COLUMBIA LIBRARIES OFFSITE .HEALTH SCIENCES STANDARD HX00060577 ^ Columbia ^nibersiitp ,^^^ College of 3^i)^i\mm mt burgeons Eefercnte Hibtatp J Digitized by the Internet Archive in 2010 with funding from Columbia University Libraries http://www.archive.org/details/manualofsurgeryfOOstew A MANUAL OF SURGERY STEWART A MANUAL OF SURGERY FOR STUDENTS AND PHYSICIANS BY FRANCIS T. STEWART, M. D. FORMERLY PROFESSOR OF CLINICAL SURGERY, JEFFERSON MEDICAL COLLEGE; SURGEON TO THE PENNSYLVANIA HOSPITAL FIFTH EDITION WITH 590 ILLUSTRATIONS PHILADELPHIA P. BLAKISTON'S SON & CO 1012 WALNUT STREET Copyright, 1921, by P. Blakiston's Son & Co. THE 'ia.A.VL.'Bi rilESS YORK I" A TO DR. ROBERT G. LE CONTE AS A TRIBUTE TO HIS ABILITY AS A SURGEON PREFACE TO THE FIFTH EDITION The manuscript of the fifth edition of this manual was practically completed by Dr. Stewart at the time of his death. His revision included radical changes in and many additions to those portions deahng with surgical technic, surgical infection and disinfection, wounds, effects of heat and cold, shock, plastic operations, blood transfusion, fractures, and amputations; also the bones, joints, nerves, chest, intestines, rectum, kidney and bladder. He wrote a new chapter on unnecessary abdominal section and rewrote the sections on the abdomen, stomach, operations on the stomach, intestines, intestinal obstruction, biliary passages and the pancreas. At the suggestion of Dr. Stewart, a study of mihtary surgery was begun in 191 5 with service in the French army and continued until my discharge from the American army in 19 19. The results of this mihtary experience have been incorporated in this edition. Dr. Edward J. Klopp, Dr. Henry P. Brown, Dr. W. Edgar Christie and Dr. S. I. Bloomhardt have given valuable assistance in the preparation of the manuscript and the reading of the proof. The pri\dlege of completing the manuscript and preparing it for publication adds to the many obligations incurred during the years I was associated with Dr. Stewart. Walter Estell Lee. EXTRACTS FROM THE PREFACE TO FIRST EDITION The following pages have been prepared for the undergraduate, whose crowded hours demand a manual stripped of verbiage and unessentials, and for the medical practitioner who seeks a guide to present-day surgery. The chief desire, therefore, has been to set down concisely and completely those facts which the student must know, and to make such suggestions in diagnosis and treatment as will best aid the physician in his daily practice. For these reasons historical matter and bibliographical references have been omitted, and emphasis has been laid on those details which experience teaches to be of the greatest clinical importance. F. T. S. CONTENTS Ch.\pter Page I. Diagnosis i II. Anesthesia 21 III. Infection and Disinfection 42 IV. Surgical Technic 59 V. Bandages 76 V'l. Inflammation and Repair 91 VII. Suppuration 106 VIII. Ulceration, Sinus, Fistula 116 IX. Gangrene 126 X. Contusions and Wounds (Mechanical Injuries) 138 XI. Chemical, Thermal, and Electrical Injuries i55 XII. General Conditions and Special Infections Following Wounds 163 XIII. Tumors and Cysts 214 XIV. Skin and Cutaneous Appendages 245 XV. Vascular System 265 XVI. Lymphatic System 335 XVII. Nerves 342 XVIII. Muscles, Tendons, Bursae 362 XIX. Bones 374 XX. Joints 452 XXI. Head 500 XXII. Spine ' • ■ • 539 XXIII. Ear, Neck, Thyroid Gland 566 XXIV. Respiratory System 586 XXV. Breast , 620 XX VI. Upper Digestive Apparatus 634 XXVII. Abdomen 665 XXVIII. Rectum and Anus 825 XXIX. Urinary Organs 843 XXX. Genital Organs (Male and Female) 882 XXXI. Extremities 975 IxDEX 1025 MANUAL OF SURGERY CHAPTER I DIAGNOSIS Diagnosis is the process whereby the nature of a disease is deter- mined; the term is appHed also to the result of this process, i.e., the name of the disease. In many instances the condition, as a crushed foot, is self-evident and a direct diagnosis may be made; in others the symptoms suggest two or more afifections. which must be distinguished by differential diagnosis; and occasionally a diagno- sis by exclusion must be made; thus in a case of retroperitoneal sar- coma, it may be necessary to consider all the other forms of abdomi- nal tumor, and to rule them out one by one, because of the absence of special symptoms, until finally the real cause of the growth is deter- mined. In order to be complete a diagnosis should include the organ or part affected {anatomical diagnosis), the nature of the aff'ection (pathological diagnosis), the constitutional change resulting from or causing the local lesion, the presence or absence of independent or associated maladies, and the individuality of the patient. A diagnosis is made by interrogating the patient (subjective symptoms) and by physical examination (objective symptoms or signs). The chief factors in diagnosis are to obtain correct facts, to interpret them properly, to know what to look for, and above aU to look. " More mistakes are made by want of looking than by want of know- ing." In practice the analytical method is usually employed; the attention is first directed to the offending part, and by examina- tion, coupled with questioning the patient, one considers the condi- tions most likely to be the cause of the symptoms, and then by further examination the diagnosis is finally reached. The synthetical or historical method is more scientific, more accurate, and better adapted for the keeping of written records. It consists of (a) the history (anamnesis), which, with the name of the patient and the date of examination, includes (i) the age, (2) address and nationality, (3) sex, (4) social condition, (5) family history, (6) previous history, and (7) the history of the present illness; and (b) the physical exami- 2 MANUAL OF SURGERY nation (status presens), which comprises (8) an examination of the affected part, (9) an examination of regions clinically related to the affected part, and (10) a general examination of the whole body. 1. The apparent as well as the real age should be noted. In childhood irritability of the nervous system is marked, and high fever and convulsions may be caused by trivial affections which would cause no such disturbances in the adult. A mahgnant neoplasm in a child would probably be a sarcoma, in later life a carcinoma. Ulcers in children may be due to tuberculosis or congenital syphilis; in adults syphilitic and traumatic ulcers are frequent; later in life the varicose ulcers and epitheliomata predominate. In the child an injury to an extremity may result in a greenstick fracture or epi- physeal separation, the same in an adult might cause a complete fracture or a dislocation. In intestinal obstruction one would sus- pect imperforate anus in the new born, intussusception in infancy, and impacted feces or cancer in old age. In children difficulty in urination would probably be due to phimosis or calculus, in adults to stricture, in old age to enlarged prostate. In childhood infantile paralysis, infantile scur\y, congenital syphilis, rickets, adenoids, prolapse of the anus, rectal polypi, malformations, nevi, noma, foreign bodies in the air passages, tuberculous lymph glands, acute infectious osteomyelitis, postpharyngeal abscess, hemophilia, renal sarcoma, hydrocephalus, cretinism, and intussusception are common; in adolescence epiphyseal separation, gastric ulcer, osteoma, chondroma, tuberculosis of bones and joints, and sexual disorders are frequent; in middle age aneurysm, carcinoma, floating kidney, mollitiesossium, and gallstones are most apt to occur ; in old age hypertrophy of the prostate and degeneration of the circulatory apparatus, leading to gangrene and other disorders, are prone to develop. Hernia is most frequent at the extremes of life. Infancy and old age do not stand operations well, but infants who escape the immediate dangers of operation often convalesce more rapidly tha;n adults. 2. Not only the present, but previous addresses should be ascer- tained, as well as the place of birth. Goiter is prevalent in moun- tainous regions; leprosy in Norway and the tropics; bilharzia hema- tobia, tetanus, filariasis, and hepatic abscess in the tropics; rachitis in densely populated centers; vesical calculus in India and parts of England; hydatid disease in Iceland and Australia. The Xegrojs more susceptible to tuberculosis, aneurysm, elephantiasis, tetanus, and benign neoplasms, especially the fibromata; less Hable to malig- nant disease, stone in the bladder, varicose veins, appendicitis, congenital deformity, enlarged prostate, and gall-stones; and less DIAGNOSIS 3 resistant to operative procedures. The Ilebreiv suffers frequently from intestinal and rectal disorders, arteriosclerotic gangrene, and is more prone to develop diabetes with its surgical complications; his symptoms should be analyzed with due consideration to his highly sensitive nervous system. 3. The sex is occasionally of some importance in making a diagnosis. Vomiting or an abdominal tumor in a woman should automatically connote pregnancy. Excluding diseases of the reproductive organs, females are more liable to goiter, floating kid- ney, enteroptosis, gall-stones, mollities ossium, Raynaud's disease, myxedema, stricture of the rectum, tuberculous peritonitis, arthritis deformans, hysteria, and other functional nervous troubles, but they stand operations better than men. Males are more apt to develop aneurysm, actinomycosis, appendicitis, cerebral abscess, cystic kidney, cirrhosis of the liver, Dupuytren's contraction, hematoma auris, hemophilia, intussusception, lymphadenoma, pancreatitis, stricture of the urethra, stone in the bladder, diverticula of the bladder, cancer of the lip, stomach and rectum, and conditions produced by exposure, hard work, and injurious habits. 4. Under the social condition note whether the patient is single or married, widow or widower. If a woman, elicit the menstrual his- tory, the amount and character of leukorrhea, the number of children and miscarriages, the date of the last confinement, and the presence or absence of puerperal complications. Ascertain the nature of previous occupations as well as the present one. Active occupations predispose to hernia, aneurysm, and various forms of injury; seden- tary occupations to gall-stones, hemorrhoids, ulcer of the stomach, and functional neuroses; standing occupations to varicose veins and flat-foot. Certain occupations, by forcing the individual to assume a particular attitude or to use a certain set of muscles, produce altera- tions in the form of the body, thus the shoemaker, tailor, and rag- picker become round shouldered, and one who carries a load on the same shoulder day after day, or who uses one arm or leg constantly,, may develop scoliosis. Constant pressure on a part, necessitated by many occupations, may produce deformity, callosities, bursse, and even neoplasms. Skin handlers and wool-sorters are predisposed to anthrax; hostlers to glanders and tetanus; butchers, doctors, and veterinarians to anatomical tubercle and other infections; painters^ potters, plumbers, lead-makers, tailors, an,d seamstresses to lead poisoning; match-makers to phosphorous necrosis of the lower jaw;, morocco workers and those who use acids to ulcers of the hands and forearms; and those who handle grain to actinomycosis. 4 MAXUAL OF SURGERY 5. The family history includes an investigation into the diseases which have occurred, or the cause of death, in the parents, grand- parents, uncles and aunts, brothers and sisters, husband or wife, and children. Especially to be inquired for are calculus, malformations, hemophilia, syphilis, tuberculosis, rheumatism, alcoholism, malig- nant tumors, and nervous affections. 6. In the previous history note the habits of the individual, espe- cially regarding alcohol, which predisposes to aneurysm, dehrium tremens, tuberculosis, neuritis, etc.; tobacco, which predisposes to carcinoma of the mouth and nervousness; tea and coffee, ^^^th refer- ence to neuroses and gastric disorders; and the sexual life, particu- larly as to excesses and masturbation. Inquiry should be made also for pre^^ous injuries, diseases, and operations. Injuries may be followed by sarcoma, tuberculosis, epilepsy, abscesses, and many other disorders. Among the diseases which may have occurred the most important are syphiHs and tuberculosis. Certain diseases pre- dispose to subsequent attacks of the same malady; among such are appendicitis, salpingitis, gall-stones, kidney-stones, erysipelas, delir- ium tremens, neuralgia, rheumatism. Others render a patient more vulnerable to dissimilar affections; appendicitis, gall-stones, and osteomyeHtis often follow typhoid fever; stricture of any of the canals of the body, ulceration: involving those canals; vesical calcu- lus, renal colic; arthritis, gonorrhea. Operations are responsible for a host of e\als, e.g., laparotomy may be followed by hernia, adhesions, or intestinal obstruction; ovariectomy by amenorrhea; gastroenterostomy by ulcer of the jejunum; thoracotomy by scolio- sis; trephining by epilepsy; thyroidectomy by tetany, myxedema, or aphonia. The history of removal of a tumor may explain obscure symptoms due to metastases. We recently saw a case in which a hernia cerebri was incised for an abscess, a mistake that could not have occurred had the physician known that a decompressive opera- tion had been performed. 7. The history of the present iUness includes not only the symp- toms, but the supposed cause, the duration, the manner of onset, and the previous treatment. As to the supposed cause, there may be a history of exposure to one of the infective diseases, such as erysipelas or syphihs; in this connection it is important to ascertain the time elapsing between the exposure to infection and the beginning of the symptoms, i.e., the period of incubation. The duration sometimes has considerable bearing on the diagnosis, e.g., a tumor which has lasted a number of years is probably benign, one which has lasted but a few months and is growing rapidly is probably mahgnant. DIAGNOSIS 5 Time is a sure diagnostic agent in pregnancy. The onset is sudden in appendicitis, perforative peritonitis, various colics, and acute in- fections; aneurysm, tumors, ascites, and strictures of various kinds come on slowly. The previous treatment may be of assistance in diagnosis; it may have failed, e.g., a tumor or ulcer unmoditied by antiluetic drugs is probably not syphilitic, chills uninfluenced by quinin are not malarial; it may have succeeded, e.g., a scrotal tumor disappearing temporarily after withdrawal of a serous fluid is a hydrocele, after taxis a hernia; it may have intensified the symptoms, e.g., intestinal obstruction is made worse by purgatives, internal hemorrhage by stimulants; or it may have created additional mis- chief, e.g., drug eruptions, mercurial stomatitis, catheter cystitis, carboHc acid gangrene, iodoform dehrium, splint sores, crutch palsy, ligature sinus, paraffin tumor, X-ray burn, cystoscopic ulcer. It may also obscure the diagnosis, e.g., chancre and epithelioma may be disfigured by caustics, the symptoms of peritonitis may be clouded by opium, and an unconscious man who has been given whiskey may be wrongly treated as an alcoholic. 8. The local examination needed will usually be indicated by the patient. By inspection the size, shape, situation, and color of the lesion may be determined, as well as abnormal motion, and the lesion may be studied with reference to the influence of posture, active or passive motions, etc. Whenever possible the size of a lesion should be expressed in exact terms, thus a tumor may be measured with calipers or tape measure, instead of being compared in size with an orange or other object. The length of a limb compared with that of its fellow is of the greatest value in the diagnosis of fractures and dislocations, as are also the length of the urethra in enlarged prostate, the width of the intercostal spaces in empyema, and the size of the head in hy- drocephalus and microcephalus. The shape may be accurately determined by a plaster cast, soft lead strips, photographs, or autoprints, e.g., in flat-foot. It is frequently of assistance in recognizing surgical conditions, es- pecially fractures and dislocations. As other examples may be mentioned the notched teeth of hereditary syphiHs, the pear-shaped swelling of a hydrocele, and the fusiform enlargement of a tubercu- lous joint. The situation of a lesion may indicate not only the anatomical but also the pathological diagnosis (see "Diagnosis of Ulcers and Tumors"). 6 ilAJSrUAL OF SURGERY The color should always be observed. Localized yellowish discoloration may be caused by xanthoma, an old bruise, or a nitric acid or iodin stain; bronze patches by syphilis, tuberculosis, scurvy, abdominal tumors, oil of cade, blistering agents, exposure to electric light or the X-ray, and the pressure of garters, belts, or collar buttons; white patches by ergotism, scars, frost bite, carbohc acid, leukoplakia, Raynaud's disease, neuritis, and leprosy; redness by acute inflammation or hyperemia (disappears on pressure but returns immediately on removal of the pressure), or by dyes, etc. (does not disappear on pressure and may be washed off); blueness, or hvidity. by venous obstruction, nevus (returns quickly after pressure is removed), beginning gangrene (returns slowly after the relief of pressure), and ecchymosis (unaffected by pressure); blackness by moles, warts, gangrene, and melanotic sarcoma; greenish discoloration by chloroma; change of color by nevi; and linear dis- coloratiofi by lymphangitis, rarely phlebitis and neuritis. The mingling of purple and red is often observed over malignant growths. Petechia and ecchymosis are unaffected by pressure; they occur in many diseases, but it will suffice here to mention only those which interest the surgeon, viz. scurvy, hemophilia, iodism, jaundice, pyemia, septicemia, snake poisoning, and lightning stroke. Oc- curring several days after an injury, ecchymosis indicates rupture of some deep structure, such as muscle or bone. Absence of motion is noticed in most inflammatory troubles, e.g., the chest in pleurisy, the abdomen in peritonitis; it is caused by a tonic contraction of the muscles, which gives another im- portant sign, rigidity. Pulsation may be expansile (the swelhng enlarges in all its diameters with each cardiac systole), e.g., in aneurysm, tumors communicating with the cranial cavity, and very vascular growths, such as goiter, some sarcomata, and certain angiomata; or transmitted fthe movement is in one direction only), e.g., in tumors situated over an artery and in the abdomen of nervous individuals. Transmitted pulsation ceases if the tumor can be lifted or. by posture, made to fall away from the artery. Increased motion is exemplified in the hurried respiration of intrathoracic disease, and the active peristalsis of intestinal obstruction. In addition to the aids to the eye which have already been mentioned are the microscope, instruments for looking into cavities of the body (ophthalmoscope, laryngoscope, bronchoscope, cystoscope, etc.). aspiration to determine the contents of a cavity or swelling, and exploratory incision. Diaphany, or translucency, is employed to detect disease of the maxillary antrum, by placing a light in the DIAGNOSIS 7 moiilh; to determine the size of the stomach, by passing a light into this organ; and to ascertain the nature of some swellings, such as hydrocele and meningocele, by placing the tumor between the light and the eye, in a dark room, and looking through the barrel of a stethoscope or a tube of paper. 'J'he X-ray is considered on a later page. Palpation is used to corroborate inspection, to ascertain the size, shape, position, etc., of a lesion which cannot be seen, e.g., by rectal or vaginal examination; and to determine the consistency, sensation, mobility, and local temperature. The consistency of normal tissues may be modified by the presence of solids, fluids, or gases. Solids, of which the most prominent example is tumor formation, may cause the tissues to become harder (osteoma, etc.) or softer (myxoma, etc.). Fluid infiltrates the tissues giving rise to edema, or accumulates in a cavity giving rise to fluctuation. Edema, which is shown by the persistence of an indentation after digital pressure, occurs in contusions, inflammations, suppuration, obstruction to the venous or lymphatic circulation, extravasation of urine, and in diseases of the heart, lungs, liver, and blood. Hyster- ical edema and myxedema do not pit on pressure. Fluctuation is the wave felt by the hand on one side of a swelling when a sharp tap is given to the other side. In order to obviate the mistake due to a wave transmitted through the skin and subcutaneous tissues, the hand of an assistant may be placed on the swelling, between the hands of the examiner. This sign is often difficult to obtain when the fluid lies beneath firm fascia or thick muscle, is small in quantity, or under great tension, and it is often fallacious in semisolid tumors. Another sign, which is often called fluctuation, is the raising of the fingers of one hand when the fingers of the other hand push into the swelling; it may be obtained in normal tissues, in soft, elastic or movable tumors, and in tumors containing gas, as well as in swellings which contain fluid. Error may sometimes be avoided in eliciting this sign, e.g., in muscular tissue, by testing it longitudinally as well as transversely. Gas in the tissues (em- physema) causes a doughy swelling which crepitates on pressure. This crepitus, which is crackling in character, should not be confused with that of fracture or osteoarthritis, which is harsh and osseous; of epiphyseal separation, which is soft and cartilaginous; of synovial inflammation, which is creaking and leathery; or with that of blood clot or hydatid disease, which is moist and yielding. In certain bone diseases fcysts, sarcomata, craniotabes, disease of the frontal and maxillary sinuses) a crackling sensation may be obtained on 8 MANUAL OF SURGERY pressure (parchment crepitus), owing to thinning of the osseous tissue; and in synovial inflammations containing rice bodies a special form of crepitation may be obtained by forcing the bodies along the sac. Related to crepitus is tJirill. which may be felt over an aneurysm or vascular tumor, and sometimes in the case of a foreign body in the air passages. Aside from pain, disorders of sensation (hyperesthesia, hypesthe- sia, anesthesia, paresthesia, alteration of the heat sense or thermesthesia, of the pressure sense, etc.) are mainly of value in diseases and injuries of the nervous system. Pain is the most frequent symptom; and tenderness, which is of more value to the surgeon than pain, is pain on pressure. Its situation does not always indicate the seat of disease. In a lesion near the origin of a nerve, pain may be felt in the periphery; in a lesion at the periphery, at the end of another branch of the same nerve. Certain diseases of the brain and spinal cord produce pain at the nervx terminations. General pain or aching of the body may be present in acute infections or intoxications. If pain corresponds exactly to the distribution of a nerve, the cause will probably be found along the trunk or at the root of that nerve; the pain of a local lesion does not confine itself to the distribution of a single nerve. Absence of tenderness in a painful region genera ly. but not invariably, indicates that the pain is referred, but even in referred pain tenderness may be present. Pain in the top or the back of the head may be due to pelvic disease; in the supraorbital regions and the temples to disease of the eye; in the side of the head and the ear to disease of the teeth; in the forehead to disease of the nose or the nasopharynx; above the left clavicle to disease of the colon or the diaphragm; in the side of the chest to disease of the vertebra or the spinal cord; in the right shoulder to hepatic disease; in the nipple and the breast to uterine disease; between the shoulders to disease of the stomach and intestines; in the sacral region to intrapelvic disorders or disease of the testicle, rectum, or hip; in the epigastrium or any portion of the abdomen to diseases of the spine or the spinal cord; along the outer side of the thigh and in the heel to ovarian disease; at the inner side of the knee-joint to disease of the hip; in the sole of the foot to disease of the prostate, ovary, or rectum; in the head of the penis to vesical calculus. The character of pain is sharp, knife-like, or lancinating in acute inflammations of serous membranes; dull or bruise-like in inflammations of mucous membrane, connective tissue, and paren- chymatous \'iscera, and in chronic inflammation; paroxysmal in DIAGNOSIS 9 floating kidney, labor, neuralgia, colics, spinal tumor, and intestinal obstruction; shifting in hysteria, rheumatism, and flatulence; gnawing or boring in cancer, diseases of bone, and sometimes in lithemia; aching in muscles; burning and itching in the skin ; smarting or scalding in the urethra; nauseating in the testicle; throbbing in sup- purative inflammations; bearing down {tenesmus) in cystitis, enlarged prostate, proctitis, and labor. Pain which suddenly ceases may be due to the passage of a stone, the sudden overcoming of some obstruction, or to beginning gangrene. It is also studied with refer- ence to the efl"ect of pressure, change of weather, movements, etc. Most pains are worse at night, particularly those due to carcinoma, diseases of bone, rheumatism, locomotor ataxia, and neuritis. Much allowance must be made for the variation in individual tolerance to pain. The degree of tenderness may to some extent be gauged by the effect upon the facial expression and the pulse, and by the presence or absence of involuntary muscular rigidity. Abnormal mobility is found in fractures, ruptures of ligaments, dissolution of joints, floating kidney, and kindred affections; more or less immobility in ankylosis, inflammatory or neoplastic infiltra- tions, and in growths springing from a fixed portion of the body, e.g., osteoma. Under this heading may be mentioned also the value of palpation in ascertaining the presence or absence of motion due to muscular contractions, e.g., in the bowel (peristalsis), uterus, fetus, and muscles under investigation for paralysis. The local temperature is elevated in inflammatory diseases and very vascular tumors, lowered in gangrene and trophic lesions. It may be accurately measured with a surface thermometer. As aids to palpation may be mentioned probes and sounds, placing the patient in various postures, and measures for relaxing muscles, particularly general anesthesia. Percussion is employed to outline organs, determine the com- position of accumulations in cavities and the presence of gas in tumors, detect points of tenderness, and occasionally, as in hydro- cephalus and certain fractures, to elicit the cracked-pot sound. Auscultation is used to detect disease in the chest, the presence or absence of intestinal peristalsis, the bruit of an aneurysm, the sound of a fetal heart, the succussion splash of a dilated stomach, the deglutition sound, and the garrulity of wounds communicating with the respiratory apparatus. Crepitus which cannot be felt may occasionally be heard, e.g., in fractures of the ribs. As aids to auscultation may be mentioned the stethoscope, the phonen- doscope, and the telephonic probe. lO MANUAL OF SURGERY The sense of smell may reveal necrosis of bone, gangrene of soft tissues, fecal fistulae, stercoraceous vomitus, and ammoniacal urine. The odor of the breath is of value in diagnosticating uremia, acetonemia, diabetes, diphtheria, and some forms of poisoning. The odor in pyemia is that of hay, in hepatic abscess liverish, in actino- mycosis earthy, in jaundice and peritonitis musty, in the critically ill cadaveric. 9. An examination of the regions clinically related to the affected part is of the greatest importance. A part should always be com- pared with that of the opposite side of the body, to detect deviations from the normal, e.g., in fractures and dislocations; and to ascertain whether the same lesion is present on both sides, e.g., hernia, tuber- culous epididymitis, chronic mastitis, salpingitis, syphilitic eruptions, and many other conditions are often bilateral. In local infections and neoplasms the anatomically related lymph glands must be examined, and conversely in lymphadenitis the regions which the lymph glands drain must be scrutinized. One should make sure the pulse is present below fractures and dislocations, motion and sensation below wounds; examine the superficial veins for distention in tumors, the muscles for atrophy in joint disease, the spine for scoliosis in asymmetry of the lower limbs, the knee for effusion in fractures of the femur, the liver for cirrhosis in hemorrhoids. Blad- der symptoms may be of rectal origin; rectal symptoms due to affections of the genitourinary organs. 10. A careful general examination is too often neglected. Attention need be called only to the fact that stomatitis may be caused by chronic nephritis; furunculosis and gangrene by diabetes; varicose veins of the leg by disease of the heart; amenorrhea by anemia; ulcer on the sole of the foot by disease of the spinal cord; and to the fact that abdominal disorders may be simulated by disease of the lungs, spine, spinal cord, and by hysteria. The height and weight should be noted. A progressive decrease in height is found in diseases like arthritis deformans. The patient's best weight and his present weight should be taken. Cachexia means marked emaciation, great weakness, and profound anemia; it is seen in carcinoma, diabetes, tuberculosis, chronic suppuration, large ovarian cysts, congenital syphilis, organic disease of the stomach, stricture of the esophagus, and in obstructions of the thoracic duct. The facial expression is of great value to the experienced eye. As examples may be mentioned the vacant expression of adenoids, the anxious expression of peritonitis, the pale frightened face of DIAGNOSIS 1 1 acute hemorrhage, the threatening and suspicious facies of delirium tremens, the staring expression of exophthahnic goiter, the mask- like expression of paralysis, the unmeaning grimaces of hysteria, the risus sardoniciis of tetanus, and the weazened face of hereditary syphilis. The Hip])ocratic face — "The sharp nose, hollow eyes, colla])se(l tem])les; the ears cold, contracted, and their lobes turned out; the skin about the forehead being rough, distended and parched; the color of the whole face brown, black, livid or lead colored," — is the face of impending death. Posture: — ^Lying on the back and constantly slipping toward the foot of the bed is seen in acute infections or great weakness; the dorsal position with both legs drawn up in peritonitis; the ventral posture in intestinal colic, sometimes in abdominal aneu- rysm and spinal caries. The patient may lie upon the affected side in empyema, and be coiled up on one side in cerebral irritability and in various forms of colic. Great restlessness in bed indicates nervous irritability, acute hemorrhage, sometimes shock; it is a bad sign in the critically ill. The body may be bent forward so that it rests upon the forehead and feet (emprosthotonos) , backward so that it rests upon the occiput and heels (opisthotonos), or laterally (pleurostJwtonos), in meningitis, strychnin poisoning, tetanus, or hysteria. Orthopnea, in which the patient sits up and grasps some firm object in order to fix the accessory muscles of respiration, is often observed in diseases of the heart and lungs, large accumulations in the thorax or abdomen, and in foreign bodies in or stenosis of the air passages. A shuffling gait with a rigid body suggests caries of the spine, a waddling gait coxa vara or congenital dislocation of the hips. The head is thrown back and the feet apart in large abdominal tumors and accumulations. The pulse, temperature, and respirations should be taken, and one should ascertain the condition of the organs of digestion, the spleen, the genitourinary apparatus, the heart and blood vessels, the lungs, the organs of special sense, and the nervous system, especially with reference to hysteria and locomotor ataxia, both of which may mimic various surgical affections. However, the presence of either of these nervous maladies may coexist in one who needs surgical treatment, and sometimes a surgical lesion causes hysteria or is the result of tabes. In special cases chemical, microscopical, and bacteriological examinations of various secretions, excretions, and discharges may be required. Blood Examinations. — The red cells may be increased in number (polycythemia) when the blood is concentrated, e.g., as the result 12 MANUAL OF SURGERY of profuse sweating, vomiting, diarrhea, starvation, and exercise; when oxygenation is impaired, e.g., by high altitudes, cyanosis, and cardiac and puhnonary disease; in erythremia, hepatic insufh- ciency, myxedema, purpura, diabetes, and direct blood transfusion; and as the result of active hemogenesis, thus after hemorrhages the blood-making organs may in time supply more than enough cells to replace those which have been lost. Oligocythemia (decrease in the number of red cells) takes place when the blood is diluted by the ingestion of large amounts of fluid, saline infusion, and when the genetic powers are overtaxed, e.g., by child-birth, lactation, and at puberty. Anemia, or a reduction in the number of red cells and the percentage of hemoglobin, may be primary, in which no cause can be found, e.g., pernicious anemia and chlorosis; or second- ary, the most common causes of which are acute and chronic hem- orrhage, bacterial infections, malignant growths, malnutrition, intestinal and blood parasites, and chemical poisons, such as lead, mercury, and the coal-tar derivatives. Mikulicz believed that no general anesthetic should be given when the hemoglobin is below 30 per cent., but surgeons do not adhere to this rule, excepting, perhaps, in cases in which delay will result in some improvement in the quality of the blood. Leukocytosis, particularly of the polynuclear cells, indicates an inflammatory lesion, but only when other symptoms of the lesion are present, and only when other causes for an increase in the white cells have been excluded; hence, from the standpoint of surgical diagnosis, leukocytosis may be divided into the noninfectious and the infectious. Noninfectious leukocytosis may be physiological, e.g., in infants, during pregnancy and digestion, and after exercise and bathing. It may occur in shock, cyanosis, rickets, cirrhosis of the liver, chronic nephritis, gout, carcinoma, and sarcoma (the lymphocytes being in excess in lymphosarcoma). It may follow the injection of toxins, including vaccins; the administration of certain drugs, e.g., the salicylates, coal-tar derivatives, potassium chlorate, camphor, digitalis, some of the aromatic oils, thyroid extract, and quinin; acute and chronic hemorrhage, general anesthesia, and consequently the various surgical operations (a rising leukocytosis after the second or third day, however, would be highly presumptive of a septic complication). The leukocytosis of lymphatic and of splenomedul- lary leukemia are easily recognized by the increase in the lymphocytes in the former, and of the mvelocvtes in the latter. Agonal leukocvto- DIAGNOSIS 13 sis, which occurs just before death, is due to the gathering of the leukocytes along the walls of the capillaries as the result of the feeble circulation, or to a terminal infection. Infectious leukocytosis may accompany any of the bacterial diseases, except uncomplicated influenza, measles, rubeola, typhoid, paratyphoid, malta fever, leprosy, and tuberculosis; malaria and trypanosomiasis, which are due to protozoa, also fail to show an increase in the white cells, but there is a moderate leukocytosis during the secondary and tertiary stages of syphilis. The most important infections from the standpoint of surgical diagnosis are those of pyogenic origin. The degree of inflammatory leukocytosis depends upon the virulence of the microorganism and the resisting powers of the patient, and some idea of the nature of these factors may be obtained by comparing the leukocyte count with the general condition of the patient. If leukocytosis is slight (12,000 to 15,000) or absent, it means, when the general condition is good, that the infection is trivial, well encapsulated or chronic, or, when the general condition is bad, that the infection is overwhelming. If leukocytosis is marked (20,000 or higher) it means, when the general condition is good, that the infection, although serious, is probably being localized or conquered, or, when the general condition is bad, that the infection, although actively combated, is too great for the patient's resistance. As with the temperature, pulse, and respira- tions, repeated observations are of more value than a single observa- tion. A rising leukocytosis indicates a spreading infection or pus formation. According to Hewitt the total leukocyte count is an index of the patient's resistance to the infecting organism, and the relative polynuclear count an index of the severity of the infec- tion. If the relative polynuclear count is between 75 and 80 per cent, infection is probably, if between 80 and 85 usually, and if above 85 almost certainly present. The normal polynuclear count is from 60 to 70 per cent, of the total number of leukocytes. lodophilia (iodin reaction in the leukocytes) is found in septic processes, but as it occurs in many other conditions, e.g., malaria, late typhoid, etc., it is of little value to the clinician. Eosino- philia occurs in parasitic diseases, such as hydatid cysts, trichiniasis, anclylostomiasis, and filariasis, but also in asthma and certain skin diseases, hence its value is not absolute. The presence of filaria is readily determined, however, by a microscopic examination of the blood during the night. An estimation of the coagulation time of the Mood is particularly indicated in cases like chronic jaundice and hemophilia, in which 14 MANUAL OF SURGERY operation may be fatal from uncontrollable oozing of blood. Nor- mally it is from three to six minutes. Tests for hemolysis and agglutination should be made before direct blood transfusion, and in hemolytic jaundice. The aggluti- nation reaction of Widal is of great importance in the diagnosis of typhoid fever. Serodiagnosis (complement fixation test) is routine in syphilis, and only occasionally employed in gonorrhea, pregnancy, carcinoma, hydatid disease, and several medical affections. Chem- ical examination of the blood for nonprotein nitrogen and sometimes for other substances is used in estimating the functional capacity of the kidney (q.v.). Examination of the blood for bacteria and acetone is sometimes desirable, both for diagnosis and prognosis. Among the diseases which may simulate surgical conditions, and which may be excluded by a blood examination, are malaria (malaria parasites), typhoid fever (Widal reaction and leukopenia), lymphatic and splenomedullary leukemia (enormous leukocytosis, particularly of the lymphocytes in the former, and of the myelocytes in the latter), and lead poisoning (basophilic granulations in the red cells). It may be recalled that pneumonia, which may simulate intraabdominal inflammation, causes a leukocytosis and that Hodgkin's disease produces no distinctive blood changes. THE X-RAY The X-ray penetrates substances opaque to the ordinary forms of light, casts shadows, causes fluorescence of certain salts, and has the same chemical action upon photographic films as sunlight. The apparatus necessary for the production of the X-ray con- sists of a sealed glass vacuum tube (Crookes tube), containing two or three electrodes, and a machine capable of generating elec- trical currents of high voltage. One of the electrodes, the cathode, is a concave metallic disk, which is connected with the negative terminal of the exciting apparatus. At the focus of this reflector is a metalhc disk called the target. The electrode connected with the positive terminal is called the anode. Electrical discharges suit- able for exciting a Crookes tube may be obtained from static ma- chines, high frequency coils, the ordinary induction coil, or prefer- ably from the more modern high-tension transformer. In a prop- erly excited Crookes tube there is a current of electricity flowing toward the cathode, from the concave surface of which it is focused upon the target. As far as we know the rays originate at this point. The green fight seen in an excited tube is due to fluorescence of the DIAGNOSIS 15 glass produced by the rays, which themselves are invisible. Coolidge has invented a new type of tube, .which is particularly valuable for therapeutic purposes. Its anode is a solid block of wrought tungsten, its cathode a spiral of tungsten wire, which is heated to a delinite temperature by the current from a 12-volt storage battery. The high-tension current will pass through the tube only when this spiral is heated to a certain degree of incandescence, and this degree of heat determines the amount of current that can be passed through the tube. Further, the voltage of the high-tension current determines the hardness or softness of the X-rays emitted, so that by means of proper meters accurate doses of the X-rays may be given. The vacuum in the Coolidge tube is about i.oco limes as great as in the ordinary tube and needs no regulation. The Fluoroscope consists of a piece of cardboard on one side of which is spread a thin layer of finely ground crystals of barium platinocyanid, potassium platinocyanid, or tungstate of calcium. This screen is mounted in an apparatus so constructed as not to expose the operator to the X-rays while studying the patient. When brought near an active Crookes tube, the crystals become luminous and give off a faint green light. The transparency of substances to the X-rays varies according to their atomic weights. If the hand be placed between an excited tube and the fluorescent screen, the softer tissues will appear as faint shadows, and the bones, which are more dense, as dark shadows. When these shadiows fall upon a photographic plate, the silver bromid is changed as with light rays, and if the plate is then developed, a permanent record of the shadows is obtained (Radiogram, or Skiagram). To make good pictures requires skill and much time, consequently most practitioners refer their cases to a Rontgenologist. The physician, however, should have some knowledge of the interpretation of plates, be famil- iar with the indications for the use of the X-ray (diagnostic and therapeutic), and know the dangers which may arise. The interpretation of X-ray pictures is a study in shadows, which, like those cast by a candle light, are subject to distortion in size and in shape. The least distortion occurrs when the object is very thin, is in close contact with the screen or plate, is as far from the tube as the rays are effective, and when the object and the target are in a plane perpendicular to the plate, hence one should know the distance between the tube, the object, and the plate, the angle at which the picture was made, and, if possible, the size of the object (Figs. I and 2). The kind of tube employed also influences the results. A high vacuum, or hard, tube gives a small quantity of i6 MAXUAL OF SURGERY deeply penetrating rays and little contrast between the tissues of different densities; a low vacuu^m. or soft, tube a large quantity of feeble rays and decided contrast between the various tissues. One must be familiar with the shadows of normal tissues at different ages. In the child the bones cast faint shadows and some of the epiphyses are not visible until puberty. Ununited epiphyses may be mistaken for fragments of bone, epiphyseal junctures for lines of fracture. Other sources of error are detective plates; finger marks; congenital abnormalities, e.g.. a bipartite scaphoid and extra bones (trigonum, tibiale externum, vesalianum. ribs); sesamoids; grooves for blood vessels and suture lines, e.g., in the skull; dense areas in the skin (warts, scars, fibromata); external apphcations (zinc, mercury, iodin. lead water) ; superimposed shadows, which may be recognized by taking a second plate at a dift"erent angle; enlarged bronchial glands, simulating aneurysm; gas in the intestine; fecal masses, calcified lymph glands. phleboKths, and like conditions, which may be mistaken for calculi and foreign bodies; and, owing to the desire to make small plates, failure to include the lesion in the area of investigation. As a diagnostic agent the fluoroscope permits quick and easy examinations, but the images lack detail, so that small foreign bodies, and fractures without deformity are frequently overlooked. Consequently the J^ Fig. I. — Note the size of the object (a) and its shadow (b) when the former is near _ . i i i • n i the tube and some distance fluoroscope IS employed chiefly to observe from the plate; and of the ^j^g movements of aneurvsms, the heart, the object (c) and its shadow (d) _ ' ' . . when the object is far from lungs, the diaphragm, and the peristalsis of the tube and near the plate, -v . i j • a i* -t^u j* t. the stomach and intestines, ihe radiograph gives a permanent picture with delicate detail and sharp outlines not found in the fluoroscopic image. These pictures are of great value in localizing foreign bodies, either extraneous, such as bullets, needles, etc., or those formed wdthin the tissues, such as renal and vesical calculi. Minute frag- ments of coal, wood, and glass other than lead-glass, however, may evade detection, particularly if overshadowed by bone, or some distance from the plate. A preliminary fluoroscopic observa- tion is made, and a mark placed on the skin directly over the foreign DIAGNOSIS 17 body. Stereoscopic plates are then taken to determine the relation of the foreign body to some surgical landmark. To obtain stereo- scopic plates it is necessary to have a plate holder, by means of which plates can be inserted and removed without disturbing the part to be skiagraphed. Two plates are exposed, the tube being moved horizontally two and one-half inches, the average inter- pupillary distance. The plates are now developed and examined with a stereoscope, when the depth of the foreign body and the perspective of the various planes of tissue can be seen. Even the lines in the skin will appear if a thin coating of bismuth be applied before the plates are made. If a surgical landmark is not in close proximity to the foreign body a special localizing technic must be \ "-iV. 3i ii__aisS3>^ VV^: -^V-.^ .^.^V^ l;b^ Fig. 2. — Diagram showing distortions produced by the X-ray. The horizontal line represents the X-ray plate, seen in profile; the objects above, broken bones; those below the shadows as seen on the plate. On the left is shown an oblique fracture with overlap- ping, the shadows of which indicate a transverse fracture with separation; on the right a transverse fracture with no overlapping, the shadows of which indicate an oblique frac- ture with overlapping. As the shadows of the fragments nearer the tube are larger and less distinct than those close to the plate, an expert might detect these errors merely from the skiagraph, but a novice could easily be deceived. In all doubtful cases a second plate, at right angles to the first, should be taken or stereoscopic plates made. employed. The simplest method is to make two plates in planes at right angles to each other. Manges, Sweet, and others have devised exceedingly accurate but compHcated forms of apparatus for deter- mining the situation of a foreign body, but the principle of all is that of angulation, as in the method here described. The target of the X-ray tube is fixed directly over the mark on the skin, the distance between the target, the skin, and the plate being measured. The tube, with the vertical distance from the plate remaining constant, is moved three inches to the left and an exposure made, then three inches to the right of the starting point and a second exposure made. The plate is now developed, the distance between the two images measured, and the depth calculated (Fig. 3). If, MANUAL OF SURGERY despite the use of these or similar methods of locaHzation, the sur- geon tails to find the foreign body, it may be extracted with the aid of the fluoroscope. However, operating in a dark fluoroscopic room is inconvenient and not without danger to the patient and the surgeon. The X-ray is indicated in the diagnosis of so many conditions, other than those already mentioned, that, in order to avoid repetition, we must refer the student for additional informa- tion to subsequent pages, particularly those deal- ing with fractures, dislocations, bone diseases, sinus and fistula, the lungs and pleural cavity, sub- phrenic abscess, the esophagus, the stomach, the intestines, and the kidney. We shall there call attention to some of the methods employed to aid in the differentiation of tissues and thus facilitate radiographic examinations, e.g., the in- troduction of opaque substances into sinuses, the alimentary canal, and the urinary apparatus, and the injection of gas into the bladder, ventricles of the brain, subarachnoid space, and peritoneal activity. The therapeutic effects of the rays may be sh^doTofVe "foreign classified as follows: (i) The production of atro- body and are }i inch p^^, changes in the appendages of the skin; (2) the apart, the same dis- '^ . . , . / \ i. tance as the shadows destruction of organisms m the tissues; (3) the ZX:naVo\S:tt destruction of certain pathological tissues; and positions of the tube; (4) their anodyne effects, (i) In hypertrichosis, S corresponds to the • r i • j -j. • j • ui distance of the target sycosis, favus, and tenia tonsurans it is desirable from the plate. The ^^ removc the hair. Atrophy and decreased f unc- point where the hnes ^ "^ intersect represents tioual activity of the ScbaCCOUS glands are in- foreign^ Vo^dy°^rlm dicated in comedo and acne. (2) Though the the surface next to j-^ys apparently have no effect on organisms grow- the plate. (American . j -j j n- t Practice of Surgery.) lug upou culture media, they have a decided enect upon their growth when in the living tissues. Thus tuberculous ulcers and sinuses and those due to ordinary pyogenic organisms may dry up when exposed to the rays. A similar effect is produced upon diseases due to mycehal fungi, such as tenia barbae, tenia tonsurans, favus, and blastomycosis. The destruction of these organisms is probably brought about by tissue cells stimulated to activity by the rays. (3) Embryonic and glandular cells are most susceptible to the destructive action of the X-rays. In inoperable mahgnant tumors, which are composed of embryonic Fig. 3.- and DIAGNOSIS 19 cells, radiotherapy is often of decided value in lessening discharge, diminishing fetor, and ameliorating pain, and occasionally the growth shrinks for a time. The only form of malignant disease that can be cured in this way is chronic superficial epithelioma, and even in this excision is quicker and safer. ' Some surgeons advise radiotherapy after all operations for carcinoma and sarcoma, to prevent recurrence. Fibroid tumors of the uterus, keloids, and scars also may be influenced by X-ray treatment. Owing to the endarteritis produced by the rays angiomata may disappear, and chronic bleeding, e.g., from the uterus, be brought under control. Good results have been claimed for this agent in exophthalmic goiter, and it is of unquestionable value in enlarged lymph glands from any cause, as well as in spleno- medullary leukemia. (4) As an anodyne the X-rays have been used not only in malignant disease, but also in neuralgia and other painful affections, sometimes with excellent results. In making therapeutic applications of the X-ray, the operator should always protect the healthy parts by a shield of lead, and when the rays are to be projected into deep structures filters of leather or aluminium should be placed between the tube and the skin. These filters absorb the softer rays, thus permitting larger doses of the penetrating rays without irritating the skin. Untoward Effects. — The X-ray burn is characterized by de- layed onset and remarkable sluggishness in healing. The acute burn, i.e., one resulting from a single prolonged exposure, usually appears on the second or third day, but may be delayed as late as the fourteenth day. It is essentially an inflammatory process, ap- pearing at first much like the erythema of sunburn, and like sunburn leaves, when it subsides, a pigmentation of the skin, which is more pronounced in those of dark complexion. If subsidence does not occur in this stage, vesicles and blebs develop which rupture and expose the inflamed corium; occasionally the deeper structures are invaded, and extensive sloughing may occur. The microscopic changes are those of degeneration and inflammation. Chronic burns occur in those constantly exposed to the rays. They appear slowly after an incubation period of from three to eleven years. The clinical features in the beginning are similar to those of acute burns, but the red color changes to a bronze or yellow, the nails show rugae of mal- nutrition, telangiectatic spots develop, and the skin becomes glossy because of the loss of glands and hair. Cracks and hyperkeratoses appear and ulcers form, often exposing the tendons and even the bones, and occasionally undergoing epitheliomatous degeneration. Porter has collected 47 cases of X-ray carcinoma, with a mortahty 20 ilAXUAL or SURGERY of 25 per cent. The skin seems to be easily protected by the ordinary clothing, for no case has been reported except upon the exposed surfaces. At the present time the operator wears leaded gloves, and stands behind a screen made of some substance impervious to the rays, as heavy plate glass, sheet iron, or lead. If heahng does not occur after the usual apphcations for ulcer, an X-ray burn may be excised, and the resulting raw surface closed by a plastic operation or covered with skin grafts. Prolonged exposure to the X-rays may cause steriHty in either sex. sometimes transient, sometimes per- manent. Examination of the blood of Rontgenologists often shows a decrease in the total number of leukocytes and an increase in the number of lymphocytes. Sometimes after the radiation of a tumor or other lesion there is a general reaction, characterized by fever, and supposed to be due to toxemia from the ab-orption of the prod- ucts of cellular degeneration. Radium and certain other mineral substances (uranium, thorium, polonium) emit rays similar to, if not identical with, the X-rays. Radium bromid is the material usually employed for therapeutic purposes. It is kept in a hermetically sealed glass tube, which may be applied to a surface lesion, or buried in the tissues after making an incision. Exposures last from one to many hours. Radium therapy has been tried in the same diseases that are treated by the X-ray. The time is not yet ripe for passing judgment on the value of this agent. Its rays seem to have greater penetrating power than the X-rays, and some beheve they have a specific action not possessed by the X-rays. The chief objections to the use of radium are its enormous expense and the difficulty in obtaining a pure sample. CHAPTER II ANESTHESIA Surgical anesthesia means loss of sensation produced by certain agents, which are called anesthetics. GENERAL ANESTHESIA is associated with unconsciousness, and is indicated to abolish pain during surgical operations, renal colic, etc.; to control convulsive seizures; to secure muscular relaxation in order to make a diagnosis, to facilitate operative manipulations, especially in the abdomen, or to carry out such treatment as reduc- tion of a hernia, a fractured bone, or a dislocated joint; and to abolish volition in order to detect a malingerer. Except for the purpose of saving life, it is contraindicated in profound shock, great exhaustion, and in acute or advanced renal, circulatory, or pulmonary disease. The general anesthetics most frequently employed are, in the order of their safety, nitrous oxid (one death in 300,000), ether (one death in 15,000), ethyl chlorid (one death in 12,000), and chloroform (one death in 3,000). The choice of a general anesthetic depends principally upon the cc)ndition of the patient and the character of the operation. Ether is the best and least dangerous general anesthetic in the hands of one with little experience, likewise in the hands of the specialist in anesthesia when, as is the case in most of the major operations of surgery, the patient is to be completely relaxed, hence, under these circumstances, it should always be employed unless there are distinct contraindications. The most important contraindica- tions to ether are (i) inflammation of some portion of the respiratory apparatus, because of the irritating action of the drug on mucous membranes, and (2) the presence of fire in an open grate or stove, which may ignite the ether. Since ether vapor is heavier than air and descends, the danger of an exposed artificial light is obviated by placing the light several feet above the level of the patient's head. The actual cautery may be used in the region of the mouth, if the precaution is first taken to remove the anesthetic and fan away the fumes. Of secondary importance, and by no means absolute, are (3) marked arteriosclerosis, which predisposes to vascular rupture during the struggling incident to etherization; (4) disease of the kid- neys (many authors believe chloroform to be more irritating to the kidneys than ether; in these cases nitrous oxid and oxygen^or 21 22 MANUAL OF SURGERY local anesthesia should be employed whenever possible) ; and (5) operations about the nose or mouth, in which the anesthetic can be applied intermittently only, and in which chloroform, being more powerful, will better maintain anesthesia; this contraindication ceases to exist if one of the insufflation methods is employed. Chloroform secures complete muscular relaxation, and does not cause the veins to distend hke ether, hence makes bleeding less annoying; it is also quicker in its action, more agreeable to the patient, and more convenient to the anesthetist and operator, espe- cially in operations about the head, face, and neck; but these ad- vantages are overbalanced by its increased danger. Chloroform is no safer in children or during pregnancy than at any other time. It is preferable in military surgery, because it economizes space and time, and is generally employed in the tropics, owing to the great volatility of ether. In diseases of the liver and in diabetes chloro- form is absolutely contraindicated. In the latter nitrous oxid mixed with oxygen is the safest general anesthetic; ether, however, must be employed if muscular relaxation is mandatory. Nitrous oxid is by far the safest anesthetic for brief operations (from two to five minutes) in which muscular relaxation is not de- sired, such as the extraction of a tooth or the incision of an abscess. For longer operations in which muscular relaxation is not important, nitrous oxid combined with oxygen or with atmospheric air is the safest anesthetic. It is particularly indicated in diabetes and nephritis. It is contraindicated when the heart or the arteries are seriously affected, when there is mechanical obstruction of the air passages, when the patient is under five years of age (owing to the ease with which infants are asphyxiated) , and when the anesthetizer is unskilled. Muscular adults addicted to the excessive use of alco- hol and tobacco are bad subjects for nitrous oxid, indeed for any anesthetic. Among the disadvantages attending the administration of nitrous oxid must be mentioned its great expense, the necessity for cumbersome and complicated apparatus, and the marked increase in venous congestion, the last constituting a decided objection in many operations. Ethyl chlorid is often used as a substitute for nitrous oxid in brief operations and as a preliminary to ether. As it is 25 times more dangerous than nitrous oxid, however, we believe it should never be employed . The preparation for anesthesia is combined with that of the operation itself (see "Surgical Technic")- One should examine the heart, blood vessels, lungs, urine, nose, throat, mouth, and in many ANESTHESIA 23 cases the blood. The bowels should be moved by a laxative, and on the morning of the operation by an enema. In the feeble and exhausted purgation should be avoided, and stimulating or nutri- tive enemas continued until within a few hours of the operation. No solid food should be given on the day of operation, although a cup of tea, coiYee, or consomme may be given not less than six hours before the time of anesthesia. Just before administering the anes- thetic the patient should pass urine, or, if necessary, be catheterized. If a woman, hair-pins should be removed and the hair braided and done up in a cap or towel. Artificial teeth or other foreign bodies should be removed from the mouth, the lips and nostrils greased, especially if chloroform is to be used, and, to prevent con- junctivitis from chloroform or ether vapor, a drop of liquid petrola- tum instilled into each conjunctival sac. The patient should be protected from cold, and jewelry of various kinds should be put away in a safe place. In emergency cases, if the patient's stomach is full, and especially in intestinal obstruction, gastric lavage should be performed previous to the administration of the anesthetic, in order to prevent sudden death from inundation of the lungs with vomited matter. In these cases an enema may or may not be given, accord- ing to the character of the operation, but in all a complete examina- tion should be made. A patient should never be anesthetized wdthout removing the shoes and without making sure that all cloth- ing about the neck, chest, and abdomen is loose; corsets always should be removed. With the possible exception of nitrous oxid, a patient should never be anesthetized in the sitting posture. The anesthetist should ascertain whether the patient has pre- viously taken an anesthetic, and whether addicted to the use of alco- hol or other drugs. He should know the results of the urinalysis, listen to the heart and lungs, study the pulse, note the color of the skin and mucous membranes, and assure himself that the mouth is free of foreign bodies. His hands should be clean, and in operations on the head and neck they should be sterilized. He should wear a sterile gown and cap. In addition to the anesthetic and inhaler one should provide himself with a mouth-gag, tongue forceps, a pair of hemostats with gauze sponges for swabbing out the pharynx, a hypo- dermic syringe with strychnin and atropin, and a tracheotomy tube. It is desirable to have also a solution of boric acid for the eyes in case they become irritated, and in some instances oxygen may be needed. A third person should always be present to assist, if necessary, in restraining the patient and to act as a witness, as unjust accusations are occasionally made against the anesthetizer, especially by females. 24 MANUAL OF SURGERY The administration of ether by inhalation is rendered less terrify- ing to the patient, and, it is said, actually less dangerous, if three or four drops of a 25 per cent, solution of oil of bitter orange peel in alcohol (75 per cent.) is placed on the mask a few minutes before adding the anesthetic. It is supposed that oil of orange, by dulhng the sense of smell to the irritating fumes of ether, prevents harmful reflex stimulation of the pneumogastric nerve. One of three methods of etherization by inhalation may be employed. In the open method, which is very slow, the ether is inhaled from a folded towel, held over the patient's nose and mouth in such a way as not to exclude the air. The closed method, in which the air is decidedly restricted, and in which the expiratory products are retained and rebreathed, is quick, and warms, moistens, and economizes the ether, but is more dan- gerous than either of the other methods. Some anesthetists main- tain, however, that rebreathing, with all forms of inhalation anes- thetics, is physiologically advanta- geous. Those who use the closed method find the Clover inhaler satisfactory. It consists of a dome-shaped ether reservoir sur- rounded by a water chamber, which maintains the ether at the proper temperature for evapora- tion. A fenestrated metal tube runs through the reservoir from a large rubber bag to the face piece. By rotating the reservoir varying quantities of vapor escape into the rubber bag, from which it is breathed backward and forward with the expiratory products; fresh air may be admitted from time to time by raising the face piece. The semiopcn method, in which the entrance of air is slightly limited, but in which the ex- piratory products are not retained, is the one commonly employed. An inhaler may be improvised by rolHng a folded towel or a piece of gauze into the shape of a cone. The Alhs inhaler (Fig. 4) con- sists of a cyhndrical metal frame with shts in the sides, through which a flannel bandage is threaded backwards and forwards. This is enclosed in a metal case or folded towel which projects beyond the frame and is fitted to the patient's face. The inhaler is placed over the patient's nose and mouth, and after several breaths have been taken to lessen fright, the ether is applied drop by drop until the patient is anesthetized, the intervals between the drops becoming shorter as the patient becomes accustomed to the vapor. The Pig. 4. — Allis' Inhaler. ANESTHESIA 25 administration should be uninterrupted and as nearly uniform as possible. During the first stage of anesthesia, which ends with the loss of consciousness, the pulse is accelerated, the pupils large and mobile, and a rather pleasant feeling of drowsiness, and tingling in the extremities, is experienced. Many patients breathe deeply, others hold their breath; in the latter instance all that need be done is to remove the cone for a moment. Cough is rarely annoying if the drop method be employed. With the onset of unconsciousness there is a short period of analgesia (primary anesthesia), during which brief operations may be performed. The second stage, or the stage of excitement, extends from the loss of consciousness to the loss of reflexes. Memory, volition, and intelligence are abolished, while laughing, shouting, and struggling may occur. Slight movements of the extremities should not be restrained un- less they interfere with the anesthetist, as such often evokes greater struggling. The pulse is rapid, the pupils are dilated and react to light, and the muscles may be rigid or thrown into clonic contrac- tions. At this time the ^ ,. . . x- , riG. 5. — Vaporizing apparatus. Note that breathing may be irregular the ether reservoir is only half filled and that the , •] A A ^^'^S tube in it is attached to the pump; if the or temporarily SUSpenaea. short tube were connected with the pump, liquid The face is congested, some- ether would be driven from the reservoir. Even when the tubes are properly arranged, a spray times cyanotic, and often of ether may be forced from the reservoir, hence covered with perspiration, ^he small bottle on the left, which acts as a ^ ^ condenser. More or less frothy mucus is present in the mouth and throat, and sometimes it becomes exces- sive. During the third stage the breathing is deep and audible, the pulse full and regular, the muscles relaxed, and the corneal reflex abolished. Touching the cornea with the finger, however, may pro- duce irritation, and it is much better simply to separate the lids and notice the presence or absence of flaccidity. The pupils are of moderate size and react to light. Dilated pupils failing to react to light indicate a dangerous degree of anesthesia. During this stage a transient roseolous rash may be noticed. Insufflation of ether into the mouth, nose, or pharynx is indi- cated particularly in operations about the head. face, mouth, and 26 MANUAL OF SURGERY neck, since it removes the anesthetizer from the field of operation and permits an uninterrupted administration of the anesthetic. Anes- thesia is induced by one of the foregoing methods and maintained by a vaporizing apparatus (Fig. 5). By means of a hand bulb, a foot pump, or an electric blower, air is forced through a bottle of ether, which is placed in a can of water at a temperature of 98° F. The ether vapor, thus warmed, an important matter according to recent investigations, passes through an empty bottle, which acts as a condenser, to the outlet tube. The outlet tube is connected by soft rubber tubing with a curved metal or hard rubber tube which is hooked in the nostril or angle of the mouth, or with a catheter which passes back through the nostril to the level of the soft palate. Intra- pharyngeal insufflation economizes ether, facilitates breathing, and causes less cyanosis and postanesthetic vomiting than the ordinary inhalation methods; free exit should be provided for the superfluous vapor by keeping the mouth open, or by inserting a tube in the opposite nostril. Intratracheal insufllation of ether (Meltzer-Auer) has supplanted the various forms of apparatus designed to prevent collapse of the lungs during intrathoracic operations, since it not only obviates the danger of pneumothorax but automatically ventilates the lungs. It keeps the anesthetizer out of the way, eliminates the possibility of obstruction of the air passages, prevents the inhalation of blood, mucus, vomitus, and other deleterious substances, and, owing to the absence of cyanosis, lessens venous hemorrhage; hence is it of great value in operations about the mouth and pharynx, in operations for intestinal obstruction in which fluid is constantly regurgitated from the stomach, in operations for goiter and similar conditions in which the trachea is displaced or distorted, and in operations in which the patient must lie face downwards. According to Peck the rehef of all strain upon the respiratory apparatus and consequently the relief of much strain upon the heart and central nervous system is one of the most valuable features of the method. " Overetherization is impossible." In cases of apnea from opium poisoning, etc., air, or air mixed with oxygen, can be blown into the trachea, thus maintain- ing aeration of the blood until spontaneous respiration returns. We have employed intratracheal insufflation of ether in many cases, and feel that its merits have not been overstated. The patient is first etherized in the usual way; then, with the aid of a Jackson laryngo- scope, a silk elastic catheter is inserted into the trachea to a point just short of its bifurcation. In addition to the noise produced by the breath passing through the catheter, one may be sure it is in the ANESTHESIA " T /2l7, trachea, unless there is a stricture or a diNcrticulum of the esophagus, by i)ushin^ rare in the United States, but is common in Mexico, South America. Norway and Sweden, and in the Orient. It occurs in two forms, the tuber- cular and the anesthetic, which are often associated. The period of incubation is generally from three to five years. Tuberculated, or cutaneous leprosy, occurs most frequently on the face, hands, feet, and extensor surfaces of the elbow's and knees. After a period of feverishness with digestive disturbances, there appear httle hyperemic nodules, which may disappear only to reappear. Later the redness fades and the nodules increase in size, occasionally becoming as large as a hen's egg. and break down to form indolent ulcers, or are converted into contracting cicatricial tissue, which causes hideous deformities, that of the face being characteristic {leotitiasis leprosa); the mucous membranes and the viscera like- wise may be involved, and there is atrophy of the testicles or ovaries with loss of sexual power. Anesthetic, or nervous leprosy, begins with neuralgia and tenderness of certain peripheral nerves, most frequently the median, ulnar, saphenous, and peroneal. Later there are anesthesia, paralysis, and trophic disturbances, the last involving the bones, joints, and muscles, as well as the skin, and producing great deformity. Whitish or browmish spots appear on the skin, and gradually grow larger and coalesce. As the result of injuries to the anesthetic areas, various secondary infections may occur, producing widespread ulceration, or even gangrene (lepra mutilans). Death occurs in from one to twenty years, from exhaustion, or from some compHcation. not uncommonly tetanus or tuberculosis. The treatment, in addition to isolation of the patient, is symp- tomatic, no specific drug being known. Of the many remedies which have been tried, chaulmoogra oil. 15 to 20 drops daily, on bread, seems to be the most beneficial. Oudin is a warm advocate of radiotherapy. In the very^ earhest stages excision of the diseased areas may be considered. In the anesthetic variety nerve stretching has been recommended. Ulcers, gangrene, etc., are treated accord- ing to general surgical principles; amputations and other operations may be required, the wounds in such cases healing without mishap. GENERAL COXDITIOXS AXD SPECIAL INFECTIONS IQI SYPHILIS Syphilis is a iiighly contagious disease due to the spirochela (treponema) pallida (Schaudinn and Hoffman), an actively motile. unicellar, spiral parasite (probably a protozoon), varying from 4 to 14m in length, and possessing pointed ends and from 3 to 12 curves. The spirocheta may be found in the primary and in all secondary lesions, also in the blood, urine, saliva, lymph glands, and internal organs. It has been found in small numbers in gum- mata and in large numbers in still-born syphilitic fetuses. It has been cultivated in artificial media (Noguchi) and produces syphilis in apes, from the lesions of which it can again be recovered. Methods of Infections. — Excepting (i) " concepiional syphilis,'' in which a mother is contaminated by a syphihtic fetus (the father having the disease) through the placental circulation, acquired syphilis is always (2) initiated by a chancre, the result of infection of an abrasion or other solution of continuity of an epithelial surface, usually of the genital organs during sexual intercourse. Syphilis insontium is a term applied to the disease innocently acquired, the chancre in these cases often being extragenital, e.g., on the lip from the use of an infected glass or pipe. The disease may be carried by a third person who does not acquire the disease; thus an uncleanly surgeon may convey the virus on his finger from one patient to another. Congenital, or hereditary syphilis, does not present a chancre; it is (i) the result of syphiUs in one or both parents previous to conception, or (2) of infection through the placenta in case the mother acquires the disease subsequent to conception. ''Accidental inoculations, conjugal syphilis, and hereditary syphilis together far outnumber the venereal cases" (Post). ''In 1080 patients in the Johns Hopkins dispensary, without reference to w^hat disease they came for (genitourinary cases excepted), there were 10.8 per cent who gave a positive Wassermann" (Walker). The disease is ac- tively contagious for several years, i.e., during the primary and second- ary stages. When the tertiary stage has been reached the disease is said to be no longer contagious, although the organisms have been demonstrated in the lesions. The germ of syphilis is difficult to kill, thus a w^ound will frequently be the site of a chancre though carefully disinfected within even a few hours after its infection. The views concerning immunity to syphilis have been revolution- ized since the discovery of the Wassermann reaction. It was formerly taught that one attack of the disease conferred immunity against subsequent attacks, that a woman might have a syphihtic 192 MANUAL OF SURGERY husband and syphilitic children without becoming tainted {Colles' immunity), and that healthy children might be born to syphilitic parents {Prof eta's immunity). It is now known that in all these instances the so-called immunity is not immunity, but insusceptibility due to latent syphilis, as the individuals in question react to the laboratory tests for syphilis. In other words, immunity to syphilis does not exist, and this means, if we are to believe the arsphenamin enthusiasts, that reinfection, which was very rare with the older forms of treatment, because the patients were not cured, will become much more frequent after the recoveries that are now being obtained with arsphenamin. The period of incubation is from one week to three months, the average being twenty-one days. During this time the breach of surface through which the organism has entered the body heals and no signs of trouble are manifest, unless there has been at the same time infection with chancroidal or pyogenic bacteria. The disease itself is divided into three stages: The primary stage comprises the chancre and indolent bubo. The time elapsing between the appearance of the chancre and the second stage, usually about six weeks, is called the period of secondary incubation. The second stage consists principally of superficial lesions of the skin and mucous membranes. It lasts from one to three years, and is followed by recovery, or by a latent or intermediate period, lasting from a few months to many years (usually two to four years), in which the symptoms are slight or absent. The third stage, the duration of which is indefinite, consists of gummatous degeneration or diffuse sclerotic changes in various parts of the body. In some cases the secondary merges with or overlaps the tertiary stage, so that no distinct line can be drawn between them. The typical chancre, or initial lesion, begins as a minute, erythe- matous, painless papule, which, as it enlarges, becomes indurated and loses its epithelial covering, appearing as a round, oval, or Hnear erosion, whose center is covered by a grayish, glistening film, and whose border is the color of raw muscle. Suppuration is slight or absent, the discharge being scanty, thin, and watery. Chancre is usually, but not invariably, single. When multiple all the chancres appear at the same time, as the infection is not auto- inoculable. A chancre does not always present the same appear- ance, being modified according to its situation and the presence or absence of complications, which are rare. On the skin a chancre not exposed to maceration or irritation does not ulcerate, or at most simply desquamates, forming a scab. When subjected to irritation GENERAP CONDITIONS AND SPECIAL INFECTIONS 193 or maceration it ulcerates {Hunterian, or ulcerative chancre), then being oval or round with sloping edges. The characteristic features of a chancre may be masked by the presence of phagedena or other forms of infection; in a "mixed cliancre" in which chancroidal and syphilitic organisms are both present, the diagnosis can rarely be made from appearances alone. The induration of a chancre, which is due to sclerosis of the blood vessels and hyperplasia of the con- nective tissue cells, is circumscribed and of the consistency of hard rubber or cartilage, but varies in thickness according to the struc- ture of the affected part; thus on the glans penis it may feel like a piece of paper {foliaceous induration) or a visiting card (parchment induration), while in laxer tissues it is greater in extent and may feel like a foreign body in the tissues (nodular induration). In rare cases induration does not occur for several weeks after the appear- ance of ulceration; in fact, in very rare instances it may never occur. With the healing of the chancre (usually in from four to six weeks) the indura- tion gradually disappears, but if origin- ally extensive, it may still be detected for months or years. Little or no scar results, unless the corium has been de- stroyed by ulceration. Ulceration or reinduration at the site of the original chancre (chancre redux) may occur after years as the result of reinfection (very rare) or gummatous degenerat on. The most frequent situation of chancre in the male is the balanopreputial fold, in the female the inner surface of the labia majora. Fournier, however, has seen chancre on every part of the body except the sole of the foot. A chancre may be easily overlooked, e.g., when on the OS uteri, when of the non-ulcerating or desquamating variety, and when situated in some extragenital region. The syphilitic bubo (satellite bubo) is a constant consort of the chancre, appearing with its induration. The enlarged glands appear in the groin when the lesion is upon the external genitals, in the submaxillary region when on the lip, and in the axilla when on the breast or hand. They are (i) small, (2) non-inflammatory (painless, freely movable, not covered by adherent or reddened skin, and do not suppurate), (3) hard (induration of the chancre transferred to the lymphatic glands), and (4) polygangUonic (pleiad of Ricord), feehng hke a group of almonds (amygdaloid) beneath the skin. An inflammatory bubo the result of any other form of 13 Fig. 75. — Chancre of arm. 194 " MANUAL OF SURGERY infection, including chancroid and gonorrhea, pursues an acute course, with pain, greater swelling, immobility of the glands, ad- herent and reddened skin, boggy induration, edema, and eventual suppuration, and does not respond to syphilitic treatment. The diagnosis of chancre may be confirmed (i) by finding the spirocheta pallida in the discharge; (2) by the Wassermann (or Noguchi) serum reaction, which appears during the first two weeks after the chancre in 50 per cent, of the cases, increases gradually in frequency up to the fourth or fifth week, when it may be obtained in from 80 to 90 per cent, of the cases, disappears when recovery takes place, when the disease becomes inactive, and when the patient is saturated with antisyphilitic remedies, and which is present only occasionally in other conditions (yaws, leprosy, noma, narcosis, pellagra, scarlatina, pneumonia, tuberculous cachexia, Hodgkin's disease, myeloid leukemia, recurrent fever, lead poisoning, sleeping-sickness); (3) by the therapeutic test (i.e., prompt response to antisyphilitic treatment); or (4) by waiting for secondary symp- toms. If one can have the laboratory tests, mentioned above, made there can be no excuse for waiting until the secondary symptoms appear before making a diagnosis. If the Wassermann test is nega- tive, the spirochetes can be found in the chancre; the tests are sup- plementary. It may be that the luetin test, described by Noguchi, also will prove an important diagnostic aid. Noguchi says it is of the greatest value in tertiary and latent syphilis, while the Wassermann re- action is more constant in primary and secondary syphiHs. Extra- genital chancres occur most frequently about the mouth (20 per cent.), breasts (10 per cent.), and anus, and are usually larger, but less indurated, than the genital chancre. The discharge is more profuse, the base of the ulcer covered with a dirty membrane or scab, the adjacent lymph glands are apt to be larger and more tender, and the constitutional symptoms more severe. Of particular interest to surgeons and obstetricians is chancre of the finger, which is fre- quently mistaken for a whitlow, as it is often accompanied by considerable pain and discharge. It is distinguished by its sharp circumscription, dense induration, long duration, failure to react to antiseptic treatment, and by enlargement of the epitrochlear gland. Chancroid has an incubation of from one to five days, is rarely seen except on the glans penis or prepuce, commences as a pustule or ulcer, is frequently multiple, and is autoinoculable; it is usually irregular in shape, punched out, and excavated, with a dirty yellow- ish, uneven base and a copious purulent discharge; if induration is present, it is softer than that of chancre, fades off gradually into GENERAL CONDITIONS AND SPECIAL INFECTIONS 1 95 the surrounding tissues, and disappears with the heahng of the ulcer; it is painful, does not confer immunity against a second at- tack, is more frequently complicated by extensive ulceration and suppurative bubo, is healed by local measures and uninfluenced by antisyphilitic treatment, and the bacillus of Ducrey may be found in the discharge. In all cases search should be made for the spirochetes, a Wassermann test made and, if negative, repeated at the end of the third and sixth weeks, and the patient watched for two months for signs of secondary syphilis. Herpetic ulceration about the genitals follows fevers, neuralgia, or irritation from dirt or discharges, and has no period of incubation. It commences as a number of vesicles, which may run together, forming a large irregular ulceration whose edges are made up of segments of circles. The discharge is purulent but not abundant, vesicles w^hich have not burst may be found, bubo is commonly absent, the ulceration is painful, superficial, not indurated, and it heals under local treatment. Urethral chancre may be mistaken for urethritis. The period of incubation of chancre is over ten days, that of urethritis under one week. In chancre the pain is felt only at the meatus, in urethritis it extends along the whole urethra; chordee is absent in the former, present in the latter. The discharge in chancre is scanty, serous, and sometimes bloody; in urethritis it is profuse, purulent, and less frequently blood stained. The characteristic induration may be felt, and superficial ulceration seen, in chancre, generally in one of the lips of the meatus. The bubo of chancre is constant and practically never suppurates; in urethritis bubo is absent, or, if present, usually suppurates. Chancre is followed by constitutional symptoms, which are absent in urethritis. Microscopic examination of the discharge may reveal the spirocheta or the gonococcus and the blood should be examined for the Wassermann reaction. Labial chancre may be confused with epithelioma. Chancre in this region shows no marked preference for either sex; it may be seen on either lip and is more frequent in the young. The general health is unafifeGted and pain is shght or absent. The ulcer is smooth, and has elevated, sloping, regular borders, a glistening or varnished base, and the sharply defined, characteristic induration; it matures in two or three weeks. Enlargement of the submaxillary glands is usually found from the beginning, a history of exposure to syphilis may be obtained, and the diagnosis may be corroborated -^by finding the spirochetge, by the Wassermann and therapeutic tests, or, when these tests are not available, by waiting for 196 MANUAL OF SURGERY the secondary symptoms. Epithelioma is more frequent in males (20 to i), is practically always upon the lower lip, is seen after middle life, affects the general health, and may be painful; the bor- ders are irre^^ular, thickened, and everted, and the base is covered with scabs, removal of which discloses bleeding, fungous granula- tions; the induration is not as hard as that of chancre and grad- ually diffuses into the surrounding tissues; the ulcer requires months for its development, the submaxillary glands are usually not palpable for four or five months or even longer, a history of chancre in youth may be obtained, the growth is uninfluenced by antisyphilitic treatment, secondary symptoms do not occur, and microscopical examination will give the picture of epithelioma. Tuberculous ulceration of the tongue is distinguished from chancre by the presence of the lesion on the inferior surface of the tongue (chancre being more frequent on the dorsum) , and the presence of several ulcers; by its greater extent, deeper invasion, irregular out- line, steep or undermined borders, yellowish uneven base, absence of induration, excessive pain, and yellowish tubercles; by the absence of secondary symptoms of syphilis, of the spirocheta, and of the Wassermann reaction, and the failure of antiluetic remedies; and by the diagnostic methods given under tuberculosis. The secondary stage of syphilis consists of lesions of the skin (syphilides) , mucous membranes (mucous patches), appendages of the skin (onychia, paronychia, alopecia), enlargement of the lymph glands in different parts of the body, neuralgic pains, inflammation and thickening of the periosteum, arthropathies, iritis (rarely other forms of eye disease), epididymitis, and interference with the general health (fever, anemia, disorders of digestion) and with the process of reproduction. Retinitis, choroiditis, affections of the acoustic nerve, and meningitis are being reported with increasing frequency, as secondary manifestations whether as the result of arsphen- amin treatment or more careful observation is a matter of dispute. During this period the disease is not serious for the patient, but is dangerous for those with whom he comes in contact and for his offspring. Abortion is frequent, or if the child goes to term, it is apt to die soon after birth. The lesions during this period are widely scattered, almost always superficial, and tend toward recovery even without treatment. The first symptom may be the rash on the skin, fever, or neuralgic pains. The ''fever of eruption''' is usually trivial and falls with the development of the eruption; syphihtic fever occurring later may be intermittent, remittent, or continuous, and has been mistaken for GENERAL CONUITIONS AND SPECIAF, INFECTIONS IQ7 such diseases as rheumatism, malaria, and tyjjhoid fever. With the onset of secondary symptoms the lymphatic glands all over the body enlarge and assume the features of the original bubo. The post- cervical, submental, and epitrochlear glands are of diagnostic value, because they are seldom enlarged from local pyogenic infection. The blood contains the organism, and shows a slight increase in the number of white cells, particularly of the lymphocytes, with a diminution in the number of red cells and the amount of hemoglobin. Syphilides generally appear in from six to seven weeks after the appearance of the chancre, occasionally earlier, and sometimes, notably when mercurial treatment has been administered from the beginning, not for several months. The secondary skin rashes (syphilodermata) may (i) ape any form of cutaneous eruption, but are always an imperfect counterfeit; they are (2) often apyretic, (3) slow in evolution, (4) non-inflammatory, (5) seldom itching or painful, (6) often of a ham or copper color, (7) apt to occur in circles or segments of circles, and (8) when affecting the extremities most frequent on the flexor surfaces (which includes the sole of the foot and the palm of the hand) ; (9) they tend to recover, and are (10) superficial, (11) piofuse, (12) disseminated, (13) polymorphous, (14) symmetrical, and (15) desquamating; (16) syphilis in other parts of the body may exist, (17) the rash responds to antisyphilitic treatment, (18) the Wassermann test may be positive, and perhaps (19) the spirocheta may be found. The features ot the tertiary syphilides are listed under the "Tertiary Stage." The chief varieties of the syphilides, progressing from the early and superficial to the late and deep, are as follows: i. Erythema (diffuse redness) or roseola (maculae or spots) occurs principally upon the trunk ; there is no elevation of the surface and the redness disappears upon pressure. 2. Papules may be small and miliary (syphilitic lichen) or large (occasionally four or five inches in diameter); they may desquamate {papulo-squamoiis syphilides), or in moist regions, as about the genitals, they may become excoriated {moist papules, mucous patches of the skin, or flat condylomata). Papulo- squamous syphilides upon the palms and soles are called palmar and plantar psoriasis; papules on the forehead the corona Veneris; and when the size of lentils lenticular papules. 3. Vesicles rarely form in syphilis, but a herpetiform syphilide is described. 4. Pustules SLiise from breaking down papules, hence syphilitic acne when the apex of the papule suppurates, syphilitic impetigo when the whole papule breaks down, and syphilitic ecthyma or rupia when the true skin is deeply invaded. In rupia successive layers of scabs form resembling igS MANUAL OF SURGERY an oyster shell. In ecthyma, if a scab forms, it is easily detached, exposing a punched out ulcer surrounded by a red zone of hyperemia. 5. Tubercular syphilides are large papules or small gummata. 6. Besides these tj^pes of eruption, discoloration of the skin, peculiarly of the neck, may occur {pigmentary syphilides). The mucous tuembranes are affected somewhat like the skin. The sore throat of secondary syphilis consists of a reddening of the fauces or tonsils, which is sharply limited, reniform in shape, and often followed by ulceration, the ulcerated area being shallow with a grayish color and steep edges. Mucous patches are papules due to the overgrowth of papillae, which, owing to the sodden condition of the epithelium, are white in color; they are circular or oval in outline, may progress to ulceration, originate a highly contagious discharge, and are commonly seen in the mouth and about the anus and genitals. Condylomata are large tubercles due to hypertrophy of papillae; they look somewhat like warts, often appear in cauliflower-like masses, and occur most frequently about the anus and genitals. Eruptions or inflammations in the larynx produce syphilitic hoarse- ness, in the ears transient deafness. Syphilitic alopecia is usually detected at the time of the sore throat and skin eruptions. It may involve the head alone or the entire body. It occurs as a general thinning of the hair or in irregu- lar patches. The skin is apt to be scaly. As the folhcles are not destroyed, the hair is usually reproduced. The nails may be shed owing to inflammatien of the matrix {onychia), or the skin around the base of the nail may be inflamed or ulcerated (paronychia). The bones in various regions may be the seat of fugitive pains, which are usually more severe at night (osteocopic pains). Nodes due to periostitis may form, especially on the skull, clavicle, and tibia. In the joints a symmetrical synovitis may be noticed. Syphilitic iritis makes its appearance in from three to six months after the chancre. It affects one eye at first, but is very apt to spread to the other. There are pain, impairment of vision, photo- phobia, lachr}Tnation, a pericorneal zone of hyperemia, often a change in color of the iris, blurring and irregularity of the pupil, which is usually small and fails to react to atropin. Syphilitic epididymitis may occur late in the secondary period, and consists of gummatous nodules which are quickly dispersed by proper treatment; it may affect one or both sides. Syphilitic orchitis {syphilitic sarcocele) is a diffuse sclerosis of the testicle itself and belongs to the tertiary period. GENERAL CONDITIONS AND SPECIAL INFECTIONS 199 111 tlie intermediate period the symptoms may be latent, or there may be ''reminders," such as the syj)hili(k's, principally syi)hilitic psoriasis, and epididymitis. Rctino-choroidilis and cndarlerili s may occur, the latter producing various forms of paralysis, owing to anemia of the motor centers. The tertiary stage is characterized by diffuse sclerosis or gumma- tous degeneration of any part of the body. As in the secondar\- stage, the blood shows a slight leukocytosis without, however, so distinct a lymphocytosis. The lesions are discrete, widely separated, and larger and less common than in the secondary stage; they are often serious to the patient but not to others. Although any of the syphilides may occur, the cutaneous eruptions are almost always tubeicular oi gummatous. The tertiary resemble the second- ary syphihdes except in the following particulars: They involve the whole thickness of the skin, do not so readily respond to treat- ment, appear irregularly, tend strongly to ulcerate and spread, and are monomorphous, asymmetrical, irregular in distribution, and not so widely disseminated. The ulcers are excavated, having sharply cut or undermined edges and a ragged base; they are painless, circular^ or semilunar in shape, often covered by thick crusts or a tough, ad- pj^ 76— Ulcerating herent, dirty yellow slough, and are not apt to gumma of hand. Note . punched out appearance. enlarge the lymphatic glands; they leave perma- nent scars which are smooth, white, and depressed below the level of the surrounding skin. Tertiary ulcers may take on a phagedenic action, boring deeply into the tissues, or eating along the surface in circles or undulating lines {serpiginous). Severe tertiary are said to follow mild secondary symptoms, and mild tertiary, violent second- ary symptoms. In diffuse sclerosis chronic inflammatory changes are followed by hyperplasia of the fibrous tissue, giving rise to endarteritis, and disease of the testicle (sarcocele), liver, spleen, kidneys, heart, nervous system, and other tissues or organs. The gumma is a nodular mass consisting of prohferated con- nective tissue cells, leukocytes, and sometimes giant cells, which, owing to the thickening of the blood vessels and the cutting ofif of the blood supply, undergoes necrotic changes {fatty or gummatous degeneration) . With proper treatment this mass may be absorbed, or the necrotic tissue becomes semi-fluid and breaks through the skin, leaving a circular ulcer with red, undermined edges, and a characteristic, dirty, yellowish-white, adherent slough 200 MAIvUAL OF SURGERY (Fig. 76). In some of the internal organs, such as the brain, testicle, and liver, the necrotic tissue may become encysted and calcified. Gummata may be single or multiple. Occasionally, instead of a well localized nodule, there may be a diffuse gummatous degenera- tion of a considerable area. The scars resulting from gummata, when situated in a canal of the body, may produce stricture. Parasyphilis and metasyphilis are terms applied to what some call the guarternary stage, in which lesions of the skin (e.g., leukoderma), of the mucous membranes (e.g., leukoplakia), of the nervous system (e.g., tabes and dementia paralytica), and of other structures may occur, lesions which are the result of syphilis, but are no part of the disease itself, as they do not react to specific treatment. Tertiary lesions affecting special structures are noticed in subse- quent pages as occasion demands. The diagnosis of tertiary lesions is made (i) by the local features mentioned above; (2) by the history, in the taking of wh'*ch, if chancre is denied, one should inquire particularly whether there has been transient loss of hair, sore throat or mouth, skin rashes, and in women frequent miscarriages; (3) by evidences of previous syphilis, e.g., periosteal nodes (especially on the skull, clavicle, and tibiae), iritis, old scars, and patches of induration on the genitals; (4) by the therapeutic test, which is not always reliable; (5) by the Wassermann reaction; and possibly (6) by recovery of the spirocheta and (7) the luetin test. In all stages of syphilis a negative may frequently be converted into a positive Wassermann reaction by the injection of arsphenamin, the blood being examined not later than 48 hours after the injection; this "provocative Wassermann" is of most service in the diagnosis of tertiary lesions. In syphilis of the nervous system the cerebrospinal fluid may give a positive Wassermann reaction, even though the blood test is negative. In these cases cytological and chemical examination of the fluid may give additional information (see "Spinal Puncture"). The prognosis of syphihs is favorable if proper treatment be administered in the early stages for a sufiiciently long period, it being generally believed that cure will result in the large majority of these cases. When the disease comes under observation late, when the patient fails to carry out the treatment, when there is an associated general disease, notably tuberculosis, often the best that can be done is to keep the disease under control. Some cases seem to be malig- nant and do not recover though proper treatment be given from even the beginning. A patient should not be permitted to marry until the disease is cured, i.e., absence of symptoms and of the Wassermann GENERAL CONDITIONS AND SPECIAL INFECTIONS 20I reaction for at least one year after the cessation of treatment, and never within four years of the chite of the chancre. The best prophylactic measure, according to Metschnikoff, is the rubbing of calomel ointment (calomel ;^;^, lanolin 67) into the site of inoculation; this is said to prevent chancre if performed within 18 hours of the intercourse (cf. "Proj^hylaxis of Gonorrhea"). The treatment of the disease itself consists in the employment of mercury, or of arsphenamin and mercury, during the primary and secondary stages, and of mercury and iodids, with or without arsphenamin, during the tertiary stage. Mercury and arsphenamin are spiro- cheticides; the iodids attack the granulomatous tissue of the gumma, thus liberating the spirochetes and rendering them vulnerable to mercury and arsphenamin. In view of the difficulty of making a positive diagnosis from the appearance of the chancre alone, many surgeons used to withhold constitutional treatment until the appear- ance of secondary symptoms. Now in even the earliest stages a positive diagnosis can be reached by the detection of the spirocheta and the Wassermann reaction. In employing mercury some prefer intermittent treatment, believing that after a time the drug ceases to be effective and the tissues need a rest. Protiodid of mercury, grain }i, is given daily for six months, then a rest of a month is taken, and treatment again given for three months, nine months of treatment being given during the first year, and eight months during the second. In the continuous method protiodid of mercury, grain }i, is given in pill form three times a day after meals, the dose being increased one pill each day, so that on the second day the patient takes %, on the third i grain, and so on, until the gums become tender, the breath fetid, and the bowels loose. The dose is then cut in half and the patient kept on this for two years. If in the absence of other symptoms diarrhea tends to per- sist, opium, grain 3^12, may be added to each pill. Any of the other preparations of mercury may be used in a similar way. When mercury is not well borne by the stomach, it may be used by inunc- tion, I dram of the ointment being rubbed into a dififerent portion of the body each day, so as to avoid irritation of the skin; the method is highly efficacious but dirty. Intramuscular injections are often painful, and sometimes produce inflammation, necrosis, or embolism. They may be indicated when a very rapid effect is desired, e.g., when a lesion is on the face or threatens life; or when, owing to gastrointes- tinal irritation, mercury cannot be administered by mouth and, at the same time, inunctions cannot be given. Many prefer the insolu- ble preparations, as they are /absorbed slowly, hence need be given 2C2 MANUAL OF SURGERY only at comparatively long intervals. Five minims of a mixture of calomel i and albolin 4. lo minims of a mixture of salicylate of mer- cury I and albolin 10. or 10 minims of gray oil may be injected once a week. The site of injection must be recorded, because if symptoms of salivation appear it will be necessary to excise the tissues contain- ing the unabsorbed portion of the drug. Bichlorid of mercury is the soluble salt usually employed. The ordinary dose is from H2 to li of a grain. ''This is injected daily, since absorption is rapid, and must be repeated in appropriate doses until the symptoms disappear, after which it is continued in series of six doses with inter- vals of six days' rest for the first year, and in series of three doses with intervals of nine days' rest for the second year, the quantity being increased or diminished in accordance with the clinical indica- tions" f Martin). The injections are made deeply into the muscles of the back or the buttocks, selecting a new site for each injection, and using a needle with a large lumen if an insoluble salt is em- ployed. In order to avoid embolism, the needle, unattached to the syringe, should first be introduced, and allowed to remain a short time, to see if it has entered a vein. Mercury has been used also by fumigation; a diam of calomel is volatilized from a water bath, which is placed under a cane seat chair upon which the patient sits naked, the fumes being confined by a blanket which reaches from the pa- tient's neck to the floor. In somewhat the same way mercury has been introduced into the body through the skin by means of baths (Hg CI2 5ss to a bath-tub full of water), in which the patient lies for an hour or longer. J ntravenous injections should not be employed. In all cases, at least during the early stages, the patient should be seen frequently, or cautioned as to symptoms of mercurialism (hy- drargyrism, ptyalism. salivation), which, owing to idiosyncrasy, may rapidly follow even small doses. The gums become soft, spongy, tender, and bleed easily; there is an excessive production of thick saliva, with fetid breath, metalhc taste in the mouth, colicky pain in the abdomen, and diarrhea. In more severe cases the teeth loosen, the alveolar process becomes necrotic, and severe ulceration of the mouth develops. Chronic mercurialism is manifested by digestive disorders, sahvation. loss of weight, albuminuria, mental depression, tremor, and general weakness. These symptoms may be prevented by careful regulation of the dose of mercury, by having the teeth put in order, by cleansing the mouth several times a day with tooth powder and tooth brush, by the use of a mouth-wash containing chlorate of potash, and by prohibiting the use of tobacco. Saliva- tion is treated bv discontinuing the mercurv. bv giving a saline GENERAL CONDITIONS AND SPECIAL INFECTIONS 203 purge, and by the use of antiseptic and astringent mouth-washes. Albuminuria calls for an intermission or a great reduction in the dose of the mercury. The general health should not be neglected, and if neces.sary tonics should be employed. The contagious nature of the malady should be impressed upon the patient, who should be directed to have separate eating and toilet utensils, to avoid kissing, to sleep alone, and to bathe frequently, paying special attention to naturally moist parts of the body, such as the axillae and the perineum. At the end of two years the patient should take mixed treatment (hy- drarg. chlor. cor. g. i, potassium iodid 5 ss, syrup sarsaparillae comp. f5iii-f oi. in water after meals) for six months or longer, or if there have been symptoms, the mixed treatment should continue for six months from the last symptom. The lesions of tertiary syphilis are controlled by mixed treatment. The mercury is used for its antisyphilitic action and the iodids for the absorption of gummatous tissue. Iodid of potassium or sodium may be given in a saturated watery solution, each drop of which contains i grain of the iodid. It is customary to begin with 5 or lo drops of this solution in plenty of water after meals, and increase the dose I drop each day, until in some intractable cases as much as 60 or more grains a day are given. Toxic effects are manifested by coryza. fetid breath, disorders of digestion, and cutaneous eruptions (acne, vesicles, bullae). The iodid should be discontinued and elimination stimulated. Belladonna and arsenic have been used to prevent the skin eruptions. Arsphenamin {saharsan, Ehrlich's "606") is a yellowdsh powder containing 34.16 per cent, arsenic, the chemical name being dioxy- diamidoarsenobenzoldihydrochlorid. It is given subcutaneously, intramuscularly, rectally, or, as preferred by most syphilographers, intravenously. At first one dose was thought to be sufficient to effect a cure. Relapses followed, however, and now it is customary to repeat the injections once a week for six or eight weeks, giving at the same time a course of mercury, which consists of inunctions of the ointment every day, of the injection of a soluble salt every day or two days, or of the interjection of an insoluble salt once a week. A rest of six weeks in then taken, and the arsphenamin and mercurial courses repeated. In primary syphilis this may be sufficient to abort the disease, but the patient should be watched for at least a year, and the blood tested every month or two during this period. In secondary syphilis at least three courses of arsphenamin with mercury should be administered, and if a positive VVassermann test 204 MANUAL or SURGERY or other evidences of syphilis continue the courses may be repeated at intervals of six or eight weeks. In latent lues more benefit is derived from the old-fashioned mixed treatment than from arsphe- namin alone or combined with potassium iodid (Fordyce). In syphiHs of the nervous system the Swift-ElHs method is often em- ployed. This consists in giving arsphenamin intravenously, and after one hour withdrawing from 20 to 30 c.c. of blood, from which the serum is separated. From 10 to 15 c.c. of this medicated serum are injected into the subarachnoid space, after performing a spinal puncture and allowing an equivalent amount of the cerebrospinal fluid to escape. The simplest method of preparing the drug for injection is that of Alt, slightly modified. The powder, which comes in glass ampoules containing 0.6 gram, the average dose, is shaken with 30 c.c. of warm normal salt solution, in a glass-stoppered bottle, until dissolved. About 2 c.c. of normal sodium hydroxid solution is then added. This precipitates a yellowish sediment, which is redissolved by adding more of the sodium hydroxid solution, drop by drop, until the fluid is clear. If the intravenous route is chosen, enough salt solution should be added to bring the quantity up to 250 c.c. A large vein is made prominent by compression, punctured with a platino-iridum needle, and, after a few drops of blood have escaped, the needle attached by means of a rubber tube to a gradu- ated glass reservoir containing salt solution. As soon as the salt solution begins to flow into the vein, the rubber tube is pinched, the salt solution poured from the reservoir, and the prepared salvarsan introduced. The drug must be prepared immediately before injection and should not be given to those with nonsyphilitic organic diseases, especially of the kidneys, heart, blood vessels, optic or auditory nerves, or central nervous system, or to those who have previously had arsenical treatment or who possess an idiosyncrasy to arsenic. The patient may be kept in bed for 24 hours after the injection. Intravenous injections may be followed by a chill or by thrombosis, subcutaneous and intramuscular injections by a painful induration or sloughing, and all methods of administration by fever, vomiting, and watery stools. The Jarisch-Herxheimer reaction is an intensi- fication of the symptoms of syphilis sometimes observed after the administration of arsphenamin or, to a less extent, mercury. Among the more serious symptoms which have been noted after the injec- tion of arsphenamin are blindness, deafness, hematemesis, melena, multiple neuritis, intractable dermatitis, albuminuria, vesical paraly- sis, irregularity of the heart, jaundice, and convulsions. A number of deaths following injection have been reported, and no doubt GENERAL CONDITIONS AND SPECIAL INFECTIONS 205 there are a number which have not been reported. It is not possible at the i)rcsent time to determine the real value of "606"; some think it a specific which will cure in a few doses, others that it is not su- perior to mercury. It is possible, however, to decide that it is a very powerful drug capable of producing alarming symptoms and even death, that it is still in the experimental stage, and that it should be used with great caution and only by those who have learned the technic of administration from the experienced. Perhaps less dangerous arsenical preparations, given more often and in small doses, will prove to be as efificient even if slower. Murphy has obtained remarkable results with sodium cacodylate, which may be given in doses of 3^^^ to 2 grains, in pills, hypodermic- ally, or by enema, repeated at intervals of three or four days. N eoarsphenamin (ncosalvarsan) is "a very soluble form of arsphe- namin obtained by the addition of formaldehydsulphoxylate of soda. It is claimed to be fully as efficacious as the old remedy and possesses certain decided advantages in the simplification of the technic of its preparation and the greater tolerance to it, permitting much larger doses at shorter intervals. It is extremely soluble in water. Neutralization with caustic soda is not necessary as with old arsphe- namin, as the new product is neutral when in solution. It is pre- pared by dissolving 0.15 gm. in 20 c.c, or 1.5 gm. in 200 c.c. of freshly distilled water; 0.8 gm. in 2 2 c,c. gives an isotonic solution." Since stale water or saline solution may contain molds or saprophytic bacteria which can give rise to foreign protein reactions with symptoms resembling acute arsenical poisoning, only freshly distilled and sterilized water should be used. "As the preparation oxidizes readily and the oxidation products are more toxic than the drug itself, the following precautions are suggested: In making the mixture it should be gently agitated and not vigorously shaken. It should not be warmed after it is made up, and it must be used immediately. Four doses are administered in succession with an interval of one day between. Schreiber's pro- cedure is to give 0.9 gm. for the first dose, 1.2 gm. for the second, 1.35 gm. on the third day and 1.5 gm. on the fourth. This equals 6 gm. of ncosalvarsan or 4 gm. of salvarsan within one week. Women receive from 0.75 to 1.2 gm., children 0.15 to 0.35 and infants 0.05 gm. In cases of meningitis or involvement of the cerebrospinal system the patient's susceptibility should be cautiously tested with small doses. Owing to its less irritating properties ncosalvarsan lends itself more readily to intramuscular use. For this purpose 0.9 gm. are dissolved in about 30 c.c. of water. Several c.c. of a i per 2o6 MANUAL OF SURGERY cent, novocain solution are lirst injected; the needle is left in situ-> and the neosalvarsan injected through it several minutes later. Schreiber has observed edema after its use, but never infiltration or necrosis. He prefers, however, the intravenous method" (Fordyce). Local treatment in syphiUs is of secondary importance. Excision of the chancre is not recommended by most surgeons, as it has no influence on the general symptoms. As pointed out by Martin, however, excision must remove a quantity of the infective material, and it provides a bit of tissue from which a diagnosis can be made. If the chancre is not excised it should be cleansed by immersion in a I to 500 bichlorid of mercury solution and dusted with an antiseptic powder. Syphilitic buboes require no local treatment, unless they suppurate because of mixed infection. Mucous patches in the mouth and syphihtic sore throat may be touched with nitrate of silver, 30 grains to the ounce, and astringent and antiseptic mouth washes used; mucous patches in other regions and condylomata should be disinfected with peroxid of hydrogen and bichlorid of mercury and dusted with calomel. Non-ulcerative tertiary lesions are treated by the application of mercurial ointment. Gummata should not be opened, even when fluctuating, as absorptijn from the internal administration of potassium iodid is still possible. Ulcerating gummata should be kept scrupulously clean, since second- ary infection may make them exceedingly foul, inaugurate a phage- dena, or markedly interfere with their healing. In some of these cases hectic fever with amyloid degeneration of the viscera occurs. Congenital or inherited syphilis results from the disease in either or both of the parents. Formerly it was thought that parents who had completed the secondary stage, i.e., after three or four years, were no longer capable of transmitting the disease to their offspring, although exceptions to this rule were noted, and that it was possible for parents in even the contagious period to bring forth healthy children. It is probable, considering the observations previously made on immunity, that in most of these cases serologic investigation would reveal latent syphilis. Active fetal syphilis generally results in death of the fetus and abortion; or if the fetus goes to term, in death at or soon after birth. Although infantile syphilis may be manifest at birth, or may not show itself for a number of years, the first symptoms are usually noticed within a few weeks or months of birth. Any of the lesions of syphilis, excepting, of course, the primary chancre, may be en- countered when the disease is inherited and the spirochetae have been demonstrated in these lesions. Of peculiar diagnostic value are the GENERAL CONDITIONS AND SPECIAL INFECTIONS 20/ wrinkled, shriveled up, old man appearance, marked anemia, the hoarse cry due to inflammation of the laryngeal mucous membrane, and snuffles due to inflammation of the nasal mucous membrane. The last may go on to ulceration and be associated with destruction of the nasal bones and cartilages, causing a falling in of the bridge of the nose (Fig. 77). The spleen and liver are usually enlarged. Mucous patches about the lips may leave radiating scars (rhagades) , especially at the angles of the mouth (Fig. 78). Pemphigus, partic- ularly on the palms and soles, is one of the earliest and most char- acteristic skin eruptions. Inflammation and thickening at the epi- physeal junctions of the long bones, and periosteal nodes, which, on the cranium, give rise to the natiform skull also are common. Many die during this, the secondary stage, and those that survive may pass through an intermediate or latent period of variable length, some- times lasting until the second dentition, puberty, or even longer. Fig. 77. — Con^itnital syphilis showing Fig. 78. — Congenital syphilis showing necrosis of skull and facial bones with necrosis of facial bones and rhagades. saddle nose. Among the tertiary phenomena which require special mention are sudden deafness in both ears without pain or discharge, inter- stitial keratitis (cornea has a ground-glass appearance, and later a salmon color due to vascularization, both are usually involved), Hutchinson teeth (the permanent upper and median incisors are dwarfed, separated, and narrower at the crown than at the root, the cutting edge being curved with the convexity upwards), and dactylitis (chronic painless enlargement of a finger or toe, due to gummatous infiltration or syphilitic osteomyehtis — Fig. 76). The treatment should be not only antisyphilitic, but also tonic, including such drugs as cod-liver oil, iodid of iron, and the phos- phates. IMercury is best administered by daily rubbing 5 or i o grains of the ointment into the soles of the feet, or by placing it on the 208 MANUAL OF SURGERY inner side of the belly band. If there is much irritation of the skin, hydrarg. cum creta, grain ^, with i grain of sugar, may be given three times a day after nursing. Potassium iodid, ^ to i grain, in simple syrup, gradually increased, is given three times a day with the onset of tertiary symptoms. The treatment should be continued for at least two years, and recommenced at each outbreak of symp- toms. Arsphenamin or neoarsphenamin also may be administered. In infants blood may be obtained for the Wassermann or other tests, or intravenous medication given, by puncturing the superior longitudinal sinus with a hollow needle, which is inserted in the posterior part of the anterior fontanel in the midline for a distance of }^{q of an inch, the point being directed downward and backward. TUBERCULOSIS Tuberculosis is an infectious and contagious disease caused by the bacillus of tuberculosis. The tubercle bacillus is a rod-shaped facultative anaerobe, measuring fom 1.5/1 to 3.5^ in length. It may be straight or curved and is frequently seen in pairs; it is non-motile and probably develops only in living tissues, although capable of maintaining its vitality for a long time outside the body. Its toxin is, as yet, little understood. The bacillus enters the body through external wounds, through the respiratory tract, through the alimen- tary canal (infected milk or meat), or in the fetus, through the placenta. The most frequent method is by the inhalation of dust, along with which the bacilli are carried. Animal tuberculosis differs in some respects from human tuberculosis, but is probably only a modified form of the same disease; that the two are inter- communicable seems to be proved. Tuberculosis is exceedingly common, indeed some would have us believe that we all are in- fected. Xaegeli found tuberculosis of some sort in 97 per cent, of 700 autopsies. There seems to be no way to avoid taking these organisms into the body, but something more than the tubercle bacillus is required for the development of the disease, viz. , inherited susceptibility, poor food, overcrowding, depressed vitality following prolonged illness or mental strains, or local injuries. The disease is rarely, but the predisposition frequently, transmitted from parent to child. Those who possess this predisposition {strumous, scrofulous, or, better, tuberculous diathesis) are often frail, anemic, and precocious; the skin is apt to be delicate, the complexion fair, the hair fine, the lashes long, the head large, the cranial bones promi- nent, the nose short and broad, the Hps thick, the lower jaw small, the muscles soft, the bones slender, the epiphyses enlarged, the chest GENERAL CONDITIONS AND SPECIAL INFECTIONS 209 small and ilat; and there is frecjuently a tendency to eczema, catar- rhal inflammation of the mucous membranes, non-tuberculous enlargement of the lymphatic glands, corneal ulcers, granular lids, and carious teeth. Tuberculosis may occur at any age, and in any portion of the body, but is most common in early life and in the respiratory tract, genitourinary organs, bones, joints, lymph glands, serous mem- branes, brain, liver, and spleen. The so-caWcd '' sensilc kiherculosis'^ presents no essential difference from the disease in the young. Tuberculosis is characterized by the formation of nodules or tubercles, which vary in size from i or 2 mm. to masses as large as a pea, and by the occurrence of inflammatory changes between and around these tubercles; in truth, the inflammatory changes may constitute the whole process, the tubercles being inconspicuous or absent. A tubercle is formed as follows: The bacilli lodge in the intimaof the small vessels, in which inflammatory changes occur, lead- ing to a proliferation of the endothelial cells (endarteritis), and sub- sequently to a proliferation of the connective-tissue cells and of the leukocytes which have wandered from the bloodvessels; thus a little mass, or tubercle, is formed, which is grayish in color and more or less translucent. A typical tubercle contains one or more gianl cells, which are due to the fusion of epithehoid cells and show many nuclei; surrounding these cells are the epithelioid cells (proliferated connective-tissue cells), which are midway in size between the giant cells and the leukocytes and contain a single nucleus; the outermost zone is made up of proliferated leukocytes {lymphoid cells). The bacilli may be found in the giant cells and occasionally in the epithe- lioid cells. The giant cell is by no means characteristic of tuberculosis, as it is found in many other pathological conditions. With the onset of necrotic changes in the tubercle, the bacilH are no longer demonstrable, but they or their spores are undoubtedly present, for the injection of such material into guinea-pigs produces tuberculosis. As the vessel from which it started becomes obliterated by the proliferated cells, a tubercle is avascular; and as no new vessels are formed owing to the anemia and the specific action of the bacillus, degenerative changes occur. There is at first a hyaline change, then coagulation necrosis, next fatty degeneration, and finlly the produc- tion of cheesy material {caseation, or caseous necrosis) . A tubercle undergoing caseation is called a yellow or crude tubercle. The fate of a tubercle is largely influenced by the general and local resist- ance of the tissue. In favorable cases it may undergo atrophy and completely disappear, or become encapsulated by dense scar tissue, 14 2IO MANUAL OF SURGERY the cheesy material either being absorbed or calcihed. In the latter instance the healed-in tuberculous material may remain latent for a long time and again be awakened to activity. In unfavorable cases the caseous material liquifies, forming tuberculous pus (see "Chronic Abscess."). Tuberculosis extends by continuit}- or contiguity of tissues, possibly aided by the ameboid movements of the leukocytes, as the bacillus itself is non-motile; in other instances it gains entrance to the lymph or blood stream and is transported to distant parts. When the bacilli enter the blood stream and produce multiple tubercles widely distributed throughout the body {acute generaU or military tuberculosis) . a tuberculous pyemia results, a condition which closely resembles and is often mistaken for typhoid fever. The diagnosis may be considered under the following headings: (i) The history of a family predisposition, of previous tuberculous lesions, of an unfavorable occupation, of unhygienic surroundings, of habitual association with tuberculous individuals; (2) general symp- toms, such as weakness, anemia, loss of appetite, indigestion, pro- gressive loss of weight, and slight afternoon rise in the temperature; (3) the type of patient (vide supra) ; and (4) evidences of tuberculosis elsewhere in the body are all suggestive but not conclusive. (5) The local features, which will be described in connection with the disease in special structures, and which may require special means, e.g., the X-ray, cystoscope, etc., for their demonstration, are often distinctive; sometimes the tubercles can be seen. The insidious onset, marked chronicity, and tendency to recurrence which characterizes most forms of surgical tuberculosis should be noted in this place. (6) Recovery of the tubercle bacillus assures the diagnosis, but even when these are not demonstrable, (7) inoculation of a guinea-pig may result in generalized tuberculosis. C8) Microscopic examination of the diseased tissues will usually show the characteristic structure of the tubercle. (9) Cytologic examination of tuberculous fluids may reveal an excess in the number of lymphocytes. (10) Blood examina- tion may show a relative lymphocytosis. Leukocytosis and iodo- philia are indicative of mixed infection. Tubercle bacilli are rarely found in the blood. The value of the agglutination test is doubtful. A persistently low tuberculo-opsonic power of the blood, according to Wright, means tuberculosis. (11) The tuberculin test may be performed in four ways: (a) subcutaneous injection causes, in a tuber- culous subject, a reaction which consists of a rise of temperature of from 1° to 3°, and a general feehng of illness, occasionally with nausea and vomiting. The tuberculous lesion itself undergoes inflammatory GENERAL CONDITIONS AND SPECIAL INFECTIONS 2 11 changes. The method should rarely be emj)loyed, because of the disagreeable reaction, the possibility of stimulating the process or of inoculating the patient with tubercle bacilli, and. because of the un- certainty of the test (the margin of error has been estimated at lo per cent.)