tried it myself more than once 
 or twice. I have seen it tried by others ; but the event has always been 
 
 fatal Nor have I ever seen any other operation that that of 
 
 amputation which has preserved the life of the patient." 
 
 John Hunter was a tremendous worker. His labors Mere almost 
 incessant. It is probable that his ignorance of what had been done by 
 others was not so great as most persons have inferred from the fiict that 
 he rarelv quotes or refers to others. It should be remembered that he 
 W!is for a long time associated with his brother, who was certainly well 
 ac(|uaiiited with medical literature, and that lie daily met men of culture 
 antl information, from whom he must have learned a certain amount of 
 what was going on elsewhere. Some of his greatest work was eflected 
 tlirough his pupils, .Tenner, Abernethy, Astley Cooper, Physick, Ever- 
 ard Home, and otliers, all of whom were trained by him and perpet- 
 uated and expanded his teachings. Since his day mere mechanical dex- 
 terity, with some knowledge of ointments and plasters, is no longer 
 thought sufficient for the stock in trade of a surgeon. The peculiar 
 combination of work in anatomy, pathology, and surgery pursued by 
 Hunter has been accepted to a large extent in England since his time as 
 a model of training fen- a surgeon, and most of the modern leading sur- 
 geons have been in their younger days teachers of anatomy and of jiath- 
 ology ; which fact has exercised a great influence upon the development 
 and methods of teaching of surgery in England. 
 
 The successor of Hunter in English surgery M-as his pupil and enthu- 
 siastic admirer, John Abernethy (17(34-18.31). He was elected assistant 
 surgeon to St. Bartholomew's in 1787 on the retirement of Mr. Pott, and 
 then began to give private lectures on anatomy at his own house, and his 
 success was such that the governors of St. Bartholomew's were induced 
 to build a lecture theatre, where in 1791 he began to lecture on anatomy, 
 physiology, and surgery. 
 
 Abernethy was the first to ligate the external iliac artery for aneur- 
 ism, in 1796, and in 1798 he liga^ed the common carotid for hemor- 
 rhage. In 179.3 he perfn-med neurectomy i'or neuralgia of the arm 
 conunencing in the finger, and proved that after the removal of half an 
 incli of the nerve reunion occurred and the skin of the finger resumed its 
 natural sensibility.^ He also introduced an improvement in the opening 
 
 ' Works of John Hiinler, edited by J. F. Palmer (London, 1837, vol. i. p. 547). 
 * See his Surgical Works (new edition, vol. ii., 1S17, p. 205). 
 
88 THE HISTORY AND LITERATURE OF SURGERY. 
 
 of lumbar abscesses by a method of" ineision wliicli sljould admit 'tlie 
 least possible amount of air. As he grew older he ceased to o|)erate, 
 and devoted himself more to the treatment of the general health of his 
 patients. The Mork by \vhi<'h he is best known is his ExKtn/ on the 
 constitutional origin of local di.seaneti. Abernethy's re])iitation was not 
 due to his books so much as it was to his lectures, which were dramatic 
 in character, and given with certain eccentricities of manner and speech 
 which considerably contributed to his rejiiitation. 
 
 Henry Cline (1750-1X27) was a j)upil of Hunter, and became sur- 
 geon of St. Thomas's Hospital and president of the Royal College of 
 Surgeons in 1823. He ^vas lecturer on anatomy and surgery in the 
 early part of the eighteenth century in the Aldersgate School, and con- 
 tributed largely to the spread of the new ideas of Hunter. He wrote 
 no special treatises, but had a number of distinguished pupils. 
 
 Sir William Blizard (1743-1835), a pupil of Hunter, became sur- 
 geon of the London Hospital in 1780 and founder of its medical 
 school, to the cost of which he contributed largely. He was twice 
 president of the College of Surgeons and founded the Jacksonian prize. 
 He was one of the first to ligate the subclavian and the first to ligate the 
 superior thyroid artery. His ])ul)lications are chiefly in journals. 
 
 Sir Everard Home (1 76.3-1 .S.32), the son of an army surgeon, was a 
 pupil of John Hunter, \\ho married his sister. He served for a short 
 time in the army, returned to London and became Hunter's assistant, 
 was appointed assistant surgeon to St. George's Hospital in 1787, and 
 surgeon to the same in 1793, after Hunter's death. He was one of 
 Hunter's executors and edited his works, was made a baronet in 1813, 
 and resigned his position at St. George's in 1827. He ^vas a voluminous 
 writer, treating on strictures of the ui'ethra, on lUcers, on diseases of the 
 prostate, on comparative anatomy, etc., but lost his reputation as an 
 author on account of the fact that he destroyed the greater part of the 
 large collection of Hunter's manu.scripts, of which he had obtained tem- 
 porary possession, and which he used in prejiaring his own papers. 
 
 Other Loudon surgeons of this century who should lie mentioned are 
 Sir Csesar Hawkins, surgeon to King George II. and King George III., 
 and surgeon of St. George's Hos])ital from 1735 to 1774; Thomas 
 Gataker, surgeon of St. George's Hosi)ital, who died in 1769; Joseph 
 Waruer (1717-1801), a pupil of Sharp, who became surgeon of Guy's 
 Hospital in 1748, first ligated the common carotid in 1775, and wdaose 
 Cases in Surgery (London, 1754 ; 4th cd., 1784) are still worth reading; 
 and Sir James Earle (1755-1817), surgeon of St. Bartholomew's Hos- 
 pital, Avho is best known by his Treatise on hydrocele (London, 1791 ) and 
 Observations on the operation for the stone (London, 1793). 
 
 Among the distinguished provincial surgeons of this period may be 
 mentioned Alanson, Park, White, Mynors, and Hey. 
 
 Edward Alanson (1747-1823) was a pupil of John Hunter, and sur- 
 geon of the Royal Infirmary at Liverpool from 1770 to 1794. He 
 published Practical obserratio)i>i on amputation and the after-treedment 
 (London, 1779), in which he recommended a method for obtaining a 
 more complete covering for the end of the bone by cutting the mus- 
 cles from below upward. 
 
 Henry Park (1744-1831) was a student of Pott and Le Cat, and was 
 
THE HISTORY AND LITERATURE OF SURGERY. 89 
 
 surgeon of the Royal Intinnary at Liverpool from 17(17 to 1798. His 
 name i^ connected with the histurv of resection of the knee and elbow. 
 
 Charles White of Manchester pul)lished his Caneiiiii SitrtjiTt/ in 1770, 
 and first excised the head of tiie luuncrus in 1768. 
 
 Robert Mynors (17oy-18U6), a surgeon of Bmningham, published 
 his Practical observations on amputation in 1783, and his History of the 
 practice of trephining the skull, etc. in 1785. 
 
 William Hey (1736-1819), a distinguished surgeon of Leeds, pub- 
 lished in 181)3 his Practical Observations in Sure/eri/, which passed 
 through two later editions, and is still worthy of consultation. He 
 described and named fungwi hamatodes. His name is connected with 
 the form of saw devised by him for use in case of fracture of the skull, 
 and with a mode of partial amputation of the foot. 
 
 At tlie end of the century the leading surgeons in Edinburgh were 
 Benjamin and John Bell. 
 
 Benjamin Bell (1 749-1 8()()) was a \m\)\\ of Monro, and l)ecame a sur- 
 geon of the Royal Infirmary in 1772. In 1778 he publislied A treatise 
 on the theory and management of idcers, etc., which went through nume- 
 rous editions and translations. His System of surgery (6 vols., Edin- 
 burgh, 1783-87) also passed through many editions, and was trans- 
 lated into German and French, being the favorite systematic treatise for 
 the next twenty years. He insisted strongly on the im])ortance of 
 saving skin in amputations and operations for the removal of tumors, 
 in order to leave as little as possible of the surface of the wound exposed. 
 
 John Bell (1765-1820) graduated in medicine in Edinburgh in 1779, 
 and in 1790 opened ii private school for anatomy, surgery, and obstetrics. 
 He was ambitious and energetic, and unsjiaving in his criticisms of his 
 seniors, Monro and Benjamin Bell, thus causing o])])osition to his school, 
 which, however, was popular and successful. His brother Charles was 
 of great assistance to him in this enterprise. He published a treatise on 
 anatomy which went through many editions : Discourse on the nature 
 and cure of wounds (Edinburgh, 1795, with several editions and trans- 
 lations) and The Principles of surgery (3 vols., London, 1801-08, 4to), 
 remarkable for the beauty of its engravings. He was the leading ope- 
 rating siu'geon in Edinburgh for nearly twenty years. As the result of 
 a bitter controyersy with Gregory the number of surgeons at the Royal 
 Infirmary was in 1800 limited to six, and Bell, with others, was excluded, 
 and thus lost the opportunity for clinical teaching. 
 
 The story of the rise and progress of surgery in Ireland is told in the 
 History of the Royal College of Surgeons in Ireland and the Irish Schools 
 of Medicine, by Charles A. Cameron (Dublin, 1886). 
 
 In 1446, King Henry VI. established, by royal charter, a fraternity 
 or guild of barbers for the ])romotion and exercise of the art of chirurgerv. 
 In 1572, Queen Elizabeth granted a second charter to the l)arbers and 
 surgeons, ordering that they should be called the " Master Wardens and 
 Fraternity of Barbers and Cliirurgeons of the Guild of Saint Mary or 
 Magdalene in our city of Dublin," and a third charter was grante(l in 
 1687 by James II., giving them full power of the guild over barbers 
 within six miles of Dublin. There were, iiowever, a certain number of 
 surgeons m4io had no connection of any kind with the company, being 
 army surgeons, or men of liberal education who had studied in the uni- 
 
90 THE HISTORY AM) LITERATVnE OF SURGERY. 
 
 versities. In 1745 the company hcfi;an to disintofrrate, and in 1784 the 
 union between the harbcr.s and tlie surgeons was praetieally dissolved by 
 the creation of the Royal College of Surgeons in Ireland. The beginning 
 of teaching in I)ul)lin is due to Sir Patrick Dun (1642-171."}), president 
 of the College of Physicians in Ireland, who left a becpiest for "one or 
 two Professors of Physiek to read ])ul>lick Lectures and make publick 
 Anatomical dissections of the several ])arts of the human Body or Body's 
 of other animals, to read Lectures of Osteolog}*, Bandages, and operations 
 of Chirurgery, to read Botanic Lectures, Demonstrate Plants puhlickly, 
 and to read Publick Lectures on Materia Medica, for the Instruction 
 of Students of Physiek, Surgery, and Pharmacy." The teaching did 
 not actually liegin until 1744. The first surgical work pulilished in 
 Ireland apj)ears to be A Concise and Impartial Account of the Advan- 
 tages avisiitg to the Public from the general use of a New Method of Am- 
 putcdion (DuhWn, 1703, pp. 13). The second was Ohserixdions on Wounds 
 of the Head (Dublin, 1776, pp. 177). This was published anonymously, 
 but a])peared in a second edition in 1778 under the name of the author, 
 AVilliam Dease (1752-98), who was one of the most energetic founders 
 of the Royal College of Surgeons, and one of the first to lecture in it. 
 He was a very successful teacher, and in addition to his work on wounds 
 of the head he published An Introduction to the Theory and Practice of 
 Surgery (London, 1780, 8vo) and a work on midwifery ^\hich became a 
 popular text-book. 
 
 In 1765, Sylvester O'Halloran (1728-1807), a surgeon of Limerick, 
 Avho had studied in Paris, London, and Leyden, jiublished at London 
 A Complete Treatise on Gangrene and Sphacelus ; vitlt. a new Method of 
 Amputation, which was a valuable contribution to the literature of these 
 subjects. 
 
 The Nineteenth Centuky. 
 
 The salient points in the history of surgery in the nineteenth century 
 are the discovery of anassthetics ; the establishment of aseptic and anti- 
 septic surgery upon the scientific foundation of the new science c)f bacteri- 
 ology ; the development of conservative surgery in the treatment of diseases 
 and injuries of the extremities and of plastic and orthopicdic surgery into 
 a specialt}' ; the rise and progress of abdominal and intracranial surgery; 
 the entrance of two new nations, the United States and Russia, into the field 
 of surgical discovery, literature, and teaching ; the change in the methods 
 of educating surgeons ; the formation of surgical societies and associations ; 
 and the cosmopolitan character of the art developed by rapid international 
 communication and liy periodicals. The founding of nuiseums like those 
 of Hunter and Dupuytren, the removal of restrictions on the study of 
 anatomy, the great advances made in pathological anatomy and ex])eri- 
 raental pathology, and the development of oi)hthalmology, otology, 
 gynsecology, dermatology, and laryngology into their present highly 
 specialized forms, have also exerted a strong influence upon surgery and 
 the work of the general surgeon. 
 
 With the increasing accunuilation of the people in cities have come 
 increased demands and o|)portHnities for surgeons, for increase of hospi- 
 tals and medical schools, for skilled nursing, ingenious mechanics for the 
 making of instruments and apparatus, and, in short, for many means of 
 
THE HISTORY AND LITERATURE OF SURGERY. 91 
 
 carrj-ing out suggestions for improvcnieuts through tlic aid of competent 
 assistants. 
 
 More progress in the art has been made since liSUO than iiad been 
 made in the two thousand years preceding that date, and this has been 
 largely due to work done in the dissecting-room and in the laboratory. 
 Consider for a moment some of the differences between the resources of 
 the surgeon of ISOO and those of the surgeon of tlu' present day. The 
 surgeon of 1800 had little more knowledge than had ilippocrates of the 
 chief causes of danger after operations, such as suppuration, pya^nia, or 
 tetanus, and groped wildly for means to avoid them. He had no clinical 
 thermometer, and could only guess at temperature and fever ; no hypoder- 
 mic syringe ; no anaesthetic ; no definite knowledge of the imjKirtanee of 
 blood-saving or of the best means of doing it. He knew nothing of plastic 
 surgery, of tenotomy, of the ophthalmoscope, or of the use of the niicro- 
 .scope in diagnosis, and had only just learned how to ligate arteries and 
 to treat ordinary wounds in a simple and sensible way. The really great 
 surgeon of that day who was bold, cool, and skilful could perform most 
 of the great oi)erations, such as amputation, ligature of hirgo arteries, 
 removal of tumors, Csesarean section, and the like, but such men were 
 few and far between. 
 
 At the beginning of the century London was the centre of surgical 
 improvement and of surgical teaching, and the leading siu'geons at that 
 time were Abernethy, Cline, Blizard, Home, Astley Cooper, Lawrence, 
 and Wardrop. The first four of these have been referred to in a pre- 
 vious section. 
 
 Astley Paston Cooper (17(38-1841), a native of Norfolk, was appren- 
 ticed in 1784 to his uncle, William Cooper, surgeon to Guy's Hospital, 
 and was soon transferred to Cline, then surgeon at St. Thomas's. He 
 attended John Hunter's lectures and spent one winter at the Edinburgh 
 Medical School, was appointed demonstrator of anatomy at St. Thomas's 
 in 17851, and two years later became joint lecturer with Cline in anatomy 
 and surgery. In 1800 he was appointed surgeon to Guy's on the resig- 
 nation of his uncle. In 1805 he ligated the common carotid for aneurism, 
 and in 1817 the abdominal aorta. In 1820 he performed a simple opera- 
 tion on King George IV., which resulted in his being made a liaronet. 
 In 182.5 he resigned his lectureship at St. Thomas's and induced the for- 
 mation of a separate medical seliool at Guy's, in which his pupil, Aston 
 Key, lectured on surgery, and his ne]iiiew, Bransby Cooper, on anatomy. 
 He was an extremely skilled anatomist, and some of his most valuable 
 contributions are connected with his work in this direction. Among them 
 may be mentioned his treatises on hernia (in two parts, 1804—07), the 
 second edition of which ap])eared in 1827, the illustrations to which are 
 said to have been so expensive that he lost a thousand pounds by the 
 publication. His book on Dislocations and Fractures of the Joints 
 was published in 182"J; his Lccfures on the Principles and Practice 
 of 8urf/eri/, with additions by Tyrrell, in three volumes, in 1824—27 : 
 the eighth edition of this appeared in 18;17 ; and his Illustrations of Dis- 
 eases of the Breast, Part I., in 1829; his observations on the Structure 
 and Diseaiies of the Testes in 1830; and his work on the Anatomy of 
 the Breast in 1840. He seems to have read little, his books contain few 
 references to the work of other men, and his reputation and iuHuence 
 
92 THE HISTORY AND LITERATURE OF SURGERY. 
 
 were due more to his personality and his great skill as an operator tiiaii 
 to his ('ontril)iiti()ns to science or practice. 
 
 William Lawrence (17S.')-1.S()7), tlie son of'a surfruoii, was a pupil of 
 Abernethy and liis demonstrator of anatomy for twelve years. He 
 became a member of tiie Collejic of Surgeons in 1805, won its prize for 
 an essay on hernia in 18()(), was ai)pointed assistant surgeon to St. Bar- 
 tholomew's Hospital in 181.3, and in 1815 became professor of anatomy 
 and physiology at the College of Surgeons. His lectures were considered 
 to flavor of infidelity, and led to a sharp controversy, which ended by his 
 recanting the objectional)le opinions and withdrawing his l)ook, On the 
 Hixtory of Man, from sale as far as he could. He was connected with 
 the Aldersgate ]\Iedieal School, and in 1823 succeeded Aliernethy as 
 lecturer on surgery at St. Bartholomew's. His principal contributions 
 to surgical literature are his Trcafii^e on Diseases of the Et/e (1833) and 
 his Lectures on Suiyeri/, jtublished in 18<!3. He was a skilled anatomist, 
 an elo(]uent lecturer, and an erudite author. 
 
 James Wardrop (1782-1869), a native of Scotland and educated in 
 Edinl)urgh, came to London in 180'(. In 1826 he founded a hospital 
 under the title of the " \A'^est London Hospital of Surgery," and in the 
 same year, in conjimction with Mr. Ijawrence, gave a course of lectures 
 at the Aldersgate Street School. His abusive articles in The Lancet in 
 1826-27 probably prevented him from having any official connection 
 with the colleges. In 1828 he was made surgeon to the king. He 
 wrote for The Lancet (1834, vol. ii.) a series of grossly personal and 
 abusive papers entitled " Intercepted Letters," purporting to be written 
 by Halford, Brodie, MclNIichacl, and others, after which the heads of 
 the profession in London had as little as possible to do with their 
 author. In 1835 he joined the Hunterian School of Medicine and 
 gave a course of lectures on surgery. His best-known work is that on 
 the diorbid Anatomi/ of the Eye. His name in the history of surgery is 
 chiefly connected with the operation first proposed by Brasdor for the 
 cure of aneurism by placing a ligatui-e on the distal side of the tumor, 
 which operation Mr. Wardrop jierformed successfully in two cases of 
 aneurism of the carotid artery, and in one ease of aneurism of the innom- 
 inate artery, in M'hich he tied the subclavian. 
 
 The following surgeons also belong to the early part of the century : 
 
 Joseph C. Carpue (1764-1846), who in An Account of two Successful 
 Operations for Eestoring a L^ost Nose, etc. (London, 1816, 4to), intro- 
 duced rhinoplasty by the Indian method, and recalled attention to the 
 high operation for stone in his excellent historical sketch. The History 
 of the Hir/li Operation for the Stone (London, 1819). 
 
 Samuel Cooper (1 780-1848), surgeon of the I^niversity College Hos- 
 l)ital from 1831 to 1848, published his Surc/ical Dictionary in 1809, the 
 first comprehensive and complete work of the kind in existence, and the 
 continued pojndarity of which is shown by the fact that its eighth edition 
 was })ublished in 1861-72. Every edition is valuable to the student of 
 the progress of surgery in the nineteenth century. 
 
 Alexander Copland Hutchinson, a naval surgeon, published Practical 
 Observations on Surgery in 1816 (2d ed. 1826), and Some further Obser- 
 vations on the subject of the proper period for Amputating in Gunshot 
 Wounds, etc., in 1817. 
 
THE HISTORY AXD LITERATURE OF SURGERY. 93 
 
 Charles Aston Key (1793-1849), a pupil of Astley Cooper, whose 
 niece he married, beeanie demonstrator of anatomy at St. Thomas's 
 Hospital in 18'2(), assistant surgeon to Guy's Hosj)ital in 1821, surgeon 
 to the same in 1824, and professor of surgery in its sehool in 1825. He 
 ligated the subelayian artery in 1825, and tied the carotid for aneurism 
 in 1830 ; introduced the use of the straight staff in lithotomy, and the 
 method of diyiding the stricture external to the sac in strangulated 
 hernia, and was one of the most popular teachers in London. 
 
 From 1820 to 1835 the leading London surgeons, in addition to those 
 already referred to, were Brodie, Bell, and Trayers. 
 
 Sir Benjamin Collins Brodie (1783-1862) was a native of Wiltshire, 
 England. He studied in London, and began to assist in teaching at the 
 AVindmill Street School in 1805, when he was twenty-two years of age. 
 In 1803 he became the pupil of Sir Eyerard Home, and in 1808 assistant 
 surgeon at St. Thomas's Hospital, where, in 1822, on the death of Mr. 
 Griffiths, he liecame full surgeon, from which position he retired in 1840. 
 He deyoted himself largely to physiological experiments, some results of 
 which appeared in the celebrated Croonian Lecture, delivered in 1810, on 
 the influence of the brain on the action of the heart, in which he re})orted 
 the results of the use of the woorara poison, and in a pa])er published in 
 1814 on The Influence of the Pneumof/adric on the iSecretions of the tStom- 
 ach. Of his surgical writings, the first, and perhaps the most important, is 
 his Pafholofjieal and Surgical Observations on the Diseases of the Joints, 
 published in 1818, and appearing in a fifth edition in 1851. His lectures 
 On Diseases of the Urinary Organs appeared in 1832, a fourth edition 
 being issued in 1849. In 1846 he published a volume of lectures on 
 various subjects in pathology and surgery. His complete works, \\ith 
 an autobiography, are ])ublished in three volumes (8yo, London, 1865). 
 He devoted himself to the scientific side of surgery rather than to opera- 
 tions, although he was a very successful operator, and for over thirty 
 years was recognized as the head of the medical profession in London. 
 Sir Charles Bell (1778-1842) was a younger l;>rotiier of John Bell of 
 Edinburgh, under whom he studied and whom he soon began to assist in 
 the teaching of anatomy. In 1804 he went to London, where he began 
 to teach in his own house in 1807, after which he associated himself with 
 Mr. Wilson in the Great Windmill Street School, where he came into com- 
 petition as a teacher with Cline, Cooper, and Abcrncthy, and met with 
 great success. In 1812 he began to deliver clinical lectures in the INIid- 
 dlesex Hospital, to whi<'h he was appointed surgeon in 1814. In 1836 
 he accepted the chair of surgery in the University of E(linl)urgh, wliich 
 he held until his death. His publications were voluminous, and include 
 his System of Operative Surgery (2 vols., 1807-09), his paper on Gunshot 
 Wounds (in 1814), his Surgical Observations (2 vols., London, 1816-18), 
 and his Illustrations of the Great Operations in Surgery, etc. {in 1821). 
 His fame, however, is 'mainly due to his ])a]K'rs relating to the ner- 
 vous system, the result of careful and long-continued experimental 
 work. His Idea of a JVew Anatomy of the Brain, printed in 1811, is a 
 pamphlet of 36 pages Avhich forms an epoch in the history of discoveries 
 relating to the structure and functions of that organ. He was a skilled 
 artist, a dexterous operator, and a conscientious and popular teacher, 
 whose fame has increased instead of diminishing; since his death. 
 
94 THE HISTORY AND LITKHATUIiE OF SURGERY. 
 
 Bcnjaiuin Travel's (ITSS-LSoS) was a pupil of Astlcy Cooper, pro- 
 sector of" anatomy at (Jiiy's Hos])ital, and surgeon of St. Tliomas's Hos- 
 pital in 1815. He was a skille(l oplitlialniolof^ist, and liis tS}/iioj)xin of the 
 Diseases of tlie ]'Ji/c (1X20) was tlie hest systematic treatise on that subject 
 which had yet appeared in Eni;lish. His tastes led him to the scientific 
 rather than to the practical aspect of surgery, and his treatises on C'on-\ 
 dituflonal Irritation (1824), A further Inquiry concerninr/ Constitutional 
 Irritation and the J\ifhologi/ of the Nervous Si/stetn (18.34), and The 
 Phi/sioloffi/ of Inflainination (1844) are specimens of physiologico-])atli- 
 ological investigation of the highest order of merit. He contributed 
 some valuable papers on aneurism and the ligature of arteries to the 
 Medieo-chirurgieal. Transactioyis, and one on wounds of the veins in the 
 8urf/ieal Essai/s, ])ul)lished by Astley Cooper and himself in 1818-19. 
 He introduced tiie use of mercury in non-specific iritis and in other 
 forms of inflammation. Of all the English surgeons of this period, 
 there are none wiiose writings are more interesting to-day than are those 
 of Travers. 
 
 In Edinburgli there was no surgeon of special note engaged in teach- 
 ing after John Bell was excluded from the infirmary and gave up his 
 school. No separate chair of surgery was established in the university 
 until 1831, owing to the persistent opposition of the second Monro, who 
 claimed to be professor of surgery as well as of anatomy. A chair of 
 surgery was instituted in the College of Surgeons in 1804, which was 
 maintained until the chair was created in the university in 1831, and 
 this was filled by Dr. John Thomson (1765-1846), who became surgeon 
 of the Royal Infirmary in ISDO, and began to give clinical lectures 
 therein on surgery in the private theatre in 1801, this being then the only 
 sejiarate course on this subject given in the city. In 1806 a chair of 
 military surgery was instituted in the university, to which Dr. Thomson 
 was appointed. His Lectures on Infiammation, etc. (Edinburgh, 1813) 
 passed through several editions and translations, and his Report of Ob- 
 servations made in the British Military Hospitals in Belgium after the 
 Battle of Waterloo, etc. is of interest to army surgeons. 
 
 A chair of clinical surgery was created in the university in 1803, 
 Avhich was filled by the appointment of James Russell, a surgeon of the 
 Royal Infirmary, who published in 1794 A Practical Essay on a certain 
 Disease of the Bones termed Necrosis (Edinburgh, 8vo), and in 1833, 
 after his retirement, Observedions on the Ti'sticlcs. 
 
 Sir George Ballingall (1780-1855) entered the army in 1806, and 
 became professor of military surgery in the university in 1823. His 
 principal work is his Outlines of the course of lectures on Military Sur- 
 gery, etc., published in 1833, which reached a fifth edition in 1855. 
 
 Here also may be mentioned John Hennen (1779-1828), a distin- 
 guished English military surgeou, a native of Ireland, who studied in 
 Dublin and Edinburgh, and entered the army in 1800. His chief work 
 is Observations on .sy>//;<' important poiids in the practice of 3Iilifary Sur- 
 gery, etc. (Edinburgh, 1818), and subsequent editions, called Principles 
 of Military Surgery (Edinburgh, 1820). 
 
 In Glasgow at the beginning of the century the leading surgeon was 
 John Burns (1775-1850), M'ho was the first lecturer on anatomy who was 
 unconnected with tlie university. His Principles of Surgery (2 vols., 
 
THE HISTORY ASD LITERATURE OF SURGERY. 95 
 
 Loiiilon, 1829-38) was dry ami lunl no success, but his Principles on 
 3Ii(ltrif('ri/ reached a tenth edition. In I8I0 he was appointed Regius 
 professor of surgery in the University of Ghisgo\\-, and held this position 
 until his death. 
 
 Allan liurns (1781-181o) was a brother of John, whose demonstrator 
 he became in the anatomical school. He first described the falciform 
 process of the fascia lata in its relations to femoral hernia in a pa])er 
 wliich he puljlished in the Edinliuiyh Mviliail Journal in 180(5. His 
 Observationn on the Surr/ieal Anatomi/ of the J [cad and Neck (Glasgow, 
 1811) is a valuable surgical work, which contains, in addition to the 
 anatomy, accounts of numerous cases of tumors in this region, a discus- 
 sion on the treatment of aneurism, etc. He suggested the ligature of 
 the innominate artery, and it was this suggestion which led to the first 
 performance of the operation by INIott in 1821. 
 
 Between 1825 and 1840 four surgeons in Edinburgh became distin- 
 guished, and two of them were transferred to London to take high places 
 there. These four were Lizars, Liston, Fergusson, and Svme. 
 
 John Lizars (1783—1860) was a pupil of John Bell, and began to 
 teach anatomy in a private school in 1815. In 1831 he became pro- 
 fessor of surgery in the Royal College of Surgeons. He was the first 
 in Scotland to ligate the innominate, and the second to perform ovariot- 
 omy, an operation which became known maiidy through his Obsermtions 
 on Extirpation of Disea><ed Ovaria (Edinburgh, 1825, fob). His name 
 is also connected with early operations for excision of the jaws. In 
 1839 he ceased teaching and devoted himself to private practice. He 
 was a skilled anatomist and a brilliant and daring operator. 
 
 Robert Liston (1794-1847), a native of Scotland, was educated in 
 Edinl)urgh and Lctndon, and l)egan to teach anatomy in 1818. In 1823 
 he gave uj> this teaching in favor of Syme and devoted himself entirely 
 to surgery. He became surgeon of the North London Hospital and 
 professor of clinical surgery in University College, Loudon, in 1834, 
 and rapidly achieved a great success. He was possessed of great per- 
 sonal strength and was a brilliant operator, having the reputation of 
 being the most dexterous surgeon of his time. His method of fiap- 
 amputatiou became very popular, and he made numerous contributions 
 to the surgery of ani])utation, aneurism, lithotomy, and lithotrity. He 
 would amputate the thigh with only the aid of one person to hold the 
 limb and tie the ligatures, compressing the artery with his left hand, 
 using no tourniquet, and doing all the cutting and sawing witli the 
 right. A large part of his skill and success was due to his knowledge 
 of anatomy, wliich he kept up by dissections throughout his life. He 
 excised the upper jaw for a formidable tumor in 1836, and the success in 
 this instance brought to him a crowd of cases. His rashness is exempli- 
 fied in the celebrated case in which he punctured an aneurism of the 
 carotid, su])])()sing it to'be an abscess, although his house-surgeon had 
 told iiim that the tumor ])uls;ited. His principal ])ublications were his 
 Elcnient.s of ,S»;Y/f/v/, published in l.S;51,and his Practie(d Surgery, in 
 1837, both of which works went through several editions. 
 
 William Fergusson (1808-77), a native of Scotland, was educated at 
 Edinburgh, being a ])upil of Robert Knox. In 1831 he was elected 
 surgeon to the Edinburgh Royal I)ispens;iry, being at this time lectur- 
 
96 THE msTonr am) liticrature of simnEnr. 
 
 ing on surgical anatomy in association with Knox, and was tiic first to 
 ligate the subclavian in Scotland. In 1840 he accepted the professor- 
 ship of surgery at King's College, London. In ISo;") he was a|)pointed 
 surgeon extraordinary, and in LSIw serjeant surgeon to tiie queen. For 
 many years he was tiie leading surgical operator in London. He resigned 
 his professorship of surgery in 1870, but remained clinical ])rofessor of 
 surgery and senior surgeon at King's College Hospital until his death. 
 He was created a baronet in 1866. His special contributions to the art 
 were largely in the line of what he called "conservative surgery," a 
 term which he first apjilied in 1852 to the avoidance of anqintation l)y 
 means of resections and to the removal of no more than is alisolutely 
 necessary in cases of diseases of the bones. His name is especially asso- 
 ciated with operations of hare-lip and cleft palate, \\'itli operations on the 
 jaws, the excisicm of joints, and with lithotomy and lithotrity. His 
 principal contribution to literature is his System of Practical Siirf/crt/ 
 (London, 1842; 5th ed. 1870). He also contrilnited many valuable 
 papers to the periodicals. His lectures on the Pror/rcss of Aiuitomj/ and 
 Surgery during the Present Century (1867) are extremely interesting to 
 the student of the history of surgery. 
 
 James Syme (1799-1870) was a jiupil of Dr. Barclay, and when only 
 nineteen years old was entrusted with the charge of his cousin Listen's 
 anatomical rooms, in which he began to teach in 1S22. In 1825 he 
 began to teach surgery, but, having quarelled with Liston, he had no 
 chance to obtain an appointment in the Royal Infirmary, and therefore 
 started a private hospital. When he succeeded Kussell in the clinical 
 chair in the university, he became one of the surgeons of the infirmary 
 in 1833, and after Liston went to London in 1834 the greater part of 
 the operative surgery of Scotland fell into his hands. In 1831 he pub- 
 lished his treatise on the Excision of Diseased Joints, which was the fir.st 
 systematic attempt to show that excision ought, in most cases, to super- 
 sede amputation, and it had the greatest influence in bringing about this 
 change in practice. The first edition of his Principles of Surgery was 
 published in 1822 ; the fifth edition in 1863. This is an extremely con- 
 cise work, and the fifth and last edition is smaller than the first. In 
 1847 he pul)lished his Contributions to the Pathology and Practice of Sur- 
 gery, in which he gives an account of the first eight cases of amputation 
 at the ankle-joint by the method which is still known by his name. The 
 date of his first case of this kind is September 8, 1842. In 1847 he 
 accepted a call as surgeon to LTniversity College, London, on the tleath of 
 Liston, but he did not find the place satisfactory, and four months later 
 he returned to Edinburgh. He was a bold, cool, and skilful operator, 
 but not a rash one. Among his most remarkable operations may be 
 mentioned those for aneurism by incision of the tumor and ligations 
 above and below, M'hich operation he performed in cases of aneurism of 
 the carotid, the axillary artery, and the iliac artery. 
 
 In 1835 the greater part of the medical teaching in London was still 
 given in private schools having no connection with hospitals, the oldest 
 and best known In'ing the Windmill Street and Aldersgate Street Schools. 
 The Great Windmill Street School was established by William Hunter 
 about 1746, and numbered among its teachers the two Hunters, Baillie, 
 Cruikshank, ^\'ilson, ]Mayo, Shaw, Brodic, Charles Bell, Carpue, and 
 
THE HISTORY AM) LITERATURE OF SUROERY. 97 
 
 Cffisar Hawkins, hut was linally destroyed by the estahlishment of tlie 
 I^oiidon University in the vicinity of the Middlesex Hospital in LS3G. 
 The Aldersgate School was also of old date, and nnnihered ainono- its 
 teachers ^^'ardrop and Lawrence. 
 
 The hospital schools of Guy's and St. Thomas's, which had been 
 nnited in 17<J8, the surgical lectures being given at St. Thomas's and 
 the medical at Guv's, were ]iracticallv separated in 182o, and entirely 
 so in 183(3. 
 
 After Liston and Fergusson came to Ijondon clinical hospital teach- 
 ing increased rapidly in favor and importance; the hospital schools 
 began to flourish and the private schools to disappear. At this period, 
 in addition to those already mentioned, the princijjal surgeons were 
 Guthrie, Green, Lloyd, South, Morgan, Stanley, and Hawkins. 
 
 George James Gutlirie (1785-1850), an ap])rentice of a London sur- 
 geon, was appointed hospital mate in the army, and sent to the York 
 Hospital at Chelsea when he was only fifteen years old. He became 
 assistant surgeon in 1801, accompanied his regiment to North America 
 in 1806, and served during the War of the Peninsula in Spain, becom- 
 ing surgeon of the forces in 1810, and commanding three divisions of 
 cavalry at the battle of Albuera. He was placed on half pay in 1814, 
 and went to the battle of Waterloo, wliere he pcrfdrmed an amputation 
 at the hip-joint on a Freiiclnnan, and tied both ends of the peroneal 
 artery, being successful in each case. He became assistant surgeon to 
 the Westminster Hospital in 1823, surgeon to the same hospital in 1827, 
 and professor of anatomy at the Royal College of Surgeons in 1828. 
 His treatise On gunKliot wounds of tlic e.vtremitics rerjuirinr/ the differ- 
 ent operations of ainpntations, etc., 1815, urging prompt amputation, 
 marks an e])och in the history of military surgery ; the sixth edition, 
 including additions relating to the Crimean War, was printed in 1855. 
 In addition to this he published A treatise on the operations for the 
 formation of an artificial pupil, etc. (1819), Lectures on the operative 
 surgery of the eye (1823 ; 3d ed. 1838), and On injuries of the head 
 affecting the brain (4to, 1842 ; 2d ed. 1847). He also contributed many 
 papers to medical journals. 
 
 Joseph Henry Green (1791-1863), a nephew and pnjiil of Henry 
 Cline, became surgeon to St. Thomas's Hosjiital in 1820 and professor of 
 surgery in King's College in 1830. In 1837 he resigned his professor- 
 ship, and in 1852 his position at St. Thomas's. His publications were 
 chiefly short papers in medical journals. 
 
 Eusebius Arthur I^loyd (1795-1862), a jjupil of Abernethy, became 
 assistant surgeon to St. Bartholomew's in 1824, and surgeon in 1847, 
 from which position he retired in 1861. He gained the Jacksonian 
 prize for 1818 by his essay on scrofula, enlarged and published in 1821. 
 
 John Flint South (1797-1882), an apprentice of Henry Cline, was 
 admitted as a member of the Koyal College of Surgeons in 1819, after 
 which he studied in CJermany, and on his return became demonstrator at 
 St. Thomas's Hospital, then lecturer on surgery, and ultimately surgeon 
 to the hospital. He is best known by his translation of Chclius's Sys- 
 tem of surgery, to which he added a large number of notes, greatly in- 
 creasing the value of the work. He also collected materials for a His- 
 tory of the craft of surgery in England, which was published in 1886, 
 
 Vol. I.— 7 
 
98 TlIK HISTORY AND LlTKUATinE OF SURdKllY. 
 
 after liis dciitli, under the Bupervision of Mr. D'Arcy Power, and is a 
 valuable hook of reference. Tiii'oiiiili liis eif'orts tlie remains of John 
 Hunter were transferred to Westminster Abbey, and the inseri[)tion on 
 the tablet is from his j)en. 
 
 John Morgan (171*7-1847), a pupil of Astley Cooper, assisted ]\Ir. 
 Key as demonstrator of anatomy in a private school, was in 1821 
 ap])ointed assistant surgeon, and in 1824 surgeon, to Guy's Hos})ital, in 
 the school of which he leetureil on anatomy and surgerv. In the latter 
 part of his career he devoted himself to ophthalniologv. He was an 
 excellent operator, ligated the iliac artery several times, was one of the 
 first to perform fiap-amputations, and was the first to use metal sutures 
 in wounds ; he was also one of the first to perform ovariotomy. His prin- 
 cipal work was Lectures on diseases of the eye (1839). He also assisted 
 Dr. Adtlison in An Essay on the operation of poisonous ayents in the 
 lirinij hody (1829). 
 
 Edward Stanley (1791-1802) studied at St. Bartholomew's, to which 
 he became assistant surgeon in 1816 and surgeon in 1838. He was 
 twice president of the Royal College of Surgeons. His jirincipal publi- 
 cation was A Treatise on the diseases of the bones (1849). 
 
 Cjesar H. Hawkins (1798-1884), prosector of anatomy in the school 
 of Great ^\'indmill Street for many years, became surgeon of St. 
 George's Hospital in 1829, and retired in 18(]1. In 1801 he was presi- 
 dent of the Royal College of Surgeons, and in 1862 Serjeant surgeon to 
 the queen, succeeding Brodie, being the fourth of his family to hold 
 this position. His works were collected and pul)lished in two volumes 
 in 1874. 
 
 Among the distinguished provincial surgeons of the century were 
 George Freer of Bii'mingham, author of Observations on aneurism and 
 some diseases of the arterial system (4to, 1807) ; Joseph Hodgson of 
 Birmingham, best known by his treatise on Diseases of the arteries and 
 veins (London, 1815; translated into French and German); John H. 
 James (1789-1869) of Elxeter, the author of the Jaeksonian ])rize essay 
 for 1818 on inflammation, and the second to ligate the abdominal aorta; 
 John Green Crosse (1790-1 SoO) of Norwieh, author of the Jaeksonian 
 prize essay for 1825 on urinary calculus, and whose fine librar}' on 
 diseases of the urinary organs came into the possession of Professor 
 S. D. Gross, and was destroyed by fire in Louisville ; John Gay 
 (1791—1870) of Swindon, a pupil of Abernethv ; John Smith Soden 
 (1780-1863) of Bath ; George M. Jones (180?-iS61) of Jersey, a bril- 
 liant operator, who performed excision of the knee-joint without know- 
 ing of Fergusson's operation a few weeks before, excised the hij) and 
 ankle-joints, extirpated the scapula, etc.; William Sands Cox (1802-76), 
 one of the founders of tlie Birmingham School of Medicine in 1828, 
 author of ]\[einoir an amj/uftition of the thif/h at the hip-joint (1845) ; 
 Thomas Pridgen Teale (1801-68), fi.under of the Leeds School of Med- 
 icine, author of A jjractica/ treatise on (dtdniniiiaf liernia (184(5; trans- 
 lated into German 1848, and into Dutch 1849), and best known by 
 his work. On amputation by a lonr/ and short rectangular flap (1858) ; 
 Joseph Jordan (1786-1873) of Manchester, the first provincial lecturer 
 on anatoni)' and surgery whose certificates were recognized by the Royal 
 College of Surgeons (in 1821), fi)under of the liock Hospital in 1819, 
 
THE HISTORY AXD LITERATURE OF SURGERY. 99 
 
 ami surjifon of tlie Mancliestcr Infirnuuy after 18.'55; George Sontliani 
 (1815-70) of Manchester, founder of the Cliathara Street School of 
 Medicine in 1850, surgeon to the Royal Infirmary in 1855, and professor 
 of surgery in Owens College on its foundation in 1872, author of He- 
 (/ional surgery (3 parts, 1882-86) ; and Josepli Sampson Gamgee (1828- 
 86), the son of a veterinary surgeon, wlio studied at University Col- 
 lege, London, and after graduation studied at Paris, Pavia, and Flor- 
 ence. In 1857 Gamgee was appointed surgeon to the Ciueen's Hospital 
 at Birmingham, which position he retained until 1881, becoming one of 
 the most distinguisluHl provincial surgeons of England. He was a bril- 
 liant operator and a tiuent speidvcr. He urged the dry, infre(juent dress- 
 ing of wounds. His principal publications are — ( )n tlic adranfagcx of 
 the starched appdrctux in (he treatincut fjf frarfures and diseases of Joints 
 (1853), Researches in pathological anatomy and clinicnl sure/ery (1856), 
 On the treatment of fractures of the limbs (1871), and On the trerdment 
 of wounds (1878). 
 
 The leading Dublin surgeons during the century were Golles, Crani])- 
 ton, Carmichacl, Porter, (_'us;ick, Adams, Harrison, Bellingham, Smith, 
 anil Tufncll. 
 
 Abraham Colics (177a-184.j) graduated at Edinburgh in 1797, and in 
 1804 became professor of surgery in Dublin, which position he held for 
 thirty-two years, and for twenty years was the chief of the Irish sur- 
 geons. His name remains connected witJi the form of fracture of the 
 carpal extremity of the radius descril)ed by him in the Edinb. Med, and 
 Surf/. Journid (1814), and with the so-callt'd "Colics' law" — /. e. that a 
 mother infected with syphilis through the ftetus acquires a certain degree 
 of immunity and will not suffer by suckling the infant. In 1816 he 
 first tied the subclavian within the scaleni. His princijial surgical 
 pul)lications are a treatise on surgical anatomy (1811) and Lectures 
 on the theory and practice of surgery (2 vols., 1844-45). 
 
 Sir Philij) Crani])ton (1777-1858), a native of Dul)lin, was appointed 
 surgeon to tlie Mcath Hospital when twenty-one years old, and was one 
 of the founders of the first private school for anatomy and surgery in 
 Dublin. He was a skilful operator and an eloquent lecturer, and con- 
 tributed numerous ])apers to medical journals. 
 
 Kichard Carmichacl (1779-1849), a native of Dublin, but of Scotch 
 descent, passed his examination as assistant surgeon wlicn seventeen 
 years old, and in 1803 settled in Dublin and was apj)ointed surgeon to 
 St. George's Hospital. In 1826 he was one of the founders of the 
 Kichniond School of Medicine, giving lectures on surgery, and was very 
 ])rominent in the various medical associations of his time. He be- 
 (pieathcd to the College of Surgeons in Ireland the sum of £3000, the 
 interest of which was to be used in giving ])rizcs every four years for the 
 best essays on the state pf the medical profession in Great Britain and 
 Ireland, and these, known as the Carmichacl prize essays, are valuable 
 historical documents. His principal works relate to venereal diseases. 
 
 William Henry Porter (1790-1861), a ])U])il of Mr. Crampton, was 
 elected surgeon to the Meath Hos])ital in 1819, and in 1836 succeeded 
 Colles as ])rofessor of surgery in the Royal College of Surgeons. He 
 was a bold ojierator, an chxpient lecturer, and an excellent teacher. 
 Besides a number of important papers in the journals, he published 
 
100 THE HISTORY AND LITERATURE OF SURGERY. 
 
 Observations on the surr/leni pafhofor/i/ of the larjpix and trachea (182G ; 
 2d ed. 1837), a classical work. 
 
 James William ( "iisa('k(l 787-1 SIJl ), sura-cdn to Stcvi'iis's and Swift's 
 hosj)itals, was in 18/32 elected to the prot'cssorship of" surgery in the 
 University of" Dublin, founded that year, and was three times president 
 of the College of Surgeons. He was a bold and skilful oj)erator, trained 
 many pupils, and enjoyed the entire confidence of his ])rofessional brethren. 
 He contributed some pa])ers to periodicals, liut wrote no S])ecial work. 
 
 Robert Adams (1791-1873), surgeon to the Jervis Street and the 
 Richmond hospitals, was one of the founders of the Hiciunoud (or, as it 
 was afterward called, the Carmicliael) School of Medicine, and in 18G1 
 was appointed Regius professor of surgery in the University of Dublin. 
 His principal work was his Treatise on rheumatic gout, or chronic rheu- 
 matic arthritis of all the joints (1857 ; 2d ed. 1873). 
 
 Robert Harrison (1796-1858), a native of Cuniljerland, was appren- 
 ticed to CoUes in 1810, took the degree of M. B. in 1824, and was 
 ap])ointed professor of anatomy and surgery in the University of Dublin 
 in 1S37. His principal work was 'The surgical anatomy of the arteries 
 (2 vols., 1824-25). 
 
 O'Bryen Bellingham (1805-57) graduated at Edinburgh in 1830, and 
 was elected surgeon to St. Vincent's Hos])ital in 1835. His name is 
 especially connected with the treatment of aneurism by compression, a 
 method which was systematized and made popular by Dublin surgeons, 
 and with regard to which his little book, Obserrations on aneurysm, and 
 its treatment by compression (1847), is still a valualile M-ork. 
 
 Robert William Smith (1807-73), a native of Dublin and an appren- 
 tice of Richard Carmicliael, was a teacher of surgery in the Richmond 
 Hospital School, and in 1849 was appointed the first j)rofessor of surgery 
 in the School of Physic of the Univei'sity of Dublin, the chairs of 
 anatomy and surgery having been luiited prior to that date. He was 
 eminent as a teacher and as a skilled pathologist, was for thirty-five 
 years secretary of the Dublin Pathological Society, and made numerous 
 and valuable contril)utions to surgical literature. His principal work is 
 A treatise on fractures in the ricinify of joints, and on. certain forms of 
 accidental and cone/enital dislocations (1847). 
 
 Thomas Jolliffe Tufnell (1819-75), a native of Chippenham, Wilts, 
 studied in London under Brodie and C^sar Hawkins, entered the army 
 medical service in 1S41, and after the Crimean War retired from active 
 service and settled in Dul)lin. He was surgeon to the City of Dublin 
 Hospital and jirofessor of military surgery in the school of the College 
 of Surgeons. His principal ^\•orks \vere — Practiced remarks on the treat- 
 ment of aneurism by compression (1851) and The successful treatment of 
 internal aneurism (1864; 2d ed. 1875). 
 
 In addition to those already mentioned, and excluding those yet 
 living, the following have been the prominent London surgeons since 
 the middle of the century : 
 
 James Luke (1798-1881) studied at the London Hospital, where he 
 became lecturer on anatomy in 1823, lecturer on surgery in 1825, and 
 surgeon to the hospital in 1833, which position he resigned in 1861. 
 His name is specially connected with a simplified method of operation 
 for femoral hernia. 
 
THE HISTORY AXD LITERATURE OF SURGERY. 101 
 
 Frederic Carpenter Skey (1798-1872), a pupil of Abernethy, was 
 for ton years lecturer on surgery in tlie Aldcrsoate School, and in 1843 
 hecanie professor of anatomy at St. Ijartlidlninew's Hospital, to which 
 lie iiad been elected assistant surgeon in 1.S27, and where he became sur- 
 geon in 1854, retiring in 18G4. His principal work was his treatise on 
 Operative surgeri/ (1850 ; 2d ed. 1858). 
 
 John Hilton (1804-78) studied at Guy's Hospital, in the medical 
 school of which he was appointed demonstrator of anatomy in 1828, 
 and held this jjosition for fourteen years, being reputed to lie the best 
 anatomist in London. In 1845 he was ajipointed assistant surgeon, and 
 in 1849 surgeon, at Guy's. He is best known by his book on Bi'sf and 
 pain (1863; 2d. ed. 1877), one of the most valuable contributions of 
 the century to surgical literature. 
 
 Edward Cock (1805-92), nephew and pupil of Astley Cooper, was 
 appointed demonstrator of anatomy in Guy's Hospital medical school 
 on its foundation in 1825, assistant surgeon to the hospital in 1838, and 
 surgeon in 1848, retiring in 1871. He is best known liy his papers on 
 puncture of the bladder through the rectum (1852) and on a method of 
 opening the urethra in cases of impermeable stricture (1866). 
 
 William Coulson (1802-77), a pupil of Tyrrell, studied in Berlin for 
 two years, and on his return was associated with Tyrrell, Jones, Quain, 
 Lawrence, and Wardrop in the medical sciiool in Aldersgate street, in 
 which he taught anatomy. At the same time he was on the editorial 
 stati" of The, Lancd. In 1851 he was elected surgeon to St. Mary's Hos- 
 pital. His jjrincipal works relate to diseases of the urinary organs. 
 
 Henry Hancock (1809-80) studied under Guthrie, became demon- 
 strator of anatomy at the Westminster Hospital School in 1835, and in 
 1839 assistant surgeon at Charing Cross Hospital, where he succeeded 
 to the lectureship of surgery on the death of Mr. Howship in 1841. 
 His principal work was On the operative surgery of the foot and ankle- 
 joint (ISl^i). 
 
 Thomas Blizard (1811-88), a native of London and nephew of Sir 
 William Blizard, became assistant surgeon to the London Hospital in 
 1833 and surgeon in 1849, from which position he retired in 1869. His 
 principal jtuhlications vtcre — A Treatise on tetanus (Jacksonian prize 
 essay, 1836), Practiced treatise on tlie diseases of the testicle, spermcdic 
 cord, etc. (L(jndon, 1843 ; 4th ed. 1878), and Observations on the diseases 
 of the recfuin (London, 1851 ; 4tli ed. 1876). He contributed a number 
 of very valuable papers to the Medico-chirurgictd Transactions, including 
 his " Improved observations on acute ulcerations of the duodenum in 
 cases of burn" (1842). 
 
 Campl)ell de Morgan (1811-76), a younger brother of the mathema- 
 tician, Augustus de Morgan, and a pupil of Sir Charles Bell, studied at 
 LTniversity College, and in 1842 was elected assistant surgeon to the Mid- 
 dlesex Hospital, becoming full surgeon in 1848. In 1866-67 he became 
 joint lecturer on surgery with IVIr. Shaw. He contributed to Holmes's 
 System of surgery and some papers to periodicals, and published The 
 ori(/in of cancer considered with reference to the treatment of the disease 
 (1872). 
 
 John Gay (1813-85) studied in London, and in 1836 became surgeon 
 to the newly-established lloyal Free Hospital. In 1856 he was surgeon 
 
102 THE HISTORY AM) LITERATURE OF SURGERY. 
 
 to the Cirt'tit Nortlicrii Hosijital. His principal works arc — On femoral 
 rupture (1848) and (Jit vnricom veins (18(J.S). He must not be con- 
 founded witli Jdlm (iay (1791-1870), a distinjrnislicd siiryicon at Rwindon 
 and a pii])il of Ahcrnctliy, wlio uradnatcd in 1 Sll , or witii liis son ot'tlic 
 same name, who died at Swindon in llSfiit. 
 
 Kobert Drnitt (18]4-8o) was not cc^nncctcd w itii any liospital and cHd 
 not pi-actise surgery, but his Vdde Meciim, the first edition of wliich ap- 
 l)eared in 1838 and contained the teaehinjis of Green and of Joseph 
 Henry, met with great favor, reaching its eleventh edition in 1878 and 
 a sale of forty thousand copies. 
 
 Kiciiard Holmes C'oote (1817-72), a }>upil of Sir William Lawrence, 
 l)ccame demonstrator of anatomy at St. Bartholomew's in 1846, assistant 
 surgeon to the hos])ital in 1852, and surgeon and lecturer on surgery in 
 1863. He contributed many ])aj)ers to journals and transactions, and is 
 best known by his treatise On joint (Jiseascx, jjublished in 1867. 
 
 John Marshall (1818-91), a student and assistant of Liston, became 
 siu-geon of University College Hospital and professor of surgery, in 
 which position he gave sjiecial attention to physiology and pathology 
 and to the views of Virchow, C'ohnheim, and other German authorities. 
 During the latter part of his life he was president of the General Medical 
 Council. His principal published work was his Outlines of phymology 
 (2 vols., 1867). 
 
 Alfred Poland (1822-72), a pupil of ]\Ir. Aston Key, became dem- 
 onstrator of anatomy at Guy's Hos])ital in 1845, assistant surgeon of 
 the hospital in 1849, and full surgeon in 1861. His Essay on gunshot 
 wounds and their treatment received the Jacksonian prize at the College 
 of Surgeons, and his paper, Tlie injuries and wounds of the abdomen, 
 gained for him the Fotherg-illian medal of the Medical Society of Lon- 
 don. He contributed many papt'rs to Guy's Hospital Reports and also 
 to the weekly medical journals, but wrote no important separate work. 
 
 John Cooper Forster (1823-86), the son of a medical man, studied at 
 Guy's, where in 1850 he was ap])ointed demonstrator of anatomy, in 
 1855 assistant surgeon, and in 1870 surgeon, which latter position he 
 resigned in 1880. He performed the first gastrostomy in England in 
 1858. His only pul)lished separate work was on The sun/ieal diseases 
 ofrhifdren (1860). 
 
 George William Callender (1830-79) studied at St. Bartholomew's, 
 where he became assistant surgeon in- 1861, surgeon in 1871, and lec- 
 turer on surgery in 1873. He contril)uted largely to St. Bartholomew's 
 Hospittd Beports, o{ which he was surgical editor from 1865 to 1873, 
 and also furnished many papers and notes of clinical lectures to journals 
 and transactions. The Transactious of the Royal iSoeiety i'or 1869 con- 
 tain an important i)aper by him on " The formation and growth of the 
 bones of the human face." He \\as one of the first to carry out in detail 
 asepsis in surgery, as contradistinguished from antisepsis. His only 
 separate work was Anatomy of the parts concerned in femoral rupAure 
 (1863). 
 
 Peter Charles Price (1832-64), the son of a physician, studied at 
 King's College, and became assistant to Mr. Fergusson in 1854. He was 
 appointed assistant surgeon to King's College Hospital in 1861. He 
 paid special attention to the pathology and surgery of the joints, and more 
 
THE HISTORY AXH LITERATURE OF SURGERY. 103 
 
 espt'c'ially to tlie diseases of the knee and their treatment hy excision. 
 His principal M-ork is .4 Description of the diseased conditiuim of the knee- 
 joint wltieh require amputation of the limb, and those conditions u^hich are 
 favorable to excision of the joint, etc., pnl)lisiied after his death in 18(55. 
 
 Charles Frederick Maunder (18:32-7!l) studied in Bristol, London, 
 Edinburgli, and Paris, served in the army dnrino- tlie Crimean War, and 
 was appointed assistant surgeon to the London Hospital in l!S()(), and 
 surgeon in 1869. He was a bold and skilful operator, and his text-book 
 on operative surgery (1860; 2d ed. 1873) was an excellent manual. 
 
 "William Frederick Teevan (1833-87) was educated at University 
 College, and was elected assistant surgeon of the West Ijondon Hos- 
 pital for Urinary Diseases in 1866, after which he devoted himself 
 more especially to the surgery of the genito-urinary organs. He is best 
 known by his work. Inquiry into the cuus(dion, diagnosis, and treatment 
 of fractures of the internal table of the skidl (1864), which is a classical 
 work of reference on this subject. 
 
 Marcus Beck (1843-93) studied at Glasgow under Mr. Joseph Lister, 
 his cousin, and at University College, Ijondon, and in 1873 was a])pointed 
 assistant surgeon to University College Hospital, becoming surgeon in 
 1885 and lecturer on surgery in the same year. He was one of the first 
 to introduce antiseptic methods in surgery in London, and, though not a 
 voluminous writer, made some valualile contriliutions to surgical litera- 
 ture, including a paper on " Consecutive nephritis," or surgical kidney, 
 in Reynolds's Si/.stem of medicine, and a jjart of the report on pvitmia 
 and septicemia in the Transactions of the Patholof/icul Society for 1879. 
 
 Frederick LeGros Clark (1811-92), an apprentice of Travers, stud- 
 ied at St. Thomas's Hospital, beginning in 1.S27, and was appointed 
 assistant demonstrator of anatomy in 1830. In 1839 he became lec- 
 turer on anatomy and ])hysiology, in 184.'> assistant surgeon to the hos- 
 pital, and in 1853 full surgeon, which office he retained for twenty years. 
 When ^Ir. St)utli resigned the chair of surgery Mr. Clark succeeded him, 
 and retained the office until he retired from the hospital in 1873. His 
 principal work was his Lectures on the jvinciples of surgical diagnosis : 
 e.speci(dfy in relation to sitock and visceral lesions (London, ]S7t); 2d 
 ed. 1872). A numlier of his papers in journals and addresses were 
 collected and printed under the title of Papers on surgery, pathology, 
 and allied subjects (8vo, London, 1889). 
 
 The two greatest advances in surgery in the nineteenth century are 
 the introduction of aniesthetics, which was due to American surgeons, 
 and will l)e referred to hereafter, and the introduction of systematic and 
 scientific antisepsis and asepsis in the treatment of wounds and the per- 
 formance of surgical operations, which is due to an P]nglish surgeon. 
 Sir Joseph Lister, who brought it into notice in 1867-68. Antiseptics 
 <3f variinis kinds had been proposed and used by others prior to this 
 date. Kiichenmeistcr 'of Dresden had reported good results from the 
 use of carbolic acid in 1860 ; Lemaire's work on carbolic acid ap])eared 
 in 1863; Cam|)bell de Morgan used chloride of zinc in 1866; but it 
 was Mr. Lister who established the method on the basis of Pasteur's 
 ex|K'riments showing that putrefaction is due to the action of micro- 
 orgiuiisms, and who systematically sought for, and found, means to jire- 
 vent the access of these micro-organisms to wounds or to destroy their 
 
104 THE insTonr and litehatt're of ST'naEnY. 
 
 vitality if tliov had already j^aiiicd adiiiissidti, and to do tliis with tlie 
 least po8sil)le injuiy to tlic li\iii<;' tissues. The aetual eauterv and tiie 
 boiling oil of the surgeons of the tifteenth and prior centuries were 
 antiseptic, no doubt, as were also some of the multifarious wound-dress- 
 ings in use since the days of Hippocrates ; but antiseptic surgery began 
 with Mr. Lister, and its progress has lieen largely due to the scientific 
 manner in which he ileveloped and expounded it. A\'ith tlie introduc- 
 tion of Koch's method of t'lilturcs on solid or scnii-solid media, wliich 
 is the fcnindation of the new bacteriology, has come a knowledge of the 
 mode of development and of the results of the growth of some of these 
 organisms which has already revolutionized operative surgery, and 
 made obsolete and com])aratively useless a vast amount of surgical 
 literature and statistics. An illustration of this is given in a compari- 
 son of the results obtained by Liston in 1S44 with those olitained in the 
 University College Hos])ital forty years later, contained in an address on 
 surgery by John Marshall in the British Medical Journal (August 8, 
 1885, p. 235). He concludes that "injuries not involving a breach of 
 the surface of the body, simple intlammations consecutive to these, or so- 
 called idiopathic local intlanuuations whicli come under the care of the 
 surgeon, such as sprains, simple dislocations, synovitis, orchitis, and 
 other cases, were not less satisfactorily treated in 1844-45 than in 1883, 
 and the progress of the patients toward recovery was quite as rapid, but 
 that in eases of wounds and operations the diifcrence in fa\-or of the 
 latter period is very striking." 
 
 After the abolition of the medical faculties and societies iri France by 
 the decrees of 1792 and 1703 the evil results of want of means for giv- 
 ing proper medical instruction soon became evident from the fact that 
 properly-qualified medical officers could not be found to supply the 
 jilaces of those who died in the service of the armies of the Rejiublic. 
 By direction of the National Convention a report was prejiared by the 
 celebrated chemist, Fourcroy, on the best plan of organizing medical 
 schools to meet this want, and in accordance with this report a law was 
 passed in 1794 establishing medical schools at Paris, ]\Iontpellier, and 
 Strasburg. The method taken to secure students was peculiar and effec- 
 tual. From each district in France a young man between seventeen 
 and twenty-six years of age, whose name had not been drawn in the first 
 conscription, was selected Ijy the governmental authorities and forwarded 
 at the expense of the State to one of these schools, three hundred being 
 assigned to Paris, one hundred and fifty to Montpellier, and one hundred 
 to Strasburg. Three years was the period of instruction alkiwed, and as 
 soon as they were considered qualified they were sent to join the troops. 
 These were really military medical schools analogous to that established 
 at Berlin. They did not confer the doctor's degree, the object being 
 simply to manufacture medical officers as soon as possible. 
 
 After several changes the Paris school was definitely organized in 
 1804, and became a medical society as well as a teaching body, the 
 object of the government being to obtain not only a medical faculty, 
 but a scientific body which should be capable of giving advice to the 
 government. The society part of this arrangement was dissolved in 
 1821 by the formation of the Academy of ]\Iedicine. 
 
 In 1806 the Imperial University was created, and in 1808 the med- 
 
THE HISTORY ASD LITERATURE OF SURGERY. 105 
 
 ical school became its faculty of medicine. In 1822, owing to political 
 trouljles, the Faculty of Medicine was suppressed, but it was re-estal)- 
 lished in 182;^ with a change in a number of the professoi's, A. Duljois 
 and Pelletan losing their chairs. 
 
 In 1830 the Faculty of IMedieine was again reorganized, the acts 
 of 1822 and 1823 being abolished and the old professors being again 
 placed in their chairs, while at the same time the concours was again 
 estal)lished as a means of tilling the professorships. Jules Rochard, in 
 his Hisfnirc fJc la ehinnyic fraiujatse an .rl.v' siec/c (Paris, 1875), gives 
 the most complete and satisfactory account of French surgery of the 
 century, and his division of it into four periods will be followed in tliis 
 sketch. 
 
 At the beginning of the century the leading surgeons in Paris were 
 Sabatier, Deschamjis, Lassus, Boyer, Dubois, Pelletan, and Lallement. 
 Sabatier and Deschamps have already been referred to in speaking of 
 French surgeons in tiie latter part of the eighteenth century. 
 
 Pierre Lassus (1741-1807), pi'ofessor of surgery in the £cole de 
 Sant6 and consulting surgeon of Napoleon I., was a learned surgeon who 
 was the author of a good history of anatomy, of a manual of operative 
 surgerv (2 vols., Paris, 1794), and of Pathologic clururf/ica/e (2 vols., 
 Paris," 1805-0(3). 
 
 Alexis Boyer (1757-1 833) was a pupil of Desault and surgeon of the 
 Charite, a modest, quiet, studious, hard-working man, without much 
 originality or brilliancy either in his clinical work or his lectures and 
 writings, but a careful compiler and a thoroughly reliable teacher. His 
 Traite den iiudarJien chirun/icalcs (11 vols., l.S14-2(j) is a practical svs- 
 tem of surgerv, the must complete of its kind then in existence, and for 
 many years it remained the highest authority in this branch of medical 
 literature. His chief contributions to practical surgery were his descrip- 
 tions of the painful crepitation of tendons, of translucency of the tumor 
 as diagnostic in hydrocele, of bleeding fungous tumors, and of the com- 
 plications of fissure of the anus. His system is ciiaracterized by Mal- 
 gaigne as a sununary of the works and opinions of the French Academv 
 of Surgery, which is no doubt correct. It is a resume of French sur- 
 gery which he gives, and he has little or nothing to say of the surgery 
 of Germany, of England, or of America. 
 
 Antoine Dubois (1756-1837), a pupil of Desault, professor of anat- 
 omy in the ftcole de Sante, was a skilful surgeon and a good clinical 
 teacher, but wrote nothing of imj)ortance. 
 
 Philippe Jean Pelletan (1747-1829), a pupil of Louis and of Sabatier, 
 succeeded Des;udt as chief surgeon at the Hotel Dieu, became professor 
 of clinical surgery at the founding of the Medical Faculty of Paris, and 
 consulting surgeon to the emperor. In 1815 he was professor of o])era- 
 tive surgerv, and retired from ])ractice in 1823. He was an eloquent 
 lecturer, but made no valuable contributions to the art. His C Unique 
 chirurr/irafe ('■'> vols.) was pul>lislied in 1810-11. 
 
 Andre Marie Lallement (1750-1830), a pupil of Desault, was surgeon 
 to the Salpetriere anil professor of surgery in the Medical Faculty. He 
 wrote only a few papers for periodicals. 
 
 To these should be added the names of Larrey, Percy, Dufouart, and 
 Siuicerotte. 
 
10() THE HISTORY AND LITERATURE OF SURGERY. 
 
 Dominique Jean Larrey (17(50-1842), the most distinguishod military 
 surgeon at the end of tiio last an<l the beginning of the present eentury, 
 served in the Napoleonic campaigns, and was professor in the military 
 school founded in 179(j at Val-de-Grace. His chief writings are his 
 3I('inoiirs de medcc'uu' ini/itaire ct campagnes (4 vols., Paris, LSI 2-1 7) 
 and his liecueil de 'inemoiir>< fJe cliirtiiyie (Paris, 1821). 
 
 Pierre Francois Percy (1754—1825) was professor in the military 
 medical school in 1820. At his suggestion a battalion of litter-bearers, 
 or a hospital corps, was created in the Italian war. 
 
 To the second period (1814-;}5) belong Dupuytren, Richerand, Roux, 
 Marjolin, Lisfranc, Sanson, and Jules (_'lo(|uet. 
 
 <Tuillaume Dupuytren (1778-ls;55)at the age of eighteen obtained by 
 concours a ])osition as prosector in the Academy, in 1801 became chief 
 of the department, in 1808 obtained a place on the surgical staff of the 
 Hotel Dieu, in 1812 was appointed to the chair of operative surgery, and 
 in 1815 became surgeon-in-chief to the Hotel Dieu. For the next fifteen 
 years he was the most distinguished surgeon in France — and, for that 
 matter, in the world, as tiie fame of his clinical teacliiug drew crowds of 
 .students from all countries. His studies in pathological anatomy and in 
 experimental physiology contributed greatly to his success, which turned 
 largely on his unequalled jiowers f)f diagnosis. 
 
 He was not a student of books, and wrote but little, and that little is 
 not remarkable. He made no great discoveries, his chief contrilmtions to 
 the art being his method of treating artificial anus by means of his com- 
 pressing enterotome, his excisions of the jaws, and the subcutaneous 
 section of the sterno-mastoid. He was a cold, i-eserved, unscrupulous, 
 and ambiti(jus man, Avith contemptuous and oftensive manners, who can 
 hardly be said to have had any personal friends; but he was an incessant 
 worker, thoroughly self-reliant, a bold operator, and unsurpassed as a clin- 
 ical teacher in the jirecision, method, and clearness with which he stated 
 all the salient points of the case on hand. His clinical lectures were 
 noted and published by Brierre de Boismont and Buet in 1832-34 in 4 
 volumes ; a second edition, in 6 volumes, appeared in 1839. Those por- 
 tions of these lectures which relate to injuries and diseases of the bones 
 were translated by F. Le Gros Clark and pul)lislie(l by the Sydenham 
 Society in 1847 ; and other selections, under the title of On /t'.s/o/(.s of tlie 
 rancular sysfein, di.seascs of the rccfinii, etc., by the same translator, form a 
 volume of the Sydenham Society's publications issued in 1854. 
 
 Balthasar Anthelme Richerand (1779-1840) pul)lished his Nomgraphie 
 rhlnn-gicale (1805-06, 3 vols.; 5th ed. in 1821, 4 vols.). He was ap- 
 pointed ]irofessor of surgical pathology in the faculty by Xapoleon in 
 1807. He was more successful as a writer than he was as an oi>erat(U- 
 or teacher, but he had nothing of the impartial spirit of the true critic, 
 and the man whom he praised one year he would denounce the next. 
 He made no special contributions to surgery with the exception of a case 
 of resection of the fifth and sixth ril)s on the left side, being the first 
 instance in which such an ojieration had been performeil to this extent. 
 
 Philibert Joseph Koux (1780-1854) was a student and warm i)ersonal 
 friend of Bichat, \\hom he succeeded as a teacher. He became surgeon 
 at the Charite in 1810, professor of surgery in the faculty in 1820, and 
 succeeded Dupuytren at the Hotel Dieu in 1835. He first became cele- 
 
THE inSTOEV AND LITERATURE OF SURGERY. 107 
 
 brated by the publication, in 1815, of his Bekttion d'nn voyage fait a 
 Londres oi I8I4.; ou parall^le de la chinuyic aiKjloinc arcc la chirurc/ie 
 franqoise — a book which had considerable influence in dilfusing in each 
 country a knowledge of what had been done in the other, in spite of the 
 crude and superficial views on many points which it presented. His 
 most important contributions to the art were in plastic surgery, partic- 
 idarlv in staphylorrhaphy, which he first performed in 181!l, and in 
 suture of the ruj)tured perineimi, which he first performed in 1832. He 
 gave the first distinct course of lectures on surgical anatomy in 1812. 
 His most important literary work was his Quarante annecs de pratique 
 chirurgicale, of which but two volumes were published, the first, relating 
 to plastic surgery, appearing in 1854, and the second, on diseases of the 
 arteries, in 1855. 
 
 Jeau Nicolas Marjolin (1780-1850) was prosector of anatomy in 
 1800, and in 1816 became second surgeon of the Hotel Dieu, but soon 
 retired to avoid unpleasant association with Dupuytren. In 1819 he 
 became professor of surgical pathology. He was a good surgeon and 
 extremely popular as a teacher, but was not distinguished as an operator. 
 His name remains connected with the form of malignant degeneration of 
 chronic ulcer of tlie leg known as the " Marty ulcer of Marjolin." 
 
 Jacques Lisfranc (1790-1847) studied at Lyons and Paris and gradu- 
 ated iu 1813, after which he served for a short time in the army and 
 then settled in Paris. In 1825 he became second surgeon at La Pitie, 
 and a short time afterward, on the death of B^clard, he became the 
 chief surgeon at this hospital. He sought to reduce ojicrative surgery 
 to mathenuitical rules, and his name is connected with methods of par- 
 tial amjjutation of the foot, of amputation at the wrist, the shoulder-joint, 
 and the hi]), and with methods of resection of the head of the humerus, 
 for removal of the lower jaw, for excision of the rectum, and for ampu- 
 tation of the neck of tlie uterus. He was an excellent operator and 
 clinical teacher, liut envious of the greater success of some of his contem- 
 poraries, particularly Dupuytren and Velpeau, and died dissatisfied with 
 himself and witii every one around him. His principal publications are — 
 Clinique chirurgicale de I'hopital de la Fitie (3 vols. 8vo, Paris, 1841-43) 
 and Precis de raedecine op^raioire (3 vols. 8vo, Paris, 1845—48). 
 
 Louis Joseph Sanson (1790-1841) was a pupil and friend of Dupuy- 
 tren. After serving in the army from 1812 to 1.S15, he returned to Paris, 
 and in 1825 became the second surgeon of the Hotel Dieu. In 1836 he 
 succeeded Dupuytren as professor of clinical surgery, winning the place 
 by concours. The first forty years of his life were a continued struggle 
 with ])overty, and his subordination to Dujniytren prevented him from 
 obtaining tlie re|)utation to which his skill as a diagnostician and operator 
 entitled him. His jjrincipal work was the Nourraux elements de patho- 
 logic medieo-chirurgicalc, par Roche et Sanson (4 vols., 1824 ; 3d ed. 
 1833), of which he wrote all the surgical part. 
 
 Jules Germain Cloquet (1790-1883) came to Paris in 1810 and be- 
 came preparer for the museum of the School of Medicine. He published 
 a valuable scries of anatomical observations on hernia in 1817, and a 
 magnificent work on human anatomy, containing a large number of plates, 
 Mhich is still classic; in 1831 he l)ecamc ])rofessor of surgical jiathoiogy, 
 and succeeded Dubois in the chair of clinical surgery iu 1833, which 
 
lOS THE HISTOKY AND LITERATURE OF SURGERY. 
 
 position he retained until ISTjO. He eontrihutcd a larjije number of 
 papers on anatomical and surgical subjects to the journals, and devised 
 a number of new instruments. 
 
 Joseph Souberbielle (1754-1846) studied at Paris under Desault and 
 entered the army. He took his degree in 1813, after \v]ii<']i he remained 
 in Paris, devoting himself chiefly to litiiotomy, and especially to the 
 supraj)ubic method. He was a relative of Frere Come and of his 
 nephew Baseilhac, and inherited their instruments and reputation. He 
 is said to have performed the suprapubic operation over twelve hundred 
 times. 
 
 To this period l)elongs the introduction of lithotritv, with mIucIi are 
 especially connected the names of Civiale, Leroy (d'lLtiollcs), and Hcur- 
 teloup. 
 
 Jean Civiale (1792-1867) studied at Paris, graduating in 1820, and 
 made a specialty of the diseases of the urinary organs, and especially of 
 lithotrity, which he successfully performed on a living human subject in 
 January, 1824. In 1828 a special section for those afflicted with calculus 
 was set apart for him in the Hospital Necker, and his practice became 
 enormous. He had much mechanical ingenuity and dexterity, but he 
 was neither a speaker nor a writer, and the greater part of the numerous 
 publications which appeared under his name were really written by 
 Jourdan, Boisseau, Begin, and others. In his first book, Xouirlles con- 
 siderations SUV la retention (F urine, etc. (1823, p. 115), he referred to a 
 report of Pouteau that " haricots blancs " had passed from the stomach 
 into the urinary bladder, etc., and said : " Si les faits rapportes sont exacts, 
 ccs corps suivent-ils le torrent de la circulation?" Some kind friend 
 pointed out the blunder to him before the edition was put on the market, 
 and he cancelled the greater part, but a few had been sent out as pres- 
 entation copies, and these are now regarded as curiosities in medical 
 literature. 
 
 Jean Jacques Joseph Leroy (d'fitiolles) (1798-1860) studied at Paris, 
 graduating in 1824, prior to which he had devised a three-pronged 
 instrument for seizing and perforating a stone in the bladder, and his 
 whole life was mainly devoted to this branch of surgery and to bitter 
 contests as to priority of invention. He was not, however, a pure 
 specialist, and was a much more scientific man than Civiale. The list 
 of his publications is a long one, but they are comparatively brief 
 papers. 
 
 Charles Louis Stanislaus Heurteloup (1793-1864), son of Baron 
 Nicolas Heurteloup, a distinguished French army surgeon, studied in 
 Paris, graduating in 1823, and almost inniiediatcly turned liis attention 
 to the suliject of lithotripsy and to criticism of the work of Civiale and 
 Leroy (d'Etiolles). He greatly improved the instruments used in lith- 
 otripsy, and is said to have spent one hundred and fifty thousand francs 
 in perfecting his inventions. From 1828 to 1832 he was in London, 
 and published there hh Principles of Lifliofriti/ {18SI). 
 
 To this period also belong Delpecli and Lallemand of INIontpellier. 
 
 Jacques Mathieu Delpech (1777-1832), a native of Toulouse, gradu- 
 ated at :Montpellier in 1801, after which he studied in Paris. In 1812 
 he obtained, by concours, the chair of surgery at Montpellier, and soon 
 became celebrated as an operator and as a clinical teacher. In the height 
 
THE HISTORY AND LITERATURE OF SURGERY. ]09 
 
 of liis fame he was assassinated by a patient wlioni lie liad treated for 
 some disease of tlie genitals. His principal contributions to snrgery 
 relate to hospital gangrene and to ortiiopivdia. He tirst j)i)inted out that 
 tubercular disease of the vertebrte was the frequent origin of Pott's dis- 
 ease of the spine, insisted on the importance of the tilirous tissues in con- 
 nection with deformities, and in 181(3 performed subcutaneous section of 
 the tcndo Achillis with the avowed intention of thus excluding the air 
 and obtaining union by tirst intention. The successor of IX'lpech in 
 the chair of clinical surgery was Michel Serre (1799-1849), who gradu- 
 ated at ^Nlontpellier in 1825, and who published his Trniie de la reunion 
 immediate, etc., in 1830, and his Traite sur Part de re.staurcr les difform- 
 ifes de la face, etc., in 1842. 
 
 Claude Fraufois Lallemand (1790-1853), a native of Metz, studied 
 at the jNIilitary Medical School of that j)lace, and at the age of thirteen 
 entered the army medical service. In 1811 he went to Paris and became 
 an assistant to Dupuytren ; in 1819 he was appointed professor of clinical 
 surgery at Montpellier ; and after the death of Delpech he was the chief 
 surgeon in the south of France. In 1823 he lost his jdace for ten months 
 through clerical intrigues, but M'as repliiced by the Council of Public 
 Instruction. He is best known as the author of T>ei< jiertes m'miiudes 
 inrolontaires (.3 vols., 183*3-42), of which several English translatiiins 
 were published. He devised the method of autoplasty by bending with- 
 out twisting the flap, and the method of treating erectile tumors by the 
 insertion of needles. 
 
 In the third period (1835-47) come Gerdy, Velpeau, Blandin, A. 
 Berard, I^augier, Jobert, Amussat, and Vidal. 
 
 Pierre Nicolas Gerdy (1797-185(3) studied in Paris under the most 
 adverse circumstances of poverty and sickness, and in 1828 became 
 second surgeon to La Piti6, where he was under the orders of Lisfranc, 
 who gave him very few opportunities. In 1831 the surgeons of the 
 hospitals were placed on an ecpial footing, the position of surgeon-in- 
 chief being abolished. In 1833, as the result of an intrigue of r)u])uv- 
 tren to suppress Velpeau, Gerdy became professor of the princij)k's of 
 surgery in the faculty, and in 1839 was appointed surgeon to La Charite, 
 taking the place of Guerbois. The list of Gerdy's works is a long one, 
 but he was a physiologist rather than a surgeon, and his most important 
 surgical publication was his Traite de.^ bandages et de.H ^Jonseinoit.t (2 
 vols., 1837-39). 
 
 Alfred Armand Louis Marie Velpeau (1795-18(37), the son of a 
 blacksmith, whose trade he learued, studied at Tours, ^\•here he received 
 the diploma of officier de sante, and in 1820 came to Paris, and soon 
 became assistant preparer for Cloquet. He graduated in 1823, and pub- 
 lished his Traite d'anatomie chirurgicule, the first complete and syste- 
 matic work in which the details of regional anatoniv were throughout 
 considered with reference to tlieir surgical relations. In 1828 he Ijecame 
 surgeon to the Hosj)ital St. Antoine, and in 1830 to La Pitie, where ho 
 remained until 1834, when he was elected to the chair of clinical sur- 
 gery in the faculty left vacant by the death of Boycr. In 1832 he ])ub- 
 lished his Noiircaux elements de medecine oprndoire (3 vols, and atlas), 
 the largest and most complete work on this subject which liad vet 
 appeared. The English translation of this by Townsend, with notes 
 
110 THE HISTORY AND LITERATURE OF SURGERY. 
 
 of Valentine Mott (New York, 1847), and especially the latest edition, 
 with additions by G. C. Blackman (New York, ISofi, 3 vols, and atlas), 
 is a ^reat storehouse of liistorical data relating- to the prineipal Oj)ei-a- 
 tions of surgery up to that date. In 18o4 he pul)lishcd his Traitf dcx 
 maladies du .sehi, a large hook, eharai'terized by Trelat as the most orig- 
 inal, personal, and probably the most durable of his works, and whicli 
 must not be confounded with his Petit traite des maladies du sein, pub- 
 lished in 1838 as a reprint of his article in the Dictionnaire de medecinr, 
 and which was translated into English by Parkman in 1840. He made 
 no great discoveries or improvements, yet he contril)uted grcatlv to the 
 progress of surgery Ix'tween 1825 and 1855, and especially in surgical 
 anatomy, the pathology of pysemia, the diagnosis of tumors, and the 
 diseases of the breast. A man of strong common sense, an indefatigable 
 M'orker, a conscientious and conservative critic, an excellent teacher and 
 operator, his lessons were followed by crowds of pupils, including mam- 
 \\'h() became distinguished surgeons in other countries as well as in 
 France. 
 
 Philipp Frederic Blandin (1798-1849) graduated at Paris in 1824, 
 in 1828 became a surgeon to the Hosj)ital Bcaujon under Marjolin, 
 and in 1841 succeeded Richerand in the chair of ojierative surgery. 
 He also became surgeon to the Hotel Dicu. Blandin was not a great 
 surgeon nor a great teacher, and there is little in his writings which is 
 of interest at the present day, but he was a sensible, practical, honest 
 man who did good Avork in iiis time. 
 
 Augusta Berard (1802-46) studied at Paris, graduating in 1829, 
 became a surgeon of the Central Bureau by eoncours in 1831, and, sul)- 
 sequently, surgeon to the hosjiitals St. Antoine, Salpetriere, Nccker, and 
 La Pitie, and in 1842 succeeded Sanson as professor of clinical surgery 
 in the faculty. The student part of his life was one of great poverty, 
 shared by his brother, P. Berard, who devoted himself to physiology. 
 A. Berard wrote some excellent eoncours theses, many articles in the 
 Dictionnaire de medecine, and began, with Denonvilliers, a Compendium 
 dc chirur</ie prati(jiic, of which only a portion was issued at his death. 
 His contributions to surgery relate to the treatment of fractures, con- 
 tinuous irrigation of wounds, erectile tuuKn's and varices, staphylor- 
 I'haphy, etc. He was a skilful operator and an excellent teacher. 
 
 Stanislaus Laugier (1799-1872), a pupil of Dupuytren, graduated at 
 Paris in 1828, became surgeon to the Hospital Nccker in 1832, to the 
 Hospital Beaujon in 1836, jirofcssor of clinical surgery in the faculty in 
 1848, and surgeon to the Hotel Dieu in 1854, succeeding Roux. He 
 first called attention to the discharge of serous tluid from the ear in 
 certain fractures of the skull, and was the first to propose suture of 
 divided nerves. He was a ]irudent, quiet, conservative surgeon and a 
 good teacher, but he wrote little and his name is now almost forgotten. 
 
 Antoine Joseph Jobert (1799-1867) studied at Paris, graduated in 
 
 1828, was appointed a surgeon of the Central Bureau by eoncours in 
 
 1829, and surgeon to the" Hospital St. Louis in 1831.' In 1853 he 
 became surgeon to the Hotel Dieu, and in 1854 succeeded Roux as pro- 
 fessor in the faculty. His childhood and student-life were spent in 
 great poverty, at times in actual destitution ; his subsequent life was a 
 very unhappy one, in S2jite of the honors and wealth to which he attained ; 
 
THE HISTORY AXD LITERATURE OF SURGERY. Ill 
 
 he became gloomy and eccentric, and cndi'd his days in an asyhini for 
 tlie insane. Lacking in preliminary edncation and in oratorical gilts, 
 liis snccess was dne to the novelty and importance of his contrihutions 
 to plastic surgery and to the surgery oi' the female organs of generation. 
 He was a better writer than speaker, and wrote much ; his Mhnoire. nur 
 les phucs (hi canal intesfiiwl, published in 1826, before his graduation, 
 was based upon the experimental method of Hunter, and demonstrated 
 the importance of producing union between the serous surfaces. His 
 most important \vorks were — Traitf dc chirurf/ie plaatignc (2 vols, and 
 atlas, 1849), Traite dcs fishdes vesico-iderines, etc. (1852), and I)c la 
 reunion en chirurgie (1864). 
 
 Jean Zulema Amussat (1796-1856), the son of a country physician, 
 entered the army medical service in 1814, after which he studied at 
 Paris, grachiating in 1826. He did not become a professor in the 
 faeultv or surgeon to a great hospital, but he commenced private teach- 
 ing even before he graduated, and he connuunicated most of his discov- 
 eries to the Academy of Medicine, which granted him prizes for liis 
 contributions on lithotrity, on the torsion of arteries, on the entrance of 
 air into the veins, on lumbar colotoniy, etc. He wrote much, but his 
 papers were never collected. 
 
 Auguste Theodor Vidal (de Cassis) (1803-56) studied at Marseilles 
 and Paris, graduating in 1828, soon after which he became connected 
 with the newly-founded Gazette des hupitau.r. He never became a pro- 
 fessor or connected with a great surgical clinic, and, being a sarcastic 
 journalist and rather bitter critic, he made few friends. His reputation 
 as a surgeon rests upon his Traitr de patlinlor/ie c.rtcrnc (5 vols., 18.">8 — 11 ), 
 which was a popular manual and reached a fifth edition in 1860. He 
 invented serres-tines, was the first to inject a solution of nitrate (if silver 
 into the uterine cavity, and conti'ibuted largely to our knowledge of 
 syphilis, successfully opposing Ricord, the great authority of the day, in 
 some important points relating to this disease. 
 
 Joseph (tcusouI (1797-1858) studied at Ijvous and Paris, graduating 
 in 1824, and in 1826 became chief surgeon of the Hotel Dieu of Lyons, 
 where he soon accjuired celebrity as a bold and skilful operator. He first 
 (in 1826) excised the entire upper jaw, in 1827 he removed the parotid 
 gland, and, first in France, excised half of the lower jaw, and he first 
 treated varices with caustic. He M'rote very little, his chief publication 
 being hia Lcffre chiriirf/icale sitr (pwltpies iii(dadicii r/ravcs du sinus ma.v- 
 illaire et de I'os ma.riUaire inferieiir (1833). 
 
 Amedce Bonnet (1802-58) studied at Paris, where he graduated in 
 1832, and in 1833 obtained the position of surgeon to the Hotel Dieu 
 at Lj'ons by concours, after which he Ijccame a professor in the school, 
 and was soon celebrated as a teac-her. His principal publications 
 are — Traite des sections tendine.uses et mnscidaircs dans la strabisme, la 
 mjinpie, etc. (1841), Traite des maladies des articidations (2 vols., 1845), 
 and Traite de therapentiqne dcs mrdadies a rticidcdrcs (1853), which latter 
 remain as valualile contributions to the surgery of the joints. 
 
 Charles Gabriel Pravaz (1791-1853) studied at Paris, graduated in 
 1824, and devoted himself to ortho]);rdic surgery, associating himself 
 with Jules Guerin in a private orthupicdic hospital. In 1835 he settled 
 in Lyons. His principal contribiuions to surgery relate to orthopiedia 
 
112 THE HISTORY AND LITERATURE OF SURGERY. 
 
 — which he was one of the first to ])lace on a scientific fonndation — to 
 the use of percliloride of iron, to tiie use of fine liollow needles for the 
 injection of varices or erectile tumors, etc. 
 
 Raoul Henri Joseph Scontettin (1799-1871), a native of Lille, 
 entei'ed the army, and i!;raduated at Paris in 1822. He liecame one of 
 the most distiniiiiisiied of Freneli military surgeons, was professor in the 
 school at Metz in 18;i(i, and in 184U held the same position in the mili- 
 tary hospital at Strasburg. In 1854 he was in charge of the military 
 liosjiital in Constantinople and Pera, after which he returned to Metz, 
 and was in charge of the military hospital until his death. He was a 
 voluminous writer on matters connected with military medicine and 
 surgery, and an excellent operator. He successfully performed traciie- 
 otomy on liis infant daughter six weeks old. 
 
 Jean Baptiste Lucien Baudens (1804-57) studied in Paris, entered 
 the army medical service in 1823, and graduated in 1829. He served 
 in Africa from 18.'50 to 1837, in 1838 became professor in the hospital 
 at Lille, and in 1842 professor at Val de Grace. He M'as a distin- 
 guished military officer, and made numerous contriljutions to military 
 surgery, among which may be mentioned his ttuuque des pluies d'armes 
 fl feu (1836) and his La guerre de Crimee, les campements, les abris, les 
 mnbulances, les hopitaux, etc., first published in the Revue des deux- 
 moiides in 1857, and in separate form in 1858. 
 
 Jean Gaspard ]?laise Goyrand {lS()3-6(j) studied at Paris, graduated 
 in 1828, and, returning to his native city Aix, became chief surgeon to 
 the hospital, and one of the most distinguished of the French provincial 
 surgeons of his day. He made important contributions to the literature 
 of am])utations, fractures of the hnver end of the radius, operations for 
 h)ose l)odies in the joints, extirpation of the tongue, urethral fistula, 
 etc. His principal work is his ('Unique cldruryicule ; viemoires et obser- 
 vations de ehirurgie, etc: (Paris, 1870), published after his death by Dr. 
 Silbert. 
 
 Jules Roux (1807-77), a native of Aix, studied at Toulon, entered 
 the naval medical service in 1828, and became professor in the school 
 of Toulon in 1842. He was distinguished as an operator and clinical 
 teacher, devised a useful modification for disarticulation of the foot, 
 made improvements in the ojteration of trephining, and was the first to 
 make use of iodine injections in disease of the shoulder-joint. He made 
 numerous contributions to the journals and learned societies, but jiwb- 
 lished no important separate M'ork. 
 
 To the fourth period (from 1847 to the present time) belong, in addi- 
 tion to those already referred to and those who are still li\'ing and do 
 not yet belong to history, a nundjer of well-known surgeons, of whom 
 the most prominent at Paris were Malgaigne, Nelaton, Denonvilliers, 
 Chassaignac, Richet, Follin, Broca, Dolbeau, Gosselin, and Tr^lat. 
 
 Joseph Fraufois Malgaigne (1806-65), a native of the Vosges, son of 
 an officier de sante, studied at l^u'is, graduating in 1831, and after a short 
 term of military service in Poland settled in Paris, where he became a 
 surgeon of the Central Bureau in 1835, and began to teach surgical 
 anatomy. He was successively surgeon to the Hospital St. Louis and 
 to La Charite, and in 1850 won by concours the chair of operative sur- 
 gery vacated by Blandin. 
 
THE HISTORY AND LITERATURE OF SURGERY. 113 
 
 Malgaigne was the greatest surgical historian and critic which the 
 worUl has yet seen, a brilliant speaker and writer, whose native genins, 
 joined to incessant labor, brought about a new mode of judging of the 
 merits of surgical procedures — the mode of statistical comj)arison joined 
 to experiment. He was not a great operator, and although he made 
 some improvement in the art, such as his hooks for the treatment of 
 fractures of the patella, his suggestion of suprathyroid laryngotomy, 
 etc., these are of small importance as compared with his work of explod- 
 ing errors, exposing fallacies in reasoning, and bringing to bear upon 
 tlie work of the present day the light of tlie experience of the past, of 
 which his treatise on fractures and dislocations affords many excellent 
 examples. The reports of his spci'clics in the Bulletins of the Academy 
 of ^Medicine are among the most delightful reading in surgical literature. 
 
 Auguste Nelaton (1807-73), the son of a French soldier, a native 
 of Paris, studied at the Hotel Dieu under Du])uytren and at the Found- 
 ling Hospital, graduating in 1836. He became professor of clinical 
 surgery in 1851, was for many years a colleague of Malgaigne at the 
 Hospital St. Louis, and for' the last fifteen years of his life was the most 
 popular surgeon in Paris. He was, in fact, in many respects, the best sur- 
 geon whom France has produced during the century, being unsurpassed 
 as a diagnostician, as an ojierator, and as a clinical teacher, and was a 
 modest, quiet gentleman who attacked no one and befriended many. He 
 made mnnv improvements in surgical tccluiiquc, among which was tlie 
 porcelain-headed prol^e wliich he devised for demonstrating the presence 
 of the bullet in Garibaldi's ankle-joint. He brought into French prac- 
 tice the principle, so strongly insisted on by Guthrie, of ligating both 
 ends of a wounded artery within the ^v()und for either primary or 
 secondarv hemorrhage, improved tlie methods of treatment of naso- 
 jiharvngeal tumors, first clearly demonstrated retro-uterine hsematocele, 
 and brought ovariotomy into good repute in France. He wrote com- 
 paratively little, his chief publication being his Elements cle pafhologie 
 chirurcjicale (5 vols., 1844—59, of which the last two volumes were pub- 
 lished by A. Jamain). The only publication of his clinical lectures is 
 that made in 1855 by Dr. ^y. F. Atlee of Phila<lelphia from his own 
 notes — a book which is not nearly as well known as it deserves to be. 
 
 Charles Pierre Denonvilliers (1808-72) studied at Paris and grad- 
 uated in 1837; became a surgeon of the Central Bureau in 1840, in 
 1842 chief of the School of Practical Anatomy and surgeon of the 
 Hotel Dieu, and in 1856 professor of surgery. He was, however, more 
 of an anatomist than a surgeon, although he was a good operator, 
 especially in tlie field of plastic surgery. His most important services 
 to medicine were rendered in his cajiacity as inspector-general of public 
 instruction for medicine, to which he was appointed in 1858. 
 
 fidouard Pierre Marie Chassaignac (1804-79) studied at Nantes and 
 Paris, graduating in 1835, and gave private courses in anatomy and 
 operative surgery, but did not become a professor in the fiiculty, 
 altiiougli he often competed for this jiosition. He became surgeon to 
 tlie Laril)oisiere in 1852. His most important contributions to surgery 
 were the introduction of the method of the drainage of wounds and 
 abscesses, his method of di'cssing wounds by complete occlusion, and his 
 invention of the ecraseur. 
 
 Vol. I.— s 
 
114 THE HISTORY AND LITERATURE OF SURGERY. 
 
 Louis Alfred Richet (1816-91), a native of Dijon, studied in Paris, 
 graduatinij in 1844. He was surgeon to tlie liospitals Loureine, St. 
 Antoine, and La Pitie, and in 18()4 became professor of elinieal surgery 
 in the faculty. His princij)al work was his TraiU' prufiqac d'anatomie 
 medico-ehirurf/lnde (Paris, 1857; 4th ed. 187.')). 
 
 Eugene Follin (182;}-67), a pupil of Veljieau, was a skilled anatom- 
 ist and excelled in diagnosis. He introduced the use of the ophthal- 
 moscope in France. His early death left his Traite rlniioitairc dc 
 pafliolni/ic c.iiciiic untinisiied, but it was continued and coni])letcd in six 
 volumes by Duplay, and is a work of much practical value. His 
 contributions to surgery are characterized by freedom from exaggera- 
 tion and by sound sense. 
 
 Paul Broca (1824-80), the son of an army surgeon, studied at Paris, 
 graduating in 1849, immediately after which he became prosector at the 
 Fcole pratique. In 185;5 he became assistant profess(U' in the fticulty, 
 and in 18(57 professor of surgery, soon after which he exchanged this 
 chair for that of clinical surgery. He was successively surgeon to the 
 hospitals St. Antoine, La Pitie, Des Cliniques, and Necker. He was an 
 original investigator of a high order, as is shown by his researches on 
 cerebral localization, aphasia, etc. Distinguished as an anatomist, a 
 pathologist, and a surgeon, he devoted himself in the latter part of his 
 life more especially to anthropology, of which he may almost be said to 
 have been the founder in France. He was the first to trephine for an 
 abscess of the brain, the location of which was determined by his study 
 in the localization of function of that organ. In fact, his studies may 
 be said to be the foundation of modern brain-surgery. 
 
 Henri Ferdinand Dol])eau (1830-77) studied at Paris, graduating in 
 1856, became hospital surgeon in 1858, serving successively at the 
 Hospital for Children, Necker, and the Hotel Dieu, where he replaced 
 Jobert in 1865, and in 1868 became professor in the faculty. He 
 contributed to our knowledge of cluli-foot, of cartilaginous tumors, of 
 epispadias, and of spina bifida, suggested lithotrity through perineal 
 section in cases of large calculus, and was an excellent practical teaclier. 
 His principal works are De V epispadias (1861), Tmite pjndicjuc dc la picrre 
 dans la vessie (1864), and Legons de dinique chirurgic(dc (1867). 
 
 Athanase Leon Gosselin (1815-87), a native of Paris, graduated in 
 1843, and became surgeon to the hospitals, and in 1858 professor of 
 surgery in the faculty, and surgeon to La Charitc in 18()7. He contrib- 
 uted to journals many \'aluable papers which were collected and pub- 
 lished in his Clinique chirurgicalc de r/topitid de la Charite (2 vols., 
 1873; 3d. ed. 1879, and translated into English, Philadelphia, 1878). 
 
 Ulysse Trelat (1828-90), the son of a physician, and a native of Pari.s, 
 studied at Paris, graduating in 1854. He became jjrosector in 1856, in 
 1857 assistant ])rofi'ssor in surgery to the faculty, and in 1S6() surgeon 
 of the Central Bureau, serving successively at tlic liospitals Maternite, St. 
 Antoine, St. Louis, La Pitie, and La Charite. He l)ecanie professor of 
 surgical pathology in the faculty in 1872. He was an eloquent speaker 
 and fond of speaking, a very popular clinical teacher, and the first in 
 France to recognize the importance of the new antiseptic method. 
 His publications were mainly in journals and transactions ; they relate 
 chiefly to plastic surgery of the j)alate and of the face, to hernia, tuber- 
 
THE HISTORY AXD LITERATURE OF SURGERY. 115 
 
 ciilosis of the tong'ue, a^s(i|)]i;iuiiti)my, etc. His Lcgons de cliniqiie 
 chu-urgicale appeared in 1877, ami his LTtnique chirun/icnlc (2 vols.) in 
 1891. 
 
 In addition to these mav be mentioned the i'olh)win<r : 
 
 Joseph Pierre Eleonor Petrequin (1809-76) studied at Paris, gradu- 
 ating in 1835, in 1838 became an assistant surgeon in the Hotel Dieu at 
 Lyons, and in 1855 became professor of surgery in the school. He was 
 a learned historian in matters pertaining to the art, a skilled physician 
 as well as surgeon, and a voluminous writer. His principal publicaticms 
 are — Traife (Vanatomie iiu'dico-c-hirurgk-ak ct topo<jfaphujue (1844 ; 2d 
 cd. 1857, translated into German, 1845), CTinique chirnrglcale dc I' Hotel 
 Dieu de Lyon (1850), Melanges de chirurgie et de medecine (1870, 1873, 
 1877), and Chirurgie d'Hipp'oerate (2 vols., 1878). 
 
 Joachim Albin Cardozo Cazado Giraldes (1807-75), a native of 
 Portugal, studied at Paris and graduated in 183(). In 1848 he liecame 
 a surgeon of the Central Bureau, and was appointed to the Children's 
 Hospital. The results of his work in this hospital ap}X'ar in his Legons 
 cliniques su)- les maladies chirnrgieides des enfants, etc. (18(J9). 
 
 Charles Emmanuel Sedill(it (1804-83),' a native of Paris, studied 
 under Rover and Roux, and in 1824 at the Val de Grace. He gradu- 
 ated in 1829, after wiiich he entered the military service, and in 183(3 
 became professor of operative surgery at Val de Grace. In 1841 he 
 became professor of surgery at Strasburg by concours, succeeding Begin. 
 He made many valuable contributions to surgery, relating, among other 
 things, to dislocations, plastic operations, urethrotomy, pyiemia, the sur- 
 gery of the bones, gastrotomv — to wliich he gave the name — operations 
 for cancer of the tongue, etc. In 1840 he performed the first successful 
 amputation at tiie hip-joint in Paris. 
 
 Paul Louis Benoit Guersaut (1800-70), son of a celebrated Paris 
 physician, studied at Paris, graduated in 1828, and in 1833 became 
 surgeon to the Children's Hospital by concours, remaining in this posi- 
 tion until 18(30. His principal work is his ^Vo^/ccs sur la chirurgie des 
 enfanh (18(34-(37; translated into English, 1873). 
 
 Jules Rene Guerin (1801-8(3), a native of Boussu (at present in Bel- 
 gium), studied at Paris, being a jiupil of B(iver and Roux, and graduated 
 in 1826. In 1830 he founded the Gazette viedicale de Paris, of wiiich 
 he was the editor for forty years. He devoted Iiimself to orthopjedic 
 surgery, having established a private orthopaedic hospital, and in 1838 
 publisiied his first memoir on deformities of the osseous system, which 
 was followed by a long series of similar jiapers. A portion of these 
 have been collected and jiublished under the title (Euvres du docteur 
 Jules Guerin, etc. (Paris, 1882), said to have been intended to fill 16 
 volumes, with 100 j)lates, but which has never been finished. As a 
 controversialist and •journalist he was better known and better liked 
 among non-jirofessional persons than among those of his own pro- 
 fession. 
 
 Felix Adolplie Richard (1822-72) studied at Paris, and graduated 
 in 1848. He became surgeon of the Central Bureau in 1852, and as- 
 sisted Nelaton in his clinical teaching. His princijial work is his Pratique 
 journaliere de la chirurgie (1868). 
 
 ^\'Iien the Austrian Netlicrlaiids became a part of the French Re- 
 
lU) THE HISTORY AND LITERATURE OF SURGERY. 
 
 public, in 1795, the five modical scIkioIs in Bclj^iiini were snpjirci^secl, as 
 those in France had been, and with much tlie same results. Each lai-ge 
 town attempted to regulate the matter by local examinations and by the 
 establishment of schools of an inferior class, mainly devoted to giving 
 instruction in surgery and obstetrics to uneducated men. \\'hcn the 
 kingdom of the Netherlands was created in 1815 the Universities of 
 Ghent and Liege were established and the iild University of Louvain 
 was rehabilitated. In organizing these schools a strong German element 
 was introduced, and it was ordered that the lectui'es should be given in 
 Latin. The result was a failure, for Paris was the great medical school 
 of the day, and the Belgian students went there. The Revolution of 
 1830 closed the universities, and in 1835 medical teaching was placed 
 substantially on the French basis. 
 
 The leading surgeons of Holland in this century have been Hen- 
 driksz, Onsenoort, Tilanus, and Ranke. 
 
 Pieter Hendriksz (1779-1845) served in the army, studied at Gron- 
 ingen, where he began to teach surgery in the hospital in 1810, in 1827 
 was called to Leyden, and in 1828 to Amsterdam as professor, which 
 position he resigned in 1832. He published descriptions of his opera- 
 tions in the Groningen hospital in 1816, in 1822, and in 1828. 
 
 Anthony Gerard van Onsenoort (1782-1841), a surgeon's apprentice, 
 served in the army, began to teach in Lowen in 1817, and in 1822 con- 
 tinued teaching in Utrecht. He publislied De mUitaire chimrr/ic (1832) 
 and iJc operative heclkunde (3 vols., 1835-37), besides several works on 
 ophthalmology. 
 
 Christian Bernard Tilanus (1796-1883), a native of Harderwijk, 
 studied at Utrecht, graduating in 1819, and then in Paris under Dupuy- 
 tren and Lisfranc, and in 1828 became professor of surgery and obstet- 
 rics in the school at Amsterdam, where he was the first to give regular 
 clinical teaching in surgery in the hospital. He ceased teaching in 
 1872. 
 
 Hans Rudolph Ranke (1849-87), a native of Kaiserwerth and a 
 pupil of Volkmann, graduated at Halle in 1874, and in 1876 became 
 professor of surgery at Groningen. He contributed a number of papers 
 to journals, but published no important work. 
 
 At the beginning of the nineteenth century the leading Italian sur- 
 geons were Scarpa, Palletta, Monteggia, and Vacca Berlinghieri. 
 
 Antonius Scarpa (1752-1832) studied at Padua under Morgagni, 
 graduating in 1770 at the age of eighteen. Two years later he was 
 ajipointed professor of anatomy and theoretical surgery at the University 
 of Modena, and in 1783 was appointed by Joseph II., emperor of 
 Austria, as professor of anatomy at the University of Pavia, to which 
 was added in 1787 the chair of clinical surgery. He retained l^oth these 
 professorships until 1803, when he gave up anatomical teaching, Init con- 
 tinued to teach in clinical surgery until 1812. He was the most cele- 
 brated Italian anatomist and surgeon of his day, and his talent as an 
 artist enal)led him to illustrate his discoveries in a manner which at once 
 attracted general attention. His name is perpetuated in surgery by 
 " Scarpa's triangle." 
 
 Giovanni Battista Palletta (1747-1832) graduated at Padua in 1769, 
 and in 1787 became chief surgeon of the Hospital Maggiore in Milan, 
 
THE HISTORY AND LITERATURE OF SURGERY. 117 
 
 ami gave lessons in anatomy and clinical snrgery. He M'as greatly 
 beloved, and his death was consitlered as a public calamity in Milan. 
 
 Giovanni Battista Monteggia (1762-1815) became professor of anat- 
 omy and surgery in Milan in 1795, and was associated with Scarpa in 
 the preparation of Istituzioiii di chii-un/ut, (5 vols., 1802-03; 4tii ed., 
 7 vols., 1829-30). 
 
 Andrea Yacca Bei-linghieri (1772-1826), son of Francesco ^'acca 
 Berlinghieri, professor of medicine at Pisa, studied at Paris under 
 Desault and at London under John Hunter, and, returning to Pisa, 
 graduated in 1791. In 1801 he became professor of surgery at Pisa, 
 and soon acquired a great reputation. 
 
 In the middle of the century the best-known Italian surgeons were — 
 Luigi Porta (1800-75), who studied at Pavia, was for three years in 
 Vienna, and became professor of clinical surgery at Pavia in 1832, 
 which ])ositi(>n he held until his death ; and Francesco Rizzoli (1809-80), 
 professor of surgery and obstetrics in Bologna in 1840, who was distin- 
 guished as an operator and teacher. 
 
 The scheme of medical studies adopted in Austria in 1810 prescribed 
 a five years' course in medicine or the higher surgery, and a two years' 
 course tVn- country doctors. In 1822 tiie course at the Military Medieo- 
 chirurgical Academy, or Josephinum, was extended to five years, and 
 this college had the right to grant degrees. In 1849 much more power 
 was given to the professors in the various universities as to the arrange- 
 ment of studies, but a complete separation between the faculties and the 
 medical associations was not made until 1873. In 1872 separate diplo- 
 mas for surgery were abolished. 
 
 In Prussia a system of medical study was arranged in 1825. It pro- 
 vided for physicians who studied at the universities, and for what were 
 called surgeons of the first and second class. The surgeons of the 
 second class were surgeons' apprentices who served for a short time 
 in a military hospital or attended a few lectures at a medico-chirurgical 
 college ; their examination was a very easy one, but demanded some 
 knowledge of anatomy, and they were mostly comparatively uneducated 
 men of an inferior class. The surgeons of the first class had to study 
 at a university or a medico-chirurgical school for three years, and were 
 not required to know Latin, as were the physicians, showing that sur- 
 gery was still considered inferior to medicine. In 1852 it ^^•as ordered 
 that there should be but one class of doctors, but the obtaining a med- 
 ical degree did not give the right to ]tractise. At present the education 
 and the standing of physicians and of surgeons are the same throughout 
 the empire. 
 
 During the first fourteen years of the nineteenth century the Xapo- 
 leonic wars produced an urgent demand for army surgeons, esjiecially in 
 Austria, which was often the field of conflict. Vienna had the leading 
 surgical schools in Germany at that time, founded by Leber in connec- 
 tion with the university, and In- Braml)illa in connection with the Mili- 
 tary Medical School, and the princijial surgeons in Southern Germany 
 after Leber were von Kern, Rudtorffer, ^^'attmann, and Zang. 
 
 Vincenz Sebastian von Kern (1760-1829), professor of surgery at 
 Laibach in 1797, became professor of practical and clinical surgery in 
 the Vienna University in 1805, and exercised a powerful influence on 
 
118 THE HISTORY AND LITERATURE OF SURGERY. 
 
 tile (lovclopnicnt of siirjierv iiiiil suru'ical teachini; in (u'niiany and 
 Xorthurn Italy nntil his resif^nation in 1824. He groatly .simplified 
 the prevailing treatment of wounds, returning to the water-dressings 
 of Magatus and I'ejecting plasters and salves, and was a skilful operator 
 and an exeellent teacher. 
 
 Franz Xav. Riidtorffcr (1 TfiO-ls;].')) commenced teaching in tlic great 
 Vienna Hospital in ISO], .nid in ISIO succeeded Ijel)cr as ])rofessi)r of 
 surgery, which position lie lield until he retired in 18121. 
 
 Joseph von Wattniann (177!)-18(j(i), son of a surgeon and })upil of 
 von Kern, became ])rofessor at Laibach in 1816, at Innsbruck in 1818, 
 and at Vienna in 1S24, retiring in 1848. He was a celebrated operator, 
 and gained great re])utation as a teacher. 
 
 Cliristoph B. Zang (1 772-1 S."]")) graduated at Vienna, entered the 
 Austrian army, and in 18U6 became professor of surgery in the Josephi- 
 num. He published Darstclhtng hlutiger hcilkunstleri.^eher Operationen 
 (4to, 181.3-21) — an excellent manual of operative surgery, which reached 
 a third edition and was translated into Italian. 
 
 In North Germany the principal surgeons of this period were 
 Mnrsinna, Rust, C. J. M. Langenl)eck, v. Walther, Hesselbach, and 
 Briinninghausen. 
 
 Christian Ludwig Mursinna (1744-1823), a barbei-'s apprentice, en- 
 tered the Prussian army in 1701 under Theden. In 1787 he became sur- 
 geon-genei'al, and professor of surgery in the military medical school 
 at Berlin, which jiosition, in connection with that of surgeon to the 
 C'harite, he retained after his retirement from military service in 1809. 
 He was a skilful operator and a good administratoi", who greatly im- 
 proved the medical service in the Prussian army, but wrote little 
 except occasional addresses and papers for journals. 
 
 Joh. Xeponudv Rust (1775-1840) studied in Vienna and Prague, and 
 became professor of surgery at Cracow in 1803. From 1810 to 18ir) 
 he was one of the surgeons of the General Hospital in A'ienna, and in 
 1816 he succeeded Mursinna in the army medical school at Berlin, 
 becoming professor in the University of Berlin in 1824. 
 
 Conrad Joh. M. Langenbeck (1776-1851) studied at Jena, Vienna, 
 and Wiirzburg, and in 1802 settled in Gottingen, where he soon began 
 to teach anatomy and surgery. In 1.S14 he became professor of anatomy 
 and surgery and surgeon-general of tiie Hanoverian army. In 1802 he 
 published a treatise on litliotomy ; in 1806 the first volume of his Biblio- 
 thck fiir die Chii-urgie, of which the eighth and last volume appeared 
 in 1828 ; and in 1822 the first volume of his Nono/or/ic ini<J Thcmpie. 
 der chiriirgiftchc7i Kranhhciten, etc., of which vol. v. appeared in IS.'iO. 
 He was a skilful anatomist and o])erator, modifying and improving tiie 
 technique, and a celebrated teacher. 
 
 Philip Franz v. Walther (1782-1849) was educated at Heidelberg and 
 Vienna, and became profes.sor and surgeon to the hospital at Bamberg 
 M-hen he was only twenty-one ^-ears old. In 1804 he became professor 
 of physiology and surgery at Laudshut, and soon acquired a high rc])u- 
 tation as an operator and teacher. In 1818 he accepted a call to the 
 newly-organized university at Bonn, where he soon became the leading 
 German surgeon of his time. In 18.30 he went to Munich as ]irofessor 
 of surgery in the university, which had been transferred to tiiat city 
 
THE HISTORY AXD LITERATURE OF SURGERY. 119 
 
 from Landshut, and as director of the surijieal clinic in the General 
 Hospital, in which positions he remained until his death. He was the 
 fountler of modern surgery in Bavaria, and his physiological training- 
 was of great assistiince in his surgical teaching. He wi'ote a Si/fitcm dcr 
 Chi I'll rr/ir (18;i3) and numerous papers for periodicals. 
 
 Franz Caspar Hesselhaeh (17.")y-181()) was a pupil of Von Sicl)old at 
 Wiirzliurg, and his assistant in anatomical demonstrations. His principal 
 ei)ntril)utions to surgery are his papers on hernia, jniiilished in ISOti, 
 1814, and 1815, in the tirst of which he gives the first distinct descrip- 
 tion of the two forms of inguinal hernia. 
 
 Hermann Joseph Briinninghausen (1761-1834) was professor of sur- 
 gery at Wiirzliurg in the early part of the century, and i)ul)lishcd his 
 J^rf(iJiruiH/cn und B<'iiicrki(iif/cn liber die Aiajjuteftion in 1818. 
 
 Between 18-2o and IS.jO the leading (Jerman surgeons were Graefe, 
 Dietfenbach, and Clielius, in addition to the survivors of those already 
 referred to. 
 
 Carl Ferdinand von Graefe (1787-1840) studied at Dresden, Halle, 
 and Leipzig, in 1810 became professor and directcu- of tiie surgical clinic 
 in the newly-founded University of Berlin, and from 181.3 to 181.5 
 served as siu'geou-general of division in the army. In 181(3 he tirst 
 performed suture for congenital cleft [lalate, and then devised blejiharo- 
 plasty and rhinoplasty, which he introduced to notice. He was one of 
 the tir.st to re-sect a portion of the lower jaw, and the first in Germany 
 to ligate the innominate artery. 
 
 Johaun Frictlrich Diett'enljach (1792-1847) was a native of Konigs- 
 berg, where he studied fmni 1818 to 1820, when he went to ]5oiui and 
 became the j)upil of von ^\'alther. In 1821 he went to Paris and Mont- 
 pellier, attending the clinics of Dupuytren and Delpech, and in 1822 
 graduated at Wiirzburg, his thesis, Xonnulla de ref/eneraiione et trana- 
 plctnUdinne, indicating the trend of his studies. In 1823 he went to 
 Berlin and devoted himself largely to plastic surgery. In 1829 he 
 became surgeon to the Charite, and in 1832 professor extraordinary in 
 the university, at which time he began his work in orthopjedic surgery. 
 In 1829 he devised the section of the tendons of the ocular muscles for 
 strabismus, which made a great sensation in the surgical world. In 
 1840, after the death of von Graefe, he became professor in the uni- 
 versity and director of the surgical clinic. He made many valuable 
 (■ontriiiutions to methods in plastic surgery and tenotomy, which are 
 summed up in his (Jpercdive C'hirurgie (2 vols., 1845-48). His enthusi- 
 asm for novelties led him into some blunders, as in his publications on 
 the cure of stammering by subcutaneous section of the muscles of the 
 tongue, but he was a great sin-geon, a most skilful operator, and an 
 extremely poj)ular clinical teacher. 
 
 Max. Jos. von f'helius (1 794-1 87<j), a native of Mannheim, gradu- 
 ated at Heidelberg in 1812, ..fter which he studied under A\'alther at 
 Landshut and Vienna, and became professor at Heidelberg in 1819. 
 Here he soon founded a surgical and ophthalmological clinic, and in 
 1822—23 published his Handbuch der Cliimrr/ie, which for the next 
 twenty-five years was the best-known manual in Crcrmany, and indeed 
 in Furope, having been translated into Fnglish, French, Italian, Danish, 
 an<l Dutch, and the eighth German edition having been issued in 1857. 
 
120 THE HISTORY AND LITERATURE OF SURGERY. 
 
 The English transhition by Soiitli (in 1847) is especially valuable, being 
 nearly doubled in size by the notes of the translator, and permitting of 
 a dii'ect comparison of the English and German surgery of that day. 
 He was one of the best-known surgeons in Europe and had many dis- 
 tinguished pupils. 
 
 To this period also belong von Textor, Jaeger, Blasius, Wutzer, von 
 Anunon, Wernher, Kuhl, Grossheim, Fricke, Mojsisovics, Holscher, 
 and Jk'uedict. 
 
 Kajetan von Textor (1782-1860) studied at Landshut under von 
 Walther and graduated in 1 808, after which he spent two years in Paris 
 mainly following the teaching of Boyer, and a season at Pavia under 
 Scarpa. In 1816 he became professor of surgery at M'iirzburg, and 
 held this position until 1853 with the exception of the years 18;32-;33. 
 He puljlished Gnmdzuge zur Lehre dcr chinirgm'hcn Operafionen, etc., 
 in 1835, and some small monographs. His chief surgical contributions 
 related to resections, in which he was a very skilful operator. His son 
 Carl (1815-80) became assistant professor of surgery at ^^'iirzl)iu-g in 
 1850, and contributed a number of surgical ])apers to periodicals. 
 
 Michael Jaeger (1795-1838) graduated at AA'iirzburg in LSI 9, and in 
 1826 succeeded Schreger as director of the surgical clinic at Erlangen, 
 becoming professor of surgery in 1831. In 1832-33 he was professor 
 of surgery at Wiirzburg during von Textor's absence, after which he 
 returned to his old position at Erlangen. He contributed materially to 
 the literature of resections and of diseases of the l:)ones and joints. 
 
 Ernst Blasius (1802-75), a native of Berlin, studied at the Friedrich 
 Wilhelm Institut and graduated in 1823, after which he served four 
 years in the array, and then settled in Halle, where he became professor 
 of surgery in 1834. His principal work was his Handbuch der Al-hm/ie 
 (3 vols, and atlas, 1830-33), but he also published collections of cases 
 and essays, a treatise on amputations, and numerous papers in the 
 journals. 
 
 Carl Wilhelm Wutzer (1789-1863), a native of Berlin, studied at 
 the Pepiniere, served in the army, and became director of the surgical 
 school at Miinster in 1821. In 1830 he succeeded Weiuhold as pro- 
 fessor of surgery at Halle, and in 1833 took the same chair at Bonn. 
 He ctmtributed numerous articles to periodicals, but wrote no important 
 works, and is best known as the originator of the method for the radical 
 cure of inguinal hernia which bears his name. He was a skilled anat- 
 omist, a good operator, and a painstaking, careful teacher. 
 
 Friedrich August von Ammon (1799-1861) studied in Leipzig and 
 Gottingon, graduating in 1821, and settled in Hresdeu, wlicre he became 
 professor in the surgical school in 1828, resigning in 1837. The greater 
 part of his numerous publications relate to ojjhtlialniology, but he also 
 devoted much attention to plastic surgery and to orthopsedia. In con- 
 nection with Baumgarten he published Die plastische Chinirgie nach 
 ihren Leistungen kritisch dargestellt (1842), and in the same year appeared 
 his Die angeboycnen Krankhcitcn r/c.s Mrnxehcn, etc. (in folio with plates), 
 which is a classic. Another finely-illustrated work is his Klini.sche 
 DarsteUung dcr Kranhheitcn und JJildiiiK/sfclder dcs mcnscJdichcn Aiigc.'^, 
 etc. (fob, 1838-41). 
 
 Adolph Wernher (1809-83) graduated in 1832 at Giessen, where 
 
THE HISTORY ASD LITERATURE OF SURGERY. 121 
 
 he became jirofcssor of surgery and directt)r of tlie surgical clinic in 
 1837, retiring in 1878. His Handbueh dcr allgemeinen und spccidleii 
 Ghirurgie (4 vols., 184(j-47) was an excellent manual, of which the first 
 volume of a second edition appeared in 18(j2-63. 
 
 Karl August Ivuhl (1774-1840) studied at Leipzig, graduating in 
 1803, after which he went to Vienna, London, and Paris. In 1817 he 
 became assistant professor, and in 1824 professor, of surgery at Leipzig. 
 He was a bold and skilful operator, and ligated the innominate, the 
 subclavian, and both carotids, all of which cases he described, but he 
 wrote no important work and made no special contributions to surgical 
 progress. 
 
 Ernst Leopold Grossheim (1799-1844), a pupil of the Friedrich 
 Wilhelm Institut in Berlin, was an army surgeon and a teacher in the 
 surgical school at Miinster, who publisiicd a Lehrbuch der o^icrativen 
 Cliirurcjie (3 vols., 1830-35). 
 
 Joh. Carl George Fricke (1790-1841) studied at Giittingen, where he 
 graduated in 1810, after which he studied in Berlin under von Graefe. 
 In 1814 he settled in Hamburg and became surgeon of the General 
 Hospital. He jjublished the records of his clinical work in the Amuden 
 der clururgisclwn AhtJicihing des cdlf/. Krankenhaunci in Hninhiirg (2 
 vols., 1828-33), and in various journals, especially in the Zdt.ichriff f. d. 
 ges. Medicin, of which he was one of the editors. His contriiiutions 
 relate to blepharoplasty, the non-mercurial treatment of syphilis, the 
 treatment of orchitis by compression, the torsion of arteries, the forceps 
 and vaginal speculum known by his name, etc. 
 
 George Mojsisovics (17!t9-l'SUU), a Hungarian, studied in Budapest 
 and Vienna and graduated in 1826. In 1828 he became assistant in the 
 surgical school at Vienna, and in 1832 first surgeon of the General 
 Hospital. He })ublished nothing of any importance. 
 
 George P. Holseher (1792-1852) studied at Gottingen, and in Lon- 
 don under Astley Cooper, and settled in Hannover, where he became a 
 teacher in the surgical school and editor of the Hannnvcrxche Amuden 
 fur ilie gcminintc Hedkuiulc (183(J-47). His publications were almost 
 entirely journal articles. 
 
 Traugott Willi. Gustav Benedict (1785-1862) studied at Leipzig, grad- 
 uating in 1810, and in 1812 became professor at Breslau, where he 
 aeijuired a reputation as an ophthalmologist. His principal surgical 
 publication is his Lchrbuidi dcr ul/grimincn Chirurgic und Oprratioiinlchre 
 (1842). 
 
 The next group ot German sui'geons to be noted includes von Lang- 
 enbeek, Stromeyer, Heyfelder, von Pitha, Schuh, von Bruns, Giinther, 
 Middledor]>f, Busch, Linhart, Wagner, and Baum. 
 
 Bernard Kudolph Konrad von Langenbeck (1810-87), the most dis- 
 tinguished German surgeon of the nineteenth century, took his doctor's 
 degree at Gottingen in 1835, became ])rofessor of surgery at Kiel in 
 1842, and succeeded I)ictl'cnl)ach in the chair of surgery at Berlin in 
 1847. In conjunction with his pupils, Billroth and Gurlt, he established 
 the Arohiv fur klinische Chirurgie in 1861, a journal which has con- 
 tained the most important contributions tt) surgery made by German 
 surgeons since that date, and he was the founder of the Dcidschc Gescll- 
 schuft fur Chirurgic in 1872. Langenbeck wrote no mamial or system 
 
122 THE irrsTonv and literature of surgery. 
 
 of siirjfcry, but contriljutcil niiincroiis jjupcrs to the Archiv fur klhmche 
 Chlran/ie, liis largest work beinjj' his Chirurgischc Beobuchtiuigen cms dan 
 Kriec/c (251 pp. 8vo, Berlin, 1874). His operations and improvements 
 of the teehnieal methods of surgical o|)erations are too numerous to 
 mention. Some of tiie most im])ortant of tiiem relate to plastic surgery 
 of tlie nose and of tlie liard palate, and to o})eration8 for tumors at the 
 base of the cranium, for removal of tiie tongue, etc. His greatest con- 
 tril)ution to surgery, however, has been his pupils, among whom may be 
 numbered nearly every prominent surgeon in Germany of the present 
 day. 
 
 Georg Friedrich Louis Stromeyer (1804-7(1), son of Chr. Fr. Stro- 
 meyer, surgeon to the king of Hannover, studied at Hannover, Gottin- 
 gen, and Berlin, and graduated in 182G. In 1829 he Ix'gan to teach 
 in the surgical school at Hannover, in 1838 succ'ceded Jaeger as pro- 
 fessor of surgery at Erlangen, in 1842 accepted the same chair in Frei- 
 burg, and in 1847 succeeded Jjangenbeck at Kiel. He became surgeon- 
 general of the Schleswig-Holstein army, serving in the war of 1849, 
 and surgeon-general of the Hannoverian army in 1854, serving in tlie 
 war of 18(i(J. His chief contributions to the art were connected with 
 orthoptedic surgery and tenotomy, and especially with resections in 
 military surgery. He performed subcutaneous section of the tendo 
 Achillis in 1831, being the first after Delpech to do so. His ])rinci])al 
 pul)lications were Beit rage znr ojicrdfircu Orlhojiadik (1838), Jldiidhiich 
 <lrr Chirnrgic (2 vols., 1844—48), and Md.rimeii dcr Kricgx/iri/kiiiixt (1 855). 
 
 .lohann Ferdinand Heyfelder (1798-18(j9), student at Berlin, Wiirz- 
 Inirg, and Breslau, graduating in 1820, in 1841 .succeeded iStromeyer as 
 ]n-ofessor of surgery at Erlangen, which position he resigned in 1854. 
 The latter part of his life was spent in St. Petersl)urg. He was a 
 learned surgeon, a skilful ojierator, a teacher of great reputation, and a 
 viiluminous writer uj)on many subjects besides surgery. He is best 
 known by his treatise Uc/jer lic.iectioncn uiid Amputationen (1854), 
 M'hieh is a standard work upon the subject. His son, Oscar Heyfelder 
 (1828-?), studied at Heidelberg and Erlangen, graduating in 1851, 
 and entered the Russian army medical service in 1859. He ])ublished 
 Lchrbifrh (Icr BcKcrtioiicii (2d ed. 18(53, and translated into French in 
 the same year), KrIcgKchirargischcs ^'(t<h' Jlcctun (1874), and numerous 
 articles in the journals. 
 
 Franz von Pitha (1810-75), a native of Bohemia, studied at Prague, 
 graduating in 1836, and in 1843 succeeded Fritz as professor of .surgery 
 in the University of Prague, in which position he soon obtained a high 
 re])utation as a teacher. In 1854 he accepted the cliair of surgery in 
 the jMedico-chirurgical .Iose|>lis Acatleniy in Vienna, re-estalilished for 
 the purpose of training medical officers for tiie Austrian army. His 
 name is best known in connection with the Handbuch der aUgemeineu 
 %md speciellen Chirurgic, edited by Billroth and himself (1865-82). He 
 was a skilful diagnostician and operator and a cultured and polished 
 gentleman. 
 
 Franz Schuh (1804-65) studied in Vienna, graduating in 1831, 
 became surgeon to the General Hospital in A'ienna in 1837, and pro- 
 fessor of surgery in 1842. He was an excellent practical teacher and 
 writer, aided much in increasing the reputation of the school, and con- 
 
THE HISTORY ASD LITERATURE OF SUR(JERY. 123 
 
 tributed niinuTous papers to tlie journals. His itrincipal l)(>oks are — 
 Uchvr die Erkcnidnhn der Pscudojihixiaen ( ISol), I'ldholoijir und Therapic 
 der P-'scudoplaKincn (1854), ami AbhandlniHjen avti dcin Hvbhie der (1il- 
 rurgie und Operationskhre (published after his death, in lcS67). 
 
 Victor von Bruns (1812-83), student at Tiibingcn, graduating' in 
 1836, Ijecame professor of surgery at Tiibingen in 1843, whicli jxisi- 
 tion he held until 1882. He was one of the founders of modern lar- 
 yngologv, and was the first to remove a laryngeal growth through tJie 
 natural passages. His prineipal works are — Vhirurgixvhcr At/as (fob, 
 1853-60), Haadbuch der praldische^i Chirurgie (2 vols., 1854-59), Die 
 Lari/ngoxkopie und die laryngoskopisclie Chirurgie (1865), Chirurgisehc 
 Heilinittellehre (2 vols., 1868-73), Die galmnokaudisclu'ii Apparate, etc. 
 (1878), and Die Ainpufafion der Gliedmassen dnrch Zirkelxi:hniH init 
 vordcrem Haidhippen (1879). 
 
 Gustav Biedermann Giinther (1801-66) studied at Ijeipzig, graduat- 
 ing in 1824, and in the following year became an assistant to Frioke in the 
 General Hospital at Hamburg. In 1831 he was appointed professor of 
 surgery in Kiel, and in 1841 accepted the same position at Leipzig. 
 He was a good anatomist and a careful, jjainstaking teacher, but was not 
 distinguished as an operator. His principal work is his Lvhre von den 
 blutigen Opendionen uin menseh/irhen Korper (4to, 1859-65). 
 
 Albrecht Theodor Middeldorpf (1824-68) studied at Breslau and 
 Berlin, graduating in 1846, and in 1856 became professor of surgery at 
 Breslau. He introduced the use of the galvano-cautery, made improve- 
 ments in the treatment of fractures and of gastric fistula, and was one 
 of the best clinical teachers of his time. His principal publications are 
 — Beiirdge .sar Lehre von den Knochcnbriiohen (1853), Die Galvano- 
 caustik (1854), Ueberblick iiber die Akidopeiradik (1856), and Co)n- 
 mentatio de fiatulin nentriculi externis, etc. (1859). 
 
 Carl David Wilhelm Busch (1826-81), son of the cclclirated obstet- 
 rician Dietrich Willi. Heinr. Busch, studied in Bei-lin, graduating in 
 1848, and after extensive travels became an assistant in Langenbeck's 
 clinic in 1851. In 1854 he accepted a call to Bonn as professor of 
 clinical surgery, and remained there until his death. He was a volu- 
 minous writer and made valuable contributions to the literature of gun- 
 shot wounds, fractures and dishjcations, diseases of the joints, plastic sur- 
 gery, and hernia, the majority ajipearing in periodicals and transactions. 
 His Lehrbueh der Chirurgie (2 vols., 1857-69) was his princij)al work. 
 
 Wenzel von Ijinhart (1821-77), the son of a surgeon, studied in 
 Vienna, graduating in 1844 ; became an assistant of Dumreicher, and 
 in 1856 accepted a call to Wiirzburg as professor of clinical surgery. 
 He was a skilled anatomist and ojicrator and an excellent teacher. His 
 principal works are his Compendium der ehiriirgiaehen Operationslehre 
 (1856; 4th ed. 1874) and Vorh'xungen iiber Vaierleibn-Hernien (1866; 
 new ed. 1882). 
 
 Carl Ernst Albrecht Wagner (1827-70), son of a celebrated physi- 
 cian, studied in Berlin, graduating in 1848; became an assistant in 
 Langenbeck's clinic, surgeon to tiie hospital in Dantzig in 1853, and in 
 1858 professor of surgery in Kiinigsberg, where he acquired great re])u- 
 tation as a teacher. 
 
 Wilhelm Bauni (1799-1883) studied at Konigsberg and Berlin, 
 
124 titt: msroRY and literature of surgery. 
 
 graduatino- in 1822; contiiiiu'd liis studies in Vienna, Ijdiidon, and 
 Pariy ; iu I80O became surgeon in charge of the municipal liospitid at 
 Dantzig ; in 1842 accepted the position of professor of surgery at 
 Greifswald ; and in 1849 tooiv the same chair at GiJttingen, from wliich 
 he retired in 1867. He was a learned man and a good teacliw', but 
 published nothing. 
 
 To this period also belong Zeis, Stilling, and Heine. 
 
 Edward Zeis (1807-68), a native of Dresden, studied at Leipzig, 
 Bonn, and Munich, graduating at Leipzig in 1832, after which he 
 settled in Dresden. From 1844 to 1850 he was professor of surgery at 
 Marburg, at the end of which ])eriod he returned to Dresden and i)ecame 
 surgeon to the city hospital. His principal publications are — HdmUmck 
 (ler plastischcii Chtrutr/ie (1838) and Die Literatur unci Geschichte der 
 plastlachcn Chirurgie (1863-64). 
 
 Benedict Stilling (1810-79) studied at Marburg, graduating in 1833, 
 and became assistant in the surgical clinic. Soon after he settled in 
 Cassel, where he remained for the rest of his life. He is much better 
 known as a physiologist and investigator of the nervous system than lie 
 is as a surgeon, but he M^as the first ovariotomist in Germany, and Ix'tween 
 1856 and 1870 published several papers on stricture and on internal 
 urethrotomy. 
 
 Jacob von Heine (1800-79), of a liimily of instrument-makers and 
 orthopaedists, student at Wiirzbui-g, graduated in 1827, and established 
 an orthopaedic hospital in Cannstatt which became celebrated. His 
 principal publications are — Bcob(ichti(iif/en iihcr Ldhvmiir/sziwtdiHje der 
 untcru Extremitdten und deren BchamUung (1840), Ueber spontane und 
 congenitale Luxationen, etc. (1842), and Spinale Kinderldhmung (1860). 
 
 Here also may be mentioned Carl "W^illielni von Heine (1838-77), 
 son of Jacob v. Heine, and professor of clinical surgery in the new 
 medical faculty of Innspruck in 1869, who wrote on gunshot wounds 
 of the lower extremities, hospital gangrene, etc. ; August Gustav Herr- 
 mann (1831-74) of Prague, author of Conipjcndium der Krieg.'t-Chi- 
 rurgic (1870); Fried. Wilh. Theodore Ravoth (1816-78) of Berlin, 
 whose most important works relate to the treatment of hernia ; Ernst 
 Ludwig Schillbaeh (1825- ?) of Jena, author of Belt rage zit den 
 Resectionen der Knoeheii (1858-60); Hermann Demme (1802-67), pro- 
 fessor of surgery in Berne, and his son, Carl Hermann Demme (1831— 
 64), author of some valuable papers on military surgery ; August Burow 
 (1809-74) of Konigsberg, a pupil of Dieffenbach, author of numerous 
 papers on ophthalmokigy, the open treatment of wounds, and plastic 
 surgery ; Hermann Julius Paul (1824—77) of Breslau, author of I>ie 
 conservative Chirurgie (1854 ; 2d ed. 1859) and Lehrbuch der spericUen 
 Chirurgie (1861); johann Balassa (1812-69) of Budapest, celel)rated as 
 an operator in lithotomy and plastic surgery ; and Joseph Blazina (1812- 
 85), who graduated in 1841 at Prague, M'here he became professor of 
 surgery. 
 
 Between 1850 and the present time the leading surgeons of Ger- 
 many, besides those already mentioned, and those who, being yet living, 
 do not come within the scope of this paper, were LoetHcr, AA'ilms, 
 Simon, Thaden, Lijcke, Hueter, Maas, Leisrink, Vogt, Volkmann, and 
 Billroth. 
 
THE HISTORY AXD LITERATURE OF SURGERY. 125 
 
 Gottfried Friedricli Franz Loefflor (1815-74) studied at tlie Fried- 
 rich A\'illu'lin Institut in Bei'lin, and became one of the most distin- 
 guished of the German army surgeons. His principal works are — 
 Lirundsatze unci Regeln fur die Behandlmig der tichusswunden im 
 Kr'iege (1859) and Das preussische Militar Sanitdtswesen und seine 
 Reform (1868-<50). 
 
 Robert Ferdinand Wihiis (1824-80) studied at Berlin, graduating in 
 1846, and in 1848 became an assistant of Eartels in the Bethanien 
 Hospital, of which he was placed in charge in 1862. He M^as one of 
 the leading surgeons in Berlin, and was popular as a teacher, but wrote 
 little beyond the rejiorts of his hospital. 
 
 Johann Dumreichcr (1815-80) graduated at Vienna in 1838, became 
 assistant to ^Yattraann, and took charge of .one of the surgical clinics 
 in 1849. He wrote very little. 
 
 Christoph Jac. Fried. Ludw. Gustav Simon (1824-76) studied at 
 Giessen and Heidelberg, graduating in 1848, and at once entered the 
 Hessian army, in which he became medical director in 1861, in the 
 same year was appointed to the chair of surgery at Rostock, and in 
 1867 accepted a call to the same position in Heidellierg. His first 
 jiublication was Ucber Schussumuden, etc. (1851), soon after which, on a 
 visit to Paris, he became accpiainted with Jobert's method of operating 
 for vesico-vaginal fistula, and on his return established a small hos|)ital, 
 acquired great reputation as an operator for such affections, and published 
 a number of pajiers on the surgery of the female genitals. After going 
 to Heidelberg he performed the first operation for nephrectomy in 1869, 
 and published his C'hirurf/ie der Nieren in 1871, the second part appear- 
 ing after his death, in 1876. He was a bold and skilful surgeon, and 
 made numerous improvements in methods of investigating and treating 
 surgical affections. He Avas also a voluminous writer, but his publica- 
 tions were concise monographs, and not large, systematic treatises. 
 
 Adolf Georg Jacob von Tliaden, a native of Holstein, studied in 
 Heidellierg and Kiel, graduating in 185.'!, after which he was for two 
 years an assistant of Esmarch, and in 1861 became surgeon of the new 
 city hospital at Altona. He was a skilful, scientific surgeon. 
 
 George Albert Liicke (1827-94), a native of Magdeburg, studied at 
 Heidellierg, Halle, and Gottingen. He became assistant to Blasius at 
 Halle in 1854, and soon after became assistant to von Langenbeck in 
 Berlin, and jirivatdocent. In 1865 he became professor of surgery at 
 Berne, and in 1872 accepted the same position at Strasburg, where he 
 remained until his death. 
 
 Carl Hueter (1838-82), son of a well-known obstetrician of Mar- 
 burg, graduated in 1859, after which he studied in Vienna, I^ondon, and 
 Paris, and became a privatdocent in Berlin and an assistant of Langen- 
 beck. In 1868 he succeeded Simon as professor of surgcrv at Rostock, 
 and in 1869 accepted a call to the same chair at Greifswald. Hueter 
 was a scientific surgeon, giving great attention to pathology and bacteri- 
 ology ; he was also a skilful operator, made many improvements in 
 method in resections, tracheotomy, excision of the rectum, etc., and \vas 
 a voluminous writer. His jirincipal works are — Klinik der Gelenk- 
 krankheiten (^1870-71 ; 2d ed. 1876-78), Die ulhjeiimite Chirurgie (1873), 
 and (Trundriss der Chirurgie (1880-82). 
 
12() THE HISTORY AXf) LITKHATVRE OF SVRGEBY. 
 
 Hermann ]\Iaas (l.S4"2-S()) orM<luat<'(] at I5reslaii in IHii^), and liccanic 
 assistant to Mid(lc'l(li>r}>f', and pri\atd(iccnt, and in l.STT prut'essor of sur- 
 gery at Freiberg. His chief" work was his Kriegschirwr/ische Beitrage 
 cms (1cm Jahre 1866 (jinblished in 1870). 
 
 Heinrioh Wilh. Franz Lcisrink (1845-85) studiiMl in Gottingen and 
 Kiel, graduating in 18()8, and settled in Hamburg, where lie beeanie 
 distinguisheil as a surgeon and I'ontribnted some valuable papers to 
 perioilieals. His most important work was Die inodcnie Radikal- 
 Opcmtion der Uiitcrkilmbruche, einc statistlsche Arbeit (1885). 
 
 Paul Fried. Immanuel Vogt (1849-85) studied at Greifswald, grad- 
 uating in 1865, and in 1882 succeeded Hueter as professor of surgery. 
 PI is principal works M'cre — TJie ehirurgixchcn Krcaiklicitcn der oberen 
 Ed'treiiiiti'iten (1881) and Mittheilungen aus der Chirurc/ischen Klinik in 
 Greifm-ald (1884). 
 
 Eichard von Volkmann (1830-89), son of Alfred Wilhelm Volk- 
 mann, professor of anatomy and physiology in the University of Halle, 
 was educated at Halle, Giessen, and Berlin, and obtained his medical 
 degree in 1854. He was an assistant in the surgical clinic of Professor 
 Blasius, in 1857 became privatdocent, and in 18(j7 ])rofessor of surgery 
 at Halle. With Langenlx'ck and Simon he founded the German Sur- 
 gical Association, and in 1874 s;iid before this society: "There is no 
 such thing as luck in surgery : for every case of pyaemia, erysipelas, and 
 necrosis after amputation the surgeon who treats it nuist be hclil respon- 
 sible." His contributions to surgery and to surgical literature were 
 numerous and important, and he was the first German carefully to study 
 Lister's methods and to ui-ge their adoi>tion upon German surgeons. 
 Volkmann was a poet as well as a surgeon, but issued his poems under 
 another name, and few persons know that Richard Leander, the German 
 poet, is the same person as Richard Volkmann, the famous surgeon of 
 Halle. 
 
 Theodor Billroth (1829-94), a native of Bergen on the island of 
 Riigen, studied at Greifswald, Gottingen, and Berlin, graduating at the 
 latter university in 1852. He became assistant to von Langeubeek, 
 privatdocent in 1856, professor of clinical surgery at Zurich in 1860, 
 and ])rofessor of surgery in the University of Vienna in 1867, succeed- 
 ing Franz Schuh. During the last twenty-five years he has lieen one 
 of the most celebrated surgeons in the world as an investigator in sui'gi- 
 eal pathology, a bold and successful operator, a voluminous writer, and 
 a clinical teacher. He first excised the larynx for cancer in 1873, first 
 successfully excised a large portion of the stomach in 1881, and gave 
 a strong impetus to the progress of operative surgery of the intestinal 
 tract. His lectiu'cs on surgical pathology and therapeutics have passed 
 through many editions and translations; his reports on clinical surgery 
 were translated into English in 1881, and the total number of his pub- 
 lished books and papers was about one hundred and forty. 
 
 The history of surgery in Denmark is merely the old story of the 
 barbers and barber surgeons until near the end of the eighteenth century. 
 The T^niversity of Copenhagen was founded in 1479, and possessed a 
 nominal medical faculty consisting of two or three physicians who read 
 the works of Galen and Avicenna. In 1559 some attempt was made to 
 introduce anatomical studies, and the young physicians had to travel in 
 
THE HISTORY AND LITER ATUBE OF SURGERr. 127 
 
 foreign countries before completing their studies and ohtaining their 
 degree. In 1577, Frederick II. issued statutes for the Collegium Chi- 
 rurgicum of Copenhagen, in which it was ordered, seeing that fnmi 
 ancient time there had been only si.x barbers in the city — i. e. barber 
 surgeons — tiiat tlie term of apprenticeshij) should be three years, and tlien 
 the apprentice was to travel in foreign countries for fiiur consecutive 
 years. Ti-avclling lithotomists had to olitain the a])pnival of tiie cor- 
 poration bcf ire thev were allowed to operate. Controversies between 
 the pliysicians and the barbers occurred as a matter of course. In 17-'!(i, 
 Simon Krueger (1687-1760), a barber surgeon, with others, founded tlie 
 "Theatrum Anatomieo-chirurgicum," a school for teaching anatomy and 
 surgery, which ]>rospered for the next twenty-four years, but was sup- 
 pressed in 1772. In 17S.3 the Academia Chirurgica was created. 
 Krueger was an excellent teacher, but wrote very little. 
 
 Heinrich von Moinichen, a surgeon of Copenhagen, published in 
 1665 his Observatioiies Jlledico-chirurgica', of which there were three 
 later editions. 
 
 Georg Heuermann (1722-GS), professor of medicine in the Uni- 
 versity of Copenhagen, pulilished in 1754-57 his Abhandlunr/ dcr 
 rornfhinxfcn cliiriirf/i.iclicn Ojicrdtioiien am ■menschUchen Korjjer, a well- 
 arranged and illustrated work. 
 
 Alexander K. Koelpin (1731-1801) graduated in 1763, after which 
 he studied under Hunter in Ijondon and Le C-at in Kouen, and returned 
 to Copenhagen and became chief surgeon of the Friedrichs Hospital in 
 1766. In 1785 he became professor of the newly-organized surgical 
 academy. 
 
 Henry Callisen (1740-1824), a native of Holstein and a pupil of 
 Simon Krueger, passed his preliminary examination in 1767, after which 
 he studied at Paris and under William Hunter in London. Returning 
 to Copenhagen, he became chief surgeon of marines, and took his degree 
 as doctor in 1772, and in 1773 succeeded Burger as professor of surgery. 
 His Inntitufloncs cJiirurf/icir hodlcrnw (1777) and his Si/stcma cliinir(/lie 
 hodierna', etc. (1778) passed through several editions and translations, 
 and were popular text-books until the beginning of the nineteenth 
 century. 
 
 Adolf Carl Peter Callisen (1787-1866), a nephew of Henry Callisen, 
 graduated at Kiel in 1809, and became a professor in the Surgical 
 Academy in Copenhagen in 1817. In 1842 he was professor of sur- 
 gery in the university. His best-known work is his Medici iiIucIk's 
 SchriftsfeUer-Lc.vicon der jvtzt kbend.cn Acvzte, etc. (in 33 vols. 8vo, 
 1830-45). 
 
 ■ The iirst distinguished surgeon in Sweden was Olaf Acrel (1717-1 806), 
 who was chief surgeon of the Sera])him Hosjiital in Stockholm after its 
 foundation in 1752. ' He becanic jirolessor of surgery in 1755, and his 
 teachings had great influence in the development of surgery in Sweden. 
 His princii)al work is Kirnrgiskn Hnndelner (Stockholm, 1759), which 
 was translated into Dutch in 1771, and into German in 1772 and 1777. 
 Peter af Bjerkin (1755-1818), a pupil of John Hunter and a sur- 
 geon in the Finnish army, became chief surgeon of Stockholm in 1809. 
 He was the greatest Swedish surgeon in the early part of this century, 
 but wrote nothing of importance. 
 
 t^ 
 
128 Till-: HISTORY AND LITERATURE OF SURGERY. 
 
 The first professoi' of .surgery and obstetrics at the University of 
 Christiania was Magnus Andreas Tiudstrup (17(39-1844), a native of 
 Copenhagen, who entered the Norwegian military niedieal service, became 
 sui'geon-gcneral, and in 1814 professor. He wrote very little. 
 
 Jacob Christian Johan HenriU (Jundelach ]Moeller (1797-1845), a 
 native of Jutland, studied in Copenhagen, and in 1842 became professor 
 of surgery, and was a distinguished clinical teacher. 
 
 Joh. August Liborius (1802-187U), a surgeon of Gothenburg, was 
 well known in his day as a skilled practitioner, and wrote on the starched 
 bandage, on hemorrhoids, and on herniotomy. 
 
 The leading surgeon of Sweden in recent years was Carl Gustav 
 Santesson (1819-8()), a native of Gothenburg, who graduated at Upsala 
 in 184(j, and became ])rofessor of surgery in the ytockholm school in 
 1849, retiring in LSS."). He contributed a number of papers to the 
 journals, and published Ojii hoftlcdcn och ledbrosken iifi anatomiskt 
 p<iflio/(H/iskt och chirurgiskt hcmseende, etc. (Stockholm, 1849). He was 
 a skilled surgeon, a great teacher, and an accomplished gentleman. 
 
 There is little to be said of the history of surgery in Ivussia prior to 
 the middle of the nineteenth century. The priests were the physicians 
 for the great mass of the people, but a few medical men ^\•ere brought 
 from other countries during the sixteenth, seventeenth, and eighteenth 
 centuries for the service of the court. Among these was Bidloo, who 
 induced Peter I. to found a medico-chirurgical college and hos]iital in 
 the early part of the eighteenth century. In 1768, Simon Zybelin was 
 professor of anatomy and surgery in the lTni\-ersity of Moscow, and in 
 1812, Andreas Sydoratzky (1788-1815) was a teacher of surgery in the 
 same university, but no record of their work is accessible. 
 
 Leo Nagumowitsch (1792-1815), an army surgeon, published, in 
 Russian, in 1832, a handbook on the treatment of gunshot wounds, and 
 Joseph Czekierski (1777-1826), a surgeon of Warsaw and professor of 
 surgery in the medical faculty created in 1809, published a manual of 
 surgery (4 vols., 1817-18). 
 
 Elias Bujalski (1789-1864), anatomist in the Military Medico-chirur- 
 gical School at St. Petersburg, published his Tabulae unatomko-chiru r- 
 gicne in 1828 and again in 1852. 
 
 Christian Salomon, jtrofessor of surgery at St. Petersburg, published 
 his handl)ook of operative surgery in Kussian, in two volumes, in 1840. 
 
 The first distinguished Russian surgeon was Nikolaus Iwanowitsch 
 Pirogofif (1810-81), who studied at Moscow and Dorpat and obtained 
 his degree' in 1832, after Avhich he studied in Berlin and Gottingen for 
 two years. On his return he gave lectures on sm-gery at Dorpat, being 
 the first Russian professor there. After five years in I>or])at, in 1840, 
 he was appointed ])rofcssor of surgery in the Medico-chirurgical Academy 
 of St. Petersburg. His attempts to improve the sanitar}- condition of 
 the military hospital connected \vith the academy created much ill-feel- 
 ing, and for a time he was considered and treated as insane. During 
 the Crimean War he was active at Sevastopol, and incurred ill-^\•ill by 
 his deHunciation of the abuses connected with the Russian military 
 administration during the siege, the rcsidt of which was that he was 
 compelled to resign his professorship in the academy at St. Petersburg. 
 His contributions to surgery ^\•ere numerous in relation to gunshot 
 
THE HISTORY AND LITERATURE OF SURGERY. 129 
 
 wounds, amputations, and the surgery of bones, and his name is con- 
 nected with a method of ostcophistic amputation through the foot devised 
 by him in 1854. The list of his publications is a long one, the most 
 important being his Rcchcrohes prutlques ct physioloffiques sur F etherisa- 
 tion (1847); I'cqijjort medical d'Kii voyage au Caueasr, contenant fa 
 statiftfiqiie compuraiiee des ainputatioiiit, etc. (1849) ; Anatome fopne/rapliica^ 
 •sectionibus per corpus huinaiium conyelatxim , etc. (fob, 1852-59) ; Chirur- 
 ffische Anatomie der Arterien-staemvie und Fascien (1861); and Grund- 
 ziiffe der allgemeinen Kriegsclnrnrgie (1864). 
 
 Little is known of the Russian surgeons who wrote only in Russian, 
 for veiy few of their worlds have been considered worth translating. 
 
 Ivan Rklizky (1805-61), professor of clinical surgery at St. Peters- 
 burg, in 1847 jniblished a treatise on operative sui'gery in Russian, of 
 which there were two later editions. 
 
 Peter Dubovizki (1815-67), professor of surgery at Kasan, in 1837 
 published a treatise on hemorrhage, and one on litliotinpsy in 1838. 
 
 Sablozky-Desjatovski (1816-82), professor of surgery at the Medical 
 Academy of St. Petersburg in 1842, wrote on hernia, diseases of the 
 testicle, and venereal diseases. 
 
 Polycarp Girsztowt (1827-77) studied in St. Petersburg, was an army 
 surgeon in the Crimea in 1853-56, and became professor of surgery in 
 Warsaw in 1860. He contributed to periodical literature, but wrote no 
 special work of any importance. 
 
 Hippolyt Korzeniowski (1827-79) studied at St. Petersburg, became 
 professor of surgery in Warsaw in 1868, and professor of surgery in St. 
 Petersburg in 1871. 
 
 Karl Daniel von Haartman (1792-1877) was professor of surgery 
 and obstetrics in the University of Hclsingfors from its foundatiou in 
 1833. He published Casus chirurgici in 1815. 
 
 One of the most distinguished and best known of modern Russian 
 surgeons was Julius Szymanowsky (1829-68), a native of Riga, who 
 studied at Dorpat, graduating in 1856. In 1858 he went to Helsingfors 
 as assistant professor of surgery, and in 1861 accepted a call to Kicw, 
 where he acquired a great reputation. He was a skilful operator and an 
 excellent teacher. His principal publications are Der Gypsverband init 
 besonderer Beriicksichfiguug der Militiirchirurgie (1857) and a treatise on 
 operative surgery in Russian (1864-65), of which the first part was 
 translated into German and published in 1872. 
 
 Carl Reyher (1846-90), a native of Riga, studied at Dorpat, gradu- 
 ating in 1871, became an assistant of von Bergmanu, and privatdoccnt, 
 entered the Russian army medical service, and became a distinguished 
 surgeon and teacher in St. Petersl)ui-g. His principal pulilications 
 relate to antiseptic methods, diseases of the joints, laryngotomy, and 
 gunshot wounds. 
 
 Upon the establishment of the Spanish rule in Mexico the medical 
 system of Spain was estal)Iished with it, including the barbers and the 
 barljcr surgeons. The first provision for the examination of physicians 
 and surgeons appears to have been made in 1646, being a l)oard com- 
 jxised of three persons, two of whom were physicians connected with 
 the university. From this date to 1700 it is reported that forty-seven 
 physicians, one surgeon, three apothecaries, and eighteen barbers were 
 
 Vol. I.— 9 
 
130 THE HISTOJRY AND LITEBATUEE OF SURGERY. 
 
 examined and .iiitlioiized to ])ractise. Evidently tlic l)art)crs iiad the 
 greater part 111' tlio siirijical ])raetice. Tii 1742 it was ordered that no 
 surgeon siiould inidertake to ])raetise niedieine iKir to give [)nrgatives or 
 emetics or diaphoretics or other drugs, and tiuit no apotiiecary siiduid 
 put up prescriptions of a surgeon for sucli drugs. In short, it is the 
 old story of an attempt by the physicians to suppress the surgeons. In 
 
 1719 it Mas ordered that in the examination of the surgeons no one 
 should be approve<l wlm had not seen some practice in hospitals, and in 
 
 1720 all the jiraetitioners of medicine, surgery, anatomy, and algeijra 
 were notified of the necessity of passing this examination. (By " algel^ra " 
 here is meant " bone-setting.") (See " Historia de la Medicina de 
 1G46-1700," by Dr. Eeyes, Ckmeta Mkliea de lle.vico, 1865-66.) 
 
 For a long time after the first settlements on the Atlantic coast of 
 North America very few educated physicians were among the immi- 
 grants. The clergy included many men of learning, talents, and piety, 
 and some distinguished lawyers accepted ottiees in the new colonies, but 
 there was little attraction for skilled physicians. Some of the so-called 
 "ship surgeons" remained, having commenced by practising on shore 
 Avhile their vessels were in port. The following extract from the Dutch 
 records, dated February 2, 1652, contains a notice of these barber sur- 
 geons : 
 
 "On the petition of the C'hirurgeons of New Amsterdam, that none 
 but they alone be allowed to shave ; the Director and Council understand 
 that shaving doth not appertain exclusively to ehirurgery, but is an 
 appendix thereunto ; that no man can be prevented operating on himself, 
 nor to do another this friendly act, provided it be through courtesy and 
 not for gain, which is hereby forbidden." It was then further Ordvr&l, 
 that ship-barbers shall not be allowed to dress any wounds, nor admin- 
 ister any jjotions on shore, without the previous knowledge and special 
 consent of the petitioners, or at least of Doctor La INIontague. 
 
 In 1662 an act regulating chirurgeons' accounts was passed in Viroinia 
 {Hen. Stat. Va., vol. ii. p. 109). 
 
 At a somewhat later ])eriod in Connecticut the popular feeling seems 
 to have been rather in favor of ignorance in a medical man, if we may 
 judge from the tact that in 1766 the physicians of Litchfield county, 
 having endeavored to form a medical association and having applied for 
 a charter for that purpose, were refused by the General Assembly on the 
 ground that it would form a monopoly, and that as to quacks and ignorant 
 men it was shown that they never administered any jihysic without the 
 prayers of the minister (which cannot be said of the I'ducated physicians), 
 and that no medicine can be serviceable without the blessing of God. 
 (See Peters' General History of Connecticut.) 
 
 In the early days of New England medicine was in its primitive 
 stage, being in the hands of the clergy. The earliest practitioners or 
 writers on medical subjects were clergymen, many of whom had regu- 
 larly studied medicine in order to fit themselves for the duties of their 
 new field, just as some of those intending to be missionaries do at 
 the present clay. For example, Charles Chauncy, the second president 
 of Harvard College, graduated in both divinity and medicine at Cam- 
 bridge, and is said to have lieen of the opiniiin that there ought to be no 
 distinction between them, educating his six sons in both professions. 
 
THE HISTORY AND LITERATURE OF SURGERY. 131 
 
 The first printed document relatini; to medicine issued in New Eng- 
 land is by a clergyniaii, Tiioraas Thatcher, who came to this country in 
 1685. It is a broadsicU' sheet or poster lieaded "Brief Kule to Guide 
 tlie Common People of Xew England How to Order Themselves and 
 Theirs in the Small Pocks or Measels." This is usually said to be the 
 first medical work pul^lishcd in ^\.merica, but several were printed in 
 Mexico during the sixteenth century, as, for example, Alphonso Lopez 
 de Hlnojoso summa y recopikicioii de cirugia con un arte para Hnngrar 
 y e.r((mcn de Bnrberos: To aiiadido en esta Kecunda edltione, el orir/in y 
 ■nacimiento de las reuinas [etc.]. (Mcxici, 159o, 4to.) 
 
 The first methodical attempt at the regulation of i)ractice appears 
 to have been made by Virginia in 1736 in an act regulating fees and 
 the accounts for the practice of physic. This fixed the fee for the ordi- 
 nary surgeons or apothecaries at five shillings a visit M'ithin five miles, 
 and ten shillings within ten miles, but those persons who have studied 
 physic in any university and taken a degree therein are allowed douljle 
 these rates. 
 
 In 1760 an act was jjassed by the city of New York forbitlding any 
 one to practise as a physician or surgeon in said city until he shoulil have 
 been examined and approved by a board composed of " one of his Maj- 
 esty's council, a judge of the supreme court, the attorney-general, and 
 the mayor," who may call in to their assistance such person or persons 
 as they think fit. A similar law was passed in New Jersey in 1772, the 
 examiners being any two of tlie judges of tiie supreme court. In Mary- 
 land, the District of Columbia, and South Carolina the business of exam- 
 ination and licensing was placed in the hands of the medical societies. 
 The distinction between jjhysieian and surgeon soon disapjjcared, and 
 there is no trace of separate organizations for these two classes of prac- 
 titioners. 
 
 The majority of the regidarly educated physicians in this country in 
 1776 were graduates of the University of Edinburgh, the first American- 
 born graduate of that school having been John Moultrie of South Caro- 
 lina, who oljtaincd his degree in 1749. The first dissection of the human 
 body in this country \vas made in New York by Drs. Bard and Middle- 
 ton in 17o(). In 17o6 a course of lectures on anatomy and surgery, with 
 demonstrations on the dead body, was given at Newport, Ivhode Island, 
 by Dr. William Hunter, a cousin of John Hunter and an Edinburgh 
 graduate. The first regularly organized medical school was estal)lished 
 in Philadelpiiia by Drs. William Shippen and John Morgan, both 
 natives of I'hiladelphia and graduates of Edinburgh ; Dr. Shi})pen lec- 
 tured on anatomy and surgery. 
 
 Tiie only surgical work by an American author printed in the United 
 States prior to 1800 was the Plain, Concise Practical lionarks on the 
 Treatment of Wounds and Fractures, by Dr. John Jones (New York, 
 1775), reprinted at Philadelphia in the following year with Van Swieten 
 on The Diseases Incident to Armies and Gunshot Wounds, the whole 
 forming a small volume wliicii was 'the manual of the American army 
 siu-geons during the Revolutionary War. 
 
 Dr. Jolm Jones (1729-91), a native of New York, studied in London 
 under Pott, in Paris under Petit and Le Dran, and in Edinburgh under 
 Monro, was surgeon with troops in the French Colonial War of 1758, 
 
132 THE HISTORY AND LITERATURE OF SURGERY. 
 
 and professor of surgery in King's (now C'olunihiit) College I'roin its 
 commencement in 1767. He is said to have performed tlie first opera- 
 tion of lithotomy in this country. His book, above referred to, is, in 
 the main, a compend of the teachings of Pott and Le Dran, but contains 
 a feworiginal observations, the most remarkable of which is a case of 
 trephining in delirium occurring eighty days after an apparently slight 
 injury of the head. There was no fracture. After perft)rating the bone 
 he opened the dura mater, but found nothing, and the result was prompt 
 recovery. At the beginning of the nineteenth century the leading sur- 
 geons in the United States were the two Warrens in Boston, Pliysick in 
 Philadelphia, and Wright Post in New York. 
 
 John Warren (17o.')-lS15) was the first professor of anatomv and 
 surgery in the Medical School of Harvard University, ^vhich ojjened in 
 1783, being the first medical school in New England. He amputated at 
 the shoulder-joint in 1781, extirpated the parotid gland in 1804, and had 
 a great reputation as an operator and teacher, but wrote only a few 
 addresses and journal articles. 
 
 His son. Dr. John Collins Warren (1778-1856), studied in London, 
 Edinburgh, and Paris, and returned and joined his father in practice in 
 1802, becoming adjunct professor in anatomy and surgery in 1806, and 
 professor in 1815. He was a skilful operator, and introduced several 
 new operations, such as excision of the li\iiid bone in 1804 and excision 
 of the elbow in 1834. In 1837 he published his Smyicd/ ohservations 
 on, iumor.-^, chiefly a collection of cases observed and treated bv him — 
 an important work for reference. He was practically the introducer 
 of antesthesia in surgical operations. 
 
 Philip Syng Physick (1768-1837), called ))y some the "Father of 
 American Surgery," a native of Pliiladel])hia, a ])U])il and personal friend 
 of John Hunter, wlio refers to him in his treatise on the blood as liav- 
 ing performed many of the cxjieriments referred to, took his medical 
 degree at Edinburgh in 1792, became surgeon of the Pennsylvania 
 Hospital in 1794, and was appointed in 1805 to the chair of surgery 
 established in the University of Pennsylvania in that year. His con- 
 tributions to practical surgery were numerous, but he wrote nothing, 
 and his views are, for the most part, known through the treatise of his 
 nephew. Dr. Dorsey. Among these contributions may be mentioned 
 the lengthening of Desault's splint for fracture of the femur, which 
 reached only to the crest of the ilium, making it extend from the axilla 
 to below the foot ; the internal division of stricture of the urethra ; the 
 use of the seton in ununited fracture ; his operation for the cure of 
 preternatural anus ; and the washing out of the stomach by means of a 
 gum-elastic catheter and a syringe in a case of poisoning. 
 
 The first lectures on surgery in Philadel])hia were given by Dr. 
 William Shippen (1733-1808), a native of Philadelphia, who studied in 
 Leyden, Edinburgh, and London, and was a special pupil of William 
 Hunter. In 1762 he gave a course of private lectures on anatomy and 
 surgery in Philadel|)hia, and in 1765 became professor of anatomy and 
 surgery in the Medical Dcjiartmcnt of the University of Penns}-lvania, 
 just established. 
 
 Wright Post (1766-1822), a native of New York, studied in London 
 in 1784-86 under Mr. Sheldon, and was apjiointed professor of surgery 
 
THE HISTORY AXD LITERATURE OF SURGERY. 133 
 
 in C'oliiinl)ia College in 1792. He, first in this country, performed the 
 Hunterian operation for aneurism of the femoral in 1796, ligated the 
 subclavian on the outer side of the scaleni in 1817, and in 1813 success- 
 fully ligated the external iliac, this being the second operation of this 
 kind. He was a skilled anatomist and a good teacher, but he wrote 
 niithing beyond a few accounts of cases. 
 
 1'iie tirst systematic treatise on surgery published by an American 
 author was the Elements of surgery of Dr. Dorsey (Philadelpliia, 2 vols. 
 8vo, 1813). of which a second edition appeared in 1818, and a third in 
 1823. 
 
 John 8yng Dorsey (1783-1818), a native of Pliiladclpliia, studied 
 under his uncle, Dr. PJiysiek, and afterward in London and Paris, and 
 in 1807 became adjunct professor of surgery in the University of Penn- 
 svlvania. His book was a popular text-book ; its chief value is due to 
 the fact that it contains so much of t^ie experience of Dr. Physick. In 
 1811 Dorsey successfully ligated the external iliac for inguinal aneurism, 
 this being the first case of that operation in the United States. 
 
 In 1819, Dr. Physick resigned as professor of surgery to become 
 professor of anatomv, tlie chair of surgerv l)eing filled l)y Dr. Gibson. 
 Dr. AVilliam Gibson (1788-1808) M'as born in Baltimore, Md. He 
 studied in Edinl)urgh, where he graduated in 1809, was a pupil of John 
 Bell, and, after his graduation, of Sir Charles Bell in London ; professor 
 of surgery in the University of ^Maryland in 1812, and jirofessor of 
 surgery in the University of Pennsylvania from 1819 to 1855, wiien he 
 resigned. In 1824 he published liis In.'ifitiitcx (iml jjracflcc of surffrri/, 
 which became a popular text-book, the eighth edition having appeared 
 in 1850. He was the first to perform the operation of ligation of the 
 common iliac, which he did in 1812, and successfully to repeat the 
 Ciesarean section on the same patient, which he ditl in 1837. His 
 reports on rn])ture of the axillary artery in attempts to reduce old dis- 
 locations of the head of tiie humerus contributed greatly to his repu- 
 tation. He formed a large and valuable collection of pathological 
 .specimens, colored drawings of tumors, etc., some of which are now 
 in the Army Medical JMuseum at Washington. 
 
 The surgeon of the first part <>f this century whose name is now best 
 known to fame was Dr. Ephraim McDowell (1771-1830), a native of 
 A^irginia, who studied in IOdinl)urgh in 179.'! under John Bell, who was 
 then giving special attention to diseases of the ovaries. In 1795 he 
 commenced practice at Danville, Kentucky, and soon became the lead- 
 ing pliysician of the West. In 1809 he performed the first methodical 
 excision of the ovary fin* the cure of tumor of that organ, and published 
 an account of it, and of two other similar cases, in the Eelcetie Repertory 
 of Philadelphia in 1817. His reports of the operation attracted little 
 attention at the time, and the few pul)lished comments on them were 
 mostly expressions of doul)t as to the accuracy of his statements ; but 
 the paper of Mr. Lizars, " Observations on the extirpation of the ova- 
 ria," in the Edlnhtirf/h Mrdiral (mil Siuyieal Journal in 1824, made them 
 generally known, and altiiough it was long after that date before ova- 
 riotomy became recognized as a jn-oper surgical operation, yet the credit 
 due to McDowell for originating it has never since been seriously dis- 
 puted. He wrote very little and very reluctantly, and was not a teacher 
 
134 THE HISTORY AND LITEIiATURE OF SURGERY. 
 
 in any sciiool, but his luinic stands hioh in tlie list of the great surgeons 
 of America. 
 
 Another distinguislied surgeon of tliis period was Dr. Nathan Smith 
 (1 7(32-1 829), a native of Massaehusetts, wlio studied in the Harvard Medi- 
 eal Seiiool, in Edinlturgii, and in Li)ii(h)n, and in 171)7 founded a medical 
 sciiodl in connection witli Dartmouth Cullege. In 181.3 he l)ecame pro- 
 fessor of medicine and surgery in Yale College. He was tlie second 
 person to perform ovariotomy in this country, which ho did in July, 
 1821, without any knowledge of the work of McDowell. He performed 
 the first amputatiim at the knee-joint in the United States in 1824, first 
 used the trejihine in loealizeil inflammation and al)seess of the shafts of 
 the long bones, and introduced the manipulation method in the treatment 
 of dislocations of the hip-joint. He wrote little, but an account of his 
 methods and practice is given in a little book entitled 2IaJical and sur- 
 gical memoirs, edited by his son, Nathan R. Smith (published at Balti- 
 more in 1831). It contains an excellent paper on necrosis, a description 
 of an improved apparatus for the treatment of fractures of the femur, 
 remarks on dislocations of the hip, etc. 
 
 Some bold operations were performed in these early days Vjy men 
 who wrote nothing and of whom little is known ; for example, abdom- 
 inal section for extra-uterine pregnancy in 1759 by John Bard of New 
 York, and in 1791 by William Baynham ; the ligation of the common 
 carotid in 1803 by Mason Fitch Cogswell, and in 1807 by Dr. Amos 
 Twitchell of New Hampshire ; the complete excision of the clavicle in 
 LSll by Dr. Charles McCreary of Kentucky ; and the excision of a part 
 of the lower jaw by Dr. Wm. H. Deadrick of Tennessee in 1810. In 
 1819, Dr. Wm. C Daniel of Savannah first employed extension by 
 means of a weight in the treatment of fracture of the femur, but did 
 not pul)lish the method until 1.S29 (Am. J. Med. Sc, 1829, iv. 330). In 
 1823, McGill of Maryland successfully ligated both carotids; in 1824, 
 Dr. D. L. Rodgcrs removed nearly the whole of both upper jaws. 
 
 Between 1820 and 1850 the prominent surgeons in the large cities 
 were John C. Warren and George Hayward in Boston ; Valentine 
 Mott, J. Kearny Rodgers, Willard Parker, Alfred C. Post, and John 
 Watson in New Y'ork ; W. Gibson (above referred to), J. R. Barton, 
 George IMcClellan, George W. Norris, and Thomas D. flutter in Phila- 
 delphia ; Nathan R. Smith in Baltimore; R. D. Mussey in Cincinnati; 
 and Daniel Brainard in Chicago. 
 
 Valentine Mott (1785-1865), a native of Long Island, the son of a 
 physician, studied medicine at Columliia College, obtaining his degree 
 in 1806. He then A\'ent to London, became a pupil of Astley Cooper, 
 returned in 1810, and was appointed ])rofessor of surgery in Columbia 
 College, and in 1813, when this school was merged in the faculty oi' the 
 College of Physicians and Surgeons, he retained the chair of surgery. In 
 1826, with the other professors of the College of Physicians and Surgeons, 
 he resigned his chair, and then M'ith several of his associates founded the 
 Rutgers ]\Iedical College ; he took the chair of operative surgery in the 
 College of Physicians and Surgeons, which he resigned in 1834 on 
 account of his health. In 1840 he was appointed to the jirofessorship 
 of surgery in the Medical Department of the University of New Y'ork. 
 For the next ten years his reputation drew crowds of students from all 
 
THE HISTORY AND LITERATURE OF SURGERY. 135 
 
 parts of the United States. In 1850 he resigned the chair, making 
 anotlier visit to Europe. In the spring of 1852 he was appointed 
 emeritus professor of surgery in tiie IMedical Department of the Uni- 
 versity of the City of New York, and from that time until liis death 
 he delivered an annual course of lectures. 
 
 ]\Iott's first contribution to operative surgery was the ligature of the 
 iiHiominate artery in 1818, the patient surviving for a long time, but 
 finally dying of secondary hemorrhage. The case established the prac- 
 ticability, and the propriety in certain cases, of the operation. It was 
 finally successfully performed by Dr. A. W. Smythe of New Orleans in 
 1864, in which case repeated hemorrhages also occurred, and the verte- 
 bral arteiy was ligated fifty-four days after the first operation. Mott first 
 applied a ligature to the primitive iliac in 1827; in 1828 he entirely 
 removed the clavicle for osteosarcoma; in 1812 he made an original 
 operation for the relief of ankylosis of the lower jaw. At the time 
 when, in 1821, he excised the right half of the lower jaw in a case of 
 tumor he was not aware that a similar oiieration had been jierformed in 
 1810 bv Dr. W. H. Deadrick of Tennessee, since no history of the 
 operation was published until 1828. Dupuytren in 1812 had removed 
 a large part of the lower jaw for cancer. Amputation of the hip-joint 
 was performed by Dr. Mott in 1824, and it was for some time supposed 
 that it was the first operation of the kind in America, but it is now 
 known that it was ]ierformed by Dr. Walter Brashear of Kentucky in 
 180(3, but no aeeount of liis case had ever l)een publislied. Speaking 
 of his excision of tiie clavicle, Dr. Mott called it his " ^\'aterlo(^ opera- 
 tion," since it was performed on the 17th of June, the day before the 
 anniversai-y of that battle. In 1813, Dr. Charles McCreaiy had removed 
 the right clavicle for disease of the bone, but it was little enlarged, com- 
 paratively isolated, and the operation was a very simple one, being 
 entirely different from the extremely difficult operation performed ])y 
 Dr. Mott. The patient rapidly recovered. Besides the innominate 
 artery, he tied the subclavian eight times, the primitive carotid fifty-one 
 times, the carotid twice, the common iliac once, the external iliac six 
 times, the internal iliac twice, the femoral fifty-seven times, and the 
 jiopliteal ten times. His writings consist mainly of reports of cases 
 and operations for periodicals. 
 
 J. Kearny Kodgers (1793-1851), a native of New York, was a pupil 
 of Dr. Wright Post and graduated at the College of Physicians and 
 Surgeons in 1816. He studied in London under Astley Cooper, became 
 surgeon of the New Yt)rk Hospital in 1822, and tied the left subclavian 
 artery within the scaleni for aneurism in 1845, the first time this opera- 
 tion had l)een perfiirmed : it was unsuccessful. The first successful 
 operation of this kind was by Dr. Halsted of Baltimore in 1892. Dr. 
 Kodgers successfully wired an ununited fracture of the humerus in 1827 
 after excision had been unsuccessfully performed, perhaps the first ope- 
 ration of this kind, and made a cuneiform osteotomy in ankylosis of the 
 hip in 1840. He wrote only a few pajiers for periodicals. 
 
 Willard Parker (1800-84), a native of New Hampshire, studied 
 under John C. Warren, and graduated at Harvard in 1X30. He was 
 for a short time professor of surgery in Berkshire Medical College, and 
 was a colleague of Gross in Cincinnati. In 1839 he became professor 
 
136 THE HISTORY ASD LITERATURE OF SURGERY. 
 
 of siivficiy in tlic College of Ph\>iciiuis and Surgeons, surgeon of 
 Bellevue Hospital in 1845, and surgeon of the New York Hospital in 
 1856. He was an excellent teacher and operator and greatly beloved 
 by his pupils, M'ho constituted his best contributions to surgery. He 
 was the first operator for strabismus in this country. 
 
 Alfred C. Post (l«(.)5-85), a native of New YorU'and a nepliew of 
 J)y. \\ right Post, graduated in medicine at the (.'ollege of Physicians 
 and Surgeons in New York in 1827, and continued his studies in Paris, 
 Berlin, and Edinburgh. He was one of the founders of the Medical 
 Department of the University of the City of New York in 1851, in 
 which he was professor of surgery and pathological anatomy. He 
 wrote no systematic treatise, but contributed numerous cases to the 
 journals, and was sjiecially skilled in plastic surgery. 
 
 John Watson (1807-63), a native of Ireland, came with liis pa- 
 rents to America in 1810, and graduated in 1832. He became sur- 
 geon of the New York Hospital in 1838, where he first introduced 
 regular clinical instruction in surgery, though Dr. Alexander H. Stevens 
 had previously delivered occasional clinical lectures. He contributed 
 many cases to journals, but wrote no systematic treatises. He collected 
 what was at that time the most valuable private medical library in this 
 country, the greater part of ^vhich, after his death, ^\•as left to the New 
 York Hos])ital Library. 
 
 John lihca Bai-ton (1794-1871), a native of Lancaster, Pa., grad- 
 uated at the Univei-sity of Pennsylvania in 181.S, and became surgeon 
 of the Pennsylvania Hospital. His name is asst)ciated with a form of 
 fracture of the lower end of the radius, with a special form of bandage 
 for fraetin-e of the jaw, and with osteotomy for ankylosis, which he 
 first performed in 1826. In 1834 he wired a fractured patella. 
 
 George McClellan (1796-1847) M-as a native of Connecticut and a 
 pupil of Dr. Dorsev, graduating at ttie University of Pennsylvania in 
 1819. He founded the Jeti'erson ^Medical College in 1824, in which he 
 was professor of surgery until 1838. He excised the body of the lower 
 jaw in 1823, excised the parotid gland for tumors, and was a bold and 
 showy operator. After his death liis Ixiok on Principles and practice of 
 surr/crj/ was published in 1848 : it is note«'orthy only for the very 
 excellent description of shock which it contains. 
 
 George Washington Norris (1808-75) was a native of Philadelphia, 
 and graduated at the University of Pennsylvania in 1830. After two 
 years' service in the Pennsylvania Hospital he went to Paris, and stud- 
 ied under Dupuytren, A^eljjeau, and Roux. He became surgeon to the 
 Pennsylvania Hospital and professor of clinical surgery in the Uni- 
 versity of Pennsylvania. His name is well known in medical literature 
 from the extremely valuable statistical contributions to practical surgery 
 which he published in the American Journal of the Medical Sciences be- 
 tween 1828 and 1854. They rank among the best work of this kind 
 which has ever been done in any country, and his results are quoted in 
 all subse(]uent treatises ujion the subjects upon which he wrote. 
 
 Thomas Dent Miitter (1811-59),'a native of Virginia, graduated at 
 the L'f^niversity of Pennsylvania, after which he studied medicine in 
 Paris. He became professor of medicine in the Jefferson INIedical Col- 
 lege in 1841, and is celebrated for his plastic operations for the cure of 
 
THE HISTORY AXD LITERATURE OF SURGERY. 137 
 
 deformities resulting from burns. He gave liis nuiscum to the College 
 of Physicians of Pliila(leli)hia, with thirty thousand dollars for its main- 
 teuauce and the endowment of a leeturesliip. In this connection may be 
 mentioned : 
 
 William E. Horner (1793-1853), a native of Virginia, who became 
 a surgeon in the hospital department of the army in 1813, when he was 
 twentv vears old and before he had graduated. He iiecame professor of 
 anatomy in the University of Pennsylvania in 1831, succeeding Dr. 
 Borscy. His name is connected with the Wistar and Horner Museum, 
 which he bequeathed to the university, and also with tlie muscle \\hieh 
 lie named the " tensor tarsi." His contributions to surgery are to be 
 found in papers in the American Journal of the 3ferlieal tSciences. 
 
 R. D. Mussey (17SO-1806), a native of New Hampshire, studied 
 medicine under Dr. Nathan Smith, and graduated at the University of 
 Pennsvlvania in 1809. He was professor of the theory and practice of 
 medicine at Dartmouth, 1814; professor of anatomy and surgery in the 
 .same school, 1819 ; professor of surgery in the ]\Iedieal College of Ohio 
 at Cincinnati in 1838 ; and professor of surgery in tlie Miami Medical 
 College in Cincinnati in 1852. He was a bold operator, and first tied 
 both carotid arteries in 1S27 for a large bleeding tumor of the head, and 
 removed the scapula and clavit'lc for tumor following amputation at the 
 shoulder-joint. His only contributions to surgical literature were in the 
 shape of re})orts of cases in the journals. 
 
 Daniel Brainard (1812-()R), a native of Western New York, graduated 
 at the Jeifcrson ^Medical College, Piiiladcliihia, in 1834. He successfully 
 amputated at the hip-joint in Chicago in 183.S, which established his 
 reputation, and in 1.S54 ])iiblished an excellent essay on the treatment 
 of ununited fractures. He was the founder of Rush jMedieal College. 
 
 One of the most celebrated surgeons of the West of this period was 
 Benjamin W. Dudley (1785-1870), a native of Virginia, who graduated 
 at the University of Pennsylvania in 1806, after wliich he studied in 
 Paris and Jjoudon, returning to Lexington in 1814, and became pro- 
 fessor of anatomy and surgery in the Medical Department of the 
 Transylvania University in 1817. His reputation rested mainly upon 
 his operations for lithotomy, which he performed two hundred and 
 tM'enty-five times with almost unparalleled success. He wrote nothing 
 except a few short essays, the first of which. Observations on injuriei< of 
 the head [inelu<ling eases of trephining for epilepsy], M'as pul)lished in 
 the first nunil)er of the Transi/Zrania Journal of Medicine in 1828, and 
 is a very important paper in the history of this operation. 
 
 We now come to an e])oeh in the history of surgery. On November 
 3, 1846, Dr. Henry J. Bigelow read before the American Academy of 
 Arts and Sciences an abstract of a paper which was published in full in 
 the Boston Medical and Hure/ical Journal of November 18, 1846, under 
 tiie title " Insensibility during surgical ojierations produced l)v inhala- 
 tion," which was the first definite account of the method of produc- 
 tion of satisfactory anaesthesia in surgical operations. W^riters of the 
 thirteenth and tourteenth centuries had described the inhalation of nar- 
 cotic vapors from certain ]ilants for this ])urpose. Sir Humjihrv Davy 
 had suggested in ISOO that "nitrous oxide may probablv lie used with 
 advantage in surgical ojK'rations." ]\lr. Hickman, a London surgeon, 
 
138 THE HISTORY AND LITERATURE OF SURGERY. 
 
 had written in 1828 a letter to Xing Charles X. (which letter was laid 
 before the Academy of Medicine of Paris), in which he said that he had 
 discovered the means of pcrforniinii; the most troublesome operations 
 without pain by produciui; insensibility by the introduction of certain 
 gases into the lungs (Archie, (jni. dr tni'd., 1st scr. xviii. p. 453). Dr. 
 Crawford W. Long of Athens, Ga., had ])ro(luced antesthesia by ether 
 in 1842 for the operation of removing small tumors, but had not pub- 
 lished the results, when Dr. Warren allowed a dentist. Dr. Morton, to 
 give ether to produce insensibility while he j)erformcd a small opera- 
 tion in the Massachusetts General Hospital. 
 
 It is to ^^^arren, Hayward, and Bigelow that the surgical world is 
 indebted mainly for a sufficient, general, and safe method of anicsthesia. 
 Morton wanted to patent his method, which was not a thoroughly safe 
 one until modified by Bigelow, and little credit is due to him or to Wells 
 or Jackson for the part which they then played in the Inisiness. The 
 statements of Dr. Bigelow were readily accc|)tcd by surgeons, and early 
 in 1847 anaesthesia was in general use througiiout the civilized world. 
 
 Nothing like it had been known before, and there has been little 
 improvement in it since, for chloroform, though more convenient for 
 use, is decidedly more dangerous than ether in many cases. Most of the 
 great operations had been devised and performed by a few skilled opera- 
 tors befoi'c the introduction of anicsthesia, but tlu' performance was not in 
 the delilx'rate, careful manner which is now ■\\'oll recognized as charac- 
 terizing the best surgery, especially in these days of asepsis and anti- 
 sepsis. The influence of anaesthesia upon surgical diagnosis has been 
 almost as great as ujton methods of operation, for with its aid it is possible 
 to explore tlie interior of the body in ways that would be impossible with- 
 out it. With its aid the recent graduate undertakes operations w liich he 
 would not dream of trying without it : it has done away with the need for 
 some of the most special qualifications which formerly were thought to be, 
 if not indispensable, at least of great importance to the oj)erator. 
 
 Henry Jacob Bigelow (1816-90), a native of Boston, took his medi- 
 cal degree in 1841, after which he spent three years in Eurojie, most of 
 the time in Paris. In 1845 he was appointed instructor of surgery at 
 the Trcmont Street Medical School. In 1846 he was made surgeon to 
 the Massachusetts General Hosjjital, and in 1849 was appointed profes- 
 sor of surgery in the Harvard Medical School, the Uvo chairs of surgery 
 and clinical surgery, jn-eviously held by Dr. J. C. Warren and Dr. 
 George Hayward, being united. He pei'formed the first excision of the 
 hip-joint in this country in 1S52, and first exi)laincd the mechanism of 
 the ilco-fcmoral ligament and its importance in reducing dislocations of 
 the hip-joint. His chief contribution to surgery was his operation of 
 litholapaxy, which has effected a great change in the treatment of vesical 
 calculus. He was a graceful and dexterous operator, a clear and epigram- 
 matic teacher, and the leading surgeon in New England until he retire<l 
 in 1882. 
 
 The number of American surgeons who have become known as 
 inventors, teachers, or writers since 1850 is very large, and only a 
 brief notice can be given of the most prominent. In New York we 
 have had William H. Van Buren (1819-83), who studied in Paris, was 
 an assistant surgeon in the army for four years, in 1845 joined Mott in 
 
THE HISTORY AND LITERATURE OF SURGERY. 139 
 
 clinical teaching, became professor of anatomy in 1852, and professor 
 of surgery in the Bellevue Medical College in 186S. His Contributions 
 to practical ^urgeri/ a])peared in 1865, and his work on Diseases of the 
 genito-urinary s}/sfcm in 1874. 
 
 Gurdon Buck (1807-77), surgeon of the New York Hospital in 1837, 
 and of St. Luke's in 1858, made vahiable contributions to surgery in the 
 method of treating fractures of the thigh by weight and pulley, in tlie 
 plastic surgery oi' the face, and in the treatment of ankyhisis of tiie 
 knee. 
 
 James R. Wood (1816-82), the first to introduce clinical teaching in 
 Bellevue Hospital, and one of the founders of Bellevue Medical College, 
 was a bold operator and a very popular teacher. He removed the entire 
 lower jaw in a case of phosphorus-necrosis, leaving the periosteum from 
 M'hich a new jaw was formed ; excised Meckel's ganglion with the superior 
 maxillary l)ranch of the fifth pair ; and was one of the first in America 
 to perform excision of the shoulder- and elbow-joints. 
 
 Frank H. Hamilton (1813-66), a native of Vermont, graduated in 
 Philadelphia in 1833; became professor of surgery in Buffalo in 1844, 
 and in the Bellevue Medical College in New York in 1862. He pub- 
 lished his Practical treatise on fractures cnid dislocations (Philadelphia, 
 1860) and his Practical treatise on militari/ surgcri/ (1861 ; 2d ed. 1865). 
 
 Alden March (1795-1869) settled in' Albany in 1820 after gradu- 
 ating at Brown University, Rhode Island, and commenced lecturing on 
 anatomy in 1821, being the first lecturer in that city. He was professor 
 of surgery in the Albany ]\ledical College in 1838, and gave one of the 
 first surgical clinics in this country. He made valuable investigations 
 in hip-joint disease, and performed a large number of surgical operations, 
 including sixty-five amputations through the thigh and eleven excisions 
 of the lower jaw. 
 
 Henry Berton Sands (1830-88) graduated from the College of 
 Physicians and Surgeons in New York in 1854; studied in Paris; 
 and on his return l>ecame professor of anatomy, and then of surgery. 
 He was surgeon to the Bellevue and New York Hospitals and to the 
 Roosevelt Hospital, and in the latter j)art of his life was the leading 
 surgeon in New York City. He was the first to operate in peritonitis 
 due to perforation of the appendix. 
 
 Here also may be mentioned J. Marion Sims (1813-83), a native of 
 South Carolina, who connnenced practice in Montgomery, Alabama, and 
 there devised his mode of operating for vesico-vaginal fistula; he came 
 to New York in 1853, and became the founder of modern gyna'cology. 
 
 The Philadelphia surgeons of this period who have finished their 
 work are Gross (father and son), Agnew, Pancoast, and Smith. 
 
 Samuel D. Gross (1805-84), a native of Pennsylvania and a grad- 
 uate of the .Jeiferstm Medical College in 1828, after tilling various 
 chairs in Western schools and in New York accepted the chair of 
 surgery in the Jefferson INIedical School in 1865, from which he retired 
 in 1882. He was a man of strong personality and great influence, an 
 incessant worker, a voluminous writer, an excellent teacher, and one of 
 tlie most distinguished surgeons of his time. He wrote the first 
 .systematic treatise on pathological anatomy by an American author, 
 made original experiments on wounds of the intestines, published 
 
140 THE HISTORY AND LITERATURE OF SURGERY. 
 
 valuahle monographs on diseases of the bladder (1851; 2d ed. 1855), 
 on foreign bodies in the air-])assages (1854), and a system of surgery in 
 two hirge vokimes (1859 ; (Jth ed. 1882), wliieli is an imjiortaut book of 
 reference. 
 
 His son, Samuel W. Gross (1837-89), graduated at the Jefferson 
 IVIedieal College in 1857. (Jn the oiitlircak of tjie Civil War he beeanie 
 a surgeon of volunteers, acting as medical director in various depart- 
 ments until 18()5. In 1882, on the retirement of his father, he was 
 elected one of the professors of surgery in Jefferson Medical College. 
 Pie made numerous contributions to surgical literature in the journals, 
 published a treatise on Tumors of the manuiiary glands in 1882, a 
 treatise on Impotence and sterility in 18X1, and assisted his father in the 
 j)re])aration of the various editions of his System of Surgery. He was 
 a bold yet careful operator and an earnest and eloc|uent lecturer. 
 
 Joseph Pancoast (1805-82), a native of New Jersey, gradu;ited at 
 the University of Pennsylvania in 1828. He began teaching ])ractical 
 anatomy and surgery in 1881. In 18.j8 he was elected professor of 
 .surgery in the Jefferson Medical College ; in 1847, professor of 
 anatomy in the same college. He published his Trrntine on operative 
 surgery in 1844 (3d ed. 1852). He was distinguished for his operations 
 in plastic surgery, especially for exstro|)hy of the bladder ; devised the 
 operation of section of the tliird branch of the fifth pair of nerves at 
 its issue from the base of the skull, and of the second branch of the 
 fifth pair at the same place ; was a skilled anatomist, a dexterous 0])e- 
 rator, and a popular clinical teacher. 
 
 Henry H. Smith (1815-90), a native of Philadelphia, graduated at 
 the University of Pennsylvania in 1837, after which he studied in 
 London and Paris. He became professor of surgery in the Uni\'ersity 
 of Pennsylvania in 1855, and resigned in 1871. His Si/sfcm of opera- 
 tive siirgeri/, published in 1853 (2d ed. in 1856), contains a valuable 
 history of surgery in the United States, with an index of the princij)al 
 contributions of American writers on subjects connected wuth operative 
 surgery down to the year 1854. 
 
 Francis Fontaine Maury (1840-79), a native of Kentucky, grad- 
 uated at Jefferson Medical College in 18G2; jierformed the first opera- 
 tion of gastrotomy in this country, excision of the brachial plexus for 
 painful neuroma, operation for exstrophy of the bladder, and two opera- 
 tions for extirpation of the thyroid gland. He was surgeon of the 
 Philadelphia Hospital. 
 
 Dr. I). Hayes Agnew (1818-92), a native of Pennsylvania, grad- 
 uated at the University of Pennsylvania in 1838. In 1852 he became 
 the head of the Philadelphia School of Anatomy, to which he soon 
 added a school of operative surgcrj' ; in 1863 he left this to become 
 demonstrator of anatomy in the University of Pennsylvania, in which 
 he became professor of clinical surgery in 1878 and professor of surgery 
 in 1871. A highly-skilled anatomist, an unusually dexterous o])erator, 
 and a keen, shrewd diagnostician, he acquired an immense ])ractical 
 experience in all forms of siu-gical affections and treatment, which he 
 embodied in his treatise on the Principles and practice of .mrgcri/, pub- 
 lished in three large volumes in 1878-83, and again in a second edition 
 in 1889. He was one of the few great surgeons who have continued to 
 
THE HISTORY ASD LITERATURE OF SURGERY. 141 
 
 practise medicine as well as surgery until the end of their career, and 
 he did tliis liecause he believed it made him a better surgeon. 
 
 J. L. Atleo (1799-1885), a native of Lancaster, Pa., graduated at the 
 University of Pennsylvania in 1820, and practised at Lancaster through- 
 out liis life. In 1843 he revived the operation of ovariotomy, and with 
 his In-other established it on a firm basis. He was the first successfully to 
 remove both ovaries at one operation. 
 
 Washington L. Atlec, his Iirotlier (1808-78), was a pupil of George 
 McClellan, and performed liis first operations for ovariotomy in 1844. 
 Tiiis operation he performed three hundred and eighty-seven times, and 
 had more influence in popularizing it than any other man in this country. 
 His most imjKirtant contribution to literature is on the diagnosis of 
 ovarian tumors, ])ublished in 1873. He was also celebrated as an ope- 
 rator for the removal of uterine tumors. 
 
 Jonathan Knight (1789-18()4) studied at the University of Pennsyl- 
 vania, and became professor of anatomy and physiology in the Medical 
 Institution of Yale College when it was organized in 1813. In 1838 he 
 became professor of surgery, and held the chair to the end of his life. 
 
 Paul F. Eve (1806-77), a native of Georgia, graduated from the 
 University of Pemisylvania in 1828. He studied several years in 
 Europe, was a volunteer surgeon in the Polish Rebellion of 1831, and 
 became professor of surgery in the Medical College of Georgia in 1832, 
 in Louisville University in 1849, in the Nashville University in 1850, 
 in the Missouri INIedical College of St. Louis in 1868, and professor of 
 operative and clinical surgery in the University of Nashville from 1870 
 to the date of his death. He published ^4 collvcHon of rcmarbihlc w.sc.s- 
 in tiurr/eri/ (Philadelj)hia, 1857) — a most useful and interesting work, and 
 it is highly desirable that a similar collection should be made for the lat- 
 ter half of this century. 
 
 George C. Blackman (1819-71), a native of Connecticut, graduated 
 in medicine at the College of Physicians and Surgeons, New York, in 
 1840, and for the next ten or fifteen years was engaged in study in Great 
 Britain and in France, and as surgeon of an Atlantic packet-ship ; in 1855 
 he liecame professor of surgery in the jNIedieal College t)f Ohio. He was a 
 skilful diagnostician and anatomist, a bold surgeon, an excellent clinical 
 teacher, and thoroughly at home in surgical literature. He contril)uted 
 largely to periodicals, re-edited Mott's edition of Velpeau, and translated 
 the work of Vi<lal on Venereal diseases, but left no monograph or sys- 
 tematic treatise. 
 
 Charles Pope (1818-70), professor of surgery in St. Louis, Mo., in 
 1847, was distinguished as an operator and teacher, but wrote very 
 little. 
 
 Elias Samuel Cooper (182.3-62), a native of Oliio, studied medicine in 
 Connecticut wlien very young ; began jiractice at nineteen years of age, 
 soon after whicli lie excised a large portion of the lower jaw, and at the 
 age of twenty -tliree ojiened a dissecting-room in Peoria, 111., and gave 
 lectures on anatomy. In 1855 he removed to San Francisco, and in 
 1858 was one of the founders of the Medical Department of the Univer- 
 sity of the Pacific, in which he became professor of anatomy and surgery. 
 He performed a number of the greater surgical operations, twice ligated 
 the innominate artery, twice performed Cesarean section, and repeatedly 
 
142 THE HISTORY AND LITERATURE OF SURGERY. 
 
 operated for ovariiin tumors. f)iic of liis most celebrated operations was 
 tlie removal of a piece of iron an incii long and three-quarters of an inch 
 thick, whicli the explosion ol' a ji'un-hnrrel had driven into the chtwt 
 l>eneath and licliind the heart, and which had remained there over two 
 months. His contributions to the literature of surgery are found entirely 
 in periodicals. 
 
 Robei't Nelson (1794-1873), a native of Canada, became distinguished 
 as a surgeon in Montreal, and especially as a lithotomist ; implicated in 
 tlie rebellion of 1837, he came to the United States, for a short time 
 filled the chair of anatomy and surgery at Castleton, A^t., and Pittsfield, 
 Mass. ; went to California in 1849, and finally settled in New York. He 
 is the author of a pamplilet, Gastrotoiiii/ for the removal of non-malig- 
 nant tumors from the abdominal cavity (New York, 1864), and of jiapers 
 in the journals, especially in the Northern Lancet, of which he was the 
 editor 'from 1850 to LSbo. 
 
 John T. Hodgen (1824-82), a native of Illinois, professor of anatomy 
 in the Missouri Medical College in 1852, and professor of clinical and 
 military surgery in 1872, made valuable contributions to methods of 
 treatment of fractures, and his splint is well known. 
 
 George Alexander Otis (1830-81) was a native of Boston, and gradu- 
 ated in medicine at the University of Pennsylvania in 1851. He studied 
 in Paris, entered the army in 1861, was curator of the Army ]\Iedical 
 Museum, and wrote the first two surgical volumes of the Medical and 
 surgical history of the war of the rebellion, using the vast material in a 
 thoroughly scientitic manner. 
 
 Moses Gunn (1822-87), a native of New York, of Scotch descent, 
 settled at Ann ^Vrlior, Mich., became jirofessor of anatomy and surgery 
 in 1850, and ])rofessor of surgery in Rush ^Medical College in 1867, 
 succeeding Brainard. He was a skilled anatomist, a ])opular teacher, and 
 wrote a valuable paper on reduction of dislocations liy manipulation. 
 
 John M. Carnochan (1817-87), a native of Savannah, (ia., a pupil of 
 Valentine Mott, a surgeon in New York City, was a daring ojx'rator. 
 He excised the entire lower jaw in 1851 and in 1864, removed IMeckel's 
 ganglion and the superior maxillary nerve in 1856, and ligated the fem- 
 oral for elephantiasis in 1851. Besides journal articles he was the author 
 of A treatise on .... congenital dislocations of the head of the femur 
 (New York, 1850, 8vo) and Contributions to opercdive surgery and sur- 
 gical jxdhology (New York, 1877-83, 4to). 
 
 Robert Alexander Kinloch (1826-91), a native of Charleston, gradu- 
 ated in medicine from the University of Pcmisylvania in 1848, after 
 which lie studied in London, Paris, and Edinburgh. During the Civil 
 War he was medical director on the staffs of Generals Lee, Pemberton, 
 and Beauregard. In 1867 he became professor of materia niediea and 
 therapeutics in the Medical College of the State of South C'arolina, and 
 soon afterward jirofessor of surgery, which position he held to the time 
 of his death. He was the most prominent surgeon in his State, and 
 Avas the first in this country successfully to excise the knee-joint for 
 chronic disease and to treat fracture of the lower jaw by wiring the 
 fragments. He was also the first surgeon to open the abdomen in cases 
 of gunshot wounds in which there is no protrusion of the viscera. His 
 contributions to surgical literature were entirely to medical periodicals. 
 
THE HISTORY AND LITERATURE OF SURGERY. 143 
 
 Other surgeons well known in their own States were George Hayward 
 (1791-lSG.S), professor of surgery in the Harvard Medieal School, who 
 published some valuable surgical reports in journals and in a volume in 
 1865; Jacob Randolph (1796-1848), surgeon of the Pennsylvania 
 Hospital, who introduced lithotrity in America ; Horace A. Ackley 
 (1812-59), professor of surgery at Cleveland, Ohio, 1843-56 ; Ely Ged- 
 dings (1799-1878), professor of surgery in Charleston, S. C, the outlines 
 of whose lectures were published in 1858; John Neill (1819-80), pro- 
 fessor of surgery in the Philadelphia College; Ernst Krackowizer 
 (1821-75), a native of Upper Austria, who came to New York in 1850, 
 and was surgeon of the Brooklyn City Hospital ; Julius F. Miner 
 (1823-86), professor of surgery in Buffalo ; Joseph C. Hutchinson 
 (1827-87), professor of surgery in Brooklyn ; and Josiah C. Nott 
 (1804-73), professor of surgery at Mobile, but better known as a 
 writer on ethnology. 
 
 The history of surgery in the United States has been told by Gross 
 (Am. Jour. 3'led. Sc, N.'S., Ixxi. 1876, 431), and its triumphs in the 
 way of first operations have been set forth by Dr. Dennis {3Icdical 
 Record of New York, 1892, xlii. 637-648), and to these papers the 
 reader is referred for details \\liich there is not space here to give. 
 
 In addition to anajsthesia, ovariotomy, and the foundation of modern 
 gyntccology, American surgeons have contributed much to the art in the 
 way of perfecting apparatus for the treatment of fractures by extension ; 
 of reduction of (lisloeations by manipidation ; of the treatment of dis- 
 eases of the liip and spine ; of tlie ligation of large blood-vessels ; of 
 the removal of tumors ; of the surgery of the brain, spinal cord, mouth, 
 jaws, kidney, liver, and urinary organs. It is true tliat the scattered, 
 um-eported "first cases" of some of the great operations by early 
 American physicians must be considered as entitling the individual to 
 praise for his boldness or ingenuity rather than as "contributions to 
 surgery," because it is not until such procedures have been made known 
 to the profession and become a part of surgical literature or teaching 
 that they have become useful ; but from the beginning of the history 
 of the art we find that the majority of the " first operations " of all 
 kinds have been made, not by distinguished professors and famous 
 authors, but by men who were neither teachers nor authors, and the 
 names of many of whom are unknown to this day. This is true of 
 amputations, lithotomy, herniotomy, trephining, excision of the breast, 
 ligation of a wounded artery, C;esarean section, hysterectomy, ovari- 
 otomy, and of the invention of many of the primitive forms of some of 
 the most important instruments of the present day. " Les petits pro- 
 phets," as Verneuil styles them, are worthy of all honor, and one of 
 the objects of a history of surgery is to keep their names at least from 
 being forgotten. American surgeons have contributed at least a fair 
 share to tlie common stock of knowledge in the past, and it seems prob- 
 able that they will do still more in the near future. They have been, 
 for the most part, " practical men :" it is only within the last twenty 
 years tiiat the scientific problems of surgical pathology have been the 
 subject of experiment and study in this country, but it is quite prob- 
 al)]e that the John Hunter or Josej)h Lister of America is now busy 
 Avith his preliminary work. 
 
144 THE HISTORY AND LITERATURE OF SURGERY. 
 
 A most imi>ortaiit stc']> in the })rogress of medicme was made when 
 physicians and surgeons began to form associations and societies for the 
 purpose of mutual improvement and for the piil)lication of papers read 
 befiire them, rather tiian for guariHng trade interests; and the trans- 
 actions of such societies form a most vakiable section of medical litera- 
 ture. The first of these societies Avhich was devoted specially to sur- 
 gery, and whose jiublications were im])ortant, was the Academic royale 
 de chirurgie, the memoirs of which appeared in o quarto volumes (Paris, 
 174.3-74, and again in 15 vols. 12mo, Paris, 1771-87, in 5 vols. 8vo, 
 Paris, LS19, and in 3 vols. 8vo, Paris, 18.38). 
 
 The MemoireH and Bulletins of the Societe de Chirurgie de Paris, 
 j)ublished from 1847 to the present time, and forming -52 volumes; the 
 VerhcnuUunr/cn of the Deutsche Gcsellschaft fiir Chirurgie, in 35 vol- 
 umes, 1872-93 ; tlie TranKoetions of the American Surgical Association, 
 in 10 volumes, 188.3-92; and the Proccs-nrboiix, mcmoirefi, etc. of the 
 Oingres fraacais de Cliirurgie, — are the most important of the purely 
 sui'gical publications of this class in the present century. No surgical 
 association ])ublishing professional reports has existed in Great Britain, 
 the Royal Colleges of Surgeons of Edinbui-gh, of England, and in Ire- 
 land not having undei'taken this line of work. 
 
 The following is a list of the most imjioi-tant journals devoted 
 especially to general surgery, arranged in order of date : 
 
 Chirnrr/ischc Bihliotliek, von August Gottlieb Richter, 1771-96, 8vo, Gtittingen 
 
 u. Giitlia. 
 Journal de Cliirurgie, par Pierre-Joseph Desault, 1791—92, 8vo, Paris. 
 Blljliothck fiir die Chirurgie, Hrsg. von C. J. M. Langenbeck, 1805-13, 8vo, 
 
 Gtittingen. 
 Neue BiUiothek fiir die Chirurgie viid Ophthalmologie, Hrsg. von C. J. M. 
 
 Langenbeck, 1815-28, 8vo, Hannover. 
 Journal tier Chirurgie und Aiigeii-IJeilkniide, Hrsg. von C. F. Graefe und Ph. 
 
 von Walther (quarterly), 1820-50, 8vo, Berlin. 
 Giornale di C hirurgia-pratica , compilato dal dott. G. Canella, 1825-29, 8vo, 
 
 Trento. 
 Aiuudes de la. ehirnrgie fraiiraise et etrangere, publiees par MM. Begin, Mar- 
 
 chal, Velpeau et Vidak 1841-45, 8vo, Paris. 
 Journal de Chirurgie, par M. !Malgaigne, 1843-46, Bvo, Paris. 
 Arehiv fiir klinisehe Chirurgie, Hrsg. von Dr. B. von Langenbeck, red. von 
 
 Billroth und Gurlt, 1860-94, Svo, Berlin. 
 Deutsche Zeitsehrift fiir Chirurgie, Hrsg. von Bardeleben (et al.) ; red. von 
 
 C. Hueter und A. Liicke, 1872-94, 8vo, Leipzig. 
 Centralblatt fiir Chirurgie, Hr.sg. von L. von Lesser, M. Schede, H. Till- 
 
 manns (weekly), 1874—94, Svo, Leipzig. 
 Revue de chirurgie, r^dacteurs en chef, MM. Nicaise et F. Terrier; direc- 
 
 teurs, MM. Oilier et Verneuil, 1881-89, 8vo, Paris. 
 Annals of fiurgery, a monthly review of surgical science and practice, edited 
 
 by L. S. Pitcher and C. B. Keotley, 1885-94, Svo, St. Louis. 
 Archives of Surgery, by J. Hutchinson (quarterly), 1889-94, Svo, London. 
 
SURGICAL PATHOLOGY, INCLUDING INFLAM- 
 MATION AND THE REPAIR OF WOUNDS. 
 
 Bv W. T. COUNCILMAN, M. D. 
 
 I. INFLAMMATION. 
 
 Inflammation is one of the most inij)oi-t;iiit subjects in medicine 
 and surgery, and one of the most difficult to comprehend. It ha.s 
 played an important part in the history of medicine, and most of the 
 theories of disease formerly held were more or less based on conceptions 
 of its nature. It is only in comparatively recent years, when patient 
 observation and experiment have taken the place of theory, that the true 
 nature of inflammation has been better understood. 
 
 ^\'ere we to take up all the phenomena of inflammation and stud}' 
 each process fully, it would ^practically include all pathology. So exten- 
 ■sive is the subject, and so intimately is it related to other pathological 
 processes, that it has recently been proposed to abolish the term " inflam- 
 mation" entirely, and to consider the various jilienomena under other 
 divisions of pathology where they naturally belong. The phenomena 
 of inflammation are closely connected with the i)athology of the circula- 
 tion, with the degeneration and regeneration of tissue, with the action 
 of bacteria, with injuries, etc. Still, it is well to have some one term to 
 include the tissue-changes following an injury, and we may define inflam- 
 mation as the sum of the phenomena which take place in the tissue as the 
 effect of an injury. The object of these various jihenomena is to over- 
 come or to diminish the eifects of the injury. The study of inflammatory 
 processes may be well begun with the changes which take place in the 
 blood-vessels, and in the connective tissue, which everywhere stands in 
 close connection with these. 
 
 It will be well to consider the character of the normal coimective 
 tissue and the relations which it has \\ith the circulation. The con- 
 nective tissue in the body serves the important function of binding 
 together the various parts, and acts as a support to the blood-vessels, 
 which, with this tissue, grow into the various structures in the course 
 of development. The connective tissue varies in its structure. It is 
 composed of cells and of fibres which differ in their physical and chem- 
 ical (lualities. In places the filn-es are loosely connected together, as in 
 the areolar tissues, and in places they are compacted in close bundles, as 
 in the tendon. The number of blood-vessels in this tissue varies greatly 
 in the different parts of the body, the number standing in exact relation 
 to the importance of the adjacent epithelial structures. Most of the 
 blood-vessels in the connective tissue do not serve the purpose of its 
 
 Vol. I. — 10 ]45 
 
146 
 
 SURGICAL PA TlKiLOG Y. 
 
 nutrition, (lie tissue simply serving as a bed for their support. Where 
 the blood-vessels in the connective tissue are for the nutrition of this 
 alone, they are not found in such large luunbers. The nutrition of the 
 tissue is carried on by means of tlie lymph -which passes through the 
 walls of the vessels and circulates through the tissue. In some places 
 there are no definite tracks taken by the lymph. In the subcutaneous 
 areolar tissue there is a loose meshwork of fibres containing a variable 
 number of cells, and the tissue is simply saturated M'ith the fluids. In 
 other places, aa in the cornea, the fibres of the tissue are compacted into 
 a dense mass containing channels and spaces in which the cells lie and 
 in which the lymph circulates. In still other plac(^s the nutrition seems 
 to take place through the cells alone. In the cartilage, for instance, there 
 is a compact intercellular suljstance, with no spaces either around or be- 
 tween the cells, so that the nutrition of this tissue is j)robably kept up 
 from cell to cell. 
 
 The vascular ])henonicna which take place in inflammation can be 
 directly studied under the microscope in a transparent part, as in the 
 web of the frog's foot or in the mesentery (Fig. 1). The mesentery of 
 
 Fig. 1. 
 
 Portion of the mesentery of a froa, showing normal circulation : a, a, small arteries just breaking 
 up into capillaries ; o, b, small veins ; c, c, wandering cells (leucocytes in connective tissue). 
 
 the frog is a thin tissue which is covered on the outside by a single layer 
 of flat endothelial cells, beneath wliich is a layer of rather firmly-inter- 
 woven connective-tissue fibres, with numerous blood-vessels, nerves, and 
 lymphatics. The arteries and veins in the mesentery are relatively more 
 numerous than the capillaries, because the tissue mainly serves to support 
 the vessels passing from its root to the inte.stine. Under the microscope the 
 
INFLAMMA TION. 
 
 147 
 
 normal circulation can be studied and the gradual development of inflam- 
 matory changes observed. In the various sorts of vessels ditferences in 
 the character of the circulation may be recognized. In the arteries there 
 is an evident pulsating stream. At each contraction of the heart the 
 blood is swept along so rapidly tiiat it is not possible to recognize tiie 
 individual coriniscles. In the diastole tlie stream becomes slower and 
 we can see the individual corpuscles. In tlie veins the movement of tiie 
 blood is a continuous one, and is slower than in the arteries. In the 
 capillaries the movement of the blood is slow and regular. Neither in 
 the veins nt)r in the arteries do the red blood-corpuscles completely fill 
 the vessel. We recognize a central core composed entirely of masses of 
 red blood-corpuscles, and between this and the wall of the vessel is a 
 colorless zone which contains no red blood-corpuscles, and in which here 
 and there single wiiite corpuscles roll along. In the frog's web it is 
 necessary to injure the tissue either by chemical or mechanical violence 
 to produce inflammation, while the mere exposure of the mesentery to 
 the air produces sufficient injury to bring about all of the phenomena. 
 
 Fig. 2. 
 
 The same vascular territory as shown in Fig. 1, two hours after exposure. All of the vessels arc 
 (lilatetl. The leucocytes aje more numerous ; they have eoUectea alonp the walls of the vessels, 
 and in several places are passing; ihrouph : at d diapedesis of the red corpuscles is shtiwn, 
 and at e emigration of leucocytes. Tlicre are large numbers of leucocytes in the connective 
 tissue. 
 
 If care be taken in placing the mesentery beneath the micrf)seope to 
 pi-oduee as little injury as possible, all of tlie phenomena will take place 
 so gradually that the single steps can be easily followed. At first no 
 changes at all are seen in the circulation. Under some circumstances the 
 first change seen is a contraction of the small arteries. This is always tem- 
 
148 SURGICAL PATHOLOGY. 
 
 porarv, and is often not observed, and in any case it quickly iijives ])lace 
 to dilatation. The dilatation of" the arteries is acconijianied hy a great 
 rapidity of circulation. The Mood tiows throut>h all of the vessels with 
 increased speed. P^ven in the capillaries the tlow is sometimes so rajiid 
 tliat the individual corpuscles cannot be seen. Vessels appear which 
 were jireviously invisible from their small size. The veins take part in 
 the dilatation, and the flow in them is also more rapid. This is the 
 stage of active arterial hypenemia. There is more blood brought to the 
 part by the dilated arteries ; more passes through and is carried oif by 
 the veins. 
 
 This condition of the circulation soon gives place to another (Fig. 2). 
 The dilatation of the blood-vessels continues, but the current becomes 
 slower. The circulation in the dilated capillaries may become so slow 
 that they become filled with red blood-eorpuscles, and appear as red 
 lines running through the tissue. The slowing of the current and dila- 
 tation of the vessels are much more evident in the veins than in the 
 capillaries, and a marked change takes place in the plasma-zone of the 
 veins. In the normal circulation the white corpuscles are confined to 
 this zone, and they roll along the wall in the clear fluid. These cor- 
 puscles gradually increase in number, and the entire plasma-zone of the 
 vein becomes filled with them. Although the blood-current of the vein 
 is slow, the progress of the white corpuscles in the plasma-zone does not 
 keep pace with that of the red corpuscles in the centre. They will fre- 
 quently cling for a time to the wall of the vessel, and then again be 
 swept away by the current. Numbers of them remain, and finally the 
 wall of the vessel becomes lined \\ith them. These corpuscles in the 
 j)lasma-zone undergo ra])id anueboid changes, and may move from place 
 to place along the vessel. Some of them become apparently fixed to the 
 wall of the vessel, and then a striking phenomenon takes place. A small 
 bud appears on the outside of the vessel opposite the point at which a 
 white corpuscle adheres. This projecting bud gradually becomes larger, 
 and at the same time that part of the corpuscle inside the vessel becomes 
 smaller, and after a variable length of time the corpuscle passes 
 entirely through the wall of the vessel. This passage of the white cor- 
 puscles through the walls of the vessels is spoken of as emigration, and 
 when it once begins it goes on witli considerable rapidity, until finally 
 the tissue outside of the blood-vessels becomes filled with these cor- 
 puscles. They accumulate in the tissue and lie in the meshes between 
 the fibrils and in the lymph-spaces (Figs. 3 and 4). The emigration is 
 not always easily observed. To see it under the best circumstances 
 vigorous frogs should be selected and care taken in spreading the mem- 
 brane out to produce as little injury as possible. It is much more easily 
 seen in the vessels of the bladder than in those of the mesentery. The 
 l)ladder can be filled with salt solution, turned out through the rectum, 
 and directly observed. Sometimes it takes more than an hour for the 
 corpuscle to pass through the \\all of the vessel. The white corpuscles 
 accumulate in the dilated capillaries, but to a much greater extent in the 
 veins. Both the red and the white corpuscles pass through the walls of the 
 capillaries. The red corpuscles may also pass through the walls of the 
 veins, but this is comparatively rare. This passage of the red corpuscles 
 through the walls of the vessels is called diapedesis. They pass through 
 
mFLAMMA HON. 
 
 149 
 
 Diagrammatic view of inflammatory changes in a small vein : a, normal circulation, showing 
 plasma-zone ; b, c, d, successive changes, showing dilatation, accumulation of leucocytes, ana 
 emigration. 
 
 the walls of the capillaries in nuich <iroater numbers than the white 
 corpiiseles. 
 
 Not only do the white and red corpuscles pass through the walls of 
 
 Fig. 4. 
 
 The process of emigration, observed under high power. The Olood is supposed to flow on the left 
 of the line in the direction indicated by the arrow. The tissue is on the right. X 1000. (After 
 Thoma.) 
 
150 SURGICAL PATHOLOGY. 
 
 the vessel, but the fluid portions of the blood also pass throngh. This, 
 of course, cannot be directly observed under tlie niicroscope, Idit we can 
 easily see that the tissue becomes thicker and inliltratcd witli fluid. A 
 part of the fluid is retained in the meshes of the tissue, and a part passes 
 directly through to the surface. Tiiese vascular changes last for a con- 
 sideraljle time, and, if the mesentery of the frog has remained under 
 observation a long while or if it be allowed to become dry, the circula- 
 tion will tinally cease and the part will become gangrenous. If care be 
 exercised in the ])reparation of the specimen and the mesentery be 
 replaced in the abdominal cavity, the vessels in the course of a few days 
 will return to their normal condition. 
 
 These are the main vascular phenomena which can be observed 
 directly under the microscope. The process in all animals is the 
 same. Tlioma has ol)served the circulation in the niesenteiy in the 
 small mammalia, under both normal and pathological conditions, and 
 the same phenomena occur. The same process may be observed in the 
 wing of a bat under the microscope, but in this case it will be necessary 
 to produce some mechanical or chemical injury to the tissues, the mere 
 exj)Osure under the microscope not being sufficient. 
 
 The inflammatory changes in the circulation may with advantage be 
 studied in the frog's tongue. This contains more vessels than the mesen- 
 tery and is relatively richer in capillaries. The tongue is attached to 
 the jaw by its anterior extremity, and it can readily be drawn from the 
 mouth, sjiread out over a cork ring, and the circulation observed. 
 Inflanunation may be produced by the application of dilute croton oil 
 (1 droj) of croton oil to 40 of olive oil) to the surface, removing it in a 
 few minutes, otherwise it will produce coagulation of the blood in the 
 vessels with entire cessation of the circulation. The same phenomenon 
 which is seen in the mesentery takes place here. There is a period of 
 intense active hyperannia which gives place to stagnation, with emigra- 
 tion of white and red corpuscles and increased transudation. The 
 tongue becomes swollen from infiltration with fluid and cells. The 
 changes are the more striking the more limited is the injury to the 
 tissue. The croton oil tends to diffuse all over the surface, but a cir- 
 cumscribed inflammation may be produced by touching the surface with 
 a crystal or a pointed stick of nitrate of silver. Various degrees of 
 vascular disturbance may be seen, which is most intense immediately 
 around the eschar which has been produced by the caustic, and which 
 gradually gives place to the normal circulation. The caustic jiroduces, 
 where it comes in contact with the tissue, coagulation of the blood in 
 the vessels, with cessation of the circulation and necrosis of the tissue. 
 The necrotic tissue is converted into a brown slough which is presently 
 cast off. Immediately around the eschar is a dark-red zone. In this the 
 blood-vessels are greatly dilated, the circulation is very slow, in places 
 com])leteh' stagnant, and the tissue between the vessels is filled witli red 
 corpuscles which have passed through the walls. The redness immediately 
 around the necrotic spot is principally due to hemorrhage by diapedesis. 
 Even with the naked eye it can be distinguished from the I'edness due 
 to hypenemia by its gi-eater intensity and dittiiseness. Outside of this 
 comes a zone in which the vessels are dilated, the circulation is slow, and 
 numbers of corpuscles, both \vliite and red, but principally white, are 
 
INFLAMMATIOX. 
 
 151 
 
 passing tliroiigli tlie walls of the vessels and accumulating in the tissue. 
 This zone gradually fades oiF into one in which there is active arterial 
 hypera^mia. In this way all the changes which gradually develop in the 
 mesentery can be seen taking place at one time. Here, as in the mesen- 
 terv, it is evident that there is also an increased exudation of the fluid 
 portions of the blood, because the tissues become swollen and- oedematous. 
 These areas, which we have referred to as zones, are not sharply marked, 
 but one gradually gives place to the other. 
 
 The same process can be studied on non-transparent parts by harden- 
 ing them at various intervals after the production of the injury and 
 examining the sections. Acute inflammation may be^ excited in the ear 
 of a rabbit by ruljbing it with croton oil. The oil should be diluted 
 with 5 or (3 parts of olive oil, otherwise a total necrosis of the tissue 
 may be produced. Almost immediately the ear becomes actively red. 
 In twenty-four hours it is red and swollen. The redness is not always 
 due to hyperemia. Here and there small, irregular red splotches may 
 be seen which are due to hemorrhage into the tissue. The swelling 
 involves the entire ear even if the croton ott was only applied to the tip. 
 On the inside of the ear small vesicles filled with clear fluid are fre- 
 quently found (Fig. 5). Sections of the ear after hardening in various 
 
 Fig. 6. 
 b 
 
 p XT'- ■•..•• -^ 
 
 ■/■■^•'^i|S«?|^'^ 
 
 Section of ear of rabbit thirty-six hours after the application of croton oil ; the connective 
 tissue is swollen from infiltration with serum, leucocytes, and fibrin : a, epidermis ; 6, vesicle- 
 formation : c, accumulation of leucocytes around necrotic hair-follicles ; «, tibriu ; e, muscular 
 layer ; /, pericliondrium ; g, cartilage. 
 
 solutions — of which Fleming's solution is the best — show the vessels 
 dilated, and in some ca,ses entirely filled with white corpuscles. Fre- 
 quently the white corpuscles are confined to the inner lining of the 
 veins, and in favorable sections they may be caught in various stages of 
 emigration. In the areas of hemorrhage the congestion is intense, the 
 tissue is filled with red corpuscles, but no rupture of the vessels can be 
 made out. In the tissue cvery\xhere there are immen,se numbers of cells 
 of the same appearance as those within the vessels. They are u.sually 
 more numerous close beneath the epidermis, and the tissue may be so 
 
152 SURGICAL PATIIOLOOY. 
 
 packed with tliera that nothing more can be seen. They are not only in 
 the tihisiiie beneath the epidermis, but numbers of tlicm have entered 
 into this, lying in the spaces between the cells, and in the fluid in the 
 small vesicles numbers of them arc seen. Toward the middle of the 
 ear, where the tissue is looser, the white corpuscles are less numerous, 
 and the meshes of the tissue are forced apart by infiltration ^\•ith the 
 fluid which has escaped from the vessels along with the leucocytes. In 
 the swollen tissue toward the root of the ear, away from the area of 
 injury, there are few or no leucocytes. Fibrin in various amounts may 
 be contained in the tissui'. 
 
 li' an injury be produced in non-vascular parts, the same changes 
 Avhich are seen in the vessels of the mesentery or in the vessels of the 
 rabbit's ear will take place in the surrounding vessels which provide the 
 nutrition for the non-vascular territory. The cornea has usually been 
 selected for the study of inflammation in non-vascular tissues. If the 
 central portion of the cornea of a rabbit be injured by touching it with 
 a stick of nitrate of silver or caustic jjotash, a necrosis of the tissues 
 limited to an area not exceeding 1 to 2 mm. in diameter may be pro- 
 duced. The tissue immediately affected by the caustic becomes white 
 and opaque ; it afterward becomes dry, and a scab is produced which is 
 thrown off. For a time no change will be perceived in any ])ortion of 
 the cornea, either immediately around the injured tissue or at a dis- 
 tance. If a very thin cornea, as the frog's, l)e chosen for the experi- 
 ment, the corneal corpuscles immediately around tlie injury are more 
 easily seen than elsewhere, and this is doubtless due either to coagula- 
 tion of the protoplasm of the cell or to changes which have taken place 
 in the intercellular substance. In the area of the eschar there has been 
 total destruction of the cells and of the intercellular substance as well, 
 but around this, where the action of the caustic Mas less intense, it is 
 probable that necrosis of the cells ^itli coagulation of the protoplasm 
 has been produced without any alteration in the character of the inter- 
 cellular substance. In the course of a few hours changes begin to 
 appear in the periphery of the cornea close to the sclera. The first 
 change which is appreciable is a slight cloudiness around the entire 
 periphery of the cornea if the injury has been produced exactly in the 
 centre. If the caustic was applied closer to one margin, the cloudiness 
 will begin on the margin nearest the injury. The cloudiness rapidly 
 increases, and extends over the entire cornea up to and around the 
 injured portion. At first the entire tissue between the sclera and the site 
 of the injury is clouded, but the cloudiness gradually becomes more 
 marked around the injury, and the periphery of the cornea after three 
 days may become completely clear, ^^'hen the cornea is removed, split 
 up into thin lamella, and examined, it is found that the cloudiness is 
 due entirely to the presence of leucocytes in the lympli-spaces of the 
 tissue. If the vessels of the sclera are examined in the beginning of 
 the cloudiness, the same changes are found in them which were seen in 
 the vessels of the frog's mesentery and tongue. 
 
 The experimental study of intlannnation of the cornea has played a 
 most important part in the develojiment of our knowledge of inflamma- 
 tion. It formed the battle-ground between the adherents of Cohnheim, 
 who believed that the cells in an acutely inflamed tissue were exclusively 
 
INFLAMMATION. - 153 
 
 derived from emigration of leucocytes from the vessels, and the adhe- 
 rents of Virchow (iind later Strieker), who believed that if emigration 
 of leucocytes took jjlace at all, it only played a subordinate i-ole, and 
 the new cells were derived from multijilication of the tixed cells of the 
 tissue. 
 
 The cornea being a non-vascular organ, it was first thought that the 
 new cells which apjieared in it after inflammation was excited must be 
 derived from the fixed cells. Cobnheim showed tliat the new cells 
 do not first appear around the injury, but in the periphery, and thence 
 gradually make their way to the centre ; further, that examination of the 
 vessels of the sclera showed the same changes which had been observed 
 in the frog's mesentery. He showed further, in a most ingenious 
 way, that the cells came from the vessels. It was known that when car- 
 mine, cinnabar, or any finely-divided solid substance was injected into 
 the circulation, the white corpuscles of the blood would take up the fin-- 
 eign material. He injected such substances into the abdominal vein of 
 a frog, and found them in the new cells of the inflamed cornea. Ac- 
 cording to the theory of inflammation develojjed by Cohnheim, which 
 was accepted without reserve by his pu])ils, the essential feature of 
 inflammation is an alteration of the walls of the blood-vessels, in con- 
 sequence of which they become more permeable, and allow not only the 
 fluid parts of the blood to pass through more easily, but the corpus- 
 cles as well. The tissue-cells played no part in the process, and not 
 only the pus-corpuscles, but all of the new cells found in the inflam- 
 matory area, came from the blood. 
 
 Cohnheim was not the first to observe the emigration of the leuco- 
 cytes. His observations were made in ignorance of the earlier work on 
 the subject, but he saw the importance of the jn-ocess and investigated 
 farther. Cohnheim's first observations on the cornea were published in 
 1867. As early as 1842, Gulliver described the cells found in severe 
 inflammation and suppuration, and com])ared them to the white coi'pus- 
 cles. He seems also to have been the first to observe an increase in the 
 number of white corpuscles in the blood during the pniccss of inflam- 
 mation. Addison in 1845 called attention to the similarity of the blood-, 
 lymph-, and pus-corpuscles. He found that all these cells had ama?boid 
 movements, that they resembled one another greatly, and thought it 
 possible tliat they might be the same cells. Quitzman, who reviewed the 
 article of Addison in CansUitt'n Jnhrcshcr'tcht, says that it shows great 
 penetration and admirable observation, but that the only proof of the 
 identity of the pus-cells and the leucocytes would be the observation of 
 the actual passage of the leucocytes through the walls of the vessels. 
 Various other observers after this called attention to the similarity in 
 the appearance of white corpuscles and pus-cells, and in some of the 
 atlases of pathological anatomy pus-cells and white blood-corpuscles are 
 shown side by side. A^irchow in numerous publications mentions tin's 
 similarity. The actual proof of the matter was given by A\'aller in 
 England in 1849, but his observations attracted little attention and were 
 soon forgotten. Then the matter rested until Recklinghausen in 1862 
 showed that the normal connective tissue contained cells, similar to the 
 leucocytes, which wandered through the tissue in the lymph-spaces. 
 Although we know now that the leucocytes form the great mass of the 
 
^r,4 SURGICAL PArilOLOGY. 
 
 colls in the exudation in an acute iiitlanuuation, they are not the only 
 ones present, and the essential feature of inflannuation is not the lesion 
 of the vessels. 
 
 For the excitation of intlanimatiou an injury of the tissue of some 
 sort must be produced, and the mode by which the injury is produced is 
 of little importance. The injury may be from a trauma, and a lesion 
 of continuity may be produced. In many cases it is difficult to show 
 the anatomical lesit)u which the injury has produced. Pressure or trac- 
 tion exerted on a tissue may act as a trauma, and the extent of the 
 injury will depend upon the elasticity of the ])art. The consequence of 
 jjressure may be the severance of the conuectidu Ix'twcen certain parts, 
 or, when the pressure is of longer duration, the nutrition of the part 
 may be aifected and necrosis take place. Very slight mechanical injury 
 in individuals with very vulncralde tissues may produce evident inflam- 
 mation. In the case of the mesentery we have seen that even the lay- 
 ing bare of a ]iart which is ordinarily covered may develoj) inflamma- 
 tion. Zahn has shown that when the mesentery is fully protected from 
 drying and other injuries, and preserved from contact with the bacteria 
 in the air, it may remain exposed for hours without inflammation tak- 
 ing place. The chemical injuries are probably more extensive than the 
 traumatic. They may directly produce a necrosis of the tissue, with 
 coagulation of the cells and intercellular fluid, or they may exert an 
 injurious action on certain special cells. The injurious action of l)acteria 
 is probably for the most part chemical, the tissue being affected by the 
 substances which they produce. The action of some of the bacteria 
 on the tissues is not inflammatory : they may exert a specific action 
 on the cells, causing them to ])r<jliferate and to produce definite new- 
 tVirmations of tissue. Even this action may be accompanied by in- 
 flammation, for all such newly-formed tissues are prone to degeneration, 
 and the tissue reacts to the injury of the.se abnormal products just as it 
 does to injury of its normal constituents. Heat and cold may excite 
 inflammation if they are of sufficient intensity or their action is suf- 
 ficiently prolonged to have an injurious influence. In the same way, if 
 injury be ])roduced by interference with the normal blood-supply of any 
 part, inflannuation is excited around the injui-ed tissue. Electrical stim- 
 ulation cannot excite inflammation unless it be of such a nature that 
 the tissue is directly injured. Foreign bodies only act as exciters of 
 inflammations by the injury which they produce in the tissue around 
 them. Even in the inflammations of internal organs which are far re- 
 moved from the dangers of traumatism the same thing is true. The 
 injury to the tissue which is the cause of infiannnation may be due 
 to the presence in the tissues of chemical substances which are formed 
 elsewhere in the body, and which exert an injurious action on certain of 
 its cells. The inflammation ()f the kidney produced by chrome salts and 
 cantharidin are examples of this. 
 
 Certain phenomena \\-hich are easily appreciable have since the time 
 of Celsus been regarded as indicating inflammation. They are in some 
 cases more evident than in others, and certain of them may be absent or 
 predominate over the rest. They apj>ear in their most typical form in 
 acute inflammations of the skin. If we take for example the furuncle 
 or the infectious infiannnation which develops in the skin around the 
 
IXFLA MM A TIOX. 155 
 
 hair-follicle or glands, we find at the height of the process that the in- 
 flamed area is retlder than the surronnding skin. It is warmer to the 
 toneh, and if the temperature be taken with a surface tiiermometer, it 
 may be several degrees warmer than the neighboring skin. It is swollen, 
 appears as an elevation, and is painful. 
 
 The redness is due to the greater amount t)f blood which is contained 
 either in the vessels or, in the form of hemorrhage, in the tissues of the 
 part. The character of the redness varies. In the early stages of the 
 inflammation and at the periphery it is a bright red, almost approaeiiing 
 the color of arterial blood. As the inflammation advances, and in the 
 centre of the furuncle, it changes to the dark color of venous blood. 
 When the blood is contained in the vessels alone, the redness may be 
 made to disappear tjy pressure, the blood in the dilated vessels being 
 driven out of them. Tlie redness is also due to hcmorrhagt' in the tis- 
 sue. The areas of hemorrhage generally appear as circumscribeil spots, 
 distinguished from the hyperajmia by the more intense color. They are 
 easily seen in the inflamed ear of the rabbit, and are most marked where 
 the action of the injurious agent has been most intense. By varying the 
 dilution of the croton oil which is applied to the ear the amount of the 
 hemorrhage in the tissue varies, and is always greatest when the less 
 diluted oil is used. There is no tissue in the body so well adajtted 
 to show inflammatory hypersemia and hemorrhage as the acutely in- 
 flamed pleura. When this is stripped off and held to the light, it is 
 of a bright-red color, a beautiful network of dilated vessels can be seen, 
 and between these the tissue has a general diffuse redness due to injec- 
 tion of the capillaries. Here and there in the tissue can be seen red 
 splotches varying in size from 1 to 10 mm. in diameter, which are due 
 to hemorrhage. More blood is brought to the inflamed part by the 
 dilated arteries, and more flows from it. This increased passage of 
 blood through the inflamed area takes place in spite of the slowness of 
 the circulation in the dilated veins. In the early stages of inflamma- 
 tion, in wliieh tliere is dilatation with increased rapidity of the circula- 
 tion, it is evident that this must be the case, and in the later stages, in 
 which there may be almost complete stagnation in the central portion of 
 the area, in the periphery there is an active circulation in dilated vessels. 
 Lawrence long ago showed that there was a greater flow of blood from 
 an inflamed part by opening corresponding veins coming from an inflamed 
 and from a normal part. 
 
 There have been various theories advanced to account for the inflam- 
 matory liyperiBmia. After Bernard showed the effect of cutting the 
 sympathetic on the circulation of the rabbit's ear, the idea arose that 
 the inflammatory hyperemia might be due to paralysis of the vaso- 
 motor nerves. It' can be shown that this is not the case. After sec- 
 tion of the sympathetic the hypenemia develops at once ; in inflannna- 
 tion it comes on slowly and extends slowly. Furtlier, the hyperivmia 
 produced by section of the sympathetic never reaches the intensity of 
 the inflammatory hypertemia. If the ear is inflamed after section of the 
 sympathetic, an intense hypersemia develops — more intense, as a rule, 
 than the inflannnatory hyperreniia of the car with a normal nervous 
 supply. Then the opposite idea was held, that the effect of the injury 
 was to produce a spasmodic contraction of the arteries, so tiiat there 
 
156 SURGICAL PATHOLOGY. 
 
 was really a diminished supply of arterial blood to the jiart ; tlie hyper- 
 {emia then was supposed to be due to the entry of blood into the intlanied 
 part from surrtpundin<; ])arts by the eollateral eirculatioii. There is 
 usually in inflammation a temporary eontraetion of the arteries, but 
 this may be entirely absent, and it quit^kly gives place to dilataticin. The 
 theory of stasis has also been used to account for the hyperemia. This 
 theory was intimately connected with the humoral patholoyy and was 
 advocated by Boerhaave. It was supposed that in inflannnation the 
 character of the blood was altered, tiie corpuscles becoming more adhe- 
 sive, and in consequence flowed tlu-ough the vessels with more difficulty 
 and accumulated in the inflamed part. These views with regard to the 
 hypersemia of inflammation have l)een given nj), and the two theories at 
 present used to explain it are that of Cohnheim and that of Yirchow. 
 Cohnheim explains all the vascular phenomena of inflammation by an 
 alteration of the walls of tiie blood-vessels produced by the action on 
 them of the agent causing the inflannnation. Virehow explains tlie 
 congestion by an alteration in the attraction between the blood and 
 the tissues. Cohnheim supi)Osed that the changes in the vessels were 
 passive in character, and were due to the effect of the injury on them, 
 and he attempted to prove this in various ways. He showed that when 
 the blood was cut off from the vessels for varying periods, and then 
 again turned into them, all the phenomena of inflammation could be 
 produced, the degree depending on the length of the ansemic period. 
 By cutting off^ the blood from them he supposed the nutrition of their 
 walls was affected, and tlnis an injury limited to the blood-vessels was 
 produced. He does not attempt to deflne the character of the altera- 
 tions which the vessels undergo, and supposed that there might be either 
 chemical or physical changes produced in them which were so delicate 
 that they could not be detected by our metiiods of investigation, and 
 which manifested themselves only by their effects. Almost all that we 
 know about pathological alterations in blood-vessels relates to the various 
 degenerations of their walls. It is certain tiiat there can be no altera- 
 tion of the walls of the blood-vessels without affecting the tissues at 
 the same time. The effects of the anaimia produced by shutting off 
 the circulation from the ear will be felt by the tissues as well as by 
 the walls of the vessels, and the inflammation which follows will be due 
 to the injury produced in the tissue. There is nuich which is opposed 
 to the theory of Cohnheim. The dilatiition of the vessels extends far 
 beyond the area immediately acted on by the trauma. Sanniel has 
 shown that if the upper portion of a rabbit's ear be inflamed Ijy ex- 
 posing it for a few minutes to water of the temperature of 54° C, an 
 intense congestion is produced which affects not only the vessels in 
 the part which has been directly acted on by the heat, Init extends to 
 the main artery of the ear. The central artery is dilated in its entire 
 course and pulsates strongly. When tile artery is cut a considerable dis- 
 tance below the inflamed area, more blood flows from it than from the 
 artery of the normal ear at the same point. In the case of the cornea 
 it is dii!lcult to assume that the action of the injury producing the 
 inflannnation could have extended to the vessels of the sclera. It may 
 probably be assumed for a chemical injury, but in the case where an 
 inflammation is excited by passing a thread through the centre of the 
 
INFLAMMA TIOX. 1 57 
 
 cornea it is impossiI)le to suppose that tlie meclianieal trauma enuld have 
 affected vessels so remote. If one hand be acutel}' inflamed, the arteries 
 on the inflamed side are dilated and jjulsate more strongly than on the 
 normal side. In vascular tissues the inflammatory phenomena, the dilata- 
 tion, the emigration, etc., do not take place so far away from the injured 
 tissue as the sclera is from the centre of the cornea. Only those vessels 
 which are immediately concerned in the nutrition of the tissue will be 
 affected. All the more recent work on the circulation has renioved the 
 blood-vessels more and more from a passive role in nutrition. The 
 increased transudation is not due to the vessels becoming simply more 
 permeable, but is due to active changes in the vessels brought about by 
 influences acting uj)on them. The view of Virchow that the hyper- 
 aemia is the result of an alteration in tlie attraction l:)etween the blood 
 and the tissues is pnjbably more nearly correct than that of Cohuheim. 
 
 The blood-supply of an organ is regulated entirely by the need of the 
 organ. An increase of function is accompanied by hypersemia. The 
 hypei'temia is not the cause of the increased function, but it is demanded 
 by the greater needs of a tissue for blood when its functional activity is 
 increased. In the case of a gland more blood must be brought to the 
 part, not only to nourish the cells in their increased activity, but to sup- 
 ply a greater amount of material from which the specific substances 
 secreted can be drawn. We know from the work of Heidenhain that 
 in the ordinary jirocess of secretion the capillaries do not play a passive 
 part, allowing indefinitely all the fluids of the blood to pass through, 
 from which the cells may take uj) certain speciflc elements, but the cap- 
 illaries themselves may be regarded as true secreting structures, and they 
 allow only the substances necessary for each particular tissue to pass 
 through them. Wiien a portion of an organ undergoes atrophy or when 
 there is a i)ermanent loss of substance, however brought aliout, not only 
 will tlie su]iply of blood be diminished by a reduction of the calibre of 
 the blood-vessels brought about by coutraetion of the muscles, but it will 
 be permanently lessened by the formation of a tissue inside of the 
 artery which brings about a permanent diminution of its calibre. On 
 the other hand, when a tissue calls for a greater amount of blood than 
 can be supplied by the artery, as in the case of collateral circulation 
 when one of a series of small arteries takes the place of a larger, the 
 calibre of the artery will not only be increased by a relaxation of its 
 walls, but it will be permanently increased; it will, in fact, become larger 
 by growth. 
 
 The hyperemia in inflammation is apparently called forth by the 
 needs of the tissue for repairing, and for in other ways setting aside 
 the consequences of the injury. 
 
 The temperature of the inflamed part is increased. It is due solely 
 to the fact that more heat is br juglit to the part by the increased afflux 
 of arterial blood, and the rapitlity of the circulation does not allow suf- 
 ficient time for its dissipation. When active hypersemia is produced in 
 the rabbit's ear by section of the symjjathetic, it can easily be sho\vn 
 by folding the ear over an ordinary thermometer that the temperature 
 of the inflamed car is four or five degrees above that of the normal. 
 The first exact experiments with regard to the temperature in inflamed 
 parts were made by John Hunter. Hunter showed tiiat the fluid con- 
 
158 SUBGICAL PATHOLOGY. 
 
 tained in a hydrocele liad a temperature when it was tapped of .'53.3° 
 C, and on the next day, after actual intlaniniation had taken ])lace, 
 the introduction of a thermometer into the sac showed a temperature 
 of 37.8°. He showed further that when an acute inflammation w^as 
 produced in internal parts, as in the pleura, the peritoneum, the peri- 
 cardium, or the deep muscles in the back and legs, the tem])eratnr(> of 
 the inflamed part not only did not exceed, but it freipiently did not 
 reach, the normal temjjcrature at the same place. As a result of his 
 experiments Hunter taught that in local inflammation the tempera- 
 ture does not exceed that of the interior of the body. The correctness 
 of Hunter's conclusion was ojiposcd later l)y Simf)n and Weber, who 
 found in peripheral inflaniinations produced l)y fracture of bones or by 
 the injection of croton oil into an extremity that the temperature of 
 the inflamed part was greater than that of the blood in the artery 
 going to the part. This was in accord with the theory of Zimmerman 
 which afterward appeared. It is known that a general systemic affection 
 in which the temperature of the entire body is increased frequently 
 accompanies a local inflammation. This is the inflammatory or traumatic 
 fever. Zimmerman advanced t\w theory that the inflamed ])art repre- 
 sented a local production of heat which led to increased temjierature in 
 the entire body, the increased tem]icrature of the body being due to the 
 heating of the blood in the inflamed part. A repetition of all of these 
 experiments \\'ith more exact methods of measuring the temperature 
 bv the use of the thermopyle and the galvanometer, which were carried 
 out by Jacobson and his scholars, showed that the temperature of the 
 rabbit's ear in the course of inflammation produced by croton oil is 
 higher than that of the normal ear, but considerably lower than that 
 of the rectum or vagina of the animal ; and further, that in inflamma- 
 tion of the deep muscles of the leg there is very slight or even no 
 increase of temperature over that of the sound leg. In acute jsleurisy 
 and peritonitis the temperature of the inflamed cavity is the same as, 
 or sometimes less than, that of the blood inside of the heart. The 
 degree of heat in the inflamed part will difl'er materially according to the 
 character of the inflammation. In the early stages of inflammation, when 
 there is an active arterial hyperiemia, the temperature will be greater 
 than in the later stages, when the active hyperannia has given place to 
 stagnation. Also, in an intense inflammation ju-oduced in the rabljit's 
 ear, in which there is stagnation and a great deal of hemon-hage in the 
 tissue, the temperature, instead of being greater, may be considerably less 
 than that of the opposite ear. In any experiments with regard to tem- 
 perature in inflammation the temperature of the inflamed part must 
 always be compared M'ith the temperature of the interior of the body of 
 the same animal. A considerable amount of fever may be produced by 
 even a comparatively slight degree of inflanunation, and if the tenijiera- 
 ture of the inflamed part were simply compared with that of the usual 
 normal temjierature of the animal, erroneous conclusions might be drawn. 
 Pain in inflammation is due to the distention of the part and the 
 ]iressure which is produced on the nerves, or by the direct action of the 
 inflammatory cause on the nerves. The character of the pain will differ 
 in different tissues of the body and in the various sorts of inflammation. 
 In very acute inflammations, when the swelling has taken place rapidly, 
 
INFLAMMATION. 159 
 
 the pain frequently lias a marked pulsiiting eliaracter, because every 
 addition of blood which is bi'ougiit to the part by the systole of the heart 
 will temporarily increase the pressure on the nerves, and consequently 
 the pain. It is evident that the pain in tissues poorly supplied with 
 nerves will be less severe than in parts which are extremely sensitive. 
 The anatomical character of a tissue will also have an influence on the 
 degree and character of the pain, which may be entirely disproportionate 
 to the abundanc^e of nerves. In inflammation of dense fibi'ous tissues, 
 which are incapable of much distention, greater pressure and injury of 
 nerves are brought altout than in a part where the tissues are more lax. 
 Inflammations of the periosteum or of the fibrous tissues about joints are 
 intensely painful. Not only do these local conditions iufluence the 
 degree and the character of the pain, but general conditions of the body 
 may also exert an influence. A condition of hypcraisthesia may be 
 brought about either by local changes in the nerves of the inflamed part 
 or by the efl'cct of fever on the nervous centres. 
 
 The swelling of the inflametl part is due to an increase of material in 
 the part. There is utit only an increased amount of fluid in the inflamed 
 part, but the cellular elements are also increased. The volume of a part 
 in the state of inflammation is also slightly increased by the increased 
 amount of blood in the vessels, but this has so slight an influence that 
 it may l)e left out of consideration. We know that hyperemia will 
 produce an increase of volume. The fluid which is present in the in- 
 flanuuatory tumor comes from the blood-vessels ; the transudation is 
 increased. Not only does the fluid accumulate in the tissues in this way, 
 but there is an increased flow in the lymphatics going from the part. 
 Cohnheim showed that when a canula is placed in a main lymphatic of 
 the leg after an acute inflaunnation has been produced in the foot by the 
 action of crotou oil or hot water, tiiere is a greatly increased flow of lym})h 
 as compared with the other side. On dissecting out the lym])iiatics 
 coming from an inflamed part they are found full and turgid. Chemical 
 analysis of the lymph in inflammation has shown that it is much more 
 concentrated than the normal lymph. A solid residue of 6 or 7 per cent, 
 has frequently been foimd in the inflammatory exudation in man, and 
 Lasser has shown that tin- lymph from the inflamed foot contains 6| to 
 8 per cent, of solid constituents. The salts are not increased. All inves- 
 tigators are agreed that they are found in almost the same proportions in 
 the inflammatory transudations as in the normal lymph. The increased 
 concentration depends entirely upon an increase in the amount of 
 albumin. Tliere is a mai-ked ditf'crcnco lietwcen the character of the 
 cedematous fluid in inflanuuation as compared with tliat of tiic ordinary 
 dropsy from chronic passive <'ougestiou. The dropsical accumulations 
 contain but little albumin, and the normal lympii has an intermediate 
 relation between the two in the projiortion of albumin. In inflam- 
 matoiy lym])h there is a greater tendency to coagulation than in 
 normal lympii. Dropsical accumulations either do not coagulate at 
 all or very slowly, and a soft clot is produced. Lasser found ditticulty 
 in obtaining lymph from the lymphatics of an inflamed part on account 
 of its great tendency to coagulation, the canula becoming in a short time 
 filled with the clot. The increased coagulability of the lymph is due in 
 great part to the increased number of colorless corpuscles. 
 
160 SVIiaiCAL I'ATIKJLOGV. 
 
 Cohnheim regards this altcratidii in the character of the transiulation 
 as due entirely to alterations in tiie walls of the blood-vessels. The 
 character of the filtrate is altered, because the character of the tilter, the 
 wall of the blood-vessel, is altered. He rightly supposed that the 
 increased transudation in inflammation is not due to a simple increase of 
 jircssure within the vessels, because the character of the fluid is difl'erent 
 from that in chronic passive congestion, which is due to such increase. 
 It is impossible to compare exactly the character of the transudation 
 in the two cases by observation of the fluid in the lympiiatic vessels. 
 In chronic passive congestion the lymph as it escapes from the vessels 
 comes in contact ^vith a tissue which is unaltei'ed. In inflammation the 
 lymph comes in contact w'ith abnormal tissues. In the tissue of the jiart 
 in which there is inflammation there are various changes taking place, 
 ^•arious degenerations have been produced by the injury which has caused 
 the inflammation, and all of these factors may exert an influence on the 
 character of lymph flowing through it. It is probably true that in in- 
 flammation the character of the transudation passing through the vessel- 
 walls is diflei'ent from the normal, and difl'erent from that in chronic 
 passive congestion. But its character is not due to changes which have 
 taken place in the walls of the blood-vessels, in consequence of which 
 they f)assively allow a ditt'erent fluid to pass through them, l)ut the 
 vessels actively secrete a difl'erent fluid. The character of the transuda- 
 tion may difier also in the various sorts of inflammation. A difl'erent 
 fluid is needed by the tissues, and there will be a diiference in the tran- 
 sudation, just as there is a difl'erent lymph secreted by the blood-vessels 
 of the kidney as compared with that secreted by the blood-vessels of the 
 pancreas. This increased flow of lym])h in inflammation has a ])urpose- 
 ful character independent of afl'ording a greater degree of nutriment to 
 the tissues. By it soluble chemical substances — substances either pro- 
 ducing the inflammation of the tissue in the first place or substances 
 which are produced in the inflamed area by the action of bacteria which 
 may be there — are diluted or washed away. 
 
 In the inflamed part the lymph will accumulate in the interstices 
 of the tissue, in the lymjjhatic vessels and lymph-spaces, and give rise 
 to oedema of the part. By pressure it may be pushed from one place 
 into another, just as by pressure the blood can be removed from the ves- 
 sels of a part. A deep dei)ression or pit remains at the seat of pressure, 
 which w'ill disappear when the fluid returns. There may be inflam- 
 mations in which the swelling is due entirely or almost entirely to the 
 increased fluid transudations. Such inflanmiations may be spoken of as 
 cedematous inflammations, and they generally represent a milder degree 
 of inflammation. One of the most marked examples of a simple cedema- 
 tous inflammation is that produced by the action of the sun. We may 
 have here a very mild degree of inflammation in which there is only 
 hypersiemia with increased fluid transudation. 
 
 Samuel, in his work on inflanunation, has very properly separated the 
 cedema in an inflamed part due to the inflammatory cause from the 
 a?dema in adjacent parts which frequently supervenes on inflammation. 
 Thus, when the extremity of a rabbit's ear is inflamed there will be 
 cedema not only in the inflamed portion of the ear, but also lower down 
 in the ear, where no injury of the tissue has been produced. This 
 
INFLAMMATION. 161 
 
 Samuel distinguishes as inflammatory oedema in contradistinction to the 
 cedematous inflammation. It is due merely to an extension of the a?dema 
 from the inflametl territory, and is sometimes spoken of as collateral 
 cedema. The same thing can be seen in tiic sulicntaneous (edema of the 
 chest-walls which sometimes accompanies inflammation of the pleura. 
 This oedema was also studied fully by John Hunter, who speaks of it as 
 being s([ueezed from the inflamed part into adjacent parts. 
 
 The tumor contains, in addition to tlie fluid, a certain portion of solid 
 material. In the first place, it contains a varial)le amount of fibrin. 
 Not only is the lymph which passes from the inflamed part richer in 
 fibrin than the normal lymph, but in many inflammations tliere is 
 formation of fibrin, a certain amount of coagulation, in the inflamed 
 part itself In the inflannnatory exudation all the necessary elements 
 for the formation of fibrin are present. P^ibrin is due to the action of 
 a ferment, usually spoken of as the fibrin-ferment, on certain substances 
 in the blood. This fibrin-ferment, there is every reason to believe, is 
 formed from the disintegration of cells. In the ordinary process of 
 coagulation it is probable that the leucocytes of the blood form the 
 source of the ferment, l)ut it may be ]iroduced by the disintegration of 
 the cells of the tissue. In the inflamed part there is an abundance of 
 fibrinogen in the exudation, and tlie fibrin-ferment is produced by the 
 disintegration of cells. Fibrin is present in almost any acute inflam- 
 mation. On examination of the inflamed car of the rabbit after suit- 
 able hardening a varying amount of fibrin is found in the exudation, 
 the amount depending largely on the intensity of the inflammation. In 
 some (;ases there are only a few fibrillte scattei'ed through the tissue, and 
 in other cases there are large masses of it. In many cases the fibrin 
 may be seen radiating out from the ni'crotic cells. The hardness of the 
 inflamed part, especially the so-called brawny induration which is found 
 in certain sorts of inflammation, is due to the presence of fibrin. In 
 certain forms of inflammation the fibrin may be present in excessive 
 amounts. 
 
 In any inflamed part in which there is an increased number of cells 
 in the tissues a certain number of red cor})uscles will nearly always be 
 found. With regard to these we know that they could only come from 
 the blood-vessels, and they are found in vai'ving numbers, dependent on 
 the character and intensity of the inflammation. In some cases they are 
 present in such excessive numbers that the inflammation is spoken of as 
 hemorrhagic. These corpuscles escape into the tissues from tlie capillary 
 vessels, and can easily be seen to pass tlu'ougli tlie M'alls of these vessels 
 when the inflammation is directly observed under the microscope. 
 
 A large jiroportion of the cells — and in some inflammations nearly 
 all — are white corpuscles which have emigrated from the vessels. With 
 the increased knowledge of the corpuscles of the blood which has come 
 from its more careful study in recent years we know that the white cor- 
 puscles ditt'cr materially fr(im one another in form, and that they have 
 difl'erent values and diflerent origins. Tlie most numerous corpuscles 
 are tlie so-called polynuclear leucocytes. These form between 80 
 and 85 per cent, of the entire number of leucocytes, and are cha- 
 racterized by an irregular nucleus. This nucleus stains brightly, and, 
 although spoken of as a multiple nucleus, it is in most cases a single 
 
 Vol. I.— 11 
 
162 SURGICAL PATHOLOGY. 
 
 nucleus divided into several masses wliieli are connected together by fine 
 tilaments. These corpuscles also differ from one another in the chem- 
 ical composition of their protoplasm. This is shown by their reaction 
 to staining agents. In the great majority of them the protoplasm con- 
 tains very fine granules which are stained with the neutral or basic 
 aniline colors. In a certain proportion of them the granules in the pro- 
 toplasm are larger and stain brightly with eosin. Next to these in 
 number and importiuice are the so-i:alled leucocytes of the blood. In 
 these two sorts can be distinguished. The most numerous arc corpuscles 
 which are about the size of the cells contained in the lymph-glands, and 
 which have a large round nucleus, and a very small amount of proto- 
 plasm around this. There are a certain number of larger cells of the 
 same character. Although other cells have been described in the blood, 
 these are the only ones which need concern us in the study of inflamma- 
 tion. In the corpuscles first described the nucleus frequently takes the 
 shape of a horseshoe. 
 
 The polynuclear leucocytes are the most numerous of the cells found 
 in the swollen tissue in acute inflammation. In some cases they are ap- 
 parently the only new cells found iu the tissue. In the inflamed cornea 
 in the early stages of inflanmiation the cells found in the lymph-spaces 
 are exclusively those. There have been many theories advanced to 
 explain how these cells pass through the walls of the vessels. The first 
 idea held by Cohnheim was that the passage was effected by means of 
 their amoeboid movements — that they crawled through the walls. The 
 corpuscles when adhering to the walls before the emigration has begun 
 show active amceboid movements, and when in the act of passing 
 through, both the part outside of tlie vessels and that inside show active 
 amceboid motion. Cohnheim afterward gave up this idea, and con- 
 sidered that the white corpuscles, like the red, did not pass through by 
 means of their own activity, but l\v passive filtration. He was chiefly 
 led to this view from the fact that when the blood-current ceased in the 
 dilated veins the process of emigration ceased. There may be another 
 explanation of this. The leucocytes are probably kept against the wall 
 of the vessel by means of the blood-current, and probably by the con- 
 tinuance of the circulation they are excited to moi'e active amoeboid 
 movements. Their collection in the vessels of the inflamed part is 
 partly due to the slowness of the circulation, but more to a voluntary 
 action on their part. The inflamed tissue exerts an attraction for them. 
 Substances which have the power of stopping the amceboid movements 
 of the corpuscles also stop the emigration. Thoma has shown that 
 when salt solution of the strength of 1 : 12 is injected into the blood 
 the amoeboid movements of the leucocytes cease, and the process of emi- 
 gration ceases in inflammation. If the frog is completely chloroformed, 
 the action of the chloroform may extend to the leucocytes and stop any 
 amceboid movements, and emigration will not take place. Cohnheim 
 supposed that the filtration of the corpuscles through the vessels was 
 due to an alteration in the vessel's wall, together with the increased 
 pressure. He did not attempt to define the character of this alteration, 
 Ijut supposed it might be physical or chemical. The most accurate 
 observations on this subject seem to show that the leucocytes pass 
 between the endothelial cells of the vessels. There are small openings 
 
IXFLAMMATIOX. 163 
 
 between these cells in the normal condition of the vessel, and these 
 V)jienini;s prol)ably become laraer when the vessel is dilated. lionciiard 
 thinks tiiat the endothelial cells in the vessels may contract and assnnie 
 a round form, leaving large openings between them through which the 
 corpuscles pass. The emigration of the leucocytes is due to active 
 amoeboid movements on their part, possibly assisted by a more porous 
 condition of the walls of the vessel. 
 
 It is known that eheniii'al substances liave the power of attracting or 
 rc])elling cells capable of indciiendcnt motion. This \vas shown first by 
 Engelman in certain of the myxomycetes. It is seen in a marked 
 degree in bacteria. The phenomenon was carefully observed in the 
 leucocytes bv Gabrischweisky. He found that when capillar}- tubes 
 were partly filled with certain substances and placed in the tissues of 
 animals, the tubes became filled up with leucocytes. When they were 
 filled witii indifferent substances, only a small number of leucocytes 
 entered into them, and other substances exerted a repellant action. 
 Necrotic tissue of all sorts attracts tiie leucocytes to it. No better 
 proof can be given of this than the collection of leucocytes around a 
 lesion in the centre of the cornea. Althougli they pass from the vessels 
 of tiie sclera, tliey do not wander into the tissue at random, but march 
 directly to tlie inflamed focus. Wiiat the nature of the chemical 
 substance is which exerts tiiis attraction for the leucocytes we do not 
 know. It is jjroduced in necrotic tissue everywhere. Although most 
 of the bacteria have a decided action in attracting leucocytes, this attrac- 
 tion is more strongly exerted when they are dead than when they are 
 living. It is prol)able tliat substances are produced in the necrotic 
 tissues whicli by diffusion extend tiieir action to the vessels, producing 
 in these the inflammatory phenomena. Not only is the influence felt 
 on tiie vessels, but it extends to the cells within them, causing these to 
 pass through the walls and to accumulate around tiie necrotic tissue. 
 
 Tiie cells in some inflammations, ami in tlie early stages of all, are 
 composed entirely of tliese polynuclear leucocytes. Along with them in 
 other cases cells similar to the lympliocytcs in the blood appear. 
 Usually they appear somewhat later than the polynuclear leucocytes, 
 and in inflammations of a less active chai-acter. They are principally 
 formed in the outermost zone of the inflammatory area, and usually are 
 seen in small groujjs around the vessels. There is mucli dispute about 
 their origin. While all observers are agi'eed that tlie polynuclear leuco- 
 cytes come from tlie blood, it is held by some that the small lymphocytes 
 have the same origin. Others iiold tliat they are formed by prolifera- 
 tion of the tissue-cells. Baumgarten especially holds the former view. 
 His studies of the cells in inflammation were «iade on the histogenesis 
 of tubercle. Tlie round ]ym])liocytes enter largely into the structure of 
 this, and lie believed tliat they come from the l)lood and enter into the 
 tubercle, which is at first formed of large cells derived from the tissue. 
 Ribbert and Marchand also believe that these cells arc leucocytes. In 
 the more chronic inflammations the new cells may be almost exclusively 
 of this character. There are many objections to these views. Although 
 we are not able to study the course of inflammation so thoroughly in 
 man aii<l the iiiammalia as in the frog, still by the modern methods of 
 histological technique we are able to study the process which is going ou 
 
164 SURGICAL PATHOLOGY. 
 
 in any one stage of inflammation. As far as I have been able to 
 observe the process of acute infiannnation in man by means of thin 
 sections of tissue carefully hardened, the jjolynnclear leucocytes are the 
 only ones which ])ass throuifli the vessels. In acute iuflainniation of the 
 skin the vessels of tJie papiihe are closely packed witli these cells, and 
 they may be observed in every stage of passage. 
 
 The origin of the cells in the inflamed territory has been a subject 
 of dispute in pathology. C'ohnhein at first believed that all the new 
 cells were leucocytes, but he afterward modified his views, and admitted 
 that in the later stages of inflammation regenerative plienomcna took 
 place in the surrounding tissue-cells, leading to the fDrniation of new 
 cells. The new cells so formed were distinguished from the inflamma- 
 tory cells, and were destined to renew the tissue which had been de- 
 stroyed. Cohnheim's view was directly opposed to that of Virchow. 
 According to Yirchow, the essential condition in inflammation is an 
 altered nutrition of the tissue. In consequence of the injury — or, as he 
 calls it, the irritant— the cells of the tissue \\erc \-ariously aifected. 
 They were roused to an increased activity which might be simply mitri- 
 tive or formative. They niiglit increase in size, with an increase of their 
 functional activity, or they might multiply. All of the vascular phe- 
 nomena he considered to l)e secondary to this altered nutrition of the 
 tissues, and due to this. Virchow was one of the earliest authors to 
 recognize the similarity of the new cells in inflammation to leucocytes, 
 but he supposed, in spite of the similarit}', that they were formed by 
 multiplication of the cells of the tissue. Vii'chow's views underwent 
 some modification at the hands of Strieker. While Strieker does not 
 deny the emigration of the leucocytes, he thinks that these form but a 
 small part of the cells which are formed in the inflannnatory exudation. 
 He accepts the view of Virchow that most of the cells are derived from 
 proliferation of the cells of the tissue, and he compares the cell under 
 its ordinary conditions to a bent bow. He holds that they have a certain 
 amount t)f stored-up formative energy, which under the influence of the 
 inflannnatory irritant can be expended in a new formation of cells, the 
 inflammatory irritant acting as the unloosing of the arrow. Afterward 
 he still furtlier modified tiiis view, holding that not only do the cells of 
 the tissue proliferate, but new cells are formed from the intercellular 
 tissue. This view, first given by Strieker, that a new formation of cells 
 can take place from the intercellular substance, has been taken up by 
 Grawitz. According to Grawitz, in the development of the tissue only 
 a certain number of cells are nsi'd uji in the formation of intercellular 
 substance. Many of them, without losing their character as cells, be- 
 come invisible and apparently form a part of the intercellular substance. 
 Under the influence of the inflannnatory stimulant these cells, which 
 Grawitz speaks of as the slumliering cells, become visible, multiply, 
 and form a large part of the cells in the inflammatory tumor. Cohn- 
 heim \vas led to alter his former views as to the exclusive ])resence of 
 leucocytes in the inflammatory tumor by the work done in his labor- 
 atory i)y Senftleben. Various oltservcrs had described changes in the 
 corneal corpuscles during inflammation. Virchow had described swell- 
 ing and nuiltijflication of cells in the periphery, and considered that the 
 cloudiness of the tissue was due to such changes in the cells. Multipli- 
 
INFLAMMATION. 165 
 
 cation of the cells was described by His and numerons otiier anthors, 
 and Axel Key described changes in the cells immediately aronnd tiie 
 inflamed area. Most of tiiese eiiang-es described in the cells were 
 cither falsely interpreted as cell-nniltiplieatiDn or tliey were degen- 
 erative phenomena. Senftlcben was the first accurately to describe the 
 changes which take place in the corneal cells in inflammation, and to 
 separate tiie newly-formed cells from the leucocytes. He showed that 
 wiicn the centre of the cornea was cauterized the corneal corpuscles 
 immediately around the eschar were killed b}' tiie action of the caustic. 
 Tile injury to tlie tissue extended farther tiian the formation of tiie 
 eschar seemed to indicate. Tiie necrotic corpuscles contracted, tlieir 
 processes were drawn in, and tliey became converted into formless 
 masses. The corpuscles immediately outside of this area underwent other 
 changes. Tlicy liecame larger and stained more brigiitly, the nuclei 
 increased in number, and long jirocesses were given off from tliem wliicii 
 extended up into the region of necrosis. Nuclei passed from tiie cells 
 into tlicse long processes, and in this way new cells were formcfl wliich 
 took the place of necrotic cells, and represented not an inflammation, 
 but a regeneration of the tissue. 
 
 These changes in the cells only take place in the corpuscles adjacent 
 to the necrosis, and no changes are seen in tlie cells in the periphery 
 where the pus-cells are entering into the tissue. It has been shown 
 that it is possibl(» to produce such sliglit injuries to the tissue that tlicre 
 is little or no infiltration with leueocytes, and tlie clianges may be limited 
 to regeneration of the cells. In almost any sort of inflammation in any 
 tissue the two jirocesses of emigration of leucocytes and new formation 
 of cells take place. The cellular proliferation takes place later tlian 
 the emigration. It can be recognized by tiie various changes whicli 
 take place in tlie nuclei preceding cell-division, and in general does not 
 begin until two to four days after the receipt of the injury. The eliarac- 
 tcr anil tlie arrangement of the cells can be easily seen in the small foci 
 of inflammation wliich form around small masses of bacteria whicli liave 
 been carried as emiioli into tlie tissue. Tliese can lie produced at will 
 by the injection of pure cultures of tlie staphylococcus aureus into tlie 
 ear-veins of rabbits, and tlieir devcl(>])mcnt observed by killing the 
 animals at successive periods after the injection. Sucli foci will serve as 
 general types of acute inflammation. The micrococci are found in a 
 small vessel, either a capillary or a small vein, wliicli tliey entirely occlude. 
 They are ])roI)ab!y not lodged here as an emliojus filling up at once tlie 
 entire vessel, but one or more lodge in tlic endothelium and the vessel 
 becomes filled by their gro\\th. In tlie older foci tlieir growth extends 
 beyond the vessel, and clumps of tliem may be found in the tissue. 
 Around tlie group of bacteria tliere is a distinct necrosis of the tissue. 
 In the necrotic mass the cells may sometimes be recognized, Init more 
 generally the whole is converted into a granular mass. In the periphery 
 of the necrosis the tissue is infiltrati'd witli polvnuclear leucocvtes. 
 Tliese form a wall aronnd and extend into the necrotic tissue. It is 
 probable that the necrotic tissue is formed, to some extent at least, 
 by the leucocytes which have wandered into it so far that they have 
 fallen victims to the same cause which jirodueed the necrosis of the 
 tissue. Although the wall of cells formed around the necrosis is, on 
 
166 SURGICAL PATHOLOGY. 
 
 the inside, composed entirely of" leucocytes, on the outside these gradu- 
 ally give place to mononuclear cells similar to the indifferent cells of 
 granulation tissue and to the lymphoid cells of the blood. The more 
 advanced the inflaniniatiun, the more numerous arc they in the tissue. If 
 tlie animal be kille<l twcnty-fbur liours after injection of the bacteria, when 
 the small inflanimatory foci arc not visii)lc to the eve, the cells may lie 
 absent. Where they are formed in the tissues is a question. From their 
 close relation to the blood-vessels, and from the fact that in the cells 
 forming the vessels the earliest and most active cell-proliferation is seen, 
 it seems probable that they arc formed from these cells. In some of the 
 inflammations produced by bacteria they may be so numerous as to con- 
 .stitute by far the majority of the new cells. Other cells make their 
 appearance in the late stages of inflammation, but they are so obviously 
 connected with repair and new formation of tissue that they will be con- 
 sidered under that head. 
 
 There is a purpose fulfilled by the presence of the leucocytes in the 
 inflamed tissue. Whenever there is any dead material in the body, this 
 becomes filled with leucocytes. In such material chemical substances 
 are formed which exert an attracting force on the leucocytes. In 
 the small foci of inflammation formed around masses of staphylococci 
 they are attracted not only by the necrotic tissue produced by the 
 bacteria, but by the bacteria themselves. Capillary tubes partly filled 
 with staphylococci and jtlaccd in the tissues speedily become filled with 
 leucocytes. They appear to pave the way for a new formation of tissue. 
 It is by means of the leucocytes that the detritus of dead tissue is 
 removed. In the acute inflanunation produced by bacteria they form a 
 wall around these, close up the lymphatics, and prevent to a large extent 
 the further action of the organisms. JNIetschnikoff has shown that they, 
 have the power of taking up and destroying bacteria, and their presence 
 is in this way a source of protection to the organism. This power of 
 eating and destroying material is termed " phagocytosis." Another 
 purpose which they serve is that of furnishing food to the large epithe- 
 lioid cells which are concerned in the f(5rmation of tissue. There can 
 be little doubt that an important purjiose may also be served by the fluid 
 exudation in washing out solul)le injurious substances from the tissues 
 and in diluting them. INIost foreign bodies, especially those of an 
 organic character, when introduced into the tissues, Avill produce to a 
 limited extent inflammatory changes in the circulation in the vessels 
 around them, with emigration of leucocytes which enter into the foreign 
 body. Pieces of sponge or ])ith placed in the abdominal cavity become 
 filled with leucocytes. Other substances have little or no effect in 
 attracting them. Finely-powdered glass introduced into the tissue 
 causes a new formation of tissue, an infiltration with round lymphoid 
 or granulation cells, and finally a capsule formation ; and this may take 
 place without the emigration of a single leucocyte. 
 
 Little is known as to the manner in which the red corpuscles pass 
 through the walls of the vessels, and the conditions favoring this. As 
 a general rule, the more severe the injury produced in the tissue, the 
 greater is the number which ])ass through. They cannot, like the white 
 corpuscles, pass through by their own active movements, and, as far as 
 can be seen under the microscope, they pass through actually intact 
 
INFLAMMA TION. 167 
 
 vessels. It may be that from the dilatation of the vessels the stomata 
 beeome so large that they are forced through by the increased pressure, 
 or small fissures not visible under tlie microscope may take place by 
 means of which they make their escape. When in the tissues they 
 appear to take no active part in the changes which are going on. In 
 part they find their way into the lymph-spaces and lymph-vessels, and 
 are removed by the lymph-stream. In part they are taken up by other 
 cells, and may contribute to the nutrition of tiiese. In part they 
 remain in the tissue and are destroyed, tlieir pigment being taken up 
 by the cells. 
 
 The general character of the &*\elling differs greatly, depending on 
 the anatomical structure of the part of the body which is inflamed. The 
 so-called parenchymatous organs — as, for instance, muscle, kidney, paro- 
 tid and other glands — swell in toto when they are inflamed. The swell- 
 ing is proportional to the degree of tiie exudation. It Mill be more 
 considerable in organs which are surrounded by a capsule or membrane 
 which is capal)lc of distention than in those which are surrounded by a 
 membrane incapable of distention. In parenchymatous organs the exu- 
 dation is in the meshes of the interstitial connective tissue, because this 
 tissue carries tlie blood-vessels and is more easily distended by fluid. 
 In the inflammation of connective tissue the exudation accumulates in 
 its meshes ; it inflltrates it. In a furuncle the exudation aceunudates in 
 the loose spaces of the subcutaneous tissue, and in meningitis it accu- 
 mulates in the spaces of the pia-arachnoid. The same is seen in the 
 substance of the cornea when it is inflamed, but on account of the 
 sliglit distensibility of this tissue the thickening in the beginning 
 of the inflammation is not a very marked one, and the inflltration 
 appears more as a cloudiness of the tissue due to an interference with 
 its optical 2>roperties than as a swelling. In cartilage, in which tiiere 
 are no distensible meshes or canals, the exudation-fluid or corpuscles 
 cannot enter into the tissue ; therefore in inflammation of the cartilage 
 of joints the exudation is found in the cavity of the joint, except in the 
 immediate periphery, tiiere under certain circumstances a few corpuscles 
 apparently eat tlicir way directly into the tissue. When the wall of a 
 large cavity is inflamed the inflammatory exudation accumulates in tlie 
 cavity. That is the case in the serous membranes, also in the dura 
 mater. In the inflammation of periosteum the exudation cannot accu- 
 mulate in tlie dense tissues, but it presses in beneatii the periosteum, ele- 
 vating it from the bone. The inflammatory exudation always accu- 
 mulates where it finds tiie least resistance ; thus in ])neunionia it enters 
 tiie alveoli of the lungs and fills up these, because it finds no place in the 
 alveolar sejita. In the same way, it is easily understood that in places 
 where a dense covering prevents the exudation reaching the free surface 
 this covering will be elevated in tiie form of a bladder or vesicle. Tiiis 
 is seen in tlie example we have given in the inflammation of the peri- 
 osteum, but a l)ettcr example is given in the inflammation of the skin. 
 In all forms of acute inflammation of the skin one of the most common 
 of all phenomena is to find the epidermis over the inflamed area elevated 
 in the form of a vesicle. In organs which freely communicate with the 
 outside, and an open way is given for the exudation, it is sinijily poured 
 out on the surface and escapes. This is the case with all mucous mem- 
 
168 SURGICAL PATirOLOdV. 
 
 hi'iUK's, beoausc their cpitlielial cdvcriiiL!; is loose ami docs not hold tlie 
 exiidation within it as does tiie epidermis. In consequence of this a 
 formation of vesicles does not take place, but the exudation passes 
 freely tin-ough to tiie surface. This is also tlie case in the kidneys, 
 where tiie exudation in ))art passes otl' in the urine and ajijjcars in the 
 form of albumin. 
 
 Inflammation lias l)een divided into two varieties, depending upon 
 the special involvement of certain elements of an organ. In a glandular 
 organ we can recognize the secreting cells and the connective-tissue 
 framework supporting the cells and carrying the blood-vessels. Accord- 
 ing as the special seat of the inflammation was supj)Osed to inv(dve the 
 specific glandular cells, the j)arent'hyina, or the interstitial tissue, the 
 division has been made of parenchymatous and interstitial inflamma- 
 tion. This division is a false one. If we regard inflammation as the 
 sum of the processes which take place in the tissues on receipt of an 
 injury, it is obvious that we cannot have inflannnations so divided. It 
 is hardly possible to conceive of an injury which will affect exclusively 
 one or the other of these constituents of an organ. There is no doubt 
 that under certain circumstances there may be accunndations of cells in 
 the interstices of an organ due to growth of the intercellular tissue, as 
 in some of the pathological conditions met with in the kidneys in scarlet 
 fever. It cannot be held that all growth in connective tissue is due to 
 regeneration following a primary lesion. In such kidneys there are few 
 or no lesions of the epithelium of the tubules. In certain liver diseases 
 a similar ])r(>liferation of the connective tissue may take place. AVe have 
 generally been accustomed to speak of such ct)ntlitions, in which we find 
 a cellular infiltration of the tissue, as inflammation, but there is no reason 
 why they should be so considered. The ])rolif'eration of the connective 
 tissue may be due to the direct action of Iwcteria or their chemical jirod- 
 ucts on the tissue, or to other influences producing it without any jire- 
 ceding injury. 
 
 Inflanmiation of a mucous membrane is spoken of as "catarrhal 
 inflammation." Virchow used the name to denote increase of func- 
 tional activity of a mucous surface. The word "catarrhal" is used so 
 loosely that it is difficult to define it. AVe may use it to designate mild 
 degrees of infianunation of mucous surfaces in which there is neither 
 idceration nor any distinctly characteristic exudation, sucli as a fibrinous 
 or a purulent one. In inflammation of the intestinal canal the word 
 is generally used to include inflammations the etiology of which is un- 
 known. The increased amount of fluid which comes from an inflamed 
 mucous surface has two sources. In the first ])lace, the mucous mem- 
 brane has not a dense tissue on the surface impervious to fluids, like the 
 horny layers of the skin, and an increased amount of exudation in the 
 subcutaneous tissue readily finds its way to the surface instead of accu- 
 mulating in the interstices of the tissues. A mucous surface is like a 
 serous surface in this respect. In the next place, the jjroper secretion 
 of the mucous surface is increased. This is in part due to the hyj)cr- 
 semia of vessels su])plying the glands, and possibly in ])art to a direct 
 stimulation of the glands by the inflammatory cause. The cells may be 
 influenced to increased action in the .same way as the blood-vessels 
 are. In most cases the serous exudation from the vessels of the tissue 
 
lyPLAMMATIOy. 169 
 
 is accoiiipanicfl bv emigration, ami the leucocytes pass as readily through 
 the epithelial layer as does the serum, and api)ear in the Huid on the 
 surface. 
 
 A more suitable classification of inflammation is one based on the 
 character of the exudation. The character of the exudation is largely 
 determined by the cause of the inflammation and the intensity of its 
 action. The causes are so manifold that it would be impossible to give 
 an etiological classification. Tlie exudation in inflammation may be 
 almost entirely serous, and such inflanmiations arc sjioken of as edema- 
 tous or serous inflammations. In any inflammation the (piantity of serous 
 exudation is increased. The tissue in serous inflanunation is infiltrated 
 with fluid. The increased transudation represents the reaction of the 
 tissue to a mild injury. One of the best examples of it is the inflam- 
 mation of tile skin which follows prolonged exposure to the sun. The 
 injection of tlie vessels is extreme and the skin is swollen and pits on 
 pressure. Most of tlie exudation accumulates in the meshes of the 
 tissue, but a certain portion passes to the surface and elevates the epider- 
 mis in the form of smaller or larger vesicles. The vesicles are filled 
 with a clear transparent fluid which on microscopic examination shows 
 few cellular elements. If the cause be removed, the contents of the 
 vesicles will be absorbed. The action of the sun has probaljly been to 
 produce sliglit injury of tlii' upper layers of the epidermis, in some cases 
 extending more or less deeply into the tissues below. In some cases 
 extensive necroses e.xtendiiig through the skin, which are followed by 
 all the phenomena of intense inflammation, may be produced. There is 
 increased serous transudation in the beginning of every inflammation. 
 In pneumonia, congestion and <edeiiia of the lung preceile the formatiiin 
 of the fibrinous exudation. In every wound a clear fluid first exudes 
 which contains but few corpuscles, and which, coagulating in a thin 
 layer on the surface, produces the glazing. The oedematous inflammation 
 may also represent the end or limit of the process. In a furuncle, out- 
 side of the central necrosis and leucocytic infiltration, the tissues are 
 infiltrated with serous fluid, and a subcutaneous ledema is often found 
 accompanying acute inflammation of the costal pleura. 
 
 In any inflammation there is an increased amount of fibrin in tlie 
 exudation as compared with the normal (Fig. 5). The fluid in the tissue 
 in cedematous inflammation contains more fibrin than when the exudation 
 is increased from some other cause, as from chronic passive congestion. 
 The fibrin may accumulate in tiie tissue and give rise to a dense, brawny 
 induration. The amount of fibrin is to a certain extent dependent upon 
 the severity of the inflammatory cause of the injury. As a general 
 rule, the greater tlie degree of necrosis the more extensive will be the 
 formation of fibrin. .The elements for the formation of fibrin are 
 present in the exudation, and tlie necrotic cells supply the fibrin-ferment. 
 To a much greater extent the formation of filirin seems to depend upon the 
 nature of the agent which produces the inflammation. The most typical 
 fibrinous inflammation is seen in acute croupous pneumonia. Even in 
 the rabbit, when inoculated subcutaneously with the organism which 
 causes this disease, a fibrinous exudation may be produced which 
 may extend over the centre of the abdomen. It is possible that sub- 
 stances may be produced by these organisms which have an analogous 
 
170 suRorrAL pathology. 
 
 action to the fibrin-ferment. Sucli iiiilnimnation.s, characterized hv an 
 excessive amount of fibrin in the exudation, are spoivcn of as fiI)rinons 
 inflammations. The term is more <;-cncrally used to specially character- 
 ize fibrinous exudations on surfaces of the body. Such exudations are 
 always accompanied by necroses, and are called diphtheritic. Formerly 
 a distinction was made between croupous and diphtheritic inflamma- 
 tions. In the croupous infiammations the exudation was supposed to 
 be seated on the surface of relatively intact mucous membranes. In 
 the diphtheritic inflammations tiie exudation was supposed to extend 
 from the surface into the meshes of the tissue. The croupous exudation 
 could be peeled as a membrane from the surface, leaving it intact ; tlie 
 dij)htheritic could not be removed without the production of a loss of 
 substance. The only difference between the processes is one due to the 
 anatomical character of the surface. In both cases there is necrosis of the 
 .surface epithelium, and the exudation, ctiming' in contact with the necrotic 
 tissue which furnishes an abundent suj)ply of fibrin-ferment, coagulates. 
 The exudation can be easily removed as a membrane on surfaces having 
 a dense basal membrane beneath the epithelium. It is not removed 
 from the surface of the epithelium, but is removed with the ejiithe- 
 lium. The exudation cannot be rt'Uioved from the surface \\here there 
 is no basal membrane beneath the eiiithelium, in which case the union 
 of the epithelium with the tissues beneath is more direct. In this ease 
 the fibrin also extends down into the tissue beneath, and there is a close 
 union with the fibrin on the surface and that in the tis.sues, aiid it cannot 
 be removed as a mass. The difference between the two is easily seen in 
 diphtheria. When the disease is localized in the pharynx the membrane 
 cannot be removed. If in the larynx an<l trachea, it can be removed, 
 sometimes representing a perfect cast of these parts. The term "diph- 
 theritic inflammation " is simply an anatomical one, and has no necessary 
 relation to the infectious disease diphtheria. This disease is charac- 
 terized by a fibrinous exudation on the surfaces affected, combined 
 with necrosis. It is very probable that here, just as in the fibrinous 
 exudation in pneumonia, the character of the exudation is due in great 
 part to the specific agents which cause the disease. In some cases the 
 membrane is much more extensive than in others, and it may be pro- 
 duced, though generally not to the same degree, by other agents than the 
 diphtheria Ijacilli. Inflammations of the same parts caused by some of 
 the ]ius-()rganisms, and even by the ap])lication of chemical agents which 
 will produce a necrosis on the surface, may be accomjianicd by mem- 
 brane-formation. The filirin on the surface does not come exclusively 
 from the exudation. The epithelium itself undergoes a form of necrosis 
 which is combined with coagulation of the protoplasm of the cell, and a 
 reticular mass is formed largely com])osed of the fibrinoid metamorphosis 
 of the cells. The fibrin in these exudations does not always have the 
 same character. In the tissues the fibrin usually appears in the form of 
 extremely fine filaments. On the surface it may appear in the form of 
 large hyaline masses or as a definite reticulum. In all of the mucous 
 surfaces this form of inflammation is frequently observed. In the large 
 intestines it forms one of the anatomical varieties of dysentery. On 
 o])en wounds a fibrinous inflammation leading to the production of dense 
 membranes is not infrocjuently observed. It may be due to infection of 
 
INFLAMMATION. 171 
 
 tlio wound with certain specific niicro-organi.sm.s. In cases of diplitlieria 
 any open wound of the body is liable to Ijecome infected with the organ- 
 isms of the disease, and a tyijical membrane may be formed over the 
 wound. I have seen two cases in which the infection of wounded sur- 
 faces resulted from accidental inoculation. In one there was a fissure of 
 the anus which became so infected, and in the other a paronychia about 
 the small toe became infected. In both the characteristic organisms were 
 obtained from cultures. In the uterus a diphtheritic membrane with 
 extensive necrosis of the surface forms one of the lesions fountl in puer- 
 peral infection. Here the condition is in nearly all cases due to the 
 presence of one of the pus-organisms, the streptococcus. Fibrinous in- 
 flannnations are also foimd on the serous surfaces, and they seem to take 
 place more readily here than in any other part of the body. The fibrin 
 is deposited both on the surface covering the viscera contained in the 
 cavity and on that lining the walls, ^^'here these two surfaces move over 
 one another, as in the pericardium, the constant adhesion and separation 
 give rise to a roughening of the surface, causing the appearance which 
 has been compared with that pro<luced by the separation of two pieces 
 of bread and butter. In serous membranes the fibrinous infiammation 
 is in part due to a greater degree of intensity in the action of whatever 
 produces the inflammation. The same agent acting in ditferent degrees 
 of strength can at one time produce a simple serous exudation and at 
 another a fibrinous exudation. When two surfaces covered with a 
 fibrinous exudation come in contact with one another, adhesions are 
 formed from the intermingling of the fibrillar of fil)rin on the two sur- 
 faces. In filn'inous inflammation of the peritoneum the adjacent surfaces 
 of the viscera become adherent. The fibrinous exudation sometimes 
 serves in this way a useful purpose in uniting wounds. The primary 
 adhesion of a simple wound is due to this intermingling of the exudation 
 from the opposing sides of the wound. 
 
 HeuKirrhagic inflammation is spoken of when the exudation contains 
 large numbers of red blood-corpuscles. This character of inflammation 
 may be due to a specific action of some agent producing the inflamma- 
 tion, or it is due to constitutional anomalies on the part of the individual. 
 Thus in scurvy and purpura an inflammation which under ordinary cir- 
 cumstances would be serous only, may become hemorrhagic. The con- 
 stitutional anomaly is due either to a condition of the lilood-vcssels which 
 allows the red blood-corpuscles to pass through them more readily or 
 possibly to changes in the blood itself. 
 
 PtmtrLENT Inflammation. 
 
 This is a form of inflammation Avhich is sliarjdy separateil from the 
 others, and is characterized by an exudation whicii is callcil pus. In 
 other forms of inflanmiation the exudations may differ, depending upon 
 the action of different causes or upon a greater or less intensity in the 
 action of the same cause. We can have from the same cause acting in 
 varying degrees of intensity a serous, a fibrinous, or a hemorrhagic 
 exudation. By subjecting the ear of a rabbit to water at different 
 degrees of temperature all the various forms of inflammation may be 
 
172 SUBGICAL PATIIOLOOY. 
 
 produced, with the exception nt' tlir puriilont. This cannot be pnxkiced 
 by the action of the most intense caustics. 
 
 Pus is a whitish or g-ravisli (>i)a((ue fluid of varying degrees of density. 
 It may acquire a reddisii tinge from an aihnixture of red corpuscles ; in 
 some cases it has a distinctly j'ellowish or bluish tinge, the latter being 
 due to certain of the bacteria which cause suppuration. The exudation 
 may infiltrate in the tissues — that is, it may be contained in the meshes 
 of the tissues, as in the serous exudation — or it may be contained in 
 cavities which are hollowed out in the tissues. 8uch a cavity containing 
 pus is called an abscess. Or, again, there may be a loss of substance on 
 the surface from which such a fluid exudes. In all other forms of 
 inflammation, particularly in the more severe forms, there is more or less 
 fil)rin in the exudation. In the purulent inflammation the exudation 
 contains either no fibrin at all or only a small amount of it. Moreover, 
 the exudation differs in the eftect which it has on the tissues of the 
 inflamed part. In the serous and fibrinous inflammations the exudation 
 either accumulates in the interstices of the tissue, or, if it cannot be con- 
 tained in this, it passes to the surface or into the natural cavities of the 
 body, always following the path of least resistance. The exudation in 
 itself seems to produce no injury to the tissue. The tissue, of course, 
 may be injured by having its nutrition interfered with by compression 
 of vessels produced by the exudation, and very extensive necrosis may 
 be produced in this way ; but the exudation in itself produces no injurious 
 action on the tissues with which it comes in contact. The purulent 
 inflammation is different. In this there is not only destruction of cells 
 by the exudation surrounding them, l)ut the intercellular substance itself 
 is destroyed and dissolved by the exudation. The exudation and the 
 softening and destruction of the tissue combine to form the abscess. The 
 dissokition of the intercellular substance takes place more easily in the 
 loose areolar tissue. Not only is this solvent action of the exudation 
 exerted on the intercellular substance, but the fibrin also, when any is 
 present, is dissolved in it. 
 
 "We can easily follow the course of development of an abscess by 
 injecting some of the bacteria, which from their specific action are 
 spoken of as the pus-organisms, into the ear-vein of a rabbit. The 
 organisms are carried into various tissues, and by their growth form 
 small masses in these. The first ett'ect of the presence of the organisms 
 is the production of necrosis in the tissue innnediately surrounding them. 
 This is accompanied by an enormous emigration of leucocytes extending 
 into the necrotic tissue, and the leucocytes to a great extent undergo the 
 same necrosis as the tissue. In the pcri]ihery they form a more or less 
 distinct wall around the necrotic tissue. In the necrotic area itself there 
 is of coui-se no inflammation. Not only are the cells destroyed, but the 
 blood-vessels as well, and no circulation takes place within the jiart. The 
 next stage in the formation of the abscess is the liquefiiction of the tissue. 
 The bacteria or their chemical products appear to exert an actual dissolv- 
 ing power on the tissue. First, apjiarently, the intercellular substance is 
 dissolved, and all of the cells, both those of the tissue and the leucocytes, 
 come together to form a single mass. Sometimes the tissue-cells more or 
 less retain their fcn-m and can be recognized, but more often they are 
 broken up into fragments or granules. In some cases the suppuration 
 
INFLAMMATION. 173 
 
 does not spread from a single point in tliis way, but from several adjacent 
 points. Then the various foci of softening come together, forming a single 
 cavity, which may contain not only the individual cells which have been 
 set free by the dissolution of the intercellular substance, but larger 
 masses of tissue into which the softening has not fully extended, and 
 which are set i'ree by the various foci of softening meeting one anotiicr. 
 The various tissues show a varying resistance to this softening power of 
 the exudation. In a glandular organ the comiective-tissue septa in the 
 gland offer the least resistance. The suppuration may extend along 
 these, and an abscess be formed which will ct)ntain large necrotic masses 
 of the glandular substance. Such masses are spoken of as sloughs. 
 
 The pus varies in consistence. Sometimes it is thick and creamy, at 
 others it is thin and similar to a serous exudation. The cells are to a 
 large extent the white corpuscles of the blood. Of course along with 
 these cells there will be otlier cells and fragments of cells which come 
 from the tissues. When the pus-cells are examined on the warm stage 
 of a iuicrosco]ic many of them show acti\-o amreboid movements. The 
 fluid portion of the pus is simply the serous exudation. The pus con- 
 tiiined in a definite abscess-cavity is frequently under considerable ten- 
 sion, sometimes apjiarently much higher than the blood-pressure. On 
 
 Fig. 6. 
 
 m 
 
 c 
 
 b 
 
 '.■■■>.:. 
 
 
 
 '^.sli^iili 
 
 
 ■y'^f^yM'' 
 
 
 
 ^p^,^:;.^.:.| 
 
 Section of a chronic abscess of the lung : a, layer of pfrannlar material composed of necrotic cells 
 and bacteria; b. layer of tissue tilled with leucocytes: c, loose granulation tissue contiunine 
 dilated blood-vessels, from wliicli active emigration is taking place ; d, denser cicatricial 
 tissue. 
 
 making an incision into an abscess the contents may spurt to a consider- 
 able distance. When the abscess-cavity has remained for some time a 
 definite wall is formed around it, which prevents its further extension 
 (Fig. 6). As the abscess is forming there is constantly going on outside 
 of the necrosis antl outside of the wall of leucocytes a gro\\th of the 
 tissue. All of the cells of the tissue, the connective-tissue cells, those 
 forming the walls of the blood-vessels, and ]>robal)ly also the specific 
 cells of the tissue, proliferate. In consequence of this proliferation 
 there is produced a dense tissue consisting to a large extent of cells 
 
174 SURGICAL PATHOLOGY. 
 
 ■similar to the lymphoid cells of the hlood. This is the sjime tissue 
 which forms the small projeeting granules seen on the surface of an 
 ulcer, and from this it has received tlic general name of granulation 
 tissue. Sometimes softening does not take place until such a definite 
 wall is formed around the focus. This action on the part of the tissue 
 varies in different cases. Sometimes it is almost entirely absent, and 
 there is nothing oj)posed to the extension of the ])rocess. In some cases 
 it would a])pear as tiiough there were a direct excitation of cell-]MX)lifcr- 
 ation of the tissues produced by the bacteria. Such a membrane lining 
 an abscess is called a "pyogenic membrane." It is a soft reddish mem- 
 brane having a slight similarity to a mucous surface. It was formerly 
 supposed that pus could be directly secreted by such a membrane. It 
 always contains, along with the cells derived from the tissue, a large 
 number of leucocytes, which are constantly passing through it into the 
 abscess, and in the vessels not only of the membrane itself, but in those 
 of the surrounding tissues, there are quantities of leucocytes. In many 
 cases the membrane does not -offer sufficient opposition to the advance of 
 the suppurative pi'ocess. The cells composing it may become necrotic, 
 soften, and form part of the contents of the abscess, and its formation 
 gradually recedes as it is gradually destroyed. There is no sharp limit 
 to the membrane-f(jrmation, but it gradually fades off' into the surrountl- 
 ing tissues. For a considerable distance around, the formation of gran- 
 ulation tissue continues, appearing as an infiltration of the interstitial 
 tissue with small round cells. Sometimes the purulent inflammation is 
 preceded by a fibrinous or serous inflammation. The fibrinous inflam- 
 mation of a serous surface may become changed into a purulent, and the 
 fibrin which has been formed becomes dissolved in the pus. There may 
 be a large amount of fibrin in the tissue surrounding an abscess which 
 may become softened by the advance of the suppuration. 
 
 We may distinguish various sorts of abscesses, depending on the cha- 
 racter of the pus and the character of the tissue in which it is formed. 
 When an abscess forms rapidly and is accompanied by a considerable 
 amount of jiain and evidences of acute inflammation, it is spoken of as 
 an acute or a hot abscess. On the other hand, the abscess-formation 
 may take place slowly, the pus may accunudate slowly, and, if this 
 takes place in an organ poorly supplied with nerves, it may not give 
 rise to any special symptoms. Again, the pus may be formed in one 
 portion of the body, and may by gravity extend into a jiortion lower 
 down, gradually dissolving the tissue as it passes along. Such an 
 abscess is called a cold or gravity abscess. One of the best examples 
 of this is the abscess which appears in the inguinal region, the pus 
 being formed in the vertebra? and descending along the psoas muscle. 
 
 The amount of pain in purulent inflammation differs greatly. In 
 feome cases it is intense ; it others it may be entirely al>sent. This 
 depends largely upon the character of the tissue and the amount of 
 nerves in the part. In an abscess of the subcutaneous tissue, where 
 pressure is exerted on the nerves of the skin, the pain may be intense. 
 In abscesses in internal organs poorly supplied with nerves, as in the 
 liver, a large abscess may be formed without any pain accompanying it. 
 The pain will also, as in an ordinary inflanunation, depend upon the 
 amount of pressure which is exerted on the nerves. In a tissue capable 
 
INFLAMMA TION. 1 7 5 
 
 of distention there will be less pain than in a firm, dense tissue. Ab- 
 scesses of bone and of the periosteum are accompanied by intense 
 jiain. The amount of i)ain will also depend upon the rapidity with 
 which the abscess is formed. If the pus accumulates rapidly, the pain 
 will 1)C more intense ; if it accunuilatcs slowly, the tissues can gradually 
 become accustomed to the ihstcntion. 
 
 Inflammation produced by Bacteria. 
 
 The action of almost all pathogenic bacteria is closely related to 
 intlammation, because such bacteria in general produce an injury to the 
 tissue where they are present. The inflannnations which arc produced 
 by bacteria are also in some ways ditferent from the chemical or mechan- 
 ical inflammations. Bacteria may act on the body in a vai'iety of ways. 
 In the first place, the organisms may enter directly into the blood, and 
 there find suitable conditions for their growth, or, without growing 
 in the blood, may be deposited by it in the ditferent organs. In 
 most cases there is a primary lesion produced, and the infection of 
 the blood follows from this. In consequence of this the bacteria may 
 be deposited in the various organs of the body, and foci similar in their 
 general nature to the primary focus of infection may be formed. A 
 distinction must be made between the cases in which the organisms grow 
 in the blood and the cases in which they may enter the blood, l)ut do not 
 find there suitable conditions for their growth, and the blood simply acts 
 as a carrier, depositing them in various organs, where they exert a local 
 action. When the organisms enter into the blood the condition of septi- 
 cemia is produced. Many of the pus-organisms have the power of infect- 
 ing the blood, and septicemia is most frequently found as an accompani- 
 ment to some one of the purulent affections. In many cases the danger 
 of septicfemia seems to stand in inverse relati(jn io the extent of the pri- 
 mary infection. The more develojjed the local infection, the less apt 
 the septicemia is to take place. Frequently the same organism which 
 causes a typical local disease in one animal will produce septicemia in 
 another. In man inoculation with the anthrax bacillus will always 
 produce an intense local inflammation at the point of inoculation, the 
 anthrax pustule, which is only exceptionally followed by septicemia. 
 Most of the local lesions produced by bacteria are distinctly infianuna- 
 tory in character. This is eminently the case in most of the acute 
 infectious diseases ; for instance, in anthrax, in diphtheria, in pneu- 
 monia. ]\Iany of the inflammations so jiroduced are j>urulent in cha- 
 racter. In other cases lesions very closely related to inflammation, or 
 which at scmie period of their course arc accomiianicd by inflammatinn, 
 will be produced. The lesions which arc produced by the tubercle 
 bacillus and by the typhoid ba^'ilhis arc at first not inflammatory in 
 character. The lesions consist in a new formation of tissue of a definite 
 type, which arises from proliferation of the fixed cells of the tissue. In 
 the bi'ginning of these formations then; may be n(j emigration of leuco- 
 cytes and no inflammatory lesions in the tissue. At a later period, 
 however, in each, necrosis and degeneration take place in this newly- 
 formed tissue, and with this the inflammatory phenomena begin. In 
 ty])hoid fever the lesions, in the first place, consist of a new formation 
 
17G SURGICAL PATHOLOGY. 
 
 of lym])lioid tissue arisinti; from tliu lyiiiplioid tissue of the iutestiual 
 canal. lu this lymphoid tissue there are no leueoeytes, and, althdugli 
 tliere may be hyperceniia of the surrounding biood-vessels, there is no 
 emigration of leucocytes and no increased exudation. It is only when 
 necrosis takes place in the hyperplastic tissue that the invasion of leuco- 
 cytes begins. The .same is true in tubercle. Emigration only begins 
 and leucocytes are only found in the tuberculous tissue when caseation 
 appears. The necrosis whicli arises in a specific tissue in this way appar- 
 ently has the same attraction for the leucocytes as has necrosis of 
 normal tissue. The same thing is true of the new formations not caused 
 by bacteria. Many of the tumors are accompanied by intlanmiation in 
 the surrounding tissues, and even in the tumor itself there may be emi- 
 gration, an increased exudation from the blood-vessels ; and this is 
 closely connected witli processes of degeneration in the tumor. These 
 processes may be related to inflammation in another way. Thus the 
 tubercle may excite inflanunation merely by its presence. It may pro- 
 duce by its presence injuries in the ti.ssue which will be followed by 
 inflammation, and which may not be immediately connected with the 
 bacteria. 
 
 The character of the inflammations produced by bacteria will be 
 largely influenced by the manner in A\hieh these gain entry into the 
 system. This may take place in various ways. They may enter into 
 the tissues, producing an inflammation at the point at which they enter, 
 or they may produce no local lesions at the point of entry, and be 
 carried by the blood to various tissues of the body and deposited there, 
 only producing lesions in the tissues for which they have a specific 
 aflinity, which is probably due to tlie fact that certain tissues offer them 
 the mo.st suitable conditions for their growth. This is the case in small- 
 pox and in scarlet fever. Although we do not know anything about 
 the virus of small-pox or of scarlet fever, it is exceedingly improbable 
 that the lesions of the disease could be produced by bacteria finding 
 entry through the skin. The same bacteria do not always act in the same 
 way. In general we are able to surmise from the character of an 
 infiannnation what is the s{)ecific organism which has caused it ; but 
 there are exceptions to this. The .same organism whicli causes a typical 
 fibrinous inflammation in the lungs may under some circumstances 
 produce a distinctly purulent inflammation Mithout any formation of 
 fibrin at all. One of the ])us-urganisms, the streptococcus, may pro- 
 duce in the pharynx as typical a fibrinous infiannnation as is produced 
 by the diphtheritic bacillus, while under other conditions it may form 
 an abscess. The bacteria may also be related to inflammation in 
 another way. They may produce local lesions, and there may be 
 ]>roduccd in these local lesions chemical poisons which will ]n'oduce 
 necrosis and degeneration in distant organs, and these may be followed 
 by inflammatory phenomena. The most typical inflannnations are ])ro- 
 duced by a group of organisms which are so closely related to sup])uration 
 that they are called the pyogenic or " pus-organisms." Suppuration may 
 under certain circumstances al.so be produced by a nimiber of other 
 organisms. The essential pus-organisms are the staplu/lococcus aureus, 
 the streptococcus pyogenes, the sfapht/lococcus cpklermidis albus, the 
 bacillus pyogenics fcetidus, and the bdci/lus pyocyaneus. In addition to 
 
INF LA MM A TION. Ill 
 
 these suppuration has frequently been found to be pi'oduced by other 
 organisms ; for instance, by the colon bacillus, by the tubercle bacillus, 
 by the clip/ococcus lanceolatus, l)y the baci/hui proteus, and by various 
 others. The most typical purulent inflammations are those produced by 
 the staphylococcus and the streptococcus. In the case of the staphylo- 
 coccus its action has been thoroughly investigated by experiments both 
 on man and animals. The most typical influnnuation in man produced 
 by it is the ordinary boil or furuncle. In this it is evident that the 
 bacteria find their way into the skin along the hair-follicles or the 
 sebaceous glands. It has been found that the mere application of the 
 organisms to the surface of the skin is not followed by any results. 
 When they are rubbed into the skin the typical furuncle may be 
 produced. They apparently do not enter into the skin by means of the 
 sweat-glands, and furuncles do not appear on the parts of the body 
 where there are no hair-follicles or sebaceous glands, as ou the jialni 
 of the hands or the soles of the feet. They are most apt to a])pear on 
 portions of the body which are subjected to the rubbing of clothing, as 
 at the back of the neck and the waist-line. There is first produced a 
 necrosis of the tissue in the neighborhood of the hair-follicles or gland, 
 and around this suppuration. The necrotic tissue which produces this 
 does not always li([uefy, but remains as the so-called core of the 
 furuncle which is cast out with the pus. The pus produced by the 
 staphylococcus, as a rule, is thick and creamy, fi'equently M'ith a 
 distinctly yellowish color, probably due to the pigment produced by the 
 organisms in their growth. The streptococcus has a greater variety in 
 its action than the staphyhjcoccus. The streptococcus may produce on 
 the surface of mucous membranes a typical fibrinous exudation, or it 
 may produce suppuration of the tissues. Its action, even in producing 
 suppuration, is not circumscribed, as is the action of the staphylococcus. 
 Typical suppuration with liquefaction of the tissues is not so apt to be 
 produced, and the pus has not the thick creamy character of that of the 
 staphylococcus. In many cases no suppuration at all is produced, but 
 simply an infiltration of the tissue with serum and leucocytes. When 
 suppuration is produced by the streptococcus ]\i/ogencs it usually takes the 
 form of purulent infiltration. Strciptococci may be found in the tissues 
 even outside of the line of leucocytes, and they do not produce so much 
 necrosis, nor do they themselves exert such a positive chemotaxis, as do 
 the staphylococci. Both the streptococci and staphylococci may produce 
 on serous surfaces extensive suppuration. On both serous and mucous 
 surfaces the inflammation produced by the streptococci is accompanied 
 by a greater formation of fibrin. The inflammations produced by the 
 streptococci are, as a rule, far more dangerous in their local and in their 
 general eflects than those produced by the staphylococci. Inflammation 
 of the uterus in puerperal fever is almost alwaj-s due to the action of the 
 streptococci. 
 
 Inflammations produced by bacteria show in one way a vast differ- 
 ence from those produced by the action of chemical and mechanical 
 causes. In inflammation produced by mechanical causes the action of 
 the cause ceases with the inflannnation. It is impossible that it should 
 extend to other parts of the body. Tlie bacteria may be in various wavs 
 carried from one portion of tiie body to another, and wherever they 
 
 Vol.. I.— 12 
 
178 SURGICAL PATHOLOGY. 
 
 come tliey produce tlie same character of inflammation as in the primary 
 focus. Those inflammations wiiich apj)ear in the dift'erent portions of 
 tiie body following a primary focus of inflammation are called second- 
 ary or metastatic inflammations. The organisms may jjass along the 
 course of the lymphatics, either producing inflammations in places 
 ooiniected immediately with the primary focus by means of the lym- 
 pliatics, as the lymphatic glands, or they may be carried by the lymphatics 
 into the blood and then into other organs. They are most apt to be 
 retained in the nearest lymphatic glands and excite these to inflamma- 
 tion and sui)paratit)n. As an example of this we have the buboes in 
 the groin which follow local processes in the external genitals. The 
 lymphatic glands may also be excited to inflammation by other products 
 than the bacteria. The chemical products which are produced in the 
 inflammatoiy focus are washed out by the exudation and carried by the 
 lymphatics to the lymph-gland, where they may excite inflammation. 
 Such inflammations are rarely followed by suppuration, anil the changes 
 in the gland more generally consist in hyperplasia and the formation of 
 a new lymphoid tissue. 
 
 When the organisms enter into the blood they are carried into all of 
 the organs and tissues of the body. But there is a decided difference in 
 their action in the different tissues. Certain of the tis,sues are more 
 lial>le to have these secondary abscesses following on blood-infection 
 than others. When the staphylococcus aureus is injected into the ear- 
 vein of a rabbit, the metastatic abscesses take ])lace in diflerent organs. 
 The organisms of course first find their way into the blood-vessels of the 
 lungs, but here it is extremely rare that we ever find any lesions pro- 
 duced by them. The secondary foci of inflammation, the abscesses, are 
 generally limited to the kidney and to the myocardium. They may also 
 develop in the muscles of the body, but here, again, the preference is 
 shown for certain regions. The muscles most frequently attacked are 
 the abdominal muscles. It is difficult to explain this. The frequency 
 with which certain organs are attacked may be due in large part to 
 special diflerences in the circulation of these organs. In both the 
 kidney and the heart the arteries are terminal ; that is, each porti(in 
 of the tissue is snpjjlied by a distinct artery without anastomoses. The 
 same condition obtains in the spleen and in the brain, but altscesses only 
 rarely develop in these parts. It cannot be due to the greater facility 
 with which the organisms are deposited in certain organs. All sorts of 
 very finely-divided foreign bodies entering into the blood are deposited 
 with greater facility in the liver than in any other organ, because here 
 there is an enormous system of cajiillaries with very slow circulation. 
 It is probable that the organisms find in the tissues of certain organs 
 more favorable conditions for development than in others. The organ- 
 isms appear to be rarely carrietl as large embolic masses plugging up 
 blood-vessels. In the kidney there is little doubt but that they do act 
 partly in this way, and the effect of their sjiecific presence may be accom- 
 panied by the mechanical effects of infarction. They are not carried as 
 embolic masses, because, even if they were injected as such into the 
 veins, they would not be able to pass through the blood-vessels of the 
 pulmonary circulation. In the kidney their action has been closely 
 studied by Ribbert. It is probable that they lodge in or are taken up 
 
INFLAMMATION. 179 
 
 at some point in the circulation by the endothelial cells of the small 
 arteries, and by their continuous growth they may plug up the vessel, 
 and from this primary focus they may be carried as masses into smaller 
 branches of the same artery. 
 
 The secondary inflanuuation may be pnjduced in another way. The 
 bacteria may lind entry into the tissue along various ducts or canals 
 which lead from the j)rimary focus into other poi'tions of the body. 
 The most typical example of this is given in the secondary abscesses 
 which develop in the kidney following a primary purulent inflammation 
 of the bladder or of the urethra. The organisms make their way from 
 the bladder into the kidney in a direction opposed to the flow of the 
 urine. It is probable that their progression is due to a gradual gi-owth 
 along the wall of the urethra and of the pelvis of the kidney. They 
 may do this without producing any inflammation of the urethra, but 
 most often there is a general inflammation of this ; or it may be that 
 they find suitable conditions for growth in the urine in the urethra, and 
 infection may follow in this way. Rinne includes among the metastatic 
 abscesses those produced by the action of bacteria which enter the body 
 without producing any lesions at the point of entry, and are often carried 
 into remote organs, where their action takes place. 
 
 There is the greatest diversity in the effects produced by the pyogenic 
 organisms. This is due to a number of factors, and, although much 
 light has been thrown on the matter by experiments on animals, there 
 remains much which is not at all or imperfectly understood. As a 
 result of the entry of the same organism into the system there may be 
 no effect produced ; or there may be a slight inflammation not leading to 
 suppuration or more or less extensive abscess-formation ; or without 
 deflnite abscess-formation an extensive and difi'use purulent infiltration 
 of the connective tissue; or without the production of any local lesions 
 there may be a general infection of the blood, and death may take place 
 in two or three days with the phenomena of an acute intoxication. I 
 saw during the last year a case in which a surgeon died several days 
 after an operation on a case of peritonitis. There was no history of a 
 wound received at the time of operation, and no definite point of entry 
 for the organisms could be found at the autopsy. The most extensive 
 lesions were in the right thigh and extended from this up to the buttocks. 
 Over these parts there were large blebs and ])artial desquamation of the 
 epidermis. The subcutaneous tissue and the adjacent muscles Avere 
 necrotic and contained masses of streptococci. The same organisms 
 were obtained in pure culture from the Idood and from every organ of 
 the body. The infection very probably took place from the thigh, and 
 the organisms possibly entered from a scratch with the nail or in some 
 such way. There was no definite suppuration, and in the necrotic tissue 
 of the muscle there were but few leucocytes. 
 
 In any attempt to explain such variation in action the resistance of 
 the tissue must he considered. This resistance is due to a number of 
 things. The blood-serum is directl)' destructive to a number of organ- 
 isms, and when they are subjected to its action, in some cases for a 
 few hours only, they are destroyed. Also, there is no doubt that the 
 leucocytes play a most important part in destroying the bacteria, in pre- 
 venting their absorption, and in warding off their action from the sur- 
 
180 SURGICAL rATHOLOar. 
 
 rdiiiKlino; tissue-cells. It is probable that this action of the leucocytes 
 is not the only way that tiie body has ul" combating tlie organisms, but 
 it plays an important part. Ditiferent animals have ditt'er(>nt degrees of 
 susceptiljility to the action of bacteria. It is probable that this is largely 
 due to differences in the destructive powers of their serum. The number 
 of organisms which are introduced into tlie body has an im])ortant influ- 
 ence. This is shown by the results of the injection of tiie staphylo- 
 coccus into the ear-vein of a rabbit. If the organisms injected are of 
 the same degree of virulence, the effect produced is lai'gely dependent 
 upon the amount of the culture which is injected. Very small doses 
 may produce no effects. The tissue into Mhicli the organisms are intro- 
 duced is of importance. After the injection of the staphylococci into 
 the car-vein of a rabbit abscesses are tlcveloped in certain organs only, 
 and this cannot be explained by the organisms entering these organs 
 only, for other organs are equally exposed to their action. The same 
 thing is seen in the direct injection of the organisms into the tissue. The 
 smallest drop of a pure culture of the staphylococcus injected into the 
 anterior chamlier of the eye of a rabbit is sufficient to develo]i an exten- 
 sive supjiuration, with loss of the eye. A much greater quantity is neces- 
 sary to produce an abscess when the injection is made into the loose 
 subcutaneous tissue of the back than is required when the injection is 
 made into the dense tissue of the ear or into the muscles. This is 
 probably in part due to the greater ease of absorption in the several 
 places. When the absorption is ra])id the bacteria can be taken into 
 the blood, and thci-e be destroyed by the serum without time being given 
 for their local action in producing necrosis of the tissue and chemical 
 poisons. Grawitz has shown the importance of absorption in his work 
 on the production of peritonitis in the dog. This animal possesses to a 
 high degree immunity to the action of the sta})hylococcus. Large quan- 
 tities of the organisms may be injected into the peritoneal cavity with- 
 out any effect, provided the tissues are normal. If the po^^'er of al)sorp- 
 tion be in any way interfered with, or if the serous surface be stripped 
 off over a small area, general purulent peritonitis results. Halsted has 
 shown that the same thing is true when, instead of a fluid culture, a 
 piece of potato with a growth of the organism on its surface is placed 
 in the cavity. In this case a fatal peritonitis is always produced. The 
 potato has nothing to do with the result beyond affVjrding a suitable ])lace 
 for the development of the organisms and allowing them to produce their 
 chemical poisons. The jjotato without the organisms becomes rolled up 
 in the omentum and encaj^sulated. If an emulsion of agar with the 
 organisms growing in it be injected beneath the skin, it is more surely 
 foli(>\\-ed l)y sujipuration than when the culture is injected in a fluid 
 medium. One of the main elements seems to be the action of the sol- 
 uble chemical poisons produced by the organisms. If the injection is 
 made into a dense tissue, the organisms may find a suitable soil for their 
 development, or they may create it by the production of necrosis in the 
 surrounding tissue. The poison which they create may not only inhibit 
 the local resistance of the tissue, but when it is gradually absorbed it 
 may destroy the germicidal power of the entire blood-current. In any 
 case it is of the utmost importance to oppose to the action of bacteria 
 as normal tissues as possible. It is probable that a great deal of the 
 
INFLAMMA TION. 1 8 1 
 
 result of modern methods of surgical technique is due as much to the 
 greater care bestowed upon wounds as to the care exercised in excluding 
 bajteria. 
 
 Differences in the virulence of the organisms play an imjiortant jiart 
 in their effects on the tissues. The pus-organisms are not definite clicin- 
 ical conijiounds, and they vary enormously in their virulence. This 
 virulence is gradually lost in the cultures. It remains longer in the 
 staphylococci than in the streptococci. A few generations of cultures 
 may suffice to destroy the virulence of the streptococci completely. In 
 the staphylococcus aureus we can to some extent estimate the degree of 
 virulence by the intensity of the color which is produced. The source 
 from wiiich the organisms are derived is also of importance, as is also 
 the fact whether the organisms are injected alone or accompanied with 
 toxic sulistanccs. The various accompanying toxic substances must play 
 a great part in the purulent infections as they occur under natural con- 
 ditions. In natui'al infection we have to do, not with pure cultures 
 of the pyogenic cocci, but with organisms which have come from all 
 sorts of sources and have been growing in various conditions, and 
 which are frequently mixed with many kinds of bacteria. There is 
 proof that under some of these conditions the infectious material 
 may acquire a degree of virulence Avhich we ai'e not familiar with in 
 artificial cultures. Bumm found that injection into the peritoneal 
 cavity of a rabbit of a fraction of a drop of the fluid from a case of 
 acute puerperal peritonitis produced acute peritonitis in the animal, 
 whereas pure cultures of the same organism were nothing like so 
 virulent. Fehleisen found that a pure culture of the staplti/Iococcus 
 aureus to which he had added a little of the clear fluid from the 
 inflammatory cedema of a spreading cellulitis was far more virulent 
 than the ordinary culture. 
 
 Any condition of the system which lowers its general resistance will 
 increase the action of the pus-organisms. It has been found that sup- 
 puration is more easily excited and is more intense in animals which 
 have been rendered aiifemic. Even when local ansemia is produced by 
 tying or constricting an artery, the suppuration following inoculation 
 with the same amounts of tlie organisms is more severe on the anaemic 
 side than on tiie normal. If the blood is rendered hydremic, the effects 
 of inoculation ai'e increased.' 
 
 Some of the infectious diseases render the tissues more liable to the 
 effects of the pyogenic organisms. This has been shown in typhoid 
 fever. An old focus of inflammation may become purulent when the 
 resistance of tiie tissues is lowered by disease. Not oidy may the gen- 
 eral resistance of th^ body be overcome, but the local resistance as \vell. 
 Various local injuries of the tissjes have been produced, and then organ- 
 isms injected into the circulation, and it has been shown that in many 
 cases the organisms have settled in the injured tissues and have there 
 produced a purulent inflammation. Sometimes the presence of other 
 bacteria increases the action of the pus-organisms. Trombetta lias 
 sliown that when cultures of the staphylococcus were mixed with tiie 
 prodigiosus the effects were increased. The tubercle bacilli and the 
 typhoid and other organisms when mixed with the staphylococci have 
 
 ' Welch : Conditions underlying the infection of wounds. 
 
182 SURGICAL PATHOLOGY. 
 
 the same effect. The resistance of tlie tissues is undoubteclly lowered 
 wlu'ii cliemical ])ro(lucts of tlie liactcria are introduced along- with tlicni. 
 In any case it is probable tiiat tlie diminished resistance of the tissues is 
 due to changes in the blood, and consists chiefly in destruction or diminu- 
 tion of the germicidal power. The presence of such chemical products 
 of bacteria may also prevent the establishment of leucocytosis. While 
 it is ]ir()bal)le that in man tlie injection of even a large number of pus- 
 organisms in tile normal blood would have little or no effect, the con- 
 dition is different when the organisms enter into the blood after its 
 germicidal jiower has been weakened by absorption of poisons from the 
 local snpjiuration. Metastatic abscesses do not develop early in the course 
 of a suppuration, but at a late period when the blood has been poisoned 
 by absorption. They are not due alone to the organisms. Even dead 
 organisms when injected into the tissues in sufficient quantities may 
 excite suppuration, for the protoplasm of the dead bacteria is a powerful 
 agent in attracting the leucocytes. 
 
 In speaking of suppuration, so far, we have only considered it in 
 relation to the bacteria. For all practical purposes that is the only way 
 in which it need be considered. All of the sujipuratlve processes whicli 
 we meet with in man are due to bacteria, and they may be obtained 
 either in cultures made from the pus or on microscopic examination of 
 the tissues. If the cultures made from an abscess are sterile, that is no 
 proof that the suppuration was not produced by bacteria. The organisms 
 may be dead or they may not grow on the medium which was used for 
 culture. Other organisms than the bacteria may excite suppuration. It 
 is known that some of the protozoa have this action. The amaha coll 
 when it enters into the liver from the large intestine will produce 
 abscesses, and it has been found to be the cause of abscess-formation 
 in other places. Flexner has reported a case in whicli an abscess of the 
 jaw was produced by this organism. 
 
 It is certain that typical suppuration may be produced Ijy chemical 
 substances, but abscesses so produced are not often met with. There 
 has been a great deal of experimenting tlone on this question, and it 
 may be regarded as established in the affirmative. Croton oil is one 
 of the most certain substances to produce suppuration when injected into 
 the tissues. In a series of experiments croton oil was enclosed in thin 
 glass capsules which were pi'eviously thorougldy sterilized. These were 
 placed beneath the skin of rabliits, and after several days, in every case 
 after the wound was thoroughly healed, they were broken from without. 
 In every case a typical focus of supjiuration was produced. It has long 
 been known that when croton oil is rubbed into the skin a crop of small 
 pustules will result. Turpentine and a few other substances will pro- 
 duce supjiuration, but not so certainly as will croton oil. There is no 
 reason why some of these substances may iKit do this. They are caustics, 
 and when they come in contact \\ith the tissues they will produce necro- 
 sis ; and they probably have in themselves, or they assist in forming in 
 the tissues, substances which have the power of dissolving the necrotic 
 tissue and the fibrin. 
 
 Not only the purulent inflammations, Ijut inflammations of any sort, 
 are affected by the condition of the liody, and especially by local or gen- 
 eral pathological conditions of the cii\-iilation. For the preservation of 
 
IXFLAMMATWN. 183 
 
 the normal coiKlition of tlie tissues a normal circulation is necessary. The 
 l^lootl must How tlirougii the tissues in the proper amount, with the 
 proper pressure, ?ind the quality of the blood must not be altered. A 
 change in any one of these conditions or all of them has an imjjortant 
 influence in modifying the course of inflammation. We have already 
 spoken somewhat of the influence of auiemia in modifying the purulent 
 inflanunation. When the central artery of the ear of a rabbit is ligated, 
 sufficient blood will enter the ear by the small arteries on the edge of 
 the ear to preserve the integrity of the tissues. If, however, after liga- 
 ting the central artery the ear be exposed to influences which in normal 
 circidation would result only in a minor degree of inflammation, a much 
 more severe tvpe, frequently ending in necrosis of the entire tissue, M'ill 
 be produced. Samuel has sliown tliat tlie exposure of the ligated ear to 
 water at a temperature which would only slightly atfect the part in a 
 normal circulation will be followed by necrosis. In a more extensive 
 series of experiments in parts subjected to various degrees of vascular 
 disturbances he found that in aufemic parts all the phenomena of inflam- 
 mation developed more slowly and ran their course in a much longer 
 time. The congestion of the tissues comes on more slowly, is more 
 extensive, and there is a tendency to coagulation of the blood in the 
 dilated vessels, producing complete cessation of the circulation. 
 
 The course of inflammation is also modified by active arterial hyper- 
 semia. Danilewski first studied this by exposing both ears of a rabbit 
 to the same injurious influence after section of the sympathetic on one 
 side. He found there was a marked difference in the course of inflam- 
 mation in the hyperiBinic ear as compared with the other, and the pro- 
 cess took a more rapid and ran a more favorable course. He, however, 
 made the mistake of regarding the ear not operated on as being in a 
 normal condition. It is now known that after section of the sympathetic 
 the hyperiemia of the ear on the side which is cut is acconqianied by 
 anaemia of tlie ear on the uninjured side ; so that he really compared 
 inflammation in a hyperKmic part witli inflanunation in a somewhat 
 anaemic part. Samuel afterward studied tlie same subject more carefully, 
 and found that in a hypercemic part a more severe type of inflannnation 
 followed the same degree of injury and lasted longer. The exudation 
 is more abundant, the swelling is greater, and all of the phenomena are 
 more active. After the inflannnatory dilatation of the artery it does 
 not so quickly return to the normal calibre in the hypcra?mic car as 
 in the normal. 
 
 Still more unfavorable are the conditions when inflammation takes 
 place in a part in which there is chronic congestion. Here the quantity 
 of the blood is increased, but, owing to the slowness of the circulation, 
 the tissues are placed in an abncrmal condition. The part can, as in the 
 anaemic ])art, preserve its integrity under tlie ordinary conditions of life, 
 but slight influences will be more easily felt. The blood flows nwre 
 slowly through the part, the blood-vessels themselves are dilated, and 
 the tissue lives on a lower plane. Its reserve force, its capacity for 
 rcjiair, is diminished. Not only will a slight cause produce a more 
 severe type of inflammation, but tlie inflammation will run a mucii 
 longer course and repair take place more slowly. Inflammation of this 
 character is spoken of as hypostatic inflammation, and a good example 
 
184 SURGICAL PATHOLOGY. 
 
 of" it is seen in the inflammation of the posterior part of the hing which 
 comes on in the conrse of various diseases when the patient iias lain for 
 a long time on the hac'iv. The ordinary effects of liypostasis in such 
 cases are increased l)y weakness of the circulation due to diminished 
 force of the heart's contraction, and the blood itself is also altered. The 
 cause of the inflammation in such cases is usually the stagnating secretion 
 of the bronchi, in which infection may take place. 
 
 Another example is seen in the inflammation of the leg in chi-onic 
 jjassive congestion due to local or general impairment of the circulation. 
 In this condition a slight blow or other form of injury whicli would not 
 be felt, or only slightly, under normal conditions, will l)e followed by 
 extensive inflammation, «hich may not heal until the part be placed in a 
 condition more nearly approaching normal. This can be done by eleva- 
 ting the leg and removing the influence of gravity. 
 
 Not only will purulent inflammation take place more readily, but any 
 inflannnation will run a more severe course in a person wlio is the sub- 
 ject of general ana'mia. Other conditions — as diabetes, for instance — 
 have a marked influence on inflammation. In diabetes the inflammation 
 tends to assume a necrotic character. It is probable that in diabetes the 
 germicidal powers of the blood-serum are greatly diminished. Infec- 
 tion witli the pus-organisms takes place more readily and is more severe. 
 The primary cause of inflannnation being injury to the tissue, however 
 brought about, we can see that a tissue placed in an abnormal condition 
 (•aunot so easily guard against an injury, and a slight cause will be fol- 
 lowed by a greater effect. The inflammation will persist until the integ- 
 rity of the tissue is restored, and this will take longer when the condi- 
 tions for the nntrition of the tissues are not so favorable. Sometimes 
 a tendency to certain sorts of inflannnation seems to be inherited. In 
 some persons, even when the circulation and nutrition seem to be pei- 
 fectly normal, inflannnation is more easily excited in certain organs 
 and takes a more severe course. Thus an individual may be predis- 
 l)osed to inflammation of the air-passages and other parts of the body. 
 In this case it is not the inflammation itself which is inlierited, but a 
 weakness or lack of resistance of the Ixidy. AVhat this is we are unal)le 
 to define. It may be, as Cohnheim suggests, an abnormal condition of 
 the blood-vessels of the part. It seems in many cases to be local and 
 not general. In some cases there appears to be a general weakness of 
 the tissues inherited. There may be an inherited lack of resistance to 
 certain causes of inflammation or to inflannnation generally. Individ- 
 uals with an inherited tendency to tuljereulosis frequently show a 
 general lack of resistance to all sorts of inflammatory causes. 
 
 Rejieated attacks of inflammation in the same part render it more 
 liable to inflammation. This is due to an abnormal condition of the 
 part caused by the repeated attacks of inflammation. At each attack of 
 inflammation the tissue may not be completely restored, and finally an 
 abnormal tissue, one of lower resistance, is established. The tissue is 
 then jjlaced in the same condition as when subject to antemia or any 
 other disturbing influence. It can only preserve its normal condition 
 under ordinary circumstances. The tissues are more vulnerable, and a 
 cause which would not be felt in a normal tissue may produce a degree 
 of injury in this ^vllicll cannot be overcome without inflammation. 
 
IXFLA .V.V.I TIOX. 185 
 
 It is not necessary to consider at oreat icnsith the diifercnces between 
 acute and clu'onic intlamnuitiun. The phenomena of inflammation vary 
 in duration and last until the tissue is brought to a normal state. In 
 general, the difference is due to the length of time that the cause of inflam- 
 mation continues. A sudden injury of the tissue, in which the cause is 
 rcmoyed as soon as tlic injury is effected, is followed by active inflam- 
 matiiry phenomena, wliicli will also sul)sidc when the cause — that is, the 
 injury which has been produced on the tissues — is removed. In some 
 cases" the injury may take place more slowly, and the injurious agent, 
 whatever its character, may act continously, and the phenomena of inflam- 
 mation develop more slowly and continue for a longer time. In those 
 cases we have the process of repair, the attempt o( the tissues to return 
 to a normal condition, going on at the same time that the injurious cause 
 is still acting, and the phenomena wliich we are accustomed to regard as 
 typical of inflammation — i. e. heat, redness, swelling, and pain — develop 
 so slowly or mav be so slight as to escape our attention entirely. These 
 chronic inflanmiations are frequently due to bacteria, which may extend 
 their action not only to the tissues into which they first enter, but may 
 continously affect the new tissue wiiich is produced in the repair. 
 
 Another variety of inflannnation is the so-called tro])liic inflammation 
 suj>})osed to be due to trophic disturbances. It is assumed by those 
 believing in this that there is a direct nervous influence acting on the 
 nutrition of the tissues, independent of the influence of the vasomotor 
 ncryes. The nutrition of each cell is sup])osed to be directly influenced 
 l)v the nervous system, and the nerves governing this nutrition are spoken 
 of as trophic nerves. Physiologists in general and pathologists do not 
 believe much in this, and the arguments advanced in favor of the view 
 have generally come from clinicians. As an example of such so-called 
 trophic inflammations we may cite the inflannnation of the cornea which 
 follows section of the trigeminus. INIagcndie first observed that after 
 section of this nerve inflannnation of the cornea, with ulceration and 
 <lestruction of the entire eye, generally takes place. Thei'c may also be 
 inflammation of the lips and other parts supplied by this nerve. It has 
 been also observed that after section of the pneumogastric pneumonia, 
 fVer|uently terminating in gangrene, develops. Another example of 
 tropiiic inflannnation is found in the j)crfbrating ulcer of the foot which 
 develops in certain diseases of the s|)inal cord. In most cases a definite 
 ])roof lias been given by experiments that these inflammations do not 
 take place when other injurious influences resulting from the section of 
 the nerve are excluded. The inflannnation of the cornea after section of 
 the trigeminus is the result of the action of particles of dust and other 
 foreign substances which the eye in its anresthetic condition is no longer 
 able to guard against. It is possible to remove the eftect of the action 
 of such traumatic influences on the cornea l)y sewing the edges of the lids 
 together or by fastening one of the animal's ears over it. Von Gudden 
 took newly-born rabbits and sewed tlie edges of the lids together, pi'o- 
 ducing a perfect union. After the wounds were healed and the eyes 
 absolutely sealed he cut the nerves, anil on 0]3ening the eyes fifteen days 
 after the nerve-section he invarialily found the cornea normal. The 
 inflammation of the lungs wiiicli follows section of the pneumogastric is 
 due to the presence of particles of fotxl and other foreign substances 
 
186 SURGICAL PATHOLOGY. 
 
 wliicli linvc been aspirntcd into flic hronclii. Paralysis of the jjlottis is 
 IH'odiiced l)y the experiment, and tlic mo.st simple way of preventinji; 
 inflammation is to lvee|) the animal experimented on in the dorsal position 
 and thus ])revent foreii;n substances ei)terin<;- into the f^lottis. 8uch lesions 
 as perforating ulcer of the foot and the various joint diseases which occur 
 in the course of certain diseases of the spinal cord are extremely rare in 
 patients whose circumstances enable them to avoid over-exertion in the 
 later stages of the disease and to oI)serve every needed care. It is easv 
 to see how this idea of trophic iutlammation may have arisen. The 
 tissues are placed in an al)normal condition. Not only is there ana?sthesia 
 of the tissue, but the circulation in tiie jjart is more or less disturbed. 
 Thus, in paralysis, extensive ulceration (the so-called bed-sore) is fre- 
 quently developed over the sacrum and other prominent bony eminences. 
 This is due to a variety of conditions — to the anaemia which is produced 
 Ijy pressure and to the acti(jn of the urine and fieces which are frequently 
 involuntarily passed by the patients, and unless the greatest care is exer- 
 cised the parts in question come in continuous contact with them. The 
 epidermis over the part will be macerated off, and the tissue beneath, 
 whose vitality is already impaired, will be exjiosed. In consequence of all 
 of these conditions the tissue becomes necrotic and large ulcers will form. 
 Such bed-sores can always be ])revented by proper care and cleanliness, 
 and in general we may regard them as due not to trophic disturljances, 
 but to bad nursing. Cystitis until comparatively recently was considered 
 to be one of the symptoms of inflammation and of injury to the spinal 
 cord. It is now regarded as a complication easily prevented by the use 
 of clean catheters introduced with care. 
 
 There seems to be much more proof in flivor of regarding some of the 
 herpetic affections as due to trophic influences. These develo]) in the 
 skin over the area supplied by certain nerves, and it has been found in 
 some cases that the nerves or the ganglia from which they arise are 
 inflamed. Samuel suggests the jiossibility that these inflammations may 
 be due to an intense hyper:emia of the part brought about by the paralysis 
 of the vasomotor nerves. Striim])el suggests the probability that the 
 inflannnation in herpes zoster may be infectious and due to a definite 
 cause. One argument in favor of this is the frequent appearance of 
 herpes zoster in an epidemic or endemic form. Pfeiffer thinks that in 
 these eases the inflammation should be regarded as an infection which 
 follows along the course of the intercostal nerves. The nutrition of 
 parts is undoulitedly affected by nerN'ous influences, and integrity of the 
 nerves is necessary to keep the tissue in a normal condition. No part 
 receives continually the same supply of blood, but the blood-supply is 
 regulated according to the needs of the tissue by the vasomotor nerves. 
 When action of these nerves is destroyed the part is simply placed in an 
 abnormal condition as regards its nutrition, and injuries are more easily 
 produced and less easily repaired. 
 
 A peculiar variety of inflannnation is that known as sympathetic 
 inflannnation. Certain organs of the body stand in a particularly close 
 relation with one another, and inflammation of one is followed by inflam- 
 mation of the other. The best example of this is given in the infectious 
 parotiditis, or mumps. In this tiie acute inflammation of the parotid 
 gland is frequently followed in the male by inflammation of the testicles. 
 
ULCERATION. 187 
 
 Avhich often reaches a severe deojree, and in the female by a similar 
 inflammation of the mammary glands and ovaries. The cause of this is 
 absolutely unknown. It may be that the infectious agent, •whatever its 
 nature, which causes the inflammation of the parotid is localized in the 
 other organs, or it may be that the chemical products which are ])roduced 
 in the inflammation of the parotid gland have a special pathogenic influence 
 on other parts of the body. The fact that the inflammation of the other 
 parts does not usually take ])lace simultaneously with that of the parotid, 
 but at a later stage of the disease, would seem to be in fiivor of the latter 
 theory. There is certainly no direct nervous or vascular connection between 
 the glands. It is only the specific infectious parotiditis which is followed 
 by these sympathetic inflammations. Abscesses of the parotid due to the 
 entry of bacteria into the gland along the duct are not followed by sym- 
 pathetic inflammations. Another example of the sympathetic inflamma- 
 tion is the inflammation of one eye which follows inflammation of the 
 other. It is only when inflammation afl'ects certain parts of the eye that 
 the other eye is apt to become attected. Inflammation of the conjunctiva 
 or of the cornea is not followed l)y any affection of the other eye. It is 
 only when the inflammation aflects the iris and the deeper parts of the 
 eye suj)plied liy the sympathetic nerves that inflammation of the other eye 
 takes place. Deutschman, who has investigated the subject by inoculating 
 one eye with various bacteria, has thought that he could follow the course 
 of the inflammation along the optic nerve to the chiasm, and then to the 
 other eye. He supposes that it is due to bacteria \\hich take this route. 
 His experiments have been carefully repeated by Randolph at the Johns 
 Hopkins Hospital with negative results. Against the view of Deutsch- 
 man that the affection of the uninjured eye is due to bacteria is the fact 
 that the specific infections of one eye are not folloM'cd by similar affections 
 of tlie other. Thus tuberculosis of the iris and of the other parts of the 
 eye may destroy one eye without producing any lesions whatever in the 
 other. As a rule, it is only acute suppurative inflammations which tend 
 to extend in this way. It is possible that the inflammation may be due 
 to the action of specific chemical substances produced in the inflamed eye 
 on the other. The M'hole question of sympathetic inflammation, how- 
 ever, is still very obscure. 
 
 Ulceration. 
 
 An ulcer is a loss of substance on a surface of the body. Ulceration 
 is very closely connected with inflammation, and is frequently due to 
 this. The ulcer really represents a part of an abscess-wall. If an 
 abscess is seated in tlie sultcutancons tissue and opens on the skin, there 
 may be continuous inflammation and suppuration along the canal which 
 leads to the abscess-cavity, and in this way fistulas are formed. The wall 
 of the fistula leading to the old abscess has the same membrane which is 
 found in the abscess itself. When the abscess is superficial, and when 
 the opening is almost as large as the aljscess itself, we do not speak of 
 it as a fistula, but the opening together with the abscess is spoken of as 
 an ulcer. In the ulcer there is always a loss of substance, ex])osing the 
 deeper parts of the tissue unprotected by epidermis, and a chronic 
 inflammation of these deeper parts. The ulcer ordinarily arises in 
 
188 
 
 SURGICAL PATHOLOGY. 
 
 consequence of inflammiitiou or injury wliifli destroys the ])rotec- 
 tive surface and lays bare the tissiu's heucatli. The base and edges 
 of the ulcer have the properties of iuHanuuatory tissue, and in their 
 structure arc similar to tissue which lines the wall of an abscess. The 
 base of an ulcer, as a rule, is co^•ered with a soft reddish tissue w^ith 
 an uneven surface. Often the surface is covered with small eleva- 
 tions varying in size, which give it a granular appearance, and the 
 small elevations are called granulations. The tissue of which the 
 base of the ulcer is composed has received in consequence the name 
 of granulatit)n tissue, and the name has been extended to all similar 
 tissues even when there are no granulations present (Fig. 7). The gran- 
 
 Fio. 7. 
 
 
 
 Dense cicatricial tissue at the bottom of an old ulcer of the le^. The blood-vessels are numer- 
 ous, but are compressed by the surrounding tissue. 
 
 ulations are simply the small elevations. The same sort of tissue is 
 found in all sorts of chronic inflanniiations, and the name has been 
 extended to characterize a group of tumors closely related to intlam- 
 mation which have received the name of granulomata, because their 
 tissue is similar to the tissue found in the granulations of an ulcer. 
 These granulations appear to be composed of projecting masses of 
 blood-vessels with newly-formed tissue around them. Sometimes the 
 grantdations are exceedingly well marked, in other cases not. They 
 are in general best seen in ulcers of the skin. They are not pres- 
 ent, to any extent at least, in ulcers formed in the alimentary canal, 
 
ULCERATION. 189 
 
 and a deep-seated abscess-cavity does not contain them. Hamilton 
 has advanced u rather ingenious explanation for the formation of 
 these granulations : It is known that all liipiids and tissues of the 
 body are under a ceitain pressure, and the force exerted in the dis- 
 tention of the blood-vessels by the heart is opposed by the elasticity of 
 the tissue around the vessels, which prevents any marked degree of 
 dilatation. All the so-called cavities of the body, such as the peri- 
 toneum, pleura, and pericardium, have their surfaces in accurate ap- 
 position or are filled with some resisting material which counter- 
 balances the pressure of the blood. If an inflammatory exudation 
 takes place between the siu-faces of the pericardium, the pleura, or the 
 peritoneum, the transudation of fluid into the cavity goes on until 
 the pressure ui the cavity becomes ecpial to that of the blood-vessels 
 in the walls. Hamilton supposes that the granulations are formed by 
 the dilatation of the blood-vessels and their extension ujjward toward 
 the surface, where they are not opposed by the pressure of the tissue 
 over them. In this way, by tlie longitudinal extension of tlie vessels, 
 projecting loops would be formed. It is very probable that this lack of 
 pressure of the surrounding parts has much to do with the dilatation 
 of the blood-vessels which is found in a granulating surface and the 
 slow movement of the blood in the vessels. The effect of removal of 
 pressure is almost the same as would be jiroduced by placing the entire 
 hand in a vessel froni which the air is exhausted. All of tlie blood-ves- 
 sels would become more or less dilated, and there would be an increased 
 difficulty for the passage of blood from the part, while the flow of blood 
 to the pai't would be greatly accelerated and the transudation of fluid 
 greatly increased. It is not probable that Hamilton is right in consider- 
 ing that the granulations on the surface of a cutaneous ulcer are due 
 solely to tlie action of these influences on the normal blood-vessels, 
 because there are no such groups of blood-vessels in the skin to which 
 these granulations could conform. , It is 23rol)able, however, that the 
 absence of pressure has something to do with it. 
 
 The ulcer represents the best type of a chronic inflammation. The 
 tissue is deprived of its ]iroteeting epidermis, and is subject to a contin- 
 uous injury which will ])crsist until the covering of epidermis is again 
 restored. Tlie tissue is not only subjected to the constant action of irri- 
 tating substances, but also to drying. On the surface of the ulcer there 
 is always a more or less superficial layer of necrosis. In the necrotic 
 tissue and immediately below it there will be a variable luunber of pus- 
 cells. Tliese come not only from the normal blood-vessels of the part, 
 but the emigration also takes place in the same way from the blood-ves- 
 sels of the granulation tissue. The granulation tissue covers the entire 
 base of the ulcer and extends to a variable depth in the tissue beneath. 
 In places this extension into the deeper tissues is much more marked 
 than in others. The granulation tissue is comj)osed of small round cells 
 closely ])acked together, with very little intercellular substance. On 
 shaking tlic cells from a thin section little or no fibrilla-connective tis- 
 sue is found l)ctween tlie cells, but the cells are held together by a 
 mucoitl substanc'c. Blood-vessels are extremely numerous in these 
 granulations. They are dilated, the blood flows in them with com- 
 pai'ative slowness, and, in spite of the number of blood-vessels, it is 
 
190 SURGICAL PATIIOLOOY. 
 
 })r()bable that less blood fldws into the part, f<jr tlio siipjjly of the large 
 vascular area of the granulation \X'ssels is frecj[uently only a small artery. 
 
 Repair of Inflammation. 
 
 When the cause of the inflaniniation is temporary the inflamed part 
 returns very quickly to a normal eonditiwi. The vessels return to their 
 normal calibre, the leucocytes cease to accunuilate in the periphery and to 
 emigrate, and the stagnation of the blood in the dilated vessels passes 
 away. This may take place before any exudation has been formed. 
 When exudation has taken place, this may not disappear, and the 
 inflamed part cannot return to its normal condition because the presence 
 of the exudation itself produces more or less injury to the tissue, atfect- 
 ing its nutrition in various ways and acting as a cause of inflammation. 
 There is no difficulty in the remo\'al of the fluid portion of the exuda- 
 tion. It is simply taken up and absorbed by the lymphatics of the 
 part — a certain amount of it also by the veins. Even while the exuda- 
 tion is taking place there is increased absorption of the fluid, and an 
 inflammatory oedema or a serous exudation soon disappears \\hen the cause 
 producing it has disappeared, and no new exudation takes place. Even 
 the corpuscular elements of the exudation, and the fibrin as long as it is 
 present in only slight amounts, may disappear. The colorless corpuscles 
 can be removed in the same way as the fluids. They can enter directly 
 into the lymphatics. The few red corpuscles in the exudatic)n gradually 
 lose their coloring material and are dissolved, and even the fibrin itself 
 becomes changed into a granular emulsion which is taken up by the 
 lymphatics. These simple processes of restoration are much more diffi- 
 cult when the mass of the exudation is very considerable, as in a large 
 pleuritic exudation, an extensive pneumonia, or an extensive purulent 
 inflammation. A large exudation may even oppose mechanical diffi- 
 culties in the way of restoration of the integrity of the tissues. The 
 absorption of these large exudations makes great demands on the func- 
 tions of the lymphatics, especially in individuals in whom the force of 
 the blood- and Ij'mph-circulation has been weakened by inflammation. 
 In any case the restoration nuist take place very slowly, and it is better 
 to shorten the process of absorption whenever it is possible by artificial 
 removal of the exudation. The blood-vessels may be compressed by 
 the exudation, and the active circulation of blood in them necessary 
 for absorption may be prevented. When an exudation is solid, being 
 composed principally of leucocytes and fibrin, it must become in a 
 measure liquefied before absorption can take place. In acute croupous 
 pneumonia the exudation in the air-cells in consequence of fatty degen- 
 eration becomes converted into an emulsion, which can then be absorbed 
 by the lymphatics and blood-vessels of tlie lung or can pass into the 
 bronchi and be so removed. It is evident that the richer the exudation 
 is in solid elements, the slower it will be absorbed, and this holds espe- 
 cially for exudations composed of pus-cells. In this the reason for 
 artificial i-emoval is still more forcible, because not only is the absorption 
 of such an exudation more difficult, Init as long as the exudation con- 
 tinues, containing as it does tiie bacteria which produce it, it acts as a 
 further cause for inflammation. 
 
REPAIR AND REOENERATION. 
 
 191 
 
 When not removed the exudation may become changed into a yellow- 
 ish-white, more or less dry mass of about the consistency of cheese. This 
 is spoken of as the caseation of the exudation. It takes place preferably 
 in those exudations due to definite causes, as in tuberculosis and syphilis, 
 but it is not exclusively confined to these. Lime-salts may be deposited 
 in this dry necrotic tissue, and it can be converted into a solid or gritty 
 calcareous mass which must always remain in the tissue. It acts here 
 as a foreign body, and, as other foreign bodies, it will continue to excite 
 infiannnation around it. 
 
 When the exudation disappears by simple absorption by the blood- 
 vessels of the part, it is spoken of as resolution. In many cases the 
 normal circulation of a part will not be sufficient to effect the removal 
 of the exudation, and new tissue and new blood-vessels must be formed 
 before the exudation can be removed. This is spoken of as the organiza- 
 tion of the exudation : it is seen best on serous surfaces. When there 
 
 Fig. 8. 
 
 
 Formation of connective tissue in blood-clot. (The specimen was obtained from Dr. Halstead.) 
 The clot first becomes infiltrated with Ic icocytes, and formation of tissue takes place, proceed- 
 ing from the deeper tissue: a, young connective-tissue corpuscles; b, leucocytes; c, uewlv- 
 lormed blood-vessel. 
 
 is on the surface of the pleura a fibrinous exudation which reaches any 
 considerable extent, it becomes organized. Beneath the exudation there 
 is a regenerative new formation of ti.ssue which takes place from the 
 normal tissues. In this a tissue similar to the granulation tissue at the 
 base of the ulcer is formed. New blood-vessels are developed in this, 
 
192 SURGICAL PArilOLOGY. 
 
 whicli project upward into the fibrin. The formation of granulation 
 tissue continues along these blood-vessels, and tinally a young connective 
 tissue is formed, the exudation disappearing as this takes its place (Fig. 8). 
 In cases of inflammation of serous surfaces tlie same cause which pro- 
 duces the inflammation on one surface will act in producing an inflam- 
 mation on the surface which it touches. When organization takes place 
 a direct union by means of young connective tissue is formed betM'een 
 the two surfaces, and produces adhesions which may give more or less 
 trouble in after life. The adhesions which are so frequently found 
 between the visceral and parietal i)leural surfaces are due to a preceding 
 inflammation, which may have been of such a slight character as to have 
 given rise to no symptoms and not to have been recognized during life. 
 The exudation may in every place undergo organization ; even in acute 
 croupous pneumonia the exudation within the air-cells of the lung may 
 in certain cases undergo organization in the same manner as tlie exuda- 
 tion on a serous surface, and there \\ill always remain in the alveoli of 
 the lung the newly-formed connective tissue. In inflammation which 
 takes place in the parenchyma of organs the exudation may be in part 
 removed in the same way, and a new tissue be formed which will not 
 completely disappear. A certain amount of this new formation of 
 tissue takes place in nearly all inflanunations, and its presence may 
 serve to indicate a preceding inflammation even when the exudation has 
 disappeared. 
 
 In the repair of inflammation, in the restoration of the tissues to 
 their normal integrity, not only must the exudation be removed, but 
 the injury of the tissue which has been the cause of the inflannnation 
 in the first place must be repaired. In any inflammation there is always 
 a destruction of tissue, and the tissue destroyed must be replaced by 
 a new formation of tissue. This begins early, and may be seen while 
 the inflammation is advancing. The new formation of tissue may be 
 better studied in slight injuries of the cornea than elsewhei'e, and liere 
 the two processes, the vascular phenomena with the formation of the 
 exudation and the new production of tissue, can be considered separately. 
 When the loss of tissue is very slight, and when the action of the injury 
 which caused it subsides at once, inflammator}' phenomena M'itli exuda- 
 tion and emigration do not necessarily take place. In the ordinary 
 physiological processes of life, and in all tissues, there is constantly 
 taking place a loss of material which is supplied without any inflam- 
 matory phenomena. The power of the tissue to sujjply a loss is greater 
 than is ordinarily called for, just as in the circulation there is a reserved 
 force in the power of the heart which can meet all ordinary conditions 
 called for, and even extraordinary conditions, by an increased muscular 
 action. In all the tissues of the body there is a greater power of repair 
 than is ordinarily called for. But in the tissues, as in the circulation, 
 this reserve force has its limit. The destruction of any considerable 
 amount of tissue is always followed by inflammation. Even when the 
 cause which produces the injury subsides at once, still the injured tissue 
 itself will act as a sufficieut cause. When a cornea is touched with the 
 end of a thread saturated with sulphate of zinc, a very limited injury 
 will be produced. This is followed by a new formation of cells in the 
 territory immediately around the injury, to take the place of the cells 
 
REPAIR ASD REGENERATION. 193 
 
 which liave been destroyed. Tliis new formation of cells begins forty- 
 eigiit hours after the injury, and the same phenomena of cell-division 
 take phice that we find in eell-di vision anywiiere. The nuclei nf tlie 
 cells divide by karyokinesis. Long processes are formed which extend 
 up into the neci'otic tissue, and the nuclei from the old cells travel up 
 into these. In many cases there seems to be a difference in the regen- 
 eration of tissue, depending upon the degree of destruction. In the 
 minor degrees of injury, where only the cells themselves are destroyed, 
 there is simply a new formation of cells having the same <'haraeter 
 as the old, witiiout any intermediate stages. In one point the jiatiio- 
 k)>jical rcoeneration of tissue differs materiallv from the ph\siolo"ical. 
 It is frequently not confined to a simple restoration of the tissue lost, 
 but the amount jJi'oduced widely exceeds this. In inflammation of the 
 skin there is often an excessive epithelial growth, and scars may be 
 ]irodaced from the connective-tissue regeneration which at first pro- 
 ject beyond the level of the skin and appear as red elevations. In the 
 inflammatory regeneration of bone more callus is produced than is neces- 
 siiry for the supply of the portions of bone which have been lost. The 
 power of regeneration is different not only in the different tissues of 
 the body, but also in different animals. The higher the organization and 
 the greater the differentiation of tissue, the less is the power of regen- 
 eration, which is greater the younger the animal and tlie nearer it comes 
 to an emljryt)nic ccmdition. In some of the lower animals, as the Crus- 
 tacea, an entire part may be removed, and it may be completely re-formed. 
 In the frog the power of regeneration is much more marked in the tad- 
 pole than in the adult. When the tail of the tadjiole is removed an 
 entire new production of tissue will take place. The different tissues 
 also show different powers of regeneration after loss. The more C(im- 
 pletely diflerentiated the tissue and the farther it is removed from an em- 
 bryonic condition, the less is the power of regeneration. In some tissues 
 it is probable that there is no new formation of cells, and only the 
 portions of the cells which have l)e(>n used u]) by tlie physiological ])ro- 
 cesses will be restored. After injury in the central nervous svstem there 
 is no new formation of nerve-cells. The same thing is true to a more 
 limited extent in the striated muscles. Any loss in these tissues is sup- 
 plied by a gro^vth of connective-tissue elements. In certain of the 
 glandular organs the power of regeneration is greatly limited. 
 
 The new formaticjn of connective tissue in inflammation does not 
 always take the form of a pure regeneration. In the place of the nor- 
 mal connective tissue a somewhat different tissue is formed, which is 
 designated as cicatricial tissue. This cicatricial tissue differs from the 
 normal connective tissue in the paucity of its cells and blood-vessels 
 and in the density of .its intercellular substance (Fig. 7). The charac- 
 ter of the intercellular substance seems to be similar in general to white 
 fibrous tissue, but its exact character has never been fully made out. 
 The fihrillie are more firmly interwoven together, and cannot be sepa- 
 rated so easily as they can in white fibrous tissue. In some inflammations, 
 especially in the more chronic, the new formation of connective tissue 
 may so greatly exceed the necessary amount to su])ply the defect, and 
 form so ])rominent a part of the inflammatory process, that inflamma- 
 tions of this character have received a different name and are known as 
 
 Vol. I.— 13 
 
194 SURGICAL PATHOLOGY. 
 
 productive inflammations. The excessive amount of connective tissue 
 wliich is formed may often exert a deleterious influence ou the future 
 life and the functions of the inflamed part. 
 
 In order tliat any new formation of tissue may take place new blood- 
 vessels are necessary. TJie okl l)lood-vessels of the part wiiere tiie new 
 tissue is to be formed have been destroyed to a great extent, and multi- 
 plication of cells will not take place except under tlic Ijest conditions of 
 nutrition. If I'cgeneration to any extent takes place in non-vascular 
 parts, these become vascular. In any extensive injury of the cornea 
 new blood-vessels grow into the tissue from the sclera in a comparatively 
 short time. In man ulceration of the cornea is always followed by a 
 vascularization of the portion of the cornea between the ulcer and the 
 sclera. These new blood-vessels are formed from the old. The for- 
 mation takes place by direct outgrowth from the old vessels. In this 
 formation both tiie endothelium of the vessels and the connective-tissue 
 cells in the neighborhood of the vessels take part. The process is the 
 same as in the new formation of blood-vessels in the embryo. It can 
 be well studied in the regeneration of tissue which takes place after cut- 
 ting otf the end of a tadpole's tail. The first thing which seems to take 
 place is an enlargement of the endothelial cells of tiie vessels. These 
 become large, filled with protoplasm, and long projections extend into 
 the neighl)oring tissue. The nucleus of the cells divides, and nuclei 
 pass up into the projection in very nuich the same way as in the regen- 
 eration of the cells of the cornea. Tlie connective-tissue cells in the 
 vicinity enlarge, and arrange themselves cither alongside of the projec- 
 tion from the endothelium or as a continuation of this. In this way 
 pointed processes of some length are formed. These meet with similar 
 processes from the same vessel or from neighboring vessels, and in this 
 way loops are formed which are at first solid. These solid processes are 
 gradually iiollowed out and l)ccome continuous with the lumen of the 
 vessel. In some cases the lumen of the vessel gradually follows the 
 formation of the sprout. In other cases loops are formed before the 
 communication with the lumen of the vessel takes place. In this new 
 formation of blood-vessels there must be a process somewhat similar to 
 chemotaxis. In the cornea the blood-vessels are always formed from 
 that portion of the sclera which is nearest the ulcer, and they show no 
 tendency at all to extend anywhere but into the cornea. In the fonna- 
 tion of the loops there must be also a mutual attraction for the cells, 
 because the meeting of the pointed process from the same or from 
 neighboring vessels, and the resulting formation of loops, cannot be 
 regarded as a matter of chance. This new formation of vessels always 
 proceeds from the capillaries, and the newly-formed vessels are always 
 of this character. They function as the old vessels. When the inflam- 
 mation continues emigration takes place from them as readily as, or 
 more readily than, from the old vessels. They are more easily dilated, 
 and when dilated the dilatation frequently persists for some time. Later, 
 these vessels may become differentiated into Iroth arteries and veins, but 
 the manner in which this differentiation is ])roduced has not been fully 
 made out. Other modes of new formation of the vessels have Ijcen 
 described. According to some authors, the cells in the inflamed part, 
 the cells of the tissue, may collect together in rows and may become 
 
REPAIR AND REGENERATION. 
 
 195 
 
 changed into enclothelial cells, and a communication be established be- 
 tween the old vessel and the newly-formed ; or large cells of the tissue 
 may become holIo\\cd out and "in this way new cells are formed. 
 
 Fig. 9. 
 
 
 :9, 
 
 ^& 
 
 
 ^>,^;^,g ^'Ojo.: i:.-v.-.,--u. 
 
 ';^/^r£.r^..:-'D. 
 
 Hi^iiiiSi 
 
 a 
 
 
 Section through a portion of a suture which had remained in the tissue eleven months. The 
 suture first becomes infiltrated with leucocytes, and the formation of connective tissue takes 
 place as in Fig. 8. The section represents only a fragment of the suture : a, a, silk flbrillse 
 surrounded by dense connective tissue; 6, 6, giant-cells enclosing iibrillae. 
 
 Strieker believes tliat not only are new vessels formed from the cells in 
 this way, but that there may be a new formation of red corpuscles in 
 the.se vascular cells in the same way as in the embryo. The essential 
 cause of the new formation of blood-vessels and the influence which 
 leads to it are obscure. We know only, in general, that they are formed 
 in accordance with the law of nutrition — that where more blood is 
 required for a part it will be given, either by a dilatation of the old 
 vessels or, if this be hot sufficient, by a new formation of vessels. 
 
 There has been considerable controversy with regard to the participa- 
 tion of the leucocytes in the new formation of tissue. Cohnheim be- 
 lieved that not only were all the cells found in an inflamed part leuco- 
 cytes, but that any new formation of tissue takes place from leucocytes. 
 He was led to this belief by a number of experiments. He showed 
 that there could be a new formation of tissue in parts in which all the 
 living cells were destroyed by boiling and which were afterward placed 
 in the peritoneal cavity of animals. The tissues became filled with 
 
196 SURGICAL PATHOLOGY. 
 
 leucocytes which ■wuiidcn'd into tiicm, and, as a iiewly-foriuecl connec- 
 tive tissue witli blotxl-vessels was afterward found in the tissue, he 
 believed that this new formation must take place from leucocytes. Some 
 experiments which Ziegler made on this siihject seemed to \w at first con- 
 clusive. He enclosed two thin jtlatcs of li'lass with a ca])illary space be- 
 tween them in the siibcntancous tissue or in the peritoneum of an animal, 
 and found that a thin laniclla of connective tissue was formed l)etw('cn 
 the plates (Fig. 9). The first thing seen in such conditions is a filling 
 up of the spaces between the plates with leucocytes and fibrin. After- 
 ward large cells with a round nucleus and a large amount of protoplasm 
 appeared, and from these large cells the formation of connective tissue 
 takes place, either by a diflt'erentiation of the body of the cell into fibrous 
 tissue or by a sort of secretion from the cell. The exact method in 
 which this formation takes place has not been fully made out. Ziegler 
 supposed that these large cells were produced directly from the leuco- 
 cytes, but a repetition of his work by other observers has shown that 
 they, like the leucocytes, wandered into the glass cell from without. In 
 any ease the new foriuation of tissue seems to take place from the 
 large protoplasmic epithelioid cells (Fig. 8). The leucocytes probably 
 take a part in the process, but only a passive one. Many of these 
 large cells are phagocytic in character, and it is probable that the leuco- 
 cytes play a distinct part in furnishing them nutrition, being taken up 
 and devoured by these large connective-tissue cells. 
 
 Sometimes there is in this way new formation of cells from the old, 
 which simply supplies the tissue which has been lost. In this new for- 
 mation of cells all of the tissues can take part. It is proliable that the 
 cells most actively concerned in it are the cells of the small blood-ves- 
 sels. In other cases there is not an immediate formation of cells from the 
 cells of the old tissue, but tliere are intermediate steps. The new tissue 
 is not formed directly from the old, Init tliere is a formation of granula- 
 tion tissue first. In the cornea, for instance, if the loss of substance is 
 extremely small, it may be supplied by a simple new formation of cells ; 
 if larger, there will be a ])receding formation of granulation tissue. 
 Some of the granulation cells will afterward ditferentiate themselves 
 into tissue-forming cells. The tissue which is formed in this way from 
 the granulation tissue is never so perfect as that formed directly. It 
 always approaches the character of cicatricial tissue. The ])rocess of 
 regeneration of tissue can also be studied on the ulcer, and in the 
 ulcer we can also study the local conditions which may interfere 
 with this regeneration. In the ulcer the regeneration of tissue nuist 
 take place in two directions. There is not only a new formation 
 of necessary tissue from the connective tissue, but a new f\)rniatioii 
 of epithelium must also take place. Until the surface is covered 
 over Avith epithelium it nuist be constantly subjected to various trau- 
 matic influences wliich will keep up the inflammation. If the ulcer 
 is small and the local conditions favorable, the epithelium will grow in 
 from the edges, cover over the surface, and the inflammation will sul)side. 
 This new formation of epithelium takes place solely from the surround- 
 ing epithelium. It has been supposed by many that a new formation 
 of epithelium may take place from the granulating surface of the ulcer. 
 The proof of this was supposed to be shown in the fact that the growth 
 
IXFLAMMATION. 197 
 
 of cpitlielium does not always prow't'd oveiily from the edges, but small 
 islands of epitlielliim are sometimes formed in the middle of the uleer, 
 and from these a growth extends upward to the edges. These small 
 islands which are formed in the centre of an ulcer do not represent a 
 new formation of epithelium from the edges of the ulcer, but are the 
 remains of epithelial tissues, such as sweat-glands or the sebaceous 
 glands of the skin, wliich were not entirely destroyed by the injury 
 whicii produced the ulcer. An ulcer never heals by a simple process 
 of tissue-formation, such as is seen in the cornea, but there is always a 
 formation of granulation tissue, and from this the regeneration proceeds, 
 leading to the production of cicatricial tissue. The amount of cicatri- 
 cial tissue varies with the extent and duration of the ulcer. It is 
 exceedingly dense, firm, and contains few bhiod-vessels. It may extend 
 into the surrounding tissues for a considerable distance beyond the actual 
 seat of the ulcer. In the most common seat of ulceration, the anterior 
 surface of the lower leg and ankle, there are numerous local conditions 
 wiiich interfere with the process of healing. In the first place, the 
 ulceration is constantly repeated at the same spot. The tissue is not 
 normal, it has not the normal vascular supply, and it reacts to injuries 
 more easily. Not only is there this abnormal tissue with weak vascular- 
 ization, but the ulcers usually arise in persons who have a local passive 
 congestion. In the process of healing the new formation of blood-ves- 
 .sels does not so readily take place. As we have seen, in spite of the 
 apparent vascularization of the tissue of the nicer, it is really poorer in 
 blood-vessels. Frequently, healing will not take place until the dense 
 cicatricial tissue resulting from a series of old ulcers is removed in toto, 
 or until incisions be made through it so as to allow vascularization to 
 take place from the deeper and more healthy tissues beneath it. 
 
 The Effect of Inflammation on the Body as a Whole. 
 
 The objection was early made to the theor}' of inflammation of Cohnheim 
 that all of the cells found in the inflamed part could not come from the 
 blood, because there were not enough cells in the blood to produce these. 
 In an acute fibrinous pneumonia one entire lung and a portion of the other 
 may lie so filled uj) with tJie inflanunatory exudation as to resemble a 
 .solid mass and to sink in water. The consolidation of the lung is due 
 in large part to an accumulation of leucocytes, and in a case of advanced 
 pneumonia the number of leucocytes in the lung could not be estimated 
 by numbers, but by pounds. The same thing is true in the large puru- 
 lent exudation which we find in empyema or in peritonitis. There 
 are at no time enough leucocytes in the blood to form such masses 
 even if all of them could be tpken u]). It was supposed also that 
 after the leucocytes had emigrated from the vessels they multiplied, 
 and that many of them could he newly formed from those whicli at 
 first emigrated. In speaking of this Cohnheim says that in general 
 we can form little idea of the number of leucocytes in the blood from 
 microscopic observation, because large luunbers of leucocytes break up 
 and disajipear the moment the blood is taken on the slide for examina- 
 tion. He also suggests that there may be a new formation of leuco- 
 cytes in the blood, and an increase in their number due to this. He 
 
198 SURGICAL PATHOLOGY. 
 
 called attention to the enlargement of the lymphatic glands and spleen 
 frecjuently seen in acute inflammation, and supposes that this may in 
 some way stand in relation to the number of leucocytes found in 
 the exudation. Cohnheini, however, made no estimate of the supposed 
 increased number of leucocytes in the blood. As early as 1842, Gul- 
 liver called attention to the similarity between the pus-eells and the 
 leucocytes, and thought that in inflammation the white corpuscles of the 
 blood were increased ; and he instances a case in which, in a stallion 
 which had a large abscess, the white corpuscles of the blood were almost 
 as numerous as the red. Virchow also, in his study of the blood in Icu- 
 cicmia, recognized the fixct that in most acute inflannnatioiis, especially 
 if they were at all extensiv'e, the white corpuscles of the blood increased 
 in number. He supposes that this is due to the fact that the lymph- 
 glands and other blood-forming organs undergo a stimulation which 
 excites them to an increased activity. We know now that in any inflam- 
 mation, and especially in an infectious inflammation characterized by 
 extensive exudation and emigration, the white corjiuscles arc increased. 
 It is only recently, when the study of the corpuscular elements of the 
 blood has received great attention, that the extent and importance of this 
 leueocytosis have been recognized. The leucocytosis keeps almost an exact 
 pace with the fever and the extent of the exudation. In croupous jineu- 
 monia we liave the greatest extent of leucocytosis, and the number of 
 leucocytes in the blood may be double or treble that of normal. The 
 leucocytes which are found in increased number are exclusively of the 
 polynuclear variety. The feet that in inflammations uncomplicated with 
 hyperplasia of the lymphatic glands there is no increase in the mono- 
 nuclear leucocytes speaks against the emigration of these and their taking 
 part in the exudation. The uKinonuclear leucocytes are increased in 
 tyjihoid fever and in other processes connected with a lymphatic hyper- 
 ])lasia. The recognition of a ]>olynui-lear leucocytosis in the blood is 
 frequently of great importance in determining the character and extent 
 of inflammation. Wc find other changes in the blood in addition to the 
 leucocytosis, but they jirobably depend in large measure ujion this. If 
 the inflammation is suiticiently extensive and lasts long enough to inter- 
 fere M'ith the general nutrition of the liody, a diminution in the number 
 of red corpuscles may take ])lace. In acute inflammations, especially 
 when connected with an extensive leucocytosis, there is an increase in 
 the fibrin of the blood. This has long been known, and M'as formerly 
 used as a diagnostic means for recognizing the extent and character of 
 an inflammation. Although the fibrin is increased in the Idood in 
 inflammation, it coagulates more slowly. Tliis slow coagulation of the 
 blood allows the red corpuscles to sink from the surface of the blood 
 before coagulation takes place. As a result of this, on the surface of 
 the clot there is a layer of coagulation which has a buify or straw color. 
 This is known as the buify coat of the blood, and in the old days of 
 bloodletting a great deal of imjiortance was attached to it. Fever is a 
 frequent accompaniment of inflammation. 
 
FEVER. 199 
 
 II. FEVER. 
 
 Fever can well be considered in connection witii inflammation, for 
 it is an almost constant accom])animeut of it, and the etfect on the general 
 organism of a local inflammation is shown first of all in the production 
 of fever. In fever the normal temperature of the body is increased. 
 Usually this increased temperature is accompanied by other abnormal 
 conditions, but these are not necessary to the condition. Observations 
 on normal individuals sIkjw that the temperature of the body, in spite 
 of variation in the surroiniding temperature and in spite of all sorts of 
 changes in the external conditions of life, has a medium value of 37.2° 
 to 37.4° C. The absolute variations in the course of the day may be 
 from 1° to 2.5° C. The body is able to maintain such a temperature, far 
 above tliat of the surrounding medium, only by the production of heat 
 by means of chemical processes taking ]ih\ce in the tissues. The produc- 
 tion of heat is oftset by a discharge of heat, which takes place by means 
 of the skin, the lungs, and the various excreta of the body. Ordinarily, 
 the production of heat and the discharge of heat are so evenly balanced 
 that the temperature of the body remains the same in all conditions. 
 
 The Production of Heat. 
 
 The various chemical processes which take place in the body are 
 accompanied by the production of heat. At every muscular contraction, 
 in all the processes of glandular secretion, heat is produced. Of all the 
 tissues of the body, the muscles, not only from their bulk, forming as 
 they do a large part of the whole frame, but also from the character of 
 their metabolism, must be regarded as the ciiief source of heat. Not only 
 is heat produced in the contractions of the muscles, but during their 
 quiescent period metabolic changes are taking place in them by which 
 heat is produced. Next in importance to the muscles are the various 
 secreting glands. Tlie secreting elements of the glands in the periods of 
 secretion, and pi'obably in the cpiiescent period, are in a state of meta- 
 bolic activity which must give rise to heat. In the case of the salivary 
 gland the temperature of the saliva secreted during stimulation of the 
 chorda tympani is 1° to 1.5° higher than that of the blood in the carotid 
 artery. The blood in the hepatic vein is the warmest in the body. In 
 the dog a temperature of 40.73° has been observed in the hepatic vein, 
 while tiiat of the vena cava was 38.35° and tliat of the right lieart 37.7°. 
 The brain, too, may be regarded as a source of heat, since its temjierature 
 is higher than that of the arterial blood with which it is supplied. The 
 other tissues of the body also serve as sources of heat, but the part they 
 play is insignificant as compared with the muscles and glands. 
 
 The increase of temperatui-e of the bfxly in fever may I)e due to 
 either of two conditions : There may be increased production of heat, 
 the discharge being the same or even increased, or, the production being 
 the same, the discharge of heat may be reduced. One of the best 
 known of the theories of fever was that advocated by Traube. Accord- 
 ing to his views, there was no increased production of heat, but the 
 increased temperature was due to a decrease in the discharge of heat. 
 The discharge of heat lie supposed to be least in the earlier period of 
 
200 SURGICAL PATHOLOGY. 
 
 fevor and increased in tiic (icf'crv<'8eence. A great deal of work lias been 
 done to determine wlietlier there is increase of heat in fever, and its 
 degree. Various methoils have been used to determine this. The heat 
 being the residt of eheniieal elianges in the body, it was sought to deter- 
 mine if these chemical ciianges were more active in fever. It is known 
 tiiat most fever patients lose weight and that there is increased consumji- 
 tion of tissue. Tiic urea is increased, and for a long time it was believed 
 that the increased excretion of urea att'ordcd satisfactory evidence of 
 increased oxidation and incrmscd production of heat. Of late years 
 investigations have been made upon the consumption of oxygen and the 
 ])roduction of carbonic acid in fever, and it is found that there is an 
 increase in the amount of oxygen consumed and in the carbonic acid 
 given off. In the Ix'ginning of fever, when the temperature is con- 
 .stantly rising, both of these processes are most active ; during the stage 
 of defervescence the consumption of oxygen may fall below the normal. 
 It has been claimed that the increased oxidation was not the cause of the 
 fever, but simply resulted from the increased temperature of the body. 
 Although it is true that there is an increase of oxidation in increased 
 temperature, the elevation of the temperature 1° C. would only increase 
 the oxidation 3.3 per cent., while in fever the oxidation may be increased 
 l."J-15 per cent. Although it has been generally accepted that in fever 
 there is increased oxidation of tissues and increased production of heat, 
 this alone would not be sufficient to explain the high tem])crature. The 
 increase in heat-production in fever is far less than would take ])lace in 
 an individual making active muscular movements in a cold environment. 
 In health the increased heat-production is met by a correspontling dis- 
 charge of heat, so that it has no effect on the body temperature. The 
 loss of heat in fever has been investigated by direct calorimetry. The 
 discharge of heat is least during the initial stage of fever, and increases 
 during the stage of defervescence. During the hot stage the discharge 
 of heat exceeds the normal, but usually, on account of the dryness of 
 the skin, is not so great as might be inferred from placing the hand on 
 the surface. In the febrile chill not only is the discharge of heat by the 
 contraction of the vessels of the skin reduced to a minimum, but heat- 
 production is excited to the utmost. As the result of the work of most 
 investigators it may be said that in fever both heat-jjroduction and heat- 
 discharge are increased. 
 
 Recently, Rosenthal, %\hi) has investigated this question by means of 
 a specially constructed air-calorimeter, using animals in whom fever was 
 produced by the injection of various substances into the circulation, has 
 returned to the view of Traube. He finds that in the initial stage of 
 fever and in the stage of gradual increase of temperature the discharge 
 of heat is diminished and there is no increased production of heat. 
 When the fever has lasted a considerable time there is a return to the 
 normal discharge of heat. The diminution in the discharge of heat he 
 thiidis is due to sudden changes in the circulation of the skin brought 
 about by vasomotor influences. In the stage of defervescence the dis- 
 charge of heat is greatly increased, and al)out corresponds to the decrease 
 in the temperature. 
 
 If the regulatory mechanism were normal, the discharge of heat in 
 fever would be increased in proportion to the increased production and the 
 
FEVER. 201 
 
 temperature would he unaltered. The regulating mechanism, although 
 jjrofoiindly disturhcd, is not jjaralyzed in fever. External cold in f'e\er 
 to some extent stimulates the heat-produetiun, but not nearly to the same 
 extent as in health. A person in te\-er is not able to maintain his tem- 
 perature under the influence of heat and cold to the same extent as a 
 person in health. It is not merely, as some have sujiposed, that the 
 regulatory mechanism is set for a higher degree (jf heat, but that it is 
 disturbed. In both health and fever tlie regulatory mechanism is under 
 the control of nervous inHueni'c. This acts through the vasomotor 
 nerves jiresiding over the sujjerticial parts of the body, and Ijy producing 
 variations in the calibre of the cutaneous vessels controls in great meas- 
 ure the discharge of heat. The jiersjjiration which plays so great a part 
 in the discharge of heat by evaporation is also under the influence of the 
 nervous system. Heat-regulation is effected not only by means of varia- 
 tions in heat-discharge, but heat-production is also under the influence 
 of the nervous system. In a cold atmosi)here more heat is produced, 
 and in a warm less heat, provided the external temperature is not so 
 high or so low as to make it impossible to preserve the body tempera- 
 ture. To regulate the temperature simply by the discharge of heat 
 would be like regulating the temperature of a room by opening the 
 doors and windows and paying no attention to the furnace. There is 
 every reason to believe that nervous impulses control chemical changes 
 which result in the production of heat independently of visible altera- 
 tions of the tissues, so that heat-production is in considerable part under 
 the control of the nervous system. The nerves controlling the produc- 
 tion of heat are known as thermic nerves, and they ai'c controlled by cen- 
 tres in the brain. The chief of these centres is in the nucleus caudatus, 
 and if this centre is stimulated by puncture with a needle or by electri- 
 cal stimulation, fever, often reaching several degrees above the normal, 
 will result. A number of cases have been collected in which fever re- 
 sulted in man from injuries involving these centres in the brain. It is 
 very probaljle that fever may lie the result of the stimulation of these 
 centres in the brain by pyrogenic substances in the blood. Opposed to 
 this is the hiemic thecny, which assumes that the increased temperature 
 is due to the direct action on the tissues of pyrogenic substances con- 
 tained in the blood. After puncture or stimulation of the caudate 
 nucleus of animals they present all the phenomena of fever. There is 
 increased heat-production, with increased consumption of oxygen, and 
 the heat-regulaticin is also interfered with. 
 
 Liebermeister regarded all tlie phenomena of fever, the changes in the 
 pulse, respiration, etc., as due simply to the eftect of the increased tem- 
 perature. He urged that the weakness of the heart, which is undoubt- 
 edly one of the most -serious dangers in fever, was due to the increased 
 tem])erature, which caused parenchymatous and fatty degeneration of the 
 cardiac muscle. According to his views, the one great indication in 
 treatment was to lower the temperature of the body. Of late there 
 has l)een a reaction against these \iews of Liebermeister, which reaction 
 has in part been brought about by the fact that antipyretic drugs may 
 reduce the temperature, but may not affect the other phenomena of" 
 fever. Some authors have gone to the extent of not only denying that 
 there is danger in temperatures whidi do not exceed a very high point, 
 
202 SURGICAL PATHOLOGY. 
 
 hut of" stating that the elevation of temperature in itself may be a benef- 
 ieent provision of nature in warding off the effects of disease. It is 
 obvious that the effects of high temperature cannot be studied in the 
 fevers of man nor in the artificial fevers produced by the injection of 
 various substances into the blood. The effects of the temperature must 
 be separated from the effects produced on the tissues by the agents wiiich 
 cause the increase in temperature. The eflects of temperature alone 
 have been studied by subjecting animals to a high temj)erature. Some 
 of the earlier experiments have seemed to bear out Liebermcister's view 
 of fever. It was found that animals whose temperatures were artificially 
 raised to 40.-5° or 41.7° C showed evidences of illness. All experi- 
 menters agree that a mammalian animal dies when its temperature is 
 raised to 44° or 45° C. Death is preceded by convulsions, and rigor 
 mortis develops almost immediately after death. Death in these cases 
 has been attributed to heart-paralysis due to lieat-rigor, but it is known 
 that heat-rigor does not take place at such tenijieratures. In all of the 
 cases in Mhich death took place after keeping the animal for some time 
 at a temperature of 40.5°-41° fatty degeneration of the heart was found. 
 The most complete set of experiments on the influence of high tem- 
 perature alone was made by Welch at the Johns Hopkins Hospital. In 
 all the jirevious experiments the animals were kejit in small, dark, badly- 
 ventilated boxes, and the influence of the high temperature was assisted 
 by the bad surroundings of the animals. In Welch's experiments the 
 animals were kept in a large box partially closetl at tiie top by a blanket. 
 The box was surrounded, except at the top, by a layer of water. The 
 animals were supplied with an abundance of green food and water, 
 which they took greedily. He succeeded in keeping two large black 
 rabbits for two weeks with an average rectal temperature in one of 
 41.4° C. and in the other 41.8°. The animals lost weight while in the 
 box in spite of their abundant food, but otiicrwise seemed perfectly 
 well. He found considerable differences in different individuals in 
 their capacity of withstanding high temperatures, and thinks, in gen- 
 eral, that black rabbits are more resistant than white. In all cases, 
 after keeping the animals for some time, extensive fatty degeneration 
 of the heart, liver, and kidneys was found. He is not inclined to 
 attach so much clinical imi)ortance to the fatty degeneration of the 
 heart as some have done. In a series of experiments which he made on 
 animals in whom fsitty degeneration of the heart had been produced by 
 heat he found that the blood-jjressure was kej)t at the usual height, and 
 the heart reacted to nervous stimulation in the usual way. In one case 
 he observed tlie contraction under the microscope of some fibres of 
 heart-muscle in which the fatty degeneration was so advanced that no 
 striation could be seen. He thinks from this that the effect of fever on 
 blood-pressure is not due to increased temperature alone, but to other 
 factors. Animals which had been rendered ana?mic by bleeding were 
 more affected by increased temperature than normal animals. Animals 
 with an artificially increased temperature had their cajiacity for temper- 
 ature regulation disturbed, so that they were more suscej)tilile to the 
 effects of heat and cold than normal animals. The various fevers differ 
 materially in the eflects jiroduced. In rclajjsing fever temperatures can 
 be withstood which in typhoid fever or pneumonia would be fatal. 
 
FEVER. 203 
 
 In fever the frequency of respiration is increased. This has been 
 atti'ibuted to tlie direct etJ'ect of tlie heated l)lood ii])on tlie respiratory 
 centres in the meduHa. The experiments of Goklstein made in Fick's 
 laboratiny are <ienerally quoted as completely settling this point. He 
 surrounded the carotid arteries with tubes in which hot water circulated, 
 and found the respirations increased. In order to produce any appre- 
 ciable increase of temperature in the blood rapidly flowing tlirougli the 
 artery, l)y exposing the vessels for a space of a few cm. to warmer sur- 
 rounilings, tlie tube around the vessel would have to be very h()t, and 
 a high temperature in the surrounding tube woukl have so injured the 
 vessel that coagulation would take place. Sihler repeated tke experi- 
 ments of Goldstein, and concluded tliat the increase in the respiration 
 was not due to heating tlie blood, but to stinudation of tke peripkeral 
 nerves. AVelck found that in tlie hot box animals with a surrounding 
 temperature of 32°-35° C. often preserve tlieir normal temperature, 
 though the respirations .are increased. When animals with fever are 
 taken out of the box the respiration often decreases before the temper- 
 ature falls. The increased frequency of the heart's action is due to the 
 direct action of the heated blood on tke cardiac muscle. Tkis lias been 
 shown by Martin on the isolated mammalian lieart. Wken the heart 
 is fed with blood of gradually increased temperature, the rapidity of 
 the heart uj) to a certain degree keeps pace witk the increased temj)er- 
 ature. The heart continues to beat when supplied with blood of a 
 much higher temperature than is found in fever. The nervous phe- 
 nomena of fever cannot be attributed to the effect of high temperature 
 on the nervous centres, for the effect of fever on the nervous centres 
 may be entirely absent in relapsing fever and in the asejjtic wound- 
 fever. 
 
 Fever may be due to an infinite number of causes. In general the 
 fevers are divided into the symptomatic and the essential, though no sharp 
 line can be drawn between the two. In the symptomatic fevers it is 
 assumed that there are local lesions soinewkere in tiie body from which 
 substances are produced which when absorbed cause fever. At one time 
 there was a theory that in an intlanunatory focus there was a direct pro- 
 duction of heat, and fever was the result of this local heat-formation. 
 In a strict sense there are no essential fevers, and the distinction is a 
 purely artificial one. Fever is generally due to the jiresence in the 
 blood of substances which are ca}>able of causing it, and to which the 
 name pyrogcuic has been given. A great deal of work has lieen done 
 of late in the investigation of these substances. Most of the normal fer- 
 ments of the body, particularly fibrin-ferment, may give rise to fever 
 when injected into the blood. Of great interest in this connection is the 
 aseptic fever which was described by Volkmann. It follows injuries to 
 the tissue in which there is no ])ossible infection. Nothing shows more 
 clearly the line which should l>e drawn between the high temperature 
 and the other phenomena of fever. Tiiis aseptic fever has no prognostic 
 importance. In a case of subcutaneous fracture, with extravasation of 
 blood into the tissues, temperatures of 40° C. or over may be seen without 
 any other phenomena of fever save slightly increased pulse and resjii- 
 ration. 
 
 Absorption of perfectly ase|)tic products of tissue-necrosis will give 
 
204 SURGICAL PATHOLOGY. 
 
 rise to fever. Gaiifrolplie and C'onmiont have sliown that the injection 
 of the fjerm-free tissue-jiiiee from j^anijrenous tissues is in a hiu;h dcg'ree 
 pyrojrenic. They also prixhiced net^-osis in the testicle by means of a 
 IJiiatMre, and fonnd tliat the fluid of tlie necrotic tissue produced fever. 
 Tile jMiwer of filiiiu-fcrnient in producing fever is well known. Any 
 sulistance which will give rise to it acts as a pyrogenic agent. Thus 
 water injected into the blood will give rise to fever. It lias been clainicd 
 that most of the substances which produce fever act by producing coag- 
 ulation in the capillaries and small blood-vessels, and so giving rise to 
 tibrin-ferment. Hildenbrandt found that after the injection of various 
 ferments into the blood there was extensive thrombosis of the small 
 vessels in the liver, intestine, lungs, and kidney. The presence of fibrin- 
 ferment cannot be regarded as the sole cause of the fever, for the highest 
 temperatures are not found in the diseases in which the greatest quantity 
 of ferment is found in the blood, and fever may be present in cases in 
 which this ferment is entirely absent. 
 
 It is questionable whether fever may be the result of irritation of 
 the peripheral nerves. The cases usually cited as e.\am|)les of this are 
 the fever of children during teething and the fever which sometimes 
 follows the introduction of a catheter. It does not seem reasonable that 
 all eases of catheterization fever should be ascribed to the introduction 
 of bacteria or to injury of the urethra. There are numbers of eases in 
 which the careful introduction of an aseptic catheter has been followed 
 by a chill and fever lasting a short time. The chill may follow so shortly 
 after the introduction of the catheter that time is not given for the in- 
 crease of Ijacteria should any have been brought with it, and it is not 
 probable that the pyrogenic substances produced by bacteria elsew^here 
 are on the catheter. Nor is time given for the development of sufficient 
 iuHanunation to cause fever even if an injury was produced by the catheter. 
 In many cases a temporary increased tenqierature is the only phenomenon. 
 The case is different when fever follows the introduction of a catheter 
 into an inflamed urethra or bladder. In regard to the question of pro- 
 duction of fever from peripheral irritation, a strong argument against it 
 is that it is only in certain ])arts of the body that such irritation is followed 
 by fever. No irritation of the skin in general which is not followed by 
 inflammation will produce fever. In the inflamed bladder or urethra the 
 pvrogenic material is already jircsent, and sufficient injury may lie pro- 
 duced to cause its absorption. Most of the chemical products of bacteria 
 are pyrogenic. These may be absorbed into the circulation from a local 
 lesion of some sort, or they may be absorbed from the alimentary canal 
 without any local lesions being present. There is no doui)t that abnormal 
 processes of fermentation in the alimentary canal may ])roduce chemical 
 substances which when al)sorl)ed may give rise to increased temperature 
 and the other phenomena of fever. 
 
 It is easy to see why inflammation should be so constantly accom- 
 panied by fever. In the inflammatory exudation, whether of an aseptic 
 <n- septic character, substances are present which, when absorbed, are 
 pyrogenic. Not only is there in every case fibrin-ferment, but the prod- 
 ucts of simple necrosis of tissue are pyrogenic. If the inflammation be 
 due to Ijacteria, there are added to the pyrogenic substances of the exu- 
 dation the chemical substances produced by the bacteria. If there is no 
 
THROMBOSIS A^^D EMBOLISM. 205 
 
 accumulation of the exudation in tlic tissue^: and no absorption, fever 
 does not take place. In wounds treated by the open method, where the 
 products of the inflammati(jn are not absorbed, there is no fever unless 
 the inflammation extends into the surrounding tissues and allows 
 absorption from these. The <lependence of fever upon abs()r])tion is 
 .shown in its prompt decline when an intlannnatory exudation, especially 
 if it be purulent, is evacuated. There is good evidence that the increased 
 temperature in fever i.< not in itself a source of danger unless it reaches 
 a very high degree. There is also some evidence that the increase of 
 temperature may not be an evil, but a beneficent agent. The most 
 dangerous cases of pneumonia are frequently not those in which the tem- 
 perature is highest. Serottin has found that wiien sterilized cultures of 
 typhoid Ijaci'li are injected into the blocid of rabbits, recovery is more 
 apt to take place when the temjierature is elevated, ^^'elch has observed 
 the same thing. Cases of typhoid fever of especial malignity have been 
 reported in which the temperature was subnormal throughout. It is no 
 longer the custom to judge the severity of wouud-fever In- the degree of 
 the temperature elevation. Many surgeons consider tiie condition of the 
 circulation and <ither things of far more prognostic value than the evidences 
 given by the thermometer. Dochman found that when cats were given 
 curare the poisonous influence of the drug was far less when the animals 
 were given a temperature of 40° C. by keejiing them in the warm chamber 
 than when they were kept in ordinary temj>eratures. A\'hile there were 
 apparently no symptoms produced in the heated animals, poisoning rapidly 
 developed when they were exposed to ordinary temperatures. He further 
 calls attention to the fact that all infectious diseases accompanied by fever 
 have a tendency to recover, while the afebrile infectious diseases, such as 
 leprosy and rabies, have no tendency to recover. 
 
 From all we have seen of inflammation it seems evident that its 
 ])lienomena are essentially conservative in their action on the organism, 
 and it cannot be assumed that so marked a phenomena as the lever 
 should have the opposite tendency.' 
 
 m. THROMBOSIS AND EMBOLISM. 
 
 Thrombosis. 
 
 Thrombosls is the coagulation of the blood in the vessels during life. 
 When blood is taken from the vessels during life, after standing some 
 time it undergoes coagulation, changing from a fluid to a solid form, 
 and the vessel containing it can be inverted without spilling tlu' I'ontents. 
 
 We owe the most of our knowledge of the process of coagulation 
 and the factors concerned in it to the work of Alex. Schmidt and his 
 pupils. Schmidt was able to separate from the blood two substances, 
 each with definite chemical ])roperties, to one of which he gave the 
 name of paraglobulin and ti> the other the name of filn-inogcn. The 
 fibrin of the blood does not exist pre-formed in the blood, but is due to 
 
 ' In these remarks on fever extensive use has been made of the Cartwright Lectures 
 on fever by Prof. W. H. Welch. 
 
20(5 SURGICAL rATHOLOGY. 
 
 the union of thoso two sulistanccs, tlie union licinfj; iironfjlit about l)y tiie 
 presence of a thinl .suii.stanee ^\•llieil lias all the characters of a fei'nient, 
 and which is called fibrin-ferment. This ferment is destroyed or ren- 
 dered inoperative at the death-jjoint of protoplasm and of the other fer- 
 ment-substances of the body ; that is, at about 58° C. If the blood be 
 heated to 58° C. before any coagulation has taken place, the power of 
 undergoing' coagulati()n is lost. The ferment appears to be principally 
 contained in the white corpuscles and is set free by their disintegration. 
 Other tissues of the body may contain this substance, or substances 
 M'hich are analogous to it and which act in the same way. A proteid 
 substance may be obtained from the thymus gland whic^li when injected 
 into the circulation pi-oduces extensive coagulation in all the vessels and 
 leads to the death of the animal. The disintegration of other tissues of 
 the body also produces fibrin-ferment. In necrosis, sul)stances are pro- 
 duced which cause coagulation in the blood-serum which comes in 
 contact with the necrotic tissue. 
 
 A new theory of coagulation has been advanced by Arthur and 
 Pages. These observers found that if a certain proi>ortion of oxalate 
 
 ' &^ 
 
 of potash be added to freshly-drawn blood, it loses its jiower of coagula- 
 tion. They attribute the action of the oxalate to the precipitation from 
 the blood of the soluble lime-salts which it contains. If a solution of 
 chloride of lime be added to the blood containing the oxalate, coagula- 
 tion will take place. No matter how long the oxalatcd blood may be 
 kept, it will remain fluid, and coagulation will take ])lace as soon as the 
 lime-salts are driven from their connection with the oxalate and again 
 set free in the fluid. The fibrin-ferment only acts on the filirinogen, 
 converting it into fibrin when lime is present. In coagulation the 
 fibrinogen undergoes a chemical change by M'hich it is converted into 
 fibrin, the fibrin being a union of lime-salts and albumin. 
 
 The coagulation of the blood in the vessels during life is jirevcnted 
 by some action exerted on the blood by the living endothelium of the 
 blood-vessels. The blood contains the necessary element for coagula- 
 tion, and a certain amount of fibrin-ferment must be constantly pro- 
 duced by the disintegration of leucocytes and other cells, which to some 
 extent is always going on. In inflammatory exudations and in the 
 necrosis of the tissues fibrin-ferment is certain!}- present, and being 
 soluljle it must enter into the circulation. If a large vein of an animal 
 be carefully ligated and removed from the body while filled with blood, 
 coagulation of the blood contained in this receptacle does not take place 
 for a long time, and when it does the clot is always thinner than when 
 formed under ordinary circumstances. The serous tissues act in the 
 same way in preventing coagulation. If small vessels are included 
 between doul^le ligatures, care being taken to pre\'ent any injury to the 
 vessel by the ligature, tlie blood in the vessels will not coagulate. Stag- 
 nation of the blood in the absence of other factors will not produce 
 coagidation in the vessels, but it will fiivor it. If the wall of the blood- 
 vessel is injured in any way, thrombi will be formed on the injured sur- 
 face. It is not known to what this action of the living endothelium in 
 preventing coagulation of the lilood is due. It is not due to the smooth- 
 ness of the surface alone, for N'irciiow has shown that thrombi will 
 foi'm around globules of quicksilver when they are brought into the 
 
THROMBOSIS AND EMBOLISM. 207 
 
 circulation. It is probable that the prevention of coagulation is a 
 property of the living endothelial cells. The endothelial cells do not 
 simply provide a physical lining to the vessels, but have as definite prop- 
 erties as gland-cells, and they may produce substances which oppose the 
 action of the fibrin-ferment. 
 
 Coagulation of the lilood takes place in the vessels a few hours 
 after death. Certain conditions favor or oppose the post-mortem coagu- 
 lation. An excess of carbonic acid in the blood retards the coagula- 
 tion, and in death after sufibcation the blood is usually found fiuid. 
 The l)]ood is fluid, or clots feebly, after death from certain poisons 
 and from a number of infectious diseases, especially those due to the 
 absorjjtion of chemical bacterial poisons. The blood is firmly clotted 
 after death from pneumonia, in which disease the fibrin-ferment in the 
 blood is increased. The clot found in the vessels may resemble the clot 
 formed outside of the body, or in certain places, notably in the heart, 
 clots are formed wliich are colorless and transparent, and resemlde the 
 clot obtained by whipping the blood and gatiiering tiie fibrin. Clots of 
 this sort are not strictly ])ost-mortcm. For their formation a certain 
 amount of motion in the blood is necessary, and it is probable that tliey 
 form in the last minutes of life, especially under circumstances in which 
 the power of coagulation is increased, as in crou])ous pneumonia. 
 
 Three principal varieties of thrombi may be distinguished, and there 
 are various intermediate stages. The white thrombus is of firm con- 
 sistency and has a grayish, and sometimes a yellowish-white, appearance. 
 On microscopic examination it is principally composed of white corpus- 
 cles and fibrin. Many of the white corpuscles are apparently normal 
 and their nuclei stain clearly ; others show every stage of disintegration. 
 The fil)rin appears either in the form of very minute filaments, forming 
 a meshwork and enclosing the leucocytes in its meshes, or the filaments 
 may be large and coarse. At times the thrombus has a hj-aline, more 
 transparent appearance, and this is due to the presence in it of large 
 masses of hyaline material which stain in the same way as fibrin, and which 
 probal)ly result from a hyaline metamorphosis of the fibrin. In many 
 cases the fibrin is arranged in definite layers which may be stripped off. 
 This is especially the case in the large thrombi formed in aneurisms. 
 The whole space of the aneurism is frequently filled with lamelhe of 
 fibrin. Along with the leucocytes and fibrin a certain nunilier of red 
 corpuscles are generally found, and a quantity of granular material, 
 which may result from disintegration of the fii)rin or white corpuscles, 
 or may have another origin. 
 
 The red thrombus is less firm than the white. The red color is due 
 to a greater numlier of red corpuscles, or pigment resulting from their 
 disintegration, entangled in the meshes of the fibrin. The red thrombus 
 shows various degrees of color, depending upon the amount of blood- 
 pigment in it, and is formed more rapidly than the white. 
 
 In the mixed thrombus there is a combination of both forms. It 
 frequently has an excjuisitely lamellated structure, a red lamella follow- 
 ing a white in regular order. This mixture of the two colors is due to 
 an alternation of rapid and slo«- coagulation on the surface. 
 
 The consistency of the thrombus may differ in different parts. We 
 can frequently distinguish a firmer portion of tiie thrombus to which 
 
208 SURGICAL PATHOLOGY. 
 
 tlie romaiiuler is loosely attai-liwl. Tlio firm jwrtion is the true tlironi- 
 I)iis, which is clue to the loeal ciuise, and tiie other is simply a eoa<;ulum 
 fdrmed on this. The soft red cnaLiidmii may extend t'nun tlie thrombus 
 a considerable distance in tiie blood-current, and is called the sec(m(lary 
 or continued thrombus. When a vessel is completely occluded the 
 thrombus extends up to the next branch entering or given oif from 
 the thrombosed vessel. 
 
 True thrombi may l)e distinguished from post-mortem coagula in 
 a number of ways. Thrombi are more consistent than post-mortem 
 clots; they are more adherent to the walls of the vessels. The adhesion 
 is due to several causes. If the thrombus be sufficiently old and if 
 organization has taken place in it, there is a definite tissue-union between 
 the thrombus and the vessel-wall. Even if there is not formation of 
 tissue extending from the wall of the vessel into the thrombus, there is 
 frequently a formation of fibrin in the wall of the vessel which unites 
 with the fibrin of the thrombus. 
 
 The thrombus may occupy various relations to the lumen of the 
 vessel. It may fill up the entire vessel or occupy only a small portion 
 of the wall, allowing the blood-current to flow past it. As a rule, 
 thrombi are formed by coagulation over a small area of the wall of the 
 vessel, and then successive coagula are formed on the first. In the heart 
 these successive coagula may be formed until a large mass ]irojecting 
 like a polypus into one of the cavities of the heart is produced. 
 
 Another variety of thrombus is due to aggregations of the blood- 
 plates. There is still much contention about these blood-plates and the 
 part which they play in coagulation and thrombus-formation. It is 
 held, on the one hand, that they are essential constituents of the l)lood, 
 and on the other that they result from the disintegration of white cor- 
 puscles. Eberth and Schimmclbusch, in studying the experimental 
 formation of thrombi, found that the first appearance of the white 
 thrombus was due to a collection of these blood-plates. They form 
 with the greatest rapidity just at the point where the vessel is injured. 
 They call the thrombus so formed the blood-plate thrombus. Welch 
 has also found that thrombi which at first are entirely composed of 
 blood-plates can be produced exjjerimcntally by slight injuries of the 
 wall of a blood-vessel, and it hardly seems probable that all the leuco- 
 cytes which had collected at such a place could have broken down. 
 Weigert does not consider these aggregations of l)lood-plates as true 
 thrombi. He considers the thrombus a true coagulation of the blood, 
 and not an aggregation of some of its constituents. A consitlerable 
 amount of granular material which is found in the thrombus may be 
 composed of these blood-plates. Zahn studied the formation of thrombi 
 in the veins of the mesentery of a curarized frog directly under the 
 microscope. He found that -when a crystal of salt was placed in con- 
 tact with the vein the first change noticed was a collection of leucocytes 
 at the point. Finally, the entire lumen of the vessel was occluded by 
 the leucocytes. In the course of some hours the thrombus underwent 
 important changes. The white corpuscles lost their form and regular 
 contours, and became changed into a more or less finely granular mass, 
 and then fibi'in-filaments appeared. 
 
 Both local and general conditions favor the formation of thrombi. 
 
THROMBOSIS AND EMBOLISM. 209 
 
 The local conditions favoring their formation are stagnation of the blood 
 and changes or injuries in the lining membranes of the vessels. Exper- 
 imentally, it seems to be shown that when the l)lood is enclosed in a vessel 
 between double ligatures coagulation will not take place if the vessels 
 be ligated so carefully that all injury to the wall is prevented. Even 
 if \ve suppose that a lesion of the endothelium is necessary for coagu- 
 lation, such a lesion may be produced by stagnation of the blood. 
 The endcjthelium of the blood-vessels is nourished by the blood, and 
 not only the blood, but its constant renewal, is necessary, and a loss of 
 function of the endothelium due to lack of nutrition would suffice to 
 produce coagulation. As a rule, the smaller the blood-vessel in which 
 stagnation takes place, the less likelihood is there of coagulation. The 
 larger the area of blood relatively to its mass ^vhich comes in contact 
 Avitli the endothelium, the less readily will coagulation take place. In a 
 small vessel degeneration of the endothelium would not be so likely to 
 take place, because it could more readily be nourished by imbibition 
 from the surrounding tissues. The thrombi produced by stagnation of 
 the blood are formed first in the pockets behind the valves, where the 
 stagnation is most complete. Thrombi may form around foreign bodies, 
 but there is little opportunity given for this mode of formation in man. 
 
 Virchow first called attention to the jiart which alterations in the walls 
 of the blood-vessels play in tlie formation of thrombi, and regarded the 
 coagulation as the result of altered molecular attraction between the wall of 
 the vessel and the blood. Ulceration, inflammation, necrosis, and various 
 other pathological conditions in the neighborhood of blood-vessels may 
 so atfect their walls as to lead to thrombosis. Frequently the coagula- 
 tion which takes place under such circumstances is essentially a con- 
 servative process, and the hemorrhage which would otherwise follow 
 the extension of the ulceration into a large vessel is avoided. Dilata- 
 tions of vessels favor the formation of thrombi. The thrombus forms the 
 more easily the more sharply circumscribed and the more partial the 
 dilatations are. In such conditions, of which the best type is given in 
 aneurism, the thrombosis is further assisted l)y calcification and various 
 degenerations of the lining wall of the aneurism. 
 
 Various conditions of the system favor the formation of thrombi. 
 They are frequently found in ^veak marantic individuals, particularly 
 when they have had long-continued supjiuration. In such individuals 
 thrombi are frequently found in the pockets behind the valves of the 
 veins, in the sinuses of the dura mater, and in tlic auricular appendages 
 and between the muscular trabccuhe of tlie licart. Virchow considered 
 the essential factor in the production of sucli thrombi the weakness of 
 the heart and circulation. Even in such conditions the thrombosis may 
 be favored by local .degenerations of the endothelium. The nutrition 
 of the vessels will suffer in consequence of the diminution in the gen- 
 eral nutritive power of the blood and the diminution in its rapidity of 
 flow. Tiiese conditions will be felt most where local conditions favoring 
 stagnation are present. 
 
 There may be certain chemical alterations in the blood which increase 
 its coagulability. The injection into the blood of the extracts of certain 
 glands, especially of the thymus gland, increases its coagulability. 
 Extracts of htemoglobin, especially the hsemoglobin derived from 
 
 Vol. I.— U 
 
210 SURGICAL PATirOLOGY. 
 
 a different animal, lias the same effeet. There were numennis ex- 
 amj)l(>s of this when the blood of different animals was used for trans- 
 fusion. Under such circumstances death frequently occurred shortly 
 after tlie transfusion, and at the autopsy extensive thrombosis was found. 
 In certain cases tlicre may be such extensive thrombosis in the vessels 
 that the existence of substances in the blood \\hich materially increase 
 its power of coagulation must be assumed. These are cases in M'hich 
 in a very short time, and apparently without any lesions in the walls of 
 the vessels, there is extensive formation of thrombi. It is possible that 
 substances may be formed in certain organs of the body, and may have 
 a local influence in assisting thrombosis. There mav be extensive 
 thrombosis, especially in the very smallest veins and capillaries, which 
 occurs in the course of certain infectious diseases. The thrombi formed 
 under these circumstances are different from the ordinary thrombi, being 
 composed almost entirely of hyaline material. Such thrombi are fre- 
 quently found in vessels of thi' kidney and the lungs. 
 
 The thromlius when once formed nndergoes various changes. It 
 contracts and l)ecomes firmer and harder. Softening frequently takes 
 place, especially in large thrombi formed in the heart and large vessels. 
 The thrombus becomes converted into a soft pulpy mass of an opaque 
 granular appearance closely resembling pus. The softening most fre- 
 quently takes place in the centre of the thnmibus. In the softened 
 material of the thrombus there is a quantity of fatty granular material 
 M'hich is derived from tlie breaking dt)wn of Ijoth the cells and the 
 fibrin. The fluid in the centre is frequently surrounded by a dense 
 outside wall. The fluid results both from the absorjrtion of fluid from 
 the blood and the contraction of the thrombus. This softening may 
 take place until the thrombus resembles a cyst filled with fluid. The 
 thrombus may become organized and converted into a mass of connec- 
 tive tissue. The manner in which the organization of the thrombus 
 takes place has been the subject of a great deal of dispute among path- 
 ologists, and the study of the jirocess has led to a material increase of 
 our knowledge about this and tiie formation of pathological connective 
 tissue in general. It was at first supposed that tlie connective tissue in 
 the thrombus was formed by a direct conversion of the constituents of 
 the thrombus into connective tissue. It is now known that the organ- 
 ization of the thrombus is due to a growth of connective tissue into 
 it from the wall of the blood-vessel. It is not probable that the white 
 corpuscles in the thrombus itself take any part at all in the organization. 
 In the first stages of the organization of the thromlius it becomes filled 
 with leucocytes which are derived from the wall of the blood-vessels. 
 In some cases it seems probable that there may l)e an invasion of the 
 thrombus by leucocytes Avhicli are derived from the blood itself. After 
 the leucocytes, and along with them, large epithelioid cells appear which 
 are derived from the M'alls of the vessels. These cells are accompa- 
 nied by a new formation of blood-vessels proceeding from the adjacent 
 blood-vessels of the tissue, and a new formation of connective tissue 
 takes place from the large epithelioid cells. The leucocytes ajipear to 
 prejiare the way for the after-formation of tissue, and, as in the connec- 
 tive-tissue formation in inflammation, it is jirobable that they to some 
 extent furnish food for the growing cells. The thrombus in the course 
 
THROMBOSIS AND EMBOLISM. 211 
 
 of organization becomes filled with large dilated blood-vessels that fre- 
 quently conmuinieate with one another. Under favorable circumstances 
 communications may be formed between the blood-vessels of the throm- 
 bus and the lumen of the vessel, and in this way the continuity of the 
 lumen of the vessel may be again accomplished. The red thrombus in 
 the course of time becomes decolorized and converted into a yellowish 
 or yellowish-brown material. The thrombus may become calcified, and, 
 in consequence of this, becomes converted into a hard, calcareous mass. 
 The so-called vein-stones, or phleboliths, are due to calcification of 
 thrombi. The calcification is due to the deposition of lime-salts in the 
 thrombus. All of these changes in the thrombus are relatively favor- 
 able. Other changes are not so favoralile. There may be an actual 
 purulent softening of the thrombus. When there is purulent inflam- 
 mation in the tissues around the tin-oml)osed vessel the suppuration 
 may extend to the blood-vessel and into the thrombus. Not onl\- may 
 the pus-cells M'ander from the vasa vasorum and enter the blood-vessel 
 and thrombus, Init the pyogenic bacteria may also be carried by these. 
 Under such circumstances no organization of the thrombus takes place, 
 and it becomes converted into a soft friable mass. 
 
 Embolism. 
 
 Although the thrombi may produce both local and general effects on 
 the circulation, these are not the chief dangers which result from them. 
 In many cases the thrombus docs not entirely obstruct the wall of the 
 vessel, and the blood circulates in the vessel beyond the thrombus. 
 Even when the thrombus completely occludes the vessel, it extends up 
 to the next collateral branch, and frequently beyond this, so that a por- 
 tion extends into a vessel where the circulation is still taking place. The 
 tin'ombi, further, are more frequently found in the \'enous side of the 
 circulation than in the arterial. The chief danger from the thrombi is 
 that portions may be Mashed off, carried into the circulating blood, and 
 finally occlude arteries. The thi'ombi being more frequent in the venous 
 system, the particles Mhich are washed off from them occlude the ves- 
 sels of the lungs. When thrombi are formed in the left side of the 
 lieart and in the arterial system generally, they M'ill be carried into some 
 other part of the circulation. The particles of the thrombus which 
 nray be broken off and enter into the blood-stream vary in size. The 
 largest pieces come from the thrombi formed in aneurisms, from the 
 heart-cavities, and from the large veins. These portions of the throm- 
 bus which are carried by the blood-current to another portion of the 
 body arc called I'lnholi. Where they will lodge depends upon the posi- 
 tion of the thrombus. If they come from the veins, they will enter 
 into the pulmonary a'rteries. Those from the arterial side — that is, from 
 the left heart, the systemic arteries, and the lung-veins — are carried 
 into the systemic arterial system, and those from branches of the jiortal 
 vein into the branches of the portal vein within the liver. These 
 emboli will be carried along by the blood-stream, and finally stop where 
 the calibre of the blood-vessels is smaller than the diameter of the emboli. 
 Virchow, and especially Recklinghausen, have called attention to the fact 
 that there may be a transportation of thrombi in a direction contrary to 
 
212 SURGICAL PATHOLOGY. 
 
 tilt' blood-stream. It is difficult to sec liow this takes place. It may be 
 assisted by gravity, and it can only take place in parts where the circu- 
 lation is exceedingly feeble and the ])lood-pressure in the veins very low. 
 Large emboli can occlude the chief branches of the pulmonary arteries, 
 or on the arterial side may occlude large arteries, such as the renal or 
 iliac, or even the descending aorta. The smallest emboli may enter into 
 the capillaries, and where the cajiillaries are relatively wide, as in the 
 lungs, they may pass through tlicsc, and afterward plug up the narrower 
 capillaries of the systemic circulation. It is evident tliat solid particles 
 whose diameter is smaller than the capillaries can pass unliindercd tiirough 
 all parts of the circulation. The emboli are apt to bo found in places 
 where the lumen of the vessel undergoes a sudden diminution in size, 
 especially where large branches are given off. 
 
 It is not uncommon to find emboli entering into each l)ranch of an 
 artery at the place of its bifurcation. Such emboli are sj)oken of as 
 riding emboli, situated as they are at the place of bifurcation, as in a 
 saddle, with one leg in each division of the artery. The emboli almost 
 always produce total occlusion of the vessel where they are found. They 
 are carried with some force into the vessel, and being comparatively soft 
 they will lie pressed into it mitil they totally occlude it. The emboli 
 may undergo the same changes as thrombi. They can become softened 
 or they may organize. 
 
 There may be special varieties of emboli ^\'liich arc not due to 
 thrombi, but which are due to substances accidentally introduced into 
 the vessels. Under certain conditions either air or a fluid which will 
 not readily pass through the ca])illarics, such as oil, may be introduced 
 into the circulation. A large number of cases have been reported of 
 death in human beings attributed to the entrance of air into the veins. 
 This accident has generally happened in surgical cases where operations 
 have been done about the neck, shoulders, and skull. Further, death 
 has occurred in cases in which air has entered the sinuses of the puer- 
 peral uterus, generally in cases of criminal abortion in which air has 
 been injected into the uterine cavity. In some of these cases death has 
 been instantaneous, and in these there seems to be no reason to doubt 
 that it has been due to the entrance of air into the circulation and the 
 stoppage of large areas of the vascular territory of the lungs. A con- 
 siderable amount of doubt, however, has been thrown on such cases by 
 the result of experiment. It has been shown that the amount of air 
 which is required to kill a dog if the air is directly injected into the 
 vessels is much greater than could possibly enter the vessels in a sur- 
 gical o]>eration. If the air is injected slowly, enormous amounts can be 
 injected without producing anything more than slight disturbances of 
 the respiration and the action of the heart. In the cases in Avhich death 
 has been attributed to the entrance of air into the veins a large quan- 
 tity of air or gas is found in the blood-vessels after death. Welch has 
 shown that this is frequently due to the growth of an aeroliic gas-pro- 
 ducing bacillus in the blood. There is no doubt that a number of the 
 cases which have been reported of death from air-embolism, in which 
 death has taken place some time after the supposed entrance of air, have 
 been due to infection with this bacillus, but there is equally no doubt 
 that there have been cases of sudden death due to the entrance of not 
 
THROMBOSIS AND EMBOLISM. 213 
 
 very large quantities of air into the circulation. The air is especially 
 apt to enter into the veins if there is an inspiration at the same moment 
 when a largo vein, such as the jugular, is opened. When a large amount 
 of air enters the heart at one time, death may ([uickly take place with 
 evidences of sutfocation. This is due to collection of air in the heart. 
 The air is not forced out of the heart at each contraction of the ven- 
 tricle, but is simply compressed. When a small amount of air enters 
 slowly it will enter into the circulation, and may produce temporary 
 occlusion of a number of the capillaries in the lungs. Unless the vas- 
 cular territory so occluded is very large there will be little inconvenience, 
 because the air will gradually be forced through the capillaries by sub- 
 sequent contraction of the heart, and in a short while most of it will 
 become absorbed. 
 
 The presence of fat-emboli in the vessels of the lung has attracted 
 considerable attention, but the importance of these emboli has been very 
 greatly over-estimated. The fat of tlie l)ody is in a fluid condition dur- 
 ing life, the fat-cell representing a drop of fluid oil enclosed in a vesicle. 
 Wiien a number of these vesicles are broken, as in extensive crushing 
 injuries, and the veins are ruptured at the same time, a certain amount 
 of this fluid fat can enter into the circulation. It is especially apt to do 
 this in injuries of the bones where there is not only a large amount of 
 fat in the marrow, but where the veins are large and do not collapse. 
 The fat entering the circulation in this way is nearly all stopped in the 
 capillaries of the lungs, and may be found there at autopsies. It was 
 at one time supposed that the shock after severe surgical injuries could 
 be in large part explained by fat-embolism. It is rare, however, that 
 the fat is jireseut in sufficient amount to produce any serious results by 
 occlusion of the capillaries. The collateral circulation in the capillaries 
 is so abundant that no result can take place from the occlusion of a few. 
 It is only when all of the capillaries of a very large area are occluded 
 that any results will follow. 
 
 The General and Local Effects of Thrombi and Emboli. 
 
 An occluding thrombus in any portion of the venous system will lead 
 to congestion and increased venous pressure in the vein behind the 
 thrombus. The severity of the changes produced will depend upon the 
 local conditions of the circulation in the part and the size of the vessel. 
 If a large vein be occluded, it is evident that the consequences will 
 be more serious than if the vein l^e a small one. Local conditions 
 of the circulation aftecting the results produced by a thrombus are 
 due to the abundanc.e or absence of collaterals. When there are two 
 veins leading from a part with "an abundant anastomosis between their 
 branches, the occlusion of one of tliem will have no eifect. The rapidity 
 witli wiiich the thrombus is formed will also influence the result. If the 
 renal vein be ligated, intense passive congestion of the kidney with hem- 
 orrhage and necrosis results. Com])lete occlusion of the renal vein by 
 a thrombus is sometimes seen without producing any results. The 
 thrombus is formed slowly, and time is given for the dilatation of the 
 vessels of the collateral venous circulation, so that by the time the occlu- 
 sion is complete these vessels are sufficiently dilated to carry off all the 
 
214 SURGICAL PATHOLOGY. 
 
 blood fnini the kidney. Tlic same tiling is true of the portal vein. 
 AVhen thi.s is ligated death results from the enormous distention of its 
 branc^hes. When it is slowly oeeluded by means of thrombus-forma- 
 tion the few collateral brancdies dilate sufficiently to carry off the main 
 portion of the blood, although the collateral circulation is rarely suf- 
 ficient to prevent ascites and passive congestion. Sudden occlusion of 
 the femoral vein in the neighboriiood of Poupart's ligament is usually 
 fiital. Intense congestion, eedema, and gangrene of the entire leg- 
 develop. When the occlusion takes 2)lace gradually by the slow forma- 
 tion of a thrombus or by pressure of a tumor, no unfavorable conditions 
 other than oedema to a greater or less degree may develop. 
 
 The local effects of an embolus will depend to a certain degree upon 
 the physical character of the emljolus. Virchow found that when hard 
 substances, especially those with irregular walls, were introduced into 
 the cii'culation, they produced intense inflammation, frequently with rup- 
 ture of the vessel at the point where they were arrested. Wherev^er an 
 embolus lodges and whatever its character, it Avill al\\ays ])roduce 
 ciianges in the wall of the vessel in contact with it. The endothelium 
 will become necrotic, and the necrosis may extend some distance into the 
 surrounding tissue. Other local changes may be produced which do not 
 depend upon the physical characters of the embolus, but upon its biologi- 
 cal characters. The embolus may consist of living tissue, which may 
 grow where it lodges. Particles of tumor are frequently carried by the 
 circulation from a primary focus to a distant organ, and develop, forming 
 secondary tumors where they lodge. Not only particles of living tissue, 
 but living organisms, may be contained in the embolus, and these will 
 produce the same lesions as in the place from which they were derived. 
 This is especially seen in the emboli which come from the purulent soft- 
 ening of a thrombus. In this way a secondary abscess may be formed 
 around an embolus. 
 
 The occlusion of an artery will jtroduce effects in the tissue supplied 
 by it. Here the effects produced will depend upon the presence or 
 absence of collateral branches going to the same tissue. In certain 
 parts of the body definite areas of tissue are supplied by definite 
 arteries without anastomoses. Such terminal arteries are found in the 
 kidneys, heart, and other organs. Tiie effect produced will also dci)end 
 upon the size of the artery. " The collateral circulation may suffice for a 
 small area, but not for a large one. There may be prculuccd by the 
 occlusion of an artery two conditions which are apparently widely dif- 
 ferent. If the artery be a terminal one, the tissue supplied by it becomes 
 necrotic. The form of necrosis produced is that described by Weigert 
 as coagulation-necrosis, in which there is necrosis of the cells with 
 coagulation. The anremic part has a whitish, opaque character, and is 
 generally triangular in shape, the ajiex of the triangle being formed by 
 the occluded artery. Or a hemorrhagic infarction may be produced. In 
 some cases hemorrhage takes place into the previous anajmic territory. 
 The source of the blood in this case has been a matter of dispute. 
 Cohnheim supposed that it was due to a backward flow from tlie veins, 
 but this can be shown to be erroneous, because the infiirction takes place 
 Avhen the veins are tied at the same time \\ith the artery. The blood 
 may have various sources. It is impossible by arterial occlusion to shut 
 
HYPERTROPHY AND REGENERATION. 215 
 
 oft' all blood from a part. There are always anastomoses with the capil- 
 laries of a neighboring part, and if the ansemic area be very small the 
 capillary anastomoses will be sufficient to preserve the life of the tissues. 
 The first effect of arterial occlusion must be to lower the pressure in the 
 circulation distal to the occlusion. The pressure will be lower in all the 
 vessels of the part, and the blood will ffow into it from all the adjacent 
 vessels. The blood-vessels become distended and diapedesis of red cor- 
 puscles takes place. If the amount of Idood entering the vessels of the 
 part is not sufficient to provide ibr a regular circulation, all of the tissue 
 becomes necrotic. The diapedesis is generally supposed to be due to 
 nutritive changes in the walls of the vessels, but it may Ite the result of 
 changes which ha\'e taken place in the character of the blood. A comljina- 
 tion is frequently seen between hemorrhagic and ansemic infarctions. The 
 centre of the infarction may be white and anremic and be surrounded 
 by a hemorrliagic zone. In this case sufficient Ithiod ddcs not enter the 
 vessels to penetrate to the centre, or necrosis with coagulation may take 
 place before it has sufficient time to do so. Various conditions of the 
 body may influence the effects jjroduccd by an embolism. If the circu- 
 lation is feeble and the general state of nutrition poor, the effect will be 
 more disastrous. Embolism of the pulmonary arteries, unless the vessel 
 be of considerable size, may not produce any effects. In the ordinary 
 conditions of the pulmonary circulation there is sufficient ca])illary 
 anastomosis, assisted by the anastomoses of the bronchial artery, to pre- 
 serve the life of the tissue. In any embarrassment of the pulmonary cir- 
 culation, especially in chronic passive congestion, infarction alwaj'S results. 
 That a part is able to retain its vitality after the occlusion of a large 
 artery supplying it with blood is due to the development of the collateral 
 circulation. After the ligation of the femoral artery below the point 
 ■where tlie jirofunda is given off, the leg not only retains its vitality, but 
 in a short time it will be able to perform all its functions as well as 
 before. It must receive the same quantity of blood, and it cannot do 
 this unless the other arteries dilate. No adequate explanation has been 
 given for the dilatation whicli takes place. It cannot be explained on 
 physical grounds, ijecause tying the artery does not produce any increase 
 of pressure in the branches given off' above the ligature. Tlie dilatation 
 of the collaterals in this case is more complicated. Every tissue receives 
 just the amount of blood which it needs for its nutrition and function, 
 but no more. The varying amount is provided for by varying degrees 
 of contraction of the muscular walls of the arteries. Where a small 
 artery has to supply a large part with blood, it not only dilates to the 
 fullest extent, but the calilire of the vessel actually grows larger. The 
 dilatation is the result of the close relation between the calibre of the 
 arteries and the needs of the tissue — a relation probably directly under 
 nervous control. 
 
 IV. HYPERTROPHY AND REGENERATION. 
 
 Ix hypertroijhv there is an increase in the size of an organ or part 
 of the body, with retention of the normal structure. In regeneration a 
 loss of substance in an organ or part of the body is restored by a tissue 
 similar to that which is lost or M'hich contains the same constituents. 
 
216 SURGICAL PATHOLOGY. 
 
 A tissue ran cnlargo either by ;iii increased power of assimilation or 
 growth, or hycliniiniition of the consumption of the tissue. Sucli a con- 
 dition is physiological during the entire period of growth. When a part 
 is growing, more tissue is formed than is used up. The normal size of 
 organs and the general conditions of growth depend upon causes which 
 are inherent in the germ. In order that growth may take place an 
 abundant nutrition is necessary, which is provided in the intra-uterine 
 life by the mother and in extra-uterine life by alimentation. The growth 
 of the individual tissues and organs is dependent also on the activity of 
 the blood- and the lymph-circulation. An extremity of a child ceases 
 to grow, or it may even diminish in size, when for any reason the blood- 
 supply is diminished. If all the conditions of nutrition are favorable, 
 and if there are no general disturbing iuHuences acting on the tissues, 
 such as abnormal temperature, for instance, the development and growth 
 of every individual take place at a rate corresponding to the age. The 
 influence of the nervous system for such growtli as this is not absolutely 
 necessary. Examples of this are given in the monstrosities in which 
 children are born without either brain or spinal cord. In these cases 
 the body may sometimes show a develo[)ment even in excess of the 
 normal. The cells apparently from the beginning have the {>ower of 
 excessive reproduction — that is, reproduction in excess of the material 
 used up — for a certain length of time, which differs in different animals. 
 This ceases in man at about the twenty-second year, and nothing can 
 again excite it. This does not hold for certain tissues ; as, for instance, 
 for muscles, for glands, and for the ejiithelial tissues generally. In these 
 the power of forming new substance does not cease with the end of the 
 period of growth. Every muscular contraction and every secretion of a 
 gland takes place at the expense of the substance of tlie muscle and the 
 gland ; and in order to supply this continual loss there must constantly 
 be a new formation of contractile substance or of gland-cells. Even in 
 the adult there may be an increase in the size of certain parts brought 
 about by exercise and good alimentation. Arterial congestion, however, 
 no matter how excessive, will not of itself produce an increased growth. 
 Apparently the cells of the muscles and glands will only assimilate when 
 they are stimulated, and congestion alone will not produce contraction in 
 the muscle nor increased secretion in a gland. In other tissues assimila- 
 tion and new formation apparently only depend upon conditions which 
 govern the growth ; that is, the inherent power of reproduction and the 
 degree of congestion. In all of these tissues an excess of production 
 may take place when they are subjected to constant hypersemia. Cohn- 
 heim thinks that the growth of these tissues is due alone to the regula- 
 tion of the blood-supply. He says that the bones and epidermis cease 
 to grow at the end of the growth period, merely because if all the other 
 organs of the body are supplied with blood in the proper measure, the 
 quantity of blood which they receive will not be sutiicient to excite 
 growth. 
 
 The increase of size of organs due to increased functional activity 
 with inci'eased blood-supply is familiar to us in the muscles and in 
 the glands. When more ^^'ork is thrown on the heart in conserjuence 
 of increased pressure which has to be overcome, or in consequence of 
 lesions of the valves, that portion of the heart which is called upon to do 
 
HYPERTROPHY AND REGENERATION. 217 
 
 an increased amount of work beeomcs cnlartjcd. An enlargement of the 
 muscular walls of tiie bladder, wliich relatively can exceed tliat of tiie 
 heart, takes place when, because of stricture of the urethra or enlarged 
 prostate, it is forced to do a greater amount of work in expelling its 
 contents. The same thing may be seen in the glands. AVhen one kidney 
 is destroyed, the other can undergo such an increase in size and weight 
 that it will correspond to both kidneys and properly perform the func- 
 tions of two. In other glands wliich are not necessary for the life of 
 the individual, but only for the jtreservation of the species, as the testicles 
 in man and the ovaries and nianimarv glands in the female, such a com- 
 2:)ensatory hypertrophy does not take place at all or only to a very limited 
 degree. Hypertrophy only occurs when in consequence of the loss of one 
 organ a gi-eater amount of work is thrown upon another organ ; and this 
 will not be the case for the testicle or the ovary. Extirpation of a jiart 
 of the thvroid gland will lead to an increased size of the part which 
 remains ; not only that, but other glandular structures whicli probaljly 
 have the same function will also undergo an increase of size after extir- 
 pation of a part of the thyroid An increase in the functional activity of 
 one portion of one lung in consequence of inactivity in other portions 
 will simply produce a distention of the alveoli of the lung which may lead 
 to atro})liv instead of hypertrophy. In general, the younger the tissue 
 the more readily will compensatory hy[)ertrt)j)hy take place. In tissues 
 which are constantly being used up a diminished consumption may also 
 produce hypertrophy. For instance, in the epidermis and the nails 
 there is constant consumption of the horny layer, and anything which 
 interferes with this constant rubbing off may lead to pathological thick- 
 ening. The removal of pressure from tissues can also lead to new form- 
 ation of tissue. The inner surface of tlie skull can become thickened 
 when the growth of the brain in childhood is inhibited. Frequently- 
 repeated mechanical and chemical irritation of the tissue may lead to 
 liypertrophy. Repeated irritation of the skin can lead to the production 
 of callosities and corns. The continuous inhalation of dust can lead to 
 development of connective tissue in the lungs, but this cannot be consid- 
 ered as hyjiertrophy in the true sense of the word. It is rather a repro- 
 duction of tissue to take the place of that which was lost, and the new 
 tissue has not the same structure and function. The cause of hyper- 
 trophy in many cases is entirely unknown. 
 
 Formerly a sharp distinction was made between hypertrophy and 
 hyperplasia. By hypertrophv, strictly speaking, we understand an in- 
 crease in the size of an organ due to an increased size of its constituent 
 elements, without any new formation. In hyperplasia there is a new 
 formation of tissue. These terms can be used interchangeably, for in 
 hypertroj)hy there is-always hyj)erj)lasia. It cannot be always assumed 
 that \\hen an organ is increased ni size there is at the same time increased 
 functional capacity, because the liyjiertmiihy may not concern all parts 
 of tlie organ. When a gland is increased in size, this may be due to an 
 increase in all of the elements of the gland, or only the connective tissue 
 may be increased in amount. This imperfect new formation of tissue 
 can reach such an extent that hy]iertrophy may take place in one tissue 
 of the gland while the other part undergoes atrophy. In such cases it 
 is generally the specific constituents of the tissue, the ganglion-cells, the 
 
218 SURGICAL PATHOLOGY. 
 
 nerves, the gland-cells, etc., that are atrophied, while the connective tissue 
 increases in amount. One of the most striking examples of this is seen 
 in the pseudo-hypcrtrojjhy of the muscles. Although the muscles appear 
 to l)e enormously increased in size, this is not due to an increase in the 
 contractile substance. Hypcrtrojjhy may also take place in the jicriod 
 of embryonic development or during the period of extra-uterine growth 
 without our being able to assign any cause whatever for the increased 
 growth of the tissue. 
 
 The power of regeneration in tissues is always more or less limited. 
 Tlie more highly develo])cd tiie tissue, the more its elements are differ- 
 entiated for particular functions, the less complete is the regeneration. 
 In the lower animals the power of regeneration exists to a very much 
 greater extent than in man. Whole extremities of crabs and lobsters 
 can be regenerated, and even in the lower vertelirates the same power 
 exists. Tiie yotmger the animal the greater the jiower of regeneration. 
 In man the power of regencrati<in is limited, ^^"hole pieces of tissue 
 built up of complex elements, such as a finger or portion of the brain 
 M-liich is lost, do not regenerate. In adults the ganglion-cells of tlie 
 nerve-centres have no power of regeneration. In the highly-develo{)ed 
 glands the power of regeneration exists to some degree, but is limited. 
 Single cells of the gland when lost are easily replaced by multiplication 
 of surrounding cells, but when large areas are lost the structure of the 
 gland is only imperfectly reproduced, and granulation and cicatricial 
 tissue take the place of the lost substance. The surface epithelium, the 
 epithelium of the glandular ducts, the connective tissue, and the nerve- 
 fibres have the power of regeneration to a marked degree. 
 
 When a tissue whose elements corresjiond to the normal, but which 
 does not perfectly agree with the type of tlie tissue in Avhich it has devel- 
 oped, is produced in a })art, such a new formation is called a heteroplasia. 
 For instance, a cicatrix in the liver rejiresents a heteroplasia, because, 
 although it is composed of connective tissue and may contain tyjjical 
 glandular elements, its whole structure does not agree with the structure 
 of the liver, although tiiis also contains connective tissue and glandular 
 elements. The connective-tissue liyperplasia which takes place in the 
 course of inflannnation may also be regarded as heteroplasia. There is 
 also a condition known as heterochronia ; that is, a tissue may be formed 
 M hich represents a normal type at a certain period of development, but 
 wliich no longer conforms to the normal type. Hypertrojjhy and regen- 
 eration are always associated with an increase in the number of the con- 
 stituent elements. Increase in size of an organ may be brought about 
 by a simple increase in tlie size of the single cells, but this does not play 
 any jjart in pathology. 
 
 Tiie division of the cells wliich leads to a new formation of tissue is 
 characterized by peculiar processes which take place in the nucleus and 
 protoplasm. Recent iixvestigations have .shown that both the body of 
 the cell and the nucleus possess a complex structure. In botli the jiro- 
 toplasm and in the nucleus a thread-like structui-e can be distinguished 
 whicli encloses more or less numoi'ous granules, some of which have a 
 perfectly definite form. Sometimes these threads are so arranged as to 
 form a reticulum or sponge-work in the tissue. In the nucleus a thread- 
 like reticulum is formed, and the points where the threads join form the 
 
HYPERTROPHY A^W REGENERATION. 219 
 
 granules. In various places the nodal jioints are larger and more 
 marked. This same tibriUa structure is more condensed around the 
 outside of the nucleus and forms here a sort of membrane. In the cell 
 itself much the same structure can be recognized, but the granules and 
 threads in the cell stain differently from those in the nucleus. The 
 division of the cell is preceded by changes both in the protoplasm and 
 in the nucleus. The chromatin of the nucleus becomes arranged in a 
 different manner, and this change in the luicleus seems to be preceded 
 by changes in a peculiar body in the eell-protoi)lasm, known as the 
 centresome. This body apparently divides first, and the two granules 
 become arranged on either side of the nucleus. An unstained, spindle- 
 formed structure extends from this botii into the cell and intc> the 
 nucleus, and then the various changes in the nucleus take place. Divis- 
 ion of the cell so brought about is known as the karyomitotic, or the 
 indirect cell-division. It was at first supposed that this was the only 
 way in which cell-division took jilace, but there is also a direct division 
 of the nucleus. This form of cell-division is seen both in the leuco- 
 cytes and in the lym]ihocytes. 
 
 Tile formation of new cells is the first stage in regeneration. The 
 new cells provide the formative tissue from which the typical tissue of 
 the part is developed. In the regeneration of tissues the different 
 embryonic tissues only produce the same tissue. The epithelial cells 
 can under no circumstances produce cartilage or bone, nor is a connec- 
 tive-tissue cell able to produce cither the surface or the glandular epi- 
 tlielium. This law was formerly not so clearly known, and many 
 authors believed that the most different tissues could be formed from 
 connective tissue. In the formation of the epithelial tissues the cells 
 become united to one another by intercellular substance, the structure 
 conforming to the type of the normal tissue. In the formation of con- 
 nective tissue the most prominent feature is the formation of intercellular 
 sulistance from the cells, and the eharai'ter of this intercellular substance 
 gives the various connective tissues their ])eculiar properties. In order 
 that hypertrophy or regeneration of the tissue may take place the cells must 
 have the power of multiplication. Most of the cells of the body possess 
 this ])ower, but others seem to have apparently lost it. These are cells 
 which in the course of development have undergone a marketl differentia- 
 tion. The more the jirotoplasm of the cell departs from the t3'pe of the 
 embryonic cell by differentiation for sjiccific purposes, the more does it 
 lose its power of regeneration. The horny layers of the epidermis, the 
 non-nucleated red blood-corpuscles, the ganglion-cells of the brain of an 
 adult, all seem to have lost their power of multiplication. The more 
 inilifferent cells, such as the connective-tissue cells, those of the bone- 
 marrow, of the spleen, of the lympli-glands, and certain of the epithelial 
 cells, have retained this power to a marked degree. 
 
 The power of multiplication is one inherent in the cells themselves, 
 and even when separated from their surroundings and placed in new 
 localities they are still able to proliferate. On this power of groMiih 
 depends the possibility of the successful transplantation of tissue ; that 
 is, the transference of a piece of tissue from one place into another part 
 of the body. Pieces of the periosteum or of the bone-marrow have 
 been placed in various parts of the body or in blood-vessels, and have 
 
220 SURGICAL PATHOLOGY. 
 
 there grown and devclojjed normal tissue. The experiments which Jolin 
 Hunter made in transplanting the spurs of young eocks into the comlj, 
 where they grew more actively than in their normal situation, are well 
 known. The tissue most frequently used for transplantation is the skin, 
 and this method may be used to make up even large losses of substance. 
 The great power of reproduction in embryonic tissues has been 
 shown by experiments in the transplantation of tissue. The cartilage 
 of an adult animal either does not grow at all or makes a very feeble 
 growth when transplanted to new tissue. Portions of embryonic carti- 
 lage so transplanted lead to an excessive growth. Leopold and Zahn 
 transplanted pieces of embryonic cartilage into the anterior chamber of 
 the eye and obtained a considerable new formation of cartilage. The 
 transplantation of tissue must be done in animals of the same species, 
 because the blood-serinn and tissue-juices of an animal of one species 
 generally have a poisonous action on the cells of an animal of another 
 species. The transplanted tissue must also have a certain amount of 
 cohesion and firmness, otherwise tiie intercellular substance will be dis- 
 solved out and the tissue destroyed. It is prol^able also that the cells 
 need contact with the adjoining cells — that they derive mutual sup- 
 port from each other in their efforts to live in strange surroundings. 
 In general, the growth of the tissue transplanted is limited. This is 
 especially the case with pieces of tissue wliich are implanted deeply 
 in the body. Growth only goes on for a certain time ; it tiien ceases, 
 and the cells may disappear by absorption. As a rule, transplantation 
 of the skin is not only the most useful, but is the most successful. The 
 transplantation of skin can be made both on fresh and granulating 
 wounds, especially tm wounds \\inch are covered with vascular, actively- 
 growing granulations. Large thin pieces of skin whirli have l)een cut off 
 Avith a sliarp knife, and which consist of only the epitlermis with the cut 
 ends of the papilhe or only the upper portion of the corium, may be 
 placed on fresh granidating wounds and kept moist. The adhesion of 
 the tissue takes place by means of the lymj)ii or blood. After about eight 
 days the transplanted tissue becomes firmly united with the tissue beneath. 
 Portions of the tissue may be kept for several hours in normal salt-solu- 
 tion before they are used for transplantation. The nutrition of tiie trans- 
 planted piece of tissue appears to take place first by means of the imbibi- 
 tion of nutrient material from the juices of the tissue. Later, a germinal 
 tissue bearing blood-vessels grows up into the transjilanted tissue. In 
 some cases it appears to be e\'ident that a direct connection is formed 
 between the blood-vessels of the transplanted tissue and those of the 
 old tissue. It is hardly possible to suppose that the ti-ansplantation of 
 large parts — such as the entire finger, for instance — would be successful 
 were this not the case. It would appear impossible for an entire finger 
 to receive sufficient nutriment l)y means of imljibition to keep alive. 
 Before new blood-vessels could grow from the Ixise of the finger into 
 the severed part necrosis would certainly take place, yet we Iviiow that 
 portions of the finger, and even entire fingers, may be cut off and kept 
 for some time, and then be successfully replaced. When the surface 
 epithelium is transplanted the horny layer is cast off, and the adhering 
 tissue at first consists only of the lower layer of germinal tissue, upon 
 which a new horny layer is formed. 
 
HYPERTROPHY AND REGENERATION. 221 
 
 The process of pigmentation in the skin has been stndied by means 
 of the transplantation of epithelium. It has been found that when the 
 skin of a white man is transplanted on a negro the transplanted skin 
 soon becomes pigmented, and the pigmented skin of the negro loses its 
 pigment when transplanted on a white man. This e.\})erinient shows 
 clearly that the skin-jjigmcnt is not formed in the epithelium, but is 
 derived fr<;>m cells in the tissue lieneath, which have the physiological 
 power of forming pigment. 
 
 The question as to the cause of pathological new growth of tissue in 
 regeneration and the conditions necessary for it to take place is quite 
 obscure. One of the theories with regard to this, and «hicli appears to 
 be very plausiljle, is that the cells of the tissue have an inherent jwwer 
 of growth wiiich is held in check by their relations to the surrounding 
 tissues. When this relation is altered in any way, as when a loss of 
 substance takes place, the cells in the vicinity, having the inhibitory 
 influence of the surrounding tissues removed, proliferate actively. Other 
 observers believe that the cells have a certain irritability, a power of 
 action which may take the form of growth, and under the influence of 
 certain conditions of irritation they may be excited to growth. 
 
 Among the influences which increase the capacity of proliferation of 
 the cells, and which lead to a new formation of cells, increased nutri- 
 tion brought about by hypcrremia has an important place. It is certain 
 that this congestive hypenemia makes possible an increase in the nutri- 
 tion of the cells. It is prol)aljly necessary for cell-proliferation, but it 
 is not probable that this ah)ne leads to proliferation. The cells are not 
 nourished, Ijut they nourish themselves. In general, it is probable that 
 proliferation of the tissue in regeneration should be regarded as a second- 
 ary process which in most cases depends upon a removal of the restric- 
 tions of growth. In various attempts which have been made to excite 
 growth by chemical and mechanical irritation a lesion of the tissue, a 
 trauma of some sort, is always produced. It may take the form of a 
 direct loss of substance or of necrosis. The regenerative changes whi(^li 
 take place in the epithelium are relatively simple. Division of cells 
 takes ])lace by means of karyokinesis, and may be easily studied. In 
 epithelium composed of several layers cell-division appears to take 
 place only in the cells of the deepest layers near the lilood-vessels. 
 These cells are always younger than the others, and their protoplasm 
 has undergone no differentiation. The formation of keratin, represent- 
 ing a differentiation of the cells of the skin, only takes place after the 
 cells have been produced a certain length of time and are removed a 
 certain distance from the centre of growth. 
 
 In the regeneration of any tissue the new formation of cells does not 
 seem to take jilace from any part of the tissue at random, but onlv from 
 certain porticjus of the tissue". This was first studied by Flenniiing in 
 the lymph-gland, and he found that in the gland there are certain cen- 
 tres of growth which he described as the " keimcentren." In the liver 
 such places are seen in the periphery of the lol)ule, and in the skin in 
 the lower layers of the e]iithelitnn. It is very ]irobable that this is due 
 to more favorable conditions of nutrition of the cells in these centres 
 of growth, but it may be that in these places certain cells retain their 
 embryonic power of growth. The newly-formed cells frequently have 
 
222 SURGICAL PATHOLOGY. 
 
 not the same morphologicuil and functional character as the old, and may 
 approach the embryonic type. In tlic new formation of epithelium in 
 the lungs which takes place in chronic inflammation accompanied with 
 extensive loss of epithelium lining tlic alveoli, the newly-formed cells 
 iu the alveoli frequently have the character of columnar cells. On sur- 
 faces which are lined with ciliated epithelium the newly-formed cells do 
 not acquire cilia for some time, and in the place of ciliated epithelium 
 pavement epithelium may be formed. This is frequently seen in the 
 healing of ulcers of tlie larynx and trachea. Small losses of sul^stance 
 in the surface cpitlielium are usually (piickly replaced by growth of tiie 
 epithelium in the neighborliood. 
 
 Loss of substance in the glandular epithelium is quickly replaced in 
 case the structure of the gland is not altered. Thus in the kidney the 
 loss of single cells in the epitiielial tul)ules after intiannnation accom- 
 panied by desquamation is cpiickly restored by regeneration jiroceeding 
 from neighboring cells without any permanent lesion being produced. 
 If, however, the structure of the tissue is destroyed and the relation 
 ■with the surrounding tissues altered, complete regeneration is not apt to 
 take place, and the site of the loss of substance is occupied by cicatricial 
 tissue. In glands in wiiich two sorts of epithelium are found — as the 
 liver, for instance, in which we find both liver-cells and bile-ducts — in 
 cases of loss of substance, regeneration takes place more readily and 
 more extensively from the bile-duets than from the liver-cells. The 
 ejiithelium lining the bile-ducts is of the same character as that of the 
 liver-cells, and represents a condition more nearly approaching the 
 embryonic state. In some cases after loss of substance in glands a new 
 formation of gland-tissue takes j>lace in the same way as in the embryo. 
 In the compensatory hypertrophy of one gland which follows the loss 
 of a gland of similar structure and function there may be both an 
 increase in the size and function of the epithelium of the remaining 
 gland and also a new formation of tissue. This has been studied in the 
 growth of one kidney which follows after removal of the other, but it is 
 riot yet fully understood. It is not certain whether there is a new for- 
 mation of complex structures in the kidney, such as the glomeruli, or 
 whether these simply increase in size and in functional capacity. If 
 new glomeruli are formed, this could only take place by a general return 
 of tlie tissues to the embryonic condition. New tubules must be formed, 
 and at the end of these glomeruli must be produced in the same manner 
 as in the embryo. In the growtii of tlie kidney which takes place 
 before the adult size of the organ is reached there does not seem to be 
 any new formation of glomeruli, wiiich simply undergo an increase 
 of size. The younger the kidney, the smaller the glomeruli. In the 
 epitliclium lining the intestinal canal extensive processes of regeneration 
 may take place." In the healing of large typhoid ulcers of the intestine, 
 ju&"t as in the healing of ulcers of the skin, there is a new growth of 
 epithelium which extends from the edges and covers over the loss of 
 substance. In the newly-formed epithelium the simple glandular crypts 
 are produced, but the more highly differentiated structures, such as tiie 
 villi, are not. The newly-formed glands are not so numerous nor do 
 they have the same typical structure as in the normal intestine. 
 
 Sometimes in the process of epithelial regeneration the new forma- 
 
HYPERTROPHY AND REGENERATION. ' 223 
 
 tion of tissue may be far in excess of that ueccssary to supply the defect. 
 The epithelium in every part of the body, especially the surface epithe- 
 lium, has an almost unlimited power of growth. If there is a definite 
 chaut;e in the character of the connective tissue beneath it — if the nor- 
 mal connective tissue, for instance, is replaced by a tissue containing 
 great numbers of cells with a small amount of loose intercellular sub- 
 stances — the epitlielium grows downward into such a tissue. At the 
 edges of ulcers of the skin this atypical growth of epithelium may take 
 place to such an extent that the structure of a typical epithelial carci- 
 noma may lie produced. The growth of the epithelium only extends 
 into the pathological connective tissue, and the normal tissues are not 
 invaded bv it. In cases of intestinal suture tlie epithelium of the crvjits 
 of Lieberkiihn grows downward through the suture, and an extensive 
 growth, resembling an adenoma and extending even to the peritoneum, 
 may take place. 
 
 In all processes of regeneration new formation of blood-vessels plays 
 an imjiortant part, because only by a new formation of blood-vessels 
 can the excessive nutrition which is necessary for regeneration be 
 brought about. New blood-vessels will be formed even in non-vascular 
 parts, as in the cornea. The new formation of blood-vessels has been 
 sufficiently considered in Inflammation. 
 
 Tlie diffi'rent members of the connective-tissue group show a marked 
 difference in their respective powers of regeneration, which are most 
 active in the periosteum, the Ijonc-marrow, and the lymphoid tissue. 
 The cartilage, on the other hand, is capable of only a slight power of 
 regeneration. On the second day after fracture of bone the cells in 
 the vicinity of the fracture enlarge and multiplication begins. In the 
 physiological regenei'ation of tissue the newly-formed cells take the 
 place of the old. It is simply a growth of tlie old tissue, without any 
 intermediate steps and without any alterations of structure. When a 
 large amount of young tissue is formetl in a short time, the character 
 of the old tissue is not immediately reproduced, but the growing cells 
 and the blood-vessels form a germinal tissue which is usually known as 
 granulation tissue. The extent to which this is produced varies in dif- 
 ferent cases, and depends upon the cajwcity of growth of the tissue on 
 the one hand and the extent of the lesion on the other. After fracture 
 of bones an excessive amount of this germinal tissue may be produced. 
 The growing cells are larger and richer in protoplasm than the cells of 
 the old tissue. They may have one or two nuclei, and sometimes cells 
 with numerous nuclei, the so-called giant-cells, appear. All the cells 
 may unite in the formation of the future tissue. Wlien connective tissue 
 develops from sucli cells they arc known as fibroblasts or inoblasts. 
 
 The formative cells of cartilage and bone have I'eceived the name of 
 chondroblasts or osteoblasts. The most varying forms of cells are seen 
 in the forming connective tissue. The first step in the formation of 
 the definite tissue is seen in the appearance of fine fibrillar bundles 
 between the cells, or a homogeneous intercellular substance may be 
 formed which afterward l^ecomes differentiated into fibrillie. The for- 
 mative cells increase in size, and finally lie in small spaces in the tissue. 
 In the development of hyaline cartilage a hyaline ground substance 
 appears between the cells, and the chondroblasts assume a round form. 
 
224 SURGICAL PATHOLOGY. 
 
 As tlie ground substaiicp increases tliese cells heconie smaller, and finally 
 lie in round spaces, tiie wall of wiiicli forms tiie capsule of the curtilage- 
 cell. 
 
 The formation of new osseous tissue is a very complex process. In 
 this a homogeneous or fibrinous substance forms between the cells, and 
 afterward becomes infiltrated with lime-salts. The forming cells become 
 smaller, and finally lie in small irregular cavities, and are designated as 
 bi)iie-cells. When there is an abundant formation of germinal tissue 
 tiiis direct change of the tissue into bone is limited. Within the ger- 
 minal tissue an irregular meshwork of firmer tissue may apjiear, due to 
 the formation of firm homogeneous tissue between the cells. This is at 
 first not calcified, and is known us osteoid tissue. Afterward the inter- 
 cellular substance becomes impregnated with lime-salts. The newly- 
 formed osseous tissue is very extensive, being softer and looser in struct- 
 ure than the old bone, and the gradual conversion of this newly-formed 
 tissue into a tissue similar to that of bone is quite a slow process. 
 Mucous tissue is formed from the germinal tissue by the formation of 
 homogeneous, gelatinous, intercellular substance which contains mucin. 
 Mucous tissue frecpiently represents a transitory stage of growing con- 
 necti\e tissue, and it may be afterward converted either into fat or into 
 fibrillar connective tissue. Adipose tissue may develop in places M'hich 
 normally contain fat or it may form in any of the connective tissues. 
 The regeneration of the blood is a process which is not well understood, 
 in spite of the frequency with which it takes ])lace. The blood is a 
 very complex tissue, containing a nimiber of elements of different 
 origin. The formation of the round mononuclear cells of the blood 
 takes |)lace in the lymphatic glands, and these cells are simply taken 
 into the blood from these glands. We know very little about the for- 
 mation of the polynuclear leucocytes. This takes place in the bone- 
 marrow and in the spleen, Ijut the various steps connected with it are 
 not known. There are cells in the blood which are regarded as pro- 
 genitors of the polynuclear leucocytes, though the number is too small 
 for us to regai'd them as the only progenitors of these cells. The new 
 formation of red corpuscles is better understood. It is supposed that 
 they are formed in the bone-marrow from certain cells which are called 
 erythroblasts, by conversion of the protoplasm of the cells into the red 
 corpuscle, the nucleus becoming extruded. 
 
 New formation" of muscular tissue takes place only to a limited 
 extent after loss of substance. The increase of size of the muscles in 
 hypertrophy is principally due to increase in size of the muscular fibres. 
 After injury or loss of substance in the muscle the muscle-nuclei become 
 elongated and divide. The cells of the connective tissue and sarcolemma 
 also show rapid proliferation. The substance of the muscle between the 
 nuclei becomes broken up into larger and smaller masses, so that the 
 muscle-cells lie in spaces between these fragments. The fragments are 
 absorbed, and a new formation of muscular tissue takes place from the 
 newly-formed cells. The process is quite a slow one, and is frequently 
 not completed until two months after the injury. When the loss of 
 substance is extensive there is never sufficient new formation to com- 
 pletely supply the defect, and the gap is occupied by connective tissue. 
 
 Regeneration of the cellular constituents of the central nervous system 
 
DEATH; XECBOSIS ; ATROPHY; DEGEXEBATION. 225 
 
 does not take place in man, or in the mammalia generally, in post-embry- 
 onic life. When there is a small loss of substance in the central nervous 
 system a formation of connective tissue takes place ; if the loss is large, 
 a cyst is formed. New formation of nerve-fibres of the peripheral ner- 
 vons system is frequently seen. It takes place in all cases when nerve- 
 fibres are cut across or in any way jxTrtially destroyed. Degeneration 
 always takes place in the iieriplieral part of the nerve-fibre after section 
 or iiijurv of any sort. The central i)art, having a connection witli the 
 nerve-cell, preserves its vitality, and from this growth takes place. 
 Regeneration begins in the central stump of a nerve a very few days 
 after section, taking place by a growth of the axis-cylinder of thecen- 
 tral end of the nerve. When the peripheral degenerated nerve is in 
 contact with the central end, the growing fibres will extend along the 
 old ner\e to its muscular or sensory distrilnition. Tlie presence of the 
 old nerve gives the proper direction to the growing fibres. If the grow- 
 ing axis-cylinders do not reach the old nerve, they may extend for some 
 distance iii the connective tissues, but more usually they either undergo 
 atropliy or take various directions into the surrounding tissues and are 
 finally lost. Regenerative processes may also take place in the central 
 ends of the nerves after amputation. The regenerative gi'owth may be 
 considerable, and large masses composed entirely of a convolution of 
 rolled-np nerves may appear on the cut ends of the nerves. These are 
 called " amputation "neuromas," and frequently give rise to a great deal 
 of pain. 
 
 V. DEATH; NECROSIS; ATROPHY; DEGENERATION. 
 
 The tissues of the body are only capable of existing and preserving 
 their function for a certain length of time. Their power of regenera- 
 tion becomes less and less as age advances, and finally the regenerative 
 processes are no longer able to keep jiace with the i-apidly-advancing 
 processes of degeneration. Deatli from old age may be attributed to the 
 gradual wearing out of the organs and the gradual loss of resistance 
 which the diminution of the powers of regeneration entails upon them. 
 Life ceases with the gradual destruction of the function of one organ 
 after another. Destruction of the function of the heart, of the lungs, 
 or of the nervous system produces death in a very short time. After 
 desti-uction of the function of the intestinal canal, of the liver, or of the 
 the kidneys the organism as a whole is just as certainly deprived of life, 
 but some time may elapse befoi'e death takes place. 
 
 In contradistinction to this general death of the organism the local 
 death of a part, or of single cells or groups of cells, is called necrosis. 
 Witii the api)earance of this' local death or necrosis, affecting groups 
 of cells or an entire organ, changes of structure take jilace. These 
 changes of structure occur so gradually that it is impossible to deter- 
 mine the exact moment when the cells cease to live, and frequently in 
 the early stage of necrosis neither the microscopic nor the macrosco])ic 
 appearance is sufficient to tell us whether necrosis has taken place. The 
 causes of necrosis of the tissue are various. The tissue may be destroyed 
 by direct mechanical or chemical action. A finger can be crushed by 
 
 Vol. I. — 16 
 
2'2C) SUJROICAL I'ATJlOLOdY. 
 
 external violence; a portion of the skin may he destroyed hv sulphuric 
 acid ; and germs may destroy tissue in which they develop. The thermic 
 death-point of protoplasm lies between 54° and 60° C. If tissues are 
 exposed to this degree of heat ibr a short time, necrosis is ]iroduced. 
 Lowering the temperature does not seem to exert the same uuliivorahle 
 intlueuce. Even in niaunnals portions of the body may be (•om])Iet('ly 
 frozen for a short time and afterward be restored to function. \\'hen 
 the tissues do not receive the proper supply of blood their function and 
 resistance may be impaired, and if the blood-supply be sufficiently 
 reduced necrosis results. This form of necrosis is called anremic 
 necrosis. Examples of it are given in the various infarctions due to 
 artei'ial occlusion. 
 
 The neuropathic necrosis is due to interference with, or inhil)ition of 
 the function of, the trophic nerves. Regeneration of the tissue and 
 nutrition generally are largely imder the control of the nervous system. 
 Regeneration does not take place so completely when the nervous supply 
 of a part is destroyed. Samuel found that when the long feathers of the 
 wings of pigeons are pnlleil out they are only incompletely regenerated 
 when the nerve of the wing has l)een cut. The supposed trophic influ- 
 ence of the nerves, however, cannot be separated from the action of the 
 vasomotor nerves which accompany them. As examples of necrosis due 
 to interference with the functions of the trophic nerves the rapid and 
 severe bed-sores which develop in the course of certain diseases, espe- 
 cially after injury of the spinal cord, are cited. 
 
 Any condition which in any way interferes with the circulation in a 
 part, such as thrombosis, embolism, closure of vessels by continual tonic 
 contraction, by lesions of the walls, by ligature, by pressure from with- 
 out, inflammation, hemorrhage, etc., can ])roduce necrosis. In certain 
 tissues temporary cessation of the circidation lasting but a short while 
 may produce necrosis. The various tissues have varying powers of resist- 
 ance to disturbances of the circulation. In general, the more highly 
 organized the tissue is, the more rapidly does it succumb. The epithelial 
 cells of the kidney will undergo necrosis when the circulation is shut off 
 for only one or two hours. The ganglion-cells of the central nervous 
 system are also very sensitive. Other tissues can withstand the shutting 
 off of the circulation for a very much longer time. The skin, the bone, 
 and the connective tissues generally may live for ten or twelve hours 
 after the circulation has been cut off'. Cases have been known in which 
 small portions of the body, such as the fingers, have united perfectly 
 when replaced six hours after removal. If the circulation in the tissue 
 is imperfect or its nutrition in any way interfered with, as in general 
 marasmus or hydriemia, it undergoes necrosis much more easily than a 
 perfectly normal tissue. Necrosis takes place much more readily in old 
 peojile and in those in whom the action <k" the heart is imperfect. In a 
 part subject to chronic passive congestion or oedema a very slight cause 
 may produce necrosis. Invalids who suffer from acute diseases, partic- 
 ularly typhoid fever, may have extensive necrosis from comparatively 
 slight pressure on projecting parts. 
 
 In consequence of necrosis of a tissue a more or less extensive inflam- 
 mation is produced in the surrounding parts. This is more intense when 
 putrefactive processes take place in the necrotic tissue, which exerts a 
 
DEATH; NECROSIS; ATROPHY; DEGENERATION. 227 
 
 positive chemotiictic attraction foi" the white corpuscles, which enter 
 into it in lariic numbers. A zone of inflammation is set up which 
 separates tiie necrotic tissue from its surroundings. The dead tissue 
 may be gradually removed by absorption, or it may be cast off as a 
 whole. A part of it may remain, wiiich can afterward undergo calcifi- 
 cation and remain in the tissues as a foreign body, and become sui-- 
 rounded by a caj)sule of connective-tissue formation, or a cyst may 
 be formed in place of tlie necrotic tissue. This most commonly takes 
 place in the brain, and it is also often seen in tumors. 
 
 One of tiie most common forms of necrosis is that designated as coag- 
 ulation-necrosis. This is necrosis M'ith coagulation of tlie necrotic cells 
 and the fluid surrounding them. Both the cells and the cell-derivatives 
 after necrosis has taken place may become changed into peculiar homo- 
 geneous, dense masses. Inflammatory exudations on a suriace also unite 
 with tlie necrotic cells of the surface and form masses of fibrin appearing 
 as a membrane. The membrane consists partly of granules and partly 
 of filaments, which are found united togetiier to form thick meshes in 
 the tissue. Large hyaline refractive masses can also form in this wav. 
 In this form of necrosis various changes take place in the cells. The 
 nuclei first lose the normal arrangement of the chromatin, and become 
 changed into solid masses which may stain more briglitly than the nuclei 
 of the normal cell. The nucleus appears solid and homogeneous. The 
 nuclei afterward lose their sharp contour, become irregular, and finally 
 break up into a mass of brightly-stained granules which may be recog- 
 nized in the tissue as nuclear detritus. The best example of coagulation- 
 necrosis is given in the infarction wiiich takes place in various organs 
 in consequence of the shutting off of the blood-supply. The cells may 
 retain their fin-m for some time. They afterward become changed into 
 finely granular, homogeneous masses which may undergo absorption. 
 Coagulation-necrosis takes a special form in striated muscular fil)res. 
 When necrosis of muscular fibres takes place in consequence of crushing 
 or tearing, or of elevation of temperature in certain diseases accompanied 
 by high fever, tiie contractile myosin becomes stiftened, and frequently 
 changes into refractive iiomogeneous masses wiiich may entirely fill up 
 the sarcolemma. This form of degeneration is spoken of as the "waxy" 
 or Zenker's degeneration. This may take place in the individual fibres 
 of a muscle or may involve large masses of a muscle. It is a total de- 
 struction of tiie tissue, and is not capable of reparation. Tiie affected 
 muscles are of a pale grayish-red color somewhat similar to the flesli of 
 fisli, and liave an opaque and dry appearance. Tliis form of degeneration 
 is fre(piently found in the muscles of tlie abdominal wall in typhoid fever. 
 Hemorrhage usually takes place in the affected areas. 
 
 Another form of necrosis is known as " caseation." This term refers 
 solely to the appearance of the necrotic tissue, and is used to designate a 
 form of necrosis in wiiich tlie tissue changes into a substance resembling 
 soft white cheese. The best example of this is seen in the necrosis which 
 takes place in tuberculous products. This caseous tissue is more or less 
 brittle, and appears as an opaque whitish or 3'ellowish-white mass. Case- 
 ation takes place when masses of cells with little or no tissue between 
 them undergo necrosis. The consistency of the caseous tissue varies 
 greatly. Sometimes it is firm and dry, sometimes comparatively soft. 
 
228 SURGICAL PATHOLOGY. 
 
 Caseation cannot be regarded as a process peculiar to tiihcrcidosis, 
 although it is seen more often in tuberculosis than in any other condi- 
 tion. It is also seen in tumors which arc rich in cells and contain 
 necrotic areas due to disturbances in luitrition, and in the pathological 
 products of syphilis, but the caseation whicli apj)cars in the course of 
 sy[)hilis has a rather different character from that seen in tuberculosis. 
 The necrotic tissue may undergo liquefaction. It becomes saturated with 
 fluid, and iinally melts up, forming a fluid mass. In an anisemic necrosis 
 of the brain the necrotic tissue breaks uji into small grnnidiii- masses, 
 which are partly absorbed and partly dissolved in the circulating lymph, 
 and a cyst filled with clear fluid takes the place of the necrotic tissue. 
 Coagulation does not take place, because the brain is so poor in the 
 elements necessary to fibrin-formation. The chemical products pro- 
 duced in suppurative inflammation also have the power of dissolving 
 necrotic tissue. 
 
 A peculiar form of necrosis is that known as fat-necrosis, and in 
 connection with disease of the pancreas it has received much attention. 
 Small opaque masses are found in the fat in various places in the 
 abdominal cavity. They vary in size from a mici'oscopic point up 
 to areas several millimetres in diameter. On section of the pancreas 
 they are also seen in the connective-tissue septa running thn)ugh the 
 gland. Fat-necrosis is associated with various diseases of the ])ancreas, 
 with hemorrhage, with acute suppuration, and with other conditions. 
 It is held by some authors that the changes in the fat arc primary, and 
 that the lesions in the pancreas are due to necrosis in the glandular 
 septa. It is held by others that the lesions in the pancreas are primary, 
 and that the necroses of the surrounding fat are due to the action of the 
 pancreatic juice which escapes into the suri'ounding jiarts. The distri- 
 bution of the areas of necrosis gives some ground for this assumption, 
 l:)ut it has not been confirmed by experiment. The necrotic areas in the 
 fat are intensely resistant. They are not aflected b}' mineral acids nor 
 by caustic alkalies. The peculiar change in the fat is due to a combina- 
 tion of lime-salts with the fatty acids. 
 
 ISInmmification, or dry gangrene, is seen in the senile necrosis of the 
 lower extremities and the toes, and in the necrosis following frost-bite. 
 Senile necrosis is due to imperfect circulation in the part, resulting partly 
 from general weakness of the circulation and partly from disease of the 
 intima of the artery with thrombosis, or from embolism. In frost-bite 
 the necrosis is produced by the influence of low temperature lasting for 
 a considerable time. In both frost-bite and senile gangrene there is 
 venous hypersemia while the necrosis is taking place. The necrotic 
 tissue is filled with blood, and by the diff'usion of the blood-coloring 
 matter the necrotic part acquires a dark-red or black ajjpcarance. 
 Vesicles are formed which rupture. The entire epidermis of the part 
 may be removed, evaporation goes on rapidly, and the ])art becomes 
 changed into a dry, hard mass with a leathery surface. A sharp line of 
 demarcation is established between the healthy and the gangrenous tissue, 
 and the gangrenous part may l)e gradually separated from the living 
 tissues by suppuration and softening. The inflannuatory exudation exerts 
 a dissolving action on the necrotic tissue. The separation takes place 
 readily through the soft parts, and in the course of time may extend 
 
DEATH; NECROSIS; ATROPHY; DEGENERATIOX. 229 
 
 tlii'onoli tlie hones. Moist ganorenc, oi- sphacelus, is ehuracterizecl by 
 decomposition or puti'efaction in the necrotic tissue. This takes phice 
 wlien the organisms of putrefaction enter into a ii'ano-renous part wiiich 
 contains a hirge amount of fluid. The gangrenous part may have its 
 temperature elevated, this being due both to the process of decomposition 
 and to a surrounding inflammation ; and this condition is known as " hot 
 gangrene." The ])utrefactive tissue soon begins to emit a foul odor and 
 becomes broken down. Sometimes the process of decomposition is accom- 
 panied with the formation of gas, which may iniiltrate the tissue. Tiie 
 various tissues of the gangrenous part show ditferent degrees of resistance 
 to the pi-ocess of putrefaction. The bone may remain for some time, while 
 the soft parts are rapidly broken down. The tendons and large arteries 
 are also relatively resistant. On microscopic examination there are nu- 
 merous liacteria jiresent, most of which belong to the anacrotjic forms. 
 The blood-corpuscles become dissolved, Ijroken up, and converted into 
 masses of granular pigment. The fat-cells are broken down, and the fat 
 appears in the form of small drops in the tissue. There are various 
 crystalline products of this decomposition. We may find crystals of the 
 fiittv acids in the form of long needles, the needle-shaped crystals of 
 tvrosin, the globular masses of leucine, and the coffin-shaped crystals of 
 triple phosphates. 
 
 Hypoplasia is the condition in which portions of the body, or single 
 organs or parts of organs, have an imperfect form of development in 
 consequence of inhibition of growth. This may be due to intrinsic causes 
 in the organs themselves resulting from imperfection in the germ, or 
 it mav ])e due to the influence of external causes. When organs or 
 parts of organs are entirely al)sent, the condition is known as aplasia or 
 agenesis. Examples of hypo[)lasia are seen in imperfect growth of the 
 bones and in imperfect development of the heart or large vessels or 
 of the genitalia or the central nervous system. The normal gradual 
 development of a part may be interfered with and a foetal conditi(jn of 
 the organ result. The hy])oplasia may affiect organs which are necessary 
 for life, or organs which serve some purpose not essentially connected 
 with the preservation of the life of the individual. For instance, the 
 genitals may remain in the fetal condition or in that of early childhood. 
 Hypoplasia may produce disturl)anees of function only, or it may be 
 incompatii)le with life. 
 
 The condition of atrophy is usually separated from that of liyjxt- 
 plasia. Atropiiy is a diminution in the amount of tissue, which takes 
 place in an organ or part which has been noi'mally developed. It may 
 be due to an imperfect power of regeneration which cannot keep pace 
 with the constant waste. Old age furnishes an example of this. There 
 may be atrophy either of the entire liody or of any of the individual or- 
 gans or tissues of the body. An individual may die from old age without 
 any preceding disease as soon as the atropiiy of important organs readies a 
 condition which is incompatible witli the proper performance of function. 
 There is a physiological atrophy of certain organs which may take place 
 in an early period of life. Certain organs which were necessary for life 
 of the embryo undergo atrojihy before birth. The sexual glands of the 
 female may become atrophied and incapable of function long before tiie 
 period of general senile atrophy is reached. The thymus gland atrophies 
 
230 SURGICAL PATHOLOGY. 
 
 before the completion of the period of growth. Anatomically, atroi)liy 
 is usiiuilly characterized bv diminution in size of an organ. Microscopi- 
 cally, it is seen in the diminution in size, and finally the complete disap- 
 pearance, of the specific elements of an organ. Atropiiy may ])n)(hicc 
 ditferent appearances in dit^'ercnt organs. In large organs rich in specific 
 elements, as the liver, the kidney, the heart, and the brain, tiie diminu- 
 tion in size is the most striking feature. If the atrophy is a general one, 
 affecting equally all parts of the organ, tlie surface may remain smooth. 
 If it takes place only in certain parts of the organ, it gives to the sur- 
 face an uneven appearance. Tiie atrophied portions will l)e depressed, 
 and the normal portions will appear correspondingly elevated. Tliere 
 may be atrophy \Nitliout any macroscopic changes in form. A bone may 
 atrophy without any change in its external size or shape, the atropiiy 
 having taken place in the interior of the bone by enlargement of the 
 medullary canal. The bones of old individuals may be little more than 
 shells enclosing a large medullary cavity. Diminution in the size of 
 atrophied organs is usually duo to destruction of tiieir specific elements. 
 The connective tissue of the organ may not take part in this atrophy at 
 all ; in some cases it may be even increased, so that an organ in \\iiich 
 a considerable degree of atrophy has taken place may be of normal size 
 or even lai-ger than normal. Tiiis condition is seen in the ])scudo-hypei'- 
 trophy of muscles. In the atro])hy of the kidneys wliich takes place in 
 old age or in various otlicr conditions the epithelial cells of the urinary 
 tubules gradually become smaller and finally disappear, and the tubules 
 collapse. The epithelium of the glomerulus also becomes destroyed, the 
 capillaries collapse, and finally the glomerulus is represented by a small 
 hard mass of connective tissue. Fat often undergoes a peculiar change 
 in conscfjuence of atrophy. Tiie fat in the cell In-eaks up into small 
 drops which become absorbed, and the cells freed from fat liecome 
 transformed into their original character as c<mnective-tissue cells. 
 
 Two forms of atrophy, active and passive, have been distinguished. 
 In active atrophy there is a diminution in the capacity of' growth and 
 regeneration of the cells, in consequence of which they cannot assimilate 
 the nutritive material whicii may l)c lirought to them in tlie proper 
 quantitv. In passive atro]ihy the cells are capable of growth and 
 regeneration, but there is a diminution in the amount of nutritive mate- 
 rial which is brought to them. Both of these sorts of atrophy are fre- 
 quently combined. Atrophy may be divided into senile atrophy, atro- 
 j)iiy in consequence of imperfect nutrition, atrophy from pressure, atroiihy 
 from disuse, and neuropathic atro])liy. 
 
 Senile atropli}' ma}' take place in all or any of the organs and tissues, 
 but it is frequently more develoj)ed in some organs than in others. 
 Organs such as the kidneys, the liver, the brain, and the heart can 
 undergo very important diminution in size. Senile atrophy is also .seen 
 in the skin of old people, and this is one of the most common atrophic 
 conditions produced liy old age. The skin loses its firmness and elas- 
 ticity and l)ecomes thin and jiarchnieiit-like. 
 
 Atropiiy in consequence of disturbed nutrition is produced by imper- 
 fect assimilation. It may affect the entire organism or lie more marked 
 in certain tissues than in others. For instance, the fat of the body, tiie 
 muscles, and the large abdominal glands show relatively a greater degree 
 
DEATH; NECROSIS; ATROPHY; DEGENERATION. 231 
 
 of atropliy than the other tissues. Local atrophy may result from local 
 interference with the circulation. An entire organ may undergo atrophy 
 in consequence of diminution in calibre of its main artery brought about 
 by disease, or only small branches of the artery may be affected, pro- 
 ducing atrophy of circumscribed portions of the organ. Atrophy may 
 be the result of pressure, even of comj)arativcly slight degree, when it 
 is constantly exerted. It is due partly to direct injury of the cells of 
 the tissue in consequence of the pressure, and partly to interference with 
 the blood-sujiply. The most typical example of this is seen in the broad 
 band across the lower portion of the liver in women, corresponding to 
 the line of the waist, and which is the result of the pressure of corsets. 
 Himetinies this is so marked that there may be almost a complete sepa- 
 ration of the lower portion of the right lobe of the liver from the rest. 
 The atrophied part of the liver is marked by a thickening and roughen- 
 ing of the surface due to increase in the connective tissue. The firmest 
 tissue may give way before a constant pressure. For instance, the pres- 
 sure by an aneurism on bone, as in aneurism of the aorta jwessing ujion 
 the sternum or uj)on the vcrtelnw, may produce complete atro})hy and 
 destruction of the lione. 
 
 Atrophy from disuse is seen in all tissues whose ordinary functions 
 are suspended. It is more marked in the muscles, glands, and bones 
 than in any other jiarts. The atropliy is essentially an active one. ^\ ith 
 the diminution in function the capacity of tlie tissue for assimilation also 
 diminishes. There is also diminution in the activity of the circulation 
 in organs \\itli imperfect function, and the atrophy may be in part due 
 to this. When the disuse appears during the period of development, 
 and when the part in consequence is imjjerfectly developed, the con- 
 dition may be regarded as one of hypoplasia. No sharp line can be 
 drawn between atrophy and hypoplasia, since the hypoplasia of tissue 
 may be associated with destruction of tissues which have already been 
 formed. One of the best examples of atrophy from disuse is seen in the 
 diminution in size of paralyzed parts. 
 
 Neuroj)athic atniphy is the result of pathological conditions of the 
 nervous system. The best examples of neurojiathic atrophy are seen in 
 the atrophy of the corresponding nerves and muscles which follows 
 atrophy of the anterior horn or anterior nerN'e-regions of the spinal 
 cord. After injury of peripheral nerves the skin corresponding to their 
 distriliution may undergo atrophy and become thin and shiny. Affec- 
 tions of one side of the brain in fcctal life and in childhood may ]n'oduce 
 atrophy of the corresponding portions of the face and body. In this 
 condition the jtrocess is not usually one of sim])le atrophy without any 
 preceding change, but is preceded by various forms of degeneration, 
 of which the atropjiy represents the last stage. It is due to interference 
 with the vasomotor system "by which every part of the body exactly 
 regulates its nutrition. Disuse of the parts and the greater suscejitibility 
 to trauma may also play an important part. Even for this form of 
 atropliy it is not necessary to assume the existence of special trophic 
 nerves. 
 
 Degeneration of Cells. — One of the forms of degeneration of cells 
 is known as cloudy swelling, or parenchymatous or granular degeneration. 
 The term M'as first used bv Virchow, who regarded cloudv swelling as 
 
232 SURGICAL PATHOLOGY. 
 
 ail inei'ease in the size of the cells pnidueed liy iiicrensed nutrition, or 
 as hypertrophy with a tcndenev to (leii;eneration, hut the ])roet'Ss is 
 now regarded as degeneration. In cloudy swelling there is an increase 
 in the size of the (!ells due to the accumulation of fine granules in 
 the protoplasm. These granules are sohible in acetic acid and insoluble 
 in caustic potash and ether. In consequence of the presence of the 
 granules in the cells the nucleus is obscured, and it only becomes 
 visible after the granules are cleared up by the addition of acetic 
 acid. The process may be recovered from and the cells return to 
 their normal state, or they may be converted into masses of granular 
 material, and then break down and disappear. Fatty degeneration of 
 the cells is frequently comljined with cloudy swelling. It is best seen 
 in the parenchymatous organs, such as the liver, the kidneys, and lieart. 
 It aj)pears in most of the acute infectious diseases, cs])eciallv in those 
 which are accompanied with high fever. The aifected organs have a 
 cloudy, dull, grayish appearance. In the highest degree of the affection 
 they look as though they had been boiled. The consistency is doughy 
 and the minor details of structure are oljscure. C'loudv swelling is fre- 
 (juently combined with a dr()])sical degeneration due to a swelling of 
 the cells from the absor])ti()n of Huid. From the absor])tion of the fluid 
 the interior of the cell apjtears clear and the granules of protoplasm are 
 separated from one another and are sometimes pressed to the periphery 
 of the cell. Such changes of the cells are found in ccdematous tissue, in 
 inflannnatory foci, and in tumors. 
 
 Cloudy swelling frequently ])asscs into fatty degeneration. In this 
 fat-drops are formed in the cells, which tinally break up into masses of 
 fatty detritus. Certain tissues of the body normally contain a varying 
 amount of fat. These tissues rejiresent a storehouse for fat, which is 
 cither introduced from without or forms in the organism and is dcj)osited 
 in these places. An inci'ease of this fat is not regarded as fatty degen- 
 eration, but as lipomatosis or obesity. Up to a certain degree it can be 
 regarded as physiological. When it becomes excessive it represents a 
 jjathological condition. The deposit of fat takes place in the cells in the 
 form of small drops, which gradually fuse together to form large globules, 
 and finally a single large glol)ule of fat may fill uj) the entire ceil. The 
 distinction which is made between lijiomatosis and fatty degeneration is 
 that in fatty degeneration the fat results from a destruction of the jn-oto- 
 ])lasm of the cells by its conversion into fat. In the jiroccss of nutrition 
 fat is probably formed by the destruction of albumin, Init in fatty degen- 
 eration it is the albumin of the cell, and not the albumin of nutrition, 
 which is broken up. Fatty degeneration especially takes place under 
 conditions in which there is at the same time a tendency for the albumin 
 of the cells to break down and a diminution of oxidation. It is fre- 
 quently found in advanced phthisis, in which the oxidation in the tissue 
 is greatly reduced on account of the destruction of lung-tissue. It is 
 found in the varying forms of ansemia — both in the antemia caused by 
 direct loss of blood by hemorrhage and in other conditions in which the 
 red blo(.)d-corpuscles are destroyed, causing a diminution in the amount 
 of oxygen conveyed to the tissues. In the fiitty degenerated cells there 
 are larger and smaller drops of fat, which are colorless, dark, and re- 
 fractive. When these drops are very small it is difficult to distinguish 
 
DEATH; NECROSIS; ATROPHY; DEGENERATION. 233 
 
 thcni from the granules in the protoplasm seen in cloudy swelling', hut 
 on the addition of acetic acid the granules are cleared U]) and the fat 
 can be distinguished. The number and size of tlu' fat-drops in tiie cells 
 vary, but in general the drops are very nuieh smaller than we lind them 
 in the accumulation of fat. In some instances the fat accunudates iu 
 certain parts of the cell only. In fatty degeneration of the kidney the 
 fat is formed in the periphery of the cells close to their insertion. The 
 degeneration may not affect all of an organ, but only certain small areas, 
 and these areas by their opacity and whiteness form a marked contrast 
 to the surrounding tissue. This is fre((ucntly seen in the heart and in 
 the kidney. In the heart the altei'uation of the fatty areas with the more 
 normal tissues gives to the organ a spotted appearance which has been 
 compared to that of a leopard skin or of a faded leaf. Fatty degenera- 
 tion may take place in tiie voluntary muscles in antemia and in other 
 cachectic conditions, but it is more often seen in cases of disuse. Muscles 
 which have been for a long time paralyzed undergo various degrees of 
 fatty degeneration — a fact which points clearly to the etfects of dimin- 
 ished oxidation. 
 
 In certain conditions glycogen may accumulate in the cells in the 
 form of roiuid globules. It can be recognized by hardening the tissues 
 in absolute alcohol and staining with iodine, which gives to the glyco- 
 gen a brownish-red color. Glycogen is normally found in the liver, in 
 voluntary muscles, in the myocardium, in the colorless blood-corpuscles, 
 in blood-serum, in cartilage-cells, and in almost all embryonic tissues. 
 In diabetes the epithelium of the kidney, especially the epithelium of the 
 tul)ules of Henle, may contain glycogen. It may be present in various 
 forms of tumors, especially in the epithelial cells of carcinoma, and is 
 more generally present in carcinoma of the testicle than in carcinoma 
 elsewhere. 
 
 In mucoid or colloid degeneration there is a formation of material 
 called mucus in the cells and in the tissues. The physiological type 
 of this formation of mucus is seen iu mucous membranes and glands, 
 also in tlie tissue of tiie umbilical cord, in the various bursie, and in 
 synovial membranes. In nuicous mcmliranes the nnicus is formed in the 
 so-called goblet-cells. These are large swollen cells which have the 
 appearance of a goblet, with a mass of mucus projecting from them. 
 Apparently, this power of forming mucus exists in only certain of the 
 ej)ithelial cells. It may be increased under jiathological conditions, as in 
 catarrhal inflannuatiou of tiie mucous membranes, in which there is an 
 increased formation of clear mucus both in the surface e])itlielial cells and 
 in the cells of tiie glands. Pus-corpuscles can undergo mucoid degenera- 
 tion and mucin be formed in them. In certain tumors, as in the niulti- 
 locular cysts of the. ovary, there is an enormous formation of mucin. 
 Witii regard to the formation of mucin in connective tissue, Virchow 
 believes that it is formed by a secretion of the cells and is analogous to 
 tiie formation of fat. Koester believes that in the mucoid degeneration 
 of the connective tissue there is no new formation of mucin. The apjiar- 
 ently mucoid tissue is really cedematous comiective tissue, and the mucin 
 already present in the tissues is swollen up by the imbibition of fluid. 
 The term " mucoid degeneration " is one which is rather loosely used, 
 and it is probable that various forms of degeneration of connective tissue 
 
234 SURGICM. PATHOLOGY. 
 
 are ineliuled under tliis general liead. Colloid degeneration is elosely 
 related to the mucoid. Its proiluet appears to be derived irom the 
 metamorphosis of albumin, although we know nothing definitely of the 
 cheniiral proeesses of its formation. It is formed from the cells, and 
 physiologically it is always present in the tiiyroid gland, giving to a 
 section of this gland a gelatinous appearance. It apjjcars first in the; 
 epithelial cells of the gland in tlie form of small globules. The entire 
 cell may undergo this transformation, or the single globules may be 
 ejected from the cells and unite to form a large colloid mass in the centre 
 of the alveolus. 
 
 A form of degeneration known as hyaline was first described by 
 Recklinghausen. Its name indicates its most characteristic feature. 
 It is a perfectly homogeneous material which has rather indefinite stain- 
 ing reactions. It stains with eosiu, with carmine, with picrocarmine, 
 and with certain of the acid anilines. It has the same reaction to 
 alcohol and various other- agents as has the amyloid material, but it has 
 not the characteristic stain with iodine which the latter has. It is very 
 probable that the hyaline material embraces a number of different jtrod- 
 ucts. It is found in certain epithelial tissues, where it is closely related 
 to the colloid material, if not identical with this. In certain forms 
 of nephritis a homogeneous, firm material accumulates in the urinary 
 tubules and is passed from the kidneys, appearing in the urine as hya- 
 line casts. This material has ap])ar('ntly been formed by a degeneration 
 of the protoplasm of the cells, and a])])ears first within the cells in tlie 
 fi)rni of small homogeneous drops. There may be a similar process in 
 the lungs. In certain forms of pneumonia in cattle the alveoli may 
 become filled with firm, transparent, homogeneous masses. Large epi- 
 thelial cells containing in their interior homogeneous globules may be 
 found enclosed in the hyaline masses, «hich probably are derived from 
 coalescence of hyaline glol)ules formed in the epithelial cells. The 
 material described as hyaline in some cases seems to be identical with 
 or closely related to fibrin. It may appear in the form of homogeneous 
 masses which entii'ely occlude small blood-vessels. This is fretpiently 
 seen in the blood-vessels of the lungs in various infectious diseases, espe- 
 cially in those due to infection with streptococci. It is also seen in the 
 l)loo"d-yessels of the kidney, where it occludes the capillary vessels of 
 the glomeruli. This fi>rm of hyaline material stains in the same way as 
 fibrin, and it is probable that it is identical Avith it. The newly-formed 
 connective tissue in chronic inflanmiations may be converted into a 
 homogeneous, firm mass in which no cells are found. This is also spoken 
 of as hyaline, but it must be regarded as entirely different from the other 
 forms of hyaline. It is probable that we shall know little of these forms 
 of degeneration until the chemistry of the process shall be in some way 
 discovered. 
 
 Amyloid Degeneration. 
 
 Under certain conditions a peculiar albuminous substance, called 
 amyloid, is deposited in the tissues. This deposition may take place in 
 almost all the organs of the Ijody, but a]i]iears most often, in the order 
 given, in the spleen, the liver, the ki<lneys, the intestine, the stomach, the 
 adrenal glands, the pauci-eas, and the lymph-glands. It is more rarely 
 
DEATH; NECROSIS; ATROPHY ; DEGENERATION. 235 
 
 seen in the adipose tissue, the thyroid, the aorta, the heart, the muscles, 
 the ovaries, and the uterus. It may taive place in organs which are the 
 seat of some other disease or in those wliieh were previously sound. 
 The amyloid material is generally found along tlie small l)lood-vessels, 
 especially in the walls of the small arteries. At first sight it appears as 
 though the entire wall of the artery were converted into amyloid, but 
 closer examination Mill show that the amyloid material is infiltrated 
 between the muscle-cells. Though spoken of as a degeneration, it 
 rcallv is not produced by a metamorphosis of the tissue, but is an infil- 
 tration which is deposited between tlie cells of tlie tissue and gradually 
 produces atrophy in tlicni. It is frequently combined witli other forms of 
 degeneration, especially the fatty. Even though an organ be sound when 
 the dei)0sit of amyloid first takes place, this deposit, from its position, 
 situated as it is about the blood-v^essels, will lead to such disturbances 
 of tlie circulation and nutrition of the organ that other fi)rnis of degen- 
 eration will occur. If a section of sucii an organ, eitJier fresh or after 
 hardening in alcohol, be treated witli an aqueous solution of iodine, the 
 amyloid material becomes a reddish-brown mahogany color, contrasting 
 sharply with the normal tissue, ^vhich has a slight yellowish tint given it 
 by the iodine. If amyloid material so stained be treated with a dilute 
 solution of sulphuric acid or with chloride of zinc, the brown color some- 
 times l)cct)mes more intensified or it may take a slight violet tone. A 
 more direct reaction is given by any of the blue aniline colors, especially 
 gentian-violet. Fresh sections of the affected tissue may be placed in 
 the coloring agent and afterward washed out in very dilute acetic acid. 
 The amyloid substance acquires a brilliant red color, and contrasts 
 sharply with the normal tissue, which has the ordinary blue stain. The 
 situation of the amyloid in the walls of tiie arteries would seem to indi- 
 cate that it is firmed either in the blood or in some special organ, and 
 afterward deposited in the walls of the vessels and in the tissues. We 
 do not know, however, any organ in which such a formation could take 
 place. The most prevalent view now held concerning it is that it is 
 fQrmed from the albumin in the place where it is found. The cells 
 seem to lose their power of properly assimilating albumin, and it under- 
 goes tliis peculiar form of degeneration. The conditions under which 
 amyloid infiltration takes place are well known. It is always found in 
 cachectic conditions of the body brought about by long-continued sup- 
 puration or by certain chronic diseases. It is rather more frequent in 
 syphilis than in any other disease, and it is rare that we find any exten- 
 sive visceral lesions of syphilis without finding a certain amount of 
 amyloid in the tissues. It is especially apt to occur in the chronic 
 afi'ections of bone. The recognition of amyloid infiltration of tissues is 
 very important. The iiutritLon ami general resistance of the tissues are 
 so impaired that surgical operations and injuries usually are not well 
 borne. 
 
 The amyloid material may also appear locally, producing localized 
 infiltration of the tissue or solid accumulations of amyloid. Large 
 nodules which are entirely composed of amyloid may form in the tissues. 
 Such nodules have been seen in the inflamed conjunctiva, in syphilitic 
 cicatrices of the liver, in the tongue, in the larynx, and in inflamed 
 lymph-glands. In cicatricial tissue, changes which appear to indicate 
 
2.3f) SURGICAL PATHOLOGY. 
 
 prcccdiiitr stages to amyloitl formation may be seen. Instead of a per- 
 fectly definite color-reaction with gentian-violet, there may be only a 
 slight reddish or mahogany tint given to the tissues. The corpora 
 aniylacea are composed of a sul)stance either amyloid itself or closely 
 related to it. These are small, firm, round bodies which varv consider- 
 ably in size, are formed normally in the prostate gland, and have a con- 
 centric structure which gives them a striking similarity to starch-gramdes. 
 They have nothing to do with the general amyloid disease, and are formed 
 in consequence of local conditions in the tissues. In the prostate thev 
 appear to be due to accumulation of degenerated epithelium. 
 
 Calcification. 
 
 Lime-salts may be deposited within the tissues in the form of a gene- 
 ral infiltration which is spoken of as calciiication, or in the form of 
 masses not connected witli the tissues and which are called concrements, 
 stones, or calculi. C'alcitication never takes place in perfectly normal 
 tissues, but the deposit of the lime-salts is always preceded bv necrosis. 
 It is probable that the necrijtic tissue undergoes certain modifications in 
 its chemical reaction, in consequence of which the lime-salts held in sus- 
 pension in the fluids of the tissue are deposited in it. Calcification is 
 especially apt to take place in dense cicatricial connective tissue which is 
 poor in cells and nuclei. It is also frequently seen in the degenerated 
 tissue in the walls of the blood-vessels, in tinnors, and, in fact, every- 
 where where there is necrotic tissue. The infiltration may be found 
 only in the intercellular substance, the cells having disappeared, or in 
 some cases it is found in the cells themselves, the intercellular substance 
 being little or not at all affected. One of the most frequent places in 
 which the lime-salts are deposited is in the walls of the large arteries 
 and in tiie left side of the heart. It would a|)pear, at first sight, as 
 though tliere might be some connection between the lime-salts and 
 arterial blood, but the truth is that the various forms of degeneration of 
 the blood-vessels and the endocardium are more common in the left side 
 of the heart and in the arteries than in the right side of the heart and 
 in the veins. Thrombi may become calcified, forming vein-stones or 
 phleboliths, and the necrotic tissue of an infarction may also become 
 completely calcified. In general, calcification takes place in the lower 
 animals, especially in the herbivora, to a much greater extent than in 
 man. In gout there is a deposit of the urate of soda in the tissues. This 
 may take place in the kidneys, in the skin, in the subcutaneous tissues, 
 in the tendons, the ligaments, the synovial membranes, and the cartilage 
 of the joints. The favorite seat of the deposit is in the metatarso-phalan- 
 geal joint of the great toe. It is probable that the deposit takes place 
 principally, if not exclusively, in tissues which have undergone necrosis. 
 It appears in the form of long, slender, needle-shaped crystals. A forma- 
 tion of free concrements or calculi can take place in the various canals 
 and cavities of the body which are lined with epithelium. Such concre- 
 tions may form in the intestinal canal, in the ducts of the large intestinal 
 glands, in the gall-ldaddcr, in the urinary tract, and in the respiratory 
 passages. All of these concrements have an organic basis, and lime-salts 
 are deposited in this material. In the intestinal glands the calculi consist 
 
DEATH; NECROSIS; ATROPHY; DEGENERATION. 237 
 
 of a deposit of lime-salts around thiekened faeces or various undigested 
 vegetable masses. Tiie most frequent j)laee for the formation of con- 
 crements is in the gall-l)la<l(k'r, wiiieh may contain but one or may be 
 filled up with large numbers of them. A\'hen there are several present 
 their surfaces become faceted by mutual pressure. 
 
 These gall-stones are usually composed of cholesterin united with 
 various constituents of the bile. In rarer cases they are formed from 
 carbonate of lime. xVfter tiie cholesterin is dissolved tliere still remains 
 a homogeneous substance. Tliere can be no doubt that the formation of 
 gall-stones is due to the incrustation of an organic mucoid substance 
 with the constituents of the bile. Colon bacilli have been found in gall- 
 stones. 
 
 The most imjiortant conci'ements and calculi of the l>ody are those 
 found in the urinary j)assages. They may form either in the kidney, in 
 the ureter, or in the i)ladder. In tlie kidney they not infrequently foriii 
 large irregular masses which may till up the entire pelvis of the kidne}' 
 and extend into the calyces, or only small masses may be formed. Con- 
 crements appear in the tissue of the kidney itself in the form of very 
 small masses, which may either lie in necrotic epithelium or in the 
 lumen of the tubules. In the so-called uric-acid infarction of the kid- 
 ney, which is so common in children who die in the first week of life, 
 there is sinij)ly a deposit of urinary sediment in the occluded tubules. 
 The large calculi formed in the urinary l)ladder consist of an organic 
 substance, jjrobably related to albumin, in which various salts are de- 
 jiosited. What sort of material will lie dejiosited in these masses depends 
 upon circumstances. If large amounts of uric acid are excreted, as in 
 the uric-acid diathesis, calculi may form conijio^ed of this. A\nicn there 
 is decomposition of the urine in the bladder, with the jiroduetion of 
 triple phosphates, calculi can be formed of this substance. When a cal- 
 culus has once been formed the irritation which it produces is favorable 
 to its increase. All sorts of foreign bodies introduced into the bladder 
 can serve as nuclei for the formation of calculi. 
 
 Pigmentation. 
 
 Many of the normal tissues of the body, both connective tissue and 
 epithelium, contain a certain amount of pigment. The pigment is 
 almost always contained in the cells, and consists of brown or dark 
 amorphous granules. Examples of such pigmentation are found in 
 the iiair and in the choroid of the eye. The nerve-cells in the central 
 norv(nis system contain a small amount of pigment, and pigment is also 
 contained in the cells of some of the glands. The skin may show a 
 general pigmentation, or the pigment is seen only at certain places ; for 
 instance, in the axilla and over the scrotum. During pregnancv the 
 pigment of the skin, especially in brunettes, undergoes a considerable 
 increase. Tiicre maybe a marked increase in the jiigment Ijrought about 
 by certain diseases, as in Addison's disease, in which lesions may be found 
 in the suprarenal capsules or in the semilunar ganglia. The pigment of 
 the heart shcnvs considerable increase in certain forms of atrophv of the 
 myocardium, especially in the atrojihy of old age. Pathological ])igmen- 
 tatiou is also seen in the freckles of the skin and in the congenital pig- 
 
238 SURGICAL PATHOLOGY. 
 
 nicnted moles. Certain tumors belonging to the sarcomas also show a 
 marked degree of pigmentation. The pigment may be brown or show 
 every degree of transition up to perfectly black masses. It usually lies 
 in the cells, and rarely in the intercellular substance. Wlicn it is found 
 in tile intercellular substance, it is probably due to its being set free by 
 rupture and destruction of cells. The formation of pigment seems to be, 
 in the main, a property of cells belonging to the connective tissue. In 
 the skin, although the pigment may be contained in or between the 
 epithelial cells, it appears to be formed in large branched cells in tiie 
 subcutaneous tissue. The source of the pigment has not been in all eases 
 definitely ascertained. It is true tiiat pigment mav be formed from the 
 blootl-eoloring matter, but hemorrhage is not generallv found in the areas 
 where pigmentation is taking place. The pigment which is derived 
 from the blood under ordinary conditions is usually brown or reddish- 
 brown, and has not the deep-brown or black color found in other con- 
 ditions. Chemical investigation has shown that some of the pigment 
 contains iron, while other pigment is free from it. The blood-extrava- 
 sation which takes j)lace in an ordinary bruise undergoes various changes 
 of color. When the extravasation has taken place in a transparent 
 tissue — for instance, in the pleura or in the peritoneum — a rusty-brown 
 color may remain for a long time afterward. All these changes in color 
 corres])ond to physical and chemical alterations of the hfemoglobin and 
 the iron contained in this. A\'hen hemorrhage takes place in the tissues, 
 the red blood-corpuscles may be takt'n up by the lymphatics in an un- 
 changed condition, or the haemoglobin may be dissolved out of them and 
 taken up by the circulation. It is this dissolved blood-coloring matter 
 which produces the various changes of color in the neighborhood of blood- 
 extravasations. Blood-crystals may bo formed from the exti-avasated 
 blood, and they are frequently found in the remains of old hemorrhages. 
 In cases of chronic passive congestion there is usually a certaiii amount 
 of diapedesis, and a brownish color may be given the tissues by the 
 presence of the blood-pigment. The best example of this is seen in the 
 chronic passive congestion of the lung, the salmon-brown color in this 
 being due to the presence of large cells in the alveoli of the lung, which 
 are filled with brownish-red or brownish-yellow' jiigment. In jaundice or 
 icterus the pigmentation is due to the coloring material of the bile. 
 During life this is easily recognized in the skin and in the conjunctiva. 
 When the jaundice first appears the tissues have a bright-yellow color, 
 and after it has existed for some time this changes into an olive-green 
 or a grayish-green color. Jaundice is usually due to some condition 
 which interferes M'ith the passage of the bile and leads to its absorption 
 into the lymphatics of the liver, and from this into the blood. Swelling 
 of the mucous membrane of the bile-ducts, due to catarrhal inflam- 
 mation, narro^ving or closure of the bile-ducts by cicatrices or by the 
 ])resence of gall-stones, tumors develojied in the bile-duct, or the pressure 
 of tumors outside of the ducts, may all be followed by jaundice. The com- 
 mon bile-duct is comparatively large and thin-walled. The pressure of 
 the bile within it is very low, and a ^•ery slight ilegree of distentii:>n will 
 lead to the retention of the bile and its absorption. Accoi'ding to various 
 authors, there is a form of jaundice, the so-called hsematogenous jaundice, 
 which is produced by the conversion of the haemoglobin of the blood in 
 
TUBERCULOSIS AND TUBERCLE. 239 
 
 the blood-vessels into hile-coloring matter. The results of experiments 
 have tended to show that a pure ha?matogenous jaundice does not exist, 
 but there niav be a destruction of red blood-corpviscles in the l)lood, and 
 the lueniatoiilin thus set free is converted in the liver into bilirubin and 
 then absorbed. 
 
 The tissues may also become pigmented from pigment which is taken 
 into the liody from without and absorbed in the tissues. The pigment 
 mav enter the bodv by means of the resjiiratory or intestinal tract and 
 from wounds. In the operation of tattooing the skin is broken and in- 
 soluble c<iloring material is rubbed into the wounded surface. A portion 
 of this material remains in the tissues at the place, and a portion is taken 
 up by the lymphatics and carried to the adjacent lymphatic glands. In 
 case the arm is tattooed the epitrochlear and the axillary glands always 
 contain the same pigment which is rut)bed into the skin. The lungs may 
 luidergo a marked ])igiuentation in consequence of the inspiration of dust 
 and jiarticles of carbon. A jiart of the dust remains in the lungs, and is 
 found both in the walls of tiie alveoli and in the thickened and indurated 
 tissue whicii results from the chronic inflanimati(3n set U]i by the presence 
 of the foreign particles. A jiart of the material is carried to the nearest 
 lymph-glands and produces pigmentation of these. 
 
 An interesting form of j)igmentation is due to the introduction of 
 silver salts into the body. When nitrate of silver has been used 
 medicinally for some time, the skin acquires a grayish-brown appear- 
 ance and the organs may also become pigmented. The silver is deposited 
 in the form of tine gi'anules in the tissues of the organs. 
 
 In malaria there is a formation of pigment in the blood. This condi- 
 tion is found in all forms of malaria, and is due to the destruction of the 
 red corpuscles by the malai-ial j)arasites which inhabit them. The pig- 
 ment which is formed is derived from the luemoglobin. It is found both 
 in the red and white corpuscles. In the red corpuscles it is found in the 
 parasites which they enclose. In the white corpuscles the pigment is 
 also derived from the parasites, the pigment produced by them in the 
 red corpuscles being taken up by the wliite corpuscles. In certain 
 stages of tiie disease pigmented parasites may also be found free in the 
 blood. The pigment is also deposited in certain organs of the body, 
 notably in the spleen and in the liver. 
 
 VI. TUBERCULOSIS AND TUBERCLE. 
 
 Tuberculosis is an infectious disease produced by the tubercle 
 bacillus. It is characterized J)y the formation of larger and smaller 
 circumscribed nodules called tubercles, by more diffuse formation of 
 tissue of the same character as that com])osing the nodules, and by 
 various forms of inflammation. The word "tubercle" was first used 
 M'ithout any specific meaning to describe a small nodule. In 1796, 
 Baillie, the nephew of John Hunter, gave the first description of 
 tubercle as found in the lungs. It was noticed that these tubercles 
 were frequently found associated with a destructive disease of the lungs, 
 and finally both the tubercles and the destruction of lung-tissue accom- 
 
240 SURGICAL PATHOLOGY. 
 
 panying their presence were referred to one and the same cause. After- 
 ward nodules of a similar character were found in the lymph-glands, in 
 the tissues of diseased joints, and in various other phices in the lx>dy. 
 It was ft)und that wherever these nodules apjieared they were eom])osed 
 essentially of the same sort of tissue, and that they were particularly 
 prone to a form of degeneration by which they became; (;hanged into a 
 substance resembling certain sorts of cheese. Tissue of the same general 
 character as the tubercles was also found, not in circumscribed masses, 
 but rather diffusely, and it was found that this tissue also underwent 
 caseation. When inflammation accompanied the process the products also 
 became caseous. There is no douI)t that althouo-h the form of dcgen- 
 eration called caseation is not a specific process limited to the tuberculous 
 tissue, it so commonly takes place in this that it has served more than 
 any other morphological factor to nnite under one head the various 
 manifestations of tiie disease. The conception of tuberculosis as an 
 infectious disease was founded on the anatomical study of the disease 
 and its mode of progression l>efore the discovery of the sj^ecific organ- 
 ism. Even twenty years before the discovery of the bacillus it was 
 found that a disease agreeing in all essential respects with the disease as 
 found in man could be induced in rabbits by inoculating them with the 
 products of the disease from man. 
 
 It is now universally acknowledged that a bacillus is the cause of the 
 disease. This was demonstrated by Koch in 1881, and all the work 
 which has since been done has served to confirm the work of Koch. 
 The bacillus tuberculosis is one of the .smallest of micro-organisms. It 
 is from one-quarter to one-half the diameter of a red blood-corpuscle in 
 length, and the length is usually five or six times the breadth. The 
 bacilli are usually somewhat bent and the ends are roiuided. Special 
 methods of staining are necessary to demonstrate them. A great many 
 methods have been given, but they all consist in the use of fluids 
 which stain intensely, followed by decolorizing solutions which remove 
 the color from everything but the bacilli. When stained the bacilli may 
 be of a homogeneous color, or they may show an alternation of intensely 
 stained particles and clear spaces. These clear spaces were first sup- 
 posed to represent spores, but it is doubtful whether they should be so 
 considered. It is probable that there is no growth of the organisms 
 outside of the body under ordinary circumstances. Special media and 
 an elevated temperature are necessary for their growth, which is very 
 slow, there being usually no indication of it for several weeks. There 
 is a great difference in the susceptibility of different animals to the dis- 
 ease. Guinea-pigs are among the most susceptible, and these succumb 
 in from six weeks to three months after inoculation. 
 
 For a long time no typical .structure was regarded as characteristic 
 of tubercle. Virchow described the tubercle as a nodule composed 
 of small round cells similar to those foimd in granulation tissue, and 
 derived from multi])lication of the connective-tissue cells, and called 
 attention to the tendency of the cells in the centre of the nodule to 
 xmdergo necrosis. As the methods of histological investigation improved 
 tubercle was studied more closely, and it was found to have a more 
 or less typical structure. Langhaus gave a more detailed description 
 of certain large multinucleated cells commonly found in tubercle ; a 
 
TUBERCULOSIS AND TUBERCLE. 241 
 
 peculiar reticulum betweeu the cells was described by other observers. 
 AMieu a very young miliary tubercle is examined after suitable methods 
 of hardening, a reticulum is seen, in the meshes of wliich the cells lie. 
 The extent to which the reticulum is developed depends upon the age 
 of tlic tubei'cle and the character of the tissue in which it develops. It 
 may be as firm and definite as the reticulum of a lymphatic gland, and 
 in other cases scarcely a trace of it may be seen. Tliere are various sorts 
 of cells in the nodule, the most prominent of which from their number 
 are the epithelioid cells. These are cells somewhat resemljling epithelial 
 cells ; they have a pale, finely-granular or homogeneous protoplasm and 
 large oval vesicular nuclei. The arrangement of these cells with refer- 
 ence to the reticulum varies. Sometimes they appear to lie in the meshes 
 of a more or less fibrous reticulum ; sometimes tiiey form the reticulum. 
 The cell-outlines are never clear and distinct ; the cells are usually fused 
 together. The epithelioid cells are also found, not as distinct groujis, 
 but more or less scattered in the tissue. Among the epithelioid cells, 
 lying bet\\"een them or in tlie meshes formed by their union, are round 
 cells similar to those found in young granulation tissue. These cells 
 vary in number, and are most abundant in the periphery of the nodule. 
 The large, multinucleated giant-cells are a prominent feature of the 
 tubercle. Sometimes one of them forms the centre of the nodule, and 
 has long processes which communicate with the reticulum ; or they may 
 be ]K'rfectly round, without processes, and lie in a space surrounded by 
 epithelioid cells. In some cases they are situated in the periphery of 
 the nodule. The nuclei of the giant-cells are either arranged around 
 the periphery, with their long axis perpendicular to the centre, or they 
 are grouped in masses at eitlier end of an elongated cell. The histogenesis 
 of the tubercle has been carefully studied, but we are still far from com- 
 pletely understanding it. Baumgarten considers the ej)ithelioid cells as 
 the most important cells found, and that they are derived from the pre- 
 existcnt cells of the tissue under the influence of the tubercle bacilli. 
 They may be formed from the epithelial cells of glands, fi-oni the con- 
 nective-tissue cells, or from the cells of the blood-vessels. According to 
 Baumgarten, the first step in the formation of a tubercle is the presence 
 of tubercle bacilli in the tissue. These enter into the fixed cells, no 
 matter what the character of these may be, and ])roduce cellular pro- 
 liferation, the newly-formed cells being the epithelioid cells. The pro- 
 duction of the giant-cells is a more obscure process. Weigert thinks 
 that they are prothuK'd by the proliferation of degenerated cells, the 
 nucleus dividing without separation of the protoplasm. In some cases 
 they appear to he produced by fusion of the epithelioid cells, and they 
 are undoubtedly sometimes formed in blood-vessels, and may be traced 
 in continuity with vessels. The}- are probably formed in a variety of 
 ways. The small round cells, found in varying numbers in the tubercle, 
 are derived, like the granulation-cells, from multiplication of the con- 
 nective-tissue cells in tlie tissue in which the tubercle is formed. Little 
 is known of the formation of the reticulum. It is probablj- in large part 
 composed of the remains of the connective-tissue fibres which have been 
 pressed apart by the proliferating cells. It may be in part newly formed 
 by the cells of the tubercle, which for the most part are derived from the 
 connective tissue and under ordinary circumstances would form such tissue. 
 
 Vol. I.— 16 
 
242 SURCICAL PATHOLOGY. 
 
 The tubercle is a non-vaseular structure. Tlie blood-vessels wliich 
 are present in the tissue where the tubercle develops become occluded l)y 
 thrombosis or from the pressure of the numbers of cells, and no new 
 blood-vessels make their way into it. 
 
 This description of tubercle applies to very young nodules in which 
 no ilcgeneration has taken place. The first evidence of such dcii'cu- 
 eration is shown in hardened specimens by the nuclei of the cells in 
 the interior staining less brilliantly. In sections of fresh tissue more 
 or less extensive fatty degeneration of the cells in the centre is found. 
 The nuclei cease to stain, and the cells fuse together in a solid homo- 
 geneous mass in which no cell-outlines can be seen. The form of degen- 
 eration is that described by W'cigert as coagulation-necrosis, and it is 
 always preceded by fatty degeneration. A zone of closely-packed fat- 
 molecules is always found around the necrotic centre. In the giant-cells 
 the same process seems to take place. The centre is similar to the necrotic 
 centre of the tubercle, and around this, just inside the nuclei, there is a 
 zone of closely-packed fat-granules. 
 
 Macrosco])ically, the tubercle when very young is pale, transparent, 
 and with difficulty distinguished in the tissue. When degeneration 
 begins it is white, opaque, and easily seen. The white color is not due 
 to the absence of vessels alone, but rather to the presence of the fat- 
 molecules. 
 
 With the appearance of degeneration in the tubercle another cellular 
 element enters into it. This is the polynnclear leucocyte. Necrotic tissue, 
 however caused, exerts a positive attraction on the leucocytes, and the 
 necrotic tissue in the tubercle has the same power. The polynnclear 
 leucocytes may be recognized by their irregularity in form and by the 
 brightness with which they stain. They enter into the tubercle and into 
 the necrotic tissue, often forming a definite ring around the latter. In 
 the degenerated area they seem to undergo the same fate as the other 
 cells. The nuclei break up into fragments and form the small, brightly- 
 staining granules seen in the tissue. Occasionally they may be found 
 within the giant-cells. 
 
 The fattv degeneration and caseation to which the tubercle is so 
 ]nTinc has been attriliuted principally to tiie absence of blood-vessels. 
 Although this may play a [)art, the degeneration of the tissue cannot be 
 attributed solely to this cause. W'c find other structures in the body, of 
 the same size as, or even larger than, the tubercle, in which there are no 
 vessels and which do not show the same tendency to degeneration. The 
 necrosis of the cells is due more to the influence of the bacilli or their 
 chemical products on the tissue than to the absence of blood-vessels. 
 
 The relation of the tnlierclc to the surrounding tissue differs. In 
 most cases there is around it a well-marked zone of granulation tissue 
 filled with round cells which become more abundant in the periphery of 
 the tubercle, and finally merge into the surrounding granulation tissue 
 without a sharp line of demarcation. As the tubercle increases in size the 
 central caseation increases in extent and the granulation tissue changes 
 into that of the tubercle, the round cells becoming epithelioid in character. 
 
 The tubercle mav undergo other forms of degeneration than tlie case- 
 ons. The entire mass may become converted into a perfectly smooth 
 hyaline substance, or, before necrosis takes place, connective tissue may 
 
TUBERCULOSIS AND TUBERCLE. 243 
 
 be formed from the cells, and such tubercles, even after caseation, are 
 nuieli firmer and harder than tliose in which tiie necrotic tissue is com- 
 posed of cells alone. 
 
 The number of tubercle bacilli in the tissue varies; they may be 
 present in large numbers or may be absent altogether. As a general 
 rule, thev are not so numerous in the youngest tubercles as they are in 
 those in which degeneration is well advanced. In certain places they 
 seem to be absent as a rule. In acute miliary tuberculosis of tlie liver 
 I have frequently not been able to find a single bacillus in any of the 
 numerous tubercles in the tissue. It is probable that under certain con- 
 ditions thev are destroyed by the tissue, or they may become so changed 
 as to be no longer recognizable. The bacilli occupy no constant position 
 in the tissue.; they may be found within or lying between the epithelioid 
 cells. Sometimes a mass of them may be seen in the centre of the case- 
 ous mass, or the giant-cells may contain them in varying numbers. 
 
 The miliary tubercles may appear alone, or in numbers forming the 
 large conglomerate tubercles. Most of the tubercles which are visible 
 to the naivcd eye are composed of several nodules united together. 
 These larger conglomerate nodules are formed around a single tubercle 
 which seems to serve as a focus of infection. The tubercle bacilli from 
 this are carried, either by the lymph-stream or enchased in wandering 
 cells, into the surrounding tissue, in which numbers of tubercles are thus, 
 developed. As the caseation in the individual tubercles advances it affects 
 also the tissue lying between them, so that finally a large caseous area 
 is formed which is surrounded by a zone of miliary tubercles. The 
 large solitarv tubercles which are frequently found in the lirain, and less 
 frequenrly in the liver and other parts of the body, are formed in this 
 wav. Although the miliary tubercle is the most characteristic of the 
 lesions produced by the tubercle bacillus, it forms but a small part of 
 the lesions of the disease. The formation of a tissue similar to that of 
 the miliary tubercle, and wiiicii appears not as a nodule, but as a diffuse 
 infiltration of the tissue, is a much more prominent part of the process. 
 The formation of tliis tissue is closely related to inflammation. Where 
 in an ordinary inflammation there would be a formation of granulation 
 tissue, under the influence of the tubercle bacillus a tissue composed of 
 epitlielioiil and giant-cells, and which is peculiarly prone to necrosis and 
 caseation, is produced. In tuberculosis of the joints the pale masses of 
 granulation tissue around tiie joints show on the outside a narrow rim 
 of caseation, and back of this a tissue composed largely of cpitiielioid 
 and giant-cells. In this tissue there are frequently circumscribed 
 tubercles. 
 
 Not only is the tubercle in its formation closely related to inflamma- 
 tory new formations of tissue, but it is always accomj)anied by inflam- 
 mation. The nodular tubercle as a foreign body excites inflammation 
 around it. The zone of granulation tissue around a tubercle is the 
 result of a reactive inflannnaticm of the tissue. The chemical sub- 
 stances which aj'e produced by the bacilli and in the tuberculous tissue 
 may exert a non-specific but simply injurious action on the surrounding 
 tissue, which will l)c followed l)y infianniiation. The l)acilli themselves, 
 instead of causing the more ty]iical tissue-formations, may excite inflam- 
 mation. The form of inflanunation varies. In some cases an exuda- 
 
244 SURdlCAL PATHOLOGY. 
 
 tion containing fibrin in v:n ying amounts may 1^<' pnidiiccd ; in otliur 
 cases a typical su]>pnratioii. In no otlicr tissue in tiie body is this inti- 
 mate association witii intlammation so evident as in tiie lungs. Apart 
 from the presence of miliary tubercles, whicii ordinarily ])!ay but a 
 small part in the process, the lesions of pulnKinary tuberculosis are 
 chiefly inflammatory. The gi-eater part of the lesions is due to tuber- 
 culous pneumonia, in which there is consolidation of the lungs, due to 
 exudation and ac(!Umulation of cells in the alveoli. The exudation in 
 some cases contains nuich fibrin ; in otiiers it may be chiefly serous, or 
 the alveoli may be filled witli a hyaline gelatinous substance. The cells 
 witliin tlie alveoli arc chiefly large, jiale, epithelioid cells, mingled witli 
 botli ^^■hite and red corpuscles. In some cases, especially on serous sur- 
 faces, the exudation is chiefly hemorrhagic. Always, particularly in the 
 lungs, along with the inflannnatory ]>roccsscs due directly to the action 
 of the tubercle bacilli and their soluble cliemical products, tliere are 
 inflammatory lesions due to conditions which the l)acilli create. 
 
 The inflammatory tissue produced in the lungs l\y the l)acilli under- 
 goes the same caseation as the tubercle. It becomes converted into a 
 dry, homogeneous, necrotic mass. The fibrin becomes enclosed in it, and 
 may still be recognized in the caseous tissue by appropriate methods of 
 staining. On microscopic examination of the brittle caseous mass the 
 , anatomical structure of the tissue comjiosing it may still be recognized. 
 In the lung the walls of the alveoli ajipear, dividing the caseous tissue 
 into small areas. The caseation follows the same course as in the 
 tubercle, commencing in the centre and gradually extending to the 
 periphery. An entire lobe, or even an entire lung, may be converted 
 into a solid, necrotic mass of tissue. 
 
 The caseous tissue docs not tend to remain, but after a variable length 
 of time it undergoes softening. The cause of this is not fully iniderstood. 
 The dry, caseous tissue becomes converted into a soft, fluid, puriform 
 mass. On microscopic examination fragments and detritus of tissue and 
 cells may be recognized, with here and there a few well-preserved leuco- 
 cytes. The cause of the softening may be due t(i changes taking jjlace 
 in the tissue spontaneously or to the action of influences from without. 
 The necrotic tissue forms a favorable seat fi)r the action of otlier micro- 
 organisms which can gain access to it by the bronchi. The softening 
 may be distinctly purulent ; there may be a purulent inflammation in the 
 tissue around it, and the caseous matter may be dissolved in the ])urulcnt 
 exudation. As soon as softening takes place favorable conditions fiir 
 further infection are produced. Not f)uly are the tubercle liacilli ])rcscnt 
 in the softened material, but tliere arc other org-anisms. It is probable 
 that even without the presence of organisms the chemical products pres- 
 ent may exert a deleterious influence on the tissues. Bronchi always 
 open into the softened area, and offer a direct route for infection of other 
 parts of the lungs. To the specific action (if the various substances in 
 the softened tissues must lie added the effects which may be produced by 
 the mechanical action of solid ])articlcs occluding the small bronchi. It 
 is easy to see why in such a tissue as that of the lungs tuberculosis should 
 produce such a variety of lesions. 
 
 There is probably no disease in which there is such a variety in the 
 lesions as is found in tuberculosis. A careful study of the lung-lesions 
 
TUBEECVLOSTS AXD TUBERCLE. 245 
 
 iu a case of flirnnie tulicroulnsis would .show nearly all the patholow'ical 
 processes. The course of the disease also varies. In some cases it may 
 advance rapitlly and lead to death in a few months or even weeks ; in 
 other cases it jiursues the most protracted course, may contmue during 
 the entire life of the individual, and in the end only indirectly contribute 
 to death. All of these differences in the effects of infection Avith the 
 bacillus de|)end upon a number of factors. 
 
 All individuals are not equally susceptible to the disease. It was 
 formerly ii-eni'rally believed that the disease itself was mherited, bnt it is 
 more jVrobable that not the disease itself, but a greater or less suscep- 
 tibilitv to the disease, is inherited. Other things being equal, children 
 of tul)erculous parents, especially if the disease has been in the family for 
 a nund)er of generations, are more liable to be aflected with tulierculosis 
 than the children of parents who were free from this disease. This 
 S])ecial susceptibility or tendency may not be expressed in any other 
 weakness or habit of the body : such children, born of parents in good 
 circumstances of life, may develop strong and robust bodies with more 
 than the average powers of endurance. One factor must always l)e 
 considered — nam^'ly, that in general these children have greater opjior- 
 tunities for infection if they are living in the house with tuberculous 
 people. It is also probable that certain races show a greater susceptibility 
 than others to this disease. In this country certainly the colored and 
 the Celtic races seem to be m(n-e liable to the disease than any other, 
 while the Jewish race appears to possess a certain degree of innnunity 
 against it. The same thing is true of cattle. The cattle coming from 
 the Channel Islands, the Alderney and Jersey stock, especially the pure 
 breeds, have much more of the disease among tlieni than any other 
 breeds. 
 
 It is probable that there are also differences in the virulence of the 
 bacilli iu different cases. Even inoculations on guinea-pigs of the same 
 age with the same amounts of virus from different sources show differ- 
 ences in the course of the disease. 
 
 The course of the disease will further be influenced by the manner in 
 which the organisms gain entrance into the tissue. They may enter 
 it bv means of canals or ducts which commimicate with the outside, 
 or by the blood- and lymphatic vessels. In this way either tuberculous 
 iniiannnations or miliary tulierdes may be produced. It is probably 
 not necessary to have an actual lesion of continuity for the bacilli to 
 pass into the tissue. It has been shown that the disease can be produced 
 by rubbing the organisms on the skin of a rabbit. Tuberculosis of the 
 aiimentary canal in man probably takes place without any preceding 
 lesion. The tubercles here a])])ear first in tlie lymj)h-glandular tissue of 
 the gut, and no lesifm of the mucous surface may be visil)le. Not only 
 is there a general difference in the susceptiliility of the tissue of different 
 individuals, but there are differences in the different tissues of the same 
 individual. Some tissues are almost exempt. In certain cases tubercle 
 bacilli may be found in great quantities in the blood, and miliary tuber- 
 cles be formed all over the body, except in the muscles. The ovary 
 shows a relative immunity, and the ])ancreas and thyroid are rather 
 rarely attacked. It canuot be tliat these organs are jirotected from the 
 entrance of the bacilli, f )r in cases of infection by the l)lood they are 
 
246 SURGICAL PATHOLOGY. 
 
 equally liable to have the bacilli carried into them. None of the tissues 
 enjoy an absolute immunity. Even the muscles may be invaded by the 
 gradual extension of tuberculous foci into them. In a tuberculous uleer 
 of the tongue tubercles are found in the nniscular tissue for :|uite a long 
 distance l)cneath tlu' ulcer. In cases of joint tulicrculosis also the adjacent 
 muscles may be involved by the extension of tiie disease. 
 
 There is always some primary focus of the tlisease in the body. The 
 primary seat of the disease in most eases is in the lungs, but it may com- 
 mence in almost any other organ of the body. From the primary foens 
 the infection extends, following various routes. There may be infection 
 of the tissues in direct continuity. The bacilli may be carried enclosed 
 in cells, or they may extend by growth into the tissue adjoining, and in this 
 way large tubercuhms nodules may be formed. The bacilli may pass 
 along the lymphatics, either into the surrounding tissue or into the 
 lymphatic glands into which the lymph-vessels empty. The infection 
 of the lymphatic glands almost surely takes place, and in many cases 
 they may jn-esent the oidy evidence of the disease. In tiU)crculosis of 
 the lungs the bronchial glands are always aifected : if the intestine be 
 aflected, the mesentery glands are tul)erculous. In many eases the 
 bacilli are probably carried directly to the lymph-glands from the seat 
 of entry without producing any lesions where they have entered. It is 
 probable that in many eases the bacilli gain entrance into the tissues 
 through the nnicous membrane of the mouth or ])harynx, and the first 
 evidence of the disease is in the cervical glands. The glands appear to 
 protect the organism from further infection for some time. The tissue 
 of the lymphatic glands offers a suitable locality for the growth of the 
 bacilli. Extensive lesions are produced in them, a.nd tinally the glands 
 serve as foci for further infection. The glands next in ordci» become 
 affected, and in this way all the lym])hatics and lyinj)h-glaiids up to the 
 thoracic duct may graduallv become tubercidous ; and finally the l)acilli 
 are carried directly into the bk)od. In most cases the infection follows 
 in the direction of the lymph-current, but it m'ay also proceed against 
 the stream. 
 
 Infection may also take place by the bacilli being carried along 
 open canals or duets from one ])art of an organ to another or to various 
 parts of the body. The lungs otfcr the most suitable conditions for this 
 mode of infection. The jirimary seat of the disease in most eases is in 
 the apices, and when softening of the caseous tissue takes j)lace the 
 detritus, full of bacilli, may be carried by aspiration into every other 
 part of the lungs. The bacilli are contained in the sputum, and further 
 infection both of the air-passages and of the alimentary canal takes place 
 from this. 
 
 This mode of infection is seen also in the genito-urinary tuberculosis 
 in the male. Here, in the majority of cases, the ])rimary seat of the dis- 
 ease is in the epididymis. It may be confined to this, or the testicle may 
 be affected by continuity. The e]iidi(lymis is converted into a more or 
 less firm, caseous mass. From this the disease extends along the vas 
 deferens, which becomes enlarged, and on section the interior is found to 
 be lincil with a whitish caseous tissue. In both the vas deferens and epi- 
 didymis the seat of the disease is primarily in the epithelium and takes the 
 form of a tuberculous inflammation. The seminal vesicles on the same side 
 
TUBERCULOSIS ASl) TUBERCLE. 247 
 
 lieeonie affoctod in uidst cases, or they may be passed by and tlie disease 
 appear in tlie prostata ov Ijladder. l^^p to this point it is easy to see how 
 tlie infection has taken phice : the extension has been in the direction of 
 the secretion, and the l)ai'illi eonUl be carried ah)ng with the secretion. 
 From the bladder the extension is in a direction opposite to the flow of 
 the secretion. With or withont any involvement of the ureter infection 
 of the pelvis of the kidney and of the adjoining kidney -tissue takes place. 
 It is prolialde that the bacilli And suitable conditions for growth in the 
 ureter, and grow along the walls, just as on the surface of a solid medium, 
 until the pelvis of the kidney is reached. There is no other way for 
 infection to take place from the bladder to the kidney than along the 
 ureter. There is no lymphatic or vascular connection. The proof that 
 this is the usual route of infection in genito-urinary tuberculosis is shown 
 by the certainty with wliicli the <lisease can be traced step by step, and 
 the extreme rarity of the disease in females as compared Avith males. 
 In some cases the tlisease appears to l3e primary in the kidney, and the 
 infection may take place in the opposite direction. 
 
 The blood plays an important j)art in the extension. Sometimes the 
 bacilli gain entrance into the blood from tlie lym])liatics. The more com- 
 mon wav is by a direct infi'ction of the blood. Tuberculosis of some of 
 the large veins of the l)ody may take place, the vein being atlectcd l)y the 
 extension of a tubi'rcuious process in an adjoining tissue. The bacilli are 
 carried by the blood into all the organs of the body, and a general miliary 
 tuberculosis is the result. Even in this some of the tissues are exempt. 
 Miliary tubercles are never found in the muscles or in the skin, and 
 only rarely in the alimentary canal or in the ovaries. Infection by 
 tlie blood may take ]>lace without the production of a general miliary 
 tul)er<'ulosis. In almost every case of extensive tuberculosis a few 
 tubercle bacilli probably enter into the blood. These will be dcjwsited 
 chiefly in those organs in which the conditions of the circulation are 
 most favorable for the retention of fine solid particles. The liver offers 
 the most suital)lc conditions for this, and in every case careful search 
 will siiow the presence of a few tubercles in this organ. In some cases 
 the bacilli may apparently gain access to the blood without j)rodncing 
 any other lesions. From the primary infection they may in some way 
 gain entrance into the blood and be dejjosited in various organs. In no 
 other way are we able to explain the ]irimary tuberculosis of the bones 
 and other organs into which tiiey could have been carried only by the 
 blood. 
 
 Of late the theory of congenital tuber'culosis, the result of intra- 
 uterine infection, has received more credence than formerly. Bauni- 
 garten particularly iqiholds tliis view, and explains in this way certain 
 cases in which the infection ij otherwise obscure. In a few cases con- 
 genital tuberculosis has been proven beyond doubt both in animals and 
 in man. The first case in whicli this was siiown was in the organs of a 
 fVetal calf, and careful investigation has shown that this condition is not so 
 very uncommon. Baumgarten found a caseous tubcrcidous noilule in the 
 cervical vertebra of a stillborn infant. Birch-Hirschfeld found tubercle 
 bacilli in a seven months' fretus and placenta removed by Csesarcan sectioti 
 from a mother affected with general miliary tuberculosis. The bacilli 
 were demonstrated both by direct examination and by the inoculation of 
 
248 SURGICAL PATHOLOGY. 
 
 giiiiic'a-])if!;s. Cases of tuberculosis in infants dying the first few days 
 or weeks after birtli are not so very uncommon, and many of tliese eases 
 sliould be regarded as due to inti'a-uterine infection, (xiirtner lias found 
 that transmission of tultercle bacilli from the inother to the fa^tus is not 
 very uncommon in mice, canary birds, and rabbits. Nor is the infre- 
 quency of tuberculosis in new-born children and infants a conclusive 
 argument aga'nst intra-uterine infection. The infection may take 
 place in intra-uterine life, and the disease remain latent for a number 
 of years. 
 
 The question as to the frequency of directly inherited or congenital 
 tuberculosis must be consideri'd in connection witli the fact, referred to 
 above (p. 245), that the children of a tuberculous jiarent usually live in 
 a house or room which is more or less infected with the specific bacilli 
 derived from the sputa of the parent, and hence are more than usually 
 liable to contract the disease. 
 
GENERAL BACTERIOLOGY OF SURGICAL 
 INFECTIONS. ^' 
 
 By WILLIAM H. WELCH, M. D, 
 
 INTEirBERS of each of the three groups of pathogenic micro-organisms 
 — bacteria, fungi, and protoztia — may (;ause surgical infeotions. Fungi 
 and protozoa, however, are far less commonly concerned in these infec- 
 tions than are bacteria. In a general consideration of the conditions of 
 surgical infection bacteria are the organisms which require chief atten- 
 tion, so that the subjects to be considered in this article can be appro- 
 priately inchuled under the designation " General Bacteriology of Surgi- 
 cal Infections." 
 
 Tlie term " general bacteriology " is here used in distinction from 
 " special bacteriology " to designate the general relations of bacteria to 
 surgical infections. It is not deemed necessary in this article to enter 
 into a detailed consideration of the mor})iiological and cultural charac- 
 ters of bacteria. This subject is fully treated in \\x)rks especially devoted 
 to bacteriology. 
 
 Infectious diseases which require especial consideration by the sur- 
 geon include, on the one hand, many specific infections, such as tubercu- 
 losis, tetanns, glanders, anthrax, and actinomycosis, and, on the other 
 hand, traumatic and other inflammatory and septic infections caused by 
 various widely-distributed bacterial sjiecies. 
 
 The specific infectious diseases, such as tul)erculosis, tetanus, etc., are 
 for the most part sliarply differentiated by their anatomical and clinical 
 characters, and are caused by micro-organisms which are constantly and 
 exclusively associated witli their respective diseases. 
 
 On the other hand, the common traumatic infections and other sur- 
 gical inflammations and septic processes do not jiresent eqtially sharp and 
 dcfiniti' differential characters, and aj)parently identical or similar patho- 
 logical processes belonging to this gi'onj) of affections may be caused by 
 various micro-organisms. Thus we do not find in such diseases as septi- 
 cemia, pyaemia, abscesses, osteomyelitis, puerperal fever, or other septic 
 and localized inflammations, or, in general, in the infections of wounds, 
 any single bacterial- species eunstantly and exclusively associated with 
 eacii of tiiese affections, but each disease of this group may be caused 
 by more tiian one species of micro-organism. 
 
 The etiology of these common septic and inflammatorj' affections 
 presents for our consideration many jiroblems quite distinct from tliose 
 pertaining to the causation of the specific infections. The views now held 
 as regards sources of infection, o])erative ])rocedurcs, and tlie manage- 
 ment of wounds have been developed largely as the I'esult of investiga- 
 tions concerning the relation of bacteria to traumatic infections. 
 
 249 
 
250 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 It is important tliat the surgeon should become familiar with the 
 various kinds of bacteria concerned in surgical infeotioris, with their 
 distribution on exposed surfaces of the body and in the outer world, 
 witli tlie ways by which they may cntci' and be (lisciiarge(l IVum the 
 body, witli tile various conditions Mliich favor their invasion and uiulti- 
 ])!ication in the body, with their jiathogenic manifestations, and with 
 the means of combating them. It is proposed in this article to 
 present the more important considerations pertaining to these .sub- 
 jects so for as they do not fall more appropi'iately for their treatment 
 to other sections of this ^\'oi-i<. 
 
 We shall consider tirst the disti'il)ution of bacteria on ex])os('d sur- 
 faces of the body, liaving especially in view its surgical l)earings. 
 Knowledge of the distribution of pathogenic bacteria is of importance 
 in the study of the causation of surgical infections, as indeed of all 
 infectious diseases. 
 
 Bacteria of the Skin. 
 
 There are various questions of surgical interest relating to the bacteria 
 of the skin. The destruction of the surface bacteria both on the hands 
 of the operator and his assistants and over the field of operation in the 
 patient is of fundamental importance in surgical techni(pie. It is 
 important to determine the possibilities of danger from infection by 
 bacteria commonly or occasionally found in or on the skin. Ignorance 
 of the bacterial flora of the normal skin has led some investigators to 
 erroneous interpretations of their observations as to the source of bacteria 
 found in wounds treated aseptically or antiseptically, and as to the 
 presence of supposed specific ]>athogenic bacteria in certain cutaneous 
 diseases. 
 
 The micro-organisms of the human skin have been studied by several 
 investigators, of whom may be mentioned Bizzozero, Bordoni-Uffrcduzzi, 
 Unna, IMaggiora, Mittmann, Fiirbringer, Preindlsberger, Robb and 
 Ghriskey, and "Welch." 
 
 As the skin is exposed to contamination from the air and all sorts 
 of sources, it is evident that there is scarcely any limit to the number 
 of species of bacteria which may possibly be found on the skin. Most 
 investigators of this subject have not had the patience or have not thought 
 it worth while to attempt to itlcntify or to describe all of the various kinds 
 of bacteria developing in cultures from the surface of the skin. Mitt- 
 mann mentions seventy-eight different species of cutaneous bacteria, of 
 Avhich fifty-six were cocci. His descriptions, however, are so imperfect 
 as scarcely to serve for the identification of the species. Preindlsberger 
 describes thirty-two species, of which twenty-eight were cocci. Maggiora 
 isolated twenty-nine micro-organisms, of which twenty-two were bacteria, 
 thi'ee budding fungi, and four moulds. ]\Iost of these bacteria are such 
 
 ' Bizzozero, Virchow's Archii; Bd. iKS ; Bordoni-Uffreduzzi, Fortxchnfte der Medk'm, 
 1886, p. 151 ; Unna, Monati:hefte J'ilr pnd-liselie Dermntnlogie, 1889, 1S90, 1891 ; Maggiora, 
 Oiornalc delta R.Socktd d'Igiene, 1889; Mittm.inn, Vircliou^s Archil; Bd. 113; Fiirbringer, 
 Desinfektion d. Hlinde d. Arstes, Wiesbaden, 1888 ; Preindlsberger, Zur Kcnnttiiiis der Rac- 
 terien dex Unternagelraumeft u. s. v., AVien, 1891 ; Rol)b and Gliriskey, Johns Hophins 
 Hospital Bulletin, April, 1892 ; Welch, Trans, of the Congr. of American Physicianis and 
 Surgeons, vol. ii., and Maryland Medical Journal, Nov. 14, 1891. 
 
BACTERIA OF THE SKTX 251 
 
 as arc often found in the air oi- on external objects. Cocci are usually 
 found much more abundantly than bacilli in cidtures from the skin. 
 
 (Jreat variations exist in different cases as to the kinds and the 
 number of bacteria found on the skin. Sometimes one species prcxlomi- 
 nates over the rest, indicating that it has multi})licil and overgrown other 
 bacteria. The conditions in general are not favorable for the growth of 
 bacteria on the surface of the skin, but under the nails and in situations 
 where moisture collects, as in the axillie, the groins, and between the toes, 
 there mav be abundant nudtiplication of certain species of micro- 
 organisms. Altiiough Ixictcria [)rcdoniiuate, budding and mould fungi 
 are often present. The large mmibcr of micro-organisms which accu- 
 mulate beneath the nails is a matter of surgical importance. From a 
 minute particle of material from this situation sometimes as many as two 
 thousand to five thousand colonies develop in culture media, although 
 Usually tlu- number is nuich less, an<l may lie very small indeed, perhaps 
 not more than tiu'ee or four colonics. 
 
 The writer in 1891 was the first to call attention to the fact that, 
 although in aeneral the bacterial flora of the skin is inconstant and indef- 
 inite in its s})ecial characters, there is one bacterial species, to which he 
 gave the ntunc of xfitjjlii/fococcu.x cpUhrinidis alhux, which is found with 
 such regularity in cultures from the skin that it may properly be regarded 
 as a regular iniialiitant of tlic normal skin, just as the bacillus coli com- 
 munis is a regular inhabitant of the intestinal canal. The principal data 
 relating to this staphylococcus were established by the researches of Robb 
 and Ghriskey. We consider this coccus to be a variety of the staphy- 
 lococcus jiyogcnes albus. It is possessed of feeble pyogenic power, and 
 usually li(piefics gelatin and coagulates milk more slowly than the ordi- 
 nary white pyogenic stajiliylococcus. For these reasons, but especially 
 to emphasize the epidermis as a normal haliitat for this organism, we 
 applied the designation mentioned. 
 
 One of the chief points of interest relating to this coccus is that it is 
 very often, prolialjly regularly, present in lavers of epidermis along tiie 
 hair-shafts, deeper than can be reached by any known means of cuta- 
 neous disinfection save tlie application of iicat. After complete sterili- 
 zation of the surface of the skin, so that scrapings are sterile when 
 inoculated into culture media, the presence of this white coccus can still 
 bo demonstrated by making cultures from sutures passed through the 
 skin or from excised pieces of skin. 
 
 Tlie sta])hylococcus epidermidis albus is usually innocuous. It is found 
 frequently in aseptic wounds of the skin without causing sup]>uration or 
 any trouble. The source of this coccus in asejitic wounds does not seem 
 to be kno\vn to many who have made bacteriological examinations of 
 such wounds; thus.Budingerj^ who examined in 1892 twenty operative 
 wounds which healed by first intention in Bilh-oth's clinic, could not sug- 
 gest any other origin i'nr its presence than the air, and C. Fracnkel- sug- 
 gests that it is lirought to the wound by the blood-current — suggestions 
 W'hich were rendered <|uite unnt'ccssary I)y our previous researches. 
 
 Although this white e])idermal staphylococcus is often found in 
 w'ounds without any disturban(;e in the process of healing, it may be 
 
 ' Biidinger, Wiener klin. Woehemidir., 1892, Nos. 22, 24, 25. 
 ^ C. Fraenkel, Baumqarlen' s Jahresberichl, 1892, p. 28. 
 
252 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 the cause of some disturbance, diaractcrized especially by elevation of 
 temperature and moderate sn])puration. This is particularly likely to 
 be the case when there is necrotic or stranjjulated tissue in the wound qv 
 when foreio'ii bodies have been introduced into the wound. It is a com- 
 mon, altiiough not the sole, cause of stitch-abscesses, and it is prone to 
 travel down along the sides of a drainage-tube, and under these circinn- 
 stances may cause the wound to sujipurate. It is often associated with 
 other pyogenic cocci in cutaneous inflammations. We can now under- 
 stand how, without any flaw in the antisejttic technique of the surgeon, 
 tiiis micro-organism may be present in wounds, and we have a satis- 
 factory explanation of the frequent occurrence of stitch-al)scesses. 
 
 This white skin-coccus is often present in cultures from blood ob- 
 tained by jjuncture of the human skin and in cultures from the sweat 
 after complete disinfection of the surface of the skin. Some observers 
 seem to have supposed that when the stapliylococcus albus is demon- 
 strated under these conditions its presence in the circulating Idood or its 
 excretion by the sweat-glands can be inferred. But it is evident that 
 such an inference is unwarranted without additional proof. 
 
 There are various other white cocci, and also several species of yel- 
 low cocci, both liquefying and non-liquefying, which are frequently 
 found in cultui'es from the skin. Some of the yellow cocci can readily 
 be mistaken for the sta]diylococcus pyogenes aureus, unless they are 
 carefully studied in culture m(>dia. Tlie staphylococcus pyogenes aureus 
 may be found on the skin, as will be mentioned presently. 
 
 The kinds and the number of bacteria found upon exposed parts of 
 the skin vary considerably according to the habits and the occupation of 
 the individual. Of especial interest in this connection are the results of 
 the examination of the skin of surgeons and others who come into con- 
 tact with infected persons either during life or at the autopsy-tal)le. We 
 have found only exceptionally the Maph)iIococcux piior/ciics aureus upon 
 the hands of those Mho do not come into proximity to surgical or infected 
 cases, Avhereas we have many times found this micro-organism upon the 
 hands of surgeons, their assistants, and surgical nurses. In examining 
 the hands of those who use corrosive sublimate as a disinfectant it is 
 necessary first to neutralize the sublimate with ammonium sulpiiide, as 
 we have found that tiie sublimate may prevent the development of cuta- 
 neous micro-organisms with which it has come into contact, although it 
 has not killed them ; and this restraining influence may be manifest days, 
 and even weeks, after the application of the sublimate. 
 
 The length of time that the yellow pyogenic staphylococcus may 
 persist upon the hands varies, and doubtless largely, according to the 
 methods and extent of cleansing tiie skin. It certainly may i>crsist for 
 several days, although it may disappear in a few hours. It does not 
 seem usualh^ to grow down, as does the white epidermal coccus, into 
 the deeper layers of the skin, so that ordinary methods of disinfection 
 of the skin are likely to remove or destroy this organism. By rubbing 
 or by the application of pressure the stajihylococcus aureus may, how- 
 ever, be pressed into the deeper layers, jwrticularly into the liair-f()llicles, 
 and there cause furuncles, as has lieen shown liy the experiments of 
 Garre, Schimmelbusch, Wasmuth, and others. The view which has been 
 advocated by some writers that it requires more thorough disinfection to 
 
BACTERIA OF THE SKIN. 253 
 
 remove or destroy patliogonie baeteria accidentally or intentionally ap- 
 jilicd to the skin than tt) kill the ordinary liacteria of" the skin is not 
 snpported liy ex])erinieiits. Tiie healthy skin in i^eneral is not a favor- 
 able resting- or breeding-place to secure tlie long persistence of patho- 
 genic bacteria, with the exception of the white epidermal coccus, which 
 possesses relatively little pathogenic power under ordinary circumstances. 
 
 The stirptocoecm pyogenes has been found less frequently than the 
 staphylococcus aureus in cultures from the skin, and liere too chieHv in 
 cultures from the skin of infected patients or of those who have been in 
 jjroximity to them. It is well to bear in mind that these pvi)genic cocci 
 are not necessarily limited to the immediate neighborhood of an infected 
 wound or focus, but may occur on other parts of the body, as well as in 
 the air or on objects which have been near the patient. Thus Preindls- 
 berger found the aureus in the dirt beneatli tiu' finger-nails of a patient 
 with fracture of tlie femur, and the streptococcus jiyogenes in the same 
 situation in a patient with osteomyelitis femoris for which necrotomy 
 had been performed. The complete disinfection of an infected wound, 
 even if that were possible, would not therefore furnish a guarantee that 
 pyogenic cocci were not present upon the surface of the patient's body 
 in other situations. 
 
 The hdciUii!^ pi/oeyaneuf! is a common parasite upon the human skin. 
 Miihsam' found it in the axilla and in the anal and inguinal folds of 
 hetdthy persons iu 50 per cent, of the cases examined. Probably local 
 conditions were concerned in these observations, as others have not 
 found this organism upon the healthy skin with such frequency. Al- 
 though tliis organism may manifest importaTit pathogenic activities, its 
 ])resc'uce in wounds is usually made evident chiefly by the green or blue 
 discoloration of the dressings. It was formerly sujjposed to enter the 
 wound from the air, but it doubtless is often derived also from the skin 
 of the patient. 
 
 The common intestinal bacterium, the hdciUiix co/i commnnls, is of 
 course often present on the skin about the anus. In abscesses in this 
 situation it is often found either alone or associated with otlier bacteria. 
 The colon bacillus may also l)e found ujion the skin in other parts of 
 the body. It is a widely-distributed bacterium outside of the animal 
 body. It has repeatedly been found in wounds in different parts of 
 the body. 
 
 Skin contaminated with the soil, whicli, as is well known, contains 
 in many situations abundant Itacilli of tetanus and of malignant cedema, 
 is likely to present these micro-organisms. This contamination relates, 
 of course, especially to the hands, and in the case of those who go bare- 
 foot or have holes in their shoes also to the feet. Maggiora M'as able to 
 demonstrate the bacillus of malignant cedema in scrapings from between 
 the toes of a jierson who had walked for half an honr in a garden with 
 a torn shoe. It is not therefore in all cases necessary to sujtpose that 
 the tetanus I)acillus enters a wound from the object which causes the 
 wound, for tiiis bacillus may previously have been attached to the skin. 
 It may in this connection be mentioned that the fseces of herbivorous 
 animals often contain the tetanus bacillus, and in a condition more 
 
 ' Miihsam, cited by Schimmelbusch, Sainml. klinischer Vortrdge von Vothnann, Serie 3, 
 Heft. ii. No. 62. 
 
254 GENERAL BACTERIOLOGY OF SURGICAL INFECTIOyS. 
 
 likely to produce tetanus than when tlio bucillus is obtained from the 
 soil. Buday ' has reported a case of tetanus fatal in twentv-four liotu-s 
 which followed the smearing of a wound v.itli fa'ces. 
 
 The .sintyma /mu-I/Iks may l)e considered in connection with the cuta- 
 neous bacteria. Tiiis l)acterium is usually present in the smegma, and 
 may be found about the penis, scrotum, vulva, and anus. iVttention 
 was first called to this bacillus by Alvarez and Tavel and \)y Mattei- 
 stock in 1886, on account of its resemblance in morphology and staining 
 reactions to Lustgarten's bacillus, which at that time was thftught by its 
 discoverer to be tlie specific cause of syphilis. Greater practical impui-f- 
 ance, however, belongs to the smegma Ixicillus at present on account of 
 the possibility of mistaking it from its staining properties for the tuber- 
 cle bacillus, and there is reason to believe that such mistakes liave been 
 made in examinations of the urine and of secretions or exudates about 
 the external genitals and the anus. The smegma bacillus resembles the 
 tubercle bacillus in th(> ])niperty of rt'taiuing the staining dye after such 
 application of acids and alciihul that all known bacteria except the tu- 
 bercle bacillus, the smegma bacillus, and the leprosy bacillus ai'e decol- 
 orized. This property probably does not inhere in the smegma bacilli 
 as such, but is due to the presence of chemical constituents of the 
 smegma, although this jioint is not positively settled. In the opinion 
 of the writer this peculiar staining reaction does not belong to onlv a 
 single species of bacillus in the smegma, but to several, so that it is 
 more proper to speak of smegma bacilli with this reaction. Mistakes 
 are particularly likely to occur when the handy and popular Gabbet's 
 stain for the tubercle bacillus is emjiloyed. The usual statement is that 
 the smegma bacilli can be distinguished from the tuljcrcle bacillus by 
 less resistance to decolorizing agents, particularly to nitric acid, hydro- 
 chloric acid, and alcohol, also to counter-stains; and tliis often holds 
 true. Nevertheless, smegma l)acilli are sometimes encoinitered ^vhich 
 are as resistant to these decolorizers as are tubercle bacilli. Especial 
 attention should be given to the morphological appearances, as the size 
 and shape of the bacilli often suflice for the distinction, although there 
 is considerable diversity as regards this feature bet\\een the different 
 smegma bacilli which resist decolorizntion. Although smegma bacilli 
 may be present with pathogenic bacteria in lesions around the genitals 
 and anus, they are not known to possess pathogenic capacity. 
 
 Mau}^ bacteria are attached to the hairs of the body, and particles 
 containing bacteria may readily be detached from the hair. luibb has 
 studied the bacteria which fall off from the hair of the head by move- 
 ment or by combing tiie hair. They are identical with those found on 
 the skin, as might be expected. Haegler has cultivated pyogenic staph- 
 ylococci from the hair of surgeons, and calls attention to the possi- 
 bility of such cocci falling from the hair into a wound or upon objects 
 coming into contact with the wound during an operation. AVriglit has 
 found the diphtheria bacillus on tlie hair of nui'ses in attendance on 
 cases of diphtheria. 
 
 The cerumen is rich in bacteria. Kohrer - isolated sixteen sjiecies of 
 micro-organisms from the cerumen of fifty cases, but he has not attempted 
 
 ' Buday, Pester Med.-chir. Pressr, 1894, No. 19. 
 ^ Eohrer, Archivf. Ohrenheilk., Bd. xxix. 
 
BACTERIA OF EXPOSED MUCOUS SURFACES. 25.5 
 
 to identify any of these with prcvious;ly-knowii Imcteria, and his .state- 
 ments as U) tht' existence of patliogenic bacteria in the cerumen are not 
 based upon conclusive observations. 
 
 Bacteria of Exposed Mucous Surfaces. 
 
 The wav is open for the access of micro-organisms to mucous mem- 
 bi'anes wliich cover parts wliicii communicate with the outer world 
 through the external oritices of the body. So far as temperature, moist- 
 ure, and the presence of nutritive pabulum are concerned, the conditions 
 are manifestly more favorable for the growth of bacteria upon mucous 
 surfaces than upon the dry skin. These relatively favorable conditions 
 for the develoiMiient of micro-organisms upon mucous membranes are, 
 however, counteracted in large measure by various mechanical and chem- 
 ical influences which prevent the prolonged survival of most of the bac- 
 teria which may enter through the external orifices of the body. There 
 are, however, many bacteria which may multiply, or persist for a long 
 time or indefinitely, upon certain mucous membranes in health, partic- 
 ularly those of the alimentary canal and of the upper respiratory tract, 
 and there are some bacterial species which find their natural home here. 
 Some pathogenic bacteria may live upon certain mucous membranes 
 without doing harm. 
 
 The study of the bacterial flora of exposed mucous membranes in 
 health and in disease has brought to light many points of surgical 
 interest. 
 
 CoN.JUNCTiVA. — The bacteriology of the conjimctiva has been inves- 
 tigated bv manv ophthalmologists, of whom may be especially mentioned 
 Fick, Weeks, Leber, Felser, van Genderen Stort, Gombert, Bernheim, 
 Hildebrandt, Franke, Marthen, and Bach.^ 
 
 When one considers the cx])osed situation of the conjunctiva, it is 
 surprising to find how small is tiie number of bacteria usually pre.sent in 
 the conjunctix'al Sac. Fick found, by microscopical examination of fifty 
 healtiiy coujunctivte, bacteria in only eighteen, aithougii in another series 
 in which forty-nine healthy eyes of paupers were examined bacteria were 
 missed in only six. A negative microscopical examination, however, 
 indicates only that the number of bacteria is small, as then their presence 
 may readily be overlooked without the aid of cultures. As a matter of 
 fact, cultures from the healthy conjunctival sac usually furnish colonics 
 of bacteria. Their number may be considerable, l)ut it oftt'n ha]ipens 
 that not more than three or four colonies develop from a loopful of fluid 
 from the conjunctiva, and it is not very unconmion for culture media 
 inoculated in this way to remain sterile. It is to be assumed that the 
 conjunctival sac ordinarily contains bacteria. The secretion within the 
 lachrymal glands is sterile. 
 
 Bach describes twenty-six species of bacteria isolated in pure culture 
 from the healthy or diseased conjunctiva. Of these, ten are liipiefying 
 cocci, nine non-liquefying cocci, five liquefying bacilli, one non-liquefying 
 bacillus, and one cladothrix. Ten of the twenty-six bacteria were found 
 to be more or less pathogenic when inoculated into the rabbit's cornea. 
 
 ' L. Bacli, "Ueb. d. Keimgehalt ties Biiidchautsackes," Archiv f. Ophthalmoloyie, lid. 
 xl. p. 130. This article contains the references to the other articles cited in the text. 
 
256 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 Pink yeast and mould fungi liave also been cultivated fnmi the con- 
 junctiva. 
 
 Bach considers that of these various bacteria ovAy the staphylococcus 
 pyogenes aureus and albas and tiie strejitococeus jn'ugenes are demon- 
 strated to be pathogenie for man, although the possibility that others in 
 the list maybe pathogenic for man must be admitted. In a few instances 
 the staphylococcus pyogenes aureus, and in more the albus, have been 
 cultivated from the healthy conjunctiva. Cultures of the staphylococcus 
 j)vogenes aureus lune l)een introduced into the healthy conjunctival sac 
 of man and animals withdut causing inflammation. 
 
 Inasmuch as many micro-organisms must enter the conjunctival sac 
 from the air, the edges of the eyelids, and from contact with the fingers 
 and other objects, and as relatively few bacteria are found ordinarily in 
 cultures from this jiart, it is evident that there must be some very efficient 
 mechanism which rids the conjunctiva of most of the bacteria which enter. 
 There are two principal agencies by which this may be accomplished — 
 namely, mechanical removal through the naso-lachrymal duct, and the 
 germicidal action of the lachrymal and conjunctival secretions. Some 
 investigators have attached the greater importance to the former, others 
 to the latter, of these agencies. Experiments have shown that each may 
 be operative, but the mechanical removal has been shown to be especially 
 efficient and prompt in its action. 
 
 Van Genderen Stort has made experiments upon raliliits, and Bach 
 upon man, by dropping pure liquid cultures of easily-identified bacteria, 
 such as the Kielwater bacillus, the bacillus coli communis, the staphylo- 
 coccus aureus, into the conjunctival sac, and then determining by cultures 
 the length of time during which they can be demonstrated. Van Gen- 
 deren Stort found after fifteen minutes the inoculated bacteria reduced 
 to a small number, and at the end of an hour they had nearly or entirely 
 disappeai'ed from the conjmictival sac. Cultures from the nose showed 
 that they had been carried down the naso-lachrymal duct, and that after 
 five minutes they were abundant in the cultures from the nasal cavity. 
 Identical results were obtained by Bach in his experiments on human 
 beings. In the experiment of Bach with the staphylococcus aureus, 
 however, which was introduced in such munber that the innnediate 
 plates from the conjunctiva contained countless colonies, there were still 
 seventy-four colonies in the plates made after twenty-four hours. 
 
 The same experiments' were made after ligation of the naso-lachrymal 
 duct. Under these circumstances the inoculated bacteria also disappeared 
 from the conjunctival sac, but more slowly than when the duct was open. 
 Still, after an hour most of the bacteria had been removed. It was found 
 that they had been carried away by the lachrymal secretion which flowed 
 over the eyelids. If the eyelids were closed by a bandage, the bacteria, 
 with open nasal duct, rapidly passed down into the nose, and they did 
 not appear to pass out between the closed eyelids. When, however, the 
 duct was closed, they appeared aljiindantly in the bandage. 
 
 Bernheim has demonstrated that the tears possess considerable bacteri- 
 cidal jjower over certain species of bacteria, and his results have been in 
 part confirmed by the experiments of IMarthen, Bach, and others. The 
 staphylococcus pyogenes aureus is killed in moderate number, and the 
 typhoid bacillus in larger number, by the lachiymal secretion. We 
 
BACTERIA OF EXPOSED MUCOUS SURFACES. ,257 
 
 must therefore assign im|)(irt;uu'e to this chemical action, as well as to 
 the mechanical removal, in ridding the conjunctiva of invading bacteria. 
 Neither of these agencies suffices to remove all of the bacteria. Some 
 bacteria grow reatlily in the fluid of the conjunctiva. As has already 
 been mentioned, the coujuctiva nearly always contains some bacteria. 
 The orifices of tlie Mciliomian glands, the cilia, and tlie edges of the eye- 
 lids usually contain many bacteria, and tliese of course may readily enter 
 the conjunctival sac. 
 
 Bach was unable to demonstrate that liacteria introduced into the 
 nasal cavity ever make their way up the nasal duct to the eye. 
 
 It is difficult to obtain complete disinfection of the conjunctival sac. 
 The number of bacteria may be greatly reduced, either by the ai)plieation 
 of antiseptics or bv simple mechanical cleansing, ct)mbined with irriga- 
 tion by an iuditferent fluid, sucli as sterilized salt-solution. Bach obtained 
 the best results by the latter procedure, by which in sixteen outof ibrty- 
 two cases he rendered the conjunctiva sterile. 
 
 The importance of familiarity with the saprophytes to be found on 
 exposed mucous membranes is illustrated by the history of the so-called 
 xerosis bacillus. Tliis bacillus was discovered by Neisser in 1882 in 
 xerosis of the conjunctiva, and was I'cgarded by liim as the cause of this 
 disease. This C(jnclusiou was adopted by several subsequent investigators, 
 who found this bacillus constantly present in xerophthalmia. This same 
 bacillus has, however, been demonstrated by Schreiber, working under 
 Neissor's direction, in various other affections of the eye, and also, 
 although in small numbei', in the normal conjunctival sac. Neisser has 
 therefore given his assent to the conclusi()n expi'essed by Schreiber:' 
 " Tlie so-called xerosis bacilli are to be regarded as saprophytes whidi 
 ai'e often present in the conjunctiva and its secretion, both in diseased 
 and healthy eyes, and they play no special r6le either in xerosis or in 
 other diseases of the eye." 
 
 The xerosis bacillus belongs to an interesting group of bacteria which 
 are characterized l)y ri'markal)lc irregularities in size and shape — so-called 
 involution fcjrms — and l)y irregularities in staining, especially by the 
 presence of deeply-staining isolated granules. It is not positively proven 
 to form spores, although some of the isolated granules are interpreted 
 as such by Ernst and by Xeisser. To this same group belong the 
 diphtheria bacillus of Lijffler and the so-called pseudo-diphtheria 
 bacilli. 
 
 Mouth and Pharynx.^ — All of tlie micro-organisms which may 
 be present in the air, food, and ingested fluids may appear temj)orarily in 
 the mouth. The number of bacteria which have been cultivated ft-om 
 the human mouth is very large. Miller has isolated over one hundred 
 species. Freund has' cultivated eighteen ditterent chromogenic micro- 
 organisms fnim the mouth. 
 
 It is important to distinguish between the countless bacteria which 
 may appear as transient visitors in the moutli and those which find their 
 permanent home there. \ remarkable peculiarity of the constant inhabit- 
 
 ' Schreiber, Forlschrilte chr Medichi, 1888, p. 656. 
 
 ■ Miller, Die Mikro-orijanismen der MundhShle, Leipzig, 1889; David, Les Slicrobes de 
 la linuche, Paris, 1890. These valuable works present the most important results hitherto 
 obtained by the investigators of the micro-organisms of the mouth. 
 Vol. I— 17 
 
258 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 ants of the saliva is that most of tlicm will not t;ru\v in unr artiticial 
 cnlturc nu'dia. This produces often a strikinji' discrepaney between the 
 results of niicroscopieal examination of tiie huceal secretions and those 
 ol)tain((l by cultures. Cover-slip specimens may show an enormous 
 number of bacteria, when cultures made from the same material may 
 show very few or even no colonies. 
 
 Miller enumerates the following as the constant buccal bacteria : 
 leptothrix buccalin innominata, bacillm buccalw ma.vimus, Upfofhrix Imc- 
 calis 'maxima, iodococcu.s rar/inatuK, xpirUIuut sjiufir/cmnii, xjiirochaic 
 (Jcnlhmi. Xone of these have been artificially cultivated. Uacillus buc- 
 calis maximus and iodococcus vaginatus are stained violet by iodine 
 solution. These bacteria are often present, with others, in carious teeth, 
 in abscesses communicating with the mouth and pharynx, and in exudates 
 on the nuicous membranes of these parts, but they have not been proven 
 to be j)atliogenie. 
 
 The frequent presence of j)athogenic bacteria in the healthy mouth is 
 of great practical importance. The following patliogenic bacteria have 
 been found repeatedly in this situation : micvococcMS lanceolatm, strepto- 
 coccus pyogenes, staphy/oeorcus pyogenes aureus and albus, micrococcus 
 tctrageuus, bacillus pneituionia: of Friedliinder, bacillus crassus sputigenus 
 of Kreibohm, bacillus coli comnmnis. Biondi, Miller, Kreibohm, Galij)pe, 
 and others have found in the mouth additional pathogenic bacteria in 
 isolated cases, mostly, however, with some morbid condition. 
 
 The micrococcus lanceolatus was discovered by Sternberg in his saliva 
 in 1880. Many names have been given to this bacterium, the more 
 common svnonvms being di]doeoeeus pneumoni;e, pneumococcus of 
 Fraenkel and M'eichselbaum, diploeoccns lanceolatus, micrococcus of 
 sputum septiciemia, and micrococcus pncumoni;e erujiosa' (Sternberg). 
 This micro-organism was found by Netter in a virulent condition in 15 to 20 
 per cent., of the healthy persons whom he examined. It varies markedly 
 in virulence, and it is probably present in a non-virulent condition in 
 many eases. Indeed, Kruse and Pansini believe that the micrococcus 
 lanceolatus is a regular inhabitant of the human mouth, although it is 
 present in a virulent state in only alxint one out of five or six persons. 
 As the lanceolate coccus, especially when its virulence is weak or absent, 
 may grow in chains and present cultural characters of the streptococcus 
 pyogenes, it is often difficult, if not impossible, to distinguish between 
 these bacteria. 
 
 The chief interest attacliing to the frequent presence of the micro- 
 coccus lanceolatus in the healtjiy mouth is that this bacterium is the 
 cause of lobar pneumonia and of many cases of broncho-pneumonia. 
 It may also be concerned in local inflammations of the throat, and as a 
 primary or secondary invader may cause serositis and localized inflam- 
 mations in various parts of the body ; but the streptococcus pyogenes is 
 a more common cause of these lesions. 
 
 Various virulent and non-virulent streptococci have been foiuid in 
 the mouth, both shoi't-ehained streptococci and long-chained forms, corre- 
 sponding to the two varieties, streptococcus brevis and strejitococcus 
 longus. The distinctions upon which these varieties were established by 
 Von Lingelsheim are often inconstant, and do not serve for a slmrj) 
 differentiation. The chief interest belongs to the presence in the mouth 
 
BACTERIA OF EXPOSED MUCOUS SURFACES. 259 
 
 and pliaryux of the streptococcus ])yogcnos. Netter found the strepto- 
 coccus p\ogenes in seven out of one hundred and twenty-seven healtliy 
 mouths examined; that is, in 5.0 per cent, of the cases. Dornberger 
 found streptococci iu the mouths of iiealtiiy cliildren in 45 per cent, of 
 the ninety-four cases examined. Widal and Besanjon found streptococci 
 constantly and in large number in the mouths of twenty healthy persons, 
 and still more abundantly in the mouth and pharynx of forty-nine 
 persons aiibcted with varii)us diseases. 
 
 It often requires a painstaking examination to detect this strcptn- 
 coccus. The colonies are minute and pale gray, and iu a plate crowded 
 with other more striking colonies the former may escape recognition 
 unless es])ecial attention is given to them. If the secretions of the 
 hcalthv mouth and throat be carefully examined both by cover-slip 
 preparations and by agar plate-cultures, streptococci will be found with 
 great frei[uency, if not reguhirly, although, as already mentioned, it is 
 by no means easy to distinguish some of the streptococci from chain 
 forms of the micrococcus lanceolatus. 
 
 The number of streptococci is increased and their detection is much 
 easier in most inflammatory conditions of the tonsils and pharynx. 
 They are commonly associated with the di]ihtlieria bacillus in dij)litlie- 
 ria, and they are capable of causing all grades of tonsillitis and pharyn- 
 gitis, from slight erythematous forms to pseudo-membranous antl necrotic 
 inflannnations. 
 
 Streptococci cultivated from the healthy mouth usually have little or 
 no virulence as tested upon animals, and the same is often true of strcji- 
 tococci cultivated from the throat in various infections, local and gen- 
 eral, although in these cases they are more likely to be pathogenic for 
 animals. 
 
 The stre])tococcus pyogenes is a common and dangerous invader of 
 the deeper air-passages and lungs and of the internal parts of the body. 
 The portal of entry is often the tonsils and throat, and predisposing 
 causes are inflammations and other lesions of these parts, particularly 
 when combined with other infectious diseases and constitutional disturli- 
 ances. Under conditions little understood the mouth-streptococci may 
 acquire enhanced virulence. 
 
 The influence of predisposing causes as a factor in the etiology of 
 infections is well exemplified by the fact that healthy mucous membranes 
 harl)or very frequently sucli pathogenic germs as the micrococcus lanceo- 
 latus and the streptococcus j)yog<'nes. These bactei'ia often, moreover, 
 cause no serious disturbance in the repair of wounds and injuries involv- 
 ing the mouth and naso-pharynx, although they must gain access to 
 such wounds. Theyare, however, a standing menace in surgical ope- 
 rations involving these parts, a'i.d they may seriously interfere with the 
 healing of such wounds, or may under these circumstances set up pneu- 
 monia and general infection. 
 
 Staphylococci are found often in the healthy mouth and the throat, 
 but the genuine pyogenic staphylococci do not appear to be present Mitli 
 great fre(juency. Vignal, Netter, and Miller met the staphylococcus 
 pyogenes, aureus only in a com])aratively small number of cases in their 
 bacteriological examinations of the healthy mouth. It is found more 
 frcfpiently in various inflanunations of the nuicous membranes of this 
 
260 GENERAL BACTEIilOLOGY OF SURGICAL INFECTIONS. 
 
 region, but it plays no such importnut role in these as does the strepto- 
 coccus pyogenes. 
 
 Wliite liquefying cocci, often described as the staphylococcus pyog- 
 enes albus, are l'(nind oftener than the staphylococcus aureus in the 
 mouth and throat. Some of these have been shown to possess j)yogenic 
 power, and may be accepted as the staphylococcus pyogenes albus, but 
 others are devoid of such power. 
 
 According to the statements of Biondi, Miller, and others, the micro- 
 coccus tctragenus, which was discovered l)y Koch and Gatfky in a 
 phthisical cavity, is often present in the mouth. In a considerable 
 number of cases examined by the writer it was absent. The frequency 
 with which certain bacteria are present in the mouth probably varies 
 considerably in different regions and according to the class of cases 
 selected for examination. There are various species of tetragenous cocci. 
 The jiathogenic form of Koch and GafFky is designated by Boutron as 
 micrococcus tctragenus septicus. This organism is present more fre- 
 quently in abscesses in the neighliorhood of the mouth and throat, par- 
 ticularly those connected with carious teeth, than in abscesses in other 
 parts of the body, although even in the former it is rarely present. 
 
 The virulent di])htheria liacillus was found by Park and Beebe ' in 
 the healthy throats of eight out of three iumdred and thirty ])ersons in 
 New York who gave no history of direct contact witli cases of <liphthe- 
 ria. Only two of these eight persons afterward developed diphtlieria. 
 They found non-virulent, but otherwise characteristic, diphtheria bacilli 
 in twenty-four throats of the same gi'oup of persons, and pseudo-diph- 
 theria Ijacilli in twenty-seven. 
 
 The pseudo-di])litheria bacillus which is occasionally found in the 
 throat is devoid of virulence, and presents certain cultural peculiarities 
 distinguisiiing it from the genuine di))htheria bacillus. It is not known 
 to be pathogenic. There is much confusion in the use of the term 
 "pseudo-diphtheria bacillus," and some writers have described under 
 this name the genuine diphtheria bacillus devoid of virulence. There is 
 ]irobal)ly more than one bacterial species which may be called pseudo- 
 diphtiicrial l)acillus. 
 
 The mouth and adjacent parts are the most frequent portals of entry 
 of the bacterium of actinomycosis. This organism is likely to lodge near 
 carious teeth. 
 
 Although the mouth and throat offer more favorable conditions for 
 the ])rolonged existence of many micro-organisms than do other exposed 
 mucous nicmljrane, nevertheless of the vast hordes of micro-organisms 
 whicli nmst gain access to the mouth only a small number actually per- 
 sist there. The conditions are evidently unfavorable for the survival of 
 the majority of bacterial species in this situation. Those which are unable 
 to gain a foothold must sooner or later pass down into the stomach or 
 intestine or out through the mouth and nose or perish within the body. 
 
 The secretions in the mouth and throat, like most of the fluids of the 
 body, possess some degree of germicidal power. Sanarelli" found that 
 the saliva is capable of killing in a short time a moderate number of 
 
 ' Welch, " BacterioloKical Investigations of Diplitheria in the United States," Am. 
 Jniim. (jf the Med. Sciences, Oct., 1894. 
 
 2 Sanarelli, Centmlbl. f. Bakle,:, 1891, Bd. x. 
 
BACTERIA OF EXPOSED MUCOUS SURFACES. 261 
 
 several pathogenic bacterial species. This was found to be the case with 
 the staphylococcus aureus, the streptococcus pyogenes, the micrococcus 
 tetragenus, tlie typhoid bacillus, and the cholera spirillum. Tiie diph- 
 tlieria bacilhis, iiowever, survived for twenty-eiglit to forty days, and the 
 micrococcus lauceolatus grew well in sidiva, although with rajiid loss of 
 virulence. 
 
 E. Grawitz and Stcffen' liave confirmed this observation of Sanarclli 
 as regards the pneumococcus, and have found that the virulence of this 
 organism may be restored by cultivating it upon pneumonic sputum pre- 
 pared as an artificial culture medium. TJiey interpret this as indicating 
 that the virulence of the jineumoeoccus may be enhanced by certain 
 chemical changes in the comjjosition of the sputum. 
 
 There is reason to believe that the virulence of pathogenic bacteria in 
 the mouth, notalily of the micrococcus lanceolatus and the streptococcus 
 pyogenes, may fluctuate, both in the direction of attenuation and of 
 exaltation, but we are not acquainted with the conditions wliich control 
 these changes. 
 
 The salivary glands and ducts are free from bacteria, except near the 
 orifice of the ducts. 
 
 Respiratory Passages and Middle Ear. — In normal respiration 
 the bacteria contained in the inspired air must enter the nasal cavities. 
 The anatomical arrangement of the nasal passages renders these an im- 
 portant filtering apparatus fur the protection of the deeper air-passages. 
 It has been shown by experiments of Wright that with a respiration of 
 one litre of air per minute from three-fourths to four-fifths of the 
 bacteria of the inspired air are retained in the nasal cavities and their 
 adnexa. 
 
 It has already been mentioned that most of the bacteria which enter 
 the conjunctival sac are carried into the nose through the nasal duct. 
 We should therefore expect that the nasal cavities would contain abun- 
 dant niicro-iirganisms. 
 
 The bacteria of the healthy nose have been studied by E. Fraenkel, 
 Loewenberg, Hajek, von Besser, Wright, Paulsen, Weibel, Deletti, and 
 others, witli much divergence in their results. Some have found few, 
 others many, bacteria in the nose ; some have met frequently jMthogenic 
 bacteria, others rarely or not at all. 
 
 Von Besser- describes twelve non-pathogenic species isolat(Ml from 
 the noses of thirty persons at work in the laboratory. In the same group 
 of cases he found in the nose the micrococcus lanceolatus six times, the 
 streptococcus pyogenes five times, the staphylococcus pyogenes aureus 
 seven times. In the nasal cavities of twenty-eight convalescent hosjiital 
 patients he found the micrococcus lanceolatus four times, and the strc])- 
 tococcus pyogenes, the staphylococcus pyogenes aureus, and the bacillus 
 of Friedliinder each once ; in twenty-three soldiers and servants, the 
 micrococcus lanceolatus four times, the staphylococcus pyogenes aureus 
 six times, the streptococcus pyogenes once, and the Friedliinder bacillus 
 once. 
 
 Wright^ isolated from the nasal secretion of ten healthy persons the 
 
 ' Grawitz and Stcffen, Berliner kliii. Wochenschr,, 1894, No. 18. 
 
 ^ Von Besser, Zirrjier.f Beitriiqe, Bd. vi. 
 
 ' Wright, New York Med. Journ., July 27, 1889. 
 
202 OEXERAL BACTERIULOGY OF SUIiOICAL lyFECTIOyS. 
 
 sta|)hyl()co('('ns jnoticnos nlhiis six times, the aureus and eitreus three 
 times, tiie baeilhis lactis aenmeiies ouee, and tlie microeoceus tetragenus 
 once. 
 
 Paulsen' uiade sixty-tour cultures from the iiealthy noses of twenty- 
 seven persons. Eleven of these were sterile, nineteen gave ten colonies 
 or less, sixteen gave u]) to one hundred colonics, twelve several hundred 
 colonies, and six furuisiicd countless colonies. Cocci were found much 
 oftener than bacilli. Only once did he find the streptococcus pyogenes. 
 Pathogenic bacteria were not observed in any other of the normal cases. 
 Upon eover-sliji preparations lie noted spirilla, and Weibel has cultivated 
 a comma bacillus from the nose. 
 
 Special interest attaches to the presence of eapsulated bacilli in the 
 nose, as these are found with great frequency, if not constantly, in 
 ozfeua. The oziena l>acilhis of Abel" resembles closely the Pricdliinder 
 liacillus, l)ut is believed by him not to be identical with it. AVhcther or 
 not this l)acillus is ever found in the healthy nose is not established. The 
 Friedliinder bacillus and the lanceolate coccus have repeatedly been 
 found in the nose, especially in inflammatory conditions. The rhino- 
 scleroma bacillus is a eapsulated bacillus much liki' the Friedliinder liacil- 
 lus, but differing from it l:>y staining -with (ii'am's method. ^A'e do not 
 at present possess an entirely satisfactory differentiation of a grou]) of 
 eapsulated bacilli to which Fricdliindcr's l)acillus, the ozrena bacillus, 
 the rhinoscleroma bacillus, the eapsulated bacillus of Pfeiffer, and some 
 others belong. 
 
 The diphtheria bacillus is constantly found in fibrinous rhinitis. 
 Various bacteria, especially dijilococci, have been found in the secretion 
 of corvza. When this secretion is abundantly ]>oured out, it often 
 happens that cultures from several drops of it contain very few colonies 
 or are sterile. 
 
 Straus has recently made the imjiortant observation that the tubercle 
 bacillus is often present in the nasal cavities of healthy pei'sons who 
 spend much of their time in proximity to tuberculous patients. He 
 examined for tubercle bacilli the contents of the nasal cavities of those 
 engaged about hospital wards containing consumjiti\cs. Twenty-nine 
 such examinations were made by the inoculation of guinea-pigs. In 
 nine cases the guinea-pig developed tuberculosis. Of these nine persons, 
 six were healthy attendants occupied in such work as sweejiing the floor 
 and shaking bed-linen, one was a patient with a chronic nou-tul)erculous 
 ailment, and two were medical students who spent several hours daily in 
 the hospital. None of these individuals presented the slightest evidence 
 of tuberculosis. These observations are even more significant than 
 those of Cornet as to the abundance and wide distribution of tubercle 
 bacilli in the neighborhood of consumptives. 
 
 Wurtz and Lermoyez have found that the nasal mucus possesses con- 
 siderable bactericidal capacity. 
 
 Von Besser found bacteria abundantly in the larynx and bronchi of 
 human corpses, but he demonstrated that after death the fluids from the 
 mouth and naso-pharynx may readily penetrate even into the smaller 
 bronchi, and moreover in his cases the lungs and air-passages Mere dis- 
 
 ' Paulsen, Cenlrolhl. f. Bitkter., Bd. viii. p. 344. 
 '^ Abel, ibid., Bd. xiii. )i. 161. 
 
BACTERIA OF EXPOSED MUCOUS SURFACES. 2G3 
 
 eased ; so tliat lie attaches no importance to his observations as hearing 
 upon the question of tlie presence of bacteria in tlicse parts in iiealtli. 
 
 Hihli'!)ran(lt ' found tiiat culture media inocuhited witli l)its of the 
 huig- and of traelieal mucus from recently-killed rabl)its usually remained 
 sterile, and he concludes that practically all bacteria which enter with 
 the air are retained in the upper air-passages and do not penetrate below 
 the larynx. This protection, however, has its limits, as when the inspired 
 air was loaded with fungus-spores these could l)c demonstrated after 
 half an hour in the lungs. That foreign particles in the air may be 
 conveyed into the lungs is evidenced by the coal particles regularly 
 found in the lungs. 
 
 Wargunin, in opposition to Hildebrandt, isolated nine different kinds 
 of bacteria from the trachea, bronchi, and lungs of recently-killed 
 healthy animals. 
 
 The observations of the writer are in harmony with Hildebrandt's 
 results as to the usual absence of Ijacteria, at least in sntticient number 
 to be demonstrable by ordinary culture metliods, in the bronchi and 
 lungs of healthy animals. 
 
 At autopsies on human beings bacteria, including the micrococcus 
 lanceolatus and the streptococcus pyogenes, may be found in tlic lungs 
 withiiut notie(>able lesion of this organ. 
 
 The action of the ciliated epitlielium and coughing would tend to 
 drive out bacteria which may have entered the trachea and bronchi. 
 
 The expired air is free from micro-organisms, except as these may be 
 mechanically detached, as in sneezing or coughing. 
 
 ^\'e are not informed as to the frequency with which bacteria are 
 ])resent in tiie healthy tymjianic cavity. That bacteria may pass up the 
 p]ustacliian tube into the middle ear is shown by the presence in otitis 
 media of various micro-organisms often finuid in the mouth and naso- 
 ])harynx, notably the micrococcus lanceolatus, the streptococcus jiyogenes, 
 the Friedliinder bacillus, and the pyogenic staphylococci. There are of 
 course other paths by which micro-organisms may be carried into the 
 middle ear, as the lymphatic and l)lood-currents, and in meningitis from 
 the cranial cavity. 
 
 Netter found constantly in the middle ear of new-born infants, at au- 
 topsy, bacteria, and among these were pathogenic forms to which he attrib- 
 utes the frequent occurrence of middle-ear inflammations in infants. In 
 autojisies upon one hundred and eight infants less than one year old 
 H. Kossel found otitis media in eighty-five cases. The most common 
 organism in these cases was a delicate bacillus, apparently identical with 
 Pfeifl'er's pseudo-influenza bacillus (38 cases). In addition were found 
 the diplococcus pneumonia (10), streptococci (4), thick bacilli (2), staphy- 
 lococci (2), and the bacillus pyocyaneus (once). One case was tubercu- 
 lous otitis. Some writei's are of the opinion that changes often found 
 in the middle ear of the new-born are jjost-mortem alterations. 
 
 Stomach and Intestine. — The study of the micro-organisms 
 present in the stomach and intestine presents many jjoints of physi- 
 ological and jKVthological interest, but we must confine our attention 
 chiefly to those of surgical interest. When we consider the relations of 
 intestinal bacteria to various surgical aflections, suc'h as perforative and 
 
 ' Hikleljrandt, Zieyler's Beitrdgc, Bd. ii. 
 
264 CKXERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 ((tlier forms of peritonitis, apjjciidicitis, and even infections remote from 
 tlu' intestinal canal, it is apparent tiiat this sulyect claims the attention 
 of the snrgeon. 
 
 The main sonrces of the micro-organisms of the stomach and intes- 
 tine are the inu^esta and the air. From tliese sonrces cc^nntlcss bacteria 
 and ftuiii'i of all kinds arc introduced into the alimentary canal, l)nt, as 
 is tnic of other exposed mucous surfaces, only a limited number of 
 species are capable of prolonged existence in this situation. 
 
 The meconium of the new-born infant is sterile, but within twenty- 
 four liours after birth it usually contains abundant bacteria. Although 
 many varieties of bacteria may be found, Eschcricii has demonstrated 
 a constant bacterial flora in the lleccs of milk-fed infants. These con- 
 stantly-present intestinal bacteria are the bacillus lactis aerogenes, pre- 
 dominating in the small intestine, and the bacillus coli communis, pre- 
 dominating in the large intestine. These bacteria remain throughout 
 lite as the obligatory and characteristic intestinal bacteria of man in 
 health, and as tiiey are frequent seccmdary invaders of the body in 
 disease, and may be concerned in various surgical and other diseases, 
 much practical interest attaches to them. 
 
 The bacterial flora of the small intestine, particularly in its upper 
 part, is more varied, as tested by jilate cultures, than that of the large 
 intestine. In fact, the comparison of the results of microscopical exam- 
 ination and of cultures from the stools indicates that a large number 
 of the bacteria in the fseces are dead. 
 
 As there is very little free oxygen in the intestinal canal, the con- 
 ditions are not favorable for the multiplication of obligatory aerobes. 
 Most of the bacteria found in the intestine are strict anaerobes or facul- 
 tative anaerobes, but anthrax sjiores, which re(juire oxygen for their 
 germination, develop into l)acilli in the intestinal canal. 
 
 It is certain that patliogenic l)acteria of many kinds often find their 
 way into the intestinal canal ; in fact, there is ])robably no pathogenic 
 germ which may not in certain individuals and in certain times and. 
 places be present in the intestine. 
 
 It is true that the acid gastric juice may kill many of the micro- 
 organisms which enter the stomach, but there are many which resist its 
 action. If we were to rely exclusively ujjon the results of experiments 
 in the test-tube on the germicidal action of the acid gastric juice, particu- 
 larly the very acid juice of some animals, we should consider this action 
 a formidable obstacle to the passage of living bacteria into the intestine. 
 But when we consider the insusceptibility of many bacteria to weak 
 acids, the relatively slight and varying acidity of the human gastric juice, 
 the absence at times of any acid in the stomach, the withdrawal in large 
 measure from the direct and concentrated action of the gastric juice f>f 
 bacteria contained in ingested masses of food and large volumes of fluid, 
 and the I'apidity with which the gastric contents may pass into the duo- 
 denum, we can understand how micro-organisms, even those very sus- 
 ceptible to acids, may find fre(]ucnt ojiportunity to enter the intestine. 
 Only a fraction, usually not more than .05 to .1 per cent., of the total 
 acidity of the stomach is due to free hydrochloric acid, and the proteid 
 hydrochlorides possess very little bactericidal power. 
 
 Many organisms can grow in the human stomach even when it is very 
 
BACTERIA OF EXPOSED MUCOUS SURFACES. 265 
 
 jiciil, as has been shown by Gillespie.' The nunil)er and variety of 
 niicro-org-anisins whieh have been isolated from tiie luinian stoniacli 
 by Maefadyen, Al)elons, Ojipler, (Jillespie, and others are very great, 
 but it wonld serve no useful purpose to enumerate them liei'e. The 
 liaeilhis lactis aerogenes, tlie baeillus coli eommunis, and the pyogenic 
 cocci may be specified as having been repeatedly found in the healthy 
 stomach. 
 
 The list of pathogenic bacteria which have been found in the intes- 
 tinal contents is a long one. Many are present only accidentally and as a 
 transient phenomenon. Some are f()und with such frecpicncy as to merit 
 special notice. In general, the conditions are not favorable for exten- 
 sive multiplication of most pathogenic micro-organisms in the healthy 
 intestine. 
 
 Pyogenic cocci are rarely absent from the intestine. They are often 
 present in such small number as to escape detection, but the great 
 frcqueni'y with which these cocci, particularly the strcj)tococcus jivogenes, 
 are found in the exuilate of perforative jjeritonitis, where they can rapidly 
 multiply, shows that they are common inhabitants of the intestine. 
 Gessner found a pathogenic streptococcus, probably identical with the 
 streptococcus pyogenes, in large numbers in the duodemnn of six persons 
 out of eighteen examined at autopsy. 
 
 The bacillus pyocyaneus and the proteus bacilli are also often jm'sent 
 in the intestine. The tetanus bacillus and the bacillus of malignant 
 cedcma are regidar inhabitants of the intestine of herbivorous animals. 
 The micrococcus lant'eolatus has been found repeatedly in the human 
 intestine, likewise the bacillus pyogenes foetidus. The bacillus aerogenes 
 capsulatus has been found l)y the writer in the intestine in two cases of 
 perf)rative peritonitis with |)rodnction of gas. The occurrence of intes- 
 tinal actinomycosis and of perityphlitis actinomycotica shows that the 
 actinomyces may find its way into the intestine. 
 
 There are various other pathogenic bacteria which have been occa- 
 sionally found in the intestine, but those which have been mentioned ai'e 
 the ones of chief surgical interest. The specific intestinal infections of 
 typhoid fever, cholera, tuberculosis, and antiirax are not considered here. 
 The amceba dysenteri;e, on account of its relation to abscess of the liver 
 and lungs, deserves mention. 
 
 In this connection it may be stated that the bile in the normal bile- 
 ducts and gall-bladder is to be regarded as free from bacteria. Under 
 various conditions, however, the colon bacillus and other Ijactcria, par- 
 ticularly the ]>yogenic cocci, often wander into the biliary passages. The 
 M'riter has found very frequently the colon liaeillus in cultures made from 
 the interior of gall-stones. It is not uncommon at autopsies to find the 
 colon bacillus, less .frequently pyogenic cocci, particularly streptococci, 
 in the bile without any alteration in the bile or evident lesion to exjdain 
 the migration of these bacteria. 
 
 Contrary to an old idea, the bile has not been found to possess any 
 decided germii'idal property, at least as regards most bacteria. 
 
 Gexito-urixary Tract. — It has been shown by Lustgarten and 
 Mannaberg, Rovsing, Steinschneider with Galewsky, Petit and Wassei'- 
 
 ' Gillespie, " The Bacteria of the Stomach," The Journal of Puthnlogy and Bacteriology, 
 vol. i. p. 279. Here can be found references to the literature of this suhject. 
 
266 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 maun, and Hofmeister' that the liealtliy ma/e urethra always contains 
 hactcria. These are abundant and varied in the fossa navi('uhiris, and 
 <liininis]i rapidly in number and kind toward the ])()sterior j)art of the 
 iiretlira. JIow far l)aek they extend is not ])ositively known. They 
 were found l)y Hofmeister as far baek as eiii;ht centimetres from the 
 external orifice under conditi(ms making it proV)able that they existed at 
 this point, and were not simply piislied back by the sterilized glass tube 
 wliich was introduced for the passage of the inoculating wire. Urethral 
 bacteria are usually present in urine voided after sterilization of the 
 meatus and fossa, even in the urine ])assed toward tlie en<l of micturition. 
 
 Lustgarten and Mamiabcrg by microscojiical examination of the 
 normal male urethra distinguished ten ditferent kinds of bacteria — 
 namely, four bacilli and six cocci. Among the bacilli was the smegma 
 l)acillus, which has already been mentioned in describing the bacteria of 
 the skin (page 254). Among the cocci was a diplococcus M'hich they 
 descrilje as identical in form and staining reactions with the gonococcus. 
 Tliey isolated in cultures seven species of cocci, white and yellow. 
 Among these cocci was found the stajihylococcus pyogenes aureus. They 
 observed that the common urethral saprophytes were ineajiable of causing 
 ammoniacal fermentation of the urine, and that they died when planted 
 in urine. 
 
 Rovsing, in opposition to most other investigators, found in the 
 normal urethra pyogenic and non-])yogenic bacteria cajiable of fermenting 
 urine and identical with many of the bacteria found in cystitis, so that 
 he concludes that the usual source of the bacteria causing cystitis is from 
 the urethral flora and not from the air bacteria. 
 
 Steinschneider deseriljes four species of diplococci, identical with 
 forms previously recognized liy Lustgarten and INIannaberg, as occurring 
 in the normal urethra. Of these, a milk-wliite di])!ococcus, which was 
 met in 87 per cent, of the eighty-six healthy and gonorrhreal cases 
 examined, is regarded as the most common bacterium of the urethra. 
 Next in frequency is an orange-yellow dijilococeus found in 44.2 per 
 cent, of the cases. These two sjiecies are stained by Gram's method, and 
 need not be confounded with the gonococcus. Steinschneider isolated 
 from three cases a grayisli-white diplococcus, and from one case a lemon- 
 yellow diplococcus, which were decolorized by Gram's stain and which 
 may correspond to Lustgarten's pseudo-gonococei. He concludes that in 
 only 5 per cent, of the eases are diplococci found which are decolorized 
 by Gram. 
 
 Petit and Wassermann, whose methods were ojien to objection, culti- 
 vated from the normal uretlira of four persons five cocci, six bacilli, 
 two sarcina?, and two yeast-fungi. They did not find a pseudo-gono- 
 coccus. 
 
 Hofmeister did not find the normal urethral flora as varied as have 
 some observers. Two species of di]ilococci — viz. a non-liquefving white 
 or yellow, large coccus and a li(juefving, smaller, gray coccus — he regards 
 as regular inhabitants of the urethra. An orange-yellow and an opaque 
 white liquefying dijilococcus he isolated, eacli from two cases. None of 
 these four diplococci from recent cultures were decolorized by Gram, but 
 
 ' Hofmeister, Fortsichrilte der l\fi''lirli), 1893, Nos. 16 and 17. Keferences to otlier arti- 
 cles cited are contained in this article. 
 
BACTERIA OF EXPOSED ML'COUS SURFACES. 267 
 
 he states that he repeatedly found in eover-elass specimens from the nre- 
 tiiKi diploeocei which were decolorized l)y Cxram. Once he found the 
 staphvlocoecus aureus. The normal urethral Hora he considers to l)e 
 non-})athogenic and incapable of surviving long in the urine, although 
 pathogenic bacteria may accidentally be present in the healthy urethra. 
 
 The occurrence of the so-called psendo-gonococci, as tirst descrilied 
 by Bumni and Lustgarten and Alannaberg in healthy and diseased nre- 
 thr:e, is of importance in reference to the diagnosis of gonorrhu'a l)y 
 microscopical examination. If all of the well-known points, as to the 
 morphology, staining reactions, and enclosure and arrangement within 
 cells, characterizing the gonococcus be observed, most autliorities believe 
 that a mistake in diagnosis is possible only in a very small number of 
 cases, if at all. Undouljtedly a microscopical diagnosis of the gouo- 
 coccus has been made in some cases uptin insufficient evidence, and it 
 must be admitted that a positive microscopical diagnosis is sometimes 
 attended with great difficulties. "We now possess methods which enable 
 us without serious practical difficulties to isolate and study the gono- 
 coccus in cultures. 
 
 It cannot be said that investigations have determined satisfactorily 
 tlie question as to the relative frequency with which the bacteria of cys- 
 titis are derived from the urethra or are introduced from without the 
 body. As the bacillus eoli communis or the bacillus lactis aerogenes is 
 one of the most common bacteria in cystitis, the infection may often be 
 from the intestinal canal through the blood-current by way of the kid- 
 neys; some believe more directly by continuity or by the lymphatic stream 
 from the rectum. These bacilli are, however, widely distributed outside 
 of the body, and may be present around the genitals. 
 
 Although the results of the bacteriological examination of the healthy 
 urine are contradictory, the weight of evidence is decidedly in favor of 
 the view that the urine in the bladder in health is free from bacteria, 
 and that if urethral saprophytes, or .even some pathogenic germs, gain 
 entrance to the bladder, they do not long survive in a healthy ])crson. 
 
 The female urethra contains bacteria, and the anatomical conditions 
 are more favoral)le than in the male for the passage of the urethral 
 bacteria into the bladder. Von Gawronsky in sixty-two cases examined 
 found bacteria in fifteen — namely, the streptococcus pyogenes (3), the 
 staphylococcus aureus (S), sta])hylococcus albus (1), the bacillus coli com- 
 munis (2), the bacillus tholoeideum (1). This last bacillus is prol)ably a 
 pathogenic variety of the bacillus lactis aerogenes. It is stated that the 
 urethra in these cases was normal. 
 
 The vagina contains bacteria in varying number and kind. The 
 cervix and uterus are normally free from bacteria. The absence of bac- 
 teria from the uterus, is not easily explained, but it has its analogy in the 
 absence of bacteria from various other canals and cavities which com- 
 nuuiicate with passages containing bacteria, as, for example, from the 
 bladder and the bile-ducts. The factors usually cilcd in ex]ilanation of 
 this important provision of nature are mechanical hinderances to the 
 pencti'ation of bacteria resulting from the anatomical structure of the 
 parts and the germicidal jirojierties of the secretions. The princiiud 
 emphasis is usually laid upon the latter factor. 
 