- It cannot be employed when the patient's temperature rises to or above ioo° V. The dose for diagnostic purposes is .i mg. for delicate individuals, and i mg. for those who are fairly robust; if no reaction is obtained from smaller doses, they may be increased to 5 or 10 mg. (b) The Calmette method consists of instilling one drop of a I per cent, solution of tuberculin into the eye; if conjunctivitis follows the test is positive. The method is not without danger, particularly if the eye is not normal, (c) The Von Pirquct method consists in inoculating the tuberculin into the skin after scarifying, non- inoculated scarification being used as control. In the tuberculous a papule forms at the site of vaccination, (d) The Moro test is per- formed by rubbing into the unbroken skin of the chest or abdomen, over an area of four square inches, a small quantity of an oint- ment consisting of 5 c.c. of old tuberculin and 5 grammes of anhy- drous wool fat. In a day or two a number of small papules appear, if the patient is tuberculous. The prognosis is good if the lesion is localized and so situated as to be susceptible of eradication by surgical means; the danger of recur- rence, however, is always present. In general, it may said that the prognosis is better in children than in adults. Undoubtedly many cases of unsuspected tuberculosis recover without treatment, but when the process has extended sufificiently to be recognizable, par- ticularly in medical tuberculosis, it has gained such a foothold that recovery is always doubtful. The treatment is local and constitutional. The most important measure in the local treatment is rest. Of some value is the injection into the lesion of various drugs, among which may be mentioned carbolic acid (3 per cent.), tincture of iodin, chlorid of zinc (i-io), balsam of Peru, oil of cloves (i-io in olive oil), and especially iodo- form emulsion (10 per cent.). It is probable that by irritation these medicaments stimulate the fibroblasts, and thus produce firm fibrous tissue which encapsulates the tubercles. Bier claims good results from the production of a permanent congestion, by a rubber tourni- quet placed on the Hmb above the tuberculous area (see "Bier's Treatment," chap. vi). Radiotherapy (X-rays, radium), photo- therapy (the Finsen light), and heliotherapy (exposure to the direct rays of the sun) have proved of value in suitable cases. Heliother- apy is best administered on a high mountain (helioalpintherapy) . 212 MANUAL OF SURGERY According to Rollier the ultraviolet rays are the real factor in healing tuberculosis; these cause pigmentation, and the pigment acts as a sort of filter, which prevents injury to the skin by the rays of short wave-length, and allows the others to penetrate, causing an inflam- matory reaction in the tissues and a positive chemotactic leukocytosis. As tuberculosis is always a general disease, Rollier always gives general sun baths, beginning, however, gradually. On the first day the feet are exposed three or four times for five minutes, later the legs, and so on, until finally the whole body may be exposed for six or eight hours. Brilhant results have been obtained with this form of treat- ment, but it takes two or three years, and in many cases operation acts just as well within a much shorter time; of course the two may be combined. The operative measures, e.g., incision and curettage, excision, amputation of a diseased limb, and removal of destroyed organs, will be discussed more fully on the pages devoted to regional surgery. The constitutional treatment consists of fresh air, food (meats, milk, eggs, cream, butter), and plenty of sunshine, which is really a form of heliotherapy. Tonics are usually indicated, and a prolonged stay at the seashore, particularly in surgical tuberculosis, is of the greatest value. The discharges should be carefully disinfected, and susceptible individuals should not associate with those in whom the disease is active. Koch's tuberculin is probably of some value in the early stages of tuberculosis, but is rarely employed by surgeons. It, of course, is impotent against the pyogenic organisms which are found so frequently in tuberculous lesions, and it should never be employed alone, but always in conjunction with other remedial measures. The dose of the old tuberculin is o.ooi c.c, injected under the skin of the back; if the patient fails to react, the doses are grad- ually increased. The does of the new tuberculin (T.R.) is 0.002 mg. every second day, increased gradually until 20 mg. is reached, so that a rise in temperature of more than a half degree is avoided. The treatment may then be discontinued or repeated after a long interval. The old tuberculin (T.) is a glycerin extract of tubercle bacilli from which the bacteria have been removed by filtering through porcelain. The new tuberculin (T.R.) is made by triturating dried bacilli in an agate mortar, the resulting powder being put into dis- tilled water and the solution centrifugahzed. The upper portion of this fluid is the tubercuhn O. (Oberer), which has the same properties as the old tuberculin; the remaining fluid, tuberculin R. {R tick stand) , causes a general but not a local reaction, its curative effect being due to the production, in the blood, of antibodies to the tubercle bacilH. GENERAL CONDITIONS AND SPECIAL INFECTIONS 213 Koch's latest tuberculin, B. E. {Bazillenemulsion) , is an emulsion of ground tubercle bacilli in equal parts of glycerin and water, the dose being that of T.R. Klebs claims good results from the use of Hiherciilocidin, or antiphthisin, which is tuberculin from which the noxious portions have been separated. Antituberculous serum made by immunizing animals with toxins of the tubercle bacillus have been employed, notably by Maragliano and Alarmorek; the value of these serums has not been determined. Among the drugs which have been used internally in tuberculosis may be mentioned arsenic, iodin, creosote, guaiacol, cod-liver oil, lacto-phospha^.es, hypophosphites, strychnin, animal and vegetable digestive ferments, iron, mineral and fruit acids, vegetable tonics, and nucleins. Tuberculosis of special structures is considered under various headings throughout the book. CHAPTER XIII TUMORS AND CYSTS A tumor, or neoplasm, is a mass of newly formed pathological tissue which tends to persist or grow and which performs no physio- logical function. Clinically, however, the word tumor is often applied to a swelling of any sort. An inflammatory swelling differs from a neoplasm in that it has a definite cause and tends to subside; a hypertrophy, in that it is the result of increased work and persists only so long as the demand for such work exists. The tissue of a neoplasm has its prototype in the human body, either adult or embryonic {Midler's law), and its cells invariably originate from preexisting cells of the body (Virc/wic's lau'). The cause of neoplasms is not known. Cohnheim's inclusion theory is that an excess of embryonic cells is manufactured during intrauterine life, and that those which are not used in the construc- tion of the fetal tissues remain in the body in a latent condition, until some irritation stimulates their development. The influence of heredity is probably much less important than was formerly believed. Injury and irritation are undoutedly important factors in some in- stances; thus sarcoma may follow a single injury, carcinoma some form of constant irritation, e.g., epithelioma of the lip, the result of smoking a short stemmed, clay pipe. ]\Iany unsuccessful attempts have been made to establish the infective nature of tumors, distinctly sarcoma and carcinoma. Sarcoma is most frequent during the early half of life, or the period of physiological activity; carcinoma, during the later part of life, or the period of physiological decline. Clinically tumors may be divided into the benign and the malig- nant. A benign, innocent, adult, or typical tumor may be multiple, strongly resembles in structure the tissue from which it springs, grows slowly, is encapsulated, does not infiltrate surrounding tissues, is usually movable (not adherent) , seldom ulcerates, does not cause metastases in the lymphatic glands or in distant parts of the body, does not recur after thorough removal, and is serious only when so situated as to press on important structures. A malignant, atypical, or embryonic tumor is usually single, is composed of cells resembhng those found in the embryo, grows rapid- 214 TUMORS AND CYSTS 215 ly, is not (.'111^11)8111^110(1, infiltrates the surroundin*^ tissues (fixed), and often j)r() ^^P WtHt^ Fig. 104. Fig. 105. Figs. 96 to 105. — Sliding flaps, pedicle not cut. This proceeding, or "waltzing" of the flap (Halstead) may, be repeated. If the flap describes a circle in its migration it is said to "loop the loop." A double pedunculated flap from the neck is 2 6o MANUAL OF SURGERY sometimes used for the chin; from the abdomen, for the hand, the hand being shpped beneath the strip of skin (Fig. io6). The apph- cation of the principles outlined above is illustrated in the sections on regional surgery, especially those dealing with the nose and the lips. 3. Skin grafting is the use of entirely detached portions of the skin for covering raw surfaces. Autoplastic grafts, i.e., those taken from the same individual, are the most successful. Homoplastic grafts, i.e., those contributed by relatives or friends, or obtained from a recently amputated limb, seldom "take," probably because the tissue fluids of the patient have a cytolytic effect on the graft, just as the blood of one individual may cause hemolysis when mixed with that of another. It is claimed that successful homoplastics grafts can be obtained when the donor and recipient belong to the same blood groups. When skin is transplanted from a negro to a white man the pigment gradually disappears and vice versa. Hetero- W Fig. 106. — Double pedunculated flap. (Binnie.) plastic grafts, i.e., those taken from the lower animals, almost always become necrotic. Wolf's method (free transplantation of skin) consists in excising a piece of skin one-sixth larger than the area to be filled, removing all fat from its under surface, and placing it in the defect, from which all scar tissue should have been removed, and in which the graft is held by the pressure of the dressings. It is preferable to leave the fat if, e.g., on the face, an indentation is to be filled. Healing is complete in from three to five weeks. Hair transplanted with the graft usually falls out, and regenerates irregularly, and the graft becomes whitish or yellowish. Many of these grafts perish, and when the dimensions are over 5 to 6 cm. necrosis is almost certain to occur. Thus the indications for the Wolf graft are restricted, despite its advantages, as compared with the Thiersch graft, of greater resis- tance, less shrinkage, and better cosmetic efi'ect. Thiersch's method (free transplantation of epidermis) is quicker (heaUng occurs in one or two weeks) and more certain than the Wolf method, and is generally used for fresh or granulating surfaces. It SKIN AND CUTANEOUS APPENDAGES 261 should not be employed when the part, e.g., the palm or the sole, is to be subjected to pressure; in these cases, if the area is too large for a Wolf graft, the raw surface should be covered with a pedunculated flap, taken for example from the abdomen in the case of the palm, from the other leg in the case of the sole. Epidermal grafts are best taken from the arm or thigh. After the raw surface has been disin- fected no antiseptic should be used. Exuberant granulations are removed with a sharp curette or, better, with a razor, which causes less injury to the remaining cells, and bleeding stopped by pressure with hot pads. The parts from which the grafts are to be taken should be sterilized and then washed with salt solution. The skin is stretched by pressure with the hand, and a long strip of epidermis, as thin as possible, is shaved off with a sharp razor (Fig. 107). The graft lies on the blade of the razor in a series of plaits and is slid onto the raw surface by fixing one end of the graft by slight pressure and carrying the razor close to and parallel with the wound. (Fig. 108.) All air bubbles should be pressed from beneath the graft, which is Pig. 107. Thiersch's skin grafting. Fig. 108. (Esmarch and Kowalzig.) then covered with strips of rubber tissue or silver-foil, and dry sterile gauze. The wound may be entirely covered with such grafts. The dressing is changed at the end of a week unless infection occurs. Instead of the dressing just described we splint the grafts with a single layer of parafiined gauze fastened at the margins of the wound with collodion thus securing free drainage into the outer dressings, preventing maceration, and allowing change of the outer dressing and irrigation with salt solution if the discharge be copious. Epidermic inlay (Esser) is a form of Thiersch grafting in which the grafts are buried. A pocket, made beneath the skin or mucous membrane, is filled with heated dental compound, which after harden- ing is removed and covered with Thiersch grafts, raw surfaces out- ward. The cast is then replaced in the pocket and the wound sutured. Two or three weeks later the wound is reopened and the cast removed. The method can be employed to skin graft the mouth, to create a socket for an artificial eye, and to obtain a flap faced on each side with epidermis. (Fig. 109.) 262 MANUAL OF SURGERY Reverdin's method is performed by lifting a small portion of the skin with a needle and removing it with curved scissors. The upper layer of the cutis vera should be included. A number of these grafts X"0^\ O YNCCH/A ■ PI VIPBP. CAiyiry- PRopuccp. >\\\;^r\^ j -PINTAL- COnPOUA/t>- WMWA ■•ii^iii- ZRAFT ■ OF PCA/r^L-APPLIA/VCC-AII/tfl-i .^f-^- Fig. 109. — Epidemic inlay of Esser (Dorrance). are placed on the granulations, raw surface downwards, and the wound dressed as in the Tiersch method. These grafts at first apparently disappear owing to disintegration of the epidermis, but later appear as SKIN AND CUTANEOUS APPENDAGES 263 bluish wliitc sjxjIs, from which the cpithchal growth proceeds in all directions. Mangoldt's mctJiod consists in "scraping the sterilized skin with a razor, down to the papillary layer, and spreading the mixture of epithelial cells and blood thus obtained upon a clean, bloodless, non- granulating wound. " Mucous membrane from man or animals has been sucessfully transi)lanted, and skin has been used to take the place of mucous membrane. When flaps are used for the latter purpose, the skin should be hairless. Free transplantation of fat is followed by partial (when auto- plastic) or complete degeneration (when homoplastic) of the trans- plant, the degenerated cells being replaced by new cells which spring from the old fat cells or from the accompanying connective tissue. As the transplant shrinks to some extent it should be cut a little larger than seems necessary, and it should not be placed immediately under a suture line. Fat transplantation has proved of value for filling cavities, e.g., in the face after fracture of the zygoma, in the breast after the excision of benign tumors, in bone after the removal of necrotic or carious areas, in the orbit after enucleation of the eye; for the prevention of adhesions, e.g., between joint surface (arthro- plasty) , around nerves and tendons, between the brain and overlying structures; for the control of bleeding from parenchymatous organs, the fat, being used as a tampon, is sutured in place; and, when inserted between the pleura and the chest wall, for producing com- pression in the treatment of bronchiectasis and pulmonary tubercu- losis. In subcutaneous emphysema the air or gas is (i) generated in the tissues or comes from (2) without or (3) within the body. 1. Aerogenic bacteria are responsible for the emphysema in gas gangrene (q.v.), which is distinguished by sloughing and general sep- tic symptoms. 2. Air may be injected beneath the skin with a syringe or an aspirator, or drawn into a wound, e.g., in the axilla or the base of the neck by the action of the respiratory muscles, and fail to escape owing to the valvular nature of the wound. Air that is left in a cavity or a wound at the conclusion of an operation is occasionally forced into the subcutaneous tissues during subsequent straining efforts. 3. One of the air containing sinuses of the head, or a portion of the respiratory apparatus or ahmentary canal, may, as the result of disease or injury, communicate wdth the subdermal cellular tissue. 264 MANUAL OF SURGERY Of special interest are emphysema of the chest and emphysema of the mediastinum, which are discussed in chapter xxiv. The symptoms in groups two and three, aside from those of the condition with which the emphysema is associated, are seldom alarm- ing. The area involved is usually small, but may be so extensive as to cover almost the entire body, the patient has the appearance of one with advanced dropsy. The swelhng is puffy looking, painless, soft, elastic, tympanitic, and crepitates on pressure and auscultation. The air may be displaced by the finger, but there is no pitting as in edema. The pufhness can sometimes be increased by raising the pressure in the cavity from which the air is derived, e.g., by having a patient with fracture of the nasal bones blow the nose. The diagnosis of crepitus is given in the section on "Palpation," chapter. The treatment in groups two and three is that of the causative lesion. The air is slowly absorbed and rarely demands multiple punctures or aspiration for its liberation. Suppuraton. which would require incision, is very unusual from the presence of air alone. CHAPTER XV VASCULAR SYSTEM In the present chapter we have freely used the article by LeConte and the author, in the "American Practice of Surgery," on the "Surgery of the Heart and Blood Vessels," to which the reader is referred for an extended discussion of the subjects herein treated. THROMBOSIS Thrombosis is the formation of a clot (thrombus) within the circulatory apparatus during life. The causes in the order of their importance are, (i) changesinthe vessel walls, the result of inflammation, necrosis, degeneration, neoplastic infiltration, or trauma; (2) changes in the blood, the result of toxemia or anemia; (3) changes in the blood current, resulting in retardation, e.g., from diminution in the calibre of the vessels, cardiac weakness, or prolonged maintenance of the horizontal posi- tion, or resulting in the production of eddies, e.g., when the blood flows into an aneurysm or a varix. As coagulation of blood depends upon the presence of fibrin ferment, which causes the fibrinogen and the calcium salts of the plasma to unite and form fibrin, and as fibrin ferment is liberated by diseased or injured endothelial or blood cells, slowing of the circulation alone, without either of the other factors, will not cause thrombosis, indeed, a vessel may be ligated at two points without coagulation taking place for a long time between the ligatures. As a matter of fact, one of the other factors is almost always present; thus, slowing of the blood current is in itself capable of inducing nutritive changes in the vessel walls, and in the enfeebled circulation attending fevers there is toxemia and often degenerative alternations in the vascular tunics. The nature of the thrombus depends upon whether it is formed slowly from a moving current of blood (white thrombus) or is the result of complete stasis (red thrombus) . The white thrombus is composed of gradually deposited white corpuscles and fibrin; when a consider- able number of red corpuscles enter into its formation it is called a mixed thrombus. The clot which is first formed (primary, or auto- chthonos thrombus) usually begins as a parietal mural thrombus, 265 266 MANUAL OF SURGERY which gradually enlarges until it fills the lumen of the vessel {occlud- ing, or obturating thro?}2bus) . It may then by subsequent additions {induced thrombus) become a continued, or propagating thrombus, usually extending in the direction of the blood current. The term secondary is applied to induced thrombi and to those forming about an embolus. A thrombus is generally adherent to the vessel walls and its advancing end conical. The end. e.g., when it projects into a collateral vessel, may be washed away as an embolus (Fig. no), or the entire thrombus may loosen and float into the blood stream. The terms infective and aseptic, or bland, refer to the presence or absence of bacteria. The changes which a thrombus may undergo are (a) organization i.e., the clot is replaced by fibrous tissue as in repair elsewhere; (b) canalization as the result of incomplete organization, thus re-establishing the circulation; (c) calcification, forming in the veins phleboliths and in the arteries arterioliths; and (d) liquefaction or softening the result of aseptic degeneration (simple softening) or sup- puration (septic softening), causing embolism and in septic softening pyemia. LocaUzation of Thrombi. — Cardiac thrombi FiG.iio. — A . Thrombus. B. Em- are of no practical importance to the surgeon. detachment of the end Arterial thrombi are most frequent in the lower of the thrombus which extremity as the result of injury, endarteritis, or projected mto the , . . . ^ ^ r a r^ larger vessel. Arrow the impaction of an embolus (see Gangrene WoJTdSefm''''"'' °^ and Embolism"). Venous thrombi are much more common than the other varieties, because of the comparatively sluggish circulation in the veins, the presence of valves, and the composition of venous blood, especially the increased amount of CO2. Venous thrombosis, unlike that occurring in the arteries, usually attacks the veins on the left side of the body. The left lower limb is the favorite site, owing to the greater length and obliquity of the left common iliac vein, which is crossed by the right common iliac and the left internal iliac arteries, and which may be pressed upon also by a loaded rectum. Capillary thrombi are gen- erally due to local conditions, such as injuries, severe inflammations, etc. ; when the larger vessels are blocked, the capillaries remain patent unless gangrene follows. The results of thrombosis depend upon the location and the extent of the thrombus, the rapidity with which it is formed, and the condition of the collateral vessels. Apart from the constitutional VASCULAR SYSTEM 267 symptoms, which vary according to whether the thrombus is septic or aseptic, and the Habihty to embolism, the phenomena are mainly those of obstruction to the blood stream, the sym})toms and treatment of which are given in the sections on "Embolism," "Contusions of Arteries," and "Phlebitis." Thrombotic gangrene is discussed under "Gangrene," post-operative thrombosis under "Phlebitis." EMBOLISM Embolism is the sudden blocking of a blood vessel by a foreign body {embolus) which has been brought by the blood stream from some more or less distant part. Emboli are usually detached por- tions of thrombi, but they may be vegetations from the valves of the heart, detached atheromatous plates, fat globules, air bubbles, portions of tumors, cells from some of the normal structures of the body, masses of bacteria, or parasites, such as the scolices of the echinococcus and the filaria sanguinis hominis. Various forms of dust when inhaled, and particles of paraffin and insoluble prepara- tions of mercury when injected subcutaneously, may float off into the blood stream as emboli. The site of impaction of an embolus depends on its origin. Those arising in the area drained by the portal vein lodge in the liver; those arising in the general venous circulation pass through the right heart and lodge in the lungs; and those from the left heart or aorta may lodge in any portion of the body. Rarely an embolus originating in a vein finds its way into the arterial circulation through a patent foramen ovale {crossed, or paradoxical embolism) and still more rarely is it transported in a direction opposite to that of the blood stream {retrograde embolism). An embolus usually lodges at the point where a vessel suddenly diminishes in size, e.g., where a large branch is given off or where bifurcation takes place. The effects of embolism, which depend upon the size, seat, and nature of the embolus, and the condition of the collateral circulation, may be studied under two headings: (i) At the seat of impaction an embolus induces secondary thrombosis, and the mass may undergo the changes already described under "Thrombus." Non-absorbable foreign bodies, if minute, may be transported by the leukocytes to the liver, spleen, or bone marrow; larger foreign bodies are encapsulated with fibrous tissue. Animal parasites perish and are absorbed or encapsulated, or penetrate the vessel wall and develop in the sur- rounding tissues. Tumor cells may proliferate and give rise to metastatic growths. Bacteria may produce changes identical with 206 MANUAL OF SURGERY those at the original point of infection. Embohc aneurysms are thought to be caused by a softening of the vessel wall, the result of bacterial activity (see "Aneurysm"). (2) The parts supplied by an embolized artery become anemic, but if there is an efficient collateral circulation the anemia may disappear and no harm result. If an embolus blocks a terminal artery (i.e., one having no collateral anastomoses, except capillary, with adjacent arteries, such as occur in the brain, retina, spleen, kidney, and lung) or one with a poor collateral circulation, the part beyond becomes gangrenous; in the viscera this area is called an infarct, and is wedge-shaped with the base towards the periphery of the organ. The infarct may remain bloodless (white, or anemic infarct), or become infiltrated with blood {red, or hemorrhagic infarct), which comes from adjacent capillaries and passes through the altered vessel walls of the part. In either case subsequent organization occurs and the area remains as a scar, which may be pigmented in the hemorrhagic infarct, or calcified especially in the lungs; occasionally infarcts in the brain form cysts. If the embolus is septic the infarct undergoes moist septic gangrene or forms an abscess {metastatic abscess). The symptoms of emboHsm are sudden severe pain at the point of impaction or in the ischemic area; absence of pulsation, which may be detected in obstruction not only of superficial arteries but also of any artery having superficial branches; hardening of the vessel at the site of the embolus; increase, after a time, in the number and size of the collateral vessels; rise in the general blood pressure at the time of occulsion of a large artery (causing, if the abdominal aorta is affected, acute dilatation of the heart, edema of the lungs, bloody stools, etc.), gradually diminishing with the establishment of the collateral circu- lation; and in the ischemic area pallor, fall of temperature, hypesthesia, and paresis, followed, in the event of gangrene, by the discoloration of gangrene, anesthesia, and paralysis. Hemorrhage, as a manifesta- tion of infarction, may show itself externally when the lung (hemo- ptysis), kidney (hematuria), or bowel (bloody stools) is affected. The remaining symptoms of infarction are impairment or abolition of the special functions of the organ affected. Pulmonary embolism is discussed below, mesenteric embolism in chap, xxvii; for the details of infarction of other viscera the student is referred to a text-book on internal medicine. Diagnosis between Embolism and Thrombosis. — The onset is sudden in embolism, gradual in thrombosis. It may, however, be slow in the former if the embolus does not at once completely occlude the artery, and abrupt in the latter if the thrombus forms rapidly. VASCULAR SYSTEM 269 The duration of llic symptoms may he brief in c'ml)()lism, because the collateral vessels promptly dilate. When an artery is slowly oc- cluded the collateral vessels progressively enlarge, so that by the time the blood stream is completely arrested, they are incapable of the further dilatation required to nourish the affected part, hence the symptoms are permanent or of long duration. If, therefore, the collateral vessels are enlarged at the onset the condition is probably thrombosis. The finding of the causative lesion may be difficult or impossible. Embolism is so much more frequent in arteries that, in the absence of a definite cause for thrombosis, the condition is generally regarded as embolism, even when the source of the embolus cannot be discovered. The treatment is first prevention (see "Pulmonary Embohsm"). The measures to be taken to prevent gangrene in embolism of the arteries of the extremities are identical with those mentioned under "Senile Gangrene." Removal of an embolus in an accessible region is possible. The treatment of embolic gangrene and of mesenteric embolism is given in the sections dealing with these subjects. The treatment of other forms of visceral infarction belongs to the phy- sician, if we except the incision of secondary abscesses, and the excision of destroyed organs, e.g., spleen and kidney. Pulmonary embolism may follow thrombosis due to disease or injury (see "Thrombosis" and "Phlebitis"); labor, owing to the increased coagulability of the blood, the trauma of childbirth, the wide veins of the uterus, and the contractions of the uterus; the injection of coagulating fluids into venous tumors, of paraffin for cosmetic purposes, and of mercury in syphilis; and certain operations (see "Postoperative Phlebitis"). The S3miptoms, excluding infective emboli, which give rise to septic processes, depend upon the size of the embolus and the condi- tion of the pulmonary circulation. I. Minute emboli give no symp- toms. 2. Emboli large enough to block a medium sized branch of the pulmonary artery may be followed by trifling symptoms, owing to the number and large size of the capillaries which supply the affected area. If, however, the pulmonary circulation is sluggish, hemorrhagic infarction may occur, the symptoms being those of pleuropneumonia. Bloody expectoration may be absent and necrosis of the infarct does not necessarily follow. Many cases of pleurisy and mild pneumonia, appearing "within a few days or a week after operation, are in reality due to embolism. 3. A large embolus occluding the pulmonary artery or one of its main branches causes death within a few minutes. If the vessel is not completely blocked 270 MANUAL OF SURGERY life may be prolonged for hours, or recovery may follow. In these cases the patient suddenly complains of severe pain about the heart and dyspnea; the respirations are rapid, the face cyanotic, the eyes protruding, the pupils dilated, the cervical veins swollen, and the pulse quick, weak, and perhaps irregular. In other cases there is dehrium, coma, or convulsions. At the onset examination of the chest may reveal nothing abnormal; later, signs of edema of the lungs appear. Excluding injuries to the major veins, emboli sufficiently large to block the main pulmonary vessels rarely occur before the second or third week of phlebitis or after the sixth week. The acci- dent often follows some movement, particularly sitting up in bed, which necessitates acute flexion of the groin, thrombosis being most frequent in the left femoral vein. The prophylactic treatment is that of phlebitis. Embolic pneumonia is managed like ordinary pneumonia. In occlusion of the pulmonary artery or one of its large branches, if the patient lives long enough, cardiac stimulants, oxygen, and perhaps bleeding may be employed. Trendelenburg suggests thoracotomy, incision of the pulmonary artery, and extraction of the embolus; this has been attempted in several cases, without, however, a single recovery. Air embolism may occur during the administration of an intra- uterine douche after labor, transfusion of blood, intravenous infu- sion, and especially during operations at the base of the neck when the veins are gaping from pathological change, anatomical disposi- tion, or the result of traction. The amount of air which might be introduced into a vein by the ordinary hypodermic syringe would probably be insufficient to cause serious trouble. It is necessary that a large amount of air be introduced suddenly. The symptoms are a gurgling sound due to the sucking of air into the vein, extreme pallor or Hvidity of the face, marked acceleration and then cessation of the pulse and respirations, and occasionally a gurgUng sound over the heart. There may be convulsions preceding death, which usually takes place within a few minutes, although it may be postponed for several hours or even days. The cause of these symptoms is overdistention of the right heart and the pulmonary vessels with air, and air embolism of the coronary and cerebral arteries. The treatment is immediate pressure on the wounded vein to pre- vent the further entrance of air. Blood may be withdrawn from a vein of the arm to relieve the distention of the heart, cardiac stimu- lants given subcutaneously, and artificial respiration performed. Puncture of the right auricle with an aspirating needle has been proposed. VASCULAR SYSTEM 27 1 Fat embolism, according to some authors, may, despite the ob- stacle presented by the lymph glands, be the result of lymphatic absorption alone, but most, while conceding that lipemia may thus arise, believe that in fat embolism the fat usually enters the blood stream solely or principally through the open ends of veins. The condition may follow injuries of fatty tissue in any part of the body, but is most frequent after fractures of long bones, because of the abundant liquid fat in the medulla of these bones, because the injured osseous veins remain gaping, because of the great pressure exerted by extravasated blood and inflammatory exudate confined to a bony canal, and because of the motion to which a broken bone is subjected during transportation, diagnosis, and reduction. Next in etiologic frequency ranks the forcible bloodless correction of de- formities, especially of the knee, during which the spongy epiphyses are violently compressed and perhaps crushed. Fat embohsm is rare in infancy and old age, owing to the small quantity of adipose tissue in the medulla at these periods. As with air, it is probable that a large quantity of fat must be introduced into the circulation in a short time in order to produce serious symptoms; indeed, a small quantity of fat is normally present in the blood. The s3'Tnptoms are similar to those produced by other forms of emboli. The fat is washed through the right heart to the lungs, where it fills the vessels, producing sudden death; or, if the quantity be smaller, severe pain, dyspnea, rapid pulse, hurried, shallow res- pirations, cyanosis, and sometimes hemoptysis. At the onset the temperature is apt to be subnormal, later it ascends. The physical signs are at first indefinite; there may be a normal percussion note, restriction of the respiratory excursion, and coarse rales; if the patient survives, signs of consolidation often appear. If the oil globules are forced through the pulmonary capillaries, there may be fat in the urine or total supression of urine, and symptoms of em- bolism of the brain (convulsions, paralysis, coma, etc.). In the pulmonary form the symptoms may appear in from one to several hours after the trauma; in the cerebral form the onset may be delayed for a day or tw^o. This free interval serves, in differential diagnosis, to exclude shock and concussion of the brain, both of which immedi- ately follow an injury. The relatively brief duration of the free interval distinguishes fat embolism from clot embolism, which is usually postponed for a week or longer after an operation or injury. In the cerebral form, however, this free interval has been misinter- preted, and the patient trephined for intracranial hemorrhage, a condition that may be recognized by the symptoms of compression of the brain. 272 MANUAL OF SURGERY In order to prevent fat embolism, injured fatty tissues should be kept at rest, and if there is much tension, resulting from the accumula- tion of wound fluids, stitches should be removed or incisions made. In dealing with ankylosis of large joints, particularly if the X-ray shows marked osseous atrophy, gradual correction or arthroplasty may be safer, at least so far as fat embolism is concerned, than forcible bloodless correction, which is particularly dangerous if several large joints are attacked at the same time. Reiner suggests that before removing the Esmarch band at the completion of an orthopedic operation, a cannula be introduced through the saphenous vein into the femoral vein, in order to allow any fat that may have entered the vein to escape. The treatment of the condition itself, in the acute cases, is external heat, cardiac stimulants, and artificial respiration. The wound should always be opened to prevent the fresh entrance of fat into the circulation. The later treatment is that of the complications. In a case of fat embolism following a fracture of the radius Willms, who accepts the lymphatic theory of fat absorption, created a temporary fistula of the thoracic duct in the neck. The patient recovered. THE HEART AND PERICARDIUM Over distention of the heart with blood, the result of acute pulmonary affections, or with air from air embolism, has been treated by tapping the cavity of the heart. As the right auricle suffers most from this overdistention owing to the thinness of its walls, it is selected for puncture (paracentesis auricidi). The needle may be introduced in the third intercostal space at the right edge of the sternum and pushed directly backwards. It traverses the anterior edge of the right lung and the pericardium before reaching the auricle. The operation is attended with the danger of a fatal hemorrhage and should rarely, if ever, be performed. Wounds of the heart may be produced by penetration from without, e.g., by gunshot or stab wounds, fractured ribs, or by foreign bodies from the esophagus, stomach, or bronchus. The heart may burst as the result of blunt force to the thorax or epigastrium and it may rupture spontaneously (disease of the myocardium or coronary artery, neoplasms, gummata, echinococci, abscess, aneurysm, etc.). Symptoms. — Instantaneous death, which probably results from injury to the nervous mechanism of the heart, is very rare, and more apt to follow a severe blow over the heart or epigastrium than VASCULAR SYSTEM 273 a penetrating wound (so-called concussion of the heart). The symptoms in a case not immediately fatal are those of acute anemia or of compression of the heart, depending upon whether the blood escapes into the pleural cavity or externally, or ujion its retention in the pericardium. Occasionally the patient may walk or even run for a considerable distance before falling to the ground. When the blood escapes into the pleural cavity (the pleura is injured in over 90 per cent, of the cases) there will be, in addition to the symp- toms of acute anemia (see "Hemorrhage"), the signs of a pneumo- hemo-thorax. Palpation may detect the apex beat. A whizzing sound due to the presence of air in the pericardium, a friction sound, or a bruit not unlike that heard over an aneurysm may be heard. If the blood escapes externally it may do so in jets, but a continuous stream accentuated by coughing, movements of the patient, and similar efforts, is more common. When the blood is confined to the pericardium the phenomena are those of compression of the heart. The pulse is slow, irregular and feeble, or absent, the apex beat imperceptible, the breathing hurried and superficial, the face cyanotic, the cervical veins dilated, and the patient uncon- scious, but the senses return on providing an exit for the blood. There may be a splashing sound disappearing with the filling of the pericardium, at which time the area of precordial dulness will be vastly increased (see "pericardial effusion"). Death after several days or weeks is usually the result of sepsis (pericarditis, empyema, pneumonia, etc.), although secondary hemorrhage is a possibility, and clot, but not air, embolism has been reported. Spontaneous recovery occurs in i per cent, of penetrating and 9 per cent, of non-penetrating wounds. The wound is repaired by fibrous tissue, not muscle, hence the possiblity of subsequent aneurysm, rupture, and of murmurs from alterations of the cardiac orifices. Pericardial adhesions probably always follow wounds of the pericardium, but cause symptoms in only a few of the cases. The diagnosis is not always easy. The superficial wound may be in the abdomen or back and the general symptoms, at least in the beginning, shght. External bleeding may be profuse and spurting from an intercostal or internal mammary artery and absent in a wound of the heart. The X-ray may show a hemoperi- cardium, or in the case of a gunshot wound the projectile in the heart or pericardium. The only safe procedure in doubtful cases presenting a wound in the region of the heart is to enlarge the wound, ascertain if it penetrates the chest wall, and if there be 2 74 MANUAL OF SURGERY symptoms of hemorrhage or "heart tamponage," to explore the pericardium and the heart. The treatment is suture of the heart. An anesthetic should be employed unless the patient be unconscious, using intratracheal insufflation if the pleural cavity has been opened. In one case, in which the pleura was unwounded, we were able to expose the heart extrapleurally. An atypical osteoplastic flap with the base towards the sternum, either in the right or left chest according to indications, and including as many ribs as may be necessary, for proper exposure, usually from two to four, will be indicated in most of the cases. The wound in the pericardium is enlarged and the bleeding from the heart controlled by a linger, by compression of the heart, by dislocating it forward, or by pressing it against the sternum. Rehn says the operation may be made bloodless by compressing the venae, cavae at their junction with the right auricle, between two fingers; in animals this procedure has been continued for ten minutes without permanent harm following. The sutures may be of silk or catgut, introduced by means of a curved intestinal needle. A continuous suture may be applied more rapidly than an interrupted and presents fewer knots on the surface of the heart. The heart may be steadied by the lingers, by forceps, or by sling sutures. If the heart ceases to beat it should be sutured quickly and massage performed. After removing the blood from the peri- cardium and pleura, these cavities should be closed. We have sutured the heart in six cases, with four recoveries. Massage of the heart, by compressing the ventricles between the thumb and lingers, 60 times to the minute, has been employed for suspended animation due to anesthetics, wounds of the heart, etc. the heart being exposed by thoracotomy, or by incising the diaphragm after opening the abdomen (transdiaphragmatic route). After laparotomy the heart may be manipulated also through the diaphragm without opening the structure (subdiaphragmatic route). The thoracic route should be selected only when a breach in the thoracic wall already exists, e.g., in operations on the heart and lungs; in all other instances the subdiaphragmatic method is easier and safer. Of 26 cases in which the massage was undertaken by the thoracic route, two were successful; of 14 by the transdiaphrag- matic route, one; of 28 by the subdiaphragmatic route, 13 (Lefevre). We have tried the last named method in a few cases without success. An incomplete form of cardiac massage may be performed by making rhythmical pressure (60 per minute) over the third, fourth, and fifth costal cartilages on the left side. In all cases it is important VASCULAR SYSTEM /:> to maintain the respirations and the bodily heat by artificial means. Pericarditis is caused by contusions or wounds; infectious diseases, such as pyemia or septicemia, rheumatism, tuberculosis, and pneumonia; and by the extension of infectious processes in the neighborhood of the pericardium. The nature of the primary infection determines the character of the microorganism found. Primary pericarditis is very rare. The symptoms are often masked by those of the primary illness and the condition is frequently overlooked. There are dyspnea, cough, fever, leukocytosis, small weak pulse, occasionally the pulsus paradoxus, frequently delirium, pain and tenderness over the heart, pain radiating down the left arm or into the epigastrium, and a friction sound, perhaps with fremitus, disappearing as the sac fills with effusion. In pericardial effusion the precordial dulness increases and becomes pear-shaped, the precordium bulges, the cardiac sounds become faint and distant, and there may be aphonia and dysphagia ; the apex beat is above the lower boundary of dulness or is absent; dulness in the fifth right interspace close to the sternum (Rotch's sign) may be present; percussion reveals flatness with marked resistance; an area of dullness with bronchial breathing near the angle of the left scapula (Bamberger's sign) may be present, as may also Eii'art's sign, in which the first rib is separated from the clavicle so that the former may be palpated its entire length. The effusion may sometimes be demonstrated with the X-ray. If the fluid becomes purulent, there may be intermittent fever with edema of the chest wall. Exploratory puncture will confirm the diagnosis. The most common conditions for which pericardial effusion is mistaken are dilatation of the heart, pleural effusion, and pneumonia. When the pain is referred to the abdomen, such conditions as appendicitis, perforation of the intestine, and acute gastritis may be simulated. The treatment, in the absence of effusion, is medical. Serous effusion, when excessive, demands aspiration. Hemorrhagic effusion {hemo pericardium) arising immediately after a wound demands exploratory pericardotomy. At a later period tapping may suffice, although even then pericardotomy may be necessary to remove clots if the symptoms persist. Nontraumatic hemopericardium, excluding scurvy, is generally due to a fatal malady (e.g.. rupture of the heart, bursting of an aneurysm, tuberculosis, cancer, Bright 's disease), hence relief from tapping is only temporary. In purulent effusion (pyopericardium, empyema of the pericardium) pericardotomy 276 MANUAL OF SURGERY is required. Puncture, as in pleural empyema, should not be used, except for diagnosis, or for palliation in cases too ill to stand peri- cardotomy. Paracentesis Pericardii (tapping of the pericardium). — The diagnosis of pericardial effusion can be assured only by exploratory puncture, which should be made with an ordinary hypodermic syringe. Large trocars are dangerous. A line needle may fail to evacuate thick pus, but it will rarely fail to obtain enough for diagnostic purposes. Although puncture of the heart with a line needle is generally harmless, death may follow, either immediately from injury to the coordination center, or later from hemoperi- cardium. The needle should be introduced in the fourth or fifth left interspace close to the edge of the sternum, so as to avoid the pleura and the internal mammary artery (LeConte). If no fluid is withdrawn, it may be entered in the fifth intercostal space, two inches from the left border of the sternum. Never should the puncture be made at the spot where friction is heard, or where the heart sounds are very distinct. If the fluid is serous or sanguine- ous an aspirator should be connected with the needle; if pus is recovered pericardotomy is mandatory, Pericardotomy (incision of the pericardium) without resection of a costal cartilage is indicated when the patient is unable to stand a general anesthetic. The tissues should be infiltrated with Schleich's fluid, and an incision made in the fourth or fifth intercostal space, beginning at a point one inch from the sternal border and extending to a point an inch within the nipple line. This avoids the interiial mammary artery, which runs parallel with, and a half inch external to, the edge of the sternum, but may injure the pleura; the two layers of pleura, however, are frequently adherent at this point in pyoperi- carditis, and the wound will be of no consequence. The pericardium is incised and a rubber drainage tube inserted. When a general anesthetic is employed a portion of the fourth or fifth costal cartilage may be resected close to the sternum, ligating the internal mammary vessels if necessary. Roberts advises turning up a flap, consisting of the fourth and fifth costal cartilages, the soft tissues of the third interspace being used as a hinge. Irrigation with salt solution may be cautiously used for the removal of clots or masses of fibrin. Cardiolysis is a resection of varying amounts of bony tissue (ribs and sternum) in order to unfetter a heart bound to the chest wall by chronic mediastinopericarditis, which manifests itself by dyspnea, ascites, and other symptoms of cardiac insufficiency, together with systolic retraction of the intercostal spaces, retraction VASCULAR SYSTEM 277 of the lower lateral and lower posterior portions of the chest (Broad- bent's sign), diastolic shock or rebound, absence of respiratory movements in the epigastrium, pulsus paradoxus (Kussmaurs sign), and diastolic collapse of the cervical veins (Friedreich's sign). In the few cases in which this operation has been performed the results have been gratifying. tht: veins Phlebitis, or inflammation of a vein, may be acute or chronic. Acute phlebitis is caused by inflammatory affections in- the neighborhood of a vein (periphlebitis), injuries, primary thrombosis (thrombophlebitis), varix, and by such constitutional affections as rheumatism, gout, and the infectious fevers. Post-operative phlebitis is sometimes due to infection, but most of the cases following aseptic operations are, we think, to be ascribed to non-bacterial changes in the blood and slowing of the circulation, because the operations most likely to be followed by thrombophlebitis are those involving varices, those on anemic patients, especially hysterectomy for bleeding fibromyoma, and those necessitating a prolonged stay in bed, e.g., abdominal section, and because, like thrombosis from other general conditions, the process is usually located in the left femoral and iliac veins, the reasons for which are give under "Thrombosis." Phlebitis of the lower extremity complicates 2 per cent, of all abdomi- nal operations, 30 per cent, of these following hysterectomy, 15 per cent, oophorectomy, 10 per cent, appendicitis, and 5 per cent, renal operations. Large emboli are detached in about 2 per cent, of the cases, and of these about one-third are fatal Tsee "Pulmonary Embolism''). The pathological changes usually begin in the intima, because it is the first to yield in contusions and is directly exposed to toxins circulating in the blood. The endothelial cells degenerate and liberate fibrin ferment, and this with the concomitant roughening of the intima leads to thrombosis. The fate of the thrombus has been mentioned under "Thrombosis." The outer coats swell owing to the dilatation of the vasa vasorum and the subsequent exudation. The inflammatory exudate and the thrombus may be absorbed or organized (exudative phlebitis), or undergo suppuration {suppurative phlebitis). The former is responsible for the massive emboli which cause sudden death, the latter for the small septic emboli which cause metastatic abscesses (pyemia). Phlebitis may be sharply localized to a small segment of a vein, notablv in varix of the leg, or 278 MANUAL OF SURGERY it may involve most of the veins of an extremity, e.g., in phlegmasia alba dolens. If it begins in a small vein it spreads in the direction of the blood current, if in a large vein in both directions. Sometimes, however, it jumps from one segment to another, particularly in gouty phlebitis. Multiple patches of phlebitis in various parts of the body may occur also in rheumatism, chlorosis, and tuberculous or cancerous cachexia. The symptoms are local and general. The local symptoms are (a) those of inflammation, viz., pain and tenderness along the vein, which may be felt as a firm cord when the vein is superficial, elevation of the local temperature and redness when the perivascular tissues are involved, and fluctuation in the event of suppuration, and (b) those of obstruction to the venous current, viz., edema and passive congestion in the region distal to the thrombus, and ultimately enlargement of the collateral veins. The small superficial veins often become prominent at once, and the skin may be bluish, glossy, and, because of the swelling, more smooth than normal. Occa- sionally, particularly in septic cases, a line of ecchymosis appears along the inflamed vein. Other symptoms, referable to disturbance of special functions, arise when the visceral veins are afifected. The general symptoms vary from a slight rise of temperature to the severer forms of septicemia. A progressive increase in the pulse rate, even without fever (Mahler's symptom), should make one suspect a beginning phlebitis. Embolism causes sudden death, pulmonary infarction (see "Pulmonary Embolism"), or, in the case of septic emboli, pyemia. The diagnosis from lymphangitis is rarely difficult. In lymph- angitis there may be several thin red lines, instead of one broad line, as in superficial phlebitis. In the former the edema is more firm, local cyanosis and varices are absent, the lymph glands are enlarged, and no clot is felt in the vein. The prophylaxis of post-operative phlebitis includes careful pre- paratory treatment, especially of the heart and lungs if they are functionally impaired; asepsis, rigorous hemostasis, protection from cold, and avoidance of rough manipulation of the tissues during operation; and after operation attention to shock, the secretions, and the bowels, and allowing the patient to resume the regular diet and to sit up as early as possible. When a prolonged stay in bed is necessary centripetal massage, active movements of the arms and legs, and breathing exercises may be ordered. If conditions favorable for thrombosis exist, citric acid, 30 grains three times daily, may be given to lessen the coagulative tendency of the blood, VASCULAR SYSTEM 279 or the milk iiia_\' l)f (lecaUifu-d by adding to each pint 30 grains of citrate of sochi (Wright and Knapp). The treatment of j^hlebitis itself is attention to any existing constitutional disease, absolute rest in the recumbent posture to lessen the force of the circulation and prevent the detachment of emboli, elevation of the jKirt, and the application of cataplasma kaolini, lead-water and laudanum, or other evaporating lotions, or equal parts of ichthyol, belladonna, mercury, and lanolin, which should be laid on, not rubbed in, and held in place with a loose bandage. Tight bandaging, inunctions, and massage are dangerous. Sitting up is not absolutely safe until the clot has become organized or absorbed (six to eight weeks), when gentle passive motions and light frictions may be employed to hasten absorption of the edema. An elastic bandage should be worn for the same purpose. In sup- purative phlebitis the vein should be excised, or, if this is not possible, incised and disinfected, and a ligature placed between the area of inflammation and the heart, in order to prevent pyemia; thus in thrombosis of the lateral sinus due to otitis media, the internal jugular vein should be tied in addition to the opening and disinfection of the sinus. Chronic phlebitis, or phlebosclerosis, is a condition similar to ar- teriosclerosis. The vein walls are thickened as the result of acute inflammation, or of overdistention, e.g., in varicose veins or other forms of obstruction. Like arteriosclerosis it may be widespread as the result of such conditions as syphilis, gout, alcoholism, etc. The treatment is that of the cause. Varix (varicose veins, phlebectasia) is an elongated, permanently dilated, tortuous vein w4th thickened w^alls. It is most frequent in the internal and external saphenous veins of the leg (Fig. in), and it is with such that we shall deal at the present time, other mani- festations of this abnormality, such as varicocele and hemorrhoids, being discussed in other sections of the book. The causes of varix are, (i) weakness of the walls of the veins, either hereditary or acquired (phlebitis); (2) retardation of the venous circulation', e.g., by cardiac or pulmonary disease, prolonged stand- ing, and obstructions, such as garters, tumors, pregnant or displaced uterus; (3) compensatory dilation, such as occurs in the superficial veins of the leg when the deep veins are blocked; and (4) an abnormal opening between an artery and vein, such as occurs in aneurysmal varix. The condition is frequently present in youth, but usually gives no trouble until middle hfe is reached. Women are more liable to varix than men, owing to the influence of pregnancy. 28o MANUAL OF SURGERY Pathology. — The dilatation induces at first hypertrophy of the tunica media and finally chronic inflammatory changes with pro- FiG. III. — Varicose veins of the lower extremities. The veins in the patient's left leg and thigh were inflamed and filled with clot (thrombophlebitis). liferation of the connective-tissue elements. The new tissue causes the vessel walls to thicken and elongate, and the elongation even- VASCULAR SYSTEM 28 1 tuatcs in tortuosity. Owing to the distention of the vein, and to the crippling of the valves by the sclerotic process, the latter structures become incompetent, and the walls of the vein must suj)port a column of blood extending to the heart, and bear the brunt of every sudden increase in the intravenous blood pressure, e.g., by coughing, straining, etc. In old cases periphlebitis, causing the vein to adhere to the environing tissues, is always present, and the inflammatory changes may extend to the remaining structures of the leg. Lym- phangitis seriously augments the edema, renders it firmer in charac- ter, and sometimes leads to enormous hyperplasia of the subcutane- ous tissues (pseudo-elephantiasis). The arteries may suffer like the veins and even become thrombosed. The nerves and muscles may be attacked by interstitial inflammation, and the bones beneath ulcers may be the seat of osteoporosis or even caries. The skin is thickened, often pigmented owing to rupture of dilated vasa vasor- um, and frequently reddend, eczematous, or ulcerated. Sjnnptoms.- — Varices usually develop insidiously, although in acute obstructive lesions and in arteriovenous aneurysm they may arise quickly. Both legs are effected in 70 per cent, of the cases, the left alone in 20 per cent., the right alone in 10 per cent. Even when bilateral, the affection is generally more pronounced on the left side, for the same reasons that venous thrombosis (q.v.) is more frequent on this side. In an uncomplicated case there may be pain in the leg and sole of the foot, heaviness of the limb, and edema, particularly after walking or standing, and sometimes muscular cramps. When varices begin in the deep veins, the usual point of origin according to some authors, these symptoms may be misin- terpreted until the superficial veins dilate, when the condition is readily recognized. The veins are at first uniformly distended, but subsequently become fusiform in places or even sacculated. Valvu- lar incompetence may be demonstrated by striking the upper part of the vein with a finger and palpating the fluctuation wave thus induced at a lower level, or by noting the impulse transmitted along the blood column when the patient coughs. Trendelenburg's test is as follows: After the patient Lies down and elevates the limb, compression is applied to the upper part of the saphenous vein and the patient told to stand. If the vein slowly distends from below upward the valves are competent; if it remains empty and, after the compression is removed, suddenly fills from above downward the valves are incompetent and the circulation reversed. Chevrier says that if, in the Trendelenburg test, the varices fill slowly from below upward while compression is maintained on the upper part of the 252 MANUAL OF SURGERY saphenous vein, the valves of the anastomatic branches between the superficial and deep veins are normal, but that if the varices distend quickly the same valves are incompetent; this is the deep, or ascend- ing reflux, in contradistinction to the superficial, or descending reflux, of Trendelenburg. Complications. — Rupture of a deep varix in the calf occurs under similar circumstances, gives the same symptoms, and requires the same treatment as rupture of the plantaris muscle (q. v.) . Rupture of a superficial varix may result from trauma, ulceration, or simply from coughing or straining; in the last instance it usually occurs where the vein is greatly thinned as the result of a saccular dilatation. The bleeding is more profuse than under normal conditions, because of the incompetent valves and the rigidity of the vein, which prevents its collapse; and when the circulation is reversed the hemorrhage is more copious from the upper end of the vein. Thromho phlebitis, usually exudative and localized to a segment of the vein, is a frequent complication, owing to the sluggish circulation and the alterations in the walls of the vein, and one which may result in obliteration of the vessel and spontaneous recovery. Embolism is not as menacing as in a non-varicosed vein, thanks to the frequency of reversal of the circulation. Ulceration, the type of which has been described in chapter viii, is the most frequent complication. It may follow the rupture of a superficial varix or a perivenous abscess, or start in a scratch, area of eczema, or minute spot of necrosis. The last is due to capillary thrombosis consequent upon the blood pressure in the veins equaliz- ing that in the arteries. Eczema and kindred dermatoses, lymphangitis, and inflammatory changes in the other tissues of the leg have been mentioned in the paragraph on the pathology. The treatment may be palliative or radical. Palliative treatment consists in removal of circular garters, and all forms of dress which constrict the abdomen, gentle massage if the skin is healthy, attention to constipation and any existing cardiac or pulmonary affection, and the application of an elastic stocking or bandage. The bandage should be taken oft" at bedtime and the skin rubbed with alcohol; after the morning bath the limb should be powdered with stearate of zinc and the bandage reapplied. The radical treatment, or operation, is followed by the best results in a unilateral circumscribed varicosity. In addition to these cases, operation is indicated when there are thin-walled diverticula which threaten to burst; when ulcers or eczema refuse to heal; when there is VASCULAR SYSTEM 283 great pain; when thrombosis occurs; when portions of the vurix are situated over the crest of the tibia, where as the result of injury they may rupture or become inflamed; and when the valves are incompe- tent as shown by the tests already described. Excluding the general condition of the patient, operation is contraindicated when the varicosity is compensatory to thrombosis of the deep veins, as this would lead to permanent edema. In many of these cases elastic com- pression also increases the circulatory difficulties. Excision of a circumscribed varix is performed by incising the skin, ligating the vein or veins above and below with catgut, and removing the varix. Total saphenectomy necessitates an incision extending from the saphenous opening to the ankle, or better, a succession of incisions, the vein being enucleated beneath the skin lying between thye cuts. Instead of using the finger for enucleation Mayo threads the vein on a ring which is attached to a handle and pushed along the vein beneath the skin. Babcock employs a long pliable probe, with an acorn tip at each end, one larger than the other. After tying one extremity of the section of vein to be removed, the small end of the varix extractor is pushed along within the vein as far as possible, at which point the vein is exposed by an incision, clamped below the end of the probe, then opened, so that the probe may be drawn out. The other end of the venous segment is then tied beneath the larger acorn which is cuffed to catch the vein, and the vein is extracted from beneath the skin by pulling on the smaller end of the probe. Mar- mourian passes a probe, eye first, through the vein between the cu- taneous incisions, fixes the vein to the eye of the probe with sutures, and extracts the vein, at the same time turning it outside in, by pull- ing on the probe. These ingenious methods for assisting saphenec- tomy are of the most value in the thigh; below the knee the veins are often so convoluted that an instrument cannot be passed along them, and the varices are often so intimately adherent to the skin that subcutaneous enucleation is impossible and a section of the skin must be removed with the veins. Trendelenburg breaks the long column of blood which the veins of the leg must support by incising about four inches of the internal saphenous vien at the juncture of the middle and lower thirds of the thigh. The latest statistics for this operation (Goerlich) show that 79 per cent, were symptomatically cured or vastly improved, although the varicosities recurred in about half the cases. Phelps uses multiple ligatures (thirty or forty). Schede encircles the leg with an incision at the junction of the upper and middle thirds, ties all visible veins, and sutures the wound. Friedel makes a long spiral incision, encircling the leg a 284 MANUAL OF SURGERY number of times, from the foot to the knee, and ties all of the exposed veins. Cecca aims to support the saphenous vein by suturing the deep fascia over it. Katzenstein sews the margins of the sartorius together over the vein, thus providing it with a muscular canal that, by its intermittent contractions, urges the blood along the vein. Delbet suggests, in cases of valvular insufficiency, ligating the internal saphenous 12 cm. below the saphenous opening and anastomosing the distal end with the femoral vein (end-to-side), thus permitting the blood to flow into the femoral below competent valves, of which there is always at least one pair between the original and the new site of anastomosis. The choice of operation, in small varices, is excision of the varix. When the veins are extensively involved the patient should wear an elastic bandage or stocking for several days; if this increases the trouble there is probably thrombosis of the deeper veins and opera- tion is contraindicated, unless the veins are enormous, in which event it might be advisable to support the vessels by the Cecca or the Katzenstein operation. If the varix is not compensatory and there is a descending without an ascending reflux the Trendelenburg opera- tion may be performed; in all other cases it is contraindicated. If there is only an ascending reflux, circumscribed excision of the varices, which necessitates ligation of the deep anastomotic branches, is the best operation. If there is both a descending and an ascending reflux the only procedure of value is total saphenectomy. This is effective also when there is only a descending or only an ascending reflux, but which, because of its magnitude, it should be reserved for the cases in which the less extensive operations are impotent. Venesection (phlebotomy), or the opening of a vein to abstract blood, has two principal indications, (i) to relieve overdistention of the right heart from any cause, and (2) to diminish the amount of toxins in the body in conditions like uremia. In the latter instance bleeding is generally followed by the intravenous injection of salt solution. The operation is usually performed at the bend of the elbow upon the median basilic vein, which is larger and more distinct than the median cephalic, but has the disadvantage of lying directly over the brachial arter}-, which may be wounded if the knife is thrust too deeply. A bandage is tied around the arm above the elbow, just tight enough to arrest the venous return without interfering with the arterial supply. The patient grasps a bandage or makes a hard fist so as to press the blood from the muscles into the superficial veins. The vein is steadied with the left hand, and opened with the right hand by an oblique incision. The blood is collected in a VASCULAR SYSTEM 285 graduated receptacle until a sufficient quantity has been withdrawn, when a finger is placed over the bleeding point, the bandage above the elbow removed, and a sterile gauze pad bandaged over the wound. Transfusion of blood has proved of value in acute hemorrhage and in pathological hemorrhage, in pure shock its remedial effects are questionable and in blood diseases and toxemias it seems of little use. In other words, transplanted blood constitutes a fluid for the heart and the arteries to act upon, is an efficient hemostatic, but that it has a hematopoietic, antibacterial, or antitoxic effect has not been proved; the nourishment it contains should be temporarily bene- ficent. Before transfusion the donor's blood should be subjected to the Wasserman test for syphilis, and as there is some danger of hemolysis and agglutination the effect of the patient's blood upon that of the donor should be studied. According to Mossall individuals may be divided into four blood groups, (i) The serum of those in this group does not agglutinate the corpuscles of any other group. The corpuscles of group i are agglutinated by the serum of group 2, 3, and 4. (2) The serum of group 2 agglutinates the corpuscles of groups I and 3. The corpuscles of group 2 are agglutinated by the serum of groups 3 and 4. (3) The serum of group 3 agglutinates the corpuscles of groups i and 2. The corpuscles of group 3 are agglutinated by the serum of groups 2 and 4. (4) The serum of group 4 agglutinates the corpuscles of groups i, 2, and 3. The corpuscles of group 4 are not agglutinated by any serum. Eight per cent, of all individuals are in group i, 40 per cent, in group 2, 10 per cent, in group 3, and 42 per cent, in group 4. If possible the donor and the patient should be in the same group, although if the donor's blood contains an agglutinin for the patient's corpuscles, this agglutinin will be rapidly diluted and no harm may follow. If the patient's serum agglutinates the corpuscles of the proposed donor, another person willing to contribute blood must be sought. It will thus be seen that a patient in group i is a ''universal recipient." and that a person in group 4 is a '"universal donor.'' If. owing to lack of facilities or time, these tests cannot be made, intravenous infusion of salt solution should be employed. Transfusion may, of course, be performed later if such seems to be indicated. There are two methods, the direct, in which the blood is conveyed directly from the vessels of one individual into those of another, and the indirect, in which the blood of one individual is first drawn into a receptacle before it is injected into the vessels of the second individual. Direct transfusion may be performed by anastomosing the radial artery of one individual with any convenient superficial vein of 286 MANUAL OF SURGERY another. Under local anesthesia both artery and vein are exposed, tied below, and secured with an arterial clamp above. Each is then cut above the hgature and the adventitia of the central end pulled down and snipped off with scissors. The vessels may then be united by the Carrel method, or by glass or metal tubes. The clamps are then removed and the anastomosis covered with a hot moist sponge, to relax the artery. The time the blood is allowed to flow depends upon the effects noted, but is usually from 20 to 40 minutes. In order to prevent acute dilatation of the heart, which sometimes follows the rapid introduction of a large quantity of blood into the circulation, Dorrance and Ginsburg suggest vein-to-vein instead of artery-to-vein transfusion. As the veins are larger than the arteries, veno-venous is much easier to perform than arteriovenous anasto- mosis, but, owing to the composition of venous blood, the chances of thrombosis are probably greater. Because of its technical difffculties and the impossibility of measuring the amount of blood transfused, the direct has been super- ceded by the indirect method of transfusion. In performing indirect transfusion Kimpton uses a number of glass cyhnders (Fig. 112), the inner surfaces of which are coated with stearin, paraflEin, and vaselin, in the proportion of 1-2-2, after the cylinders have been heated over a Bunsen burner and the paraffin mixture hquefied Fig. 112.— The glass ^y placing the jar in which it is kept in a basin cylinder, of whatever . . . j - capacity desired, is closed of hot water. A prominent vein IS exposed at above by a cork. Below ^^ ^ ^ ^f ^^^^ gH^^^^. ^f ^ j^^ ^^j^^j. ^^ j recipient the upper end is a side _ ■' tube. The lower end is and two ligaturcs placed under each vein. A fashioned into a cannula. . . . i ^i j j tourniquet is drawn around the donor s arm just tight enough to produce congestion, and the proximal ligature tied. The distal ligature, untied, serves, when drawn upon, to close the vein. A slit is made in the donor's vein between the hgatures, and the cannula inserted toward the hand. In the course of two or three minutes the cylinder is full of blood, during which time the vein of the recipient is tied distally, and opened, the proximal liga- ture being employed in the same manner as the distal ligature on the vein of the donor. The cannula of the full cylinder is now in- serted into the vein of the recipient, care being taken during the transference to place the thumb over the side tube, and to keep the side tube uppermost and on the same level as the cannula. The VASCULAR SYSTEM 287 cylinder is held uj)riji;ht and, with the aid of a rubber bulb which is attached to the side tube, emptied. The cannula is withdrawn while still tilled with blood. As many cylinders as may be needed are tilled and emptied, using the same veins. The sodium citrate method (Lewisohn) is the one usually employed. Chemically pure sodium citrate added to freshly distilled sterile water is boiled for two minutes, or put in papers and sterilized dry for 30 minutes, at 248 degrees F. Nine grs. of sodium citrate in I ounce of water makes approximately a 2 per cent, solution, and this solution is used in the proportion of i part to 9 parts of blood, thus making a 0.2 per cent, solution of citrated blood. A tourniquet is applied to the donor's arm, and the median basilic or the median cephalic vein punctured with a large calibred needle, or exposed by an incision and a cannula inserted. The blood is collected in a graduated glass receptacle, containing the citrate solution, with which it is mixed by stirring gently with a glass rod. If 450 c.c. of blood are to be given, the receptacle should contain 50 c.c. of the two per cent, citrate solution. As clotting sometimes occurs with this mixture many surgeons use 30 c.c. of the 2 per cent, citrate solution, larger amounts of blood being treated proportion- ately. The blood is introduced into the patient's vein in the same manner as salt solution (vide infra). In addition to clot embolism, hemolysis, agglutination, and acute dilatation of the heart, the possible dangers of transfusion are infec- tion from faulty technic, a danger common to all operations; recur- rent bleeding, if the transfusion is performed for post-hemorrhagic anemia and the source of the bleeding has not been controlled; and transmission of disease from one individual to another, which can be avoided, at least in one direction, by selecting a healthy donor. The danger signs during transfusion are cough, dyspnea, cyanosis, car- diac oppression, syncope, marked slowing or great rapidity of the pulse, and violent pains throughout the body, especially in the lumbar region. If any of these symptoms of incompatibility appear the transfusion should be stopped and a new donor obtained. After transfusion from 15 to 20 per cent, of the patients have a chill, fol- lowed by fever, urticaria, erythema, or a similar eruption. Intravenous infusion of salt solution, the preparation of which is given under "Technic," finds its chief indication after severe hemor- rhages, but is used also in shock, in toxemic conditions, after vene- section, in order to "wash the blood," and as a diuretic when little or no urine is being secreted. The infusion apparatus consists of a graduated reservoir connected with a blunt beveled cannula by 255 MANUAL OF SURGERY means of a rubber tube. In an emergency a fountain syringe, or an ordinary funnel, and an aspirating needle may be employed. The entire apparatus should be sterilized by boiling, or if sterilized by chemical means, all traces of the antiseptic should be removed by flushing with normal salt solution before use. The fluid may be injected into any vein of sufficient calibre, but the median basilic or the internal saphenous is usually the most convenient. A bandage is tied around the limb in order to make the veins prominent, and the vein exposed by an incision and two Hgatures of catgut passed beneath it. One ligature is pulled into the lower angle of the wound and tied. The vein is then opened by a transverse incision, and the cannula inserted after some of the solution has been allowed to flow through it in order to exclude air. The upper hgature should be tied about the cannula by the first half of a surgeon's knot, so that at the completion of the operation it may be tightened and secured by a second turn after the cannula has been withdrawn. The temperature of the fluid should be iio° F. in the reservoir, as it loses some heat before entering the vein. The amount injected will usually be one pint. If the cannula is in the vein, and the bandage around the hmb has been removed, the fluid flows readily with the reservoir elevated several feet and no pumping apparatus is necessary. At the comple- tion of the operation, the wound is sutured and a sterile dressing applied. Intravenous infusion may be accomplished also by plunging a fine hollow needle through the skin, directly into a vein that has been made prominent by compression. Kuettner suggests introduc- ing oxygen with the salt solution. "A reservoir is filled with looo c.c. of salt solution, and oxygen allowed to flow in from a tank until loo c.c. of the solution is displaced. The reservoir is then closed and shaken until the oxygen is absorbed by the solution." The dangers of intra- venous infusion, excluding air embolism and infection, which can be prevented by proper technic, are hemolysis if the solution is hypoto- nic, salt poisoning if the solution is hypertonic (vide infra), poisoning from the products of dead organisms if stale water is used to make the solution, acute dilatation of the heart and edema of the lungs and brain if too much solution is introduced, and recurrence of bleeding if all wounded vessels have not been secured. The chill which sometimes follows intravenous infusion is apparently harmless. Hypodermoclysis, or the subcutaneous injection of salt solution, and enteroclysis, in which water is introduced into the rectum, may be used to substitute or supplement infusion when time is not an element of great importance. Hypodermoclysis is performed with the same precautions as intravenous infusion, by introducing an aspira- VASCULAR SYSTEM 289 tor needle into the loose connective tissue of the buttock, back, ab(lt)nien, or axilla. 'I'he needle is connected with a reservoir by means of a rubber tube, and the reservoir held several feet above the point of insertion of the needle, so that the lluifl is slowly forced into the tissues, forming a swelling which gradually subsides as the fluid is absorbed. If more than a pint is injected, the needle should be introduced in another situation; or, in order to save time, two needles, each connected with one limb of a Y-shaped tube may be employed. Occasionally suppuration or sloughing follows, particu- larly in septic cases. Enteroclysis must never be performed quickly, otherwise the fluid will be rejected. Eight fluid ounces of water may be given every three or four hours, in a slow trickle, so that from 20 to 30 minutes will be consumed during the injection; or the con- tinuous method may be adopted, as described in the section on the "Treatment of Peritonitis." We prefer the intermittent plan, as it is less disgreeable to the patient, and never use salt solution. Salt solution when introduced in enormous quantities is not entirely free from danger. As much as 48 pints, which contains six ounces of salt, has been given in one day, and this is too much, especially in view of the case recently reported by Brooks, in which, after a simple appendectomy, death followed the injection of an enema containing 9 ounces of salt, a strong stock solution having been carelessly substituted by a nurse for the physiologic solution. A somewhat similar case is reported by Campbell: A mother ignorantly gave her child an enema containing a pound of salt, this was followed promptly by thirst, fever, purging, convulsions, and death. Contusions of veins may result in Assuring of the intima and thrombophlebitis, particularly if the vein is diseased, as in varix. The symptoms and treatment of thrombosis from injury are those of phlebitis. Sloughing of the vein and secondary hemorrhage are most frequent after infected gunshot wounds. Wounds of veins are classified like wounds of arteries. The symptoms and treatment are given in the section on "Hemorrhage." The dangers are severe or fatal primary hemorrhage, air embolism, clot embolism (which if septic will lead to pyemia), phlebitis, edema, gangrene, and secondary hemorrhage. Free venous transplantation (usually the internal saphenous or the external jugular) has been employed 13 times to replace a seg- ment of an artery (popliteal, femoral, external iliac, axillary, brachial) removed for aneurysm or tumor, with eight successful results, and once with success to reestablish the continuity of a vein (Moure). Segments of a vein have been used also to drain the lateral ventricle 19 290 MANUAL OF SURGERY in hydrocephalus, and the peritoneal cavity in ascities, to act as a conduit between the ends of a severed nerve, to prevent adhesions after neurorrhaphy and tenorrhaphy, to reinforce the suture line after urethrorrhaphy. Attempts to restore the urethra, the ureter, and the common bile duct by a free venous graft have failed, although the urethra and Steno's duct (q.v.) have been repaired by a pedun- culated venous graft. I THE ARTERIES Arteritis, or inflammation of an artery, may be acute or chronic. Anatomically, it may be divided into periarteritis, mesarteritis, and endarteritis, but as all three coats are usually more or less affected at the same time, this classification is of little value. Acute arteritis may be suppurative (necrotic) or productive (plastic). Acute suppurative arteritis results from suppurative lesions in the neighboring tissues, or from an infected embolus. In the smaller vessels the process usually leads to thrombosis, in the larger arteries the walls may give way and serious hemorrhage result. Secondary hemorrhage is practically always due to this cause. An acute infectious endarteritis resembling malignant endocarditis, with which it is usually associated, has been described. Acute productive, or plastic arteritis, occurs as the result of injury or the lodgment of an embolus, in the absence of infection. It is nature's method of closing vessels after ligation, torsion, and wounds. The vasa vasorum dilate, exudation occurs, the intima prohferates, and the clot becomes organized, the new connective tissue obliterating the lumen of the vessel (see "Arrest of Hemorrhage")- Acute arteritis, manifested by pain, tenderness, and occasionally redness and swelling along the course of an artery, particularly of the lower limb, may occur during the course of, or just subsequent to, the infectious fevers. In these cases thrombosis and gangrene may develop. The treatment of acute arteritis occurring in the course of infectious fevers is that of phlebitis. The treatment of threatened gangrene from arteriothrombosis has already been discussed. Acute suppurative arteritis is seldom suspected until the occurence of secondary hemorrhage. Chronic arteritis {arteriosclerosis, chronic endarteritis, atheroma) is a chronic inflammatory and degenerative process of the arterial walls. The disease may involve the capillaries as well as the arteries (arteriocapillary fibrosis) and may invade even the veins {angio sclera sis). VASCULAR SYTSEM 29I The causes of arteriosclerosis are old age, and chronic intoxica- tions, amonj^^ which may be mentioned syphilis, gout, alcoholism, lead poisoning, nephritis, rheumatism, and diabetes. The increased blood pressure incident to habitual overeating and muscular overwork is said to be of etiologic importance and the disease is sometimes found after acute infections, such as scarlet fever, typhoid fever, and influenza. Arteriosclerosis may be circumscribed or diffuse. In the former, commonly seen in the large vessels, particularly the aorta, the deeper layers of the intima prohferate and give rise to more or less nodular patches, which may become fibrous, calcified {atheromatous plate) , or fatty; in the last event a cheesy mass may be formed {atheromatous abscess), which on discharging leaves a necrotic patch {atheromatous ulcer). The middle coat of the artery is invaded by the disease and the outer coat is thickened. Diffuse arteriosclerosis more com- monly attacks the small vessels. The entire arterial wall becomes thickened, and the internal coat undergoes fatty degeneration {athe- roma) and may subsequently become calcified. Arteriosclerosis is recognized by increased arterial tension, hyper- trophy of the heart, accentuation of the aortic second sound, and by feeling the superficial arteries, which are found to be thickened, rigid, or even calcified. Calcareous arteries can be demonstrated by the X-ray. Although the treatment belongs to the physician, the surgical relations of arteriosclerosis should not be overlooked. Chronic arteritis results (i) in dilatation or rupture when the degenerative changes in the musculoelastic median coat predominate; (2) in narrowing or obliteration when the proliferation of the subendothelial layer is in excess {endarteritis obliterans); or (3) simply in loss of elasticity, without alteration of the lumen, when these changes are equalized. I. Aneurysm is most frequently due to syphilitic arteritis. Syphilitic arteritis attacks a series of vessels, a single vessel, or a segment of a vessel, and is sometimes bilateral; the middle coat is most afTected, being invaded with round cells, and its fibers degen- erated, atrophied, or fragmented; rupture may follow, as in apo- plexy, or, if only the middle coat gives way, a scar results, which may subsequently yield and form an aneurysm; the latter applies par- ticularly to large arteries; the tendency in small vessels is towards obliteration. The possibility of arterial rupture should be kept in mind when attempts are made to reduce an old dislocation or to straighten a contracted joint, in an individual with atheroma. 292 MANUAL OF SURGERY 2. Narrowing of the arteries may be responsible for many nutri- tional disturbances, among which may be mentioned, as of surgical interest, neuralgia, pancreatitis, gastric and intestinal ulceration, arteriosclerotic coHc, intermittent claudication, and gangrene. Arteriosclerotic colic may simulate gallstones, appendicitis, and other abdominal affections. In advanced arteriosclerosis wounds are often slow in healing, and in these cases only urgent operations should be performed. Even a trivial operation on the toe may inaugurate gangrene, and after enterorrhaphy necrosis of the margins of the incision and fecal fistula are of frequent occurrence. Primary hemorrhage from a narrowed artery is comparatively slight, but, owing to the danger of cutting through of the ligature, secondary hemorrhage is relatively frequent. Diseased arteries are predis- posed to thrombosis from injury, hence the danger of the Esmarch band, of Bier's treatment, and of tight bandages in those with arteriosclerosis. 3. Loss of elasticity in collateral arteries accounts for many of the bad results after ligation, thrombosis, and the impaction of an embolus. Diseased arteries may supply a part with adequate nourishment when it is at rest but fail to dilate in response to in- creased activity, thus lack of elasticity in the cerebral vessels may cause transient paralysis, in the cardiac vessels angina pectoris, in the abdominal vessels arteriosclerotic colic, and in the arteries of the leg intermittent claudication. The last manifests itself as attacks of pain and weakness, especially in the calf, and is a prodro- mal symptom of gangrene. Injuries of arteries may be contusions or wounds. Contusion of an artery varies in its results according to the violence of the injury and the state of the arterial walls. Normal arteries, owing to their elasticity, are not often seriously affected by a contusion unless it be of the severest grade.- In atheromatous arteries a slight contusion may be followed by rupture of the inner coats and thrombosis, the detachment of an atheromatous plate, sloughing and hemorrhage, or aneurysm; if the artery be the main vessel of an extremity gangrene may ensue. The treatment of a contused artery consists in absolute rest, and preparations for the immediate control of hemorrhage should it occur. In the event of thrombosis prophylactic measures against gangrene should be taken. The treatment of thrombotic gangrene is given in chap. ix. Traumatic arterial stupor (Viannary) is a locahzed contraction of an artery due to trauma, resulting in temporary impairment or suppression of the circulation. No surgical treatment is required. VASCULAR SYSTEM 2Q,^ The condition has been observed during exi)h)ralory operations after severe injuries. Wounds of arteries may be incised, punctured, gunshot, or huerated. RujUures of arteries also come under this heading. An incised wound is followed by profuse hemorrhage, which is more severe in transverse than in longitudinal and oblique wounds. Punctured wounds produced by very fine instruments, such as an intestinal needle, cause but little hemorrhage, which is easily and permanently controlled by pressure applied for a short time. If the opening is of larger size the bleeding is copious and may exsanguinate the patient, or if the wound in the skin is closed by suture, clot, or dressing, a diffuse traumatic aneurysm may develop. Gunshot injuries are usually contusions or lacerations, although the modern bullet may produce a clean-cut wound and an alarming or fatal hemorrhage. A lacerated wound involving the entire circumference of an artery is usually followed by slight hemorrhage, owing to the curling up of the internal coat, the contraction of the middle coat, and the prolapse of the stretched external coat over the end of the artery. Secondary hemorrhage, however, is Hkely to occur unless the vessel is permanently secured by a ligature. Partial lacerations do not permit retraction and contraction, hence spontaneous hemos- tasis is uncommon. Rupture may follow severe injuries or strains, particularly in the presence of atheroma, and the surgeon should always have this injury in mind when reducing an old dislocation, when forcibly straightening a contracted joint, or when giving ether to an aged individual. Partial rupture, i.e., of the middle and inner coats, may be regarded as a contusion. Complete rupture results in a lacerated wound. Unless the blood escapes through an external wound or into one of the large cavities of the body, a difuse trau- matic aneurysm (false traumatic aneurysm, arterial hematoma) devel- ops, the symptoms of which differ somewhat from those of a true aneurysm, owing to the fact that the effused blood forms a soft clot which is constantly enlarged by the leaking artery. There is sudden and acute pain, followed by rapid sweUing and, after a time, by ecchymosis of the skin. The size of the swelling is enormous when, as in the axilla, the tissues are lax, and small when growth is restrained by dense fascia, e.g., in the palm and at the bend of the elbow. It is tense, seldom fluctuates, cannot be reduced by pres- sure, and owing to the absence of a distinct wall is more irregular and not as sharply defined as a true aneurysm. Pulsation is usually present, thrill and bruit often absent, but these signs depend upon the size of the opening in the artery. Even when the wound does not 294 MANUAL OF SURGERY involve the entire circumference of the artery, the pulse below may be absent as the result of pressure from the effused blood, and this leads to coldness, numbness, pallor, and partial paralysis of the limb. The constitutional symptoms, which are those of hemorrhage, vary with the amount of blood extravasated. The swelling may rupture, resulting in immediate death; suppurate with the same result; persist as an aneurysm; cause gangrene by pressure on the vessels of the limb; or the blood may coagulate, the opening in the vessel heal, and the clot be absorbed or organized. Dry wounds of arteries (Fiolle) attracted notice during the war. Clinically there is no bleeding, external or internal, and no hema- toma, but later secondary hemorrhage or an aneurysm may develop. Arterial wounds without bleeding are due to laceration (vide supra) ; associated contusion, extending some distance along the vessel and producing thrombosis; obturation of the opening in the artery by the projectile, a piece of clothing, a fragment of leather, or other foreign body; or to a concomitant wound of a vein and an artery, the blood passing from the artery into the vein (arteriovenous aneurysm), not only because this route presents the least resistance, but also because of the venous aspiration. The treatment of wounds of arteries is that of hemorrhage; ruptures are dealt with in the same way as open wounds, after making an incision to expose the source of bleeding. Arterial varix corresponds to a varicose vein, a single artery is dilated, elongated, thickened, and tortuous. When a number of adjacent arteries are similarly affected, the condition is called cirsoid aneurysm. Cirsoid aneurysm {plexiform angioma, racemose aneurysm, aneurysm by anastomosis) is most frequently found in the scalp, and less commonly in the extremities, labia pudendi, and spermatic cord. Some cases develop from a preexisting angioma, some after trauma, and some spontaneously. It can be mistaken for no other condition, as the pulsating varicose arteries are readily seen and felt. Thrill and bruit are often present, and pressure on the main feeding artery materially reduces the size of the mass and the force of the pulsation. The skin is usually thinned and sometimes ulcerates, giving rise to alarming hemorrhage. Excision is the best treatment, but is often impracticable. Among other methods which have been tried are ligation or compression of the main artery or arteries of supply, galvano-cauterization, electrolysis, the X-rays, and the injection of coagulating fluids. When affecting the hand amputation may be required. Aneurysm is a hollow tumor containing blood and communicating VASCULAR SYSTEM 295 with the lumen of an artery. Excluding the cirsoid variety, which has just been described and which is really a form of arterial varix, aneurysms are divided primarily into the simple, or arterial, and the arteriovenous. When referring to the former, however, it is cus- tomary to employ the term aneurysm without a qualifying adjective. The parts of an aneurysm are, (i) the sac wall, (2) the contents, and (3) the mouth, i. The sac wall is composed of one or more of the arterial coats {true aneurysm) or of condensed perivascular tissues {false aneurysm). As a matter of fact, the walls of any aneurysm of large size consist, not of the walls of the vessel, but of fibrous tissue, and even a false aneurysm which has existed for any length of time may be lined by a structure identical with the intima. Fig. 113. — Thoracic aneurysm showing laminated clot. 2. The contents vary according to the size, character, and duration of the aneurysm. At first the contents are only fluid blood. As the aneurysm enlarges, however, and becomes more and more saccu- lated, particularly if the mouth remains small or is so located as to protect the walls from the full force of the circulation, the blood is thrown into eddies, and this leads to the separation of fibrin, which is deposited on the interior of the sac in concentric layers (Fig. 113), the outer and older layers being dry and light in color, the inner and younger soft and red. Spontaneous cure may be effected in this way. 3. The month of the sac is the portal through which the blood enters the aneurysm; upon its size and situation depends to a large extent the rapidity with which the aneurysm enlarges. According to whether the whole or only portion of the circum- 296 MANUAL OF SURGERY ference of an artery is involved an aneurysm is said to be fusiform (tubulated) or sacculated. Fusiform, or tubulated aneurysm, is a dilatation and elongation of a section of an artery. It is most frequent in the cranium, the thorax, and the abdomen, and is always spontaneous in origin. Although the walls are seldom coated with layers of fibrin, rupture is unusual, death generally being due to pressure upon the surrounding organs. Sacculated aneurysm springs from the side of an artery, rarely from the side of a fusiform aneurysm. There are two forms, the circumscribed, in which the sac wall is distinct and complete, and the diffuse, in which the blood has extravasated into the surrounding tissues. The latter is said to be primitive when due to rupture of an artery (vide supra), consecutive when due to rupture of an aneurysm {vide infra) . According to etiology aneurysms are divided into the traumatic and the spontaneous. Traumatic aneurysm may be true or false, but is always saccu- lated. True traumatic aneurysm may result from an arterial contu- sion which causes the inner coats to rupture, or from a wound of the outer coats, leading to a hernia of the intima {hernial aneurysm) . False traumatic aneurysm follows a penetrating wound or a complete rupture of an artery (see "Wounds of Arteries")- Spontaneous, or idiopathic aneurysms, may be congenital or acquired. Congenital aneurysms are rare, and due to defective development of the elastic elements of the arteries, hence often multiple. Acquired spontaneous aneurysms, although occasionally due to infective softening of the vessel walls from the impaction of an embolus {embolic aneurysm) , to ulceration of the outer coats {aneu- rysm by erosion), or of all the coats (e.g., when an artery perforates into an abscess), are almost always the result of chronic arteritis combined with an increase in the blood pressure. As has already been pointed out, chronic arteritis, particularly the syphilitic va- riety, causes marked degenerative changes in the musculo-elastic tunica media, and this, especially in the early stages, before compen- satory thickening of the intima occurs, leads to aneurysmal dilata- tion. In dissecting aneurysm, which is a rare form confined almost exclusively to the aorta, the blood makes its way through an athero- matous ulcer and dissects the outer from the inner half of the middle coat, forming a sort of sac, which may again open into the artery through another atheromatous ulcer, or rupture into the perivascular tissues. Increase in the blood pressure, the result of hypertrophy of VASCULAR SYSTEM 297 the heart, strains, hi})orious oecu])ati()ns, and violent exercise, is an important factor when combined with disease of the arteries, hence the predisposition of the male sex (7 to i), and of the fourth and fifth decades, during which arteriosclerosis frequently begins, but during which the bodily condition is such as to lead to overexertion. The symptoms of aneurysm are, (i) those peculiar to the aneu- rysm itself and (2) those due to pressure, i. The syniploms peculiar to the aneurysm itself are, the presence of a sweUing in the line of an artery; movability of the tumor, in the absence of adhesions, trans- versely to but not in the axis of the artery; reducibility on direct pressure and fluctuation, but only in the early stages when the walls are thin and the contents are fluid; pulsation synchronous with each cardiac systole and expansile in character, i.e.. in all direc- tions, so that the palpating fingers are not only lifted but separated; cessation of pulsa- tion, with shrinkage and soften- ing of the tumor, when proxi- mal pressure is made on the artery, distal pressure acting in a reverse manner; the pre- sence over the sac and along the artery of a systolic bruit, which is usually loud and harsh; occasionally a thrill corresponding with the bruit; and retardation of the pulse below, due, not to pressure, but to the additional time con- sumed by the blood current in passing through the aneurysm, hence almost a pathognomonic sign. 2. The pressure symptoms are similar to those of other tumors. Pressure on the artery causes diminution in the size of the pulse distal to the tumor, hence enlargement of the collateral arteries; on the veins edema and distention of their super- ficial branches; on the nerves pain and possibly paralysis and trophic disorders; on the muscles displacement and atrophy; on the bones erosion, severe, constant, boring pains, and occasionally spontaneous fracture; on the trachea dyspnea; on the esophagus dysphagia; on the recurrent laryngeal nerve change in the voice and brassy cough; on the cervical sympathetic nerve dilatation of the pupil and widening of the palpebral fissure, and later contraction of the pupil and ptosis Pig. 114. — Aneurysm oi the innominate artery treated by wiring and electrolysis. Note ptosis from pressure on the cervical sympathetic nerve. 