 The bacterial flora of the normal vagina contains various bacilli and 
 
2C,9. riEXERAL BACTEnTOLOOY OF SURGICAL INFECTIONS. 
 
 cocci, wliicli do not <^row on onr ordinary cnltnro media, bnt can I)C rec- 
 ognized by micro8ct)pical examination. Doederlcin ' lias described a 
 non-])athogenic bacillns or a grouj) of bacilli which he has cultivated 
 upon a sjM'cially prepared acid medium, and which are characterized by 
 marked acid fermentation of sugar. Tlicse vaginal bacilli are regarded 
 by Doederlcin as the only bacteria to be found regularly in the normal 
 vaginal secretion, and u])on their jiresence or absence he has l)asetl his 
 distinction between normal and pathological vaginal secretions. It has, 
 however, been shown by Kriinig and Menge that Doedcrlein's bacillus 
 is often absent from the normal vagina, and that it cannot, therefore, 
 serve as a distinguishing character of the normal secretion. 
 
 According to Knniig^and JNlenge'' the regular bacterial inhabitants 
 of the normal vagina are obligatory anaerobes, and can be cultivated 
 only in anaerobic cultures. Tiiey do not describe in detail the characters 
 of these vaginal anaerobic bacilli and cocci, but they say tliat they are 
 non-pathogenic. In microscopical jireparations Mcnge found in the 
 normal vaginal secretion of non-pregnant women bacilli more abun- 
 dantly than cocci, but the latter were never missed. He found Poeder- 
 lein's l)acilli in the minority of cases, and more frequently short, thick 
 rods and delicate, thin, curved rods. 
 
 According to INIenge, bacteria capaljle of cultivation in alkaline 
 aei'obic culture media are present abundantly near the outlet of the 
 vagina, but are usually absent, and wlien present only {'(^w, in the ujiper 
 part of the normal vagina. He found tmly once out of fifty cases exam- 
 ined a pyogenic coccus. This was the streptococcus pyogenes, wliicli 
 existed as a persistent organism throughout the vaginal canal of a non- 
 ])regnant woman with gonorrhoea of the cervix and thin cervical dis- 
 charge. The reaction of the vaginal secretion was alkaline. 
 
 Diplococci similar to those from the urethra already described occur 
 also in the vagina, and what was said in that connection as to pseudo- 
 gonocoeci apjjlies here. Koplik*has isolated from the normal vagina 
 of children a white diplococcus, and from the \'aginal discharge in 
 simj)le, not gonorrheal, vulvo-vaginitis in children two white diplo- 
 cocci and a yellow diplococcus. None of these were decolorized by 
 Gram's method or need be mistaken for the gonococcus. 
 
 The question as to the occurrence of pathogenic organisms in the 
 normal vagina has been and is still a subject of vehement contro\ersy 
 among obstetricians, who are divided into two camps as to the desira- 
 bility of antiseptic irrigations of the vagina and as to the frequency of 
 so-called auto-infection as a cause of puerperal infections. The question 
 is also of interest to the surgeon in relation to hysterectomy and in 
 general to operations involving the vagina and uterus. 
 
 The results of different investigators on this point have been ex- 
 tremely divergent, and, notwithstanding the large amount of work done, 
 it is not possible at present to express a final judgment. Some inves- 
 tigators have found pyogenic bacteria frequently in the vagina of preg- 
 nant women. Thus, Stetfeck found pus-produciiig organisms in 41 per 
 
 ' Doederlein, Das Scheithnsrkret, v. s. w.. Leijizig, 1892. 
 
 * Kronig, Deutsche mrd. Wochenschriff, Oct. 25, 1894. 
 
 3 Menge, ibid., Nov. 15, 22, 29, 1894. 
 
 ■" Kojilik, Journal of Cuianeous mid Genilo- Urinary Diseases, June and July, 1893. 
 
BACTERIA OF EXPOSED 3IUC0US SURFACES. 269 
 
 cent, of thf twontv-nine pregnant women examined. Others have faik'tl 
 to find pyogenic bacteria, with tiie exception of tiie gonococcus, in all of 
 the cases examined, or have met them only exceptionally. Most of the 
 later investigations in which a proju'r technicjue was adopted are in 
 accord as to tiie infreqnency with which pathogenic bacteria, with the 
 exception of the gonococcus, are to be found in the vagina of either 
 pregnant or non-j)regnant women. 
 
 In a bacteriological examination of one hundred and ninety-five preg- 
 nant women Doederlein found in 55.3 per cent, acid normal vaginal 
 secretion, according to his definition. The only bacteria were tlie acid- 
 producing vaginal bacilli. In 44. (J per cent, of the cases he found what 
 he calls pathological secretion, which was feebly acid, neutral, or alka- 
 line, and contained various bacilli and cocci. The streptococcus pyog- 
 enes he found in 9.2 per cent, of the so-called pathological secretions, 
 or in 4.1 per cent, of the one hundred and ninety-five cases examined. 
 To the staphvlococci present he attributes no imjHirtance in the causation 
 of puerperal fever. The oidium albicans is often finuid in the vagina, 
 but is without significance as a cause of primary infection. 
 
 Kronig found the vaginal secretion of all the pregnant women (about 
 five hundred) whom he examined to be acid, the intensity of the reaction 
 varying in different cases. The bacterial flora was of the same general 
 character as tliat already described for the normal vagina. In no case 
 did he find the streptococcus pyogenes or pyogenic staphylococci. His 
 conclusion, that the streptococcus pyogenes and the ])yogenic staphylo- 
 cocci are never present in the vagina of pregnant women, and that if 
 they should enter they must of necessity be (juiekly destroyed, cannot 
 Ije accepted without discrediting the results of other comjietent investi- 
 gators, but we may admit that they are jiresent only exceptionally. 
 
 Experiments have been made by Kronig and Menge proving tliat 
 bacteria, including the streptococcus pyogenes and jiyogenic staphylo- 
 cocci, introduced, even in large number, into the vagina of ])regnant or 
 non-pregnant women, disap))ear in a short time. Thus, Kriuiig found 
 that the bacillus pyocyaneus disappeared from the vagina of pregnant 
 women in from ten to thirty hours, the staphylococci in from six to 
 thirty-six hours, and the streptococcus ])yogenes, with which only three 
 experiments were made, within six hours. No difference \\as observed, 
 as to the rapidity with which these foreign organisms disajipeared, 
 between the normal and pathological secretions in Poederlein's sense, 
 including those containing gonococci. Wenge found in non-pregnant 
 women that the V)acillus pyocyaneus disapjieared from the vagina on the 
 average in twenty-one hours, the staphylococcus jn'ogenes aureus in 
 twenty-six hours, aod the streptococcus pyogenes in twenty-two hours. 
 In only one case did the vagina become infected, and this was with the 
 sta]ihylococcus aureus in consequence of an accidental injury to the wall. 
 In the other cases the bacteria immediately after their introiUiction began 
 to disappear. In most instances an increase in the leucocytes in the 
 vagina was ol:)served. 
 
 Menge has attempted to discover the factors concerned in the pro- 
 duction of this powerful bactericidal property of the vaginal secretion. 
 He attaches some importance to the acid reaction to which Doederlein 
 had called attention as the essential factor, but this cannot be the sole or 
 
270 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 tlic principal faotcir, as tlio vaginal secretion of non-i)r("gnant women, 
 altluiuti'li usually acid, may he alUaline, anil the bacteria (lisaj)peare(l 
 ahdut as rapidly from the alkaline as from the acid secretion. AVe 
 cannot at present give any satisfactory explanation of the bactericidal 
 properties of the vaginal secretion. 
 
 Irrigation of the viigina with water or with antiseptics diminished 
 the rapidit}' with which bacteria intnxluced into the vagina disap- 
 peared. 
 
 Bacteria introduci'd into the cervix uteri likewise disappeared in a 
 short time. The secretion here is alkaline. 
 
 As a result of the investigations of numerous observers we mav con- 
 clude that the normal vagina of pregnant and non-pregnant women may 
 contain ])athogenic bacteria. With the exception of the gonococcus, 
 such Ijacteria are not often jiresent, and the vaginal secretion does not, 
 as a rule, permit the prolonged survival of most of the bacteria, includ- 
 ing pathogenic forms, which may enter. Powerful as these normal de- 
 fences ai'c, they may, however, be overthrown imder conditions which 
 we now only imperfectly understand. 
 
 IMucli emphasis has been laid upon the fact that jnogcnic cocci occa- 
 sionally found in the vagina iiave manifested, with few exceptions, little 
 or no virulence when inoculated into animals. It should, however, be 
 remarked that the same negative result of the animal experiment some- 
 times follows the inoculation of streptococci cultivated from cases of 
 jnierperal infection. The animal ex])criment is not decisive as to the 
 possibilities of these pyogenic bacteria in man, and it has been jiroven 
 that ])yogenic cocci without virulence for animals mav infect human 
 beings.' 
 
 Bacteria in Woman's Milk. — Serious errors of interpretation of 
 their observations have been made by several investigators of the subject 
 of excretion of bacteria by the milk, by not recognizing the fact that milk 
 obtained from the breasts of healthy women regularly contains bacteria. 
 The milk as secreted by the gland is undoubti'dly sterile in health, but 
 bacteria derived from the skin are mingled with the milk. These bac- 
 teria gain access to the milk in the lacteal ducts within the nipjile. By 
 far the most common of these bacteria is the staphjloeoccus epidermidis 
 albus, described by investigators of this subject as the staphylococcus 
 pyogenes albus. This coccus is a regular inhabitant of the milk in the 
 lacteal ducts near their outlets. Surprise has been expressed liy Honig- 
 mann- and others that of all the cutaneous bacteria this should be usually 
 the predominant or the only one found in the milk, but it appears to the 
 writer that his investigations as to the behavior of this organism in the 
 skin explains satisfactorily the appearance of this coccus in the milk. 
 Of all the cutaneous bacteria, this is the only one which penetrates regu- 
 larly into the deeper layers of the epidermis and into the glandular 
 appendages of the skin. Occasionally other bacteria, also derived from 
 the skin, are present in the milk. The staphylococcus pvogenes aureus 
 
 ' A full review of the baeteriolnsical literature of the subject of puerperal auto-Infec- 
 tion up to the date of its pulilieation, together with the re])ort of original observations, 
 will he found in a jiaper by J. Wliitridge Williams in The American Journal of the Med- 
 ical Sciences, .July, 1893. 
 
 'Honigmunn, ZcUschriJt fur Hygiene, Bd. xiv. p. 207. 
 
SOURCES OF THE BACTERIA I\ SURGICAL INFECTIONS 271 
 
 has been found in tlie milk of healtliy women in a number of 
 instanocs. 
 
 It is not Ivuown liow far up the lacteal ducts this normal bacterial 
 flora extends. It is probable that the mammary gland conforms in this 
 matter to the behavior of other ghiuds wliose duets open upon surfaces 
 containing bacteria, and that bacteria in demonstrable number are found 
 only in the excretory ducts near their outlets. 
 
 As the staphylococci normally present in the milk have the property 
 of coagulating milk, it can hardly be tiiat any considerable multiplication 
 of these bacteria occurs in tiie milk within the lacteal ducts. Fokker 
 observed a limited germicidal effect of fresh milk in some cases, but 
 Honigniann in a larger number of experiments with proper technique 
 was unable to determine any such property, even as regards the typhoid 
 and the cholera bacilli, which are readily killed by blood-serum. 
 
 Sources of the Bacteria in Surgical Infections. 
 
 Internal Sources. — We have learned that pathogenic bacteria, and 
 particularly the pyogenic micrococci, may be present upon the skin and 
 various exposed mucous membranes of healthy human beings. These 
 bacteria are of course derived primarily from external sources, but some 
 of them may live for a long time or indefinitely on exposed sui'faces of 
 the l)ody, and are found here so often that it is proj^er to recognize the 
 patient's own body as one source of the bacteria concerned in surgical 
 infections. 
 
 Internal sources of wound-infection are in general less commonly 
 operative and less dangerous than the external sources. One explanation 
 of this is that the pyogenic bacteria commonly found in the healthy body 
 are often less virulent than those derived from many external sources. 
 Tlie streptococcus pyogenes when cultiv;ited from healthy nuicous mem- 
 branes is often of very slight or no virulence, as tested upon animals, 
 although occasionally highly virulent streptococci are found under these 
 circumstances. The pyogenic staphylococci, and particulai-ly the sta- 
 phylococcus albus, are often of greatly attenuated virulence when isolated 
 from the ex}iosed surfaces of healthy persons. The lanceolate micro- 
 coccus is present in a virulent state in the mouths of only about 15 per 
 cent, of healthy persons, although it is oftener present in a non-virulent 
 condition. The bacillus coli communis obtained from healthy fffices is 
 usually of very slight pathogenic power. 
 
 There are various influences wliich may be cited to explain tin; 
 relatively sligiit virulence of many of the jKithogenic bacteria present in 
 the healthy body. Among the most a])parent are the struggle for exist- 
 ence with the regulaf saprojihy-tic flora of the body, the influence of the 
 products of the latter organisms, and especially the antiliacterial proper- 
 ties of the fluids, secretions, and living cells of the body. That under 
 circumstances which we at present little understand the bacteria of the 
 Ijodv mav ac(|uire unwonted virulence seems certain. 
 
 ilighiv virulent staphvlococci and streptococci may be present on the 
 exposed surfaces of the healtliy body without doing any harm. The pro- 
 tection of the body from infection with the pathogenic bacteria which it 
 often harbors is due not so much to the lowered virulence of these bac- 
 
272 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 teria as to the defences wliicli liave been set up against tlieir invasion and 
 to tiie loeal and general resistance offered to their growth. 
 
 These defences may, however, he overthrown, and luider tliese cir- 
 cinnstances patiiogenic bacteria originally {)rcsent on exposed surfaces of 
 the IxkIv may cause various loeal and general diseases. The unsatisfac- 
 tory term " auto-infection " is sometimes applied to diseases thus pro- 
 duced. 
 
 The internal organs and fluids of the healthy body are normallv free 
 from bacteria. Bizzozero and Kibhert have found bacteria, often Avithin 
 cells, regularly in the lymph-follicles of the normal rabbit's cieeuni, and 
 Bizzozero has found spirilla often in the e])ithelial cells lining the necks 
 of the gastric tubules in dogs. These are the oidy examples known of 
 the presence of bacteria in the living cells of the jjcrfectly healthy l)ody, 
 and here the bacteria have penetrated only a short distance beneath the 
 free surface. 
 
 It is probable that pathogenic as well as other bacteria occasionally 
 get into the tissues and circulation of healthy persons without doing any 
 harm. It is claimed by some that the invasion of bacteria into the 
 healthy body is not unc^ommon, and this d((ctrine is called latent micro- 
 bism by some French writers. The occasional t)ccurrence of supjjuration 
 in a simple fracture of bone or in other injured parts remote from an 
 exposed surface is best explained, at least in many cases, by the lodge- 
 ment of pyogenic bacteria which have been carried from an exposed sur- 
 face to the part by the blood or lymphatic current, and which j)resumably 
 would have done no harm without the presence of a locus minoris resist- 
 entiffi. The infrequency of this event, however, indicates that the pres- 
 ence of pathogenic bacteria in the internal organs and fluids of the healthy 
 body is exceptional. 
 
 Can a wound become infected by liacteria conveyed to it by the 
 circulating blood? This may happen in individuals already infected, 
 although, even when it is certain that pyogenic cocci are present in the 
 circulating blood, a wound may heal without suppuration. The possi- 
 bility of the infection of a wound in a previously uninfected person by 
 bacteria conveyed by the blood-current cannot lie denied, but we possess 
 no stringent proof of such an occurrence, and all experience goes to show 
 that wound-infection from this source must be very exceptional, if it 
 occurs at all. 
 
 AA'ith jiroper technique the surgeon has, as a rule, little to fear from 
 the bacteria of the patient's skin as a source of infection of operative 
 wounds. The only bacterium of the skin which is not usually destroyed 
 by thorough disinfection of the surface is the staphylococcus e])idermidis 
 albus, which lies often deeper than can be reached by any of the prac- 
 ticable methods of cutaneous disinfection. This coccus is found with 
 great frequency in wounds treated asej)tically or antiseptically, but ordi- 
 narily it does not interfere with the process of repair. Under certain 
 circumstances, particularly mIicu foreign bodies are introduced into the 
 wound or when there is strangulated tissue in the wound, it may cause 
 rise of temperature and sup])uration. It is the most common cause of 
 stitch-abscesses. It is often associated with otiier bacteria in suppura- 
 tion of external wounds and in inflammations involving the skin. It is 
 identical with, or simj)ly a variety of, the staphylococcus pyogenes albus, 
 
SOURCES OF THE BACTERIA IN SURGICAL INFECTIONS 273 
 
 but for reasons which have been stated the latter name seems inappro- 
 priate for this ordinary, harmless skin coccus. This white staphylo- 
 coccus is a widely-distributed organism, and it may enter a Avouud from 
 witiii.Hit as well as directly from the surface of the body. 
 
 The source of the bacillus pyocyaneus in wounds is often from the 
 skin of the patient, but this is a widely-distributed organism, and it 
 may also enter from without. 
 
 The mucous membranes which normally harbor bacteria on their sur- 
 face cannot be completely disinfected by any practicable methods, al- 
 though it is possible to reduce the number of bacteria, in some situa- 
 tions more readily than in others. The utility of attempting before 
 operation disinfection of a mucous surface — as, for example, in opera- 
 tions involving the conjunctiva, mouth, rectum, and the lower genito- 
 urinarv tract — must be determined by experience, and on this point the 
 views of surgeons are not in harmony. 
 
 Bacteria cannot be completely kept out of wounds of exposed mucous 
 membranes. The kinds of bacteria in the patient's body which are 
 likely to enter such wounds and the special conditions relating to tiie 
 bacterial flora of the ditferent mucous membranes ha\'e already been 
 described. Although wounds involving such mucous membranes as those 
 of the mouth and intestine, Mdiich contain vast numbers of bacteria, 
 including often |)yogenic varieties, often heal satisfiictorily, and even by 
 first intention, the surgeon has no such guarantee of securing primary 
 union as in operative wounds through the slvin. The fact that these 
 Avounds often heal quickly and without suppuration demonstrates that 
 the mere presence of certain bacteria, even in large number, in a wound 
 does not necessarily interfere witii healing. It also supports the view 
 already advocated that the pyogenic cocci often present on certain exposed 
 mucous surfaces are usually of weakened virulence. But tiie main factor 
 is, after all, the vital resistance of the living tissues to bacteria, including 
 many virulent species. 
 
 The pathogenic bacteria often present on the exposed surfaces of the 
 healthy body are, however, of surgical interest, not so much as a source 
 of primary wound-infection, but ratiier as the specific agents of infection 
 in various local and general surgical diseases. As examples of local 
 diseases of tiiis category may be cated otitis media, appendicitis, per- 
 forative and other forms of ptn-itonitis, some cases of cystitis, and cer- 
 tain abscesses. The pneumonias, localized abscesses, pysemia, and sej)- 
 ticsemia which are such fret[uent complications of diphtheria and certain 
 general diseases, as typhoid fever and other infectious fevers, are due in 
 many instances to the secondary invasion of pathogenic bacteria, par- 
 ticularly pyogenic cocci, normally jiresent on mucous membranes. It is 
 chiefly from the mouth, tonsils, -pharynx, and intestine that these invaders 
 enter the body. The primary disease is often one which is attended by 
 some lesion of the mucous membrane which opens the way for the pass- 
 age of the micro-ors;anism. But it is not enough for the o-ate to be 
 thrown open. The defenders within must be overcome. Hence it is 
 particularly in conditions where the vital powers of resistance are lowered 
 that we meet with affections caused by the invasion of pyogenic bacteria 
 from the exposed surfaces of the body. That under these conditions, as 
 
 Vol. I.— is 
 
274 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 well as under otliers, attomuitcd bacteria of the body may become exalted 
 in virulence is liiolily probable. 
 
 The term " auto-inlcction " is associated particularly with the discus- 
 sions on the causation of puerperal fever. The bacteriological data 
 entering into this discussion have Ixicn given in describing the bacteria 
 of the vagina. The evidence! is contradie^tory, but on the Avhole is 
 opposed to recognizing so-called auto-infection as a cause of ])Uerp('ral 
 fever, save in a small proportion of cases. 
 
 The bacteria most often foinid in cystitis are such as might readily 
 gain entrance at times to the healthy urethra, but in most cases of this 
 disease, as in so many others, an essential etiological factor is some pri- 
 mary damage to the part, which permits the survival and growth of the 
 invading micro-organisms. 
 
 The most common secondary in\-ader of the body is the bacillus coli 
 communis. The first observations of the general invasion of the inter- 
 nal organs of the body t)y the colon bacillus were made by the writer 
 and reported in May, 1890. We have found in 40 per cent, of the 
 autopsies at the Johns Hopkins Hospital the colon bacillus in one or 
 more of the internal organs, those most frequently invaded being tlie 
 lungs, kidneys, liver, mesenteric glands, and gall-bladder. In the great 
 majority of these cases the colon Ijacilli were present \\ithout any 
 organic lesion which could be referred to them. Intestinal lesions 
 were found in 75 per cent, of our post-mortem cases of invasion of the 
 colon bacillus. Very little importance is to be attached to the demon- 
 stration of this bacillus in internal organs of the body at autopsies in 
 cases without any lesion ■which can be referred to it. 
 
 The fact that the colon bacillus is found with great frequency in 
 internal organs of the body after death from all sorts of causes, and 
 without doing any manifest injury, necessitates caution in the interpreta- 
 tion of cases where its presence is associated with definite lesions. That 
 in some of the cases reported as infections by this bacillus its presence 
 was only that of an accidental, secondary invader seems to the writer 
 certain. ' There can be no doubt, however, that under certain conditions 
 the colon bacillus may be pathogenic. It is prone to settle in jtarts 
 already damaged either by some other micro-organism or by some non- 
 infectious agent. In forty-eight cases of acute inflammation, of various 
 kinds and situations, in which we found the colon bacillus, it was the 
 sole organism ])resent in only fourteen. In the majority of cases of 
 appendicitis and of perforative jieritonitis we have found associated with 
 the colon bacillus other bacteria, and particularly the ordinary pyogenic 
 cocci. There is reason to believe that the highly i-esistant colon l)acillus 
 may survive in an inflamed part after the primary organism which 
 started the trouble has died out or has l)een crowded out by the invader. 
 
 The colon bacillus has been repeatedly observed alone or in combina- 
 tion with other bacteria in wounds. That it may be the primary infec- 
 tious agent in various surgical and other inflannnations in different parts 
 of the body is established by numerous observations. 
 
 The bacillus lactis aerogenes, which most investigators no longer 
 attempt to separate sharply from the bacillus coli communis, is likewise 
 a common invader from the intestinal tract under conditions similar to 
 those relating to the colon bacillus and with similar pathogenic effects. 
 
SOURCES OF THE BACTERIA IN SURGICAL INFECTIONS. 275 
 
 The streptococcus pyogenes is a far more important cause of surgical 
 infections than is the colon bacilhis. It is more commonly present than 
 other pyogenic cocci in appendicitis, peritonitis, and other inflannnations 
 of serous meaihranes, and in septic infections secondary to other diseases. 
 It is a frequent cause of secondary inflammations in the lungs, serous 
 membranes, and other parts, and of general septictemia in diphtheria, 
 tuberculosis, scarlet fever, typhoid fever, and other infectious fevers, and 
 also in many non-infectious diseases. The source of these various second- 
 ary streptococcus infections is often from the mouth, tonsils, throat, and 
 intestine, parts which in their normal condition often harbor strei)toeocci. 
 
 Of (ither bacteria more or k'ss frequently present on exposed surfaces 
 in health, and concerned in various surgical infections, may be especially 
 mentioned the staphylococcus aureus and albus, the micrococcus lanceo- 
 latus, the bacillus pyocyaneus, the micrococcus tetragenus, bacillus pro- 
 teus, and the bacillus of Friedliinder. 
 
 External Sources. — Bacteria derived from without the body, are 
 those chiefly concerned in infections of wounds and most other primary 
 surgical infections. Abundant experience has demonstrated that if all 
 patliogenic bacteria from external sources, as well as those which may 
 happen to be upon the surface of the skin, be kept out of an external 
 wound, no suitpuration of the wound occurs. 
 
 There airt two ways by which external bacteria may enter a wound: 
 one is by contact \vith objects contaminated with bacteria ; the other is 
 by the air. Strictly speaking, air infection is also contact infection, but 
 the distinction implied in the customary use of these terms is a useful 
 one. Experimental and clinical observations have shown conclusively 
 that contact infection is far more dangerous and common than air 
 infection. 
 
 The main emphasis of modern surgical technique is laid upon the 
 sterilization of all objects, such as instruments, ligatures, dressings, and 
 the hands of operator and assistants, which are brought into contact with 
 the wound. The principal sources of contact infection of wounds, as 
 enumerated by Park,' are the skin and hair, instruments, sponges or 
 their substitutes, suture material, tlie hands of the surgeon and his assist- 
 ants, drainage materials, dressing materials, miscellaneous — c. g. drops 
 of perspiration, an unclean irrigator-nozzle, the nail-brush, tlie clothing 
 of the O])erator or the bystanders, etc. Of these objects the most difficult 
 to disinfect is the skin. We have already considered this subject, so far 
 as it belongs to this article, in describing the bacteria of the skin. 
 
 The pyogenic cocci, which are the bacteria concerned in the great 
 majority of cases of wound-infection, are ubi(piitous, and it would be 
 useless to attempt to specify all the objects upon which they have been 
 found. The source from which tiiese cocci are derived is not, however, 
 a matter of indifference. The jjyogenic cocci, and particularly the strej)- 
 tococcus, derived from infected persons, as from a case of erysipelas or 
 peritonitis or septiciiemia, are more likely to cause serious infection of 
 wounds than cocci of the same sjM^cies derived from other sources. 
 
 Of other bacteria sometimes concerned in wound-infe(^tion, the bacillus 
 coli communis not only is a constant inhabitant of the normal intestine, 
 
 'Eoswell Park, "Wound-infection," American Journal of the Medical Sciences, Nov., 
 1891. 
 
276 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 but is widely distributed in cxtcnial uaturc, and the bacillus pyoeyu- 
 lUMis, often present on tlie iiealtliy skin, is likewise a Midely-dis- 
 tributed organism. The bacillus j)y()cyaneus is a comparatively harm- 
 less organism in external wounds, but it is capable of exerting serious 
 pathogenic activity, especially in infections from the intestine. The 
 soil is the natural home of the tetanus bacillus, whicli is abundant in 
 certain localities and rare in other places. It has been found with 
 especial frequency in garden earth and about stables. It is present very 
 commonly in the fteces of herbivorous animals, as has already been men- 
 tioned. Sormani observed that tetanogenic material introduced into the 
 alimentary canal of dogs, which subsecpiently were prevented from 
 receiving additional tetanus l)acilli, could be demonstrated as long as 
 sixteen days after its recejition. The bacillus of malignant tedema is 
 likewise a common inhabitant of the soil. In infected localities the 
 anthrax bacillus lives in the soil. In fact, the upper layers of the soil 
 are the great home of bacteria of all sorts, and pyogenic cocci have 
 been found in this situation. The proteus bacillus, which is cajiabh' of 
 assuming pathogenic activity, is commonly found in decomjMsing animal 
 substances. 
 
 Flies and other insects may l)c the carriers of all sorts of infectious 
 agents. Pyogenic staphylococci have been found in the excrements of 
 flies, and even the susceptible cholera bacillus jjasses unharmed through 
 the alimentary canal of flies. 
 
 Certain surgical infections are associated particularly with injuries 
 from definite objects, as, for example, necrogenic warts, containing tuber- 
 cle Itacilli, from cadavers ; zoonotic erysipeloid from crabs and other 
 shellfish ; oyster-shucker's keratitis ; actinomycosis from oats and other 
 grains ; anthrax from hides, wool-sorting, and other handling of material 
 from infected animals. 
 
 It has been demonstrated by La Garde ^ that bullets obtained from 
 previously unopened boxes as sent out by the manufacturer are ]>raetically 
 sterile, but that if the bullets become contaminated with pathogenic 
 bacteria, the latter are not destroyed in the discharge and transit of the 
 bullet, and are capable of infecting wounds. He was able to infect rab- 
 bits with the streptococcus pyogenes and other jiathogenic bacteria by 
 firing infected bullets through the ear. 
 
 As compared with contact infection, infection of wounds from the air 
 is of minor importance, but surgeons are not agreed as to whether or not 
 the dangers of air infection are so slight under ordinary conditions that 
 they need not be taken into consideration at all. In the early days of 
 antiseptic surgery bacteria of the air Mere thought to be frequent agents 
 of wound-infection and the carbolic s]iray was introduced Ijy Lister with 
 the intention of destroying them. There followed a period when sur- 
 geons considered that the air bacteria could be wholly neglected as a 
 source of traumatic infection, and this is probably still the opinion of the 
 majority of surgeons. At present there is a tendency again to pay more 
 attention to the possibilities of infection from this source, and some sur- 
 geons have even gone back to the use of the spray. 
 
 Bacteria are always present in the air over the ground and around 
 human habitations, whereas sea-air at a considerable distance from land 
 
 ' La Garde, New York Medical Journal, Oct. 22, 1892. 
 
SOURCES OF THE BACTERIA IN SURGICAL INFECTIONS. 277 
 
 and the air at high altitudes is nearly or quite free from micro-organisms. 
 Bacteria do not usually occur in the air as single, detached cells, but 
 ratiicr as clumps attached to particles of dust, so that in a perfectly 
 quiet atmosphere, as in a closed room, these particles containing bacteria 
 rapidly settle upon underlying objects. Bacteria, being thus attaclied to 
 particles of dust, are readily filtered out from the air by passing it 
 through porous substances, such as cotton-wool. The bacteria are car- 
 ried down by drops of rain, and the air of a room may be freed from 
 floating bacteria by producing an artificial rain by some form of douche 
 or s|)ray a[)paratus. 
 
 Whatever creates dust, such as tlie entrance or exit of a body of 
 students, and other movements in a room, brings bacteria into the air. 
 
 It is a fact of fundamental hygienic importance that fine particles, 
 including bacteria, are not detaciied from moist surfaces even by strong 
 currents of air. Hence conies the iiygienic value of using moist cloths 
 in removing dust and in cleansing a room. Substances containing 
 infected material sliould not be allowed to dry under conditions in 
 whii'h dust therefrom can be conveyed into the air. In the present era 
 of dry dressings for wounds there is frequent opportunity for the scatter- 
 ing of dust from the discharges dried on the dressings in the removal 
 and snbsecpient handling of these dressings, unless especial care be 
 tid^en to pi-event this in all cases where pathogenic bacteria may be 
 present. 
 
 Tlie number of bacteria in the air varies greatly under different con- 
 ditions. In general it may be said that living micro-organisms are less 
 abiuulant in the air than was formerly supposed. They cannot multiply 
 in the air, and only those whose vitality is not destroyed by drying can 
 exist in the air. Desiccation may lessen the virulence of pathogenic bac- 
 teria without actually destroying them. 
 
 Wiiat interests us chiefly in this connection is to know whether patho- 
 genic bacteria, and more particularly tiie pyogenic cocci, occur in the 
 air, and, if so, how frequently and under what conditions. 
 
 Pyogenic staphylococci and strejitococci have been repeatedly found in 
 the air, althougli generally only in small number. Olttaincd from this 
 .source, these cocci are often of only sligiit virulence, but highly virulent 
 sta])hylococci and streptococci have been isolated from the air. Among 
 those \vho have isolated pyogenic cocci from the air may be especially 
 mentioned von Eiselsberg, Emmerich, Neumann, Prudden, Ullmann, 
 Ilaegler, C. Fraenkel. Haegler ' demonstrated that streptococci may 
 j)reserve their vitality and power of development for at least thirty- 
 six days, and staphylococci for one hundred days, in pus dried on 
 bandages. 
 
 Pyogenic staphylococci and streptococci have been found far more 
 frec|uently in hospital wards and operating amphitheatres than else- 
 whei'c. Haegler found stajihylococci and streptococci in the majority 
 of his examinations of the air in the wards antl operating-rooms of the 
 hospital in Basle, and tlie number of such cocci present was in general 
 proportionate to the opportunity for entrance into the air of cocci from 
 dry material and to the amount of stirring uji of dust by movement in 
 the room. He also detected in a number of instances the bacillus pyo- 
 ' Haegler, Beiirdge zur klinischen Chirurgie, Bd. ix. p. 496. 
 
278 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 cyaneu.s in tlic air. Streptococci have been found frequently in the air 
 of rooms containing cases of erysipekis. 
 
 Haegler foiUKl the pyogenic cocci on the hair antl coats of surgeons, 
 and in cobwebs in hospital rooms, as well as on other objects. He con- 
 cludes from his investigations that the danger of infection from (he air 
 is greater than is assumed by many surgeons. 
 
 Schimmelbusch and some other investigators have found pyogenic 
 cocci very rarely in surgical wards and operating-rooms. It is suf- 
 ficiently apparent that various circumstances, such as the care exercised 
 in the destruction or sterilization of material infected witli discharges, 
 the use of disinfectants, the isolation of infected cases, and the observ- 
 ance of strict cleanliness, must influence the results of these examina- 
 tions of the air of hospitals, and that tlie danger of air infection may be 
 cousideral:)le in one place and reduced to a minimum in others. 
 
 Air infection may readily become contact infection by bacteria from 
 the air being deposited upon the hands of the operator or his assistants, 
 upon instruments, dressings, or other objects which are brought into 
 contact with the wound. 
 
 jMicro-organisms which are capable of develojinient only within the 
 living body are called obligatory parasites. A facultati\'e parasite is 
 one whose or'dinary mode of life is .saprojjhytic, but which is capable 
 of a parasitic existence, and a facultative saprophyte is one whose ordi- 
 nary existence is parasitic, but which can grow outside of a living host. 
 These distiuotions, however, cannot always be sharply carried out in 
 practice. Although we can cultivate the gonococcus outside of the body 
 in specially prepared artificial media, there is no reason to suppose that 
 it multiplies, or even long survives, in the outer world under ordinary 
 conditions, and immediate contact with the infected person is the princijial 
 source of infection. The tubercle bacillus also can he cultivated arti- 
 ficially, but conditions must be excejitional which permit its nudtiplica- 
 tion outside of the body. Unlike the gonococcus, the tubercle bacillus 
 is capable of prolonged survival outside of the body, and, as is well 
 known, it is a widely-distributed organism. The leprosy bacillus has 
 not been cultivated artificially, and it is ranked among the obligatory 
 parasites. Intimate contact with an infected person seems to lie the 
 usual source of infection, although opinions are divided as to the mode 
 of transmission of this disease. The micro-organisms causing syphilis 
 and hydrophobia are unknown, but they are doubtle.ss obligatory para- 
 sites. 
 
 The bacteria causing anthrax, tetanus, malignant oedema, and actino- 
 mycosis are facultative parasites. The jiyogenic cocci find the best con- 
 ditions for their multiplication in the living body or material rich in 
 organic matter, but these ubi(|uitous bacteria can often find natural 
 opportunity for multiplication outside of the body. 
 
 The only bacteria infectious for human beings which are positively 
 known to develop spores are the bacilli of tetanus, anthrax, and malig- 
 nant oedema, all killed by exposure in a moist condition for a few 
 minutes to boiling temjieraturc. It is generally stated that the tubercle 
 bacillus forms spores, but this is not positively demonstrated. There is 
 still greater doubt as to the formation of spoi'cs by the bacilli of gland- 
 ers, typhoid fever, and lej)rosy. The tubercle bacillus, the pyogenic 
 
POBTALS OF ENTRY OF BACTERIA IN SURGICAL INFECTIONS. 279 
 
 cocci, and the typlioid bacillus are among the more resistant bacteria 
 which are not proven to form spores. 
 
 Portals of Entry of Bacteria in Surgical Infections. 
 
 The portals of entry or atria of infection are the skin and the 
 exposed mucous membranes of tlie respiratory, alimentary, and genito- 
 urinary tract, and wounds of these surfaces. The fcctus may become 
 infected either by germinal, or far more frequently by ])lacental, trans- 
 mission of infectious micro-organisms. In our lalroratory experiments 
 we rarely imitate the precise conditions of natural infection, but we 
 malce fre(pient use of methods of inoculation which occur only excep- 
 tionally or not at all under natural conditions, such as the injection of 
 bacteria directly into the vessels, into the serous cavities, and beneath 
 tile skin, and forced inhalations of large numbers of micro-organisms. 
 
 Most of the hatttcria concerned in surgical infections are capable of 
 entrance tlirougli any portal and of pniducing inl'ection in any part of 
 the body, but there are some which are restricted to certain modes of 
 entrance and to certain parts of the body. Examples of the latter group 
 are the bacteria causing gonorrhea and tetanus. 
 
 Let us consider briefly the defensive arrangements which exist nor- 
 mally at the various pt»rtals of entry. These are jiartly mechanical, and 
 due to the anatomical structure of the ])art. The thick epidermal cover- 
 ing of tlie skin and orifices of the body is impenetrable to most bacteria. 
 The thick layer of laminated flat epitlielium covering the mucous mem- 
 branes of the mouth, esophagus, and vagina is a hardly less efficient 
 mechanical protection. The more delicate raucous membranes covered 
 by cylindrical epithelium are so situated as to be less exposed to injury, 
 but even tiiese surfaces do not ordinarily permit the penetration of l^ac- 
 teria witiiout the occurrence of some damage to their integritv. The 
 ciliated epitlielium of the respiratory tract drives foreign particles 
 toward the natural outlets. The tortuous arrangement of the upper 
 air-passages filters out most of the bacteria which are inhaled. Bacteria 
 which may iiappen to enter the bladder or uterus or the glandular ducts, 
 such as the salivary, Ijiliarv, or pancreatic, which are normally free from 
 bacteria, would be likely to be discliarged with the secretions. Obstruc- 
 tion of these ducts predisposes to their infection. 
 
 There are certain situations, particularly the tonsils and the lymphatic 
 follicles of the intestine, M'liich, by the delicate nature of their covering, 
 are especially exposed to tlie invasion of bacteria. These are vulnerable 
 parts, as is sliown Iiy the frecpiency with which primary and secondary 
 infections start froui them, but there is reason to believe that the Ivm- 
 phatic tissue in these situatioi.s is richly endowed with vital jirojierties 
 hostile to the development of bacteria. 
 
 Of equal importance with these mechanical defences arc the anti- 
 bacterial properties of the secretions on mucous membranes. These 
 properties depend partly on the chemical reaction (gastric juice, vaginal 
 secretion), jiartly on the antagonism offered to invaders bv the regular 
 bacterial flora of the surface, but mainly upon bactericidal qualities at 
 present little understood as to their cause, but unquestionable as to their 
 existence. 
 
280 GENERAL BACTERIOLOCrY OF SURGICAL INFECTIONS. 
 
 Mi('ro-()i-i;aiiisins find at tlie fratos of entrance livin<>- cells and fluids 
 which in healtJi are capable of destroying many of them, and if thcv 
 pass these gates, it is usually only to be arrested and destroyeil at the 
 nearest lymphatic glands. Xor are these j)rotective agenci(>s"liniited to 
 the lymi)hatics or to any jiarticular organs : they are present in the blood 
 and everywhere througjiout tiie living body, altliougli more highly devel- 
 oped in some places than in others. Whether the battle against the 
 invaders be within the cells, as is assumed in the phagocytic theory, or 
 outside of the cells, the weapons of attack must be furnished bv" the 
 cells. The living body is amply protected in health against all ordinary 
 bacteria which may seek entrance, and the study of the etiologv of infec- 
 tious diseases involves the consideration not oidy (if the characters of the 
 specific agents of infection, but also of the ways in which the natural 
 defences of the body have been overcome. There are infectious micro- 
 organisms to which the healthiest and strongest body is able to offer no 
 resistance, and there are other micro-organisms which are I'ajiable of 
 doing harm only -h hen tlie vital resistance of the body has liecn lowered. 
 
 Can micro-organisms penetrate the intact skin or mucous membranes, 
 or must there always be some jtathological change or lesion of continuity 
 of these parts to permit their entrance ? This question has been variously 
 answered, but, at least as for as certain membranes and certain micro- 
 organisms are eoncerned, the evidence must be regarded as conclusive 
 for the affirmative answer. It cannot be doubted that the infectious 
 agents causing malaria, relapsing fever, and the eruptive fevers may 
 enter tlie body without any defect in the skin or mucous membranes, 
 but our concern is not with this class of diseases. 
 
 Garre,' in 1885, was the first to make a self-sacrificing experiment 
 which has since been rejieated \\ith similar result In' several others. He 
 rubbed into the skin of his fu-earm, in the same way as one \\-ould rub 
 in an ointment, a large quantity of a virulent culture of the staphylo- 
 coccus pyogenes aureus. The skin was left intact. After six hours a 
 prickling sensation, associated ^ith redness and turgescence, developed, 
 and in a few hours more about twenty pustules, each developing about 
 a laimgo hair, had formed. In the course of four days an extensive 
 carbuncle, which discharged pus through seventeen openings, formed, 
 and the axillary glands were swollen. 
 
 The largest numlicr of experiments of this character have been by 
 Wasmuth.^ The experiment succeeds almost invariably when virulent 
 staphylococci are thoroughly rubbed into the human skin, but fails 
 almost constantly to give a positive result ujion the skin of animals 
 (rabbits, guinea-pigs). The failure with animals is not due to greater 
 impenetrability of their skin to bacteria, for anthrax bacilli and some 
 other pathogenic bacteria when rubbed into the skin of animals are 
 capable of causing infection. Animals are less susceptible than man to 
 these pyogenic cocci — a fact which should not be lost sight of in draM'- 
 ing inferences applicable to man from experiments upon animals with 
 these organisms. Biidinger has shown that pyogenic cocci nearly devoid 
 of virulence for animals may produce abscesses when rubbed into the 
 human skin. 
 
 ' GaiT^, Forlxchrilk der 3fedicin, Bd. iii. p. 165, 1885. 
 
 2 Wasmuth, Ccntnilblalt fiir Bacleriohyie, Bd. xii. pp. 824 and 846, 1892. 
 
PORTALS OF EXTRY OF BACTERIA IN SURGICAL IXFECTIOyS. 281 
 
 The mere application of tlie ijaeteria to the siirflice of tlie skin i)ro- 
 duccs no infection either in man or animal^;. The bacteria must be well 
 rubbed in or pressed in to cause infection. 
 
 Throuiiii wiiat channels do the bacteria penetrate the skin in these 
 experiments? There are tlu'ce possil)ilities — namely, through the epi- 
 dermis into the rete Malpighii, into tiie sweat-glands, or into the hair- 
 follicles and sebaceous glands, yciununelbuscli, Machnoif, and Wasnnith 
 have demonstrated that they enter by way of the hair-follicles, and the 
 last-named author considers that they can enter the intact skin in no 
 other way. He finds a principal support for this view in the fact that 
 he was unable to produce any effect l)y rubbing the cultures into the skin 
 of the ball of the thuml), where there are no hair-follicles, and in the 
 actual demonstration liv himself and previous experimenters of the bac- 
 teria in the hair-follicles. This conclusion is in accord witli the clinical 
 fact that furuncles form almost exclusively in parts of the skin provided 
 with hairs and sebaceous glands, and often begin as pustules around the 
 hairs. 
 
 The ol)jection mav be raised that these ex])eriments do not actually 
 prove the possibility of infectious agents penetrating the intact skin, as 
 microscopical lesions may be caused by tlie rubbing or the }3ressure. 
 Macroscopical and microscopical examinations, however, failed to show 
 any lesion of the epidermis. Still, a microscopical defect might be diffi- 
 cult to detect, and Schimmelbusch considers it possible that in these 
 experiments a minute Ijreach of continuity may be produced. 
 
 As experiments uj)on rabbits with bacilli of anthrax and of rabliit 
 septictemia have shown, general as well as local infection may follow the 
 rubbing of certain pathogenic bacteria into the skin. These experiments 
 simplv show that certain pathogenic organisms are capable of settling in 
 the iiealthy skin and causing local infections, which may, however, be 
 the starting-point of general infections. They do not show that micro- 
 organisms can pass through the healthy skin and thence invade the body 
 witliont jiroducing any damage at the point of entrance. It is a well- 
 known clinical fact that in wounds this local damage may be very slight 
 and readily overlooked. Indeed, there is a certain antagonism between 
 the extent of the local infection at the point of invasion and the likeli- 
 hood of general infection. 
 
 We have no conclusive experimental evidence that bacteria can enter 
 the circulation through an intact mucous membrane without causing any 
 lesion whatever at their point of entry. There are, however, many ex- 
 amples of ]iathogenic bacteria which are cajmble of attacking a healthy 
 nuu'ous membrane and of ])roducing local and general infection through 
 this cluuMiei. The lesion of tlie mucous membrane in some of these cases 
 maybe slight and not. readily demonstrable. The gonococcus is certainly 
 capable of infecting an intact mucous membrane. A large number of 
 infectious diseases can be produced by feeding cultures or material con- 
 taining certain pathogenic bacteria. Examples of such intestinal infec- 
 tions are tuberculosis, anthrax, typhoid fever, Asiatic cholera, hog cholei'a, 
 and chicken cholera. As has already been mentioned, the points in the 
 alimentarv canal most vulnerable to infection are tlie tonsils and the 
 lymphatic follicles. 
 
 As is well known, indifferent foreign particles, such as coal-dust, may 
 
282 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 be taken up from tlie air-cells ni' tlie liiiijis and eonveycd by the lymphatic 
 current to the broneliial lym])liatie liiands, but under normal conditions 
 these ])artieles do not enter tlie ti'eneral cireulation. It is ])robable that 
 bacteria maybe disjiosed of in tlie same way. It is said that some of tlie 
 bacteria of the septicsemias of animals — as, for example, the bacillus of 
 rabbit septicaemia — may enter the circulation through the lungs without 
 leaving behind any manifest lesion. We have no conclusive evidence 
 that the mieroeoeeus lanceolatiis, the streptococcus pyogenes, or the other 
 pyogenic bacteria can ])ass through the intact lungs into the general cir- 
 culation without causing some intlammation of the lungs. 
 
 The lungs possess the power of disposing of many pathogenic bacteria 
 which have been introduced into tiiem. There have been many experi- 
 ments made to determine the ]M)Ssibility of infection with anthrax bacilli 
 bv way of the lungs, and the conclusions drawn from them hav(> been 
 wi<lelv divergent. Buehner and his (inpils claim to have succeeded, but 
 Baumgartcn and his co-workers reached a ditferent conclusion, (irainat- 
 schikoti' finds that the intratraciieal injection of anthrax bacilli or spores 
 is incapable of causing infection if infection through the wound be 
 avoided. The bacilli quickly perished in the lungs, sections showing 
 degenerated Ijacilli within four to ten hours. 
 
 No infection of an intact mucous membrane, either in man or animals, 
 has been produced experimentally l)v the mere application to the surface 
 of the membrane of the pyogenic cocci, altliough thei'c is clinical evidence 
 of the possibility of such a mode of infection. 
 
 The chief surgical interest of the cpiestion of the permeability of intact 
 mucous membranes to bacteria relates to the explanation of tuberculosis 
 of internal parts without tubercular lesion at any portal of entry, and to 
 cases of osteomyelitis, internal abscesses, and, in general, the cases of so- 
 called cryptogenetic septicaemia and jjysemia, in which the most careful 
 examination fails to detect any point where the bacteria could have 
 entered. 
 
 Most authorities are of the opinion that tubercle bacilli can pass 
 through a mucous surface without leaving any trace liehind of their 
 presence at the point of entrance. The main support for this doctrine 
 of the passage of tubercle bacilli through intact mucous membranes is 
 found in the clinical facts. Orth and Wesencr, however, claim that 
 occasionally animals fed with tubercle bacilli develop tuberculosis of the 
 mesenteric glands without any tubercular alteration of the intestinal mu- 
 cous membrane. Baumgartcn contests this, and holds that in all cases 
 of experimental tuberculosis there is a tuberculous lesion at the point of 
 entry. He explains the cases of tuberculosis of lymphatic glands, of 
 bone, and of other parts observed not infrequently in man without 
 tuberculosis of the lungs or any exposed surface by assuming that they 
 are all instances of inheritance of tubercle bacilli. This well-known 
 doctrine of Baumgartcn involves also the assumption that tubercle bacilli 
 mav remain for an indefinite time alive within the body in a latent con- 
 dition. 
 
 In the opinion of the writer the evidence is in favor of the view that 
 tubercle bacilli may enter the lym))hatic circulation without causing any 
 tuberculous aifection at the ])oint of entrance. In many cases, however, 
 where this exjjlanation might at first be thought to be the correct one, 
 
PORTALS OF ENTRY OF BACTERIA IN SURGICAL INFECTIONS. 283 
 
 careful seai'ch will reveal the atrium morbi, not infrequently in the 
 form of a small healed tuberculous focus in the lungs or other exposed 
 part. H. P. Loomis has found tubercle bacilli in the bronchial glands 
 with(iut tul)erculous lesion in any part of the body. 
 
 It is not possil)le at present either to prove or to disprove, for man, 
 the possibility of the passage tiirougli an intact mucous membrane of 
 the pyogenic cocci, whicli are the organisms usually concerned in the 
 so-called ervptogenetic pytemic and septic processes. It is true that the 
 most careful examination in many of these cases fails to reveal the atrium 
 of infection, but wlio can say that it may not have been overlooked? 
 The more painstaking the search, the more likely is some portal of entry 
 to l)e found. Tliis portal may be the root of a carious tootii, the middle 
 ear, one of the nasal sinuses, or some other j)art not usually examined 
 at autopsies. Who can feel sure that in the whole vast extent of tiie 
 alimentary, respiratory, or genito-urinary mucous membranes some 
 minute lesion, serving as a point of entry, does not exist? Sucii a lesion 
 may be microseopic in size, perliaps no more than a necrotic epitlielial 
 cell. Moreover, we have to consider that the original lesion at the point 
 of entry may have healed without leaving any recognizable trace ; nor 
 need this lesion be a recent one. There are instances of fatal septiciemia 
 following mere punctures and scratches of the skin which gave rise to 
 .scaiwly any local intlamniation, and the septicaemia may develop after 
 the point of original injury lias healed and been forgotten. Bacteria, 
 including pathogenic species, may n^main alive, but (juiescent, for weeks 
 and months, in some instances it W(Kild seem even for years, within the 
 body, and tiien, as the result of a trauma or some other cause, their 
 pathogenic energies may be stimulated into activity. 
 
 A\'hile it is certain that in many instances pathogenic micro-organisms 
 may invade an intact mucous membrane and cause local and general 
 infection, and tliat in some instances the organism may enter the circula- 
 tion and be transported to distant parts without manifest lesion at the 
 point of entrance, and while the possibility of the latter occurrence can- 
 not lie disjiroven in the case of tiie pyogenic cocci, nevertheless there 
 can be no doubt that pathological alterations and wounds of tiie exposed 
 surfaces of the body open the way for the entrance of the pathogenic 
 micro-organisms in most surgical infections. For some pathogenic organ- 
 isms, including pyogenic cocci of exalted virulence — such as may come 
 from a case of puerperal peritonitis, for example — all that is needed is 
 that the parts siiould be thus opened, and infection is sure to follow tiieir 
 entrance. But we JKne only to contrast the frequency with wliich 
 streptococcus and other pyogenic infections complicate or follow the 
 infectious fevers, such as ty])iioid, characterized by lesions of nuicous 
 membranes, or tlie ' frequency witii wliich infection follows external 
 wounds in diabetic and dropsical persons, with the rarity of such a sequel 
 to injuries of the same parts in a healthy person, to appreciate the 
 importance of other factors than tlie mere breach of continuity in an 
 exposed surface in predisposing to local and general infections. We 
 shall consider later these local and predisjiosing causes of surgical 
 infections. 
 
 Interesting experiments have been made by Schiinmelbuseh, Nissen, 
 Pfulil, and others as to the rapidity of absorption of bacteria from fresh 
 
284 GENERAL liACTh'n/O/JjaV OF SUHCICAr. IM'KCTIoys. 
 
 womids. They liavo demonstrated tliut bacteria are taken np witliin 
 a very short time, by the lymphatic and blood-vessels, t'rom a fresh 
 blcedinir wound. Mice inoculated witli anthrax l)acilli at the tip of 
 the tail died of anthrax in si>ite of amputation of tiic tail ten mimites 
 after the inocnlation. Nissen found anthrax bacilli in the neai-est Ivm- 
 phatic glands within one hour and a half after peripheral inoculation 
 of an extremity. The application to smooth fresh wounds by Schini- 
 mclbusch of a moderate tjuantity of a culture of the anthrax bacillus 
 or of a streptococcus lethal to mice was fatal, notwithstandinii- an innne- 
 diate attempt at disinfection of the wonnd witii the strongest antiseptics, 
 ychimmclbusch and IJicUer' were able to demonstrate in cultures from 
 tiie internal organs (lung, liver, spleen, kidney) anthrax bacilli in an 
 hour, or even half an hour, after the incjculation of fresh wounds of 
 mice with this organism. They showed that this rapid absorption of 
 bacteria from fresh bleeding wounds applies equally to pathogenic and 
 sa]n-o])hytic bacteria. In cultures from the internal organs mad(> five 
 mimites after the infection of a fresh wound of a rabbit's thigh with the 
 bacillus jjyocyancus they found many colonies of this bacillus. In 
 making the cultures it is necessary to use the whole organ finely 
 divided. 
 
 The significance for the individual of the rapid absor])tion of bacteria 
 from fresh wounds depends, of course, primarily, uixm the character of 
 the bacteria. If these in small or moderate number are cajjablc of 
 causing fatal septicemia, as is the case with virulent anthrax bacilli in 
 highly susceptible animals, the issue is necessarily fatal ; if, as is the 
 case with the pyogenic cocci, the bacteria do not readily gain a foothold 
 where they can multiply, their absorption is of little consequence in 
 most cases, and, so far as the ordinary saprojihytes are concerned, their 
 aljsorption from fresh wounds is a matter of indifference. 
 
 The period during which this rapid absorption of bacteria from 
 a fresh wound takes place is of short duration. As soon as a coagulum 
 has formed on the surface of the wound and the open mouths of the 
 lymjihatic and blood-vessels are plugged, the conditions are changed, 
 and fine particles like bacteria are no longer (piickly transported into the 
 lymj)hatic and blood circulation. The surface of a healthv granulating 
 wound ofiiers great resistance to the invasion of bacteria, almost as nuich 
 as an intact exposed surface of the body. Slight injuries, however, such 
 as probing, the removal of dressings, and other manipulations, may con- 
 vert a granulating surface into a fresh wound, with the accompanying 
 dangers of infection. 
 
 Elimination of Bacteria in the Secretions. 
 
 In former times it M'as thought that the body gets rid of infectious 
 agents chiefly by their excretion through the eniunctory channels. We 
 now know that micro-organisms ai'e destroyed within the body by the 
 living cells and fluids, and that this method of freeing the Ixidy from 
 living bacteria is far more efficient and of much greater importance than 
 that of their excretion by the cmiuictorics. 
 
 Pathogenic bacteria often appear in the secretions in various infectious 
 
 ' Schimmelbusch, Deutsche med. Wochemchrift, July 12, 1894. 
 
ELIMINATION OF BACTERIA IN THE SECRETIONS. 285 
 
 diseases, and it is of interest to know under what conditions they are 
 excreted and in what secretions they occur. The mode of conveyance 
 of infectious organisms from an infected individual to others, and the 
 practical measures of prevention, are determined in large measure by tlie 
 manner of elimination of these organisms from the infected body. 
 
 Wyssokowitsch, as the result of a long series of experiments, came to 
 the conclusion that bacteria in the circulation are never discharged from 
 the body through the healthy organs, but escape only through some 
 breach df continuity or other lesion in the excretory membrane. Hence 
 those pathogenic bacteria which cause some damage to the excretory 
 surflices — and there are many such bacteria — arc most likely to appear iu 
 the excreta, although bacteria without this capacity may escajjc through 
 lesions preforuied from other causes. 
 
 Not all subsequent investigators of this subject have been able to con- 
 firm this law of Wyssokowitsch, aud it is true tliat l)actcria may be elimi- 
 nated from the circulation Ity way of tiic excretions without demonstral>le 
 lesion of the organ tlirough whicli they liave passed. It is to be remem- 
 bered, however, that the lesion may be difficult to detect, or may be of 
 some such undemonstrable character as that of the vascular walls in 
 inflammation which permits the passage of leucocytes and red blood- 
 corpuscles. 
 
 There ha\-e been many special and incidental investigations of the 
 subject of the escape of bacteria ^vith the secretions. Of the experimental 
 investigations relating to the subject in general the most important are 
 those of Wyssokowitsch, Pernice and Scagliosi, and Sherrington.' 
 
 Sherrington experimented on mice, rabbits, and guinea-pigs by the 
 subcutaneous or intravenous iuoculation of eleven, mostly pathogenic, 
 species of bacteria. In sixty-eight observations the presence of the 
 .specific micro-organisui introduced was detected in the urine twenty- 
 one times ; on eight of these twenty-one occasions the presence of blood 
 in the urine was ascertained by the spectroscope ; and in a ninth case 
 gross lesions (tubercle) were found in the kidney. Sometimes the urine 
 contained much coagulable albumin. Of the bacteria of surgical im- 
 jjortance tested, tlie stapliylococcus aureus, the bacillus pyocyaneus, the 
 bacillus anthracis, and a bacillus jirobaljly identical with the Friedliinder 
 bacillus were found frccpicutly in the urine. In Ibrty-nino experiments 
 the specific bacilli were found in the bile in eighteen. The bacillus of 
 mouse septicremia appeared in the conjunctiva, which became inflamed, 
 under conditions making it probable that it did not enter from without. 
 Among the points especially emphasized by Slierrington are tlie fol- 
 lowing : 
 
 "At a time when every drop of the circulating blood is teeming with 
 micro-organisms there may not be the slightest transit of them into the 
 urinary and biliary fluids then secreted, and they may be completely 
 absent from the aqueous humor of the eye-ball." 
 
 "When certain pathogenic s]iccies are employed, a number, often 
 very consideral)lc, of tlie injected bacteria tend after a time to appear in 
 the secretions of the kidney and liver, and their escape in the secreta is 
 
 ' Sherrington, " Experiments on tlie Escape of Bacteria with the Secretions," The 
 Joui-nal nf PalhtiUnjtj and Bacteriology, Feb., 1893. This vahiable article contains a full 
 review of the literature. 
 
286 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 sometimes accompanied by an escape of actual blood," although not infre- 
 (juently there is no blood in the secreta. 
 
 " The evidence is aoainst believing- tiiat when this transit of bacteria 
 across the sccretinii; nienihrane occurs tiie membrane is still normal in 
 condition, althougiiat the same time it need not be ruptured or pervious 
 to red blood-corpuscles." 
 
 " The fact that the escape of the bacteria tends to occur, not immedi- 
 ately upon the introduction of them wholesale into the circulation, but 
 in the late stages of the communicated disease, suggests that tiie healthy 
 secreting membranes arc not pervious to bacteria, and that only after 
 soluble jioisons j)roduced by the infection have had time to act upon 
 them do the membranes became pervious to tlie germs. The fact that 
 species which are innocuous did not in the experiments appear in tiie 
 secreta at any time is in conformity with this conclusion." 
 
 Pernice and iScagliosi experimented with stapiiylococcus aureus, 
 bacillus prodigiosus, bacillus anthracis, bacillus pyticyaneus, and liacillus 
 subtilis, and they found that these bacteria were constantly excreted 
 through the urine and bile, and might escape through various mucous 
 membranes. This excretion begins six to eight hours after their inti'o- 
 duction. Virulent bacteria retain their virulence, as a rule, in the 
 excreta. 
 
 There are numerous observations in human beings of the escape of 
 infectious bacteria tin-ough tiie excretions. The pyogenic cocci are par- 
 ticularly prone to settle in the kidney and cause focal inflammations, but 
 even witiiout actual foci of suppuration they often escape into tlie urine. 
 Xannotti and Baciochi, Ijoth in grave suppurative processes and in slight 
 ones, foimd the specific bacteria ■with great frequency and of customary 
 virulence in the uriiK'. They disapjieared from the urine t^^■cnty-four to 
 tiiirty-six hours after tlie evacuation of the pus. In experimental pyo- 
 cyaneus infections the specific bacillus is found regularly in the urine. 
 The micrococcus lanceolatus in pneumonia and other pnenmococcus 
 infections, the tvj)hoid bacillus in typhoid fever, the streptococci in 
 erysipelas and other streptococcus infections, are often present in the 
 urine. The bacillus coli communis, tlie most common of all secondary 
 invaders, often escapes through the kidney. 
 
 Pathogenic bacteria are eliminated very often through the bile. One 
 of the most common lesions in various infectious diseases is the presence 
 of focal necroses, sometimes visible to the naked eye and sometimes seen 
 only with the microscope, in tiie liver, and these jiermit the passage of 
 bacteria into the bile. It is not, however, necessary that such necroses 
 should be present in order to permit tlie escape of bacteria into the 
 bile. 
 
 Blachstein, in experiments made under the direction of the writer,^ 
 demonstrated that the colon bacillus and the typhoid bacillus injected 
 into the veins of rabbits often aji])eared in the bile, ^\•llere they frc(|uently 
 remained alive and in large number wcel^s and months after they had 
 disappeared from all of the internal organs. In many of these cases 
 there were focal necroses in the liver. The passage from the circulation 
 into the bile of the anthrax bacillns, of the micrococcus lanceolatus, the 
 streptococcus pyogenes, the pyogenic stajihylococci, the bacillus pyocya- 
 ueus, and of other bacteria has been repeatedly demonstrated. Patho- 
 
ELIMINATION OF BACTERIA IN THE SECRETIONS. 287 
 
 gcnic bacteria arc quite as frequently discharged through the bile as 
 through the urine. 
 
 Of course bacteria iu the bile will enter the intestine with this secre- 
 tion, and it is therefore not always easy to determine whether specific 
 pathogenic bacteria found in the intestine in infectious diseases have 
 been discharged through the wall of the intestine or through the liver. 
 ]\Iost of the observations recorded concerning the transit of bacteria 
 through the intestinal wall from the circulation have not been made so 
 as to determine whether or not the escape is really through the intestinal 
 mucosa or by way of the bile. Nevertheless, the frequency with which 
 hemorrhages, necroses, inflanunations, and ulcers of the hitestinal nuicous 
 membrane occur in various infectious diseases makes it highly probable 
 that pathogenic bacteria may be eliminated through this channel. Cer- 
 tain it is that the specific infectious bacteria, not only of diseases like 
 typhoid fever, cholera, and tuberculosis, characterized by definite intes- 
 tinal lesions, but of many other diseases, such as croupous pneumonia, 
 septieiemia, py;emia, are often found in the ffpces. 
 
 Tuljercle l)acilli may be present in the milk of tnljcrculous cows even 
 when there is no demonstrable tuberculosis of the udder. The state- 
 ments as to the frequency of this occurrence vary. Ernst demonstrated 
 by the microscope tubercle bacilli in the milk of 28.5 per cent, of the 
 thirty-five tuberculous cows examined, and by in(jculation experiments 
 in 50 per cent, of fourteen cows. Bang by the inot'ulation test found 
 tubercle bacilli in the milk of only nine out of sixty-three tuberculous 
 cows without mammary tuberculosis. When the udder is tuberculous 
 the bacilli are always in the milk. 
 
 Numerous observations have been made to determine whether or not 
 the pyogenic cocci are excreted with the milk in puerperal infections, 
 but since we now know that the stajihylococcus albus is regularly, and 
 the staphylococcus aureus is sometimes, present in the milk of healthy 
 women, the demonstration of these cocci in the milk in eases of puer- 
 peral fever has lost much of its diagnostic significance. There is, 
 however, reason to believe that, although the ordinary source of the 
 staphylococci found in the milk is from the skin, they may be excreted 
 through the gland from the blood in pyogenics infections. The 
 presence of streptococci in the milk is more significant of such ex- 
 cretion than that of staphylococi'i. In several cases of puerjieral 
 fever streptococci have been found in the milk, although more fre- 
 quently they are missed in this secretion under these circumstances. 
 There is evidence that the ]iyogenic cocci causing mastitis may enter 
 either from without through the lacteal ducts or may have been depos- 
 ited from the circulating blood. Karlinski claims to have demonstrated 
 that the staphylococcus aureus injected into the blood of rabbits mav be 
 excreted through the mammary gland. 
 
 Foil and Bordoni-Ulfreduzzi and Bozzolo have found pneumococci in 
 the milk of pregnant women affected with lobar pneumonia, and the 
 former investigators demonstrated their presence in the milk of preg- 
 nant rabbits inoculated with this organism, and noted j)neumococcus 
 septicicmia in young rabbits which sucked the breast of their infected 
 mothers. 
 
 The typhoid bacillus has been fi)inid exceptionally in the milk in cases 
 
288 GENERAL BACTERTOLOGY OF SURGICAL INFECTIOyS. 
 
 of typhoid fever. In ex]icriin(iital imtlirax the specific bacillus appears 
 in the milk only exoe|)tionally. 
 
 Brunner found the staphylococcus all)us, von Eiselsber<j, Preto, and 
 Tizzoni the staphylococcus aureus, in the sweat in cases of ])yiuniia. The 
 detection of staphylococci, particularly of the stajjhylococcus albus, in 
 the human sweat does not necessarily prove that they have been excreted 
 throup^h the sweat-glands from the 1)1o(k1, for even after the most thor- 
 ough disinfection of the surface of tiie skin the white staphylococcus has 
 not usually been destroyed in the deeper layers, as has already been 
 explained in describing the bacteria of the skin. Still, it is ])rol)al)le 
 that pyogenic cocci may be eliminated by the sweat-glands, for Erunner 
 has shown that the staphylococcus aureus and the bacillus prodigiosus 
 injected into the circulation of swine can be demonstrated in the sweat 
 from the snout after administration of pilocarpine. He was also able to 
 detect the anthrax Itacillus in the sweat from the paw of an infected cat 
 after stimulation of the sciatic nerve. He reports only three experiments, 
 and it is desirable that more work should be done on this subject, as the 
 frequency with which pathogenic bacteria may appear in the sweat in 
 infectious diseases is of imjiortance, especially with reference to possibil- 
 ities of contagion and to measures of disinfection. 
 
 In Brunner's experiment with the bacillus prodigiosus this organism 
 was found also in the saliva, and there are other observations whicii indi- 
 cate the possibility of elimination of bacteria through the salivary glands. 
 
 Conditions favoring the Development of Surgical Infections. 
 
 There ai-e various conditions, relating partly to the micro-organisms 
 concerned and partly to the individual receiving the organisms, which 
 are determining factors in causing infection. The factors pertaining 
 to the individual are usually grouped under the vague but indispensable 
 term " predisposition." 
 
 Dosage and Virulence of Infecting Bacteria. — In the case 
 of some pathogenic bacteria a single bacterial cell may be capable of 
 infecting a highly susceptible animal, whereas with a less susceptible 
 animal a large number of the same kind of bacteria may be required. 
 In his interesting studies on the relation of the dosage of bacteria to 
 infection Watson Cheyne^ showed that whereas a single virulent bacillus 
 of rabbit septicaemia was capable of causing fatal septicaemia in the 
 highly susceptible rabbit, in tlie less susceptible guinea-i)ig the fatal dose 
 was 300,000 bacilli and upward ; between 10,000 and 300,000 bacilli 
 produced abscesses, and smaller doses were without effect. In a mouse 
 a single bacillus of mouse septica?mia, and in a guinea-pig a single viru- 
 lent anthrax bacillus, were capable of producing fatal infection, whereas 
 in rabbits and sheep a considerable quantity of the anthrax bacilli was 
 required to kill the animals. 
 
 Animals are in general insusceptible to small quantities of the pyo- 
 genic cocci, whether introduced sul)cutaue(iusly or into the circulation. It 
 generally takes several hundred thousand of the cocci to produce local 
 abscesses by intravenous or subcutaneous injection. Man is more sus- 
 ceptible to these cocci. 
 
 ' Watson Cheyne, The British Medical Journal, July 31, 1886. 
 
CONDITIONS FAVORING THE DEVELOPMENT OF INFECTIONS. 289 
 
 Thi.s question of dosage is largely one of individual or racial suscept- 
 ibility on the one hand, and of virulence of the micro-organisms on the 
 other hand. 
 
 The kind of infection produced by some bacteria varies with the 
 dose. It often liappens that the inoculation of a very small number of 
 certain pathogenic bacteria produces no effect, a lai'ger number cause only 
 a local abscess, and a still larger number cause fatal septicemia. Tiiis is 
 illustrated by the micrococcus lanceolatus, some varieties of the strepto- 
 coccus pyogenes, and other pyogenic cocci. 
 
 We are familiar with varying degrees of virulence in the case of a 
 large number of patliogenie bacteria. Influences known to be capable 
 of affecting the vitality and the virulence of bacteria, such as sunlight, 
 desiccation, saprophytic growth, association witii other bacteria or their 
 products, are widely operative in nature. The virulence of a micro- 
 organism depends probably maiidy upon its capacity to form toxic 
 prnducts, as it is by these products that bacteria chiefly produce their 
 pathogenic effects. 
 
 Bacteria which enter the body associated with their toxic products 
 are mucii better adapted to cause infection tiian when they enter deprived 
 of these products. Tiiese toxic substances, by damaging immediately the 
 cells and fluids which protect tlie body from infection, enable the invader 
 to gain a foothold whicli it might otiierwise not have secured. Vaillard 
 claims that tetanus spores, deprived by heat or by washing of their 
 toxines, are incapable of germinating in the animal body without the 
 aid of accessory causes, such as the presence of other micro-organisms, 
 dirt, other foreign substances, necrotic tissue, although the spores them- 
 selves are still alive and in suitable media capable of development. If, 
 however, as is usual in our laboratory experiments, the spores or bacilli 
 be inoculated with the toxin, which in most minute doses is of appalling 
 potency, tetanus is sure to develop. In fact, our experimental tetanus 
 is, as a rule, essentially a pure intoxication. 
 
 The varying results which follow the introduction into the body of 
 pyogenic cocci derived from different sources depend doubtless in part 
 upon whetlier these cocci enter tiie tissues already equipped with a 
 reserve force of poisonous products or must Ix'gin the fight unarmed. 
 The inoculation of infectious material coming directly from the human 
 body, as from a case of puerperal peritonitis, and received perhaps only 
 in a puncture or scratch of the skin, may manifest disastrous effects with 
 wliich we are not familiar iu inoculations witii our artificial cultures of 
 the pyogenic cocci obtained from the same source. 
 
 Tiie micrococcus lanceolatus, the streptococcus pyogenes, and the 
 pyogenic stajihylococei are notable for tlie wide variations of their 
 virulence. The lanceolate cocci's (piiekly loses its virulence in artificial 
 cultures. 
 
 Tlie writer has reported observations as to tiie varying virulence of 
 the staphylococcus aureus cultivated from different sources. Some broth 
 cultures were fatal to rabbits within twenty-four to forty-eight hours 
 when injected into the circulation in tlic dose of 0.1 c.c, and other 
 cultures injected in the same way produced no apparent effect in the 
 dose of 1 .5 c.c. Between these extremes were cultures of all degrees of 
 intermediate virulence. In the majority of cases 0.2 to 0.3 c.c. of fresh 
 
 Vol.. I.— 19 
 
290 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 bouillon cultures killed the animal witliin three to seven days after 
 intravenous injection. The variations in virulence of the stre])ti)r()(^('US 
 pyogenes are even more strilvint;-. Pathogenic bacteria, especially pyo- 
 genic cocci, obtained from an inf'ccte(l individual arc more likely to be 
 highly virulent than wlien cultivated from other sources. There are, 
 however, many exceptions to this general rule. 
 
 In various ways the weakened virulence of pathogenic bacteria may 
 become augmented. Among th(! most important of those ways with 
 which we are acquainted are re])cated ])assagc through the animal body, 
 association with other bacteria or their products, and the atldition of cer- 
 tain chemical substances. 
 
 The character of the infection varies often with the degree of viru- 
 lence of the sjjecific micro-organism. Bacterial species, which when highly 
 virulent may kill cpiickly \\itli septica-mia, may, with weakened viru- 
 lence, require a much longer jxM'iod to produce the same eifects, or may 
 give rise to only local inHammatidu without general infection. It is 
 especially with bacteria of attenuated virulence that the matter of 
 dosage may be a controlling factor. 
 
 The varving virulence of the ])yogenic cocci is one of the factors in 
 the explanation of the remarkably diverse effects which these organisms 
 are capable of producing in the animal body. These cocci may under 
 different circumstances cause all grades and kinds of inflammation, serous, 
 fibrinous, suppurative ; they may cause localized inflammations and gen- 
 eral infections. But there are other circumstances besides the degree of 
 virulence which control these varying results. Equally important, in 
 manv cases more important, controlling factors are the manner of inva- 
 sion of the micro-organism and varitius local and general predisi)osing 
 conditions. 
 
 In fact, there is no definite and constant relation between the charac- 
 ter and the severity of an infection produced in man by pyogenic cocci 
 and the virulence of the cocci cultivated from the case. From the 
 gravest septicicmias cocci of slight degrees of virulence may be culti- 
 vated, and from a simple epidermal pustule cocci of high virulence, as 
 tested upon animals. There is reason to believe that the virulence of 
 tlie micro-organisms may be modified during the course of an infection, 
 so that we cannot necessarily draw conclusions as to the primary viru- 
 lence of the organism at the time of its invasion from the virulence 
 noted in cultures from later stages of the disease. 
 
 Bacteriai. Association. — Bacteria are not usually found in the 
 external world under natural conditions in pure culture, but they are 
 mixed together. Mixed infections are common in human beings. In 
 suppurating wovmds we usually find more than one bacterial species. It 
 is of importance to learn the relations of these bacterial associations to 
 infection. We are at present only imperfectly informed as to these rela- 
 tions, but we know that they are often of great significance. Only the 
 more salient points which directly bear upon our theme can be con- 
 sidered here. 
 
 The association of one bacterial species with another may be without 
 influence upon the development or the properties of either, or one species 
 may be favorable to the gi'owth or enhance the virulence of another, or 
 one species may be antagonistic to another or in various ways modify its 
 
CONDITIOyS FAVOJRjyG THE DEVELOPMEXT OF INFECTIONS. 291 
 
 characters. Bacteria exert their influence on each other in large part 
 throiioh their chemical products, and it is often possible to bring about 
 modifications of character l)y exposing one species to the action of the 
 chemical products of another species. 
 
 The pathogenic, the chromogenic, the fermentative, and the other 
 vital manifestations of bacteria may be influenced by their combination 
 with each other. The bacillus pyocyancus may lose its power of pro- 
 ducing ])igment when combined with certain other bacteria (Miihsam 
 and Schinnuellmsch). In mixed cultures of certain bacteria chemical 
 products mav be formed and fi^rmcntations produced which neither of 
 the species in the culture is capable of producing by itself alone (Xencki, 
 Burri, and Stutzer). In mixed cultures of two pathogenic bacteria a 
 larger amount of the toxic products of one or both may be formed than 
 either produces when in pure culture (von Schreider). 
 
 The effects following tiie concurrent inoculation of two kinds of 
 bacteria varv. The association may be without influence as regards 
 infection. The result may be that the develo])nicnt of a deadly species 
 of bacterium is checked by the introduction of another species which is 
 relatively harmless. The only striking instance of this is the effect of 
 the inoculation of the streptococcus of erysipelas, the bacillus of Fried- 
 liinder, and of several other species of bacteria simultaneously with or 
 shortly before or after inoculation with the anthrax bacillus. These 
 bacteria or their products introduced into the body are capable of pre- 
 venting the developing of the anthra.x bacillus and of rescuing the 
 animal from certain death (Emmerich and others). Various explana- 
 tions of this effect are given by different writers. The effect is prob- 
 ably referable not so much to a direct antagonism of one species to the 
 otiier as to an augmentation of the antibacterial jiroperties of the cells, 
 which, according to von Dungern and Metschnikoff, is manifested by 
 increased phagocytic activity of the leucocytes. Bacteria in general 
 wliich cause suppuration may thereby prevent the development of the 
 anthrax bacillus in the focus of suppuration. 
 
 More frequently the concurrent inoculation of two species of bacteria 
 increases the danger to the animal from one or both. A combination 
 of two species, each in itself liarmless, may prove fatal to the animal 
 (Roger). A bacterium of attenuated virulence may become augmented 
 in virulence by inoculation in combination with another species which 
 need not necessarily be itself jiathogenic, nv sometimes simplv in com- 
 l)ination with the chemical products of another species. The following 
 are examples of the exaltation of the virulence or of the pathogenic 
 effects of one kind of bacteriinn by combined inoculation with another 
 kind or its |>roducts : that of the niici'ococcus lanceolatus by combination 
 with the proteus vulga'ris, the anthrax bacillus, or the diphtheria bacillus 
 (Monti, Pane, Miihlmann, Mya) ; the streptococcus pyogenes with the 
 proteus vulgaris, bacillus prodigiosus, bacillus coli communis (Klein, 
 Monod, and Macaigne) ; the pyogenic sta|)]iyloc()cci with the bacillus pro- 
 digiosus or its products and otiier bacterial ))r(iducts (Grawitz and De 
 Bary and others) ; the diphtheria bacillus with the streptococcus ])vogenes 
 or its products (Roux and Yersin and others) ; the typhoid bacillus with 
 the streptococcus pyogenes, colon bacillus, and proteus, or their products 
 (Vincent, Sanarelli) ; the bacillus coli communis M'ith the typhoid bacil- 
 
292 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 lus and the streptococcus pyogenes (Pisenti and Hianclii-Mariotti) ; the 
 bacillus of symptomatic; authrax with the liacillus jjrotligiosus (Roller). 
 Mention has already been made oi' the pathological importance of tiic 
 association of the tetanus bacillus with other bacteria. Of especial 
 interest are the experiments of Prudtieu demonstrating that the intra- 
 tracheal injection of cultures of the streptococcus pyogenes in tuber- 
 culous rabbits leads to the formation of regular phthisical cavities in the 
 lungs — a result which is not obtained by the inoculation of either micro- 
 organism alone. Jiernheini has demonstrated that the dijilitln'ria bacillus 
 grows more luxuriantly and with a larger production (jf toxin in the 
 filtrate of streptococcus bouillon cultures than in ordinary bouillon. 
 
 A most important group of infections, many of them of surgical 
 importance, is furnished by the secondary invasion of pathogenic bacteria 
 in the course of various infectious diseases, such as ty])hoid fever, tuber- 
 culosis, diphtheria, scarlet fever, small-pox, and other exantliematous 
 fevers. The streptococcus pyogenes is more frequently the infections 
 agent in these secondary infections than any other organism, but the 
 other pyogenic cocci are not uncommonly concerned. The primary 
 infection increases susceptibility to these common pyogenic cocci, which 
 often find the way open for their invasion by some lesion of an exposed 
 surface of the body. It is also very jirolialtle that the primary infection 
 may brine about conditions which enhance the virulence of the bacteria 
 concerned in the secondary infection. Although it is not necessary to 
 suppose that these common secondary invaders are always derived from 
 tlu)se \\hich are present in health uj)on exposed mucous membranes, 
 nevertheless they doubtless often have this origin. Pyogenic cocci 
 obtained from these .■secondary infections ai-e usually, although by no 
 means always, more virulent than when cultivated irom the healthy 
 mucous membranes. 
 
 Of especial frequency and importance among the mixed and second- 
 ary infections here in consideration is the association of the tubercle 
 bacillus with the streptococcus jn'ogenes, the tyj)hoid bacillus Avitli 
 pyogenic cocci, and the diphtheria bacillus with streptococci. 
 
 The characters of the various mixed infections are probably deter- 
 mined less by a direct influence of one bacterial species or its products 
 upon another, although this factor ajipears in some cases to be an import- 
 ant one, than by the action exerted by one or both species upon the 
 resisting powers of the fluids and cells of the body. 
 
 Immunity and Pkedisposition. — In no class of infectious diseases 
 is the influence of ])redis])osition as an etiological factor more a])parcnt 
 than in many of the surgical infections. If a wound could be kept 
 entirely free from pathogenic bacteria, it would not suppurate, no matter 
 how favorable in other respects the local and general conditions for infec- 
 tion might be. The occurrence of suppuration in human beings from 
 sterile chemical irritants is so exceptional that we need not consider this 
 form of suppuration here. It is not, however, possible in all, or even 
 in most, cases to keep bacteria wholly out of a wound. The examina- 
 tion of so-called aseptic wounds shows with great frequency the presence 
 of bacteria, and notably of the white skin-coccus, but also sometimes 
 of other pyogenic cocci, including the staphylococcus aureus. Although 
 the cocci found under these circumstances are usually of -weakened viru- 
 
CONDITIOXS FAVORING THE DEVELOPMENT OF INFECTIONS. 293 
 
 lence, nevertheless, as shown bv Biidinger and others, they are of some 
 virulence, and may be decidedly virulent. The frequency with which 
 pyogenic bacteria enter wounds is by no means expressed by the fre- 
 quency with which wounds suppurate. Every surgeon knows that in 
 certain persons and in certain conditions of the body a wound is much 
 more likely to suppurate than in others, altliough the same precautions 
 are taken to guard against the entrance of micro-organisms. It is there- 
 fore a matter of prime importance, no less of practical than of scientific 
 interest, to learn, so far as we may, what are the conditions which jire- 
 dispose an individual to infection. Unfortunately, we are at present 
 only imperfectly informed as to many of these conditions. 
 
 Predisposition is of most inqiortance in the etiology of those infec- 
 tious diseases which are caused by micro-organisms to which the individ- 
 ual or the species is not in the Iiigiiest degree susceptible. Tiie pyogenic 
 cocci, in general, belong to this group of micro-organisms, although they 
 may exist in a condition of such exalted virulence that predisposition 
 becomes a factor of no significance. 
 
 The degree of susceptibility to a specific micro-organism influences 
 not only the capacity to acquire the infection, but also the course, 
 severity, and character of the infection. In an individual of great 
 susceptibility a micro-organism of attenuated virulence may produce 
 effects which in a relatively insusceptible person can be accomplished 
 only by a highly virulent micro-organism of the same species. 
 
 The astonishing variety of affections which may under different cir- 
 cumstances be caused by pyogenic cocci, from a simple epidermal pustule 
 to tile gravest septicemia and pyarnia, from a serous to a suppurative 
 inflammation, are to be explained in part by variations in the local or 
 general susceptibility of the individual, although, as already explained, 
 other factors, such as the degree of virulence of the organism, the 
 manner of invasion, and the number of organisms introduced, are also 
 inq)ortant. We possess aliundant experimental evidence of the fact that 
 in the relatively insusceptible many patliogenic bacteria remain localized, 
 causing inflauiniation, whereas tiie same bacteria in the highly susceptible 
 invatle the blood and internal organs, causing general septictemia. 
 
 Ijimuxity. — Our comprehension of the nature and importance of 
 predisposition as a factor in the causation of infectious diseases has been 
 facilitatt'd by the increase of our knowledge concerning the factors upon 
 M'iiicii immunity from the invasion and nuiltiplication of bacteria depends; 
 but our understanding of the nature of innnuuity is still most incom- 
 plete. It is not necessary for our purjjoscs in this connection to enter 
 into a detailed consideration of the various doctrines of immunity, 
 important as are the results of recent investigations upon tliis subject. 
 It will suffice to state briefly tlie more inqiortant facts and hypotheses 
 so far as they bear upon the (piestion now under consideration.' 
 
 We distinguish natural or hereditary imuuuiity from acquired immu- 
 nity. Imnuinity may be acquired by recovery from an attack of a specific 
 infectious disease, or may be artificially produced by vaccination with 
 the specific micro-organism or its products, or by the injection of the 
 
 ' The following statements concerning immunity are taken chiefly from the fuller 
 article on this subject by the writer in Pepper's Teil-Iiook of the Theory and Practice of 
 Medicine by American Teachers, vol. ii., Philadelphia, 1894. 
 
294 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 hliHKl-.scrum or otlier fluids fmin individuals rcndorcd artificially 
 iniiiiune. 
 
 It is certain that the various kiniis of immunity do not all depend 
 upon the same causes. The leading theories of immunity may be 
 brought into two classes — one which attributes immunity to the direct 
 and active intervention of the living cells of the body, and the other 
 which explains immunity by the ])roperties of the extra-cellular fluids. 
 In the last analysis these properties of the body fluids nnist dei)eud 
 upon the activities of cells, so that we must have recourse either directly 
 or indirectly to cellular functions in any adequate explanation of im- 
 munity. 
 
 The leading representative of the cellular theories is the phagocytic 
 theory, so elaborately and charmingly developed by ^Nletschnikoff. This 
 supposes that immunity depends u})on the seizure of invading micro- 
 organisms by anitt'boitl cells, chiefly leucocytes and other mesodermic 
 cells, and the subsequent destruction of these organisms in the interior 
 of the cells. According to this view the leucocytes are charged with 
 the defence of the l)ody and engage in a veritable conflict \\ith the 
 parasites. The significance of inflammation, according to Metsclmikotf, 
 is to bring the leucocytes to the seat of danger, to which they arc attracted 
 by the j^ositivcly chemotactic substances furnished by the micro-organ- 
 isms. Immunity is acquired when the phagocytes have gained tolerance 
 of the poisons of the specific micro-organism and are no longer repelled 
 by them. 
 
 There exists in a very large number of cases unquestionably a paral- 
 lelism between phagocytosis and immunity, but the action of phagocytosis 
 is by no means always apparent. \ye know that micro-organisms may 
 be destroyed by extra-cellular agencies as well as within the cells, and it 
 is a fair question whether the micro-organisms before their reception by 
 cells have not already been damaged by these other agencies. It is true 
 that jNIetschnikofF has proven that phagocytes may take ujj li\-ing and 
 virulent bacteria, and that these bacteria may degenerate and die in the 
 interior of cells, but he has not shown that, as a rule, bacteria when taken 
 up by cells have suft'ered no injury from extra-cellular agencies. We 
 possess direct observations which prove that bacteria introduced into the 
 body may degenerate and die not only within cells, but also outside of 
 them in the humors. 
 
 The humoral theories of naturid inuuunity have been based largely 
 upon the demonstration by Nuttall, Buchner, and others of the bacteri- 
 cidal properties of the blood and other fluids of the body. Buchner has 
 given the name of " alexins," and Hankin that of " defensive protcids," 
 to these bactericidal substances. The bactericidal alexins are believed 
 by Kossell and Vaughan to be nucleins or nucleinic acid. Their action 
 is not exerted equally ujjon all bacteria, and there is often no parallelism 
 between the ])resence of this bactericidal property in the blood of the 
 normal animal and the insusceptibility of the animal to a given micro- 
 organism. The important observation has been made, however, that 
 as the result of the introduction of certain micro-organisms the body 
 fluids may acquire bactericidal proj)crties as regards the organism intro- 
 duced. 
 
 The search for the origin of the alexins has led to the view that they 
 
b 
 
 CONDITIONS FAVORING THE DEVELOPMENT OF INFECTIONS. 295 
 
 are derived directly from the cells, and particularly from the leucocytes. 
 This lias led to a partial reconciliation between the phagocytic and the 
 most prominent humoral tiieories of immunity. The leucocytes and 
 other cells are, indeed, tlie defenders of the body against intruding micro- 
 organisms. I'hey furnisli the alexins, the weajions of attack. AVhere 
 they accunudate the defensive material is concentrated, but it is not 
 necessary that the bacteria should be actually incorporated in the body 
 of the cells, although the germicidal properties may be more intense 
 within than without tlie cells. Such is the explanation of natural inunu- 
 nitv now adopted l)y Buchner and many others. 
 
 There is a kind of acquired inununity wliich is not known to have a 
 parallel in forms of natural imnuuiity. Tiiis is tlie so-called antitoxic 
 immunity. Here, as the result of vaccination with the specific micro- 
 organism or its products, tiie blood and fluids of the immunized animal 
 have acquired the property of neutralizing the poison formed by the 
 specific organism from which the individual has been immunized. The 
 principles of antitoxic immunity liave been worked out for the toxic 
 infections, tetanus and diphtheria. The same principle doubtless holds 
 good for acquired immunity from some other diseases, but for how large 
 a number we cannot say. A most important characteristic of this anti- 
 toxic immunity is that by successive injections of increasing amounts of 
 the ])oisonous substances into the animal the antitoxic or immunizing 
 power of the fluids can be augmented to an astounding degree. It is in 
 this way that the antitoxic power of the fluids may be rendered sufticiently 
 high to exert curative effects when injected after the reception of the 
 specific micro-organism or its ju'oducts. This so-called serum-therapy 
 has thus far Ijcen apjilied with beneficial results only to cases of tetanus 
 and of di[)litlicria, and, as regards human beings, it is more efficient in 
 diphtiieria tiian in tetanus. 
 
 Local Piiedisposition. — The term " predisposition " is often used 
 in a loose sense to designate all sorts of conditions M'hich increase the 
 chances of infection, or which augment susceptibility to infection, or 
 which influence the localization, duration, character, or severity of infec- 
 tions. A name which is used to refer to conditions belonging to such 
 ditterent categories, having often nothing in common, is of course objec- 
 tional)le, but common usage sanctions the term, and there appears to be 
 no lietter one under which to include the various points here to be con- 
 sidered. 
 
 We distinguish racial and individual predisposition, inherited and 
 acquired predisposition, local and general ])redisposition. 
 
 Instances abound of diflerences in susceptibility to infectious diseases 
 between ditt'erent species of animals, and tiiere are differences also between 
 different races of nien ; but tho most important kind of predisposition, 
 as regards those surgical infections which we are here considering, is 
 individual predisposition. 
 
 This iudividnal |)redisposition may be either inherited or acquired. 
 It may pertain only to one part or to certain parts of the body, or it may 
 belong to the body as a whole. A\'e cannot in many instances determine 
 whether the predisposition is local or general, and, indeed, it is often 
 imjiossible to draw any sharp dividing-line between local and general 
 predisposition. 
 
296 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 Local predisposition may be limited to one or more of the portals of 
 entry for miero-(jriianisnis, or it may exist at some point within the Ixidy, 
 constitiitint;- a so-called locus minoris resistcntiie. 
 
 We shall consider first prcdisposinii' causes of infection at the portals 
 of entry. We shall have in view under this headinj;- min'c pai'ticidarly 
 causes which act locally, hut it is to be understood that general ])redis- 
 posing factors to be described later may produce local predisposition. 
 
 Under the heading of " Intlannnation produced by Bacteria" Dr. 
 Councilman in the pre(;eding article has described the intluenec upon 
 pyogenic infections of many local predisposing factors, such as the 
 character of the tissue invaded, local ana-mia, passive hypera^mia, the 
 withdrawal of nerve-impulses from a part, rapidity of absorption, the 
 introduction of chemical bacterial jiroducts, the presence of foreign 
 bodies, jirevious attacks of inflammation ; and the reader is referred to 
 Dr. Councilman's article for these points. It has there been made clear 
 that any interference with the integrity of the tissues and of the local 
 blood- and lymph-circulation is likely to render them more susce]>tible to 
 jiyogcnic agents, and to influence nnfiivorably the character and course 
 of a subsequent inflammation. Wounds through a thick layer of adipose 
 tissue or cicatricial tissue or other poorly-vasenlarized parts are less able 
 to resist the action of jwogenic bacteria than wounds of such vascular 
 parts as the face. 
 
 To the predisposing conditions enumerated may be added redema of 
 tlie tissues. How important this is may be inferred from the frequency 
 with which erysipelas and suppuration follow so slight an injury as 
 puncture of an a?dematons scrotum or leg. Biidinger found that ])vo- 
 genic cocci so weakened in \-irulence as to produce no effect Mhen inoc- 
 ulated into the normal ear of a rabbit set up local suppuration Mhen 
 inoculated into an ear rendered hy2)er8emic and a?dematous by tempo- 
 rary application of a rubber band around the root of the ear. 
 
 The withdrawal of nerve-impulses from a part may increase its lia- 
 bility to infection. The factors here concerned are various, the most 
 apparent ones being anaesthesia, disturbances in the lymphatic and 
 blood circulation, and nutritive changes. The question as to the exist- 
 ence of special trojihic nerves, the interference with whose function pre- 
 disposes the part to infectious inflammations, has been considered by 
 Dr. Councilman. In a personal conmiunication Dr. Weir Mitchell has 
 kindly favored the writer with the following expression of his views 
 on this point : " I think it true that the withdrawal of nerve-im])nlses 
 from a part favors infection ; that the withdrawal of nerve-influence 
 with partial failure of circulation in some cases of injury still further 
 favors infection ; that there is a condition of traumatic nerve-irritation 
 which, probably by its abnormal influence on nutrition, favors infection. 
 A partial injury of a nerve sets up local neuritis and may bring on idcers 
 of a jiecnliar character.' It seems to me that if we injure a nerve-supply, 
 the changes in muscular and nerve conditions which immediately take 
 place would favor such chemical changes in the tissues as to make them 
 more or less susceptible to infection." 
 
 Abnormalities in the secretions on exposed mucous surfaces and in 
 
 ' Interesting examples of sucli uleere nre here cited by Dr. Mitcliell from the forth- 
 coming book of his son, Dr. Jolin H. Jlitcliell, on Nen-e-injuries and their Remote Results. 
 
CONDITIONS FAVORING THE DEVELOPMENT OF INFECTIONS. 297 
 
 the glands communicating with them may be a local predisposing cause 
 of iuf't'ction. Obstruction to the outflow of secretions, and the presence 
 of calculi or foreign Ijodies in cavities or glandular ducts opening upon 
 exposed surfaces are important prcdisjiosing causes of infection, as is 
 exem[)lificd by inflammations of the vermiform appendix, renal pelvis, 
 urinary and gall-ldadders, urethra, the l)iliary, pancreatic, and salivary 
 ducts. 
 
 In general, all traumatic and pathological lesions of exposed surfaces 
 of the I)ody, such as wounds, hemorrhages, necroses, waxy degeneration, 
 inflammation, ulcers, stricture, strangulation, pcrfn'ation, increase in 
 greater or less degree the opportunities for the entrance, lodgement, 
 and multiplication of pyogenic and other micro-organisms. 
 
 A suppurating surface, however, offers considerable resistance to the 
 growth and invasion into the body of most jiathogenic bacteria. Pus is 
 endowetl with marked bactericidal properties, both in its corpuscular 
 elements and its fluid constituents, and tlie o]>portunities for absorjition 
 from a suppurating surface are nuich less favorable than from a fresh 
 wound. Scstini found that the bacilli of anthrax and of rabljit sejjtica- 
 mia when applied to a suppurating wound of tlie rabbit's skin produced 
 no infection, although they readily did so when introduced into a fresh 
 wound. The existence of sujipui-ation, however, lowers the general 
 resistance of the body to bacteria. 
 
 The various lesions which interrupt the continuity and integrity of 
 the exposed surfaces of the body become most dangerous channels of 
 infection when the general resistance of the body to infectious agents is 
 lowered, as in various infectious fevers and constitutional diseases. 
 
 J^xperiments and clinical observations have been made with reference 
 to tile amount of damage to the intestinal coats which is requisite in 
 order to permit the passage of bacteria from the intestinal canal into 
 the peritoneal cavity. Most observers have found the fluid in the sac of 
 a strangulated intestinal hernia free from bacteria in the great majority 
 of cases. Garre found bacteria only once in eight cases ; Rovsing did 
 not find them at all in five eases ; nor did Ziegler in five cases ; Tavel 
 and Lanz obtained a positive result only twice in seventeen cases of in- 
 testinal strangulation ; in two out of three omental strangulations they 
 found l)actcria ; Tietze found bacteria in four out of nine cases, with the 
 possibility that in some of the four cases they were accidentally intro- 
 duced from without. Sanguineous hernial fluids with bloody infiltration 
 of the intestinal coats were observed without the presence of bacteria, and 
 even the fluid in sacs containing necrotic intestine did not always contain 
 bacteria. The presence of fibrinous peritonitis over strangulated intestine 
 does not necessarily involve the presence of Iwctcria in the exudate, as 
 this form of peritonitis may be caused by the absorption of the chemical 
 products of bacteria from the intestine (chemical peritonitis). Definite 
 relations lietween the condition of the intestine and the presence of bac- 
 teria in the hernial sac were not ol)scrvc<i. 
 
 For some at present inexplicable reason Boenneckcn found bacteria 
 in the sacs of all of the eight strangidated iiernias which he examined. 
 
 Arndt has shown by exj)eriments on rabbits that bacteria may pass 
 through the strangulated intestinal wall without the existence of necrosis 
 of the intestine, and when the condition of the intestine is such that it 
 
298 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 quickly returns to the normal state upon relief from the stranjyulation. 
 The presence of bacteria in the hernial fluid does not necessarily involve 
 the development of peritonitis, 'i'lie conditions which jicriuit l)actcria to 
 wander from the intestine tin'oug'li its wall into the peritoneal cavity 
 have not as yet been made clear. Tietze has shown that the fluid from 
 a hernial sac possesses marked bactericidal power over some intestinal 
 bacteria.' 
 
 The entrance of the colon bacillus into the circulation is usually, in 
 our cxjicrience, associated with some lesion of the intestinal nnicosa, 
 although this is not invariably the case. Absorption of pathoi,renic bac- 
 teria, jiarticularly the pyogenic cocci, from the diseased intestinal mucosa 
 is a fruitful source of various infections of internal parts, and many 
 cases regarded as cryptogenetic septico-pysemia have this origin. 
 
 The importance of accessory and jn-edisposing causes of inflanmia- 
 tions due to bacteria is nowhere better illustrated than in the etiology of 
 peritonitis, as has been set forth l)y Dr. Councilman on page 180. There 
 are two principal classes of predis])osing causes of peritonitis — namelv, 
 substances which damage the endothelial cells of the peritoneum, and 
 solid, unabsorbable substances. 
 
 Of especial importance to the surgeon is a knowledge of tlie local 
 and general predisposing causes of the infection of womids. The gen- 
 eral predisposing fiictors we shall consider later. From what has alirady 
 been said, it is ap])arent that while the surgeon should use every effort to 
 keep bacteria out of a wound, he should refrain so far as possible from 
 doing anything which interferes with the power of the fluids and cells to 
 ovei'comc invading micro-organisms. 
 
 Among the local conditions" which have been found fiivoralde to the 
 growth in wcjunds of l)act('ria which otherwise might be disjjosed of by 
 the tissues and animal fluids without harm may be mentioned strangu- 
 lation of masses of tissue l)y ligatures ; the presence of foreign bodies, 
 such as drainage-tubes and coarse ligatures ; interference with the cir- 
 culation and absorption and the vitality of tissues resulting from undue 
 pressure or tension ; dead spaces ; accumulation of the fluid and solid 
 discharges from a wound, especially when associated with tension ; necro- 
 sis and degeneration of tissues caused by the contact of strong chemical 
 irritants. If it were within the power of the surgeon to keep bacteria 
 entirely out of wounds or to destroy them without damage to the tissues 
 after they enter, the conditions just mentioned could not by themselves 
 alone cause infection, but this power he does not at present possess. The 
 so-called aseptic A\-ound of the surgeon is not usually aseptic in the 
 bacteriological sense ; that is, free from bacteria. 
 
 The following objections to the insertion of drainage-tubes into 
 Avounds have been elsewhere formulated by the M'riter : ^ First. They 
 
 ' For the literature and the most important experiments and observations thus far 
 made upon the subject of bacteria in hernial sacs consult Tavel and Lanz, " Ueber die 
 Aetiologie der Peritonitis," Mittlieilntu/eii «i(s Ktiniken nnci mad. Instil, d. Schceiz, Basle 
 and Leipzig, 189:3; Arndt, "Ueb. d. Diircb];issie;keit d. Darmwand eingeklemmter Briiche 
 fiir Mikroorganismen," ibid., 1893; and Tietze, Arrh.f. klin. Cliirurgii; I'd. 49. 
 
 ^The writer wishes to acknowledge his indebtedness to his colleague, Dr. William 
 S. Halsted of the Johns Hopkins Hospital, for information and numerous suggestions as 
 to tlie influence of many local and general causes predisposing to the infection of wounds. 
 
 ■' Welch, " Some Considerations concerning Antiseptic Surgery," The Maryland 
 Medical Journal, Xov. 14, 1S91. 
 
COSDITIOXS FA VORIXG THE DEVELOPMENT OF INFECTIONS. 299 
 
 tend to remove bacteria which may get into a wound from the direct 
 bactericidal influence of the cells and animal juices. Second. Bacteria 
 may travel bv continuous growth or in other ways down the sides of a 
 drainage-tube, and so penetrate into a wound which they otherwise would 
 not enter. We have repeatedly been able to demonstrate this mode of 
 entrance into a W(jund of the white staphylococcus found so commonly 
 in the epidermis. The danger of leaving any part of a drainage-tube 
 exposed to the air is too evident to require mention. Third. The chang- 
 ing of dressings necessitated by the presence of drainage-tubes increases 
 in pnipDrtion to its frequency the chances of accidental infection. Fourth. 
 The drainage-tube keeps asunder tissues which might otherwise inniic- 
 diately unite. Fifth. Its presence as a foreign body is an irritant and 
 increases exudation. 'Si.iih. The withdrawal of tubes left any consider- 
 able time in wouuds breaks up forming granulations, and thus both pro- 
 longs the process of repair and opens the way for infection. Cxrannlation 
 tissue is an olistaclc to the invasion of pathogenic bacteria from the sur- 
 face, as has l)een proven by experiment. Seventh. After remo\-al of the 
 tube there is left a tract prone to suppurate and often slow in healing. 
 
 The advantage from the employment of drainage-tubes or other drain- 
 age material is, of course, the removal of secretions, and this indication 
 becomes an urgent one if the cavity with which the tube connnunicates 
 is infected and su])purates. In a given case the surgeon nuist weigh the 
 advantages and the disadvantages and act according to his judgment. 
 The practice of most surgeons at the jjrcsent time (jf restricting within 
 much narrower limits than formerly the use of drainage-tubes, and of 
 discarding them for all wounds which offer a fair prospect of primary 
 union, is a distinct advance in the technique of antiseptic surgery. 
 
 The presence of blood in a wound is not itself to be desired, and 
 modern surgeons justly lay stress upon prompt and careful ha;mostasis 
 in surgical operations. Blood in a wound is not, however, so dangerous 
 a thing as some have supposed it to be, and where for the obliteration 
 of cavities in a wound the choice lies between a blood-clot and the intro- 
 duction of foreign substances, or the exercise of undue tension by sutures, 
 or the application of a very large number of sutures, or forcible ]3res- 
 sure, it is, as a rule, better to take the chances that the spaces will till 
 with blood (Halsted). Blood possesses bactericidal properties, and experi- 
 ments made by the writer and Howard ' showed that virulent pyogenic 
 staphylococci injected into blood-clots which had been allowed to fill 
 wound-cavities did not multiply and occasioned no suppuration. Joiui 
 Hunter was find of dwelling upon what he called the vitality of blood, 
 and John Chicne has directed attention anew to similar views. Schcde 
 brought prominently to the notice of surgeons the value of the blood-clot 
 in the healing of a certain class of wounds, and Halsted '" further extended 
 the field of its application. The unintended presence of blood in a wound 
 by occasioning undue tension and in other ways may be a dangerous 
 thing, and is something very ditferent from the purposeful apj)lication of 
 
 ' Welch, " Conditions iimlerl.ving thi' Infection of Wonnds," Transactions of tlie 
 Second Congress of American Phijuiciann and Siirf/eoiia, vol. ii., 1891. 
 
 ^ Halsted, " The Treatment of Wounds with especial reference to the Value of the 
 Blood-elot in the Management of Dead Sjiaces," Tlic Johns Hopkins Hospital Peporls, vol. 
 ii. No. o. 
 
360 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 the metliod of healing by so-called organization of blood-coagula. It is 
 of the first importance to prevent so far as possible all tension in a 
 wonnd. 
 
 T^ndne stress is sometimes laid iijion artificial devices to close the so- 
 called dead spaces of a wound. These spaces when not drained, nor 
 stutted with foreign substances, nor obliterated by siitui'es or pressure, 
 nor pei'mitted to fill with blood, do not, unless very large, remain empty 
 spaces. They quickly fill with exudations of fluids and cells, and these 
 fluids and cells possess antibacterial jiroperties as well as blood. For 
 cavities with unyielding walls, such as those in bone, the blood-(dot 
 method of treatment has been found especially useful. 
 
 Surgeons are not agreed as to the value of the application of antiseptic 
 fluids and substances to fresh wounds. There has been in recent years, 
 under the name of asejttic surgery, a general tendency to consider them 
 useless or harmful, but .some surgeons still advocate the antiseptic irri- 
 gation of fresh wounds. The (jucstion is one which can lie decided only 
 by clinical ex^jcrience. The experimental data bearing upon the (pies- 
 tion are the only ones appropriate to consider here. 
 
 The principal objections urged against the employment of the a]ipli- 
 cation of such disinfectants as corrosive sublimate and carbolic acid to 
 fresh wounds are — -fir.'^t, that tliey accomplish little or nothing in the way 
 of destroying bacteria wliich may have entered the MOund ; and, second, 
 that they cau.se necrosis or other impairment of the tissues, and thereby 
 ^\•eaken or abolish the antibacterial properties of the tissues, and thus 
 predispose to infection. 
 
 The conditions for the destruction of bacteria by chemical disinfect- 
 ants in the fluids and tissues of the animal body, even -when the bacteria 
 are only upon an exposed surfiice, are most unfavoral)le as compared 
 Avith those in experiments with the same agents in test-tubes. The 
 experiments of Schimmelbuseh, already cited, do not, as he seems to 
 suppose, demonstrate the uselessness of antiseptic applications to wounds 
 in general. He found that the fatal infection of mice with the bacillus 
 anthracis and that of rabbits with tJie bacilli of rabl>it septicsemia, intro- 
 duced in large number into fresh wounds, could not be prevented by tlie 
 irrigation of the wound with corrosive sublimate (1 : 1000) or carbolic 
 acid (5 per cent.) or other antiseptics. But some of the bacteria thus 
 introduced, as has already been ex])lained, are immediately or very soon 
 al)sorlicd from fresh wounds, and if one bacillus or a very few bacilli of 
 the kind used by Schimmelbuseh were thus absorbed, the death of the 
 animal was sure to follow; whereas a similar absorption of a few ordinary 
 pyogenic cocci is usually without significance. It is evident that these 
 experiments are not conclusive as to the influence of antiseptics upon 
 bacteria which remain in the wound, and are not applicable to the ordi- 
 nary conditions of wound-infection during a surgical operation. 
 
 Henle' in his experiments conformed more closely to conditions of 
 wound-infection in man. He found that in wounds of the rab1)it's ear 
 inoculated with streptococcus ])us the streptococci remained in tin' wound 
 for six hours, after which the cocci began to occupy the neighboring 
 lymph-spaces. He found that regularly up to the end of the second 
 hour a complete disinfection of the M'ound with sublimate (1 : 1000) or 
 
 ' Henle, Cenlralblalt /iir Chirurgie, 1894, No. 30, Beilage. 
 
CONDITIONS FA VOBING THE DEVELOPMENT OF INFECTIONS. 301 
 
 carbolic acid (4 per cent.) could be attained, and that even after six hours 
 the disinfection sometimes })revented tiie development of the disease, and, 
 if not completely successful, rendered the subsc(|Ui'nt infection milder than 
 in the inoculated control ear wliicli was not disinfected. 
 
 Loffler has shown bv his carcftd tests of the action of various anti- 
 septic substances upon diphtheritic throats that it is possible to destroy 
 the superficial bacteria by antiseptics without serious injury to the tissues. 
 It is possible that disinfectants, without actually killing bacteria, may 
 restrain their power of development or weaken their virulence. 
 
 Messner' experimented by inocidating fresh wounds of rabbits with 
 pus or with cultures eontaininji' pyogenic cocci, wiiich caused [)rogressive 
 phlegmonous inflammation with fatal termination. He found that, with 
 one exception, all of the ten wounds inoculated with the cocci, and then 
 irrigated with sterile salt-solution and treated aseptically, suppurated, 
 witli the development of progressive phlegmons which killed the animal 
 Mithin two weeks. On the other hand, all of the ten wounds, with one 
 exception, similarly inoculated and treated antiseptically with lysol or 
 3 per cent, carbolic-acid solution, healed and the animals survived. Two 
 of the wounds treated antisejjtically healed without suppuration ; the 
 remaining eight suppurated, showing that the cocci had not actually 
 been destroyed, but the process remained localized. Pus from the 
 wounds treated aseptically presei'ved its virulence, whereas pus from the 
 wounds treated antiseptically was devoid of virulence when inoculated 
 into animals. 
 
 Hermann and others have shown that if carbolic acid, corrosive sub- 
 limate, and various other chemical irritants be injected subcutaneously 
 into the tissues and soon afterward pyogenic micro-organisms be injected 
 into the same locality, the formation of an abscess is much more likely 
 to follow than when the bacteria are injected into the healthy tissues. 
 But, as Messner has shown, a similar favoring influence upon the devel- 
 opment of suppuration under these circumstances is exerted by the injec- 
 tion of common salt-solution into the subcutaneous tissues. These exper- 
 iments are not a])])licable to the conditions existing in an open wound, 
 Imt tliev confirm clinical observations as to the great danger of intro- 
 ducing into tlie subcutaneous tissues of man, with a hypodermic syringe, 
 fluids containing pyogenic l)acteria. 
 
 Uncpiestionably, the presence of necroses, such as may be produced 
 by strong chemical disinfectants, -jiredisposes to pyogenic infection. In 
 some situations, as in a closed cavity like the jieritoneal, the jiresence of 
 even superficial necroses, which may afl'ect oidy the endothelial cells, is 
 an important ])redisposing cause of infection, but only experience can 
 decide whetiier such slight sujierficial necrosis or other injury wliich the 
 ordinary antiseptics may prodnce in an external wound is in itself an 
 important predisposing factor in the pyogenic infection of wounds, or 
 even if a predisposing factor is not more than counterbalanced by bene- 
 ficial influences exerted by tlie a|)plication of antiseptics. Messner has 
 reported experiments on rabl)its which seem to show that the irrigation 
 of fresh wounds with 3 per cent, carbolic-acid solution does not lessen 
 the \ital resistance of the tissues in a wound to subsequent inoculation 
 with pyogenic cocci. 
 
 ' Jlessner, Jhid. 
 
302 GENERAL BACTEBIOLOaY OF SUROTCAL INFECTIONS. 
 
 Experiments upon animals, tlicrcforc, favor ratlior than o])post' the 
 antiseptic treatment of wounds, as distinguished from so-ealled asepsis. 
 
 We turn now to the consideration of local predisposition existing at 
 some jioint within the body, the so-called locus minoris resisteutise. After 
 the infectious agents have passed through the portal of entry and entered 
 the general circulation tluy may find local conditions favoring their lodge- 
 ment and development. Without such local predisposition they are often 
 incapable of doing any harm. 
 
 Injury, inflammation, and other pre-existing disease of an internal 
 part are important and common conditions favoring the lodgement and 
 growth of micro-organisms. The classical experiment of Chauveau many 
 years ago demonstrated the ])redisposition of injured internal parts to 
 infection. He twisted off without ru])ture of the skin one of the testicles 
 of a young ram from its vascular connections (bistournage), and observed 
 that when he had injected shortly before the operation putrid fluid con- 
 taining micro-organisms directly into the circulation the injured testicle 
 became the seat of septic gangrene, while without such injection the tes- 
 ticle became neci'otic and was absorbed without becoming infected. 
 
 The experiments of Rosenbaeh, Orth and ^\ yssokowitch, Prudden, 
 and others have shown that bacteria do not readily become attached to 
 the smooth surface of the heart-valves, but that pyogenic cocci readily 
 adhere and set up septic endocarditis when the valves have been jjre- 
 viously torn by a sterile probe passed down the carotid artery. The 
 predisposition of injured joints and Ijones to the settlement of pyogenic 
 cocci and of tubercle bacilli is established both by clinical and exper- 
 imental observations. Pyogenic cocci often invade foci of disease caused 
 primarily by other organisms, as is exemplified in tuberculous and gonor- 
 rhoeal arthritis, actinomycosis, echinococcus cysts, amoebic abscesses of 
 the liver, etc. In some situations, particularly in the kidney and urinary 
 tract, the colon bacillus often settles in pre-existing foci of disease. The 
 ansemic and dry conditicin of the lung induced l)y pulmonary stenosis 
 favors the development of pulmonary tuberculosis. The hypersemic and 
 moist condition associated with mitral regurgitation is comjiaratively 
 unfavorable to such development, although by no means excluding this 
 disease. Pyogenic cocci not infrequently settle in the joint-lesions of 
 locomotor ataxia and cause suppuration. 
 
 The existence of a diseased or injured part within the body by no 
 means involves, of necessity, the localization therein of infectious jjro- 
 cesses which may be caused by pathogenic micro-organisms in the circu- 
 lation. The damaged part may be spared and an apparently healthy 
 part attacked. The endeavor to obtain experimentally in animals the 
 localization of suppuration in a fractured bone or other injured or dis- 
 eased part by pyogenic cocci injected into the circulation often fails, and 
 in the hands of Rinne failed so regularly that he opposes, although 
 without sufficient reason, the whole doctrine of locus minoris resistentise. 
 By a different line of expei'imentation Gottstein came to the same con- 
 clusion as Rinne. 
 
 We are undoubtedly able in some cases to explain the localization of 
 an infection by such apparent local predisposing causes as those which 
 have been mentioned, but in many, indeed in the majority of, instances 
 of localized infections of internal parts M'e are unable to give any satis- 
 
CONDITIONS FA VOEINO THE DEVELOPMENT OF INFECTIONS. 303 
 
 factory explanation of the localization. We know that many patho- 
 genic micro-organisms have a decided preference for certain organs and 
 tissues. Tlie injection of the staphylococcus aureus into the circulation 
 of rabbits does not lead to the formation of abscesses in all parts of the 
 body, althougli tlie cocci must be carried by the blood-current evcry- 
 Avhere. The abscesses are found most freijuently in the kidneys and 
 myocardium, sometimes in the muscles elsewhei-e, and in young ral)bits 
 often in the bone-marrow and joints. To say that the tissues in one 
 part of the body offer better conditions for the growth of the micro- 
 organisms than in other parts is only another way of saying that the 
 organisms jynxhice disease in one part and not in another. Such phrases 
 offer no real explanation unless the nature of these Ijetter conditions can 
 be defined. 
 
 Sometimes we can explain the localization by the manner of recep- 
 tion of the virus, the vascular relation of the part to infected areas, the 
 size and number of the capillaries, the velocity of the circulation, and 
 the readiness witli whicli foreign particles arc filtered out. We know 
 that fine particles are deposited from the lymphatic current in the lymph- 
 glands, and from the blood-circulation chiefly in the spleen, mari'ow of 
 the bones, liver, and lymph-glands. More often we are unable to give 
 any adequate exiilanation of the localization of an infectious process in 
 internal parts of the body. 
 
 General Predisposition. — Under this heading we shall consider 
 predisposing causes wiiich act more or less generally upon the whole 
 body. The effect of such causes may be to increase the susceptibility 
 of the whole body or only of pai'ticular pai'ts of the body to infection. 
 The factors here concerned are for the most part less tangible than the 
 local causes of ])redisposition. 
 
 Organs and parts of tlic body may inherit special vulnerability to 
 certain infections. Susce[)til)ility to certain infectious diseases may be 
 manifest in races and families. The negro race is less susceptible to 
 yellow fever than the white. Algerian sheep are in large measure insus- 
 ceptible to anthrax, which is very fatal to other sheep. Black rats are 
 more resistant than gray, and gray rats more resistant than white, to 
 anthrax (IMiillcr). 
 
 Age intlueiK'es predisposition, as regards some infectious diseases favor- 
 ably, as regards others unfavorably. Wounds in children, as a rule, 
 heal more (juickly, and with less danger of suppuration should pyogenic 
 bacteria enter, than in old jjcople. Certain infectious diseases are most 
 common in infancy, otliers in adolescence or in maturity or in old age. 
 Osteomyelitis is nuich more common in eiiildren than in adults. This 
 has been attributed to the predisposing influence of injuries to which 
 children are more liable. Doubtless injuries enter into the causation as 
 a predisposing factor, but it has been shown experimentally that there is 
 a special susceptibility of the bone-marrow of young growing animals to 
 infection by jn'ogenic cocci injected into the circulation (Rodet, Colzi, 
 Courmont and .Taboulay, Tvannclongue and Achard, Lexer). In labora- 
 tory experiments young animals, as a rule, are found to be more suscept- 
 ible to most pathogenic bacteria than old ones. There is a special insus- 
 ceptibility of sucklings during the first months of life to certain infectious 
 diseases, such as mumps, measles, scarlet fever. As will be explained 
 
304 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 later, the embryo possesses remarkable insusceptibility to some infec- 
 tions. 
 
 There is no evidence that tiiore is any difFerence in predisposition to 
 infection between males and females, except as regards infections directly 
 related to sexual functions. 
 
 General antemia, induced by loss of blood, has been shown experi- 
 mentally to increase susceptibility to infection with various micro-organ- 
 isms, including the pyogenic cocci, Friedliinder's bacillus, and the an- 
 thrax bacillus (Rodet, Gartner, Ghauveau, and others). Operative and 
 other wounds arc more likely to su]ij)urate when there has been much 
 hemorrhage than when the loss of lilood is slight. In general, imjiaired 
 vitality and nutrition of the body may predispose to certain infections, 
 including wound-infection. More or less plausible predisposing causes 
 operating in this May are bad and insufficient food, overwork, depressing 
 emotions, exposure to heat or cold, overcrowding, bad air, and, in general, 
 insanitary surroundings and all conditions of misery. 
 
 A large number of experiments ha\e been made upon animals to 
 determine the influence of various factors in increasing susceptibility to 
 infection. The results of these experiments are interesting and suggest- 
 ive in many ways. Some of them evidently correspond to conditions 
 observed in man, but it is to lie remembered that without additional evi- 
 dence we have no right to a])ply the results directly to human beings, or 
 to any other bacteria or other animals than those ex]ierimented with. 
 The more important results of these animal exjoeriments are the fol- 
 lowing : 
 
 Prolonged narcosis may imjjair resistance to some pathogenic micro- 
 organisms. Klein and Goxwell made frogs and rats highly susceptible 
 to anthrax by narcosis witli ether and chlorof )rm, and similar results 
 have been obtained with curare, alcohol, chloral, morphine, and upon 
 other animals and with other diseases. In speaking of the effect of 
 antesthetics in predisposing to wound-infection Eoswell Park ' says : 
 " There is good reason to think that chloroform and etlier administered 
 for some time may produce such changes in the blood and tissues that 
 vital processes of repair, cell-resistance, and chemotaxis may be so far 
 interfered Mith as to facilitate subsequent infection." 
 
 Feser, Hankin, and Miiller found that rats fed on bread are more 
 susceptible to anthrax than those fed on meat. Miiller observed the 
 same degree of insusceptibility when the extractive substances from meat 
 were fed. 
 
 Canalis and Morpurgo, and Sacchi rendered pigeons highly suscept- 
 ible to anthrax by hunger, and Bouchard noted the lowering or disap- 
 pearance of artificial immunity in rabbits from anthrax by starvation. 
 Prolonged abstinence from water was observed by Pernice and Alessi 
 to render relatively insusceptible animals more susceptible to anthrax. 
 Charrin and Roger found in fatiy-ue induced bv working a treadwheel 
 
 . . ... * 
 
 a factor which increased the .suscc])tibility of rats to anthrax and symp- 
 tomatic anthrax. 
 
 Various chemical substances introduced into the body may increase 
 susceptibility to certain infections. Gottstein and Mya and Sanarelli 
 have shown that poisons, such as chlorates, pyrogallic acid, pyridin, 
 
 ' Park, loc. cit. 
 
CONDITIONS FAVORING THE DEVELOPMENT OF INFECTIONS. 305 
 
 ■whifli destroy red blood-corpuscles, may render insusceptible animals 
 highly susceptible to certain pathogenic micro-organisms, although hse- 
 matolysis thus produced in the case of some animals and certain micro- 
 organisms did not weaken natural immunity. Bonome found tliat 
 luematolysis and hajmoglobinuria causeil by injection of water into the 
 circulation of rabbits lessened the bactericidal power of the blood as 
 regiirds the staphylococcus aureus. By feeding w'hite mice with phlor- 
 idzin, which j)roduces glycosuria, Leo i-endered these animals highly 
 susceptible to glanders, from whicli normally tliey are immune. 
 
 Tlie most important class of experiments showing the predisposing 
 influence of certain chemical substances upon infection are those in wliich 
 various ferments and bacterial products have been used. In considering 
 bacterial association (page 291) attention has already been called to the 
 fact that the chemical products of some bacteria favor the development 
 of infection with other bacteria. The susceptibility of an animal to 
 infection witli a specific micro-organism can often be increased by the 
 preliminary or simultaneous injection of the products of the organism. 
 It is not only the products of jjathogenic bacteria which may thus 
 increase susceptibility, but also those of certain saprophytic varieties, 
 particularly of the ordinary putrefactive bacillus proteus. Nor is it 
 necessary that tlie bacterial products in order to weaken resistance to 
 infection sliould cause distinct toxic symptoms. We do not possess any 
 satisfactory experimental evidence that the volatile and stinking products 
 of putrefactive decomposition augment susceptibility to infection. 
 
 Park, Bouchard, and others lay much emphasis upon auto-intoxication 
 from absorption of fermentative products in the stomach and intestine as 
 a [ircdisposiug cause of infection, ])articularly with the pyogenic cocci. 
 Neumann and Canon, in order to test the predisposing influence of 
 absorption of fermentative products from tlie intestine, ligated aseptically 
 the small intestine of rabbits near the ileo-csecal valve and injected sub- 
 cutaneously a streptococcus culture. The animals with intestinal obstruc- 
 tion, with few exceptions, died with streptococcus septic£emia, whereas 
 the streptococci injected into normal rabbits produced only local inflam- 
 mation at the point of injection. The ligation of the intestine close to 
 the stouiach was not followed by generalization of the stre]>tococcus 
 infection. So deadly an operation as ligation of the intestine introduces 
 so many other factors than the possible absorption of poisonous intestinal 
 products that these experiments caimot be considered to prove what they 
 were intended to demonstrate. Extirpation of the kidneys, with sub- 
 cutaneous injection of streptococci, also leads to general streptococcus 
 infection. 
 
 That many acute and chronic diseases lower the resistance of the body 
 to pathogenic micro-organisms has repeatedly been mentioned in the 
 course of this article, and is universally admitted. The influence of 
 certain infectious diseases in favoring the development of secondary and 
 mixed infections has been sufficiently i-efcrred to. 
 
 Diabetes mellitus is well known to increase in a marked degree the 
 susceptibility to infection, particularly with pyogenic cocci and the 
 tubercle bacillus. Among other diseases characterized by lessened resist- 
 ance to infection may be especially mentioned acute and chronic Bright's 
 disease, arterio-sclerosis, cardiac disease, alcoholism, syphilis, rickets, 
 
 Vol. 1—20 
 
306 GENERAL BACTERIOLOGY OF SURGICAL IXFECTIONS. 
 
 sciu'vv, leucocythsemia, Hodgkin's disease. All (if these diseases are 
 prone to lessen resistance to pyogenic cocci, and especially to the strep- 
 tococcus pyogenes. A localized streptococcus infection is much more 
 likely to become generalized when it develops in persons affected \\ith 
 any of these diseases than when it appears in a previously healthy 
 person. Here also attention may be called to the terminal strepto- 
 coccus septicaemias occurring in Bright's disease, heart disease, and 
 various chronic diseases. They may not be distinguished by character- 
 istic symptoms during life, and are to be ranked among such events as 
 terminal pneumonia and dysentery. The portal of entry is most fre- 
 quently the lungs, skin, and intestine. 
 
 Of 218 autopsies of chronic Bright's disease, general arterio-sclerosis, 
 and chronic heart disease at the Johns Hopkins Hospital, in 154 there 
 were definite infectious. Of .32 cases of local streptococcus infection, 
 excluding perforative peritonitis, tabulated from the autopsy records of 
 the hospital by the writer, chronic nephritis, general arterio-sclerosis, or 
 chronic heart disease was present in 18. In 11 out of 14 cases of general 
 streptococcus infection one or more of these diseases was present. We 
 have observed several cases of general streptococcus infection in Icuco- 
 cytha?mia and Hodgkin's disease. 
 
 In a large number of cases we are able to find no explanation of the 
 existence of individual predisposition. 
 
 In conceding to predisposition its full importance as a factor in the 
 etiology of surgical infections, we are not to forget that pyogenic cocci 
 occur of such virulence that they can readily overcome the natural resist- 
 ance of the most insusceptible human being. 
 
 FcETAL Infection. 
 
 The embr}-o may be infected by transmission of the specific micro- 
 organism with the ovum or semen. The only example of this germinal 
 infection in which the conditions are thoroughly understood is jiebrine 
 of silkworms caused by sporozoa, which have been studied in all stages 
 of transit through the ovum and si)ermatozoa to the infected offspring. 
 
 The only infectious disease of human beings which has been proven 
 to be capable of conveyance to the offspring through the ovum or 
 spermatozoa is syphilis. Congenital syphilis is usually due to germinal 
 infection, and it'may come from either a syphilitic father or a syphilitic 
 mother. 
 
 Intra-uterine or placental infection of the foetus may occur in many 
 infectious diseases. Although the intact placenta is a perfect jihysiologi- 
 cal filter, which does not permit the passage of inanimate particles from 
 the blood of the mother to that of the foetus, nevertheless pathogenic 
 micro-organisms are capable of breaking through this barrier. The 
 conditions Avhich permit the passage of micro-organisms from mother to 
 foetus can sometimes be demonstrated in the form of definite lesions of 
 the placenta, either pre-existing or caused by the specific micro-organ- 
 isms or their products. Circulatory disturbances, hemorrhages, defects 
 in the epithelium covering the chorion villi, areas of necrosis, and tuber- 
 cles in the placenta have been observed with more or less frequency in 
 cases of fa?tal infection, but often no placental lesion could be detected. 
 
F(ETAL INFECTION. 307 
 
 In the later stages of pregnancy and during parturition the anatomical 
 and physiological conditions would seem to be more favorable for the 
 escape of micro-organisms from the mother's blood to the foetus than 
 in the early stages. 
 
 Some micro-organisms are much better adapted than others to pass 
 through the placenta from mother to fcetus. In animals the bacilli of 
 chicken cholera and of symptomatic anthrax and the pyogenic cocci 
 frequently make this passage. Although there has been much contro- 
 versy as to anthrax, it is now settled that anthrax bacilli often pass from 
 mother to fa^tus, but generally in such small numbers and without sub- 
 secpient multijilication in the fcetus as to require special methods and 
 careful search for their detection. 
 
 In human beings infection of the fwtus in utero has been observed 
 in small-pox, measles, scarlet fever, relapsing fever, syphilis, tuberculosis, 
 croupous pneumonia, typhoid fever, anthrax, and affections caused by 
 pyogenic cocci. In general, such infection is exceptional, but in some 
 diseases it is comparatively common. Surgical importance attaches to 
 the fact that both experiments on animals and clinical observations show 
 that the pyogenic cocci are frequently transmitted to the fcetus from an 
 infected mother. 
 
 Developed tuberculosis in the new-born infant is extremely rare, 
 although it has been observed, but this rarity does not prove that tubercle 
 bacilli may not often be transmitted from mother to foetus. It takes 
 time and susceptibility for tubercle bacilli to produce recognizable 
 lesions. Tubercle bacilli without developed tuberculosis have been 
 repeatedly found in the fcetus of tuberculous mothers. Birch-Hirschfcld 
 detected in a seven-months' fcetus, removed by Cfesarean section from a 
 mother with acute miliary tuberculosis, tubercle bacilli both by micro- 
 scopical examination and by inoculation of guinea-pigs. There were no 
 tuberculous lesions in the fcetus. The failure to find tubercle bacilli in 
 a large number of similar cases can hardly be regarded as proof of their 
 absence, when one considers the difficulty of demonstrating tubercle 
 bacilli in small number irregularly distributed through a large mass 
 without any lesion to indicate where they are most likely to be found. 
 Gartner finds that the transmission of tubercle bacilli from mother to 
 fcetus is common in the experimental tuberculosis of mice, rabbits, and 
 canary birds. 
 
 There is reason to believe that the embryo offers great resistance to 
 the growth of tubercle bacilli. Maffucci has found that tubercle bacilli 
 inoculated into hens' eggs before incubation remained quiescent during 
 the period of embryonic development, but caused the death of most of 
 the chicks from tuberculosis in three weeks to four and a half months 
 after birth. We have evidence tnat in human beings living and virulent 
 tubercle bacilli may remain latent in the body a long time. As already 
 mentioned, the chances of penetration of bacilli into the fcetus appear 
 to be more favorable during the later period of pregnancy than earlier. 
 The frequency of tuberculosis increases very rapidly with each succeeding 
 ■week after birth, until during the second half of the first year and during 
 the second year of life fotal tul)erculosis is very common, and then 
 becomes less frc-quent until after jniberty. Infantile tuberculosis is far 
 more commonly situated in internal organs, such as the lymphatic glands, 
 
308 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 meninges, bones, and joints, without tiil)ercnions lesion on ;niv exposed 
 surface of the body, tlian is tulxrcuiusis (if adults. 
 
 Tiiese are the arguments wiiich are urged Ijy IJauingarten and others 
 with great force in favor of frequent bacillar heritage. The majority of 
 autiiorities, however, are rehictant to abandon the older views, and the 
 final settlement of this important question involves great difficulties not 
 likely to be soon overcome. 
 
 The portal of entry to the fcetus is the umbilical vein, and therefore 
 micro-ortjanisras wtiuld be carried first to the liver and the ritjht side of 
 the heart. Corresponding to this, we find that lesions of the liver and 
 of the right side of the heart are particularly common in congenital 
 infections. Pyogenic cocci, as already mentioned, break through the 
 placental barrier with comparative ease, and these are the bacteria most 
 often associated with endocarditis, which is more common on the right 
 side of the heart in the foetus and new-born than in the adult. 
 
 Although the foetus may react to pathogenic micro-organisms in the 
 same way as the mother, or even more severely, it possesses a remarkable 
 insusceptibility to some infections, as has been proven experimentally 
 and clinically. There are several instances in which the specific bacteria 
 of cn)upous pneumonia and of typhoid fever have been found in the 
 stillborn embryos of mothers affected with these diseases, but there is no 
 satisfactory recorded instance of an infant born with the lesions of 
 typhoid fever or those of lobar pneumonia caused by the pneumococcus. 
 Some bacteria which cause localized infections in the mother may pro- 
 duce in the toetus general septicemia without localizations. 
 
 General Considerations concerning Pyogenic Bacteria. 
 
 The pyogenic bacteria play such a predominant role in surgical in- 
 fections, and their pathogenic (;haracters jjresent so many jieculiarities, 
 that it is appropriate to consider here the general relations of pyogenic 
 bacteria to surgical infections, although the consideration of the special 
 diseases caused by these bacteria does not fall within the scope of this 
 article. 
 
 There are no specific bacteria of suppuration. On the one hand the 
 number of bacteria which under special conditions are capable of causing 
 suppurative inflannnation is large, and is not limited to any particular 
 group, and on the other hand the bacteria which are most fre(|Uently the 
 cause of suppuration are capable of causing other forms of infiammation 
 and of producing infection without inflammation. 
 
 Certain staphylococci and streptococci, however, are found in jnirulent 
 inflammations in human beings so much more frequently than other 
 micro-organisms that they are the ])yogenic bacteria par e.i-ccllence, and 
 are the ones generally understood when the expression " micro-organisms 
 of pus" or " pvogenic bacteria" is used without any qualification. These 
 staphylococci and streptococci are endowed with pus-producing properties 
 in larger measure than are other bacteria, and of all their pathogenic 
 effects the production of suppurative inflammation is the most promi- 
 nent. 
 
 The most connnon pyogenic cocci are the staphylococcus pyogenes 
 aureus, the streptococcus pyogenes, and the staphylococcus pyogenes 
 
CONSWERATIOXS CONCERNING PYOGENIC BACTERIA. 309 
 
 albus, including the staphylococcus epiderniidis albus. In the second 
 rank, as regards both fretiuencv and virulence, arc tlic stapliylococcus 
 pyogenes citreus, the staphylococcus cereus allnis, and the staphylococcus 
 cereus flavus. More common and far more important than the cocci of 
 the latter group are the micrococcus lanceolatus and the micrococcus 
 gonorrhoese. Although these are not always ranked among the pyogenic 
 cocci in the restricted sense, they are genuine pus-producers. The 
 micrococcus tetragenus septicus is rarely the sole cause of suppuration. 
 The status of the micrococcus pyogenes tenuis is uncertain. It is per- 
 haps identical with the micrococcus lanceolatus. 
 
 There is a long list of bacilli wdiich have been shown with greater or 
 less certainty to be capable of producing suppurative inflammations in 
 man. The principal ones arc bacillus pyogenes fietidus, bacillus coli 
 communis, bacillus typhi abduniinalis, bacillus tuberculosis, bacillus 
 pyocyaneus, bacillus pneumoni;e of Friedlander, bacillus proteus. Acti- 
 nomyces belongs to the class of schizomycetes and is a pus-producer. 
 
 Several anaerobic bacilli have been found both in pure culture and 
 associated Avith other bacteria in closed abscesses. Of these may be 
 especially mentioned bacillus ])hlcgmones emphysematosa; of E. Fraeidvcl, 
 which is j)robably identical witli bacillus aerogenes capsulatus previously 
 described by Welch and Xuttall, and which occurs in some phlegmons 
 containing gas. 
 
 The list of demonstrated pus-producing bacteria is by no means ex- 
 hausted by those enumerated. In the experience of the writer bacilli 
 are more common causes of spontaneous abscesses in laboratory animals 
 than cocci. A very large number of bacteria are capable of jiroducing 
 experimental abscesses in animals. 
 
 It is fair to say that not all of the bacteria mentioned above are 
 recognized as pyogenic for man by all authorities, and particularly that 
 some do not so regard the typhoid bacillus and the tubercle bacillus ; 
 but in the opinion of the writer their pyogenic capacity has been demon- 
 strated. 
 
 We have very little definite information as to the underlying condi- 
 tions which control the pyogenic manifestations of such bacteria as the 
 typhoid bacillus, the tubercle bacillus, and others which do not ordi- 
 narily cause purulent inflammations. These conditions seem to pertain 
 ]>artly to the degree of virulence of the micro-organism and jiartly to the 
 local susceptibility of the tissues invaded and the general susceptibility 
 of the iutlividual. We find in experiments upon animals that Ijactcria 
 of weakened virulence in susceptible animals, or those of 'usual virulence 
 in insusceptible animals, are prone to ])roduce localized abscesses. In 
 an animal which has been rendered artificially immune from septicsemia 
 caused by certain pathogenic bai teria immunity is not usually produced 
 from the develojimcnt of local abscesses by tiie specific organism, in case 
 this is capable of forming abscesses. 
 
 Statistical statements as to the relative frcfiuency with which the dif- 
 ferent pyogenic cocci occur in general in su])purative and septic aifections 
 vary a(u;ording to the class of cases which preponderate. The staphylo- 
 coccus aureus is by far the most conmion micro-organism in furuncles and 
 osteomyelitis, and is common in circumscribed subcutaneous abscesses. 
 The streptococcus pyogenes is by far the most ci>mraon organism in 
 
310 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 spreading plegmonous cellulitis, inflammations of serous membranes, 
 puerperal infeetions, and sojiticremia. It is the cause of erysijiclas in 
 practically all cases of this disease. It is a frequent cause of all kinds 
 of inflammations of the throat and of broncho-pneumonia. The staphylo- 
 coccus albus is often associated with the other p^-ogenic cocci, espe- 
 cially in inflammations involving the skin. It occurs most frequently 
 in the same general class of cases as the staphylococcus aureus. Al- 
 tliough capable of causing grave infections, the characters of the inflam- 
 mations in which the white staphylococcus is found alone are usually 
 mild. Two or more species of pyogenic cocci are often combined. 
 
 The relative frequency of occurrence of the pyogenic cocci seems to 
 vary somewhat according to the locality. Levy finds in Strassburg the 
 staphylococcus aibus more frequently than the staphylococcus aureus in 
 all suppurative aifections except furuncles, and he was unable to confirm 
 the usual statement that the albus is less virulent than the aureus. 
 
 The following table gives the results of the bacteriological examina- 
 tion of 135 ambulatory and ojierative surgical cases by Dowd ' in the 
 Vanderbilt Clinic and Cancer Hospital in New York. It affords a good 
 idea of the relative frequency of the different pyogenic cocci in the chiss 
 of cases which most frequently come to the attention of the surgeon : 
 
 Streptococcus pyogenes alone 
 
 Streptococcus pyogenes predominant 
 
 Streptococcus pyogenes relatively few 
 
 Staphylococcus pyogenes aureus alone 
 
 Staphylococcus pyogenes aureus predominant .... 
 
 Staphylococcus pyogenes aureus relatively lew .... 
 
 Staphylococcus pyogenes or epidermidis albus alone . 
 
 Staphylococcus pyogenes or epidermidis albus pre- 
 dominant 
 
 Staphylococcus pyogenes or epidermidis albus rela- 
 tively few 
 
 Staphylococcus cereus albus 
 
 Staphylococcus citreus 
 
 Bacillus pyocyaneus 
 
 Bacillus coli communis 
 
 Very few growths on agar 
 
 No growths on agar 
 
 Few undetermined colonies 
 
 9 
 23 
 
 3 
 11 
 
 S 
 
 13 
 1 
 
 10 
 3 
 1 
 
 12 
 
 Ha 
 
 
 
 6 
 
 1 
 
 1 
 
 3 
 3 
 3 
 11 
 6 
 
 The cases from which no growth occurred were tuberculous abscesses 
 and buboes. 8 of the 51 cases of cellulitis showed a persistent tendency 
 to spreading inflammation with undermining of the ti-ssues. In all of 
 these 8 cases streptococci were foinid. In 2 cases of pysemia staphy- 
 lococcus aureus and streptococci were present in the original woiuid, but 
 onl}' streptococci in the metastases. 
 
 It is interesting to contrast with these results of the examination 
 
 ' Charles X. Dowd, "Some Considerations on Different Types of Exudative Inflam- 
 mation," Medical Recurd, Xew York, Sept. S, 1894. 
 
CONSIDERATIONS CONCERNING PYOGENIC BACTERIA. 311 
 
 of ambulatory and operative surgical cases the results of the bacterio- 
 l(igical examination of post-mortem cases. In about 500 autopsies at 
 the Johns Hopkins Hospitiil there were found in 185 cases the follow- 
 ing bacteria : 
 
 Number of 
 cases. 
 
 Bacillus coli communis i^o 
 
 Streptococcus pyogenes 62 
 
 Staphylococcus pyogenes aureus 43 
 
 Micrococcus lanceolatus 29 
 
 Staphylococcus pyogenes albus _ 14 
 
 Bacillus typhosus, as the cause of special complications 7 
 
 Bacillus pyocyaneus S 
 
 Proteus 4 
 
 Micrococcus tetragenus 2 
 
 Staphylococcus pyogenes citreus 1 
 
 Pneumobacillus of Friedliinder 1 
 
 Bacillus pyogenes fietidus 3 
 
 Bacillus aerogenes capsulatus .... 3 
 
 Undetermhied bacteria 35 
 
 The streptococcus cases do not include those in which streptococci 
 were found only in phthisical cavities or adjacent lung. The cases with 
 micrococcus lanceolatus are tliose in Avhich this organism was found 
 without pneumonia or as the cause of some e.xtra-thoracic complicatioia 
 of pneumonia. No cases are included in which the bacteria were found 
 simply on e.xpo.sed surfaces of the body. Among the undetermined bac- 
 teria are several interesting pathogenic forms which could not be posi- 
 tively identified with species already described. Mention has already 
 been made of the frequent invasion of the colon bacillus without any 
 pathogen ic manifestations. 
 
 The preceding table is inserted not with the intention of analyzing 
 in this article the cases ' composing it, but to show the great differences 
 l)ctween the results of the bacteriological study of living surgical cases 
 and those of the antop.sy material of a general hospital, and especially 
 to emphasize the preponderance of streptococcus cases over staphylo- 
 coccus and all other pyogenic cases in such material. 
 
 All of the affections caused by one species of the pyogenic cocci may 
 l)e caused bv anv of the others. For example, the staphylococcus aureus 
 may produce spreading phlegmons, infiaTumations of serous membranes, 
 puerperal infections, general scptica^niia as well as the streptococcus pyo- 
 genes, and the streptococcus pyogenes may cause circumscribed abscesses 
 and osteomyelitis as well as the yellow or white staphylococcus. Jordan 
 claims that the staphyh^coccus aureus may cause erysi jielas, but Petruschky 
 does not regard his observations on this point as conclusive. 
 
 J^^U'thermore, these pyogenic staphylococt'i and streptococci may cause 
 all kinds of iuHammation besides tiie suppurative. Tiiey may, and often 
 do, cause serous, sero-fibrinous, and fibrinous inflammations of serous 
 membranes. The streptococcus pyogenes may cause catarrhal and 
 fibrinous inflammations of mucous membranes. Pyogenic cocci may be 
 the cause of simple inflanniiatory (edema or serous infiltration of the 
 tissues. They are sometimes found in cutaneous vesicles and blebs 
 containing clear serum. They may be the sole organisms present when 
 
 ' The analysis of these cases was the sul'ject of the Middleton Goldsmith lecture by 
 the writer in .Vpril, 1S94 {Tmiui. N. Y. I'athulwjical Society for 1894). 
 
312 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 the inflammatory exudate is heinorrhajjic. Tlicy may produce exten- 
 sive nocrosis of tlic tissues witli scarcely any infiammatory exudate. We 
 find tlie same sta])hyl()C(K'ci and streptococci in tliose rarer forms of 
 osteomyelitis which do not suppurate as in the ordinary sup]>nrative 
 form. They are the usual cause of periostitis and ostitis alhuminosa, 
 in A\hich the exudate is serous. A serous or sero-fibrinous inflannua- 
 tion caused by pyogenic cocci may be transformed into a purulent one 
 without the appearance of any new species of micro-organism. 
 
 We cannot at present give any satisfact(jry explanation of these 
 diverse effects produced by one and the same bacterial sjiecies. We 
 seek to exjtlain these differences usually by referring to such factors as 
 the degree of virulence of the organism, the manner of its invasion, the 
 site of infection, and the condition of the patient. Variations in viru- 
 lence and the general condition of the jiatieut cannot be the sole explan- 
 ation, for these pyogenic cocci may in tiie same individual cause a sup- 
 ])urative inflanunation in one part of the bodv and a serous or a 
 sero-fibrinous inflammation in another part, without any bacteriological 
 difference. We have observed this in some instances of multiple sero- 
 sitis, and Schrank has reported a case in which periostitis ali)urainosa 
 was associated with suppurative osteomyelitis in the same tibia. The 
 same micro-organisms, staphylococci and streptococci, were jiresent in 
 the exudate in both situations. They had produced pus in the bone- 
 marrow and a simple serous exudate between the periosteum and bone. 
 The deciding factor must have been in the tissues, and not in the micro- 
 organisms or the general predisposition of the individual, and this same 
 factor, the specific character of the tissues, little as we may comprehend 
 its nature, is doubtless the explanation of their varying reactions to the 
 same infectious agents in many other cases — a point which has been 
 justly emphasized by Kurt Jliillcr. 
 
 It might be inferred from what has been said as to the interchange- 
 able effects produced by the different pyogenic cocci that no diagnostic 
 or prognostic imjwrtance is to be attached to the determination of the 
 particular species of pyogenic coccus present. If the streptococcus can 
 do everything which the sta]>hylococci can do, if each s])ecies can pro- 
 duce mild as well as grave infections, it is argued by some that it is of 
 no practical importance to determine what particular micro-organism is 
 present in a given case. 
 
 It is more important for the surgeon to understand the general rela- 
 tions of bacteria to traumatic and other jn'ogenie infections than to become 
 familiar with the special characters of the individual micro-organisms 
 which cause these infections, and therefore the principal part of this arti- 
 cle has been devoted to a consideration of these general relations. But 
 apart from the interest which pertains to the study of all asjiects of 
 disease, even those without evident practical bearings, it would be a 
 mistake to suppose that the bacteriological examination of infectious 
 processes caused by pyogenic cocci is devoid of value for diagnosis, prog- 
 nosis, or treatment. 
 
 There are certain general rules as to the characters of the infections 
 most likely to be produced by the different species of pyogenic cocci, and 
 as to the probability of finding a given species in a certain kind of infec- 
 tion. It would lead too far to attempt to consider here all the differ- 
 
COySIDEEATIOA^S CONCEBNmO PYOGENIC BACTERIA. 313 
 
 ent surgical infections with reference to these points. A few illustrative 
 examples may be cited. 
 
 The white staphylococcus causes severe local and general infections so 
 infreiiueutly, at least in this country so far as we are informed, that the 
 recognition of its exclusive presence in an inflamed external part of the 
 body justifies the probable conclusion that the inflammation will pursue 
 a mild course and bo readily amenable to treatment. 
 
 The streptococcus pyogenes may possess all degrees of virulence. 
 Although a streptococcus coming from a case of erysipelas or puerperal 
 fever may not be distinguisiicd botanically from a streptococcus coming 
 from a liealthy mucous membrane or caught from the air, it is a very 
 different thing in its possibilities for infection. The streptococcus py- 
 ogenes, for niore frequently than other bacteria, causes s.jjreading phleg- 
 monous inflammations and grave forms of septicemia. The importance 
 and the frc(picncy of streptococcus septicaemias accompanying tuberculosis, 
 diphtheria, typhoid fever, scarlet fever, the jiuerperal state, erysipelas, 
 cellulitis, and traumatic infections are probably not even yet sufficiently 
 appreciated by physicians and surgeons, notwithstanding the rapid exten- 
 sion of our knowledge of this subject in recent years. Septicemias pro- 
 duced bv other pyogenic cocci under these circumstances, although they 
 may be of equal "severity and similar character, are in a small minority. 
 
 In view of the fearful pathogenic possil)ilities with which streptococci 
 may be endowed, a surgeon cannot regard the presence of these micro- 
 organisms in a wound or inflamed part with as little concern as he may 
 the white or even the yellow staphylococcus, although it may be that the 
 particular streptococcus in question is of relatively slight virulence. If 
 his patient have chronic Bright's disease or general arterio-sclerosis or 
 chronic cardiac insufficiency, tiie anxiety of the surgeon will be increased. 
 Intlanunations of external parts produced by staphylococci are in general 
 more amenable to treatment and rccpiire less vigorous interference than 
 those caused by streptococci. Streptococcus cases are in general more 
 dangerous to other surgical patients in their proximity than staphylo- 
 coccus cases, and are therefore more likely to require isolation. 
 
 The gravest staphylococcus infection with which the surgeon has 
 commonly to deal is acute osteomyelitis. In this particular field the 
 staphylococcus aureus takes rank over the streptococcus, although there 
 is no specific micro-organism of osteomyelitis any more than there is of 
 suppuration in general. Osteomyelitis may be caused by the strejito- 
 ooccus pyogenes and other jnogenic bacteria, but, although these other 
 bacteria not infrotpiently cause periostitis, they are very rarely the cause 
 of tnicomplicated suppurative osteomyelitis. 
 
 The especial conditions under which, in cases of infection caused by 
 pyogenic cocci, the cocci apjiear in the blood in sufficient number to be 
 demonstrable by our methods of examination are far from clear. We 
 find tiiem far more frequently in the blood at autopsies, even very fresh 
 ones, than we are able to do during life. Tiie ])yogenic cocci, like most 
 l)athogenic bacteria, only excejitiniially are able to multi]dy in the cir- 
 culating blood of human beings. The greater frc(picncy of their presence 
 in demonstrable number at autopsy may be due in part to their multi- 
 jjlication after death, but this cannot be the sole explanation, as the cocci 
 are found in autopsies made very early after death more frequently than 
 
814 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 they are found diirinii' lifV. T\w cxphiiiation is probably that during the 
 last liours of life they often tind suitable conditions for their multiplica- 
 tion in the blood. A similar phenomenon can often be observed in 
 inoculated animals. All bacteria, includiufi; those of the typical septi- 
 ctemias of animals, such as the bacillus of rabbit sejitica'mia, of anthrax, 
 the micrococcus lanceolatus, injected into the blood (piickly disupjicar 
 from the circulation. The pathogenic forms grow outsiile of the circula- 
 ting blood, and often do not make their rca])pearancc in any considerable 
 number in the circulation until shortly before death and after the mani- 
 festation of grave constitutional syni|)toms. This is true of pneumo- 
 coccus septiciemia, anthrax, and other typical septicicniias of animals. 
 
 In examining the blood of living patients for pyogenic cocci a few 
 drops of blood do not generally suffice, as the cocci are rarely so numer- 
 ous as to be detected thus. The blood is obtained by wet cups by 
 Petruschky, who has developed a special technique for these examina- 
 tions. To the demonstrations of the white staphylococcus in blood with- 
 drawn by cutting or pricking the skin, which have been made by a 
 number of investigators, the writer attaches no diagnostic significance, 
 for reasons which have been stated. The detection <jf streptococci is 
 significant. Petruschky and Canon found streptococci in the blood 
 during life in a number of cases of pytemia, septicEemia, and localized 
 infection. They were more likely to be present in severe than in the 
 milder cases, but they were occasionally found in cases which recovered, 
 and even in very mild infections. Cocci arc found in the blood in cases 
 both with and without metastases. 
 
 Doubtless jjyogonic cocci often enter the circulation in small number 
 from a localized focus of inflammation caused by them. They are often 
 disposed of without doing any harm by the bactericidal cells and fluids. 
 Their fate, however, is not always one which is so advantageous to the 
 patient. They may lodge and grow in internal parts, causing inflam- 
 mations of serous membranes, ulcerative endocarditis, and other meta- 
 static inflammations. They may survive, and even multipl)-, in the blood, 
 with or without the production of metastases. These general infections, 
 particularly those with the streptococcus pyogenes, are far more likely to 
 occur with primary localized infections, such as erysipelas, infected 
 wounds, abscesses, in persons with chronic Bright's disease, and other 
 conditions which we have repeatedly specified as predisposing causes, 
 than in previously healthy persons. 
 
 The usage has grown up among bacteriologists of limiting the name 
 " septicajmia " to infections characterized by a large multiplication of 
 bacteria in the blood during life. Septicfemias in this bacteriological 
 sense occur in man, l)ut they are not common. Far more common are 
 cases of human se]5ti«emia in which a moderate or small number of 
 pyogenic cocci are found in the blood, but there is no definite relation 
 between the number of bacteria in the blood and the character and 
 gravity of the symptoms. We cannot explain these symptoms nor 
 some of the lesions without assuming that they are referable to the 
 action of toxic products of the liacteria, and that these toxic products 
 may be absorbed from localized foci of inflanmiation. 
 
 There are no specific bacteria of either septicaemia or pyemia. The 
 same bacteria are found in both diseases. 
 
BACTERIA OF SURGICAL ISFECTIO^^S. 315 
 
 Bacteria of Surgical Infections. 
 
 The leading characters, especially tlie pathogenic, of the bacteria 
 concerned in surgical infcetidns will here be brietly described. Cer- 
 tain rare and unnamed and insufficiently itlentified bacteria wliich have 
 been described as occurring in surgical diseases will not be considered. 
 
 Sfaphi^lococcus Pyogenes Aureim (Plate II., Fig. 5). — Observed by 
 Ogston (1881), first accurately described V)y Becker (1883), Ilosenbach 
 (1884), and Passet (1885). Appears in the form of spherical cells, 
 averaging 0.8 jul in diameter, which by ditferential staining often show 
 a diplococeus or biscuit shape. Occurs usually in clumps, also in jiairs 
 and short chains. May be found both within and outside of pus-cells 
 in abscesses. Stains readily with aniline dyes, including Gram's stain. 
 Forms an orange-vellow pigment, but only in the presence of free 
 oxygen. Grows at ordinary temperatures, most rapidly at body temper- 
 ature. Grows on all culture media both with and without free oxygen. 
 Licpiefies gelatin rapidly. Coagulates milk ; clouds bouillon. May sur- 
 vive in dried pus for one hundred days ; is killed in a much shorter 
 time by desiccation when contained in thin media. In the moist con- 
 dition is killed in ten minutes by a temperature of 58° C. (Sternberg). 
 When dried a higher temperature — 1)0-100° C. — is required to kill it in 
 a short time. In bouillon cultures all of the cocci may be killed in five 
 minutes by sublimate, 1 : 1000, but frequently some survive longer, even 
 uj) to thirty minutes (Abbott). Killed in a few seconds by 3 per cent, car- 
 bolic-acid solution. Virulence variable. Pathogenic properties for animals 
 and man have already been described. (See pp. 280, 289, 303, and the pre- 
 ceding section, " General Considerations concerning Pyogenic Bacteria."') 
 
 Staplii/locoix-us Pyogcnett Albua. — Cultivated by Kosenbach from pus 
 in 1884. Differs from the aureus only by absence of pigment. As the 
 pigment may form in aureus cultures very slowly, the cultures should 
 be watched for several days, up to two weeks, before making a diagnosis 
 of the albus. Pathogenic effects similar to those of the aureus, but 
 usually the virulence of the albus is less than that of the aureus. 
 
 Sfapliy/ocoeeuii Epiderinidi'i Albus (M\^lch). — Is probably only a vari- 
 ety of the staphylococcus pyogenes alijus. Usually grows somewhat more 
 slowly ; liquefies gelatin and coagulates milk less rapidly. Is of little 
 virulence under ordinary conditions. Is a regular inhabitant of the epi- 
 dermis, lying deeper than can be reached by disinfection of the surface of 
 the skin. Its behavior has already been described (pj>. 251, 270, and 272). 
 
 Sfnplii/locoecKs Pyogenes Citreiis.—( "ultivatcd liy Passet from al:)sccsses 
 (1885). Differs from the aureus and albus only by forming lemon-yellow 
 pigment in the presence of free oxygen. Pathogenic effects similar to 
 tiiose of the aureus and albus ; often of less virulence than the aureus, 
 but may be highly virulent. Is found less frequently than the preceding 
 sta])hyl(ic()cci. 
 
 Staphylococci forming pigments intermediate in tint between the 
 aureus and citreus occur, also cocci witli the production of only a very 
 faint yellowish color, perhaps produced only after prolonged growth. 
 This has led Lubinski and others to the view that these various pyo- 
 genic staphylococci are only physiological varieties of one and the same 
 species. 
 
316 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 iSfaplii/lococcns Cereus Alhiix. — Cultivated from two abscesses by 
 Passet (18<sr)). Pyofrenic i>o\voi- not considered to be demonstrated by 
 Passet and Fliigge. Lew, liowever, found tliis coccus in pure culture 
 in abscesses and other inflammations, and ])roduct'd su])])urati(in bv inoc- 
 ulating it into the rabl)it's eye. Kesenibles the aureus and albiis, but it 
 does not liquefy gelatin and it forms no ])ignient. 
 
 The staphylococcus cereus favus was isolated by Passet in ])ure culture 
 from a chronic suppurative periostitis, but it does not appear to have 
 been found again in abscesses. Passet was unaljle to cau.se abscess by 
 inocadating it into animals. Diflfers from the staphylococcus cereus albus 
 only by tlie formation of lemon-yellow pigment. 
 
 Htreplococcas Pyogenes ; tStreptococras Erysipddtos (Plate I., Fig. 3). 
 — Observed by Ogston in pus (1881); cultivated by Fehleisen from 
 erysipelas (1883), by Rosenbach from pus (1884). The streptococcus 
 of erysipelas does not ditfer in nu)rphology or cultural characters from 
 the streptococcus jn'ogenes. The same pathogenic effects may be pro- 
 duced by each in animals and in man, so that the weight of evidence 
 is in favor of the identity of the streptococcus ervsipelatos with the 
 streptococcus pyogenes, although opinions are still di\'ided on this 
 question. 
 
 The streptococcus pyogenes grows in chains of variable length. The 
 individual cocci vary in size, .sometimes in the .same chain. They aver- 
 age somewliat larger than the staphylococci. In pus they occur in chains, 
 also in pairs. Stain readily with aniline dyes and by Gram's method. 
 Grow Avith or without free oxygen in all ordinary culture media. Most 
 stre])tococci grow at room temperature, but more slowly than at body tem- 
 perature. The streptococcus pyogenes does not liquefy gelatin, or does so 
 .slightly in some cases. Forms small, gray, granular colonies on gelatin 
 and agar. Grows invisibly on potato, but may grow visibly. May or may 
 not coagulate milk and cloud bouillon. Some cultures are short-lived, 
 others may live several months. The streptococcus jiyogenes may survive 
 in dried pus for fourteen to thirty-six days. Is killed in ten miiuites by 
 €X])osure to 54° C. (Sternberg). Is killed in eight seconds by 3 per cent, 
 carbolic-acid solution. Inoculated cutaneouslv into the rabliit's ear, viru- 
 lent streptococci usually produce erysipelas, from which the animal recov- 
 ers. The virulence is extremely varialde, and is best tested Ijy inoculating 
 mice into the peritoneum, either with the first generation of a pure culture 
 or directly with the blood or exudates containing the streptococci. Very 
 virulent streptococci in small doses produce rapidly fatal septicjemia in 
 mice ; less virulent ones, a more or less ])roti'acted sciUicicmia or local 
 inflammations ; and the mou.se may die after a longer or shorter period 
 from the eilcets of the inoculation without the presence of stre])tococci 
 at the autopsy. Streptococci are often devoid of virulence for mice. 
 The virulence for mice does not correspond definitely to the character 
 and severity of the streptococcus infection in the patient from whom 
 the streptococci were obtained, although it is a general rule, with many 
 exceptions, that the most virulent streptococci come from grave strepto- 
 coccus infections in man. The pathogenic properties of streptococci for 
 man have already been mentioned so far as they relate to surgical infec- 
 tions. (See pp. 258, 25fl, 292, and the preceding section, " General Con- 
 siderations concerning Pj-ogenic Bacteria.") 
 
BACTERIA OF SURGICAL IXFECTIOXS. 317 
 
 Streptocdcei dhtaiiied from ditferent sources, and even those culti- 
 vated from ditferent cases of tiie siuiie disease, vary greatly in morphology, 
 cultural characters, and pathogenic properties. So far as virulence is 
 concerned, this property alone cannot serve as a basis of distinction into 
 species, as this is the most variable of all properties of pathogenic micro- 
 organisms, and in the case of no micro-organism more vurial)le than 
 with the streptococcus jiyogenes. The virulence of streptococci a])j)ears 
 to vary not only in degree, but in kind, so that a streptococcus endowed 
 with the projjerty of producing one kind of infection — as, for example, 
 er^-sipelas — may not be qualified under ordinary conditions to produce 
 another kind of infection — as, for example, an abscess. But avc observe 
 such ready transformations in these varying degrees and qualities of 
 virulence, and such modifications of the pathogenic eftects by other cir- 
 cumstances than the virulence, such as the manner and site of invasion 
 and the susceptibility of the individual, that it seems hopeless to attempt 
 any division into physiological varieties on the basis of the quantity and 
 quality of virulence, significant as this property is for our understanding 
 of diverse streptococcus diseases in man. 
 
 jNIany attempts have been made to establish different S](ecies or vari- 
 eties of streptococci on the basis of morphological, cultural, and patho- 
 genic differences. These attemjits have met with only ])artial success. 
 They have tended to demonstrate the great variability of one and the 
 same species, rather than to establish definite and constant distinctions 
 between supposedly different species or varieties. So far, at least, as the 
 streptococci which we ordinarily meet, and particularly those of interest 
 for human pathology, are concerned, most authoritii's are of the opinion 
 that no satisfactory division into separate species can at present be estab- 
 lished, although it is convenient to classify streptococci according to 
 certain jirominent but varying characteristics. The characteristics which 
 ai-e most useful in this classification are those which appear in bouillon 
 cultures. They are the length of the chains, the ]iresence or absence of 
 cloudiness of the bouillon, and the kind of sediment jiroduccd by the 
 growth of the cocci. We thus distinguish short-chained streptococci 
 {streptococcus brevis), long-chained .streptococci (streptococcuti longus), 
 streptococci which render Ijouillon cloudy and those which do not, 
 streptococci which form Hoeculent or sandy or scaly or viscous sedi- 
 ments. The uiimc strcpforoceus conf/fomcmtiis is given to a streptococcus 
 which grows, without clouding the l)ouillon, in the form of dense, sep- 
 arate particles, scales, or thin membranes at the bottom and sides of the 
 tui)e, and on shaking the sediment it breaks up into little specks without 
 producing unifiirm, diffuse cloudiness. On microscopical examination 
 the chains in the latter case are long and interwoven in conglomerate 
 masses. Streptococcus chains may be straight or wavy or twisted. 
 These various distinctions are only of relative value. One firm may 
 change into another. Virulent streptococci may be found among all 
 the groujis mentioned. The streptococcus of erysipelas and most of 
 the streptococci from abscesses and sejitica?mia grow in long chains in 
 bouillon. 
 
 MicrococcKs Tetragcnus. — Isolated by Koch and Gaffky (1S81) from 
 phthisical cavities. Grows in tetrads enclosed in gelatinous capsules. 
 Stains by Gi-am. Grows on all media at room temperature, with or 
 
318 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 without oxygen. l<\irnis clovatcd, wliitc, n()ii-li(|iicf'vin(j colonics on 
 gelatin. Pathogenic for mice, guinea-pigs, and, hy. intravenous and 
 intra-jjcritoneal inoculation, also I'or ral)liits. Found not inf're(|Uently in 
 ])lithisical cavities and sputum, oceasiouallv in association with ])yo- 
 genic cocci in abscesses connected witli carious teeth and about the neck 
 and jaws and middle ear, rarely in abscesses elsewhere. It has been 
 considered to be non-pathogenic for man, but it has been found in pure 
 culture in closed abscesses in man, and Yiquerat has proven experiment- 
 ally that it is capable of causing stipjjuration in human l)eings. He 
 considers that suppurations ])roduced by the tetragenus alone are mild in 
 character, painless, with little reaction, easily cured. Boutron jjroposes 
 the name " micrococcus tetragenus septicus" for the Koch-Gaii'ky micro- 
 coccus to distinguish it from other similar tetragenous cocci. The latter 
 are ncm-pathogcnic. 
 
 Micrococcus Lanccolattis (Plate I., Fig. !j). — Synonyms : Diplococ- 
 cus pneumoniffl, Pnoumococcus of Fraenkel and AVeichselbaum, Diplo- 
 coccus lanceolatus. Micrococcus of sputum septieannia. Micrococcus pneu- 
 moniiE cruposfe, etc. Discovered by Sternberg in his saliva in 1880. 
 Demonstrated to be the cause of lobar pneumonia by Fraenkel and 
 by Weichselbaum in 1886. Capsulatcd, lance-shaped coccus, occurring 
 usually in ])airs and short chains, sometimes in long chains. Stains by 
 Gram. Grows best at body tenijierature ; may grow at tempcratm-e of 
 18—22° C. Capable of cultivation on all ordinary alkaline media, but 
 susceptible to slight variations in com]X)sition of culture medium. Colo- 
 nies small, round, gray. Does not liquefy gelatin. Faculative anaerobe. 
 Loses virulence and dies quickly in cultures. May survive in dried 
 sputum or blood for four months. Killed in ten minutes at 52° C. 
 A'^irulence and other properties extremely variable. Pathogenic for 
 mice and rabbits, in less degree for guinea-pigs. Causes localized in- 
 flammations and se])tic8emia. 
 
 Present often in the mouth of healthy human beings (page 258). Next 
 to the pyogenic staphylococci and streptococci, it is the most common 
 cause of inflammations in human beings. It is probably the sole specific 
 cause of genuine acute lobar pneumonia, and a frequent cause of broncho- 
 pneumonia, otitis media, and meningitis. With or without pneumonia 
 it may cause inflammation in any organ or part of the body. It can 
 produce all kinds of inflammatory exudates — serous, sero-fibrinous, puru- 
 lent. It most frequently invades the body from the bronchi or lungs, 
 sometimes from the nose, nasal sinuses, and pharynx, and occasionally 
 from the intestine. The list of diseases which it is capable of producing 
 is a very long one, including inflammations of any of the mucous and 
 serous memlji'anes, abscesses in an}- part of tJie body, mono- and jioly- 
 arthritis, osteomyelitis, periostitis, parotitis, thyreoiditis, nephritis, acute 
 ulcerative endocarditis, etc. It may cause septicsemia with single or 
 multiple localizations. It is the most frequent cause of metapneumonic 
 pleurisies, including empya-nia. Although it may cause the gravest dis- 
 eases, it is ranked as a relatively lienign organism in comjtarison with 
 the streptococcus pyogenes, particularly in pleurisies and suppurations. 
 It may die quickly in inflammatory exudates, as well as in cultures, but 
 it may also persist weeks and months. 
 
 Micrococcus Pyogenes Tenuis. — Found by Rosenbach in pus (1884). 
 
BACTERIA OF SURGICAL INFECTIONS. 319 
 
 Has been described iu about twelve cases of suppurative inflammation. 
 It is probably identical with the micrococcus lanceolatus (Neumann). 
 
 Micrococcus Gonorrhoece or Gonococcuf! (Plate I., Fig. 4). — Discovered 
 by Neisser in gonorrhcail pus in 1879. First cultivated by Bumm in 
 1885 on human blood-serum. Found constantly in gouorrJKval pus. The 
 cocci are in jiairs, with tiie adjacent sides flattened against each other, with 
 a clear interspace (biscuit shape). Grou{)s of four with adjacent sides flat- 
 tened also occur. Particularly characteristic is the inclusion of the cocci 
 ■within leucocytes, but they occur also free and attached to epithelial cells. 
 Of diagnostic importance ii? failure to stain by Gram, which distinguishes 
 the gonococcus from all the preceding cocci, but not from the so-called 
 psendo-gouococci (pp. 2G6 and 207). Facultative anaerobe. Grows only 
 at body temperature or neighboring temperature. Docs not grow on nu- 
 trient gelatin or plain agar, or on the latter oidy with difficulty and occa- 
 sionally. Grows best on a mixture of human blood-serum and nutrient 
 agar (one to two or three parts) (Wertheim). The addition of sterile human 
 urine improves the seruui-agar mixture (Steinschneider). Surface colonies 
 pale, gravis]), translucent, finely granular, with finely notched borders. 
 Forms a membrane in bouillon and Ijlood-serum mixed, leaving the fluid 
 clear. Cultures on seriun-agar when prevented from drying may live 
 forty-five days. Inocidation of pure cidtures into healthy human urethraj 
 ])roduces typical gonorrhcea. The gonococcus is a strict human parasite. 
 It dies (piickly in dried pus outside of the body. Virulence soon disap- 
 pears, as a ride, in artificial eultiu'cs. 
 
 The gonococcus is in general non-pathogenic for animals, but when 
 inoculated witli bits of agar into the eye or into the peritoneal cavity of 
 mice and guinca-jjigs it may cause suppurative inflannnation. In human 
 beings its growth is usually superficial, and by preference on mucous 
 membranes covered by cylindrical or transitional epithelium, but it may 
 grow down deeply into connective tissue anil i)etween muscle-fibres, and 
 may attack mucous membranes covered by Hat epithelium. It is the 
 cause of most cases of salpingitis, pyosalpinx, and the accompanying 
 peritonitis. It may produce genuine abscesses (ovarian, peri-urethral). 
 It may be conveyed by the blood-current and cause inflammations in 
 distant parts, most commonly arthritis, also endocarditis, pericarditis, 
 pleiu'isy, and myocarditis. Every condition of rigid proof of the 
 causation of artiiritis l)y the gonococcus (exclusive presence, isohition in 
 pure culture, and experimental ])roducti<in of gonorrho'a by inoculation) 
 has been fulfilled. It is the usual cause of gonorrhceal rheumatism. All 
 of these conditions, complicating gonorrhcea, may, however, be produced 
 by other invading micro-org-anisms or be mixed infections with the 
 gonococcus. 
 
 BarlZ/uf! Pncii,mo)i!ir of Fr'cdJdmJcr (Pneumo-l)acillus or Pneumo- 
 coccus of Friedliinder). — Isolated by Frieilliinder iu ISS:') from croupous 
 ])neumonia. Short, ]>lump roils with roinided ends ])riivided with dis- 
 tinct capsules in the animal body. Does not stain by Gram. Facultative 
 anaerobe. Grows at room tem])(!raturc. Forms ])rominent, opacpie-white, 
 non-liquefying colonies on gelatin. Grows on all media. Ferments glu- 
 cose and lactose and produces gas-bubbles on jiotato. Pathogenic for 
 mice, less s(» for guinea-pigs, and still less sn for rabl)its, which, however, 
 may become infected by intra-peritoneal inoculation. Found occasionally 
 
320 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 in tlie healthy human iiKnitli and nose, also outside of the hody. It is 
 found most frecjuently in inilanunations of the mouth, nose, and middle 
 car. It may cause broncho-])ucumonia, and has been observed in a very 
 few cases of empyjema and of meningitis secondary to raiddlc-ear disease 
 and to injury. It is a rare organism in this country. 
 
 The badllus of rhinoaclerovut resembles closely the Friedliinder ba- 
 cillus, and, according to some, there is no reliable differential character, 
 not even the greater resistance to decolorization by Gram's method, which 
 has been the point chietly emphasized. There is a group of capsulated 
 bacilli, resembling the Friedlander bacillus/ some from human beings, 
 others from animals, which have not been satisfactorily differentiated 
 from each other (see page '2(J2). 
 
 I>((ci/lus Pi/oci/anewi (Phite I., Fig. 2). — First cultivated by Gessard 
 from blue pus (1882). A slender, motile, liquefying bacillus, decolorized 
 by Gram, growing rapidly, even at ordinary temperatures, in all cul- 
 ture media. In. the jircsence of oxygen forms bluish, fluorescent green 
 and a whole scale of pigments. Interesting modifications of character, 
 especially as to color production, can be produced artificially, and are 
 observed under natural conditions, constituting, according to some writers, 
 distinct varieties of the bacillus. Is widely distributed, occurring often 
 on the human skin, in the fieces, and outside of the body. In wounds 
 stains the dressings bluish green, and produces a somewhat characteristic 
 offensive odor. Increases su])])uration of wounds, usually with little 
 constitutional disturbance. I'atliogenic for animals. Is found not 
 infrequently in perforative peritonitis and ap})endicitis, sometimes in 
 piilegmons, otitis media, broncho-pneumonia, and inflammations of serous 
 membranes, associated usually with other bacteria. It was found by 
 Ernst in tuberculous pericarditis (Plate I., Fig. 2). Often found in 
 diarrhoeal and dysenteric discharges. May cause general infections in 
 human beings, ^yith or without general infection it may cause hemor- 
 rhagic and necrotic enteritis, a form of ])yocyaneus infection in human 
 beings which we have repeatedly observed at autopsy. Instances of 
 invasion of the body from wounds by the bacillus pyocyaneus have not 
 been observed. 
 
 Bacll/i(f< Pi/or/enes Fa'ti(1i(.'<. — First cultivated by Passet from stinking 
 pus of a perirectal abscess (1 885). Siiort bacilli with rounded ends. Cul- 
 tures have a foul odor ; in other rcsj)ects they do not appear to differ 
 from those of the bacillus coli communis. This bacillus probably belongs 
 to the group of colon bacilli. It has been found in pure culture in 
 closed abscesses, but more frequently is associated with other bacteria. 
 
 Baeillm Coli Communis. — Isolated by Escherich from faces of infants 
 (1886). There isS a group of bacilli, called the colon group, presenting 
 similar characters, but with much variation in their cultural and other 
 properties. Short rods with rounded ends, also longer forms. Either 
 motile or non-motile. Do not stain by Gram in cultures or in the tissues, 
 but do in normal stools. Grow at low as well as high temperatures on all 
 media. Facultative anaerobes. Form large, spreading, grayish-white, non- 
 li(iuefying colonies with notched borders on gelatin and agar, sometimes 
 circumscribed, round, white colonics. On potato, brownish, yellowish, 
 white, or even scarcely visible growtli. Coagulate milk, ferment glucose, 
 lactose, and maltose." Constant inhabitants of the intestine, also widely 
 
PLATE 1. 
 
 Fig. 1. 
 
 
 
 ,-\ zy::A'^>^j(- 
 
 Section through all 1 abscess sho gstapl 1 coccus 
 pyogenes aureus (p. 315). Baumgarten. 
 
 ''^ 
 
 
 Cover-glass i)repuration of pericardial 
 exudate showing bacillus pyocyaneus 
 stained blue, and the tubercle bacillus 
 stained red (p, 320). Ernst. 
 
 Fig. 3. 
 
 i 
 
 ffM 
 
 -^ 
 
 streptococcus i>yuj4eiK*s ; streptococcus L'iysii)elatos fp. 316), Prudden. 
 
 Fig. 4. 
 
 Fig. 5. 
 
 r I 
 
 
 
 1^ 
 
 Blicrococeiis gonorrliCEae or gonococcus (p. 319). 
 Abbott. 
 
 Micrococcii.s Lanceoliiiu.s (p. :ilS). Abbott. 
 
BACTERIA OF SURGICAL INFECTIONS. 321 
 
 distributed iu external nature. The colon bacillus is a frequent invader 
 of the internal organs in all sorts of diseases, especially when there are 
 intestinal lesions. It manifests no evident i)atliogenie action in most of 
 these cases, and is then \\itliout clinical signihcance. It occurs frequently 
 associated with other bacteria iu infected wounds and other inflammations 
 of exposed surfaces. Here also it does not usually appear to cause seri- 
 ous disturbance. The fact that the colon bacillus is so common and 
 widely distributed, and found so often as a harmless invader, should lead 
 to mucii caution iit interpreting the significance of its presence when it 
 occurs in definite lesions. There is no doubt, hiiwever, that it may be 
 pathogenic for man. It plays an important role in inflammations of the 
 urinary tract and biliary passages ; also, but usually with less independence, 
 in peritonitis and appendicitis. The list of diseases in wJiich it may be 
 found is a very long one, and includes inflannuations in all organs and 
 parts of the body. Attention has already been called to its })atho- 
 genic properties for man (page 274). In general these pro])erties are of 
 a mild character. One of its leading roles is to invade territory already 
 occupied by other bacteria or previously damaged. It may be concerned 
 in the production of gall-stones, in the interior of which it has been found 
 by the writer with great frequency. Its virulence as tested upon animals 
 is variable, liut is generally manifest oidy after inoculation of large doses, 
 which kill by intoxication rather than infection. 
 
 Bacillus lactis ucrogenes is described by Esch-crich as shorter and 
 plumper than the colon bacillus. Forms more circumscribed, elevated, 
 Mdiite colonies, and coagulates milk and produces gas on ])otato more 
 quickly and energetically than the latter. Predominates iu the upper 
 part of the small intc^stine. Of late most writers include this bacillus iu 
 the colon group, with which it corresponds in its general pathogenic 
 characters. It is sometimes described as an opaque variety of the colon 
 bacillus. 
 
 Bacillus Typhi Abdominalis. — Mention is made of this bacillus, which 
 is chiefly of medical interest, not to describe its characters, but to call 
 attention to its capacity in rare instances to produce genuine sup])urative 
 inflammations in man, and especially to cause periostitis and osteomye- 
 litis as a sequel of typhoid fever. Most suppurations accompanying or 
 following typhoid fever are due to the pyogenic cocci or are mixed infec- 
 tions, but the tyjihoid bacillus may occur alone in abscesses. The most 
 connnon post-typhoid osseous affection is periostitis with cortical ostitis. 
 The exudate, when caused by the typhoid bacillus alone, may be dark 
 and thin with much detritus, or syrupy in consistence, or genuine pus. 
 The affection is oftener in the ribs than elsewhere, and may be obstinate 
 toward treatment. ■ It may develop several months, and it has been 
 claimed even years, after tyjihoid fever. Some observations indicate 
 that the typhoid bacillus may cause meningitis and inflammations of 
 serous memi)ranes. 
 
 Bacillus Proteus. — In 1885, Hauser isolated from putrefying sub- 
 stances the rapidly-liquefying profeus vulgaris, the slowly-liquefying 
 proteus mirabilis, and the non-liquefying profeus Zenkeri, which he 
 originally supposed to be three distinct species, but which he now 
 regards on satisfactory evidence as three varieties of the same species, 
 called bacillus jjroteus. The main characters of this bacillus are its 
 
 Vol. 1—21 
 
322 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 pleoniorphism, and especially movinjj, Avanderinii;, irregular projections 
 and islands I'roni its colonies on gelatin and agar (swarming colonies). 
 It is motile. This is one of the most widely-distributed bacteria, and 
 is concerned in tiie decom]iosition of animal and vegetable material. 
 It is not uncommon in the intestinal contents. Althougii repeatedly 
 observed in iiiflanuiiations of exposed surfaces, in appendicitis, in ])er- 
 forative peritonitis, and even in closed abscesses in association with other 
 bacteria, it has been generally considered to be non-pathogenic for man, 
 but our autopsy material has convinced us that it may be jiathogenic. 
 It may be unassociated with other bacteria in abscesses and in periton- 
 itis, and it may cause general infection l)y invading tlie blood and inter- 
 nal organs (Flexner). In moderate and large doses it is pathogenic for 
 animals. 
 
 BaciUufi G^dcnudis Mulii/ni. — Long spore-forming l^acillus resembling 
 the anthrax bacillus, but narrower and with rounded ends. Forms long 
 threads. Strict anacrol>c. Ijicpiefies gelatin with gas-production and 
 foul odor. Widely distributed in the soil and in the fjeces of animals. 
 Pathogenic for animals. No instance is recorded of infection of a pre- 
 viously healthy person with this bacillus, but Briegcr and Ehrlich have 
 reported two cases of malignant oedema following the hypodermic injec- 
 tion of musk in a typhoid patient. The bacilli were accidentally intro- 
 duced l;)y the syringe. 
 
 Bacillus Acrorioics ('apxiildfiis ; Bdcilbis Phlrf/mones EmpJii/scmafnsce. 
 — An anaerobic bacillus first described by A\"elch and Nuttall in 1<S()2 as 
 the cause of rapid formation of gas in the blood-vessels and organs after 
 death. Capsulated thick bacillus, averaging 3 to 6 ,« in length. Readily 
 stained by aniline dyes, including Gram's stain. Grows slowly at room 
 temperature, best at body temperatui'c. Produces gas abundantly in all 
 media containing fermentable substances. Does not form spores. When 
 injected subcutaneously or intravenously into animals which are killed 
 shortly afterward, it develops rapidly, with abundant formation of gas 
 throughout the body. The gas is odorless and burns with a blue flame. 
 There is at first no jiutrefactive decomposition. In the first case reported 
 by Welch and Nuttall tiic autopsy was made eight hours after death 
 in cool weather, and gas was abundant in the l)lood-vessels and liver. 
 This bacillus is doubtless the cause of the gas-formation in many cases 
 reported as death from the entrance of air into the veins, esjjecially from 
 the uterus after abortion, as was proven to be true in a case reported by 
 Graham, Steward, and Baldwin, and in two cases reported by P. Ernst. 
 This bacillus was found in a case of emphysematous gangrene of the 
 hand reported by Mann. It is probably identical with the bacillus found 
 by E. Fraenkel in four cases of emiiliysematous phlegmon reported in 
 1893, and called by him bacillus phlcymoncs emphysematoscc. It has 
 been found by the writer in three cases of perforative peritonitis. It 
 may cause emphysema of the subperitoneal tissues. It is probably a 
 rather widely distributed bacillus. 
 
 Bacillus i);>/i//ien"rt'.— Observed by Klebs (1883), first cultivated and 
 accurately descrilied by Loffler (1884). Straight or slightly curved 
 rods, averaging 1.2 to 2.6 /i in length, characterized especially by irreg- 
 ularities in shape and staining. Particularly characteristic are swollen 
 ends and deeply-staining chromatin-granules in the bacilli. Stains by 
 
BACTERIA OF SURGICAL INFECTIONS. 323 
 
 Gram. Not motile. Does not form spores. Facultative anaerobe. 
 Optimum temperature for growth 33-37° C. Grows only slowly and 
 slitriitly, if at all, below 20° C. Grows on all alkaline culture media, 
 invisibly on potato, best on Loffler's blood-serum bouillon mixture. Does 
 not liquefy gelatin. Forms on agar grayish-white, granular colonies 
 with slightly irregular margins. In bouillon grows in the form of 
 small grayish particles, with or without clouding of the medium, often 
 with formation of surface membrane. Particularly important as a 
 diagnostic critei'ion is the change of the alkaline to acid reaction by 
 forty-eight hours' growth in bouillon containing carbohydrate. Thermal 
 death-point, 58° C in ten minutes. May survive in some culture media 
 eighteen months, but may die in three or four weeks. Lives longer in 
 the dark than when exposed to light. Resistant to desiccation. jMay 
 survive for three to five months in dry membranes, but usually dies 
 sooner. Cultures dried on threads survive three to four weeks at room 
 temperature. Both virulent and non-virulent diphtheria bacilli occur, 
 the latter rarely in diphtheria. Pathogenic for many animals, and 
 especially for guinea-pigs. By suhcutaneous inoculation there is pro- 
 duced extensive local inflammation antl necrosis. The animal dies 
 usually in thirty-six to sixty hours, with necrotic foci in various internal 
 organs and serous transudates in the serous cavities. The bacilli are 
 found only near the seat of inoculation or in very small number in the 
 organs. With less virulent cultures or smaller doses subacute and 
 chronic infections or intoxications ensue. Genuine pseudo-membranes, 
 as a rule with little tendency to sjiread, follow inoculation of nuicous 
 membranes superticially injured. The virulent diphtheria bacillus pro- 
 duces by its growth in cultures or in the animal body a powerful poison, 
 called the toxin or toxalbnmin of diphtheria, to which the constitutional 
 symptoms, the lesions of internal organs, and the paralysis are due. 
 
 The diphtheria bacillus is the cause of all cases of genuine diphtheria. 
 Similar pseudo-mcml)ranous inflammations of the throat and air-passages 
 may be caused by streptococci. The intensity of the affection caused 
 by the dij)htlieria bacillus varies from a slight inflannnation without 
 false membrane to the gravest pseudo-membranous inflanmiatious. 
 
 The dipiitheria bacillus is incapable of attacking the intact skin. It 
 may, however, produce pseudo-membranous inflannnations on excoriated, 
 ulcerated, and wounded skin. Neisser has reported the case of a child 
 five and a half years old with diphtheria of the throat in whom thick, 
 firmly-adherent pseudo-membrane covered the skin alwut the anus over 
 a sjiace 10 cm. long and 4 cm. broad. There was cedema of the scrotum 
 and |)enis. L<)tfler bacilli were found in the false membrane and through- 
 out the infiltrated corium. The localization of the diphtheria bacillus 
 in cutaneous surfaces which have been deprived of the epithelial cover- 
 ing by excoriation, eczema, ulceration, herjics, wounds, has been observed 
 many times in persons afl'ected witli diphtheria of the throat, although 
 it is not common. This localization may be attended by a pseudo- 
 membrane, or by simple superficial necrosis, or by ordinary suppuration 
 or inflannnation in no way suggesting diphtheritis. Park found diph- 
 theria bacilli in two cases in wounds of the finger received by physicians 
 in intubating children with di[)htlieria. They persisted for six weeks 
 in one case. Wright has demonstrated the presence of this bacillus in 
 
324 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 excoriated or ulcerated surfaces of the skin in 7 cases, in paronychia in 
 1, in mastoid abscess in 1, in ])urulc'nt ct)niunctivitis in 1, — all in cases 
 of diphtheria. The dipjithcritic })rooess may extend by continuity to 
 a tracheotomy wound. More freipiently the wciund is unatfected, even 
 in cases where the diphtheria bacillus may be demonstrated upon its 
 surface. Extensive necrotic and septic involvement of tracheotomy 
 wounds is more frequently due to streptococci, with or without associ- 
 ation with the diphtheria bacillus, than to the latter micro-organism 
 alone. Brunner has reported three cases of infection of wounds with 
 the diphtheria bacillus in association with pyogenic cocci in persons 
 without demonstrable connection with other cases of diphtheria and 
 Avithout any affection of the throat. In only one case was there pseudo- 
 membrane. The presence of the diphtheria bacillus was not suspected 
 in any of these cases before the bacteriological examination. 
 
 In this connection a few words may be said regarding the general 
 subject of wound diphtheritis, concerning which nuich confusion exists. 
 Here, as well as in diphtheritis of mucous membrane, it is important 
 to bear in mind that the term " diphtheritis " is a purely anatomical one, 
 and implies nothing as to the causation of the affection. The term 
 " diphtheria," on the other hand, should be restricted to the affection 
 caused by the Loftier l)acillus wherever this may be localizi'd. There 
 are three anatomical" conditions of a Mound to which the epithet " diph- 
 tlieritic " has been applied — namely, first, the presence of an adherent 
 fibrinous false membrane incorjiorated with underlying necrosis of the 
 tissues ; second, the presence of a fibrinous pseudo-membrane loosely 
 attached to the underlying tissues, which may present no distinctive 
 alteration ; and, third, more or less extensive necrosis of the tissues of 
 the wound without a distinct false membrane. Only the first condition 
 is properly called diphtheritis ; the second may be called simple pseudo- 
 membranous or croupous inflammation, and the third is necrotic inflam- 
 mation. 
 
 Wound diphtheria is infection of a M'ound by the Loffler bacillus. 
 It may or may not be wound diphtheritis in the anatomical sense. 
 Wound diphtheria may manifest itself as a simple inflammation, or 
 inflammation with sujjerficial necrosis, or inflammation with more or 
 less adlierent pseudo-membrane. Pyogenic cocci are usually associated 
 with the L(')ffler bacillus in the diplitheria of wounds. Paralysis may 
 follow wound di])htheria. As the same anatomical conditions in a wound 
 may be produced by various causes, a positive diagnosis of wound diph- 
 theria can be made only by bacteriological examination. The conditions 
 as regards var'ying intensity and character of the infection, association 
 with other bacteria, particularly streptococci, and the necessity of a bac- 
 teriological examination to establish the diagnosis, are in no way differ- 
 ent in the diphtheria of wounds from those in diphtlieria of mucous 
 membranes. As has already been stated, wound dijihtheria may occur 
 without demonstrable connection with cases of dijihtheria and without 
 affection of the throat in the individual attacked, but such occurrences 
 are rare. 
 
 Diphtheritic, necrotic, and croupous inflammations of wounds are 
 caused most frequently by other micro-organisms than the Lofiler 
 bacillus. Here, as with similar inflanuuations of mucous membranes, 
 
BACTERIA OF SURGICAL INFECTIONS. 325 
 
 the streptococcus pyogenes appears to be an important causative agent, 
 so far as can be judged from the small number of cases hitherto exam- 
 ined bactcriologically. In this comparatively rare class of streptococcus 
 infection of wounds the intensity and extent of the inflammation vary 
 witiiin wide limits. 
 
 It is not, or formerly was not, a particularly rare occurrence for 
 coherent false membranes to develop upon granulating surfaces without 
 notable disturbance in the process of repair and Mdthout constitutional 
 disturbance. The membrane in these cases can be readily stripped off, 
 after which another membrane is likely to form. It has been proposed 
 to call tiiis relatively inoffensive wound complication " wound croup," in 
 distinction from the more severe Avound diphtheritis. In two cases of 
 croupous membranes on granulations Brunner found the streptococcus 
 pyogenes in pure culture. In similar cases he and Tavel have found 
 also the bacillus coli communis in pure culture. The condition may 
 doubtless be associated with the presence of various micro-organisms, 
 and is not, therefore, a specific one. In croupous inflammations of 
 fresh wounds Brunner found the streptococcus pyogenes in association 
 with other pyogenic cocci. 
 
 How much the development of diphtheritic and necrotic inflamma- 
 tions of wounds is influenced by the general condition of tlie patient 
 is shown by the greater frccjuency of its occurnMice in persons pros- 
 trated with typhoid fever, scarlet fever, septicaemia, pytemia, and other 
 debilitating causes. 
 
 Diphtiieritic inflammation of operative woimds involving the mouth 
 and the bladder is more common than a similar affection of wounds in 
 other parts of the body. The Loffler bacillus is not concerned, as a 
 rule, with diphtheritis of these wounds, any more than it is with diph- 
 theritic cystitis or enteritis. 
 
 Much interest attaches to the question of the causation of hospital 
 gangrene, that frightful sc(.)urge of pre-antiscptic surgery iu crowded 
 hospitals, particularly in military hosjiitals. Hospital gangrene has 
 been designated " wound diphtheritis," but it differs from the necrotic 
 and diplitheritie inflanunatidus of wounds, which are now occasionally 
 observed, in many features, particularly by its phagedenic eliaracter and 
 its mortality. It has apparently disappeared, at least from civilized 
 coiuitries, and there has been, therefore, no opportunity to make a bac- 
 teriological examination by modern methods of any case of this disease. 
 Although some of the older writers identified the cause of hos})ital gan- 
 grene witli that of true diphtlieria, it seems, with our present Ivuowledge, 
 highly im]irobal)le _that tliis is true. Our ol)servations of the effects 
 produced by the diphtheria bacillus with or without association with 
 other Ijacteria in wounds do not indicate that this orgtmism can have 
 played any essential role in the causation of hospital gangrene. Some 
 authorities are of the opinion that hospital gangrene is a s])ceific infec- 
 tion tine to a specific micro-organism wliich has disappeared from civil- 
 ized countries, as the micro-organism of tlic plague has disappeared. It 
 seems to the writer more probable that it was due to pyogenic liacteria 
 which still exist, l)ut whicli under the special conditions prevailing 
 where hospital gangrene occurrcid had acquired a degree and kind of 
 virulence with which we are no longer familiar. Thanks to antiseptic 
 
326 (IKNERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 surgery, these special coiulitions aiv not likely to be repeated in civilized 
 countries. 
 
 BucaUus Tctuiii. — Observed by Nieolaier (1884) in wounds in cases 
 of tetanus and demonstrated in garden eai'th, first obtained in pure 
 culture by Kitasato (1889). Slender, straight bacilli, varying in length 
 from sliort rods to long threads. iSluggishly motile. Splierical spores, 
 tliirker than the rods, develop at one end of the bacilli, giving them a 
 drumstick or pin shape, ytains by Gram. Anaerobic. Grows best at 
 body temperature, slowly at 18-20° C, not at all below 14° C. Spores 
 are formed in cultui'cs at body temperature in thirty hours, in cultures 
 at 20° to 25° C, not until after a week. Grows in nutrient gelatin, 
 whicli is slowly liquefied with slight gas production ; in agar and bouillon 
 wJien free oxygen is excluded. Growth in gelatin is fuzzy, radiating, 
 like a thistle. Dried spores live months and years. Cultures contain- 
 ing spores dried on silk threads were found alive after several months 
 by Kitasato. Henrijean demonstrated living, virulent tetanus spores on 
 a j)iece of wood which had been extracted eleven years previously from 
 the wound in a boy with fatal tetanus. The sjiores are killed in five 
 minutes by moist heat at 100° C. They withstand in the moist con- 
 dition for an hour a tem])erature of 80° G. — a jtrojierty ^\•hich \vas 
 utilized by Kitasato to destroy other bacteria in obtaining pure cultures 
 of the tetanus bacillus. The spores survive and jireserve their virulence 
 for ten hours in 5 per cent, carbolic acid ; they are killed in fifteen hours. 
 They are not killed by putrefactive Ijacteria. 
 
 The tetanus bacillus is more or less pathogenic for nearly all warm- 
 blooded and some col(l-l)looded animals. Infection takes place only 
 through a wound. The period of incubation varies from a few hours to 
 several days, according to the susceptibility of the animal and the dose. 
 Experimental tetanus corresponds in all essential particulars to human 
 tetanus. Tetanic s})asm appears first in the muscles nearest the seat of 
 inoculation. 
 
 Tetanus is a toxic infection. The bacilli multiply only in the imme- 
 diate neighborhood of the wound, and do not invade the blood and 
 organs. Inoculation with jiure cultures is a pure intoxication as a rule, 
 with but little nuiltiplication of the bacilli, so that at the autopsy it may 
 be difficult to find any bacilli. ^\nien imjnire cultures and foreign 
 bodies are introduced into the wound the bacilli are more readily 
 demonstrable at autopsy. There are no demonstrable lesions of internal 
 organs in experimental tetanus. 
 
 All of the symptoms of tetanus can be produced by the germ-free 
 filtrate of tetanus cultures. It is the only infectious disease known every 
 feature of which can be produced experimentally by injection of the poi- 
 son without the micro-organisms. In the case of diphtheria all of the 
 symptoms and lesions can be produced by the jjoison except the local 
 false memlirane. This requires the presence of the liacilli. 
 
 Brieger found in impure tetanus cultures foiu' crystallizable alkaloidal 
 substances belonging to the class of ptomaines. Three of these he called 
 tetanin, tetanotoxin, and spasmotoxin. He found also an unnamed base. 
 As these ptomaines produced spasms by injection into animals, this residt 
 was at first thought to indicate that the poison of tetanus had been iso- 
 lated in a state of chemical purity. Subsequent investigations have 
 
BACTERIA OF SURGICAL INFECTIONS. 327 
 
 shown that these jitoinai'ne.s do not rci)ro(Uice all of tlic characteristic 
 symptoms of tetanus. They are not the real tetanus poison, and no 
 particular interest any longer attaches to them. 
 
 The real poison of tetanus belongs to a different class of substances — 
 namely, the so-called toxic proteids or toxalbumins, substances al)out 
 ■which we know yery little chemically, but a great deal physiologically. 
 We do not eyen know j)ositiyely tiiat the tetanus toxin is a proteid, but 
 it is generally assumed to be. To this same class of substances belong 
 the toxin of diphtheria, the venom of snakes, and certain poisonous sub- 
 stances produced l)y vegetable cells, as ricin, abrin, robin. 
 
 The specific tetanus toxin has been demonstrated both in cultures of 
 the tetanus bacillus and in the bodies of animals. It has been found 
 in the blood both during life and after death. It does not appear 
 to be eliminated iu ap[)reciable amount by the urine unless very large 
 doses are given. According to Kitasato, the poison is destroyed in the 
 presence of water in five minutes at 65° C, in one and a half hours at 
 55° C ; it stands drying at ordinary temperatures ; is not injured by 
 dilution with water or bouillon ; is sensitive to acids and alkalies. It is 
 destroyed by the acid gastric juice. It is injured by exposure to light. 
 So sensitiye is the tetanus poison to chemical reagents that Kitasato was 
 unable to find any means of obtaining the poison in a condition approach- 
 ing purity, and he expressed ignorance as to its real nature. Brieger and 
 Cohn have, however, been more successful, and have isolated a substance 
 possessing the properties of the tetanus poison in a condition approac^hing 
 purity. As this sul>stance was found to be without most of- the proteid 
 reactions, they consider that it is not an albumin in the ordinary sense 
 of that term. 
 
 The tetanus toxin is of appalling potency. Kitasato obtained liquid 
 cultures of such virulence that 0.00001 ccm. of the germ-free filtrate, 
 corresponding to 0.00023 mgm. of the dried filtrate, sufficed to kill a 
 mouse with tetanus. ( )f course only a i)art of the dried substance is the 
 real jxiison. Of tlie jiuritied substance obtained by Brieger and Cohn, 
 who had at their tlisposal cultures of less primary virulence than those 
 of Kitasato, 0.000,000,05 grm. killed a mouse of 15 grm. weight. As 
 the fatal dose of the tetanus poison increases with much regularity in pro- 
 portion to the weight of the animal, this would represent 0.23 mgm. as 
 the fatal dose for a man weighing 70 kilo. When it is coiisidered that 
 the minimal fatal dose of atropine for an adult is l.'>0 mgm. and of 
 strychnine is 30-100 mgm., some conception of the terrible energy of 
 this bacterial weapon can be obtained. The substance se])arated by 
 Brieger and Cohn was not in a state of chemical j^urity. The tetanus 
 poison, like the diphtheria poison, does not cause symptoms immediately 
 after its introduction. With small doses it may he days before recog- 
 nizable sym]>toms ap|)ear. This behavior is unlike that which we are 
 accustomed to attril)ute to ciiemical poisons, and raises the question 
 whether the poison may not be reproduced in the body, or whether the 
 substance injected is itself the poison, and may not be in the nature of 
 an enzyme which leads to the production of the real poison within the 
 body. These (juestious cannot at present be answered. 
 
 An interesting examjile of the effect of the pure tetanus toxin upon 
 man is reported by Xicolar. In working with the filtrate of a tetanus 
 
328 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 culture he accidentally stuck the point of the needle of a hypodermic 
 syringe containint;- some of the fluid into iiis left hand. Only the moist- 
 ure adiiering to the needle was introduced into tiie puncture. After 
 three and a half days the iirst symptoms of tetanus were manifested by 
 contracture of the left thumb. There followed in succession contraction 
 of the hand, the arm, then trismus, opisthotonos, general contractures, 
 and convulsions. The treatment was by large doses of chloral. After 
 three weeks improvement began, and recovery was comi)letc after forty- 
 one days. In this uui(jue case the tetanus toxin was introduced in min- 
 imal amount without the bacilli. Nicolar, in view of the fact that no 
 symptoms were manifested until the third day, adopts the view that the 
 culture fluid does not contain the real poison, but produces it by a kind 
 of fermentation after introduction into the body. 
 
 The distribution of the tetanus liacillus and the factors favoring infec- 
 tion with tetanus have already been described (pj). 25.'j, 2(J5, 270, and 28!:l). 
 
 Susceptible animals may be rendered immune from tetanus by the 
 injection of the tetanus poison, at first weakened by chemical agents or 
 heat, and then administered in full strength in constantly increasing 
 doses. This is antitoxic inuniuiitv, already dcscrilicd, which has nothin<>: 
 to do with natural imnuuiity. The hen is natui'ally immune from tetanus, 
 but not by virtue of any antitoxic power of the blood. The blood-serum 
 and other fluids of animals rendered artificially imnuuie from tetanus are 
 capable, by virtue of their antitoxin, of rendering susceptible animals 
 resistant to tetanus (passive immunity), or even of preventing the develop- 
 ment of the disease or of curing the disease after reception of the virus. 
 Bchring in 1.S92 reported that in the course of two years he had by suc- 
 cessive injection of increasing doses of the tetanus toxin rendered a horse 
 so highly immune that the immunizing value of its blood-serum was 
 1 to 10,000,000, by which is meant that TTiWoTrTTotli fcm. of serum will 
 protect 1 grm. weight of mouse from the effects of the subsequent injection 
 of the smallest fatal dose of the tetanus poison, or 1 ccm. of serum suffices to 
 imnuuiize 5()0,(l()0 mice, weighing each 20 grams, or 200 shee]>, weighing 
 each 50 kilo. When, however, the attempt is made to prevent the develop- 
 ment of the disease immediately after the reception of the virus, a larger 
 quantity of the serum is required to afford protection than a few hours 
 previously, and as time elapses the amount of scrum required rajiidlv 
 increases, until, as soon as the very first symptoms of the minimal fatal 
 dose of tetanus poison appear in the mouse, one thousand times the 
 quantity of serum necessary for simple preventive imnumization must 
 be injected. After twenty-four hours the necessary quantity of serum 
 possessing an immunizing value of 1 to 1,000,000 is too great to be intro- 
 duced into the animal. To produce the same curative effects in large 
 animals as in small it is necessary to inject jiroportionately larger amounts, 
 the dose being in approximately direct ratio to the respective weights of 
 the animals. These considerations manifestly suggest serious difficulties 
 in the application of the antitoxic treatment of tetanus to human beings. 
 But there is another difficulty of probably greater force — namely, that 
 we have no indication that tetanus will result from a woimd in man 
 until characteristic symptoms have appeared. By that time tetanus 
 poison has accumulated in considerable amount in the system. Kitasato 
 was unable to prevent the develojjment of tetanus in mice by the com- 
 
PLATE I I. 
 
 ^ il 
 
 
 // 
 
 ■*^ v1" 
 
 •# 
 
 \ 
 
 ^V 1\ lU' 
 
 II 
 
 
 I -}l 
 
 V 
 
 Tubercle bacillus and streptcicocci in s])Utum 
 (p. 329). Abbott. 
 
 Anthrax bacillus in section of liver of mouse 
 (p. 331). Abbott. 
 
 1 f 
 
 Tetanus bacillus ip. 326). Abbott. 
 
 Fig. 6. 
 
 Fig. 4. 
 
 
 Section of glanders nodule, sbowing glanders bacilli 
 
 (p. 330). FLt'GGE. 
 
 '<.••,'■"»■•'' 
 
 .. ' c ■ ^ ^ , ?, V-"- ■ '-V- «■■ -.? vs.g 
 
 Longitudinal section of rabbit's tibia showing osteomyelitis produced by intra- 
 venous injection of the staphylococcus pyogenes aureus. The cocci are colored 
 blue, a, Compact tissue of bone; 6, Haversian canal filled with staphylococci 
 (p. 31.i). L.4NNELONGi'E and Achard. 
 
BACTERIA OF SURGICAL IXFECTIOXS. 329 
 
 pletc excision and thorough cauterization of tiie wound one hour after 
 inoculation with tetanus bacilli. It is not positively proven that cura- 
 tive antitoxic serum neutralizes poison which has already been received 
 into the system before injection of the serum, although it is capable of 
 neutralizing poison formed after its administration. \Ve stand in a much 
 less favoral)le position for tiie successful treatment of human tetanus by 
 antitoxin than is tiie case with diphtheria, where the conditions are more 
 favorable both as regards progressive increase of dosage in proportion to 
 the weight, and especially as regards the possibility of beginning treat- 
 ment before the absorption of large quantities of the poison. These are 
 the scientific considerations relating to the treatment of tetanus by anti- 
 toxin. Its practical a]>plication and the results of treatment in human 
 beings belong to the article on Tetanus in this work. 
 
 Baci/las TiihciTulosis. — Discovered and first cultivated liy Koch (1882), 
 independently and at about the same time demonstrated microscopically 
 in tubercles by Baumgarten. Slender, straight, or slightly curved or bent, 
 non-motile rods, 1.5 to 4 // in length, which averages live to six times 
 the breadth. In unstained specimens glistening dots, in stained speci- 
 mens clear spots, are often seen in the rods, which thereby j)resent a 
 beaded appearance. Tiiese are interpreted by Kc)ch and others as spores, 
 but this has not been proven. Xo greater resistance to heat and other 
 injurious agencies has been demonstrated for bacilli containing these sus- 
 pected spores than for l)acilli without them. Tubercle bacilli take up 
 staining dyes with difficulty, Imt when once thoroughly stained by 
 intense aniline dyes they retain the color after it has been extracted by 
 acids, alcohol, and other dec<ilorizers from all other known bacteria 
 except the leprosy bacillus and some examples of smegma bacilli. (See 
 p. 254.) It is by this peculiar staining reaction that tubercle bacilli 
 are differentiated from other bacteria. The tubercle bacillus grows best 
 in the presence of free <ixygen, but is capalile of growth without free 
 oxygen. 0])timtnn temperature for growth, 37 to 39° C. Does not 
 grow below 29° C. Was first cultivated by Koch on solidified cow's 
 blood-serum ; has since been culti\'ated on potato, and on nutrient agar 
 and bouillon to Avhich 5 to 6 per cent, glycerin has been added. On 
 blood-serum the growth first becomes visible after ten to fourteen days. 
 It forms dry, lustreless, compact white scales, loosely attached to the sur- 
 face. By coalescence of the (Milonies extensive membranous growtiis are 
 formed. GroMs in the form of a membrane on the surface of fluid media, 
 without clouding the fluid. The tubercle bacillus is the most resistant 
 to heat of all pathogenic bacteria not positively proven to form spores. 
 The stiitements of different experimenters as to its thermal death-point 
 arc so widely divergent that bacilli from different sources, or at least 
 under different conditions, would seem to vary in this respect; but it is 
 more prol)able tiiat tlie discordant results are due to failure to ensure 
 exposure of tiie bacilli to the actual temperature of the surrounding 
 fluid. The physical conditions as regards distribution of the temper- 
 ature in heatecl animal fluids, culture media, etc., especially when solid 
 masses are present, are not of so simple a nature as many of the experi- 
 menters upon the subject of the thermal death-point of bacteria seem to 
 suppose. According to tlic careful ex]ieriments of Foi-ster, tnljcrcle 
 bacilli are killed, or at least arcv rendered incapable of infecting guinea- 
 
330 GENERAL BACTERIOlJXiY OF SUBOICAL INFECTIONS. 
 
 pigs, V)y ten niiiiiitcs' exposure to a teni])oratiiro (if 70° C and l)y one 
 liour's t'Xjiosure to 60° C. Tlioy were not killed in forty-five minutes 
 by heatinjr to 60° C. They are surely killed in a few minutes by the 
 boiling temperature. They ro'tain their vitality in dried sputum for nine 
 or ten months, but at the last with some loss of virulence. They resist 
 putrefaction for a considerable time. They are killed in sj)utum by 3 
 per cent, carbolic acid in twenty hours ; they are killed in a few minutes 
 by 3 to 5 per cent. carl)olic acid when the acid can come into direct 
 contact with the bacilli. They resist the action of the gastric juice. 
 AA'hen expo.sed in thin layer to the direct action of the sun's rays they 
 are killed in a few minutes — much more slowly when in a thick layer. 
 
 The tubercle bacillus is a strict parasite, incapable under ordinary 
 conditions of multiplication in the outer world, but capable of jirolonged 
 survival outside of the l)ody. It is the sole cause of tuberculosis. The 
 pathogenic manifestations of the tubercle bacillus have been described 
 by Dr. Councilman (p. 2.">9), and will be further considered in the articles 
 treating of the various forms of surgical tuberculosis. 
 
 The bacillus of avian tuberculosis is a different species, or at least a 
 different variety, from that of human tulicreulosis. 
 
 Bacilhis Lcpnr. — Discovered l)y Hansen (1879) in leprous tubercles. 
 Morjiliologieally, the le])rosy liacillus resembles very closely the tubercle 
 bacillus, from which it probably cannot be distinguished in size and 
 shape. It presents clear, unstained dots like those observed in tubercle 
 bacilli. It resembles the tubercle bacillus also in its staining reactions, 
 the only important difference being that it is more readily stained by 
 aniline dyes than the tubercle bacillus. It stains well by Gram's and 
 A\'eigert's fibrin stain. It is non-motile. Although many observers claim 
 to have cultivated the leprosy bacillus, none of these claims have been 
 established, at least not to the satisfaction of most bacteriologists. Most 
 experimenters have had only negative results from the inoculation of 
 leprous material into animals. The positive results rejwrted by Damsch, 
 Vossius and ]\Ielcher, and (Jrtman are o])en to criticism in their interjire- 
 tation. The apparently successful inoculation of a condemned criminal 
 in the Sandwich Islands by Arning has also been criticised as not con- 
 clusive. The constant and exclusive presence of the bacillus lepra in 
 leprosy cannot be reasonably interpreted otherwise than that the liacillus 
 is the cause of the disease. The characteristic bacilli arc present in enor- 
 mous number in the lejirous nodules, being chiefly enclosed within cells. 
 They have also been found in the lesions of the disease in all parts 
 of the body. They are very rarely in the blood. 
 
 BacUliifi Mallei. — Discovered by Loffler and Schlitz (1882) in the 
 lesions of glanders. Somewhat shorter and thicker than the tubercle 
 bacillus. Presents often clear, unstained s]iaces in the rods. It probably 
 does not form spores. Decolorized by (xram. Stains with the usual 
 aniline dyes, but is so easily decolorized that its demonsti-ation in sections 
 is somewhat difficult. Like the typhoid bacillus, it occurs in the tissues 
 especially in clumps. Non-motile. Facultative anaerobe. Grows best at 
 body temjierature, but is capable of growth at room tcmjierature. Grows 
 on all culture media, but, as has been shown by Theobald Smith, far 
 better on acid (non-neutralized) than on alkaline media. Particularly 
 characteristic is the growth on potato, on which the glanders bacillus 
 
BACTERIA OF SURGICAL IXFECTIOyS. 331 
 
 forms at first a transliict'iit, amber-yellow layer, later a reddish-brown 
 layer with discoloration of the potato. Growth on agar whitish, moist ; 
 if the medium be acid, thick and abundant. The virulence diminishes 
 in successive generations in artificial cultures. The glanders bacillus may 
 survive in the dried condition for three and a half months, but usually 
 dies within two or three weeks. There arc t)l)scrvations which indicate 
 that it may survive for at least a year and a half in unoccupied, infected 
 staliles. By inoculation of horses with pure cultures glanders is pro- 
 duced. The bacillus is pathogenic for several species of animals. The 
 guinea-pig and the field-mouse are particularly susceptible. White mice 
 are resistant. The field-mouse dies from experimental inoculation usually 
 in three or four days with acute infection and miiuite tubercle-like 
 nodules in the spleen and liver. The lesions in the guinea-jiig arc most 
 characteristic, consisting in a caseous ulceration at the scat of subcutaneous 
 inoculation, which, however, is often absent; swelling and necrotic sup- 
 puration of the testicles ; swelling and idceration of the joints ; and 
 nodules in the spleen and liver, sometimes elsewhere. The best method of 
 diagnosing a suspected case of glanders is to inoculate the material into the 
 peritoneal cavity of a male guinea-pig. In four or five days, at the most 
 in eight or ten days, the characteristic swelling and infiannnation t)f the 
 testicles can be detected. The bacilli arc in the lesions, but scanty or 
 absent in the blood. Mallcin is a product derived from cultures of the 
 glanders bacillus, and is analogous in its properties and uses to tuberculin 
 derived from the tubercle bacillus. It is used for the diagnosis of glan- 
 ders in animals, as tuberculin is used for the diagnosis of tuberculosis. 
 
 Bacil/itx Aiithrdcix. — Discovered in the blood of animals affected 
 with anthrax by Pollender (1849) ; also observed by Davaine (1850), 
 Eayer (1851), and Brauell (1857). The studies upon the anthrax 
 bacillus laid the foundation-stone of modern bacteriology. The bacil- 
 lus is 1 to 1.5 II broad and 3 to 10 // long. It grows out into long 
 threads made up of bacilli, the adjacent ends of which are sharply cut 
 and slightly concave. Not motile. Stains readily with aniline dyes, 
 including Gram's stain. Forms spores in the presence of oxygen, but 
 never within the animal body. Grows at room temjjerature, best at body 
 temperature; does not grow below 12° C Grows on all culture media. 
 Li(]Uefics gelatin with moderate rapidity. Colonies on gelatin are whit- 
 ish, often with fuzzy, irregular, hair-like projections. Similar bristle-like 
 projections often characterize the growth in the bne of i)nncture in gel- 
 atin and agar. Desiccated spores may survive for years. Anthrax 
 spores are usually killed in four minutes by boiling temperature, but 
 they vary in their resistance, and may withstand boiling temperature 
 for twelve minutes (von Esmarch). Some anthrax spores are killed by 
 5 per cent, carbolic acid in two days ; others survive for forty days. 
 Various modifications of character of the anthrax bacillus can be ])ro- 
 duced by cultivation at high temperatures (42—43° C.) or by the addi- 
 tion of dilute antiseptics, the most Imjiortant modifications being the 
 production of an as]iorogenic variety of the bacillus and the loss of 
 virulence. Any degree of attenuation of virulence can be produced 
 down to com]ilete loss. These attenuated cultures serve as vaccines to 
 rcn<ler animals insusceptible to anthrax. The anthrax bacillus is a 
 facultative parasite. It is in the highest degree virulent for mice and 
 
332 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 guinea-pigs, somewhat less so for rabbits. Sheep and cattle are the ani- 
 mals which sui!er the most from the natural disease. Swine, dogs, and 
 most birds are immune. Kats and pigeons are resistant, but not wliolly 
 insusee|)til)le, to anthrax. Man does not rank among those higlily sus- 
 ceptible to the disease. Infection may occur from the skin, intestine, or 
 lungs. In small susceptible animals experimental anthi'ax is a septi- 
 caemia with abundant bacilli in the blood. In man anthrax usually 
 occurs with localized inflammations at the seat of invasion (malignant 
 pustule, intestinal anthrax, wool-sorter's disease). In some cases the 
 disease remains localized ; in others general infection and multiple 
 localization occur. 
 
 Aefinoinyces, or Bay Funr/Hs. — First recognized as a living organism 
 by Bollinger in 1877 in actinomycosis or lump-jaw of cattle; obsei'ved 
 in man in 1845 by B. von Ijangenbeck, whose disco\'ery, however, was 
 not published until 1878, when it was mentioned by J. Israel, to whom 
 belongs the credit of first recognizing the ray fungus as a distinct micro- 
 organism pathogenic tor man. 
 
 There are various species or varieties of the genus actinom3-ces, but 
 we are al)le with our present methods to differentiate them from each 
 other only imperfectly. Actinomyces honiinis, which is probal)ly iden- 
 tical with actinomyces bovis, is the oidy s])ecies which will lie considered 
 here. Authorities are not agreed as to the botanical j)osition of this 
 organism, but most writers now regard it as belonging to the group of 
 the more highly-organized pleomorphic bacteria, and allied to clado- 
 thrix or streptothrix. Some, however, class actinomyces with the fungi. 
 
 Actinomyces is the cause of a chronic inflammatory affection, pre- 
 senting sometimes the characters of an abscess, at other times more 
 those of a tumor, with suppurating tracts and cavities. The })rescnce 
 of the parasite can usually be detected a\ ith the naked eye by finding in 
 the pus small yellowish granules. These granules vary in size, shape, 
 and color. They are usually described as about the size of a jiin's liead. 
 They may be much smaller, even microscopic in size, and exceptionally 
 they may be massed together in clumps the size of a pea. To the naked 
 eye they generally appear round, l)ut microscopicall}' their contours are 
 seen to be irregular. They may be grayish and translucent like sago 
 particles, or opaque gray or white, or yellow, greenish-yellow, brownish, 
 even black. Bostroem has demonstrated that these various tints depend 
 partly ujion tlie stage of develoj)ment of the organism, the younger forms 
 witliout club-like terminations being pale and transparent. The black 
 granules have been observed only in intestinal actinomycosis. The con- 
 sistence of the granules or cokmies in their early stage of development 
 is soft and gelatinous ; later it becomes firm and compact, and it may 
 become hard and gritty from deposit of lime salts in the old, degen- 
 erated colonies. The young, translucent bodies are most abundant in 
 foci of rapid softening and liciuefaction of the tissues. The number of 
 the bodies present in the pus varies in different cases. They may be so 
 few as to require long search to find them ; usually they are numerous, 
 and sometimes there are myriads of them. 
 
 These characteristic granules, visible to the naked eye, are colonies of 
 the actinomyces or clumps of colonies. The youngest colonies are not 
 visible to the naked eye. These consist of a central interlacing mass of 
 
BACTERIA OF SURGICAL INFECTIONS. 333 
 
 braiicliino; threads \Aitli radiating projections of threads. The most coni- 
 nioii and characteristic appearances are found in okler colonies (called by 
 the Germans " Drnseu "). Here we find the centre of each colony com- 
 posed of extremely fine interlacing threads and small round bodies 
 resembling cocci, and the periphery made up of bulbous, club-like 
 terminations of the threads. It is jiarticularly this outer ring of radi- 
 ating, club-shaped projections which gives to these bodies their most 
 diagnostic feature. It requires careful study and differential staining to 
 make out the real structure of the actinomyccs bodies. Ordinarily, the 
 central ])art of the colony appear,^ simply as a confused granular and 
 finely-filamentous mass. It has, however, been shown to consist of 
 extremely delicate rods and threads, which branch dichotomouslv, and 
 which, ari'anged somewhat loosely in the centre, become more densely 
 interwoven and larger toward the periphery, and there pass in a radiating 
 manner one into each of the swollen bulbs. This Ijulbous swelling ap- 
 pears to be due to an accumulation of a clear hyaline material in the 
 sheaths of the fibres, and to represent only an involution or degenera- 
 tive condition, not forming an essential part of the living structure of 
 the parasite. The hyaline bulbs may present an appearance of concentric 
 striation, and each one may break up into finger-like jirojections or have 
 somewhat the appearance of a pine cone. They may become calcified. 
 These are all degenerative changes. Both within and outside of the 
 threads are seen round bodies like cocci, which are considered by Bos- 
 troem to be spores, but whose nature is undetermined. They may be 
 very abundant, so that the central part of the colonies consists almost 
 mIioIIv of these round granules with very few threads. Cases of actino- 
 mycosis occur exceptionally in which there are no bulbous endings to 
 the threads composing the colony. In addition to the colonies, numer- 
 ous bacilli are often foiuid scattered throughout the inflammatory nod- 
 ides of actinomycosis. Pyogenic cocci are frequent secondary invaders 
 in actinomycotic growths. Gram's and Weigert's fibrin stain and luemat- 
 oxylin and eosin can be used to advantage in the microscopical study of 
 actinomyccs. 
 
 Many investigators claim to have cultivated the ray fungus. There 
 is so much discrepancy in their descriptions of the characters and con- 
 ditions of these cultures that we cannot recognize all of them as genuine 
 cultures of actinomyces. Probably the most confidence is to be given to 
 the cultures obtained by J. Israel and M. Wolff. They found that actin- 
 omyccs grows best anacrobically and at the temperature of 3o°-37° C. 
 They used chiefly as their culture media nutrient agar and hen's and 
 pigeon's eggs. The growth is slow and in the form of drj^, small, pro- 
 jecting, irregular colonies, which arc at first gray and ti'anslucent, and 
 later opaque. On agar actinomyces grows chiefly in the form of rods — 
 in eggs, in the form of interlacing, branching thi'eads. Bulbous termina- 
 tions of the threads are not tibserved in the cultures. 
 
 The majority of experimenters have obtained only negative results 
 in attempting to produce actinomycosis experimentally in animals by 
 inoculation of material containing the specific micro-organism. Bos- 
 troem in his elaborate article on actinomycosis considers all of the positive 
 results reported up to the date of its publication (1890) as inconclusive. 
 Since that date, however, several observers have reported more or less 
 
334 GENERAL BACTERIOLOGY OF SURGICAL INFECTIONS. 
 
 success in producing the disease experimentally ; and here, again, the 
 results obtained by Israel and Woltf' are the most noteworthy. They 
 succeeded by introduction of their pure cultures of actiuomyces into the 
 peritoneal cavity of rabl)its and jj;uinea-pigs in producing siuall nodules 
 in the ])eritoncuni and spleen. These nodules contained typical actiuo- 
 myces colonies with the bulbous rays. Further investigation is needed 
 regarding the experimental inoculation of actiuomyces. 
 
 Infection both of human beings and of cattle with actinomycosis has 
 been often traced to the penetration of vegetable grains (wheat, barley, 
 oats) or bits of vegetable fibre into tlie tissues. The portal of entry is 
 frequently the mouth, particularly the neighljorhood of the teeth, but it 
 may be through a wound of the skin or through the mucous membranes 
 of the tln-oat, respiratory tract, oesophagus, intestine, or middle ear. 
 It is not always possible to find the jjoint of entrance, as this may 
 heal completely. 
 
 Various clinical types of actinomycosis are recognized according to 
 the seat of tlic afl'ection, such as actinomycoses of the jaws and else- 
 where about the head and neck, of the lungs, the pleura, the vertebrse, 
 the intestine and other abdominal organs, the brain, the middle ear, the 
 skin. There is usually a single localization, but there may be multiple 
 foci, ])resenting sometimes anatomical and clinical characters of pyemia. 
 
 The histological changes are characterized by necrosis and liquefaction 
 of tissue with emigration of white blood-corpuscles as the inunediate 
 effect of the parasite, and a secondary reactive inflammation in the form of 
 vascidar granulation tissue. By some the changes are considered to be 
 more closely allied to those of infectious granulomata than of ordinary 
 inflammation. In some cases the process is rapid and destructive, with 
 little new formation of tissue, and with the pnxluetion of large abscesses j 
 in others the affection may be very chronic, of limited extent, and encap- 
 sulated by new growth of tissue. When bone is involved there may be 
 formed osteophytes and sclerosing ostitis, or there may be simply destruc- 
 tion without new formation of bone. Metastases do not appear to occur 
 in the lymphatic glands comnuniieating by the lymph-current with a 
 j)rimary focus of actinomycosis. 
 
 Madura disease, or mycetoma, both in the melanoid and the ochroid 
 varieties, has been shown by Kanthack to be due to a parasite very 
 closely allied to the ordinary actiuomyces hominis. Kanthack considers 
 that the parasite is simjily a variety of the ordinary actiuomyces. 
 
SYMPTOMS, DIAGNOSIS, AND TREATMENT OF 
 INFLAMMATION, ABSCESS, ULCER, AND 
 GANGRENE. 
 
 By CHAS. B. NANCREDE, A. M., M. D. 
 
 Inflammation is "the succession of changes which occur in a liv- 
 ing tissue when it is injured, provided the injury is not of sucli a degree 
 as at once to destroy its vitality, these changes tending to the repair of 
 tissues or the neutralization or removal of tlie jirimarv niicrohic cause." 
 
 This definition indicates that there are two distinct forms of inflam- 
 mation. The first is a purely regenerative process, which, occurring in 
 aseptic tissues, is productive of cell-proliferation, these new cells devel- 
 oping into a normal, ]iernianent tissue. It must never be forgotten 
 that the processes of infianunation are essentially the sanie in the vascu- 
 lar, the soft and the hard, the superficial and the deep tissues. 
 
 Acute Simple or Plastic Inflammation. 
 
 Because this is a purely regenerative process some contend that it 
 should not be described as a disease. While this is partly true, aseptic 
 inflammation must be here studied, not only because at the outset 
 microbic inflammation presents similar microscopic and macroscopic 
 phenomena, and, when recovery ensues, healing occurs by the same 
 histological changes, but also to learn how microbes interfere with re- 
 generation, and how the surgeon can minimize their malign effects when 
 he cannot wholly exclude them. 
 
 Redness, heat, ])ain, swelling, and impaired function, the classical 
 symptoms of inflammation, can rarely be all detected except when the 
 superficial parts are aflected. The redness, at first uniform, fading 
 into the hue of the surrounding healthy parts, temporarily disappears 
 on pressure, but later becomes mottled with patches of a deeper hue 
 which are uninfluenced by pi'cssure. The uniform tint is from excess 
 of blood in the vessels, while the mottling results either from the 
 diapedesis of red cells, their escape by rupture of the capillaries into 
 the tissues, or from clotting (tlirombosis) of blood in the vessels ; 
 hence pressure influences the first, but not the second, condition. To 
 this excess of blood is also due the increased temperature of the part, 
 although some allege tliat chemico-vital phenomena account for part 
 of the heat : it is doubtful if tlie temperature of an inflamed part is 
 ever higher tlian tliat of the blood in the heart of the individual, in 
 whom, it must l)e remembered, the whole mass of the blood is warmer 
 than in health because of the fcbii/e heat. Swelling also is at first due to 
 
 335 
 
336 DIAGNOSIS AND TREATMENT OF INFLAMMATION. 
 
 excess of blood, but soon the distended blood-vessels jiermit the escape 
 of serum, then licjuor sanguinis and leucocytes, the latter migrating 
 through the vessel-walls l)y virtue of their amoeboid movements. At 
 the jjcriphery of the inflammation little but scrum or some licjuor san- 
 guinis distends the tissues, which, if the jjart be su])erficlal, gives rise to 
 the symj^tom cedema — /. c. the tissues remain pitted for some time after 
 firm pressure has been made, and the part is often paler than normal. 
 This succulence of the tissues has been experimentally demonstrated by 
 examining the amount of fluid returned by the lymjthatics leading from 
 an inflamed area, as compared with that poured out wlien the vessels of 
 the corresponding meml)er were divided : the neighboring lymphatic 
 glands are often enlarged and tender from the ])assage of this excess 
 of lymph, which contains irritating materials. Pain results from the 
 stretching of the nerves due to swelling, from their compression by 
 exudates, their exalted sensibility from increased vascularity, and from 
 the chemical irritation of ptomaines or toxalbumins when present. As 
 the microscopic phenomena of inflammation are described elsewhere, it 
 is only necessary to advert for clinical jiurposes to certain points — viz. 
 that after the primary acceleration of the blood-current a gradual " slow- 
 ing " of this occurs, allowing germs as well as leucocytes to accumulate 
 in the circumferential colorless current ; that from this time on the 
 white blood-cells migrate in increasing numliers until the focus of in- 
 flammation is crowded with leucocytes — indeed, the cell-islets of the 
 tissues are jjractically replaced by the migrated white Ijlood-corpuscles, 
 with a varying number of red cells ; that next stasis of the blood-current 
 occurs, but that if the exciting cause of the inflammation ceases all these 
 processes will be reversed, for the blood which is at rest is not clotted. 
 Thus the central mass of red cells first oscillates, then the current com- 
 mences, the white cells slowly mingle with the central column of red 
 cells, the migrated leucocytes pass off through tlie lymphatics or disin- 
 tegrate, and their remnants are disposed of by the same route, together 
 Avith the excess of fluid, the parts being left in their normal condition. 
 
 When these changes are rapidly effected the inflannnation is said to 
 terminate by " delitescence ;" when the tissues have to be cleared of the 
 migrated cells by their disintegration, " resolution " is the term employed 
 for this slower process. Should these favorable changes not take place, 
 permanent stasis must occur, thrombi forming in the vessels; the effused 
 liquor sanguinis coagulates in the tissues, and the inflamed area, from the 
 combined effect of the original injury, plugging of its vessels, accumula- 
 tion of fluids and of cells, is deprived of j^roper nutriment and disap- 
 pears by absorption, leaving nothing but a mass of young cells held 
 together with a small amount of intercellular cement. That this cellular 
 mass may develop into permanent tissue, its due blood-supply must be 
 furnished, which comes by the ingrowth of capillary loops springing 
 from the blood-vessels of the surrounding undamaged tissues : in other 
 words, fullj'-formed granulations are formed. When the bulk of the 
 cells develops into fibrous tissue a subcutaneous scar results, with its 
 ulterior evil effects, but when less sear-tissue forms, and it is somewhat 
 diffused throughout the part, the condition is termed "fibroid" or 
 " chronic " thickening. 
 
 If during the first stages of inflammation, when the vital resistance is 
 
INFECTIVE INFLAMMATION. 337 
 
 lowered, microbes reach the tissues, an infective inflammation will result, 
 but if their advent be delayed until tlie second stage, that of fully- 
 formed granulation tissue, be reached, mierobic invasion is always vig- 
 orously, and often successfully, resisted. When the so-called third stage 
 of inflammation has been attained — i. e. that of a mature but low-grade 
 tissue, possessing for the time an excessive vascular supply — microbes 
 can exert no more harmful influence than upon any other similar tissue. 
 
 Infecti'Ve Inflammation. 
 
 This is a result of the interference produced by microbes with the 
 processes of repair always attemjited by nature, and tlie products of 
 tissue-metamorphosis do not undergo development intt) a permanent 
 tissue, but sutt'er from degenerative cliangi's. Eitlier tiie ptomaines, 
 peptonizing ferment, or certain toxalbumins are the direct causes, not 
 the germs themselves. These substances produce coagulation-necrosis, 
 directly or indirectly solution of the intercellular cement binding the 
 exudate together, and the fatty degeneration and death of the cells, 
 these latter l^eing gradually absorbed after cessation of the cause, as in 
 certain cases of tuberculosis, or, dying more rapidly, mingle with the 
 pus-cells whicii float in the liquefied intercellular cement mingled with 
 the serous exudate — i. e. the liquor purin. 
 
 Suppuration is now said to be establislied. When this occurs upon a 
 free surface, as that of the skin or a mucous membrane, with loss of sub- 
 stance, the process is termed " ulceration ;" tiie resultant loss of substance, 
 an "ulcer." Occurring distinctly circumscribed in tlie depths of the 
 tissues, it is called an " abscess," or wlien not so sharply defined from the 
 surrounding tissues, a " purulent collection." The pus being evacuated 
 by nature or art, if death does not result from absorption of ptomaines 
 or toxines, the parts revert to their normal condition, except wiiere the 
 tissues have been destroyed in the suppurative process : here a scar com- 
 posed of newly-formed cijiiiiective tissue forms. 
 
 Tlie rapidity with which the inflammatory process passes through its 
 various phases — i. e. whether it is acute, subacute, or chronic — depends 
 first upon the nature of the micro-organisms causing it. Thus infection 
 by the ordinary germs of su])puration or by those of gonorrhoja pro- 
 duces an acute process ; the germs of glanders induce a subacute or 
 clininic inflammation, while tliose of tubercle produce a chronic inflam- 
 mation. Tiie number of any form of germ present influences tlie rapid- 
 ity and severity of the inflammation, for healthy tissues can inhibit the 
 growth of, or entirely resist the action of, and remove, germs, if not too 
 numerous. A few of the minute processes must be briefly reviewed in 
 order to understand mierobic inflammation. 
 
 The primary acceleration and increased volume of tlie blood-current 
 prevent mural implantation of germs or sweep away sucii as liave be- 
 come attached to the vessel-walls. During the second stage — i. e. tliat of 
 the formation of granulation tissue — this process is successfully carried 
 out around the primary infected area, but the pejjtonizing ferment or the 
 ptomaines destroy this boundary-area, and continue to do so until tlie 
 virulence of the cause is exhausted. Tiien the last-formed granulations, 
 surrounding the pus or tlie specific tissue, produce healing of the cavity 
 
 Vol. I.— 22 
 
(^ 
 
 338 DIAGNOSIS AND TREATMENT OF INFLAMMATION. 
 
 after tlie pus oi- liquefied tissue with the germs has been evacuated. In 
 certain instances of cin-oni(^ infective processes, as tubercle, under favor- 
 able conditions, retrograde processes do not occur, the embryonal cells 
 becoming converted into scar-tissue. 
 
 Certain inicrobic jirocesses, such as tubercle or acute osteomyelitis, are 
 not commonly excited by severe injuries, but by slight ones producing a 
 locus mlnorls n'sidcntia'. The increased afflux of blood induced by a 
 severe injury, and the cellular exudate, some of whose elements are 
 doubtless phagocytes, probably ex])lain this. Again, the numerous 
 wliite cells by their power of incorporating foreign bodies serve to 
 remove after such injury germs which are destroyed by the nucleins of 
 the blood or arc excreted l)y the kidneys. The imperfectly vascularized 
 granulation tissue resulting from such chronic infective inflammations as 
 actinomycosis, tubercle, etc. predisposes to supjiuration by preparing a 
 soil for secondary infection with pyogenic organisms. 
 
 To recapitulate : the terminations of inflammation are, for the ])lastic 
 variety, delitescence, resolution, and fibroid thickening ; for infective 
 inflammations, suppuration or ulceration. Gangrene is not a termination 
 of any form of inflammation, but a consequence and an accidental result 
 of the inflammatory process. 
 
 The old view, that inflammation involved an increase in the nutritive 
 activity, is no longer tenable for the infective forms, lowered vitality 
 being the predisposing cause, and, later, the efficient cause of their con- 
 tinuance and spread : this fact is the key to their treatment. 
 
 Inflannnation is primarily a molecular change which may be due to 
 microbic ferments, ptomaines, or toxallnnnins circulating in the blood, 
 or to traumatism so damaging the tissues tiiat the changes of a plastic 
 inflammation will result ; or, from the physical conditions produced, 
 gei'ms, entering elsewhere, will accumulate, producing some variety of 
 microbic inflammation. 
 
 Precisely similar inj\iries inflicted upon different individuals, or upon 
 the same individual before and after an attack — say, of rubeola' — will pro- 
 duce in one instance nothing but a plastic process, in another a grave 
 microbic inflammation. Precedent conditions which of themselves are 
 incapable of producing evil in the absence of some exciting cause, as a blow 
 or wound, thus favor the production of inflammation ; these conditions 
 are termed prcdisposinf) causes. They act by so lowering the vitality 
 of the parts as to render them unable to resist deleterious influences. 
 Among the most common are the impoverishment of the l)lood and the 
 weakened heart's action resulting from insufficient or improper food, 
 the former lowering the tissue-resistance to microbes, the latter so slow- 
 ing the cinndation as to favor the accumulation of germs. The acute 
 antemia and weakened heart produced by hemorrhage act similarly. The 
 weak heart-action often seen in old age favors stasis, and thus aceunnda- 
 tion of germs if any gain access to the circulation, which the ill-nourished 
 
 ' It is important to remembpr th.it not only is inflannnation modified by certain erup- 
 tive ailments, but also tliat inflammation following operation may predispose to them. 
 Thus, scarlatina sometimes promptly follows upon operation where no known exposure 
 has occurred, tlie lowered somatic vitality favoring the development of the eruptive 
 disease. Of course reference is not liere made to the scarlatinoid eruptions of sepsis, but 
 to the genuine eruptive fever, scarlatina. For the pseudo-scarlatina the reader is referred 
 to the section on Septicemia, etc. 
 
INFECTIVE INFLAMMATION. 339 
 
 tissues cannot resist. The dejiravation of tlie blood by the retention of 
 the excreta in ehronic renal and hepatic diseases, as well as in gout, 
 svphilis, and diabetes, predisposes to inflammations. The vasomotor dis- 
 turbances following certain nerve-injuries lead to such imperfect nutri- 
 tion and tendency to stasis that, as is well known, inflammation readily 
 occurs. 'The relation of the so-called strumous diathesis is difficult to 
 understand unless upon the assumption that in some individuals 
 there exists a tendency to excessive cellular proliferation upon trivial 
 injury. The numerous cells so outstrip their nutrient supply that case- 
 ous degeneration is i)rone to occur, pro\-iding an excellent culture- 
 medium for the germs of tubercle primarily, and for those of pus later. 
 
 The exciting causes of inflammation are usually stated to be direct vio- 
 lence — ('. e. mechanical injuries — heat, cold, electricity (as a cauterizant), 
 tension, acids, or alkalies ; but violence per se can only induce primarily a 
 plastic inflammation, nor will the other agencies do more unless infection 
 by micro-organisms ensues ; so that the only exciting cause for inflam- 
 mations which arc not simply the conservative processes of repair (/. c. 
 plastic inflammation) are the ptomaines, peptonizing ferments, or tox- 
 albumins resulting from the development of micro-organisms, direct 
 violence being rclegateil to the category of jjredisposinr/ causes. That 
 healthy tissues can inhil)it tlie growth of or destroy numerous bacteria 
 must never be forgotten, this truth reconciling many apparently con- 
 tradictory facts as to the relation of micro-organisms and inflammation. 
 
 A broad distinction must be made between the micro-organisms of 
 putrefaction and those which are infective or pathogenic, the former 
 living only in dead or dying tissues and generating various poisonous 
 ptomaines, the latter capable of developing in living tissues, thriving in 
 tlie innermost recesses of organs if carried there by the lyinjih or blood, 
 and producing wherever located each its special ferment, toxalbumin, 
 etc. The entrance-point, or " infection-atrium," is usually a wound, 
 especially a foul, ill-drained one, but germs may enter through trivial 
 lesions of the cutaneous, respiratory, or alimentary tract. 
 
 Treatment. — Tliis should be preventive when feasible : the appro- 
 priate measures will be found in the section on the aseptic and antise|)tic 
 treatment of wounds. The curative treatment must first aim to remove 
 the secondary causes which maintain the process, and next to minimize 
 the inevitable damage. Kest in its widest sense must be secured — by 
 quiet of the jiarts obtained by splints or other dressings ; by the drainage 
 eftected by incision and position, thus securing undisturbed contact of 
 healing parts ; by relief of tension, effected by the preceding measures 
 supplemented by incisions other than those for drainage ; by lessening 
 the force and frequeilcy of the heart's action ; by diminishing the blood- 
 supply by local astringents ; by evacuation of irritating materials, as 
 putrid urine, blood, or pus; by the use of non-irritating dressings; 
 and by the recognition and treatment of such predisposing conditions 
 as rheumatism, syphilis, gout, and tubercle. If these measures do not 
 result in the subsidence of the inflammation, the second indication — viz. 
 to lessen the extent of the inevitable damage — must be carried out by 
 measures adapted to improve the nutrition of the tissues, thus prevent- 
 ing local or somatic death. 
 
 The alinormal blood-pressure maintains the dilatation of the vessels 
 
340 DIAGNOSIS AND TREATMENT OF INFLAMMATION. 
 
 and the accumulation and esca])e of licjuid and solid exudates, which by 
 their mechanical pressure on the tissue-cells interfere with their nutri- 
 tion. A lessening of the blood-sujjply will diminish all this and the 
 tendency to stasis. The measures already detailed will effect much, but es- 
 ])ecially treatment of the dyscrasia acting as a predisposing cause. Pain 
 nuist l)e relieved, because it can alone increase local vascularity, induce 
 rise of temperature, ])revent sleep and ingestion of food, thus dii-ectlv 
 lowering vitality ; moreover, severe pain maintains shock and probablv 
 actually kills the very old or very young. The rapidity of cure is often 
 dependent upon the relief of pain and irritati(»n. A close watch must be 
 kept upon the action of the kidneys, skin, and liver — viz. the emunctories. 
 AVhile too free movements of the l)0wels must be checked, in sejjtic con- 
 ditions this attempt of nature to evacuate peccant matters must be most 
 cautiously interfered with. 
 
 From what precedes it is evident that both local and general meas- 
 ures are available, the former sometimes being alone requisite. 
 
 Local Measures. — Rest, com})lete and physiological, must be main- 
 tained. Elevation of the part, by interfering ^\ ith the access of arterial 
 blood, favoring the egress of venous blood, and aiding drainage by the 
 lymphatics, is very useful. Cold is effective, Ijut demands caution, and 
 is best used as a preventive before stasis has taken place, although later 
 it may do good by lessening the congestion at the periphery, even when 
 stasis has occurred at the focus. It is usually only harmful in the later 
 stages, especially if strangulation of the tissues exists, when cold may 
 determine mortification. 
 
 As cold can only act through the vasomotor nervous system, first 
 causing contraction of the arterioles, then of the capillaries and veins, 
 indirectly relieving intravascular pressure, it is only necessary to impress 
 the sensory nerves of the part by moderate cokl, because intense cold 
 directly lowers the vitality of the tissues and jiromotes adhesion of the 
 leucocytes, precipitating stasis, as occurs in frost-bite : moderate cold 
 doubtless renders the amoeboid action of the leucocytes more sluggish, 
 thus opposing diapedesis. To be effective it must l)e continuous. As moist 
 cold, water at the proper temperature can be allowed to drip on the parts 
 — covered with lint or cotton to diffuse the fluid over a wider area — or 
 can be conducted to this covering from the vessel by capillarity, using 
 strips of lint or gauze. The \\ater may contain any germicide desired, 
 this measure being often desirable if sujjpuration is present. Dry cold 
 can be applied by ice-bags or bladders or by Leiter's coils, which can be 
 extemporized out of a few yards of small rubber tubing wired into shape 
 or sewed to a piece of muslin. 
 
 Heat possibly acts derivatively by dilating the peripheral capillaries 
 and those of the skin, but the chief benefit derived from its use is that, 
 when suppuration cannot Ite avoided, it hastens the ])rocess, tending to 
 localize it by promoting the flow of blood and stinudating the amoeboid 
 action of the leucocytes, causing their rapid aecumulati(jn at the focus of 
 inflammation. When resolution is possible the increased blood-supply 
 caused by the application of heat favors absorption of the liquid exu- 
 dates, and the increased anifeboid activity of the wandering cells enables 
 them to migrate through the lymph-spaces, thus clearing the tissues of 
 the solid exudate. 
 
INFECTIVE INFLAMMATION. 341 
 
 Heat may be employed dry by hot- water bags, by bottles, by heated 
 bags of salt, or by Leiter's tubes ; moist heat can be employed by irri- 
 gation or by some form of poultice — /. e. some coherent sulistance, as 
 flaxseed meal, cotton batting, etc., wliicli will retain heat and moisture. 
 Poultices, other tlian wet absorbent antiseptic dressings covered witli 
 oiled silk or rubber tissue, sliould never be employed after a suppurating 
 focus has been opened or when Nature may evacuate this at any moment, 
 since asepsis would be impossible. 
 
 Bloodletting. — To be efficient, this must de})lete the vascular area 
 involved, even at a distance. Thus, blood drawn over the temples is 
 removed from veins which communicate witli the ophthahnic vein ; 
 leeches o\er the mastoid process abstract blood from the radicles t)f tiie 
 mastoid vein, which empties directly into the lateral sinus. Local bleed- 
 ing can do good only in the earlier stages of inflammation, when stasis 
 is about to occur or has just occurred — /. e. before thrombosis has taken 
 place. Employed at this stage, the stagnant blood can be seen to resume 
 its flow through the occluded vessels, and a rapid reversal of the inflam- 
 matory processes takes ))lace.' Leeching or cn])piug is the best means 
 for the local abstraction of blood. Incisions are useful to relieve 
 mechanical tension, to give vent to exudates, and to remove the con- 
 stricting efll'cts of tense skin and f:\scia. The escape of ptomaines and 
 toxalbuniins in the exudate, whose absorption is favored by the extra- 
 vascular pressure of tension, is another benefit. Many short incisions 
 through skin and fascia, thus, — 'Z^ — ZZ — , will relieve tension better 
 
 than one long incision. 
 
 As inflammation is almost solely a vascular process, it may lie proper 
 to starve it, as it were, in rare instances, by pressure upon, or ligature of, 
 the main vessel of the part. 
 
 Astringents are possibly useful at the very outset, when the primary 
 vascular dilatation is commencing, but are better employed during the 
 terminal stages of certain inflanunutions of the mucous membranes of 
 the mouth, nose, urotln'a, conjunctiva, etc. 
 
 Certain drugs possess a limited value. Tims purgatives dejilete, 
 excrete ptomaines and toxalbuniins, revulse, and are intlicated in orchitis, 
 gonorrhcea, and septic peritonitis. Diaphoretics and diuretics do to a less 
 extent what jnirgatives effect, and also lower tcnijicrature. Remedies 
 lowering the cardiac frequency and force are beneticial only at the outset, 
 wliile later digitalis, (piinine, and alcoliol are rctjiiisite to sustain the 
 heart. Auscultation of the heart to ascertain whether the first sound is 
 normal or weakened is more to be depended upon than the character of 
 the pulse. Opium relieves pain," prevents exhaustion from loss of sleep, 
 and contracts the peripheral -^'apillaries : except in children it is best 
 given hypoderniically. Excessive felirile heat, dangerous at any age to 
 the heart and nerve-centres, but especially in the young and tlie old, often 
 causing in the former convulsions, should l)e moderated by cpiinine, 
 
 ' See author's paper in Tmngaclinnit of Avxer. Siirr/. Axxncialinn, vol. i. p. 185, " Have 
 we any tlierapentic means, :ls proven by experiment, which directly afi'ect the local pro- 
 cesses of inflammation?" 
 
 ^ Care should be exercised lest two evils follow : first, checking of the secretions so 
 essential as a means of elimination, and the induction of morphinism when the case re- 
 quires prolonged treatment. 
 
342 DIAGNOSIS AND TREATMENT OF INFLAMMATION. 
 
 dia])horetic.s, .sponging, and the cautious use of antijiyretics. If any 
 constitutional vice l)e detectable, as gout, rheumatism, or syphilis, 
 n])])ni|)i'iate remedies nuist be given. When nervous symjttoms are 
 j)i'onounced in drinkers, chloral and the bromides are indicated to pre- 
 vent delirium tremens. 
 
 CoNSTiTiTTiONAL TREATMENT. — There is no special treatment for 
 inflammation. If the bowels are confined, give a laxative, preferably 
 calomel, followed by a saline, when from over-eating, sedentar}- habits, 
 or drinlc the liver acts inefficiently, not because mercury has any specific 
 action, but because it is acceptable to the irritable stomach so often pres- 
 ent and is an intestinal antiseptic. Under such circumstances moderately 
 restrict food and drink, l)ut never alter a patient's habits unnecessarily. 
 In all cases get the history of the patient. If underfed, feed up ; if over- 
 fed, restrict the diet. If alcohol is used, ascertain the form and (|uantity, 
 and employ the minimum recjuisite to keep the patient from running the 
 risks of the total withdrawal of stinudants; a gin-drinker will not do 
 well on chanii)ague, nor a beer-consumer on M'hiskey. In malarial 
 neighborhoods quinine is usually advisable. In the young and vigorous 
 less food than usual, and that of an easily digestible nature, must be em- 
 ployed at the outset, but the feeble, in whom an asthenic type of inflam- 
 mation is apt to prevail, should receive from the beginning as large 
 quantities of easily digestible food as can be assimilated. 
 
 Chronic Inflammation. 
 
 The pathological processes are essentially the same as in acute inflam- 
 mation, the vessels remaining dilated with continuous escape of leucocytes 
 and li<|U(>r sanguinis, which stinudatc growth and excessive prolifcrati<tn 
 of fixed connective tissue, and jwssibly other cells. The caitscn are the 
 same as for the acute process, but they act more slowly and with less 
 intensity. Passive congestions, the strumous, rheumatic, or gouty diath- 
 esis, with constitutional syphilis, often serve as predisposing causes. 
 The exciting causes are often so trivial as to be overlooked, but second- 
 ary causes maintain the inflammation. Thus the tension from synovial 
 effusion produced by the use of a joint in a rheumatic person after a slight 
 injury may keej) uj) trouble for years. Unsuspected latent tubercular foci 
 may give trouble only after over-exertion or a slight traumatism has so 
 increased their vascularity that renewed growth and continuous extension 
 occur. 
 
 Symptoms. — The redness, if present, is dusky ; there is apt to l)e 
 pigmcntatioii from the constant escape of red blood-cells. A dull 
 aching, most marked at night, increased l>y pressure, or perhaps tender- 
 ness only, is complained of, rather than acute pain. While slight increase 
 of heat may be noted, often there is no local rise of temperature. Swell- 
 ing is always well marked and detectable if the part be not too deeply 
 seated. Constitutional symptoms, as fever, are sometimes alisent, espe- 
 cially if no important organ is involved, but the patient is usually out 
 of health, and may present evidences of syphilis, rheumatism, gout, or 
 tubercle. The possible terminations of chronic inflammation are resolu- 
 tion, sujipuration, or ulceration, chronic induration or thickening, casea- 
 tion, and calcification. 
 
ULCERATION AND ABSCESS. 343 
 
 Treatment. — All secoiulary causes of irritati(in must he removed, the 
 dilated vessels with their sluggish current promoting constant escape of 
 leucocytes, and the formation of a low grade of interstitial connective 
 tissue — *. e. scar-tissue — must be stimulated to contraction. The nutrition 
 of the tissues should be ])rom(ited by the access of arterial blood and the 
 free return of the venous blood, and means sliould be taken to promote 
 the absorption of intlammatory exudates. Sup[)orting pressure will 
 reduce the size of the vessels and induce atrophy of the poorly-organized 
 exudate. Massage will break down exudates, force the cells into the sur- 
 rounding lvmj>h-spaces, increase the arterial afflux, and favor the venous 
 efflux. Aiteruatc hot and cold douches are also valuable vascular stimu- 
 lants. Counter-irritation l)y l>listers, the actual cautery, etc. is of value 
 if employed upon tiie contiguous vascular areas above or below the part, 
 but can only jjro\'e harmful \vhen applied to the part itself. Improve- 
 ment of the general health by appropriate remedies and attention to any 
 goutv, rheumatic, tubercular, or syphilitic taint is essential to success. 
 
 Gener.\l Considerations. — Ulceration and Abscess. 
 
 These processes are always the result of microbic infection interfering 
 with the normal processes of repair, the so-called " plastic inflammation," 
 which results from the injury of aseptic tissues, provided their vitality 
 be not at once destroyed. All su|)purative processes are essentially de- 
 structive, resulting in loss of tissue. A\'hen such microbic inflammation 
 takes place upon a free surfiicc, as a cutaneous or mucous membrane, loss 
 of substance occurs by molecular destruction of tissue, the processes 
 which produce this being called " ulceration," and the resultant area of 
 inflamed tissue which has suffered loss of substance is called an " ulcer." 
 
 All ulcers heal by the organization of granulations which become 
 covered by epithelium. When primary iniion fails or when sloughing 
 results from traumatism, tlie term "ulcer" is aj)p]ied to any granulating 
 surface left, because healing takes place by the same proces.ses. Although 
 the pathology of inflammation and suppuration will receive extended 
 notice elsewhere, it is essential here to describe briefly certain portions 
 . of these ]iroces.ses, that the reader may comprehend what follows. 
 
 From the ))resence of microbes at the outset, or because of their sec- 
 ondary implantation at the focus of inflammation, the tis.sues at this spot 
 become so crowdcil with exudates that they are practically replaced by 
 masses of young cells, anil the vessels are thrombosed, so that a return 
 to the normal state is impossible unless a new vascular supply enables the 
 cells of the exudate to develop into a permanent tissue. In the normal 
 reparative processes- nutriment from the surrounding vascular areas 
 reaches the most centrally located cells, passing from cell to cell or be- 
 tween them, tile cells Ix'iug held in contact by the intercellular material 
 until vascular loops interpenetrate the exudate. 
 
 The presence of microbes changes all these processes. The resultant 
 peptonizing ferments or the ptomaVnes cither attack the vitality of the 
 cells, or, by disassociating tiicm t)y dissdlving the intercellular cement, })ut 
 tlicm into condition to undergo fatty degeneration, to die, and to become 
 suspended in a fluid, the /itjuai- puriK, composed of exuded serum, lique- 
 fied intercellular cement, and exudate. When these processes are very 
 
344 DIAGNOSIS AND TREATMENT OF ABSCESS. 
 
 rapid small areas of tissue beeonio surrounded by others so tii<)roiii;hly 
 infiltrated with cells that upon their st)lution into pus these conipara- 
 ti\-ely unaltered fragments are seen floating as shreds in the ])us. \\'hen 
 this occurs upon a free surface a variety of sloughing ulcer results. 
 AVhile many forms of microlx's have at times proved to he j)yogenic, 
 the most common varieties found in acute abscesses are the ytiijiliiilo- 
 coccus pi/of/ciici aureus and a/bus. The fact that these germs tend to 
 aggregate into clusters (hence their name) would seem to exjjlain the 
 circumscribed chai'acter of the suppurations they initiate. A marked 
 difference is usually noticeable in ]iurulent conditions induced by strep- 
 tococci. These germs rapidly become diffused through the tissues by 
 way of the lymphatics, and are therefore apt to originate diffused sup- 
 puration. 
 
 That microbes are the cause of suppuration would seem to be contra- 
 dicted by the occasional failure to find them in cold abscesses, but the 
 explanation of the ajjparent exception is twofold : either that they were 
 present earlier, but died from lack of pabulum or self-poisoned bv their 
 own excreta, or that in the given instance the tubercle l)aeillns acted as 
 a pyogenic organism; which is unciuestionably, although rarely, true. 
 Again, however closely it may resemble pus, the fluid contained in many 
 cold abscesses is not pus, but liquefied caseated tubercle, no pus-cells 
 being discernible. Local sujipuration can be promptly and certaiidy 
 produced by the inoculation of ordinary pus-germs, as liy rubl)ing pure 
 cultures into the intact skin. The fluid resulting from the injection of 
 aseptic chemical substances, such as turpentine, croton oil, etc., is puruloid, 
 but is not pus. It is merely a fibrinous exudate containing numerous 
 cells ; is only seen when exceptionally favorable laboi'atory conditions 
 are secured ; shows no tendency to spontaneous evacuation, as true pus 
 does, because the solvent action of the peptonizing liacterial ferment is 
 absent, which also prevents the coagulation of new exudate ; and finally, 
 is never found clinically. Again, the injection of a jitomaine into the 
 tissues merely reproduces the conditions which would be furnished if 
 bacteria were present. 
 
 Predisposing- Causes. — Abscess being a result either of primary or 
 of secomlary microbic inflammation, those ccmditions which experience has 
 .shown to predispose to this variety of inflammation nnist favor pus-j)ro- 
 duction. Local conditions which lower the vitality of the tissues, and 
 general impairment of nutrition, however effected, favor microbic inflam- 
 mation. Temporary slowing of the circulation from accidental causes, 
 especially when aided by anatomical conditions, favors localization of 
 microbes. Thus a trivial contusion of the medulla of bone, rupturing a 
 few vessels in which thrombi form, produces a collateral hyperemia which 
 produces a slowing of the circulation, so that mechanically — being heavier 
 than the blood-cells — the germs accumulate. The tortuosity of the medul- 
 lary vessels, and in consequence the sluggish current flowing through them, 
 favor microbic implantation, so that exjiosurc to cold, driving the blood 
 from the surface, may cause such additional dilatation of the vessels as 
 to determine an accumulation of germs if they have gained access to the 
 circulation by any distant infection-atrium. 
 
 General Symptoms of Abscess. — Pus-formation is so often pre- 
 ceded by a chill or rigor that when this occurs during an attack of local- 
 
ACUTE ABSCESS. 345 
 
 ized inflammatioii it is too commonly vicwi'il as a oonelnsive symptom, es- 
 pecially if the fever which results is followed by a second chill. This idea 
 is erroneous, as in some individuals, especially when certain parts or organs 
 are involved, the chill may he only indicative of the thorough establish- 
 ment of the intlanimatory process or the sudden involvement of a new 
 area : again, all malarial poisoning nuist be excluded. Fever will be 
 present in varying degrees, witli its concurrent anorexia, coated tongue, 
 dry skin, confined bowels, and scanty urine. In some individuals de- 
 lirium may be present ; but all these symptoms, it must be remarked, 
 are not those of abscess specially, but of the inflammatory process which 
 is terminating in sujtpuration. 
 
 As the thoroughly infiltrated focus dissolves into pus the peripheral 
 area, just about to be converted into granulation tissue by the ingrowth 
 of capillary loops, is attacked by the ingrowing germs and tlieir solvent 
 ])roducts, and breaks down into pus, thus enlarging the abscess-area. 
 This futile attempt at the formation of gramdations usually goes on 
 until nature or art evacuates the abscess, when, the tension being 
 relieved, the excessive vascularity disai)pears, the perijihcral layer of 
 granulations becomes perfected, the cavit}' collapses, the apposed sur- 
 faces fuse, and, epidermis forming over the skin-orifice, cicatrization is 
 completed, the granulation tissue becoming converted into connective 
 tissue ; i. e. a subcutaneous contracting xcar forms. 
 
 When the jn-ocesses are slowcn-, or from any cause the ])vogenic organ- 
 isms lose tiieir virulence, the peripheral layer of intiltratctl tissue becomes 
 converted into granulation tissue, but from the non-evacuation of the 
 pus is prevented from fulfilling its normal function — viz. conversion 
 into fidly-formed but low-grade connective tissue ; this process stops 
 halfway, the deeper layers undergoing this change, while the superficial 
 remain here and tliere as scattered, ill-formed granulations : this mem- 
 brane-like structure is the miscalled pyogenic membrane. 
 
 Acute Abscess. 
 
 The causation, pathology, and mcth(^d of healing must be sought in 
 the section on Inflammation. 
 
 Symptoms. — During an acute inflammation the process becomes 
 more localized at one point. Throbbing ]iain is felt, and a chill often 
 occurs when pus forms. If superficial, the inflammatory redness and 
 swelling become more circumscribed ; palpation discovers central soften- 
 ing and fluctuation : this spot becomes more ]5ronnnent — /. c. ])ointing 
 takes place. The skin, becoming j)urplish, glazed, and thinned, gives 
 way, either after the- sejiaration of a slough or by ulceration following 
 the formation and rupture of a bleb of cuticle. A deep-seated absces.s 
 is shown by oedema, mottling of the skin, tenderness, and localized 
 induration, or a sense of resistance of the deeper parts, with obscure 
 fluctuation ; fever, and probably rigors, having preceded these symptoms. 
 When in doubt the grooved needle nnist be emjiloyed. 
 
 Treatment. — Up to the time of incision or rupture warm jioultices 
 will hasten the process and limit its extent, but when about to be spon- 
 taneously evacuated moist antiseptic dressings must be substituted. Pus 
 should always be early evacuated by incisions made at the mo.st depend- 
 
346 BIAGNOSIS AND TREATMENT OF ULCERS. 
 
 ent part to facilitate drainage if no important s^tructnrcs are in the way. 
 Snch incisions must be free, and should l)e followed l)y the introduction 
 of drainage-tubes. Sometimes counter-openings are advisable. Pus ought 
 to be allowed to flow away, because pressure will rupture granulations, 
 the only barrier against absorption of noxious })roduets. Subsequently, 
 antiseptic dressings must be used— never a poultice. Pus is always de- 
 structive, causing absorption of the tissues as it pursues the line of least 
 resistance, and may open into joints, nnicous canals, etc. ; hence, when 
 in the perineum, near the peritoneum, in a tendon-sheath, beneath tense 
 fascia, or compressing a canal, as the trachea or urethra, especially 
 prompt intervention is demanded. In exposed parts the sear of an 
 incision is less unsightly than that following Nature's efforts. When 
 pus deeply underlies important vessels or nerves a small incision through 
 the skin and fascia should be made, the tissues bored through with a 
 grooved director until pus is reached, along this instrument a pair of 
 dressing-forceps be introduced, closed, and withdrawn partly opened, thus 
 lacerating the structures without risk to arteries or nerves ; a drainage- 
 tube can then be inserted. This is " Hilton's method." Rarely, from 
 loss of support, severe venous hemorrhage follows ojjening an abscess, 
 or later a large vessel — vein or artery — ulcerates. 
 
 [So-called chronic or cold abscess, being really a tubercular process, 
 will be treated of in another part of this work. 
 
 Ulcers. 
 
 As already stated, an ulcer is a solution of continuity, situated upon 
 the skin or a mucous membrane, jtroduced by molecular loss of sub- 
 stance, sometimes increased by sloughing, the result of microbic in- 
 flammation : any granulating surface left after accident or operation is 
 also called an " ulcer." 
 
 Although ulcers may be described as belonging to one or other of 
 certain classes, accidental conditions may cause them to change their 
 characteristics. Ulcers are divided into those where the characteristic 
 appearances are due to local conditions, and those resulting from specific 
 or constitutional causes. In this section we arc concerned with the first 
 class only. 
 
 Simple Healthy or Healing Ulcer. — As every ulcer must 
 attain this condition as it cicatrizes, the appearances of this form of 
 ulcer must be carefully studied, all non-specific ulcers being mere varia- 
 tions from this type, the result of ol)staeles to Nature's attempt to heal 
 by the organization of granulations and their covering over by epi- 
 dermis. 
 
 The margins are smooth, shelving down to a level base, which is cov- 
 ered by healthy granulations moistened -with a small quantity of creamy, 
 inodorous pus. The surroun<liug tissues are healthy, and not inflamed. 
 The edges of the ulcer are not tender, and merge gradually with the 
 granulations by a bluish-white film, opacpie and whiter on the skin side, 
 bluish and translucent at the j)oint of junction with the granulations. 
 These appearances are due to the advancing epithelial covering, consist- 
 ing of many layers resting upon slightly vascular, newly-organized 
 granulation tissue where opaque and white, allowing the tint of the 
 
ULCERS. 347 
 
 more vascular, iinperfeotly-dcvcloped siramilation tissue to show through 
 the thimier kiyers of epitlieliuin wliere hhiisli. 
 
 Treatment. — Protection from irritants and rest for the part are all 
 that are usually requisite unless the surface be very extensive, when skin- 
 grafting, preferably by Thiersch's method, may become requisite. 
 
 Fungous Ulcei;. — Let anything interfere with the return circula- 
 tion from a simple ulcer, as position, or excessive formation of scar-tissue 
 in and around the margins of the ulcer, and the granulations will 
 become congested, overgrown, ill-formed, projecting above the healthy 
 margins, bleeding upon the slightest touch, and secreting an abundant 
 thin, purulent, possibly blood-stained, discharge. 
 
 Treatment. — Remove the cause, by position favor the return of 
 venous blood, emjiloy agents which will constringe the vessels of the 
 granulations, and give mechanical suj>port to the circulation — /. e. pres- 
 sure. Solutions of sulphate of cojipcr (gr. j-x to fsj), sulphate of zinc 
 or nitrate of silver in the same strength, sterilized oxide-of-zinc oint^ 
 ment, with occasional use of the solid stick of nitrate of silver, and 
 sometimes compression effected by a roller bandage, usually suffice. 
 
 The CEdematous Ulcer. — Employ wet dressings or prolonged 
 ])oulticing, especially with a feeble venous circulation in the part, and, 
 although the margins of a previously healing ulcer may remain fairly 
 healthy, the granulations will become swollen, flabby, pale, semi-translu- 
 cent, and friable from aKlema, and will extide much watery pus. 
 
 Treatment. — Here more blood, and blood circulating at a proper 
 iiite, is demanded ; hence stinudant ajjplications, as grs. v-x of chloral 
 to .y of water, resin ointment, l>alsam of Peru, or some astringent, and 
 meclianical support, are indicated. 
 
 The Inflajimatory Ulcek. — Let certain individuals indulge freely 
 in alcohol, especially if previously ill-nourished and improperly fed dur- 
 ing their drinking-bout, and a traumatism which would in others, or even 
 in them under more favorable circumstances, produce an ordinary ulcer, 
 often will residt in a ra]Mdly-enlarging ulcer of irregular form, having 
 sharp-cut or ragged margins, the Itase formed of the red, inflamed tissues 
 freely secreting a sero-sanguinolent discharge, which often contains 
 shreds of tissue. If the inflanmiation is hyperacute, the base of the 
 ulcer may be covered with yellowish sloughs. The circumjacent skin 
 is inflamed and cedematous. 
 
 Inflamed Ulcer. — When a ])rcviously healthy ulcer is irritated, 
 neglected, and dirty, especially in drinkers, inflanunation may attack the 
 granulations, which become red and swollen, and slough ; the margins 
 break down, the ulcer spreads, and the surrounding tissues present the 
 ordinary phenomena 'of inflammation. 
 
 Treatment. — Removal of all local irritation, elevation of the parts, 
 warm, moist, unirritating antiseptic lotions, as of boric acid, or, better, 
 when feasil)le, the continuous warm antiseptic bath, are indicated. 
 Drinking should be stopped, more food and of a better quality must be 
 provided, and the eliminative organs stinudated. This combined local 
 and general treatment will usually soon convert either the inflanunatory 
 or the inflamed ulcer into a simple one. 
 
 The Sloughing Ulcer, except when this term is applied to the 
 worst cases of the varieties just described, is rarely seen except in con- 
 
348 DIAGNOSIS AND TREATMENT OF ULCERS. 
 
 nection witli venereal disease in those broken-down by ak'ohol and 
 sexual excesses. In such patients destruction of parts ])r()grcsses with 
 great rapidity. The cellular tissue is more extensively dcstmyed than 
 the skin ; hence the edges of the ulcer are undermined and inverted, 
 and of a dusky-red hue, the base being covered with gray (ir black 
 sloughs. Tliere is great pain, and severe constitutional disturbance is 
 the rule. 
 
 Treatment. — This docs not differ from that of the inflamed ulcer, 
 except that anodynes will be required to relieve pain, and, as svpliilis is 
 often present, mercury must be used with a sparing hand or be entirely 
 withheld. Tonics, good food, and stinndants will often be requisite. 
 
 The Phagedenic Ulcer is believed to result from the multipli- 
 cation of a specific micro-organism in the tissues of those broken down 
 by intemperance, bad food, etc., and is usually of venereal (chancroidal) 
 origin. The surrounding skin is of a dusky-red or ])urplish hue. The 
 margins of the ulcer are ragged and uudcrmiiUMl, tiie l)ase is covered 
 with bloody discharge and sloughs, and when tiiis last condition is pro- 
 nounced what is termed a " sloughing phagedena " results. The tissues 
 melt away with astounding rapidity, the external genitals of the male 
 or female sometimes being totally removed. Great pain and high fever 
 are the rule. 
 
 Treatment. — As infection by a virulent organism is the cause, thor- 
 ough destruction of the surface and margins of the ulcer, with some of 
 the adjacent tissues, must be effected by strong nitric acid, bromine, or 
 the actual cautery. In the milder forms disinfection with a 1 : 1000 
 corrosive-sublimate solution, followed by the free use of iodoform, may 
 suffice. The continuous warm antiseptic bath may supersede or supple- 
 ment other methods. Opium, tonics, stimulants, and good food are 
 imperatively demantled, with improvement of the patient's hygienic 
 surroundings if these be poor. 
 
 Indolent or Chronic Ulcer. — Let any granulating surface have 
 its healing processes repeatedly interfered with bj' mechanical or other 
 irritatiiin, and, while the formation of epidermis is prevented, the em- 
 bryonic tissue forming the margins and base will develop into dense 
 filn'ous tissue, fixing them to the subjacent fascia, periosteum, or lione. 
 This is aided by a weak venous circulation, favoring congestion, which 
 condition of the circulation may result either from a feeble heart, vari- 
 cosity of the veins, the dependent position, or all combined. In addi- 
 tion, the contracting cicatricial tissue cuts oft' much of the arterial supply, 
 preventing the formation of healthy granulations. Healing is also seri- 
 ously interfered with Ity cicatricial fixation of the margins and base of 
 the ulcer, for, as will be explained (see p. 368), much of the healing of 
 any granulating surface depends upon diminution of its superficial area 
 by contraction of the deeper layers of granulation tissue, which fixation 
 of the base to the deeper structures absolutely prevents. These points 
 must be kept in view as governing thei'apeutics. 
 
 Symptoms. — The lower third of the leg is the favorite position, and 
 the poorer classes the victims. The edges are smooth, rounded, much 
 elevated, insensitive, while the circumjacent skin is bronzed or purplish : 
 eczema is quite common. The base has few if any granulations, and 
 these are scattered, pale, and flabby, and covered with an oftentimes very 
 
ULCERS. .349 
 
 offensive thin, piiruloid, or sanious discharg'e. Usually hut little pain is 
 experienced. When left untreated they last for ten, twenty, thirty, or 
 forty years. Certain of these ulcers, if subjected to constant irritation, 
 undergo an epithelioniatous change, and are then known as " jNIarjolin's 
 ulcer.'' 
 
 Treatment. — This must depend ujjon the conditions. If access of 
 arterial lilood is prevented by the cicatricial margins, radiating incisions 
 through these may be made, a fly blister may l)e applied covering base 
 and margins, tincture of iodine may be similarly employed, or ati'ophy be 
 induced by the pressure of an elastic l3an<lage or adhesive-plaster strap- 
 ping. If venous return is markedly interfered with, as is so common, rest 
 in bed, if possible, must be employed or support afforded the veins by 
 bandaging or an elastic stocking. In a few instances, where further 
 contraction of the base is rendered impossible by the adherent margins, 
 interrupted or comjjletely encircling incisions, placed aliout one inch 
 from the margins, will ])rove useful, the free bleeding being arrested by 
 antiseptic packing. Again, the base and margins may be curetted, free 
 disinfection effected by chloride of zinc in solution, peroxide of hydrogen, 
 etc., when subsequent antiseptic dressings and the recumbent posture will 
 often effect a cure. Where the power of the margins to reproduce epi- 
 thelium is impaired, and the jihysical conditions are unfavorable for 
 diminution in area by contraction, skin-grafting is indicated. Araputa- 
 tum is occasionally, but rarely, demanded. 
 
 When eczema of the skin surrounding any variety of ulcer is 
 marked, the term "eczematous ulcer" has been applied. If varicose 
 veins exist, the ulcer is often called a " varicose ulcer." Except for 
 the fact that in the first case tlic condition of the skin may call for 
 somewhat different dressings, and in the second that interference with 
 venous return prevents that proper condition of the circulation in the 
 parts which is essential to the formation of healthy granulations, 
 these distinctions are worse than useless as implying some specific 
 cause. 
 
 In certain women — usually over forty years of age — a form of ulcer 
 is seen called the " irritable or painful." It is connnonly situated above 
 and near to the ankle — is small, superficial, and usually markedly con- 
 gested. There can be no question as to the involvement of some nerve- 
 filament standing in a causative relation. This is shown by treatment. 
 In a few instances examining the surface carefully with the point of a 
 probe will demonstrate some sjiccially tender point. 
 
 Treatment. — Rest in bed, elevation of the parts, simple, non-irritat- 
 ing antiseptic dressings, passing a tenott)me liencath the margin of the 
 ulcer at any spot where -by point-pain the involvement of a nerve-twig is 
 demonstrable, or, where this cannot be detected, the administi-ation of 
 a grain of opium three or four times daily, will usually effect a cure : this 
 latter drug is really curative, as under its use tlic congestion disappears, 
 because irritation of a sensory nerve will produce congestion in tlie area 
 supplied by that nerve. 
 
 Descriptions of syphilitic, gouty, tubercular, lupous, scorbutic, and 
 carcinomatous and rodent ulcers — which last are really superficial epi- 
 thelioniatous ulcers — must be sought for in the proper sections of this 
 work. 
 
350 DIAGNOSIS AND TREATMENT OF FURUNCLE. 
 
 PUBUNCLE. 
 
 Furuncle, or boil, is a localized, deep-seated inflammation of the skin, 
 producing one or many circumscribed, firm, acuminated, painful swell- 
 ings, in which central sloughing and .suppuration usually occur. Occur- 
 ring in numbers and successive crops, the term " furunculosis " is applied 
 to the condition. 
 
 Symptoms. — First, a small, reddened, ill-defined, tender point 
 appears in the true skin. This increases in size, becomes elevated, 
 pointed, is densely hard, very painful, and dusky red. In from a 
 week to ten days central sujipuration occurs, the little jiustule ruptures, 
 revealing a yellowish central slongli, at the periphery of which pus can 
 be expressed. In a day or two the slough separates with rather free 
 suppuration, leaving a little crater-like cavity. The pain and snjipura- 
 tion now jiromptly subside and cicatrization occurs, leaving a purplish 
 indurated mass for some little time. Sometimes the inflannnation stops 
 shoii of suppuration, a " blind boil " resulting. 
 
 Sites. — Any portion of the cutaneous surface, but preferably the face, 
 neck, and contiguous parts, the back, axillre, buttocks, perineum, scrotum, 
 and extremities. 
 
 Causation. — Mental overwork, excessive bodily fatigue, irregular hab- 
 its, improper food, and all causes which depress vitality seem to predi.s- 
 pose to boils. Diabetics and ansemic patients, and those suffering from 
 urffimia or from sepsis, are pi'one to them. Occasionally persons appar- 
 ently in vigorous health will have frequently-recurring boils. It is 
 alleged that the pseudo-epidemics of boils which sometimes prevail dur- 
 ing the spring and autumn are due to atmospheric influences : this can 
 only lie true because rapid variations in temperature and atmospheric 
 pressure produce changes in the cutaneous circulation. 
 
 Diagnosis. — The boil can hardly be confounded with anything but a 
 carbuncle, which is larger, flattened, has many points of suppuration, 
 is single, and is painful, but not tender. 
 
 Treatment. — Success is often not easy to attain. Removal of the 
 cause when possible to ascertain, fresh air and moderate exercise, atten- 
 tion to the bowels and digestion, carefully-regulated but varied diet, 
 tonics, quinine, arsenic and iron, sulphide of calcium, sulphite or hypo- 
 sulphite of calcium, etc., have all proved useful at times. 
 
 Ahorfive Treatment. — When a hair is in the centre of the boil its 
 evulsion will sometimes arrest the process. I am doubtful whether pen- 
 etration of the ajiex with a hot needle or the use of carbolic acid is 
 advisal)le, although these procedures have high authority upon their 
 side. 
 
 Local Treatment. — As the penetration of germs, notably the stajiliylo- 
 coccus pyogenes aureus, into the hair- or sweat-follicles, and thence into 
 the epidermis, causes boils, cleansing of the parts and arrangement of the 
 clothing, so as to prevent friction aiding penetration of micro-organisms, 
 are important. Thus, after cleansing, a 10 per cent, salicylic-acid oint- 
 ment may be gently rubbed into the skin, or ichthyol in full strength or 
 diluted. 
 
 When .suppuration has occurred or is threatening, a moist, weak germ- 
 icidal dressing covered with oil-silk or rubber tissue is indicated. Anti- 
 
PAPMXYCHIA. 351 
 
 sepsis and asepsis should be maintained, as more than one fatal case of 
 pyaemia or septico-pyiemia has had its origin in a boil. 
 
 Paronychia. 
 
 Felon, or paronychia, is an infective cellulitis attacking the soft parts 
 of the fingers, and more rarely those of the toes. This may involve 
 the sheaths of the tendons or the periosteum. The anatomical disposi- 
 tion of the structures forming the pulp of the fingers will ex])lain cer- 
 tain differences in the course pursued by a whitlow of a distal as com- 
 jjared with one of a proximal phalanx. The distal phalanges possess no 
 separate ])eriostenm, the vessels supplying these hones ramifying in the 
 dense cellulo-adipose tissue forming thi' finger-pulps, which tissue is con- 
 tinuous with the skin and bone through the medium of numerous con- 
 necting fibrous bands. Hence a destructive infianuuatiou, if deep seated, 
 especially if it lead to sloughing of the pulp, almost necessarily leads to 
 necrosis of the underlying jjortion of the phalanx. As the first and second 
 phalanges possess a distinct periosteum, abscesses of the soft parts cover- 
 ing them, or a suppurative teno-synovitis, may occur without death of the 
 bone, although this often <iccurs in neglected cases. Su[)purative teno- 
 synovitis in this locality may, however, extend upward, producing 
 palmar abscess, or even, when localized, sloughing of the tendon. Par- 
 onychia is alleged sometimes to occur as an epidemic, but it more 
 usually results froua infection by pyogenic organisms of some trivial 
 puncture, cut, or contusion, in the last event the germs gaining access 
 to the circulation by some distant infeetion-atrium and liecoming local- 
 ized at the point of injury — /. c. a locus ininoris resistcntiaj. 
 
 Symptoms. — There are two distinct varieties — viz. a superficial and 
 a deep. The superficial may attack one or several fingers in turn, and 
 often affects the tissues around or under the nail. When slight the dis- 
 ease may promptly subside, but if more severe, serous or purulent col- 
 lections take place beneath the epidermis, whicli, if removed, leaves a 
 raw, reddened, or ulcerated derm, the cicatrix remaining for some time 
 reddened and tender. A\'hen the inflammation runs high suppuration is 
 free, and fungous granulations are apt to form beneath or around the 
 nail, which after weeks, or perhaps months, exfoliates in whole or in 
 part. 
 
 Treatm.ent. — Rest, elevation, and moist, non-irritating antiseptic 
 dressings are all that are requisite for the milder cases. For the more 
 severe type antiseptic gauze or cotton poultices,' and prompt aseptic 
 incision when pus forms, are indicated. Tonics and good food are 
 recpiired if the patient be in feeble health. If the nail mechanically 
 maintains the irritation, it must he removed partially or entirely, the 
 exuberant granularions lie destroyed by the curette or powdered nitrate 
 of lead, and asepsis be secured and maintained by proper dressings. 
 
 The deep whitlow, while it may start in the dorsum or some other 
 surface of any jihalanx if an injury be there situated, most commonly 
 originates on the palmar surface of the finger-tip. Deep-seated inflam- 
 
 ' By this term is meant the maintenance nf warmtli and moisture by covering tlie 
 wetted cotton or gauze with a substance impervious to moisture, and which retains tlie 
 heat, as oiled silk, waxed paper, or rubber tissue. 
 
352 DIAGNOSIS AND TREATMENT OF DRACONTIASIS. 
 
 niations, shown by redness, tendei-ness, swellin<j, tension, and tlin)l)l)ing 
 pain, manifest themselves in from a few lionrs to several days after the 
 injury, with inereasing fever. All the ioeal conditions are agfi;ravated 
 by the dependent position. Suppuration is the rule, resolution the 
 exception, pus usually formincr early, but, owing to the density of the 
 tissues, fluetuation is difHt'ult to detect. Care must be exercised not to 
 overlook the more deep-seated pus because of the occasional formation 
 of a superficial collection of matter. Gangrene, although i-are, has been 
 observed. Abortive treatment by nitrate of silver, iodine tincture, etc. 
 is so rarely successful that it cannot be recommended. Hot fomen- 
 tation.s, followed by warm antiseptic poultices, may be tried for about 
 forty-eight hours, wlicn, if decided retrogression of the symptoms does 
 not occur, free aseptic incision must be resorted to, esj)ecially when the 
 last phalanx is involved, when an early cut reaching to the bone often 
 atibrds the only chance of preventing necrosis. If the tissues over the 
 first or second phalanx be involved, the early incision had better open 
 the tendon-sheath, because probably at this time only a suppurative teno- 
 synovitis exists, but later lateral or other incisions may become requisite, 
 which should extend down to the bone. Sjjontaneous separation of the 
 necrosed distal ])halanx near the epiphyseal line will often take place, 
 leaving a deformed but useful tinger-tip. Death of a first or second 
 phalanx usually indicates amputation, although sometimes excision of 
 the necrosed portions may leave a fairly useful finger. 
 
 Dbacontiasis. 
 
 This is due to the development of a nematode worm (Filaria or Dra- 
 cunculus Medinensis, Guinea-worm) in the tissues, resulting in the for- 
 mation of a subcutaneous tumor just before the exit of the worm. The 
 larv;e of the parasite gain access to the system by the drinking-water. 
 In Guinea, the Gold Coast, Arabia, Upper Egypt, Nubia, Abyssinia, 
 Hindostan, and a few other localities it is endemic. 
 
 Symptoms. — Until the worm is nearly mature there are no symptoms, 
 but a small coiled-up mass can be felt subcutaneously. In mild cases a 
 small, circumscribed tumor forms, accompanied by itching and tension. 
 The tumor may not form exactly where the worm was first detected. 
 From scratching or other cause the tumor ruptures, serum escapes, and 
 the white extremity of the worm can be seen in the cavity left. If ])ro])- 
 erly treated, the worm, which soon protrudes, should be gotten rid of 
 in from three to ten clays. Some patients suifer from violent, painful 
 infiammation along the entii'e worm-track, resulting in abscess with 
 marked ct)nstitutional symptoms. Sometimes in these cases the worm 
 perishes, softens, and thus leads to the serious accident of its breaking 
 during extraction, which, setting free the embryos — Mhether the Avorm 
 be dead or not — may lead to gangrene or death. This accident may some- 
 times end more fortunately by the discharge of the worm later on, after 
 the formation of a new tumor. The favorite site (90 per cent.) for the 
 extrusion of the worm is the foot, preferably the heel, but it may escape 
 from the leg or, exceptionally, from any part of the body. While only 
 one worm is the rule, t^No, or ver}' rarely even fifty, have been noted. 
 
 The female, \\ hich produces the symptoms, has a slightly convex head, 
 
3rADUBA FOOT. 353 
 
 a pointed tail, is about oue-teuth of an incli in diameter, and varies in 
 length from one to six feet, measuring upon tlie average from two to 
 two and a half feet. Crowded ^vith embryos, upon escaping from its 
 human host, if reaehing water, these penetrate a minute crustacean of 
 the genus Cyclops, and there reach full larval development. When 
 their crustacean host is swallowed the larvae develop, conjugate, and the 
 female migrates through the muscles, the male probably perishing and 
 being passed with the faeces. From nine to ten months are consumed 
 within the deep tissues in the develoj)mcnt of the female before she 
 appears superficially. 
 
 Diagnosis. — This can only be made Ijy detecting the worm by the 
 touch and noting its change of position. 
 
 Prognosis. — Unless attended l)y severe inflammation from the start, 
 or the worm is broken during extraction, recovery readily occurs. 
 
 Treatment. — Antiseptic poulticing will facilitate opening, when the 
 worm must be gently drawn out, ceasing the eitbrt if any resistance is 
 felt : wind what has been withdrawn around a small stick, which should 
 be given one or more turns each day until the worm is extracted, scru- 
 pulously avoiding breaking it. Non-irritating antise])tic dressings may 
 be applied. Asafo?tida in large doses internally is said to kill the worm. 
 The violent inflammation so commonly following rupture of the worm 
 must be treated upon general surgical j)rinciples. If gangrene occur, 
 amputation may become neces.sary. 
 
 Madura Foot (Mycetoma; Fungous Disease of India). 
 
 Endemic in certain portions of India and occurring only in natives, 
 this disease most frequently attacks males, especially field-workers and 
 those who pursue their avocations with bare feet. Although found at 
 any age, it is rare below puberty. Some trivial injury, as a prick or an 
 abrasion, is alleged as the exciting cause, but often neither predisposing 
 nor exciting cause can be detected. From the ditterence in color two 
 forms have been described — viz. the pale and the black, the latter being 
 the more common. 
 
 Pathology. — Vandyke Carter's original explanation no longer holds 
 good — viz. that the disease results from the fungus Cluonyphe (Jarteri — 
 but his later suggestion, made in 1886, has received confirmatory proof 
 by the recent work of Kauthack, who has shown IMadura foot to be a 
 variety of actinomycosis, his conclusions being as follows : " That (1) the 
 fish-roe masses are undoubtedly a form of actinomyces ; (2) the black 
 masses in their most perfect shape are also und(iul)tedly of this natui'e, 
 but in a state of degeneration ; (3) a degenerated form of the yellow 
 variety is occasionally found, in ap])earance not wholly unlike these black 
 masses, so that the relation between all these forms seems to be fully 
 e-stablished." ' Fibroid and fatty changes so alter the tissues that it is 
 often diflicult to distinguish them apart, all being changed into an oj)aque, 
 hoinogenetius, gelatinous mass, many of tlie bones being replaced by 
 fibrous tissue. The muscular tissue is the least altered, while the adipose 
 tissue is much increased and often contains pigment-granules. The 
 sinuses which riddle the foot in all directions are peculiar in that, while 
 
 ^Journal of Pathology and Bacteriolofft/, vol. i. p. 140, et seq. 
 Vol. I.— 23 
 
354 DIAGNOSIS AND TREATMENT OF PERNIO, OR VIIILULAIN. 
 
 2>ic'reing tlie bones "as if tlicy liad hecn drilled," their osseous walls are 
 often unaft'ected with the degeneration, and that they open into single or 
 multi|)le rounded cavities eontaining numerous granides, which latter are 
 likewise scattered over the sinus-walls or arc free in their luniina. The 
 lighter granules consist of a central close mycelial netw()rk "and a peri- 
 peripheral fringe of more transparent, more or less glassy, rays." The 
 black granules are chiefly formed of the inorganic constituents of the 
 tissues, ]>igment, and the more or less altered fungus. 
 
 Symptoms. — The j>art attacked is nearly always the foot or leg, next 
 in frequency the hand or arm, ^'ery rarely the shoulder or scrotimi. The 
 onset varies. Thus, a toe or finger, or the foot itself, may l)e attacked, 
 very little swelling, redness, or circumscribed induration being noticeable. 
 Again, either a superficial or deep ]ia])ule, pustule, or tubercle may ap- 
 pear, moderately tender, which on rupturing discharges pus, but later the 
 characteristic granules. Occasionally a subcutaneous mottling exists for 
 some time before the skin gives way. Slowly, accom])anied by severe 
 pains, the foot becomes enormously swollen, distorted, and useless ; the 
 arch of the ibot gives way from destruction of the bones, so that even 
 over-extension of the toes takes place. Scattered over the skin are small 
 elevations, whose centres are the orifices of the sinuses leading into the 
 cavities before mentioned. These latter may be near the surface or deeply 
 seated, and sometimes involve the lower ends of the tibia and fibula as 
 well as the bones of the foot. The discharge is sero-purulent, and con- 
 tains the characteristic white, yellow, black, or very rarely pink or red 
 granules resembling fish-roe. The granules also lie scattered on the sur- 
 face around the orifices of the sinuses. It may take six to twelve years 
 completely to disorganize the member, but the disease tends to a fiital 
 termination. 
 
 Diagnosis. — Commencing as a tubercle or pustule, until either rup- 
 tures it might be difficult to decide between mycetoma and the Guinea- 
 worm disease, but the absence of the worm and the roe-like material in 
 the discharge would settle its nature. In advanced cases the fact of an 
 extremity being concerned, the marked swelling, the numerous sinuses, 
 and the characteristic granular discharge should suffice. 
 
 Prognosis. — If left to nature, complete disorganization of the mem- 
 ber will result. 
 
 Treatment. — When superficial, early free curetting has proved effi?et- 
 ual. If only a finger or toe is involved, its prompt removal will usually 
 suffice. In more advanced cases amputation is the sole resort, and, as 
 the leg-bones niay have undergone change much higher than external 
 appearances would indicate, the bones must be removed well above any 
 suspicious point. 
 
 Pernio, or Chilblain. 
 
 This is produced by the sudden ap])lication of cold to any exposed 
 portion of the body where the circulation is impaired. The vascular 
 condition maybe due to a weak heart or to the distance of the part from 
 the centre of the circulation, as in the case of the ears or toes. In the 
 latter instance the compression of the foot-gear also favors antemia. 
 Sudden aj)proach to the fire after exposure is a common cause, owing to 
 the change of tempei'ature causing intense congestion from vasomotor 
 
FROST-BITE. 355 
 
 paresis. Cliildren ^vhose power of g;enerating heat is feeble, and those 
 adults who resemltle them in this particular, are most lialile to chilblain. 
 
 Symptoms. — The mild form amounts only to a moderate redness of 
 the skin and some swelling, with hi'at and itching of tiie parts, which dis- 
 a])pear spontaneously. Another variety is evidenced l)v marked swelling 
 and redness, the latter often assuming a purplish hue due to venous con- 
 gestion. The heat, itching, and tingling pain are very marked, especially 
 when the parts become warm after the slightest chilling. This form 
 usuallv does well with proper treatment. In its worst form pernio 
 closely rcsendiles frost-bite from the severity of the inflammation, blebs 
 forming which on rupturing leave indolent ulcers, sometimes covered 
 with sloughs, " yielding a thin ichorous or sanious discharge." 
 
 Treatment. — Prophvlaxis is important, and consists in woollen cover- 
 ings for the feet and appropriate ones for the hands and exjiosed parts. 
 Local stimulation of the circulation by dry frictions or with alcohol, 
 spirits of camphor, or soap liniment is useful as a i)rophylactic. Entei- 
 ing a warm room or coming close to a fire, even after exposure to slight 
 cold, must be avoided. When the milder form is threatened gentle fric- 
 tion with snow or ice-water until reaction begins to be established, in 
 a cold or only moderately warm room, is to be rcconnnendcd, followed 
 by an alcohol dressing, or even tincture of iodine when no Idisters 
 have formed. AMicre jjcrsistent congestion with tendency to swelling, 
 attacks of itching, etc., repeatedly occur, the constant current and local 
 applications' to produce contraction of the paretic vessels, coupled with 
 tonics and measures calculated to invigorate the circulation, will usually 
 give relief. If ulceration or sloughing occur, it must be treated ujjon 
 general principles. 
 
 Frost-bite. 
 
 This term includes the more serious effects resulting locally from the 
 abstraction of heat — miscalled " application of cold." Exposure to low 
 temperatures causes destruction of jiarts in two ways — /. e. (1) directly, 
 by freezing the tissues so thoroughly and for such a time that, even when 
 most cai'efully treated, after thawing they are found to be dead ; and (2) 
 more connnonly indirectly, gangrene resulting partly from the lowered 
 vitality, but chiefly from the subsequent inflanmiation, causing strangu- 
 lation and death of the enfeebled tissues by the exudates ; in other words, 
 so-called " inflammatory gangrene " determines the sloughing or sphac- 
 elus. The effect of cold being to promote adhesion of the leucocytes, 
 cajiillary thromboses are readily formed, favoring and often determining 
 gangrene. 
 
 Symptoms. — First, numbness with loss of power is felt, usuall}' in 
 peripheral parts, as the nose, ears, fingers, or toes ; then tingling and a 
 sensation of weight are noticed. Inspection now shows that the parts 
 are bleached white and icy cold to the touch, all sensation being lost. 
 If ho])elessly frozen, discoloration and swelling follow the ]irimarv 
 blanching ; the parts next shrivel and contract ; a line of separation fol- 
 lows ; putrefactive changes ensue ; and the nose, ears, feet, or hands may 
 
 'Camphorated soap liniment, turpentine witli copaiba, lead-water, alum in solution, 
 with numerous similar suhstances, have been all vaunted, but careful prophylaxis is requi- 
 site to render any treatment of avail. 
 
356 SYMPTOMS AND TREATMENT OF GANGRENE. 
 
 be spontant'ou.sly amputated. When too rapid tliawing jw'ecipitates gan- 
 grene, or judicious eif'orts fail to maintain the vitality of the part, the 
 primary swelling and ah)iormal sensibility are followed by intense in- 
 flanniiatory phenomena ; blebs form ; tiie pain ceases; the skin becomes 
 mottle(l and discolored ; and finally the parts manifest all the phenomena 
 of moist gangrene. 
 
 Treatment. — This nnist secure a most gradual restoration of circula- 
 tion, and with this the power of (calorification. Sudden increase of 
 temperature will induce such a paretic condition of the vasomotor sys- 
 tem as will produce stasis, coagulation-necrosis, and gangrene. Com- 
 mencing by frictions with snow, then immersion of the part in water, all 
 treatment being conducted in a cold apartment, the temperature of the 
 ap])lications and of the room must be gradually raised nntil the somatic 
 and local temperatures have nearly attained the normal, when applica- 
 tions which tend to stimulate to action the paretic local vasomotor 
 apparatus are indicated, such as diluted alcohol or diluted spirits of 
 camphor. Elevation of the parts, which should be swathed in raw cot- 
 ton, M'ill tend to relieve the venous stasis by favoring the return of 
 blood. Warm stimulating drinks, as hot coffee, aromatic spirits of ammo- 
 nia, or whiskey diluted with hot water, are now indicated. Should 
 inflammation run high, threatening gangrene, antiseptic irrigations may 
 be employed, and in any event asepsis and antisepsis must be maintained 
 throughout. If gangrene results despite all efforts, the constitutional 
 and local treatment advised on pages 358, 359 should be adopted. 
 
 Gangrene. 
 
 Sphacelus, gangrene, mortification,' and sloughing are all terms which 
 indicate the death of tissues in greater or smaller masses. This condition 
 is always the result of two factors combined in varying proportions — 
 viz. an insufficient supply of nourishment to the cells, producing a lowering 
 of tissue-cell vitality, and their mechanical destruction. The deprivation 
 of pabulum may be induced in many ways. Thus, the main artery of 
 tlie limb may be occluded suddenly or gradually ; the main veins may 
 become thrombosed, preventing the return of blood, or both conditions 
 may obtain : again, inflammation may lead to such free exudation that 
 the blood-vessels, plasma-channels, and even the cells themselves, may 
 be so compressed as to be unable to maintain their vitality. If to this 
 last condition be added death of some of the cells by mechanical injury, 
 or their lowered vitality brought about by other predisposing conditions, 
 mortification still more readily occurs. In certain injuries of the cerebro- 
 spinal axis or of the peripheral nerves, local gangrene often supervenes, 
 precipitated by pressure, but probably predisposed to by interference 
 with vasomotor equilibrium. 
 
 Two types of gangrene exist — the moist and the drj' — the presence 
 or absence of fluids in the tissues when gangrene occurs determining to 
 which class the case belongs, the difference being purely a physical one. 
 
 Dry Gangrene. — This is usually caused by a gradual diminution 
 
 • Necrosis is a term which should be restricted to death of bone or to g.ingrene of 
 the viscera where the absence of putrtifactive organisms admits of absorption of tlie 
 dead tissues, a scar remaining. 
 
GANGREyE. 357 
 
 of the arterial supply, the venous blood having free egress. Occasionally 
 dry gangrene follows embolism. Because atheroma leads to such arterial 
 changes as interfere with tlic vascular supply, and as this disease is more 
 common in the old, in whom the feeble heart also predisposes to malnu- 
 trition of the peripheral tissues, dry gangrene is often called " senile 
 gangrene ; " but with the same physical conditions, notably in chronic 
 ergotism, typical gangrene of the feet, hands, nose, and tips of the ears 
 mav occur in the young. Vasomotor spasm, a feeble heart, and ill- 
 nourished tissues all result from living for long periods on spurred rye. 
 
 Symptoms. — Coldness and numbness of the feet, with cramps in 
 tliem or in the calf-nuisclcs, are fre(pient prodromes. After bruising a toe, 
 trimming a corn too closely, or from the friction of the boot, congestion 
 and inflammation occur. The blush deepens, becomes purplish ; the 
 part is insensitive and cold, but oftentimes severe pain is experienced in 
 the neighboring tissues. The dead parts dry, shrivel, and blacken, emit- 
 ting the odor of decomposition. An inflammatory line of demarcation 
 marks the boundary between the dead and living tissues, shifting upward 
 as the disease progresses until it is arrested, when septic ulceration soon 
 establishes a line of separation. The gangrene may be restricted to one 
 toe or may gradually involve the whole foot and leg, but usually stops 
 just below the knee — /. c. about the bifurcation of the popliteal artery. 
 Little if any fever may attend upon destruction of one or two toes, but 
 where much tissue dies septic fever becomes more or less pronounced. 
 Pain varies from a mere burning sensation to such agony as to require 
 the constant use of morphine. 
 
 Moist Gangrene. — Sudden obstruction to the main arterial current, 
 as by embolism or ligature, interference with the return of the venous 
 blood, and cutting otf of the ultimate blood-supply to the tissues by 
 the pressure of inflammatory exudates are the usual causes. Because 
 moist gangrene so often follows traumatism it has been sometimes called 
 "traumatic gangrene." The disease may occur either as a localized 
 traumatic or a spreading traumatic gangrene. 
 
 Localized Traumatic (Jaiif/rcne. — The injury unquestionably phj^sically 
 devitalizes portions of the tissues, but the chief destruction results from 
 the pniducts of the scjitic inflannnati(jn so compressing the vascular sup- 
 ply (capillary and arterial) to the tissue-cells that they die : doubtless fer- 
 ments and ptomaines also play a part. The damaged tissues perish with 
 some of the surrounding parts from the inflammation, but the process 
 docs not extend indefinitely. 
 
 Symptoms. — Tiie liurning pain often preceding mortification entirely 
 ceases ; the skin is cold, pale, insensitive, then becomes mottled green or 
 red, and finally livid. Blebs form containing brownish serum. Wlien 
 the blebs are ruptured they leave a dermis resembling moist smoked 
 beef; moreover, before rujiture they can be slipped around over the dead 
 derm, because the devitalized epithelium reatlily separates, thus being 
 distinguishable from the lilisters forming after inflannnation. The sur- 
 faces of the wound become puljiy, yellowish or grayish, and exude a 
 profuse oifensive discharge, and the dead part undergoes putrefactive 
 changes. The dead tissues contrast sharply M'ith the living, intensely 
 reddened tissues, separation occurring from septic ulcerative inflammation 
 unless the patient dies from sapriemia, which is unusual, and recovery 
 
358 SYMPTOMS A\D TREATMENT OF GANGRENE. 
 
 ensues. Hemorrhage is not common, bw^ause softening of" tiie tln-onihi 
 wliieli form in the vessels by the action of the products of germ-growtii 
 rarely occurs. The prognosis is better wheu the original injury has ])ro- 
 duced either an extensive wound or many wounds of tiie soft parts, which 
 allow vent for the poison-laden discharges. 
 
 Spi'eadiiir/ Trauiiiaiic Gangfene. — This results from specific infection 
 of tissues whose vitality has been lowered by severe traumatism, espe- 
 cially if the main vessels are destroyed. Where the vessels are intact 
 the rapidly-spreading infective inflannnatiou destroys the tissues, partly 
 by strangulation of their minute lilood-supply, lint chiefly by the effects 
 of the ptomaines, peptonizing ferments, etc. which are generated and 
 confined under pressure. Hence severe crushes with but trivial division 
 of the soft 2>arts are most dangerous. The infection is often a mixed 
 one, but sometimes one only of the pathogenic germs is present. The 
 cellular tissue is that which is chiefly attacked ; hence the disease is more 
 extensive than external appearances would indicate. 
 
 Symptoms. — Tiie linil) becomes tense and brawny, the skin of a dull 
 reddish brown, variegated with streaks and spots of green or black. 
 Emphysematous crackling can often be felt, which extends somewhat 
 above the point of apparent skin-involvement, and usually higher upon 
 the inner side of the limb. The gangrene extends witli lightning speed, 
 sometimes in less than forty-eight hours involving a wliolc lower limb 
 with half of the abdomen and trunk. So soon as the local condition is 
 fairly started, owing to the absorption of enormous doses of ptomaines 
 and toxines by the lymphatics of the cellular tissue, which are un- 
 blocked by any exudate upon the proximal side, marked constitutional 
 symptoms of saprremia develop, which soon terminates fatally unless art 
 intervenes. 
 
 VoriKfifidional St/mptoms. — If the process be extensive or involves 
 an important organ, the heart acts feebly, the pulse is quick, compressible, 
 and small, the tongue dry, brown, and covered with sordes which extends 
 around the teeth and upon the lips ; in fact, a typhoid state exists. 
 
 Treatment. — If possible, remove the determining cause, which can 
 often be done by strict antisejjsis after injuries, especially in the aged, and, 
 in threatened gangrene of a crushed limb, by incisions which will give exit 
 to septic discharges and I'elieve strangulation of tissue. If obstruction 
 of the main vessel has occurred, favor the establishment of the collateral 
 circulation b}' moderate elevation of the limb, warmth, and cardiac stim- 
 ulants. Thorough disinfection of gangrenous parts, followed by dry 
 antiseptic dressing, such as iodoform or boric acid combined with ]30w- 
 dered charcoal, often jn-cvents septic infection. Inflammatory products 
 must be evacuated by incisions carried, when possible, through the dead 
 tissues. When the process tends to self-limitation in senile gangrene, 
 delay is advisable, removing the dead tissues from time to time ; second- 
 ary amputation may be done later if the stump does not heal. When 
 senile gangrene spreads, although an amputation lielow the knee may 
 succeed, removal of the limb at the lower third of the tliigh is better, 
 because the blood-supjily to the Haps comes from the profunda femoris. 
 
 In embolic gangrene it is best to delay until a line of demarcation 
 forms, otherwise an unnecessary sacrifice of parts may result. 
 
 For localized gangrene — ;". e. sloughing of the skin and subjacent 
 
i? 
 
 & 
 
 GANGRENE. 359 
 
 tissues — nothing is requisite, except incisions through or partial removal 
 of the dead tissue to evacuate pus, until the line of separation forms. 
 Gangrene caused by crushing of a limb demands immediate amjnitation 
 if the process is rapidly extending. If, however, it is localized, the 
 general condition of the patient must decide what nuist be done — *. c. if 
 septic absorption is producing marked constitutional eftects and the 
 patient can stand the shock, am})utate ; if not, strive to improve the 
 general condition, endeavoring to prevent further absorption of, and to 
 eliminate, all ptomaines which have been already taken up. The 
 only measure otfering any ]irosj>cct of success in spreading traumatic 
 gangrene is prompt amputatimi far above the apparent external limits 
 of the disease. Sometimes, as at the shoulder-joint, flaps may be 
 successfully fashioned out of infiltrated, oedematous tissue. The flaps 
 must be long, and if there be doubt if all infected tissue has been 
 removed, primary suturing had better be avoided, antiseptic irrigation 
 employed, and secondary suturing resorted to later. Alcohol and cardiac 
 stinuilants, with quinine and opium to secure sleep, must be given. 
 Large quantities of easily-assimilable food should be provided. Care 
 must be taken to see that the kidneys and bowels eliminate properly. 
 
 Hospital Gaxgrexe is an infective microbie disease which usually 
 attacks an open wound, but has followed subcutaneous injuries. The 
 disease is hardly known now, owing to the avoidance of overcrowding of 
 patients and to antisepsis, the vii'us probably being a special micrococcus 
 which may reacli the wound through the medium of the air, the nurse's 
 or surgeon's hands, instruments— above all, sponges. The microbes, 
 in both masses and chains, are jjresent in the slough and the surrounding 
 tissues, but not in the blood. Three distinct forms have been described 
 — viz. the dipiitheritic, tiie ulcerative, and the Jjulpv. The first variety — 
 thought by some to be a mild form of hospital gangrene, but by otiiers 
 to result from a diiferent and specific micrococcus — produces a coagula- 
 tion-necrosis of the graiuilations, the wound-surface being covered Avith 
 a yellowish or grayish-white, tenacious pseudo-membrane ; the discharge 
 is at first scanty, but later becomes more almndant and watery. This 
 form is but slightly contagious, and only j)r(jduces systemic results by 
 jitomaVne absorption. When the sloughs sc])ai'ate a deep excavation is 
 left, but during the whole process there is little inflammation in the sur- 
 rounding tissues. The ulcerating vai'iety is characterized by a rapidly- 
 spreading, rather superficial ulcer, covered by unhealthy grayish gran- 
 idations, with inflamed, reddened, sharji-cut edges : the discharge is free 
 and excessively offensive. The pulpy form is often epidemic, and when 
 attacking an open wound causes gr(>at swelling of the granulations. 
 Pultaceous, ash-gray, adherent sloughs soon form, extending rapidly in 
 depth and extent,' with a profuse, thin, greenish or sanious offensive 
 discharge. The surrounding tissues are dusky-red, swollen, (edematous, 
 the margins of the ulcerated surface being sharp-ent, elevated, and 
 excessively tender. The main vessels may l)ecome eroded, producing 
 hemorrhage, and even large joints may be laid open. Profound consti- 
 tutional symptoms, assuming a tyj)hiii(l character, due to ptomaine 
 absorption, set in early, sometimes producing death in a few hours. 
 
 Treatment. — Prompt isolation must be effected. Where numbers 
 of patients, as soldiers, are attacked, tents or huts are preferable, even 
 
360 SYMPTOMS AND TREATMENT OF GANGRENE. 
 
 ill cold weather, to crowded wards. Tlie patient's strenijtli must he sus- 
 tained hy food, stimulants, quinine, strychnia, and (lii;-italis, and opium 
 given to ohtain sleep. The enuuictorics — hy which the ahsorhed jitoiuainos 
 may he eliminated — should be stimulated. Locally, in the diphtheritic 
 form, efficient disinfection, followed by the free use of iodoform, will 
 often suffice, but in the more severe varieties the patient must be anies- 
 thetizcd, all sloughs cleared away, and what still adheres of them, with 
 the surrounding infected area, nuist l)e thoroughly destroyed with Ijromiiie, 
 nitric acid, or the thermo-eautcry. After this, free dusting with ioiloform 
 and the careful use of wet antiseptic dressings will bring about recovery 
 if the systemic infection be not too great, provided all infected tissue has 
 been destroyed; if recrudescence of the local symptoms occurs, a repetition 
 of the caustic treatment is indicated. 
 
 Bed-80RES, or Decubitus. — Tliis is a moist gangrene, produced by 
 pressure mechanically interfering with the access of blood to the tissues 
 of patients lying for a considerable time in one position. The weak 
 heart and tissues of such individuals predispose to gangrene, bed-sores 
 occurring most frequently during acute or chronic exhausting ailments 
 or in ])arts deprived of nerve-influence, as after fracture of the spine. 
 When the slough has separated the ulceration sometimes extends widely 
 and deeply, and may end in death by j)y:emia, hectic, or exhausting (hs- 
 charges. The most common sites for bed-sores are over the coccyx and 
 sacrum, the great trochanters, the shoulder-blades, malleoli, and back of 
 the heels. 
 
 Treatment. — Bed-sores can usually be prevented by frequent bathing 
 of parts subjected to pressure, covering the same with soap plaster spread 
 upon wash-leather, removing pressure by padded or air rings, pillows, 
 etc., and frequent change of position. Once formed, removal of pres- 
 sure as far as possible, disinfection, and dry dressings must be tried. 
 After separation of the sloughs the resultant ulcer must be treated as 
 recommended elsewhere. 
 
 White Gangrene. — The etiology is obscure, and it is said to be 
 due to some general, not local, cause. It is a recurrent disease, and 
 appears during early adult life in those who are feeble and ill-fed. It 
 is probably due to some peculiar localized vasomotor condition producing 
 a nearly perfect anaemia of the dead parts. 
 
 Symptoms. — Although any part may be the seat of the disease, the 
 extremities are the i)arts usually attacked, and by preference the lower 
 ones. Pain, following the course of the main nerves if a limb is 
 attacked, jjrecedes each attack, lasting for weeks or even months. 
 Irregular menstruation and various nervous symptoms are observed 
 in females. Locally, a circumscribed spot on the limb, usually circular 
 in outline, or a toe, becomes dull A\'hite ; the skin soon dries and shrivels ; 
 b}' a septic inflammation a red line of separation forms, and the slough 
 comes away, leaving a granulating surface. When only the skin is 
 involved, the disease is comparatively trivial, but when all the soft 
 parts down to the bones are destroyed, it is a serious, and sometimes a 
 fatal, atfection. 
 
 Treatment. — This does not differ from what is recommended for the 
 other forms, but the constant current is suggested, so as to modify the 
 vasomotor condition of the parts. 
 
GANGRENE. 361 
 
 Glvcosttria. — Tlic relation borne by glycosnria to ganp;rene may be 
 briefly stated thus : While patients whose urine contains sugar are more 
 liable to sutler from gangrene whieii pursues a rapid course, because the 
 tissues of diabetics are weak and prohalily attbrd favorable pabulum 
 for the growth of germs, the mere presence of sugar does not cause the 
 disease. Again, diabetics very frequently have arterio-sclerosis ' and a 
 variety of peripheral neuritis closely resembling that produced by 
 alcohol. The neuritis" attacks liy preference the nerves of the lower 
 extremities, giving rise to perforating idcer, the knee-jerks being tem- 
 porarily or permanently abolished, but the Argyll -Robertson pupil has 
 not been observed. Gangrene occurs in patients with sugar in the urine 
 wlio belong to three main classes, as pointed out by Godlee — viz. (!) 
 simple dialectics ; (2) gouty persons with sugar in the urine ; and (3) 
 diabetics who are also gontv. The determining causes are inflammation 
 (perhaps very slight), coinciding with either arterio-sdcrosis or neuritis, 
 the first variety usually being painful and spreading rapidly, the neurotic 
 form being slower and comparatively painless. 
 
 Treatment. — All operative interference has been opposed until re- 
 cently, but numerous observers have shown that when painful and rap- 
 idly spreading — /. c. when arterio-sdcrosis is present with plugging of 
 the vessels — a prompt knee or thigh amputation often saves life, and the 
 sugar sinks to a minimum after healing, when during the gangrenous 
 inflammation neither medicine nor diet availed. The chief' causes of 
 failure are a too low amputation through the area whose main vessels are 
 thrombosed, including infected tissues in the flajis, after infection, and 
 late operation, especially in those in whom the urine has become albu- 
 minous. In the neurotic form, where one or two toes are involved, 
 spontaneous separation and recovery sometimes occur, and in this 
 variety, and in that starting from a perforating ulcer, delay with I'cmoval 
 of the dead parts and antisepsis is permissible — nay, often advisable. 
 Dietetic and medicinal treatment after operation is requisite, often con- 
 verting the more acute into the chronic form of diabetes, and in the 
 chronic form, where of course tlie prognosis is better, life may be pro- 
 longed for many years.^ 
 
 Symmetricai> Gangrene, or Raynaud's Disease, is a rare affection, 
 believed to arise from a condition of the vasomotor apparatus in which it 
 reacts abnormally to cold or other irritants, producing by reflex action 
 persistent vaso-constrictor spasm. Although attacking any peripheral 
 parts exposed to cold, the tip of the nose, an ear, the cheeks, and tlie 
 tips of the fingers and toes are the parts usually involved. Children 
 or young adults are those usually attacked. 
 
 Symptoms. — Usually a varying period, marked by intermitting 
 attacks of pallor, coldness, ard numbness of the parts, is noted — i. e. 
 local sj/ncopc ; in many cases tlie next symptom is a bluish, congested 
 appearance presented l)y the parts (local at<plii/.i-ia), which is accomjm- 
 
 ' Israel found this in 13 of 20 diabetics. 
 
 ^ Zierassen first suggested tliis causal relation of sugar and this form of neuritis in 
 188.5, while Leydcn in 1888, and later writers, have classified the varieties. 
 
 ' The reader is referred to vol. Ixxv. |ip. 39o-4()8, and vol. Ixxvi., of the Mcdico-Chi- 
 rurgkal Trans., p. 37 et seq., for two admirable articles on the suliject of diabetic gan- 
 grene. An excellent bibliography will be found, and a resume of the whole subject to 
 date. 
 
362 SYMPTOMS AND TREATMENT OF BURNS AND SCALDS. 
 
 nied by burning pain ; finally, gangrene actually sets in, usually assum- 
 ing till! dry form, but at times it is preceded by the formation of blebs, 
 when of course moist siuuiirene or slousrliiuff results. Hsematuria is a 
 frequently associated couilition. 
 
 Prognosis. — As yet no deaths have resulted. 
 
 Treatment. — Protection of the jiarts from cold and the application 
 of the constant descending current have been alleged to have ])roven 
 effectual in warding off gangrene when only the stage of local asphyxia 
 has been reached. 
 
 Burns and Scalds. 
 
 Burns result from direct flame, radiated heat, or heated substances ; 
 scalds, from hot fluids — /. c moist heat. The former are apt to be deeper 
 and more circumscribed, the latter more superficial and covering a M'ider 
 area, because fiuid flows over surfaces or is diffused by saturation of the 
 clothing. Burns and scalds are clinically so nearly alike that they will 
 be considered together. 
 
 The sun's rays, direct flame, heated water, coffee, oil, or other dense 
 fluids, molten metal, concentrated acids and alkalies, arc the agents ]iro- 
 ducing these injuries. The effects dejiend, first, upon the actual tem- 
 perature, and second, upon the period of application. Thus, instanta- 
 neous contact of even molten metal splashed so as to touch the skin 
 produces vesication, while boiling water or oil kept in contact for a 
 longer period will destroy the skin or even deeper tissues. While severe 
 scalds from water may leave the cutaneous hairs, thus enabling us to dif- 
 ferentiate a scald from a burn, the hairs may be destroywl by dense 
 liquids, which can be raised to a much higher temperature. Concen- 
 trated acids and alkalies do not vesicate, inflammation promptly super- 
 vening with marked cellulitis, the surface being covei'cd with a grayish 
 exudate. On the face these injuries give rise to rapid erysipeloid s\vell- 
 ing. Nitric acid stains the parts yellow, sulphuric acid reddish, and 
 carbolic acid, after the white .stage is past, of a peculiar coppery color. 
 
 Constitutional Effects of Burns. — Shock is pronounced in all severe 
 burns, varying according to position. Thus even superficial burns of 
 the chest, abdomen, head, or neck, if covering much surface, will produce 
 more shock than deep destruction of a foot or hand : shock is often fatal. 
 A severe chill is not uncommon after extensive burns, and but little pain 
 may be complained of; coma sometimes sets in, death resulting from cere- 
 bral and other visceral congestions. If reaction takes place, sthenic 
 fever is pronounced in from twenty-four to forty-eight hours, inflamma- 
 tion occurring around the burned spots. The congestion of the viscera 
 which occurs during the stage of shock may run on to inflammation, 
 and perforating duodenal ulcer may now commence. During and after 
 separation of the slouglis death may result from suppuration, exhaustion, 
 and hectic, aidetl perhaps by secondary hemorrhage. 
 
 Capillary embolism of the kidneys and other organs by the debris of 
 altered and destroyed red corpuscles is supposed to explain certain cases 
 of sudden death after burns, because large numbers of these cells have 
 been shown by Ponfick to be destroyed immediately after severe burns 
 inflicted on animals. 
 
BUBNS AND SCALDS. 363 
 
 Complications of Burns and Sfalds. — Scalds of the mouth and pliar- 
 ynx, chietiy incurred bychilch'en attempting to (h'inlv Ixtiling- water from 
 the spouts of tea-kettles, and burns where su])erlieated air is inspired, 
 often cause oedema of the glottis, commonly a fatal condition even after 
 tracheotomy or intnliation. Gastro-intestinal irritation or inflammation 
 is frequent, varying from a little nausea and vomiting, with an occa- 
 sional loose movement, to constant rejection of food and frequent stools 
 containing blood. In the latter condition duodenal ulcer is jirobable if 
 sudden collapse occurs, especially if jiain and tenderness have been noted 
 in the epigastrium. 
 
 The pathology oi gastric or duodenal ulcer under such circumstances 
 is uncertain. These lesions probably result from local arrest of the cir- 
 culation, brought about by thrombosis of the small vessels initiated by 
 accumulation of the remains of disintegrated cells durins; the congestion 
 occurring in shock, and the subse(|uent digestion of these necrotic areas 
 by the digestive juices. According to Ziemssen, botli gastric and duodenal 
 ulcers have sharp-cut edges, which are indurated when the process is old, 
 and are of a funnel-shape because more mucous membrane is gone than 
 muscular substance, and less muscular than serous tissue if actual per- 
 foration has <)c<'urred, as occasionally happens. 
 
 All)umin is always present in the urine, excej)t in injuries t)f the tirst 
 degree where no rise of tem])erature occurs, the (juantity seemingly being 
 in proportion to this rise. Htemoglobinuria is also common. 
 
 Classification. — The classification adopted by Morton is better, 
 because less conqilex, than that of Dupuytren — viz. First degree : 
 Hyperiemia, erythema, or inflammation of the skin without vesica- 
 tion ; no scar results. Second degree : Inflanuiiation of skin with 
 vesication ; no scar, but staining possibly from pigmentation follows. 
 Third degree : in addition to all seen in the other degrees, destruction of 
 the skin and subjacent tissues to varying degrees up to complete charring 
 of the parts ; much of the subsequent scarring and deformity results 
 not from the primary injurs-, l)ut from the consecutive sloughing or 
 gangrene. 
 
 Symptoms. — BuRXS of First Degree. — Local Symptoms. — The 
 diffused redness disappears upon pressure, instantly to return. Swelling 
 sometimes occurs, and the pain is burning or smarting. Lasting from a 
 few hours to some days, these symptoms decline, cjiidermic desquamation 
 then occurring. 
 
 Constitutional Sj/mptoms. — While unusual, slight fever may develop, 
 but in certain patients and from the extent of surface involved shock is 
 pronounced, and even death may result. This almost certainly occurs 
 if two-thirds of the skin is merely reddened. Cerebral, pulmonary, 
 gastro-intestiual, anit even vesital complications have been reported. 
 
 Burns of the Second Degree. — Local Si/mptoms. — The inflamma- 
 tion goes on to separation of the e]iidermis from the derm by serum, form- 
 ing vesicles or Itulhc. If these foi-m very rapidly, the epidermis may ru]»- 
 ture, leaving collapsed, wrinkle<l, whitish pellicles, through which here 
 and there can be seen the inflamed hypersensitive derm. If suppuration 
 and idceration do not occur — /. c. if infection is prevented — tlic e])i- 
 dermis is re-formed in a week or two, possibly leaving some pigmen- 
 tation. 
 
364 SYMPTOMS AND TREATMENT OF BURNS AND SCALDS. 
 
 Consfitational iSi/mjdoms. — Wlicn involviiifr a limited area only sligjlit 
 eifects result, but wlien coverinii- mueli sui'face tlie shock is severe, often 
 promptly terminating in death with delirium and coma or sym])toms of 
 congestion of the lungs or other viscera. If reaction takes ])iace, visr 
 ceral congestions may terminate in visceral inflammations. Still later, 
 albuminuria is common and intestinal ulceration occasional. 
 
 Burns of the Third Degree. — Local I'^i/mptoms. — It is impossible 
 immediately to determine by inspection how deeply the tissues are 
 destroyed, as the surface indications are very similar " when the muscles 
 or the deeper parts, even the bones, have been involved." Moreover, 
 much of the subsequent destruction results from the sloughing and gan- 
 grene from septic inflanunation. It is therefore useless to attempt to 
 describe the endless differences in appearance presented by this class of 
 burns. Sometimes fingers, toes, parts of hands, or feet may be burnt 
 off. Molten metal poured into a puddler's boot will produce such an 
 injury. 
 
 Constitutional Symptoms. — If reaction takes place, death from cerebral 
 coma, caused by serous effusion, sometimes occurs. Congestions followed 
 by inflammations of lungs, kidneys, or intestines may result fatally. 
 Pyasmia, septicemia, exhaustion aggravated by hemorrhages, tetanus, 
 one or all, may cause death during the process of separation of the 
 sloughs or subsequently. High temperature Avith renal trouble is 
 common. 
 
 Prognosis of Btirns. — This depends on many circumstances. Asep- 
 tic and antisejitic methods have so diminished the death-rate that the 
 old statements as to the mortality of an injury of given extent and 
 depth must be modified. Young children and those suflering from 
 shock may be severely burnt or scalded by comparati\-ely low tempera- 
 tures, the injury at first appearing trivial, but soon extending to the 
 deeper parts. Old drunkards, those with renal or hepatic disease, often 
 succumb when those with healthy organs would recover. Laryngitis 
 with oedema glottidis places patients in great peril. Delirium due to 
 changes in the l>lood-supply of the cerebral cortex has been observed : 
 this is explainable by the reflex effects produced upon the vasomotor sys- 
 tem or by thrombosis produced by disintegrated red corpuscles. 
 
 Treatment. — First relieve pain and treat the shock. "Where mere 
 erythema exists, unless much surface is involved, only local treatment 
 is requisite, dressings such as will exclude the air or will neutralize the 
 acidity of the secretions being indicated. Oil, fresh lard, or cosmoline, 
 previously sterilized by heating, best fulfil the first indication, while a 
 paste of bicarbonate of soda made with sterilized water will meet the 
 second. In burns of the second and third degree, if much surface is 
 damaged, two courses are open — viz. a preliminary thorough disinfec- 
 tion with a weak mercuric-bichloride solution, followed by a moist 
 dressing impregnated with some non-poisonous germicide, as boro- 
 salicylic solution or hydronaphthol, the whole covered with oiled silk ; or, 
 after the preliminary cleansing, all injured parts must be carefully 
 covered with protective, outside which a wet sublimate or other poison- 
 ous germicide may be safely applied, with abundance of cotton externally. 
 When such a dressing requires changing — which should only be done 
 at as long intervals as possible — any cleansing needed can be effected by 
 
BURNS AND SCALDS. 3G5 
 
 sterilized watei' or some non-poisonous, non-irritating antiseptic solntion. 
 Irritating and readily-absorbed poisonous substances, lilie carbolic acid 
 and corrosive sublimate, should be esciiewed if possible, and never kept 
 in contact with large surfaces, lest constitutional effects result. The 
 constant warm sterilized-water bath, when feasible, or antiseptic irriga- 
 tion, is useful where much sloughing results, but is only apjjlicablc to 
 extremities, and is not easy to manage effectively : moreover, absorption 
 of poisonous substances readily occurs during irrigation or baths, and 
 must be carefully guarded against. 
 
 After separation of the sloughs healing of the granulating surface 
 must be promoted, upon general principles. The granulations are apt 
 to become either congested and fungous, bleeding readily, or (edematous. 
 For the former condition soothing and slightly astringent ajiplications, 
 such as sterilized zinc-oxide ointment, nnist be used ; for the latter moist 
 dressings should be, as a rule, avoided : astringent and stimulating dress- 
 ings, as resin cerate, a])])lications of solution of zinc sulphate (grs. j-x to 
 f SJ) or of copper sulphate in similar pi'oportions with each dressing, with 
 the occasional use of solid nitrate of silver to tlie margins, are about the 
 best. Chloral hydrate, grs. x to f gj aquiB, applied by means of lint cov- 
 ered with oiled silk, will often act admirably, but is apt to produce a con- 
 gested, fungous state (if the granulati<:)ns if employed too long. It 
 must be remembered that unless the whole thickness of the skin be 
 destroyed the epithelium around the liair- and sebaceous follicles will 
 proliferate, thus accounting for the epidermic islets appearing in the 
 midst of tlie granulating surfaces left after burns. These centres of 
 cicatrizati(jn must be carefully conserved. Skin-grafting, preferably by 
 Tliiersch's method, and plastic operations, are often requisite to secure 
 healing. Tiie deformities resulting from cicatricial contraction may to 
 a certain extent be ob\'iated by positi(jn, s[)lints, etc. employed during 
 the healing process, but when much skin and fascia have been destroyed 
 some plastic procedure will become requisite. Such operations are in- 
 advisable until all tendency to contraction has ceased — /. <;. usually in 
 from six to nine months — unless the lower jaw is becoming curved down- 
 Avard by the traction in the very young, when periiaps some operative 
 interference may bo warranted earlier. 
 
 SuxBtJRX. — While usually only annoying, causuig much burning 
 pain, wiien a great extent of surface, as two-tiiirds, is involved, death 
 has resulted from the severe dermatitis and subsequent gangrene. Exten- 
 sive vesication is conunon. Erysipelas is closely simulated at times 
 when the face and eyelids are involved, but there is no febrile disturb- 
 ance.' 
 
 Treatment. — It is that of a burn of the first degree. 
 
 Brush Burn. — This variety of contused wound is caused by rapid 
 friction, as that produced by the revoK'ing leather belts of machinery or 
 tile dragging of a i)atient oxev the roadbed by a train of cars or by a run- 
 away team. This painful condition may vary from a superficial abrasion 
 to complete destruction of the skin and undcrl}ing tissues. It is rarely 
 extensive enougli to be dangerous. 
 
 ' See vol ii. p. 224, Intrnxit. Enci/. of Suir/. Longstreth here reports one case where tlie 
 muscles and synovial teudinous sheaths of the forearm and wrist became secondarily 
 involved. 
 
3C() SYMPTOMS AND TREATMENT OF WOUNDS. 
 
 Treatment. — This is identical with that of a contused wound which 
 sloughs. 
 
 IjK;htnixg-.sti!OKE. — Wliile it is true that the passage of a power- 
 ful current of aerial electricity througji the human frame usually results 
 in death, tliis is not invariable. \\ liat is commonly called "struck by 
 lightning " means that air-indueed electrical shock occurs in the individ- 
 ual when some contiguous object, as a tree or another person, receives 
 the direct (>leetrical discharge. 
 
 Symptoms. — In non-fatal cases the phenomena of shock are jiro- 
 nounced, luicousciousness or coma lasting from a few hours to daj'S. 
 Im})airment of one or more of the special senses is common, v.'ith paresis 
 or paralysis of both upper and lower extremities. Localized aufesthesia 
 is quite usual. These pareses or paralyses are usually transitory, except 
 perhaps that of vision. Locally, burns of varying depths are not 
 uncommon, while simple or compound and conuninuted fractures, and 
 even partial or comj)lete avulsions of extremities, have been reported. 
 A peculiar arborescent series of tracks, characterized bj- slightly cedema- 
 tous, raised, bright-red lines, often diverge from the point where the 
 current entered. Where death is delayed it results from shock, cerebral 
 efiPusions — hemorrhagic or otherwise — or hemorrhages into some of the 
 great cavities, with perha])s rupture of some of the contained organs, 
 or the severe fractures already mentioned. 
 
 Treatment. — This must be conducted upon the general principles 
 governing the treatment of shock, burns, or paralysis of any nerve or 
 nerves. 
 
 Wounds. 
 
 A wound is a solution of continuity suddenly effected by anything^ 
 which cuts or tears. When this is effected without division of the skin, 
 the term "subcutaneous" is employed, the injury giving rise to little or 
 no constitutional symptoms, and healing taking place by simple adhesive 
 inflammation. 
 
 Wounds are usually classed, according to their causation, as incised, 
 when resulting from a sharp-edged object ; contused, when produced 
 by more diffused force, which divides the tissues, leaving the woiuid- 
 edges bruised, as i'rom the blow of a bludgeon ; laeei-ated, when irregu- 
 larly torn, as by the bite of a wild beast, entanglement in machinery, 
 etc. ; punctured, when the depth much exceeds the superficial area, as 
 bayonet, knife, and sword \vounds. 
 
 Incased Wounds. — Because the injury cleanly divides the tissues, 
 not dragging on or tearing contiguous sensitive parts, the pain is apt to 
 be less in this variety of wound. The bleeding varies, but is much 
 freer than in lacerated or contused wounds. Wounds of the face bleed 
 very freely even if no considerable vessel be divided, the same being 
 true of the seal]); but in this latter situation the hemorrhage occurs 
 because the density of the scalp-structui'es interferes with the contrac- 
 tion and retraction of the vessels. 
 
 Retraction of the edges of incised wounds always occurs, dependent 
 upon the position and subjacent structures. This point it is important to 
 remember, because if incisions are properly planned few sutures will be 
 requisite, and these will be efficient ; thus skin and fascial wounds made 
 
WOUNDS. 367 
 
 transverselv to the course of underlying muscular fitjrcs will gape widely, 
 but if made parallel to the muscle their edges will either remain in contact 
 or require but little artificial aid in maintaining this position. " Langer's 
 investigations into the direction in which the skin splits show that the 
 tension of the skin varies greatly in two different directions : two incisions 
 vertical to each other exliibit a varying retraction of the wound-margins ; 
 Avhile one gapes widely, the edges of the other remain in contact even 
 without artificial means." . . . . " Fortunately, the course of the nerves 
 and vessels largely coincides with the direction in which the skin shows 
 the greater tension." ' Skin and muscle gape most widely when divided, 
 the one across the line of cleavage, the otlicr at right angles to its fibres. 
 Gaping is greater when there is much inHainmatory tension of the sub- 
 jacent parts. 
 
 Union of Incised Wounds. — The hemorrhage having been arrested, 
 the wound, accurately closeil, drained if necessary, kept aseptic and at 
 rest, unites without supjniration by simple adhesive inflammation. If 
 the epithelial covering be thin, the edges may occasionally present for the 
 first twenty-four to seventy-two hours a faint blush, Init this is often absent. 
 They are ])erhaps slightly swelled, are hotter and tender on pressure, but 
 are devoicl of pain : sometimes all these symptoms are absent. Even at 
 the end of three days, although the union seems firm, the wound-edges 
 can be pulled apart — the union is mechanical, not vital, resulting from 
 the gluing together of parts Ijy cellular exudate and fibrin. If undis- 
 turbed, in a few more days a narrow reddened -streak indicates the 
 position of the former cut, the color fading in time into white until 
 the scar almost disappears. This process is primary union, or " union 
 by first intention," and an attempt to secure it should always be 
 made. If perfect coaptation, drainage, and asepticism be impossible, 
 the faintl}'-reddened margins soon show a decided inflammatory blush ; 
 the edges become swollen and tense, throbbing pain is complained of, 
 union fails to occur, and pus forms. A chill or rigor may occur, and 
 headache, fever, anorexia, coated tongue, constipation, scanty high- 
 colored urine, with nervous symptoms varying from mere restlessness 
 to slight delirium, indicate that septic traumatic fever has supervened. 
 If, now, effective drainage and antisepsis be instituted, all the symji- 
 toms will decline: granulations form; the wound-margins ai'c no longer 
 elevated, but rather depressed ; the masses of granulations level the 
 inequalities of the depths of the wound ; the deeper layers become 
 convertetl into young connective tissue, which contracts, thus lessening 
 the superficial area of the \\ound ; epithelial cells extend inwai'd from 
 the margins until cicatrization is completed, first a red, and finally a 
 white, scar remaining. This process constitutes healing by granulations, 
 or " healing by second intention." 
 
 In brief, the process of repair l>y primary union is as follows : A 
 small quantity of exudate, containing fibrin-forming constituents, coagu- 
 lates, temporarily gluing together all surfaces which arc in apposition, 
 the excess of exudate, if any, being drained off. Leucocytes collect 
 along the line of the wound, gradually increasing in numbers until 
 many of the original tissue-elements disappear, leaving only a mass of 
 so-called " indifferent cells " lying in the meshes of a granular or fibril- 
 
 ' Kocher's Operative Surf/ery, 1894, p. 29. 
 
368 SYMPTOMS AND TREATMENT OF WOUNDS. 
 
 lated reticular intercellular substance. At first these cells receive nutri- 
 ment indirectly from the lilood-vessels through the plasma-eanais de- 
 scribetl by Thiersch, whicli are themselves in direct connnunication 
 with the blood-vessels. While granulation tissue contains leucocytes, 
 the weight of evidence favors the view that the cells of granulation 
 tissue result from the iiroliferation of the fixed connective-tissue cells 
 and possibly those of the parencliyma of organs, the leucocytes serving 
 as food for these cells. Soon capillary loops develop from pre-existing 
 blood-vessels, penetrate the masses of cells, and pass across from one 
 side of the wound to the other. Pari passu with this spindle-eells develop 
 from the round-cells. Most of these spindle cells, in turn, disappear as 
 the new fibrous tissue forms, either by conversion into this or by granular 
 degeneration and absorj)tion. On the surface of the wound new epithelial 
 cells are formed from the deeper layers of the rete mucosum, sometimes 
 under a scab of dried blood and exudation-material, beneath which the 
 young cells remain undisturbed until fully developed, when this portion 
 of the process is essentially what has been termed " healing under a 
 scab " or " by scabbing." 
 
 If too much exudate, serous or primarily more solid, is allo^ved to 
 accumulate iu a wound, the mechanical bond effected by the fibrin is 
 broken down, thus delaying union ; if excessive congestion occur, 
 much more if inflammation results from any cause, this mechanical 
 disturbance from excess of exudate is probable. It also favors infec- 
 tion and interferes witli the processes of repair. The same processes 
 occur in wounds with loss of substance or where primary coaptation 
 has been neglected. In lacerated and contused wounds the damaged 
 tissues must, indeed, be first removed, which is effected — whether 
 tliev be hard, as bone, or soft, as cellular tissue — by the accumulation, 
 at the junction of the dead and living tissues, first of numerous leu- 
 cocytes, then of cells gradually forming granulation tissue, substitut- 
 ing the tissues at such points. Finally, the intercellular cement or 
 reticulum of the boundary layer of cells dissolves, loosening the slough, 
 which floats away in the liquid exudate, leaving a layer of healthy 
 granulations beneath. When situated upon a free sui-face healthy 
 granulations present a level, slightly granular surface, whicli does not 
 project above the margins of the wound ; they are of a pink color, a small 
 amount of creamy pus being secreted if infection has occurred, or an 
 opaque serous or occasionally viscid fluid in aseptic cases. The mar- 
 gins are smooth, shelving, uninflamed, and an advancing border of 
 bluish-white new epithelium is present. 
 
 Healing by Second Intention. — This is the normal method where 
 loss of substance has occurred either from accident, operation, or where 
 gaping results from failure of primary union. While it is usually stated 
 that the wound " fills up," the fact is that, although this occurs to a lim- 
 ited extent, the organization of the deeper portions of the gramdations 
 causes a marked diminution in area of the surface and a drawing down 
 of the margins, leaving a much smaller surface to be covered in by epi- 
 dermis than is usually supposed. Upon this organization into scar- 
 tissue of the granulations, and tiicir uninterrupted subsequent contrac- 
 tion, depends the healing of many ulcers. Healing by granulation is 
 then the rule in contused and lacerated wounds, and in incised wounds 
 
WOUNDS. 369 
 
 whose surfaces cannot be coaptated or where primary union lias failed. 
 AVheu two surfaces covered by iieahhy granuhxtions are held in contact, 
 fusion often occurs ; loops of blood-vessels pass from one side to the 
 other, fibre-cells stretch across, and the wound promptly closes by seo- 
 ondari/ (tdhcsion, or " by third intention." This process is purposely 
 utilized in certain cases, " secondary suturing " being employed for coap- 
 tation. 
 
 Treatment of Incised Wounds. — First arrest the hemorrhage, then 
 cleanse the jtarts In- a gentle stream of sterilized or antiseptic water. 
 Ne\er distend a wound-cavity. Remove foreign bodies with forceps ; 
 do not rub the surfaces with a sponge. If the dry method of operating 
 be jjreferred, of course no water is employed, the wound being cleansed 
 with pledgets of sterilized gauze, etc. Where the wound is irregular 
 and deep, especially in not very vascular parts, one of two courses must 
 be pursued — viz. either all spaces where blood and serum can collect 
 must be effaced h\ buried sutures, or some means must be provided for 
 the free escape of blood first, and scrum later ; which latter is exjjressed 
 from the clots or exudes from the irritated surfaces : the coagulable mate- 
 rial probably contains nucleins enough to destroy germs, but the serum 
 does not. 
 
 Drainage is not usually necessary for more than twenty-four to forty- 
 eight hours. If, however, infection has occurred and disinfection cannot 
 be assure<l, drainage is certainly indicated until the dangers of sepsis are 
 passed. When only blood and serum need removal, capillary drains will 
 suffice, but these must never be employed for pus, tubes being here relied 
 upon. A capillary drain may be either absorbable or non-absorbable, 
 the former being comjjosed of fine catgut, the latter of sterilized horse- 
 hair. From ten to twenty or more strands of fine gut should be secured 
 in the middle by a single ligature threaded on a needle, whereby the 
 drain is sewed to the deepest portion of the M'ound. Between the buried 
 sutures, if such are employed, three to four strands are brought to the 
 cutaneous surface. Each set of strands is now included between two 
 interrupted sutures, the individual threads are laid carefully parallel 
 and in contact, and the ends cut off square about an inch beyond the 
 margins of the wound. To prevent drying, and thus converting the 
 strands into narrow tapes which will not drain, the protective must 
 extend some distance beyond the ends of the drains. Employed in 
 this manner, amputation or other large wounds can be readily drained. 
 When tubes are used, they must only reach into the cavity to be drained, 
 and he cut flush with the surface ; must be there secured by a stitch or 
 Siifety-pin ; had better — as in amputations of the breast — be brought 
 out through a special incision at the most dependent portion ; must 
 be of glass if likely to be kinked or flattened by pressure ; and must 
 be removed at the earliest possible moment. When used for pus- 
 cavities they must be gradually shortened. For superficial wounds, 
 especially in vascular parts, for absolutely aseptic wounds, and 
 where by buried suture all spaces are effaced, they are umiecessary 
 and injurious. Some surgeons employ both tube and capillary 
 drainage, removing the first within twenty-four hours and leaving 
 the absorbable drain, or, if horse-hair be employed, pulling out a 
 few hairs at a time during subsequent dressings. Placing the parts 
 
 Vol. 1.-2.1 
 
370 SYMPTOMS AND TREATMENT OF WOUNDS. 
 
 at iK'i't'cct rest, as on » .splint, compresses, and gentle but firm 
 banclajjing will aid in doing away with drainage by securing prompt 
 union of the dee]) as well as of the sujierficial parts. Aseptic or 
 antiseptic dressings in amount proportioned to the probable extent 
 of oozing must be applied. 
 
 The closure of incised wounds may be effected by sutures, which 
 may be interrupted or continuous. The ideal method of suturing is to 
 unite, by buried sutures, muscle to nuisele, fascia to fascia, and skin to 
 skin, neither inverting nor everting the latter. Buried sutures of the 
 skin, passing the stitciies so as to include merely the dense corium, but 
 not tlic epithelium, are preferred by many surgeons because of lessened 
 chances of stitch-abscesses resulting from infection by germs resident 
 in or upon the skin, and the avoidance of the scars lelt by the punc- 
 tures. 
 
 Coaptating sutures must never be drawn too tight, lest they imperil 
 the vitality of the included tissues, thus favoring sujipu ration. In a 
 thoroughly aseptic ^\•ound any pliable aseptic material will serve for 
 sutures, as silk, silkworm-gut, catgut, kangaroo or dog-tail tendon, 
 but non-absorbable substances may at any future time give rise to 
 trouble, so that where kangaroo or other tendon has sufficient .stability 
 for the purpose it shoukl be employed, and next to this Cliinese twist 
 silk. Needles may be straight, curved, or jiartially curved, according to 
 whether the woimd be in a free surface or a concave or convex one, and 
 should never l)e larger tlian requisite to carry the thread. The Hagedorn 
 needle is coming into vogue, and serves a good purpose in many situ- 
 ations, but often makes too large a wound. A round sewing-needle is 
 best for all operations on the bowels, bladder, or peritoneum. Sutures 
 may, in certain localities — as, for instance, the scalp — be substituted by 
 strips of gauze fixed first on one side of the wound by collodion ; the 
 lips are to be approximated by traction on the strip, which nuist then be 
 secured on the opposite side by more collodion. After removal of sutures 
 the same means can be employed to su])port the\\'Ound. Adhesive straps 
 should never be used to draw a wound together, but may be employed 
 to take strain off the stitches or to support the recent scar Ijy interposing 
 several layers of antise])tic or aseptic gauze. Antiseptic compresses and 
 proper bandages, exercising pressure through layers of elastic materials, 
 such as cotton, oakum, etc., sometimes serve as suecedanea to suturing by 
 maintaining quiet of the deeper parts, promoting drainage, and relieving 
 strain upon the stitches. 
 
 Essentials requisite for good wound-dressings are tliat they shall be 
 absorbent — /. e. favor drying, which interferes with germ-growth — and 
 that they shall contain germicidal substances, preventing infection of the 
 discharges, which in turn may reach the wound : both of these properties 
 render frequent dressing unnecessary, thus giving rest to the wound. 
 Sterilized iodoform promotes drying of the secretions, and, if sepsis occurs, 
 will hel]i to destroy the resultant ptomaines. One indication for chang- 
 ing the dressings will be their penetration by the discharges, but if the 
 discharge is slight and jirompt drying occurs at the margins of the stained 
 area, a pad of fresh antiseptic gauze may be secured over that part if it be 
 undesirable to uncover the wound. Again, if the temperature indicates 
 ti'ouble which is not exjjlainable by complications located elsewhere, the 
 
WOUNDS. 371 
 
 wound must be inspected, lest drainage be defective or infection may have 
 occurred. 
 
 Constitutional Treatment. — During the first few days simple, easily- 
 digestible liquid or soft diet is indicated, after which, if the bowels act 
 normally, fever being absent, ordinary full diet may be given should the 
 patient desire it. If loss of blood or 2:)revious drain of pus has occurred, 
 forced alimentation may be requisite, with stinudants, as alcohol in some 
 form, and such drugs as ammonia, strychnia, digitalis, (juinine, etc. 
 ^\'atch must be kept that tlic bladder is properly emptied — that tlie 
 renal and alvine secretions are normal in character and quantity. Proper 
 sleep must be secured, especially for the young and the old. 
 
 Treatment of Lacerated and Contused "Wounds. — As some con- 
 tusion is present in most lacerated wounds, the treatment of both 
 varieties will be considered together. 
 
 The cleansing and rendering tlicse wounds thoroughly aseptic is a 
 most difficult task, which is too often but partially done : still, every 
 reasonable etfort must be made. Tube-drainage must be employed unless 
 the wound lie so shaped and situated that it will drain itself. The ap- 
 parently hojiclcssly tlamagcd tissues may be removed, except about the 
 face, mouth, and scalp, where the vascularity is such that nothing had 
 better be removed. Possibly slight trimming of the margins of a face- 
 wound in order to secure primary union may be permissible, but unaided 
 nature will here do marvels, and subsequent defonuity may later be re- 
 moved by operation. Sutures are rarely advisable or necessary, except 
 in the face, where their judicious use will often secure a good result. Rest 
 to the part, with a voluminous dressing, outside of M'hich dry cold may 
 be applied, is often useful, lessening the severity of the inflammation 
 and consequent sloughing. \yith extensively contused wounds cold 
 must be cautiously employed, lest the sloughing be increased. Where 
 contusion is the chief feature but little primary hemorrhage occurs, as 
 is also true of lacerated wounds, but much blood is cxtravasated in the 
 tissues. This interferes with the circulation in the tissues ; hence slough- 
 ing is more apt to be extensive than in lacerated wounds, so that second- 
 ary hemorrhage, when the sloughs separate, is an accident to be dreaded. 
 Suppuration and destruction of tissue by sloughing are apt to occur in 
 both classes of wounds, despite all eiForts to secure antisepsis. Such 
 complications as spreading cellulitis or gangrene, or any variety of sepsis 
 or infection, arc all possible. Extensive scarring especially follows con- 
 tused wounds. When feasible, if spreading cellulitis with free suppu- 
 ration occurs, antiseptic irrigation or the continuous bath — warm or cold 
 according to the condition as to sloughing, etc. — is often better than an 
 ordinary closed dressing. 
 
 Punctured Wounds. — Th^ dcptli of tliese wounds is greater than 
 their width. Tiiey are produced l)v pointed objects, as knives, bayonets, 
 swords, nails, umlirella-sticks and walking-canes, splinters of wood, 
 stakes, etc. The dangers of these wounds are — hemorrhage from deep 
 vessels, damage to important nerves, penetration of cavities, and deep, 
 widespreading suppuration. When inflit^ted by a sharp uninfected instru- 
 ment, as a trocar, they pursue a course similar to other wounds, but when 
 resulting from a rough object, such as a board-nail, the end of a stake, a 
 cane-ferule, and like objects, the results differ, because often fragments 
 
372 SYMPTOMS AND TREATMENT OF WOUNDS. 
 
 of clothing, the inner sole of a shoe, or fragments of the more superficial 
 tissues-are torn oH'and deposited in the dejiths of the wound. It is this 
 fact, rather than l)ccause the various planes of tissue change their i-ela- 
 tions after the wound has been inflicted so that exudates cannot escape, 
 which exj)lains the gravity of punctured woimds. Hence for therapeutic 
 purposes punctured M'ounds must be divided, as Van Buren teaches, into 
 the smooth and the rough. 
 
 Treatment. — Hemorrhage having been arrested and asepsis secured 
 and maintained, nothing beyond securing rest to the jjarts by splint 
 or position is requisite for the smooth variety. If infection has oc- 
 curred, symptoms of deep eellulitis or of pleuritis or peritonitis will 
 develop, according to the parts involved, in which case the therapeutics 
 of these conditions are indicated. Kough punctures, where foreign bodies 
 or fragments of dead tissues may be present to act as infected foreign 
 bodies, must be treated by effectual disinfection, a drainage-tube intro- 
 duced to the bottom of the wound, absolute rest of the part, perhaps sup- 
 plemented by primary counter-openings, and ceiiainly by a sufficient 
 number of these later on if deep suppuration occurs. 
 
 Poisoned Wounds. — These are treated of in the chapter on " Sep- 
 tica?mia, Pynemia, and Poisoned Wounds," by Dr. Carmalt, and will be 
 but briefly referred to here. Formerly, when no preservatives were em- 
 ploj-ed in the preparation of bodies for dissection, so-called dissection- 
 wounds were common and serious. At present post-mortem examinations 
 of bodies recently dead from infective diseases are practically the only 
 source for these wounds. For a short time after death the infective 
 micro-organisms can maintain their virulence, but the bacteria of putre- 
 faction soon replace them, after which only local inflammation can result 
 from wounds contaminated during post-mortem examinations. The 
 bodies of those dying of septicemia, pyaemia, septic peritonitis, or of 
 erysipelas have i)roved the most dangerous. Those in vigorous health 
 and in the habit of performing post-mortem examinations are rarely 
 afl'ected — /. e. they have an acquired immunity from frequent exposure. 
 
 Symptoms. — These vary with the previous health and the poison. 
 Sometimes a pustule forms, ruptures, scabs over temporarily, and a pain- 
 ful inflamed ulcer forms, persisting for months ; again, a ■\\'art-like mass 
 forms, both conditions being often tubercular. A combination of local 
 and systemic infection is more common, where the piuncture or wound 
 becomes inflamed and suppurates ; the superficial or deep lymjihatic 
 vessels, or both sets, become involved ; the lymphatic glands enlarge 
 and often suppurate ; while early in the case a sharp rigor, followed by 
 fevei*, and perhaps sweating, is common. Some cases belonging to this 
 class have a repetition of rigors ; a typhoid state is early developed, with 
 multiple glandular suppuration, and purulent peri-adenitis involving the 
 axilla, neck, and side of the thorax. In some of the more serious cases 
 neither distinct local sym])toms nor involvement of the lymphatic ves- 
 sels precede the onset of the constitutional symptoms and the axillary 
 adenitis, etc. 
 
 The prognosis in this last class of cases is bad, death often taking place 
 in from a few days to three or four weeks. More rarely recovery ensues, 
 leaving an impaired constitution for long periods or for life. 
 
 Treatment. — When the injury is recognized at the time, encourage 
 
WOUNDS. 373 
 
 fi'ee bleeding, cleanse carefully hy prompt soaking of the part in the 
 most reliable germicidal solution attainable, followed by a moist anti- 
 septic dressing. Sores and warts must be destroyed by caustics or curet- 
 ting, or both. The brawny indurations of cellulitis must be freely incised, 
 pus-pockets be opened and drained, and sloughs be allowed exit. Measures 
 adapted to the maintenance of the patient's strength must be used, such 
 as stimulants and good, easily-digestible food. Cardiac stimulants — 
 strychnia, quinine, and digitalis — arc invaluable. Sleep must be secured 
 and the eliminating powers of the skin, bowels, and kidneys called uj)on. 
 
 Contusions. — These are subcutaneous lacerations, the skin surtiuie 
 remaining unbroken. They are caused by blows with hard, blunt 
 objects or by violent compression. The connective tissue with its 
 vessels suffers most, but muscles, veins, arteries, and lymphatics may 
 all be lacerated, the nerves escaping as a rule. Every grade, from a 
 slight bruise to a pulpefication of the part, may occur. In the slighter 
 grades a few vessels are ruptured, producing swelling and discoloration 
 of the parts. In other instances, where the tissues are lax or the injury 
 is severe, as in a crush of a limb, the major part of the skin may be 
 stripjx'd oft" from the deep fascia and tlie internuiscular spaces be dis- 
 tended by such an enormous extravasation that death results from the 
 sudden abstraction of blood from the circulation. 
 
 When a blood-collection becomes circumscribed by condensation of 
 the surrounding tissue, it is called a hasmatoma, in certain regions, as the 
 scalp, receiving a prefix, as ccphal-hrematoma. When the pressure of 
 the extravasation prevents furtlicr effusion of blood, this usually clots, 
 later breaking down into a thick reddish fluid.' Absorption is the rule 
 unless the tissues have their nutrition seriously impaired, the extravasa- 
 tion be large, or in predispomng conditions infection occurs, when sup- 
 puration will take place. When the pressure is great, so that the nutri- 
 tion of the skin stripped from the subjacent tissues is much impaired, 
 blebs form through which infection occurs, or the germs may reach this 
 locus minoris rcsistcntiic through the circulation. In certain localities 
 pus forms more readily than in othei's, as in the thoracic and abdominal 
 walls. Cephalhiematoma in infants never appears to suppurate. 
 
 The irritated tissues son^etimes develop a layer of granulation tissue 
 around the effusion, which may be converted into fibrous tissue, or in 
 some cephalhfematomata into bone. The central liquid portion becomes 
 decolorized, and if surrounded by a sac of fibrous tissue a serous cyst 
 is formed. This may remain unchanged, or, the fluid contents being 
 finally absoi'bed, a dense mass is left, which in time perhaps undergoes 
 absorption. 
 
 Symptoms. — The pain, unless a nerve-truidv is involved, is depend- 
 ent upon the tension. This, in turn, is due to swelling, which varies 
 with the amount of blood eflused and tlie laxity of the tissues. The 
 discoloration promptly appears if the bruise be superficial, but may not 
 be shown until many days have passed if only the deeper parts are 
 involved or the extravasation occurs beneath a dense fascia. First dark 
 purple, the color changes to green, then to yellow, finally fading out. If 
 a large vessel be concerned, the loss of blood may be very dangerous, 
 if not fatal, as in a case of my own where the external iliac vein with 
 ' Moullin states that this changes to a lighter hue when exposed to the air. 
 
374 SYMPTOMS AND TREATMENT OF TRAUMATIC DELIRIUM. 
 
 tlic (k'L'p circumflex arterv was turn. The extravasation occupied the 
 whole lower extremity, ancl formed an enormous subperitoneal lueniatoma. 
 Fever is usually in proportion to the extravasation and laceration of 
 tissues — /. €. the amount of fibrin-ferment and nucleins absorbed. When 
 near the surface the overlyiufi' skin presents the evidences of a plastic 
 inflammation, which soon disappears unless infection causes suppuration. 
 Treatment. — Rest for the part, and spirit and water or diluted lead- 
 water lotions so applied as to permit constant evaporation taking place, 
 serve best for the more superficial varieties. In the more severe cases 
 gentle elastic pressure, effected l)y bandages applied over a thick layer 
 of cotton-wool, after having emj)tied all blebs and protected them anti- 
 scptically, often checks the ett'usic)n and promotes absorption. Because 
 in severe contusions portions of the skin may have been killed, light 
 antiseptic dressing must always be ajiplied to obviate accidental infection. 
 Where the tension compromises the integrity of the parts or suppuration 
 seems imminent, aseptic aspiration, followed by pressure, is indicated. 
 When the collateral circulation is seriously interfered with, as the blood 
 ])robabIy comes from a large vessel or vessels, incision, ligatures, antl 
 proper drainage and asepsis are indicated. 
 
 Traumatic Delibium. 
 
 This, which sometimes follows certain injuries or operations, results 
 from several distinct conditions. Thus it is a symptom of septic trau- 
 matic fever, when it usually l)ecomes pronounced during the height of 
 this — viz. from the second to the fifth day — subsiding with the fever 
 producing it. It is most marked at night, and is usually in pro])ortion 
 to the pulse and temperature. 
 
 Prognosis. — This is favorable if the cause is removable, as is usually 
 the case. 
 
 Treatment. — Disinfection and drainage of the wound, with cold to 
 the head, laxatives, and possibly diaphoretics or diuretics to aid in the 
 excretion of ptomaines, are all that are requisite. Accidental or operative 
 traumatisms inflicted upon those jireviousl}' subjected to prolonged brain- 
 work, especially if of a susce])til)le nervous temperament, occasionally 
 give rise to a delirium sometimes called nervous trauinatic delirium. 
 This occurs without fever and in those not addicted to the use of 
 alcohol. While usually low and nuittering, the delirium may be 
 violent, even maniacal. 
 
 Prognosis. — This is usually favorable, especially if sufficient sleep 
 can be secured. 
 
 Treatment. — Carefully-selected, nourishing food, with stimulants if 
 requisite, will improve the nutrition of the nervous system, which has 
 suffered from the previous over-strain. While this is being effected the 
 cerebral centres must be kept at rest, to prevent exhaustion, by the 
 judicious use of opium, bromides, chloral, or a combination of the last 
 two. Quiet of mind and body should be maintained. 
 
 Delirium Tremens, or the delirium occurring in alcoholics, is charac- 
 terized in its uncomplicated forms by the absence of fever, but it nuist 
 not be forgotten that it may occur after a serious injury, ^vhich in itself 
 produces fever. The delirium is usually of the low muttering, busy, 
 
TRAUMATIC DELIRIUM. 375 
 
 vi<>'ilant form, with delusions, the patient seeing snakes, insects of all 
 kinds, animals, or devils, constantly conversing with himself, and, while 
 capable of answering rationally on other subjects than his delusions, 
 when left to himself promptly becoming again incoherent. At times 
 maniacal outbreaks occur, with suicidal and nunxlerous impulses, usually 
 resulting from injury received during alcoholic excesses: this is true 
 mania d potu. Such apparently suicidal acts as jumping from windows 
 are often only eiforts to get away from pursuing de\-ils or imaginary per- 
 sons threatening bodily injury. Unless restrained, the patient will not 
 remain in bed, making efforts to get up despite a broken limb. The skin 
 is moist, tlie hands siiaking ; the tongue when protruded is trenudous, 
 coated witli creamy fur at first, later, in bad cases, dry, brown, and cov- 
 ered with sordes ; the pulse is full, soft, and (juick ; and the temperature 
 is about normal. The face and whole manner indicate suspicion and 
 fear. Constipation is the rule ; comi)lete anorexia is present, although 
 fluids may be greedily swallowed, and sleep is impossible. 
 
 Prognosis. — If the patient is young and has sound kidneys, recovery 
 is the rule, Init when the reverse olitains death by exhaustion is not un- 
 conuuon. 
 
 Treatment. — In drunkards attention to the bowels, anodynes to pro- 
 duce sleep, proper food, and lessening (but not stopping) stimulants will 
 often ward off an attack, which the experienced surgeon anticipates in 
 those tremulous, sleepless individuals so often brought into our large 
 hos]>itals. Traumatisms inflicted upon individuals who are only mod- 
 crate drinkers often suffice to bring on delii-ium tremens, wliich other- 
 wise would never have occurred. Sudden withdrawal of the accus- 
 tomed stimulant sometimes ])recipitates an attack. 
 
 During an attack two indications are imperative — viz. to induce sleep, 
 thus jircvcnting fatal exiiaustion of the nerve-eeutres, and to maintain 
 their nutrition l>v proper food. A laxative or an enema should be given, 
 and, as liquids are usually acce})table, tlie patient can be induced to take 
 beef-tea or meat-broths, which, in the case especially of old drunkards, 
 will be rendered more palatable by considerable quantities of cayenne 
 pe])per, this condiment acting as a stimulant of both digestion and the 
 cirt'ulatiou. Occasionally forced feeding Mith the stomach-tube may be 
 requisite. With the older patients, where the kidneys are apt to be dam- 
 aged, opium is not advisal)Ie, but in young, sound patients the hypodermic 
 use of morphia may prove useful. Chloral, in from 15- to 20-gr. dt)ses, 
 combined with potassium bromide, every two hours until sleej) is induced, 
 and carefully watched, is usually both safer and more prompt in action. 
 AVhile it may be safe to at once withdraw all stiuudauts from the young 
 anil robust, such practice is not wise in the old or in feeble patients. 
 That stimulant which tlie individual is accustomed to should be given, 
 but in smaller quantities than usual, and it should be gradually with- 
 drawn. After securing prolonged sleep, tonics, good food, and gradual 
 stoppage of stimulants will usually effect a cure. The judicious use of 
 strychnia hypodermically will aid this, while supporting the heart aud 
 nervous system. While it may be pt)ssible to secure to the bed a jiatient 
 who has a fractured lind), it is exceedingly difficult to avoid further 
 injury to this, a simple fracture often l)eing converted into a compoimd 
 one. Where, owing to restlessness, well-padded splints cannot be em- 
 
376 SYMPTOMS ASD TREATMENT OF TRAUMATIC HYSTERIA. 
 
 ployed — for tlie patient will jji-obably break a gypsum dressing by jiound- 
 ing tiie limb about — the limb uuist be enveloped in an antiseptic dress- 
 ing and then tirmly bandaged in a feather pillow. If now the injury 
 be rendered compound, no special harm will result. Securing patients 
 to the bed by approi)riate ajjparatus will often be requisite, as they will 
 get \\\) and walk even upon a broken liml). 
 
 Traumatic Hysteria. 
 
 This term is applied to tiie nervous symptoms often observed after 
 severe physical shock, especially when combined with mental shock.' 
 As such comliiuations are more fretjuent after railway accidents, tlic 
 term "concussion of the sjiine " has been until recently often applied to 
 the condition, or " railway spine," but similar cases result from other 
 forms of accident. Physical injuries to the nervous system, or the re- 
 sults of such, as inflammatory or degenerative changes ; the arousing of 
 latent pathological conditions, with all distant injuries of peripheral 
 nerves giving rise to reflex effects ; or an ascending neuritis causing 
 central trouble, — must not be confounded with traumatic hysteria. 
 
 Neurasthenia, arising as it does from " a general defect in tiie mitri- 
 tion and action of the nervous system," must not be confoimded ^vith 
 traumatic h3'steria. According to Thorburn, the following complexus 
 of symptoms is, with slight variations, constant after many injuries, 
 especially railway ones ; it follows tliose of shock, showing exhaustion of 
 the nervous system, lint usually soon disappears under " time " treatment, 
 and must be carefully distinguished from iiysteria. 
 
 Symptoms of Neurasthenia. — Tiiese are "general debility, confusion 
 of thought, loss of memory, mental irrital)ility, disturbed sleep, dreaming, 
 headache (usually posterior), interference with visual accommodation, 
 photophol)ia, palpitation, frequency of pulse, dyspeptic troubles (furred 
 tongue, foul breath, constipation, and nausea or epigastric pain), sweat- 
 ing, a concentrated condition of tlie urine, etc."" While neurasthenia 
 is often associated with hysteria, and is nmch more frequent than the 
 latter, it is probably a distinct condition, hysteria being due to " sug- 
 gestion " or " auto-suggestion," and neurasthenia to mere exhaustion. 
 
 Age predisposes to traumatic hysteria and neurasthenia, these affec- 
 tions belonging chiefly to middle life. Hysteria is more likel}' to occur 
 in females if injured, but as nu)re males are exposed to the causes of 
 traumatic hysteria, more men actually suffer from it. A neurotic tempera- 
 ment and chronic alcoholism both favor traumatic hysteria, as they do 
 the ordinary form, but do not have so much influence as in the latter 
 variety, especially the neurotic tenqierament. The exciting cause is 
 
 'Oppenheim calls these troubles traumatic neuropsychoses. Thorburn classifies 
 functional neuroses following traumatisms as follows : 1. Acute effects : («) general nervous 
 depression — "shock" or "collapse;" (b) a more localized and defined disturbance of 
 cerebral (cortical) origin — "acute hysteria" or " hysterics." 2. Chronic after-effects: (o) 
 general nervous depression — "neurasthenia;" (h) a more localized and defined disturb- 
 ance of cerebral (cortical) origin — " chronic hysteria." Thorburn's definition of traumatic 
 hysteria is: "A functional affection of the nervous system resulting from an injuiy, due 
 probably to a change localized in some portion of the cerebral cortex, and manifested by 
 correspondinglv well-defined and localized symptoms." — A Contribution to the Surgery of 
 the Spinal Cord, Wm. Thorburn, B.S., B.Sc, M.D. (Lend.), p. 186 et seq. 
 
 = Thorburn: Op. cit., p. 185. 
 
TRAUMATIC HYSTERIA. 377 
 
 some accident, but mental impressions Iiave a large share in tlie cansa- 
 tion of" traumatic hysteria ; thus Thorburn insists that a previous period 
 of terror, horrible surroundings, and the instantaneous occurrence of the 
 accident have more effect tluui the physical injury. Direct injury to a 
 nerve-trunk is a "potent cause" of hysteria. While the severity of the 
 traumatism itself has no special tletermining influence, the locality has, 
 "complete hemiantesthesia or double monoplegia" on the same side as 
 that of the lesion often occurring after head-injuries. Surgical operations 
 are traumatisms, and oft«n give rise to various functional neuroses. 
 
 Symptoms. — While the ordinary screaming, laughter, crying, or 
 possibly convulsions so often observed after accidents are evanescent 
 and of no moment, leaving at most some temjxn'ary ner\'ous exhaustion, 
 there are certain peculiarities observable at times, especially after railroad 
 accidents. Thus patients will maintain that they have been unconscious 
 for a longer or shorter period, yet investigation shows by the absence of 
 vomiting, relaxation of the sphincters, etc. that this condition could not 
 have been due to cerebral concussion. Such patients walk, travel long dis- 
 tances, do many voluntary acts almost automatically, sometimes regaining 
 their consciousness, astliey describe it, after a considerable interval of time 
 and distance of space. They present a peculiar dazed appearance — in fact, 
 resemble in many Avays those in the somnambulistic state. Exaggerated 
 or purely imaginary statements are made pertaining to the accident. 
 These illusions are ])robably the results of "auto-suggestion" during a 
 state closely approximating that of the "minor degrees of hvpnotism."' 
 These preceding conditions have been called acute hysteria, while those 
 following belong to ciironic hysteria. 
 
 It will be impossible to more than mention the chief manifestations 
 of chronic hysteria. According to Thorburn, thev may be — (1) psychi- 
 cal, including e[)ileptiform attacks and hysterical insanity ; (2) motor, 
 including jiaralysis and contractures of the limbs and special effects 
 upon the larynx and the bladder ; (3) sensory symptoms — anesthesia, 
 hypersesthesia, and paraisthesise of the general or sensory nerves ; and 
 (4) vasomotor, secretory, and trophic troubles." ^ In most eases symp- 
 toms suggestive of combined neurasthenia are present. 
 
 Prognosis. — Under f ivorable circumstances, with proper treatment, 
 and when pecuniary comj^ensation is not sought or is promptlv granted, 
 recovery seems frequently to take place. Chronic alcoholism, a distinct 
 neurotic tendency, and the male sex are unfavorable. Marked changes in 
 severity of the symptoms, transference from one side to the other, and 
 temporary disappearance afford grounds for a favorable prognosis. 
 
 Treatment. — Isolate from friends and relatives, encourage use of 
 any paretic part, discountenance the idea that true paralysis exists, 
 employ massage and faradism, secure prompt settlement of legal ques- 
 tions, give tonics, possibly employ overfeeding, and eschew bromides 
 unless necessitated by " nuich cerebral excitement," when " bromide of 
 ammonium appears preferable to the potash salt."' Hypnotism and 
 "transference" have been' claimed to be efficacious in some cases. 
 
 ' Thorburn, op. cit, p. 194. ^ Op. cit., p. 194. » Op. cit, pp. 224, 225. 
 
378 SYMPTOMS AND TREATMENT OF HEMOBBHAGE. 
 
 Hemorrhage. 
 
 Tliis may be arterial, venous, or eapillary, or may arise from all these 
 sources. Unless arteries of a certain size are divided, bleedinj^ from them 
 and from the veins sjiontancously ceases and (■a])il]arv oozinj^ alone persists. 
 PI(iiiiirrliafi;e is called external when occurrinu- upon a free cutaneous or 
 nuicous surface — internal \vlien the lilood is pnui'cd into sucli cavities as 
 those of the abdomen, [)ericardiuni, pleura, or mediastiiunn. This term is 
 sometimes also applied to hemorrliages into hollow viscera, as the stomach, 
 intestines, or bladder. When blood is poured out in small amount into 
 the cellular tissue ecehyraoses or bruises result, while if the anioiuit be 
 large the term " extravasation " is employed. Traumatic hemorrhages 
 are called " primary " when immediately following tiie injury; "inter- 
 mediary " when they occur between the stage of shock and that marked 
 by suppuration, tJie bleeding I'esulting either from the increased vascular 
 tension of reaction or from coagula occluiling vessels becoming loosened by 
 the premature removal of external ])i-essure ; " secondary" when they occur 
 after supjturation has been established, lieing due to separation of sloughs 
 in\ olving the vessels, or to septic or infective inflannuation of the vessels, 
 leading to their ulceration or rupture or to the solution of the occluding 
 thrombi ; " parenchymatous " when there is a general capillary oozing, 
 due cither to inflammatory dilatation and canalization of the smaller 
 vessels or to throniljosis of the principal vein or veins. 
 
 Treatment of Heniorrhag-e. — Great losses of blood are dangerous 
 because of the risk of fatal syncope. This must be combated by the 
 retention of a functioning amount of blood in the l)rain, especially iu 
 the respiratory centres. The head and shovdders should be promptly 
 lowered, and this position maintained by elevating the foot of the bed 
 some inches, neither ])illow nor bolster being left beneath the head. The 
 limbs should be raised nearly to a right angle with the body, and thus 
 held. Sometimes, instead of this, Ksmarch or ordinary nuislin bandages 
 can be applied to one or all of the lindjs, or digital or instrumental com- 
 pression of the arteries of the limbs may be substituted. Many lives 
 would be saved if the more essential, if not all, of these measures were 
 instituted \\here the accident has occurred, instead of waiting for removal 
 to a hospital, house, or even to a couch. 
 
 Next, stimulants by the mouth or rectum must be employed. Tur- 
 pentine rectal euemata act well. Subcutancously, whiskey, ether, atropia, 
 and strychnia will prove beneficial. Artificial heat by hot bottles, and 
 a sinapism over the heart, are useful. Transfusion of a saline solution 
 into the cellular tissue of the pectoral or abdominal region, by means of 
 a hypodermic needle attached to a few feet of small rufjber tubing and a 
 funnel, acts nearly as well as intravenous saline transfusion, and is nuich 
 moi-e readily done : indeed, considerable quantities of sterilized normal 
 salt solution may be injected in a .short time by the rapid use of an ordi- 
 nary hypodermic syringe. As occasion permits, concentrated hot meat- 
 essences, milk, hot coffee, etc. must be given — /. e. liquids which when 
 absorbed will supply the heart with a bullv of fluid sufficient to carry on 
 its functions. As the patient rallies the bandages nuist, one by one, be 
 cautiously removed, the limbs then lowered, but the dejjcndent position 
 of the head must be maintained until all risk of .syncope has passed away. 
 
HEMORRHAGE. 379 
 
 Later, iron, tonics, and nutritions food are indicated to snpply tlie loss 
 of red cells. Ergot, snlplnn-ic acid, acetate of lead with opium, have all 
 been occasional!}' useful in recurring hemorrhages where the bleeding 
 points cannot be reached — /. c. in enterorrhagia, hseniatemesis, etc. 
 
 H^EMosTASis. — Tiie local means for temporary hajmostasis are local 
 pressure by lingers, com])resses, tourniquets, bandages, etc. over the 
 wound or on the l)leeding vessel in the wound ; compression of the 
 main vessel above or below the wound by similar measures ; and flexion, 
 especially of the elbow or knee, for wounds of the arteries of the hand 
 or foot. A compress should be placed in front of the elbow or behind 
 the knee, and the limb bent until bleeding ceases, the member being 
 thus maintained by a handkerchief or bandage. Only such styptics are 
 permissibk' as imitate or hasten Nature's efforts, which are, in the case 
 of arteries, lessening of calibre and retraction within their sheaths, with 
 the formation of an external and an internal clot, and in veins their col- 
 lapse and consequent thrombosis. 
 
 Exposure of wounds to the air after removing all clots, a current of 
 cold water flowing over their surfaces, or ice itself in the wounds or 
 api>lied over tiie dressings by means of an ice-bag or an ice-bladder, are 
 the best means of employing cold. 
 
 Hot water (125°-130° F., roughly estimated as the greatest heat bear- 
 al)lc for a few moments by the back of the hand), poured over or better 
 applied by pressing a towel wrung out of the water on the wound, acts bet- 
 ter tlian cold and docs not depress tlie vital powers. Alcohol or tincture of 
 iodine pure or variously diluted has been successfully employed by some. 
 Perchloride and subsulphate of iron are poj)ular but unreliable styptics ; 
 moreover, they render asepsis and immediate union impossible. While 
 Monsel's solution is useful for free bleeding from leech-bites, it is better 
 even for such accidents to transfix tiie lips of the minute wounds with 
 fine sewing-uecdles, around each of wiiich a figure-of-8 ligature should 
 be cast. Tannic and gallic acids are less olijectionable than the iron 
 salts, while alum apjjlied by means of cotton saturated in a hot solution 
 has been much vaunted : probably pressure has much to do with its effi- 
 cacy, and an iodoform-gauze tampon would be vastly better. These 
 chemical styptics arc only mentioned to condemn them, excejjt where 
 nothing else is available, as will sometimes occur.' 
 
 The actual caatcrji, applied at a dull-red heat, is most efficient when 
 primary union is not aimed at or in the peritoneal cavity, in the latter 
 case no eschar being separated. The cautery is often the only resort in 
 such operations as removal of the upper maxilla, where the vessels can- 
 not be isolated. The thermo-cautery is the best form, but any metallic 
 substance, as wire, knitting-needles, etc., can be heated in the fire or gas. 
 
 Measures for the Permanent Arrest of Hemorrhag-e. — While the 
 cautery for certain cases and the antiseptic tamponade may be employed 
 for this purpose, certain otiier measures are more commonly employed. 
 
 Torsion. — Only divided vessels can be twisted. Drawing out the 
 whole cut end of the vessel with one pair of catch-forceps, grasp the 
 vessel transversely close to the tissues with a second ]iair. The end of 
 the vessel can then be twisted off, or three or four siiarp turns can be 
 given until the inner and middle coats give way, resistance to further 
 
 ' In bleeders, but here the thermo-cautery would be better. 
 
380 SYMPTOMS AND TREATMENT OF HEMORRHAGE. 
 
 torsion tlien suddenly diminishing. Sniallci" vessels which cannot be 
 isolated can be seized with some of the surrounding tissues, all of which 
 should be twisted off. 
 
 Forcipre.ssure is effected by seizing the vessel or tissues with catt^h- 
 forccps, which can be removed in from a few minutes to forty-eight 
 hours. 
 
 Ligature. — Properly-prepared silk, kangaroo tendon, and catgut form 
 the best ligatures. If tying a divided vessel, draw its end out by for- 
 ceps or a tenaculum just far enough to place the thread securely. If in 
 dense tissues, the tenaculum sliould be used, and slightly Avithdrawn as 
 the first half of the knot is tightened. A curved needle armed Avith tlie 
 thread can sometimes be more conveniently employed, passing it around 
 the vessels so as to include a little of the surrounding tissues, thus jire- 
 venting the ligature from slipping. When tightening the knot the sur- 
 geon's thumbs or forefingers must jiress somewhat down against the for- 
 ceps or tenaculum, so as not to j)ull the instrument off the vessel or out 
 of its sheath, this latter accident favoring secondary hemorrhage. When 
 the ligatures are to be cut short, whetlier silk or catgut, tlic first half of 
 the knot must be tied only so tight as th(n-oughly to occlude the vessel 
 and maintain its position, damaging the coats as little as possible : when 
 a ligature is to come away, the aim is to divide the inner and middle 
 coats, so that only the external coat remains for the thread to ulcerate 
 through : both modern surgical practice and theory condemn this. A 
 " reef " or " square " knot must be employed to the exclusion of the 
 " granny." 
 
 An artery wounded in its continuity must be reached through the 
 wound with the least damage to parts, the proximal and distal ends 
 tied, and also any branch opening into the part included between the 
 ligatures.' 
 
 Mmmres for Recurrent or Secondary Hemorrhaf/e. — Ligature of the 
 bleeding points, when feasible, followed by antiseptic tamponade when 
 a cavity is concerned, is the best. As the bleeding from an artery tied 
 in continuity usually comes from the distal extremity, especially when 
 overlying a bone, a graduated comj)ress and bandage may suffice : this 
 may be tried before religation or amputation. If methodic compression 
 is to be employed, control the artery by pressure above, clear out the 
 clots, apply the compress directly on the bleeding point, and secure it by 
 bandages, which must support the circulation of the whole limb, below 
 and above. Not much pi-essure must ho used, and this should be relaxed 
 after twenty-four to thirty-six hours, to prevent the formation of a slough 
 with renewed Ideeding ; l)ut the compress must be allowed to come away 
 of itself. Where no room remains for the application of a ligature, the 
 wound may be filled with shot or a shot-bag employed as a compress. 
 When all means fail, if an extremity is involved, amputation should be 
 done. 
 
 ^ Aciipresmre may be used to occlude a vessel, thus: Pass a threaded needle through 
 the tissues beneath a vessel, cast over its jioint a loop of metallic wire, and compress the 
 vessel by securing the wire by a turn or two around the eye-end of the needle; traction 
 of the thread removes the needle, freeing the wire loop. Again, a long, stout steel pin 
 can be passed through the skin and tissues at one side of the vessel and over it, and be 
 made to emerge through the skin on the opposite side. According to the size of the 
 vessel the needle or pin can be removed in from thirty to sixty hours. 
 
HAEMOPHILIA. 381 
 
 HEMOPHILIA. 
 
 This disease consists in a tendency to excessive and continnons hemor- 
 rhages, occurring spontaneously or after traumatism. Swelling of the 
 joints is frequently associated with the external hemorrhages. It is 
 congenital, attacks males, and is usually inherited through the mother, 
 who herself escapes. The first manifestations nearly invariably occur 
 before the second year of life, the ])rimary bleeding rarely appearing 
 after puberty. In fact, after this period the tendency to bleed dimin- 
 ishes. The oozing, continuing for hours, days, or even weeks, is always 
 capillary. Epistaxis is the most common form of spontaneous hemor- 
 rhage : slight scratches of the skin, bites of the tongue, leeching, blisters, 
 extraction of teeth, and circumcision are some of the tranmatic causes ; 
 the last three seem especially dangerous. In the sligliter form petechia, 
 €cchvmoses, and hiematomata may occur, either spontaneonsly or from 
 trivial injury. Jcnner reports a hematoma extending from the knee to 
 the trochanter produced by the fall of a rubber ball on the tliigh.^ The 
 petechife, which occur chiefly beneath the skin of the extremities, 
 although sometimes seen on mucous and serous membranes, may be 
 accompanied by swelling and ]>ain in the joints. Either with or with- 
 out these purpuric spots arthritic complications are very connnon. These 
 vary from simple pain to suddenly-develoj^ed redness and intense inflam- 
 mation accompanied by fever, thus closely simulating acute rheumatism. 
 The knee-, elbow-, ankle-, and shoulder-joints are those most usually 
 aifected. Repetition of the attacks commonly results in marked deform- 
 ity and disability. With the exception of ordinary anfemia just after 
 the bleeding the Iilood is normal, wounds healing as in other anemic 
 patients. Histohjgical examination of the vessel-wall has only once 
 afforded confirmation of the statement of Blagden, made in 1817," that 
 the walls are unusually thin, Ividd ^ finding degeneration of the muscular 
 tissue of the middle coat of the arteries and proliferation of the endo- 
 thelium of the arterioles, veins, and capillaries. Hemorrhage into or 
 around the capsules of the joints accounts for much of tlie articular 
 swelling. Inflammation of the synovial fringes and ulceration and de- 
 struction of the articular cartilages have also been reported. 
 
 Pathology. — Although there must be some peculiar frangibility of 
 the vessels and failure in prompt coagulation of the blood, there are no 
 histological or chemical facts explaining what these abnormalities arc. 
 
 Diagnosis. — In a lileeder family this is easy. If occurring in a 
 member of a family hitlierto free, and not resulting fi'om slight pro- 
 longed sepsis, reliance must be placed on these points : The spontaneous 
 or tramnatic hemorrhages are multiple, joint complications are frequent, 
 the tendency to bleed persists for years : this would constitute a congen- 
 ital l)lceder, not an hereditary hicmophiliac, and if a male, he would be 
 likely to found a "bleeder family" if he should have offspring. The 
 differential diagnosis from simple hemorrhagic or infective purpura, 
 peliosis rheumatica, etc., mu.st be sought elsewhere. 
 
 Prognosis. — Few die from the first bleeding. The older the patient 
 the better the chances, especially in girls, who do not seem specially 
 
 ' Legg : On HminophUia, p. 68. ^ Medko-ckirurg. Trans., vol. xli. ' Loc. cil. 
 
382 DTAGNOSIS AND TREATMENT OF HEMOPHILIA. 
 
 prone to post-partum liemorrhages, although often menstruating early 
 and profusely. 
 
 Treatment. — Prophylaxis is imperative ; all operative injuries, ex- 
 traction of teeth, and anything but life-saving (jperations must be inter- 
 dicted. In the presence of hemorrhage cleansing of the \\(>inid, followed 
 by pressure, should be employed. Antipyrine may do good, while repeated 
 injections of cocaine into the gum has checked the oozing after pulling a 
 tooth. Ergot by the stomach, purges of sodium sulphate — except in 
 enterorrhagia — large doses of tincture of chloride of iron, have all 
 seemed to do good. Tonics, iron, cod-liver oil, etc. are in<licated after 
 the attacks, with residence in a Avarm climate. The joint-trouliles must 
 be viewed as grave. If absolute quiet with moderate compression be 
 employed, a first attack often leaves an articidation normal, but when 
 untreated or repeated bleedings occur an arthritis results resembling 
 some forms of tuberculosis.' While a very dangerous jirocedure, Konig 
 has thrice punctured the joint, using antiseptic irrigations, and has had 
 two cures and one improved case. 
 
 Bertrand ^ and Pilcher ' think that the dangers of capital operations 
 are overrated, because the larger vessels bleed no more than in ordinary 
 patients. While operations should be avoided when possible, if they are 
 requisite careful ligation of the smallest vessels, with firm compressing 
 bandages to control parenchymatous bleeding, will often suffice. If neces- 
 sary, the actual cautery and tamponade with gauze impregnated with 
 iodoform or chloride of iron will render success more frequent. Asepsis 
 is imperative, " since secondary subcutaneous or intermuscular hemor- 
 rhages make the danger of suppuration " greater. 
 
 ' Med. and Surg. Reporter, June 25, 1892, F. Konig. 
 
 ' Hiedel : Inmig. Dissert., 1892, referring also to successes by Cramer, Schede, Czerny, 
 and Miiller. 
 
 ■' See Annals of Surgery, p. 499 et seq., vol. xvii., 1893 (Pilcher), for special means 
 adopted. 
 
SEPTICiEMIA, PYEMIA, AND POISONED 
 
 WOUNDS. 
 
 By WILLIAM H. CARMALT, M. D. 
 
 Septicemia. 
 
 By septiciemia, or septic or putrid fever, we understand a general 
 disease which occurs by reason of the introduction into tlie circulation 
 of the products of decomposition, and which is characterized by certain 
 definite changes in the blood, a typical succession of intlammatory pro- 
 cesses, and a continued fever with jicculiar nervous symptoms and cuti- 
 cal secretions.' 
 
 This definition, in allowing us to include the absorption of the prod- 
 ucts of decomposition, without the actual presence in the blood of the 
 micro-organisms thereof, conforms to the clinical phenomena as we find 
 them in surgical practice. Cases of I'xtensive sulx'utaneous lacerations, 
 followed by fever and other clinical phenomena of the absorption of 
 septic material, are of frequent dccurrcncc, yet the most careful investi- 
 gation does not reveal the presence of infective micro-organisms. The.se 
 cases are regarded as instances of the absorjition of the chemical sub- 
 stances, toxines or ptomaines, produced in the decomposition of the blood- 
 clot, ])oisonous in their action, causing a form of septic intoxication to 
 which Matthews Duncan gave the name of " saprsemia." 
 
 In a few hours — variably from twelve to seventy-two — after the 
 reception of a subcutaneous laceration of the soft parts, with extrav- 
 asation of blood into the connective tissue, or after a surgical operation 
 in which the hsemo.stasis has not been complete, or — taking an illustration 
 out of strict surgical practice, though of like pathological significance — 
 after the act of parturition, a disturbance shows itself, usually first noticed 
 on the part of the nervous system. The jiatient has a headache, a flushed 
 face ; the appetite fails ; there may be nausea ; there is a marked feeling 
 of depressi(jn, even anxiety ; there may or may not have been a slight 
 chill ; the temperature is from 100° to 102° F. or more ; the tongue 
 becomes dry, and air acute sense of smell will perhaps detect a .slight 
 odor to the wound or discharge. If the projier treatment be not 
 immediately instituted, these .symptoms increase, though not uniformly 
 so in all cases : headache may not be complained of, but the senso- 
 rium becomes greatly blunted ; the patient is apathetic, lies rather in 
 a stupor, and, though answering f|uestions intelligently, is slow to be 
 aroused; the nausea becomes more pronounced; the food is vomited ; 
 the temperature keeps up all the time, in the afternoon rising a degree 
 
 ' Gussenbaur : " Sephthiimie, Pyohiimie, und Pyo-sephthiimie," p. 2, Deutsche Chi- 
 rurgie, Lief. 4. 
 
 383 
 
384 SEPTICAEMIA, PYAEMIA, AND POISONED WOUNDS 
 
 or over, ranging between 101° and 103° F. ; the tongue becomes drier, 
 perhaps not more coated ; tlie patient at times is delirious, able to answer 
 if aroused, though not always correctly ; the pulse becomes rapid and 
 feeble, the respiration Juirricd and superficial ; if drink is offered, it will 
 be taken with avidity, but the patient does not ask for it; the sensoriuni 
 is benumbed ; the muscular strength fails greatly, aud the patient sinks 
 down in the bed. In bad cases these symptoms increase rapidly : the 
 benumbing of tlie sensorium, as shown in the stupor and delirium, be- 
 comes greater, the heart's action more feeble ; there may be subsulfus 
 tcii(Uimiii; the half-closed eyes become glazed with mucus, which col- 
 lects upon the cornea and around the edges of the lids ; if care be not 
 taken, involuntary discharges of urine occur from overflow of the blad- 
 der, the jxitient being unconscious of the distention ; the bowels are 
 constipated, and if a cathartic be administered the discharge will be 
 unnoticed ; the face, at first flushed, liecomes, as the heart's action fails, 
 dusky and livid, and death comes on the fourth or fifth day. 
 
 With all these grave constitutional disturbances, however, it is to 
 be remarked that there are but few changes in the wound-surface ; the 
 odor of decomposition may remain, or, if the . parts are not thoroughly 
 washed, it may increase ; but the tissues around the cut surfiice do not 
 show any changes to indicate that they have become the seat of deposits 
 of micro-organisms, nor does the post-mortem examination show the 
 ckiudy swellings in the parenchymatous organs associated with septi- 
 caemia. The clinical phenomena are those of the nervous system being 
 overwhelmed by the action of a substance resembling a narcotic poison. 
 
 In milder cases — i. e. those in which the amount of poison absorbed 
 has not been great, or in which a rational treatment has been promptly 
 and successfully instituted — the symptoms disappear as rapidly ; the 
 headache and other nervous disturbances pass off; the appetite returns; 
 the pulse regains its tone and strength, and the temperature becomes 
 nomial. 
 
 The prognosis depends upon three factors : 
 
 First : the amount of })oison absorbed — as for other poisons, upon the 
 dose administered. Regarding the disease as due to direct absoi'ption 
 of the poisonous products of decomposition, and not to the presence of 
 micro-organisms multiplying in a fertile culture-medium, it is evident 
 that a large dose will have more effect than a siuall one. This depends, 
 therefore, either on the size of the blood-clot undergoing the decompos- 
 ing processes, or on the extent of tissue destroyed from which the toxine 
 is evolved to be distributed to the nervous system, upon which, it is evi- 
 dent, it most powerfully acts. In this there is a striking contrast to 
 other more positive septicemic processes, where a small wound — -the 
 prick of a needle or a scalpel in a dissecting wound — is followed later 
 by extremely serious consequences. 
 
 Second: the time M'hich elapses before the proper treatment is applied : 
 the longer the poison acts by its depressing influence upon the nervous 
 system, the higher the pulse and temperature become, the more are they 
 using up the ^jatient's vital forces. 
 
 Third: the constitutional habit — viz. the strength of the individual 
 to resist the action of the poison. This factor does not require explana- 
 tion ; it is the same for all diseases. The prognosis, of course, is more 
 
SEPTICEMIA. 385 
 
 unfavorable in the exti'emes of age or if this disease be complicated with 
 some other. 
 
 The treatment consists, first, in removing the source of the disease, 
 removing all blood-clots, and, if it be a wountl, washing off the absorbing 
 surface. In this condition the use of germicidal solutions — the so-called 
 antiseptics — is no more beneficial than that of sterilized water. The only 
 advantage they have is in the destruction of any possible germs, or their 
 spores which may not yet have become active, but which, under favor- 
 able conditions, are likely to become so and to lead to more serious dis- 
 ease. Blood-clots and all matters which serve as a basis for the devel- 
 opment of the products of ilecomposition must, however, be thoroughly 
 removed and their fiirtlier ccjllcction be prevented. 
 
 It depends on the violence of the s)-mptoms as to how far we must 
 go in exposing a raw surface for the purpose of getting rid of the poison : 
 a single thoi'ough washing out of the uterus after parturition is often 
 sufficient to reduce the temperature to normal without a relapse ; occa- 
 sionally it is required to repeat it a few times at lengthened intervals, or 
 in other cases it must be done every few hours. In the case of Mounds 
 where we are hoping to get union by first intention, a single washing out, 
 with pressure firmly applied over the skin of the stump (if it be an 
 amputation), will frequently suffice. If this does not answer the pur- 
 pose, the introduction of a drainage-tube becomes necessary, and more 
 frequent cleansing with the more positive germicides, owing to the 
 danger tliat septicemia may take the place of sapra'mia. Alercuric 
 bichloride in the proportion of 1 : 2000-10,000, and carbolic acid in 
 from 1 to 3 per cent., are at this period of great value. The further 
 carrying out of local treatment is included in that of septicsemia. 
 
 The treatment of the constitutional condition consists in strengthen- 
 ing the action of the heart and that of the general system by the admin- 
 istration of stimulants : whiskey, St. Croix rum, and brandy in milk- 
 punch or egg-nog are preferable, as thereby nourishment is also given ; 
 quinia or tr. cinchona is of great value, but the use of the recently- 
 invented antipyretics is of little benefit. 
 
 In a certain number of cases, where the amount of poison evolved 
 and absorbed is not sufficient to cause the death of the patient, and in 
 which treatment is not ])ropcrly instituted for recovery, in the course of 
 some days another condition of the general system is brought about, due 
 to further changes in the blood-clot and in the neighboring tissues. The 
 micro-organisms producing the putrefaction of the clot penetrate in time 
 into the several blood-vessels of the woiuidcd part, there finding a soil 
 more fertile for their further multiplication and development. A\'e then 
 have another set of symptoms, in many respects, it is true, similar to those 
 of the septic intoxication, but with tiiis important difference — that their 
 severity is due not so much to tne amount of a poison absoi'bed as to the 
 activity of growth of the bacteria. In other instances than the one men- 
 tioned of a retained blood-clot we find the same set of symjitoms fc>llow)ng 
 trivial as well as severe injuries — the mere prick of an infected lancet, 
 the most indifferent scratch. I have in mind the prick of a wooden 
 toothpick received in the hand in takijig it out of the pocket, necessi- 
 tating subsequently the amputation of the arm to preserve life : medical 
 literature reports similar cases in abundance. It is only necessary that 
 
 Vol. I.— 25 
 
386 
 
 SEPTICEMIA, PYJEMIA, AND POISONED WOUNDS. 
 
 the bacteria be given access to tlio circulation in order that the disease 
 may be set up ; an evident wound is not necessary. It must not be 
 understood, liowever, tliat all persons thus injured, who are subjected to 
 the same infection, respond ecjually and are su"scci)tible in a like degree to 
 the deleterious effects. It would seem that all blood is not equally good 
 soil for the growth of the germs, or tiiat the tissues of some persons 
 resist their action, so that the general infection does not follow the 
 exposure, and the individual escapes. 
 
 The infection in septicaemia is shown botli locally and constitutionally, 
 but not uniformly in either way. It depends largely on the character of 
 the wound, but in some degree also upon tlu' virulence of the infection. 
 In cases of open wounds, such as compound fractures or severe lacera- 
 tions of the soft parts, including the skin, with I'ontaniiuatiou of the tis- 
 sues, a class of wound most frequently followed by septicsmia running a 
 typical course, the skin at the seat of injury becomes reddened, swollen, 
 and painful, and the wounded surface becomes covered with a dirty- 
 looking, somewhat thick secretion, which will jiartially wash off, but 
 leaves the tissue underneath of a dull, more or less variegated gray 
 color, -without distinction between different anatomical parts, with a 
 superficial slough and an ajipreciable odor of decomj)osition. This last 
 is an exceedingly important symptom, to be sought for early with great 
 care; and it may be here stated that the great objection to iodoform as a 
 dressing for fresh wounds is that Ijy its strong odor it masks the first 
 positive evidences we have of putrefaction, anil in just so far increases 
 the danger of acquiring the general condition of scpticiemia. At the time 
 that these changes appear in the wound, or very soon afterward, the 
 general system shows evidences of participation, in that the temperature 
 rises — it may be a degree or two, it may l)e more — the pulse and resj)ira- 
 tion are accelerated, the tongue becomes coated, and the })atient complains 
 of a general sense of discomfort ; in other words, an active febrile move- 
 
 FiG. 10. 
 
 ment with some, but not severe, evidences of affection of the nervous 
 system, inasmuch as stupor and aj)athy are not so prominent, in this 
 respect differing from the condition of saprtemia or septic intoxication 
 just described. The fever is continuous, but with morning remis- 
 
SEPTICEMIA. 387 
 
 sions and afternoon exacerbations, gradually on successive days rising 
 higher and higher — the morning remission not reaching that of the 
 previous day — until the acme is reached : this occurs about the fourth 
 ■or fifth day, when, ^^•ith the appearance of suppuration in the wound, 
 the constitutional symptoms abate and the fever sul)sides l)y a similar 
 gradation of declining steps at each day, though more rapidly than 
 it arose, so that, while it Avas from three to six days rising, it falls 
 in from two to four days to a nearly or quite normal temperature. The 
 temperature-chart of a typical case of septicaemia going on to recovery 
 is sliDwn in tlie accompanying diagram (Fig. 10) of a case of com])ound 
 comininuteil fracture of both Ijones of the leg by a railroad injury, 
 occurring in an otherwise healthy man of about twenty-five years of age. 
 
 The character of the wound, the method or al)sence of treatment em- 
 ployed, the nature of the infective material with which it is contaminated, 
 and the constitutional condition of the individual as to power of resisting 
 the invasion of the infective micro-organisms and the develoj)ment of the 
 toxines, arc, however, factors that modify the course of the disease, both 
 locally and constitutionally, in a great variety of ways. It is of the 
 highest interest to surgeons to know just how to meet the manifold 
 phases. 
 
 The septic process may spread locally along certain definite anatomical 
 lines ; it may invade all the tissues of a limb or a part, attacking, perhaps 
 ■destroying, every tissue that it meets. The most frequent anatomical 
 site, however, is perhaps the connective tissue, where, owing to the loose 
 arrangement of lymph-spaces, vessel-sheaths, and intermuscular planes, 
 the development of the bacteria is given every facility, and where they do 
 grow almost witliout limit. These are the cases of cellulitis so constantly 
 met with in the hands, less fretpiently in the feet, of tradespeople and 
 those who are exposed to infection from their occupation. Wo find them 
 arising from the most trivial, many times undetected, injuries, usually 
 spreading rapidly, with great pain and swelling. 
 
 In other instances entrance is gained into the sheaths of the tendons, 
 and tendo-vaginitis of an exceedingly severe character is excited, often 
 going on to suppuration, extending into the palm of the hand, and so on 
 up to the wrist, with the result of the impairment, if not absolute aboli- 
 tion, of function by the destruction of the sheath from sloughing or from 
 the necessary treatment in laying it fi'eely open, the subsequent cicatriza- 
 tion producing adhesions obliterating the sheath, or so attaching it to 
 neighboring ])arts as to prevent the normal play. These cases are 
 intensely j>ainful, owing to the confinement of the swelling inside the 
 fibrous sheatlis, and, while not so deforming as when the connective tissue 
 alone is involved, the integrity of the hand is in greater danger even if 
 am]>utation be avoided. 
 
 The various distributions of the lymphatic system serve frequently, 
 both in common with the connective tissue and alone, as media for 
 the transmission of the micro-organisms : it may be as a simple lymph- 
 angitis or lymphadenitis, and we may regard septic osteomyelitis as 
 belonging here. These cases are always serious by reason of the 
 very great facility with which they spread, either continuously along 
 the course of the vessels, or more erratically, leaping from one set of 
 glands to another, sometimes quite at a distance, each set serving as a 
 
388 SEPTICEMIA, PYAEMIA, AND POISONED WOUNDS. 
 
 focu.s for the storing up and further di.strihution of the bacteria. Occa- 
 sionally they suppurate, though they usually do not, but where they do 
 it simulates pyajmia, and tlie diagnosis is then difficult. The more acute 
 course, coming on before supi)uration has appeared in the wound ; the 
 character of the fever, being continuous instead of intermittent; the ab- 
 sence of repeated chills and the torpor of the nervous system, — determine 
 clinically the septic rather than the purulent character of the process, as 
 is confirmed at the autopsy by the absence of abscesses in the parenchy- 
 matous organs. 
 
 The most virulent form of septic infection, however, appears in the 
 immediate invasion of all the tissues of a part — skin, connective tissue, 
 muscles, lymphatic vessels, and blood-vessels. This invasion is of great 
 gravity, and comes on usually as the residt of extensive injuries to both 
 soft parts and bones. 
 
 A man of not very robust physique, but otherwise in good health, 
 had his left foot causrht between an elevator-car and the floor above in 
 such a way that most of the sole of the foot, including the tuberosity of 
 the OS ealcis, was nearly crushed off. The ragged skin and enclosed 
 pulpefied mass of bruised tissue were stitched together by an incompetent 
 practitioner, bandaged firmly with cotton roller bandages halfway u]) to the 
 knee, and left practically without further treatment. He was admitted to 
 the New Haven Hospital on the fiiurth day after. There was an extremely 
 offensive odor of putrefaction ; the foot was black and gangrenous; the 
 whole injui'ed portion and the leg to just above the knee swollen, emphy- 
 sematous, and of a peculiar shiny-brown or bronzed color — not reddish. 
 This color had been noticed only on the day previous to admission, but 
 had advanced rapidly after making its first appearance. The pulse was 
 about 105, of good force; the intellect clear; there was considerable^ 
 pain in the leg. The temperature was 100^° F. A free incision was 
 made about halfway to the knee at the spot where the emphysema was 
 most evident ; no pus was found, but the w^ound discharged a thin sani- 
 ous fluid of a more or less yellowish color, mixed with gas, and gas could 
 be pushed out of the wound in the foot from above ; the incision through 
 the skin scarcely bled ; there was no undermining of the skin or opening 
 of the muscle-planes, and it was impossible to get a drainage-tube in 
 Avithout breaking through fresh tissue. An active system of antiseptic 
 irrigation was instituted, but the infection of the tissues continued to 
 advance, and the next morning the discoloration was two inches higher y 
 the temperature a trifle higher, 100j*g°, the pulse 80, the mental conditiou 
 Still good. That the foot would require amputation was without question, 
 and the advancing infection of the leg made it appear as if it would be 
 necessary to take the leg ofl' high up, above the knee, to save life, but 
 the very rapid advancement left it uncertain just where. In the after- 
 noon the discoloration had reached the irregular line shown in the illus- 
 tration (Fig. 11) taken from a photograjjli. At this time the temperature 
 was 101^°, the pulse 115 and more feeble, but there was no stupor or 
 other disturbance of the nervous system other than could be accounted 
 for by the natural anxiety of what the outcome was to be, for it now 
 looked as if the thigh must be ami)utated in the upper third, if not at 
 the hijJ-joint. During the next night there was no advancement of the 
 discoloration, and the temperature had fallen to 101°, in the afternoon 
 
SEPTICAEMIA. 389 
 
 to 101 j^°, and from this time tliore was a steady subsidence of the un- 
 toward symjttoms, Ijoth locally anil constitutionally, .so that on the ninth 
 day after admission I was able to amj)utate at aliout the middle of the 
 leg. The tissues at the site of the operation still showed evidences of 
 
 Fio. 11. 
 
 Bronzed discoloration of skin of leg and tliigh following traumatic gangrene of foot, appearing 
 third day after injury— photograph taken second day thereafter. (From records of New Haveu 
 Hospital.) 
 
 the diseased condition in that they were infiltrated with serum and did 
 not heal by first intention, but the course of the operation was almost 
 aseptic throughout in that the rise in temperature on the afternoon of 
 the day following the operation was lOOj^g-" F., falling at the next obser- 
 vation to normal. 
 
 The fortunate result in this case cannot be regarded as the rule, how- 
 ever, in cases of general septic infection with traumatic gangrene, as is 
 illustrated in another case, likewise under my care at the same hospital, 
 where a woman of fifty-eight was subjected to the manipulations of a 
 notorious "bone-setter" for a dislocation of the left shoulder-joint of 
 two weeks' duration. After jirolonged and violent attempts at reduc- 
 tion the arm was finally left with the elbow bound firmly to the side 
 and a pad in the axilla. I saw it first three days afterward : the 
 arm was then black and gangrenous to the elbow, with great swelling 
 and a reddish discoloration of the arm above. The pain was severe, 
 the pulse of the opposite arm rapid and feeble ; the temperature was 
 102° F. ; the patient was alert in mind, aware of her danger, and 
 anxious to have the arm removed ; the tongue was already dry, and 
 there had been some vomiting. Amputation was deferred to try — first, 
 to improve the heai't's action by stimulants ; second, to try the eifect of 
 anti.septic treatment in reilucing the fever ; third, to see if some line of 
 demarcation would not show itself. The first only of these desiderata 
 came about : the heart did gain strength, but the putrefaction inci'cased, 
 the swelling and redness extended over the shoulder, and began to 
 invade the neck. On the first day after admission the temperature was 
 103y\j-° F., falling the next morning to 100^*^° F., and rising in the after- 
 noon to l()3/jy° F. ; the tongue continued dry. Incisions were made in 
 the arm for the purpose of washing it out antiseptically. It being evi- 
 
390 SEPTICEMIA, PYAEMIA, AND POISOXED WOUNDS. 
 
 dent, however, that the sepsis was increasing, and the patient's general 
 condition not improving, tiie arm was am])ntated at about the middle on 
 the second day. At the operation it was found that, instead of a dislo- 
 cation, there was a fracture of the sui-gieal neek (whether this was the 
 original injury or was produced by the violent etforts made to reduce 
 the tlisloeation could not bo told), and that all the tissues at the line of 
 amputation were intiltratcd witii a foul-smelling serum, particularly in 
 the intermuscular planes of connective tissue. The bone was removed 
 at the seat of fracture, and the sinus thus left was mopped out with ])ure 
 carbolic acid, and the wound freely irrigated with mercuric bichloride, 
 1 : 1000. There was a decided imjn'ovement in her condition immedi- 
 ately and for a few days following the operation ; the temperature fell 
 to iOO° F., but her heart failed ; she was soon after attacked with a 
 septic gastro-enteritis, causing profuse watery discharges, \vhich became 
 choleraic later and involuntary ; her stomach refused to retain anything j 
 she became indifferent to her surroundings, and finally comatose, dying 
 in this condition thirteen days after the injury, eight days after the 
 amputation. This gastro-enteritis is not unusual in severe cases, and is 
 regarded by Gussenbaur as directly due to the action of the products of 
 the septic micro-organisms uixin the intestinal tract. 
 
 While these two cases bear, in their local action, a marked resemblance 
 to the ffcmgrene foudroyante of Maisonneuve, there is an imjJortant differ- 
 ence in the symptomatology — viz. that the nervous symptoms were by no 
 means so prominent. In the case of the wound of the foot, although the 
 local progress was most rapid, to l)e seen advancing almost from hour to 
 hour, the patient's mind was clear : he ap])reciated the danger of his situa- 
 tion, was desirous to have whatever done that his medical adviser deemed 
 best, and was in no way either apathetic or over-anxious as to his situa- 
 tion. In the other case it was not until just before the arm was ampu- 
 tated, five days after the injury, that the torpidity of the intellect as 
 given by Maisonneuve became a prominent symptom. His cases are 
 described as "being from the l)eginning in a condition of complete 
 apathy ; the wound and its parts affected by the septic infection are 
 almost painless; the patient does not ask for drink, though his dry 
 tongue cleaves to his gums," though in other cases there is great rest- 
 lessness, indeed manifest delirium, with unconsciousness of surround- 
 ings and disposition to toss about in spite of the injuries ; the skin is 
 bathed in perspiration ; the urine and tVeces are passed involuntarily ; 
 the respiration is hurried and superficial, the jjulse weak and intermit- 
 tent ; in other words, there is a condition of extreme collapse, in M'hich 
 the fatal termination appears in from twenty-four to ninety-six hours. 
 In the cases which last long an icteric hue to the skin becomes evident, 
 showing the effect of the jioison on the liver, which on autopsy is usu- 
 ally found swollen and soft. 
 
 This description is very like that given of septic intoxication 
 (sapraemia), but we are taught that in this the local changes are as 
 nothing. It is therefore evident that the most active fulminating putre- 
 factive local ]irocess may go on for days in an extremity, with no absorp- 
 tion taking place of the products of decomposition to affect the cerebral 
 functions, and finally recover; and, further, that symptoms identical 
 M-ith this acute disease, saprsemia, may come on as a secondary fever 
 
SEPTICEMIA. 
 
 391 
 
 several days aftei" the reception of the injury, an intermediary, compar- 
 atively afebrile, stage being passed through. 
 
 The effect of the septic infei'ticin, as has been stated, is much the most 
 marked in the systemic disturbances ; the tissue-changes, aside from tiie 
 direct injury, are not very great. They consist in an interference with 
 or a cessation of the proper process of repair, rather than in active 
 destruction. There are cases, however, where the local destruction is 
 excessive, as in tlie gangrenous stomatitis or cancrum oris of children. A 
 characteristic instance of this occurred in my service at the New Haven 
 Hospital.' We have here to deal with the invasion of the tissues by the 
 bacteria to such an extent as to destroy them en masse. It is not a 
 question of a cutting off of the blood-sujjply by an embolic process, 
 as in gangrene of a limb, nor of the destruction of the vitality of the 
 tissues by a violent force, as in railway injuries, nor, again, of the infec- 
 tion of the system from a trivial injury, as in a dissecting wound, but 
 the almost sinudtaneous destruction of all the tissues of the part Ity the 
 apparent invasion of the wiiolc by countless myriads of bacteria of 
 various kinds, staphylococci, streptococci, and micrococci all being found. 
 These cases usually occur in children already reduced in vitality by 
 some debilitating disease, as typhoid fever, but in whom access to the 
 tissues by the micro-organisms is obtained by some slight abrasion — in 
 this the picking at a tooth witli her tinger-nails produced a slight abra- 
 sion which rapidly increased U) an area of iuHannnatiou, followed by 
 
 Fig. 12, 
 
 Gangrenous stomatitis following tvplidid fovor about twilfth day after beginning of ulceration. 
 (Records of Now Haven Hospital.) 
 
 necrosis and gangrene, so that mIicu I first saw her, about ten days 
 from the beginning of the local trouble, there was an area of gangrene 
 involving the entire thickness of the cheek from near the median line 
 
 * Dr, C. J. Foote, in the American Journal of Med. Scknces, Aug., 1893. 
 
392 SEPTICEMIA, PY.EMIA, AND POISONED WOUNDS 
 
 to beyond what had been the angle of tlie month, exposing both upper 
 and lower jaw-bones ; the teeth were loosened from their sockets ; shreds 
 and masses of necrotic tissue were lying loose in the ulceration ; the 
 odor was indescribably offensive ; the child lay quiet and sonmolcnt 
 unless aroused, and then shrieked and tossed al)out in angry delirium ; 
 the pulse was 130 and feeble, tlie i'esj)iration about 25, temperature 
 102^ij° F. ; the skin around the ulceration was swollen and reddened. 
 In spite of energetic treatment the gangrene extended without the 
 slightest check, and in two days the cavities of the nose and mouth were 
 both, exposed and the palate was gone ; in another the lower o'velid had 
 fallen away from the upper by the detachment of its inner eonuuissure ; 
 a large part of both jaws was denuded of periosteum at the bottom of 
 the ulceration, and the bones themselves were already necrotic. The 
 pulse was about 140, the respiration about 40, the temperature varying 
 from 101° to 104° F. On the fourth day after admission the morning 
 temperature was 104j*o° F., the afternooii 9d^^° F. She died on the 
 fifth day after admission, about the fourteenth day from the invasion 
 of the tissues by the bacteria. This extensive destruction by gangrene 
 of all the tissues, the blood-supply not beiaig cut off, is exceptional and 
 only found in similar conditions ; it woidd seem that young tissues, 
 especially when reduced by debilitating illness, afford the most favor- 
 able soil possible for the growth of these micro-organisms ; or, jierhaps 
 it is the same thing to sa}', have no power of resistance to their growth. 
 
 Multiple peripheral neuritis has been mentioned as the result of sep- 
 ticsemia. One well-marked case occurred under my observation in the 
 person of a professional colleague who wounded himself in the hand at 
 an operation for the opening of a phlegmonous cellulitis. The resulting 
 inflammation was of decided severity, but not extreme, and after a|)parent 
 recovery, having resumed practice, he exjierieneed a gradual loss of 
 power with pain along the nerve-trunks, first in the arm which had been 
 the seat of the injury, but gradually invading both upper and lower 
 extremities. It lasted nearly a month, and gradually disappeared, the 
 recovery being comjjlete.' 
 
 Gussenbaur's definition of septicaemia, which I have adopted, fixes 
 no definite period of time for the termination of the disease, but the 
 course as described is essentially acute. It is usually a matter of l)ut 
 a few days before death closes the scene or convalescence is established, 
 or, pus forming, the subsequent course is claimed to transfer it into a 
 pyaemia of one form or another. It has seemed to me, however, that if 
 in a certain — and that not infrequent — number of cases the acute nervous 
 symptoms subside and pus in moderate amount apjiears, the character and 
 persistence of the febrile movement justify us in regarding the condition 
 as chronic. It is a continuous fever, with about the diurnal variation that 
 belongs to health, but is from one to two degrees higher. The tempera- 
 ture, instead of running along between 98° and 99° F., runs between 99° 
 and 100° F. or 100° and 101° F., with, occasionally, a rise of a degree 
 or a fraction of a degree more, but seldom falling below ; not presenting 
 the characteristic features of the pyaemic chart, of great diurnal varia- 
 
 ' Consult Dr. J. J. Putn.im : " Pathology and Etiology of Infectious Processes on the 
 Nervous System," Transactions of TIdrd Triennial Congress of American Physicians and Sur- 
 geons, vol. iii., 1894. 
 
SEPTICEMIA. 393 
 
 tions, but keeping the surgeon always anxious lest this sh(iuld develop. 
 This condition will sometimes last for weeks : every hosintal surgeon 
 must recognize the clinical description. I am unaware of any i)ac- 
 teriological observations having been made to establish the patiiological 
 condition behind it, but when we recognize that the occasional sudden 
 accessions of temperature are always to be referred to some circumstance 
 having to do with an increase in the production of the jitomaines of 
 putrefaction, as by a remission of strict antiseptic treatment, intentional 
 or otherwise, and that when this is re-established the temperature returns 
 to its former, but still abnormally elevated, degree, luitil recovery is 
 brought about by the curative processes of nature, the inference seems 
 justitied. 
 
 It may be urged that I am here giving anotlu'r name to irritative 
 fever. I prefer to give these cases a pathological rather than a purely 
 theoretical classitication. 
 
 The prognosis of scpticjemia, like that of other acute infectious dis- 
 eases, depends more upon the strength of the individual than upon any- 
 thing else. There are two points, however, to be considered in this 
 relation : the power of resistance of the tissues to the invasion of the 
 micro-organisms, as shown by the rajiidity of extension of the local 
 process, and the amoiuit of systemic disturbance which the individual 
 suifers, as shown in the force and frequency of the heart's action. Single 
 observations of temperature, even though high, are not of much import- 
 ance in a prognostic point of view, but a continuously high fever has^ a 
 bad outlook always. Age is an imjjortant factor, the very young and the 
 aged witlistanding the effects of septic fever and intoxication but poorly; 
 and it goes without saying that any complicati(jn of septic infection occur- 
 ring in ])ersons already reduced by organic affection of an internal organ, 
 be it kidneys, lungs, or heart, is of the gravest prognosis. 
 
 Other tilings being equal also, the prognosis is greatly influenced by 
 the promptitude and thoroughness of the ti'catment. The inaugura- 
 tion of an active antisejitic treatment, though the temperature be very 
 high, M'ill usually i)e followed by a remission if undertaken before ner- 
 vous symptoms become severe. 
 
 The treatment of septicaemia must have I'clation to prophylaxis as 
 well-as to the later manifestations shown in the general condition. In 
 the early stages it is mainly local, and means the application of all the 
 rules and remedies of the so-called autisejitic surgery of to-day ; in the 
 later period, when the heart threatens to give out, or the intestinal tract 
 becomes irritable, or the brain is oppressed by the presence of a poison, 
 the specific treatment of the disease, the antisepsis, becomes subordinate 
 to that directed to overcoming these c(mditions of the general system. 
 The projihylaxis of septicsemia, however, belongs to another subject ; it is 
 included in the treatment of all wounds, whether operative or otherwise ; 
 it has to do with the jireparation of the patient for an operation — the 
 operating-room, the instruments, dressings, the operating held, the per- 
 sonal cleanliness and disinfection of the surgeon and attendants of every 
 grade, or, when these are not at hand as in a well-regulated hospital, to 
 aim for them as far as possible, supplementing them, however, with 
 remedies having in view the destruction of infectious substances which 
 may have gained access to the wound before the care of the surgeon is 
 
394 SEPTICAEMIA, PYJEMIA, AND POISONED WOUNDS. 
 
 given it. It would, however, involve a repetition if these matters were 
 given at length here ; they will be treated of under the aseptic treat- 
 ment of wounds. We have here to speak only of the treatment of 
 wounds whieh have become infected : wliether this be from the fault 
 of the surgeon in not having achieved the desired asepsis, or from the 
 nature of the accident and its surroundings, is indifferent; its existence 
 is determined when the conditions heretofore described are foinid. 
 
 If the wound has become infected, the treatment is started antisep- 
 tically at once. The two princijial methods are the dry and the moist. 
 The first is founded on the well-known fact that the development of 
 bacteria requires heat and moisture : if either of these be absent — /. e. if 
 the temperature be near the freezing-jjoint or if the parts be absolutely 
 dry — no putrefaction can take place. The first of these conditions is, 
 for obvious reasons, impossible of fulfilment, but the latter, if the 
 wound be not very large or ragged, may be approximately, often suf- 
 ficiently, achieved by the employment of materials of various kinds 
 which will absorb the discharges of the wound and A\ith that sterilize 
 the soil in which the micro-organisms breed. Iodoform, l)oric acid, bis- 
 muth, inditferent substances, as starch, lycopodium, have this in common, 
 and when freely applied with a thick sterilized dressing, as gauze, dried 
 moss, jute, oakum, or even absorbent cotton, over them, \\ill occasionally 
 serve this })urpose. The application of this method is, however, limited : 
 it requires that the wound shduld be fairly smooth, with a minimum of 
 ragged edges or exposure of smiace, and that the secretion should not be 
 very abundant : this occurs only in quite recent Avounds. 
 
 When the wound is extensive, not capable of nearly complete closure, 
 has a quantity of ragged edges and exposed muscles, with the intermus- 
 cular spaces and connective tissue leading along the vessel-sheaths laid 
 bare, in every one of \\hich the secretions of the wound collect and 
 serve as fertile breeding-grounds for the bacteria, it is necessary that 
 some means be employed either to remove them or to destroy the germs 
 and their spores in situ. For this purpose various antiseptic solu- 
 tions are employed in many different methods to suit exigencies and to 
 meet mechanical difHculties of situation, etc. There are three princij)al 
 methods of applying the moist dressings : first, intermittent washing of 
 more or less frequency ; second, constant irrigation ; tiiird, application 
 of dressings wrung out in various solutions or combinations of these 
 solutions. Appreciating the importance of rest in every healing wound, 
 as little disturbance as is consistent with the thorough removal of the 
 infectious matter should be employed : we judge of the thoroughness of 
 the removal by the effect on the temperature. The washing is done 
 most conveniently with a so-called fountain syringe or irrigating bottle 
 suspended above the level of the wound, to get the amount of force 
 required to inject the washing fluid into all the interstices of the wound, 
 using best a glass point for ct)ntact with the wound (in a hospital a sepa- 
 rate point is kept for each patient), which in the intervals between use is 
 kept in an antiseptic solution. 
 
 As warm water is usually more grateful to the jiatient's feelings than 
 cold, it is in most cases best to use it ; there are cases, however, when the 
 j)utrefaction is active, in which the inhibiting efl^ects of cold on the devel- 
 opment of the micro-organisms may be tried with advantage, especially 
 
SEPTICEMIA. 395 
 
 if the bodily temperature be high, inasmuch as by reducing this we are 
 restricting the activity of their reproduction. Having regard, tlien, to 
 the temperature, the wound may be washed off with simply sterilized 
 water ; with a solution of carbolic acid from 1 to 5 per cent. ; with mer- 
 curic bichloride of from 1 : 500 to 1 : 20,000 ; with potassium perman- 
 ganate of from 1 to 10 per cent. ; with hydrogen peroxide of from 1 : 1 
 or from that to 1 : 15 ; with Tiiicrsch's solution ' — according to the effect 
 to be produced as shown by the odor and the degree of temperature. This 
 is but a small list of the remedies recommended : tliey are, lH)wever, 
 those in principal use, having stood the test of practical applications 
 in many different hands and under various conditions. As to a choice 
 between them, one is guided by idiosyncrasies of individuals and 
 the effect on the tissues. CJarbolic acid produces an unpleasant anses- 
 thetic effect on the part if allowed to remain in contact witii it long or 
 if used in sufficient strength to be a germicide. JMercurie bichloride 
 is the best germicide, but acts unfavorably upon the tissues themselves, 
 and there is always the further danger of sidivation if used freely. 
 Potassium permanganate is expensive and stains everytliing with which 
 it comes in contact, whereby the local process is hidden and one is at a 
 loss to know what is going on in the wound ; indeed, later investigations 
 seem to show also that its disinfectant properties at least have been over- 
 rated. Hydi'ogen peroxide, which has been extensively advertised and 
 lauded to an extent in some quarters that renders one suspicious, has 
 very decided objections : it is expensive, is extremely uncertain in 
 quality of manui'acturc, requires particular care for its preservation, 
 and if used I'reely will salivate. For these reasons it is not adaptable 
 for ordinary use. Taking it altogether, mercuric bichloride meets the 
 indications for practical use the best, though it requires care about the sick- 
 room in that tiiere is nothing in its appearance or smell to distinguish a 
 solution of it from water. Pharmacists have met the demand for its use by 
 preparing tal)lets combined witii ammonium (or sodium) cidoride of 
 definite strength, one of which, dissolved in a ])int of water, makes a 
 solution of 1 : 500, and with this as a standard the strength may be varied 
 according to the indications. In order to identify the solution, tablets 
 are occasionally colored with some indifferent coloring matter. In the 
 hands of the laity this may be a wise precaution, but the solution is 
 disagreeable to work witli, to say the least. 
 
 In case of extensive laceration of skin and more or less exposure of 
 underlying tissues, where a loss by slough is inevitable, and where, 
 under ordinary circumstances, the slougiiing process would surely be 
 accompanied by a septic process of considerable if not dangerous inten- 
 sity, where the prac'tical indication is tlie apjdication of a poultice to 
 hasten the process of separation, my practice is to ajiply a thick layer 
 of cotton or jute or mixed tissue freely wetted \vith a hot solution of 
 mercuric bichloride of about 1 : 4000, covered with a rubber clotii or 
 oiled silk to keep it from drying ; this, which I call an antiseptic poultice, 
 is changed every few iiours (dej)ending upon the urgency and the effect 
 produced) by rinsing the dressing oil' by wringing it out once or twice 
 with a fresh solution, and is again ajiplied hot. By this means I am 
 frequently able to treat an extensive slougiiing process with little or no 
 ^ Salicylic acid, 2 ; boric acid, 12 ; boiling water, 1000 : jiarts by weight. 
 
396 SEPTICEMIA, PYJEMIA, AND POISONED WOUNDS. 
 
 febrile movement. A cnsc! in point occurred in a man the bottom of 
 whose foot had been ahnost torn oil' in a "planer," the injury being 
 very similar to the one above cited of f/ciiif/rene fond roy ante, but in 
 which I was able within a few hours to institute the treatment above 
 described, and, although the suppurating process lasted several weeks, it 
 was throughout its course absohitely odorless and afebrile. This ex- 
 tremely favoral)le course, however, is jtossible only when tlie treatment 
 is instituted early, bclbrc the septic j)roccss has l)egun : it is really asep- 
 tic treatment, and not the treatment of sei)tic:cmia. It shows, however, 
 what may be accomplished by that method of treatment, for frequently 
 Avhen the septic process is already in full swing the ap|)lication of an 
 antiscpti(> poultice as described will reduce the activity of the process or 
 stop it altogether. If it does not, the dressing may be removed every 
 two or three hours, the wound thorougldy ^vashed out in every part 
 of the interstices with a solution of 1 : 2(J(X), and the poultice reapplied, 
 carrying it well up to above the limit of the wound. In severe cases a 
 more frequent change is required, and the solution should be allowed to 
 drip constantly over the dressing, provision being made to carry it off: 
 in aggravated cases a stream of the solution may be arranged to play 
 constantiv over the wound, at once disinfecting it and washing the loose 
 and soluble products of decomjjosition away. This constant irrigation, 
 however, requires caution, as it may salivate, and it should therefore not 
 be used in greater strength than 1 : 10,000 for any length of time. I 
 sometimes alternate the washing off of the wound with the solution 
 once in two or three hours, with irrigation of sterilized water to wash 
 away whatever sublimate may have remained on the surface or in the 
 interstices of the tissues. Depending, hence, upon the temperature and 
 the local swellings, the strength and the length of time of the appli- 
 cation are to be judged, varying from intermittent washings of sterilized 
 water to constant irrigation with a sublimate solution. 
 
 The entire submersion of an extremity in an antiseptic solution is 
 practised in some cases when the laceration is extreme and the mechan- 
 ical ditticidties in the way of a thorough irrigation cannot be otherwise 
 overcome. Following the practice first observed at the Massachusetts 
 General Hospital, I have used the coal-tar product of sulphonaphthol 
 in the proportions of from 1 to 5 per cent., the usual strength being 2 
 per cent. The limb is kept innnersed in this solution for a few hours, 
 the moist dressing sul)stitutcd, and, if the temperature rises, the limb is 
 reimmersed : I have used this quite siitisfactorily in cases already septic 
 when admitted to the hosjiital. The objection to it is a liability to pro- 
 duce dermatitis of the healthy skin above the seat of the injury, and a 
 shininess of the surfiice where the moisture, which bears a certain re- 
 semblance to an emulsion, comes in contact with the raw surface. 
 Patients, however, usually express themselves as relieved from pain in 
 a short time. " Creolin " may be used in the same way. 
 
 Incisions through the skin into the swollen tissues to allow the escape 
 of the infiltrated serum serve also as avenues through which the solution 
 may be injected into the tissues where the products of putrefaction are 
 developing : these incisions often require to be numerous and deep, and 
 are frequently the means of saving a limb or life that otherwise would 
 be sacrificed. 
 
SEPTICEMIA. 397 
 
 In septic lymphangitis and adenitis it is sometimes also necessary to 
 dissect out tlie contents of tlie axilla or groin, whicli have become foci 
 from which the septic process is further distributed. Unfortunately, 
 however, none of these precautions or remedies is suflticient to clieck the 
 onward course of the disease : the piilegnionous process extends near 
 and nearer the trunk ; more and more of the limb becomes gangrenous ; 
 the fever becomes woi'se, the brain symptoms more pronounced ; it is 
 evident that unless the patient is relieved from the continued absorption 
 of the putrefactive products death will ensue. Under these circumstances 
 the removal of the whole limb is an imperative necessity, and witli it 
 comes the decision of the seat of the amputation. Will it do to operate 
 through soft tissues already infiltrated witli the products of decomposi- 
 tion, or must the whole limb be sacrificed, adding to the dangers of tlie 
 operation, already very great? While such a thing is of course undesir- 
 alilc per sc, and, other tilings being equal, is to be avoided, yet operation 
 through infiltrated tissues is not absolutely forbidden. It depends upon 
 the character and extent of tlie septic ])rocess. One cannot advise cutting 
 through a gangrenous tissue or one in the immediate neighborhood thereof, 
 but I have repeatedly, under stress of circumstances, amputated in regions 
 where the tissues were infiltrated and discolored, and witli care have had 
 recovery. I have in mind a man who was cut on the foot with an axe 
 wliich passed deeply lietween tlie great and second metatarsal bones ^\'itll- 
 out injuring either, but in whom the \vound b(!came infected : gangrene 
 appeared in isolated spots on the leg above the ankle ; tiie jiatient's gen- 
 eral condition became exceedingly bad — could hardly be worse ; pulse 
 and temperature both high, and, quite incapable of appreciating his 
 condition, he lay in a muttering delirium. The local a])pearances grew 
 worse, tlie gangrenous spots appeared aliout the knee, and in desperation 
 amputation was performed at about the junction of tiie middle and U])j)er 
 thirds of the leg as the highest point at which it was believed he would 
 survive the shock of operation. He was so torpid by the eifect of the 
 poison on his brain that he required almost no ether ; he was unconscious 
 of tiie operation for several days after it was over. The cut surface 
 hardly bled ; it was discolored and dirty with sanguineous serum ; the 
 arteries were occluded. There was no odor to the Jreshli/-cut surface or 
 stump aftertcard. There was no union by first intention, the skin-flaps 
 became gangrenous along their edges, and yet the patient in time got 
 well with a useful stump. This was an extreme case, and very doubtful 
 in progress for a long time, but the end justified the rislv ; and, as less 
 severe cases have also recovered, it can be claimed that while the practise 
 is not desirable as a rule, it is sometimes good surgery. 
 
 An elevated position to the aftccted limb, if it be such, is most desira- 
 ble, and the importance of rest in keeping the circulation as inactive as 
 practicable is not to be forgotten ; therefore the suspension of an arm 
 or leg is to be practised if possible. 
 
 As to the treatment of the constitutional complications which occa- 
 sionally arise, we are guided by general principles. The disease is from 
 the beginning depressing, as shown in the lieart's action ; stimulants of 
 all kinds are therefore allowable, the choice being left to the taste of the 
 individual (surgeon). The necessity and the amount required are indicated 
 quite as much by the dryness or otherwise of tlie tongue as by anything 
 
398 SEPTICAEMIA, rV.EMIA, AXI> POISONED WOUNDS. 
 
 else, thougli the state of the jHiLse of course is to be considered. Brandy, 
 St. Croix rum, B(inrhon whiskey, in about the order mentioned, witii tiie 
 bitter tonics of cinciiona and gentian, are the most desirabk'. If tiie 
 patient can take milk, this in the form of millv-])uneh and egg-nog 
 gives nourishment with the stimulation; if there l)e vomiting, "ginger 
 ale," champagne, and carbonated water will frequently control it, and I 
 have known fresh buttermilk to be retained wiien every other form of 
 nourishment was rejected. Other forms of intestinal disturbance, as diar- 
 rli(pa, are to be treated by the ordinaiy astringent and sedative remedies 
 of acetate of lead, opium, catechu, tannin, etc. I iiave sometimes thought 
 that good results in the beginning of an attack followed tiie admin- 
 istration of a brisk saline cathartic, wiiich ap])ears to reliexe some of 
 the toxic symptoms, and the opium is then better bcn'ne. When a diar- 
 rhoea occurs, it is best to stop the use of the mercuric bichloride and 
 substitute something ha^'ing less tendency toward intestinal irritation. 
 If the diarriicea becomes dysenteric in ciiaracter, euemata of opium and 
 starch and lead will frequently stop it. Great care must be taken in the 
 nursing of patients in the severe cases, as the stupor is so great that the 
 skin over prominent points becomes ulcerated, and bed-sores of great 
 extent and obstinacy result. This is especially tiie case when the urine 
 and freces are discharged involuntarily. Tiie patient should, if possible, 
 lie upon an air- (or water-) bed, or, if that is unattainable, air-cushions 
 and ring-pads, to take tlie pressure from the threatened jioints, and, above 
 everything else, the most constant, unremitting attention must be given 
 to keeping the patient clean and dry. Use frequent bathing with alco- 
 hol or cologne, dusting zinc powder or starch or lycopodium upon the 
 parts afterward, and ciiange the ])osition from back to side and from 
 side to side as much as the proper treatment of the local disease will 
 permit. It must be remembered that the disease is most exhausting, and 
 convalescence is correspondingly slow. 
 
 Pyemia. 
 
 A secondary fever with certain constant characteristic diurnal feat- 
 ures, coming on in tiie course of the healing of a wound by suppura- 
 tion, has been known since the earliest medical writings. In the wars 
 of the Middle Ages epidemics of such a fever attracted the attention of 
 Ambrose Pare and of Paracelsus. The former noticed that fractures 
 of the liones of the skull by sabre cuts, etc. were followed by abscesses 
 of the liver ; Paracelsus, that the fever was intermittent, commenced 
 with a chill, and was frequently accompanied by inflammation of, and 
 purulent deposits in, the joints. Morgagni described the abscesses as 
 metastatic, and stated that the pus was carried to various internal organs 
 — tlie lungs, liver, spleen, etc. — and tliere dept)sited from the blood-ves- 
 sels ; he described an exudation into tiie pleura also as the result of puru- 
 lent absor]ition from a wound. Tiie intermittent tyjie of the fever and its 
 epidemic ciiaracter led to the opinion that it was of miasmatic origin. Mod- 
 ern research, however, especially Vircliow's investigations on embolism 
 and thrombosis, the experiments of Billroth and Otto Weber, and finally 
 those of Robert Koch on the traumatic infective fevers, demonstrated 
 that we have to do with the absorption of pus infected with micro-organ- 
 
PY^JIIA. 399 
 
 isms ; and the definitiou of Gussenbaur is now regarded as correct — viz. 
 pyismia, or purulent fever, is " a general infective disease which arises 
 from the entrance into the blood of the constituents of infected pus. It 
 is distinguished from other septic infective diseases by the development 
 of multiple abscesses in various organs, and by an intermittent fever." ' 
 
 A pre-existing supjjuration, which implies a process of several days' 
 or weeks' duration as the source from which the infected pus is derived, 
 is the almost constant rule in pyajmia, though there are exceptional cases 
 in which the injury — not always an open wound, even — and the general 
 infection run a sinudtaneous course, with the general symptoms of a 
 septic;emia rather than those to be described as characterizing pytemia, 
 but where the autopsy discloses the presence of metastatic abscesses and 
 purulent exudations. There are others, again, in which the original wound 
 has healed, but the general disease has afterward occurred, running to a 
 fatal termination, mIicu the autopsy again shows multiple abscesses and 
 purulent exudations in the serous cavities and joints. 
 
 Making the post-mortem appearances the diagnostic criterion, we learn 
 that pyffiuiia may occur as either a primary or a secondary fever — that 
 there may also be a period of incubation after the reception of the 
 injuiy, with no general or local symptoms, during which the infection 
 is, so to speak, working like an exanthematous fever, the general disease 
 breaking out subse((uently and running its course indejK'ndently of the 
 original injury, ^\'hen venesection was a more frequent j)ractice such 
 cases occurred more often than they now do. 
 
 Pyaemia may run an acute or a chronic course, more frequently the 
 former, death occurring in the course of from five to fifteen days ; it 
 may, however, last many months. It must be understood, at the same 
 time, that the division is principally clinical ; the pathology is the same — 
 viz. the entrance into the blood of the elements of infected pus ; and 
 this differentiation has to do, first, with the amount taken up at any one 
 time, and, second, with the power of the individual to M'ithstand the in- 
 fection. An attack of acute pyaemia may, though it is unusual, subside 
 into a chronic course, and, rice i-ersd, one that has been pursuing a chronic 
 course may quite unexpectedly become acute. 
 
 The course of a typical case of pyaemia is, in general, that at a \'ari- 
 able period after suppuration has been established, the wound granulating 
 and the dischai'ge creamy, in all respects the M'ound pursuing a normal 
 course, the patient has a chill — variable in intensity from a crawling 
 along the back to the teeth chattering and the extremities shaking, 
 in difi'crent cases also lasting variably from a few minutes to an hour 
 or more. This is followed, sometimes accompanied, by an increase of 
 temperature, which may rise two or three or even more degrees, fall- 
 ing to normal or below the -next morning. This succession of chill 
 and fever, with morning remission, may occur daily or every other day, 
 and the likeness to malarial fever becomes marked. Along with 
 the febrile movement there is a condition of general malaise — loss of 
 ap])etite, thirst, and headache, with some sleeplessness ; the patient is 
 quite aware that he is not so well, and, if he be from or in a malarial 
 district, will himself insist that he is suffering from malaria, the sub- 
 jective symptoms are so identical. At the same time, or perhaps ante- 
 
 ' Op. cit., p. 158. 
 
400 SEPTICEMIA, PYJEMIA, AND POISONED WOUNDS. 
 
 cedent to the febrile movement, the wound indicates that something 
 has taken place to interfere with the healing process. The suppuration 
 ceases ; the granulations become ]iale and ilabby, and may break down 
 entirely, leaving the wound with a thin, dirty, sanious discharge ; the 
 edges of the wound becc>me swollen and (edematous ; frequently we are 
 able to detect cord-like swellings along the course of the larger veins 
 leading from the j^art : these are hard and tender to the touch, and may 
 extend some distance up the limb toward the trunk. The limb will soon 
 after swell in its whole extent, the prominences and depressions become 
 obliterated, and the natural configuration of the limb quite lost. 
 
 The repetition of the chills and febrile movement continues with 
 greater intensity, frecpiency, and irregularity ; the alternations with 
 subnormal temperature are more marked, falling sometimes to 95° F. 
 or less, only to rise in a few hours to perhaps over 104° F. This great 
 range, repeating itself for several days, irregular as to the time of day, 
 is a striking feature found in almost no other condition. The patient 
 emaciates rapidly, the tliirst increases, the appetite fails, the tongue 
 becomes red and dry, the skin, alternately bathed in sweat or abnor- 
 mally dry, is apt to become yellowish in color, due not so much to inter- 
 ference with the function of the liver as to a change in the blood itself, 
 the coloring matter being liberated [lufmator/enous ictcrua) by destruction 
 of the red blood-corpuscles ; the pulse increases in frequency and be- 
 comes weaker. In contradistinction to septicaemia, the mind is not often 
 affected ; instead of Ijeing apathetic and somnolent, the patient is con- 
 scious of his weakened condition, often wakeful, and annoyed by lights 
 or sounds, and likely to be querulous and complaining. In cases which 
 run a protracted course the breath frequently exhales a peculiar mawk- 
 ishly sweet odor, compared sometimes to newly-mown hay, and the 
 patient complains of a disagreeable taste always present. As the disease 
 progresses secondary involvement of distant organs or parts becomes 
 evident ; the patient complains of pain in moving some particular and 
 usually distant joints : it simulates rheumatism at first, and is frequently 
 mistaken for that disease. The joint is tender on pressure or movement, 
 red and swollen, but in the course of a few days fluctuation appears, and on 
 puncturing or incising it pus is found : this condition may occur in several 
 joints if the patient lives long enough. Other situations in the extrem- 
 ities — the subcutaneous connective tissue, the muscular interspaces, even 
 the muscles themselves — are not infrequently the seat of the metastatic 
 abscesses, and particular mention must be given to their occurrence in 
 the medullary canals of the bones, where they may be undetected until 
 they have made extensive ravages, or be only discovered at the autopsy. 
 Their presence is to be suspected when the patient complains of severe 
 pain in the bones with exquisite tenderness along the shafts : the slight- 
 est movement is agony. At first the tenderness is usually located at 
 distinct points, afterward, however, extending over the whole bone. At 
 first there is not much else than the jiain, Init later the tissues over the 
 bone become oedematous, and, if the patient lives long enough unrelieved, 
 other evidences of pus in redness and fiuctuation become manifest, and by 
 incision the involvement of the bone is shown in the loosening of the peri- 
 osteum. Like the disease of the joints, the resemblance to rheumatism 
 at the outset is considerable, in both the local and the constitutional symp- 
 
PY^3IIA. 401 
 
 tomatology ; it is not until latei* that tlie true condition becomes locally 
 manifest. It is therefore necessary to be keenly on the alert in the case 
 of a suppurating wound to detect these evidences of transference to distant 
 parts, because if the treatment be initiated early there is a chance of 
 saving- life or limb, which chance, however, grows rapidly less as the 
 suppuration extends through the whole bone. In the beginning the 
 abscesses, as in other situations, are single or isolated, but they increase 
 in number and run together until the whole canal is occupied with pus. 
 
 Of other accessible organs, the secondaiy abscesses are to be looked 
 for in the jxirotid and thyroid glands, and exceptionally in the testicle. 
 Metastatic deposits in the internal organs often go undetected, their 
 presence being, of course, by no means so evident as in the situations 
 mentioned. Indeed, the special symptomatology of abscesses in internal 
 organs — and they may occur in almost any — is^ not characteristic : in the 
 lungs there may be cough and expectoi'ation, with some dyspnoea, but so 
 long as the abscesses are small there is little to judge from. With pleuritic 
 exudation, however, the evidences of dyspnoea, with dulness on pressure, 
 faintness or absence of respiration- and voice-sounds, indicate the con- 
 dition ; sometimes there are the other evidences of pleurisy — the inabil- 
 ity to take a long breath, difficulty in lying upon one side or the other, 
 and increase in frequency of the respiration. 
 
 Icterus is liable to l^e present in metastases into the liver, but, as this 
 is also present as the result of the destructitin of the red blood-corpuscles 
 in hajmatogenic icterus, tlie condition is not diagnostic of the metastases 
 unless it be associated with increased area of liver-dulness and localized 
 tenderness, with possibly a tumor if the abscess become very large. In 
 splenic involvement the increased area of dulness is almost the only 
 sign to indicate the local trouble, and it is a further source of confusion 
 if the question of malaria comes up. The spleen is, however, one of the 
 rarer seats of secondary deposits. 
 
 The only case of secondary pysemic abscess in the muscular tissue of 
 the heart that I have any knowledge of I saw at the autopsy of an 
 Italian laborer who died in the New Haven Hospital after an illness of 
 nearly two months. This case will be referred to again in speaking of 
 the mixed form of pyosepticsemia. 
 
 We have learned that a typical case of pyjemia consists clinically of 
 — first, an open suppurating wound ; second, a chill; third, a fever and 
 sweat, these occurring irregularly ; fourth, thrombosis ; fifth, metastatic 
 abscess ; sixth, death in the course of two weeks ; but, except the meta- 
 static abscess or serous exudations, nothing is constant. As stated in the 
 beginning, an open suppurating wound is not an absolute or constant 
 feature. Wunderlich reports that a young working-woman suffering 
 with an ordinary 'coryza wet her clothes during a hard day's work in 
 which she perspired freely. The next morning, on getting up, she 
 became faint and fell, injuring her right hand. Recovering conscious- 
 ness, she was seized with a heavy chill which lasted some time ; she had 
 pain in her sternum, headache, vertigo, and diarrhcea. She died on the 
 fourth day in collapse, having had a continuous higli fever with erythe- 
 matous bulhe on both feet. The autopsy siiowed a slight effusion of 
 blood in the injured hand ; the blebs on the feet were filled with hem- 
 orrhagic pus; the joints of both hands and feet were normal, as also the 
 
 Vol. 1.-26 
 
402 SEPTICEMIA, PYJEMIA, AND POISONED WOUNDS. 
 
 vessels of the extremities, but tlierc wei'e luiiltiplc abscesses in the thyroid 
 gland, the liver, and the kidneys, fresh extravasation in the brain, purulent 
 myocarditis, pleuritis, ledema of the lungs, and a softened spleen. 
 
 Gussenbaur reports the case of a physician who iiad a boil following 
 the examination of carcinoma of the uterus wliieh healed vp completely, 
 and three weeks after h(> became ill with afternoon fever, bronchitis, 
 double-sided empyema, and tedema of tiie lungs, from which he died on 
 the fourteenth day. The autopsy revealed, besides the pleural implica- 
 tion, multiple abscesses in the luugs, a large abscess in tiie liver, and a 
 softened spleen. 
 
 Although the ciiill is by far the most frequent inauguration of the 
 proper pysemic process, every surgeon wiio has much to do witii tiie 
 disease recognizes cases in which it is wanting or first appears after the 
 fever ; and, further, while the repetition of the chill is the rule, it .some- 
 times does not reappear at all. Tiiese variations, iiowever, have no 
 appreciable effect on the course of the disease nor on the termination. 
 Billroth remarked, iiowever, that disturl)anee of tiie wound was very 
 apt to be followed liy a chill ; dressings of the wound, probings, and 
 reposition of fragments of broken bones were followed by chills in the 
 course of from two to six hours ; it was remarkable how frequently the 
 morning and evening visits of the surgeon were followed by chills. 
 
 While the type of pyemic fever is tiie intermittent, this is not abso- 
 lute. The " pyiEuiic curve " of the temperature cliart lias liecii spoken 
 of as though it were something positive and pathognomonic, but it has 
 just been shown that the fever may be continuous, the fact being that it 
 depends largely upon the severity and rapidity of the infection as to 
 whether this variation in the height of the fever is marked or not. 
 
 It also presents variations, even in its intermittence, wiiich are to be 
 noted, and which make the diagnosis doubtful if we depend upon the 
 chart alone to determine it. The fever will sometimes rise by gradual 
 steps, as between morning and evening, in the course of two or three 
 days, to a considerable degree, 103° F. or over, then fall either as grad- 
 ually or suddenly to normal, giving rise to the hope that the infection 
 has been eliminated, only, however, to repeat the process of elevation. 
 At anotiier time in the same case tlie temperature will go suddenly up 
 for a day, and in the next few hours fall again. Individual cases being 
 liable to these striking variations from tlie type, little can be judgeil of 
 a given case from the chart alone, except that great and repeated varia- 
 tions from subnormal to very high tenqierature after a suppurating wound 
 indicate that infected pus lias gained entrance into tlie circulation. As an 
 instance of the great variations in the temperature occurring in a few 
 hours, and also of the great irregularity in the course of the fever, take 
 the accompanying chart of the course of an acute pyaemia in a child of 
 about five years of age, paralyzed with a spina bifida, who was admitteil 
 with a great bed-sore alongside of and exposing the sacrum and coccyx. 
 In spite of the utmost care after admission, it extended deeper, and after 
 several months her temperature was one day found to be 101° F. in 
 the morning, and slie was feeling unwell. The child was too young to 
 describe her sensations, and there was no olijcctive evidence of a chill 
 until later, but the variations in the temperature began at once, for on 
 the second day it swung from 2?>f^° to 102/^° (4°), and on the third 
 
PY^3IIA. 
 
 403 
 
 day from 97^° to 104° between 5 A. M. and 12 m. (6^°) ; at 4 p. m. it 
 had fallen to 98°, only to rise to 105-;^° at 10 p. M. (7^°), to fall the 
 next morning, the fonrth day of the attack, to hclow 95°. As the clinical 
 thermometer was not graded below 95°, it was too low to register, but it 
 
 Fig. 13. 
 
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 fell at least 11° in six hours : in tlie afternoon it rose to 102 ^%° (8°). 
 On the fifth day it oscillated between 98° and 103° at 4 p. M. to 104y«^° 
 at 9 P. M., and the next moniiu;/, tlie sixth day, it was 105^°, to fall in 
 the afternoon (in opposition to the rule) to 98-fL°, continuing to fall in 
 the morning of the seventii day to be again bcloir 95° ; it only rose that 
 afternoon to 97^°. It continued to rise botli morning and afternoon 
 on the two succeeding days to 104y\°, and without further remarkably 
 abnormal variations siie died at the end of the eleventh day. At the 
 autopsy it was found that the bed-sore had cau.sed a necrosis of the 
 .sacrum — that pus had invaded the right sacro-iliac synchondrosis ; there 
 were numerous non-suppurating infarcts in the lungs, and in the left 
 pleural cavity was a large aniount of scro-purulent exudation. 
 
 Chronic pysemia is characterized clinically by a ftdrlv regular liut 
 excessive diurnal range in temperature, continuing for weeks or months; 
 few or no striking exacerbations of this range are noted, but it varies 
 from 98° F. or below to 102° or over almost daily. This condition, 
 which has been described as hectic or irritable fever, is associated with 
 slight and infrequent chills, with great loss of muscular vigor, emacia- 
 tion, a red hut not necessarily dry tongue ; there is constant thirst. 
 Usually the ajipetite is good, lint the frerpient attacks of diarrhoea and 
 the emaciation show that the digestive tract does not assimilate the food 
 taken ; the ansemia becomes marked, the skin jiale and even slightly 
 
404 SEPTICEMIA, PYEMIA, AND POISONED WOUNDS. 
 
 sallow or yellow. The intellect is clear, the sensibilities acute, but, 
 owinw to the extreme weakness, the patient remains in one position, 
 sunken down in the bed, and lied-sores are liable to form : tliese appear 
 especially in those who liave diarrhiea, owing to the difficulty in keep- 
 ing dry. The patient sweats botii sleeping aud waking, and trembles at 
 the slightest exertion ; even the effort of" speaking exiiausts, the voice 
 trembles, and he weeps readily. Tiie termination comes by exhaustion 
 from the diarrhoea, or an exacerbation of the attack carries iiim off in a 
 cou])lc of days. 
 
 There are undoubted cases of infective fevers in which the symptoms 
 are sufficiently marked to justify the opiuion that products of decom- 
 position in the wound and infected pus may be present at the same 
 time, producing a septic pya'mia, or pyosepticannia as one prefers to call 
 it. The clinical course of such a condition is characterized by prom- 
 inent symptoms of both diseases, and the autopsy reveals the presence 
 of metastatic abscesses. An Italian laborer thirty-six years of age, who 
 had been working in a sewer, was admitted to the New Haven Hospital 
 on July 10th with a very incomplete history, but the distinct statement 
 that he had had " chills and fever" for two M'eeks. He was assigned to 
 the medical division and treated for malarial fever. On admission his 
 temperature was 103° F., and under treatment it fell to 99^° in the 
 evening of the second day. His countenance was dusky, and he M'as 
 somnolent most of the time, or talking in his sleep and breathing irreg- 
 ularly, sometimes stertorously : his temperature rose again, however, and 
 for the next three days it was irregularly between 99° and 101 j^° F. 
 He had several loose movements of his bowels — Mas occasionally delir- 
 ious, with twitching of muscles cf face and tearing at the bed-clothes. 
 He drank plentifully of milk ; on July 14th a large abscess was found 
 upon his right thigh and another on his right forearm ; these were 
 evacuated and found to contain 6 ounces and 1 ounce of pus, respec- 
 tively. The mental condition remained about the same, and the 
 temperature arose the next morning, July loth ; after opening the 
 abscesses (which were washed with an antiseptic solution and drained) 
 the temperature arose to 101.8° F. The temj^erature for the next thir- 
 teen days fluctuated daily from about 99° to 101 j^° F., on one occasion 
 going up to 103^° F. At first his general condition improved and 
 his appetite was good, but on the seventeenth day he refused liis food, 
 as it distressed his stomacii, and he vomited oecasionall}'. He got over 
 this, and his general symi)toms were more satisfactory again in that he 
 ate and slept fairly well, with occasional lapses of his bowels, and his 
 mental hebetude disappeared. On July 28th his temperature arose to 
 105° F., falling the next morning to 99 jij-°, and on the 30th it arose to 
 103j&5-°, to fiill to 100.4° ; and tliis was the last marked fluctuation, for 
 the fever now became continuous, ranging for the next three days just 
 across the 100° F. line, then for a couple of days at the 101° F. line; 
 from this time, August 6th to 12th, it ranged across tlie 102° line, and 
 on the evening of the 12th it arose to 105y*„° F. During this time his 
 general condition failed ; he became weaker, had from time to time vom- 
 iting and diarrhoea, with appetite in the intervals ; there was no change in 
 the condition of the abscesses on his thigh and arm, and no other devel- 
 opment externally. On August 8th a yellowish color appeared on the 
 
PYEMIA. 405 
 
 skill ; on the 13tli the teraiieraturc was lower, ami continued to fall, until, 
 on the nioruing of the 14th, it was at Q9^jf° F., as low as it had been for 
 three weeks. He died the following day, the temperature having gone up 
 to 106y*^° at the last. The course of the disease was therefore about fifty 
 days, but during all this time he was acutely sick. The autopsy showed 
 the liver large, fatty, of a light color and jjasty consistence ; the spleen 
 large, soft, and pulpy, with embolic infarctions. In the wall of the left 
 ventricle of the heart (auriculo-vcntricular valves) there was an abscess, 
 the size of a walnut, which luul opened into the ventricle. Both kidneys 
 were enlarged, the left the most, with a great number of small abscesses 
 interspersed through it ; the right liad a large abscess in the lower por- 
 tion, with smaller ones in numberless quantity throughout the whole 
 organ. Those in both kidneys were undoubtedly metastatic, and when 
 one appreciates the abscess of the wall of tlie heart opening into the 
 cavitv of the left ventricle, pumping pus into the circulation with every 
 pulsation, the source of the countless abscesses of the kidneys becomes 
 evident. How long it had been doing this could not be determined 
 from the symptoms. The urine was repeatedly examined, but beyond 
 a "trace" of albumin showed nothing abnormal. 
 
 The treatment of pyaemia resolves itself, like that of other septic 
 infectious processes, into local and constitutional, and the local into 
 prophylactic and symptomatic ; and of the latter it must be said our 
 means of relief are very limite<l. What access can be had to niultii)le 
 metastatic abscesses of the lungs, liver, or kidneys ? The proplis'laxis 
 of pysemia, however, is one of the greatest triumphs of modern surgery, 
 if not the greatest. When Volkmann, at the International Congress 
 of 1881 in London, stated that before the introduction of the antiseptic 
 treatment of wounds the mortality in hospitals after major operations, 
 from septic or pviemic conditions, was from 80 to 85 per cent., and that 
 since, if a case was lost from such causes, there was somewhere a surgical 
 error, he said nothing that has not been abundantly confirmed by the 
 experience of the surgeons of to-day. Pyiemia, which twenty-five 
 years ago was the horror of military and hospital surgery, is now un- 
 known — nay, impossible — as the result of operations in a well-ordered 
 hospital or of a properly-conducted surgical procedure, and instead of 
 hospitalism being the reproach of surgery, we now prefer to have our 
 operations performed in hospitals, feeling more confidence that we can 
 command the asepsis there than in other places. We meet pysemia 
 occasionally, it is true, but in cases that we do not have control of. It 
 is as preventible as any other infectious disease. Knowing precisely the 
 nature of the infectious elements and what will destroy them, knowing 
 exactly from what point they gain access to the circulation, and in most 
 cases having control over this process, it would seem that the surgeon's 
 duty is fairly easy of fulfilment. The fact is, as above stated, that in 
 operations where the wounds are frf)m beginning to end under the con- 
 trol of a surgeon who appreciates the importance of asepsis and antisep- 
 sis, the disease does not occur. In these days we find it limited entirely 
 to cases that do not come under proper surgical care until suppuration 
 and infection are established ; to cases of osteomyelitis in which the 
 diagnosis is not made early or the proper treatment not instituted ; fol- 
 lowing cases of plilegmonous erysipelas with extensive subcutaneous or 
 
40(3 SEPTICEMIA, PYEMIA, AXD POISOyED WOUXDS. 
 
 subfascial suppuration, and similar conditions of septic infection which 
 liave ^\•itllstood the action of tlie micro-organisms of decomposition, 
 but have left a field in which the resistance to purulent infection is of 
 the slightest. 
 
 The treatment of the preliminary conditions leading up to pysemia con- 
 sists of the most rigid antisepsis. Frequent dressings for the removal 
 of pus, washing of the wounds with solutions of mercuric l)ichloride or 
 other of tlie antiseptic or disinfectant remedies that have been referred 
 to under the treatment of septicemia, laying open freeh' pockets or 
 sinuses of pus, making the position of the part such as to allow free exit 
 of all drainage, — are matters of great importance, as also the sterilization 
 by heat or otherwise of all bandages and dressings, and the most thor- 
 ough surgical cleanliness, especially in avoiding any possible contact 
 with other suppurating wounds, and of the instruments or utensils or 
 other apparatus used upon them without intermediate disinfection. In 
 some hosjiitals separate wards are pi'ovided for the suppurating and 
 non-suppurating cases, so rigorous is the warfare against c(intagi(m : iu 
 Iviug-in hospitals it is the rule that septic cases are at once to be iso- 
 lated. 
 
 If the metastatic abscesses are Avithin reach, they are to be treated as 
 abscesses everywhere, and as energetically as possible : in the subcutane- 
 ous or subfascial planes they slioukl be as freely opened as is necessary to 
 obtain and maintain complete evacuation of the pus, and then be disin- 
 fected as actively as possible. Much knowledge may be gained of the 
 formation of these abscesses, and the necessity of looking for them, by 
 carefully watching the temperature. In a case presenting distinct pyemic 
 features following a phlegmonous erysipelas I was able, by judicious 
 observation on the part of the nurse as to chills and the following rise in 
 temperature, to diagnosticate some twenty to twenty-five small abscesses, 
 one after the other, in the subcutaneous tissue, which would otherwise 
 have escaped observation until they had ol>tained a large size or had 
 served as secondary foci. The certainty that the chill was the evidence 
 of a fresh dejjosit of pus was the incentive to more careful searching, 
 and in almost no instance were we deceived, and the patient recovered 
 from a condition that seemed at times hopeless. Suppurating joints are 
 to be freely incised and carefully washed out ; if tiie suppuration has 
 spread into the neighboring tissues, amputation is to be considered, and 
 has been performed with the result of saving life otherMise doomed. 
 Similar advice should be rendered in cases of pysemic osteomyelitis, 
 with even more insistence than with joints, for the medulla is a lymph- 
 channel, and, being hidden, is just so far a more dangerous situation 
 from wliicli tlie infected i)us may be spread. It is a matter of saving 
 life rather than of conservative surgery. 
 
 When throml)osis occurs, with the j)ossible sequence of embolic meta- 
 stasis of the infected clot, the proposition has been made to in some way 
 check the current of the circulation l^etween the thrombosis and the 
 heart, and in this way to ])revent the wider distribution of the disease. 
 Compression, isolation, and ligation of the vein have fmm time to time 
 been em])loyed, and iu some cases with success. These are, however, 
 unusual cases, and the practice has not become general ; the fact that 
 all thromboses do not lead to emboli, that a fairly large number get 
 
POISONED WOUNDS. 407 
 
 ■well, makes it iueumbent on the surgeon to hesitate before undertaking 
 an oiJeration that might possibly hasten the very process it is intended 
 'to check, but instead to try, by warm, moist antiseptic applications, sus- 
 pension or elevation of the limb, and complete rest, to obtain regressi(m. 
 Besides the local treatment, the general condition of the patient 
 demands attention : the indications are to suj)port the patient by stinui- 
 lants and tonics and to nourish by food. Milk-punch and egg-nog made 
 up with St. Croix rum or brandy fulfil the therapeutic indications. Cin- 
 chona is also frequently of benefit — whether the bark or its alkaloid is 
 not of esjiecial importance, exce])t for the smaller dosage of the latter. 
 Too much stress cannot be placed on the absolute necessity of an abun- 
 dance of fresh air in the treatment of pyiemia and septicaemia. 
 
 Poisoned Wounds. 
 
 In poisoned wounds there is introduced at the reception of the injury 
 some substance having a deleterious influence either upon the tissues at 
 the point of entrance or on the general system, or on both, it being dis- 
 tributed to the general system through the circulation, the deleterious 
 result being out of all proportion to the injury received. 
 
 The influence is .sometliing more than that of a foreign body wliich 
 excites local action in attempts to get rid of it, and if prolonged gives 
 rise to fever. It is difi'crcut from the morbific action of the toxines of 
 septicemia induced by micro-organisms of various kinds. It is differ- 
 ent, again, from wounds in which the diseased secretions of animals are 
 introduced into the circulation, giving rise to the phenomena of disease 
 at a later dav, as hydrophobia. It is the direct action of the substance 
 itself upon the tissues (using the term in its largest sense) with which it 
 is brought in contact, and the ettect j)roduced depends, in a given case, 
 entirely upon the amount introducetl into the circulation. 
 
 The poisons are both vegetable and animal : the former are usually 
 introduced on weapons of warf\irc liy the natiA'es of the islands of the 
 Indian Archipelago and of South America ; the latter, by certain insects 
 and reptiles. 
 
 In the East Indian islands the jioison is procured from incisions 
 made in the bark of the upas tree, of which there are two species, the 
 Upcw aiitinr and the Upaa ticute, the poison of the latter being the more 
 active of the two. Fabulous tales have been reported of the effect of 
 poisonous exhalations from these trees; these are now known to be 
 untrue. There exudes from the incision a gum-resin, which is poison- 
 ous taken internally or introduced into the circulation. The arrow- or 
 lance-points are smeared with this resin, and the effects of the poison are 
 great prostration, a feeble ir'.-egular pulse, vomiting, involuntary evacua- 
 tions, convulsions, and death from cardiac paralysis. 
 
 I am unaware of any direct antidote to this poison, or indeed of any 
 investigations looking to that end, but, judging from the symptoms as 
 detailed, the indications are for active stinmlation, alcoholic and diffu- 
 sible. 
 
 Tlie South American Indians use a poison variously named woorari, 
 urari, or curare, which is i)btained from various species of Strychnos 
 growing in the Amazon and Omnoco regions and in British Guiana. 
 
408 SEPTICEMIA, PYEMIA, AND POISONED WOUNDS. 
 
 An extract is made from the bark and leaves, and in tliis tlie points of 
 the arrows arc dipped. It is very powerful ; a small quantity introduced 
 into the circulation acts by paralyzini>; the motor nerves, shown first in a 
 feeling of weariness and disinclination to move, followed rajiidly by 
 complete paralysis of all muscles, inciudinjjj those of respiration, by which 
 death comes, the heart acting after the respiration has ceased. In larger 
 doses the vagus nerve and heart become paralj'zed. The action is quite 
 rajiid, death occurring in a few minutes Avith fatal dosage. If the amount 
 introduced be not sufticicnt to kill at once, life may be saved by keeping 
 up artificial respiration until the j)oison be eliminated by the kidneys, 
 which occurs fairly raiiidly. 
 
 There is no evidence that the North American Indians have ever used 
 poisoned arrows as such. The traditions to that end are based on certain 
 rites with which they intersperse their war-dances preparatory to a foray. 
 They mix up a lot of stuff in which jnitrcfying animal matter obtained 
 from snakes and other reptiles enters largely ; in this they dip the pciints 
 of their arrows, using various incantations of a semi-religious kind, in 
 order that the arrows may be more potent against their enemies. This 
 mess of course contains a great number of microbes of decomposition, 
 which, entering the tissues at the wound, may produce scpticaMuia, and 
 be so far poisonous ; beyond this there is nothing. 
 
 Animal poisons are introduced either as stings or as bites. Stings are 
 usually made by insects carrying the A\'capon at the posterior extremity 
 of the body, the venom being secreted by a gland, and emptied into the 
 wound at the time of puncture by the sting, which is usually barbed or 
 serrated along its edges. The sting is really an ovipositor, consequently 
 only females sting. Exceptions to this are found in certain gnats and 
 bugs, of which the common mosquito and bed-bug are familiar examples: 
 these sting by a proboscis, and both sexes are venomous, as is also the 
 case with biting insects, of which the spider is the most common. 
 
 The venomous sting-carrying insects Avith which the physician has 
 principally to do are wasps, hornets, bees, and some species of scorpions. 
 This by no means exhausts the list of poisonous insects, and there are 
 some venomous flies, but they are rare. Care must be taken, however, 
 to difierentiate between venomous flies and those which serve simply as 
 carriers of infective material. There are no known scavengers compar- 
 able to the common house-fly : frequenting and living upon decomposing 
 animal matter, it may, and frequently does, carry the microbes of putre- 
 faction and of infection to minute wounds, and thereby excite a septic 
 process which kills. 
 
 The action of the venom upon the human subject is similar in all. A 
 local irritation of varying intensity is excited, depending upon the amount 
 of poison injected. If there be enough of it, constitutional symptoms 
 are excited, but there are great differences in individuals as to the amount 
 required to produce such effects. It is also well established that persons 
 may become in time immune to the actit)n of the poison ])y repeated stings : 
 this is the experience of most people living contimiously in mosquito- 
 infested localities, and with those who work among bees the effect l)e- 
 comes less and less with successive doses of the poison, so that finally in 
 each case the sting excites no more action than the simple jiunctui-e. 
 
 Usually the sting produces much more pain than can be ascribed 
 
POISOXED WOUyDS. 40ft 
 
 to the puncture alone, lasting some hours. In a very short time, a 
 few minutes, after the puncture an area of redness surrounds the point, 
 which also rapidly becomes oedematous : with the appearance of the 
 cedema the centre becomes white, and there is then a swollen, red areola 
 with a white spot in the centre, which itches and burns. It is evident that 
 the action of the poison is first to produce a paralysis of the vasomotor 
 nerves, allowing the dilatation of the blood-vessels for a considerable 
 area around the puncture, but whether the white spot in the centre be 
 due to a cutting off of the circulation by the swelling around it (Van 
 Buren), or to a constriction of the vessels themselves l)y the action of the 
 poison emptying them of blood, may be a question ; but, taking into con- 
 sideration the fact that in severe cases there is a slough at the centre, I 
 am disposed to regard the white centre as the innncdiate effect of the 
 poison. Not infrecpiently tiie sting itself is broken off and remains in 
 the wound : this occurs if, as is usually the case, the insect is knocked 
 away at the moment of stinging ; if, however, it be not disturbed, the 
 weapon is withdrawn entire. Where the sting remains there is the ad- 
 ditional irritation consequent to the presence of the foreign body. Not 
 infrequently there is vesication over the reddened area, and in a consid- 
 erable number of cases the redness and swelling and irritation extend 
 perhaps over the whole extremity, with considerable pain lasting for 
 several days, even weeks, and a feeling of numbness with autesthcsia and 
 stiffness in movement, showing that the nerve-trunks are affected in both 
 their sensory and motor filaments. Usually a sting or two or three do 
 not produce an effect upon the general system, but if there be a large 
 number the constitutional effect may be great. Death has followed in a 
 few minutes after tlie attack of a swarm of bees wliicli had been disturbed. 
 The symptoms are referable to the heart and lungs : the pulse is feeble 
 and irregular, the respiration hurried, superficial, and gasping, the 
 countenance livid, the skin clammy ; there are great prostration and 
 veritable collapse, in which condition the patient dies. Additional 
 danger exists when the stings are in the vicinity of the air-passages 
 from the swelling interfering with the respiration, death having taken 
 place from a?dema of the glottis producing suffocation. Wounds in 
 the mouth occur sometimes in eating fresh honey in the comb or in 
 eating fresh fruit picked up from the ground with the insects upon it. 
 
 The treatment of the local irritation, after removing the sting, 
 consists in cold applications, with amnioniacal water if agreeable. The 
 indications for general treatment depend a little on how the heart is 
 acting : if that be fairly strong, anodynes may be given to allay the 
 pain and irritation, but if it l)e feeble, both alcoholic and diffusible 
 stimulants must be used ; besides the usual forms of alcohol or brandy, 
 whiskey, etc., the preparations of amnuniia, carbonate or muriate, and 
 camphor, may be exhibited, together with hypodermic injections of 
 digitalis, nitro-glyceriu, and strychnia. 
 
 Many varieties of spiders arc venomous, the tarantula being perhaps 
 the most so, but scorpions, galeodes, centipedes, are all more or less 
 dangerous. The effect of their bites is in the main similar to that of 
 stings, as just described, but they are apt to be more severe, leaving their 
 effects upon the nerve-trunks much longer. These animals are usually 
 shy and keep themselves hidden until disturbed, and then rush out from 
 
410 SEPTICEMIA, PYMMIA, AND POISONED WOUNDS. 
 
 inipxpec'tcd places, retreatinsj; ao;ain to tlicir hiding-places. The taran- 
 tula, luiwever, iiiiist be reoartlcd as an exception, as it is liable to be quite 
 piiirnacioiis, attacking animals much larger than itself" most vigorously. 
 The hiding-places are oftentimes quite unexpected, as appears from 
 an account in the Australian Ilediml Gazette for June, 1894, in Mhieh 
 three cases of s])ider-l)ites upon the penis are detailed, the nesting-jdace 
 of the animal being under the seat of an out-of-doors privy closet. All 
 the cases occurred in the month of Marcli, and in each case the exami- 
 nation of the locality revealed a brood of spiders of the genus Lathro- 
 dectus, consisting of a mother with from twenty to thirty young ones ; 
 and Dr. Parry, who reports the cases, suggests that they are venomous 
 only during the breeding season : it is jirobable that they are simply 
 more easily excited to attack at this time, owing to the maternal 
 instinct. In these cases, besides the usual local effects of a burning 
 pain and swelling, the remote effects on the nervous system were 
 .shown l)y the occurrence in the course of a couple of hours after the 
 injury of an exceedingly disagreeable pain, as of pins pricking him, in 
 the patient's toes : this gradually spread up to his ankles and knees; the 
 part became bathed in a cold perspiration. The temperature Avas 
 .sligjitly sulinormal and tiie heart's action feeble. The pain continned 
 for forty-eigiit hours, and the perspiration, conhned at first to the lower 
 extremities, became general, and so profuse as to soak through the 
 blankets on the bed. It gave off a peculiar, very offensive cadaverous 
 odor. The patient was exceedingly restless, unable to sleep without 
 anodynes, and suffered pain all the time. He was confined to his room 
 for five days, but for two weeks there were darting jiains through his 
 legs and around the lower part of his abdomen. Dr. Parry regards the 
 lesion as that of a peripheral neuritis. 
 
 Of poisonous serpents there are four genera in this country — viz. of 
 the rattlesnake there are two, the Crotahis, with fourteen distinct species, 
 and the C'«(/(//.so(i«, with four; the copperheads and moccasins are of 
 one genus, the Aricistrodon, divided into four species; the vijjers 
 Ektps are of five species. 
 
 The first three genera above mentioned have movable poison-fangs 
 situated in the njijier jaw, which ordinarily, and always when the mouth 
 is closed, lie folded back and are concealed Ijehind the upper li])s, Imt 
 which on opening the mouth widely are capable of becoming erect. The 
 viper has small permanently-erect poison-fangs, situated fai-ther back in 
 the jaw than in the Crotalidfe. 
 
 In Europe the viper, Pelias berus, is the only venomous serpent met 
 with, and, as comjiared with those of America and India, it is ahuost 
 harmless ; deaths from viper-bites are extremely rare in Europe. 
 
 It is in India, however, that the venomous snakes are met with in the 
 greatest number, variety, and virulence, the mortality from snake-bites 
 being very great. According to Sir Josej)h Fayrer, the deaths fr( im snake- 
 bites alone are about 1 : 10,000 of all deaths. The iirincipal genera are the 
 cobra Naja, or hooded snake, the krait Bungarux, the ophiophagus, 
 and the daboia. The first named is the most venomous known and is 
 the most frequently met with : nearly one-fourth of the deaths from 
 serpent-bites are caused by the cobra. Next in frequency are the kraits ; 
 then ojjhiophagus, a large and very ferocious snake, having the habit of 
 
 fe 
 
POISONED WOUNDS. 411 
 
 devoui'ing other snakes, lience the name ; the daboia is of tlie viper 
 genus and most venomous of its race. There are many other genera, 
 but thcv are rehitively unimportant, except as showing the great numbers 
 in that country. The true Hydrophidea (water-snalies or sea-serpents) 
 are found principally in the neighborhood of the islands of the Indian 
 and Pacific Oceans and of the seas between China and Australia. They 
 are exceedingly venomous and somewhat aggressive, but not large, 
 usually less than five feet in length. 
 
 The mechanism of the poison apparatus is essentially the same in all. 
 The venom-gland, analogous to the ])aroti(l, i* situated upon the superior 
 maxilla below and behind the eye ; it is a flattened oval in shape, taper- 
 ing forward to a duct leading to the base of the fang in front. There 
 is no especial sac or reservoir for the collection of the venom, but as the 
 duct runs through the centre of the gland it dilates a trifle, and in this 
 there is a small store of venom collected. The fang itself is not, as is 
 commonlv supposed, movable at its attachment to the jaw, but that por- 
 tion of the maxilla witii the fang inserted in its socket is attached loosely 
 to the rest of the bone, and on dilating the mouth widely this portion 
 of the jaw turns in such a way as to bring the point of the fang to 
 project downward and a little backward ; with the closure of the jaws, 
 the fangs being erect, they are driven into the skin if it lie an animal : 
 tlic temporal muscles press upon the gland and squeeze the poison out 
 into the duct and along the groove in the posterior edge of the fang, and 
 it is thus led to and injected into the tissues of the animal attacked. 
 The fang itself is very sharp, sickle-shajicd, with the concavity back- 
 \\ard. The erection of the fang is a voluntary act in itself, not the 
 effect simply of opening the jaws widely ; the mechanism is quite com- 
 ])lex, but it is luinecessary to describe it here. In feeding the fangs are 
 not erected, but are kept folded l^ack and covered by a sheath of mucous 
 membrane. The poison is ejected with considerable force, sufficient 
 when it misses its mark to throw it five or six feet away. 
 
 In the vipers the fangs are permanently fixed, and are situated farther 
 back in the jaw than in the serjients aljove described ; they are not so 
 long or curved, and the groove is not so deep. The gland is not so 
 large, either ; the jaws eann(jt be opened so widely, and the muscles 
 do n(3t act with so much force. Taking it altogether, it is a much less 
 effective mechanism, and in consequence vipers are not nearly as 
 ])oisonous. 
 
 The effect of the injection of the venom is a " swelling at that point, 
 with intense violet-black discoloration of the skin, whieli gradually 
 extends over an area of several scpiare inciies. The tissues in the 
 immediate neighborhood are soaketl with extravasated blood. If death 
 occurs soon, local ex'ti'avasation may be all that is visible, but if it be post- 
 poned for a short time, then smaller extravasations are found in distant 
 tissues. Most frequent and most ])r()uounccd are subpleural, subperito- 
 neal, and subpericardial ecchymoses, l)ut tlie whole organism is deeply 
 affected, the tissues being congested and presenting a much darker apjiear- 
 ance than normal. The blood does not seem to coagulate readily within 
 cavities or interstices of the body unless death follows almost instan- 
 taneously. In cases which live longer the blood remains constantly in 
 a li(iuid state or coagulates imperfectly, and then only after being 
 
412 SEPTICEMIA, PY/TIMIA, AND POISONED WOUNDS. 
 
 exposed to the air, resembling in tliis particular the state of that fluid 
 observed in conditions of asphyxia." ' 
 
 The symptomatology is similar for the different genera, the diiferences 
 being due to the amount of venom injected and individual susceptibility. 
 Besides the points just given, the whole limb swells, ecchymoscs a])pear 
 under the skin and s:uiious vesicles upon the surface, and if the patient 
 lives the skin directly about the wound becomes gangrenous. The con- 
 stitutional symptoms are of great severity and rapidity : the pulse is 
 feeble and fluttering ; at first nausea and looseness of the bowels may 
 occur, followed by involuntary evacuations of urine and faeces ; there 
 is great difficulty in breathing, with pain about the prsecordia ; at first 
 there are great anxiety and restlessness, but as the effect of the poison 
 extends to the nervous system the sufferer becomes delirious, then indif- 
 ferent, then somnolent, and dies in a state of coma. The time of death 
 varies from a few minutes to several hours after the bite. 
 
 In non-fatal cases there is considerable variety in the symptoms, and 
 cases are reported of singular delay in their appearance. Thus, Dr. 
 Yarrow^ states that constitutional symptoms were not present until four 
 days had passed, the local symptoms also being sim])ly troublesome; 
 but with the coming on of the constitutional symptoms the local became 
 more active, simulating phlegmonous erysipelas. The ])atient continued 
 to grow worse for twelve days, when under treatment the disease took a 
 favorable turn, and he eventually, in the course of about four months, 
 recovered. In other cases, again, there arc recurrent symptoms, coming 
 on after intervals of varying length ; nor are the symptoms themselves 
 constant. Dr. Piifard of New York reports a case where a vesicular 
 eruption appeared at varying intervals of from three months to a year 
 in a young woman whom he first saw six j^ears after the bite. Dr. Cole- 
 man reports a scaly eruption resembling ichthyosis coming on in two 
 successive years after a venomous snake-bite (variety not given), and 
 Dr. Yarrow's case had marked constitutional symptoms at about the 
 anniversary of the bite, Avith a good deal of local reaction : he reports 
 two other cases having similar experiences. The evidence of these 
 recurrences comes from too reliable observers to be ignored. It is diffi- 
 cult to explain them, but that they have to do with a neurosis is quite 
 evident. 
 
 The evidence that the Hdodcrma Ruspedum (the "Gila monster"), a 
 lizard found in Northern Mexico and the South-western United States, 
 is poisonous is too conflicting to allow a positive expression of opinion, 
 the latest experiments by Dr. Yarrow being altogether negative, though 
 most careful observers have thought it is poisonous, the grooved fling 
 indicating poisonous qualities. 
 
 The treatment of venomous snake-bites, to be efficacious, requires 
 to be of the most energetic character. The first aim is to prevent the 
 poison from getting into the general circulation, or to have it enter in 
 such small quantity and so slowly that it shall not act powerfully on the 
 nervous system — that its action be delayed. Therefore tie a ligature as 
 tightly above the bitten part as jjossible to be borne : the larger tlie 
 
 ^ Mitchell and Eeichert : " Researches on the Venom of the Rattlesnake," Smithsonian 
 Contributions to Knowledge, No. 647, p. 139. 
 
 ^ Amer. Jour, of Med.. Sciences, April, 1884, p. 422. 
 
POISONED WOUNDS. 413 
 
 limb — /. e. the nearer the body — the more difficulty there will be in 
 doing this. Then the part may be suckeil (with sound lij).s), but, better 
 yet, let it be excised freely and deeply, the sucking applied afterward, 
 and bleeding facilitated. I can see no good to be accomplished by cau- 
 terizing : the wound is too small to be followed into its recesses by any 
 caustic liquid or solid, and nothing is gained by cauterizing the skin 
 over and around it. The ligature should be kept on if the patient can 
 bear it, even after constitutional symptoms have become severe, as it 
 must delay the rapidity of the entrance of the poison into the general 
 circulation. The indications for constitutional treatment arc active dif- 
 fusible and alcoholic stimulants. Aromatic spirits of ammonia, whis- 
 key, brandy, camphor, etc. are in order, but the overwhelming of tlie 
 system with whiskey or alcohol, in obedience to the ])opular fallacy that 
 to get a man drunk will cure him, has undoubtedly cost many lives from 
 the whiskey. Patients are usually greatly excited, and tlicrcfore can 
 tolerate large quantities of stimidants \\ithout intoxication, but if a man 
 be intoxicated he is in a less favorable condition to eliminate the poison. 
 So long as the heart's action is feeble and the pulse intermittent, stimu- 
 lants and digitalis and strychnine, Avith perhaps nitro-glycerin, may be 
 given freely. 
 
 The cautious statement of Drs. Mitchell and Reichcrt that " potassic 
 permanganate, ferric chloride in the form of the liquor or tincture, and 
 tincture of iodine seem to be the most active and promising of the gen- 
 erally available local antidotes," is sufficient answer to the vaunted 
 claims of all sorts of nostrums as antidotes. 
 
 Death comes, according to the observations of these most capable 
 oliservers, " through paralysis of the respiratory centres, paralysis of the 
 heart, hemorrhages in the medulla, or possibly through the inability of 
 the profoundly altered red corpuscles to perform their functions. There 
 can be no question, however, that the respiratory centres are the j)arts of 
 the system most vulnei-able to venom, and that death is commonly due to 
 their paralysis." ' " The outlook, then, for an antidote for venom which 
 may be available after the absorption of the poison lies clearly in the 
 direction of a physiological antagonist, or, in other words, of a substance 
 which will oppose the action of the venom on the most vulnerable parts 
 of the system. The activities of the venoms are, however, manifested in 
 such divers ways, and so profoundly and rapidly, that it does not seem 
 probable that we shall ever discover an agent which shall be capable at 
 the same time of acting efficiently in counteracting all the terrible ener- 
 gies of these poisons." " 
 
 ' Amer, Jour, of Med. Sciences, April, 18S4, p. 156. ^ Ibid., p. 157. 
 
TRAUMATIC FEVER, ERYSIPELAS, AND 
 
 TETANUS. 
 
 By J. COLLINS WARKEN, M. D. 
 
 I. Traumatic Fever. 
 
 The constitutional disturbance which occurs during the healing of a 
 wound is known as traumatic fever. 
 
 Traumatic fever may be divided into two principal varieties — primary 
 wound-fever and secondary wound-fever. 
 
 Primary wound-fever may be also subdivided into two varieties — 
 aseptic fever and septic or surgical fever. 
 
 Aseptic fever is a febrile disturbance which occurs in woiuid-healing 
 by first intention. In this form of healing the syuiptoms of local iuflam- 
 mation are absent, and it was supposed in the early days of antiseptic 
 surgery that sucli wounds would not be accompanied by fever. It w^as 
 found, however, that the fever-ciu've often rose to a considerable height. 
 In tins respect the conditions differ from those seen in surgical fever, 
 where the constitutional disturbance keeps pace with the varying con- 
 ditions of the inflammation in the wound. 
 
 The cause of tliis rise of temperature was at first not fully under- 
 stood, but experiments on anunals have shown that the absorption of 
 fibrin-fermeut is often accompanied by serious symptoms. Fibrin is 
 formed l)y the union of two filirin-generators, fibi'inogen and para- 
 glolmlin, with the co-operatiou of fibrin-ferment. Fibrinogen is fotnid 
 in the blood-plasma, wliile the fibrin-ferment and the paragloliulin are 
 for the most part found in the white blood-corpuscles. If the fibrin- 
 ferment is introduced experimentally into the circulation, extensive 
 coagulation of the blood will be the result, and the death of the animal 
 speedily eusues. 
 
 During the process of healing by first intention a certain amount of 
 fibi-in-ferment is absorbed from tlic extravasated blood, and also otiier 
 substances which are found in the exudation which accompanies the 
 inflammatory process. 
 
 In a large wound healing l)y first intention we find not only extrav- 
 asated blood and exuded serum, but minute fragments of tissue wliich 
 have been separated from the surface of the wound during the opera- 
 tion, and are subsequently disintegrated and absorbed. These materials 
 when absorbed exert a pyrogenic action upon the system. Their 
 close relationship to living substances, however, renders them but 
 slightly injurious, and they produce in consequence only a mild type 
 of fever. 
 
 415 
 
416 TRAUMATIC FEVER, ERYSIPELAS, AND TETANUS 
 
 Tho symptoms of aseptic fever arc few in nunibcr. The patient 
 experiences no sense of discomfort, such as is observed in other forms 
 of fever. The skin is not so hot or dry, tiie urine is not diminislied, 
 and there is far less loss of weight tiian in septic fever. The thermom- 
 eter, however, shows that there is a I'isc of temperature of from one to 
 tliree degrees, and tiicre is also a corresponding increase in the pulse-rate, 
 which continues so long as any absorption is taking place from the inte- 
 rior of the wound. The patient is, however, unconscious of fever, and 
 is often able to move aliout the room witiiout discomfort. This form of 
 fever lasts usually from one to five days, or may continue longer when 
 hemorrlingc has taken place and a considerable amount uf blood has to 
 be absorbed. Fever of tiiis type is seen in cases of simple fracture and 
 in large wounds healing by first intention, in cases of luematoma, and 
 in contused wounds where there has been considerable iicmorrhage. 
 
 Sejitie or surf/icd/ fever is observed in wounds liealing witii more 
 or less septic inlliunmation, such as are seen following accidents or in 
 cases M'here the j)rinciples of antiseptic surgery have not been observed. 
 In such cases, although the wound may unite in the larger part of its 
 extent, there is a great amount of redness and swelling and the other 
 symptoms of local inflammation. A considerable discharge will take 
 place from any ojien jioint in the wound, and perhajis also from the 
 openings around the stitches, and in a few days a more or less extensive 
 supjjuration may take place, although in fortunate cases a great portion 
 of the wound may be healed before the formation of pus has taken 
 place. These active changes in the wound were formerly supposed to 
 be symptoms of the brisk reaction in the wound, and were thought 
 essential to the pi'ocess of repair. We now know that they are due to 
 sepsis. The constitutional symptoms are corresjjondingly severe in these 
 cases, and keep pace pretty accurately with the amount of inflammation 
 which occurs in the wound. 
 
 As an ordinary result of an operation or accident there is a certain 
 amount of shock, the temperature falls below the normal, the skin 
 is cold and clammy, and the pulse weak. The following day reaction 
 occurs : the pulse and tcmperatiu-e rise, the skin becomes hot and dry, 
 the tongue coated, and the patient suffers from considerable thirst and 
 restlessness. On the evening of the second day the tempei'ature is still 
 higher ; there is great discomfort, and the patient may also suffer from 
 pain owing to the swelling of the wound. On this account sleep is dif- 
 ficult ; the patient may not only suffer from insomnia, but nervous 
 symptoms will be present, and in severe cases often dclirimu. The tem- 
 perature drops slightly c\-cry morning, to rise still higlier in the evening. 
 With the subsidence of the local inflammation the temperature also falls, 
 and with the discharge of pus from the wound the fall may be quite rapid, 
 and there will be at the same time relief to all the other symptoms of 
 inflanunation. 
 
 Traumatic fever usually lasts about a week, at which time, if no 
 extensive suppuration has occurred, the temperature will be found to 
 have reached the normal line. 
 
 The cause of this form of fever is found to be the presence of bac- 
 teria in the retained secretions of the wound. A limited number of 
 micro-organisms find their way into tlie circulation from this source. 
 
TRAUMATIC FEVER. 417 
 
 The decomposition which they have set up in the retained fluid liberates 
 a certain number of cliemieal substances which are also absorbed. The 
 ptomaines and toxiucs thus introcUiced into the circulation exert a pyro- 
 genetic action. It is probable that no one form of virus habitually 
 causes traumatic fever, but that various substances have this effect. For- 
 tunately, they do not exert a very poisonous action upon the tissues, but 
 sutficient to cause considerable fever and discomfort io the patient. AVith 
 the advent of suppuration these substances and organisms are carried 
 away in the discharge from the wound, and, as those wliicli have already 
 obtained an entrance into the circulation are speedily eliminated, the 
 fever then disappears. 
 
 Sccniid/irt/ trdioid-fcrfr, or suppurative fever, occurs when pus has 
 formed which has not an opjxn'tunity to escape from the wound, and in 
 consequence chemical substances formed in the pus by the bacteria are 
 absorbed into the system. In this case the fever-curve, instead of falling 
 to the normal line at the end of the first week of the healing process, 
 rises again, and this rise in some cases may be accompanied by a chill. 
 There is usually a marked morning remission, with a subsccpient rise of 
 temperature every evening, which becomes more exaggerated as the sup- 
 purative process extends. Marked types of this form of fever are seen 
 in the su})purati()n which follows compound fractures and in operative 
 wounds in which the flow of pus has been obstructed. The pus conse- 
 quently burrows in the surrounding connective tissue. In these cases 
 the symptoms which accom|)any the rise of temperature are similar to 
 those which we have just desi'ribed. The patient suffers from dryness 
 of the skin and coated tongue, headache, malaise, and in severe cases a 
 mild delirium. When a free evacuation of the pus has been obtained the 
 symptoms disappear and the temperature falls to the normal line. In 
 unfavorable cases, where the jius has burrowed in various directions, 
 chronic suppuration is established, and the fever now resumes the cha- 
 racteristic remittent type. In the morning the tem])erature is normal or 
 even subnormal, but in the evening there is a sharp rise, varying from 
 one to six degrees. Unless the progress of the suppuration is checked 
 there is a marked change in the appearance of the patient. .The loss of 
 flesh is often very great, prostration occurs with the evening rise of tem- 
 perature, the characteristic hectic flush is established, and with the tall 
 during tlic night there is the jirofuse perspiration or night-sweat which 
 is so characteristic of this condition. Diarrluea may also set in to aggra- 
 vate the patient's condition. In fatal cases emaciation becomes extreme, 
 the joints are unusually prominent, and bed-sores appear. The patient 
 finally becomes exhausted and succumbs to the disease. 
 
 Tlie })rincipal change found at the post-mortem examination is 
 amyloid degeneration, which occurs in the spleen, liver, intestines, and 
 kidneys. This is supposed to be caused by the constant presence of 
 alkaline salts produced by suppuration. This type of fever has been 
 sometimes confounded with pyiemia, and is called by some authors 
 pyajmia simplex, in contrast with the multiple or metastatic form of 
 pyiemia. It should not, however, be confounded with this affection. 
 
 Treatment. — Aseptic fever usually requires little or no interference 
 on the part of the surgeon. Persistence in the rise of temperature indi- 
 cates the presence of an unusual amount of blood collected beneath the 
 
 Vol. I.— 27 
 
418 TRAUMATIC FEVER, ERYSIPELAS, AND TETANUS. 
 
 lips of the wouikI. In such cases tlio hciding ]>rocess maybe hastened by 
 the introduction of the probe or of a temporary drain to allow the escape 
 of the blood-serum, whieli prevents tlie accurate coajitation of the surfaces 
 of tiie wound. In surgical fever a careful watcii nnist l)e kept as to tiie 
 condition of the wound, in order that, if su|)puration is established, pro- 
 vision may be made ibr the proper evacuation of jnis. The removal of 
 one or more stitches or the introduction of the drainage-tube may be 
 sufficient for this purpose. If, liowever, tiie general appearance of the 
 wound is threatening, it should be freely opened, a thorough disinfec- 
 tion of its surfaces siiould lie effected, and provision made for the free 
 discharge of tiie products of dccomj)osition. 
 
 When it is clear that su]ipurative fever is cstablislied, the pus which 
 is causing this disturliance should be followed relentlessly in all direc- 
 tions. In localized collections of pus a moderate opening is often suf- 
 ficient to check the furtiier progress of 'sujipuration, but wlicn pus begins 
 to ijurrow free incision shoukl be made and the walls of tiie wound 
 should be curetted, so as to remove, if possible, all jiyogenic organisms. 
 When it is impossible to lay open the wound in its entire extent, a 
 connter-opening should be made at some prominent point, througii which 
 drainage-tubes leading in various directions may be introduced. The 
 wound should lie thoroughly flusiied with some antisejitic agent suf- 
 ficiently weak to avoid poisoning by absorption. For this purpose car- 
 bolic acid in tiie strengtii of 1 : 200 may be nsed, or corrosive sublimate 
 in a solution of the strength of 1 : 5000. The penetrating power of the 
 corrosive is not so great in this case as that of carbolic acid, as the latter 
 is able to incorporate itself more completely with greasy substances. 
 Sulpho-naphthol, in a strength of 1 : 260, or creolin may be used. Tiie 
 disinfection of suppurating wounds may also be eft'ectually accomplished 
 by the application of'peroxide of liydrogen. 
 
 The drainage may consist of rubber tubing or of strands of iodoform 
 or sterilized gauze. 
 
 The strength of the patient should be carefully watched. Alcoholic 
 stimulation is of great importance in these cases. The patient will often 
 be able to bear a large amount of alcohol witliout discomfort. Good 
 hygienic surroundings should be secured, and tlie patient may often be 
 placed in the open air for many honrs at a time, even in cold weather, 
 with benefit during the process of chronic suppuration. 
 
 n. Erysipelas. 
 
 Erysipelas is an acute inflammation of tiie skin spreading along its 
 upper layers and occasionally penetrating to the deeper tissues. It may 
 involve mucous membranes. It is accompanied by fever. It lias a tend- 
 ency to more or less complete recovery, but it may recur. The name is 
 derived from ipu3p6c, red, and vtirAa, skin. 
 
 Although the disease was known to the ancients, reliable reports 
 previous to the epidemic described in France in 1750 are rare. Epi- 
 demics are described as occurring in Great Britain in 1777 and 1780, and 
 also in 1821 and 1832. A very extensive epidemic of erysipelas occurred 
 in this country in 1842, and the disease is described as prevailing in vari- 
 ous parts of Europe in the following year. The accounts of this last 
 
ERYSIPELAS. 419 
 
 epidemic are clear, and show the disease to have existed in a far more 
 malignant type than that seen to-day. In fact, epidemics of this disease 
 are at the present time practically unknown in civilized communities. 
 The disease often assumed at that time the phlegmonous type, and 
 worked its way deeply between the muscles of the trunk, and some- 
 times involved a whole extremity. In New England it spread from 
 village to village and many lives were sacrificed. 
 
 The streptococcus of erysipelas was first described by Fehlciscn.' 
 The cocci grow in serpentine chains. They are small, varying from 0.3 fi 
 to 0.4 p in diameter ; they are, however, somewhat larger than the strepto- 
 coccus pyogenes. The culture of the coccus upon gelatin develops slowly, 
 and appears as a very delicate grayish-white film, not unlike that of the 
 streptococcus. 
 
 The question of the identity of these organisms is still a mooted one, 
 although the feeling at present tends to the belief that the streptococcus of 
 erysipelas is a specific organism. It has been suggested by some observers 
 that in the suppurati\'e forms of erysipelas pus is developed by the action 
 of the pyogenic cocci ; others believe that the streptococcus of erysipelas 
 when developing in the subcutaneous tissue has a more virulent local 
 action and may become pyogenic. 
 
 The cocci are found in the capillary h'mphatics of the skin chiefly, 
 but are also occasionally seen in the capillary blood-vessels and small 
 veins. The growtli of tiic organism is most active near the red margin 
 of the er^'sipclatous l)lush. The virus may lie transmitted to different 
 parts of the body through the circulation, and the constitutional dis- 
 tui'bance is probabh' due to the presence of the cocci or their ptomaines 
 in the circulating blood. The virus gains entrance to the body almost 
 invariably through a wound : even in the so-called cases of idiopathic 
 erysipelas the cocci find their way through some minute abrasion in 
 the skin. 
 
 The clinical evidence of the contagiousness of erysipelas is abundant. 
 Stille^ reports the following striking example: In 1852 a man arrived 
 in Platte county, INIissouri, suffering from erysipelas of the face. He 
 was nursed by a farmer, who himself fell ill of the disease. A second 
 farmer, who assisted in nursing these two patients, was seized by the 
 disease, and subsequently six other persons, who helped to nurse in their 
 turn, were attacked. No other case occurred in the neighborhood. 
 
 The occurrence of erysipelas following vaccination was so frequent 
 in Boston in the winter and spring of 1850 that vaccination was 
 temporarily abandoned. The disease was probably not conveyed in 
 the vaccine virus, but by an unclean instrument. 
 
 The close relationship of ervsi]ielas and j)uerperal fever has been 
 recognized by many authorities, and the impropriety of attending a 
 case of confinement after handling erysipelas is now well understood. 
 Trousseau describes an epidemic of puerperal fever which rendered the 
 closing of a hospital necessary. In the hospitals to which pregnant 
 women were transferred er^-sipclas liroke out among the surgical cases 
 in many instances. 
 
 Exposure to cold was for a long time supposed to be a cause of ery- 
 
 ' Die Etiologk des Erysipels, Berlin, 1883. 
 
 '' International Encyehpctdiu of Surgery, vol. i. p. 165. 
 
420 TRAUMATIC FEVER, ERYSIPELAS, AND TETANUS 
 
 sipclas, but it acts uudoubtedly us u predisposing cause only, i-cndering 
 the patient debilitated and therefore more susceptible to the disease. The 
 spring and late winter months are regarded by many surgeons as a par- 
 ticularly favorable season for the development of the disease. 
 
 Erysipelas is comparatively rare in childhood, although it is seen in 
 badly-arranged lying-in hospitals as erysipelas iwoiiatornm when puer- 
 peral fever prevails. It does not occur so often in old age as in the 
 prime of life. 
 
 Certain constitutional conditions, as alcoholism and diabetes, are 
 supposed to act as predisposing causes, and some individuals frequently 
 attacked by erysipelas are supposed to have a predisposition to the 
 disease. 
 
 Symptoms. — The disease usually manifests itself at first by a chill, 
 with fever and symptoms of gastric disturbances. The tongue is coated, 
 and there is often a sense of oppression at the epigastrium, and some 
 enlargement of the lymphatic glands belonging to the vessels leading 
 from the jwint of infection. An examination of the wound does not, 
 however, show any origin, as yet, of an infective inflammation. Occa- 
 sionally the constitutional disturbance is so slight as to pass unnoticed, 
 and the first sign of any disorder is in the Mound itself. In twenty-four 
 to forty-eight hours from the time of the beginning of the attack there 
 is an itchmg or inirning sensation in the vicinity of the wound and the 
 skin becomes tender to the touch. There is at first a blush on the skin 
 in the vicinity of the wound, ^diich gradually deepens in tint and has a 
 more dusky hue than the rose color t)f hj^pertemia. There is a yellowish 
 tinge mingled with the red, and this becomes more evident upon pres- 
 sure, which shows a yellow stain to the diseased part during the moment 
 in which the blood is pressed aside. The swollen tissues become tense 
 and hard and do not pit on pressure. The swelling is most evident 
 about the eyelids, where the skin lies loose, and also about the genitals. 
 As the swelling and infiltration of the part increase, small vesicles form 
 which may at times attain considerable size. 
 
 When the local inflanmiation is fully developed it shows a tendency 
 to spread, and the outline of the diseased part is usually well marked 
 and is often quite irregular. The inflammation runs its course at any 
 one particular point in three or four days, but in the mean time it has 
 invaded new regions, and this process may go on for a considerable 
 period of time, and the surfaces involved in the inflammation are often 
 quite extensive {erysipelas mic/raris). It may even revisit jtarts which 
 have already been infected and are convalescent from the original attack. 
 The tendency to recur is a marked feature of the disease, but so also is 
 the tendency to recovery, and it is rare that the attack lasts longer than 
 two weeks. As the inflammation subsides there is an abundant desqua- 
 mation, and, as in the superficial form of erysipelas there is no sup- 
 puration, there is a complete return to the normal condition of the skin. 
 
 The condition of the wound during an attack of erysijielas varies 
 greatly. In the early stages of the healing process a wound the edges 
 of which are in apposition may reopen, the interior presenting a slough- 
 ing aspect, and in the severer forms extensive destruction of tissue may 
 take place, which may involve vessels of considerable size, producing 
 secondary hemorrhage. At other times, particularly when the disease 
 
ERYSIPELAS. 421 
 
 has attacked a wound in tlie stage of granulation, there appears to be 
 little local disturbance, and the healing process may go on even more 
 rapidly tlian l)ef<»rc. 
 
 The constitutional symptoms correspond pretty closely with the 
 amount of local inflammation in the majority of cases. Accompanying 
 the gastric disturbance there are usually a chill and a rapid rise of tem- 
 perature, follo\vcd liy a slight fall on the following morning. The sub- 
 sequent changes of temperature are most erratic, corresponding to the 
 amoiuit of inflammation — as a rule, however, showing the remittent 
 
 The tongue is heavily coated, and there may be vomiting and diar- 
 rlicea. In the most severe cases there may be delirium, and the disease 
 shows a tendency to assume a tyjihoid type. 
 
 The variety of erj'sipelas known as facial cnji^ipelas is often called 
 idiopathic, as it does not appear to take its origin from a wound. The 
 virus in these cases probably obtains an entrance through some small 
 wound, abrasion, or pustule in the skin. The disease is first observed 
 on the nose or near one of the lachrymal ducts, and spreads slowly along 
 the lines of the cheek beneath the orbit in the direction of the ear. As 
 it approaches the temple it may rise to tlie forehead and invade the 
 scalp, or it may turn downward to invade tlie neck. The chin is rarely 
 involved. In mild forms the disease gradually fades away as it reaches 
 the ear, and the amount of constitutional disturbance is in such cases 
 very slight. In the severer types of facial erysipelas the amount of 
 swelling is usually very great ; the eyelids become oedematous, and the 
 eyes are closed, the disiigurenient becoming at times so great that the 
 patient is unrecognizable. The color of the skin is scarlet, and tlie sur- 
 face is covered with vesicles wliich here and there run together, forming 
 bullffi of considerable size. Tlie lymphatic glands in front of and behind 
 the ears are enlarged, and when the scalp is invaded the glands in the 
 back of the neck are involved. In the severer forms of facial erysipe- 
 las, particularly if the scalp be involved, there is delirium, and a slight 
 tendency to tlelirium is noticed even in mild forms of the disease. This 
 appears to be caused either by reflex nerve-irritation, or by a vasomotor 
 disturbance causing hypersemia of the meninges, or by an extension of 
 the septic processes through the orbit to the membranes of the brain. 
 Fortunately, the latter complication is of rare occurrence, and with the 
 sul;)sidence of the inflammation of the skin the cerebral symptoms 
 usually disappear. 
 
 The tendency of the inflannnation to involve the deeper tissues of 
 the orbit is characteristic of the graver forms of erysipelas, and blind- 
 ness is sometimes caused by the extension of the septic process to the 
 eye itself, jiroducing either a panophthalmitis or degenerati\'c changes in 
 the optic nerve. A rare complication is the formation of an orbital 
 abscess. 
 
 The duration of facial erysipelas, like that of other forms, is cpiite 
 variable. In mild cases the disease rarely lasts beyond one week ; in 
 the severer types, or in cachectic individuals, the inflannnation may last 
 several weeks before it entirely disa])pears. 
 
 Phleojioxous Erysipelas. — When the disease spreads to the 
 deeper tissues the virus appears to assume greater activity. The amount 
 
422 TRAUMATIC FliVER, ERYSIPELAS, AND TETANUS. 
 
 of swelling is in sucli cases much greater, and tlie skin 1)eeomes tense 
 and hard. Vesicles form, wliieh are sometimes filled with bloody fluid, 
 and the surrounding parts are swollen and (edematous. The eonstitu- 
 tioual disturbance is great. Chills frequently occur, and the fever 
 assumes a typhoid character. As pus forms in the subcutaneous 
 tissue, the skin above loses its tension, and becomes boggy and more or 
 less movable on the parts below. A free incision gives vent to a 
 sanious ])us, mingled with shreds of sloughing tissue which have been 
 likened to masses of wet blotting-paper. The suppurative process gen- 
 erally extends for some distance beneath the surface, and several incis- 
 ions are usually necessary to drain the parts properly. The muscles 
 may be separated from one another, and even joints may be involved in 
 the septic process. 
 
 In some cases gangrene of the skin may occur, and on such occasions 
 the skin Ijecomes a dusky-red in color and large bnlhe form filled with 
 bloody serum. It is principally in old and feeble iiulividuals that such 
 a complication occurs. It is known as gangrenous erysipelas. The con- 
 stitutional disturbance is in such cases very great, and many patients will 
 succumb with symptoms of pysemia or of septictemia. 
 
 EEYSIPELA.S Neonatorum is most freciuently seen in hospital prac- 
 tice. It takes its origin from the granulating surface of the stump of 
 the umbilical cord. The slight blush about the navel is at first accom- 
 panied by but little fever. As the disease progresses the septic process 
 may extend over the abdomen and involve the genitals and thighs. 
 There is then high fever, and the child cries and is restless. In the 
 later stages collapse supervenes, and the child dies on from the sixth to 
 the tenth day of the disease. Gangrene is an occasional complication 
 of this form of erysipelas. The disease may spread along the hypogas- 
 tric arteries or the umbilical vein, and peritonitis may occasionally occur 
 in consequence. 
 
 Erysipelas of Mucous Membranes occasionally occurs. When 
 the pharynx is involved the color of the throat is a dark red, and 
 there is a tendency to dyspnoea and difliculty in deglutition. There 
 is also a marked enlargement of the cervical glands. The thorax may 
 become the seat of diphtheritic inflammation, and suppuration may take 
 place in the submucous tissues. The mouth may also be involved in 
 the inflammatory process, and the tongue then becomes greatly swollen 
 and congested, giving rise to that variety of disease known as " black 
 tongue." 
 
 The disease is said to extend along the air-passages to the lungs, giv- 
 ing rise, perhaps, to oedema of the glottis or to septic pneumonia or jmeu- 
 monia migrans. Such forms of erysipelas arc extremely rare at the 
 present time, and were observed principally in those malignant epidemics 
 which have already been mentioned. 
 
 Erysipelas may occasionally extend from the vulva to the vagina and 
 from the nates into the rectum. 
 
 Pathological Anatomy. — An examination of the principal seat of 
 the disease — the skin — shows that there is a considerable exudation 
 in the rete mucosum and in the upper layers. The superficial net- 
 work of lymphatics is filled with streptococci, which are most numerous 
 near the margin of the inflammation. There is a considerable hyper- 
 
ERYSIPELAS. 423 
 
 jemia of the blood-vessels of the affected part, and the surrounding 
 tissues are infiltrated with leucocytes. In some types of erysipelas 
 minute abscesses, which during life have escaped observation, are often 
 found in the cutis. 
 
 The changes observed in the circulating blood are supposed to be due 
 to the micrococci, although they are rarely found there in large numbers. 
 The red corpuscles are found to assume a erenated appearance, and dis- 
 solve and run togetiier readily. The white corijuscles are usually in- 
 creased in number. Endcjcarditis is occasionally observed. Tiie gastric 
 symptoms appear to be due to the condition of the system, rather tiian 
 to any local change. Catarriial ulcers are, however, sometimes found in 
 the small intestines. The brain and membranes are hyperjemic and 
 cedematous in tiie severe forms of facial erysipelas. Suppurative men- 
 ingitis is, however, extremely rare. Enlargement of the spleen is often 
 found, and there is frequently some cloudy swelling in the kidneys. 
 Tlie }>arotid gland may also become inflamed. 
 
 The curafire influence of erysipelas (erysipele salutaire) has long been 
 recognized. Wounds iieal more rapidly, cin-onic inflammations of the 
 skin disappear, and old ulcers begin to granulate. Tilmans reports 
 several eases of sarcoma of the face and neck which either disappeared 
 after an attack of erysijielas or were greatly reduced in size.' In one 
 case the patient died of the erysi})elas, and the cells of the tumor were 
 found to have undergone extensive fatty degeneration. Fehleisen, in 
 order to demonstrate the specific character of tiie streptococcus of ery- 
 sipelas, inoculated man on several occ^asions witii success, the human 
 inoculations being used also for tiie purpose of testing the curative clia- 
 racter of tiie virus. A death luu'ing occurred in the hands of uuitators 
 of tills method, the experiments were abandoned. 
 
 Recently, Coley ^ has experimented with the virus, and has collected 
 38 cases of malignant disease in wliicli erysipelas had occurred either by 
 accident or intent. There were 17 cases of carcinoma, of which 3 were 
 permanently cured, and of 17 cases of sarcoma 7 were well and free 
 from recurrence from one to seven years after the attack of erysipelas. 
 As in some cases when the pure culture has been used death has followed 
 the inoculation in the hands of other surgeons, Coley has substituted the 
 toxic ]iroduets of tiie erysijielas coccus for tiie pure culture. Tiiey are 
 thus obtained : The strejitococeus is planted in bouillon culture and 
 allowed to grow for six weeks, wlieii tlie bouillon is filtered. The fil- 
 tered material contains no bacteria, but is rich in toxic products. 
 
 Spronck's method of preparation is as follows:* The streptococcus 
 is planted in two large flasks of equal size nearly filled with bouillon. 
 Tile cotton plugs are covered witli a layer of paraffin. The flasks are 
 sul)jccted to a temperature of from 33° to 35° C. for fifteen days. After 
 the purity of the culture has lieen verified, the contents of one of the 
 flasks, to which 5 per cent, glycerin lias been added, is subjected for 
 three hours to a current of steam at 100° C, and is finally reduced to 
 one-tenth its volume by boiling. After cooling this liquid is added to 
 the contents of the other flask and the mixture is filtered. 
 
 ' Deutsche Ch!riir<i!p, Lieferung 5, 1880. 
 
 " American JiniriKil Medical Sciences, May, 1893. 
 
 ' Annates de I'Insliiul Pasteur, No. 10, 1892. 
 
424 TRAUMATIC FEVER, ERYSIPELAS, AND TETANUS. 
 
 The diagnosis of erysipelas is not easy to establish definitely in the 
 early stages. The chill, tlie gastric syniptoins, and the enlargement of the 
 lymphatic glands are indications which should canse the surgeon to exam- 
 ine the wound carefully for signs of the disease. It is not until the 
 blush appears that a certain diagnosis can be made. The doughy swell- 
 ing with tenderness of the skin and tlie irregular raised margin of the 
 infianied area serve to distinguish it from erythema, which may originate 
 in some local irritation or infiannnatory process. There may at times be 
 difficulty in deciding between phlegmonous erysipelas and diffuse suppu- 
 ration of the cellular tissue. This latter complication arises usually 
 from a wound, and from the l)eginning the signs of a deep-seated sup- 
 purative inflannnation are manifest, whereas in erysipelas tlie inflamma- 
 tion liegins upon the surface, and the superficial changes are then not a 
 marked feature. 
 
 The prognosis of erysipelas is, as a rule, fiivorable. There is a tend- 
 ency on the part of the disease to self-linxitation, and the disease does 
 not remain in any one spot more than four or five days. If erysip- 
 elas attacks a wound during the early stages of the healing process, it is 
 more likely to be severe than during the granulation stage. It varies also 
 with the age of the patient. In very young infants it is a most serious 
 condition, and in the aged it is with difficulty that the disease is thrown 
 off, ])articularly in tlie traumatic form of erysipelas. In facial erysipelas, 
 which attacks old people so frequently, the disease is often very mild in 
 its course. 
 
 The severity of the disease may be said to vary according to the 
 resisting j^ower of the patient. The tendency to relapse should always 
 be borne in mind. 
 
 Although the disease may not lie severe in its type, it may pro- 
 duce fatal complications, such as secondary hemorrhage. The sight 
 may be lost in facial erysipelas, and spasm of the glottis may occur 
 if there is great swelling in the neck during an attack. The effect of 
 antiseptic surgery seems, however, to render the attacks, as a rule, 
 milder. 
 
 Treatment. — The treatment of erysipelas may be both local and con- 
 stitutional. In general, it may be said that the treatment should be 
 supjiorting and that depletion should be avoided. The diet should be 
 carefully adapted to the disturbed digestive functions, but should be 
 nutritious. Alcoholic stimulants may be used freely in the asthenic 
 cases, but care should be taken as to over-stimulation M'liere there are 
 symptoms of cerebral hyperaemia. 
 
 The use of iron has been strongly recommended in P]ngland. Bell 
 recommended 25 drops of the tincture of tlie cliloride of iron every two 
 hours, day and night. Iron is supposed to exert a favorable action upon 
 the red blood-corpuscles and to have a constringing effect upon the blood- 
 vessels. Quinine may be combined with it, but these remedies are not 
 so much used since more dependence has been placed upon the local 
 treatment. Camjihor, digitalis, and aconite have also been recommended 
 for this disease. 
 
 Antipyretics exert but little influence upon the fever, and are to be 
 avoided, owing to their depressing influence upon the heart's action. 
 Delirium may be relieved by the use of the bromides or chloral, and 
 
ERYSIPELAS. 425 
 
 opium in some form may be needed to ensure relief from jwin and to 
 give repose. 
 
 Among local remedies, iodine enjo_yed for a long time a great rcputa^ 
 tion, as it was supposed to prevent the sj^read of the local inilammation. 
 It has now been replaced by antiseptics. The effect of antiseptic drugs, 
 applied to the snriace of the skin, upon the bacteria in the capillary 
 Ivmphatics is not as great as might be supposed. Although the skin 
 absorbs certain drugs freely, particularly those containing carljolic acid, 
 it is probable that the organisms are restrained in their activity to a cer- 
 tain degree only, and are rarely destroyed by this agent. 
 
 Carbolic acid may be applied to the part in an ointment in the strength 
 of 1 : 1 ( )0, oi- it may 1 )e used in an antiseptic poultice which has been dipped 
 in a solution of 1 : 200. James C. White recommends a lotion containing 
 1 drachm of carbolic acid to 4 ounces each of alcohol and water. This 
 should be applied upon a cloth, and, as it evaporates quickly, should fre- 
 quently be renewed. It is M'ell adapted to facial erysipelas and to parts 
 that can conveniently be exjiosed. 
 
 Carbolic acid can theoretically be brought more intimately in contact 
 with the bacteria by subcutaneous injections. These should be made 
 along the margin of tlie diseased area. The dilhculty of introducing a 
 sufficiently large quantity of the solution at the most needed points is an 
 obstacle to the success of this method. It should always be remembered 
 that carbolic poisoning may result from a too free use of the drug, and 
 the urine should be watched for the characteristic olive-colored staining 
 \vhile this treatment is employed. 
 
 Creolin and phenyl are preparations which are good substitutes for 
 carbolic acid in antiseptic poultices. Phenyl (sulpho-naphthol) may be 
 used in a strength of 1 : 250. Ichthyol may be applied when it is desired 
 to avoid strong antiseptic dressings. Mild zinc ointment and ])lain vaseline 
 are comfortable applications. Tiie frequent application of licpiid vaseline 
 to the face, or a solution of carbolic acid in oil 1 : 100, with a camel's-hair 
 brush, is a mode of treating facial erysipelas which is both comfortable 
 and effective. If it is desired to retain a dressing ujion the face, this 
 may be done by means of strips of gutta-percha tissue, which is light and 
 easily holds oily sul^stances in contact with the skin. 
 
 When the infective process goes on to suppuration, as in phlegmonous 
 erysipelas, drainage nuist be obtained by free incisions as the surest means 
 of arresting the spread of the disease. The knife should penetrate as far 
 as the subcutaneous cellular tissue, as it is at this point that pus will be 
 found. The sloughing tissue should be removed as thoroughly as pos- 
 sible, and the infected area disinfected by antiseptic solutions. Carbolic 
 acid and peroxide of hydrogen are probably more effective agents for this 
 ])urpose than corrofiive sublimate. Antiseptic baths may be used, the 
 limb being submerged for half an hour once or twice a day in weak anti- 
 septic solutions. 
 
 When pus forms in the orbit, it is necessary to make an early and 
 deep dissection in order to reach the point of infection and prevent grave 
 injury to the optic nerve. 
 
 Erysipelas is now generally recognized as a contagious disease, and it 
 is therefore important that early attention should be given to the isola- 
 tion of the patient from other surgical patients, and great care should be 
 
42G TRAUMATIC FEVER, ERYSIPELAS, AND TETANUS. 
 
 exercised by the surgeon and liis assistants to avoid tiie transmission of 
 the disease to others. In hospitals such cases should be transferred to a 
 special ward and placed under the charge of a member of the staff spe- 
 cially selected for the j)urpose. In no case is careful attention to the 
 hygienic surroundings of the patient of greater ini})ortance. A thorough 
 ventilation of the apartment and frequent change of the clothing and 
 liedding are jirecautions which may serve to favor the removal of the 
 germs of the disease as they accumulate and to ward off a reinfection of 
 the patient. Relapses, M'hicli are so characteristic of erysipelas, may in 
 this way frequently l)e avoided. The patient should not be released from 
 his isolation until ail tendency to desquamation has ceased. 
 
 HI. Tetanus. 
 
 Tetanus is an infectious disease, generally traumatic in origin, charac- 
 terized by painful contractions of the muscles, beginning with those of 
 the jaw or the neck and affecting progressively the muscles of the trunk 
 and the extremities. It is accompanied by convulsive paroxysms, and 
 is due to the presence of a bacterial poison in the blood and tissues. 
 
 Etiology. — The bacillus tctani was first discovered in 1885. It is a 
 very slender rod with somewhat rounded ends. Spore-formations which 
 are spherical in form take place at one end of the rod, and, l)eing con- 
 .siderably greater in diameter than the rod, give to the Ijacillus a drum- 
 .stick or pin shape. It is a strictly anaerobic organism, and grows at a room 
 temperature in the usual culture media. It rapidly dies when ex})osed to 
 the air. Spores are formed in cultures kept in the incubating oven at 36° C. 
 at the end of thirty hours. The spores retain their vitality in a desic- 
 cated condition for several months. The bacillus is colored by methyl-blue 
 and fuchsin. The method of Ziehl may be employed for doulile staining 
 of bacilli and spores. It can be cultivated in cultures of gelatin mixed 
 with grape-sugar. In stal)-cultures development takes place along the 
 line of puncture a considerable distance below the surface in innumera- 
 ble radiations, giving the apjiearance of an inverted fir tree. 
 
 Through the researches of Brieger and Kitasato a toxic substance has 
 been obtained called hianhi. This substance has been obtained not only 
 from cidtures, but from the tissues and blood of individuals affected with 
 tetanus. A substance known as tetanoioxin and also as yxtsmotoxin has 
 also been obtained. 
 
 The organism is found principally in the tissues near the wound, 
 and rarely in the blood, the internal organs, or the central nervous 
 system. Injected into animals, the organism produces symptoms of 
 tetanus in twenty-four hours, and at the autopsy a slight infiltration 
 is seen at the point of injection, but no coarse ])athological changes are 
 found elsewhere. Few bacilli are found, and the symptoms produced 
 are consequently ascribed to the tetanin, which is supposed to disseminate 
 itself tlu'ougli the body. 
 
 The bacilli are found in the superficial soil in temperate, and par- 
 ticularly in tro]iical, regions, in the nnid of the streets, in garden soil, 
 and in crumbling masonry, and they have been observed frequently 
 in manure. Although so widely distributed, these organisms are rarely 
 able to exert their pathogenic action, owing to their anaerobic nature. 
 
TETANUS. 427 
 
 It is only in deeply-punctured wounds, tlicrefore, that we find the con- 
 ditions fuvurable for their growth. 
 
 Among tlie predisposing causes of tetanus meteorological influences 
 have been supposed to i)lay an important jiart. Epidemics of tetanus 
 are reported as following a sudden change of weather after great battles. 
 In tropical countries the type of the disease is said to be much more 
 virulent. 
 
 Injuries of nerves have been supposed, by older writers, to give rise 
 to tetanus, and the disease has been sup|)(jsed to follow injuries to cer- 
 tain portions of the body, as the hands and feet ; but statistics do not 
 appear to support these views, for the disease is known to occur after 
 injury in almost every locality, and has even occurred where no appre- 
 ciable lesion could be found. 
 
 Age appears to exert a certain influence. Yandell found that in 7 
 per cent, of the cases collected by liim the patients were under ten years 
 of age. These figures do not include cases of trismus nascentiimi. The 
 disease is said to be rare among the aged. 
 
 Although cases of idit)pat]nc tetanus are occasionally repoited, it is 
 probable that the disease is always traumatic, the point of inoculation 
 being so small as frequently to escape notice. 
 
 Varieties. — Tetanus is both acute and chronic. Puerperal tetanus 
 and trismus naseentium are usually considered separately from traumatic 
 tetanus, but are etiologically in no way to be distinguished from this 
 form of the disease. 
 
 Acute tetanus usually appears during the first week after the infliction 
 of the wound. In chronic tetanus the symptoms are found in the second 
 week, and sometimes even later than the fourteenth day. 
 
 Symptoms. — After a comfortable night's rest the patient usually 
 wakes with the sensation of having taken cold. He complains of a 
 stifl' neck, but attaches no importance to tlie symptom. During the day 
 there is a slight stiffness of the muscles of the jaw which makes it 
 diflicult for Jiim to open his mouth. The muscular rigidity is presently 
 followed by jiowerful muscular contractions, which soon become so pain- 
 ful and continuous that the jaw cannot be ojiened, and considerable 
 difliculty is experienced in swallowing even liquids. The masseters are 
 found to be in a state of rigid contraction (trismus or lockjaw), and the 
 muscles in the back of the neck are so unyielding that it is difficult to 
 ap})roximate the chin to the sternum. Tlie nmsdes in the abdominal 
 parietes are soon found to be firm and rigid, and toward the end of the 
 first da}' the muscles of the back will also become involved, producing 
 arching of the spine, or opisthotonos. The muscular contractions, which 
 are now almost continuous, are kno\\n as tonic contractions. Attempts 
 to swallow are painful and inefft'ctual, owing to the paroxysmal increase 
 in the muscular contraction. The patient usually suffers from retention 
 of urine. 
 
 On the second day the jaws are locked as firmly as before, and nearly 
 all the muscles of the body, except those of the upper extremities, are 
 involved. The arms are only partially affected, liut the lower extremities 
 are usually rigidly extended. The uuiscles of the face are also now 
 affected, the eyelids are contracted, the nostrils raised, and the mouth 
 puckered in such a way as to give a peculiar expression to the patient 
 
42.S TRAUMATIC FEVER, ERYSIPELAS, AND TETANUS. 
 
 (risus sardonicus). The eyes arc drawn in and are j^artially clo.setl, and 
 occasionally there is strabismus. 
 
 Any disturbing influence brings about an exacerbation of the mus- 
 cular spasm which exists throughout the body. The muscular conti-ac- 
 tions are exceedingly painful, and any attempt to jirevent them or to 
 straighten a liml) may lead to rupture of the nuiscular filjre. 
 
 Tiie attitude of the patient in bed is characteristic. He lies usually 
 upon his side, and is apparently motionless. Close inspection M'ill, how- 
 ever, show that the head is drawn rigidly backward and that the arch of 
 the spine is greatly increased. The rigidity of the nuiscles of the mouth 
 does not permit distinct articulation, and the patient emits only muffled 
 groans in answer to questions. The spasm of the sphincters renders 
 movements of the bowels and evacuation of the bladder extremely 
 difficult. 
 
 There is but little pyrexia at first, and there is usually no character- 
 istic temperature-curve. There may be a rise of temperature during the 
 later stages of the disease, and even post-mortem. Diajdioresis is a 
 marked feature of the disease, occurring principally after each convul- 
 sion, and doulitless aids in preventing an excessive rise of temperature. 
 
 But little sleep is obtained, owing to the almost continuous muscular 
 contraction. Short periods of slumber may be secured by the use of 
 drugs, but the patient is soon roused Ijy renewed convulsive movements. 
 During these attacks, which last usually a few seconds oidy, there are 
 some cyanosis of the face and foaming at the mouth. There is also 
 marked dyspnoea ; the pulse is greatly accelerated ; the muscular con- 
 tractions usually produce at this time a marked opisthotonos. 
 
 Attempts to swallow often bring on spasm of the glottis, and death 
 has occurred during such a crisis. Sjiasm may also be produced by 
 attempts to expectorate the mucus which has accumulated in the throat. 
 As the result of these constant muscular etforts and the loss of udurish- 
 ment and sleep thei'e is great prostration. The face is pale and emaciated, 
 and if not convulsed there is an expression of great apprehension. The 
 voice is feeble, and the skin is constantly bathed in sweat. The mind is 
 clear, and the patient is fully sensible to the agony of his disease. Dur- 
 ing the last moments the tetanic spasms may relax, but they are usually 
 maintained imtil the end. 
 
 In chronic tetanus the period of incubation is longer than that of 
 acute tetanus, the first symptoms appearing usually in the second or third 
 week after the injury. The order in which the symptoms appear is the 
 same as in acute tetanus. The development of the early symptoms may 
 also be as rapid as in the acute form, but there are frequent periods dur- 
 ing which the patient obtains a respite from the nuiscular contractions. 
 During these intervals the patient is able to take nourishment, and his 
 strength is corresj)ondingly maintained. As time passes these intervals 
 become longer and the muscular spasms are less severe, and the jjatient 
 has an opjiortunity to obtain sleep. Prostration is, however, extreme, 
 and any mmsual excitement or irritation lirings back the spasms. The 
 period of convalescence is liable to be interrupted by numerous relapses. 
 The disease is likely to be greatly prolonged in this way. 
 
 Head Tetanus occurs after injuries in the region of distribution of the 
 cranial nerves. It is chai'acterized by spasm of the pharyngeal muscles 
 
TETANUS. 429 
 
 and paralysis of the facial nerve. There is also trismus, and occasion- 
 ally tetanic contractions of the muscles of the neck and abdomen. This 
 form of tetanus occurs usually after a \vound in the fiicc. The difticulty 
 in swallowing has given rise to the term "tetanus hydropliobicns." 
 Like other forms of tetanus, it may be either acute or chronic. 
 
 Tliere is nothing characteristic in the condition of the wound. Ac- 
 cording to Poncet, the suppurative process is less healthy in character 
 and the tissues appear to be in a state of irritation. Occasionally a slight 
 blush is seen along the edges of tlie wound, or there may be evidence 
 of a lymphangitis. Occasionally a slight pricking sensation, and even 
 pain, is experienced in the alFected limb. Experiments by Buschke and 
 Oergel show that granulation tissue taken from the wound of a boy who 
 died from tetanus, and inoculated into mice produced symptoms of teta- 
 nus with a fatal result. 
 
 Wounds of the extremities are said to be more frequently followed 
 by tetanus than those of any other region. This is borne out by the 
 observations of Yandell and the statistics given in the Surgical History 
 of the War of the Rebellion. 
 
 This a[)parent preference of locality is probably due to the fact that 
 punctured woinids are more frequent in the hands and feet. The ])res- 
 ence of a foreign body is supposed to lie a jiredisposing cause, lint teta- 
 nus may follow even slight injuries. The fact that tetanus is frequent in 
 military surgery is, however, due not only to the penetrating nature of 
 the wounds, Ijut also to the frequent presence of a foreign body. 
 
 Post-mortem Changes. — Evidence of intlammation of the brain 
 and meninges is wanting, but signs of intlammatiiin in the nerves and 
 in the cells of the metlulla and cord ha\-e been observed. Grinelle in an 
 analysis of 52 cases reports that 29 presented lesions in tiie cord and 
 membranes, in 3 changes were noticed in the brain, and in 11 in the 
 nerves and muscles. Loekhart Clarke found a disintegration and soft- 
 ening of a jjortion of the gray substance of the cord. Ranvier was, 
 however, unable to find any pathological changes in the cord in four 
 cases of tetanus. Laveran found connective-tissue changes in the tibial 
 nerve of a patient who died of tetanus following amputation of the leg. 
 Jewell thinks the principal seat of the disorder is in the posterior cornua 
 and the contiguous central gray matter. 
 
 Diagnosis. — The diagnosis of tetanus may be difficult in the earlier 
 stages of tlie disease. Stillness of tlie muscles of the neck and jaws may 
 be due to inflammatory affections of the mouth or teeth or to abscess of tiie 
 cervical glands. Rheumatic inHannnation of the temporo-maxillarv artic- 
 ulation is usually accompanied by sufficient signs of local inflammation 
 to be readily recognized. Hysterical contraction of the masseter mus- 
 cles is not liable to give rise to a mistake in diagnosis, as sufficient time 
 will usually have elapsed to" enable the surgeon to exclude tetanus. 
 Temporary spasms following tlie dressing of a painful wound are not 
 likely to Ije mistaken for tetanus. 
 
 Cases of tetanic spasm due to peripiieral irritation by scars or foreign 
 bodies are reported, and in some instances terminate fatally. Some 
 of these cases may be true tetanus, but others are probably examples of 
 severe reflex irritation. 
 
 In cases of strychnia-poisoning there is spasm of the muscles of the 
 
4;50 TRAUMATIC FEVER, ERYSIPELAS, AND TETANUS. 
 
 limbs and body, with acliing of the back and laryngismus. The per- 
 sistency of the spasm depends, however, upon the frequency of the dose. 
 A characteristic feature of strychnia-poisoning is hypertesthesia of the 
 retina, and objects are seen green in color. 
 
 Tetany is not often seen in this country : it affects young persons 
 chiefly, and consists in tonic sj)asnis of various groups of muscles, most 
 often those of the upper extremity. Opisthotonos may occur, but there 
 is never trismus. The attacks are short and more or less localized, and 
 Trousseau's symptom, seen in no other convulsive disease, is always 
 present, pressure upon the n(>rve-trunk leading to the affected group 
 of muscles always bringing on a cliaracteristic attack. 
 
 Prognosis. — Acute tetanus is one of the most fatal of diseases, but 
 in cln-onic tetanus the percentage of mortality is very much less. The 
 longer, therefore, the patient lives, the greater are his chances of recov- 
 ery. Yandell in a study of 415 cases noted a marked falling off in the 
 number (jf deaths on the fifth day, after which period the mortality 
 steadily diminished. 
 
 Tetanus occurring in military surgery appears to be unusually fatal. 
 In the Surgical History of the War of the RcbcUion 505 cases are recorded, 
 the mortality being 89.3 per cent. Of Yandell's cases, which wei'e col- 
 lected from various soui-ces, 213 recovered and 182 died. The date of 
 the first appearance of the disease is a sign of prognostic value. Yan- 
 dell found that where the symptoms were delayed until the fourteenth 
 day from the time of injury the recoveries exceeded the deaths. 
 
 The gravity of the wound does not appear to have any influence 
 upon the severity of the disease. In tropical climates the disease is 
 much more fiital than in the temperate zones. 
 
 Treatment. — In estimating the value of any particular drug it is 
 important to remember the statement of Yandell, that when tetanus 
 continues fourteen days recovery is the rule and death the exception, 
 apparently inde])cndent of treatment. 
 
 Yandell places chloroform at the head of the list of drugs in cases 
 of acute tetanus. The weight of evidence appears to be in favor of 
 the sedative action of this drug upon the nervous system. It may be 
 administered by inhalation, eitlier to the point of anajsthesia or a napkin 
 may be placed upon the chest of the patient, who is thus exposed to the 
 influence of the drug. Its action is not, however, so enduring as that 
 of chloral. 
 
 Chloral seems to be most efficacious in chronic tetanus. It appears 
 to act by diminishing reflex excitability in the nerve-centres ; it relieves 
 pain and prevents spreading of the muscular spasm and the recurrence 
 of the convulsions. It may be continued for one or two weeks at a 
 time, and in this way an almost permanent sleep may be maintained, 
 which paves the way to convalescence. In doses of 100 to 200 grains 
 a day it will relieve muscular spasm in acute tetanus, but it does not 
 appear to have any appreciable effect upon the mortality. 
 
 Opium, when used, must be given in large doses to control the spasm, 
 and the digestive disturbance caused by the drug is a contraindication to 
 its use. 
 
 Bromide of potassium can be given in connection with chloral, or in 
 the convalescent stage as a substitute for that drug, but it is altogether 
 
TETANUS. 431 
 
 too mild a remedy to produce an appreciable effect in the more active 
 stages of the disease. 
 
 Calabar bean, or its active principle, when given in small doses, 
 I'elieves the muscular contraction ; the jaws relax, and the head reposes 
 quietly upon tlie jjillow. If given in large doses, the spasms appear to 
 be greatly aggravated. Poncet explains the favorable action of the drug 
 by its eifect upon the conductibility of the motor nerves by which the 
 muscular system is, as it were, isolated from the nerve-centres. He 
 prefers to give it by the mouth rather than In' subcutaneous injectii)n, 
 as the dose can be more carefully regulated and the action of the drug 
 observed by tills method. From | to 1 grain of the extract may be given 
 by the mouth every four hours, and 15 to 20 drops of a 1 per cent, 
 solution may be injected subcutaneously. The statistics of Knecht give 
 a mortality of 45 per cent, in 60 cases in which this drug was used. 
 
 Warm baths and dia}ilioretics have been used extensively in the 
 treatment of tetanus, doubtless in imitation of Nature's method of giv- 
 ing rebel", as diajihoresis is a frequent symjitom of the disease. Vapor 
 baths are probably the most efficacious way of carrying out this treat- 
 ment, as they are less likely to disturb the patient and thus aggravate 
 symptoms. In no disease should the comfort of the patient be so care- 
 fully studied, and every eifort should lie made to avoid disturbance or 
 irritation of any kind. The value of skilled nursing is shown nowhere 
 to greater advantage tlian in tliis disease. 
 
 Due attention siiould be given to the wound, and an eifort shoidd be 
 made thoroughly to disinfect it. The wound should consequently be 
 laid open, and its surfaces not only exposed to the action of oxygen, 
 but to powerful antiseptics, as in this way the amount of the virus may 
 possibly be diminished. Punctured wounds should be opened sufficiently 
 to admit of thorough disinfection. It is possible that the present asep- 
 tic method may permit the early closing erf a punctured wound, and 
 thus favor the development of the tetanus bacilli in the deeper layers 
 of the wounded part. The old-fashioned poultice by setting up suppu- 
 ration ftvvored a discharge of all poisonous material. In some cases the 
 scar is red, tender, and swollen. Such scars should be excised, and in 
 all cases it is advisidde to open and explore the cicatrix, as in some 
 instances particles of dirt have been removed with the cicatricial tissue. 
 
 Experiments u])on animals have shown that immunity can be obtained 
 by inoculations with minute doses of the poison or with a filtrate Avhich 
 has been exposed to a temjjcrature sufficient to destroy its activity (Kita- 
 sato). Immunity was also obtained for a certain time by inoculating 
 animals with the filtrate from the culture of the tetanus bacillus, and 
 subsequently by inoculating them at the same point with a solution 
 of terchloride of iodine. It was further found that the blood-serum 
 of an immune animal when injected into another animal protected it 
 from the effects of the inoculation with the tetanus bacillus, and that 
 inoculated animals in whom the tetanic symptoms had already made 
 their appearance were preserved from death by the injection of the 
 blood-serum of an immune animal (yternberg). Tizzoni and Cattani 
 gave the name " tetanus antitoxine " to the substance existing in the 
 blood of an immune animal which produced these results. Behring 
 found that the more intensely the animal was inoculated to render it 
 
432 TRAUMATIC FEVER, ERYSIPELAS, AND TETANUS 
 
 immune, and the longer it liad remained inoculated, just so much less 
 of its serum was required to cause iiunuiiiity in another animal. A 
 more powerful dose was, however, required for therapeutic purposes to 
 check tetanus which had already made its appearance. 
 
 These interesting experiments have led, as yet, to a limited employ- 
 ment only of the antitoxine in the treatment of tetanus in man. A 
 number of successful cases have been reported, Init the treatment seems 
 to have been employed almost invariably in chronic tetanus. In a case 
 reported by Rotter treatment was not begun until the fourteenth day of 
 the disease : 36 grammes of blood-serum from an immunized horse, with 
 5 per cent, of carbolic acid, were injected into the back. The injections 
 were continued for five days, and the patient recovered, the symptoms 
 rapidly yielding to the treatment. 
 
RABIES; HYDROPHOBIA; LYSSA. 
 
 By HERMANN M. BIGGS, M. D. 
 
 Rabies is an acute infectious disease occurring in many species of 
 animals and in man. It is transmitted solely by inoculation from an 
 infected animal, usually through a bite, and is characterized by a long 
 period of incubation, paroxysmal convulsions, great mental disturljance 
 and excitement, fever, often l)y general motor paralysis, and terminates 
 almost invariably in death. Wiien rallies occurs in man it is connnonly 
 called hydrophobia, because of peculiar spasms of the muscles of the 
 throat whi(^li follow any attempts at deglutition, or which may occur 
 even at the sight of water or food. These are extremely ]iainful and 
 produce great terror in the patient, and Jienee the name "hydrophobia." 
 
 Rabies ix Animals. — Rabies may occur in many species of animals 
 besides dogs, especially in those of the canine genus, wolves and foxes, 
 and in skiudvs. Cats are sometimes aifected, although less commonly 
 than dogs. It may also be transmitted to herbivora — to horses, cattle, 
 sheep, goats, rabbits, pigs, guinea-pigs — and less readily to other species 
 of animals, either ex])eriuientally In' inoculation or through the bites of 
 rabid dogs. .Vdami has reported a very extensive epidemic of ral)ies 
 which occurred in 1885 among the deer in Richmond Park in England 
 and afterward in the park of the marquis of Bristol. Rabies is rarely 
 transmitted from other animals than those of the canine genus. 
 
 In dogs the symjitonis of rabies vary somewhat, but the first real 
 symptom, usually not noticed, is a rise in temperature. This is fol- 
 lowed by dnlness, with an indisposition to move; later, the animal 
 becomes shy, suspicious, restless, and irrital)le, often snapping at any- 
 thing which comes near. At tliis period he frequently leaves home if 
 he is not confined, and may make long excursions, sna])ping'at everv- 
 tiiing in his way, and particularly attacking other dogs or animals. 
 Tln-oughout this early period there is a depraved appetite, the animal 
 rejecting tiie usual food and devouring hay, cloth, wood, coal, gravel, 
 fiecal matter, or even its own hair or tail. This symptom is important 
 and rather characteristic, although it is by no means pathognomonic, for 
 frequently it may be seen in other diseases than rabies. Almost in\'ari- 
 ably the bark is altered ; it is hoarse, unlike its usual tone, and ter- 
 minates with a peculiar howl. In one variety of the disease in dogs 
 there is intense, almost maniacal, excitement ; in another there is early 
 paralysis of the muscles of the jaw (so that it hangs down and allows 
 frothy saliva to escape from the mouth), followed by general motor 
 paralysis. In all varieties there is commonly weakness of the muscles 
 of deglutition : this interferes \vith swallowing, but at no time in the 
 disease is there any fear of water. A rabid dog will often plunge his 
 
 Vol. I.— 2S 433 
 
434 BABIES; HYDBOPIIOBIA; LYSSA. 
 
 nose and partially suhmergo his head in a disji of water or in rnnning 
 water. There exists a popnlar and danujeroiis fallacy rejjardino tliis fear 
 of water, wiiich is no doubt based on tiie name " hydro]iliol)ia." It is 
 eoninionly believed by the laity that a dog cannot be rabid if he drinks 
 or submerges his head in water. 
 
 After a longer or shorter period, in all cases paralysis appears, and 
 the dog staggers in attempts to walk, and often falls. Finaliv, tlie 
 weakness in the legs becomes so marked tliat the animal is unal)le to 
 stand, and dies completely paralyzed. A distinction has often been 
 made between dumb or paralytic and furious rabies, but the difference 
 is largely one of degree of excitement, which may depend upon the 
 conditions surrounding the animal in the early part, and the rapidity of 
 the course, of the disease. In every case, ultimately, there is paralysis 
 more or less complete. A change in the disposition oi' an animal, siiy- 
 ness, restlessni^s, illusions of sight and heai'ing (shown by sna]iping at 
 invisible objects in .the air, elevation of the ears, an attentive j)osition, 
 due to the hearing of sounds which do not exist), perversion of appe- 
 tite, wandering from home, and similar modifications of the nsual 
 apj)earancc, action, and manner, are all symptoms suggestive of the dis- 
 ease in the early stage. 
 
 It is an important point to determine when a raljid animal can 
 transmit the disease. Experimental observations have shown that 
 there is commonly an elevation of temjierature in dogs before any 
 other symptoms of the disease appear, and at this time, and even per- 
 haps for twenty-four or forty-eiglit hours or more before tlie elevation 
 of temjK'ratui-e, the l)ite of tlie animal may be virulent. In this way 
 are explained the eases of rabies which have been reported as resulting 
 from the bites of animals ajiparently in perfect health, and to this, no 
 doubt, is due the belief which formerly existed that nnder certain con- 
 ditions the bites of animals might produce hydrophobia wlien they them- 
 selves \\ere not affected by the disease. 
 
 Kabies in dogs almost invariably terminates fatally. There are, 
 however, some very rare cases in which recovery occurs. The duration 
 of the disease is variable, sometimes death occurring in twenty-four or 
 thirty-six hours, while in other cases it is postponed for seven, or even 
 very rarely for nine or ten, days, \yhen a person has been bitten by a 
 dog, whether suspected of being rabid or not, instead of destroying the 
 dog innnediately, as is too frequently done, the animal should be placed 
 in confinement and kt'jit under observation for several weeks if necessary, 
 so that it may be witli certainty determined whether the dog was or was 
 not rabid. If the dog is destroyed, it is of course impossible to determine 
 whether it was ral)id or not, except by the inoculation of other animals, 
 by the subdural method of Pasteur, witli the medulla or spinal cord. As 
 will lie seen later, however, a jimliable diagnosis can frequently be based 
 upon the autopsy-findings and the microscopical examination of certain 
 portions of tlie brain. 
 
 In the rabbit the sym])toms, as produced by inoculation, commonly 
 resemble those of dumb or paralytic rabies as it occurs in dogs. They 
 are not unlike those found in the human being in acute ascending 
 paralysis, and consist in dulness with some pyrexia, followed by weak- 
 ness in the hind legs, which gradually increases and extends for\vard 
 
DISTRIBVTIOX AND FREQUENCY.— ETIOLOGY. 435 
 
 until a complete jicneml paralysis results. Tiie animal lies tlicn upon 
 its side, with dittieult and labored respiration and complete motor 
 paralysis. 
 
 The period of incubation in animals is exceedingly variable, espe- 
 cially when the disease is produced by subcutaneous inoculation. It 
 varies from seven or eight days to a month or more. In the subdural 
 method of inoculation of Pasteur, after the virus has been passed through 
 a series of rabbits the period of incubation in tliese animals l)ecomes per- 
 manently shortened to about seven days, and remains uniform at this 
 point when the inoculations are made by this method. 
 
 Distribution and Frequency. — For a long time it was assumed 
 that ral)ies \vas confined to, cir was chiefly found in, temperate regions. 
 Furtlier observation lias shown, however, that it occurs in all parts of 
 the world, excei)ting perliaps in Australia, New Zealand, and one or two 
 other isolated localities wliere it apparently has not yet been introduced. 
 The frequency with which the disease occurs varies greatly. Like other 
 epizootic diseases, it often appears in epidemic form. It can be entirely 
 eradicated by the efficient enforcement of a law ]>roviding for the muzzling 
 of dogs. Rabies has bec(jme practically an unknown disease in many 
 parts of Germany ami some other Eurojiean countries as the result of 
 properly enforced laws regarding nuizzling. 
 
 Under all conditions rabies is a comparatively rare disease in man. 
 Boudin, in a communication to the Frencii Academy in 1863, gave the 
 number of deaths from iivdrop]iol)ia in Prussia, from 1854 to 1858, as 
 196 ; in Belgium, from 1856 to 1860, as 26 ; in England, from 1853 to 
 1857, as 100 ; in Scotland, from 1855 to 1S63, 10 ; in Sweden, from 1856 
 to 1860, as 42. In Ireland the nmnber of deaths for ten years ending 
 in 1879 was 21 ; in London, according to the Registrar-General's return, 
 thei'e were no cases from 1856 to 1862, 2 in 1863, none in 1864, 9 in 
 1865, 6 in 1866, 2 in 1879, 3 in 1880, 5 in 1881, 4 in 1882, 8 in 1883, 
 9 in 1884, and 27 in 1885. Muzzling was enforced in 1886, and the 
 number suddcidy fell to !), all of which occurred in the early part of the 
 year. In 1887 and ISSS there was not a single death reported. The 
 number of cases occurring annually in this country has been very small, 
 although the actual number cannot be determined. In New York City, 
 during tiie ten years ending in 1891, there were in all 9 deaths reported 
 to tlie Health Department as being due to rallies. In 1887 in the wliole 
 of tiie German Empire there were only 4 deaths from rabies. In France 
 rabies is apparently more prevalent, although, according to the reports 
 of Tardieu and Brouardel for tiie years 1850 to 1872, there were in all 
 685 deaths, an average of a little less than 40 yearly. Tardieu says of 
 his reports that nearly all departments replied to his inf|uiries, and 
 Brouardel, tliat alxmt two-thirds were included in liis. Since tlie pul)lic 
 announcement of the discoveries of Pasteur regarding the preventive 
 treatment of rabies, however, apparently the numlier of cases of infec- 
 tion has largely increased, if we are to assume that all those inocadated 
 iiad really been bitten l)y rabid dogs, for from 1200 to 2000 French- 
 men liave been inoculated each year. 
 
 Etiology of Rabies. — Tliere is but one efficient cause of rabies, the 
 introduction of a specific virus derived from a ral)id animal. Of the 
 nature of this virus we have as yet no absolute knowledge, lint there 
 
436 RABIES; HYDROPHOBIA; LYSSA. 
 
 can be no I'easonable donbt, reasoning from analogy, tliat it is a niicro- 
 organisni of some kind. Nnmerons other causes liave been commonly 
 supposed to be efficient in the production of the disease. There are 
 popular supei'stitions to the eii'ect that the bite of an angry dog or of 
 one in rut may be followed by rabies, that the disease is especially prev- 
 alent during the hot months of the year, and that certain breeds of dogs 
 are particularly susceptible to rabies. These superstitions are not at all 
 borne out by experience or statistics. Law (piotes statistics from Bouley 
 showing that in the winter months among dogs there occurred 75i3 cases 
 of rabies ; during the three spring montlis, 857 ; during the three sum- 
 mer months, 788 ; and during the three autumn months, 696 ; which 
 indicated that the largest number of cases occurred in the spring months, 
 but tliat there was really little difference in the ntnnber of cases occurring 
 in any season of the year. 
 
 There are certain questions which arise in connection with the etiol- 
 ogy of rabies which are of importance and interest. The virus undoubt- 
 edly resides, particularly in dogs, in the saliva and salivary glands. 
 The disease was long ago produced in dogs by ^lajendie by inoculating 
 them with the saliva of hydro])h()l)ic patients and of rabid dogs. 
 Pasteur has shown that the virus exists after death in the central 
 nervous system, particularly the medulla or sj)inal cord, and also in 
 the peripheral nerves, as well as in the salivary glands, and that 
 the disease may be produced more certainly and with a more uniform 
 period of incubation when inoculations are made beneath the dura 
 mater after tre])hining the skull than when they are made by subcu- 
 taneous injection of the virus. It is probable that the disease may be 
 communicated from one human being to another, although no well- 
 authenticated cases of this sort have been recorded. JMedical men and 
 nurses who are in attendance on cases of hydrophobia always escape, 
 although the saliva is often thrown upon the faces, hands, or clothing. 
 The virus is, as a rule, rajiidly destroyed by decomposition, although one 
 or two cases have been recorded where hydrophobia ajijiarently resulted 
 from accidental inoculation at the post-mortem examination of cases 
 of rabies. 
 
 In a large majority of all cases in the human being the disease is 
 contracted from the bite of a dog, in a very few cases from the bite 
 of a cat, and occasionally, especially in Russia, from the bite of rabid 
 wolves or foxes. Bites on uncovered jiarts of the body, as upon the 
 face or hands, are f\ir more likely to be followed b}- the disease than if 
 inflicted u])on jjortions covered with clothing, as in the latter case the 
 virulent saliva is frequently entirely wiped off from the teeth. The dis- 
 ease has l)een caused bv a rabid dog licking a scratch u]ion the hand, and 
 apparently it has followed the scratch of a rabid cat, the animal's saliva 
 having been probably thus introduced. There is absolutely no reason to 
 suppose that the disease can ever result from the bite of any animal not 
 suffering ft-om rabies. Undoubtedly, the cases in which this is supposed 
 to have occurred have been either otherwise inoculated or have been 
 infected by an animal apparently well, but in which the s3'mptoms had 
 not yet appeared, as it has been shown that the saliva may be virulent 
 for several days at least before the appearance of the disease. A large 
 proportion of the cases occurring in the human being are in children, 
 
INCUBATIOX. 437 
 
 because tliev are more likely to be bitten, and becaose tliey are more 
 frequently bitten on exposed parts of the body. In rare instances the 
 disease has l)een transmitted to human beings and to other animals from 
 rabid cattle, horses, sheep, etc. In these animals the saliva may be also 
 virulent. 
 
 The saliva from rabid animals will retain its virulence for a consider- 
 able period after having been dried. Pasteur has shown that the spinal 
 cords of ri'bid animals which have been dried lose their virulence at the 
 end of about fourteen days. Exposure to comparatively low temj)era- 
 tures also destroys the virulence of rabic virus ; that is, exposure for 
 one hour to a temperature of 50° C. The direct rays of the sun and 
 exposure to the action of 1 per cent, sublimate solution or 1 per cent, 
 carbolic solution for three hours have the same cflFect. Byron has shown 
 that the virulence may be preserved l)y immersing the rabic spinal cord 
 in pure glycerin or by sealing up aseptic pieces of the spinal cord in 
 test-tubes. 
 
 The susceptibility of animals to the virus varies with the kind of 
 tissue into which it is injected. Intravenous injections are not often 
 followed by the disease. Injections into the muscular tissue are more 
 freipientlv followed bv infection than injections into the subcutaneous 
 tissue, and the apjjlication of the virus to divided nerve-filaments is 
 generallv etficacious in ])roducing the disease. Divestin, Zagari, Pas- 
 teur, and others have apparently shown that the virus extends from the 
 seat of infection along the uerve-trunk to the spinal cord, and if the 
 animals arc killed at the proper time the virus may be found in the 
 nerves leading from the part infected when it is as yet absent in other 
 parts of the nervous system. Tims in bites of the posterior extremities 
 it is jn'cscnt in the lumbar cord when absent in the cervical region or 
 medulla. It is apparently sometimes present in the pancreas and lach- 
 rymal glands, and rarely in the secretion of the mammary glands ; but 
 it is usually absent from the blood, liver, spleen, and kidneys. 
 
 Incubation.— The incubation period of rabies in dogs varies widely. 
 The shortest period is apparently six days, and the longest al)out eight 
 months. In the majority of cases it varies between fourteen and thirty 
 days. In horses, cats, sheep, and swine it is ordinarily from twenty to 
 thirty days, but the period may be prolonged considerably beyond tliese 
 limits. Bollinger says that in 60 per cent, of all cases in the human 
 subject it is between eighteen and sixty days ; in 6 jier cent., between 
 three and eighteen days; and in 34 ])er cent, the period is longer than 
 sixty days. Cases have been recorded where the incubation has ap})ar- 
 ently been greatly prolonged to from one to three or five years. These 
 cases, however, are not well authenticated, and in well-observed cases the 
 incubation rarely, if ever, is more than twelve months. In 132 cases 
 cpioted by Fagg from the Registrar-Gi'ueral's reports, selected because 
 the circumstances regarding the incubation were accurately known, 
 the shortest incubation was eleven days — a case in which a child was 
 bitten by a rabid cat; in 23 cases it was under a month; in 64, be- 
 tween one and two months; in 21, between two and three months; in 
 24 cases it was more than three months. The average incubation 
 period is about six weeks, but the length is undoubtedly affected by 
 the seat and severitv of the wounds and the atre of the i)aticnt. It is 
 
438 BABIES; UYDBOPUOBIA ; LYSSA. 
 
 shorter, as a rule, wlicrc the wounds are on exposed parts and very ex- 
 tensive, and is shorter in children tlian in adults. As has been stated, 
 by the inoculation of rabbits with the spinal cord of others dead of 
 rabies Pasteur was able to reduce the incubation period to about seven 
 days, at M'hieh point it remained constant. This virus is known as " the 
 tixe(l virus (cinis fi.rt') of Pasteur." 
 
 Symptoms in Man. — The symjrtoms of rabies in man present a 
 general similarity to those manifested in rabid animals, although the 
 most striking symptom, that from which the disease in man has derived 
 its name, is peculiar to him. The disease has been commonly called 
 "hydrophobia" in man because during the furious stage violent spasms 
 of the muscles of the pharynx and the elevators of the larynx and 
 hyoid bone occur, which are associated with intense suffering. When 
 the disease is fully develojjed these paroxysms are often brought on not 
 only by attempts at swallowing, but even by the sight of water or food, 
 or, in fact, by any peripheral irritation. Thus the patient, although 
 often suffering intensely from thirst, is tilled with such terror by these 
 spasms that he cannot be induced to make any attemjit to take fluid. 
 
 The disease may be divided into three stages — the prodromal stage, 
 the stage of excitement, and the jiaralytic stnge. 
 
 Prodromal Stage. — In the prodromal stage symptoms may or may 
 not be present. In many cases in adults, where the person has been 
 bitten by a dog which is suspected of being rabid, there develojjs 
 gradually, as a result of aiiprehension and fear of the tlisease, intense 
 mental depression. The fear of the disease acts as a constant nightmare, 
 preventing sleep, disturbing all of the functions of the body, causing 
 the patient to relinquish his usual occupation and often to resort to 
 alcohol or narcotics to relieve the mental suffering caused by fear. In 
 some instances the })aticnt may become almost insane from terror even 
 when there is no good reason to believe the animal by which he was 
 bitten was rabid. In (ither cases the flepression dt)es not appear until 
 a few days before the apj)earance of the disease, and then the j)atient 
 becomes de]iressed and melancholy, or nervous, restless, sleepless, and 
 irritable. There may be pain in the scar of the original bite ; it may 
 become swollen, tender, and blue ; in some instances it is said that the scar 
 opens again and discharges a thin watery fluid, or a papular or vesicular 
 eruption appears round it. Occasionally there are severe shooting pains, 
 beginning in the scar and extending toward the trunk. The patient 
 carefully avoids mentioning the circumstances regarding the bite, makes 
 light of the symptoms, and searches for diversion away from home, or 
 it may be seeks solitude at lH>me. There may be even now some in- 
 crease in the sensibility of the special senses, light and sound ])roducing 
 discomfort, and the patient may complain of chilliness while the ther- 
 mometer shows an elevation of temperature of one or two degrees. After 
 a period varying from a few hours to six or eight days the symptoms 
 become more defined and the stage of excitement begins. 
 
 Stage of Excitement. — This may be considered as really the beginning 
 of the attack. The first svmptoms which arouse suspicion as to the 
 nature of the disease are usually some pain in the nuiscles of the throat 
 and stiffness or difliculty in swallowing. This difticulty in swallowing 
 rapidly increases, and soon any attempts at deglutition are followed by 
 
SYMPTOMS. 439 
 
 violent spasms of the muscles of the pharynx and hirvnx, and are 
 (ifteii associated with or followed by spasms of the respiratory muscles. 
 An iutense hypenesthesia now rapidly develojis, botii of the nerves of 
 special sense and of general sensibility ; the intensity of the muscular 
 spasms increases and the duration of the interval between them dimin- 
 ishes, while at the sauie tiuie they extend, iiivolvino- not only the nniscles 
 (if the pharynx, laryux, and respiration, Init, to a less degree, all <)f tlie 
 voluntary muscles of tlie body. At first these paroxysms are l)rougiit 
 on only by attempts to swallow, but later the sight of fluids or food, tiie 
 sound of running water, a ray of bright ligiit, a slight sound, touching 
 the stu-facc of the skin, or an i/ afferent impression may serve to excite the 
 ])ar(ixvsms. During tlie paroxysms the breathing is greatly embarrassed 
 and painful, and is interrupted by frequent short exjiiratory efforts ; tiiere 
 is great suffering and a sense of impending suffocation. The expression 
 of the face shows most intense anxiety and apprehension. The patient, 
 although suffering intensely from thirst, refuses to attempt to drink, or 
 wlicn the litpiid touches his lips draws back in terror because of the 
 recurrence of the spasms. Tiie spasms are of variable duration, lasting 
 from a few seconds to several minutes, and in rare instances death has 
 taken place during a paroxysm from aspiiyxia. The muscular contrac- 
 tions are of a tetanic character, although opistiiotonos does not occur. 
 
 At first the mind is unclouded, but later delirium is frequent, and 
 is especially marked during the paroxysms ; at such times " tlie patient 
 may make violent efforts to strike or injure tlie attendants about him, 
 and cries, howls, strikes or attempts to bite others or himself, until lie 
 sinks back exhausted, and remains quiet until aroused by anotlier par- 
 oxvsm." As a rule, the mind is clear in the interval between the par- 
 oxysms. There is a great increase in the secretion of saliva : it is thick 
 and tenacious, and, as the patient cannot swallow it, it drivels from the 
 mouth or he violently attempts to spit it out. The spasms of the mus- 
 cles of the throat and chest are often associated with the production of 
 a peculiar sound which the imaginative bystanders transform into a bark. 
 It is this that is described when the patient is said to " bark like a dog." 
 
 Pyrexia is, as a rule, moderate, although the temperature may go to 
 104° or 105° F. Vomiting is common, the matter rejected being usually 
 of a greenish-brown color. There may be incontinence of urine and 
 fieces. The urine often contains albumin in large quantity, and there 
 may be casts and blood. Sugar is occasionally present. 
 
 The mental delusions are frequently associatcil in a strange way with 
 animals, and especially dogs, and the mental excitement and fear are 
 stronglv increased bv the sight of a dog. In children the mental dis- 
 turbance is connnonly less marked, and it bears some relation apparently 
 to the dc]iression'and disturbance caused by the fear of the disease wliii'h 
 has preceded its advent. The stage fif excitement lasts a varying j)criod, 
 from a few hours to eight or ten days. As a rule, however, cases termi- 
 nate in four or five days. 
 
 l'(ir(di/flc Star/e. — A few hours before deatii the paroxysms become 
 less severe and occur at longer intervals. The ])atient may be able to 
 swallow and take I food without difficulty; tiie mind may again become 
 clear, but the pulse is rajiid and feeble, and the disease soon terminates 
 in death. Occasionally there is more or less complete paralysis, com- 
 
440 RABIES; UYnRorilOBIA ; LYSSA. 
 
 nienpiii^' in the muscles of the jaw and involving partially or completely 
 all the muscles of the body (paralytic rabies), and rarely coma occurs. 
 In a few cases, where persons have received very extensive bites from 
 wolves on exposed parts, the disease takes early the form of paralytic 
 rabies. This is also true in a few cases whei'e death has occurred after 
 inoculation according to Pasteur's method. In children the mental 
 symptoms are usually less pronounced, and the disease terminates earlier 
 in death. 
 
 Prognosis. — Where the symptoms of true rabies have once devel- 
 oped there is no reason to look for recovery, for, although tliere have 
 apparently been a few cases which have recovered without treatment or 
 under various modes of treatment, they are of such rare occurrence that 
 they give little reason for hope in any individual case. Nevertheless, 
 the various means of symptomatic treatment recommended should be 
 employed to relieve the severity of tiie paroxysms. 
 
 The percentage of eases in which rallies follows the bites of animals 
 shown to be rabid or supposed to be rabid is variously estimated — from 
 5 to 60 or 80 per cent. The bites of wolves are most virulent, and next 
 those of cats, foxes, and dogs, in order. Bites on exposed parts are far 
 more likelv to l:)e followed by the disease than those upon covered jiortions 
 of the body, and punctured or greatly lacerated wounds are apparently 
 the most dangerous. Horsley estimates the percentage of eases of hydro- 
 phobia following the bites of animals shown to be rabid as about 16. 
 Boul6, however, says that the proportion fixed by Hunter (5 per cent.) 
 approaches nearer the truth. Following bites by wolves the percentage 
 of cases is i\ir higher, varying apparently from 40 to 80 per cent, 
 of those l)itten. 
 
 Diagnosis. — Great suspicion has been thro\\n upon the diagnosis in 
 a large proportion of the cases of reported rabies, and much has been 
 written about lyssophobia or pseudo-hydrophobia, the residt of fear. 
 Numerous cases have been recorded in which patients apparently sufler- 
 ing from true rabies suddenly recovered when the animal by which they 
 were bitten appeared before them well or when they were convinced 
 in some other way of the absence of rabies in it. 
 
 In a well-marked case of rabies there should be no great difficulty 
 in making a diagnosis. No doubt a part of the difficulty usually ex- 
 perienced is due to the extreme rarity of the disease, few physicians in 
 this country having had the opjiortunity of seeing a single case. By 
 far the most characteristic symptom is the peculiar respiratory spasm 
 caused by attempts to swallow li(iuids, and where this is present increased 
 significance is given to it by the history of a recent bite. Tliere is rarely 
 some difficulty in differentiating rabies from tetanus and certain forms 
 of organic disease of the lirain and insanity, but in true rabies the occur-, 
 rence of the respiratory spasms with increasing intensity and frequency, 
 the intense hypera?sthesia, and the existence of great mental disturbance 
 — these symptoms followed j)erhaps l)y paralysis — make the diagnosis 
 clear. The absence after death of gross lesions sufficient to account for 
 the condition during life increases the ceitainty of the diagnosis. This 
 mav be absolutely confirmed by the inoculation of rabbits with the spinal 
 cord after the sul)dural method of Pasteur. 
 
 Pathological Anatomy. — There is a remarkable variation in the 
 
PATHOLOGICAL ANATOMl'. 441 
 
 post-mortem lesions found in different cases of rabies as it occurs in 
 animals. Not infrequently there are no macroscopical changes found 
 after death which are in any way characteristic, Init in those cases occur- 
 ring in dogs, which may be considered most tyi)ical, we find that the 
 mucus membrane of the mouth and fauces is greatly congested and 
 covei-ed by a thick, tenacious, mucous or muco-purulent secretion, often 
 mixed with dirt. The mucous membrane of the larynx, trachea, and 
 bronchi may also present similar appearances. The lungs are usually 
 congested, and there may be petechial liemorrhages into the pleura. 
 The heart and the large vessels arising from it are filled with dark 
 blood, completely fluid or containing only soft dark clots. The most 
 characteristic changes are found in the stomach. This is usually filled 
 with all sorts of foreign bodies if the animal has been free, or, if it has 
 been confined, with such as are within reach. In animals which have 
 been running loose, hay and straw, pieces of w"ood, coal, leather, })ortions 
 of cloths, stones, sand, earth, and ficces are indiscriminately mixed 
 together, and not infrequently similar contents are found in the small 
 intestines. The large intestine is often empty. The mucous membrane 
 of the stomach and of the small intestines, particularly of the stomach, 
 .shows clianges quite similar to those found in the throat and larynx, but 
 in a higlier degree. The mucous memlirane of the stomat-li is intensely 
 swollen, hvpeneiiiic, filled with extravasations of blood, and may be the 
 seat of nuiuerou-; ciosions. It is covered with a thick, tenacious mucus. 
 i'lic jiif; -linal nuicous membrane presents the same appearance in a less 
 (iegree. The kidneys are commonly swollen, of diminished consistence, 
 and show marked hy])era3mia. The bladder is emjity, or at most C(jntains 
 a small (piantity of cloudy, and it may be albuminous, urine ; occasion- 
 ally the urine contains blood. The mucous membrane of the Itladder 
 is also swollen, and sometimes shows petechial hemorrhages into its sub- 
 stance. In the central nervous system there are no characteristic changes 
 visible to the naked eye. As a rule, there is marked hyperemia of the 
 spinal cord and the medulla and their meninges, and occasionally minute 
 hemorrhages may be found in tiie floor of the fourth ventricle. The 
 brain and its meninges may also present the same appearances, but these 
 are not constant or eharacterlstie enouo-h to have great sionificance. Not 
 infrequently, especially in those cases which terminate rapidly, there may 
 be few or no lesions in any way characteristic. The stomach may be 
 empty, and at most the mucous membrane of the respiratory and alimen- 
 tary tracts aj)]3ears swollen and somewhat hy]iera?mic. The intestines 
 may contain no normal jn'oducts of stomach digestion, and the contents 
 show littl(> or no bile-staining. There may be nothing else abnormal 
 found in the thoracic or abdominal viscera. The brain and spinal cord 
 may present no changes. 
 
 In man the post-mortem changes apparent to the naked eye are 
 essentially those of an acute infectious disease, with possibly more 
 marked congestion of the mucous membrane of the alimentary and 
 respiratory tracts, and more marked hv]5er;emia of the lirain and spinal 
 cord and their meninges, than is usually present in other types of 
 infectious disease. It is, however, rather the absence of characteristic 
 changes M'hich is significant in post-mortems on suspicious cases than the 
 presence of any definite gross lesions. 
 
442 RABIES; HYDROPHOBIA; LYSSA. 
 
 The microscopical finding's in tlic spinal cord and medulla are more 
 characteristic, and assist in tlie diagnosis of doubtful cases. Sections 
 should lie made through the hulh or cervical division of the cord. In 
 these regions there is found microscopically marked hypersemia, with 
 perivascular foci of embryonic cell infiltration, and little nodules of em- 
 bryonic cells surrounding degenerated or proliferating nerve-cells. If 
 these nodules are not found, probably the case is not rallies; if found, 
 probably the case is rabies. The nodules arc less conspicuous in animals 
 killed in the first stages of rabies than in those which have succumbed to 
 the disease. 
 
 We ma}^ also find (1) hypenemia and acute (jedema of the meninges, 
 with small hemorrhages around some of the vessels; (2) proliferation of 
 the epithelium of the central cerebro-spinal canal, hemorrhages in the 
 gray matter, and obliteration or throndjosis of some of the small vessels 
 by a hyaline pigmented substance, by leucocytes, or by hyaline degenera- 
 tion ; (o) little foci of degeneration in the gray matter. These foci are 
 often visible to the naked eye. 
 
 The lesions of the nerve-cells in special regions are characteristic. 
 They consist in the signs of proliferation, and even in the presence of 
 several small cells in the pkjce of a large one, or in a uniform degenera- 
 tion. jMonomiclear, and rarely i)olynuclear, cells of lymphatic origin 
 invade the protoplasm of the cell and fill the pericellular lymphatic 
 spaces, dilating them to form nodes (Roux). 
 
 When a human l)eing has been l)ittcn by an animal which has been 
 afterward killed, it is advisable, if possilile, to make a diagnosis from the 
 autoj)sy and the microscopical examination of the medulla antl cord, so 
 that ])roper advice may be gi\'en regarding the necessity of treatment. 
 
 Prophylaxis. — The importance of prevention in any disease is pro- 
 portionate tx) its frequency and mortality, and while in hydrophobia, 
 because of its rarity in man, the prevention is seemingly of less import- 
 ance, yet, because of its almost universally fatal ending, pro})hylaxis 
 becomes of great moment. As there is positive proof that the disease 
 is the result only of infection, and, in the vast majority of cases, of 
 infection through the bite of a rabid animal, the prevention of hydro- 
 phobia in man resolves itself into the jirevention of rabies in animals ; 
 and experience has shown without question that the disease in animals — 
 in dogs — can be completely stani]ied out by the eificient enfn-cement of 
 laws rec[uiring the registration and muzzling of dogs. In Prussia the 
 disease has become practically extinct through such means ; in Holland 
 the same is true ; and, in flict, in every country, city, or district in which 
 laws requiring the muzzling and registering of dogs have been efficiently 
 enforced the disease has promptly and completely disappeared. 
 
 Treatment. — Preventive. — In 1885, after a long series of exper- 
 imental investigations on animals, Pasteur announced the discovery of 
 a method for the jirevention of rabies in those who had been bitten by 
 rabid dogs, and in July of that year he first apjilied the treatment to a 
 human being in the case of a boy named Joseph jNIeister. 
 
 The Pasteur system of treatment dejiends upon the following obser- 
 vations : (1) the rabic virus is especially present in the medulla and 
 spinal cord of animals dead of rallies; (2) by the successive subdural 
 inoculation of rabbits with an enudsion prepared from the spinal cord 
 
TREATMENT. 443 
 
 of an animal dead of rabies the incubation period is gradually shortened 
 until it tinally becomes fixed at seven or eight days ; (3) spinal cords 
 removed from animals that have died after such inoculations, if dried in 
 sterilized jars over potash at a temperature of about 73° F., gradually 
 lose their virulence, and at the end of fourteen days are innocuous when 
 used for the inoculation of animals or men ; (4) if an animal or man is 
 inoculated on succeeding days with the spinal cords which have been 
 dried for successively sliorter periods, the individuals are gradually 
 rendered insusceptil)lc to tiie more virulent cords l)y tliosc of less viru- 
 lence which were previously used ; (5) if these inoculations are made 
 after an individual has been bitten by a rabid dog, protection may be 
 still conferred in the majority of instances, providing too much time has 
 not elapsed between the bite and the beginning of the inoculations. 
 
 The fornuda for the treatment t)f ordinary l)ites (not those about the 
 head) is given below : 
 
 1st day, cord of 
 
 12 
 
 I 14 diivs in dose of 3 cm. of emulsion. 
 I 1.3 "■ 
 
 2d " " Wi 
 
 3d •' 
 
 4th 
 
 5tli 
 
 6tli 
 
 7 th 
 
 8th 
 
 9th 
 
 10th 
 
 11th 
 
 12th 
 
 13th 
 
 14th 
 
 15th 
 
 (10 
 1 9 
 
 ( S 
 
 1 ' ' 
 ( 6 " 
 
 
 2 cm. 
 
 l 6 " 
 
 
 " 
 
 5 " 
 
 
 u 
 
 5 " 
 
 
 u 
 
 4- " 
 
 
 " 
 
 3 " 
 
 
 1 cm. 
 
 5 " 
 
 
 2 cm. 
 
 5 " 
 
 
 " 
 
 4 " 
 
 
 « 
 
 4 " 
 
 
 (( 
 
 3 " 
 
 
 " 
 
 3 " 
 
 
 u 
 
 For bites about the head and face a somewhat intensified method is 
 emj>loyed. 
 
 From 1886 to 1891, inclusive, nearly 10,000 persons were inoculated 
 in the Pasteur Institute, with the result as shown below : 
 
 Year. 
 
 Persons treated. 
 
 Deaths. 
 
 Percentage of mortality. 
 
 1886 
 
 2671 
 
 25 
 
 .94 
 
 1887 
 
 1770 
 
 13 
 
 .73 
 
 1888 
 
 1622 
 
 9 
 
 .55 
 
 1889 
 
 1830 
 
 7 
 
 .39 
 
 1890 
 
 1550 
 
 5 
 
 .32 
 
 1891 
 
 1559 
 
 4 
 
 .25 
 
 In these statistics, in the later years the deaths have been excluded when 
 they occurred within fifteen days of the la.st inoculation, as it was then 
 assumed that the virus intniduccd by the bite was acting on the central 
 nervous system before imnumity had been conferred by the inoculations. 
 There were five cases of this kind in tlic year 1891, which have been 
 excluded from these statistit-s. 
 
 The cases treated have been divided into three classes : (a) persons 
 bitten by dogs in which the existence of rabies was proved by inf)eula- 
 
444 RABIES; IIYDROPnOBTA ; LYSSA. 
 
 tion or by the sul)s('([utMit iiccurrciicc of" raljics in iinotlicr aniiiuil ; (b) 
 persons bitten by animals in whicli the existence ot" rabies was confirmed 
 by a veterinary surgeon ; (c) persons bitten by animals suspected of having 
 rabies. Roux refers to 710 cases treated in Class a, where the bites were 
 on exposed parts about the head, in which only 24 died — a mortality of 
 3. .38 per cent. He declares that the mortality in this class of cases with- 
 out treatment would be about SO per cent. It is particularly in those 
 cases in wliich the bites are upon exposed parts that the mortality is 
 greatest. 
 
 Whether we accept as final oi- not the statistics of the Pasteur Insti- 
 tute as t( > the efficiency of the treatment, yet it may lie safely concluded from 
 the results of the Pasteur inoculations that tiicre is comjtarativclv little 
 danger from the inoculation itself, and that the mortality in ])ersons 
 after treatment bitten In' dogs knoMn or suspected to be rabid is far 
 lower than it has ever been before. 
 
 Treatment of Bites. — In the immediate treatment of bites from ani- 
 mals supposed to be rabid the main object is the elimination of the 
 poison. If the \vound is in an extremity, where the circulation can be 
 controlled, a ligature should be immediately applied, bleeding promoted, 
 the ])art thoroughly soaked in an antiseptic solution, or, if it is a punc- 
 tured wound, the wound sucked and the mouth afterward repeatedly 
 washed out with a disinfecting solution ; intermittent squeezing and 
 wringing of the ]iart while it is soaked in warm water is an excellent 
 method for jiromoting bleeding and eliminating the poison. The 
 M'ound may be o|)ened to its depth and cauterized witii actual cautery 
 or with mineral acids or nitrate of silver, or the wound may be excised. 
 Tlie more quickly and completely the poison is eliminated after the bite, 
 the less is the danger from the bite. However, there is good reason to 
 believe that even if the treatment of the wound is not begun until some 
 hours after the wound was inflicted, yet a considerable measure of pro- 
 tection may l)e thus granted, for it seems probable that the poison may 
 be localized for a considerable period at the point of its introduction ; 
 hence in any case where it is thought possible that the wound was 
 inflicted by a rabid animal it should be thoroughly washed and cauter- 
 ized even if a considerable period has elapseil since the injury. 
 
 Therapeutic. Treatment. — During the incubation period the psychical 
 treatment is of special importance. Great care should be taken to dis- 
 tract the patient's attention from the subject of the bite, and nothing 
 should be said or done which directs attention to it. The other meas- 
 ures during the ])criod of incubation pertain simjily to general hygiene. 
 After symptoms have appeared there is little reason to anticipate anything 
 but a fatal rcsidt, and the treatment should lie purely symptomatic, and 
 consist in the use of spinal and cerebral sedatives and antisjiasmodics. 
 
 Some observations have recently been reported — jiartieularly by 
 Chantemesse, Tizzoni, Centanni, and Babes — M'hich offer bright hof)e 
 in the early future of the perfection of a specific means of treatment 
 of hydrophobia through the use of an antitoxine separated from the 
 blood of animals which have been rendered artificially imnume to 
 rabies. The observations thus far made, however, arc as yet too incom- 
 plete to render the measures available for the practical treatment of 
 hydrophobia. 
 
GUNSHOT WOUNDS. 
 
 By p. S. CONNER, M. D. 
 
 No class of injuries has more occuijicd tlie attention of surgeons and 
 surgical writers than tliose jjroduced l)y gunshot, and from the study 
 of no other class has greater benefit accrued to the art of surgery in 
 general. But the great changes that in very recent times have been 
 made in weapons, in missiles, and, especially, in the treatment of all 
 wounds, necessitates reconsideration of not a few questions connected 
 with the nature, tiie care, and the results of these wounds ; respecting 
 which mucli that has been written is now of historic rather than 
 practical value. 
 
 As met with in civil life, gunshot wounds are commonly produced 
 by pistol halls or small siiot ; in military service, by rifle bullets, by 
 large solid shot or shell, or by balls tin-own out from case or canister 
 shot. A small proportion of the injuries are caused by caps, by por- 
 tions of a gun whicli has burst, or by a splinter of wood or a piece of 
 stone or metal set in motion by impact of a shot. 
 
 Missiles. 
 
 Small shot vary greatly in size and weigiit, the extremes being " fine 
 dust," the particles of which weigh less than 2^,5- gr. each, and buckshot 
 of .44 in. diameter and 153 grs. weight. Pistol balls also are of various 
 shapes, sizes, and weights, ranging from a calibre of .22 to .45 of an 
 inch, and a weight of from 25 to 250 grs., all more or less conical, made 
 
 Country. 
 
 Austria . 
 Belgium . 
 Denmark 
 England . 
 France 
 
 Type. 
 
 Mannlicher . . 
 Mauser .... 
 Krag-Jorgensen 
 Lee-Metford . . 
 Lebel 
 
 Berlhier .... 
 Germany iMannlicher . . 
 
 Italy jCarcano . . 
 
 Japan Murata 
 
 Portugal Kropatschek . . 
 
 Russia Mouzin . . 
 
 Spain Mauser 
 
 Switzerland Sclimidt .... 
 
 United States, new . Krag-Jorgensen 
 United States, old . . Springlield . . . 
 
 .315 
 
 .301 
 .315 
 .303 
 .315 
 
 .301 
 .311 
 
 .256 
 .315 
 .315 
 .300 
 .295 
 .295 
 .300 
 .450 
 
 .244 
 .217 
 .235 
 .215 
 .231 
 
 .231 
 .227 
 
 .155 
 .238 
 .245 
 .211 
 .245 
 .211 
 .220 
 .500 
 
 to 2 
 
 c5 to 
 
 42 
 38 
 34 
 30 
 43 
 
 43 
 42 
 
 32 
 .S6 
 
 35 (bl 
 35 
 38 
 
 aek) 
 
 70 (black) 
 
 Bullet-covering. 
 
 Steel 
 
 'German silver 
 
 Copper 
 
 Nickel and copper .... 
 
 Mailleohort (alloy of cop- 
 per, nickel, and zinc) . 
 
 Mnillrchort 
 
 strcl {plated with aUoy of 
 cnp]n.-r :ind nickel) . . 
 
 Muilk'chort 
 
 Copper 
 
 Copper 
 
 Mailleehort 
 
 Maillechort 
 
 Copper or steel 
 
 German silver 
 
 1968 
 1980 
 1950 
 2000 
 
 2073 
 2971 
 
 2034 
 2329 
 1857 
 1984 
 2000 
 2285 
 1969 
 2000 
 1300 
 
 445 
 
446 
 
 GUNSHOT WOUNDS. 
 
 a 
 
 ^^ 
 
 
 o" lO oi 
 
 00 
 
 
 
 .5 bt' 5 p, 
 
 a III 
 
 
 Qj a; oj ?- 
 
 (-< (H ^ 
 
 £.'S£a> 
 iC oo ^> 
 
 :> .-'(NM 
 
 M4 ^ 
 
 either of .soft lead or of lead hardened l\y admixture of tin from 1 to 
 40 to 1 to 20 parts. Until recently army bullets were of large size, 
 those employed in our late war varying in calibre from .50 to .71 of an 
 
MISSILES. 447 
 
 incli, and in weight from 400 to 760 grs., and even to-day the service 
 bullet of our army has a diameter of .45 in. and a weight of 500 grs. 
 Yerv soon, however, in common with other nations, we will have a 
 iitandard ritle of small calibre and a l)ullet of tlie modern type, long, 
 slender, cvlin<lro-ogival, of calibre of about .30 in. ]\Iadc of hardened 
 lead (lead and antimony), the new bullet is covered witli a thin jacket 
 of steel, coi)j)er, nickel, or au alloy of these metals, with or without zinc 
 addition.' To further reduce its weight, it has been proposed to tunnel 
 it from end to end, making of it a sort of punch. The weight of the 
 bullet issued to the Euroj)ean armies varies from 155 to 245 grs., and 
 its lengtli from ■^ to 4 calibres. That the desired momentum may be 
 had, lessened weight is compensated for by increased velocity, 'iOOO feet 
 or over per second (2971 feet with the Berthier carbine of the French), 
 instead of 1300, as is the case when black powder and the Springfield 
 rifle are used. Because of its swiftness of fligiit and the increased rota- 
 tion due to the changed rifling of the piece, tlie trajectory of one of 
 these bullets is very flat, its range very long, and its penetrating ])ower 
 very great." It is little likely to be deformed, and, especially when 
 steel-mantled, any deformity produced is usually but a slight flattening 
 of the apex. It almost never breaks up, and sjilitting or stripping ofl' 
 of the jacket in part or whole is rare ; particularly so when of steel, 
 copper vielding much more readily. Boring rather than crushing, in 
 vcrv exceptional cases lodging, and then t>nly when near the end of 
 a long flight or after having previously encountered much resistance, 
 these new bullets may be expected to produce lesions in many respects 
 different from tho.se met with heretofore. Experimentally, much has 
 been determined, and the limited experience that has been had in recent 
 wars in Africa, South America, and Asia conflrms the results of the 
 experiments made by European and American surgeons' upon animals 
 and human cadavers. 
 
 Gexerai. Consider.\tions. — With few exceptions, gunshot wounds 
 are of the lacerated and contused order. According to direction and 
 momentum, the shot may graze or bruise the surface of the body, may 
 enter and lodge, or pass through and out — in other words, contuse, pen- 
 etrate, or perforate. In proportion as tlie bullets have been made harder 
 and their velocity increased the likelihood of their lodging in the body 
 has been lessened, so tiiat even in the pistol wounds of civil life perfora- 
 tion is of frequent occurrence, or the bullet is often found to be lodged just 
 under the skin, the elasticity of which has prevented its passing through. 
 
 Leaving out of consideration the injuries inflicted within tlie " zone 
 of explosive action " and aft'ecting bone, tliat witli few exccjitions have 
 up to the present time been only experiiiK'ntaliy produced, and in wliich 
 the exit wounds are 6f very large size, the old-time great difference in the 
 size of the wounds of entrance and exit no longer exists, even when the 
 ball has passed through bone. The diameter of each wound is aliout 
 that of the Itullet ; it may be a little smaller, it may be a little larger. 
 
 ' See table at font of pajje 445. 
 
 - The degree of (jenetratian as rompared with that of the old bullet is shown by the 
 accompanving figure (Fig. 14 1, taken from Asst. Snrg. La Garde's report to the Surgeon- 
 General of our army. 
 
 " Delorme, Chavasse, Chauvel, Nimier, Koclier, Bruns, Busch, Keger, Morosow, 
 Tauber, Pawlow, Ilabart, Horslev, La Garde, and uthere. 
 
448 
 
 G VNSHO T WO UNDS. 
 
 The skill about tlu' wotiiid of entrance is often somewhat depressed, about 
 the wound of exit everted. Both wounds may appear as if made with a 
 punch ; that of exit is very often stellate, ti-iangular, or even linear. A 
 narrow dark-colored ring surrounds the opening, especially that of entrance, 
 due not to the heat of tlie shot, but to the extravasation of blood from 
 vessels of the superticial fascia, which because of its lessened elasticity is 
 somewhat stripped off tlie skin. As far liack as the time of Pare and 
 Maggius it was demonstrated that the shot was not hot enough to ignite 
 gunpowder in sacks into which it had been fired, and could not thei'efore 
 burn the edges of a wound. W^hen the wound has been inflicted at very 
 close range powder-staining of tlie parts has been often observed; with 
 the use of metallic cartridges and the improvements in powder manufac- 
 ture, securing more tiioroiigli combustion, such staining is becoming less 
 and less frequent. The distance at which the marking may occur is by 
 no means absolutely determined (as reported, varying between 2 and 10 
 feet), and cannot be definitely stated because of the variations in the 
 quality of powder used. In some experiments made by Professors Frost 
 and JJartlett of the I)artmoutli jMedical College three years ago with 
 Winchester-rifle cartridges cal. .44, fii'ed from a revolver, it was found 
 that at 3 feet distance heavy wrapping paper was " perforated with clean 
 
 Fig. 15. 
 
 ;Miiltipk' shot-wounds of anas nnd Imck. The opcMiinp <ivit the spine was produced by pressure, 
 not by the bull. (Ciise in Cincinnati Huspitul, ISM.) 
 
 sharp angular holes in great number. These holes, though less in num- 
 ber at the circumference, extended H feet from the bullet-hole or covered 
 a circle 3 feet in diameter, the bullet-hole being in the centre." 
 
MISSILES. 
 
 449 
 
 At times the course of the bullet carries it in and out and in and out, 
 giving rise to two, four, six, or more wounds (see Fig. 15), or, if lodge- 
 ment finally takes place, three, five, etc. 
 
 Occasionally it may Ijecome a question A\hcther two existing wounds 
 
 are those of entrance and exit of a single ball or of entrance of t\vo 
 
 balls, but the answer will likely be found in the position of the openings 
 
 relative to the line of fire. At times, because of splitting of the bullet,' 
 
 Fig. 16. Fig. 17. 
 
 % 
 
 E.xtfi'iur view (A. M. M., Sect. 1, Spec. 2121). Interior view. 
 
 there may be two wounds of exit — a condition which is much less likely 
 of occurrence now tiian formerly, since the pistol ball is so often of 
 hardened lead, and the mantled riHc bullet will maintain its integrity no 
 matter what it strikes in the biidy. 
 
 In its passage through any tissue the shot commonly destroys out- 
 right tiiat which is in front of it, and to a variable distance devitalizes 
 that which surrounds its track. The greater the elasticity of the tissue, 
 the less the direct destruction ; e. r/. the skin may be only split, or the 
 cranium may be pierced anil yet but a crack be observed, or even this 
 not be discovered. The gross anatomical structure of the part may 
 greatly limit the destructive action of the bullet, as in a muscle longi- 
 tudinally traversed, in which the track may be traced with great difficulty 
 or not at all. The area of devitalization varies with the tissue, the size, 
 shape, and velocity of the l)all, and the period of flight in which impact 
 occurs. Stated in a general way, it is decidedly less than in former 
 times, the bullets being smaller, less deformed, and having a quicker, 
 steadier flight. In the experiments that have been made it has been 
 noticed that in the early and late portions of their flight — /. e. within 
 300 to 500 yards and beyond 1800 or 2000 yards — the new army bullets 
 destroy as nmch as, or more than, the Imllets jn-eviously used, but in the 
 intermediate distances the damage done is markedly less. In ]>art, at 
 least, an explanation of the observed differences maybe found in the lat- 
 eral swing of the ball before its axial rotation is thorouglily established 
 and after its velocity becomes greatly diminished, as in the early and late 
 wabbling of a top, which spins steadily during the middle period of its 
 rotation. So great is the destruction effected in the shorter ranges that 
 these latter constitute a "zone of explosive action," tlie middle distances 
 belonging to the " zone of penetration," beyond which, near the end 
 of the missile's flight, is the "zone of contusion." The most inten.se 
 explosive action is seen in wounds of tissues rich in fluid contained 
 
 ' As illustrating the splitting of a bullet, Figs. 16 and 17 are given of specimen in the 
 Array Medical Museum at Washington. 
 Vol. I.— 2S) 
 
450 GUNSHOT WOUXDS. 
 
 within comparatively iinyieklin^ walls, as in lesions of the brain, though 
 saeh hydrostatic — or, better, hydrodyiianiie — pressure may be strongly 
 exerted ujjou the solid viscera of the abdomen, and even upon the hollow 
 viscera wlien full (if fluid or semi-fluid contents. 
 
 The course of the ball may be expected to be direct. Deflection of 
 the new army bullet will probably never occur, and as the pistol ball is 
 made harder and the (juality of the powder improved, it will become 
 more and more rare to find in civil life a change in the line of direction. 
 Even with tiie soft-lead conical ball such change is not very likely to 
 happen, and in many cases in which it has l)een believed to occur the 
 course has been a straight one, the body as it was struck having been 
 put into such position as to give an appearance of deflection. 
 
 Much less frequently than before will blood-vessels in the track of 
 the bullet escape injury ; but the smaller .size of the missile and the 
 diminished cross-section of the ai'ea of devitalization must lessen the 
 number of vessels damaged. Nerve-trunks are more likely to be 
 uninjured than the vessels. 
 
 As a rule having comparatively few exceptions, the damage done by 
 a bullet is produced in its passage, and when it lias come to a state of 
 rest it commonly ceases to do harm, at least wlien the lodgement is in 
 the soft parts. Though when so located it sometimes changes position 
 because of weight and muscular action, it ordinarily does not, but quickly 
 becomes encapsulated and fixeil. In one of the softer viscera, especially 
 the brain, it may produce serious pressure-symptoms either where pri- 
 mai'ilv ])laced or in some more de])endent position to which it has in 
 time gravitated ; resting against the wall of a hollow viscus, it may 
 afterward by ulceration reach its interior. 
 
 That lodgement has occurred may be inferred with almost absolute 
 certainty when there is present a wound of entrance only. The old- 
 time round ball, even of considerable size, sometimes carried in a piece 
 of clothing, in which it rested as a finger in a glove, and with the with- 
 drawal of such pocket the shot was pulled out ; but the bullet of to-day 
 is excessi\ely unlikely to behave in such manner. In a few cases on 
 rectnxl the shot has passed out of a natural opening, as in other cases it 
 has entered through such. 
 
 Determination of the position of a bullet may be made by palpation 
 of the injured area or of the surface toward which tlie shot was tending, 
 bv digital exploration of the wound, by jjrobing, and by the use of an 
 electrical apparatus. Very often the desired information will be gained 
 by palpation, and in the wounds of the external soft parts met with in 
 civil life a bullet that cannot be thus located had better be let alone 
 rather than sought for instrumentally. "When the track of the ball is large 
 enough to permit of the use of the finger, this best of instruments should 
 be employed, as by it can be well ascertained the nature and extent of 
 the damage done. By it alone can the ]iresence of pieces of clothing 
 be determined. Enlargement with the knife of the wound of entrance 
 and of the track, of which in the jKist there have been many strong 
 advocates, is certainly not required in cases of pistol-ball injury, and 
 with the new military rifle the wounds in very large proportion will be 
 those of perforation, not penetration. If in any given case there is good 
 reason for believing that a piece (not shreds) of clothing has been carried 
 
MISSILES. 
 
 451 
 
 in with the l)all, careful search for it slioiild he made with the fin<>'er, 
 with or without enhirgement of the wouikI according to circumstances. 
 By no probing with a metallic instrument can the presence of cloth be 
 ■determined, and if left in place it is certain to be a source of infection. 
 Fortunately, the modern conical bullet with its great velocity compara- 
 tively rarely carries in with it this septic complicating foreign Ixxly. 
 
 If a probe is to be nsetl, it should be bulbous-ended and of a diam- 
 eter but little less than that of the bullet, is best made of aluminum, 
 because of the lightness of this metal, and never should be employed 
 without precedent thorough cleansing. Under no circumstances should 
 a gunshot woun<l be touclied with unclean finger or unclean probe ; far 
 better that it sliould liave nA treatment at all. The ])orcelain-tij)ped 
 probe with which Xclaton's name is so commonly associated, that rubbed 
 against the bullet takes a lead stain, has often proved of value, but not in- 
 frequently has failed of accomplishing its purpose, either the surface of 
 the bullet not being exposed or the pressure upon it not suificiently great. 
 
 Of electrical devices to determine the presence and place of a ball, 
 not a few have been ])resented to tlie surgical world, some indicating the 
 presence of the missile by deflection of a galvanometer, others l)y sound. 
 Of these latter the best is the telephonic probe of Girdner. Its employ- 
 ment does not necessitate the use of any battery, as the operating current 
 
 Fig. is. 
 
 Girdner's telephonic probe ready for use. 
 
 is taken directly from the body of the patient. Tlic instrument, which 
 consists of receiver, wires, bidb, and ])robe, is thus described by Dr. 
 Girdner.' Fig. 1(S rejiresents the instrument ready for use. 
 
 ' To eacli of the binding posts of the receiver attach one end of each of the con- 
 ducting wires, O, O. To tlie free end of one of these wires attach the bulb, C, to the 
 
452 GUNSHOT WOUNDS. 
 
 When the aluniiiium probe is passed into the wound no current is 
 obtained wliile it touches the flesh, because it is the same metal as the 
 bulb in the mouth, but so soon as this probe touches the leaden bullet 
 tlie circuit is completed, a current passes, and the fact is announced liy 
 a loud clickinu; in the receiver at the ear. If the probe used was of 
 any other metal than the bulb in the mouth, the current would be estab- 
 lisiietl as soon as it touched the flesii in passinij into the track of the 
 bullet. Hence it becomes an axiom that the bulb in the mouth and the 
 probe at the end of the other wire must be of tlie same metal and differ- 
 ent from the metal sought for. If this condition is kept in view, any 
 metal, as silver, copper, etc., may l)e used for the bull) and jtrobe. 
 
 " The shafts of the probes are insulated by being enclosed in a fine 
 rubber tube which can be I'emoved for cleansing and replaced. This, 
 was found necessary because the end of the probe might fail to touch 
 the bullet, and the shaft touch it some way back from the point, and 
 thus deceive the surgeon as to the exact dcjith of the missile. It also 
 sometimes happens, where tlie bullet has entered tlie cranial cavity, that 
 a piece of the lead is torn off and lodged just within the external wound, 
 while the main portion has jienetrated deeper. In such a case, if the 
 shaft were not insulated, all efforts to locate the main body of the missile 
 would be frustrated l)y the continual responses caused by the shaft of 
 the probe coming in contact with the sliver of lead lying on the side 
 of the track made by the l)ullet. 
 