298 MANUAL OF SURGERY (Fig. 114); on the thoracic duct inanition; on the phrenic nerve hiccough. The duration of aneurysm is usually a matter of some years, spontaneous recovery or death being the natural termination. Spontaneous recovery is rare. It may be due to obliteration of the sac with laminated fibrin; to suppression of the circulation within the sac, the result of the impaction of an embolus above or below the mouth, or the pressure of the aneurysm itself on the artery; or to inflammation of the sac. The aneurysm becomes solid, and is ultimately represented by a mass of fibrous tissue. Death is the result of rupture of the sac, pressure upon important structures, cerebral embolism, or sepsis from suppuration of the sac or gangrene of the parts nourished by the artery. Rupture of an aneurysm is the result of stretching and thinning of the wall from intrasaccular tension, or of ulceration, suppuration, or gangrene of the sac. Rupture through the skin may be immediately fatal, or death may be deferred several days, the blood leaking from a small opening {leaking aneurysm) , which is at times temporarily plugged by a clot. Rupture internally, into one of the cavities or hollow organs, causes sudden pain, symptoms of acute anemia, and death. If the aneurysm breaks into the esophagus or trachea blood will pour from the mouth. Rupture into the subcutaneous tissues is an- nounced by severe pain, increase in the size of the swelling, indis- tinctness of its outline, diminution or disappearance of pulsation and bruit owing to coagulation of the blood, and cessation of the pulse below the swelling. Death from acute anemia follows, or if the surrounding tissues restrain the blood, a consecutive false aneurysm develops. Inflammation of the sac, when mild in character, thickens the walls and encourages coagulation of the blood. In the severer form there is redness of the skin, pain, elevation of the local temperature, and edema,, the last causing the aneurysm to become less distinct in outline. Suppuration or gangrene of the sac may follow. Gangrene of the parts distal to the aneurysm may be caused by obliteration of the artery from the pressure of the aneurysm, from the pressure of extravasated blood when rupture occurs, from the impaction of an embolus derived from the aneurysm, or from throm- bosis the result of inflammation. The diagnosis of aneurysm may be difficult or even impossible, since pulsation and bruit may be absent in an aneurysm, and present in other tumors. Any swelling, whether pulsating or not, in the line of an artery must be carefully investigated for evidences of VASCULAR SYSTEM 299 aneurysm. Perhaps the most frequent mistake is to take a non- pulsating inflamed aneurysm at the base of the neck for an abscess. A cyst, tumor, or abscess lying upon an artery may be lifted with each pulse beat, and cause a murmur by narrowing the artery, but the pulsation is not expansile, and it, with the murmur, ceases if the tumor can be lifted, or by posture made to fall away from the vessel (Figs. 115, 116). Compression of the artery above or below the tumor does not, as in aneurysm, affect the size and the consist- ency of the swelling, and after removing the proximal compression the first pulsation is of full strength, while in aneurysm it may take several pulse waves to distend the sac and make the pulsation as strong as it was before. Any tumor which presses on an artery may make the distal pulse smaller, but retardation is caused only by aneurysm, a sign which becomes more evident after temporarily compressing the artery above the swelling; in a non-aneurysmal tumor the pulse reappears at once, in an aneurysm several beats t5 Pig. 115. — Transmitted pul- Pig. 116. — Expansile pul- sation. Tumor over artery sation. Aneurysm spring- (A). Arrow indicates direc- ing from artery (A), from tion of the pulsation. which it cannot be separated. Arrows indicate direction of the pulsation. may be lost. The exploratory needle may sometimes be employed to determine the contents of the swelhng. The X-ray shows a distinct shadow in aneurysm, the pulsation of which can be observed with the fluoroscope. Radiography is of particular value for the diagnosis of aneurysms in the cranium, the chest, and the abdomen. Angiomata and round-celled sarcomata may have expansile pulsa- tion and bruit, but may not correspond to the line of an artery or affect the pulse below. Pressure on the artery proximal to the growth may cause it to shrink, but not so markedly as in aneurysm, and it may be more irregular, less distinct in outline, and more variable in consistency; a ruptured or an inflamed aneurysm also may be indistinct in outhne. In sarcoma the superficial veins are dilated over and proximal to the growth, in an aneurysm causing pressure on the deep veins the superficial collaterals are most numerous distal to the swelling, and the limb is edematous. The X-ray usually fails to demonstrate round-celled sarcoma, unless it has invaded osse- ous tissue. A cervical rib or a neoplasm under an artery may simu- 300 MANUAL OF SURGERY late an aneurysm, but only the artery, and not the growth which displaces it, pulsates. A cervical rib and certain forms of neoplasm may be shown by the X-ray. Aneurysmal pain has been mistaken for rheumatism, neuralgia, lumbago, etc. The treatment of aneurysm may be medical or surgical. Medical treatment aims to decrease the blood pressure and in- crease the coagulabihty of the blood. It is used as an auxiliary to surgical treatment, or when surgical treatment cannot be apphed. TiifnelVs method consists in absolute rest in bed for at least three months, and a daily diet of six ounces of bread, a little butter, three ounces of meat, and eight ounces of milk. Among the drugs recom- mended are iodid of potassium, especially in syphilitic cases, iron, acetate of lead, ergotin, aconite, veratrum viride, and calcium chlorid. Opium or the bromids are used for pain, purgatives to thicken the blood and prevent straining from constipation. Venesection has been employed when the blood pressure is very high. Eggs have been recommended to increase the coagulability of the blood. Lan- cereaux reports good results from the hypodermatic injection of a I or 2 per cent, solution of gelatin in normal salt solution; about 200 cc. are injected beneath the skin of the thigh every ten days, until from ten to thirty injections have been given. As twenty-three deaths from tenanus have followed this method of treatment (Dieulafoy), the gelatin should be thoroughly sterilized, or, better, since its coagulative effects are not destroyed by digestion, adminis- tered by mouth. Gelatin is said to be irritating to the kidneys, hence is contraindicated in the presence of renal disease. Many surgeons doubt the efficacy of this treatment. The surgical treatment consists of (i) compression of the artery or the aneurysm; (2) the temporary or permanent introduction of foreign bodies; or (3) operative treatment. I. Compression of the sac itself by bandages, or by flexion of the limb, e.g., in aneurysms at the bend of the elbow or knee, and mas- sage of the sac, with the idea of occluding the artery with a fragment of the clot, are ancient methods which are apt to be followed by rupture or suppuration of the sac, or gangrene of the hmb. Reid's method of rapid cure by compression aims to retain the blood in the sac until it coagulates. The patient is anesthetized, and an elastic bandage applied from the extremity to the root of the hmb, exclud- ing the aneurysm, which should be full of blood. A tourniquet is then apphed above the band, and allowed to remain for an hour and a half, after which it is gradually loosened, so as to prevent a sudden gush of blood, which might wash away the clot. This method VASCULAR SYSTEM 301 is occasionally successful, hut is often followed by gangrene. Pressure on the artery feeding the aneurysm may be made by the thumb (digital pressure), a method which requires relays of assistants, or by means of tourniquets or compressors (instrumental compression) , the pressure being continuous or intermittent. The skin should be protected with a piece of chamois and by shifting the point of pres- sure, and the main vein and nerves avoided. Although some assert that it is not essential to obliterate the pulse, complete suppression of the circulation through the sac, gives the best results. In the intermittent method pressure is made for a number of hours each day, but the patient allowed to sleep at night. In the continuous method pressure is sometimes maintained for two or three days, but if coagulation, which reveals itself by absence of pulsation and hardening of the aneurysm, does not occur within thirty-six hours the method should be abandoned. As the pressure is agonizing to the patient narcotics are required. Pressure upon the artery distal to the aneurysm may be employed as an aid to proximal pressure, or in cases, such as aneurysm of the root of the carotid, in which proxi- mal pressure cannot be applied. Intermittent pressure is useful in dilating the collaterals before the apphcation of a ligature, thus preventing gangrene. The treatment of aneurysm by proximal pressure is successful in about 50 per cent, of the cases and is attended by little danger, but is tedious, extremely painful, and is rapidly being displaced by the operative methods. 2. The introduction of foreign bodies into the sac should be per- formed only in inoperable cases. Acupuncture consists in the intro- duction of fine needles in such a way that they will cross one another and whip the fibrin from the blood; they are withdrawn after several days. Macewen's method consists in the introduction of a long needle, with which the whole lining membrane of the sac is scratched, the idea being to excite a mild inflammation which will cause the walls to thicken and the blood to coagulate. Moore^s method consists in the introduction of a number of yards of coiled steel wire through a cannula; the wire assumes a spiral shape in the sac, and is allowed to remain permanently. Silk, horse-hair, catgut, and other materials have been used in a similar way. Electrolysis may be employed by introducing two needles which are insulated where they come in contact with the tissues. The points of the needles are slightly separated, and a constant current of from 5 to 6 milliamperes passed through the sac for from one-half to two hours. A combination of the last two methods (Moore-Corradi method) has proven of some value in sacculated aneurysms of the aorta. The author has ob- 302 MANUAL OF SURGERY tained marked and lasting improvement in one case,- and one case has been reported in which cure apparently occurred. From five to fifteen feet of drawn gold wire, according to the size of the sac, is introduced through a gold cannula insulated with porcelain, and connected with the positive pole of a galvanic battery, the negative pole being apphed to the abdomen or back. The current is gradu- ally increased, often to 80 milliamperes, and as gradually decreased to zero, from forty-five minutes to one and one-half hours being consumed in the process; the cannula is then withdrawn, and the wire cut off close to the skin, beneath which it is buried. The method is not without danger. Coagulating injections, such as Monsel's solution, acetate of lead, and tannin, have been employed while pressure is made upon the artery on both sides of the aneurysm. The method is not recommended in aneurysms of the extremities, which are better treated by operative measures, and in other cases it may be followed by very serious results owing to the dislodgment of emboli. ffl 3. Operative treatment includes liga- Ji 'Hu\Ttn ^ion, incision, endoaneurysmorrhaphy, ex- .---'/^^Hi '^'^^'^ tirpation, arterial anastomosis, venous '^^"^l^.-.-BRAsoop transplantation and amputation. jm!^....mf}DRop Ligation may be performed in one of ■~^ ^ five ways (Fig. i^i 7) . AneVs method is liga- FiG. 117.— Methods of ligation ^^^^ immediately above the sac. Hunter's for aneurysm. -^ operation is ligation above but some dis- tance away from the sac, so that anastomotic branches exist between the ligature and the aneurysm; thus the blood supply to the sac is not completely cut off, but is greatly diminished, allowing contrac- tion and gradual consolidation. Although most surgeons prefer the Hunter to the Anel operation, we believe the former increases the danger of recurrence if the anastomotic branches between the liga- ture and the aneurysm remain pervious, and the danger of gangrene of the limb if these branches suffer obliteration. The objection that the artery is more diseased near the aneurysm is not a valid one, as the degenerative changes are often more marked in the seg- ment which would be ligated in the high operation. Proximal liga- tion is contraindicated when serious disease of the heart or a coexist- ing internal aneurysm is present, because of the sudden rise of blood pressure that follows ligation of a large artery; when compression of the feeding artery does not materially diminish the pulsation; when the arteries are extensively diseased; when inflammation is present; when gangrene of the limb is threatened; and when the bone is VASCULAR SYSTEM 303 deeply eroded. The accidents which may follow are secondary hemorrhage, suppuration and rupture of the sac, gangrene of the limb, and secondary aneurysm at the point of ligation. Return of pulsation in the sac is observed in the majority of cases after a day or two, owing to the establishment of a collateral circulation; in favorable cases as the sac contracts this diminishes and finally dis- appears. Pulsation beginning a number of days after operation generally means recurrence of the aneurysm. Pesquhi's method, or ligation above and below the sac, is indicated only in cases which are better treated by extirpation. Brasdor's operation, or ligation of the artery distal to the sac, is employed only in cases in which a proximal ligature cannot be applied, e.g., aneurysm of the root of the carotid. Wardrop's operation is ligation of one of the branches of the artery distal to the ^ sac, e.g., ligation of the sub- • clavian in aneurysm of the ~y^\v \ \.r\^^-~SHIN innominate. ^^$i^O<^ V' xX^^^^^^ Incision of the sac ^^^^V^&^^^^P*^ (method of Antyllus) , after ^^^^^^^^^^ — ligating the artery immedi- ^^'ilml 2 ately above and below, is in- j,Mfl| i dicated in the presence of wiWi suppuration. The sac is ^^^^ cleared of its contents, F'G. h 8.— Diagram of obliterated sacculated , . , , aneurysm, parent artery preserved. (Matas.^ i. packed with gauze, and Sutures closing mouth of sac. 2. Lembert sutures allowed to granulate. reducing size of sac. 3. Through-and-through " sutures bringing roof and floor of sac m contact, Endoaneurysmorrhaphy and tied over roll of gauze. 4. Sutures holding f -ir , t J • \ -ii 1 skin and sac in contact with bottom of cavity. {Alatas operation) will prob- ably be the operation of the future in all cases in which the circulation through the sac can be provisionally controlled. The circulation is arrested by means of a tourniquet or, when this is impracticable, by exposure and compression of the main artery on each side of the aneurysm. The sac is then opened and emptied, and, according to the character of the aneurysm, an obliterative, restorative, or recon- structive operation performed. In the obliterative operation, which is indicated in a fusiform aneurysm, the orifices of the sac, and of any collateral arteries which may open into the aneurysm, are sutured with chromicized catgut, but the continuity of the artery is not restored. In the restorative operation, which is applicable only to a small mouthed saccular aneurysm, the mouth of the sac is sutured without imping- ing on the lumen of the vessel, thus curing the aneurysm without cutting off the circulation of the limb. In either case the walls of 304 MANUAL OF SURGERY the sac with the overlying skin are inverted and so sutured as to obhterate the sac (Fig. ii8). Matas suggests that in certain fusiform aneurysms it may be possible to reconstruct the arterial channel by suturing two folds of the sac over a rubber catheter, in a manner similar to the formation of the canal in the Witzel gastrostomy. The catheter is removed before the last sutures are tied. Even in cases in which the circulation through the main artery is stopped, gangrene is less likely to follow than after other methods of operation, because the collateral circulation is practically undisturbed. The state of the collateral circulation may be determined before any of the operations mentioned above by the Matas method (see "Indications for Amputation," chap. xxxi). Extirpation of the sac, after ligation of the artery above and below, is followed by permanent cure, but in a large aneurysm is a formidable operation which may seriously interfere with the collateral circulation and be followed by gangrene. It is the best operation for aneurysm of a small artery, e.g., the radial, and may be tried previous to amputation in cases which have recurred after other methods of treat- ment, or in cases in which the sac has ruptured or is inflamed and suppurating. End-to-end anastomosis of the artery, after excising the sac, is indicated in small traumatic aneurysms, but in the spontaneous variety is less apt to succeed, because of the diseased state of the artery. Of nine operations of this character eight were successful (Abalos). Venous transplantation has been performed in eleven cases in which, after excision of the sac, the interval between the ends of the artery was too great to permit end-to-end anastomosis. Six of the patients recovered. The internal saphenous or the external jugular is the best vein from which to take the transplant. Amputation of the limb is indicated in gangrene, in marked erosion or dissolution of a joint, in some cases of rupture, suppuration, or secondary hemorrhage, and in a rapidly growing aneurysm which has resisted other means .of treatment. Amputation of the arm has been performed to lessen the quantity of blood flowing through a subclavian aneurvsm. Fig. 119. — Arteriovenous aneurysms. On the left aneurysmal varix, on the right varicose aneurysm. Note that below the arteriovenous fistula, in each instance, the artery is contracted, the vein dilated and varicose. The arrows in- dicate the direction of the blood current. VASCULAJt SYSTEM 305 Arteriovenous aneurysm (^i•,^ 119) is the condition resulting from an abnormal communication between an artery and a vein. The traumatic variety usually follows a stab or gunshot wound; the spontaneous variety is rare and results from the rupture of an arterial aneurysm into a vein, the aorta and vena cava being the vessels most often affected. The artery may communicate directly with the vein {aneurysmal varix) or there may be an intervening sac {varicose aneurysm). The important symptoms are pulsation of the vein, which becomes varicose, and a characteristic thrill and bruit, the latter resembling the buzzing of a fly. Both thrill and bruit are continuous, but rein- forced at each cardiac systole, and transmitted along the vein, both centrally and peripherally. Proximal pressure on the artery, com- pression of the intermediary sac, or closure of the arterial opening by pressure on the vein, causes the swelling to shrink, and the thrill, bruit, and pulsation to cease; distal pressure intensifies these signs. Edema, cyanosis, and motor, sensory, and trophic disturbances are of common occurrence, while in arteriovenous aneurysm of the com- mon carotid and jugular, headache, vertigo, and other cerebral symptoms may appear. The condition may slowly advance, or remain stationary for years. Rupture is more frequent in varicose aneurysm than in aneurysmal varix. The diagnosis, even in the absenceof venous pulsation, is assured if the characteristic thrill and bruit are present. The bruit of an art- erial aneurysm is intermittent, and, although sometimes propagated along the artery, is never transmitted towards the heart. The venous hum, occasioned by pressure or anemia, which is at times heard at the root of the neck, although continuous and transmitted towards the heart, is intensified, not by cardiac systole, but by diastole or inspira- tion. In cirsoid aneurysm pulsation is uniform and confined to the arteries, thrill and bruit weak or absent; proximal compression of the main artery does not wholly suppress these signs, and the con- dition is most frequent on the scalp and hand, where arteriovenous aneurysm seldom occurs. The differential diagnosis between aneur- ysmal varix and varicose anuerysm is seldom possible without ex- ploratory incision, although a soft, oval, fluctuating, easily-reducible swelling points to the former, and a firm, irregular, immobile tumor which cannot be completely reduced, to the latter. The treatment of aneurysmal varix is the application of an elastic bandage. If this does not check the progress of the growth, if pain is severe or rupture threatened, operation is demanded. Varicose aneurysm should never be treated expectantly. The ideal operation 306 MANUAL OF SURGERY is separation of the vessels with suture of the openings, thus preserv- ing the circulation. We have successfully performed this operation in three instances (carotid, brachial, femoral). When suture of the vessels is inapplicable, extirpation, after tying both vessels above and below, is the best procedure. Proximal ligation of the artery, liga- tion of the artery above and below, or better, ligation of both vessels above and below may be indicated when, owing to dense adhesions or unfavorable situation, extirpation seems too formidable. HEMORRHAGE Hemorrhage is divided, (i) according to its cause, into spontane- ous and traumatic; (2) according to the vessels injured, into arterial, venous, and capillary; (3) according to the time following the injury, into primary, intermediary, and secondary; and (4) according to its location, into external and internal. I.- — S pontaneous hemorrhage, non-traumatic ,{?< the result (i) of ul- cerative, degenerative, or inflammatory diseases of the vessel walls ; (2) of increase in blood pressure, e.g., hypertrophy of the heart, straining, coughing, vomiting, and convulsions; (3) of alterations in the constitu- tion of the blood, e.g., certain forms of anemia, notably progressive pernicious anemia and leukemia, snake bite, phosphorous posioning, malaria, yellow fever, jaundice, scurvy, septicemia, and purpura hemorrhagica; and (4) of obscure nervous influences, e.g., hysteria, vicarious menstruation, and certain other nervous conditions. The cause of bleeding in hemophilia is not known. Traumatic hemorrhage is the result of wounds of vessels, or of contusions which weaken the vessel wall and are followed by rupture. 2.- — In arterial hemorrhage the blood is bright red, and is pumped from the vessel in spurts synchronous with the cardiac systole. It oxygenation of the blood is deficient from any cause, the blood may be dark in color, e.g., in deep narcosis and asphyxia. Pressure on the artery between the wound and the heart stops the bleeding, unless the collateral circulation is well developed ; pressure distal to the wound augments the bleeding only when the artery is incom- pletely severed. In venous hemorrhage the blood is dark in color and flows in a steady stream. Bleeding from the central end of a severed vein soon ceases, unless the valves are incompetent or absent, or unless a large branch opens into the vein between the wound and the next valve above. Pressure on the vein below the wound checks the bleeding; proximal pressure, if the wound is lateral, increases the bleeding. The opposite is true, however, when, as in certain varices, the circulation is reversed. The application of a tourniquet to the VASCULAR SYSTEM 307 limb above the wound makes the bleeding worse, unless the con- striction is tight enough to compress the arteries, when the bleeding will cease, after the perijiheral segment of the vein and its tributaries have emptied themselves. Capillary hemorrhage is characterized by a general oozing of blood. The term parenchymatous is sometimes applied to a free general oozing from all the vessels. 3. — Primary hemorrhage occurs at the time ot injury. Inter- mediary, reactionary , recurrent, or consecutive hemorrhage is the bleeding which recurs within twenty-tour hours of the cessation of primary hemorrhage. It is due to the cutting through (in friable, inflammatory, or neoplastic tissue, or in atheroma), slipping off, untying, or breaking of a ligature; to neglect of the distal end of a severed artery, which may start to bleed only after the collateral vessels have dilated; to dislodgment of a clot as the result of restless- ness (local or general) ; or to the washing of coagula from the ends of the vessels as the result of increased blood pressure coincident with reaction from shock. Secondary hemorrhage occurs after twenty- four hours. It may be due to the causes mentioned above, but is usually the result of infection, which opens the vessels by ulceration or sloughing, by breaking down the coagulum, or by disintegrating an absorbable ligature. Secondary hemorrhage of the septic type is often delayed for a week or longer, and usually manifests itself by repeated bleedings, which are at first slight, but grew progressively more copious. The patient must never be treated expectantly, even though the bleeding is slight or has ceased, becaused it is almost certain to begin again. 4. — In external hemorrhage the blood escapes from an external wound. In internal hemorrhage it accumulates in the tissues (extrav- asation, diffuse traumatic aneurysm), in one of the cavities of the body (hematocele), or in one of the hollow viscera. Various other names are applied to hemorrhage according to its location, such as epistaxis (nose bleed), hematemesis (vomiting of blood), metrorr- hagia (uterine hemorrhage between the menses), hemothorax (bleeding into the pelural cavity), etc. The constitutional symptoms of acute hemorrhage are rapid, feeble, easily obliterated, dicrotic pulse; subnormal temperature with cold, clammy skin; increased and frequently irregular respirations with dyspnea {air hunger) ; marked pallor of the skin and mucous mem- ranes; failing sight and dilatation of the pupils; ringing in the ears {tinnitus aurium); restlessness, and great anxiety; muscular twitch- ing or convulsions; thirst, and sometimes nausea, vomiting, or de- lirium; recurring attacks of vertigo or syncope; and finally, in fatal 3o8 MANUAL OF SURGERY cases, collapse and death. These symptoms vary in frequency and intensity according to the amount of blood lost and the rapidity with which such loss takes place. The most important symptoms are a rising pulse, a falling temperature, and increasing pallor. It should be noted, however, that the pulse may be slow in intracranial hem- orrhage, owing to cerebral compression; in intrapericardial hem- orrhage owing to pressure on the heart ; and in some cases of rupture of the liver, owing to bihary absoprtion; and that the temperature may be high in pontine hemorrhage. Pallor in the negro is detected by inspecting the conjunctivae and the mucous membrane of the lips. A sudden violent hemorrhage may cause death in a few seconds, small but repeated bleedings may not effect the same result for years. It is said that loss of half of the blood (the total amount of blood is an eighth of the body weight) usually causes death. The effects of hemorrhage, however, are much greater in infants, in the aged, and in the debilitated, and much less in the plethoric, and in women during parturtion after a severe hemorrhage. Reaction is attended by a slight rise in temperature {hemorrhagic fever) , the result of nervous influences or the absorption of fibrin ferment. There is sometimes a low form of dehrium, and as the result of the asthenia, the patient is predisposed to infective processes. Although, owing to the contrac- tion of the vessels and the absorption of fluids, the blood pressure is quickly restored, the number of red cells, the amount of hemoglobin, and the specific gravity and coagulation time of the blood are reduced, while the number of leukocytes is increased for a number of days, no doubt the result of the large quantity of lymph taken up by the circulation at this time. The most important symptoms of chrtniic hemorrhage, i.e., fre- quently repeated small bleedings, are pallor, rapid dicrotic pulse, dyspnea, hemic murmurs over the heart, edema of the face and feet, predisposition to syncope on slight exertion, and, as pointed out above, the blood changes of secondary anemia. Natural arrest of hemorrhage may ])e only temporary, or it many be permanent. Temporary hemostasis is effected in the following manner: A severed artery retracts within its sheath because of its elasticity; its orifice is diminished in size by contraction of the trans- verse muscular libers in the media, by a curling up of the intima, and by the pressure of the perivascular tissues, and as the result of the fall in blood pressure and the increased cogulability of the blood conse- quent upon hemorrhage, a clot {external coagulum) gradually forms in and around the sheath, until it is sufficiently firm to resist the diminishing force of the circulation. The bleeding is now checked, VASCl'LAK SYSTEM 309 and coagulation proceeds \\itbin the vessel {internal coagulum) until, in some cases, the first collateral branch is reached. This clot may be washed out with the increase in the force of the heart during the reaction from shock, hence over-stimulation should be avoided. After wounds of veins the process is much the same, although for the reasons pointed out under thrombosis, coagulation occurs more promptly. Capillary bleeding soon ceases as, owing to the minute size of the vessels, the smallest coagula readily fill their orifices. Permanent hemoslasis is the result of displacement of the internal clot by fibrous tissue, the changes being those already described under "Repair." For the fate of extravasated blood see section on "Contusions." Delayed Jiemostasis, in addition to the conditions mentioned under "Spontaneous Hemorrhage,'' may be due to a large wound in the tissues over the injured vessel, the tissues offering no obstacle to the free escape of blood; an incised wound, or incomplete division, of a vessel, the latter preventing contraction and retraction; gaping of a vessel because of rigidity of its walls, as in varix, or because of its attachment to environing structures, such as is normally the case with vessels in bones and in the scalp, with viens at the root of the neck, and with the cranial sinuses; infection of the vascular walls; increased blood pressure from plethora, inflammation, congestion, restlessness, cardiac stimulants, transfusion, or the introduction of salt solution into the circulatory apparatus; diminished coagulability of the blood the result of the ingestion of ammonia, acid fruit juices, or large quantities of water, inhalation of oxygen, restriction of food or lime salts, vegetarian diet, smoking tobacco, hyperthyroidism, leech bite, or the injection of hirudin (leech extract) ; or to motion of the part, which may prevent the formation of, or dislodge a clot. Accelerated hemostasis may be due to a long narrow wound in the perivascular tissues; a contused or lacerated wound of a vessel, which increases contraction and retraction; atheroma, owing to the small calibre of the vessel and the roughened intima; decreased blood pressure, particularly that due to shock or hemorrhage; increased coagulability of the blood the result of asphyxia, hypothyroidism, the puerperium; certain forms of anemia (distinctly that due to hemorrhage) ; the ingestion of large quantities of milk, small quanti- ties of w^ater, or the medicaments listed below in the paragraph on styptics; or to immobility of the injured part. The diagnosis of hemorrhage is attended with difficulty only when the bleeding is internal; it is then most Hkely to be mistaken for shock (q.v). 3IO MANUAL OF SURGERY The treatment of hemorrhage is constitutional and local. The constitutional treatment, which is that of shock (q.v.), should be instituted while measures are being taken to control the bleeding, and not before, because of the danger of increasing the loss of blood. The local treatment embraces (i) cold, (2) heat, (3) elevation, (4) styptics, (5) compression, (6) acupressure, (7) forcipressure, (8) torsion, (9) ligation, and (10) suture of the vessel. 1 . Cold in the form of ice, cold water, or evaporating lotions will hasten the arrest of hemorrhage from small vessels, but should not be used in open wounds, because of the danger of sepsis. Exposure of a wound to air facilitates coagulation partly as the result of the lowered temperature. The ice bag is frequently employed in internal hemorrhages not suitable for operation. 2. Heat in the form of hot water (120° to 150° F.) is sometimes useful as a hemostatic; it, like cold, stimulates the muscular fibers of the vessels to contract. Warm water relaxes these libers and encour- ages bleeding. The actual cautery should rarely be employed, as it causes sloughing, which interferes with the healing, and predisposes to secondary hemorrhage. When used, it should be at a dull red heat; if bright red it cuts like a knife and does not stop bleeding. Electrohemo stasis, in which the tissues to be divided during an opera- tion are crushed with special forceps and baked with an electric current, possesses no advantages over the ligature. 3. Elevation alone may stop hemorrhage from the larger veins; it is especially applicable in bleeding from the extremities. 4. Styptics, such as antipyrin, Monsel's solution (cotton contain- ing Monsel's salt is called styptic cotton), alcohol, turpentine, tannic or gaUic acid, silver nitrate, alum, sodium chlorid, vinegar, chlorid of zinc, and tincture of matico, are seldom applied to a wound by the sur- geon, as most of them produce a tough coagulum which interferes with healing. Adrenalin chlorid, however, contracts the vessels, and is fre- quently employed, particularly in bleeding from mucous membranes. It may be applied by a swab or as a spray in the strength of from i to 1,000 to I to 10,000. At least one case of poisoning has resulted from its use locally; when administered internally for a long time it is said to cause arteriosclerosis. Gelatin, 5 to 10 per cent., in normal salt solution {Carnot's solution), has been used locally as a hemostatic; reference has already been made to the importance of having it absolutely sterile and to its use internally. Among the other agents which increase the coagulability of the blood, or con- tract the vessels, when taken internally, are turpentine, oil of erigeron, stypticin, cephalin, magensium carbonate, opium, dilute sulphuric VASCULAR SYSTEM 311 acid, acetate of lead, ergot, hamamelis, pituitrin, and chlorid of cal- cium. Chlorid of calcium, gr. x, t.i.d., is frequently employed to increase the coagulability of the blood previous to operation incases of chronic jaundice. The injection of alien blood serum or transfusion of blood is of particular value in hemophilia (q.v.). Kocher and Fonio suggest coagulin as a hemostatic agent. It is a grayish powder made from the blood platelets of animals, and can be dusted on wounds, or used in a solution; in the latter instance the fluid may be boiled for one or two minutes for the purpose of sterihzation, and can be injected intravenously. Radiotherapy and electrolysis are sometimes employed to check uterine bleeding. (5) Compression may be direct or indirect, i.e., upon the ends of the divided vessel, or upon the vessel some distance from the wound. Direct compression may be made with the fingers, or with tamp- ons, compresses, or pads. The ultimate principle of all hemostatic agents is, of course, pressure in some form. Direct digital compression will control the most violent hemorrhage from any part of the circulatory apparatus, and is to be employed in an emergency until more permanent hemostasis can be secured. Capillary hemorrhage, or a general oozing from small arterioles and venules, is quickly checked by the pressure of aseptic gauze which has been steeped in hot water. Firm gauze packing will control any venous and many forms of arterial bleeding. The graduated compress, which is made of layers of gauze successively increasing in size from below upwards, so as to form an inverted pyramid or cone, was at one time used to control arterial hemorrhage in regions in which incisions to expose the wounded vessels, e.g., the palmar arches, might injure important structures. The pressure exerted on oozing points by the apposition of a wound with sutures or sterile adhesive strips is frequently sufficient to control bleeding, especially when such pressure is reinforced by a firm bandage. Bleeding from hone may be controlled by plugging the openings with antiseptic wax, catgut, filaments of gauze, pieces of crushed muscle, or fragments of bone produced by striking the bone with the blunt end of a chisel; a large canal may be filled with a bit of sterilized wood. In the rectum pressure may be made by introducing and inflating a rubber bag, e.g., the colpeurynter. The shirted cannula {cannula a chemise) is used after lithotomy, to make pressure and maintain drainage (Fig. 1 20) ; the shirted portion is stuffed with gauze, In bleeding from a tooth socket the cavity may be packed with gauze containing an astringent, and the pressure aug- mented by bandaging the jaws tightly shut. In the urethra pressure 312 MANUAL OF SURGERY may be effected by inserting a large sound, or in the deep urethra by compressing the perineum. In oozing from the brain small particles of the temporal muscle may be plastered on the bleeding points; this not only obstructs the orifices of the vessels but probably has also a styptic effect; the same principle may be used elsewhere. Wounds of parenchymatous organs in the abdomen have been covered with a free transplant of fascia, or stuffed with omentum, muscle, or fat, held in place with sutures. Other forms of direct pressure, viz. acupressure, forcipressure, ligation, etc., are dealt with later. Indirect pressure is employed chiefly to control bleeding until more permanent measures can be applied, or to prevent hemor- rhage during operations. In the limbs a tourni- quet (Fig. i2i), applied above the wound, is the most reliable procedure; in an emergency a belt, a pair of suspenders, or a handkerchief may be tied about the limb, and tightened by pushing a stick beneath the band and twisting it. A tourniquet should be applied above the elbow or knee, as the vessels in the forearm and leg are protected by bones and not so readily compressed. The dangers of the tourni- quet, which are greater when the tourniquet is applied to the arm than when applied to the thigh, are injury to the nerves and soft Fig. 120.— Catheter a chemise. (Heath.) 121. — Esmarch band Fig. 122. — Petit's tourniquet apphed to the brachial. tissues, especially if the limb is moved about; contusion or rupture of the artery, particularly in atheroma ; and gangrene if the touriquet is left in place for several hours. A disadvantage is the increased oozing of blood following the removal of the tourniquet. In opera- VASCULAR SYSTEM 313 tions the vessel may be compressed at a distance by a clani]), tape, or the fingers of an assistant. Forced flexion is seldom em})l()ycd at the present time; a pad is i)laced in the popliteal space, groin, or bend of the elbow, and the liml) secured in strong flexion by means of a bandage. Indirect digital compression, although lacking the dis- advantages of the tourniquet, calls for a strong, skilled hand and, if pressure must be continued for a long time, relays of assistants. The common cartoid, the vertebral, and the inferior thyroid arteries may be compressed against the transverse process of the sixth cervical yertehm (C/iassaignac's tubercle) at the anterior margin of the sterno- mastoid ; the facial, against the lower jaw just in front of the masseter ; the labial and coronary, by grasping the lip at the angle of the mouth between the fingers; the temporal, against the zygoma immediately in front of the ear; the occipital, against the skull about midway between the mastoid process and the external occipital protuberance; the subclavian, against the first rib, by the thumb, or by the padded handle of a door key, pressed downward, backward, and inward just behind the clavicle and to the outer side of the sternomastoid ; the axillary, against the head of the humerus at the inner border of the coraco-brachialis, with the arm raised to a right angle; the brachial, against the humerus at the inner edge of the biceps; the radial, at the wrist, just outside of the flexor carpi radialis; the ulnar, in the same situation, just outside of the flexor carpi ulnaris; the abdominal aorta, if the patient is not too stout, against the vertebrae on a level with and just to the left of the umbilicus; the external iliac, against the brim of the pelvis, above the middle of Poupart's ligament; the coTumon femoral, immediately below Poupart's ligament by pressing upwards and backwards midway between the symphysis pubis and the anterior superior spine of the ilium; the popliteal, against the femur a trifle to the inner side of the middle of the popliteal space; the anterior tibial, midway between the two malleoli; the posterior tibial, half an inch behind the tip of the internal mal- leolus. When there is danger of secondary hemorrhage, the point for compression may be marked with ink or iodin, so that, in the event of bleeding, the nurse may press on the right spot at once. It is much better, however, in such cases, to apply an Esmarch band loosely to the limb; if hemorrhage occurs the band can then be tightened without regard to the situation of the artery. (6) Acupressure is rarely employed, (i) A long needle may be pushed into the tissues, then over the vessel, and again into the tissues, in the same way that one fastens a flower to the lapel of a coat; (2) the needle may be passed into the tissues on one side of 314 MANUAL OF SURGERY the vessel, twisted 180°, and reinserted into the tissues; or (3) the needle may be thrust under the vessel, and wire or silk passed over the ends of the needle in a ligure-of-8 fashion. (7) Forcipressure, or the crushing of the end of the vessel with hemostatic forceps, is frequently employed with very small vessels, thus, many of the little bleeding points caught with hemostatic forceps during an operation require no further attention after the forceps have been removed at the end of the operation. When ligation is very difficult and the vessel large, the forceps may be left in place for twenty-four or forty-eight hours, being, of course, protected with sterile dressings. Forcipressure before ligating en masse renders bleeding from shrinkage of the tissues much less likely to occur. Very powerful forceps (vasotribe, or angiotrihe) are sometimes used for this purpose, and some surgeons do not even ligate after removing the instrument. (8) Torsion is useful in certain plastic operations where the presence of knotted ligatures is undesirable. It should not be used in cases of atheroma. Free torsion is the twisting of a vessel several times after the application of hemostatic forceps; it is used chiefly for small vessels. Larger vessels are occluded by limited torsion] the artery is drawn from its sheath with a pair of forceps, grasped close to the tissues with a second pair, then twisted with the first forceps. Torsion ruptures the inner and middle coats, which contract and curl up, and twists the outer coat; the end of the vessel should never be twisted off. (9) Ligation is the method of choice when dealing with vessels large enough to be seen by the naked eye. Catgut is the material usually employed, although with very large arteries or with thick pedicles many surgeons prefer silk. Ligation may be total, or circumferential, when the vessel is occluded by the ligature, or lateral when a wound in the side of a vessel is closed without inter- rupting the circulation. A circumferential ligature is applied to the bleeding end of a vessel {terminal ligation), or to the vessel some distance from the wound {ligation in continuity, p. 319). In the former the end of the vessel is seized with hemostatic forceps, drawn a little from its sheath, when such exists, and the ligature tied above the forceps in a reef knot. If catgut is used, a third knot always should be added. As it is difficult to catch small vessels without including a little of the surrounding tissue, the forceps should be removed as the first knot is tightened, otherwise the ligature may slip off when the forceps are removed. A suture-ligature (Fig. 123) is one passed through the tissues about an artery by means of a needle. VASCULAR SYSTEM 315 It is used in dense tissues from which the vessel cannot be drawn; in necrotic tissues and in atheroma in order to prevent cutting through of the ligature; in tissues like the dura, mesentery, and omentum; and in any region in which there is danger of slipping of the ligature. A lateral ligature is one applied to the side of a vessel, generally a vein, after the edges of the wound have been drawn up in the form of a cone with hemostatic forceps (Fig. 124). In order to insure against slipping the ligature may, by means of a fine needle, be passed through ^the venous wall on each side of the forceps. The efects of a ligature, when it is tied tightly, are rupture of the inner and middle coats, which retract and invert, and the formation of a small thrombus, which is finally replaced by fibrous tissue. Atheromatous arteries and very large arteries, e.g., the subclavian and iliac, should be tied only firmly enough to approxi- mate the walls, without rupturing the intima, else the ligature may cut through, or the vessel may dilate and rupture immediately proximal to the point of ligation; some surgeons apply this rule to all vessels. The liga- PiG. 123. — Suture-ligature. Fig. 124. — Lateral ligature. (Esmarch and Kowalzig.) (Esmarch and Kcwalzig.) ture itself is encapsulated if of non-absorbable material. The liga- tion of a large artery causes a rise in the general blood pressure, which gradually falls as the collateral circulation is established. (10) Suture of blood vessels (angiorrhaphy) is the ideal method of dealing with wounds of arteries whose ligation might lead to gangrene or other serious disturbance in the parts which they supply, e.g., the common carotid, axillary, brachial, aorta, external iliac, femoral, popliteal, and large abdominal arteries. If, after the principal artery of a limb has been wounded, the limb is cold and pale, the peripheral end of the artery does not bleed, and congestion below the wound does not follow compression of the chief vein, the collateral circulation is probably incompetent to maintain the life of the limb, and ar tenorrhaphy is mandatory (other methods for testing the colateral circulation will be found in the section on "Amputations"). The danger of tearing out of the sutures, even in the presence of atheroma, is no greater than that of cutting through of a ligature, and if thrombosis occurs, the clot may form 3l6 MANUAL OF SURGERY slowly enough to allow the collateral vessels to dilate, a distinct advantage over ligation. Although occlusion of the main veins of the limbs is usually followed by nothing worse than edema, gangrene may result if the collateral vessels are diseased or injured, if the circulation is sluggish from cardiac or pulmonary derangement, or if the vitality of the part is impaired by debilitating maladies, hence suture should be preferred to ligation. In wounds of the superior mesenteric, portal, vena cava above the origin of the renals, and both internal jugulars, suture must be chosen, as ligation gener- ally ends in death. The technic of angiorrhaphy, which includes arteriorrhaphy (suture of arteries) and phlehorrhaphy (suture of veins) is as follows : After controlling the circulation by the application of a tourniquet, or by compressing the vessel above and below the wound between the fingers of an assistant or by rubber-coated clamps, the sheath is pushed back, but no farther than is absolutely necessary, and the edges of the wound, if lacerated, made smooth with a sharp knife; scissors produce too much bruising. The sutures should be of fine silk, threaded on the finest needle, and sterilized by boihng in vaselin, as suggested by Carrel, who applies vaselin also to the margins of the wound to prevent drying. In a lateral wound the operation may be facilitated by passing a guide suture, to be held by an assistant, through each end of the wound. The con- tinuous suture is more rapid and less apt to permit leakage between the points of insertion than the interrupted. The suture should penetrate all of the coats of the vessel, and slightly evert the margins of the wound so as to bring intima in contact with intima, the points of insertion being about one milhmeter apart. The blood current is now slowly turned on, pressure being applied to the suture line until the stitch holes cease to bleed. The sheath is then sutured, then the fascia, then the skin. If more than one-third of the cir- cumference of the vessel is cut, the section should be completed and an end-to-end anastomosis performed. Although various forms of special apparatus may be used for this purpose, the best method is that of Carrel. After cutting the ends of the vessel square across and trimming away any of the external coat which prolapses into the lumen, three guide sutures are passed through both ends of the vessel at points equidistant around the circumference, which, by traction on these sutures, is transformed into a triangle, whose sides, after being elongated as much as the elasticity of the vessel permits, thus preventing stricture, are sutured with a continuous suture (Fig. 125). The author has successfully sutured the axillary artery in four instances, the abdominal aorta in one, the common carotid VASCULAR SYSTEM 317 in one, the radial in one, the femoral in five, and the popliteal in one' five of these being end to end anastomoses. Resume. — The treatment of alarming hemorrhage from any open icound is, first, the immediate control of bleeding by the appli- cation of digital pressure to the vessels in the wound; then, in the extremities, the application of a tourniquet above the wound. Nothing further should be done until the patient has reacted from shock, when the parts may be carefully disinfected and the vessels ligated, enlarging the wound as much as may be necessary, and remembering that both ends of large arteries and veins should be tied, and that, if the wound is a lateral one, the vessel must be Hgated above and below the w;ound and severed between the ligatures, thus permitting retraction and contraction. The desirabihty of suturing important vessels instead of occluding them by ligation, should be borne in mind. A general oozing which seemingly comes from no particular point is controlled by firm gauze packing, or by suture of the wound and the application of a firm bandage. An artery capable of producing vigorous bleeding must be lig- ated in the wound, though even an opera- tion is necessary for such purpose. Liga- tion in continuity for hemorrhage should be performed only under very exceptional circumstances, as it is often ineffectual, owing to a free collateral circulation; if the collateral circulation is poor, there is danger of gangrene or, in the case of the common carotid, paralysis and death; again the bleeding vessel may be a large vein, or an artery not derived from the vessel ligated. Possibly in cases in which the tissues are rotten from infection, or in which packing fails to control permanently a bleeding artery whose exposure would necessitate the destruction of important structures, ligation in continuity may be indicated. In the former instance recurrence of bleeding would call for amputation. In re- gions such as the neck where elastic constriction is impracticable, digital compression must be maintained until the wound has been sufficiently enlarged to secure the vessel with hemostatic forceps. The patient may then be brought out of the shock, and the hemor- rhage controlled as outlined above. Dangerous hemorrhage in the chest or abdomen is treated, after opening these cavities, by ligation, suture, gauze packing, or, in rare instances, by the cautery; often an Fig. -Carrel's technic for anastomosis of blood vessels. 3l8 MANUAL OF SURGERY important organ, e.g., spleen, kidney, or uterus, must be removed. In these cases the surgeon must operate immediately, in the pre- sence of even the most profound shock. Hemorrhage into the cra- nium or spinal canal is dangerous, not from the loss of blood, but from the pressure exerted upon the central nervous system; it is controlled, alter trephining or laminectomy, by ligation or packing. The treatment ot serious bleeding into the subcutaneous tissues, in- cluding diffuse traumatic aneurysm, is immediate digital pressure on the main artery above, until a tourniquet can be applied; after the patient has reacted from shock, the bleeding vessel is exposed by incision and ligated or sutured. Serious bleeding from arterioles, venules, or capillaries is dealt with under "Hemophilia." Hemophilia {hemorrhagic diathesis) is a congenital and hereditary tendency to excessive bleeding, arising spontaneously, or from wounds of even the most trivial character. The cause is not known. It is far more frequent in males than in females, but females are much more Hable to transmit the disease to their offspring; indeed a female belonging to a bleeder family, but who is not herself subject to the affection, is likely to beget bleeder children, especially if they be males. About 50 per cent, of those with hemophilia die before the tenth year, and only 10 per cent, reach maturity. The presence of hemophilia, which may be suspected from the history and con- firmed by estimating the coagulation time of the blood, contrain- dicates all but the most urgent operations (see also "Spontaneous Hemorrhage"). The treatment consists in the internal administration of tonics and the careful avoidance of all forms of injury; even the most trivial operations, like vaccination or circumcision, must be regarded as highly dangerous. In the presence of bleeding ergot, acetate of lead, gelatin, calcium lactate, or calcium chlorid may be given inter- nally. Thyroid extract has been recommended, although, according to Kocher, hyperthyroidism is accompanied by a decrease in the coagulability of the blood. Adrenalin or Carnot's solution and pro- longed pressure with elevation are used locally. The application of coagulin, or of clotting blood from a healthy individual may be tried. The most effective measure is the transfusion of normal blood. If this is not done one may inject 10 to 20 c.c. of normal horse serum into a vein, or 20 to 40 c.c. beneath the skin; antidiph- theritic serum also has been used in hemophilia and other hemor- rhagic diseases. Escharotics or the actual cautery may temporarily check the oozing, but it is very Hkely to recur with the separation of the sloughs. Petechise and ecchymoses require no local treatment; VASCULAR SYSTEM 319 hematomata and hem arthroses should be protected from injury and never opened. LIGATION OF ARTERIES IN CONTINUITY The indications for ligation in continuity are aneurysm, arterial hemorrhage under the circumstances mentioned above, malignant growths whose progress may be hindered by shutting off the blood supply, and operations on very vascular structures in order to reduce the loss of blood. In addition may be mentioned the very doubtful indications of enlarged prostate, for which the internal ihacs have been tied, trigeminal neuralgia, for which the carotid has been tied, and epilejjsy, for which the vertebral has been tied. In cases in which the necessity for ligation is not pressing, the state of the collateral circulation may be determined before operation by the Matas method (see "Indications for Amputation," chap. xxxi). If the collateral circulation is inadequate it may be rendered more active by intermittent compression of the artery, or by partly oc- cluding the artery with a band of aluminium (Halsted) or fascia, and completing the ligation after a week or ten days. Chromicized catgut should be used for all but the largest vessels, for which floss silk is the best material. The operation is preceded by mapping out the course of the vessel by an imaginary line. The skin and fascia are then divided along this line, important structures drawn aside, and the vessel located by means of anatomical guides, e.g., a muscle, a bony promi- nence, a nerve, or another vessel. The artery itself is recognized by its pinkish color, the thickness of its walls, and by pulsation, the veins being dark in color, thin walled, and non-pulsating. The arteries of the upper extremity, the leg, and most of the smaller arteries of the trunk have venae comites; those of the thigh, the head, and the neck, except the lingual, have but one companion vein. Pressure upon the vessels will distend the vein, collapse the artery, and obliterate the pulse below the point of pressure. The anatom- ical guides, however, are more reliable than the indi\ddual features of the artery, as even pulsation may be transmitted to the vein, or be absent in the artery as the result of pressure or hemorrhage. The sheath of the artery is opened for about half an inch by Hf ting it from the artery with forceps, and incising just beneath the forceps with the flat of the knife towards the artery (Fig. 126 A). The sheath is then held by forceps, and separated from the artery by an aneurysm needle armed with the ligature, which is carried around the vessel, in 320 MANUAL OF SURGERY C. the direction away from the most important neighboring structure, which is usually the vein (Fig. 1 26 B) . The ligature is then tied in a reef knot by placing the ends of the thumbs or index fingers upon the knot, and separating them by using the middle joint as the basis of support (Fig. 126 C). The second knot should be tied firmly, but should not be jerked, as such may break the hgature; a third knot always should be added when cat- gut is employed. With the smaller arteries the ligature may be tied with sufficient firmness to rupture the inner coats. With very large arteries this may result in the cutting through of the ligature, or in dilatation and rupture immedi- ately proximal to the ligature In these vessels the walls should be approximated only, the stay knot being employed (Fig. 127). The principal dangers following liga- tion in continuity are secondary hemorrhage and gangrene. The innominate artery has been tied forty-three times with seven recoveries, the chief causes of death being sepsis, secondary hemor- rhage, and cerebral lesions. An incision is carried for three or four inches along the anterior margin of the right sternomastoid to the episternal notch, then outward along the upper margin of the inner third of the clavicle, severing the skin, platysma, and the superficial and deep fasciae. The sternohyoid, sterno- thyroid, and inner edge of the sterno- mastoid are divided and retracted. The anterior jugular vein is severed between two ligatures, the carotid sheath opened, and the carotid artery followed to the bifurcation of the in- nominate. Resection of the sterno- clavicular articulation may be necessary to expose the vessel pro- perly. The inferior thyroid veins are tied or drawn aside, the right internal jugular and right innominate vein are pushed to the right, and the left innominate vein is displaced downwards. A strongly curved aneurysm needle is passed from without and below, upwards Fig. 126. — A. Opening the sheath. Drawing ligature round the artery. Tying artery. (MouUin.) Fig. 127. — Stay knot. (Balance and Edmunds.) VASCULAR SYSTEM 321 and inwards, care being taken not to injure the pneumogastric nerve and pleura, which He to the right. The ligature should be of floss silk, tied in a stay knot. The common carotid arises from the innominate on the right, from the arch of the aorta on the left. The line of the artery is from the sternoclavicular articulation to midway between the angle of the jaw and the tip of the mastoid, the vessel bifurcating at the upper border of the thyroid cartilage. Whenever possible the vessel is tied above the anterior belly of the omohyoid, i.e., in the superior carotid triangle, or the triangle of election, as here the vessel is more super- ficial and the operation less difi&cult. The triangle of election is Fig. 128. — Ligature of the common carotid and facial arteries. (Moullin.) bounded above by the posterior belly of the digastric, behind by the sternomastoid, and in front by the anterior belly of the omohyoid. The inferior carotid triangle, called the triangle of necessity because the vessel is tied here only when absolutely necessary, is bounded above by the anterior belly of the omohyoid, below by the sterno- mastoid, and in front by the median line. Ligation in the triangle of election (Fig. 128) is carried out with a sand pillow beneath the neck, the head turned towards the opposite side, and the chin raised. A three inch incision, the center of which is on a level with the cricoid cartilage, is made along the arterial line, severing the skin, and both layers of the superficial fascia, between which lies the 322 MANUAL OF SURGERY platysma, and exposing the anterior edge of the sternomastoid, which is the muscular guide to the artery. After cutting the deep fascia which is attached to the border of the sternomastoid, this muscle is retracted outwards, the omohyoid drawn downwards, and the costal process of the sixth cervical vertebra (carotid tubercle of Chassaignac) , which Hes immediately under the artery at the point where it is crossed by the omohyoid, felt with the finger. The sheath of the vessel is identified by means of the descendens noni nerve, which descends upon it, and opened on the inner side to avoid the internal jugular vein, which lies to the outer side in a separate compartment. The pneumogastric nerve lies behind and between the artery and vein, in a separate compartment of the same sheath. The needle is passed from without inwards. Ligation in the triangle of necessity (Fig. 128) is performed by making a three inch incision downward along the arterial line from the level of the cricoid cartilage. The sternomastoid is drawn outwards, the sterno- hyoid and sternothyroid inwards, the omohyoid upwards. The sheath is opened on the inner side and the operation completed as described above. The inferior thyroid veins may be tied it they are in the way; in the lower part of the neck the anterior jugular, and on the left side, the internal jugular, lie in front of the artery and must be carefully retracted. The recurrent laryngeal nerve and the inferior thyroid artery are on a deeper plane and should not be encountered. Ligation of the ccmmon carotid, in one-fourth of the cases, results in cerebral complications, which may be immediate, such as collapse from cerebral anemia, or which take the form of cerebral soitening, causing hemiplegia. One-half of those developing intracranial trouble die. The internal carotid is rarely ligated. The line of the artery is parallel with and a trifle external (not internal as one would suspect from the name) tc that of the external carotid. The muscular guide is the sternomastoid, and the incision that for the external carotid. The sternomastoid is retracted backwards, the posterior belly of the digastric upwards, and the external carotid forwards. The needle is passed from without inwards, avoiding the internal jugular vein, the pneumogastric nerve, the cervical sympathetic nerve, and the ascend- ing pharyngeal artery. The external carotid extends from the bifurcation of the common carotid, on a level with the superior border of the thyroid cartilage, to midway between the external auditory meatus and the condyle of the lower jaw. The line of the artery is the upper portion of that for the common carotid, the muscular guide the sternomastoid, and the VASCULAR SYSTEM 323 position of the patient that for h'gation of the common carotid. A three inch incision, with the center at the great cornu of the hyoid bone, is made along the arterial line, severing the skin, both layers of the superficial fascia, which includes the platysma, and the deep fascia. The sternomastoid is retracted outwards, the posterior belly of the digastric and the stylohyoid upwards, and the hypo- glossal nerve inwards. The point of election for ligation is opposite to the tip of the great cornu of the hyoid bone, and between the superior thyroid and lingual arteries. The superior thyroid, lingual and facial veins, which lie in front of the artery, should be avoided, and any lymphatic glands which are in the way removed. The needle is passed from without inward, carefully avoiding the superior Fig. 129. — Ligature of subclavian and lingual arteries. (Moullin.) laryngeal nerve, which lies behind the artery. The artery is distin- guished from the common carotid and from the internal carotid by the presence of branches. The superior th5T:oid arises from the external carotid close to its origin, passes upwards and inwards, then downwards and forwards to the thyroid gland. A two inch incision, with its center on a level with the upper edge of the thyroid cartilage, is made along the carotid line, and the external carotid exposed. The artery is then tied, care being taken to avoid the superior thyroid veins and the superior laryngeal nerve. The lingual artery (Fig. 129) may be tied close to its origin through the incision for the exposure of the external carotid, or under 324 MANUAL OF SURGERY the hyoglossus in the submaxillary triangle. In the latter operation the patient is placed in the same position as that for the ligation of the carotid. A curved incision, with its center opposite the greater cornu of the hyoid bone, is made from below and external to the symphysis menti, to below and within the point where the anterior edge of the masseter joins the lower border of the jaw, severing the skin, both layers of the superficial fascia, and the platysma. The submaxillary gland, which lies in a compartment of the deep fascia, is retracted upwards after severing the deep fascia, thus exposing the two bellies of the digastric, the posterior edge of the mylohyoid, and the hyoglossus. The digastric tendon is retracted down- wards, and the hypoglossal nerve (the guide to the artery) and the ranine vein, which cross the hyoglossus, are pushed upwards; the hyoglossus is divided transversely between the nerve and the hyoid bone. The artery lies immediately beneath the muscle on the middle constrictor of the pharynx, and is tied by passing the needle from above downwards. The facial artery (Fig. 128) maybe tied through the incision for ligation of the external carotid, or at the point where it crosses the lower border of the jaw im- mediately in front of the masseter, by making a small transverse incision through the skin, platysma, and fascia. The needle is passed from behind forwards, to avoid the vein, which lies behind. The temporal artery may be tied in front of the auditory meatus at the point where it crosses the zygoma. A small vertical incision is made through the skin and fascia, between the tragus and the condyle of the jaw, and the vessel tied just above the root of the zygoma, avoiding the auriculo- temporal nerve and branches of the temporo-facial portion of the seventh nerve. The occipital artery may be tied at its origin, through the incision Fig. 130.- — Diagram to show the collateral circulation after ligature of common carotid, sub- clavian, and axillary arteries. A. Common carotid. B. Internal carotid. C. External carotid. D. Vertebral. E. Circle of Willis. P. Basilar. G. Subclavian. H. Thyroid axis. I. Inferior thyroid. J. Superior thyroid. K. Occipital. L. Princeps cervicis. M. Deep cervical. N. Transversalis colli. O. Suprascapular. P. Posterior scapular. Q. Dorsalis scapulae. R. Infrascapular. S. Subscap- ular. T. Long thoracic. U. Short thoracic. V. Superior in- tercostal. X. Internal mam- mary. Y. and Z. Aortic inter- costals. ("Walsham.) VASCULAR SYSTEM 325 made for the external carotid, or behind the mastoid process. In the latter operation an incision is made from the tip of the mastoid upwards and backwards towards the occipital protuberance. The posterior fibers of the sternomastoid, the splenius, and the trachelo- mastoid are severed, and the vessel tied between the mastoid process and the transverse process of the atlas. The subclavian artery (Fig. 129) arises from the innominate on the right, and the arch of the aorta on the left, and extends from the sternocla\'icular joint to the lower border of the first rib. It is divided into three parts by the scalenus anticus, the first portion lying to the inner side of the muscle, the second behind, and the third to the outer side. The third portion lies in the subclavian triangle, which is formed by the clavicle below, the posterior belly of the omohyoid on the outer side, and the posterior border of the sternomastoid on the inner side. Ligation of the first or second portion is very rarely performed. The line of the third portion is from the posterior border of the sternomastoid to the anterior border of the trapezius, half an inch above and parallel to the clavicle. The muscular guide is the outer border of the scalenus anticus, which lies approximately behind the outer border of the sternomastoid. The bony guide is the tubercle on the first rib into which the scalenus anticus is inserted, the artery lying directly behind it. In ligation of the third part of the artery the thorax is raised, the neck extended, and the head turned to the opposite side. The size of the subclavian triangle is increased by pulling down the arm, and fixing it in this position by pushing the forearm under the back. An incision is made over the claxacle, from the outer margin of the sternomastoid to the inner margin of the trapezius, after the skin has been drawn down. This maneuver protects the external jugular vein, and when the skin is released leaves the wound half an inch above the clavicle. The incision involves the skin, superficial fascia and platysma, and the deep fascia. The external jugular vein is retracted inward or divided between two ligatures, the posterior belly of the omohyoid retracted upwards, and the scalenus anticus with the tubercle on the first rib identified. The transverse cervical and the suprascapular arteries should not be injured, as they assist in the collateral circula- tion. The subclavian vein lies in front of and below the finger as it rests on the scalene tubercle; the artery lies behind and can be felt pulsating on the first rib. The brachial plexus lies above and to the outside, the lower cord passing behind the vessel. With the finger guarding the vein, the needle is passed from above downwards close to the artery, to avoid the lowest cord of the plexus. There is also some danger of wounding the pleura. 326 MANUAL OF SURGERY The internal mammary artery courses downwards on the inner surface of the chest wall, about half an inch from the edge of the sternum. It may be tied after dividing the intercostal structures outwards from the edge of the sternum for an inch or more. In order to secure both ends of a divided internal mammarj', which is absolutely necessary owing to the freedom of the collateral circula- tion, a portion of the costal cartilage may be resected. The vertebral artery has been tied for wounds, secondary hemor- rhage following ligature of the innominate, and for epilepsy. An incision dividing the skin, superficial fascia, platysma, and deep fascia, is made along the lower half of the posterior border of the sternomastoid. This muscle is retracted forwards with the external jugular vein and the scalenus anticus, upon which lie the phrenic nerve and the transverse cervical artery. The transverse process of the sixth cervical vertebra is defined, and the artery found below this point in the interval between the scalenus anticus and the longus colli. The vein lies superficial to the artery and is drawn to the outer side, the needle being passed from without inwards, care being taken to avoid the pleura and the thoracic duct. The inferior thyroid may be tied through the incision made for ligation of the common carotid in the triangle of necessity. The sternomastoid and the carotid sheath are drawn outwards, the omo- hyoid upwards, and the sternohyoid and sternothyroid divided if necessary. The artery is found below the transverse process of the sixth cervical vertebra and behind the carotid sheath. Care should be taken not to injure the middle cervical ganglion, the recurrent laryngeal nerve, the esophagus, or, low down in the neck, the thoracic duct. The axillary artery extends from the lower border of the first rib to the lower border of the tendon of the teres major. It is divided into three portions by the pectoralis minor, the first portion being above the second behind, and the third below that muscle. The line of the artery is f f om the middle of the cla\'icle to the junction of the anterior and middle thirds of the outlet of the axilla. The second portion of the artery is not tied, owing to its depth and to the fact that it is closely surrounded by large nerve trunks. Ligation of the first portion may be accomplished through an incision from the coracoid process of the scapula to within one inch of the sternoclavicular joint, parallel with and half an inch below the clavicle. After di\'iding the superficial structures, the clavicular portion of the pecto- ralis major is severed and the costocoracoid membrane incised below the subclavius. The acromiothoracic artery and cephalic vein are VASCULAR SYSTEM 327 avoided, the pectoralis minor drawn downwards, and the needle passed from below upwards to avoid the vein, which is below and to the inner side, while the finger guards the brachial plexus, which lies above and to the outer side. In ligation of the third portion (Fig. 131) the arm is abducted, and a three inch incision made along the inner border of the coracohrachialis, dividing the skin and fascia?. The median nerve lies on the artery and, with the musculocutaneous nerve, which is more external, is drawn outwards. The axillary vein and the ulnar and internal cutaneous nerves, which lie to the inner side, are separated, and the ligature passed from within out- wards. Ligation of the termination of the axillary or the beginning of the brachial, i.e., between the circumflex and the superior profunda arteries is more dangerous than above or below these points, since there exists only one small collateral branch running f romi the poste- rior circumflex to the superior profunda. f'^rrr/'a h-neMaile m/aclf- W.cefis muscle me-rye Pig. 131. — Ligature of axillary artery. (MouUin.) Ji££dian. iieri>'e Fig. 132. — Ligature of brachial artery. (Moullin.) The brachial artery underlies a line drawn from the junction of the anterior with the middle third of the outlet of the axifla, to a point midway between the two condyles of the humerus. The muscular guide is the inner border of the biceps. Ligation at the middle of the arm (Fig. 132) is conducted with the arm ab- ducted and the forearm supinated. There should be no support beneath the arm for fear that the soft structures might be pushed forwards over the artery and so comphcate the operation. An incision two or three inches long is made along the inner border of the biceps, severing the skin and fasciae. The muscle is retracted outwards and the median nerve, which at the middle of the arm crosses the artery from without inwards, located. The nerve is displaced to the more convenient side, and the needle passed from it, after separating the venae comites and, above the middle of the arm, 328 MANUAL OF SURGERY the basilic vein, which here Hes beneath the deep fascia and close to the artery. The ulnar nerve lies to the inside. At the bend of the elbow the biceps tendon is the guide. A two inch incision is made along the inner edge of the biceps tendon extending down to the crease of the elbow. The median basilic vein is drawn downwards and in- wards, the bicipital fascia incised, the venae comites separated, and the ligature passed from within outwards to avoid the median nerve. The ulnar artery curves from its point of origin about one inch below the bend of the elbow, to the ulnar side of the forearm, thence passes downward to the radial side of the pisiform bone. The line of the upper third is from the middle of the front of the elbow joint to the junction of the upper and middle thirds of the ulna. The line of the lower two-thirds is from the apex of the internal condyle of the humerous to the radial side of the pisiform bone. The muscular guide is the outer border of the flexor carpi ulnaris. Ligation at the wrist (Fig. 133) is accomplished by making an incision an inch or more in length along the radial border of Bcrfifaseia ^^vq flexor carpi ulnaris, which is drawn inwards after the deep fascia has been opened. The ligature is passed from within outwards to avoid the ulnar nerve, which lies to the ulnar side of the artery. Ligation of the middle third is performed by making a three inch incision in the Fig. 133.— Ligature of the radial line of the vcsscl, dividing the deep and ulnar arteries. (MouUin.) . • ^ n fascia, and separatmg the nexor carpi ulnaris from the flexor sublimis digitorum; this interspace is marked by a whitish or yellowish line, which is often indistinct and sometimes absent, but may always be distinguished by moving the wrist and the fingers. The radial artery underMes a line drawn from midway between the tips of the condyles of the humerus, to the ulnar side of the sty- loid process of the radius. The muscular guide is the inner border of the supinator longus. For ligation in the upper third make a three inch incision along the line of the vessel, divide the fasciae, retract the supinator longus outwards, and pass the needle from without inwards. The radial nerve lies to the radial side of the vessel. For ligation above the wrist (Fig. 133) an incision is made in the line of the vessel, the fasciae divided, and the vessel found between the supinator longus and the flexor carpi radiahs. In this situation the radial nerve lies on the dorsum of the forearm and is not encountered. A small superficial vein may overlie the artery, and branches of the VASCULAR SYSTKM 329 external cutaneous nerve may be seen. At the back of the wrist, or in la tahatiere (snuff box), which is bounded internally by the tendon of the extensor primi internodii, and externally by the extensor secundi internodii pollicis, the line of the artery is from the tip of the styloid process, to the posterior angle of the first interosseous space. An incision is made between the tendons, from the styloid process to the base of the first metacarpal bone. Beneath the skin will be found the superficial radial vein and a few branches of the radial nerve. The deep fascia is then opened and the artery exposed. The abdominal aorta has been tied 15 times with 15 deaths, although one patient lived 10 days, one 39 days, and one 48 days. The opera- tion is performed by opening the abdomen in the median line, retracting the intestines, incising the posterior parietal peritoneum, and tying the vessel. The common iliac artery extends from the aorta, opposite the left side of the body of the fourth lumbar vertebra, for two inches, to the upper end of the sacroiliac synchondrosis. The line of the arterv is the upper two inches of a ' . brachial, radial, and hne drawn from a point half an inch below and ulnar arteries, a. Bra- to the left of the umbilicus, to midway between ui?a;;D: Su^'perS'pro: the anterior superior spine of the ilium and the funda; e. inferior pro- , . , . ,_, , , .11 funda; F. Anastomotica symphysis pubis. Ihe vessel may be tied by magna; G. Radial re- the transperitoneal or by the retroperitoneal current; H. interosseous ^ _ -^ ^ recurrent; I. Anterior "route. The transperitoneal route is preferable, and k. Posterior ulnar The abdomen is opened through the left rectus L.^^c^o^mmon interos- muscle bv an incision whose center is a Kttle ^^0^^= ^^- Posterior in- ' . . terosseous; X. Anterior below the umbilicus. The intestines are pushed interosseous; 00. aside, the posterior parietal peritoneum opened,. tZt'^^^eZ'^X'^r and the needle passed from the patient's right arch; Q. Superficial ,, ii'i -111 -i- palmar arch, R. Poster- to let t. on both Sides ot the body, as the vein lies ior circumflex; s. Sub- behind the artery on the right side, and behind scapular. (Waisham.; and internal to it on the left. In the retroperitoneal metJwd an in- cision is made from just above the internal abdominal ring, above and parallel to Poupart's ligament, curving upwards as the outer end of this structure is reached, to near the tip of the cartilage of the eleventh rib. The abdominal muscles and the transversahs fascia are divided, and the unopened peritoneum pushed upwards and in- PlG. 134. — Diagram to show the collateral circulation after liga- ture of the axillary. 33^ MANUAL OF SURGERY wards. The ureter crosses the artery but usually adheres to the peritoneum and is carried out of harm's way with it. The deep muscular guide is the inner border of the psoas magnus muscle. The ligature is passed as in the previous operation. The internal iliac may be tied extraperitoneally or transperi- toneally through the incisions given for the common iliac. The gluteal artery emerges from the pelvis through the upper part of the great sacrosciatic foramen, at the junction of the upper and middle thirds of a line drawn from the posterior superior spine of the ilium to the top of the great trochanter. An incision is made along this line, the libers of the gluteus maximus separated, the deep ^erttencam. SarCeriua muscle/ Fig. 135.- -Ligature of external iliac and superficial femoral arteries. In this figure the incision for the femoral artery is placed too low. (Moullin.) fascia opened, and the artery exposed by separating the gluteus medius from the pyriformis. The sciatic and internal pudic arteries may be reached through an incision parallel with, but one and one- half inches lower than that used for the gluteal artery. The libers of the gluteus maximus are separated, and the vessels found emerg- ing from the lower part of the great sacrosciatic foramen, at the lower border of the pyriformis and just below the great sciatic nerve. The external iliac artery underlies the lower two-thirds of a line drawn from one-half inch below and to the left of the umbilicus, to midway between the anterior superior spine of the ilium and the VASCULAR SYSTEM 33 I sNinphysis pubis. The artery may he tied hy the transperitoneal method through an incision in the middle h"ne or in the semilunar line. The extraperitoneal method (Fig. 135) is performed through an incision about four inches in length, extending from one-half inch above the middle of Poupart's ligament, to a point one inch above and one inch internal to the anterior superior iliac spine. After dividing the skin, superficial fascia, and external oblique, internal obliciue, and transversalis muscles, the transversalis fascia is cautiously opened and the peritoneum pushed upwards and inwards until the psoas muscle along the inner border of which the vessel runs, has been exposed. The needle is passed from within outwards to avoid the vein. One should be careful not to injure the epigastric or the circumflex artery, as they are important aids in establishing the collateral circulation. The line of the femoral artery is from midway between the anterior superior spine of the ilium and the symphysis pubis, to the inner condyle of the femur. The muscular guide is the sartorius, which lies external to the vessel in the upper third, in front in the middle third, and to the inner side in the lower third. The artery may be ligated just below Poupart's ligament, at the apex of Scarpa's triangle, or in Hunter's canal. Ligation of the common femoral just below Poupart's ligament is rarely performed, because its num- erous branches may interfere with perfect occlusion, and the col- lateral circulation is much more free after ligation of the external iliac. An incision through the skin and superficial fascia is made in the line of the artery, from a httle above Poupart's ligament down- wards, for two or three inches. The superficial veins and the lymp- hatic glands are drawn aside, the fascia lata divided, and the sheath opened. The needle is passed from within outwards to avoid the vein. The anterior crural nerve lies to the outer side. For ligation of the superficial femoral at the apex of Scarpa's triangle (Fig. 136) an incision four inches in length, the center of which is four inches below Poupart's ligament, is made along the arterial line, dividing the skin and fasciae. The sartorius is retracted out- wards, and the needle passed from within outwards to avoid the vein, which in this situation lies to the inner side of and behind the artery. The internal cutaneous nerve lies in front of the vessel, and the long saphenous nerve lies to the outer side on a deeper plane. For Ugation in Hunter's canal a four inch incision is made in the line of the artery in the middle third of the thigh. After dividing the fascia lata the sartorius is retracted inwards, the fibrous roof of Hunter's canal, running from the abductor longus to the vastus internus, incised, and the sheath of the vessel exposed. The long 332 MANUAL OF SURGERY saphenous nerve lies upon the sheath and should be drawn out of the way. The needle is passed from without inwards to avoid the femoral vein, which lies behind and slightly to the outer side. The popliteal artery should rarely be liga- ted, since gangrene of the leg follows in about one-half of the cases The artery extends from the lower end of Hunter's canal, at the junction of the middle and lower thirds of the thigh to the lower border of the popliteus muscle. The line of the vessel is from a point one inch internal to the upper angle of the popliteal space, passing midway between the condyles of the femur, to the apex of the lower angle of the space. The muscular guide in the upper third is the inner border of the semi- membranosus; in the lower part the vessel lies midway between the heads of the gastrocne- mius. The internal pophteal nerve is super- ficial to the artery, and the vein is external above, but crosses the vessels lower down, lying between the artery and the internal popliteal nerve. The external popliteal nerve Hes well to the outer side. In ligation of the the'^coiiatltaT^lrSio^n ^PP^^ third an incisiou four inches in length is after ligature of the com- made along the outcr border of the semimem- mon iliac, external and in- , , . , . , , . i ii • ternai iliac, femoral, popii- branosus, which IS retracted mwards, the m- teai, and arteries of the leg. temal popHtcal ncrvc displaced outwards, A. Common iliac; B. Ex- -^ ^ ternai iliac; c. Internal and the needle passcd from without inwards, nk,4uSba^r! P. ESgSrk; ^s in this situation the vein is slightly external. G. Circvimflex iliac; H. Tj^g lower part of the vessel may be tied Obturator; I. Gluteal; J. , . , . . i i j Lateral sacral; K. Sciatic; through an mcisiou midway between the heads ko'?rdT;'N."int"rtr^^ c^: ^^ ^he gastrocnemius, which are separated while guarding the saphenous vein from harm. The vein and nerve are drawn to the inner side, tica magna; s s. Superior ^^^ ^^g needle passcd froni within outwards. articular; T T. Inferior articular; u. Tibial recur- The postcrlor tibial artery is marked by a Anteriol' tibiai^^''?' p^l ^^'^^ ^^^^ the Center of the popliteal space, to terior tibial; Y. Peroneal, a point a finger's breadth behind the internal (Walsham.) . . • j ji /• .1 i malleolus. Ligation in the middle of the leg (Fig. 137) is performed with the leg flexed and lying on the outerside. An incision four inches long is made a fingers' breadth cumflex; O. Femoral; P. Comes ischiatici; 0, Perforating; R. Anastoma- VASCULAR SYSTEM 333 behind the internal border of the tibia, dividing the skin and super- ficial and deep fasciae, and avoiding the long saphenous vein and nerve. The gastrocnemius is drawn inwards, the soleus and the aponeurosis on its under surface severed and retracted backwards Fig. 137. — Ligature of posterior tibial artery. (Moullin.) and the vessel with the posterior tibial nerve to the outer side ex- posed on the tibiahs posticus. After separating the venae comites the needle is passed from without inwards. For ligation behind the malleolus make the incision one finger's breadth behind the malleolus, Tihialis anticus ^Uxtensor prei>is digiterum] muscle JH^/ensor /ofif/u.f digiioruhi Pig. 138. — Ligation of the anterior tibial artery. (Moullin.) TenrJon q^ 7\/rfcnsor /irojuiiis I /lolllcis Pig. 139. — Ligation of the dorsalis pedis artery. (Moullin.) open the internal annular ligament between the tendons of the flexor longus digitorum and flexor proprius pollicis, and pass the needle from behind forwards thus avoiding the nerve, which is posterior and external. The tendon sheaths should not be opened, and the annular Kgament should be sutured after the vessel has been tied. 334 MANUAL OF SURGERY The line of the anterior tibial artery is from a point midway between the head of the fibula and the outer tuberosity of the tibia, to a point midway between the two malleoH. The muscular guide is the outer margin of the tibiaUs anticus. For ligation in the upper third of the leg make an incision in the hne of the artery, incise the deep fascia, and separate the tibiahs anticus from the extensor communis digitorum. The artery will be found in the intermuscular space upon the interosseous membrane, the anterior tibial nerve lying to the outer side. The needle should be passed from without inwards. In the middle of the leg (Fig. 138) the same inter- muscular space is opened, and the vessel found between the tibiahs anticus and the extensor proprius pollicis; the nerve hes in front of the artery and slightly to the outer side; it should be retracted outwards and the needle passed from without inwards. In the lower third of the leg an incision is made in the line of the artery along the external border of the tendon of the tibiahs anticus. After dividing the deep fascia separate the tibialis anticus from the extensor proprius polhcis, retract the nerve, which hes in front and a little external, outwards, and pass the needle from without inwards. The line of the dorsalis pedis is from the midpoint between the malleoh, to the upper end of the interosseous space between the first two metatarsal bones. The muscular guide is the outer margin of the tendon of the extensor proprius pollicis. An incision is made in the line of the vessel along the outer border of the extensor proprius polhcis, the deep fascia opened, the extensor proprius polhcis retracted inwards, and the extensor brevis digitorum outwards. Locate the nerve and pass the needle from it (Fig. 139). The line of the peroneal artery is from the posterior border of the head of the fibula, to the point where the outer border of the tendo- Achilles is inserted into the oscalcis. Make an incision along the arterial line, incise or draw inwards the soleus, which arises from the upper third of the bone only, divide the flexor longus polhcis close to the bone and incise the aponeurotic structure covering the vessel, which is found close to the fibula. The needle may be passed in either direction and the venae comites tied with the artery. CHAPTER XVI LYMPHATIC SYSTEM Wounds of the thoracic duct during operations on the neck are probably more frequent than is generally believed, but as there may be two or more ducts, the accident may not be followed by serious consequences, and is overlooked. Of thirty-one recorded cases, two were fatal. The accident is recognized during operation, by the escape of a white fluid which coagulates on standing. In many cases the leakage is not noticed until several days later, owing to the mixture of the lymph with blood, and to the small amount of food taken immediately after operation. The quantity of lymph lost varies; when the thoracic duct is not supplemented by a rich col- lateral circulation, it may be two or more quarts a day. In these cases there are great thirst, exhaustion, emaciation, hunger, and deficiency or suppression of urine; the general condition, owing to the dehydration, resembling cholera. Wounds or ruptures of the thoracic duct lower in its course may give rise to chylous ascites or chylothorax. The treatment, if the wound is recognized at the time of operation, consists of suture of the duct, ligation, forcipressure or gauze tamponage. If not recognized until after operation, compres- sion with gauze may be tried, and faihng in this, if there is progres- sive emaciation, reopening of the wound and suture or ligature of the duct. In one case the end of the duct was implanted into the jugular vein (Deanesley). Lymphangiectasis, or dilatation of lymphatics, may be congenital or acquired. Congenital lymphangiectasis may occur as varicose lymphatics more or less generalized over certain portions of the body, or as a localized lymphatic dilatation with marked prohferation of the connective tissue elements of the part, such as is seen in macro- glossia, niacrocheilia, and in nevus lymphaticus. Acquired lymphangiectasis is the result of obstruction from tumors pressing on the lymph vessels, wounds and cicatrices involving the lymph vessels, filaria, thrombolymphangitis, or chronic inflamma- tion, neoplasms, or removal of lymph glands. Rupture of dilated lymph vessels is followed by lymphorrhea, causing chyluria, chylous ascites, chylothorax, chylous diarrhea, chylous hydrocele, etc. Obstruc- 335 336 MANUAL OF SURGERY tive lymphangiectasis is accompanied by a solid or lymphatic edema in which there is little or no pitting on pressure. This absence of pitting on pressure is due, not to the consistency of the lymph, which is fluid, but to the hyperplasia, especially of the connective- tissue cells, consequent upon the overnutrition. The skin and subcutaneous tissues are greatly thickened, the former presenting a coarse, corrugated surface, sometimes covered with lymphatic warts, which may ulcerate and give rise to lymphatic fistulcE. When the hyperplasia becomes enormous the condition is called elephan- tiasis; elephantiasis Arabum, or true elephantiasis, when due to the filaria sanguinis hominis; pseudoelephantiasis, when the result of other forms of obstruction. Elephantiasis Arabum is rarely seen outside of the tropics. The parts most frequently affected are the legs {Barhadoes leg), scrotum (Fig. 140), and vulva. The part becomes gigantic, the scrotum sometimes reach- ing the ground. The filaria sanguinis hominis passes its intermediate stage in the body of the mosquito, the ova entering the human body by means of contaminated water, or possibly di- rectly from the bite of a mosquito. The worm ^^^^^^^W finally lodges in the lymphatics, produces ob- ^^^^^ T struction, and liberates a large number of em- ^^^K '■" bryos. The adult worm may be as long as ^^^K^ three inches. The embryos are about ^^0 of ^^^^PHh an inch'in length, and are found in the blood dur- ing the night, or at least during the time that the Fig. 140. — Elephantiasis \- . i . r a r i i of scrotum. (Nolan.) paticuts sclccts tor rcposc. Arcas 01 lymph- angiectasis are subject to attacks of inflamma- tion, often associated with chill and fever (elephantoid fever), and sometimes eventuating in abscess. The treatment of lymphatic varix is excision. Lymphedema should when possible, be treated by removing the cause, e.g., a tumor. The excision of lymph glands, however, may augment the edema. In a few cases of true elephantiasis the parent filaria has been localized and removed. When the cause cannot be removed, and the trouble progresses despite elevation, massage, and the appHcation of an elastic bandage, operative measures may be considered. Multiple punctures, and ligation of the artery of supply are not recom- mended. In lymphedema of the upper extremity due to carcinoma of the breast and axillary glands Handley has obtained much benefit by passing long silk threads through the subcutaneous tissues of the forearm and arm to the subcutaneous tissues of the chest, thus LYMPHATIC SYSTEM 337 providing caj)illary drains for the lymph. Kondolcon has secured good results in several cases of lymphedema of the lower extremity by excising long strips of the deep fascia; this permits the subcu- taneous lymph to pass to the deeper structures, which, according to Kondoleon, are normal and capable of absorbing the lymph. In the worst cases of elephantiasis wedge-shaped sections of the diseased tissues may be excised, or the entire part (scrotum, labium, upper or lower extremity) may be amputated. Lymphangioma (see chapter on "Tumors")- Acute lymphangitis always follows infective processes within the area drained by the inflamed vessels. The walls of the lymphatics and generally the tissues surrounding the vessels take on the ordinary changes of inflammation, and lymph thrombosis may ensue. The process ends in resolution or in suppuration. In the former instance recovery may be only partial, obliteration or dilatation of the vessels ensuing. , The S3miptoms are those of sepsis. In tubular lymphangitis, in which the large lymph vessels alone are involved, red lines may be seen coursing from the infected area of the nearest glands. There may or may not be tenderness and edema. Confusion with phlebitis (q.v.) is possible. In rctij'orm lymphangitis the capillary lymph vessels are affected and the redness is general; this condition is practically the same as erysipelas. In either instance suppuration may be en- countered, either along the lymph vessels or in the lymphatic glands. The treatment is primarily the disinfection of the wound from which the absorption of infection Is taking place. The limb should be elevated and put at rest, and the lymph vessels covered with an ointment containing ichthyol, belladonna, and mercury. In the early stages cold, and later heat, may be of service. Suppuration demands incision and drainage. The constitutional treatment is that of sepsis. Chronic lymphangitis may follow an acute attack, or it may be chronic from the 'beginning, e.g., in syphilis, tuberculosis, and ele- phantiasis. The treatment is that of the cause; in some instances, particularly in the tuberculous variety, excision may be attempted. Acute lymphadenitis is due to the same causes as acute lymphan- gitis, and occasionally follows cold or injury, inflammatory processes in contiguous structures, or infection from the blood stream. The lymph vessels may or may not participate in the inflammation. The glands enlarge as the result of the hyperemia and exudation, and the surrounding tissues are usually more or less involved in the process (periadenitis) . 338 MAXUAL OF SURGERY The symptoms are those of fever in all cut the mildest cases. The glands are tender and palpably enlarged. In the severer cases the overlying skin becomes red. edematous, and adherent, and the glands are welded into one mass, which finally softens owing to the formation of pus. The treatment in the early stages is that ol acute lymphangitis. The source of infection is often of a trivial nature and frequently overlooked. A scratch on the foot is sufficient to produce a Je- moral adenitis, in which the glands about the saphenous opening are involved. In inguinal adenitis, in which the glands running parallel to Poupart's ligament are inflamed, and to which the term bubo is commonly apphed, the penis, urethra, scrotum, lower part of the abdomen, anus, perineum, and buttock should be carefully examined. In cervical adenitis the scalp should be inspected for conditions like eczema or pediculosis, the ear for chronic inflammation or skin lesions, the Hps for cracks or ulcers, the teeth for caries, the gums for pyorrhea, and the tongue and throat for lesions through which infection might gain access. When suppuration is threatened poul- tices may be applied, but pus should be evacuated as soon as it forms. Chronic lymphadenitis follows the acute form, particularly when the source of irritation has not been removed ; it also occurs as the result of chronic infection, particularly by the infectious granulo- mata, the most important of which are syphilis and tuberculosis. The diagnosis of the cause of chronically enlarged glands, which are sometimes loosely called lymphadenoma or lymphoma, involves a consideration of (1) the chronic simple form, (2) the tuberculous and (3) the syphiHtic varieties, (4) Hodgkin's disease, (5) lymphatic leukemia, and (6) neoplasms. 1 . In chronic simple lymphadenitis some source of continuous irri- tation in the area drained by the lymph glands may be discovered. Although the glands are enlarged and perhaps tender, they do not tend to mat together or to suppurate. The treatment consists in rest of the part, remioval of any source of infection, the local application of iodin, belladonna, mercury, or ichthyol, and the administration of tonics. If recovery does not follow appropriate treatment, a strong suspicion of tuberclosis should be entertained. 2. Tuberculous lymphadenitis is often painless, progresses despite local treatment, and successively involves gland after gland. The glands show a strong tendency to adhere to each other and to the skin, and to undergo caseous degeneration. The condition is most common in children, in whom other signs of tuberculosis may be LYMPHATIC SYSTEM 339 recognized. The family history is of some importance. The use of tuberculin for diagnosis is not generally employed (see "Diagnosis of Tuberculosis"). In the neck tuberculous glands usually make their appearance first in the submaxillary triangle. Calcified tuberculous lymph glands may be shown by the X-ray. The treatment is removal of the diseased glands, if possible, and attention to the general health as in tuberculosis elsewhere. Recurrence takes place in probably one-half of the cases, and should be dealt with in the same manner as the primary focus. When complete extirpation is impracticable, as much of the broken down tissue as possible should be removed with the curette. Encouraging results have been obtained with radio and heliotherapy. 3. Syphilitic lymphadenitis is diagnosticated by the history of a sore, by associated lesions of syphilis, by the Wassermann test, and by the results of treatment. The glands are hard, discrete, not adherent to each other or to the skin, do not tend to suppurate, and are neither painful nor tender. The enlargement in the primary stage is confined to the glands anatomically related to the sore; during the secondary period the distribution is general, the epitro- chlear, the submental, and post cervical glands always being in- volved ; in the tertiary period a gland or a group of glands may become gummatous. The treatment is that of syphilis. 4. In Hodgkin's disease {pseudoleukemia, general lymphadenosis) the enlargement is usually first noticed at the root of the neck, and then spreads to other regions, sometimes involving the lymphatic structures throughout the body and often the spleen. The glands increase rapidly in size, forming enormous masses in which the indi- vidual lymph nodes are readily made out, each mass resemb- ling a bunch of large grapes ; there is little or no pain or periadenitis, and rarely suppuration (Fig. 141). In some instances the disease remains localized for a considerable time. The nature of the condi- tion is not quite clear, some believing it to be sarcomatous, some tuberculous, and some a distinct morbid entity that is due to a bacillus that can be recognized by microscopic study of an excised gland. Recurring attacks of intermittent fever are common. The blood shows no characteristic changes beyond those of a progressive anemia and occasionally eosinophilia. The disease is fatal in from a few months to several years. The treatment, if the glandular enlargement is sufficiently localized, is excision; in other cases arsenic and radio- therapy. Coley's fluid has been tried, and Yates uses a vaccin prepared from a diphtheroid bacillus, which is believed to be causa- tive. 340 MANUAL OF SURGERY 5. Lymphatic leukemia closely resembles Hodgkin's disease, but the blood shows a marked leukocytosis; or a relative lymphocytosis, without an increase in the total number of white cells. Spleno- medulluary leukemia and chloroma also may present enlarged lymph glands. The treatment of these conditions is similar to that of Hodgkin's disease. 6. Neoplasms of the lymph glands, excluding Hodgkin's disease and leukemia, may be primary or secondary. The primary growths are (a) lymphosarcoma, (b) ordinary sarcoma, (c) endothelioma. a. Lymphosarcoma arises from the lymphatic tissue and consists chiefly of lymphocytes, hence the term lymphocytoma. It differs from ordinary sarcoma in that it may begin in several glands of the Fig. 141. — Hodgkin's disease. (Longcope — Pennsylvania Hospital.) same region at the same time; it rarely breaks down or ulcerates through the skin, although it infiltrates environing structures; it metastasizes by the lymphatics ; and when the tumor cells reach the blood stream, possibly through the thoracic duct, they often give rise to secondary growths in the lymphatic tissue of the intestine, a region in which metastases from ordinary sarcoma or carcinoma seldom occur. Lymphosarcoma grows rapidly and is quickly fatal, b. Ordinary sarcoma springs from the connective tissue of a lymph gland, and is composed of round or spindle cells, or both, hence the clinical course varies in difit'erent cases. However, the tumor always begins in a single gland, ultimately infiltrates the surrounding struc- tures, ulcerates, and metastasizes by the blood. Sometimes the affected gland reaches an enormous size, looking like a kidney, before the neoplasm breaks through the capsule. LYMPHATIC SYSTEM 341 c. Endothelioma {lymphangioendothelioma) is derived from the endothelium of the sinus of a lymph gland. One or several nodes may be involved. The tumor often grows slowly, recurs locally after excision, and does not metastasize to distant parts (cf. endothe- lioma of the carotid body and of the parotid gland). In other cases it exhibits all the features of ordinary sarcoma. The secondary growths are usually carcinomatous, the primary neoplasm being, or having been, in the area drained by the affected glands. Lymphosarcoma, melanotic sarcoma, and sarcoma of the tonsil, testis, and thyroid also cause secondary growths in the lymph glands. The treatment of all neoplasms is, if possible, excision. Radio- therapy may be employed after operation to prevent recurrence, and is often of decided benefit in inoperable cases. Status lymphaticus, or lymphatism, is a hyperplasia of the thy- mus, spleen, lymph tissues, and lymphatic glands of the entire body, including the lymphoid bone marrow. It may be associated with rickets, goiter, or hypoplasia of the heart and aorta. It may be found in adults but is most frequent in children. This condition is of interest to the surgeon, because every now and then it is respon- sible for sudden death during or some time subsequent to operation, often of the most trivial nature. The cause of death is not clear; in a few instances pressure of the enlarged thymus on the trachea seems to be responsible, but in most cases a lympho- or thymo-toxemia better fits the conditions found postmortem. The diagnosis of lymphatism should make one hesitate to perform an operation of election. The patients are usually anemic, the tonsils hypertrophied the lymph glands generally enlarged, the thyroid more prominent, and the thymus increased in size (see Hyperplasia of the thymus). CHAPTER XVII. NERVES Neuritis may be acute or chronic; limited to a single nerve or group of nerves, or widely di&tribu.ted{polyneuritis or multiple- neuritis). It is caused by external influences, such as cold, injuries and extension of inflammation from contiguous structures; or by toxic or infectious agents reaching the nerves through the blood, such as lead, arsenic, alcohol, diphtheria, gout, rheumatism, syphilis, beri-beri, etc. The symptoms of the localized form, which alone is amenable to surgical treatment, are sharp pain and tenderness along the nerve, which is sometimes palpably swollen. In the early stages there may be hyperesthesia of the skin, and twitching or spasms of the muscles; later with the onset of degenerative changes there are paresthesia, such as numbness or formication, and possibly complete anesthesia, paresis or paralysis of the muscles, and various trophic lesions, such as edema, glossy skin, loss of the hair and nails, ankylosis of joints, ulcers, localized sweating, and atrophy of the muscles (which show the reaction of degeneration). Particularly in traumatic cases the inflammation may spread upwards to the spinal cord, and even to the corresponding nerve on the opposite side of the body. The duration of neuritis varies from days to months or years and recovery may be complete or only partial. The treatment is removal of the cause if possible, and during the early stages, complete immobilization, cold or heat, and nerve sedatives. Counterirritation with a series of blisters is often of value. Any existing diathesis should be treated. In the later stages strychnin, massage, electricity, and active and passive motions for the prevention or alleviation of degenerative changes are indi- cated. When internal medication fails, the nerve may be pierced with needles, which are allowed to remain for a short time (acupunc- ture) ; injected with cocain, chloroform, alcohol, Schleich's solution, or osmic acid (see ' ' Fifth Nerve ") ; cut {neurotomy) ; resectedineurectomy) or avulsed if the nerve itself is of little importance ; when the nerve is an important one, it may be stretched (neurectasy) ; or the sheath opened and the fibers separated by blunt dissection; and finally, in desperate cases, the sensory roots in the spinal canal or the skull may be divided or the ganglia excised. 342 NERVES 343 Neuralgia is a paroxysmal stabbing or burning pain in a nerve or group of nerves, lasting from a few seconds to hours, and recurring at widely varying intervals. The nerve may be tender at a point where it leaves a bony canal or courses over a resistant structure {points douloureux) and pressure on these points may precipitate an attack. The muscles may twitch or be violently contracted during the paroxysm, and trophic changes may be found in the area over which the nerve presides. Causalgia (W(jir Mitchell) is severe burn- ing pain, coming in paroxysms, which may be induced by a light touch, cold, heat, and even emotional influences. It follows injury to a nerve, most often the median, and is generally due to adhesions about the nerve or to neuritis. The causes of neuralgia are those of neuritis, or those of reflex irritation, such as carious teeth, errors of refraction, worms, and diseases of the nose, throat, and ovary. Anemia, nervous tempera- ment, and physical debility strongly predispose to, if not actually cause, the disease in many cases. Neuralgia is called true when no cause can be found, secondary, or symptomatic, when due to some general or local affection. The more thoroughly one studies the disease the more often will the source of irritation be discovered; thus sicatica may be due to a pelvic tumor, intercostal neuralgia to spondylitis or a tumor of the spinal cord, and neuralgia of the testicle to an incipient hernia. The treatment of symptomatic neuralgia is that of the cause. In true neuralgia, the general health should be built up by fresh air, good food, and tonics. Nerve sedatives and hypnotics are used during the attack, which in some cases may be terminated by pres- sure over the nerve, or by freezing with chlorid of ethyl. Morphin is often absolutely necessary, but in chronic cases, as in neuritis, should be used with caution. The surgical treatment is that of neuritis. For the special forms of neuralgia the reader is referred to the section on "Special Nerves" and the chapters on regional surgery. Tumors of nerves include the true neuromata (rare) , made up of medullated {myelinic) or non-medullated {amyelinic) nerve libers, and the false neuromata, which are usually fibrous or myxomatous growths arising from the peri- or endoneurium. Occasionally sarcoma develops in the same situation. False neuromata may be single or multiple, and vary greatly in size. A painful subcutaneous tubercle is a small fibroma developing from the sheath of a nerve filament. When involving a large nerve, a false neuroma may be painless except when pressed upon. The function of the nerve is seldom disturbed. 