 " When the telephonic bullet probe is used, there is never any ques- 
 tion whether a hard substance felt in a wound is bone or Indlet" 
 (Girdner). '\\'^hcn the former is touched, nothing is heard " but a 
 
 free end of tlie otlier attach the probe-hantlle, and in the sUit of the hancUe place the 
 probe, or needle, you wish to use; be certain all binding posts are tightly screwed and 
 electi-ical contact perfect at each joint, and the instrnmcnt is ready for use. 
 
 Place the bulb, (', in the patient's mouth — ('. c. between the teeth and the cheek in 
 the buccal cavity — taking care tliat the ninisturc in the mouth makes a perfect electrical 
 contact between bulb and cheek ; the o)ierator holds the receiver to his ear with one hand, 
 as when listening in a speaking telephone, while with the other hand he passes the probe, 
 P, into the wound in search of the bullet. Nothing will be heard until tlie probe tonches- 
 the bullet, when there will be heard a distinct rasping, grating, or clicking sound in the 
 receiver, and you know certainly that the probe has located the missile. The lighter the 
 contact of the probe with the bullet, the louder the sound heard; continuous contact of 
 probe with bullet ])roduees a contimioun current, and hence no sound in the receiver; the 
 •inlerriipird current, produced by making and breaking the contact when the probe is 
 gently passed over the little irregularities on the surface of the bullet, is what ]uoduces- 
 the sound in the receiver at the ear. 
 
 It is well to experiment with the instrnnient before using it in actual practice, and 
 for that purpose place the bulb in the buccal cavity of an assistant, and after tlioruiic/hly 
 nvttiiifi one of his hands place in that hanil a piece of lead large enough to enalile him to 
 grasp itfirndy ; then the operator places the receiver to bis ear and probes the lead in the 
 assistant's hand by gently passing the probe over it, and he will find no sound produced 
 in the receiver wlien the finger-nails or flesh of the hand is touched, Ijut the slightest 
 touch of the probe to the lead causes a grating sound. The hand holding the lead must 
 be Lrpt wer or the instrument will not work. 
 
 Ry ex]ierimenting in ibis way the ear becomes trained, so that there is no trouble in 
 determining the presence or .aliseuee of a bullet in a wound probed. There is liotli a 
 steel and an alumimim bulb in the case, and also aluminum probes and steel needles; 
 when an aluminum probe is used, the aluminum bulb must be used on the other wire, 
 but the steel bulb mu.st be used if it is desired to use the needles. The needles are to he 
 thrust through the tissues in searching for the bullet when its course has been so tortuous 
 that it cannot be followed by the probe, or in cases of old gunshot wounds when the mis- 
 sile is still in the tissues and the track made by the bullet has healed. 
 
jMISSILES. 453 
 
 characteristic clicking or grating when lead is touched and gently 
 rubbed. This sound, once heard, is never forgotten " (Girdner). 
 
 Tliough this and other electric appliances have at times been found 
 of service, their use has been too limited to indicate their real value. 
 As it would seem at present, only exceptionally are they likely to be 
 employed. 
 
 Its position having been determined, whether or not the bullet should 
 be extracted \\ill depend upon how much damage will j)robaI)ly be done 
 in searcliing for and n-moving it, and the projxtrtioii of such danger 
 relative to that consequent uptm leaving the ball in place. It may be 
 taken out either through the track of the wound or through a counter- 
 opening, according as the one or the other is most convenient and least 
 harmful, l)ut under no circumstances should the bullet be cut for unless 
 its position lias been positively determined. 
 
 If cut down upon, care must be taken to hx it tirmly while the 
 incision is being made, and that it may be readily removed it must be 
 thoroughly exposed. Its extraction may be effected by the use of a 
 special bullet-forceps (of which that which is long, slender, its blades 
 toothed, and one of them preferably fenestrated and having two short 
 teeth (U. S. Army pattern), will lie found most generally servicealile), 
 or it may be caught by any firm-bladed forceps ; not seldom an ordinary 
 hiiemostatic or seciuestrum forceps will prove effective. In the military 
 practice of the future the removal of bullets will doubtless be of ex- 
 ceedingly infrequent occurrence, as only very rarely will the momentum 
 of the shot be so reduced as to permit of lodgement. 
 
 The impression has long prevailed that gunsluit wounds do not bleed, 
 nor do they, at least those of the soft parts, but exceptionally as they 
 come under care. At the time of the injury hemorrhage does occur, 
 and aside from those shot through the head the majority of the wounded 
 who sj)eedily die do so from loss of blood. But unless a large trunk 
 has been opened the bleeding quickly subsides, natural hremostasis tak- 
 ing place, and even if it is a large vessel the hemorrliage mav not cause 
 early death. During our late war cases were under treatment in liospital 
 in which upon autopsy it was found that the vertebral, carotid, sub- 
 clavian, axillary, and common iliac arteries, and the internal jugular, 
 internal iliac, and femoral veins, had been opened. There has come 
 under personal observation a case of pistol-shot division of the super- 
 ficial and deep femoral arteries and the superficial femoral vein, in 
 which dentil did not occur for ten hours, and one of the left subclavian 
 artery in wiiich it was delayed vuitil the eleventh day. Severe or fatal 
 primary hemorrhage may he expected to be more common in wounds 
 made by the new bullet than it used to be, though it may prove other- 
 wise, since there will be none of the extensive tearing that was often 
 produced by the irregular, deformed, jagged soft-lead ball. Secondary 
 hemorrhage, that formerly was so common and so fatal, will \)v infre- 
 quent in ]n-oportion as an aseptic condition of the wound is secured and 
 maintained. 
 
 The jiain accompanying a gunshot wound is very variable in amount, 
 according to the velocity of the ball, the part injured, and the sensibility 
 of the individual, natural or for the time being. Occasionally acute, it 
 is more generally dull and tingling, the part often feeling as if it luul 
 
454 GUNSHOT WOUNDS. 
 
 been struek with a stick. Under lii^^h excitement no pain may be 
 experienced tor a time, even thoiifih tlie injury is a severe one. 
 
 Siiock, like pain, is ordinarily experienced by one who has been sliot, 
 and is commonly most mai'ked in those whose wounds are of the brain 
 or spinal cord or of parts intimately connected with the solar plexus. It 
 varies in amount from that which is very slight to that which is quickly 
 destructive of life. Its symptoms are often blended with those of col- 
 lapse ; indeed, in the majority of cases the nervous distuii)auces are 
 largely secondary to the primary disturliance of the circulation. As 
 respects diagnosis and prognosis, the most important of these svnij)toms 
 is a lowering of the body-heat. After careful observation of fifty cases 
 during the siege of Paris, Redard declared that " a fall of temperature is 
 a constant phenomenon. Every wounded man brought to field hospital 
 presenting a temjierature lower than .j5.5° C (about 96° F.) will suc- 
 cumb, and conse(|Ueiitly it is useless in such eases to resort to any opera- 
 tion. Every wounded man in whom a salutary reaction does not come 
 on by the end of the fourth hour, and in whom the reaction is not in 
 direct proportion to the fall (of temperature previously), ought to be 
 considered as in a verv serious state. Penetrating' wounds of the alidomen 
 produce an exceptionally low fall of temperature, which is more marked 
 as the stomach is apj)roached. M'ounds by shell, other tilings being 
 ecpial, produce a more marked fall of temjterature than those by ball." 
 
 The ultimate result of a gunshot wound depends upon the size and 
 velocity of the vulnerating body, the parts injured, and the early and 
 after treatment I'cceived. Its fatality is consequent upon shock, hemor- 
 rhage, and septic infection ; the first two being the causes of death 
 occurring quickly, the last that of the great majority, certainly more than 
 two-thirds, of the cases coming under professional care. Due regard to 
 this fact must be had in studying the mortality-rate of any given wound, 
 the statistics that have been accumulated being in large measure those 
 of army practice, of cases not treated aseptically or treated so only in a 
 very limited degree. Recovery from pistol-shot injury is of far more 
 likely occurrence than from a wound made by a service bullet, old or 
 new, the lesion being not so great and the case ordinarily coming under 
 care more speedily. 
 
 Shock and primary hemorrhage may be expected to be as great or 
 greater in the wars of the future, in which use will be made of the small- 
 calibre bullet, as in those of the past ; but the death-rate of cases coming 
 under treatment will l)e very greatly reduced if tiie wouiuled can be 
 protected from erysipelas, septicaemia, gangrene, and tetanus, all these 
 lieing infective diseases the causes of which, and the means of prevent- 
 ing which, have in large measure been ascertained only in the last few 
 years and since the time of any great war. 
 
 The organisms causing the infection of a shot wouml may lie introduced 
 on the bullet, carried in on a jiiece of clotli or other foreign body, be 
 present in the blood extravasated into the damaged area, or introduced 
 upon finger or instrument employed in exploration and treatment. 
 
 Rarely will the bullet be the carrier of infection, but the carefully- 
 conducted experiments of La Garde and Messncr show that pathogenic 
 organisms are not necessarily destroyed by the heat of the firing — a heat 
 which V. Beck has proved to be much less than is common!)' supposed, 
 
MISSILES. 455 
 
 the temperature of the recovered titeel-jacketed cal. .30 shot being but 
 78° C, and of the copper-jacketed one 110° C. v. Coler and Schjer- 
 ning have found tliat in passing tin-ougli ])orti<)ns of the human body the 
 temperature of a projectile only in excejitional cases exceeds 95° C. 
 
 Infection through the medium of a jtieee of clothing may be expected 
 to occur as often as sucii piece is carried in ; but the pointed, small-calibre, 
 swift-moving bullet will leave it in the track much less frequently than 
 did the old-time ball. If this is the only infection of the wound, the 
 ett'ect mav be but a slight one, and that readily overcome, and if the l)it 
 of cloth is not removed or spontaneously extruded, it may be encapsulated 
 and thus rendered harmless. 
 
 Germ-laden blood will without doubt be occasionally poured out of 
 the torn vessels to poison the wound-area, but practically this source of 
 infection may be disregarded. In wounds of the intestines a constantly 
 present and potent cause of sepsis is to be found in the contents of the 
 canal. 
 
 Bv far the most common and most important media of infection are 
 the hands and finders of the surtreon and dresser and the instruments 
 that are introduced into the wound. There was certainly much truth in 
 Nussbaum's declaration that the fate of a woinided man is in the hands 
 of the surgeon who first attends him. In civil practice infection of 
 srunshot lesions other tiian abdominal is in verv lartre measure due to 
 uncleanly examinations and dressings. It is to abstention from active 
 interference with the wound, either altogether or until it could be done 
 aseptically, and to rigid antiseptic after-treatment, that M'e are to attrib- 
 ute the generally successful result that has of late years been had in 
 the non-visceral wounds treated in the hospitals of our country, and the 
 nnich less fatality of wounds of the head, the chest, and the abdomen. 
 How far it may be possible in war to prevent septic infection by pri- 
 mary dressings and later care experience only will determine. The con- 
 ditions under which the wound is received, the length of time that often 
 must elapse before any assistance can be rendered, the movings that 
 must be made, the hurried dressings that not seldom must be applied — 
 all the unfavorable conditions of field practice — will combine to limit, it 
 may be in high degree, the asejiticity that can be secured. On board 
 ship much l)etter opportunity will be afforded to carry out in detail the 
 modern woinid-treatment. 
 
 Wounds produced by large shot or large fragments of exploded 
 shells as they come under observation are usually very extensively lace- 
 rated, even uj) to complete or nearly complete carrying away of the 
 part struck. At times, as has already been stated, the skin may re- 
 main apparently intact though widespread pulpification of nuiscle and 
 great comminution oT bone have taken place. The momentum of even 
 the nearly "spent shot" is sufficient to produce very serious injnrv, and 
 soldiers have long recognized the danger there is in attempting to stop 
 the progress of a round shot slowly rolling on the ground. Occasion- 
 ally balls or fragments of several pounds' weight have lodged in the 
 body, even escaping early detection. The only question of interest that 
 is likely to jiresent itself in relation to these severe injuries is whether 
 or not prompt removal of the ])art shall be done or an attempt made at 
 conservation. When amputation is decided upon, it must be borne in 
 
456 GUNSHOT WOUNDS. 
 
 mind tliat tlie muscle-lesion at least is not limited to the ]iart struck ; 
 consec|uently the operation nuist be done at a level well ahove tliat of 
 the wound. In civil practice extensive injury is often ])r<)duced by a 
 charge of " small shot " at short range acting as a single ball or scatter- 
 ing but little. If the main vessels or nerves of the region are not 
 involved in the destruction, conservative treatment may frecpu'iitly be 
 successfully adopted, though ani])utation or (if tliere is shattering of a 
 joint) cxsection, complete or partial, will often be required. In the 
 " small-shot " wounds at a distance of more than a few feet conserva- 
 tism should be the rule, the lodged shot being removed or left accord- 
 ing as their extraction is easy or otherwise. In a limited number of 
 cases serious injury is done by these small missiles, as in tlie eye, the 
 larynx, or the antcro-lateral regions of the neck. 
 
 Treatment. — The two most important elements of the treatment in 
 general of these wounds are the prevention of infection and the secur- 
 ing of rest. Bullets may or may not liave to be sought for, bone-frag- 
 ments may or may not have to be removed, torn vessels may or may not 
 have to be tied, but, that promjit repair may take place, everv gunshot 
 wound must be made and kept aseptic or so antisc[)tical]y treated that 
 suppuration will occur in but a limited degree; and by immobilization, 
 so far as it may be practicable to establish it, the damaged area must be 
 kept quiet. In the majority of pistol M'ounds, other than those neces- 
 sarily mortal, when they are treated in the ordinary aseptic and antisep- 
 tic way tlie prognosis is good and repair may be cx])cctcd to take jilace 
 prom])tly. The wounds made l)y the new Ijidlct will witimut doul)t be 
 found to heal nuich more quickly than those produce<l l>y the oltl large- 
 calibred, soft-lead bullet. As a rule, the closing of the track com- 
 mences in its central portion and proceeds thence toward the wounds 
 of entrance and of exit, the former commonly healing last of all. Such 
 closure, especially in lesions of the soft jiarts, may and frecjuently does 
 occur without suppuration ; more often the jius-formation is slight, and 
 chiefly in and near the entrance wound, and this even tliough bone has 
 been damaged. It is the recognition of these facts that is leading sur- 
 geons more and more to treat at least pistol-ball injuries in the most 
 simple manner, actively interfering with the wounds only when pain, 
 heat, and swelling make it evident that foreign bodies are to be re- 
 moved or free drainage secured. When, in consequence of small-shot 
 injury of an extremity inflicted at very short range, or of a rifle-ball 
 laceration within the zone of explosive action, or of a crush by a large 
 shot or a large fragment of shell, a limb is very extensively mangled, 
 amputation will generally be required, or, but less often, an exseetion. 
 It will, however, doulitless be found that such operations will be much 
 less frequently demanded in the future tiian they were in former times, 
 just as it is now with cases of extensive compound fractures due to 
 traumatisms other than gunshot. 
 
 The primary effects of a gunshot wound (shock, pain, and hem- 
 orrhage) are to be treated in the ordinary way. As has already been 
 stated, bleeding in any considerable amount is not of frequent occur- 
 rence in the generality of flesh wounds, though a moderate degree of 
 oozing during some hours, or even days, may lie expected. Bone wounds 
 are attended with a greater loss of blood, but, as commonly met with 
 
EFFECTS UPON THE VARIOUS TISSUES 457 
 
 in civil life, the iu'iiiorriiage in connection witli them does not necessi- 
 tate any special treatment. In the lesions of tlie liead, chest, and abdo- 
 men serions hemorrhage very often is present, and, as we siiall see iiere- 
 aftcr, in many cases demands prompt operative interference ; and the 
 same is trne of wonnds of the neck, tiie axilla, and the groin. W'liere 
 vessels of larger size, arteries or veins, have been torn, recourse must 
 be had to either compres.sion or ligation. Compression often answers 
 a good purpose when jmiperly and methodically a[)])lied, more so in 
 cases of vein-wounds tlian in those of arteries, but wlien tlie l>Iecding 
 is at all ])rofuse tlie wounded vessel should be freely exposed and tied 
 above and below the point of injury. Chemical styptics — e.g. tiie per- 
 salts of iron — should never be employed : again and again they have 
 proved inefficient and their use productive only of evil. If cold (or, 
 much better, h(it) water does not stop the bleeding, compression or the 
 ligature siiould l)e applied. In a few of tiie cases in which the main 
 artery and vein of a limb have been sinudtaneonsly lacerated am[)utation 
 may have t(j be performed to prevent the occurrence of gangrene of tiie 
 extremity. 
 
 Secondary hemorrhage when it takes place (and it may occur at a 
 very late day) will ordinarily necessitate ligation of the vessel — in the 
 wound if possible ; if not, well above the level of injury — thougli at 
 times com])ressiou has proved of service, or even the laying open of the 
 wounded part. Wiiether or not ligation should be done when tiie vessel 
 is not bleeding has long been a question. There may be no recurrence 
 of the hemorrhage, and the disturbance of the wound necessary to the 
 tying can only increase the gravity of the situation ; on the other hand, 
 if ligation is not done, a later l)leeding may occur — fatal it may be, cer- 
 tainly adding to tlie existing danger. As a general rule, the wisest 
 course is not to ojierate after a first bleeding, but to do so always after a 
 second. There is every reason to believe that in the military practice 
 of the future secondary hemorrhage will be much less frequent than 
 heretofore, due as it is to suppurations and septic processes that can be 
 largely prevented by antiseptic treatment. In civil practice secondary 
 bleeding is of very infrequent occurrence. 
 
 Effects upon the Various Tissues. 
 
 Skin. — According to the velocity of the bullet and the angle at which 
 it strikes, the skin may be merely grazed, strongly contused, or jicne- 
 trated. In the former case there will be developed an erythema which 
 will soon subside, or a superficial devitalization mav be efil'ctcd, causing the 
 formation of a thin dry slough, the separation of which will be followed 
 by slight scarring. 'When the contusion has been more severe, without 
 material injuiy to the parts beneath, under antiseptic treatment the slough 
 (which may include the entire thickness of the derm) will still be dry, 
 and when its se]iaration takes place it will be found tiiat there has l)een 
 healing under the crust. In rare instances the elasticity of the skin will 
 prevent its laceration, although the tissues beneath are extensivelv crushed, 
 as has been observed in certain cases when the part has been brushed by 
 a large shot or massive piece of shell in full flight or struck by such when 
 nearly spent. Not seldom when the ball ])asses for quite a distance just 
 
458 GUNSHOT WOUNDS. 
 
 iin<l(>r tho skin its trnok will he marked hv a deeji diseoloration of the 
 iiiteti'iiineiit, and the at'ter-sejiaratidn of the slough will leave a depressed 
 guttered wound, and later a eicatrix. 
 
 Fascia. — The formerly often-observed deflection of a ball by a layer 
 of firm deep fascia very rarely occurs when the wound is j)roduced by a 
 pistol shot of to-day, and can never do so when the missile is one of the 
 new army bullets. The fascial fibres being in considerable measure 
 separated rather than torn, some closing in of the openings through the 
 layers may be expected, which may render ])robing more difficult and 
 drainage less free and complete. It is not likely that surgeons of the 
 future will see, other than very exceptionally, permanent openings with 
 rounded edges in the outer layer of the deep fascia, through which hernial 
 protrusion of muscle can occur— openings tliat were frequently the result 
 of wounds made by round balls and the earlier-employed large conical 
 bullets. 
 
 Muscles. — As made by bullets, except within the zone of explosive 
 action — and there is no such zone with reference to jiistol shots — muscle- 
 wounds are not attended with any extensive destruction of tissue, and the 
 associated blood-extravasations arc not large. When the shot jiasses in 
 the line of the muscular filircs there may often lie separation rather than 
 destruction, rendering it very difficult, it may be impossible, to follow the 
 track. Passing transversely, though the laceration may be quite great, 
 there is very seldom a complete severing of the muscle. ^Mien struck 
 by large shot or a large piece of an exploded shell widespread destruction 
 is effected, with resulting great loss of substance and the after-formation 
 of an extensive and deep scar. Tendons are more often severed, but as 
 a rule a piece is cut out or a perforation made. At times the impact of 
 the shot causes a rupture of the muscular belly above, the tendon itself 
 being only contused. Whether or not the tendon will often be pushed 
 out of the way by the new bullet, and thus escape injury, remains to be 
 seen. 
 
 Blood-vessels. — Arteries and veins in the track of the modern bul- 
 let, pistol or rifle, especially the latter, will rarely if ever be uninjured. 
 As before, they may be completely or partially divided or may be con- 
 tused, with liability to the later occurrence of hemorrhage or the formation 
 of an aneurism. Associated perforation of both artery and vein may be 
 followed l)y the development of an arterio-veuous aneurism. 
 
 Nerves. — Contrary to what was formerly true, nerve-trunks are less 
 likely to l)e damaged than the larger blood-vessels. When in tho path 
 of the ball they generally, however, are torn or contused, with resulting 
 impairment or entire loss of motion or sensation ; pain of greater or less 
 severity and continuance, at times burning (causa/c/ia) ; trophic changes ; 
 or absolute destruction of the vitality of the parts to which they are 
 distributed. 
 
 Boxes and Joixts. — Among the more serious lesions met with in 
 military practice are wounds of bones and joints, which constitute about 
 one-fifth to one-fourth of all the injuries coming under care. In civil 
 life the proportionate number is much smaller and their gravity is as a 
 rule nmch less, caused as they generally are by bullets of less weight 
 and, still more, less velocity. 
 
 A bone injured may be either contused or fractured according to the 
 
EFFECTS UPON THE BONES. 459 
 
 angle at which it is struck, and, especially, the momentum of the bullet. 
 Contusions jn'oduced by pistol balls, more often of course those of small 
 calibre, are frequently of sucli sliu'ht severity (mere jarrings) that their 
 existence is unsuspected or thought probaljle only because the missile, 
 flattened out it may be, is found resting against the bone. More often, 
 the blow being stronger, some subperiosteal extravasati(.)n occurs, and in 
 a limited number of cases the impact of the shot is sufficient to destroy 
 vitality, the necrosed, later separated, piece of bone varying nuich in 
 tiiickness. 
 
 Musket-liall contusions, which were formerly not uuconunon, and 
 were often followed by local and general septic infection, will in all prob- 
 ability be almost or quite unknown in the future, the new rifle bullet 
 fracturing, not bruising, any bono that it may strike. Antiscptically 
 treated, the bone-contusions may be expected to lie rapitlly recov- 
 ered from without either permanent thickening or persistent neuralgia 
 resulting. 
 
 Fractures are of various kinds, according to the force and angle of 
 impact, the character of the bone struck, and in the long bones the part 
 injured, whether in the shaft or near the extremity. Whatever they may 
 be, they are, in general, due to contact or penetration, the former being 
 mediate or immediate, the result of a tangential or a direct blow ; the 
 latter partial or complete, tiie Ijall entering and remaining, or passing 
 entirely through to lodge in the soft parts or emerge tiu'ough the skin. 
 The simplest form of contact-injury is a mere crack, of greater or less 
 length, curving oftentimes at its extremities — a lesion of little moment, 
 very frequently overlooked, and recognizable with great difficulty except 
 upon actual inspection. Percussion, by developing the " cracked-jiot " 
 sound, lias at times been of diagnostic value, and it may be that evidence 
 of importance may be affi)rded by the pain in a limited area, which has 
 been shown to be produced by the passage of a galvanic current tin-ough 
 a broken bone. 
 
 As an exaggeration of this linear fracture there may be a fissure, the 
 edges of the crack separating somewhat, in a superficial lione ])ermitting 
 of recognition of the gap upon palpation. When such fractures are pro- 
 duced by direct strolce, the missile must have in large measure lost its 
 momentum. Rarely, but probably more often than has been sup])osed, 
 the crack or fissure may extend transversely or obliquely through the 
 entire thickness of the bone, causing the simplest form of a complete 
 fracture, and in a few cases such sej)aration has been found to have 
 occurred not in the area directly injured, but at a level considerablv above 
 or below. Because of tiie al)sence of nniscular traction upon them, or 
 of an incomplete tearing of the periosteum over them, the fragments may 
 remain in apposition,' to be perhaps later separated by movements of the 
 part or by muscular contractions after the untorn periosteal bands have 
 softened. These contact-fractures, which, as has already been stated, 
 will often be overlooked, require no special treatment. If protected from 
 infectiiiu and the injured area is innnobilized, rapid repair will take 
 place. 
 
 It is by penetration that the great majority of fractures are produced, 
 the essential character of the injury being a driving in of the part of the 
 bone struck, with or without associated fissures passing out in various 
 
460 
 
 GUNSHOT ]VOUi\I)S. 
 
 directions and to varyinjj distances (Figs. 19, 20, 21, 22, 23, and 24 
 are from tiie report of ^Vsst. yurg. La Garde, U. S. A., Report of the 
 tiuiycon-Geiierat of the Army, l&Vo). 
 
 Fig. 19. 
 
 Gunshot injury by the ."30-calibre German silver Jaclteted projectile, possessed with the velocity 
 
 usual at 2000 yards. 
 
 Flu. iO. 
 
 Posterior view. 
 
 The central depression may be lint sliglit, even absent altogether ■\vhcn 
 examination i.s made, having been overcome by the elasticity of the osse- 
 ous tissue, or the piece of bone may be forced in (to the medullary cavity, 
 for example, in a long bone, or %vithin the cranium in a skull-injury), 
 or it may be completely pulverized and its dust driven out of the body 
 or scattered along the track of the ball, the differences in the condition 
 of the ])iece directly struck — and they are very wide — depending upon 
 the shape, size, and hardness of the bullet and its velocity. The iissures 
 passing out from the centre of violence are also very variable in num- 
 ber and extent, ranging from a scarcely perceptible crack to a complete 
 breaking up of the bone. When the fracture is in the shaft of a long 
 bone the characteristic fissuring, as Dclorme has .shown, is that of an 
 elongati'd x (Figs. 25 and 26), the four primary parts of which may be 
 secondai'ily .split into a few or many pieces. Sometimes the .sj)lintering 
 extends into or through the epiphysis ; occasionally it ends abruptly 
 
EFFECTS UPON THE BOXES. 
 
 4(J1 
 
 above and below in an ahno.-;t transverse break, tlie intervenins;' portion 
 of the shaft being spHt up into many completely separated wedge-shaped 
 
 Fig. 21. 
 
 Injury liy the ,"30-calibre German silver jacketed projectile, with the velocity common at 1200 
 yarfis. The oritice of entrance has a puuched-out appearance eiiual iu diameter to that of the 
 projectile. 
 
 Fig. 22. 
 
 Posterior view : fissures are exaggerated by drying. 
 
 fragments, sneh condition being consequent upon an injury at siiort range. 
 It has long been recognized that the number and size of the fragments 
 
 Fig. 23. 
 
 Injury liy the ."30-calibre German silver jacketed projectile, with the velocity common at 1200 
 
 yards. 
 
 Fig. 24. 
 
 Posterior view. 
 
 are in inverse proportion to the velocity of the missile. The sequestra 
 may be entirely detached or partially adherent — /. c primary or .second- 
 
462 
 
 G UNSiio T war tnds. 
 
 arv. Ill ])ist()l-shot wounds few of them are likely to be found free, and 
 tiiese ordinarily small, and in the wounds made by the new bullet in the 
 middle ranges the fragments are mueh more largely adherent than they 
 were in the wounds formerly observed. Very fre(|ut'ntly ])istol balls 
 have foree enough only to fraeture the bone or to ])enetrate its substance 
 for a short distance. 
 
 When tlie wound is located in the epiphysis or in tiie juxta-ejiiphvs- 
 eal area, and the injury has not been inilicted at short range, splinter- 
 ing is nuich less than when it is in the shaft of the bone, a clean pcrfor- 
 
 FiG. 25. 
 
 Gunshot injurv of the right femur at junction of miihlle and upper thirds by the ."30-ealibre German 
 silver jaclc'eted projectile, with the velocity common at awo yards (Asst. Surg. La Garde, V. S. 
 A., loci cit.). 
 
 Fig. 26. 
 
 Posterior view. 
 
 ation with little or no associated fissuring being often observed (Figs. 
 27 and 28). 
 
 Almost or <|uite as clean a jierforation may occur at .some dis- 
 tance above the articulating e.xtrcmity, as illustrated by Figs. 29 
 and 30. 
 
 As in the case of wounds of the diaphysis, the ball may remain 
 external to the bone, lodge in it, or pass thn)Ugh it, but, because of the 
 lessened resistance of the cancellous tissue, is more likely to ])erforate, 
 making a comparatively clean canal, with an outlet wound commonly a 
 little larger than the bullet. 
 
 AVounds of the irregular bones much resemble those of the sj)ongy 
 extremities of the long bones, but because of their small size these bones 
 may be expected to be largely sjilintored, without, however, in many 
 cases, much sepai-ation of the fragments. 
 
 The flat bones may be extensively shattered or perforated, as is much 
 
EFFECTS UPON THE BOXES. 
 
 4(;3 
 
 more often the case now than in former times. The perforation will 
 commonly be found to be somewhat eunical, its edge on the side of exit 
 being more or less bevelled at the expense of the outer layers. Such 
 perforation may or may not be associated with fissures running for a 
 variable distance into the bone. 
 
 Ever since the adoption of the conical bullet military surgeons have 
 observed that there is a marked difterence in the damage done to bone 
 according to the range. The destruction produced by a shot at compar- 
 
 FiG. 27 
 
 Perforation bv the ."30-calibre German silver iaclceteti projectile, with the velocity common at 1200 
 yards. The diameter of the traeli of the bullet in the bone corresponds to the diameter of the 
 missile (Asst. Surg. La Garde, U. S. A., loc. cit.). 
 
 Fig. 28. 
 
 Posterior view. 
 
 atively .short distance is so enormous that it seems as if the bullet nnist 
 have been an explosive one, and within such distance has been placed 
 the "zone of explosive action." With the old liullet it extended to 200 
 to 250 yards, sometimes a little more ; with the new it is increased 
 to 350, 400, or even 500 yards. As La Garde (Asst. Surg. U. S. A.) 
 has stated it : " There are no special features, as a rule, to describe about 
 the wounds of entrance, except the appearance at times of bony .sand in 
 the tract leading to a fractured bone. When a resistant bone has been 
 hit, the foyer of fracture will show great loss of substance : the bone 
 
464 
 
 GUNSHOT WOUNDS. 
 
 will have been driven n(it only in the direction in whieh the projectile 
 ■was travelling, but in all directions, and the pulpifieation of the soft 
 parts will not be limited only to the track of the bullet, but the utter 
 destruction is noticed some distance into the tissue. The wound of exit 
 
 Fig. 29. 
 
 Injury Ijy the ."30-calibre German silver jacketed projectile with the velocity common at 120O 
 yards. The fissure occurred in drying ; it was not present in the recent state lAsst. Surg. La 
 Garde, U. S. A., loc. cit.). 
 
 Fig. 30. 
 
 Posterior view. 
 
 appears like a bursting forth of the skin ; the track leading to the bone 
 is conical in shape, the base of the cone corresiionding to the wound of 
 exit in the skin, and the apex to the seat of fracture." 
 
EFFECTS UPOX THE BOXES. 
 
 465 
 
 In certain cases the exit wound has been found to have a length of 
 four, six, or even more inches, and a width of three or four, and occa- 
 sionally honc-fra<inu'nts driven out have jjierccd tiie shin at j)oints out- 
 side of the main laceration. No very marked ditferenccs have been found 
 to exist between the destructive effects of the old and the new missiles, 
 though doubtless those of the latter are somewhat less. In the woimds 
 produced l)y pistol ixdls no explosive action takes jilace, tlieir momentum 
 not being sutticiently great. Perhaj)s in small measure due to the sway- 
 ing of the ball, the axial rotation of whicli has not become fully settled, 
 practically the immense destruction effected within the zone of explosive 
 action is due to hydraulic pressure, and is pro])ortionate to the fluidity 
 of the tis.sue struck. At distances outside the zone of explosive action, 
 anil up to a range of 1200 to 1500 — it may be even 2000 — yards, bone- 
 wounds made by the now bullet are of least severity ; and it is in this 
 "middle distance" that there occur clean ])erforations or perf\)rations 
 with the formation of a few though large fragments, and these chiefly, 
 it may be almost wholly, adherent. Beyond a distance of 1500 or 2000 
 yards connninution and disj)lacemcnt of fragments again become greater, 
 
 Fig. 31. 
 
 Complete perforation in the upper part of the shaft of the left tibia by the ."30-calibre German 
 silver jaekete'l projectile, with the veloeitv common at V2W yards. There is also an injury in 
 the mi'idic of the shaft by a ."3n-calil>ru prcpjectile at the same range. The bullet struck the 
 crest "f the tibia, passing wholly in fmni of the medullary canal, guttering the crest. There 
 is a complete fracture (..\sst. Surg. La Oarde, U. S. A., loc. cit). 
 
 Fig. 32. 
 
 Posterior view. 
 
 the result doubtless of the wabbling of the sliot ; and such smashing of 
 the bone continues up to the extreme range of fracturing. 
 
 When it is a ridge or crest of bone that is .struck, or the ball crosses 
 a curved surface tangent ially, guttering is often produced (Figs. 31 and 
 32), the notch or furrow being at times quite clean cut, at times as.so- 
 ciated with fl.ssurings. A ball im|)inging upon a ridge or ercst may be 
 split into two pieces of nearly iMpuil or very unequal size, either entirely 
 
 Vol. I.— .'iO 
 
466 GUNSHOT WOUNDS. 
 
 separated or held togctlier at tlic haso. Similar splitting is occasionally 
 found when it is the convex surltiee of the skull that has been struck. 
 The hardened lead pistol ball is niueli less likely to be affected in this 
 way than is the soft lead one, and sncii splitting will not occur, or only 
 exceedingly seldom, wlien the missile is a jacketed rifle ball. 
 
 Tiiat fracture by jK'uetration lias occurred may or may not be easy 
 of determination. A\'hen crepitus is recognized, deformity is present, 
 preternatural mobility exists, and the functional integrity of the limb 
 is lost (in other words, when there are the ordinary symptoms of frac- 
 ture), there can be no question respecting the diagnosis, particularly so 
 if in addition there are bonc-fragmcnts or bone-dust in the track of the 
 ball and the exit wound is of large size. Thi' bone-fragments, if found 
 at all, will be between the bone and the outlet wound, except in inju- 
 ries within the explosive zone, when at times small fragments are also 
 carried back toward the orifice of entrance. As a general rule, a length 
 of exit wound exceeding an inch indicates that there has lieen bone- 
 injury ; and, as Delorme has shown, a fairly safe conclusion as to 
 whether or not sucli injury has lieen received may be drawn from inspec- 
 tion of the exit hole in the clothing, whicii is very generally larger in 
 cases of fracture than in those of wounds of the soft parts only. But 
 small size of perforation-wounds by no means indicates absence of bone- 
 lesion or its limited extent.' Occasionally, in the absence of other 
 signs, ]>erforation is made certain by the presence of evidences of injury 
 of a viscus wiiicli could only have been reached after the ball iiad jiassed 
 through the overlying bone. 
 
 When the symptoms mentioned are wanting and the lesion is rendered 
 likely only because of the direction of the shot, it will often be the 
 wiser course to be content with the establishment of a jirobable diag- 
 nosis, since in the effort to secure certainty the l)onc-iiijurv may be 
 much aggravated and the after condition of the patient made much 
 worse. 
 
 The primary treatment must of course vary with the extent of bone- 
 injury. \\^hen this is but slight, thorough cleansing of the external 
 wound, and, as far as it may be practicaldc, of the track, being effected, 
 the part, if the lesion is in an extremity, siiould be innnobilized. If 
 more severe, comjjletely detached fragments should be removed if they 
 
 ' In illustration of the truth of this statement niav be qnoted a recent report of an 
 experimental case observed l)y Lt.-Col. Stevenson of the British army, }irofessor of 
 military surgery at Netley. The tiring was done at a 50 yards' range. "The bullet 
 passed through the ankle-joint, entering the astragalus behind, above the surface for 
 articulation witli the os calcis, and passed out in front through the neck of the bone. 
 The skin-wounds were very small, that of entrance being a little less in diameter than 
 the bidlet, and that of exit a little smaller than the former. On dissection it was found 
 that the bullet had passed through tlie astragalus about half an inch beneath the artic- 
 ulating surface for the tibia. All the astragalus except its head was pulverized, and all 
 its articulating surfaces s]ilit except that for the scajihoid. The lower end of the tibia 
 was fissured in many directions, and to a certain extent pulverized, although the bullet 
 had not actually touched any part of this bone. The cause of this condition of the 
 tibia was evidently the bursting apart of the astragalus while firmly held by the grasp 
 of the two malleoli. The attachment of the external malleolus of the fibula to the outer 
 surface of the tibia did not give way, and the internal malleolus was not fractured; thus 
 'it was that when the bullet passed through the astragalus, greatly distending that portion 
 of the bone held between the malleoli, the articulating surface of the tibia was sjilit and 
 the lower end of the bone extensively fissured." 
 
EFFECTS UPON THE BOXES. 467 
 
 can readily be gotten at, the canal drained, the limb imniobilizetl, and 
 antiseptic treatment maintained nntil healing takes place. Fragments 
 which are adherent should be left in })lacc, after having been as much 
 as possil)le ])ressed intd position if found to be decidedly tilted off from 
 the normal line of the bone. Not infrequently a sequestrum which is 
 ajjparently entirely separated is really fastened at one extremity by peri- 
 osteal bands, and its removal can be accomplished only with difficulty 
 and with resulting increase of damage to the bone. When so fastened 
 it should be treated as an adherent fragment, since if sepsis is prevented 
 its vitality will probably be preserved, and if not it i-ui be extracted 
 later. Until recently the general rule has been to remove an impacted 
 ball, wound-infection being almost certain to occur, and, if the foreign 
 body was left, necrosis of greater or less extent of the bone was quite 
 sure to follow ; and now, if the missile can be located and readily taken 
 awav, such removal should be made. But if, as is so generally the case 
 in pistol-shot injuries in civil life, to find and remove the bullet necessi- 
 tates doing much damage to the parts, it had better be left undisturbed. 
 If protected from wound-infection the injured urea will generally do 
 W'cll, whether the missile is left or is taken away. When the shot has 
 gone through and out and the crushing has not been very great, as it 
 will not be except at short range, the same general principles t)f treat- 
 ment must govern the conduct of the surgeon — removal of se])a rated 
 fragments (and, as has already been stated, they will be found between 
 the bone and the wound of exit), antiseptic cleansing, and dressing and 
 immobilization of the part. When there has been great destruction (as 
 from a rifle ball within the explosive zone, a load of shot from a gun 
 but a few feet away, a large shot, or a shell fragment), whether or not 
 the liml) can be siived will depend upon the extent of comminution and 
 the amount of injury done the soft parts. Gunshot fractures, so far as 
 treatment is concerned, do not differ materially from other compound 
 fractures, and if it is possible to employ the same methods of cleansing 
 and dressing, similar good results may be expected. In military ]>ractice, 
 from the necessities of the situation, thorough and rigid antise])tic treat- 
 ment cannot be applied otiier than exceptionally, but from the limited 
 experience of the hist twenty years it may be reasonaldy hoped that 
 much can be done to lessen the old-time mortality of bone-injuries. In 
 civil life amputation will be required only when the limb has been 
 extensively shattered, and not even then in many cases unless there is 
 an associated laceration of the main vessels or nerves. But on the field, 
 removal of the limb is called for not only when there has been great 
 shattering of bone with or without extensive laceration of the soft parts 
 and injiuy of vessels and nerves, or when a portion of the extremity 
 has been completely devitalized or has been carried away, but also in less 
 severe cases because of the unhealthy surroundings of the soldier, the 
 existing necessity of transporting him long distances, and the limited 
 attention that it may be possible to afterward give him. Neither in 
 civil nor in military practice should anq>utation be done when there is 
 a reasonable probability of sjiving a tolerably useful limb, even though 
 such limb be deformed or the source of some, it may be considerable, 
 discomfort. Often has it hap))ened to surgeons in our country in tiie 
 last thirty years U> see amjmtation stumps that were painful, frequently 
 
468 GUNSHOT WOUNDS. 
 
 iilconiting', and of little fuiictidnal value. Formal cxsections in the 
 shafts of the long hones, operations " in continuity," should not be 
 done, more of the bone l^eing taken away and the end results being less 
 satisfactory than when there has been an informal removal of non- 
 adherent sequestra. 
 
 Later in the progress of the case, as in ordinary comjionnd fractures, 
 removal of the limb may have to be made because of infective processes 
 in the part, sujipurations, osteomyelitis acute or chronic, or gangrene. 
 Even under the most rigid antiseptic treatment compression-gangrene 
 necessitating amputation may occur. 
 
 Joint-wounds. 
 
 These are either extra- or intra-articular, and, like those of bone, are 
 of greatly varying degrees of intensity. The several joints vary much 
 in liability to injury according to their anatomical position and their 
 exposure to traumatism. As generally stated, in order of frequency are 
 found lesions of the shoulder, knee, elbow, wrist, ankle, hip, though in 
 our late war the wounds of both knee and elbow were more numerous 
 than those of the shoulder. 
 
 Extra-articular injuries might well be considered simply as wounds 
 of the soft parts, were it not for the fact that at times, either because of 
 injudicious examinations or more often of extension of septic inflamma- 
 tion, the synovial membrane is ojiened and the joint involved. A seton 
 wound may be present, or a eonsideralile extent of the coverings of the 
 articulation may be carried away or later destroyed by gangrene. 
 Tendon-sheaths are often opened with or without injury of the tendons, 
 and sometimes because of such openings there is so much discharge of 
 synovia-like fluid as to lead to the erroneous diagnosis of actual jienetra- 
 tion of the joint. The old-time round ball occasionally ran around the 
 joint through a large arc, and some have believed that it is not impos- 
 sible for the conical iiall to take a similar curved course : the probabili- 
 ties are, however, that in the cases in which such wounds have seemed 
 to exist the ball really passed sti'aight from entrance to exit, })iercing the 
 joint-cavity, but speedy closure of the middle part of the track occurred 
 and the joint-lesion gave rise to no wcll-detinod symptoms. 
 
 Intra-articular wounds may be due to the direct entrance of the ball 
 from without or througli one of the bones of the joint, to primary 
 laceration of the synovial membrane in connection with a bone-fissure 
 or later opening by ulceration, or to crushing of the parts by a large 
 shot or a shell fragment. As a rule having few exceptions, a bullet 
 passing through the joint damages one or both of the bones entering 
 into its composition, fissuring, canalizing, grooving, or notching it or 
 them. In the knee it may traverse the u]iper pouches of the synovial 
 membrane M'ithout causing osseous lesion, or if the leg is somewhat 
 flexed upon the thigh (at an angle of from 150° to 170°), it may pass 
 from side to side below the patella without impinging upon either femur 
 or tibia. 
 
 That a joint has been injured may be readily determined when there 
 has been extensive Iacerati()n ; when upon palpation much comminution 
 is found to exist ; when great fulness of the synovial cavity is rapidly 
 
JOINT- WO rXDS. 469 
 
 developed, showing: that tlicre has been a large extravasation of blood 
 into the joint ; when there is free diseliarge of mingled blood and 
 synovia from the wound of entrance or of exit or from both ; or when 
 bone-dust or fragments are found in the exit wound. But when none of 
 these symptoms are present the diagnosis must rest upon impairment 
 of funetioii, ujion escape of synovia, and upon the position of the wounds 
 of entrance and exit with reference to the articulation. Inability to use 
 the limb has little or no signiticance, as it may be an<l often is associated 
 with an extra-articular injury. Escape of synovia in limited amount 
 may be from an opened tendon-sheath. Of much greater value is the 
 direction of the line joining the wounds, for it may be very confidently 
 assumed that when tiiis line leads through the joint a conical ball, pistol 
 or rifle, has gone througii tlie articulation. In the knee and elliow, less 
 often at tiie ankle, by digital pressure crepitus and yiekiiug of fragments 
 may frequently be detected. The appearance of the wound gives no sure 
 indication of the condition of tiie parts within. As has been truly said, 
 "that which more than everything else characterizes these injuries is the 
 insignificant lesion of tiie fibrous and cutaneous envelopes, concealing 
 damage, often very considerable, of the cutis of the bones." Probing 
 in doubtful cases should not be resorted to, for it may open a previously 
 intact capsule. Accuracy of diagnosis is not necessary in such cases, the 
 wound being regarded as an articular one and treated accordingly in a 
 conservative way. When the bullet has passed through the epiphysis the 
 splintering is likely to be confined to it; when tiu'ough the juxta- 
 epipiiyseal area it will jirobably affect botli the eiiiphysis and the lower 
 part of the iliaphysis. The tissuring at times is both radiating and 
 circular. The ex|)erimeuts made with tiie new bullet show tiiat in the 
 middle ranges canalization with little or no splintering will often be pro- 
 duced, especially in those articular extremities that contain much cancel- 
 lous tissue. Commonly the sefpiestra are few and but little displaced. 
 M'itiiin tile zone of explosive action great destruction is effected. In a 
 limited number of cases there are complicating lesions of large vessels 
 or nerves, as also at times of tiie chest and abdomen, in injuries of the 
 shoulder and hip. 
 
 The prognosis in these joint-wounds lias always been grave, even in 
 the accidents of civil life. The average mortality of the cases tabulated 
 by Longmore was 32. 2o per cent., and of tiiose occurring during our late 
 war 33.58 per cent., and as respects the various articulations ranged 
 from 12.9 |)er cent, in wounds of the wrist to 85 per cent, in those of the 
 hip. But these are the death-rates of cases not protected by the treat- 
 ment of to-day agiiinst the septic infections, and to such infections from 
 three-quarters to nine-tenths of the mortality has been due. It cannot 
 but be tiiat in future wars, however defective the wound-dressings uiav 
 be because of the conditions necessarily associated with field service, there 
 will be a saving of a much increased ])roportion of those shot througii 
 the articulations. In civil practice the proliabilities of recovery are now 
 great, and a fatal result of an uncomplicated joint-wound is not to be 
 expected. 
 
 Heretofore, in cases tliat have not died and in which amputation has 
 not been done, the functional value of tlic jirescrved limb has usually 
 been far from very good. Ankylosis, eitiier true or false, to a greater or 
 
470 GUNSHOT WOUNDS. 
 
 less extent, has been present in the hirge niajority, the fixation often 
 being angular antl det'orniing ; frequently chronie osteomyelitis, with 
 consequent bone-fistulfe, has been observed ; dangle-joints have followed 
 many of the extensive resections; and an irritable neuralgic condition 
 of the damaged part, lasting for years (U' during the whole after-life of 
 the wounded man, has often been experienced. Here, again, it is to be 
 hoped — indeed, expected — that the future will be better than the past, 
 since in no small measure the difficulties mentioned have been due to, or 
 at least much aggravated by, sujipurative inflammations. Protected from 
 such, it has more than once been shown that even lodgement of a foreign 
 body — e. r/. a bullet — in the articulation may not pre\-ent recovery with 
 free mobility of the joint. 
 
 Tile treatment of joint-wounds is either by expectancy, by excision, 
 or by amputation. Expectancy, which includes removal of foreign 
 bodies (bullets, free sequestra, etc.), is a method of treatment, as we will 
 see later when considering the lesions of special joints, the adoption of 
 which in the past was at the risk of great danger to ])art and life in 
 \\ounds of other than very minor gravity. Supj)urations, necroses, gen- 
 eral infective diseases, either death or late amputation, — such was too 
 often the record in the cases of articular injuries treated conservatively ; 
 but as it is now possible in wounds in civil life to prevent the develop- 
 ment of morbid processes consequent upon the action of pyogenic organ- 
 isms, either wlioUy or in great measure, rarely shoidd any other than 
 conservative treatment be adopted — never, except when there has been 
 such destruction of the joint and parts about as to make it impossible to 
 save the limb, or to save it with reasonable expectation of its being 
 serviceable. Not even the laceration of the main vessels or nerves 
 absolutely compels primary amjiutation. 
 
 In a rigidly antiseptic way loose fragments of bone and pieces of 
 cloth should lie removed, and the bullet also if it has lodged and the size 
 of the canal permits of its being readily reached and extracted. Com- 
 monly, the diameter of the track is small and the bullet is firmly fixed 
 in position, so that more harm will likely be done in finding the ball and 
 taking it away than by the missile itself if left undisturbed. The wound 
 and the skin about the orifice of extrance and exit having been thor- 
 oughly cleansed, the limb should be antiseptii'ally dressed and immo- 
 bilized in the same manner as in the case of an articular traumatism 
 other than gunshot. If largely distended with blood, the joint should 
 be aspirated. The effort to render the wound aseptic and to maintain it 
 so failing, the resulting suppurative inflammation will ordinarily be of 
 limited extent and is to be treated in the usual manner. 
 
 Though experience only, and that the large one of a great war, Mill 
 definitely settle tlie question, tiiere is every ])robal)ility that the joint- 
 wounds produced by the new small-calibred bullet will in large measure 
 be safely and satisfactorily treated expectantly ; and bullet wounds will 
 be, as they always have been, the great majority of articular lesions.' 
 Septic arthritis, when it ai-ises, is to be treated by free incisions, thorough 
 cleansing, and the maintenance of full drainage. Formerly common, it 
 will doubtless hereafter be developed in l)ut a limited number of cases, 
 
 ' In our late war they were ribniit 87 per cent. ; in the last three Prussian wars, 93 
 per cent. ; 94.5 per cent, in that of 1870-71. 
 
WOUNDS OF SPECIAL JOINTS. All 
 
 those in wliich either the primary disinfection of the wound has been 
 defective or tiie after-treatment has failed of preventing the occurrence 
 of snp|)iiration or infective osteomyelitis. If upon opening up the artic- 
 ulation extensive destruction of Ixine is found to exist, amputation or 
 excision should be resorted to, tliough tiie probability of recovery is not 
 very great. 
 
 The extreme fatality of lesions of the major articulations treated 
 expectantly during the wars of the first half of this century led to the 
 establishment of the rule that in such injuries amputation or, much less 
 often, excision should be done — a rule very generally observed during 
 the wars of the third quarter, though removal of the damaged part, rather 
 than of the limb, was more freely resorted to, especially in wounds of 
 the shoulder and elbow. Even under such treatment the mortality-rate 
 was high, 33.5 per cent, of the joint-wounds in our late war terminating 
 fatally, chiefly because of septic infection. 
 
 In all probability, in the future amputation will be done only when 
 tlicrc has been extensive crushing of the joint and parts about, or the 
 articular wound is complicated by such vessel- or nerve-injury as to pre- 
 vent tiie preservation of the vitality of the limb. Excision (which dates 
 back to the time of ]\Ioreau and Percy) will be done but seldom, not 
 l)ecause of its fatality, for that will l)e greatly reduced (it is now only 
 about one-eighth of what it was in pre-asc])tic times), but because the 
 end-result of the operation is not so good as tliat following conservative 
 treatment. Gurlt, having studied the after-history of 652 soldiers upon 
 whom resections had been done during the late German wars, found that 
 there was good functional use of the limb in less than 37 per cent, of the 
 cases ; limited use, and that often only when jirothetic a]i])aratus was 
 employed, in 50 per cent. ; and in more than 13 ])er cent, the liml) was 
 useless, or worse, a burden. It is much to be regretted that no one has 
 in a similar manner determined and reiwirted the end-results of the 1346 
 cases of excision of one or other of the six larger joints during our late 
 war which are known to have recovered from the operation. Were it 
 possible to operate subperiosteally, such regeneration might be expected 
 as woidd materially increase the functional value otherwise secured, but 
 in a ])rimary operation for gunshot injiu'v only very exceptionally can the 
 periosteiun be saved, and the attempt to do so is almost always but a 
 waste of time. 
 
 Wounds of Special Joints. 
 
 Shoulder. — About 2 per cent, of all wounds received in action are 
 of this articulation, and about one-sixth of ;dl the articular lesions. The 
 injury is almost always one of penetration, the ball citiier striking the 
 joint or fracturing the humerus, and, througii s])lintering, opening the 
 .synovial cavity. In war the left joint is more often wounded than the 
 right, because of its advanced position in infantry firing. With cavalry- 
 men the reverse is true, the right shoulder being carried forward in the 
 use of the sabre or pistol. The degree of injury caused ]>y the new 
 bullet, except at short range, will doubtless prove to be decidedly less 
 than by the old, canalization being largely effected, with but a moderate 
 amount of associated splintering and nnich less separation of the frag- 
 ments. Lodgement of the bullet, occasionally observed heretofore, is 
 
472 GUNSHOT WOUNDS. 
 
 not to be expected ; even in tlie pistol wounds of civil life the ball 
 rarely fails to perforate. Determination of the part of the hunierus 
 struck, whetlier head or neck, annti>nii('al or surgical, must rest usually 
 upon the positions of the wounds of entrance and of exit, and is really 
 a matter of very little importance. That a fracture of any kind has 
 occurred will often be knt)\vn only from the direction of the shot, the 
 fragments being so held together that neither crejiitus, preternatural 
 mobility, nor deformity can be discovered. 
 
 The prognosis may now l)e regarded as very good in cases uncom- 
 jilicatcd with lesions of the larger vessels or nerves or of the chest, and 
 in individuals whose personal condition and hygienic surroundings are 
 not bad. Formerly it was otherwise ; the mortality-rate during our 
 war was 34 per cent. But statistics of date prior to twenty years ago 
 liave only an historic value. 
 
 The treatment in civil life is l)y expectancy, and doubtless will be 
 so hereafter in army practice. Amj)utation will be reserved for cases 
 of extensive crushing and of associated laceration of the important 
 structures in the axilla. Even in these last conservatism will be 
 largely employed in non-military traumatisms. When both scapula 
 and clavicle are injured, as well as the humerus, it may at times be 
 advisable to amputate high up, doing an interscapulo-thoracic opei'ation 
 after the method of Bergcr. 
 
 Excision, which was so much favored and so extensively practised in 
 the ten years between 1861 and 1871, will rarely be employed, for it 
 has proved, as observed in our own country and in Germany, that the 
 late condition of the great majority of those thus ojierated upon is far 
 from being satisfactory,' and a more useful lind) may reasonably be 
 expected to be secured by conservative treatment. Moi'eover, so far as 
 we may infer from the experience of our late war, excision is more 
 dangerous than either conservatism or amputation (36.6 per cent. ; 27.5 
 per cent. ; 29.1 per cent.), and, though the present wound-treatment will 
 greatly reduce the mortality-rate, the reduction must apjily ef|ually to 
 the three methods of treatment. 
 
 Elbow. — These injuries, which constitute about one-tenth of the 
 wounds of the upper extremity, are occasionally jieriarticular, but very 
 generally perforative, the missile rarely lodging. In a few instances 
 the capsule has been opened without any bone-lesion being produced, 
 usually when the forearm is somewhat flexed and the ball has passed 
 just above the olecranon. 
 
 The extra-articular wounds, pro{)er]y treated, are of importance only 
 as there is serious nerve-injury or because of hemorrhage. 
 
 As in other articular lesions, the extent of damage to the bones varies 
 within wide limits, but in a large projiortion of the cases as now met 
 with comminution is not great, and the fragments are chiefly, it may be 
 entirely, held in close relation with each other. The humerus, the ulna, 
 or the radius may be wounded, or any two of them, or all three in the 
 
 ' In 213 cases Giirlt found that there were but 4 in which the functional value of 
 the limb was very satisfactory (1.87 per cent.), 90 in which it was good (42.25 per cent.), 
 and in 119 it was either Ijad or very bad (55.88 per cent.). After conservatism in former 
 times an ankylosed shoulder was usually present (in seven-eighths of the cases, according 
 to Chenu) ; after excision there was often a dangle-joint. 
 
WOUNDS OF SPECIAL JOINTS 473 
 
 extensive crushings of the joint. The lesion of the Immerns may be 
 confined to an epicondyle, may affect only the articulating surface below 
 the epiphyseal line, or may be located in or just above that line. At 
 the present time it may be ex])ected to be less extensive than formerly, 
 wlien the soft-lead, large-caliltre ball 
 
 was used, an illustration of the destruc- ''^^' ^^' 
 
 tive action of which is giv^en in Fig. 33. 
 
 As a rule, the precise character of 
 the injury can be determined only with 
 difficulty, except so far as it is indicatctl 
 by tiie direction of the line joining tlie 
 wounds of entrance and exit. E([ually 
 as a rule, such determination is of little •"'>"' '' a°^L m° spe^il^""'''"' 
 practical value. The complicating in- 
 juries are of the arteries, usually the braciiial, and of the nerves, the 
 ulnar being much more often the one wounde<l. Because of the nerve- 
 lesions there may be disturbance of sens;ition (hypersesthesia or autes- 
 thesia) or impairment of motion of the iiand and fingers. 
 
 When the joint-wound is due to pistol shot the |n-obabilities are very 
 great that the limb can be saved, and that with. considerable, it may be 
 quite perfect, after-usefulness ; and the same will doubtless prove to be 
 largely true in the injuries caused by the new missile, except those 
 received within the explosive zone. Associated wounds of the lu'aehial 
 artery and the median and museulo-spiral nerves have long been iield to 
 necessitate am])utation, but by ligation of tiie vessel and rigid antisei)tic 
 treatment it will doubtless be possible at times to save the arm, though 
 its functional value will be much impaired. In the crushings Ijy large 
 shot and in the extensi\e lacerations produced by small shot at short range 
 ani|)titation will ordinarily have to be performed. Occasionally the ope- 
 ration may be done at the joint, Init commonly the damage to the soft 
 parts will be such as to necessitate removal higiier up. Heretofore the 
 mortality-rate of such operations has been greater than that of amputa- 
 tion through the middle of the arm or above that level (20.70 per cent, as 
 agiiinst 12.30 per cent., or 13.(57 per cent, as given by Otis), but prob- 
 ably not only the actual but the relative death-rate will be nuich lowered 
 under antiseptic treatment, ])articularly so if, as has been thought, the 
 greater mortality of operations in tiie lower tliird has been due to unno- 
 ticed fissiu'es extending above the level at which the removal is made, 
 through which fissures pyogenic organisms have entered the bone. 
 
 In tiie great majority of cases these wounds should be treated expect- 
 antly, by immol>ilization, and with the most thorough antisepsis. 
 
 The result may l)e expected to be not only better than that following 
 operative interference-, but mucii better than that heretofore secured — 
 fewer ankyloses, less impairment of the motions of the hand and fingers, and 
 much more perfect use of the preserved joint. It is not likely that under 
 the present method of dressing from first to last a future investigator will 
 find, as did Dominick after the Franco-(Tennan War, that in 163 cases 
 there was complete ankylosis in 82.8 ])er cent., incomplete in 11 per 
 cent., and free mobility in l)ut 0.2 per cent. 
 
 Aminitation, as has already been stated, is indicated only when there 
 has been great injury to both bones and soft parts. Excision, which 
 
474 GUNSHOT WOUNDS. 
 
 done for disease is liifjlily successful, and wliicli was extensively tried 
 in the late wars in our CDuntrv and in Eurojie, is not now regarded 
 with favor hv the irreat majority of surgeons. Its mortality-rate in ])re- 
 asej)tic days Mas from 20 to 25 per cent., and that whether the ui)era- 
 tion was partial or complete, and the end-result was not good in about 
 75 per cent, of those who recovered. Gurlt's statistics show that in 44.3 
 per cent, there was ankylosis of the elbow, and in o(J.2 j)er cent, altnormal 
 mobility, and in only 32 per cent, was the usefulness of the hand pre- 
 served. Of course much of the after-ditliculty was due to inflannnations 
 and snp[)urations which can now be prevented, and further experience 
 may show that excision is a better operation than it is to-day believed 
 to be. 
 
 Wrist. — This injury, which is not very connuon and is often in asso- 
 ciation with lesion of the lower ends of the radius and ulna above and of 
 the second row of the carjnis and the metacarpus below, is more frequently 
 met with on the left than on the right side. When the bullet passes 
 antero-posteriorly, much less damage is done than when its course is 
 from side to side. Neither the pistol ball nor the small-calibred bullet 
 of to-day is likely to do anything like as much harm as was done by the 
 old .45, .50, or .55 calibre soft-lead bullet, except when fired at close 
 range. Associated injury of tendons, l>ursw, nerves, and vessels, one or 
 all, is frequent, and much of the gravity of the lesion in former times was 
 due to suppurative inflammation of the tendon-sheaths and of the palmar 
 bursa, by contiguity led up along the fascial planes of the forearm. To 
 such septic inflammations and those of the damaged bones was due almost 
 entirely the genei'al mortality-rate of these wrist-wounds — during our late 
 war 12.9 per cent., and in the Franco-(ierman War 12 per cent. 
 
 The prognosis, therefore, at the present day must be greatly more 
 favorable ; it certainly is so in the wounds of the joint that commonly 
 come under care in private practice. 
 
 The treatment should t)e expectant, except when the laceration is so 
 very extensive as to necessitate primary anq)utation. Formal excision 
 should not be done ; the mortality attending it during our war was more 
 than twice that after conservative treatment (15.6 against 7.67 per cent.); 
 in only 3 out of 72 cases were the results in " any way good " (Gurlt) ; 
 of 16 German patients, but one had a good arm and hand ; eight times the 
 ]>arts were but tolerably useful ; six times they were bad ; and once the 
 forearm and hand were worse than useless: well might (lUrlt say that 
 the results were " very unfavorable." Removal of the lower cn<l of 
 either radius or nlna alone was almost certain to be followed by lateral 
 deflection of the hand even to a right angle. The ankylosis, deform- 
 ities, and impaired finger-movements that so generally followed con- 
 servative treatment als(j in the past will do so in much less degree in 
 any future war, when wounds will be rendered and kejit in some measure 
 at least free from infection, immobilization of the forearm and hand 
 secured, and methodical movements of the fingers duly made. 
 
 Hip. — Wounds of this joint are of infrequent occurrence, being but 
 from one and a half to three in the thousand of all gunshot injuries, yet 
 are of extreme imjiortance, "pre-eminentlv hazardous to life, obscure in 
 diagnosis, and difficult in treatment " (Huntington). 
 
 In about one-eighth of the cases in our war the lesion was periarticular 
 
WOUyDS OF SPECIAL JOISTS. 47-") 
 
 (49-386), the capsule, however, being probably opened in a considerable 
 proportion of them. The diagnosis of sucli injuries often remains uncer- 
 tain, and prognosis is grave or (jtherwise according as there are or are not 
 serious complicating wounds of vessels, nerves, or the abdominal organs, 
 or (and this is one of their chief dangers) as septic joint-intlaniniation is 
 or is not secondarily developed. Of the 49 cases in our war, 21 proved 
 fatal. Uncomplicated, their treatment is that of flesh-wounds in general, 
 excejit in those cases in which a trochanter is guttered or perforated 
 withdut Assuring into the neck, and then it is that of ordinary bonc- 
 injiiries of like character. 
 
 An articular lesion may be of the neck, the head of the femur, or of 
 the acetabulum, or of two or all combined. That it has occurred when 
 the vulnerating body is a bullet whicii has made the usual narrow track — 
 and this is the more common condition — may be indicated by free dis- 
 charge of bloody synovia or by the usual symptoms of fracture ; but in 
 a large number of cases its determination must rest on the line of direc- 
 tion of the ball, the bone-fragments being mainly held in place, and those 
 which are detached being at such depth in and around the capsule as not 
 to be discovered except upon free opening up of the joint. Even though 
 extensive Assuring be present, the wounded man may yet be able to stand 
 upon the limb and walk, occasionally for several days. Twelve such 
 cases are reported liy Deininger. Tlie results in all past wars have been 
 exceedingly bad : in the French arm}- in the Crimea the mortality-rate 
 was 93^ \)QT cent. ; in our war, 84.7 per cent. ; in the German army in 
 1870-71, 77.9 per cent. In civil life the injury is very rare and often 
 associated with grave vessel or visceral wound ; the chances of recovery, 
 when it occurs, are of course better than in military practice, but still 
 far from being good. 
 
 The fatality in cases ending quickly is due to shock, M'hicli is great, 
 to hemorrhage from large vessels in the vicinity of the joint, or to asso- 
 ciated abdominal wounds ; in those living some days it is due almost 
 entirely to septic infection. The lethal influence of shock will be much 
 as it has been ; that of hemorrhage may lie expected to be somewliat 
 lessened, as ligations may l)e done with much less danger of after-sup- 
 purations and secondary hemorrhage ; that of wound-infection will be 
 removed in great measure in civil, in considerable measure certainly in 
 army ))racticc. 
 
 Treatment is, as in other joint^lesions, conservative or operative. 
 Much more largely than heretnfire will it be by expectancy. Never 
 again, in all probability, will its mortality-rate be anything like so 
 frightful as in our war (98.87 per cent.), when those who lived Ijcyond 
 tiie first few days with scarcely an exception died of suppurative inflam- 
 mation of the joint and the structures around ; nor that of the war of 
 1870 (75 per cent., Deininger; 71.59 per cent., Langenbeck). Gunshot 
 groovings and perforations antiseptically treated, well immobilized, with 
 the parts maintained in ])roper position by extension, siiould unite mudi 
 as do tlie ordinary fractures of the liip ; and there is every reason to 
 believe that they will. If re(piirc(l, arthrotomy for the removal of 
 loose fragments or the disinfection and drainage of the joint, or late 
 formal resection, may be done with a fair prospect of a favorable ter- 
 mination of the case. Primary exsection rarely need be performed, and 
 
47(1 GUNSHOT WOUNDS. 
 
 in tlic ahscnce of septic inflammation and suppuration tliere will he no 
 .sucli danger in operating after a f(.'\v days or weeks as there was for- 
 merly, when the so-called intermediary and secondary resections were 
 done.' In a word, though probably excisicjn, which was first done by 
 Oppenheim in 1829, will seldom be required, its I'esults will be much 
 better, and quite a considerable proportion of those operated upon will 
 be able, as a very few heretofore have been, to stand and walh with 
 much freedom and but little fatigue. The oj)eration may be done either 
 through one of the ordinary posterior incisions or through the anterior 
 incision of Hueter, according to the i)art of the bone most extensively 
 damaged. 
 
 Amputation, originally performed by Larrey in 179o, will be re- 
 served for those eases in which the destruction of the l)one and the adja- 
 cent soft parts has been ver'y great, those in which the femoral vessels 
 (arteries and veins) liav^e been damaged, and as a late operation when the 
 condition of the parts that have been treated expectantly or even by 
 excision is such as to make it evident that the limb cannot be saved, or 
 if saved that it will be of little value. As has been stated of the other 
 methods of treatment, the adoption of this will in the future be followed 
 l)y better results than in the jiast, and for the same reasons, though 
 shock and hemorrhage must still exercise a very grave influence ; and it 
 was chiefly to these that we must attribute the death within twelve 
 hours of 16 out of the 22 cases that died after primary amputations 
 done during our war. Hemorrhage at the time of the ojieration may 
 now be very thoroughly controlled by the use of long ])ins (as in the 
 method of Wyeth), or, if the character of the wound foi'bids their use, 
 by amputating through the thigh and later extracting the bone above 
 after a method like that of Furneaux Jordan. Historically, it is a 
 matter of much interest to know that the mortality-rate of all the 
 amputations at the hi])-ioint during our late war, 66 in numlier, was 
 83.3 per cent. — 88 primary, 100 intermediary, 55.5 secondary; in the 
 war of 1870-71, 100 per cent; in all the wars of the century up to 
 the close of the Franco-German War, as published in the Medical and 
 Surgical History of the War of the Bebellion (250 cases), 89.1 per cent. 
 
 Knee. — The exposed position of this joint renders it very liable 
 to be injured, the lesion being articular in about nine-tenths of the 
 cases. 
 
 When periarticular, it is most often behind the joint in the popliteal 
 space, and, aside from septic complications, is dangerous only in pro- 
 portion to the injury done the vessels and nerves, ^^'ounded vessels 
 being tied and antiseptic dressings applied, with immobilization of the 
 limb, recovery may be expected to follow, the leg and foot, however, 
 not seldom being seriously damaged functionally on account of nerve- 
 lesion. Under the old method of treatment secondary hemorrhage 
 often occurred, and at times gangrene from thrombosis of the contused 
 popliteal artery or vein. Removal of the limb can be required only 
 when the injury to the parts has been very extensive. Of the 351 cases 
 
 ' In our late war the niortalitv-nite of primary excision was 9ti.9 per cent., inter- 
 mediary 90.9, secondary 72.7 ; Langenbeck's statistics slinw 100 jier cent, of deatlis after 
 primary and intermediary, and 75 per cent, after secondary operations, and Gurlt's, 100 
 per cent, after primary, 85.7 after intermediary, and 93.7 after secondary. 
 
WOUNDS OF SPECIAL JOINTS in 
 
 observed in our war, 27.9 per cent, died, the mortality-rate of the 313 
 cases treated conservatively being 22 per cent. 
 
 Of the articular wounds a few are without bone-injury, the shot 
 passing tlirough the U})per synovial pouch or across the front of the 
 joint in flexion. A few (about 1 per cent, during our war) are of con- 
 tusion only, but the great majority are of fracture, the patella alone 
 being damaged in somewhat less than 10 per cent. The ball may come 
 into the joint through the femur or tibia, or the bone-lesions may be 
 secondary to the piercing of the capsuU'. The cavity may be opened at 
 once by cracks running from the track of a ball that has penetrated or 
 more often perforated the condyle, or secondarily because of septic Ijone- 
 inflammation. If the bullet has passed through the bone into the joint, 
 tiie incrusting cartilage may be largely destroyed or only split open, the 
 slit-like wound rapidly closing. 
 
 All the characteristic symptoms of joint-injury are here manifested 
 in high degree, and in pre-aseptic days septic intlanunations (osteomye- 
 litis, arthritis, periarthritis) were almost alisolutely certain to be rapidly 
 developed. Associated wounds of the popliteal vessels and nerves are 
 at times present. 
 
 Prior to 1876 the prognosis of these knee-fractures was very grave, 
 death occurring in more than two-tliirds of the cases. In the Crimean 
 M'ar, according to LoTigmore, not a man recovered except after ampu- 
 tation, and niue-tenths of those operated upon died. In our war the 
 mortality-rate of the 3355 cases reported was 53.65 per cent., and of 
 these cases 28.3 were of injury of the patella only. But, beginning 
 with the cases treated l>y v. Bergmann and Reyher, the results of the 
 comparatively few injuries observed in recent years have been greatly 
 more encouraging. Protected from infection, there is no good reason 
 why the mortality-rate shoidd not be very much lowered, especially in 
 the injuries observed in civil practice, which, comparatively, are not 
 severe. 
 
 As with the other joints, so here : three methods of treatment are 
 before the surgeon from which to choose — exjiectancy, amputation, 
 excision ; and, as is true of the other joints, the knee may now in the 
 great majority of cases be treated most satisfactorily liy the first. Selec- 
 tion of method is not to be determined by consideration of statistics. 
 It matters little that under conservative treatment the American mor- 
 tality was 60.6 per cent. ; that of 1866, 43.5 ; tliat of 1870-71, 48.1 
 (German), 50.7 (French); that of 1877, 28.3; that after ani]>utation 
 the death-rate in 1861-65 was 53.6 per cent, when the removal was 
 through the lower third of the femur, 56.6 when at the knee-joint; that 
 excision terminated fatally with us in SI. 4 ])er t'cut. of the cases, in 
 1864 in 85.7 percent., in"lS66 in 86.6, in 1S70-71 in 80, in 1876-77 
 in 100 per cent. These figures have now but an historic value; the 
 conditions under which treatment by any method is carried out ai'e 
 materially changed. 
 
 When the injury is other tlian a very extensive one conservatism 
 should be employed ; when the liml) evidently cannot be saved it sh;)uld 
 be taken off. What is to be the place of excision in the future remains 
 to be determined. The operation in civil life for pathological conditions 
 and f >r ordinary traumatisms (in the few cases in which it has been 
 
478 GUNSHOT WOUNDS. 
 
 eni])loy('(l) has been so free from risk to life, and so satisfactory in its 
 end-result, tliat it is quite prohalile that where the surroundings are 
 favoral)le and the patient need not he moved, excision will at times, 
 perhaps often, Ije done. After this operation, and especially in the cases 
 treated expectantly, the functional value of the part will hereafter be 
 much greater tlian heretofore, since the ankyloses will be fewer and the 
 periarticular thickenings and adhesions decidedly less. During the 
 course of treatment constant care nnist be taken to prevent, or at least 
 to limit as nuich as possil)le, angular deformity. 
 
 Ankle. — ^\'ounds of the foot and of the lower part of the leg 
 involving the ankle-joint have been often observed in time of war, 
 this articulation being the fourth of the six larger joints in order of 
 frequency of damage, and occasionally, though rarely, such lesions are 
 met with in civil life. 
 
 The periarticular injuries, which constitute but a very small minority 
 of the cases coming under care, are of more than ordinary interest 
 because of the frequency of tendon-lesions, with their associated danger 
 of suppurations ruiniing up along their sheaths, and of the later restric- 
 tion of movements of the ankle and foot. Division of the anterior or 
 posterior tibial artery necessitates ligation. 
 
 Unless produced at short range, wounds of the bones of the joint 
 by pistol balls or the small-calibred bullet are not ordinarily attended 
 with such comminution as to compel operation. Quite often the frag- 
 ments will be found so little displaced that no positive evidence of 
 fracture can be secured by either jiressure or wai-rantable movement 
 of the foot upon the leg, and, as a considerable amount of synovia may 
 be disi'harged from the opened tendon-sheaths, the diagnosis must be 
 but a probable one based upon the course of the missile. Even this 
 may not in pistol wounds be apjjarent, because of lodgement of the 
 bullet, which occurs in an exceptionally large number of cases as 
 com parcfl with the lesions of other joints. The new bullet will almost 
 certainly pass through and out. 
 
 Formerly the mortality-rate was quite high (2(3 per cent, in our war), 
 but antiseptically treated these injuries should be recovered from in 
 very large measure. Of 24 Austrians wounded in Bosnia, every one 
 got well, and Nimier reports from Tonkin that only 1 out of 23 cases 
 jn'oved fatal, and that not from the injury, but from an intercurrent 
 dysentery. 
 
 Conservative treatment should be adopted unless amputation is 
 necessitated by the great extent of damage done the bones and soft 
 parts. By expectancy a very serviceable limb is generally secured. 
 Care must be taken through the whole course of the treatment to keep 
 the foot in proper jjosition, as there is a strong tendency to its over- 
 extension and to lateral deviation. If amputation must be done, it 
 may be at the ankle or through the lower part of the leg, according to 
 circumstances. Chauvcl and Nimier have suggested that at times, \\hen 
 the destruction has been of the parts about the heel and the posterior 
 part of the sole, an osteoplastic resection (the Wladimirotf-Mikulicz 
 operation) might well take the place of an amjiutation. 
 
 Exsection of the ankle yielded very unsatisfactory results in both 
 our own war and the Franco-German, and its death-rate was high (35.5 
 
WOUNDS OF REGIONS. 47!) 
 
 per ceut. with us, nearly three thiies that of ankle-jdint aniputatiuns, 
 13.43 per cent., and nearly 10 per cent, higher than that of leg ampu- 
 tations in general, 26.02 per cent.). It is doubtful if it ever will be 
 much favored, as most if nut all of its advantages can be secured by 
 an intormal removal of fragments if any active interference is re<(uirc(l, 
 and tills will not often be tiie ease. As with joint-wounds generally, liy 
 a strict antiseptic treatment and firm immobilization not only will life 
 be saved, but a serviceable limb secured — far better, as a rule, than any 
 artificial leg. Occasionally, of course, here as in other articulations 
 there may be such persistent bone-disease as will compel a late ojieration — 
 sequestrotomy, excision, or amputation ; but just in ])roportion as an 
 aseptic state of the wound is secured and maintained will the likelihood 
 of this be diminished. 
 
 Wounds of Regions. 
 
 Head. — Injuries of the head are among the more common wounds 
 met with in war, and of not infrequent occurrence in civil life. They 
 are either of the scalp or of the cranium — many more of the former than 
 of the latter as they come under treatment (7739 against 4350 in our late 
 war). But it must be remembered that one-half of these head-lesions 
 have proved fatal on the field, and it may reasonably be expected that a 
 much larger number will be killed by the new bullet, because of its 
 greatly increased velocity. 
 
 The scalp-wounds are either contusions (rarely met with), lacerations, 
 perforations, or penetrations with lodgement of the ball. Injuries of the 
 latter class have been but seldom seen in military service, and are not 
 likely to be produced by the modern missile — never except when it is 
 very near the end of its flight. Pistol lialls, especially those of small 
 calibre, are often buried in the tissues, frecpiently nuich flattened. Com- 
 monly they can be easily felt or their situation determined by ])robing. 
 When in the temporal muscle their location may be indicated only by 
 pain upon movement of the lower jaw and upon pressure above the 
 zygoma. Laceration of a temporal or occipital artery may give rise to 
 considerable hemorrhage and, as is the case in other traumatisms of the 
 scalp, the development of a condition simulating depressed fracture. 
 Such blood-accumulation, if not rajiidly absorbed, should be aspirated or 
 cut down upon and washed out with an antiseptic solution. Properly 
 treated, these injuries may be expected to be readily recovered from, 
 though heretofore the mortality-rate has been from 6 per cent, to nearly 
 30 \)er cent, in different wars, the fatality being consequent upon septic 
 disease of one form or another. The ordinary antiseptic treatment 
 should be thoroughly carried out, the l)ullet if lodged being removed 
 when its location has been determined. 
 
 The cranial lesions are those of either contusion, penetration, or jier- 
 foration. Contusions, which were about 7.5 per cent, of these lesions as 
 met with during our war, are produced by the glancing imjxict of a 
 rapidly-moving missile or the direct blow of a shot having but little 
 momentum. They jirobably will not be caused by the new bullet, as 
 almost certaiidy it will fracture the bone when it strikes it. As is the 
 case with like injuries of other bones, the damage done may be slight. 
 
480 
 
 GUNfSHOT WOUNDS. 
 
 giviiiij rise to no syniptonis ; or iiiorc severe, causing limited extravasa- 
 tions, after a time absorbed, or superiicial necrosis and exfoliation ; or 
 sutttciently great to cause a sej)aration of the outer table over a small 
 surface ; or, but very rarely, to destroy the vitality of the entire thickness 
 of the bone. The inner table may he fractured, with more or less dis- 
 placement of fragments toward the interior of the skull, but this is of 
 infrequent occurrence (Fig. 34). 
 
 Gunshot contusion of cranium, witlx fracture of internal table, exterior and interior view (A. M. 
 
 M., Spec. 2313). 
 
 The wound becoming infected, inflammation of the diploic veins is 
 very likely to follow, with resulting pvieniia with ab.sce.sses in the lung 
 or liver, or a sujjpurative meningitis. Ivarcly is the " putfy tumor" of 
 Pott present. 
 
 It is to such infection that the fatality of the.se contused injuries has 
 been chiefly due, the percentage of which reached 16.8 in our war, and 
 the prevention of such septic conditions will ensure recovery in the great 
 majority of the cases — in all, we may expect, except tho.sc in which 
 fragments of the inner table are driven down or the associated brain- 
 concussion, laceration, and hemorrhage are of themselves mortal. The 
 wound must be thoroughly cleansed, an anti.septic dressing applied, 
 and the patient ke])t (juiet. If eonstitntii^nal sym]itoms of decided 
 severity arise, indicating infective inflammation of bone or meninges, 
 the contused area should be freely exj)osed and trephining done. 
 The operation as now conducted will not add to the gravity of the 
 case, whatever may have been true of it formerly, and it will make 
 it possible to remove any detached pieces of the internal table, to disin- 
 fect, and to secure drainage. Sometimes — and, iinfiDrtiinatcly, not so 
 very rarely — no symjitoms of moment are jiresent for many days, when 
 suddenly violent headache is experienced, followed by eonvulsions, coma, 
 and death from cerebral abscess. For three months or more, the 
 huntlred-day period of Pare, the patient is exposed to this danger. 
 
WOUNDS OF REGIONS. 481 
 
 Except in the mildest cases, such as may readily escape detection, and 
 frequently do so, there is usually, after recovery from the immediate 
 effects of the wound, and it may be for a long time, more or less head- 
 ache, often associated with dizziness, intolerance of light and sound, 
 nausea, and vomiting. Epilejjsy, paralysis, and mental irritability have 
 in many cases been produced, as in similar contusions from violence 
 other than gunshot. The prognosis, therefore, is more grave than the 
 mortality-rate would indicate. Occasionally, though not often, bone- 
 atroi)hy follows, exceedingly seldom hypertrophy. 
 
 Tiie fractures produced by gunshot are graver lesions than those con- 
 sequent upon other traumatisms, because of the greater intensity of the 
 vulnerating force. Association of brain-injury is more constant and the 
 visceral damage much more extensive ; and this whatever the form of 
 fracture, which varies from a linear break to a shattering of several, it 
 may be all, of the bones of the skull. This shattering in bullet-injuries 
 is due, as in other fractures of the head, to fissures starting from the 
 original wounds, to vibrations conducted along the cranial tiiickenings 
 from vault to btise or from the occipital bone forward, and also, and much 
 more largely, to the liydraulic pressure set in action Ijy tiie ball as it passes 
 through the brain. Numerous experiments, beginning with those of Busch 
 and Kocher, have proved beyond question that there is such pressure in 
 gunshot wounds of semi-fluid tissues, that it is proportionate to the fluidity, 
 and that it is most strongly manifested in the brain, whicii is structurally 
 fitted to develoj) it and is confined within rigid ^valls that will in the 
 highest degree display the effects of it. Within the zone of explosive 
 action, which with respect to tiie head extends, using the modern arm, to 
 600 or 800, even to 1000, yards, this hydrodynamic pressui'e produces 
 ■\vide destruction — so wide that life is very unlikely to be preserved. At 
 close range brain and bone may be lilown into fragments — less likely to be 
 witii the small- tlian the large-calibred bullet. Wagner of the Austrian 
 army, having observed nine suicidal cases among soldiers in which death 
 was immediate, reports that there was less destruction than in similar 
 cases previously seen in which a large ball was used ; the greater part of 
 the brain was intact, there was less crushing of bone and less fissuring, 
 and the greatest damage was about the wound of exit. Only exception- 
 ally does tlie hydraulic pressure cause fracture of the base, and then in the 
 great majority of the cases it is the ethmoid or the orbital surfaces of the 
 frontal that are broken, though it is possible, doubtless, that tlie tliin plate 
 of the temporal covering the internal ear may yield. Pistol balls do not 
 ordinarily have sufficient momentum to develop an explosive action, but 
 womids jiroduced by tliem at short range at times show splintering of the 
 orbital plates, even witii depression toward the orl)ital cavity. jMucIi 
 interest in sucli injuries has been taken since the death of President Lin- 
 coln, and a numbe'" of cases quite similar to his have been put on record. 
 At the autopsy of the President the bullet, which had entered througii the 
 occipital bone, was found to have passed forward in the brain and lodged 
 just above the anterior ])ortion of the left corpus striatum. Botii orbital 
 plates were comminuted, tiie fragments being forced inward ; tiio dura 
 mater, however, was uninjured. 
 
 The crusliiuffs caused bv larsre shot and bv sliell-fraffments, and the 
 bullet wounds and those made by charges of small shot at close range 
 
 Vol. r.— 31 
 
482 GUNSHOT WOUNDS. 
 
 which are immediately or very quickly fatal, have no practical interest. 
 It is in these cases, iu which death occurs at once, that there is 
 observed at times a stiifening of the body in the position had at the 
 moment of injury. In a case in Northern New Ham})shire some years 
 since, in which tlie top of the head was blown off' by a load of shot 
 from a gun but a few feet away, the body of the woman was found sit- 
 ting in a chair before the fire in the attitude of knitting, with the needles 
 which she had been using still held in her hands. This "traumatic 
 cataleptic rigidity," though met witli in those shot through the chest 
 and abdomen, is usually associated with cranial injuries. 
 
 As in other bones, there may be in the skull groovings, fissurings, 
 penetrations, and perforations. The groovings are usually associated 
 with fissures, which may affect only the external table, but are gene- 
 rally found to extend through the entire thickness of the bone — always, 
 perhaps, excejit when it is " the supraorbital ridge, the zygoma, or the 
 mastoid or occipital protuberance that has Ijcen struck, or the lesion is 
 caused by a sharp fragment of shell " (Otis). In individuals who have 
 passed the age of puberty the outer wall of the frontal sinus may be 
 broken in without accompanying injury of the inner wall, rarely hap- 
 pening, however, excei)t when it is a pistol ball that is the vulnerating 
 body, the shot often lodging in tlie sinus, from which it may be readily 
 extracted. In children penetration in this region almost certainly 
 means piercing of the entire thickness of the skull and wound of the 
 brain. 
 
 When both tables of a cranial bone are broken from without the 
 damage to the internal is usually decidedly greater than that to the external 
 table, the more so as the fracture of the latter is circumscribed. Such injury 
 is in accordance with " Teevan's law," that fracture always commences 
 in the line of extension, not that of compression. When the vulnerat^ 
 ing force acts from within, the splintering is greatest in the outer table, 
 which then might be named the " vitreous " one, cases of injury of this 
 kind being observed in suicidal and other shots through the mouth and 
 face, when the ball, ranging upward, emerges through the vertex. In 
 the exit wound of a perforation there will be noticed the same excess of 
 splintering in the outer table. The elasticity of the skull causes at times 
 a return nearly to its original position of a fragment at first sufficiently 
 depressed to permit of the entrance of a bullet. In a few cases pene- 
 tration has been indicated only by the presence of hair in the fissure, 
 as in those reported by Assistant Surgeon Howard of our army and 
 by Koenig ; ' and it is possible, as in a case of v. Bergmann's, that a 
 piece of a projectile may upon autoj>sy be found in the brain, and 
 nothing but a mere crack be discovered through which it could have 
 entered. 
 
 When the momentum of the ball is not great the fracture may be 
 confined almost entirely to the surface struck, slight depression occur- 
 ring or a jiiece of the skull of about the diameter of the missile being 
 driven in below the general level of the internal table. Sucli a typical 
 punctured fracture is not likely to be observed except when the ball is 
 small, fired usually from a pistol or a toy rifle. In cases of more 
 
 ^ In a case reported by Matthew, from the Crimean War, hair was found in a fissure 
 of the external table only. 
 
WOUXDS OF REGIONS. 483 
 
 extensive, but still not great, splintering the lesion is commonly confined 
 to the bone struck or passes but little beyond it. 
 
 Penetrating and perforating wounds are always very grave injuries. 
 The bi'aiu is seriously damaged in those wounds of this class not speedily 
 causing death from shock and hemorrhage, and in cases of penetration there 
 are the added dangers conscijut'nt upon the presence of bone- fragments and 
 the missile. The shot may jiass antero-posteriorly, laterally, or obliquely 
 at any angle, rarely from below upward, and almost never directly from 
 above downward, except when produced by bursting shells. Basal frac- 
 tures, which are not very common, are met with as continuations of those 
 of the vault, en- in wounds through the neck or face, largely suicidal. 
 
 That a cranial fracture (other than of the internal table alone, which 
 is always conjectural) has been received is usually readily determined by 
 palpation, by inspection, by jirobing, or by percussion, which may give 
 the " cracked-pot " sound. The course of a ball which has not passed 
 through is often very uncertain, the missile frequently striking the oppo- 
 site wall of the skull and being deflected, it may be at a large angle. To 
 trace it a probe must be employed. If metallic (one made of aluminum 
 is far the best), it should be used with ligiit hand, the head being inclined 
 and the instrument allowed to fall by its own weight, since it is very 
 easy to push it through the soft cerebral mass. Oftentimes a moderately 
 firm, elastic one, such as an urethral bougie, will be preferable. Always 
 the instrument must be surgically clean, and it should be used only after 
 careful disinfection of the external wound and the pai'ts about. It is in 
 these injuries that the telephonic probe has been found of service. If 
 probing shows that the track has passed across the head, but the missile 
 is not detected, a button of bone should be removed over the end of the 
 canal, and search be made back along the track from that side or for the 
 opening of the new canal made after deflection. As in the memorable case 
 reported by Fluhrer in 1884, a second trephining may have to be done to 
 find the course of the shot yet further deflected. Before any exploration 
 of the track is made the opposite side of the head should be carefully 
 examined, as it may be that the ball lies under the skin or is in the bone, 
 and is forcing it out in such way as to be easily felt or to be indicated by 
 pain on pressure. If the missile cannot be found after reasonable careful 
 search — and very often this is the case — it will have to be left. Occa- 
 sionally cerel^ral symptoms (paralysis or disturbances of smell, sight, or 
 hearing) mmII indicate, if not the location of the ball, at least the course 
 that it has taken ; but these symptoms are less reliable than they other- 
 wise would be because of the widespread injury of the brain outside of 
 the immediate track of the shot. The symptoms of basal fracture are the 
 same as those of similar injury from ordinary violence. The development 
 of complicating septic ioflanmiations is indicated by the usual symptoms 
 of such affections. As is the case in the ordinary tnuunatisms of civil 
 life, meningeal suppurations are accompanied with decided elevation of 
 temperature ; those of the brain are not, and no paralysis occurs in 
 meningitis at the base. Fungus cerebri, misnamed hernia, has been met 
 with (at least sixty-one times in our war), and must be so in the future 
 in cases that have become infected. 
 
 The prognosis is always grave. As has been stated, one-half of 
 those wounded in action never come under care, and of the other half 
 
484 GUNSHOT WOUNDS. 
 
 73.8 per cent, died in the Crinioa, 4(3.1 in 1859, 59.2 in 1861-65, 51.3 in 
 1870-71. Of perforating and penetrating wounds in our war, 80 and 85 
 per cent, proved mortal. Balls lodged in tiie frontal lobes have Ijeen l)etter 
 tolerated tlian those elsewhere. Though much of tlie fatality heretofore 
 has been because of septic complications, nuicli of it has l)eeii from causes, 
 chictiy shock and hemorrhage, that no treatment c((uld have jirevented. 
 Of the 91 pistol-shot wounds occurring in recent years, tabulated by Brad- 
 ford, 51 died (50 per cent.), and of these 39 (42.86 per cent.) died within a 
 few days, 19 (21 per cent.) within a few hours; that is, 76.47 and 37.21 ])er 
 cent, of all who died. As I'epresenting the probal)le death-rate under 
 present methods of treatment and in a class of cases more likely to recover 
 than those in whicli the damage lias been done by an army bullet, the 
 pistol-ball injuries studied by Bradford are very instructive. Of 25 cases 
 shot in the temple, 16 (64 per cent.) died ; of 5 in which the ball entered 
 through the ear, all died ; when the bullet entered in front of the plane 
 of the external auditory meatus, 59 cases (57.7 per cent.) died ; when 
 in such plane or posterior to it, 32 eases (59.4 per cent.) died ; the 
 mortality when the ball was removed was 33-^- per cent., Aviien it was 
 left, 54 per cent.; of 25 cases treated expectantly, 52 per cent. died. 
 Lesions of the anterior part of the cerebrum were thought by Guthrie 
 to be more grave than those of the posterior, and so Bradford found 
 them in a percentage of 1.7. Wiiarton's table, however, shows a much 
 heavier deatli-rate in Mounds through the occipital bone, and in the 
 Crimea the wounds in the anterior half of the head proved to be less 
 dangerous. Wounds from side to side, especially those through the ear 
 or very close to it, are much more serious than antero-posterior ones. 
 In part this may be due to their being largely suicidal injuries, and 
 therefore received at veiy close range, the mental condition, moreo\"er, 
 having of itself in these wounds, as in those of otlier regions, a depressing 
 influence, decidedly increasing the risk to life. Lesions of the cerebellum 
 almost always prove quickly fatal. Meningeal inflammation and brain- 
 abscesses are excessively dangerous, as tliey always are, though by open- 
 ing up the inflamed area, if it is a limited one, evacuating the pus, and 
 securing proper drainage, relief at times may be afforded. Fungus 
 cerebri is very apt to terminate fatally, esjiecially Mhen actively treated ; 
 82 per cent, of the cases reported in 1861-65 died — a mortality-rate, 
 however, much greater than in all probability will occur hereafter. But 
 death in a few days or a few weeks is not the only bad result of these 
 cranial fractures. Injury of the optic nerves causes blindness — of the 
 auditory, deafness. Necrosis of bone, rarely caries, was formerly very 
 common, and must always occur at times desi)ite the most rigorous anti- 
 sepsis. Cerebral disturbances of all kinds have been noticed again and 
 again, and in greater or less measure are almost certain to come on. 
 Epilepsy, paralyses, headaches, amnesias, changes in temper and in 
 habits, imbecility, insanity, diabetes, each has often appeared, and tliat, 
 not seklom, years after apparent recovery. When the ball remains in 
 the head it ordinarily does not become encapsulated, but slowly moves 
 under the influence of gravity, and because of tlie pressure exerted by 
 it and the organic changes induced by its irritating action the almost 
 absolute certainty is that some form of brain-trouble will at some time 
 manifest itself. 
 
WOUNDS OF BEGIONS. 485 
 
 The treatment of these lesions has reference to the wound itself and 
 to the complications that may arise. As has been already stated, much 
 of the fatality is consequent upon shock and primary hemorrhage, for the 
 relief of the former of which, wlien severe, nothing- can be done, and but 
 little for the latter, the cases occurring in military practice and living 
 long enougli to come under care being almost certainly hopeless. In the 
 wounds of civil life, if the bleeding is from an external vessel, com])res- 
 sion may arrest it, but, as a rule, ligation should be done ; and such 
 should be the practice when a meningeal artery (usually the middle) has 
 been injured. It may doubtless at times be found advantageous to 
 introduce a sterilized gauze plug wlien the hemorrhage is from the track 
 of the bullet in tlie brain ; and in certain exceptional cases periiaps, 
 when the compression-symptoms indicate a progressive bleeding, ligation 
 of the carotid may be of service. 
 
 The wound being from pistol shot, the scalp should be shaved, the 
 damaged area antiseptically cleaned, and if penetration has occurred a 
 button of bone including the entrance wound removed by trephining ; in 
 other words, the injury should be treated as though it was an ordinary 
 punctured fracture of the skull. Removal of the bone does not add to 
 the gravity of the lesion, and permits of the taking away of any frag- 
 ments that may be present at the orifice and the more ready examination 
 of the track within. Careful search for tlie ball and deejily located bone- 
 splinters should then be made, and if found they should be removed with 
 a forceps no larger- than is absolutely recpiired. But in searcliing and 
 extracting care must be taken to do as little violence as possible to the 
 brain already seriously injured. When the foreign bodies have been 
 taken out, or if the bullet is not found, or if found is at such dejith as 
 to make it unwise to attempt its removal, the blood-clots and devitalized 
 tissue in the canal (which is always of a diameter much larger than that 
 of the missile) should be washed out very carefully or scraped away, a 
 drainage-tube introduct'd, and an antiseptic iiead dressing applied. If 
 the ball has passed through and out, the exit wound also may be tre- 
 phined, or only its detached fragments removed to such extent as will 
 allow of free drainage. Here the external table is certainly as much, 
 probably more, splintered than tiie internal, and the ends of partially 
 separated sequestra are pushed away from the meninges and brain 
 instead of toward them. The securing of tiiorough drainage is of the 
 higiiest importance, for increase of pressure upon the brain from extrav- 
 asated blood adds much to the gravity of the wound. If, though the 
 ball has not passed out, it can be located under the skin or in the bone, it 
 should l)e removed and the injiny thus converted into a perforating one. 
 
 Bradfiird's statistics indicate tiiat cases in which the lodged ball is 
 removed ai'ter trejiliining are more likely to recover than those of per- 
 foration, probal)ly l)ecause in the great majority of such cases tiie bullet 
 has not penetrated deeply and the brain has been less seriously damaged. 
 These statistics furtiier show that if the bullet remains in the head the 
 termination of the case is about tlie same whether any operative interfer- 
 ence is made or the case is treated expectantly. 
 
 When tlie wound is produced by one of the new rifle bullets, if the 
 missile enters tiie cranial cavity it will, except at an extreme range, pass 
 through, and there will be no occasion for searching for it or extracting it. 
 
486 GUNSHOT WOUyoS. 
 
 If the lesion is not one of peneti'ation, the fracture should be treated 
 on the same general principles as apply to a similar one due to an ordinary 
 trauma, trephining heing done or fragments Ijcing removed in a more 
 informal way whenever there is depression or any decided cunnninution. 
 The adoption of aseptic; and antiseptic methods of operating and dress- 
 ing has greatly changed the status of these procedures, which as now 
 carried out do not, or but in slight degree, expose to the danger of the 
 lighting up of septic inflammation, the development of which in former 
 times was so general and so fatal. Any discovered clot under the skull 
 or under the dura should be removed by irrigation or by the finger or 
 an instrument. 
 
 The secondary complications that may arise and that demand treats 
 ment are the infective diseases of the meninges and brain, with result- 
 ing ditfused or circumscribed collections of j)ns, and secondary hemor- 
 rhage. Meningitis and nieningo-encephalitis, which ordinarily come on 
 from the third to the sixth day, but are often deferred for as many weeks, 
 and which present no features other than those met M-ith in cases of trau- 
 matisms not produced by gunshot, are to be treated in the same M'ay as 
 in the latter, no treatment commonly being of much avail. They are to 
 be prevented, if possible, by the adoption of a rigidh^ antisejjtic wound- 
 treatment, and without doubt it -will be possible to prevent them in a 
 considerable proportion of the cases in civil life. 
 
 When the sympttmis present indicate the formation of cerebral 
 abscess — and these, unfortunately, do not ordinarily show themselves 
 until rupture has taken place into a lateral ventricle or the pressure 
 exerted upon the Ijrain is great — there should be an active interference at 
 once. Trephining, if necessary, should be done, and exploration made 
 by the use of an aseptic director, or, better, an aspirator needle, or such 
 exploration be made through the already exj)osed meninges or cortical 
 substance. There should be no hesitancy in carrying the needle deeply, 
 and, if required, in various directions, in the hope of finding the abscess, 
 since the exploration does not materially, if at all, increase the gravity 
 of the situation, and only in ])romj)t evacuation of tlie pus with the 
 securing of after free drainage is there any chance (if saving life. Occa- 
 sionally such fortunate result will folloAV, but ordinarily the case soon 
 terminates fatally. 
 
 Secondary hemorrhage, almost invariably due to septic changes in and 
 about the wound, should be treated by ligation of the bleeding vessel, or, 
 if this cannot be efi^ected, of the main trunk, the exti'rnal or common 
 cai'otid. The mortality attending the latter operation, formerly great 
 (68.75 per cent, of the cases I'eported during the wars of 1861-65 and 
 1870-71, 11 out of 16 patients dying), should hereafter be less in pro- 
 portion as the fatal result was directly due to the ligation, though ex- 
 haustion from previous loss of blood, cerebral softening, or accompany- 
 ing septicaemia or pyaemia must still carry off many of those operated 
 upon. Ligation of the external carotid \\hen the bleeding is from one 
 of its branches should be preferi-ed to that of the common ti'unk, as all 
 recent experience has shown that it is a much safer operation (as 11 to 
 78), and at the same time more effective in controlling the hemorrhage. 
 Fungus cerebri, if it forms, should be treated expectantly by moderate 
 compression. Operations on such mass (ligation, excision, injection, 
 
WOUNDS OF EEGIOyS. 487 
 
 cauterization) have not nsually proved of service, the mortality attending 
 tiieni in 1861-()5 being 75. S per cent. 
 
 In the treatment of basal fractures in which there is discharge of 
 blood or serum from the nose, mouth, or ear, the nasal cavity, the naso- 
 pharynx, and the external auditory canal are to be thoroughly disinfected 
 aud plugged with sterilized or antiseptic gauze. 
 
 Face. — Wounds of the face are perhaps about 4 per cent, of those 
 received in action (3.83 ])er cent, in our war), and are not seldom met 
 with in civil life, wiiere they are caused l)y small sliot single or in mass, 
 by pistol balls, and, in a \'ery few cases, by pieces of caps or fragments 
 of a gun that has burst. They are of interest chiefly because of the occa- 
 sional occurrence of dangerous hemorrhage, primary or secondary, or of 
 the not infrecpient extensive lacerations that they produce and the re- 
 sulting deformity, often very disfiguring. Their mortality-rate has not 
 been great — 4 to 7 per cent, in different wars, and this chicily in the 
 cases of fracture, flesh wounds rarely causing death (in 1.5 per cent, 
 only of the nearly five thousand (4914) cases tabulated by Otis). Even 
 this rate may be expected to be much lowered hereafter in degree pro- 
 portionate to protection against sepsis. Flesli wounds made by pistol 
 balls firetl from a distance or by small sliot are attended with but little 
 destruction of tissue, and are quickly recovered from, the resulting scar- 
 rino; beino; usually but sliaht. Occasionally the bullet or charge of small 
 shot seriously damages the eyelids, the lips, or the soft pai'ts of the chin, 
 witii later cicatricial contraction that may necessitate operative treatment. 
 Generally, howevei", these graver lesions are associated with injuries of 
 bone, which occur in about one-third of the cases. Any bone may be 
 injured, but most connnonly it is the inferior maxilla, tiie fracture of 
 which much resembles, as respects s])liutering, that of a long bone. The 
 superior maxilla was frequently much connninuted by the old large-cal- 
 ibred Ijullet, though tlie fragments were generally adherent; with the 
 new bullet in the middle ranges much less splintering may be expected 
 to be produced. Pistol balls crush it but little, as a rule, except when 
 tiie wcajjon is disciiarged at very short distance, and not always then. 
 The cavities, orbital, nasal, and oral, are often penetratetl or perforated, 
 the shot at times doing no direct damage to the eye or tongue. Tiieir 
 penetration may take place without any injury to bone. A bullet may 
 pass out through the mouth or the anterior nares, not wounding, or but 
 slightly wounding, the lijis or tiie nose. In a case reported from the 
 Franco-Gcrmau War a ball entered through the anterior nares, struck 
 the posterior pharyngeal wall, and, reboundilig, made exit through the 
 mouth. When tiie missile passes antero-posteriorly the brain, spine, or 
 great vessels of the neck are often damaged, though not seldom in suicidal 
 wounds through the mouth the brain is uniniured, backward jerking of 
 the liead causing the ball to take an upward course in front of the cranial 
 cavity. When the bullet enters the lirain through the orbit or tlie mouth, 
 death is almost sure to follow from the primary injury or secondary septic 
 inflammation. Passing transversely, one or more of the larger blood- 
 vessels of the face or upper part of the neck may be wounded, and it is 
 the likelihood of the occurrence of sucii lesion that renders injuries of the 
 bodv of the lower jaw of grave import. Ijodgement of the ball, especially 
 in pistol shots, often occurs, such lodgement being in bone or in one of 
 
488 OUNSIIOT wouyDS. 
 
 the cavities — the frontal sinus, the antrum, the nasal fossa, or the orl)ital 
 cavity. In many eases, after havint;' remained in the face for a lonjj time, 
 the bullet has heen s])()ntaiieously extruded, or, haviiiji; uleerate<l its way 
 into the nasal fossa, has heen removed. Jn elfeetinji; sueh removal through 
 the anterior nai-es (it should not be pushed baekward, lest it drop down 
 the throat) much diiK(udty is often experienced, particularly so if the 
 bullet is deformed. In such case the nasal outlet should be enlarged, 
 or, better, the fossa opened throuuh the vestibule of the mouth by turn- 
 ing up the lip after the metlmd of liouge — an operation which gives free 
 and ready access to tiie nasal fossa and leaves no after def()rniity. 
 
 Striking an orbital ridge, tlie soft lead ball has frequently split. The 
 eyeball is quite often wounded, in civil life many of the injuries being 
 caused by pieces of cap or small shot. As a result the eye, if not de- 
 stroyed at once, is very apt to be lost through inflanuiiation, and there is 
 always much danger that sym|)athetie ophthalmia will be developed in 
 the other eye if the injured organ is not promptly removed. In a trans- 
 verse wound of the face the Indict may cut off the optic nerve, producing 
 immediate blindness, or so contuse it or lacerate the parts immediately 
 about as to cause, through nerve-concussion or inflammation, or through 
 pressure from a clot, temporary or permanent loss of vision. A like loss 
 of vision may be consequent upon a wound in the ff)rehead, by some at- 
 tributed to a reflex disturbance from a damaged sujtraorbital nerve, but 
 generally due to fracture running through the orbital canal (that Berlin 
 found to exist in every one of the thirty-four cases that he examined), 
 though it may be because of retinal hemorrhage from concussion. 
 
 Wounds of the side of the face may involve Steno's duct and cause 
 a salivary fistula. Generally such a fistula may be expected to close 
 spontaneously, and only very exceptionally will it fail to do so under 
 ordinary treatment. 
 
 Passing through the mouth, a bullet often wounds the tongue, either 
 grooving it or tunnelling it. The resulting swelling of the organ, which 
 rapidly comes on, may reach a high degree, so as much to interfere with 
 speech, swallowing, and breathing, and to cause protrusion beyond the 
 line of the teeth. The lesions, however, are not grave, except when the 
 Avounds involve its under part and the lingual artery or one of its large 
 branches is torn. Not infrequently a tooth or a piece of a tooth is driven 
 into the tongue, where it may at times be felt, often being mistaken for a 
 lodged ball until its removal. In rare instances the ball does lodge, and 
 cases are on record in which it has remained in place for years. 
 
 The treatment of these face-wounds is by expectancy, except as 
 vessel-lesions necessitate ligations. Entirely detached fragments of 
 bone are to be taken a^ay ; but oidy such, any adhesion, bony or peri- 
 osteal, being sufficient f)rdinarily to preserve vitality. By manipulation 
 partially adherent secpiestra can be largely brought into place, and if in 
 the lower jaw they cannot be properly maintained in apposition, they 
 mav be wired together. As is true in all the fiice-MOunds ordinarily 
 coming under care, none of the soft parts are to be cut away, no matter 
 how extensively torn and cruslu'd. ^\'hcn in communication A\ith the 
 mouth or nasal cavity the Avounds are always more or less septic, and 
 great care must be taken to keep them as clean as possible, frequent 
 irrigations being required. Besides the ordinary reasons for maintaining 
 
WOUNDS OF SEGIOXS. 489 
 
 cleanliness, there is here the additional one that grave distm-banees of 
 nntrition will be indnced by the passage into the stomach of foul dis- 
 chai'ges from the mouth. 
 
 Primary hemorrhage, when not from one of the large trunks, either 
 ceases spontaneously or is arrested by the application of hot water or by 
 compression. When from the tongue, it may l)e so profuse as to necessi- 
 tate plugging of the wound with gauze, its closure by sutures, the use of 
 the hot iron, or the ligation of the lingual or external carotid arter\-. li' 
 it is one of the main arteries that has been torn, the bleeding point should 
 be found if possible, and a ligatm'e applied above and below ; and if this 
 is impracticable, ligation should be done of the trunk near its origin, 
 of the external carotid, or (but never when it can be avoided) of the 
 common carotid. 
 
 Secondary hemorrhage, if severe, always if recurrent, should be 
 treated by ligation, which frequently, because of the condition of the 
 parts, will have to be at a distance. As has been stated before, chemical 
 styptics should never be employed : many a wounded man has lost his 
 life through violation of this rule. 
 
 Following destruction of tissue, soft and hard, cicatricial contractions 
 are often met with, atfecting the eyelids, the nose, the tongue, or the 
 temporo-maxillary articulation, producing deformity and impairing, in 
 high degree, it may be, the functional action of the parts. For the 
 relief of these, plastic operations may have to be done upon the eyelids 
 or the nose ; the tongue loosened up ; and a jaw-ankylosis treated Ijy 
 excision of the band or by resection of the joint, or, better, the establish- 
 ment of a new joint in front of the angle, according as the ankylosis is false 
 or true. ^Nluch can often be done by ])lastic operations or by the applica- 
 tion of a proper prothetic apparatus when there has been an extensive loss 
 of substance, the result generally of wound by a cannon shot or shell-frag- 
 ment. It has long been known that recovery takes place far more fre- 
 quently than would naturally be expected in these often frightful destruc- 
 tions of the face. A\'hen tiie superior or inferior maxilla has been crushed 
 and much of the bone has ijeen lost, in the process of healing considerable 
 approximation of the remaining fragments may take place, ranch lessen- 
 ing the amount of plastic or mechanical work that will have to be done 
 to repair the damage or to conceal the deformity. 
 
 Neck. — About one in fif^y of those wounded in action and reporting 
 for treatment has been found to be shot in the neck. For practical as 
 well as to])ographical reasons the wounds may be classified as of the 
 antero-lateral and of the jjosterior regions, the line of separation con- 
 veniently following the anterior borders of the trapezius muscles. In 
 front of these borders, except when very su])erficial, gruN'ity attaches to 
 the wounds because of the danger of a conij)licating injury of important 
 vessels or nerves, of the air- or food-tulies, or of the sjiine — injuries, 
 however, that are of comparatively infrecpient occurrence, though often 
 enough met with to make the mortality-rate of the lesions, taken together, 
 from 4 to 33 per cent, in different wars, 15 per cent, in our war.' Such 
 infrequency would be very surprising, considering the number and size 
 
 ' The number of wounds of the larger vessels in 1861-(Jo was 235 (211 arteries, 24 
 veins), about 1 in 21 of the injuries of the region ; of those of the air-passages, 75, about 
 1 in 50; and of the pharynx and oesophagus, 29, about 1 in 170. 
 
490 GUNSHOT WOUNDS. 
 
 of the vessels, the exposed position of the larynx and trachea, and in less 
 degree of the pharynx and wsoj)hagiis, and the size of the vertebral bodies 
 and the spread of the posterior arches, were it not for the knowledge that 
 the great majority of those wounded in these parts are left upon the field, 
 having been over 3 per cent, of those killed among the German troops in 
 1870-71. The posterior wounds chiefly damage the muscles, though 
 occasionally the spine is injured, and their mortality-rate is very much 
 lower than that of those located fiu'ther forward. These muscle-wounds, 
 whatever the region, are of intci'cst only on account of the tendency to 
 subsequent contraction and the f()rmation of adhesions, which, one or 
 both, may decidedly limit the motions of the head. Any produced 
 torticollis is likely to improve as time passes, but not seldom the deform- 
 ity has been a persistent one. 
 
 In the anterior and antero-lateral wounds, if suppurative inflamma- 
 tions arise, there is a strong probability that unless speedily j)revented 
 by free incision and thorough drainage it Mill extend along the fascial 
 planes into the chest or the axilla. Such inflammations, formerly so 
 common and often so grave, may now be expected to be prevented in 
 the greater part of the cases treated. 
 
 Hemorrhage as met with in military practice ^vill ordinarily be sec- 
 ondary, occasionally intermediary, almost never primary ; in ci\il jtractice, 
 the cases, as a rule, coming under care comj)aratively (|uickly, early 
 bleeding will be more often seen. It is to be treated as in other regions ; 
 when from an artery, by ligation if that can be effected, otherwise by 
 compression ; when from a vein other than the internal jugular, preferably 
 by compression, which often ans\vers the desired purpose. The internal 
 jugular had better be tietl, though its rounds have been so luiiformly 
 fatal that there is not much to encourage o]ierative interference. The 
 difliculty not seldom experienced in determining what vessels have been 
 Avounded or of getting at the bleeding point in the midst of the infiltrat- 
 ed — it may be sloughing — tissues \vill often compel ligation at a distance. 
 As has already been stated, the external carotid should be tied for a 
 wound of one of its branches rather than the common trunk, and when 
 there is micertainty as to whether it is the external or the internal carotid 
 that has been damaged, the vessels should be exposed at the bifurcation, 
 pressure employed on them alternately, and that one tied the compression 
 of which arrests the bleeding. Past experience proved the dangerous 
 character of these ligations in the neck ; in the future there ought to 
 be a lessened death-rate in proportion as sejitic infections are pre- 
 vented. Of the 76.8 per cent, moi-tality after ligation of the common 
 carotid in our war, and 68.75 per cent, among the Germans in 1870- 
 71, a decided proportion must have been due to infection, more than 
 would ajipear from the jmblished statistics ; and the same is true of 
 ligation of the subclavian and its branches (74.5 per cent, in 1861-65). 
 
 Aneurism has occasionally dcvelojtcd after these injuries — eleven 
 times in 1861-65, with 9 deaths (81.8 per cent.), ligation saving 1 
 case out of 5 (common carotid), and without ligation 1 out of 8 surviv- 
 ing, also of the common carotid. In a very few cases an arterio-venous 
 aneurism has formed, wounds of the vessels having established a com- 
 munication between the internal jugular vein and the c(immon, the in- 
 ternal, or even the external carotid artery. Such aneurism has proved 
 
WOUNDS OF BEGIOXS. 491 
 
 but little dangerous to life, though cerebral softening has been known to 
 follow, the more serious effects ordinarily met with being headaches, 
 dizziness, and the annoyance of the persistent bruit and thrill. As 
 respects treatment, non-interference should be the rule of conduct. 
 
 Nerve-lesions, as might naturally be expected, are frequent (in 1 in 
 12 of the neck- wounds among the Germans in 1870-71), many due to 
 direct injuries of the trunks, some to associated wounds of the spine, 
 even contusion of which may be followed by temporary paralysis, affect- 
 ing in rare instances the four extremities. Wounds of the larger nerve- 
 cords produce impairment of motion and sensation in the parts supplied, 
 of varying degree according to their extent, and reflex disturbances may 
 be set up in regions quite remote. Lesion of the hypt)glossal nerve has 
 caused motor paralysis and unilateral atrophy of the tongue ; that of the 
 sympathetic, contracted pupil, ptosis, and flushing of one side of the face ; 
 to injury of the pneuniogastric Larrey attributed the intense thirst which 
 is at times experience<l after wounds of the oesophagus. The brachial 
 plexus being wounded by ball or bone-fragment, not only may there be 
 paralyses of the muscles of the extremity, with after contractures, but 
 trophic changes in the skin, and that burning pain (causalgia) which is, 
 as Mitchell has declai-cd, " the most terrible of all the tortures which a 
 nerve-wound may inflict." Serious nerve-symptoms have at times been 
 consequent upon the pressure of a lodged ball, ceasing when the bullet 
 has been removed. Several important nerves may be injured by the 
 same shot,. as in a case reported by Stromeyer in which the phrenic, the 
 pneuniogastric, the middle ganglitin of the sympathetic, and the desceu- 
 dens noni were wounded, together with the larynx and pharynx. 
 
 The superficial position of the larynx and trachea exposes them to 
 considerable risk of being wounded, either alone or together or in asso- 
 ciation with injury of the pharynx or oesophagus : 82 such cases were 
 reported during our war, and 59 among the Germans in the Franco- 
 German ^\'ar. Their mortality is heavy (42.7 per cent, in 1861-65, 55.9 
 in 1870-71), more so in tracheal than in laryngeal wounds ; but much 
 of such fatality may fairly be attributed to accompanying lesions of 
 blood-vessels, spine, etc. In civil practice these injuries are commonly 
 much less serious, especially when made by small shot, and are often 
 contusions or groovings, not penetrations. The symptoms are, in general, 
 difficulty of breathing, inqiainnent of voice, spasmodic cough, and more 
 or less bloody expectoration and jiain, either or all of which may be pres- 
 ent when the air-passage has only been contused. When penetration 
 has occurred there may be in addition emphysema, a passage of air 
 through the wound on expiration causing a more or less decided blow- 
 ing sound, and, if the jiharvnx or oesophagus has also been opened, an 
 escape of li([ui(ls, though this latter symptom is not certain proof of 
 lesion of the food-tube, since it may occur because of an inactive epi- 
 glottis. If a laryngoscopic examination can be made, the internal wound 
 or the lodged shot may at times be seen. Qilema of the larynx may 
 come on rapidly and at any time, or the trachea be later compressed by 
 blood or exudations outside of it. Hemorrhage into the air-tube may 
 cause its oljstruction. So far as the wound itself is concerned, tiie treat- 
 ment is that of wounds in general. The liability to tiie sudden and 
 unexpected occurrence of suffocation makes it wise early to perform 
 
492 GUNSHOT WOUNDS. 
 
 tracheotomy, or at least to liave tlie jiatient so earefully and intelligently 
 watehed that the operation may be ])roinptly done if it sliould l)ecome 
 necessary. Very possibly an early intubation might often be done 
 instead of a tracheotomy, which latter ojieration in tlie wars of 1861-65 
 and 1870-71 was followed by death in 22 out of 34 cases (04.7 per 
 cent.). A lodged missile should, if possible, be removed, as its presence 
 is almost certain to cause trouble sooner or later. It has been knoAvn to 
 ulcerate its way into the oesophagus and be discharged at stool. At 
 times it may be taken out through the mouth by an intra-laryngeal ope- 
 ration. If the W(jund does not prove mortal, there is aj)t to be a per- 
 manent impairment of the voice ; often because f)f existing cicatricial 
 stenosis a tube has had to be worn ; necrosis of the cartilages is not 
 infrequent ; and aerial fistulas at times remain. 
 
 The pharynx and oesophagus are wounded much less often than the 
 air-passages, but the mortality of such wounds is gx'eat (54.84 per cent, 
 in our war), chiefly because of other grave lesions almost necessarily asso- 
 ciated with them, thougji difficulty of feeding and the occurrence of food- 
 pneumonia has not a little to do with it. Unless there is discharge of 
 food through the external wound, the diagnosis will largely rest upon the 
 determination of the direction of the shot, and often must remain only 
 conjectural. INIore or less associated laryngeal disturbance may be ex- 
 pected to be jiresent. As far as it can l)e dune, escape of the fond must 
 be prevented by suturing, by packing the wound with gauze, or by the use 
 of the oesophageal tube, according to circmnstances, since the presence of 
 food in the neighboring tissues is certain to cause an infective inflamma- 
 tion. In any case, sn})puration occurring, free exit must be given the 
 pus as soon as possil^le and drainage maintained. Much care must be 
 taken to secure to the jiatient a sufficient quantity of food, given by ])ref- 
 erence, as a rule, through a tube. Strictures and jiermanent fistula have 
 resulted in a small proportion of the cases that ha\-e survived the original 
 wound. 
 
 A wound of the thyroid gland, if not com]>licated by tracheal or 
 oesophageal injury, is of interest only because of the bleeding that occurs 
 — bleeding to be controlled by ligation of the vessel or by suturing, plug- 
 ging, or cauterizing the wound. 
 
 Spine. — In these wounds a vertebra may be contused ; one or other 
 of its component parts, body or posterior arch, fractured ; or the canal 
 opened, with associated lesion of the meninges or the cord, the latter 
 being much the more se\'cre injury. These wounds are produced by mis- 
 siles (bullets or shell-fragments) striking the back, passing from side to 
 side, and injuring the spine in its course, or coming from in t\x)nt, aflect- 
 ing the vertebra only after having wounded the jiarts anterior in the 
 neck, chest, or abdomen. It is to these last-mentioned complications that 
 much of the great gravity of these wounds is to be attributed. As is 
 true of head-injuries, this gravity is in but slight measure due to any 
 existing bone-lesion, being chiefly due to the damage done the cord or 
 its coverings, to concussion or compression from l)lood-elot or jius- 
 collection, to organic changes in the meninges or the nerve-tissue, or to 
 destruction of such tissue. Shock is always great, even to the extent 
 of producing instantaneous death with following traumatic cataleptic 
 rigidity ; and the same physical conditions that favor explosive action 
 
WOUNDS OF REGIONS. 493 
 
 in the head are here present — ahimdance of fluid and a rigid bony 
 envelope. 
 
 The symptoms are those of any and every injury of the oord, though 
 more marked, as a rule, than after other traumatisms. They are im- 
 pairment of the motions of the back ; partial or complete paralvses of 
 muscles of the trunk or extremities ; anesthesias and hyperfesthesias ; 
 peculiar and severe pains of a girdling, gnawing, tearing, or burning cha- 
 racter ; disturbances of respiration, of circulation, of defecation, of mic- 
 turition ; neurotic gangrenes, often of rapid development, in parts pressed 
 upon, as on the back, over the trochanters or heel, or at the distal ex- 
 tremities of the limbs from defective blood-supply, such as not seldom 
 also follow injuries of the nerve-trunks. Sometimes, MJien there has 
 been penetration of the canal, this fact will be evidenced by escape of 
 cerebro-spinal fluid ; but this symptom is by no means a constant one, 
 and when present only shows that the theca has been opened, not that 
 the medulla has certainly been damaged. Contusions of the spine usually 
 cause but temporary disturbance of motion or sensation, occasionally a 
 meningo-myelitis ; such inflammation, however, is lighted up less often 
 than after similar injuries of the cranial bones. These effects, aside from 
 those of infective character, are, as a rule, quickly recovered from with- 
 out serious after-consequences, though at times stiffness of the back or 
 some paralysis of an extremity remains, and in rare instances necrosis 
 takes place, as in a case reported by Keen, in which there was sponta- 
 neously discharged, after about three months, " nearly the entire body of 
 the third cervical vertebra, including the anterior half of the transverse 
 process and the vertebral foramen." 
 
 The fractures that come under care are largely those of the spinous 
 and transverse processes. Those of the body are nuich graver lesions, 
 and that whether the bone-lesion be one of groo\-ing, of penetration 
 with lodgement of the ball, or of perforation. In them the bone is often 
 much fissured. The lower in the column the fracture, the less severe it 
 is likely to be, the mortality-rate, as stated in the Medical and Surffical 
 History of our war, being 70 per cent, in the cervical, 63.5 in the dorsal, 
 and 45.5 in the lumbar regions. 
 
 Hemorrhages outside of the dura, within the theca, or in the sub- 
 stance of the medulla, especially the first two, are very generally asso- 
 ciated with spinal injuries, causing severe pain, often shooting around 
 the body and serving to indicate the location of the injury. Such pain, 
 when the extravasation is l)ut slight, ordinarily subsides in a short time, 
 returning again temporarily when the period of reaction sets in, and 
 then, as absorption takes place, more or less rapidly passing aM'ay, to- 
 gether with the paralytic condition produced by the clot. When the 
 clot is a large one, its pressure-effects are correspondingly great, and 
 there is generally an associated infective myelitis. Compression of the 
 cord is produced also by a lodged ball, or, more often, by depressed bone- 
 fragments. As in brain lesions, there is here always more or less con- 
 cussion of the medulla, and with the jarring there is usually associated 
 contusion of greater or less amount, thougii the cord is more protected 
 by the " water-bed " in which it rests than is the brain. Such contusion 
 with its associated laceration varies from that which is quickly recovered 
 from, without any organic change being produced, to that which is destruc- 
 
494 OUNSHOT WOUNDS. 
 
 tive to a part of tlio coic). Tlip extensive tearings and crushings, however, 
 are cliiefly due in tlic action of eitlier hail, l)one-fragment, or Ijotii. 
 
 I'lie prognosis in military jjraetice lias always been very grave, one- 
 half, two-thirds, three-quarters, nine-tenths of the cases coming under 
 treatment dying, the most of them within a few days. In civil life there 
 is more chance of recovery, the injury, as a rule, being less severe and the 
 patients coming sooner under care, and that after com])aratively little mov- 
 ing. Wlien the canal has l)een opened — by j)cnetration or by perforation, 
 it matters little wliieli — the danger is very much greater than in other 
 cases because of the compression or laceration of the medulla ; tlie wound 
 in those who have recovered heretofore liaving been almost always of the 
 sacral or lower lumbar vertebra' ; that is, below the end of the cord 
 proper. Antisejitic treatment may be expected to lessen somewhat this 
 mortality-rate, l3ut in all proljability its beneficial eiiect will not be very 
 great, as in many cases it will be impossible to secure asepticity ; and 
 sepsis is l)y no means the chief cause of death, which so oiten must result 
 from shock, hemorrhage, or associated lesions of imjwrtant viscera. 
 When there has been no injury of the cord or theca, other than perhaps 
 a limited extravasation of blood outside the sheath or a slight concussion 
 of the medulla, recovery may take place, and that with little after-dis- 
 turljance, organic or functional, this being especially true of wounds of 
 the processes, particularl)- the spinous. Kareh', however, is the wounded 
 man so fortunate. Almost certainly there will later be stiffness and weak- 
 ness of the back, impairment of function in arm or leg, muscular atrophies 
 frequently with e(jntractures, urinary troubles of greater or less severity, 
 neuralgias, ataxias, mental disturbances, one or more ; in other words, the 
 jirimary lesion, if it does not kill, may be expected to be followed by 
 ciironic inflammations and scleroses that cannot but be greatly disabling, 
 the effects of which may not perhaps be manifested for years. When a 
 nerve has been damaged close to its intervertebral foramen, the parts to 
 which it is suj>plied will be found to be seriously affected as respects both 
 sensation and motion. 
 
 Treatment, aside from that to protect against infection and that of 
 the ordinary complications of spinal injuries in general, has reference to 
 the removal of foreign bodies and the securing of rest to the injured part. 
 When the bullet has been located and its extraction is feasible, it should 
 be taken away and the wound cleared of such non-adherent bone-fragments 
 as can be found. Sometimes the extraction of the ball has been followed 
 by hemorrhage sufficient to necessitate plugging. Karely has ligation of 
 an artery been required. Recently nnich attention has been directed to 
 the performance of laminectomy for the relief of pressure, whether caused 
 by a displaced fragment, by a blood-clot, or, later, by an overgrowth of 
 bone. In the present state of surgical jiractice a jiroperly-conducted 
 operation of this sort does not mateinally add to the dangers of the ease, 
 and permits of a determination of the condition of the theca and cord, 
 the removal of whatever may be pressing upon the medulla, the extrac- 
 tion sometimes of a l^all lodged in the body of the vertebra, and the 
 thorough cleansing of the wound. To open up the canal a trephine may- 
 be employed, or, better, the chisel and the cutting forceps. In gunshot 
 even more than in other fractures of the spine, operative interference 
 promises to be of veiT much service, freed as the operation now is of the 
 
WOUNDS OF liEGIONS. 495 
 
 greater part of the danger of lighting uj) a septic raeningo-myclitis. If it 
 does no good, it will ordinarily do no harm. The cases in which it iias 
 been done are as yet too few to permit of tiieir statistics being regarded 
 as establishing a rule of conduct ; but mere numbers of reported deaths and 
 recoveries ouuht never to be so regarded. Sound reasonina- and observa- 
 
 o o o 
 
 tion of the analogous ordinary accidents of civil life certainly now justify 
 — more, authorize — the operation in any case in which there is not such 
 associated injury of vessel or organ as makes recovery under any circum- 
 stances imlikely. The coexistence of any serious visceral lesion contra- 
 indicates any operative interference. Whether an operation is done or 
 not, the spine should be immobilized and rest as absolute as possible 
 secured to the patient. 
 
 Chest. — A considerable proportion of the wounded in action (6, 8, 
 even 10 per cent, of those receiving treatment during a given war, and 
 one-third to one-half of those killed outright) have been found to have 
 been shot in the chest. In civil life such injury has been frequent, ])i'o- 
 duced either accidentally or with intention. The wound may be of the 
 parietes or involve the cavity by jienetration or perforation, and if of the 
 chest-wall may be associated with fracture (costal, sternal, vertebral, clavic- 
 ular, or scapular) or with lesion of an important vessel or nerve. 
 
 When there is no such complication a non-penetrating wound is usually 
 one of little moment — simply a flesh wound, to be treate<l in the ordinary 
 way. Formerly, especially when the round ball was used, the missile at 
 times ran for a greater or less distance around the chest, but such course 
 will not be taken by the bullet of to-day, pistol or rifle ; the exceptions 
 to this rule being only apparent, involuntary muscular action, as shown 
 by Bardeleben, so changing the position of the parts as to cause the actual 
 straight line to seem to be a curved one. 
 
 As the result of the blow upon the chest, concussion of the lung in 
 greater or less measure occurs, indicated by difliculty of breathing, pain, 
 and the symptoms of shock, all usually of but temporary duration. 
 When the force of impact has been very great, commonly in shell-frag- 
 ment injury, contusions of the hmg-surface, lacerations, or injuries of 
 the main blood-vessels have occasionally been observed, the parts being 
 forcibly compressed between the chest-wall (the elasticity of which per- 
 mits of its being strongly crowded backward) and the distended lung, 
 the air in which may be held in place by an associated closure of the 
 glottis. In such injuries the concussion symptoms just mentioned are 
 more severe, those of collapse are not seldom added, and a quickly fatal 
 termination has at times been reached — an almost certain result when the 
 laceration has been extensive. The occurrence of bone-lesion decidedly 
 increases the gravity of the case, though in less degree now than prior to 
 the adoption of the antiseptic method of treatment ; and danger from this 
 cause may be expected to be less in future wars than in those of the past 
 in proportion as the new bullet is smaller than the old and produces 
 less separation of fragments. The sternum may be grooved, and with 
 the groove made by the modern missile there will ])rol)ably be fissures, 
 and very likely a transverse crack through the entire thickness of the 
 bone ; the rib-fracture M'ill almost certainly cause injury to the pleura ; 
 the clavicle may, though very rarely, be transversely broken without 
 splintering — ordinarily its fracture will be compound and conuninuted ; 
 
496 GUNSHOT WOUNDS. 
 
 tlie scapula may be perforated or extensively splintered ; tlie vertebral 
 injuiy will commonly be of" tlie sjiinous jjrocess without injtu-y to the 
 cord or its coverings. The gravest of the non-penetrating woiuid.s are 
 those in which the axillary vessels, those just above the clavicle, or 
 those around the scapula have been M'ounded, a decided proportion of 
 which are quickly fatal. Karcly met with, these vessel-injuries may 
 be more conveniently considered in comiection with perforating K'sions, 
 of which they are at times complications. Taken all together, the 
 external chest-wounds have a very low mortality-rate (1.5 per cent, 
 in our war — 1 per cent, only excluding the fracture cases). Their 
 treatment is the ordinary antisejitic one, combined with comfortably 
 firm bandaging of the chest or immobilization, as fiir as may be jirac- 
 ticable, of the whole thoracic region. When pneumonia or pleuro- 
 pneumonia comes on in consequence of lung contusion or laceration, it 
 is to be treated in the usual way, though in the absence of the specific 
 infective organisms of true pneumonia or those of suppuration the 
 traumatic inflammations arc of mild character. 
 
 Of far greater severity, though fortunately of decidedly less fre- 
 quency as they come under care, are the penetrating and ]>crforating 
 lesions. Among wounds received in action hereafter rarely will there 
 be found one of the former, the new bullet almost certainly passing 
 through and out, and in the large majority of pistol-shot wounds the 
 ball is now found to jierforate either comj)letely or so far as the thoracic 
 cavity is concerned. The result is and will be that a larger percentage 
 of the cases not quickly fatal do and \vill get well, freed as they must 
 be more or less completely from the dangers of suppurations, fistulte, 
 and septic infection. Prompt healing characterized the cases observed 
 by Stitt in the late Chilian AVar. Even when the ball has lodged, if let 
 alone it commonly does no harm when an aseptic or antiseptic state of 
 the wound is secured. Never again, probably, will the death-i'ate of 
 the cases treated reach 80 or 90 per cent., as in the Crimea, or 65 per 
 cent., as with us, or 68 per cent., as in 1870-71. Very much more than 
 half of the pistol-shot cases in our ho.spitals recover ; indeed, death is 
 exceptional in those not almost necessarily fatal from the nature of the 
 injury. 
 
 Wounds of both lungs, the shot having passed from side to side or 
 very obliquely antero-i:)Osteriorly, are and nuist be grave lesions, because 
 of shock, hemorrhage, or developed septic inflammations, but because 
 of the smaller smoother bullet and protection from sepsis they are now, 
 and will be in the future, less frequently than heretofore followed by 
 death. 
 
 Multiple wounds are but little if any more dangerous because of 
 their number, their gravity being determined by the character of the 
 individual injuries. 
 
 That penetration has occurred may or may not be clearly ap])arent, 
 the only positive proof of lung-wound being afforded by ])rotrnsion of 
 a part of the organ (primary hernia), the regular to-and-fro j)assage of 
 air synchronously with the respiratory movements (traumatopncca), actual 
 inspection of the lung through the wound, or upon digital exploration. 
 The evidence from neither sight nor touch is obtainable in the ordinary 
 bullet wounds of to-day, and the hernia and peculiar breathing only very 
 
WOUNDS OF REGIONS. 497 
 
 rarely are to be observed. Probing should not be resorted to, as if the 
 diagnosis cannot be otherwise made it is not necessary to establish it, and 
 much harm may easily be done by such exploration. ^Vhen there is 
 present a wound of exit as well as one of entrance, and the line joining 
 them passes through the cavity, it may now be taken for granted that 
 there has been penetration, for deflection of such Ijidlets as are in use 
 (i)ther than perhaps the smallest) will not occur. Emphysema also might 
 be regarded as proof positive were it not for the fact that in a limited 
 degree it may be present in a non-penetrating injury, air sucked in from 
 without being, because of the valvular character of the track, prevented 
 from entirely escaping upon expiration. 
 
 The ratit>nal symptoms, in general, ai'e pain, difficult, or more prop- 
 erly constrained, breathing, spitting of blood, and cough ; there being in 
 addition, when air or blood in quantity is in the pleural sac, compression 
 of the lung on one side with tliminution or arrestation of the chest move- 
 ments on that side, increased resonance on jiercussion when air, dimin- 
 ished Avhen blood, is present, with shock or collapse symptoms in greater 
 or less degree. Penetration may occur without injury to any part other 
 than the pleura, the ball cutting it in passing across the chest between 
 two ribs — an accident )irol:iably of very infrequent occurrence, very 
 luilikely to be recognized, and without interest except such as attaches 
 to the non-penetrating wounds. 
 
 Complicating these wounds are hemorrhages, lodgement of foreign 
 bodies, fractures, accunudations of air or j>us in the plcui'a or (jf pus in 
 the mediastinum, and associated lesions of the spine or of the parts below 
 the diaphragm. The bleedings may be cither external or into the chest- 
 cavity, the former when other than slight being ordinarily from the large 
 arteries or veins in the neck or axilla, the latter from the intercostals, 
 or, much less frequently, the internal mammary artery, from the great 
 vessels in the chest, or from the heart, those from the last two sources 
 commonly causing death so promptly that they need not now be consid- 
 ered. Bleeding from the lung-tissue is ordinarily not very abundant, 
 especially when the wound is toward the periphery of the organ, though 
 to it is to be attributed the bloody expectoration which is so frequently 
 observed during the tirst few days, and in some cases the produced hemo- 
 thorax — a complication, so far as it comes under treatment, commonly 
 due, ho^vever, to injury of the intercostals. Tlie hemorrhages from the 
 axillary or subclavian may be either primary or secondary, in the former 
 case the blood being discharged externally or infiltrating the surrounding 
 tissues, forming a fiilse aneurism. In a few cases late opening of the 
 subclavian has been consequent upon the fretting away of the arterial 
 wall by the rough end of a clavicle-fragment. 
 
 The lodged foreign bodies have usually been bullets, which have 
 become encysted, remaining at times for years without doing any harm, 
 or have been coughed up or by ulceration worked tiicir way into tiic 
 oesophagus to be later discliarged at stool (occurrences that have been 
 very infrequent), or have dropped into the pleural cavity to remain or to 
 be removed after ojjening of an enqiycma. No such lodgement may now 
 be looked for cxce]>t in a small minority of the pistol-shot wounds, and 
 in these cases encaj>snlation may l)e expected very generally to I'ollow. 
 
 Fractures are of much less importance as complications than hereto- 
 
 VoL. I.— 32 
 
498 GUNSHOT WOUNDS. 
 
 Cove, except wlicii frnirnK'nts of tlie broken l)one (coninioiily a rib) are 
 detached and driven into tlie bnijj;, and even tlien tlie resulting danger is 
 decidedly less than formerly. Protected from the development of septic 
 intlammations, neither a costal nor a sca])ular fracture produced by an 
 outgoing ball adds materially to the gravity of the case. Heretofore frac- 
 tnre of both scapulfe has been largely a fatal injury, but will be so here- 
 after only as the result of associated lesion of the spine or of important 
 structures in front of it. 
 
 Pneumothorax is but little likely to follow \vounds made by the mod- 
 ern small-calibred ball, and is very rarely seen to any serious extent after 
 pistol-shot injuries. 
 
 Pus-collections in the lung, the mediastinum, or the pleural sac must 
 also be much less frequent than before, though no antiseptic treatment 
 can be pursued that will prevent such infection of the blood-clot in tlie 
 pleural cavity as is j)roduced by organisms coming in through the air- 
 passages, or overcome the .septic influences of discharges into the medias- 
 tinum from an opened oe.sophagus — a complication of extreme rarity, yet 
 which may be present. 
 
 Associated wound of the abdomen, as might be expected, is one of 
 the graver com])lications, about three-quarters of the cases terminating 
 fatally, but fortunately is not very common, having been observed in 
 less than 1.5 per cent, of the chest- wounds reported by Otis. In civil 
 life the frequency is greater, but the mortality less. 
 
 In a limited number of cases, though the patient does not die, the 
 recovery is imperfect, the lung being contracted and bound down by 
 adhesions or being the seat of chronic inflammations or tubercular de- 
 posits ; fistulie may be persistent ; lateral curvatures of the spine may 
 be induced, etc. 
 
 The treatment of these penetrating wounds consists chiefly in secur- 
 ing rest. Shock, if severe, may necessitate the administration of ether 
 or strychnia by the mouth or hypodermically, alcoholic stimulants being 
 avoided as much as possible. No search for a lodged liall should be 
 made ; if it can be felt in the chest-wall, it may be removed at once or 
 left undisturbed for some days until the track may have so far healed 
 as to ensure jDrotection against any possible infection of its deeper part. 
 Any bleeding vessel that is in sight should be tied. The wound or 
 wounds should be thoroughly cleansed and closed with sterilized gauze, 
 and then the chest immobilized as far as practicable and rest as abso- 
 lute as possible maintained. Lately it has been advised to efl'ect 
 immobilization by the ajiplication of the plaster-of-Paris jacket, and 
 a series of twenty successful cases of pistol wounds thus treated has 
 been reported from the City Hospital of St. Louis. The effect of immo- 
 bilization, in whatever way it may be eftected, is, by restraining the 
 movements of the damaged part, to lessen bleeding, to jirevcnt the occur- 
 rence of inflammation, to favor absorjition of cfl'usions, exudations, or 
 extravasations, and to secure more rapid healing of the track. If there 
 is troublesome bleeding from an intercostal vessel, recourse should be 
 had to ligati(3n or compression, the ligature being applied directly to the 
 artery or thrown around the rib, and compression made by ha?niostatic 
 forceps or by tampon. Similar treatment should be ajijilicd, if jiossiljle, 
 to a bleeding internal mammary artery ; fortunately, wound of this vessel 
 
WOUNDS OF REGIONS. 499 
 
 is very rarely observed. Hemorrhage from lesion of a large external 
 vessel above or below the clavicle should he arrested whenever it can be 
 done by the aj)plication of a ligature, and such operation must certainly 
 prove less dangerous hereafter than heretofore (75 to 85 per cent, mor- 
 tality of the subclavian and axillary ligations) ; if for any reason ligation 
 cannot be eifeeted, compression must be employed. Hiemothorax, if the 
 accumulation is large and the produced dyspnoea great, may be treated 
 by aspiration, but it ('ertainly is better freely to lay ()i)en the chest, 
 remove the clot, ami wash out tiie pleural cavity — treatment impera- 
 tively demanded at once if tlic clot becomes infected, as indicated by 
 the ordinary symptoms of septic infection. 
 
 Empyema should always be treated by incision, with exsection of a 
 piece of rib sufficiently large to ensure free drainage. An Estlander 
 operation may be required under conditions similar to those making it 
 proper in eases not consequent upon gunshot injury. 
 
 Suppurative intlammations in the mediastinum necessitate prompt 
 and tiiin'ougii opening of the abscess and careful drainage, any foreign 
 body, ball, bone, or other, lodged in the space being removed. 
 
 Should an cesopliageal M'ound be recognized, the patient must be fed 
 througli a tube carried into tiie stomacii ; but as only two cases of such 
 woun<l are on record, and one of these is doubtful (Delorme), there is 
 little likelihood of this l)ein": found necessarv. ' 
 
 Here, as in the extremities, fractures are to be treated largely expect- 
 antly, completely detached fragments only being taken away. The sharp 
 ends of a broken rib or clavicle may very properly be taken off with the 
 cutting forceps. In scapular wounds no effort to remove fragments 
 should be made, since such fragments are so generally held in place by 
 periosteal, muscular, or fascial attachments tiiat, protected from sepsis, 
 their reunion may be looked for. If necrosis of tlie bone, partial or com- 
 plete, occurs, late sequestrotomy may be safely performed. 
 
 Secured from infection, no lung inflammation, pro]ierly speaking, will 
 be developed, the reparative changes going on about the track of the ball 
 giving rise to little or no constitutional disturbances and requiring no 
 special treatment. If true pneumonia is lighted up, it must be cared for 
 in the ordinary way, as also any localized suppurations or gangrene. 
 
 Hernia of tiie lung, should it be present, necessitates return of the 
 protrusion, and its retention by an appropriate compress and bandage. 
 Such complication, which may occur at once through the wound or later 
 under the skin because of inq)erfect closure of tlie o])ening in the chest- 
 wall or of yicl<ling of the cicatrix, lias always been of extreme rarity, and 
 is very unlikely ever to be associated with wounds made by the small 
 bullets of the present time. The same is true of omental and intestinal 
 protrusions, which Iiave been liuown to occur when a shot has passed 
 through the seventh, eigiith, or ninth intercostal space, especially the 
 latter, and tlie diaphragm lias been wounded, jiarticularly on the left side. 
 
 In civil life a proper antise})tic treatment will almost certainly be fol- 
 lowed by speedy recovery in cases not necessarily fatal from the character 
 and extent of the wound ; and the same may be hoped for in military 
 practice in proportion as it is possible to institute and maintain such 
 treatment. 
 
 Heart. — These injuries, of not very frequent occurrence and still 
 
 & 
 
500 GUNSHOT WOUNDS. 
 
 less often coniinjr under treatment beeaii.se of tlieir sreat primary mor- 
 tality, are either contusions, openings of the pericardium, t)r [)euetrations 
 or perforations of the heart itself. 
 
 Contusions must generally be consc(juent uj)on the imjjact of a missile 
 the velocity of which is almost spent, though even then there may be force 
 enough left to cause a laceration of the heart or of its envelope. 
 
 Oj)ening of the perieardiuiu without visceral wound can l)e caused 
 only by a tangential blow, and its diagnosis nuist commonly remain 
 doubtful. 
 
 Penetration of the organ with lodgement of the missile (almost cer- 
 tainly in the ventricular wall or septum, occasionally in the cavity) will 
 be met with only in pistol-ball or small-shot injuries, the bullet of the 
 service rifle always perforating. 
 
 As might be expected from the anatomical relations of the parts, 
 wound of the pleura with or without wound of the lung very generally 
 accompanies the heart wound. 
 
 Though the prognosis is very grave, yet life may be prolonged for 
 days, weeks, or even months (o^■er three years in a case personally ob- 
 served '), a blood-clot or contractions of the muscular filjres closing the 
 wound until organic union can be effected. Fischer found in the cases 
 analyzed, 72 in number, 16 per cent, of recoveries, a percentage doubt- 
 less much higher than it really is. In the cases that do not quickly die 
 a heart lesion, pericardial or endocardial, almost certainly remains. The 
 chances of recovery are much greater in wounds of the ventricles than in 
 those of the auricles, injury of the right ventricle being less dangerous 
 than that of the left. 
 
 Whether penetrating or perforating, it matters not — for ordinarily the 
 one class of injuries cannot be diagnosticated from the other — the symp- 
 toms of these wounds are tluise of profound shock and collapse, with great 
 irregularity of the pulse and alteration of the heart-sounds, the bruits 
 being confused and confusing. In the case mentioned of extraordinary 
 prolongation of life they were of the most bizarre character, blowing, 
 churning, rasping, altogether unlike those ordinarily heard. There may be 
 considerable hemorrhage from the wound, or, as often hapjiens, the blood 
 may accumulate in the pericardium, l)y its pressure much enfeebling the 
 heart's action. When there is such jjcricardial extravasation there is a 
 mucli increased area of dulness on percussion ; the opposite condition of 
 exasaerated resonance has been noticed in a few cases in which there was 
 an accumulation of air in the cavity. Very rarely has a suppuratnig 
 pericarditis been observed. 
 
 The treatment should be directed toward relieving shock, arresting 
 hemorrhage, and controlling the heart-inflammations, the wound being 
 antiseptically closed and the chest innnol>ilized. When there is a dis- 
 turbing amount of blood in the pericardium, jiaracentesis should be cm- 
 ployed, or, better, free incision of the sac — an operation Avhich cannot 
 materially increase the existing danger and may prove of great benefit. 
 Suturing of the wound in the heart-wall has been proposed ; it is not 
 likely to be often done. 
 
 Abdomen.— About 1 in 30 of those wounded in the ^vars of the last 
 half-century and 1 in 9 of those killed in action were shot in the abdo- 
 
 ' Reported in Tlie Clinic, t'incinuati, 1876, x. 253. 
 
WOUNDS OF REGIONS. 501 
 
 men. In approximately equal proportion the wonnds have been found 
 to be of the ])arietes outside the peritoneum and intra-peritoneal, pene- 
 trating or perforating. Hereafter the army bullet will almost certainly 
 go through, the only foreign bodies lodging being pieces of cloth or other 
 substances accidentally carried in. In civil practice the deep wounds are 
 much the more comuKm, certainly so as cases present themselves in hos- 
 pital, and their ratio to the whole number of gunshot injuries is higher; 
 very possibly, however, their universally recognized gravity causes them 
 to be more generally brought under such care. 
 
 Of the extra-peritoneal wounds a few are contusions, l)ut in the great 
 majdrity the missile has either entered and lodged or passed through the 
 wall without damaging the serous membrane. Contusions have become 
 less and less common as impi'ovements have been made in weapons and 
 poM'der. Generally produced by spent shot, they are very apt to be 
 complicated by visceral lacerations, which have caused death in from 
 one-half to two-thirds of the whole number of cases. In tlie milder 
 injuries muscle-rupture has been frequently observed, and gangrene of 
 the damaged area with after-suppurations in the wall. When internal 
 lesions are not present the treatment is a simple antiseptic one, with as 
 absolute rest of the parts as can be secured ; but if because of profound 
 shock and collapse there is good reason to believe that visceral ruptiu'e 
 has occurred, laparotomy should be done, though the prospect of saving 
 life is but slight. In civil life these contusions are very unlikely to be 
 met with. 
 
 When the missile has merely passed into the wall, whether it stops 
 or goes out, the wound produced is an ordinary flesh one, the dangers of 
 which are hemorrhage and septic infection. Foreign bodies, if they can 
 be located, should be extracted, though there is not now the same neces- 
 sity for finding them as in former times ; bleeding, if severe or persistent, 
 as it often is, should be arrested by ligation of the vessel, free incisions 
 being made if recpiired ; and a most careful antiseptic dressing should be 
 applied. Under such treatment there is no good reason why healing 
 should not very generally and readily take place, and the mortality-rate 
 be decidedly reduced from the 8 per cent, or more of our late M'ar. 
 When the injury produced l)y the shot has been an extensive one, there 
 is much lial)ility to the after-development of ventral hernia. 
 
 The Wdunds of special interest are those in which the peritoneal cav- 
 ity has been opened. In ])crhaps 3 per cent., or even 5 per cent., of 
 these the viscera have escaped injury,' but the probabilities in any given 
 wound that serious damage has been done are so great that it should be 
 assumed as a fiict that such has been the case — certainly so if the ball 
 has ])assed from side to side, the antero-postcrior woiuuls only being 
 those in which the organs may escape. The intestinal tract is the 
 part most likely to be wounded, the small intestines being damaged 
 four times as often as the large ; then follow in order of frequency the 
 liver, the stomach, the kidney, the s|)leen, the pancreas. Of any 100 such 
 wounds as tiiey occurred in 18(31-65, tiicre were 64 of the intestines, 17 
 
 ' Recliis and Nogiife found this condition existing in 1 out of 38 experimental shots; 
 Senn, in 4 out of 14 ; in 30 laparotomies tabnlated bv MacCorinac simple penetrating womid 
 was twice fonnil ; Senn observed it in 2 of his (> cases of operation (in one of which 
 there was a piece of cloth in the cavity), and Kechis and Xogues report it as present in 
 17 out of 123 collected cases of shot and stab wounds. 
 
602 GUNSHOT WOUNDS. 
 
 of tlie liver, 7f each of the stomach and kidney, 3 of the spleen, and J 
 of 1 of the pancreas. Ahiiost certainly the lesions are multiple, of the 
 hollow viscera, of the solid, of the oiuciitiim or mesentery, of the lung, 
 of the great vessels, etc. The number of intestinal perforations aver- 
 ages between 4 and 5, and has been knt)\\n to reach as high as 16 or 
 even more. 
 
 The extent of damage to any viscus is very variable, an apparently 
 explosive action being at times oljserved in the solid viscera, and even in 
 the stomach or intestine when full of Huid. 
 
 The general mortality has been very high, its rate being in our war 
 87.2 per cent., and in various wars, as tabulated by Otis, 75.1 per cent. 
 Even in the less grave injuries of civil life caused by pistol balls the 
 death-rate has until recently been generally much above oO ]ier cent. In 
 the Chambers Street, the New York, and tiic Roosevelt hos])itals, in the 
 vears 1876-84, of 23 cases treated conservatively 15 died — 65 per cent. 
 (Stimson). In the five years immediately jireceding iNIay, 1887, of 32 
 cases in the Charity Hosj)ital of New Orleans, 19 died — 59.4 per cent. 
 (T. G. Richardson). Of 91 cases collected by Reelus and Nogues, but 
 22 died — 24 per cent. As Ave shall see later, the average death-rate of 
 cases operated upon during the last ten years has been abt)ut 66.2 per 
 cent. 
 
 This very heavy mortality has been because of shock, of liemori-Jiage, 
 and of septic inflammation — of the latter in those cases in A\hich life is 
 prolonged beyond a few hours. The organisms causing such inflamma- 
 tion may be introduced from without (chiefly on the fingers of those who 
 handle the wounded man or ujxm the instruments of the surgeon), are 
 present in the discharges from the intestinal canal, have been carried to 
 the damaged area in the blood-stream, or have passed through the un- 
 wounded bowel. Shock must remain as heretofore, but under modern 
 methods of treatment hemorrhage can be largely controlled by ligation, 
 and the introduction of pyogenic bacteria from without be prevented, or 
 their deleterious influence when introduced from within in some measure 
 lessened by thorough cleansing of the soiled cavity and closure of the 
 visceral wounds. In both hollow and solid viscera there must hereafter 
 be less damage done by the small-calibred bullet than was formerly 
 caused by the large, often deformed, mini& ball, at least outside the zone 
 of explosive action. 
 
 The mortality of wounds of the several \-iscera varies within rather 
 wide limits. As observed in 1861-65, it was of the liver 63.5 per 
 cent., of the kidneys 66.2, of the stomach 75.9, of the pancreas 80, of 
 the intestines 89.4, and of the spleen 93.1. Of 50 cases of kidney 
 wound studied by Edler, the mortality-rate of the 20 uncomplicated 
 wounds of the organ was 25 per cent., and of the 30 in which there 
 were associated wounds of importance 44 per cent. ; of 42 wounds of 
 the spleen 83.37 per cent. died. In the pistol-shot wounds of civil life, 
 though the present fatality of each of these visceral lesions is decidedly 
 less, there is still a marked difference between them, the prognosis of in- 
 juries of the stomach or of the large intestine being, as it always has been, 
 much more favorable than of those of the small intestines. In all of 
 the wounds of the alimentary tract, those, received A\'hen the stomach or 
 bowel is emj)ty are less dangerous tiian those received when it is full. 
 
WOUNDS OF REOIONS. 503 
 
 The diagnosis of penetration, at times easily and definitely estab- 
 lished, is not seldom very uncertain in default of an opening up of the 
 track of the ball or an abdominal sectii)n. If through the external 
 wound there is an escape of intestinal contents or of l)ile, or ])rotrusion 
 of bowel, omentum, or j)ortion of a winuKled solid viseus, there can be 
 no question respecting the opening of the cavity. But such positive 
 evidences of penetration are affordetl in but a minority of cases. The 
 presence of even small quantities of the intestinal contents in the per- 
 itoneal cavity has been comparatively rarely noticed in pistol-shot 
 wounds operated upon, much less often have such matters been dis- 
 charged externally ; and the same will doubtless be true of the injuries 
 caused by the new bullet. The ojienings are often so small that they are 
 plugged by the pouting mucous membrane or closed by changes in the 
 parallelism of the coats of the bowel or by the adhesion of adjacent coils 
 of intestine oi' omentum. Sometimes the fecal extravasations have occurred 
 only after tlie lapse of some hours or even days (because of the primary 
 paralysis of the bowel), at a time, therefore, when this diagnostic 
 evidence is of little practical value. Escape of bile, indicative of 
 Hvei- wound, may be expected to take place in but about two-fifths of 
 the cases of injury of that organ, only probably in those affecting its 
 central part, and in but a portion of these cases will it flow out through 
 an external wound. Hernia, whether of intestine, omentum, or of a 
 portion of a damaged solid viseus, very rarely occurs, and is not to be 
 ex]K'cted in M'ounds made by pistol balls or the small-calibred rifle 
 bullet. Otis found but two instances of bowel protrusion rej)orted to 
 the Surgeon-General during our war, a number without doubt much 
 smaller than that of the cases actually occurring. One such case, of 
 which no record appears in the Med. and Suiy. Histori/, came under 
 personal observation during the siege of Port Hudson, the protruding 
 knuckle of small intestine showing perforation wounds.' 
 
 As a rule having few exceptions, the diagnosis of penetration will 
 have to rest upon observation of the position of the wound — or, better, 
 wounds, the ball having gone through — iqion hemorrhage from the 
 stomach or tlie l)o\vel, blood-stained vomited material, extreme shock, 
 collapse indicating hemorrhage in considerable amount, or, after the 
 lapse of days, the discharge of the ball at stool. Neither shock, nor 
 vomiting of blood or blood-stained mucus, nor bloody stools positively 
 indicates penetration of the stomach or bowel, as either may possibly 
 be consequent upon contusion ; liut the occurrence of these symptoms 
 in connection with the location of the wound makes the diagnosis very 
 
 ' In 1872, Asst. Surg. Patzki, U. S. A., reported to the Surgeon-General from Fort 
 Clark, Texiis, an accitrental wound made by tlie ball of a Derringer pistol, cal. .3(5, at 
 1 foot distance, the shot entering li inches above the umbilicus, J inch to the right of 
 the median line, and lodging, its location being undetermined: 2.] inches of the omentum 
 protruded. On the seventh day after the injury this protruding omentiuu was removed 
 with a wire ecraseur. It was at the time " firudy adherent to the sides of the wouud, 
 thickened, more solid (carnitied), covered with grauulations secreting oticnsive pus. 
 Patient's condition very good. Vomiting after injury, but no blood in the vomited matter 
 or stools. The protruding ouientum, being useful as a plug, closed wound liermetically. 
 No attempt made to return it. No symptoms of internal hemorrhage, fecal extravasa- 
 tion, or peritonitis. Expectant treatment." Recovery rapid ; wound cicatrized eleven 
 days later. Returned to duty twenty days after receipt of injury, bullet still remaining 
 in the bodv. 
 
504 GUNSHOT WOUNDS. 
 
 probaljlc. A Imll ])assin^ from side to side at or below the level of 
 the uiiibilicus, at such deptli beneath the highest point of the curve 
 of the altdomiual wall as will more than carry it thmugh the thickness 
 of the wall, must certainly wound the intestines. When Seun in 1888 
 rejjorted upon the results of the experimental rectal insufflation of 
 hydrogen gas, it was hoped that there had been found a sure and safe 
 method of establishing the diagnosis of bowel-wound. Hydrogen gas 
 slowly and continuously introduced under a pressure of from l to 2 
 pounds was shown to pass the ilco-csecal valve and traverse the entii'e 
 length of an uninjured alimentary canal, while if there was a wound 
 at any point it would escape through such, distend the abdominal cavity, 
 obliterating the liver-dulness, and find its way out through the external 
 shot-opening, as proved Ijy its ignition when a flame was l)rought near 
 such opening. Unfortunately, experience has shown that the test is not 
 always reliable, the passage of the gas being at times obstructed by 
 fecal accumulations in the lower bowel, or its escape externally being 
 prevented by adhesions, ordinarily omental, at the inner opening of the 
 track through the al)dominal wall. When, then, there is serious question 
 of there being penetration, the wound should be carefully laid open 
 until it is clearly shown that it does or does not involve the peritoneum. 
 If the shot has passed transversely, the cut may be made in the middle 
 line, when, if the wound is extra-peritoneal, its track will be crossed 
 before the peritoneum is reached. It is never wise to explore the track 
 of the ball with a finger or, much more, a probe, since penetration may 
 thus be made in cases in which the serous membrane has not been 
 pierced, or adhesions may be broken up or hemorrhage excited. 
 
 Kidney lesion is established as a ])robability liy shock, the direction 
 of the course of the shot, and the discharge from the bladder of bloody 
 urine, though the latter symptom may be present in connection with 
 ureteral contusion or laceration, or with injury of the bladder itself. 
 When the wound is from behind, the visceral A\ound may be altogether 
 extra-peritoneal, and urine may escape externally or into the tissues 
 about the organ. If there is associated penetration of the j>eritoneum, 
 there may or may not be extravasation of urine into the abdominal 
 cavity. 
 
 As shown by Redard in 1870, grave lesion of the contents of the 
 abdominal as of the cranial and thoracic cavities is always to be inferred 
 when there is from the beginning for four, six, or more hours a sub- 
 normal temperature. 
 
 The occurrence of j)ei'it<initis (which if it is developed is almost cer- 
 tain to be so in from eighteen to thirty-six hours) is indicated by the 
 ordinary symptoms of the disease, the marked acceleration of the pulse 
 (it is often very great) being of much more diagnostic value than the 
 temperature-changes, which are frequently but slight. 
 
 Treatment is either by abstention or by ojierativc interference. Up 
 to a time not fifteen years ago surgeons generally were content to apply 
 cold ; to put on a bandage, even of plaster of I*aris (Xeudorfer) ; to main- 
 tain rest as absolute as possible ; to feed sparingly, and that with fluids ; 
 and to administer opium, given at times with so free a hand as to make it 
 questionable whether the fatal result was due to the injuiyor to the treat- 
 ment. But the death-rate was so high that not a few were dissatisfied 
 
WOUNDS OF REGIONS. 505 
 
 with the course adupted. Sims had advised laparotnniv that l)lee<Hng 
 vessels might be toiuid and tied, and Bahr had reeonnnended that on the 
 battle-fiekl the wound of the al5<h)niiual wall should be laid open and 
 enlarged, the cavity cleansed of fceal matter, and the wound of the bo\vel 
 closed by suture. Otis had protested against the " do-nothing system," and 
 ^leGiiire had urged operation, declaring that if such measure was a desjier- 
 ate one the peril was so extreme that under the usual treatment nearlv all 
 the patients died. In 1881, Kinloeh did an exploratory laparotomv and 
 closed three perforations ; two years later Koclier by a similar operation 
 saved the life of his patient, and in 1884, Bull was equally fortunate, his 
 case being the first successful one in our country. In the same year 
 Parkes as chairman of the Surgical Section rejtorted to the American 
 ]\Iedical Association the results of many experiments upon dogs, and 
 advised and urged direct operative interference in all intra-peritoneal 
 wounds. Since that time the ijuestion has been not whether the abdomen 
 should be opened and lesions treated surgically, but in what cases it should 
 be done — or, rather, whether or not it should be done always and as soon 
 as possible. To answer this question it must be known what are the proba- 
 bilities of recovery when operation is not done, and what have been the 
 results of the sections that have been made. 
 
 It has already been stated that in three of the New York hospitals 
 65 per cent, of the cases treated expectantly during the years 1876-84 
 died ; in the Cliarity Hospital of New Orleans, in five years prior to May, 
 1887, 59.4 per cent, died ; and of 91 cases collected l)y Reclus and Nogues, 
 largely from journal reports, but 24 per cent. died. Reclus has latelv 
 reported that of 114 revolver wounds of the abdomen treated expectantly 
 94 recovered — 82 per cent. The experience of surgeons generallv has 
 been such as to make them unwilling to accept these figures of Keelns 
 (24 and 18 per cent, of mortality) as representing the ordinary death-rate 
 at the present time of the wounds under consideration when ])roperly 
 treated by abstention. If they do, such treatment is very mucii better 
 than that by operation. It is very pi'obable, though, that the ordinarily 
 stated mortality-rate is too high, and would be found to be much lowered 
 in the practice of those willing to carry out fully and fi^iithfully the 
 strictest antiseptic method, and capable of doing so. 
 
 Of the death-rate after operation \ve can now speak quite definitely. 
 It was, in the eases collected by Korte, 65.6 pev cent. (64—42) ; by 
 Reclus and Nogues, 78 ])er cent. (73-57) ; l)v ^lorton, 67.27 per cent. 
 (110-74); by Barrow, 66 per cent. (112-74); by Martin and Hare, 
 66f per cent! (129-86) ; by Coley, 67.27 per cent. (165-111). Personal 
 reports from fifty-five of our American surgeons of all their cases give 
 a mortality-rate of 70.66 per cent. (174-123). Twenty-three had ope- 
 rated l)ut once, with a death-rate of 82.6 per cent., nine twice, with 
 death-rate of 95 per cent. ; eight had each seven or more cases, aggre- 
 gating 82 witli 50 deaths — 61 per cent. Here, as in other abdominal 
 operations, with increased experience come better results. In no small 
 measure certainly this larger percentage of recoveries is due to more rapid 
 operating, the time of exposure of the abdominal organs being a very 
 important factor in the ease. As shown by ]\[artin and Hare, an opera- 
 tion completed in an hour is three times as likely to be followed by recov- 
 ery as one completed in two hours. Of necessity, much time must be taken, 
 
606 GUNSHOT WOUNDS. 
 
 but it need not be on an average an hour and tliree-f|narters, as stated by 
 Pclornie. Tlie tedious part of the o]H'ration is tlie finding of tlie ])erfora- 
 tions and making sure tiiat they have all been found. Inch by inch the 
 small intestine must be examined, either laid out upon the abdominal wall 
 (protected by hot sterilized gauze or towels) or, much better, returned to 
 the cavity as fast as it has been inspected. Proper search must also be 
 made for any wound of the stomach, the large intestine, or the bladder, 
 an<l the jjresence or absence of a lesion of liver, spleen, or kidney deter- 
 mined. All this takes time, and time means risk, and not seldom, 
 notwithstanding the time taken and care exercised, a perforation or per- 
 forations have been overlooked by the best of surgeons. Insufflation of 
 hydrogen has at times proved of much service, lieing injected from ojien- 
 ing to opening from below nj)ward. In place of hydrogen, atmospheric 
 air may be used. Could the gas or air Ije always relied upon, and did 
 not its use expose to the risks of forcing open perforations already 
 closed and of expelling fecal matter into the peritoneal cavity, it would 
 be of extreme value because of the rapidity with which the wounds can be 
 located. 
 
 The necessary manipulations of a la])arotomy must now and then be 
 the cause of the breaking up of already-formed protective adhesions of 
 bowel to bowel, of bowel to omentum, or of bowel or omentum to the 
 abdominal wall. 
 
 The earlier the section is made the better, that bleeding may be arrested 
 and fecal extravasation ])revented, or, if it has occurred, that the exceed- 
 ingly irritant matter may Ijc removed before it has had time to exert to 
 the full its deleterious influence. All observation has shown that the 
 chances of recovery rapidly diminish as the hours go liy, the jiatient com- 
 paratively seldom surviving a lapartitoni}- done a half day or more sub- 
 sequent to the shooting. When j)eritonitis is fully developed, death is 
 almost sure to occur, but as once in a while relief is afforded by operation, 
 the section may properly be made. 
 
 In civil ])rai'tice la])arotomy should always lie done, and that at once — 
 
 1. When there is positive evidence of penetration in the protrusion of 
 bowel or omentum, though occasionally recovery may take place with- 
 out section after return of the protrusion or, if omental, its removal at the 
 time or later ; 
 
 2. When there is discharge externally of fteces, bile, or urine ; 
 
 3. When severe and rapidly-developed collajise sho^\■s that a large 
 vessel (or vessels) has been torn ; 
 
 4. When the wound has been made by a bullet of other than small 
 calibre, particularly if it is at or below the umbilical level, and especially 
 if the shot has passed from side to side. 
 
 In field service it will be quite difficult, and often altogether impos- 
 sible, to treat these wounds actively ; and, as military necessities may 
 compel at times an early removal of the wounded, this of itself will render 
 a successful termination of an ojieration much less probable than after 
 similar work in a well-organized hosjiital. 
 
 When the injury has been inflicted by a small liall of calibre not 
 above .22, and affects probably only an empty stomach or the colon or 
 one of the solid viscera, operation may very properly be postponed so 
 long as neither local nor constitutional symptoms of severity are present. 
 
wouyns of EEGioys. 507 
 
 Though stomach wounds made by a large bullet are among the gra%'er 
 abdominal lesions, from tiiree-quarters to seven-eighths of tiiem in 18(Jl-65 
 and 1870-71 dying because of hemorrhage or extravasation of the con- 
 tents ol' the organ, they may be expected to be much less dangerous 
 when produced by the present army bullet, unless received within the 
 zone of explosive action. As met with in civil life, where they are often 
 caused by small bullets, a considerable ])ro])ortion may be recovered 
 from eitiier with or witliout operation. The same is true of liver- 
 wounds, in many of which the diagnosis without section is quite uncer- 
 tain : the track is small, the bleeding is not excessive, jaundice very 
 rarely occurs (not in one in twenty cases probably), even a lodged ball 
 may be well borne, and if bile escapes into the peritoneal eavit_y it is 
 very much less irritant tlian was formerly supposed. Kidney-wounds, 
 if made from behind and not complicated by intra-abdominal lesions, 
 may he treated expectantly, unless tiie hemorrhage is great or there is 
 urinary intiltration of the surrounding tissues, when the organ should be 
 cut down u])on, ligation if necessary done, and free escape of the urine 
 secured, or, if the organ is much injured, nephrectomy performed. There 
 is douljtless much v.isdom in Titlany's suggestion to treat the kidney- 
 wound like any other, suturing it, draining it, and removing so much 
 of the viscus as lias been disorganized, remembering that if necessary the 
 whole kidney can later be taken away, and that with less risk than at- 
 tends a primary operation. Often wounds of this organ are complicated 
 with those of the liver or the vertebra. 
 
 The teclini(]ue of laparotomy for gunshot injury is in the main that 
 of the operation for otlier causes. Incision, as a rule iiaving few excep- 
 tions, should be in the median line, and not tlirough the wound, as thus 
 more ready access may be had to all parts oi' the alidominal cavity. 
 Bleeding should be first attended to, clots removed, the source of the 
 hemorrhage discovered if }iossible, and the wounded vessels tied. At 
 times an intei'costal artery or the internal mammary has been wounded, 
 and not seldom one of the large vessels of tiie pelvis ; but in very many 
 cases the bleeding is from the mesentery or from one of tlie solid viscera. 
 If active bleeding is going on, it may be temporarily controlled by 
 compression of the aorta or by gauze compresses, so that the parts 
 mav l)e rendered dry enough to permit of the vessel being seized and 
 tied. 
 
 The alimentary tract is then to be examined. All openings in the 
 bowel should be stitched up, except those so large that their closure 
 must be followed by marked constriction, or the very small ones that 
 are already plugged by the everted mucous membrane, which may be 
 left to tlieraselves if the general condition of the patient compels quick 
 completion of the operation. F'ue silk is far the best suture material. 
 Contused patches, if the injury is other than slight, had better be treated 
 as if they were open wounds, or they may be covered witii an omental 
 graft, which latter is often of service in giving additional protection to 
 the sewed wound. The ordinary I^embert stitch is commonly employed, 
 and as far as possible the seam should be made tran.sversely. When the 
 wounds are too large to be safely sewed uji, the damaged section of tlie 
 bowel must be excised, and either end-to-end or lateral anastomosis ef- 
 fected, preferably the former as a rule. If iatei'al anastomosis is made, 
 
508 GUNSHOT WOUNDS. 
 
 excision of the lacerated l)owel need not necessarily he done. Plates or 
 buttons may he used, tliough tliey are ntit necessary. Mesenteric ojien- 
 ings shoidd be closed and any bleeding mesenteric vessel ligated, either 
 catgut or, better, fine silk being employed. If there has been any con- 
 siderable laceration of the omentum, the damaged piece shoidd be tied 
 off' and cut away. 
 
 An existing wound in tlie liver should be sutured if it can be done; 
 if not, plugged with gauze, a drainage-tube (jireferably of glass) being 
 used if necessary. It has been advised to always take away a l)adly- 
 damaged kidney, but partial removal will doubtless often be found 
 sufficient. Lesions of the spleen, if much disorganization has not been 
 produced, may be treated simply ; when tlie tearing has been great 
 splenectomy is certainly indicated, in default of whicii plugging must be 
 resorted to — a method of treatment which nuist be used if tiiere is a 
 wound of the pancreas. 
 
 Cleansing of the abdominal cavitv should be verv thoi'ough, and it is 
 in this part of the ojieration that much time is often consumed. The 
 closure of the external wound is effected in the usual way, a drainage- 
 tul)e being used when there has been much bleeding or much soiling of 
 the cavity with alimentary matters. 
 
 The patient must be kej)t (juiet ; shock relieved by the administra- 
 tion hypodermically of ether or strychnia (hot- water douching of the 
 ca\ity is of great value in relieving shock temporarily while the opera- 
 tion is in progress) ; fluids witidield as far as possiljle for at least twenty- 
 four hours ; and after that for several days an absolute milk diet observed, 
 milk, besides its value as a food, having been clearly shown to have a 
 decided germicidal action. As after the moi-e common laparotomies, the 
 administration of saline cathartics is of service in relieving gaseous dis- 
 tention and preventing peritonitis. 
 
 In a limited number of eases (very rarely, however, in civil practice) 
 fistuhe have followed abdominal wounds, almost always in connection 
 with the large intestine. The spur so often ob.servcd in artificial anus 
 after hernia has been very infrequent. Generally these ffstulas have 
 closed spontaneously in the course of a few months. If such closure 
 does not take ]ilaee, they should be operated upon in the usual way. 
 
 Rectum. — Wounds of the rectum may be in connection with those 
 of the bowel higher up, of other pelvic organs, of the ))oncs of the 
 pelvis, or of the perineum and parts adjacent. In tliemselves they are 
 of interest chiefly because of the extensive suppurations and gangrenes 
 so often consequent upon fecal extravasations through them. Allien 
 such infection of the connective tissue does not occur, the uncomplicated 
 wound heals ra])idly, and, if made by pistol liall or small-ealibred bullet, 
 without after-fistula or stricture. 
 
 Even the necessarily more or less defective antisepsis that can be 
 secured in military practice will doubtless be sufficient to decidedly 
 reduce the former mortality-rate of wounds of this kind received in 
 action (between 40 and 50 per cent.) ; and it may reasonal)ly be expected 
 that in the perforating injuries that will be made by the new bullet there 
 will be less laceration of the bowel and less likelihood of extravasation, 
 and ]irobably better drainage of tlie damaged area. 
 
 If the rectal wound is but one of several intraperitoneal lesions, if it 
 
WOUNDS OF REGIONS. 509 
 
 <!an be gotten at it should be stitcliod, otherwise the gauze tampon must 
 be employed. A pistol-ball injury below the peritoneal refleetion will 
 make necessary only careful cleansing and disinfection of the bowel and 
 the observance of the ordinary rules of wound-treatment ; and the same 
 is true of any uncomplicated lesion higher up. After the lower bowel 
 has been well washed out with an antiseptic fluid, the more quiet it is ke[)t 
 the better. Surgeons have long recognized the benetieial ettects of the 
 internal administration of opium given in dose sufficient to constipate. 
 If because of infection ischio-rectal inflammation occurs, free incisions 
 must be promptly made and an antiseptic treatment thoroughly car- 
 ried out. 
 
 Bladder. — Bullets passing into or through the pelvis not seldom 
 MOund the bladder — much more frequently, of course, when the viscus 
 is iull than when it is em])ty. These shots may come in any direction, 
 and very generally they injure some part of the bony wall. Not neces- 
 sarily so, however, for they may enter fi'om above or from below 
 and lodge in the pelvic cavity, or they may pierce the anterior inferior 
 abdominal wall just above the pubes and emerge through a sacro-sciatic 
 foramen. Their course usually is antero-posteriorly with more or less 
 oblicjuity, though the bladder may be damaged by a ball passing from 
 side to side, rarely, h(jwever, if it is emptor. Sometimes the vesical wall 
 is so pierced as to prevent escape of urine in any considerable amount, 
 and gutterings without penetration may take place, the ball track ordi- 
 narily, however, soon opening up by ulceration. 
 
 In the large majority of cases the lesion is a complicated one, the 
 rectum Ix'ing conunonly wounded when the direction of the bullet is 
 from behind forward or from before backward, unless the momentum is 
 so slight that the shot lodges against or in the anterior wall of the 
 bladder or in its cavity. In not a few of the cases there is in associa- 
 tion so serious a lesion of the blood-vessels of the region that death 
 quickly occurs from hemorrhage. The wound may be in a part of tiie 
 bladder covered with peritoneum or may be cxtra-periton(>al, the gravity 
 of the case being much greater when in the former situation, extravasated 
 urine finding its way into the abdominal cavity instead of into the con- 
 nective tissue. It is to such extravasation with its resulting septic infec- 
 tion that death is commonly due in cases not fatal from bleedingr or 
 from associated visceral lesions. 
 
 The mortality-rate of cases coming under care in military ])ractice has 
 been about one-half (45-55 per cent.), but of those in civil life early and 
 properly treated it is decidedly less, very much so when the bladder was 
 empty at the time of its injury. 
 
 The symptoms are — sliock, pain in the region or diffiiscd over the 
 abdomen, and general weakness, eaeii commonly in high degree ; much 
 irritaljility of the bladder and rectum ; luematuria ; and escape of urine 
 tlirougli the external wound, either persistently or intermittently accord- 
 ing to the low or high location of the opening. The last two symptoms 
 are of great diagnostic value, though the presence of blood may be con- 
 sequent upon contusion of the l)ladder or upon wound of some other jiart 
 of the urinary tract, and leakage of urine may j)ossil)ly come from lesion 
 of an ureter or the urethra, and whatever its origin it is actually met 
 witli in Itut a limited portion of the cases of wounds caused by pistol or 
 
510 GUNSHOT WOUNDS. 
 
 small-calibre rifle balls. When there is an associated opening of the 
 rectum fecial matter may be discharged with the urine or the urine 
 passed through the anus. Voluntary micturition may be possible or 
 catheterization re(|uired ; in the latter case it is advantageous for every 
 reason to keep tiie catheter in, rather than to introduce it at stated 
 periods or as necessary. Sometimes so much blood accumulates in the 
 bladder that aspiration will have to be done. When there has been dis- 
 charge of urine into the abdominal cavity, certainly in any considerable 
 amount, symjitoms of peritonitis or of grave septicemia are ra})idly 
 developed, the latter at times so quickly latal that upon autopsy 
 no evidences of inflammation are to be seen. Left to itself, a case of 
 this kind is certain to die. When urine is extravasated into the con- 
 nective tissue in front of the bladder or into the meshes of the recto- 
 vesical fascia, abscesses soon form or, by contiguity, peritonitis is 
 induced. The progress of these cases of bladder-wounds illustrates 
 the truth of Bichat's declaration that " urine is the most baleful fluid 
 in the economy;" if not so when of normal quality, tuKpiestionalilv so 
 when in the presence of blood and air it has become se})tic. 
 
 Treatment varies as the lesion is intra- or extra-peritoneal. In the 
 latter case a catheter may be introduced and retained and the patient 
 treated exjiectantly. But unless, from the location of the wound or 
 wounds antl the direction of the shot, it is very certain that the injury is 
 outside of the peritoneum, laparotomy should be done at once, the abdom- 
 inal cavity cleansed, and the wound in the bladder stitched ; and if there 
 is any doubt about the nature of the injur}-, su])ra])ubic section should be 
 made and the prevesical space, if not the abdominal cavity, opened up^ 
 Any wound should be stitched, the parts cleaned and disinfected, and 
 drainage secured, preferably by a gauze plug. If a foreign body, ball or 
 bone, has lodged in the bladtler (and such loilgement has taken place in a 
 disproportionately large number of vesical wounds), it should be removed 
 at once if a laparotomy or a suprapubic section has been done, otherwise 
 it may be taken away through a perineal opening either early or after 
 the wound in the bladder has healed. Occasionally there has been an 
 extraordinary tolerance for months or years of the foreign body. In a 
 number of cases the ball or Ijone, or even a piece of cloth, in the Ijladder 
 has served as a nucleus upon which the phos})hates have been deposited 
 and stone formed. When the ball has been lodged externally, it has 
 been known to ulcerate its way into the bladder after a time, years even, 
 and then require removal ; and the same has been true of pieces of bone, 
 fragments detached at the time of the injury or later separated by necro- 
 sis. Otis reported twenty lithotomies done on account of such injuries 
 received during our late war. Very small balls have at times been 
 spontaneously discharged through the urethra. 
 
 In the beginning of the treatment, whether operative or otherwise it 
 matters not, fluids should be given very sparingly. Rest as absolute as 
 possible should be maintained. Any abscess that can be located should be 
 promptly opened. In favorable cases healing may be expected to take place 
 in from three to six weeks. In many of the cases heretofore observed 
 in time of war in which death did not speedily follow, recovery was very 
 protracted and imperfect, bone-sinuses or urinary fistulae remaining ; 
 but such sequelae are not likely to be frequently met with hereafter, 
 
WOUNDS OF REGIONS. 511 
 
 in either military or civil life, because of the changes both in missiles 
 and in treatment, especially the latter. 
 
 Genital Organs. — Injuries of these organs, rare in civil life, not 
 very uncommon in military practice, may be either superficial or deep ; 
 occasionally they are contusions, generally penetrating or perforating 
 wounds, in a few instances extensive destructions. Associated injury 
 of tiiigh or abdomen is of frequent occurrence, and to such complication 
 death, wher. it takes place, is usually due (of 1152 wounds in our war, 
 144 died— 12.5 per cent.). 
 
 Superficial wounds of the penis or scrotum ' are injuries of little 
 gravity and require no special treatment, any produced hajmatocele or 
 hernia of the testis (conditions at times observed) differing in no respect 
 from that consequent upon ordinary traumatisms. Occasionally there 
 has been lodgement of a ball, even of large size, under the skin, the 
 removal of which has been easy ; in certain cases in which it has not 
 been taken out it has become encapsulated and remained harmless for 
 years, though its presence is likely to be troublesome. 
 
 The corpora cavernosa when perforated always show considerable 
 laceration, and the same is true of the glans penis. A'ery generally the 
 urethra also is torn, in which case, unless proper treatment is pursued, 
 urinary infiltration and abscess are apt to be produced. As late results 
 of these wounds of the penis there have been seen troublesome and 
 deforming cicatricial contractions of the organ, strictures, and fistulas, 
 penile, scrotal, or perineal according to the location of the wound. 
 
 Primary treatment has reference to the arrest of hemorrhage, the 
 securing of jirompt closure of the wound, and the prevention or 
 relief of urinary retention. Bleeding, which is apt to be quite free, 
 may be controlled by the stitching of the edges of the wound together, 
 by ligation of any divided vessel seen, or by pressure, a catheter being 
 introduced and a bandage applied around the organ. Protecting the 
 wound from infi'ction by the use of an ordinary antiseptic dressing will 
 commonly secure its prompt healing. To prevent urinary disturbances 
 (retention or infiltration) the bladder must be kept empty by a retained 
 catheter, the edges of the urethral laceration being stitched over it if 
 practicable, or if the loss of substance has been great the M'ound allowed 
 to close by granulation. Much benefit will often follow perineal section 
 and the turning of the urine through such ojiening. 
 
 No matter how much the penis may have been damaged, it is ordi- 
 narily unwise to amputate ; any part of it that can be saved should be 
 saved. If the entire organ has been carried away, the urethra should 
 be dissected back and a new meatus established in the perineum if the 
 patient's general condition permits of the operation. 
 
 In other than the most su))eificial wound of the scrotum the testis or 
 cord may be expected to be injured ; in a tiiird of the cases studied by 
 Fischer both testes were struck. The damage done the gland liy a l)ullet 
 except at short range is rarely such as to necessitate its removal. Hernia 
 of the testis, formerly often seen in cases of lesion by a large ball, is 
 very unlikely to follow pistol shots or wounds by the new bullet, but 
 atrophy of the organ has been frequently noticed, as has more or less 
 persistent, and often intense, neuralgia. Antisepticallv treated, supi)ura- 
 tion ought not to occur — a complication that until lately was almost 
 
512 GUNSHOT WOUNDS. 
 
 certain to lie developed. A\^hen Ixjth testicles have been disorganized 
 they should be removed, and the wound closed by a short scrotal flap if 
 there is enough healthy tissue left to allow of its formation. 
 
 Wounds of the female genitals are rare, and they are usually in asso- 
 ciation with grave abdominal or pelvic lesions. In the very infrequent 
 cases in which they are inflicted at very short range the laceration that 
 takes place is extensive. In a case personally observed in which the 
 nuizzle of the pistol Mas thrust between tlie Ial)ia the combined effect of 
 the bullet and the gases of explosion was to destroy almost comjjletely 
 the vagina and the uterus. A ball passing through the unimpregnated 
 uterus ordinarily does comparatively little harm, but where pregnancy 
 exists there is much risk of an early fatal termination from aljortion 
 (almost certain to take place), from hemorrhage, from shock, or from 
 septic inflammation. In certain cases which have survived, flstula has 
 been noticed, giving passage to the menstrual fluid for a time or perma- 
 nently. 
 
 Sword and Bayonet Wounds. 
 
 Wounds of this character have been rarely seen in recent times — .37 
 per cent, only of the grand total of wounds in LSfJl-Oo, 1.3 per cent, in 
 1870-71, .9 per cent, in all the wars from the Crimean to the Franco- 
 German, both included (437,636-4890). They must probably be much 
 less frequent in future military operations ; the new magazine rifle, that 
 M'ill disable if not kill at a mile, a mile and a half, or two miles' distance, 
 p^e^■enting any considerable force of either infantry or cavalry apj)roach- 
 ing sufticiently near to use bayonet or sabre. Surgeons hereafter will, as 
 a rule having few exceptions, see these injuries only as they may result 
 from individual quarrels or in mob-fighting. As made by the bayonet, 
 and, much less often, by the straight sword, the wounds are j^imctured ; 
 by the sabre, when sharp, incised, when with dull edge, as it generally 
 is, lacerated and contused. The bayonet injuries are more common in 
 the lower extremities than elsewhere (46 per cent, of the whole number 
 reported in 1861-65), sabre wounds in the head and upper extremities 
 (89 per cent, in the same war), though the proportionate local frequency 
 has been quite different in different wars. Leaving out of consideration 
 cases dying on the field, the mortality-rate is low ; with us it was 7.7 per 
 cent, for the bayonet and 5 per cent, for the sabre wounds, the fatal cases 
 being very largely those in which one or other of the great cavities was 
 opened; of the 712 cases in which they were not ojiened only 16 died 
 (2^ per cent.). Aside from visceral lesions and injuries to the large ves- 
 sels, the chief danger of the penetrating M'ounds is in the damming up 
 of fluids in their depths and the develojiment of su]>purative inflam- 
 mations ; the chief danger of the contused and lacerated wounds is the 
 occurrence of septic conditions. 
 
 The appearance of the wound varies as it is made by thrust or by 
 cut, the former being in form slit-like, triangular, or more or less cres- 
 centie according to the shape of the weapon ; the latter sho^Wng a straight 
 cut with more or less contusion and laceration of the edges, or the forma- 
 tion of a flap, or an ovoid somewhat tnipped open wound from complete 
 or nearly complete detachment of a flap, \vhich latter in injuries of the 
 cranium may have in it a piece of the skidl of thickness according to the 
 
A BROW WOUNDS. 
 
 -513 
 
 depth of" the wound. In wounds involviufj tlie kirynx, trachea, or hnig 
 empliy.sema is often present, it may be in higli degree. 
 
 The treatment is tiiat of lesions of like character otherwise produced. 
 By thorough cleansing and proper dressing an aseptic condition may 
 generally be secured. Vessel-wounds will necessitate the application of 
 ligatures or not according to circumstances. Detached bone-fragments 
 will have to be taken away. If there is puncture of the skull, trephin- 
 ing should be done. Any foreign body, clothing, hair, or other, that may 
 happen to have been carried in should be removed if its presence can be 
 detected, clothing being especially likely to be lodged in the seton wounds 
 of the soft parts. An existing emphysema, if it does not soon subside 
 spontaneously, will necessitate puncture. 
 
 Arrow Wounds. 
 
 Once so common, arrow wounds are now seen extremely rarely, and 
 hereafter their consideration will have but an historic value, since among 
 other tlian the lowest and most isolated tril)es of savages firearms have 
 taken the place of the bow. As met M'itli, they were of tiie nature of 
 both punctured and incised wounds, penetrating, even perforating, the 
 
 Fig. 35. 
 
 Skull with arrow-head fixed in it. taken from mound in Boone Co., Ky. : .1. stone arrow-head 
 lodged ; B, injury accidentally done by pick at time of removal. 
 
 body, their tracks th;-ough the tissues straight and clean cut, with 
 entrance wounds somewhat brui -ed and di.scolored from extravasated 
 blood, and exit ones (if present) mere slits. Within a range of one 
 hundred yards or less their force of penetration might be very great, 
 depending of course upon the strength and skill of the bowman. 
 Often an arrow was sent through the body of an animal as large as the 
 buffalo, bone being ])ierced as with the point of a large, strong, shttrj) 
 knife. Striking a blood-ve.ssel, a nerve-trunk, or an intestine, such part 
 could not glitle out of the way, but was certain to be wounded. Severe 
 Vol. I.— 33 
 
514 GUNSHOT \vuryi>s. 
 
 hcniorrliafjo was likoly to occur. The ujiper pai't of tlic body was much 
 uiore ot'teu injured than tlie lower, and visceral wounds were of course 
 niucii tiie nioi'c daniicrous. ThoutJcli, as has been stated, tiie course of the 
 arrow was straigiit, when tiie luad was of iron and tiiin it at times upon 
 striking a bone bent itself around it. From tlie nature of tiic missile 
 and the almost necessarily unhygienic surroundings of the patient, these 
 wounds were in great measure infected ones; and so nuich of the mor- 
 tality following them as was not due to loss of blood was conse(|Uent 
 u])on se])sis. When the head iiad lodged, it was taken out whenever it 
 was practicalile to do so, as if left it was certain to cause trouble. Such 
 extraction, when it was separated from the shaft, was often iliHicult both 
 in the seizing and removing. Snares and forceps of different kinds were 
 employed to facilitate the operation, an excellent instrument which com- 
 bined the (pialities of both snare and forceps having been <levised by the 
 late Dr. J. H. Bill. To him, a distinguished officer of our army who 
 had a long service with troops in the " Far West," Me are indel)ted for 
 much information respecting the nature and effects of arrow injuries. 
 In concluding his article in the Intcniatiorial Encyclopaedia of Surgery 
 upon this subject he sums up his views in the fc)llowing words : 
 
 " (1) An arrow-head nuist be removed as soon as found. 
 
 "(2) In the search tiir the arrow extensive incisions are justifiable. 
 
 "(3) An arrow may l)e pushed out as well as plucked out. 
 
 "(4) The linger should be used for exploration in preference to a 
 probe. 
 
 " (5) Great care must be taken to avoid detachment of the shaft. 
 
 "(6) Healing by first intention should be enccturaged. 
 
 "(7) The surgeon should strive to comfort the ]wtient. Although 
 arrow wounds are not attended with nuieh shock, they are usually the 
 cause of great dejiression of spirits. The constitutional disturliances 
 following these wounds .... arc liable to be out of all proportion to 
 the apparent amount of damage. There are almost ahvays consider- 
 able sleeplessness and great irritability, dejection of s])irits, and intol- 
 erance of pain. The tendency to despondency becomes frequently a 
 prominent symptom, to be carefully combated, and ever}-thiug should 
 be done to cheer the patient." 
 
FRACTURES. 
 
 By FEEDERIC S. DENNIS, M. D. 
 
 A FRACTURE is a solution in tlie contiiiuity of liono or cartilage, pro- 
 duced l)v violence, muscular action, or disea*'. The word "fracture" 
 is derived from the Latin verb f ran c/o, meaning "to bi'eak." Epiphys- 
 eal separation is also classed with fracture, because the injury is pro- 
 duced by the same causes, presents the same signs, and retjuires tlic same 
 treatment. Fractures may be coinpfctc or incomplrfc. 
 
 Complffr frnctuvex are su1)divided into sim|)lc, compound, ciimmi- 
 nuted, multiple, complicated, and impacted. Some of these varieties may 
 again be subdivided, according to the direction ol' the fracture, into 
 oblique, transver.se, longitudinal, and dcntated. 
 
 IncQinpIde fractures may be subdivicled into greenstick, jtartial, fis- 
 sured, stellate, and spiral. 
 
 EpiphjiKcal >iCjtariitioii may be considered as a species of fracture, 
 since tlie injury involves a tearing away, by a sudden act of violence, of 
 the epi])hysis from the diapiiysis of the bone, the separation occurring at 
 the cartilaginous line of union. This injury is found only in persons 
 under twenty-one years of age, since after that ])eriod the epi]iliyses are 
 usually united l)y bone to the diaphyses. The rejiair is effected l)y 
 osseous tissue, and as a result the bone ceases to develo]) at the fractured 
 end. Shortening occurs, which may be very great if tlie patient at the 
 time of the injury has not attained his or her full height. 
 
 A complete fracture is one which entirely traverses the bone. A 
 simple fracture is one in which the bone is broken at one point and the 
 seat of fracture lias no comnuuiication with the external air. 
 
 A compound fracture is one where the bone is liroken at one or 
 m()re points and the seat of fracture has comnuuiication with the exter- 
 nal air. A compound fracture must not lie mistaken for a simple frac- 
 ture attended by a wound in the soft parts. In the former case the 
 wound is the result of the fra( ture, and comes from within, while in 
 the latter case the wound is ind('|)cndcnt of the fracture, and comes 
 fnini without. 
 
 A commhiiili'd fracture is one in which the bone is broken into niaiiv 
 small fragments (Fig. .'}()). 
 
 Amultijile fracture is one in which several liactui'es occur in the .same 
 bone (Fig. 37). 
 
 A complicated fracture is one which is associated with a wound ojwn- 
 
 515 
 
516 
 
 FRACTURED 
 
 ing into a joint, or is accompanied by an injury to an internal organ, to 
 an artery, or to a nerve, or wiiich coexists with a dislocation. 
 
 Fr«. 3H. 
 
 CinuininutL'd fracture of tibia and filmla. 
 
 An impacted fracture is one in which tiie fragment consisting of 
 compact bone is driven into the fragment of cancellated bone (Fig. 38). 
 
 Fig. 37. 
 
 Multiple fracture of both 
 bones of the leg. 
 
 Fig. 38. 
 
 Impacted fracture of the neck of the 
 femur. 
 
 Fractui'es may l)e subdivided again according to the direction of the 
 line or plane of separation. 
 
 An oblique fracture, which is the most common form, is one in which 
 the line of separation is at an acute angle to the long axis of the bone 
 (Fig. 39). A tranm-crse fracture is one in which the line of separation 
 
DEFINITIONS. 
 
 517 
 
 is at a riglit angle to tlic loiiii' axis of the bone. This variety is found 
 chiefly in children and seldom in adults. 
 
 A longitudinal fracture is one in which the line of separation is par- 
 allel to the loner axis of the bone. 
 
 This variety is rare, and is usually 
 associated with gunshot injuries 
 (Fig. 40). 
 
 A dentatcd fracture is one of 
 such a character that the oppos- 
 ing surfaces denticulate with each 
 other, so that the projections of 
 one fragment tit into the depres- 
 sions of the other fragment. 
 
 An incomplete or partial frac- 
 ture is one which only partially 
 traverses the bone, as in a fracture 
 of the external table of the skull 
 while the internal table remains 
 intact. 
 
 Fig. 39. 
 
 lli!V 
 
 Fio. 40. 
 
 Oblitjiie fracture of the humerus. 
 
 Longitudinal fracture of femur. 
 
 A greenstick fracture occurs when the bone merely bends. In this 
 fracture a portion of the fibres are broken, while the remainder hold the 
 bone intact (Fig. 41). This may occur as an intra-uterine fracture when 
 the soft bones of the fcetus are bent as a result of alinormal uterine eon- 
 tractions, or by external violence, as in consequence <jf a fall experienced 
 by the parturient woman. 
 
518 
 
 FRACTl'RES. 
 
 Fig. 41. 
 
 A fimurcd fnirfurr is one in wlii(-ii a linear divison has occurred 
 without any displacement. This variety is seen in tiie skull, especially 
 over the vertex. 
 
 A .stellate fracture is one Avhieli radiates from a cen- 
 tral axis, somewhat after the shaj)e of a star. This 
 variety is seen chiefly in the skull, although occasionally 
 it occurs in long bones, like the i'cnuu-, after a iiiinshot 
 injury. 
 
 A .spiral fracture is one in which the line of the 
 break assumes a spiral course. This variety is seen 
 in the bones of the cranium, but it is also occasionally 
 observed in the long bones (Figs. 42 and 43). 
 
 A r/un.sJwt fracture is one in which the Ixme is broken 
 as a result of a gunshot wound. This special \ariety of 
 fracture may be either complete or incomplete. 
 
 Etiology of Fractures. — The causes of fracture are 
 prcdi.sjio.siu;/ and e.rcitiiuj. The former include all cir- 
 cumstances which tend to make the bone more brittle, 
 while the latter include all actual or direct forces cau.sing 
 the injurv. If a bone fractures without any apparent 
 p.iitiai or green- excitiug causc, it is Said to be a spontaneous fracture. 
 the 'rad'ius^''^ "^ AuioHg the predisposing causes may be mentioned the 
 influence of age, since the tendency to fracture increases 
 as age advances. This is because the bones in the aged are less elastic 
 and more brittle as a result of the loss of organic matter, and at the 
 same time the muscles have lost a ceitain amount of their elasticity. 
 
 Fig. 42. 
 
 Fig. 13. 
 
 Sex is another predisposing cause, since fractures are fomid more fre- 
 quently in the male, with the exception of the intra-capsular fracture of 
 the neck of the femur. This is due to the foct that the female is less 
 active and less exjxised to violence. 
 
 Season is a predisposing cause, since in winter fractures are much 
 more frequent than in summer. Tliis may be due to the presence of ice, 
 
ETTOLOar. 
 
 519 
 
 ■\vliicli increases the lialiility to l)i)(lily falls, and also because the muscles 
 are supposed to be less elastic in eokl weatlier. 
 
 The liabiliU/ of certain bones to fracture may be considered a predis- 
 ]iosing cause, since the bones upon the right side of the body are more 
 frc([uently fractured than those upon the left side. This is due to the 
 tact that the right side of the body is used more tlian the left for the 
 ])urposes of attack and defence. The bones Ibrming the trunk are less 
 frequently broken than those of the upper extremity, and the bones 
 of the up|)cr extremity less frequently than those of the lower ex- 
 tremity. Again, the long bones are more frequently broken than the 
 short bones. The two individual bones which are most susce])tible to 
 fracture are the clavicle and the radius. As to the relati\-e frequency of 
 fractures attcctiug the ditfcrent bones, Ourlt's tal)le is here introduced, a 
 studv t)f which affords some valuable intbrmation : 
 
 Fractures treated in the London ITospitals, 1843-77, Archiv. f. kiiii. CIdr., xxv., 1880, p. 469. 
 
 Skull . . 
 Faoe . . 
 Spine 
 Pelvis . 
 Coccyx . 
 Ribs . . 
 Stern lira 
 Scipula . 
 Clavicle 
 Arm . . 
 Forearm 
 Hand . 
 Tliish . 
 Patella . 
 Leg . . 
 Foot . . 
 
 In 
 
 Hospital. 
 
 730 
 732 
 169 
 139 
 5 
 
 4784 
 
 4.5 
 
 135 
 
 382 
 
 1064 
 709 
 856 
 
 3072 
 649 
 
 8067 
 965 
 
 22,503 
 
 Out-patients. 
 
 27 
 
 513 
 
 3 
 
 3 
 
 10 
 
 3477 
 
 7 
 
 290 
 
 74.58 
 
 3020 
 
 8731 
 
 4S99 
 
 171 
 
 15 
 
 256 
 
 555 
 
 29,435 
 
 Total. 
 
 757 
 1245 
 
 172 
 
 142 
 
 15 
 
 8261 
 
 52 
 
 425 
 7840 
 4084 
 9440 
 5755 
 3243 
 
 664 
 8323 
 1520 
 
 Per cent. 
 
 1.457 
 2.397 
 0.331 
 0.273 
 0.028 
 
 15.905 
 0.1 
 0.818 
 
 1.5.094 
 7.863 
 
 18.175 
 
 16.080 
 6.243 
 1.278 
 
 16.024 
 2.926 
 
 Head, 2002 ; 
 3.854 per cent. 
 
 Trunk, 9067 ; 
 17.457 per cent. 
 
 Upper cxtremiti/, 27,119 ; 
 52.214 per cent. 
 
 Lower extremity, 13,750 ; 
 26.473 per cent. 
 
 51,938 
 
 Certain diatheses are predisposing causes of fracture, including the 
 results of such diseases as syphilis, cancer, sarcoma, rickets, scrofula, 
 rheumatism, gout, mollitics ossium, and mercurialization. Fatty degen- 
 eration and senile atrophy arc conditions favorable to the production of 
 fracture. 
 
 The (Writing causes of fracture are indirect violence, direct violence, 
 and muscular contraction, which are mentioned in the order of fre- 
 quency. 
 
 In indirect violence a force is applied to two parts of a bone, and a 
 fracture occurs between the two points of violence. 
 
 In direct violence a force is a])plic(l to a certain part of the bone, and 
 at the point of impact a fracture occiu-s. Tiie results of fractiu-e by 
 direct violence are more serious than those by indirect violence, since 
 here is the additional injury inflicted upon the soft parts, and sometimes 
 injury to important organs. 
 
 Jrn.'<cul(ir contraction is the rarest cau.se of fracture, taken as a whole, 
 although in certain individual bones it is most frecpicnt. The special 
 bones which are most fre(|uiiitly the scat of fracture by muscular con- 
 
520 FRACTURES. 
 
 traction arc tlic os calcis, tiliia, patella, rcnim-, olecranon ])roccss of ulna, 
 liiiincrus, an<l (daviclc. 
 
 Repair of fractures is considered in the article on Surgical Pathology, 
 and the reader is referred to it for information u])on this important 
 subject. 
 
 Symptoms and Signs of Fractures. — There is occasionally a slight 
 rise of tenijtcrature following the recei])t of a fracture, hut the elevation 
 is of no special significance. A chill sometimes occurs, hut it is nervous 
 and not septic in charac^ter, and is of no s])eeial importance. Shock also 
 often accompanies a fracture, but this condition soon passes away unless 
 the fracture is compound or com])licated. 
 
 The first sign of fracture consists of unnatural mobility, or the exist- 
 ence of a false or abnormal point of motion, which is present except 
 in the impacted variety or M'lierc the fracture involves certain bones, 
 as the skull or the body of a vertebra. There are different methods 
 of ascertaining the presence of a false point of motion. In fracture of 
 the fibula or radius both hands should envelop the limb, with the 
 thumbs placed over the suspected site of fiacture. The alternate 
 pressure of the thumbs will cause the fragments to s|iriug out beyond 
 each other. In fracture of the tibia it is best to hold tirndy the upper 
 fragment, and then move the lower one. In fracture of the ribs or of 
 the sternum the palm of the hand can be placed over the thorax and the 
 patient requested to cough. In case of fracture of the thigh or humerus 
 rotation of the limb will demonstrate a false point of motion. The nearer 
 the fracture is to the centre of the bone, the greater the mobility. The 
 mobility is passive in character, and not active. 
 
 Another sign consists of rotary displacement of the limb, caused 
 chiefly by its weight, by muscular contraction, and by the violence pro- 
 ducing the fracture. In estimating the displacement careful inquiry 
 should be made to ascertain if any ])revious deformity existed. The 
 amount of displacement is often influenced l)y the direction of the frac- 
 ture in the bone. 
 
 Still another sign is angular deviation from the normal axis, which is 
 especially seen in the impacted variety caused by great violence. It is 
 absent if one only of two bones in the limb is broken or if the fracture 
 is longitudinal. 
 
 Crepitus is a pathognomonic sign, the presence of which can be deter- 
 mined by firmly fixing the upper fragment and moving the lower one. 
 In certain fractures — as, for example, those about the hip-joint — slight 
 rotation of the limb will serve to demonstrate the presence of this al)so- 
 lute sign. 
 
 When crepitus is found, it is an nnecjnivocal sign of fracture, but its 
 absence will not exclude the presence of fracture. C'rejiitus is absent 
 in imjiacted fractures, in cases of widely-seiiarated fragments, as in 
 fracture of the jiatella or olecranon, in cases where blood-clots or fascia 
 or muscle intervene between the broken ends of the bones; also after 
 a few days following the injury, at which time the fragments are covered 
 l)y inflammatory exudations. Finally, crepitus is absent in the green- 
 stick fracture and in the fractures involving the cranial bones. There 
 are many conditions which may be mistaken for cre])itus ; for example, 
 emphysematous crackling caused by the presence of air in the tissues, 
 
DIAGNOSIS. 521 
 
 albuminoid crepitation, the creaking of tendinous sheaths in thecal 
 inflammations, joint effusions, and bursitis, the grating- of osti'o])]iytes 
 in riicumatoid artiiritis, and the ])lcuritic friction caused in injuries of 
 the chest. The use of tlie stethoscope lias been suggested witii a view 
 to ascertaining the presence of crepitus when it cannot be heard by the 
 ear or felt by the hand. 
 
 The presence of locntizcfl pain and tenderness and of ecchymosis is an 
 important link in the chain of evidence. The tenderness is present 
 immediately upon receipt of the injury, while the ecchymosis is not well 
 marked until a few days after the occurrence of the fracture. The 
 ecchymosis is due to a hemorrhage from a rupture of the small blood- 
 vessels in the limb, also from laceration of the medulla of the bone. A 
 mottled appearance after a fracture indicates that the source of the blood 
 is from the medullary cavity of the bone. The ecchymosis is more 
 ajiparent when the fracture involves a large bone or when the fracture 
 is extensive or situated close to the skin. If the extravasated blood 
 extends and causes pressure u]ion the synovial capsule of a joint, so as 
 to cause irritation, the intra-articular effusion of Gosselin results. The 
 ecchymosis may spread along planes of muscles, and be observed at 
 a point distant from the seat of fracture. This clinical fact is presump- 
 tive evidence of the existence of a fracture, provided no contusion is 
 present to explain the ecchymosis. If a wound of the soft parts exists 
 near a fracture, the })resence of fat-globules upon it or in the blood 
 indicates the origin of the globules from the medulla, and hence this 
 sign is pathognomonic of fracture. 
 
 Shortening of the limb is a sign of fracture when it involves the 
 extremities. The direction of the fracture influences tiie amount of 
 shortening. A fracture of tlie obli([ue variety is usually attended by 
 shortening, while the transverse variety, ()r a fracture near a joint, is 
 seldom accompanied by shortening. The amount of shortening may 
 be from one to three inches, and in estimating the amount the fact of 
 asymmetry of limbs must not be overlooked, since investigation has 
 demonstrated that oftentimes there is a variation of as much as half 
 an inch in the length of a pair of unfractured limbs. There are a few 
 fractures— for example, of the ])atella and the olecranon — wliere length- 
 ening instead of shortening of the l)one occurs. 
 
 The diag-nosis of fracture is attended with no difficulty, provided 
 the signs of displacement, mobility, and crepitus are present. Tiie 
 diagnosis, however, may be extremely difficult if inflammatory swelliiig 
 has taken place, if the fracture is impacted, if its situation is near a 
 joint, if only one of two parallel bones is broken, or, Anally, if the 
 break traverses the Ixme transversely. In these obscure cases it is 
 better to defer the flnal examination luitil it can be made under the influ- 
 ence of an ansesthetic and when everything is prepai'ed to adjust some 
 permanent splint. The auiesthetic should not be employed unless the 
 patient's ])hysical condition justifles the use of this measure for the 
 purpose <if arriving at a correct diagnosis. In all cases of doubt tiie 
 injury should be treated as if a fracture existed. In cases where a 
 dislocation coexists with a fracture amesthcsia is indicated, since by 
 this means only can the exact diagnosis be established, the dislocation 
 reduced, and the fractured bone accurately adjusted. In the differential 
 
522 FRACTURES. 
 
 <liagnosi.s between fraeture and disloeation tlie surgeon must not over- 
 look the fact that in dislcR'ation tliere is no shortening of tlie shaft of tlie 
 bone or false point of motion (jr inmatural niol)ility, while in the ease of 
 frai'ture there is shortening of the shaft of the bone, and mobility and 
 a false point of motion exist. A contusion is often mistaken for a frac- 
 ture, but the absence of shortening, bony crepitus, mobility, and disjilace- 
 nient serves to establish the ditt'erential diagnosis. 
 
 The prognosis of fraeture depends upon the age, sex, and general 
 condition of tiie patient, as well as upon the character of the fracture 
 and the special form of apparatus employetl. A compound fracture is 
 nuich more serious than a simple one, and requires three times as long to 
 repair. A gunshot fracture is the most serious of all varieties, and the 
 involvement of a joint adds to the gravity of the case. An oblique 
 fracture requires twice as long to rcjiair as a transverse one. 
 
 The general management of fractiu'cs rccpiires careful consideration. 
 Fractures are a common cause of trouble between the patient and sur- 
 geon. The sui'geon, to protect himself against a suit for damages, should 
 exercise great care in the treatment of the fracture, and at tlie same 
 time possess a full knowledge of the pi'incijilcs involved in tlie manage- 
 ment of tlie special fractures. The tiirmcr condition re(piircs constant 
 and untiring attention to the j)atient ; the latter, careful study and ob- 
 servation of the injury. Wlien these two conditions are fulhlled, no suit 
 for malpractice can be sustained. 
 
 The examination of the fracture should be deferred until the patient 
 is at his home. The j)atit'nt sliould at once Ite jilaccd u])on a wire or hair 
 mattress and a firm bed, but never upon a canvas or feather bed. An 
 ordinary hair mattress can be converted into an excellent fracture-bed by 
 placing under the mattress some boards sawed the j) roper length, to take 
 the place of the springs. In case of fracture of the lower extremity the 
 boots or slioes should be cut off and the trousers rip])cd up at the seam, to 
 avoid any unnecessary movement of the limb. If suitable sjilintsare not 
 at hand, tlie limb can be ])]accd in a fracturt^-box, in wliich oakum or 
 bran can l)e used witli great advantage as a tenqxirary dressing. A most 
 important procedure is the lifting of the broken limb. This should 
 be accomplished for the lower limb by the surgeon seizing the foot near 
 the toes with Ins right hand and the heel witli tiic left hand, and then 
 making slow but steady extension in the line of tlie normal axis of the 
 linil). After full extension in the axis is acc<inq)lislied tlie entire limb 
 can t)e raised to any height. The muscles often resist the surgeon, who 
 should never relax his extension, since by so doing the danger of pro- 
 ducing a compound fracture is very imminent. The extension should 
 never l)e suddenly exercised, but slowly and uniformly, and always in 
 the normal axis of the limb. It is at this time that a thorough exam- 
 ination of the fracture can be satisfactorily made, and its exact seat 
 and direction and its tendency to disjilacemcnt l)e ascertained. 
 
 In making extension and counter-extension the surgeon must avoid 
 compressing muscles ])assing over the fracture, distribute the force 
 over a large surface, and extend slowly in the normal axis of the bone. 
 Tliere are often obstacles met with in attempts to employ extension and 
 counter-extension, among wliich may be mentioned the irregularity of the 
 fracture, interposition of nmst'lcs and tendons, tonic contraction of tlie 
 
COMPOUND FRACTURES. 523 
 
 muscles, and the presence of s])linters of bone. The condition of shock 
 often enables the sui-geon to reduce a fracture when it would lie otherwise 
 impossible to accomplish the oljjcct without aiucstliesia. The tonic con- 
 traction of the nuisclcs often presents an insurmountalilc barrier to tiie 
 reduction of fractures of the extremities. It is of little use to employ an 
 anaesthetic iu these cases, and the only sure and certain way to ett'cct a 
 reduction is to perform tenotomy for any or all muscles which resist. 
 This method is not only certain to ])ermit of the easy reduction of any 
 fracture, but the physiological rest thus secured to the fragments is most 
 beneficial, since the irritability of the muscles continues unless the 
 operation is performed. 
 
 After the reduction of the fracture is accomplished, the next object to 
 be secured is the retention of the fragments in their proper place. The 
 accomplishment of this object is olitaincd by suitable apparatus iu tlie 
 form of splints or bandages. Occasionally a limb is covered with 
 phlyctenfe or blebs, which prevent the immediate application of a per- 
 manent splint. The use of a fracture-box is indicated until the blebs 
 disappear. The blebs sliould be pnnctui'cd with a clean aseptic needle, 
 and the serum thus allowed to escape, and a piece of non-irritating but 
 aseptic gauze should be placed over the site of the vesicle for a few days. 
 In the forearm a bandage should never be placed over the limb in eon- 
 tact witii the skin and under any splint, since it may cause undue 
 approximation, or even fusion, of the two bones, and thus prevent the 
 movements of pronation and supination. If any tension exists, cotton 
 should be wrajiped around the limb luider any s])lint, since the inflam- 
 matory swelling will tlien less endanger the limb, as the cotton yields 
 and adapts itself tu the varying conditions of tension. 
 
 (For a full description of the different varieties of l)andages and their 
 application the reader is referred to the article on Mincn- Surgery.) 
 
 Compound Fractures. 
 
 Compound fractures require immediate and prompt attention. The 
 fate f)f a ])atient with a compound fracture often Iiangs upon the surgeon 
 who first touches it. It should be a ruh; of practice that antiseptic irri- 
 gation should be employed at the station-house or upon the sidewalk 
 bef()re the temporary sjjlint is adjusted, and that at once after the irriga- 
 tion a clean antiseptic dressing lie applied before the patient is lifte<l into 
 the ambulance to be carried to the hospital or to his home. If no anti- 
 septic solution can be olitained, wash tiie wound in water that has been 
 raised to the boiling-point and cooled. 
 
 The patient having been carried either to the liospital or to iiis home, 
 the temjjorary dressing is now to be removed, the fracture adjusted, and 
 the first dressing ap])lied. Too much emphasis cannot be ])laced upon 
 the point that the firxt and axepflo dreiixinf/ irill lair/c/i/ iiitfiicticc the 
 prnr/jtosis. Tliis dressing, therefore, in a hospital should be made in the 
 operating-room, because tlie germ-laden air of the hosjiital ward is not 
 a safe place in which to expose a compoimd fracture. The instruments, 
 sutures, ligatures, drainage-tubes, and everything possibly required for 
 the operation should be immersed in carbolic-acid solution (1:40). 
 Several towels wrung out in a solution of bichlori<le of mercury (1 : 500) 
 
524 FRACTURES. 
 
 should lie ]ir(>]wrc(l for use alioiit the table and around the limb, in order 
 to protect the wound from any ])ossil)le contaet with a surface not ren- 
 dered aseptic. The wound itself should be covered by antisc|)tic jjauze, 
 while the limb is washed with soap and water, then shaved and irrigated. 
 Upon the limb is then poured a saturated solution of naphthalin in ether 
 or of iodoform in ether. This application removes all the fat, and the 
 naphthalin or iodoform remains as a layer upon the surface and protects 
 the ]xirts. 
 
 Having made aseptic all the adjacent |)arts, the wound itself requires 
 attention. All blood and debris shoidd be washed away by a stream of 
 warm biehloride-of-mercury solution (1 : 4000). The interior of the 
 wound should be thorouohly irrigated with the same solution, and all 
 hemorrhage completely arrested. Loose pieces of bone not attached to 
 periosteum should be removed. The fragments can now be adjusted, 
 and if the displacement is great a silver wire can be introduced to keep 
 them in place. Again, it may be necessary to introduce, besides the wire 
 through the bone, some deep catgut sutures, which are carried through 
 the muscles. Deep sutures are necessary in all extensive and gaping 
 wounds of the soft parts, especially when such uuiscles as the biceps and 
 triceps or the (juadriceps extensor are divided. These sutures must be 
 independent of the superticial set. All fragments of fascia, fatty tissue, 
 muscular shreds, and lacerated integument should be cut aw'ay with scis- 
 sors, and then a final ablution made. A drainage-tube should be intro- 
 duced into the bottom of the wound, and if the wound is so situated as to 
 drain well, there is no necessity for a counter-opening. Such wounds as 
 just described require free drainage, and couriter-openiug may be neces- 
 sary iu order to meet the requirements of the case. The tube is then 
 cut off flush with the surface of the skin and fastened by a safety-pin. 
 The wound is now closed by catgut sutures, which completes the opera- 
 tive technique. The towels should now be changed and clean ones 
 substitutetl, which should also be wrung from bichloride solution. This 
 dressing can be done without an anicsthetic and, as a rule, with little 
 or no pain. When the compound fracture is extensive, it is necessary 
 to administer ether, so that the dressing can be completed from the 
 beginning to the end while the patient is under the influence of an 
 anaesthetic. 
 
 A class of eomjiound fractui'cs is often met in which the wound is 
 very small, and with these cases a different ]ilan should be adopted. The 
 irrigation should l)e made around and iu the wound, and then it can be 
 hermetically sealed by spriidiling iodoform upon a small jiiece of 
 absorbent cotton and ]>lacing it over the perforation, and painting styptic 
 collodion over it. This mixture will soon coagulate, the medium of 
 sealing is surgically clean, and then the fracture is ready for the dress- 
 ings. Thus small wounds can be hermetically scaled, medium-sized 
 wounds closed by sutures and drained through the existing opening, 
 and large wounds tlrained by a counter-opening and sewed with deep 
 sutures, and the fragments held together by silver wire. 
 
 Having completed the 0])erati\-e technique in one of the three ways 
 mentioned, the parts are now prepared for the antiseptic dressings. 
 Iodoform gauze or a small piece of oil-silk jtrotective should l)e jdaced 
 over the wound, witii a hole cut in it to allow the mouth of the drainage- 
 
COMPOUND FBACTUBES. 525 
 
 tube to drain into the dressings. Iodoform gauze is used, because 
 liirhloride gauze irritates tiic wound. The bichhiride gauze is next 
 applied in loose pieces over the iodoform gauze and around the wound. 
 This dressing is moist, because dry antiseptic dressings adjacent to a 
 wound are sources of infection. The loose and wet gauze is held in 
 situ, by the application of a moist bandage. Over this deep dressing 
 absorbent cotton is placed and retained by a dry bandage. 
 
 This last dressing affords a means of securing equable and uniform 
 compression around the liml) and over the fracture. The cotton by 
 its elasticity accommddates itself to the swelling of the parts in the 
 vicinity of the fracture. This part of the dressing is very important 
 as a means of preventing inflammatory swelling and of affording 
 comfort to the patient. Four strips of sheet iron about one inch 
 in width are now adjusted, (^ne strip is to pass down on the pos- 
 terior part of the limb and over the heel and upon the sole of the foot. 
 Two strips are placed upon the sides of the leg and one v\\)^n\ the front 
 of the leg, and bent so as to conform to the shape of the dorsum of the 
 foot. Over these strips plaster-of-Paris bandages are now applied, and 
 the dressing is completed. These strips ])revent any backward as well 
 as any lateral displacement of the fracture, and also do away with the 
 necessity of a heavy splint. 
 
 In three days a fenestrum is cut over the wound, and under continuous 
 irrigation the drainage-tube is removed. 
 
 The (juestion of how long this first dressing should remain is an im- 
 portant one. Experience has taught that no splint shoidd be left on a 
 limb longer than eight days without an inspection of the compound frac- 
 ture. The author has seen several bad restdts arising from a neglect of 
 this rule. In one case a fracture which was skilfully dressed with ])laster 
 of Paris ^^'as Hrst examined at the expiration of six weeks, during \xhicli 
 time the patient's general condition was in every way satisfactory. After 
 removing the splint the bone was found protruding and considerable 
 luiion had taken place. An osteotomy corrected tiic (k^formity, and in six 
 additional weeks a perfectly satisfactory I'esult followecl. If tiiis fracture 
 had been examined in eight days after its receipt, tiie protrusion of the 
 bone would have been detected and the faulty jjosition rectified, ^\'hile 
 this result is excejjtional, such unfortunate complications can ahvays be 
 obviated by a routine inspection of the fracture. 
 
 There are some questions that are of great interest when discussed in 
 the light of recent revelations in surgical jiathologv, and which call for 
 special study and observation in connection with the treatment of com- 
 jjound fractures ; such aix" malignant disease, tenotomy, healing by 
 Schede's method, amputation, the conversion of simple fractures into 
 compound, and compound fractures involving the major joints. 
 
 The question of malignant di ease following fracture is an exceedingly 
 important one in surgical pathology. The late Dr. S. D. Gross |)ointi'd 
 out the important fact that almost half of the cases of malignant bone 
 disease can be traced to traumatism. 
 
 The author recently operated upon a child with an inmiense sarcoma 
 upon the occiput. The child had sustained a heavy fall upon the back 
 of the head six months previously, followed at once by the develojiment 
 of a large luematoma. The luematoma was not incised, and a linear 
 
526 FRACTURES. 
 
 fracture existed beneath it. For some weeks after the injury ihcre Mas 
 nothiiifi' sj^eeial excepting the ])resenee of tlie ineniatonia, but tlie tumor 
 then l)eg'an to grow very rapidly, and in less than six nu^Tiths from the 
 reeeij)t of the injury the sarcoma was much larger than the child's head. 
 The patient died some weeks after an incomplete operation for removal 
 of the tumor. I have many beautiful specimens illustrating the fact that 
 a fracture may be the starting-])oint of this variety of tumor. 
 
 The prognosis of sarcoma affecting bone as a result of fracture, while 
 grave, is not necessarily fatal, ])rovick'd the tumor is recognized before 
 glandular swelling appears and the operation is performed early and 
 includes the tissues far from the seat of disease and the bone itself. 
 
 Ejiiihelioma also may develop indirectly as a result of a comj)ound 
 fracture, but this malignant growth has its origin from the soft tissues 
 in connection with a sinus leading down to necrosed bone. If a sinus 
 is not healed, it becomes lined with epithelium, and a discharge of ichor- 
 ous pus through it from time to time sets up an irritation with a pro- 
 liferation of epithelial cells, and epithelioma may in this way secondarily 
 develop. While the epithelioma is not directly connected with the seat 
 of fracture, as is the case in sarcoma, ncverthek'ss, the disease inav have 
 its origin in conditions arising from secjucstration in a com])ound frac- 
 ture. The closure of sinuses in connection with necrosis following a 
 fracture should always be aimed at by the surgeon. 
 
 Six years ago the author called attention to tenotomy in the treatment 
 of compound fractures, and in a luinibcr of cases since then he has been 
 impressed with the value of the oj)eration in all obli(|uc i'om]iound frac- 
 tures, as well as in many sim]>le fractures. Tenotomy relieves at once 
 any^ contraction of the muscles, permits the fragments to be placed in 
 accurate coaptation, and secures physiological rest to the fracture. It 
 affords also great comfort to the patient, and is a valuable means of 
 fixation during the first ten days. Tenotomy may be employed upon 
 the tendo Achillis, u])on the hamstring nuisclcs, u])on the tendons of the 
 arm and forearm, and even upon the sti'rno-eleido-mastoid nuiscle in 
 fractures of the clavicle. In several cases of compound fracture of the 
 tibia where the line of fracture was parallel with the long axis of the 
 bone, with considerable separation, a horseshoe tourniquet has been found 
 to be a most valuable instrument in closing the long fissure. The instru- 
 ment by pressure overcomes the lateral separation, just as tenotomy by 
 relaxation overcomes the oblique disjtlaccmcnt. The pad can be ap]>lied 
 upon one side of the bone, and pressure be made by applying the other 
 pad over a thick plaster bandage. The screw can be graduall}- tight- 
 ened, and in a few days the bone can be ajiproximated and the instru- 
 ment discarded. This is a safer and more satisfactory instrument than 
 the apparatus devised by Malgaigne. IMuscnlar spasms can in most 
 eases be overcome by position. Eelaxation of the muscles will always 
 relieve the spasm. The use of suljihonal, as well as of many other drugs, 
 has been suggested, but, as a rule, they do not relieve the condition. 
 
 Healing h\ Schede's method is effected by the intervention of blood- 
 clots. It has usually been taught that blood-clots in wounds are obsta- 
 cles to repair by primary intention, and that these clots act as foreign 
 bodies. 
 
 Fluid blood and clots, if perfectly aseptic, are valuable adjuncts in the 
 
COMPOUND FRACTURES. 527 
 
 repair of oonijiound fractures. They are, however, most jiotent sources 
 of evil if any infectiou reaches the ehit tliroui;li carelessness of the sur- 
 g'eoii. It is a most vahiablc contriinition to the treatment of compound 
 fractures if tiie blood whicli escapes between the ends of the fraii'ments 
 can be in the future utilized as a means of hastening and jierfccting 
 union by primary intention. The reason why so important a principle 
 in snruieal patholooy has l)cen so long unknown is explained by the fact 
 tliat blood-clots, until rigid asepsis was established, were recognized 
 st)urces of septic infection. If all the surrounding jinrts in every 
 compound fracture are made asc|itie, clots and fluid blood can i>e utilized 
 for the purpose of healing. Anything short of absolute surgical clean- 
 liness \vill convert these clots and the bhxid into dangerous agents of 
 infection. 
 
 Amjyiihttioii. — Anijnitation of the liml) in comjxtuiid fracture was 
 formerly resorted to with great frequency in hospital ])ractiee. Before 
 the introduction of antiseptics pyremia destroyed the life of almost every 
 j)atient suffering from compound fracture who was brought to a large 
 metropolitan hospital. The time is within my own recollection when, 
 in Bellevue Hospital, amputation was immediately performed as a rou- 
 tine treatment to prevent blood-poisoning iijion tiie admittance of a com- 
 pound fracture ; and tliis operation was considered by surgeons as offer- 
 ing to the patient the i)nly chance of recoxt'i-y. At the present time 
 limbs are saved which Avould then have been sacrificed, and it is a rare 
 event to witness an amputation in compound fracture. Extensive frac- 
 ture of the bone with ])rotrusion of the fragments through the soft struc- 
 tures would not now form an indication for amputation unless the soft 
 structures were badly lacerated. Formerly the loss of a few inches of 
 the bone called for primary am])utation, but this no longer offers an 
 indication, for the bones are brought together by silver wire, and, though 
 the limb may be shorter than its fellow, the member is still retained, 
 and elevation of the shoe compensates for any slight irregularity in the 
 length of the limb. 
 
 The limits within which amputation in compound fracture may be re- 
 sorted to are now exceedingly narrow and restricted, and this clinical 
 fact is one of the most notable steps in the advance of modern surgery. 
 Another im])ortant point in reference to amputation in compound fracture 
 is the proper line of treatment to be pursued up to the time of the ope- 
 ration. It often happens that a patient is suffering too profoundly from 
 shock to make it expedient to amputate. In these cases great benefit is 
 to be derived from deferring the amputation even many days, until the 
 condition is such as to justify the operation. Formerly this could not 
 be practised without subjecting the patient to a greater risk from septic 
 infection than wouldbe incurred by an amjiutation during shock. If the 
 wound is at once made aseptic and com]n-esses are jilaced over the frac- 
 ture to control the hemorrhage, and these compresses do not extend 
 higher than the wound itself, the amputation can be deferred. It is 
 important that these compresses be apjilied only over the wound, and 
 that no tourniquet or any other form of compression be a]>]ilied to the 
 limb in the continuity of the artery above the injured part for any 
 length of time, since if this is done there is danger of gangrene in the 
 fla]is after the amputation. In one ease gangrene followed an ani])uta- 
 
528 FRACTURES. 
 
 tion of tlic leg where a tourniquet liad lieeii ])lacecl over the femoral 
 artery. This j)atieiit was l)rou<;ht to tlie hospital from a ueighborino; 
 town with a tourniquet upon the femoral artery for the ])urpose of arrest- 
 ing hemorrhage in a compound fraeture of the leg, and I call attention 
 to the case in order to em])hasize forciljly this point. 
 
 The conversion of simple fractures into coni|)ound or complicated 
 fractures may ha|)pen, especially when the muscular spasm is great, or 
 (hiring the transportation of a patient suffering from a sim])le fracture.; 
 or there may be spontaneous conversion by means of the necrosis of a 
 small fragment. An abscess subsequently forms and pus is set free, 
 and the seat of fracture is exposed to the atmosphere. The author 
 has observed, for example, a Pott's fracture — that is to say, a frac- 
 ture of the filmla three inches above the tip of the external malleolus, 
 with a laceration of tiie deltoid ligament — converted after several weeks 
 into a typical compound and complicated fracture, owing to the ne- 
 crosis of the distal fragment. Suppurative arthritis of the ankle- 
 joint ensued, with caries of the astragalus. The ankle-joint was opened, 
 the carious fragments removed, the joint freely irrigated, and an anti- 
 septic dressing ap])lied. The patient recovered in a few weeks with a 
 useful joint. The possibility of nature transforming a simple fracture 
 into a complicated one must not be overlooked. In such cases promj)t 
 surgical interference may arrest the progress of the disease and effect 
 perfect restoration of a joint ; otherwise this complication leads to irre- 
 ])arable damage, if not to loss of life. 
 
 The treatment of compound fractures involving major joints has been 
 entirclv revoluti()nizcd since the introduction of aseptic surgery. The 
 unsatisfactory results in fracture-dislocations are due in a large measure 
 to a want of rigid asepsis on the one hand, and a too extensive operative 
 interference on the other. For examjile, the joint may not be rendered 
 thoroughly aseptic at the beginning, and may be too extensively inter- 
 fered with as regards operative procedures. 
 
 In the 171 compound fractures involving joints recorded in the 
 1000 cases referred to below the results as regai'ds the usefulness of the 
 joint have been in nearly all the cases perfect. To have a compound 
 fractiu-e-dislocati(jn of the ankle-, knee-, elbow-, or shoulder-joint re- 
 paired with complete restoration of function is the aim of the surgeon. 
 In one of the cases the asti'agalus extruded from the joint, and was rein- 
 serted, and perfect movement of the joint followed. These ideal results 
 are to be obtained only by the exercise of great care. In all fracture- 
 dislocations the joint should be immediately rendered absolutely aseptic 
 by thorough irrigation. The drainage should be entirely across the joint, 
 otherwise a ]50cket for the retention of inflammatorv exudates is sure to 
 form in the fold of the capsule. These products luider certain conditions 
 are sources of great danger. A careful study of cases of fracture-dis- 
 location reveals the history of an abscess-formation upon the side of the 
 joint opposite to the original wound several weeks after the injury. This 
 complication may be obviated by free drainage. It is not sufficient to 
 drain one side only, and that side through the original opening into the 
 joint, but the tube must pass entirely through and across the joint. 
 Physiological rest for many weeks must then be secured, and no jiassive 
 motion employed for at least six Meeks. Passive motion too early em- 
 
COMPOUND FRACTURES. 529 
 
 ployed has often excited inflammation which has led to suppurative 
 arthritis. Active motion must follow in its turn, but not for some 
 time after the employment of passive motion and massage. A proper 
 sequence in the employment of these different agencies is most iinjJort- 
 ant in order to reach an ideal result. 
 
 The complete Iiistories of the one thousand cases of compound frac- 
 tures have been carefully recorded. Tiie general summary is as follows : 
 
 Skull 178 
 
 Nasal, malar, maxilla;, and patellae 89 
 
 Arm 40 
 
 Forearm 41 
 
 Fingers and toes 97 
 
 Ilium, clavicle 2 
 
 Thigh 87 
 
 Leg ^ . ._ 295 
 
 Fractures involving shoulder-, elbow-, or wrist-joints as a result of disease 
 
 or accident 39 
 
 Fractures involving hip-, knee-, or ankle-joints as a result of disease or 
 
 accident 85 
 
 Fractures involving carpal or metacarpal, tarsal or metatai-sal joints as a 
 
 result of disease or accident 47 
 
 1000 
 
 Xow, following the example of surgical writers who have carefully 
 tabulated the results of treatment in compound fractures, the author has 
 eliminated all those cases in which primary amputations were performed, 
 because they do not concern the jioint at issue, and, according to the 
 practice of writers, has rejected all those cases which died of hemorrhage, 
 collapse, shock, etc. within forty-eight hours ; in fact, most of such cases 
 died within a few hours after injury. He has also left out cases of com- 
 pound fractures of the hand and foot as too insignificant to be classed 
 with compound fractures of the long bones or of the skull. 
 
 In the total of 1000 consecutive (and, of course, unselected) cases of 
 compountl fractiu'cs produced by tramnatism or by operation, there were 
 101 deaths, (JO ])rimary amputations, and 4 cases where the results were 
 unknown on accoiuit of the removal of the patients from the hospital, at 
 their own request, immediately after their admittance. In the 101 deaths, 
 82 died within forty-eight hours after the accident and during shock, and 
 consequently these deaths siiould not be included in any figures to a.scer- 
 tain the percentage of mortality, becau.se the patients died before anv plan 
 of treatment could be adopted having reference to the repair of the frac- 
 ture or to the prevention of septic infection. 
 
 The remaining 19 deaths occurred from the following causes: One 
 from tuberculous meningitis following some weeks after a resection of 
 the hip-joint, so that, this case died from other causes than septic infec- 
 tion ; another from uriemia in ••hronic Bright's disease one week after 
 wiring the patella. The wound was, however, healed and ])erfectlv 
 aseptic, so that this case died from other causes than septic infection. 
 Another died one month after tre]>hining, from exhaustion and inanition, 
 with the wound perfectly healed l)y primary intention, and, as shown by 
 the autopsy, with no evidences in the brain of the pathological changes 
 of sepsis, so that death in this case cannot be attributed to septic infec- 
 tion. Two other cases died from irreparable damage to the brain, in one 
 
 Vol. I.— 34 
 
530 FRACTURES. 
 
 of which the lock of a gun was driven tlinnigii tlie skull into the brain, 
 and in the other a fracture at the base was found at the autojjsy in addi- 
 tion to the fracture of the parietal bone, so that death in neitlier of those 
 two cases was due to pya?mia or septicemia. Four other cases died from 
 cerebral softening, which was situated at a distance from the original 
 wound. One case died from dipiitiieria after the external wound of the 
 ciimpound fracture had liealed. Tlie wound was asejitic, and was never 
 the seat of any disturbance, and, as the diphtheria aft'ected the larynx and 
 trachea, the cause of death was in no way connected with the fracture, 
 altliough, of course, the time was too short to have the bone firmly united. 
 One case of compound fracture of the skull died on the fifth day, but in 
 this case the ])atient was suffering from a fracture of the spine which 
 caused his death by myelitis. One case died within forty-eigiit liours 
 after admittance from cerebral abscess connected with a punctui-ed fracture 
 of the skull, which had been operated upon two Mceks previously by a 
 surgeon in a neighboring town. During tlie jiatient's sojourn in the 
 hospital he was trephined and seven ounces of pus were evacuated from 
 the brain, but he died a few hours later. This case is excluded, on the 
 gnnuid that the patient's injury was not treated in the hospital, and 
 that he did not enter the hospital until within forty-eight liours of 
 liis death. The death was clearly due to sepsis, but the circumstances 
 were such as to relieve the hospital surgeon from all responsil^ility. 
 One case died after forty-eight hours, but it was a case of primary ampu- 
 tation. The patient was run over by a locomotive ; both feet were 
 crushed, and the hanging toes were removed as soon as his condition 
 would permit. One case similar to the last died fi-om a crushed foot 
 ninety hours after the accident. The jiatient was over sixty years of age, 
 and never reacted from the shock. The remaining case of death was due 
 to lej)tomeningitis, which occurred fifty-two hours after trephining, and 
 was due to sejisis. 
 
 Finallv, in order to arrive at the mortality in this list of one thousand 
 compound fractures, there must be deducted from the original 1000 eases 
 60 primary amputations, because no treatment of the fracture itself was 
 undertaken ; 82 deaths from shock occurring within forty-eight hours, 
 because no treatment was begun ; 4 cases where the result is unknown, 
 because the patients left the hospital of their own accord; 155 cases 
 of compound fractures of the fingers and toes, because tiiey are too 
 insignificant ; also 1 8 cases just mentioned in detail. There then remain 
 681 cases of compound fractures witli one death due to sepals. This 
 gives a death-rate of about one-seventh of 1 per cent. The reduction of 
 the death-rate from 48 per cent., which half a century ago was considered 
 a brilliant achievement and a result which was thought worthy of jniblica- 
 tion, to that of one-seventh of 1 ycr cent, represents what surgery has done 
 for the amelioration of human sufi'ering and the preservation of life in 
 this special field of sui-gery. To Pasteur and to Lister the profession are 
 indebted for this great work — the former as the discoverer of the means, 
 and the latter as the one who ap|)lied the discovery to surgery. 
 
 Complications. — Compliccdions during and after repair of fractures 
 forms a most interesting subject for observation and study. The com- 
 plete usefulness of a limb is not fully restored as soon as the fracture 
 has been repaired. During the process of repair, as well as after union 
 
COMPLICATIONS. 531 
 
 is complete, it is jjossible for many comjilications to arise that rccjuire 
 special treatineut. 
 
 Surgical emphysema is a condition that is often met with in the man- 
 agement of fractnres. This consists of the entrance of atmosplicrie air 
 into the meslies of the connective tissne, and is termed "surgical emphy- 
 sema " to distinguish it from emphysema of the lung. The source of 
 tiic intiltratiiin of the air into tlie connective tissue may be from injury 
 of the lung in fracture of the rib, in wiiich case the emphysema has been 
 observed to reach to the scrotum, and at times it may spread over the 
 face, so that the jiatient is unrecognizable. The air may escape to such an 
 extent as seriously to embarrass respiration. Another source of emphy- 
 sema may be from the generation of gases as a result of putrefactive 
 changes or of the growtii of gas-producing bacilli in the tissues. There 
 are only a few cases oljserved of emphysema in simple fractures ; the 
 majority of the cases have been comjilications in compound fractures. 
 Or the gas may escape from a wound in tlic intestine, or even from the 
 air-sinuses in the bones of the face and skull. 
 
 If the emphysema arises from injury to the lung, no interference is 
 indicated unless the emphysema is so extensive as to produce dyspnoja, 
 in which case free incisions can be made or the air allowed to escape 
 through a trocar. The air is usuall}^ absorbed in a few weeks, and 
 produces no harm, since it has been filtered in its jiassage through 
 the lungs, and is therefore incapable of setting up inflammation. In 
 case tile condition arises from putrefactive changes, the apjilication of 
 the ]>rinciples of antiseptic surgery is required ; if from a wounded 
 intestine, a laparotomy must be performed at once, the peritoneal cavity 
 rendered aseptic, and the wound closed. 
 
 Q^demn consists of the infiltration of serous fluid into the interstices 
 of the areolar tissue, and, unless it is due to some organic disease of the 
 liver, kidney, or heart, is the result of too tight bandaging or the sudden 
 removal of tiie splint, or, finally, of obliteration of the large veins 
 frijui thrombosis. If due to local causes, the oedema usually disappears 
 after the removal of the cause, or, if to a loss of support of the vessels 
 by the removal of the splint, the oedema rapidly subsides as soon as the 
 function of the limb is restored. Placing the limb under a faucet and 
 doucliing it alternately with hot and cold water will stimulate the circu- 
 lation ; and this treatment, aided by the action of the muscles when the 
 patient begins to walk, will relieve the condition. 
 
 Delirium tremens and traumatic delirium are two complications that 
 frequently occur. The differential diagnosis is often difficult to make, 
 but tremor in the limbs and an alcoholic history, with absence of fever, 
 point to the former as contrasted with the latter condition. In both 
 forms of delirium the ]iatient has delusions, mutters incoherently, is 
 often violent and excitable, and has a dry, tremulous tongue accompanied 
 by free diaphoresis. 
 
 The treatment consists in placing the fracture at once in a plaster-of- 
 Paris splint and watching the jiatient carefully, even to the extent of 
 employing a special attendant. If the delirium becomes too active, and 
 it is impossible to restrain the jiatient, a strait-jacket must be cmplo}'e<l. 
 If the patient is robust and young, alcohol can Ije witiiheld, but if aged 
 and feeble, it is necessar}' to continue stimulants with judgment. 
 
532 FRACTURES. 
 
 The bromides, chloral, hyoscyamus, and in some cases morphine, are 
 the remedies which have proved the most successful. In organic disease 
 of the kidney morphine is apt to cause suppression of urine, and must 
 be enijtloyed with caution. The diet must be nutritions and abundant, 
 and the patient's strength maintained. 
 
 Fncumonia is a complication likely to arise during the repair of a 
 fracture. It is especially likely to occur in alcoholic patients and in 
 compound fractures, and forms a most serious complication. The treat- 
 ment of the disease is conducted upon the same principles that govern 
 the physician in a case of ordinary pneumonia. 
 
 Tetanus is fortiniately a rai-e complication occurring during the repair 
 of fracture. In a tabulation of over twelve thousand fractures there were 
 25 deaths from tetanus, or about 1 case in 5U0 fractures. In the 25 cases 
 of tetanus taken from this large list the disease develojjed in only 3 
 simple fractures. The propoi'tion of cases of tetanus in all kinds of 
 fractures is only about 1 per cent. The greater nundjer of cases of tetanus 
 occurring in compound fractures is explained by the entrance of the 
 bacilli of tetanus from external sources of infection, as dirt, air, and 
 surrounding media. This percentage was derived from cases treated in 
 pre-antiseptic days, so that with antiseptic princijiles applied to the 
 dressing of a compound fracture tetanus ought not to apjiear as a com- 
 plication. In tlie author's list of one thousand cases of compound frac- 
 tures no case of tetanus appeared. The tlisease usually occurs in com- 
 pound fractures, and esjjccially those of the fingers and toes, in which 
 over 50 per cent, of the cases of tetanus occurred. Compound fractures 
 of the thigh furnished a large percentage of the cases. The cause of the 
 disease is tlie presence of the bacillus of tetanus. The treatment con- 
 sists of division of the main nerve-trunk or stretching it, or even ampu- 
 tation of the extremity. Calal)ar bean, morphine, chloral, the bromides, 
 the inhalation of chloroform, and the Russian bath have been emjjloyed 
 with varying degrees of success. For a full description of the treatment 
 the reader is referred to the article on Tetanus. Strict antisepsis must 
 be rigidly enforced in any case, since the disease is due to the presence 
 of a specific germ. 
 
 OdeornycUfis is a form of supjnu'ation in bone, and is caused by 
 the presence of septic micrococci in the wound. It is therefore most 
 likely to occur in compound fractures, although the disease in the form 
 of acute abscess may occur after any traumatism of bone. The osteo- 
 myelitis sets up necrosis of bone, and the patient may die from septic 
 infection before the sequestrum can be removed. Septic emboli may 
 start from the thrombi, and metastatic abscesses develop. The treatment 
 of this condition consists in freely exposing the seat of the abscess, and 
 tre]>hining the bone above it if necessary in order to reach the disease, 
 with a view to destroying the micro-organisms with a solution of bichlor- 
 ide of mercury. The application of the ]n-inci])lcs of antiseptic surgery 
 will destroy the disease, and if not amputation of the limb is indicated. 
 
 Fdf-cmbolism was first fully described by A\'agner and Zenker. 
 Fat-embolism means the entrance of fluid flit from the medulla of the 
 bone into the veins in the immediate vicinity of the fracture, and 
 through these channels into the capillaries of the brain, spinal cord, 
 lungs, kidneys, and other essential organs. The presence of fluid fit in 
 
COMPLICATIONS. 533 
 
 the blood was descril)ed in 1836 by Dr. R. W. Smitli, but the clinical 
 importance of this condition was not I'ecognized until recently through 
 the investigations i)f Bergniann, Czerny, and Scriba. Dejerine has ex- 
 perimentally produced fat-embolism in the lower animals by inserting 
 laminaria tents into the medullary cavity of the l)one. The symjitoms 
 of fat-embolism appear on from tiie third to the fifth day as a rule, and 
 resemble those of secondary shock. They occur before the time at which 
 venous thrombosis or pulmonary embolism would be expected to appear. 
 Great dyspntea, associated \vith tlie Cheyne-Stokes respiration, irregularity 
 of the heart's action, with a sudden rise of temperature, together with 
 twitching of the nuiscles, as well as paralysis of certain muscles, have 
 been observed in these cases, and also fat-globules are found in the 
 urine. There have been no metastatic abscesses discovered where an 
 autopsy has been made. This group of symptoms must not be mis- 
 taken for shock following fracture nor for jiulmonarv enil)olism. 
 Shock may be said to be present three hours: after the fracture, fat^ 
 embolism ihrer dai/s after, and jiuliiKinary embolism three veeks after. 
 For convenience these complications have been arranged in the order 
 in which they are most likely to occur, and by associating these condi- 
 tions, which simulate each other, with the time at Avhich they appear, 
 no mistake in diagnosis is likely to arise. 
 
 The treatment of fat-embolism consists in the administration of etiier 
 in the form of some such preparation as Hoffman's anodyne, or even l)y 
 hyjiodermic injection. In ease of great dyspnoea venesection has been 
 suggested, and also artificial respiration. The pulmonary oedema must 
 be relieved by cardiac stimulants and by cupping. The fracture should 
 be kept perfectly quiet, lest any movement of the fragments might cause 
 furtlier absorption of the fat by disintegrating the medulla. In cases 
 wliere there is great cimiminution of bone and disintegration of the 
 medulla amputation may be immediately indicated as a life-saving 
 expedient. 
 
 <Tanf/rene of the limb may occur either as a result of mechanical or 
 traumatic causes or from septic infection. Gangrene arising from mechan- 
 ical causes is due to the application of too tight a splint or bandage or 
 to the improper and prolonged use of a tourniquet. The gangrene 
 resulting from traumatic causes is due to a crushing or laceration of the 
 soft structures near the fracture, or else to the rupture of the main ves- 
 sels by the same agency which produced the fracture, or by the sharp 
 fragments of bone, or, finally, to pressure from hemorrhage or from an 
 unreduced fragment. The occurrence of gangrene often leads to suits 
 for malpractice in the treatment of fractures. It is therefore important 
 for the surgeon to define clearly the causes over which he has control, 
 and those which are beyond his control, such as contusion, laceration of 
 blood-vessels or nerves, pressure of a fragment of bone, or the oblitera- 
 tion of the lumen of the artery from thrombosis due to senile changes or 
 calcification of the artery, and the jiresence of diabetes, with Mliich gan- 
 grene is so often associated, especially after an injury. 
 
 The treatment nuist depend upon the cause, the extent, and the gen- 
 eral infection of the patient. In small, localized areas of gangrene 
 measures should be adopted to encourage the separation of the slough, 
 while in gangrene with a line of demarcation forming amputation can 
 
53-1 FRACTURES. 
 
 be resorted to when the heahhy and dead tissues are clearly defined. In 
 case of rapidly-spreading gangrene, with symptoms of serious septic 
 intoxication, amputation high above the gangrene shuukl be immediately 
 performed. 
 
 Fi/cvmia and .scptic.cemia are conditions which arise in the course of 
 the repair of a fracture, and for a full description of these complications 
 the reader is referred to the article devoted to a consideration of this 
 subject. 
 
 Thrombosis is a complication that under rare circumstances occurs. 
 When a vein has been wounded, a clot forms which closes the vessel. 
 From this thrombosis an embolus has been known to originate and 
 travel to the lung, where it has caused death by plugging up the pul- 
 monary artery. This complication occurs, without any warning, about 
 three ^^■eeks after the receipt of tlie fracture. The patient exjiires sud- 
 denly witli great dys])n(ea, cyanosis, feelile pulse, and angina pains. 
 It occasionally happens that small emboli may become detached, and 
 produce alarming symptoms which gradually disappear. In all cases 
 where there has been obliteration of the veins, with formation of 
 thrombi, it is dangerous to jiractise massage early or to disturb the seat 
 of fracture, since an embolus might be torn a^\■ay from the thrombus 
 and set free in the circulation. 
 
 Hemorrhage to a certain extent occurs after every fracture, but the 
 amount is usually so small that it requires no treatment. If, however, 
 the quantity is large, there is danger of sloughing and gangrene, owing 
 to pressure. The seat of the hemorrhage is between the integument 
 and fascia, or it may be beneath the fascia. The source of the hemor- 
 rhatre mav be from the medulla of the bcme, from the associated contu- 
 sion and laceration of the soft structures, or even from a rupture of 
 the main artery or vein of the limb. When the hemorrhage is from 
 the medulla the blood escapes from the broken ends of the fragments, 
 and after a few days undergoes absorption. When the hemorriiage is 
 from the contusion of the soft parts the amount may he considerable. 
 The blood may apjiear in the form of a fluid tumor t)r as a semi-solid 
 mass due to coagulation. If the l)lood is fluid, an aspirating needle, 
 rendered aseptic, can be introduced into the tumor and the blood with- 
 drawn, and at the same time equable compression can be employed in 
 order to obliterate the space or cavity which is formed by the sudden 
 withdrawal of the blood. If the blood has coagidated, the clot may 
 undergo a certain amount of absorption and contraction, or it may by 
 pressure cause irritation, and by tension set up inflammatory reaction, 
 quickly followed by suppuration. If the latter takes place, the abscess 
 must lie opened, the remnants of the clot removed, the cavity irrigated 
 with a bichloride solution, and then dressed antiseptically. If the 
 hemorrhage proceeds from a rupture of the main artery of the 
 limb, a traumatic aneurism is formed. If the aneurism is small, the 
 pulsation is feeble, and the circulation is good in the distal branches of 
 the artery, slight digital pressure on the main artery above the aneurism 
 Avill sometimes cure the aneurism. If an artery is wounded subcu- 
 taneously as a result of fracture, and the hemorrhage is not excessive, 
 it often happens that in a healthy patient repair will take place without 
 any operation. If, however, the aneurism is large, the pulsation strong, 
 
COMPLICATIONS. 535 
 
 the circulation below the injured vessel feeble or entirely shut off, and 
 the patient in a dangerous condition from loss of blood, the operation 
 of cutting down upon the vessel, turning out the clot, and ligaturing 
 both cndx should be immediately performed. If the femoral artery is 
 wounded, or both til)ials, this operation of ligating may be inadequate, 
 and the condition may call for amputation. In primary hemorrhages 
 both ends of the divided vessel should be sought for and ligated in the 
 wound, while in secondary hemorrhage the vessel sh(juld be tied in its 
 continuity, and above in healthy tissue. 
 
 Atrophji of the limb following fracture is a complication that is likely 
 to occur, especially when there has been long-continued disuse of the limb, 
 as in fracture of the patella. The atrophy is most marked in the muscles 
 above rather than in those below the joint nearest to the fracture, and it 
 is especially prone to appear in rheumatic diatheses and to involve the 
 extensor muscles. Tlic atrophy involves the connective tissue as well as 
 the muscles, and the condition may be dependent upon an injury to the 
 nerves in the limb, or possibly to a too-prolonged use of contimious 
 compression. The atrophy,is susceptible to treatment by gentle massage, 
 hypodermic injection of strychnia, shampooing of the limb, and mod- 
 erate exercise. 
 
 Parali/fiis of the viu.'<o/cs below the seat of fracture may occur as a 
 complication during the repair of fracture, as a result either of associated 
 injury to the nerves supplying the affected muscles or of an inclusion of 
 the nerves in an exuberant callus during the process of repair. In the 
 former case the paralysis is present simidtaneously with the occurrence 
 of the fracture, and if the nerve is a mixed one there will be loss of 
 motion and sensation. The simple tests for motion and sensation 
 should be made in examining every case of fracture, since a paralysis 
 which is overlooked at the time of the examination of the fracture 
 may be attributed subsequently to carelessness on the part of the 
 surgeon. This knowledge will prevent any j)0ssible claim for dam- 
 ages. In the latter case, where the paralysis results from pressure of 
 callus, the symptoms appear gradually and some time after the occur- 
 rence of the ft'acture. 
 
 In cases where the paralysis is due to pressure, electrical stimulation 
 of the main nerve-trunk above the callus fails to excite the muscles to 
 wliich tiie nerve is supplied. 
 
 The treatment consists in extricating, if ])ossible, the nerve from the 
 callus by means of a surgical operation, and the application of the con- 
 stant current to the nerve until it has regained its function. 
 
 Anki/losis of jotntx occurs as a complication following fracture. The 
 ankylosis may be either jiermanent or temporary. The permanent 
 variety consists of all osseous ankylosis, and the condition is a result of 
 a fracture directly into the joint, so that the fragments within the j(jint 
 have become united. For the removal of this condition surgery can 
 offer no relief unless an asejitic resection of the joint is performed, and 
 this operation is limited to a few of the joints, like the shoulder, elbow, 
 wrist, and ankle, with possibly a few others. The tem]iorary ankylosis 
 is the result of a concomitant injur}- which has set uj) an arthritis, or 
 it may be due to the prolonged use of extension in the treatment of 
 certain fractures, or it may be the result of hemorrhage into the joint 
 
C36 FRACTURES. 
 
 which lias excited a synovitis and artliritis, witli tlie formation of intra- 
 articular Ijands of fibrous tissue. In Colles's fracture the fing'ers ai'e often 
 stiff from a thecal inflammation, and it is with great difficulty that this 
 condition can be relieved. 
 
 The treatment consists in massage, shamjiooincj-, the use of hot fo- 
 mentations of bran, the alternate douching with hot and cold water, and 
 active movement. 
 
 Necroi^i.s of hone occurs as a complication during the repair of frac- 
 ture, and is due to the fact that the jieriosteum has been detached from 
 the fragment or else from the shaft of the bone. In the former case the 
 loose fragment should be removed at the time of the reduction and first 
 dressing ; in the latter case the superficial scale of bone undergoes ne- 
 crosis, owing to its diminished vascular sujiply. Generally a sinus leads 
 down to the exfoliated bone. This tract should be excised and the bone 
 removed, as a long-continued sinus discharging ichorous pus is a condi- 
 tion favorable to the development of an ejiithelioma. 
 
 Non-union of bone occasionally occurs. In many cases the frag- 
 ments may fail to unite at the usual time, and even fail after several 
 attempts to induce repair; but eventually union can be accom]>lished. 
 The author some yt'ars ago published a report of one thousand com- 
 pound fractures, and in this list there was no case in which finally 
 union was not obtained. Assuming that one eomjiound fracture occurs 
 to every ten simple fractures, there woidd be nearly ten thousand cases 
 of fractured bones in which the author cannot recall a single case of per- 
 manent non-union. AMiere the fragments could be approximated they in 
 a few cases failed to unite after several attemjrts in the way of o])erative in- 
 terference, but finally a union was effected, although in several cases as many 
 as seven or eight operations were performed. The femur and the hiimerus 
 occasionally fail to unite, and, next to these, the bones of the leg, and 
 lastly the bones of the forearm. That part of the bone which is away 
 from the direction of the nutrient artery is most likely to give rise to 
 non-union. In the sitting posture, if the elbow- and knee-joints are 
 strongly flexed, the nutrient arteries take a direction downward, or in the 
 upper extremity the nutrient arteries run loirard the central joint, wliile 
 in the lower extremities the nutrient artries run cncaji from the central 
 joint. From this anatomical law the upper part of the humerus would 
 be the most frequent seat of ununited fracture ; and in siqiport of this 
 statement out of 13 cases reported of ununited fractures of the humerus, 
 9 were in the upper extremity of the bone. In 8 ununited fractures of 
 the forearm, 7 were in the lower part. In the same manner, ajiplying this 
 anatomical law to the lower extremity, it is found that the cases of non- 
 union are found in a very large proportion of the cases in the lower jiart 
 of the femur and in the upper part of the tibia. The intra-capsular frac- 
 ture of the neck of the thigh-bone is an exception, but in this case the 
 non-union is due to special causes, which will be considered in a dis- 
 cussion of this special fracture. 
 
 The (xtuscs of non-union in bones after fracture are constitutional and 
 local. Among the constitutioval causes, in which the reparative action 
 is impaired or misdirected, may be mentioned old age and certain con- 
 stitutional diseases, as fevers, syphilis, scurvy, malignant disease of bone, 
 and rickets. Paralysis may also be a cause, as is illustrated by a case 
 
NON-UNION OF BONE. 537 
 
 of spinal injury with fracture of the linnierus and leii of the same side, 
 in whieli the arm united, hut the k'g failed to unite. 
 
 The puerperal state is another eonstitutional cause whicii has been 
 mentioned hv some writers, but the author has never found this condition 
 to permanently cause a non-union in fractured bones, although in some 
 cases the bones fail to unite until after parturition or until several opera- 
 tions have been performed. 
 
 Among the local causes of non-union may be mentioned the direc- 
 tion of the line of fracture, since oblique fractures are more frecpiently 
 attended Ijy failure of tuiion tJian transverse or impacted. Among the 
 other causes may be found sei)a)-auon of the fragments, the interpositiou 
 
 Fig. 44. 
 
 of foreign botlies between the ends of the broken bones, or suppuration, 
 profuse hemorrhage, the continued use of wet dressings, and, finally, 
 improper dressings, in which the splints are either too tight or too loose 
 
 The treatment ot non-iuiion of bone following fracture is to be con- 
 sidered from a constitutional as well as a kical jioint of view. It is 
 the union of the two methods that is sure speedily to bring about the 
 desired object. In every case a careful incpiiry should be made in regard 
 to certain diatheses. The treatment of this unfortunate condition has for 
 its oliject the correction of any constitutional dyscrasia. A syphilitic 
 diathesis should be treated with the full administration of antisyphilitic 
 remedies ; a gouty or rheumatic tendency, by remedies suited to these 
 special diseases ; scurvy, rickets, scrofula, tuberculosis, and marasmus 
 should be treated with tonics and a nutritious diet, with the aid of the 
 best hygienic surroundings. The tonics best suited for those condition.' 
 in which the general health is impaired are iron and the phosi)hates. 
 
 In conjunction with the general management the local treatment is to 
 be pursued. The means emjiloycd must consist of the removal of any 
 offending body between the fragments and the excitation of a certain 
 amount of inflammation aroiuid the ends of the fragments. The local 
 treatment must further consist in the application of an immovable splint 
 specially ada])ted to the exigencies of the case. 
 
 The operations which have been devised with a view to effecting union 
 in ununited fra<"ture are nniltifarious. They all have one common olijcet — 
 viz. the excitation of inflanimation ; but many of the old operations are 
 at the present time abandoned as a result of the introduction of anti- 
 septic surgery. The use of the seton, the injection of irritating fluids, 
 the cauterization of the fragments, the application of blisters and of 
 caustic alkalies to the skin over the site of the ununited fracture, the 
 
 s 
 
538 
 
 FRACTURES. 
 
 Fig. 45. 
 
 introduction of electrical cnrrents, the violent jiercus.sion witii the mallet, 
 — are among the varions operations which are practically discarded as 
 luisnitalile, and in their place.s modern surgery has instituted a number 
 of asej)tic operations. 
 
 Before any other operation is attempted it is good surgery to try and 
 perforate the bones, which is best accomplished by a Bi-ainard drill. 
 This operation is simi)le, is attended with no special danger, and in the 
 majority of cases will bring al)out firm union. This method is espe- 
 cially indicated in cases where the patient's healtli is impaired, or the 
 patient is aged, or where any lesion of important organs exists, such 
 as would render a more serious operation a source of great danger. This 
 operation can be accomplished without the administration of ether, and 
 with but little pain, by the use of the freezing atomizer and by the 
 hyjHidermic injection of cocaine through the ana\sthctized skin : a small 
 incision is made, and the drill is thrust into the Ijone. The drill pene- 
 trates the fragments in twenty or thirty places from the same opening in 
 the skin. In these cases the ends of the fragments are usually devoid 
 of periosteum, and the intervening tissue forming a false joint is jiartially 
 insensitive ; hence the pain is not unbearable. The soft parts around the 
 seat of fracture shoidd be thoroughly cleansed before drilling the bones, 
 and the small puncture in the skin made aseptic before being hermet- 
 ically closed. Closure of the wound is best eft'ected by iodoform powder 
 freely sprinkled over the wound, and over the powder should be painted 
 
 styptic collodion with a thin film of 
 borated cotton, and in this way a firm 
 scab is formed, which closes the wound 
 and converts the small comjiound frac- 
 ture thus made into a sim])le one. 
 The drilling causes considerable in- 
 flammation, and the determination of 
 1)1(1(1(1 to the part carries with it the 
 materials for osseous repair. This 
 simple operation is worthy a trial in 
 ununited fractures, even though sub- 
 sequently a more serious operation 
 under ether might become necessary. 
 The operations fiir non-union in 
 fractures where drilling has failed 
 consist of cutting down upon the site 
 of the fracture and exposing the false 
 joint. Great care should be exercised 
 to avoid wounding any of the import- 
 ant vessels and nerves. The inter- 
 vening fibrous tissue should now be 
 cut away, the two ends of the bone 
 brought out, and a small piece of each 
 end sawed otf, so as to .secure a fresh 
 osseous surface. The manner of further 
 procedure must necessarily depend upon whether there are two parallel 
 bones or there is only one single bone in the extremity. If there are 
 two bones, no union can be effected unless a corresponding section of 
 
 w 
 
 \V 
 
 I 
 
COMPLICA TIONS. 
 
 539 
 
 the opposite bone is removed, in order to have tlie broken ends brought 
 in apposition (Fig. 45). 
 
 Tliere are several methods of fixation of the exposed fragments. In 
 some cases the ends can be sutured by silver wire, and little shortening 
 
 Fig. 46. 
 
 'J u 
 
 Volkmaun's operation for pseudarthrosis. 
 
 is likely to follow. . In other cases this method is inapplicable, since 
 the ends are often too pointed to afford a sufficient breadth of surface 
 
 Fig. 47. 
 
 n. H. Smith's splint for ununited fracture of the thi^^h. 
 
 for union. Under these circumstances the jieriosteum should be pre- 
 served as far as possible, and a resection be made in each fragment, as 
 
 Fig. 48. 
 
 
 H. H. Smith's splint for ununited fracture of the les. 
 
 shown in Fig. 46. The fragments can be fastened together by ivory 
 pegs or by steel nails, or even sutured by strong silver wire. 
 
 Palliative measures are sometimes indicated where an operation for 
 
540 FRACTURES. 
 
 any reason seems inadvisable. The aceompanying cuts illustrate the 
 principle upon whicli sucli treatment is based (Figs. 47 and 48). 
 
 In extreme cases, where tlie limb is useless, and suppuration is present 
 to such an extent as to endanger life, am})utation may be called for. 
 Such treatment may be indicated where an operation to effect union 
 has failed and su])iiuration and necrosis have followed. 
 
 It occasionally happens that no operation for pseudarthrosis is per- 
 missible, in ^\hieli case a splint should be used, so that the patient can 
 have a greater sense of security. 
 
 Special Fractures. 
 
 Fracture of the phalanges occurs as a i-esult of direct 
 violence, such as the passage of a wagon-wheel over the toes or by 
 the fall of a heavy N\eight directly upon the ])art. Fractures of the 
 toes may also be caused by the patient striking the foot against a chair 
 or sofa while walking barefooted in the dark. If the fracture is 
 compound, the wound can be dressed aseptically and a small splint 
 applied, and the entire foot envelojied in a plaster-of- Paris bandage. 
 The soft j>arts are very vascular, and tlie repair is very ra])id and satis- 
 factory. The danger from tetanus in ccmijiound fractures of the toes 
 must not be overlooked. In the sim])le fracture* of the phalanges a 
 pasteboard splint should be a])plicd ^\•et and moulded to the toe, and the 
 foot placed in a plaster-of- Paris bandage. 
 
 Fractures of the metatarsal bones occur in much the same 
 way as those of the phalanges, only the degree of injury inflicted is 
 greater. The same general rules will suffice in the management of 
 fracture of these bones. 
 
 Fracture of the tarsal bones occurs from direct violence, and 
 is usually associated with great destruction of the soft tissues. The skin 
 is very apt to slough, and much care must be exercised in order to pre- 
 serve the integrity of the tissues. Fractures of the scaphoid, cuneiform, 
 and cuboid bones do not require any special consideration beyond that 
 exercised in the general management of fractures of the metatarsal 
 bones of the phalanges. 
 
 Fracture of the calcaneum usually is the result of a fall from 
 a great height M-here the patient strikes upon the heel. This fracture 
 has occurred a number of times in workmen on elevated railroads. The 
 men in endeavoring to avoid a passing train have lield themselves sus- 
 pended in tiie air from the iron structure, and, not having strength 
 enough to hold on until the train had passed, have dropped to the ground, 
 and, striking ujion the hard pavement, have broken the calcaneum of each 
 foot. The fracture may also be produced by a wheel of a carriage 
 or cart passing over the foot laterally while the patient is lying on his 
 side upon the ground (Fig. 49). Fractures of the calcaneum may occur 
 from muscular action, as \\here the tendo Achillis is suddenly contracted 
 and tears the insertion of the muscle from its attachment. The detached 
 tendon often carries with it a thin shell of bone from the posterior part 
 of the OS calcis. 
 
 The signs and symptoms of fracture of the calcaneum are such as 
 to render the diagnosis clear. Crepitus, pain, swelling, and ecchymosis 
 
SPECIAL FRACTURES. 
 
 541 
 
 are present. The heel itself is often contnsed, and is discolored from 
 the bruise caused by falling upon the integument over the heel. The 
 arch of the foot is often destroyed. The disjilacemcnt varies in degree 
 according to the situation of the fracture ; thus, if the break traverses 
 
 Fig. 49. 
 
 Fracture of os calcis. 
 
 tlie part of the calcaneum in front of tiie attachments of the lateral 
 ligament, there is usually but slight deformity, since the strong ealcaneo- 
 astragaloid ligaments holds the fragments in situ. On the other hand, 
 if the fracture is behind the insertion of the lateral ligaments, the tendo 
 Achillis dra\vs the posterior fragment well up, so as to cause a marked 
 and characteristic displacement. The dcn.se fibrous tissue surrounding 
 the Ijone also helps to prevent much displacement. 
 
 The treatment of .fracture of the calcaneum varies somewhat accord- 
 ing to the seat of fracture. If the bone is broken in front of the inter- 
 nal lateral ligaments, the den.se fibrous tissue about the bone and the sole 
 of the foot prevents any marked dis])lacement. The foot should be 
 placed in the .^lightly extended position and a plaster-of-Paris bandage 
 at once applied. If the bone, on the other hand, is I)roken behind the 
 insertion of the lateral ligament, the disi)lacement is well marked, and 
 it becomes necessary to place the leg upon a double-inclined plane in 
 order to relax the tendo Achillis, which causes the displacement. In 
 
542 FRACTURES. 
 
 the treatment of tliis fracture division of the tendo Achillis will at onee 
 cause the deformity to disa])pear and the fra<rnient to assume its natural 
 jjosition. Tlie physiological rest thus secured will result in rapid repair 
 of the fracture. It occasionally happens that neither the use of the 
 douhle-inelined plane nor tenotomy will result in a coaptation and 
 retention of the fragments. Under these circumstances the fragments 
 can be wired by an aseptic operation, or an ivory peg can l)e driven into 
 the fragment and thus fasten it firmly to the bone. If the fracture is 
 compound and the fragments are loose, it is best to remove them, since 
 necrosis of the small detached fragment is very likely to follow. 
 
 Fracture of the astragalus occurs usually at the neck, since this 
 is tlie weakest part of the bone. Fractures, however, are found through 
 other ])arts of the bone, and also associated with fractures of the other 
 tarsal bones, and even of the tibia and fibula. Fracture of the astrag- 
 alus is jjroduced in the same maimer as that of tlie os calcis, excepting 
 that it is never caused l)y muscular action, since there are no muscles 
 attached to tlie bone. The bone is sometimes crushed between the tibia 
 and the os calcis, and the fracture may also be accompanied by a fracture 
 of the fibula or the os calcis, or even with a dislocation of the ankle- 
 joint. Generally the ordiuaiy signs of fracture are present, such as 
 crepitus, pain, tenderness, and inaliility to bear pressure on the bone. 
 Tile displacement is slight, as there is no muscle to cause traction on the 
 fragment. The joint is often inflamed and the synovial fluid is abiui- 
 dantly secreted, so as to destroy the landmarks of the joint. 
 
 The treatment of this fracture is often fraught with difficulty, since 
 it is attended with more or less synovitis. This comjtlication is best 
 treated by fixation of the joint in a fracture-box or some other tempo- 
 rary apparatus, and employing an e\'aporating lotion for a fcM' days until 
 the swelling has in a measure subsided. If the fragment projects under 
 the skin, it is very apt to cause sloughing of the soft parts. If jjossible, 
 the fragment should be pushed back in its ])lace, even if it requires the 
 employment of anesthesia, for which nitrous oxide is the best form to 
 use, since it is safe and lasts a sufticient length of time to make the 
 adjustment. If the projei'ting fragment will not resume its jjrojier posi- 
 tion, division of the tendo Achillis will enable the surgeon to reduce the 
 displaced fragment. The danger is very great that the fragment in frac- 
 ture of the astragalus may become necrosed, and necrosis be followed by 
 suppuration in the j(iint. This of necessit)' prepares the May for a second- 
 ary resection of the joint. 
 
 After the swelling has subsided the leg can be placed in lateral 
 splints with rectangular foot-pieces, and thus maintained until the frac- 
 ture unites. A plaster-of-Paris bandage or felt or leather splints can 
 be used with cotton. The foot should be placed at a right angle to the 
 leg, and there should be no inversion or eversion of the sole. If the 
 fracture of the astragalus is compound, the fragment not only should 
 be at once removed, but the wound and the joint irrigated with a 
 weak antiseptic solution. It is important to introduce the drainage-tube 
 entirely through and across the joint, since its employment with only one 
 outlet is sure to be followed by serious after-effects. The anatomical 
 arrangement of the joint is such that ordinary drainage is insufiicient to 
 meet the requirements of the case, and special emjjhasis is placed ujjon 
 
SPECIAL FRACTURES. 543 
 
 free and complete bilateral drainage secured by a tube pas.sina: straight 
 across from one malleolus to the other and placed in the most dejiendent 
 portion of the joint. Great care should be exercised not to begin passive 
 motion for at least three weeks, and active motion not sooner tluui five 
 weeks. There is no doul>t that tiie bad results after this fracture are due 
 to incomplete drainage, to imperfect antisepsis, to improper splints, to the 
 adoption of too early passive motion, and, finally, to the employment of 
 active motion before the ])roper time has arrived. 
 
 The question of incision into the joint in a case of simple fracture 
 of the astragalus, with a view to removing the fragment, is one about 
 which no unanimity of opinion exists. Some surgeons prefer to wait 
 and let Nature make the expulsion of the fragment, and not to interfere 
 until suppuration ensues, while others believe that with the aid of anti- 
 septic surgery a bold operation should be essayed. No general law can 
 be laid down, and each case must be treated on its individual merits. 
 
 Fractures of the leg may be classified into four groups: Frac- 
 tures of the tibia and hlnda, of the tibia, of the filnda, and epiphyseal 
 separations. 
 
 Fractures of the leg form about 1(3 per cent, of all fractures. They 
 are rare in inf incy and during childhood, but between the ages of thirty 
 and sixty the greatest number t)f fractures of the leg are found. Fractures 
 of the leg are usually the result of direct, although they may be caused 
 by indirect, violence, or even l\y muscular action. As a rule, the direction 
 of the fracture in the lower part is oblique, while in the upper extremity 
 of the limb the fractures are transverse. 
 
 At the outset too much stress cannot be placed upon the importance 
 of so lifting the broken leg as to ensure absolute certainty against the 
 conversion of a simple into a compound fracture. The patient should 
 first be instructed to relax the muscles of his broken leg, and on no 
 account, no matter how severe the pain is, to contract his muscles so as 
 to resist the assistarit whose duty it is to raise the limb. Ha^'ing fully 
 explained the importance of this to the patient, the assistant should grasp 
 the foot at the juncture of the phalanges with the metatarsal bones, and 
 make gradual extension in the long axis of the limb before attempting 
 to raise it. As soon as the fracture is reduced he should lift the leg 
 slowly from the bed. In this manner no accident can follow, and the 
 pain consequent upon this necessary manipulation is very slight. 
 
 Fractures of the tibia, and fibula occur by direct violence in the great 
 majority of cases. They may, however, result from indirect violence or 
 even by muscular action. They are produced by heavy weights falling 
 upon the limb, by the kick of a horse, or by the passage of a car- 
 wheel or heavy truck over the leg. When both of the bones of the leg 
 are broken by indirect violence, the tibia is fractured lower than the 
 fibula. This is probably due to tlie fact that the tibia is broken first, and 
 the fibula then gives way upon a higher level. 
 
 The signs and symptoms of fracture of the tibia and fibula need no 
 special description, since they are most marked in this special fracture. 
 The irregularity of the line of the tibia is often a most important 
 diagnostic sign. The displacement in fracture of both bones of the leg 
 needs special consideration. The lower fragment, with the foot, is drawn 
 upward and backward behind the upper fragment by the action of the 
 
544 
 
 FRACTURES. 
 
 Fig. 50. 
 
 Fracture-box, with movable sides. 
 
 (ing. It is axiomatic in fractures tliat tlio sooner a broken 
 n a permanent splint or ban(lao;e the better it is for many 
 
 gastrocnemius, while the upper fraojment prnjei'ts just under the skin. 
 Thei'e are likewise abduction of tlie foot and rotation of the leg out- 
 ward, caused by the weight of the foot and of the lower fragment, owing 
 to the loss of support. 
 
 The treatment oi'a simjile fracture of Ixith bones of the leg eonsi.sts in 
 the application of a suitable retentive a])]iaratus. If there is much tension 
 
 and swelling on account of inflammatory 
 exudation, with hemorrhage and blebs 
 or phlyctena', the limb should be -placed 
 in a fracture-box ( Fig. .50), so that it is 
 surrounded by oakum or bran. In a few 
 days the swelling subsides, provided the 
 limb has been kept quiet in the fracture- 
 box. The phlyctenre will disappear after 
 they have been simply punctured with an 
 aseptic needle and a small piece of iodo- 
 form gauze placed over the collapsed vesicle. If, on the other hand, 
 there is no marked swelling, and no blebs upon which the pressure of a 
 splint would cause .sloughing exist, the limb can be immediately placed in a 
 permanent dre 
 bone is placed 
 
 reasons. The early dressing of a fracture often jtrevents the swelling so 
 frequently found where there has been delay in the a])plication of a ])er- 
 manent and early splint or bandage. As to the selection of a special 
 dressing for fractures of both bones of the leg, the opinions of surgeons 
 are at variance. The writer has no hesitancy in recommending, with the 
 exception nientioned, the inuiicdiate use of plaster of I'aris in fractures 
 of both Ixines of the leg. The great objection raised to immediate appli- 
 cation of the plasti'r-of-Paris bandage is the danger of gangrene from 
 pressure due to swelling. The writer has seen this unfortunate accident 
 occur on several occasions in the hands of well-known surgeons ; but it 
 is certain that the gangrene was not due to the use of the plaster-of-Paris 
 bandage per .sc, but to the improjier and careless use of it. The writer 
 has also seen a case of fracture of both bones of the leg in which plaster 
 of Paris was immediately applied, and the entire limit became one ma.ss 
 of sloughing material concealed under the bandage, Avhile the septietemia 
 resulting from this condition gave rise to the incorrect diagnosis of typhoid 
 fever, from which sujjposed cause the patient died, but the incidental 
 removal of the ]>laster bandage at the dead-house revealed the true cause 
 of the septica'mia. 
 
 The manner of applying a plaster-of-Paris liandage (Fig. •'Jl ) is fully 
 described elsewhere, but the special points in connection with the manage- 
 ment of this particular fracture are first the use of a thick layer of 
 absorbent cotton which will yield to any .swelling, and thus prevent 
 the danger of gangrene ; and, second, the use of strips of jterfoi'ated 
 tin or zinc placed over the limb to give uniform support, and thus to 
 obviate the necessity for a heavy bandage. These strips should be fitted 
 to the sound limb, and then placed laterally in front, and along the 
 posterior part of the broken leg, and bent around the heel .so as to prevent 
 any backward displacement of the limb during the repair. Great imjiort- 
 ance is to be attached to this posterior splint. As a matter of precaution 
 
SPECIAL FRACTURES. 545 
 
 the toes should be examined after six hours to see if they are numb or 
 if there are any signs of obstructed circuhition, in whicii case tlie splint 
 should be immediately cut off and a new one applied. At the expira- 
 tion of eight days, if everything lias proceeded favorably, a new splint 
 should be applied. In another week the bandage should be removed to 
 
 Fig. 51. 
 
 Leg encased in plaster-of-Paris bandage. 
 
 inspect the fracture, since occasionally the fragments become disturbed 
 under the l)andage, and at this time they can be readjusted when later it 
 would be impo.ssible. 
 
 If the surgeon prefers a .splint instead of the pla.ster-of- Paris bandage, 
 the classical double-inclined plane of Mclntyre is one in common use. 
 Where there is much deformity and the fracture is not easily retained in 
 apposition, this splint is useful, since it relaxes the mn.scles of the calf 
 by flexion of the knee. In some cases of oblicpie fracture this splint is 
 not well ada])ted to meet the emergencies of the case, as it does not over- 
 come the tendency to rotation, and also because in flexion of the knee the 
 quadriceps extensor muscle of the thigh has a tendency by its contraction 
 til tilt forward the lower end of the upper fragment. 
 
 Hahsted's sliding splint is most excellent when there is any tendency 
 for the upper fragment to jjrotrude. The writer has employed in certain 
 cases the ordinary fracture-bo.x with the addition of a weight and pulley 
 to the lower fragment. After the leg has been placed in the fracture- 
 box, which is filled with bran or oakum, with the movable sides turned 
 down, a pad is placed under tlie tendo Achillis, and the sides are now 
 closed up, leaving the vertical foot-piece flat. In cases where there are 
 great .swelling and a tendency fir the njipcr fragment to protrude through 
 the skin this dressing is fiund most useful. 
 
 Nathan R. Smith's iuiterior sj)lint (Fig. 52) is recommended in frac- 
 tures of both bones of the leg, as well as in fractures of tlie thigh. 
 
 The Bavarian splint is excellent if the fragments can be kept in appo- 
 sition without artificial extension or muscular relaxation. In this same 
 category may be mentidued the silicate-(if-soda bandage, the lateral 
 splints of leather or gntta-])ercha, and tlie heavy pasteboard side-splints. 
 In the use of any of these side-splints care must be exercised to avoid 
 the tendency of the backward displacement of the lowei- fragment with 
 the foot. 
 
 Vol. I.— 3j 
 
o4G FRACTURES. 
 
 The writei' cannot too highly recommend division of tlie tendo Aehil- 
 lis in f'nictnres of botii bones of tiie leg when any tendency to muscular 
 spasm or to marked deformity, or any ])rcnionitions of delirium tre- 
 mens, exist. 
 
 Wliatever dressing is em})loye(l, the surgeon must bear in mind the 
 fact that the inner side of the ball (jf the great toe must be brought in 
 
 Fig. 52. 
 
 Nathan R. Smith's anterior splint. 
 
 line with the inner edge of the patella, and the foot maintained at a right 
 angle to the long axis of the limb. 
 
 In fractures of the n})per part of the leg the knee-joint may be in- 
 volved, and then hwmarthrosis results, \vhich may lead to serious joint 
 disease. If the fracture is compoimd or complicated, the knee must be 
 thoroughly irrigated and drainage-tubes inserted into the sides of the 
 joint, since the open wound is often unsuitable to utilize for ])urposes 
 of drainage. This is a serious operation, and nnist be performed in con- 
 formity to the rules laid down in connection with compound dislocations 
 of the knee-joint. 
 
 Fracture of the tibia is of more frequent occurrence than frac- 
 ture of the fibula, because the lione is less protected by muscles and 
 receives the principal weight in falling. The fracture may occur at any 
 point in the shaft, but the junction of the middle with the lower third 
 is the more frc(pient seat, since this jwrtion is anatomically the weakest 
 part, owing to the fact that the diameter of tlie bone is less at this place 
 than at any other part of the shaft. In this jtart the jieculiar anatom- 
 ical arrangement of the bony columns is such as to favor fracture upon 
 the receipt of indirect violence. The bone is fractured at this place 
 often by torsion. 
 
 Fractures of tlie tibia occurring in the lower part of the bone are 
 usually obli(jue from ai)oye, downward and inward, while those in the 
 upper part are transverse. The fractures in the lower part may be from 
 direct, but usually they are from indirect, yiolenec, while those in the 
 upper part are generally produced by direct- violence. 
 
 Fractures of the tibia may occur at the lower end, through the shaft, 
 or at the upper end. 
 
 A fracture occurring at the lower end of the tibia usually involves the 
 
SPECIAL FRACTURES. 
 
 547 
 
 Fracture of the 
 internal mal- 
 leulus. 
 
 internal malleolus. There is very little displacement, because the inter- 
 nal lateral or deltoid ligament, which is attached as well to the borders 
 as at the apex of the malleolus, prevents the fragment from 
 becoming detached. This injury often results in a perma- 
 nent ankylosis of the ankle-joint (Fig. 53). 
 
 The signs and symptoms are so apparent that they need 
 no special tlescription. 
 
 The treatment consists in placing the detached fragment 
 in its proper position and retaining it by the use of com- 
 presses placed between the malleolus and the inner side of 
 the splint. It is highly important to ha\c the fragment 
 accurately adjusted, since any union in an abnormal position 
 will result in too great lateral motion to the astragalus, and 
 thus render the patient unable to walk with any sense of 
 security. If the fragment cannot lie placed and retained in 
 its proper position by the ordinary measures, the operation 
 of cutting down upon the fragment and wiring it, or of 
 fixing it by the use of an ivory peg, would be in the hands 
 of an antiseptic surgeon a just procedure. If the union 
 is fibrous, it is a})t to interfere with the free movement of 
 the ankle-joint. 
 
 Fractures of the shaft of the tibia are not attended with much dis- 
 placement, since the fibula acts as a side splint to keep the parts in 
 apposition. In some cases the only signs that are present are fixed 
 pain, localized tenderness on pressure, ecchymosis, a tendency to back- 
 ward displacement, a slight irregidarity upon jKissing the finger down 
 the tibia, as well as an irregularity upon the surface of the bone. If the 
 fracture hapjiens to be in the lower third of the tibia, crepitus may be 
 felt by gras])ing the foot firmly and rotating it. 
 
 The treatment consists in the application of side-splints of leather, 
 pasteboarfl, or gutta-percha, or in the use of a plaster-of-Paris bandage 
 applied in the manner already descrilied. 
 
 Fracture of the upper end of the tiljia is usually transverse and the 
 result of direct violence in consequence of which the soft parts are more or 
 less bruised and contused. There is usually but little displacement, since 
 the transverse direction of the fracture prevents any marked deformity ; 
 if, however, the fracture is oblique, then the displacement is prominent. 
 In this fracture by direct violence, where the bone is liroken transversely, 
 occasionally a T-fi'acture is found, and the line of fracture extends verti- 
 cally into the kn.cc-joint. In tliis case a eonsiilerable degree of deformity 
 is jiresent, since the knee-joint becomes at once the seat of acute synovitis, 
 produced by the presence of blood within the capsule and also by the 
 direct effects of the trainnatism. ' If the fracture is oblique, the leg is 
 defleetcd to one side, o)i])osite to the direction of the line of fracture. 
 
 Tile treatment of this injury, situated in the up]ier part of the tibia, 
 consists not onlv in the iiianagemcnt of the fracture itself, but also in 
 attention to the joint complication. It must embrace, therefore, a plan to 
 reduce the infianimatory joint affection, as well as a retentive ajiparatus 
 for the fracture. If the displacement is considerable, the deformity can 
 be best overcome by the use of Mclutyre's (Fig. 54) double-inclined 
 ])lane, which 1)V relaxing the hauistring luuscles prevents any move- 
 
548 
 
 FRACTURES. 
 
 ment in tlie long lower fragment, and makes this fragment conform 
 to the upper or short fragment. The action of the quadriceps extensor 
 is to tilt the upjier fragment forward in case too great flexion of the knee 
 is allowed. If but slight deformity exists, the fracture can be com- 
 pletely reduced and a plaster-of-Paris bandage employed, with a com- 
 
 FiG. 54. 
 
 Mclntyre's splint, modified by Listen. 
 
 press over the upper fragment. In some cases, where the muscles of 
 the calf make traction on the lower fi-agment, tenotomy of the tendo 
 Achillis will often overcome any tendency of the upper margin of the 
 lower fragment to override the lower margin of the upper fragment. 
 After three weeks gentle passive motion should be employed in order to 
 prevent adhesions in the knee-joint. 
 
 At the beginning of the treatment it may be neces.«ary to use cold 
 evaporating lotions, the ice-bag, or Leiter's coil to reduce the local 
 
 Fig. 55. 
 
 Mclntyre's splint ami Salter's swing. 
 
 inflammatory condition of the joint. In all fractures of the leg in 
 ^xhich the j>laster-of-Paris bandage is employed it will be found that 
 a suspension apparatus, such as Salter's swing (Fig. 55), will enable the 
 patient to keep the fragments more quiet than when the leg rests entirely 
 upon the mattress. 
 
SPECIAL FRACTURES. 
 
 549 
 
 Fig. 57. 
 
 Fig. 58. 
 
 Epiphyseal separations (Fig. 56) occur in young people under 
 twenty years of age, and since they are produced in the same way as 
 fractures, and present the same sym])t()ms, and finally 
 demand the same treatment, there is little to say in 
 connection with them beyond what has already been 
 said in relation to simple fractures of the bone in 
 these localities. If the epiphysis is separated in a 
 child, the growth of tlie bone is very nuich aflbcted, 
 so that when the patient has attained his full size 
 the injured leg is much shorter tiian the opposite 
 one. This shortening must be relieved by the use 
 of a cork sole applied to the shoe. 
 
 The treatment should be the same as for a Separati..ii ..i lUe i.jw.r 
 
 n . i> ii 1 • -ii i. ii epiphysis of the femur 
 
 fracture ot the lione occnrruig either at the upper (Bryant). 
 or the lower part of the siiaft. 
 
 Fracture of the pibuea may occur at any point, but there is 
 only one special fracture that tleserves separate consideration. This 
 is known as " Pott's fracture," and consists 
 of a fracture of the fibula about three 
 inches above tiie external malleolus, with a 
 laceration of the internal lateral or deltoid 
 ligament, and in some cases a slight chip- 
 ping off of the tip of tiie internal malleolus 
 at or near the insertion of tlie ligament. 
 This fracture is pi'oduced by a fall ujion 
 the foot, and the foot is twisted (Figs. 57, 
 58) outward, and occasionally there is a sligiit 
 dislocation of the ankle-joint, caused by the 
 astragalus rotating upon the under surface 
 of the tibia. In some cases, besides the 
 lesions just mentioned, the foot may be dis- 
 located backward, since the lateral supports 
 
 have been destroyed. Displacemcut m Potfs fracture. 
 
 Tlie treatment ot fracture of tlie nbula, 
 with the exception of Pott's fracture, is extremely simple, since the 
 tibia itself acts as a splint, and any ordinary dressing, such as leather, 
 pasteboard, gutta-percha, or side-splints, will answer every purpose. In 
 Pott's fracture there are only two dressings which are woi'thy of special 
 consideration : the first being a plaster-of- Paris bandage, a|)plied while 
 the foot is held in marked inversion, witii the addition of a strong poste- 
 rior splint of perforated ziiie, which is moulded first to the sound leg and 
 then applied to the broken limb, in order to prevent the backward dis- 
 j)lacement, a deformity .so apt to follow during the rejiair of this frac- 
 ture. The otiier dressing is that known as Dupuytren's (Fig. 59), which 
 consists of a board about four inches in width and of sufficient lengtli 
 to extend from the popliteal space to three inches l)elow the foot. On 
 the fractured leg a pad is placed which reaches from the popliteal s]>ace 
 to the internal malleolus, with a thickness of one inch at the upper end 
 and three inciies at the lower end, where it extends to the tip of the 
 internal malleolus. The leg, with the pad applied, is now laid laterally 
 upon the splint, wliicli is maintained by means of a few turns of a 
 
550 
 
 FRACTURES. 
 
 roller bandage above and lielow. The application of the lower bandage 
 eauses adduction of the foot, which relaxes the internal lateral ligament 
 and brings the fragments in correct ajiposition. The limb is placed 
 upon the side with the splint in contact with the bed. 
 
 Fig 
 
 IKipuytreirs ;sj"lint. 
 
 Fractitre of the patella demands careful consideration on 
 account of its close proximity to tiie knee-joint, and also in consequence 
 of the imperfect way in which the fragments usually unite. Fracture 
 of this bone occurs in about 2 per cent, of all fractures, and it is found 
 more frequently in the male than in the female — in the proportion of about 
 5 to 1. The period of most frequent occurrence is between the ages of 
 thii'ty and fiity. If the fracture occurs in extreme okl age, it is very 
 likely to be found in the female. 
 
 Fracture of the patella is caused by muscular action or by direct 
 violence. The direction of the fracture may be transverse, vertical, 
 oblique, or even stellate. In the fracture produced by sudden and 
 violent muscular contraction the transverse variety usually oeem's. When 
 the fracture is caused by direct violence the direction may be vertical, 
 oblique, or stellate, or the fracture may be eonniiinuted. The fracture by 
 muscular action occurs when the knee is in the position of semi-tlexion. 
 When the joint is in this position the middle portion of the nnder surface 
 touches the anterior surflice of the condyle. A sudden and forcible con- 
 traction of the quadriceps extensor muscle, which acts at nearly a right 
 angle to the vertical surtiiee of the patella, causes it to snap, just as a stick 
 is broken across the front of the knee. A fracture caused by nniscular 
 action is complete, and has also associated with it a tearing of the 
 aponeurotic and fibrous coverings of the bone, as well as a laceration 
 of the synovial membrane of the joint and a rupture of the prepatellar 
 bursa. In consequence of the peculiar nature of this injury the joint 
 is soon filled with blood, and the synovial secretion becomes abundant 
 as a result of the irritating pressure of the blood-clots. 
 
 In fracture of the patella the knee-joint is always opened, unless the 
 extreme lower end of the patella is broken, in which case it is possible 
 for the fracture to exist without the joint involvement. Both patellae 
 may be fractured by muscular action. The writer has seen this in a case 
 of an insane patient who suddenly attenqited to sj)ring out of a window. 
 This accident has also been re])orted as the result of sudden extension 
 of both limbs during the performanct' of lithotomy without an anaes- 
 thetic. The fracture of both patellae has also been observed in a patient 
 who attempted to save himself from falling backward on account of a 
 misstep. 
 
 Fracture of the patella caused by direct violence is the result of 
 sudden force applied directly to the bone, such as a kick from a horse, 
 
SPECIAL FRACTURES. 
 
 551 
 
 Fig. do. 
 
 a blow upon the anterior .surface of the bone, or a fall directly upon 
 
 the front of the knee-joint. In this 
 
 fracture there is more injury to the 
 
 soft parts about the joint, alth<>u<;h 
 
 usually the .separation of the fray- 
 
 nients is not so great, on account of 
 
 the al)senc'e of muscular contraction. 
 
 This fracture produced by direct yio- 
 
 lence is often compound, and also, in 
 
 some cases, connuinuted (Fig. (JO). 
 
 The signs of fracture of the paiella 
 vary sonie\yhat according to the man- 
 ner in which the injury occurred. The 
 history of a fall during which the 
 patient felt a sudden snap, or of a 
 blow upon the knee-joint with some 
 instrument, or of a kick by an animal, 
 together with sudden loss of p(jwer 
 in the limb, lengthening of the patella 
 Avith a well-marked sulcus, with ec- ,, , , , , . n 
 
 . . - . -' Cumpountl frat'lure of i)atL'lla. 
 
 chymosis and swelling rapidly appear- 
 ing, with a loss of the general contour of the joint, — are characteristic 
 indications of fracture of the patella. The amount of separation between 
 the fragments depends upon the (k\gree of muscular contraction at the 
 time of the accident, together with the amount of synovial secretion 
 and the extent to whicli the lateral attachments of the patella are 
 lacerated, and, to a certain extent, u))on the contraction of the liga- 
 mentum ])atell8e. A patient has been known to walk after fracture of 
 the patella, but this is a most unusual eyeut. C're])itus is generally 
 absent in this fracture, on account of the separation of, and the inter- 
 vention of blood-clots and fibrous tissue between, the fragments. 
 
 A certain amount of displacement is sometimes found after the fracture 
 has been re])aired ; for example, the fragments may be displaced to the 
 side or in front. The lateral displacement is caused by the ligamentous 
 or fibrous union stretching unequally, while the anterior dis])lacement is 
 due to the pressure of pads placed above and below the fragments, which 
 causes them to tilt forward. The fragments may be i)uslied up by the 
 underlying fluid, so that their anterior surfaces are not on the same plane. 
 
 The usual mode of union, to which, of course, there are exceptions, 
 is not osseous, unless the fracture has been treated by opening the joint 
 and suturing the fragments with silver wire. The question as to whether 
 bony union eyer takes jilace In- the older method of treatment is settled 
 without any doubt. A s])ecimcn in support of this statement is fouii<l in 
 the Wood Museum, where the union is by bono (Fig. (H ), the patient 
 haying been treated by Dr. Charles Phelps. The medium of union 
 where the fracture has been subjected to the ordinary methods of treat- 
 ment is fibrous tissue. Occasionally no direct union occurs, and the 
 fragments are siin])ly held in contact by the thickened fibrous capsule 
 of the joint and the snrrouii<ling lateral tissues outside of the joint 
 (Fig. (i2). The reason why a transyerse fracture of tlu^ ])atella s(>l(lom 
 unites by bone is that at the tune of the accident the fibrous tissue or the 
 
552 
 
 FRACTURES. 
 
 capsule of the anterior .surface of the patella falls down between the frag- 
 ments, and thus acts as a foreign body and prevents the coaptation of the 
 bony surfaces, and consequently union by bone is rendered imjiossible. 
 The treatment of fi-acture of the patella consists in the aj)plicatioD 
 
 Fic. 61. 
 
 Fiu. 62. 
 
 Osseous union after a fract\ire of patella. Ligamentous union after fracture of the patella. 
 
 of a suitable a|)paratus designed to bring into apposition the fragments. 
 Some special mnnagenient of the joint-infiammation before applying any 
 permanent dressing is necessary. There have been pnblishe<l innumer- 
 able devices to meet the diiSiculties surrounding the treatment of this 
 fracture. Concentric pressure causes a deficiency in the blood-supply ; 
 the small size of the fragments often cau.ses them to tilt upward, and the 
 bulging of the condyles with the leg extended prevents clo.se apposition 
 of the fragments ; the synovitis and ha;marthrosis retard the union by 
 .separating the broken surfaces; and many other causes are in operation 
 to prevent the osseous repair of this fracture. 
 
 Before any method is resorted to with a view to bringing the frag- 
 ments into apposition the surgeon must endeavor to control and modify 
 the joint-inflammation. The ice-bag is used with signal benefit during 
 the first few days, after wJiich lead-and-opium wash can be a})plied. 
 Cold irrigation is sometimes employed instead of the ice-bag, and in 
 some cases, where there is a good deal of superficial ecchymosis, a \\arm 
 fomentation is applied. As soon as the heat has subsided gentle uni- 
 form compression with sponges can be em]iloyed around the joint, with a 
 view to promoting absorption of the fluid in tiie joint. IJlistei's have been 
 suggested, but their use is attended by so much inflammation of tiie .skin 
 as to prevent the application of any apparatus. After the expiratitin of 
 a week the joint-complication should be sufficiently controlled to allow 
 the application of some permanent dressing. The limb can be so placed 
 that position alone affords an excellent method of treatment. Home 
 surgeons simply place the limb on a splint and elevate the heel, so that 
 the foot is from two to three feet abo\e tiie foot of the l)ed ; and in this 
 way the rectus, crureus, and vasti are relaxed, so that tiiere is no traction 
 upon the upper fragment. With a view of still furtiier relaxing the 
 muscles the ])atient can be jirojiped up on a bed-rest. If now the entire 
 limb is bandaged and then the limb is bandaged to the splint, the 
 
SPECIAL FE.WTVEES. 553 
 
 essential condition of the treatment is fultilled. Without doubt tliis 
 metiiod has met witli excellent success, but in the event of failure to 
 secure a satisfactory result a surgeon might be exposed to criticism on 
 the part of the patient, which might be an opening wedge for a law- 
 suit for damages. 
 
 Another plan has been suggested, which is likewise liable to result in 
 an unsatisfactory manner, and that is immediate aspiration of the knee- 
 joint and tenotomy of the quadriceps extensor nuiscle. Tliis plan is too 
 bold to recommcntl, since in some cases it has proved most disastrous by 
 provoking a suppurative arthritis. 
 
 Still another plan has been suggested by Schede, of aspirating the 
 joint, and then injecting into it a 3 per cent, solution of carbolic acid 
 until the fluid withdrawn is perfectly clear, and at once applying a plas- 
 ter-of-Paris Ijandage. This operation has been attended in some cases 
 by suppuration, and in others by secondary amputation, pya?mia, and 
 death. This plan, therefore, has not been received with favor. 
 
 The ap])aratus that seems best to meet tlie difficulties of the case 
 consists of plaster-i)f-Paris compresses applied with or without a figure- 
 of-8 bandage. A compress can be placed just above the upper margin 
 of the upper fragment, and then with a strip of rubber plaster about 
 eighteen inches in lengtli and one inch in width the compress can be 
 fixeil and the fragment drawn down by liringing tlie strips downward 
 under the calf of the leg. Another compress is placed just beneath tlie 
 lower margin of the lower fragment, and the compress held in place by 
 a similar strip of plaster, which runs upward under the thigh. These 
 two strips, crossing each other upon the outer and inner sides of the 
 joint, cause the fragments to come in close apjiosition. A third com- 
 press is placed over the entire fractured patella, so as to prevent the 
 tilting upward of the fractured ends. This dressing must l)e frequently 
 changed, since the plaster is likely to slip, and each day the knee-joint 
 becomes less in diameter, owing to the absorption of the fluid in the 
 joint. The limb can now be placed upon an inclined jjlane, and the leg 
 and the thigh fastened to the splint by a few rollers of plaster-of-Paris 
 bandages. 
 
 Dr. Little employed a similar apparatus in which the adhesive plaster 
 was omitted and a wet plaster roller in the form of a figure of 8 was 
 applied in the same manner as the adhesive plaster already described, and 
 while the plaster was wet the finger and thumb of one hand indentated 
 the plaster above, and the finger and thumb of the other hand likewise 
 indentated the wet plaster bandage on the lower fragment. The frag- 
 ments were thus pressed together and p^^, gg 
 firmlv held until the plaster had finally 
 "set." 
 
 Malgaignc em]iloyed a pair of dou- 
 ble hooks (Fig. G3), the ])oints of which 
 passed tlirough the integument and 
 pierced the upper and lower fragments. 
 The hooks were now brought close to- 
 gether bv means of a screw until the 
 
 Y > • ^ i- rr<i Malgaigne s hooks. 
 
 bony surfaces were in coaptation. 1 lie 
 
 method is an ideal one, and the most satisfactory results have been obtained 
 
554 
 
 FRACTURES. 
 
 Fic. 64. 
 
 by these liooks, hut it is seldom that a jiatient will endure the ])ain and 
 
 discoini'urt which tiiey produce. 
 
 Levis improved tiie nietliod In' using a douhie jiair ofdouhle hooks (Fig. 
 64), which are j)laced obliquely ; while Trelat, to 
 overcome the objection of pain, substituted gutta- 
 percha plates heated in a flame and accurately ad- 
 justed to the fragments, and into these plates the 
 hooks arc inserted (Fig. 65). 
 
 Hamilton's metiiod "consists of a single inclined 
 plane of sufficient length to support the thigh and 
 leg, and about six inches wider than the limb at the 
 knee. This plane rises from a lioi'izontal floor of 
 the same length and breadth, and is suj^jiorted at 
 its distal end by an upright piece of board which 
 serves both to lift the ]>lane and to su])port and 
 steady the foot. The distal end of the inclined 
 plane may be elevated from six to twelve inches 
 according to the length of the limb and to other cir- 
 cumstances. Upon either side, about four inches 
 below the knee, is cut a deep notch. The foot- 
 piece stands at right angles with the inclined plane, 
 and not at right angles with the horizontal floor. 
 Having covered the ap])aratus with a thick and soft 
 cushion carefully ada])ted to all the irregularities 
 
 of the thigh and leg, especial care being taken to fill completely the space 
 
 under the knee, the whole limb is now laid upon it, and the foot gently 
 
 Levis's modification in 
 place. 
 
 Fig. 65. 
 
 Trtlat's dressing for fracture of patella. 
 
 secured to the foot-board, between wliich and the foot another cushion is 
 placed. The body of the patient should also be flexed upon the thigh, so 
 as the more cflectiially to relax the (juadricejis femoris muscle. A roller 
 is now apjjlied to the knee by obliipic and circular turns, commencing 
 above the ]>atella, and traversing the notch in the .sjilint, each successive 
 turn covering more of the front f)f the knee until the whole is enclosed. 
 With a second roller the entire liml) must then be secured to the splint, 
 this roller extending from the ankle to the groin " (Fig. 66). 
 
 Agnew's method consists of " a piece of sjilint somewhat convex 
 longitudinally, on the upper surface thirty inches long and five inches 
 wide at one end, tapering to foiu- inches at the other. On each side, a 
 
SPECIAL FRACTURES. 
 
 555 
 
 short distance above and lielow the middle of the lioard, are to be bored 
 two holes, into which are litted four pegs with square heads (Figs. 67, 
 
 Fig. 06. 
 
 68). This s]:)lint must be well padded and jilaeed under the thigh and 
 the leg, the limb being at the same time moderately elevated. Below 
 the knee and the lower fragment are next to be a[)plied, partially over- 
 
 FiG. 67. 
 
 Asnew's splint for fracture of the patella. 
 
 lapping each other, two or three strips of adhesive plaster, each three- 
 quarters of an inch wide and thirteen inches long. These .strips are 
 brought together at their extremities and wrapped around the upper 
 
 Fig. 68. 
 
 ,,j|iJijiiji3l)i)pi%;ith 
 
 Agnew's splint applied. 
 
 pegs. This .secures in position the lower fragment. Five strips of 
 plaster of like length and width are next a])])lied three or four inches 
 above the knee, descending toward the joint, each strip overlapping one- 
 
556 FRACTURES. 
 
 tliird of the preceding one. Bringing tlie ends of the plaster together, 
 lliey are to be M'ound around the lower pin, when, by screwing or twist- 
 ing the pegs of the two sides, the lower fragment will be l)rf)ught into 
 near apposition with the upper. To prevent the broken surfaces from 
 tilting forward a broad strij) of plaster may be drawn over the line of 
 approximation and fastened to the splint l)elow. A roller is now 
 applied above and below, which secures the thigh and leg to the splint 
 (Fig. (58). As the swelling subsides all that is necessary to maintain 
 the adjustment is to tighten the strips by screwing up the pegs to which 
 they are fastened. By this plan the removal of the dressing is ren- 
 dered unnecessary until the cure is complete. Between the third and 
 fourth weeks the strijjs may be separated from the jiins, the knee gently 
 moved so as to overcome stiffening, and the dressing again adjusted. 
 This process should be repeated every five or six days until the fifth 
 week, \\-hen the splint may be laid aside and the patient be placed on 
 crutches." ' 
 
 Wiring the patella is an operation which within a few years lias been 
 brought prominently into notice, especially through the labors of Dr. 
 Charles Phelps. The operation is one about which much honest diver- 
 sity of opinion exists. The arguments in favor of the operation are the 
 absence of great danger to life and limb, the superior results as regards 
 the function of the joint, and the greater rapidity of repair. In refer- 
 ence to the danger to life, it may be stated that Dr. Phelps reported (in 
 1890) 111) cases of wiring the patella in New York City, in wliich there 
 was no death directly attributed to the operation, and but one death due 
 to delirium tremens — a complication tliat would have occurred in any 
 other operation. In the hands of a thorough aseptic surgeon the danger 
 to life from sepsis is insignificant. The superior results as regards the 
 function of the limb are demonstrated by the invariable presence of 
 bony union and a freely movable joint. The rapidity and completeness 
 of repair is made evident when it is considered that ]iatients have 
 walked well within three weeks after the ojieration, have walked a mile 
 within six weeks, and later on have played football. 
 
 On the other hand, some surgeons claim that the operation is too seri- 
 ous, and that results which are sufficiently satisfactory can be obtained 
 by less severe measures. Tlie author feels justified in recommending 
 the operation in cases where there is no organic disease, when every pos- 
 sible antiseptic precaution can be secured, and M-here the 2)ers<inal cir- 
 cumstances of the patient make it an object to assume a minimum of 
 risk for a maximum of good. It is a serious matter if a laboring-man 
 with rent to pay and children to feed and clothe must remain idle for 
 three months, and then be practically incajiacitatcd for hard work for 
 eighteen months, instead of resuming work witliin two months from the 
 time of the accident. The question, however, of wiring the patella must 
 rest upon the individual circumstances in each case, since no rule M'hich 
 is universal can be formulated. 
 
 In investigating the history of this operation it is ascertained that 
 Rhea Barton in 1834, McClellan in 1838, Cooper in 1861, and later 
 Logan and Green, wired the patella. All (if tliese operations, successful 
 and unsuccessful, were performed at a period mIucIi antedates Cameron's 
 
 ' Agnew's Surgery, vol. i. p. 974. 
 
SPECIAL FRACTURES. 557 
 
 sug'gestion and practice nearly forty years, and, tliousih tlie principle 
 U])tin which the operation is now performed is widely ditt'erent fi-oni that 
 wiiich inspired the early pioneers in American surgery, yet tiie fact is 
 that here this operation was conceived and born, but in Scotland it has 
 developed. 
 
 Wiring the patella should not be performed inunediately after the 
 accident, as inflammatory action is likely to follow the receipt of the 
 injury. It is wise to wait eight or ten days until the jjarts are in better 
 condition. In case the fracture is compound, tlie operation siiould be per- 
 formed without delay. Before wiring tlie fragments of a fracture of tlie 
 patella the entire limb, including die foot, should be thoroughly scrubbed 
 and washed with soap and iiot water, after which ablution the jiarts should 
 be carefully washed in a solution of bichloride of mercury of about the 
 strength of 1 : 2000. Over the joint itself a saturated solution of iodo- 
 form in ether or of naphthalin in ether should be poured. Tiie parts 
 above and below the joint are surrounded and enveloped by towels satu- 
 rated in a solution of liidiloride of mercury of the strength of 1 : 2000. 
 The opposite leg is covered by wet towels, and the parts are in readiness 
 for the surgeon. From the beginning to the end of the operation con- 
 tinuous irrigation of the interior of the joint is kept up with a 1 : 10,000 
 solution of bichloride of mercury. It is unnecessary to add that tlie ope- 
 rator and iiis assistants are thoroughly disinfected, and all instruments, 
 wire, sutures, ligatures, and sponges are pre])ared with the greatest care. 
 The incision can be either longitudinal, transverse, or crucial. The 
 transverse incision is preferred, though the longitudinal is tlie one more 
 frequently eni]iloyed. The fragments and the joint are freely exposed, 
 and all blood-clots from the joint, from the synovial jiouch under the 
 quadriceps extensor muscle, and from between the fragments are removed. 
 The two fragments are refreshed by being scraped m itli a Heber scoop, 
 and the intervening tissue, consisting of the anterior fibrous capsule, is 
 elevated from between the fragments. The Arciiimedean drill is now 
 made to perforate the upper fragment, and then the lower fragment, care 
 being taken to have the point of the drill emerge from the lo\ver surface 
 of the patella just above the lower cartilaginous surface. In case one 
 fragment is very small, it should be drilled first, so as to bring it into 
 better ajiposition with the larger fragment. The bottom of tiie .synovial 
 pouch is felt upon its outer side, and an opening made, through which a 
 red-rubber drainage-tube, which contains no free sulphur, is inserted into 
 the cavity of the joint. This tube should be removed in three or four 
 days, although Fowler has demonstrated, in his wonderfully successful 
 case of eomiiound fracture of the ])atella, that it is juissible to allow the 
 tube to remain two weeks with impunity. The wire, which should be of 
 silver, is of moderate thickness, and is twisted and cut off and hammered 
 down upon and into the tissues over the line of fracture. Experience 
 shows that no harm ever results from burying the wire in the tissues of 
 the wound. The a])oneurotic fascia and soft tissues in front of the jiatella 
 are now nicely sutured, which procedure hermetically seals in twenty-four 
 hours the front of the joint from anv serous discharo'e infiltratin<r tlirouirh 
 the fissure made by the fracture from the soft parts over the front of the 
 patella. All loose pieces of tissue are removed and any torn or lacerated 
 shreds are cut away by a pair of scissors. The integument is now sutured 
 
558 FRACTVBES. 
 
 and tlie line of incision is closed. The linear incision can be ])ainted over 
 with a layer of styptic collodion and tiien dusted over with iodoform or 
 naplithalin. A posterior splint is now adjusted, and a regular plaster-of- 
 Paris sj)lint is applied over tlie layers of antiseptic dressings. At the 
 expiration of three days the tube is removed througli a i'enestra cut in the 
 splint. Instead of a plaster-of- Paris splint, a wire-netting splint is used 
 by some surgeons. The patient is now kept in bed, though he can sit up 
 very soon after the operation, and the first dressing should be removed 
 in the course of the first week. In four weeks he can be allowed to get 
 up from his bed, and shortly after walk about the ward. Massage, sham- 
 jiooing, friction, electricity, and gentle }>assive motion will soon restore 
 the joint to its jJerfect function. 
 
 The conclusions, after a careful analysis and study of all the reported 
 and as many unrej)orted cases, are these : 
 
 In compound fractures of the ])atella there is not the slightest question 
 as to the ])ropriety of the operation of wiring the fragments. 
 
 In recent and old fractures, with the facts fully presented to the patient 
 and under the strictest antise]itic precautions, the operation, in the light 
 of present statistics, is wholly justifiable. 
 
 In debilitated patients and in those suffering from any organic disease 
 the operation siiould not be employed, and is, in fact, contraindicated, 
 as are all other o])erations of expedieu(y. 
 
 It is not an operation whieli can l)e indiscriminately performed, and 
 never by an ordinary practitioner with little surgical experience and with 
 little faith in the germ-theory of inflammation. 
 
 The success of this operation depends wholly upon conscientiously 
 carrying out the smallest details needed to secure aseptieity, and the 
 surgeon ^vho is not imbued \\\i\\ the true spirit of antiseptic surgery 
 ought not to ])erform this operation. 
 
 While the number of cases yet operated upon is too limited to admit 
 of deductions by means of which a final settlement of this question can 
 he made in the minds of surgeons, the future practice of the surgery of 
 this and of other countries will soon enable us to condemn it as an unsafe 
 and unjustifiable procedure, or else it will be conceded as one of the 
 grandest triumphs of our art. 
 
 Compound fracture of the patella is a most serious accident. Thei'e 
 is but one method universally recommended, and that is, under the influ- 
 ence of an anaesthetic, to enlarge the original wound, irrigate thoroughly 
 the joint, drain it with rubber tubing, and wire the fragments with silver 
 wire. If the operation is performed with aseittic precautions, tiie tubes 
 can be removed upon the third day and the wound closed, and an ideal 
 result secured. This injury in pre-antiseptic days was usually attended 
 by a fatal result, but with the application of the principles of modern 
 surgery the cases, as a rule, do well, and the final result is perfect as 
 regards the restoration of the function of the joint. 
 
 Fractures of the Femur form about 6 jier cent, of all fractures. 
 In the aged they occur usually in the upjier third, in ciiililrcn in the 
 middle third, while in adults the fractures are generally found in the 
 lower third of the bone. Fractures of the shaft, however, may occur at 
 all ages, but fractures of the neck of the thigh-bone are usually found 
 in the aged, and esj)ecially in women. 
 
SPECIAL FRACTURES. 
 
 559 
 
 Fractures of the temur in the upper third may be classified according 
 to the seat of the fracture ; thus, intra-capsular and extra-capsular frac- 
 ture of tlie cervix femoris ; trochanteric fracture and subtrochanteric 
 fracture of the shaft ; in the middle third according to the variety of the 
 fracture : thus, simple, compound, comminuted, gunshot, and complicated 
 fracture ; in the lower third according to the part fractured ; thus, exter- 
 nal, internal, and supracondyloid fracture and ej)iphyseal separation. 
 
 Epiphyseal separation is an injury which is classified with fractures 
 for reasons already mentioned. This injury occurs before the twentieth 
 year of life, at which time the lower epiphysis unites to the shaft, and any 
 injury of the lower part of the bone occurring as the result of accident 
 or during an attemj)t to lircak up ankylosis of the knee in a patient 
 under twenty with tiie symptoms of fracture suggests a separation of 
 the epiphysis from the diaphysis. In the discussion of supracondyloid 
 fracture the treatment of epiphyseal separation will be considered. 
 
 Supracondyloid fracture occurs about two inches above the epiphyseal 
 line, and is usually the result of direct violence, as a blow upon the side 
 of the fenuir or a l)low upon the patella while the knee is flexed. The 
 fracture is situated at the point where the cancellated bone tissue joins 
 the compact bone tissue. 
 
 The signs and symptoms are the same as in any fracture, with the 
 additional sign of loss of contour of the knee-joint. The femoral artery 
 
 may be wounded in this fracture, caus- 
 Fjg. Oy. ing a false aneurism, %vhicli is of serious 
 
 import. 
 
 The displacement consists of flex- 
 ion of the lower fragment on its trans- 
 verse axis by the action of the (Fig. 
 69) gastrocnemius, plantaris, and pop- 
 liteus muscles, while the rectus and 
 hamstring muscles tend to i)ull the 
 
 Fracture of ilic lower part of 
 tlK* femur. 
 
 Iuterenudvl<'i>l h.n 
 of the fiiiiur. 
 
 lower fragment upward, and the aljductor muscles draw the up]ier 
 fragment inward. The lower fragment drops backward with tiie 
 upper end of the tibia, M'hile th(> jjatclla is thrown forward. This 
 causes the lower end of the U])per fragment to rest upon the an- 
 
560 
 
 FRACTURES. 
 
 tcrior surface of the lower fragment. This disj)laceinent can be over- 
 come in one of two ways : either by division of the tendo Achillis or by 
 the use of tiie double incline plane. The contour of the joint is so 
 destroyed by effusion, esjjccially when the upper margin of the upper 
 
 Fio. 71. 
 
 Union "with deformity in supracondyloid fracture. 
 
 fragment has wounded the cul-de-sac extending upward upon the front 
 of the femur, that the diagnosis is rendered extremely tliliicult unless it 
 is iiiade immediately after the injury, before swelling supervenes. It 
 occasionally happens that the joint becomes involved by the fracture 
 
 Fig. 72. 
 
 ^Jt 
 
 II 
 
 -M 
 
 1 
 
 Natlian R. Smitli's anterior splint. 
 
 assuming a T-shape (Fig. 70) and thus extending into the joint through 
 the intercondyloid notch. 
 
 The treatment of supracondyloid fracture, as well as of epiphyseal 
 separation, is conducted upon one of two principles : either by relaxing 
 by natural means the hamstring muscles by the use of a double-inclined 
 
SPECIAL FRACTURES. 
 
 5C1 
 
 ])lano, or by artificial means, by division of tlie tendo Achillis, which 
 secures physiological rest to the limb by causing a temporary jiarah'sis 
 of the muscles, and thus preventing them from contracting and drawing 
 down the lower fragment. Extension should never be employed in the 
 straight jiosition, since tliis has a tendency to iutcnsifv (Fig. 71) the dis- 
 placeuKnit and cause permanent ankylosis in the knee-joint. The leg 
 and thigh can be placed in a wire cuirass, which is bent to represent a 
 doul)le-inclined plane, or Nathan Smith's anterior splint (Fig. 72) can be 
 used, or jtlaster of Paris can be a[)plied witli tlie knee-joint sliglitlv Hexed. 
 In case tiie fracture is compound, the wound must be made thorougiily 
 aseptic, and free drainage of the knee-joint, with complete immobiliza- 
 tion, must be employed. 
 
 Internal comlt/loid fracture (Fig. 73) is produced by direct violence 
 through a fall upon the bent knee, or by a blow upon the condyle, or 
 by a severe lateral wrench. Tlie accident may be 
 serious on account of the proximity of the knee- 
 joint to the fracture. 
 
 The signs and symptoms are the same as are 
 found in ordinary fractures, such as localized pain, 
 ecchymosis, crej^itus, and mobility of fragments. 
 The length of tlie limb is not altered, but the nor- 
 mal contour of the j'»int is destroyed. 
 
 The treatment consists in jtlaciug the entire 
 limb in the straight position and applying some 
 evaporating lotion over the knee-joint for a few 
 days, so as to raodif}' the inflauimatory reaction. 
 The fragment must then be adjusted in its proper 
 ])lace aud held in tiitii by compresses. Flexion of 
 tlie knee has a tendency to displace the fragment 
 upward. Ankylosis is apt to follow unless the 
 joint is subjected to gentle passive motion at the 
 end of three weeks. The important clinical fact 
 must not be overlooked that the fragment may foil to unite, and sup- 
 puration of the knee-joint has liecn observed in a few cases. Such a 
 complication calls for the practice of bold antiseptic surgery. Aspira- 
 tion of the joint in this fracture is unwise, since it might lead to serious 
 joint-complication. 
 
 External condyloid fracture is caused by a blow or a fall upon the 
 condyle when the knee is flexed, and, like fracture of the internal con- 
 dyle, may be serious on account of its close proximity to tlic knee- 
 
 joi'^it- 
 
 The signs and symptoms are the same as in internal condyloid 
 fracture, and tlie treatment mentioned for one is applicable to the 
 other. 
 
 Fractures of the tthaff of the femur usually occur about the centre of 
 the bone. Tliey are generally oblique, with the line of fracture in the 
 antero-posterior direction. Tliey are (caused liy direct or indirect violence 
 or by muscular action. Direct violence causes fractures in the lower 
 third ; direct and indirect violence, as well as muscular action, may 
 cause fractures in the middle third ; while fractures in the u})per third 
 of the bone are generally the result of indirect violence. Fractures of 
 
 Vol. I.— 36 
 
 f the internal 
 if the femur. 
 
562 
 
 FRACTURES. 
 
 tlu' tlii<i;li in its lower tliird by direct violence may be associated with 
 injury to the femoral ai'tery and vein, which lie in close ])roximity to- 
 the ])Osterior surface of the bone. 
 
 The displacement in fracture of the femur is influenced somewhat 
 by the position of the fracture. For general purposes it may be stated 
 that the lower fragment is drawn upward and to the inner or outer side 
 of the upper fragment, and is rotated outward (Fig. 74). This displ 
 
 Fig. 74. 
 
 lace- 
 
 DisiilaeeuK'Ut in fractures of shaft of femur. 
 
 ment is due to the action of the vastus externus, vastus internus crureus, 
 adductor magnus, and adductor longus mnsi'les. The ujipcr fragment is 
 flexed by the action of the psoas and iliacus muscles, and abducted 
 (Fig. 75) by the external rotators of the thigh. It occasionally happens 
 
 Fig. 75. 
 
 Displ.^comcnt on account of action of psoas and iliacus muscles and external rotators. 
 
 (if this member is pro- 
 impacted or else to the 
 
 that instead of evcrsion of the foot inversion 
 duced, due either to the fact that the fracture i 
 action of the pectineus and adductor brevis. 
 
 The signs and symptoms of fracture of the shaft of the femur 
 consist of shortening of the limb to the extent of from one to tliree 
 inches, swelling at the seat of fracture, absolute inability to raise or 
 rotate the limb, eccliymosis, crepitus, localized tenderness and pain, 
 slight flexion and abduction of tiie upper fragment, and, finally, unnatural 
 mobility. Synovitis of the knee-joint often occurs in fractures of the 
 shaft, and has been variously ascribed to extravasation of blood into the 
 joint, or to a concomitant sprain, or to a disturbance of the venous 
 circulatitin. 
 
 The prognosis in fracture of the shaft varies according to circum- 
 
SPECIAL FRACTURES. 
 
 563 
 
 stances. The injuiy in any case is more or less serious, since it con- 
 fines the patient to bed for many weeks, compels him to rely upon 
 crutches for some time, and finally may cause permanent lameness from 
 shortening. In compound fracture the j)r(igii(>sis is exceedingly grave, 
 owing to the shock from wliich the patient sutlers. The author has seen 
 death result in conseipience of shock incident to simple fracture, but, on 
 the other hand, has treated several cases of double compound fracture of 
 both thighs in which but little shock was present and the patients made 
 excellent recoveries. If the fracture is complicated with an injury to 
 the femoral vessels or a laceration of the main nerve-trunk, the progno- 
 sis is most serious, since gangrene may occur. 
 
 The treatment of Iracture of the shait of the femur is somewhat 
 complex, on account of the many different varieties of fracture which 
 present themselves, as well as owing to the multifarious methods still 
 in vogue. The indications are to overcome shortening, to control 
 muscular pain and spasm, and to produce fixation of the fragments. 
 
 Fi(i. 76. 
 
 Adliesive plaster applied for extension. 
 
 It seems wholly umiecessary to review the older methods of treat- 
 ment, since the recent ones are generally accepted as far superior in 
 every respect. The first indication 
 
 VIZ. to overcome shortening — is 
 
 Fig. 77. 
 
 E.xtension apparatus fur Iracture of the tliigh (modifierl from Gurilcn B\uki. 
 
 met l)y the u.se of the weight and pulley (Fig. 77), known as Buck's 
 extension method. The amount of weight required (k'pends upon the age 
 of the individual, the amount of mu.scular rigidity to be overcome, and the 
 
564 
 
 FRACTURES. 
 
 Fig, 
 
 direction of the fracture. In applying tiie adhesive plaster to the limb 
 the strip slioukl extend above the knee-jidnt and 
 nearly iij) to the seat of fracture, since this gives 
 less freedom of motion and takes the strain off from 
 the knee-joint. The amount of weight required to 
 overcome the shortening varies from five to twenty- 
 five pounds. The less weight that is used, the more 
 likely it is that the ])atient will tolerate the extension 
 for a long time (Fig. 77). The counter-extension 
 is made by elevation of the loot of the bed. Another 
 method of maintaining extension to overcome short- 
 ening is by the use of a spica of plaster-of- Paris band- 
 age applied while the muscles are relaxed during 
 anaesthesia. This extension is maintained by the use 
 of strips of perforated zinc or tin under tlie jilaster, 
 and a])plied according to Fluhrer's method. Still 
 other methods are by the vertical extension of the 
 thigh (Fig. 78); or by Liston's long sj)lint with its 
 perineal band, consisting of a tubular bag filled with 
 wool or a soft jmkI made of leather ; or by Owen 
 Thomat^'s hip-s]ilint ; or l)y the stirrup of Brown or Cripps ; or, finally, 
 by Nathan K. Smith's anterior sjilint. 
 
 The next indication — viz. to control muscular spasm and pain — is 
 best met by the use of a long sj^lint to which the thigh can be bandaged, 
 and the entire limb thus kc])t in its proper relation to the trunk. If the 
 nniscvilar si)asm and irritability are severe and cause mucli pain, tenotomy 
 of the hamstring muscles will at once relieve this condition. 
 
 Tiie last indication is met l)y the use of coa])tation splints, four in 
 number, placed around the thigh over the seat of fracture. They should 
 be two inches wide and about eight inches long, well padded and fixed 
 to the limb by strips of adhesive or rubber plaster about one inch in 
 width. 
 
 In case of fracture of the thigh in children, employ either the spica of 
 
 Fracture of the femur 
 in a child treated by 
 vertical extension. ' 
 
 Fig. 79. 
 
 Hamilton's splint for fracture of the femur in children. 
 
 plaster-of-Paris bandage with Fluhrer's perforated strips, or Hamilton's 
 double splint (Fig. 79), consisting of two long straight splints connected 
 below the foot by a cross-piece, and extending on both sides from below 
 
SPECIAL FRACTURES. 
 
 565 
 
 the feet to the axillse, with tlie linihs l):in(l;i<i:e(l to tlie thi<rh. Cliildren 
 with fracture of the tliigii euii he carrietl about in this dressing, and are 
 therefore not so niueh confined as by the otlier nietlKxh 
 
 Fracture just below the trochanter is substantially a fracture of the 
 shaft of tlie bone in its upper part, and special consideration is given 
 to it only because it jiermits of but one kind of treatment. The upper 
 fragment is tilted ujiward and abducted by the action of the psoas and 
 iliacus, which are inserted into the process, and al)ducted by the external 
 rotators. The lower fragment is abducted and drawn up Ity the extensor 
 muscles. 
 
 The treatment consists in placing the limb in an apparatus which will 
 cause the axis of the lower fragment to conform to that of the upper or 
 small fragment. This can be accomplished only by the use of a double- 
 inclined plane, and the shortening must l)e overcome by Buck's exten- 
 sion, wliicli is iqiplicd to the lower fragment. The upi'ight over or 
 through which the j)ullcy runs must be placed several feet above the 
 level of the foot of the bed, so that the traction is in the line of the 
 long axis of the femur while resting upon the upward plane of a Mc- 
 Intyre splint. This method must be observed in order to prevent 
 union of the fragments with angular deformity. 
 
 Fracture of the trochanter major is caused by a blow direct upon the 
 process or by a fall upon it. The fragment is displaced by the action of 
 the external rotator muscles, which draw the fragment upward and Ijack- 
 ward. 
 
 The signs and symptoms of this fracture arc those found in ordinary 
 
 Fid. 80. 
 
 Fracture of trnchantir major. 
 
 fractures, with the exception that, while there is no shortening in the 
 limb itself, the line in Bryant's triangle is shortened the same as in frac- 
 ture of the neck of the thigh-bone (Fig. 80). 
 
 The treatment consists in abductiny the limb of the affected side and 
 
566 
 
 FRACTURES. 
 
 placing a compress above and heliind the frnjiment. The compress is to 
 l)e kci)t in place by strii)s of rnblier (jr adliesive ])lastcr. 
 
 J'J.rfra-cci psu/ar frdctnre of the ccrrixfciaoris jrencrally occurs as a result 
 of direct violeuce, either by a blow upon the trochanter major or else by 
 a fall upon the hip. The \veight of the body in falling comes directly 
 upon the neck of the thigh-bone, and, since the neck is attached ol)li<|Uely 
 to the shaft, the force of the fail or blow is transmitted to it and a frac- 
 ture follows. If the force wiiich produces the fracture continues to act, 
 the compact tissue of the neck of the bone is driven firndy into the loose 
 cancellated tissue of the trochanter, and an impacted fracture is ])ro- 
 dueed. The direction of the fracture in front is along the insertion of the 
 capsular ligament, which is the anterior intertrochanteric line, and behind 
 the fracture is outside of tlie cajwule, but just internal to tlie ])osterior 
 intertrochanteric line (Fig. 81). In many eases the line of fracture is 
 
 Fig. 81. 
 
 Intra- and exlra-capsular fracture of neck ot femur. 
 
 found to be partly within and partly without the capsule of the joint, 
 and in some eases there are several distinct fragments — viz. one composed 
 of the head and neck of the bone, another of tlie trochanter, while still 
 another may consist of a part of the shaft of the bone. 
 
 Before entering ujjon a study of the signs and symptoms of extra- 
 capsular fracture of the neck of the thigh-bone it is necessary to exjilain 
 Bryant's triangle and Nelaton's line, with a view to a complete under- 
 standing of the nature of this injury. This knowledge will be useful in 
 
SPECIAL FRACTURES. 
 
 567 
 
 considering all injuries about the hip-joint, and therefore will be intro- 
 duced in connection with a study of this special variety of fracture. 
 
 Bryanfs ilio-fenwral triangle is formed by drawing a line from the 
 anterior superior spinous process of the ilium to the trochanter major 
 as line a, b, and another line perpendicularly from the anterior superior 
 spinous process to a point on a level with the termination of line A, B, 
 
 Fig. 82. 
 
 Bryant's ilio-feinoral triangle, for diagnosis of fracture of tlie necli of tlie fonmr. 
 
 as in line A, c. A third line, e, B, joining the.se two points of termi- 
 nation in a normal joint measures about two and a half inches (Fig. 82). 
 In case of fracture the base line is less than two and a half inches, or 
 less than a corresponding line in a triangle upon the opposite hip. 
 
 Nelaton's line is drawn from the anterior superior spinous process of 
 the ilium to the tuberosity of the ischium, and should in the normal 
 joint just toucii tlie ujiiier border of tlic trochanter major. In case of 
 fracture or dorsal di.slocation of the hip-joint the upper border of the 
 troclianter major is above Nelaton's line. 
 
 The signs and S3nnptoms of extra-ca{)sular fracture of the neck of 
 the thigh-bone consist of crepitus, elicited by placing the palm of the 
 hand over the trochanter major during forced rotation of the thigh, 
 superficial pain, tenderness and swelling, shortening of the limb to the 
 extent of about two and a half inches, rotation outward of the thigh, and 
 complete eversion of the foot, with contusion and ecchymosis over the 
 joint. The arc of the circle transcribed by the trochanter major is less 
 than it is over the sound joint, since the trochanter major moves upon 
 a shorter radius. These signs, together with the history that the patient 
 has received a severe fall directly upon the trochanter major or a blow 
 transversely ap])lie(l, and is, as a rule, under fifty years of age, indicate 
 this form of fractiu-e. In case the fracture is impacted many of the 
 signs mentioned are not present. The trochanter is often broadened or 
 enlarged, while its relation to the base line in Bryant's triangle is altered. 
 Another sign of extra-capsular fracture of the thigh-bone has been pointed 
 out by Allis — viz. the relaxation of the fascia lata. 
 
 The prognosis is serious as regards life, since in some eases pneu- 
 monia, Ijronchitis, fat-embolism, pulmonary thrombosis, inanition, bed- 
 sores, or traumatic delirium destroys the life of the patient. In other 
 cases the prognosis is unfax'orable in regard to the function of the limb, 
 which is more or less impaired. Asa rule, a person over seventy years 
 of age with a fracture of the neck of the thigh will be jiermanently a 
 crip])le, and often Ix'dridden. 
 
 The treatment of extra-ca])sular fracture consists in the application 
 
5G8 
 
 FRACTURES. 
 
 Fig. 83. 
 
 of a plaster-of-Paris spiea to the liij) wliile extension is made during 
 
 ansesthesia. Tiie limb within tlie splint is prevented from retracting 
 
 by the use of perforated strips of zinc or tin adjusted to the outer side 
 
 of the s]ilint between the layers of plaster. 
 
 Another method of treatment is by Liston's long splint in conjunction 
 
 with the weight-and-pnlley apj)aratus, as described in connection with 
 
 fractures of the shaft of the fenuir. 
 
 This fracture usually unites firmly, and the result is satisflictory 
 
 except in old persons, but occasionally there is some slight rigidity in 
 
 the hip-joint. 
 
 The prognosis as regards recovery and usefulness of the limb is in 
 
 marked contrast to the result usually obtained in the intra-capsular 
 
 fracture. 
 
 Intra-capsular fracture of the neck of the tliif/h-bone is of frequent 
 
 occurrence, and is usually seen in elderly people, chiefly in women. 
 
 The frequency of this fracture in the aged is ascribed to certain 
 
 senile changes which take place in the bone itself or in the angle 
 
 which the neck of the bone assumes to the shaft late in life. In tlie 
 
 young and during adult life this angle is 
 oblique, while in the aged it becomes almost a 
 right angle, and the head of the bone is sunk 
 below the level of the top of the trochanter. 
 Besides the changes in regard to the angle 
 at which the neck is jilaced to the shaft the 
 cancellated tissue undergoes a senile atrophy 
 owing to fiitty degeneration, and the com- 
 pact bony tissue becomes thin and fragile. 
 This fracture is generally caused by some 
 slight injury, such as trij)]iing the toe over 
 the threshold of the door, or slipping upon 
 a rug or o\'er a curbstone, or even turning 
 suddenly over in bed. The seat of the frac- 
 ture, as its name implies, is within the cap- 
 sule of the joint (Fig. 83). This fracture is 
 occasionally impacted, and in this case the 
 
 intra-eapsuiar fracture ofthe neck of neck of the bone is driven into the cancel- 
 
 the femur. 11. n ^ ^ t ,' ^ ^ T 
 
 lated tissue oi the head oi the bone. Im- 
 paction, however, is rare as compared with the same condition as found 
 in the extra-capsular fracture. 
 
 The signs and symptoms of intra-capsular fracture of the neck of 
 the thigh-bone consist of crepitus and pain which are deep-seated, and 
 shortening ofthe limb to the extent of an inch at first, and subsequently 
 more on accoiuit of atrophy and absorption of the neck ; shortening of 
 the base line in Bryant's triangle ; the projection of the trochanter major 
 above Nelaton's line, thus pnjducing a closer proximity to the crest of 
 the ilium ; alteration in the sliape of the hi]i, manifested by flattening 
 of the trochanter, and in the axis of the limb ; relaxation of the fascia 
 lata, tensor vaginae femoris, and gluteus medius muscles ; puckering of 
 the integument over the ligamentum patelhe, due to shortening of the 
 limb ; outward rotation of limb and eversion of foot, due to a mechanical 
 cause, since the centre of gravity is below a line drawn from the ace- 
 
SPECIAL FRACTURES. 569 
 
 tabulum to the heel, and tlie weight of the limb thus foils outward ; and 
 also to a physiologieiil cause, since the external rotators act upon tiie lower 
 fragnicut ; and tiie absence of the ecchymosis over tiie joint which is 
 seen in extra-capsular fracture. The arc of the circle transcribed by 
 the trochanter major is greater than in the extra-capsular fracture, but 
 less than upon the opposite side, owing to a shorter radius. These signs, 
 together with the history of a slight fall upon the knee or foot in an 
 aged individual, especially a woman, make the diagnosis certain. If 
 inversion of the foot occurs, it is exceptional, and is due to impaction 
 of the fragment'^ or possii)Iy to a paralysis of the external rotators; 
 whicii condition may be the result of an injury received at the same time 
 as the fracture. 
 
 The treatment of intra-cajisular fracture, as a rule, is unsatisfactory, 
 since the patients, on account of their age, are usually in jxior physical 
 condition, and hence the reparative process is retarde(l. The fracture 
 generally fails to unite, owing to tiie non-approximation of the frag- 
 ments, to the enfeebled condition of the patient, to a lack of sufficient 
 arterial supply, and to the presence of synovia between the fragments. 
 
 The surgeon must not mistake for an intra-capsular fracture a dis- 
 location of the hip, the differential points of which are ]>resented at 
 length under Dislocation. In contusion of the hijHJdiut the presence 
 of tlie head of the bone in the acetabulum and the al)sence of all the 
 characteristic signs belonging to fracture serve to render the diagnosis 
 clear. A fracture within the capsule can be diagnosticated if the 
 head of the bone is in the acetabulum and immediate shortening has 
 occurred, for under these circumstances, unless the fragments are 
 impacted, crepitus, eversion of the foot, shortening of the limb, and 
 loss of function are always present, and make the diagnosis certain 
 and the s]>ecial line of treatment perfectly clear. The surgeon should 
 make a judicious choice as to the special method by which a patient 
 with this injury is to be treated. If the patient is in good phys- 
 ical condition, not too aged, and not of a nervous temperament, an 
 attempt shduhl be made to secure union in the fracture. To this end 
 a long Liston splint should be adjusted, and a weight and pulley 
 attached to the foot in order to steady the leg and overcome a certain 
 amount of shortening. During the period of repair attention must l)e 
 directed to the avoidance of bed-sores and to the maintenance of the 
 general health, upon which so much depends in the management of 
 these cases. All parts of the hndy must be kept strictly and absolutely 
 clean, and the patient sujtported by the most nutritious diet, with 
 judicious stinndation if necessary. Anodynes may be indicated in 
 case of loss of sleep or to contnd pain, while remedies to aid digestion 
 and tonics containing the hypophosphites of lime and soda can be 
 emjdoyed M'ith advantage. 
 
 In some cases this fracture can lie treated by a plaster-of-Paris spica, 
 wliich is a form of dressing which does not confine the patient to the 
 bed, but permits him or her to rest on a lounge or even to be moved 
 around in a roller chair. Great care nuist be exercised lest the splint 
 produce excoriation of the skin in elderly people, since this will lead to 
 the formation of bed-sores, a most unfortunate, painful, and often fatal 
 complication. In ntlier cases patients arc intolerant of the use of any 
 
570 
 
 FRACTURES. 
 
 splint or dressing, and seem nidre (Mimfortabie witlioiit any fixed appa- 
 ratus, except ])erliaps sand-hags, wliieii serve to prevent rotation of 
 the linil). A liglit weigiit applied to the foot will sometimes help to 
 keep the fracture quiet and atlbrd the patient relief. 
 
 It has been suggested to unite the broken surfaces by ivory pegs, but 
 this operation is one of a serious nature and of doubtful expediency in 
 tiie ag<>d. Tile best result that can l)e attained is often very unsatisfactory, 
 and in many cases the ])atieuts succumb from the effects of this injury. 
 \i tile fracture is imjiacted and the patient is in good physical condition, 
 occasionally an excellent result follows. 
 
 Fractures of the pelvis form considerably less than 1 per cent, 
 of the fractures, and derive their chief importance from accomjianying 
 injury to the pelvic viscera. In this resj)ect fractures of tiie ])clvis 
 resemble fractures of the skull, in which tiie gravity is influenced not so 
 mucli l)y tlie extent of the fracture as liy the damage sustained by the 
 contents of the skull. 
 
 Fractures of the pelvis (Fig. 84) may be situated along the crest of 
 
 Fiii. 84. 
 
 Fracture of the pelvis. 
 
 the ilium, in the pelvic basin, or in the acetabulum. Fractures involv- 
 ing the crest of the ilium are usually produced Iw direct violence, as by 
 the pa.ssage of a wagou-wheel across the pelvis, or Ijy a heavy weight 
 falling upon the patient, or by crushing while in the act of coupling 
 cars. 
 
 The signs of this fracture are pain, crepitus, ecchymosis, and ina- 
 bility to move the muscles attached to the ilium. 
 
SPECIAL FRACTURES. 571 
 
 The treatment consists in keeping tlie patient quiet in bed and the 
 application of a long Liston splint reaching from the axilla to the ft)ot. 
 The fragments themselves can be adjusted and held in .sitii by the 
 aj)plication of pads or compresses, which are retained by adhesive 
 plaster, or liy a Bavarian plaster-of-Paris splint applied so as to tit all 
 the salient points of the pelvis, or by a gutta-pereha or felt splint 
 applied after first moulding it to the sound side. 
 
 Frnrfure offhrpdvicbaniii is usually situated in the jiubic bone. The 
 direction of the fracture is through tlie ujiper ranuis upon the inner side of 
 tlie jM'ctineal eminence, and tlien through the lower ramus near the point 
 at wliich tlie pubis joins the iscliium. 
 
 The displacement is very slight, as a rule. Palpation of the outline 
 of the pelvis will often reveal the amount of displacement. 
 
 The prognosis in this fracture is dependent upon the existence of 
 visceral injury. In the absence of any injury to the viscera suppuration 
 in the loose connective tissue in front of the bladder is a complication 
 that often ensues. 
 
 The signs and ssrmptoms of fracture of the pelvic basin consist of 
 localized pain, greatly increased upon pressure, inability to elevate the 
 limb, crepitus, ecchyniosis, and displacement. In these cases there is 
 usually injury to the pelvic viscera. The urethra may be lacerated as 
 it passes under tlie arch of the }>ubis, either by a sharp fragment of 
 bone or by separation of the symphysis. A catheter, thoroughly cleansed 
 and boiled, should be introduced into the urethra down to the seat of 
 the laceration, and then an external perineal urethrotomy performed. It 
 may not be necessary to o]ien into the bladder, but a sound must be passed 
 ut stated intervals in the future to avoid the formation of traumatic 
 •strictures. A catheter should be immediately introduced into the bladder 
 for the purpose of ascertaining whether a rupture of this viscus has oc- 
 curred. If clear urine escapes, it is presumptive evidence that the blad- 
 der is uninjured. This, however, is not an absolute proof, and further 
 investigation should be made. Eight ounces of Thiersch's antiseptic 
 fluid should be injected into the bladder, and if this exact amount is 
 immediately witlidrawn ruptui-e of the bladder is in all probability not 
 present. Even this procedure is not an infallilile test, since a rent in 
 tlie bladder-wall has been found of a valve-like character, so that disten- 
 tion of the bladder closes the opening and no fluid escapes into the peri- 
 toneal cavity, although a rupture of the bladder-wall exists. If after a 
 few hours folhjwing this examination Inematuria occurs, some doubt may 
 arise as to tlie accuracy of the diagnosis. The question then to decide 
 is whether the blood found in tlie urine has its origin from the bladder, 
 or wlicthcr the liiood is from tlie kidney as a result of laceration of tliis 
 organ. The presence.of hiematuria occurring some hours after a pelvic 
 fracture, the fact that the blood is uniformly mixed with the urine, and 
 not found in clots, as is usual in hemoi'rhage from the bladder, and the 
 evidence derived from the microscopical examination of the bloody urine, 
 will make aljsolutely certain the diagnosis as to the source of the hemor- 
 rhage and the injury of the viscera. 
 
 Hsematuria, due to an injury to the bladder-wall or to the kidney- 
 substance, must not be mistaken for a hemorrhage from the urethra 
 dependent upon a laceration of this canal at the triangular ligament. 
 
572 
 
 FRACTURES. 
 
 The passage of a sound will ciiMbk' the surgeon to arrive at a conclusion 
 as to this possible source oi" Jieniorrhagc. A digital examination of the 
 rectum should be made to ascertain if the pelvic vessels are torn or if 
 the bowel itself has sustained any injury. If the patient is a female, 
 it may be necessary to make a vaginal examination in order to be sure 
 that none of tlie pelvic organs are injured by tiie fracture. If the exam- 
 ination reveals the fact that the bladder is injured, a lajjarotomv should 
 be immediately performed, as tirst descril)ed in detail l)v Sir Wm. Mac- 
 Cormac, the peritoneal cavity should be irrigated, the wound in the blad- 
 der-wall closed, and drainage during repair maintained, either by a tube 
 brought out at the lower angle of the abdominal \\onnd or else by a soft 
 catheter introduced into the urethra and kept ase])tically clean. 
 
 The management of the fractur(> itself is conducted uj)on the same 
 principle as that of fracture of the ilium. The long Liston splint should 
 be applied to both limbs, slight flexion of the knees with modi'rate 
 extension by the double weight and jiulley should be employed, and the 
 adaptation of some form of pliable splint or bandage, such as felt, leather, 
 or plaster of Paris, should be made in order to kec]) the fragments at rest. 
 Fractures of the acetabulum may occur sinuiltaneously witii a disloca- 
 tion of the hip, but this special variety of 
 fracture is exceedingly rare. The frac- 
 ture, when independent of a dislocation, 
 may involve only the rim of the acetab- 
 ulum, most fre(piently the posterior lip, 
 or it may involve the floor of the acetab- 
 ular cavity. It sometimes haj)pcns that 
 the head of the femur is driven through 
 the floor of the joint-socket into the pel- 
 vic cavity (Fig. 85). 
 
 The signs and symptoms of fracture 
 of the acetabulum consist of pain, ren- 
 dered acute by pressure over the trochan- 
 ter major ; an acute synovitis of the hip- 
 joint, with all the manifestations of effu- 
 sion within the capsule ; the presence of 
 crepitus in some cases ; or the evidences 
 of impaction of the head of the bone in 
 Comminuted fracture of the acetabulum. Other cases. If the head of the bone 
 
 has been forcibly driven through the 
 floor of the joint-cavity into the pelvic cavity, there are also present 
 the signs of injury of the pelvic viscera. 
 
 The complications are to be treated according to the rules just laid 
 down in discussing this question in connection with fractures of the 
 pelvic basin. The fracture itself can be best treated by the same 
 method as intra-capsular fracture of the neck of the thigh-bone or a 
 fracture of the pelvic basin. 
 
 Fracture of the iiyoid boxe seldom occurs, owing to the mobility 
 of the bone and the protection which is aftorded to it by the inferior maxil- 
 lary bone. These fractures are usually caused by a direct blow upon the 
 neck or by some one throttling the patient in an attempt at violent 
 assault, or by a fall from a height, or during the act of judicial or 
 
SPECIAL FRACTURES. 
 
 573 
 
 suicidal lianging. The junction of the body of the bone with the 
 greater cornu is the usual seat of the fracture. There are some cases 
 recorded where a fracture of this bone has occurred as a result of mus- 
 cular action. 
 
 The signs and ssnnptoms are those wliich are found in common 
 witli ordinary fractures of other bones. The patient usually hears a 
 sudden sna[), and at the same time experiences, with a sense of sutfoca- 
 tion, acute pain. There is usually a slight hemorrhage from the mouth, 
 produced by a laceration of the mucous membrane of the pharynx. 
 Movement of the head is attended witli severe pain, and tlie j)atient is 
 unal)le to ])rotrude the tongue. The voice is hoarse, and articulation as 
 well as deglutition becomes very painful. Dyspncea, expectoration of 
 bloody mucus, and irregularity of the pulse are symptoms often 
 observed. 
 
 The prognosis is favorable if the fracture of the bone is not asso- 
 ciated with injury to the larynx, but when this complication is present 
 nearly 50 per cent, of the eases are fatal. The danger of axlema 
 glottidis must not be lost sight of, since this condition is likely at any 
 time to arise. 
 
 Treatment. — An attempt should be made at once to reduce the frag- 
 ments l)v placing the left index finger of the surgeon in the patient's 
 moutli, and witli the thumb and index finger of the right liand making 
 external jiressure until the fragments arc brought into apposition. If tiic 
 parts art' not easily bi-ouglit together, it may he necessary to administer 
 an auiestiietic, during wliich the surgeon must guard against the danger 
 of the patient swallowing the tongue. The patient's head should now be 
 flexed forward, and lield in this position by some retentive apjiaratus 
 which extends from liotli sides of the head to the slioulders. A collar 
 consisting of leather or felt or jilaster of Paris, like the Bavarian splint, 
 can he jtlaccd around the neclv and ap])licd to 
 it wliile wet, so that the collar can adapt itself to 
 the salient points of the neck. The oesophageal 
 tube must be used to feed the patient, who for 
 ten days at least must not be allowed to talk. 
 
 (Edema f//ofii(lin (Fig. 8ti) is a coni]ilication 
 that may arise at any moment, and if iiiflani- 
 niation or dyspncea is present a prophylactic 
 tracheotomy should be immediately performed. 
 If the soft parts within the mouth are lacerated 
 and there is much ecchymosis externally, it is 
 best to perform a prophylactic tracheotoiiiy, as 
 it is unsafe to <lelay this operation until cedcma 
 glottidis is established, as in these cases death 
 occurs instantly and without any warning. 
 
 Fracture of the rib occurs in the proportion of about 18 per 
 cent, of all fractures. This fi-acture is frequent in adults, but very 
 itifrc(|uent in children, owing to the elasticity of the cartilage connect- 
 ing the rib to the sternum and the strength of the ligament connecting 
 the rib to the vcrtelira. The elasticity is so great in children that the 
 arch yields without breaking upon the application of violent jiressure. 
 A carriage has been known to pass over the chest of a child, and on 
 
 Fio. 8G. 
 
 CEdema of the glottis. 
 
574 FRACTURES. 
 
 account of the elasticity no fracture occurred. In tlie aged this elasticity 
 is lost, owing to a certain anioiuit of ossification of the cartilage and to 
 senile atrojthy of the rib itself, wiiieh causes it to be fragile and inelastic. 
 'J^he ril)s of tlie insiuie are said to be very brittle, owing to the great pro- 
 portion of earthy to organic matter. 
 
 The ribs most frequently fractured are from the fourth to the eighth, 
 the seventh rib being the one most frequently found to be the seat of 
 fracture. The uj)per ribs are ])roteeted from injury by the pectoral 
 muscles and the clavicle, wliile the lower or lidse rilts yield on account 
 of their great mobility. Indeed, fractures of the first and last ribs are 
 almost unknown. The fracture is usually at or near the angle of the 
 rib and about four inches from its attachment to the vertebral column, 
 since at this point the two forces, the blow and the recoil, meet. Occa- 
 sionally, however, a fracture is found near the junction of the costal 
 cartilage. 
 
 The cause of fracture of the rib may be direct violence, as when 
 the rib is struck and the fragments are driven inward. In this variety 
 of fracture the pleura and lung may be injured. The fracture may also 
 be caused by indirect violence, as when the chest is suddenly compressed 
 and the. fragments are driven outward and snap. Finally, fracture of the 
 rib has been caused by nniscular action during the act of ])artnrition. 
 Malgaigne has i-eported a case of fracture due to the impulse of the heart. 
 
 Fractures of the ribs are simple, or compound as in gunshot or 
 .stab wound, or complicated, as when the diaphragm, ])leura, lung, or 
 the peritoneum is M'ounded. A complicated fracture of tlie rib has 
 been observed in a few cases where the fragment injured the heart, or 
 where the chest-cavity has been compressed so as to cause an injury of 
 the heart without an accompanying wound of the ])ericanlium. A com- 
 plicated fracture of the rib has been ol)served by the writer in which 
 the patient fractured one of the floating ribs in an attempt to get out of 
 a berth while on shipboard. The patient was thrown violently against 
 the side of the berth and struck the lower rib, which suddenly fractured, 
 and at the same time womidcd the peritoneum, so tliat a traumatic peri- 
 tonitis was developed ; from which attack, however, the patient made an 
 excellent recovery. 
 
 The signs and symptoms of fracture of the rib may be classified 
 as local and general. Among the local signs are sharp, circumscribed 
 pain, increased upon inspiration by manual ])rcssurc applied to the 
 sternum, -which causes the fragment to spring out and increase the pain ; 
 diaphragmatic and abdominal breathing; crepitus, heard l)y the stetho- 
 scope j)laced over the fracture, or felt by jdacing the jialm of the hand 
 over the fracture while the patient coughs ; and also abnormal outline of 
 the chest side-wall. If the fracture happens to be compound or from a 
 gunshot \\ound, hemorrhage from the seat of fracture is a jn'ominent 
 sign. This hemorrhage may originate from a wounded intercostal 
 artery, in which case the lilood is bright red in color, and comes in spurts 
 synchronous with the action of the heart, or else the hemorrhage may 
 come from wounded lung-tissue, in which case the blood wells up from 
 the bottom of the \\ound and is very dark in color, due to the presence 
 of carbonic acid. 
 
 Among the general signs and symptoms are hsemoptysis, or the ex- 
 
SPECIAL FRACTURES. 575 
 
 pectoration of blood from the wounded lung ; and emphysema, or the 
 escape of air from the lung into the surrounding tissue. The emphysema 
 is first noticed upon the side of the chest-wall, and it may extend to the 
 neck, and even over the abdomen. The writer has on several occasions 
 observed air in the connective tissue as far down as the scrotum, although 
 it is not liivcly to go below Poupart's ligament. Pneumothorax and 
 htemothorax also may be present in fracture of the rib. It is apparent 
 that these general signs indicate the presence of a complicated fracture. 
 Occasionally pulmonary apo[)lexy and ])ulmonary enii)hysema may also 
 be found in fracture of tlie rib. 
 
 Tlie treatment of fracture of the rib sluiuld be directed to tlic relief 
 of pain, to tile diminution of the respiratory movcnuMits, to the fixation 
 of the fragments, to the arrest of hemorrhage, and, finally, to the antici- 
 pation of, as well as to the control of, inflammatory complications. Witli 
 a view to the first and second objects opium is indicated. This drug is 
 the sheet-anchor in tliis fracture, because it not only relieves pain by its 
 specific action and by its reducing tlie number of the respirations, but it 
 also has a salutary influence upon inflammatory reaction. M'itii a view 
 to accomplishing tiie third object — viz. the fixation of the fragments — a 
 six-inch broad and a three-feet long strip of rubber or adhesive plaster 
 should be applied around the chest, the centre of which strip should 
 pass over the site of tlie fracture. The plaster should l)e tightened dur- 
 ing forced expiration, so tliat upon inspiration tlie injured cliest-wall will 
 have a firm support. This simjile apj)aratus attbrds tiie greatest possible 
 comfort to the patient. Tiie heiuorriiage, if pulmonary, can be controlled 
 by packing the wound with iodoform gauze in the form of a tampon ; if 
 arterial, the wound must be enlarged so as to .secure both ends of the 
 divided intercostal artery. In case the vessel cannot be found, a square 
 piece of gauze aliout tlie size of a sheet of letter-paper can be introduced 
 into the wound and beyond the rib by forcing it with a director placed 
 in the centre of tiie piece of gauze. Into tliis glove-finger-shaped piece 
 of gauze small narrow .strips of iodoform gauze can be pushed, and when 
 the bottom of the glove-finger tampon is well filled the entire compress 
 can be partially withdrawn until it comes in contact with the inner sur- 
 face of tlu> upper and lower rilis in tiie interspace. Tlie pressure can 
 now be made directly upon tlie l)leeding vessel. This tampon can be 
 subsequently removed by diminishing its size by removing some of the 
 narrow strips of gauze with wliich the glove-finger has been packed. 
 
 The emphysema is not to be interfered with, since the air will event- 
 ually become ab.sorbed, and, altiiough the patient may be unrecognizable 
 on account of the general swelling, tlie condition itself gives no cause 
 for alarm. It occasionally hapjiens tliat the air is so freely distrilmted 
 that wiien it reaches the 'loose cellular tissue of the neck respiration is 
 seriously embarrassed, and in this ease a few incisions through the 
 integument will suffice to allow the air to escape. It is, however, only 
 under extraordinary circumstances that incisions should be made, since 
 this apparently simple procedure has been followed by death. If the 
 emphysema invades the mediastinnm or forces its way into the inter- 
 lobular tissue of the lung, tliis condition is not amenable to surgical 
 treatment and forms a most serious complication. 
 
 In fracture of the ribs in which there is little or no collapse, and the 
 
576 FRACTURES. 
 
 patient is a strong, pletiioric individual and suffering from dyspnoea and 
 impending asphyxia, venesection is indicated, and will remove at once 
 tlie alarming distress and discomfort, since by this means the venous 
 congestion and pulmonary engorgement are innnediately relieved. 
 
 The coHtal cdiiildt/c^ may be fractured, either at their junction with 
 the rib or even in the middle of the cartilage itself. The fracture of 
 the cartilage is jirodueed by the same causes as fracture of the ribs, and 
 the signs and symptoms and treatment are similar. 
 
 FitACTURE OF THE STERNUM occurs in less than 1 per cent, of all 
 fractures. This is owing to the elasticity atibrded to it by its connec- 
 tions with the ribs, and also to its sjiongy structure. It may be caused 
 by direct violence, as a heavy blow upon the chest, or by a heavy 
 weight falling upon the patient, or by a gunshot wound. This injury 
 has also been observed as the result of indirect violence, as in bending 
 the body suddenly liackward or forward, and occasionally a fracture has 
 been observed after a fall Tijion the shoulder, in which case the force is 
 transmitted along the clavicle and ribs. Several cases of fracture of 
 this bone have been reported as a result of muscular action during 
 labor-pains. A case has also been reported where the patient fractured 
 the sternum by endeavoring to lift a weight with the teeth while the 
 body was placed in the position of ojjisthotonos. 
 
 The fracture is usually simple and transverse, and it is generally 
 situated at the junction of the manubrium with the l)ody of the bone 
 (Fig. 87). If the fracture is due to a gunshot wound, it may of course 
 be situated at any part of the bone. It sometimes happens that the lower 
 extremity of the bone or the ensiform cartilage is the ]iart broken. 
 
 The displacement is usually slight, on account of the periosteum in 
 fi'ont and behind the bone. The lower fragment is usually displaced 
 forward and (iverla))s the lower margin of the ui>per fraoment. 
 
 -'» 
 
 Tiie signs and symptoms of fracture of the sternum are — fixed jiain, 
 which is increased by a deep inspiration or expiration ; cough, attended 
 by expectoration of blood and marked irregularity of the action of the 
 heart, with dys}>nwa ; flexion forward of the head and trmik ; change in 
 the outline of the bone ; and crepitus, felt by placing the jwhn of the 
 hand over the sternum while the ])atient coughs. In some cases, how- 
 ever, crepitus can be detecteil only by means of the stethoscope. 
 
 The prognosis in this fracture is favorable, unless it is complicated 
 with a fracture of the sjiinal colunui or the ribs or the clavicle, or by a 
 hemorrhage into the anterior mediastinum. 
 
 The treatment consist in the application of a liroad band of adhesive 
 plaster placed around the chest in the manner already described in the 
 dressing of a fractured rib. It may be necessary to a]>j)ly a compress to 
 the fragment which is tilted forward, and this dressing will maintain the 
 apposition of the fragments. In reducing the fracture the jjatient should 
 be placed in the position of opisthotonos, with a hard jiillow under the 
 back. In this attitude of the body the advancing fragment can be brought 
 into coaptation with the receding fragment. The suggestion of Petit, of 
 cutting dt)wn upon the bone and elevating the fragment, or that of Nelaton, 
 of passing a hook under the fragment, is not to be recommended. The 
 dangers of injury to the pleui'a and pericardium, of suppuration in the 
 anterior mediastinum, and of conversion of a simple into a compound frac- 
 
SPECIAL FRACTURES. 577 
 
 ture, are too great risks to run to relieve a deformity which ordinarily pro- 
 duces no disturbance. Trepliining of the sternum is likewise to be con- 
 demned, as well as the use of the gimlet, since these measures have been 
 
 Fig. 87. 
 
 Displacement of fragment.s in fracture of sternum. 
 
 attended with serious result. Tlic movements of respiration should be 
 dimiui.-ihed by the use of opium, and the |)aticnt |ilaccd in the ])ositiiin in 
 whicii he can breathe witii the least difficulty. 
 
 FR.vcTrRp:s of the clavicle occur in about lo per cent, of all 
 fractures. They are common, because the bone is prominently ex]50sed, 
 and receives all shocks transmitted to it by falls ujion the shoulder, elbo\\', 
 and hand. This injury also occurs from direct violence, as a blow upon 
 
 Vol. L— 37 
 
5/8 FRACTURES. 
 
 the shoulder or by a heavy weifi;ht falliiij;- u]W)ii it, and has been known 
 to result from nuisciilar aetioii, on aeeount of the strong contraction of 
 the deltoid and the clavicular ])ortion of the pectoralis major, an 
 example of which is reported in an atteni])t to lift a carriage-top while 
 seated in the carriage. Fractures of the clavicle are rare in elderly 
 pe(i])le, and exceedingly comnicm in rhildrcii, in wliom half of tlie cases 
 occur before the fiftli year. 
 
 The seat of the fracture may be in the body of the bone or at the 
 acromial or sternal extremity. The most frequent .seat of fracture of the 
 clavicle is in the body of the bone just external to the centre, since at 
 this place the bone is least in diameter, and at the same time it is the 
 junction of the outer and sudilcn curve with the inner curve. This is 
 the case upon exposure to indirect violence, while following direct vio- 
 lence any portion of the bone may be broken ; but the sternal end is less 
 frecpiently broken, since the direct force of a blow upon the shoulder is 
 usually attended by fracture of the acromial end, which receives the full 
 force of the injury. 
 
 The fracture is generally simj)lc, altiiough the writer has seen two 
 cases of compound fracture, excluding gunsiiot fractures. The double 
 curve in the body of the clavicle prevents it from breaking as often 
 as if it were perfectly straight, since the curves transmit the force over 
 a greater space. It is a noteworthy fact that it seldom happens that 
 
 Fig. S8. 
 
 Displacement of inner and outer fragments in fraeture of clavicle. 
 
 fracture of the clavicle is associated with other injuries, such as fracture of 
 the adjacent ril)s, injury of tlie pleura, laceration of the important axillary 
 vessels, or stretching of the cords of the brachial plexus. Any or all of 
 these complications may occur, but, considering the frequency of fracture 
 of the clavicle, it is extremely rare to find any of these concomitant 
 injuries. 
 
 The displacement in fractures of the clavicle consists of an elevation 
 
SPECIAL FRACTUBES. 579 
 
 and projection of the sternal end of the hone by the aetion of the clavic- 
 ular portion of the sterno-eleido-mastoid muscle (Fig. 88), and a depres- 
 sion of the acromial extremity by the weight of the arm and by the action 
 of the pcctoralis minor muscle, and also by the lower fibres of the pectoral is 
 major and the deltoid acting from its humeral insertion. The outer frag- 
 ment is also rotated by tlie action of the scrratus magnus muscle, which 
 has a tendency to draw backward the inner extremity of the outer frag- 
 ment ; which fact explains the frequency with which the fragment per- 
 forates the loose skin over the clavicle, and thus causes a compound 
 fracture. 
 
 The signs and symptoms of fracture of the clavicle vary some- 
 what according to the special seat of the fracture. Besides the ordinary 
 signs indicative of fracture, there are some special signs and symptoms 
 which are characteristic, among which may be mentioned the interrup- 
 tion in the line of the bone; the loss of power in the muscles attached to 
 it ; the flattening and depression of the shoulder, which falls downward 
 by the weight (if the arm, inward by the action of the pectoralis minor 
 and the subelavius, and to some extent of the pectoralis major nuiscle, 
 and forward, on account of the shape of the thorax ; and, finally, the 
 turning of the head and neck toward the injured side in order to relax 
 the muscles, which cause pain by their contraction. Among other signs 
 may be mentioned the nearer approach of the affected shoulder to the 
 mesial line of the sternum, the close proximity of the arm to the side 
 of the chest, and the loss of th.e support of the elbow, which is generally 
 held up by the patient's other hand. 
 
 The treatment of fracture of the clavicle, on account of its extreme 
 frequency, has commanded the attention of surgeons in every country. 
 The different kinds of apparatus and appliances all aim to bring the 
 shoulder upward, outward, and backward in order to overcome the dis- 
 placement, which is downward, inward, and forward. Tf a jxitient will 
 consent to lie on his back in bed for two weeks upon a firm and hard mat- 
 tress, with a small pillow under the head, and the affected arm held close 
 to the side of the chest by a long, heavy sand-bag, this supine position 
 will accomplish more satisfactory results than any dressing yet devised. 
 The recumbent position upon the back causes the shoulder to assume its 
 normal relation. A sand-bag placed over the point of the shoulder will 
 assist l)V depressing it, and tlicrcby bringing the fragments into apposition. 
 The results obtainctl by this simple method are far superior to those 
 obtained by any other, since the fragments unite without any overlap- 
 ping and the callus is not so exuberant ; and in the case of a lady, in 
 whom the recjuirements of dress compel her to expose her neck, the dis- 
 figurement of a callus is sometimes more dreaded than the forced con- 
 finement in bed for t\\'o weeks. It is only occasionally that a woman's 
 vanity will induce her to choose this mctiiod of treatment. 
 
 li' the patient will not consent to remain in bed, the best and simplest 
 method is that of Sayre, who describes his dressing in the following 
 manner: " After drawing the arm backward and retaining it tiiere by 
 a sti-i]i of adhesive ])laster, pass another piece of plaster from the well 
 shoulder across the l)ack, and by pressing the elbow well forward and 
 inward the first ])Iaster around the middle of the arm is made to act as 
 a fulcrum, and the simuldcr is necessarily carried upward, outward, and 
 
580 
 
 FRACTURES. 
 
 backward ; and the plaster, being' cari-icd o\'er the elbow and forearm 
 (wliieli i.s flexed across the chest) to the opposite siioulder, the place of 
 starting, and then secured by pins or stitches, permanently retains the 
 
 parts in position Strong and good adhesive ])laster is cut into 
 
 two strips three to four inches wide (narrower for children), one piece long 
 enough to surround tlie arm and go (•(ini]>letely annuid tlie body, the otlier 
 to reach from the sound shoulder around the elbow of the fractured side and 
 back to the place of starting. The first piece is passed around the arm just 
 below the axillary margin, and pinned or stitched in the form of a loop suffi- 
 ciently large to prevent strangulation, leaving a portion on the back of the 
 arm uncased by the ])laster. The arm is then drawn downward and back- 
 ward until the clavicidar jiortion of the pectoralis major muscle is put suf- 
 ficiently on the stretch to overcome the sterno-cleido-mastoid, and thus 
 pull the inner portion of the clavicle down to its level. The plaster is 
 then carried smoothly and completely around the body, and pinned to 
 itself on the back to prevent slipping, as seen in Fig. 89. Tlie first 
 
 Fig. 89. 
 
 Savre's adhesive-plaster dressing for 
 'fracture of elaviele (first piece}. 
 
 Ihe same (secund piece). 
 
 strip of plaster fulfils a double purpose : first, by jiutting the clavicular 
 portion of the ])ectoralis major muscle on the stretch, it prevents the 
 clavicle from riding upward ; and secondly, acting as a fulcrum at the 
 centre of the arm \\-hcn the elbow is pi'essed downward, forward, and 
 inward, it neces.sarily foi'ces the other extremity of the humerus (and 
 with it the shoulder) upward, outward, and backward ; and it is kept in 
 this position by the second strip of plaster, which is applied as follows : 
 Commencing on the front of the shoulder of the sound side, draw it 
 smoothly and diagonally across the back to the elbow of the fractured 
 side, where a slit is made in its middle to receive the projecting olec- 
 ranon. Before applying this plaster to the elbow an assistant shouhl ]>ress 
 the elbow Avell forward and inward (Fig. 90), and retain it there while 
 
SPECIAL FRACTURES. 
 
 581 
 
 Fig. 91. 
 
 the plaster is continued over tlie elbow and forearm (pressinfj the latter 
 close to the chest and .securing the hand near the opposite nipple) ; cros.s- 
 ing the shoulder at the place of beginning, it is there secured by two or 
 three pin.s, as seen in Fig. 90. 
 
 "When this has been done the dcfurniity will 
 have entirely disappeared, the fractured bones 
 will be accurately adjusted, and as long as the 
 strips of plaster maintain their position no 
 amount of force can displace them." 
 
 Velpeau's dressing is made by means of a long 
 roller bandage. The patient's hand is placed 
 upon his opposite shoulder, the elbow against 
 the front of the chest, and a bandage is started 
 in the opposite axilla and carried obliquely 
 across the back over the affected shoulder (Fig. 
 91), down in front of tlie arm, and under the 
 elbow tn the other axilla. After the arm is 
 thus vertically bandaged and brought snugly 
 against the chest, the roller is carried in a 
 circular manner around the thorax from below 
 upward until the arm and the forearm are cov- 
 ered by this bandage as high as the axilla on the unaffected side per- 
 mits. Tills entire dressing can be made stiff by the applit-ition of loose 
 plaster or silicate of soda, or even by stitching it in many places, so 
 that tlie roller will not l)ecome displaced by slipping. 
 
 Moore's dressing consists of a figure-of-8 bandage (Figs. 92 and 
 
 Fig. 92. Fig. 93. 
 
 Velpeau's dressing for frac- 
 ture of the clavicle. 
 
 Jloore's dressing for fractured clavicle. 
 
 Moore's dressing for fractured clavicle. 
 
 93), a detailed description of wiiich, in his own words, is: " T use a 
 shawl or piece of cotton cloth, whicii, wlien folded like a cravat eight 
 
582 FRACTURES. 
 
 inches in bivndtli at tlie centre, slicmld Ite alxmt two yards long. 
 Plaeint; this at tlie centre across the ])aliii of tlie suri;'eon, he seizes witii 
 tliis iiand tiie elhow of the jiatient wliieii corresponds with the liroken 
 cla\'iclc. 'I'lic two ends of tlie hantlaii'c hang to tiie floor. Tiie one 
 falling inward toward tlie patient is carried upward in front of the 
 shouhler and over the back, making a spiral movement in front of the 
 shoulder. This is entrusted to an assistant. The outer end is then 
 carried across the forearm, beliind the back, over the ojijwsite shoulder, 
 and around the axilla. Tiiis meets tiie other end, wliicii niav be carried 
 under the axilla and over the shoulder of the opposite side, thus making 
 the tigure (8) turn around the sound shoidder. This twist, it will be 
 seen, also makes the tigure (8) turn around the elbow of the affected 
 side." 
 
 Fracture of the scapula is rare, on account of the mobility of 
 the bone, the elasticity of the ribs, the protection which is atforded to it 
 by tiie cushion of muscles upon its dorsal surface, and the support 
 which it has from the thoracic wall. 
 
 Fractures of the scapula are caused usually by direct violence, 
 although a case has been reported in which the fracture was said to 
 have occurred as a result of muscular action. 
 
 The varieties of fracture of the scapula are — fif the body, of the 
 acromion process, of the coracoid process, and of the neck of the bone. 
 When the body is fractured the line of fracture is usually just below 
 the spinous process (Fig. 94). 
 
 Fig. 94. 
 
 Fracture of borty ot s( nimla. 
 
 The signs and symptoms are — crepitus, pain, dis])lacement, and 
 ecchymosis. The crepitus is found by placing the palm of one hand 
 
SPECIAL FRACTURES. 583 
 
 iipiin tlie back over the seapiila ami moving the arm witli the otlier 
 hand. 
 
 The chsphicement consists of the drawing upward and forward of 
 the lower fragment by the action of the scrratus magnus and the teres 
 major muscles, and the drawing backward and upward of the upper 
 fragment hv the rhoml)oideiis major nuiscle. 
 
 The treatment of fracture of tiie body of the scapula is tlie same 
 as that described for fracture of the rib, with the addition of a compress 
 over the body of the bone. The above-mentioned muscles causing the 
 displacement should be relaxed by position. It has been suggested to 
 place a gutta-percha mould over the bone, an<l thus hold it in sitil until 
 tiie fracture has lieen repaired. 
 
 Fracfnre of the acromion prooe^s is the result of direct violence, and 
 may involve the tip of the process only or tlie entire thickness in 
 a transverse or an (iblique direction. 
 
 The signs and symptoms are — pain, crepitus, ecchymosis, flattening 
 and falling downward, forward, and inward of tlie point of the shoulder, 
 inability to raise the arm, and interruption of tiie line of the spinous 
 process as felt by the finger passe<l over the surface. Any movement of 
 tile shoulder will lie attended witli great ])aiii, and crepitus is distinctly 
 felt. These signs are well marked when the fracture of tiie acromion is 
 behind the acromio-clavicular articulation, but when in front of this 
 ligament the displacement and the signs are not so pronounced. 
 
 The treatment consists in elevation of the elljow, while at the 
 same time a pad is jilaced l)etweeii tiie elliow and the thoracic wall. 
 The elevation is maintained by a baiulage from tiie elliow to the opposite 
 shoulder. This makes the head of the humerus act as a splint against 
 the broken acromion. A pad sliould not be jilaced in the axilla, since 
 this would have a tendency to draw the head of the humerus too far 
 outward, and then it would not act as a splint. The fragment of the 
 acromion should be strapped down by strips of adhesive plaster pulled 
 down with coiisideral)le strength. If tlie ])atient will submit, a most 
 desirable result can be obtained liy placing liim upon his back, and then 
 bringing the arm out at a riglit angle to the trunk. This position 
 relaxes the deltoid muscle and brings the fragment into apposition. 
 
 The eoracoid procefi>! is rarely fractured. The accident is usually the 
 result of direct violence. The apex of the process is jiulled downward 
 ami inward by the action of the pectoralis minor, the short head of the 
 biceps, and the coraco-brachialis muscles. It sometimes happens that 
 little if any displacement is noticed, since the strong coraco-clavicular 
 ligament remains untorn and the dense periosteal and fibrous tissue holds 
 the fragments in place. 
 
 Tile signs and symptoms consist of crepitus, mobility of the process, 
 marked impairment in tlie movements of the arm, and the stationary 
 position of tlie fragment when the arm is passively moved. 
 
 The treatment consists in flexing the forearm ujion the arm, and 
 then drawing well forward tlie elbow ujion tlie antero-lateral part of the 
 chest. This position relaxes the two muscles having their origin from, 
 and insertion into, the coracoid process. 
 
 Fracfnre of the snrc/ical neck of the scapula (Figs. 95, 96) occasion- 
 ally occurs, and often in conjunction with a fracture of the floor of 
 
584 
 
 FRACTURES. 
 
 the glenoid eavitv. Tlie fraeture may he situated at tlic anatomical 
 or surgical neck, the anatomical necU consisting ot" tliat part of tiie 
 bone which is external to tiie coracoid process, and just beliind tiie 
 glenoid fossii, tlie surgical neck end)racing tlie anatomical neck and 
 inchKliny: the coi 
 
 d 
 
 I'ta. 95. 
 
 procc 
 
 Thus A fracture of the anatomical neck 
 Fio. 9(1. 
 
 Fracture of tlic nock of the scapula (according to 
 Sir A.stley Cooper). 
 
 Comniinutcrl fnu'tvirc of the 
 cavity. 
 
 enoid 
 
 would cause a separation of the glenoid cavity only, while that of the 
 surgical neck would involve the coracoid process. This fact must not 
 be overlooked, since the disjilaeement in case of fraeture of the surgical 
 neck is well jjronounced, wiiile tliere is little deformity if only the 
 anatomical neck is fractured. The cause of this fractm-e is liy direct 
 violence, either from a blow upon the shoulder or from a fall from a 
 height in which the patient strikes upon the shoulder. 
 
 The signs and s3miptoms eon.sist of a flattening of the shoulder, 
 simulating a dislocation ; jii'ominence of the acromion, with a slight 
 sulcus beneath it sufficient to receive the index finger placed laterally 
 under it; lengthening of the arm ; the movement of the coracoid process 
 with the humerus ; crepitus produced by elevation of the elbow and rota- 
 tion of tiie humerus ; the eomj)lcte restoration of the landmarks of the joint 
 by lifting the arm at the elbow, and their immediate loss ujion removal 
 of the support ; and the presence of the glenoid cavity felt in the axilla. 
 
 The treatment consists in elevation of the elbow after flexion of the 
 forearm upon the arm, fixation of the i^cajtula by means of compresses 
 held in place by strips of rubber plaster, and the adjustment of a pad in 
 the axilla. 
 
 The Velpeau dressing, as used in fracture of the clavicle, is an excel- 
 lent dressing for this injury, since it supports the arm and causes lateral 
 pressure of the arm to the chest-wall. 
 
 P^RACTUREs OF THE HUMERUS form about 8 percent, of all fractures, 
 and the classification is similar to that of fractures of the femur : in the 
 U])per third, according to the seat of fracture, thus : fracture of the 
 anatomical neck, of the tuberosity, of the surgical neck, and epiphyseal 
 
SPECIAL FRACTURES. 
 
 585 
 
 separation ; in the middle third, according to the variety of tlie fractnre, 
 thus : simple, compound, cunmiinuted, and complicated ; in the lower 
 third, according to the part fractured, thus : external and internal 
 condyloid fractures, supra-condyloid fracture, and epiphyseal sejtaration. 
 
 FradnrvK of f/ic Luirrr End of the Hninerun. — Epiphi/sca/ Sepani- 
 tion. — Epiphyseal separation is likely to ha])pen Ijcfore the eighteenth 
 year, and may occur in the form of a detachment of the articular 
 extremity from the diaphysis. The condyles remain attached to the 
 shaft, since they undergo ossification by separate centres, or the condyles 
 witli the articular extremity may become detached from the shaft of the 
 humerus. In some respects e]Mphyscal se|)aration resembles a supra- 
 eondyliiid fracture or a backwanl dislocation of the forearm. In incom- 
 plete epiphyseal separation the forearm is Hexed, and assumes a position 
 midway between supination and pronation, while the normal relations 
 which exist between the condyles and the olecranon are destroyed. The 
 measurement of the forearm reveals shortening between the condyles 
 of the humerus and the styloid processes of tlie radius ami the ulna. In 
 the eomitlete epi])!iyseal separation tlie relations which exist l)etween the 
 condyles and the olecranon are not disturbed, since the separation occurs 
 above the condyles. The differential points between the fi'actures in this 
 region on the one hand, and a backward dislocation of the forearm on 
 the other, are the tendency of the deformity to return in fractures as 
 soon as reduced, and the ditfieulty of maintaining perfect apposition 
 even with suitable splints; also the preternatural mobility, crepitus, 
 shortening of the arm from the acromion to the condyle, and more or 
 less rigidity of the muscles, with ecchymosis over, and swelling in, the 
 elbow-joint. 
 
 A dislocation of both liones of the forearm backward is distinguished 
 from epiphyseal separation by immobility, absence of crepitus, no altera- 
 tion in the length of the shaft of the humerus, the great prominence of 
 the olecranon, which is nearer to the acromion than upon the opposite 
 side, and the greatly altered relations of the olecranon process and the 
 condyles. 
 
 The treatment of epiphyseal separation is the same as that of supra- 
 condyloid fracture, since the two injuries require practically the same 
 kind of surgical dressing. 
 
 Svpni-coiithihiid fr<(rii(iT is usually trans- 
 verse, but it is at the same time oblique from 
 above downward and forward. 
 
 The signs and symptoms are in some 
 respects similar to the l)ackward displace- 
 ment of both bones of tlie forearm (Figs. 97, 
 98, and 99). The diagnostic signs of supra- 
 condyloid fracture 'are the ])rojection of the 
 olecranon, the swelling in front of the elbow- 
 joint, slight flexion of the forearm, prona- 
 tion of the hand, and inability to flex the fore- 
 arm. Marked crepitus is elicited by flexion and extension of the forc- 
 ami. The signs which distinguish this injury from dislocation of both 
 bones of the forearm backward have Iteeu enumerated in connection 
 with ejiiphyseal separation. It sometimes luippens that a vertical frac- 
 
 FiG. 97 
 
 Supra-eondyloid fracture of the 
 hnmenis (Hutchinson). 
 
586 
 
 FRACTURES. 
 
 ture occurs in connection witli tlic sii])rn-con(lyloi(l fVacturc, in which tlie 
 line of" fracture extends downward between the two condyles, forming 
 what is called a " T-sliaped fracture" (Fig. lOOj. This injury results 
 
 Fio. 9S. 
 
 Fio. 99. 
 
 Supra-condyloid fracture of the 
 humerus. 
 
 .Supra-coiKl.i i..,.. 11..' iiuv nf the humerus: 
 union with displacement. 
 
 from direct violence which is applied posteriorly, and is also seen in 
 gunshot fractures. The additional .signs of this complication consist of 
 an increase in the breadth of tlie condyloid extremity of the lower end of 
 the humerus and .severe joint-inflammation attended with great effusion. 
 The treatment of supra-condyloid fracture after comj)lete reduction 
 consists in the application of a well-padded anterior angular splint and a 
 
 Fig 100. 
 
 T-fracture above the condyles and extending into elbow-joint. 
 
 short posterior splint, with the forearm flexed to a right angle upon the 
 arm and the hand placed in the supine position. Some surgeons advise 
 the use of the internal angular splint with the forearm placed midway 
 between jironation and supination and the ])alm of the hand pointing 
 inward and the thumb upward. Passive motion sliould not be em])loyed 
 until tiie end of the fourth week, as the fracture does not extend into the 
 ell)ow-joint, and such movement before consolidation has taken place is 
 likely to disturb the union of the fragments. 
 
 Internal condi/loid fractior occurs as a result of direct violence, and 
 the line of fracture generallv extends downward and outward to the tro- 
 
SPECIAL FRACTURES. 
 
 587 
 
 Fracture of the inter- 
 nal epicondyle of 
 the hiimer\is (epi- 
 trochlea) (Gurlt). 
 
 chlear surface of the Immerus, and passes throuo-h the olecranon and 
 coronoid fossae. Tlie fragment is displaced upward and backward and 
 slightly inward, and it is accompanied by the ulna. 
 
 The signs are — removal of the internal condyle from its normal 
 position, crepitus, moljility, pain and swelling over the internal condyle, 
 increase in tiie breadth of the lower end of the humeriis 
 Fig. 101. (Fig. 101), greater prominence of the ulna posteriorly 
 
 during e.xtension of the forearm, and a corresponding 
 swelling upon the front of the elbow-joint, due to the 
 projection of the lower end of the humerus. 
 
 The treatment of this fracture consists in the apidi- 
 cation of some evaporating lotion over the condyle and 
 the joint with a view to reducing the inflammatory swell- 
 ing. As soon as the inflammation has subsided the frag- 
 ment, consisting of the internal condyle, should be jjlaced 
 in its proper position, and held //( xitu 
 l)y niean-^of a pad. An angular s))lint Fig. 102. 
 
 siionld now be applied, with the fore- 
 arm flexc'l upon the arm to a right 
 angle and placed in the position of 
 supination, or midway between pro- 
 nation and supination, with the 
 thumli upward. In the use of an 
 angular splint tlie surgeon must guard against any 
 undue pressure, which might cause a slougii over 
 any bony prominence or even gangrene of the Angers. 
 Since this fracture involves the elbow-joint, passive 
 motion must be instituted after the second week in 
 order to prevent ankylosis. In ease the fracture is 
 T-sha]ied, cold evaporating lotions should be first ap- 
 plied, and after the subsidence of the inflammation 
 the fragments should be adjusted and the same kind 
 of splint applied. Ankylosis follows, since no passive 
 motion can be made, and the degree of ankylosis de- 
 pends upon the amtnuit of joint-complication. 
 
 External condi/loid fracture is often .seen in chil- 
 dren. While it may be the residt of direct violence, 
 it is more often caused by a fall upon the hand. It 
 usually involves the elbow'-joint, or the fracture ex- 
 tends downward and sejwrates the capitellum from 
 the artictdar surface, and the liead and shaft of the Showing the transmis- 
 
 ,. ] . • i ^1 -i 11 rni sion through the ex- 
 
 racluis are driven up against the ca])itciliim. J he ternai coiidyie of a 
 fragment is displaced ujixvard and backward and [ir/paim'"''"' "P"" 
 slightly outward (Fig. 102). Dr. Oscar H. Allis has 
 called attention to the deformity arising from impi'oper treatment of frac- 
 tures of the lower end of the humerus (Fig. 10.3), and has pointed out the 
 important fact that the outward deflection of the forearm is essential to 
 serve for tiie purpose of the " I'arrving function " (Fig. KM). The reader 
 is referred to Dr. Allis's interesting monograph upon this subject.' 
 
 The signs and symptoms of fracture of the external condyle are — 
 
 ' Ann, Anat. and Stirg. Soc. Brooklyn, 1880, ii., 289. 
 
.588 
 
 FRACTURES. 
 V\G. 103. 
 
 Deformity after fracture at the lower end of the humerus (Allis). 
 
 pain, swelling over the external condyle, the presence of an ill-defined 
 
 tumor, tenderness upon pressure, crepitus by pronation and supination 
 
 of forearm, and sometimes by moving fragment, and 
 
 Fig. 104. finally, inijiairnient in tiie movement of the joint. 
 
 I The treatment of this fracture is similar to that 
 
 employed in fracture of the internal condyle, so tliat 
 
 a separate description is unnecessary. 
 
 Fracture of the shaft of the humerus is frequent- 
 ly observed, and it is produced by direct as well as 
 by indirect violence, and even by muscular action, 
 and, again, bv uterine contraction. It has been 
 produced during the act of parturition. The lower 
 half of the bone is more frequently broken tiian tlie 
 upper half, and the line of fracture is generally 
 oblique from al)ove downward and outward. A 
 transverse fracture is more frequent in the Inuiierus 
 than in the other bones. Fractures involving the 
 shaft include all below the surgical neck to the con- 
 dyles of the bone. 
 
 Tlie displacement in fracture of the siiaft of the 
 humerus largely depends upon its situation in refer- 
 ence to the attaclnnent of tlie deltoid muscle. If aljove 
 the insertion of the deltoid and below the insertion of 
 the pectoralis major, hitissimus dorsi, and teres major, 
 the lower fragment is found to lie external to tlie ujiper 
 fragment and is drawn upward by the deltoid nuis- 
 cle, while the upper fragment is drawn inward by the 
 action of the pectoralis major, latissimus dorsi, and teres 
 major muscles. If the fracture takes place below the 
 insertion of the deltoid muscle, the lower fragment is 
 drawn to the inner side of the upper fragment by 
 the action of the triceps and biceps muscles, and the 
 The outward deflection upper frajrment is abducted by the action of the del- 
 
 of the forearm— the , '.', i^, ,, ,. -i p i i ii 
 
 "carrying function." to id, and at the same time drawn torward by tlie an- 
 
SrECFAL FRACTURES. 
 
 589 
 
 terior fibres of tlie deltoid and the pectoralis major. There is very little 
 displaeement in fractures of the shaft of the humerus in the lower j)art 
 of the bone, since the broad insertion of the brachialis anticus in front 
 is counterbalanced by the insertion of the triceps behind. These two 
 muscles so completely surround the shaft of the humerus that little or no 
 disj)lacement occurs. 
 
 The signs and symptoms of fracture of the shaft of the humerus 
 consist of pain and swelling, with eeehymosis at the seat of frai'ture, 
 crejiitus. false poiut of motion, shortening of the arm, and complete loss 
 of function. 
 
 The treatment of fracture of the shaft of the humerus depends upon 
 the special seat of the fracture. As a general rule, the best dressing, if 
 there is only sligiit displacement, is a bandage of plaster of Paris ajiplied 
 over a layer of absorbent cotton. The bandage must include the ticxetl 
 forearm as well as the arm, and then form 
 a spica over the shoulder. In ease the Fi<s- 106. 
 
 fracture is attended with much shortening, 
 and extension seems necessary, the short 
 internal an<l the long external splint (Fig. 
 105), madi' of leather or gutta-percha or 
 pasteboard, can be fitted and moulded to 
 the opposite arm, and then adjusted to the 
 broken one. Usually the weight of the 
 arm beloAv the fracture, together with the 
 forearm, afford sufficient extension when 
 the hand is swung in a sling. Great care 
 should be exercised lest the internal splint 
 cause compression of the axillary vessels. 
 
 Fig. 105. 
 
 I'liysirk'.s i.lljiJK->|ili!]l, 
 
 Clark's extonsinn in fracture of the neck 
 of the hunieru.s. 
 
 In s])ecial cases, requiring greater extension to overcome the deformity 
 and to maintain the ap]i(isiti(jn, the surgeon can employ an extension 
 apparatus by means of adhesive jilaster applied from the upper end of 
 the lower fragment to the elbow-joint, and from the cross-piece below 
 the joint attach a bag of sand, as suggested by Clark (Fig. 106). The 
 patient can be up and walk about during the repair of the fracture, or, 
 if for any reason he is obliged to remain in bed, a weiglit and ]iullev can 
 be used as in fracture of the tibia. 
 rately adjusted to the existing 
 
 The weight, however. 
 
 ]1Ul 
 
 must be aeeii- 
 
 conditious, since too great weight might 
 
590 
 
 FRACTURES. 
 
 Fig. 107 
 
 soj)arate the fragments ami cause non-union of the fractui-e, a not uncom- 
 mon complication in fractures of the humerus. Where the ui)])er fnig- 
 ment .shows a tendency to hecome al)ducte(l with a slight foi'wanl incli- 
 nation, a splint in tiie form (if a triangle has been suggested, l)Ut its 
 emj)loyment is attendeil witii much ditliculty. 
 
 In fractures of the shaft there is danger of non-unittn, and also some 
 danger of gangrene of the fingers from too tight bandaging or from too 
 great axillary compi-ession if s})lints or pads are employed. If the radial 
 artery cannot be felt at the wrist, no bandage or splint should be employed, 
 since its application migiit be considered as the cause of gangrene. 
 There is also an additional danger of subsccjueiit paralysis of the mu.s- 
 
 cles presiding over supination of the 
 forearm and extension of the hand and 
 fingers, causing pronation of the hand 
 and wrist-drop. This may occur as a 
 result of injury to the nmsculo-spiral 
 nerve (Fig. 107), or in conse(juence of 
 an exuberant callus which enslieaths 
 and compresses the nerve (Fig. 108). 
 In the latter case the nerve can be 
 tunnelled out after the fracture is re- 
 paired (Fig. 109), or in some cases the 
 two ends of the divided nerve may 
 be found and sutured. In fractures 
 of the humerus Stromeyer's cushion (Fig. 110) is often of great service 
 if for any reason the fracture cannot be placed permanently in a retentive 
 apparatus. 
 
 Fractures of flir Tapper End of the Hiimcrvs. — Epiphyseal se]iaration is 
 usually the result of direct violence, as a fiill or blow upon the shoulder. 
 This injury is not observeil after tiie twentieth year of life. 
 
 The signs and symptoms are a jirominence below tiie coracoid pro- 
 
 TT ,no Fig. 109. 
 
 Fig. 108. 
 
 Paralysis of hand (wrist-clrnp) after fracture 
 of liumerus. 
 
 Permanent flexure from 
 paralysis after fracture 
 of tlie humerus. 
 
 -->' 
 
 Apparatus for wrist-drop after fracture of the 
 humerus. 
 
 cess, due to the upper end of the hiwcr fragment, whicli ]iroiects in front 
 of the shoulder-joint ; slight crcjiitus, which is obtained l)y mtatiim 
 of the shaft of the humerus (Fig. Ill) ; the alteration in the axis of the 
 shaft, which above is drawn inward by the action of the anterior jiectoral 
 muscles, and is directed downward and slightly backward and outward 
 (Fig. 112) ; the head of the bone is felt in the glenoid cavity, but does 
 not move with the shaft during rotation ; ecchymosis, tenderness, and 
 pain are well marked. 
 
 The treatment consists in making extension upon the shaft of the 
 bone until the projection in front of the joint disappears. At the .same 
 
SPECIAL FRACTURES. 
 
 591 
 
 time the tliumb of the surgeon shoukl push hack tlie u]ipcr edge of the 
 lower fragment into its proper place. The elbow-joint should 1)0 carried 
 inward to the side of the tiiorax. Compresses and pads should be placed 
 
 Fig. no. 
 
 Stromeyer's axillary cuf>liinn. 
 
 over the front of the joint, and they should be held in place by a felt 
 shoulder-cap or a leather caj), applied wet and accurately moulded to the 
 sound shoulder. Care should be exercised lest any undue pressure 
 
 Fig. 111. 
 
 Separation of the upper epiphysis of the humerus : displacement forward of the lower fragment. 
 
 upon the front of the joint result in a slough. Some slight deformity 
 may exist after repair of this injury, but the movements of tlie shoulder- 
 joint are not much interfered with, since the separation is outside of the 
 capsule. 
 
592 
 
 FIIACTUBES. 
 
 Fracture of the tuberoftitj/ of the shaft occurs as a result of direct vio- 
 lence. The iintero-posterior diameter of tiie joint is increased, and there 
 is a sulcus found between the front of the joint and the fragment, which 
 
 Fi(^ 112. 
 
 /\ 
 
 Separation of the upper epiphysis of the humerus (R. W. Smith). 
 
 is drawn upward and abducted by the external rotators, giviuw tiic 
 slioulder a peculiar contour, described by some authors as trumpet- 
 shaped, on account of the double tumor, one under the acromion, and 
 the other under the coracoid process. There is a well-marked depres- 
 sion just beneath the acromion process, and crepitus is easily obtained 
 by rotation of the shaft with the fingers holding the sejiarated tube- 
 rosity. The rotation of the humerus siiows no impairnuiit in the move- 
 ment of the head of the bone in the glenoid cavity. 
 
 The treatment of fracture of the tuberosity consists in making the 
 .shaft of the bone adajjt itself to tlie detached tuberosity. This is best 
 aeconi])lished by a pad in the axilla, whicii throws the ujtper end of the 
 bone outward. The elbow sluaild be l)rought to the side of the chest- 
 wall and the forearm suspended in a .«ling. A pad should lie placed 
 behind and above the tubercle after it is reduced, so as to prevent it 
 from slipping upward and backward by the action of the rotators 
 attached to the fi'agmcnt. 
 
 Fracture of the .surgical ucck is situated outside of the capsule of the 
 joint, and corresponds to the extra-capsular fracture of tlie cervix fenio- 
 ris. The line of fracture is l)elow the tul)erosities, but above the inser- 
 tion (Fig. 113) of the pcctoralis major, latissimus dorsi, teres major, and 
 deltoid muscles. 
 
SPECLiL FRACTURES. 
 
 593 
 
 Fig. 113. 
 
 P'rat'ture of the surgical neck of 
 the humerus. 
 
 The displacement consists of an external rotation and abduction of 
 the upper fragment, caused by tlie action of the muscles inserted into 
 the greater tuberosity— viz. tlie supra-spinatus, the infra-spinatus, and the 
 teres minor muscles — while tlie shaft of the 
 bone is drawn upward into the a.xilla by tlie 
 action of two of the three muscles which 
 take tiieir origin from the coracoid process 
 — viz. the bice])s and the coraco-bracliialis 
 muscles — and inward by the action (if tlie 
 peetoraiis luajor and the teres nuij(ir muscles. 
 
 Tlie signs and symptoms are — absence 
 of rotation of the head of the bone with the 
 shaft, while at the same time the head of the 
 bone remains in the glenoid cavity ; shorten- 
 ing of the arm to the extent of al)out one 
 incli ; crepitus, unless the fracture is im- 
 pacted ; swelling, pain, and ecchymosis ; al- 
 teration in the a.xis of tiie bone, wliicii is di- 
 rected downward and outward ; and a pecu- 
 liar flattening of the shoulder just Ijclow the 
 acromion. This flattening is not so marked 
 as ill dislocation, but more so than in fracture 
 of the anatomical neck. 
 
 The treatment consists in the application 
 of a plaster-of- Paris bandage, which includes 
 coaptation splints to the broken arm and a spica over the shoulder, 
 with the forearm flexed to a right angle, and the eiiiploynient of tlie 
 axillary pad. In case the fracture is attended with mucli deformity, a 
 splint in tlie form of a triangle lias been employed with great success, 
 since the apparatus makes the shaft adjust itself to the upper fragment. 
 If it is unnecessary to employ the triangle, the elbow should be carried 
 well forward and brought close to the side of the body ; which position 
 has a tendency to overctime the inward displacement of the shaft. 
 
 Fracture of the anaioutiatl ncch is produced tiy direct violence, as in 
 a gunshot wound or by a fall upon the shoulder. The fracture is within 
 the capsule of the joint, and corresponds to the intra-capsular fracture 
 of the cervix femoris. The fragment receives no lilood-supply,and is 
 prone to undergo necrosis and to establish sujijiuration in the joint. 
 Union may result if iiii]iaction is present, and for this reason any 
 attempt roughly to niaiiipulate the fracture with a view to a diagnosis 
 may be attended with serious results. 
 
 The displacement is very slight, if any, owing to the peculiar 
 anatomical conditions. 
 
 The signs and symptoms consist of a prominence of the acromion 
 and flattening of tiie shoulder, both of wjiich, liowever, exist only to a 
 moderate degree; shortening of the arm to the extent of about half an 
 inch, with pain, swelling, and crepitus, unless the fracture is impacted ; 
 and absence of ecchymosis, since the fracture is within the <-a])sule. 
 
 The treatment consists in the ajiplication of evaporating lotions for 
 a few days to control the inflammation in tiie joint, and afterward in 
 the adjustment of a felt or plaster-of-Paris shoulder-cap and a ])ad in the 
 
 Vol. I.— 3S 
 
594 
 
 FRACTURES. 
 
 axillii. Groat care (should be exercised lest tlie snrireon break up tbe 
 iinj)a(ti(iii ami thus prevent union ol' the t'ra<;iiients. 
 
 FiiACTUREs OF TiiK FOKKAKM may bc divided into fracture of the 
 coronoid or olecranon process of the ulna, of tiie shaft of the ulna, of 
 the styloid process of the ulna, of tlie liead and neck of the radius, of 
 the shaft of the radius, of the lower end of the ra<lius (Colles), and of 
 both radius and ulna. 
 
 Fnicfnrca of the nidius and ulna usually occur as the result of direct, 
 but they may be caused by indirect, violence. The seat of the fracture 
 is usually about the centre of the shaft of each bone (Fig. 114). If by 
 direct violence, the fracture may occur at any place, but generally at 
 
 Fracture in the middle tliird. 
 
 the lower end, since this part is more exposed to injury, and is less pro- 
 tected bv a cushion t)f muscles. 
 
 The displacement varies according to the situation and line of frac- 
 ture. The bones may be so displaced as to form an angle either in front 
 or behind, or even laterally. In sfime cases the fragments overlap, so as 
 to cause great shortening of the forearm. 
 
 The signs and symptoms of fractures of the radius and ulna are 
 those which are ordinarily found in any fracture, such as crepitus, loss 
 of function of limb, great jiain and tendernes.s, unusual mobility, ecchy- 
 mosis, and swelling. 
 
 The treatment consists in reducing the fracture by the surgeon 
 making extension with the patient's fingers flexed and grasping the entire 
 hand, while counter-extension is made by an assistant, who seizes the 
 elbow-joint while the forearm is flexed. If the fracture is below the 
 insertion of the pronator radii teres, two lateral splints should bc applied, 
 and the forearm placed midway between pronation and supination. The 
 
 Fig. 11.5. 
 
 Fusion of bones after fracture of radius, destroying pronation and supination. 
 
 splints should be wider than the forearm, so that the bandage or strips of 
 adhesive plaster will not press the bones together and cause fusion of the 
 bones, which ^\•oldd destroy the function of pronation and supination 
 (Fig. 115). If there is any tendency of the lower fragments to drop, the 
 
SPECIAL FRACTURES. 
 
 595 
 
 lateral splints should extend below, so as to support and include the 
 hand. If the fraoture is above the insertion of the pronator radii teres, 
 the forearm should be strongly supinated and a posterior angular sjilint 
 applied (Fig. IK!). 
 
 An exeellent metliod of treating this fracture, if the individual will 
 submit, is for the patient to lie in bed, and then to extend the arm and 
 
 Fig. 116. 
 
 IJr. Scott's splint for fracture of the forearm. 
 
 forearm upon a long flat, firm cushion. This position brings the fragments 
 into accurate ajiposition. In treating any fracture of the forearm in the 
 flexed position with sitlints great care must be exercised lest the splints 
 should cause undue pressure and produce gangi-ene of the fingers. The 
 pressure of the .splints and the flexed j)osition of the forearm necessarily 
 retard the free flow of blood through the vessels, and for this reason the 
 possibility of gangrene must be always borne in mind. 
 
 Fmdurr of fhc lower end of (lie rdcliii.'^ is known as Colles's fracture, 
 after the renowned Irish surgeon who first described the nature of this 
 injury. The seat of the fracture is about one inch above the articulation, 
 at the junction of the compact with the cancellated bony tissue. This 
 fracture has also been called the "silver-fork fracture," because the 
 characteristic deformity reseml)les the slia]ie of an ordinary silver fi>rk. 
 Tiie dorsal proniiuence is due to the riding ujiward and l)ackward of the 
 lower fragment witli tlie carpus, while tjie palmar deformitv is produced 
 by a projection forward of tiie lower end of the upper fragment, which is 
 pronated by the action of the pronator quadratus and pronator radii teres 
 muscles. The internal lateral ligament is generally torn out of its inser- 
 tion into the styloid process, and Moore has demonstrated tliat the process 
 becomes entangled in theanuidar ligament. Tlic lower end of the up]>er 
 fragment is generally driven into the upper end of the lower fragment 
 by the continuance of the same force that originally caused the fracture. 
 This impaction of the upper fragment, consisting of compact bony tissue, 
 into the lower fragment, formed of cancellated tissue, explains the frequent 
 absence of crepitus in the fracture (Fig. 1 17). 
 
 The signs and symptoms of fracture of the lower end of the radius 
 are — inability to sup])ort the firearm, the position of the hand midway 
 
596 
 
 FR A ('TUBES. 
 
 between pronation and su|iiiiatii)ii, the flcxidii of (lie fingers, the silver- 
 fork deformity, tlic great |)r(»iiiiiK'nce of the styloid process of tiie uhui, 
 
 Fig. 117 
 
 CoUes's fracture: union with persistence of displacement (Smith). 
 
 the loss of snpination and pronation, severe pain, and often swelling due 
 to eifusion into the sheaths of the tendon. 
 
 The treatment of this fracture consists in overcoming at once the 
 deformity hy prom])tly reducing the fracture and tiien retaining the 
 fragments immovably fixed in tlieir proper j)ositiou. The reduction is 
 made by the surgeon grasping the hand of the patient as if to shake 
 hands with him, and tlien making forcible continut)us and gradual 
 extension, so as to disengage the impaction and bring the lower frag- 
 ment into apposition with the upper. The surgeon should place the 
 thumb of the left hand against tlic styloid process of the ulna and push 
 it around, so as to bring it into its normal ])osition. In some cases it 
 may be necessary to administer an ana'.sthetic in order to reduce sati.s- 
 factorily the deformity. The fixation of the adjusted fragments can be 
 maintained by several dift'erent forms of splints. 
 
 The best dressing is by two lateral splints, which should be well 
 padded and broad, and extend from the extreme u]iper end of the fore- 
 arm to exactly the lower margin of the lower fragment, and leave the 
 wrist-joint free. The forearm should then Ix- placed in a sling, so that 
 the hand falls downward and is adducted by its own \veight, in M'hicli 
 
 Fin lis. 
 
 Gordon's splint for fracture of the lower end of the radius : B, the palmar splint ; C, the dorsal 
 splint ; A, the two splints applied to the forearm. 
 
 position the torn ligament from the styloid fossa is relaxed and the frag- 
 ment of the radius is brought into accurate apposition. This freedom 
 
SPECIAL FRACTURES. 
 
 597 
 
 of motion of the wrist -joint docs not interfere with the complete fixation 
 of the fragments, and prevents ankylosis of the joint, as well as any snb- 
 seqnent rigitlity of the fingers. 
 
 Gordon's apparatns consists of two pieces, a palmar splint (Fig. 118) 
 constructed so as to overcome the forward displacement of the fragment 
 bv the addition of a conical piece, whicii produces jiressure upon the 
 lower end of the ujiper fragment, and thus has a tendency to elevate 
 it, while the hand itself raises the lower fragment. The other splint is 
 applied to the dorsal surface of the ftirearm, and by its thick padding 
 over the wrist has a tendency to overcome the deformity. 
 
 Carr's apjiaratus (Fig. 119) consists of a palmar splint padded so as 
 to obliterate the depression over the radius. To the extremity of this 
 
 Fm. 119. 
 
 Carr's spliut for a loft CuUes fracture. 
 
 palmar splint is attached an oblique vertical piece, and on this round bar 
 the fingers are flexed. This palmar spliut is supplemented by a second 
 or dorsal splint. 
 
 Bond's apparatus (Fig. 120) consists of a splint made of a piece of 
 wood, to the lower extremity of which is fixed a curved block which 
 
 Fig. 120. 
 
 Bond's splint. 
 
 should fit the hollow of the palm in order to give support to tiie hand 
 and fingers. The splint should be well jiadded, so as to fill up the con- 
 vexity of the radius on its palmar side. In conjunction with the palmar 
 splint a dor.sal splint is used, with a compress so adjusted as to etl'ect the 
 reduction of the lower fragment. 
 
 A fracture consisting of a chipping off of the posterior liji of the 
 articulating surface of the radius has IjCen described by Barton, after 
 whom the fracture is named. The fracture clinically requires the same 
 treatment as that indicated for Colles's fracture. 
 
 Fracture of flic xhaft of the radinH occurs by direct violence, as a 
 blow upon the forearm, or by indirect violence, as a fall u])on the hand. 
 As a rule, however, a fracture of the radius caused by a fall upon the 
 
rm 
 
 FRACTURES. 
 
 Fracture of the radius 
 
 liaiid is situated in tlic lower end, Imt occasionally this injury causes 
 a tVaetiire of the shaft of the hone. 
 
 The displacement in fractures of tiie shaft depends u]ion the situation 
 of the fracture, since the deforniity varies accordinti; to wlicther the frac- 
 ture is above or below the insertion of the pronator radii teres muscle. 
 If the fracture is above the insertion of this muscle and below that of 
 the biceps, the upper fragment is strong'ly supinated and flexed, while 
 the lower frafi-ment is ]ironated Ity the pronator radii teres and the pro- 
 nator (juadratns. Tliis displacement is not very ap])arent, on account of 
 tile anatomical conditions; but if union takes place without correcting 
 the deformity, fusion of the bones occurs and the movements of prona- 
 tion and supination are lost ; and this movement can only partially be 
 accomplished by the shoulder. If the fracture is situated below the 
 
 insertion of the pronator radii 
 F'f-- 121. teres, this muscle oj)poses the 
 
 action of the biceps ;ind the 
 supinator brevis, so that the 
 forearm remains in a position 
 midway between pronation and 
 supination (Fig. 121). The 
 supinator longus below o])poses 
 the feeble action of the ])rona- 
 tiir ((uadratus. Tlie disjdacc- 
 ment consists of slight flexion 
 of the upper fragment by the 
 biceps and pronation by the 
 pronator radii teres, and a drawing inward of the lower fragment by the 
 pronator (piadratus, assisted l)y the supinator longus, which by traction 
 of the lower end of the lower fragment tilts the upper end of the lower 
 fragment toward the ulna. 
 
 The signs and symptoms of fracture of the shaft of the radius are 
 those usually found in any fracture, such as pain; talse point of motion; 
 and crepitus, which in this special fracture is elicited by rotating the 
 hand while the surgeon places his thumb on the head of the radius, 
 or by indentation of the two broken ends at the seat of fractiu'c. 
 
 The treatment varies according to the seat of the fracture. From a 
 careful study of the dis])lacement when the fracture is above the inser- 
 tion of the pronator radii teres, it is evident that the forearm must be 
 strongly supinated in order to bring the fragments into accurate apposi- 
 tion. For this purpose it is necessary strongly to supinatc the forearm. 
 Tills can be done by placing tiie jwticnt in bed and stretching his arm 
 out at a right angle from the trunk, and allowing the supinated arm to 
 rest upon a hard cushion ; or, if the patient is unwilling to be confined 
 to the bed, the forearm can be flexed to a right angle with the arm, and 
 a splint applied to the arm and forearm (Fig. 122), so that the palm is 
 directed upward. If the fracture is below the insertion of the pronator 
 radii teres, tlie application of two lateral splints can be made, with the 
 forearm midway between pronation and supination. Some surgeons 
 recommend that the sjilint extend only to the wrist-joint, but if there is 
 much mobility it may be well to have the splint extend below and sup- 
 port the hand, since there is no tendency for the wrist-joint to become 
 
SPECIAL FRACTURES. 
 
 599 
 
 ankylosed. A small strip or pad down the centre of the splint has been 
 suggested, so as to separate the radius and ulna to prevent au}- union 
 
 Fig. 122. 
 
 Dr. Scott's spliut for fracture of the forcani 
 
 Fig. 123. 
 
 of the two bones, which would imjiair the movements of 2>ronation and 
 supination. 
 
 Fntcfurc of the hnifl (uifJ neck of the nifliiix I'arely occurs, except 
 in connection with a dislocation backward of both bones of the forearm 
 or witli a fractiu'c of the coronoid process of the 
 ulna. The fracture may be, however, occasionally 
 observed as the result of a gunshot injury, or it may 
 be jirescnt in the form of a compound fracture, in 
 M-hich ca.se the head and neck are usually sijlintercd 
 in the long axis of the bone (Fig. 123). It is some- 
 times found to be comminuted. 
 
 The signs and symptoms are inability to pro- 
 nate or supinate the forearm ; crcj)itus at the .seat 
 of fracture, elicited by seizing the patient's hand 
 and proiiating the forearm while the thiiml) of 
 the surgeon's otlier hand is placed over the orbic- 
 ular ligament; the presence of an unnatural bony 
 prominence at the in.sertion of the biceps, due 
 to the Hexion and supination of the fragment by 
 the action of this muscle ; the presence of ecchy- 
 mosis and localized pain ; and the jieculiar position Fracture of neck of rajius. 
 of the forearm, wliich is pronated. 
 
 The treatment consists in placing the forearm in a position of 
 extreme flexion, which relaxes the biceps, which tilts forward the frag- 
 ment. A compress should be applied to the fragment in order to 
 keep it in position, and the limb bandaged to an angular s])lint. Care 
 must be taken not to produce any compression upon the brachial 
 artery while the forearm is extremely flexed, lest the circulation be 
 disturbed and gangrene ensue. Passive motion must not be practised 
 until the fragment is well united, lest the biceps, contracting during 
 forced extension, might separate the fragment. If there is great tend- 
 
600 FRACTURES. 
 
 ency for the fragment to become flexed and supinated by a rigid con- 
 traction of the biceps, tenotomy will iniincdiately overcome the deform- 
 ity, and the parts will be at once adjusted. 
 
 FracUiir of tli<' sti/loid jtronns of the iiliKt occurs as a result of direct 
 violence. The fragment is distinelly felt just beneath the skin. 
 
 The signs and symptoms are too a])parent to require any special 
 description. The broken fragment should be manipulated until it is 
 brought into its proper position, and then maintained there by the use 
 of a compress which is held firmly in n'tiu by strips of rublx'r jilaster. 
 It is advisable to keep tiie wrist- and elbow-joints at rest for a short 
 time until the fragment tmites, as any movement of these joints has 
 a tendency to displace the broken part. 
 
 Fracture of the shaft of the ulna occurs as a result of a fall, or in 
 boxing, in warding f)ff blows aimed at the face, and its seat is usually 
 just below the midille of the bone, since at this point the bone is not so 
 thick and is less protected by a cushion of muscles. 
 
 The displacement is caused by the action of two muscles — viz. the 
 brachialis anticus, wliich has a tendency to flex the upjier fragment, 
 and the pronator quadratus, which has a tendency to abduct it and 
 thus draw it toward the radius. 
 
 The signs and symptoms are localized pain, tenderness, and ecchy- 
 mosis, the presence of a tumor, the existence of crepitus and great mobil- 
 ity. The finger, if passed along the sliaft of the Ixme, will usually detect 
 the fracture, as the bone is quite superficial in the lower half of the 
 shaft. 
 
 The treatment consists in the application of two broad lateral 
 .splints from the ell)ow- to the wrist-joint. Before adjusting the splints 
 the broken ulna should 1)(> forced away from the radius, so as to jtrevent 
 any fusion of the bones of the forearm, which would impair pronation and 
 supination. The forearm should be flexed at a right angle in order to 
 relax the brachialis anticus, which has a tendency to tilt forward the 
 upper fragment, and also be placed midway between pronation and 
 supination. The forearm sliould be carried in a sling, and the lateral 
 splints should be broad enough to prevent any pressure upon the broken 
 bone, which pressure would have a tendency to cause fusion of the two 
 bones of the forearm. 
 
 Fracture of the coronoid and olecranon processes of the ulna occurs as 
 a result of a fall upon the back of the elbow during semi-flexion of the 
 forearm, or by muscular action. Fracture of either process is seldom 
 seen in a person under fifteen years of age. 
 
 Fracture of the coronoid process usually occurs as a comjilication in 
 backward dislocation of both bones of the forearm, whicli acciilcnt is 
 usually the result of a fall upon the palm with the elbow-joint partially 
 flexed. The fracture has been observed as a result of muscular action 
 in attempts to lift the weight of the body with the hand or in grasping 
 by the hands an object in the act of falling from a height. 
 
 The sig-ns and symptoms are backward dislocation of botli bones 
 of the forearm, the presence of crepitus, the existence of a bony prom- 
 inence in the transverse fold of the elbow-joint, and a tendency to return 
 of the deformity after reduction. 
 
 The treatment consists in placing the forearm in an extremely 
 
SPECIAL FRACTURES. 601 
 
 flexed position to relax the brachiali.s antieus muscle, and applying an 
 angular splint with an aligle adapted to the position. II' the fragment 
 persists in becoming displaced, it can be wired to the shaft. In such au 
 operation the close proximity of the brachial artery must not be over- 
 looked. Unless the fragment is sutured, the union is likely to be liga- 
 mentous, and passive motion should bo instituted after three weeks iu 
 order to preserve the mobility of the joint. 
 
 Fracture of the olecranon jyrocess of the ulna occurs during adult life 
 iind seldom before the fifteenth year. The fracture is the result of 
 direct violence, either from a blow upon the process or by a fall upon the 
 part when the elbow-joint is flexed to a riglit angle. This fracture also 
 occurs by muscular action, as in sudden I'ontraction of tlie triceps dur- 
 ing extension of the forearm. The mechanism of fracture by this cause 
 is tliat of a lever across the condyles t)f the humerus. 
 
 The signs and symptoms are — well-marked depression at the back 
 of the elliow-joint, produced by the action of the triceps in drawing 
 upward tiie fragment ; the presence of crepitus, elicited by flexing and 
 extending the forearm ; abnormal mobility of the fragment; tiie exist- 
 ence of synovitis of the elbow-joint ; the stationary appearance of the 
 fragments ; and the separation of the shaft of the ulna from it during 
 extension. 
 
 The treatment consists in placing a compress over the fragment 
 after it has been reduced, and applying a strip of adhesive plaster to 
 keep the fragment innnovaljly fixed to the shaft of tlie ulna. A straight 
 splint which is M-ell padded should now be adjusted to the arm and 
 forearm upon their anterior surface, with the limb in an extended 
 position. If the fragment cannot be kept iu place, sutui"iug it to the 
 shaft is indicated. This operation must be done with every aseptic pre- 
 caution, since the wound conununicates with the joint. If the fracture 
 is compound, suturing is indicated, and at the same time free drainage 
 of the joint for a few days must be employed. If for special reasons 
 suturing is not advisable and a stiff joint is likely to ensue, the fore- 
 arm should be placed midway between flexion and extension, since this 
 position renders the upper extremity more serviceable than the straight 
 position, whicli gives the patient practically a useless arm. 
 
 Fracture of the carpal bones is rare, and occurs, as a rule, 
 from direct violence. Owing to the strong ligaments which hold the 
 carpal bones together, there is little displacement. Fractures of these 
 bones are often overlooked on account of the extensive damage of tlie 
 soft parts and the consequent swelling of the wrist-joint. There is 
 very little dis])lacement, owing to the anatomical arrangement of the 
 wrist articulation. 
 
 Tlie sig-ns and symptoms are crepitus, swelling, pain, and loss of 
 function of the joint. 
 
 The treatment consists in placing the hand upon a long palmar 
 splint, at the smne time ajiplying over the injured part warm fomenta- 
 tions or cold evaporating lotions until the acute inflammation has sul)- 
 sided. In severe contusion of tlic soft parts without wound the warm 
 applications are best suited, wliile iu severe inflammatory reaction unac- 
 companied by external wound the cold lotion is indicated. Absolute 
 rest, a moderate amount of compression, and an immovable splint to give 
 
602 FRACTURES. 
 
 support to the liantl, \vi"ist, and ibroarm are required. \\'hen tlie signs 
 of acute inflaiiiniation have di.sapj)eared, a splint shouhl he a])iilied, and 
 passive motion bcnuu after a fortniglit in order to preserve the motion 
 of the joint. If the fraeture is ('ompound, the loose fragment must bo 
 removed, the joint thoroughly irrigated, and a drainage-tube passed 
 through from the dorsal to the j)almar surface, and antise})tic dressing.s 
 applied together with a splint. 
 
 Firictures of the iiwtacarjMtl honefs are common, and are usually the 
 result of direct violence. On account of tiie exposed jxisition of the 
 first metacarpal bone, it is found to l)e tiie one most fre(piently fractured, 
 and after it, next in point of frequency, the second, \vhilc the third is 
 less frequently broken than the others. The ujjper fragment is usually 
 disjilaced downward toward the ])alm of the hand, owing to the action 
 of the interosseous muscle and the natural shape of the shaft of the 
 bone. 
 
 The signs and symptoms consist of crepitus, pain, swelling, inter- 
 ruption of the continuity of the shaft of the bone, prominence in the 
 palm of the hand due to the presence of the distal end of the proximal 
 fragment, the dropjiing of tlie knuckle, and the depression on the dorsum 
 due to tlie falling down of the two fragments. 
 
 Tlie treatment consists in jilacing tiie hand upon a long palmar 
 splint extending from the elbow to a point biyond the tingers, with a 
 pad over the seat of fracture on the palmar surface of the hand, or by 
 flexing tlie hand over a ball, so as to push up the displaced fragments by 
 mechanical action and by extension of the fragments, and at the same 
 time ap])lying the long splint. 
 
 Too much importance cannot be attached to the conservative treat- 
 ment of compound fractures of these bones. The parts are so vascular, 
 and the retluction of the fragments so easy, that it seldom becomes 
 necessary to perform amputation if proper antiseptic precautions are 
 emploved. The fragments should be wired if greatly displaced, or 
 some of the connninuted pieces should be removed and the periosteum 
 left, or even transplantation of the bones can be accomplished when 
 the necessary conditions are present. In Figure 124 is shown the 
 result obtained in a case of a compound, conmiinuted, and complicated 
 fracture of the second metacarpal bone and the two phalanges of the 
 thumb. As the two phalanges of the thumb were spontaneously ampu- 
 tated l)y machinery at the time of the acci<lent, the metacarjial bone 
 of the thumb, whicli was not injured, was transplanted and attached to 
 the proximal end of the first |)lialanx of the index finger, which was also 
 uninjured. The metacarpal bone belonging to that finger was conmii- 
 nuted, and its pieces forced out of the hand, so that its place was now 
 occupied by the first metacarpal bone of the thumb. The result of the 
 operation was most gratifying, since the patient had a most useful hand, 
 which was sujierior to any artificial one. The ojieration was performed 
 in my hospital service by Dr. Ran, the house-surgeon. 
 
 Avulsion of the phalanges requires consideration. This accident 
 occurs where the finger is held in a door of a stage or car, or where the 
 finger is caught upon some object while the patient is running. The 
 entire jilialanx is torn away from its nearest articulation, and with it the 
 tendon of the muscle which is inserted into it. Avulsion of the thumb. 
 
DISLOCATIONS. 
 
 603 
 
 with tlie tendon of tlie flexor lonsus pollicis, has oocnrivd in violent 
 attempts to reduce a ilisloeation of the thumb, a beautiful example of 
 
 Fk;. 1-24. 
 
 Amputation f>f first and second phalanges of the thuml), and excision of the metacarpal bone of 
 index linger; transplantation (jf metacarpal bone of the thumb to the index linger. 
 
 which, as well as of similar results from other causes, is seen in the 
 accompanying plate (Fig. 12">). 
 
 The treatment of simple fractures of the phalanx consists in restor- 
 ing the fragments to their proper place and holding them in sift} by 
 means of a gntta-jtercha, jxisteboard, metal, or leather splint, accurately 
 moulded to the corresponding finger of the opposite hand, and then 
 aj)plied to the injured and extended phalanx. In addition to a s])lint 
 directly applied to the fractured part, a long splint should extend from 
 the palm of the hand to the tip of the linger, so as to keep the frag- 
 ments inmiovaljly <piict during the repair of the fracture. If the frac- 
 ture is compound and comminuted, the surgeon should endeavor to save 
 as much as possil)le, and remove only j)ieces which are detached from 
 the periosteum, since the reparative process is so great that a fracture in 
 this i)art would repair where elsewhere the bone might undergo necrosis. 
 
 Fracture of the phalanges occurs as a result of direct violence, and 
 on account of the exposed position of the hand is frequently observed. 
 The important fact must always be borne in mind that while an artificial 
 limb can be substituted fi)r the arm or forearm, the leg or thigh, no 
 prosthetic apparatus has been devised to take tlie ])lace of tiic finger. 
 For this reason it is imperative for the surgeon to apply the principles of 
 extreme conservatism in the management of fractures of the phalanges, 
 and in carrying out this principle too much importance cannot be jilacecl 
 on the great vascularity of the parts and their tendency to heal even after 
 the most extensive iniurv. 
 
 Dislocations. 
 
 A dislocation is a solution in the contiguity of bones, and is in con- 
 trast to a fracture, which is a solution in the continuity of a bone. A 
 diastasis is where the bones are separated from each other, as when 
 the pubic bones separate at the symphysis pubis. The term " disloca- 
 
604 
 
 FRACTURES. 
 Fig. 125. 
 
 Specimens showing avulsion of tlie distal phalanges in attempts to reduce a dislocation of the 
 thumb, the result of an accident. 
 
DISLOCATIOXS. 
 
 605 
 
 tion" is derived from the Latin preposition r/w, meaning a separation, 
 and the noun locus, denoting a phiee. 
 
 Disloeations are less frequent than fractures in ahout tlie proportion 
 of 1 to 8. A simple dislocation is one in which the joint is displaced 
 without concomitant injury to vessels, nerves, or bones. A compound 
 dislocation occurs when the displacement is of such a character as to 
 open the joint and expose it to the external air. A dislocation is com- 
 plicafed when the dis])lacement is associated with a laceration of the 
 vessels or nerves or a fracture coexists. A compldc dislocation is one in 
 wiiich the joint-surfaces are entirely se]iaratcd. An iiirtniiplrtc disloca- 
 tion is one in which the joint-surfaces are only partially separated. From 
 a study of Gurlt's, Kronlein's, and Prahl's tables it is demonstrated that 
 dislocations of the upper extremity form nearly three-fourths of all dis- 
 locations, that the shoulder is the most fre(piently dislocated joint in the 
 body, and the ell)ow next, while in the remaining one-fourth dislocations 
 of the fingers ami the hip are in tile majority. In regard to sex, it is 
 also proven that dislocations are three times more frequent in males, 
 with the exception of the jaw, where the proportion is more than 
 
 Fig, 126. 
 
 Fig. 127. 
 
 Congenital dislocation of hip. 
 
 reversed. As regards age, it is demonstrated that between the ages 
 of fifty and sixty dislocations are most frequent, and that dislocations 
 
606 
 
 DISLOCATIONS. 
 
 Fia. 128. 
 
 are less fro(|tient (luring tlio years wlicii fractures are most common, 
 especially during infancy and youth. 
 
 There are three distinct varieties of dislocations — tiie congenital, the 
 jjdfliolof/iral, and the traumatic. 
 
 A cdiii/ciiitfi/ dislocation is one in wliich tlic joiiil-surfaces do not fit, 
 owing to arrest of dcveloptncnt in tiic fcetus or to some nialfurinatiun 
 of the parts, as in tiie different varieties of club-foot, torticollis, or 
 s])inal curvature. This variety occurs in 87 per cent, of the cases in 
 females, and affects generally the hip-joint (Fig. 126). It may also 
 occur as a result of abnormal uterine contraction, or of fiills upon the 
 abdomen during jiregnancy, or of some violence during obst(>trical 
 manipulation in a case of ditiicult labor. Congenital dislocation may 
 also result from disturbance of the nervous centres, as in spastic 
 contractions of the muscles, in infantile paralysis, and in pseudo-hyper- 
 trophy. A congenital dislocation is not always recognized at the time 
 of l)irth, and often not until the child makes attempts to walk. The 
 hi]), shoulder, knee, ankle, patella, tarsus, and phalanges are among the 
 joints and bones that are most frequently the seat t)f this special variety 
 of dislocation. 
 
 The pathological dislocation, as its name implies, is one produced as 
 the result of (lisease. This variety is seen during the progress of 
 morbus coxarius, and also in chronic disease of the knee-, ankle-, and 
 other joints. The joint disease produces absorption of the head of the 
 
 bone with destruction of the capsule, 
 and the entire cavity and the head of 
 tile bone become more or less oblit- 
 erated (Fig. 128). Another variety 
 niav occur as a result of reflex muscu- 
 lar contraction from disease of the spi- 
 nal cord, and in tiiis variety a distinc- 
 tion must be made from the preceding 
 |iatliological dislocation, since tlie joint 
 itself is not the seat of bone disease. 
 This same variety may also occur in the 
 course of certain fevers, as typhoid, 
 or articular rheumatism : suddenly the 
 joint, usually the hip, Ijccomcs dislo- 
 cated, the ca])sule having ruptured 
 from over-distention. 
 
 The traumatic dislocation, which 
 is due to external violence, may oc- 
 cur in almost any joint in the body. 
 The injury may result in either a 
 complete or an incomplete luxation 
 of the joint, the special form of which depends upon the amount of vio- 
 lence exercised, together with the peculiar anatomical conformation of 
 the joint. Kronlein has demonstrated that about 90 per cent, of the 
 traumatic dislocations affect the upper exti-emity, while only about 5 per 
 cent, involve the lower extremity, and the remaining affect the trunk. 
 The ages between twenty and forty are the periods when traumatic dis- 
 locations are most frequently observed. 
 
 Pathological dislocation of the hip-joint. 
 
DISL CA TIOKS. 60 7 
 
 Tlie pathology oi" clislocation involves miicli more tlian the mere 
 luxation of tlie joint, since in every case the injiirv not only affects the 
 articiilatin<>' surfaces, hut in addition the liiianicnts are torn, the muscles 
 are lacerated, the cartilages are contused, the arteries are ruptured, the 
 nerves are stretched, and the fascia emhracinii- the joint is torn away 
 from its attachment. In compound dislocation the skin is broken and 
 usually destroyed, while the larger vessels are often torn. It is thus 
 evident that a dislocation is a serious injury, and if it happens to affect a 
 large joint and is compound in character, it involves life itself, and in 
 all cases aff'X'ts to a greater or less degree the future usefulness of the 
 joint. In gouty, syphilitic, tubercular, or rheumatic persons a dislocation 
 of a joint is often tlie starting-point of a chronic su|)pnrativc arthritis, 
 wiiich assumes a peculiar type according to the diathesis, and leads 
 eventually to resection of the joint or even amputation of the limb. 
 
 In dislocation of the shoulder, occasionally, the branches of the 
 axillary, or even the axillary itself, are wounded, either bv rujHure of 
 the middle and internal coats or by rupture of the three coats sim- 
 ultaneously. If the former has occurred, an aneurism slowlv develops, 
 while if the latter has occurred, a rapidly-growing traumatic aneurism 
 develops, with signs of collapse and gangrene of the extremity. This 
 same condition may obtain in reference to the popliteal vessels in dislo- 
 cations of the knee. The management of such ancimalous cases includes 
 reduction of the dislocation and an operation for the inuuediate relief of 
 the hicmatonia. This latter operation is to be performed according to 
 the rules governing the methods of treatment discussed under Aneurism. 
 
 Large nerve-trunks may be injured as a result of a dislocation. The 
 jiaralysis may be due to pressure owing to the presence of blood or bone. 
 This disturbance of function in the nerve disappears after alisorption of 
 the extravasated blood and removal of the bonc-ju'csstirc. The ])aralvsis 
 may be due to laceration of the nerve, wliich condition is not likely to 
 disappear, or it may be caused by injury during attempts to reduce a 
 dislocation. A neuritis, or even traumatism of the nerve-trunk, may 
 cause a paralysis, and this condition result from the same injury that 
 produced the dislocation. In investigating a dislocation the possibility 
 of injury to internal organs must not be overlooked. The pelvic organs 
 in disliicatiiin of the hij), and the wsojihagus in dislocations of the clav- 
 icle, are often tiie seat of injury which leads to distui'bance of function 
 or destruction of the organ or viscus. 
 
 In considering the signs of dislocation it is not inappro]iriate to 
 compare tiiis injury with fracture, which is usually a less serious acci- 
 dent. In dislocation the sliaft of the bone belonging to the affected joint 
 is not shortened, though the entire limb may be shortened. In dislocation 
 there is alisence of mobility, and hence the false point of motion, which 
 is so characteristic of fracture, is absent in dislocation. There is no 
 tendency for a dislocation to r"turn after reduction unless further vio- 
 lence is exerted, while the deformity is likely at once to reappear in a 
 fracture left to itself. In dislocation there is often present a kind of 
 crepitus wliich nuist not l>e mistaken for tliat of fracture. The crepitus 
 found in dislocations is of a peculiar kind, and is not bonv unless a frac- 
 ture coexists : it is due to blood-clots, lymph, ov albumin, and in .some 
 cases to a roughening of joint-surfaces. 
 
608 DTST.OCATIONS. 
 
 In tuircdvcrd dislocation the result varies according to the ]ioint In- 
 volved and tiie extent of the injury. Jn the hip and ankle and tlu; shoul- 
 der and elbow changes occur throngli the efforts of Nature, by means of 
 which often a most serviceable joint is constructed. The connective tissue 
 undergoes a certain amount of condensation, and mechanically jirevcnts 
 the ho>ad of the disj)lacc(l lionc from fai'thcr receding troni its new posi- 
 tion. The active use of the new joint causes a certain amount of absorp- 
 tion of bone, and makes the globular iiead move with comparative free- 
 dom in its newly-made socket. The irritation set up causes proliferation 
 of the connective tissue, which is soon transformed into fibrous tissue, 
 and around the head of the bone a comjjlete wall is thus formed, the 
 inner side of which is lined l)y flat cells which secrete a small amount 
 of Huid, which in tui'u serves to lubricate the new joint-socket. Often 
 some part of the synovial membrane is torn away, and if nourished con- 
 tinues to secrete some synovia. The changes which occur in the bone 
 and its coverings are of interest to the pathologist, since the periosteum 
 often produces bone and the fibrous tissue undergoes ossification. The 
 pressure of the head of the bone on the periosteum, whicli is not de- 
 tached from the bone, causes it to inflame from continual irritation, and 
 thus new bone is develoj)ed to aid in the formation of a bony cavity for 
 the reception of the displaced head. During these changes tlie original 
 joint-socket becomes gradually obliterated by a process of absorption and 
 by the development of granulation tissue in the bottom of the cavity. 
 A study of all of these changes in the new socket, in the head of the 
 bone, and in tlie original joint-cavity, with the Ijlood-vessels and nerves 
 imbedded in the newly-formed infiannnatory tissue, teaches the import- 
 ant lesson that the surgeon must not overlook the danger of attempting 
 by violence to reduce old dislocations, since the risk of tearing vessels 
 and nerves, and even of causing a fatal issue, is imminent. 
 
 The causes of dislocation may be divided into predixpoxinf/ and 
 e.reitinr/. Among the predisposing causes may be mentioned unusual 
 freedom of movement in a joint, the male sex, the adult age of the 
 ])atient, the arrest of joint-development, and senile or pathological 
 absorption of the head of the bone with changes in the joint-cavity. 
 Among the exciting causes may be mentioned mechanical violence and 
 nmscnlar action. 
 
 The signs and symptoms of dislocation are — disturbance of function 
 of the joint, interference with passive motion, su<lden loss of motion, 
 absence of the natural contour of the joint, changes in the relation of 
 the muscles about the joint, alteration in the shape of the limb, pain, 
 tenderness, and ecchymosis. Immobility is present, with no shortening in 
 the shaft of the bone, altliough there may be shortening of the entire limb. 
 
 The subsequent effects of dislocation vary according to the special 
 joint involved and to the amount of violence exercised at the time of 
 the receipt of the injury. The future usefulness of the joint depends 
 upon the degree of success attained in the reduction. If the dislocation 
 is simple and is quickly reduced, beyond the fact of a slight tendency to 
 a redislocation no bad effects may ensue. In certain cases paralysis of 
 the limb may follow, owing to a concomitant injury of the nerves. If, 
 on the other hand, the dislocation is compound, amputation or resection 
 may be required. 
 
DISLOCATIOXS. 609 
 
 The general treatment of siin])lo dislocations consists in the imme- 
 diate reduction and fixation of tlic joint. Tlicrc arc, liowever, certain 
 causes which prevent reduction, such as intervention of soft jiarts ; too 
 small tear in the capsule or too rapid healing of the capsule ; absorption 
 of the joint-cavity ; and, finally, obliteration of the cavity by granulation 
 tissue. In considering the subject of reduction there are certain dangers 
 v.-hieh must not be overlooked, such as fracture of the bone, tearing im- 
 portant vessels like the subclavian, and even comj)lcte avulsion of tiie 
 limb, especially when Jarvis's adjuster is employed under the influence 
 of anaesthetics. 
 
 The question as to how long a dislocation can exist and yet be reduced 
 is one which interests the surgeon in connection with the general principles 
 involved in the treatment of this injury. There are rejiorted cases where 
 the wrist has been dislocated tor six years, the shoulder for two years, 
 and the hip for nearly three luonths, and yet these dislocations have 
 been reduced, but they are surgical curiosities. As a rule, after a fort- 
 night it is extremely difficult to reduce a dislocation. In these days, 
 however, a resection can be made and a useful joint obtained, even 
 though the dislocation has existed indefinitely. 
 
 In case a fracture coexists with a dislocation, the reduction of the 
 dislocation should precede the treatment of the fracture, and in all cases 
 in which shock is present the surgeon should avail himself of this condi- 
 tion to reduce the dislocation. In cases where shock is extreme a short 
 delay may be necessary in order to adopt measures to bring about 
 reaction. 
 
 The treatment of congenital dislocation is chiefly palliative, since the 
 absence of a fully-developed joint makes it impossible to reduce the 
 dislocation. Some patients adapt their movements to the limited func- 
 tion of the joint, while others lind a congenital dislocation most dis- 
 tressing. The liability to fall, or the loss of complete function of a joint, 
 can often be overcome by some special ai)paratus designed to meet the 
 peculiar exigencies of the case. If the joint is practically useless and 
 tile patient jterfcctly healthy, the question of forming a new joint by 
 radical opcrati\e interference can be considered. 
 
 The treatment of pathological dislocation involves the question of 
 exsection of the diseased joint with the formation of a false joint. The 
 results have been in some cases most satisfactory. The operation must 
 be ])erformed according to the general principles involved in exsection 
 of diseased joints. 
 
 The treatment of the traumatic variety consists in immediately redu- 
 cing the dislocation. The object can be accomplished by manipulation or 
 by extension and counter-extension. The manipulative method is the 
 simplest, and is generally successful if attempted during the relaxation 
 of the muscles consequent upon shock or ana\sthesia. If reaction from 
 shock has taken place and the .nusclcs are in a condition of spasmmiic 
 contraction, an aiuesthetic is indicated, since the nuisclcs become at once 
 relaxed and the reduction is accomplished without any difficulty. 
 
 In employing manipulation the surgeon endeavors to reduce the dis- 
 location l)v relaxing those muscles which by their contraction prevent 
 the return vt' the head of the l)one into the socket, and also liy certain 
 movements to make the head of the dislocated bone travel back by the 
 
 Vol. I.— 39 
 
filO 
 
 DISLOCATIONS. 
 
 .same route by which it made its cscaj)e from tlio joint. If niaiiipiilatioii 
 fails to restore the joint to its normal eondition, tiic use of extension 
 and counter-extension is indicated. 
 In eni) 
 
 n enipiovniij; c.vlcnuioii and cotintcr-c.vtcnmon tlie surgeon endeavors 
 
 Fi(i. 129. 
 
 Jarvis's adjuster applied for reduction of a dislocation of the hip. 
 
 to overcome by force the contraction of tlie muscles which act as the 
 chief barriers to the reduction of the dislocation. The object is to over- 
 come all sources of resistance of whatever kind liy the application of a 
 
 Fig. 130. 
 
 Reduction of a dislocation on the dorsum ilii by the Spanish windlass (Gilbert). 
 
 force sufficient to aecomjilish tlie end. Many serious accidents have hap- 
 pened in trying to reduce old dislocations by a too violent exercise of 
 force. Limbs have been entirely torn from the body, large arteries 
 
TREATMENT OF DISLOCATIONS. 
 
 611 
 
 Fig. 131. 
 
 have been raptured, important veins have been torn, main nerve-trunks 
 have been irreparably lacerated, bone.s have been fractured, muscles and 
 fascia have been torn from tiieir insertions, and g-angrene of the limb 
 has been produced. All these accidents have occurred, and in some cases 
 with fatal results. Since the introduction of anaesthetics these fatalities 
 have been numerically lessened, but it must not be forgotten that the 
 influence of the anaesthetic is in itself a source of very great danger. 
 Jarvis's adjuster (Fig. 129) is one of the means which are emjiloveil 
 to reduce old dislocations. The instrument is so constructed that ex- 
 tension is made by a ratchet, and counter-extension by a perineal band 
 attached to a long shaft fixed to the limb. The 8j)anish windlass 
 (Fig. 130), as suggested by Gilbert, and the Bloxam " dislocaticm 
 tourniquet" (Fig. l-'il) are also employed. Hippocrates designed an 
 instrument for the ])urpose of reducing old dislocations. There are 
 other instruments with certain mechanical \ari- 
 ations, all of which have one common object in 
 view. It seems unnecessary to give any special 
 description of the different varieties of apparatus 
 proposed for this purpose, since their employ- 
 ment has been jiractically abandducd on account 
 of the intn)duction of manijuilation under an- 
 £esthesia, and, in the event of failure to reduce 
 the dislocation by this method, it is preferable to 
 cut down directly ujjon the joint and divide all 
 structures offering any obstruction to the reduc- 
 tion, scraping out the joint-cavity if necessary, 
 and returning the head of the bone into its 
 proper place. This operation, with every anti- 
 septic precaution, is immeasurably safer than the 
 use of any of the powerful instruments, \\ith 
 the exception ]X'rhaps of the comjjound ]>ulleys 
 (Fig. 132), which can be used with a certain 
 amount of ssifety in careful hands. Malgaigne has laid down the rule 
 that no force beyond 440 pounds should ever be employed, and a 
 
 Fig. 132. 
 
 Bloxam's dislocation tournl- 
 yuet. 
 
 CVimpmmrl pulleys, and rini.' to which one end of llic i.uUcy-rope is fiistened. 
 
 dynami)meter should be attached to the pulleys in order to ascertain tli 
 precise amount of force exercised. 
 
()12 DISLOCATIONS. 
 
 In some cases spc('i;illy-coiistrtict«l fon'cps, or the Indian puzzle (see 
 page 626), or the ck)ve-hitch (Fig. 133) with a wet towel, may he employed 
 
 Fig. 133. 
 
 I' ' 
 
 Clove-hitch (Ei-ii lison). 
 
 M'ith comparative safety under the influence of an anipsthetie. Subcu- 
 taneous division of tendons often aids the surgeon in the accomplish- 
 ment of his object, aiid this simple operation caunot be too highly 
 recommended. 
 
 Too prolonged extension should never be employed, since serious 
 damage can arise from this cause. No surgeon should continue perma- 
 nent extension over twenty consecutive minutes. All adhesions should 
 be broken up as far as possible before aj)plying the extending and 
 counter-extending force, as this is often of signal benefit in antici|)ation 
 of, and in conjunction with, the employment of forced extension. 
 
 After a dislocation has been successfully reduced the joint should be 
 immi)val)ly fixed for at least a week, after which time the dressings 
 should be rem<jved, and a slight amount of passive motion employed to 
 prevent adhesions and to overcome any contraction of the muscles and 
 ligaments. Active motion should not be permitted for at least a fort- 
 night, and in some joints not for a month, since this might provoke 
 inflammatory reaction, tear anew the capsule, and cause a recurrence of 
 the dislocation. In case any stiffness or rigidity of the joint remains, 
 galvanism, massage, shampooing, and inunctions of oil often assist in 
 restoring the usefulness of the joint. 
 
 The general treatment of compound dislocations is largely influenced 
 by the particular joint involved and the extent of the joint-injury. 
 Besides the displacement, the soft tissues about the joint are lacerated, the 
 ligaments are torn, the " synovial " capsule is opened, and the tendons, 
 mu.sclcs, and vessels are ruptured. In some cases a fracture coexists, 
 and this extensive damage gives rise to inflammation, suppurative 
 arthritis, abscess, cellulitis, and even gangrene. The condition which 
 confronts the surgeon is serious, not only for the future usefulness of 
 the joint, but for the life of the patient. There are three plans of 
 treatment which must be considered — conservative surgery, primary 
 resection of the joint, and amputation. The general rules governing the 
 .surgeon in this dilemma have already been mentioned, and consist of 
 consideration of the special joint involved, the age, constitution, and 
 hygenic surroundings of the patient. 
 
 Conservative treatment involves the question of the preservation of the 
 
TREATMENT OF DISLOCATIONS. 613 
 
 joint, without at the «inie time exposing' the patient's life to too great a 
 rislv. In all the joints, except tiie knee, it' the skin is not seriously 
 damaged and the vessels are uninjured, conservatism can be practised. 
 In the case of the knee this plan can he adopted only if the vessels are 
 uninjured, the ])atient is young and healthy, and the wound in the soft 
 parts small. To meet with success in tiie conservative jtlan the soft 
 j)arts ahout tiie joint should he rendered immediately aseptic, the wound 
 if small should he sufficiently enlarged to enable the surgeon to explore 
 thoroughly the joint, which should be irrigated with a warm bichloride 
 solution of 1 : 10,(300, and then a large-sized rubber drainage-tube intro- 
 duced into and through the joint, so that one end at least is in the 
 dependent jjortion of the joint. The enlarged wound can be sutured so 
 as to close it sutiicicntly to allow the tube to ])roject flush with the sur- 
 face of the skin. The parts are now thoroughly again irrigated, and 
 antiseptic dressings applied, over which absorbent cotton shoidd be placed 
 so as to include the entire limb, and a ]>laster-of- Paris bandage supported 
 with a few strips of tin or zinc to strengthen it. In three to five days 
 a fenestruni should be cut, the joint again irrigated through the tube, 
 which, if the temperature, pidse, and respiration are normal, can either 
 be entirely removed or at least shortened, and finally removed at a sub- 
 sequent dressing in forty-eight hours. This ilrcssing should be conducted 
 witli the same antiseptic precautions and under continuous irrigation, pre- 
 <-isely in the same manner as the initial dressing. The plaster sliould 
 remain on for at least four weeks, and then gentle passive motion should 
 be employed, and at the expiration of two additional weeks a limited 
 amount of active motion should be permitted. If this plan has failed, 
 suppurative arthritis ensues, and a secondary resection or amputation 
 must be performed. 
 
 Primary exci.sioii of the joint is the second plan of treatment when it 
 is not considered best to attempt conservative measures. In this case 
 the joint is widely opened, the loose pieces of comminuted bone are 
 removed, the torn fascia is cut away, and the wound is rendered aseptic. 
 In the shoulder-, elbow-, wrist-, and ankle-joints a movable joint should 
 be secured, while in the knee an osseous ankylosis is probable. Primaiy 
 excisions are very unfavorable as compared with secondary resections, 
 and a ease of primary excision under these conditions gives rise to great 
 anxiety. 
 
 Pr'unari/ (iiiijiiitdtion is indicated where it is not best to attempt either 
 a conservative j)lan or a primary excision, and therefore embraces a class 
 of cases found in elderly persons in whom the joint is seriously damaged 
 and the main vessels are torn. 
 
 Dislocation of the ribs is seldom observed, since they have very 
 limited motion and great elasticity, and are held together by strong lig- 
 anicrits. Tiie ribs iii'ay be separated from the bodies of the vertebne in 
 fracture of the spine, in which case the head of the rib is found lying 
 upon the front of the .spine. The ribs may also be dislocated in con.se- 
 quence of severe fills, or even blows upon the back, with or without 
 fracture of the spine. 
 
 The sig-ns and symptoms of this dislocation are obscure, and are 
 generally arrived at liy exclusion. There is a depression, with no crep- 
 itus, but with a peculiar grating sound, caused by the head of the rib 
 
()U DISLOCATIONS. 
 
 ridiiifi' on the front of the spine wlieii tlie rilj is pusiied from the front ; 
 the pain is sometimes very severe. 
 
 The treatment is substantially the same as it wouiti he in fracture 
 of the l)oue. 
 
 Dislocation of the c'ai;tila(;k.s from tiie sternum oeeurs especially 
 in young people. The first rib, having no synovial capsule and true 
 joint, is so protected that it is not liable to dislocation. The second to 
 tile seventh ribs may become! dislocated at their junction with the sternum. 
 The accident may be complicated witli fracture of the stei-num. 
 
 CosTO-STERNAL Di.si/)CATiON may occur as a residt of a blow, or in 
 consequence of a sudden violent com})ression of the chest, or even by 
 muscular action. 
 
 The sig-ns and symptoms are the presence of a subcutaneous tumor 
 u[)on the front of the sternum, produced by the dislocated cartilage, and 
 severe pain over the site of tlie injury. 
 
 The treatment isists in reducing tlie <lislocation l)y making tlie 
 
 patient assume the position of opisthotonos and pushing the projecting 
 end into its proper place. If the patient is unable voluntarily to assume 
 tliis ]iosition, a sand-bag can be placed between the scajiulse and the 
 shoulders pushed back, when the dislocated end will usually resume its 
 U(U-mal position. A tirm, hard compress should be jdaced over the dis- 
 located cartilage and hehl in situ Ijy broad strips of adhesive plaster, 
 which should encircle the thorax. 
 
 DlSLOL'ATION OF THE SIXTH TO TIIE TENTH "CARTILAGES from One 
 
 another occurs as a result of a fall upon the back or in consequence of 
 a violent contraction of the pectoral or abdominal muscles. The upper 
 margin of the lower cartilage slips beneath the upjier cartilage. 
 
 The signs and symptoms are severe pain and prominence of the 
 cartilage. 
 
 The treatment consists in instructing the patient to take a deep, full 
 inspiration, and tlien attempting to disengage the dislocated cartilage. 
 The same kind of a bandage which is employed in fracture of the rib 
 sliould be applied witli a eomjiress over the site of the lesion. This will 
 help to hold the dislocated end in place and serve also to restrain the 
 movements of the thoracic parietes. 
 
 Dislocation of the sternum occurs at the junction of the manu- 
 brium with the gladiolus, where an arthrodial joint exists. The injury 
 is caused in the same manner as a fracture, presents many of the same 
 signs and sym]>tonis, and requires the same treatment. 
 
 Dislocations of the clavicle occur either at the sternal or 
 acromial end. These dislocations are extremely rare, on account of the 
 strength of the short ligaments, and in this resjiect differ from frac- 
 tures of the clavicle, which are exceedingly common. Dislocation of 
 the clavicle at the sternal end may be forward, backward, or upward. 
 
 The forward dislocation is caused by some violence ajqilied to the 
 acromial end of the clavicle, by a fiill upon the front of the sliouldcr, or 
 in liending the shoulder suddeiilv backward in certain gymnastic move- 
 ments. The writer has seen a dislocation of the clavicle occur in playing 
 lawn tennis. The dislocated end of the clavicle lies upon the front of 
 the sternum just beneath the articular facet, and upon the sternal origin 
 of the steruo-cleido-mastoid muscle (Fig. 134). 
 
SPECIAL DISLOCATIONS. 
 
 615 
 
 Fig. 134. 
 
 Dislocation of the sternal end of the 
 clavicle forward. 
 
 The signs and symptoms con.sist of a subcutaneous tumor, produc- 
 ing a prominence upon the front of the manubrium ; the aljrujtt ending 
 of the chivicle ; the shortening between the slioulder and the mesial line 
 of the sternum as compared ■with the opposite side ; the inclination of the 
 head to the affected side, owing to the fact that the sterno-cleido-mastoid 
 muscle is made tense by the protrusion 
 of the clavicle against it ; and severe pain, 
 increased bv any movement. 
 
 The treatment consists in dniwing 
 back simultaneously both shoulders by 
 placing the knee in the interscapular 
 space, and then having the end pushed 
 into its proper place. A firm compress 
 should be immediately applied over the 
 site of the dislocation and held in tiifil by 
 adhesive plaster and bandages. If the 
 dishicated cud lias a tendency to slip out, 
 and thus to cause the deformity to reap- 
 pear, and if all the circumstances are favorable, the tlislocated end can be 
 fastened by a metallic suture. 
 
 Dislocation of the clariele backward occurs in consequence of a kick 
 from a horse or a fill npt)n the shoulder. The dislocation may be a 
 pathological one, secondary to lateral curvature of the spine. The dis- 
 located end may be thi-ust backward and slightly upward, just above its 
 natural jjosition, or it may be pushed downward just behind the sternum, 
 beneath the articulating facet, near the origins of the sterno-hyoid and 
 sterno-mastoid muscles. 
 
 The signs and symptoms consist of pain, k)ss of function of the 
 affected arm, turning of the head toward tiie dislocated side, approxima- 
 tion of the shoulder to the mesial line of the sternum, a fossa at the 
 articular facet, dyspnoea from pressure on the trachea, or dysphagia 
 from compression of the oesophagus, or disturbance in both res]iiration 
 and deglutition if the dislocated end is driven down liehind the sternum. 
 If the end of the bone descends low enough, it may by pressure on the 
 subclavian arterj' cause diminution or cessation of the radial pulse, or 
 by pressure upon the brachio-cephalic vein 
 prevent the return current in the vessel 
 and cause passive hyperemia. 
 
 Treatment. — The dislocation can usu- 
 ally be reduced by the means already de- 
 scril)ed, but in case the bone cannot be 
 returned to its proper position, and diffi- 
 culty of respiration and deglutition is 
 present, the end of the bone should be 
 sawed off to relieve the pres.^^ure. Thi.s 
 procedure, however, is seldom nece.s- 
 .sirv. 
 
 Dis/ocution of the clavicle upirard 
 occurs as a result of indirect violence, and is exceedingly rare. 
 
 The signs and symptoms are tumor, formed by the projecting end 
 just beneath the in.sertion of the sterno-cleido-mastoid muscle (Fig. 135); 
 
 Fig. 135. 
 
 Dislocation of the sternal end of the 
 clavicle upward. 
 
(5 Hi DISLOCATIONS. 
 
 slidi'tciiino; from tho tip of (lie sliouldcr to tlic mesial lino of the ster- 
 num ; tx'casional (lys|ni(>'a from iircssurc-t'lft'cts; and sonu'tiines (lyspiiaii'ia. 
 
 Tile treatment is suhstantialiy tlie same as lias already l)een described 
 in conneetion with otiier dislocations of this bone. In addition, an axil- 
 lary pad can be employed as a fidcrnm, so as to use the arm as a lever, 
 and tlins the clavicle can be drawn away from tlie mesial line, and its dis- 
 located end I)V manijiuiation be pushed into the articiilatini;- socket, where 
 it can be retained by compresses and a Velpcau dressinjj, with the elbow 
 brought well forward. It is often very <litHcult to keep the dislocated 
 end in place, and if the arm is rendered useless by the permanently 
 tmrediiced dislocation, it can be wired to the sternum by an antiseptics 
 operation. 
 
 DiNlordtumK of tlif acroinidl end of llir cJaride are not so fi'c(|Ucnt as 
 at the sternal end, on account of the stronir conoid and trapezoid iiga- 
 ments which bind this part of the clavicle down to the scapula. The 
 accident usually occurs as a result of a severe blow upon the back part 
 of the shoulder or of a fall from a height upon the outer part of the 
 shoulder. The bone may be dislocated upward or downward. In the 
 upward variety the end of the l^one is found upon the superior surface 
 of the acromion process of tiie scapula. 
 
 Besides the presence of the tumor, the signs and symptoms are 
 severe pain, inability to use the arm, depression of the affected shoulder, 
 approximation of the shoulder to the mesial line of the sternum, length- 
 ening of the arm, which hangs close to the side of the thorax, and con- 
 traction of the clavicular portion of the trapezius muscle. 
 
 The treatment consists in reducing the dislocated end by pushing it 
 down into its socket after drawing the shoulder well backward. The 
 axillary pad may be necessary, in which case it acts as a fulcrum and the 
 humerus as a lever. Sometimes the arm can be raised to a right angle 
 with the trunk, and in this position the dislocation will slip into place. 
 The trapezius muscle has a tendency to elevate the dislocated end, and 
 if it can be isolated and divided by a tenotome, the displaced end will 
 be held in place until the tendon has united. When the bone has been 
 reduced great difficulty is found in holding it in place. Compresses have 
 been used over the end, and these bound down firmly by long strips of 
 ruijber or adhesive plaster. The skin soon becomes excoriated by the 
 plaster, and the patient is unable to tolerate the dressing. In these cases 
 the metallic suture under proper antiseptic precautions is indicated, and 
 the bone can thus be permanently fixed in its proper position. 
 
 D'wlocation of the ncroiaicd end downward is an exceedingly rare 
 accident. The injury is the result of a blow from above directly upon 
 the clavicle, or a fall in -which the body is thrown forward and the force 
 of the fall impinges upon the ujiper surface of the clavicle. In this dis- 
 location the acromio-clavicular ligaments are ruptured, and the end of 
 the bone rests upon the capsule of the shoulder-joint, or it ma}' descend 
 and be found beneath the coracoid process of the scapula. 
 
 The signs and symptoms are projection inward of the superior angle 
 of the scapula and protrusion outwai'd of the inferior angle of the same 
 bone, great pain and tenderness, marked depression over the inner side 
 of the acromion, inability to move the arm, and projection of the coro- 
 noid process. 
 
SPECIAL DISLOCATIOXS. 617 
 
 The treatment consists in rc'tliifinu- tlie dislocation by dra^^^ng the 
 shoulders outward and backward and jnishing the interior angle of the 
 scapula in\yard. The scapula should be held in slfii by compresses in a 
 manner similar to that described in treating fractures of this bone. 
 
 Dixhieatlon of the clavicle simultaneouali/ uf the acromion and sternal 
 eiiiln has ix'en reported by a few surgeons. The accident occurred in 
 falls upon the back of the shoulder. 
 
 The signs and symptoms are those indicated in the respective dis- 
 locations, and the treatment consists in reduction by the plan already 
 described. 
 
 DiSLOCATiox OF THE SCAPULA occurs as a result of the bone slipping 
 from under the tendon of the latissimus dorsi muscle, which traverses 
 and covers the inferior anffle of the scajnda. This bone may also become 
 dislocated as a result of paralysis of the serratus magnus muscle or the 
 long thoracic nerve. 
 
 The signs and sjrmptoms arc a wing-like projection of the dorsal 
 border of the inferior angle of the scapula, and loss of motion in certain 
 movements of the arm anil shoulder. 
 
 The treatment consists in replacing the bone under the latissimus 
 dorsi tendon and holding it in its proper position by compresses, wliioli 
 in turn are held in place by some apparatus similar to that employed in 
 fracture of the rib. If the displacement is due to paralysis of the mus- 
 cle, hypodermic injections of strychnia into its substance, combined with 
 the use of electricity, iron, and massage, will often relieve the troul)lc. 
 
 Disi.ocATiOX OF THE SHOFLiiER-.loiNT occurs more frequently than 
 dislocation of any other joint in the Ixidy, forming a little over 50 per 
 cent, of all dislocations. This fact is due to certain anatomical features 
 of the joint, such as great freedom of motion, shallowness of glenoid 
 cavity, laxity of capsular ligament, absence of muscles adapted to give 
 support and strength, and, finally, to the immense leverage oMing to 
 the length of the upjier extremity. 
 
 The shoulder may be dislocated by indirect violence, as a foil upon 
 the elbow or hand, or by direct violence, as a severe blow upon the ante- 
 rior or posterior part of the shoulder while the arm is separated from 
 the body, or, finally, by muscvlar action. 
 
 The varieties of dislocation of the shoulder are subcoracoid, sub- 
 glenoid, subspinous, and subclavicular. 
 
 The Hnhcoracnid varieti/ is the most frequent. The head of the 
 bone lies under the coracoid process of the scapula (Fig. 136), and 
 escapes from the joint through a tear in the inner and lower part 
 of the capsule, where the opening of the biceps bursa begins. The 
 anatomical neck lies upon the anterior lip of the glenoid cavity, and 
 tile posterior part of the capsule is stretched tightly across the glenoid 
 f >ssa. The tendon of the biceps is usually pulled out of its groove, and 
 the muscles attached to the tuberosity are torn from their insertion into 
 the bone. In this variety the axillary vessels are usually not pressed 
 upon by the head of the bone. 
 
 The snhf/lenoid varieti/ appears next in point of frequency, and the 
 head of the bone escapes either below the insertion of the subscajnilaris 
 nuiscle (Fig. 137) or forces its way through the substance of the nuiscle 
 itself. The capsule is torn below, and the head of the bone causes 
 
618 
 
 DISLOCATIONS. 
 
 compression of the axillary vessels an<l nerves, which results in oedema, 
 cyanosis, and great pain. 
 
 The mljclaricular i-drirli/ is rare. Tlie licail cif (iic hdiie is carried 
 to the inner side of the coracoid process heneatii and across the pectoral 
 
 Fig. 136. 
 
 Fid. 137. 
 
 Subcoracoid dislocation of the shoulder. 
 
 Subglenoid dislocation of the humerus. 
 
 muscle, and is prominent under the skin. In this variety the external 
 rotators attached to the greater tuberosity are completely torn from 
 their insertion, or else the Ijony process is fractured. This dislocation 
 is tlie result of great violence (Fig. 138). 
 
 Fig. 138. 
 
 Fig. 139. 
 
 Dislocation of the shoulder downward 
 under the clavicle. 
 
 Subspinous dislocation of the shoulder, 
 unreduced ; new socket formed. 
 
 The subspinoiis variety is found where the posterior and lower part 
 of the capsule has been torn (Fig. 139), and the head of the bone is 
 forced to rest upon the dorsal surface of the scajjula below the spine 
 and beneath the infraspinatus muscle. In this variety the subscap- 
 
SPECIAL DISLOCATIONS. 
 
 619 
 
 Tilaris nmscle is strctclied iun'oss tlie glenoid cavity in the same manner 
 as the external rotators are in the forward varieties of disloeation. 
 
 In addition to these four varieties, occasionally there are slight 
 departures from the ordinary types — for example, subacromial or 
 supra-coracoid — but a careful examination of tiie injured joint will 
 demonstrate the fact that these variations arc ditlerent in degree and not 
 in kind. 
 
 The signs and symptoms of dislocation of the shoulder are very 
 similar, irrespecti\e of the special variety. They ai'e — flattening of the 
 shoulder ; prominence of the acromion ; depression beneath the acro- 
 mion ; absence of the head of the bone from the glenoid cavity ; pre- 
 ternatural immobility ; pain in the joint and along the cords of the 
 bracliial plexus ; rigidity of the surrounding nnisclcs ; inclination of 
 the patient's head toward the atiected joint ; flexion of tiic ell)ow to 
 relax the biceps ; obliteration of the infra-clavicular fossa ; prominence 
 of the head of the bone under the skin in certain varieties ; axis of limb 
 abducted ; «dema from mechanical pressure ; the affected foreai'm is 
 supported by the ojtposite hand ; the anterior axillary fold is less prom- 
 inent ; and the head of the bone is felt in the axilla or bcneatli the skin 
 below the acromion or the clavicle. 
 
 In addition to these signs, Hamilton has demonstrated that a ruler 
 placed upon the acromion will touch the external condyle of the humerus 
 in a dislocated joint ; Callaway has shown that the vertical mcasin-ement 
 over the acromion and around the axilla is some two inches greater upon 
 the afl'eeted side ; and Dugas has proved that in disloeation of the 
 shoulder the hand cannot touch the ojjposite shoulder if the elbow of 
 the affected side is brought in contact with the thorax. 
 
 The signs of dislocation of the shoulder must be distinguished from 
 those of fractures of the upper end of the humerus and of the neck of 
 the scapula, and from those of paralysis of the deltoid muscle. 
 
 Fig. 140. 
 
 Sir .\stley Cooper's metlioil of applying extension with the heel in the axilla. 
 
 PiinJjixix of flir (Ic/toid is diagnosticated by the presence of unusual 
 mobility in the joint, by tlie relaxation of the muscles, bv inability to rai.se 
 the arm at right angles to tlie trunk, l)y the negative results of Dugas's and 
 
620 
 
 DISLOCATIONS. 
 
 Callaway's tests, and, finally, by the presence of the head of the humerus 
 in the ujlenoid cavity. This condition can also be ascril)cd to some 
 traumatisin affecting the deltoid nniscle. 
 
 The FKACTURE8 OF THK ri'I'KI! EXI) OF THE HUMERUS, including 
 
 those of tl)e anatomical and surgical neck and the tuberosity, are distin- 
 guished l)y tiie signs already gi\-cn under Fractures. The fracture of 
 tile neck of tiie scapula, besides the ordinary signs of fracture, has one 
 ])eculiarity — viz. the defcjrraity can be at once removed by simjjly lifting 
 the entire arm u[)\vard, when the normal relations of the joint are imme- 
 diately restored, hut only so long as the arm is supported l)v the surgeon, 
 since withdrawal of the support is f()llowed by a return of the defonnitv. 
 Tiie treatment of dislocation of the humerus may be accomjilisiied 
 by Kocher's method, by flexion of the forearm upon the arm to a right 
 angle and then bringing it close to the side. The surgeon then grasps 
 the forearm thus flexed and turns it away from the body as far as pos- 
 sible, to cause external rotation of the arm. During this movement the 
 
 head of the btjue rolls outward in front 
 Fig. 141. of ;nid below the acromion, the elbow 
 
 is tiien carried well forward and up- 
 ward, and then the arm is rotated in- 
 ward and the elbow lowered. Manipu- 
 lation by an assistant with his hand in 
 the axilla is often of great service. 
 
 Sir Astley Cooper's method consists 
 in the surgeon making extension with 
 his foot in the axilla while the patient 
 lies upon the edge of a table or upon 
 the floor (Fig. 140). 
 
 The same method can be employed 
 by the surgeon standing behind and 
 ])lacing his knee in the axilla of the 
 ])atient, who is seated upon a low stool. 
 The surgeon now presses down upon 
 the acromion process (Fig. 141) with 
 one hand and makes traction downward 
 upon the arm with the other hand, 
 while at the same time he raises his 
 heel so as to push the head of the bone 
 outward. This method , combines extension, leverage, and abduction 
 with manipulation. 
 
 Skey used an iron knob (Fig. 142) in place of the heel in the axilla, 
 in conjunction with the use of compound pulleys (Fig. 143). 
 
 Fig. 142. 
 
 Sir Astley Cooper's mode of operating 
 with the knee in the axilla. 
 
 Iron knob employed hy Skey, instead of the heel. 
 
 Wood reduced these dislocations by having an assistant stand upon a 
 firm table and make counter-extension with a towel passed under the 
 
SrECIA L DISLOCA TIONS. 
 
 G21 
 
 axilla of the patient, who stands by the side of the tahle wiiile the sur- 
 geon makes extension from tiie arm below. 
 
 H. H. Smith employed the following method : " Elevate the elliow 
 and arm as high as possible and Hex the forearm at right angles with the 
 arm, thus relaxing the supraspinatus muscle. Then, using the forearm 
 
 Fig. 143. 
 
 Skcy's mc'tliocj of makinj; extension sine! counter-extension witli pulley. 
 
 as a lever, rotate the head of the humerus upwai'd and forward, so as to 
 relax the infraspinatus muscle, carrying the rotation as far as possible 
 or until resisted by the action of the subscapnlaris muscle, keeping the 
 forearm for a few .seconds in its ])osition with the palm of the hand 
 looking upward ; then bring the elbow promjitly but steadily down to 
 the side, cai'rying the elbow toward the body and keeping the forearm 
 so that the palm of the hand yet looks to the sui-geon. Then quickly 
 but gently rotate the head of the humerus upward and outward by carry- 
 ing the jialm of the hand downward and across the patient's body, and 
 the bone will usually be replaced." 
 
 Dislocations of the elbow-.joint occur very fiv(iucntly in young 
 persons : 50 per cent, of the cases are said to Ik- found in persons under 
 fifteen years of age. This dislocation is therefore an exception to the 
 rule that dislocations are usually observed during adult life. It is 
 generally the result of direct violence by a fall ujion the palm of the 
 hand or upon the inner side of the forearm or upon the olecranon. It 
 has also been ol)served as a residt of a twist to the ulna in Mhich the 
 coronoid process is drawn downward, inward, and backward. There arc 
 several varieties, some affecting both bones of the forearm, others the 
 radius alone, and still others the ulna. The varieties alfeeting both 
 bones are backward, forward, outward, and inward ; those involving the 
 radius alone ave backward, fonrard, ax\d oxihrard ; and that involving 
 the ulna, backward. 
 
 Before describing tiie dilfcrcut dislocations of the elbow-juint it is 
 very important to a com]>lete understanding of these various injuries to 
 study the anatomical relations of the normal joint. The external con- 
 dyle of the humerus, the olecranon, and the internal condyle of the 
 humerus should be in a transverse line across the posterior part of the 
 joint when the forearm is extcndrd u])ou the arm. Any deviation from 
 this iKirmal relation indicates a disliication or a fracture. 
 
 The signs and symptoms of dislocation of l)oth bones of the elbow- 
 
622 
 
 DISLOCATIONS. 
 
 joint backward, the most frequent variety, are — projection of the olecra- 
 non l)ack\vard ; strcteiiing of the tricc]>s over the lower exjxised snrface 
 of the htuncrns ; exposnre of the articulatinji' surface oi' the liiuneriis ; 
 shoi'tcninii' of the forearm; fixation, partial ti<'xion, and slialit pronation 
 of the forearm; crepitus, provided the coronoid ])rocess is fi'actured, 
 and, if it is not fractured, its presi'nee in the olecranon iiissa (Fig. 144). 
 
 Fig. 144. 
 
 Dislocation of radius and ulna backward. 
 
 Fig. 14.5. 
 
 The signs and symptoms of dislocation of both bones forward, in 
 whicli the olecranon is usually fractured, are — lengthenino; of the forearm ; 
 depression in front of arm eorrespondins;- to the sigmoid notch ; great 
 j)rominence of the condyles of the humerus ; depression behind, where 
 the olecranon belongs, with aljsence of this process from its normal place, 
 and its presence in the trochlear fossa on the front of the condyles of 
 the humerus. 
 
 The signs and symptoms of dislocation of both bones outward or 
 to the radial side (Fig. 145) are — flexiqn and immobility 
 of the forearm ; jironation of the forearm, with the head 
 of tile radius upon the outside of the joint and rotating 
 just beneath the skin ; and great prominence of the in- 
 ternal condyle of the humerus. This dislocation is in- 
 complete, since the ulna catches against the external con- 
 dyle. 
 
 The signs and symptoms of dislocation ot both bones 
 inward or to the ulnar side consist of prominence of the 
 external condyle, flexion of the forearm and pronation of 
 the hand, and the presence of the olecranon jirocess npon 
 the inner side of the joint. This dislocation is not as 
 common as the preceding one, on account of the obliquity 
 of the articulating surface, which is higher internally. 
 
 The signs and symptoms of <lislocation of the 
 radius backward are absence of the head of the radius 
 from its normal place and its presence behind the exter- 
 nal condyle beneath the skin, and fixation of the fore- 
 arm. In this dislocation fracture of the external con- 
 dyle often coexists. 
 
 The signs and sjTmptoms of dislocation of the radius 
 forward (Fig. 14(5) are — flexion and .semi-]ironation of 
 the forearm ; head of the railius upon the front of the external condyle ; 
 a depression upon the radial side of the forearm ; and inability com- 
 
 Disloeation of the 
 head of the radius 
 outward. 
 
SPECIA L DISLOCA TIOXS. 
 
 62:5 
 
 pletely to flex tlie forearm, owing to tlie fact that the head of the hone 
 impinges against tiie external eondvle. 
 
 The sign of dislocation of the radius outward consists of the presence 
 
 Fig. 146. 
 
 Dislocation of radius forward. 
 
 of the head of the radius njion the outer side of the external condyle, 
 just heneath the skin, which is stretched tightly over it. 
 
 The signs and symptoms of dislocation of the ulna backward (Fig. 
 147) are — projection of the ulna behind, rotation of head of radius in 
 its normal socket, crepitus if the coronoid process is fractured, pronation 
 of the hand, and great shortening of the forearm upon its ulnar side. 
 
 Fig. 147. 
 
 Dislocatifii ul iln.' upper cud ul ilic ulna liari^uard. 
 
 The treatment of dislocations of the elbow-joint consists of fixation 
 of the humerus, flexion or extension of the forearm, and digital pressure 
 of the dislocated end, so as to ]iush it into the joint-socket. In case of 
 dislocation of both bones or of the ulna alone, the extension should be 
 made by gras]iing firmly the forearm ; if of the radius alone, the extend- 
 ing force should be applied from the hand. It is .seldom necessary to 
 give an ansesthetie, but if it is employed the reduction can be easily 
 eifected. After reduction cold evajxirating lotions of lead-o])ium wash 
 or Goulard's extract, or some stimulating liniment, should be aj)])licd 
 to the joint for a few days until all inflammatory action has subsided. 
 In a fortnight gentle pa.-isive motion should be employed. 
 
 Di.sLOCATioNs OF THE WRIST-JOINT are extremely rare. Dupuytren 
 has stated that this dislocation never occurs. This would apply to intra- 
 carpal dislocations, but not to I'n-ist-johif dislocations, as shown below in 
 Figs. 148 and 149. The author has ol)scrved four well-marked cases 
 of this injury — one in private pra<'tice and three in hosjiital service — 
 one of which was compound. 
 
 The causes of dislocation (^f the wri.'^t-joint are falls upon the jialm 
 with the hand bent forward. The impacted fracture of the lower end 
 of the radius simulates this injury to some extent. 
 
624 
 
 DISLOCATrOXS. 
 
 'I'lie varieties arc hdckirdnl and Jnnrdnl. 
 
 I'lic signs and symptoms in the buckifurd variety consist of" a dorsal 
 prominence, prodnced hy the carpus overlapping the lower end of the 
 radius (Fig. 148) ; the iiand lies on a plane sujicrior to the forearm, and 
 
 Dislocation of the carpal bones Ijackwarii (Fergusson). 
 
 the continuity of the parts is thus destroyed ; the forearm is shortened 
 from the elbow to the tips of thi' fingers; there is absence of crepitus, 
 and, if the deformity is reduced, tiiere is no tendency to return. 
 
 The signs and symptoms in the fonvard variety of dislocation of 
 the wrist-joint consist of a palmar prominence produced by the carpus 
 sliding up upon the anterior surface of the radius; the hand is on a plane 
 inferior to the forearm (Figs. 14(1 and 1.50). The remaining signs arc 
 similar to those in the backwanl dislocation. 
 
 The differential diagnosis of either of these dislocations from 
 Colles's fracture is made l)y the absence of the characteristic signs of 
 fracture and the disturbed relation of the styloid processes to the bones ; 
 
 in sprains all the characteristic 
 signs of dislocation and fracture 
 are absent ; in ganglia, the pres- 
 ence of fluid, ascertained by the 
 use of a hypodermic needle, and 
 the peculiar deformity caused by 
 the fluid dipping under the annu- 
 lar ligament, are characteristic-. 
 
 Fig. 150. 
 
 Fig. 149. 
 
 Dislocation of the carpal bones forward. 
 
 Dislocation of the carpal bones forward. 
 
 The treatment consists in adopting the genei'al principles laid down 
 in reducing any di.-ilocatiou by e-xtension and counter-extension. After 
 the reduction is effected the hand slionld be placed upon an antero-pos- 
 terior splint and kept at rest for several weeks. 
 
SPECIAL DISLOCATIONS. 
 
 625 
 
 In one case of conijKmnd dislocation wliicli the aiitlior ha<l under 
 treatment tlie ulnar artery was ruptured antl gangrene of the hand 
 ensued, -which conditit)n led to amputation of the forearm. 
 
 DlSLOCATIOX OF THE PROXIMAL PHALANX OF THE THUMB OCCUrs 
 
 as a result of a blow or a fall upon the distal end and palmar surface of 
 the thuml>, so as to cause forced extension. 
 
 There are two varieties, the backward and the forirard, and the 
 
 Fig. l.il. 
 
 Fifi. 152. 
 
 Unreduced dislocation of the thumb (Ashhurst). 
 
 signs and symptoms are too evident to require any special description 
 (Fig. lol). This is often the nio.st difficult dislocation in the body to 
 reduce, and also, at times, the most 
 easily reduced of all di.slocations (Fig. 
 152). 
 
 There have been many reasons as- 
 signed to explain the occasional dif- 
 ficultv of reducing this dislocation. 
 Erichsen thinks that the head of the 
 metacarpal bone becomes locked be- 
 tween the two heads of the flexor 
 brevis poUicis ; Cooper believed the 
 difficulty to lie <liu' to the presence of 
 six powerful muscles ; Hey thought 
 that the obstacle to reduction lies in 
 the fact that the head of the bone is 
 constricted between the lateral liga- 
 ments of the joint ; Dupuytren held the 
 view that the lateral ligaments, which 
 normally arc parallel, jire in this injury 
 at rio'lit angles to the axis of the nieta- 
 carpal bone. The infolding of the an- 
 terior ligament and the intervention of a sesamoid bone between the joint- 
 surfaces have also been assigned as obstacles to reduction. 
 
 The treatment consists in tlie application of extension and tlcxiou in 
 many different ways, ("oopcr suggested bending tlic tiiunih toward the 
 jialni in order to relax the flexors, and then a})])lyinga clove-hitch to the 
 Vol. I.— 10 
 
 Dislocatiiin ef the mctacarpo-phalangeal 
 joint of the thumb. 
 
626 
 
 DISLOCATIONS. 
 
 distal phalanx ; Bell suggested division ol' tlic lateral ligaments; Roser 
 recommended extreme dorsal flexion, with a view to increase the amount 
 of extension. Various instruments have been devised, such as tiie 
 Indian puzzle (Fig. 15;3) and [jcvis's instrument (Figs. 154 and 155). 
 
 " Indian luizzle," emijluyei-i f-jr the reduction uf dislocations in small joints. 
 
 In certain cases, after every method fails, a resection of the head of 
 the bone is indicated The author has performed this operation in two 
 
 Fig. 1.54. 
 
 Levis's instrument lor reduction of h dislocation of the lingers or the thumb. 
 
 cases where, after repeated trials under anjesthesia, reduction could not 
 be effected. The joint-wound healed by primary intention, and the 
 
 Fig. 155. 
 
 Levis's instrument applied to the first tin^'cr. 
 
 function of the joint was so completely restored as to afford no incon- 
 venience to the patient. 
 
 Dislocation of the phalanges often occurs, and is the result of 
 mechanical violence. 
 
 The signs and symptoms are too apparent to require any special 
 description. 
 
 The treatment consists in reducing the diislocation by extension and 
 counter-extension, and placing the finger on a .splint and applying a few 
 turns of plaster-of- Paris bandage to keep the parts quiet until tiie ligaments 
 are healed. It may be necessary after tlie removal of the s])lintto employ 
 gentle passive motion until the function of the joint is fully restored. 
 
 Dislocations of the hip form about 9 per cent, of all dislocations. 
 The wide range of motion which this joint enjoys ex))lains, in a measure, 
 the frequency of this special injury as compared with other dislocations 
 in the lower extremity. Albert has shown that the hip-joint can be 
 fle.xed and extended to an angle of 140° if only the bones and ligaments 
 
SPECIAL DISLOCATIOXS. 
 
 627 
 
 are attached, and abduetidii and adduction at an ano-le of 90° to 100° 
 can be produced under the same conditions. If tlie muscles are in 
 place, flexion is diminished to about 30°, and adduction to 20°. He 
 has thus demonstrated that extension and abduction are limited by the 
 li^raments, while flexion and adduction are limited by the muscles or by 
 mechanical obstacles, such as the limb meeting- the abdomen. In regard 
 to age, cases have been rejiorted from the extremes of life, one case at 
 six months and another in the ninety-second year. 
 
 There are four diti'erent varieties of dislocation of the hip. They 
 can be classified according to the frequency of occurrence and also by the 
 emplovment of a figiu'e whicii illustrates the anatomical 
 arrangement. If a circle is drawn, a represents the iijj- 
 ward dislocation on the dorsinn ilii ; H, the bachrctrd 
 variety into the ischiatic notch ; c, the doirnward variety 
 into the obturator foramen ; and i), the forward variety 
 upon the os pubis. In studying the varieties of disloca- 
 tion it is well to adopt a definite ])lan, which can be :i]i- 
 plied to all the difTercnt varictit's. 
 
 The first variety of dislocation is i<jiir(ird,n\n\ forms about one-half of 
 all the cases. The head of the bone lies ujion the dorsum ilii (Fig. 156) 
 
 Fio. 156. 
 
 Dislocation of the femur upon the dorsum ilii. 
 
 and upon or under the gluteus minimus muscle. The injury is usually 
 produced by a fall U])on the outer side of the knee or foot when the limb 
 is abducted and thrown forward. 
 
 The signs and symptoms of this dislocation can be best enumerated 
 if the surgeon begins his examination by first inspecting the toe, then the 
 foot, knee, thigh, trochanter major, limb, and gluteo-femoral fold, in the 
 
(528 
 
 DI.SLOCATIOXS. 
 
 order mentioned, from below upward. By this plan he can readily detect 
 tile variety of dislocation. In this first variety the toe is tnrned toward 
 the opj)osite instep ; the foot is inverte<l ; the knee is sliij;htly flexed, and 
 toiielies or is nearly in contact witli tiie n])pcr maru-in of tiie op]iosite 
 patella; the thijih is rotated inward, sligiitly ticxe(l, and addncted ; tlie 
 trochanter major is more prominent, and is distinctly felt ; tlie entire 
 limb is shortened abont two inches; and the gluteo-femoral fold is higher 
 than upon the opposite side. 
 
 Fig. 157. 
 
 Dislocation of the femur baekward into the ischlatie notch. 
 
 There are only two injuries which could possildy be mistaken for dis- 
 location upon the dorsum ilii. The first injury it^J'racture of the neck of 
 the thigh-bone, in which crepitus, mo])ility, eversion of the foot, less 
 amount of sh(n-tening, less jn-ominence of the trochanter major, and its 
 occurrence in an aged patient, are the differential points. The second 
 injury is contuaion of the hip-joint, in which the absence of crepitus, the 
 presence of the head of the bone in the acetabulum, the absence of short- 
 
SPECIAL DISLOCATIONS. 
 
 629 
 
 eninfj, and the tests made by Nelatoii's lint' and Bryant's triangle (see 
 ])a<re 5()7) form a group of signs whicli serve to characterize the nature 
 of tile injury. 
 
 Tlie second variety of dislocation is hcd-iranJ into the isehiatic notcli 
 (Fig. 157). The injury results from a fall upon the knee or foot while 
 the limb is in front of the body. 
 
 Adopting the plan of descrijrtion given for the preceding variety, the 
 toe is turned toward the opposite toe ; the foot is inverted ; the knee is 
 slightly tlexed ; the thigh is rotated inward, flexed, and adducted ; the 
 trochanter major is prominent and is <listinctly felt, and is nearer the 
 anterior superior spinous process of the ilium; the limb is shortened 
 about one inch ; the gluteo-femoral fold is higher than normal and the 
 head of the bone can be felt in the notch if the finger is introduced into 
 the rectum or the vagina. The two injuries that might be mistaken for 
 this dislocation are those described under the preceding variety. 
 
 Fig. 158. 
 
 Dihlwi atiuii t.f the femur downward intu the obturator inraiuen. 
 
 The third variety of dislocation of the hip is dowmrani into the 
 obturator foramen (Fig. 158). The head of the bone lies upon the 
 obturator externus muscle. The injury is caused by a fall when the leg 
 is abducted. 
 
 The toe points downward and ibrward ; the foot points forward and 
 is everted ; the knee is slightly flexed ; the thigh is slightlv flexed and 
 abducted; the trochanter major is flattened and is nearer the mesial line; 
 the entire limb is lengthened about two inches ; and the gluteo-femoral 
 fold is obliterated. 
 
mo 
 
 DISLOCATIONS. 
 
 Tlio fourth variety of dislocatidii of the liip \ii forintrd upcm tlic Imri- 
 zontal jxirtioii of the os ]>uliis (Fig. 159). Tiic head of tiic hone lies 
 
 Fio. 159. 
 
 Di.slocatiun uf the femur forward upon the os pubis. 
 
 upon the outer side of the femoral artery and al)ove Poii])art's ligament. 
 The injury i.s produeed by a tidl when tlie limb is thrown backward and 
 behind the centre of gravity. 
 
 Adopting again the same plan of description, the toe points outward; 
 the foot is eveited ; the knee is slightly tle.xed ; the thigh is rotated out- 
 
 FiG. 160. 
 
 Reduction of dislocation on the dorsum ilii (Sir Astloy Cooper's method). 
 
 ward, slightly flexed, and abducted ; the trochanter major is rotated 
 backward and has lost its prominence ; the entire limb is shortened 
 about half an inch ; and the gluteo-feiiioral fold is obliterated. 
 
SPECIA L DISL CA TIONS. 
 
 Fig. 101. 
 
 (i:51 
 
 Reduction of dislocation into the sciatic notcli iSir A. I'ouper's mctliudi. 
 
 Fi<;. 162. 
 
 It", now, tlie first and hccoikI rnritilcs are considered tooetlier, it is evi- 
 dent that tlie signs and symptoms differ only in deori'e and not in kind, 
 since in both varieties the toe and foot are inverted, tile knee flexed and 
 adducted, the thio;h rotated inward, with siiort- 
 ening of linih and prominence of tlie trochanter 
 major, and elevation of tlie ghiteo-femoral folds. 
 
 If the third and fourth varieties are con- 
 sidered tojiether, it is evident that many of 
 the signs and symptoms differ asjaiii only in 
 degree and not in kind, since in both varieties 
 the toe and foot jioint downward and forward 
 and are everted, the knee is nearly straiijht, and 
 the trochanter major flattened. In the doirii- 
 trard dislocation there are two inches of leiioth- 
 ening, while in the bachirard dislocation there 
 is half an inch of shortening. The inversion 
 of the toe and foot in the first and second varie- 
 ties is due to the outer band of the Y-ligament 
 of Bigelow, since division of this causes the 
 sign of inversion to disa]i]K'ar, as pointed out 
 by Bigelow. 
 
 In considering the treatment of dislocation 
 of the hip the obstacles which prevent reduction 
 must not be overlooked. They consist of the 
 Y-lig;niient ; the capsule which girds the neck 
 of the bone, the small rent in which pi'c- 
 vents the free return of the Ijone into the 
 joint ; the sciatic ncVve, which may become 
 entangled by forming a loop around the neck 
 of the bone; the obturator externus tendon, 
 which becomes ten.se over the back of the 
 neck of the bone; and, finally, the muscles, 
 which often ciiibrace the head in a slit-like aperture. The treatment by 
 manipulation consists in overcoming by certain movements these various 
 obstacles to reduction. The leg is flexed upon the thigh to serve as a 
 
 I'islucation into tlie obturator 
 foramen. 
 
632 
 
 DISLOCATIOSS. 
 
 \v\v\- for tlie surgeon ; tlic tliitili is tlien flexed iipdii the pelvis to relax 
 the Y-li<;aiiient. The entire liinl) is tlien :ih(hiete(l and rotated outward 
 in the first and second varieties, in order to throw tlie head oi' tiie thit;h- 
 hone over the acctahnhun, wiiile in the third and fourth varieties tiie 
 entire liuil) isadihieted and rotated inward. After <'iliier of these move- 
 ments has been executed, aeeording to tlie variety of disloeation, the limb 
 should be suddenly raised in order to throw the head of the Ixine over the 
 margin of the aeetaljuhnn, after which the limb sliould be extended in 
 its normal position. iJricflv, tiie two joints are flexed, flie lindj alxlueted 
 and pulletl (Uitward and lifted, in the first or second variety ; or the two 
 joints are flexed, adducted, and ]inslied inward and lifte(l in the third or 
 iiiurth variety. Sir Astlcv Cooper's methods of reduction by extension 
 are shown in Figs. 160, 161, 162, and 163. 
 
 The results of treatment of unreduced dislocation of the hip have not 
 been satisfactory. In six cases reported, only two were reduced by an 
 
 Fig. 16.3. 
 
 la^ ■ l| 
 
 ^ 
 
 >^rNr— ^ 
 
 "xi— ^ 
 
 ;^^3^5r^'CF5 , 
 
 /' iS^ 
 
 
 i 'il i il-^" V \ ^^^^ i : 
 
 Reduction of dislucatiun on the pubes by Sir A. Cooper '^ method. 
 
 operation, and in one of the two cases the patient died as a result of the 
 operation, and the other patient suffered from caries of the bone. 
 
 Compound (fisloaifions of the hip are extremely rare, only about a 
 dozen cases ever having been rep<n'ted. The treatment of such an injury 
 must be conducted on the lines governing the management of compound 
 dislocations in general. 
 
 Dislocation of the knee is a serious injury, on account of the 
 damage sustained not onlv bv tlie blood-ve.ssels, muscles, ligaments, and 
 cartilages, but also by the joint itself, which may undergo su])puration 
 as the result. Fortunatelv, it is rare, as it occurs in less than 2 per 
 cent, of dislocations, owing to the number and arrangement of the pow- 
 erful ligaments. The injury occurs as a result of some direct, sudden 
 mechanical violence. 
 
 The varieties are — oafinird (Fig. 164), burnvd (Fig. 165), forward 
 (Fig. 166), backward (Fig. 167), and l)v rotation. The second and third 
 varieties are often incomplete. The dislocation occurs fonmrd in nearly 
 half the cases, and about 20 per cent, of the forward dislocations are 
 compound. 
 
 The signs and symptoms are too apparent to rerpiire any special 
 description. The iri-egular a|>pearance of the knee-joint, the unusual 
 prominence of the condyles, tlie immovably fixed position of the joint, 
 
SPECIAL DISLOCATIONS. 
 
 633 
 
 the increase in the antero-posterior or lateral diameters of the joint, the 
 loss of parallelism in the two limbs in the first and second varieties, or 
 great shortening' in the forward and l)ack\\ard \arieties, distinguish the 
 
 Fig. 16-1. 
 
 Fig. 165. 
 
 Subluxation of the head of 
 tlie tibia outward. 
 
 Subluxation of the head of 
 the tibia inward. 
 
 nature of the injury. In dislocation by rotation the leg is twisted upon 
 its own vertical axis either inward or outward, the latter variety being 
 the more frequent. The appearance is so characteristic that a description 
 of the signs and symptoms is unnecessary. 
 
 Fig. 167. 
 
 Subluxation of the head of the tibia 
 forward. 
 
 Complete dislocation of head of 
 the tibia backward. 
 
 The treatment of dislocation of the knee-joint e(insists of extension 
 of the leg, with coiinter-e.xtension from the thigh and pressure of the 
 head of the tibia inward, outward, Ijackward, or forward, according to 
 
634 DISLOCATIONS. 
 
 the special variety. Care siiouid be taken to avoid hyper-extension of 
 tile leg, as the popliteal vessels might he injured. In the dislocation by 
 rotation the rethiction is easily effected by twisting the leg in tiie long 
 a.xis of the limb in the opposite direction, while extension at the same 
 time is nutintaini'd. jVfter reduction of the tlislocation the entire limb 
 should be placed in a plaster-of-Paris bandage, and retained in an 
 innnovable position for several weeks. Passive motion should be 
 employed after the removal of the splint, and no active movement 
 allowed for another week after the discontinuance of the splint. 
 
 Compoinul dift/ocafion of the knee-joint is a most serious injury, owing 
 to the large size and complicated structure of tiie joint. If the wound is 
 small and nothing foreign lias entered tiie joint, the aperture can be her- 
 metically sealed with styptic collodion painted over a thin iilm of absorb- 
 ent cotton. The wound, including the joint, should be dressed ascptically 
 and the limb placed in a plaster-of-Paris splint. If the wound is barely 
 large enough to admit the finger, the joint should be thoroughly irrigated 
 with warm bichloride-of-mercury solutic^n of the strength of 1 : 10,000, 
 prepared with distilled water. A counter- and dependent opening should 
 be made in order to drain freely the cavity of the joint, and after dress- 
 ing the knee aseptically the conventional retentive apparatus of plaster 
 of Paris should be applied. If the wound is larger than is sufficient 
 to admit the finger antl the soft parts are lacerated, a jjrimary resection 
 should be performed, provided the patient is young, ^itli healthy viscera 
 and organs, and no large vessels or nerves are injured. Under these 
 same conditions primary amputation is indicated when the patient is old, 
 feeble, or affected with visceral disease, or when the main vessels and 
 nerves are injured. Conservative surgery can accomplish nuich in 
 these days in cases where a few years ago amputation was tlie only 
 hope for tiie patient's life. In severe cases thrombus of the popliteal 
 vessels has been observed, and gangrene resulted, requiring immediate 
 amputation. 
 
 Dislocation of the semilunar cartilages involves a sub- 
 luxation of the cartilage from its normal position, Avhich may occur 
 in consequence of a sudden twist or wrench in elderly people, or 
 the dislocation may occur as a result of chronic disease of the 
 joint. 
 
 In this injury there is sudden loss of the joint-function, attended 
 by excruciating pain, which is often so intense as to cause the patient 
 to faint and to fall to the ground. There are no immediate character- 
 istic signs, as far as the joint is concerned, l)ut tlie joint soon becomes 
 swollen from effusion and the inflaunnatory reaction is very great. This 
 dislocation nuist not i>e mistaken for a loose cartilage in tlie joint, which 
 is a chronic condition often recurring with some of the signs of disloca- 
 tion, only of not so severe a character. 
 
 The treatment consists in returning the cartilage to its normal posi- 
 tion while the patient is under tiie influence of an ansesthetic. The 
 jxitient should be jilaced u])on his iiai-k, tlie surgeon's left arm should be 
 passed under the popliteal space, and the leg seized and flexed by an 
 assistant. This manipulation under anaesthesia separates the joint-sur- 
 faces, and the cartilage can be now pushed back into its normal place by 
 the surgeon's right hand. After reduction the ice-cap should be placed 
 
SPECIAL DISLOCATIONS. 
 
 635 
 
 Fig. 168. 
 
 Apparatus employed to limit motion in disloca- 
 tion of the semilunar cartilages. 
 
 Fig. 169. 
 
 over the joint for twciity-four lioiirs, and then a plaster-of-Paris splint 
 applied over a thick layer of absorbent cotton to produce unitbrni and 
 equable pressure. If the disloca- 
 tion has a tendency to recur, the 
 surgeon can cut down upon the 
 loosened and displaced cartilage 
 and suture it to the bone, or even 
 excise it. This operation must be 
 undertaken with every antiseptic 
 precaution. In cases where no 
 operation seems advisable some ap- 
 paratus should be made to limit 
 the amount of movement in the 
 joint (Fig. 168). 
 
 Dislocation of the patella occasionally occurs, and forms 
 only about 1 per cent, of all dislocations. The injury may be the re- 
 sult of mechanical violence from a blow or a fall upon the side of 
 the bone, especially when the knee is slightly flexed, or the dislocation 
 may occur from muscular ai'tion, or the condition may be congenital. 
 
 The varieties are outward, inward, vertical, and upward. Any of 
 these varieties may be complete or incomplete. The out- 
 ward variety (Fig. 169) is the most common, though the 
 natural plane of the trochlear surface Mould seem to favor 
 the inward variety. 
 
 The signs and symptoms of outward dislocation 
 of the patella are flatness of tiie knee, tense condition of 
 the quadriceps extensor muscle, inability to flex the knee- 
 joint, and the patella resting upon the external condyle. 
 
 In the imoard variety the signs and symptoms are 
 similar to the above, except that the signs are found upon 
 the opposite side of the condyle. This variety is always 
 the result of mechanical violence. 
 
 The rertical or rotary variety has been observed upon 
 a few occasions, and is caused by a sharp blow U])on the 
 side of the patella mIicii tiic knee is in the semi-flexed 
 position. 
 
 The upward variety occurs only with rujiture of the 
 ligamentum patelhe. The accident is accompanied by considerable 
 .synovitis. The upward dislncation occurs when an attempt is made 
 to prevent one's self from falling backward, or it may follow as a 
 result of falling ujjon a liroken ])iece of glass or by a sabre cut. 
 
 The treatment of dislocation of the patella in the outward, inward, 
 and vertical varieties consists in elevating the entire limb, so as to relax 
 the quadriceps extensor nuiscle, which should be pushed toward the 
 patella while tliC limb is tlius hyper-extended. The bone itself is now 
 pushed by means of digital pressure into its proper position. Hooks 
 have been inserted under the skin to make outward traction, but their 
 use is attended with more or less danger. In the upward variety the 
 ligamentum patelhe nuist be sutured to its original point of attachment 
 to the tibia at the place from wliich the tendon lias l)een torn. This 
 operation mu.st be performed with great care and with every antiseptic 
 
 Andrews's case of 
 dislocation of 
 
636 DISLOCATIOXS. 
 
 preciiiition, since the close proximity to tiie knee-joint niiikes the opera- 
 tion one of more or k'ss gravity. The knee shoiikl he placed, aiter 
 reduction, in a plaster-(ji'-Paris splint. ^Vf'ter several weeks the dressing 
 can he removed and an elastic knee-cap applied over the joint, in order 
 to maintain tlu' jiatella in its proper position, and also to att'ord greater 
 security to the patient. In the congenital variety a knee-cap should be 
 worn, which has a tendency to prevent the bone from slij>ping too far 
 out of its place. 
 
 Di.SLOf'ATiox OP THE FIBULA occurs as a result of mechanical 
 violence, muscular action, or disease or arrest of growtii of the bone, or 
 some attV'ction of an adjacent joint, or even by lengthening of the tibia 
 or tibula l)y hypernntrition. 
 
 There are two varieties — one in the upper part, at the superior tibio- 
 fibular articulation, and the other in the lower part, at the inferior fibio- 
 fibular articulation. In the first variety the dislocation may be either 
 forward, backward, or upward. This variety is caused by a blow 
 upon the head of the fibula, or by a sudden contraction of the Inceps 
 muscle, or by shortening of the tibia in consecpience of fracture of tlie 
 bone. Dislocation in the lower end of the fibula may be also either /or- 
 ward or backward. In this variety a fracture is often associated with 
 the dislocation. 
 
 The signs and symptoms are to(j apparent to require any special 
 description. 
 
 The treatment consists in pushing the dislocated end back into its 
 place after first relaxing, by flexion, the muscles the contraction of which 
 would interfere with the rcducti(in. If this fails, the knee can be 
 extended with the foot strongly flexed. When the bone is in its proper 
 place a compress should be applied to the dislocated end, and the entire 
 limb placed in a plaster-of-Paris bandage for several weeks. 
 
 Dislocation of the ankle-.ioixt forms about 3 per cent, of all 
 dislocations. The injury is usually caused by a fill ujjon the foot, or 
 by a force expended upon the part of the ankle opposite to the disloca- 
 tion. A fracture is very often associated with this dislocation. 
 
 The varieties are outward, inward, forward, backward, and upirard. 
 The fibula is usually fractured in the outward, forward, and backward 
 varieties, and the tibia in the inward variety. 
 
 In the outward dislocation (Fig. 170) the foot is twisted and its 
 plantar surface is turned toward the filiula, the internal lateral ligament 
 is usually torn, and the inner malleolus projects just beneath the skin. 
 This variety is often mistaken for Pott's fracture. 
 
 In the inward dislocation the internal niallef)lus is usually fractured ; 
 the other side of the foot rests upon the ground, and tlu' inner side of 
 the foot is turned upward. 
 
 In the forward variety the foot is very much lengthened and the 
 tibia rests upon the upper and posterior part of the os calcis. This 
 form of dislocation is exceedingly rare. 
 
 In the backward variety the foot is very much shortened, the internal 
 lateral ligament is torn, the external lateral ligament and the fibula are 
 broken, the heel is very prominent, the toes point down, and the end of 
 the tibia is thl•o^^•n upon the scaphoid and the internal cuneiform bone. 
 
 In the upward variety the tarsal bones are forced up between the 
 
SPECIAL DISLOCATIONS. 
 
 637 
 
 tihia and fibula, and the ankle-joint is very much increased in its lateral 
 diameter, while the vertical measurement of the toot is much less than 
 normal. 
 
 The treatment consists in flexing the leg upon the thigh to relax 
 the tendo Achillis, and in making forcible but gradual traction upon 
 
 Fig. 170. 
 
 Dislocation of tlio ankle-joint outward. 
 
 the foot in the opposite direction to that from wliich the foot was thrust 
 at the time of the accident. Division of the tendo Achillis may be 
 performed with a view to facilitate the reduction. The foot should be 
 ])]aced at once in a plaster-of-Paris splint, or in lateral wooden .splints 
 witii holes in the si(ic to correspond to the salient points formed by the 
 two malleoli. In simple dislocation of the ankle the reduction is easily 
 accomplished, and if the joint is given sufficient pliysiological rest the 
 injury will repair witluiut any difficulty. 
 
 Compound dislocation of the ankle-joint was formerly considered a 
 mo.st serious injury. Even in tliese days, at a time when the technitpie 
 of aseptic surgery is nearly perfect, the management of these cases is 
 often attended with unsatisfactory results. The mortality in past years 
 was very great, and blood-poisoning was the usual cause of death. At 
 the present day this cause of death has been practically removed, but 
 
638 DISLOCATIONS. 
 
 tlie question as to the adoption of tiie best means of restoring the perfect 
 function of the ankle-joint is a most inij)ortant one. 
 
 Tiiere are certain Procrustean rules the strict observance of whicth 
 has given to the writer most satisfactory results — first, as regards the life 
 of the patient, and second, as reganls the complete function of the joint. 
 These rules are immediate ase])sis of the entire limb ; thorough irriga- 
 tion of, and free di-ainage entirely through and across, the ankle-joint ; 
 the securing of perfect inuuol)ility with plaster of Paris; removal of the 
 drainage-tube on the third day, with final irrigation and closure of the 
 drainage o|)euiiigs ; the employment of gentle passive movements and 
 massage at the end of the tiiird week ; and the free use of the joint with- 
 out crut(!iies or cane at the end of the sixth week. 
 
 Any result other than one attended with no constitutional disturb- 
 ance and with complete restoration of the joint may be called unsatis- 
 factory. The adoption of merely one or several of these rules will not 
 yield a good result. Their adoption from the l)eginning to the end in the 
 order mentioned is necessary to secure a satisfac-tory result. Perfect 
 asepsis at the stiirt will not yield brilliant results unless faithful and 
 conscientious attention is paid to the subsequent details. Each rule 
 must be observed in proper sequence in order to obtain at the end of 
 the treatment an ideal result. 
 
 Immediate. Axcpxix of the Entire Limb. — Too much importance can- 
 not be jilaeed upon this first rule. Tiie extremity should immediately be 
 thoi'ougidy washed with an abundance of soap and warm water, protect- 
 ing at the same time with iodoform gauze the ojiening into the joint 
 durino; this ablution. The entire limb should be clcanlv shaved with a 
 razor and again washed, after which the parts should be freely irrigated 
 with a 1 : 500 solution of bichloride of mercury. A saturated solution 
 of iodoform in ether should be poured over all the limb. The part 
 should now be protected with towels wrung out in a bichloride solution, 
 1 : 2000. Having removed the wet towels ])laced under the leg during 
 the aseptic cleansing of the limb, and having substituted clean bichloride 
 towels, attention is next directed to the joint itself. 
 
 Thorough Irrif/ation of the Joint. — An irrigator suspended a few feet 
 above and filled with a hot 1 : 5000 bicidoride solution should now be 
 used. The nozzle of the syringe should be introduced into the joint 
 and all the blood-clots washed out, together with debris that may have 
 entered the joint. A strong director should be passed through the joint 
 until its blunt end is felt at a point opposite, and then it should be cut 
 down upon and the wound made large enough to admit a large-sized 
 drainage-tube. 
 
 Surgeons have been accustomed to drain the joint upon one side, and 
 introduce the tube at the opening made at the site of the injury. This 
 is inadequate and insufficient. A pocket upon the opposite side of the 
 joint is formed in which l)lood-serum, lymph, and synovia collect, and 
 thus a nidus is formed for infection. Unless the joint is thoroughly 
 irrigated in all its parts there is danger of abscess. If a study of com- 
 pound dislocation of the ankle-joint is made, the interesting fact is 
 observed that abscesses are subsequently formed upon the side of the 
 joint directly opposite to the original opening. The time of formation 
 of these abscesses, and their situation and character, point to the fact that 
 
SPECIAL DISLOCATIONS. 639 
 
 their ilevclopmcnt Is due to sepsis originating within the joint. The 
 curious clinical fact tliat some time after the original injury to tiie joint 
 an abscess forms upon the opp(.isite side, and wiiere the tissues are all 
 sound and uninjured, suggests at once that the abscess is due to sepsis 
 and caused by the ix^tcntion of septic material in the pocket of the joint 
 distant from the original ^V()und. By free and perfect tlrainage, by anti- 
 septic irrig-ation at tlie time of the first dressing, and by providing a 
 free outlet tipon the healthy side of the joint, we may make sure that 
 no retention of blood or lymph or synovia can take place, and ^\•llerever 
 such perfect drainage is established the abscess is prevented. The abscess 
 that forms under these circumstances is prolific of evil. It sets up free 
 suppuration in the joint, and this is followed by necrosis, and then resec- 
 tion or amputation nuist be performed as a dernier ressort to save the 
 patient's life. 
 
 The next rule to adopt in the management of these cases is the imme- 
 diate fixation by plaster of Paris. Perfect immobility is essential, and 
 this can be best secured by the employment of the plaster-of-Paris band- 
 age. The wound having been covered by iodoform gauze, and jiieccs 
 of wet bichloride gauze having been jilaced loosely over the wound and 
 upon the foot and leg, a wet antiseptic bandage should be ajiplied to 
 keep the loose dressing in place. Over this a coml)incd dressing or 
 layers of purified cotton should be rolled, and a bandage to keep the 
 dressing in place. A piece of sheet iron about one inch in breadth, 
 and lient at the heel so as to extend from the toe down the plantar sur- 
 face of the foot over the heel and up on the posterior surface of the leg, 
 reaching above the knee-joint, should be adjusted. A corresponding 
 strip of sheet iron bent to fit the dorsum of the foot, the front of the 
 ankle, and the anterior surface of the leg should next be ajiplied. Two 
 short lateral splints of the same material should be placed on either side. 
 The plaster-of Paris bandage can now be rolled over the splints, and a 
 light ])laster l)andage applied, which now possesses great strength on 
 account of the splints, but which is not heavy or cumbersome. At the 
 first dressing a fenestrum can be cut over the \\ounds in order to with- 
 draw the drainage-tube. The leg can be suspended by a Salter swing, 
 which will enable the patient to move about in all directions in bed 
 during the repair of the wound. If there is any difficulty in placing 
 the fi)(>t and limb in proper position, the tcndo Achillis can be divided, 
 aTid thus physiological rest is at once enforced. 
 
 Still another rule refers to the time of removal of the drainage-tube. 
 If the wound is small and there has been little laceration, the third day 
 is the most appropriate time for the entire removal of the drainage-tube. 
 If, however, there is an excess of discharge from it, the tube can be 
 allowed to remain until the following day. At this dressing on the third 
 day, if it is thought lyest, for the reasons given, not to remove the tube, 
 then it should be irrig-ated, the iiozzle of the syringe being introduced 
 into one end of the tube, and a weak bichloride solution passed through 
 it and through the joint, and the drainage made once more free. 
 
 It sometimes happens that after the joint has lieen irrigated the tube 
 can be divided into two parts and a short end inserted into each of the 
 bilateral wounds, and these left in until the following day. If the tubes 
 remain longer than three or four days, they excite irritation in the joint 
 
640 DISL CA TIONS. 
 
 and may set \\\> suppuration. Ajjain, the rnhlter tulles beeome softened 
 in tiiree days, and are likely to tear aj)art, owinji' to the tension prodneed 
 l)y withdrawintr them throni;h tissnes to which they have become afiiiln- 
 tinated by inflammatory adhesion. Finally, after three days the tiilx's, 
 having accomplished the object for which they were employed, should 
 be removed, because they are not intended to drain pus, but to carry off 
 the products of acute intlanunation arising from the traumatism to the 
 joint. 
 
 The rule which relates to passive movements and massage at the end 
 of the third week is an important one to observe. Any movement of 
 the joint prior to this date is attended with danger. The parts are not 
 ready for passive motion before three weeks, and an attemj)t to move the 
 joint prior to that time will excite a new inflammation which may lead 
 to supjniration. If the joint is not moved at this time, the adhesions 
 become firm, and ankylosis is certain to follow, and consequently the 
 function of the joint is destroyed. Shampooing and gentle friction are 
 also valuable adjuvants at this period in the history of the injury. It is 
 to be especially noted that the movement allowed to the joint is not 
 active, but passive, and the former should not be permitted until six 
 weeks from the date of the accident. The rule that Sir James Paget 
 has given is here especially applicable. He taught that an acutely- 
 inflamed joint with heat and tenderness in it should be kept physiologi- 
 cally at rest, and that a joint that was stiff and partially ankylosed, but 
 was free from all inflammatory action, should be treated by passive 
 motion and massage. 
 
 The last rule refers to the time when the patient should begin active 
 movement in the joint. Active motion in the joint is necessary at this 
 period to excite the secretion of synovia, to release the tendons from any 
 adhesions due to a thecal inflammation, to disintegrate fibrous adhesions, 
 to restore the natural motion in the joint, and to absorb any of the products 
 of inflammation or of collateral ledema and ecchymoses in the surrounding 
 soft structures. It sometimes happens that at this stage swelling occurs 
 in the leg or in the foot from the removal of the plaster bandage. This 
 is, however, only temporary, and will soon disappear njion the patient 
 walking about for a few days. If active motion is allo\\'ed earlier than 
 the sixth week, there is danger of exciting new and suppurative inflam- 
 mation in the joint, and a joint that gave every prospect of becoming 
 perfect in function at the end of the second or third, or even the fourth, 
 week may become totally destroyed by a too early employment of motion 
 at a time when absolute rest is imperatively demanded. 
 
 No hard-and-fast rule can be made as to the amount of movement 
 that the patient should be allowed to make. The best guide is the feel- 
 ings of the patient. Too much exercise is as harmful as too little, and 
 exercise attended with ]xiin and fatigue is as injurious as movement of 
 the joint a week after the injury. The patient should be advised to 
 move the joint l)ut little at first, and by increasing the amount of move- 
 ment daily perfect restoration of the joint can be secured. 
 
 Dislocation of the astragalus occurs as a result of falls from a 
 height or of a sudden wrench or twist of the foot. In these injuries the 
 ligaments are torn from their attachment, and the bone, being free, is 
 thrust out of its position by the tibia, while the foot is strongly flexed, 
 
SPECIAL DISLOCATIONS. 641 
 
 extended, or inverted. The bone is dislocated from its relative position 
 between the os calcis and the tibia and fibula. This injury must not be 
 mistaken for dislocation of the ankle-joint, a description of which has 
 alreadv lieen given. In dislocation (if the astragalus tiie bone not only is 
 separated frtmi the malleolar arch, l)ut also from its attachments beneath 
 to the bones of the tarsus. In dislocation of the ankle-joint the astrag- 
 alus maintains its relative position to the bones of the tarsus. 
 
 The varieties are forward, backward, outward, or inward, and by 
 verition. 
 
 In the fonrard dislocation, wiiich is tiic most frequent, the bone 
 becomes displaced in consc(picnce of a fall or by a twist of the foot, 
 which is at the time of the accident in tiie position of full extension. 
 The astragalus is thus thrown forward against the astragalo-scaphoid 
 lig-amcnt, which gives way and permits the bone to be thrust out of its 
 socket and become lodged just beneath the skin on the dorsum of the 
 foot. 
 
 The signs and symptoms are tlic presence of the rounded head of 
 the astragalus ujioii tlic dorsum of tiic foot, the disappearance of the 
 normal landmarks of the joint, the complete loss of function, the short- 
 ening of the limb, owing to the position of the malleoli near the sole of 
 the foot, the prominence of one malleolus and the obliteration of the 
 other, M'ith either inversion or evcrsion of the foot. 
 
 Dixlocntioii of the astrdi/a/iis Ixtcku-drd occurs as a rare injury. In 
 this varictv the bone is forcibly driven backward and either outward or 
 inward u]ion one or the other side of the tendo Achillis. The inferior 
 surface of the bone lies upon the back part of the superior surface of the 
 OS calcis. This accident occurs when the foot is in extreme flexion, the 
 reverse of the position when a forward dislocation occurs. The injury 
 results from a severe twist or wrench which causes rupture of the poste- 
 rior fibres of the deltoid and external lateral ligaments, as well as of the 
 interosseous ligament. 
 
 The signs and symptoms are the presence of a bony prominence 
 just above the heel, with the tendo Achillis stretched tightly over it 
 upon one or the other side ; a marked depression u])on the front of the 
 ankle-joint, witli a prominent ridge above the fossa, consisting of the 
 anterior articulating margin of the til)ia ; complete loss of function and 
 marked flexion of the foot and innnobility of the ankle-joint. 
 
 Dislocations of the asfrar/alus outward and inicard occur with equal 
 frequency, although either variety is seldom observed. If the disloca- 
 tion is complete, a fracture of the corrcs]ionding malleolus occurs, and 
 the dislocatiori is thus complicated. This act'idcnt results from some 
 severe violence or by a fall U])on the side of the body when the foot 
 is caught and held firndy within tiie tight grasp of some object while 
 the person is in moti'on. 
 
 The signs and symptoms of lateral dislocation are — presence of a 
 bony prominence upon one side of the foot, with a corresponding depres- 
 sion u])on the opposite side of the joint ; and crepitus, as a rule, since 
 the malleolus upon the affected side is fractured. 
 
 Dislocation of the astrrir/ahis bi/ version occurs from a sudden twist 
 or wrench of the foot, and the bone may undei'go rotation upon a hori- 
 zontal or vertical axis. During the receipt of the injury the foot is 
 
 Vol. I.— tl 
 
642 DISLOCATIONS. 
 
 usually placed midway between Hcxinn mikI cxtcnsidn, and ron.«efjueiitly 
 at a riiflit angle to the leg'. 
 
 Tlu' signs and symptoms are cliicHy neiiative, since tliere are no 
 eharacteristie ehanges which enable the surgeon to diagnosticate the pre- 
 cise nature of the injury. The diagnosis must be established upon the 
 sudden loss of motion in the joint, severe pain increased by movement 
 of the foot, a rapidly-oeeurring synovitis, partial loss of the normal con- 
 tour of the joint, and, tinally, the existence of a serious sudden joint 
 affection, without any bony prominences to serve as a guide to determine 
 the character of the injury. 
 
 The treatment of dislocation of the astragalus is complex, varying 
 somewhat according to the special variety and the extent of damage 
 inflicted. In the incomplete form the dislocation is easily reduced. In 
 the coni])lete form often great difficulty is met with in attempts to rectify 
 the condition. In the forirard variety continuous traction of the foot 
 upon the leg must be made, with the knee flexed to relax the tendo 
 Achillis. It is usually necessary to make this manipulation with tiie 
 patient under the influence of an auiesthetic. If by flexion, extension, 
 traction, and manipulation the bone cannot be returned to its ]iroper 
 place, the tendo Aciiillis and any other rigid tendon shoidd be divided. 
 Tenotomy usually permits the reduction of the dislocation. If, now, 
 the surgeon is still unable to return the bone to its proper jilace, an 
 incision should be made and the obstacles to I'cduction removed if ])os- 
 sible. If this fails, the question of a primary resection, conservatism, 
 or amputation arises. The operation of resection depends upon the con- 
 stitution, age, and extent of damage to soft jiarts. If the jtatient is 
 young or in adult life, witii healthy viscera, and the astragalus is causing 
 pressure enough to produce slougiiing of the skin, a resection should be 
 made, since with antiseptic surgery a primary resection is far better than 
 to wait until abscesses form and extensive caries follows, which neces- 
 sarily leads to secondary resection or amputation. If the dislocation 
 can be partially reduced and movement in the joint is possible, and the 
 patient is feeble or aged, conservatism should be tiie line of treatment. 
 It is surprising how useful a joint can l)e secured in these cases under 
 such conditions. If the dislocation is compound, the patient aged, and 
 the soft parts are badly damaged, Synie's amputation is indicated. 
 After reduction of a dislocation of the astragalus a plaster-of-Paris 
 splint should be applied and the joint kept absolutely quiet for at least 
 six weeks. If a resection is performed, the rules already given for 
 resections should be adopted, and if amputation is re(]uircd, the ordi- 
 nary rules governing this operation should be observed. 
 
 SubaMmriaJohl dislocation consists of a sejiaration of the astragalus 
 from the scaphoid and os calcis. In this dislocation the connection 
 between the astragalus and the tibia and fibula is not disturbed. 
 
 The varieties are forwurd, Ixicl-irnrd, oidirard, and inwiird. If the 
 foot is dislocated forirard, the head of the astragalus rests upon the 
 calcanear facets ; if hacbcard, upon the dorsd surface of tiie scaphoid 
 or cuboid bones; if outward, upon the cuboid lione ; if inward, u|)on the 
 tuberosity of the scaphoid bone (Fig. 171). These subastragal()i<l dislo- 
 cations are caused b}' violent sprains or twists of the foot, and the liga- 
 ments connecting the astragalus with the scaphoid or os calcis tear. 
 
SPECIAL DISLOCATIOys. 
 
 643 
 
 while the lisjcaments between tlie ai?tni<;;a]iis and tlie til)ia and tibula 
 
 remain unbroken. 
 
 The signs and symptoms are extension of the toot, whieli is k'ngtii- 
 
 ened beiiind and shortened in front ; prominence of the head of the 
 
 astragahis, witii the skin stretched tiglitly over it ; aversion or inversion 
 
 of the foot according to the special va- 
 riety of the dislocation ; and great promi- 
 nence of one malleolus, witli a partial ob- 
 literation of the ]irominence of the oppo- 
 site malleolus and of the astragalus. 
 
 The treatment consists of extension 
 of the foot wiiile the knee is flexed, and 
 manipulation of the tarsus during exten- 
 sion. The patient should be placed upon 
 
 Subastragaloid dislocation 
 inward: 5, sustentaculum 
 tali ; 4, inner malleolus ^Du 
 Bourg). 
 
 The same: 1, head of astragalus; 3, 4, old cioatrires; 5, a 
 fistula ; 6, fracture of the fibula (Du Bourgi, 
 
 his back upon a tal>le, and the leg held firmly down, while the foot 
 hangs just over the edge of the table. If the tendons resist, they must 
 be divided. After reduction the rules governing the management of 
 dislocations in general should l)e strictly adliered to in every case. 
 
 In coinpoxnd mihaxtraf/aloifl dislocation a primary resection offers the 
 best chance for the recovery of the ])atient and for tlie future usefulness 
 of the joint. If the Ijone projects and its ligamentous attachments are 
 torn, the bone is likely to become carious, which eventually leads to a 
 secondary resection, and the results ol)tained under these conditions are 
 not so advantageous as those from a j)riiiiary resection under improved 
 antiseptic methods. 
 
 Dislocation of the medio-farml lioiirs: is occasionally observed. The 
 OS caleis, scaphoid, cul)oid, and the cuneiform bones have all been dislo- 
 cated, either alone or in conjunction with each other, and generall}' such 
 dislocation is as.sociated witli a fracture. 
 
 The signs and sjrmptoms arc tlie ]iresence of a dorsal bony promi- 
 nence, a depression corresponding to the situation of the bone, and oblit- 
 eration of tlic plantar arcli of the foot. 
 
 The treatment consists in traction of the anterior jjart of tlie foot 
 while the heel is held firmly, and digital pressure to push the bone into 
 its noi'mal place. In uncomplicated cases reduction has usually been 
 effected. In comjwnnd dislocation of the medio-tarsal bones the ex- 
 tended bone .should be removed if the skin is badlv damaoed and the 
 
644 DISLOCATIONS. 
 
 bone is free from its ligiimt'titous attachmonts ; otlicrwise caries of these 
 articulations is likely to folK)W and necessitate a secondary resection or 
 amputation, the ultimate result of which is not so favorable as is that of 
 a primary excision of the dis])laced bone under strict ase])sis. 
 
 Dislocation op the Jii-yrATAiiSAL boxes may occiu- as a result of 
 a fall from a hciirht in which the ])atient strikes upon his foot, or by a 
 heavy weight tailing directly upon the dorsum of tiie foot, and in excep- 
 tional cases even by muscular action. The first metatarsjil bone is more 
 frequently dislocated than the second. The third, fourtli, and iifth are 
 usually dislocated togethei', rather than singly. In some cases all of the 
 metatarsal bcjues lui\e been sinudtancouslv dislocated. 
 
 The signs and symptoms are too apparent to require any special 
 description, since the character of tlu; injury is at once recognized. 
 
 The treatment consists in traction of the toes while the heel is held 
 firmly and mani])ulative pressure exercised. If this fails, the bone can 
 be cut down u[ion and forced into its position. Asa rule, reduction is 
 most easily acconqtlislied. In those few cases where fiihire to reduce 
 the bone was reported the foot was fairly useful, notwithstanding the 
 unreduced dislocation. In compound dislocation with extensive bruising 
 of the soft parts, and with the ligaments badly torn, a primary resection 
 of the bone is indicated, and in only very exccjitional cases would an 
 amj)utation be performed. 
 
 Dislocation of the phalanges is not often observed. The dislo- 
 cation occurs as a result of a fiill upon the toes or liy direct violence, as 
 in kicking some object or stubbing the toe against a stone. The great 
 toe is more often the seat of dislocation than the others. 
 
 The signs and symptoms are too apparent to need any description. 
 
 The treatment consists in traction of the dislocated toe while the foot 
 is held tirndy by an assistant. If the reduction cannot be effected in this 
 way, some form of traction forceps, such as are ust'd in case of dislocation 
 of the thumb, can be employed. If this manipulation fails, the bone can 
 be cut down upon and another attempt made, and in case of repeated 
 failure a primary excision of the phalanx should be performed, or even 
 an amputation of the toe, especially if it is any otiier than the great toe. 
 
ANESTHESIA. 
 
 By h. c. wood, :m. d., ll. d. 
 
 Ik considering the subject of anaesthesia the first question wliich arises 
 is as to the choice of tlie antestlictic, and in discussinji' tiiis it seems to me 
 important to cull attention briefly, but emphatically, to the relations 
 which ought to exist between clinical and experunental medicine. The 
 value of experimental medicine to the profession is very great, but it is 
 entirely possible to go wrong in the practice of medicine by attaching too 
 nuich weight, or rather by attaching improper weight, to the apparent 
 results of experiments. The ultimate ajtpeal for a final decision in thera- 
 penties nuist always be to clinical medicine. Experiments upon the 
 lower animals are sometimes useful as guides in making experiments 
 upon human beings, but their chief value is to be found in the intei'pre- 
 tation of the results reached at the bedside. So much attention has been 
 in the past few years given to the experimental study of anaesthetics that 
 there has been danger of undervaluing the clinical side of the suliject. 
 In the present article it is proposed to consider first the clinical, second 
 the experimental, evidence. 
 
 In the selection of an antesthetic the question of safety is jiaramount. 
 One anaesthetic may be more convenient than another, less disagreeable 
 to the patient, less costly in time to the surgeon ; but the question of 
 safety should dominate all otiiers. It should never be forgotten that at 
 present we know of no true aniesthetic (for nitrous oxide, for reasons 
 given hereafter, scarcely belongs to the class) whose use is unaccompanied 
 with danger. It is true that recent, and perhaps even the older, medical 
 literature is flecked with the assertions of various surgeons that not only 
 have they given anajstheties many hundreds of thousands of times with- 
 out accident, but also tliat these results have been due to their own indi- 
 vidual skill, and that if their methods of administration were adhered 
 to all the danger of ansesthesia would be overcome. 
 
 There are few things more tiresome in medical literature than these 
 clamorous outcries of conceit and vanity. The surgeon who claims that 
 in his hands anaesthetics are free from danger, forgetful that death from 
 ana?sthesia has occurred in the practice of Simpson, Symes, Gross, Agnew, 
 Billroth, and almost the wliole of the list of the world's greatest of sur- 
 geons, causes in us some amusement, and still more disgust. Anaesthesia 
 produced in any way is a condition of danger, and the one great hope of 
 safety on the part of the patient lies in the recognition of this fact by the 
 anfesthetizer. Despite all precautions, given so many thousand anaesthe- 
 sias there will be so many deaths from the anasthetic ; the oulv ho])e is 
 by careful study and by careful administration to reduce the mortality 
 
 645 
 
646 ANJESTHESIA. 
 
 to tlif iniiiiinum : tlic unexpected will in all ])robability sometimes happen 
 to the end of time. 
 
 These things being so, the lirst matter to be decided is what the clin- 
 ical records reveal as to the comparative frequency of the deaths from 
 the various anaesthetics. Fortunately for our purpose, there have been 
 recently published several elaborate studies of these records — studies so 
 complete that reliance upon them is justitialjle and further examination 
 of the original records almost a waste of time. The number of sub- 
 stances which have been used by the surgeon to produce unconsciousness 
 is quite large, yet three anaesthetics — nitrous oxide, ether, and chloro- 
 form — stand out before all others so prominently that I shall first study 
 their comparative safety and use, afterward calling attention to some of 
 the minor anaesthetics as a sejiarate group. 
 
 In viewing any subject statistically there is always danger of being 
 misled by fallacies which are too commonly recognized to be here dwelt 
 upon in detail. There are two ways in which these fallacies may be more 
 or less completely avoided : first, by the selection of a comparatively 
 small cluster of observations made by a single individual or a small group 
 of individuals under circumstances as nearly uniform as may be ; second, 
 by the gathering together of an immense number of statistics, made under 
 all conceivable circumstances by all sorts of observers — a collection in 
 which the mass is so large that there is hope that mistakes in one direc- 
 tion may be counterbalanced by mistakes in the other. The best recent 
 exam])le of the first method applied to anaesthesia with which I am 
 familiar is in the table cdrnpiled from the St. Bartholomew Hos]>ital 
 Reports by Dr. Geo. M. Gould, editor of the Medical News of Philadel- 
 phia. From 1875 to 1890, inclusive, in the St. Bartholomew Hospital 
 anaesthesia was produced 19,526 times by chloroform, 8491 times by 
 ether, and 12,941 times by ether preceded by nitrous oxide. The num- 
 ber of deaths were respectively l-'}, 3, 1, giving the mortality of chloroform 
 as 1 in 1502, ether as 1 in 2830, and ether preceded bv nitrous oxide as 
 1 in 12,941. 
 
 Of statistics in which it has been attempted to avoid error by mass 
 the most recent and probably the best is the table prepared by Dr. Gould 
 based upon that pul)lished by Julliard, who in turn used that of Compte 
 as a foundation. In this table there are included 638,461 administrations 
 of chloroform, with a total of 170 deaths; 300,157 administrations of 
 ether, with a total ^A' IS deaths, giving a mortality of chloroform anaes- 
 thesia as 1 in 3749, and ether anajsthesia as 1 in 16,675. 
 
 The probable correctness of the conclusions reached by the Gould- 
 Julliard-Compte statistics is strongly confirmed by the closeness vnth. 
 which the results coincide with those obtained from other large statistics. 
 Many years ago Dr. Richardson of London placed the jirobaljle number 
 of deaths from chloroform as 1 in 3000. In a careful iliscussion of the 
 statistics of anaesthesia Dr. H. ]\I. Lyman reached the conclusion that 
 the proportion of chloroform deaths is 1 in 5860. In the proceedings of 
 the German Surgical Society in Berlin, 1891, sixty-six European sur- 
 geons reported nearly 23,000 cases of chloroformization, with 6 deaths, 
 giving a proportion of 1 in 3776. 
 
 In the report of the Lancet Commission for the clinical study of ana?s- 
 thetics it is attempted to get at the proportionate number of deaths by 
 
STATISTICS OF DEATHS IN ANAESTHESIA. 647 
 
 ostimating the ])rohalik' total ininilKT (if an;pstliosias and tlio total num- 
 ber of reported deaths. The difiieulty with this method is obvious: 
 only a portion of tlie an;estlietic deaths are reported, and the estimation 
 of the number of inhalations is nothing else than guesswork. The con- 
 clusion reached by the eonnnission is that there liave been thirteen times 
 as many deaths from ehlonifurm as from ether, and that the number of 
 inhalations of ehlorofirm has been six times as great as those of ether ; 
 which gives a mortality-rate to chloroform more than double that of 
 ether. These results cori'espond with the statistics of the St. Barthol- 
 omew Hospital, but are very much more favorable to chloroform than 
 are the conclusions to be drawn from the large mass of statistics, which 
 mass gives the proportionate mortality about as four and a half to one. 
 I ])ersonally believe that the large statistics, overwhelming as they are 
 in the number of cases rejiorted, represent as near as can be the true 
 state of the case, and that the surgeon mIio administers chkiroform faces 
 the fact that the dangers of its use are more than four times those which 
 confront the man who administers ether. 
 
 In strong contrast to the clinical results of the use of chloroform 
 and ether is the history of nitrous-oxide inhalation. The Linicct Com- 
 mission has collected seventeen deaths as having occurred during the 
 auifsthetic use of the gas : several of these eases are, however, not fliirly 
 attributable to the inhalation, but even if they all be accepted as accu- 
 rate reports, the mortality is scarcely more than nominal. The gas is 
 prol)ably administered to seven or eight hundred thousand people 
 annually by lecturers, dentists, etc., some of them men of education, 
 others men of ignorance. In other words, many millions of inhalations 
 have been given, many of them by incompetent ])crsons, and yet less 
 than two dozen cases of death have occurred during the decades since the 
 first administration of the gas. Dr. Chas. M. Buchanan' is probably not 
 far out of the wav in his conclusion that the mortalitv of nitrous-oxide 
 inhalation is 2 ii"i 10,500,000. 
 
 The startling ditfcrence between nitrons oxide and the other agents 
 used leads nati:rally to a search for causes. The reason of the difference 
 is that nitrous oxide lies apart from other aniesthetic agents in being an 
 inert substance so far as the human organization is concerned. In the 
 production of anaesthesia it acts by shutting off the oxygen from the 
 blood, as is shown by the fact — established by Jolyet and Blanche, 
 bv Elihu Thompson, and by my own ex]ieriments — that an animal will 
 live in nitrogen, in hydrogen, or even in a vacuum, as long as in pure 
 nitrous oxide ; and that, as shown by myself,- the circulatory phenomena 
 of nitrous-oxide ansesthesia are very similar to those which are caused 
 bv the inhalation of jiure nitrogen or by mechanical asphyxia ; that, as 
 demonstrated by the French observers, coma is not developed until the 
 oxygen in the blood is reduced to 3 or 4 per cent. ; that, as proven by 
 my own experiments,' the time recpiired for the jiroduction of ana\sthesia 
 is practically the same with nitrous oxide as with mechanical asphyxia ; 
 and finally, as was shown in my own experiments, that the addition 
 of 3 per cent, of oxygen doubles the time necessary for the production 
 of ana:;sthesia, wliilst the addition of 5 ])er cent, of oxygen more than 
 
 ' Medical News, vol. l.xii., 1893. ^ TItemp. Gaz., 1890. 
 
 ' Denial Cosmos, 1893. 
 
()48 ANESTHESIA. 
 
 sextuples the time required, and S ptT cent, of oxyircu indefinitely post- 
 pones the production of eonipiete ;in;estliesia, at least in tlie doii-. 
 
 During the use of the true anajstlictic there is a ])oison cireulatinii' ''^ 
 tile blood, and when an accident occurs time is recjuired for tlic removal 
 of this poison even if no more of tiie an.estiietic be administered. In 
 nitrous-oxide ansesthesia there is no poison in the blood, and if at any 
 time the partial arrest of function which has been produced by shuttinsj 
 off the sustaining oxygen becomes too complete, tiie introduction (tf 
 oxygen into tlie l)loo(l finds the nerve-centres ready at once to res])ond 
 to their natural stimulus. Unfortunately, tiie brevity of the action of 
 nitrous oxide prevents its general use for the purjioses of the operating 
 sui'geon. When, however, a tooth is to be drawn, an abscess to be 
 opened, or other surgical jjrocedure involving but a moment of time 
 gone through, nitrous oxide is the safest and best of known auiesthetics. 
 
 The second sulj-(|UCstion whieli presents itself for studv in as to the 
 method in which aiuesthetics jn'oduce death ; and here, again, tlie pro- 
 fession is under great obligation to the Lancet Commission for the 
 extraordinary labor with which it has searched out clinical records. 
 It has analyzed and tabulated the reports of 384 deaths during clilor- 
 oformization, and has shown that out of this number in 227 cases the 
 pulse fiiiled entirely before the cessation of respiration ; that 77 times 
 cardiac and respiratory action ceased simultaneously ; and that only in 
 80 cases did respiration stop before tiie heart. 
 
 Whatever the results of experimentation with anesthetics ujxjii the 
 lower animals may be, it seems to me absurd for any one to claim that 
 in man chloroform does not frequently produce death by an action ujion 
 the heart. In numerous cases of chloroformization tiie action of the 
 heart has been tested not only Iiy feeling tlic pulse, Init also bv auscul- 
 tation — tested, too, witii a full knowledge on the part of the observer 
 that leaders of the profession have declared that chloroform never kills 
 by its action upon the heart ; and yet in nearly four cases out of five 
 it has been noted that the death came through the heart. If clinical 
 observations upon the simplest questions be of any value whatever, the 
 conclusion must be tluit in the large majority of cases cliloroform death 
 has been due to cardiac arrest. It must lie remembered that the average 
 intelligence and skill of the surgical observers who have recorded fatal 
 accidents from ansesthesia is simply the general average intelligence and 
 skill of the surgical profession ; and if these gentlemen are not to be 
 trusted to observe such jiatent phenomena as indicate a cessation of cir- 
 culation or of respiration, to whom are we to look for such data? 
 
 All observers, clinical and experimental, are in accord in acknowledg- 
 ing that when chloroform paralyzes the respiration it does so by a direct 
 action upon the respiratory centre ; the matter still requiring careful dis- 
 cussion is as to the way of the syncopal deaths. 
 
 When chloroform is given to the lower animals there is always after 
 the first half minute of tlie inhalation a progressive lowering of the 
 arterial jiressure. Uj) to this point tiiere seems to be no discordancy, 
 and in the controversy which has raged for the last few years on the 
 subject Ave get one firm, indisputable point — namely, that ether is a 
 atiiimlant and chloroform a depressant to the circulation. For many 
 years all observers have agreed that cliloroform directly lowers the arte- 
 
ANESTHESIA. 649 
 
 rial pi'essure, but great has been and still is the dispute as to the imme- 
 diate mechanism of the tall which the drug- ])roduccs. Docs the pressure 
 come down through the widening of the blood-])aths by a centric or 
 vasomotor ]xiralysis, or is tlie fail in jxirt or altogx^ther due to an action 
 upon the heart '.' In other words, is chloroform a vasomotor depressant 
 simply, or is it also a cardiac depressant? 
 
 Sausom and Harley state that during chloroformization a spasm of 
 the small vessels can be readily seen to occur in the M'eb of the frog. 
 Not until the tliird stage is reached, according to these authors, do the 
 vessels relax into dilatation. If these observations be correct, chloro- 
 form tirst stinndates and afterward depresses the vasomotor centres. In 
 accordance with this are the experiments of Gaskell and Shore,' who 
 find that the local application of chloroform to the medulla or its injec- 
 tion into the cerebral artery produces an immediate rise of blood-pres- 
 sure, usually accompanit'd l)y a slowing of the heart, this rise being fol- 
 lowed by a fall of pressure so soon as the chloroform is able to diffuse 
 itself over tlie circulation. In a further very ingenious series of experi- 
 ments, Gaskell and Shore connected the carotid artei'ies and jugular vein 
 of an animal (A) with the similar vessels of the second animal (B), so 
 that the l)rain of A was fed exclusively with lilood from B. It is plain 
 that chloroform given to B would reach the brain of A, but woidd not 
 reach tiic heart of A. Under these circumstances it Mas found that 
 chloroform administered to B produced rise of pressure in A. In a 
 second series of experiments the blood-vessels of A were so connected 
 with those of B that when chloroform was administered to B it reached 
 the lu'art of A and all other portions of the body except the brain. 
 AMien this was the case, chloroform given to B produced an innnediate 
 fall of arterial pressure in A, without any previous rise. In other 
 words, when chloroform reached the vasomotor centres, and not the 
 heart, it caused rise of arterial pressure ; when it reached the heart, 
 and not the vasomotor centres, it caused fall of pressure. 
 
 The only experiments with which I am aecpiainted to which any 
 weight should be attached as indicating that chloroform primarily para- 
 lyzes the vasomotor centres are those published as long ago as 1S74 liy 
 H. P. Bowditch and ('. S. Minot." In tiiese experiments, which were 
 made upon curarized animals, " irritation of the sajihena nerve caused 
 a much less marked rise of blood-tension than when the ansesthetic 
 was not used. Sometimes there was absolutely no rise of tension to be 
 observed, while at other times the rise was from one-third to one-half 
 that jiroduced by the same irritation on an animal not subjected to the 
 action of chloroform." Further, compression of the carotid in the cldoro- 
 formed aniiuai did not cause the customary spasm and rise of arterial 
 pressure. 
 
 It must be remembered thi-t these experiments of Bowditch and 
 ]\Iinot were made at a time when the importance of the suliject had not 
 been fully realized ; that on the carotid lint a single experiment was 
 made; and that there was frequently in the ex])eriments of Bowditch 
 and Minot a great rise of pressure following irritation of the sensitive 
 nerve, though the rise was not as great as in the normal dog. There 
 seems to be no doubt that late in chloroform-poisoning there is vasV)- 
 
 ' British Med. Journ., vol. i., 1S93. ^ Boston Med. and Surg. Jnurn., 1874. 
 
().")() ANESTHESIA. 
 
 iiiotKr paralysis, and it may very well he (hat in (he single carotid 
 experiment of" Bowditeii and Miiiot the ciilorofiirmization had been 
 earried on to tlie fullest extent, whilst the rise of ])ressiii'e which 
 occurred in many of their chloroformed dogs when the saphena nerve 
 was irritated show's that at such times, at least, the vasomotor centres 
 \vere not ])aralyzed, though tht^ arterial pressure had fallen very dis- 
 tinctly. The results, therefore, of J5owditch and Minot are not in any 
 way |)roof of the incorrectness of the theory of Gaskell and Shore, and 
 the drift (»f the present evidence is to show that chloroform in the earliest 
 stayes of its (tction stimulates rather than depresses the vasomotor centres. 
 
 On the heart itself chloroform undoubtedly exerts a steady, power- 
 ful depressing influence. Injected into the jugular vein (see also 
 MacWilliani's experiments), it instantly arrests the iieart's action and 
 destroys its muscular irritability. Even the vapor of chloi'oforni, when 
 locally applied to the exposed heart, paralyzes it.' When artificial res- 
 piration is maintained the effect of chloroform upon the heart is very 
 apparent.^ By a very ingenious series of experiments Dr. MacAYilliam * 
 has [)roven that very early in chloroform anaesthesia there is a mai-ked 
 diminution of the force of the auricular and the ventricular beats, acconi- 
 })anied with dilatation of the cardiac chambers, due to the direct influ- 
 ence of the chloroform. Again, as pointed out in the paper of Gaskell 
 and Shore, even the tracings of the Hyderabad Commission show that 
 from the very beginning of chloroformization the excursions of the 
 heart-beat, as portrayed by the Fick manometer, get smaller and smaller 
 in the most typical manner. Indeed, as Gaskell and Shore .say, " every 
 one Would agree with the commission that tluy (tlie ])ulse-waves) are of 
 the t)pical kind which would he j)roduced if direct \\eakening of the 
 heart were the cause of the fall of blood-pressure in chloroform admin- 
 istration." 
 
 Putting all the evidence together, it seems to me to have been com- 
 pletely demonstrated by jihysiologists — first, that chloroform is a direct 
 depressant and p(irali/zant to the heart-inusclc or its contained r/an(/lia ; 
 second, that the early fall of blood-pressure which occurs in chloroform- 
 ization is in great part, if not altogether, due to this direct depression 
 of the heart. 
 
 This conclusion having been reached, attention is next naturally 
 directed toward a study of the action of ether upon the circulation. 
 
 It is firndy established by the coinciding results of very many 
 experiments performed by various observers that during etherization 
 there is usually a pronounced rise in the arterial pressure, which is com- 
 monly maintained even through a prolonged narcosis, and may continue 
 after manifest failure of respiration. Sooner or later, if the inhalation 
 be continued, the rise of arterial jiressurc is followed by a fall, which 
 may progressively increase until the manometrical needle reaches almost 
 zei'o. There have been very few careful studies of the details of the 
 action of ether ujion the circulation, but such facts as we have go to 
 show that the primary influence of the drug is to stimulate both vaso- 
 motor centres and heart, and that during the stage of low pressure there 
 is depression of the vasomotor centres and also of the heart. The 
 
 ' Edinburgh Med. Joum., 1842. • ^ .loiirn. Annt. and Physiol., xiii., 226. 
 
 ' British Med. Joum., vol. iii., 1890. 
 
ANESTHESIA. 651 
 
 belief ill tiio primary stimiilatii)ii of tiie vasomotor centres rests almost 
 entirely upon the research of Professors Bowditeh and Minot, made in 
 1<S74, and the snbject is well \\ortliv of a careful re-study. There is 
 much reason for the belief that in advanced and profound ether- 
 narcosis the blood-vessels are alfected by the direct action of the sub- 
 stance upon their coats. 
 
 The clinical and physiological fticts which have thus far been brought 
 forward in this paj)er would seem in themselves, and in tiicir accordance, 
 .<utticieut to prove that fatal syncojie by direct effect of chloroform upon 
 the heart is the common cause of chloroform death, and that ether is the 
 safer remedy, because it usually primarily stimulates the heart. The 
 matter is not, however, (piite so clear as it seems. It has been within 
 the last few years repeatedly asserted by physiologists of repute that 
 neither ether nor yet chloroform ever kills the lower animal by cardiac 
 paralysis; or, in other words, that it is not possible to produce in the 
 lower animals by iniialation of ether or chloroform arrest of the heart's 
 action before arrest of respiration. This is, however, an error. I have 
 been seeing chlorofoi'm death in animals with great frequency for nearly 
 twenty-five years in the physiological laboratory, and I have made a 
 large number of experiments in the most careful manner, and I know 
 that in the dog t'hloroform may ])roduce death liy a centric respiratory 
 paralysis, but more commonly in my experiments has there been a 
 simultaneous or almost simultaneous arrest of respiration and circula- 
 tion, and occasionally, and as a rare phenomenon, primary arrest of the 
 heart has occurred. I have seen the respirations continue for fully two 
 minutes, much of the time full and fairly frequent, although there Avas 
 no blood-movement whatever in an exposed carotid artery or any move- 
 ment of the heart that could be detected l)y the hand f)r ear. 
 
 Again, in exceptional cases the stimulant influence of ether upon the 
 circulation is very slight and transient, so that in the physiological 
 laboratory I have seen the blood-pressure begin to fall during an early 
 stage of ether ana'sthesia, and I have in one or two cases seen a cardiac 
 arrest jiroduced by ether at a time when the respiratory function was 
 still active. As every one knows, the Hyderabad Commission, the great 
 sujiporter of the exclusiveness of respiratory death, dei'ived most of its 
 authority from the presence on it of Lauder Brunton of London, who in 
 a recent publication says : "If we drive chlorofVirm into the trachea, or 
 air very heavily loaded with chloroform vapor into the lungs by artificial 
 respiration, it will be absorljcd in sufficient (piantitics to paralyze the 
 heart." This is a jiractical giving away of the whole case of the Hy- 
 derabad Commission, at least as I have understood it, and as I believe 
 it to have been understood by the general profession. However this 
 may be, it is a confession that the chloroform death is not of necessity 
 due to asphyxia, so that it mast be admitted, first, that both ether and 
 chloroform may kill the man or the lower mammal either l)y arrest of 
 respiration or by syncope ; second, that syncopal death from chloroform 
 is not common, though it docs occur in the lower animals, Init is not rare 
 in man ; third, that the chief difference between ether and chloroform, so 
 far as the mode of death is concerned, is that that form of death (synco- 
 j>al) which is cranmon under the influence of chloroform is rare under 
 the influence of ether. 
 
652 ANESTHESIA. 
 
 Tlio cardiac action of chloroform is evidently one cause of the greater 
 fatality of ciilomforniization, hut it is not the only reason why chloro- 
 form kills so much mcjrc frecjncntly tlian docs ether. In my experi- 
 ments upon the lower animals I have noted that chloroform lets go its 
 hold much less readily than does ether. This, I had always supposed, 
 was simply due to the greater volatility of ether, but a recent very 
 interesting research by Mr. Julius Pohl seems to show that chloroform 
 has a primary attachment, so to speak, for the brain — /. e. a temlcncy to 
 aecunuilation in the brain-tissues. Mr. Pohl found on chemical examina- 
 tion tiiat there was much more chloroform present in the brain-tissues 
 than in the blood passing to the brain — a fact to be explained only as a 
 result of storing up in the brain. It may well be that one cause of the 
 persistency of the action of chloroform upon tiie nerve-centres is due to 
 this tendency to escape from tlie blood-vessels into the nerve-tissues. 
 Nevertheless, the comparative volatility of the two ansesthetics and the 
 comparative diffusibility of their vajjors appear to be distinct elements 
 in the eomparati\'e danger of their use. There is very great reason for 
 lielieving that chloroform is less Ictiial in hot climates than in colder 
 I'egions. The British surgeons of India aver with one voice that they 
 can administer it without evil effect. Tlie aiisesthetizers of the exti'eme 
 southern or Gulf tier of American States are almost equally urgent in 
 claiming safety for the use of chloroform, whilst on the continent of 
 South America it is solely employed, again with alleged freedom from 
 ill effect. The only explanation of these facts which seems to me ])lau- 
 sible is that at high temperatures cidoroform va])or diffuses very rajiidly, 
 and consequently escapes from the blood and from tlie lungs witii extra- 
 ordinary rai^idity. 
 
 So far as concerns what may be considered the major antesthetics, 
 the question asked in the beginning of this essay has n(jw been 
 answered ; the answer being — first, that nitrous oxide is the safest and 
 best of the amesthetics when the ])urposes of the anaesthesia admit of its 
 use — that is, when the anaesthesia needs only to be of sliort duration ; 
 second, that both clinical and experimental evidence agree in showing 
 that ether is much safer than chloroform, and, as safety is under ordinary 
 circumstances the one quality that the surgeon should consult in the 
 choice of an anaesthetic, no surgeon is justified in emploving chloroform 
 unless it be under certain peculiar circumstances and for certain definite 
 reasons or purposes. 
 
 Having arrived thus far, the next (juestion naturally is, ^^'hat arc the 
 circumstances which justify the use of chloroform? 
 
 Before, however, discussing this it seems but right to consider the 
 possibility of substituting for chlorotbrm and ether some other anaesthetic. 
 This leads, in turn, to the study of \\liat may be termed the minor aiurx- 
 thriicfi. 
 
 Of the numerous substances which have been more or less clamor- 
 ously put forward as valuable anaesthetics, but few require notice here. 
 
 Bichloride of methylene was originally highly recommended by Dr. 
 B. W. Richardson in 18G7, and ga\-e rise to a considerable controversy. 
 In 1883, j\IM. Kegnauld and A'illejeau obtained directly, through agents 
 accre<lited l)y Sir Spencer Wells, tlie great advocate for the use of methyl- 
 ene bichloride, the article employed as the l)icidoride in England. On 
 
MrXOB ANJESTHETICS. 653 
 
 careful elicmical study tlicy fouud tliat it contained no liicliloride of 
 methylene, but was composed of four j)arts of chloroform and one jiart 
 of methylic alcohol. About this time, without knowing anything of 
 this work, I had a bichloride of methylene of a leading London chemist 
 examined in the chemical laboratory of the University of Pennsylvania, 
 and i'ouud that it was almost ])ure chloroform ; so that there can be no 
 doubt that commercial bichloride of uietliyleue has been generally a more 
 or less impure chloroform. 
 
 In the further studies of Eegnauld and Villejcau it was determined 
 that chemically-pure methylene bichloride is very difficult and costly of 
 ]n-e])aration, and that when it is given to the lower animals as an anes- 
 thetic it produces not a qniet anesthesia, but choreic movements and 
 cpilc]itilbrm convulsions. There are m\ record at least nine deaths ])ro- 
 ducctl by the commercial drug, and it dt)es not seem necessary further 
 to discuss the matter here ; the bichloride of methylene must lie dismissed 
 from the list of practical anesthetics. 
 
 Pciifal, a very recent candidate lor professional favor, is a colorless, 
 highlv inflammable liquid, boiling at 100.4° F., which when admin- 
 istered produces with extraordinary promptness a narcosis which is said 
 to disappear more rajiidly than does that caused by chloroform or ether, 
 but less rapidly than does that produced by ethyl bromide. In a study 
 of the drug made by Dr. David Cerna and myself it w-as found that 
 pental anesthesia in the dog is always accompanied by a very pronounced 
 fall of the arterial pressure, and the conclusion was reached that the 
 remedy is a jiowerfid di'iiressant to the heart. Further, it has been noted 
 by Kleindienst that in man three uv four days after ])ental narcosis the 
 urine very frequently becomes heavily charged with albumin, and that 
 not rarely hematuria or hemoglobinuria occurs. This, if confirmed, 
 shotdd put an end to any anesthetic use of pental. Finally, according 
 to the only statistics upon the subject that I know of — namely, those of 
 Gurlt — pental would appear to be the most dangerous of all the anes- 
 thetics in its action, there having been three deaths in the six hundred 
 reported narcoses. The future does not look bright for pental. 
 
 Efhi/I bromide is a colorless, very volatile liquid, which has been 
 confounded with ethylene bromide with fatal results. The substances 
 are essentially different, chemically as well as physiologically. Ethyl 
 bromide does" not solidify at 32° F., and has a specific gravity of about 
 1.49; ethylene bromide has a sjiecific gravity of 2.16, and at 32° F. 
 solidifies into a crystalline mass. Ethyl bromide was first projiosed as 
 an anesthetic by Dr. Thomas Nunnelly in 1 S49, but was not brought 
 earnestly before "the profession until 1876-77, when attention was called 
 to it by Rabnteau in France and T>awrence Turnbull in the United 
 States. Its influence is usually manifested a few seconds after the begin- 
 ning of an inhalation, and lasts from one and a half to three minutes 
 after the removal of the drug irom the mouth. A peculiarity that has 
 been rioted by several observers is a tendency for sensibility to be lost 
 before consciousness is completely destroyed, and Professor Montgomery 
 has especiallv noted that during ]>arturition it will do away with most 
 of the suflering without arresting the ])ains or producing complete luicon- 
 sciousness. The narcosis is only in rare instances accompanied by com- 
 plete relaxation of the muscles ; indeed, it appears to be common for the 
 
654 ANAESTHESIA. 
 
 general niuseiilar tonus to be greatly increased. According to Professor 
 flolin H. Brinton, muscular rigidity, local spasms, and even gcn(>ral 
 tetanus with opisthotonos, occur so frequently as seriously to interfere 
 with the eni])l<)yment of the drug as an antesthetic, especially as this 
 condition of muscular excitement, when it develops during a sui'gical 
 operation, is attended liy great increase of hemorrhage.' During narco- 
 sis the corneal and pupillary reflexes are usually preserved, and the eyes 
 are sometimes wide open and crossed from contractions of their muscles." 
 
 Tlie physiological action of ethyl bromide has been studied bv 
 Schneider, by Abonyi, by Thornton and INIaxwell,' and by myself. 
 Schneider states that the arterial ])rcssure does not fall until very late 
 in the bromide narcosis, and that death takes place always through 
 arrest of the resjiiration. In these statements he is in accord with 
 results obtained by Abonyi,^ who was not able to detect any alteration 
 in the beat of the exposed heart of the frog in which narcosis was pro- 
 duced. On the other hand, the experiments of Thornton and Maxwell 
 are in agreement with my own, in showing that the arterial pressure 
 falls early and increases steadily with a persistent inhalation. In my 
 own experiments ethyl bromide seemed to act on the circulation simi- 
 larly to chloroform, although less powerfully. 
 
 It is possible that the ditterence of result ol)tained by physiologists 
 has depended ujwn the ethyl bromide being impure. In the eighth 
 edition of my Treafi'^e on Thrrapcutirx it was stated that clinical results 
 would jirobably show that ethyl bromide is a very dangerous ansesthetie, 
 at the time of issue of the work there being thi-ee deaths reported as 
 occurring in a very limited number of administrations.^ To these cases 
 must be added the death rejiorted by Dr. A. Gleieh,'' also that recorded 
 by Dr. Reich. On the other hand. Dr. Gllles claims ^ that there were 
 given in Germany during three years twenty thousand administrations 
 without a single fatal result, and that there is no fatal result on record 
 in which it has been proven that a chemically-pure bromide has been 
 administered. 
 
 This statement is, however, at present not correct. 16 cases of death 
 from the ethyl bromide have been collected by Dr. Reich,' and of these 
 in 5 the bromide is asserted to have been pure. It is remarkable that 
 out of the 7 cases in which any information as to the time of death is 
 given, in only 2 did death take place during the narcosis ; in the other 5 
 cases it occurred from one to three days after. In Dr. Reich's case ' the 
 inhalation of the bromide was followed by immediate and continuous 
 vomiting, with development of symptoms similar to those of acute 
 phosphorus-poisoning, ending in death on the seventh day. At the 
 auto])sy the liver and kidneys were found in active fatty degeneration. 
 After the inhalation it was remembei'ed that the bromide used had 
 a faint yellow color, and it may possibly be, therefore, that the fatal 
 result was produced by some decomposition-product. Early in the 
 
 • Themp. Gaz., viii. « Dr. Gillos : Berlin, klin. Wochenscli., xxix., 1892. 
 3 Therap. Gaz., 1892. • Wiener K/inik., 1891, Heft 1. 
 
 * Therap. Monatxli., vol. ii., 1888; ami TurnbiiU's Amesthtsia. 
 6 Wien. kiln. WoehcHxeh., vol. v., 1892. 
 
 ' Berlin, klia. Wochenaeli., vol. xxix., 1892. 
 
 8 Wien. vied. Wochensck, 1893, p. 1179. ^ Op. cil., p. 1226. 
 
CIRCUMSTANCES MODIFYING THE CHOICE OF ANAESTHETIC. 655 
 
 present year Koclilcr reported a case' in wliieh the antesthetic was 
 given in small quantities with a mask, and in whieh, after a very 
 transient and mild stage of excitement, the heart's aetion suddenly 
 ceased and could not be restored, although the breathing is said to have 
 continued for a long time. At the autojj.sy the muscular structure of 
 the heart was found in a condition of extreme fatty degeneration. 
 
 Our present clinical experience certainly indicates that the use of 
 ethyl bromide is not devoid of dangei', but there seems to be no sufficient 
 reason for believing that with an absolutely pure article the danger is 
 greater than with chloroform. The brevity of the narcosis and the 
 great muscular excitement which the bromide is apt to provoke stand 
 greatly in the way of its general use as an auiesthetic, though they 
 especially fit it for employment on certain occasions. It seems probable, 
 also, that it will be found to be a successful ]>raetice to give the ethyl 
 bromide at the beginning of an anaesthesia which is to be maintained 
 by the use of ether. There are certain persons, especially alcoholics, 
 who greatly resist ethyl bromide, and various surgeons strenuously assert 
 that under these circumstances no attempt should be made to force 
 anaesthesia by this agent, but that chloroform or ether should at once 
 be substituted. 
 
 The best method of administering ethyl bromide appears to be to place 
 about two drachms in an Allis inhaler or upon the cone-shaped napkin. 
 
 Mixed An.esthetics. — Various mixtures of chloroform and ether 
 or alcohol, chloroform, and ether (the latter the famous A. C. E. mix- 
 ture) have been employed by surgeons with results \\hich have been on 
 the whole unsatisfactory. These unsatisfactory results are probably, at 
 least in part, dejjendent upon the different volatility of the different 
 agents, making it impossible to know exactly what va])ors are contained 
 in the air breathed by the patient. All these mixtures are, in my 
 opinion, more dangerous than the individual drugs of which they are 
 composed, and their use should be eschewed. The method of producing 
 antesthesia with one agent and continuing it with another is entirely 
 different from that which uses throughout a mixture of the two agents, 
 and at present writing there seems to be reason to commend this form 
 of mixed anaesthesia. Thus, it is probable that many of the difficulties 
 Avhich attend the use of ether can be overcome by putting in the inhaler 
 or on the sjionge ethyl bromide and then ether, the j)atient ])assing 
 insensil)ly from the bromide narcosis into that of ether. In England 
 it seems to be a not rare practice to commence antesthetization with 
 nitrous oxide and to continue it with the use of ether, and, if the statis- 
 tics given by Dr. George Gould are correct, this method of antesthetiza- 
 tion would seem to be the safest known, for in 12,941 anaesthesias so 
 produced in the clinic of St. Bartholomew's Hospital there has been 
 1 death. Certainly 'by the primary use of nitrous oxide the feelings of 
 the patient and the time of tiie surgeon are spared. 
 
 Circumstances wbich modify the Choice of Anesthetic. 
 
 In answering the inquiry as to the circumstances which should modify 
 the choice of the ana;sthetic by the surgeon I shall first consider those 
 
 ' CmtraU.f. Chh:, 2, 1894. 
 
()")() ANJESTHESIA. 
 
 iKidifying circumstances wliicli arc siiii])lcst and least doubtful, and shall 
 
 arrange the matter under eiuuneratcd licads 
 
 First. When ch-cumstances make it practically impossible to obtain 
 the ))uli<ier antesthetic. Thus in war-times the difficulties of trans]»(>r- 
 tiitidu, determining as they do the niovements of great armies and the 
 residtsof great national U])heavals, may make it practically impossilile 
 for tJie surgeon to have choice, antl certainly under such circumstauces 
 it is better to use chloroform than to do without ansesthctics. 
 
 Second. When the symjitoms tliemselves are of such character as to 
 immediately threaten life, especiaiiy if they at the same time interfere 
 with the entrance of tlie auicstiietic into tlie lungs, the use of clilnrof irm 
 may well be justiiied. Tlius, when a tetanus spasm locks the cliest- 
 wails it often would be folly to wait for the action of ether, and yet it 
 must be rememljered that under just such circumstances chloroform has 
 ajiparently destroyed life. 
 
 Perhaps under this heading the use of chlorofoi-m during parturition 
 should be alluded to. It has Ijccn stated from time to time by vari- 
 ous writers tliat tlie excitement of labor in some way guarantees the 
 system against the deleterious intluences of chloroform, and that it may 
 be used with impunity. This is not correct : death has occurred from 
 the ana;sthetic use of chloroform during parturition. Only infrequent 
 occurrences in parturition make it necessary to use chloroform. Ether 
 commonly acts with sufficient jiromjitness, and should tlierefore be pi'c- 
 ferred. In a violent case of ])uei'j)cral convulsions, however, and in 
 other critical conditions, cldorof)rm may be superior to ether. The 
 known action of ethyl bromide gives great force to the statements of 
 Professor Montgomery, that it is especially valuable during labor, and 
 further trial of the agent seems to be demanded. The obstetrician, how- 
 ever, should exert extraordinary care to see that he has a ]iure s]iecimen 
 of the drug. 
 
 Third. There are certain bodily conditions, iiardly to be sjioken of as 
 disease, which would exert some intluence in the selection of the anaes- 
 thetic. In his recent book Dr. Frederic W. Hewitt states that old 
 persons whose chests have become rigid seem not to be able to resjiond 
 sufficiently to the demand made upon them by ether, and tliat very old 
 persons hear chlorof )rm practically well. In applying such a principle 
 as tliis it must be remembered that it is not the years of the person, but 
 the extent of senile changes in his tissues, which should influence the 
 ansesthetizer. Dr. Hewitt recommends in such cases the A. C. E. mix- 
 ture ; if such mixture be employed, it should always be freshly made at 
 tlie time of its administration. 
 
 Extreme obesity is another bodily condition in which it is affirmed 
 that ether is often not well boriu', producing so much excitement and 
 respiratory irritation as to forbid its use. Under these circumstances 
 again Hewitt recommends the A. C. E. mixture, but states that there 
 are certain cases in which chloroform is necessary in order to secure suf- 
 ficient tranquillity of breathing. I have not had practical experience 
 witii such patients of sufficient amount to be weighty, but my feeling is 
 tiiat in such cases ether should be first tried, and then, if it be not well 
 borne, chloroform substituted, ether being again employed when quiet 
 anaesthesia has been thoroughly established. 
 
CIRCUMSTANCES MODIFYING THE CHOICE OF ANESTHETIC. 657 
 
 Fourth. Various diseases contraindicate the use of an anesthetic, and 
 also modify the proper choice of tlic surgeon, and I sliall therefore under 
 the present iieading consider diseases as general contraindications to 
 auicsthetics and also as modifying the selection by the surgeon. 
 
 The diseases which are generally thought to more or less positively 
 contraindicate the use of aniesthetics are Organic Brain Disease, includ- 
 ing Tumors; Atheromatous Conditions of the Vessels; Diseases of the 
 Heart ; Diseases of the Linigs ; and Diseases of the Kidneys. 
 
 Brain. — It appears from the recorded accidents of ansesthesia that 
 the existence of brain tumor and other organic forms of brain disease is 
 more often the cause of death tlian are att'cctious of tlie heart. AVhen 
 the brain-arteries are believed to be atheromatous, although no positive 
 signs of organic brain disease are present, aniesthesia should be induced 
 by the surgeon with the greatest reluctance. The cause of the extreme 
 danger in these cases is probably the ease witli which congestions are 
 developed in a brain which is abnormal, and the loss of resisting power 
 in the resjiiratory centres when weakened by disease. I know of no 
 clinical data which will enable us to decide which is the safer agent, 
 chloroform or ether, in the class of cases now under consideration. The 
 greater power, however, of chloroform and the greater permanency of its 
 influence would make it, a priori, probable that ether would be the less 
 dangerous of the two. 
 
 Heart xVnd Blood-vessels. — Widespread arterial atheroma should 
 certainly give to the surgeon wlio desires aiiicsthesia much fear as to the 
 result. The great increase of the arterial pressure wliich takes place in 
 nitrous-oxide narcosis may very well endanger the integrity of an athero- 
 matous vessel. In 1890 a gentleman arose from a dentist's chair in 
 Philadelphia after an inhalation of nitrous oxide, staggered, and fell in 
 an apojilexy. Dr. F. A. Ashford ' reports a case of a young woman who 
 grew faint and dizzy shf)rtly after waking from nitrous oxide, passed 
 into a condition of disturbed consciousness, and found when she came 
 fully to iierself that her left arm was useless. It apjiears to me, there- 
 fore, that nitrous oxide should never be administei'ed when there is 
 marked degeneration of the vessels, and that the danger of its employ- 
 ment woidd be especially great if there should be an aneurism with 
 feeble walls. 
 
 Ether certainly raises the blood-pressure, but the amount of increase 
 is not nearly so great as when nitrous oxide is given. Moreover, in 
 the majority of cases arterial degeneration is associated with either 
 cardiac or renal disease, or very generally with both, so that the choice 
 Ijctwecn the two auiesthetics is commonly to be dominated not by the 
 atheroma itself, but by the coexisting disease. In atheroma with failing 
 lieart ctlier should certainly be ))refcrred ; in atheroma with renal disease 
 and a normal heart chloroform ivotdd proI)ably be the safer agent. Of 
 course an apoplexy may occur at any time during an antesthesia : the 
 late Professor D. Hayes Agnew once lost a case during etherization ; and 
 in the London Lancet^ is reported a ease in which a chloroform inha- 
 lation was followed by aphasia, believed to be due to rupture of tlie cere- 
 bral vessels. 
 
 Valvular disease of the heart is sometimes alleged to be a positive con- 
 
 ^Amer. Jonm. Med. Sei., vol. Ivii., 1869. 2 yo] j^ jgyo 
 
 Vol. I.— 42 
 
658 ANESTHESIA. 
 
 tniiiidicutloii to aiisesthctic agents. Wlicn, however, the organic disease 
 does not prochice any absolute functional disarrangement' of" the heart, 
 and when the heart-muscle is in a fair condition of health, ansesthesia 
 may l)e induced, provided the circumstances of the ease are such as to 
 justify the surgeon taking a slightly increased risk. The key to the situ- 
 ation is not the valvular lesion, but the conchtion of the muscle ; a loud 
 murmur usually depends, to some extent at least, for its loudness upon 
 the character of the valvular lesion, but it is also dependent, in part, for 
 its loudness upon the force which drives the Ijlood through the diseased 
 orifice. A loud murmur is therefore, on the M'hole, not more strongly 
 contraindicative of aniesthesia than is a feeble one ; indeed, as the feeble 
 murmur is more commonly associated with feeble walls, greater care must 
 be exercised when such murmur exists than when a loud bruit every- 
 where forces itself upon the physician's attention. In all cases of heart 
 disease whenever it is possible to avoid the use of an anaesthetic by the 
 emploj'ment of cocaine or by other local device this should be done. No 
 condition of the heart is, however, an absolute contraindication to the use 
 of the anaesthetic ; under certain circumstances anaesthesia may be pro- 
 duced \vhen the heart is in advanced fatty degenei'ation. It must be 
 remembered that the shock and nerve-strain which attend a major sur- 
 gical operation without anaesthesia would endanger the arrest of a fatty 
 heart even to a greater degree than would anaesthesia itself, so that 
 the question is, after all, as to the imperativeness of the proposed 
 operation. 
 
 In diseases of the heart ether is usually preferable to chloroform ; in- 
 deed, when the heart is very feeble or the cardiac muscle is degenerated 
 the action of chloroform upon the heart makes it a vei'v dangerous remedy. 
 In some cardiac cases there is a widespread pulmonic engorgement, with 
 a tendency to exudation into the lung-vessels and smaller bronchial tubes. 
 Under such circmiistances the local irritant action of ether upon the 
 mucous membranes is so deleterious that the surgeon is placed as it were 
 between Scylla and Charybdis, and may in an individual case have great 
 difficulty in deciding what is best. The A. C. E. mixture under these 
 circuiustances may be sometimes selected with propriety. Chloroform is 
 especially dangerous when ortiiopncea exists ; it is doubtful whether in 
 such a case its use is ever justifiable. 
 
 Respiratory Apparatus. — The existence of severe organic disease 
 of the lungs seems to be a less serious bar to the use of ansesthetics than 
 would be naturally expected. Of all the chronic pulmonic affections, 
 probably emphysema, associated as it so frequently is with weakness of 
 the right heart, causes the most solicitude to the ansesthetizer. The 
 irritant local action of ether is an important element when the lining 
 membrane of the tubes or air-vessels is seriously implicated ; indeed, my 
 own opinion is very positive that in some of the deaths which have 
 occurred in persons with diseased kidneys from oedema of the lungs 
 directly after etherization the cause of death has been the local irritant 
 influence of the ether. It would ajipear, also, that \\idespread organic 
 changes in the lung sometimes so interfere with the alisorption of ether 
 that it becomes exceedingly difficult to produce complete ansesthesia. 
 The dictum of Hewitt, that in extreme emphysema in chronic bronchitis 
 attended by expectoration and dyspnoea, and in advanced pulmonary 
 
CIRCUMSTANCES MODIFYING THE CHOICE OF ANESTHETIC. 659 
 
 phthisis, chloroform or some mixture containing chloroform sliould be 
 employed, is worthy of great respect. 
 
 In all cases of lung disease it is important to remember tliat the more 
 chronic the disorder the less important is it as a contraindication to the 
 use of an anjesthetic, and that aniesthetics are especially badly borne when 
 there is acute or subacute pulmonary disease. Only nnder tlie most 
 urgent circumstances should aufesthesia be attempted when in an acute 
 pulmonary disease the symptoms are of sufficient intensity to produce 
 even slight dyspnoea. In recent pleurisy or pleuro-pneumonia, with any 
 embarrassment of the respiration or duskiness of the countenance, anpes- 
 thetization is attended with very grave risk. 
 
 In obstructive laryngeal disease, or Avhen contraction of the trachea 
 either from witiiin or without, or other mechanical obstruction, jn'oduces 
 dyspnoea, the greatest caution must be exercised in the nse of the antes- 
 thetic. Under these circumstances the chances of ether increasing the 
 mechanical asphyxia by irritating the larynx or trachea are very great, so 
 tiiat chloroform is preferable to etlier ; or chloroform may be employed 
 at first, and ether given when the reflexes have been abolished bj^ the 
 ol)tunding of the nerve-centres. When the laryngeal obstruction is of 
 tile nature of a spasm, and not of an organic change, the use of the 
 an;esthetic is free from extraordinary danger ; but it must be remem- 
 bered that fretpiently in such cases there is more or less larj-ngeal 
 irritation, so that chloroform is preferable to ether — a conclusion which 
 is strengthened by the necessity M'hich often exists for the prompt action 
 of the aniesthetic. 
 
 In certain cases the mechanical obstruction may be a tumor in the 
 mouth or other lesion above the respiratory tract proper, but if the 
 respiration be interfered with, the general ])rinciples just enunciated 
 hold good. Obstruction is a comparatively trivial matter, but, when it 
 is complete, requires the surgeon by the use of the mouth-gag or other 
 procedure to see that respiration througli the moutli is unimpaired. 
 
 Operations. — The choice by the surgeon of an anajsthetic is often 
 modified by the nature of the operation. In operations on the parts 
 about the moutii it is often difficult to maintain anaesthesia on account 
 of the mechanical interference on the part of the surgical operator. 
 In such cases the rule should be for the patient first to be placed 
 tlxiroughly under the influence of ether, and, unless the operation is 
 to be a very lengthy one, to have been in this condition for several 
 minutes before the surgeon begins. Usually, when the tissues and 
 blood have been thus surcharged with ether, antesthesia can be main- 
 tained by occasional whiifs of chloroform given as opportunity is 
 afforded during the surgical procedure. Indeed, the first anfestlietic 
 saturation is often • sufficient to carry the patient througli the more 
 painful portion of the surgical work. In tliis, as in otiier cases, wlien 
 chloroform is to be administered to an etlierized patient it is essential to 
 remember that often during etiicrization breatiiing is heavier and deeper 
 than in the normal individual, so that it is entirely possible inadvertently 
 to give an overdose of chloroform. Tiie frequency of the entrance of 
 blood into the larynx in tiiese cases comes rather within tiie ken of tlie 
 surgeon than of tlie an;csthetizer, Init it seems worth while to copy the 
 rules of Hewitt, that unless the convenience of the operator makes it 
 
G(i() ANJESTHESTA. 
 
 iinpo.ssil)lc, drainage fi-oiii tlie iiioutli s^lioiild be secured by the patient 
 being placed in one of tliree positions : 
 
 1. Somewhat npon the side, with one cheek resting upon tiie pillow, 
 and so that tiie face is turned slightly downward. 
 
 2. Sitting up, with the head and shoulders thrown Mell forward, the 
 face looking toward the couch or bed. 
 
 3. Supine, with tlie head completely extended and in the mid-line. 
 
 As the diseases for which the ojierations of cerebral surgery are under- 
 taken often in themselves contraindicate the use of anesthetics, great 
 importance attaches to tlie question of aui^sthesia in these cases. Pro- 
 fessor Victor Horsley has claimed that the hypodermic injection of mor- 
 jihine before the use of chloroform is in this class of operations exceed- 
 ingly advantageous, not simply because it lessens the amount of the antes- 
 thetic required, but also because it decreases the cerebral congestion and 
 the consequent hemorrhage on section. This practice has had consider- 
 able following, but its correctness seems to be open to grave doubt. As 
 long ago as 1863, Professor Nussbaum of Munich found that when hypo- 
 dermic injections of morphine were given during chloroformization deep 
 sleep continued for a considerable time after the withdrawal of the chloro- 
 form, and that the jiatient awoke without nausea or vomiting. In 18G9 
 the researches of Claude Bernard were published, and led to the wide- 
 sjjread trial of the conjoint use of morphine and chloroform. 
 
 A-priorl reasoning would render it probable that anresthesia woidd 
 be more easily produced and would be more prolonged in the semi-nar- 
 cotized patient than in the normal individual, and clinical experience 
 has confirmed this. But in the prolongation of the anjesthesia would 
 seem to lurk a danger. Certainly, it is but natural to suppose that 
 an anaesthetic accident occurring in a person who is under the influ- 
 ence not only of a volatile and easily-dissipated poison, but also of a 
 non-volatile and comparatively permanent poison, would be far more 
 serious than if the failure of respiration or of circulation were the out- 
 come purely of an agent which could rapidly be removed. Several sur- 
 geons have shown that this reasoning is not devoid of practical support, 
 and a number of cases have been ])ublished in which very serious symp- 
 toms, or even death, have occurred during the mixed narcotism. In one 
 case of Hewitt's the importance of the more persistent agent was shown 
 by the fact that artiticial respiration had to be kept up continually for 
 four hours before any automatic breathing appeared, the fact indicating 
 that, at least in that case, the morphine had more to do with the complete 
 arrest of respiration than had tiie etiier. Further, in many persons the 
 use of opium is prone to be followed by excessive nausea and distress; 
 in such an individual the disagreeable! after-effects of the anaesthetic 
 would certainly be aggravated. 
 
 Some surgeons consider that ether should not be used in abdominal 
 surgery on account of the frequent respiratory movements, the cough, 
 the retching, the vomiting, etc., which sometimes attend the employ- 
 ment of this anpesthetic, interfering with the delicate work of the sur- 
 geon. The presence of these disturbances, however, is usually an indi- 
 cation of improper ansesthesia. Rigidity of the abdominal nmscles, 
 retching, and general restlessness are to be overcome by the free use 
 of the ansesthetic. The disturbances of respiration may depend upon 
 
CIRCUMSTANCES MODIFYING THE CHOICE OF ANESTHETIC. (Kil 
 
 interference with the supply of air, or perchance may be the beginning 
 asphyxial symjrtonis due to the excessive etherization. Viok'nt and 
 excessive vomiting after an abdominal operation is a serious thing, and 
 certainly it is more apt to occur when ether has been used than when 
 cidoroform has been employed. It can, ho\\"cver, be largely prevented 
 by proper method of administration. 
 
 Acute intestinal obstruction, with the general colla])se which so often 
 accompanies it at the time when the case comes into the surgeon's hands, 
 requires great care t)n the part of the antesthetizer, and some surgeons 
 even go so far as to assert that complete antesthesia at such times should 
 not he jtroduced.' The pain and terror, however, of abdominal section, 
 the struggles of the patient, the general horrors of the situation, would 
 seem to demand the use of the antesthetic, even though the risk be 
 grave. In such a case, before the anaesthetic be given, the stomach 
 .should always be thoroughly emptied, and no more of the vapor should 
 be inhaled than is absolutely necessary ; rapidity of action on the part of 
 the surgeon becomes a matter of great moment, since the danger 
 increases in almost geometrical ratio with prolongation of the ansesthesia. 
 Ether is usually preferable to chloroform, thougli not rarely it is a very 
 good pi'actice to begin the ansesthetization with chloroform and afterward 
 maintain it with cth(>r. 
 
 Kidneys. — Writing in 1890, Dr. Lawrence Turnbull said that "it 
 is of the greatest importance that attention should be given to tlie condi- 
 tion of the kidneys, and an examination made of the urine when an 
 ana?sthetic is to be administered. Deaths, unaccountable otherwise, are 
 due to this cause. In diseases of the kidneys, the blood being loaded 
 with urea, ana?stheti<'s almost invariably produce convulsions, coma, and 
 death." These words of Dr. Turnbull reflect a widespread pn>fessional 
 ojjinion. If, then, disease of the kidneys be so strong a contraindication 
 to the use of anesthetics, it is necessary to examine very carefully as to 
 the jiroper choice of the anaesthetic when, notwithstanding the existence 
 of renal disease, ansesthesia must be superinduced. It is jilain that two 
 distinct dangers underlie the use of the ansesthetic in renal disease : one 
 has to do with the influence of the drug upon the diseased kidneys ; the 
 other has to do ^vith the relations between the secondary conditions of 
 Bright's disease and the anaesthetic. Markedly atheromatous arteries 
 ■contraindicate nitrous oxide ; a degenerated heart-muscle contraindicates 
 chloroform ; and it may very well be that sometimes the choice of the 
 surgeon shoidd light uj>on the anjesthetic which threatens the kidneys 
 most, because it is the least dangerous to those organs which have become 
 sec<mdarily dis(>ased. 
 
 As throwing light upon sudden death during antesthesia it is worthy 
 of note that in Dr._ Geo. B. ^\^)0(^s experiments," referred to lielow, 
 several times in dogs who were suffijring from nephritis artificially ]>ro- 
 duced by the use of cantharides or present as the outcome of natural 
 disease sudden fatal arrest of respiration occurred, suggesting that there 
 may be in urremia or uriemic conditions a special inability of the respi- 
 ratory centres to resist the eflect of narcotic poisons, and that anu>ngst 
 the secondary effects of Bright's disease should be put lack of resistive 
 power in the respiratory centres. 
 
 ' See British Med. Journ., March, 1892. » Univ. Med. May., vi., 189-1, p. 802. 
 
662 ANESTHESIA. 
 
 Ill attcmptintj to dcfidc as to the clioicc of an anresthctic for an urse- 
 inio patient it is pro[)fr first to stmly tlic relations of the aiuestlietic to 
 the ividneys themselves. So far as my reading goes, Dr. Thos. A. Emmet 
 of New York was the first to call attention to the possibility of the pro- 
 duction of fatal suppression of urine in persons suffering from chronic 
 Briglit's disease by the use of ether. In his first experience complete 
 suppression, and death in three days from nrpemia, occurred in a patient 
 suffering from ciiroiiic cystitis and probably renal degeneration. Subse- 
 quently to this Dr. Emmet is said to have had five such cases. Without 
 attempting to go over the whole literature of the subject, attention may 
 be called to the cases rcjiortcd by Professor W. F. Norris to the Amer- 
 ican Ophthalinolooieal Society in 1881, especially to the one in -which 
 death in convulsions followed ether anaesthesia in a child suflering from 
 fatty kidneys, and in which after death the kidneys were found intensely 
 congested. Various cases similar to these have been pultlished in med- 
 ical literature, and it does not suffice to answer, as has been done, that 
 ether has been frequently employed in Bright's disease without bad 
 results. 
 
 It ought to be possible positively to determine whetlier or not ether 
 is capable of affecting tlie secreting structure of the normal kidney. In 
 the British Medical JouvnaP Dr. Lawson Tait records a remarkable 
 case in which, the ureters being exposed, it was found that the contin- 
 uous administration of ether prevented the secretion of urine, and so- 
 long as the narcosis persisted there was no flow of urine. This obser- 
 vation is said to have been repeatedly confirmed by Tait himself,- and 
 is of great importance as evidence that ether does affect the human 
 kidney. It is evident that experiments upon animals should be made, 
 in which, the ureters having been exposed and canulated, it should be 
 determined whether these observations of Tait are exceptional or not. 
 Albuminuria after ordinary anresthcsia is probably rare, but it certainly 
 does occur at times. Patein' found it once in every three cases, but 
 this is plainly much above the average. In elaborate studies made in 
 the physiological laboratory of the Univei'sity of Pennsylvania by my 
 son. Dr. Geo. B. Wood,^ it was found in dogs that during ether anses- 
 thesia the kidneys become markedly congested, and almost invariably, 
 if the anfesthesia had been protracted over fifteen minutes and the dog 
 then" killed, it was possible to demonstrate cloudy swelling of the nuclei 
 and contents of the secreting cells. The cells of the convoluted tubules 
 were those primarily affected, the tufts and corresponding tubules only 
 showing change when the antesthesia had been greatly prolonged. It is 
 true that Fueter'^ fliiled to detect changes in the kidneys of etherized 
 dogs, but this negative testimony can hardly stand against the positive 
 evidence with specimens which were studied and accepted as conclusive 
 by Dr. Guiteras, professor of pathology in the University of Pennsyl- 
 vania. 
 
 These researches and studies may seem to the reader at first sight to 
 demonstrate that chloroform is the safer anaesthetic when renal disease 
 exists. The case is not, however, so clear, for it has undoubtedly been 
 shown that chloroform itself has a very deleterious influence upon the 
 
 ' Vol. ii., 1880. " London Lancet, .Ian., 1883. ' Paris Thesis, 1S88. 
 
 * Loc. at. ^ Inaug. Diss., Leipzig, 1888. 
 
AFTER-EFFECTS OF ANESTHESIA. 663 
 
 kidney strueture. Alhuminuria has been iioticeil hotli in man and in 
 animals after eiiioroform nareosis.' Dr. Eugene Fraenkcl ^ has fotuKl 
 that after death from protraeted ehldroform narcosis the seereting renal 
 epithelium is in a condition of profound degeneration — a conclusion 
 which he subsequently confirms, stating^ that the alteration in the kid- 
 ney epithelium is never wanting after death from prolonged chloro- 
 formization. 
 
 It would seem, therefore, that botii ether and chloroform have a dis- 
 tinct deleterious infinence upon the kidneys. I am myself inclined to 
 believe that of the two agents ether is the more dangerous to the kid- 
 neys, especially on account of the great quantity which it is necessary 
 to use. 
 
 The second division of the present subject concerns the relation of 
 the an£esthctic to the secondary ett'ects of kidney disease. The most 
 dangerous of these secontlary effects, so far as anesthetics are concerned, 
 and the one which almost invariably occurs if the patient live long 
 enough, is degeneration of the heart-muscle. It is very evident that 
 when this is present chloroform is a much more dangerous anjesthetic than 
 is ether ; indeed, under such circumstances the danger from chloroform 
 grows extreme <lirectly as the cardiac lesion deepens. The action of ether 
 upon the secondary diseased tissues of the body in Bright's disease does 
 not seem to me in any way especially deleterious. When, however, the 
 condition of the body is such that there is tendency to the jirodnction 
 of oedema of the lungs or to the filling up of the small tubules of the 
 lungs with watery secretion, ether is highly dangerous. I believe 
 myself that in a number of cases death has under such circumstances 
 resulted from the sudden outpouring of serum provoked by the local 
 irritant action of the ethereal vapor. 
 
 From what has been said it is plain that the selection of an anaesthetic 
 to be used in a case of Bright's disease is a matter of grave responsibility, 
 and must be based upon a consideration of all of the features of the indi- 
 vidual case. If there be no secondary lesions, chloroform is probably 
 safer than ether ; if there be secondary lesions, especially secondary 
 lesions affecting the heart, ether may well be safer than chloroform. In 
 doubtful cases my own practice has been to commence the ansesthesia 
 Avith ether, and when the stimulant effect of the ether upon the heart 
 has become manifest to use chloroform, believing that in this way the 
 least possible strain is put upon the heart and the kidneys. 
 
 After-effects of Anesthesia. 
 
 In discussing the choice of an ansesthetic I have refrained from any 
 aUusion to the after-effects of these agents, for the sufficient reason that 
 our knowledge is at present so imperfect that it can scarcely lie applied 
 with safety. It is, however, necessary to show that the matter is of much 
 more serious import than is generally sup]iosed. The subject is, of course, 
 beset with great difficulties : it may be almost impossible to decide how 
 far any sequela; which may follow an operation ai'e due to the emotional 
 strain which ])reccdes and follows the work of the surg(!on, to the ope- 
 
 ' See H. C. Wood's Therapeutics, 9th cd., p. 149. 
 
 ' Virchmifs Archiv, Bd. 127, 1892. » Virchov^s Archiv, Bd. 129, 1892. 
 
G(i4 ANESTHESIA. 
 
 ratiuii itself, to tlie ansestlietic, or to extraneous causes. Among the after- 
 effects of antesthesia various writers place insanity. 
 
 Mental Disturbance. — There can be no doubt but tliat confusional 
 insanity often follows a surgical operation, but it is by no means certain 
 that the antesthetic has any <'ausal connection with the cerebral disturb- 
 ance. It is affirmed that in some cases symptoms of mental aberration 
 have developed immediately after an anaesthesia. Dr. Geo. H. Savage' 
 records a case in which violent delirium with insensibility of the con- 
 junctiva, ending in three weeks in complete dementia, followed in a 
 chronic (Irinker innnediately upon nitrous-oxide inhalation. Such a case, 
 however, obviously separates itself from one in which a true aniesthetic 
 lias been enqiloyed. It is entirely jiossible that during the venous stasis 
 of the artificial asphyxia rupture of small vessels may occur or perhaps 
 minute thrombi be formed in the cerebral cortex. 
 
 It is certainly exceptional for the symptoms of confusional insanity to 
 follow immediately or even rapidly upon the aniBsthesia. The disease is 
 not a very rare one, and I have myself seen a large nunilier of cases. In 
 no one instance has any relation between the ansesthesia and the mental 
 symptoms been traceable ; always some days, and usually several weeks, 
 have elapsed after the operation before the coming on of the mental 
 symjitoms. Under such circumstances the disturbance of mentality can 
 hardly be attributed to the narcosis. Rather is it the outcome of a j)ecu- 
 liar depression of the cerebral cortex produced ]>robably by the coinci- 
 dent action of the shock of the operation itself, of the emotional strain, 
 and of the various depressing factors inseparal)le from a surgical illness. 
 
 Disturbances of Renal Secretion. — The subject of the action 
 of anaesthetics upon the kidney structure has already been, I think, suf- 
 ficiently discussed in connection with the cpiestion as to the influence of 
 disease upon the choice of an aniesthetic. 
 
 Many years ago a well-known Philadelphia surgeon attributed the 
 diabetes which occurred, and finally proved fatal, in his own person to 
 the inhalation of nitrous oxide, and in 1886 the French writer. Dr. 
 Lafont,- affirmed that he had seen abortion with death of the foetus 
 occur at the moment of anaesthesia from nitrous oxide, and that he had 
 noticed chlorosis, albuminuria, and especially true diabetes, follow the 
 inhalation of the gas. He especially warns against the possible ]>roduc- 
 tion of diabetes mellitus, reporting a case in which sugar appeared in the 
 urine twice after use of the gas ; and also stating that he had been 
 enabled to produce glycosuria in the dog and also in his own person by 
 the inhalation. The high blood-pressure which occurs during the nitrous- 
 oxide narcosis is without doubt attended with venous stasis, and it does 
 not seem, a priori, impossible to have as an after-effect of such narcosis 
 various symptoms produced by change in the cerebral centres. 
 
 On the other hand, nitrous-oxide anesthesia has been produced so 
 many millions of times that, if it were really often the cause of serious 
 after-effects, it seems hardly possible but that overwhelming evidence 
 would be at this time forthcoming ; and careful inquiry made by myself 
 of persons whose sole business has been for years the administration of 
 nitrous oxide for the extraction of teeth shows that in no instance have 
 patients returned to them with complaints. Moreover, in experiments 
 
 * Brit. Med. Joiini., 1887. ^ La France mkl, vol. i., 1886. 
 
AFTER-EFFECTS OF ANESTHESIA. 665 
 
 upon five dogs made by Drs. Geo. S. Woodward and Alfred Hand in 
 the pharmaciilogioal laboratory of the University of Pennsylvania 
 nt'itiu'r albmninuria nor glycosuria was produced by the repeated and 
 prolonged iniiahition of nitrous oxide. At ])rcscnt, therefore, it would 
 .seem that when the patient is a normal individual the surgeon should 
 have no fear of any after-eifects from nitrous oxide. 
 
 Disturbances of the Liver. — Frericiis states that jaundice some- 
 times follows the inhalation of chloroform and ether, but such cases must 
 be of exceeding rarity. I have myself never met with tliem in litera- 
 ture, and Murchison states that after careful examination he has never 
 been able to find a record of a case. On the otiier hand, Bernstein,' and 
 also Levden,^ have found traces of bile-|)igment in the human urine after 
 chloroform narcosis ; and Nothnagel ' has recognized biliary coloring 
 matters in the urine of rabbits after subcutaneous injection of chloroform 
 or ether; but Kappeler^ in twenty-five cases of chloroform narcosis was 
 not al)le to obtain a trace of biliary coloring matter ; further, ciiloroforra 
 mixed with blood outside of tiie body raj)idly destroys the red corpusi'les, 
 liberating iia?moglobin, and it is possible tiiat in rare cases of protracted 
 chloroform narcosis some such action occurs within the body, yielding 
 icteric products. On the whole, it does not seem probable that chloro- 
 form lias any important influence upon tiie liver, save only as part of the 
 wides})rcad action upon the tissues next to be spoken of. 
 
 The General Nutrition. — As long ago as 1850, Caspar mentioned 
 fthronic poisoning by means of chloroform, and somewhat later Liman 
 affirmed that after 2>rolonged chloroformization patients sometimes pass 
 into an abnormal condition whicli continues for days, even for weeks, and 
 finally ends in deatii, tlie whole being tiie result of the influence of the 
 cidoroform. These views met with little acceptance, and, indeed, seemed 
 eonnnonly to have been overlooked or disregarded, until Dr. E. Ungar 
 demonstrated by experiments upon the lower animals that prolonged 
 chloroform narcosis has a profound influence upon the general nutrition.^ 
 He found that in the dog, when narcosis was kept up for many hours 
 and repeated once or twice at short intervals, tiiere was a widespread 
 fatty degeneration, usually of a very liigh grade, in tlie heart-muscle 
 and in tlie liver and kidneys, but more or less pronounced in the spleen, 
 in the general epithelial tissues, in the voluntary nuiscles, and, in fact, 
 in all of the higher tissues. That this change was not secondary to any 
 alteration in tlie blood by the chloroform is believed by Ungar to be 
 shown by the fact that no change could be noted in the red blood-cor- 
 puscles, nor were bile acids to l)e found in the urine, nor was there ever 
 any h;emoglobinuria. 
 