344 MANUAL OF SURGERY The treatment of neuroma is removal. A false neuroma of a large nerve can usually be enucleated alter splitting the neural sheath longitudinally and separating any nerve fibrils that may be spread over the growth. If removal cannot be effected without destroying the continuity of the nerve, this should be done and the ends sutured. The treatment of traumatic neuroma, a term often apphed to the bulbous proximal end of a divided nerve, is excision (see "Amputa- tions")- Neurofibromatosis {Recklinghausen'' s disease) may be congenital, hereditary, or familial, and effects the male more often than the female. It is of long duration, and finally terminates in death, often owing to the development of sarcoma or phthisis. The varie- ties mentioned below may exist singly or in combination. Multiple neuro fibromata may be limited to a single nerve trunk, or to a nerve and its branches {plexiform neuroma), often one of the head or the neck, in which event the thickened, tortuous, elongated filaments can be felt beneath the skin; or there may be a widespread thickening {generalized neuro fibromatosis) of many, indeed all, of the nerves of the body, with the development of multiple tumors spring- ing from the connective tissue of the nerves. The tumors may be tender or there may be no symptoms. Paralysis is uncommon, unless growths arise in the spinal canal. Cutaneous neurofibromata {molluscum fihrosuni) are soft, lobulated, or flap-like tumors which vary greatly in size, and may be scattered over the entire body, except the palms of the hands and the soles of the feet. They are supposed to originate in the sheaths of the dermal nerves. Elephantine thickening of the entire cutaneous and subcutaneous tissue covering a part, e.g., the leg {elephantiasis neuromatosa, pachy- dermatocele) , is really a dift'usion of molluscum fibrosum. It differs from other forms of elephantiasis in that it may exist at birth {con- genital elephantiasis) and be associated with multiple neuromata. Brownish pigmentation of the skin, in patches or diffused, may appear in any of the forms of neurofibromatosis, the face, the neck, and the trunk being the regions most often discolored. The treatment of plexiform neuroma is, in some cases, excision. Generalized neurofibromatosis is not amenable to surgical treatment if one excepts amputation for an elephantiasis neuromatosa that, by its size and weight, interferes with locomotion. Injuries of Nerves.- — Concussion of a nerve may occur when it is violently jarred, e.g., by a bullet which passes close to the nerve. In the pure form there is no anatomical lesion and only a temporary. NERVES 345 usually inc()ni])lete, suspension of the function of the nerve (cf. "Cerebral Concussion"). Contusion of a nerve causes violent pain, and if severe, signs of incomplete or complete section of the nerve (vide infra). It may be followed by neuritis and subsequent degeneration. The treatment is rest, and later massage and electricity. If the symptoms are those of complete section and the reaction of degeneration appears, the nerve should be exposed by an incision, when it may be discovered that the injury is a rupture instead of a contusion, in which event the nerve should be sutured. Usually the site of injury is marked by a thickened, indurated area, which should be resected, and the ends of the nerve sutured. If no change in the nerve can be found, the incision is closed. Compression of a nerve may be caused by tumors, aneurysms, fractures, dislocations, cicatricial tissue, callus formation, tourni- quets, splints, crutches, etc. Acute compression, such as that due to lying on the arm during sleep or other unconscious states, causes anesthesia and paralysis, or in the slighter forms a sensation of numbness or tingling. Chronic compression, gradually produced, causes at first increase in the function of the nerve, i.e., neuralgia, and twitching or spasms of the muscles, and later, anesthesia, paraly- sis, and trophic changes. The treatment is removal of the cause, massage, and electricity. After the liberation of a nerve from callus or cicatricial tissue (neurolysis) its sheath, if much thickened, should be split longitudinally, in order to relieve the fibers of the pressure thus exerted, and the nerve may be wrapped in muscle, Cargile membrane or, best, fat to prevent the reformation of adhesions. After neurolysis the function of the nerve is restored in 65 per cent, of the cases (Hashimoto). Complete rupture or section of a peripheral nerve is followed by (i) immediate paralysis if it contains motor fibers; (2) imme- diate anesthesia if it contains sensory fibers; and (3) by trophic changes. 1 . Paralysis involves all the muscles supplied exclusively by the nerve. It may be recalled that certain muscles are supplied by more than one nerve, and that as most movements are the result of the action of several muscles, it is necessary, in order to determine the exact extent of the paralysis, to investigate the muscles themselves rather than the movements which they produce. 2. Anesthesia of the skin is complete only in the area supplied exclusively by the nerve; in the parts which it supplies in common with other nerves, loss of sensation is incomplete or absent. Sherren 34^ MANUAL OF SURGERY divides the peripheral sensory nerve-fibers into three classes: (a) Nerve- fibers of deep sensation recognize deep pressure and the position and movements of the bones and joints. They accompany the motor nerves to the muscles and course through tendons, ligaments, and bones, hence deep sensation is rarely impaired, unless the nerve is divided above all its motor branches or unless the muscles and ten- dons are severed, (b) Protopathic nerve-fibers are important agents in the production of reflex movements. They appreciate pain, e.g., a pin prick, and great variations in temperature, but the sensations are badly localized, radiate widely, and are accompanied by tingling, As the protopathic fibers of adjacent nerves overlap to a considerable extent, section of a single nerve results in a loss of their functions in a small and variable area, (c) Epicritic nerve- fibers perceive and accurately localize light touches, e.g., of a hair, trivial changes in temperature, and the contact of two points, e.g., of a compass, close together. These fibers do not overlap so much as the protopathic fibers, hence after section of a nerve their functions are destroyed over a well defined and larger area, which corresponds in outline to that given in an anatomical treatise as representing the distribution of the nerve. 3. The trophic changes are at first hyperemia and elevation of the local temperature, owing to vasomotor paralysis; later the parts become cold and livid. If neuritis is absent, the skin becomes dry, rough, scaly, and edematous; if neuritis is present, thin, smooth shiny, and often bathed with sweat. In the latter instance vesicular and pustular eruptions, painless ulcers and subcuticular abscesses, and chilblains may occur. The nails may become curved, brittle, and ridged transversely and longitudinally, sometimes being shed as the result of paronychia. The hair likewise becomes brittle and is lost. The subcutaneous tissues and the bones may atrophy, and the joints, especially those of the fingers, may be the seat of a plastic synovitis that eventuates in ankylosis. The muscles atrophy and are ultimately replaced by fibrous tissue, deformities often resulting from contraction of the unopposed normal muscles. The electrical reac- tions are altered. The nerve slowly fails to respond to the faradic and galvanic currents, all excitability disappearing after twelve days. The muscles cease to react to the faradic current in from three to eight days, but during the first few weeks excitability by the galvanic current is increased and the reaction of degeneration appears, i.e., the anodal closure is greater than the cathodal closure contracture, which is the reverse of normal. As the degenerative changes in the muscles advance, excitability by the galvanic current slowly diminishes, until NERVES 347 finally, after a year or perhaps several years, all contractility is lost, and recovery cannot occur. Secondary^ or Wallerian degeneration, takes place in the proximal segment as far as the tirst node of Ranvier, and in the entire distal segment, the medullary substance undergoing segmentation, and with the axis cylinders finally becoming absorbed. These changes are said to occur whether the nerve is sutured at once or not. If the nerve does not unite, the central end becomes bulbous, owing to the formation of hbrous tissue in which coils of new axis cylinders appear. Thus the end-bulb is really a neurofibroma, and sometimes, particularly after amputations, it becomes excessively painful (see "Amputations''). The peripheral end also may become bul- bous, but more commonly it shrinks. Regeneration is thought, by some, to be due to the outgrowth of the undegenerated axis-cylinders of the prcximal segment, which, when the ends of the nerve are approximated and occasionally when the ends are separated some distance, force their way downwards through the distal segment. Others believe the axis cylinders are reformed by proliferation of the neurilemma cells, and that the distal segment regenerates even when not brought in contact with the proximal segment; certain it is that sensation sometimes returns so rapidly after secondary suture as to be explainable only by the union of the axis- cylinders from each segment. As a rule regeneration is not completed for many months and sometimes not for several years. In Gosset's series of cases of nerve suture, the first voluntary movements were observed at periods ranging from three months (median nerve) to 21 months (sciatic nerve), the average varying from about six months (median nerve) to 16 months (sciatic nerve) . Restoration of function is first manifested by an improve- ment in the nutrition of the part. Sensation always reappears before motion, which in many cases is never perfectly regained. The treatment is immediate suture, or neurorrhaphy . The principles of neurorrhaphy are asepsis; gentleness (tHe nerve should not be handled with forceps) ; resection, mth a sharp knife, of lac- erated ner^^e ends or, in secondary neurorrhaphy, scar tissue; ap- proximation without tension or axial rotation, one or two catgut sutures being passed through the ends of the nerve, and the sheath accurately stitched with the same material; prevention of adhesions by covering the suture line with fat; rigorous hemostasis; no drain- age. In secondary neurorrhaphy i.e., weeks or months after the injury, the ner\-e should first be isolated above and below the scar. After the ends have been found, they are removed by shaving oft" 348 MANUAL OF SURGERY successive transverse sections until the nerve fasciculi project as isolated bundles free from fibrous tissue. When the resulting gap is wide it may be closed by the following methods: (i) The ends of the nerve can be brought together by stretching each segment and by flexing the neighboring joint, the flexion being maintained for three or four weeks, after which the joint is gradually extended ; by altering the course of the nerve, e.g., by transferring the ulnar nerve to the front of the elbow; or by resecting bone in order to shorten the limb. When the ends of the nerve are directly united more or less function returns in about 75 per cent, of the cases. (2) Neuroplasty (Fig. 142) is generally regarded as illogical, since the terminations of the axis cylinders, at least in one segment, are not brought in contact. (3) Anastomosis with, or transplantation to, a neighboring nerve has given an occasional success (Figs. 143 to 146). (4) Free trans- plantation is in the experimental stage, but a few successful results Pig. 142. Figs. 143, 144, i45. 146. Neuroplasty. Nerve transplantation or anastomosis; paralyzed nerve shaded. Fig. 147. Suture a distance. have been reported. The transplant can be obtained from the paralyzed nerve, by taking one half of its thickness for an appro- priate distance; or a relatively unimportant nerve, e.g., the radial, the long saphenous, or the musculocutaneous of the leg, can be excised, cut into suitable lengths, and the pieces tied together with catgut so as to form a bundle. Grafts from a recently amputated limb and froni lower animals also have been tried. (5) Suture a distance (Fig. 147) is useless unless the "distance" is very short. (6) Tubulization consists in placing each end of the nerve in an ex- cised segment of the vein, a segment of formalinized artery, a tube composed of fascia, decalcified bone, or other material, to prevent the intervention of surrounding structures. In nine cases of tubu- lization in animal experimentation the result was "good" in one, "fair" in one (Lewis). If the patient has had an infected wound neurorrhaphy should not be performed until the wound has been healed for several [months, because of the danger of mobilizing NERVES 349 latent bacteria. Before and after operation overstretching of par- alyzed muscles should be prevented by splints or braces, and mas- sage, electricity, and passive motions used as long as the paralysis continues. If the operations listed above are inapplicable the function of the part may sometimes be improved by tenoplasty, myoplasty, or the adjustment of orthopedic apparatus. Partial section of a mixed nerve, if not more than one-third is divided, may cause no symptoms. Paralysis, when present, is incomplete, and, although the muscles may tail to respond to farad- ism, they react promptly to the galvanic current and without showing the reaction of degeneration, i.e., polar reversal. Anesthesia involves principally the epicritic nerves, i.e., those which appreciate light toucti. Trophic disturbances are slight or absent, unless a neuritis is inaugurated. Aside Irom removal ot a foreign body, which might prevent union of the divided fibers or cause irritation, the treatment is expectant; and the prognosis is good. If susbequent to the injury a lateral neuroma forms and causes trouble it m.ay be resected and the divided fibres sutured, after separating them, if necessary, from the healthy portion of the nerve, in which case the latter would, at the completion of the operation, be thrown into a series of curves. LESIONS OF SPECIAL NERVES In affections of the cranial neive trunks the loss of function is on the same side as the lesion; if the lesion be central, i.e., in the brain the symptoms are referred to the opposite side of the body. The olfactory nerve may be injured in fractures of the cribriform plate or in contusions of the forehead, resulting in transitory or permanent anosmia (loss of smell). The optic nerve also may be involved in a fracture of the base of the skull, resulting in rupture or compression of the nerve. In the former event blindness is permanent, in the latter, particularly when due to blood, vision may be restored. The optic nerve may be compressed also by inflammations in the orbit, or by tumors, aneur- ysms, foreign bodies, or cicatricial tissue. Optic neuritis {papil- litis, choked disc) is usually the result of increased intracranial pres- sure, e.g. from tumor or abscess of the brain. The third nerve (motor oculi) may be affected centrally in cerebral affections, or peripherally by trauma, tumors, etc. The nerve supplies the iris and all the muscles of the orbit except the superior oblique and the external rectus. Paralysis of the nerve causes ptosis, external squint with the eye turned a little downwards, mydria- 350 MANUAL OF SURGERY sis, loss of accommodation owing to paralysis of the ciliary muscle and slight exophthalmos owing to the loss of tension exercised by the muscles. The fourth nerve fpatheticus) supplies the superior oblique, paralysis of which causes impaired movement of the eye downwards and outwards. The fifth or trigeminal nerve supplies the face with sensation and the muscles of mastication with motion. It is rarely affected in head injuries, but is often the seat of neuralgia. Trifacial or trigeminal neuralgia, (called also tic douloureux in contradistinction to tic convulsif, which is a spasm of the facial muscles, and which may or may not be associated with neuralgia of the fifth nerve), usually begins in the infraorbital or inferior dental branches. It is charac- terized by paroxysms of excruciating pain, often provoked by the slightest irritation, such as a breath of air or attempts at mastication. There may be lacrymation, an increase in the amount of saliva and nasal mucus, unilateral sweating of the head, and, as already men- tioned, spasm of the facial muscles. There are two forms, the reflex or symptomatic, which may occur at any time of life, and true tic douloureux, which generally occurs after the fortieth year, and which is thought to be due to a senile sclerosis of the nerve or the blood vessels. The treatment is the removal of any reflex irritation, such as errors of refraction, diseases of the nose, teeth, ear, etc., and the comibating of any existing constitutional affection, such as malaria, anemia, syphilis, gout, rheumatism, or other toxic or infectious condition. Of the many local measures which have been used may be mentioned cold, heat, menthol, belladonna, chloral croton, blisters, the cautery, freezing of tender points {points douloureux) , and the galvanic current. Nerve sedatives and hypnotics must be used for the pain. Strychnin in increasing doses, until some physiological results have been obtained, has been highly recommended. When these measures fail operative treatment will be demanded. Facial neuralgia has been treated by ligation of the common carotid, resec- tion of the superior cervical ganglion of the sympathetic, and by stretching the seventh nerve when associated with tic convulsif, but practically all surgeons prefer to attack the fifth nerve itself. Simple division of the nerve and nerve stretching are very transient in their effects and are not recommended. In order to effect a physiological section, 5 or lom. of a 1.5 per cent, solution of osmic acid are in- jected into the branches of the nerve after they have been exposed by incision. Alcohol (80 per cent.), formalin, and other substances have been used in a similar way, or injected subcutaneously into NERVES 351 the nerves at their points of exit from the cranium. The last named procedure requires special skill and is not without danger. The relief obtained may last from a few weeks to a few months, occasion- ally a few years, and rarely it may be permanent. More satisfactory from a surgical standpoint is resection of the peripheral branches of the nerve, which may have to be repeated, owing to the regeneration of these filaments. Regeneration is especially likely to occur when the nerve occupies a bony canal, hence, after resection, some surg- eons plug the canal with gold foil, dental paste, or a similar material. Kanavel suggests covering the foramen with a flap of periosteum, or lining the canal with an osseous transplant. When the entire nerve is involved or recurrences are frequent, more formidable operations are required, even to resection of the Gasserian ganglion. Resection of the supraorbital nerve may be performed through an incision about one inch long in the line of the eyebrow, after this has been removed by shaving. The nerve makes its exit through the supraorbital notch or foramen, at the junction of the inner and middle thirds of the upper margin of the orbit. As much of each end as possible is removed. The supratrochlear nerve may be found at a point where a line drawn from the angle of the mouth to the inner canthus touches the upper margin of the orbit. The infraorbital nerve emerges from the infraorbital foramen about one-third inch below the middle of the lower margin of the orbit. A curved incision is made below the lower margin of the orbit and the nerve isolated. The periosteum of the orbital floor is then elevated, the roof of the infraorbital canal opened, and the nerve divided as far back as possible and drawn out through the foramen. By this method even the main trunk of the superior maxillary may be reached and divided. The superior maxillary nerve and Meckel's gangUon may be removed by the Carnochan-Chavasse operation. A T-shaped inci- sion is made, the horizontal portion of which runs from canthus to canthus beneath the lower margin of the orbit, and the vertical, downwards from the center of this incision to, but not into, the mouth. The infraorbital nerve is isolated and secured with a piece of silk, and both the anterior and posterior walls of the antrum are opened by a gouge or chisel, care being taken not to injure the internal maxillary artery. The infraorbital canal is opened on the roof of the antrum, and the nerve divided on the cheek and pulled down through the antrum. It is then traced backwards to the foramen rotundum, where after shght traction it is divided. Meckel's 352 MANUAL OF SURGERY ganglion is brought away with the nerve. The same procedure has been carried out through the orbit, and from the side of the face after resection of the zygoma and coronoid process of the lower jaw. The inferior dental nerve may be resected by making an incision along the lower border of the jaw back to the angle. The masseter is scraped from the bone, which is then chiseled or trephined about one and one-fourth inches above the angle, so as to remove the outer half of the thickness of the bone and expose the nerve at its entrance into the inferior dental foramen. The nerve is lifted from its bed by a sharply curved hook, and as much of each end as possible re- moved by avulsion. The inferior dental may be resected also through the mouth. A gag is placed between the teeth of the opposite side, and an incision made along the anterior border of the ramus of the lower jaw to the last molar tooth. After separating the internal pterygoid muscle from the bone and locating the spine of Spix, at the base of which is the inferior dental foramen, a hook is passed around the nerve and as much of it as possible removed. The lingual nerve may be exposed in the mouth by making an incision midway between the tongue and the gum of the last molar tooth, or externally by an incision in the submaxillary triangle. The auriculo -temporal nerve may be exposed at the root of the zygoma by a vertical incision between the temporal artery and the pinna. The buccal nerve may be exposed by a vertical incision through the mucous membrane and buccinator fibers, the center of the incision being at the middle of the anterior border of the vertical ramus of the inferior maxilla. The inferior maxillary nerve may be divided at the foramen ovale after resection of the zygoma or coronoid process, or both. Another method is to deepen the sigmoid notch of the lower jaw three-fourths of an inch or more. M5^ter's operation is a resection of the second and third divisions of the fifth nerve at their exit from the skull, after temporary resec- tion of the zygoma. In Abbe's operation the external carotid is ligated and a vertical incision made above the middle of the zygoma. The skull is then opened by gouge and rongeur, and the second and third divisions exposed extradurally and severed at the foramen rotundum and foramen ovale. A slip of gutta-percha tissue is placed over the foramina in order to prevent the junction of the divided nerves. Removal of the Gasserian ganglion is indicated in cases in which the entire nerve is involved, or in which less dangerous operations NERVES 353 have failed. In the llartlcy-Krause methods horseshoe-shaped osteo- plastic flap consisting of scalp and bone is made in the temporal rei!;ion with the base at the zygoma. In raising this flap the middle meningeal artery is often injured. The dura mater is not opened, but is stripped from the middle fossa of the skull until the second and third divisions of the nerve are found; these are traced backward to the ganglion at the apex of the petrous portion of the temporal bone. The dura I envelope (cavum of Meckel) of the ganglion is then opened, the ganglion separated from this envelope, the second and third divisions divided near their foramina, and the ganglion twisted out with forceps. Cushing, after cutting through the zygoma at each end, opens the skull lower down, so as to avoid injury to the middle meningeal artery. Rose reaches the ganglion through the pterygoid region after resecting the zygoma and the coronoid process of the lower jaw. In Horsley's method the dura is opened and the ganglion removed. In the Spiller-Frazier operation the sensory root of the ganglion alone is divided. The mortality of these operations is from lo to 20 per cent., but the chance of permanent cure in those who survive is very great. Ulceration of the cornea may occur, and should be anticipated by suturing the eyelids together at the time of operation, and later, if there is the slightest irritation, by the wear- ing of a watch glass over the eye. The cavernous sinus and the sixth nerve have both been injured during operation. Division of the sixth nerve causes internal squint as the result of paralysis of the external rectus. The seventh or facial nerve may be paralyzed (Bell's palsy) within the cranium from tumor, abscess, hemorrhage, thrombosis, embolism, softening of the brain, etc.; in its passage through the Fallopian canal from fracture of the base of the skull and middle ear disease, causing compression or neuritis; and at its emergence from the styloid foramen by trauma, tumors, and neuritis from cold. When the nerve is affected in the cortex, corona radiata, or internal capsule, the lower half of the opposite side of the face is paralyzed, usually with hemiplegia, and the reactions of degeneration are absent. When the lesion is in the lower part of the pons, the face is paralyzed on the same side, and the arm and leg on the opposite side {crossed paralysis), owing to the fact that the motor fibers to the arm and leg decussate in the medulla. A lesion between the brain and the Fallopian canal is often accompanied by deafness, and the paralysis involves the entire face of the same side. Section of the facial nerve, where it is accompanied by the chorda tympani, i.e., between the geniculate ganglion and the lower part of the Fallopian canal, causes loss of 23 354 MANUAL OF SURGERY taste over the anterior two-thirds of the corresponding half of the tongue. The treatment is removal of the cause, whenever possible. Mas- sage, electricity, and iodid of potassium are used in cases not suitable for surgical treatment. In cases of extracerebral origin in which electrical examination reveals the presence of fairly healthy muscles, the nerve may be severed at the stylomastoid foramen and the distal end sutured into the spinal accessory or hypoglossal nerve. The extent of recovery is limited to associated movements in conjunction with the shoulder. The cases most suitable for operation are those in which the palsy has lasted for six months without any signs of recovery. The operation may be done also in severe cases of facial tic (clonic spasms of the facial muscles) which have resisted medical treatment and neurectasy (Ballance and Stewart). The eighth or auditory nerve may be involved in tumors, menin- gitis, hemorrhage, or traumatism, often resulting in incurable deafness. It has been divided for uncontrollable tinnitus of peripheral origin. Lesions of the glossopharyngeal nerve are rare; paralysis would affect taste, swallowing, and possibly speaking. The tenth or pneumogastric nerve may be compressed by tumors or aneurysms, or injured in fracture of the base of the skull or in operations on the neck. Irritation may cause vomiting, inhibition of the heart, and spasm of the laryngeal muscles. Division of one pneumogastric may be followed by few or no symptoms, but division of both nerves causes death from paralysis of the laryngeal muscles. A lesion of the pneumogastric nerve in the lower part of the neck, or of the recurrent laryngeal branch, causes paralysis of the muscles of one side of the larynx, with resulting hoarseness and impaired phonation. The eleventh or spinal accessory nerve is exposed to wounds and many forms of irritation. Section of the branch which joins the pneumogastric results in paralysis of the laryngeal muscles. The external branch is distributed to the sternomastoid and trapezius, which muscles may not be completely paralyzed after division of the nerve, as they receive filaments also from the cervical nerves. The nerve has been stretched or divided for spasmodic torticollis. The twelfth or hypoglossal nerve when divided, causes paralysis of one side of the tongue, which, when protruded, is directed to the paralyzed side; deglutition also may be impaired. The phrenic nerve, when irritated, causes hiccough, and when divided, paralysis of the diaphragm, which, if unilateral, is often scarcely noticeable, but if bilateral may cause instant death. NERVES 355 The brachial plexus miiy be injured (a) above or (b) below the clavicle. (a) Supraclavicular injuries may be direct, e.g., from penetrating wounds, fracture of the clavicle or cervical spine, or pressure of a cervical rib; or indirect, the nerves being overstretched or ruptured as the result of traction, the direction and violence of the force determining the grade and extent of the paralysis, of which there are three common types. 1. The upper arm, or Duchenne-Erh type, is the most frequent. It is due, not to the pressure of the clavicle, as has been thought, but to a forcing apart of the head and shoulder, the brunt of the strain falling upon the anterior primary division of the fifth cervical nerve, hence paralysis of the deltoid, supraspinatus, infraspinatus, biceps, brachiahs anticus, supinator longus, and supinator brevis, which causes loss of abduction and outward rotation of the arm and loss of flexion and supination of the forearm. Sensation is not im- paired. When the traction is less severe only the upper part of the fifth cervical may be ruptured, resulting in paralysis of the deltoid and spinati; as these cases follow a blow on the shoulder they are frequently diagnosticated as injury to the circumflex nerve (Sherren). 2. The lower arm, or Klumpke type, is caused by upward traction on the arm. e.g., when a man saves himself from a fall from a height by clutching a projection of some sort. In these cases the first dorsal nerve is stretched or torn, and the intrinsic muscles of the hand and often the cervical sympathetic nerve are paralyzed. Anesthesia exists over the inner side of the arm and forearm, and occasionally along the ulnar border of the hand. 3. The whole plexus type may be due to upward or downward traction, when of severe grade. All the muscles of the upper ex- tremity, excluding the rhomboids and the serratus magnus, are paralyzed, usually with impairment of the functions of the cervical sympathetic nerve. Anesthesia exists over the whole limb, except- ing the area along the inner side of the arm suppHed by the intercosto- humeral nerve. (b) Infraclavicular injuries, aside from penetrating wounds, are usually the result of direct pressure, e.g., from a crutch, from disloca- tion or fracture of the upper end of the humerus or attempts to reduce the deformity in these cases, especially by the heel-in-axilla method. The two common forms are the whole plexus type, which differs from that of the supraclavicular variety, in that the anesthesia is complete, and the inner cord type, which gives the symptoms of injury to the ulnar nerve, with paralysis of the muscles of the hand 356 MANUAL OF SURGERY supplied by the median nerve. Lesions of the outer cord are accom- panied by paralysis of the biceps, coracobrachialis, and the muscles innervated by the median, except those of the hand, and by anesthe- sia of the outer side of the forearm. Lesions of the posterior cord cause symptoms identical with those of the musculospiral and circum- flex nerves. Post-anesthetic paralysis of the brachial plexus is usually of the Duchenne-Erb type, the causative traction being exerted by the abducted arm hanging from the edge of the table. Those cases following elevation of the arm above the patient's head are due to pressure of the upper end of the humerus, and are of the infraclavicu- lar variety. Brachial birth paralysis usually involves the left arm and is usually due to forcible separation of the head from the shoulder, hence of the Duchenne-Erb type, although the lower arm type may follow a breech presentation with the arms extended, and in severe cases the whole plexus may be involved. The treatment of brachial paralysis depending upon direct wounds, or pressure from callus, displaced bone, etc., is that of the same injuries afTecting other nerves. Spontaneous recovery is the rule in post-anesthetic paralysis, crutch palsy, and lesions of similar intensity. Birth paralysis ultimately disappears in perhaps three- fourths of the cases, but in adults not more than 40 per cent, of the traction paralyses due to great violence recover without operation. In all cases, as soon as the tenderness due to the accident has sub- sided, massage, electricity, and passive motions should be ordered. If, in the course of several months, improvement does not follow this form of treatment, and especially if the muscles show the reaction of degeneration, operation should be advised. Kennedy, however, counsels delay in birth palsy for at least one year. An incision is made from the junction of the upper and middle thirds of the posterior border of the sternomastoid to the junction of the middle and outer thirds of the clavicle, and, if the lower branches of the plexus must be exposed, the clavicle divided temporarily. After severing the deep fascia an attempt is made to identify the individual parts of the plexus, often a most difficult undertaking, owing to the mass of cicatricial tissue in which they are imbedded. If the nerves have been divided they are sutured; if destroyed by scar tissue, resected and then united. If so much of a nerve must be excised that its ends cannot be brought together, the distal segment is anastomosed with a neighboring nerve. If operation on the nerves fails, muscular transplantation may be tried. In Duchenne-Erb paralysis Tubby NERVES ,^57 has restored llexion of the forearm by transj)hinting a portion of the triceps to the biceps, and alxluction of the arm by transplanting a portion of the i)ectoraHs major and tra])ezius to the deltoid. Xeurilis of any of the nerves of the arm may spread to and involve the entire brachial plexus, and the plexus is occasionally the seat of intractable neuralgia, for which it has been exposed and stretched. The posterior thoracic nerve may be injured or inflamed, causing paralysis of the serratus magnus, or winged scapula (q.v.). The circumflex nerve winds around the neck of the humerus three-fourths of an inch above the middle of the deltoid. It is often involved in injuries about the shoulder, resulting in paralysis of the deltoid and teres minor, and transient anesthesia of the posterior fold of the axilla. The musculospiral nerve is the largest nerve in the arm and the most abused nerve in the body. It is often injured by gunshot and stab wounds, and, especially where it lies close to the bone in the musculospiral groove, by fractures of the humerus. It is frequently compressed also in crutch palsy, by lying on the arm, and by a tourniquet, and is pecuHarly prone to be affected by lead poisoning. Division of the nerve near the plexus causes paralysis of the extensor muscles of the elbow, wrist (wrist-drop), fingers, and thumb, and, excepting the biceps, of the supinators of the forearm (Fig. 148). Extension of the terminal phalanges may still be accomplished by the interossei and lumbricales. Sensation is lost over the anterior and posterior aspects of the radial side of the elbow and forearm, the radial side of the posterior surface of the wrist and hand, and over the dorsal surface of the thumb, first, second, and half the third fingers (Fig. 151). In lead palsy both arms are usually involved, but the supinator longus and the triceps often are unaffected. In cases of pressure palsy massage and electricity will be required, recovery usually ensuing in a variable length of time. When the nerve is caught in callus or divided, operation will be necessary. So long as the paralysis continues the wrist and the proximal phalanges of the fingers should be kept extended by means of a splint or by orthopedic apparatus. When the nerve cannot be repaired the treatment just mentioned may be employed, or the tendon of the flexor carpi radialis implanted in the extensor tendons of the fingers (Murphy). The median nerve, when divided above the bend of the elbow, causes paralysis of the pronators, flexor carpi radialis, palmaris longus, flexor longus pollicis, flexor sublimis, and the radial half of the flexor profundus digitorum, with the following, which alone are 358 MANUAL OF SURGERY involved in an injury just above the wrist, abductor, opponens, and outer half of the flexor brevis pollicis, and the two radial lumbricales. There is loss of sensation in the skin of the radial side of the hand, the flexor surface of the thumb, and in the first, second, and half the third fingers, which are involved to a varying degree also on the dorsal surface (Fig. 151). There are loss of pronation, impaired radial flexion and abduction of the wrist, loss of the hand grasp on the Pig. 148. — Wrist-drop after section of Fig. 149. — Hand after section musculospiral nerve. (Gowers.) of median nerve. (Dagron.) radial side, and wasting of the thenar eminence (Fig. 149). Flexion of the proximal phalanges by means of the interossei is still possible. The ulnar nerve suppHes the flexor carpi ulnaris, the ulnar half of the flexor profundus, the two ulnar lumbricales, all the interossei, the muscles of the little finger, the adductors of thumb, the ulnar half of the flexor brevis pollicis, and the skin of the anterior and posterior surfaces of the ulnar side of the hand, including the little finger and the ulnar half of the ring finger. After division of this nerve there are anesthesia in the area just mentioned (Fig. 151), impairment of ulnar flexion and adduction of the wrist, weakened hand grasp in the ring and little fingers, loss of adduc- tion and abduction of the fingers, and extension of the proximal phalanges and flexion of the second and third phalanges of all the fingers (claw hand), with atrophy of the interossei, causing marked prominence of the interosseous spaces (Fig. 150). Dislocation of the ulnar nerve in front of the inner condyle may occur; it has been treated by suturing a flap of fibrous tissue over the nerve to the triceps tendon, after reduction has been eft'ected. A simple test for determining the integrity of the nerves supply- FlG. 150. — Hand after section of ulnar nerve. (Gowers.) NERVES 359 ing the hand is as follows: If the wrist can be extended the musculo- spiral is intact; if the index finger can be flexed while the wrist is flexed and pronated (position of wrist drop) the median is intact; if the little finger can be abducted and adducted the ulnar is intact. The lumbar plexus may be affected by injuries, by tumors, and by disease of the vertebra?. It supplies sensation to the lower part of Itl DIVISION OF 5(h Sd DIVISJOS OF Slh . W Dl VISIOS OF Slh GKFA T A VRICULA R t, 3 C, SUPERFICIAL CERVICAL CIRCVMFLEX LA TERA L CUT A SEOVS SERVES ASTERIOR CUTANE- OUS SERVES IBSSBR rSTBR.VAL CCTAyg- orS ASO IS7ERCOSrO-HU- MBRAL. I. s D VPPER EI7SRSAL CPTANB- urs OF MVSCVL0-3PIRAL ISTERSAL CUTANEOUS SUPRAORBITAL Or.EAT OCCIPITAL iMALL OCCIPITAL S.VA I.LEST OCCIPITAL (iREAT AURICULAR SUPERFICIAL DE- SCESUISG CERVI- CAL,!, kC CIRCUMFLEX, 5,6 C lATSRCOSTO-Bl'MSRAL LESSSR 1ST. Ci'TASEOt y ISTERSAL CITASEOVS OF KUSCULO-CUTANEOUS - GESITO-CRURAL RADIAL. 6 C nio-isaviSAj..t l—- HE V IAS. t, 7.9 C.I D ULSAR, 1 D SlFPl.IED BT ISTERSAL gUTANBOUS — MIDDLE CUTANEOUS ■ - EXTERNAL POPLITEAL INTERNAL SAPHENOUS •-• MUSCULO-CVTANEOVS E-^TERNAL SAPHENOUS - ANTERIOR TIBIAL - ISTERSAL PLaSTAP. EXTERNAL POPLITEAL.S L.l.iS INTERNAL SAPHESOrs. S.l L ■ EXTERNAL SAPIIESOVS, l.tS EXTERNAL PLANTAR, 1, INTERNAL PLANTAR. '., S L.l S Pig. 151. — Diagram showing the areas of distribution of cutaneous nerves. (Morris.) the abdomen, the anterior and lateral aspects of the thigh, and to a portion of the inner side of the leg and foot. It supphes also the flexors and the adductors of the hip, the extensors of the leg, and the cremaster. The obturator nerve may be injured during parturition, resulting 360 MANUAL OF SURGERY in paralysis of the adductors of the thigh, the patient being unable to cross the legs. External rotation also is impaired. The anterior crural nerve, when divided, results in paralysis of the extensors of the knee, and anesthesia over the front and sides of the thigh, and the inner side of the leg, foot, and big toe (Fig. 151). The sacral plexus innervates the rotators and extensors of the hip, the flexors of the knee, all the muscles of the foot, and the skin of the buttock, posterior surface of the thigh, outer and posterior portion of the lower leg, and almost the entire foot. It may be compressed by pelvic tumors or inflammations, injured during child birth, or involved in a neuritis, which is often an extension from the sciatic nerve. The superior gluteal nerve supplies the gluteus medius and mini- mus, hence its division results in loss of abduction and circumduc- tion of the thigh. The small sciatic nerve is not often injured. Its division results in paralysis of the gluteus maximus, and anesthesia of the posterior surface of the middle third of the thigh, and of the upper half of the calf of the leg. The great sciatic nerve, when severed near the sciatic notch, causes paralysis of the flexors of the leg (which are also extensors of the hip), and of all the muscles below the knee joint; the latter muscles alone are involved when the injury is below the middle of the thigh. Anesthesia exists in the outer half of the leg, and in the sole and the greater part of the dorsum of the foot. This nerve is frequently affected by a very painful form of neuralgia (,?«cz//'cfl), in intractable cases of which neurectasy may be required. This has been accom- plished by flexing the extended lower extremity upon the abdomen, under an anesthetic. In the open operation the nerve is exposed midway between the great trochanter and the tuber ischii, by an incision three or four inches long, made in the middle of the thigh from the gluteal fold downwards. The lower border of the gluteus maximus is exposed, the ham-string muscles retracted inwards, and the nerve hooked up by the finger and stretched both centrally and peripherally, enough force being used to lift the lower extremity from the table. The external popliteal nerve may be severed in cutting the tendon of the biceps subcutaneously, or compressed against the neck of the fibula by bandages or splints. Section of this nerve causes paralysis of the peroneal group of muscles, the tibialis anticus, the extensor longus hallucis, and the extensor longus and brevis digitorum, with anesthesia of the outer half of the anterior surface of the leg and the NERVES 361 dorsum of the fool. The ankle cannot be flexed on the leg {jool- drop), and in old cases talipes equinus develops. The internal popliteal nerve, when divided, causes paralysis of the muscles of the calf, extensors of the foot, flexors of the toes, and of the muscles of the sole of the foot. Talipes calcaneus develops after a time, and the toes become claw-like, owing to extension of the proxi- mal and flexion of the second and third phalanges. There is anes- thesia along the back of the leg and over the sole of the foot. The cervical sympathetic nerve may be injured by wounds, or compression by tumors or aneurysms. Irritation of the nerve causes unilateral sweating of the head and face, dilatation of the pupil on the same side, widening of the palpebral fissure, slight exoph- thalmos, increased intraocular tension, contraction of the blood vessels of the head and neck, and tachycardia. Division of the nerve causes contraction of the pupil, ptosis and narrowing of the palpebral fissure, decrease of ocular tension with recession of the eye- ball, dilatation of the vessels of the head and neck with increase in the flow of tears, nasal mucus, and sweat, and bradycardia. Excision of the cervical sympathetic ganglia, or Jonnesco's operation, has been performed for epilepsy, exophthalmic goiter, tic doulou- reux, and glaucoma. An incision is made along the anterior border of the sternomastoid, the carotid sheath with its contents retracted forwards, and the upper or, in some cases,, the entire three ganglia excised. The value of the operation is not yet fixed. CHAPTER XVIII MUSCLES, TENDONS, BURS^ Contusion of muscles is followed by swelling, rigidity, and by late ecchymosis if some of the blood vessels have been injured. Pain and tenderness are made worse by active motion, but are unaffected by passive motion, unless the muscle is stretched by such procedure. The treatment is rest and relaxation of the muscles, by splints, posture, or strapping with adhesive plaster; the application of ichthyol or evaporating lotion; and later massage. Wounds of muscles gap widely if they traverse the muscle fibers. A wound parallel with the fibers causes little or no separation. Suturing is readily carried out in longitudinal or oblique wounds, but is often difficult in transverse wounds, the stitches tearing out when approximation is attempted. In such cases mattress sutures may be employed; a number of sutures may be placed in each end of the muscle and tied, then the ends of the sutures in the upper segment tied to those in the lower segment; or the muscular wound may be cov- ered with a free transplant of fascia, which can be employed also to bridge a gap when a portion of the muscle has been destroyed. Chromicized catgut is the best suture material. The muscles should be relaxed by suitable posture or splint, and massage and electricity employed when healing has been completed. Strain of muscles is an overstretching of the fibres with possibly some tearing. Glass arm is a strain of the long head of the biceps; lawn tennis arm, of the pronator radii teres; riders leg, of the adduc- tor muscles of the thigh. The symptoms and treatment are those of contusion of muscle. Rupture of muscles and tendons usually occurs as the result of great violence to a contracted muscle, or as the result of a sudden, powerful, and strongly opposed contraction, but may follow even feeble efforts in muscles degenerated in consequence of senility or fevers. Rupture of the sheath or of the deep fascia may result in hernia of the muscle, a protrusion which is most marked during contraction, and which often disappears during relaxation of the muscle, when the opening in the aponeurosis may be felt through the skin. In recent cases rest and relaxation are required. Later if the hernia is large and causes inconvenience, the opening in 362 MUSCLES, TENDONS, BURS^ 363 the sheath may be sutured, or, if large, patched with a transplant of fascia lata. A muscle most frequently ruptures at the junction with its tendon, although the belly itself or the tendon may tear. In some cases the tendon is torn from its attachment, bringing with it a portion of the bone. At the time of rupture there is a sudden sharp pain, with, in some cases, an audible snap. This is followed by loss of function, tenderness, pain on motion, swelling, and ecchymosis. The gap may be felt in superficial muscles. Among the muscles and tendons most frequently ruptured are the sternomastoid (during labor), rectus abdominis, quadriceps, ligamentum patellae, tendon of the adductor longus (from riding), plantaris (tennis leg, chap, xxxi), long head of the biceps cubiti (Fig. 152), flexor muscles Fig. 152. — Rupture of biceps muscle. or tendons of the fingers, extensors of the fingers (mallet finger, (chap. xxxi). The treatment in partial ruptures is rest and relaxation; in large or complete ruptures of important muscles the ends should be ap- proximated as described above, and the part splinted. Massage, electricity, and passive motions are employed after union has taken place. Dislocation of tendons is most frequent at the point where a tendon passes along a bony groove in order to change its direction, e.g., the long tendon of the biceps, and the tendons about the wrist and ankle. It is usually the result of injury, hence may be accompanied by a fracture of a bone or a dislocation of a joint, but it occurs also as the result of chronic afTections of joints associated with displacement. 364 MANUAL OF SURGERY There are pain and weakness, and in some cases the dislocated tendon can be felt, with the groove in which it normally lies. In dislocation of the long head of the biceps the head of the humerus passes slightly forwards {subluxation) . The treatment is reduction of the tendon, relaxation of the muscle, and the application of a splint, with pressure over the tendon to hold it in place. If this treatment fails in the course of six weeks or two months, the tendon may be exposed by incision and the edges of the the torn sheath sutured with catgut. This operation is most fre- quently indicated in dislocation of the peroneus longus tendon from behind the external malleolus. Myositis, or inflammation of muscles, may be acute or chronic. Acute myositis may be due to injuries {traumatic myositis), infec- tion from the surrounding parts, exposure to cold {rheumatic myosi- tis), and to infectious fevers. The symptoms are pain, swelling, tenderness, and sometimes edema of the skin. When due to local infections or pyemia, suppuration follows. Polymyositis affects many muscles, is of obscure origin, and strongly resembles trichino- sis, hence the term pseudotrichinosis . When there is an overproduc- tion of fibrous tissue the muscle is shortened, thus in the sternomas- toid torticollis may be produced, and in the forearm Volkmann's contracture {ischemic myositis, chap. xxxi). The treatment is rest, sedative applications, and constitutional treatment according to the general condition of the patient. Sup- puration will require incision. Massage and electricity are indicated to prevent muscular contractures, which, when present, may require tenotomy or, better, tendon lengthening; resection of bone to shorten the limb also has been performed in certain cases. Chronic myositis results from the acute form, or from syphilis, tuberculosis, rheumatism, actinomycosis, or the lodgment of para- sites (trichina, echinococcus). It may cause suppuration, or degen- eration with fibrous overgrowth. In the latter event ossification may occur, particularly in the vicinity of bone, or where the parts are constantly irritated or strained, e.g., rider^s bone due to ossification of the upper portion of the adductor tendons of the thigh, and localized ossification of the deltoid in soldiers. In myositis ossificans progressiva a large part of the muscular system may be calcified. The cause is not known. It is most frequent in young males, and is sometimes associated with shortening of the thumbs and great toes. The treatment is directed to the cause. In localized myositis ossi- ficans the bony plates may be excised. In the progressive form treatment is of no value. MUSCLES, TENDONS, BURS^ 365 Tumors of muscle include fibroma, myxoma, lipoma, angioma, chondroma, osteoma, myoma, and most important of all, sarcoma; carcinoma is always secondary. A desmoid is a fibroma or fibro- sarcoma of the rectus abdominis, usually occurring in women who have borne children. A tumor in a muscle is movable i)erpendicu- larly to but not in the axis of the muscle, and becomes fixed when the muscle is contracted. The treatment is excision. Tenosynovitis, thecitis, or inflammation of a tendon sheath, may be acute or chronic. Acute tenosynovitis is caused by injury, strains, overuse, neighboring infections, gout, rheumatism, syphilis, gonor- rhea, and the infectious fevers. The symptoms are swelling and tenderness, with pain and fine crepitus upon motion. Suppuration may occur when the sheath has been opened by a wound, or when the thecitis is secondary to neighboring infections. The symptoms are then intensified, the skin reddened, and constitutional symptoms of sepsis present. The treatment is immobilization on a splint, with the application of ichthyol or evaporating lotions. Pus formation demands incision and drainage, which, if carried out early, may prevent sloughing of the tendon. Massage and active and passive motions are useful in the later stages to prevent adhesions. Sup- purative thecitis of the finger and palmar abscess are described in chapter xxxi. Chronic tenosynovitis may follow the acute form, in which case the sheath is distended with synovial fluid. There are weakness, swelling and fluctuation along the tendon sheath, and possibly crepitus. In most instances the condition is tuberculous. Tuber- culous tenosynovitis may present the same signs, or the swelling may be doughy owing to the thick, pulpy granulation tissue which lines the sheath. Often there can be felt sUpping beneath the fingers little rounded bodies (rice, riziform, or melon seed bodies), which are laminated masses of fibrin. The treatment of chronic tenosynovitis is attention to any existing constitutional disease, and locally the use of a splint, with compression or counterirritation. If this fails, the sheath may be opened, its contents evacuated, iodoform emulsion injected, and the wound closed; or an attempt may be made to re- move the diseased sheath by dissection. Ganglion is a tense sac connected with a tendon sheath, and filled with a transparent, whitish, jelly-like material. It may follow an injury or strain, and is then probably due to an encarcerated hernia of the synovial lining of the tendon sheath; in other instances it is due to a localized thecitis, a colloid degeneration of a synovial fringe, or perhaps, as some maintain, to a hyperplasia of the connective tissue 366 MANUAL OF SURGERY followed by cystic degeneration. It is most common on the back of the wrist, but may occur elsewhere. It is painful and tender when increasing in size, but usually gives no trouble when it has ceased to grow, except possibly for some weakness of the affected tendon. It may be so hard as to resemble an exostosis. Compound ganglion is a tuberculous thecitis of the flexor tendons of the wrist, projecting above and below the annular ligament. The treatment is rupture of the ganglion by strong pressure with the thumbs, or by dealing it a sharp rap with a book; expression of the contents through a small puncture, and firm pressure for several days; the injection of iodin; or in recurring cases excision. OPERATIONS ON TENDONS Tenotomy, or division of a tendon, may be open or subcutaneous It is employed chiefly in cases of deformity, and occasionally to overcome muscular spasm, e.g., cutting of the tendo Achillis in fractures of the leg. The subcutaneous method should be used only in regions in which important structures are not close to the tendon. Under aseptic precautions a sharp pointed tenotome is pushed through the skin to the tendon, and is then replaced by a blunt pointed tenotome, which is passed over or under the tendon. The tendon is then made tense and is cut by a sawing motion. The little puncture is sealed by collodion. In the open method an incision is made over the tendon and the section carried out under the eye, so that there is little danger of wounding neighboring structures. The wound is then sutured. After either method the deformity is cor- rected, and the parts are immobilized with plaster-of-Paris or other form of splint. Division of the sternocleidomastoid muscle. (See "Torti- colHs.") The tendo Achillis is divided subcutaneously. With the foot on its outer side and the tendon relaxed, the tenotome is inserted about one inch above the os calcis, and the tendon divided after it has been made taut by flexion of the foot. The tibialis anticus is divided about one inch above its insertion. The tenotome is introduced from the outside and the section made from below upwards. The peroneal tendons are cut just above and behind the external malleolus, in which situation the synovial sheath is absent. The tenotome is introduced between the bone and the tendons, which are made tense and severed from below upwards. MUSCLES, TENDONS, BURSiE 367 The tibialis posticus is severed above the internal annular liga- ment and above the origin of the synovial sheath. The tenotome is inserted just above the base of the inner malleolus, between the Fig. 153. Fig. 154. Fig. 155. Figs. 153 to 156. — Tenorrhaphy. (Monod and Vanverts.) tendon and the tibia, and hugs the bone closely. There is some danger of injury to the posterior tibial vessels. A B Fig. 157. — Tenorrhaphy. (Binnie.) Fig. 158. — Tenorrhaphy. (Binnie.) The plantar fascia is divided subcutaneously just in front of the OS calcis, by inserting a tenotome between the fascia and the skin from the inner side of the sole, and cutting towards the bone. The semimembranosus and the semitendinosus may be divided subcutaneously just above the knee joint, but section of the biceps 368 MANUAL OF SURGERY femoris is best done through an open incision, because of the proxi- mity of the pophteal nerve. Tenorrhaphy (tendon suture) is best performed with chromicized catgut. The various methods are shown in Figs. 153 to 161; Figs. Fig. 159. Fig. 160. Figs. 159 to 161. — Tenorrhaphy. (Vulpius.) (. .) Fig. 162. — Tenorrhaphy. (Binnie.) Fig. 162a. — Tenorrhaphy. Fig. 163. — Tenorrhaphy. (Binnie.) 162 and 163 show the methods for preventing the tearing out of sutures. Generally the distal stump is easy to find, but the proximal retracts, and in order to bring it into view the joint or joints may be moved in the direction which will relax the tendon and its muscle, the limb massaged or bandaged centrifugally, or slender forceps MUSCLES, TENDONS, BURS.E 369 passed up the sheath, which should not be opened any farther than is necessary, and, at the completion of the operation, should not be sutured if such produces stricture. To prevent adhesions the suture line should be enveloped with fat. After tenorrhaphy the part is splinted. Gentle passive motion should be started at the end of Fig. 164. Fig. 165. Figs. 164 to 166. — Tendon lengthening. Fig. 166. (Monod and Vanverts.) two weeks, but forcible movements, if needed, postponed until the fourth week. Tendon lengthening is occasionally employed in deformities due to shortened tendons, or in cases in which, after accidental division of a tendon, the approximation is difficult owing to retraction of the n Pig. 167. — Tendon lengthening. (Binnie.) Fig. 168. — Catgut graft, and Kowalzig.) (Esmarch the ends (Figs. 164 to 168). When the ends of a divided tendon cannot be sufficiently elongated to approximate them, the lower end may be sutured to a neighboring tendon with a similar function, or the upper end to the periosteum as near the normal insertion as possible; a graft may be made from adjacent fibrous tissue, from a neighboring tendon, from the fascia lata, from the tendon of an 24 370 MANUAL OF SURGERY animal, or from silk, catgut (Fig. 169), linen thread, or the osseous insertion may be transplanted (Fig. 170). Tendon shortening is illustrated in Figs. 171 to 173. Tendon transplantation has been employed for the relief of deformities due to paralyzed muscles. The tendon of the paralyzed Fig. 169. — Tendon lengthening. (Binnie.) V'EIVil Pig. 170. ^Tendon lengthening by transplantation of osseous inser- tion. (IMonod and Vanverts.) muscle may be divided, and its distal end threaded through a split in an active tendon and there sutured (Figs. 159 to 161). Other methods are elucidated in Figs. 174 to 181; the paralyzed tendons are shaded. Free transplantation, as described under tendon Fig. 171. Fig. 172. Fig. 173. Figs. 171 to 173. — Tendon shortening. (Binnie.) lengthening, may be tried when a portion of a tendon has been destroyed". Free transplantation of fascia, usually fascia lata from the upper and outer part of the thigh, has been employed to strengthen MUSCLES, TENDONS, BURS^ 371 Sutures Fig. 174. Fig. 175. Fig. 176. Fig. 177. Fig. 178. Fig. 179. yf^ If f f ' /■'J Pig. 180. Fig. 181. Figs. 174 to 181. — Tendon transplantation. (Vulpius.) 372 MANUAL OF SURGERY ligaments and joint capsules, to bridge gaps in muscles, to take the place of tendons, to close defects in the dura, pleura, diaphragm, bladder, air passages, and other hollow viscera, to reinforce the suture line in operations for hernia, to render joints movable (arthro- plasty), to control bleeding from and to prevent the cutting of sutures in parenchymatous organs, to occlude the pylorus after gastroenterostomy, to support prolapsed organs, to cover the osseous stump after amputation, and to act as a substitute for suture material. For the building of a tendon sheath or a nerve sheath fascia is unsuited, as it may produce firm adhesions. DISEASES OF BURSiE Adventitious bursae not uncommonly develop in situations habitually exposed to pressure, e.g., on the shoulder, under the scapula, and over the internal condyle in knock knee. Wounds of bursae differ from ordinary wounds in that the continuous escape of synovial fluid may interfere with healing and necessitate excision of the bursa or destruction of its lining membrane. Acute bursitis is usually the result of traumatism. A painful and tender cir- cumscribed swelling forms in the situa- tion of a bursa, which fluctuates and is Fig. 182.— Prepatellar bursitis frequently the Seat of a fine crepitus. (housemaid's knee). Suppuration may occur as the result of infection through a wound or from the blood. The treatment is rest, the appKcation of ichthyol or evaporating lotions, and later, compression to hasten absorption. If suppuration occurs incision and drainage are indicated. Chronic bursitis may follow the acute form, or result from chronic irritation, syphilis, tuberculosis, gout, or rheumatism. The bursa is enlarged and fluctuates, owing to the eft'usion of serous fluid within. In old cases the walls may be so thickened as to simulate fibroma. In tuberculous cases the swelHng may be doughy, owing to the thick layer of edematous granulations fining the cavity, or rice bodies may be detected. In late syphifis there may be a gummy degeneration, and in gout deposits of urate of soda {tophi). The treatment in simple cases is rest, compression, and counter- irritation with bfisters or iodin. If the effusion persists it may be MUSCLES, TENDONS, BURS^E 373 as]>iratc(I or the bursa excised. In tuljerculous cases and in those with thick walls, excision should be performed. Constitutional treatment will be needed in the presence of syphilis, tuberculosis, gout, or rheumatism. Among the bursae which are more commonly diseased are the following: A bursa over the melatarso-phalangeal joint of the big toe is called a bunion (see "Hallux Valgus"), the retro calcaneal bursa, when inflamed, Albert's disease (chap. xxxi). The prepatellar bursa is often enlarged as the result of frequent kneeling, and is known as honsemaid's knee (Fig. 182). The infrapatellar bursa lies between the ligamentum patellae and the tuberosity of the tibia, and when inflamed causes a fluctuating swelling on each side of the tendon, which is more marked when the leg is extended. The symptoms may be somewhat similar to a dislocated semilunar cartilage, owing to the pinching of the hgamenta alaria, which are crowded back between the bones. Of the popliteal bursce the one which lies between the gastrocnemius and the semimembranosus, and extends beneath the inner head of the gastrocnemius, is most frequently enlarged. It is hard and prominent when the leg is extended, and may exhibit transmitted pulsation; when the leg is flexed it is soft and may be difficult to detect. It is tedious to remove, and, as it frequently communicates with the joint, a ligature or suture will be required to close the synovial membrane at this point. The iliopectineal {iliopsoas) bursa, when enlarged, presents a swelling at the base of Scarpa's triangle, under or to the outer side of the femoral artery (Fig. 451). Sometimes the swelling is reducible, the fluid passing into the hip-joint or a neighboring bursa. Pressure of the bursa on the anterior crural nerve may cause pain running down the thigh, which is often slightly flexed, abducted, and rotated outward. The diagnosis from hip disease and femoral hernia is given under these headings. Psoas abscess is associated with disease of the spine. A neoplasm may closely simulate iliopsoas bursitis, and occasionally can be distinguished from it only by exploratory incision. The bursa of the great trochanter, when inflamed, causes abduction and eversion of the thigh, and a swelling which is most marked just behind the great trochanter. It is distinguished from coxalgia by the absence of restricted movements of the hip- joint. Enlargement of the bursa over the tuber ischii is known as Weaver's bottom, of the olecranon bursa, miner's elbow. Subacromial (subdeltoid) bursitis is described in chapter xxxi. CHAPTER XIX BONES INJURIES OF BONES A fracture has been defined as a sudden solution of the con- tinuity of a bone, generally from external violence. The Varieties. — Fractures are divided as follows: i. Accord- ing to the cause, into traumatic and pathological or spontaneous (resulting from trivial force to a diseased bone). Traumatic frac- tures are subdivided, according to the nature of the force, as explained below in the paragraph on "Exciting causes." 2. Accord- ing to the lines of fracture, into transverse, longitudinal, oblique, spiral, dentate, stellate, V-shaped, and T-shaped. A comminuted fracture is one in which the bone is broken into three or more fragments, with intercommunication of the fracture lines. A multiple fracture is one in which there is more than one fracture in a bone, the lines of which do not communicate. Fractures of several different bones also are spoken of as multiple fractures. A splintered fracture is one in which a splinter of osseous tissue is broken from a bone. 3. Accord- ing to the degree of fracture, into complete, which extends completely through a bone, and incomplete, in which the bone is not completely divided. A green-stick fracture (infraction) is an incomplete fracture resulting from the bending of a bone, the osseous tissue of the convex side separating and that of the concave side remaining intact. A fissure fracture is an incomplete fracture occurring as a crack, usually in the outer table of the skull. A subperiosteal fracture, which may or may not extend through the rest of the bone, leaves the periosteum intact. 4. According to the position of the fragments, into impacted, in which one fragment is forced into the other, and depressed, in which the bone is crushed in. Other terms used with reference to dis- placement are, transverse, rotary, angular, and longitudinal (either overlapping or separation). 5. According to the presence or absence of a ivound in the soft parts, into closed or simple, in which there is no external wound in the soft parts, and open or compound, in which such a wound exists. A complicated fracture is one in which there is injury to an important vessel, nerve, joint, or viscus. 6. Accord- ing to the situation of the fracture, into intraarticular or extraarticular, 374 BONES 375 with reference to a joint, and intra- or extracapsular, with reference to the capsular Hj^ament of a joint. Epiphyseal separation also may be put under this heading. An intrauterine fracture occurs before birth, a congenital fracture at birth. The causes of fracture arc predisposing and exciting. The predisposing causes are physiological and pathological. Among the former are age, sex, occupation, season of the year, and structure and position of the bone. Fractures are frequent in infancy because of the many tumbles which occur at this time, but owing to the elasticity of the bones, the breaks are often incomplete or of the green stick variety. In old age the brittleness of the bones is such that even a trivial injury may produce fracture. During adolescence and adult life fractures are more frequent in the male sex, owing to the greater exposure to injury. Occupations entailing daily exposure to injury predispose to fracture. In winter fractures are more frequent because of the presence of slippery ice under foot. The structure and position of certain bones render them more liable to fractures. The pathological causes are atrophy of hone, the causes of which are given on p. 442, general disease of the osseous system, such as osteomalacia, rickets, idiopathic fragilitas ossium, ostitis fibrosa, and ostitis deformans; and localized disease of hone, such as malignant disease, caries, necrosis, actinomycosis, syphilis, gout, scurvy, tuberculosis, and cysts. The exciting causes are external violence and muscular action, e.g., fracture of the patella from contraction of the quadriceps. The former may be direct (the bone breaks directly beneath the point injured), in which case the fracture is usually transverse or commin- uted, or indirect (the bone breaks at some distance from the point of violence). Gunshot and punctured fractures are special varieties of direct fractures. Indirect fractures may be designated according to the nature of the force as hending (e.g., fracture of the clavicle from a fall on the shoulder), torsion (e.g., fracture of the tibia from twisting of the leg), compression (e.g., certain fractures of the skull, and fracture of the tarsus from a fall an the foot), or avulsion frac- tures (e.g., fracture of the internal malleolus through the action of the internal lateral ligament when the foot is everted). An intrauterine fracture is the result of violent uterine contrac- tions, or of blows upon the abdomen. ^Multiple intrauterine frac- tures occur in syphilis. Congenital fractures result from uterine contractions, or more frequently from the manipulations of the obstetrician. 376 m:a.nual of surgery Epiphyseal separation, or diastasis, occurs before the age of twenty-two (Fig. 183). The bones most frequently affected are the humerus, radius, femur, and tibia. As the end of a diaphysis is usually cup-shaped to receive the convex epiphysis, the deformity is Fig. 183. — Time of bony union of the various epiphyseal junctions. (Brewer.) often difficult to reduce. A pure epiphyseal separation is uncommon except in infants; in older children the Hne of cleavage usually in- volves at least a part of the end of the diaphysis. During the process of repair the epiphyseal cartilage may prematurely ossify and thus BONES 377 interfere with subsequent growth. Suppuration occasionally follows, and jKirtial detachment or sprain of an epiphysis sometimes precedes tuberculous disease. Spontaneous separation is always the result of some disease of the epiphysis, such as rickets, scurvy, syphilis, tuberculosis, or acute infections. The Symptoms.— Excepting certain cases of spontaneous fracture, there is a history oj injury, at which time the patient may feel some- thing give way, or hear a cracking sound. Pain is severe at the time of injury, but may be insignificant in pathological fractures. The location of acute tenderness is of great value in diagnosis. Swelling quickly supervenes, and within a day or two blebs, or bulla), may form, the exuded serum from the deeper tissues passing beneath the epidermis. Ecchymosis occurs within a few hours or not for one or more days, according to the depth of the broken bone and the extent of the injury to the soft parts. Loss of function is caused by pain, or by loss of mechanical support; it may be absent in an incom- plete or impacted fracture, or in a fracture of a bone whose function is supplemented by another bone, e.g., the fibula. Muscular spasm is a common symptom, particularly in the arm and thigh. Deform- ity, or change in the length or contour of a limb, is due to displace- ment of the fragments by the force of the injury, by the weight of the limb, or by muscular action. Preternatural mobility may be obtained by grasping the limb just above and below the fracture and mak- ing pressure in opposite directions, or by moving the limb as a whole. In fractures ot the forearm or leg, the parallel bones may be alter- nately pressed together above and below the seat of fracture. A deceptive sense of abnormal mobility may be present in elastic bones like the fibula and ribs, in bone diseases like rickets, in normal infants, and in the neighborhood of joints. Abnormal mobility may be absent in an impacted, an incomplete, or an intraarticular fracture. Crepitus is a grating sensation or sound obtained by rub- bing the ends of the bone together. It may be absent in an incom- plete or an impacted fracture, in one in which the fragments are greatly overlapped or widely separated, or in one in which soft tissues lie between the fragments. It is dry and harsh, and thus differs from the crackling of air or blood beneath the skin, or the creaking of inflamed synovial membranes, viz., those of joints, tendons, and bursge. The crepitus of epiphyseal separation is soft o/ moist. The constitutional symptoms are trivial or absent in simple un- complicated cases. Shock is usually absent, except in severe or complicated fractures. Fracture fever is an aseptic fever due to the 378 MANUAL OF SURGERY absorption of fibrin ferment, the temperature being elevated one or two degrees during the first two or three days or longer, according to the amount of blood extravasated. The Diagnosis. — The injured limb should be compared with the sound limb by inspection, palpation, and measurement. An ancient deformity should not be mistaken for a recent one. A knowledge of the normal relations of bony prominences will aid in the quick recognition of detormity. If a stethoscope is placed over one end of the bone and the other end percussed, the sound may not reach the ear if a fracture exists. In many cases, owing to rigidity of the muscles, pain, and fright, a proper examination can be made only under an anesthetic. In all cases an X-ray examination should be made. A more accurate idea of the amount and character of the dis- placement is obtained by taking two skiagrams, one at right angles to the other or by making stereoscopic plates (see Fig. 2). Single exposures, especially in the region ot the elbow, knee, ankle, and in oblique fractures of the long bones, may sometimes show apparently normal shadows, when a fracture really exists. Epiphyses cannot be recognized until sufificiently ossified to cast shadows. In inter- preting skiagrams the inexperienced may mistake an ununited epiphy- sis for a fragment of bone, and an epiphyseal juncture for a line of fracture. The complications of fractures are: (i) Those occurring at the time of injury, which may be (a) general, i.e., shock, or (b) local, such as sprain, dislocation, and injuries to the vessels, nerves, mus- cles, tendons, or viscera; (2) those appearing during the time of treatment or later, which again may be (a) general, such as sepsis, tetanus, fat or clot embolism, hypostatic congestion of the lungs, delirium tremens, delirium nervosum, and suppression or retention of urine; or (b) local, such as excessive swelling from effusion of serum or extravasation of blood; inflammation, ulceration, sloughing, or gangrene, from swelhng, pressure of splints or bandages, or from thrombosis; muscular spasm; necrosis of bone; stiffness or ankylosis of joints; atrophy of muscules, either from disuse, or from paralysis the result of nerve injury; excessive callus formation, usually there- suit of incomplete reduction; tumors of bone; stiffness of tendons from thecitis; contractures of muscles from myositis or neuritis; neuralgia; crutch paralysis; persistent edema, due to vasomotor paralysis or venous thrombosis; vicious union; non-union; delayed union; and fibrous or cartilaginous union. Repair of fractures is analogous to the repair of other wounds, except that the reparative material ultimately becomes bone instead BONES 379 of scar tissue. Immediately following a fracture blood extravasates between and around the fragments, which are freciuently united by a bridge of untorn periosteum. The surrounding blood vessels dilate, and serum and leukocytes escape into the tissues. The connective tis- sue cells proliferate (fibroblasts) and replace the blood clot, which, dur- ing the first week or ten days, is gradually absorbed and devoured by the leukocytes. At the same time there occurs a proliferation of the osteoblasts, which are found in the medulla and the deeper layers of the periosteum. This mass of actively multiplying cells is vascu- larized from neighboring vessels, becomes calcified, and is finally transformed into bone as the result of the activity of the osteoblasts. If the osteoblasts are slow in action, calcification is preceded by the formation of fibrous tissue by the fibroblasts, or in some instances bone fails to form and the fragments are united by fibrous tissue only. When the osteoblasts are more active, bony reproduction is preceded by the formation of cartilaginous tissue, which in some cases is as far as repair extends, the union being cartilaginous only. During the process of repair the ends of the bone become softened as the result of a rarefying ostitis, the roughened ends being smoothed by a process of absorption and covered with granulations, which are probably derived chiefly from the medulla. The compact bone itself is thought to take but little part in the process of repair. The mass of repara- tive material which forms between and around the fragments is called callus. The callus surrounding the fracture is called ensheathing or external callus, that in the medullary canal internal or central callus, and that between the ends of the bone intermediate callus. The ensheathing callus is finally absorbed, although it may persist and interfere with the motions of joints or tendons, unite the bone to a neighboring bone, or engulf an adjacent nerve. The central callus may be absorbed, although this is not common. Ossification begins in the first week and is complete in from ten days (in the small bones of the face) to six or eight weeks (in the femur) . The treatment of simple fracture is (i) reduction, (2) retention. (3) restoration of function. In transporting a patient with a broken limb it may be necessary to improvise splints from canes, umbrellas, etc. A fractured humerus may be fastened to the chest, a broken forearm may be supported by pushing a folded newspaper up the sleeve of a coat, the lower limb may be tied to its fellow or held between the rolled up ends of a blanket. The Thomas splint has, in military practice,_met all the requirements of transportation in fractures of the upper and lower extremities see Fig. 184. , 38o MANUAL OF SURGERY (i) Reduction, or setting, of a fracture should be performed as soon after the accident as possible. It is accomphshed by manipulations to relax muscles or other soft structures while the ends of the bone are being maneuvered into place. Relaxation may be obtained by traction; by extension and counterextension; by posture, e.g., flexion of the leg in fracture of the tibia; by tenotomy, e.g., of the tendo Achillis in fractures near the ankle; and by general anesthesia, which always should be employed if reduction cannot otherwise be readily affected. In addition to muscular contraction the obstacles to reduction are interlocking of the frag- ments, separation of the fragments by soft parts or bone, entanglement of one fragment in the fascia or skin, and impac- tion. In the last instance reduction is contraindicated unless the deformity is excessive. (2) Retention or immobilization is maintained by some form of splint, which may be of wood, metal, felt, leather, plaster-of-Paris, etc. Before the application of a splint abrasions should be covered with stearate of zinc powder, and blebs punctured without removing the epidermis. The sphnt should be thickly padded, particularly where prominent subcutaneous bony points will rest. As a general rule the joints above and below the fracture should be immobihzed. The hmb should not be bandaged beneath the dressing holding the splint in place, unless such bandage is of soft material loosely apphed Fig. -Thomas splint. Pig. 185. — Blake's modification of Thomas splint. for the purpose of padding. Great care should be exercised not to make the bandage too tight, for fear of sloughing or gangrene, or ischemic myositis. If the fingers or toes are left exposed, they will serve as an index to the general conditon of the Hmb. If they be- come cold, blue, or numb, or if there is great pain in the hmb, the bandages should be removed and the parts inspected. The so-called fixed dressings (see section on bandages), such as starch, silicate of soda, and plaster-of-Paris, are frequently employed after the subsidence of swelling, although many surgeons apply them as a primary dressing. The dangers of the latter method, BONES 381 viz., sloughing or gangrene due to great swelling beneath the case, and undetected displacement of the fragments, are prevented by cutting the dressing immediately after its application if it encases the entire limb, removing all but enough to form a trough, or by applying the material as a large poultice would be applied and then allowing it to harden. Plastic splints, such as cardboard, felt, leather, and gutta percha, are cut to the desired pattern, soaked in hot water to render them pliable, and allowed to harden while bandaged to the limb. Gooch 's flexible wooden spHnts consist of thin strips of fir glued upon canvas; they are flexible transversely and rigid longitudinally. (3) Restoration of function is obtained first by accurate reduction and the application of evaporating lotions or an ice bag to limit effusion, and during the subsequent treatment by massage and pas- sive and active motions. In the early part of the treatment of a fracture the patient should be seen each day, and the dressings removed if such be indicated; later, in many instances, the dressing should be done every two or three days. The parts should be in- spected, the skin kept in good condition by gentle friction with alcohol, and in suitable cases the muscles masseed and the neigh- boring joints moved, in order to prevent atrophy and stiffness. Lucas-Championiere advises massage from the very beginning in all fractures except those of the patella. In many instances in which there is no tendency towards recurrence of displacement the bone is not even splinted, and active motions are encouraged at an early period. There is no doubt of the value of massage and early mobili- zation of joints during the treatment of fractures, but in all cases the fragments themselves must be immobilized and kept so until the callus is sufficiently firm to obviate all danger of recurrence of displacement. Blake, as the result of his experience with gunshot fractures believes that traction in the axis of the proximal fragment of the bone, while in its position of relaxation, will provide sufficient force, through the tense muscles and fascias, to maintain the fragments in their normal relations. His suspension and extension treatment of fractures is based upon this principle see Fig. 211. Some surgeons treat fractures of the lower extremity, even as high as the middle of the femur, by the ambulatory method. A large pad is placed beneath the sole of the foot and a plaster cast applied to above the seat of fracture, so that when the patient walks the weight of the body is supported by the limb above the fracture. In cases in which successful reduction cannot be secured or main- tained, operative treatment is indicated, providing aseptic details can 382 MANUAL OF SURGERY be observed and the requisite skill is possessed by the operator; hence the more conservative plan of splint treatment should be employed by one who does not possess such qualifications. The fragments should be exposed by a suitable incision and the obstacle to reduction removed; this will often be found to be muscle, fascia, or other soft parts between the fragments. In bringing the fragments into alignment Lane uses, in addition to traction, strong long-handled forceps (Fig. 186) to grasp the ends of the bones. Martin has devised a method of traction that is efficient even in old cases with consider- able shortening. He employs "a long, strong canvas strip pocketed in the middle and looped at the ends. The bones at the seat of fracture are freed, the pocket is slipped over the proximal end of the distal fragment, the ends of the canvas strip are carried in the long axis of the limb, and in the loops is fixed a cord to which are attached weights. By thumb pressure the bone is kept from angling out of the wound, and the weights, up to 100 pounds or more, are attached to the rope. In from three to five minutes the shortening is over- come. " When the measures just mentioned fail it will be necessary Fig. 186. — Lane's forceps. to saw off a portion of each fragment before approximation can be accomplished, and in the forearm or leg an equal portion of the com- panion bone also must be removed. Unless is there no tendency for the bones to slip out of place the fragments must be held in posi- tion. Probably the best method for this purpose is transplantation of bone, the general principles of which are summarized at the end of this chapter. A graft can be cut from one of the fragments or from another bone (e.g., the crest of the tibia or a rib) and used as an intramedullary splint. This is driven into the medulla of the upper fragment, then pushed into the medulla of the lower fragment; if the latter maneuver is difficult the medulla can be opened by raising a portion of the cortex on a hinge of periosteum. If the osseous splint is loose it may be held in place by nailing transversely, or, better, by passing catgut or kangaroo tendon through holes drilled in the frag- ments and the splint. Another method which is rapidly gaining in favor is to removed an oblong piece of the cortex from each fragment with a chisel or motor-driven saw, the cut surfaces being beveled, so that the grafts will not fall into the medullary cavity when replaced, and one graft being cut much longer than the other. The longer BONES 383 graft is made to bridge the line of fracture, and the cavity thus left is filled with the shorter graft (Fig. 187). Fixation may be secured also by silver wire passing around the bone or through holes bored in the bone, by kangaroo tendon or aluminium bronze wire, both of which are ultimately absorbed, by silver or steel plates which are fastened to each fragment with screws (Fig. 188), or by means of nails, screws, ivory pegs, metallic staples, bone ferrules, or intra- FiG. 187. Fig. Fig. 187. — The small diagram to the right represents the grafts cut from the inner surface of the tibia. A, from the upper fragment; B, from the lower fragment. They are reinserted into the bone, as shown on the left, and held in place with catgut sutures traversing the periosteum. Fig. 188. — Lane's plate, and Lowman's apparatus for holding the plate and the broken bone in position while the screws are forced into the bone. medullary splints of metal, ivory, or bone. The last may be living, as mentioned above, or dead. Dead bone may be decalcified, which is unnecessary, or simply boiled and cleansed of medulla and soft parts. We have employed lamb and ox bone prepared in this way for ferrules and intramedullary splints. The special forms of apparatus consisting of long screws held by external clamps (Parkhill, Keetley, Freeman, Lambotte) are too compHcated and necessitate leaving the wound open, thus predisposing to infection. After the 384 MANUAL OF SURGERY fragments have been fixed in place the incision in the soft parts should be closed, -and the limb immobilized by plaster-of-Paris or a suitable sphnt. The cast should be put on the limb before the operation and anesthesia; split into anterior and posterior halves after harden- ing; then applied again after completion of the operation, and bound with adhesive plaster or bandages. When non-absorbable foreign material has been used to fix the fragments, its removal is not infre- quently demanded after union has occurred, owing to the formation of sinuses. The treatment of compound fractures is that of the wound in the soft parts and of the broken bone itself. The constitutional symp- toms are more severe than in simple fracture, there being a varying amount of shock according to the degree of injury, and later a higher rise in temperature, even when asepsis has been maintained. In some cases the fracture is non-comminuted, the injury to the soft parts slight, the opening in the skin small and comparatively clean; in such cases the wound may be disinfected with iodin and covered with a sterile dressing, the fracture reduced and immobilized, and the patient watched for evidences of sepsis. In others the injury is so extensive that amputation is required. The following remarks apply to cases of compound fracture of the extremities between these extremes. The dangers are hemorrhage and sepsis. Severe primary hemorrhage is temporarily controlled by the tourniquet, and meas- ures are taken to react the patient from shock. In the absence of shock the patient should be anesthetized and thorough disinfection carried out, and the primary dressing should be approached as one would an abdominal operation. The limb should be shaved, scrub- bed with soap and water, and washed with bichlorid of mercury, i to 1,000, or disinfected with iodin. Devitalized tissues, extravasated blood, tissues into which dirt has been ground, completely detached fragments of bone and all foreign bodies should be removed by clean, sharp dissection, enlarging the wound in the skin as much as may be necessary. Pieces of bone firmly attached to the soft parts often retain their vitality and may be left in place. If internal fixation is desired, only absorbable materials should be used, silver wire, steel plates or screws should not be employed. External fixation by means of traction and splints is usually adequate. The hemorrhage is controlled in the usual way, and the injuries to the soft parts carefully repaired, e.g., suturing of a torn nerve or muscle. The anatomical closure of the soft tissues with catgut and the skin with silkwormgut, at the time of the primary operation, is the ideal pro- ceedure. This primary closure oi compound fractures has been found. BONES 385 in military practice, to be a safe method when (i) the interval of time is less than 12 hours (2) it has been possible to remove all foreign bodies and devitalized tissues (3) and the wound does not contain streptococci. If these conditions cannot be obtained or closure of the wound is a mechanical impossibility, delayed primary or secondary closure, after surgical sterility is obtained, may be practiced. The limb is spHnted. If a plaster cast is applied, it should be made in the form of a gutter sphnt. When the wound is left open and requires frequent dressings the suspension apparatus of Blake is to be preferred (Tigs. 189, 211). Fracture complicated with dislocation is treated by first reducing the dislocation by manipulations, aided, if need be, by a splint to give sufficient rigidity to the limb; or through an incision the articular end of the bone may be maneuvered into place by the fingers or by a hook. Some advise setting the fracture and, after union has been obtained, trying to reduce the dislocation. Ununited fractures, delayed union, and non-union are due to infection; imperfect immobilization; the presence of muscle or other soft tissue between the fragments; marked overlapping; wide separa- tion; defective nutrition of the bone as the result of injury to its blood supply; general or local diseases of bones, such as are mentioned among the pathological causes of fracture (p. 268) ;or to constitutional diseases, such as syphilis, gout, rheumatism, scurvy, or other affec- tions causing debility. Non-union may be distinguished from de- layed union by the absence oi pain and the presence of voluntary motion in the former. These conditions are most common in the patella, olecranon, and similar situations where strong muscular contraction tends to separate the fragments, and in the middle of the humerus and upper and lower thirds of the femur. Absolute non-union, i.e., when there is absolutely no attempt at repair, is seldom seen apart from malignant disease of bone. In most instances the ends of the bone become rounded, the medullary canal closed, and the fragments joined by fibrous tissue {fibrous union). In a pseudoarthrosis, or false joint, the fragments are held together by a capsule of fibrous tissue, within which is developed a bursa the result of the friction of one bone on the other, and the ends of the broken fragments are covered with cartilage. The treatment of delayed union is prolonged immobiKzation in plaster-of-Paris, and attention to the general health. Some advise the induction of congestion or inflammation by rubbing the ends of the bone together, by scraping the ends with a long and strong needle pushed in through the skin, by the injection of a 10 per cent, solution 386 MANUAL OF SURGERY of chlorid of zinc, or by applying a rubber band around the limb above the fracture. Bier injects fresh blood between the fragments; Dilger an emulsion of periosteum, the periosteum being obtained from the patient. The internal administration of thyroid extract and potassium iodid are thought to encourage callus formation. Non-union is treated by resection of the ends of the fragments, and fastening them together by one of the methods mentioned above (,p. 273), the best of which for non-union is bone transplantation. Codivilla wires the fragments, and envelops the fracture with a strip of periosteum to the under surface of whicli is attached a thin slice of bone. When the ends are overlapped, and resection would prove a formidable operation owing to the situation of the bone, screws or pegs may be inserted into drill holes which traverse each fragment from side to side. Vicious union, or union with great deformity, is due to imperfect reduction, recurrence ot displacement, bending or overproduction of callus subsequent to the removal of splints, or to bone diseases, such as fragilitas ossium and osteomalacia. It may be treated, in the early stages while the callus is plastic, by pressing the bones into place, and later, if deformity or disability is miarked, by osteo- tomy, by chiseling away projecting areas, or by resecting the callus and fastening the fragments with bone, wire, plates, etc. Disunited fracture, or separation after the fragments have united, may occur from violence, and occasionally during the progress of an exhausting disease. SPECIAL FRACTURES The nasal bones are usually broken in their lower third, the fracture being frequently compound through the skin or mucous membrane. The cause is direct violence, the degree and direction of which determine the amount and character of the displacement. The nasal septum is often injured, resulting in lateral displacement, which may later give rise to nasal obstruction. The symptoms are pain, swelling, crepitus, deformity, and epistaxis. Abnormal mobility may be fallacious in the lower third owing to the great mobihty of the cartilages. The complications are emphysema, cere- bral concussion, fracture of the neighboring facial bones or of the base of the anterior fossa of the skull, and later suppuration and necrosis of bone or cartilage. The treatment should be prompt, as the bones early consolidate in deformity. In all cases the septum should be examined to deter- BONES 387 mine whether or not it is broken. No apparatus is needed if there is no deformity or if the deformity does not recur after reduction. Reduction is accompHshed by external pressure, and by lifting the fragments from within by means of a padded, narrow instrument, such as a grooved director, or by a rubber bag which is passed into the nose and distended with air. The septum may be straight- ened by a finger introduced into either nostril or by septum forceps. Either cocain or ether anesthesia may be necessary. In depressed fractures reduction may be maintained by packing the nostrils with gauze, or by passing a strong pin (Mason's pin) through the skin, beneath the fragments, and making external pressure by means of gauze, held in place by figure of-8 turns of silk around the ends of the pin. Lateral displacement requires an external compress or molded splint, held in place by adhesive plaster, or an apparatus consisting of a metallic band around the forehead with a support, provided with a pad and screw for making pressure, running down to one side of the nose. If the septum is deformed, it may be held in place by gauze packing, or by means of rubber, vulcanite or metallic tubes, which have perforations in the side for drainage, and which are made in various sizes. Roberts inserts one or more long pins into the septum in such a way as to press on the deviation as the stem of a flower is pressed upon when pinned to the lapel of a coat. In any case the nose should be sprayed several times daily with an antiseptic solution, and the patient cautioned about blowing or wiping the nose. The prognosis is usually good, although some deformity is very apt to remain in bad ases. Union is complete in from ten days to two weeks. The lachrymal bone is rarely broken alone, and the treatment is directed principally to the neighboring bone. Obstruction of the lachrjTnal duct may be prevented by the passage of a probe. The malar bone is fractured by direct violence, usually with injury to adjoining bones. Sometimes the whole bone is pressed into the bones on which it rests. The symptoms are deformity, conjunctival hemorrhage when the orbital surface is involved, and interference with the motions of the lower jaw when depression is sufficient to encroach upon the coronoid process. Crepitus and abnormal mo- biHty may be absent. In favorable cases the deformitj" can be corrected by pressure beneath the bone within the mouth. If this is unsuccessful, particularly in cases in which the movements of the lower jaw are impaired, the bone may be elevated through an external incision. Xo retentive apparatus is required, as displace- ment does not recur. The bone unites in two weeks. 388 MANUAL OF SURGERY The zygoma is fractured by direct force, or by indirect force when the malar is depressed. There is usually an indentation just behind its junction with the malar bone. The Ireaiment consists in the apphcation of pressure within the mouth or externally, in order to effect reposition. Failing in this, especially if the movements of the lower jaw are defective, a piece of silver wire may be passed through the skin and beneath the depressed fragment, in order to pull it into place. A retentive apparatus is seldom required. Union is complete in two or three weeks. The superior maxilla is usually broken by direct blows, which in most instances break also contiguous bones. It may. however, be broken by indirect force through the chin. The fracture is almost always compound and comminuted, and often bilateral. There are pain, great swelling of the face, and interference with mastication; deformity, abnormal mobility, and crepitus are detected through the nose, mouth, or cheek. The complications are emphysema, violent hemorrhage from the internal maxillary or its branches, and injury to the lachrymal duct, infraorbital nerve, or the brain. Suppuration and necrosis may occur. The treatment is careful disinfection, and molding of the bone into position through the nose or mouth, or through an external wound if it be present. Loose teeth should be put back in place and fastened to their fellows by wire. In fractures involving the alveolus the lower jaw may be used as a splint by means' of the Barton or the Gibson bandage, or an interdental splint may be employed. It may be necessary to insert a tube into the nose to maintain its patency. The nose and mouth should be washed several times a day with an antiseptic solution, and the wounds dressed daily. Liquid food is administered through a nasal tube, or by passing it into the mouth behind the last teeth. The bone unites in three or four weeks. The inferior maxilla is generally broken by direct violence, but a fracture near the middle line may result from a force which presses the bodies together, and fracture of the condyle may follow a fall on the chin. The bone is most frequently broken just external to the symphysis, owing to the weakness occasioned at this point by the deep socket of the canine tooth and the mental foramen, just posterior to it. As a rule the fracture is compound internally and not infrequently there are multiple breaks. The symptoms are pain, laceration of the gum at the point of fracture, bleeding from the mouth. sweHing of the face, abnormal mobihty, crepitus, and deformity as demonstrated by imperfect alignment of the teeth. When the bone is broken in front of the masseter, the posterior BONES 389 fragment is pulled upward by the masseter and temporal muscles, while the depressors of the jaw (geniohyoglossus, geniohyoid, anterior part of mylohyoid, digastric, and platysma) draw the anterior fragment downwards and backwards. In fractures of the neck of the condyle, the jaw is drawn toward the injured side by the ptery- goids of the sound side, and the condyle is pulled forward and inward by the external pterygoid. Fracture of the coronoid is very rare, and displacement is usually slight, because the temporal muscle is attached farther down on the inner than on the outer side; if the fibres of attachment are torn the process is drawn upward by the temporal muscle. The complications are suppuration, and necrosis of bone, with the ills that they may produce, e.g., cervical aden- itis, and digestive or pulmonary disorders from swallowing or inhaling foul discharges. Fracture of the base of the skull may be produced if the condyles are driven forcibly upwards. The treatment consists in reduction by direct pressure, immo- bilization, and careful and frequent cleansing of the mouth. In cases in which there is little tendency to displacement, sufficient immobilization may be obtained by a molded chin piece (Fig. 195) of felt, cardboard, leather, or thick flannel impregnated with plaster- of-Paris, the chin cup being held in place by a Barton or a Gibson bandage. If the displacement tends to recur, and this is true in the large majority of cases, the adjoining teeth, it not loose, may be tied together with wire, or fastened by Angle's bands, which are thin pieces of metal that are clamped about several teeth in each jaw by means of a screw, the jaws being held together by wire or silk running from the clamps on the lower jaw to those on the upper jaw. Ham- mond's splint consists of a wire frame work which surrounds all the teeth of the lower jaw and which is fastened in place at several points by wire running between the teeth. In many instances accurate apposition can be obtained only by wiring the jaw itself, or far better, with an interdental splint. Interdental splints are made of vulcanite, hard rubber, or metal, from a plaster-of-Paris cast of the teeth; they can be made only by a skilled dentist (Fig. 190). An impression of the teeth is first taken by a dental modeling compound, which is softened by heat and allowed to harden on the teeth. A plaster cast of the two jaws is made from this mold, the cast of the lower jaw severed at the point of fracture, the displacement in the cast corrected, and an interdental splint made from the plaster cast. Bars curving backwards over the cheeks are sometimes attached to support a bandage passing under the chin, so that the jaw will be held in place even when the mouth is open (Fig. 189). Moriarty 39° MANUAL OF SURGERY fastens a metallic chin piece to these side bars by several vertical supports. Matas has constructed an adjustable metallic interdental splint, which may be applied by any medical man without special dental skill. The spUnt is a sort of clamp which holds the jaw be- tween a mouth piece and a chin cup. It is made in three sizes, the smallest for children, the medium for youths, and the largest size for adults; the chin cup may be adjusted to various degrees of progna- FiG. 189. — Kingsley's interdental splint. (Brophy after Kingsley.) thism by a sliding joint (Fig. 191). If the teeth are loose, the gutter of the mouth piece may be filled with a dental modeling composition. In any case the mouth and teeth should be frequently cleansed and irrigated with a mild antiseptic solution. If inadvisable to open the mouth, the patient may be fed as described under fracture of the upper jaw. Fractures of the coronoid process and the condyle are treated by a Barton or a Gibson bandage. The hyoid bone may be frac- tured by constriction, such as occurs in throtting and hanging. The symptoms are pain, swelling, deformity, bleeding from the mouth, and interference with breathing, speaking, or swallow- ing. Abnormal mobihty and crepitus are present in a few cases. The treatment consists in the correction of the deformity, if possible, by a finger in the mouth and the hand externally, and the appHca- tion of a molded cardboard splint to the neck. The head, neck, and lower jaw may be immobilized, and the patient fed by rectum; talking is forbidden. The bone unites in four weeks. Edema of the glottis may demand intubation or tracheotomy. The laryngeal cartilages may be fractured, particularly in old age Fig. 190. — Band splint to embrace four teeth, two on each side of fracture. (Brophy.) BONES 391 owing to the deposition of lime salts. The symptoms are similar to those of fracture of the hyoid bone, except that dyspnea and inter- ference with the voice are more marked and emphysema more common. The treatment is similar to that of fracture of the hyoid bone. The ribs may be broken by direct violence, or by indirect vio- lence, e.g., compression of the chest, in which case the rib breaks at its most convex part, or near the angle. In a few cases violent muscular action, such as occurs in coughing and straining, is respon- sible for the accident. In earlv life the ribs are verv elastic and in- PlG. 191. — The Matas splint for fracture of the lower jaw. The spUnt consists of the followng detachable parts; (a) a mouth piece of soft metal (block tin); (b) a clamp adjusted and tightened with a screw; (c) a chin plate (of perforated aluminiim), which can be moved backward or forward by sliding on the lower limb of the clamp. This is fixed and held in place by a thumb-screw. complete fracture is not uncommon. As a rule more than one rib is broken, those suffering most frequently being from the fifth to the ninth, as the upper ribs are better protected and the lower ribs more movable. The fracture may be compound into the lung or through the skin. The symptoms are localized pain increased by movements of the chest or pressure over the sternum, grunting respirations, suppressed cough, emphysema if the lung is wounded, and rarely deformity or abnormal mobility. Crepitus is frequently absent; it is obtained by placing the hand or the ear over the point of greatest tenderness while the patient takes a full breath, or by alternately pressing on the bone on either side of the fracture. Hemoptysis 392 MANUAL OF SURGERY indicates injury to the lung. The complications are injury to the heart, lung, diaphragm, liver, spleen, and colon, and hemothorax, pneumothorax, pleurisy, pneumonia, bronchitis, and empyema. The treatment is immobiHzation of the affected side of the chest with adhesive plaster. In the male the chest should be shaved and a piece of lint placed over the nipple. Adhesive plaster strips, three inches wide and long enough to extend about three-fourths around the chest, are applied from below upwards during expiration, each strip overlapping the preceding one (Fig. 195). The dressing is changed once a week, and discarded at the end of three weeks, or later if there is much pain. If strapping increases the pain, it should not be employed, as the ends of the bone are probably driven in- wards; these cases should be confined to bed with a compress between the shoulders. In the presence of marked displacement which is irreducible by external manipulations, the deformity may be cor- FiG. 192. — The Sayre dressing for frac- Fig. 193. — The Sayre dressing for frac- ture of the clavicle; posterior view. ture of the clavicle; anterior view. rected through an incision, and the fracture immobilized by suture. The patient should be guarded from draughts, and sedative expec- torants employed if there be cough. The costal cartilages may be broken, or separated from the ribs or sternum. The symptoms and treatment are those of fracture of the rib. The sternum is usually fractured at or near the junction of the manubrium with the gladiolus, as the result of direct violence, although it may be broken by indirect force from excessive extension or flexion of the body, such as occurs in fractures of the spine, and by muscular action in the same way that the ribs may be broken. The upper fragment passes behind the lower fragment, sometimes pro- ducing severe dyspnea and occasionally injury to the aorta. The symptoms are pain, deformity, abnormal mobihty, crepitus, forward bending of the body, and in many cases dyspnea and cough. Com- plications are frequent, there usually being fractures of the ribs and BONES 3Q3 spine, and often injuries to the thoracic viscera; aneurysm of the aorta, mediastinitis, and necrosis of the sternum are late complica- tions. The treatment is rest in bed, with a compress between the shoul- ders, and a broad strip of adhesive plaster carried across the chest over the fracture. Reduction may sometimes be accomplished by extending the spine and making pressure on the lower fragment while the patient breathes deeply. If this fails and there is dyspnea due to the depression, the displacement may be corrected and the fragments fixed in position through an external incision. Union is complete in five or six weeks. The clavicle, with the possible exception of the radius, is broken more frequently than any other bone in the body, owing to its slenderness, its exposed position, and to its transmitting the force of blows or falls from the upper extremity to the trunk. Consequently the usual cause of fracture is indirect violence, although direct violence also is responsible for a certain number of cases. The injury is most frequent in children, and is then often of the green- stick variety. The fracture may be located at the sternal end (unusual); just external to the middle, which is the usual situation, because it is here that the two curves of the clavicle meet, that the bone is most slender and that fewer muscles are attached; between the coracoclavicular ligaments, in which case there is little displace- ment; or at the acromial end, at which point too, the displacement may be sUght. The symptoms are those of fracture in general. The patient supports the elbow with the hand of the uninjured side, and bends the head toward the affected clavicle to relax the sternomas- toid, which pulls on the inner fragment only. The shoulder with the outer fragment is displaced downwards, inwards, and forwards, owing to the weight of the extremity and the contraction of the subclavius and muscles of the axillary folds, viz., pectoralis major and minor, teres major, latissimus dorsi. The inner fragment ascends slightly, as the result of the action of the sternomastoid. The complications are injuries to the brachial plexus, subclavian vessels, pleura, and lung. The treatment which gives the least deformity is the placing of the patient upon a firm mattress, with a pad between the scapulae, a shot-bag on the affected shoulder, and the arm bound to the chest with upw^ard pressure on the elbow. Union is usually firm in three or four weeks, when the patient may be allowed to get up with the arm in a sling. But patients do not often select this form of treat-' ment. In an incomplete fracture with little deformity a sling for the 394 MANUAL OF SURGERY forearm is all that is needed. Reduction is easy to accomplish by carrying the shoulder backwards, outwards, and upwards, but in ambulatory cases is very difficult to maintain. The Sayre dressing is one of the best for this purpose. Two strips of adhesive plaster three or four inches wide, and long enough to extend around the chest one and one-half times, are prepared. Lint powdered with zinc stearate is placed in the fold of the elbow and between the arm and the chest. A collar of lint as wide as the adhesive strip is placed about the arm just below the axilla, and over this is applied the end of one of the strips of plaster, so as to form a loop; the strip is now used to pull the arm backwards, and is fastened around the chest (Fig. 192). The hand of the affected side is placed on the opposite shoulder, and the second strip of plaster, with a hole for the point of the elbow, is run from the back of the sound shoulder, under the elbow of the affected side, over the sound shoulder, to the back (Fig. 193), thus drawing the elbow forwards and upwards, and, with the aid of the first strip, which acts as a fulcrum, forcing the shoulder backwards and out- wards. A pad, held in place by a strip of adhesive plaster, may be placed just above the clavicle to press the fragment downwards. The Velpeau bandage is fre- quently employed, that of De- sault is seldom used (see bandaging). A posterior figure-of-8 bandage, pulling the shoulders backwards, may be combined with an axillary pad, and a forearm sling which pulls the elbow inwards and upwards. The fragments may be wired when the fracture is compound or multiple, or when there is great deformity, pressure upon nerves or blood vessels, or a sharp fragment which threatens to perforate the skin. The prognosis is very good concerning the function of the arm, but after a complete fracture between the rhomboid ligament on the inside and the coracoclavicular ligament on the outside, deformity to a greater or lesser degree is sure to persist. The body of the scapula is broken by direct violence. The Fig. 194. — Fractures of the neck of the scapula. A, Through the glenoid fossa; B, through the anatomical neck; C, through the surgical neck. (Rose and Carless.) BONES 395 symptoms are swelling, abnormal mobility, crepitus, and pain upon abduction of the arm or rotation of the scapula. Deformity is usually absent. The treatment is immobilization of the shoulder and arm by a bandage passing around the chest, and a sling for the fore- arm. Strapping the chest in a way somewhat similar to that used for the ribs also is useful. The surgical neck of the scapula, when broken (Fig. 194), causes flattening of the shoulder, prominence of the acromion, lengthening of the arm (from acromion to external condyle), a swelling in the axilla, and crepitus on rotating or raising the arm. The deformity is reduced by pressing upwards on the elbow and on the axillary swelling, a pad placed in the axilla, and a Velpeau bandage applied. The dressing may be removed in five weeks. The anatomical neck of the scapula or the glenoid cavity may in rare instances be broken, resulting in slight lengthening of the arm and a fullness of the axilla. Crepitus may be obtained by pushing up on the elbow or by rotating the arm. The treatment is that for fracture of the surgical neck. The acromion process is broken by direct violence. The symp- toms are pain, loss of abduction of the arm, flattening of the shoulder, and abnormal mobihty and crepitus, obtained by pushing upwards on the elbow. The treatment consists in pushing the elbow upwards, thus supporting the acromion process with the head of the humerus. The position is maintained for four weeks by a Velpeau bandage or the third roller of Desault. The coracoid process may be broken by direct violence or muscu- lar action, but the accident is rare. Deformity is not noticed, but crepitus and abnormal mobility are often obtainable. A Velpeau bandage should be worn for four weeks. The htunerus may be broken through the upper extremity, the shaft, or the lower extremity. The upper extremity of the humerus may be broken at the anatomical neck, at the surgical neck, or through the head of the bone or the tuberosities, or the upper epiphysis may be separated. The anatomical neck of the humerus is broken by direct violence applied to the shoulder, particularly in the aged. The line of fracture may be wholly wdthin the capsule of the joint (intracapsular frac- ture), but in many instances it extends beyond the capsule. Impac- tion is frequent, and even when the head of the bone is movable on the shaft it, as a rule, still remains attached to the capsule at some parts, so that necrosis is not as frequent as one might expect. The symptoms are pain, swelling, broadening of the neck of the bone. 396 MANUAL OF SURGERY interference with the functions of the shoulder, sHght shortening of the arm from acromion to external condyle, and in unimpacted cases abnormal mobility and crepitus; the last two symptoms are Fig. 195. — I. Fracture-box. 2. Double inclined plane fracture-box. 3. Jaw-cup unfolded. 