 These researches have been confirmed in their general results in 
 numerous exjieriments npon animals by Strassmami,^ by Ostertag,'' and 
 bv Kast and Mcster.**' Further, in a series of very careful studies upon 
 four human subjects dying after prolonged chloroformization Dr. Eugene 
 FraenkeP has fi)und a widespread necrotic degeneration, associated with 
 
 ' Muleschatf.1 Uidersuchungen, 1870. 
 
 '' lii'itnige zur Pathnhgie Sea Icterus, Berliu, ISGO. 
 
 ' liidin. klin. Wochetisch., 1866. * Die Ana'slhetlca, Stuttgart, 1880. 
 
 ' Vicrktjuhresb. f. Geriehlliche med., N. F., 46-47, 1887. 
 
 8 Virchow's Archie, Bd. 11-^. ' Pml., Bd. 118. 
 
 ^ Zcitichr. klin. Med., xviii., 1891. ' Virchow's Archie, Bd. 127 aud 129. 
 
6^6 AN^HSTIIESIA. 
 
 ■A deposition of much pigment in many places and in all portions of the 
 Ixidy, but especially affecting the heart-muscle and the epithelium of the 
 kidney. 
 
 In further conlirmation of the powerful iuthience of cliloroform on 
 nutrition there are the observations of Salkowsivi, that marked increase 
 in the output of nitrogenous waste is caused by the administration of the 
 drug to dogs; of Kust and Mester, that there is a marked increase in 
 the elimination of chlorine and nitrogen produced by the auiustlictic ; 
 and of Petruschky, that after death from ehlorcjform the intercellular 
 juices become rapidly acid. Ostertag in his conclusions differs some- 
 what from Ungar in believing that the fatty degeneration is in part due 
 to the destruction of the red blood-corpuscles by the chloroform. As, 
 however, he also believes that the destruction of the protoj)lasm is in 
 part effected by the direct influence of the chloroform, the difference 
 between his views and those of Ungar is not vital. Moreover, whatever 
 of scientific interest may attach to the method in which chloroform pro- 
 duces its ravages, to the surgeon the method is of little practical import- 
 ance, the vital fact l)eing that chloroform itself, directly or indirectly, 
 destroys the living protoplasm in almost all portions of the human body. 
 It seems to me, therefore, that it nuist be considered an estiiblished fact 
 that a prolonged inhalation of chloroform directly affects the general 
 nutrition of the vital organs, and is capable in this way of causing organic 
 changes which may produce death very soon after the inhalation, or may 
 take days or even weeks to work out the fatal result. 
 
 Certainly, enough has been made out in regard to the action of chlo- 
 roform upon the nutrition to condenui the present total disregard by 
 practical surgeons ( if this influence. When the amiesthesia is of short dura- 
 tion the influence of the chloroform uj)on nutrition is probably of little or 
 no importance, but in those operations which require one or several hours 
 for their performance the matter seems very serious. In such a case it 
 is essential to sele(.'t that ansesthetic which has the least influence upon 
 nutrition. Unfortunately, though we know so much in regard to chloro- 
 form, we have no positive knowledge in regard to ether. Undoubtedly, 
 it shares the power of chloroform of destroying the red blood-corpuscles 
 and setting free the oxyhemoglobin in freshly-drawn blood, but beyond 
 this we have no evidence. A-priori reasoning, however, leads to the be- 
 lief that ether probably disturbs nutrition much less than does chloroform. 
 The researches of A. Zeller' indicate that chloroform is in part at least 
 decomposed in the system. Chlorine is chemically very closely allied to 
 iodine ; the deleterious influences upon protoplasm of the iodine com- 
 j)ounds set free by the decomposition of iodoform are well known ; prob- 
 ably the chlorine compounds set free by the decomposition of chloroform 
 act similarly. There is also much reason for tlie belief that bromide 
 of ethvl is lial)le to be decomposed in the system and to yield bromme 
 compounds capable of seriously att'ecting nutrition. 
 
 Ether is not eliminated to any ajipreciable extent by the kidneys : in 
 the experiments of Dr. Geo. B. ^\'ood it was found that whilst one drop 
 of ether could be detected in two ounces of urine by the process used, no 
 ether whatever could be found in numerous trials in the urine drawn at 
 the time and at varying intervals after prolonged surgical etherization. 
 
 ^ Ze'U^chr. f. pJuji^ioloij. ChcmitJ, Bd. viii. 
 
ADMINISTRATION. 6G7 
 
 Tliere is, of course, much escape of etlier from tlic body through the 
 hing-s, hut plainly it, like alcoiiol, is larirely destroyed in the organism. 
 In its destruction it must yield the same products as does alcoiiol, and, 
 since no deleterious compound can be educed from it, it seems highly 
 improbable that it should affect nutrition as does chloi'oform. On the 
 otiier hand, it is probable that the long-continued use of alcohol will 
 cause fatty degeneration, and the matter is so important that it should 
 be at once put to the test of experiment. 
 
 In reviewing the whole subject it seems to me that, although our 
 knowledge is imperfect, the surgeon who desires to produce a prolonged 
 narcosis should prefer ether to chloroform, unless there be in the peculiar- 
 ities of the individual case positive reasons to the contrary. 
 
 Administration. 
 
 "V^lieuever it is possible the patient should be prepared for the use of 
 an anesthetic by an abstinence from food for at least four hours, and 
 usually any food given inside of six hours should be very light and 
 thoroughly digestible, so that the ana^sthetizer can be sure of the em])ti- 
 ness of the stomach. Whenever circumstances render such preparation 
 im])ossible, and the ansesthetic has to be given although the stomach is 
 full, the greatest care should be exercised to prevent any of the contents 
 of the stomach from entering the trachea. It should be remembered that 
 vomiting may occur not only after the antesthesia, but at any time dur- 
 ing its course, in which case the patient should be placed with the head 
 upon one side or ])artially downward to facilitate the possibility of 
 discharge through the mouth, (yoe ]). 060.) 
 
 It is a common belief, at least in some ])ortions of America, that the 
 administration of an ounce of whiskey or brandy before the use of the 
 anaesthetic lessens the chances of severe nausea or vomiting. The cor- 
 rectness of this belief is not certain, although I deem the procedure a 
 good one. 
 
 In cases in which there is any especial reason to fear the action of 
 the anaesthetic upon the heart, a hypodermic injection of the tincture of 
 digitalis may be administered from half an hour to an hour before the 
 an;¥sthesia. Ten to fifteen minims thrown into the subcutaneous tissues 
 with proper antiseptic precaution will rarely jn-oduce any local disturb- 
 ance bevond some burning or smarting. In cases of very weak heart it 
 would probablv he wiser to begin to produce the influence of the digitalis 
 twelve to twenty-four hours before the administration of ether. Even 
 in ordinary cardiac cases the hypodermic use of strychnine before the 
 inhalation may be of great service ; and when there is a general tendency 
 toward collapse or shock atropine or strychnine should always be admin- 
 istered to ])revent, if possible accident. The action of the various 
 anavtlKtics is so different tiiat different methods of administration are 
 required. 
 
 Ktheriz<dion. — The instruments and mctiiods which have been brought 
 forward from time to time for the giving of ether by inhalation are 
 legion, but all plans now in use may be arranged under two headings : 
 first, open administration — methods in which free access of air is 
 allowed ; second, closed administration — methods in which the patient 
 
668 ANESTHESIA. 
 
 broatlies out of and into a bag with more or less imperfect supply 
 of air. 
 
 It is evident that when a patient breathes in and out of a receptacle 
 containinir ether, in addition to etlierization there is more or less complete 
 asphyxiation, tiie degree of tlie aspiiyxia of course l)eing dependent upon 
 the size of the original reservoir of air and the amount of fresii air allowed 
 to enter the reservoir tluring the inlialati(jn. 
 
 Some years ago, at the clinic of the hospital of the University of 
 Pennsylvania, etherization was produced by simply setting a large 
 bottle freshly tilled with other in hot water, and C(jnnecting this with 
 a face-mask which was so ])laced over the mouth and nose of the patient 
 that the breathing was simply in and out of the bottle. The result of 
 this simple apparatus was at first all that could be desired : anaesthesia 
 was usually complete in two or three minutes, was well and thoroughly 
 maintained, but the jiractice had not long been kept uj) when serious 
 asphyxial accidents began to occur, and became so frequent and so 
 severe as rapidly to lead to the abamlonment of the method. There 
 can be no doubt but that just in ])roportion as the jiatient is not 
 allowed to breathe fresh air is the rapidity of the etherization hastened ; 
 but it seems to me apparent that in proportion as the rapidity of the 
 coming on of anasthcsia is hastened, so is the danger of asphyxia 
 increased. 
 
 I am not able to give positive statistics, but the number of deaths 
 reported in the last eight years in England from ether is, I believe, 
 much greater than those which have been reported as occurring in the 
 United States, although ether is much more largely used in the latter 
 than in the former country. The closed method of administration is 
 very rarely employed in America, and it seems a natural conclusion 
 that the closed method of administration is more dangerous than the 
 open — a conclusion which is greatly strengthened by the fact tiiat Dr. 
 Hewitt, who practises the closed method, is continually cautioning his 
 readers to see that the air-valves are opened, so that a free admission of 
 air is allowed -whenever previous disease adds more than the wonted 
 danger to the use of ether. In recommending Ormsby's inhaler as 
 superior to Clover's for maintaining etherization Professor Hewitt 
 says : " I have often known cyanosis quickly to vanish and the lireath- 
 ing to become less hampered by effecting this change of inhalers during 
 deep ether ansesthesia." I believe any closed inhaler hampers the 
 breathing and increases the cyanosis of etlierization. There ought not 
 to be any cyanosis in etherization. My own experience with closed 
 inhalers has not been large — indeed, solely with Clover's apparatus — but 
 whenever I have seen closed ether ajiparatus used the evidences of 
 asphyxia and early disturbances of respiration have certainly been much 
 more frequent than I have been accustomed to witness with the open inha- 
 lation. The saving of ether effected by the closed method is of no import- 
 ance Avhatever ; the saving of time is very slight. In a series of obser- 
 vations which were made for me at the surgical clinic of the Jefferson 
 Medical Hospital of Philadelphia the average time required for the 
 ])roduction of complete unconsciousness by the open method was eight 
 minutes ; and in a similar series of observations made in the surgical 
 •clinic of the hospital of the University of Pennsylvania the average 
 
ADMINISTRATION. 669 
 
 time required for complete etlicrizatiou by the Allis inhaler was seven 
 and nine-tenths minutes. The results of these two series are so close 
 that eight minutes must be considered as the average time required for 
 full open etherization ; with closed etherization this period can scarcely 
 be shortened to less than fonr or five miiuites. 
 
 Open Etherization. — Open etherization is often practised by simply 
 folding a towel into the form of a cone, pinning the edges with safetv- 
 pins, and ])utting the ether inside. This is a rough and disagreeable 
 plan — a jilan which involves the greatest amount of suffering to the 
 patient and the least amount of satisfaction to the surgeon. In many 
 cases the towel is so used as mechanieally to interfere with respiration. 
 The inhaler invented by Dr. O. H. Allis is based upon the theorv that 
 the patient to be etherized should be supplied with an abundance of air 
 saturated with the vajxir of etlier. It consists essentially of a series of 
 foldings of muslin on a wire framework, arranged almost like the gills 
 of a fish, so as to allow the air to pass freely through, but everywhere 
 to come in contact with ether. It should be placed upon the face of the 
 patient dry, and the ether gradually pf)ured from a bottle whose cork 
 has two small tubes so placed in it that when the bottle is tilted ether 
 runs out of one tube and air enters through the other. Such a bottle is 
 known in Philadelphia as the " polyclinic liottle." When ])ropcrlv used 
 the Allis inhaler largely does away with the sense of suflbcation, and the 
 consequent struggles which have made etherization so repidsive alike to 
 patient and surgeon. 
 
 Vto.'ied Etherization. — In England the Clover and Ormsby inhalers are 
 very commonly used. Of these inhalers, Ormsby's appears to me to be 
 simpler and the less dangerous, because of its being more open. The 
 following general rules are copied from the recent book (1893) of Pro- 
 fessor F. W. Hewitt, to which the reader is referred for further details. 
 No one imaccustomed to the use of these inhalers should, in mv opinion, 
 attempt their eni])loynient without having carefully studied pages 145 
 to 150 of the work just alluded to. 
 
 Clover Inhaler. — 1. Pour out any ether that may have been left 
 from a previous administration. 
 
 2. In cold weather partially immerse the ether reservoir in warm 
 water for a few minutes before use. 
 
 3. Pour in through the filling tube one and a half ounces of ether, 
 rc])lace the stopper or cork, and turn the indicator to " 0." 
 
 4. Fit on a face-piece of ajipropriate size, and blow out through the 
 apparatus, in order to expel all traces of ether vapor that might possibly 
 be present in the shaft of the aj)paratus. 
 
 5. Gently but accurately adapt the face-piece to the face of the 
 patient, and request- him to breathe in and out quite freely. 
 
 6. When the patient is breathing freely attach the bag to the ether 
 reservoir. 
 
 7. Allow the jiatient to breathe backward and forward for about 
 half a minute before turning on any ether vapor. 
 
 8. Having allowed the patient to breathe his own expirations back- 
 ward and forward for the time mentioned, very gradually rotate the 
 ether reservoir, so that the " " on its circumference moves almost 
 imperceptibly but yet continuously away from the indicator. 
 
670 ANESTHESIA. 
 
 9. Fresh air should not he given till there is a distinct indication 
 for it. 
 
 10. AVlien a breath of fresh air is j^iven the strengtli of vajxjr should 
 be increased, otiierwise the j)atient may come out of the auiesthcsia. 
 
 11. Should symptoms of excitement arise and struggling commence, 
 the inhaler should be kept closely applied. 
 
 12. When the breathing has become r(>gular and stertorous and the 
 conjunctiva insensitive (these signs usually manifest themselves in about 
 two and a half or three minutes) the inhaler should be removed for 
 two or three In'caths. 
 
 13. In ordinary cases it is unnecessary, in order to secure full 
 anaesthesia, to rotate the ether reservoir beyond " 3." 
 
 14. When once full surgical anaesthesia has become established the 
 anresthetist will be able to turn back the ether reservoir to " 2," 1^," or 
 even " 1," and to admit air in sufficient quantities to avoid cyanosis. 
 
 15. Be careful to replenish the ether reservoir before the ether in it 
 is exhausted. 
 
 Oniifibi/ Inhaler. — 1. Wring out the sponge in warm water, and, 
 having squeezed it as dry as possible, place it in the cage. 
 
 2. Pour upon the sponge about half an ounce of ether. 
 
 3. Very gradually bring the inhaler toward the face of the patient, 
 and if an air-slot be used see that it is open. 
 
 4. Encourage the patient to breathe as freely as j)0ssible, and grad- 
 ually close the air-slot. 
 
 5. Be prepared for the patient attempting to push away the inhaler, 
 rising from the bed, etc. 
 
 6. Should the sponge freeze, another one, wrung out as before, should 
 be substituted and fresh ether added. 
 
 7. When more ether is needed about half an ounce at a time should 
 be added to the sponge. 
 
 Except inider the most peculiar circumstances the ansesthetic should 
 always be administered by a skilletl attendant rather than by the operating 
 surgeon. This rule rests upon two foundations : In the first place, occa- 
 sionally during the stage of antesthetic excitement there is sexual stim- 
 ulation which may go on to a complete orgasm and lead to after-compli- 
 cations if the operator and patient be of opposite sexes. In the second 
 place, the person who gives the antesthetic must pay the strictest atten- 
 tion during the whole period to the condition of the patient, as the life 
 of the latter may dejiend upon the recognition of the early symptoms 
 of accident. The celebrated Hyderabad C'ommission, in the most urgent 
 and forcible terms, has drawn attention to the respiratory function 
 as affording the chief seat of danger, and has asserted that failure of 
 respiration always precedes, and is really the cause of, collapse of the 
 circulation. There is no room for dispute as to the importance of a 
 gradually produced asphyxia in the weakening of the heart, but cardiac 
 depression and fiilure of circulation are just as important as is failure of 
 the respiration, so that the ana\sthetizer who neglects the pulse is most 
 culpable. Both respiration and circulation must be relentlessly watched. 
 
 Failure of the circulation occurring at any time during ansesthesia is 
 of most serious import, but the meaning of respiratory failure depends 
 ujjon when it occurs. Especially is this true if ether be employed. 
 
ADMINISTRATION. G71 
 
 Early in etherization the irritating influence of the va})or upon the 
 mucous membrane and the ftiuces of the upper respiratory tract fre- 
 quently produces reflex disturbances or even arrest of the respiratory 
 movements. Such an occurrence should, however, be the signal for 
 giving the anfestiietic more freely, since tlie respii-atory disturbance is 
 not accompanied with any danger, and is at once suspendeil ^\hcn suf- 
 ficient of the anaesthetic has been taken to obtund the nerve-centres. 
 On the otlier hand, any irregularities of respiration occurring after 
 aniesthesia has been thoroughly induced imjieratively demand the imme- 
 diate withdrawal of the anesthetic. In 1874, Dr. Baudin called atten- 
 tion to tiie jiupil as a guide in chloroformization, stating tliat it is at first 
 uniformly dilated, Init afterward is uniformly and immovably contracted, 
 and tiiat the jieriod of contraction is the period for operation. Since tlie 
 publication of Baudin's memoir the matter has been much discussed 
 both by physiologists and clinicians. As a general rule, during deep 
 chloroform auresthesia there is decided but not minute contraction of tlie 
 pupil, and if during tlie antesthesia the jnipil returns to norm, more 
 chloroform is required, but if it suddenly dilate, danger is imminent. 
 It has been shown, however, by the experiments of Holmgren, Kratsch- 
 mer, and others that this general rule is often departed from — that in the 
 lower animals the pupils vary greatly during chloroformization ; and 
 there can be no doubt that this is also true in regard to man. Sometimes 
 the pupil dilates early in the chloroformization, and remains dilated 
 througii the comj^lete anaesthesia ; again, nor rarely, especially wiien the 
 operation occurs in the region of the neck, the ])upil alternately dilates 
 and contracts during a chloroformization. 
 
 During etherization the common rule is for tlie pupils to be of mode- 
 rate size or even slightly dilated, whilst in very deep ether anesthesia 
 there is often, perhaps commonly, pronounced dilatation. On tiie otiier 
 hand, in a considerable projwrtion of cases the ]>u])ils contract during 
 etiierization, whilst in other cases the size of the pupil varies very much, 
 and often inadvertently, during one etherization. It is evident that the 
 pupils cannot be relied upon as a guide during the administration of an 
 anesthetic, though some inference may be derived from their study. 
 
 Much more important to the anestiietizer are the color and expression 
 of the tace. The face should be carefully watched ; any cyanotic apjiear- 
 ance denotes ajiproaching asphyxia, whilst an excessive pallor is indica- 
 tive of failing circulation. Severe ansesthetic accidents are often, if not 
 usually, immediately preceded by a sudden change sweeping over the 
 expression of the face like the alteration of the summer landscape by a 
 flying cloud. This danger-signal is so imjwrtant, so freciuent, and so 
 imperative that the anesthetizer should always carefully watch the 
 countenance of the patient. 
 
 The importance of a careful watch over the jiulse is so obvious as 
 not to need any detailed discussion here, and I only call attention to the 
 convenience of the temporal artery for the purposes of the aniesthetizcr. 
 
 Any danger-signal occurring during the administration of an anes- 
 thetic should lead to the immediate withdrawal of the inhaler and the 
 attempt at resuscitation of the patient. The measures employed fiir the 
 latter puiiiose of course vary according to the direction from which the 
 danger comes. Usually the first procedure is to see that there is no 
 
672 ANJESTHESIA. 
 
 ohstriic'tioii to the respiratory passages by the tlirowiiig back of the 
 paralyzed parts upon the larynx. Various methods have been advo- 
 cated. Formerly all that ^vas considered necessary was simj)ly to draw 
 forward the tongue, but Dr. Benjamin Howard showed that this does not 
 necessarily accomplish the ]nirpose, and proposed the extension of the 
 head and neck. In an elaboi-ate series of experiments, however, made 
 in the lal)oratory of the University of Pennsylvania, Drs. Hobart A. 
 Hare and Edward Martin proved that the method of Howard is often 
 inefficient, and that the best results are to be obtained by carrying out 
 the following rule : " Place the index finger of each hand upon the cor- 
 responding cornua of the hyoid bone, whilst the middle fingers rest upon 
 the angle of the jaw, and then ])ress forward and upward, the same force 
 serving to extend the head uj>on the neck ; if this fails to open the glottis, 
 by means of a tenaculum thrust far back into the base of the t»ngue 
 draw it forward." 
 
 Whilst the manipulation spoken of is going on an assistant should 
 strip the chest of the patient, and by slapping it with a cold wet towel 
 or by pouring a little ctlier over it, so as to get the effect of cold, should 
 endeavor to stimulate respiration. If there be failure of the pulse, no 
 time is to be lost ; inversion of the body is to be practised immediately. 
 This method of treating anaesthetic cardiac fiiilure has been commonly 
 claimed, especially in Europe, as having originated with the Parisian 
 surgeon, Nelaton, but the profession is really indebted for it to an Amer- 
 ican, Dr. E. L. Holmes t)f Chicago, who as long ago as 1868, speaking 
 of anaesthetic accidents, said : " WJienever there is any failure of the 
 heart's action, as is nearly always the case, the body should be laid at 
 an angle of forty degrees, with the head downward, so as to favor the 
 passage of arterialized blood to the brain." 
 
 Inversion of the body does not, however, act as a resuscitant in the 
 manner which was believed by Dr. Holmes and universally accepted by 
 the profession. The series of experiments which I made for the address 
 delivered before the Berlin Congress of 1890 demonstrated that in the 
 body of the animal whose circulation has been paralyzed by chloroform 
 the whole arterial and venous system acts in a measure like a single tube 
 filled with fluid. Thus, if the feet of the dog were raised \ertically 
 above the head M'hilst the latter remainetl n])on the table, an immediate 
 rise of pressure always occurred in the carotid artery, even if the heart 
 had practically ceased beating, ]irovided that the head of the animal ^^'as 
 kept upon a level with the table — that is, upon a level with the mano- 
 metrical tube. If, h(jwever, the head of the animal was de])ressed below 
 the level of the table for a distance ecpial to, or greater than, the length 
 of the body of the animal, a decrease of the arterial pressure occurred at 
 once, although the animal was in a vertical position. The phenomena 
 observed were precisely such as would have been produced if the canula 
 had been inserted into a tube filled with fluid, instead of into the carotid 
 artery, and the elevation and depression of this tube had registered itself 
 on the recording drum in obedience to the ordinary laws of hydrostatics. 
 The phenomena were entirely independent of any beat of the heart, and 
 could usually be produced when the animal was dead, provided the 
 death had not occuri-ed too long previously. Sometimes, even a very 
 few minutes after the cessation of the heart-beat, it was impossible to 
 
ADMINISTRATION. 673 
 
 bring about the changes of pressure, pmhably because coagulation of 
 tlic blood had occurred to an extent sufficient to interfere with the liquid 
 properties of the fluid. In no case was any etfect upon the respiration 
 caused by change in the position of the animal. In a number of cases, 
 however, when the feet were elevated the heart, which had entirely ceased 
 beating, recommenced its work, and I have several times seen a j^ulse 
 entirely disappear when the animal \vas taken from the vertical to the 
 horizontal position. On the other luind, very frequently it was impos- 
 sible to afieot the cardiac action by changing the position of the animal. 
 N(>vertheless, the restoratiou of cardiac movements occurred too fre- 
 quently to be a mere outcome of chance, though I several times noted that 
 tiie heart was more affected by alternately elevating and depressing the 
 feet of the animal than by keeping it in a steadily elevated or horizontal 
 position. The action of inversion in the ana?sthetic accident is therefore 
 not upon the respiratory centre, but upon the heart. When the circu- 
 lation has practically ceased in anesthesia, inverting the body must cause 
 the blood which has collected in the extremely relaxed vessels of the 
 abdomen to flow into the right side of the heart and distend it ; and this 
 distention, tliis increase of intra-cardiac pressure, may at a critical mo- 
 ment have an influence upon the failing organ sufficient to recall it into 
 functional activity. 
 
 The question of the use of drugs in tiiese accidents is, of course, an 
 extremely important one. The more important remedies which previous 
 to 1890 were used by clinicians for the averting of threatened death 
 were ether, alcohol, ammonia, amyl nitrite, digitalis, atropine, and caf- 
 feine. Although, at least in America, hypodermic injections of ether 
 have been frequently employed, even in ether accidents, such tise is so 
 absolutely absurd that it does not seem to me to require any exper- 
 imental evidence of its futility. Ether in the blood acts as ether, 
 whether it finds entrance through the lungs, through the rectum, or 
 through the cellular tissue ; and the man who would inject ether hypo- 
 dermically into a patient who is dying from ether should, to be logical, 
 also saturate a sponge \\ith the ether and crowd it upon the nose and 
 mouth of his unfortunate victim. 
 
 Of all the drugs, that which was primarily most relied upon by the 
 clinicians as a cardiac stimulant in auiesthesia was alcohol. The chemical 
 and physiological relations of alcohol to ether and chloroform are, how- 
 ever, so close that many years ago I became very doubtful of the value 
 of this drug as a stimidant to a heart dejiressed by ana?sthesia. These 
 doubts continually grew stronger from what I saw and read as to the 
 effects of the administration of alcohol during ana?sthesia, and were 
 finally changed into conviction by the experiments of R. Dubois,^ who 
 found that in the animal to which alcohol has been freely given much 
 less cldoroform is required than in the normal animal to anaesthetize or 
 to kill; or, in other words, that alcohol intensifies the influence of chloro- 
 form and lessens the fatal dose. 
 
 In my own experiments, made for the a<l(lress already spoken of, from 
 5 to 20 c.c. of an 80 per cent, alcohol, well diluted with water, were in- 
 jected into animals in which the heart was failing during advanced 
 chloroform anaesthesia. In no case was I able, whether the amoiuit was 
 
 ' Progres medical, 1SS3. 
 Vol. I.— 13 
 
674 AN^STJTESSTA. 
 
 larov or small, to detect the sliffbtest increase in the piilse-M'ave or in the 
 arterial pressure produced by the alcohol. Wlieiiever the amount of 
 al(!oliol was sufficiently large to produce any effect, there was always an 
 increase of rapidity in the fall of arterial ])ressure and also a lessening in 
 the size of the jiulse- waves. I have myself no douht tiiat in not a few 
 cases deaths which have been attriltiitcd to ether and other anajsthetics 
 have been in fact tlue to the alcohol whicii has been given to the patient; 
 and it seems to me an unalterable rule of practice that no alcohol should 
 C-ver be given to the patient suffering from anaesthetic cardiac failure. If 
 in the course of the ansesthesia cardiac failure results from hemorrhage 
 or other surgical cause, alcohol may seem to some surgeons to be indi- 
 cated, but under these circumstances any gtxjd effect which would l)e 
 obtained by alcohol would be more rapidly reached by the further 
 administration of ether. 
 
 The effect of ammonia upon the failing heart of chloroform anaes- 
 thesia has been in my experiments uncertain — sometimes distinct, some- 
 times very fugacious, sometimes iniperccjitible. Twenty cubic centimetres 
 of a 10 per cent, solution of aqua ammoni;e fortior (U. S. Pharmacopceia) 
 injected into a vein in the aniesthetized dog did sometimes produce an 
 immediate rise in the arterial pressui-e, and even fugaciously register 
 itself in the respiratory rate, but perhaps more fretjuently it failed in its 
 influence. 
 
 The influence of injections of digitalis has been, in a munber of exper- 
 iments, very pronounced in causing during aniesthesia in the dog a per- 
 sistent gradual rise of the arterial ]>ressure with an increase in the size 
 of the individual pulse-beats. In several instances death was apparently 
 averted by its injection, and I saw in one or two experiments, in which 
 large amounts of the digitalis had been employed, sudden systolic cardiac 
 arrest, indicating that digitalis, if in sufficient amount, is able to assert 
 itself victoriously in opposition to chloroform. Moreover, when I have 
 given chloroform to dogs whose hearts were already under the influence 
 of digitalis there has seemed to be a peculiar steadying or sustaining 
 power combating the circulatory depression naturally produced by the 
 amesthetic, and I believe that in all cases of weak heart in man a full 
 dose of digitalis given hypodermicallt/ before the administration of chlo- 
 roforiii would greatly lessen the danger of cardiac collapse. 
 
 With amyl nitrite, for which much has been claimed as a cardiac 
 stimulant, I was never, in my experiments, able to obtain any rise of 
 the arterial pressure, and very rarely any alteration in the size of the 
 pulse-wave ; occasionally the pulse-wave did appear to be a little fuller. 
 My own belief is that the amyl nitrite is a doubtful i-emedy '\\liich 
 must be used with the greatest caution in ana?stlietic syncope ; certainly 
 the least overdose most seriously adds to the dej^ression of the heart. 
 
 Of all the experimental results ^vhich I reached, those with strych- 
 nine were to me the most surprising. I found that the injection of 
 strychnine into the jugular vein of a dog whose circulation and respira- 
 tion were failing from an overdose of chloroform was usually followed 
 by a gradual rise of the arterial jiressure, and always by an immediate 
 and extraordinary increase of the rate and depth of the respiration. Thus 
 I have seen a respiration which had [>ractically ceased for ten seconds, 
 under the influence of the injection of strychnine become at once very 
 
ADMINISTRATION. 675 
 
 large and full and reach the rate of 130 a minute. In order to get any 
 effect from the alkaloid, however, it is essential to give it in large doses ; 
 to a robust adult with serious anesthetic heart or respiratory failure -^ 
 of a grain may be given at once hypodermically. 
 
 I have never performed any experiments to determine the effects of 
 cocaine in anfesthesia, but I have proven it to be one of the most pow- 
 erful of the respiratory stimulants, and that it is also able to act as an 
 adjuvant to strychnine, so that in the cliloralized dog, wlien the respira- 
 tion has bci'n raised as far as could be done with strychnine without 
 incurring too much risk of poisoning, cocaine was able still further to 
 improve it. I believe, therefore, that hypodermic injections of strychnine 
 and cocaine woukl act more effectually in the accidents of aniesthesia 
 than would either alkaloid by itself. 
 
 The most rcmarkal)le results whicli I liave reached in bringing about 
 recovery of animals to all ordinary intents and purposes dead were 
 obtained through the use of artificial respiration. Thus I have seen an 
 animal in which no respiratory movements whatever had taken place 
 for two minutes, and in which during that time no movements of blood 
 had occurred in the carotid artery, and in wiiicii, therefore, tiie heart 
 liad practically ceased to beat, rapidly and jjermanently restored by 
 artificial resj)iration. I have no doubt that in a large proportion of the 
 deaths which have occurred in man from antesthesia the fotal result 
 might have been avoided by the use of an active artificial respiration. 
 The difficulty with artificial respiration, as it has been hitherto practised 
 upon man after the Sylvester or other methods, is its inefficiency ; 
 whereas the artificial respiration of the pliysit)logical laboratory is 
 much more efficient than natural breathing in causing circulation of air 
 through the lungs, and therefi)re in removing excess of the anajsthetic 
 from the residual air in the lungs and from the blood. The use of what 
 may be called " forced " artificial respiration by the physiologist so natu- 
 rally suggested a similar practice in man that the celebrated John Hunter 
 invented for the jmrpose an apparatus which consisted of a Ijcllows so 
 constructed that when it was extended one compartment drew in air 
 from the lungs, whilst the other drew air from the atmosphere, and 
 when it was closed the process was reversed, the fresh air being thrown 
 into the lungs, the foul air into the atmospliere. 
 
 There is, however, no need of drawing the air out of the fully-filled 
 lungs ; the chest-walls even after death, nuich more during life, have 
 sufficient elasticity to force the air out of the lungs, and all ordinary 
 laboratory apparatus for artificial respiration is based upon this fact. 
 For forced artificial respiration upon man an ordinary bellows is all 
 that is requir(>d for the motive power. In 1887, Dr. George E. Fell of 
 Buffalo introduced the use of forced respiration to the profession as a 
 means of treating morphine-poisoning, and devised an apparatus which 
 consists of a pair of foot-bellows liv which air is forced into a receiving 
 chamber, which in turn 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 the tracheal tube. When the valve 
 is opened the air rushes through the chamber into the lungs and exjiands 
 them ; the finger is lifted, the valve shuts, the lungs contract ; and so 
 the respiration goes on. I have no doubt that this apparatus is very 
 
67G ANESTHESIA. 
 
 efficient in practice, but it seems to me to be open to the serious oI)j('('- 
 tion of being unnecessarily com])lex and costly. A much cheaper, 
 simpler, and probably e(|ually efficnent ajiparatus may consist simply of 
 a ])air of bellows of proper size, a few feet of india-rubber-tubing, a 
 face-mask, and two sizes of intubation-tubes ; there should also be set 
 in tile rubber tubing a metal tube, similar to the ti'aciieal cauula of the 
 physiological laboratory, so that it is in the power of the operator to 
 allow for the escape of any excess of air thrown by the bellows. I 
 suppose this whole apparatus could be prepared at the expense of less 
 than five dollars, and it seems hardly necessary to point out its probable 
 value, not only in narcotic poisonings, but in all accidents or diseases in 
 which life is threatened by a temporary paralysis of the respiratory 
 centres. 
 
THE TECHNIQUE OF ANTISEPTIC AND 
 ASEPTIC SURGERY. 
 
 By ABPAD G. GERSTER, M. D. 
 
 I. Infection, its Agents and Carriers. 
 
 Modern surgery, as uuderstood and practised to-day, has been made 
 possible by two thinus. One was the discovery of antesthesia ; the otiier, 
 the firm estal)lishment of the Listerian principle of snrgical cleanliness. 
 The changes bronght about by tiie general acceptance of the Listerian 
 principle are rarely realized by that younger generation of surgeons 
 whose medical education was finished after 1885. The terrors of the 
 surgical practice of those former days — terrors which surgeon and patient 
 faced meekly and in resigned despair — ^such as unavoidable sui)puration, 
 pyajmia, septicaemia, erysipelas, tetanus, and, worst of all, hospital gan- 
 grene, are so rare now that some of them, notably hospital gangrene, 
 may safely be declared to be extinct. All of them are looked upon 
 now as exceptional and always due to ascertainable and avoidable con- 
 ditions. Hence, even suppuration not being considered an unavoidable 
 but rather an unusual conn)lication, the possibility of its occurrence is 
 allotted a diminishing share in the determination of the advisability of 
 all oj)crations. 
 
 Adequately to point out the enormous practical gain due to mod- 
 ern methods as compared with pre-Listerian results, it may suffice to 
 state that, according to Lind]>aintncr,' "80 per cent, of all wounds" — 
 treated in Nussbaum's clinic in Munich — " were attacked by hospital 
 gangrene. Erysipelas was tiie order of the day to such an extent that 
 its occurrence could almost have been looked u])on as tlic normal course ; 
 not to suture any scalp-wound was a firm princijile ; healing by primary 
 union did not exist, and suturing of a wound would have simply led to 
 retention and the further encouragement of erysi])elas. Within one 
 year 1 1 out of 1 7 patients subjected to amputation died of pyemia ; to 
 observe the course uf a compound fracture was a great rarity in our 
 clinic, as it was customary to perform amputation immediately, other- 
 wise purulent infection, hos]>ital gangrene, or septicaemia led to a fatal 
 termination within a few chiys." In Volkmann's clinic at Halle the 
 usual rate of mortality in compound fracture was 40 per cent. 
 
 To illustrate by American examples we may mention that Ashhurst" 
 in 1881 gives a rate of mortality of 28 per cent, after 100 major ampu- 
 tations performed by iiimsclf, judging this to be below the general 
 average, which was al)out 33 per cent. 
 
 ^Deutsche Zeitschrift fiir Chirurf/ie, 1S77. 
 ^ Encyclopedia of Surgery, vol. i. p. G17. 
 
 677 
 
678 THE TECHNIQUE OF ANTISEPTIC AND ASEPTIC SURGERY. 
 
 What a change has taken ])hu'0 since then is attested by the reniari?- 
 able improvement in the dcatii-rate after all forms of o])erativc work. 
 To give an instance, it may be stated that of 318 major amj)ntations 
 done by Volkmann under antiseptic; precautions, 28 cases ended fatally ; 
 that is, his rate of mortality was about S) per cent.' Still another and 
 more forcible illustration of the influence of antiseptic jirinciple.s is the 
 report (»f Dennis conipi'ising 1000 cases of compound fracture treated 
 by him in four large metropolitan iiospitals, covering a period of several 
 years, with a death-rate from se[)tico-jiyiemia of \ of 1 ])er cent. This 
 is in marked contrast to the published report in pre-antiseptic days of 
 the Obuchow Hospital of St. Petersburg, where the death-rate reached 
 as high as 68 per cent, in 106 cases of compound fractures; or of the 
 Pennsylvania Hospital from 18.'31 to 1851, where the death-rate was 44 
 per cent, in 116 cases; or of the New York Hospital during the same 
 period, where the mortality was 48 per cent, in 126 cases." 
 
 A corresponding improvement is observable in all other branches of 
 surgery. The lai-ge cavities of the human body are fearlessly invaded 
 now, the cranial contents, the pleura, peritoneum, or large joints form no 
 more a noli me tangerc, and what used to be called the surgeon's " luck" 
 or "misfortune" is now considered to be the direct consequence of a 
 sound or of an improper tecliniipic of cleanliness. 
 
 In another direction great progress for the better has been secured, 
 materially affecting the welfare of patients and hospital economics, inas- 
 much as the average duration of time needed for curing most surgical 
 complaints requiring operation has been materially reduced, To give a 
 typical illustration, it may suffice to say that where in former days three 
 to six months were consumed in healing the wound after ablation of the 
 mamma, two to four weeks are at present amply sufficient for the purpose. 
 
 It is a matter of curious interest to see the laborious compilation of 
 statistical tables contained in many of the older works on surgery, in 
 which the influence of the external temjierature, the seasons, barometric 
 pressure, sex, nationality, or race exerted ujjon the success of operations 
 is seriously considered. We kno^v to-day that the healing of a wound 
 is entirely uninfluenced by these as well as b}' other factors formerly con- 
 sidered important, such as, for instance, constitutional taint or individual 
 predisposition. This change for the better is solely due to our know- 
 ledge that, like fermentation and jiutrefoction, the infection of wounds is 
 directly due to the importation anil ])roliferation of minute organisms. 
 Protect the wound from these organisms and it will heal kindly in a 
 tuberculous, syphilitic, or cancerous subject in man and woman, in the 
 young and old. 
 
 a. Atmospheric and Contact Infection. — The belief that the 
 air may be, and often is, the medium of the transportation of morbid 
 agents is as old as human tradition. The knowledge that the course of 
 subcutaneous injuries is widely diiferent from that of open wounds was 
 clearly expressed by John Hunter, since whose time it has assumed the 
 character of a surgical tenet. Yet the nature of the precise agent con- 
 tained in the atmospheric air, and notoriously injurious to Avounded 
 tissues, remained a mystery. INIalgaigne's experiment of pumping the 
 
 ' Oberst: Die Amputationen, etc., Halle, 1882. 
 2 Philad. Medical News, April 19, 1890. 
 
INFECTION, ITS AGENTS AND CARRIERS 679 
 
 subcutaneous tissue of animals full of atmospheric air, thus rendering 
 them emphysematous, then fraeturinu; bones, dividing subcutaneously 
 tendons, etc., without producing suppuration, only served to thicken the 
 mystery. 
 
 It is Lister's immortal merit to have directed surgical endeavor into 
 the I'ight channels in utilizing the hints afforded by the labors of Pasteur 
 and others. He showed that the decomposition (if dead organic sub- 
 stances is due not to the gaseous, but to accidental and corpuscular, 
 elements floating in the air. As a direct outcome of the theory that 
 disturbances in the healing of a wound were produced by a sort of fer- 
 mentation analogous with the decomposition observed in dead organic 
 matter, leister endeavored to destroy tlie nocuous contents of the air by 
 the use of his carlxtlic spray, and sought, further, to prevent the ingress 
 of these organisms into tlie wounds by the emj)loyment of various occlu- 
 sive measures, the tinal form of which, the typical Lister dressing, revo- 
 lutionized surgery. Though the theory lacked scientific confirmation, 
 the enormous improvement of the results of surgical operations done 
 under Lister's precautions, as compared with former ones, was very appa- 
 rent to candid oliservers. 
 
 The fierce and unphilosophical opposition of Lister's countrymen did 
 not prevent ^'olkmann from studying and benefiting by the new light 
 issuing from Scotland, and to his unreserved and generous approbation 
 is due the rapid acceptance of Lister's principle throughout Germany, 
 the continent of Europe, and America. To England belongs the doubt- 
 ful distinction of harboring the last reiunants of a truculent negation of 
 M'hat tlie grateful world has learned to value as a great benefaction to 
 suffering humanity. 
 
 As before mentioned. Lister's theory lacked scientific proof long after 
 its great utility had been abundantly proven in surgical practice. The 
 actual scientific demonstration of the micro-organisms causing wound- 
 infection, their separation and classification by secondary culture, in 
 short, their natural history, are the outcome of the methods of research orig- 
 inated by Robert Koch, who furnisjied the long-lacking scientific proof 
 of the correctness of the Listerian theory. 
 
 Bacteriology has shown that the air contains various micro-organisms 
 in varying proportions and quantities, the variations being veiy great 
 under different circumstances. AVhile l)acteria and cocci prevail in the 
 air of inhabited dwellings, the spores of mould and the fungi of alcoholic 
 fermentation firm the majority of the micro-organisms contained in the 
 open air. 
 
 We know that the air of cities contains more germs than that of the 
 country ; that in diy weather there are more germs floating in the air 
 than in rainy weather; and that tlie air carries more germs when there 
 is wind than wiien it is calm. The air in mid-ocean, on top of the highest 
 mountains, and in the middle of large tracts of uninhabited damp forests 
 is practically germ-free. A sea-breeze carries fewer germs than a land- 
 breeze.' 
 
 These facts point irresistibly to the assumption, now abundantly 
 
 ' Condorelli-Mangeri : " Variazioni numeriche dei micro-organismi nell' aria, etc.," 
 Atli deW Acarleynia, etc., Catania, 1888, Ser. iii. T. xx. ; Uffelmann : " Luftuntersuchun- 
 geii," Arcli.fiir Hygiene, Bd. viii., 1888, p. 262. 
 
680 7-/77? TECHNIQUE OF ANTISEPTIC AND ASEPTIC SURGERY. 
 
 proven, that tlic nidus of all minute orfjanit^ms i.s not the air — that they 
 are not bred in the air, as formerly believed, but that their breeding- 
 places are to be looked for in organie substances, mainly on the surliiee 
 of the earth, whence they are occasidually and temjK)rarily displaced to 
 float in the air. As soon as the disturbing agents subside the tldating 
 germs will settle back on the surtace. 
 
 (Jrganic germs \\\\\ best float in air when they assume the form of dry 
 powder or of dust ; and Naegeli has demonstrated that they will never 
 enter the air from fluid media by the instrumentality of ordinary agents, 
 such as common winds or drafts of air. Hence the belief that sewer-gases 
 may cause infectious diseases is erroneous, as the stinking air of a damp 
 sewer contains, as a rule, fewer germs tiian the best ventilated or unven- 
 tilated dwelling or the open street. To become dangerous the contents 
 of the sewer or water-closet must be first dried, then pulverized, and 
 finally wafted in air.' It may be added that micro-organisms may be 
 carried from liquid media into, and remain susjiendcd in, the atmosphere 
 by inordinately strong winds, .such as prevail during storms. This is 
 explained by the tendency of strong winds to dash water against shores, 
 to make the waves break, and thus to produce spray, which is readily 
 transported by high winds.^ 
 
 In further confirmation of the fact that dryness and agitation of the 
 air favor the increase of the number of micro-organisms contained in it, 
 may be mentioned the facts that C'ondorelli-Mangeri found in the air of 
 Catania a decided increase of germs at times when a fair or otiier popular 
 gathering was held. The relative number of germs will rapidly increase 
 in the air of workshops after work has commenced, and the same thing 
 is observed as to the air of barracks, Iiospital wards, and dwellings shortly 
 after their Iieing sMcpt and dusted. Accoi'ding to Hesse, in the air of 
 school-rooms, originally containing 3000 germs per cubic metre, their 
 number will increase to 20,000 during school-hours, and to 40,000 when 
 the children leave school. 
 
 It is of considerable interest to note that the breath of healthy and 
 diseased animals or human beings, be it however foul, has never been 
 found to contain micro-organisms. The moist surfaces of the bronchi 
 and lungs act as a filter by which germs carried into the respiratory tract 
 are retained, the expired air being almost entirely free from germs.^ 
 
 Thus we find that all microbes foiind suspended in air are derived 
 from the exposed surfaces of organic material. In examining the relative 
 proportion of living germs contained in sputa, pus, street-dirt, slops, and 
 the water of open sewers and canals we encounter truly apjialling quan- 
 tities, and far outnumbering anj-thing ever found in the foulest atmo- 
 sphere. According to the researches made by the Berlin Hygienic 
 Institute, each cubic centimetre of the water of the river Spree contains 
 from 3200 to 154,000 germs, the average being 37,525.^ There are in 
 each drop of pus millions of microbes, and similar proportions prevail as 
 to every kind of decomposing organic material, t om])arcd \\ith tlii.?, 
 
 ' Petri : " Eine neue Metliode, Bacterien-Polvsporen, etc.," Zeitsclirifl J'iir Hygiene, 1888. 
 ' Fontin : Wratsch, 1888, Nos. 49 and 50. 
 
 ' Strauss : " Sur I'absence des microbes dans I'air expire," Annates de I' Inst. Pasteur, 
 1888, p. 304. 
 
 ' Scliimmelbusch : Aseptische Wundbehandlung, p. 13. 
 
INFECTION, ITS AGENTS AND CARRIERS. 681 
 
 the 40,000 germs found in a eul)ic luetre of the vitiated air of a lecture- 
 room are truly iusignifieant. 
 
 With these facts in view, the statement may readily he accepted that 
 contact of a wound with any of these substances will involve a much 
 greater chance of infection than exposure to atmosplieric air. And long 
 before actual proof of these relations existed, the I'esults of actual 
 practice had demonstrated tliat Lister's fears of aerial infection were 
 exaggerated. Hence the early abantlonment of the carbolic spray and 
 the later one of irrigation. The only precaution worth taking against 
 the possibility of atmospheric contamination of a wound is the avoidance 
 of acts tending to stir up dnst. iS\\ee})ing, dusting, and ventilating of 
 localities to l)e shortly used for operative work is ini]>roper. These pro- 
 cedures should be gone through with far enough ahead of the time of 
 operation to permit the laying of the particles of dust before the opera- 
 tion begins. Should time be lacking to fulfil this condition, it will be 
 best not to disturb any hanging or piece of furniture, not to open doors 
 and windows simultaneously ; in short, to avoid everything tending to 
 stir uj) dust. 
 
 b. Infective Agents. — As the sulyect of surgical bacteriology has 
 received adequate treatment in the preceding articles of this work, it will 
 be sufficient to point out the jjractical outcome of the labors of the bac- 
 teriologist as far as they concern the surgeon. Though it is known that 
 certain sul)stances, organic and inorganic, injected into living animal 
 tissues, are apt to cause a i>rocess similar to microbial sup])uration, it is 
 just as well known that this manner of causation is very rare, and in no 
 wise comparable as to frequency and general importance with the forms 
 of progressive suppuration directly dependent upon the action of the 
 various pyogenic micro-organisms. The overwhelming majority of sup- 
 purations, and other disturbances of a similar natui'e to which the human 
 tissues are subject, certainly depend upon the direct influence of patho- 
 genic germs imported from without. Their proliferation and the kical 
 and general etiect of their products constitute what are termed " infec- 
 tion " and " disease ; " that is, a progressive development of symptoms 
 well defined and typical. Tliis progressive character of the symptoms 
 accompanying tiie lodgement and proliferation of jiathogenic organisms 
 in the living tissues is what distinguishes an infectious process from other 
 processes similar to, but essentially different from, the former, and pro- 
 duced by chemical, mechanical, or caloric agencies. 
 
 With a full understanding of the overwhelming importance of the 
 microbial factor in producing certain morbid states, it would yet be one- 
 sided to attribute the production of these morbid conditions to the pres- 
 ence of microbes alone, and to nothing else. Altliough we admit that 
 ordinarilv tliere canntjt lie suppuration without microlics, we know, on 
 the other hand, that the j)resence of microlies in itself will often fail to 
 cause suppuration unless the state of the tissues themselves or the general 
 state of health favors their germination. In M'hat this predisposition of 
 certain tissues of a body consists we do not know ; nor can ^ve positively 
 define wliy tlie s;ime individual will show different degrees of resistance 
 to the same form of infection at different times. So much, however, is 
 fairlv certain, that to account for tlie various forms of microbial infec- 
 tion we nuist assume two nearly etpially important factors : First, the 
 
682 THE TECHNIQUE OF ANTISEPTIC AND ASEPTIC SURGERY. 
 
 lodgemont of pathogenic organisms within the living tissues ; and, sec- 
 ondly, a condition of these tissnes favorable to the development and 
 multiplication of microbial growth. To illustrate this relation of things 
 it may suiiice to mention the marked predisposition to suppurative pro- 
 cesses observed in diabetes mellitus. 
 
 n. Disinfection and Sterilization. 
 
 Foremost among the means for disinfection stand the homely but 
 thoroughly efficient and sound methods of mechanical pin-ificafion, as, 
 for instance, maceration, scrubbing, washing, scraping, shaving, M'ith or 
 without the aid of emollients, among which the jirincipal one is soap. 
 Being aware of the fact that the sparse number of infectious germs con- 
 tained in the air is far outnumbered by the millions of microbes incor- 
 porated \\ith the various forms of gross filth and dirt adherent to almost 
 every surfoce exposed to contact with the outer world, our princijial 
 endeavor at disinfection must be directed, in the first place, toward the 
 removal of these gi'oss lumps of filth. How much can be acconn)lished 
 in surgery by means of these simple methods was first demonstrated by 
 the brilliant results of men like Lawson Tait, whose reliance was placed 
 almost exclusively upon ordinary measures of personal and domestic 
 cleanliness. The mechanical removal of the great bulk of microhicd dirt 
 from the objects to be bn)Ught in contact \\ith a wound i.s the mod im- 
 portant preparatory act of all forms of disinfection. 
 
 Methods of chemical disinfection have undergone manifold changes 
 since the davs of the universal reign of carbolic acid. Formerly, some 
 deodorizing agents were considered good disinfectants, and the valuation 
 of the merits of the various disinfectants was extremely uncritical. We 
 owe the more correct appreciation of the value of these substances to the 
 labors of Koch, who by pure culture taught us to isolate the several 
 species of pathogenetic germs, and showed us how to recognize their dif- 
 ferent vegetative forms. 
 
 Some of these microbes are jiroductive of spores ; others are sporeless. 
 In general, it may be said that the spores of micro-organisms offer a 
 much greater resistance to disinfecting agents than the mother-plant, 
 and, furthei-more, it was learned that the ditferent species of microbes 
 also differ from each other materially in this respect. 
 
 In estimating the bactericidal value of a chemical disinfectant a 
 number of precautions ' have to be observed to eliminate errors, and dis- 
 crimination must be used in ajijilying the results thus gained to the 
 actual conditions met with by the sui-gcon in his practice. 
 
 Another factor materially influencing the development of microbes 
 is the presence or absence of certain cardinal conditions necessary for 
 their proliferation. A suitable pabulum, a certain quantity of moisture, 
 and a certain temperature are indispensable. Withdraw one or more of 
 these conditions, and the microbes u-ill either jierish or their grorrth will be 
 retarded. 
 
 For ascertaining the relative value of a number of the common dis- 
 infectants, as to their power of retarding bacterial growth, Koch selected 
 the spores of the anthrax bacillus, one of the most resistant forms of 
 ' Geppert : "Zur Lehre von den Antisepticis," Bed. Icliu. Woclienschrift, 1889, No. 36. 
 
DISINFECTION AND STERILIZATION. 
 
 683 
 
 pathogenetic bacteria. The results of his investigation are contained in 
 the following table : 
 
 In the proportion of— 
 
 Bichloride of mercury 
 Oil of niiistard ... 
 Arseniate of potash . 
 
 Thymol 
 
 Oil of turpentine . . 
 
 Osmicacid 
 
 Oil of cloves .... 
 
 Potash soap 
 
 Iodine ... . . 
 Salicylic acid ... 
 
 Camphor 
 
 Eucalyptol 
 
 Borax 
 
 Benzoic acid 
 
 Bromine 
 
 Chlorine 
 
 Permangan. potash . 
 
 Boracic acid 
 
 Carbolic acid . . . 
 
 Quinine 
 
 Chlorate of potash . . 
 
 Alcohol 
 
 Cooking salt 
 
 Growth markedly 
 checked. 
 
 Entire cessation 
 of growth. 
 
 
 1,600,000 
 
 333,000 
 
 100,000 
 
 80,000 
 
 75,000 
 
 1 
 1 
 1 
 
 300,000 
 33,000 
 10,000 
 
 
 6,000 
 5,000 
 
 
 
 
 5,000 
 
 
 
 
 5,000 
 3,300 
 2,500 
 2,500 
 2,000 
 2,000 
 
 1 
 
 1 
 1 
 
 1 
 1 
 
 1,000 
 1,500 
 1,250 
 1,000 
 700 
 
 
 1,500 
 
 
 
 
 1,500 
 
 
 
 
 1,400 
 1,250 
 
 1 
 
 800 
 
 
 1,250 
 
 1 
 
 850 
 
 
 830 
 
 1 
 
 625 
 
 
 250 
 
 
 
 
 100 
 
 1 
 
 12.5 
 
 
 04 
 
 
 
 It is well to remember that this table shows only the effect of a nnmber 
 of chemicals as to their influence in retarding ov checking the germination 
 of anthrax spores, and not at all their capacity of killing these s])ores. 
 It is much easier to clieck the growth of bacteria than to kill tiiem, 
 especially to kill them within a few minutes, which is an es.sential con- 
 dition of the ])ractical utility of a germicidal agent. 
 
 The most important of all bactericidal agents, because easily pro- 
 cured, rapidly effective, and practical, is heat. It can be used in the 
 form of — 
 
 1. The actual cautery ; 
 
 2. Boiling water ; 
 
 3. Steam ; 
 
 4. Hot air. 
 
 The actual cautery is one of the most ancient and most effective dis- 
 infectants. It must suffice merely to mention it here, as it properly 
 belongs to the subject of o))crative technique. 
 
 Of the other agents, boiling wafer deserves to be placed first of all. 
 ^.s to its bactericidal' value, it is known that it icill kill spores of anthrax 
 in two minutes, and will destroy the vegetative forms of any coccus or 
 bacteria in from one to five seconds. 
 
 Next in importance is steam., which, to be ftdly effective, must not be 
 mixed witii air, but ought to be pure and " saturated." Steam can be 
 used in several ways, vithev quiescent ov moving; it can be used under 
 increased pressure or superheated. Of tiiese several forms, moving steam 
 has been found most useful, and it will kill anthrax spores in from five to 
 fifteen minutes. 
 
684 THE TECHNIQUE OF ANTISEPTIC AND ASEPTIC SURGERY. 
 
 Less t'flw^tivc tli;iii stc;iMi is hot :iir, to which, at a temperature of 140° 
 Celsius, spores will siicciinih only alter an exposure of three honvs. 
 Anotiier great drawbaek of hot air is its great inferiority of 'penetration 
 as compared with lioiiing water and flowing steam.' 
 
 The badericklal value of the commonly employed cheniieals of sur- 
 gery falls far below that of the caloric agents just enumerated. There 
 are \evy few chemicals which even in a concentrated state will destroy 
 anthrax spores within twenty-lour hours. Of these may be mentioned — 
 
 Bichk>ride of mercury, 
 
 Iodine, 
 
 Chlorine, 
 
 Bromine, 
 
 Trichloride of iodine, 
 
 Cresol mixed with sul|)luu'ic acid. 
 
 Of chemicals that require a nuich longer time to kill anthrax spores 
 there are — 
 
 Carbolic acid, 5 : 100. 
 
 Creoline, 
 
 Ligneous vinegar, 2 days. 
 
 Chlorate of lime, 5 : 100, 5 "' 
 
 Turjientine, " 
 
 Formic acid, " 
 
 Chloride of iron, 5: 100, " 
 
 Quinine mur., 1 : 100, 10 " 
 
 Arsenious acid, 1 : 1000, " 
 
 Muriatic acid, 2 : 100, " 
 
 Ether, sulphuric, 30 " 
 
 Among substances that even after months have exerted no influence 
 whatever upon the vitality of the spores of the bacillus of anthrax, there 
 are — 
 
 Absolute alcohol. 
 
 Distilled M'ater, 
 
 Chloroform, 
 
 Glycerin, 
 
 Benzoic acid. 
 
 Ammonia, 
 
 Concentrated solution of cooking salt, 
 
 Chlorate of potass. (5 : 100), 
 
 Alum, 
 
 Borax. 
 
 These lists demonstrate the remarkable insisting power of spores to the 
 various chemical disinfectants. The vegetative forms of pathogenetic micro- 
 organisms, the bacilli and cocci, show a much lower degree of vitality, 
 and w ill more easily succumb to the effects of even the weaker chemicals. 
 But under the most favorable conditions their effect is not nearly as 
 rapid as that of boiling water, Mhieh will destroy the more resistant 
 spores in from two to five minutes, while the effect of a 1 : 1000 solu- 
 tion of bichloride of mercury upon the much less resistant bacilli of 
 anthrax or upon the staphylococcus pyogenes is not assuredly destructive 
 in fifteen minutes (Geppert). 
 
 ' Wolfhiigel : MUtheUmujen aus dem Kais. Gesundheilsamt, 1881. 
 
CLEANSING OF THE SKTN AND OF MUCOUS SURFACES. 685 
 
 It \vas pointed out before that the unqualitiwl application of the 
 results of ('X[)erinicnt to the conditions of actual surgical ]iractice would 
 lead to serious error. While in cx]K'rinient a small (juantity of bacilli 
 gained by pure culture and soaked into a single thread of silk is exposed 
 to tiie effect of a large volume of the germicidal solution, in surgical j)rac- 
 tice enormous naasses of various microbes, imbedded in solid and semi- 
 solid tissues, sloughs, scabs, blood, fffices, grease, and dirt, are encountered 
 by a limited quantity of the germicide. While in the experiment the 
 germicide will penetrate, reach, and bathe every singh' individual of the 
 micro-organisms, in practice — for instance, in a suppurating wound — 
 only a very limited ((uantity of the vast masses of microbial matter \\\\\ 
 come in actual contact with the solution. Finall}-, where under ex- 
 perimental conditions the chemical action of the germicide is unim- 
 paired by accidental disturbance, here, in the wound, most of the active 
 princi]de of the solution will be neutralized by contact with albu- 
 minoid components of the tissues and discharges. Hence it follows 
 tiiat the theoretical results of experiment as to the value of this or 
 that germicide must differ materially from those gained in actual 
 practice. 
 
 The principal substances that frustrate the usefulness of germicidal 
 acpieous solutions are, first, a coating or adiaLrfurc offatfi/ matter impen- 
 etrable to water ; and, secondly, the albumin contained in human tissues 
 and their discharges, which, united with some of the strongest metallic 
 germicides, changes them to inert albuminates and annihilates their ger- 
 micidal properties. 
 
 In estimating the practical utility of the various methods of disin- 
 fection two questions are of the utmost importance : First, How 
 much time is consumed by the procetlure to be effective? and, secondlj/, 
 Will not the objects to be disinfected be damaged by the jirocess ? Where 
 the process must lie accomplished in a few minutes, germicidal solutions 
 are entirely inadequate, \vhile boiling is perfectly satisfactory. Where 
 metal instruments are to be disinfected, corrosive sublimate, for instance, 
 is inadmissible, but in the disinfection of the skin of patient and sur- 
 geon boiling water would not be proper or agreeable. Thus it will be 
 seen tiiat the external eonditions influencing disinfection are variable, 
 and tiiat under changing eonditions a variation of the process of disin- 
 fection must take place. Often — in fact, as a rule — several of the known 
 methods of sterilization have to be combined, their application being 
 either simultaneous or successive. To illustrate this we may mention 
 that the patient's skin, for instance, is first macerated, then shaved, 
 scrubbed, freed from grease by ether, and finally exposed to bichloride 
 of mercury ; or the instruments are first soaked, then scrubbed, polished, 
 finally boiled in sodn, solution, and so forth. 
 
 m. Cleansing of the Skin and of Mucous Surfaces. 
 
 The surface of the human body is a very hotbed for the ])ropagation 
 of a great variety of micro-organisms. With the aid of a little methyl- 
 ene blue it can be readily shown that the surface of the skin, even of 
 a very cleanly person, is literally swarming with fungi, bacilli, and cocci. 
 The predominance of this or that microbe is determined by the habits, 
 
686 THE TECHNIQUE OF ANTISEPTIC AND ASEPTIC SURGERY. 
 
 opciipatioii, and state of li(>altli of tlic individual.' Ilairv jilacos, as the 
 licad, armpits, etc., and es))('cialiy the ininicdiatc nfij>liijorliood uf the 
 natural apertures of the body, are very rieh in microbes, which become 
 iiotahly multiplied whenever even a slight disturbance of the normal 
 stati! of health of any portion of the skin occurs. Sweating or a slight 
 catarrhal or eczematous condition favors tlie multij)lieation of their 
 growth to an incredible extent, which will be still more rank in the 
 jtresence of a suppurating wound, sinus, or ulcer. And, as we never 
 can tell whether pathogenetic microbes are present or not, one of the 
 most indispensable conditions of safe surgery is the scrupulous cleansing 
 of the skin of the field of an operation and of the hands of those that 
 are to come in contact with it. The surgeon's hand, having often 
 unavoidable contact with unclean surfaces infected with pathological 
 organisms, is a most connnon carrier of infection. 
 
 The disinfection of the hands is not an easy or rapid process. The 
 slipshod methods of cleansing tlie hands practised in the early period of 
 the antiseptic era, when a scrubbing even was deemed superfluous and 
 main reliance was placed on the efficacy of the carbolic lotion, were 
 found to be entirely inadecpiate. Fiirbringer's excellent labors have 
 taught us that here, as elsewhere, the action of the chemical disinfect- 
 ants is accessory only, the chief importance belonging to the prejiaratory 
 mechanical cleansing. The dry and crusted masses of bacterial dirt 
 must be first softened by the use of a strong alkaline soap and hot 
 water; the coatings of grease must be dissolved by the application of 
 ether, benzine, or alcohol ; then the razor and scrubbing-brush have to 
 sweep away the masses of macerated filth. Only after the large bulk 
 of dirt has been removed by these means will the application of a ger- 
 micidal lotion be of any use. In fact, a very careful and thorough 
 mechanical cleansing will under most circumstances render the use of 
 germicidal lotions supcrfuous. 
 
 Simple as this jH'ocess of cleansing seems to be, its value will depend 
 on the conscientious thoroughness with whicli it is applied, which thor- 
 oughness again presents the most remarkable personal variations in 
 various medical men. While with some few a sublimate lotion is a real 
 superfluity, the cleansing processes of others are so shallow — in fact, a 
 mere sliam — that in their ease the al)andonnient of chemicals would 
 mean all forms of surgical disaster. And as long as the meaning of 
 the canons of cleanliness will have to depend on the individual inter- 
 jiretation of the practitioner, the use of chemicals cannot be excluded 
 from sui'gical practice. 
 
 The difference between what is termed asepsis and antisepsis is strik- 
 ingly illustrated by the preceding remarks. Where mechanical and 
 caloric measures are applicable and sufficient to the attainment of a 
 state of freedom from micro-organisms, there we have asepticism. Where 
 this is not the case — that is, -where, either on account of the inherent 
 condition of the surfaces to be dealt with, or because of the low order 
 of the conception of purity of the medical attendant, heat and scrubbing 
 cannot or are not used to their full extent — chemicals must be accepted 
 as a makeshift, and the process is termed antisejisis. 
 
 'Fiirbringer: " Untersuchungen iiber die Desinfection der Hiinde," Deutsche med. 
 Woehenschrift, 1888, No. 48. 
 
CLEANSING OF THE SKIN AND OF MUCOUS SURFACES. 687 
 
 Among the several methods of disinfecting the surffcon'.i hands, this 
 one can be conscientiously recommended : 
 
 1. Rub a sufficient quantity of green or soft soap into the hands and 
 n{)on the bared arms ; then scrub them in hot water with a stitf brusli 
 for one minute, paying special attention to the nails and the subungual 
 spaces. 
 
 2. After scrubbing, the spaces under the nails must be carefully freed 
 from all loose matter by the use of a nail-cleaner. 
 
 3. The iiands are now immersed for one minute in strong alcohol (80 
 per cent.). 
 
 4. Finally, they are immersed in a 1 :100() solution of bichloride of 
 mercury for one minute, during which tiiis solution is to be well rubbed 
 into all folds and creases by the aid of a brush. 
 
 There are other raetiiods just as reliable as this one, notably that in 
 wliich permanganate of potash is used ; but the necessity of employing 
 oxalic acid for the decoloration of tiie epidermis, deeply stained by the 
 manganate salt, is a great drawback to its use. 
 
 Similar principles jirevail in cleansinff the skin of the patient, with 
 some important modifications rendered necessary by unusually adherent 
 deposits of dirt : 
 
 1. The skin is shaved, not only in the armpits, on the head, flice, 
 pubic and anal regions, but wherever an operation is to be performed. 
 
 2. Whenever possible a general bath should precede the consequent 
 steps. 
 
 3. Where, as on the hands of laboring-men, or on the feet of people 
 accustomed to go barefoot, or in persons of unusual uncleanliness, tiie 
 deposit of dirty e])iderniis is very thick and massive, the parts should 
 be envelo])ed for several hours in a wet jiack of soajj-water, by which 
 the epidermal coating will Ije sufficiently macerated to yield to tiie scruli- 
 bing-brush. 
 
 4. Friction with water, soap and brush, and ether must then be 
 applied until all crumbs and flakes of loose epidermis are removed and 
 the skin becomes clean and glossy. 
 
 5. Finally, the skin is rubbed off with a 1 :1000 solution of Ijichlo- 
 ride of mercury. 
 
 We cannot leave this subject without devoting a few remarks to the 
 tools and substances used for cleansing, notably to soap and brushes. 
 
 Eiselsberg ' ascertained that all fiirnis of soap manufactured by a 
 process of boiling are, as a rule, germ-free ; on tlie other hand, soap 
 produced by a cold process of blending tiie alkali with fats is unreliable 
 and sliould be shunned. 
 
 As to inrushes, it will need no special jiroof — though this lias been 
 abundantly furnished. by Schimmclbusch " — tiiat after having been used in 
 contact with filthy surfaces, with blood, pus, and faeces, they must become 
 ciiarged with enormous masses of noxious germs. The destruction of tiiese 
 germs by diemical agents alone is uncertain and reipiires a verv long time. 
 On tlie r)tlier iiand, a short boiling of five minutes in jilain water or 
 in water ciiarged with 1 per cent, of common soda will surely render 
 any brush germ-free. The cheap brushes made of vegetable fibre should 
 
 ' " ITeber den Keimgehalt von Soilen, etc.," Wiener med. Woclienscliri/t, 18S7, No. 29. 
 2 Archiv fib- CKiruryic, 1891, pp. 1(13-170. 
 
(588 THE TECHXIQUE OF ANTISEPTIC AND ASEPTIC SURGERY. 
 
 receive the preference, because hnislies made of bristles are claniap;e(l by 
 boiliiifi'. The brushes used in an operating-room should be boiled every 
 day with the instruments. Those that were used in contact with sej)tic 
 material should either be set aside or nuist be immediately boiled bctbre 
 being used again. After boiling in soda solution the brushes should be 
 kept immersed in a 1:1000 solution of sublimate. The brushes eni- 
 jiloyed on the washstantls of liospital wards or bed-rooms also need fre- 
 quent boiling. 
 
 The dcaimng of mucous surfaces with a view to their disinfection i.s 
 a much more difficult matter than that of the outer skin, and here the 
 use of chemical germicides is strictly limited by the dangers of absorp- 
 tion and poisoning. Hence tlie jirocesses of wiping, flushing, and the 
 mechanical remoral of fa;ces or mucus, together with measures directed 
 against the escape fif tieces, bile, or urine during an operation, as by i)hig- 
 ging or temporary ligature, will deserve the preference over germicidal 
 lotions. 
 
 IV. The Sterilization of Instruments. 
 
 For preparing instruments for an operation their mechanical cleansing 
 from lilood, pus, shreds of fibrin and tissues, or caseous or greasy material 
 by soa})-water and a brush must be the initiatory step. Though by these 
 means the bulk of the noxious substances clinging to the irregular sur- 
 faces of the instruments will certainly be dislodged, yet a sufficient 
 quantity of microbes will still adhere to them to menace the welfare of 
 the wound.' Hence to render the instruments perfectly germ-free some- 
 thing more will have to be done. 
 
 What is desired is a mcthfid that is adequate and practical — that is, 
 not consuming too much time or injurious to the instrumeuts. 
 
 To eflect an adequate sterilization of metal instruments hot air, steam, 
 or boiling in water can be considered. The first is impractical, as it de- 
 mands special and bulky apparatus and consumes considerable time.^ 
 The second is objectionable, because it rusts the instruments. The third 
 — that is, boiling — is simple, rapid, and adequate. Its objectionable 
 feature — that is, the rusting of the instruments — has been admirably 
 eliminated by Davidsohn's and Schimmelbusch's exjjedient of charging 
 the water with cooking soda in tlie jiroportion of 1 per cent, of its quan- 
 tity. The presence of the soda will not only prevent rusting, but also 
 will render the disinfection more tliorougli and rapid.^ To test this very 
 question Schimmelbusch ^ has impregnated strands of silken and woollen 
 thread with pus and pure cultures of staphylococcus pyogenes aureus, of 
 the bacillus pyocyaneus, and with anthrax spores, after which they were 
 immersed for varying lengths of time in a boiling soda solution. It was 
 found that, ^vithout exception, the micro-organisms contained in pus, as 
 well as the staphylococcus and bacillus pyocj'aneus, were destroyed in 
 from two to three seconds, whereas the spores of anthrax which had re- 
 sisted the effect of steam heated to 100° Celsius for twelve minutes were 
 
 • Schimmelbusch : Berliner Uin. Wochenschrifi, 1888, No. 35. 
 
 ' Poupinel : " Sterilisation par la Chaleur," Revue de Cliirwgie, 1888. 
 3 " Wie soil der arzt seine instrumente desinficiren," Berliner kliyi. Woctiemchrift, 1888, 
 No. 35. 
 
 * Aideiiung zur asepl. Wundbehandlung, p. 65. 
 
THE STEEILIZATIOy OF INSTRU3IENTS. 
 
 689 
 
 invariably Ivillcd l)y the Ijoiling- soda sDlution within two minutes. Ac- 
 cordingly, it may be asserted that a brief submersion, extending over a 
 few seconds, in a boiling soda solution Mould under ordinary circum- 
 stances sterilize a surgical instrument, but that a boiling of five minutes 
 will certainly and relialily jinuluce this eifect un<ler any and all circum- 
 stances. 
 
 The eminent disinfecting ([ualities of the soda solution were carefully 
 tested by ]jchring,' who found tluit by the ordinary processes of the laun- 
 dry, during which a temperature of 80-85° Celsius is rarely exceeded, 
 the spores of anthrax were very often destroyed in four, and certainly 
 \vithin eight or ten, minutes. 
 
 Aside from its eminent l)actericidal power, this method commends 
 itself to the practitioner by its general applical)ility. Water, soda, a pan 
 or pot, and tire to heat them, will be found everywhere, and under all 
 circiunstanccs aTid almost anywhere can the surgeon secure a reproacliless 
 state of asepticism for his instruments. For practical purposes it may 
 be said, then, that one tablvxpoonful of flic common irasliinr/ aoda to a quart 
 of irate r, boiled for fire miinifex iritli (lie instnimentx, /.v fhe best means of 
 (lislnfectine/ f/tein. 
 
 For clinical purposes, when the same set of instruments has to be used 
 in two or three separate and subsequent operations, Schimmelbusch has 
 
 Flu. 173. 
 
 Schimmclliuscli's instrument-boiler. 
 
 devised a very practical boiler heated by gas-jets (Fig. 173). The instru- 
 ments are placed on a wire tray with suitable handles, which tray is 
 immersed in the solution for five minutes, after whicii the in.striiments 
 
 ' ZeilschriJ'l J'iir Hyyiene, 1890. 
 Vol. 1.— 44 
 
690 TIIK TECHNIQUE OF ANTISEPTIC AND ASEPTIC SURGERY. 
 
 can bo At once placed in the tray which is to hohl thcni during tlie 
 operation. For various )-eason.s it is i^ood to keej) them there in a batli 
 oi' plain hoik'd water, or, better still, in a cold so(hi solution, ijuantities 
 of which can be kept on hand. 
 
 It is necessary to add that old-t'asliioned instruments, provided with 
 wooden or ivory handles, Avill very soon be ruined by tliese procedures ; 
 hence it is desirable that such only should be used as arc entirely com- 
 posed of metal parts. The nickel-plating of instruments can be entirely 
 <lispensed with as unnecessary. Aluminum is ])ronij)tly attacked by 
 alkaline solutions, and is not to be subjeeti'd to tiiis form of sterilization. 
 
 The receptacles, cases, and safes for tlie keejiing of instruments siiould 
 have tight doors. They arc best constructed of iron with glass panels 
 and shelves, and should be kept closed against dust all the time. 
 
 The old-flisiiioned silk-lined ])ocket-instrument case of leather is out 
 of date, and should be supplanted by a washal)le canvas case, which ought 
 to be cleansed l)y boiling as often as practicable. 
 
 Afiplrat'niy and Injecting Syringes. — Tiie disinfection of syringes and 
 hollow needles used for aspiration and for the injection of liquids into 
 human tissues requires special attention. The sources of infection may 
 l)e here the skin of tlie patient, the injected fluid, and the syringe. The 
 careful cleansing of the skin should precede every puncture, whether for 
 asj)iration or injection, as a matter of course. As to the fluids to be 
 injected, this may be said, that Schinnuelbusch ' examined a number 
 of standard solutions, proi'ured either from leading drug-stores or from 
 the Avards of the Berlin surgical clinic, and foimd tiiat they all contained, 
 as a rule, large quantities of micro-organisms. Solutions of 1 per cent, of 
 j)ilocarpine muriate, for instance, were swarming with bacteria ; a solu- 
 tion of ergotine contained 10, (MM) germs to the cubic centimetre ; and tiie 
 standard solution of morphine rarely contained less than from 200 to 300 
 germs per c.c. Much purer were found iodoformized glycerin (10 per 
 cent.), camphorated oil, and the watery sf)lutions of hydroeldorate of apo- 
 morphia, of bisulphatc of eliinine, of antipyrine, and of the mercurial salts. 
 
 Ferrari' studied the behavior of various noxious miero-t)rganisms 
 introduced into substances used for hypodermic injections, and found 
 that staphvlococcus pyogenes aureus was instantly killed by ether, tinc- 
 ture of musk, and concentrated solutions of chiniue — that it still lived 
 after two hours in a 10 per cent, solution of cocaine. The same 
 organism died in a 2 per cent, solution of morphia only after twenty- 
 four hours, in glycerin after six days. In distilled water, however, in a 1 
 ]>er cent, solution of atropia, and in ordinary morphine solutions the micro- 
 oriranisms not only remained living fir weeks and months, but increased 
 and multiplied to an enormous extent. 
 
 It stands to reason that certain strongly germicidal substances, as 
 ether, alcohol, tincture of iodine, solutions of carbolic acid and of 
 bichloride of mercury, need no s])ecial prejiaration ; but solutions of 
 atropine, morphia, eticaine, and pilocarpine, whieii are especially prone 
 to microbial invasion, must receive more than ordinary attention. Of 
 these, especially cocaine is used frequently in small o])erations, and when 
 
 ' Schimmelbusch and Holil: Ankihinfi zur asept. Wnndhehtnirllmici, p. 120. 
 '' " Ueber das Verhalten der Micro-organismen in den subcutan. einziisjiritzeiiden Fliis- 
 sigkeiten," Ccnlralblatl Jiir Backrioloyie, vol. iv. p. 744. 
 
DRESSINGS. 691 
 
 impiiro may lead to serious disturbances of tlie liealing of a wound. A 
 brief ])reliniinary boiling in a teaspoon over a lamp- or gas-flame will be 
 I'ound a rcuily means of destroying germs contained in any of these solu- 
 tions. Where larger (juantities are to be preserved, an addition of a few 
 <lr(>ps of concentrated carbolic acid to, say, an ounce of solution will be 
 fountl very useful. As to the syringes themselves, it must be said that 
 they are, as a rule, easily infected and very hard to keep clean, especially 
 those made of hard rubber and having leather washers. Koch's balloon 
 .syringe is easilv cleansed and reliable, but not useful for the purposes of 
 tile .surgeon, and is far surpassed by tlie old-fashioned barrel-syringe. 
 Overlach has constructed a barrel-syringe whicii has a compressible 
 rubber ])ist(in, glass barrel, and metal mountings. This instrument can 
 be Ixiiled without injury and can be easily made aseptic. 
 
 To study the value of the various ordinary methods of cleansing 
 hypodermic svringes Schimmclbusch ' first thorf)Ughly sterilized an 
 Overlacii syringe, then tilled it with pus, emptied it, then repeatedly 
 tilled it with and emptied it of distilled water. Tile number of cocci 
 was thus materially diminished, but after ten fillings and emptyings the 
 ejected water still contained thousands of germs. A 3 per cent, solution 
 of carbolic acid, 1 : 2000 of corrosive sublimate, and absolute alcohol 
 gave somewhat better results, but the best of all was squirting hoUing 
 water through tiie syringe. After the instrument was thus filled and 
 enij)tied five times it was found absdluteiy sterile. 
 
 Tlie iiolldw needles used for injection and aspiration are liest disin- 
 fected by boiling in soda .solution. Drawing them through an alcohol 
 flame will certainly sterilize them, but also will destroy their temper, 
 as they are made of steel. Platinum-iridium canulas will withstand red 
 heat excellently, but are expensive. 
 
 V. Dressings. 
 
 In oiiserving the course of one of the many small wounds accident- 
 ally inflicted upon ourselves with a clean instrument, of a wound left 
 entirely to itself and not interfered with in any way, we shall get the 
 model of repair which is the i<leal aim of the surgeon. After cessation 
 of tiie iieniorrhage tlie li])s of the wound ln'come agglutinated by l)lood- 
 dot, whicli gradually desiccates and occludes the wound in the manner 
 of a hermetic seal. After the first smarting has passed away there will 
 be no jiain, no redness, no heat as long as the ]iarts are left undisturbed, 
 and after the lapse of six or seven days the dry crusted blood will peel 
 off' and the fresh sound cicatrix will come to view. AVliere the wound 
 is somewhat more extensive, yet not large enough to rei|uire suture, the 
 drying of the blood-clot is preceded by .some oozing of blood-serum out 
 of tiie clot. The watery part of this serum will gradually evaporate, and 
 its solid constituents will ultimately form into a dry crust, forming a sort 
 of ])roteetive seal both to the edges of the wound and to the clot filling it. 
 In this case the course of liealing will lie identical witii that just depicted, 
 always ]irovidcd, however, that the protective crust is not interfered 
 Avith and that no septic matter enters the wound at any time. 
 
 Using this experience as a paradigm, the surgeon may safely imitate 
 
 ' Antfitung, etc., p. 124. 
 
692 THE TECHNIQUE OF ANTISEPTIC AND ASEPTIC SURGERY. 
 
 the process in the treatment of comparatively small and simple wounds, 
 such, for instance, as occur in dclii;atioii of artei'ies in continuity, in 
 herniotomy, or in the extirpation of small tumors. T(j ensure the stabil- 
 ity of the relations of the several parts of a small wound we apply an 
 appropriate number of catgut stitt^hes ; then spread over the line of 
 union a narrow strip of gauze, and saturate this with flexible collodion, 
 which will seal up hermetically the wound and its inHn<'diate cdufincs. 
 If there be no persistent and copious oozing, the wound will heal under 
 this artiiicial scab without trouble. In about ten davs the collodion will 
 become loose, and, it being raised, the stitches will be found absorbed and 
 the wound firmly healed. 
 
 But where the wound is extensive, and where the oozings are too 
 copious to be promptly desiccated by evaporation, another method must 
 be pursued to secure rest to the wound and to jirevent infection from 
 without. Ah.wrhenf drcssinr/.s take their jilace here, and will now re- 
 quire our consideration. 
 
 To answer modern requirements dressing materials must possess the 
 following qualities : 
 
 1. They must be absorbent to a high degree; 
 
 2. They nuist be aseptic ; 
 
 3. They nnist possess the quality of remaining aseptic even if satu- 
 rated with tliseharges. 
 
 Of the various materials used for dressings, gauze or cheese-cloth, first 
 selected by Lister himself, has remained to this day the most highly 
 prized and most universally used. Of others we may mention fuller'.s 
 earth, sawdust, ashes, sand, peat, oakum, jute, tow, asbestos, spun glass, 
 wood-wool, cotton batting, lilotting-papcr, and moss, — among which, 
 however, only the last three and sawdust have a practical utility. Saw- 
 dust, cotton batting, and absorbent cotton, finally blotting-paper, may 
 furnish very good material for extemporized dressings in emergencies. 
 Sterilized moss (various species of sphagnum), being highly absorbent 
 and very cheap, is, on account of the great saving that is involved by its 
 use as against the more costly gauze, very important in hosjiital economy. 
 
 As to energy of absorption both as to quantity and raj)idity, absorb- 
 ent gauze and moss occupy the highest point. Excellent absorbent 
 gauze can be procured now everywhere in suitable quantities and for 
 little money. Where it cannot be bought the surgeon may easily render 
 common unbleached cheese-cloth absorbent by boiling it for half an hour 
 in a 5 per cent, solution of soda or in ]>otash lye, liy which process sa- 
 ponification of the oily matter contained in the cotton fibre is effected. 
 The cheese-cloth is rinsed in cold water, and after drying possesses con- 
 siderable though not as high absorbent power as the bleached manufac- 
 tured article of trade. 
 
 The second and most indispensable condition which mu.st be fulfilled 
 before any dressing material is fit for surgical use is a complete freedom 
 from pfdhof/cnetie (/ermf;. 
 
 Our present knowledge of the ])art ])layed by noxious germs in the 
 causation of wound diseases has fully confirmed the epigrammatic saying 
 of Volkmann, that the human organism is not a test-tube filled with 
 gelatin or agar-agar. We know that not every contact with noxious 
 germs must inevitably lead to infection ; but, on the other hand, we also 
 
DRESSINGS. 693 
 
 know how promptly the streptococcus of" erysipelas, for instance, will 
 enter the lymphatics through a superficial denudation. Hence measures 
 at rendering our dressings germ-free must be considered important 
 indeed. 
 
 Freedom from germs of the gauze sold in neat tin boxes by various 
 wholesale drug firms is, though expressly guaranteed, very unrelial)le. 
 ^\^nd if we consider the ordinary methods of mamifa<^ture and trade, we 
 shall not expect too much from that source. Fortunately, we have at 
 our connnand ready and prompt means for rendering dressing materials 
 aseptic. 
 
 Of these, impregnation of the fabric used for dressings icith chemicals 
 must be first mentioned. Lister's first efi'orts were made in this direction 
 when he saturated gauze with a resinous mixture chargctl witJi carljolic 
 acid. Later, corrosive sublimate displaced carbolic acid, but most of 
 the objections justly raised against the former also applied to the latter. 
 Aside from the fact that the ordinary processes of imj)regnation gave 
 verv unequal results, tlic objection that carbolic acid eva])(>rated from the 
 dressings was etpialled by the fact that the mercurial salt was also evan- 
 escent, and, moreover, was liable to decomposition. Furthermore, the 
 serious drawback became only too often evident that both of these 
 irritated the skin, protlueing very acrid eczemata, and often led to raoi"e 
 or less dangerous states of intoxication due to direct absor])tion by the 
 blood. The simple fact that impregnation or sterilization was not the 
 last, but the first, step in the preparation of the dressings, and that it 
 was followed by more or less unavoidable handling by attendants and 
 nurses in the course of drying, foldiug, cutting, and storing of the 
 gauze, made this plan extremely unrelialile. 
 
 Most of these objections disappear when we employ heat for steril- 
 izing dressings. Here all the cutting and folding can be done in advance ; 
 the prepared dressings are sterilized and left until needed in the wrap or 
 receptacle in which tiiey were subjected to the influence of heat. Should, 
 however, circumstances compel the practitioner to rely upon chemical 
 sterilization, it is best to impregnate the dressings immediately preceding 
 their use. Sublimate deserves the preference over cai'bolic acid, and the 
 strength of the solution should be 1 : 2000. 
 
 In hospital practice, and where the conveniences can be easily pro- 
 cured, sterilizing by sleaui has nuich to commend it, but in an emergency 
 am/ fabric to be sterilized extempore can be made reliably aseptic by 
 boiling for fifteen minutes in a 1^ per cent, solution of mishing soda 
 in water. 
 
 For steam sterilization excellent aud sim])le apparatuses have been 
 devised, their prineij)le being mainly derived from Koch's sterilizer. In 
 hospitals an existing steam-])lant can be conveniently connected with the 
 sterilizer, in which all the dressing materials, gowns, roller bandages, 
 aprons, etc. needed for the day may receive their purification just before 
 use. 
 
 The ])rinciples upon which all useful sterilizers of large size must be 
 constructed are these : 
 
 1. Tiie objects to be disinfected must receive a j)reparatory warming 
 within the apparatus to prevent precipitation of steam. 
 
I)il4 THE TECHNIQUE OF ANTISEPTIC AND ASEPTIC SURGERY. 
 
 2. Tlic steani iiiiist enter the iippiiratus i'roiii aljovc and not from 
 below. 
 
 3. The steam nmst liave a certain degree of tension. 
 
 4. The dressings must be dry when tiiey leave the apparatus. 
 Preparatory warming is inij)ortant, because the contac-t of hot steam 
 
 with cold dressings will produce condensation, and the dressings will 
 become damp or even wet. This pre])aratory warming is secured by a 
 double jacket to the apparatus. Steam circniatcs through this and warms 
 tlu' contents of the central s])ace before this is entered by steam. Gruber, 
 Frosch, and Clarenbach have demonstrated that when steam enters the 
 disinfecting space of an apparatus from below the atmospheric air is not 
 driven out at once and as uniformly as ^^■hen the steam enters from 
 above. The cause of this is the fact that air, being heavier than hot 
 steam, will naturallv tend to return to the bottom of the a])paratus in 
 eddies, much of the steam escaping directly above, without uiiit()rmly 
 jjcrmeating the entire enclosure. When steam enters from above the air 
 is displaced gradually, uniformly, and steadily. Teuscher's observations, 
 made on an ajiparatus that admitted steam either from above or from 
 below, showed tiiat, steam being admitted from below, tlie recjuisite tem- 
 perature of 100° Celsius was reached in twenty -two minutes and twenty 
 seconds, whereas if the steam entered from above the same temperature 
 was registered after seventeen minutes. 
 
 A slightly increased tension, which is gained by resistance offered to 
 the escape of the steam through the apparatus itself, is useful, because 
 
 Fig. 175. 
 
 -2_ 
 
 ■» J 
 
 t ) 
 
 pr 
 
 (Front view. I (Sectional view.) 
 
 Schimnielbusch's combined sterilizer. 
 
 it guarantees a ra])id ])crmeation of the dressings and facilitates their sub- 
 sequent spontaneous drying, which will l)e all the prom])ter as the pre- 
 liminary warming was thorough. 
 
 Schimraelbusch ' and Willy Meyer - have described very useful small 
 sterilizers, for the use of the surgeon in jirivate practice, that have stood 
 
 ' Anleittrng, etc., p. 84. = 3Ied. Record, M.irch 3, 1894, p. 285. 
 
DRESSINGS. 
 
 695 
 
 Fig. 176. 
 
 the test of actual use and can be well reci^nnniendcd. Tiiey permit of 
 a combined sterilizatiou both of instruments by boiling in soda solu- 
 tion and of dressings in the escaping steam. For 
 hospital use Lautenschlager's apparatus Mill 
 answer admirably. Schinnnell)usch's capsules 
 or boxes, proviiled with a number of lateral 
 holes which can be opened or closed by a single 
 sliding arrangement, have been found extremely 
 useful. The number of these boxes to be pro- 
 vided de])ends upon the amount of operative 
 
 work rcgularlv done in a given institution. 
 
 All 
 
 Box fur dressing. 
 
 the dressings, bandages, gowns, etc. pertaining 
 to one operation are placed in one of these 
 boxes, which is then closed. The lateral aper- 
 tures are thrown open and the box is put in tiie sterilizer. Having 
 been exposed to the action of steam for thirty minutes, the box is removed 
 from the sterilizer, tlie lateral holes are closed, and now the box with 
 its contents can be left hermetically sealed until the moment wiien the 
 dressings are actually needed. A large apparatus will hold six or eight 
 such boxes, and, the handling of the dressings having all been done before 
 sterilizing, these will come to the wound in an ideally clean condition. 
 
 It was pointed out before, that, to be admissible, a dressing must 
 have the (piality of preventing the undue multiplication of pathogenetic 
 germs in the discharges by which it becomes permeated, or even have a 
 direct germicidal influence upon those germs that are natui-ally contained 
 in the secretions. Formerly we endeavored to accomplish this by im- 
 pregnation with chemical agents, as, for instance, carbolic acid or cor- 
 rosive sublimate. But the defects of this plan, developed in the course 
 
 Fig. 177. 
 
 Willy Meyer's portable sterilizer. 
 
 of actual practice, and mentioned before, are so serious and important 
 that the necessity of an inipni\'ement was keenly felt everywhere. j\.s 
 an expression of this must be taken the long series of trials witii various 
 chemicals, whici), iiowever, but strengtiiened tiie distrust felt toward them. 
 Only since Neuber demonstrated that the most energetic parasiticide is 
 
cm THE TECHNIQUE OF ANTISEPTIC AND ASEPTIC SURGERY. 
 
 (Iryneas — that by encouragino; a rapid evaporation of the fluid j)art of 
 the discharges ountained in a dressing; we shall check much luore effec- 
 tively the proliferation of microbes tlian by means of chemical agents 
 
 Flci. 178. 
 
 Fig. 179. 
 
 External and sectional views of Lautenschliiger's sterilizer. 
 
 added to the gauze, — only since then Mere we able to relinquish the use 
 of unreliable, irritating, and poisonous chemicals. Xeuber demonstrated 
 
 in actual practice that a dressing, however soaked 
 Fig. 180. full with the first discharges of a fresh wound, 
 
 remained perfectly sweet for an indefinite time 
 
 Fig. 181. 
 
 LiLutunsfhlujicr's sturilizur: StliimiiiLlliiiM.li's dressing-box. 
 
 if by rapid evaporation a drying up of the discharges was brought 
 about. The crusted discharges thus formed a sort of aseptic seal, like 
 
DRESSINGS. G!I7 
 
 the dried blood-clot in the small wound we have used as an illustration 
 at the beginning- of this paper. Practically, the wound by this process 
 was converted into a subcutaneous injury. 
 
 But all this refers only to fresh wounds, the discharges of which are 
 serous, thin, and not septic. Where we have to deal with suppiu-ating 
 wounds, with secretions that are thick, viscid, and often contain consid- 
 erable masses of deeomjiosing detritus and slough, rapid evaporation and 
 inspissation become a drawback. First, the dressings cannot readily 
 absorb the discharges, which remain pent up, as it were, altout the 
 orifice of the wound. As soon as evaporation leads to crusting, these 
 discharges become sealed, and retention with all its harmful consequences 
 is the direct effect. Here, then, woLs-t dressingf!, the jH'evention of evap- 
 oration by the use of impermeable coverings, and frequent changes of 
 dressing accompanied by a thorough cleansing of the wound, represent 
 the order to be followed. 
 
 Wherever, for various reasons, it is needed to ])ack or tampon a 
 wound, moist treatment is preferable to the dr}-, and here imj)regna- 
 tion of the packings ^vith Iodoform is highly convenient. The inhib- 
 itory action of iodoform upon the development of the ordinary micro- 
 organisms of suppuration is still unexplained, but is not doubted by 
 any practical surgeon. IMosetig-Moorhof tirst demonstrated its great 
 eftieacy in preventing septic processes in wounds freely conmuuiicating 
 with the orifices of the digestive tract, notably the oral cavity. Subse- 
 cjuently it was emploj-ed with great success in wounds around the anus 
 and rectum or the vagina or bladder ; finally in wound-cavities of any 
 description that recpiired temporary or prolonged packing, ultimately even 
 in the peritoneal cavity (Mikulicz). 
 
 But whenever iodoform is employed it must be used with caution, 
 especially in anajmic and elderly subjects, as dangertuis fiirms of intoxi- 
 cation are apt to follow its indiscriminate and unrestricted exhibition. 
 Another drawback is the tendency of iodoform to ]iroduce in certain 
 persons an angry eczema. 
 
 The iodoform powder itself may be the carrier of infection ; hence it 
 ought to be washed in a solution of corrosive sublimate before use. The 
 best method of impregnation of dressings with iodoform is the mechan- 
 ical one, which is preferable to that by the use of ethereal solutions, 
 which are very apt to decompose. Crystalline powder of iodoform is 
 simply scattered as evenly as possible over the moistened gauze, then 
 rubbed into its meshes by luuul. (xauze thus ])repared nuist be kept in a 
 tight receptacle to prevent its drying, which is still furtiier j)rcvented 
 by the addition of a little glycerin to the plain boiled water used for 
 moistening. Light will also tend to decompose iodoform ; hence the 
 powder and iodoform gauze ought to be kejit in vessels that exclude 
 
 When iodoform gauze is badly borne, or where its use is contraindi- 
 cated for other reasons, the powder of siihnitratc of bismuth might be 
 advantageously substituted ; or the gauze might be moistened with either 
 a 3 per cent, solution of cwctate of alumina (Burow's solution) or a 1 per 
 cent, solution of chloride of zinc. 
 
 In regard to the technique of tamponade the following hints may be 
 found useful : The width and Icny-th of the strips of ffiuize used for 
 
G!).S THE TECHNIQUE OF ANTISEPTIC AND ASEPTIC SUROERY. 
 
 jiiickings should be regulated by the shape and extent of the cavity to be 
 Hllcd. Each rcocss ought to receive a strip of its own ]iacked down 
 loosely and its end lirouglit out, corresponding to the location of the 
 recess. The end of each stri|) must ]>rotrude from the wound, otluTwise 
 it might become lost. When very large cavities are to Ite treated, it 
 might be objectionable to use the large amount of iodoform gauze retpu- 
 site for filling the space. Here an ample compress of iodoform gauze 
 ought to be made to serve as a /iniiif/ of the cavity, the central space 
 being filled with strips of jilain or medicated gauze other than iodoform. 
 The oozing of serum out of tamponaded wounds is often very copious. 
 Plere the superficial dressings slnjuld he changed frequently. After the 
 lapse of twice or three times twenty-four hours the packings have to be 
 removed or renewed when secondary sutures are contemplated — as, for 
 instance, from amputation wounds or the peritoneal cavity. From the 
 mouth, larynx, circumrectal sjtaces, or the bladder the packings are not 
 removed until they become loosened, unless special indications compel 
 their earlier withdrawal. Whenever the packings of a septic wound 
 are removed, it is well to observe a system or order in removing them. 
 As soon as a strip is removed it ought to be replaced at once by another 
 clean strip, then another strip is removed and replaced, and so on until 
 the entire wound is cared for ; otherwise recesses might be overlooked and 
 thus give rise to retention. Where special precaution is demanded, as, 
 for instance, in the removal of tamjions covering intestinal sutures, these 
 tampons must be marked by tying a knot in their distal end. 
 
 As most of the dressing material used by the general practitioner is 
 necessarily derived from drug-stores, it would seem very desirable for the 
 manufacturers of dressings to adopt a method of sterilization by steam, 
 according to which the dressings, put up previously in suitable paper or 
 muslin packages, were to be subjected to sterilization irithiit oikI together 
 vufh their c/oaed wrappings. Thus the contents of each package would 
 certainly remain sterile until needed. 
 
 VI. Sponges and their Substitutes. 
 
 For the rapid and thorough removal, during the progress of various 
 operations, of blood, and in some instances of pus, sponges are indis- 
 pensable. All the ditferent substitutes that have been suggested instead 
 of sponges lack the imique qualities of a good sponge. Its softness, 
 the avidity with which it absorbs liquids, and the readiness with which 
 it yields them on pressure, are all due to the incomparal:)le elasticity and 
 porousness of its substance. Fortunately, we liave in this country a 
 cheap and abundant snjiply of reef spniu/es, chiefly In-ought from Florida. 
 and the Bahamas. They possess all the main qualities of a good sponge, 
 and, being very inexpensive (about $2.00 to |2.50 a pound), need not be 
 used oftener than once in aseptic cases. Those saved from an aseptic 
 operation can be resterilized, and are excellent for operations on septic 
 wounds. 
 
 The difficulty of a reliable disinfection of sponges has been well rec- 
 ognized by practical surgeons since early times, and the search after a 
 good method of cleansing has resulted in a number of propositions. One 
 of the oldest procedures is as follows : The sponges are thoroughly freed 
 
SPONGES AXD THEIR SUBSTITUTES. iiW 
 
 from calcareous matter by beatintr witli a stick ; are then immersed for 
 twenty-four hours in a watery sokitiou of permanganate of potash, 
 1 : 500, from \\ hich they are transferred into a 1 per cent, sokition of 
 subsulphate of soda, to which is added pure muriatic acid in the propor- 
 tion of 8 per cent, of the volume of the subsulphate-of-soda solution. 
 Tliis bleaches the sponges and frees them of the renuiant of calcareous 
 dust. After this follows a thorougii rinsing in water and immersion in 
 a 5 per cent, solution of carlxilic acid, and the lunger the bt'tter, as a 
 short immersion is often insutticient for a thorougii sterilization.' 
 
 Kiinmiel's plan is very much simpler, but still less reliable. How- 
 ever, it would be improper to condemn it altogether, as it has been found 
 excellent and very reliable after the addition of a few simj)le improve- 
 ments of the method. 
 
 Gerster's modification of Kiimmel's method is as follows : The 
 sponges are beaten, then immersed for twenty-four hours in an 8 per 
 cent, solution of muriatic acid to free them of calcareous sand. After 
 this they are rinsed in cold water and put in a closed jar filled with 
 water in a warm place for three days. During this time the spores con- 
 tained in the meshes of the sponge all germinat(% and thus become more 
 sensitive to the infiuence of germicides, and hardened collections of tilth 
 are also macerated and softt'ued. After three days the sjionges are 
 thrown into a vessel containing hot water, and each sponge is thoroughly 
 kneaded and rubbed with green soap, which carries the maceration and 
 softening of the dirt adhering to the meshes to such a point that most of 
 it is removed by a subsequent rinsing in cold water. Each sponge is 
 now dipped in alcohol, S(jueezed, and thrown into a jar containing either 
 a solution of corrosive sublimate 1 :1000, or a o per cent, solution of 
 carbolic acid, in which it remains until needed, (^n account of the pre- 
 cipitation of the mercurial salt the sublimate solution ought to be re- 
 newed every few weeks. In carbolic acid, which is more durable, the 
 sponges are apt to turn brown, which, however, does not diminish their 
 usefulness. 
 
 The simplest and most conveni(>nt mode of disinfection by boiling in 
 soda solution cannot be employed with sjionges, as their softness and 
 elasticity are destroyed by excessive hardening and shrinkage. Dry 
 heat will sterilize them thoroughly, but will also cause shrinking and 
 hardening unless the sponge is first freed from every trace of atmo- 
 spheric moisture — a somewhat difficult and impracticable process. 
 
 Schimmelbnsch - has devised the simplest and best mode of disinfect- 
 ing sponges, which has stood the severest tests both of practical expe- 
 rience and of bacteriological scrutiny. The sponges are first freed from 
 sand in the usual manner, then ai'e rinsed in cold water, in which they 
 are left to macerate "for a week or so. After this they are cleansed of 
 gross dirt by washing in warm water, from wliich they are taken and 
 enclosed in a nuislin bag. In the mean time a suitable quantitv of a 1 
 per cent, soda solution is brought to the boiling-point in a pot or boiler. 
 As soon as it is boiling freely the pot is withdrawn from the fire, and 
 into this scalding solution the bag of sjjonges is immersed for thirty 
 
 ' Frisch : " Ueber Desinfection von Seide und Schwiimmen," Arckiv fiir klin. C/tir., 
 1888, p. 749 
 
 ^ Anleiluny zur asept. Wundbehandtung, p. 116. 
 
700 THE TECHNIQUE OF ANTISEPTIC AND ASEPTIC SVIKIERY. 
 
 Fig. 183. 
 
 niinutcfi. The soda solution will retain u teni]>eratiire of from 80 to 
 DO degrees Celsius for a considerable time, and tiiis is sufficient to 
 destroy all germs, even the \erv resistant an- 
 thra.x s])ores, within ten minutes (Beliring). 
 After thirty minutes tiie l)ag is removed from 
 the l)oiler, and the sponges arc lilicratcd of their 
 c<»ntents of s(Kla by rinsing in plain Itoiled water, 
 which should be done while the sponges are 
 still within the bag. Finally, they are ])laeed 
 in snldimate or carbolic .solution until rccpiircd 
 for use. 
 
 xV fair sul)stitutc for sponges are tiie xpoiigiiii/ 
 pads (" Tupfer") used by a number of surgeons 
 exclusively and in preference to sponges, and 
 employed by all in emergencies. They consi.st 
 cither of a square piece of absorbent sterilized 
 gauze, 10 by 10 inches, crushed into a ))all, or 
 
 Mop, a substitute of the sponge. ~,. ,, ' ,. /-n i •,! •,! 
 
 ot a smaller square oi gauze, hlled cither with 
 sterilized moss, wood-wool, or absorbent cotton, and tied in a neck with 
 sterilized cotton thread. 
 
 Fin. 184. 
 
 Vn. Sutures and Ligatures. 
 
 The substances used for tying vessels and for the appro.ximation of 
 
 the edges of wounds by suture are either absorbable or nou-absorbalde. 
 
 Non-absorbable are silk, silkworm gut, cotton thread, hor.se-hair, and 
 
 silver wire. Their sterilization can be reliably done either by boiling 
 
 in soda solution or by exposure to a current of 
 steam, the former at the same time with the 
 instruments, the latter with the dressings. The 
 non-irritant quality of any one of these sub- 
 stances depends entirely and solely upon their 
 freedom from noxious germs, and on nothing 
 else. Hence if they are to be buried in the 
 tissues it is advisable to sulijcct silk and silver 
 wire to a thorough disinfection juxt before use. 
 Tiie silk employed in suturing may be .steril- 
 ized once, and then preserved in a tight vessel 
 containing citlier carbolic or sublimate solution. 
 Of absorbable threads there are catgut and 
 ktingaroo tendon (Marcy). The endeavor of the 
 older surgi'ons to gain an al)sorI)ali]e material 
 for ligatures led to the tentative eiiij>loymciit of 
 buckskin, the aorta of the ox, fresh intestinal 
 fibre, fresh tendon, and raw hide ; and the 
 Metni case for steam-sterilized great advantage of a material that, after hav- 
 
 dry silk (SeliimiiK'lt)iisch). v /. i . , ^ ,. t -j.! a 
 
 ing ))eriormed its tunction, ih.sappears without 
 any further aid, is very evident. Moreover, it is well known that 
 many aseptically buried silk or wire threads will ultimately work out 
 to tiie surface, though this may happen without active suppuration. 
 Hence we owe a debt of gratitude to Lister, who .systematically iiitro- 
 
SUTUEES AXD LIGATURES. 
 
 (01 
 
 duced animal or oatji'iit ligatures into surgical practice. Catgut, long 
 since in use on musical instruments and in certain trades, is made of the 
 fibrous portion of the nuiseularis of the small intestine of sheep. 
 The process of maceration, liy which the nuieous, serous, and circular 
 
 Fig. is.-,. 
 
 (ilass jar U>v wet cat^ait or silk. 
 
 muscular constituents of the intestinal wall are prepared for their 
 mechanical removal, involves decomposition, and ]>ermeation with mil- 
 lions of miero-organisius, aioong which the spores and Itacilli of anthrax 
 may be and have been represented (Volkmann). Therefore a thorough 
 disinfection of catgut becomes one of the most important desiderata of 
 clean surgery. Of Lister's original method, of disinfection by immer- 
 sion in carbolized oil, it need only be said that it is entirely inadequate, 
 and has been universally abandoned. 
 
 Lixter'n vhromichcd citfr/uf offers more security against infection, 
 because chromic acid, a strong germicide, is employed in addition to 
 carbolic acid, and the solutions used are aqueous, not oleaginous; hence 
 much more etfective. The object of the addition of chromic acid, how- 
 ever, was not the attainment of a more complete asepticism, but a hard- 
 ening of the gut to prevent its too rajiid or ])remature absorption. 
 
 Chromicized catgut is prepared as follows : To a 5 per cent, carbolic- 
 acid watery solution is added crystalline chromic aci<l in the jiroportion 
 of 1 : 4000, in which the catgut remains inunersed for forty-eight hours. 
 Then it is taken out, dried, and kept in carbolized oil, 1 : 5. 
 
 Koclier'ii preparation wifh oil of juniper has yielded good results, 
 though it has led to failures ii: the hands of Kocher himself. Cats;ut is 
 placed in the oil of the berry of juni|)er for twenty-four hours; then it 
 is taken out and kept in absolute alcohol. 
 
 Bcrr/mnnn's procedure is very reliable, and can be warndy recom- 
 mended. First, the vessel to serve as a reccjitacle is sterilized in steam 
 for three-quarters of an hour ; then raw catgut is wound u])on suitable 
 glass bobbins, and is placed in sulphuric ether for twenty-four hours to 
 free it from fat. X(jw the ether is j)oured off and replaced by a solution 
 
702 THE TECHNIQUE OF ANTISKPTJC AND ASEPTIC SURGERY. 
 
 of corrosive suhliiiuite 10 parts, al)S(iliit(' alcohol 800 parts, and dis- 
 tilled water 200 parts. This alcoholic solution becomes turbid after a 
 day, and should be renewed twice. After three times twenty-f(jur hours 
 the sublimate solution is replaced bv absctlute alcohol, in which the cat- 
 gut is kcjit permanently. 
 
 The methods of sttTilization by boiling and steaming arc not a])])li- 
 cable to catgut unless another medium than water is employeil. I5run- 
 ner's' j:)rocess by boiling in xylol, and Dowd's in alcohol, arc both com- 
 plicated, and not more reliable than Bergmann's plan. 
 
 The modus of the absorption of catgut buried in living tissues has 
 been studied by Ijcsser'-and others, and consists first of .swelling by 
 imliibition ; then its interstices are invaded by leucocytes, to be soon 
 followi'd by granulation tissue, under the influence of which it becomes 
 disintegrated and assumes the character of detritus, which is gradually 
 carried away by the lymphatic circulation. 
 
 Vm. Drainage. 
 
 Since Chassaignac, who was the first to use it, systematic tubular 
 drainage has remained firndy established in surgery. It is true that its 
 scope lias been considerably curtailed by simple canalization (Neul)er) 
 and capillary di'ainage ; still, in the vast field of suppurative affections 
 and in the surgery of certain cavities tubidar drainage remains indis- 
 pensable. 
 
 The selection of the jtrojicr form of drainage must depend u])on the 
 nature of the discharge to be drained away. Where serinn, or bloody 
 serum of an aseptic character, is to be expected, esjiecially when the 
 shajie of the wound is not comjilicated and not too deep, capillary drain- 
 age by the aid of a few strands of horse-hair or catgut will be in place, 
 or even the leaving of one or more angles of the wound slightly 
 patulous, or the placing of sparser suture-points, will be found sufficient, 
 iSniall wounds can be tightly closed without any drainage [f the siirc/eon's 
 aseptic mensiires are perfect. Even as large Mounds as those made in 
 amiiutation of the mamma have been habitually closed by the author 
 with sutures without any drainage, and out of 29 cases, in 28 healing 
 took place without trouble and by the first intention. But in the twenty- 
 ninth the ]>atient came very near losing her life by acute sepsis inadver- 
 tently carried into the wound at the time of the operation from a neigh- 
 boring patient suffering from acute osteomyelitis. Before the wound was 
 examined extensive sloughing of the fasciie and of the outer skin took 
 place. 
 
 From tubular drainage where thick, consistent, and rojiy masses of 
 ))us are to be carried out of a cavity, to capillary or no drainage where 
 a perfectly dry and asejitic wound treated without chemicals promises 
 to remain dry and aseptic, the transitions and gradations are many, and 
 their proper selection and adaptation must depend on the skill and judg- 
 ment of the surgeon. 
 
 Whatever material is to be employed for drainage, it is indispensable 
 that it should be made absolutely sterile before use. 
 
 ' "Uelier Catgiitinfection," Bdlrdge. filr hlin. Ckir. (Bruns.), 1890. 
 2 " Ueber das Verhalten des Catgut," Virchmh Arch., vol. 95, 1884. 
 
LOTIONS, IRRIGATING SOLUTIONS, ETC. 703 
 
 Neuber's absorbable drainage-tubes, prepared out of decalcined ox- 
 bones, and siuiilur ones made of the lonjj bones of large l)irds (Trendelen- 
 burg, ^laeEweu), have all been abandoned as inipraetieal. Glass drain- 
 age-tubes are very neat and clean, and can be readily sterilized, btit are 
 rigid, fragile, and cannot be shortened to suit varying conditions ; hence 
 they have come into use only here and there. Rubber drainage-tubes are 
 still considered the most adaptable, cheap, and useful material for wound- 
 drainage. Their disinfection can be safely done by boiling for five 
 minutes in soda solution (1 per cent.) or by steaming during fifteen to 
 twcutv minutes. Tiiis will not harm the rubber. After disinfection 
 the tubes ought to be preserved by preference in a 5 per cent, solution 
 of carbolic acid, which will not become inert by contact with rubber, as 
 will corrosive sublimate. The best receptacle is a tall fruit-jar. The 
 tubes should be cut into proper lengths — that is. a little shorter than the 
 height of the jar — and are to be put in ujjright — that is, standing on end 
 — to facilitate removal. 
 
 IX. Lotions, Irrigating Solutions, and Antiseptic Powders. 
 
 Water, the usual solvent in preparing lotions, is never free from germs 
 when found in its natural state in springs, wells, running water, ponds, 
 lakes, and the ocean. Only in the state of very deep ground-water and 
 as atmospheric vapor is it known to be germless. As soon as it apjjroaches 
 the earth's surface, either from below (sjirings) or from above (rain), it 
 becomes ciiarged with micro-organisms, which are often pathogenetic. 
 Sea-water also contains pathogenetic germs near the shores, where it 
 mingles with the drainage of inhabited areas of land. 
 
 To be admissible for surgical use water must be freed from its 
 mici'obial contents. This can be done by precipitation, by filtration, 
 by boiling, and, finally, by the addition of chemical germicides. 
 
 Finely-])owdered insoluble substances mixed with water will, on set- 
 tling to the bottom, carry with them into the sediment a certain propor- 
 tion of the microbes suspended in the water. The finer the powder and 
 the slower the process of sedimentation, the better will the water be 
 purifieil, but ;i perfect state of sterility can never be reached by this 
 method. 
 
 Filtration by the various usual methods will very materially diminish 
 the number of germs contained in the water from lakes and rivers. The 
 filters of the waterworks of the city of Berlin, for instance, are .so effect- 
 ive as to reduce the number of microbes contained in a cubic centimetre 
 of the water of the river .Spree from hundreds of thousands to an aver- 
 age of from fifty to seventy. Here the filtering-beds are made of gravel 
 and sand. But even where tight porous vessels made of ])ottcr's earth 
 (Chamberland-Pasteur) or of "an impalpable powder (like Kicselguhr ' ) 
 are used, the certainty of an alisolutc detention of all microbes in the 
 filtering medium is assured only for a certain time. In addition to this, 
 large (luantities of water cannot be treated by tliis method in a practical 
 manner. 
 
 Boiling is far superior to either sedimentation or filtering. Almost 
 all of the germs contained in water are surely destroyed by boiling for 
 
 '■ Nordtmayer: " I'eber Wasserliltration," Zeituchrift fiir Hi/i/iene, vol. .x., IS'Jl, j). 1-15. 
 
704 THE TECHNIQUE OF ANTISEPTIC AND ASEPTIC SVIUIERY. 
 
 five minutes, and tliis ajiplies to tlic dirtiest :is well as to the cleanest water. 
 Dor and Vinay,' who boiled the water of tiie river Khone, eontainin>j an 
 average of 33,000 germs per litre, found that only 941 of them survived 
 tiic process ; that is, more than 97 per cent, were destroyed. In addition 
 to this it must be said that the germs eapal^le of surviving the ordeal of 
 boiling are not pathological ; as, for instance, the hay l)aeillus. The 
 method commends itself for its simplicity, safety, and general appli- 
 cability ; hence in important cases it will be good for the surgeon to 
 provide an ample quantity of boiled water. The dipper or pitcher to 
 be used for ladling should be boiled together with the water. In hospi- 
 tals running hot water is provided from a central boiler. 
 
 But even this simple method of sterilizing water bv boiling is not 
 always applicalde ; therefore it is very convenient to have another, more 
 ready way of accomplishing the same result by the addition of a chem- 
 ical germicide to the water. On account of the fact that the microbes 
 contained in ordinary pure water are widely distributed, and not collected 
 in dense masses, hence freely accessible from all sides, their destruction 
 by chemicals readily dissolved in the medium is not difficult. Not so 
 easy is the disinfection of the turbid and much-polluted waters of canals, 
 ponds, and stagnant pools located near human hal)itations. The cause 
 of this is to be sought in the fact that these waters contain smaller and 
 larger lumps of gross dirt of varying density, aggregations of organic 
 matter teeming with microbial life. To render chemical disinfection 
 possible, such water must be first })urged of gross filth by filtration. 
 iShould this not be feasible, boiling will have to be resorted to, and w ill 
 prove even here fully effective. 
 
 Where only the mechanical effect of a lotion is desired, as in many 
 aseptic operations, the phj'siologically nnirritant solution of common 
 cooking salt, 6 to sterilized water 1000, Mill be found convenient. This 
 solution does not cause smarting in a fresh wound. 
 
 The most effective and most useful of all chemical germicides is corro/iive 
 sublimate, suggetited by Koch and introduced into surgical practice by Berg- 
 mann. It is a very poisonous and very cheap ^vhite, crystalline, odorless 
 powder, readily dissolved in water and promj>tly decomposed by contact 
 with metals. Hence it cannot be used for the disinfection of instruments, 
 nor can it be kept in metallic vessels. As connnou drinking-water often 
 holds in solution considerable quantities of the alkaline earths, notably 
 lime, which eagerly decompose the mercurial salt, forming insoluble 
 deposits, it is necessary to counteract this tendency by the addition to 
 the solution of some acid. Either acetic or tartaric acid, or finally com- 
 mon cooking salt, will perform this service, a good rule being to take 
 either of these correctives in the same proportion as the corrosive sulj- 
 limate. To a 1 : 1000 solution, for instance, would be taken 1 gramme 
 of corrosive sublimate, 1 gramme of cooking salt, and 1000 grammes of 
 water. 
 
 Corrosive sublimate is used in solutions of 1 : 5000 f)r continuous 
 irrigation during prolonged operations about the anus ; 1 : 2000 and 
 1 : 1000 for washing septic wounds, and for disinfecting the skin of 
 patient and surgeon; 1 : 500 for the final disinfection of bone-cavities 
 after necrotomy to prepai'e them for Schede's plan of after-treatment. 
 
 ' " De la sterilisation de I'eau, etc.," Lyon medical, 1889, No. 23. 
 
LOTIONS, IRRIGATING SOLUTIONS, ETC. 705 
 
 A very convenient mode of preparing snblimate solutions is that by 
 means of sublimate tablets sold by the drug-firms. Transportation and 
 dosage are very easy. In the absence of tablets the surgeon will prepare 
 a concentrated alcoliollc laothcr-solufion, from wliieh tiie weaker solutions 
 are made as reipiired. A 10 per cent, solution w\\\ be found very useful 
 and not too bulky. Two teaspoonfuls of this, added to a cjuart of water, 
 will give the proportion of about 1 : 1000. For the transportation of 
 this strong solution a glass-stoppered bottle in a wooden case will be 
 needed. 
 
 The symptoms of systemic sublimate poisoning, caused by indis- 
 criminate use, are those of an intense enteritis with colicky, often bloody, 
 stools and salivation. Local irritation, assuming the form of an angry 
 dermatitis, is often caused by moist sublimate dressings. 
 
 Carbolic acid, Lister's original disinfectant, forms colorless crystals 
 when undissolved. It is volatile and strongly corrosive. Solutions are 
 prepared as follows : The crystalline acid is liquefied by moderate heat; 
 then water is a<lded in due projiortion. Its usual solutions are the weaker 
 one, 1 or 2 per cent., for the innnersion of instruments, for lotiiins and irri- 
 gation, and the stronger solution, 5 per cent., for tlie disinfection of septic 
 wounds, and for irritant injections into joints, cysts, or hydrocele. This 
 solution, freely applied to a fresh wound, will produce a grayish glaze, 
 due to superficial corrosion of tlie tissues. It is very poisonous, espe- 
 cially to small children. 
 
 One of the first symptoms of carbolic poisoning is the characteristic 
 olive-green coloring of the urine. It is soon followed by headache, 
 vertigo, fainting, vomiting, irregular breathing, and a thready pulse. 
 In severe cases coma, contracted rigid pu]>ils, clonic muscular spasms, 
 pulselessness, suppression of urine, and intestinal hemorrhages often 
 lead to a fatal termination. The skin is also very sensitive to carbolic 
 acid, often responding to its irritant action liy fiorid eczema. Strong 
 solutions of carbolic acid applied to small members, as the fingers and 
 toes, often cause a dry form of gangrene. 
 
 Creolin, mixed with water, forms a milky lotion, which is about 
 three times as eifective as carbolic acid. The usual prop(irtions are 1 
 and 2 per cent. Its odor is very disagreeable, but it is non-poisonous. 
 
 Lysol, like carl)olic acid and creolin, is a coal-tar pi'oduct. It is a 
 poisonous, soapy liquid, which yields a somewhat less turbid solution 
 with water than creolin, and is about as effective. 
 
 Salici/lic acid (Thiersch), a good, though weak, non-poisonous anti- 
 se])tic powder of white color, is intensely irritating to the nasal and bron- 
 cliial mucous membranes. In combination with boric acid it firms the 
 poptdar T/iirrsch solution: salicvlic acid 2 parts, boric acid 12 pai'ts, 
 hot water 1000 parts. 
 
 Acetate of alumina (Burow's solution), a very effective, adstringent, 
 and deodorizing antiseptic, is especially useful where the skin is very 
 vulnerable and apt to become eczematous under the dressings. It is 
 also nuich used in phlegmonous affections requiring permanent immersion 
 or irrigation. A 1 per cent, solution is prepared by mixing 24 granunes 
 of alum with -''S grammes of sugar of lead in 1000 grammes of water. 
 After twenty-four hours the clear part siiould be decanted from the 
 insoluble sedijuent. 
 
 Vol. I.— to 
 
70C THE TECHNIQUE OF ANTISEPTIC AND ASEPTIC SUIlCEUy. 
 
 Tlij/mol (Ranke), a mild, n()n-])oisonoiis antiseptic of ])k'asaiit odor, 
 non-irritant, is used in the stren<;tii of 1 : 1000. 
 
 l\'nitaiif/an(ii<' of jiotaxli is a very soluble, mild disinfectant, and a 
 strono; deodorizer, but of evanescent effect, as it is prdiiijitlv ileeoni- 
 posed by contact with the secretions. It is used in the strength of 
 from 1 :500 to 1 : 2000 as a month-wash and as an irrit^atinfj fluid for 
 the urethra and bladder. 
 
 Chlorine, a very jiowerful antiseptic, is used in the sliajie oi' rhlor'nu- 
 water. 
 
 Peroxide of hi/drogen (Troninisdorff ), a very strong antiseptic fluid, 
 non-poisonous, is used in the strength of 8 per cent, for the disinl'eetiou 
 of suppurating and ill-smelling wounds ; is also a good sty])tic. 
 
 Certain aniline dyes, as methyl-blue and pyoktanin (Stilling), are of 
 undoul)ted antiseptic value in the treatment of ulcerating and sloughing 
 malignant new growths. 
 
 Among the antiseptic powders, iodoform is to be flrst mentioned. It 
 is a light-yellow, crystalline powder of peculiar odor, non-soluble in 
 water, soluble in alcohol, ether, and some oils. Its antiseptic ]iro])erties 
 are developed indirectly by contact with the products of microbial decom- 
 position (ptomaines and toxalbmnin). Their chemical actii)n liberates 
 a certain [u-oportion of free iodine, which inhibits a further development 
 of microbes. It is very poisonous, especially to elderly and antemic 
 subjects, and often is also very irritant to the skin. Its offensive odor 
 can be effectively masked by an admixture of burnt-coffee powder and 
 .some aromatic oils. It is used for dusting the line of union of a sutured 
 wound, and most effectively in the vicinity of the natural a])ertures of 
 the human Ixidy, where perfect asepsis is not attainable. In tiic sha]ie 
 of iodoform glycerin, from 10 to 20 per cent., it is injected with good 
 effect into tuberculous foci. A.s iodoform gauze it is an indispensable 
 aid in treating wounds communicating with the oral cavity, the rectum, 
 vagina, and bladder, in the temjwrary tamjxjnade preceding secondary 
 .suture, in forming a protective dam against infection of the healthy ])eri- 
 toneum in operations for appendicitis; finally, in plugging irregular 
 denuded cavities caused by various intra-abdominal ojicrations. 
 
 The symptoms of iodoforni-poisoning are rubescence of the skin, 
 headache, dejection, nausea, and vomiting ; in the more serious cases, 
 sleeplessness* great frequency of the ))ulse, restlessness, fever, delirium, 
 maniacal attacks, finally coma and convulsions. In these cases iodine 
 is found in the urine, in wiiieli its jm-scnce is demonstrated by the addi- 
 tion of dilute sulphuric acid and fuming nitric acid, together with a 
 small quantity of chloroform. If this mixture is violently shaken, the 
 chloroform assumes a purjile color under the influence of free iodine. 
 
 Subnitrafe of bi.wuitli (Kocher) is a good antiseptic powder, though 
 somewhat poisonous if used in large quantities. It is a strong exsic- 
 cative. 
 
 Xaphtlwline (E. Fischer) is also a good, non-poisonous, but very ill- 
 smelling, antiseptic ])owder. 
 
 Oxide of zinc, a mild antiseptic powder, is one of the components of 
 Socin's paste, which is used for a covering of small sutured ^\•ounds of 
 the face, instead of regular gauze dressings. Its formula is : oxide of 
 zinc, 50 grammes ; chloride of zinc, 5 grammes ; Avater, 50 grammes. 
 
OPERATING-ROOM AXD SICK-ROOM. iH' 
 
 lodol, sozoiodol, dcrmafol, arixtol, nulphainhiol, and salol are all recom- 
 mended as eifective substitutes for iodoform. 
 
 X. Operating-room and Sick-room. 
 
 The modern operating-room should be tlie embodiment of what is 
 immaculate. Everything tending to the generation and accunudation 
 
 Fig. 186. 
 
 .^tand for irrigiiturs and liasins. 
 
 of dirt and dn.st .-^liuuld l)c l)ani.-.h((l fnmi it. A tiled Hoor, a tiled dado, 
 the simplest and easily cleaned wash-basins, the upj)er part of the walls 
 
708 THE TECHNIQUE OF ANTISEPTIC AND ASEPTIC SURGERY. 
 
 finislied in enamel paint, without cornices, angles, or projections of any 
 kind — in short, everything of a nature admitting the easiest and most rad- 
 ical cleansing by scruhbing-hriish and the watering-hose — are necessary. 
 The fiirnitnre, uperating and other taldcs, should be constructed of iron 
 and glass, and should l)c kept tidy and Itrigiit by frequent wasiiing and 
 the apjilication of white enamel jiaiiit. The floor should be a gently 
 inclined plane and water-tigiit, atfordiiig the possibility of an unstinted 
 use of water. The sterilizing apparatus for instruments and dressings 
 has to be within comfortalile reach of the operating-table ; tlie instru- 
 ment-cases, constructed of enamelled iron and glass, ought to be in a 
 side room, as the al)undant use of water ami steam in the operating- 
 room, however favorable against the creation of dust, is apt to cause 
 rusting. For the reception of soiled linen a covered and enamelled 
 metal receptacle is to be provided ; fin" catching pus, ichor, urine, cystic 
 and other pathological fluids, glass pus-basins and co^•ercd l)uckets will 
 be needed. All of these must be innnediately removed from the ope- 
 rating-room with their contents, and should not be suflcrod to remain 
 there longer tiian unavoidably necessary. The dressings sliould be kept 
 in the closed metal boxes in which they were sterilized until the moment 
 when they are actually needed for use. 
 
 For the storing and use of the various irrigating fluids an iron-and- 
 glass stand is needed, on which are disposed suitable bottles, the con- 
 tents of which can be readily brought to the wound by means of rubber 
 tubing and glass nozzles. 
 
 An ample supply of glass vessels and trays, of smaller and larger 
 size, for the laying out of instruments and for the rinsing of hands and 
 sponges in antiseptic or aseptic fluids during the course of an operation, 
 forms a necessary complement of the outfit of the operating-room. 
 
 Where the operating-room serves the purposes of teaching, the 
 
 Fig. 187. 
 
 Simple operating-table (Rotter). 
 
 benches and seats provided for the audience should be of the simplest 
 kind, admitting of an easy mode of cleansing by the watering-hose 
 and mop. 
 
OPERATING-ROOM AND SICK-ROOM. 
 
 709 
 
 Separate operating-rooin.s for septic and for aseptic cases are very 
 desirable, as by attending to septic cases in strictly separate rooms, 
 furnished with distinctly separate sets of instruments, the chances of 
 accidental infection of clean wounds will be considerably diminished. 
 Should this dualism be impossible, and there be only one room in which 
 laparotomies, artiirotomics, and operations for j)lile!jnionous atlections 
 must be dealt with one after the other, then the invariable rule ought to 
 prevail, to do the aseptic operations first, and to leave the work on septic 
 wounds to the last. 
 
 When, in private practice, a living-room of the dwelling of the 
 patient is to serve as an operating-room, it will be impossible to ci'eate 
 
 Fig. 188. 
 
 Table for instruments and dressings (Rotter). 
 
 conditions of such exquisite cleanliness as are demanded by, and indis- 
 pensable in, the tainted surroundings of a hospital. And, luckilv, they 
 ar(> not necessary, as it is known that the atmosphere and dust of private 
 dwellings contain much fewer pathogenetic germs than those of hospitals. 
 It is a good rule, however, to select that one of a set of rooms wliich is 
 least inhabited, and not to disturb the furniture and hangings unless this 
 — that is, theii- removal — can be done from six to eight lK)urs ]>receding 
 the time of tiie operation. In short, unless the clearing and cleansing 
 of tiie room be done a good while before the operation, giving ample 
 time for the settling of the dust, it is better simply to cover the tables 
 to be used with clean white cloths, to wipe chairs with a wet towel, and 
 to avoid every unnecessary disturbance of the rest of the furniture that 
 may tend to stir up dust. 
 
 Sick-rooms or sici--iranl.-i require a similar management ; that is, 
 scrupulous attention to cleanliness, facilitated by the practical simplicity 
 of the utensils and fiu'uisiiings. Glass and iron deserve the preference 
 over .so-called artistic furniture, and all unnecessary hangings and orna- 
 ments should be eschewed, especially where we have to deal with infec- 
 tious forms of disease, as, for instance, di])htheiMa, profuse supjinrations, 
 typhoid and other fevers, etc. In wards the floors should be eitlier tiled 
 or maile of terrazzo, and tiien covered witli rugs in a suitable manner, or, 
 if they are to be of wood, the work should be dose-jointed and the sur- 
 
710 THE TECHNIQUE OF ANTISEPTIC AND ASEPTIC SURGERY. 
 
 face kept ln'iii'lit ami liiylily ])iilisli((l or cuvcred witli a frequently- 
 renewed eoat iif paint. 
 
 Abundant and (•iiMif(irtal)lc liatliiiii;' provisions fonn an indispensable 
 eoncdinitant of [jvopcrly furnisiied wards and siek-rooins. 
 
 The c/iangc of (Ircn.siiujx is an important function involving some 
 risk, and therefore must be surrounded by adequate safeguards. Tlie 
 first one of these is the strict separation of patients Avith infected 
 wounds from those whose wounds are aseptic. Sliould this be imjios- 
 sil)le, tiien the clean cases ougiit to be attended to first, the infected 
 ones attended to the last in seipicnce. Wlien there is a great accumula- 
 tion of patients, many of whom require the change of extensive and 
 bulky dressings, it is very desirable, for many reasons, to have a sepa- 
 rate room, a so-called " dressing-room," for the renewal of all larger 
 dressings, or, in tlie absence of this, to change dressings in the operat- 
 ing-room. The advantages accruing from tliis plan are — first, the avoid- 
 ance of excitement among the rest of the ]>atients, who witness the fear 
 and outcries of the individual whose dressings are being changed ; 
 secondly, small corrections of the state of the wound, such as incisions, 
 dilatation of sinuses, etc., can be at once performed as required, and 
 more readily than in the wards ; thirdly, the soiling of the floors and 
 bedding and the raising of dust from the dressings removed are avoided 
 in the wards. 
 
 Another safeguard, too often neglected in our hospitals, is this : that 
 surgical rounds, necessitating the exposure of wounds, shoidd not be 
 made directly after the methodical sweeping and dusting. 
 
 Every year at least once, l>ut preferably twice or three times, each 
 ward should be completely cleared of ]iatients and furniture, and receive 
 a very thorough cleansing by the scrul)l)ing-brush, soap, whitewash, and 
 fresh paint. No great reliance should be placed in this animal house- 
 cleaning upon chemical methods of disinfection, as, for instance, fumi- 
 gations with suljihur, chlorine, or sublimate, or washings with antiseptic 
 lotions. As it is known that the germs of infection are imbedded in 
 gross masses of dirt encrusting the surfaces of walls, floors, door-knobs, 
 furniture, etc., the rational thing to do is a thoroughgoing mcchanmd 
 c/('fn(s/?jr/ of all these articles with hot soda-and-soap solutions and by the 
 scrubbing-brush, to be followed by the application of a fresh coat of 
 jiaint. Such a radical cleansing of a ward or sick-room might be ren- 
 dered necessary at any time by the a]ipearance of erysipelas or other forms 
 of infection with an epidemic tendency. 
 
 XI. Aseptic and Antiseptic Operating and After-treatment. 
 
 To illustrate in a coherent manner the progress of an aseptic operation 
 we shall take as an example the account of an amputation of the female 
 breast. 
 
 Assuming that the operation is to lie done in the middle of the day, 
 the patient should receive only a light liquid breakfast early in the 
 morning. The operation should be preceded by a full bath if possible, 
 and a careful shaving and scrubbing with soap and water of the field 
 of operation, which then should be enveloped in a moist pack of towels 
 dipped in a weak sublimate or carbolized solution. After this a clean 
 
ASEPTIC AND ANTISEPTIC OPERATING, ETC. 
 
 711 
 
 set of iiiidur-clotliiug is donned h\ tlie patient, who is now ready for 
 the o])eration. As a matter of course, on the day preceding the opera- 
 tion a hixative is administered. 
 
 In tlie mean time, tlie operating-room is prepared. The instruments 
 to he used are hoiked and arranged in glass trays tiUed with a weak car- 
 bolic solution (1 or '1 per cent.), which, like all the other utensils, are 
 placed on glass tables previously spread with clean sheets. Ligatures, 
 sutures, and the thermo-cautery (its handle wrapped with sterilized gauze), 
 are put conveniently in readiness. Likewise enamelled or glass basins 
 containiugu 1 : 2()t)0 solution of corrosive sublimate, or, when theabdomen 
 is invaded, boro-salieylic solution, are prepared for the fre(|uent rinsing 
 
 of the surgeon's hands. A suit^ 
 able number of sterilized sponges 
 are thrown intoaclean glass basin, 
 alongside of which stands another 
 basin tilled with hot sterile water 
 lor rinsing them of l)lood. The 
 dressings are arranged on another 
 table in the closed receptacles 
 within which they were steamed, 
 
 Fig. 190. 
 
 0|)fmting-liabit of surgeon. 
 
 Operating-liabit of nurse. 
 
 or, siioidd steaming be impossible, are cut and folded in the order in 
 winch they are to be apjilicd to the wound, and are then wrapj)ed in a 
 clean towel ready for u.-.e. 
 
712 THE TECHNIQUE OF ANTISEPTIC AND ASEPTIC SURGERY. 
 
 Before touchinji^ any of tlic a|)](iirtcnances of the operating-room the 
 surgeons and nurses divest tiieniseives of tiieir ordinary wearing ajiparel, 
 Avhich notoriously contains large (juantitie.s of dust and dirt, seruli and 
 disinfect their hands in the manner formerly described, and ilon 
 clean, well-sterilized operating-gowns made of strong linen or duck 
 
 Fig. 191. 
 
 Fig. 192. 
 
 \ 
 V 
 
 / 
 
 J 
 
 Aseptic chloroform mask of ScUiimii^ ll.u.-ih. 
 
 (Figs. 189 and 190). Where the operator has to work in the sitting 
 posture, as in rectal and urethral operations, he wears a rubljcr apron 
 
 underneath the linen gown. 
 
 These measures should all l)e carried out 
 
 Fig. 193. 
 
 Applying aseptic cap (first step). 
 
 with due thoroughness, but without finick-t/ exaggeration. Finally, the 
 hands are once more washed immediately before the beginning of the 
 operation. 
 
 The patient is now ana?sthetized. The metal frame of the chloroform 
 mask to be used must be previously boiled, then covered \\ith sterilized 
 
ASEPTIC AND ANTISEPTIC OPERATING, ETC. 
 
 713 
 
 gauze. Ethei' nia.<k.s arc more difficult to cleanse, but they caa also be 
 rendered safe by dipping the mask for ten minutes into hot soda solu- 
 tion having a temperature just below the boiling-])oint. The sponge 
 in Ormsby's apparatus ought to be renewed for each separate an:esthesia. 
 The gags, tongue-forceps, sponge-holders for wij)ing out the fauces, the 
 hypotlermic syringe — in short, all the utensils of the ana^sthetizcr — should 
 be rendered aseptic before use. During the ])rogress of the operation it 
 is the duty of the anpesthetizer to manage the head of the patient so as 
 not to have vomit and s;iliva contaminate the wound. 
 
 As soon as the ana'sthesia is complete the hair of the pailcnt is freed 
 of hairpins, is arranged on the top of the head, and is enveloj)ed in a 
 cap made of a towel wrung out ofsul)limate solution, which, again, is 
 secured by a few turns of a narrow bandage (Figs. 193, 194, 195). 
 
 Fig. 194. 
 
 Applying aseptic ivip (second step). 
 
 Now the jjatient is placed on the o]ierating-table, and the field of 
 operation, being exposed, is once more subjected to a thorough scrubl)ing 
 with hot water anil soft soap, followed by washing with ether and a 
 
 Fig. 195. 
 
 Aseptic cap in situ. 
 
 1 : 1000 solution of corrosive sublimate. Only the field of ojieration re- 
 mains exposed, .tile rest of the body lieing ]irotecte<l bv flannel leggings, 
 blankets, and rublier sheet.s, which in turn are coveretl close up to the 
 
714 THE TECHNIQUE OF ANTISEPTIC AND ASEPTIC SURGERY. 
 
 limits of tho field of openitimi with sterilized towels. These prevent 
 accidental contact witli non-stcrilizcd parts of the bodv of tiie j)ati('nt, 
 and enable the surgeon to rest his liand and arm or to lav down an in- 
 strument witiiont fear of infection. 
 
 Now the operation begins. Each assistant and atti'nihmt ought to 
 know precisely vvliat his duties are : these ought to be performed (piickly, 
 promptly, but without haste, in an orderly, systematic manner, and with 
 sucli an intelligent steadiness that tlieir constant and detailed sn])ervis- 
 ion and control by tiie o])erator ought to be unnecessai'y. Ks))('cially 
 in unexpected anil critical emergencies no panic shoultl l)e tolerated, 
 as this usually leads to gross violations of aseptic discipline. But in 
 this matter the operator himself must lead by good example. A\'iien- 
 ever it becomes necessary for any one engaged about tiie wound to touch 
 an undisinfected ol)ject, a careful reclcansing by soap and brusii and re- 
 disinfection must follow. Especially important is this rule if the sur- 
 geon's fingers come in contact, accidentally or intentionally, with sejjtic 
 surfaces, as, for instance, when a digital exploration of the rectum or oral 
 cavity is done for this or that purpose. The hemorrhage is stilled by the 
 application of hsemostatic forcejis until the breast and tlie axillary con- 
 tents are removed ; then each vessel is carefully tied with catgut and the 
 wound is filled with dry sterilized gauze to check cajiillary oozing. JVo 
 irrif/aiion whatcrcr is employed, as it only tends to irritate the tissues. 
 
 The suturing of the edges of the wound is begun and carried down 
 from the median angle toward tlie axilla, into which a drainage-tube is 
 now inserted through a buttonliole made from the posterior aspect of the 
 latissimns muscle ; tlie gauze [)acking is withdrawn, leaving a perfectly dry 
 wound ; and the suturing is completed from end to end. As soon as tiie 
 wound is closed, constant pressure is exerted upon the wound-cavity l^y 
 sponges in the hands of the assistants. The bloody towels used for pro- 
 
 Fio. 196. 
 
 Completed dressing after breast-amputation (Gerster). 
 
 tection are removed, the patient's skin is cleansed, and the dressings are 
 now applied so as safely to enclose the wound, at the same time exerting 
 a moderate degree of elastic pressure. First comes, next to the wound, a 
 
ASEPTIC AXD AXTISEPTIC OPERATING, ETC. 715 
 
 strip of sterilized I'ubber tissue protective, tlien a strip of iodoform gauze, 
 tiien a genenins padding of crumpled loose gauze balls to till up the 
 hollows, tinally a number of large gauze com2)resses far overlapping the 
 edges of the wound in all directions. Now projecting parts, the other 
 breast and axillary margins and the corresponding arm, are covered Mith 
 strips of al)S(irl)ent cotton (previously prepared in the shape of roller 
 bandages), and the whole mass of dressings and the arm are included in 
 as many turns of a sterilized muslin roller as necessary. The patient is 
 provided with clean warmed clothes and is placed in bed (Fig. I'JG). 
 
 The endeavor of every well-trained modern surgeon must lie to arrange 
 the wound at the time of the operation and while the patient is under the 
 influence of the aniestiietic in such a manner, if ])(issil)le, as to accomplish 
 primary and uninterrupted union without any further interference. To 
 do this a number of indispensable conditions must licfultilled in addition 
 to surgical cleanliness. 
 
 First. There must be a very thorough attention paid to the stoppage 
 of hemorrhage. All bleeding points must be secured by ligature, and 
 the use of irritating chemicals u])on the raw surfaces must be avoided, 
 as it tends to dissolve thrombi and to cause profuse cajiillary oozing. It 
 is true that a perfectly aseptic wound ought to behave like a sul)cuta- 
 neous injury — for instance, like a fracture — but it is just as true that 
 even the most scrupulous endeavors at asepticism will occasionally fail 
 on aceonnt of various accidental influences. Although we know that a 
 really aseptic, artiticially-closi'd wound may and often does heal without 
 suppuration, even if it l)C disten<lc(l by a massive blood-clot, we know, 
 on the other hand, just as well, that should an however minute infection 
 have taken })lace, the microbes deposited in the blood-clot \\ould not 
 only find a favorable pabulum for their development, but that the direct 
 germicidal effect of the fresh circulating blood and of the living tissues 
 sejiarated from the microbes by the clot could not be exerted; hence 
 breaking down and su|>puration would inevitably follow. A massive 
 blood-clot in the wound is dangerous l)ccausc it serves as a culture 
 medium to accidentally-entered microbes, and because it jirevents con- 
 tact of the living walls of the wound. It must be added, however, that 
 as we are better able to produce really aseptic wonnds, so in propor- 
 tion the danger from this source is diminishing. Were this not so, then 
 a healing uiulcr the hlood-c/of, as observed in irregular hollow wounds 
 treated according to Schede's method, would l)c an impossibility. 
 
 The second desideratum in the treatment of fresh wounds is the 
 prevention of the accumulation and retention of bloody serum. This 
 also is a good jiabulmn for the growth of micro-organisms and tends to 
 separate the walls of the woun<l and to create tension. To jirevent this 
 disturbance we have' to estal>lish ettective drainage, especially in deep, 
 sinuous wounds and in those the walls of which cannot l)e kcjit in actual 
 contact by external pressure or by buried sutures. Whether the means 
 of drainage should be a gauze wick or a drainage-tube, or merely the 
 leaving open of an angle of the wound, or sparingly-employed sutures, 
 — this nmst be left to the skill and judgment of the surgeon. The 
 selection of the site of the drainage is also an important one, a dependent 
 situation being preferable. (Jood ilraiuage will keep the wound dry and 
 empty — will permit its walls to remain in close contact. It will prevent 
 
71 <i THE TECHNIQUE OF ANTISEPTIC AND ASEPTIC SURGERY. 
 
 tho retention of fluids ]iroiic to serve as a hotbed for tiie propagation 
 of noxious ijcrnis. ]5ut iiere, as in regard to h»mostasis, it may be 
 saiil tliat tile more perfect tiie surgeon's aseptic slvill, tlie wider will 
 beeome the margin of cases in which lie can dispense with formal 
 drainage. 
 
 The third requirement is not to tear and bruise the wound-surfaces. 
 The rough handling due to inadecpiate external incisions and the 
 so-called blind methods of preparailou necessarily damage the tissues 
 much more tlian the clean and easy stroke of a sharp knife. The 
 slightest infection carried into such damaged tissues must result in their 
 destruction by supjniration, while it might have been overcome by the 
 undiminished energy of the circulation of viable tissues. But even this 
 generally sound rule admits of exceptions, as we know that a perfectly 
 aseptic wound will tolerate and permit not only encapsulation of dead 
 organic substances, but also of inorganic material. As a proof of this 
 statement may serve the behavior of the average buried pedicle cut 
 ofi' from circulation by a ligature. 
 
 A fourth requirement is intimate contact not only of the edges of the 
 external wound, but of all the inner surfaces. Superficial and deep-buried 
 sutures and external elastic jircssure liy suitable bandaging of the dress- 
 ings must accomplisli this. Perfect rest of the wound in the condition 
 created by the surgeon must be further secured by splints and otlier 
 means of fixation according to necessity. 
 
 The last condition of success is the prevention of any interference 
 with the circulation of the parts bordering the wound by too tight 
 bandaging, false position, or other influences. 
 
 Where all of these ccmditions can be fulfilled without the necessity of 
 leaving in the wound any foreign unalisorbable substance, the ideal of 
 modern ^vound-treatment — that is, hca/ine/ under one dressing — will be 
 the gratifying result. And it affords the surgeon much pleasure to 
 observe that the limits of this ideal treatment are being safely and 
 steadily widened all the time. 
 
 When Neuber first advanced the jirinciples of strongly absorlicnt 
 exsiccating dressings, which were to hv left undisturbed until the wound 
 was healed, many surgeons were unwilling to try the new metliod, fear- 
 ing to forego the precaution of inspecting the wound at frequent inter\als. 
 But the great safety of Neuber's " ]iermanent dressing " (Dauerverband) 
 has been abundantly jiroven. It is universally accepted now, and we 
 have learned to estimate with great accuracy the exact condition of a 
 wound witliout actual inspection. From this new experience was dra^^■n 
 the fundamental rule of never disturbing a dressing without a clear and 
 urgent indication. Let us first see what is the course of events Avlien a 
 wound heals without disturl^ance of the natural process. Immediately 
 following the operation there will be some restlessness, nausea, even 
 vomiting, due to the anttsthetic, and later on com])laints of pain, which 
 will need some attention. But on the day following the patient will 
 comj)lnin much less, and his general aspect will be a favorable one. The 
 temperature, often subnormal directly after the operation, will have risen 
 somewhat, occasionally even as high as 103° F., but the jjatient's general 
 condition and morale do not jiroelaim him to be sick. The assumption 
 that every asejjtic operation ought to be followed by a feverless process 
 
ASEPTIC ANB ANTISEPTIC OPEBATING, ETC. 717 
 
 of healing is misleading, and docs not correspond with ai-tual facts 
 ackn(i\vk'tlgo(l hy honest observers. Almost every subeutaneons, hence 
 perfectly aseptic, fracture is tbllowed by some fever, which occasionally 
 rises as high as 105° F. Volkmann made carefnlly-reet)rded observa- 
 tions on a series of fourteen subcutaneous fractures of the thigh. 
 Eleven of these had fever, three had none. Mostly the fever continued 
 for three or four days, with elevations of the temperature to fmni 103° 
 to 10.j° F. Two patients were feverish for ten days, one for eleven, 
 another one for sixteen days. But all of these jiaticnts, tiiough their 
 faces were flushed, were not ill in the least ; they \\ere simply going 
 through an aseptic fever due to the absorption and elimination of the 
 Jibrln-fermenf furnished by the extensive blood-clot surrounding the 
 place of fracture. This fever interferes in a very slight degree, if at all, 
 with the well-being of the ]iatit'nt ; it generally begins almost iminiiU'ife/i/ 
 after the (ipi'ration, and gradually subsides into a normal state of health. 
 Volkmann was not far from the truth when he stated that about one- 
 third of all patients treated successfully according to the aseptic plan 
 \\ere feverless, one-third had moderate fever, and the last third higli 
 fever. 
 
 When moderate or even high fever is observed, beginning slowly 
 after an oiK'ration, but not accompanied by severe disturlxuice of the 
 general well-being, when at the same time the pain in the wound is 
 clearly diminishing and the pertinent lymphatiG glands do not become 
 tender to touch, the surgeon is justified in assuming that the wound is 
 doing well and the dressings need not be disturbed. 
 
 When, on the otiier hand, the fever is due to septic infection, it gen- 
 erally sets in on the second or third day. While absorption of the 
 fibrin-ferment begins immediately following the formation of clot, the 
 proliferation of septic germs must reach a certain extent before they can 
 provoke any serious systemic disturbance. Therefore, whenever an infec- 
 tion of the wound has taken place, tlie septic fever, usually ushered in by 
 a rigor and followed l)y tlie well-known appearances of general intoxica- 
 tion and local inflammation, rarely sets in before the third day. A\'Iii]e 
 aseptic i'ever generally subsides l)y the fourth day, septic fever continues 
 until a healthy condition of the wound is established. 
 
 A change of dressings should take place under the following indica- 
 tions only : 
 
 1. If the dressings appear to be thoroughly soaked with disciiarges ; 
 
 2. M^henever it becomes necessary to remove drainage-tubes and 
 stitches ; 
 
 3. Immediately when a well-grounded suspicion arises that the 
 wound has been infected. 
 
 ^'ery often, after- a large operation, especially when Esmarch's 
 bandage has l)een used, a Ihnited area of the dressings becomes per- 
 meated with blood or bloody serum. This does n(jt necessitate a cjiange. 
 It will be sutficient under these circumstances to dust the soiled spot with 
 iodoform and to bandage one or more clean compresses of absorbent 
 gauze over it. Should the entire dressing become wet with bloody 
 serum, only the superficial dressings need be changed. The iodoform 
 compress which forms the inmicdiate covering of the wound ought not 
 to be disturbed under these circumstances. 
 
71.S THE TECHNIQUE OF ANTISEPTIC AND ASEPTIC SURGERY. 
 
 Sliould the dressiiijrs become soiled from witliout, especially by faeces 
 and iii'inc, a chanj^c will be indisjiensable. 
 
 Silk sutures and rubber drainanc-tubes are foreign bodies tliat must 
 be witlidrawii as soon as their ofHee is fultillcd. The oo/.ing of 
 bloody st'rum from an aseptic wound has generally ceased after seventy- 
 six hours, and the agglutination of the sutured edges of a healthy 
 wound is by this time also secured. But as the vital processes are 
 somewhat slower in some than in other persons, it will be safest to 
 remove both sutures and drainage-tubes by the fourth day. When on 
 inspection the wound is found normal, the tube ought to be withdrawn 
 at once and for good. When a clean and iirm blood-clot is found 
 occupying the hollow of the witiidrawn tube, this gives a safe assurance 
 of the asepticity of the wound, which does not need any further diain- 
 age. Should there be any doubt on this point, however, then it will be 
 wiser to re])lace the tube until the doubt is dispersed. The idea that 
 tiihcx irritate wounds is entire/j/ fa/lacions : tubes become irritant only 
 when pvogenetic germs are carried In' them into the wound, which may 
 occur when they are replaced after having been infecteil outside of the 
 wound by contact with filth. If things prosper, a drained wound 
 may be entirely healed under two or three dressings. 
 
 This normal proceeding and course of healing is the nde in the 
 majority of wounds caused by the surgeon. It will be proper to devote 
 a few remarks to the exce})tions. 
 
 Occasionally tissues are invaded which are very vascular, and from 
 which, though the larger vessels were all secured, a profuse capillary 
 <iozing will continue for a long time. To check this oozing the surgeon 
 must resort to packing. Or, to take another example, a large vein is 
 accidentally injured in a place where the application of a ligature is 
 impossible, as, for instance, about the intracranial sinuses. Here also 
 packing is the only remedy. 
 
 In the first case, where cessation of capillary oozing only has to be 
 waited for, the packings can be withdrawn in forty-eight hours. The 
 wound will be found dry, and just as fresh as it was before packing. 
 It can be treated as a fresh wound — that is, sutures are to be a]i])lied — 
 and in most cases it will behave like a fresh wound and will heal by 
 primary adhesion. After excisions of a joint, esjiecially that of the 
 hip, operations for vascular tumors, and some amjjutations, this form 
 of treatment will yield excellent results. 
 
 When a large venous trunk has to be occluded by packing, it \\ ill 
 not be safe to disturb the plug Ix'fore either a solid thrombus has formed 
 or adhesion of the cumjiressed walls of the injured vessel has taken place. 
 This will rarely hap]H'n in less than a week, after the lapse of which tiie 
 plug will become loosened and can be removed without fear. 
 
 In operations about the oral cavity, pharynx, and larynx, as well as 
 the rectum, contact of the natural discharges with the wound-surface 
 will lead unavoidably to infection and serious mischief. This contact 
 cannot ever be absolutely jirevented, but it can be materially modified as 
 to its cf)nsequenccs Injudicious jiacking. We see after an excision of 
 the jaw or tongue, for instance, that a properly-])lugiied wound does not 
 become infected, inflamed, and fetid, though the tampons are more or 
 less soaked with saliva, blood, or vomit for a week or ten days. 
 
ANTISEPTIC METHODS. 719 
 
 Finally, it is necessary to mention another class of wounds in which 
 treatment In- packing yields excellent results. Tiiese arc wounds the 
 asaptkity (if irli'u-h in (i maffcr of doubt ; for instance, the wound after 
 excision of suppurating lymphatic glands or a suppurating tuberculous 
 joint. Here the surgeon would run great risk by closing the wound. 
 Temporary jjacking will be much safer, as it affords excellent and most 
 aljundant capillary drainage, by which all infectious material that might 
 be lingering in the wound is carried away, and the i)lugs themselves exert 
 an antiseptic action. 
 
 Prolonged piickiii;/ without detriment to the wound Ijccame a recog- 
 nized method only after the wonderful (pialities of iodoform were clearly 
 understood and appreciated, ^\'hatever the chemism may be by which 
 iodoform develops its antiseptic properties, no .surgeon of this day has 
 any doubts about them. By the aid of iodoformed tanij)ons severe hem- 
 orrhage can lie safely controlled witiiout conniromising our chances for 
 the hi'aling of tiic wound by primary adhesion ; and, finally, wounds of 
 doubtful asej)ticity can be rescued l)y the same process from suppuration. 
 
 By mentioning this last contingency Ave have trenched on the field of 
 anflsejific technique, which must now engage our attention. Wherein 
 lies the difference between aseptic and antiseptic management? 
 
 Axepsifs is the teciniique by which a primarily clean and germ-free 
 wound is maintained in its original condition ; untifsepxix, on the other 
 hand, is the procedure the object of which is the destruction and elimi- 
 nation of noxious germs that have found lodgement in the human tissues 
 and are damaging them. 
 
 Let us now I'xamine the agencies by M"hich a sejitic or infectious 
 process established in the human tissues can be .stopped. The agencies 
 that can come in question are — 
 
 1. Thermic ; 
 
 2. Chemical ; 
 •3. Mechanical. 
 
 The power of the actual cautery to stop various forms of progressive 
 ulceration is a fiu^t known to the oldest surgical A\riters. It is based upon 
 tlie destruction of all or most of the pathogenetic germs causing the 
 ulceration, together with the tissues within whii'h they have proliferateil. 
 Tissues and germs are converted into a dry eschar, which remains for 
 some time an unfavorable breeding-place for any germs that might have 
 escaped destruction by the red heat. Chancres, lupoid and tuberculous 
 ulcers, even hospital gangrene, are all amenable to the action of tiie 
 actual cautery. The field of its application is limited, but where it can 
 be employed it is very trustworthy and entirely safe. 
 
 Chemical means of absolutely sto])ping a progressive septic process 
 must be employed in such a manner as to imitate the action of the actual 
 cautery. Weak solutions will certainly lave and cleanse, even disinfect 
 to a limited extent, the xurfiee of an inflamed septic^ area, but the deeper 
 and deepest portions of the infected mass of tissues will not, and cannot, 
 be influenced in tiie least by a weak apjilication, temporary or even ])er- 
 manent. To influence a carbuncle, for instance, a mild external applica- 
 tion of any disinfectant will be utterly useless. Infection of new ai-eas 
 and necrosis of tiie affected tissues will go on througii the entire thickness 
 of tiie diseased skin. To stop the process in its inception by chemical 
 
720 THE TECHNIQUE OF ANTISEPTIC AND ASEPTIC SURGERY. 
 
 influences the entire area of infected tismies viuM be destroyed or comwrted 
 into a dry enchur. So, for instance, the s])read of a carbuncle can be 
 .stoj^pcd very promptly by the corrosion of the incipient focus throughout 
 its whole extent and depth with dry bichloride of mercury, or a paste of 
 chloride of zinc, or by chromic acid or nitric acid. Just as the actual 
 cautery, so these chemicals, to be etifcctive must include in their grasp 
 ev<'rything that is diseased. Hhoitid a portion e>J' the infected area not be 
 included in the eschar, the disease 'will continue to advance. Where the 
 escharotic has destroyed all of the infected mass the fever and the 
 local irritation will diminish or cease at once. 
 
 Where very extended areas are involved tlie ;t]>])licati(in of chemical 
 escharotics is forbidden on account of their poisonous t'tl'ect. 
 
 AYe have seen that escharotics, however reliable and excellent, admit 
 only of a limited application ; further, we have shown in former sections 
 of this paper that the influence of weaker solutions of the useful germi- 
 cides is very superficial, non-penetrating, and is furthermore restricted 
 by the danger of poisoning by absorption. Let us now examine what 
 further means the surgeon possesses for the elimination of septic material 
 from the tissues of the human body. 
 
 Here, as well as in the practice of asepsis, mechanical measures are 
 of the first and, utmost importance. By mechanical measures we under- 
 stand — 
 
 1. Incisions. — Tlieir object is first to relieve tension. To do this they 
 must be very ample and free, and should penetrate that layer of tissues 
 beneath which is situated the cause of tension. In osteomyelitis the 
 periosteum and cortical layer of the affected bone must be laid open to 
 relieve tension ; in subfascial phlegmon the fascia, in glandular phlegmon 
 the glandular capsule, must be freely split to give relief. Very often in 
 tlie most malignant forms of deep-seated phlegmonous inflammation 
 free and deep incisions for the relief of tension are urgently indicated 
 very long before any defined abscess and fiuctuation could develop. To 
 wait for fluctuation in these cases means simply a sacrifice of the patient. 
 If an early and ample incision is made in a bad case of deep-seated 
 phlegmon — for instance, in Ludwig's angina — the knife will divide a 
 nearly bloodless, recently necrosed, intensely foetid and septic mass of 
 indurated tissue, from which no pus, only a limited quantity of ichor, 
 will escape. 
 
 The second object of incisions is the evaeuedioit of li(]uid, semi-liquid, 
 and solid products of suppuration. More or less thickened pus, shreddy 
 and often considerable masses of necrosed fascia, must be evacuated. 
 To aid the first evacuation of abscesses irric/ation of the cavity may be 
 employed. As the mechanical effect of the irrigating stream is the one 
 we want, its chemical effect being insignificant, irrigation nuist be based 
 on correct hydrostatics, which will enable a stron;/ current of solution or 
 plain boiled water to sweep through the cavity, carrying with it all the 
 pus and detritus. Two incisions (counter-incision), or, where only one 
 incision is feasil)le, the introduction of two parallel drainage-tubes, one 
 used for the influx, the other for the outflow of the irrigating fluid, will 
 be more efficient tiian one single tube. Irrigation tIiroit(/h a single tube 
 ought to be done cuutiou,4y, so as not to cause over-disfeidion and rupture 
 of the walls of the abscess-cavity — a warning especially to be heeded in 
 
ACCIDENTAL WOUNDS AND EMERGENCY DRESSINGS. 721 
 
 abscesses near tlic peritoneum and pleura. Evacuation of an abscess 
 should never be aided by squeezing and pressure, as they are barbarous 
 and might lead to further and serious infection. 
 
 Drainage of abscess-cavities through incisions by means of rubber or 
 glass tubes or a gauze packing /.s imporfanf, and h indicated as long as 
 the u-alls of the earlfi/ continne to slicd effete or dead material. The tubes 
 should be ample and should occupy the most dcixMideut position, so as 
 to carry away the discharges by the aid of the force of gi'avity by the 
 shortest and most direct route. They must be placed so as not to be 
 liable to be expelled, and should not impinge on nerves or vessels. 
 Their daily cleansing and revision — to extract large masses of sloughing 
 tissues, for instance — are imperative. Likewise, insjji-^sation by evap- 
 oration at their external orifices must be prevented bi/ means of moist 
 dressings, otherwise retention might ensue in sjiite of drainage. 
 
 As soon as the discharges become serous and limpid the cleansing of 
 the cavity is finished, and the drainage-tubes should be removed. 
 
 Drainage bij packing, usually with iodoform gauze, is indicated 
 where the whoif extent of an infecte<l cavity must bi' kept patulous for 
 some time. Where and how long this has to be done cannot be dis- 
 cussed here, and must l)e looked up elsewhere. 
 
 A very important aid to drainage is posture of the body or a limb, 
 by which not only the efflux of discharges may be facilitated, but also 
 impediments to the circulation may be counteracted or even eliminated. 
 
 A well-drained wound does not need either squeezing or irrigation. 
 Where proper drainage is impossible for anatomical reasons, irrigation, 
 occasionally frc(pient, sometimes even permanent, must make u|) for the 
 defective drainage. Xon-poisonous substances, as salicylic acid or ace- 
 tate of alumina, are the only ones that ought to be used for this purpose. 
 
 As long as the cleansing of an incised and drained focus has not been 
 manifested In' the cessation of fever, pain, and the final change of the 
 discharge from ichorous and purulent to a bland, scanty, and serous one, 
 the dressings should Ix' moist and need frequent changing. As soon as 
 the cavity is cleaned and the drainage-tubes are withdrawn a dry, evap- 
 orating dressing ought to be applied, and this should be left on for a 
 considerable time, often to the very healing of the wound. 
 
 Xn. Accidental Wounds and Emergency Dressings. 
 
 In dealing with accidental wounds our first endeavor must be not to 
 inflict additional damage by ill-considered and hasty attempts at relief. 
 Ex])erience has shown abundantly that a vast projiortion of all acci- 
 dental wounds are aseptic, and if managed pro)X'rly will heal kindly and 
 without untoward con>i>lications. TJicrcfore, all forms of first aid given 
 to the wounded nuist he of ^ucli a character as not to compromise the 
 possibly aseptic character of tlie injury. 
 
 HastLi and unprepared e.rji/oratlons by finger or probe are abso/ute/i/ 
 reprehensible and useless, as their ordinary consequence is an infection 
 of the deeper parts of the wound. 
 
 The efforts of the surgeon sliould be directed toward a protection of 
 the wound bv an aseptic dressing, which, n]i]ili<'d with a niodcrato 
 amount of pressure, will sufiice to check ordinary liemorrliage. Siiould 
 
 Vol. I.— 46 
 
722 THE TECHNIQUE OF ANTISEPTIC AND ASEPTIC SURGERY. 
 
 hemorrhage be profuse on account of injury to a large vessel, jiroximal 
 or distal compression by an exteni])orized tourniquet made of an elastic 
 suspender, or by a iSjnmisli windlass (Fig. 197), will be sufficient to fulfil 
 
 Fig. 197. 
 
 Spanish windlass. 
 
 the immediate requirements for hiemostasis until the transfer of the 
 patient to his home or to a hospital is completed. Should a fracture be 
 jjresent, the application of a splint in addition to the occlusive dressing 
 is all that is required. 
 
 Injury of the large vessels of the neck or groin, requiring imme- 
 diate pressure by the tinger-tip in the bottom of the wound, is extremely 
 rare. Here, of course, we have no choice, as time is precious and a few 
 minutes of unchecked hemorrhage may result in the patient's death. 
 But this class of cases is the only one where the introduction of an 
 uncleansed finger might be pardonable. 
 
 Washing or rinsing of an accidental wound with styptics, caustic 
 solutions, vinegar, arnica, or even the polluted water of a well, spring, 
 river, or canal, is also injudicious, as it is useless and may carry infection 
 into the wound. The wisest thing to dt) is to wipe away the blood and 
 dirt from the vicinity of the wound, which ought theu to he covered 
 with a clean, newly-washed, and ironed cloth, fastened down with a few 
 turns of roller bandage or hrmly tied on with a handkerchief. If time 
 and cii'cumstances permit, sterilized or iodoformed gauze should be pro- 
 cured for this first dressing. 
 
 As soon as the patient is in his home or in a hospital, the permanent 
 disposal of the indications arising from the injury will be iu order. The 
 parts will have to be prejiared as for any operation according to tlie 
 priuci])les described in the preceding sections, and then the necessary 
 operative steps can be safely taken. 
 
 Small penetrating Avounds of the extremities, caused by penetration 
 
BEGIONAL TECHNIQUE. 723 
 
 of fractured bones or by gunshot, unless arterial hemorrhage demand 
 Inral or proximal deligation, will not need anything but thorough 
 eleansing of the neighl)orhood of the wound, together witii an occlusive 
 aseptic dressing. 
 
 Large lacerated and contused wounds, much soiled by contact with 
 street-dirt, will require careful cleansing after complete exposure of all 
 soiled recesses, followed by drainage and a suitable dressing, with or 
 without fixation. 
 
 Under the application of these principles the results achieved by the 
 surgeon in cases of compound fracture and of gunshot injury are 
 excellent. 
 
 Xm. Regional Technique. 
 
 The general rules governing aseptic and antisejitic practice everv- 
 where must be somewhat supplemented whenever certain special regions 
 are invaded. 
 
 The careful dismfcction of the oral caviti/ is a most important 
 preparation for all operations to be done in the mouth and the adjoin- 
 ing hollow spaces. A foul set of teeth, accompanied bv acute or chronic 
 gingivitis, an ichorous discharge caused by necrosis — syphilitic or other 
 — of the nasal, maxillary, or palatal liones, are serious counter-indica- 
 tions to any operation not imperatively needed. The extraction of 
 decaying teeth or of sequestra, the curing of acute or chronic stomatitis 
 or rhinitis, ought to precede every important operation to be performed 
 in the mouth or nose. Cleansing of the teeth by tooth-brush and todtli- 
 powder — in short, a careful oral toilette — is here indispensable. In some 
 cases of excessively neglected oral hygiene it will be even necessary to 
 subject the patient to a systematic jireliminary treatment before attempt- 
 ing an operation the success of which depends on a faultless primary 
 union ; as, for instance, uranoplasty and staphylorrhaphy. 
 
 The after-treatment of many oral operations has been robbed of most 
 of its terrors by the employment of tiie permanent iodoform ijauze pack. 
 This, though ])ermeated with tlie discharges, will protect the wound most 
 effectively against septic infection. It should be left undisturl)cd until 
 it becomes loosened by the granulations, when usually the dangers of 
 infection are overcome. It is remarkable how closely an iodoform gauze 
 dressing will cling to the wound-surface. To pull it away before it is 
 S'jiontaneously loosened will not only cause considerable jiain, often also 
 hemorrhage, but will especially expose the fresii wound to septic influ- 
 ences, which afterward are very hard to combat. 
 
 The cavities of the human body, — namely, the mibaraehnoidal space, 
 pleura, peritoneum, and the large joints — also require special care, as 
 their infection is followed by most serious, often fatal, consequences. 
 
 A\ hen the .*/.•*/// is to be opened, xharine/ of the entire head is absolutely 
 indisjiensable. In aildition to this the scalp should be well scrubbed, 
 and tiicn enclosed in a wet paeiv, which has to remain in sitii until the 
 patient is anaisthetized. After the removal of the wet pack the head 
 is once more scrubbed with soap and water to get rid of all loose ejiidcr- 
 mis. Where a cerebral ahucesa is looked for, the exposed brain should 
 be well protected by an iodoform gauze dam before the abscess is incised. 
 After the incision of the abscess all shreds of pus must be carefully 
 
724 THE TECHNIQUE OF ANTISEPTIC AND ASEPTIC SURGERY. 
 
 washed away with a strong jet of irrigating fluid — a wealv sublimate 
 sohition — before the paclvings are removed. 
 
 Whenever the jj/cura nr the pcrifoneum is acckleufa/lj/ injured 
 during tlie progress of an o])eration it is good praetiee to paeii an 
 iddoiorm gauze eomjiress into tiie rent, to be h'ft tiiere until it can be 
 closed by suture, or, if this be impossible, for a longer ])erio(l of time. 
 This packing will not only protect the serous surfaces against infection, 
 but in the peritoneal cavity M'ill also prevent prolapse of intestine. 
 
 Whenever accidental soiling by the escape of pus or cystic fluid or 
 fseces is to be feared, ihc Jicid of operation our/ht to be effectirely walled 
 off from the red of the peritoneal or pleural cariti/ Iji/ a ra reftdl tj-con- 
 strueted dam of iodoform (jauze. Many intestinal operations can be 
 done entirely outside of the abdominal cavity, for which purpose it is 
 advisable to withdraw from the belly the jiortion of gut to be ope- 
 rated on, if such a step be feasible. 
 
 All ojierations upon the intestine should be ])receded, if possible, by 
 a careful preparation. Systematic laxation witli tiie administration of 
 lifpiid food should cleanse and leave the bowel comparatively empty. 
 The stomach will need siphoning and washing \\henc\'cr fecal vomit 
 exists in cases of intestinal obstruction. Likewise will gastro-enterostomy 
 or pylorectomy need a preliminary careful toilette of the stomach. 
 Lavage is best done with a (iilOOO salt solution. 
 
 During intestinal operations involving enterorriiaphv the greatest 
 care must be exercised to prevent soiling of the held of operation by 
 fasces. The intestinal coil to be operated on is stripped of its fecal con- 
 tents by finger pressure ; two ligatures — one proximal, one distal — are 
 applied to prevent the escape of faeces, and the fecal matter still con- 
 tained in tlie immediate vicinity of the intestinal wound is wiped away 
 by sponges or pads of dry gauze, or, when the intestine can be with- 
 drawn from the belly, is thoroughly flushed away in addition to wiping. 
 Strong germicides are not to be used, as this might lead to poisoning, 
 and the main reliance is to be placed here too upon mechanical instead 
 of chemical processes of cleansing. 
 
 Similar are the measures of cleansing employed about the rectum and 
 anu><. Thorough evacuation, if possible, done lioth by laxatives and by 
 enemata, is to precede all important rectal oj)erations. M'iiere tight 
 strictui'e prevents a thorough emptying of the gut, inguinal colotomy 
 must o])en the way to thorough purgation. Immediately precetling the 
 operation a large sponge attached to a stout thread is thrust high up into 
 the bowel, the distal part of which is now well swabbed and douched 
 either with Thiersch's solution or with plain boiled water. 
 
 Where a rectal or anal wound cannot be closed by suture the iodo- 
 form pack will render most valuable service in protecting the raw sur- 
 faces against infectious contact with fseces and urine. 
 
 The genito-urinary tract is very often infected by uncleanly catheters 
 and bougies, the care and management of which demand some con- 
 sideration. 
 
 Urine secreted by healthy kidneys and as contained in the healtliy 
 l)ladder is always free from micro-organisms of any kind (Cazeneuvc and 
 Livon). On the other hand, the decomposition of urine, with the sub- 
 sequent inflammation of the mucous lining of the bladder, is always the 
 
REGIONAL TECHNIQUE. 725 
 
 direct consequence of tlie iiitrodiiction of certain microbes into the vis- 
 cus, either from above — that is, from tiie Ivithieys — or, much more com- 
 monly, from behjw and witiiout — tiiat is, tlirongh tiie urethra by un- 
 ck'unly instrumentation. According to Kovsing,' the causative factor 
 of cystitis is the presence of j)yogenic sta})hyk)cocci and strej)ti)Cocci. 
 Schnitzicr's^ investigations of twenty patients sufltcring from purulent 
 cystitis resulted iu the finding of a bacillns in thirteen of these cases, 
 M'hich he named iti'o-bacillu.s pyogenes scpticu.s. All of the organisms 
 causing cystitis are anaerobic ; hence they are not identical witii the 
 germs that induce the decomposition of voided urine. 
 
 Fortunately, the introductiijn of septic germs into the healthy blad- 
 der is not always and necessarily followed by cystitis. Ordinarily, a 
 moderate amount of noxious germs accidentally intrixhiced in the blad- 
 der will be prom])tly removed with the urine. Infection will take place 
 much more readily where morbid conditions — as, for instance, stone or a 
 tumor — are jiresent ; and these are the very instances in which instru- 
 mentation of the bladder is demanded. On the other hand, it nuist be 
 clearly stated that, both according to the experience of practice and 
 according to the results of ex|)crinK'nt (Schnitzlcr), the simple introduc- 
 tion of pathogenetic germs into a jterfectly normal l)ladder may be fol- 
 Io\\ed by very virulent cystitis. Therefore we are morally Ijound to 
 exercise the utmost care and cleanliness where catheterism of the healthy 
 bladder becomes necessary, as, for instance, immediately following rectal 
 operations. 
 
 Bou'/ies (infl citllictcrx mav be made of metal, of flexible or hard rub- 
 l)er, and, finally, of a fiexii)le material consisting of a wel)bed textile 
 groundwork satiu'ated with a giuinny substance. As all of these instru- 
 ments need lubrication, and as the lubricants most commonly employed 
 are fats or oils, the coating of the surfaces of the instrument with fat 
 will render disinfection by simple rinsing with or st)aking in a germicidal 
 .solution absolutely worthless. 
 
 Metal iiixtnimciifK will readily lend themselves to the most simple and 
 most reliable mode of disinfection — tliat is, that by heat. Either b(jil- 
 ing in plain water or soda solution, or passing the instrument through a 
 gas or alcohol Hame or through the bed of glowing coals in a stove or 
 grate, will certainly destroy all organic life contained in the hollows or 
 upon the surface of metal catheters. Where constantly needed they can 
 be safely preserved in glycerin or alcohol, but nuist be thoroughly flushed 
 and wiped after each use. Twice a week they ought to be boiled. 
 
 More difficult is the management of soft-rubber or N&laton catheters. 
 They can be thoroughly sterilized bi/ immersion for fifteen minutes in a 1 
 per cent, irnteri/ solution of soda just below the boiling-jjoint without 
 injury to their cohesion ami flexibility ; but this jirocess, re])eated too 
 often, will finally make them hard and brittle. After a first disinfection 
 by heat it is best to kec]i them jiermanently sus])cnded in a tall specimen- 
 jar filled with either a 5 per cent, solution of carbolic acid or a 1 : 1000 
 solution of corrosive sublimate frequently renewed. Before use, adherent 
 traces of these solutions must be first removed by rinsing and flushing 
 with boiled water, as the urethral uuicous membrane is easily irritated 
 
 ' Dk Bldfcnentzundimy, etc, Berlin, 1S90. 
 
 - "Zur Aetiologie der acuten t'ystitis," Centralbl. J'iir Baclerioloyie, IS',10, p. 7S9. 
 
72(i THE TECHNIQUE OF ANTISEPTIC AND ASEPTIC SURGERY. 
 
 by eitlier of these chemicals. After use all traces of iii'iiic iiiiist be 
 M'ashed away before the instrument is returned to its reee])taeie. 
 
 Still more dittieult is the cleansinj;- and suitable ])reservation o^ v ebbed 
 f/um bou(/ics and catheters. They will stand neither heat nor prolonjjjcd 
 soaking in antiseptic solutions, and, being very useful and the better 
 grades rather expensive, a practical method for their safe management 
 is of the utmost importance. Schinnuelbusch ' has demonstrated that 
 bri.skly-e.reeuteel friction of a webbed gum catheter or liougie during one 
 minute with a wet compress or towel, followed by energetic ruhliing 
 with a dry sterile cloth — as, for instance, a freshly-laundried towel — 
 iri/l tlioroiighly dimnfect j7.« .mrface, even if it was previously smeared 
 with and soaked in fojtid jjus. 
 
 How to sterilize the hollow interior of these webbed catheters was 
 unsolved until L. Farkas of Budapest constructed a small poi'table 
 steam-boiler with safety-valve and conical nozzle, upon which is slipped 
 the base of the rubber or gum catheter to be disinfected. Steam is 
 
 Fig. 198. 
 
 CatlH'Ur >lri ilizt-r of Farkas. 
 
 gotten up in a few minutes over a gas or alcohol flame, and is made to 
 escape through the hollow of the catheter without injury to its quality. 
 
 The lubricant employed in catheterism also needs attention, as it may 
 be the carrier of infection. Glycerin is preferable to fats. Both 
 glycerin and fats or oils siiould be boiled before use. It is best to 
 preserve them in metal cans or collapsible tubes that permit the escape 
 of a small quantity only, just sufficient for one lubrication. Machine- 
 oil cans, or for vaseline paint-tubes, will ensure against contamination 
 of the bulk of their contents. If is h((d. practice to dip the instrument 
 into the bottle or can filled irilli the lubricant. 
 
 Finally, before doing catheterism, it is important to consider the con- 
 dition of the urethra, which, according to Lustgarten and INIannaberg,^ 
 regularly harbors, even in its normal state, a variety of micro-organisms, 
 
 ' Anieitung zur asepi. WimdbehaniHung, 1892, p. 129. 
 
 '^ " Ueber die Micro-organisnien der nnrmalen miinnlichen Urethra, etc.," Vierteljahr- 
 scfirift fill' Dermatologie unci Syphilis, 1S87, No. 4. 
 
REGIONAL TECHNIQUE. 727 
 
 some of which, carried into the bladder by the catheter, are capable of 
 inducing cystitis. In thv presence of a. virulent urcfhrUli^ catluieri.sni is 
 uhsohdely prohibite<T, and even evacuation by suprapubic puncture de- 
 serves the preference. 
 
 The milder forms of urethritis do not absolutely forbid the use of 
 urethral instruments, but any form of instrumentation in presence of 
 urethral irritation is justified only under urgent indications, and must be 
 preceded by a vrri/ tliorour/h irrir/cdioti of the anterior a nfl posterior parts 
 of the urethra. The principal objt'Ct of this is the mechanical dislodge- 
 ment of the tenacious mucus (uretliral threads) coating especially the 
 recesses of the urethra. 
 
 Whenever possible the urethra, as well as the bladder itself, should 
 be thoroughly M'ashed out before an incisive exploration or operation is 
 to be done in these organs. Or, if this be impossible before, it should 
 be done as soon d urine/ the pjrof/rei<s of the operation as access is gained 
 to the urethra and bladder. 
 
 Normal salt, or Thiersch's, or boracic-acid solution, or plain boiled 
 water, is to be used rather than carbolic acid or sublimate. 
 
 Since the regular emj)loymcnt of the preliminary toilette of the 
 urethra j)receding exploration and urethral operations, the frequency of 
 urethral fever has been remarkably diniinislied. 
 
 Another important element of the j)reparation of the urinary channels 
 for explorations and operations, especially where (ystitis and pyelitis are 
 an established complication, is the internal administration of certain bal- 
 .samic substances and of some mineral and organic acids. By their ex- 
 hibition for some time before an operation the quality of the urine may 
 be materially improved in several ways. Its alkaline reaction may be 
 changed to acidity, and its contents of pus may be eonsi<leral:)ly dimin- 
 ished. (For further particulars the reader is referred to the paper on 
 the Surgery of the Urinary Organs.) 
 
 The female c/cniial tract also needs special ])reparation for all forms 
 of surgical interference with its constituent organs. The vagina, even in 
 its normal state, serves as the habitat of numerous more or less noxious 
 organisms, which thrive luxuriantly in the moist, warm pabulum of vagi- 
 nal mucus and decayed epithelia. No thorough cleansing can be effected 
 by an antiscjjtic douche alone, as this is unable to wash out all the effete 
 material lodged in the folds and reflections of the mucous membrane. 
 To reach a satisfactory state of vaginal cleanliness soaji, hot water, ami a 
 narrow vaginal or jeweller's brush (Fig. 199) have to be plied energetic- 
 
 Fui. 199. 
 
 ally until all effete material is loosened. After this it can be readily 
 washed away by the jet of tlic douche. 
 
 The endometrium and lining of the cervical canal will also need a 
 
728 THE TECHNIQUE OF ANTISEPTIC AND ASEPTIC SURGERY. 
 
 special (•k'un^ing' liuforc any exploration or operation involving a lesion 
 of continuity of the orj^an can be undertiikeii. If the os is contracted, it 
 will have to be dilated to give access to the blunt or sharp curette, irri- 
 gating ])oint, and iddoforni-ganze packing. Especially wlien a purulent, 
 catarrlial, or ulcerative ])roccss or neoplasm is present this scoojiing away 
 of septic, broken-down material must be very tiiorougli to prevent an in- 
 fection of the peritoneal cavity. As seen by the i)rcccding remarks, here 
 also as elsewhere mechanical processes of depuration constitute the main 
 portion of disinfection. 
 
OPERATIVE SURGERY. 
 
 By 8TEPHEN SMITH, M. D. 
 
 No openition slioukl ho performed, except in urgent cases, unless the 
 patient's liistorv and general condition have been scrupulously inquired 
 into ; even in cases demanding an immediate oj)eration there may still be 
 opportunity for inquiry as to previous health and habits, and to examine 
 the heart and lungs, and perhaps the secretions of the kidneys. In de- 
 layed operations the surgeon would be culpably negligent who did not 
 inquire into constitutional peculiarities and functional and organic affec- 
 tions, for the timely discovery of morbid conditions of the viscera renders 
 pi)ssil)le the use iif appropriate remedies before the oi)cration. The occa- 
 sional fatal results of anaesthetics are sometimes cUie to organic diseases 
 of the kidneys, which by proper care might be protected from the injurious 
 effects of these agents. 
 
 Diag-nosis. — It is not always possible to discover the exact condition 
 of a diseased or injured organ or tissue, anil it is a fact of daily experience 
 that surgeons of the greatest skill will differ in their diagnosis of the 
 nature of a given disease, but failure to detect the more obvious and 
 essential changes will always be construed as culpable negligence. As it 
 is admitted tliat errors in diagnosis are due in a great majority of cases 
 to haste and inattention, tiie surgeon should seek by tiiorough and patient 
 investigation of every case, aided by the most approved instruments and 
 a])pliances, to protect himself from such a charge. The elements of a 
 correct tliagnosis are found in the history of the patient, the causes and 
 progress of the disease, and the physical examination. 
 
 1. The hiiitori/of the })atient includes the following series of inquiries: 
 Sex, in its tendencies to special forms of disease at different periods of 
 life and to nervous phenomena ; age, as it affects the development of 
 bones and organs, the integrity of tissues, and the occurrence of organic 
 and malignant diseases ; heredity, in the perpetuation of diseases and 
 peculiarities of ancestors ; previous diseases, which leave their sequelae, 
 as syphilis, scrofula ; occupation, which develops special maladies, as 
 necrosis of jaw from ph()s|)horus ; ]ial)its, with which certain affections 
 are likely to be associifted, as venereal diseases with prostitution, nervous 
 derangements with niastu'-bation ; social condition, as it is related to 
 secret or conjugal vices of the sexes. 
 
 2. The jM-oc/ress of the disease relates to — date of the attack or injury, 
 on which dejiends the progress of the malady ; alleged changes, which 
 may be tlie clue to the true cause ; symptoms which, taken in their ovthr 
 of development, giv(^ much of the clinical history and aiVord reliable data 
 for a differential diagnosis ; the present attitude, form, and condition of 
 the part compared w ith the past ; tlu' operations which may have been 
 
 729 
 
730 OPERATIVE SURGERY. 
 
 performed and their residts ; the eourse of treatment and its most im- 
 portant cifects, whicii may he tiie very touchstone reveahng tlie nature 
 of the comphiint. 
 
 .'>. The plujmcal cxoiiiiiinfloii must he made with all necessary aids 
 and ap])liances, visual, mannai, and instrumental. 1. Color determines 
 the circulation in a part; form indicates the existence or non-existence 
 of enlargements of regions when deciding as to tumors, dislocations, 
 fractures ; translucency reveals the presence of serum, as in hydrocele. 
 2. Consistence must he noted in inflammatory swellings and tumors; fluc- 
 tuation in collections of fluids; crei)itus in fractures; crepitation in col- 
 lections of air or gas beneath the skin. 3. The exploring needle detects 
 the consistence and contents of swellings and tumors ; the hypodermic 
 syringe withdraws the fluids of abscesses and cavities; the trocar removes 
 pieces of muscle for examination ; the microscope determines histological 
 peculiarities ; the oj)hthalmoscope reveals the deep structures of the eye, 
 the laryngoscope of the laryngeal jiassages, the speculum of the ear, the 
 vagina, and rectum, the urethroscope of the urethra, and the endoscope 
 of the urinary bladder. With, antiscjitic precautions exploratory opera- 
 tions may now be safely made for the purpose of accurate diagnosis. 
 
 Prognosis. — The prognosis is an estimate of the results which will 
 follow any operation. It must dejiend primarily upon the knowledge 
 obtained in the diagnosis, and secondarily upon that larger inquiry which 
 seeks to discover tendencies and conditions alfecting the ultimate issue of 
 diseases and operative procedures undertaken for their cure. Due weight 
 must be given to the steady imj)rovements in the details of the treatment 
 of wounds and the constant enlargement of the field of operations. The 
 mortality of ordinary operations has been surprisingly reduced by the 
 em|)loyment of means of jircventing sujipuration, while the range of ope- 
 rations is daily and rapidly increasing. The following facts are always 
 Avorthy of consideration, whatever may be the ojieration : 1. The native 
 bears operations better than the immigrant. 2. The sex which has the 
 greatest endurance is the female. 3. The age is not in itself a barrier to 
 any necessary operation ;' however, with it we connect the most regular 
 average diiference in capacity to bear operations ; the most favorable 
 period is between five and fifteen ; tlie next, between fifteen and thirty ; 
 after thirty the risk to life is more tlian twice as great as it was at the 
 same period after birth. Young and healthy children are in danger 
 through shock, aggravated by pain, Init bear very well the loss of blood 
 and are little liable to pysemia after wounds. Old persons are likely to 
 have organic diseases and degeneracies, and feeble circulation, inducing 
 congestions, due to the sinking of the blood in the lungs, liver, intestines, 
 and other dependent parts; are liable to die of shock or mere exhaus- 
 tion, and do not bear losses of blood, lowering of temperature, or want of 
 food ; they convalesce slowly, or after partial recovery fade, waste, and 
 die ; but the thin, dry, tough, clear-voiced, and bright-eyed, with good 
 stomach and strong will, nniscular and active, bear very well all but 
 the largest operations. 
 
 Constitutional diseases greatly modify the prognosis. In general they 
 influence operations as follows : Scrofula gives a considerable mortality ;' 
 generally its ill eifects are seen chiefly in the imperfect healing of 
 
 ' Paget. 
 
' OPERATIVE SURGERY. 731 
 
 wounds, the swollen cellular tissues, the thin anil lowly-organized cica- 
 trix, or indolent ulcers :uid siiuises ; in the large majority of chronic cases 
 the removal of a scrofulous part is followed l)y impixived health, but the 
 ])atient remains scrofulous, and, if old, may uot bear confinement well. 
 Syphilis is liable to delay reparative action, and the operation in those 
 who have tertiary sores may be followed by renewed tertiary symptoms ; 
 rheumatism and gout ]iredispose to structural clianges of arteries and kid- 
 neys and to organic disease of the heart ; cancer contraindicates ope- 
 rations only in its later stages, when th(> general health is failing ; an;emia 
 is not a bad condition in which to operate ; wounds heal slowly and 
 soundly, but if erysipelas or like casualties supervene patients are less 
 likely to recover. 
 
 Habits and temperament' should also l)e duly considered; intem- 
 perance increases the dangers of operations in ])ro])ortion as it is habitual ; 
 slight intemperance is much worse than occasional great excesses; avoid 
 oj)erating on confirmed drunkards, unless compelled by the necessity 
 of the case ; operations are hazardous on all persons who require stimu- 
 lants before tliey eat or work ; over-eating is closely allied to intem- 
 perance in increasing the dangers of operations, especially if the over- 
 eating is of meat and other nitrogenous foods ; the over-fat are a bad class 
 when their fatness is not hereditary, but due to over-eating, soaking, indo- 
 lence, and defective excretions, their pendulous bellies indicating omental 
 fat and deficient portal circulation ; persons in whom the vital processes 
 are M'cak, lint without morbid action, repair wounds feebly, and are espe- 
 cially liable to diseases of the blood and tissues, and operations u])on such 
 persons should be deferred, if practical)le, to some ])eriod of l)t'tter health, 
 for fear of Im'al f:iilui-e, rather than of incurring any unusual risk of life : 
 allied to this class are the cold-blooded, with cold, damp hands and feet, 
 dusky appearance of vascular parts, feeble circulation, small pidse, slow 
 digestion, constipation ; nervous persons, who are exceedingly mobile and 
 excitable, whether in their sensitive or motor organs, their whole cereI)ro- 
 spinal system being altogether too alert and vivacious, pass through the 
 conse(|uences of ojterations with as great imjtnnity as any other class ; 
 malarial affections do not contraindieate operations, but in the course of 
 con\'alescence ague fits, resembling those which precede pyaemia, may occur. 
 
 Deranged or diseased conditions' of many organs variously affect the 
 results of operations. Of the digestive organs, gastric dyspepsia is 
 followed only by flatulence, unless vomiting is a symptom, when anaes- 
 thetics are liable to excite cmesis, with dangerous prostration ; great 
 caution is required with those whose biliary secretions are habitually 
 unliealtiiy, or who have been often jaundiced, or who have a sallow, 
 dusky complexion, dry skin, dilated small blood-vessels of the face, sal- 
 low and l)loodshot coirjunctivtc — symptoms which indicate deranged func- 
 tions and aixlominal plcth'ira ; eidargemcnt of the liver, wiictiier amyloid 
 or fatty, is often coincident with chronic diseases of the bones in children, 
 and tends to cause dcatli either b}' exhaustion or secondary hemorrhage. 
 Of the organs of circulation, affections of the heart are not serious liind- 
 rances to recovery from operations ; shock and loss of blood are attended 
 with more than ordinary risk in jiersons whose hearts are feeble or embar- 
 rassed i)y valvular obstruction, but a rapid or irregular pulse, witliout 
 
 ' Paget. 
 
732 OPERATIVE SURGERY. 
 
 (irfiaiiu! disease of tlie heart, and witli respiration not exceedinjj 20 or 25, 
 does not contraindicate an operation ; degeneraeies of the arteries are 
 only serious wiien general in the extremities, espeeially the lower, render- 
 ing ]>rinuirv licniorrhage ditiicult of eontrol, and seeondar\- hemorrhage 
 more fVe<|U('nt and dangerous after amputation, and so interfering witii 
 miti'ition that desti'uetive suppuration is liahh' to oeeur, with slow and 
 imperfeet iiealing of the wound ; diseased veins complieate operations 
 only when varicose, and cut through, as in amputations, thus exciting 
 inflammation. Of the diseases of the resjiiratory organs, chronic hron- 
 cliitis and empliysema, especially in old jteopie, render operations ex- 
 tremely hazardous, owing to imperfect respiration, cough, and loss of 
 slec]) ; ])htliisis, wlieii progressive, adds greatly to tiie dangers of ope- 
 rations from the consequent fever, loss of food, and pain, hut, when chronic, 
 operations are advisable which relieve the system of jiainful and wasting 
 local diseases ; persons suffering from long-standing strumous affections, 
 with the appearance only of tui)ereular disease, may be greatly benefited 
 by the removal of the diseased ])art ; menstruation and pregnancy are 
 conditions rendering operations uudesiral)le. 
 
 Various other affections ' often motlify the prognosis as foUoM's : Severe 
 operations during the stage of shock after injuries and during the period 
 of acute inflammation, with high temjierature, are dangerous ; sjireading 
 erysi])elas, cellulitis, and gangrene add so nnich to the dangers of severe 
 operations tliat the chances of life are best when only the ordinary treat- 
 ment is followed : avoid operations in acute ])y;enua when there are 
 rigors once or more in a few days, and profuse sweatings, with very 
 rapid pulse and breathing, and with delirium and rai)id wasting, or with 
 dry tongue and yellowness of skin, or any considerable number of these 
 symptoms; but an operation is justifialile in chronic jtysemia when there 
 are wasting and sweating, \vitli tiu' formation of al^scesses here and there, 
 and tlie injured ])art is manifestly useless and a source of irritation or of 
 exiiaustion ; crouji does not contraindicate tracheotomy, nor peritonitis 
 herniotomy, \v'hich are operations of necessity, and are not materially 
 affected by the general acuteness of the existing affections. Of the dis- 
 eases of the kidn(y, those associated with the constant presence of albu- 
 min in the urine predispose ojxTatcd patients to erysij)c]as and jiyelitis. 
 
 Decision as to Operation. — The (pie.stion of an operation enters as a 
 new and most important element in the ease, and always demands the mo.st 
 serious consideration, for cutting operations must be regarded as injuries, 
 inflicted at the will of the surgeon, \\hich may destroy a person enjoying 
 comparatively good health, or fatallv aggravate other but not serious affec- 
 tions. The question of operation may l>e involved in doubt and uncer- 
 tainty, re((uiring for its projx'r solution a nice a]»])reciation of pathological 
 conditions, operative procedures, and reparati\-e processes. Surgeons 
 may honestly differ in their views as to whether an operation would 
 ]iroduce a cure, or be of some benefit although not a radical cure, or 
 whctlier the benefit would justify the operation, or, finally, whether the 
 operation could l)c ])erformed at all without destruction of life. An 
 operation is not justifiable when the patient can be cured by any medical 
 or other means. If the disease can be cured by a bloodless operation, 
 as well as by one with cutting, choose the bloodless method, for the 
 
 ' Paget. 
 
THE GENERAL PREPARATION FOR THE OPERATION. 733 
 
 danti'ci' is comparatively sliglit when the operation does not involve the 
 injury of tissues. The object of the surgeon is twofold — viz. to save 
 life and to promote comfort. He must never argue that life is not worth 
 saving or jjrolonging. Any operation is, therefore, of undoubted pro- 
 priety which is immediately necessary to save life, as tracheotomy in 
 laryngeal obstructions, excision of poisoned wounds ; or when it is less 
 severe tlian other measures, as excision of small growths, instead of em- 
 ploying caustics; or wiien it is the only measure possible, as amputation 
 of cruslied limbs; or the last resort, all other suitable remedies having 
 failed, as lieruiotomy in strangulated hernia. Or, if an operation prom- 
 ises a complete cure or long immunity from an otherwise certainly fatal 
 malady, it is right to operate, though the procedure be severe and dan- 
 gerous, as in the removal of cancerous growtlis. An operation is also 
 justifiable wlien there is a reasonable jtrobability that it will promote 
 comfort, thougli it does not eradicate the disease, as in excising a can- 
 cerous growth. In whatever form the question of an operation is j)re- 
 sented, all of the evidence for and against it shoukl be personally 
 considered by the surgeon with judicial impartiality. He should never 
 be over-persuaded by patient or friends, nor undtdy influenced by 
 counsel, to oi)erate against convictions deliberately formed. Neither the 
 consent, nor even re((uest, of the patient can justify such an operation. 
 
 The consent of the patient, or of those resj)onsil)le for him, to the 
 operation sliould, if jjossible, always be obtained. If he is not capable, 
 as when intoxicated or comatose, or if he is a child and parents or guar- 
 dian are inaccessible, operate only from clear necessity. In order that 
 he or tliey may form a correct judgment, conununicate the decision and 
 the reasons tiiat liave led to the conclusion ; make every necessary expla- 
 nation as to the nature of the injury or malady, its jirolxible course and 
 termination, and the advantages, disadvantages, and liabilities of the 
 proj)osed operation : thus you will discharge every obligation, and remit 
 to the patient or friends or guardian the responsibilities of a final judg- 
 ment as to the course of procedure. As fir as practicable, the delib- 
 erations of the ])atient and his advisers should be influenced by no other 
 considerations than tliose presented by the surgeon. Should the decision 
 be favorable to an O|)eration, the patient again returns to the surgeon's 
 care and a new series of obligations is incurred. The pre])ai"ation for 
 the operation, its manual performance, and the after-treatment present 
 questions which will tax his knowledge, skill, and care. 
 
 The General Preparation for the Operation. 
 
 No ingenuity of conception or brilliancy of execution of the operator 
 can excuse the neglect .to secure, by previous preparation, every possible 
 advantage which can in any way, however trivial, minister to success ; 
 even a successful issue cannot justify tlie siu'geon in sul)j('eting his patient 
 to an avoidal)le risk. He shoukl strive to make the ]irognosis less seri- 
 ous and to assure the success of the operation. Tiiis residt lie will more 
 certainly attain by properly prejiaring tlie ])atient, choosing the most 
 favorable moment for the operation, adojiting the best method of })er- 
 forming it, and a]iplying the most efficient dressing. 
 
 The Preparation of the Patient. — The first care nuist be given to 
 
734 OPERATIVE SURGERY. 
 
 the patient. It is iniportaiit that every organ and the entire system he 
 so prepared for tiie injury ahout to he intiieted tiiat the issue will be 
 favoi'able, for the timely discovery of morbid conditions of the viscera 
 and the use of appropriate remedies Ix'fore the operation might, in a 
 large proportion of cases, prevent disastrous results. The efl'eets of 
 hal)its of excessive boflily indulgence in food and stimulants may be 
 amended in a comparatively short time ; jtrevious rest, important to the 
 recovery of the part about to be operated upon, may be secured ; slight 
 derangements, which are readily amenable to treatment, such as indiges- 
 tion, constipation, diarrluea, may at once be corrected; grave affections 
 of the kidneys, liver, heart, lungs, and nervous centres may be so im- 
 proved or the system so protected that the o])eration will not be serious'. 
 Even ansemic persons with feeble circulation, when suitably pre- 
 pared by tonics, as iron, improve their condition and bear operations 
 well, being singidarly little liable to erysipelas, pyaemia, and other dis- 
 orders of the blood. The patient should be placed under the most 
 favoralile hygienic conditions; jnire air, suitable exercise, Mholesome 
 food, and undisturbed slee|) are im])ortant features in the final ])rej)ara- 
 tion ; the morale nuist, as far as possible, be sustained by such assurances 
 as will secure mental quietude and hopefulness as to the result of the 
 operation : do not exaggerate its nature, but speak encouragingly of it 
 and of its prospeeti\-e success. Finally, as a severe shock to the nervous 
 system, produced by an exhaustive surgical operation and ]irolonged an- 
 sesthesia, may for a time so paralyze the stomach that digestion ceases or 
 is greatly impaired, and the food that it contains at the moment may 
 undergo such putrefactive changes as will render it an irritant, the food 
 taken within six hours of the operation should be quickly assimilable 
 and in limited quantities : milk is, in general, the best food for this pur- 
 pose, especially with children, to which may be added a small amount 
 of whiskey ; a warm, well-seasoned, and well-cooked cup of broth or a 
 fragrant cup of hot coffee and milk may be preferred by the adult. 
 
 The Time for the Operation. — The time appointed must be so fixed 
 as to avoid the error of omission, delay — or of commission, haste— by a 
 careful consideration of tlie nature of the disease, the condition of the 
 patient, and the surrounding circumstances. It must be immediate 
 when life is threatened and the operation offers the only chance of re- 
 covery, and should be delayed when any of the conditions enumerated 
 would render the operation dangerous to life or abortive in its results. 
 But not unfrequently the disease, the patient, and the circumstances 
 combine to enable the surgeon to appoint the month, the day, and the 
 hour. The emi)loyment of anrestheties has so diminished the fear of 
 operations tliat the surgeon may exercise his discretion as to the propri- 
 ety of informing the patient of the day and hour selected. 
 
 The Place for the Operation. — In the selection of the place refer- 
 ence must be had to the comfort and safety of the patient. The office 
 of the surgeon is frequently the most convenient place, but a risk to 
 the ]iatient may thereby be incurred, which it is better to a\-oid — namely, 
 the liability of rendering a simple operation dangerous by the subse- 
 quent imprudent conduct of the ]Kitient, as exposure to the elements, 
 excitement, f\itigue, or excesses of appetite. 
 
 The room in the private dwelling should be chosen for its accessibility, 
 
THE GENERAL PREPARATION FOR THE OPERATION. 735 
 
 its size, and its exposure to light at tlie liour of the ()i)eration ; tlie best 
 liofht on a clear day for delicate operations is reflected from tlie nortliern 
 sky. The air of the room in which an operatiou-wonnd is inllictcd 
 should be as free as it can be made from all forms of putrefactive organ- 
 isms ; it should not immediately communicate with water-closets and 
 other sources of defilement, nor be occupied as a living- or audience- 
 I'oom. The best results, after large oiierations, have been obtained when 
 the operating-room has been first purified the preceding day, and l)oth 
 operator and assistants have bathed and had their clothes and all the 
 materials used about the wound thoroughly disinfected. 
 
 The Selection of Instruments. — In selecting instruments care must 
 be taken that they are of approved utility and in good condition. The 
 surgeon cannot employ rude articles, as a butcher's knife or a carpen- 
 ter's saw, in amputation, unless he is placed under circumstances which 
 prevent his oi)taining suitable instruments. And he is required to 
 employ the more recently devised instruments which liave been recom- 
 mended by the best authorities as preferable to those formerly in use, 
 provided they are reasonably accessible to him. They should be so 
 constructed as to be readily made aseptic and maintained in that condi- 
 tion. For this jjurpose the handle should be, as far as practicaljle, 
 smooth, and made from non-absorbent material, and the setting of the 
 blade or shatt should iiave no recesses for filth. They must be kept in 
 good order, as dull knives, broken forceps, or imperfect saws seriously 
 complicate operations. They must, finally, be kept in a state of scrupu- 
 lous cleanliness, as blood and pus may convey contagion to the person 
 next operated, and dust and filth may fiitally poison a wound. The 
 miniu- apparatus, also, nuist be carefully selected, for an operation may 
 be spoiled by sometliiiig tliat was tliought too trivial for care. 
 
 The testti of the quality of instruments are as follows : Draw a cutting 
 instrument from heel to point slowly across the border of the nail, and 
 it will catch or stop at every "nick ;" draw it across the ffat of the nail, 
 and if at any point the edge is seen to be wiry or smooth, it is soft, and 
 must be reapplied to the hone; ])ut if it becomes serrated like a fine 
 saw, the edge is brittle and camiot be remedied by the hone. For 
 pointed instriunents stretch upon a test-drum (a contrivance for the 
 piu-pose for sale by instrument-makers) a very thin piece of kid or gold- 
 beater's skin and push the point through. If it enter smoothly and 
 easily, the point is good ; but if a slightly crackling noise is heard, it 
 is defective. If a lancet is tested, see-saw the edge in the opening, and 
 if it glides over without cutting or cuts rougiily the edge is imperfect. 
 
 The preservation of instruments in good condition requires carefid 
 attention to tlie following details : Select a place always free from moist- 
 ure and dirt fi>r tlieir safe-keeping. Polished instruments shoidd be 
 suspended or placed in metallic cases. After being used every in- 
 strument siiould be thoroughly cl(>aned with warm water, and perfectly 
 dried witli cliamois or the fire before it is returned to the ease. Silver 
 instruments tarnish when tiiev arc exjiosed to the air or are brought in 
 contact with hard or soft rubber, caustics, or acids. To preserve the 
 etlge and polish of instruments, the surgeon requires two or three small 
 hemes, some fine emery-])a|)er, two or three screw-drivers, small files, 
 rouge, crocus, or other polishing powder, chamois, antl gold-beater's or 
 
7.36 OrERATTVE SURGERY. 
 
 kid skin. C^ittinii' iiistruiiiciits sliould have their h]aflos kcjit in jH'rfcct 
 onk'r Ijy tho judicioiis use of tlie hone. Oecasionally the blade miLst be 
 ground by a competent workman. Blunt instruments, Avhich are 
 designed to enter natural or other passages, should hv frequently 
 polished with fine emery-paper, and then with rouge and chamois-skin, 
 in order to remove every jtartiele of rust and to maintain smooth, 
 unblemished surfaces. Saws are sjiarpened with three-corncreil files 
 applied in the direction of the original cut of the teeth. 
 
 The case of instruments which the surgeon must jjrovide depends 
 upon the variet}' of operations which he undertakes : if limited to 
 ti-ifiing operations, he retpiires oidy the pocket-case ; if he pei'form 
 minor operations, he requires the minor operating-case; if he assumes 
 every grade of operation, be must add the general operating-case. In 
 .selecting any case the surgeon should exercise his own judgment as to 
 the number and kind of instruments, rather than accept the list of the 
 maker or of any other surgeon. The best assorted ease contains many 
 instruments which the general practitioner never has occasion to use. 
 The case which immediately contains the instruments should l)e made of 
 metal, and should be adjustable, so that the whole or the different parts 
 may be jilaced in boiling water. Aluminum is adapted for a small case, 
 and rolled copper for a lai'ge case. 
 
 Convalescence. — The hygienic conditions which surround a patient 
 the subject of an operation materially affect the results. Foul air, filthy 
 dressings, and indigestible food will thwart the best ])lanned and exe- 
 cuted o])eration. It is therefore the duty of the surgeon to secure to the 
 patient all the advantages which healthful conditions afford. These are 
 largely found in the room and its various ajipointments. 
 
 The room in the private dwelling best adapted for convalescence is on 
 the secf>nd floor from the grotnid ; the exposure should be to the south, 
 with ample window space, and with opposite or partially opposing win- 
 dows for thorough ventilation. The size of the room is of slight import- 
 ance, except as to convenience, compared with the provisions fV)r the out- 
 flow of foul air and the infl(jw of fresh air. Large cubic sjiace does not 
 secure purity of the air, and hence is of minor importance if the neces- 
 sary amount of fresh air is sup])lie<l and properly distril)uted without 
 unpleasant currents. It would, however, always be wise to ])rovide at 
 least two hundred feet superficial area and three thousand cubic feet of air 
 to the patient and his attendant, each, during the first few weeks, to guard 
 against defects in ventilation. As in private residences there are no other 
 motors for changing the air than differences of temperature and move- 
 ment of the air which can be excited by heat or wind-fans, these agents 
 must be employed to give motion to the air. The conunon ojien fire- 
 place, well heated, furnishes the best heat-supply for movements of the 
 air, while the inlet and outlet of air is maintained by raising and drop- 
 ping the sashes of the windows. The walls should be freshly lime- 
 washed, floors cleaned with carbolic solution ; no sink for slops, nor 
 wash-bowls drained into common house-drains, nor water-closet, should 
 be in or communicate with the room ; the furniture should be as free as 
 possible from absorbent materials ; bed- and window-hangings, carpets, 
 and ujjholstery are objectionable, and if old are dangerous. Floors, fur- 
 niture, and woodwork should be cleansed, without water, by rubbing 
 
THE PREVENTION OF HEMORRHAGE. 
 
 737 
 
 with au ab.s()rl)ont material. Do not place the bed near the wall, in a 
 corner, nor in air-di-aughts. 
 
 The ward of the hot^pital to which tiic patient is to be conveyed should 
 be free from suppurating wounds, erysipelas, and low forms of fever ; 
 the lied should be exposed to the sunliglit, with any necessary screen for 
 tile face ; it should liave at least one iuuidred feet of su]ierficial area and 
 four tliousand cubic tcct of air ; the jiosition of the bed siiciuld be tiu'ce 
 or four feet from the wall, witli complete ventilation around it; if tiie 
 tick is filled with straw, it must be fresh ; if a hair mattress is used, it, 
 with the bed-linen, should be clean and previously well aired and sunned. 
 
 The nurse should be skilled in the care of persons suffering from 
 operations, for freipicntly success depends upon the skill in the manage- 
 ment of the details of nursing after special operations. Cleanliness of 
 the wound, the patient, the clotiiing, tlie room, is of the first importance ; 
 the diet and the remedies are to be airefidly attended to ; and the prog- 
 ress of the case, as indicated by the wound, the pulse, and the tempera- 
 ture, is to be noted at sufficiently frequent intervals to make the record 
 of the case complete in the absence of the surgeon. 
 
 The Prevention of Hemorrhage. 
 
 It is important to make suitable preparation for the prevention of 
 hemorrhage, for excessive bleeding, due to defective measures for its 
 arrest, shows cul]>able negligence. The preparation must be adapted both 
 to control the cinulation in the limb or part during the operation, and 
 to permanently close the divided vessels after the o])eration. 
 
 Elastic Compression. — The most perfect method of preventing loss 
 of blood during the operation is by elastic compression, so applied as to 
 remove the blood from the part and prevent it from re-entering the 
 vessels. 
 
 The elastic haiifhtf/i' (Fig. 200) is tlie most serviceable and convenient 
 appliance yet devised to meet all of these important indications. While the 
 
 Fio. 200. 
 
 Fig. 201. 
 
 (^ 
 
 
 Elastitt banUa.ije. 
 
 Elastic bandage applied. 
 
 patient is Iteing brought luider the ana'sthetic apply the bandage, with 
 uniform tightness, from tiie extremities of the toes or fingers, according 
 to the limb about to be operated upon, to a point above the place of o])e- 
 ration ; where the bandage ends ap]ily india-rubber tubing, well drawn 
 out, four or five times roiiii<l the thigh, and connect one end with tjic 
 other by means of a hook and brass chain ; now remove the bandage 
 first applied, commencing with tiie last turn and descending to the toes 
 Vol. I. — 1" 
 
738 
 
 OPERA TI 1 7i' SUE UER Y 
 
 Of fiiiircrs, leaving;; tlic tiil)ing in position 
 
 The l)!ui(lag(> may be fixed 
 with a .strong- tape j)asscd under the two or three hist turns and tied 
 firmly ; then begin with the first turn at the extremity and remove the 
 banchige to the |)oint where it is fastened. Tlie india-rubber tubing so 
 tlioronghly compresses all the soft parts, including the arteries, that not 
 a drop of blood can enter the parts Ix'hnv. Even in the most muscular 
 and obese individuals we are able thoroughly to control the su])j)ly of 
 l)lood l)v this simple jirocess ; the limb below the tubing resembles com- 
 pletely that of a corpse, and we may operate as on the dead sulyect. 
 This method may be adopted in almost all operations on the extremities 
 with more or less complete success. In extirjiatiou of tumors, tying of 
 arteries, and in resections of smaller bones and joints the comjiressing 
 tul)ing need not be relaxed until the dressing of the wound is completely 
 finished. When operating upon ])arts infiltrated with purulent matters 
 do not apply the elastic bandage, as there is danger of forcing the puru- 
 lent matters upward through the meshes of the cellular tissue, but raise 
 the limb and empty the vessels as completely as possible before applying 
 the tubing. 
 
 Arterial Compression. — The control of the circulation may be 
 effected by compression of the artery which supplies the ])art. As this 
 method, however carefully applied, }>ermits of the loss of the blood con- 
 tained in the limb, the amount should be diminished, as far as possible, 
 by first elevating the limb and rubbing it towai'd the heart. 
 
 The fingers afford ready and aN-ailable means of arterial compression 
 when the artery is accessible and lies upon a bone (Fig. 202). If the 
 
 Fig. 202. 
 
 DigitJil compression. 
 
 thumb is used, it must be laid flat upon the vessel ; in either case the 
 pressure must not be relaxed ; if the vessel slips from the grasp, it 
 should be instantly compressed again upon the bone by the fingers or 
 
THE PREVENTION OF HEMORRHAGE. 
 
 739 
 
 thumbs, but not by grasping- tlie linil) ; the fingers are best employed 
 in compression of the brachial, the radial, and the ulnar arteries ; the 
 thumb in compressing the carotid, the abdominal aorta against the 
 vertebne, the external iliac against the brim of the pelvis, the femoral 
 against tlie pubis, or against the femur in the upper part of the thigii. 
 
 The key, the ring being so ])addc(l as to make a hard mass, is used to 
 compress deep-seated arteries, as the subclavian. 
 
 The tourniquet has several modifications (Fig. 203, «, h, c), but the 
 most important difference is in the efi'ect upon the venous circulation ; 
 it may compress the limb only at opposite points («) or the entire 
 limb, the pad being placed over the artery \b, c). The most useful 
 instrument is that in common use {b). In its application it is usual 
 
 Fig. 203. 
 
 Fig. 204. 
 
 Tourniquets. 
 
 Tourniquet applied. 
 
 to put several turns of a roller loosely around the limb at a point where 
 it is applied, terminating with placing the cylinder of the roller over 
 the arterv as a compress ; the tourniquet should now be applied, but the 
 screw .should not be placed over the cylinder, lest the liall roll from the 
 arterv when the screw is worked. The screw being ])laced at one side 
 of the limb (Fig. 204), the strap should be buckled tightly and the 
 ■screw gradually turned to the nece-ssary tightness. If the point of 
 compression of the arterv admits, put the cylinder of the roller between 
 the pad and the strap and apply it directly over tlic artery. 
 
 Fig. 20'>. 
 
 Tenaculum. 
 
 Fig. 200. 
 
 .\rtery forceps. 
 
 Ligation. — During the operation tiic hcinnrrhage should be tempo- 
 rarily controlled by .•seizing the bleetling points with the catch forceps 
 (Fig. 207), and allowing them to remain in jxisitirm until the oj)eration 
 has ])rocceded so i'ar that they inu.-it l)e removed, w iicn antiseptic ligatures 
 should i)c applied to each. 
 
 In aj)i)lying the ligature to large arteries the coats of the artery 
 
740 
 
 OPERATIVE SURGERY. 
 
 slioiikl, as far as ])()ssil)l{', be isolated from the surrouiiding tissues. On 
 applyino; the ligature make the surgeou's knot (Fig. 208) or the reef 
 knot (Fig. 209). 
 
 In some cases the lileeding vessels cannot be isolated, and it becomes 
 
 Fig. 207. 
 
 Fig. 208. 
 
 Siirf,'('<iirs knot. 
 
 Fig. 209. 
 
 Catch-forceps. 
 
 lWv( knnt. 
 
 necessary to enclose a small area with a ligature (Fig. 210) passed around 
 it Avith a needle. 
 
 Torsion. — The twisting of an artery upon its axis is designed to 
 cause laceration of the internal coats ; they then roll into the calilire 
 of the vessel and form a mesh, within which a blood-clot forms and 
 
 Fig. 210. 
 
 Fig. 211. 
 
 Ent'lusing tissues. 
 
 Everted end of innci coals. 
 Torsion .applied. 
 
 becomes organized ; the external twisted coat remains as a protection 
 and support. Torsion is a reliable method, especially when ap2)lied to 
 small arteries, but is not generally approved for large arteries. 
 
THE PREVENTION OF HEMORBHAQE. 
 
 741 
 
 Free torsion is applicable to small arteries, and consists in seizing the 
 extremity of" the vessel with iirnily-united forceps, drawing it out from 
 its connection, and rotating it several times (Fig. 211). 
 
 Limited torsion is applied to large arteries, as follows: Seize the 
 extremity of the artery with strong catch-forceps luning blunt serra- 
 tions ; draw it well out of its sheath ; grasp it firndy with a second 
 forceps about one inch from the end ; now rotate the first forceps three 
 or four times or until all resistance ceases. 
 
 Acupressure. — Compression of the artery in the wound by means 
 of a needle (Simpson) is only adapted to cases in whicli the artery 
 cannot be seized or is friable. The instruments required are bayonet- 
 pointed pins varying in length from three to five inches, with glass heads 
 to facilitate their introduction, needles threaded with iron wire, and loops 
 of slender annealed iron wire five or six inches in length. On the cut 
 surface of a flap tlie ordinary sewing needle answers j)erf'ectly well. 
 There are several metiiods of employing the pins to accomplish com- 
 pression, l>ut they may be reduced to three (Fig. 213, 1, 2, 3), and will 
 be understood by the illustrations. 
 
 Acupressure is seldom resorted to, as with antiseptics it has no advan- 
 tage over the ligation, exc^ejit when the artery cannot otherwise be eon- 
 trolled. 
 
 Direct compression (Fig. -12) is made by the pin thrust through 
 tile flaj), j)assed over tiie artery, and brought out 
 of the integument of the opposite side in such 
 manner as to firndy compress the mouth of the 
 artery against the muscle upon which it lies. 
 
 Acupressure by forcejjs (Allis) is an inge- 
 nious method of com])ressing vessels when there 
 is much oozing from surfaces : the instrument 
 consists of two blades (Figs. 214, 215) under the 
 command of a spring, the lower of which is a 
 needle and designed to transfix bleeding tis- 
 sues ; which done, the grasp of the hand is released, and compression is 
 instantly efl'ected between the blunt blade which lies upon the surface of 
 the bleeeling vessels and the needle which lies beneath them. 
 
 Direct acupressure. 
 
 Fig. 213. 
 
 Different modes of niii>lying acupressure. 
 
 Cauterization. — The cautery, once the only metliod of arresting 
 bleeding after operations, is now requii-ed only when deep-seated parts 
 are involved, or tissues to which the ligature cannot .safely be applied. 
 
742 
 
 OPER. 1 TI VE S UR CER Y. 
 
 Tlie actual cautery consists of an iron or steel knob, at the extremity 
 of a long shaft, secured to a handle Tlie shape of the extremity may be 
 round or pear-shaped, or flat like a l)utton ; eacli form is adapted to 
 
 special conditions rcquirinjr its use. It 
 may be heated in the flame of a spirit 
 lamp ; when employed to arrest hemor- 
 rhage its temperature should be at a 
 dull red heat. 
 
 Fic. 215. 
 
 Acupressure forceps. 
 
 The thermo-oanterii (Fig. 217) is an in.strument by which a high de- 
 gree of heat of the cautery may almost instantly lie ol)tained, and may 
 be maintained for any length of time without the slightest inconvenience. 
 
 Fig. 216. 
 
 C. tIEMANN'CO. 
 
 =« 
 
 Cauteries. 
 
 By adapting a blade to it dissections may be made, and with the wire 
 ccraseur tumors may be removed in a l)lo<)dless manner. 
 
 Ligation of Arteries. — The application of a ligature to an artery can 
 now scarcely be considered a serious operation, for when the antiseptic 
 
 Fig. 217. 
 
 Paquelin'.? cautery. 
 
 method is pursued suppuration does not occur, and if the proper kind of 
 ligature is used division of the artery docs not follow, and hence there is 
 n( I danger of secondary hemorrhage. It is now established that when an 
 artery is cli:)sed by an aseptic ligature it is not necessary to divide the 
 internal coat, but only to press its opposing surfaces together temporarily, 
 to secure permanent obliteration of its canal. In this process the intima 
 becomes covered with granulations; these unite and form a firm union; 
 
THE PREVENTION OF HEMORRHAGE. 
 
 743 
 
 also new tissue fornis around the ligature, Hive a ring of callus, strengtli- 
 ening the point of ligation ; meantime the ligature undergoes absorption 
 and the cure is complete. By the antiseptic operation the artery is 
 strengthened at the seat of ligature, and there can be no danger of hem- 
 orrhage. It should, however, be borne in mind that to secure the best 
 results the ligature must be of an absorbable nature; for ligatures which 
 permanently resist absorption destroy tlie continuity of the \-essel, and, 
 instead of adding sti'ength to the perivascular cicatrix, \\eaken the vessel- 
 walls at the seat of ligation. 
 
 The in.^fndiu'nty required are a scalpel, force})s, aneurism needle, liga- 
 ture, director, and retractin's or spatulas. Tiie connnon scalpel is best adap- 
 ted for the dissection, and the broad extremity of the handli' can be used 
 to advantage in separating layers of fascia and parts where the cutting edge 
 is not desirable ; the dissecting forceps should have accurately fitting teeth, 
 and not liable to open at the extremity when firmly closed ; a pair of 
 small forceps may also be required. The aneurism needle is a curved 
 blunt instrument, with an eye near the extremity and firmly fixed in a 
 handle (Fig. 21S). When used, the extremity is gently insinuated under 
 the vessel, and as it appears upon the oppo- 
 site side the loop of the ligature is seized Fif- 219. 
 with the forceps or a hook, and, one end 
 being drawn through, it is held as the in- 
 strument is withdrawn carrying the other 
 end, and thus leaving the ligature under 
 the vessel. A needle well adapted to those 
 cases where the artery lies deeply consists 
 of the handle and hook (Fig. 220) and the 
 l)lunt needle with two eves (Fig. 219); the 
 needle is fitted to the sliaft (Fig. 220) by a ^''?/|lti'ons^''P 
 screw ; when used, the ligature is inserted 
 into the second eye ; the needle is then passed under the 
 artery, and as the extremity emerges upon the opposite 
 side the hook is inserted into the first eye, and the 
 needle is thus held until the handle is unscrewed, when 
 it is drawn through with the ligature. It is sometimes 
 necessary to include other tissues with the arterv, when 
 the sharj)-pointed needle (Fig. 219) should be used. The 
 director is used in the dissection to raise the fascia before 
 Aneurism needle, its division ; it is Sometimes passed under the artery as a 
 guide to the needle. Two retractors are often reciuired, 
 with which assistants separate the sides of the wound and expose the 
 deci)-seated parts ; jneces of fiexihle metal or wood mav be used. 
 
 The aseptic cafi/iif or Ki/l:iroriii-r/iit Ihidiiirr more effectually meets the 
 indications present than other kinds. When so applied as not to sever the 
 tunics of the ligate'd vessel it is gradually displaced bv organized tissue 
 which increases the resisting capacity of the vessel. It is stated that the 
 most careful microscopical examinations have shown that catgut increases 
 to a considerable extent the resisting capacity of an artery in forming 
 firm connective-tissue connections with the vessel. It follows that cat- 
 gut ligature should be ])referred, and that it is onl}- necessary to tie with 
 sufficient force to approximate the inner surflices of the intima with a 
 
744 
 
 OPERATIVE SVnOERY. 
 
 vi('w to ensure effective j)ro\isi()nal ohiitenition, when cicatrization will 
 follow. 
 
 Fig. 220. 
 
 3b 
 
 Artcry-hdok and handle for needle. 
 
 The operation is a,s follows : Determine the precise location of the 
 artery — (1) by its pulsation ; (2) by reference to anatomical jioints in the 
 
 vicinity. To render tlie former dis- 
 tinct, tile liinl) should l)c placed in 
 a ])osition favorable to arterial cir- 
 culation ; to render muscles and 
 tendons most distinct, the limb 
 should be forcibly extended at the 
 commencement of the operation. 
 A^^len the dissection has pnx'eeded 
 so far as to reach the vicinity of the 
 artery, the operator is aided in 
 detecting its position by flexing tlie 
 limb, so as to relax the muscles and 
 tissues. Before the first incision is 
 made guard against wounding supe- 
 ficial veins. Their position is readily 
 defined by comjiressing the parts 
 above the point of the proposed 
 operation. When the first incision 
 is about to be made the skin should 
 be rendered tense by the thumb 
 and forefinger of the left hand ap- 
 plied, one on either side of ves.sel, or by the fingers apjilied at the extrem- 
 ity of the proposed incision parallel to its course : if the first metiiod is 
 chosen, care must be taken mit to make more traction on one side than 
 on the other. The second method answers where the skin is naturally 
 tense and but slight traction is necessary ; make the incision directly 
 over and parallel to the artery, through the skin only if the artery is 
 superficial, but also through the cellular tissues if it is deep, its length 
 varying with the depth of the vessel and the adipose tissue. Tlie incision 
 is sometimes made in the direction of the fibres of the muscle covering 
 the artery, as where the great pectoral overlies the axillary ; at other 
 times it should l)e curved, so as to raise a flap. 
 
 The length of the incision cannot be prescribed, but it should always 
 be ample. Pinch up the fascia carefully with the forcejjs (Fig. 221) ; 
 nick it M'ith the scalpel applied horizontally ; incise freely on a director 
 introduced beneath. In dissecting amony; muscular structures enter 
 the muscular interstices and do not wound the substance. These inter- 
 muscular spaces are marked by deposits of fat, esjiecially toward the 
 terminal extremity of the muscles, and hence we should commence the sep- 
 aration of muscles as nearly as possible at their terminal extremity. If there 
 is doubt as to the line of separation, a puncture will disclose adipose or 
 
 Opening the sheath. 
 
THE PREVEXTION OF HEMORRHAGE. 
 
 745 
 
 miisfulai- tissue, aceoriling to the nature of tlie underlying structure. If 
 the dissection is made througii the body of the muscle, the fibres separate 
 more readilv in an inverse direction — namely, from their origin to their 
 attachments. The muscles may be separated witli the handle of the 
 scalpel or the tinger-nail. 
 
 The larger arteries have firm sheaths, which reijuire to l)e opened by 
 dissection ; the smaller vessels have but slight investments, and are 
 
 Fig. 222. 
 
 Fio. 223. 
 
 Passing tlie needle: first stage. 
 
 Passing the needle : second stage. 
 
 readily exposed with the jioint of a director or the aneurism needle. 
 The sheath is opened by pinching up a small jjortion with the forceps and 
 nicking it slightly with the scalpel ; into the opening thus made intro- 
 duce the point of the needle (Fig. 222) ; by slight movements of its 
 point, first uiion one side and then upon the other, separate the sheath 
 completely around the vessel to an extent sufficient to allow simply the 
 passage of the ligature ; as the extremity of the instrument emerges on 
 the opposite side, with the finger of the left hand or the thumb and fore- 
 finger pressed together steady its jioint as it penetrates the last portion 
 of the sheath. If the artery is small and very superficial, a director may 
 be passed under and along its groove, a l)lunt needle carrying the liga- 
 ture. If more deeply situated, the common aneurism needle (Fig. 218) 
 or the doul)le-eye needle (Fig. 219), should be used. The point of the 
 needle, gently moved laterally, aids materially in separating the artery 
 fi-oni the sheath (Fig. 223). The needle should be passed from the 
 veins ; no force should be used, lest the instrument penetrate the coats 
 of tlie artery. 
 
 The ligature should l)e ])laced at a right angle with the long axis of 
 a vessel, and the reef-knot (Fig. 2(l!>) tied unless there are special reasons 
 for adopting the surgeon's knot (Fig. 20S). The first knot is tightened 
 around the vcs.sels firmly, on either side of the ligature, near the artery, 
 with the index fingers carried to the bottom of the wound (Fig. 224). 
 The decree of constriction varies with the size of the arteries, but it 
 
746 
 
 OriiRATIVE SURGERY. 
 
 Fig. 224. 
 
 need not be so great as to rujitiirc tlie internal coats. In tyin<i: tlie second 
 knot care must be taken not to tiglitcn the thread firndy until traction 
 
 is made on a ])lane witii the first knot, 
 with the fingers again carried down to 
 the vessel. The two ends of the liga- 
 ture must be cut not too near the knot. 
 TIk^ dressimi of the tvound should l)c 
 strictly antisejitic for the ])urj)osc of se- 
 curing inunediate union. A catgut drain 
 should be placed in the lowest angle. 
 The deeper .structures may first be 
 stitched with the continuous catgut su- 
 ture ; then, if the MOund is large, two 
 or three deep sutures of relaxation may 
 be inserted. Close the cutaneous wound 
 with the continuous or interrupted su- 
 ture. Complete the dressing Ijy antiseptically cleaning the external sur- 
 face, dusting it with iodoform, and applying the iodoform gauze or a 
 bandage of bichloride gauze. 
 
 Tying the knot. 
 
 ARTERIES OF THE THORAX, NECK, AND HEAD. 
 
 The innominate artery is in relation on the right with the pleura, right 
 vena innominata, and right pneumogastric nerve ; behind, with the 
 trachea ; on the left, with the left carotid ; in front, above, with the 
 sternum and the origin of the sterno-hyoid and thyroid; Ix'low, with tiie 
 inferior thyroid vein and left vena innominata. 
 
 Operation. — Place the patient on the back, with the shoulders .slightly 
 raised, the right arm drawn downward, and face turned to the opposite 
 
 side ; make an incision three inches in 
 Fig. 225. length just above the clavicle) ter- 
 
 minating over the trachea, and, if re- 
 (piired, a second of the same length 
 from this point along the inner bor- 
 der of the sterno-mastoid ; divide the 
 ^ ^s^'ffev sternal and part of the clavicular por- 
 
 j ^. -----^i^P ?'^^k *^'^'" ^'^ ^'^^ sterno-mastoid (Fig. 225, e) 
 
 ^.■;^.flir.I-~:.".~~v:""/-:^l^^ffV on a director and turn out\\-ard ; divide 
 
 « -^^"^93^^^ the sterno-hyoid and thyroid in the 
 
 ( same manner ; draw them inward, ex- 
 
 posing the sheath of the carotid, par 
 vagum, and internal jugular vein ; now 
 Innominate artery. Separate the par vagum, b, from tiie 
 
 carotid ; draw the vein, c, to the out- 
 side, and the artery toward the trachea, and expose the subclavian ; the 
 innominate artery, (J, is now uncovered ; pass the needle from below 
 upward and inward ; care is necessary to avoid wounding the pleura 
 behind. 
 
 The sitbclarian and common, carotid arteries (Fig. 226) may be ligated 
 by the following operation : Place the patient in the position for ligature 
 of the innominate ; make an incision three inches in length through the 
 
LIGATURE OF ARTERIES. 
 
 747 
 
 integuments, along the space separating the clavicular and sternal attach- 
 ments of the sterno-cleido-mastoid muscle ; tliis interval is marked by a 
 depression above the clavicle at the 
 
 articulation of" the clavicle and ster- Fio- 226. 
 
 num ; flex the head ; slightly separate I 
 
 the internal portion of the nuisclc, a, I 
 
 from the external, b ; divide tiie sterno- ^// ^sk. 
 
 hyoid and thyroid on the director. The ^ 13Z"^;;Z!!^.'".f. ^^rt>^\ ^1 
 
 innominate, h ; tiie common carotid, c ; '■ '~"yz,i /"' ii£ "Ull '''^^ ' • 
 
 the pneumogastric, f7, and its branch, / ^^a»*^'°'^"4€ll ll ^ i 
 
 the recurrent laiyngeal ; the origin of '^ Z".V.'Z\'.'-.'^^...--^^r\ jfi '''Xf^'"^ 
 
 the subclavian, //, and its branches, the •' " Wit > ! 
 
 vertebral, c, and inferior thvroid, are '» "^r^^- b-^-^ 
 
 now un<ler control. y nT^V / ^ 
 
 The common carotid arteries extend ^'' \cj 
 
 on the right side from the innominate, subclavian and common carotid arteries. 
 
 and on the left from the highest point 
 
 of the arch of the aorta, to the upper border of the thyroid cartilage ; 
 the direction is obliquely from before backward, and from within out- 
 ward, along the external side of the trachea and larynx, in a line drawn 
 from the sternal end of the clavicle below to a point midway between 
 the mastoid process and angle of the jaw above. The sheath is derived 
 from the deej) fascia, and contains the internal jugular vein and the 
 pneumogastric nerve, the vein being externtd and the nerve between. 
 («) At the base of the neck the artery is deeply seated. The carotid 
 tubercle is a guide to the position of the artery ; this tubercle is the 
 anterior projection of the transverse process of the sixth cervical vertebra, 
 which is two inches above the clavicle, and is a precise guide to the 
 ai-tery when the neck is sti-aight ; it corresponds in front and a little inside 
 to the artery (Fig. 227). The patient being in the recumbent position, 
 
 Fig. 227. . 
 
 ) 
 
 Common carotid ; first part. 
 
 the head extended and inclined to the opposite side, recognize the inter- 
 val between the two attachments of the sterno-mastoid muscle, and make 
 an incision from the clavicle, two and a half inches, obliquely along this 
 interspace ; divide the skin, ])latysina, an<l deep fascia ; draw the internal 
 portion of the muscle, c, inward, and tiie external, a, outward, by means 
 of spatulas; this exposes the internal jugidar vein, b, the pneumo- 
 
748 
 
 orjJIiA TI VE SUIWEB Y. 
 
 gastric nerve, c, lying hotwcon tlio vein, h, and tlie artery, /, and the 
 (inio-liyoid muscle, (/, crossing tlic upper part of the wound ; open the 
 sheath and pass the needle from without inward, carefully avoiding tlie 
 internal jugular vein and par vagum ; a linger pressed upon the vein at 
 the upper part of the wound will cause it to collapse. 
 
 {J)) Below the omo-hyoid the artery is much more accessible (Fig. 
 228). Place the patient on the back, with the head thrown back ; make 
 
 d the 
 
 Fig. 2l!9. 
 
 Common carotid below omo-hyoid. 
 
 an incision three inches in length along the inner border of the sterno- 
 mastoid mnscle, in the line above given, terminating at the top of the 
 sternum ; successively divide the skin, superficial fascia, platysma, and 
 dec]) fascia, and expose tlie inner border of the sterno-niastoid, v ; care- 
 fully avoid the steriio-iiiastoid artery and middle thyroid vein ; throw 
 the head forward and draw the stcruo-mastoid muscle outward 
 stcrno-hyoid and thyroid mu.scles inward ; expose 
 the anterior belly of the omo-hyoid muscle, a, which 
 should be drawn upward ; divide the deep ftiscia ; 
 expose the sheath of the vessel ; open it directly 
 over the artery, avoiding carefully the dcscendens 
 noni, which runs along the tracheal side ; press the 
 pneumogastric nerve, il, and internal jugular vein, 
 c, outward, and pass the needle from M'ithout in- 
 ward, carefully isolating the vessel from the infe- 
 rior thyroid artery and recurrent laryngeal nerve 
 which lies behind it. 
 
 (c) Above the omo-hyoid the artery is still 
 more snperficial, being covered only by the 
 skin, the two fasciae, platysma, and the border of 
 the sterno-mastoid ; it is in relation internally 
 with the larynx and pharynx, and externally 
 with the jincumogastric nerve and internal jugu- 
 lar vein {Fig. 229). Place the patient on the 
 back, the shoulders raised and the head turned to 
 the opposite side ; make an incision from a little 
 below the angle of the jaw, in the line given, 
 along the internal border of the sterno-mastoid, 
 three inches in length ; di\ide the integuments, superficial fascia, and 
 platysma ; raise the deep fascia cai'efully on a director ; avoid the small 
 
 Right common carotid ar- 
 tery at the seat of liga- 
 ture: pi, platy.sma; ,»!. m, 
 sterno-mastoid, drawn to 
 one side ; o. A, omo-hyoid. 
 drawn downward and in- 
 ward : *■. h, sterno-hyoid ; 
 a, the artery ; v, internal 
 jugular vein ; d.n.n, de- 
 "scendens noni nerve. The 
 pneumogastric is not seen, 
 as it lies behind the ves- 
 sels. 
 
LIGATURE OF ARTERIES. 
 
 749 
 
 underlving- veiiiir ; flex the head to relax tlie nuiseles, and draw tlie wound 
 apart l)y .sj)atuhe ; avoid the descendeas iioni nerve and superior thyroid 
 arteries, and open the sheath over the artery ; if the internal jugular 
 vein swell up into the wound, compress it in the upper and lower jjarts 
 of the wound, and draw it outward ; pass the ligature from without 
 inward, the point of the needle lieing kept close upon the artery, to 
 avoid wounding the vein or ineluding the pneuniogastric nerve (Fig. 2."]0). 
 The external and infernal carofidn arise from the common trunk at 
 the upfier border of the thyroid cartilage, the external being more 
 
 Fig. 230. 
 
 Pueumogastric nerve. 
 
 .Tiigular vein ; venous compartment of 
 sheath, the part to be avoided. 
 
 Carotid artery, sliowing arterial 
 compartment of sheatii. An 
 arrow indicates the part to be 
 opened. 
 
 Diagram of the carotid sheath (Sir W. llacCurmac). 
 
 .superficial than the internal at their origins. ^Take an incision along the 
 inner luai'giu of the sterno-niastoid, three inches in length, from the 
 angle of the jaw to the cricoid cartilage, through the skin, platysma, 
 superficial and deep fascia ; the internal margin of the sterno-mastoid 
 now appears; cautiously separate the cellular tissue, and, the wound 
 being drawn apart, the external carotid artery is exposed ; draw the 
 digastric muscle and hypoglos.sal nerve upward and the internal jugu- 
 lar outward ; both arteries may now be ligated, or either artery sei)aratelv. 
 
 The external carotid, artery ascends from its origin at first sligiitly 
 forward, then backward, to the space between the condyle of the lower 
 jaw and the meatus auditorius ; above the digastric the arterv lies more 
 deeply and is crtKs.sed by the stylo-hyoid nuisele. Make an incision from 
 near the angle of the jaw to tlie middle of the thyroid cartilage, along 
 the inner margin of the sterno-mastoid, about three inches ; divide the 
 skin, platysma, and fascia; seek with the linger the tip of tiie great 
 cornu of the hyoid bone. 
 
 The superior thyroid artery arises from the external carotid, just 
 l)el(iw the greater cornu of the hyoid bone, and passes inward to the 
 thyroid gland in a tortuous course. Place the head in an extended 
 position ; make an inoision an inch and a half along the internal border 
 of the sterno-mastoid, the centre of which corresponds to the great cornu 
 of the thyroid cartilage ; incise the; skin anil platysma ; draw the sterno- 
 mastoid outward and expose the omo-hyoid nuiscle, internal jugidar 
 vein, and primitive carotid artery ; the artery lies between these vessels 
 and the IoIk' of the thyroid body ; ])ass the needle from aliove downward 
 with the point inclined to tlie thyroid Ixidv. 
 
 The lingual artery (Fig. 232), the secontl branch of the external caro- 
 
750 
 
 OPERATIVE SURG EI! V. 
 
 tid, nriscs just above tlic superior tliyroid, aseeiids to tlie <rreat cornu of 
 the liyoid hone, runs ])arallel with it and passes inward on the middle 
 constrictor and jicnio-hyoirlossns to the outer edge ol' the hvoglossus 
 muscle ; it tlien passes upward and inward beneath the digastric, stylo- 
 hyoid, and hyoglossus muscles to the base of the tongue. The artery 
 passes througii three regions: (1) external to the hyoglossus muscle, (2) 
 beneath the muscle, (3) from its inner margin to the tip of the tongue ; 
 the second ))orti<jn is selected for ligation. Turn tlie iiead to the oppo- 
 site side; make an oblique incision an inch and a half in length, a little 
 above the body of the hyoid bone, and j)arallcl with it, near the median 
 line, and curved backward, outward, and downward, ])arallel with the 
 sujjerior border of the great cornu of the thyroid cartilage (Fig. 231) ; 
 
 Fig. 231. 
 
 Lines of incision for ligature of tlie first part of the axillary artery, the third part 
 of the subclavian, the common carotid, and the lingual. 
 
 divide the superficial parts, and with the finger recognize the direction 
 of the great cornu ; divide uj)on it the aponeurosis which covers the deep 
 parts ; this e.xposes the digastric muscle, the submaxillary gland, hypo- 
 glossal nerve, and stylo-hyoid muscle ; now isolate the great cornu of the 
 hyoid bone, and the fibres of the hyoglossus muscle, \vhich are attached 
 at this point, come into vic\\' ; divide this muscle at the superior border 
 of the great cornu ; draw it upward and backward, and the artery is 
 found l)ehin(l it ; the needle should pass from above downward. 
 
 The fiiridi (irterij (Fig. 2-32) arises a little above the lingual, is iirst 
 directed obliquely forward and upward beneath the base of the maxil- 
 lary bone, where it changes its direction and pas,ses up^vard over the 
 base of the lower maxilla in front of the masseter muscle. It consists 
 of a cervical and facial jjortion : the first is comparatively superficial, 
 being covered only by the jilatysma and fascia, is crossed by the digas- 
 tric and stylo-hyoid muscles, and then enters the submaxillary gland. 
 Emerging from the gland, the second part turns over the jaw, covered 
 
LIGATURE OF ARTERIES. 
 
 751 
 
 bv the platvsma and fascia, and ascends to the inner canthus of the eye. 
 In the first part nialve an incision similar to that for exposing the lingual 
 arterj', but nearer tlie base of the jaw ; incise the skin and tissues over 
 
 Fic. 232. 
 
 Facial vein. 
 
 f,-. Masvter. / 
 
 Mi/I't liyoid. 
 . . \ (' Ijigastric. 
 
 \l.iiigual\ \ Ui liyuides. 
 
 art.\ Lingual vein. 
 Hypuglussai nei've. 
 
 Siylu-hyoid. 
 
 Int.jugiilar. 
 Auatomicjil relations of the lingual and facial arteries (Tillaux). 
 
 the submaxillary gland ; draw the gland ujnvard, and the artery will also 
 l)e raised, when it can he easily separated from the vein and ligated. 
 In tlic second part (Fig. 2.3.3) recognize at the junction of the posterior 
 third with the anterior two-thirds of the body of the bone the pulsation 
 
 Flo. 233. 
 
 The facial and temporal arteries 
 
 of the artery ; make an incision an inch in length along the course of 
 the vessel, as already, given, through the skin, fascia, and platvsma ; the 
 wound being separated and the til)rous tissue divided, the artery, c, is 
 
752 
 
 OPERATIVE SURGERY. 
 
 exposed, and tlie vein, J), and nia.sseter muscle, <(, are drawn outward and 
 the needle passed. 
 
 The icmpond artcrt/ (Fig. 2'V-V) runs u|)ward toward the temporal 
 region from its origin at the condyle of the jaw, in front of the concha ; 
 two inches above the zygoma it divides into the anterior and posterior 
 branches. Recognizing the jiosition of the artery by its pulsation, at a 
 point above the zygomatic arch and in front of the ear make an incision 
 through the skin an inch in length; divide the dense cellular tissue on 
 a director, and the artery, a, will be exjwsed ; pass the needle from 
 behind forward to avoiil the temporal vein, b, and the auriculo-tem- 
 poral nerve. 
 
 The middle incniiH/c(d artcri/ is the largest branch of the internal 
 maxillary and the largest artery which sup}>lics the dura mater. It 
 ascends under the external pterygoid muscle, and enters the skull 
 through the sjnnous foramen of the sphenoid bone ; within the skull 
 it passes beneath the dura mater to the middle fossa, where it divides 
 into two terminal bi'anches ; the anterior, the larger, passes upward on 
 the great wing of the sjihenoid in a deep groove in the anterior inferior 
 angle of the parietal bone, where it divides. This division may be 
 ligated for intracranial hemorrhage. The artery is most accessible 
 where it crosses tiie anterior inferior angle of the jiarietal bone. De- 
 termine the position of the artery by the intersection of a horizontal 
 line drawn two inches above and parallel ti) the zygoma, M'ith a vertical 
 die an inch behind the posterior sujjerior border of the malar bone; 
 make a crucial incision througii the skin, <lividc the temporal muscle, 
 and expose the skull ; the bone is unerjually thick in this region, and 
 care must be taken in using the tre|)hine ; the circle of bone being 
 removed, the bleeding vessel may be ligated or pressure may be employed 
 to arrest hemorrhage. 
 
 The occipital artevy arises from the posterior part of the external 
 carotid, opposite or a little above the facial, ascends beneath the poste- 
 rior belly of the digastric muscle to the space between the transverse 
 
 process of the atlas and the mastoid 
 process, and is distributed to the o(^cip- 
 ital region. 
 
 At its origin the artery is covered by 
 the stylo-hyoid and digastric nniscles, 
 and the hvjioglossal nerve winds around 
 it from behind forward. Make an in- 
 cision along the inner border of the 
 sterno-mastoid muscle, two inches in 
 length, at the angle formed by this mus- 
 cle and the digastric ; the deep fascia 
 being carefully divided, expose and iso- 
 late the artery, the nerve being pro- 
 tected. 
 
 Behind the mastoid process (Fig. 
 234) the artery passes upward in a tor- 
 tuous direction, and divides into branches 
 upon the occiput ; it is covered by the sterno-mastoid and splenius mus- 
 cles. Make an incision, one inch long, half an inch behind, and a little 
 
 Occipital artery. 
 
LIGATURE OF ARTERIES. 753 
 
 beneath the mastoid process, obliquely upward and backward ; divide 
 the skin and aponeiu\>sis of the sterno-mastoid muscle, c, as also the 
 splenius muscle, through the whole lengtii of the wound ; the pulsations 
 of the artery, a, are recognized by the finger a little above the obliipie 
 muscle, 6, and it is isolated from its veins. 
 
 The posterior attriciilar artery arises in the parotid glanil nearly oppo- 
 site the apex of the mastoid process ; it ascends to the interval between 
 the mastoid process and external auditory meatus, where it divides. 
 Make a vertical incision midway between the two points above given ; 
 the pulsations of tiie artery will prove the immediate guide for its 
 ligation. 
 
 The internal carotid artery continues directly upward from the ter- 
 mination of the common carotid, opposite the upper border of the thyroid 
 cartilage to the carotid foramen of the temporal bone; at first it is 
 covered onlv by the sterno-mastoid muscle, platysma myoides, and 
 fascia ; it lies to the outer side tif the external carotid. ]\Iake the same 
 incision as for the common trunk, its centre being one-half to three- 
 quarters of an inch above the ui)per border of the thyroid cartilage; 
 veins will be met with which must be a\oided or tied ; tiie descendens 
 noni nerve runs along the artery, and the hypoglossal crosses it about 
 one inch from its bife.rcation. First find the external carotid, and draw 
 it inward. Pass the needle from the outer side, carefully avoiding the 
 jugidar vein and pneumogastric ner\-e externally, the hypoglossal nerve 
 suix'rficially, and the external carotid internally. 
 
 The internal mammary artery arises from the subclavian on its lower 
 and anterior })art, opposite the tliyrt)id axis and close to the anterior 
 margin of the scalenus anticus ; it runs directly downward and slightly 
 inward beliind the clavicle on the inner surface of the costal cartilages 
 near the sternum. The internal jugular and snliclavian veins and the 
 phrenic nerve cross the upper part ; in the chest it at first lies on the 
 costal cartilages and intercostal muscles, covered by the pleura behind ; 
 but lower it is covered also by the triangularis sterni muscle. It may be 
 tied in the second, tliird, or fourth intercostal spaces. Make an incision 
 along tile upper edge of the costal cartilage, connnencing at the sternum, 
 in either space, slightly upward and outward, an inch and a half in 
 length ; divide the skin, cellular tissue, pectoralis major muscle, fascia, 
 and intercostal muscle successively ; a thin layer of cellular tissue is 
 exposed, which conceals the ai'tery ; pass the needle cautiously from 
 within outward. 
 
 Tiie vertebral artery (Fig. 235) arises from the upper and l)ack ])art 
 of the subclavian artery in the first part of its course, about one-third 
 of an inch internal to the inner border of the scalenus anticus muscle, 
 and passes directly along the spinal column to the foramen in the trans- 
 verse process of the sixth cervical vertebra, and then ascends through 
 tile series of foramina of the transverse jirocesses to the cavity of the 
 cranium. Before enteriiig tiie vi'rtel)ral canal tiie artery passes l)cliind 
 the internal jugular vein and inferior thyroid artery to the sjiine, where 
 it lies between the scalenus anticus and longus colli, and in a line drawn 
 from tlie posterior part of the mastoid jirocess to the junction of the 
 internal fourth with the external three-fourths of the clavicle. Place 
 the ])atient on the liack, the shoulder depressed, and the head turned to 
 Vol. I.— 18 
 
■54 
 
 OPERA TIVK SURGER Y. 
 
 tlie opposite side; make an incision tln'ci' inclios in luni^tli from tiie 
 claviclo along tiie outer border of the sterno-niastoid muscle ; divide the 
 the skin, and cellular tissue ; bring into view the common sheath of the 
 
 Fig. 28o. 
 
 *- u H » 
 
 Anatomy of the vertebral iiml inferior thyroid arteries (from Treves): yl, thyroid gland; ;;. tra- 
 chea: C, clavicle; _/>, strrnuthyroid; A', scalenus medins ; /'. longus colli, with symi»atlie1ic 
 nerve upon it; G, scalenus :inticus (cut): if, subclavius ; /.transverse yjrocess of the sixth 
 cervical vertebra: 7. l>r;ielii;il jilexus; a. left innominate vein, receiviiiir internal jugular:/j. 
 ju,£rular vein, entering sulu-bnian vein: c, eommmi carotid artery, with vagus nerve to its 
 inner side ; rf, subclavian ai-teiy crossed by ner\ e to subclavius : f. vertebral artery and vein ; 
 ,/, inferior thyroid artery. 
 
 carotid, the internal jugular, ;uid the pncumogastrie nerve ; separate 
 with the finger the cellular connection of the sheath with the sterno- 
 thyroid muscle, and finally with the longus colli ; the head is now rai.sed, 
 though still turned t<i the o))posite side, and the sides of the wound 
 forcilily .'<c]>aratc(l ; divide the cellular tissue at the bottom, and expose 
 an aponeurosis which })as.ses from the scalenus anticus to the longus colli 
 and the anterior part of the transverse process of the sixth cervical 
 vertebra, the carotid tubercle ; then open the ajioneurosis an inch below 
 this point at the external border of the longus colli muscle ; the artery 
 is exposed verj- dee})ly situated. 
 
 The inferior flii/roiil arferi/ (Fig. 235) is a branch of the thyroid axis ; 
 it ascends the neck obliquely, passing behind the internal jugular, the 
 pncumogastrie nerve, the carotid artery, and omo-hyoid muscle to the 
 thyroid body. On the left side it lies on the oesophagus, and the thoracic 
 duct is at first posterior, and afterward arches over it in front of the 
 artery to the left suljclavian vein ; near tlie gland the recurrent laryngeal 
 nerve often passes l)etwecn its terminal l)ranehcs. Make the same incis- 
 ion as for the ligature of the common carotid (Fig. 227). When its 
 sheath is reached, draw it outward ; the artery crosses obliquely inward 
 opposite this point ; when the vessel is fully exposed ajiply tlie ligature 
 as near the carotid as you can to avoid the recurrent laryngeal nerve. 
 
 ARTERIES OF THE UPPER LIMB. 
 
 The subclavian artery arises from the innominate on the right side, 
 and from the arch of the aorta on the left ; it extends in a curved direc- 
 
LIGATURE OF ARTERIES. 755 
 
 tion from its origin to the lower border of the first rib. It may be 
 lio-ateil ill three places — viz. inside, between, and outside the scaleni 
 nm.scles ; the latter location is always to be preferred, and will be 
 described. Outside of the scaleni muscles (Fig. 236) the artery passes 
 
 Ligature (if the right subclaTJan (third part) (from Treves): J, clavicle; B, sterno-mastoid ; C', 
 trapezius; D, omo-hvoid; E, anterior scalena; F, cervical fascia; a. subclavian artery; 6, 
 subclavian vein ; c, cxt. jugular vein ; d, transverse cervical artery ; 1, brachial plexus. 
 
 downward and outward, lying in a groove on the first rib. It first 
 passes through the supra-clavicular triangle, and is then covered only 
 by the deep fascia, the ])latysnia, and skin ; lower in its course it is 
 covered by the clavicle and sulx'laviaii muscle ; the subclavian vein lies 
 lower and in front of the artery, separated from it by the insertion of 
 the scalenus anticus muscle ; the external jugular vein crosses in front 
 of the artery ; the brachial plexus of nerves lies above and behind the 
 artery. The depth of the artery may vary from one to three inches, 
 according to the depth of fat. Search for the artery in the supra- 
 clavicular triangle, which is bounded externally by the omo-hvoid 
 nuisclc, internally by the scalenus anticus, and below by the first ril) ; 
 place the patient on his back, the shoulders depressed, and the head 
 turned to tlie opposite side ; the skin over the parts being drawn down 
 upon the clavicle, make an incision along the bone from the anterior 
 bonier of tlic trajK'zius to the posterior border of the sterno-mastoid; 
 divide the platysina and superficial fascia, care being taken to draw tiie 
 external jugular outward, or, if cut, to tie tiic ends; with the director 
 and finger separate the celkdar and fatty tissue, and draw the omo-hyoid 
 muscle aside ; divide the deep fascia, and, the border of the scalenus 
 being defined, pass the finger along its margin down to the first rib ; 
 recognize the tubercle for the attaclinient of tiiat muscle, just external to 
 which tile artery will be felt pulsating ; se])arate the attaclimeuts of the 
 artery witli the finger-nail, and gently insinuate the aneurism needle 
 l)crieath it, from before backward, and slightly from M'ithin outward, 
 avoiding the vein ; guide the jioint of the needle by the end of tlie 
 finger, and prevent it, when it emerges upon the opposite side, from 
 engaging a branch of the bracliial ph'xus. It must be remembered that 
 the sterno-mastoid may have an unusually extended insertion upon the 
 clavicle, as also the trapezius, in wiiich case the incision must involve 
 the clavicular attachments of the former ; the external jugular, supra- 
 scapular, and transverse cervical veins form ;i jilexus immediately over 
 
756 
 
 OPERATIVE SURGERY. 
 
 the artery ; the external jiif;iilar may I'un so near to the sterno-mastoid 
 as to be involved in tlie incision, unless it is carefully isolated and drawn 
 to the outer or inner side ; the transverse cervieal and supra-sca])idar 
 arteries may he met \yith in this dissection, and if wounded shoidd be 
 iiniiiediately ligatcd ; tlie tubercle of the rib is sometimes not well 
 defined, in which case the tense cdfi'c and attachment of the scalenus 
 to tlie rib are the guides to the artery, which is found just posterior to its 
 insertion ; there is a liability to include the lowest cord of the brachial 
 plexus, or even to mistake it for the artery; the former is round and 
 tense, the latter is flattened. 
 
 The aj-illari/ (irfcri/ extends from the lower border of tlie first rib to 
 the lower margin of the tendon of the latissimus dorsi or the inferior 
 boundary of the axilla, in a line dividing the anterior and middle third 
 of the axilla. It may be ligatcd in two places, (a) Below the clavicle, 
 in its upper part, the axillary artery is covered successively by the 
 insertion of the pectoralis minor ; higher up by the pectoralis major 
 muscle, from which it is separated l>y a layer of adipose tissue contain- 
 ino- numerous small veins and arteries; and finally liy tlie fasciae and 
 the skin (Fig. 237). The supra-scapular artery crosses the base of the 
 neck just above the clavicle ; the axillary vein, in front and to the 
 inner side of the artery, is not in immediate contact with it ; the cephalic 
 vein passes upward in the interspace between the deltoid and jieetoralis 
 major muscles, crosses the axillary artery above the jiectoralis minor, 
 and empties into the axillary vein ; the nerves of the brachial plexus lie 
 behind and above ; a thoracic branch often crosses the artery, sometimes 
 in front antl sometimes behintl it. Place the patient on his back M'ith 
 
 his shoulders slightly raised, the 
 elbow a little separated from the 
 body, and the head inclined to 
 the opposite side ; make an in- 
 cision, three inches in length, 
 thrcc-(juarters of an inch below 
 the clavicle, and commencing 
 about two inches outside of the 
 sterno-cla vicular articulation, 
 through the skin, platysma, and 
 subcutaneous cellular tissue ; sep- 
 arate the fibres of the pectoralis 
 major gradually until the posterior 
 investment of this muscle, like an 
 aponeurosis, appears ; now depress 
 the shoulder and tear this fascia 
 with the point of the director ; press downward and out-\vard w ith the 
 finger the upper border of the pectoralis minor, when the axillary vein 
 is lirought to view ; draw this gently forward with a blunt hook, and 
 behind it the artery is found, with the nerves of the brachial plexus 
 still farther behind and above ; pass the needle from within outward. 
 (6) Below the ]icctoralis minor, in its lower third, the artery is super- 
 ficial, covered only l>y the integuments and deep fascia. The coraco- 
 braehialis muscle is in contact A\'ith the artery, and may be found at its 
 internal and posterior border ; the bj-anches of the brachial plexus of 
 
 p. in 
 
 The first part of the right axillary artery : p. m. a, 
 peetoralis major, thti fibres separated in llie 
 inner half of the wouud and divided in the 
 outer; p.vi.i, pectoralis minor; a. t, aeromio- 
 thoracic artery and vein ; v, axillary vein ; a, 
 axillary artery ; n, brachial plexus. 
 
LIGATURE OF ARTERIES. 
 
 757 
 
 nerves surround the artery ; tlic niusculo-cutancous lies along the outer 
 side ; the two roots of the median meet in front at the loMer border of 
 tlie pectoralis minor ; the nerve then lies in front and to the outer side 
 of the artery ; the internal cutaneous lies in front and to its inner side ; 
 the ulnar and radial are still farther within and Ijehind ; the axillary 
 vein is in front of the arter}- and nerves, which it partly conceals (Fig. 
 238). Place the patient on the back, the arm rotated outward ; stand 
 on the outside if it is the right arm, and on the inner side if it is the 
 left ; recognizing the inner border of the coraco-brachialis muscle and the 
 
 Fig. -IZ^. 
 Caraco-brachlatis viuscle. 
 
 %S!- 
 
 Jvt. ciUaneoas nerve. 
 
 Ligature of axillary artery, upper third. 
 
 })ulsations, make an incision two or tJn-ee inches in length in the line 
 indicated, dividing only the skin; incise the fascia on a director; with 
 the end of the director ])ush the axillary vein backward, then the bra- 
 chial ])lexus ; the median nerve is now recognized, and, being brought 
 forward, while tiie internal cutaneous and ulnar are pushed backward, 
 the artery is exposed ; separate the artery carefully from the vein, which 
 is pushed backward, and tiie nerves which surround it, and pass the 
 needle from behind forward. 
 
 The bmchial artery extends from the lower margin of the axilla to 
 an inch below the bend of the elbow, in a line drawn from the junction 
 of the anterior with the middle third of the axilla to the middle of the 
 bend of the elbow. 
 
 (ff) In the upper third, the arm being extended as before, make an 
 incision two and a half inches in length along the inner border of the 
 coraco-brachialis ; the artery is readily exposed, lying between and 
 behind the median and ulnar nerves, the former to the outside and the 
 latter to the inside. 
 
 (6) Tn the middle of die arm the l)rachial descends on tlie inner side, 
 first of the coraco-brachialis, and afterward of the liice]is. It is covered 
 by the fascia and integuments, and overlap])cd slightly by the biceps ; 
 its sheath contains the two vente comites ; the internal cutaneous nerve 
 lies superficial to it ; the median is superficial to it above, and rather to 
 its outer side ; about the middle of the arm it crosses the artery, and 
 
ros 
 
 OPERATIVE SURGERY. 
 
 iiifcriorly it is to its ulnar side ; the ulnar nerve is internal to the artery, 
 and at some distance from it interiorly; the spiral nerve is posterior, and 
 .separates it above from the trieej)s (Fifj. 239). The arm extended at 
 i'i};iit angles to the hody and held sujiine, the course of the artery may 
 he recognized by its pulsation ; by the internal margin of the biceps and 
 
 Fio. 239. 
 
 Biceps muscle. 
 
 Median nerve. 
 Brachial artery iu the middle of the arm. 
 
 coraco-brachialis ; by the median nerve, to the inner side of wliich it 
 lies ; or by the line above given. Make an incision two or three inches 
 in length along the inner border of the biceps down to the fascia, which 
 incise on a director ; tlie ])ositioii of the median nerve is detected in the 
 wound ; push it aside with the bice|)s ; the artery is found immediately 
 beiiind and inside, accompanied by its vcnse comites. The arm is now 
 flexed, the vessel isolated, and the ligature passed from witliout inward. 
 If the incision is made a little too far back, the ulnar nerve is exposed, 
 and is liable to be mistaken for the median ; and this error may be con- 
 firmed by the presence of the vein, occupying the same relative position 
 
 Fig. 240. 
 
 Tendinous aponeurosis 
 divided. 
 
 .->> 
 
 Brachial arterj at tile elbow. 
 
 as the brachial to the median, which may be mi.staken for the artery, and 
 then the inferior jirofunda will be tied for the brachial. 
 
 (c) At the elbow the brachial artery lies in the centre of a triangular 
 sjiace formed by the supinator longus externally and the pronator radii 
 teres internally. It rests on the brachialis anticus ; the median nerve 
 
LIGATURE OF ARTERIES. 
 
 759 
 
 lies to the inner side half an inch ; the tendon of the Ijiceps lies on the 
 outer side ; its coverings are the skin, superficial fascia, and the median 
 basilic vein, which is separated by the bicii)ital fascia. 
 
 The arm extended and hehl in a supine position (Fig. 240), malve an 
 obliijue incision, two inches and a half in length, along the internal edge 
 of tile tendon of tile biceps, within tiic median basilic vein, dividing imly 
 tiie skin ; push aside the vein and divide tiie aixinenrosis, which is tlie 
 deep fascia, on a director; the tendon of the biceps is now seen, and on 
 its inside the artery with its two veins, and still farther inward the 
 median nerve ; slightly flex the forearm, and pass the needle from within 
 outward, carefully avoiding the veins. 
 
 Tlie mdial artery, though the smaller brancli of the brachial, lies in 
 the direct course of the latter like a continuation ; its course is marked 
 by a line drawn from tlie centre of the elbow to the inner side of the 
 styloid process of the radius; is superficial tliroughout nearly its entire 
 course ; the needle may be passed in either diri'ction. (a) In its upper 
 third the artery lies between the supinator longus and the pronator radii 
 teres; the radial nerve lies immediately on its external side (Fig. 241). 
 
 Fio. 241. 
 
 Supinator tongus. 
 
 Ligature of radial artery in its iijii)CT third. 
 
 The limb being extended supine, tiie superficial veins made prominent 
 by pressure of the thumb above, make an incision two or three inches in 
 length on the internal border of the su]iinator longus, if recognized by 
 the depressidu, or on a line drawn from the middle of the bend of the 
 elbow to the inner side of tiie styloid ])r(icess of the radius, dividing tlie 
 skin and sin)erficial fascia ; divide the deep fascia on a director; flex the 
 arm slightly to relax the muscles; the supinator longus being drawn 
 aside, the sheath of the artery is exposed ; pass the needle from Mithout 
 inward. 
 
 (h) In its lower third the artery is sujierficial, lying between the 
 tendons of the supinator longus and the flexor carpi radialis ; it is accom- 
 panied by vena^ eomitcs and by tlie radial nerve, wiiich lies external ; 
 its |)ulsati(m is easily detected (Fig. 244). The arm held su])ine, the 
 hand forcibly extended to make prominent the flexors, and the operator 
 standing on the external side of the limb, make a light incision two 
 inches in length, from half an inch above the articulation of the radius, 
 on the external border of the flexor caqii radialis, or on a line joining 
 the external with the three internal fourths of the arm; the dee]) fascia 
 is raised on a director, exposing the artery with its two veins, and the 
 
760 
 
 OPEEATIVE srnOERY. 
 
 l'(IR' IIKIV !)(' 
 
 pa; 
 
 sed in citlier dir 
 
 rcc- 
 
 Radial artery at the wrist. 
 
 nerve, external and posterior ; tlie nci'( 
 tiou. 
 
 ((•) On the dorsum of tlie wrist (Kig. 24'2) the artery passes in the 
 
 groove between the up])er extremi- 
 ties of the first metacarpal bones ; 
 a fibrous band separates it fi-om 
 the tendons of the thunil). It may 
 be tied just as it is about to form 
 the palmar arch, or as it passes 
 under the extensor muscle of the 
 tliumlj, between the extensor primi 
 internodii and tlie extensor secundi 
 internodii pollicis, a little below 
 and posterior to the extremity of 
 the styloid process of the radius. 
 Make an incision an inch in length 
 along; the outer borders of the ex- 
 tensor secundi and metacarjii pollicis, at the angles formed by the two 
 first metacarpal bones, care being taken not to wound the sujierfieial 
 veins ; the artery is readily cxjiosed. At the higher jioint ])lace the hand 
 between pronation and supination, the thumb strongly abducted so as to 
 render prominent the extensors, and make an incision an inch in length 
 between the tendons of the two extensors, commencing at the lower 
 extremity of the radius and in the line of the axis of the first metacarpal 
 bone ; makes these incisions lightly, to avoid the superficial vein of the 
 thunil); draw the extensor ossis metacarpi pollicis, a, inward, and the 
 extensor secundi internodii pollicis, d, outward ; expose the artery, c, 
 and its accompanying veins, b. 
 
 The ulnar arfcri/ is indicated by a line drawn from the internal tuber- 
 osity of the OS brachii to the external side of the pisifiirni bone, (a) In 
 its upper third the ulnar artery curves inward deeply liencath the fiexor 
 muscles, and passes along the ulnar side of the forearm, between and 
 covered by the ilexor carpi ulnaris and flexor sublimis digitorum ; it is 
 accompanied by two veins and by the ulnar nerve, which is more super- 
 ficial and internal (Fig. 24.3). The forearm being supine, the hand 
 
 extended and inclined to the radial side, make 
 an incision on the imaginary line given, three 
 inches in length and l)egiiining three fingers' 
 breadth below the internal condyle through 
 the skin and superficial fascia, and recognize 
 the aponeurotic connection of the flexor carpi 
 ulnaris and flexor sublimis, which is of a 
 yellov>ish-wliite color ; divide it on the direc- 
 tor from lielow, where it is the most delicate, 
 carefully avoiding the division of muscular 
 substance ; the flexor sublimis, a, is drawn 
 outward, and the deep aponeui-osis exposed, 
 under which lies the artery ; if the vessel is 
 not seen, press the flexor carpi ulnaris, e, inward, and expose the ulnar 
 nerve, b, a little external to which lies the arter}-, e, ^^•ltll its two veins, 
 
 Fig. 243. 
 
 abed e 
 The ulnar artery in its upper third. 
 
LIGATURE OF ARTERIES. 
 
 761 
 
 d ; isolate the artery by Hexing- the arm slightly and the hand strongly ; 
 pass the needle from \vithoat outward. 
 
 (6) In its lower third the artery is superficial, iiaving upon its inner 
 side the flexor carpi ulnaris and ulnar nerve, and upon its external side 
 the flexor sublimis digitorum. Place the arm supine and extend the 
 liand so as to make prominent the tendon of the flexor carpi ulnaris ; 
 then along the radial border of this nniscle (Fig. 244), or at the union 
 
 Fig. 244. 
 
 Fig. 245. 
 
 Ligature of the radial and iilnar arteries at the lower third. 
 
 of the external four-fifths of the arm with tlie internal fifth, or on a line 
 drawn from the internal condyle to the pisiform bone, make an incision 
 about two inclies in lengtii through the skin and subcutaneous cellular 
 tissue ; raise the deej) fascia on a director or with the forceps, and incise 
 it, exposing the tendon of the flexor carpi 
 nhiaris ; this should be pressed inward, and 
 immediately behind it the artery will be 
 found with its two accompanying veins, and 
 the nerve upon the inside. 
 
 {(■) At the wrist (Fig. 245) the artery lies 
 to the radial side of the pisiform bone, and 
 is accompanied by its veins, b, and the ulnar 
 nerve, c, which lies on its internal and ])os- 
 terior aspect. The hand being held back, 
 make a slightly curved incision on the radial 
 side of the pisifijrm l^one, through tlie skin 
 and adipose tissue, about three inches in 
 length, its concavity looking inward ; the 
 artery, o, is dee})ly seated in a groove, and the dissection should be con- 
 tinued along the side of tlie pisiform bone until it is exposed : the latter 
 part of the dissection will be facilitated by flexing the hand upon the 
 forearm ; pass tiie needle beneath from within outward. 
 
 The SHpcj-firial palmar arch is tiic continuation of tiie ulnar artery 
 into the hand (Fig. 24(j). Near the lower border of the annular liga- 
 ment tills artery turns oblicpiely outward across the palm of the hand 
 toward tiie middle of tiie muscles of the thumb, where it inosculates with 
 a small branch of the radial, the superficialis volse. At its commence- 
 ment it rests on the annular ligament of the wrist and slightly on the 
 siiort muscles of the little finger, then on the tendons of the superficial 
 flexor of tlie fingers aii<l the divisions of tlie median and ulnar nerves, 
 tlie latter nerve acconii>aiiyiiig the vessel for a short distance ; it is cov- 
 
 a h c 
 Ulnar artery at the wrist. 
 
702 
 
 OPERATIVE SURGERY. 
 
 ci'cd townnl the ulnar hordcr i)f tliu hand hy tlic palmaris brcvis and the 
 [lahnar tiiscia and intcgnmcnt. The central purtiun of a transvei'se line 
 ilrawn across the palm, from the angle of the web between the thumb 
 
 Fig. 247. 
 
 Fic). 246. 
 
 Position and mode of formation of the 
 palmar arches and distribution of 
 the digital arteries. 
 
 Lines of incision : .4, line indicating convexity of 
 arch ; A', line of incision for arch : B, line indi- 
 cating the cubital branch of the arch ; B', line 
 of incision for this branch ; PI, inferior palmar 
 fold (Chalot). 
 
 and index finger, corresponds pretty accurately with the position of the 
 middle of the superficial palmar arch ; if tlie tliumb be abducted, its 
 anterior surface is continuous in direction with the ])almar outline of the 
 ball of the thumb, which will then become parallel to the middle palmar 
 fold ; the vessel lies jjarallel to and equidistant between them (^NlacCor- 
 mac). Make an incision one inch long midway between and parallel to 
 these lines, and nearly opposite to the bases of the middle and ring 
 fingers ; divide the skin and palmar fascia, and the arch will be brought 
 to view at the thicker part of the ulnar artery (Fig. 247). 
 
 ARTERIES OF THE LOWER EXTREMITY. 
 
 The abdominal aorta lies in front and a little to the left side of the 
 bodies of the vertebme, having the vena cava on its right side, the sym- 
 pathetic nerve on its left, and the left lumbar veins behind ; it divides 
 on the lower part of the fourth lumbar vertebra at a j)oint nearly corre- 
 sponding to the uml)ilicus ; it may be ligated about one inch above its 
 bifurcation, between it and the origin of the mesenteric. It can be ex- 
 posed and successfully ligated by the operation for the common iliac : 
 the artery being separated from the vein, with the finger or a director 
 pass the needle from right to left. Or make an incision along the linea 
 alba three inches in length, the middle of it on a level with the umbil- 
 icus, but a little to the left ; open the peritoneum ; push the intestines 
 aside ; detect the artery by its pulsations ; separate the ])critoneal cover- 
 ing with the finger-nail on the left side, carry the finger under the vessel 
 
LIGATURE OF ARTERIES. 
 
 763 
 
 and pass the needle ; or make an incision from the extremity of the tenth 
 ril) downward six inches, curving Ijackward to Mithin an inch of the 
 anterior spine of the ilium, Q (Fig. 24S), and reach the aorta from the 
 side bv raising the peritoneum. All the antiseptic precautions of peri- 
 toneal section must be enforced. 
 
 The common iliac, artery (Fig. 248) varies from three-quarters of an 
 
 Fig. 2-18. 
 
 The common iliac. 
 
 inch to three inches in length, averaging about two ; it passes from the 
 bifurcation of the abdominal aorta on the left side of the body of the 
 fiurth lumbar vertebra, a point corresponding with the left side of the 
 nnil)ilieus, on a level with a line drawn from one crista ilii to the other, 
 <l(iwnward and outward along the margin of the pelvis to the sacro-iliac 
 svnchondrosis ; the artery upon the right side is on an average the same 
 length as that upon the left, and has in front the peritoneum and at its 
 point of division the ureter. The following method of operating is now 
 to be preferred : Provide large flat aseptic sponges, small sjjonges with 
 sjionge-liolders, hot sublimate solutions for douche, spatulte, and an aneu- 
 rism needle armed with a carbolized silk or catgut lig-ature ; cleanse the 
 surtace of the abdomen and empty the bladder. Make an incision in 
 the median line four inches in length, commencing at the symphysis, 
 through the superficial tissues down to the linca alba ; ligate all bleeding 
 vessels ; open this aponeurosis at the upjier end of the incision cautiously 
 bv raising a fold with forceps and cutting witli the point of the knife ; 
 divide it throughout on the director; in the same manner incise the 
 transversalis fascia, thus exposing the ]ieritoneum ; raise a fold of the 
 peritoneum with foreejjs and open it with the point of the knife, and 
 then enlarge the opening on the fingers. Now, with tlie flat sponges 
 wrung out of liot bichloride solution, push the intestines gently upward 
 until tlic region of the artery is fidly ex])osed ; if the intestines are so 
 distended that they cannot be pushed U])ward out of the way, draw them 
 gently out of the wound upon the abdomen, first covered with towels 
 wrung out of the hot sublimate solution, and keep them covered with 
 the hot sponges. Drawing the side of the wound toward the artery 
 with a spatula, the vessel will be fully exposed; avoiding the ureter, 
 pick up the sheath of the artery with forceps; open it with the point of 
 
764 
 
 OPERATIVE SUIiGERY. 
 
 tlif knife on the inner aspcrt and niifover the vessel ; pass tlic needle 
 fVoin within ontward. After ligating the artery ent the ends of the liga- 
 ture ; with tlie small sponges remove tlie idood, if tliei'e is any, from the 
 eavity ; return the bowels gently with as little manipulation as possible. 
 
 If the operation be performed without opening the peritoneum, pur- 
 sue the following method : The i)atient being ])laced on the itack (Fig. 
 '248), inclining to the opposite side, make an incision, n, eonuuencing just 
 anterior to the t'xtremity of the eleventh I'ib downward, one and a half 
 inelus within tile anterior su})erior spine, and terminating just al»ove the 
 internal ring liy a sharp curve upward and inward of an inch ; the entire 
 length is about seven inches ; divide the integuments and superticial 
 fascia ; then the three abdominal muscles ; cautiously raise the fiiscia 
 transversalis from the peritoneum, first at the u])per part of the wound 
 where the union is slightest; now gently elevate tlie peritoneum and 
 press it inward from the iliac fossa toward the pelvis; the ])nlsations of 
 the external iliac, f, arc first recognized, and the finger carried upward 
 along this vessel reaches the common trunk ; the ureter, H, in front is 
 carefully pushed aside, and the needle jiassed from within outward. 
 
 The interndl iliac (trfer//, e (Fig. 248), is an inch and a half in length, 
 extending from the bifurcation of the common iliac downward and for- 
 ward to the upper margin of the great sacro-seiatie foramen ; it is in 
 relation anteriorly with the ureter, ii, which se])arates it from the perito- 
 neum ; posteriorly with the internal iliac vein ; it rests on the sacral 
 
 Fig. 249. 
 
 Position nnd direction of tlie superficial incisions which must be made to secure the gluteal artery 
 and the sciatic or pudie arteries: A, posterior superior iliac spine: B, great trochanter; C\ 
 tuberosity of the ischium; />, anterior superior iliac spine. 
 
 Aj B, ilio-trochanterlc line, divided into thirds. This line corresponds in direction with the fibres 
 of the gluteus niaximus muscle. The incision to reach the gluteal artery is indicated by 
 the darker j.urtii.n of the line. Its centre is at the junction (it the ui'iier withtlie middle third 
 of the iliO'trochanteric line, and exactly corresponds with the point of emergence of the 
 gluteal artery from the great sciatic notch. 
 
 -1, (\ iiio-ischiatic line. The incisitm to reach the sciatic artery, or internal pudic, is indicated by 
 the hiwer dark line. It is also tn be made in the direction of the fibres of the gluteus maximus 
 muscle. The centre of the wound corresponds to the junction of the lower with the middle 
 third of the ilio-ischiatic line. 
 
 plexus of nerves and the pyriformis muscle ; on the left the rectum lies 
 ])artially over it. The artery may be exjiosed and ligatcd by the methods 
 described in the operation on the primitive iliac. 
 
 The gluteal artery emerges from the ])clvis at the upper part of the 
 
LIGATURE OF ARTERIES. 
 
 765 
 
 Fig. 250. 
 
 Ligature of gluteal artery. 
 
 great i.'^c-hiatic notch, above tlie ui)per border of the pyriformis mu.scle.s. 
 A line drawn from the posterior superior spine of the ilium to the top 
 of the great troehanter marks the course of the artery (Fig. 249). In 
 the oi>eration (Fig. 250) place the patient in a prone position ; make an 
 incisiiin on the line above indicated four or iive inches long, terminating 
 about an inch and a half from the spine ; the cut is 
 parallel with the fii)res of the gluteus maximus, 
 which should be separated, and the finger intnxlueed 
 to detect the pulsations of the artery ; separate the 
 pvriformis and gluteus medius muscles, the borders 
 of ^v•hich cover the vessel, and isolate the artery 
 from its veins, and pass the needle as deeply as 
 possible, as the artery divides just after its emerg- 
 ence. 
 
 The sciatic artery escapes from the pelvis between 
 the jivriformis and coccygeus muscles, and descends 
 in tiie interval between tiie trochanter major and 
 tuberosity of the iscliium. It is covered by the 
 gluteus ma.Kimus, and is accompanied by the sciatic 
 nerve and the vein which lies to its posterior and 
 inner side ; the centre of a line drawn from the 
 posterior superior spinous process of the ilium to 
 the tuberosity of the ischium marks the point of exit of the artery from 
 the pelvic cavity. The patient being jirone, make an incision four 
 inches in length, the centre of wliich falls upon the jioint of emergence 
 of the artery, as given above (Fig. 249) ; divide the skin, cellular tissue, 
 and the fibres of the gluteus maximus ; the artery is found to the inside 
 of the nerve, and must be carefully isolated from the vein. 
 
 The internal pudic artery, the smaller of the two terminal branches 
 of the internal iliac, ])asses out of the pelvis through the great sacro- 
 .sciatie foramen, internal to the sciatic artery ; it again enters the pelvis 
 through the lesser sacro-sciatic foramen, runs 
 along the I'amus of the ischium and pubis, 
 and divides into the arteries of the penis. 
 
 {a) At the greater saero-sciatie foramen 
 make the same iucisi(jn as in the ligature of 
 the sciatic artery ; the pubic is found a little 
 internal, accompanied by its veins and the 
 pudic nerve. 
 
 (Ij) In the perineum (Fig. 251) the artery 
 may be ligated as it descends the ramus of 
 the ischium ; draw a line from the middle 
 of the puljcs to the internal Ijorder of the 
 tuber ischii. The pirtient being placed in 
 the position for lithotomy, make an in- 
 cision two inches in length along the ramus 
 of the pubis, near the arch ; the vessel is 
 
 found along the inner border of the ramus, Ligature of hii.mni i.u.iio artery. 
 where it may be isolated and the ligature 
 applied; care .should be taken not to incise the corpus cavernosum. 
 
 The external iliac artery (Fig. 252), fmr inches in length, passes ob- 
 
 FiG. 2.51. 
 
766 OPEnATIVE SURGERY. 
 
 licjiK'lv (lowmvard niid out WMrd IVoni the saoro-iliac symphysis to Pou]iai't's 
 litiaiiicnt, in a lint' drawn from the left side of the umbilicus to a point 
 midway between the anterior supt^rior spine of the ilium and the symphysis 
 pubis. In its u]iper jiortion it has in front the peritoneum and intestines, 
 and near Pou])art's liiiaiiient the s])ermatic vessels, genito-erural nerve, cir- 
 cumflex iliac vein, lyinpliatie vessels and li'lands ; externally, tlic jisoas mau- 
 nus, from wliich it is separated by the: iliac fascia ; internally, the external 
 iliac vein ; below and curving;; along its side, the vas deferens ; behind, it 
 rests above upon the external iliae vein, which gradually ])asses to its 
 internal side. Place the jjatient in a recumbent position, the muscles 
 relaxed by elevation of the jx'lvis; make an incision three or four 
 inches in length, commencing about an inch and a half within the 
 anterior superior spine of tlie ilium and on a level with tliis ])rocess, and 
 extending in a curved direction downward and inward nearly ])arallel 
 with Poupart's ligament, and terminating an inch and a half above it, 
 just outside of the external abdominal I'ing. On the left side it will be 
 found convenient to eonnnencc tiie incision internally, at the externa! 
 ring and carrv it upward and outward to the point indicated within 
 the anterior superior sjiine. Incise the integuments and fascia, care- 
 iully av(_)iding the superficial epigastric artery ; the aponeurosis of the 
 
 Fig. 252. 
 
 Ligature of right external iliac artery (mndiUccl Cooper's method) : A, aponeurosis of externaloblique: 
 B, conjoined tendon ; C, internal' oblique ; D, transversalis fascia; £, peritoneum ; a, est. iliac 
 artery ; b, est. iliac vein ; c, deep epigastric artery (Treves). 
 
 external oblique muscle is now exposed and divided on a director ; in 
 the same manner divide the tibres of the internal oblique and tran.s- 
 versalis muscles until the transversalis fascia, recognized by its white 
 opaque ap})earancc, is exposed ; cautiously open this membrane and 
 incise on the director; the peritoneum is now exposed and carefully 
 detached from the iliac fossa, and pushed toward the pelvis ; the artery 
 is readily felt pulsating at the bottom of the wound, along the inner 
 border of the psoas muscks the vein being on the inner aspect, the 
 o-cnito-crural nerve external ; open the sheath and insinuate the needle 
 from within outward to avoid the vein. Or the finger may be passed 
 
LIGATURE OF ARTERIES. 
 
 mi 
 
 Fig. 253. 
 
 into tlio internal ring along- the sperniatie eord and the iliac fascia rai.sed 
 in tills manner. Other incisions are made in the course of tjie artery 
 (Fig. 248, a), tliree inches in lengtli ; a curved incision (Fig. '248, c), 
 commencing a little above the spine of tiie ileum, and terminating a 
 little above the internal edge of the inguinal ring ; an incision (Fig. 
 248, b) in the centre of the space between the interior spine and the 
 symphysis pubis. 
 
 'V\w femoral aiienj extends from Poupart's ligament to the tendinous 
 opening in the adductor magnus nuiscle, at the junction of the middle 
 and lower tiiird of the thigh, in a line drawn midway between the ante- 
 rior superior spine of the ilium and the symphysis pubis and the inner 
 .side of the internal condyle. 
 
 (ii) Tile common femoral artery extends from Pou])art's ligament to 
 the origin of the dee]) femoral, about one iiu'li and a half. It is super- 
 ficial, lieing covered by the skin, supi'rticial and deep fasciie, and lym- 
 phatic glands ; the vein lies on its inner side, and the anterior crural 
 nerve half an inch to its outer side ; the vessels lie in a canal formed 
 by the parting of the two layers of the fascia lata, and are separated by 
 this septum. Half or three-quarters of an inch below Poupart's liga- 
 ment will be the most favorable locality for ligature (Fig. 253). The 
 pulsation lieing recognized midway between the 
 anterior superior spine of the ilium and the 
 pubes, make an incision two inches in length 
 over the artery, commenc-ing over Poupart's 
 ligament ; divide the skin and cellular tissue ; 
 raise the fascia on a director and expose the 
 sheath ; open it, and examine iov the origin of 
 the profunda and epigastric ; draw the vein in- 
 ward and pass the needle around the artery 
 from within outward, ligating it above the pro- 
 funda femoris. The incision has been made 
 parallel with Poupart's ligament. In persons 
 of ordinary Hcsh the fold of the groin corre- 
 .sponds exactly with Poupart's ligaineiit, but in 
 thos(> who are very fleshy the fold is somewhat 
 below Poupart's ligament, and should this be 
 taken as the guide to the commencement of the 
 incision, there would lie danger of applying tlie 
 ligature just below tile origin of the profunda ; 
 it is advisalilc to bring the ligament into view 
 before the ligature is applied, and to pass the 
 needle a finger's breadth below. 
 
 (b) The superficial femoral artery lies in a 
 ti-iaugle, Scar])a's space, formed by Poii]iart's 
 ligament above as its base, the sartorius exter- 
 nally, and the adductor brevis internally ; it is very superficial, lieing 
 covered by integument, the superficial and dee]) fasciae, and lymphatic 
 glands ; the vein is on the inner and slightly |)osterior jiart (Fig. 254). 
 Abduct and })lace the thigh on its external asjicct ; make an incision, 
 commencing about four inches below Pou])art's ligament, along the inner 
 margin of the sartorius muscle, three inches in length ; the saj)henous 
 
 p, - 
 
 1- 
 D- 
 
 Ligature of right common fem- 
 oral at base of Scarpa's tri- 
 angle : A, line of Poupart's lig- 
 ament; /?, superficial fascia: C, 
 fiiscia lata; D, sheath; a, fem- 
 oral artery ; b, femoral vein : c, 
 internal saphenous vein; 1. 
 yeuito-erural nerve (Troves). 
 
■768 
 
 OrmiA TIVE STJRGER Y. 
 
 Fig. 254. 
 
 vein, first made prominent by pressure above, is left to the inner side; 
 divide tiie i'aseia lata, a, expose and draw outward the sartorius, h, and 
 
 the sheath of the vessels beeomes ap- 
 parent ; the position of the artery is 
 recognized by its pulsations; open tlie 
 sheatii to a suffieient extent, and then 
 pass the needle, very eautiously, from 
 within outward to avoid the vein, c ; 
 tlie point of the needle should be kept 
 close to the artery, </, as the vein lies 
 , closely on its inner and posterior 
 aspect. If the saphenous vein is 
 wounded, compression is sufficient for 
 itstreatment : if the incision fallsujmn 
 the sartorius, this mustbedrawn aside, 
 (c) The portion of the femoral 
 artery at the apex of Scarpa's space 
 (Fig. 255) is covered by the skin, superficial and deep fascire, and sar- 
 torius, and is contained in a fibrous canal ; the femoral vein lies on the 
 
 outer and posterior part of the 
 artery, and the long saphenous 
 nerve more externally. Place the 
 limb in position, and make an in- 
 cision three or four inches in length 
 at the middle of the thigh, on the 
 line given or on the inner l)ordcr 
 of the sartorius muscle, its upper 
 extremity being six lines, and the 
 lower two lines, from the internal 
 
 Fig. 256. 
 
 Femoral artery in Scarpa's space. 
 
 Fig. 
 
 B-- 
 
 Ligature of right femoral artery at apex of 
 Scarpa's triangle: A, fascia lata; B. sarto- 
 rius; C, adductor longtis; />, sheath of ar- 
 tery ; a, femoral artery ; 6, tributary to inter- 
 nal sai:)henous vein ; 1, long saphenous 
 nerve ; 2, internal cutaneous nerve (Treves). 
 
 The left femoral artery in Hun- 
 ter's canal : .s, sartorius drawn 
 inward ; /, fascia closing the 
 canal, opened freely; o, the 
 artery, with a small opening 
 iu its sheath for the passage of 
 the needle ; s.n, long saphe- 
 nous nerve. 
 
 border of that muscle, care being taken to avoid the internal saphenous 
 vein, the course of which is made apparent by compression al)ove ; expose 
 
LIGATURE OF AETEPdES. 
 
 769 
 
 the sartorius by dividing the f;wcia lata ; draw it outward ; expose and 
 divide tiie fibrous connection between tiie vastus and adductor muscles ; 
 the sheath of the vessel now appears, wliich is readily opened, and the 
 needle passed from within outward, avoiding the vein and long saphenous 
 nerve. 
 
 [d) At the inferior part of its course the femoral artery enters a 
 fibrous sheath formed by the fibrous bands which extend from the 
 vastus internus to the adductor magnus and longus, having over it the 
 sartorius muscle, fascia\ and integuments (Fig. '2o(J). Flex the thigh on 
 the pelvis, the limb resting on its external surface ; make an incision 
 three inches long on the outer margin of the sartorius innscle, if recog- 
 nized, or on the line above given ; the skin being divided, the sartorius 
 recognize<l, and the fascia divided on a director, two lines within its 
 external i^ordei, draw the muscle backward and divide the posterior 
 part of its sheath ; the s]iace between the vastus internus and adductor 
 magnus is now recognized, which contains the canal of the artery; open 
 this canal on a director, and the artery is exposed, with the vein on its 
 inside and the saphenous nerve on the outside ; the vessels are united by 
 very dense cellular tissue, and great cai-e is necessary to isolate the artery. 
 The poji/ifcnl nderji extends from the o]iening in the adductor mag- 
 nus to the lower boixler of tiie po])liteus nuiscle, in an oblique direction 
 downward and outward. In the popliteal space the 
 external saphenous vein runs per])endicularly in the 
 median line ; the popliteal nerve passes down the 
 middle of the popliteal space, superficial to, and on 
 the outside of, the jxipliteal vessels, from which it is 
 separated by adipose tissue ; the popliteal artery is 
 covered in its whole course, and crossed at the middle 
 of the popliteal space, by the popliteal vein, the di- 
 rection of which is vertical ; the artery, always be- 
 neath the vein, is somewhat internal to it above and 
 external to it lielow ; the vessels are covered supe- 
 riorly by the Ijclly of the semi-membranosus ; below, 
 tlicv pass between the two heads of the gastrocnemius. 
 They are connected tiigether, thi'oughout their course, 
 by dense cellular tissue, which renders their separa- 
 tion difficult. 
 
 (a) In its upper part make an incision three inches in length, from 
 the infi'rior third of the thigh and passing along the external margin of 
 the semi-meml)ranosus muscle ; divide the skin and fascia ; separate the 
 cellular tissue with the director and finger ; now flex the leg, and the 
 nerve first appears, then the vein on its inside, and lastly the artery ; 
 pass the needle from within outward. 
 
 (b) In its lower part (Fig. 2-")S) the ])nti<>nt is laid on his face, and an 
 incision made througii the integument three inches long, slightly nn the 
 outside of the median liiie ; the external saphenous vein, c, which lies 
 under the skin, is carefully avoided ; the fiiscia, J, is divided, and the cel- 
 lular substance in the space between the two heads of the gastrocnemius 
 is separated with the finger, exposing the popliteal nerve, 1, the vein, h, 
 and most external, the artery, <i ; the nerve and vein are drawn inward, 
 and the needle is passed from witiiin outward. 
 
 Vol. I.— 49 
 
 Left popliteal artery : .1, 
 popliteal artery ; 1', 
 vein ; N. internal pop- 
 liteal nerve ; M, biceps 
 muscle. 
 
770 
 
 OPERATIVE SURGERY. 
 
 Fig. 258. 
 
 The poderior tibial artery, a hraiicli of the popliteal artery, extends 
 from the lower boi'dcr of the poj>liteus muscle, in an obliipie direction, 
 
 from Avithout inward to the annular lijja- 
 nient ; its course is in a line commencing in 
 the centre of the ])opliteal sjiacc and termi- 
 nating behind the internal malleolus. 
 
 («) In its upper third the artery is 
 covered by the tibialis posticus, the deep 
 aj)i)neurosis, the soleus, and the gastrocne- 
 mius. The liml) Ijcing |)laced on its outer 
 side, the knee Hexed, make an incision at 
 least four inches in length, at a distance of 
 ' two-thirds of an inch from the internal 
 J3 border of the crest of the tibia through the 
 integuments and deep fascia ; carry tiie in- 
 dex Hngcr into the wound, detach and push 
 (lutward the internal head of the ga.stro- 
 cnemius, and divide also the attachments 
 of the soleus, thus exposed, from the pos- 
 terior surface of the tibia ; whilst an as- 
 sistant keeps this muscle held backward 
 and outward with a blunt hook, divide tlie 
 deep layer of aponeurosis u})on a director, 
 "i^faseia*-'i'gas?roJnt^^^^^ and search for the vessel immediately _be- 
 
 iiteai artery; b, popliteal vein; c, neath ; dctach the artery, and pass the liga- 
 
 external saphenous vein; 1, inter- , ,i., •,!,!, ii 
 
 nai popliteal nerve; 2, muscular ture ueucatli it witli the artery needle. 
 
 branches; 3, external saphenous ^^^ j,j j^^ ^^^jj^ij^ ^j^j^.^l ^|-^. .,,,j^,,,^, ^^^^^ 
 
 parallel with the inner border of tiie tibia, 
 from which it is separated by the flexor longus digitorum ; it is cov- 
 ered by the internal border of the soleus, it has venae comites, and 
 the posterior tibial nerve is on its inner side. The limb is placed as 
 in the last position, and an incision made three inches in length, three- 
 fourths of an inch posterior to the internal border of the tibia ; the 
 integument and deep fascia being divided, the fore border of the gastro- 
 
 FiG. 259. 
 
 Divided tibial origin uf 
 soleus. 
 
 Ligature of the posterior tibial artery in its middle third. 
 
 cnemius is seen and drawn backward, exposing the soleus ; the fibres of 
 this muscle should be divided on a director ; the arterj- is now felt pul- 
 
LIGATURE OF ARTERIES. 
 
 ■71 
 
 sating about an inch from tlio maririn of'tlu' tibia ; the pcarl-colorcd deep 
 aponeurosis which overlies is divided, and then the muscles relaxed bv 
 the position of the limb ; the artery is isolated from its veins, the nerve 
 being pressed to the outside ; the needle is passed from M'ithout inward 
 (Fig: 259). 
 