4. Jaw-cup (folded). 5. Anterior angular splint. 6. Internal angular splint. 7. Bond splint. 8. Shoulder-cap. 9. Dupuytren splint in Pott's fracture. 10. Agnew splint for fracture of the metacarpus. 11. Agnew splint for fracture of the patella. 12. Agnew splint applied. 13. Strapping the chest in fractured ribs. 14. Extension apparatus in fracture of the femur. 15, 16. Adhesive strips for extension apparatus. (DaCosta.) obtained by grasping the head of the bone, and gently rotating the humerus by manipulating the elbow with the other hand. These movements should never be violent, because of the danger of sepa- BONES 397 rating an impaction, or tearing away that portion of the capsule which remains attached to the head. The treatment in impacted fracture is a sling for the limb, gentle massage from the beginning, and early passive motion. In other cases a pad should be placed in the axilla, a cap of cardboard or felt (Fig. 195) molded to the shoulder, and the arm and forearm (flexed to a right angle) bandaged to the side. Union may not occur for five or six weeks or longer. The prognosis is good as far as union is concerned, but stiffness of the joint, atrophy of the muscles, and persistent pain are common sequelae. The surgical neck of the humerus is usually broken by direct violence, occasionally by indirect violence, rarely by muscular action. The symptoms are pain (which may be reflected along the large nerves from pressure), abnormal mobility, crepitus, shortening of the limb (one inch or more) , a depression just below the shoulder and abduction of the elbow from the side of the body. The upper end of the lower fragment passes into the axilla, owing to the inward traction of the muscles at- tached to the bicipital groove (pectoralis major, teres major, latissimus dorsi) , and the upward pull of the deltoid, biceps, coracobrachialis, and triceps; the upper ^i^- 196.— A, normal shoulder; B, dislocation of shoulder; C, fragment may be abducted by the sup- fracture of surgical neck of raspinatUS, but there is Httle or no rotary humerus. (Rose and Carless.) displacement, because the subscapularis in front and the teres minor and infraspinatus behind nearly or quite balance each other; if impaction be present the signs are obscure and the diagnosis diflficult. The deformity resembles that of dislocation of the shoulder, but in the former the depression is lower (Fig. 196), the head of the bone is in place, and, when the arm is rotated, there is immobility of the head with crepitus. The complications are injuries of the axillary vessels or nerves, particularly the circumflex nerve, which passes around the bone at or near the line of fracture. The treatment may require only that of fracture of the ana- tomical neck. The triangular axillary splint provides a position of complete muscular relaxation and immobilizaton of the fragments. Reduction is accomplished by extension counterextension, and manip- ulation. Extension may be maintained during the course of treat- ment by attaching a weight to the elbow; also The Thomas splint or the extension and suspension apparatus of Blake (Fig. 198). Gentle passive motions are begun at the end of three weeks. The 398 MANUAL OF SURGERY prognosis is good, but in the old and rheumatic stiffness and pain are frequent legacies. The head of the humerus may be broken by direct violence, but the accident is rare, and seldom recognized without the aid of the X-rays. It is treated by immobilizing the shoulder. The greater tuberosity may be bi'oken by direct violence, or torn from the humerus by contraction of the attached muscles (supra- and in- fraspinatus, teres minor). The injury may complicate fracture through the neck or anterior dislocation of the shoulder. The symptoms are pain, swelhng, crepitus, and loss of outward rotation of the arm. If completely de- tached, the fragment is drawn upwards and backwards by the supra- and in- fraspinatus muscles. The treatment is that of fracture of the anatomical neck or, if there is much separation, incision with wiring or pegging the fragment in place. A theoretically correct but im- practicable plan is to place the patient in bed and hold the arm abducted and rotated outward by means of sand bags. The lesser tuberosity is said to have been fractured but three times. Separation of the upper epiphysis of the humerus occurs before the twentieth year, as the result of direct violence, but the accident is not common. The symptoms resemble those of fracture of the surgical neck, except that the crepitus has a much softer quality. Displacement is often slight owing to the presence of an untorn periosteal bridge. The treatment is that of fracture of the surgical neck. Reduction is sometimes difficult, owing to the conical shape of the upper end of the shaft and the smallness of the upper fragment, but is of the greatest importance, because of the danger of arrest of growth in the Hmb. It is best accompHshed by slight rotation, and by bringing the elbow forwards and upwards, as the untorn periosteal bridge is usually situated on the posterior surface of the bone. Fig. 197. — Skiagraph of fracture of the humerus above the insertion of the deltoid. (Pennsylvania Hospital.) BONES 399 The shaft of the humerus is frequently broken, usually by direct violence, but also by indirect force, and occasionally by muscular action. The symploms are those of fracture in general. The displacement depends on the situation of the fracture. When the bone breaks above the insertion of the deltoid, the upper fragment is drawn inwards by the muscles attached to the bicipital groove (pectoralis major, teres major, latissimus dorsi), the lower fragment upwards and outwards by the deltoid (Fig. 197). When the fracture is below the insertion of the deltoid, the usual situation, the upper Fig. 198. -Blake's suspension and extension dressing applied to fracture of the arm. In bed. (American Ambulance.) fragment is drawn outwards by the deltoid, and supraspinatus, forward by the coracobrachialis and anterior portion of the deltoid while the lower passes upwards and inwards (Fig. 198). The com- plications are injuries to the brachial vessels and the nerves, partic- ularly the musculospiral, which lies close to the bone; non-union is more frequent here than in any other bone in the body, probably owing to the method of treatment, in which, as the result of im- perfect fixation of the shoulder, movements at the seat of fracture are not entirely prevented. The treatment is reduction by extension and direct pressure. If prolonged extention is necessary, the dressing of Blake, . 400 MANUAL OF SURGERY Figs. 198-199 should be used. The triangular axillary splint, provides the best method of immobilization in a sling. The dressings are removed in five or six weeks if the fracture is firm. The lower extremity of the humerus may be broken above the condyles {siipracondyloid fracture) , above and between the condyle {T- or Y- shaped fracture), or through either condyle or epincondyle, or the lower epiphysis may be separated. Fig. 199. — Blake's suspension and extension dressing applied to fracture of the arm. Out of bed. (American Ambulance.) The examination of an injured elbow should be made with the greatest care, in order to exclude fracture and dislocation. General anesthesia is often necessary in fracture, to permit diagnosis and facilitate reduction, and the X-ray should be used in all doubtful cases. The injured elbow is compared with that of the opposite side while both are in a similar position. There are four landmarks whose position must be determined viz., the two condyles, ole- cranon, and the head of the radius. In the normal extended elbow the tip of the olecranon is a trifle below the intercondyloid line, but nearer the internal than the external condyle, while the three points are in a plane parallel to the back of the arm when the forearm is flexed to a right angle. The intercondyloid line is per- BONES 401 pendicular to that of the axis of the arm. The head of the radius is immediately below the outer condyle, at the bottom of a dimple, which is easily seen when the arm is extended. Normally the axis of the supinatcd and extended forearm is directed away from the Fig. 200. — Fracture of the humerus below the insertion of the deltoid. body, forming an angle of about 15 degrees with that of the arm (Fig. 201). Deviations from this angle should be noted, as well as any lateral motion which is not present in the normal elbow. Meas- urements may be made from the tip of the acromion to the tip of Fig. 201. — Outlines of upper extremity to show A, normal carrying angle; B, cubitus varsus; C, cubitus valgus. (Rose and^Carless.) Fig. 202. — Supracondyloid fracture of humerus. (Gray.) the external condyle, from the tip of the external condyle to the styloid process of the radius, and from the tip of the olecranon to the tip of the styloid process of the ulna, as well as between the con- dyle and from either condyle to the olecranon. Supracondyloid fracture is caused by a fall on the hand when the elbow is flexed, or by direct violence. The symptoms are pain, 402 MANUAL OF SURGERY swelling, loss of function, abnormal mobility, crepitus, and deformity. The lower fragment usually passes backwards and upwards, thus resembling a dislocation of both bones of the forearm backward (Fig. 202). In dislocation the relation of the olecranon to the con- dyles is altered, in fracture the relations are normal; in dislocation the forearm is shortened, in fracture the arm is shortened. In dislocation the lower end of the humerus*causes a smooth projection at or below the crease of the elbow; in fracture the upper fragment presents a sharp projection above the crease. In dislocation reduc- FiG. 203.- -Pastening figure-of-eight cra\-a: over folded compression on. opposite side of chest. Elbow region open to inspection. (Scudder.) tion is difficult but permanent, in fracture reduction is easy, but difficult to maintain; there is no crepitus or abnormal mobility in dislocation, and the X-ray will show the bones out of place. As complications may be mentioned injuries to the brachial artery and median nerve. The treatment is the application of an anterior angular sphnt (Fig. 195), and a posterior molded trough to the back of the elbow after effecting reduction by drawing downwards and forwards on the forearm, and pressing backwards on the upper fragment. A Stromeyer splint is hinged and provided with a screw, so that the BONES 403 angle may be changed and thus some passive motion secured without removing the dressings. The Jones position, i.e., acute flexion of the elbow, is maintained by tying the wrist to the neck, or by means of a broad adhesive strap passed around the arm and forearm, which are supported by a figure-of-8 sling (Fig. 203). It is the best form of treatment for all fractures about the elbow, except those of the olecranon (separates the fragments), T-fractures of the lower end of the humerus (coronoid wedges fragments apart), fractures with great swelling (shuts ofif circulation), and fractures involving the groove of the ulnar nerve (nerve slips into line of fracture). The Jones position, indeed any kind of firm compression, should not be used, however, immediately after the accident, because of the danger of ischemic myositis (see prophylaxis of ischemic myositis, chap, xxxi). Acute flexion reduces the fragments, and holds them in place between the coronoid process of the ulna and the trochlear surface of the olecranon in front, and the triceps posteriorly; it preserves the carrying function, and gives a useful elbow even in the presence of ankylosis; one must make sure that the compression at the elbow is not too great by feeling the radial pulse at the wrist. Some surgeons treat all fractures of the elbow in the extended position, by means of a long splint or a plaster cast. It is the best position for those cases in which the Jones method is contraindicated. It preserves the carrying angle, but if ankylosis occurs the limb is in the worst possible position. The right angle position rarely holds the fragments in place, but if ankylosis occurs the arm is still useful. Gentle passive motion may be commenced in three weeks, and the splint removed at the end of the fifth week. The prognosis of fractures about the elbow should be guarded, and the danger of limitation of motion explained to the patient. In most instances, however, a useful arm is obtained, although this may not be for a number of months. Intercondyloid, T- or Y-shaped fracture, is a supracondyloid fracture with a fissure extending down between the condyles into the joint. It is caused by direct violence. There are widening of the elbow', shortening of the humerus, and the usual signs of fracture. The treatment is complete extension on a straight splint for three weeks, at which time passive motions should be commenced, the limb being placed on an internal angular splint for two weeks longer. The internal epicondyle may be broken by direct violence, forced abduction of the extended elbow, or muscular action. There are crepitus and mobility. Fracture of the external epicondyle gives 404 MANUAL OF SURGERY the same signs, and very rarely exists without other injury. The treatment is the Jones position. The internal condyle of the humerus is broken by direct violence the line of fracture running into the joint. The symptoms are pain abnormal mobility, and crepitus; the fragment with the ulna passes upwards, thus destroying the carrying function of the arm. The treatment is the Jones position. The external condyle may be broken by a fall on the hand, or by direct force. The line of fracture enters the joint and includes the capitellum, or a part of even the trochlear surface. The displace- ment is usually slight, but pain and swelling are generally marked. Crepitus and abnormal mobility are detected by grasping the condyle or by rotating the radius. The treatment is the Jones position or an internal angular splint. Separation of the lower epiphysis of the humerus is not uncom- mon during childhood, at which time the entire epiphysis, consisting of several centers of ossification, is detached. The symptoms are practically identical with those of supracondyloid fracture, except that the crepitus is softer. The treatment is the Jones position. The possibility of interference with growth should not be forgotten. The ulna may be broken through the olecranon, the coronoid process, the shaft, or the styloid process. The olecranon is usually broken by direct violence, occasionally by muscular action. The symptoms are pain, swelhng, abnormal mobility, and separation of the fragments owing to the action of the triceps. Crepitus is not obtained unless the fragments are approxi- mated. If the periosteum or the tendinous fibers of the triceps covering the bone are untorn, separation may be unappreciable even on flexion of the forearm, which ordinarily widens to a large extent the breach between the fragments. The complications are injury to the ulnar nerve and forward dislocation of the bones of the forearm. The treatment is the application of a straight or nearly straight anterior splint, the upper fragment being pulled into position by means of adhesive strips. When union has become firm enough, possibly at the end of three weeks, the elbow should be flexed to a right angle, and placed on an internal angular splint for one or two weeks longer. The most satisfactory treatment in cases in which there is wide separation is the suturing of the fragments with ab- sorbable materials through an incision. The prognosis should be guarded. Fibrous union often occurs, although such may not interfere with the usefulness of the elbow. BONES 405 'JI1C coronoid process is rarely broken alone. The fracture may be associated with backward dislocation of the bones of the forearm in which case reduction is associated with crepitus, is easily made and hard to maintain. The fragment may be felt above its normal position, where it has been drawn by the brachialis anticus. There may be inability to flex the elbow. The treatment is the Jones position. The shaft of the ulna is broken by direct violence. The symp- toms are swelling, localized pain, abnormal mobility, and crepitus. There is little or no shortening unless the radius is broken, but the lower forearm is thickened owing to the action of the pronator quad- ratus, which draws the lower fragment into the interosseous space while the upper fragment is drawn slightly forward by the brachialis anticus. The treatment is an internal angular splint of wood or light moulded plaster gutter which immobilizes the elbow and places the forearm midway between pronation and supination, in which position the bones are farthest apart and the danger of their union by callus is least. A posterior splint, reaching from the elbow to the wrist also may be applied, while pieces of rubber tubing may be strapped over the interosseous space on each side of the forearm, in order to widen the interval between the bones. Union occurs in four weeks. The Styloid process is broken by direct violence, and is frequently detached in Colles' fracture. The loose fragment may be detected near the wrist. The treatment is a Bond's splint (Fig. 195), with a pad over the styloid process. The radius may be broken through the head, neck, shaft, or lower extremity. The head of the radius is seldom broken alone, but the break may complicate dislocation of the elbow or fracture of the external con- dyle. There are crepitus and immobility of the head when the forearm is rotated. The treatment is the Jones position or an anterior angular splint. If the head escapes into the joint as a loose body or unites wath deformity, its excision may be called for to restore the movements of the elbow. The neck of the radius is seldom broken. There are crepitus and immobility of the head on rotation of the forearm, and a promi- nence in front of the elbow, caused by the lower fragment, which is pulled upwards and forwards by the biceps. The forearm is pro- nated and voluntary rotation lost. The treatment is the Jones position or an anterior angular splint. 4o6 MANUAL OF SURGERY The shaft of the radius is usually broken by direct violence, and and occasionlly by a fall on the hand. The symptoms are loss of volun- tary rotation in the forearm, localized pain, and immobility of the head and upper fragment with crepitus upon passive rotation of the forearm. The displacement varies with the site of fracture. When the fracture is above the insertion of the pronator radii teres, the upper fragment is flexed and supinated by the biceps and supinator brevis, while the lower fragment is pulled towards the ulna and pronated by the pronator quadratus and the pronator radii teres, hence the forearm is thickened below the seat of fracture. The treatment of these cases is full supination of the forearm on an anterior angular-' splint, in order to bring the lower fragment in contact with th^pper, which, owing to its situation and small size, is not under control. Union takes place in three or four weeks. When the fracture is below the insertion of the pronator radii teres, the upper fragment passes inwards and forwards, owing to the action of the biceps, supinator brevis, and the pronator teres, which hold it also between pronation and supination. The lower fragment passes into the interosseous space and is pronated by the pronator quadratus; the supinator longus tilts the upper end inwards, but is not suflficiently powerful to overcome the pronation. The treatment is the same as that for fracture of the shaft of the ulna, the arm being placed midway between pronation and supination, because of the danger of union with the ulna by callus formation. The dressings may be removed in four weeks. The lower end of the radius is broken with great frequency. A Colles' fracture is nearly transverse, and is situated within one inch of the articular surface of the radius; it may, however, be oblique laterally or anteroposteriorly. A Barton'' s fracture involves the posterior lip of the lower end of the radius, the line of fracture entering the wrist joint. Colles' fracture is most frequent in old women, but may occur in either sex at any age. It is practically always the result of a fall upon the palm of the extended and pronated hand. Impaction, fracture of the lower end of the ulna or its styloid process, and tearing of the internal lateral ligament with subsequent dislocation of the lower end of the ulna, are not unusual complications. As a rule a strip of periosteum on the posterior surface remains untorn. The symptoms are swelling, localized pain, and loss of function. Abnormal mobihty and crepitus are frequently absent. The lower fragment passes upward and backward as the result of the direction of the violence, producing the silver fork deformity fFig. 204) ; as BONES 407 most of the force is transmitted through the ball of the thumb, the displacement is also outward, thus causing abduction of the hand and prominence of the styloid process of the ulna, which is found on a level with or lower than the radial styloid, which is nor- mally the lower point. The lower fragment is also tilted, because the brunt of the force is received on the posterior lip of the articular surf- ace, which looks downward and backward instead of downward and forward. The hand is pronated, and separated from the fore- arm by a deep depression on the flexor surface, caused by the back- ward displacement of the lower fragment and the prominence of the lower end of the upper fragment. The distance between the styloid processes is lengthened and that between the external condyle and the radial styloid is shortened. In rare instances, as the result of falls on the back of the hand, the lower fragment is displaced forward instead of backward (Fig. 205). The Treatment." — Reduction is accomplished by hyperextension, to free the fragments and relax the untorn dorsal periosteum, and Fig. 204. — CoUes' fracture showing Fig. 205. — Fracture of lower end silver fork deformity. of radius with forward displacement, showing gardener's spade deformity. direct pressure on the lower fragment, to force it in place, as the wrist is flexed and the hand adducted (toward the ulna). These movements may be quickly performed by locking the fingers be- neath the upper fragment and using the thumbs to control the lower fragment. Great force is often required to reduce this fracture, and unless such can be effected quickly and at the first attempt, the patient should be anesthetized. Reduction is best maintained by means of the Bond splint (Fig. 195), fully padded beneath the hollow of the wrist, so that when placed on the splint the hand will be semi- flexed and adducted. The fingers are not bandaged. The dressings are changed every two or three days, and while the fragments are held firmly in place with one hand, the fingers and wrist are gently moved, at even the second dressing. The splint may be permanently removed in three weeks. The Levis sphnt (Fig. 206) acts on the same principle as the Bond splint. A moulded plaster gutter splint can be shaped as the Levis splint. Roberts uses a straight pos- terior splint. When the fragments are perfectly reduced and im- 4o8 MANUAL OF SURGERY pacted some surgeons do not use splints Ijut have the wrist and forearm carried in a triangular muslin sling supported from the neck. In simple Colles' fracture in the young and healthy the prognosis is good both regarding contour and function, but if there is comminution or much impaction, some deformity will result no matter what treatment is employed, while in cases with associated joint injury, or in the old and rheumatic, limitation of motion frequently follows the most careful treatment. If the bone has Fig. 206. — The Levis splint. united in deformity and there is much impairment of function, reduction after osteotomy should be considered. Separation of the lower epiphysis of the radius may occur before the twentieth year, the epiphysis passing backward. It differs from Colles' fracture in that the dorsal swelling is less, the flexor or diaphyseal projection is greater, lateral deformity is rarely present, and crepitus is softer and more easily obtained. The treatment is Fig. 207. — Jones' cock-up splint. that of Colles' fracture. The danger of interference with the growth of the radius should be borne in mind. Fracture of both bones of the forearm (Fig. 207a) may be due to direct or indirect violence; it is most frequent in the middle and lower thirds. As a rule the upper fragments are approximated and pronated, w^hile the ends of the low^er fragments also approach each other and may be found in front of or behind the upper fragments, hence the forearm is narrowed from side to side and thickened BONES 409 anteroposteriorly. There are also shortening, crepitus, preternatu- ral mobility, pain, swelling, and loss of active rotation. The treatment of fractures below the insertion of the pronator teres is the same as that for fracture of the shaft of the ulna, .the forearm being placed midway between pronation and supination, and the interosseous space preserved by means of pads. In fractures above this point the forearm should be put on an anterior angular splint, in full supination. If there is a persistent tendency to ulnar bowing of the forearm, i.e., convex toward the ulnar side, the elbow may be extended and a long straight splint or a plaster cast appHed. Union is usually firm in four weeks. The carpal bones are seldom broken, except in crushes in which the fracture is compound and associated with injuries to neighboring bones. Until the advent of the X-ray simple fractures of the carpal bones were usually treated as sprain, weak wrist, rheumatism, etc. Although any of the carpal bones may be involved in a simple fracture, the scaphoid is the one most frequently broken, often being associated with anterior disloca- tion of the semilunar bone; the proximal fragment passes for- ward with the semilunar. There is a ''history of a fall on ^i^- 207a.— Fracture of both bones of the forearm. the extended hand; localized swelling of the radial half of the wrist joint; acute tenderness in the anatomical snuff-box when the hand is adducted; limitation of exten- sion by muscular spasm, the overcoming of which by force causes unbearable pain. The possibility of the existence of a bipartite scaphoid should be considered in interpreting X-rays of simple frac- ture of the scaphoid" (Codman and Chase). Crepitus may be ob- tained in some instances of simple fracture of the carpus. The treatment in compound fractures is disinfection and the application of a straight palmar splint, or possibly resection of bone or amputa- tion. In simple fractures deformity, if present, should be reduced by traction and direct pressure, and the wrist immobilized for three or four weeks by a palmar or dorsal splint. If pain and stiffness persist after fracture of the scaphoid, excision of the bone through a dorsal incision may give rehef. 4IO MANUAL OF SURGERY The metacarpal bones may be broken by direct or indirect force. Bennett's fracture is a fracture of the proximal end of the metacarpal bone of the thumb involving the articular surface. The symptoms are pain, swelling, crepitus, abnormal mobility, posterior angular deformity, and flattening of the knuckle of the affected bone. The treatment is reduction by traction and direct pressure, and the appli- cation of a straight palmar splint, well padded to fill up the hollow of the palm. It may be necessary to apply a dorsal pad over the deformity, and permanent extension to the finger by adhesive strips passing to the end of the spHnt. The dressing should be worn for three weeks. The phalanges are generally broken by direct violence, which frequently renders the fracture compound. The symptoms are pain, swelling, mobility, crepitus, loss of function, and little or no deformity. The treatment is the application of a molded splint of cardboard or a straight wooden splint, which in fracture of the proximal phalanx should extend into the palm. In some cases it may be desirable to bandage adjacent fingers together on a spHnt, so as to provide lateral support. The splint may be discarded in three weeks. Fractures of the pelvis are due to direct violence, as in a crushing accident, or to violence transmitted through the vertebral column or the femora. Fractures of the false pelvis, i.e., of the spines, crests, or ala of the ilia, are not in themselves serious, as displacement is slight. The complications may, however, be highly dangerous; they are more often associated with comminuted fractures, and involve the abdo- minal viscera. The symptoms are pain, swelling, ecchymosis, mobility, crepitus, and but little or no deformity. The treatment is rest in bed, with the shoulders elevated and the thighs flexed to relax the muscles, and the appUcation of a broad flannel binder around the pelvis. Rupture of the bowel will require laparotomy. Union occurs in four or five weeks. Fractures of the true pelvis are always serious because of the danger of complicalions, such as rupture of the bladder, urethra, or injury to the bowel, uterus, or vagina. The fracture usually extends into the obturator foramen, either through the horizontal ramus of the pubes or the ascending ramus of the ischium. It may be associated with fracture through the opposite sacroiliac joint, or there- may be many lines of fracture in different parts of the pelvic ring. The symptoms are shock, pelvic pain, especially on coughing, straining, or moving the legs, swelling, BONES 411 ecchymosis, inability to sit or stand, and rarely deformity. Mobility and crepitus may be obtained by grasping the pelvis on each side and making alternate pressure or by inserting the finger into the vagina or rectum while one side of the pelvis is moved on the other. It should be remembered that rough manipulations may drive sharp fragments into the viscera. Bleeding from the urethra, vagina, or rectum should be most carefully investigated. The treatment is first to react the patient from shock, and care- fully exclude visceral injuries, which if present, are to be repaired as described under their respective headings. The fragments are reduced by external manipulation, or by combined external and internal manipulation, and the patient placed on a firm bed or a Brad- ford frame, with a broad binder encircling the pelvis. In some frac- tures of the pubic bone wiring may be indicated. Union occurs in about six weeks, but the patient should be kept in bed several weeks longer, then allowed to get about with a firm binder and crutches. Fracture of the acetabulum may complicate dorsal dislocation of the femur, the posterior lip giving way; or the head of the femur, in falls on the trochanter, may fissure the acetabulum, or even perforate it and enter the pelvis, in which case the viscera may be damaged. In fracture of the posterior lip the head of the femur is easily reduced, with crepitus, but the deformity shows a strong tendency to recur. When the head of the bone has been driven into the pelvic cavity a fracture of the neck of the femur may be simulated, but there is less mobihty, and greater flattening of the trochanter, and the head of the bone may be palpated through the rectum. The treatment is reduction by traction and external manipulation, and the applica- tion of permanent extension as in fracture of the neck of the femur. The sacrum is broken by direct violence. Comminution may be present, and injury to the sacral plexus is frequent, perhaps causing paralysis of the bladder and rectum. In a transverse fracture the lower fragment generally passes forwards, and may press upon or tear the rectum. Mobility and crepitus may be detected by placing one finger in the rectum and making external pressure. The treatment is reduction by pressure within the rectum, and the application of a pelvic binder, with a large pad over the upper part of the sacrum, so that external pressure will not be made on the lower fragment. Laceration of the rectum may require suture. In the presence of injury to the sacral plexus elevation and fixation of the depressed fragments through an external incision will be indicated. In these cases great care must be taken lest bed sores develop or lest infection 412 MANUAL OF SURGERY of the bladder from catheterization result. The bone unites in four or five weeks. The coccyx is normally mobile, but it may be broken by a fall or a kick. The symptoms are pain, more marked on walking, coughing, and defecation; mobility; crepitus; and perhaps turning in of the fragment, appreciable on rectal examination. The treatment is rest in bed for four weeks; the bone cannot be splinted. Coccygodynia is a severe form of neuralgia following injuries to the coccyx. It may be due to non-union or vicious union, but occasionally occurs in cases in which there has been no fracture. The pain is similar to that occurring in fracture, and may be so harassing as to induce neurasthenia. If relief cannot be obtained by medical treatment, the coccyx may be excised through a straight incision in the middle line, care being taken not to injure the rectum. Fractures of the upper extremity of the femur include intra-and extracapsular fractures of the neck, fractures of the great trochanter, fractures of the lesser trochanter, and separation of the upper epiphysis. Intracapsular fracture of the neck of the femur is most frequent in elderly women, although it may occur in either sex or at any age. In old age the neck of the bone is more horizontal, and the bony tissue is atrophied and infiltrated with fat, hence slight indirect force, such as catching the toe in a piece of carpet, or suddenly throwing the weight of the body upon the lower extremity, is a frequent cause of this accident in the elderly. Impaction is unusual, and although some of the reflected fibers of the capsule or a portion of the periosteum may remain untorn, the head of the bone, as a rule, is entirely separated except for its attachment to the acetabulum by the ligamentum teres, through which it receives sufficient blood to maintain its vitahty. Hence non-union or at best fibrous union is a frequent occurrence, particularly in the aged and debilitated. The symptoms are pain, little or no swelhng and ecchymosis (unless the patient has fallen on the trochanter after the neck has broken), loss of function, helpless eversion (the limb lying on its outer side as the result of gravity and the action of the external rotators; inversion is possible but very rare), crepitus if there is no impaction, lessened arc of rotation of the great trochanter (the radius extending to the line of fracture instead of to the acetabulum), inward dis- placement of the great trochanter (found by measuring the distance between the median line of the body and the outer surface of each trochanter) , and slight shortening (one-half to one inch) , which in a few days may increase to two or more inches, owing to muscular BONES 413 spasm, unlocking of impacted fragments, or laceration of untorn periosteal or fibrous tissue. Shortening may be determined by one of the following methods: i. The limbs may be measured from the anterior superior spine of the iHum to the internal malleolus. The patient should be perfectly Hat and straight upon a firm bed, so that a straight line drawn from the episternal notch to midway between the internal malleoli will intersect the umbilicus, the symphysis pubis, and the midpoint between the knees, and a line passing through each anterior superior spine of the ihum will be perpendicular to the axis of the body. The tip of the anterior superior spine and the tip of the internal malleolus are marked with a pencil, and in measuring the skin is not pressed upon lest it become displaced. A difference of a quater of an inch is not unusual normally, and excep- tionally it may be even much greater, so that in case of doubt the tibiae may be measured to determine the presence or absence of symmetry. Normally a straight line from the anterior superior spine to the tip of the malleolus passes through the center of the patella. 2. Nelatons^s line is one passing from the anterior superior spine of the ilium to the most prominent part of the tuberosity of the ischium. Normally when the lower limb lies in the axis of the body, midway between „ .^^ ^t-, . i- -^ ' . Pig. 208. — AD, Nelaton s line; internal and external rotation, the top abc, Bryant's triangle; BC, test- Of the trochanter touches the middle Ime^f^rJ^racture or shortening of neck of this line; in fracture it passes above the line. 3. Bryant's triangle (Fig. 208) consists of a line from the anterior superior spine to the top of the trochanter, and another from the anterior superior spine, drawn downward perpendicularly to the axis of the body, to meet at a right angle one drawn upward from the trochanter. Shortening of the last line as compared with the opposite side of the body shpws the amount of shortening of the limb. 4. Relaxation of the fascia lata, as determined by pressure above the great trochanter, also indicates shortening of the femur. In children, in whom this fracture is more common than was once supposed, there is usually the history of a severe fall rather than a trivial twist, and the fracture is often impacted or of the green-stick variety, so that the disability may be slight and the bony injury readily overlooked. Later, however, owing to the lack of proper treatment, the neck bends (coxa vara) and a permanent limp is 414 MANUAL OF SURGERY produced, which, with the slight pain and limitation of motion, may be mistaken for hip disease. The symptoms of fracture of the femoral neck in children are slight eversion, limitation of abduction, and shortening; crepitus and abnormal mobility are usually absent. The diagnosis is confirmed by the X-ray. The complications in the old are mainly due to confinement to bed, e.g., bed sores and hypo- static pneumonia. Non-union, fibrous union, atrophy and absorp- tion of the head, in the old, and coxa vara in the young are among the sequelae. The treatment is seldom satisfactory. Aged patients rarely tolerate confinement to bed for the necessary length of time to obtain union, and, should there be evidences of impairment of the general health, the patient should be allowed to sit up and leave the bed at the earliest possible date, making no attempt to fix the fracture. The usual method of treatment is by Buck's extension apparatus, with sand bags for lateral support. The patient is placed on a firm mattress, which is kept flat by boards placed between it and the frame of the bed. Impaction should never be broken up, except possibly in the young, hence one should never try to obtain crepitus and mobihty, and should be careful in moving the patient. A hairy leg should be shaved, and the foot and ankle bandaged. A strip of adhesive plaster, about two inches wide, and long enough to run from the seat of the fracture to below the sole of the foot and back again, is prepared by fastening to its center a piece of board, with a hole in the middle, and a little longer than the width of the foot (Fig. 195). The plaster is apphed to the sides of the lower extremity up to the seat of the fracture, and the bandage continued over the plaster. A piece of rope is knotted, then passed through the open- ing in the board and over a pulley at the end of the bed (Fig. 195) To this should be attached a weight of five pounds ( a brick weighs about five pounds), unless there is great shortening and no impaction, in which case the weight should be sufficient to restore the normal length of the hmb. The foot of the bed is raised five or six inches to obtain counterextension by the weight of the body. The limb is slightly abducted, rotated inward to correspond with the other limb, and supported from the sides by sand bags, the outer reaching from the chest to below the foot, and the inner from the perineum to below the foot. A pad is placed beneath the popliteal space, and a bird's nest of cotton beneath the heel to relieve pressure. A cradle (Fig. 209) may be placed over the leg to support the bed clothing. The patient should be kept in bed six or eight weeks, and should bear very little weight on the extremity for three months from the BONES 415 time of injury, indeed crutches, or at least a cane, are usually neces- sary for many months, if not permanently. Senn encases the pelvis and the lower extremity in plaster-of- Paris leaving an opening over the great trochanter, upon which lateral pressure is made by means of a screw apparatus which has been incorporated in the plaster. Tlie Thomas hip splint (Fig. 247) immobilizes the fracture by fixing the pelvis and the thigh, and allows the patient to be moved about without danger of disturbing the fragments. The sphnt is of iron, with bands encircling the chest, thigh, and calf. The method is an excellent one if the splint is at hand and the practi- tioner possesses the requisite skill to adjust it. Whitman advises the breaking up of impaction under anesthesia, and fixation of the limb at the limit of normal abduction, by means of a plastcr-of-Paris spica. He beHeves this treatment is applicable to all cases. If non-union occurs in young and healthy adults, the fragments may be fixed by driving a nail, screw, or bone peg through the trochanter into the head of the femur, after exposing these parts by incision. The prognosis is bad in the old. Death may occur from shock, exhaustion, or from pneumonia or other visceral disease. Complete recovery is rare, there usually being pain, weakness, and limping. In cases of non- union not suitable for operation, some relief may Pi^. 209.— Cradle. be obtained by means of a hip support. The so-called extracapsular fracture of the neck of the femur is in reality only extracapsular posteriorally, the line of fracture anterior- ally being covered by the capsule. The cause is direct violence to the trochanter as a fall on the hip, hence impaction is common; if the vio- lence be greater the trochanter is involved, sometimes with extensive comminution. The symptoms are much the same as those of intra- capsular fracture, except that in the former there is greater pain swelling, ecchymosis, and primary shortening, and later more thickening as the result of callus formation. The treatment is the same as that of intracapsular fracture. The prognosis is very much more favorable than in intracapsular fracture; bony union is the rule, although some shortening is inevitable. Fracture of the great trochanter is the result of direct violence, the line of fracture running through the base of the trochanter to the lower part of the neck of the bone. The symptoms are very simi- lar to those of extracapsular fracture. The lower fragment with the lesser trochanter passes upward and backward toward the sciatic 4l6 MAXUAL OF SURGERY notch, and may be palpated posteriorly. The treatment is that of extracapsular fracture. Separation of the great trochanter without fracture of the shaft is very rare, and in youth is due to separation of the epiphysis of the great trochanter. The cause is direct violence. The symptoms are mobility of the trochanter and crepitus. The length of the Umb and the motions of the hip joint are not affected. The treatment, if there is little or no displacement, is that of fracture of the neck. If the fragment is pulled upward and backward away from the shaft, the thigh may be flexed and rotated externally, while adhesive straps are applied to pull the trochanter downward. Far better in such a case is fixation by screws, or bone pegs, through an open incision. Fracture of the lesser trochanter may occur in the young. Eight cases have been reported, one from direct violence, and the rest from avulsion the result of contraction of the psoas when the thighs were spread apart. The symptoms are external rotation of the thigh, pain and tenderness two or three inches below the groin in Scarpa's triangle, and ecchymosis along the inner surface of the thigh. Crepitus and abnormal mobility cannot be ehcited, owing to the depth of the injury, and there is no shortening or deformity. The patient is able to raise the heel from the bed when lying down (as this is done by the rectus and the muscles on the anterior surface of the thigh), but not when sitting, as the rectus is then relaxed and the psoas must do the lifting (Ludlow's sign). This sign differenti- ates this injury from a fracture of the femoral neck, in which the leg cannot be raised when the patient is lying down. The diagnosis is confirmed by the X-ray. The treatment is fixation of the thigh in flexion and internal rotation, in order to relax the psoas. Separation of the epiphysis of the head of the femur is uncommon, but may occur in early life. Growth of the limb may be impaired, or coxa vara may result. The symptoms are those of intracapsular fracture, although less marked and accompanied by soft crepitus. The treatment is that of intracapsular fracture. The diagnosis of injuries about the hip should be made only after a comparative examination of both sides. The tape measure and the X-ray are the greatest aids. In contusion or sprain men- suration will reveal neither shortening of the limb nor flattening of the hip, although individual variations from the normal should be remembered. It should be recalled, however, that shortening may som^etimes occur late after contusion, owing to atrophy and absorp- tion of the head of the bone. Crepitus with shortening may be BONES 417 found in chronic osteoarthritis of the hi]), hut they antedate the accident and are probably associated with similiar changes in other joints; moreover, the trochanter is more often prominent than flattened, and there is no relaxation of the fascia lata. An impacted fracture gives no crepitus, and presents a large arc of rotation of the great trochanter, but is accompanied by shortening which is not affected by extension. Dislocation occurs in young adults, never as the result of direct violence, but always from force applied to the knee, foot, or back when the thigh is flexed; there is no crepitus and the head of the bone may be felt in its new position. In dorsal dislocation the limb is adducted and inverted, while in forward dislocation there is abduction and outward rotation; in the obturator variety of the latter there is lengthening of the hmb. Fractures of the shaft of the femur are most frequent in the middle third. Fracture of the upper third is uncommon and usually due to indirect violence. Fracture of the lower third is usually due to direct violence. The middle of the bone may be broken in either Fig. 210. — Fracture of the shaft of the femur. way and occasionally from muscular action. The fractures are generally oblique and displacement is the rule, hence injury to the soft parts is of frequent occurrence, and occasionally the vessels or nerves are lacerated. The symptoms are pain, swelling, muscular spasm, abnormal mobihty, crepitus, deformity, and shortening. In the upper third the upper fragment is pulled forward by the iliopsoas, and drawn outward and rotated externally by the external rotators; the lower fragment is pulled upward by the flexors and extensors of the leg, inward by the adductor muscles, and rolled outward by the weight of the limb. In the middle third the displacement is much the same, although here any variety of deformity may be produced, according to the form and the direction of the violence. In the lower third the gastrocnemius draws the lower fragment backward, and thus endangers the popliteal vessels. The treatment of fractures of the upper third is flexion of the thigh, to place the extremity in the position of muscular relaxation, and 27 4i8 MANUAL OF SURGERY traction to reduce the deformity, this position is best obtained in the suspension and extension dressing of Blake (Fig. 211) with extension in the axis of the thigh. The principle of the double-inclined plane is utilized also in the Mclntyre splint, the Nathan R. Smith anterior spHnt, and the Hodgen splint. The Nathan R. Smith sphnt is made of strong wire, bent to the de- sired shape; it is applied to the anterior surface of the limb and suspended by cord and pulley. The Hodgen sphnt consists of two long pieces of wire joined at thedistal extremity and reinforced at the middle and upper end by cross pieces. The limb rests in a trough of flannel or towels attached to the frame. A Buck's extension is Fig. 211.^ — Blake's suspension and extension applied to the lower extremity with a Hodger splint. applied and attached to the foot piece, and further extension made by suspending the limb by cords, passing obliquely upward to a vertical post at the foot of the bed. The apphcation of a Buck's extension to the thigh below the fracture or by skeletal trac- tion to the Icwer fragments are recent modifications of the original Hodgen method and supplant the indirect traction upon the leg. All forms of treatment, however, are unsatisfactory, and if the displace- ment is marked and the patient young and healthy, operative fixation should be considered. In fractures of the middle third a Buck's extension is apphed up to the seat of fracture, and enough weight attached to the cord to overcome the shortening. Lateral displacement is corrected by sand bags, lateral splints, or a molded BONES 419 splint. In the lower third horizontal traction may ])c tried, as in the middle third, but if there is a marked tendency to displacement of the lower fragment backward, the double-inclined plane should be used. Tenotomy of the tendo Achillis is useful in some cases. Bardenheuer treats fractures in all parts of the femur, and indeed fractures in other bones of the extremities, by lateral as well as longi- FiG. 212. — Calipers for skeletal traction. tudinal extension (Fig. 213). In order to make powerful traction Steinmann advises "nail extension." As the Steinmann procedure is attended by some danger of infection, it has been replaced by the skeletal calipers or ice tongs of Ransohoff (Fig. 212). Fractures of the thigh unite in six or eight weeks. The suspension and extension dressing of Blake can be used in the treatment of any fracture of the thigh or leg. 420 MANUAL OF SURGEEY In children Bryant's method may be used; the h'mb is splinted, flexed to a right angle with the body, and extension made from a cross bar above the bed (Fig. 214). The child may be fastened to a Bradford frame, which is simply an oblong of gas pipe to which can- vas is attached, a space being left beneath the buttocks. Van Arsdale's triangular splint is made of thick cardboard, in the shape ^ of two cards of spades joined at their apices (Fig. 215). When the splint has been folded, it forms a triangle, segment 2 being molded to the abdo- men and segment 3 to the thigh. ''The extreme flexed position of the thigh relaxes all the muscles and neutralizes any tendency to displacement; the child can sit on the floor or chair and creep about, and the genital and anal regions are well away from the dressings" (Gallant). The splint is worn for three weeks. The prognosis in childhood is very good, but decreases with the advance of years, so that in adult life probably only one-half secure limbs which give them no trouble, and in old age per- fect functional results are very rare. Except- ing incomplete fractures, some shortening is inevitable. Supracondylar fracture of the femur is identi- cal with fracture of the lower third of the bone. , , , T- or Y-shaped fracture exists when a sup- band passing around ^ t" the injured thigh and racoudylar fracture is complicated by a separa- under the sound thigh; . , , . , . -i -i rm (c) of traction on upper tiou ot the coudylcs ouc from the other. The end of lower fragment, Iq^^qx end of the f cmur is broadened, one condyle by band passing around _ ' _ -^ the thigh ;(d) of traction may be movcd ou the other with crepitus, and Each'^of°these^ bands ^^^ knee joiut is filled with blood. The treatment passes over a pulley at jg that of fracturc of the lowcr third of the femur. the side of the bed and ^^ , e •,-, i i • i i r is attached to a weight. Fracture of either condyle is the result of The upper end of the jj^.^ ^ f^^^^ ^j^^ fragment is displaced upward distal fragment IS forced o f f outward also by adduct- and the leg deviated toward the affected side; ^"^ ^ ' there are crepitus, broadening of the lower end of the femur, and distention of the joint, but no shortening. The treatment is a double-inclined plane. Separation of the lower epiphysis occurs before the twenty-first year, is the most frequent of all epiphyseal separations, and is usually the result of the leg being caught in the spokes of a wheel. The symptoms are much hke those of supracondylar fracture, except that Fig. 213. — Barden- heuer's method of treat- ing fractures of the femur, (a) Direction of traction by Buck's ex- tension apparatus; (b) of traction on lower end of upper fragment, by BONES 421 the crepitus is moist, and the lower fragment is often displaced forward owing to the action of the quadriceps on the tibia; the lower end of the diaphysis passes backward, thus endangering the popliteal vessels. Fig. 214. — Vertical traction as used in treatment of fracture of femur in children or in adults with anterior displacement of upper fragment. Suppuration may occur and the growth of the bone may be impaired. The treatment is reduction by traction while pressure is made on the fragments and the thigh gradually flexed. The limb is then put on a double-inclined plane. Longitudinal fractures entering the knee joint may cause broadening of the bone, but are difficult to detect. The treat- ment is immobilization in a horizontal posi- tion for six or eight weeks. Occasionally a small piece of the articular surface of one of the condyles is chipped, but unless an X-ray picture is taken, the diagnosis is rarely made until some time later, when a foreign body is detected in the joint. Fracture of the patella is produced by direct violence, or much more frequently by muscular action. Fractures by direct violence are usually vertical or oblique, and not infrequently comminuted. As a rule the fibrous capsule of the patella is not separated to any great Pig. 215. — Segments, i, 2, 3, 4, each cut the length of child's thigh from groin to patella, and flanges C to D the same width. The width of sections i and 4 equals thickness of the middle of the thigh. Fold on dotted lines overlapping i and 4 after moistening. (.A.nnals of Surgery.) 42 2 MANUAL OF SURGERY extent so that marked displacement is absent. The treatment of these cases is immobihzation of the knee by a posterior spHnt for six weeks. Effusion into the joint is reduced by cold and compression and later by massage; in four weeks gentle passive motion is begun. Fractures due to muscular action are transverse or slightly oblique, the fibrous capsule usually tearing so that marked separation takes place. The joint is therefore usually opened. When the knee is half flexed, the middle of the patella lies against the condyles of the femur, while the upper portion projects above ; in this position sudden contraction of the quadriceps, as in an attempt to save oneself from a fall, may result in a transverse fracture. The symptoms are pain, effusion of blood into the knee joint, inability to extend the leg although walking backward is possible, separation of the fragments, and if they can be brought together, crepitus. The separation is produced by the action of the quadriceps and also by the effusion in the knee joint. The treatment is at first the application of a posterior splint, with cold and compression to reduce the swelling. If there is great disten- tion of the joint, the effusion may be drawn off by a trocar and can- nula. After the swelling has been controlled the fracture may be treated by the non-operative method or by operation. The non-operative method is without risk to life and is generally followed by a useful joint, although it consumes more time than treatment by operation. It should be employed by the general practitioner who is not surrounded by facilities for perfect asepsis. Cases in which the fibrous capsule of the patella and the lateral fascial expansions are not torn through, i.e., cases in which there is but little or no separation, are best treated by the conservative plan no matter what the surroundings. The limb is placed on a posterior splint, the lower end of which is elevated to relax the quadriceps, and the fragments are approximated and held in place by two strips of adhesive plaster, one of which passes from below the joint on the outside, above the upper fragment, then down to the inner side of the lower part of. the knee. The second strip in a similar way carries the lower fragment upward. A third strip should be put across the line of fracture to prevent tilting of the fragments. Hopkins applies to the thigh a wickerwork of adhesive plaster, to which is attached an extension apparatus in order to relax the quadriceps and pull down the upper fragments. Agnew's splint (Fig. 195) is simply a posterior splint with rotating pins on the side for the attachment and tightening of the strips of adhesive plaster applied to hold the frag- ments in place. Massage may be used from the beginning. During BONES 423 the tifth or sixth week the splint may be removed, and the patient allowed to walk with a molded support to keep the knee stiff ; passive motions are used at this time, but active movements are reserved until the end of two months; all support is removed at the end of six months. The operative treatment of fracture of the patella is gaining in favor, and indeed with some surgeons is almost routine practice. It should never be employed unless facilities for aseptic work are available, as infection of the knee joint may result in its destruction, in amputation of the limb, or in death. Convalescence is more rapid after the operative treatment, and it offers the best chance for accurate apposition and bony union. Granting a healthy subject, it is par- ticularly indicated in cases in which there is wide separation, in which soft tissues intervene bo tween the fragments after their apposition, and in cases of com- pound fracture, re^racture, or fibrous union in which the func: tion of the limb is considerably im paired. In the laborer or in on» whose occupation necessitates pro longed standing or much walking, operation offers the best chance for a strong patella. Operative treat- ment may be either subcutaneous or open. As an example of the former may be mentioned the antero-posterior suture of Barker. A special instrument somewhat like an aneurysm needle sharpened at the end is passed through a knife puncture just below the patella, then beneath the bone to and through the skin above the upper fragment, where it is threaded with silver wire and withdrawn to the point of entrance and unthreaded ; it is then pushed upward between the skin and the fragments to the opening above, threaded with the other end of the wire, and with- drawn. After rubbing the fragments together to dislodge blood or soft tissues, the ends of the wire are twisted, cut short, and pushed beneath the skin. In a somewhat similar manner Roberts passes a silk suture around the fragments laterally (circumferential suture). The subcutaneous possesses all the dangers of the open method with- out its advantages, viz., evacuation of the joint, removal of the 210. — Skiagraph of patella. fracture 424 MANUAL OF SURGERY fibrous or other tissue from between the fragments, and accurate apposition. The open operation is performed by exposing the frac- ture by a longitudinal or transverse incision, perferably the latter. The joint is irrigated with salt solution, the fragments brought to- gether after removing any intervening soft structures. The wound is closed without drainage. When the fragments come together without much tension, the fibrous capsule of the patella is sutured and the lacerations in the lateral fascial expansion with strong chro- micized catgut. If there is a great deal of tension it may be neces- sary to pass kangaroo tendon through vertical holes bored in the fragments. Massage is begun as soon as the wound is healed, and the patient is allowed out of bed with a molded splint at the end of three or four weeks, when passive motions are commenced ; all dress- ings are removed in two months, and at the end of three or four months recovery is complete. The prognosis after non-operative treatment is good regarding the function of the leg, although fibrous union is the rule and some stiffness and weakness are generally present. After operation bony union may be secured, but pain and stiffness are by no means un- usual. Of 373 cases of fracture of the patella, 48 suffered a refracture at the same point, in periods ranging from a few months to four years; the majority of these were treated by the conservative plan (Lauper) . The tibia may be fractured at the upper end, at any portion of the shaft, and at the lower end, and the tubercle, or the upper or lower epiphysis may be separated. The upper end of the tibia is broken by direct violence. The symptoms are often masked by the swelling of the overlying soft parts. When the fracture is transverse there is but little displace- ment, when oblique the leg deviates from the axis of the Hmb. The fissure may enter the joint, which will then be greatly distended. Mobility and crepitus are present. The treatment is reduction by traction and pressure on the fragments, and immobilization on a double-inclined plane or in a plaster cast, for four or five weeks. The tubercle of the tibia may be torn off by violent contraction of the quadriceps, in individuals under the age of twenty. The fragment is drawn upward, and the injury may be mistaken for fracture of the patella, in which, however, there is no depression at the upper extremity of the tibia, the upper end of the lower fragment is ser- rated, and a finger pressed between the fragments touches the femur. If the separation is partial the diagnosis is made by pain, tenderness, localized swelling, and the X-ray. The treatment is a posterior BONES 425 splint; if there is much separation, the tubercle may be fastened in place by pegging. Separation of the upper epiphysis of the tibia is an extremely rare injury which may occur before the sixteenth year and be productive of dwartlng of the leg. The treatment is that of fracture of the upper end of the tibia. The shaft of the tibia is usually broken by direct violence, occa- sionally by indirect violence or torsion. Generally speaking the fracture is transverse when in the upper part of the bone, oblique or spiral when in the lower portion (Fig. 217). The symptoms are localized pain, irregularity of the crest of the tibia, crepitus, and mobility. In transverse fractures there may be no deformity, and even in obhque frac- tures the splinting action of the fibula may prevent much displacement; as a rule, how- ever, the upper fragment is tilted forward by the. quadriceps, while the lower fragment is rotated inward. The treatment is the applica- tion of a fracture box (Fig. 195), until the swelling has been controlled by evaporating lotions or the ice bag; the leg is then put up in a plaster-of-Paris cast, which is worn for five weeks. The cast should be split before it has hardened, so that it may be removed every few days for inspection and massage of the leg. The internal malleolus is broken by direct force, or its tip may be torn off by the in- ternal lateral ligament when the foot is strongly everted. The symptoms are pain, mobility, crepitus, effusion into the ankle joint, and possibly downward displacement of the fragment. The treatment is that of fracture of the shaft. Wiring or pegging should be considered if there is much displacement, as vicious union in this situation is followed by lameness. Separation of the lower epiphysis of the tibia is very rare. The treatment is that of fracture of the shaft. The fibula may be broken by direct or indirect force, or by muscular action (biceps). The upper end of the fibula, when broken, causes localized pain, particularly on adduction of the leg. There may be no displace- ment, or the upper fragment may be drawn up by the biceps. Crepi- FiG. 217. — Skiagraph of torsion fracture of tibia. 426 MANUAL OF SURGERY tus and mobility are present; the external popliteal nerve may be injured. The treatment is the application of a plaster cast for five weeks. If there is displacement the knee may be flexed to relax the biceps. The shaft of the fibula, when broken, causes localized pain and tenderness. Deformity is not seen, but on pressing the tibia against the fibula, crepitus and abnormal mobihty may be detected. As the bone is normally elastic, comparison with the other leg should be Fig. 2 1 8. — Pott's fracture. made before deciding that abnormal mobility is present. The treatment is a plaster cast for five weeks. The lower end of the fibula may be broken by direct force, but the usual cause is a twist of the foot. Pott's fracture is caused by ever- sion and abduction of the foot, rarely by inversion and adduction. In a typical case there are three lesions, a fracture of the fibula about three inches above the tip of the malleolus, a fracture of the internal malleolus due to traction of the internal lateral ligament (or rupture BONES 427 of the ligament), and rupture of the tibiofibular ligament (or avul- sion of that part of the tibia to which it is attached) . The number of lesions and consequently the amount of deformity depend upon the degree of eversion and abduction. In the slighter forms the internal malleolus alone is broken or the internal lateral ligament ruptured. Continuation of the force presses the astragalus against the external malleolus and, with the tibiofibular ligament as a ful- crum, breaks the fibula above the ankle by indirect force, the upper end of the fragment passing toward the tibia. These injuries cause simply marked eversion of the foot. If the tibiofibular ligament also ruptures, or the tibia to which it is attached gives way, there is Pig. 219. — Skiagraph of fracture-dislocation of ankle. added displacement of the foot upward and backward; to this variety the term fracture-dislocation (Fig. 219) may be properly applied. If the outward dislocation is complete the injury is called Dupuytren's fracture. Occasionally the fracture of the fibula is accompanied by a transverse fracture of the tibia immediately above the inner malleolus, in which case the projection of the lower end of the upper fragment of the tibia may be mistaken lor the internal malleolus. In Pott's fracture by inversion the astragalus presses against and fractures the internal malleolus, and the fibula is broken above the ankle by the violent traction on the external lateral ligament, the tibiofibular joint acting as a fulcrum. 428 MANUAL OF SURGERY The symptoms in a typical case are aversion of the foot with displacement upward and backward. There is great sweUing, the ankle joint being distended with blood. The internal malleolus is prominent, the ankle joint widened, and the foot shortened, i.e., from the tibia to the toes. There are three points of great tender- ness, corresponding with the three lesions mentioned above; the joint can be moved laterally and antero-posteriorly, and crepitus obtained. Fig. 220. — Fracture of both bones of the leg. The treatment is reduction by carrying the foot inward, forward, and downward, and the application of a fracture box until the sweUing has been controlled. The foot is fastened to the foot-piece of the box by a bandage, and pads so arranged as to maintain reduc- tion, relaxation of the tendo Achillis and prevent pressure on the heel. When the swelhng has subsided, the leg may be put up in plaster, care being taken to maintain the foot at right angles to the leg and slightly adducted, and to continue extension on the foot until the plaster has hardened. The cast is permanently removed at the end of the fifth week. Du- puytren's splint is a straight board extending from the knee to five or six inches below the foot. The lower extremity is notched. The splint is applied to the inner surface of the limb, after being thickly padded down as far as a point corresponding to the internal malleolus, so that the foot may be inverted over the lower end of the pad by bandages, extending from the foot to the serrations in the end of the spHnt (Fig. 195). This splint is well suited to cases in which there is eversion and upward displace- ment, but does not correct backward displacement of the foot. If reduction cannot be effected or maintained, even after flexion of the knee or division of the tendo AchilHs, fixation of the fragments by operation is indicated. Fig. 221. — Traction by means of a stock- ing glued to the foot and ankle. BONES 429 Fracture of the shafts of both bones of the leg (Fig. 220) may be due to direct violence, in which case the fracture may be transverse and at the same level in each bone; indirect violence frequently produces an obhque or a spiral fracture at about the junction of the middle and lower thirds of the tibia, the fibula yielding at a higher level. All the symptoms of fracture are in evidence. As a rule the lower fragments pass up behind the upper fragments, owing to the action of the calf muscles, and are rotated outward by the weight of the foot. The treatment is reduction by flexing the knee to relax the calf muscles, and traction on the foot while the bones are forced into place; division of the tendo Achillis is occasionally necessary. The limb may then be placed in a fracture box, and after the subsidence of swelling in a plaster-of-Paris cast. Some surgeons apply molded lateral splints, others the Nathan R. Smith anterior splint. Stein- mann employs "nail extension" (p. 419), the nails being driven into the malleoli. The caliper is to be preferred. The ambulatory treatment also may be used in this region. Splints may be removed in five or six weeks. Whatever treatment is employed, one should guard against rotation of the lower fragments and shortening; the former is absent if the inner surface of the great toe, the in- ternal malleolus, and the inner edge of the patella are in the same plane. The prognosis of fractures of the leg in the young is quite favorable ; in adult life, and more so in old age, pain, stiffness, and swelling may be present for many months. Next to the patella and humerus non- union is more frequent in this region than anywhere else. After a classical Pott's fracture some stiffness of the ankle and deformity are almost inevitable. To prevent eversion of the foot tapering wedges should be placed along the inner edge of the shoe, ^{q inch in the heel and }i inch thick in the sole. Should the eversion per- sist there will be traumatic flat-foot, which will necessitate a support to the instep, or possibly in some cases osteotomy of the tibia and fibula. Fracture of the astragalus is due to direct violence or to a fall on the sole of the foot. Many of the slighter forms are incorrectly diagnosticated as sprains of the ankle, as there are pain and great swelling. In the absence of deformity and crepitus a correct diagno- sis can be made only with the X-ray. There are often associated lesions of neighboring bones. The trejtment is a fractuie box, and later a plaster-of-Paris cast for five weeks. 43° MANUAL OF SURGERY The OS calcis is usually broken by a fall on the foot, and rarely from violent contraction of the calf muscles. The Hne of fracture may be in almost any direction; if in the anterior portion of the bone there may be no deformity, if through the sustentaculum taU there will be flattening of the foot, and if more posterior the fragment may be drawn up by the calf muscles. In the latter instances crepitus and mobility may be detected. The heel is often enlarged from side to side. Cotton lays the inner side of the foot upon a sand bag, places felt over the outer side of the os calcis and impacts the frag- ments by blows from a mallet. Impaction is employed only after the position has been carefully corrected by manipulation or exten- sion with tongs. The treatment, in the absence of deformity, is a fracture box, and later a removable plaster-of-Paris cast for four weeks. Widening of the heel may be corrected with lateral pads, flattening of the foot with an instep support. When the posterior fragment is drawn upward, the tendo Achillis may be cut, or the knee bent, and the foot fixed in plantar flexion by a slipper whose heel is connected with the thigh by a cord. Far more satisfactory, however, is wiring or pegging the fragment in place. The remaining bones of the tarsus may be broken by direct violence, which is usually of such a nature as to cause an open wound and comminution of bone, hence excision of fragments with drainage, or in some cases amputation, is required. The metatarsal bones may be broken by direct or indirect vio- lence. Tlpie fracture is frequently compound. The usual symptoms of fracture are present. The treatment is a molded splint for four weeks. The treatment should be supplemented by the use of felt pads in the sole of the shoe so shaped as to preserve the arches of the foot. Fractures of the phalanges of the foot are usually compound, and often require amputation. In other cases the toes should be fixed on a molded sphnt of cardboard, extending well up on the sole of the foot. DISEASES OF BONES Inflammation of bone begins in the periosteum or the medulla , from which structures the osseous tissue receives its blood supply. The phenomena, viz., hyperemia, exudation, and changes in the perivascular tissues are much the same as in other structures, except that death of the bone is more likely to ensue, owing to the unyielding character of the canals in which the vessels run. Inflammation here as elsewhere terminates in resolution, new growth {condensing ostitis, BONES 431 or osteosclerosis), or death of the part. Death of bone is brought about by ulceration {caries, inflammatory osteoporosis, or inflam- matory rarefaction) , abscess formation, or gangrene {necrosis) . Ana- tomically, inflammation of bone may be divided into periostitis, ostitis, and myelitis; clinically, however, periostitis is always linked with inflammation of the subjacent bone, myelitis with involvement of the surrounding osseous tissue, hence the terms osteoperiostitis and osteomyelitis are more nearly correct. Osteoperiostitis (periostitis) may be acute or chronic, localized or diffuse. In the acute form the periosteum is red and swollen. This is followed by resolution {simple periostitis) , by suppuration {puru- lent periostitis), or by permanent thickening owing to the deposition of new bone {ossifying or osteo plastic periostitis) . Periostitis serosa or albumitiosa (Oilier and Poncet) is a variety of suppurative periostitis, probably due to organisms of low virulence. A serous or mucoid exudate, rich in albumen and containing staphy- lococci or streptococci forms beneath the periosteum. The course is subacute or chronic. In old cases there is Httle tenderness and the condition may be mistaken for a cyst or, when on the skull, for a meningocele. The causes of osteoperiostitis are contusions, wounds (including fracture), extension from neighboring tissues, and infection by way of the blood, such as rheumatism, gout, gonorrhea, syphiHs, pyemia, tuberculosis, and acute infectious fevers. Periostitis may occur also at the point of attachment of muscles which are used to an abnormal extent, or as the result of pressure, e.g., periostitis of the os calcis in flat foot. Marie's disease, or pulmonary hypertrophic osteoarthro- pathy, is an enlargement of the bones of the forearms, hands, legs, and feet from ossifying osteoperiostitis, and occurs in association with chronic lung disease. The symptoms are aching pain, worse at night and increased by pressure, palpable thickening of the periosteum in subcutaneous bones, and, in the event of suppuration, edema and redness of the skin and later softening of the swelHng. After the abscess has been opened, denuded bone may be felt, which, as a rule, undergoes caries or necrosis to a variable extent, and is removed by the surgeon or separated by nature. In the presence of suppuration there will be constitutional symptoms of sepsis. In chronic periostitis, in the absence of suppuration, there may be no symptoms but a tender swelHng of the bone. Ossifying periostitis m^ay produce exostoses or osteophytes, particularly about a chronically inflamed joint. The treatment of acute periostitis is rest, elevation, and cold 432 MANUAL OF SURGERY locally. Constitutional treatment is directed toward any existing diathesis. Suppuration demands incision and drainage. Chronic periostitis is treated by mercurial ointment locally, and potassium iodid internally, even in the absence of a syphilitic taint. The cause should, of course, be removed if possible. Removal of newly formed bone or osteophytes is occasionally indicated. Acute osteomyelitis is also described by some authors under the following headings: acute infective osteomyelitis, acute septic osteomyelitis, acute diffuse infective periostitis, acute diaphysitis, acute panostitis, acute necrosis. Perhaps panostitis is the best term, as all the structures of the bone are sooner or later involved. The cause is always infection by micro-organisms, among which are the staphylococcus, streptococcus, pneumococcus, gonococcus, typhoid bacillus and the bacillus coli communis. Bacteria may gain entrance through a wou"nd, e.g., in compound fracture, amputa- tion, osteotomy, etc.; or infection may extend from neighboring tissues, or come by way of the blood, e.g., in infectious fevers, not- ably measles and scarlet fever. Typhoid osteomyelitis is always subacute or chronic. When osteomyelitis occurs in a healthy individual without an open wound, the organisms are supposed to have entered the blood through the tonsils, or through the respiratory, intestinal, or genitourinary mucous membranes. In some of these cases chilling of the body, or a strain, sprain, or contusion, precedes the outbreak of symptoms. Children are peculiarly liable to this form of osteomyelitis, the process usually starting in the end of the diaphysis, rarely in the epiphysis {acute epiphysitis). The neighbor- ing joint is apt to be involved if the epiphyseal line lies within the capsule {acute infantile arthritis), as in the hip and elbow joints. In the diaphyseal end of growing bone, or metaphysis as it is sometimes called, the vessels are arranged in terminal loops, which retard the blood stream and favor the deposition of organisms;, moreover, this region is more exposed to injuries from wrenches or twists. The favorite sites for osteomyelitis are where the greatest growth in length takes place, viz, the lower end of the femur, the upper end of the tibia, the upper end of the humerus, and the lower end of the radius. Although it is possible for the mildest cases to terminate without suppuration, such an event is of rare occurrence. As a rule suppuration of the medulla occurs, and pus appears in the Haver- sian canals and finally lifts the periosteum from the bone, or escapes through the epiphyseal line, thence infiltrating the surrounding tissues. Necrosis of a portion or of even the entire shaft follows. Involvement of more than one bone is uncommon {multiple osteomye- BONES 433 litis), and occasionally the disease reappears in the same situation {osteomyelitis rccidiva) . The symptoms are sudden in onset, generally beginning with a chill, which is followed by high fever. The limb is painful and tender, and soon becomes hot, swollen, and edematous. The super- ficial vessels are distended, and finally pus may make its way to the surface and give rise to fluctuation. If there is a wound the dis- charge will be copious and offensive and the bone tender. It may be possible to see the thick, red, and separated periosteum and the fun- gous suppurating medulla. The X-ray may show a subperiosteal exudate, but acute osteomyehtis ought to be recognized clinically long before there is sufficient destruction of bony tissue to show in a skiagraph. The constitutional symptoms are those of septicemia or pyemia, and these may predominate and mask the local pheno- mena, so that a diagnosis of typhoid fever, rheumatism or some similar condition may be made. The adjacent joint is often swollen, usually containing sterile serum, sometimes pus. In the mildest cases of osteomyehtis the only symptoms are pain and slight fever. The so called growing pains are supposed to be due to this cause. The diagnosis may be difficult, but is most frequently not made because of an incomplete or careless examination. Rheumatism affects more than one joint, the tenderness is most marked in and not above or below the joint, the local phenomena are less marked, and the constitutional symptoms are less serious. Gonorrheal rheumatism is preceded by gonorrhea and does not give tenderness in the bone. Typhoid fever is slow in onset and does not present local bony s}Tnptoms in the early stages; the blood shows the Widal reaction, and a leukopenia instead of a high leukocytosis. Tubercu- lous arthritis starts in the metaphysis, not in the diaphysis; the onset is slow, and the local and constitutional symptoms much less severe. In infantile scurvy the bone is tender and enlarged, but many bones are apt to be involved, and there are other evidences of rickets, with marked anemia, swollen and bleeding gums, perhaps a normal temperature and, characteristic radiographic changes. The prognosis is always grave. Death may occur from septic absorption before the local signs are well marked. Later dangers are exhaustion and amyloid disease. The neighboring articulation may be destroyed, resulting in either ankylosis or flail joint; growth of the limb may be checked from involvement of the epiphyseal cartilage; or it may be necessary to remove the limb because of septic symptoms, or because repair of the bone is impossible owing to destruction of the periosteum. I 434 MANUAL OF SURGERY The treatment is immediate drainage. After making a longi- tudinal incision in the soft parts the periosteum is reflected, and the medulla opened with a trephine, gouge, or chisel (Fig. 222). Suffi- cient bone is removed to expose all the infected medulla, thus in some instances it is necessary to chisel a gutter in the bone almost from one end to the other. In children, excluding the rare cases in which the epiphysis as well as the diaphysis is diseased, care should be taken not to injure the epiphyseal line, because of the danger of interfering with the growth of the limb. The suppurating medulla is removed by gentle curettage, in order to do as little harm as possible to the endosteum, which may possibly have some influence in subsequent repair. The wound is irrigated with Dakin's solution. The use of the chlorine antiseptics is of peculiar value in these cases. The constitutional treatment is that of septicemia. Should drainage and chemical sterilization fail to mitigate the constitutional symp- toms, amputation may be performed as a life saving measure. The treatment of the subsequent necrosis is given below. Chronic osteomyelitis (chronic ostitis) follows the acute form or is chronic from the beginning. To the latter class belong the chronic bone inflammations caused by typhoid fever, syphilis, tuberculosis, actinomycosis, leprosy, and glanders. Typhoidal osteomyelitis usu- ally appears during convalescence, the tibia and ribs being most frequently affected. The infection may be a pure one or mixed with pyogenic organisms. Like the gall-bladder and spleen, the medulla of bones may harbor typhoid bacilli for years before causing trouble. Workers in wool, jute, and mother-of-pearl may breathe in particles of these substances, which finally lodge in the medulla and cause sudden painful swellings at or near the end of the diaphysis; suppura- tion does not occur. The S3rmptoms of an osteomyelitis which is chronic from the start are pain, tenderness, swelling, and but slight constitutional disturbance. These cases may terminate in suppuration, or in hypertrophy of the bone {osteosclerosis, condensing ostitis) ; in the former the X-ray shadows are less dense, in the latter more dense than normal. The treatment is rest, ichthyol or mercurial ointment locally, and iodid of potassium internally. If these measures fail or if pus forms, the bone should be opened and drained, except when syphilis is the cause. Necrosis, or gangrene of bone, is death of a portion of bone en masse. The dead portion {sequestrum) varies in size from a small superficial flake, such as follows suppurative periostitis, to a mass BONES 435 representing the entire shaft of the bone, such as not infrequently follows acute osteomyelitis. The causes are acute and chronic inflammations of the periosteum, bone and medulla. Removal of periosteum in the absence of in- flammation does not induce necrosis. Injury to the nutrient artery or the lodgment of an embolus is rarely a cause of necrosis. Phos- phorus and mercury may cause necrosis of the lower jaw, particu- larly in the presence of carious teeth, which permit infection of the bone whose nutrition is altered by the poison. Quiet necrosis is a rare condition following injury; it is unaccompanied by suppuration. The sequestrum separates from the living bone by a line of ulceration or demarcation much the same as in gangrene of soft parts. The surrounding living bone usually undergoes a condensing ostitis and becomes much harder than normal. Small and superficial sequestra may be discharged spontaneously through a sinus, which inevitably exists in all but very small aseptic sequestra, in which complete absorption without suppuration is possible. If the necrotic mass is large or centrally located, spontaneous discharge is impossible, and sup- purative inflammation may continue for years. The dense bone which surrounds the sequestrum in these cases is called the involucrum, and the sinus leading from the surface down to the cavity in which the sequestrum lies is called the cloaca. The symptoms of necrosis are a discharging sinus or sinuses which have resulted from a preceding suppurative inflammation of the bone. The necrotic mass may be felt by the probe or demonstrated by the X-ray. In a skiagraph a sequestrum, because of its porosity, appears as a light shadow, surrounded by a clear area, representing the cavity in which it lies (Fig. 221). The treatment in the early stages, that is, after providing ample drainage for the suppurative inflammation which has induced the necrosis, is frequent antiseptic irrigations and dressings until the sequestrum has separated, or at least until the destructive process has reached an end. This time varies, according to the age and Fig. 221. — Skiagraph of chronic osteomyelitis showing involucrum and sequestrum. 436 MANUAL OF SURGERY general condition of the patient, the size and situation of the seques- trum, and the cause of the necrosis, from a few weeks to several months. In performing sequestrotomy, i.e. , removal of the sequestrum, the bone is exposed by a suitable incision, the periosteum retracted, sufficient involucrum removed by gouge or chisel, the dead bone extracted with forceps (Fig. 222), and then treated by chemical germicides — preferably the chlorin group. If the sequestrum has not separated, the dead bone must be chiseled away. Dead Pig. 222. — (i) Periostea! separator, (2) lion-jawed forceps, (3) curette, (4) seques- trum forceps, (5) Macewen's osteotome, (6) chisel, (7) gotige, (8) chain saw, (9) bone cutting forceps. bone is softer than normal, often whitish in appearance, and does not bleed when cut. If the cavity is small it rapidly fills with granulations, which are ultimately replaced by bone. If it is large, healing is very slow, hence the following methods to assist repair. Dehelley removes subperiosteally more than one-half of the bony wall of the cavity which permits of the filling of the remaining cavity by the collapse of the adjacent soft tissues. The cavity has been filled with aseptic sponge, decalcified bone chips, gutta-percha, plaster-of-Paris, BONES 437 bisnuith i)aste, lead, blood clot, mixture of i)ararrin and iodoform, etc., but owing to the presence of infection, such materials act simply as foreign bodies and are ultimately discharged. Recently, however, encouraging results have been obtained with Moorhofs hone wax, which consists of iodoform 20 parts, spermaceti 40 parts, and oil of sesame 40 parts. The cavity is rendered dry and sterile, and the mixture, heated to 50° C, poured into the cavity and allowed to solidify. Ihe wax is ultimately absorbed and replaced by fibrous tissue or bone. Neuber fastens the flaps of skin to the walls of the cavity by nails or stitches, and thus secures heahng with a trough- like depression lined with skin. Skin grafting has been used with a similar idea. Nelaton filled a cavity in the clavicle with a peduncu- lated flap of muscle; Makkas, one in the os calcis by the free trans- plantation of fat; Makkas says the fat is displaced later by fibrous tissue, which may ultimately ossify. Transplantation of bone also has been successfully performed to fill osseous defects (see p. 449)- When the periosteum has not been destroyed, it can confidently be expected to replace even the entire shaft of the bone. Nichols has recently investigated this subject and the following is from his paper: "The operation consists of an incision through the skin and ossified periosteum down to the necrotic shaft, reflexion of the perios- teum, removal of the shaft, either entire or partial, folding of the plastic periosteum in such a way as to approximate the internal layers, suture of the edges by absorbable sutures, suture of the soft tissues, with provision for moderate drainage and complete immobilization." The shaft is sufiiciently solid for use in from four to eight months. In regions such as the thigh or arm where there is no companion bone to act as a splint and maintain the length of the limb, one should wait until the periosteal shell of regenerating bone is sufficiently advanced to preserve the contour of the limb and prevent shortening. This stage is reached when the periosteal shell as determined by the X-ray is equal in thickness to one-fourth of the diameter of the or- iginal shell. If delay is not advisable sequestrotomy may be per- formed and a magnesium splint, or a prop of bone obtained from another portion of the body, inserted. In a recent case of this character we maintained the length of the femur, until new bone had been formed, by means of a piece of sterilized ox bone. Caries {inflammatory osteoporosis, rarefying ostitis, ulceration of bone) is molecular death of bone. The bone is soft and honey- combed, and crumbles when pressed upon by a probe. Caries is the result of inflammation, particularly that form due to syphilis or tuberculosis. The ulceration which separates living bone from 438 MANUAL OF SURGERY dead is a form of caries. The spaces in carious bone (Hou'ship's lacuncE) are the result of suppuration, or absorption by large giant cells {osteoclasts). Caries sicca is caries without suppuration. In caries Jungosa there is an excess of granulation tissue. Caries necrotica is the form in which small crumbHng fragments are dis- charged. The symptoms of caries are those of necrosis, except that the probe detects rough and friable bone instead of a firm sequestrum. The treatment is exposure of the bone, and removal of the diseased tissue with curette or gouge, and the treatment of the ca\-ity as described in necrosis, pages 436-437. The limits of the disease are reached when the bone becomes pink and firm and bleeds on cutting. Tuberculosis of bone may be generaHzed in the course of acute miliary tuberculosis. Loca- lized tuberculosis is most frequent in early hfe, and usually follows infection in some other por- tion of the body, notably the lungs and the l}Tiiph glands. In the long bones the disease usually begins in the metaphysis in children, in the epiphysis in adults; in the other bones it begins in the periosteum, or more frequently in the cancellous tissue. Tuberculosis of the „ c • phalanges is called tuberculous dactvUtis, or Fig. 223. — Spina ven- -re ^ ^ ' tosa, so called because of spina ventosa (Fig. 223). Occasionally the the flask-like inflation of ,. ,.. . . ^ , j-i- 1 the bone: it may be due diseasc bcgms m a jomt and sccondarily mvolvcs to any of the causes of ^j^g bone. The pathologv is much the same as bone inflammation, but is usually syphilitic or that of tuberculosis elsewhere, the tuberculous tuberculous. mass Undergoing caseation and Hquefaction, and being surrounded by a zone of inflamed bone. The diseased bone may separate as a sequestrum, but as a rule it under- goes caries, which progressively invades the surrounding bone. When the process remains localized and undergoes suppuration, it forms an abscess (Brodie's abscess), which is Hned by a pyogenic membrane and surrounded by a zone of condensing ostitis. Such abscesses are most frequent in the ends of long bones, particularly the tibia and femur. These abscesses may perforate the periosteum and infiltrate the soft tissues. The term cold abscess is applied to these tuberculous collections in the soft tissues see p. 112. Trau- matism, often slight in nature, frequently determines the site of the lesion. BONES 439 The symptoms are boring i)ain, tenderness, and thickening of the bone. The X-ray will show the disease as soon as the process of disintegration is advanced far enough to lessen the density of the bone and long before the clinical period of softening. If allowed to progress, the disease invades the neighboring joint, or the pus finds its way to the soft parts about the bone and finally presents itself beneath the skin, sometimes a long distance from its point of origin. After the abscess breaks or is opened, infection with pyogenic organisms causes hectic fever, and in neglected cases this leads to exhaustion or amyloid disease. The treatment is removal of the diseased tissue by gouge, curette, excision, except in children under 2 years of age, or in some cases even by amputation. Spina ventosa, according to Pels-Leusden, should be treated by excision of the diaphysis with the periosteum, and transplanting to its place a segment of the tibial crest or a phalanx from a toe. In the early stages of osseous tuberculosis, before the formation of pus, or in the later stages if the site of the disease is inaccessible, the affected parts are immobihzed by plaster-of-Paris or by other means, and a cure some- times obtained. Passive hyperemia, radiotherapy, and heliotherapy are employed by some surgeons. Syphilis of bone occurs in the secondary and tertiary periods, and like tuberculosis, the site is often determined by trauma. In the secondary stage osteocopic pains occur, apparently with no organic change in the bones. The periostitis of the second stage results in resolution, rarely in suppuration, and. most frequently in ossification of the exudate, leaving a permanent node. In the tertiary stage the bone may become the seat of a condensing ostitis, or gummata may form in periosteum, bone, or medulla, the skull, sternum, and tibia being the favorite sites. With appropriate treatment, the gummatous material may be absorbed, but frequently degeneration occurs and the puruloid material ultimately evacuates itself through the skin. The bone is then carious and worm-eaten, and beyond this there may be a zone of sclerotic osseous tissue. Necrosis occurs in some cases (Fig. 224) owing to the constriction of the vessels by the surrounding sclerotic tissue; the sequestra in such cases may not separate for years. Should sepsis supervene, the soft parts become infiltrated with foul smelhng pus, which in the skull may spread to the brain or its membranes. As in tuberculosis, amyloid disease may appear. Syphilitic dactylitis (Fig. 223) occurs in the late secondary stage as a periostitis, or in the tertiary stage as a gummatous osteomyelitis. 440 MANUAL OF SURGERY Congenital syphilis produces the same bone lesions as the acquired form. The site of the disease, however, is more often influenced by rapid growth than by traumatism, hence the frequency of syphilitic epiphysitis, or osteochondritis as it is sometimes called. The ends of the bones enlarge in these cases, and present some resemblance to rickets. The swellings, however, occur much earHer in Ufe than rickets, are associated with other symptoms of syphilis, and are influenced by syphihtic treatment. Suppuration, separation of the epiphysis, and deformity may follow. Periosteal nodes occur, and when situated about the anterior fontanelle are called Parrot's nodes. Craniotabes is a thinning of the calvarium. which may crackle on pressure. Occasionally a bone is stimulated to overgrowth,*^ and Fig. 224. — Syphilitic necrosis of the skull. when there is a companion bone, as in the forearm or leg. marked curvature results. The treatment is that of syphihs. Sinuses should be kept clean lest septic symptoms supervene. Necrotic or carious bone is treated as already indicated. Rickets, or rachitis, is a constitutional disease due to malnutri- tion, and often associated with bad hygienic surroundings and improper diet. It usually occurs during the first three years of Ufe. The so-called congenital rickets is generally achondroplasia or osteogenesis imperfecta. The symptoms in the early stages are disorders of digestion, anemia, sweating about the head, swelling of the abdomen, and BONES 441 enlargement of the spleen. The important changes are those in the bones (Fig. 22-5), in which, although there is an active pro- liferation of the cellular elements, prompt calcification does not occur. The epiphyses are swollen and tender, and the shafts of the long bones softened. Later ossification occurs, frequently with deformity. The head becomes square and the frontal eminences prominent, the fontanelles and sutures close late, and craniotabes may occur. Eruption of the teeth is delayed, and they are often dwarfed, deformed, and the seat of early caries. The spine may become curved and the chest "chicken-breasted." The ribs are enlarged at their junctions with the costal cartilages {rachitic rosary) , and there may be a marked groove extending from the axilla down toward the end of the sternum (Harrison '5 sulcus) . The pelvis may be dis- torted and the limbs curved, e.g., bow-legs, knock-knee, etc. Growth of the entire body is often defective. The treatment is correction of the diet, fresh air, sunshine, and attention to the bowels, together with cod-liver oil, syrup of the iodid of iron and hypophosphites. De- formities are prevented by keeping the patient in bed, and they are corrected, while the bones are soft, by daily manipulations and braces. After two or three years de- formities usually require osteotomy or other form of operation. Scurvy rickets (acute rickets, infantile scurvy, Mceller- Barlow disease) is a combina- tion of rickets and scurvy, either of which .hfidsix years old. showing may predominate. It is most frequent in the osseous changes of rickets the children of the well-to-do, and arises from malnutrition resulting from the administration of artificial foods. The symptoms of rickets may or may not be marked wnen the scorbutic features predominate. There may be spongy, bleeding gums, and bleeding from the mucous membranes, beneath the skin or periosteum, or into the muscles or joints. An epiphysis is sometimes separated from a diaphysis by hemorrhage, and the pain and swelling caused by this or by bleeding beneath 442 MANUAL OF SURGERY the periosteum, particularly when associated with fever, may be mistaken for acute osteomyehtis (q.v.). Recovery occurs in 91 per cent, of the cases. The treatment is fresh milk, beef or lime juice, and the juice of oranges, lemons, grapes, or apples. A painful limb should be kept quiet, and in some cases bandaged or splinted. Achondroplasia {chondrodystrophia fetalis, micromelia) is a rare congenital disease characterized by defective development of certain portions of the skeleton. Death at or soon after birth is the rule, although in a few instances adult life has been reached. The trunk is of normal length, but the bones of the limbs are short and bowed and abnormally thickened at the points where the muscles are attached. All the fingers are of the same length, and a wide interval exists between the second and third finger, giving rise to the "trident hand." The base of the nose is depressed and the vault of the cranium large, but the intelHgence is in no way impaired. The pelvis is small, the belly prominent owing to lumbar lordosis, and the genitals normal. Rickets differs from this condition in that it is post-natal; the bones are soft, not hard; the trunk is affected; there is no pug nose; and the cranium is bossed. In cretinism the intelligence is defective, the hair scanty and coarse, and the patients improve after taking thyroid extract. Syphihtic pug nose is due to bone disease, not to premature union of the bones at the base of the skull as in achondroplasia. There is no treatment for achondroplasia. Atrophy of bone may be congenital; or it may be due to inflam- mation, disease or injury of the epiphysis; disuse; pressure, e.g., from a tumor or aneurysm; or to disease or injury of the nervous system, e.g., tabes, section of nerves, syringomyelia, paresis and other forms of insanity. It is normal in old age, as is best seen in the cranium, lower jaw, and neck of the femur. Atrophied bone breaks easily, so that one should bear the above causes in mind during forcible manipulations, such as are employed in breaking joint adhesions, etc. Fragilitas ossium, or osteopsathyrosis, is a condition in which there is an abnormal predisposition to fractures, even from slight force. There are two forms, the idiopathic and the symptomatic. Idiopathic fragilitas ossium is congenital and often hereditary. In some cases {osteogenesis imperjecta) fractures occur before, during, or soon after birth, and the children are still-born or survive only a few months. In others the tendency to fractures is most marked between the second and twelfth years, and usually disappears with the advent of adult life. Union is prompt but often with con- BONES 443 siderable deformity. The cause and pathology are not known. The symptomatic form is due to any of the other conditions mentioned amonu the pathological causes of fracture (p. 375). Osteomalacia, or mollities ossium, is a disease in which the bones become abnormal!}' flexible owing to the absorption of cal- careous material. It is rare in the male and peculiarly frequent in puerperal women. The cause is not known. The bones become distorted and break with greater ease than normally; in the latter instance non-union often occurs. Of great importance is deform- ity of the pelvis, because of the difficulties which may arise during labor. It is usually compressed laterally, the pubes passing for- ward, thus giving it a triangular shape. The patient is weak and emaciated, and complains of pain in various parts of the skeleton. Death after many years is the usual result, although recovery occasionally occurs. The treatment is tonic and stimulating, with phos- phates, cod-liver oil, and bone marrow^. Braces may be needed, and means should be taken to prevent pregnancy. Removal of the ovaries some- times results in cure. Hypertrophy of bone may be congenital, or it may be due to increased use, e.g., w^here muscles are attached, or to in- creased nutrition the result of inflammation. Giant growth of the fingers or toes {^nacrodactylia), of an entire Hmb, or of the entire body, may be congenital or acquired; the cause is not known. Progressive hypertrophy of the bones of the skull is called leontiasis ossium (Fig. 226). It begins in early life, and terminates fatally after a number of years, sometimes from compression of the brain. No curative treatment is known. Acromegaly is a skeletal overgrowth due to increased activity of the anterior lobe of the pituitary body (hyperpituitarism) some- times induced by tumor or hypertrophy. All parts of the body are enlarged, particularly the forearms, hands, legs, feet, jaws, lips tongue, nose, and orbital ridges (Fig. 227). The hands are spade Fig. 226. — Leontiasis ossium. 444 MANUAL OF SURGERY shaped, the fingers sausage-hke, the jaw prominent (prognathism), the teeth separated, the face triangular with the base downward (the face of Paget 's disease is triangular with the base upward, that of myxedema is moon-shaped), and the spine kyphotic, the attitude of the patient resembhng that of the gorilla. The thyroid Fig. 227. — Acromegaly. gland is often enlarged and arteriosclerosis is not uncommon. The principal symptoms are headache and malaise. Glycosuria is some- times present. The disease is fatal, usually after many years. The treatment is symptomatic, unless evidences of tumor of the pituitary body be present, when its removal is indicated (see tumors of the pituitary body, chap, xxi) . BONES 445 Ostitis deformans, or Paget s disease, consists of enlargement or softening of the bones, usually after the age of forty. The cranium enlarges but the facial bones are not involved, the face being trian- gular with the base upward. The patient diminishes in height owing to kyphosis and outward curvature of the lower extremities. The chest is sunken and the pelvis broadened. The patient com- plains of rheumatic pains and has an awkward gait. The disease is very slow in progress. Multiple sarcomata of the bones develop in some cases. The treatment is symptomatic, no remedies being known. Ostitis fibrosa (von Reck- linghausen) is classified by some writers with the in- flammatory, by others with the non-infiamma-tory affec- tions of bone. Its cause is unknown, some think that it is of infectious origin, others that it is of a syphilitic or parasyphilitic nature. There is extensive lacunar absorp- tion of the osseous tissue with fibrous changes in the medulla, giving rise to a whitish or brownish-red tumor. This fibrous tissue usually melts down in places, thus forming multiple cysts (Fig. 228) containing serous or serosanguineous fluid {ostitis fibrosa cystica) , but it may harden and ultimately ossify (ostitis fibrosa osteo- plastica). The disease may appear at any time of life, and attack one or much more frequently a number of bones. The affected bone is enlarged, often curved, and sometimes the seat of spontan- eous fracture. The swelling may be mistaken, clinically and micro- scopically, for giant-celled sarcoma. Some authorities hold ostitis fibrosa responsible for leontiasis ossium, ostitis deformans, epulis, and certain cases of fragilitas ossium. When the disease is con- fined to one bone recovery ma}- follow curettage or excision. Tumors of bone may be benign or malignant. The benign Fig. 228. — Ostitis fibrosa cystica. (Henderson.) 446 MANUAL OF SURGERY tumors are osteoma, chondroma (p. 223), fibroma, lipoma, myxoma, and angioma. The only primary malignant tumor of bone is sarcoma, although it may be invaded secondarily by carcinoma (especially from the breast, thyroid, and prostate) and sarcoma. Metastatic osseous growths are sometimes the first sign of hyper- nephroma. Pig. 229. — Sarcoma ot the femur, showing radiating spicules of bone. Periosteal sarcoma is of the spindle- or round-celled variety, grows rapidly, and causes early metastases, although it may undergo more or less complete ossification, as shown in Fig. 229. Central sarcoma, beginning in the osseous tissue or medulla, causes expansion of the bone, and is usually found near the end of a long bone, but rarely invades the joint. If of the round- or spindle-celled variety the degree of mahgnancy is high, if giant-celled, or myeloid, it is comparatively benign. The overlying bone may become so thin BONES 447 as to crackle on pressure, and spontaneous fracture is not unusual. In all forms of sarcoma pulsation may occur owing to the great vascularity, and some degree of ossification is usually present; the superficial veins are distended and clearly evident beneath the whitened skin. Hemorrhagic infiltration and cystic degeneration are of frequent occurrence. The diagnosis may be very difficult, owing to the resemblance to chronic osteoperiostitis, ostitis fibrosa, or syphilitic or tuberculous disease of bone. Sarcoma grows steadily, is irregular in contour and density, is apt to pulsate, causes distention of the superficial veins, and may give a crackling sensation on pressure owing to thinning of the bone. The X-ray shadow of the tumor is often sharply limited; it shows absorption of bone in the more malignant cases, spicules radiating at right angles to the bone in the more benign varieties (Fig. 229). In inflammatory bone diseases there is apt to be diffuse mottling, surrounded by a dense shadow corre- sponding to the zone of condensing ostitis; in syphilis and tuberculosis this dense shadow may extend over a large part of the diaphysis. In ostitis fibrosa the multiple cysts may show in the skiagram as numerous light areas. . Often a positive diagnosis can be made only after exploratory incision. The treatment in all but the myeloid form is early amputation through the next joint above. In the myeloid variety excision of the growth alone often results in cure, although in some instances ampu- tation well above the growth is required. Osseous defects following operation may be filled by bone transplantation. Primary multiple myelomata may arise simultaneously in the marrow of many bones, particularly those of the trunk (vertebrae, ribs, sternum) ; less frequently the skull and the femora are affected, and rarely almost the whole skeleton is invaded. The tumors consist of myelocytes, are sharply circumscribed, and usually dark red in color. The bones may become thin and bend, producing kyphosis, etc., or break. Occasionally the growth extends to the periosseous tissues, and sometimes metastases occur; myelocytes have been found in the blood of the liver and the spleen, the Bence- Jones body in the urine. The patients ultimately die of exhaustion; about 50 cases have been reported. Cysts of bone are usually due to degeneration of sarcoma or myx- oma. Parasitic cysts (echinococcus, cysticercus) and dermoid cysts are rare, cysts or cyst-like cavities may occur in ostitis fibrosa, perios- titis serosa, osteomalacia, and ostitis deformans. Cysts of the jaw odontomata) are described in the chapter on tumors. 448 MAXUAL OF SURGERY Large solitary cysts of long hones {osteodystrophia juvenalis cystica of ^Mikulicz) are the only ones requiring special notice in this place. The cyst is usually found near the epiphyseal Hne of a long bone Pig. 230. — Albee's armamentarium for bone work. i. Calipers. Doyen washers or guards for motor saw. 3. Spray and guard for saw. 4. Twin saw. 5. Dowelling instrument or lathe. 6. Right angle twin saw. 7. Wrenches for twin saw and drill chuck. 8. Drill with guard to prevent it penetrating too deeply. 9. Drill chuck and small drill in place. 10. Burr for drilling fractured neck of femur for peg graft. 11. Small circular saw. 12. Large saw. 13. Carver's gouge. 14. Lowman fracture clamp. 15. Berg fracture clamp. 16. Wide osteotome for splitting spinous processes for the insertion of bone-graft for Pott's disease. 17. Surgical electric motor. 18. Compasses. 19. Lambotte fracture clamp, large and small. (femur, tibia, humerus, less frequently metacarpal or metatarsal bone) in an infant or adolescent, and often follows an injury. It is single, unilocular, benign, serous or serosanguineous. and surrounded BONES 449 by a zone of ostitis fibrosa. There may be pain and tenderness, but never signs of inflammation. The swcUing is ovoid, regular, occa- sionallv presents parchment crepitation or even fluctuation, and is sometimes discovered only after a spontaneous fracture. The X- ray shows an ovoid, regular, clear area, corresponding to the cyst. The treatment consists in opening the cyst, curettage, and gauze packing, or, as packing predisposes to infection, filling the ca\dty with fat, bone wax, or by one of the other methods described in the treatment of necrosis. Transplantation of bone may be indicated to fill developmental defects (e.g., spina bifida, congenital saddle-nose, absence of radius or other bone), to replace bone destroyed by injury or disease (e.g., osteomyelitis, syphilis, tuberculosis, neoplasms), to immobihze broken bones or to induce ununited fractures to consolidate, and to secure rigidity of joints which are too mobile because of paralysis, or which are diseased, e.g., bone grafting for tuberculosis of the spine (Albee's operation). It has been stated that an osseous graft always perishes and is absorbed, being replaced by new bone derived from the periosteum; from the osteoblasts in the bone, the perios- teum acting merely as a Hmiting membrane ; or from the li\dng bone with which the graft is brought in contact, the graft possessing not osteogenetic, but simply osteoconductive functions. In view of the fact that periosteum without bone, bone without periosteum, and isolated fragments of either or both may persist and grow, perhaps we may conclude that a bone graft does not always succumb, and that new osseous tissue can be formed from the osteoblasts of the deeper layer of periosteum or from those of the bone itself. It seems, however, that a bone graft with its periosteum is twice as likely to survive as one without that membrane, probably because of the greater number of blood vessels in the periosteum. For a similar reason OUier emphasized the importance of the medulla in preserving the life of a graft. McWilliams found that if a section of a bone is removed subperiosteally, the bone regenerates between the frag- ments; that without a periosteal or bony bridge there is very little attempt at repair ; that small fragments of a bone shorn of periosteum are more apt to five than large ones, because the blood has easier access to the smaller fragments; and that periosteum alone when transferred to soft parts may create new bone. In performing bone transplantation strict asepsis, rigorous hemostasis, and gentle handUng of the graft are essential. No attempt should be made to fill a septic cavity with a bone graft. Because of the cytolytic effect of the blood and the body fluids on alien cells, autoplastic grafts, 29 450 MANUAL OF SURGERY i.e., from the same individual, are the most successful. If a homo- plastic graft, i.e., one from another individual, must be employed one of the same blood group should be selected, and a Wassermann test made to exclude syphilis. Some surgeons have taken advantage of the opportunity offered to obtain bone from a freshly amputated limb which has neither been infected or the seat of a malignant neoplasm, e.g., a limb amputated for injury or dry gangrene, or from an individual immediately after death from an injury. Heteroplas- tic grafts, i.e., from the lower animals, generally become necrotic or are absorbed, although a few successful transplantations from the dog, the lamb, and the ape (which as man's nearest animal relative is to be preferred) have been reported. When sutures are needed to fix the graft in place, chromicized catgut or kangaroo tendon is the best material to employ, as wire, nails, and other non-absorbable substances predispose to suppuration and sinus formation. When- ever possible incisions should be made in such a way that the suture line in the skin shall not lie immediately over the graft. After trans- plantation the part must, according to the size and situation of the graft, be immobilized for from several weeks to several months. The methods of bone transplantation may be divided into two groups, viz., transplantation by flaps and free transplantation. Transplantation by flaps is illustrated by the various osteoplastic resections and amputations (see Figs. 580, 581, 585, and 585 to 588) A periosteal flap with a thin slice of bone attached can be raised from the bone on one side of an osseous defect, and turned over so as to bridge the defect (Oilier). Flaps oj muscle have been employed to swing a piece of the ihac crest into the femur, a piece of the scapula into the humerus (Codivilla) . Flaps of skin have been utilized in a similar way, thus we have transplanted a metatarsal bone to the tibia, and in a case in which the lower ends of the bones of the fore- arm had been destroyed, a fragment of the ulna to the radius. Bone may be grafted also one end at a time. Huntington closed a defect in the tibia by severing the fibula at its upper end and placing it in contact with the upper end of the tibia. After union had occurred the lower end of the fibula was transferred to the lower end of the tibia. Subsequent to this operation the fibula thickens in response to the demand made upon it. Morton, in a similar case, united the lower ends of the bones of a dog's leg to the upper end of the tibia, and five weeks later amputated the dog's leg and placed the bones in contact with the astragalus. A useful leg resulted. In free transplantation the grafts are usually taken from the tibia, fibula, clavicle, scapula, rib, upper third of the ulna, or crest of the BONES 451 ilium. Periosteum with a thin slice ot osseous tissue may be used to envelop the ends of a broken bone that have been joined by wire or other means (Codivilla). Small bone chips have been employed by Macewen to fill defects in the bones of the extremity, by Keen to close gaps in the skull. With rongeur forceps or chisel the excised frag- ment is broken into small pieces, which are placed in the cavity to be filled.. The wound is closed without drainage. A large section may be cut from a bone with a chisel, or an electric saw, and transferred quickly, without washing in salt solution, to its new habitat, where it may be fixed with chromacized catgut sutures, or bone pegs. If a chisel is employed one must proceed cautiously and with Hght blows, so as not to splinter or fragment the graft. This form of grafting is employed in the Albee operation for tuberculosis of the spine, and is rapidly displacing other methods in the operative treatment of fractures (q.v.). Transplantation of joints is mentioned under ankylosis, implantation of dead bone and other foreign substances under necrosis and the operative treatment of fractures. In the sections on regional surgery also reference is made to bone trans- plantation, when the particular condition may be so treated. Transplantation of cartilage is more apt to be successful when the cartilage is accompanied by its perichondrium. Pieces of the costal cartilages have been used to fill defects in the face, to establish new joints, to supply the place of absent phalanges. Transplantation of an articular cartilage with its attached bone (fibula) likewise has been performed. Whether or not a transplanted epiphysis can participate in the growth of a Hmb is a question that is still unanswered. Kutt- ner, however, one year and eight months after transplanting the fibula of an ape to the leg of a child, in whom the fibula was con- genitally absent, found by X-ray examination that the epiphyseal line was fully preserved. CHAPTER XX JOINTS INJURIES OF JOINTS Woiinds of joints should always be regarded with apprehension. Extensive wounds are often associated with dislocation or compound fracture. A small penetrating wound may be recognized by the escape of synovial fluid, although this may not occur if the aperture is valvular or very narrow, and synovia may escape from injured bursa. A probe should not be ernployed. The external parts should be disinfected, the entire wound excised and, if no foreign body remains in the joint, closed with the usual technic of primary suture. The joint should be im- mobilized with a splint in a position which will give the best function in the event of ankylosis. At the first symptoms of infection, viz., pain, swelling, fever, etc., the wound should be reopened and if it is not so placed as to provide adequate drain- age new incisions should be made; the pus washed from the joint cavity with a weak antiseptic solution, preferably Dakin's, and drainage instituted. Military experience has shown drainage material must not be introduced within the synovial cavity, gauze should never be employed. Infected joints can be sterilized with the chlorine antiseptics and delayed primary and secondary suture practiced. Willems insists upon the active movement of open suppurating joints to facilitate the drainage of the purulent discharge and prevent the formation of adhesions. It has been most successful in the large joints as the knee and shoulder. If the joint is wounded by an instrument which is known to be grossly infected, one should not wait for the appearance of septic symptoms, but open, disinfect, and drain the joint at once. Resection or amputation may be necessary if severe constitutional s3''mptoms continue. A sprain has been defined as a self-reduced dislocation. As the result of a twist, some fibers of the hgaments are stretched or lac- 452 Pig. 231. — Strapping of the ankle. JOINTS 453 eratcd ami ihc sNiioxial nu'inljianc contused. The symptoms are severe pain, tenderness, swelling of the joint from effusion of blood and lymph, loss of function, and in some instances shock. Many cases of fractures about joints have in the past been diagnosticated as sprains. If the swelling is great, fracture can be excluded only by the X-ray. The treatment during the lirst twenty-four hours is elastic com- pression, and cold in the form of an ice bag or evaporating lotion, thus limiting effusion. Compression is best made with a firm band- age over a layer of cotton. If the effusion is excessive, aspiration should be considered. Later absorption should be promoted by heat and massage. The joint should be kept at rest until the pain and swelling have disappeared. Compression with a certain degree of fixation may be obtained by applying overlapping strips of adhesive plaster around the joint as shown in Fig. 231, Subsequent stiffness may be relieved by the hot air treatment and by frictions with stimulating liniments. The prognosis is good in uncomplicated cases; suppuration is rare, although tuberculosis may occur in those prone to this disease, and persistent pain and stiffness are common in the gouty and rheumatic and in the old. Absorption of the head of the femur may occur after sprain of the hip. Ankylosis is the chief danger. DISLOCATIONS A dislocation, or luxation, is an abnormal displacement of the articular end of a bone. Dislocations may be congenital or ac- quired, and the latter may be traumatic or spontaneous (patholog- ical) . Congenital dislocations are usually due to'defective development, although it is possible that a few are due to violence to the mother's abdomen during pregnancy, or to a vicious position of the child in the uterus, the result of tumors, etc. Although various joints may be affected in this way, in 90 per cent, of the cases the hip is involved. Congenital dislocation of the hip is more frequent in females, both or more commonly one joint being involved. Damany states that the luxation rarely exists at the time of birth, but occurs during the first year of Ufe, owing to an increased forward obliquity of the acetabulum and an exaggeration of the normal torsion of the femur, thus causing a progressive displacement of the head of the femur when the thighs are extended. However this may be, congenital dislocation of the hip is seldom recognized until the child begins to walk. The dislocation causes atrophy of the abandoned acetabu- 454 MLA.NUAL OF SURGERY lum, Stretching or rupture of the round ligament, shortening and anteversion of the neck of the femur, flattening of the head of the bone from before backwards, and elongation with occasionally hour-glass constriction of the capsule of the joint. The limb is atrophied and the muscles altered in length. The head of the bone almost invariably passes onto the dorsum of the ilium, thus causing shortening with flexion and adduction of the thigh, compensatory obliquity of the pelvis, and anterior curvature of the lumbar spine (Fig. 232). In bilateral dislocation there is a peculiar waddling gait, in unilateral cases there is limping and associated scoliosis. In early cases the length of the limb may be restored by traction. The treatment, when the condition is recognized before the child begins to walk and before marked changes in the soft struc- tures occur, is continuous traction on the limb to bring the head of the bone down to the acetabulum, while the limb is fixed in abduction and pressure is made over the great trochanter. This treatment must be continued for six months or a year. At a later period, up to four or five years in bilateral cases and about seven years in unilateral cases, the Lorenz blood- less method may be tried. The author of this method claims 50 per cent, anatomic cures. Under anesthesia the shortened muscles are stretched by flexion, extension, and abduction of the thigh, during the last of which the adductor muscles are power- fully kneaded. The head of the bone is then drawn down to the level of the acetabulum by traction on the leg. and the thigh flexed on the abdomen, rotated internally, abducted, and finally rotated outwards while pressure is made on the trochanter. With the hmb in flexion, abduction, and eversion, a plaster-of-Paris cast is applied to the pelvis and thigh as far as the knee. The child is allowed to walk \^'ith the limb in this position in order to deepen the acetabulum. At the end of three months the cast is re- moved, the flexion and abduction lessened, and another cast put on for three more months. In children too old for the bloodless method Hoft'a and Lorenz Fig. 232. — Bilateral congenital dislocation of hip. (Hopkins.) JOINTS 455 have each devised a bloody method. The former opens the joint by an incision similar to that of Langenbeck in resection of the hip, severs shortened iibers of muscle and fascia, enlarges the acetabulum with a gouge, reduces the dislocation, fixes the limb in eversion and abduc- tion for a few weeks, and linally straightens the limb. Lorenz opens the joint from in front, does not cut the muscles, but severs the ham- strings if necessary. The rest of the operation is much the same as that of Hoffa. Pathological dislocations occur from shght force or spontaneously, as the result of disease, such as tuberculosis, osteoarthritis, Charcot's disease, and unopposed action of muscles in paralysis. Those occurring in the course of fevers (Fig. 233) are due to distention of the joint, and are most frequent at the hip, owing to habitual flexion of the thighs in bed. Fig. 233. — Dislocation of hip in typhoid fever, and large bed sore. (Pennsylvania Hospital.) Traumatic dislocations, like fractures, may be simple (closed), compound [open), complete, incomplete [subluxation) , or complicated (associated with injury of the soft parts, vessels, nerves, or viscera). K fracture-dislocation is one associated with a fracture entering the joint (Fig. 219). The causes of traumatic dislocations are predisposing and excit- ing. The predisposing causes are powerful muscular development, thus dislocations are more frequent in males and in middle life; occupations which demand hard labor and exposure to injury; structure and situation of the joint, e.g., the shoulder, which is a ball and socket joint and exposed to many injuries; and diseases or pre- vious injuries of joints which relax the ligaments or markedly alter the axis of the hmb. The exciting causes are external violence (direct, or more commonly, indirect) and muscular action. The pathology consists of a tearing of the ligaments and fre- 456 MANUAL OF SURGERY quently of the soft structures around the joint, owing to the displace- ment of the articulating surfaces; effusion of blood into and about the joint; contusion of the synovial membrane and articular cartilages; and occasionally fracture, or compression or rupture of important nerves, vessels, or viscera. If the dislocation is reduced, the subse- quent traumatic inflammation subsides with or without adhesions. If the torn ligaments are not fully repaired, there is a predisposition to the recurrence of the dislocation. In an unreduced dislocation the organization of the effused blood and exudate fills the normal articular cavity with fibrous tissue and fixes the head in its new situation, where, if persistent movements are made, it may form a pseudoarthrosis. The displaced head becomes more or less deformed, and wears a hollow in the bone on which it rests. The surrounding muscles atrophy, and are altered in length to accommodate them- selves to the new position of the limb. The symptoms are pain, swelling, ecchymosis, rigidity of the muscles, loss of function, and deformity, as evidenced by the alteration in the axis and length of the limb, by the disturbed relations of the bony prominences about the joint, and by feehng or seeing, with or with- FiG. 234. out the X-ray, the empty articular cavity and the Clove-hitch. ]• i 11 • •- •. .• displaced bone m its new situation. The treatment is (i) reduction, (2) retention, (3) restoration of function, (i) Reduction should be made at the earliest possible period by manipulation or extension, with or without anesthesia according to the difficulties encountered. Manipulation consists in such movements of the limb as will cause the dislocated bone to reenter the joint by the path through the torn capsule which it has already traversed, hence it should be employed whenever possible, because but little additional injury is inflicted upon the tissues. Extension, or more commonly extension and counterextension, are used to draw the dislocated bone into place despite the resistance of muscles and other structures. Extension is made by the hands of the surgeon, by a broad band fastened about the extremity in a clove-, hitch (Fig. 234) and passed around the waist or shoulders of the surgeon, or, much more rarely, by compound pulleys. Counter- extension is obtained by the hands of an assistant, by a broad band or by the knee or the foot of the surgeon. The application of great force, however, is very dangerous, and if sufficient relaxation cannot be obtained with ether, reduction through an incision should be employed. The bone usually goes back into place with an audible snap. (2) After reduction the joint is immobilized until the lacera- JOIN.TS 457 tion in the capsule has healed, ij,) Duriiiji; the I'lrst twenty-four hours compression with a bandage and the api)Hcation of evaporating lotions or an ice bag serve to limit the swelling. Subsequently absorption is hastened by massage, heat, and liniments, and at the end of from ten days to two weeks passive motions are begun. Compound dislocations are very grave injuries, w^hich require the same care as compound fractures (page 384). The supervention of sepsis may necessitate resection or amputation. The treatment of fracture near a dislocated joint has already been discussed. Old tinreduced dislocations are difficult to treat owing to the firm adhesions which anchor the bone in its new position. There is no fixed rule as to the time when reduction should no longer be at- tempted, as replacement may be effected sometimes after a number of months have elapsed. A general rule is to attempt reduction under anesthesia without the use of too great force, as such may seriously injure important vessels or nerves, or result in fracture; if reduction is not successful and the limb is incapacitated by pain or marked limitation of motion, the joint should be opened and the bone replaced, or in some cases the head of the bone excised. In joints in which bloodless reduction has not been successful, but in which there is fair motion and little or no pain, operation should not be undertaken, since persistent movements may result in a fairly useful pseudoarthrosis. SPECIAL DISLOCATIONS The lower jaw may be dislocated upwards, the condyle entering the cranial cavity, or backwards; but these are extremely rare and the usual displacement is forwards, either one or much more com- monly both sides being affected. The condyles pass forward over the eminentia articularis into the zygomatic fossa, as the result of blows on the chin, or contraction of the external pterygoids when the mouth is opened in yawning, vomiting, trying to take a big bite, etc. The symptoms are an open mouth which cannot be closed, pro- jection of the low^er jaw forwards, drooling of saliva, and some inter- ference wdth speech and swallowing. The condyles may be felt anteriorly and there is an abnormal depression in front of the tragus. In the unilateral variety the symptoms are less pronounced and the chin passes towards the sound side.- The treatment is pressure downw^ards and backwards on the last lower molar teeth with the thumbs, protected by bandages, while the chin is elevated with the fingers. The mouth should be kept shut 458 MANUAL OF SURGERY by a Barton bandage for two weeks, after which the patient should be cautioned against opening the mouth too widely. In old cases excision of the condyle may be indicated. The sternal end of the clavicle may be dislocated forward, back- ward, or upward. Forward dislocation is caused by violence which pushes or pulls the shoulder backwards. The end of the bone is in front of the sternum, the acromion process nearer the middle line, and the clavicular head of the sternomastoid unduly prominent. Reduction is effected by pulling the shoulders backwards while the knee is placed between the scapulae and pressure is made upon the displaced bone. A pad is fixed over the joint by adhesive plaster and the shoulders are pulled backwards by a posterior figure-of-8 bandage; recumbency is a great aid to the maintenance of reduction. The dressing should be worn for one month, and even then some degree of displacement is likely to remain. Backward dislocation is rare, and is caused by direct violence, or by a forcing of the shoulder forwards and inwards. The head of the bone lies behind the sternum, a depression exists over the joint, the acromion is nearer the middle line, movements of the head and neck are painful or impossible, and occasionally there are dyspnea, dysphagia, or congestion of the head, from pressure upon the trachea, esophagus, or blood vessels. Reduction and treatment are the same as those for forward dislocation, except that pressure is not made on the head of the displaced bone. If reduction cannot be promptly made in cases with serious pressure symptoms, the head of the bone may be excised, or wired in place. Upward dislocation is very rare, and is caused by violent depres- sion of the shoulder. The head of the bone may be felt in its new situation, where it may press upon the esophagus or trachea. The shoulder falls downwards and inwards. The bone is replaced by pressing the elbow inwards over a pad in the axilla, while downward pressure is made on the head of the bone. The limb is bandaged to the side in this position for several weeks. The acromial end of the clavicle may be dislocated downwards, but the usual displacement is upwards. The cause is violence to the shoulder. In dislocation upwards the outer end of the clavicle is prominent, the shoulder passes downwards and inwards, and its movements are limited. Dislocation downwards causes a depression over the joint and a prominence of the acromion. The shoulders should be pulled backwards, and pressure made upon the outer end of the clavicle or upon the acromion according to the displacement. JOINTS 459 A bandage or adhesive strap is then passed over the shoulder and under the elbow, and held in place by a band passing around the chest. Some deformity is very apt to persist, and in bad cases suturing of the bones with silver wire or kangaroo tendon should be considered. Dislocation of the lower end of the scapula (sec scapulum alatum) . Dislocation of the shoulder is the most frequent of all dislocations, owing to the exposed position and great mobility of the joint, and the disproportion between the head of the humerus and the depth of the glenoid cavity. A fall upon the outstretched hand or elbow is the usual cause. As a rule the head of the bone is forced through the weakest portion of the capsule, i.e., the lower and inner part, into the axilla; it remains in this situation (subglenoid) , or, as the result of muscular action or the direction of the force, passes back- wards and downwards beneath the spine of the scapula (subspinous) , forwards and upwards beneath the clavicle (subclavicular) , or most commonly three-fourths of all the cases) forwards and downwards beneath the coracoid process (subcoracoid) . The subclavicular, subcoracoid, and subspinous dislocations may,, however, be primary, i.e., the head of the bone may pass directly to its new situation with- out first entering the axilla. Two other forms, which are very rare, may be mentioned, viz., the supracoracoid, in which the head of the humerus passes above the coracoid and usually fractures it or the acromion process, and luxatio erecta, in which the head of the bone lies in the axilla, but the humerus projects upwards against the head of the patient. The symptoms of all varieties of dislocation of the shoulder except luxatio erecta are (i) pain, swelling, rigidity, ecchymosis, and loss of function; (2) flattening of the shoulder and prominence of the acro- mion process (Fig. 235), so that a ruler can be made to touch the acromion process and the external condyle at the same time; (3) a hard swelling in the situation abnormally occupied by the head of the bone; (4) Dugas' sign, i.e., projection of the elbow from the side when the hand is on the opposite shoulder, and inability to place the hand on the opposite shoulder when the elbow is forced against the side (this may be absent in some subcoracoid dislocations) ; (5) increase in the vertical measurement around the axilla (Callaway's sign) with lowering of one of the axillary folds (Bryant's sign) ; and (6) dis- placement as shown by the X-ray. The variety of dislocation may be diagnosticated by the situation of the head of the bone; by the axis of the limb, the elbow projecting from the side in all instances, but decidedly backwards in the subcoracoid and subclavicular 460 MANUAL OF SURGERY forms, slightly backwards in the subglenoid, and forwards in the subspinous; by the length of the Hmb, which is lessened in the sub- clavicular, increased very little if at all in the subcoracoid, slightly increased in the subspinous, and decidedly increased in the sub- glenoid; and by the X-ray. Rupture or compression of the axillary vessels or brachial plexus may occur. Subluxation of the shoulder is a condition in which the head of the bone passes forwards, owing to rupture or displacement of the long head of the biceps. The treatment is reduction by manipulation or extension, employ- ing ether if much difficulty is encountered. Kocher's method is Fig. 235. — Subcoracoid dislocation of the shoulder. useful in forward dislocations. The elbow is flexed to a right angle and pressed to the side. External rotation is then performed by abducting the forearm until it is at a right angle with the sagital plane of the body. If this does not cause reduction, the elbow is drawn forwards until the arm is at a right angle with the coronal plane of the body, and internal rotation performed by placing the hand on the sound shoulder and the elbow in contact with the chest. Ex- ternal rotation relaxes the posterior untorn portion of the capsule, which lies across the glenoid cavity, and causes the opening in the capsule to gap. When the elbow is carried forward, the capsule above the rent is relaxed, and the lower margin of the opening acts as a taut band which directs the head of the bone into the glenoid JOINTS 461 cavity. The method should not be used if there is great resistance to external rotation, as in such instances the neck of the bone may be broken. In Smith's method, for anterior dislocation, the surgeon stands in front of the patient and, if the left humerus is dislocated grasps the shoulder with his left hand, the fingers resting on the scapula and the thumb on the head of the bone. With the right hand the elbow is abducted to a right angle, extended, everted, and carried towards the sternum while pressure is made on the head of the bone. For the right shoulder the position of the surgeon's hands is reversed. In subspinous dislocation the surgeon stands behind the patient and in a similar manner abducts and extends the arm; external rotation is then performed, and the elbow carried towards the spine while the thumb presses the bone forwards into the glenoid cavity. In reduction by extension the patient Hes down, and the arm is pulled directly outwards while counterextension is made by placing the unshoed foot against the chest close to the head of the bone. If this fails, the arm is carried downwards while the foot is used as a fulcrum to drive the head of the bone into place. Some surgeons make the extension downwards, others place the foot over the acromion and pull the arm above the head. Cooper's method consists in placing the knee in the axilla of a sitting patient and forcing the elbow to the side. In all methods of extension, and particularly in the vertical form, there is danger of injury to the axillary nerves or vessels. After reduction the joint should be immobilized for a week or ten days by a Velpeau bandage. Recurrent dislocation of the shoulder is due to relaxation of the capsule as the result of nonunion of the laceration in it or stretching of the cicatrix. The shoulder may be strengthened by electricity, massage, and a support, or, after making an incision similar to that recommended for excision of the joint the gap in the capsule may be sutured or the capsule reefed. We have employed Thomas's incision for capsulorrhaphy. The incision is made in the axilla, along the anterior border of the coraco-bracialis, which with the biceps and pectoralis major is retracted outwards, the axillary vessels and nerves, including the musculo-cutaneous nerve being drawn inwards. The anterior circumflex vessels are ligated and cut, and about half the width of the subscapularis divided, care being taken not to injure the circumflex nerve or the posterior circumflex vessels. The myeloplasty of Clairmont-Erlich consists in wrapping a strip of muscle, taken from the posterior border of the deltoid, around the inferior part of the capsule, and suturing the strip to the anterior margin of the deltoid. 462 MANUAL OF SURGEEY Dislocations of the elbow are most frequent in children, and are caused by direct or indirect violence. In dislocation of both bones of the forearm the displacement may be backwards, forwards, or lateral. Dislocation of both bones backwards is the most frequent variety. The coronoid process lodges in the olecranon fossa, the forearm being flexed, midway betw^een pronation and supination, and shortened. Occasionally the coronoid process is broken (mobihty and crepitus) . The lower end of the humerus displaces the artery and soft tissues forwards, and projects at or below the crease of the elbow; the upper ends of the bones of the forearm form a projection posteriorly, and the relations between the olecranon, head of the radius, and condyles Fig. 236. — Old backward dislocation of the elbow, reduced after opening the joint. are markedly ajtered (Fig. 236). For diagnosis see fractures about the elbow. The treatment is reduction by strong traction, and flexion of the forearm across the knee, which is placed in the bend of the elbow while the patient is in the sitting position (Cooper's method) . The arm is placed in the Jones position for a week or ten da3^s. Dislocation of both bones forwards seldom occurs without frac- ture of the olecranon. The forearm is lengthened and flexed and the normal prominence of the olecranon is absent. The treatment is pressure downwards on the bones of the forearm by the knee in the bend of the elbow, the forearm being drawn upon and flexed by one hand, while the other makes forward traction on the humerus. The arm is then dressed in the Jones position for a week or ten days. JOINTS 463 Lateral dislocation of both bones, cither outwards or inwards is infrequent and usually incomplete. In either instance the forearm is flexed and fixed, and the joint widened; the form of displacement is determined by studying the relations of the bony landmarks about the elbow. Reduction is made by traction on the forearm, the upper end of which is pushed inwards or outwards according to the form of dislocation. The arm should be placed in the Jones position for a week or ten days. Dislocation of the ulna alone is rare, and can occur only in a backward direction; the forearm is flexed, fixed, and pronated, and the olecranon is unduly prominent. The treatment is the same as that for dislocation of both bones of the forearm backwards. Dislocation of the radius alone may be forwards, backwards, or outwards. Forward dislocation is the usual variety; it results from a fall on the hand when the forearm is pronated and extended, or from direct violence to the posterior part of the joint. The forearm is midway betW'Cen pronation and supination, and cannot be flexed beyond a right angle, as the head of the bone strikes the lower end of the hum- erus. The head can be felt rotating beneath the skin, and a depres- sion is noticed posteriorly beneath the external condyle. Reduction is the same as that for dislocation of both bones forwards. The arm should be kept in the Jones position for several weeks, as deformity is likely to recur owing to rupture of the orbicular hgament. Backward dislocation is rare, and is caused by a fall on the hand, or a blow on the head of the bone from the front. The forearm is flexed, fixed, and pronated, and the head of the bone can be felt rotating behind the external condyle. Reduction is the same as that for both bones backwards, the arm being fixed in the Jones position for several weeks, although recurrence of the deformity is not as menacing to the function of the elbow as in the preceding dislocation. Outward dislocation is very rare. The head of the bone may be felt external to the outer condyle; it is reduced by extension and direct pressure, and the forearm is dressed in flexion. Dislocation of the radius forwards and ulna backwards is exceedingly rare, and causes great deformity and impairment of function. Subluxation of the head of the radius occurs in children as the result of a forcible pull on the forearm. The head of the bone is displaced downward and a fold of the orbicular ligament becomes pinched in the joint. The forearm is flexed pronated, and powerless, 464 MANUAL OF SURGERY ../^ and pain and tenderness, increased by supination, exist over the head of the radius. The forearm should be forcibly supinated and then flexed, and the elbow immobilized for a few days. Dislocation of the wrist is rare, but may follow a fall on the hand or direct violence. The displacement may be backwards or for- wards; the deformity of the former resembles Colles' fracture, but the styloid processes of the ulna and radius project beneath the skin on the flexor side of the wrist, and their relations to each other are not disturbed. In forward dislocation the deformity is reversed. Reduction is effected by traction on the hand and pressure over the deformity, and the wrist is immobilized on a Bond splint for two weeks. Dislocation of the lower end of the ulna forwards, or more com- monly backwards, occasionally occurs in twists of the forearm; the deformity is readily detected, and easily re- duced by extension and pressure. The fore- arm and hand should be splinted for several weeks. Dislocation of the carpal bones is un- common apart from crushes. It is possible for the second row of bones to be dislocated backward or forwards from the first, or for any one of the carpal bones to be individually dislocated. The most frequent injury is anterior dislocation of the semilunar, a sort Fig. 237. — Complete ^^ r ■, backward dislocation of of silver-fork deformity resulting, owing to thumb. (Agnew.) ^^^ prominence of the os magnum, and the depression just above it caused by the forward displacement of the semilunar, which is felt under the flexor tendons of the wrist. The relations between the styloid processes and the radius are unaltered, although the distance from the radial styloid to the base of the first metacarpal is lessened. Reduction may be effected by hyperexten- sion, then hyperflexion over the thumbs of an assistant, which press on the semilunar (Codman and Chase). Excision of any of the bones may be demanded in irreducible dislocations. Dislocations of the metacarpal bones, i.e., at the carpo-meta- carpal joint, are infrequent. The metacarpal bone of the thumb is the one most frequently displaced, the cause being powerful flexion or direct violence. The base of the bone forms a posterior promi- nence, which is easily reduced but hard to keep in place. An adhesive strap should be put over the joint, and the thumb fixed in abduction on a palmar splint for two weeks or longer. JOINTS 465 Dislocation of the metacarpo-phalangeal joints, excepting that of the thumb, are infrequent. Forward dislocations are readily recog- nized and easily reduced. Backward dislocation of the thumb or of any of the lingers is often dilllcult to reduce, and the treatment of the former will serve as a guide for that of the latter. There are three forms of backward dislocation of the thumb. The incomplete some persons are able to produce at will by hyperextending the thumb until it forms an obtuse or even a right angle with the metacarpal bone. The complete is caused by forced extension, the first phalanx project- ing backwards at a right angle, the terminal phalanx being flexed, and the head of the metacarpal bone forming a prominence anteriorly (Fig. 237). The anterior hgament is lacerated, and with the sesa- moid bone is pulled up on the posterior surface of the head of the metacarpal bone, the long flexor tendon slipping to the inner or the outer side. The complex form may be caused by flexion of the thumb Fig. 238. Fig. 239. Pigs. 238 and 239. — Levis apparatus for dislocations of the phalanges. in attempts to reduce the complete form. The thumb is parallel with, but posterior to, the metacarpal bone. Reduction consists in increasing the extension, making strong traction, pushing the base of the thumb downwards, then pressing on the head of the metacarpal bone and flexing the thumb. If this is unsuccessful, as it often is, a palmar incision should be made over the head of the metacarpal bone and the ligament nicked between the sesamoid bones, when replacement will be easy. A splint should be used for at least three^^ weeks. Dislocation of the phalanges may be backwards, forwards or lateral. Deformity is obvious and reduction usually easy. In difhcult cases a firmer grasp on the finger can be secured by the Levis apparatus (Figs. 238, 239). The fingers should be sphnted for one week. Dislocations of the ribs, costal cartilages, sternum and pelvis are 30 466 MANUAL OF SURGERY very rare, and give the same signs and require the same treatment as fractures. Dislocations of the hip are comparatively infrequent owing to the great strength of the joint. The cause is never direct violence but always force transmitted from the feet or knees, or from the back when the hips are flexed. After the fortieth or fiftieth year dislocation is very rare owing to the fragility of the neck of the femur, which predisposes to fracture. The upper portion of the hip joint is formed by the rim of the acetabulum; the capsule is markedly strengthened in front by the iliofemoral or Y-ligament and to a lesser degree by the pubofemoral ligament, while posteriorly it is reinforced by the ischiofemoral hgament; hence the weakest portion of the joint is below, and it is through this part of the capsule that the head of the bone usually passes when dislocated, thence passing forwards or backwards^according to the presence of abduction at the time of the accident. The innominate bone is made of two planes, the ilio- ischiatic and the pubo-ischiatic, which meet and form a right angle at a line drawn from the anterior superior spine of the ilium, through the acetabulum, to the tuberosity of the ischium. When the head of the femur escapes through the lower portion of the capsule, it slides off this angle upon one or the other of these planes, according to the direction of the force; hence all dislocations of the hip are either in- ward (forward) upon the pubo-ischiatic plane or outward {backward or dorsal) upon the ilio-ischiatic plane. The head may lie upon any portion of either of these planes within a circle whose radius is the untorn portion of the capsule; consequently AUis, to whom belongs the credit for working out this problem, subdivides the inward dis- locations into the (a) high (pubUc and subspinous of other writers) (b) middle (thyroid of others), (c) low (perineal of others), and (d) reversed; and he divides the outward or dorsal into the (a) high (on dorsum of ihum), (b) low (sciatic, or dorsal the tendon of others) and (c) reversed (everted dorsal, anterior obHque, and supraspinous of Bigelow). In three-fourths of the cases the dislocation is out- wards, and in two-thirds of these it is high, i.e., upon the dorsum of the ilium; of the inward dislocations the middle (into the thyroid foramen) is the most frequent. Some writers state that the head of the bone may be pushed through the capsule, e.g., by force applied to the knee when the thigh is flexed and adducted, directly onto the dorsum of the ilium, but Allis explains all cases by leverage; thus outward dislocations are caused by flexion, adduction, and inward rotation of the thigh, which pry the head out of the place by the ful- crum action of the iliofemoral ligament, which passes across the front JOINTS 467 of the neck oi the hone; uuvard dislocations are caused hy ahduction, the head of the hone heing forced out of the socket hy the great trochanter impinging against the rim of the acetabulum, which acts as the fulcrum. The ligamentum teres is of course ruptured. If the tear in the capsule is close to the femur, its infolding may offer an obstacle to reduction. The Y-ligament is rarely ruptured; tear- ing of its outer branch permits the femur to rotate externally and results in reversed (everted dorsal) dislocations. If the entire liga- ment is ruptured, the head of the bone will be freely movable instead of lixed. The muscles about the joint are contused or lacerated to a greater or lesser degree. Rupture of the obturator internus allows the head of the bone to ascend and become high dorsal if the muscle remains intact, the low dorsal (dorsal below the tendon) will likely ensue. It is possible, however, for the head to leave the joint above the tendon of this muscle, or leaving it lower down to ascend in front of the tendon. The sciatic nerve may be contused, compressed or lacerated, but the femoral vessels are very rarely injured. In dorsal or outward dislocation the thigh is flexed, adducted, rotated internally, and shortened, while the trochanter is above Nelaton's line and -farther away from the median line of the body, so that the hip ap- pears broadened. A depression exists over the front of the joint and the head of the bone can be felt posteriorly. The knee is flexed and the heel raised. Passive movement is Fig. 240.— High dorsal ., , 1 • ji T ,• c 1 f •. dislocation of the hip. possible only in the direction 01 deformity, (Tiiimanns.) and indeed the affected limb can be flexed to a right angle with the body without bending the knee. If both knees are flexed while the thighs are vertical, the patient lying down, the foot on the affected side touches the bed. In the high dorsal (Fig. 240) these signs are all marked, in the low dorsal they are less in evidence; e.g., in the former there is two or three inches shortening, the axis of the affected thigh passes through the lower third of the sound thigh, the foot passes over the sound ankle; in the latter the shortening is an inch or less, the axis of the femur passes through the sound knee, the foot crosses the great toe of the 468 MANUAL OF SURGERY sound side. In the reversed dorsal the lower limb is rotated exter- nally, instead of internally owing to tearing of the outer branch of the Y-ligament. For diagnosis from fractures see p. 416. Reduction should be performed under ether with the patient lying on the back. Bigelow's method consists in flexion of the leg on the thigh and the thigh on the abdomen, abduction, inversion, strong traction upwards, and external circumduction, i.e., the knee is swept upwards towards the opposite shoulder, then towards the shoulder of the same side, and finally downwards with the limb in extension (Fig. 241). As there is some danger of hooking up the sciatic nerve by the head of femur in this method, Allis flexes the thigh, performs internal rotation by carrying the foot outwards, draws the thigh up- wards to lift the head to the level of the acetabulum, and has an assistant push inwards on the head as the thigh is rotated externally and extended. In this method it is necessary to fix the pelvis firmly to the floor by straps or by the hands of an assistant. Rediiction by exten- sion is made by traction in the axis of the displaced thigh while pressure is made over the great trochanter. Extension by pulleys destined to rupture the Y-ligament is danger- ous and should not be employed. After re- duction the patient is confined to bed for two or three weeks with the legs tied together. Inward or forward dislocations are characterized by flexion, abduction, and ex- ternal rotation of the thigh. The hip is flattened, the trochanter being nearer the median line; the acetabular cavity is empty; and the head of the bone may be detected in its new position. The adductor muscles are prominent and the knees cannot be approx- imated. In the high thyroid dislocation, i.e., upon the pubes (Fig. 242), flexion is less marked, but eversion is greater and the limb is shortened about one inch; in the low thyroid (Fig. 243) flexion is greater and the Hmb is lengthened one or more inches. In the re- versed thyroid external rotation may be so great that the toes point directly backwards. In the reduction of inward dislocations Bigelow advised flexion of the leg and thigh as in the treatment of dorsal dislocation, then abduction, eversion, strong traction upwards, and internal circum- duction, i.e., the knee is swept upwards towards the shoulder of the Fig. 241. — Bigelow's method of redtxcing backward dislocation ot hip. JOINTS 469 same side, then towards the opposite shoulder, and finally down- wards with the limb in extension (Fig. 244). Allis, in order to avoid injury lo the sciatic nerve, flexes and abducts the thigh, makes strong Fig. 242. — High thyroid (pubic dislocation.) (Tillmanns.) Low thyroid dis- (Tillmanns.) traction upwards, and abducts while an assistant pushes on the head of the femur. Reduction by extension alone is made by traction in the axis of the displaced thigh, the unshoed foot being placed in the groin for counterexten- sion. After reduction the subsequent treat- ment is the same as in the dorsal variety. The knee may be dislocated forward, backward, inward, or outward, and these may be complete or incomplete, the symp- toms consequently varying in degree. The cause is violent force, either direct or indirect. In forward dislocation the lower end of the femur passes backwards and compresses the popliteal vessels, and the tibia is displaced forward. The leg is shortened and extended, although it may be flexed; in the former case the patella is loose. Backward dislocationfis more frequently due to disease of the knee Pig. 244. — Bigelow's method of reducing forward dislocation of hip. 470 MANUAL OF SURGERY joint than to injury. The leg is shortened and usually somewhat flexed, and compression of the popliteal vessels or nerves is generally absent. Inward and outward dislocations are usually incomplete. The leg is partly flexed and often rotated, but not shortened. Reduction is accomplished by traction and direct pressure while the leg is extended and the thigh flexed. The knee should be im- mobilized on a splint for three weeks, and a support worn for some some time longer. Dislocations of the patella are due to muscular action or direct violence. An insidious outward dislocation may be caused by knock- knees or hydrarthrosis. The patella may be dislocated upwards, downwards, outwards, or inwards, or it may be rotated on its per- pendicular or horizontal axis, or there may be a combination of any of these varieties. Dislocation upwards or downwards is due to rupture of the liga- mentum patellae or the quadriceps tendon, and is to be treated as a rupture of a tendon. Outward dislocation is the most frequent variety; it usually occurs when the limb is extended, as in flexion the patella is firmly held between the condyles of the femur. The patella lies upon the anterior or outer surface of the external condyle, according to whether the dislocation is incomplete or complete; in the former the outer edge projects forward, in the latter the inner border presents in front. The leg is extended, the knee broadened, and the intercondyloid notch perceptible. Reduction is made by pressure inwards on the outer margin of the patella while the thigh is flexed and the leg extended to relax the quadriceps. Incision is needed in some cases. The knee should be immobilized for several weeks. Inward dislocation is rare; the signs and the treatment are the reverse of those of outward dislocation. In rotation on the perpendicular axis (verticle or edgewise dislocation) either the outer or the inner border of the patella, usually the latter, lies between the condyles while the opposite border pro- jects forward. In two cases the bone has been turned over, the articular surface looking forwards. Reduction may be efi'ected by pressure while the knee is extended, but is often more difl&cult than at first sight appears, and incision may be necessary. Rotation on the horizontal axis has been recorded in six instances, and the author has seen one case which has not been reported. In five of these the tendon of the quadriceps was torn and the upper border of the patella wedged between the femur and the tibia, in two the lower edge was torced into the joint, the articulating surface of the JOINTS 471 patella looking upwards. In live cases incision was necessary to free the patella. Dislocation of the semilunar cartilages of the knee joint (subluxa- tion, internal dcrangcmoil of the knee ) follows a twist of the partly flexed knee. The condyles fix the cartilages, which are torn from the tibia by rotation of the leg, the attachments ol the cartilages to the tibia being relaxed when the knee is bent. The internal cartilage is the one usually affected. Any of its attachments or even the cartilage itself may be ruptured. The sjonptoms are severe pain in the knee and effusion into the joint, which is locked in flexion, i.e., flexion may be increased but extension is impossible. Sometimes there is no locking, and these cases are diagnosticated sprains. In the latter tenderness is more generalized, and extension may relieve rather than increase the pain. This displaced cartilage is occasionally felt, but more often palpation will reveal nothing but marked tenderness along the front of the upper surface of the tibia. Recurrences are frequent. The treatment is reduction by increasing the flexion, rotating the leg, making firm pressure over the situation of the displaced cartilage, and extending the leg. Often spontaneous reduction occurs before the surgeon is called. The synovitis should be treated and the knee immobihzed for five or six weeks. In order to prevent recurrence an elastic knee cap should be worn for several months. If relapses are frequent, a brace may be appHed which, while allowing flexion and extension, prevents rotation; or the joint may be opened by a curved incision along the upper edge of the tibia, and the cartilages stitched to the periosteum with catgut, or excised if they are ruptured or deformed. The fibula may be dislocated at either end, either backwards or forwards. The injury is very rare. The leg is flattened from side to side and a depression is found over the end of the bone, which is felt in its displaced position. Reduction is effected by flexion of the knee and direct pressure, the leg being put up in plaster of Paris for several weeks. At the. upper end displacement is Hkely to recur owing to the contraction of the biceps. Dislocations of the ankle joint are often compUcated by fracture. In the order of their frequency the displacements are outwards, inwards, backwards, forwards, and upwards. Lateral dislocation is caused by a twisting or turning of the foot, and the resulting injury is a fracture dislocation, known as Pott's fracture or Dupuytren's fracture, (q.v.) . Dislocation backwards is caused by stumbling when jumping or 472 MANUAL OF SURGERY running, or by direct violence; both malleoli are commonly broken. The heel is prominent, the dorsum of the foot shortened, and the relations between the malleoli and the tarsus altered. Forward dislocation rray occur without fracture. The dorsum of the foot is lengthened, the heel inconspicuous, and the normal hollow in front of the tendo Achilhs bulged by the tibia and fibula. Both these dislocations are reduced by strong traction, direct pressure, and rotation, while the knee is bent to relax the tendo Achillis, which in some instances it may be necessary to sever. The after treatment is that of fractures about the ankle. Upward dilsocation of the ankle is a rare injury in which the astragalus is thrust upward between the tibia and fibula as the result of a fall upon the feet. The ankle is widened and the foot flattened, the malleoh having descended towards the sole of the foot. Reduc- tion is made by powerful traction and countertraction, the after treatment being that of fracture. In dislocation of the astragalus the bone, as the result of falls or twists, is detached from the remaining tarsal bones as well as separ- ated from the bones of the leg. The displacement may be complete or incomplete, the bone passing forwards or backwards or rotating upon its perpendicular or horizontal axis; or these lesions may be combined. In forward dislocation the astragalus forms a prominence in front of the ankle, the dorsum of the foot and the leg are shortened, and the malleoh are nearer the sole of the foot, which is either turned inwards or outwards. In backward dislocation the astragalus lies between the malleoh and the tendo AchilHs. If either horizontal or vertical rotary dislocation alone occurs, the astragalus simply rotates mthout being displaced from between the bones of the leg and the bones of the foot, a positive diagnosis can seldom be made without the X ray. Reduction if the bone is not completely displaced, is effected by traction on the foot and direct pressure on the astragalus while the knee is flexed to relax the calf muscles. If the dislocation is complete, reduction is rarely possible, and excision will be required. Subastragaloid dislocation is a disrupture of the joints between the astragalus, and the os calcis and scaphoid, as the result of twist- ing. It is possible for the foot to pass forward, backward, inward, or outward, but in most instances the displacement is backwards, or inwards, or backwards and outwards. If the displacement is backuards and inwards, the external malleolus is prominent, while the situation of the internal is occupied by a hollow. The foot is inverted JOINTS 473 and the astragalus conspicuous, thus resembling talipes equino varus. If the dislocation is hackivards and outwards, the deformity is the reverse of the preceding form and resembles talipes equino valgus. In either of these varieties the foot is shortened on the dorsum and the heel elongated, while the tendo Achillis forms a curve which is concave in the direction of the displacement. Reduction is accomplished by traction in an opposite direction to that of the deformity, the leg being flexed or the tendo Achillis cut to secure muscular relaxation. The foot and ankle are put in plaster for several weeks. Dislocations of the remaining tarsal bones are quite rare, and are treated by extension and direct pressure upon the displaced bone or bones. Dislocations of the metatarsal bones are uncommon, and cause a backward or forward projection with shortening of one toe, if one bone is dislocated, or shortening of the entire foot, if all the bones are dislocated. Reduction is made by extension and pressure, a -splint or a cast being worn for two or three weeks. Dislocations of the toes are v-ery rare, the metatarso phalangeal joint of the great toe being affected most frequently. The symptoms and treatment are similar to those of like injuries of the hand. DISEASES OF JOINTS Examination of a diseased joint should be preceded by obtaining the history of the patient and of the disease. The cause of most joint affections is injury, infection, or nervous disturbances. If the cause is a severe injury and the onset immediate the condi- tion is probably a sprain, ruptured ligament, intraarticular fracture or a dislocation. A trivial injury followed by immediate distention of a joint strongly suggests hemarthrosis due to hemophilia. A trivial injury followed, after an interval, by an insidious joint disease points to tuberculosis. Infection gains entrance through a wound, extends from neigh- boring structures (most often bone) , or comes by way of the blood, e.g., in pyemia, syphiHs, gonorrhea, tuberculosis and acute fevers (variola, scarlet fever, enteric fever, measles, erysipelas, pneumonia, etc.). Gout and rheumatism may, at least for convenience, be placed under this heading, although some might consider "faulty metabolism" a more appropriate legend. "Rheumatism" is a com- mon designation for many cases of infective arthritis, the source of infection being the tonsil, prostate, etc. (see diagnosis of sepsis) . 474 MANUAL OF SURGERY The nervous disorders which may be responsible for joint disease are central (e.g., locomotor ataxia, syringomyeHa) , peripheral (e.g., neuritis, section of nerves), or emotional (e.g., hysteria). As the nature of hemophilia is not known, it will not fit into any of these classes. The symptoms of a general nature, when present, are those of sepsis or of the general diseases just mentioned. The local symptoms that annoy the patient are pain and inter- ference with the Junction of the joint. If these are intermittent the trouble may be due to a dislocated cartilage or a loose body; if remittent and chronic to osteorathritis. Chronicity with slow steady progress indicates tuberculosis. It should be recalled that pain may be referred to distant parts; thus hip joint disease may cause pain in the knee, disease of the vertebral joints in the areas supplied by the spinal nervies. A number of joints may be involved in general infections, e.g., in pyemia, rheumatism, gonorrhea, osteoar- thritis, and in the acute infectious fevers. In the local examination one should always compare the joint with that of the opposite side. The position of the joint is generally one of flexion; in hysteria it may be rigidly extended. The skin may be white in tuberculosis, ecchymotic after injuries, hyperemic in acute inflammation. Numbness immediately after trauma may be due to local shock; persistent anesthesia, to nerve injury or hysteria. The amount of swelling may be accurately determined with a tape-measure, being careful to measure the corresponding joints on each side of the body at the same place and to have the joints in the same position. The situation, shape, and consistency of the swelling should be noted. It may involve the joint cavity alone (synovitis), or also the ends of the bones (arthritis), or it may be extraarticular, e.g., in bursitis, tenosynovitis, celluHtis. Heat, redness, and edema are characteristic of acute inflammation, some times induced, however, by irritating applications. Atrophy of neighboring muscles may occur in any case of long duration, even in hysteria, but is most marked in osteoarthritis depending upon injury or inflammation of the nerves and in tuberculosis. Crepitus on pressure or motion may indicate, by its character (p. 7), blood clot, rice bodies, synovitis, or arthritis. Its exact situation must be ascertained, as it may originate in adjacent bursas or tension sheaths, a fact that can sometimes be elicited by JOINTS 475 moving the bursa, e.g., prepatellar bursa, or the tendons, e.g., those of the wrist, without moving the joint. Alteration of the relations of the bony landmarks about a joint indicates fracture or dislocation, either of which may be the result of injury or disease. Motions, both active and passive, are usually restricted or abolish- ed, but occasionally the joint may be abnormally movable, e. g., in Charcot's disease. Caution must be exercised to fix adjacent parts lest their movement be wrongly interpreted as belonging to the joint under inspection, thus the scapula must be immobilized in examining the shoulder joint, the pelvis in examining the hip joint. The X-ray may show distension of the joint cavity, lesions of the cartilages and bones, displacements, movable bodies and similar conditions. During the second stage oi- general anesthesia rigidity due to voluntary muscular contraction ceases, e.g., in hysteria and in ma- lingerers, but deep anesthesia is necessary to relax involuntary muscular spasm. Limitation of movements after complete anesthesia indicates ankylosis. Aspiration is indicated when the nature of an effusion is doubtful. Incision, for exploration, should be reserved for cases in which all other methods of diagnosis fail and in which the disabiHty is marked. Synovitis is inflammation of the synovial membrane alone, the remaining structures of the joint being unaffected. It may be acute or chronic, simple or suppurative. Acute simple synovitis is caused by a closed injury (contusion, sprain), low grade infection, or nervous influences (p. 474). The synovial membrane is red and swollen, and the joint is distended with fluid consisting of synovia, inflammatory exudate, and some- times blood, hence it is coagulable. Precipitated lymph may be absorbed, or become organized and result in adhesions. The symptoms are pain, tenderness, increased heat, a fluctuating swelling, and in some cases hyperemia of the skin. The muscles fix the joint in the most comfortable position, usually some degree of flexion, in which position there is more room for the fluid. The effusion stretches the softer tissues entering into the formation of the joint and leaves it a little weakened and relaxed, at least temporarily. The constitutional symptoms vary with the cause of the synovitis and the size of the joint. Effusion is detected in the various joints as follows: The shoulder is increased in size, and swelling may be noticed along the bicipital groove and in the axilla. In subdeltoid bursitis axillary swelHng is absent, and, although 476 MANUAL OF SURGERY active motions are painful, gentle passive movements of the shoulder may be painless. In the elbow the swelling is on each side of the olecranon and tendon of the triceps. In the wrist swelling is most marked posteriorly. In the Jiip effusion is usually not detected, but reliance is placed upon the tenderness, limitations of movements and upon the position of the thigh in flexion, abduction, and external rotation. In the knee swelling is detected upon each side of the patella and its ligament, and beneath the quadriceps. The patella is floated away from the condjdes, and if tension is not too great it may Fig. 244a. — Lateral incisions for drainage of knee joint. Fig. 2446. — Posterior incisions for drainage of knee joint. be pushed backward by the finger and made to tap on the femur. In the ankle fullness may be seen in front, but is most in evidence on each side of each malleolus. The treatment is immobihzation and elevation of the joint, and in the first stage cold in the form of an ice bag or evaporating lotions later absorption should be promoted by the use of heat, compression; and ointments containing ichthyol, belladonna, mercury, or iodin. If the effusion is large or unaffected by other forms of treatment aspiration may be advisable. The position of the joint should be such as to give a useful limb even in the event of ankylosis. Thus JOINTS 477 the elbow is j)ut on an internal an,u;ular splint, the hip and knee are fixed in extension, the wrist midwa}- between flexion and extension, the ankle at a right angle, and the shoulder with the arm to the side. Traction by means of adhesive plaster, as for fracture, is of service when the hip or knee is involved. During the convalescing stage, liniments, massage, and elastic compression are useful. As soon as the intlammation has subsided gentle passive motions should be started, in order to prevent ankylosis. Acute suppurative synovitis {empyema of a joint) may be a later stage of simple synovitis. More commonly it is suppurative from the onset, the cause being an open w^ound, neighboring inflammatory process, or a hematogenous infection (pyemia). The symptoms are those of simple synovitis, but more intense, and accompanied by marked general evidences of sepsis. The diagnosis may be confirmed by exploratory puncture. The treatment is that of acute suppurative arthritis, into which untreated suppurative synovitis merges. Chronic simple synovitis follows the acute form or is chronic from the beginning. The synovial membrane is thickened and the joint contains an excess of fluid, which, when large in quantity, is called hydrops articuli. The symptoms are slight pain when the joint is moved, fluctuation owdng to the presence of effusion, weakness with restriction of motion, atrophy of neighboring muscles, and in some cases cerpitus on pressure or when the thickened layers of synovial membrane are rubbed together by motions of the joint. In some situations, e.g., the knee, hypertrophied synovial fringes may be palpated. The treatment is immobilization, compression, and counterirrita- tion with blisters, iodin, or occasionally the actual cautery; stimu- lating liniments and massage are useful, as an ointment containing equal parts of ichthyol, belladonna, mercury, and lanolin. Baking the joint by means of a hot-air apparatus or radiant heat, usually gives at least temporary relief. Aspiration is occasionally employed. Arthrotomy is reserved for cases which resist all other forms of treatment. In these cases the joint is irrigated with salt solution and hypertrophied fringes removed; other undiagnosticated con- ditions, such as loose bodies, ruptured or inflamed semilunar car- tilages, lipoma arborescens, tuberculous disease, etc., may be found and will require treatment. Constitutional treatment, of course should be administered in the presence of any diathesis. Chronic suppurative synovitis is usually a legacy of the acute form, or when originating insidiously, due to syphiUs or tuberculosis, under which headings the treatment will be considered. 478 MANUAL OF SURGERY Arthritis {panarthritis) is inflammation of not only the synovial membrane, but also the cartilages, bones, and hgaments of an articu- lation, in a word all the structures of a joint. Clinically, arthritis is distinguished from synovitis by the tender, swollen articular ends of the bones, by the greater pain on active as compared with passive motion, and in the later stages, after the cartilages and bones have become eroded, by starting pains p. 481), by cartilaginous or bony crepitus, and by the X-ray. Arthritis is classified like, and is due to the same causes as, synovitis. Acute and chronic simple arthritis are treated like acute and chronic simple synovitis. Joint inflammations occurring during or after acute infectious fevers commonly terminate without suppura- tion the symptoms being much like those of rheumatic synovitis, one or several joints being involved. In some cases, notably in typhoid arthritis, there is little pain, although dislocation may occur. In some cases aspiration of the joint, with, if need be, microscopic examination of the fluid, will reveal the presence or absence of pus. Acute suppurative arthritis is always due to micro-organisms which enter the joint through a wound, from neighboring tissues or by way of the blood, e.g., in pyemia and acute infectious diseases. The entire joint and the periarticular structures participate in the inflammation, which destroys the cartilages, relaxes the ligaments (sometimes permitting luxation) , and invades the neighboring bone and soft structures. The symptoms are great pain and tenderness, and j&xation of the joint, which is hot, swollen, and fluctuating. There are redness and edema of the skin and severe constitutional symptoms (septic intoxication or septicemia) . The ends of the bones enlarge (ostitis) , and finally, in progressing cases, ulcerate (caries), at which time starting pains (p. 481) may occur and osseous crepitus be obtained. If proper treatment is withheld and the patient sur\'ive, pus per- forates the capsule, infiltrates the surrounding tissues, and finally breaks through the skin, the joint becoming abnormally movable and dislocated to a greater or lesser degree. The patient may die from toxemia during the acute stage, or succumb to chronic infection and exhaustion in the later stages. Should recovery ensue ankylosis is almost inevitable. The treatment consists in freely opening the joint, irrigating with salt or Dakin's solution, establishing free drainage, institut- ing chemical sterilization p. 149-150-151 and treating constitutionally as for sepsis. No drainage material, i.e., rubber tubing or gauze, should be introduced into the synovial sock. Willems institutes JOINTS 479 motion in the joint, passive and active, beginning immediately after operation. Excision or amputation will be required if, after free drainage septic symptoms threaten life. Murphy treats infective athritis by aspirating the fluid and injecting lo cc. of a 2 per cent, dilution of formahn in gylcerine. This procedure is repeated every few days if the effusion reappears. Others have great, and we think unwarranted, faith in vaccine therapy. Chronic suppurative arthritis follows the acute form, or is due to one of the infective granulomata, notably syphilis or tuberculosis (vide infraV Pneumococcal arthritis is due to pneumococcemia, although the organism is not always recoverable from the blood. The original infection is usually a lobar pneumonia, sometimes, however, a pneumococcal meningitis or peritonitis ; rarely a primary focus cannot be found. In about two-thirds of the cases only one joint, usually the knee, is affected. The effusion may be serous, but is generally purulent. The diagnosis is made by bacteriologic examination of the aspirated joint fluid. The treatment is that of simple or sup- purative arthritis, according to whether the fluid is serous or purulent. Gonorrheal arthritis {gonorrheal rheumatism) is due to the gonoco- ccus, which is carried by way of the blood from the urethra, or rarely from the conjunctiva in gonorrheal ophthalmia. As a rule it appears during the subsiding stages of an acute gonorrhea or in chronic cases. Men are said to be more frequently affected than women, but this is probably owing to the fact that the diagnosis is seldom made in the latter. One or several joints may be involved, generally the former, the knee, ankle, and wrist being most fre- quently affected. The inflammation may be acute or chronic, and varies in extent as well as in degree. Although the s^movial mem- brane alone may be involved, the Hgaments and periarticular struc- tures are very apt to be thickened and infiltrated. Except in the mildest cases, the pain is severe and there is fever. Suppuration may occur, and ankylosis is xery prone to follow even the milder cases. Endocarditis and like compKcations of general infection occasionally occur. In doubtful cases some of the fluid from the joint may be secured by aspiration for bacteriological examination. The complement-fixation test for gonorrhea, if positive is of the greatest value in many obscure articular inflammations, but of no significance when negative. The treatment is unsatisfactory the disease being apt to persist or recur. The urethritis should be combated, the seminial vesicles carefully examined and drained or excised if necessary, and the 480 MANUAL OF SURGERY joints immobilized and treated locally as in other forms of arthritis. As soon as the pain subsides, passive motions should be employed to prevent ankylosis. Among the internal remedies which have been used are the salicylates, iron, quinin, strychnin, and the iodids. If suppuration occurs, the joint should be opened, irrigated, and drained. Rogers and Torrey claim good results from the hypoder- mic injection of an antigonococcus serum, prepared by injecting cultures of the gonococcus into rabbits. From twenty to sixty minims are administered every day or every other day until the pain and disability subside. Vaccines made from the gonococcus also have been employed. S3rphilitic gummatous arthritis occurs in the tertiary period. The onset is insidious; the disease begins in one portion of the joint, and is associated with but little pain. If unchecked it finally reaches the surface, when the characteristic gummatous material will be exposed. The symmetrical form of synovitis occurring in the secondary period has already been mentioned. There is also a form of gummatous synovitis resembling tuberculosis, and a form of chondroarthritis analogous to osteoarthritis. The history, the evidences of syphilis elsewhere, the Wassermann reaction, and the response to appropriate treatment, are important factors in making the diagnosis. The treatment is that of syphilis; excision or amputa- tion may sometimes be required. Tuberculous arthritis [-d:liite swelling, pulpy degeneration) is much more common in children, the joint generally being invaded from an adjacent epiphysis; in adults the primary focus is probably in the synovial membrane as often as it is in the neighboring bone. The tubercle bacillus is transported by the blood to the joint, in which an area of lessened resistance has often been created by some slight injury, the patient possessing a hereditary predisposition to the disease. The pathological anatomy is as follows: When beginning in the synovial membrane, whitish or pinkish pulpy granulations are formed and eventually fill the joint, giving a characteristic doughy feel. In other cases the membrane is covered with small tubercles and the joint is filled with fluid. The tubercles caseate and liquefy, forming tuberculous pus. The ligaments become softened and finally destroyed; the cartilages are eroded and eventually the bones; and the surrounding soft tissues are edematous. When the disease begins in the bone, the changes are those of tuberculous ostitis, the joint being aft'ected secondarily. In any case the tuberculous pus generally finds its way to the exterior by one or more sinuses. JOINTS 481 Tlu- symptoms are very slow in onset. At first there is slight pain, causing some limitation of motion and, in the lower extremities, limping. Later, swelling is noticed and the muscles rigidly hold the joint in a semiflexed position. In a well developed case the joint is spindle-shaped, due not only to the swelling, but also to the atrophy of the neighboring muscles, and the skin is white, owing to oblitera- tion of the subjacent vessels, and is adherent to the parts beneath. A peculiar doughy or elastic sensation is imparted to the fingers on palpation, but fluctuation is detected only when a cold abscess approaches the surface, or in the rare cases in which the effusion predominates. Rice bodies are sometimes found in the latter variety. Night cries {starting pains) indicate erosion of cartilage or bone; when the patient falls asleep the rigid muscles relax, permitting some alteration in the relation of the joint surfaces, and producing severe pain which causes the patient to wake with a start. Partial or even complete luxation may be induced by tonic contractions of the muscles upon the disorganized joint. The local temperature of the joint is raised, and later, when sinuses form, hectic fever develops owing to mixed infection. The diagnosis may be difficult in the early stages, in deep seated joints, and in cases with a large effusion, which resembles chronic synovitis. The examination of aspirated fluid and the X-ray are often of great value, and some recommend the tuberculin test. Doubtful cases should be regarded as tuberculous. With proper treatment the prognosis is good regarding life, metastases being uncommon. Ankylosis generally follows, and indeed is nature's method of cure. In late cases, i.e., those with sinuses, the patient may develop amyloid disease or die of exhaustion. The treatment is constitutional (see tuberculosis) and local. The local treatment may be conservative or radical. Conservative treatment, which is indicated in the early stages, includes immobiliza- tion, often for months, by feplint, plaster-of-Paris, or extension apparatus; baking with the hot-air machine; Bier's passive hypere- mia; aspiration of the joint fluid and injection of 10 per cent, iodo- form emulsion (two to five drams according to the age of the patient) or other antiseptic (see tuberculosis) at intervals of a w-eek or longer; phototherapy (Finsen light) ; radiotherapy (radium, X-rays) ; and heliotherapy (see tuberculosis). Compression, counterirritation, and external applications of various lotions and ointments are useless. As soon as detected, absceses should be tapped with a large trocar and cannula, irrigated with salt solution, and injected with iodoform emulsion. If sinuses exist injections of Beck's bismuth paste may 31 482 MANUAL OF SURGERY be tried before proposing operation (see section on sinus). If the disease continues to progress, or if the general condition of the patient is such as to forbid prolonged treatment, radical measures are de- manded. The joint should be opened and the tuberculous tissue removed by erasion (arthrectomy) or excision, according to its extent. Amputation is indicated in cases too far advanced for excision, or in cases in which excision has failed. Tuberculosis of Special joints. — In the shoulder joint the disease is more frequent in adults than in children, but is not common in either. It usually begins in the head of the humerus and rarely attacks the glenoid cavity. Abscesses, which are rather unusual, point on either side of the deltoid or in the axilla. In caries sicca, which occurs more often here than in any other joint, instead of doughy swelhng, there is shrinkage due to muscular atrophy and destruction of the head of the humerus. Immobilization should be persisted in for a number of months. If sinuses form, however, excision of the head of the humerus will usually be required. The elbow is affected more often than either the shoulder or the wrist, because the nutrient arteries of the humerus, radius, and ulna run towards the elbow, thus favoring the deposition of bacterial emboli in this region. The disease is most frequent during adoles- cence, beginning, in the order of their frequency, in the synovial membrane, or in the epiphysis of the humerus, ulna, or radius. The characteristic spindle-shaped swelling is well marked. Abscesses point on either side of the olecranon, or occasionally follow the ulnar nerve and present on the inner side of the arm. Immobilization at a right angle, with the forearm midway between pronation and supina- tion, is the correct treatment in the early stages, but if the bones are much involved, either erasion, or in adults excision, is the quickest and best treatment. Tuberculosis of the wrist is comparatively infrequent, but may be met with at all ages. It may begin in the synovial membrane, or be secondary to disekse in the carpal bones, lower end of the radius, or neighboring tendon sheaths. If, after several months of conserva- tive treatment, the disease is not checked, erasion or excision is usually advisable, and if the disease is very extensive, amputation will offer the only hope or relief. Tuberculosis of the sacroihac joint is of infrequent occurrence, and is most commonly seen in adults. It may be synovial in origin but more often arises in adjacent bones. There is pain in the back, in the joint, or down the thigh, which is increased on standing, walk- ing, or rocking the pelvis with the hands. The patient limps and JOINTS 483 puts most of his weight 011 the sound leg, the body being bent for- ward and away from the affected side, thus causing apparent lengthen- ing of the limb corresponding to the diseased joint. There may be swelling and tenderness directly over the articulation, and in the later stages abscesses discharge in this situation, in the lumbar region, in the iliac fossa, in the groin, or even alongside the rectum. The diagnosis may be difficult in the early stages. Lumbago follows exposure to cold, affects both sides, and is transient in charac- ter. Sciatica causes a very severe shooting pain, tenderness of the nerve, no apparent lengthening of the limb, and no increase in pain when the iliac bones are pressed together or pulled apart. Hip disease causes rigidity of adjacent muscles and hmitation of hip movements, which, if the pelvis is supported, are not present in sacroiliac disease. If there is an iliac abscess in sacroiliac disease, the thigh may be flexed, but the hip can be freely moved. In disease of the spine there are pain, tenderness, rigidity, and perhaps deformity in the affected segment. "Theprog- _,--., nosis, owing to the deep situation of the joint, is often unfavorable. The treatment is rest in bed with a felt or plaster-of-Paris case for Pig. 245. — Lordosis of lumbar spine, ^1 1 • Tf 1 r ^T- disappearing, as indicated bv the dotted the pelvis. If abscesses form, the ^^^ ^^en the thigh is flexed. joint should be opened, and the dis- eased tissue removed as thoroughly as possible, with gouge, chisel, or curette. Hip joint disease {morbus coxce, coxitis, coxalgia) without qualifi- cation means tuberculosis of the hip, although any other form of joint disease may occur in this articulation. The disease may origin- ate in any of the structures of the joint, but the primary lesion is most often in the femoral epiphysis. It is very much more frequent in children than in adults. The symptoms in the beginning are shght lameness and stiffness of the hip. Pain is present in the hip or along the inner side of the knee (both joints being suppHed by the obturator nerve), and is increased by movements of the joint. Very likely a history of tuberculous disease in the immediate ancestors, and a history of a shght injury, will be obtained. Examination reveals hmitation of the movements of the hip and slight flexion, due to rigidity of the muscles which guard the joint. With the child in the recumbent posture the lumbar spine wiU curve forwards if the knee on the affected side is pressed down to the table (Fig. 245) . Slight fullness about the joint or muscular atrophy may be observed at this time. With the 484 MANUAL OF SURGERY progress of the disease flexion increases and is associated with abduc- tion and eversion of the thigh, a position which relaxes the ligaments, increases the capacity of the joint, and thus secures the greatest comfort. If the patient stands or walks, most of the weight is borne on the sound leg, causing lowering of the pelvis on the diseased side with apparent lengthening of the limb (Fig. 246-B), and a compensa- tory lateral curve of the lumbar spine, convex towards the affected side. Flexion may be obscured by compensatory lordosis, abduction by tilting of the pelvis and lateral curving of the lumbar spine, but eversion is never masked. At this stage muscular rigidity is well marked, the pelvis moving upon any attempt to move the thigh; if the lumbar spine is made to approach the table by flexing the sound thigh on the abdomen, the thigh on the diseased side wifl rise accord- FiG. 246. — A. Abducted thigh. B. Apparent lengthening when limbs are parallel. C. Adducted thigh. D. Apparent shortening when limbs are parallel. Note the effect on the pelvis and the lumbar spine. ing to the amount of flexion present. The gluteal crease is obliterated (due to muscular atrophy and flexion) or, if present, is on a lower level than its fellow, and some fullness may be detected in the upper part of Scarpa's triangle. Pain increases, is rendered more severe by any jarring motion to the knee or foot, and is apt to wake the patient suddenly from sleep {night cries, starting pains). Abscesses may now form and point in the buttock, above or below Poupart's ligament, on the inner side of the thigh, or most frequently at the front of the great trochanter; hectic fever is thus established, and anemia and emaciation become more marked. The ligaments are softened and weakened, the limb flexed, adducted, and inverted, the pelvis elevated on .the diseased side, and the lumbar spine convex towards the sound side. Hence the hmb appears shortened (Fig. JOINTS 485 246-D) ; later, owing, to erosion of f)one or in some cases to dislocation backwards, real shortening becomes evident. Ankylosis and re- covery are possible at any period; death occurs from tuberculosis elsewhere, or in the late stages from septicemia, exhaustion, or amyloid disease. The diagnosis may be very difficult in the early stages. The patient should always be stripped and both sides carefully examined. Pain in the knee, especially in a child, always indicates a careful examination of the hip. Spinal disease, sacroiliac disease, infantile paralysis, and other conditions not immediately connected with the joint are not associated with restricted motions of the hip. In inflammation of the iliopsoas bursa there may be pain on extend- ing the hip, but after flexion the thigh may be rotated without dfs- comfort. In gluteal bursitis there may be limp and restriction of motion, but not the characteristic deformity of hip disease; in some cases fluctuation or crepitus may be obtained over the bursa. In flexion of the thigh due to intraabdominal disease, the movements of the hip are free. Any form of joint disease may occur in the hip, and if the synovial cavity is distended there will be flexion, ab- duction, and eversion. Chronic inflammation of the hip in child- hood should, however, always be regarded as tuberculous unless proved otherwise. The X-ray is of value in differentiating from dislocation and in determining the presence and extent of bone disease. The prognosis is favorable if the diagnosis is made early and the proper treatment instituted. In the later stages recovery will always be associated with shortening and ankylosis. The treatment in the early stages is rest in bed, and traction by Buck's extension apparatus to overcome muscular spasm and prevent deformity. If flexion is marked, extension should be at first in the axis of deformity, and as the muscular spasm diminishes, it may be gradually lowered to a horizontal position. Young children who are difficult to keep still should be strapped to a Bradford frame. The proper weight for traction will vary between one and six pounds or more, according to the age and the effects of the extension. The constitutional treatment is that of tuberculosis (q.v.). When the deformity has been corrected and pain has subsided, a brace may be appHed and the patient allowed to get about on crutches. Of the many mechanical appliances w^hich have been used, the Thomas hip spHnt (Fig. 247) or one of its modifications is the most useful. A patten or thick soled shoe is worn on the foot of the sound side, and the patient walks with crutches, the affected limb hanging some distance away from the 486 MANUAL OF SURGERY ground, thus acting as an extension weight. In the presence of deformity the brace may be bent to accomodate itself to the altered position of the limb. Some surgeons apply plaster-of-Paris to the limb and pelvis. Traction splints are those which may be length- ened by a sliding rod or movable foot piece, counterextension being supplied by perineal bands. A brace should be worn for six months after all symptoms have disappeared. Intraarticular injections of iodoform or other antiseptics are occasionally used. Abscesses should be tapped with trocar and cannula and injected with iodo- form emulsion. Sinuses may be injected with Beck's paste, but if they persist or recur they should be explored, and necrotic or carious bone removed by erasion. Formal resection of the hip results in immediate shortening, and in children interfere with the growth of the femur, so that it should not be performed unless the disease progresses despite other means of treatment. If excision fails, or if there is an extensive osteomyelitis of the femur, amputation will be required. The knee, with the possible exception of the hip, is more frequently attacked by tuber- culosis than any other joint. The term white swelling when used alone means tuberculosis of the knee. In children the disease usually begins in the lower end of the femur, in adults in the synovial membrane. The symptoms are those of joint tuberculosis in general. Flexion is present, and in the later stages backward dis- location of the tibia often occurs. The treatment is immobihzation with plaster-of-Paris or a traction knee splint (Fig. 248). Other conservative methods also may be employed. If the progress of the disease is not checked by these measures, or if the case is seen in a late stage, erasion or excision will be indicated. Amputation should be reserved for cases in which the disease is very extensive, or in which excision has failed. Ankle joint disease begins most frequently in the synovial membrane, next in the astragalus; it may, however, commence in the tibia or fibula, or be secondary to disease of the tarsus or tendon sheaths. The usual symptoms of joint tuberculosis are present; the foot is extended, as in this position the narrowest part of the articulating surface of the astragalus is between the tibia and fibula. Antero-posterior movements are markedly limited, but Fig. 247. — Thomas hip splint. Patten on sound limb. JOINTS 487 inversion and eversion of the foot may be made if the subastragaloid and mid-tarsal joints are free of disease. The treatment is im- mobilization in plaster-of-Paris with the foot at a right angle to the leg. Other forms of conservative treatment are also of service. In the presence of sinuses or disorganization of the joint erasion or excision should be performed. The disease is apt to invade other tarsal bones besides the astragalus and to extend into the surround- ing soft tissues; in these cases amputation will be the operation of choice. Rheumatic arthritis, when aaite, is characterized by fever, anemia, Icucocytosis, acid and sour smelling sweats, concentrated highly acid urine, and by the successive involvement of a number of joints; and it is often comphcated by sore throat, pericarditis, endocarditis, or pleurisy. The his- tory of previous attacks is often obtained. There is nothing characteristic in the local symptoms to distinguish it from infective arthri- tis, indeed, many believe it to be infective in origin, and even incision and irrigation of the joints have been recommended. For a full con- sideration of this subject the reader is referred to a book on practice of medicine, it being neces- sary in this place only to caution against a too ready diagnosis of rheumatism without a careful investigation, particularly if but one joint is l^eta^ plate involved. In the chronic variety the history, the in volvement of several joints, the presence of car- *ended^b^^*^he^%Sip diac lesions, and the detection of rheumatic over the opposite nodules on tendons or fascia, or about joints, will usually lead to a correct diagnosis. The synovial membranes and the ligaments are thickened and sometimes the cartilages eroded; grating, or crepitus, may be felt on moving the joint, and ankylosis occasionally occurs. Gouty arthritis is characterized by sudden severe pain, which often comes on during the night and attacks the smaller joints, particularly that between the great toe and its metatarsal bone. The articulation is swollen, the skin red, shiny, and edematous, and there is moderate fever. A history of previous attacks may be elicited, and other evidences of gout, e.g., tophi (chalky deposits in or around the joint), dyspepsia, and atheroma may be present. For the treatment the reader is referred to a book on internal medicine. Pig. 248. — Thomas knee splint. The is several inches below the foot. A patten is worn on the sound foot, and 488 MANUAL OF SURGERY Osteoarthritis {rheumatoid arthritis, arthritis deformans, rheu- matic gout, malum senile) is a chronic disease of joints associated with great deformity. The cause is not known. Some beheve it to be of nervous origin because of the accompanying trophic lesions, others that it is due to microorganisms because, in about half the cases, it is preceded by some infectious disease. It is more common in women, and is sometimes associated with disease of the uterus or ovaries. Traumatism is often a factor in monarticular cases; the disease is not very uncommon in the old after a Colles' fracture, or after a fracture of the neck of the femur. It may occur at any period of life, but is most frequent after middle age. The cartilages become eroded and the ends of the bones exposed, the synovial membrane and the ligaments are markedly thickened, and exostoses, or osteophytes, form about the joint, leading to ankylosis and great de- formity. Partial dislocation may occur. The disease begins in several ways: i. Heberden^s nodes are little hard knobs de- veloping on the dorsal sur- faces of the second and third phalanges, subsequently to recurring attacks ofin- eibow; note flammation in the interphal- angeal joints, which finally become ankylosed. They are most common in neurotic women between the ages of thirty and forty, and are incurable. 2. General progressive osteroarthritis begins as an acute process somewhat resembling rheumatism, or more commonly in a chronic manner. In the latter variety the joints of the hands usually swell and become tender, and with the subsidence of inflammation they creak, becoming more and more deformed with each succeeding attack. Gradually other joints are involved, until in the worst cases practically every arti- culation in the body may be affected. The muscles atrophy and by their contractures further increase the deformity. The progress of the disease is very slow, and although no remedy is known, it may be spontaneously arrested at any stage. 3. The monarticular form is the only one which concerns the surgeon. It occurs chiefly in old men and follows injury. In the hip it is known as morbus Fig. 249. — Osteoarthiritis of osteophytes and enormous lips on the ends of the bones. (MouUin.) JOINTS 489 coxce senilis, in the spine as spondylitis deformans; spondylosis ritizomelique, or ankylosis of the spine, hips, and shoulders is a form of osteoarthritis. In the early stage there are pain, stiffness, and perhaps a little swelUng and creaking in the joint. Later motion is less free, bony crepitus becomes evident, neighboring muscles atrophy, osteophytes form, and finally ankylosis occurs. Occa- sionally, however, the joint becomes loose and the bones displaced. The diagnosis is made by the chronic nature of the affection, the absence of suppuration, the deformity (lipping of the ends of the bones and osteophytes — Fig. 249) crepitus, the frequent history of injury, and the advanced age of the patient. The prognosis is unfavorable. The treatment is unsatisfactory. The general health should be improved, colds and draughts avoided, and perhaps iodid of sodium or arsenic administered. In view of the possible bacterial origin of the disease, the whole body should be reviewed for sources of infection, not forgetting the nose, accessory sinuses, ear, teeth, tonsils, rectum, colon, and genitourinary organs. When the joints are swollen and tender they should be treated like synovitis. Dur- ing the quiescent period, the hot-air apparatus, stimulating lini- ments, massage, and passive motions are useful, as they hinder the development of ankylosis. When the disease is limited to one joint, e.g., the temporomaxillary, shoulder, elbow, or knee, excision or arthroplasty may be performed if the function of the articulation is seriously disturbed. Neuropathic arthritis resembles osteoarthritis, and is the result of disease or injury of the central or peripheral nervous system. That form occurring in locomotor ataxia is called Charcot's disease. The joints of the lower extremity, particularly the knee, are most frequently affected. As the result of a slight injury, or often with- out such history, the joint rapidly and painlessly swells, and in even a few hours may be dislocated, or so freely movable that it can be bent in any direction. The disease may, however, run a chronic course and end in ankylosis. A somewhat similar joint affection occurs in syringomyelia, but the joints involved are usually those of the upper extremity, and suppuration is more frequent than in Charcot's disease. Every painless osteoarthritis should rouse a strong suspicion of syringomyelia or tabes dorsalis. The treatment of neuropathic arthritis includes that of the causative disease. In some forms massage and passive motions are indicated, but in Charcot's disease, if there is a tendency towards ankylosis, it should be encouraged. As this is seldom the case 490 MANUAL OF SURGERY some form of support will usually be required. Resection has been performed, but is not generally regarded with favor. If suppuration or extensive disorganization occurs, amputation is the best treatment. Neuralgia of joints usually depends upon some local or con- stitutional cause, although cases occur in which neither of these can be found. After injury loose bodies, adhesions, or small areas of inflammation may be responsible. It may be due to disease of the central or peripheral nervous system, or be reflect from disease or in- jury of nerve fibers coming from the same trunk that supplies the joint, and it may be associated with gout, rheumatism, syphiHs, malaria, neurasthenia, or hysteria. Like neuralgia elsewhere, the pain is paroxysmal. The treatment is that of the causative lesion, if such can be found; other cases are treated as neuralgia elsewhere. Hysterical joint (neuromimesis) is characterized by pain and tenderness, hyperesthesia or anesthesia of the overlying skin, rigidity of the joint, muscular atrophy from disuse, and absence of local heat and swelHng, unless these be present from the use of irritating apphcations. The condition is most frequent in the knee and hip, usually of young women. Some cases follow injury, others arise spontaneously. The diagnosis is made by carefully excluding all organic disease, and by finding associated symptoms of hysteria. The joint may be fixed in a position contrary to that usually assumed in disease, and be freely movable under light anesthesia or when the patient's attention is diverted. The position of the limb may vary, sometimes quite suddenly. The treatment is that of hysteria. Electricity, massage, and passive motions are use- ful, but may do harm by concentrating the patient's attention upon the joint. Hemarthrosis (effusion of blood into a joint) , apart from injury may be due to a number of causes (see spontaneous hemorrhage). In hemophiha, following a sKght injury or sometimes spontaneously, a joint becomes distended with blood, which may gradually be ab- sorbed, leaving the joint again normal, or become organized and lead to adhesions and obhteration of the joint. The history is the most important factor in diagnosis. The treatment is immobilization and compression. Massage and passive motion may be used with caution in the later stages. Under no circumstances should the joint be aspirated or opened, as such treatment migh be followed by uncontrollable hemorrhage. Loose bodies in joints {joint mice) consist of fibrin, fatty tissue fibrous tissue, cartillage, or bone. Those made of fibrin are usually JOINTS 491 small and numerous, and are best seen in tuberculosis of joints bursas, or tendon sheaths {rice bodies). Occasionally they are due to other causes, e.g., a small foreign body, blood clot, or detached synovial villus, around which the fibrin collects. Such loose bodies frequently become fibrous. Bodies which are at first pedunculated othenar eminences j (C. 7-D. i). I In a total lesion just below this segment the flexors of the wrist and intrinsic muscles of the hand are the only muscles of the upper extremity paralyzed. C. 8 Flexors of wrist. Interossei and lumbricales (C. 8-D. i). Palmar. SPINE 543 SiiGiiENT. Muscles. D. I Intcrcostals (D. 1-12). Erector spinie (D. i-L. 5). I Below this level the arms escape paralysis. RiCfLEX. D. 2-12 Rectus abdominis and external oblique (D. 5-12). Internal oblique and transversalis (D. 7-L. i). Paralysis of these muscles interferes with cough- ing, defecation and all straining movements. Severe meteorism may develop and interfere with respiration. L. I Quadratus lumborum (T>. 1-2). Cremaster. Psoas magnus (L. 1-3). L. 2 Iliacus. Quadriceps (L. 2-4). j Pectineus. Sartorius (L. 2-3). Adductors of thigh (L. 2-4). In lesions below this level the lower limbs are not completely paralyzed. Epigastric (D. 4-7). Abdominal (D. 9-12). Cremasteric (L. 1-2). L. 3 Internal rotators of thigh. Adductors of thigh (L. 3-4). Patellar. L. 4 ' Flexors of knee (L. 4-5). Extensors of ankle (tibialis anticus, etc). Gluteus medius and minimus (L. 4-5). Flexors of ankle (calf muscles) (L. 4-S. 2). Extensors of toes (L. 4-S. i). Gluteal. L. 5 i External rotators of thigh. Gluteus maximus (L. 5-S. i). Peronei (L. 5-S. 3). Flexors of toes (L. 5-S. 2). S. 1-2 Small muscles of foot. Ankle clonus. Plantar. 3-5 Levator and sphincter ani (S. 3-4). Bladder (S. 3-4). Perineal muscles (S. 4-5). In all total lesions of the spinal cord and of the Cauda equina the bladder and rectum are para- lyzed, causing retention and later dribbling of overflow in the former, and incontinence in the latter. Anal. Vesical. Erection of penis. 544 MANUAL OF SURGERY Laminectomy, or removal of the laminse of the vertebrae, may be performed for exploration, wounds or compression of the cord, section of the sensory roots, or for diseases of the bones. A straight incision is made over the spinous processes; the laminae exposed by separating the muscles from the bone with a rougine; the bleeding controlled by gauze sponges, held beneath the retractors which separate the wound; the spinous processes removed with rongeur forceps; the laminae excised with bone-cutting forceps, chisel, or saw; the contents of the spinal canal examined; the dura opened, if necessary, by a longitudi- nal incision, using the same precautions as in opening the dura of the brain; the cord examined, being very careful not to exert undue com- pression; the dura sutured with fine catgut, without drainage when- ever possible; and the muscles approximated with catgut and the skin with silkworm gut, superficial drainage being employed for twenty-four hours, or longer if there is infection. Osteoplastic resec- tion, with the base of the flap above or on one side, is more laborious and no more useful. One need not fear to make a large exposure, as such does not permanently weaken the spine. Braces or casts are seldom required after operation. The dangers of infection are no greater than in the skull, chest, or abdomen, and the escape of cere- brospinal fluid seems to do no harm. Resection of the posterior roots of the spinal cord is commonly called Foerster's operation, although it was lirst suggested by Dana. The operation has been performed for intractable pain of various sorts, including the gastric crisis of tabes, and for athetosis, spastic paraplegia, and other forms of spasticity, the idea being to break the reflex arc of the affected muscles. Laminectomy is performed, the dura opened, and the roots isolated separately and divided. The location of the pain or the spasticity determines the roots to be sacrificed. In order not to induce complete anesthesia and flaccidity in the affected region, not more than two of the three sensory roots presiding over a given area should be severed. For spastic paraplegia Foerster advises division, on both sides, of the second, third, and fifth lumbar, and the second sacral. The seventh to the tenth dorsal roots on both sides have been divided for gastric crises in locomotor ataxia. Other combinations can be worked out from Fig. 271 and the table on p. 541. The operation has given satisfactory results in some cases; in others it has not secured the desired result. In at least one case a Brown-Sequard paralysis followed. Spinal puncture (subarachnoid) may be made anywhere between the lower end of the cord and the lower end of the dural sac (Fig. 270), but the favorite spot is just below the fourth lumbar vertebra. The SPINE 545 back is bent forward, the left index finger placed on the selected spinous process, the needle (three or four inches long, i to 2 mm. in diameter, and containing a stylet) entered just below and to the out- side of the finger and pushed slightly inwards and upwards for from 3^^ to 3 inches, according to the age of the patient and the thickness of the tissues, the stylet withdrawn, and the fluid collected in a sterile test tube. Spinal puncture has been employed for anesthetic (see anesthesia) therapeutic, and diagnostic purposes. The therapeutic indications are to relieve pressure, e.g., in cerebrospinal meningitis and compres- sion of the brain, and to inject medicaments, e.g., antitoxins, salvar- sanized serum, etc. For diagnostic purposes not more than 5 cc. of the fluid in a child, 10 cc, in an adult, should be withdrawn, as a few cases of collapse after the withdrawal of a large quantity have been reported. Headache and a rapid fall in the spinal fluid pressure are indications to stop the procedure. A dry tap usually indicates that the needle is not within the dural sac. Normal cerebrospinal fluid is clear, colorless, alkaline, has a specific, gravity of from 1002 to loio, and contains chlorids, a trace of protein, o.i per cent, of glucose (or dextrose), and very few leukocytes and endothelial cells (from I to 10 per c. mm.). It escapes, when the patient is recumbent, under a pressure of from 5 to 7.5 mm. of mercury. The specific gravity is increased in meningitis, the pressure in meningitis and all forms of compression of the brain (except when the fluid accumulates above a closed foramen of Majendi or aqueduct of Sylvius, or when the communication between the subarachnoid spaces of the brain and cord is obstructed) , the protein in meningitis, hydrocepha- lus, acute infectious diseases, subarachnoid hemorrhage, and in syphihtic and parasyphilitic affections of the cerebrospinal tract. Noguchi's globulin test is positive in meningitis and cerebrospinal syphilis. Glucose disappears early in meningitis, "due to autolysis controlled by leukocytic ferments, the glucose being converted into lactic acid" (Kopetsky). The Wassermann test of the fluid is positive in nervous syphilis, as in the Lange or colloidal gold test. Microscopic examination for cells (cytodiagnosis) may reveal a large number of polynuclear leukocytes (suppurative meningitis), lymphocytes (tuberculous and epidemic cerebrospinal meningitis — moderate lymphocytosis may occur in superficial tumors and syphilis of the brain or cord, in alcoholic meningitis, in uremia), or erythro- cytes (fracture of the skull or spine, subdural hemorrhage, hemor- rhagic meningitis). In the last instance the fluid should be collected in two tubes, and only that in the second one examined. Bacterio- 3.5 546 MANUAL OF SURGERY logic examination may discover the organism responsible for a meningitis, f q.v.) , for poliomyelitis, or for sleeping sickness (trypano- soma Gambiense). INJURIES OF THE SPINE Sprains of the spine are caused by falls, twists, and violent shocks when, as in a railway accident, the muscles are not on guard. The pathology is that of sprains elsewhere. The symptoms are pain, tenderness, and rigidity. Fracture without displacement and with- out nervous symptoms might give identical symptoms, and the author has seen several cases in which a correct diagnosis could be made only by an X-ray examination. In a strain of the back, such as is produced by heavy lifting, the lesion is in the muscles, not in the joints. Sprains are rarely serious, although they are occasionally followed by bleeding into the spinal canal, extension of the inflam- mation to the meninges, traumatic neuroses, or, in those so predis- posed, by spinal caries. The treatment is local applications as in sprains in other parts of the body, and rest in bed in the severer cases. Concussion of the spinal cord is caused by blows or falls which shake or jar the cord. Theoretically at least, no anatomical change is produced. When minute hemorrhages or like lesions occur, the term contusion is applicable. Concussion is becoming rarer with improved methods of investigation, and some have doubted even its existence. The author, however, has seen two cases of gunshot wound, close to but not invoh'ing the dorsal cord, in which there were t\'pical symptoms of a total transverse lesion, but in which autopsy revealed no anatomical changes in the cord. The symptoms are those of shock, and usually a limited, incomplete, and transient interference with sensation and motion, although, as noticed above, they may be those of a total lesion. After any injury to the cord the reflexes may be absent, at least for a time. The prognosis in the mildest cases is good, the symptoms disappearing within a few hours or days. If the symptoms are severe and persist, the condition is probably one of contusion or compression rather than concussion. Neurasthenia, hysteria, or organic cord disease may follow even the sKghtest cases. The treatment is reaction from shock and rest in bed. If compression is suspected, laminectomy may be indicated. Traumatic neuroses may occur after any injury or severe mental shock, but are most frequently the result of sprains of the spine or concussion of the cord due to railway accidents, hence the term ''railway spine;" when following an injury to the head the condition has been termed ''railway brain."' The symptoms^ which may closely SPINE 547 follow the accident, or be delayed for hours or even days, are those of neurasthenia {traumatic neurasthenia), hysteria {traumatic hysteria), or hystero-neurasthenia, and are identical with those occurring in non-traumatic cases, for which the reader is referred to a text-book on medicine. Other nervous affections, such as neurotic diabetes, paralysis agitans, chorea, exophthalmic goiter, tabes, myelitis, and similar inflammatory and degenerative processes, may follow acci- dents such as have been described above. The diagnosis of traumatic neuroses requires great care, first to rule out organic disease, secondly to detect malingerers who feign disease in order to secure damages. The prognosis is generally favorable. The treatment is that of non- traumatic neurasthenia and hysteria. Compression of the spinal cord develops suddenly in fractures, dislocations, foreign bodies, and intramedullary hemorrhage; more slowly in extramedullary hemorrhage (within twenty-four or forty- eight hours), inflammatory exudate, e.g., in acute spinal meningitis (in the course of several days), and pachymeningitis (a week or longer) ; and very gradually in tumors, cysts, aneurysms, callus formation, cicatrices, etc. The symptoms and the means of determin- ing the level of the lesion have already been considered under spinal localization. The treatment varies with the nature and cause of compression, and will be given when the individual forms are discussed. . Fracture of the spine is caused by direct, or much more fre- quently by indirect violence. In the former the break is situated at the point struck and the arches are particularly liable to sufifer, a spicule of bone often being driven into the cord. In the latter the injury is usually due to hyperflexion of the spine, such as occurs when a man dives into shallow water, falls from a height on the feet or buttocks, or is doubled up by the caving in of an embankment, the vertebral column generally breaking at the junction of a freely movable with a comparatively fixed portion, i.e., in the cervico-dorsal (most frequent) or dorso-lumbar region. The bodies of the vertebrae, with or without the arches, are broken, and the upper segment usually displaced forwards (fracture-dislocation) , thus contusing or compressing the cord. The muscles, ligaments, and membranes may be torn, and blood may collect between the bone and the membranes, or between the membranes and the cord. The symptoms are (i) shock of varying degree; (2) local evidences of fracture, such as pain, sweUing, tenderness, usually deformity and possibly crepitus; and (3) interference with the functions of the cord, due to concussion, contusion, or compression, i.e., more or less 548 MANUAL OF SURGERY complete paralysis and anesthesia below the injury, with decrease or abolition of the reflexes, and trophic changes (see spinal localization). Without displacement, cord symptoms may be absent, and in some cases the diagnosis can be made only by the X-ray. In seven cases at the Jefferson and Pennsylvania Hospitals careful X-ray examinations failed to show fractures revealed at operation. Paralysis coming on after a short interval may be due to edema of the cord, extramedul- lary hemorrhage, inflammatory exudate, or secondary displacement of bone. The symptoms of complete transverse destruction of the cord have already been given. Incomplete destruction may be diagnosticated when there is incomplete paralysis, partial anesthesia, and retention of the reflexes in the parts supplied by the cord below the injury; not infrequently, however, the symptoms will be identical, sometimes for several days or longer, with those of a total transverse lesion. The prognosis in all cases with total paralysis and complete anesthesia is distinctly unfavorable, both regarding life and return of function. The higher the lesion the worse the prognosis. Death occurs immediately from shock or interference mth respiration (in the upper cervical region) ; during the first week from suffocation with mucus (in the lower cervical region) or from meningitis; or after weeks or months from exhaustion and sepsis the result of extensive bed sores, cystitis, or pyonephrosis. With even a completely divided cord, however, life may be prolonged for years if the injury is in the dorsal or lumbar region. The treatment is first reaction from shock. Whether or not operation has been decided upon, the patient should be placed on an air or water bed and most carefully nursed to prevent bed sores. The bladder should be catheterized every eight hours, or more often, with the most rigid aseptic precautions to prevent cystitis. Massage and electricity should be employed to maintain the nutrition of the paralyzed parts. Attempts to effect reduction by extension and pressure, without operative exposure of the parts, are too dangerous to be recommended. Excepting fractures in the cervical region, sand bags, plaster casts, etc., are seldom required to immobilize the parts. There is no general agreement as to the indications and time for operation. Many neurologists and a few surgeons doubt the value of laminectomy in any case. This condition of aft"airs is due to the difficulty of differentiating concussion from compression, and to the teaching that the tissues of the cord are incapable of regenera- tion; the latter is true w^th regard to the brain, however, but does not deter surgeons from operating early and radically in fractures of the skull. The author's views, which are not those generally SPINE 549 adopted, arc as follows: Fractures of the spine should be treated like fractures of the skull, i.e., for (i) disinfection; (2) depression, and (3) compression, i. All compound fractures must be disinfected. 