 (c) In its lower third the artery passes behind the internal malleolus, 
 at first parallel with the tendo Aehillis, and then midway between tiie 
 internal malleolus and the tuberosity 
 of the OS calcis ; it is very superficial, 
 and is in relation anteriorly with the 
 tendons of the tibialis posticus and 
 flexor longus digitorum, and poste- 
 riorly witii the jiosterior tibial nerve ; 
 it has vena> comites (Fig. 260). The 
 leg being placed on its external aspect, 
 the foot Hexed, make an incision, two 
 inches in length, a finger's breadth 
 posterior to the inner edge of the 
 tibia and parallel with it ; the integu- 
 ments are divided ; the deep fascia 
 raised on a direct<ir, and a small mass 
 of fat opened, which will expose the 
 artery and the veure comites and the 
 jMjsterior tibial nerve ; the sheath of 
 tendons should lie carefully avoided ; it should be noticed that the artery 
 ,sometin\es lies anterior to the incision here given. The artery may be 
 ligated a little lower by making a curved incision 
 one-third of an inch behind the external malleolus. 
 At this part of the leg the anastomoses of large 
 branches of the internal saphenous vein are numer- 
 ous, and generally run transversely ; these may be 
 brought out by compressing the trunk of the vein 
 above, and thus be avoided, at least in part. 
 
 The anterior tibial artery emerges upon the an- C 
 terior part of the leg, at its upper ]iart, through the i 
 interrosseoiis membrane, about the level of the lower 
 margin of the tubei'osity of the tibia, and passes 
 down to the ankle, in a line drawn from the inner 
 side of the fibula to a point midway between the 
 two malleoli ; the anterior tibial nerve is closely 
 applied to the outside of the artery throughout ; it 
 may be ligated at any jioint in its course. 
 
 (a) In its upper third ( Fig. 2(51) the artery lies be- 
 tween the til)ialis anticus and extensor lontrus diffi- 
 torum, which have their origin in part from the deep 
 fascia, hence the intermuscular septum is not easily 
 recognized, nor are the muscles readily separated. 
 The limb being turned inward and the foot ex- 
 tended, take as a guide the line already given, or 
 a point ten lines to tiie outer side of the spine of the tibia, and make an 
 incision about four inches in length through the integument ; divide the 
 
 Ligature of posterior tibial artery behind 
 inner malleolus. 
 
 Fig. 261. 
 
 -I) 
 
 A — 
 
 Ligature of right anterior 
 tibial artery (upper third) : 
 A, faseia of leg: B, tibialis 
 antieus ; C, extensor com- 
 munis digitorum ; a, an- 
 terior tibial artery ; b, an- 
 terior tibial veins ; 1, an- 
 terior tibial nerve. 
 
772 
 
 OPERATIVE SURGERY. 
 
 (k'Cj) fascia witli a crucial incision to allow of its complete sejjaration ; 
 the intcrniiisciilar so])tuni is now sought for, and may he recognized : (1) 
 as the first intermuscular space from the tit)ia ; (2) on ])ressure from witliin 
 outward l)y tlie resistance of tlie other nuiscles ; (."]) by tlie fact tliat at 
 the lower part of tlie wound the wliite line of tlie muscular interspace is 
 more marked. Tiie foot being flexed, separate tiie nuiscles with the index 
 finger, and, the wound being held apart, expose the artery with its two 
 veins and nerve, the latter being outside ; pass the needle from without 
 inward, avoiding the nerve. 
 
 (//) In its middle third tlie artery is covered by the deep fascia; 
 on the inner side it has tiic tibialis anticiis muscle, and on the exter- 
 nal the extensor longus digitorum and extensor ])roprius pollicis (Fig. 
 2(32). The limb being placed as in the former ])osition, make an 
 incision three inches or more in length in the course of the artery, as 
 above given ; the septum in the deej) fascia 
 uniting the two nuiscles is recognized by a 1"'ig. 26S. 
 
 white line ; divide it longitudinally and also 
 by a crucial incision ; flex the foot to relax <, 
 
 the muscles, and, the wound being separated ;' 
 
 by drawing the tibialis anticus, 6, internally \ \ 
 
 and the extensor longus digitorum and 
 extensor projirius pollicis externally, the 
 nerve is met with more superficially than the 
 arter}', rl, with its veins, c ; pass the needle 
 from within outward, avoiding the nerve, 
 (c) In its lower third (Fig. 263) the artery 
 
 Fig. 262. 
 
 Anterior tibial artery in its middle third. 
 
 Ligature of right anterior tibial 
 artery (lower third) : A, anterior 
 annular ligament; B, tibialis 
 anticus : C, extensor proprius 
 pollieis; a, anterior tibial ar- 
 tery ; 6, anterior tibial veins ; 1, 
 anterior tibial nerve. 
 
 is covered bv the fascia, and is crossed by the extensor jiroprius pollicis ; 
 it lies at first between the tibialis anticus muscle and the extensor pro- 
 prius pollicis, the latter muscle crossing to the inner side ; the artery lies 
 between the tendon of this muscle and that of the extensor longus digi- 
 torum ; it is accomjianicd by vense comites and the anterior tibial nerve, 
 which here lies to the outer side. The leg being jtlaced in a horizontal 
 position, the foot extended, and the tibialis anticus nuiscle recognized, 
 make an incision along the external border of that muscle, on the line 
 already indicated, three inches in length, but not extending to the annu- 
 lar ligament ; carefully incise the deep fascia on a director, and find the 
 space between the . tibialis anticus and extensor jjroprius pollicis, and 
 
RESECTION OF BONES. 
 
 773 
 
 separate the two muscles with the index fingei- ; now flex the foot, and 
 ex]iose the arterv restino; on the tibia with the nerve snjierficial to it ; 
 isolate it from the two veins, and ]>ass the needle from witiiin outward, 
 the nerve being drawn iuward. if the incision falls between the exten- 
 sor proprius poUiois muscle aud the extensor couununis digitoruni, the 
 ligature may still be applied. 
 
 The dorsalis pedis artery terminates the anterior tibial, and runs in 
 a line drawn from the middle of the intermalleolar space, measured 
 from tlie extremities of the malleoli, to the space between the first meta- 
 tarsal l)oues. It is covered by the integuments, fascia, and innermost 
 tendon of the extensor brevis digitdruni ; ou its iuner side is the exten- 
 sor proprius poUicis, and externally, the inner tendon of the extensor 
 longus digitoruni ; on its external aspect is the anterior tibial nerve. 
 Make an incision (Fig. 264) two or three inches in length parallel to the 
 
 Fig. 264. 
 
 Exlensor 
 
 brevin digitoruuiTjf^' 
 muscle. 
 
 external border of the tendon of tiie extensor proprius pollicis muscle ; 
 divide the skin and deep fascia on a director, and draw the internal 
 division of the extensor brevis digitoruni outward, exposing tiie arterv 
 and its accompanying veins ; the nerve is on the outside ; pa.ss the needle 
 from within outwanl. 
 
 The Resection op Bones. 
 
 Resection of a bone, in part or wiiolc, is required after injuries which 
 have destroyed its vitality, or after diseases which have resulted in caries 
 or necrosis, or in the removal of tumors ; but the oi)eration is justifiable 
 only when it is evident that resection is preferable to every othei" 
 remedial measure. When inidertaken it must be so planned and 
 executed as to become tiie first step in a process of repair by which 
 
774 
 
 OPERATIVE SURGERY. 
 
 a part that would otherwise have been sacrificed is restored to more or 
 less cdinplete nsefiihiess. Tiie operation must be determined by the 
 cimdition of tlie ]iatient and of tlie diseased part. As a rule the opera- 
 tion is indicated only wlien the fryneral hcaltli admits, for if the patient 
 is suti'ering from a progressively wasting disease, as tuberculosis or 
 marasmus, which will necessarily prove fatal, resection would be unwise, 
 as repair would not follow. In injuries, as gunshot, only such frag- 
 ments of bone should be removed as are nearly or fpiite detached from 
 the periosteum. In caries of a hollow bone the ulcer may be tlioroughly 
 cleaned out witli the gouge and the cavity be allowed to close by gran- 
 ulation, but if the bone is small extirpation may be necessary to arrest 
 the process at once. If a hollow bone is affected throughout, as with 
 periostitis, external and internal caries, or partial internal and external 
 necrosis, extirpation of the entire bone may be required as the only 
 alternative of amputation. Tumors of bone, if not malignant, must be 
 removed from their locality, but if malignant, extirpation of the bone 
 or wide resection is necessary. 
 
 Resection of a joint is necessary for such shot injuries as the commi- 
 nution of the ends of the bones, or tlie impaction of a ball in the end of 
 tlie bone in such manner that it cannot be removed without destruction 
 of the bone ; in compound dislocation with extensive injury of the soft 
 parts, or complicated with fracture, and in caries which has destroyed 
 the articular surface and continues to progress in spite of well-directed 
 efforts to control it. Compound dislocations and fractures involving 
 joints, once so fatal from inflannnation, do not now always necessitate 
 excision, for when antiseptic methods are rigidly enforced from the first 
 suppuration does not occur. 
 
 Tlie fimc of operating after an injury, as a gunshot, should, if pos- 
 sible, be within twenty-four hours of the accident, or primary ; if it is 
 delayed beyond this period, it sliould not be performed until the inter- 
 mediary stage of inflammation is passed. If the bone is necrosed, the 
 rule should be not to attempt removal laefore complete, or nearly com- 
 pleted, detachment, because the dead bone can rarely be taken out with- 
 out removing healthy and newly-formed bone, and the new bone is not 
 firm enough before the sequestrum is detached. 
 
 The ■instrimienfs required in resection and excision may be few or 
 many, both in number and variety, according to the nature of the case. 
 (1) The knife (Figs. 265 and 266) should be broad and firmly set in 
 
 Fio. 265. 
 
 Fir,. 2m. 
 
 Scalpels 
 
 a rough handle, which mav or may not terminate in a periosteotorae 
 (Fig. 266). (2) The retractors may consist of broad metal plates 
 properly curved (Fig. 267) or take" the form of hooks; the latter 
 
RESECTION OF BOXES. 
 
 775 
 
 Fio. 267. 
 
 are less liable to slip out of the wound, but do not so 
 effectually open it. (3) Tlie periosteotome takes many 
 forms (Figs. 268, 269); it is always a blunt instrument, 
 and in its use care must be taken not to contuse the peri- 
 
 FiG. 2G8. 
 
 Fi«. 21)9. 
 
 Retractor. IV'riDstrotunics. 
 
 osteum when it is desirable to preserve its function. (4) The bone- 
 cutting instruments are numerous and important. The straight bone for- 
 
 FiG. 270. Fig. 271. Fig. 272. Fig. 273. Fig. 274. 
 
 Fig. 275. 
 
 CuttiiiK ffroeps. 
 
 ceps (Fig. 270) is a most useful instrument in the section of the small bones 
 wherever it can be brouglit to bear. But frequently it is quite difficult 
 to roach tiie part, which may be more readily 
 divided with the forceps than the saw unless 
 the blades are curved at a considei'able angle ; 
 in such cases a forceps curved (Figs. 271 or 
 272) will lie found serviceable. The bone- 
 gnawing forceps (Figs. 273, 274), or rongeur, 
 is indispensable in many resections, as it 
 enables the operator to remove projecting 
 
 ?arts not accessible to otlier instruments, 
 "he saw in one of its various forms is neces- 
 sary. Tiie chain .saw (Fig. 275) consists of 
 a number of pieces, with movable artic- 
 ulations, terniinatc'(l at each extremity by 
 handles with whicii it is worked. To use 
 this saw, one handle is removed from tiie 
 hook, and a needle, armed with a strong 
 thread, is attached to the end ; the needle 
 is passed under the bone, and the saw drawn 
 into its jwsition, with the cutting edge up- 
 Mard, and the liandle is tiien re-attached; ihainsuw. 
 
776 
 
 OPERATIVE SUEGERY. 
 
 the operator, grasping the handles, draws the saw alternately from side 
 to side, until the bone is divided : there is great danger of breaking this 
 saw if it is worked carelessly; it should l)e drawn from side to side 
 steadily, at an angle of 45° to the long axis of the bone. The sections 
 may consist of metallic Iteads strung on a wire with handles ; such a 
 saw will act efficiently in whatever direction it is held. 
 
 Other saws, of pecadiar shape, arc often useful in the removal of 
 certain bones, though not absolutely essential ; the saw (Fig. 276) with 
 
 Fjo. 276. 
 
 Saw with movable back. 
 
 a movable back may be used to advantage in most resections of bones 
 of the extremities ; in the removal of the superior maxilla the right and 
 left bone saws (Figs. 277, 278) enable the operator to separate its supe- 
 
 FiG. 277. 
 
 Fig. 278. 
 
 Right and left sa\v.s. 
 
 rior attachments with great fiicility ; a small straight saw (Fig. 279) is 
 often recpiired, and when it is necessary to use a part of the edge an 
 india-rubber tube may be drawn over the part unused to prevent its 
 
 Fig. 279. 
 
 Fig. 280. 
 
 
 L....A 
 
 straight-back saw. 
 
 Hey's saw. 
 
 injuring the soft parts ; occasionally a saw having a circular as well as a 
 straight edge (Fig. 280) is required in removing sharp ])oints or thin 
 bones ; a saw concealed in a sheath is very useful in subcutaneous 
 division of bones (G. F. Shrady) ; finally, a saw is essential which may 
 be taken from its position (Fig. 281), where it is firndy held by a spring 
 connected with the handle, and passed under the bone, if required, and 
 the ends, being re-attached in the frame, the bone is as readily divided 
 from beneath as from above ; the saw may be turned laterally also or be 
 made to cut in a curve ; the tension of the saw is regulated by a spring 
 enclosed in the handle. Bone drills for the introduction of the wire 
 suture must be provided, and an osteotrite will often l)e necessary (Fig. 
 282). The gouges, the chisel (Fig. 283), and the mallet (Fig. 284), are 
 
RESECTION OF BONES. 
 
 777 
 
 often required ; to thorouglily clean out all forms of carious cavities two 
 or more gouges and spoons arc necessary with different cutting edges ; 
 
 Fig. 281. 
 
 Butcher's saw. 
 
 the mallet may be of wood or metal with a firm handle. (5) The seizing 
 forceps may be the common dressing forceps (Fig. 285) for small frag- 
 
 Fifi. 282. 
 
 Drills. 
 
 ments, and larger furceps for large fragments (Fig. 286) ; they should 
 also have straight and curved beaks (Figs. 287, 288) to seize fragments 
 
 Fig. 283. 
 
 Chisel and gouges vviili udjustal>lu liandlu. 
 
 Fig. 284. 
 
 M 
 
 Mallet. 
 
 that are concealed. The bone scoop (Fig. 289) is neces.sary in removing 
 all the dead tissues in bone-eavities. 
 
 An instrument capable of seizing the bone and holding it in position 
 
778 
 
 OPERATIVE SURGERY. 
 
 while ii saw adjusted in it can be so operated as to divide the bone is 
 often desirable. Such an instrument has been devised, and in modified 
 
 Fig. 285. 
 
 Fig. 286. 
 
 Fig. 287. 
 
 Fig. 288. 
 
 r creeps. 
 
 form (Fig. 290) has proved very useful. It consists of handles having 
 a fixation clamp, /; by opening or closing the handles the jaws, g, ai'e 
 
 Fig. 289. 
 
 G.T\«^^UU.& CCl 
 
 Bone scoop. 
 
 separated or closed ; the saw, I, is in shape like a chisel and works in a 
 shield, h. The bone to be exsected having been exposed, with its peri- 
 
 Fig. 290. 
 
 Combined forceps and saw (Wyeth). 
 
 o,steum peeled off in common with all the circumjacent tissues, the ope- 
 rator, holding the handle uf the instrument in his left hand (the saw 
 
RESECTION OF BONES. 779 
 
 being entirely removed), opens the jaws, g, wide enough to insinuate 
 them about tiie bone ; as soon as this is aceomjilished, witii the right 
 hand slide the saw into the shield, /*, down until the teeth engage against 
 the bone; a slight oscillation of the handle of tiie saw with recjuisite 
 pressure carries it through the bone with remarkable rapidity and with- 
 out wounding or bruising the contiguous soft tissues. 
 
 The preparations for the operation are as follows : Cleanse the hands 
 and nails with soap, water, and nail-brush and wash them in liichloride 
 solution ; put the instruments in the tray and cover tiieni with carbolic- 
 acid solution 1 : 20 ; prepare the solution of bichloride, 1 : 2000, in the 
 irrigator, the water being hot. The parts to be operated should l)e anti- 
 septically prepared on the preceding day, and wrapped with aseptic 
 dressings. Bind towels, wrung out of the bichloride solution, around the 
 limb, one above and one below the point, and spread others over all the 
 region of tiie wound, so as to protect the hands and instruments from 
 contact with soiled surfaces or materials. Apply the elastic bandage 
 luiless tlie parts are infiltrated with pus. 
 
 The operation is as follows : (a) In the removal of the bone the 
 method of operating must be adapted to each particular case. In shot 
 fractures the extirjxition of fragments must be through openings extend- 
 ing from tiie wound ; in necrosis tiic sinuses are iiiiides for incisions : in 
 the e.Kcision of the bone for morbid growths the incisions must l)e largely 
 in the direction of the tumor. The incision in general should be made 
 as nearly as possible over the bone to be removed and parallel with 
 arteries, nerves, and muscles. The soft parts should not be destroyed, 
 e.xcept so far as they have undergone degeneration or interfere witJi the 
 proper closure of the wound. Injuries to lilix id- vessels and nerves lying 
 in the track of the incision should lie scn-upulously avoided by drawing 
 them aside; muscles and tendons siiould, if possilile, not he divided nor 
 their attachments incised, but should be separated to the necessary extent 
 with a blunt instrument. The bone being exposed, the operator should 
 preserve in the wound, and, as far as possible, in its original position, the 
 periosteum of the bone to be removed, in order to the rejirodiiction of 
 suftlcient new bone to preserve the function of the part. The periosteum 
 is best jireserved by first incising it to the extent of the bone to be re- 
 moved, and then separating it with tlie periosteal knife or the end of the 
 scalpel. Tiie periosteum being separated, the bone must be divided by 
 cutting forceps or the saw, and each jiortion separately removed ; if the 
 saw is used, the soft parts should lie cait'fuily protected by compresses or 
 a spatula introduced underneath the bone. In some eases the interior of 
 carious caiiceliatetl bones may be scooped out and the external shell be 
 left as the basis of new bone. The scoop may be a curved chisel, the 
 periosteal knife, or other instrument which can be applied to the inte- 
 rior of the carious cavity. 
 
 (fj) In the resection of joints the operator should aim (1) to remove all 
 diseased structures withdtt needlessly sacrificing jiarts ; in children, espe- 
 cially, the epiphyses of bones must be preserved with the most scrupu- 
 lous care, to ensure their future growth ; in adults the amount of bone 
 removed will always have regard to the future usefulness of the joint. 
 (2) If the functions of the joint are to be preserved, as of the upper ex- 
 tremities, the fibrous structures must be saved in their projier relations ; 
 
780 OPERATIVE SURGERY. 
 
 the periosteum must be preserved wit li tlic attacliniciits to tlic capsule; 
 tlic muscular attaciiuieut.s must lie separateil uuinjureil or witli the bony 
 fraaineuts (if their insertidus, to ensure tiieir future usefuluess ; the Ijones 
 may be so sJuqx'd and placed in position as to maintain their s])ecial 
 movements, preserving even a useful hinge-joint at tiie elljow. (3) If the 
 joint is to be ankylosed, as tiie knee, the surfaces of the excised bones 
 must be accurately applied and maintained to secure firm union. The 
 bones may be maintained in apj)osition by wire, catgut, prepared silk, 
 and by nails and metallic jiins driven through the fragments. The silver 
 M'ire is, in general, the best material for that purpose. It should be so 
 inserted as not to recjuire removal — viz. after being twisted, cut it off and 
 turn the twisted ends downward between the extremities of the bones. 
 
 The treatment of resection wounds should secure rest, and free- 
 dom from irritation. Rest is obtained by a])])aratus adapted to each 
 case; in general the immovable apparatus of plaster of Paris is most 
 availal)le and useful. Tliough these wounds usually heal liy granula- 
 tion, yet by carefid attention to the use of antise})tics suppuration may 
 be entirely prevented. They are peculiarly liable to be poisoned by 
 septic ferments from the putrefactive matters already existing in the 
 wound. The dressings shoidd, therefore, be scru])ulously antiseptic 
 throughout the stage preceding granulation and subsequently to such 
 degree as will jirotect the granulations from any infectious matter which 
 may enter or form in the wound. Irrigate the wound after the operation 
 with bichloride solution, 1 : 2000 ; remove every particle of dead tissue ; 
 apply drains to every recess which will retain fluids ; and close the wound 
 with sutures to the fullest extent practicable. Ajtjily iodoform dressings 
 covered with bandages of bichloride or earbolized gauze, and finally two 
 or three layers of plaster-of- Paris bandages. Pe-drcss at intervals of 
 several days only, or when there are indications of disturbances in the 
 wound. 
 
 BOXES AND JOINTS OF THE UPPER EXTREMITIES. 
 
 Resection is to he preferred to amjiutation in the greater muiiber of 
 lesions of the upper extremities, as the princijial ftmetion involves that 
 of mobility. 
 
 The phalanges may be resected in part or whole, but the results are 
 not always favorable, owing to the stiffness, shortening, and deformity 
 which so often follow. The incisions should be on the side of the joints 
 to be excised. Efforts should be made to preserve the periosteum with a 
 view to the ]>roduetion fif new bone in the shafts of the bones that have 
 been removed. In the after-treatment apply a splint to the palmar sur- 
 face, and make such extension as will maintain the full length of the 
 j)halanx. The entire phalanx is removed by an incision over the shaft 
 of the bone on the side ; the tendons being raised, introduce the bone 
 forceps, divide the bone, and remove the two halves sejiaratelv at their 
 articulation. In removing the third or ungual jihalanx make on the 
 palmar surface a doul)le T-ineision, one end Corresjxmding to the artic- 
 ulation, the other to the extremity of tiie finger; denude the phalanx 
 from the end toward its base, the nail remaining intact. 
 
 The Metacarpal Bonesi. — The superficial condition of the dorsal 
 aspect of these bones and the important anatomical relations of their 
 
RESECTION OF BONES. 
 
 781 
 
 palmar surfaces require that all operations for their excision be com- 
 menced on the posterior part or dorsum. 
 
 («) The entire bone is removed as follows : Make an incision along 
 the dorsal surface of the tliird and tlmrth metacarpal liout's, avoidinji' 
 the extensor tendons, and on the radial siile of the second antl ulnar side 
 of the fifth ; draw the extensor tendon on one side and relieve the sides 
 of the bone of the soft parts ; separate the periosteum as much as possi- 
 ble and divide the centre with the bone 
 
 forceps (Fill'. 291) or with the chain saw, Fk;. 292. 
 
 the soft parts being protected by a com- 
 press or spatula ; the fragments arc then 
 separately elevated, and disarticulated 
 with the point of the knife (Fig. 292). c^^. 
 
 This operation may be variously modi- 
 
 Resection of metacarpal bone. 
 
 Resection i.>f the proximal end. 
 
 fied, according to the condition of the ]iart affected. Wlien there is 
 nuich swelling make a short lateral incision at each extremity of the 
 longitudinal cut. The incision may also be made lietwecn the tendons 
 of the long and short extensors on the dorsum along the radial border. 
 In resection of the metacarpal the cut may be a T or an L. 
 
 (6) The shaft is removed by a longitudinal incision on the radial 
 border of the first and second, on the ulnar border of the fifth, and the 
 dorsal surface of the third and fourth ; carefully avoid the extensor 
 tendons, and with a chain saw or cutting forceps divide at two points 
 the denuded bone. 
 
 (c) The proximal portion of the bone is resected by a longitudinal 
 incision over the upper extremity of the metacarpal bone ; avoid the 
 extensor tendon, separate the soft ]iarts from the sides of the bone ; 
 divide the bone at the rec[uisite point witli bone forceps or witli the 
 .saw, after being isolated from the soft parts, and as far as ]>ossible 
 from the periosteum ; seize the fragment with the forccjis ; rai.se it 
 from its bed (Fig. 292), and disarticulate the joint with the point of 
 the knife. 
 
 {d) In complete resection the extremity of the metacarpal lione and 
 
782 OPERATIVE SURGERY. 
 
 its correspondinir cari):!! Iionc miv removed by a single longitudiiuil 
 incisidii made over tiie superior extremity of the met!iear]);il Ixiiie, wiiich 
 is deinided of soft parts and siiwii at tiie ))ro]K'r ])(iiiit ; remove tiiis 
 part at its articulation, and then extirpate the earj)al l)one. 
 
 {e) The phalangeal extremity of the metacarpal bone (jf the thumb 
 is removed thus : Make an incision on its dorsal surface ; draw aside the 
 extensor tendons carefully ; divide with a chain saw at the proper point ; 
 seize the diseased jxirtion with the forceps, bring it forward and expose 
 the articular extremity with the point of the knife, by wliich it is readily 
 disarticidated. 
 
 The phalangeal joinh .should be excised by an incision along the side, 
 sliglitly convex downward ; through a single incision the extremities of 
 the bones may often be reached and excised by turning them outward. 
 In the treatment make sufficient extension by means of a palmar splint 
 to keep tlie bones apart, and l)egin jiassive flexion as soon as repair is 
 established. 
 
 The inefacarpo-jjiia/a iii/cal jointu should be excised by dorsal incisions 
 along the margin of the extensor tendons, which must be drawn on one 
 side ; the articular surfaces being cleared, excise them with cutting for- 
 ceps, a fine saw, or chain saw. The treatment is the same as after ex- 
 cision of the phalangeal joints. 
 
 The irrlxt-joiiit is j)roperly limited to the articular end of the radius 
 and the first row of earpals. But excision at the wrist includes the 
 removal, not only of the radius and first row of carpal bones, but of 
 a part or whole of the ends of the radius and ulna, a part or M'hole 
 of the carpus, the proximal ends of the metacarpal bones, or all of these 
 at once. The radio-carpal articulation is formed between the radius 
 and triangular fibro-eartilage above and tlie scaphoid, semilunar, and 
 cuneiform bones below ; the carpal articidations are arthroidal ; the 
 synovial sacs are so arranged that their communications are limited : 
 this anatomical peculiarity should be remembered in the eflbrt to remove 
 portions of the carpus, as it is desirable not to open these cavities far- 
 ther than is absolutely necessary ; the ligaments are dorsal, palmar, and 
 interosseous. 
 
 There are several methods of operation, but those devised by Lister, 
 Oilier, and Boeckel are to be preferred. 
 
 (a) Lister's excision of the entire M'rist consists of a series of opera- 
 tions, each of which must be executed with scrupulous care, as follows : 
 Break down adhesions of tendons l)y freely moving all the articulations 
 of the hand ; commence the first incision at the middle of the dorsal 
 aspect of the radius, A (Fig. 293) on a level with the styloid ])rocess; 
 carry it toward the inner side of the metacarpo-phalangeal articulation 
 of the thumb, running jiarallel in this course to the extensor secundi 
 internodli ; on reaching the line of the radial border of the second meta- 
 carpal bone carry it downward longitudinally half the length of the 
 bone, the radial artery lying tiirther to tlie outer side of the limb ; detach 
 the soft parts from the bone at the radial side of tlie incision, the knife 
 being guided by the thumb-nail ; divide the tendon of the extensor carpi 
 radialis longior at its insertion into the base of the second metacarpal 
 bone, and raise it along with that of the extensor carpi radialis brevior, 
 previously cut across, and the extensor secundi internodii, while the radial 
 
RESECTION OF BONES. 
 
 783 
 
 im^(^'' 
 
 Excision of wrist: ^, Lister's radial incision; 
 B, Lister's ulnar incision ; C, Oilier ; D, 
 Boeekel. 
 
 is thrust some'what outward ; separate the trapeziinn from the rest of the 
 carpus by cuttiug forceps apjtlicd in tlie line M'ith the lougitudinal part 
 of the incision ; leaving the trape- 
 zium in position until the rest of Fi<*. 293. 
 the carpus is taken away, dissect 
 the soft parts on the ulnar side of 
 the incision from tlic carpus as far 
 as convenient, tlic hand hcing bent 
 back to relax the extensor tendons 
 of tiie iingers ; commence the sec- 
 ond incision, B (Fig. 293), on the 
 palmar surface, at least two inches 
 above the end of the ulna, imme- 
 diately anterior to the bone, and 
 carry it downward between the 
 bone and flexor carpi ulnaris, and 
 on in a straight line as far as the 
 middle of tlie ttfth metacarpal bone 
 on its pahnar aspect ; raise the 
 dorsal lip, cut tiie extensor carpi 
 ulnaris at its insertion into the 
 lifth metacarpal bone, and dissect 
 it from its groove in the ulna 
 
 without isolating it from the integuments ; separate the extensors of the 
 fingers from the carpus, and divide the dorsal and internal lateral liga- 
 ments of the wrist-joint ; leave the connections of the tendons witii tiie 
 radius undisturbed ; now clear the anterior surface of the ulna bv cutting 
 toward the l)one, avoiding the artery and nerve; open tlie articulation 
 of the pisiform bone, and separate the flexor tendons from the car- 
 pus, the hand being depressed to relax them ; clip througli the base of 
 the process of the unciform bone with pliers, but avoid carrying the 
 knife tartiier down the hand than the bases of the metacarpal bones ; 
 divide the anterior ligament of the wrist-joint ; separate the carpus from 
 the metacarpus with cutting j)liers, and extract the carpus with setpies- 
 trum forceps through the ulnar incision, dividing any ligamentous 
 attachments ; the articular ends of the radius and ulna may be pro- 
 truded at the ulnar incision and excised ; divide the ulna obliquely with 
 a small saw so as to take away the cartilage-covered rounded part over 
 which the radius sweeps while the base of the styloid process is retained ; 
 clear the radius sulKciently to remove the articular surface ; if the caries 
 is slight, remove a thin slice without disturbing the tendons in their 
 grooves on the back of the bone ; clip away the articular facet of the 
 ulna with bone forceps applied longitudinally ; if the caries is extensive, 
 remove freely all the diseased bone with pliers and gouge ; examine the 
 metacarpal lioiies and excise the articular surfaces only if they are sound, 
 and more extensively if diseased ; next seize the trapezium with strong 
 f()rce])s, and dissect it out without cutting the tendon of the flexor carpi 
 radialis, and excise the end of the metacarpal bone ; clip ott' the articular 
 facet of the pisiform bone, and, if sound, leave the remainder in position ; 
 close the radial incision firmly throughout with sutures, and also the ends 
 of the ulnar incision, but the middle must be kei)t open by pieces of lint 
 
784 
 
 OPERATIVE SURGERY. 
 
 introduced lightly to give support to the extensor tendons and afford free 
 escape of discharges. 
 
 (b) In Bocckcl's operation tlic iiicisidu may l)c made fnmi the middle 
 of the ulnar l)ordcr of the nietacar|)al bone of tlie index linger upward 
 to the middle of the dorsal surface of the c})iphyses of the radius, 1) 
 (Fig. 293), crossing to the ulnar side of the extensor carpi ulnaris at its 
 insertion into the base of the third metacarpal bone, and dividing the 
 dorsal ligament of the carpus between the tendons of the long extensor 
 of the tlannl) and the extensor indicis ; the soft parts l)eing raisi'd 
 through this incision by careful mani[)ulation (jf tlie liand, the carpal 
 bones may be removed, one by one, by dividing the ligaments which 
 bind them together and to other bones. 
 
 (c) Oilier makes an incision, ('(Fig. 293), from an inch below the 
 styloid }>rocess of the radius upward along the external l)order of that 
 bone, to a sufficient extent ; a brancli of the radial nerve being pre- 
 served, the extensor tendons of tlie thumb arc exposed and drawn aside 
 and the insertion of the superior longus exposed. A\'ith a pcriosteotome 
 detach the tendon of the supinator ; denude the end of the radius of the 
 periosteum and bend the carpus forcilily inward, dislocating the head of 
 the radius outward. After separating the fibrous attaclnncnts excise the 
 requisite amount. Tlie end of the ulna may be reached through the 
 same wound, or an incision along the inner border will expose it. 
 
 The after-treatment must be pursued with due recognition of the 
 fact that the new joint at the wrist is produced by an ajiproximation of 
 the bones of the forearm and of the metacarpus, partly by shortening 
 of the limb and partly by the growth of new bone from the divided 
 ends ; with projjer care, perfect symmetry of the liand can always be 
 ensured, for as tiie radius and ulna aliove and the metacarpus below are 
 divided in parallel lines, the shrinking of the new material between 
 them draws the hand equally upward toward the ftu'earm : the surgeon 
 should aim to maintain flexibility of the fingers by frequently moving 
 them, and at the same time to procure firmness of the wrist by keeping 
 it securely fixed during the process of consolidation. These indications 
 are met by placing the limb on Lister's splint (Fig. 294), which consists 
 
 Fig. 294. 
 
 Hand after excisiun ot wii^t, laid in spliiil 
 
 of an obtuse-angled piece of thick cork attached to a splint, with a cross- 
 bar of cork attached to the under surface' about the level of the knuckles ; 
 on the splint the hand lies semi-flexed, its natural ]iosition, the fingers 
 midway between the extremes of flexion and extension, into \\']iich it is 
 necessary to bring them in the daily passive movements ; the thumb is 
 to be kept from the index finger by a pad of cotton maintained between 
 
RESECTION OF BONES. 
 
 785 
 
 behind 
 
 Fig. 295. 
 
 them ; flexion and extension of tlie fingers slionld be commenced on the 
 .second day whetlier inflammation has subsided or not, and continued 
 daily, each flnger being flexed and extended to the fullest degree possible 
 in health, care being taken that the metacarpal bone concerned is held 
 steady ; pronation and supination must ni)t be neglected, and, as the 
 wrist acquires flrmness, flexion and extension, adduction and abduction, 
 should be occasionally encouraged ; jJassive motion must l)e continued 
 until there is no longer a tendency to contract adhesions. 
 
 The radius may be resected for necrosis with excellent results, the 
 mortality being small and the usefulness of the hand and wrist being 
 well preserved. In the after-treatment secure rest by a wire, tin, or 
 sole-leather splint applied to the inner surface of the arm and forearm, 
 and use iodoform dressings. 
 
 (rt) The lower extremity is broad, of a quadrilateral form, ha\ing two 
 articular surfaces, one concave, on the lower part, for articulation with 
 the .scaphoid and semilunar bones ; the other, on the inner side, narrow 
 and concave, to articulate with the lower end of the ulna. Make a 
 longitudinal int'ision along the radius on its external anterior border 
 (Fig. 2!lo), extending downward to a point opposite and a little 
 the styloid process ; if necessary, add two 
 terminal incisions at the extremities of the 
 first one ; remove the periosteum, and make 
 section of Ijone by means of the chain-saw ; 
 isolate the lower part of the radius from its 
 attachments at the radio-carpal articulation, 
 without injury to the artery (a), nerves, or 
 tendons. 
 
 (b) For the middle portion make a long 
 straight incision on the external aspect of 
 the bone parallel with its shaft ; denude the 
 bone, divide it at the two points selected, 
 and raise the fragment from its bed, leav- 
 ing the pcriosteimi. 
 
 (c) The head of the radius is quite superficial on its posterior part 
 and surrounded liy tiie orijicular ligament, which reti.ius it in the lesser 
 sigmoid cavity of the ulna. Resect by making a straight incision on the 
 posterior and external j)art of the arm over the bone, divide the bone 
 cautiously, and raise it from its articulation by cutting the ligaments 
 with the point of the knife. 
 
 (r/) In excision of the entire radius make an incision along the outer 
 surface of the radius from the styloid process t<i the head of the bone at 
 the elbow-joint; divide the fascia along the outer border of the supinator 
 longus muscle, and separate the muscles along this line down to the 
 bone ; incise the periosteum the length of the wound and separate it 
 from the bone ; divide the b(jne in the middle and remove each extrem- 
 ity separately. 
 
 The nhui, like the radius, may be resected for necrosis with very 
 favorable results, i)oth in regard to mortality and usefulness of the limb; 
 l)nt for shot injuries the mortality is in the aggregate augmented by ope- 
 rative interference, except \vhen antiseptics are employed. The after- 
 treatment is the same as in resections of the radius. 
 
 Vol. I.— 50 
 
 Resection of lower end of radius. 
 
786 OPERATIVE SURGERY. 
 
 Romoval of the lower extreniitv and the middle ])ortion of the shaft 
 is eft'eeted by the same metliods as those <>i\-en fcjr the radius. 
 
 The upper extremity, inehiding the olecranon, is exsected as follows : 
 Make a longitudinal incision, live inches in length, over the middle of 
 the olecranon, extending three inches above and two below it, penetrat- 
 ing to the bone ; divide the triceps tendon at its insertion toward either 
 edge, care being taken to avoid cutting across the aponeurosis, whicli is 
 continuous from the edges of the tendon over the muscles lying on the 
 posterior part of the forearm and inserted into the edges of the olecra- 
 non ; dissect up these insertions of the fascia, as well as the origins of 
 the muscles beneath it, from the bone to the extent of nearly two inches, 
 which allows the olecranon to be exposed, when the edges of the incision 
 may be drawn asunder over* the condyles, broad, curved spatuliB being 
 used for this purpose ; with the amputating saw cut through one-half 
 the thickness of the bone ; comjjlete the section \\\i\\ a fine saw, after 
 which separate com])letely with a chisel and mallet. 
 
 The entire ulna may be removed by the following method : Rotate 
 the limb inward from the shoulder-joint, and carry the pronation of the 
 forearm so tar as to cause the jialm of the hand to look directly outward ; 
 slightly flex the elbow-joint and elevate the hand ; this twisted position 
 places the ulna ujjon the posterior and outer asjject of the forearm, and 
 renders it more easily accessible ; the limb thus placed, the assistants 
 maintaining the arm and fiircarm steadily, make an incision along the 
 jiosterior and inner asjject of the idna, commencing at the lower part of 
 its superior third and extending downward to a point over the extremity 
 of the styloid jtrocess, make a transverse incision, about an inch long, 
 from the loAver extremity of the first incision, detach the tendon of the 
 extensor carpi ulnaris from its groove on the lower part of the ulna, 
 the ulnar artery and nerve being carefully avoided ; divide the bone at 
 the lower part of the middle third, and separate the lower and upper 
 fragments from their articular connections as in the removal of these 
 bones already described. 
 
 The radius a\n\. ulna may be I'emoved together, and if the periosteum 
 remains a useful limb may result. Make a straight incision the entire 
 length of each bone on the dorsal surfaces, separate the muscles, and 
 when the Ijone is reached raise the periosteum and detach the articidar 
 extremities ; keep the limb well extended during the after-treatment. 
 
 The elbow-joint has two motions, flexion and extension, which are 
 limited to the locking of the coronoid and olecranon processes in the 
 respective fossae of the humerus. The usefulness of the joint after excis- 
 ion depends upon the perfection of the hinge- or antero-posterior motion. 
 The extreme conditions in which it may be left are ankylosis and a flail- 
 like or dangle-joint action. Though in both cases the limb is often very 
 useful, yet ever}^ effort should be made to avoid such results. After- 
 treatment has much to do with the prevention of ankylosis, but, in gen- 
 eral, the extent of exsection determines the degree of mobility, and also 
 the power of controlling it ; if too little is taken away, there will be 
 more or less comjilete ankylosis, and if too much, there will be such 
 relaxation of the muscles as to prevent their efficient action : excisions 
 which have given the best results have been at the commencement of the 
 condyloid projections of the humerus and at the base of the coronoid 
 
RESECTION OF BONES. 787 
 
 process of tlie ulna. The periosteum should be carefully j>rc.ser\-e(l, 
 whatever method is adojjted. It may be established as a rule that excis- 
 ion for injury shoidd be partial and conservative, and for disease it 
 should be entire or limited only by the removal of the diseased boue. 
 Wlien the disease or injury is limited, it is of doubtful propriety to inflict 
 additional injury by section of healthy bones, for excellent results have 
 been obtained when the joint-ends of either the upper or forearm have 
 been removed after complete exposure of the joint and the uninjured 
 portions of the articulation have been unmolested. In general, the 
 longitudinal incision, by giving sufficient exposure of the joint and 
 enabling the operator to avoid easily the transverse division of muscidar 
 attachments, ligaments, and fibrous structures, should be preferred. The 
 subperiosteal method gives the best results as to the usefulness of the 
 limb, and should be performed unless the conditions recpiire the sacrifice 
 of these tissues. Subperiosteal exsection is as follows : Make an incision, 
 A (Fig. 296), three inches long on the posterior surface of the joint, a 
 little internal to the middle of the olecranon, beginning about an inch 
 above the tip of the olecranon, and extending an inch and a half or two 
 inches above that jioint, upon the border of the ulna, and through mus- 
 cle, tendon, and periosteum to the bone ; with the elevator raise the peri- 
 osteum of the ulna toward the inner side, and detach the inner half of 
 the tendon of the triceps in connection with the periosteum by means of 
 short, parallel, longitudinal incisions; with the left tiiumb-nail draw the 
 soft parts which cover the internal condyle and enclose the ulnar nerve 
 toward the epicondyle, and detach them by means of curved incisions 
 until the epicondyle is entirely uncovered ; the last incisions separate the 
 origins of the flexor muscles and the internal lateral ligament, their con- 
 nections with the jjeriosteum being retained ; noAV draw the outer portion 
 of the triceps tendon outward and separate it by short incisions from the 
 olecranon, maintaining, however, its connections with the ]>eriosteum of 
 the outer side of the ulna, which is raised from the bone with the inser- 
 tions of the anc(incus ; by repeated incisions along the bone loosen the 
 fibrous capsule of the joint from the margin of the humerus, first over 
 the trochlea, until the internal condyle appears ; detach the external lat- 
 eral ligament and origins of tlie extensor muscles, so that all remain in 
 connection with each otlier and the periosteum ; now forcibly flex the 
 arm, ])rotrude the articular surfaces through the wound, and saw them 
 off; if the idna is sawn off l)elow the coronoid process, separate the 
 upper fasciculi of the brachialis anticus without disturbing the union t)f 
 the tendon with the periosteum. Subperiosteal resection may be so pei- 
 formed as to retain the origins of muscles as follows : Make parallel 
 incisions of proper length over the external and internal condyles ; raise 
 the soft parts from the internal condyle, separate the attachments of the 
 flexors with lamelhq of Ijone by means of a chisel ; raise the peri- 
 osteum on both surfaces with the elevator, and divide the lateral liga- 
 ment ; repeat the same operation on the external condyle ; now divide 
 the humerus above the condyles ; scjiarate the attachments of the triceps 
 with the periosteum and laniellaj of bone ; detach the coronoid jjrocess 
 from the ulna ; divide the extremity of the ulna and remove it. 
 
 Other incisions mav be made as follows: Fig. 296, B, Oilier; Fig. 
 297, A, Nelaton, B, C, Hiiter. 
 
788 
 
 OPERATIVE SURGERY. 
 
 An osteoplastic operation may be jicrloinicd as follows (^1, Fig. 298) : 
 Make an incision from the end of the external condyle across the olecra- 
 
 FiG. 296. 
 
 Mt'thorls of Van Lan- 
 genbeck and Oilier. 
 
 Fig. 297 
 
 ^ 
 
 11 
 
 ■B 
 
 r-A 
 
 Methods of Nflatou and 
 Huter. 
 
 Fig. 298. 
 
 '. B 
 
 \ I 
 
 Osteoplastic method : A, 
 Von Mosetig-lloorhof; 
 B, by external incision. 
 
 non, then upward alono; the olecranon to a point an inch above its end ; 
 draw aside the ulnar nerve and divide the olecranon ; now expo.se the 
 hiunerus and saw it oif below the epicondyles ; remove the head of the 
 radius and reunite the olecranon with wire. An external incision, B, 
 can be adopted. 
 
 The humerus is generally resected in part, though it has been re- 
 
 FiG. 299. 
 
 Resection of lower end of humerus. 
 
 moved entire, (n) The lower extremity of the humerus is resected as 
 follows : ISIake a straight incision on tiie posterior and external part of 
 
RESECTION OF BONES. 
 
 789 
 
 the arm (Fig. 299) sufficiently extensive to give a free exposure of the 
 boue, u, when the wound is separated ; denude the bone and divide with 
 the chain saw ; raise the cut end, and ])roceed to disarticulate with the 
 point of the knife, carefully avoiding the brachial artery in fi-ont and 
 the ulnar nerve behind and at the inside. 
 
 (6) Resection of the shaft requires the utmost care to avoid wounding 
 the brachial artery, which, with the median and ulnar nerves, passes 
 along the posterior margin of the biceps nuiscle, and the superior pro- 
 funda arterv and museido-spiral nerve, which wind around the posterior 
 and external jiart of the upper and middle portions of the shaft. If the 
 u])]K'r portion of the shaft is to be removed, make a straight incision on 
 the external part of the deltoid muscle, care being taken not to extend 
 the incision upw'ard so as to involve the circumflex artery and nerve ; 
 when the lower part of the shaft is excised, the incision should be along 
 the outer border of the braehialis anticus muscle, avoiding the musculo- 
 spiral and external cutaneous nerves ; the bone is readily exposed and 
 removed to the required extent. 
 
 (c) The upper extremity consists of the head surrounded by the cap- 
 sular ligament, the tuberosities, and shaft. Resect thus : Make a straight 
 incision, commencing a little above and outside of tlie coracoid process 
 and half an inch below the clavicle, and carry it downward to the 
 requisite extent along the deltoid muscle on the anterior part of the 
 joint ; the bone is here quite superficial, and is most readily exposed ; 
 the bicipital groove being found, dislodge the long head of the bicejjs 
 muscle and draw it aside (Fig. 300, b) ; divide the tendons of the sub- 
 
 FiG. 300. 
 
 Resection of upper end of humerus. 
 
 seapularis, supra- and infra-spinatus, and teres minor as they are made 
 tense by rotation of' the bone outward and inward ; open the capsule 
 and resect. 
 
 {(I) The entire humerus may be extirpated : tlie thickened periosteum 
 must be left in the wountl, and the lengtli of the limb j^rescrved in order 
 to aid the formation of new bone, on which the usefulness of the extremity 
 will depend. If no new bone forms, the patient may have a useful arm 
 suppoi-ted by a ball-and-socket aj>paratus from the shoulder. The in- 
 
790 
 
 OPERATIVE SURGERY. 
 
 Fig. 301. 
 
 cision must be the same as for the resection of the upper and lower ex- 
 tremities, avoiding carefully the musculo-spiral nerve. 
 
 The nhouldcr-Joiiif consists of the large and hemispherical head of 
 the humerus, opjtosed to the nnich smaller surface of the glen()i<l eavity 
 of tlie scapula; the ligaments are the capsular, which invests the joint; 
 the coraco-humeral, a broad bundle of iibres extending over the upper 
 and outer part and attached to the root of the coracoid process ; and the 
 glenoid, which surrounds and deepens the articulation. The method of 
 operation has a marked relation to the usefuhiess of the limb ; e. (j. the 
 longitudinal incision gives <S per cent, perfect and 45.6 per cent, useful 
 limbs; the various other incisions give but a fracticin over 1 per cent, 
 perfect, and at the highest 1 1 per cent, useful limbs. The straight in- 
 cision should, therefore, be preferred in oi'dinary excisions. iSubperios- 
 teal excision of the humerus should, as far as possible, be practised in 
 order to secure greater length of limb, for while the degree of shortening 
 ordinarily bears a certain relation to the extent of bone excised, in sub- 
 jx'riosteal exsections this law docs not hold good, the shortening l)eing 
 comparatively vastly less in the latter ; c. g. 3.93 inches removed with 
 periosteum gave 3 inches shortening, while 4 inches removed subperios- 
 teal gave only ^ an inch shortening. 
 
 Exsection may be periornied l)v the methods alrendv given (Fig. 
 300), or as follows : The patient lying on the back, the shoulder raised 
 on a cushion, and the external condyle looking forward, make an in- 
 cision, A (Fig. 301), from the acromion 
 directly downward through the deltoid 
 muscle to the capsule and periosteum ; 
 draw aside the margins of the wound 
 with retractors and recognize the tendon 
 of the long head of the biceps ; run the 
 point of the knife along the outside of 
 the tendon, ojjening the groove and cap- 
 sule to the acromion ; draw the tend(in 
 to one side, and, while the arm is rotated 
 outward, with a circular sweep of the 
 knife, held perpendicularly to the bone, 
 divide the ca2:)sule and the attachment 
 of the subscapularis to the lesser tuber- 
 osity ; then rotate the arm inward, and 
 in the same manner sever the capsule 
 and the insertions of the supra- and infra-spinatus and teres minor from 
 the greater tuberosity : the head of the bone is now thrust out of the 
 wound and removed by a narrow back saw passed behind it. Any por- 
 tion of the glenoid cavity may be exsected through this wound. If 
 larger space is required, an additional incision may be such as to com- 
 pletely expose the joint and parts adjacent, B (Fig. 301). Subjicriostcal 
 resection may be eft'ccted by this method as follows : Di\ide the pei'i- 
 osteum along the incision and raise it from the bone, first on the inside 
 while the arm is rotated outward, detaching with it the insertions of the 
 subscapularis ; then on the outside while the arm is rotated inward, sep- 
 arating the insertions of the external rotators ; this pai't of the operation 
 is difficult in jjrimary resection owing to the thinness of the periosteum ; 
 
 Excision of the shoulder: A, regular In^ 
 cisiou ; B^ supplementary. 
 
RESECTION OF BONES. 
 
 791 
 
 the head of the bone being now exposed, it may be turned out and ex- 
 cised. 
 
 The treatment consists in fixing; tiie arm upon the triangular cushion, 
 and applying iodoform dressings and inserting a suitable drainage-tube ; 
 in ])riinai'y exsection the tube may pass out of an opening made poste- 
 ri(_)rly, the wound itself being iirmly closed l)y sutures. 
 
 The scapula, in part or in whole, has been resected for shot injuries, 
 necrosis, and morbid growths. For shot injuries it is sometimes neces- 
 sary to excise undetached portions of bone to facilitate the extraction of 
 foreign bodies, and when there is great comminution it may be advisable 
 to excise considerable portions of bone ; there may be conditious also 
 resulting from lacerations by large projectiles which would render jiriniary 
 extirpation of the scapula advisable ; but, as a rule, it is better, after 
 removing detached fragments, to wait the efforts of nature to consolidate 
 the fractured bone, and to resort to resection as an intermediary or 
 secondary measure in cases of extended necrosis. Extirpations of the 
 entire scapula for morbid growths have proved so successful as to render 
 it a legitimate operation. 
 
 (a) Till' body may be removed to a greater or less extent, as follows : 
 Make three incisions, one along the spine and the other two from its 
 extremity, one upward and the other downward ; dissect flaps from the 
 supra- and infra-spinatus fossae, saw through the root of the acromion, and 
 denude the anterior and posterior surfaces of the bone ; reverse the body 
 of the scapula from within outward, and divide the part at the ])ro])er 
 point witli the saw. Or make a longitudinal incision extending from tlie 
 superior to the intiM-ior angle along the vertebral border, a second parallel 
 incision extending from the neck of the acromion to the middle of the 
 anterior border ; a transverse incision 
 unites these along the spine ; dissect 
 the flaps, detach the muscles poste- 
 riorly and anteriorly, and divide the 
 bone with the ciiain saw or forceps. 
 
 (6) The s])ine may bo resected by 
 an incision made parallel to its bor- 
 der ; if required, the incision may be 
 curved downward, so as to raise a 
 flap ; tlie l)one being denuded, the dis- 
 eased portions may be removed with 
 a strong cutting forceps. To resect 
 the acromion make a semihuiar inci- 
 sion at the posterior part of the shoul- 
 der with the convexity downward ; 
 pass the chain saw under the nar- 
 row part of the neck of the acro- 
 mion, divide the bone at this part, 
 and disarticulate ; or make a crucial 
 or T-ineision. An angle of the scap- 
 ula may be resected by a transverse, or 
 a V, or a crucial incisi<m over the part. 
 
 ((•) C'halot descril)es a suljspino-glenoid and a retro-coraco-glenoid ex- 
 cision by the lines of incision shown in Fig. 302. 
 
 Fig. 302. 
 
 aft, subspino-glenoid excision : ac, retro-coraco- 
 glenoid excision (Chalet). 
 
792 
 
 OPERATIVE SURGERY. 
 
 {iJ) Tlic entire scapula is reinoved hy an iiicisidii from tlie acromion 
 process to tiie posterior etlj^o of the scapula, and another from the centre 
 of this one downward ; reflect the flaps thus formed, separate the scap- 
 ular attaclinient of the deltoid, and divide the connections of the acro- 
 mial extremity of the clavicle ; to command the subscapular artery 
 divide and tie it without delay ; next cut into the joint and around the 
 glenoid cavity, hook the finger under the coracoid process, so as to foeil- 
 itate the division of its muscular and ligamentous attacinnents ; then, 
 pulling back the l)one foreil)ly with the left hand, separate its remaining 
 attachments with rapid sweeps of the knife. 
 
 The clavicle has such immediate relations to the upper walls of the 
 thoracic cavity that operations for its extirpation must be cautiously per- 
 formed. In shot fractures, detached splinters sliould always be imme- 
 diately extracted ; necrosed bone should be cautiously removed, in order 
 not to injure neighboring parts; tlie removal of morbid growths in- 
 volving the clavicle may prove to be a most serious operation. 
 
 (a) The scapular extremity is broad and flat, and is removed by a 
 curved incision with its convexity forward and a little outward, which, 
 reflected backward, completely exposes the bone. For a tumor make a 
 crucial incision through the integuments and the platysma myoides, one 
 limb nearly in a line with the clavicle and the otlier at right angles, and 
 dissect the flaps and fascial coverings suecessi^■ely down to the external 
 basis of the tumor ; carefully detach the pectoralis and deltoid muscles 
 from their clavicular origin, avoiding the cephalic vein, and divide on a 
 director the fibres of the trapezius and the cleido-mastoid muscles. Dis- 
 
 FiG. 303. 
 
 a b, resection of diaphysis of clavicle ; cde f g k, resection of entire clavicle 
 i jy total resection of cartilage of rib. 
 
 articulate the scapular extremity of the bone, and the mobility thus com- 
 municated to the mass facilitates the completion of the operation. 
 
 (b) The entire clavicle may be resected by an incision ]iarallel to its 
 inferior border extending to or a little beyond its extremities ; add t\\o 
 
RESECTIOy OF BONES. 
 
 793 
 
 Frci. 304. 
 
 vertical incisions, of one to two inches in length, at the ends of the first 
 incision ; the flap resulting from which divisions, on being raised up, 
 completely lays bare the bone (Fig. 303). For a tumor make an incision 
 from the acromial extremity of the clavicle to the sternal extremity of the 
 clavicle of the <)p])()site side ; cross this by an incision at right angles with 
 it in the middle of the clavicle ; dissect the four flajis from the surface of 
 the tumor; detach the deltoid from its anterior and tlie trapezius from its 
 posterior edge, and divide the coraeo-clavicular ligament ; pass the chain 
 .saw and divide the bone ; seize the fragment with the forceps, and detach 
 the soft parts with the point of the knife, the edge being kept constantly 
 turned toward the bone, in order not to make the slightest wound of the 
 .soft parts. 
 
 ((•) The sternal extremity is of a triangular form, and has on its postero- 
 superior surface the sterno-mastoid and 
 sterno-hyoid muscles, on its anterior sur- 
 face the pectoralis major muscle ; poste- 
 riorly it is in near relation with the 
 pleura, internal mammary artery, sub- 
 clavian vein, and transverse cervical 
 artery ; the innominata is on the right 
 and the thoi"acic duct on the left side. 
 Resect as follows : Make (Fig. 304) an 
 incision curved downwai'd, the degree of 
 the curvature depending upon the size 
 of the bone, but ah\'ays so arranged as 
 to enable the operator to raise it by dis- 
 section to the upper part ; after raising 
 the flap, instead of separating the mus- 
 cles, pass a chain saw at the point where 
 the bone is to be divided ; remove the 
 fragment l)y carefully disarticulating it with the point of the knife, and 
 avoid wounding the important parts posteriorly. 
 
 Rescctiou of sternal end of clavicle. 
 
 Fig. 305. 
 
 BONES AND JOINTS OF THE LOWER EXTREMITIES. 
 
 The lower limbs are employed in support and progression, and hence 
 resections should be so performed as to preserve the utmost stability. 
 
 Tiie plKtlangcs of the toes and their joints may be resected by the 
 nietliods given for the corresponding bones of the fingers. The great 
 toe is of the utmost value in progression, and in removing diseased bone 
 from any ])art of it every effort must be made 
 to ritaiu periosteum, with a view to the pre- 
 .servation of its function. 
 
 The metntarml bones, like the metacarpal, 
 may be partially or entirely removed, and by 
 similar methods. The resection of the entire 
 first and fifth metatarsal bones requiresacurved 
 incision witli its convexity downward, a, h, <■ 
 (Fig. 305), and extending beyond tlie articu- 
 lation ; the bone Ijeing exposed, the middle of the shaft should be divided 
 with the saw and the fragments separately disarticulated. In the removal 
 
 Resection of metatarsal bone. 
 
794 
 
 OPERA TI T 'E S VR GER Y. 
 
 Fig. 306. 
 
 of the three middle metatarsal bones a long straight incision should be 
 made, the bone divided in its centre, and the operation (completed as in 
 the preceding case. 
 
 The metatarso-tarsal joiiit>< are exsccted by a semilunar incision on 
 the dorsum of the foot, exposing the first row of tarsal bones. Remove 
 
 their surfaces with a saw ; now expose the 
 arti(!ular surfaces of the metacarjjal bones 
 and excise them. 
 
 Tlie Utrxdl hones vciay require removal 
 singly or in groups. These operations 
 have never been performed according to 
 any prescribed rules, but each operator 
 lias adapted his incisions to the exigencies 
 of the individual operation. In many cases 
 the hones iiave not been resected entire, 
 but the portion of bone diseased has been 
 removed with a gouge. Care should be 
 taken not to involve the synovial mem- 
 brane of adjacent articulations which do 
 not conmiunicate with the point involved 
 (Fig. 3()(i), and, whenever practicable the 
 periosteum should be preserved. The as- 
 tragalus and OS calcis require special notice. 
 The astragalus has most important con- 
 nections : above it articulates with the tibia, 
 laterally with the malleoli, and t)elow with 
 the ealcaneum by two surfaces. It is attaciied 
 to the ealcaneum by the interosseous, pos- 
 terior, and external ligaments, and to the scaphoid by a ligament passing 
 from its anterior extremity. Excision may be made with slight injury 
 to the tendons which pass over that region or by their destruction. The 
 
 a,b. 
 
 , d, e, distribution of synovial 
 membranes. 
 
 Fig. 307. 
 
 A. excision of astragalus (inner incision) ; A, excision of ankle (inner incision). 
 
 former methods are very tedious, but give the best results. Excision is 
 as follows : Make an external incision two and a half inches in length, 
 A (Fig. 308), from the lower extremity of the tibia and anterior to the 
 
RESECTION OF BONES. 
 
 r95 
 
 external malleolus, to the middle of the cuboid bone, and a second 
 incision backward from the centre of this incision just under the mal- 
 
 FiG. 308. 
 
 A, excision of astragalus (outer incision) ; B, excision of ankle (outer incision) ; C, excision of 
 
 OS calcis. 
 
 Fig. 309. 
 
 leolus ; the bone is thus exposed between the peroneus brevis and tertius ; 
 
 all its connections should be divided. ISIake an 
 
 internal incision two inches long, A (Fig. 308), 
 
 from just below the tip of the inner malleolus, in 
 
 a curved direction, along its anterior margin, 
 
 forward and upward ; separate all ligaments ; 
 
 seize the bone with strong forceps and withdraw 
 
 it, dividing any remaining attachments. 
 
 The OS calcis articulates above with the astrag- 
 alus by two articular sm-faces having an inter- 
 osseous ligament ; in front with the cuboid, to 
 which it is firmly bound by four ligaments, two 
 plantar, which are very strong, a dorsal and an 
 interosseous. Kesection by the plantar flap (Fig. 
 309) gives ready access to the bone and removes 
 the cicatrix from the plantar surface. The 
 patient lying upon his face, make a horseshoe 
 incision ; carry it from a little in front of the 
 calcaneo-cuboid articulation around the heel, 
 along tiie sides of the foot to a corresponding 
 point on the opposite side ; dissect up the elliptic 
 flap thus formed, the knife being carried close to 
 the bone, and thus expose the whole under sur- 
 face of the OS calcis ; then make a perpendicular 
 incision about two inches in length behind tiie 
 heel tlu'ough the tendr> Achillis, in the middle 
 line and into the horizontal one ; detach the 
 tendon from its insertion and dissect up the two 
 lateral flaps, the knife being kept close to the 
 bones, from which the soft parts are well cleared ; 
 then carry the blade over the upper and posterior pai*t of the os calcis, 
 
 Excision of the os calcis. 
 
796 OPERATIVE SURGERY. 
 
 open the articulation, divide the interosseous ligaments, and then by a few- 
 touches with (lie ]ioint det;ieli the Ixine from its coinieetions with tiie 
 cuboid. Faral)euf has modified this metiiod, (' (Fig. •"JOT, Treves), by 
 making an incision from the base of the fifth metatarsal bone along the 
 margin of the sole to a point one and a quarter inches to the inner side 
 of the median line ; another incision, two inches long, parallel to and a 
 little in front of the tendo Achillis, joins the first. The flaps are raised 
 from the bone, the periosteum cut vertically and raised from the bone, 
 <'are being tiiken not to injure the j)eronei tendons in front. By careful 
 dissection the bone is freed from its attachment and removed. 
 
 The tarsal joints generally become carious in connection with such 
 extensive caries of the tarsal bones as necessitates the extirpation of 
 entire bones. Single joints may be excised when the disease is limited, 
 as the astragalo-seaphoid, a (Fig. oOG), the calcaneo-scaphoid, the cal- 
 caneo-cuboid, h. The incision should be made over the aflected joint 
 and curved, and the articular surfaces should be removed with a fine saw 
 or gouge. 
 
 The ankle-joint is a hinge ; the inferior extremities of the tibia and 
 fibula united form a kind of arch which embraces transversely the 
 superior articular surface of the astragalus so as to render lateral move- 
 ments impossil)le when the ligaments are tense. 
 
 The operation which best preserves vessels, nerves, and tendons, as 
 well as the periosteum, is by two longitudinal incisions, one over the 
 external and the other over the internal malleolus, and extended above 
 and l)clow sufficiently to give free access to all of the diseased bone. 
 All transverse incisions involving tlic vessels, nerves, and tendons should 
 be avoided. The limb being turned on the inner side upon a firm pil- 
 low, make an incision two or three inches long i^ (Fig. 307) on the mid- 
 dle of the fibula down to the point of the malleolus, and sufficiently deep 
 to divide the periosteum ; from the extremity of the malleolus continue 
 the incision backward, around the malleolus, an inch, merely through 
 tlie skin, so as not to injure the tendons, and yet permit of their being 
 raised from behind the malleolus ; at the point where the bone is to be 
 divided separate the periosteum with the raspatorium, and turn down as 
 much as circumstances will permit ; introduce the point of the index 
 finger or a spatula into the interosseous space to protect the soft parts 
 during the act of sawing ; incline the saw slightly toward the joint, so 
 that the part to be removed will be external at the point of division ; 
 seizing the upper extremity of the fragment with very strong forceps, 
 separate its connections with the raspatorium and knife when necessary. 
 Now turn the foot upon the external surface, and make the same straight 
 incision as upon the fibula, and a transverse one at its lower end, B (Fig. 
 308); the periosteum is more easily separated than from the fibula ; saw 
 the til)ia in j)lace with a fine-bladed saw when the parts are unyielding 
 from chronic inflammatory infiltration ; in recent injuries and acute sup- 
 jiurations it may be j)ossible, after the jjcriosteum has been separated 
 and the ligaments incised, to gradually dislocate the foot outward with 
 the aid of the knife, and remove tlic tibia with the saw. To gain more 
 complete access in many cases the incisions made along the centre of the 
 malleoli may be extended laterally along the margins of the extremities 
 of these bones. Or the same result may be attained by extending the 
 
RESECTION OF BONES. 
 
 r97 
 
 Fig. 310. 
 
 incisions made along the posterior margins of the tibia and fibnla around 
 the kiwer and anterior margins of tlie niaUeoli. 
 
 A convenient method of suspending the limb is as follows : Make a 
 splint of wood or metal fitted to the anterior 
 surface of the leg and ankle (Fig. 310), with 
 rings inserted at three points for suspension ; 
 in its application the splint is well padded 
 and laid on tlie front part of the leg and tiie 
 limb fixed in the ordinary bandage, the ankle 
 being free (Fig. 311); or the gypsum band- 
 age may be applied over the splint and around the leg, a layer of old 
 flannel being first adapted to the leg, and the ankle left exposed. 
 
 Fig. 311. 
 
 1 
 
 Suspension splint. 
 
 Leg suspended. 
 
 Osteoplastic excision of the ankle-joint (Mikulicz) (Fig. 312, ^1), is as 
 follows : Place the patient in a prone position, and make the following 
 incision.s down to the bone : 1st, across the sole of the foot from a 
 point a little in front of the tubercle of tiie scaphoid to a point just 
 l)chind the tuberosity of tlie fifth metatarsal bone; 2d, from the extrem- 
 ities of this incision two incisions to the base of each malleolus; 3d, a 
 transverse cut joining tlie ends of these incisions, a ; 4th, then flex the foot, 
 divide the lateral ligaments, and open the joint from behind, separate 
 the OS calcis and astragalus from their attachments, and remove them at 
 the medio-tarsal articulations. Remove with the saw the extremities of 
 the bones of the leg at the base of the malleoli, A, and the articular sur- 
 faces of the scaphoid and cuboid. Attacli tlie incised bones of the tarsus 
 to the cut surface of the tibia by wire, and apply the usual antiseptic 
 dressings supported externally by gypsum bandages. The result is a 
 talipes equinus (Fig. 312, E). 
 
 The fibula may be resected in whole or in part with the best results. 
 No formal method is to be pursued. Make a straight incision over the 
 part, uncover the boiic, separate the periosteum, divide with a chain 
 saw, and remove the fragments (Fig. 313). 
 
 Th(! tibia is subjected to resection more frequently than any other 
 long lione, owing to its subcutaneous situation. The results are most 
 favorable, as new bone is readily reproduced when the periosteum is 
 well preserved. 
 
 {a) The lower extremity forms tiic uj)per and internal part of the 
 
798 
 
 OPERA riVE SURGERY. 
 Fia. 312. 
 
 Osteoplastic excision of the foot. 
 
 ankle-joint ; it is closely invested with tendons, and upon its postero- 
 internal border the posterior tibial artery and nerve pass to the foot. 
 
 Fig. 313. 
 
 Resection of fibula. 
 
RESECTION OF BONES. 799 
 
 Resection by the subperiosteal method of the entire diaphysis and lower 
 epiphysis has resulted in reproduction of the bone removed and a useful 
 limb." Make a straight incision along the crest to the ankle-joint; saw 
 the bone at the requisite height ; raise the bone from its periosteal bed 
 by carefully separating the periosteum ; dislodge the tendons from their 
 grooves, divide the ligamentous structures, and complete the resection by 
 tletaching the bone from the articulation. 
 
 (f)) The shaft of the tibia is subcutaneous on the anterior and inner 
 part. On the posterior part it gives attachuicnt to muscles, and along 
 its external border is attached the interosseous ligament connecting it to 
 the fibula. The operation will depend upon the extent of the disease 
 and the location of the sinuses if the disease is necrosis. The incision 
 should be ah^ng the subcutaneous borders of the bone, and extend beyond 
 the diseased portion ; the periosteum should l)e thoroughly separated 
 from the shaft, and the bone divided with a chain-saw at either extrem- 
 ity ; the fragment is then easily separated. 
 
 (c) The upper extremity of the tibia is broad, and presents upon its 
 ujiper surface two cup-shaped cavities for articulation \vith the condyles 
 of the femur. The operative process is entirely subordinated to the 
 degree, actual situation, and form of the disease, so that there may be 
 occasion for the crucial, the elliptical, or a simple incision, and also for 
 a variety of saws and bone-cutting instruments. When practicable, sub- 
 periosteal resection should always be performed. 
 
 The knee-joint mav be regarded as consisting of three articulations 
 conjoined — namely, that between the patella and femur, and two others, one 
 between each condyle of the feiuurand the tibia : the ligamentura muco- 
 sum is an indication of the original distinctness of the synovial mem- 
 branes of the inner and outer joint ; the crucial ligaments may be re- 
 garded as the external and internal lateral ligaments of those two joints 
 respectively ; each portion of the articular surface of the femur belongs 
 either to one or other of the three component joints of the knee, and no 
 part is common to any two of them. The knee is a hinge-joint, having 
 free motion in but two directions ; it is sui)ported principally by the 
 lateral, the internal, and the posterior ligaments, and in front by the 
 jiatella and its ligamentous attachments ; it has also a capsular ligament ; 
 the articular face of the tibia has a semilunar fibro-cartilage which deepens 
 the articular surface for the condyles of the fcnuir. 
 
 Present experience indicates that excision should be had recourse to 
 M'henever the injury or disease is of a nature to destroy the function of 
 the joint and to require ankylosis to render the limb useful. It is gene- 
 rally undertaken for chronic affections which cause ulcerative processes 
 within the joint. The antiseptic method has relieved the operation of 
 all of its former dangers. It is no longer a question of age or sex, or 
 even physical health, but the decision should rest entirel}' upon the deter- 
 mination of tiie nature'of the disease and its final results ujjon the use- 
 fulness of the limb. 
 
 The following suggestions as to the extent of the excision are import- 
 ant: The patella should not be removed, unless diseased, as it is essential 
 to the formation of a firm, wcll-a23i)lied flaj) ; if carious, the diseased 
 part may be removed with the gouge or forceps ; in excision of the knee- 
 joint in children remove at first a thin slice of bone, and, in case this 
 
800 
 
 OPERATIVE SURGERY. 
 
 should not suffi(!e, with tlie gouge scrape out carefully the softened and 
 broken-down osseous tissue, leaving tlie niucli-thinued cortical substance, 
 with tlie periosteum, behind ; the cpi2)hyseal cartilage is often by this 
 means laid entirely bare from the side of the Joint ; if perforated with 
 fistulous openings, a small s|)oon must be introduced and every particle 
 of diseased tissue removed; in very young (•hildrcn it will often even 
 not be necessary to remove any part of the tibia with the saw, it being 
 practicable to remove the diseased part with the spoon ; if the epiphyseal 
 cartilage can be saved only in part, no more should be sac'rificed than is 
 actually necessary. 
 
 The method of operating will dc|icud upon the kind of joint sought 
 to be obtained : if union of the excised bones is necessary, the U-sha|)ed 
 incision is in general preferable to others, as it permits the removal tA' 
 any necessary amount of bone without injuring the soft parts, and both 
 corners of the wound are situated as low as the anatomical conditions 
 will allow. If an attempt is made to retain motion, a lateral incision is 
 to be preferred, wiiich admits of exseetion witii the least destruction of 
 the ligamentous tissues of the joint. The amount of bone removed 
 must, of course, depend npon the extent of the disease. 
 
 Exsect as follows : The leg being slightly flexed on the thigh, make 
 a curved incision, commencing at the insertion of the internal lateral 
 ligament into the inner condyle of the femur, and, passing just below 
 the lower extremity of the patella, terminate it at the same point on the 
 external aspect of the joint ; the lateral incisions should not be made 
 lower than the insertion of the lateral ligaments, to avoid division of the 
 articular arteries ; reflect this flap upward (Fig. 314) ; remove the patella, 
 if diseased ; if not, leave it undisturbed and divide the lateral and inter- 
 articular ligaments ; pass a fold of antiseptic gauze through the joint, 
 
 Fig. 314. 
 
 Fig. 315. 
 
 Excision of knee. 
 
 Excision of tlie knee by tlie sawing of the tibia (Treves). 
 
 and draw it firmly under the extremity of the bone to be sawn, thus 
 completely isolating the soft parts behind ; apply the saw first to the 
 extremity of the femur, and then to the articular head of the til)ia. 
 
RESECTION OF BONES. 
 
 801 
 
 The position of the saw should not deviate from a right angle to the 
 shaft of the bones, so that when union takes place the liml) will be 
 nearly straight (Fig. 315). The hones must be maintained in apposition 
 by two or three silver wires, which should now be introduced into th(^ 
 anterior part of the tibia and femur, and, when sufficiently twisted, cut 
 off and the ends turned down between the bones. To fix the bones in 
 position use has been made of nails, wiiich are removed at the end of two 
 or three weeks. 
 
 The dressings should be antiseptic — viz. layers of iodoform gauze 
 next to the wound, tJieii gauze Ijandagcs treated with bichloride solution, 
 next borated cotton firmly bound by gauze bandages, and last a wire 
 splint retained by gypsum bandages to immobilize parts above and 
 below the knee. The knee itself should be so protected that it can be 
 examined without disturbing tlie other dressings. The more superficial 
 dressings should extend from tlic hip to the ankle. The limb should 
 now be iilaccd in a sling. The dressings should not be changed, except 
 to remove the drainase-tube, for several weeks. The wires are allowed 
 to remain, but nails must be withdrawn after several weeks. 
 
 The folloMing dressing can be readily applied : IMake a wooden con- 
 cave splint to the calf of the leg and back of thigh, but narrow at the 
 knee ; also, if possible, an iron rod fi>r suspension. Apply the dressing 
 thus : Pad the posterior splint with lint or cotton-wool, and cover that 
 part corresp(inding to the site of the wound with gutta-percha cloth or 
 hot paraffin ; place the limb in position and carefully adjust it ; place 
 
 Fig. 316. 
 
 Suspension of leg. 
 
 the iron rod on the front and lay folded lint between it and the limb at 
 the groin, at the upper part of the tibia, and at the bend of the ankle ; 
 apply an open woven roller bandage around the whole dressing from the 
 toes upward except at the site of the wound ; over this apply the gyp- 
 sum l)andage in two or three layers ; when tlie dressing is firm suspend 
 tlie limb l)y the hooks; the wounds may now be dressed \vithout dis- 
 turbing the ])art. 
 
 The patcUu, though in immediate relation with the knee-joint, may 
 be exci.sed with good results. Make a crucial incision, the transverse 
 branch being over the base of the bone, or a second transverse incision 
 may be made near the apex ; dissect tlie flaps off cautiously, and remove 
 
 Vol. I. — 51 
 
802 OPKRATJVE SURGERY. 
 
 tlic hone or its frasjincnts ; tlic t('ii<liiii)iis expansion surroiinrlinji: tlio hone 
 should 1)0 se|)aratt'(l, and not di\i<l('<l, as far as possihle. The antis('|)tit; 
 method shonld he strictly juirsned, and the iodoform dressinjrs a]i|)lied. 
 It the tVai;nients of hone are not too nuieh detached, they may he united 
 witii catgut sutures and union secaired. 
 
 T\\Q femur is the largest bone of the skeleton. Resection of different 
 portions of the bone ui'e very frequent and give satisfactory results, espe- 
 cially when the periosteum is preserved, as new bone is reproduced. The 
 lower extremity is rarely removed, except in exsections of the knee-joint. 
 When it is necessary to (ji)erate for necrosis in this region tiie sinuses are 
 the safest guides to tlie dead bone. The shaft of the femur gives attach- 
 ment to muscles tliroughout nearly its entire extent, and to reach it with- 
 out injury to the soft parts the museular septa must be followed, either 
 along the antero-external region of the limb or as indicated liv the seat 
 of the disease. The limb must l)e well supported by the firm gvjisum 
 dressing during the after-treatment. The trochanter major gives attach- 
 ment to the gluteus medius and minimus, and by its fossa to the external 
 rotators. In resection make a free crucial incision through the skin and 
 tendon of the gluteus maximus, and when the surface is sufficiently ex- 
 posed use the sharp spoon to remove diseased parts. 
 
 The Itip-joiiit is a large ball-and-socket joint in which the globular 
 head of the femur is received into the acetabulum or cotyloid cavity of 
 the innominate bone : this articulating surface is deepened by a broad, 
 ribbon-shaped cartilage occupying the upper and outer part and folded 
 round a depression ^\■llich, extending from the notch, is hollowed out in 
 the bottom of the eayity, and is occu})ied by delicate adipose tissue cov- 
 ered with syni>vial membrane ; the articulating surface of the femur 
 presents a little beneath its centre a pit in which the round ligament is 
 attached ; movement is allowed in every direction, extension being limited 
 by the anterior fibres of the capsular ligament, and flexion by the con- 
 tact of the neck of the femur with the acetabulum. The extent of the 
 resection should depend upon the amount of disease; if limited to the 
 head, that part alone should be removed ; if the neck is carious, the 
 trochanter may still be preserved ; but if the latter is involved, the bone 
 must be divided at the trochanter minor. 
 
 The methods of operating are numerous, but the single incision, with 
 subperiosteal removal of the bone, most nearly meets the anatomical 
 indication of the ])art. Of the several arteries distributed to this 
 region — namely, the gluteal, sciatic, obturator, external and internal 
 circumflex, and the superior perforating l)y anastomosis — the only one 
 which approaches the line of this incision near enough to be incised 
 before dividing into branches of distribution too small to give rise to' 
 noticeable hemorrhage is a twig of the internal circumflex, which at 
 one-eighth to one-fourth of an inch from the insertion of the obturator 
 extermis breaks up into its terminal divisions ; this branch may be 
 avoided by keeping the jKiint of the knife well against the bone, and 
 dividing the tendon of the obturator externus muscle in the digital 
 fossa. 
 
 The patient lying on the sound side, with a strong knife commence 
 an incision, A (Fig. 317), at a point midway between the anterior infe- 
 rior spinous process of the ilium and the top of the great trochanter ; 
 
RESECTION OF BONES. 
 
 803 
 
 carrv it in a curved line over the ilium in contact with the bone, aero:is 
 to tlie top of the great trochanter; extend it not directly over the centre 
 
 Fig. 318. 
 
 Excision of the hip; A. Sayrc; B, Oilier. 
 
 Passing chain saw. 
 
 of the trochanter, hut midway hetween the centre and its jw.^tcrior bor- 
 der ; complete it by carrying the knife forward and inward, making the 
 whole length of the inci-sion four to six or eight inches, according to 
 the size of the thigh ; if the periosteum has not been divided by the first 
 incision, carry the point of the knife along the same line a second or 
 tliiril time ; an assistant separating the wound with the fingers or retrac- 
 
 Fio. 319. 
 
 Dressing in hip-joint abscess, with elastic appliiMl. Tlie same dressing is adaptcil to excision : the 
 position of the drain is seen (Cheyne). 
 
 tors, the great trochanter, h (Fig. 318), is exposed ; with a narrow, thick 
 knife make an incisictn through the periosteum only at right angles with 
 
804 
 
 OPERA TIVE S Un CER Y. 
 
 the first at a point an incli or an iiicli and a half below tlic top of tlie 
 irroat trochanter, opjjosite or a little above the lesser troehanter, and 
 oxteud it as far as jiossible around the bone, making sure that the peri- 
 osteum is freely divided ; at the junction of the two ineisions of the 
 periosteum introduce the blade of the ])eriosteal elevator, and srradually 
 peel up the periosteum from either side witli its fibrous attariuiirnts until 
 the digital foss;i has been reached; with the ])oint of the knife applied 
 to the bone divide the attachments of the rotator muscle, and continue 
 to elevate the periosteum, carefully avoiding rupturing it at any point ; 
 when the periosteum is removed as far as necessary, adduct the limb' 
 sliglitly, depress the lower end of the fenuu- sufficient to allow the head 
 of tiie bone to be lifted out only so far as is reijuisite to ])ermit its 
 removal with the saw,//; divide the bone just above the trochanter 
 minor and remove the fragment ; if the head of the bone cannot be 
 raised before division on account of the involucrura, saw the bone first 
 and then remove the head ; if the shaft at the point of section is 
 necrosed, expose and exsect more ; examine the acetabulum, and if found 
 diseased remove all dead l)one; if perforated, the internal ])criostcum 
 will be found peeled off, making a kind of cavity behind the acetabulum, 
 and all diseased bone must be very carefully chipjicd otf down to the 
 point where the pei'iosteum is reflected from sound bone. P]very part 
 of the wound and all sinuses must be thoi'oughly cleaned of ])articles 
 of bone and false membrane. Or, make an incision, B (Fig. -jIT), com- 
 mencing about three inches below the crest of the ilium, and at the same 
 distance posterior to the antt-rior superior spine, downward to the tro- 
 chanter major, and then along the centre of the 
 shaft of the bone, and proceed as above. 
 
 The dressings of the wound are as follows : In- 
 troduce the drainage-tube to the bottom, then pack 
 the wound with iodoform gauze, or close the wound 
 ^vith sutures to the tul)e and apply iodoform-gauze 
 pails. Enveloj) all with a wide and thick layer of 
 borated cotton and apply the gauze bandage firmly. 
 Place the patient on a smooth mattress and make 
 extension at the foot with a six-pound weight. The 
 upright position of the foot should be maintained, 
 and the dressing shoidd be changed as seldom as 
 possible. When completed the dressings should 
 envelop the upper part of the thigh, the hiji, and 
 pelvis (Fig. -319). The patient should not attempt 
 to walk with crutches until the external wound is 
 quite healed, which ordinarily occurs with antiseptic 
 treatment in five or six weeks. Attempts to bear 
 weight on the foot should not be encouraged for 
 six months, in order to allow the fibrous struc- 
 tures to consolidate. During the period between 
 the healing and using the limb the hip splint (Fig. 
 320) should be worn. 
 With children, extension by the application of weights and proper 
 positions of the limb is the best means: the patient may be placed 
 on a divided mattress, of whicli the two difterent parts are separated 
 
 Fig. 320. 
 
 Hip splint. 
 
RESECTION OF BONES. 805 
 
 by an interstice of several inches exactly corresponding to the spot 
 where the excision was made. 
 
 BONES OF THE TRUNK. 
 
 The vertehne have been suljjected to fro(piciit partial resections. The 
 removal of loose fragments after severe injuries, as from shot, is perfectly 
 rational, and has resulted iu a fair measure of success. In the removal 
 of a spinous process or arcii make a long incision above the ridge of 
 tiie spinous process, the mickUe of wliicli is opposite the displacement ; 
 divide all the attacliments of tiie nuiscles to the articular processes; as 
 one end of each muscular bundle is separated from its attachment, it 
 retracts and needs little holding back ; the saw or the nippers are gen- 
 erally sufficient to divide the vertebral arch ; in sawing or cutting out 
 the arch grasp the spinous process, if it l)e not broken, with a pair of 
 stout tooth forceps, which are to be preferred to the elevator for lifting 
 the detached bone from its natural connections ; a small crowned trephine 
 may be used to cut through the vertebral arch, or Hey's saw. 
 
 The cocri/.v may be excised in whole or part for necrosis, fracture, or 
 for a painful aiFection, coccydynia, thus : Place the patient on the side, 
 the thighs flexed, and the hips close to the edge of the bed ; the buttocks 
 being separated, make an incision in the median line extending from the 
 extremitv of the coccyx upward to the re(piisite extent ; remove the dis- 
 eased bone either with the gouge or the drill, or the bone maybe divided 
 with the cutting forceps. The fore finger in the rectum determines the 
 progress and extent of the resection. 
 
 The ribs are closely invested on their internal surface by the pleura, 
 and along the groove on the lower liorder runs the intercostal artery. 
 The only admissible primary interference when the ribs are fractured by 
 balls is the extraction of loose fragments and the smoothing oti' of sharp- 
 pointed ends. Resection for necrosis slK)uld be made by opening existing 
 sinuses and carefully separating the thickened periosteum with the pleura. 
 In the removal of morbid growths portions of ribs may require resection ; 
 great care must be taken to separate the pleura with the periosteum with- 
 out wounding the former. Proceed as follows : Place the patient upon 
 the sound side, and expose the bone by an incision along tlie middle of 
 the rib, or the incision may be curved downward : divide the intercostal 
 muscles and disengage the intercostal artery from its groove in the in- 
 ferior border of the bone ; separate the pleura cautiously with the handle 
 of the scalpel or similar instrument, ami pass a thin piece of antiseptic 
 pasteboard or other substance behind; divide the bone with the chain 
 saw. Section of the posterior part of the ril) may be first made to avoid 
 wounding the pleui-a ; scrape carefully each border of the bone, and do 
 not incline the point of the knife toward the intercostal sjiace. In re- 
 moving the false ribs support the free extremity while the rib is divided 
 posteriorly. The costal cartilage may be removed by an incision along 
 its centre and vertical incisions at each extremity. 
 
 The stern inn has been frequently ])artially resected for shot injuries, 
 and with verv favorable results, the mortality being very slight. When 
 subperiosteal resection has been made for necrosis new bone has been 
 reproduced. The incision for resection may be crucial or vertical, accord- 
 
806 OPERATIVE SURGERY. 
 
 ing to the extent of injury or disease, and the parts may be removed by 
 the trepiiine, gouge, or forceps. Tlie iijiper jiortion may lie removed l)y 
 a vertical incision, with transverse incisions at each extremity. The hone 
 
 is divided witli a saw, and (lie costal carti- 
 '"■ ^^^' lages with a strong scalpel from before 
 - backward (Fig. 321). 
 
 ,•■"■■;;;."■ bones oy the face. 
 
 •- ■"'. In resection operations on the bones of 
 
 the face it is important to avoid, as far as 
 
 25*'^''*'ble, incisions which will leave un- 
 
 ./ C sightly scars and the removal of bones 
 
 ;"'...-.: .!," " which destroy the symmetry of the fea- 
 
 '•-,"""■--.,. tures. When praetical)le, ])erform intrn- 
 
 ..■••■■'_..-•'.' ■■••■..""■■■■■.. i buccal resections witliout extcnjal incision ; 
 
 ...■•'''/■, ..'•-/" " make incisions along the natural folds of 
 
 //['•■ K ' '■■.. "■•- skin and preserve borders of the mouth 
 
 ■ /./ ...' \ '■... from division ; in all eases that admit of 
 
 subperiosteal resection this method is to 
 
 Incision for resection of upper part of ]jg preferred 
 
 sternum. J , . j. '. .„ . .. , i 
 
 ine nijenor maxilla is very liable to 
 injury and necrosis and to be the seat of morliid growths. In com- 
 minuted fractures the fragments should be preserved unless quite 
 detached, as they have great vitality and are important in the pre- 
 servation of the contour of the jaw. For necrosis the resection 
 should as far as possible be subperiosteal and intral)iiccal, and both 
 objects may often be accomplished by occasionally aiding the slow pro- 
 cess of separation of the necrotic l)one from its attaclunents to bone 
 and periosteum with the elevator or the handle of the scalpel or a 
 spatula. By degrees the sequestrum is loosened, new bone forms around 
 it from the periosteum, and eventually the dead bone may be lifted from 
 its bed with perhaps slight incisions of the gum ; liy this method large 
 portions of the jaw, and even the entire jaw, may be rejiroduced during 
 the process of sequestration, and not (inly its coutDur, but its function, be 
 preserved. This method is preferable to early resection, which is liable 
 to be followed by great contraction of the parts, even if the periosteum is 
 preserved and new bone is produced. In resection for tumors ample 
 external incisions are often recjuired, and large portions of tlie bone must 
 be sacrificed. But small tumors, involving only the alveolus, may be 
 removed with bone forceps without incision of the skin. A considerable 
 portion of the central jiart of the jaw may be removed without incising 
 the lip if the mucous membrane is freely divided between it and the bone 
 and the lip is drawn well down. The wound must be disinfected with a 
 weak bichloride solution, 1 : 5000, care being taken to prevent its entering 
 the stomach. In closing these wounds endeavor to unite first the cut sur- 
 faces of the mucous membrane by sutures so applied as to cause slight 
 evei'sion of the free margins into tlie mouth. Tiien accurately close the 
 external wound, using catgut drains, and ajiply iodoform dressings. 
 
 (o) When the central part is to be resected jiroeeed as follows : Pass 
 a stout ligature through the tip of the tongue to hold it in position when 
 
RESECTION OF BOXES. 
 
 807 
 
 Fig. 322. 
 
 AB, incision for resection of the middle 
 iiart of tlie body of the lower jaw (Cha- 
 lot). 
 
 the muf-fles are incised ; an assistant, standing- beliiud the patient, holds 
 
 liis heail tirnily uinl compresses tiie two tai'ial arteries at the points 
 
 where they cross the lower jaw. Standing in front, seize with the left 
 
 hand one of the angles of the lower 
 
 lip, while an assistant holds the other 
 
 angle from the bone and the whole in 
 
 a state of tension ; dividi' the lip witii 
 
 a vertical incision tlirough the median 
 
 line down to the os hvoides, thns 
 
 making flaps. 
 
 Or make a single curved incision 
 along the lower margin of the jaw ; 
 raise the periosteum from the bone to 
 be removed ; extract a tooth opposite 
 to each point where bone is to be sawn 
 through ; use a small Hey's saw or 
 the chain saw ; the bone being sawn 
 through on both sides, divide the mus- 
 cles attached to it as closely as possible 
 to their insertion, carrying the knife 
 along the concave surface (Fig. .'322). 
 Unite the two flaps with silver-wire 
 sutures passed through to the mucous 
 membrane, adjusting tlie margins of 
 the lip ; or use the hare-lip pins with 
 tigure-of-8 suture if there is much tension ; attach the ligature holding 
 the tongue to a fohl of adhesive strip firmly fastened. 
 
 (6) The horizontal portion has the following anatomical parts to be 
 considered : Attached on its internal surface is the mylo-hyoideus muscle, 
 beneath which is the fossa for the submaxillary gland ; on its external 
 surface along its lower margin is the attachment of the platysma myoides 
 muscle, and along its alveolar margin the buccinator ; tlie facial artery 
 mounts over its lower Ixu-der just anterior to the insertion of the mas- 
 .seter muscle. Resect as follows : Make an incision commencing l)ehind 
 and a little above the angle, avoiding the facial nerve and parotid duct 
 along the border of the jaw, terminating from a (puirter to half an inch 
 below the symphysis menti ; raise and reflect the flaj) on the face, tying 
 botli ends of the divided facial artery ; the bone being denuded or the 
 periosteum raised, divitle witli a chain saw passed at the proper point 
 anteriorly, a tooth being removed if necessary ; seize the end of the frag- 
 ment with strong forceps, and divide with the chain saw at or near the 
 angle, as may be required ; close the wound firmly, care being taken to 
 compress the surfaces of the incised mucous membrane closely to secure 
 prompt union. 
 
 (c) The half of fhe lower jaw has the following additional relations : 
 The ramus terminates in two processes, one for articulation and the other 
 to give attachment to the temporal mu.scles ; the articulation is supported 
 by an external and internal lateral and the capsular ligament ; the stylo- 
 maxillary ])asses from the styloid ]irocess to the angle of the jaw ; the 
 internal maxillary artery passes behind tiie neck of the condyle in such 
 proximity as to render care necessary to avoid wounding it in disartic- 
 
808 
 
 OrEBATIVE SURGERY. 
 
 Illation of the jaw. Ri'scct as flillows (Fio;. ;52o) : Place the ])atieiit with 
 the shoulders raised and head turned to the opposit(.' side ; eomuienee the 
 incision at the zygomatic arch behind the condyle, carry it downward 
 behind the ramus to the angle and under the body of the bone to a point 
 
 Fig. 323. 
 
 Excision of half of lower Ja^^ 
 
 one-quarter of an inch below the symphysis menti if the operation is for 
 an old necrosis, but througli the centre of the lip if for the removal of 
 bone for other affections : in the former ease incise the perio.steum and 
 raise it from the bone throughout, but otherwise, for the removal of a 
 tumor, the facial artery must be cautiously divided and secured. Sub- 
 periosteal resection may no\v be rajiidly jierformed for necrosis, the bone 
 being divided with the chain or small straight back saw, and the cut end 
 used as a lever to raise it from its position during the jn'ocess of enu- 
 cleation. If the periosteum is not saved, liaving divided the bone, seize 
 the cut extremity with the hand ; raise it from its bed, carefully separat- 
 ing all tissues adherent to the body and ramus ; carry a narrow-bladed 
 knife or curved scissors beneath the zygomatic arch and behind the coro- 
 noid process, and with it divide the tendon of the temporal muscle while 
 depressing the bone to disengage the jtroeess and luxate the <'ondyle ; 
 ]mll the bone strongly outward, as far as possible from the vessels, in 
 order to avoid especially the internal maxillary artery, and complete the 
 operation by dividing the pterygoid muscles and the articular ligaments. 
 Secure every bleeding vessel and close the wound by carefully adjusting 
 the margins of the integument and of the mucous membrane. When the 
 tumor is large and completely wedged in the upper part of the bone, so 
 as to hinder the freeing of the coronoid process and prevent dislocation, 
 cut otf the tumor as high as possible with the bone forceps or saw, and 
 
BESECTTON OF BONES. 
 
 809 
 
 then remove the remaining portion of the jaw only in case the disease is 
 malignant. 
 
 ((/) The entire lower jaw is removed as follows : Pass a ligature 
 through the anterior part of the tongue, and trust it to an assistant; make 
 an incision commencing opposite the left condyle downward toward the 
 angle of the jaw, ranging at about two lines in front of tlie posterior 
 border of the ramus, thence along the base, to terminate at tiie median 
 line a little posterior to the most prominent part of the border of the 
 jaw. Dissect upward the tissues of the cheek, and reflect downward, 
 for a short distance, the lower edge of the incision ; separate the tissues 
 forming the floor of the mouth, situated njion the inner surface of the 
 body of the bone, from their attachments from a point near the median 
 line as far back as the angle of tlic jaw ; next divide the attachments of 
 the buccinator ; secure by ligature the facial artery, the submental and 
 the sublingual ; expose the external surface of one branch of the jaw and 
 of the temporo-maxillary articulation by dissecting the masseter upward 
 as far as the zygomatic arch ; seize the ramus and pull the coronoid pro- 
 cess downward Ix'low the zygoma; divide the insertion of the ptery- 
 goideus intcrnus, grazing the bone in doing so ; carefully avoid the 
 lingual nerve, here in close proximity ; divide the dental artery and 
 nerve ; separate the tissues attached to the inner face of the bone as high 
 up as a point situated about a line below the sigmoid notch, between the 
 condyle and the coronoid process; detach the tendon of the temporal 
 muscle by means of l)lunt curved scissors or a probe-pointed bistoury, 
 keeping close to flie hone ; make use of the rannis, now movable, as a 
 lever to aid in the disarticidation of the bone : to efiect safely the tlisar- 
 ticulation of the condyle, peiietrate the joint by cutting the ligaments 
 before backward and from without inward ; the articulation thus opens 
 sufficiently to allow the condyle to be completely luxated ; blunt scissors 
 may now be used to cut cai'efull}' the internal part of the capsule and 
 the maxillary insertion of the external pterygoid muscle ; by a slow 
 movement of rotation of the raunis upon its axis the condyle is detached 
 and the operation completed. To effect 
 the removal of the other half make the 
 same incision on the opposite side, so as to 
 meet the first on the median line ; the dis- 
 section is similar. 
 
 The aupertor maxiUa has the following 
 important anatomical features : It is at- 
 tached to other bones at but three princi- 
 pal points : First, by its ascending process 
 and articulations with the os unguis and 
 ethmoid ; second, by the orbital border of 
 the malar as far as the spheno-maxillarv 
 fissure; third, by the ' articulation of the 
 two maxillaiy bones with each other and 
 the palate-bone ; there is a fourth point of contact behind with the ptery- 
 goid process and the palate-bone, wliich yields easily by simple depres- 
 sion of the maxillary bone into the interior of the month : in attacking 
 these different points no large vessel is injui-ed ; the trunk of the internal 
 maxillary artery may be easily avoided, or in any case tied after the 
 
 Fig. 324. 
 
 Liiaes of incision for resection of 
 upper jaw. 
 
810 
 
 OPERA TTVE S URGER Y. 
 
 Fig. 325. 
 
 removal of the bone ; moreover, in ca.sc of unforeseen heniorrliage during 
 the operation we have a resource in compression of the carotid ; only one 
 important nerve-trunk, the superior ma.\illary, need be divideil. 
 
 Resection of the bone is performed for tiie extirpation of malignant 
 growtLs and to gain access to naso-])iiarvngeal tumors : in the former 
 case it is ju.stifial)lc only wiiere the disea.se is limited to the upper jaw 
 and its corresponding palate-bone, owing to the certainty of recurrence 
 if the disease extends beyond. The methods of procedun; are numerous, 
 and give great and desirable latitude to the operator. Early operators 
 cut boldly through the clieck, 1 (h'ig. o'-i-l), but to avoid unsightly .scar.s 
 the rule now obtains of making the inci.sion in the cour.se of natural 
 folds of the skin, 2 and 4 (Fig. 324). Subperiosteal resection may be 
 made by these incisions, but a more formal operation is made by fol- 
 lowing the line 1 (Fig. 324). 
 
 Resect the superior maxilla below the floor of tlie orliit by the 
 following operation (Guerin) : Make an incision .slightly convex back- 
 ward, conmiencing at the ala of the no.se and terminating at the cor- 
 responding connnissure of the lip, 
 following the naso-labial fold or fur- 
 row, 4 (Fig. 324); dissect up the 
 two fla])s resulting from this incision 
 until tlie nostril is exixised and the 
 malar process isconipletcly denuded ; 
 witli a small saw held in the right 
 hand, saw through the malar pro- 
 cess from above downward, and a 
 little from within outward ; the soft 
 palate having been detached from 
 the posterior border of the palatine 
 bone by a transverse incision made 
 at the posterior border of the last 
 great molar, and an incisor tooth 
 having been extracted, divide the 
 horizontal portion of the maxilla 
 from before backward with cutting 
 forceps, one branch being in the 
 mouth, and the other in the nares ; 
 make a section of the bone from the 
 divided malar process to the nares 
 by the forceps ; seize the bone with 
 •strong forceps, and remove, fractur- 
 ing the pterygoid jirocess (Fig. 325). 
 After thorough disinfection of the 
 wound apply iodoform dressings. 
 
 The entire maxilla or portions 
 may be resected as follows : Exti-act 
 the incLsor teeth of that side ; divide the upper lip in tlie median line 
 to the nostril ; continue the incision around the ala and up the side of 
 the nose toward the inner canthus of the eye, thence continue it in a 
 slight curve below the orbit, 2 (Fig. 324), or to the malar bone ; reflect 
 the skin from the bone, and with a narrow saw passed into the no.stril 
 
 Method of removing the resected portiou 
 (Farabeuf). 
 
AMPVTATION. 
 
 811 
 
 divide the alveolus and hard palate ; incise the imieous menihrane of the 
 mouth as far back as the soft palate ; cut partially also the malar process 
 of the maxillary bone, or, if necessary, the bone itself, and the nasal pro- 
 cess of the superior maxilla, and complete the division of these bones 
 with the forceps ; grasp the bone with the lion forceps and detach it 
 forcibly from the pteryyoid process and palate-bone; when the bone is 
 loose raise the fascia t)f the orbital palate, si'parate the infra-orbital nerve, 
 the soft palate, and any adhering tissues. The hemorrhage must be sup- 
 pressed by ligatures and the actual cauteiy, and the wound adjusted at 
 the lips by hare-lip pins and in other parts by carl)olized silk sutures. 
 The KUpcvior ma.rilke may be removed at a single oju'ratinn by an 
 incision, 3 (Fig. 324), along the centre of the nose and through the ujiper 
 lip; additional incisions may be made, if rc(iuired, under the orbit later- 
 ally. Or, a fonr-cornereil tlap may be made by an incision on either side 
 from the angles of the mouth to the external angles of the eye, 1 (Fig. 324). 
 The divisions of the bone by the different operations are instructively 
 shown by Treves. 
 
 Fig. 326. 
 
 Saw incisions in the maxilte: A, B, C. excision of the upper jaw; /), Boeckel's operation (nasal 
 polypusi; E, V. Guerin's /iperation (partial excision); F, F, Langenbecl<'s operation (nasal 
 Ii:>lypusi; li. excision of lower jaw ; if, removal of portion of alveolus ; J, Esmarch's opera- 
 tion (anlij-losis of Jaw) (Treves). 
 
 The Extremities. 
 
 Amputation. 
 An amputation is required only when the question of recovery by other 
 means is negatived beyond all reasonable doubt, or when the presence of 
 
812 
 
 OPERATIVE 8VRQERY. 
 
 Fi(i. 327. 
 
 an incurable disease is a source of such evil or discomfort as to render the 
 loss of the limb desirable or beneficial to the patient. The Knal judg- 
 ment as to the necessity of an ani])utation in any given case must be 
 sustained bv the latest sui'uical ('\|i( liencc, for an amputation that would 
 formerly have been justified would now be repudiated liy the best au- 
 thorities, and the o])crator justly charged with 
 ignorance and unskilfulness. 
 
 The instruments required to form a complete 
 amjnitating case are a long and short knife and 
 catling (Fig. •527), metacarpal saw, scalpel, te- 
 iiaculuin, saw, bone forceps, artery forceps, need-. 
 Ics, t()m'ni(|uet, and elastii' bandage. The knife 
 should be al)out twice the length of the diam- 
 eter of the limb. The catling is a double-edged 
 knife, the two edges being parallel until they 
 converge to form the point ; the scalpel is large 
 and strong, having a firm handle. The saw 
 (Fig. 328) should have a strong back and be 
 well set. The Ixtne forceps shotdd lie cutting. 
 . The tourniquet should be strong (Fig. 203), 
 
 I I ''"'•^ applied as in Fig. 204. The clastic band- 
 
 ' lli ^>^'^ '^ '^^'^'" *" ^'^' ^*^*^' ^"*"^ '^'' apjilication in 
 
 Fig. 201. The artery forceps may be dog- 
 toothed (Fig. 206) or with a slide. There 
 should be six or more catch forceps (Fig. 207). 
 The time of tlie operation must be fixed with 
 due regard to the cause which necessitates the 
 amputation and the condition of the jiatient. 
 There is a time when interference nuist be 
 avoided rather than courted, but the limits of 
 the two periods are not always ^\'cll defined, 
 and must be left to the judgment of the sur- 
 geon in each individual case. In general, it 
 may be advised, thus: (1) injuries necessitate 
 inunediatc amputations, but the ojx'ration 
 should not be performed during the period 
 of reaction from shock ; (2) if the disease is 
 acute, avoid the period of active inflammation 
 and rapidly-spreading gangrene ; (3) in chronic 
 affections the surgeon should regulate the time 
 of operation according to the j)rinciplcs detailed. 
 Tlie jildce of (imputation must be deter- 
 mined with regard (1) to the safety of the 
 ])atient, and (2) to the serviceableness of the 
 resulting limb. Divisions of amputations 
 based on the place of operation — namely, (1) 
 in the continuity of the shaft; (2) in the con- 
 V)ones — are now comparatively unimportant, as 
 experience proves that both for safety to the patient and servicealileness 
 of stump no distinction should be made between amputation in the con- 
 tinuity and contiguity, with the exception of the ankle. In the upper 
 
 X3r 
 
 Antiseptic knives, 
 handles. 
 
 tiguity or articulation of 
 
AMPUTATIOX. 
 
 813 
 
 extreraitv all the conditions unite in favor of tlie least possible sacrifice 
 of parts, for the safety (tf the jiatient is in j)rop()rtit)n to the distance of 
 the wound from the Ijody ; and tlie vahie of tiie stump in preliension 
 depends upon the number of articulations preserved. In the lower 
 extremity the same rule applies to the wound, but as the stump is to 
 be used in locomotion, it rc(|uires breadth and firmness to sustain con- 
 tact witli the artificial appliances used in jtrojiression, and hence a place 
 of amputation must be selected which will secure tlu'sc conditions. TJiis 
 place is not always the farthest point from the trunk at wliich an am2)u- 
 tation could be performed in a given case. But in practice it is not 
 difficult to harmonize the two indications : when the amputation nearer 
 the trunk would give the better stump, the danger of the wound is not 
 
 Fig. 328. 
 
 ■^ ^v^■^^v.^^vwvAWvw^^vw^AvAVW>AAA^A^^^v/AV.^^A^J^^^/A^^Av 
 
 .Amputating saw. 
 
 SO much greater, generally, as to forbid accepting the sliglitly increased 
 risk for the lifelong ail vantage gained. 
 
 Tlie immediate pvepumfion for an amputation should include all of the 
 appliances necessary to render the wound entirely aseptic, as fully stated 
 in the section giving the details of an antiseptic operation. The limb to 
 be amj)utated shoulil l)e scrupulously cleansed, disinfected, and shaved as 
 directed on the day preceding tiie operation. When other preparations 
 are comjjlete, apply the elastic liandage from the extremity to a point 
 sufficiently above the place of the division of the bone to pi'event its 
 interfering with the formation of the flaps (Fig. 329). 
 
 Fig. 329. 
 
 Elastic bandage in amputation at the knee-joint. 
 
 Tlie method of operation should aim to secure a well-nourished cover- 
 ing of the stump, neither scant}' nor redundant, and freely movable 
 cicatricial tissue. To obtain such results, (1) the soft parts must be very 
 nicely adapted to the surface to be covered and well supjilied with blood- 
 vessels ; (2) the cut surface of bone must l)e immediately covered by tlie 
 pericsteum or the deep fascia of the part, iu order to pre\-cnt the super- 
 
814 OPERATIVE SUROEBY. 
 
 ficial fiiscia and intfwtiniciit from hccominfi; too firmly attaflicd liy the 
 cicatricial tissue to tiic cirI of the hone. Tliese resiihs are secured hy 
 raisiufi' tlie periosteum with the soft tissues and applying it to the cut 
 end of the bone. The objection to the periosteal covering of the bone 
 that osteophytes are liable to form on the extremity and render the 
 stump tender are trivial wlien C()m])ared with the advantages which fol- 
 low the protection wliieii it affords from necrosis and osteomyelitis, and 
 the l)asis which it forms for a moval)lc covering. If osteoi)hytcs become 
 tronblesome, they may readily be removed bj' a slight operation. It also 
 freipiently happens that the mutilation of parts by the injury is so great 
 that the surgeon can form the coverings of the stump by no fixed rules, 
 but must exercise his ingenuity in ])atchwork. If the conditions essen- 
 tial to a sound and useful stump are constantly kcj)t in view, any of the 
 stereotyped or extemporized methods may, with ])atience and dexterity, 
 be made to yield good results. The recognized methods of amputation 
 are: (1) the circular ; (2) the single flap ; (3) the double flap ; (4) the 
 rectangular flap ; (5) the bilateral flap ; (0) the periosteal flap. 
 
 The circular operation can be executed more quickly by the following 
 than by the ordinary method : Stand u])ou the right side of the limb, 
 the left foot thrown forward and placed fii'mly upon tiie floor, the right 
 knee bending sutticiently to give freedom of motion to the body; grasp 
 the limb above the jioint of operation with the left hand, and take the 
 handle of the knife l)etwecn the thumb and fore and second fingers of 
 the right hand, lightly supported by the other fingers; stoojiing suffi- 
 ciently to allow the right arm to encircle the limb readily, carry the 
 knife around until the blade is nearly perpendicular to tiie long axis of 
 the limb on the side next to you with the point downward and the hand 
 above the limb. Commence the cut \\\{\\ the heel of the knife, giving 
 slightly sawing motions, and bring the hand under the limb, and then 
 directly njiward upon the side next to you, until the heej touches the 
 point of commencement ; the handle of the knife held thus delicately 
 will change its relative positions as it passes around the linili without the 
 slightest embarrassment to the operator. The ease with which the incision 
 is completed will depend much upon whether it commences ^^•ell down 
 upon the side of the limb next to the ojierator ; raise the skin from the 
 first layer of muscles by dissection, and turn it upward, t\vo or three 
 inches according to the diameter of the limb, like the cutt' of a coat. 
 Divide the first layer of muscles at the margin of the retracted integu- 
 ment by the cir<'ular incision, as of the skin ; raise this layer with the 
 knife and draw it still farther upward ; divide the last layer of muscles 
 down to the bone (Fig. 330) by the same sweep of the knife as before 
 given. Saw the bone at the apex of the cone. 
 
 The single flap, or a short anterior and long posterior flap, is performed 
 as follows : Stand ujiou the right side of the limb ; grasp the thigh with 
 the left hand, placing the fingers and thunii) upon ojiposite points; then 
 apply the heel of a long amputating knife on the farther side of the limb 
 at the ends of the fingers, and draw it in a semicircular direction over the 
 limb to the end of the thumb; with this single sweep divide all the soft 
 parts down the bone : Avithout entirely removing the knife withdraw it 
 sufficiently to enter the point at the angle of the wound, and transfix the 
 limb, passing under the bone, and emerging at the angle of the wound 
 
AMPUTATION. 
 
 815 
 
 on tlie opjjosite side ; make a flap of the requisite length from tlie poste- 
 rior part of the tiiigli. Tlie flaps are reti'aeted, the knife earried around 
 the bone, and the saw applied at the highest part of the wound. 
 
 Double fl<ipx are formed as t()llows : Grasp the soft parts and briiig 
 them forwai'd ; transfix the lind), the knife grazing tiie upper surface of 
 
 Fig. o30. Fio. 331. 
 
 Circular amputation 
 
 DoubJe-tlap amputation. 
 
 the bone, and make a short anterior flaji ; reintroduce the knife, and, pass- 
 ing under the bone, make a posterior flap longer than the anterior to com- 
 pensate for the greater retraction ; complete the operation as in the former 
 method. Flaps may also be made from the sides of the limb by intro- 
 ducing the knife in the centre of the limb directly down to the bone, on 
 one side of which it is jiassed to the oppo.site side of the limb, and a flap is 
 then formed (Fig. 3-"51) ; the knife is reintroduced and a flap made from 
 the opposite side ; the Haps are .strongly retracted and the bone sawed. 
 
 The redaiujidar flap method is as follows: Make a longitudinal 
 incision on either side of the limb (Fig. 332), in length equal to two- 
 
 FiG. 332. 
 
 Lino.s of incision in Teale's amputation. 
 
 thirds of the circumference of the limb at this |)art ; make a second 
 incision to the Ixme; unite the lower extremities of these two incisions; 
 raise this quadrilateral flap from the bone ; make a third incision trans- 
 versely down to the bone, forming the posterior flaj) ; raise liotli flajts 
 and firndy retract them; saw the bone at the junction of the flaps, and 
 unite the flaps. 
 
 Double flnpx of the infer/itments and circidur incittion of the muscles 
 require that the flaps should be sufficient to meet without cftbrt, should 
 correspond in size, and shotdd not be made too arched ; in dividing the 
 muscles the knife, uidcss the limb be of unusual dimensions, should be 
 carried down to the bone at once, and this can only he done by the appli- 
 cation of considerable force, great care being taken that the muscular 
 mass behind the bone be not pushed before the knife, but divided without 
 displacement from its natural relations to the parts around. AMicn the 
 
816 
 
 OPERATIVE SURGERY. 
 
 liinl) is very larnco it would ho well to divide the superficial muscles first, 
 and allow tlicm to retract hcthre the divisiou of tlie remaiuder. 
 
 The periodeal ft(ij) is most pei'feet when made as follows : Make a 
 circular incision directly down to the bone ; saw the bono ; while an 
 assistant grasps the extremity with stout forceps, the operator raises the 
 periosteum, beginning at the extremity of the cut bone, separating its 
 
 Fio. 333. 
 
 Method of forming periosteal flaps. 
 
 attachments to the linea aspera with the knife ; the periosteotome may 
 be used, but in general the thumb-nails will be found most efficient. 
 The periosteum, thus raised, covers the central part of the flap (Fig. 333), 
 and when the flap is brought over the extremity the jjcriostcian makes a 
 perfect covering, and the tissues between the skin and periosteum, being 
 uninjured, rapidly unite. 
 
 Fig. 334. 
 
 A stump showing mode of applying sutures and drainage-tube. A drainage-tube 
 is sliovvn at the left. 
 
 The bone must always be divided as follows : The jieriosteura 
 having been I'aised as high up in the flap as possible, first a]iply the heel 
 of the saw and draw it slowly but firmly across the bone to make a 
 groove ; then move it rapidly until the bone is nearly divided, when it 
 is to be moved more slowly to avoid splintering the last connections ; 
 with the bone forceps clip off' any sharji or projecting edges and l)evel 
 the end of the bone smoothly. Where there is a single bone it will be 
 
AMPUTATION. 
 
 817 
 
 found easier to apply the saw nearly iierpondicularly on tlie side opposite 
 to the o])crator ; where there are two Ixines the saw shoiikl be first and 
 last applied to the larger and firmer hone, the smaller bone being eom- 
 pletely divided while the saw is engaged in the larger bone. 
 
 The wound must be closed and dressed according to the principles 
 already given. The application of hot water (1-30° F. to 140° F.) by 
 rapid douches to amputation wounds is an excellent method of arresting 
 hemorrhage and preparing the surfaces for pronijit union. The hot 
 water must not be allowed to remain in contact with the limb. The 
 vessels having been secured, if the fibrous sheaths are seen, as in ampu- 
 tations at the metacarpo-phalangcal articulations, close them with two or 
 three fine sutures. Then close the wound with two or three deep and sev- 
 eral superficial interrupted sutures (Fig. 334) ; place in the angles of the 
 wound proper drainage-tubes so as to relieve it of all accumulating fiuids ; 
 snjiport the jiarts in such manner l)y sjilints, or slings, or pads, that it 
 need not be moved in dressing ; apply such dressings as will support and 
 protect the wound, but admit of easy change. 
 
 Fig. 335. 
 
 I. AMPUTATIONS IN THE HAND. 
 
 Operative and mechanical surgery unite in enforcing the rule that 
 in the hand no part should be removed that can be saved ; no instru- 
 ment-maker can contrive anything 
 as useful as a finger. A great vari- 
 ety of methods of operation have 
 been devised to meet the emergen- 
 cies which arise from injuries of 
 the hand retpuring amputation (Fig. 
 335). 
 
 The plialangefi are often injured in 
 such a manner as to compel the sur- 
 geon to perform a circular, flap, or 
 some modified operation to secure 
 the requisite covering; but, when the 
 parts will admit, a palmar flap is 
 preferable, as the cicatrix is by this 
 method removed to the dorsal sur- 
 face, the stump is firm and well 
 ada|)ted for use, and the tactile sen- 
 sation is less impaired. 
 
 The anatomical guides to the ar- 
 ticulations are the transverse depres- 
 sions (Fig. 336) in the skin on the 
 palmar surface. Between the bony 
 l)rojcctions at the side 'of the finger, 
 
 at the articulation of the second and -•'. ''isarticulntion of phalanx, palmar flap; B, 
 
 I . . , , , . amputation in eontinuitv. circular : C, lueta- 
 
 tllirU plialanges, a depression marks carpo-plialansical fUsarticulation ; _D, ampu- 
 
 xi „ •■• i» ,1 _,. 1 ,. tation of a nii-tac;iri)jil bone in continuitv; 
 
 tne position Ot the articulation; a JS. ilisarticulatlnn ..f little linger: /-.disloca 
 
 tion of fifth metacarpal ; <»', amputation of 
 wrist, circular; H, amputation of wrist. 
 
 jirominence is readily detected on the 
 dorsum of the second i)halanx just 
 in front of its articulation with the distal extremity of the first phalanx ; 
 
 Vol. I.— 52 
 
818 
 
 OPERATIVE SURGEnY. 
 
 the articulation of the first |)iialaii,\ with liic iiu'tacarpal l)on(' is ininu'- 
 diatcly bchiiul the bony proiiiiiifiices of tlu' proximal extreiiiity of the 
 first phalanx. The transverse depressions in the 
 skin on the palmar surface of each finger are three 
 in number, and have the follo\vin<i; relation to the 
 corresponding- articulations, conunencing with the 
 extremities of the fingers held in an extended posi- 
 tion : The first dejiressiou is situated about a line 
 
 Fig. 337. 
 
 Fig. 338. 
 
 Guides to articu- 
 lation. 
 
 Plialanx flexed. 
 
 The mode of holding the finger during 
 disarticulation of the last phalanx. 
 
 and a half above the articulation, / (Fig. 336), between the third and sec- 
 ond phalanges ; the second depression is situated exactly over the articula- 
 
 FiG. 339. 
 
 Amputation of a finger: cutting the flaps by transfixion (Erichsen) 
 
 tion, d (Fig. 336), between the second and first ])halanges ; the third 
 depression, e (Fig. 336), situated at the commissure of the fingers, is 
 about an inch below the articulation, b (Fig. 336), of the first phalanx 
 
AMPUTATION. 
 
 819 
 
 Fig. 340. 
 
 with the metacarpal bone. When the finger i.s placed in a state of 
 extreme fiexiun it will be seen (Fig. 337) that the relations of the artie- 
 iilatit)n ciiange, and hence the point at which the articulation is to be 
 souglit will depend on the position of the finger. 
 
 The palmar flap of a finger is made tiius : Pronate tiie hand and 
 reciuire an assistant to Iiold apart the sound fingers; seize the phalanx 
 witii tiie thumb and index finger, and bend it to an angle of forty-five 
 degrees; recognize the line of tiie joint as follows: On the dorsal sur- 
 face there is a well-marked fold in the skin, and the joint is half a line 
 below it ; or, if this is not found, recognize the dorsal projection formed 
 bv flexion, and cut half a line Ix'vond it; or seek the termination of the 
 j>almar fi)ld, and find the joint iuilf a line below it. In amputations 
 tiin)Ugh tlie shaft of a jihalanx tlie ])almar flap may be made by trans- 
 fixion (Fig. 339). Make first the dorsal incision, then make a palmar 
 flap of ample dimensions (Fig. 338, Treves). 
 
 The oval method at the articulations is as follows : Grasp the finger 
 in a prone position on its palmar and dorsal surfaces by the fingers and 
 thumb of the left Iiand, and flex to 
 an angle of forty-five degrees ; make 
 an incision iialf an inch long on the 
 dorsal aspect of the joint a quarter 
 of an inch above it, C (Fig. 340), 
 and carry it then across tiie palmar 
 surface to the opposite side, tiie fingi'r 
 iH'ing fi)rcibly extended ; tlience, the 
 finser beintr asain flexed, tiie incision 
 is continued upward to the dorsum ; 
 dissect the borders of the wound 
 from tiie head of the phalanx, enter 
 tiie joint on its dorsal aspect, divide 
 the extensor tendons and lateral lig- 
 aments, increase the flexion, wath an 
 eft"ort to luxate the joint, which 
 renders tlie flexor tendons easy of 
 division. The oval amputation, D 
 (Fig. 340, Treves), wiiieli is designed 
 to ])lace tlie cicatrix beyond pressure, 
 is useful (Faralieuf ). 
 
 A single finger may be removed 
 at the metacarpo-phalangeal articula- 
 tion by the oval method (Fig. 340, 
 Treves). A single finger and its meta- 
 carpal hone may be removed by ex- 
 tending tlie preceding incision (Fig. 
 340, Treves). 
 
 The/our fingers nlay be removed 
 at a single operation. The distal 
 extremities of the metacarpal liones 
 are not all on the same line ; those 
 of tlie index and ring fingers are nearly on a level, while that of the 
 middle finger is about half a line lo\\er, and that of the little finger is 
 
 ^, disartioulation by single external flap: S, 
 ami)Utatii>n by lateral flaps ; C, disarticula- 
 tion by oval or raoket incision; D, modified 
 racket incisiiiii fur imlcx finger: E, circular 
 niclhnd, w itli \i'rtii'iil <lorsal cut: F. incision 
 en cnnipih'e; G, interuo-palTnar flap method 
 for little finger : H, disarticulation by single 
 palmar flap; /, disarticulation by racket 
 incision: A', amputation of the fingers with 
 their metacarpal bones; L, circular disartic- 
 ulation at the wrist. 
 
820 
 
 OPERATIVE SURGERY. 
 
 half a line higher. The hand being- well pronated, grasp the four 
 fingers with the left hand and flex them moderately while an assistant 
 supports the hand and retracts the skin as much as possible ; with a 
 
 Fig. 341. 
 
 Amputation i)f nil the fingers. 
 
 straight narrow knife make a curved dorsal incision, a, b, e (Fig. 341) 
 %\ith its convexity looking downward, fi'om six to eight lines below tlic 
 heads of the metacari)al bones, from the index toward the little finger 
 if the left hand, and in the opposite direction if the right ; the exten.sor 
 tendons being exposed by the retraction of the integuments, which is 
 assisted by a few strokes of the knife, open each of the metacarjio- 
 phalangeal articulations ; divide the extensor tendon first, then the 
 lateral, and finally the palmar ligamentous attachments ; carry the knife 
 
 Fig. 342. 
 
 Fig. 344. 
 
 Eesults of amputation at metacarpo-phalangeal artie\ilation in middle, index, and ring fingers. 
 
 through the articulations to the jialmar as]K'ct of the phalanges, and cut 
 outa fia]> limited anteriorly l)y the folds in the skin at the base of the 
 fingers on their palmar surfaces. 
 
 Bv the same method two or three fingers may be amputated, the 
 sound fingers being held aside ; the dorsal flap is then formed by the 
 
AMPUTATION. 
 
 821 
 
 Fig. 345. 
 
 point of the knife; or the hand may be held in the supine position and 
 the flap made first from the pahuar surface. The appearance of the 
 stump is improved by sloping the projecting portion of each knuckle 
 with cutting pliers. 
 
 The results of these amputations are excellent both as regards the 
 usefulness of the hand and its appearance (Figs. 342, 343, 344). 
 
 The thumb may be amputated at its phalangeal or metacarpal articu- 
 lation. The first is performed in the 
 .same manner as that of the fingers, 
 but the removal at the metacarpo- 
 phalangeal articulation reqiures a 
 large flap, owing to the great size of 
 the head of the metacarpal bone. 
 Make an incision on the dorsal aspect, 
 convex upward, the centre being a 
 little above the joint, and the ex- 
 tremities terminating on each side at 
 the end of the palmar transverse fold ; 
 extend the thumb and make a palmar 
 convex incision, uniting the extremi- 
 ties of the first, the centre extending 
 midway between the transverse cuta- 
 neous fold alluded to and tliat mark- 
 ing the articulation of the first and 
 second phalanges ; open the joint and. 
 complete the disarticulation, remov- 
 ing the sesamoid bones, D (Fig. 341, 
 Treves). The palmar flap, applied 
 to the end of the bone, sin mid accu- 
 rately fit the curved incision above. 
 Or the flap may be made by trans- 
 fixion (Fig. 346). 
 
 Tlie appearance of the hand after 
 amputation of the thumb is good ; 
 the power of grasping is lost, but 
 prehension remains. 
 
 A single vietacarpal bone is re- 
 moved by an incision on the dorsal aspect corresponding in length with 
 the portion of the bone to be removed. Separate the soft parts cautiously 
 from the bone, the knife being carried parallel with its long axis to 
 avoid wounding the palmar arch ; having made, the incisions on both 
 sides, pass the point of the knife under the bone, so as to appear at tiie 
 opposite side, and then, by carrying it fi)rward in contact with the under 
 surface of the bone, di.vide the soft parts at one section : if the operation 
 is of either the third or fourth metacarpal bone, the section should be 
 made with the bone forceps ; if of the metacarpal bone of the thumb, 
 saw it perpendicularly to its axis ; if of the index finger, make a section 
 obliquely from without inward, tiie hand being supine ; if of the little 
 finger, from within outward (Fig. 347), a, the soft parts being withdrawn 
 by the retractor, b. 
 
 Amputation throiufh the four metacarpal bones (Fig. 348) is made as 
 
 A, disartieulatiou by special externo-palmar 
 flap ; B, disarticulation by lateral flaps ; C, 
 am)iutatiiin liv unequal dorso-palmar flaps; 
 J), disarticulation by oblique palmar flap; E, 
 disarticulation of the rins tinker with its 
 mctac ar|>al bi.uc bv racket incision ; F, same 
 operation upon tlic little liiiKer : G, Dubru- 
 eil's disarticulation at the wrist. 
 
822 
 
 OPERATIVE SURGERY. 
 
 follows : Make a palmar flap as in disarticulation of all the fingers, and 
 a similar incision on the dorsum ; jiass the i^nife into the interosseous 
 spaces, separate the muscular attachments, and divide the periosteum ; 
 
 Fig. 34G. 
 
 Amputation of the right thumb by transfixion : cutting the anterior flap. 
 
 apjily a five-tailed retractor, a (Fig. 348), and saw the hones with a meta- 
 carpid saw, or the palmar flap may be convex forward and the dorsal 
 flap concave, k (Fig. 340). 
 
 Fig. 34 
 
 Amputation of a single metacarpal bone. 
 
 Disarticulation of the thumb irilh flic first metacarpal bone is performed 
 as follows : The joint is of a mixed character between arthrodial and 
 ginglymoid ; on its dor.sal surface it is almost subcutaneous, but covered 
 with thick muscle on its palmar aspect ; the radial artery passes around 
 
AMPUTATION. 
 
 823 
 
 its ulnar side ; it has a loose capsule ; the joint runs in an oblique 
 direction, in a line drawn from its external side to the root of the 
 
 Fig. 349. 
 
 Amputation of aU the metacarpal bones. 
 
 little finger; its position is easily deterniined liy the projection of the en- 
 largement of the head of the bone on pressing the thumb into the palm ; 
 it lies ;ui inch and a quarter below the styloid 
 process of the radius. Hold the liand in a 
 position I)etween supination and pmuation ; 
 make an incision along tiie dorsal surface of 
 the metacarpal bone of the thumb, connnen- 
 cing six lines above its articulation (Fig. 349, 
 Treves) with the trapezium, and extending 
 througli all the tissues down to the bone, to 
 the inner side of tiie liead of the first ])iialanx 
 of the tiuunb, on a level with the conunissure 
 between the thumb and index linger ; carrying 
 the hand to pronation, continue the incision 
 around the palmar surface of the phalanx to 
 its outside, and thence to the dorsum of the 
 metacarpal bone to join the first incision al)out 
 its middle ; detacli ti'.e nuiscles and integu- 
 ments from either side of the bone, and open 
 the articulation from its dorsal aspect (Fig. 
 350) ; then, endeavoring to dislocate the bone 
 outward, complete the division of its rcmain- 
 ijig attachments. 
 
 JJi-sarficuhttion of the ficcoricl metacarpal 
 bone is rendered especially difficult on ac- 
 count of the prolongation of that jjart of its head that is in relation 
 with tile trapezoid, os magnum, and third metacarpal. The hand held 
 in ])ronation, tiie thumb and fingers separated, make an incision, com- 
 mencing about half an inch in front of the styloid ])roccss of tlie radius, 
 but on a line witli the .second metacarpal bone, d (Fig. 350), and con- 
 tinue to tlie internal side of the base of the first phalanx, o ; now carry 
 
 Disarticulation of the thumb with 
 its metacarpal bone by a racket 
 incision. 
 
824 
 
 OPERATIVE SURGERY. 
 
 it around the palmar surface in the cutaneous fold — represented on the 
 dorsum by the line b, c — to the point c; and thence to jioint of com- 
 mencement, (/ ; dissect the soft parts by keeping the knife close to the 
 bone, tlu' wound being held apart; carry the knife up along the internal 
 side of the bone to the union of the Pj,. 351 
 
 two metacarpal bones, and, turning 
 its edges inward, divide the inter- 
 
 FiG. 350. « — 
 
 Line of incision for removal of second 
 metacarpal bone. 
 
 Amputation of tirst metacarpal bone. 
 
 osseous ligament, and in the same manner enter the knife into the 
 articulation of the metacarpal bone with tiie trajiezius ; the anterior and 
 posterior ligaments are next divided, the bone di.^located, and the knife, 
 entered flatwise and horizontally under the ujijier part of the bone a and 
 6 (Fig. 351), is carried downward, completing the operation ; care should 
 be taken in dividing the ligaments not to penetrate any adjoining articu- 
 lar cavity. 
 
 Dimrticiilation of the fifth metacarpal bone may be performed by two 
 methods : The unciform receives the fifth metacarpal lione upon a sur- 
 face concave from behind forward ; the line of articulation, if prolonged, 
 would fall upon the middle of the second metacarpal bone. (1) Pronate 
 the hand and commence an incision one line above the articulation F 
 (Fig. 345, Treves), and carry it along the dorsum to the commissure, 
 then under the finger, along the fold of the integument, to the opposite 
 side, and tlience back to the point of dejiarturc ; dissect the soft 
 parts from the bone and di.sarticulate. (2) The hand being held in a 
 state of forced pronation, commence at the carpo-metacarpal joint with 
 a slight lateral incision, and carry it down in a straight line to the inner 
 border of the first phalanx of the little finger until it meets the depres- 
 sion at the base of the little finger on its palmar surface ; then continue 
 it around the base of the finger, following this depression exactly, and, 
 lifting the little finger, continue the incision around to its inside and 
 upward to join the first portion about opposite to the centre of the meta- 
 carpal bone ; detach the integuments and muscles from the bone, and 
 divide its articular connection with the point of the bistoury in the 
 manner already described. 
 
 Disarticulation of a mdaearpal bone is as follows (Fig. 345) : Make a 
 transverse incision, E, a little in front of the articulation, another upon 
 the dorsum of the metacarpal bone ; the disarticulation is then readily 
 effected. 
 
AMPUTATION. 
 
 825 
 
 Disarfiindntini) of the metacarpal honeH of the foar fingers \s performed 
 thus : Hold the hand in the position of forced su])ination and introduce, 
 opposite the articulation of the fifth metacarpal \\itli the unciform boue, 
 
 Fig. 352. 
 
 Fia. 3.53. 
 
 Disarticulation of metacarpal bones of four fingers. 
 
 a small, straight knife Itetween the bones and the soft parts, carrying it 
 a little below the projections formed by the unciform and the trapezium, 
 so as to bring out its point below the thumb ; carry the blade of the 
 
 Fig. 3.'54. 
 
 Fig. 355. 
 
 Amputation at the wrist by long palmar flap 
 ^Eriehsen). 
 
 Same disarticulation by external flap. 
 
 knife along the jialniar surfaces of the metacarpal bones, and cut out a 
 large flap of an elliptical outline, a, h, <• (Fig. .352) ; turn the hand to a 
 prone position and make a semicircular incision across its back, two- 
 
82G OPERATIVE SUIIGERY. 
 
 tliii-(ls of an inch below the lino of the articulations, and, carrying the 
 knife through the tissues connecting the thumb with the index finger, 
 «, 6, c (Fig. 353), join the first incision ; while an assistant is drawing the 
 intcgunients U]n\!ir<l lidhl the metacarpus in tlie li'ft hiind, disarticulate 
 friim tlu' front, conuncncing with tlie metacarpal bone of tlic index or 
 little finger, according as the operation is upon the rigiit or h'ft hand. 
 
 Dharticidatlon at the ivrist-joint gives the best results when a 
 fla]) is taken from the palmar surface of the hand. To determine the 
 articulation, (1) strongly bend the hand backward ; the summit of the 
 angle formed by it M-ith the forearm indicates the radio-carjial articula- 
 tion ; (2) feel in front of the transverse line of the ra(Hus ; the joint is 
 one line below it, and two-thirds of an incli above the I'rcase in the skin 
 tliat separates the palm of the hand from the forearm ; (3) determine the 
 summit of the styloid processes and draw a transverse line between them; 
 this line will be two lines and a lialf below the joint. 
 
 A tiUu/Ie pahiutr flap is made as follows : An assistant holds the hand 
 in a supine position ; grasp the extremity in the palm of the left hand, 
 jilacing the thuml) and forefinger on tiie extremities of the styloid pro- 
 cesses ; make a semicircular flap from tiie palm (Fig. 354), extending 
 from just below the processes ; dissect the flap and turn it back, make 
 a small flap at the dorsum, and divide the tendons, the radio-carpal and 
 lateral ligaments. An external flaji (Dubrueil) may be made wliich will 
 give a good covering (Fig. 355, Chalot). 
 
 AMPUTATION THROUGH THE FOREARM. 
 
 It is important to preserve as long a stump as possible of the forearm 
 for various occupations and for tiie application of apparatus. It is better, 
 therefore, to amputate near to than at the elbo\v -joint, for the smallest 
 movable part of tiie forearm may be useful. The arteries are the radial, 
 ulnar, and anterior and posterior interosseous; two bones of diiierent 
 diameters, at different parts of the limb, are to be divided. 
 
 Semicircular skin-flaps and circular of the muscles is the best method 
 of amputation in any part of the forearm. The skin is usually too thin 
 for one long skin-flap, and there are too many tendons fiir the rectangular 
 flap. Operate thus : The arm being held with the hand supine, so as to 
 render the bones parallel, cut from the anterior and posterior surfaces 
 semicircular flaps of suitable length, including the tissues above the mus- 
 cles ; turn these flaps backward and with a long knife divide the tissues 
 to the bone (Fig. 356) ; saw the two bones at the same time. 
 
 Fig. 356. 
 
 Vminitati II i nin 1 v mixed method (Bryant). 
 
 The^«;j method maybe single or double. The arm being held in the 
 position between pronation and supination, with the thumb uppermost. 
 
AMPUTATION. 
 
 827 
 
 SO tliat the radius and ulna are in one line, insert a sharp-pointed knife 
 close to the inner edge of the radius and bring it out opposite at tiie edge 
 of tiie ulna : if a single flap is to be made, it must be taken from the 
 anterior face, and be long enough to completely cover the stump ; if a 
 double flaji is preferred, make an anterior flap the length of half the 
 diameter of the arm and a ])osteri()r flap of equal length ; turn hack the 
 flaps, divide the tendinous nuiscular or interosseous flbres not cut through, 
 and divide the bones as in the circular operation. 
 
 Fig. 357. 
 
 AMPUTATION' AT THE ELBOW-.K )IXT. 
 
 Amputation at the elbow-joint is to be preferred to amputation 
 through the arm if no artificial arm is to be aj)])lied, as the stump is 
 broad and firm and can be made more useful. Several methods are 
 adapted for this articulation (Fig. 357). The cir- 
 cular and single anterior flap methods are generally 
 to be preferred. 
 
 The exact position of the joint is determined 
 by careful attention to the anatomical relations of 
 the following osseous prominences about the joint: 
 the epicondyles, or the most prominent points on 
 the condyles of the os brachii are recognized, the 
 internal more readily than the external ; also the 
 olecranon, c (Fig. 359) ; a line drawn through the 
 lower j)oints is, on the outside, a quarter of an inch 
 above the interarticular line, b (Fig. 358), and on 
 
 Fig. 358. 
 
 Fig. 359. 
 
 Amputation at the elbow- 
 joint: .1, antiTior flap: i?, 
 external flap ; C. circular 
 method. 
 
 Anatomical points about the elbow-joint. 
 
 the inside three-quarters of an inch, e ; the articulation of the radius and 
 humerus is transverse, that of the ulna irregular, and owing to its pro- 
 jections must be entered e.xternally. Two facts appear : first, that the 
 articular interline is very oblique from without inward and from above 
 tlownward ; second, that it is very mucii l)elow the tuberosities of the 
 humerus. If, then, in cutting the anterior flap its base is extended up to 
 the level of these tuberosities, it will almost always he too short to cover 
 the bone, which will project, especially on the inside and downward ; 
 therefore enter the knife one inch below the middle projection of the 
 epitrochlca to bring it out half an inch below the prcjectiou of the 
 epicoudyle. 
 
828 
 
 OPERATIVE SURGERY. 
 
 The circular method is as follows, (' (Fig. 357) : The arm being held 
 in a sui)ine position, make a circular incision through the skin only, 
 three or four inches according to the size of the limb below the joint ; 
 dissect uj) the integuments to the joint and reflect backward, a, h (Fig. 
 
 Fig. 3CjO. 
 
 Fig. 3G1. 
 
 Circular amputation at the elbow. 
 
 Flap amputation at the elbow. 
 
 360) ; divide the muscles in front and the ligaments, enter the joint, and 
 complete the disarticulation by dividing the triceps or .sawing off the 
 olecranon ; the brachial artery is divided above its bifurcation. 
 
 The niiif/Zc (inferior fiiip is made thus: Supinatc and slightly flex the 
 limb, and make a flap from the .soft parts of the ji>int ; insert a straight 
 knife an inch below the internal condyle, traverse the limb close to the 
 ulna, until it appears one and three-quarters inches below the external 
 condyle, to allow for retraction of muscles arising from the humerus ; 
 (tut an inferior flap a, b, c (Fig. 361), about three inches in length ; retract 
 tins flap, and jniss the knife l)ehind the liml), and enter the heel on the 
 outside between the radius and os brachii, and extend the incision ; 
 draw it across the back part of the joint, dividing all the tissues to the 
 internal angle of the wound ; divide the anterior ligament and the lateral 
 ligaments, luxate the bones forward, cut the triceps, and complete the 
 operation. 
 
 An external flap, B (Fig. 357), maybe preferred in some cases of 
 accident : Make the flap by transfixing the limb upon the outside ; insert 
 the point of the knife just ■s^'ithin the head of the radius ; traverse the 
 neck, cutting out a larger external flap ; a second flap is made from the 
 inside of the arm by cutting from without inward and from below 
 U])ward, the soft tissues immediately covering the joint are then divided 
 and disarticulation completed. 
 
 AMPUTATION OF THE AEM. 
 
 Amputation of the arm may be performed at any point, but, as a 
 rule, as little should be sacrificed as possible. Owing to its uniform 
 size and single central lionc any of the different methods may be applied, 
 but the periosteum should be raised for a covering to the l)onc. There 
 are two elliptical methods: one on the posterior and the other on the 
 anterior face of the limb, the highest point in the former' being the 
 olecranon, and of the latter the bend of the elbow. The former is to be 
 
AMPUTATION. 
 
 829 
 
 preferred (Fig. 362), as it furnishes an ample covering and posterior 
 cicatrix. 
 
 Tlie circular operation gives a good stump, and is as follows : Place 
 the arm at right angles to the body ; standing on the rigiit side of the 
 limb, make a circular incision through the integuments ; roll the flap one 
 and a half to t\\-o inches, according to the size of the limb ; make a second 
 incision at the margin of the retracted skin ; divide and retract the 
 superficial muscles, and make a third incision down to tlie bone ; raise 
 the periosteum an inch and sa\\' the bone ; the brachial artery lies on the 
 inside, between the biceps and internal portion of the triceps muscles. 
 
 The flap operation, may be single, and may be made at any point pre- 
 senting on one surface a suflflcient amount of tissues ; two flaps of equal 
 size are preferable generally ; they are anterior and posterior ; the arm 
 being carried at a right angle with the body, grasp 
 Fig. 362. with the left hand the tissues on the anterior or 
 
 lateral part of the arm, and, passing the knife down 
 to the bone, carry it over to the opposite side, and 
 cut out a flap in length three-fourths the diameter 
 of the limb (Fig. 363) ; insert the knife close to the 
 
 Fig. 363. 
 
 Disarticulation at liie elbow-joint 
 by tlie posterior ellipse method. 
 
 Amputation of arm by flap operation (T. Bryant). 
 
 bone on the opposite side and make a similar flap ; firmly retract the 
 flaps, divide the tissues covering the bone, and saw the bone at the 
 highest point betM'een the flaps. 
 
 AMPUTATION AT THE SHOULDER-JOINT. 
 
 The shouhler-Joint is arthrodial ; the articular head of the os brachii 
 is very broad, and articulates by scarcely one-third with the siiallow 
 glenoid cavity of the scapula ; it is connected, too, by a loose capsular 
 ligament ; tiie joint is strengtlicned by tiie long head of the biceps and 
 the muscles arising fronr the scapula and inserted in the vicinity of the 
 joint ; the joint is protected above by the extremity of the clavicle and 
 the acromion process. 
 
 It is of tlie utmost importance to prevent hemorrhage during the 
 operation, and to effect this object there are now entirely reliable means. 
 
830 
 
 OPERATIVE SURGERY. 
 
 Pressure upon the sutx^lavian with a key and seizing' tlie flap contain- 
 ing the axillary artery are unsafe measures, and should be resorted to 
 only in the absence of the proper ajjjjliances. The elastic bandage may 
 be applied (Fig. 360) so as to render Itleeding im]X)ssil)le either from 
 the axillary artery or smaller vessels. Pins may be employed, as fol- 
 lows : Select two pins, sharp-])oiiit('d and cylindrical, eleven inches long 
 and one-fourth of an inch in diameter near the lica<l; introduce the first 
 pin through the middle of the anterior axillary fold, a little nearer to 
 the body than the transverse centre of the transverse fold made by the 
 pectoralis major; the place of emergence should bean inch within the tip 
 of the acromion ; the jioint of the i)in when in position should I)e ])ro- 
 tected by a sterilized cork. The second pin should Ite introihiccd at a 
 corresponding point through the posterior axillary fold, the tendon of 
 the latissimus dorsi, emerging an inch within the tip of the acromion. 
 A piece of black-rubber tubing, half an inch in diameter, should now be 
 wound tightly around the limb above the pins, so as to completely inter- 
 rupt all circulation. The vessels should be ligated as quickly as possible, 
 and the tulting and pins removed. Ligation of the vessels in the space 
 between the deltoid and the great pectoral has been performed, with good 
 results, before amputation. 
 
 The oval method is well adapted to cases of fracture near the joint. 
 Make a vertical incision from the end of the acromion process over the 
 head of the humerus down to the bone, A (Fig. 364) ; then two oblique 
 
 Fig. 365. 
 
 Disarticulation at the slioulilcr; .1, oval 
 method ; B, metliod by deltoid flap. 
 
 Disarticulation at the .shoulder ; 
 Spence's method. 
 
 incisions starting from the lower end of the vertical, one on the anterior, 
 the other on the posterior, aspect of the joint, carrying them through the 
 tissues composing the anterior and posterior walls of the axilla to the 
 lower border of each, and dividing their attachments to the humerus. 
 Push the edges of the wound on cither side to expose the joint, and open 
 it, making traction on the Ixme to put its ligament on the stretch ; luxate 
 the head of the bone, pass the knife behind it, and finish the operation by 
 cutting directly through the tissues in the axilla which intervene between 
 
AMPUTATIOX. 
 
 831 
 
 the extremities of the incisions alreadv nuidc, recollecting that they con- 
 tain the artery, which requires to lie compressed by an assistant. The 
 
 Fig. 3(36. 
 
 Esmarch's tournuiiiet applied to shouMer. 
 
 wonnd which results from this operation is almost perfectly oval iu 
 shape. Or, the head of the bone may be dissected from its cavity, 
 
 Fig. 367 
 
 Amputation at shoulder, modifled oval (Spence). 
 
 M-ith the knife held vertically, first upon one side and then upon the 
 other, and the operation completed by dividing the axillary portion. 
 
m-1 
 
 OPERA TI VE S UR GER Y. 
 
 The modified ocal opcrafion (Fi<j. 367) is adapted to gniislHit wounds. 
 It is as follows : Slightly ahduct the arm and rotate the humerus out- 
 ward ; commence an incision just external to the coracoid process, and 
 carry it doM'n through the chivieular filjres of the deltoid and pectoralis 
 major muscles to the humeral attachments of the latter musc-le, which 
 must be divided ; then carry the incision across and through the lower 
 fibres of the deltoid toward, but not through, the j)osterior l)order of the 
 axilla; next carry an incision through the skin and fat only from the 
 point where the straight incision terminated, across the inside of the arm, 
 to meet the incision at the outer part. If the fibres of the deltoid have 
 been thoroughly divided, the flap, together with tlie jjosterior circumflex 
 artery, can be easily separated by the point of the finger from the Ijone 
 and joint, and drawn ujiward and backward, so as to expose the liead and 
 tuberosities. Now divide the tendinous insertions of the capsular mus- 
 cles, the long head of the biceps, and the capsule, and disarticulate and 
 divide the remaining attachment (Fig. 3fi7). 
 
 The singJe-jiap method may be ftjllowed \\ lien there is no fracture, B 
 (Fig. 364) : the arm being held away from the trunk, grasp the deltoid 
 in its entire length and thickness in the left hand, and with tlie riglit 
 pass a double-edged knife through its base, under the acromion, and, 
 grazing the surface of the Juimcrus, cut an external and superior flap 
 of sufficient extent ; an assistant raises it ; then, by approaching the arm 
 to the body, expose the tendons of the muscles inserted into the head of 
 the humerus and cut them ; grasping the arm with the left hand, dis- 
 locate the head of the Iwne outward ; pass the knife beliind it and incise 
 the soft parts, while an assistant seizes the flap in such a manner as to 
 prevent hemorrhage from the divided axillary artery, and, if the tissues 
 are hardened, taking care not to allow air to enter the veins. 
 
 The double-jieip is as follows : The arm is kept close to the trunk, the 
 head of the humerus being pusheil U])ward and outward as much as pos- 
 sible ; recognize the exact position of the acromion and coracoid pro- 
 cesses ; on the left shoulder enter the 
 point of a long knife almost parallel 
 Avith the humerus at the outer side of 
 the posterior border of the axilla, in 
 front of the tendons of the latissimus 
 dorsi and teres major muscles, c (Fig. 
 368). As the knife passes in the plane 
 of its blade it should form an angle of 
 thirty-five degrees with the axis of the 
 shoulder, and its point should graze the 
 ])osterior and external surface of the 
 humerus until it reaches the luider sur- 
 face of the acromion ; at this point the 
 handle of the knife should be raised 
 and its point lowered, so that it is 
 brought out beloAV and in front of the 
 the clavicle, u, in the triangular space 
 between the acromion and coracoid pro- 
 cesses, which is bounded posteriorly by the clavicle. Make the knife 
 cut its way outward around the head of the humerus, h, and as soon as 
 
 Fig 
 
 Duublo-flap* amputation at shoulder. 
 
AMPUTATION. 
 
 833 
 
 it becomes disengaged from henoath the aeroinion process carry the arm 
 away from the trunk ; now grasp tlie deltoid muscle with the left hand, 
 raising it as much as possible from the bone, and carry the knife directly 
 downward, grazing the bone, and cut out a semicircular flap about three 
 inches in length. In making this flap the upper part of the capsvde of 
 the joint should be divided as well as the tendons of the latissimus 
 dorsi, teres majt)r and minor, and part of the deltoid ; raise; the head of 
 the humerus from the glenoid cavity, pass tiic blade of the knife behind 
 it, and carry it downward and forward, grazing the humerus, to cut out 
 the internal flap, and at this moment the axillary artery should be com- 
 pressed by an assistant. 
 
 Amputntion of the ami and scapu/a may be performed for severe 
 injuries and malignant growths. Treves-Berger's operation is as fol- 
 lows : Place the patient on the back, the shoulders raised, and make an 
 incision along the clavicle down to the bone, commencing at the external 
 border of the sterno-mastoitl and ending just beyond the acromio-clavic- 
 ular articulation (Fig. 369). The periosteum being separated at the 
 
 Fig. .Sf)9. 
 
 Interscapulo-thoraeic amputatiou. 
 
 inner extremity of the wound, pass a blunt hook carefully around the 
 bone at this point and divide it, either with the chain or the keyhole 
 Siiw ; now separate the periosteum from tiic outer portion of the clavicle, 
 and saw the bone again at the junction of the middle and outer thirds; 
 remove this middle portion of the clavicle. 
 
 The subclavius muscle is next turned outw^ard so as to expose the 
 vessel.s, and double ligatures are applied, first to the artery, and then to 
 the vein, and the vessels are divided between these ligatures. The patient 
 is now ])laccd on the edge of the tai)le on a hard cushion ; the scapular 
 region is free ; an assi taut draws the limb away from the body, and 
 the surgeon takes a position on the inner side of the limb. Commence 
 an incision at the centre of the clavicular incision ; curve it downward 
 and outward, passing just outside of the coracoid process, along the 
 deltoid muscle, ])arallel to, but to the outer side of, the groove be- 
 tween that muscle and tlie ])ectoralis major; the incision should now 
 Vol. I.— 53 
 
834 
 
 OP EH ,1 TI VE S UR GER Y. 
 
 cross tlie lower margin of tli(> pcctoralis major and pass transversely 
 across upon the axillary surface of the arm to the lower margin of the 
 tendons of the latissimus dorsi and teres major, and, while the arm is 
 raised, be continued downward and inward to the posterior surface of 
 tiie inferior angle of the scapula, along the groove between the vertebral 
 border of the scapula and the mass of muscle composed of the U-xas 
 major and the latissimus dorsi; dissect up this flap, dividing the pcc- 
 toralis major where it is becoming tendinous, and the minor at its inser- 
 tion into the coracoid process ; divide the brachial plexus close to the 
 first rib, also all other connections, thus freely opening the axilla. The 
 arm is now carried across the chest and the scapular region well exposed ; 
 the operator takes his position on the outside of tiie extremity, and 
 makes an incision from the outer end of the clavicular incision back- 
 Mard directly over the spine of the scapula to the termination of tile 
 anterior flap at the inferior angle of the scapula ; the attachments of the 
 trapezius to the clavicle and scapula are divided, then the omo-hyoid, 
 levator anguli scapuhe, riiomboidcus minor and ma_joi', and the serratus 
 magnus ; sever the remaining connections while 
 Fifi. 370. an assistant moves the limb so as to expose at- 
 
 tachments. 
 
 Amputations of the arm, scapula, and clavicle 
 liave been performed for malignant diseases by 
 extension of this method. 
 
 AMPUTATION OF THE FOOT. 
 
 In all amputations of the lower extremity the 
 surgeon should l)e governed in the selection of the 
 point of o])eration and the method to be adopted 
 5r"~^C (1) by the mortality of the operation in question; 
 (2) by the ada])tability of the stump to the most 
 serviceable artificial limb for locomotion. 
 
 Amputation of the phahtnycs in the continuity 
 or contiguity is jjerformed by the same rules as 
 have been given for similar amputations of the 
 fingers, a flap being generally formed from the 
 plantar surface. 
 
 Disdiiicalafion of single toes must be under- 
 taken with due regard to the following facts : 
 Surgical guide to anatomy of The extremity of the first metatarsal bone is 
 footM. cuboid bone t^Bj^arj large, and requires a very liberal flap to cover 
 
 ticulation of scap 
 
 idltion' TiSiii'''cune'i; '* Ton the plantar surfiice of the articulation are 
 form and first metatarsal; two or tlircc sesamoid boncs ; the intcrarticular 
 line is farther from the interdioital fold tlian in 
 
 D, articulation of astragalus 
 and sraj.liiiid : A', ns caleis; 
 
 m\d'cubo\d\''///artiouh^^^^^^^^^ tlic hand, but tiie second space is much nearer 
 
 of cuboid and tiftli meta 
 tarsal. 
 
 the joint than the others. 
 
 The oval method is as follows : Holding the 
 toe with the finger and thumb, commence an incision over the joint, .,1, 
 B (Fig. 371), and carry it downward and forward along the side of the 
 toe to the commissure of the toes, around under the toe, along the trans- 
 verse linear depression to the opposite side, and thence up to the point 
 
AMPUTATION. ' 
 
 835 
 
 of commencement ; divide the extensor tendons and lateral ligaments 
 with the point of the knife, open the joint, and complete the disarticula- 
 tion bv cutting the tissues upon the under part of the joint. 
 
 Tiie xingk phuitar fiap requires a transverse incision over the joint, 
 and hiteral incisions to divide its connectii)ns ; depress the toe and pass 
 the knife through the joint and along the under surface of tlie bone until 
 a sufficient flap is formed; or, dissect off the flap from before backward. 
 The lateral flap for the great and for the little toe is made on the same 
 ])lan as the oval (Fig. 371). 
 
 Disarticulation of all of the toes through the metatarso-phalangeal 
 artit'ulations requires the "operator to note that these joints, a, b, c 
 
 Fk;. 371. 
 
 Fio. 372. 
 
 .4, disarticulation of the second pluilanx 
 of a toe by the raclcet or oval incision : 
 H, disarticulation of the great toe by 
 the racket or oval incision. 
 
 DisarticuUuiuu of the great 
 toe by internal plantar 
 flap. 
 
 Fig. 373. 
 
 (Fig. 373), represent a curved line with its convexity downward, due 
 to tlie ditt'erence in the metatarsal bones ; the second is half a line 
 longer than the first, the third is half a line shorter 
 than the second, the fourth is half a line beliind the 
 third, the fifth is still farther bcliind. The single 
 flap is made in nearly the same manner as in am- 
 putation of all the fingers. If the operation is on 
 the left foot, grasp the toes with the left liand, the 
 thumb applied to the backs of the toes, and make a 
 .semicircular incision in front of the joints, commencing 
 at the internal side of the head of the first metatarsal 
 bone, and ending at the external side of the fifth ; dis- 
 sect up the flap, open the joints, and divide the lateral 
 ligaments with tiie point of the knife ; now pass the 
 knife behind the phalanges and cut a flap from the 
 plantar .surface. Or, niake the plantar flap by extend- 
 ing an incision along the cutaneous fold at the base of the phalanges and 
 dissecting backward (Fig. 374). 
 
 Amputation through the metatarsal bones is performed with plantar 
 and dor.sal flaps, as on the metacarpus. Make a curved incision on the 
 dorsum of the foot, convex downward, dividing tiie soft parts down to 
 the bone ; transfix the j)lantar surface, grazing the bones, and make a 
 
 Amputation of the 
 toes. 
 
836 
 
 OPERATIVE SURGERY. 
 
 flap reaching to the commissure of the toes; divide tlic interosseous 
 muscles with the point of the knife, apply a six-tailed retractor, and 
 divide; the bones with a fine saw (Fig. 370). 
 
 J)is(irli('nJ(iti(>ii of (lie first mefdtursdl bone is best jxTfuriued bv the 
 oval method. The articulation is one or two lines behind the tirst pro- 
 jection found on the posterior portion of the metatarsal bone, and an 
 inch anterior to the prominence of the scaphoid, E (Fig. 370) ; the direc- 
 tion of the line of articulation is from within forward and outward. 
 
 Fui. 374. 
 
 Fig. 375. 
 
 Aiuinitation througli the metacarpal bones. 
 
 Fig. 376. 
 
 Commence two lines behind the joint, a (Fig. 376), an incision di- 
 rected obliquely from within outward to the commissure of the toes, e, 
 
 and pass around the base of the first 
 phalanx, following the crease on its 
 plantar surface ; withdraw the liistoury 
 and replace it on the internal side of the 
 phalanx, b, in the inferior angle of the 
 incision, ascend on the internal side of 
 the metatarsal bone and phalanx, and, 
 following a line slightly oblique from 
 within outward, rejoin the point of com- 
 mencement ; the skin being cut, ilivide 
 successively in the \\'holc extent of the 
 incision the extensor tendons of the toe and fibres of the dorsal inter- 
 osseous muscle. Dissect out the bone (Fig. 377), leaving the sesamoid 
 bones in the phalangeal articulation ; divide the internal ligament, hold- 
 ing the point of the instrument |)erpendicularly and the edge sliglitly 
 obli(|ue from within outward and from behind forward to follow the 
 direction of the joint ; next divide the snjierior ligament, and direct the 
 bistoury upward and push its point at an angle of forty-five degrees into 
 the interosseous space formed by the external surface of the first cunei- 
 form and the extremity of the second metatarsal bone ; when the point 
 
 Incision for removal of great toe and 
 metatarsal bone. 
 
AMPUTATION. 
 
 837 
 
 has pcnotratod to the plantar layer raise the blade again to the perpendic- 
 ular and divide the interosseous ligament. 
 
 Disarticu/dtion of the fifth metatarsal bone is by tiie oval method. 
 This bone artieulates with the cuboid, /' (Fig. 370), by a triangular sur- 
 
 FlG 
 
 Amputation of the great toe by the oval method. 
 
 face, and with the fourth metaearjtal ; it has a tubercle on the external 
 part of its base, which is easily felt and into which is inserted the pero- 
 neiis brevis muscle; the line of the articulation is ol)li(juely forward and 
 inward. Commence an incision just behind the joint, carry it forward 
 toward the commissui-e, thence under the toe, along the transverse linear 
 depression to the opposite side, and then along the external margin to 
 the point of departure ; dissect (Fig. 378) the soft parts from the bone 
 and enter the joint found just behind the tubercle; from the outside 
 divide the ligaments which unite it to the fourth metatarsal, and com- 
 plete the operation by dividing the plantar ligaments. 
 
 Fig. 378. 
 
 Amputation of the little toe nnil its metatarsal bone by the raeket-shaped incision. 
 
 DharHciiIatio)! of sinf/Ie iiirtafiirxal hnnex mav be made bv the oval 
 method, as described fur similar ojierations on the hands. 
 
 Disurtictildtinn of the two outer nietaiarsal bones is made as follows: 
 
838 
 
 OPERATIVE SURGERY. 
 
 Imh. 379. 
 
 Commence an incision ;i finger's breadtii bciiind the juint of the fifth 
 metatarsal bone, in the niiddle, between tlie articnla- 
 tion of the two bones ; carry it forwaril to the com- 
 niissnre, tlien along the under surface in tlie trans- 
 verse line to the outer side of tlie little toe, and 
 tiiencc back to the beginning ; dissect tlie soft parts 
 from the bones, divide the lateral ligament, and dis- 
 articulate the joints by entering them from tiie out- 
 side and following the line above given (Fig. 379). 
 
 Disdiiicnldlioii at the turso-mctdtdrnd/ drtirii/dtioii 
 (Hey's operation) is effected as follows : (irasp tlie 
 sole of the foot (the right) with the left hand, placing 
 the thumb on the outer side of the proximal end of 
 of the fifth metatarsal bone, a (Fig. 380), and the 
 index finger at tlie extremity of the first metatarsal 
 bone, or one incli anterior to the prominence (»f the 
 scaplioid, Ij ; make a semilunar incision, witli its con- 
 vexity looking downward, from without inward, across the dorsum of 
 the foot, passing about iialf an inch below the articulation down to the 
 bones ; divide the dorsal ligaments with the point of the knife, carrying 
 it along the line of the articulation from without inward, recollecting 
 that the articulation of the second metatarsal lies four lines behind the 
 first and third : this mortise, containing the liead of the second metatar- 
 sal, is opened by entering the knife between the internal cuneiform and 
 the head of the first, its edge being turned upward and making an angle 
 of forty-five degrees with the axis of the foot (Fig. 381) ; now carry the 
 
 Incision for removal of 
 two toes. 
 
 Fig. 380. 
 
 Fig. 381. 
 
 ...b 
 
 Disarticulating second metacarpal joint. 
 
 knife up to a right angle, its point traversing 
 the whole of the inner surface of the mortise, in 
 order to ensure the division of the interosseous 
 ligament ; then divide that on the outer surface, 
 depress the metatarsus to separate the articular 
 surfaces, and divide the remaining ligamentous 
 attacliments, especially on the plantar aspect of 
 tiie articulation, so that the knife may be readily carried beneatli the 
 heads of tlic metatarsal bones ; cut out from the sole of the foot a flap 
 
 Points of incision for removal 
 of foot at tarso-metatarsal 
 articulation. 
 
AMPUTATION. 
 
 839 
 
 somewhat larsz:pr at its internal tluin at its external part (Fig. 382), 
 and extending internally nearly to tiie base of the great toe ; externally 
 it may be of less extent. Do not include the sesamoid bones in the flap. 
 
 Fig. 382. 
 
 Fig. 383. 
 
 Plantar llap. 
 
 Fig. 384. 
 
 Formatiou of plantar flap. 
 
 Or, a plantar flap may be made by carrying a 
 curved incision from the internal extremity of 
 the dorsal incision (Fig. 383) to the sesamoid 
 bones, then curviny; forward across the sole of 
 the foot to the junction of the anterior with 
 the middle third of the fifth metatarsal bone, 
 thence to the beginning of the dorsal incision. 
 
 Fig. 385. 
 
 Chopart's amputation. 
 
 Stump after amputation. 
 
 The stump after this operation is useful (Fig. 384). 
 
 Mcdio-tarsal disarticulation (Chopart's) is still 
 ap])rovcd and perfirmed by surgeons, but is much 
 inferior in utility to Syme's amputation (Figs. 386, 
 387, Treves). 
 
 The line of articulation, D (Fig. 370), is determined as follows : On 
 the internal surface o? the foot, about one inch below the end of the 
 malleolus, two ])rominences are readily recognized on the same plane : 
 the joint is midway between them ; on the external side it is six lines 
 behind the ju-oininence of tiie tifth metatarsal bone. The centre of the 
 articulation is immediately in front of the iicad of the astragalus, which 
 is made prominent by extending and abducting the foot. The line of 
 the articulation is changed according as the foot is flexed or extended ; 
 
840 
 
 OPERATIVE SURGERY. 
 
 when it is flexed tlie articular surfaces of the astragalus and calcaneum 
 are nearly on the same line ; when extended the calcaneum is at least 
 three lines in front. Holding the foot (left) in the hand, the pahn on 
 
 Fig. .'iSi;. 
 
 Outer siile of foot : A, Chopart's amputation ; B, Syrae's amputation ; C. subastragaloid amputation ; 
 D, line of section of bone in Syme's amputation. 
 
 the dorsum, with the thumb on the outside and the index on the inside, 
 define the two extremities of the articulation ; make a semilunar incision 
 between these two points, the middle of which is half an inch lievond 
 the articulation ; then, passing the heel of the knife under tlie left thumb, 
 its handle inclined as above, open the joint in tlie direction jHiintcd out; 
 when the joint is half opened, cany the knife in front of the head of 
 
 Fig. 387. 
 
 Inner side of foot: A, Chopart's amputation ; B, Syme's amputation ; C, subastragaloid 
 
 amputation. 
 
 the astragalus, and cut the dorsal ligaments without penetrating between 
 the bones ; carrying the knife to the other side of the foot, the heel in- 
 clined toward the toes at an angle of forty-five degrees, finish ojiening 
 the external side of the joint; the dorsal ligaments being thus divided, 
 push the point of the knife under the external and anterior side of the 
 astragalus, with its edge directed forward, and cut the interosseous liga- 
 ment in the direction of the articular surface of the calcaneum ; the joint 
 
AMPUTATIOy. 
 
 841 
 
 being now open, carry the knife under the jilantar h'sjaments and pass it 
 under the bunes, grazing them, tu cut a sutficient flap (Fig. o8S), avoid- 
 
 FiG. 388. 
 
 Fig. 3S9. 
 
 Chopart's amputation. 
 
 Stump after Chopart's 
 amputation. 
 
 Fig. 390. 
 
 ing the protuberances of the cuboid and scaphoid, and, farther on, of 
 tlie fir.st and fifth metacarpal bones ; the foot during this time i.s hehl in 
 the horizontal position ; raise the handle of the knife sligiitlv, to follow 
 more exactly the concavity of tlie tarsus and metatarsus. 
 
 Disiirfiriilcdioii of the fursu>s under the astragalus (subastragaloid) 
 may be ])ractised as follows : Commence at the outer edge of tlie inser- 
 tion of the teiido Achillis, A (Fig. 391), and make an incision through 
 the skin forward two fingers' breadth below the 
 malleolus, to witliin a finger's breadtli of tlie upper 
 part of the base of the fiftii metatarsal bone ; now 
 carry the incision upward, forward, and inward, so 
 as to reach the inner margin of the tendon of the 
 extensor proprius pollicis just at the first metatarsal 
 articulation, C (Fig. 387) ; then cut downward and 
 forward, and enter the sole a finger's breadtli in 
 front of tlie dorsal wound ; next carry the incision 
 \\ith a gentle forward curve, outward and back- 
 ward, until it can be made continuous with the first 
 portion of the wound below the outer malleolus, I) 
 (F'ig. 386). Retract the integument half an inch, 
 and divide the dor.sal and plantar structures and 
 teiido Achillis ; separate them from the lioues, great 
 care being taken to preserve uninjured the vessels 
 contained in the inner part of the plantar fiap ; now 
 di.sarticulate the cuboid and scaphoid from the as- 
 tragalus, passing the knife between tlie astragalus and os calcis, .so as to 
 divide the interosseous ligament ; separate the .soft parts from the under 
 surface of the os calcis wiiilo .<o twisting the foot as to make the tissues 
 tense ; di.sarticulate the os ctdcis from tiie a.sti'agalus. 
 
 In Tripier'.^ operation the os calcis is sawu through in a direction 
 
 Triplet's operation of the 
 foot. 
 
842 
 
 OPERATIVE SURGERY. 
 
 from behind ami within forward and outward, so as to leave a surface 
 wliic'h will be at right angles with the axis of the tibia when the limb 
 assumes the position for walking, A, B (Fig. 390). 
 
 Farabeuf makes a large internal and plantar flaj), .1 (Fig. 392, 
 Treves). ' 
 
 Begin 
 
 it the outer margin of the tendo Aohillis, eurve tiie 
 
 Fig. 391. 
 
 Fio. 392. 
 
 Inner and outer sides of the right foot, to show the incisions in 
 Farabeuf 's subastragaloid amputation : V, the lines of Ver- 
 neuirs subastragaloid amputation. (For otlier references see 
 text.) 
 
 Plantar incisions : .1, Lisfranc; 
 B, Chopart; C, Pirogoff; D, 
 Syme ; E, Faral)euf 's subas- 
 tragaloid amputation : F, 
 Farabeuf's amputation at 
 the ankle. 
 
 incision up to a point an inch below the external malleolus, then forward 
 to B on the line of the fifth metatarsal bone, with the joints between 
 tlie scaphoid and cuneiform bones ; then across the dorsum to A' (Fig. 
 391), to the tendon of the exten.sor proprius pollicis ; the incision crosses 
 the inner border of the foot along the line of the cuneo-metatarsal joint ; 
 then across the centre of the sole to I), whence it curves back along the 
 outer border of the foot to tiie external border of the os calcis, E, then 
 upward to the point of commencement, ^1. 
 
 Verneuil commences the incision at about the same point, and carries 
 it forward to within an inch of the posterior and internal extremity of 
 the fifth metatarsal bone, thence with a downward curve across tlie 
 dorsmn of tlie foot to the middle of the internal cuneiform bone, thence 
 across the sole of the foot from M'ithin outward and from before back- 
 ward to the commencement (Fig. 391, Treves). 
 
 AMPUTATION AT THE ANKLE-JOINT. 
 
 Disarticulation of the ankle-joint with a heel-flap has justly been 
 regarded as one of the greatest improvements in amputation of modern 
 times. Not only is the mortality of this operation very small, but when 
 
AMPUTATION. 
 
 843 
 
 compared with tlic stumps made at any other point of the foot or leg, 
 those made at the ankle-joint have proven eminently superior, being 
 less subject to such untoward complications and sequelas as ulcers, con- 
 gestions, necrosis, and chronic tenderness, which impair the subsequent 
 usefulness of appropriate and well-adapted compensative apparatus. 
 The broad articular surface of the lower extremity of the tibia, with 
 its internal projection, the internal malleolus, and the large projecting 
 extremity of the fibula, the external malleolus, form a mortise to which 
 the lateral and upper surfaces of the astragalus are so accurately adapted 
 that there can he no lateral motion, and disarticulation can only be 
 accomplished when the foot is firmly extended and the knife penetrates 
 the anterior part of the articulation. 
 
 Syme's ainpufution is as follows : Place the foot at a right angle to 
 the leg; enter the knife at the point of the external malleolus, B (Fig. 
 386), and carry it directly across the sole of the foot to a point opposite, 
 or six lines below the internal malleolus, B (Fig. 387) ; the posterior 
 tibial artery divides beneath the internal annular ligament into the in- 
 ternal and external plantar ai-feries, and if the incision extends to the 
 point of the internal malleolus, the vessel may be divided ; join the two 
 extremities of this incision by an anterior incision in a direct line over 
 the instep, so that the cicatrix may come well in front (Fig. 393). In 
 dissecting the posterior flap, place the fingers of the left hand upon the 
 heel, and with the thumli press the 
 edge of tiie flap tirndy Ijackward, cut- 
 ting between the nail of the thumb 
 and the tuberosity of the os calcis 
 
 Fig. 393. 
 
 Fig. 394 
 
 Symo's amputation of the foot : anterior 
 incision and disarticulation. 
 
 Syme's amputation of the foot : 
 cleaning the os ealcis. 
 
 (Fig. 304), so as to avoid lacerating the soft parts ; the tendo Achillis is 
 exposed and divided. Disarticulate the foot and saw off the malleoli, D 
 
844 
 
 OPHRAriVE SURGERY. 
 
 (Fij;. 380) ; leave the articular extremity of tiie tibia uninjured, fur it is 
 better not to interfere witii tlie bone if it is iiealtliy. 
 
 There are many metiiods of niocHfying the construction of flaps to 
 cover tlie ends of the tibia and fibula, adapted to the various forms of 
 injury of the soft ])arts : all eoverinirs, whether from tlie sole, the lateral 
 surfaces, or IVom tlie dorsum of the loot, are useful, and should be pre- 
 served for that purpose when tiie heel-flap is wantinij. In the first 
 examjile insert the knife in the middle line of the posterior aspect of the 
 ankle, on a level with the articulation ; carry it doM'nward obliquely 
 across the tendo Achillis toward the external border of the jilantar aspect 
 of the heel, alonii' which it is continued in a semilunar direction ; curve 
 the incision across the sole of the foot, and terminate it on the inner side of 
 the tendon of the tibialis antieus alioiit an inch in front of the inner malle- 
 olus; carry the second incision across the outer aspect of the ankle in a 
 semilunar direction, between the extremities of the first incisions, the con- 
 vexity of the incision downward, and passing half an inch below the 
 external malleolus. In lloux's ojieration make an incision from the 
 junction of the tendo Achillis with the os calcis around the external sur- 
 face of the foot immediately below the external malleolus ; then carry it 
 inward toward the internal border ; curve forward and al)out an inch in 
 front of the ankle-joint ; then pass along the internal border of the foot 
 to the ])oint of dt'parture. 
 
 In otiti'oplasfic ampuUdlon of the anl;h -joint (PirogofT) the covering of 
 the stump consists of the posterior jxirt of the os calcis enclosed in the 
 integument of the heel. The results are favorable, but the additional 
 length of limb is not desirable for an artificial limb. Commence the 
 incision close in front of the outer malleolus ; carry it downward and for- 
 ward nearly to the posterior extremity of the fifth metacarpal bone, into 
 the sole of the foot, ^1 (Fig. 395), then transversely across the sole, and 
 
 Fig. 39o. 
 
 Plrogoff's amputation: A, cutaneous incision, outer side ; B. line of section of the bones. 
 
 lastly obliquely upward and backward to the inner malleolus; terminate 
 it a coujile of lines anterior to the malleolus ; divide all the soft parts at 
 once quite down to the os calcis ; now connect the outer and inner ex- 
 tremities of this first incision by a second semilunar incision, the convex- 
 
AMPUTATION. 
 
 845 
 
 Fig. 396. 
 
 itv of which looks forward, carried a few lines anterior to the tibio-tarsal 
 articulation ; cut through all the soft parts at once down to the hones, 
 and then proceed to ojien the joint from the front, cutting through the 
 lateral ligaments, and thus exarticulate the head of the astragalus ; now 
 place a small, narrow amputation .saw obliquely upon the os calcis behind 
 the astragalus, and saw through the bone carefully, or the anterii)r sur- 
 face of the tendo Achillis, which is only covered by a layer of fat and a 
 thin fibrous sheath, may be injured ; raise the short anterior flap from the 
 two malleoli, and make a section of the tibia and fibula just above the 
 articular surfaces ; turn this flap forward, and bring the cut surface of 
 the OS calcis in apposition with the cut surface of the tibia (Fig. 396) ; 
 the tendons nuist not be cut off too near the 
 point where their .synovial sheaths are cut 
 through ; if (Uit too short, the}' conceal them- 
 selves in the fibrous canal, or, when the limb is 
 moved, slip upward out of their sheaths. Other 
 methods are outlined in the illustration. 
 
 Sujini-jiirt/lcolar (iiiijiiiiiiHon should always 
 be preferred to any operation at a higher ])(>int, 
 and the flap should lie taken from the firmest 
 tissues accessible. The following method 
 (Guyon), B (Fig. 401), gives a good stump: 
 Make an incision from the base of the exter- 
 nal malleolus, posteriorly, around the external 
 surface of the foot iunnediately below the 
 malleolus, and inward toward the internal 
 border, but curved forward to a point an inch 
 in front of the ankle-joint (Fig. 397) ; make 
 a similar incision on 
 Fig. 397. the internal surface, and 
 
 unite the two behind 
 by a transverse incision 
 having a slight con- 
 vexity downward ; separate the soft parts from the 
 bones, and saw the tibia and fibula at the lia.se of 
 the malleoli about an inch above the articular sur- 
 face. 
 
 Pirof^off 's amputation : appearance 
 (if the parts after removal of mal- 
 leoli (J. E. Eriehsen). 
 
 AMPUTATION OF THE LEG. 
 
 Amputation of the leg involves new and most 
 Supramalleolar amputation. im])ortant jirinciplcs, both ill operative and mechan- 
 ical surgery. At no other point is it more neces- 
 sary to seciu'e a sound and u.seful stump than in this part. This is due 
 to the incessant use. to which it must be applied and its ex]iosure to 
 injury. But it presents intrinsic difliculties in the application of the 
 ordinary methods of amputation. This is apparent in the development 
 of the muscles of the calf, the tajiering form of the lower portion, and 
 the subcutaneous position of the tibia. The circular flap cannot be re- 
 tracted without dividing it longitutliiially ; the single jiosterior fla]) is of 
 immense size, and is counteracted only by the integument of the anterior 
 part of the leg; the double flap gives a great inequality of flaps; the 
 
84G 
 
 OrT:n. 1 TIVE SVRGF.R Y. 
 
 single external flaj) leaves liie crest of the tibia hut slightly covered. 
 The results of amputation of the leg have, in consequence of these con- 
 ditions, been more unsatisfactory than at any other point. Necrosis of 
 the tibia, conical stumps, ulcerated coverings, and tender cicatrices have 
 been the rule when the old methods have been jtreferred. J^)Ut bilateral 
 Haps of the soft parts and periosteal coverings of tiie tibia give a tirm, 
 compact, and enduring stump. 
 
 Tlie place of division of the bone may be at any point, but at the 
 lower part of the leg the commencement of the calf is most favorable for 
 a symmetrical stump, and at the upper part is to be preferred a point two 
 inclies below the tubercle of the jiatella, which permits the knee to be bent 
 and brings the support upon tlie condyles of the femur. An am])utation at 
 the latter point is indicated wlienever tlie leg is permanently flexed either 
 at a right or at an acute angle with the thigh. If the amputation must 
 be very close to the joint, disarticulation shoidd be preferred, for the risk 
 to the jiatient of the knee-joint amjjutation is no greater than of an am])U- 
 tation of the extreme upj)er third of the leg, while its practical benefits are 
 much superior, as confirmed l)y experience. The elastic l)andage siiould 
 be first applied to a point above the knee (Fig. 329). The bilateral Haps 
 here recommended should be made as follows: Commence an incision 
 with a large scalpel in the centre of the anterior surface (Fig. 398), and 
 
 Fio. 398. 
 
 Bilateral flaps. 
 
 carrj' it downward along the side of the leg so as to make a slightly 
 curved flap with its convexity below ; after the incision has passed over 
 the prominent ]>art of the leg toward the posterior surface, incline it 
 slightly upward until the middle of the limb is reached, where it should 
 be continued directly up to the point at which the bone is to be divided ; 
 make a similar incision on the oppo.site side ; these lateral flaps should 
 consist of the skin and superficial fascia ; dissect them upward to the 
 extent of one inch in the leg and two inches in the thigh ; now make a 
 circular division of the muscles to the bone with a long knife ; saw the 
 bone or bones at tiiis point, and direct an assi.stant to seize and hold the 
 extremity firm with strong forceps (Fig. 333) : with the perio-steal knife 
 or the thumb-nails (which are equally efficient) raise the peri(isteum from 
 the tibia to the point where the latter is to be cut ; divide the bone at the 
 base of the periosteal flap. The periosteum must be cut at its attach- 
 ments to the linea aspera of the bone, and should lie raised only from the 
 tibia, the fibula being fir.st exsected. The covering thus prepared has the 
 integument externally, the perio.steum internally, while the intervening 
 tissues, muscles, vessels, nerves have not been disturlied in the dissection; 
 the periosteal flap falls like a hood over the end of the bone, the skin- 
 
AMPUTATION. 
 Fig. 399. 
 
 847 
 
 stump after bilateral flaps. 
 
 flaj)s lie in contact without tension, and the drainage is direct from the 
 angle of the wound beneath. "When cicatrization is complete the cicatrix 
 lies posterior to tiie end of the stump, the cushion is freely movable, and 
 the bone does not undergo the usual amount of atrophy (Fig. 399). 
 
 Fi«. 400. 
 
 Fig. 401. 
 
 Amputation of leg 
 rectangular florae 
 upper third 
 
 «.,......v».v.. w. Its. -^1 modifierl circular; B, 
 
 rectangular flaps ; ('. antero-posterior flaps. 
 
 Amputation of leg: A, long anterior flap; li, 
 supra-nialleolar am]>utation by long poste- 
 rior flap ; C, at the upper third. 
 
848 
 
 OPERATIVE SURGERY. 
 
 The various other methods of opiTatinji are indicated by the illustra- 
 tions (Figs. 400, 401). The reetaiiguiar Haj), B (Fig. 400)", is sometimes 
 made in the lower part of the leg ; the rules given as to the formation 
 of the flaps in this o[)eration must be stricth' observed. The flap ojiera- 
 tion is very often selected for the upper part of the leg, and is veiy simple 
 in its details, C (Fig. 400). Skin-flajts and circular section of the mus- 
 
 Ampntation of the leg liy the mixed method (T. Bryant). 
 
 cles, the mixed method (Fig. 402), is to be preferred to the common flap 
 amputations. 
 
 AMPUTATION AT THE KXEE-JOINT. 
 
 This amputation now ranks among the most successful operations both 
 for safety and the usefulness of the stump ; as compared with amputa- 
 tions through the thigh it is quicker, easier, and requires sim])l('r instru- 
 ments, and there is less shock ; the integuments preserved are, as a ride, 
 better adapted to sustain pressure ; there is less risk of injury to flaps 
 from a rough-sawn bone, and less retraction of muscles ; the sustaining 
 power is more quickly acquired ; the j^oint of support is broader and 
 better fitted for pressure ; from large anastomoses about the joint the 
 blo()(l-su])])ly is more quickly established. 
 
 This amputation may be made by simple disarticulation, or in addition 
 the condyles of the femur may be sawn through. If there is no disease 
 and ample flaps can be made, the bone should not be sawn. The follow- 
 ing opinion of an experienced mechanical surgeon (Dr. E. D. Hudson) 
 is most instructive : 
 
 " The practice of dividing the condyles cannot be sustained by any 
 rational hypothesis nor practised on any scientific principles : except dis- 
 ease or injury of the condyles compels their excision, their osseous cover- 
 ing and cartilage investments should be kept inviolate from knife and 
 saw, for, as constituted, they are the strongest, most tolerant, and import- 
 ant supports in the entire body ; the inter-condyloid fossa is readily 
 filled, even with the convexity of the condyles, with a neatly-shaped 
 elastic pad of wool felt made to extend over them for a cushion in 
 the adaj)tation of jn-othetic apparatus. Equally reprehensible is the 
 method of placing the patella over the fossa with a view to making that 
 a point of support, and also of sa^\ing off the condyles and applying the 
 j)atella to the cut surface : these and other ingenious experiments are of 
 no practical value." 
 
 There are many methods of operating, but the bilateral-flaj) method, 
 devised by the author, is to be preferred for the reasons above given ; the 
 joint surface of the bone should not be disturbed unless diseased, and 
 
AMPUTATION. 
 
 849 
 
 the patella may be left in its ])luce, though it is of no value to the stump. 
 The line of the articulation lies internally nine lines above the promi- 
 nence of the tibia ; the lower border of tlie patella is on a line with the 
 articulation, and externally it is nine lines below the prominence of the 
 external condyle. 
 
 Operate as follows : Select a large scalpel, and eonuncnce an incision 
 about one inch below the tubercle of the tibia, and cut to the bone ; 
 carry it downward and forward beyond the curve of the side of the 
 leg, thence inward and backward to the middle of the leg, thence 
 upward to the middle of the popliteal space ; repeat this incision upon 
 tlie opposite side; raise the i\:\]>, consisting of all tlie tissues down to 
 the bone, until the articulation is reached ; divide the lateral ligaments, 
 enter the joint, and sever its connections internally and externally. 
 Care should be taken that the incisions incline moderately forward, 
 down to the curve of the side of the leg, to secure ample covering for 
 the condyles ; the incision upon the internal aspect should have additional 
 
 Fig. 403. 
 
 Fig. 404. 
 
 Stephen Smith's amijutation at the knee-joint. 
 
 fulness for the ])urpose of ensm-ing sufficient flap 
 for the internal condyle, which is longer and 
 larger than the external. 
 
 The flaps completely cover the condyles (Fig. 
 403), and are readily approximated, leaving am- 
 ple .<pace for direct drainage at tlii' upper angle 
 of the -woimd ; a drainage-tube may be inserted 
 if necessjiry ; tlie flaps arc well nourished and 
 union takes place rajiidly, giving a well-rounded 
 stump with the cicatrix sunk in the inner con- 
 dyloid fo.ssa (Fig.. ;3y9). 
 
 T)t><nrticii(<dion u-Uh a hi);/ (nttcrior flap (Fig. 
 404), requires an incision from the head of the 
 fibula. A, or the margin of the outer condyle, 
 B, downward on the side of tlie leg five inches 
 below the lower edge of the patella, then curved 
 across the front to tlie opjiositc side, thence 
 upward to a corresponding jxiint inside. 
 
 AmpuUdhin throiKjh the coikIij/c.^ (Garden), 
 consists in reflecting a rounded or .semi-oval 
 flap of .skin and fat from the front of tlic joint, B, B' (Fig. 404), dividing 
 
 Vol. 1.-54 
 
 Amputation at the knee and 
 hiwer third i.f tlie thi^-h : A. 
 flisartieuhitiuii. luni; anterior 
 ilap: it, aini>ntatH)n tlirough 
 the ec)ndyle.s (Cardeni; C, 
 modified nap amputation at 
 the hiwer tliird of the tliigh 
 (Syme). 
 
850 
 
 OPERATIVE SURGERY. 
 
 everything else down to the bone, and sawing the bone slightly above 
 tlie jilanc of the nmsclos, tluis forming a flat-faced stump with a body 
 of integument to fall over it. 
 
 Osteoplaatic aiii'putation of the knee (Gritti) consists not only in remov- 
 ing a portion of the condyles, but also of incising the patella, A (Fig. 408), 
 anil placing the cut surface upon the sawn condyles for the purpose of 
 securing union of the bones. Stokes modified this operation by dividing 
 tlie bone from a half to three-quarters of an inch above the condyles, in 
 order to secure a surface better adapted to the patella. 
 
 The modified circular method (J. Lister) is as follows : First cut 
 transversely across the front of the limb from side to side, at the 
 level of the anterior tuberosity of the tibia, and join the horns of 
 this incision by carrying the knife at an angle of forty -five degrees 
 to the axis of the leg through the skin and fat ; elevate the limb, 
 dissect up the posterior skin-flap, and then proceed to raise the ring 
 of the integument as in a circular operation, taking due care to avoid 
 scoring the subcutaneous tissue ; by dividing the hamstrings as soon 
 as they are exposed, and bending the knee, the upper border of the 
 patella is exposed; then sink the knife through the insertion of the 
 quadriceps extensor (Fig. 405), and having cleared the bone inunediately 
 
 Fig. 405. 
 
 Lister's ampntiitidii through the condyles hy modified circular method. 
 
 above the articular cartilage, and holding the limb horizontally, apply 
 the saw to the bone, so as to ensure a horizontal surface for the patient 
 to rest on. 
 
 AMPUTATION OF THIGH. 
 
 The thigh is composed principally of muscular structures, which sur- 
 round the femur in two distinct layers, the superficial and deep ; the 
 superficial nuiscles all spring from the pelvis and go to the leg, and the 
 lower they are cut the more they retract, and vice versd. 
 
AMPUTATION. 
 
 851 
 
 Observation and cxjierience (E. D. Hudson) teach that amputations 
 of tlie thigh, as ordinarily pertonned and ul- Fiu. 400. 
 
 timately treated with prothetic apparatus, are 
 unnecessarily disabling; but with the bilat- 
 eral and periosteal ilap, and as full length 
 of the femur for leverage as the injury or 
 disease will safely allow, a quality and ca- 
 paeitv of stump may be obtained which, with 
 appropriate, well-adapted apparatus, will as- 
 sure the patient a firm basis of support on a 
 line with the axis of the thigh. Ample lever- 
 age and adequate motor power enable him to 
 balance his weight exclusively on his artificial 
 limb, and to walk without a cane with ease 
 and gracefulness. The method of procedure 
 ret[uires the same incision as the operation on 
 the leg already detailed (Fig. 407). It is 
 highly important to save all the blood possible, 
 and for this purpose the elastic bandage should 
 first be applied, and carried to the hip, where 
 the elastic tourniquet is applied (Fig. 409). 
 If the bandage is not at hand, the tourniquet 
 may be placed loosely around the thigh, the 
 thigh raised for a few minutes while it is 
 rubljcd toward the hip, and then the tourniquet 
 is tightened (Fig. 40(5). 
 
 Anfcro-jjostcrior flaps are made thus : Stand- 
 ing at the right side of the limb, grasp the soft 
 ])arts and bring them forward ; transfix the 
 limb, tiie knife grazing the up])er surface of 
 the bone, and make an anterior flap (Fig. 
 407) ; reintroduce the knife, and, passing it 
 under the bone, make a posterior flap longer than the anterior to com- 
 pensate for the greater retraction ; complete the operation as in the lat- 
 eral-flap method. 
 
 Fig. 407. 
 
 Lister's method for bloodless 
 amputation. 
 
 Amputation of the thigh by flap operation. 
 
852 
 
 OPEBAriVE SURGERY. 
 
 Another method is as follows: Stamliiiii ;it the ritilit side of the linih, 
 frrnsp the thij>'li with the left hand, ])lacin<r the tini^iTs aiul tlniml) on 
 opposite points; aj)ply the heel of a loni;- amputating knife on the iarther 
 side of the linih at the ends of the tingers, and draw it in a seniieirenlar 
 direction over the limb to the end of the thumb, dividing by this single 
 sweep all the soft parts down to the bone ; without removing the knife 
 withdraw it sufficiently to enter the point at the angle of the wound and 
 transfix tlie limb, passing under tiie bone to the angle of the wound on 
 the opjwsite side ; cut a fiap of the requisite length from tlie posterior 
 part of the thigh. 
 
 Other methods of operating are indicated in Fig. 408. 
 
 DISARTICUI^ATION AT THE HIP-JOINT. 
 
 The hip-joint is formed by the liead of the femur and t]i(> acetabu- 
 lum, into which it is received ; its ligaments are the round ligament, 
 which attaches the head of the bone to the bottom of the cavity, and the 
 
 capsular ligament, surrounding the joint ; 
 Fig. 408. it is deejdy situated under thick and 
 
 powerful muscles, and can be felt only on 
 the anterior part ; it nuist be recollected 
 thatthe})laneof the margin (if the acetal)- 
 ulum inclines downward and forward, 
 projecting more posteriorly than ante- 
 riorly ; the arteries are the femoral, the 
 obturator, the ischiatic, and external and 
 internal circimifiex. The following are 
 anatomical guides to the joint: (1) The 
 anterior inferior spinous process of the 
 ilium is three-quarters of an inch above 
 the superior margin of the acetabulum ; 
 
 Fig. 409. 
 
 ^.Gritti's amputation at the knee : A', lines 
 of division of bone ; B, long anterior flap 
 (S^dillot); fi', division of liiine; C, ampu- 
 tation at lower tliinl (.T. sprneei: r'. di- 
 vision of bone ; D, disarticulation of hip. 
 
 Arrest of hemorrhage : operations on 
 tlie hip-joint. The dotted line is the 
 incision for the oval amputation at 
 the hip-joint. 
 
AMPUTATION. 
 
 853 
 
 Fig. 410. 
 
 the anterior superior spinous process is about iin inch and three-quarters 
 above the same point and tin-ec-cpiarters of an incli to its outer side. (2) 
 The anterior border of the acetabuhini is from an ineii to an inch and a 
 quarter to the outside of the spine of the pubes. (3) The axis of the 
 horizontal ramus of the pubes, extended by an imaginary line, crosses 
 the acetabulum at the junction of its superior with its middle third. (4) 
 Tlie superior border of the trochanter major is on a level with the upper 
 third of tlie cavity of the joint. 
 
 Amputation may be performed by the single flap, anterior or internal ; 
 the double flap, lateral or antero-posterior ; the oval ; and the circular 
 (Fig. 408). These different methods have been almost indefinitely modi- 
 fied. Hemorrhage should Ijc prevented by the application of the elastic 
 bandage (Fig. 409) ; or by the figure-of-8 elastic bandage, carried above the 
 iliac crests around the liip, and the transfixion l)y a single needle passed 
 in front of the neck of tlie femur and beneath the vessels, over the ends 
 of Avhich a rubber cord is carried only in front of the thigh (Trendelen- 
 burg), or by the elastic bandage applied above two needles (Wyeth) 
 (Fig. 412) ; "this latter has jiroved the most effective method yet devised. 
 
 The irrfieal and ciiTitfar method (F. Jordan) is performed as follows 
 (Fig. 410) : Alake an incision along the outer side of the thigh, extend- 
 ing downward from tiie top of tlie trochanter for six or 
 more inches ; enucleate the head of the femur from the 
 acetabulum ; sejwrate the muscles and tissues ; now make 
 a circular incision down to the bone at the requisite point ; 
 saw the bone ; while an assistant seizes and holds firmly 
 the lower end of the u])|ier fragment, complete the disar- 
 ticulation. If the artery is not compressed sufficiently 
 certainly to prevent hemorrhage, it may be tied in the 
 flap. 
 
 Double aidero-posterior flaps are made thus: The 
 elastic bandage being in plai'c, standing on the outside of 
 the limb, insert tlie point of a long catling about midway 
 between the anterior superior spinous process of the ilium 
 and trochanter majc^r, keeping it rather nearer the former 
 than the latter ; then run it across the fore part of the 
 neck of the bone, and push it through the skin on the 
 opposite side about two or three in(thes from the anus ; 
 next carry it downward and forward, so as to cut a flap 
 from tiie anterior aspect of the tliigh about four to six 
 inches in length. When the blade is entered the limb should be held 
 up, and even slightly l)ent at the joint : the instrument will then pass 
 along more readily than if all the textures were thrown on the stretch ; 
 moreover, there is greater certainty of passing it behind the main vessels, 
 and even dividing sonw of the Hi)res, if not the whole, of the iliacus 
 internus and ])soas muscles. The flaj) being raised, the ])oint of the knife 
 .siiould then be struck against the head of the bone, so as to divide the 
 anterior part of the capsular ligament and any texture in this situation 
 which may not have been included in the flap. To facilitate this part 
 of the operation, the knee should be forcil)ly depressed bv the assistant 
 who holds it; tlie head of the bone will thus be caused to start from its 
 socket, and, if the round ligament is not ruptured by the force, a slight 
 
 Furneaux Jordan's 
 method of ampu- 
 tation at the hip- 
 joint. 
 
854 OPERATIVE SURQERY. 
 
 touch with the edge of the knife will cause it to give way. At this period 
 depression being no longer reipiircd, the assistant should bring the head 
 of the femur a little forward, to allow the knife to be slipped over and 
 l)eliindit; it should then be carried downward and backward, so as to 
 form a Hap somewhat longer than that in front, the last cut completing 
 tlie separation of the limb. 
 
 Thv mn(jlv-fl(tp mcfhod admits of very ra]>id ])('rf(irmance. The fol- 
 lowing are the several steps: The patient lying u]»on the edge of the 
 table, the hip projecting, the artery is compressed upon the horizontal 
 branch of tiie pubis ; tiie o])erator then takes a position on the outside 
 of the limb (the left), which is separated from the other and slightly 
 flexed on the pelvis, and, raising the soft parts, which cover the anterior 
 face of the limb, enters u very long doul)le-l)laded knife midway i)e- 
 tween the great trochanter and the anterior superior sjiine of the ilium, 
 directing it at first slightly from below upward and from without inward, 
 so as to reach the head of the femur and open the capsule of the joint ; 
 he now elevates the handle and carries the knife in a proper direction, 
 the point emerging about an inch below and in front of the tuberosity 
 of the ischium ; the knife is then carried downward along the anterior 
 surface of the bone, and a large semilunar Haj) is made, extending nearly 
 half the length of the thigh, or six inches: care should l)e taken that the 
 Hap is as long on the inside as on the outside : an assistant raises 
 the flap, at the same time compressing the artery which it contains ; 
 the knife is now applied to the capsule, which is divided close to the 
 acetabulum, as if about to cut across the middle of the head of the 
 fenuir and at least half of its circumference ; the limb is then abducted 
 to luxate the head of the bone, the knife passed l)ehind it, and the soft 
 parts on the posterior portion of the limb divided as in the circular 
 operation. 
 
 Lateral flaps (Fig. 411) are made as follows: The patient must be 
 laid upon his back with the tuberosities of the ischia pn jecting slightly 
 beyond the edge of the bed and the limb held in a position lietween 
 abduction and adduction. Then, having determined l)y anatomical rules 
 the anterior and external side of the articulation, the operator, holding 
 perpendicularly a long double-edged knife, introduces it at this point 
 with its lower edge looking downward toward the great trochanter. As 
 the point of the knife enters it should be carried around the head of 
 the femur on its outer side, whilst its handle is inclined upward and out- 
 ward and pushed steadily on in this direction, so that it ])erforates the 
 integuments a few lines below the tuberosity of the ischium. While 
 this is being done an assistant grasps the tissues over the trochanter 
 and carries them outward in order to assist in the formation of the 
 external fla]), and the knife is carried dowuM'ard and outward with 
 a slightly sawing motion, around the great trochanter and along the 
 fenuir, cutting out a flap from three to four inches in length. The first 
 flap being thus made, the operatcn', grasping the tissues on the inside of 
 the thigh and carrying them inward, introduces the knife below the head 
 of the femur and in the inner side of its neck, holding it in a perpen- 
 dicular position. As it enters the point of the knife should pass around 
 the neck of the femur and come out at the lower angle of the wound 
 already made, without coming in contact with the bones of the pelvis ; 
 
AMPUTATIOX. 
 
 855 
 
 it is then carried downward along the femur and avoiding the lesser 
 trochantei", so as to make an internal flap of the same length as the 
 external. The flaps being drawn aside by the assistants and the arteries 
 
 Fig. 411. 
 
 Amputation at the hip-joint by external and internal flaps (T. Bryant). 
 
 tied, the surgeon grasps the femur with his left hand, and, holding the 
 knife perpendicularly on the inner side of the head of the bone, cuts the 
 capsular ligament without attempting to penetrate the articidation. The 
 joint being opened, the disarticulation is concluded by cutting the fibrous 
 and mu.scular tissues which remain. 
 
 Double flapH, long anterior and short posterior, give good results 
 (C. Heath). The surgeon inserts the point of the knife between the 
 spine of the ilium and the trochanter major, and carries it across the 
 thigh, as near as may be to the head and neck of the femur, until the 
 point appears on the inside near the scrotum, which should have been 
 previously drawn away. The knife is tt) cut slowly downward to make 
 a flap, under which an assistant inserts his four lingers in order to be able 
 to grasp the flap and aid in compressing the principal artery as the 
 operator completes the flap, which should be a large one. The assistant 
 h(jlding up the flap, the surgeon cuts the attachment of the gluteus medius 
 muscle from the upper edge of the trochanter if it has not been already 
 done, opens the capsular ligament of the joint, and divides the ligamcn- 
 tum teres. The head, of the bone can then be readily withdrawn from 
 the acetabulum. The knife, being placed behind the head of the bone 
 and the trochanter, should be carried obliquely downward and backward 
 so as to form a shorter flap behind than Mas made before. 
 
 The bloodless amputation of Wycth is described bv him as follows : 
 " 1. With the jiaticnt in the usual position for a hiji-joint amputation, 
 the limb should Ix- cin]>ticd of blood either by elevatit)n of the foot and 
 lowering of the trunk, or l)y the Esmarch bandage applied from the toes 
 
85G 
 
 OPERATIVE SURGERY. 
 
 to the trunk. Under certain conditions the bandage can be only partially, 
 or may be not at all, applied, ^\'hen a tmnor exists or when sejjtic infil- 
 tration is present, pressure should only be exercised not quite to the dis- 
 eased portion, for fear of driving septic matter into the vessels. After 
 injuries attended with great destruction, crushing, or pulpification, of 
 course tlie Esmarcli Itandage is not applicable, and one must trust to 
 elevation to save as much blood as possible. 
 
 " 2. While the member is elevated, or before the Esmarch bandage is 
 removed, the rubber-tubing constriction is applied. 
 
 "The object of this constriction — and it is the chief point in the 
 method — /.s the absolute occlusion of every vessel ett the level of the hijj- 
 
 FiG. 412. 
 
 The needles and constrictor applied: circular and longitudinal incisions for skin flap. 
 
 joint sf(feli/ above the field of operation, permittiur/ the clisarticulatio)i to 
 be completed and the vessels secured before the touruiepiet is removed. 
 
 "To prevent any possibility of the tourniquet slipping, I employ two 
 large mattress-needles or skewers about three-sixteenths of an inch in 
 diameter and ten inches long, one of which is intniduced one inch below 
 the anterior superior spine of the ilium and slightly to tlie inner side of 
 this prominence, and is made to traverse superficially the nmscles and 
 fascia on the outer side of the hip, emerging on a level with, and about 
 three inches from, the point of entrance. The point of the second 
 needle is made to enter one inch below the level of the crotch internally 
 to the saphenous opening, and, passing squarely through the adductors, 
 comes out an inch below the tuber ischii. The points are at once 
 shielded by l>its of cork to prevent injury to the hands of the operator. 
 No vessels are endangered by these skewers. A piece of strong white- 
 rubber tube, half an inch in diameter and long enough when tightened 
 in position to go five or six times around the thigh, is now wound very 
 tightly around and above the fixation needles and tied. If the Esmarch 
 bandage has been employed, it is now removed. Lanpliear succeeded in 
 holding the constriction in place with only one (the outer) needle. 
 Deaver was equally successfnl in holding the tubing well up by two 
 strips of roller bandage, one before and one behind, held by an assistant, 
 and thus dispensing with the needles. Since the needles, are, however, 
 
AMPUTATIOy. 
 
 857 
 
 ahsolutelv safe, easy to obtain, and entirely out of tlie way, lie does not see 
 any benelit to be derived from their disuse. On the contrary, he would 
 beafraid to operate without them. As the pressure of the constricting 
 rubber is considerable, they should be strong. Bristow states that ou 
 one occasion a skewer of inferior quality gave way, and hemorrhage 
 was narrowly averted. 
 
 " 3. In tlie formation of Haps the surgeon must be guided by tlie con- 
 dition of tlie parts within the held t>f operation. When permissil)le the 
 following method seems ideal : About six inches below the tourniquet a 
 circular incision is made, and this is joined by a longitudinal incision 
 commencing at the tourniquet and passing over the trochanter major. 
 A cuff tiiat includes the subcutaneous tissues down to the deep fascia is 
 dissected off to near the level of tlie trochanter minor. At about the 
 level of the trochanter minor tlie remaining soft parts, together with the 
 vessels, are divided down to the bone by a circular cut, and, in order to 
 facilitate the search for the vessels, the soft parts are rapidly removed 
 from the femur for several inches below the line of the divided muscles. 
 At this stage of the operation the larger vessels, veins as well as arteries, 
 should be tied with good-sized catgut. Now leave the entire extremity 
 
 Fifi. 41 s. 
 
 Cuff iif skin and subcutaneous fat turned baek.niuselcs divirterl at level of small trochanter, bone 
 partly stripped, and lar^'e vessels exposed for deligation. 
 
 intact and use the full length of the limb as a lever in dislodging the 
 head of the bone. When tlie larger and easily-recognized vessels have 
 been secured, the muscular attacliments to the u})per extremity of the 
 
858 OPERATIVE SURGERY. 
 
 bone are lifted off with scissors or knife, keeping:; along very close to the 
 hone. Holding the soft ])arts away with retractors, the eapsnlar liga- 
 iiU'iit is exposed and divided in its cinnunfcrence. Forcible elevation, 
 abduction, and adduction of the thigh permit the entrance of air into 
 the socket, and at the same time rnpture the ligamentum teres, and the 
 disarticulation is thus easily and rapidly effected. If, now, the tourni- 
 quet be carefully and gradually loosened, each bleeding jioint may be 
 determined, and the force])s applied as required initil the tul)e is entirely 
 removed. tShonld any diiKeulty be encountered in the effort at enuclea- 
 tion (which is scarcely possible), the same precaution in securing all 
 bleeding points sliould be exercised in removing the tourniquet, and 
 enucleation completed with the tourniquet out of the way. 
 
 "4. In the closure of the wound silkworm gut is preferred for suture 
 material, and one good-sized rubber drain from the acetabulum out at 
 the most dependent part of the wound. When by reason of the prox- 
 imity of a neoplasm or the destruction of the parts by accident or disease 
 this ideal method is not practicable, any modification may be jiractised, 
 preference being given to the incision that keeps farthest from the tumor 
 or gives the healthiest flaps. When there is not sufficient material for 
 perfect closure, it is even safer to err on the side of an unclosed wound 
 and trust to granulations or grafting for ultimate closing of the wound. 
 When, by reason of severe hemorrhage before operation, or when from 
 any pathologic ansemia or condition of weakness, the operation should 
 be rapidly completed and the small amount of blood that will necessarily 
 be lost from capillary oozing should be saved, sutures of silkworm gut 
 should be rapidly introduced, the wound jiacked with hot sterilized, plain 
 gauze (not iodoform or bichloride gauze), and the sutures temjtorarily 
 tightened for snug compression of the wounded surfaces. This packing 
 at once controls all oozing, and can be removed in from twenty-four to 
 forty-eight hours after reaction, and tlic sutures finally secured." 
 
 Accidents ■which may Occub during an Amputation. 
 
 Shock, a distnrliance or paralysis of nerve-centres, is liable to 
 supervene toward the close of an operation, especially on a sudden loss 
 of blood, when the operator is least prepared to encounter so formidable 
 a complication. In general, it is remarkable how little impression is 
 produced by even the most severe operations, and hence the surprise 
 which the discovery of the ]>resencc of shock creates. The patient often 
 passes suddenly from a state of jn-oper anaesthesia, and without any ad- 
 ditional ansesthetic, to a condition of more or less profound shock. 
 There is no warning of its approach, and the first impression is that too 
 much of the anaesthetic has been given. This is not narcosis from ana3s- 
 thesia, but shock. The degree of jn-ostration depends somcMhat upon 
 the previous condition of the patient and tlie nature of the disease, but 
 more markedly upon the degree of shock from the injury wliich gave 
 rise to the operation, the amount of blood lost, and the length of the 
 operation. The bodily tejuperature and pulse are the best guides to de- 
 termine the severity and danger of shock, and ought to be noted, first, 
 before the operation, and, second, during and after the operation : vari- 
 ations not accounted for by obvious causes will indicate the effect of the 
 
ACCWESTS WHICH MAY OCCUR DVRINO AN AMPUTATION. 859 
 
 operation, and often give timely warning of impending danger. In an 
 average of cases of operations recoveries liave a fall of temperature of 
 less than one dejrree, and deaths of more than three deiirees ; a fall liddw 
 97° F. is very critical, but recoveries exceptionally occur. When the 
 condition of the patient or the symptoms indicate a susceptibility to 
 shock jn-eventive measures should be adopted. One of the most simj)le 
 and efficacious is the repeated administration of brandy or whiskey sev- 
 eral hours preceding the operation. An ounce of whisk<y in six or eight 
 ounces of hot milk given ten hours before the operation, and rejicated 
 once or twice at two hours' interval, unless the signs of intoxication 
 become very manifest, will often secure a full pulse, allay all previous 
 fear, and render the patient so susceptible to the antesthetic that but very 
 little will be required. Shock is qnite impossible under such circum- 
 stances even if there is a sudden loss of blood. Tlie effects of this 
 stimulation continue often forty-eight hours or more, and thereby pre- 
 vent secondary shock and depression. Opium or a hy])odermic injec- 
 tion of morphia and atropia before the operation tends to protect the 
 heart and nervous system from depression. A cup of hot and strong 
 cotfee an hour or more before the operation is a simple and useful remedy 
 against the depression caused by ether ansesthesia. 
 
 St/ncope may be regarded and treati'd as an early stage of collapse. 
 These conditions differ only in degree and duration. In the former the 
 crisis is more ra])id, and in the latter the effects are more extensive and 
 profoiuid. The symptoms are pallor, sighing respiration, feeble pulse, 
 and other signs of great prostration. The indications of treatment are 
 to arouse the nervous system by stimulation. Place the head low ; apply 
 vapor of ammonia cautiously to the nostrils; give brandy l>y hypo- 
 dermic injection or by tlie mouth or rectum ; apply external heat to the 
 whole body, and by cloths wrung out of hot mustard-water over the 
 region of the heart and stomach. 
 
 Collapse may rapidly succeed, with cold, clammy moisture of skin, 
 and often distinct droj)sof sweat ujion the brow, shrunken and contracted 
 features, reduced bodily temperature, almost imperceptible and often 
 irregular pulse, short and feelile or ])anting resjiiration. To the treat- 
 ment of shock add hypodermic injections of brandy, gss to ,^j, repeated 
 every five minutes, in the arms; or ether, 10 to 30 minims, every ten 
 minutes; strychnia, gJj^ grain ; or weak liquor ammonise, 5 to 10 minims, 
 may be injected into the veins ; large hot-water enemata should be given 
 witli the preceding remedies. Electricity, applied to the regit)n of the 
 heart, sliould be used. .Vs the most unfavorable cases will frequently 
 recover if energetically treated, the efforts at restoration should not be 
 relaxed until recovery is secure or death has occurred. If reaction be- 
 gin, stimulation should in part give place to nutrition ; the patient must 
 remain in the Jiorizontal position ; beef-juice, with brandy, should be 
 given at first, and hot coffee and milk should soon be added, yubcuta- 
 neous injections of morphia are very important in securing rest and 
 quiet, or, if the morpiiia t'annot be taken, hyoscyamus may be combined 
 or substituted. Finally, tincture of digitalis may be required if reaction 
 is delayed, in 10 to 20 minim doses. External heat is always to be 
 applied to the whole body, and (-loths wrung out of hot water over 
 the stomach and heart ; friction of the limbs may be usefully added. 
 
8G{) 
 
 OJ'i:i!.lTIVE SURflERY. 
 
 Anannid may occur from the loss of blood and ho tlic cause of col- 
 lapse. To the former treatment must now he addetl positicju ol' the l)o<ly 
 to secure the flow of hlotid fo the head and heart, as partial inversion; 
 add to this bandaginjj of the limbs from their extremities toward tlie 
 trunk. If the aiiiiemia is extreme, transfusion should be promptly re- 
 sorted to or the re-injeetion of the blood collected durint;' the oj)eration. 
 
 Compensative Appliances. 
 
 The application of artificial limbs to su])])lement the losses occasioned 
 by amputation must be reganled as the higliest expression of mechanical 
 art. The perfection of the mechanism of these appliances when ])ro- 
 
 duced by skilled lal)or is not excelled in any 
 FiG^414. branch of human invention. Hands and (trms, 
 
 feet and legs, may now be obtained M'hieh are 
 scarcely less useful, and are often even more 
 ornamental, than the original limbs. And 
 these ajipliances are now within the reach of 
 the most Jnniible person. '^Die surgeon can 
 no longer io;nore these facts and discriminate 
 between the rich and poor man's stuni])S, 
 nor can the selection of the.se appliances 
 longer be left to the patient himself, who i.s 
 liable to be imposed upon by mere manufac- 
 turers having no ade(piate knowledge of the 
 proper functions of the apparatus which they 
 are re(|uired to sujiply. It not unfrequently 
 ha])}K'ns that the surgeon does not so fully 
 unilerstand the mechanism of these ap])lianees 
 as to be qualified to advise in their selection. 
 Such ignorance implies also a want of good 
 juilgment in the formation of the stump to 
 \\ liicli the appliance is to be adjusted, and has 
 received judicial condemnation. The impoi't- 
 ant principle to be constantly borne in mind 
 in adapting stumps to artificial limbs is the 
 necessity of adecpiate leverage and a well- com- 
 posed and compact covering (E. D. Hudson). 
 The finfferi<, individually or as a group, 
 may be supplied with apparatus which admits 
 The fingers should be so placed and moved as 
 to enable the normal thumb to oppose each one at all of its articulations, 
 
 and when the fingers are closed 
 the thumb should be in position 
 to close over the first and second. 
 If the thumb alone is lost, the 
 substitute should be adapted to 
 ojipose the fingers (Fig. 415). 
 If the thuml) and forefiuffer are 
 
 Apparatus for useless elbow, 
 
 of seizing and grasping, 
 able the 
 
 Fig. 415. 
 
 Fig. 416. 
 
 Apparatus for fingers. 
 
 supplied, they must be in a state of opposition for the purpose of grasp- 
 ing, but the latter must be susceptible of easy extension (Fig. 416). 
 
COMPENSATIVE APPLIANCES. 
 
 861 
 
 Fig. 41 
 
 Apparatus for hand. 
 Fig. 418. 
 
 The hand and forearm are best supplenientcd when the stump i.s matle 
 above tlie wri.st-joint and through the lower portion of the shaft of the 
 uhia and radiu.s : the bulbous extremity of the radius, when the stump 
 is at the wrist-joint, is not adapted to the form of .socket of the artificial 
 limb. Tlie position of tiie fore and secontl fingers and thumb should be 
 as far as possible that of opposi- 
 tion when clo.sed. I'ronation and 
 supination are secured in the fore- 
 arm, and the flexion and exten- 
 sion of the carpus are effected by 
 cords acting' through springs (Fig. 
 417). The cords may be acted 
 upon by the movements of the 
 opposite shoulder (Fig. 418). 
 
 The spiral .spring, i (Fig. 418), 
 draws the fingers, /, constantly 
 toward the thumb, d, and retains 
 any article placed witliin tlie hand 
 and lictwcen the thumb and fin- 
 gers ; the hand may be opened by 
 a motion of the opjiosite shoulder 
 drawing on the shoulder-strap, m, 
 and cord, I:, or liy extending the 
 artificial hand and arm ; the fin- 
 gers are constructed on the metal- 
 lic bar, ff. 
 
 The arm and forearm, with 
 the hand, are supplied in amputa- 
 tions in the arm liy a])paratus 
 which derives its motion from the 
 stump; tlie backward motion extends, and the firward motion flexes, the 
 joints of the arm and forearm. In these cases the upper arm consists 
 of a socket to receive the stump of the limb, and is secured by straps 
 to the person with a certain degree of rigidity ; the anterior and poste- 
 rior tendons or rods have a firm attachment at or near the sjioulder, pass 
 along or througii the uj)per section, an<l are attached to such |)oints on 
 tiie forearm that as one or the otlicr is tightened tlie forearm is flexed or 
 extended ; in some cases the oscillation of tiie elbow articulation is 
 obtained by cords which have direct or intermediate attachment to the 
 forearm ; in others the cords or bars move a toothed wheel which engages 
 a pinion on tlie elbow axis and gives motion to the forearm; the back- 
 ward motion of the stum]) tends to strain the anterior tendon, which is 
 so connected to the forearm behind the elbow-joint as to extend tlie fore- 
 arm ; the forward motion of tlie stump strains the jiosterior tendon which 
 connects to tlie fbrearm in front of the articulation, and thus flexes it 
 as the stump is moved forward. These motions follow the natural ones; 
 as, for instance, in the act of raising the liand to the nioutli it is usual to 
 o.^cillate the arm forward on the shoulder as a ]iivot, and l)ackwardly as 
 the hand descends ; in tiie natural arm the pivotal ]iositioii of the fore- 
 arm is varied so as to cause the arm to swing in an arc wliicli will liring 
 the hand to the required place, as the mouth ; in the artificial arm the 
 
 .\pparatus for head and arm. 
 
8G2 
 
 OPERATIVE SURGERY. 
 
 motion on tlie sluiiiKk'r is tlie generator of the motion on the ell)()\v, and 
 a certain amount oi'iiradicc and adjustment is required to proptn'tion tlie 
 parts so tiiat the eonsentaneous aetiim of tiie parts wliich ])ri((hic(' the 
 compound motion may, witiiout ap])arent constraint or indecision, hind 
 tlie hand at the olyect. When the trunk of a person attbrds points of 
 attachment for the flexor and extensor straps, the motion of the shoulder 
 itself relatively, to the thorax, and involving the clavicle and scajiula, 
 may be matle to assist in executing the motions required. The primary 
 motion of the stump having been communicated to the forearm by the 
 means described (or other special devices which are various and very 
 ingenious), the motions of the hand are derived from that of the fore- 
 arm by means of tendons, slides, or other attachments (Fig. 419). 
 
 Fig. 419. 
 
 Appfiriitiis for forearm and arm. 
 
 The toes may l)e supplemented by artificial means, but, in general, a 
 boot provided with a heavy sole answers every purpose in progression. 
 The same is true of am])ntation of the metacarpus. 
 
 The foot cannot be ad('(jnatcly substituted when the amputation is 
 below the ankle-joint. The tarso-metatarsal and medio-tarsal amputa- 
 tions do not admit of useful artificial appliances. 
 
 The ankle-joint stump affords space, firmness, and leverage for the 
 artificial foot, and should be jircferred whenever any considerable por- 
 tion of the foot must suffer amputation, and whenever any of the soft 
 tissues of the heel or beneath the malleolus, or of the dorsum of the 
 foot, are sufficient to constitute cither a single 
 or double flap, even if necessary to form the 
 cicatrix over the conical jiart of the base of the 
 stump. The appliance should have only flex- 
 ion and extension, as the ankle-joint (Fig. 420), 
 and flexion of the toes. 
 
 The leg stump may l>e formed at any part, 
 but the apparatus is the same in each case. 
 
 Fig. 420. 
 
 Fig. 421. 
 
 Artificial foot. 
 
 Artificial leg. 
 
COMPENSATIVE APPLIANCES. 
 
 863 
 
 Fig. 422. 
 
 The foot should be of the same mechanism as in tlie aukle-joiut stump 
 — nainely, a socketed axial bolt passing transversely through it, giving 
 only Hexiou and extension (Fig. 421). The construction of the leg- 
 piece is designed to give lateral support hx a well-sliai)ed and fitting 
 socket ; a thigh-piece with joints in the steel side- 
 pieces is necessary to sustain the limb, and elastic 
 straps are sometimes added which are attached to 
 a yoke strap over the shoulder. 
 
 The kiur-Joinf rnnpiitdtion leaves a broad, well- 
 covered stump, which readily takes direct support, 
 and iience, with a well-adjusted a]>j)liancc, is ex- 
 tremely serviceable. Tiie foot- and leg-pieces are 
 the same as those already given. The knee-joint 
 may be perfect in the motions of flexion and ex- 
 tension, and the padded socket should be exactly 
 adapted to the form of tiie stump. The thigh 
 should lace up in front, and straps may be added 
 to sustain the whole upon tiie shoulder. Tiie 
 same apparatus is necessary when the amputation 
 is at the point of election, for by flexion of the 
 short stump the hearing is taken on the condyles 
 of the femur in the same manner as in knee-joint 
 amputation. 
 
 The (hi(/h ampufafion rcipiircs a socket extend- 
 ing to the hip, with bands attached which may 
 be applied over the slioulder to support the appa- 
 ratus. The construction of other parts is the 
 same as in amputation at tiie knee. In cases of 
 double amputation tiicse appliances may be adapted to both legs, so that 
 the individual will liave good motion (Fig. 422). 
 
 Tlie hip-joint dii<iuiicidation, though the severest form of mutilation, 
 admits of the application of a useful limb. The principles governing 
 the construction of tlie artificial limb have been stated as follows: The 
 position and size of tiie tulierosity of the ischium, tiie thickness and the 
 elasticity of tlie tissues wiiicli cover it, the very great density of the 
 skin, render this region very appropriate for the support of the weiglit 
 of the body. It is equally well adapted to transmit it, and a proper 
 regard for tliis governs tlie prothcsis, and should also regulate the ope- 
 rative procedure. Nevertheless, however fortunately arranged the tulie- 
 rosity of tlie iscliium seems to he, it forms, in tlie case of tlie loss of a 
 lower exti'eniity, a very narrow I^ase of support either for standing or 
 walking ; it is not sufBciently prominent to allow us to attacii tlio arti- 
 ficial limb ; it is immovable, and consequently incapable of communicat- 
 ing movement ; no natural intermediate substance does effectually deaden 
 the shock caused by tjie artificial limb coming in contact witli tlie ground. 
 In the normal condition tlie lower extremities serve as a counter-balance 
 for the u])pcr jiart of the body and broaden its seat. The coxo-femoral 
 disarticulation iiaving been performed on one side, the body ceases to lie 
 balanced, and rests merely on a bony protuberance — large, it is true, but 
 convex, and merely touching the plane of supjjort by a single point, and 
 a simple keel adjusted to tliis tuberosity would leave the patient in con- 
 
 Artinr'iiil ]<%s 
 
 imbs. 
 
864 OPERATIVE SURGERY. 
 
 tinual vacillation. Nature has admiral liy arranged that the weight of 
 the body pass in a straight and central line, because there are distributed 
 about it contractile agents which maintain the equililjrium ; but we are 
 de])rived of these remai'kable agents, antl in order to suj)j)ly the mechan- 
 ism of tlie natural limb it is necessary that the means of prothesis 
 embrace the whole space (occupied by tliem. Now, tiie space rccpiircd 
 for the attachment of tlie artificial limb is not reduced to the cylindrical 
 circumference of the thigh ; it embraces the surface of the pelvis, to 
 which are inserted the muscles which while standing or walking assure 
 a normal harmony between the j)elvic bones and the fenuir. 
 
 The a])])aratus made in accordance with these principles consists of a 
 gutta-percha bonnet covering the entire region of the stump, and re- 
 tained in place by a broad belt around the body. To this bonnet is 
 attached the artificial limb, by means of a joint which gives adequate 
 motion for jji'ogression. 
 
INDEX. 
 
 ABDOMEN', shot wounds of, 500 
 Abdciminal section for sliot wounds, 
 505 
 
 surgery, anesthesia in, 660 
 Abernethv, 87 
 Abscess, i72, 343 
 
 metastatic, 178, 400 
 Abscesses, bacteria causing, 308, 309, 310 
 
 expei'imental jiroduction of, 280, 303 
 
 secondary to typlioid fever, 321 
 Absorbent dressings, 692 
 Accidents during operation, 858 
 A. C. E. mixture, 655, 657 
 Acetabulum, fracture of, 572 
 Acliley, H. A., 143 
 Acrel, O., 127 
 Acromion, fracture of, 583 
 Actinomyces, association with pyogenic 
 cocci, 302 
 
 characters of, 332 
 
 in tlie intestine, 265 
 
 in lladura disease, 334 
 
 in tlie mouth, 260 
 
 pyogenic capacity, 309, 334 
 
 in vegetable grains, 276, 334 
 Actinomycosis, 353 
 Actual cautery, 742 
 Acupressure, 741 
 Adams, K., 100 
 Aetius, 31 
 Age, influence in infections, 303 
 
 influence of. in operations, 730 
 Agnew, D. H., 140 
 
 Agnew's method for fracture of patella, 554 
 Agucro, B. d , 69 
 Air, bacteria of, 276, 679 
 Air-embolism, 212 
 Air-passages, bacteria in, 262 
 ■Vhmson, E., 88 
 Mbucasis, 36 
 \lcazar, A., 00 
 
 ■Vlcoholism, relation of, to infections, 305 
 Alexins, 294 
 
 Allis, on fractiu-e lower end of humerus, 587 
 Allis's acupressure forceps,' 741 
 
 sign, 507 » 
 
 Alumina, acetate of, 705 
 Annuann, P., 60 
 Anmion, P. A. von, 120 
 Aniicba coli, 182 
 
 dyseiiteriie, 265, 302 
 Amputation, 32, 54, 811 
 
 at ankle, 842 
 
 of arm, 848 
 
 Vol. I. — 55 
 
 Amputation, Berger's, 833 
 
 Garden's, 849 
 
 Cliopart's, 839 
 
 circular method, 814 
 
 in compound fractures, 527 
 
 double llaji, S15 
 
 at cUiow-joint, 827 
 
 of Hngers, 817 
 
 flap method, 60, 67, 814 
 
 of foot, 834 
 
 of forearm, 826 
 
 Gritti's, 850 
 
 Guvon's 845 
 
 He/s, 838 
 
 at hip-joint, 476, 852 
 
 interscapulo-thoracic, 833 
 
 at knee-ioint, 848 
 
 medio-tarsal, 839 
 
 at metacarpus, 823 
 
 at metatarsus, 837 
 
 Pirogoff's, 844 
 
 subastragaloid, 841 
 
 supramalleolai', 845 
 
 Syme's, 843 
 
 tarso-metatarsal, 838 
 
 Teale's, 815 
 
 of thigh, 850 
 
 of thumb, 821 
 
 of toes, 835 
 
 Tripier's, 841 
 
 at wrist, 825 
 Amussat, J. Z., Ill 
 Amyloid degeneration, 234 
 Ana-mia, relation of, to infections, 296, 304 
 Anaerobic bacilli in intestine, 264 
 in pus, 309 
 in the vagina, 268 
 Antesthesia, 137, 645 
 Aniesthetic, 61 
 Ana'sthetics, choice of, 655 
 
 mixed, 055 
 Andrv, N., 71 
 Anel,' D., 73 
 Aneurism, 33, 37, 52 
 
 ligature of, 52, 73 
 
 needle, 743 
 Ankle, shot-wounds of, 478 
 Ankle-joint, amputation at, 842 
 
 dislocation of, 636 
 
 resection of, 796 
 Antisepsis, ](«, 719 
 Antiseptic .solutions, 395 
 
 surgery, 677 
 
 experiments, 300, 301 
 
 865 
 
866 
 
 INDEX. 
 
 Antiseptics, 683 
 Antitoxic immunity, 295 
 Antitoxine of tetanus, 431 
 Antyllus on aneurism, 33 
 Aorta, ligature of, 762 
 Aplasia, 229 
 
 Apparatus, compensatory, 860 
 Aiipoiidicitis, actinomyces in, 265 
 
 bacillus coli communis in, 274 
 proteus in, o22 
 
 predisposing intiuence of obstructions in, 
 297 
 
 pyogenic cocci in, 274, 275 
 Ariieus, F., 68 
 Arderne, John, 61 
 Argelata, Petrus d'l, 44 
 Arm, amputation in, 828 
 
 artificial, 861 
 Arra_y surgeons, 78, 79 
 Arnaud de Ronsil, 73 
 Arris and Gale lectures, 64 
 Arrow-poisons, 407 
 Arrow-wounds, 513 
 Arteries, ligature of, 742 
 
 torsion of, 740 
 Arterio-sclerosis, in relation to pyogenic in- 
 fections, 306 
 Artery forcei)s, 739 
 Artificial limbs, 860 
 Aseptic fever, 203, 415, 717 
 
 surgery, 677 
 
 wounds, bacteria in, 251, 272, 292 
 Astnigalus, dislocation of, 640 
 
 fracture of, 542 
 
 resection of, 794 
 Atheroma in ana'sthesia, 657 
 Atlee, J. L., 141 
 
 W. F., 113 
 
 W. L., 141 
 Atria of infection, 279, 283, 339 
 Atrophy, 229 
 
 after fracture, 535 
 Auricular artery, posterior ligature of, 753 
 Austria, history of surgery in, 79, 117 
 Auto-infection, 268, 272, 274, 305 
 Autopsies, pyogenic bacteria found at, 311 
 Avian tuberculosis, bacillus of, 330 
 Avicenna, 36 
 
 Avulsion of phalanges, 602 
 Axillary artery, ligature of, 756 
 Ayur-\'eda, 25 
 
 BACILLUS aerogenes capsulatus, 322 
 found at autopsies, 311 
 chtiracters of, 322 
 in intestine, 265 
 pathogenic manifestations, 322 
 anthracis, 331 
 
 antagonized by other bacteria, 291 
 
 characters of, 331 
 
 dosage, 288 
 
 elimination by secretions, 285, 286, 288 
 
 enhances virulence of micrococcns lan- 
 
 ccolatus, 291 
 germination of spores in intestine, 264 
 infection by feeding, 281 
 infection through lungs, 282 
 
 Bacillus anthracis, in hides, wool, etc., 276 
 not absorbed from suppurating wounds, 
 
 297 
 placental transmission of, 307 
 predisposition to, 303, 304 
 rapidity of absorption from fresh wounds, 
 
 284, 300 
 virulence for different races of animals, 
 303 
 liuccalis maximus, 258 
 capsulatus of Pfeiffer, 262 
 of chicken cholera, placental transmission 
 
 of, 307 
 coli comnuniis, in abscesses, 310 
 in ap]iendicitis, 274 
 in the bile, 265 
 
 cause of hepatic neuroses, 286 
 charactei's of, 320 
 conditions of inviision, 274 
 in the conjunctiva, 256 
 frequency of presence in organs at 
 
 autojjsy, 311 
 in the mouth, 258 
 outside of the body, 253, 267, 276, 
 
 320 
 pathogenic action, 274, 286, 302, 309, 
 
 321 
 in peritonitis, 274 
 on the skin, 253, 267 
 in the stomach and intestine, 264, 274, 
 
 320 
 in the lu-ethra, 267 
 virulence of", 271, 291, 321 
 in wounds, 253, 274, 321 
 crassus s])utigenus, 258 
 dij)htheria>, characters of, 322 
 
 destruction in the throat liy chemical 
 
 disinfectants, 3(11 
 in fibrinous rhinitis, 262 
 on the hair of nurses, 254 
 in the healthy throat, 260 
 modification of virulence by other bac- 
 teria, 292 
 relation to xerosis bacillus, 257 
 in surgical infections, 323 
 of glanders. See Bitfillii>i Mttllei. 
 lactis aerogenes, characters of, 231 
 in c.ystitis, 267 
 in the nose, 262 
 relation to bacillus coli communis, 
 
 274, 321 
 in the stomach and intestine, 264 
 lepra?, characters of, 330 
 
 spores of, 278, 330 
 of malignant a'dema, characters of, 322 
 in the intestine, 265 
 on skin contaminated with soil, 253 
 in the soil, 276 
 mallei, artificial predisposition to, 305 
 characters of, .330 
 spores, 278, 330 
 of mouse septicemia, dosage, 288 
 
 elimination by conjunctiva, 285 
 of oziena, 262 
 
 phlegmones emphysematosa, 309, 322 
 pneumonia^ of Friedhinder, antagonism to 
 infection by anthrax bacillus, 291 
 
INDEX. 
 
 8G7 
 
 Bacillus pneumonia of Friedlander, elimina- 
 tion by secretions, 285 
 on exposed surfaces, 275 
 in the middle ear, 263 
 in tlie mouth, 258 
 in the nose, 261 
 pathogenic manifestations, 275, 309, 
 
 311, 320 
 predisposition to, 304 
 relatiim to rhinoscleroma bacillus and 
 otlier capsulated bacilli, 262, 320 
 prodigiosus, elimination by secretions, 
 " 286, 288 
 enhances virulence of other bacteria, 
 291, 292 
 proteus, cliaracters of, 321 
 
 in decomposing substances, 276, 322 
 enhances virulence of otlier bacteria, 
 
 291, 305 
 on exposed surfiices, 275 
 in tlio intestine, 265 
 pathogenic manifestations, 275, 309, 
 
 311, 322 
 varieties — proteus vulgaris, mirabilis, 
 
 and Zenkeri, 321 
 pseudo-diplitlieri;e, 257, 260 
 pyocvaneus, in abscesses, 310 
 in the air, 277 
 cliaracters of, 320 
 elimination in secretions, 285 
 in the intestine, 265, 320 
 in tlie middle ear, 263 
 |)athogenic action, 320 
 on the skin, 253, 273, 320 
 in the vagina, 269 
 in wounds, 253, 273, 284, 310, 320 
 pyogenes ftetidus, character of, 320 
 in intestines, 265 
 
 pathogenic manifestations, 309, 311, 
 320' 
 of rabliit septicaemia, dosage, 288 
 invasion from the lungs, 282 
 not absorbed from suppurating 
 
 wounds, 297 
 rapidity of absorption from fresh 
 wounds, 300 
 of rhinoscleroma, 262, 320 
 of smegma, 254, 266, 329 
 of symptomatic anthrax, 292, 304, 307 
 tetaiii, 326, 426 
 
 antitoxic immunity from, 295, 328 
 in feces of herbivora, 253, 265, 276 
 influence of association with toxic prod- 
 ucts and other bacteria, 289, 292 
 in soil, 275 
 toxins, 326 
 
 viability in dog's intestine, 276 
 tholiieideus, 267 
 
 tuberculosis, association irith streptococ- 
 cus pyogenes, 292 
 in bronchial glands, 283 
 characters of, 240, 329 
 ditiercntiation from smegma bacilli, 
 
 254 
 in the healtliv nose, 262 
 in milk, 287 " 
 in necrogenic warts, 276 
 
 Bacillus tuberculosis, placental transmission 
 of, 307 
 predisposition to, 302, 305 
 prolonged latency of, 282 
 pyogenic capacity, 309 
 of tuberculosis of fowls, 330 
 typhi abdominalis, association with pyo- 
 genic cocci, 291, 292, 321 
 cause of hepatic necroses, 286 
 cause of osteomyelitis and periostitis, 
 
 321 
 eliiiiiuation by secretions, 286, 287 
 placental transmission of, 307, 308, 
 pyogenic capacity, 309, 321 
 resistance, 279, 256, 261 
 susceptibility of fcetus to, 308 
 vagin;e of Doederlein, 268, 269 
 xerosis, 257 
 Bacteria, 175 
 
 action of chemical disinfectants on, in 
 
 wounds, 284, 300 
 in air, 276, 079 
 
 in aseptic wounds, 251, 272, 292, 298 
 in the blood in surgical infectious, 252, 
 
 313 
 in cerumen, 254 
 of the conjunctiva, 255 
 destruction of, by living cells, blood, and 
 other fiui'ds of the body, 256, 260, 
 262, 264, 265, 267, 269, 271, 279, 
 
 282, 294, 298, 299, 300, 314 
 dosage and virulence of, 288 
 elimination of, in secretions, 284 
 of the genito-urinary tract, 265 
 germinal and placental transmission of, 
 
 306 
 of the hair, 254, 278 
 within the healthy body, 272 
 in liernial sacs, 297 
 immunity from, 279, 293 
 infecting, dosage of, 288 
 in milk, 270 
 
 mode of entrance of 279 
 of the moutli and pharynx, 257 
 parasitic, 278 
 
 pathogenic, spore-forming, 278 
 placental transmission of, 306 
 pyogenic, 308 
 
 rapidity of absorption of, 283, 284, 300 
 of the respiratory passages and middle 
 
 ear, 261 
 saprophytic, 278 
 in secondary and mixed infections, 273, 
 
 283, "290, 302, 305, 313 
 of the skin, 250 
 
 of the soil, 276 
 
 of the stomach and intestine, 263 
 
 of surgical infections, morphological and 
 
 biological properties of, 249, 315 
 in the sweat, 252, 288 
 virulence of, 288 
 
 wound-infection by, 249, 252, 253, 272, 
 275, 292, 298, 309, 324 
 Kacterial association, 290 
 Bactericidal properties of bile, 265 
 of blood, 280, 294, 299, 314 
 of gastric juice, 264 
 
808 
 
 INDEX. 
 
 Bactericidal iii'opcrties of laclirvrnal secre- 
 tion, "Joti 
 
 of leucocvtes and other cells, 294, 300 
 
 of milk, 271 
 
 of nasal secretion, 202 
 
 of saliva, 200 
 
 of nrine, 207 
 
 of nterine secretion, 270 
 
 of vaginal secretion, 2(ill 
 Bacteriological examinations of surgical 
 
 infections, value of, 312 
 Bacteriologv, surgical, 249 
 Balassa, .V.', 124 
 Ballingall, Sir ( jeorge, 94 
 Bandage, clastic, 737 
 Barber surgeons, 42, 03, 127 
 Barbette, P., 58 
 Bard, J., 134 
 Barton, J. K., 136 
 Baseilhac, 74 
 Bass, H., 78 
 Battns, C, 58 
 Baudens, J. B. L., 112 
 Baum, W., 123 
 Baynham, W., 134 
 Bayonet wounds, 512 
 Beaulien, J. de, 71 
 Beck, Marcus, 103 
 Beckett, W., 84 
 Bed-sores, 180, 300 
 Bee-stings, 408 
 Bell, B.," 89 
 C, 93 
 .7., 89 
 Bellingham, O'Bryen, 100 
 Belloqi J. L., 74 ' 
 Benedict, T. W. G., 121 
 Benedictus, Alexander, 45 
 Eenevoli, A., 81 
 Berard, A., 110 
 Berengarius C'arpensis, 45 
 Berlinghieri, A. V., 117 
 Bertrandi, G. A., 81 
 Bible, medicine of, 19 
 Bienaise, J., 58 
 Bigeloiv, H. J., 138 
 Biggs, IT. M., on rabies, 433 
 Bile, bacteria in, 265, 285, 286 
 Bilgner, 78 
 Bill, J. H., 514 
 
 Billings, J. S., ou history of surgery, 17 
 Billroth, T., 126 
 Bismuth subnitrate, 697 
 Bites, spider-, 409 
 Bjerkin, P. af, 127 
 Blackman, G. C, 141 
 Bladder, bacteria in, 267 
 rupture of, 571 
 shot-wounds of, 509 
 supra-pubic puncture of, 70 
 Blandin, P. F., 110 
 Blasins, E., 120 
 Blazina, J., 124 
 Bleeders, 381 
 Blegnv, N. de, 58 
 Blizarcl, T., 101 
 W., h8 
 
 Blondus, M. A., 45 
 
 Blood, bacteria in, 252, 299, 313, 314 
 
 bactericidal power .,f, 280, 294, 299, 305, 
 314 
 
 coagulation of, 206 
 
 conveyance of bacteria by, 272, 302, 314 
 
 in healing of wounds, 299 
 
 regeneration of, 224 
 Blood-clots, healing by, 526, 715 
 Blood-plates, 208 
 Blood-pressure, in ana?sthesia, 648 
 Blood-vessels, formation of, 194 
 Bloxam's dislocation tourniquet, 611 
 Blue pus, 253, 320 
 
 Boeckel's mctliod for excision of wrist, 784 
 Bond's splint, 597 
 Bone forceps, 775 
 
 scoop, 778 
 Bones, resection of, 773 
 
 shot-wounds of, 459 
 Bonnet, A., Ill 
 Botallo, L., 45 
 Bougies, 725 
 Boyer, A., 105 
 
 Brachial artery, ligature of, 757 
 Brain, abscess of, 486 
 
 disease, in anaesthesia, 657 
 
 shot-wounds of, 483 
 Brainard, D., 137 
 Brainard's drill, 538 
 Brambilla, G. A., 79 
 Brasdor, P., 74 
 Breast, excision of, 67, 710 
 Bright's disease, in anesthesia, 061 
 
 in pvogenic infections, 306 
 Broca, P'., 114 
 Brodie, B., 93 
 Bromficld, W., 84 
 Bronchi, bacteria in, 262 
 Brown, J., ()7 
 
 Briinninghansen, H. J., 119 
 Bruns, \. von, 123 
 Ernnscbwig, H., 53 
 Brush-burn, 365 
 Bryant's triangle, 567 
 Bnck, G., 139 
 
 Buck's extension method, 503 
 BnfT\' coat, 198 
 Bnjalski, E., 128 
 Bu'llets, infected, 276 
 Burns, 362 
 Burns, A., 95 
 
 J., 94 
 Burow's solution, 697, 705 
 Busch, C. 1). W., 123 
 Butcher's saw, 777 
 
 pALCANEITM, fracture of, 540 
 
 \j resection of, 795 
 
 Calcification, 236 
 
 Callawav's test, 619 
 
 Callender, G. W., 102 
 
 Callisen, H., 127 
 
 Camper, P., 80 
 
 Canape, J., 51 
 
 Caucrnm oris, 391 
 
 Caiisulated bacilli, 262, 320 
 
IXDEX. 
 
 869 
 
 Carbolic acid, 705 
 
 Garden's amputation, knee, 849 
 
 Cardiac disease in pyogenic infection, 300 
 
 Carnialt, W. H., on septica;mia, etc., 383 
 
 Carmicliael, R., 99 
 
 Carnocliau, J. M. , 142 
 
 Carotid, common, ligature of, 88, 134, 747 
 
 external, ligature of, 749 
 
 internal, ligature of, 753 
 Carpal ijones, dislocation of, 624 
 
 fracture of, (iOl 
 Carpue, J. C, 92 
 Carr's splint, 597 
 
 Cartilages of ribs, dislocation of, G14 
 Caseation, 227 
 Catarrhal intlammation, 168 
 Catgut, disinfection of, 701 
 Catlieter fever, 204 
 Catlieters, 725 
 
 lubricants for, 726 
 Caulay, C, 72 
 Cauteries, 742 
 Cells, slumbering, 164 
 Cellulitis, liacteria of, 310, 311 
 Celsus, 29 
 Centresome, 219 
 Cerumen, bacteria in, 254 
 Cicatricial tissue, 193 
 Civialc, J., 1(18 
 Chain saw, 775 
 Cliarethanus, J., 56 
 Chassaignac, E. P. M., 113 
 Chelius, M. .1. von, 119 
 Cheselden, W., 83 
 Chest, shot-wounds of, 495 
 Chilblain, 354 
 
 Cliina, ancient surgery of, 28 
 Chionyphe I'arteri, 353- 
 Chloroform, 64S 
 
 eliccts on nutrition, 665 
 
 mask, 702 
 Chondroblasts, 223 
 Chopart, F. , 75 
 Cliopart's amputation, 839 
 Chromatin, 219 
 Clark's extension method, 589 
 Clavicle, dislocation of, 614 
 
 fracture of, 577 
 
 resection of, 134, 792 
 Cline, H., 88 
 Clociuet, J. (x., 107 
 Clou<ly swelling, 231 
 Clove-hitcli, 612 
 Clover's inhaler, 668 
 Clowes, \V. , 1)3 
 Coagulation necrosis, 214, 227 
 Coccyx, excision of, 805 
 Cock, K., 101 
 Cogswell, M. F., 134 
 Colndieim, 153, 155, 160 
 Col de Villars, E., 73 
 Collapse, 859 
 Collateral circidation, 215 
 Colles, A., 99 
 CoUes's fracture, 595 
 
 law, 99 
 Colloid degeneration, 233 
 
 Colot family, 48 
 Colotomy, 71 
 Compression, digital, 738 
 Concretions, 236 
 Congestion, 156 
 Conjunctiva, bacteria of, 255 
 
 disinfection of, 257 
 
 elimination of bacteria by, 285 
 Connective tissue, 145 
 Coimer, P. S., on gunshot wounds, 445 
 Constantinus Africanus, 39 
 Contact infection, 275 
 Contusions, 373 
 Convalescence, 736 
 Cook, J., 66 
 Cooper, Sir Astley, 91 
 
 E. a, 141 
 
 S., 92 
 Cooper's method in dislocations of hip, 630, 
 632 
 of shoulder, 619 
 Coote, R. Holmes, 102 
 Coraeoid process, fracture of, 583 
 Coronoid process of ulna, fracture of, 600 
 Corpora amylacea, 236 
 Corrosive sublimate, 252, 300, 704 
 Corsets, 231 
 Cortesi, G. B., 57 
 Coryza, bacteria in, 262 
 Costo-sternal dislocation, 614 
 Coulson, W., 101 
 
 Councilman, W. T., surgical patholog}', 145 
 Covillard, 58 
 Cox, W. S., 98 
 Crampton, P., 99 
 Cranium, fracture of, 22 
 
 shot-wounds of, 479 
 Creolin, 705 
 Crepitus, 520 
 Crosse, J. G., 98 
 Croupous intlammation, 170 
 Crvptogenetic septico-pva;niia, 283, 298 
 Cusack^J. W., 100 
 Cystitis, bacteria in, 267, 274 
 
 pre<lisposing causes of, 274, 297 
 Czekierski, J., 128 
 
 DACA CHACON, D., 69 
 Dalecbamps, J., 51 
 Daniel, \V. C, 134 
 DaniU'wski on intlammation, 183 
 Deadrick, W. H., 134 
 Dease, W., 90 
 
 Decubitus, 360 , 
 
 Defences against bacteria, 279 
 Defensive proteids, 294 
 Degeneration, amyloid, 234 
 
 colloid, 233 
 
 fatty, 232 
 
 hyaline, 234 
 
 waxy, 227 
 Delirium, 374 
 Delitescence, 336 
 Dc1]kmIi, J. M., 108 
 Dclt.iid, paralysis of, 619 
 ])emarcation, line of, 358 
 Demme, 11., 124 
 
870 
 
 INDEX. 
 
 Denmark, surgery in, 126 
 
 Dennis, F. S., on fractures, etc., 515 
 
 Denonvilliers, C. P., llo 
 
 Desault, P. J., 74 
 
 Descliainps, J. F., 76 
 
 Deutsclinian, 187 
 
 Diabetes, 1S4 
 
 following anaesthesia, 664 
 
 relations to infection, 305 
 Diapedesis, 14M 
 DietlenliacI), J. F., 119 
 Digbv, Kenelm, (i.S 
 Digital comjiression, 738 
 Dionis, P., 70 
 Diphtheria, antitoxin of, 295, 329 
 
 bacillus of See Bacillus Diphlherice. 
 
 secondary infections of, 292, 323 
 
 toxins of, 323 
 
 of wounds, 324 
 Diplococci in the urethra and vagina, 266, 
 
 268 
 Diplococcus pneumoniae. See Micrococcus 
 
 Lanceolalm. 
 Disinfection, 682 
 
 of mucous membrane, 257 
 
 of the skin, 251, 252 
 
 of the vagina, 270 
 
 of wounds, 284, 300 
 Dislocations, 23, 603. See also under names 
 
 of bones and joints. 
 Dissection wounds, 372 
 Dolbeau, H. F., 114 
 Dorsalis pedis artery, ligature of, 773 
 Dorsey, J. S., 133 
 Dosage of infecting bacteria, 288 
 Douglas, J., 84 
 Dracontiasis, 352 
 Drainage, 702 
 
 of wounds, 369 
 Drainage-tubes, 703 
 
 objections to, 252, 298 
 Dressing-rooms, 710 
 Dressings, aseptic, 691 
 
 permanent, 716 
 Drill, Brainard's, 538 
 Drills, 777 
 Drnitt, K., 102 
 Dubois, A., 105 
 Dubovizki, P., 129 
 Dudley, K. W., 137 
 Dugas's test, 619 
 Dumreicher, J., 125 
 Duodenal ulcer, 362 
 Dupuytren, G., 106 
 Dupuytren's splint, 550 
 Dust, bacteria in, 277 
 
 EAR, middle, bacteria in, 263 
 Karle, Sir James, 88 
 Edinhvn-gh, history of surgery in, 65, 83, 94 
 Elastic bandage, 737 
 Elbow-joint, amputation at, 827 
 
 dislocations of, 621 
 
 resection of, 786 
 
 shot-wounds of, 472 
 Elimination of bacteria, 284 
 Embolism, 211 
 
 Embolism, air, 212 
 
 fat, 21.3, .532 
 
 jiulmonarv, 534 
 Emergency dressings, 721 
 Emigration of corpuscles, 148, 162 
 Emphysema in aniesthesia, 658 
 Emphysematous iihlegmons, 309, 322 
 Endocarditis, in the fa'tus 308 
 
 gonococcns in, 319 
 
 production of, 302 
 English surgery, history of, 60, 81 
 Epidermis, staphylococcus in, 251 
 Epiphyseal sejiaration, 585 
 Epithelioid cells, 241 
 Epithelium, new formation of, 196 
 Erysipelas, 418 
 
 neonatorum, 422 
 
 virus, for tumors, 423 
 Erysipeloid, zoonotic, 270 
 Esmarch's ehustic bandage in amjiutation 
 
 at shoulder-joint, 831 
 Ether, 646 
 Etherization, 667 
 Ethyl bromide, 653 
 Ethvlene bromide, 653 
 j;ve", P. F., 141 
 
 Excisions of bones and joints, 773 
 Executioners, 76 
 Explosive zone, 481 
 Extension apparatus, 134, 563 
 Exudation, 190 
 
 FABRICIUS D'AQUAPENDENTE, 56 
 Fabricius Hildanus, 59 
 Face, shot-wounds of, 487 
 Facial artery, ligature of, 750 
 Facultative parasites, 278 
 Fieces, bacteria of, 264 
 Falcutius, N., 42 
 False joint, 536 
 
 Farabeuf's method, excision of upper jaw, 
 810 
 snbstragaloid amputation, 842 
 Farkas' catheter sterilizer, 726 
 Fat-embolism, 213, 532 
 Fat-necrosis, 228 
 Fatigue, relation to infection, 304 
 Fattv degeneration, 232 
 Faudacq, C, 80 
 Fave, U. de la, 73 
 Felon, 351 
 
 Femoral artery, ligature of, 767 
 Femur, fracture of, 558 
 of neck of, 566 
 
 resections of, 802 
 Fergusson, Sir W., 95 
 Ferrius, A., 45 
 Fever, 199 
 
 aseptic, 203, 415, 717 
 
 irritative, 393 
 
 purulent, 399 
 
 pyaemic, 402 
 
 surgical, 416 
 
 traumatic, 415 
 Fibi'in, 161 
 Filirin-fermeut, 206 
 Fibrinous intlammation, 169 
 
IXDEX. 
 
 871 
 
 Fibroblasts, 2-23 
 
 Fibula, dislocation of, 636 
 
 fraoture of, oW 
 
 resection of, 797 
 Finger-nails, bacteria beneath, 251, 253 
 Fingers, amputation of, 817 
 
 avulsion of, 602 
 Fischer, (i., 76 
 Fistula in ano, 61 
 Flies as carriers of infection, 276 
 Fludil, K., 68 
 
 Fetus, infections of the, 304, 306, 308 
 Follin, E., Ill 
 Foot, amputations in, 834 
 
 artiticial, 862 
 Forceps, 778 
 Forearm, amputation in, 826 
 
 fractures of, 5;14 
 Foi-ster, J. Cooper, 102 
 Foster, W., 68 
 Four Mastei's, 39 
 Fourcrov, 104 
 Fracture-box, 544 
 
 Fractures, 515. See also under names of 
 bones. 
 
 compound, 523 
 statistics of, 529 
 
 gunshot, 459 
 
 non-union of, 536 
 
 repair in, 223 
 
 statistics of, 519 
 
 suppuration in, 272, 302 
 
 ununited, seton in, 132 
 Fragosa, J., 69 
 Franco, P., 48 
 Freer, G., 98 
 French surgery, history of, 42, 49, 58, 70, 
 
 104 ■ 
 Frere Come, 74 
 
 Jaccpies, 71 
 Fricke, J. C. G., 121 
 Friedlander bacillus. See Micrococcus Lan- 
 
 crolatns. 
 Friedrich Wilhelms Institut, 78 
 Frost and Baitlett, 448 
 Frostbite, 355 
 Fungus cerebri, 486 
 Furuncle, 252, 280, 350 
 
 GAGO DE VADILLO, P., 69 
 Gale, T., 62 
 Galen, 30 
 Gall-stones, 237 
 
 bacilli in, 265, 321 
 Ganigee, J. S., 99 
 (iangrene, 228, 356, 533 
 
 amputation in, 397 
 
 hospital, 359 
 
 hot, 229 
 
 traumatic, 389 
 fiarengeot, R. J. C. de, 71 
 (ias phlegmons, 309, 322 
 Gastric juice, germicidal action of, 264 
 (Jataker, .T., 88 
 Ciav, 9S 
 
 j., 101 
 Geddiugs, E., 143 
 
 Genitals, shot-wounds of, 511 
 Genito-urinarv tract, bacteria of, 265 
 
 tuberculosis, 246 
 Gensoul, J., Ill 
 Gerdy, P. N., 109 _ 
 
 (iennan surgery, history of, 52, 54, 76, 117 
 Germinal centres, 221 
 
 infections, 306 
 Gersdorfi; Hans von, 53 
 Gerstcr, A. (i., antiseptic surgery, 677 
 (Tibsim, W., 133 
 (iiraldcs, J. A. C. C, 115 
 t4irdner's telephonic probe, 451 
 (i landers. See Barilhia Mallei. 
 Glaudorp, M. L., 60 
 Glands, regeneration in, 222 
 (ilottis, u'dema of, 573 
 ({luteal artery, ligature of, 764 
 Glycogen, 233 
 Gonococcus, 267 
 
 associations of, 302, 319 
 
 charactersof, 319 
 
 dift'erentiation of, 267 
 
 pyogenic capacity of, 309, 319 
 
 iii vagina, 268, 269, 270 
 Gonorrlueal complications, 319 
 Gooch, B., 84 
 Gordon's splint, 596 
 Gosselin, A. L., 114 
 Gouges, 777 
 Govrand, J. G. B., 112 
 Graefe, C". F. von, 119 
 Gran\ilar degeneration, 231 
 Granulations, 188 
 Green, .J. II., 97 
 Greenstick fracture, 517 
 Gritti's amputation, knee, 850 
 Gross, S. L)., 139 
 
 S. W., 140 
 Grossheim, E. L., 121 
 Growth, 216 
 Giinther, G. B., 123 
 Guerin, J., 115 
 Guersant, P. L. B., 115 
 Guillemeau, J., 52 
 Guinea-worm, 352 
 Gunn, M., 142 
 
 Gunshot wounds, 44, 276, 445, 459 
 Gurlt, statistics of fractures, 519 
 Guthrie, G. J., 97 
 Guy de Chauliac, 41 
 Guy's Hospital, 81 
 
 HAARTMAN, VON, 129 
 Habits, etl(»ct of, in operations, 731 
 ILcmatolysis in infections, 305 
 Hoemopbilia, 3S1 
 Hiemostasis, 379 
 Hair, bacteria on, 254, 278 
 Hair-follicles, penetration of pyogenic cocci 
 into, 281 
 staphylococcus epidermidis albus in, 251 
 Halle, J., 63 
 Haller, A. von, 77 
 Halsted's .sliding splint, 545 
 Hamilton, F. H., 139 
 Hamilton's double splint, 564 
 
872 
 
 INDEX. 
 
 Hamilton's mctliuil for fracture of palilla, 
 
 554 
 IlaiKock, II., 101 
 Hand, amputation of, 821 
 
 artilicial, XdO, Stil 
 llariils, disinfection of, 086 
 llan"-li|i, (iO 
 Harrison, K., 100 
 Hawkins, Sir Cffisar, 88 
 
 C. IL, 98 
 Hay ward, G., 143 
 Head, sliot-wounds of, 479 
 Head-tetauus, 428 
 Healing by second intention, 368 
 Heart, abscess in, 405 
 
 shot-wounds of, 499 
 Heart diseiise in ana?sthesia, 657 
 Heat-production, 199 
 
 Heath's metliod, amputation of hip-joint, 855 
 Heine, C. W. von, 124 
 
 J. von, 124 
 Heister, L., 77 
 Heliodorns, 30 
 Heloderma suspectum, 412 
 Hemorrhage, 32, 378 
 
 prevention of, 737 
 
 secondarv, 457, 486 
 Hendriksz,"P., 116 
 Ilennen, J., 94 
 Hernia, femoral, 58 
 
 strangidated, bacteria iu, 297 
 Herophilus, 28 
 Herpetic diseases, 186 
 Herrmann, J. P., 124 
 Hesselbacli, F. C, 119 
 Heterochronia, 218 
 Heteroplasia, 218 
 Heuermann, O., 127 
 Heurtelou]), C. L. S., 108 
 Hey, W., 89 
 Hey's saw, 776 
 HeVfelder, J. F., 122 
 Hifton, J., 101 
 Hip-joint, amputation at, 476, S";2 
 
 dislocations of, 626 
 
 resection of, 802 
 
 shot-wounds of, 474 
 Hippocrates, 22 
 Hodgen, J. T., 142 
 Hodgkin's disease, streptococcus infections 
 
 in, 306 
 Hodgson, J., 98 
 Holder, J., 56 
 Holscher, G. P., 121 
 Home, Sir E., 88 
 Homer, surgery of, 20 
 Home, J. von, 59 
 Horner, W. E., 137 
 Hosjiital gangrene, 325, 359 
 Hospitals, 52 
 Hotel Dieu, 75 
 Hot gangrene, 229 
 Hueter, 1"., 125 
 
 Hneter's method for excision of elbow, 788 
 Humerus, fracture of, 584 
 
 resections of, 788 
 Huuczovsky, J. N., 80 
 
 I lunger, predisposing cause of infections, 304 
 Hunter, Jolni, 85 
 
 William (of Xewport), 131 
 Hutchinson, A. C, 92 
 
 J. G, 143 
 Hyaline degeneration, 234 
 Hyderaliad Connnission, 651 
 Hydidgen ]>eroxide, 395 
 Hydrophobia, 433 
 
 statistics of, 435 
 
 treatment of, 442 
 Hyoid bone, excision of, 132 
 
 fracture of, 572 
 Hypersemia, 155 
 Hyperplasia, 217 
 Hvjiertropliv, 215 
 Hyp<.phisia,'229 
 Hypostatic inllamination, 183 
 Hysteria, traumatic, 376 
 
 ILIAC, common, ligature of, 763 
 external, ligature of, 87, 765 
 internal, ligature of, 764 
 Immunity, 293 
 India, ancient surgery of, 24 
 Indian puzzle, 626 
 Infection, 677 
 
 atria of, 279, 308, 339 
 bacteria of, 315 
 
 influence of nerve-impulses on, 296 
 Infections, surgical, bacteriology of, 249 
 conditions favoring, 288 
 localizations of, 302 
 predisposition to, 295, 303 
 pyogenic forms, 308 
 secondary and mixed, 259, 273, 283, 
 
 290, 292, 302, 305, 313 
 sources of, 271, 275 
 Inflammation, 145, 311 
 clu'onic, 342 
 infective, 337 
 serous, 169 
 svmptoms of, 335 
 treatment of, 339 
 Inhalers, 668 
 
 Innominate arterv, ligature of, 95, 135, 746 
 Inoblasts, 223 
 Insanity, confnsional, following ansesthesia, 
 
 664 
 Instruments, 735 
 
 sterilization of, 688 
 Interscapnlo-thoracic amputation, 833 
 Intestines, ;uito-infection from, 306 
 bacteria of, 264 
 infections of, 281 
 
 invasion of bacteria through mucous mem- 
 brane of, 273, 274, 275, 279, 281, 
 282, 298, 321 
 obstruction of, as predisposing cause of 
 
 infection, 305 
 passage of bacteria through strangulated, 
 
 ' 297 
 wounds of, 57 
 Intra-uterine infection of the foetus, 306 
 lodococcus vaginatus in the mouth, 258 
 Iodoform, 697, 706 
 gauze, 723 
 
INDEX. 
 
 873 
 
 Ireland, siirRerv in, S9, 99 
 
 Irrigating solnticms, 703 
 
 Irritable ulcer, 349 
 
 Irvine, C. cle, 68 
 
 Italian surgery, history of, 45, 56, 116 
 
 JAEGER, M., 120 
 James, J. H., 98 
 Jarvis's adjuster, 610 
 Jaw, lower, resections of, 806 
 
 upper, resections of, 134, 809 
 Jesseuius a Jessen, 60 
 Jobert, A. J., UO 
 Joint, false, 536 
 Joints, pyogenic bacteria in, 302 
 
 resection of, 779 
 
 shot-wounds of, 468 
 Jones, G. M., 98 
 
 Jolni, 131 
 Jordan, J., 98 
 
 Jordan's method, amputation hip-joint, 853 
 Josephinum, 117 
 Joubert, L., 50 
 Journals, surgical, 144 
 
 KARYOMITOSIS, 219 
 Keratitis, oyster-slmcker's, 276 
 Kern, V. 8. von, 117 
 Key, C. A., 93 
 Kidney, ettects of ether on, 662 
 
 elimination of bacteria bv the, 285, 286 
 Kinlock, K. A., 142 
 Knee-joint, am]jntation at, 134, 848 
 
 disliicatiniis of, 23, 632 
 
 resection of, 799 
 
 shot-wounds of, 476 
 Knight, J., 141 
 Koelpin, A. K., 127 
 Krackowizer, E., 143 
 Krueger, S. 127 
 Kuhl, K. A., 121 
 
 LA GARDE, L. A., 454, 460 
 Lallemand, C. P., 109 
 Lallement, A. M., 105 
 Lancisi, G. M., 81 
 Lanfranc, 40 
 Langenbeck, B. R. K. von, 121 
 
 C. J. M., 118 
 Langenbeck' s method for excision of elbow, 
 
 788 
 Laparotomy for shot-wounds, 505 
 Lapevronie, F. de, 72 
 Larrey, D. J., 106 
 Larynx, bacteria in, 262 
 
 excision of, 126 
 Lassus, P., 105 
 Latent microliism, 272 
 Laugier, S., UO 
 Lautenschlager's sterilizer, 696 
 Lawrence. W., 92 
 Leander, R., 126 
 Leber, F. von, 79 
 Le Cat, C. X., 73 
 Le Clerc, G., 71 
 Le Dran, H. P., 73 
 Leech-book, the, 60 
 
 Leg, amputation of, 845 
 
 artificial, 862 
 
 fracture of, 543 
 Le Gros Clark F., 103 
 Leisrink, II. W. P.. 126 
 Le Lievre, E., 51 
 Leprosy. See B(iciUii.< Leprae. 
 Leptotiirix buccali.s, 2.J8 
 Leroy (d'Etiolles), J. J. J., 108 
 Leucocytes, 161 
 
 as phagocytes, 291, 294 
 
 polynuclear, 242 
 Leucocythiemia, streptococcus infections in, 
 
 306 
 Leucocytosis, 198 
 Levacher, P. G., 74 
 Levis' s hooks, 554 
 
 instrument for dislocation of fingers, 626 
 Lib.,rius, J. A., 128 
 Ligature of arteries, 32, 50, 742 
 Ligatures, 380 
 Lightning-stroke, 366 
 Lingual arterv, ligature of, 750 
 Linhart, W. von, 123 
 Lipomatosis, 232 
 Lisfranc, J., 107 
 Lister, J., 103 
 Lister's nni]iutation, knee, 850 
 
 metliod for excision of wrist, 782 
 
 splint, 784 
 Liston, R., 95 
 Litliotomy, ancient methods, 34, 38, 47, 61 
 
 suprapubic, 48 
 Litbotrity, 108 
 Little's a])paratus for fracture of patella, 
 
 553 
 Littre, A., 71 
 Liver, eflects of chloroform on, 665 
 
 elimination of bacteria by, 286 
 
 focal necroses in, 286 
 Lizars, J., 95 
 Lloyd, E. A., 97 
 Local iisphyxia, 361 
 Locus minoris resistentia', 302, 338 
 Loeffler, (i. P. P., 125 
 Long, C. W., 138 
 Louis, A., 72 
 Lowdham, C. I)., 67 
 Liieke, G. A., 125 
 Luke, J., 100 
 Lump-jaw of cattle, 332 
 Lungs, bacteria in, 263, 282 
 
 sbot-wonnds of, 496 
 Lymi)li in inflannnation, 159 
 Lymphocytes, 163 
 Lysoi, 705 
 
 MAAS, II., 126 
 McClcUan, G., 136 
 McDowell, E., 133 
 Mc<;ill, i:u 
 
 Mclntvre's splint, 545, 548 
 Madui-a, foot, 334, 352 
 Magati, C, 57 
 Maggius, R, 45 
 Malgaigne, J. P., 112 
 Malgaigne's hooks, 553 
 
874 
 
 INDEX. 
 
 Malignant a'dema, bacillus of. See BacUlux 
 of Mitli(jiiniit (Edema, caused by 
 livjioilfriiiic injections, 322 
 Malleolus, internal, fracture of, 547 
 March, A., 139 
 Marchetti, P. de, 57 
 Mareschal, G., 70 
 Marian operation, 47 
 Marjolin, J. N., 107 
 Marshall, J., 102 
 Masiero, F., 58 
 
 Mastitis, sources of bacteria causing, 287 
 Mauchart, B. D., 77 
 Maunder, C. F., 103 
 Mauquest de la Motte, G., 73 
 Maury, F. F., 140 
 Maxilla. See Jaw. 
 Meconium, bacteria in, 264 
 Meekren, J. J. von, 59 
 Mery, J., 70 
 
 Metacarpal bones, disarticulation of, 821, 
 823 
 fracture of, 002 
 resection of, 781 
 Metastasis, 401 
 
 Metatarsal bones, amputation through, 835 
 dislocation of, 644 
 resection of, 793 
 Methylene bichloride, 652 
 Mexico, surgery in, 129 
 Micrococcus gonorrho?*. See Gnnoeoccus. 
 lanceolatus, characters of, 318 
 elimination of, 286, 287 
 frequency of, in infections, 309, 311, 
 
 318' 
 in the intestine, 265 
 in the lungs, 258, 263 
 in the middle ear, 263 
 in the mouth, 258, 271, 318 
 in the nose, 261 
 
 pathogenic eflects, 258, 275, 309, 318 
 placental transmission of, 307, 308 
 variations in virulence, 258, 261, 271, 
 289, 291, 318 
 pneumonite cruposse. See 3Iicroeoccus 
 
 LdiiceolafiiK. 
 pyogenes tenuis, 309, 318 
 of sputum sc|itic,-emia. See Micrococcm! 
 
 Jjifiirt'iihitiis. 
 tetragenus, characters of, 317 
 in the mouth, 2-58, 260, 261 
 in the nose, 262 
 pathogenic manifestations, 260, 275, 
 
 309, 311, 318 
 septicus, 260, 318 
 Middcldorpf, A. T., 123 
 Middle ear, bacteria in, 263 
 Mikulicz's method for excision of ankle, 797 
 Miliary tubercle, 241 
 Milk, bacteria in woman's, 270 
 bactericidal pro])erty of, 271 
 elimination of bacteria in, 287 
 tubercle bacilli in, 287 
 Miner, J. F., 143 
 IMissiles, 445 
 
 Mitchell, Weir, on nerve-influence on in- 
 fection, 296 
 
 Mixed infections, 290 
 
 Moeller, J. H. G., 128 
 
 Moinichen, H. von, 127 
 
 Mojsisovics, G., 121 
 
 Mondeville, Henry de, 40 
 
 Monnikof, J., 80 
 
 Monro, A., 85 
 
 Monteggia, G. B., 117 
 
 Monteraayor, C, 09 
 
 Moore's dressing for fracture of clavicle, 
 581 
 
 Morand, S. F., 72 
 
 Morgan, C. de, 101 
 J., 98 
 
 Morstede, J., 61 
 
 Morus, H., 64 
 
 Mosetig-Moorhof's method for excision of 
 elbow, 788 
 
 Mott, v., 134 
 
 Mouth, bacteria of, 2-57 
 disinfection of, 723 
 
 Mucoid degeneration, 233 
 
 Mucous membranes, bacteria of, 255 
 
 elimination of bacteria through, 284 
 penetrabilitv of, bv bacteria, 279, 280, 
 
 281, 282 
 possibility of infection of, 257, 273 
 
 Mutter, T. I).", 136 
 
 Mummification, 228 
 
 Mummy, 55 
 
 Muralt,' J. von, 60 
 
 Mursinna, (.'. L., 118 
 
 Muscles, regeneration of, 224 
 
 Muscles, gunshot wounds of, 458 
 
 M-usitanus, ('., 58 
 
 Mussev, K. I)., 137 
 
 Muy.s,'j., 59 
 
 Mycetoma. See Bladara Foot. 
 
 Mvddvai, physicians of, 61 
 
 Mynors, K., 89 
 
 NAGUMOWITSCH, L., 128 
 Nancrede on symptoms and treatment 
 
 of inflanmiation, etc., 335 
 Nannoni, A. and L., 81 
 Naplitluduic, 706 
 Narcosis as predisposing cause of infections, 
 
 304 
 Nasal secretion, bactericidal property of, 
 
 262 
 Neck, shot-wounds of, 489 
 Necrogenic warts, 276 
 Necrosis, 165, 225 
 
 a predisposing cause of infection, 301 
 Neill, J., 143 
 Nelaton, A., 113 
 N^laton's line, 567 
 
 metliod for excision of elbow, 788 
 probe, 451 
 Nelson, R., 142 
 Nephrectomy, 125 
 Nephrotomy, 21 
 Nerve-impulses, influence of, on infection, 
 
 296 
 Nerves, regeneration of, 225 
 Netherlands, surgery in, 58, 80, 115 
 Neuber's tubes, 703 
 
INDEX. 
 
 875 
 
 Neurasthenia, 376 
 
 Neiirectomv, 87 
 
 Neuritis, multiple peripheral, 39"2 
 
 Neuropathic atrophy, 231 
 
 Neurotomy, SO 
 
 Nitrous oxide, 647, 664 
 
 N orris, tr. W., 136 
 
 Norsiui, the, 47 
 
 Nose, bacteria of, 261 
 
 tubercle bacilli in, 262 
 Nott, J. C, 143 
 Nuclein, bactericidal pi'opert)' of, 294 
 
 OBESITY, ertect of, in an*sthesia, 656 
 Obligatory parasites, 2/8 
 Occipital artery, ligature of, 752 
 Oi^dema, IGO 
 
 glottidis, 573 
 
 influence of, on infection, 296 
 O'llalloran, 8., 90 
 Oidiuni albicans in the vagina, 269 
 ( )il of ]iiippies, 49 
 Olecranon process, fracture of, 601 
 OUier's method for excision of elbow, 788 
 of hip-joint, 803 
 of wrist, 784 
 Onsenoort, A. G. von, 116 
 Operating-rooms, 707, 735 
 Operating-tal)lc, 708 
 Operations, ]ircparations fur, 733 
 
 a-septic, 710 
 Operative surgery, 729 
 Oribasius, 31 
 Ormsby's inhaler, 669 
 Os calcis. See Vnlcnneum. 
 Osteoblasts, 223 
 
 Osteomvelitis, bacteria causing, 282, 309, 
 311, 312, 321 
 
 experimental production of, 303 
 Osteoplastic amputation of ankle-joint, 844 
 
 excision of ankle, 797 
 
 excision of elbow, 788 
 Ostitis albuminosa, bacteria causing, 312 
 Otis, G. A., 142 
 Otitis media, bacteria in, 263 
 Oval method in amputation of fingers, 819 
 Ovariotomy, 72, 124. 133, 134 
 Oystcr-sliHi'ker's keratitis, 276 
 Oza-na, bacillus of, 262 
 
 PACKING, 71§ 
 Pain in inflammation, 158 
 Palfvn, J., 80 
 Palletta, G. B., 116 
 Palmar arch, ligature of, 761 
 Pancoast, J., 140 
 Papyrus Ebei-s, 18 
 Paquelin's cautery, 742 
 Paracelsus, 54 
 Parasites, obligatorv, 278 
 Pare, A., 49 
 Park, H., 88 
 Parker, W., 135 
 Paronychia, 351 
 
 Pasteur's treatment for rabies, 442 
 Patella, dislocatiims of, 635 
 excision of, 801 
 
 Patella, fracture of, 550 
 
 wiring of, 556 
 Patliologv, surgical, 145 
 Panl, H.'J., 124 
 Pauhis -Egineta, 31 
 Pelletan, P. J., H)5 
 Pelvis, fracture of, 570 
 Pental, 653 
 Pepiniere, the, 78 
 Percv, P. F., 106 
 Periosteal flaps, 816 
 Perioslcotonics, 775 
 Periostitis following typhoid fever, 321 
 
 all>nminosa, bacteria causing, 312 
 Peritonitis, bacteria in perforative, 265, 274 
 Pernio, 354 
 
 Peroxide of hydrogen, 706 
 Petit, Jacques, 75 
 
 J. L., 72 
 Petrecjuin, J. P. E., 115 
 Pfolzprundt, M., 53 
 Phagocytic theory, 166, 294 
 Phalanges, dislocations of, 626, 644 
 
 fracture of, 540, 603 
 
 resection of, 780, 792 
 
 of foot, amputation of, 834 
 Pharynx, bacteria of, 257 
 Phelps, C., on wiring the patella, 556 
 Phioravanti, L., 51 
 
 Phlegmons, bacteria causing, 309, 310, 311 
 Phloridzin, increases susceptibility to gland- 
 ers, 305 
 Physick, P. S., 132 
 Physick's elbow-splint, 589 
 Pigmentation, 221, 237 
 Pigrav, P., 52 
 Pirogotr, N. I., 128 
 Pirogofl's amputation, 844 
 Pitcairn A., 83 
 Pitha, F. von, 122 
 Placental transmission of micro-organisms, 
 
 306 
 Plainer, J. Z., 77 
 
 Pneumococcus. See Micrococcus Lanceolatus. 
 Poland, A., 102 
 Poisons, animal, 408 
 Pope, C, 141 
 
 Popliteal artery, ligature of, 7ti9 
 Porta, L., 117' 
 Portals of entry of bacteria in surgical 
 
 infections, 279 
 Porter, W. H., 99 
 Post, A. C, 136 
 
 W., 132 
 Potassium permanganate, 706 
 Pott, P., 85 
 Pott's fracture, 549 
 Pravaz, C. G., Ill 
 Predisposition, 292, 295, 303 
 Price, P. C, 102 
 Probe, Girdner's, 451 
 
 Nelaton's. 451 
 Prognosis in operations, 730 
 Proteids, defensive, 294 
 Proteus. See BnciUus Proteus. 
 Pseudarthrosis, 536 
 Pseudo-diphtheria bacillus, 257, 260 
 
876 
 
 INDEX. 
 
 Pseudo-gonococci, 206, 2G7, 208, 319 
 
 I'seiul()-iiiHueiiz;i liacillus of I'i'eitier, 203 
 
 I'uliic liniif, I'nicliiii' (if, 571 
 
 I'lidic arU'i-v, intunial, ligature of, V(>o 
 
 I'lK'ipural infection, bacteria of, 208, 274 
 
 I'lippies, oil of, 49 
 
 I'lirmaiiii, M. < 1., 00 
 
 I'liruk-iit intlanimatloii, 171 
 
 Pus, 172 
 
 blue, 253, 320 
 
 micro-organisms of, 176, 308 
 Pyfcmia, 249, 273, 2S3, 314, 314 
 
 crviitugenetic, 283, 298 
 Pyogenic bacteria, 170, 179, 289, 308 
 
 cocci, 308. See also Staphylococcus Pyo/j- 
 enes and Streptococcus Pi/ogenes. 
 
 absorption of, 284, 300 
 
 associations of, 291 
 
 efiects of, 290, 302, 311 
 
 elimination of, 285 
 
 predisposition to, general, 303, 306, 318 
 local, 290, 298, 301, 302, 312 
 
 virulence of, 270, 271, 273, 275, 283, 289, 
 292, 296, 312 
 
 in air, 277 
 
 in bile, 263 
 
 in blood, 314 
 
 on external objects, 275, 278 
 
 in Hies' excrement, 276 
 
 in tlie fo'tns, 307 
 
 on tlie liair, 254, 278 
 
 in the lungs, 282 
 
 in milk, 270 
 
 in the mouth, 259 
 
 in the nose, 201 
 
 on the skin, 252 
 
 in the soil, 270 
 
 in the stomach and intestines, 265, 298 
 
 in the urethra, 207 
 
 in the vagina, 208 
 membrane, 174 
 Pyosepticfemia, 404 
 Pyrogenic substances, 203 
 
 Q 
 
 UERfETANUS, 51 
 Qucsnay, F. , 70 
 
 RABIES, 433 
 Kadial artery, ligature of, 759 
 Eadius, dislocation of, 022 
 
 fracture of, 594 
 
 resection of, 785 
 Randolph, J., 143 
 Ranke, H. K., 116 
 Rau, J. J., 80 
 Ravaton, H., 74 
 Rarotb, F. W. T., 124 
 Raynaud's disease, 361 
 Read, A., 04 
 Rectum, cancer of, 01 
 Reef-knot, 740 
 Regeneration, 193, 219 
 Repair, 190 
 Resections, 773 
 Resolution, 191, 330 
 Respiration, artificial, 075 
 Respiratory passages, bacteria of, 201 
 
 Key her, ('., 129 
 
 Rhinitis fibrinosa, diphtheria bacillus in, 
 
 202 
 Rhinoplasty, 4() 
 
 Rhinoscleroma, bacillus of, 202, 320 
 Ribs, dislocation of, 013 
 
 fracture of, 573 
 
 resections of, 805 
 Richard, F. A., 115 
 Richerand, B. A., 106 
 Richet, L. A., 114 
 Richter, A. G., 79 
 Riding endjoli, 212 
 Rigidity, traumatic, 482 
 RizzoU; F., 117 
 Rklizkv, I., 129 
 Rochard, J., 105 
 Rodgers, J. K., 135 
 Roger of Parma, 39 
 Roland, 39 
 
 Romanes, John de, 47 
 Roonhuvsen, H. van, 59 
 Roux, J., 112 
 
 P. J., 106 
 Roux's amputation at ankle-joint, 844 
 Rubber drainage-tubes, 703 
 Rudtorfier, F. X., 118 
 Russell, J., 94 
 Russia, surgery in, 128 
 Rust, J. N., 118 
 Ruvsch, F., 80 
 Ryff, W. H., 54 
 
 SABATIER, R. B., 75 
 Salire-wounds, 512 
 St. Bartholomew's Hosjiital, 81 
 St. C'6me, College of, 72 
 St. Thomas's Hospital, 81 
 Salernum, School of, 39 
 Salicylic acid, 705 
 Saliva, germicidal power of, 260 
 Salivary glands and ducts, bacteria in, 261 
 
 elimination of bacteria by, 288 
 Salter's swing, 548 
 Samuel, 150,' 160 
 Sanctus Barolitanus, M., 46 
 Sands, H. B., 139 
 Sanson, L. J., 107 
 Santesson, C. G., 128 
 Saprsemia, 383, 390 
 Saprophytes, 278 
 Sarcoma of bone, 525 
 Saviard, B., 71 
 Saw.s, 770 
 Say re's method for excision of hip-joint, 803 
 
 for fracture of clavicle, 579 
 Scalds, 362 
 Scalpels, 774 
 Scapula, dislocation of, 617 
 
 fracture of, 582 
 
 resections of, 790 
 
 and arm, amputation of, 833 
 Scarpa, A., 110 
 Scarpa's triangle, 707 
 Schede's method, 494, 526 
 Schillbach, E. L., 124 
 Schimmelbusch's boiler, 6S9 
 
INDEX. 
 
 877 
 
 Schiramelbusch's sterilizer, 094 
 Sehlichtinsj, J. D., «0 
 Sc'limatis, L., 4o 
 Schmidt, J., 60 
 Sclimuclcer, J. L., 78 
 Schuh, F., 122 
 
 Sciatic arterv, ligature of, 765 
 Scoiitettin, R. II. J., 112 
 Scott's splint, 595 
 Sciiltetus, J., 59 
 
 Secretions, bactericidal properties of, 256, 
 260, 2()2, 264, 265, 267, 269, 271 
 
 elimination of bacteria in the, 284 
 Sedillot, C. E., 115 
 
 Semilunar cartilages, dislocations of, 634 
 Sei)tic:emia, 175, 249, 314, 383 
 
 crvptogenetic, 283, 298 
 
 bacteria, due to exposed mucous surfaces, 
 273, 275, 283 
 
 due to streptococcus pyogenes, 283, 306, 
 313, 314 
 
 secondary, 273, 275, 283, 292, 300, 308, 
 313, 314 
 
 terminal, 300 
 Septico-pya^mia, cryptogenetic, 283, 298 
 Serous iuHammation, 109 
 Serpent-bites, 410 
 Serratns magnus, paralysis of, 617 
 Serre, M., 109 
 Serum-therapy, 295, 328 
 Seyerinus, M. H., 57 
 Sharp, S., 84 
 
 Sherrington on elimination of bacteria, 285 
 Shippeu, W., 132 
 Shock, 454, 858 
 Shoulder-joint, amputation at, 829 
 
 dislocation of, 017 
 
 resection of, 790 
 
 shot-wounds of, 471 
 Shrady's saw, 770 
 Siebold, C. C. yon, 79 
 Sigault, J. R., 76 
 Silyer-fork fracture, 595 
 Simon, C, J. F. L. G., 125 
 Sims, J. M., 139 
 Skey, F. C, 101 
 Skev's method in dislocation of shoulder, 
 
 020 
 Skin, bacteria of, 250, 272 
 
 cleansing of, 251, 27'J, 085 
 
 normal defences against bacteria, 279 
 
 penetrability to bacteria, 252, 280 
 
 persistence of corrosiye sublimate on, 
 252 
 
 white coccus of, 251, 272, 292 
 Sloughs, 173 
 Slumbering cells, 164 
 Smegma bacillus, 254, 206, 329 
 Smith, II. H., 140 
 
 (II. H. ), method in dislocations of shoul- 
 der, 621 
 .splint, 539 
 
 N., 134 
 
 R. \V., 100 
 
 Stephen, method of amputation at knee- 
 joint, 849 
 on operatiye surgery, 729 
 
 Smith's anterior splint, 545, 560 
 Societies, surgical, 144 
 Socin's paste, 700 
 Soden, J. S., 98 
 Soil, bacteria in, 253, 276 
 Solingen, C, 59 
 Sorauus, 30 
 Souberbielle, J., 108 
 
 Sources of bacteria in surgical infections, 271 
 South, J. F., 97 
 Southam, G., 99 
 Spain, history of surgery in, 68 
 Spanish windlass, 610, 722 
 Spa.smotoxin, 320 
 
 Spence's method of amputation at shoulder- 
 joint, 830 
 Sphacelus, 229 
 Spider-bites, 409 
 Spigelius, 57 
 
 Spine, shot-wounds of, 492 
 Spirilla in epithelial cells of dog's stomacli, 
 272 
 in the mouth, 258 
 in the nose, 202 
 Spirillum sputigcmun, 2.58 
 Spirochiete dentium, 258 
 Spleen, excision of, 58 
 Sponges, 698 
 Spore-forming bacteria, list of pathogenic, 
 
 278" 
 Stanley, E., 98 
 Staphylococcus, 177 
 
 cereus albus, characters of, 310 
 
 pathogenic characters of, 309, 310, 
 316 
 flayus, 309, 310 
 epidermidis albus, in abscesses and other 
 inHammatious, 310 
 in aseptic wounds, 251, 272, 292 
 in blood, 252, 314 
 characters of, 251, 315 
 cause of stitch-abscesses, 252, 272 
 infection fayored by drainage-tube 
 
 and necrotic tissue, 251, 272, 299 
 in .sweat, 252, 288 
 in women's milk, 270, 287 
 pyogenes albus, characters of, 315 
 frequency of, 310 
 yirulenceof, 271, 310, 315 
 in aseptic wounds, 272, 314 
 in conjunctiva, 250 
 in the mouth, 258, 260 
 in the nose, 202 
 in woman's milk, 270, 287 
 
 aureus, in asc|itic wounds, 292 
 in blood-dots in wounds, 299 
 characters of, 315 
 in the conjunctiya, 256 
 elimination of, 285, 286, 287, 288 
 freciuency of, 310 
 in the milk, 270, 287 
 in the mouth, 259 
 in the nose, 201 
 in osteomyeliti.s, 303, 313 
 pathogenic ettects, 252, 280, 303, 309, 
 
 311 
 on the skin, 252 
 
878 
 
 IMiEX. 
 
 Staphylococcus jivogenes aureus in the 
 sweat, 28S 
 iu tlie uretiira, 2(5^, 207 
 in tlie vagina, 2(i9 
 virulence of, 2S9 
 citreus, characters of, 315 
 
 pathogenic eflects, 309, 311, 315 
 Steam sterilizers, 093 
 Sterilization, 082, ()93 
 Sternum, dislocation of, 014 
 fracture of, 570 
 resections of, 805 
 Stilling, B., 124 
 Stings, 408 
 
 Stitch-abscesses, 252, 272 
 Stomach, bacteria in, 203 
 
 resection of, 120 
 Streptococcus, 177 
 brevis, 258, 317 
 conglomeratus, 317 
 erysipelatos, ol(i 
 
 antagonistic to infection with anthrax, 
 291 
 longus, 258, 317 
 
 pyogenes, antagonisms of, 291. See also 
 Pi/oqenic Cocri. 
 associations of, 259, 291, 292, 324 
 characters of, 316 
 elimination of, 280, 287 
 frequency of, 310, 311 
 pathogenic eflects of, 259, 275, 289, 292, 
 
 300, 310, 313, 310, 324 
 varieties of, 258, 317 
 virulence of, 259, 271, 277, 289, 291, 
 
 313, 310, 317, 325 
 in the air, 277 
 in the bile, 265, 286 
 in the blood, 314 
 in the conjunctiva, 256 
 in tlie intestine, 205 
 in the lungs, 259, 263 
 in the middle ear, 263 
 in the mouth, 258 
 in the nose, 261 
 in secondary and mixed infections, 259, 
 
 275, 283, 292, 313 
 in septicaemia, 300, 313, 314 
 on the skin, 253 
 in the urethra, 207 
 in the vagina, 269 
 in wounds, 300, 313, 324 
 Stromeyer, G. F. L., 122 
 Stromeyer's cushion, 591 
 Styptic, 54 
 Subastragaloid amputations, 841 
 
 dislocation, 642 
 Suliclavian artery, ligature of, 746, 755 
 Subcoracoid dislocation, 617 
 Subperiosteal exsection of elbow, 787 
 Sue, J. J., 74 
 Sulpho-naphthol, 396 
 Sunburn, 305 
 Suppuration, 172, 182 
 
 accompanying or following tvphoid fever, 
 
 32i 
 bacteria of, 308 
 bactericidal intluence of, 297 
 
 Supi)uration, local causes favoring, 291, 
 290, 301, 303, 313 
 
 from sterile chemical substances, 292 
 
 in subcutaneous fractures, 272, 302 
 Su]ira-condylciid fracture of humerus, 585 
 Supra-mallcolar amputation, 845 
 Surgeon's knot, 740 
 Surgery, conservative, 96 
 
 history of, 17 
 
 oijerative, 729 
 Sm-giial infections. See Infections, Surgieal. 
 
 jiHuijals and societies, 144 
 Su.sccplibility, 293 
 Susrula, 24 
 Sutures, 98, 700 
 Sweat, elimination of bacteria by, 288 
 
 staphylococcus epidermidis albus in, 252, 
 " 288 
 Sweden, surgery in, 127 
 Swelling in inflammation, 159, 107 
 Syme, J., 90 
 Syme'.s amputation, 843 
 Sympathetic inflammation, 186 
 
 powder, 68 
 Symptomatic anthrax, bacillus of, 292, 304, 
 
 307 
 Syncope, 859 
 Syphilis, 44 
 
 Syringes, disinfection of, 090 
 Sz}'manowsky, J., 129 
 
 TASSONI, G., 81 
 T.agliacotius, G., 40 
 Talmu<l, surgery of, 19 
 Tamjionade, 697 
 Tarsal bones, dislocation of, 643 
 fracture of, 540 
 resection of, 794 
 Tarso-metatarsal articulation, amputation 
 
 at, 838 
 Tarsn-s, synovial membranes of, 794 
 Tassin, L., 58 
 Taylor, J., 84 
 Teale, T. P., 98 
 Teale's amputation, 815 
 Tecvan, W. F., 103 
 Tcevan's law, 482 
 Telepliouic ])robe, 451 
 Tem]ioral artery, ligature of, 752 
 Tenaculum, 739 
 Teno-syuovitis, 351 
 Tenotomy in compound fractures, 526 
 Tetauiu, 32() 
 Tetanotoxin, 326 
 Tetanus, 426 
 
 autitoxiue of, 395, 328, 431 
 
 bacillus of See Baeillus Tetani. 
 
 after fracture, 532 
 
 ptomaines of, 326 
 
 toxin of, 327 
 Tetany, 430 
 Texto'r, K. von, 120 
 Thaden, A. G. J. von, 125 
 Theden, J. C. A., 78 
 Tliermo-cantery, 742 
 Thiersch's solution, 39-5, 705 
 Thigh, amputation in, 850 
 
INDEX. 
 
 879 
 
 Thomson, J., 94 
 Thrombosis, 205, 40() 
 Thulstrup, M. A., 128 
 Thumb, amjjutation of, 821 
 
 disloraticin of, 025 
 Tliymol, 70() 
 Thyroid artery, inferior, ligature of, 754 
 
 superior, ligature of, SS, 749 
 Tibia, resections of, 797 
 
 dislocations of liead of, 633 
 
 fracture of, 546 
 Tibial artery, anterior, ligature of, 771 
 
 posterior, ligature of, 770 
 Tilanus, C. B., il(j 
 Titsingh, A., SO 
 Toes, amputation of, 834 
 Tolet, P., 51 
 
 Tongue, shot-wounds of, 488 
 Tonsil, as atrium of infection, 259, 279 
 Torsion of arteries, 740 
 Tourniquet, t)7, 71, 739 
 
 Bloxarn's dislocation, 611 
 Toxalburain «( diplitheria, 323 
 
 of tetanus, 327 
 Toxic prodticts of bacteria, 289, 291, 314, 
 
 323, 327 
 Toxines, 289 
 
 Transplantation of tissue, 220 
 Traumatic delirium, 374 
 
 fever, 415 
 
 rigiditv, 482 
 Travers,"B., 94 
 Trelat, U., 114 
 
 Trelat's method for fracture of patella, 554 
 Trephining, 57 
 
 prehistoric, 18 
 Tripier's amputation, 841 
 Trochanter major, fracture of, 565 
 Trophic inflammation, 185 
 Tuberculosis, 239 
 
 bacillus of. See Bacillus Tuhercxdosis. 
 
 congenital, 247 
 
 infectiuns secondary to, 292, 302, 313 
 
 inheritance of, 282, 307 
 
 of internal parts without demonstrable 
 atrium morbi, 282 
 
 intestinal, experiments concerning, 282 
 Tufiiell, T. J., 100 
 Tumors, treatment with erysipelas virus, 
 
 423 
 Twitchell, A., 134 
 Tympanic cavity, bacteria in, 263 
 Typhoid fever, ostenniyelitis and periostitis 
 following, 321 
 suppurations accompanving or follow- 
 ing, 321 
 surgical infections secondary to, 273, 
 275, 283, 292, 3l5, 321 
 
 ULCERATION, 187, 343 
 Ulcers, 346 
 Ulna, dislocations of, 622 
 fracture of, 600 
 resection of, 785 
 Ulnar artery, ligature of, 760 
 I'nited States, surgery in, 130 
 Ununited fracture, 536 
 
 Urethra, bacteria in, 266 
 disinfection of, 727 
 
 Urine, bacteria in, 266 
 bactericidal power of, 267 
 elimination of bacteria in the, 285 
 of tetanus toxin in the, 327 
 
 VA(H\A, bacteria in, 267 
 disinfection of, 727 
 Vaginal bacilli, 268, 269 
 
 secretions, bactericidal powers of, 269 
 Valsalva, A. M., 81 
 Vauguion, de la, 58 
 Veins, throniljosis of, 213 
 Velpeau, A. A.L. M., 109 
 Velpeau' s dressing for fracture of clavicle, 
 
 581 
 Venoms, 408 
 
 Verneuil's subastragaloid amputation, 842 
 Vertebne, resections of, 805 
 Vertebral artery, ligature of, 753 
 Vevras, J., 51 
 Vicarv, T., 62 
 
 VidaUdeCassisX A. T., lU 
 Vigo, John de, 44 
 Virchow on intiammation, 164 
 Virulence of infecting bacteria, 289, 291, 
 
 312 
 Vogt, P. F. I., 126 
 Volkmann, R. von, 126 
 Volkmaun's operation for psoudarthrosis, 
 
 639 
 
 WAtiNER, C. E. A., 123 
 Waltber, P. F., von, 118 
 
 "^Vard, J., 67 
 
 Wardrop, J., 92 
 
 Warner, J., 88 
 
 Warren, .)., 132 
 J. (_;., 132 
 
 on traumatic fever, erysipelas, and teta- 
 nus, 415 
 
 Warts, necrogenie, 276 
 
 Water, sterilization of, 703 
 
 WatS(m, J., 136 
 
 Wattmann, J. von, 118 
 
 \\'axy tlegeneration, 227 
 
 Weapon-salve, 68 
 
 Welch, ^V. II., bacteriology of surgical in- 
 fections, 249 
 
 Wernlier, A., 120 
 
 White, C, 89 
 
 White gangrene, 360 
 
 William of Salicet, 40 
 
 Willv Mever's .sterilizer, 695 
 
 Wilms, 125 
 
 Wiseman, R., 66 
 
 Wood, ii. B., experiments on ansesthesia, 
 661 . 
 H. C, on anaesthesia, 045 
 J. R., 139 
 
 Wood's method in dislocations of shoulder, 
 620 
 
 Woodall, J., 65 
 
 Wound-fever, 56, 415 
 
 Wound- infection, 271 
 
 \\'ounds, 366 
 
880 
 
 INDEX. 
 
 'Wounds, absorption of bacteria i'roiii, 284, 
 
 297, 300 
 air-inlVrtion of, 276 
 
 antiseptic treatment of, experiments con- 
 cerning, 300 
 
 aseptic treatment of, experiments concern- 
 ing, 301 
 
 bacteria in infected, 249, 251, 253, 272, 
 273, 275, 284, 292, 298, 300, 310, 
 313, 324, 325 
 
 blood-clot, healing of, 299 
 
 conditions favoring infection of, 252, 295, 
 
 298, 303 
 contact, infection of, 275 
 diphtlieria of, 324 
 disinfection of, 253, 284, 300 
 drainage of, 369 
 
 hospital gangrene of, 325 
 
 of mucous membranes, bacteria in, 259, 
 
 273 
 necrotic inflammation of, 324 
 sources of bacteria in infected, 271, 272,275 
 treatment of, 715, 721 
 arrow-, 513 
 
 aseptic, bacteria in, 251, 272, 292 
 bavonet-, 512 
 gunshot, 49, 53, 276, 445 
 
 Wounds, jioisoned, 372, 407 
 
 sal>re-, 512 
 Wrist, shot-wounds of, 474 
 \\'rist-(lrni), 590 
 Wrist-joint, amputation at, 82G 
 
 dislocations of, 623 
 
 resection of, 782 
 Wry-neck, 67 
 Wurtz, F., 55 
 Wutzer, V. W., 120 
 
 Wyetli's bloodless method of amputation of 
 hip-joint, 855 
 
 saw, 778 
 Wyssokowitsch on cliiriination of bacteria, 
 285 
 
 yEKOSIS BACILLUS. 257 
 
 YONGE, J., 66 
 Yperman, J., 40 
 
 ZANG, C. B., 118 
 Zeis, E., 124 
 Zenker's degeneration, 227 
 Zoonotic erysipeloid from crabs and other 
 shell-tish, 276 
 
COLUMBIA UNIVERSITY LIBRARY 
 
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 System of surgery 
 
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