2. Obvious depression of the laminae will often be associated with symptoms of compression, but even in the absence of such symptoms, the depressed bone should be removed, because of the danger of injury to the cord by displacement of the fragments during subsequent treatment, and because of the danger of pressure from callus on the cord or nerve roots at a later period. 3. All fractures, whether simple or compound, with symptoms of compression require laminectomy as soon as shock has subsided, unless in the meantime the symptoms have distinctly ameliorated. The more severe the symptoms the more impera- tive the operation. It is true that at this period one cannot always be sure whether the symptoms are those of con- cussion, contusion, or compression, but pure concussion is rare, and contusion with its subsequent edema can only be benefited by the drainage of operation. The compressing agent (bone, blood clot, foreign body) should be removed before the onset of secondary degeneration. Removal of the posterior arches may be p^^ 272.-Diagram of frac- all that is required, or compression may ture-disiocation of the 'spine, , ., . , 111 r showing compression of the cord be caused likewise by the body of a verte- by the lamina of the 9th dorsal bra (Fig. 272), in which case reduction I'^'^^^lt i^'^' T'^^Ju^^lf^ n ^ o I ■> y ^ ^ the I oth dorsal vertebra (B). • C. maybe attempted by extension and direct Spines in same case as felt from pressure, or failing in this, the projecting edge of bone should be bitten away with rongeur forceps, taking care not to contuse the cord. If the dura is distended or bluish and no pulsation can be detected, a subdural clot exists, and such should be removed. If the spinal sheath seems empty, the dura should likewise be opened and the divided cord, for such will probably be found, sutured with catgut (see also wounds of the cord). Operation is not indicated in simple fractures without obvious depression or cord symptoms, or in simple fractures with cord symptoms which are improving. Dislocations of the vertebrae without fracture are extremely rare and confined almost exclusively to the cervical region, usually the lower half. The upper vertebra is called the dislocated one contrary to the custom when speaking of dislocations elsewhere. 55° MANUAL OF SURGERY The usual cause is hyperflexion, both articular processes of the upper vertebra passing in front of those of the lower vertebra, i.e., a com- plete bilateral anterior dislocation (Fig. 273). Bilateral posterior dislocation ma}' be caused by hyperextension, unilateral dislocation by forcible approximation of the head and shoulder combined with rotation. Incomplete dislocation also may occur (Fig. 274). The ligaments and intervertebral discs are torn, and in complete bilateral cases the cord is almost always compressed, usually causing, in the upper cervical region, immediate death. In many incomplete or unilateral cases, the cord may escape pressure by bone, although it may still be compressed by blood clot, and the nerve roots may be stretched or torn, causing neuralgia, etc. In forward dislocations the head is displaced forwards and bent towards the chest. In backward dislocations the head is displaced backwards and the face turned upwards. In unilateral dislocations the head is bent towards Fig. 273. — Complete dislocation. (Marion.) Fig. 274. -Incomplete dislocation. (Marion.) the sound shoulder. The deformity may be felt externally or through the pharynx, and demonstrated with the X-ray; in any case there is likely to be difficulty in swallowing. The treatment of unilateral and incomplete dislocations is reduction, under an anesthetic, by traction and approximation of the head towards the sound shoulder to unlock the processes, then rota- tion of the head, the ear on the sound side moving forwards. In long standing cases reduction cannot be effected, but operation may be undertaken to reheve pressure on the spinal nerves. Bilateral dislocations may be reduced by bending the head towards the right shoulder and rotating the head (the right ear being carried forward) , thus converting the dislocation into a unilateral one, which may be reduced by reversing the movements just described. These manipu- lations are so dangerous, that it is probably best to relieve pressure by at once removing the laminae of the dislocated vertebra, and then reducing the bones under the guidance of the finger and eye. If sufficient traction cannot be exerted to unlock the processes, as little as possible of the upper margin of the upper articular processes of the lower vertebra should be removed to permit reduction. SPINE 551 Removal of the whole process would, of course, permit recurrence which however, might be prevented by fixing the spinous processes with a transplant from the spine of the scapula. The dura may be opened to remove coagulated blood. Wounds of the spinal cord are usually the result of stabs or gun- shot injuries. There may be complete paralysis below, or if half of the cord is divided, loss of motion on the same side and anesthesia on the opposite side, or again the injury may be limited to the nerve roots. It is generally taught that regeneration of the cord never occurs. The treatment is laminectomy, removal of foreign bodies and com- minuted bone, and suture of the wound of the cord and of the severed spinal nerves with catgut. The dura should be closed whenever possible. Probes should never be employed to explored the wound. In the cervical region it may be necessary to tie the vertebral artery. Intraspinal hemorrhage may be extradural, subdural, or intramed- ullary. It is usually the result of injury, but may be due to other causes, e.g., acute infectious fevers, convulsions, rupture of aneu- rysms, etc. In extra- and subdural hemorrhage {heviatorrhachis) the symp- toms are pain in the back and irritation of the nerve roots (pain hyperesthesia, and spasms in the parts supplied by the affected nerves), followed by symptoms of compression, the paralysis and anesthesia coming on suddenly, or perhaps slowly from below up- wards as the blood increases in amount. Complete recovery may occur in traumatic cases. The treatment, excepting the milder forms, is, in the early stages when the blood is still fluid, spinal puncture, and at a later period laminectomy and removal of the clot. Intramedullary hemorrhage {hem atomy elia) is most frequent in the lower cervical region. The symptoms are sudden paralysis and anesthesia of the parts below, and intense pain in the back. The lesion may be unilateral (paralysis on one side, anesthesia on the other), or if the bleeding is slight, signs of irritation may be present. but are not so common as in extrameduUary hemorrhage. The usual treatment is that of concussion. DISEASES OF THE SPINE Spina bifida (jachischisis) , or failure of the spinal laminae to unite, is present in about one in every 1,000 children born. Sometimes there is a small congenital gap in the spine, the cord and membranes remaining in the canal {spina bifida occulta) ; the skin is frequently indented over this defect and the dimple filled with hair. These 552 MANUAL OF SURGERY cases need no treatment unless there are symptoms of pressure on the cord, when the removal of such compression, which may be due to hypertrophy of the skin and subjacent soft parts, would be indicat- ed. In 2 per cent, of the cases the cleft is wide, the skin is absent, and the cord protrudes through the opening, its central canal com- municating with the surface of the body {myelocele) . This condition is not compatible with existence. In lo per cent, the membranes alone escape through the opening {meningocele), but in the vast majority (about 75 per cent.) there is also a portion of the cord in the protuberance {meningomyelocele), and very rarely the tumor is the result of a dilatation of the central canal of the cord {syringomyelocele) . The last variety is often situated laterally. More than one vertebra is usually fissured, and cases have been reported in which all the vertebrae were involved. Rarely the body of the vertebra is implicated {anterior spina bifida). One- half of all cases occur in the lumbar region, and more than one-third in the lumbosacral or sacral portion of the spine. Diagnosis. — The swelling is congenital, almost central, and partly reducible, pressure causing the fontanelles to bulge and some times producing con- vulsions or other nervous symptoms. Palpation and the X-ray reveal the cleft, and there is bulging on crying or coughing. Translucency may be de- tected, with the cord or nerves represented as shadows. There may be other developmental de- PiG. 275.— Spina fects, such as hare-lip and talipes (Fig. 275), and as bifida and club foot, ^i ^^ c • i ^•.• r .^ (Kirmisson.) the rcsult ot comprcssion or abnormalities of the nervous elements, anesthesia, paralysis or trophic changes may be found below the cloven spine. The prognosis is bad, although spontaneous recovery may occur in rare instances when the opening is small and the skin thick and healthy. Death is due to marasmus, to the sequelae of paralyses, or to meningitis following rupture or inflammation of the sac. The treatment, if operation is not decided on, is protection of the sac by collodion or a suitable cap, in order to prevent rupture. Morton's fluid (iodin gr. 10, potassium iodid gr. 30, glycerin i oz.) may be injected in the dose of 2 dr., repeated in ten days if necessary care being taken during the injection to obliterate the neck of the sac as much as possible by compression. This plan has so often been followed by sloughing and rupture of the sac, by convulsions and meningitis, and by paralysis and hydrocephalus (mortality 40 per SPINE 553 cent.), that most surgeons j)refer excision (mortality 2>, percent.). The lumbar region in infants is so difficult to keep clean that opera- tion should be postponed as long as possible. If the skin is thin, or threatens to ulcerate, or if the tumor is enlarging, operation becomes imperative. An elliptical incision is made about the tumor, and the sac opened laterally by a small transverse cut, in order to avoid the cord, which may be adherent in the middle line, and the nerves which run at right angles to it. If no nervous tissues are present, the sac is removed and the opening sutured with catgut. If nervous struc- tures are present, they are separated from the sac; if intimately ad- herent, that portion of the sac in which they are incorporated may be reduced with them into the spinal canal. The muscles on each side are then loosened, sutured together, and the skin closed. The bony defect has been closed bv drawing the remnants of the laminae, if Fit.. 276. — Sacrococcygeal teratoma. present, over the gap; by swinging a flap of bone, attached by its peri- osteum, from the outer table of the ilium; by a bone graft, such as the scapula of the rabbit; and by foreign substances, such as a plate of celluloid; procedures of this character are rarely necessary. Recurrences sometimes occur and hydrocephalus may follow. Congenital sacrococcygeal tumors occur on the dorsal or ventral surface. Lipomata may communicate with the interior of the spinal canal, dermoids with the rectum, bladder, , or spinal meninges. Cystic tumors containing a myxomatous material and developing between the rectum and sacrum originate in the remains of the postanal gut, or neurenteric canal (the canal which connects the neural and enteric tracts in early fetal life). Teratomata (Fig. 276), sarcomata, and spina bifida constitute the remaining congenital tumors in this region. The treatment is removal; it may be necessary to excise a portion of the sacrum or split the posterior wall of the rectum. 554 MANUAL OF SURGERY Sacrococcygeal fistulas or Pilonidal sinus are the result of imper- fect coalescence of the skin, or persistence of the postanal gut. The simplest form is the postanal dimple. Others may communicate with the rectum or spinal canal. The treatment is excision unless the condition gives no trouble. Spinal curvatures include scoliosis, kyphosis, and lordosis. Scoliosis, or lateral curvature, rarely involves the spine in one curve {total scioliosis) ; as a rule there are two or more lateral curves with their convexities in opposite directions (Fig. 277). Lateral deformities of the spine due to caries, fracture, tumors, etc., are not placed under this heading. The causes are rickets; asymmetry, the result of shortness of one leg, empyema, torticollis, etc,; faulty post- ures, the result of habit (e.g., standing on one leg), occupation (e.g., constantly working a lever with one hand or foot), or disease (e.g., sacroiliac disease) ; and central nervous diseases, producing unilateral atrophy or spasms of the muscles. The most common form is the scoliosis of adolescence, due to relaxed muscles and hgaments which do not develop as rapidly as the spine. One of the causes men- tioned above may be a contributing factor. The patients are usually anemic girls, easily fatigued, and frequently assuming attitudes of rest, e.g., standing with the weight resting on one leg or lounging in a faulty position. Symptoms and Pathological Anatomy. — In the usual variety the lumbar spine becomes convex towards the left, and later a compen- satory dorsal curve with the convexity to the right develops; there may or may not be an associated kyphosis. The vertebral column not only deviates laterally, but is twisted in a spiral direction, the spines rotating towards the concavity, so that they do not give, an accurate indication of the degree of curvature. The ribs on the right side are separated, more horizontal, and bent at their angles; the shoulder is raised, the scapula more prominent, and the front of the chest flattened. On the left side the ribs are crowded together and their angles are more obtuse, so that the shoulder is lower, the scap- ula less prominent, and the chest projects anteriorly. The sternum moves towards the concavity and faces the convexity. In the worst cases the thoracic and abdominal viscera are displaced. The left hip projects and the waist on the right side is more marked. In the initial stages the deformity disappears on bending forward, or on hanging from a bar, but in the fixed stage when the bones have be- come altered in shape this is im.possible. Malaise, backache, inter- costal neuralgia, dyspnea, and dyspepsia may annoy the patient. The prognosis is good if the cause can be removed and the spine SPINE 555 Pig. 277. — Scoliosis. (Philadelphia College of Physicians.) 556 MANUAL OF SURGERY straightened by extension. In the later stages improvement may be obtained or at least the progress of deformity interrupted. The treatment is removal of the cause when such is possible, the correction of vicious attitudes, massage and electricity to the weak- ened muscles, and gymnastic exercises, such as swinging from a bar, riding a bicycle with an inclined seat, balancing a light weight on the head, placing the hands together above the head and bending for- wards, etc. The general health should receive attention and the patient should rest in the recumbent posture daily. Braces and supports tend to weaken the muscles, and are employed only when deformity is advancing despite other treatment. In suitable cases Abbott's method seems to offer the best prospects for complete re- covery. The patient lies with the back flexed in a canvas hammock. Straps are passed around the body in various directions, and fastened to a frame of gas pipe, the bars of which are rotated, thus winding up the straps, until the deformity is corrected as far as possible. A plaster-of-Paris jacket, with pads arranged to maintain the correc- tion, is then applied. After the plaster has hardened windows are cut in the jacket posterolaterally over the site of the previous con- cavity of the spine, and anterolaterally over the site of the previous convexity. Through these windows felt pads are introduced to gradually increase the amount of correction. The casts are changed every four to six months, until overcorrection is obtained. The patient then wears a celluloid jacket, except when taking exercises to strengthen the muscles, until there is no longer any tendency toward recurrence of the deformity. Kyphosis, or dorsal convexity of the spine, may involve the whole column, as is physiological in infants, but is usually confined to the dorsal region and may or may not be associated with a compensatory lumbar lordosis. The causes are rickets; faulty postures, the result of habit (as in piano playing), occupation (cobblers, tailors, etc.) or disease (myopia, dyspnea, asthma, emphysema and chronic abdominal disease) ; afections of the spine, such as tuberculosis, syphilis, malignant growths, aneurysmal erosion, osteoarthritis, ostitis deformans, osteomalacia, hypertrophic pulmonary osteoarth- ropathy, and acromegaly; /mc/z/r^5; and senile atrophy. The round shoulders of adolescence occurs in the same type of patients as the scoliosis of adolescence. The treatment varies with the cause; many of the forms mention- ed above cannot be remedied. In adolescence round shoulders may require the correction of myopia or the removal of adenoids. Vicious postures should be corrected, and the muscles strengthened by SPINE 557 massage, electricity, and exercises; rest should be taken on a hard mattress, with a pillow beneatii the deformit)'. If the deformity is progressive, a brace may be required. Lordosis, or anterior curvature of the lumbar spine, is compensa- tory in kyphosis, large abdominal tumors, pregnancy, etc. The most common cause is fixation of the hip in flexion, e.g., in congenital or unreduced dislocations and in hip disease or ankylosis. It occurs also in rickets, caries of the posterior part of the vertebral bodies, progressive muscular atrophy, pseudohypertrophic paralysis, and spondylolisthesis. The treatment is removal of the cause when such is possible. Spondylolisthesis is a rare condition confined almost exclusively to the lumbosacral joint. As the result of imperfect development or fracture of the articular processes, the spinal column slips downward and forward from the sacrum, thus causing marked lordosis and shortening of stature. The treatment is extension in the recumbent posture. If the patient sits up or w^alks, a brace will be needed to convey the weight of the body to the pelvis. Ryerson treated one patient successfully by splinting the spine with a bone graft. Spondylitis deformans is osteoarthritis of the spine w-hich results in locking of the vertebrae by osteophytes. There .are pain and ten- derness, with kyphosis and perhaps pressure on the nerve roots. The treatment is that of osteoarthritis elsew^here. Braces are occa- sionally required to prevent increase of deformity. T3rphoid spine is a term applied to a periostitis or ostitis following t>^hoid fever. There are pain, tenderness, and weakness of the spine, with muscular rigidity. Suppuration rarely occurs. The treatment is a plaster cast or leather jacket, and later massage and electricity. Acute osteomyelitis of the vertebrae is uncommon and is due to the same causes as osteomyelitis elsew^here. When the arches are in- volved the condition is easily recognized, but when the bodies are aft'ected the diagnosis is often difficult, the condition being mistaken for typhoid fever, peritonitis, etc. The infection may spread to the meninges, the symptoms then being those of meningitis. The symp- toms are acute pain and tenderness, rigidity of the spinal muscles, and the constitutional symptoms of sepsis. The abscess may appear posteriorly or anteriorly (retropharyngeal, mediastinal, lumbar, or pelvic). The treatment is that of osteomyelitis elsewhere, viz., in- cision and drainage, and at a later period removal of the sequestrum. Tuberculosis of the spine (Pottos disease, angular curvature, spondylitis) may occur at any period of life, but is most frequent 558 MANUAL OF SURGERY between the sixth and tenth year. Heredity, impaired health, poor hygienic surroundings, and injuries, often shght in nature, provide a favorable soil for the tubercle bacillus. The disease may occur in any portion of the spine, but is most frequent in the lower dorsal region. The pathology is that of tuberculous bone disease elsewhere. The starting point is usually on the anterior surface of the body just beneath the periosteum, or at the upper or lower epiphyseal Hne; the posterior arches are rarely involved primarily. The cancellous bone of the body is gradually destroyed, and the disease spreads to neigh- boring vertebrae beneath the anterior common ligament, or by disin- FiG. 278. — Dorsolumbar Pott" s disease, with section of vertebrae showing absorption of bodies. (Young.) tegrating the intervertebral cartilages. Caseous changes occur, and pus forms, and burrows in the direction of least resistance. Caries without suppuration {caries sicca) and caries with the forma- tion of sequestra {caries necrotica) occasionally occur. Owing to the destruction of the bodies of the vertebrae, the spine bends and a posterior angular deformity is produced (Fig. 2 78) . The spinal cord is occasionally involved. Cure is effected by the formation of new bone, ankylosis of the vertebrcC, and the organization or calcification of the surrounding inflammatory tissue. The local symptoms are pain, rigidity, deformity, abscess, paraly- sis. Pain is rarely severe, indeed may be absent. It is increased by SPINE 559 local pressure, movements, and jarring of the spine. \\ hen the nerve roots are irritated the pain is referred to the area supplied by these nerves. Rigidity in the early stages is due to muscular spasm, which is nature's effort to protect the diseased part. In the convalescing stage immobility of the spine is due to ankylosis. Movements of the spine are instinctively resisted. The patient walks like a marionette, refuses to jump, stoops by bending the knees and hips and not the back, turns around by moving the whole body as a unit instead of rotating the spine (particularly in cervical caries), and when sitting takes the weight of the upper part of the trunk from the diseased vertebrae (lower dorsal or lumbar caries) by grasping the arms of the chair. The hardening of the muscles is easily appreciable to the fingers. Deformity varies in nature and degree according to the location and extent of the disease. In the early stages a slight lordosis in the cervical or lumbar region may be caused by muscular spasm, very rarely by caries of the posterior part of the vertebral body. Disease of the arches does not produce deformity. When the disease affects one side more than the other and lateral curvature occurs, the torsion of the vertebrae is in the opposite direction to that of scoliosis, i.e., the bodies occupy the concave side of the curve. Posterior angular deformity is the typical one; the more vertebrae involved the more obtuse the angle. In the cervical and lumbar regions the spine necessarily becomes straight before posterior de- formity can occur; in the former situation it is rarely marked. Com- pensatory curves form in the remaining parts of the spine, and when the dorsal vertebrae are badly deformed secondary changes in the shape of the thorax occur. Abscesses occur in the later stages, and owing to their deep origin usually attain a large size and travel a long distance before being recognized. In the cervical region the pus collects behind the posterior pharyngeal wall (chronic retropharyngeal abscess, see pharynx). In the upper dorsal region the abscess usually perforates the intercostal structures and appears posteriorly (dorsal abscess) ; rarely it comes to the surface at the base of the neck. In the lower dorsal or the lumbar region the pus passes backwards (lumbar abscess), or enters the psoas sheath (psoas abscess) and gravitates downwards, either forming a large swelling in the iliac region or pointing below Poupart's ligament, usually external to the femoral vessels. A psoas abscess may, however, come to the surface on the inner side of the vessels, on the inner side of the thigh, or even as low as the heel; occasionally it bursts into the rectum, bladder, vagina, or on the perineum. Paralysis is not frequent (about 7 per cent.) and occurs only in the later stages. It is rarely sudden in 56o MANUAL OF SURGERY onset, and is then probably due to displacement of bone. As a rule it appears slowly as the result of compression of the cord by tuber- culous masses or pus, or most commonly pachymeningitis. Sensa- tion is affected later. The constitutional symptoms are those of tuberculosis elsewhere. The diagnosis may be difhcult before the onset of deformity. Localized tenderness and rigidity are the most important symp- toms in this stage. The reflected pains may be mistaken for pleurisy, abdominal disease, neuralgia, rheumatism, etc. Angular de- formity may be caused also by syphilis, malignant growths, and aneurysmal erosions. In kyphosis due to other causes, the deformity is usually a long curve rather than a limited angular projection, and rigidity is generally absent. Flexion of the hip due to psoas abscess should not be mis- taken for hip joint disease, and it should be recalled that psoas abscess may be due to other causes than tuberculosis, as may also abscesses in the other regions indicated above. The osseous lesion can almost is a \ever%ith^its iuicrum always be demonstrated with the X-ray; point at small F The arrow the tubcrcuHn test is Occasionally of service. on the vertebral bodies at 2, 2, indicates lines of force from The pTOgnosis is good in children who ruSspt3;.:?:Ce"cS ="-e efficiently treated from the beginning. crushing of vertebral bodies The higher the discase, the more vertebrae and progress of deformity by . ^- ^ ^1 the approximation of the mvolved, and the older the patient, the anterior lever arms which is ^^.^^^^ ^^^ prOgnOsis. AbsCCSSCS which be- associated with an equal sepa- ^ ° ration of the spinous processes come infected with pyogeuic organisms or the posterior lever arms; i ., • r i j^ ^ • ^ • ^ this is prevented by a pull causc hcctic fcvcr and cveutuate m amyloid lengthwise on the graft as in- discascunless the iufcction cau be controlled. dicated by the small arrows situated at each spinous proc- Paralysis is a gravc Complication, but with Sl;dJection''offo''rc?Sundlr Suitable treatment may entirely disappear, a great mechanical ad- Death is usually the rcsult of cxhaustion, vantage. (Albee.) • ^ i i • 1 i • i sepsis, tuberculosis elsewhere, involvement of the cord or meninges, or an intercurrent malady. Sudden death from dislocation may occur in disease of the atlas or axis. The treatment is local and constitutional. For the latter see tuberculosis. The local treatment is (i) rest, (2) correction of de- formity, (3) evacuation of abscesses and possibly removal of diseased SPINE ;6i bone, and (4) the care of i)aralysis if il should occur. Local applica- tions are useless, and blisters and the actual cautery may be harmful in predisposing to bed sores, i . Rest is best obtained by the recum- bent posture and the application of extension. In cervical caries extension is applied to the head only (Fig. 280), the head of the bed being slightly elevated, and sand bags being used to prevent lateral motions. In the lower dorsal or lumbar region extension should be applied also to the legs. Restless children may be fastened to a Brad- ford frame in which an opening has been provided for the discharges from the bowels. After a number of months when the pain and acute symptoms have subsided, or even before in adults or in children who do not stand bed treatment well, a plaster cast or a leather brace should be apphed and the patient allowed to walk about. Sayre's plaster jacket is applied as follows: An armless undershirt, of wool or stock- Fig. 280. — Head_extension^for Pott's disease. (Young.) ingette reaching below the iliac crests, is put on the patient, who is sus- pended from a tripod (Fig. 281) with the toes just reaching the ground; instead of using the axillary straps the patient may grasp the cross bar above. In some cases the cast should be applied in the recum- bent posture while extension is being made. A folded towel is placed over the epigastrium, and this ''dinner pad" is withdrawn after the plaster has set; padding is placed also over the posterior deformity, the iliac crests, and the breasts. Plaster bandages are now applied about the trunk from the axillae to below the iliac crests. In disea;se above the middorsal region it will be necessary to apply a jury mast (Fig. 282), or to include the neck in the plaster bandage, so as to take the weight of the head from the body. The cast may be split down the front and provided with hooks for lacing, so that it may be re- moved and reapplied from time to time, or a new cast may be ap- plied every two or three months. The cast or a suitable leather or 562 MANUAL OF SURGERY felt jacket should be worn for at least six months after the patient is apparently cured. In order to secure ankylosis, the spinous processes of the vertebrae may be split longitudinally and a segment of the crest of the tibia (Albee), or of the vertebral border of the scapula (Ombredanne) implanted into the osseous wound. 2. Deformity when recent may be gradually corrected by exten- sion, and gentle pressure over the gibbosity, either by means of a pad left in place or by daily pressure with the hand. In old cases after ankylosis has occurred, removal of the spinous processes may be indicated. Forcible correction at one sitting, first proposed by Chipault, who also wires the spinous processes together to maintain the reduction, is often called Calot's method because of the enthusi- FiG. 281. — Sayre's tripod. Fig. 282. — Sayre's jury mast. asm with which he has advocated it. Most surgeons consider the method dangerous. 3. Abscesses should be evacuated when detected. The general principles of the treatment of chronic abscess have been considered in chap, vii, and the treatment of retropharyngeal abscess will be described under diseases of the pharynx. In abscesses due to disease of the posterior arches, a free incision should be made, the diseased bone removed, and the cavity disinfected and packed with iodoform gauze. Dorsal, lumbar, and psoas abscesses should be incised at the point where they are nearest the surface, the pyogenic membrane and cheesy masses removed by curetting with a piece of gauze on a long pair of forceps, the cavity irrigated with salt solution and in- SPINE 563 jected witli iodoform emulsion, and the wound closed with sutures. Some surgeons prefer to tap with a trocar and cannula, but irrigation is unsatisfactory through a cannula and removal of the debris is impossible. These operations may have to be repeated. If diseased bone is found it should be removed. Treves^ operation may be per- formed in disease of the twelfth dorsal or any of the lumbar vertebrae. An incision is made along the outer edge of the erector spinae from the last rib to the crest of the ilium, and the tissues divided until the quadratus lumborum is exposed, which with the underlying fascia is cut transversely to avoid the lumbar arteries. The abscess is opened, irrigated, the pyogenic membrane excised, diseased bone removed with forceps or chisel, and the wound closed with sutures. If pyogenic infection is present, the wound should be left open, sterilized with chemical antiseptics and then closed according to the technic of secondary suture. Similar operations have been per- formed in the cervical and, after resection of the ribs, in the dorsal regions. 4. Paralysis is treated by extension and gentle pressure to correct "the deformity, care being taken to preserve nutrition, prevent bed sores, cystitis, etc., as indicated under fracture of the spine. As compression of the cord is usually caused by pachymeningitis, and as recovery frequently follows this treatment, laminectomy is employed only when the symptoms persist or increase after months or even a year of extension, when the patient's life is threatened by sepsis the result of cystitis or bed sores, when the posterior arches are diseased, or when the compression is acute in onset, indicating bony displace- ment. Spinal meningitis extends from the membranes of the brain or begins as a local affection. Pachymeningitis may follow disease or injury of the vertebrae and is often syphilitic or tuberculous in nature. A hemorrhagic pachymeningitis interna analogous to that found in the head, occurs chiefly in the cervical region. The symptoms of pachymeningitis are first those of irritation of the nerve roots, i.e. shooting pains and perhaps spasms in the parts supplied by the nerves, and later those of a gradually oncoming compression of the cord. The treatment is removal of the cause, rest, and potassium iodid. Laminectomy may be indicated in the later stages. Acute leptomeningitis may follow disease or injury of the spinal column, or wounds of the membranes. It usually extends to the cerebral meninges, and then presents the symptoms described under inflammation of the latter structure, and is treated by the same means. Chronic leptomeningitis may follow the acute form. 564 MANUAL OF SURGERY When chronic from the beginning it is usually localized, and is prone to attack the syphilitic and alcoholic. The symptoms are localized pain in the back, rigidity of the spinal muscles, and evi- dences of irritation of the nerve roots as described above. If granu- lations form, the symptoms will be similar to those of tumor. The treatment is rest, counter-irritation, sedatives, potassium iodid, and laminectomy if pressure symptoms ensue. Intraspinal tumors are generally gliomata, gummata, or tuber- culous masses. Lipoma (usually congential), fibroma, angioma, myxoma, chondroma, hydatid and dermoid cysts, secondary car- cinoma, and sarcoma also occur. The tumor may be extradural, subdural, or intramedullary. The symptoms are those of a gradually oncoming compression with perhaps localized pain and tenderness over the segment involved. The disturbances of motion, sensation, and of the reflexes, develop from below upward and are often at first unilateral. In the beginning the symptoms are those of irrita- tion, i.e., shooting pains, hyperesthesia, localized spasms (perhaps causing lateral curvature, the concavity being on the side of the tumor), and increased reflexes. Later there are paresis, hypesthesia, and decrease of reflexes, and finally paralysis, anesthesia, loss of reflexes, and trophic disturbances. Motion is usually affected before sensation, but this will necessarily depend somewhat on the situation of the growth. The pupils may be affected if the lesion is above the second dorsal segment. The diagnosis of the nature of the growth is usually impossible, although a previous history of syphilis, tuberculosis, or a malignant growth elsewhere, should be sought; a tumor occurring soon after birth would probably be a lipoma. The X-ray and the Wassermann and tuberculin tests also may give valuable information. The seat of the tumor is determined by the localizing symptoms (see spinal localization). Intramedullary growths usually produce bilateral symptoms and earlier signs of compression. ExtrameduUary growths are apt to cause earlier and more severe signs of irritation. Chronic inflammation of the meninges or cord may produce similar symptoms. The prognosis is much more favorable than in cerebral tumors. About one-half are operable and about one-half of those operated upon are benefited. The mortality of operation is 10 per cent. The treatment, if syphihs and metastatic growths can be ex- cluded, is laminectomy and removal of the tumor. Infantile paralysis {acute anterior poliomyelitis) usually occurs within the first three years of life, is mildly contagious, and due to a specific micro-organism (Flexner and Noguchi), whose point of SPINE 565 ingress and egress is the nasal mucous membrane. The biting stable fly (stomoxys calcitrans) and ])robably also the common fly and the bedbug transmit the disease. It is characterized by slight fever, and sudden paralysis of a group of muscles, followed by rapid atrophy because of the destruction of their trophic centers in the anterior horns of the cord. The face and neck are very rarely involved, but the muscles of the back and abdomen may be affected. In the upper extremity the deltoid, brachialis anticus, biceps, supinator longus, extensors or flexors of the wrist or iingers may be attacked; in the leg, the favorite site, the tibials anticus and other muscles on the front of the leg; and in the thigh the quadriceps and the adductors. The surgical treatment, in the early stages, is to prevent deformity and increase the nutrition of the muscles by massage, electricity, passive and active motions, and special shoes or braces, either during the night, or in bad cases also during the day. When deformity has developed, various measures may be indicated in addition to the above: forcible correction under an anesthetic, tenotomy, fasciotomy, myotomy, tendon transplantation, nerve transplantation, osteotomy, arthrodesis, or rarely amputation when a limb is absolutely useless. CHAPTER XXIII EAR, NECK, THYROID GLAND THE EAR Only those conditions peculiar to the ear which more or less directly concern the surgeon will be considered in this chapter. The external ear may be abnormally small (microtia), or it may be completely or, more commonly, partly absent, and such defects can rarely be benefited by plastic surgery. Accessory auricles should be amputated. Congenital fistulaeand fissures are the result of incom- plete closure of the first branchial cleft; the former may be excised, the latter sutured after paring the edges. Very large ears(niacrotia) have been reduced in size by the removal of a wedge-shaped section from the upper part of the pinna with subsequent suture. Promi- nent ears may be brought closer to the head by the excision of an elliptical portion of the skin on the posterior aspect with subsequent suture, or by denuding the groove between the ear and the skull and closing the wound with sutures. Woimds of the auricle are often slow in healing and are occasionally followed by necrosis of the car- tilage; if the meatus is involved it may be necessary to graft skin to prevent atresia. Loss of a portion of the ear may be supplied by a pedunculated flap from the neighboring skin, the pedicle being cut after union has taken place {otoplasty) ; artificial ears of papier- mache or metal are usually more slightly than the shapeless mass which generally follows an attempted otoplasty when the entire auricle has been lost. Hematoma of the ear [othematoma) generally occupies the concavity of the auricle, the blood separating the perichondrium from the cartilage. It follows injury [boxers ear), or occurs spontaneoulsy, most frequently in the insane, and is then apt to be followed by great thickening and distortion. The treatment is aspiration, and pressure by means of bandage. Should suppuration occur, a free incision will be needed. Inflammatory affections and tumors of the external ear present the same features and require the same treatment as elsewhere. Atresia of the meatus, congenital or acquired, when membranous in character may be treated by excision of the membrane and skin grafting. Impacted cerumen (plugs of wax) causes diminution in hearing, 566 EAR, NECK, THYROID GLAND 567 tinnitus, and sometimes vertigo and inflammatory troubles. The diagnosis is made by the speculum. The Ireatment is removal by syringing with warm bicarbonate of soda solution. The wax may first be softened by having the patient retain in the ear for fifteen minutes or longer a mixture of glycerin and water. Foreign bodies also are removed by syringing. Live insects may be killed with sweet oil; if fastened to the wall of the canal it will be necessary to use angular forceps to remove them, the ear being illuminated with a head mirror. Vegetable bodies which swell should be removed at once by instrumental means if syringing fails. If unskilled, one may do much harm with instruments in the ear, hence if syringing fails the case should be referred to an otologist. Rarely will it be necessary to turn the auricle forwards and enter the meatus from behind. The surgical complications of suppurative otitis media are often of the gravest nature, consequently this condition should never be neglected. Pyeinia, even without local complications may occur, and miliary tuberculosis occasionally develops when the affection is tuberculous in nature. The local complications may be (i) extra- cranial, (2) cranial, or (3) intracranial. 1. The extracranial complications are eczema 2j\6. fnnmcles of the meatus, cervical adenitis, and suppurative arthritis of the temporo- maxillary joint. 2. The cranial complications. — Carious or necrotic ossicles may be removed through the meatus, and disease of adjacent bone is occasionally treated in the same way, but more frequently a mastoid operation will be required and the disease can then be dealt with from behind. Granulations and polypi may dam up the discharge, and are removed by the currette, forceps, or snare. Suppuration of the labyrinth can be treated only by providing free drainage of the tympanum; there is considerable danger of extension to the brain. Facial paralysis is due to neuritis, pressure being exerted by the increase in the size of the nerve and the thickening of its osseous canal. The nutrition of the facial muscles should be maintainedby electricty and massage, and if no signs of recovery appear after six months, the nerve may be anastomosed with the spinal accessory or the hypoglossal (see chap. xvii). Fatal hemorrhage from erosion of the internal carotid, internal jugular, middle meningeal, or lateral or petrosal sinus is a rare but possible complication. 568 MANUAL OF SURGERY Mastoiditis of some degree is probably associated with every acute suppurative otitis media, but if the tympanum is promptly drained, no ill effects need follow. The mucous membrane alone may be involved, but what is recognized clinically as mastoiditis is usually an osteomyelitis. There may be a desquamative inflammation which fills the cavities with cholesteatomatous material. Although the mastoid antrum is present at birth, the mastoid cells and the mastoid process are not well developed until after puberty. These cells surround and communicate with the antrum and are very variable in extent; they may extend forwards above the meatus, backwards to the occipital bone, upwards to the parietal bone, and downwards to the apex of the mastoid. The S3miptoms are pain and tenderness, both of which may however, be absent in chronic cases with a thick cortex or limited dis- ease. In acute cases there may be fever and leukocytosis. The most important sign is edema and bulging of the upper posterior wall of the auditory meatus. If the infection spreads outwards there will be redness and edema of the skin over the mastoid and possibly the formation of a subperiosteal abscess, which may perfor- ate and form a subcutaneous collection of pus. or spread downwards and give rise to a cellulitis of the neck. Extension inwards through the tegmen tympani may cause inflammation of the external semi- circular canal or the facial nerve; upwards, abscess on either side of the dura, septic meningitis, or cerebral abscess; downwards, deep celluHtis of the neck; forwards, a sinus of the meatus; and backwards, thrombosis of the lateral sinus or abscess of the cerebellum. Often the discharge from the ear abates when the mastoid symptoms are active. A skiagraph is usually of value in diagnosis. The treatment in acute cases with pain and tenderness only, is draining and cleansing of the tympanum, cold to the mastoid, and the artificial leech. If the symptoms persist for several days, or if there is external edema, continuous headache, or constitutional symptoms, the mastoid should be opened and drained. A mastoid operation is indicated likewise in cases of incurable chronic otorrhea even when there are no symptoms of mastoiditis. In acute mastoid- itis the Schwartze operation, or simple opening of the antrum with drainage, may be all that is required. In chronic cases it will be necessary to clean out and convert into one cavity the antrum, attic tympanum, and meatus (Schwartze-Stacke operation). In the Schwartze operation the antrum may be opened with a trephine, awl, gimlet, or with a bur propelled by a surgical engine but probably most surgeons use a gouge or a chisel. A curved EAR, NECK, THYROID GLAND 569 incision is made about one-fourth inch posterior to and parallel with the insertion of the auricle, from above the ear to the tip of the mastoid, the flap including the periosteum pushed forwards, the mastoid vein examined for thrombosis (indicating thrombosis of the lateral sinus) and the bone for sinuses. In the absence of a sinus, which should be followed if present, the antrum is opened in Macewen's suprameatal triangle, which is bounded above by the posterior root of the zygoma, in front by the posterior wall. of the external meatus, and behind by a line joining these two. With the ear pulled well forward this triangle can be recognized as a depression in the bone. In young children the antrum may be perforated with a curette. In adults the chisel or gouge, one-fourth inch in width, may be used, thin slices of bone being removed in a direction downwards, forwards, and slightly inwards. Unless the bone is thickened the mastoid cells will be encountered just below the surface. The antrum, too, is superficial in the child, but in the adult its depth beneath the surface of the bone varies from one-eight to three-fourths of an inch. One should never penetrate more than three-fifths of an inch from the anterior edge of the external opening, because of the danger of wounding the facial nerve or the external semicircular canal. The opening should be enlarged, and all infected cells removed with curette, gouge, or rongeur. The dura and sigmoid sinus need not be feared if care is taken to remove very thin slices of bone, and to explore the minutest opening with a probe. The cavity is smoothed with the curette, irrigated with salt solution, packed with gauze, and the external wound partly closed. In the Schwartze-Stacke operation the antrum and all the mastoid cells are obliterated as described above, remembering the extreme limits at which these cells may be found. The postero-superior wall of the meatus is next removed almost as far as the floor of the meatus, but sloping upwards in the deeper parts to avoid the facial nerve. The remains of the tympanic membrane, malleus, and incus are removed. A probe may be passed through the opening between the antrum and attic, to protect the facial nerve and the external semicircular canal, which He behind, while the bone in front including the outer wall of the attic is removed. The inner wall and floor of the antrum should not be disturbed, because of the danger of injury to the facial nerve or external semicircular canal. After smoothing the walls of the cavity and irrigating with salt solution the posterior wall of the cartilaginous meatus is split longitudinally, and the flaps thus formed stitched to the posterior margin of the skin wound, so that the whole cavity can be inspected through the meatus. 570 MANUAL OF SURGERY The operation is completed by filling the cavity with gauze, intro- duced through the meatus and posteriorly, and by partly closing the wound in the skin. When granulations have covered the bones heahng may be faciUtated by the use of Thiersch's skin graft. 3. The intracranial complications of otorrhea are thrombosis of the lateral sinus, meningitis, and extradural, cerebral, or cerebellar abscess (see chapter on the Head). THE NECK In the development of the face and neck five processes {branchial arches) are formed on each side, and between these arches are the four branchial clefts. The first arch joins its fellow in the middle line to form the lower jaw, the malleus developing from its upper end. A process from the base of this arch extends forward to join the fronto-nasal process jutting down from above, and forms the upper jaw; when these processes fail to unite, cleft palate and harelip result, The second arch forms the incus, stapes, styloid process stylohyoid ligament, and lesser cornu of the hyoid bone. The remains of the cleft between the first and the second arch is seen as the Gasserian fissure, external auditory meatus, tympanum, and Eustachian canal. The tonsil is formed from the second branchial cleft. The third arch forms the body and greater cornu of the hyoid bone, the thymus gland and parathyroids bodies are formed from the third branchial cleft while the rest of the neck develops from the remaining arch. A rudimentary fourth branchial cleft or the fifth arch may give rise to a post branchial growth. Branchial fistulae result from imperfect closure of the branchial clefts; they open on the skin, in the pharynx, or in both places. During the closure of branchial clefts (gill clefts) portions of the walls of the clefts may become enclosed within the tissues of the neck causing various sorts of tumors and cysts. If derived from the external furrows, they are dermoid in character, lined with ecto- dermal derivatives, and contain sebaceous matter. If derived from internal furrows they contain mucous fluid, the Hning epithelium is likely to be columnar and sometimes ciliated. Fistulae and fissures in the neighborhood of the ear are vestiges of the first branchial cleft. Congenital fistulae of the neck are most frequent in the neighborhood of the fourth cleft and open externally at the anterior edge of the sternomastoid closer to its lower end. Fistulae at the anterior or posterior edge of the sternomastoid at the level of the larynx are the remains of the second or third cleft. The internal opening is usually EAR, NFXK, THYROID GLAND 571 in the lower part of tlu- j)luir\ iix or behind the tonsil. An incomplete internal listula may cause a congenital diverticulum of the esophagus. Of similar origin are some median fistula), which may open into the trachea or larynx, and which when incomplete internally may beget air tumors {laryngocelc or tracheocele). Other median fistulae are due to a patent thyroglossal duct, which in the embryo passes from the isthmus of the thyroid gland up in front of the trachea and larynx, then behind or through the body of the hyoid bone, to open at the foramen cecum of the tongue. Accessory thyroids may spring from any portion of this duct. All these fistulae are lined by mucous membrane and hence give rise to a mucoid discharge. Fig. 283. — Hydrocele of neck. Cysts of the neck may be congenital or acquired. Congenital cysts, which may not appear for some years after birth, include the branchial, thyroglossal (either of which may be mucoid or dermoid), and blood cysts, and cystic lymphangioma. Branchial cysts arise from unobliterated portions of the branchial clefts, and usually lie beneath the muscles of the tongue or behind the sternomastoid; in the former situation they may be mistaken for ranulae, in the latter they are often closely connected with the great vessels. They are lined by epithelium and contain a serous or mucoid material {hygroma, hydrocele of the neck — Fig. 283), or sebum, hair, teeth, etc. (dermoids) . Thyroglossal cysts arise from any portion of the thyroglossal duct, hence are median in position; they may 572 MANUAL OF SURGERY contain mucus or dermoid material. Sublingual dermoids and subhyoid cysts belong to this class. Blood cysts probably arise from a congenital diverticulum of one of the large veins of the neck; if the communication persists, they may be reduced by pressure, and vary in size during respiration. Cystic lymphangioma (Fig. 84), sometimes improperly called cystic hygroma, is due to dilated lymph vessels and spaces, hence is multilocular and lobulated; it may spread to the face "and into the thorax and is then beyond operative aid. Acquired cysts may be sebaceous (chap, xivj, hydatid (chap. xiii). thyroid (see cystic goiter), bursal, or malignant. Bursal cysts may develop over the thyroid cartilage, or between it and the hyoid bone. Occasionally one encounters a carcinoma deep in the cervical tissues without finding a primary growth elsewhere. These cases may be regarded as branchiogenic carcinoma of glandular tvpe derived from embryonic inclusions of epithelium derived from infolding of ectoderm forming the inner clefts; if squamous celled from either entoderm or ectoderm. After a time they undergo cystic degeneration (malignant cysts of the neck), or break down into a puruloid material, and may superficially resemble a chronic cellulitis of the neck. Sarcoma of the neck likewise may undergo cystic degeneration. The treatment of all the conditions mentioned above is excision, which is often a difficult matter. Fistulae and cysts which cannot be excised may be opened, and the lining mem- brane destroyed by cauterization. Blood cysts may necessitate suture or ligature of the jugular or subclavian vein. Torticollis, or wry neck, is a deformity in which the head is bent towards the shoulder, and the face turned towards the opposite side False torticollis is seen in cases like fracture of the clavicle, and tumors and inflammations of the neck; it results also from rheuma- tism or cold (stiff neck) and hysteria. The treatment is directed to the cause. True, or chronic torticollis, may be (i) spasmodic or (2) perma- nent. I. Spasmodic torticollis (tonic or clonic) usually affects one sternomastoid only, but occasionally that of the opposite side as well as the posterior deep cervical muscles also are involved, so that the head is drawn backwards {retrocollis) . The spasm may be persistent, or it may intermit for days or weeks, but in either event it is usually absent during sleep. It may result from direct irritation of the nerve supplying the muscles, e.g., by tumors, enlarged glands, cervical caries; or from reflex irritation, such as carious teeth, worms, and pelvic troubles; but is usually seen in the neurotic and hysterical and EAR. NECK, THYROID GLAXI) 573 may possibly hr diu' to irritation of the motor centers. I'he treatment is removal of any source of irritation, the treatment of any associated neurosis, and the administration of antispasmodics. If these meas- ures fail, the spinal accessory nerve may be stretched or severed; the posterior cervical nerves may be similarly treated if the posterior cervical muscles also are affected. 2. Permanent torticollis is the result of malformation, vicious intrauterine position, or prenatal disease of the muscle or nerves {congenital torticollis) ; it may be caused also by strabismus, scoliosis, Fig. 284. — Congenital torticollis. The X-ray showed areas of ossification in the con- tracted sternomastoid and a large exostosis at its clavicular insertion. paralysis of the opposite muscle, or by cicatricial shortening of the muscle or surrounding tissues, following laceration at birth or subse- quent injuries or inflammations. The sternomastoid alone may be at fault, or the trapezius and deeper muscles also may be implicated and the deep cervical fascia shortened. In congenital cases (Fig. 284) or those arising soon after birth, the face of the aft'ected side fails to develop as rapidly as the sound side. A compensatory lateral curve, concave towards the affected side, develops in the cervical spine, and a secondary dorsal curve, concave in the opposite direction, is formed, leading to changes in the shape of the vertebrae. 574 MANUAL OF SURGERY The treatment in early cases is masage, manipulations to straighten the head, and a brace or support to maintain the corrected position. Any contributory lesion, such as strabismus, scoliosis, etc., likewise should receive attention. In most cases, however, little progress can be made until the sternomastoid muscle has been divided. The subcutaneous operation for this purpose is unsafe and incomplete and will not be described. In the open method the muscle is isolated and divided through a transverse incision about one-half inch above the clavicle, the skin is then sutured, and the head fixed in the cor- rected position by plaster-of-Paris or other apparatus. Mikulicz removes the entire muscle as far as the spinal accessory nerve. Cervical rib springs from the anterior transverse process of the seventh cervical vertebra. It is bilateral in about two-thirds of the cases; more common in females; rarely a second cervical rib may- arise from the sixth cervical vertebra. The anterior extremity is usually free, but it may unite with the first rib or with even the stern- um. The brachial plexus and subclavian artery pass over it, and with the growth of the rib or its ossification these structures are compressed, causing pain, weakness of the arm, trophic troubles, or even obliteration of the pulse and gangrene. It may be mistaken for neuritis from other causes, Ra}'naud's disease, as well as aneurysm. There is no edema of the arm, i3ecause the subclavian vein lies in front of the scalenus anticus muscle and escapes pressure. The rib forms a prominence in the neck, which has been mistaken for aneurysm, because it pushes the subclavian artery forwards and upwards. The X-ray will dispel all doubt. If there are pressure symptoms, the rib may be removed through a transverse incision after separating the nerves and vessels. Cellulitis of the neck is usually secondary to infections in the area drained by the cervical lymph glands, but may follow also cold, injury, and acute infectious fevers. The process varies greatly according to its situation, the virulency of the infection, and the resist- ance of the individual; thus it may be superficial or deep (with refer- ence to the cervical fascia), circumscribed or diffuse, acute or chronic. Superficial inflammatory troubles of the neck differ Httle from Hke lesions elsewhere and require no special mention. Deep celluHtis or abscess is often of the gravest nature because of the danger of exten- sion to the axilla, mediastinum, 'or pleura, rupture into the trachea or esophagus, or edema of the glottis. External fluctuation and pointing are the exception. In addition to the general septic symptoms the neck is swollen and hardened and the skin red and edematous. The head is bent towards the affected side, and there EAR, NECK, THYROID GLAND 575 may be dysphagia, dysj^nca. and SNiiij^ttoms of pressure on Ihe vessels or nerves. A streptococcic cellulitis of the sublingual and submental region is called angina Ludovici. The floor of the mouth, the inter- muscular and su])cutaneous tissues of the submaxillary region are involved in a tense phlegmon which tends toward gangrene. A chronic form of cellulitis of the neck with little or no pain and fever and presenting a board-like inflammatory hardness, has been des- cribed by Reclus under the term phlegmone ligneuse du cou, or woody phlegmon of the neck. After a time a small abscess forms and healing ensues, although in one case death was due to edema of the glottis. These cases resemble a carcinomatous infiltration of the neck. The treatment in acute cases is prompt incision, never waiting for fluctuation. A general anesthetic should not be given if pus is discharging into the mouth or there is trismus. An abscess may be opened by Hilton's plan (see abscess). Tracheotomy is sometimes necessary. The constitutional symptoms of sepsis should be com- bated. Cut throat may be homicidal or suicidal. In the latter the wound is usually between the hyoid bone and the larynx and deepest on the side opposite to the hand employed. In either case, however, the wound varies both as to depth and to situation, and any of the struc- tures of the neck may be involved. The effects of division of the nerves have already been mentioned. The diagnosis of a wound of the air passages is easily made. Injury to the esophagus is much less common and may be accompanied by hematemesis, dysphagia, and the escape of mucus or food through the wound. The immediate dangers are shock, hemorrhage, air embolism, and asphyxia due to blood or displaced structures. The secondary dangers are cellulitis septicemia, pyemia, edema of the glottis, secondary hemorrhage, inspiration pneumonia, and emphysema of the cellular tissues. The treatment is arrest of hemorrhage, even the smallest bleeding point being attended to, because of the danger of blood trickling into the air passages; removal of clots from the trachea; saline infusion and other means to combat shock; disinfection of the wound; and suture of divided nerves, esophagus, trachea, larynx, and muscles. Drainage should be employed in order to provide a vent for blood, air, or esophageal secretions. In an extensive transverse wound of the trachea the sutures almost invariably tear out. If the larynx has been opened, safety demands the performance of a high tracheot- omy, as breathing is sure to be obstructed. The neck is dressed with the head flexed on the chest, and the patient fed per rectum or 576 MANUAL OF SURGERY through a tube in the esophagus, if that structure has not been wounded. Among the sequelce may be mentioned stenosis of the larynx, esophagus, or trachea (q.v.) ; esophageal fistula, which usually closes after a time; aerial fistula, which if persistent may be closed by freshening and suturing the opening in the air passage, care being taken first to make sure that there is no stenosis above; and lesions which may follow division of nerves, e.g., aphonia from a severed recurrent laryngeal nerve. THE THYROID GLAND The parathyroid glands are four in number. They are brownish red, oval bodies, about one-fourth inch in length, lying upon the posterior surface of the capsule of the thyroid gland, one near the pole of each lobe. Each parathyroid has a terminal artery, usualh' derived from the anastomotic branch between the superior and infe- rior thyroid arteries. A knowledge of the existence and situation of these bodies is of great importance to the surgeon, as their destruc- tion results in tetany, severe and fatal if none is left, milder if one or two remain. In about 10 per cent, or more of lobectomies (so called intra capsular) parathyroids are removed, but no tetany fol- io w^s, those on the other side being sufficient. Poole says that at least one lobe must always be left. In 3203 goitre operated upon the Mayos report only one case of tetany. The symptoms of this tetany parathyreopriva. as it is called, are those of other forms of tetany, for which the student is referred to a text-book on medicine. The treatment is administration of parathyroid extract or serum, and calcium lactate, in a 5 per cent, solution, by mouth, rectum, or intravenously; transplantation of parathyroids from animals also has been tried. Wounds of the thyroid cause severe bleeding, which may be checked by sutures or by gauze packing. In some cases it may be necessary to extirpate the gland. Accessory thyroids may be found about the thyroid gland, in the upper portion of the chest, or along the course of a thyroglossal duct as far as the base of the tongue {lingual goiter) . If increasing in size or causing pressure symptoms, medical treatment as de- scribed below may be tried for a time, but will usually fail, and then extirpation should be performed, first making sure that the normal thyroid is present, as the accessory gland may be the only one the patient has, and its removal would then be followed by myxedema^ EAR. NECK, THYROID GLAND 577 The presence of an accessor)' tliyroid explains ihe absence of myxede- ma in some cases of comjjlete thyroidectomy. The occurrence of a non-intlammalory tumor along the course of the thyroglossal duct, particuhirly in a woman, should always make one think of the possi- bility of an accessor)' thyroid. Ai)sence or deficiency of the internal secretion, the result of atrophy or absence of the thyroid, causes a peculiar group of symp- toms, which is called cretinism when developing soon after birth, myxedema when occurring in adults, and cachexia strumpriva when following extirpation of the gland. The essential features of these conditions are a non-pitting edema of the subcutaneous tissues, due to infiltration with a mucin-like substance (myxedema), pallor and dryness of the skin, loss of hair, and in children dwarfing of the body and idiocy, and in adults marked impairment of the intellectual faculties and loss of sexual power. According to Kocher the coagula- bility of the blood is increased in hypothyroidism. The treatment is thyroid extract, one grain three times a day, gradually increased to 10 or more grains, watching for symptoms of thyroidism, i.e., tachycardia, nervousness, delirium, etc. When cure has been effected, it will usually be necessary to administer small doses, per- haps for the rest of the patient's life. Congestion of the thyroid, evidenced by slight enlargement, may be due to cardiac disease, obstruction to the veins in the mediasti- num, anemia, overexertion, or emotion; in women it may occur at puberty, or during pregnancy or menstruation. No surgical treat- ment is required. Thyroiditis is usually a complication of one of the acute infectious diseases, but may follow injury. In addition to the ordinary signs of inflammation there may be pressure symptoms much like those which occur in ordinary goiter. Inflammation of a goiter is called strumitis. The treatment is that of inflammation elsewhere, includ- ing incision should suppuration occur. Tracheotomy, preceded by division of the isthmus or in some cases extirpation of the organ, may be required if breathing is seriously embarrassed. Tuberculosis, gummata, actinomycosis, and hydatid cysts are treated as are such conditions elsewhere. Tumors of the thyroid are sometimes called malignant goiters, and indeed it is often difficult to make a sharp distinction between certain goiters and some neoplasms. An adenoma theoretically is is distinguished from an adenomatous goiter by its typical micro- scopic picture, and by the fact that the tumor is circumscribed and separated from the healthy gland tissue. It, however, together 37 j 78 MANUAL OF SURGERY with carcinoma and sarcoma (Fig. 285). may give rise to metastases, hence all tumors of the thyroid gland shold be regarded as mahgnant and be extirpated at the earliest possible moment. They usually develop after forty, often from a simple goiter, are hard, fixed, and irregular in contour, grow rapidly, quickly produce pressure symp- toms, and often come under observation only when they have in- vaded surrounding tissues and are inoperable. If the entire gland is removed, the patient should be fed on thyroid extract subsequent to operation. In the later stages of inoperable growths it may be necessary, in order to prevent death by suffocation, to perform trache- otomy, a most difficult and dangerous procedure under the circumstances, as one must quickly remove sufficient of the tumor tp expose the trachea be- fore it can be opened and a tube introduced, and even then it may be found that the site of the compression is retrosternal, in which event a long flexible tracheotomy tube must be in- troduced, or. if this is not at hand, a flexible catheter. Goiter, struma, or broncho - cele is a h}'perplasia of the thyroid gland not of infectious or neoplastic origin. The dis- ease may involve any part or all of the gland, but is most common in the right lobe, and -Sarcoma of the thyroid gland. Note enlarged veins. Fig. 28, Note enlarged veins. ^kjxx±xi.i^. occurs more frequently m females, usually after the tenth year. The cause is not known. The theory that it is due to magnesium or calcium salts or some other substance in the drinking water probably has the most advocates. It occurs sporadically in all parts of the world, and is endemic in Central Asia. Switzerland and the contiguous portions of France. Italy, Austria, and Germany; in England it has been called Derby- shire neck owing to its prevalence in that locahty; in this country it is most common in certain parts of ^Michigan and in the mount- ainous regions of Pennsylvania. The varieties of goiter are: i. The parencliymatous, in which the whole gland is involved, although one lobe may be larger than the 1:AR, NKCK, TllVROII) (W.AM) 579 other. The swelling; is soft, elastic, and painless. When there is an excessive development of the stroma, the gland is harder and perhaps lobulated (Jibrons goilcr) ; when the connective tissue is small in amount and the acini arc distended with colloid material, the gland is softer {follicular or colloid goiter). Cystic goiter is due to the confluence of the acini. The cysts may be single, or multiple, vary greatly in size, and contain a colloid or serous material, which may be brown or black from the presence of altered blood. In- tracystic papillomata are sometimes found. 3. Adenomatous goiter (Fig. 286) resembles an adenoma in structure; it may develop in one portion of a normal gland and subsequently involve the whole thyroid, or it may be a secondary change in a parenchymatous goiter, and not infrequently it is followed by the formation of cysts. A sharp distinction cannot be made between adenomatous goiter and adenoma of the thyroid. 4. Exophthalmic goiter is des- cribed below. In any of these varieties certain secondary changes may occur, e.g., in- flammation, abscess, hemor- rhage into the gland, calcifica- tion, or malignant disease, and in any there may be enlarge- ment of the thymus gland. Carinoma occurs most fre- quently in the adenomas, and is to be suspected when a nodular goiter rapidly increases in size. The exopthalmic type rarely shows malignant change. Simmons found thymic hyperplasia in less than one-half of the cases of ordi- nary goiter, and in three-fourths of the cases of exophthalmic goiter. Kocher states, however, that in 5740 operations for ordinary goiter he saw not one thymic hyperplasia, and not one patient died from status lymphaticus. The S)niiptoms are (i) the presence of a tumor, (2) evidences of pressure and (3) signs of excess or deficiency of the thyroid secretion. I. The tumor in horseshoe-shaped or oval, varies greatly in size, sometimes being as large as a man's head, develops insidiously, rises and falls during swallowing, is painless, and, excepting the trachea, is not adherent to the surrounding tissues. Inflamed, malignant, and very large goiter, however, may not move with deglutition, and other cervical swellings, e.g., thyroglossal cysts, subhyoid bursa?, and abscesses, lymph glands, and malignant Fig. 286. — Adenomatous goiter. 580 MANUAL OF SURGERY growths that are adherent to the larynx, trachea, or esophagus, may move with deglutition. 2. The pressure symptoms depend upon the situation of the growth, thus a retrosternal goiter quickly produces symptoms, and they may be absent in even the largest goiters. The larynx and trachea may be pushed from the middle line, or the latter may be flattened from side to side, causing dyspnea and cough if both lobes are equally enlarged. Pressure on the esophagus causes dysphagia; on the vessels of the neck headache, flushing of the face, and epistaxis; on the recurrent laryngeal nerve alteration in the voice or, if both are involved, bilateral paralysis of the muscles of the larynx and death (Mayo states that in one fifth of all cases of goitre there is paresis or paralysis of one or both cords) ; on the pneumogastric alteration of the heart's action; and on the sympathetic dilatation of the pupil, etc. (chap. xvii). 3. Signs of excess or deficiency of the thyroid secretion also may be encountered ; the former are given under exophthalmic goiter, the latter under absence of the thyroid. The treatment in the early stages may be medical, viz., iodid of potassium internally, and red oxid of mercury ointment or iodin locally. Thyroid extract is of value, particularly if there are any signs of myxedema. Electrolysis and radiotherapy have tem- porarily benefited a few cases. Medical treatment is of most value in parenchymatous goiter. If the goiter increases in size or there are pressure symptoms, operation is indicated. Before operation the larynx should be examined, to determine the condition of the vocal cords, and if there is any suspicion of an intrathoracic growth or if one is not sure of the position of the trachea a skiagram should be made. Ligation of the thyroid arteries, and exothyreopexy, i.e., drawing the thyroid into a wound in the neck so that it may atrophy, have been employed, while as a palliative or emergency operation in cases of severe dyspnea, the ribbon muscles of the neck or the isthmus of the gland have been divided. The usual operations are intraglandular eniilceation, which is indicated in a localized adenoma or a single cyst, or in a small collection of cysts, and partial excision, or thyroidectomy, which is indicated in all other varieties, care being taken to leave at least one-fourth of the gland in order to prevent myxedema. Local anesthesia is strongly recommended by many surgeons, in order to prevent the congestion of the neck incident to ether and chloroform, to avoid postoperative vomiting, which may start bleeding, and in order to have the patient speak during the operation, so that the surgeon may know when he is in the vicinity of the recurrent laryngeal nerve. We prefer ether, administered EAR, NECK, TUVROll) (ILAND 581 by iiUralraclu'al iiisuftlalion. 'I'lu" i)])C'ralive field is made prominent 1)V placing a sand i)ill()\v under the neck, and, in order to lessen bleeding, the uiii)er i)ortion of the body is elevated (reversed Tren- delenburg posture). Intraglandular enucleation is ])erformed by exposing the gland by a transverse or oblique incision, incising the gland down to the tumor, and shelling out the tumor with the fmgers or a director; the wound is then quickly j^acked with gauze because of the free bleeding, and as the gauze is gradually removed, the bleeding points are ligated or surrounded by sutures. The cavity is closed by catgut sutures and the skin approximated, leaving space for a gauze drain for twenty-four hours. Partial thyroidectomy usually means removal of one lobe. A curved transverse incision, with the concavity upwards, is made over the tumor from the outer border of one sternomastoid to beyond the middle line, the skin and platysma divided, the ribbon muscles separated in the median line or divided transversely, and the tibrous capsule opened. The fibrous, or surgical capsule, lines the cavity in which the thyroid lies, and is separated from the true, or glandular capsule, by loose areolar tissue. All bleeding is checked, the lobe dislocated from its fibrous envelope, the superior thyroid vessels divided between two ligatures, and the inferior thyroid vessels tied close to the gland in order to avoid the recurrent laryngeal nerve. The thyroidea ima if present also is tied. The parathyroids are avoided by tying all vessels close to the true capsule, or, as suggested by Mayo, leaving that portion which covers the posterior surface of the gland. The isthmus of the gland is crushed with strong forceps and ligated in sections, or it may be divided and the bleeding controlled with sutures. Any attachments to the cricoid are separated, or perhaps better, a thin slice of the gland is left in place in this situation to avoid injury to the recurrent laryngeal nerve. The wound is irrigated with salt solution, the remaining portions of the gland should be oversewn with catgut to further insure hem- ostasis, and closed after suturing the divided muscles, a small space being left for drainage with silk worm gut strands for twenty-four hours. The normal anatomy is necessarily disturbed in large growths; thus the jugular vein, which has branches coming from the tumor, moves forward with the growth, while the artery, which has no such connections, is pushed backwards and outwards and may lie external to the vein. The tracheal rings may be absorbed or softened, hence more easily injured; in some cases the trachea collapses as soon as the support of the tumor is removed, the patient 582 MANUAL OF SUKGEKY dying of asphyxia unless a tube is inserted. Sudden death may occur also from reflex inhibition of the heart, the status lymphaticus or from the absorption of thyroid secretion from the wound. It is necessary to gently handle the gland to avoid squeezing its toxic secretion into the circulation. In other cases thyroid intoxication will cause high fever, rapid pulse, and dyspnea subsequently to operation. If too much of the gland is removed, myxedema may follow; and if the parathyroids are excised tetany develops. Kocher's mortality in over 5000 cases is less than i per cent. Exophthalmic goiter (Graves' disease, Basedow's disease) is of unknown origin. Ninety per cent, of the cases are females, gen- erally between the ages of fifteen and thirty. It may follow severe emotional storms, overwork, worry, pregnancy, or ordinary goiter {Basedowified goiter). Microscopic examination shows a marked increase in the epithelial elements and little or no colloid material. Judging from the results of operative treatment the chnical pheno- mena are due to derangement of the sympathetic nervous system, in consequence of excessive thyroid secretion, or of some toxin in the blood which, under normal conditions, the thyroid gland destroys. Thus the exophthalmos, long thought to be due to an increase in the orbital fat, is, according to Landstrom, the result of stimulation of the cervical sympathetic, which presides over Miiller's muscle, and a film of muscular tissue passing around the eyeball from the fascia behind to the lids and anterior orbital fascia. These muscular fibres pull the eye forwards and the lids backwards, serving normally to antagonize the four orbital muscles, which tend to draw the eye backwards. Recent investigations, however, seem to indicate that Graves' disease is only one of the numerous manifestations of incoordination between the various ductless glands. Of particular interest at the present time is the relationship between goiter and hyperplasia of the thymus. "No Basedow without thymus" is the opinion of Klose. Kocher says that in 61.2 per cent, of the cases of exopthalmic goiter coming to autopsy there is some increase in the parenchyma of the thymus, but that clinically only 30 per cent, show enlargement, the greatest number being in the first two decades, while exophthalmic goiter is most frequent in the second and the third decades. The cardinal sym- ptoms are the presence of a goiter, in the capsule of which are numer- ous large vessels, hence pulsation, thrill, and bruit are commonly found; exophthalmos, causing a widening of the palpebral fissure with frequent and incomplete winking (Stellwag's sign), retardation of the movement of the upper lid when the eyeball is rotated down- EAR, NECK, IIIYKOII) GLAND 583 wards (\()n (iraofe's sign), and inahilily to maintain the eyes in convergence (Mcebius's sign); lacliycardia, often with palpitation and dysjmca; and a line tremor. In the later stages the cardiac muscle degenerates and permanent dilatation ensues (goiter heart). Sometimes scleroderma or symmetrical lipomata develop, and many cases terminate in myxedema. Numerous other symptoms referable to the nervous system, the cardio-vascular apparatus, the gastrointestinal tract, or the anemia, are described, e.g., irritability, attacks of mania, prostration, flushing of the face, excessive sw.eating, throbbing of the arteries, capillary pulse, indigestion, diarrhea, glycosuria. Kocher says there is leukopenia, particularly of the polymorphonuclears, lymphocytosis, and diminution in the coagu- lability of the blood. Halstead ascribes the lymphocytosis to the thymic hyperplasia. The diagnosis is never difficult, except in the form fruste, in which the goiter or the exophthalmos, or both, may be absent. Many of these cases are incorrectly diagnosticated hysteria or neurasthenia. The treatment in the beginning is medical. Absolute rest, cardiac sedatives, an ice bag to the heart, ergot, belladonna, phosphate of soda, and extract of the thymus, pituitary, spleen, pancreas, or suprarenals are recommended. Thymus therapy benefits 50 per cent, of the patients, causes an increase in the cardiac symptoms in 10 per cent. (Kocher). Electrolysis and the radiotherapy have been employed. Recently encouraging result have been obtained with a serum obtained from animals injected with increasing doses of human thyroid extract. Iodides, thyroid extract, and the in- jection of various medicaments into the gland are contraindicated. As soon as medical treatment has failed, i.e., after a few months, operation should be proposed before the condition of the patient has markedly deteriorated. Ligation of the thyroid vessels (usually the superior including the upper pole of the gland) may be indicated in mild cases, as a preliminary operation to thyroidectomy in severe cases, and as an auxihary procedure to excision of one lobe, the vessels of the other lobe being tied. Partial thyroidectomy is the operation of choice. The average results are "71 per cent, cured; 9.6 per cent, improved; 6.4 per cent, unimproved, failures, lost sight of, or partly benefited; and 12.6 per cent, died (Hartley). Kocher 's mortahty in 535 cases is 5.1 per cent, but he refuses to operate upon "bad risks." The dangers have been mentioned under partial thyroidectomy. Improvement is immediate, but the exopthalmos may persist for months, and recurrences have been noticed in a few instances. Bilateral resection of the cervical sym- 584 MANUAL OF SURGERY pathetic ganglia (see cervical sympathetic nerves, chapter xvii, page 256 gives less favorable statistics, but may be indicated in Graves' disease without goiter, or combined with thyroidectomy, in cases in which the ophthalmic symptoms predominate. Thymec- tomy, without removal of the thyroid, has been performed for Graves' disease by a few surgeons. The thymus should certainly be sought during thyroidectomy, and if enlarged removed. The other operations mentioned under the treatment of goiter also have been employed for Graves' disease. The thymus gland usually begins to shrink at the end of the second year and at the time of puberty can no longer be found. When it persists and enlarges pressure may be exerted on the trachea, the great blood vessels, or on the left pneumogastric or its recurrent branch. Hyperplasia, or hypertrophy, as it is sometimes called, may be an independent affection, rarely occurring except in infants, or it may be associated with leukemia, Hodgkin's disease, ordinary goiter, exophthalmic goiter, or the status lymphaticus. Clinically the pressure effects are continuous or intermittent. In the continuous form (thytnic stenosis of the trachea) there is progressive dyspnea, with stridor and crises of suffocation. The dyspnea is chiefly expiratory, as the gland is drawn down into the mediastinum during inspiration, thus freeing the air passages The diagnosis is made by feeling a tumor mounting in the episternal notch during expiration and disappearing during inspiration, by dulness on percussion over the manubrium, by the associated lymphocytosis, and by the X-ray, all of which signs, however, may be present when the trouble is due to enlarged mediastinal lymph glands. In one case of enlarged thymus Jackson demonstrated the stenosis by bronchoscopy. In the intermittent form (thymic asthma) the attack appears suddenly, possibly as the result of extension of the head or venous engorgement of the gland. Death occurs within a few minutes, or the infant recovers, only to suffer from subsequent paroxysms which become more and more frequent. The treatment of thymic stenosis of the trachea and thymic asthma is exothymopexy (i.e., drawing the gland up over the sternum and securing it with sutures) or, better, subcapsular enucleation, after making a median incision just above the manubrium. Olivier (191 2) has collected 42 cases ot thymectomy, with 15 deaths. Radiotherapy may possibly be of service in cases not suited for operation. The carotid gland or body, when present, is attached to the EAR, NECK. TllVkoll) (.LAM) 585 cart)ti(l sheath al or near the Ijifurcalion of the artery. It is about the size ol a rl)ital notcli, the aiUcrior wall hcin*!; ])erf()ratc(l wilh a trephine or tj;oii,u;<'' ji-'^l bi'low the line joininii; the two suj)ra()rbital notches and a little away Irom the median line. The sinus may be curetted, irrigated, and jxicked with gau/e. so that it may ch)se by granulations and shut off the nasofrontal duct, or it may be neces- sary to remove the entire anterior wall, but this should be avoided whenever possible, owing to the disfigurement. Killian removes the anterior wall and floor of the sinus, leaving a bridge of bone at the inner angle of the orbit to lessen deformity. Some surgeons push a small tube into the nasofrontal duct in order to drain the sinus into the nose, and then close the skin incision. It may be possible for a skilled rhinologist to enter the infundibulum from the nose after removing the anterior tip of the middle turbinate, but the duct cannot be enlarged without great danger, so that, although catheteri- zation may be useful from a diagnostic standpoint, it should not be used as a means of treatment. Tumors, both benign and malignant, may arise in the frontal sinus. When of large size, they may press on the brain or on the eye, causing blindness and displacement of the eyeball. They should be excised. Ethmoiditis may cause pain and tenderness at the root of the nose, disturbance of vision, mental hebetude, anosmia, and possibly cellulitis of the orbit, meningitis, or abscess of the brain. There may be a continuous discharge of pus from the nose and polypi in the middle meatus. Probing reveals necrotic bone and opacity can be demonstrated by the X-ray. The treatment is excision of the anterior end of the middle turbinate, to permit drainage and removal of the cells by curettage. The best way to reach the ethmoid cells by an external incision is through the inner wall of the orbit, and such is particularly indicated if the pus has perforated in this direction. The sphenoidal sinuses open at the junction of the roof of the nose with the wall of the nasopharynx, and this opening may be en- larged in a downward and outward direction in cases of sphenoidal empyema. Sphenoidal and ethmoidal disease are commonly asso- ciated, and may cause meningitis, abscess of the brain, or thrombosis of the cavernous sinus. Pus flows into the superior meatus, necrotic bone may be detected with the probe, and the X-ray shows abnormal density. The sinus may be opened through the posterior ethmoidal cells after the removal of the middle turbinate, through the orbit and posterior ethmoidal cells, or through the antrum of Highmore and posterior ethmoidal cells. Empyema of the antrum of Highmore (the maxillary sinus) is 598 MANUAL OF SURGERY most frequently due to carious teeth, but may result also from infec- tion of the nasal cavities, or from the entrance into its opening of pus from the frontal or ethmoidal sinuses. Injury is responsible for a small number of cases. The symptoms are pain, tenderness, edema of the cheek, and an intermittent unilateral discharge of pus from the middle meatus, most marked when the diseased side is upward or when the patient bends forwards, and is accompanied by marked sub- jective fetor. If the opening into the middle meatus is obstructed, the cavity becomes distended, causing in extreme cases stenosis of the nostril, exophthalmos, depression of the palate, and a promi- nence beneath the malar eminence due to bulging of the outer wall, which in old cases may crackle under the finger. Acute cases may be associated with septic constitutional symptoms. Percussion over the antrum will give a dull instead of a tympanitic sound, and trans- illumination, by placing a small electric light in the patient's mouth in a dark room, or the X-ray, will show the diseased much darker than the normal side. In doubtful cases in which pus cannot be seen coming from the antral opening, an exploratory puncture may be made in the inferior meatus, one inch behind the anterior end of the inferior turbinate, or if the nostril is blocked, by making a similar puncture through the canine fossa, pushing the cannula upwards at an angle of 45 degrees. The treatment, when the condition is due to a carious tooth, usually the second bicuspid or the first molar, is extraction of the tooth, and opening upwards through the socket to the antrum by directing the drill or gouge towards the supraorbital notch. The cavity is irrigated, and permanent drainage secured by a gold or silver tube, which may be closed with a stopper during meals. Irri- gation may be practised likewise through the natural opening, or through an opening made through the inferior meatus or canine fossa. Small openings of this character are exploratory or palUative and are not suited for chronic cases. The radical operation is per- formed by making an incision at the junction of the buccal and alveolar mucous membranes, and opening the antrum with a gouge through the canine fossa, about one inch above the border of the gum, on a level with the second bicuspid tooth. The opening may be enlarged sufficiently to explore and curette the antrum thoroughly, and a counteropening may be made into the inferior meatus of the nose. A tube may be passed through both of these openings and the cavity irrigated daily. Tumors of various kinds may develop in the antrum; about two- thirds are malignant. The so-called hydrops, or dropsy of the an- RESPIRATORY SYSTEM 599 tnnn, is practically always due to cystic degeneration of tumors, or to cysts connected with the tooth follicles, although a true dropsy from closure of the natural opening of the antrum is said to occur. Large growths cause expansion of the walls of the antrum, and when malignant soon spread to adjacent parts. Transillumination and percussion will give the same results as in empyema, and the intro- duction of a small cannula will determine the presence or absence of fluid and the density of the growth. In doubtful cases the cheek may be reflected as for excision of the jaw and the anterior wall of the antrum removed. Polyps, cysts, and other benign tumors may be removed through this opening; if malignant disease is found, the entire upper jaw should be resected. LARYNX AND TRACHEA Congenital fissures and fistulce, laryngocele and tracheocele^ and wounds of the air passages, have been referred to in the chapter on surgery of the neck. Foreign bodies in the air passages may be of any nature, provid- ing they are small enough to enter the larynx or trachea. Those most often found are, in the order of their frequency, a grain of corn, watermelon seed, bean, and grain of coffee. Congenital defects or destruction of the epiglottis by ulceration, certain diseases like bulbar paralysis, and unconsciousness from any cause, predispose to this accident. Foreign bodies may be introduced through the glottis or through an artificial opening in the trachea, and they may penetrate from without, as a bullet, needle, or other sharp body. They may ulcerate into the respiratory tree from the esophagus, mediastinum, or one of the subphrenic organs, stomach, colon, liver, or spleen, and they, may be formed in the lung itself {lung stones) . If not arrested in the pharynx or larynx, or of such a nature as to catch in the wall of the trachea, the foreign body usually descends into the right bronchus, because of its greater diameter and because the bronchial septum is situated to the left of the median line. For- eign bodies may be expelled through the mouth or through an arti- ficial opening; they may be coughed into the pharynx and swallowed; and rarely may they gain exit through the chest wall by ulceration. Vegetable substances swell and sometimes sprout. Death is due to asphyxia from complete blocking of the respiratory channel or from edema or violent spasm of the glottis, or it occurs later from septic inflammation. Rarely hemorrhage may cause a fatal issue, as in a case in which an inhaled dart pierced the innominate artery. If the foreign body is not large enough to block the air channel 6oO MANUAL OF SUEGERY completely, there are great dyspnea, violent cough, lividity of the countenance, writhing of the patient, and partial insensibihty, followed by expulsion of the foreign body or a variable lull in the symptoms, then by recurrence of the symptoms, and so on until spasm or edema of the glottis causes asphyxia, or the body descends into the lung. The diagnosis is usually made from the history, but if the patient be unconscious or a child from whom no history can be obtained, the symptoms may be mistaken for asthma, pertussis, epilepsy, apoplexy diphtheria, cardiac disease, spasmodic croup, laryngismus stridulus, edema and ulceration of the larynx, the laryngeal crisis of locomotor ataxia, or for worms. Even after expulsion doubt may arise, owing to the persistence of symptoms due to irritation. In children with sudden respiratory difficulty one should think always of a foreign body. The breathing is slow compared with that of disease, inspira- tion prolonged and difficult with retraction of the lower ribs, and the respiratory murmur diminished or absent on the corresponding side if there be impaction in the bronchus, the pulmonary resonance, however, remaining normal. The symptoms are intermittent and in the beginning there is no fever. Sometimes the foreign body may be heard rising and falling in the trachea with each respiration. The pharynx may be explored with the finger, the larynx and upper part of the trachea with the laryngoscope, the bronchi with the broncho- scope. It should be recalled that blocking of the esophagus may cause suffocative symptoms. When the infective sequelae from irritation of a foreign body have become estabhshed, the diagnosis may be impossible without a guiding history. These cases must be differentiated from inflammatory diseases from other causes, and from chronic largyneal, tracheal, or bronchial stenosis, which may be extrinsic or intrinsic. As extrinsic causes may be mentioned cica- tricial contractures; localized emphysema; enlarged thyroid, thymus, or lymphatic glands; extensive pericardial exudate; dilatation of the left auricle; disease or injury of the clavicle, sternum, or vertebrae; and cervical or mediastinal cyst, abscess, neoplasm, or aneurysm. Among the intrinsic causes are malformations; neoplasms; inflamma- tory thickening; intussusception of the trachea; paralysis of the posterior cricoarytenoids; longitudinal involution of the trachea after tracheotomy; adhesions of the epiglottis, vocal bands, or arytenoids; cicatrices, syphihtic. tuberculous, or traumatic; and cicatrices following diseases like scarlatina, diphtheria, variola, rubeola, an enteric fever. The characteristic inspiratory dyspnea is sufficient to establish the diagnosis of stenosis. If the voice is RESPIRATORY SYSTEM 6oi altered, with i)ain and rhoncus in a larynx whose pitch rises and falls with each respiration, the lesion is probably in the larynx, and the diagnosis may be confirmed by examination with reflected light. Dysphagia has been observed in some cases, and the head is apt to be held backward in laryngeal constriction, and slightly depressed with extended neck in tracheal stenosis. The respiratory murmur is diminished over both lungs in any constriction above the tracheal bifurcation, and the voice may be weakened owing to the lessened column of air impinging on the vocal bands. Fixed pain and rhon- cus, with visual examination through the mouth, would locate the stricture in the trachea. Narrowing of a bronchus may be recog- nized by physical examination of the chest, or by direct inspection with the bronchoscope. Diminished respiratory dilatation of one lung, as evinced by inspection, palpation, and mensuration, with diminished vesicular murmur and vocal fremitus, and retention of resonance, can be caused only by narrowing of the bronchus or pneumothorax. A whiring rhoncus occupying the same place and having the same character and intensity on different examinations, with fixed pain and thrill over the spot corresponding to a bronchus, will definitely settle the point of constriction. The diagnosis of a foreign body would be made by excluding the other causes of ob- struction. An X-ray plate might facilitate the differentiation. The treatment in a great emergency is to thrust a knife through the cricothyroid membrane; if there be less urgency, a low and rapid tracheotomy may be performed; and if the patient is seen during a quiescent period, a careful examination should be made. When above the vocal bands the body may be removed wdth the finger or forceps, but when in the larynx below this point and irregu- lar or jagged, permenant injury to the vocal bands may follow forcible extraction from above. Foreign bodies in the trachea or the bronchi should, whenever possible, be removed through a bronchoscope. The best bronchoscope is probably that devised by Jackson. It is a long, sti'aight, slender speculum, wath an electric lamp at the distal end. Under local anesthesia the glottis is exposed with Jackson's direct laryngoscope, the patient being in the dorsal position with the head fully extended, i.e., the occiput is forced down toward the shoulders, thus elevating the anterior part of the neck. The bronchoscope is passed through the laryngoscope into the larynx, the laryngoscope is withdrawn, and a ''bite-block inserted to prevent the patient biting the thin walled bronchoscope. The bronchial tree is exceedingly elastic and flexible, and may be explored by following the lumen by sight." During the exploration "the head 6o2 MANUAL OF SUEGERY and neck should be out in the air beyond the table and supported by an assistant, so that the head may be freely movable as needed. For instance, it must be moved to the right for the bronchoscope to enter the left bronchus, and vice versa to enter the right bronchus; and it must be slightly lowered to enter the middle lobe bronchus of the right side, raised to enter the posterior branch bronchi" (Jackson). Secretions are removed by aspiration or by sponging. Foreign bodies are removed with suitable forceps. The sooner the bronchoscopic examination is made the greater the chances of success, as after twelve hours the foreign body may be concealed by swollen mucous membranes. Successful removal has been affected, however, even after years. If impossible or injudicious to extract the body from above, the patient may be inverted and succussed with a pillow, a procedure which is occasionally successful, especially when the alien is small, round, and heavy. Inversion, however, without adequate means for immediately opening the trachea, is dangerous, because of the possibility of death from impaction or spasm of the glottis, the foreign body suddenly striking the larynx from below. If inversion fail, the trachea should be open low down though the symptoms are even not urgent, because of the danger of death from impaction or convulsive closure of the glottis, or from subsequent inflammation. The body is frequently expelled as soon as the trachea is opened; expulsion may be facilitated by turning the patient face downward, or by inversion and succession. These measures f aihng, a careful search should be made, and removal effected with finger, forceps, scoop, hook, probe, coin catcher, or wire. The bronchi may be inspected with a short bronchoscope introduced through the tracheotomy wound. A powerful magnet may attract bodies Like needles, and a Bigelow evacuator may be used to aspirate small foreign bodies, if all efforts are unavailing, the wound should be kept open by sutures or hooks, and a second trial made the next day. A tracheotomy tube would hinder expulsion of the foreign body. Laryngotomy, because of the danger of injuring the vocal bands, should be performed only when the foreign body is in the larynx and cannot be removed in any other manner. Several attempts have been made to remove foreign bodies in the bronchi which could not be dealt with through a low tracheotomy wound, by splitting the sternum or by opening the thorax posteriorly, with, we believe, but a single success. If a foreign body causes pulmonary abcess or gangrene which can be localized, these should be opened and drained, when the irritating body may be detected, or perhaps discharged later. RESPIRATORY SYSTEM 603 Edematous laryngitis (edema of the glottis) niu}- be caused by other forms of laryngitis, by injuries, such as fractures of the larynx, scalds, and foreign bodies, by inflammatory conditions in the vicinity, such as cellulitis of the neck, and by Bright's disease, angioneurotic edema, the acute infectious fevers, and the internal administration of potassium iodid for other forms of laryngeal trouble. The symptoms are interference with breathing, particularly inspiration, with cyanosis, etc., as the obstruction becomes more complete. The diagnosis is made by the laryngoscope and by feehng the swollen epiglottis with the linger. The treatment in the milder cases is multiple punctures or scarification of the swollen tissues, the inhala- tion of steam laden with compound tincture of benzoin, and ice to the neck. In more severe cases high tracheotomy should. be performed, not waiting until the patient is in extremis. Intubation is to be preferred, providing the swelling is not too great to prevent the introduction of a tube. Chrondritis is always associated with perichondritis, and may be due to trauma, chronic laryngitis, syphilis, tuberculosis, epithehoma, typhoid fever, or the exanthemata. The cricoid and arytenoid cartilages are most frequently affected. Necrosis may occur and pus may form {abscess of the larynx), which may discharge internally or externally; subsequently cicatricial contraction is very apt to cause stenosis. The symptoms are pain, tenderness, cough, hoarse- ness, dysphagia, and dyspnea. SwelHng may be noticed externally, or perhaps detected only with the laryngoscope. The treatment is much like edema of the glottis. Abscesses may be opened within the larynx or externally, according to where they point. In the later stages removal of necrotic cartilage may be indicated. Syphilis of the larynx may appear in the secondary stage as mucous patches or condylomata, and in the tertiary stages as a gummatous degeneration, causing extensive destruction of tissue with subsequent cicatrization and stenosis. A subacute or chronic laryngitis without ulceration, causing Httle or no trouble beyond hoarseness, also occurs. In the ulcerative form the symptoms are pain, cough, hoarseness, dyspena, and dysphagia. Syphilitic lesions are present elsewhere and the ulcers revealed by the laryngoscope are usually symmetrical; in the tertiary stage the epiglottis is par- ticularly apt to be affected. The treatment is that of syphilis, with the insufflation of iodoform into the larynx. Potassium iodid, how- ever, must be used with caution, lest it produce edema of the glottis. Tracheotomy may be needed for edema, convulsive closure of the glottis, or later for cicatricial stenosis. 6o4 MANUAL OF SURGERY Tuberculosis laryngitis may be primary, but is usually secondary to phthisis. Tubercles form, break down, and become ulcers, which coalesce and often cause great destruction of tissue. The most common situtaion for these ulcers is about the arytenoid cartilages, the vocal cords, and the under surface of the epiglottis. Elevated granulations on the posterior wall of the larynx are strongly suggestive of tuberculosis. The subjective symptoms are those of syphilis of the larynx. Tubercle bacilli may be found in the expecto- ration. The treatment is that of tuberculosis elsewhere, with applica- tions of lactic acid and insufflations of iodoform or thymol iodid. Tracheotomy may be needed for the same conditions as in syphilis of the larynx. Tumors of the larynx may be benign or malignant. The papill- omata are the most common; they are most frequent on the vocal cords and sometimes undergo an epitheliomatous change. The symptoms are hoarseness or aphonia, cough, dyspnea, and sometimes pain and dysphagia. In adults the growth may be seen with the laryngoscope; the warty-like appearance of the papilloma is dis- tinctive. The treatment is intralaryngeal removal by special forceps or snare, or by cauterization. Cysts may be incised. In children and in extensive subglottic growths it will usually be necessary to split the thyroid cartilage in the middle line (thyrotomy) and deal directly with the growth. Malignant tumors may be sarcomata, but are usually epitheliomta which frequently result from previously benign tumors and grow slowly. The symptoms are those of benign tumors, but pain shooting towards the ears and hemoptysis are more frequent, and there is likely to be emaciation and lymphatic involvement. The diagnosis in the early stages is often difficult; in doubtful cases a piece of the grow^th should, if possible, be secured for microscopic examination. The treatment is removal of the growth by thyrotomy, or by partial or complete laryngectomy, according to its extent. A preliminary tracheotomy is usually required. Cure has been obtained in 26.6 per cent, of the cases (Kocher). Endolaryngeal operations are not competent to deal with malignant disease. In the later stages tracheotomy may be performed to relieve dypsnea. Tiuncrs of the trachea have in a general way the same features as those of the larynx, except that respiration is more apt, to be affected than phonation. The tumor may be of any variety, is often recog- nized by the laryngoscope, and may in suitable cases be excised through a tracheotomy wound. RESPIRATORY SYSTEM 605 OPERATIONS UPON THE AIR PASSAGES Subhyoid pharyngotomy may be performed to gain access to the pharynx or upjxT ])art of the larynx, but the operation is rarely used A transverse incision is made between the hNoid bone and the thy- roid cartilage and the ])harynx opened, the epiglottis being detached from the tongue. Intratracheal insufllation anesthesia, or a pre- liminary tracheotomy will be necessary in removing growths, etc., which cause much hemorrhage. The structures are sutured at the completion of the operation. Transhyoid pharyngotomy maybe used for the same purposes as the above. An incision is made in the median line from the chin to the thyroid notch, the hyoid bone divided, and the pharynx opened. Etherization by intratracheal insufflation obviates the necessity for a preliminary tracheotomy. Thyrotomy exposes the interior of the larynx by splitting the thyroid cartilage in the median line, after performing tracheotomy and inserting a tampon cannula into the windpipe, or continuing the anesthesia by intratracheal insufflation. The wound in the thyroid cartilage is widely separated and the interior of the larynx exposed to view. The wound may subsequently be closed by sutures. Laryngectomy is performed for malignant disease and occasion- ally for other conditions, such as extensive stenosis or ulceration. It may be complete or partial according to the extent of disease, and in a few cases adjacent portions of the tongue, pharynx, and esophagus have been excised. After unilateral laryngectomy the patient is able to speak, after total laryngectomy he is able to whisper. A low tracheotomy should be performed a week or more before the excision of the larynx, especially if there is much dyspnea, in order to accus- tom the patient to breathe through the tube, to faciUtate anesthesia, and to lessen the time of the larger operation. The patient is ether- ized through the tracheotomy wound by means of intratracheal in- sufflation, or chloroformed after the insertion of a tampon cannula. A median incision is made from the hyoid bone to below the cricoid cartilage, a transverse cut made at either end of this incision, the flaps reflected, the larynx isolated by blunt dissection, and removed by cutting through the thyrohyoid space above and the trachea be- low. The upper end of the trachea is sutured to the skin and the wound packed with gauze and partly sutured, the patient being fed by means of a tub(^ introduced into the esophagus through the nose or the mouth. The cervical lymphatic glands are of course removed before completing the operation. When healing is complete the 6o6 MANUAL OF SURGERY patient may wear an artificial larynx. Some surgeons prefer perform- ing the tracheotomy immediately before the laryngectomy, others discard the preHminary tracheotomy altogether, and after isolating the larynx sever the trachea, suture it to the skin, and close the opening in the pharynx; this of course prevents the use of an artificial larynx. Larjmgotomy is an emergency operation in cases of laryngeal obstruction from any cause. A vertical incision is made over the cricothyroid membrane, the cricothyroid membrane divided trans- versely close to the cricoid cartilage, and a tube introduced. The cricothyroid artery may be injured and require a ligature. In a great emergency the whole operation may be completed by a single transverse incision made with a penknife, and the patency of the opening maintained with the handle of the knife. The operation is not applicable to children, owing to the small size of the cricothyroid space; if ever performed before puberty, it should be combined with division of the cricoid and possibly the first ring of the trachea (laryngotracheotomy) . Tracheotomy is performed for serious obstruction to respiration, for the removal of foreign bodies, and as a preliminary to operations on the mouth, pharynx, or larynx. The high operation, i.e., above the isthmus of the thyroid gland, is always selected when possible, because in this situation the trachea is superficial and the operation much more simple. When the obstruction is low down, however, or when one desires to search for a foreign body in the trachea or bronchi, the low operation is indicated. High tracheotomy may be performed under a general or a local anesthetic, or indeed in urgent cases without any anesthetic. A pillow is placed under the shoulders so as to extend the head, and an incision, exactly in the median line, is made from the cricoid down- wards for one and one-half inches, dividing the skin and superficial and deep fascse. The trachea is now exposed by separating, if necessary, the sternohyoid muscles. The isthmus of the thyroid gland normally lies over the third and fourth tracheal rings. If it be in the way, it may be depressed after dividing the deep fascia trans- versely, or it may be incised in the median line, without ordinarily giving rise to much hemorrhage. A tenaculum is inserted below the cricoid to steady the trachea, which is opened from below upwards, being careful to guard the knife with the index finger so as not to injure the posterior wall. Ordinarily two or three rings are divided, the cut being exactly in the middle line. A pair of hemostats should be introduced into the trachea before the knife is withdrawn and a tracheotomy tube inserted as the blades of the forceps are sep- RESPIRATORY SYSTEM 607 arated. The tenaculum should not be removed until the tube is in place. The tube is held in position by tapes tied around the neck. In the absence of a tube one may suture the edges of the tracheal wound to the skin. Bleeding from the small veins which have been divided usually ceases promptly when the trachea is opened. The wound is sutured, leaving sufficient opening for the tube, a couple of layers of gauze are placed beneath the flange of the tube, and one or two layers moistened with boric acid solution over the orifice of the tube. In low tracheotomy the skin incision may reach the sternum, but the lower part of the wound should be deepened very cautiously because of the danger of wounding the innominate vein or the thyro- idea ima. Often the inferior thyroid veins are large and numerous and lie directly over the trachea; they should be ligated or pushed aside. If need be, the isthmus of the thyroid gland may be pushed upwards. The rest of the operation is pre- cisely the same as the high operation. In children the low operation is extremely difficult because of the depth and small size of the trachea, the shortness of the neck, and the large size of the thymus gland. If the obstruction is still below the tracheo- tomv opening a long tube or catheter mav possibly be passed beyond it. ' ^^°- 3 07. -Tracheotomy tube. Tracheotomy tubes are made of hard rubber, silver, or aluminum. They are always double, the outer tube having a flange with slots, through which tape may be passed, and the inner tube being fastened to the outer by a little catch on the side so that it may be re- moved and cleansed as often as necessary (Fig. 307). Some of these tubes are provided with a long handle or introducer and a special speculum-like apparatus or dilator to facili- tate introduction, but such are usually unnecessary. When a tracheotomy is performed preliminary to operations on the mouth, larynx, etc., a tampon cannula, i.e., one encased in a rubber sac, which may be inflated in order to fill the space betw^een the tube and the tracheal wall, or covered with a compressed sponge which swells when moistened, is sometimes employed to prevent the entrance of the blood into the lungs, although with intratracheal insufflation anesthesia such appliances are not needed. After Treatment. — The room should be kept at a uniform tem- perature of 75°F., the air moistened by steam, and the gauze over the tube changed as often as the patient coughs, so that the mucus, etc. 6o8 MANUAL OF SURGERY will not fall back into the tube. The inner tube should be removed every two or three hours by the nurse and cleansed, the outer tube may be removed once a day by the physician for the same purpose. Mucus in the trachea may be extracted by a sterile feather moistened with bicarbonate of soda solution, 20 grains to the ounce. If there is much difficulty in breathing, oxygen may be given by intratracheal insufflation. The tube should be removed permanently as early as possible, but the time that it should remain in place will vary greatly with the condition; thus after the removal of a foreign body it may be only twenty-four hours, in some cases of stenosis it may be for the rest of the patient's life. Tubes are constructed with an opening in the convex portion, so that part of the air will pass through the larynx; if breathing is free when the outer opening is plugged, the tube may be removed with safety. Among the complications of tracheotomy may be mentioned ulceration of the trachea from a poorly fitting tube, cellulitis, secondary hemorrhage, mediastinal emphysema, bronchitis, pneumonia, and stenosis of the larynx, or trachea. Stenosis of the larynx may be treated by gradual dilatation with O'Dwyer's tubes, or in some cases by removing the cicatricial tissue and skin grafting the interior of the larynx. Intubation of the larynx may be used for many forms of stenosis of the larynx, but is chiefly employed in that form due to diphtheria. It is rapidly performed with much less risk than tracheotomy, but requires special instruments, and the presence of the surgeon if the tube should be coughed up. The instruments are shown in Fig. 308. The child is wrapped in a blanket to control the arms and legs, and is held upright by a nurse seated in a chair, while an assist- ant holds the head upon the nurse's left shoulder and prevents the mouth gag from slipping. A long piece of silk is passed through the small opening in the upper part of the tube, the tube fastened to the introducer, and the silk looped around the little linger. The left index finger is passed into the throat, and draws the epiglottis and base of the tongue forward, while the tube is passed along it into the glottis. The left index finger is then made to press upon the head of the tube, which is released by pulling the trigger on the introducer, which is then withdrawn. When one is assured that the tube is in the right place and that the symptoms are relieved, the silk loop may be cut and withdrawn while the finger is again made to press down on the tube. If the tube is coughed up, it is too small and the next larger size should be introduced. In cases of diphtheria the membrane may be pushed before the tube and cause asphyxia, which, if not immediately relieved by expulsion of the membrane RESPIRATORY SYSTEM 609 after the tube has been pulled out by the string, will demand tracheo- tomy, hence instruments for this operation should always be at hand. The ])atient speaks in a whisper, and is apt to inhale food during deglutition, hence feeding should be per rectum or by nasal tube, although some advise feeding with the head lower than the body, or the giving of semi-solids, which will more easily pass over the glottis. The tube remains in place several days, and is then removed with Fig. 308. — To the left is the mouth gag, and the scale for determining the proper sized tube according to the age of the patient. Next is the introducer, next the extractor. On the right are the tubes, which are expanded above the rest on the ven- tricular bands, with a prominence posteriorly which rests between the arytenoid cartilages. The middle of the tube is enlarged, the enlargement resting just below the vocal cords, to prevent displacement of the tube upwards when it is in position. Be- tween the tubes on the right is the obturator, which fits into the tube and is screwed into the holder, and which is hinged in the middle so that it may be withdrawn after the tube is in position. The scale indicates the length of tube to be used, measuring from bolow upward the figures represent the age of the child. the child in the same position as for introduction, by passing the left index finger down to the tube and slipping the point of the extractor into its opening, the tube being engaged by pressing the spring on the shank of the extractor. SURGERY OF THE CHEST Contusion of the chest may cause superficial bruising of the skin, laceration of the muscles, fracture of any portion of the wall of the thorax, or more or less extensive injury to the contained viscera. Occasionally a severe blow on the chest or epigastrium (so-called 39 6lO MANUAL OF SURGERY solar plexus blow) will be followed by severe shock or even death, without causing any gross anatomical change; this condition has been termed concussion of the chest and is probably due to direct concussion of the heart muscle or its nerve mechanism. Owing to the lack of functionating valves in the jugular and facial veins, forcible compres- sion of the chest of some minutes' duration, such as may occur in a struggling mob, may cause a bluish or black discoloration of the face and neck, subconjunctival ecchymosis, and hemorrhages into the retina and brain (traumatic asphyxia). Rupture of the lung is recog- nized by cough, dyspnea, hemoptysis, subcutaneous emphysema, and hemo-pneumothorax. Ruptures of the large vessels, trachea, or esophagus are associated with such widespread injury that death quickly follows. For injuries of the heart see chap, xv, and for rupture of the diaphragm, chap, xxvii. The treatment of con- tusion of the chest is reaction from shock, and immobilization of the thorax as in fracture of the ribs. In the presence of marked evidences of internal hemorrhage, thoracotomy and efforts to check the bleeding are indicated. The treatment of pneumothorax is given on a later page. Wounds of the chest may be penetrating or non-penetrating; the latter are treated as wounds elsewhere. Penetrating wounds are usually caused by stabs or bullets. The diagnosis may be made by signs of injury to the viscera, or by exploration of the disinfected wound with a sterile finger; the latter is always advisable, particu- larly in wounds in the neighborhood of the heart, or below the sixth rib, as in this situation penetration of the diaphragm and injury to the abdominal viscera may easily occur. Wounds of the heart have already been discussed and injuries of the abdominal viscera will be considered in a subsequent chapter. The possible symptoms of a penetrating wound of the lung are those of rupture of the lung with a bleeding and a sucking external wound. The treatment in the absence of serious hemorrhage or the lodge- ment of a foreign body is debridement, suture of the external wound and immobilization of the affected side of the chest. Hemor- rhage from the internal mammary or intercostal artery may be con- trolled by ligation, or by pushing a gauze sac between the ribs and filling the inner end of the sac with gauze so that when drawn upon it will make pressure from within outwards. Excepting extensive wounds, bleeding from the lung is rarely fatal, as the bleeding is checked by collapse of the lung. In the absence of external hemor- rhage, serious loss of blood is diagnosticated by the constitutional signs of acute anemia and a rapidly accumulating hemothorax. RESPIRATORY SYSTEM 6ll Bastinelli sug'phoid bacillus, etc. The symptoms and signs are those of serous effusion, with, in a typical case, irregular fever, possibly chills and sw^eats. leukocytosis, edema of the chest wall, and absence of the whispered pectoriloquy which may be heard in serous effusions (BaccelWs sign). The diagnosis is contirmed by exploratory puncture. In some cases the pulsations of the heart are transmitted through the eff'usion {pulsating empyema). The pus may be localized by adhesions {encapsulated empyema), or fill the whole pleural cavity {total empyema). Spon- taneous recovery is possible but very rare. An empyema may per- forate the chest wall {empyema necessHatus), or it may break into the lung, esophagus, stomach, pericardium, or peritoneum. Rarely it may form a lumbar or psoas abscess. In acute cases the pleura is but httle altered, and although the lung is compressed, it readily expands when drainage is established. In chronic cases, however reexpansion is prevented by sclerotic changes in the lung and by the 6l4 MANUAL OF SURGERY dense and thickened pleura. In these cases nature tries to obliterate the cavity by causing a hypertrophy of the opposite lung, an ascent of the abdominal viscera on the affected side, a sinking in of the chest, a lateral curvature of the spine, and an abundant growth of granulations from the pleura. If the cavity is large, healing can take place only with the aid of surgery. The prognosis is considerably modified by the character of the infection thus a pneumococcal empyema in the early stages may often be cured by aspiration alone, as the organisms quickly perish, while the presence of other pyogenic bacteria will always indicate free drainage, and even then extensive subsequent operations may be demanded. A tuberculous empyema will of course present a grave prognosis. Cultures in these cases, as well as in a late pneumococcal empyema, may be sterile. The earlier drainage is instituted, the greater the chance of reexpansion of the lung. The treatment of acute cases is aspiration, intercostal incision, or rib resection, depending upon the character of the exudate, chronic cases may demand the Estlander, Schede, or Fowler operation. The principle in acute cases is to remove the fluid with out the collapse of the lungs, in chronic cases to obhterate the cavity by causing the chest wall to collapse or the lung to expand, by removing adhesions or the thickened pleura. Dunham and Moschowvitz advise the repeated aspiration of the plural effusions until they become macro- scopically purulent. Before this stage pleural adhesions are not formed and if a pneumothorax is produced not only collapse of the involved lungs occurs but also of the opposite lung. According to Graham and Bell the normal mediastinal tissues are so mobile the thorax must be considered as one cavity in relation to pressure changes. Paracentesis thoracis (tapping) may be performed with an ordinary trocar and cannula, but as this permits the introduction of air, aspiration should be employed whenever possible. A hypodermic or an antitoxin syringe, with a long and strong needle of large calibre, may be used for diagnostic purposes. Fig. 309 shows an aspirator. The stopper is inserted into a large glass bottle, the stop-cock A closed and the stop-cock B opened, a vacuum created in the glass bottle by the pump, and stop-cock B closed; after the needle has been inserted into the chest, stop-cock A is opened and the fluid in the pleural cavity enters the bottle. The skin and needle should be dis- infected, and the patient placed in a semi-recumbent posture, unless such is contraindicated. Local anesthesia is usually unnecessary, although it is desirable to give a little whiskey before operation. The puncture is generally made in the eighth intercostal space near KESPIRATORV SYSTEM 615 the angle of the scapula, or in the sixth interspace in the midaxillary Hne, remembering that the pleura does not extend as low in children as in adults. A small puncture is made over the lower rib with a knife, and the skin pulled upwards, so that the needle, guarded by the index finger, may be introduced close to the upper edge of the rib, in order to avoid the intercostal vessels; thus the opening is valvular and closes as soon as the needle is withdrawn. If the tap be dry, a stylet may be introduced into the needle to make sure that it is not plugged and if fluid still fails to come, the needle should be partly withdrawn, and reintroduced at a different angle. The fluid is withdrawn slowly, and the flow stopped for a time if there is faint- ness, violent cough, or marked alteration in the pulse. The puncture in the skin is covered with collodion. Although it is true that aspiration will occasionally cure empyema it is generally regarded Pig. 309. — -Aspirator. by surgeons as an exploratory or palliative measure or as a prelimi- nary measure to permanent drainage. Thoracotomy (opening the pleural cavity), with or without resection of a rib, is the means of providing more or less permanent drainage. Thoracotomy with- out resection of a rib is indicated when the patient's condition is very serious, as it is easily performed under local anesthesia, by making an incision about two to four inches in length along the lower border of the seventh or eighth intercostal space in the post- axillary line. A small opening is made in the pleura, in order to allow the pus to escape slowly; the opening is then enlarged, loose pieces of lymph removed, and a short rubber tube introduced. The tube should be sutured to the skin, to prevent its expulsion, and transfixed with a large safety pin, to prevent its dropping into the cavity. Resection of a portion of a rib is the usual operation, as it allows more room for exploration and free drainage. Ether 6l6 MANUAL OF SURGERY is contraindicated, because of its effect on the lung. The best general anesthetic is nitrous oxid and oxygen, but chloroform may- be employed, local anesthetic is the method preferred. The patient lies on his back or as suggested by Elsberg, on his face and is brought to the edge of the table. A two to four inch incision, with its center in the post axillary line, is made over the seventh rib, and the periosteum divided and separated from the entire circumference of the rib with closed curved scissors or a perios- teal elevator. The rib is divided at each extremity of the in- cision with bone forceps and removed, the intercostal vessels having been pushed aside with the periosteum; the pleural cavity is opened by an incision through reflected periosteum and the operation then proceeds as in thoracotomy without resection of the rib. Irrigation of the cavity should never be employed in acute cases as it is occasionally followed by death. In chronic cases, however, and in those which the adhesions are firm, ir- rigation is advisable. The tube may remain in place until the purulent discharge ceases, or, better, it may be removed at the end of a week, and a Bier suction pump used once or twice daily until the lung is fully expanded. Moschcowitz advocates intercostal incision, the insertion of a rubber drainage tube having a cuff of rubber dam which lies in contact with the skin and is held in place with adhesive strips. To the outer end of this tube is attached a combination instillation and suction apparatus by means of a Y tube. At first hourly and later second hourly instillations of Dakin's solution are employed. After six or seven days this suction ap- paratus is removed and one to four Carrel tubes inserted. An additional plain, non fenestrated rubber tube, guarded by a safety pin, is introduced to permit of a free escape of Dakin's solution and secretions. The same technic is followed as in all infected wounds, and when surgical sterility is obtained the tubes should be removed and the intercostal wound allowed to close. If the sinus persists (pleural fistula), there is caries of a rib, non-obliteration of the cavity, pleuro pulmonary or broncho cutaneous fistulae. In either case a secondary operation will be required. If the lung fails to reach the chest wall after several months, the chest wall should be taken to the lung by thoracoplasty (Estlander of Schede operation). One may first try, however, injections of Beck's bismuth paste (see Sinus). The cavity is filled with mixture No. i (not more than loo grams being used) and the opening allowed to close. If the temperature rises above ioi° or severe pressure symptoms appear, the accumu- lated fluid is evacuated and the opening again allowed to close RESPIRATORY S\STEM 617 Repetition of the injection is necessary only when the paste is dischara5w) is character- ized by atony and dilatation of the gullet with spasm of the cardia; which of these is the primary lesion is a matter of dispute. It may be associated with esophagitis or disease of the stomach or liver, but in many instances no cause for the spasm can be found, beyond the fact that the patient is nervous. The symptoms are first those of spasmodic stricture, and, as the spasm becomes continuous, those of organic stricture (vide infra). The X-ray and the esophagoscope are important aids in making a diagnosis. If due to functional disease of the nervous system treatment with atropin is useful. Bromids, and valerian may also be tried. If these fail instruments should be used. The treatment is dilatation through the mouth by means of large bougies; by means of a rubber bag attached to a tube, and distended after it is in place; or by means of a special divulsor introduced through the esophagoscope. In the worst cases the cardia may be stretched with the fingers or a uterine dilator, after opening the stomach. More severe operations, e.g., division of the cardia longitudinally with transverse suture, resection of the cardia, esophagoplication through the abdomen or thorax, should very rarely be indicated. Wounds of the esophagus from without have already been referred to under cut throat. Internal injuries, e.g., from foreign bodies, bougies, and the swallowing of caustics, cause painful dyspha- gia, bleeding, and emphysema if the wall is perforated. The patient is fed by rectum for a week or more, and sounds used when healing has occurred, in order to prevent the development of a stricture. After the swallowing of a caustic the proper antidote should, of course, be administered. UPPER DIGESTIVE APPARATUS 659 Foreign bodies in the esophagus arc most frequent in children and lunatics. They are aj^t to be arrested at the narrowest portions of the tube, viz., opposite the cricoid cartilage (6 inches from the teeth), at the level of the left bronchus (12 inches from the teeth), and at the diaphragmatic opening (16 to 18 inches from the teeth). The symp- toms are dysphagia, pain, and sometimes dyspnea. Sharp or rough bodies may cause hemorrhage; prolonged impaction may lead to per- foration and death. Owing to the irritation which isi)roduced, the symptoms sometimes persist for a time, even after the foreign body has been removed. Foreign bodies may be detected with the bougie, with the esophagoscope, or if dense, with the X-ray (Fig. 3 70) . When lodged in the cervical portion of the tube external palpation may be of some value. The patient is usually able to indicate the site of im- paction. The best treatment is extraction under the eye by means of Fig. 370. — Skiagraph showing location of penny in esophagus above a stricture, the result of swallowing lye. long slender forceps introduced through an esophagoscope. Of 193 cases of esophagoscopy for foreign bodies, performed by skillful opera- tors, the foreign body was removed 155 times, and escaped into the stomach 26 times. Twelve of the patients died (Jackson). If one has no esophagoscope, or no skill in using it, and the patient cannot be sent to a specialist, one of the older methods of extraction must be selected for which purpose the size, shape, situation, and nature of the body should be ascertained whenever possible. Bodies like pins and fish bones may be extracted with the expanding horsehair probe (Fig. 371) discs and coins with the coin catcher (Fig. 372). Round and smooth objects may sometimes be pushed into the stomach. When in the cervical portion of the esophagus, the offending substance may often be removed with long curved forceps. Esophagotomy is indicated when a body is impacted in the upper part of the tube, the esophagus being exposed in the neck as described in the treatment of diverticula, and sutured after extraction of the foreign body. 66o MANUAL OF SURGERY Impaction in the lower part of the esophagus may demand gastrot- omy, and extraction of the foreign body by the finger or forceps intro- duced through the cardiac orifice of the stomach. The mortality of cutting operations for foreign bodies in the esophagus is 20 per cent. Stricture of the esophagus may be (i) inorganic or (2) organic. I. Inorganic or spasmodic strictiu'e (esophagismus) is usually hysterical in origin, the spasm beginning below and ascending (globus Fig. 371. — Expanding horsehair probang. Fig. 372. — -Coin- catcher. Fig. 373. — Esophageal bougies. hystericus) , but occasionally occurs in tetanus, and as the result of reflex irritation in diseases of the larynx (opposite the larynx), liver, and stomach (at the cardia) . In the last situation it may become permanent and give rise to the so called idiopathic dilatation of the esophagus (q.v.). The symptoms are sudden in onset, intermittent in character, and associated with evidences of the causative lesion. There is a spasmodic choking sensation, with dysphagia and some- times regurgitation of food. Anesthesia relaxes the spasm and per- UPPER DIGESTIVE APPARATUS 66 1 mits the i)assage of a full-sized bougie. The treatment is directed to the cause. The passage of bougies will do more harm than good in hysterical cases. 2. Organic stricture is usually (a) cicatricial or (b) malignant, although it may be congenital or be caused by foreign bodies or the pressure of aneurysms, tumors, etc. (a) Fibrous or cicatricial stric- ture is generally the result of the swallowing of corrosives, but may follow also other injuries and ulcerations. It is most frequent in the young and often situated opposite to the cricoid cartilage. In some cases there are multiple strictures. The S5miptoms come on slowly, there first being difficulty in swallowing solids and finally in swallowing liquids. When the stricture is near the stomach, food may not be returned immediately but may collect in the pouch which forms, and regurgitated after an interval, the reaction being alkaline, not acid as would be the stomach contents. Pain is slight or absent and, as a rule, the patient is able to locate the site of obstruction. In the later stages there is marked emaciation from starvation. The diagnosis is confirmed and the stricture located wdth an esophageal bougie (Fig. 373), which in the adult should normally enter the stomach 16 to 18 inches from the teeth. The patient is seated with the head forward and the jaws open; the bougie is warmed, lubricated with glycerin, and passed downward into the esophagus while the left forefinger depresses the tongue and guards the orifice of the larynx. Great force should never be employed, particularly if cancer is suspected, as perforation and death may follow. Furthermore, it is well to rule out the pres- ence of aneurysm before passing a bougie. In all cases there is a delay in the swallowing sound, which is normally about four seconds in length, i.e., from the time the patient begins to swallow a mouthful of water until the last gurgle into the stomach is heard; the ear is applied to the vertebral groove near the angle of the left scapula. Finally the esophagoscope may be used to determine the nature and site of the stricture, and the seat of narrowing may be graphically depicted by a radiogram, after the ingestion of bismuth. The treatment is gradual dilatation by passing increasing sizes of bougies every second or third day. In order safely to penetrate a minute stricture, a filiform bougie may be inserted under direct in- spection through the esophagoscope. Plummer has the patient swallow sLx yards of fine silk, three in the evening and three the following morning. The portion first swallowed passes into the intestine, so that the thread hanging from the mouth may be pulled taut. A bougie with a perforated olive tip is then threaded on the silk, which 662 * MANUAL OF SURGERY acts as a guide to the orifice of the stricture. In cases in which dilatation cannot be practised a Symond's tube may be used. This is a rubber tube, funnel-shaped at the upper end where it rests against the stricture. It is inserted by a whalebone introducer, and removed every two or three weeks by means-of a piece of silk attached to its upper end and issuing from the mouth. Retrograde dilatation by means of the linger or bougie may be practised after opening the stomach when the lesion is near the cardiac orifice. Abbe's operation is applicable to strictures in the thoracic portion of the esophagus which have resisted other means of treatment. A shot clamped to the end of a fine piece of silk is swallowed by the patient. The stomach is then opened and coarse silk attached to the thread and pulled through the stricture, which is then divided by sawing move- ments, while it is made tense by the pressure of a bougie passed from below. In some cases the silk is brought out through an esophago- tomy wound in the neck instead of through the mouth. The calibre of the esophagus is maintained by the passage of bougies. Ochsner 's method consists in opening the stomach, and passing a long loop of silk through the stricture by means of a whalebone probe. A small rubber tube is passed through this loop, and drawn through the stric- ture while on the stretch. When released the rubber swells and dilates the stricture. Increasing sizes of tubes are thus employed. Internal esophagotomy by means of an instrument with a concealed kniie, forcible dilatation by special divulging instruments, and electro- lysis have been successfully utilized with the aid of the esophago- scope. External esophagotomy has been employed in high strictures, the contraction being divided, dilated, or even excised. Esophagos- tomy consists in suturing the mucous membrane of the esophagus below the stricture to the skin, thus making an artificial mouth. Gastrostomy is indicated when swallowing is impossible, in order to feed the patient. A stricture which is thus rested may after a time become passable to bougies. If the stricture remains impermeable esophago plasty (vide infra) may be tried. (b) Malignant stricture is most frequent in men after the age of forty, and most comrnon at the narrowest portions of the esophagus, viz., opposite the cricoid, at the level of the left bronchus (being epitheliomatous in both instances), and at the cardia, when it is a columnar-celled carcinoma. The symptoms are those of cicatricial stenosis, but there are greater pain, more rapid emaciation, and often cough, and regurgitation of blood-stained food. The tumor may be felt when the cervical portion is involved. Other symptoms mav arise owing to invasion of surrounding structures. As the UPPER DIGESTIVE API'ARATUS 663 a])i)caranccs of carcinoma are distinctive, the diagnosis may be made, even in the earliest stage, by means of the esophagoscope, a bit of tissue being removed for microscopic corroboration; and since resection of the esophagus has been successfully performed, early diagnosis is essential, if more patients are to be saved. The bougie and the X-ray are valuable only in the later stages, for determining the site of the stricture, but are incompetent to establish definitely its carcinomatous nature. Moreover, since the bougie is blind and a carcinomatous stricture often friable, esophageal sounding is attend- ed by greater danger than exploration under the guidance of the eye. The treatment in the early stages is generally the passage of a soft rubber bougie to keep the canal open. Symond's tube has been used in some cases. The insertion of a capsule of radium through the esophagoscope is a palliative measure of some value. Gartros- tomy, which permits the patient to be fed and puts the esophagus at rest, should not be postponed until swallowing is impossible, but should be preformed as soon as the dysphagia becomes pronounced. Esophagectomy should, we believe, be recommened in suitable cases. Esophagectomy for a growth limited to the cervical portion of the gullet has been performed successfully a number of times. In one case we removed the cervical esophagus, the larynx, the trachea as far as the manubrium, and the thyroid gland. Excision of the thoracic portion of the esophagus has been attempted extrapleurally, after resecting a portion of several ribs near the spine, but more room can be obtained by the transpleural route, the operation being conducted, in order to prevent collapse of the lung, with the aid of differential pressure (positive or negative), or, better, with the aid of intratracheal insufflation anesthesia. Efforts to anastomose the esophageal segments left after excision of the growth, or to anastomose the upper segment with the stomach, have resulted in failure. Torek's patient, who is still living eighteen months after excision of the thoracic esophagus, was operated upon in two stages A gastrostomy was first performed. At the second operation a cut was made through the entire length of the seventh left intercostal space, thence upwards through the seventh, sixth, fifth, and fourth ribs, between their angles and tubercles. A rib spreader was placed between the seventh and the eighth ribs, the esophagus separated by blunt dissection, cut at each end between ligatures, and removed. The upper end was brought out at the base of the neck, the lower end invaginated. The chest was closed by passing sutures around the seventh and the eighth ribs, the lung being fully inflated before the last stitch was tied. Zaaijer and Ach have successfully excised a 664 MANUAL OF SURGERY carcinoma of the cardia. Zaaijer first established a gastrostomy. In the second stage he resected a number of ribs so as to allow the thoracic wall to collapse, thus lessening the distance to the growth. At the third operation the pleural and the peritoneal cavities were opened, the diaphragm was split up to the hiatus, the growth re- moved between clamps, the stomach closed, and the lower end of the esophagus sutured to the skin near the posterior axillary line. After operations of this character food may be led from the lower end of the remaining portion of the esophagus to the opening in the stomach by means of a rubber tube, or an artificial esophagus may be con- structed as described in the next section. Esophagoplasty, or the formation of an atificial esophagus may be tried in cases of impassable, inoperable, cicatricial stricture of the esophagus, or in cases in which the esophagus has been resected. The skin between the esophageal and the gastric fistulae may be fashioned into a tube, the outer surface of which is covered with flaps from the chest (Bircher). The upper part of the jejunum (Roux) or the transverse colon (Kelling, Vulhet) may be isolated, except for the mesenteric attachment, and drawn up beneath the the skin of the thorax, the lower end of the transplanted intestine being anastomosed with the stomach, the upper with the stump of the esophagus. Hirsch suggests employing the anterior wall of the stomach, Jianu the whole length of the greater curvature; in these methods one end of the new esophagus is already attached to the stomach. Fink proposes severing the pylorus, drawing it up beneath the thoracic skin, and performing posterior gastroenter- ostomy. Intra-instead of antethoracic transplantation of a segment of the stomach or the intestine also is a possibility. CHAPTER XXVII ABDOMEN The postures different operations may require and the situation of the incisions for exposure of various organs, are given with the description of the operations on the viscus concerned. In order to give an idea of the way in which the abdomen is opened and closed, we shall here describe only the median incision, since it is often selected, not only because it avoids the larger nerves and blood vessels, but also because it permits exploration of both sides of the abdominal cavity. When it is necessary to pass the umbihcus, the left side is chosen to avoid the round Hgament of the liver, although some operators excise the umbihcus because it is difhcult to sterilize and to suture. After incising the skin and subcutaneous tissues, instead of locating the linea alba with nicety, the anterior sheath of the rectus, usually the right, is spHt longitudinally a short distance from the median line, the muscular fibres separated with the finger or the handle of the knife, and the posterior sheath and transver- saHs fascia divided. Thus are presented several layers of tissue giving broad apposition for subsequent union, instead of the single aponeurotic layer formed by the linea alba. The peritoneum, which is recognized by the presence of fatty tissue in front of it, is elevated from the viscera with forceps and opened sufficiently to admit the finger, which guards the intestines while the opening is enlarged with the scissors. After the intraperitoneal manipulations have been completed the wound is closed with great care in order to prevent the development of a hernia. Buried sutures should be of catgut, sutures which are subsequently removed, of silkworm gut. Through and through sutures, which are introduced about one-fourth inch from the edge of the wound and about one-half inch apart, obHterate all dead spaces, stop oozing, give firm support, and permit rapid work. Suture of the individual layers of the abdominal wall is anatomically more accurate, and, owing to the smaller amount of tension on each suture, less apt to cause necrosis. The various ways of closing the skin incision, when the tier suture is employed, are given in the chapter on "Wounds". The author, whenever possible, puts a purse-string suture of catgut in the peritoneum, thus making a dot instead of a line of scar tissue and lessening the chances of adhes- 66s 666 MANUAL OF SURGERY ions; the suture is tied, and the needle passed from within outwards through the muscle and its anterior sheath and temporarily laid aside; through and through sutures of silkworm gut are passed through all the layers except the peritoneum; the anterior sheath of the rectus is closed with a continuous suture, using the same thread that was placed in the peritoneum, thus drawing the peritoneum up under the muscle and preventing the formation of a dead space; and finally the silkworm-gut sutures are tied. In the upper abdomen the perito- neum tears so easily that the purse-string suture is inapplicable. In this region, therefore, the peritoneal suture should include a portion of the muscle and be applied in the direction of the wound in the abdominal wall. The wound is dressed with aseptic gauze, retained in place by adhesive plaster and a firm binder. The patient is not allowed to sit up for from ten days to three weeks or longer, according to the situation and length of the incision and the presence or absence of drainage or infection. In most instances the patient should wear an abdominal support for a week or two after leaving bed, or, if the wound has healed by second intention, for a year, when the scar may be inspected for bulging, and the support discarded if no hernia be found. The indications for abdominal section {celiotomy, laparotomy), in order to deal with particular affections of the various intraperi- toneal organs, are given on the pages devoted to the surgery of these organs. Often, however, the surgeon who is confronted by a patient with abdominal symptoms finds that he is unable to make a precise anatomic and pathologic diganosis, and is forced to be content if he can decide whether or not an operation is necessary, when it should be performed, and where to make his incision in the abdominal wall. Immediate abdominal section to save life may be demanded to control hemorrhage, to combat infection, or to relieve obstruction. Hemorrhage due to traumatism may arise after contusions of the abdomen which rupture one or more of the viscera or important blood vessels, after penetrating wounds, and after abdominal operations. Nontraumatic hemorrhage may result from the rupture of an aneurysm, a hematoma of the ovary, the tube in ectopic pregnancy, the uterus during labor, or an enlarged spleen in typhoid fever. Infection can often be prevented by timely operation, notably in cases of abdominal injury which cause extravasation of the contents of a hollow viscus or extrusion of the viscera through the abdominal wall, and in cases of pathologic perforation of a hollow ABDOMEN 667 viscus (stomach, inlcstinc, gall bladder, urinary bladder). It is in the stage of contamination, i.e., during the first few hours after the accident or the perforation, that the surgeon must act to secure the best results. After twelve hours, and, more emphatically, after 24 hours, the infection (peritonitis) has become well established, and the chance of survival greatly diminished. In another group of cases the infection has already occurred, but is confined to a single organ (appendix, Meckel's diverticulum) or circumscribed by adhesions or inflammatory tissue (acute abscess within or behind the peritoneum). In these cases early operation may prevent extension of the infection. Although acute pancreatitis may be of a chemical rather than of a bacterial nature, and acute hemato- genous infection of the kidney requires a lumbar incision rather than celiotomy, both of these affections should be mentioned among abdominal emergencies, because the first often causes widespread fat necrosis of the omentum and meserrtery, and the second is frequently confused with intraperitoneal lesions, especially appen- dicitis. Acute obstruction of the intestine, including strangulated hernia; of the stomach (volvulus); of the blood vessels, e.g., in thrombosis or embolism of the mesenteric vessels, volvulus of the omentum, ovarian cyst or floating kidney with twisted pedicle; or of the ureter of an only existing or active kidney (obstructive anuria) must be operated upon at once. Delayed abdominal section may be advisable in two groups of cases. In the first the lesion is relatively benign, and the operation may be arranged to suit the convenience of the patient and the surgeon. Indeed, in some instances, e.g., reducible hernia, the patient may, with reason, decide on nonoperative treatment. In a second group of cases the operation is postponed in order to secure a more favorable opportunity for intervention. The cases in this group may be considered under the three headings of hemorrhage, infection, and obstruction. Acute hemorrhage into the stomach, e.g., from an ulcer, is rarely an indication for immediate celiotomy, since the bleeding often ceases spontaneously, at least for a time, and the operation can be more safely performed after the patient has recovered from the effects of the sudden loss of blood. Chronic hemorrhage from any organ requires careful investigation to determine its nature, and then prompt operation, if the condition is amenable to operation. Acute infection which tends to become subacute or chronic, e.g., acute cholecystitis, acute salpingitis and ovaritis, is usually not 668 MANUAL OF SURGERY attacked surgically until it becomes quiescent, hence less virulent. The chief concern in these cases is that of mistaking an infection that often extends for one that generally localizes or subsides, e.g., a perforated duodenal ulcer for acute cholecystitis, an appendicitis for a salpingitis. Chronic infections, e.g., of the gall bladder, appendix, and Fallopian tube, should, if possible, be dealt with before they cause acute symptoms or troublesome complications. The same may be said of chronic infections like tuberculous peritonitis, tuberculosis of the cecum, and actinomycosis of the cecum. Acute transient obstruction of the biliary ducts (hepatic colic) or of the ureter (renal colic) is treated medically, operation, if necessary, being deferred to a later period. Chronic obstruction of these ducts or of any portion of the gastrointestinal canal seldom necessitates an emergency operation, although the obstruction should be removed at an early period. Unnecessary abdominal section is sometimes impossible to avoid, especially in the presence of alarming symptoms which might be due to hemorrhage, peritonitis, or obstruction. The prominent features of these affections, viewed collectively, are pain, tenderness, muscular rigidity, vomiting, constipation, and tumor, with shock or fever, yet one or more of these features may exist in various maladies that do not demand laparotomy. The affections of the abdominal wall that may simulate intra- peritoneal lesions are muscular soreness from coughing, myositis, herpes zoster, neuritis, and neuralgia. Operable conditions of the abdominal wall, e.g., tumors, and abscesses, are of less importance, from our present standpoint, because they should, in any event, be treated surgically. Sometimes, however, a parietal abnormality may be completely overlooked, thus in a small epigastric hernia the pain and indigestion may be erroneously attributed to disease of the stomach or gall bladder, and in incipient inguinal hernia to disease of the appendix. The affections of the intraperitoneal and retroperitoneal structures that have caused error are acute gastrectasia, which very rarely requires operation; cardiospasm; acute irritation or inflammation of the stomach or intestines, e.g., from "indigestion," parasites, poisons (including ptomain poisoning, morphinism, and lead poison- ing), dysentery, typhoid fever, angioneurotic edema, and Henoch's purpura; mucous colitis; constipation; fecal impaction; unimpacted foreign bodies in the intestine; cirrhosis of the liver, with pain and swelHng in the region of the gall bladder, jaundice, hematemesis, melena, or ascites, thus resembling gall stones, gastric ulcer, or ABDOMEN 669 tuberculous peritonitis, with which conditions, indeed, hepatic cirrhosis is sometimes associated (cirrhosis of the Hver is occasionally operated upon, as will be noted later); cardiac liver, i.e., the large, painful, perhaps pulsating liver due to chronic valvular disease of the heart; splenomedulary leukemia; normal pregnancy, because of the tumor, the vomiting, and sometimes pain; abortion, which the patient may attempt to conceal, or which may be confused with ectopic pregnancy; dysmenorrhea; pelvic cellulitis, which, as a rule, should not be operated upon, unless of the suppurative variety; epididymitis; inflammed undescended testicle, unless suppurative or gangrenous; vesiculitis; Addison's disease, in which there may be vomiting, constipation, and abdominal pain; chronic nephritis leading to uremia, which may be associated with abdominal pain, tympanitis, and vomiting (more often the opposite mistake is made, i.e., an old lady with vomiting and oliguria is treated for uremia when the causative lesion is a small strangulated femoral hernia) ; ectopic or pelvic kidney; pyelitis; operable lesions of the kidney and ureter, which, not infrequently, are mistaken for intraperitoneal disease; distended urinary bladder; enlarged retroperitoneal lymph glands, e.g., , from Hodgkin's disease, leukemia, typhoid fever syphilis, tuberculosis (tabes mesenterica) , or metastatic tumors, especially metastases from malignant disease of the testicle and lymphosarcoma of remote regions like the neck; aneurysm of the aorta; arteriosclerotic colic (abdominal angina); iliac and femoral phlebitis; and phantom tumor. The thoracic diseases that may cause abdominal symptoms are pneumonia, phthisis, pleurisy (including diaphragmatic pleurisy) angina pectoris, pericarditis, dilatation of the right ventricle of the heart, and, as mentioned above, endocarditis which leads to con- gestion of the liver. Diseases of the spine, especially Pott's disease, often produce symptoms suggestive of intraabdominal trouble. The diseases of the central nervous system that should be noted in this connection are brain tumor (vomiting), cerebrospinal men- ingitis (fever, vomiting, abdominal pain, and rigidity), abdominal crises of locomotor ataxia, neurasthenia, and hysteria. Finally acute general infections, like influenza and small pox, may, because of pain, vomiting, and fever, be mistaken in their early stages for surgical diseases of the abdomen. The technic of abdominal section follows the general rules already laid down in chapter iv, to which the student is referred for the details concerning the preparation and after care of the patient. 670 MANUAL OF SURGERY the precautions to be taken in order to avoid leaving instruments or sponges in the peritoneal cavity, and the indications for and the dangers of drainage. Contusions of the abdomen vary from a superficial ecchymosis to the most extensive shattering of the viscera. Sudden and immedi- ate death following a blow on the abdomen, without gross injury to the viscera, has been attributed to shock, or disturbance of the solar plexus, but is probably the result of violence to the heart or to its nerve mechanism. Hematoma and suppuration of the abdo- minal wall may follow a contusion as elsewhere. Muscular rupture follows a violent force to a normal muscle in extreme tension, or a trivial injury to a degenerated muscle. The rectus tends to rupture more frequently than the broad muscles of the parietes. A rup- tured muscle should be sutured because of the subsequent danger of hernia. When a blow is expected, the body is bent, the muscles contracted, and the force expended on the abdominal wall, but a blow received when the muscles are flaccid is very apt to injure the viscera. The most serious intraabdominal injury may be present without any evidence of injury to the skin or muscles. The effects of visceral injury are manifested immediately, as shock, hemorrhage, or peritonitis; intermediately, as when peritonitis follows a per- foration through a contused necrotic patch in the intestine, the patient having been apparently well for one or more days; or remotely, as adhesions, stricture of the bowel, aneurysm, etc., developing after a prolonged period. In all cases of abdominal injury the surgeon should look not only for signs of shock, internal hemorrhage, and peritonitis, but also for signs of gas or fluid in the peritoneal cavity, and for blood in the vomitus. urine, and bowel movements, as well as for bleeding from the vagina. Ruptures of most of the large intraabdominal vessels have been recorded. Providing there be time, the abdomen should be opened and the hemorrhage checked. If the vessel be severely contused, bleeding may be postponed until sloughing of the arterial wall en- sues, or thrombosis, embolism, stenosis, or aneurysm may develop, and the parts suppUed by the artery may become gangrenous. From its elasticity and more protected position beneath the ribs, the stomach is less hable to be afifected by trauma than the intestines. The anterior wall is the most frequent site for rupture. One or all the coats may be torn. The symptoms are those of shock and per- forative peritonitis. Hematemesis may be present or absent. The stomach should be sutured and the treatment for peritonitis insti- tuted. ABDOMEN 671 Rupture of the intestine is frequently the result of a horse-kick, a man-kick, or a run-over accident, the intestine being crushed be- tween the vulnerating body and the bony parts behind. A fall from a height or a blow upon the back also may tear the intestine, particularly where it is iirmly fixed, e.g., the duodenum. 7'he most im]:)ortant sjonptoms are pain, tenderness, rigidity of the abdominal wall, and an an.xious facial expression. Shock is shght or absent in 25 per cent, of the cases. Absence of liver dulness with a flat abdo- men is a valuable sign of pneumoperitoneum, which may be demon- strated also by the X-ray. Cellular emphysema is rare and indicates a lesion of the bowel beyond the limits of the peritoneal space. Movable dulness in the flanks is a sign of fluid in the peritoneal cavity, which may be serous, sanguineous, or fecal. Fecal extravasa- tion is rarely great in rupture of the bowel, owing to the contraction of the muscular coat, while hemorrhage is slight unless the mesentery or other vascular structure is torn. Abdominal distention, fever, and other symptoms of widespread peritonitis are later symptoms, and usually mean that the favorable time for operation is past. Vomiting immediately after the accident is unimportant, but recur- ring vomiting is ominous. There may be absence of peristalsis, a friction sound on auscultation, and sometimes tenesmus with a frequent desire to defecate. Rectal examination in some instances may detect resistance in the vicinity of the rupture, due to the forma- tion of adhesions around the laceration. Bright blood in the stools points to a rent in the large bowel, tarry movements to a lesion higher. The temperature, pulse, and respirations augment with the spread of the peritonitis, which will cause also a leukocytosis and a rise in the blood pressure. The rectal insufflation of hydrogen or ether to detect the perforation is too dangerous to be employed. The treatment is laparotomy and suture of the perforation. Death is almost inevitable without operation; with operation 20 per cent, recover. The difficulty is to make an early diagnosis. In the presence of the first four signs mentioned above, exploration is urgently demanded. As a rule a median incision is made below the umbilicus, and the rupture found between the seat of the surface injury and the spine; the possibility of more than one perforation should be kept in mind and discolored spots treated as ruptures. Extravasation of blood behind the peritoneum, particularly with air crepitation, may be due to retroperitoneal rupture of the colon or duodenum. Resection or extraperitoneal isolation of the injured bowel (according to the condition of the patient) may be indicated, because of the severitv of the contusion, the extent of the laceration. 672 MAXUAL OF SURGERY or because of detachment or injury of the mesentery. Omental grafts, held in place with sutures, may be of service in any case in which it is feared that leakage may occur. The peritoneal cavity should be cleansed, and closed or drained, as described under ''Pene- trating Wounds of the Abdomen. " In tears of the omentum and mesentery the immediate danger is hemorrhage. Later an inflammatory mass or embarrassing adhesions may develop. When the mesentery is \aolently contused, or stripped from the bowel, intestinal gangrene follows. The intestine may become strangulated through a sHt in the mesentery. Sanguineous mesenteric cysts also may develop. The treatment is ligation of the bleeding vessels, and excision of omentum or intestine, if such be needed. The liver is frequently lacerated, particularly the right lobe. One half of the cases die within twenty-four hours from hemorrhage. Pain is severe and shock profound, and there are symptoms of internal bleeding, with movable dulness in the flanks. In some cases, probably as the result of bihary absorption, the pulse is slow instead of rapid. Hepatic dulness is increased. Jaundice some- times develops after twenty-four hours, and bile and sugar may ap- pear in the urine. Peritonitis frequently occurs in those who sur- vive the initial shock and subsequent hemorrhage. Operation is imperative to check hemorrhage, which may be controlled by suture, Hgature, cautery, or tampon. Sutures should be given the prefer- ence; to prevent their tearing out the capsule of the liver may be fortified by a transplant of fascia, but if they fail to stop the bleeding, or if the wound is so situated as to make suturing difficult, the wound may be stuft'ed with gauze, or, better, with omentum, muscle, or fat, held in place, when possible, with a few sutures of catgut. Cauterization is not suitable for large wounds and is hable to be followed by secondary hemorrhage. Ruptures of the gall-bladder, cystic, hepatic, and common bile ducts have occurred. The symptoms are pain, shock, biliary ascites and later in some cases peritonitis, as the bile is irritating even if sterile. In a complete rupture of the hepatic or common duct there would be jaundice, cholemia, and inanition. The gall-bladder may be sutured or removed, according to the degree of laceration. Drain- age is the treatment when the ducts are damaged, although in a suitable case anastomosis would be the ideal procedure. The spleen is not as frequently ruptured as the Hver. Enlarge- ment of the organ predisposes to injury. Hemorrhage is the great danger, but is not as quickly fatal as one would suppose, owing to the ABDOMEN 673 elasticity of the organ, and to the fact that the blood coagulates rapidly because of the large number of leukocytes present. Abscess or peritonitis may follow. The symptoms are those of internal hemorrhage, with pain and tenderness over the spleen, and sometimes pain in the left shoulder, indicating irritation of the phrenic nerve endings in the diaphragm. Splenic dulness is increased, and fre- quently does not disppear when the patient is turned on the right side, because the blood is often clotted. Operation should be im- mediate; its nature depends upon the condition of the patient and of the spleen. If the patient has lost much blood, if the spleen is large and extensively adherent, and if the tear is favorably situated, suture with a transplant of fascia, as for the liver, is to be chosen. If the capsule is thin, the spleen soft, and the tear unfavorably situated, packing with gauze, omentum, muscle, or fat is to be considered. Ordinarily a large laceration in a normal spleen is best treated by splenectomy. Of thirty-four cases of splenectomy for rupture, 41.2 per cent, were fatal. The pancreas is seldom ruptured alone. In the absence of fatal hemorrhage, gagrene, suppuration, or chronic pancreatitis may ensue. The so-called trumatic cysts of the pancreas are probably collections of blood and pancreatic fluid in the lesser peritoneal cavity, the fora- men of Winslow having been closed by adhesions. The symptoms are those of shock and internal hemorrhage. The bleeding is checked in the same way as bleeding from the liver, or by partial excision, being careful to preserve the canal of Wirsung, Posterior drainage through the left lumbar fossa is to be employed, to drain off any leakage of pancreatic juice, which may cause peritonitis or fat necro- sis. The kidney is well protected by its position and by an enveloping bed of fat, yet it is not infrequently injured. The rupture is usually transverse to the long axis of the kidney. If the capsule remains intact, hemorrhage takes place into the organ; if it is torn, blood and urine collect in the perinephritic tisues. If the peritoneum is lacerated urine and blood accumulate in the abdominal cavity. Bilateral and occasionally unilateral injuries of the kidney may be fatal from anuria, in the latter instance the sound kidney refusing to act from reflex inhibition. The symptoms are shock, pain, and hematuria. Hematuria may be absent if the kidney is separated from the renal vessels or the ureter, or if there be a clot in the ureter, or an extensive laceration of the pelvis of the kidney. Absence of hematuria has been caused also by thrombosis of the renal vessels and a preexisting stricture of the ureter. Cystoscopy in these cases will show that no 674 MANUAL OF SURGERY urine is coming from (he ureter on the injured side. lirownish urine coming from the ureter indicates clotting in the pelvis of the kidney. Hemorrhage and sepsis are the dangers. Symptoms of internal hemorrhage, with an increasing tumor in the loin, demand immediate exploration. If the kidney is hopelessly destroyed, or if ligation of the renal vessels be necessary to control the bleeding, the organ should be removed. If but moderate laceration is present, disinfection and drainage, with suture or partial nephrectomy, is indicated. If tamponage is chosen, fat or muscle, held in place with a few sutures, is probably superior to gauze as a hemostatic agent. Defects in the pelvis, if too large for simple suturing, may be repaired by turning down a flap of the capsule, or by transplanting a piece of fascia. The possibility of injury to the intraperitoneal organs should not be forgotten. Mild cases are treated by ice to the loin, internal astringents, urinary antiseptics, and rest. Rupture of the ureter is caused by its being crushed against the transverse process of the third, fourth, or fifth lumbar vertebra, or by traction on the ureter. All ruptures are above the pelvic brim. Shock is neither profound nor persistent, unless there be some injury to the other abdominal organs. A few drops of blood in the urine, with persistent pain and tenderness in the side, point to injury of the ureter. If the duct be completely ruptured, cystoscopy will reveal no urine escaping from the affected ureter, and a retroperi- toneal accumulation of urine and blood will appear after several days. Complete obstruction of the ureter will cause atrophy of the kidney; partial obliteration may result in a pyo- or hydronephrosis. If the injury be uncomplicated, the danger to life is slight, although there is little tendency towards spontaneous repair. A tear in the peritoneum may lead to a fatal peritonitis. Immediate anastomosis is the ideal treatment. Lumbar incision and drainage are indicated after infection has taken place; if a ureteral fistula follows it should be treated as described in chap. xxix. Rupture of the bladder is extraperitoneal, intraperitoneal, or combined extra- and intraperitoneal. Laceration of the mucous membrane alone, with hematuria, may follow a blow on the hypo- gastrium. Extraperitoneal rupture is usually associated with fracture of the pelvis. Intraperitoneal rupture is generally caused by a forc- ing backward of the distended viscus against the promontory of the sacrum, although in some cases it may result from contre coup. In uncomplicated cases the rent is vertical and occurs at the upper and posterior part of the bladder. Normal urine may come in contact with the peritoneum without causing inflammation, but if allowed to ABDOMEN 675 remain or if bacteria are present inflammation quickly ensues. The injury is fatal without operation. With operation over one-half die from shock, hemorrhage, or peritonitis. The symptoms are shock, hypogastric pain, a sensation of something having given way, rectal tenesmus, and an urgent desire but inability to urinate. The catheter reveals a little bloody urine or no urine at all; it may pass directly into the abdominal cavity. Cases have occurred in which unstained urine has been withdrawn from a torn bladder. A measured quantity of boric acid solution may be injected into the bladder; if the same amount returns, the bladder is probably intact. Air or hydrogen may be pumped into the bladder, and if the viscus is intact, it will rise above the pubes as a symmetrical tumor, tympan- itic on percussion, and the air will rush out again when allowed to do so. When the tear involves the peritoneum, the gas will cause a general distention of the belly; when the rent is extraperitoneal, an emphysema of the extravesical connective tissue. These injection tests are not infallible, and may spread infection. Movable dulness in the flanks suggests intraperitoneal rupture, unilateral tenderness and tumor extraperitoneal rupture. A differential diagnosis is, however, unimportant before operation. When symptoms of rupture are present, the prevesical space should be opened through a suprapubic incision, and if this be healthy, indicating the absence of extraperitoneal rupture, the incision may be continued upwards and the abdominal cavity opened. An intraperitoneal rupture should be sutured and the peritoneal cavity cleaned and drained. As a rule in extraperitoneal rupture, drainage is all that can be done. Rupture of the diaphragm ( see Diaphragmatic Hernia) . Wounds of the abdomen may be penetrating or non-penetrating. Non-penetrating woimds should be excised, the fact of non- penetration established by inspection, and the divided parts sutured, especial care being taken to approximate the severed aponeuroses and muscles, in order to guard against hernia. If, however, there are signs of intraabdominal injury particularly after blunt violences or a gunshot wound, the peritoneal cavity should be opened and ex- plored, since, as mentioned above, the viscera may be ruptured without penetration of the abdominal wall. Penetrating wounds, including those produced by gunshots and stabs, are readily recognized if the viscera or the contents of the viscera escape through the wound. The symptoms and the dangers of visceral injury are those of contusions of the abdomen. The treatment, even without symptoms of visceral injury, is laparotomy, in order to explore the abdomen, check hemorrhage, and close such 676 MANUAL OF SURGERY viscera] perforations as may be tound. A stab wound in the parieties should be excised. If the omentum protrudes it should be ligated and removed; if the intestine, washed with salt solution and replaced in the abdomen. The opening, if conveniently situated for abdominal exploration, may then be enlarged with a fresh knife. In other cases the opening left by the excision may be sutured, and the exploration conducted through a separate incision made with separate instru- ments. Gunshot ivounds are treated on the same principles. If the missile is lodged, the X-ray will locate it, and the point of localization, when considered in relation to the wound of entrance, will give the length and direction of the track of the bullet. This is of particular importance when the external wound is in some remote region, like the chest, the loin, or the buttock. The parietal wound of entrance should be treated as directed above for a stab wound. The extent of the damage depends on the course of the bullet, but in all cases it is necessary to review the whole of the small intestine since the coils are mobile, and, owing to their arrangement, perforations from a single missile may be found many feet apart. Perforations espe- cially liable to be missed are those of the posterior wall of the stomach or the colon, of the hepatic and splenic flexures of the colon, and of the lower sigmoid and upper rectum, hence these regions must be carefully examined when lying in or near the track of the bullet. After dealing with the lesions of the individual organs, as just out- lined under "Contusions of the abdomen," the peritoneal cavity should be cleared, by sponging, of any blood or extra vasated visceral contents which may be present. Irrigation with hot salt solution is favored by some surgeons, especially when there is much fecal may be oation, but is falling more and more into disuse. Drainage contaminmitted if the peritoneal cavity can be left grossly clean and dry, but if there is still some oozing of blood, an established peri- tonitis, much contamination by fecal leakage, or a suture line through which the surgeon fears leakage may occur, drainage should be em- ployed. Retroperitoneal lesions of the large bowel are predisposed to leakage, hence must be drained, the best site for the drain being the loin. Unless found quickly the missile should be disregarded. The patient should receive a prophylactic injection of tetanus anti- toxin, and, if necessary, the general treatment for shock and hemorrhage. In the first months of the European war, military surgeons, follow- ing the experience gained in previous conflicts, treated abdominal injuries by rest, morphia, and starvation. The resulting mortality according to Wallace, was about 80 per cent., most of those recover- ABDOMEN 677 ing bein^ ])aticnts without \iscc'ral injury. Later, when the battle line became stationary, the means of trans])ortation more ra])i(J, and the hospitals further advanced toward the front, many of the patients were received at a sufficiently early period to permit operation. According to Hull, of the total number of wounded reaching a hos- pital, from I to 2 per cent., suffered from abdominal injury, and 20 per cent, of these were moribund on arrival. Of those subjected to laparotomy 46 per cent, recovered, the recovery rate in those with wounds of the hollow viscera being 35 per cent. From the foregoing it may be concluded that a solider with a wound of the abdomen should, if proper facilities are available, be treated exactly like a civilian with a similar wound i.e., by early exploration. Late opera- tion, i.e., after 24 or 36 hours, is almost invariably useless or fatal, useless if the patient shows no signs of peritonitis, fatal if he does. Phantom tumor of the abdomen generally occurs in hysterical females. It is due to either a localized contraction of the abdominal muscles, usually a section of the rectus, or a tetanic spasm of the intestine. The swelling may be as hard as bone, but as a rule varies in consistency on different examinations, and disappears under anesthesia, with gurgling if it be intestinal. The treatment is that of hysteria. THE UMBILICUS Inflammation and abscess are commonly the result of uncleanli- ness, especially after separation of the cord, or in corpulent adults in whom the umbilicus is deep. Eczema likewise is observed. Tetanus neonatorum and erysipelas may be caused by infection of the um- bilicus soon after birth. Benign and malignant tumors may occur in this region, but are rare. Among the cysts may be mentioned the dermoid, sebaceous, vitelline (developing from an unobliterated portion of the vitelline duct), serous (due to a shutting ofT of an empty hernial sac), and the urachal. The last are caused by disteu' tion of an unobliterated portion of the urachus, which normally extends from the bladder to the umbilicus; they are properitoneal, median in situation, sometimes of large size, and may open both into the bladder and at the umbilicus. The treatment of cysts is excision. In some urachal cysts this is not possible, and incision and drainage are all that can be accomplished. UmbiHcal fistulae may be congenital or acquired. Fecal fistulce resulting from non-closure of the omphalo-mesenteric duct (Meckel's diverticulum) are first observed after the umbilical stump has separated. The mucous membrane may become everted and form 678 AIAXUAL OF SURGERY a red tumor, which has been called a polypus or adenoma when the communication with the intestine has become obliterated. When the duct is wide and short a portion of the intestine may protrude through the opening. Fecal fistulae in the new-born have been caused also by including within the ligature which surrounds the cord a small umbilical hernia. Acquired fecal listuLT follow condi- tions like strangulated hernia and tuberculous peritonitis. Urinary jistulcB are caused by non-obliteration of the urachus, mucous fisttdce by the omphalo-mesenteric duct or the urachus which has become closed at the visceral end. These fistulae should be excised and the opening into the viscus closed. A biliary fistula, following perfora- tion of the gall bladder, is occasionally seen at the umbilicus. It should be excised and the diseased gall bladder drained or removed after extracting any stones that may be present. Umbilical sinuses are the result of abscesses, and require incision and packing. Umbilical hernia (see Hernia). THE PERITONEUM, OMENTUM, AND MESENTERY Peritonitis, or inflammation of the peritoneum, is practically always bacterial in origin. It is divided primarily into the acute and chronic forms. Acute peritonitis is caused by perforations of the hollow viscera, wounds of the abdomen, extension of inflammatory processes from the abdominal organs by contiguity or continuity (e.g., from the Fallopian tubes), and by infection coming through the blood or lymph vessels. Idiopathic peritonitis does not exist; rheumatic peritonitis probably seldom or never occurs. A great variety of micro-organisms have been cultivated from cases of peritonitis, and in most instances the infection is a mixed one. The streptococcus pyogenes is responsible for the most severe forms; the staphylococcus pyogenes is less virulent. The colon bacillus is usually found in cases secondary to intestinal lesions. The diplococcus of pneumonia and the gonococcus are much less virulent in this situation than are other organisms. Two forms of acute peritonitis are described, (i) the localized, and (2) the diffuse, or generalized. I . Acute localized peritonitis is most frequent in the vicinity of the gall bladder, the Fallopian tubes, and the appendix. There is a subperitoneal collection of round cells, and the peritoneum becomes congested, looses its luster, sheds its endothelium (especially in viru- lent infections), and exudes a sero-fibrinous material, which surrounds the aft'ected area, and which may become purulent, forming a local- ABDOMEN 679 izcd abscess. 'Vhv i)us may break through tin- barrier of adhe- sions and cause a generalized peritonitis, or it may break into one of the hollow viscera. In rare cases it points externally, and in a few- instances in which it is well encapsulated, it becomes inspissated or even calcareous. The fibrinous material which glues adjacent peritoneal surfaces together may be absorbed, or become organized into fibrous adhesions. The symptoms are localized pain, tender- ness, and muscular rigidity, with fever, increase in the pulse rate, vomiting, and constipation. Later the inflammatory mass may be palpated, giving either a dull or tympanitic note on percussion. When near the surface, redness and edema of the abdominal wall may be noted. Unless the infection is well encapsulated, leukocyto- sis is present. The treatment is given under the conditions w-hich give rise to the localized peritonitis, as it varies somewhat according to the region affected and the cause, thus acute pelvic peritonitis caused by the gonococcus is usually treated symptomatically until quiescent, while locaHzed peritonitis the result of appendicitis requires early operation. It should not be forgotten, however, that a diffuse peritonitis always begins as a more or less localized process, and that in many instances prompt and efficient treatment of the infection while still limited may prevent its generalization. 2. Acute diffuse or generalized peritonitis is usually the result of an extension of a localized peritonitis, although a large area of the peritoneum may be flooded wath infective material from the bursting of a localized abscess, or the perforation of a hollow viscus. The peritoneum is congested and lusterless and in fulgurant cases death may occur from toxemia before further changes take place. As a rule, however, there is some serous exudation, and fibrinous patches form on the area from which the endothelium has been shed. At a later period the exudate becomes purulent and occasionally bloody. The symptoms at the onset are those of localized peritonitis, or when a large amount of infective material has been suddenly dift'used, as in perforation, there will be sudden violent pain, profound shock, and in some cases death within a few hours. The patient usually survives the shock, however, and the temperature ascends to and then above normal, and finally falls to subnormal as death ap- proaches, but the pulse remains quick, and becomes hard and wiry owing to the rise in blood pressure, though in the final stages it is running and compressible. Chills are uncommon except in puerperal cases. Vomiting is early and persistent, and in the final stages stercoraceous material is regurgitated without effort. Hiccough is not infrequent, and is particularly distressing because of the increased 68o MANUAL OF SURGERY pain produced by the spasmodic contraction of the diaphragm. There is usually obstinate constipation, occasionally diarrhea. The patient lies on the back with the knees drawn up, and the face has a characteristic anxious and pinched look. The abdomen is tender, rigid, motionless, the breathing being quick, shallow, and entirely thoracic. Later the abdomen becomes tensely distended and tympanitic, with an amelioration in the pain. Percussion may show movable dulness in the flanks when the effusion is great, or absence of Hver dulness in perforative peritonitis. Air in the peri- toneal cavity may be demonstrated also by the X-rays. On auscul- tation peristaltic gurgling is absent, and occasionally friction sounds can be heard, more often in the upper abdomen, where, owing to the action of the diaphragm, the viscera cannot be kept entirely at rest. Vaginal and rectal examination may reveal tenderness and sometimes an inflammatory mass. Leukocytosis is present unless the infection is overwhelming. The urine is scanty, often contains albumin and indican, and sometimes tube casts (toxic nephritis). For the condi- tions simulating peritonitis but not requiring operation the student is referred to the section on "Unnecessary Abdominal Section." Here we may note the diflticulty often encountered in differentiating peritonitis from intestinal obstruction, and from intestinal paralysis (q.v.) due to causes other than inflammation of the peritoneum. Local peritonitis, too, is often confused with generahzed peritonitis. Treatment of a prophylactic nature includes operation for chronic infections that may become acute and spread, e.g., chronic appendi- citis; for abscesses that may rupture into the peritoneal cavity; for lesions that may perforate, e.g., duodenal ulcer, and for abdominal injuries that may be followed by peritonitis. Medical treatment in acute peritonitis is indicated when operation is inadvisable. Ochsners method consists in gastric lavage, and no food, water, or purgatives by mouth. Purgation makes the feces more liquid, hence more apt to leak through a perforation, and in- creases peristalsis, which disseminates the infection. The lower bowel may be emptied with an enema, water administered by rectum as described below, and the patient put in the Fowler position. Poultices or ice bags on the abdomen are comforting, but have no influence on the disease. Morphine lessens the pain and quiets peristalsis, hence may hinder diffusion of the inflammation, but, since it obscures the symptoms, it should, if possible, be withheld until a positive diagnosis is made. Tympanites may be treated as described under "After Treatment" in chap. iv. In considering operation for acute generalized peritonitis the ABDOMEN 68 1 disease may be divided into three stages. In the first, or the stage of contamination, which hists from 12 to 24 hours, laparotomy should be performed in all cases, excepting puerperal peritonitis and that form following salpingitis. Operation in this stage might, with propriety, be included among the prophylactic measures. In the stage of established infection or suppuration, i.e., during the second and third days, and sometimes for a longer period, the chances for recovery are, generally speaking, as good without as with opera- tion. It is necessary, however, to study the individual case before coming to a decision, which is rendered much easier if the source of the infection can be diagnosticated. Thus in some instances, notably acute perforation, and peritonitis due to gangrene or stran- gulation of the intestine, death is almost certain if the condition be left unmolested, while operation offers a slight prospect for recovery. Unfortunately it is often impossible to determine the cause of the peritonitis before opening the abdomen, and in these cases one may operate with the hope of finding a condition whose removal will benefit the patient. In the third stage the process is subsiding and localizing, and operation should be posponed until the maximum improvement has been obtained. The most important principles involved in any operation for peritonitis are rapidity and gentleness. Unless the starting point of the inflammation can be localized, the incision should be made in the middle line below the umbilicus, and the cause of the peritonitis, e.g., a gangrenous appendix, surrounded with gauze and quickly removed. The gauze packing prevents further dissemination of the infection and absorbs a large quantity of the peritoneal exudate. Drainage may sometimes be avoided in early operations (see "Penetrating Wounds of the Abdomen"), but should always be empl- oyed when there is suppuration. All that is usually necessary is to pass a gauze drain down to the site of the original focus of infection. In some cases, however, an additional drain may be placed in the lowest portion of the pelvis (gaining exit, in the female, through the vagina). Irrigation of the abdomen increases the shock and may disseminate the infection. Rubber tubes in the free peritoneal cavity likewise are contraindicated, as already explained under "Surgical Technic." After the gauze pack has been removed, the wound is sutured, except at the point where the drain emerges, and covered with a sterile dressing. The patient may then be put in the semi-sitting posture, or the head of the bed raised two or three feet (Fowler's position), in order to drain the fluids into the pelvis and away from the diaphragm, in which region absorption is said to be 682 MANUAL OF SURGERY most active. In the gravely ill, however, the depressing effects of the upright posture upon the heart far outweigh the theoretical advan- tages just mentioned. The writer prefers to place the patient in the Sims position, i.e., almost on the abdomen, on the right side if the incision is right-sided or median, on the left side if the incision is on the left side. Water should be given by bowel, eight ounces every three hours, or by continuous proctolysis {Murphy method), i.e., by means of a fountain syringe, the reservoir of which, surrounded by hot water bags, is but shghtly higher than the rectum, so that the water shall enter no faster than absorption takes place, the patient getting perhaps a pint or two in the course of an hour (see " Enteroclysis ") • This stimulates the heart and kidneys, eliminates septic material which has entered the circulation, and reverses the current in the lymphatics of the peritoneum, making that membrane a secreting instead of an absorbing one. Occa- sionally proctolysis seems to increase the distention and provoke vomiting, in which event salt solution may be given intravenously or subcutaneously. Nothing is given by mouth until the stomach is retentive, stimulants are freely administered, and an early movement of the bowels is secured by means of enemata. When there is great distention which cannot be relieved by the usual remedies for tym- panities, an artificial anus may be established. The prognosis will depend upon the character, duration, and extent of the infection, and the resistance of the individual. Including all forms, irrespec- tive of the cause, the mortality is from 15 to 20 per cent, in cases which are in fair condition at the time of operation, and 50 per cent, or more in those in bad condition. Chronic peritonitis may be (i) simple or (2) tuberculous. 1. Simple chronic peritonitis may be localized or diffuse. It generally follows the acute form, but may in mild infections be chronic from the start. The peritoneum is thickened, and the adja- cent surfaces fastened together by more or less firm adhesions. Sac- culated effusions are sometimes encountered. Syphilis is said to be responsible for some cases. The treatment is directed to the cause. Adhesions may be separated if they give rise to symptoms, e.g., pain or obstruction. 2. Tuberculous peritonitis may be primary, but is usually second- ary to disease in a distant organ, or to tuberculosis of some other abdominal structure, particularly the lymph glands, the intestine, or the Fallopian tubes. It is more common in females, and is rarely seen before the third or after the fiftieth year. Three forms are described : (a) the ascitic form presents itself as a free or sacculated ABDOMEN 683 serous, sero-fibrinous, or occasionally purulent exudate, as the result of a diffuse miliary invasion of the peritoneum; it is sometimes com- plicated by cirrhosis of the liver, and it may eventuate in the adhe- sive form, (b) The fibrous or adhesive variety is characterized by a slow course and the absence of fluid. The abdominal organs are glued together, and gray or yellow tubercles are found among the adhesions. Not unusually the omentum is rolled upon itself and is palpable as a transverse mass in the upper part of the abdomen. (c) The caseous or suppurative form is a later stage of the adhesive variety. The tubercles caseate and give rise to abscesses, which may point externally, especially at the navel, and lead to fecal fistula), the bowel often being opened by ulceration. The local S5nnptoms may arise suddenly and resemble those of acute appendicitis or other acute intraabdominal conditions, or the general symptoms may predominate and typhoid fever be simulated. ]\Iost of the cases, however, are chronic. Pain and tenderness are rarely severe and may be entirely absent. Dysuria is not uncommon, particularly in women. The digestion is disturbed, although vomit- ing is rare, and diarrhea is absent unless there is disease in the intes- tine. The temperature rises one or two degrees in the evening, night sweats may occur, and there is a gradual loss of weight. The subcu- taneous abdominal veins are generally distended, and free or encapsu- lated fluid may be detected in the peritoneal cavity and not infre- quently in a patent processus vaginalis or canal of Xuck. The rolled up omentum can be felt and sometimes seen. Masses of adherent intestine or enlarged lymph glands may be found on external, vagi- nal, or rectal palpation. Symptoms of stenosis of the intestine may be present, the liver and spleen are often enlarged, and tuberculosis may be detected in distant parts of the body. The treatment may be medical or surgical. Medical treatment includes the general measures employed for tuberculosis elsewhere and local applications of green soap, mercurial ointment, iodin, elastic collodion, or guaiacol. The X-ray and intraperitoneal injections of a weak solution of iodin also have been used. Surgical treatment is of the greatest value in the ascitic form, in which laparotomy is followed by at least 50 per cent, of permanent cures. All that is needed is to open the abdomen, evacuate the fluid, and close without drainage. If the cause of the disease, e.g., a tuberculous appendix or Fallopian tube, is discovered, this may be removed. Separation of adhesions is not infrequently followed by fecal tistulae. The reason for the beneficial effect of a simple laparotomy is not known. It has been supposed that the operation causes hyperemia, and the 684 MANUAL OF SURGERY F.L. L.L C.oy/dB.L. outpouring of an antitoxic serum. If fluid recollects, it may be aspirated or a second laparotomy performed. Malignant disease of the peritoneum may be primary (endothe- lioma), but is usually the result of secondary deposits from a papil- liferous cyst of the ovary or a carcinoma of the ovary, stomach, liver or intestine, the cancer cells having been diffused by the peritoneal currents and the movements of the viscera. The symptoms are those of cachexia and ascites. The fluid withdrawn by tapping is often blood stained and sometimes contains the tumor cells. Multi- ple nodules can be felt through the abdominal wall and by rectum and vaginae. Paracentesis abdominis is performed for the removal of fluid from the peritoneal cavity. The bladder should be emptied, and a spot of absolute dulness selected in the median line below the umbilicus. The patient sits up, and a broad flannel binder with an opening in front is passed around the abdomen and held by an assistant behind, so as to make pressure upon the abdo- men. The skin is then sterilized, a small incision made in the skin with a scalpel, the trocar and cannula in- serted, and the trocar withdrawn. Subphrenic abscess is an abscess just beneath the diaphragm. About one-third of the cases are due to rup- (6) Right and (7) left retroperitoneal tured gastric or duodenal ulcer, one- spaces. T • • fourth to appendicitis, one-nfth to infections of the liver and biliary ducts, and the remainder to per- foration of the intestine, trauma, pyemia, and suppurative processes in the female generative organs, spleen, pancreas, kidney, ribs, verte- bras, or pleura, hence the abscess may be (a) intraperitoneal or (b) retroperitoneal, (a) In the intraperitoneal variety (83 per cent, of 890 cases collected by Piquand) the infection is transmitted from the primary focus by the intraperitoneal lymph stream, which flows towards the diaphragm, or by a spreading peritonitis. Its situation depends upon the location of the causative lesion and the arrange- ment of the subphrenic peritoneal fossae, which are five in number, four phrenohepatic, formed by the cruciform reflection of the peri- toneum from the liver to the diaphragm, and one phrenosplenic Fig. 374. — Diagram showing the various locations of subphrenic abscess. Liver and spleen shaded. Peritoneal reflection to diaphragm in red. V . Vena cava. A . Aorta. F.L. Falciform ligament. L.L. Left lateral ligament. C. and R. L. coronary and right lateral ligament, (i) Right anterior, (2) right posterior, (3) left anterior, and (4) left posterior phrenohepatic spaces. (5) Phrenosplenic or perisplenic space. ABDOMEN 685 (Fig. 374). (i) Right anlcrior plirciio/ic/xilic abscess is the most fre- quent (36 per cent.) ; it lies between the right lobe of the liver and the diaphragm, to the right of the falciform ligament, and in front of the coronary and right lateral ligaments. (2) The right posterior form (10 per cent.) is behind the coronary ligament, extends down towards the right kidney, and is often associated with the right anterior form. (3) Left anterior abscess (30 per cent.) presents in the epigastrium, adhesions limiting it below. (4) A left posterior coWection (3 per cent.) distends the lesser peritoneal cavity, consequently is behind the stomach. (5) Phrenosplenic or perisplenic abscess (4 per cent.) occupies the space above and about the spleen, (b) In retroperi- toneal abscess the infection travels by way of the lymph vessels or by a spreading cellulitis, (i) Right retroperitoneal abscess (15 per cent.) may extend forwards between the layers of the coronary and falciform ligaments and point in the epigastrium, or downwards and point in the right loin; (2) left retroperitoneal (2 per cent.) forwards between the layers of the left lateral ligament and downwards to the left loin. A subphrenic abscess often contains gas, owing to the presence of the colon bacillus, or to perforation of the gastro- intestinal canal or lung. It may cause empyema, rarely pyoperi- cardium, by breaking into the pleural cavity or pericardium, or by extension of the infection along the lymphatics through the diaphragm without perforation. It may break also into the lung, the general peritoneal cavity, the stomach, the intestine, the mediastinum, or in rare instances externally (hypochondrium, epigastrium, loin). The symptoms are usually preceded or accompanied by those of the causative lesion. The general phenomena are those of sepsis. Locally there are pain and tenderness, muscular rigidity, perhaps swelling and edema, and, on percussion, a tympanitic area which moves with the position of the patient, or dulness. Friction sounds are occasionally heard and when the abscess contains gas all the signs of pneumothorax may be present, hence the term false pneumo- thorax. Fluoroscopic examination reveals elevation and possibly im- mobility of the diaphragm on the affected side, below which (patient in erect position) is a clear area if the abscess contains gas. The liver or the spleen is depressed. Explorator}- aspiration may be made in the tenth, ninth, eighth, and seventh interspaces, in the order, named, first, below the scapula, and then, if no pus is found, in the midaxillary line, but never through the peritoneum, and only when all prepara- tions have been made for immedite operation in case the abscess is located. The diagnosis of subphrenic abscess is often difficult, and the conditions which it resembles are often associated with it. 686 MANUAL OF SURGERY In hepatic abscess there may be jaundice and gas is never present. Pancreatitis may reveal itself fey the laboratory tests for this condi- tion. In empyema the pulmonary symptoms are more marked, the upper level of the fluid is concave instead of convex, the heart is pushed to one side rather than upwards, the liver is not depressed, the obliquity of the ribs is increased (being decreased in subphrenic abscess), the level of the diaphragm as shown by the X-ray is not disturbed, the Litten phenomenon (visibility of the excursions of the diaphragm in the intercostal spaces) is absent, and Traube's space is rarely obliterated, a sign which may occur in left subphrenic ab- scess. Bronchial breathing, owing to compression of the lung, is sometimes heard in subphrenic abscess, but never egophony. In empyema, on exploratory puncture, the pus is more superficial, escapes under greater pressure during expiration (the reverse being true in subphrenic abscess), and the needle does not oscillate. When the needle passes through the diaphragm its outer end ascends on inspiration, descends on expiration. When a serous pleural effu- sion and a subphrenic abscess are both present, one may obtain serous fluid superficially and fetid pus at a deeper level, or serum in the sixth or seventh interspace and pus in the ninth or tenth. The mortality of subphrenic abscess is almost loo per cent, without opera- tion, 50 per cent, with operation. . The treatment is evacuation. According to the situation of the abscess, the incision will be made in the epigastrium, the hypochon- drium, the loin, or through the diaphragm after resecting the ninth or tenth rib and pushing the pleura upwards (subpleural route), or sewing the diaphragm to the parietal pleura (transpleural route). The omentum has been called "the policeman of the abdomen," because of its tendency to adhere to and surround diseased processes and prevent their diffusion; it, therefore, participates in diseases common to the peritoneum. Volvulus of the omentum in most instances is caused by forcible taxis of an epiplocele, although it may occur without the presence of a hernia. The omentum becomes gangrenous, and the patient is usually operated upon with the idea that he has a strangulated hernia or appendicitis. A doughy abdominal tumor coming on after attempts to reduce a hernia should make one suspicious of an omental torsion. The involved portion should be excised. Timiors of the omentimi and mesentery are uncommon, and are generally sarcomatous in nature, although benign growths and secondary carcinoma may occur. Free fatty tumors in the peritoneal cavity represent lipomata of the omentum or epiploic appendages, ABDOMEN 687 the pedicle of which has broken. The rolled up tuberculous omen- tum has already been described. Cysts of the omentum and mesen- tery also are rare, and are frequently caused by the echinococcus or by cystic degeneration of malignant disease. In the mesentery serous, sanguineous, chylous (Fig. 375), and dermoid cysts have been observed. These tumors and cysts are freely movable, surrounded by tympany on all sides, and are not connected with the pelvis. The treatment is extirpation, an operation that may necessitate intestinal resection. When the extirpation of a cyst is impossible it may be opened and stitched to the abdominal wall. Retroperitoneal tumors, excluding those of the kidney and the pancreas, are usually sarcomata, lipomata, or dermoids. Tabulated swellings representing enlarged lymph glands may be due to syphilis, tuberculosis, leukemia, Hodgkin's disease, typhoid fever, primary lymphosarcoma, or to secondary new growths, either sarcoma or carcinoma. Particular mention should be made of the metastatic involvements of these glands occurring in chloroma, lympho- sarcoma of the neck, and malignant dis- ease of the testicle. Failure to ascertain the nature of a tumor that has been ex- cised from the neck, or to note that the testicle has been removed or is diseased, may lead to a useless abdominal opera- tion. Chronic abscesses, most fre- quently originating in a tuberculous Pig- 3 7S-— Cyst of mesentery, prob- spondylitis or lymphadenitis, also are observed, and the possibility of aneurysm should not be forgotten. The distinguishing features of a retroperitoneal tumor are its im- mobihty, the presence of tympany in front of it, and often the ab- sence or paucity of symptoms referable to the intraperitoneal organs. Retroperitoneal tumors amenable to operation may be extirpated from the front, thus going through the anterior and posterior parietal peritoneum. Abscesses should be drained extraperitoneally, by an incision in the loin or above Poupart's ligament. Thrombosis or embolism of the mesenteric vessels causes gan- grene of that portion of the intestine supplied by the vessel involved, unless the vessel be small, when there may be only engorgement of the intestine, or ulceration, followed perhaps by perforation. In some cases the mesentery is distended with extravasated blood. The condition is rare in children, most of the cases occurring between the 688 MANUAL OF SURGERY thirtieth and seventieth years, men being affected nearly twice as often as women. Embolism is frequently the result of cardiac disease, and is sometimes associated w^ith the presence of emboli in other por- tions of the body. Thrombosis is caused by acute or chronic phle- bitis, the result of infection from the intestine or other organ, or by chronic endarteritis. In Trotter's collection of 366 cases, the arteries wTre involved in 53 per cent., the veins in 41 per cent., both in six per cent. The superior mesenteric vessels were more often occluded than the inferior. The diagnosis, before operation or autopsy, was made thirteen times. The symptoms are sudden intense pain, bloody diarrhea in half the cases, vomiting, subnormal temperature, rapid pulse, meteorism, and abdominal rigidity. The treatment is resection of the gangrenous intestine, if the process be sufficiently limited. If the superior mesenteric artery is occluded near its origin, the entire small intestine, with the ascending and transverse colon, will be gangrenous and no treatment applicable. In Trotter's series 36.2 per cent, of those operated upon recovered. THE STOMACH Congenital stenosis of the pylorus is due to spasm or to what is probably the result of persistent spasm, hypertrophy of the sphincter with fibrous overgrowth of the submucous tissues. The symptoms which usually begin from a few days to a few weeks after birth, are vomiting, intermittent if caused by spasm of the pylorus, persistent, regular, projectile, and not bile stained if the result of complete stenosis; distention of the upper abdomen, due to dilatation of the stomach; retraction of the lower abdomen, due to collapse of the bowel; palpable pyloric tumor in two-thirds of the cases; visible gas- tric peristalsis, passing from left to right; emaciation, progressive in complete stenosis; oliguria; and constipation, alternating with diarr- hea in pylorospasm, and extreme in complete stenosis, an additional sign of which is the failure of methylene blue to appear in the stools after being taken by mouth. X-ray examination, after the adminis- tration of barium, shows the gastric dilatation; in pylorospasm the bismuth may be retained in the stomach for a variable period and then passed rapidly into the duodenum; in complete stenosis the bis- muth remains in the stomach until vomited. The treatment of spasmodic or incomplete stenosis is daily gastric lavage; small quantities of peptonized milk or beef juice by mouth supplemented by nutrient enemata and cod-liver oil inunctions; heat to the abdomen; and small doses of the bromides or opium per ABDOMEN 689 rectum. If V()niitiii<,f and emaciation continue, or if there are signs of complete occlusion, the Rammstcdt oprriilion should be performed. A short incision is made through the right rectus muscle, the pylorus grasped between the thumb and the index finger, and its outer coats severed, from the normal gastric wall almost to the duodenum, in the axis of the pylorus, over the least vascular portion of the tumor, which is usally the upper and outer quadrant. The mucous mem- brane bulges into the gap, which may be widened by inserting the end of a pair of hemostatic forceps and gently separating the blades. The pylorus may then be dropped back into the abdomen, or the gap may be filled with fat or muscle, or covered with a flap of peri- toneum. As soon as the eiifects of the anesthetic have disappeared, the baby may begin to nurse from the breast, at first for brief periods, w^hich are gradually lengthened until the normal is reached. The special dangers of the operation are perforation of the mucous mem- brane, particularly when the incision approaches the duodenum; hemorrhage, which may prove fatal after operation, unless great care is taken to stop all bleeding, even though it may appear to be of a trivial nature; and breaking open of the incision in the abdominal wallowing to s training and crying, hence the stitches should be allowed to remain for two weeks, and the abdomen supported with broad bands of adhesive plaster. The mortality of gastroenterostomy for congenital pyloric stenosis is about 50 per cent., that of the Ramm- stedt operation about 25 per cent. The Rammstedt operation necessitates only a short incision in the abdominal wall, and can be performed much quicker than gastroenterostomy, both of which features are of considerable importance when dealing with an infant. Rupture of the stomach (see "Contusions of the Abdomen")- Foreign bodies which are swallowed may give no trouble, and finally be expelled through the anus. Balls of hair, etc., which have formed as the result of the habit of swallowing small particles of such material, may reach a great size and be mistaken for a neoplasm. In these cases, or in case a small foreign body lodges and causes mischief, gastrotomy may be performed and the offending material removed. The X-ray will often be of value for diagnostic purposes. Peptic ulcer of the stomach is due to auto-digestion of the gastric wall as the result of excessively acid gastric juice {hy perchlorhydria) , the resistance of the mucous membrane often being lowered by anemia, gastritis (especially the alcoholic form) , sometimes by throm- bosis, and occasionally by injury. Ulcers due to syphilis, tubercu- losis, neoplasms, certain forms of toxemia (hemorrhagic erosion), the swallowing of corrosives, etc., are not included under this heading, 44 690 MANUAL OF SURGERY although the symptoms may be identical with those of peptic ulcer. Ninety per cent, of the peptic ulcers are situated on the posterior wall of the pyloric region near the lesser curvature, because it is against this point that the gastric contents are hurled, during diges- tion, by the contraction of the greater curvature. Two forms are described, the acute and the chronic. Acute ulcer is round, smooth, and funnel-shaped, with the base towards the cavity of the stomach. The edges are sharply defined, have little or no induration, and healing takes place with scarcely any contraction. Acute ulcer is most frequent in chlorotic females between the fifteenth and the thirtieth year. It is generally single, but sometimes there are multiple ulcers, which may involve not only the stomach, but also the duodenum and the lower end of the esophagus. Chronic ulcers are usually solitary (95 per cent.), have indurated edges, and may be large and irregular. They produce great con- traction when they heal, are often adherent to adjacent viscera, and usually ocur in males (75 per cent, of the cases) between the ages of thirty and fifty. According to Mayo two-thirds of all ulcers of the stomach and duodenum are duodenal. Duodenal ulcer is discussed in the section on "The Intestines." Symptoms may be entirely absent {latent ulcer). In a typical case there is, in addition to the symptoms to be noted below, indiges- tion, i.e., flatulence, acid eructations (heart burn), and a sensation of fullness, heaviness, burning, or uneasiness in the epigastrium. Although almost all patients with gastric ulcer have indigestion, in most cases of indigestion the cause is not in the stomach, and in many cases not even in the abdomen. The pain of gastric ulcer is dull and gnawing, occasionally sharp. It occurs in the region of the ulcer, often passes through to the back, and is sometimes felt beneath the sternum, around the heart, in the neck over the corresponding vagus, or in the larynx. It is relieved by sodium bicarbonate and vomiting. If the pain is continuous, or does not cease after vomit- ing, it is generally not due to ulcer, unless the ulcer has reached the peritoneum or become malignant. The time the pain occurs depends upon the situation of the ulcer. In ulcers to the left of the median line pain may be experienced as soon as food enters the stomach; in pyloric ulcer pain may not occur for one, two, or three hours after meals. When pain is deferred until near the next meal and is relieved by eating (hunger pain) the ulcer is usually in the duodenum. Pain after eating is due to peristalsis, gaseous distension, physiologic congestion, increase in the HCl, and to direct irritation of the food. ABDOMEN 091 The K-iulcriicss, as a rule, is sharph' localized to one point, the situation of which is governed by the situation of the ulcer (Fig. 376). Rigidity of the epigastric muscles is most frec^uent when the ulcer spread to the peritoneum. Vomiting occurs at periods fixed by the pain. Tt may be self-induced, but is more often involuntary, being caused by pylorospasm in acute ulcer and in the early stages of chronic ulcer, and usually by mechanical obstruction in late cases. Vomiting without pain or indiges- tion is rarely due to ulcer. Bleeding mani- fests itself by hematemesis, visible or occult blood in the stools, or by the general symp- toms of anemia. Hematemesis occurs in one-third of the cases, the quantity of blood varying from a few drops to a pint or more. In chronic cases a tumor may sometimes _ . . ^iG- 376. — Tender points be felt. As a rule the appetite is good, but in some abdominal affections. the patient is afraid to eat. Anorexia is Jj ^'dZ.S^o'Z' iT^iTt.! more frequent in carcinoma. The symp- median line; pain may radiate . ,. ,, . . '. '•iP beneath the sternum and toms recur periodically, ottener in winter to the heart. 2. uicer near than in summer, so that relapses after ap- the pylorus. 3. Duodenal , , , ulcer. In I, 2, and 3, pain may parent cure are common. Emaciation is strike through to the back. 4. .,,.,, .,, ... ., Affections of the gall-bladder induced in those cases With persistent vomit- (Robsons point); pain may ing. Examination of the stomach contents radiate to epigastrium, around . , the right side of the back, and shows an excess of HCl. After administer- up to the right shoulder. 5. • _ u • iL 1 T 1 1.. Chronic pancreatitis (Des- ing barium, the ulcer, it deep, may show on .^^^.^,^ p^^P,). ^^^ ^^^.^^^^ a skiagram as a notch with the base towards ^o the epigastrium and some- . times to the left shoulder. 6. the stomach, and opposite this there may Appendicitis (Mc Bur ney's be a sharp indentation of the greater curva- f"'''*^'. p^!" °^*^^ ^l^'""' l"" '^ ^ _ the epigastrium or about the ture, due to spasm. An aero-bismuth diver- umbilicus. 7. Diverticulitis. . • 1 . 1- 1 , , • • 1 8. Ovaritis; pain may radiate ticulum. I.e., a light stain superimposed on down the thigh. 9. Renal a dark stain, means penetration into a foli'^: P^i" radiates from the loin, along the ureter, to the neighboring viscus, usually the pancreas or genitals. 10. Direction of pain the liver, hence may require a profile picture guinarhernil'affeSro^he' for its demonstration. In most instances, testicle and spermatic cord, vesiculitis. however, the ulcer does not show, and the X-ray demonstrates merely a dilatation of the stomach, due to pyloro- spasm or cicatricial stenosis, with a delay, often of six hours or more, in the passage of the bismuth into the duodenum. Reversed peristalsis and numerous large peristaltic waves, as observed with the liuoroscope, is indicative of pyloric stenosis. Among the complica- tions and sequelae are perforation (general peritonitis, subphrenic 692 MANUAL OF SURGERY abscess, etc.), grave hematemesis, tetany, perigastric adhesions, bilocular stomach, orifice (spasmodic or cicatricial), and carcinoma. Because of the deformities of the stomach they may produce and the possibility of malignant degeneration, gastric ulcers are generally regarded as more serious than duodenal ulcers. The treatment of uncomplicated acute ulcer is medical. Chronic ulcer should be treated by gastroenterostomy if marked improvement or recovery does not occur after three months of medical treatment. The mortality of chronic ulcer treated medically is 25 per cent. (Robson), of gastroenterostomy for this condition three per cent. As to the late results about 75 per cent, regain good health, 10 per cent, are much improved, 5 per cent, are slightly improved, and 5 per cent, develop a recurrence, a carcinoma, or some other compli- cation or sequel. Moynihan, in addition to gastroenterostomy, inverts the ulcer with sutures to prevent perforation, and ties all visible vessels leading to the ulcer to prevent hemorrhage. Gastro- enterostomy drains the stomach, puts the ulcer at rest, and, by allow- ing a slight reflux of bile and pancreatic juice through the anastomotic opening, partly neutralizes the gastric acidity. When the pyloro- spasm ceases food tends to pass again through the pylorus, thus oc- casionally leading to recurrence of the ulcer. This fact, with the observation that the best results are obtained when the pylorus is stenosed, has suggested that, whenever gastroenterostomy is per- formed the pylorus, if open, be closed artificially (see "Exclusion of the Pylorus"). Excision of the ulcer, followed by gastroentero- stomy, is recommended by a few surgeons for all cases, but as the operation is more difficult and dangerous (mortality 10 per cent.) than gastroenterostomy alone, it should be practised only when the induration be such as to give rise to a suspicion of cancer, when the the ulcer is so situated, e.g., at a distance from the pylorus, as to be little influenced by gastroenterostomy, or when the ulcer has given rise to repeated hemorrhages. The differentiation at operation between ulcer and carcinoma is often difiicult. The clinical history and the results of the laboratory tests, including the X-ray examina- tion, should be taken into consideration. In ulcer there is more apt to be edema and extensive inflammatory adhesions, and there are no carcinomatous foci in the neighborhood. Enlarged glands may be found in both ulcer and carcinoma. In some cases a frozen section may be made to decide the question. Excision gets rid of the ulcer, but unfortunately not of the cause of the ulcer, hence does not exclude, as some believe, the possibility of recurrence and carcinoma. For the methods of excision see "Partial Gastrectomy." ABDOMEN ■ 693 If, at operation, no ulcer can be demonstrated a gastroenterostomy should not be performed on the theory that it will do no harm, be- cause if it is not indicated, it may do harm, especially in the neu- rotic. The inexperienced ma\' easily be deceived by the localized muscular contraction of the gastric wall that follows pinching; this hard area, if watched for a short time, can be seen to relax. When no ulcer is present the other abdominal organs should be reviewed and any lesion in them corrected. The appendix should be mentioned particularly, as it not infrequently produces symptoms closely resembling those of gastric ulcer {appendicular dyspepsia). Perforation of the ulcer occurs in about 10 per cent, of the cases, and is much more frequent on the anterior than the posterior wall, owing to the formation of protecting adhesions to the pancreas in the latter situation. The symptoms vary in intensity according to whether the perforation is actite (no adhesions, wide diffusion of stomach contents through peritoneal cavity), subacute (minute opening and gradual leakage), or chronic (protecting adhesions and localized peritonitis). Acute perforation is announced by sudden violent pain in the epigastrium, which often radiates to the back, up to the left shoulder, and down into the right iliac fossa. There are great tenderness, marked rigidity of the abdominal muscles, and shock of varying severity. Pneumoperitoneum may be shown by absence of the liver dulness and by the X-ray. Movable dulness in the flanks is unusual unless the quantity of gastric contents extra- vasated is very large. In about half the cases the stomach contents are vomited, but rarely is there any blood. In 10 per cent, of the cases there is no previous history of indigestion. There may be a leukocytosis. The treatment is immediate abdominal section, any existing shock being combated while the preparations for operation are under way. The incision is made through the right rectus muscle above the umbilicus, and the perforation closed by a double row of Lem- bert's sutures of silk without excising the ulcer. In cases in which owing to the friability of the tissues, or the size or situation of the perforation, suture is impossible, the opening may be closed with omentum, gauze packing, or by covering it wdth the adjacent portion of the duodenum. The possibility of a second perforation should never be forgotten. Gastroenterostomy should be performed if there is much stenosis of the pylorus. In other cases it may be performed, if the patient is in good condition. Drainage is generally unnecessary in early cases in which the perforation has been securely closed. It should be employed in late operations, i.e., after the first 694 MANUAL OF SURGERY 12 or 18 hours, when the exudate is purulent, when a large quantit of food has escaped into the peritoneal cavity, and when the perfora- tion cannot be closed satisfactorily. In these cases a gauze drain may be placed in the vicinity of, but not in contact with the sutured perforation, and a second incision made above the pubes for the purpose of draining the pelvis. The mortality of early operation is five per cent., of late operation 50 per cent. Hematemesis, or gastrorrhagia, becomes a compHcation of ulcer of the stomach when it is persistent or grave. It may occur at any time during the progress of the ulceration, and is the cause of death in from 3 to 5 per cent, of all cases (Welch). In the acute form the patient vomits a large quantity of blood, sometimes a quart or more, and may never have another hemorrhage, or the hematemesis be repeated at intervals of several days or longer. Death from one hemorrhage is not common, but such may take place, even without the vomiting of blood, when a large artery, like the coronary or the gastroduodenal, is opened. The chronic form consists in repeated small hemorrhages. The diagnosis involves a differentia- tion from hemoptysis, and conditions like epistaxis, in which the blood has been swallowed and subsequently vomited. In hemoptysis the blood is frothy, bright red, and alkalin instead of acid; it follows coughing, and the physical signs of phthisis are present. An ex- amination of the nose and throat will usually reveal a lesion if the blood has been swallowed. Besides ulcer, hematemesis may be caused by a leaking aneurysm, rupture of varices of the stomach or esophagus due to obstruction of the portal circulation (e.g., in aft'ections of the heart, spleen, pancreas, and liver, particularly atrophic cirrhosis), cancer of the stomach or other tumor, ingestion of caustics, '^hemorrhagic erosion" (e.g., in uremia, phthisis, chronic alcoholism, yellow fever, scorbutus, and leukemia), post-operative hematemesis, which is supposed to be of infectious origin and follows abdominal operations, fieuropathic hematemesis, and vicarious menstruation. For clinical purposes it may be said that a gastric hemorrhage occurring in the apparently healthy, or in those who complain of pain and dyspepsia, is due to an ulcer. The treatment of a first attack of ac^lte hemorrhage is absolute rest, no food by stomach, ice to the epigastrium, and the injection of horse serum or the transfusion of blood. Chlorid of calcium per rec- tum, one to two grams, adrenalin by mouth, and the subcutaneous injection of gelatin or ergotin also have been recommended. With this treatment the hemorrhage will cease in 93 per cent, of the cases, operation under the same circumstances has a mortality of ABDOMEN C95 37 per cent. Should the hemorrhage be repeated once, or at most twice, operation may be undertaken, but is often unsatisfactory, as the bleeding point may not be found, or, if found, hemostasis may be difficult or impossible. The stomach is exposed by a median incision and the exterior examined for evidences of the ulcer (adhe- sions, scar, thinning of the coats) ; if such are absent, the stomach is opened, emptied, everted, and the mucous membrane carefully exam- ined. The bleeding point is ligated, sutured or cauterized ; or the ulcer is ligated en masse or excised (partial gastrectomy or pylorectomy) . If the bleeding point cannot be found, or if there is general oozing, or pyloric stenosis, a gastroenterostomy should be performed. Chronic liemorrhage is treated by gastroenterostomy, with infolding or, better, excision of the ulcer. Gastric tetany presents the same symptoms as other forms of tetany. It is very rare and almost always associated with gastrec- taisa, hence the treatment is that of dilatation of the stomach. Perigastric adhesions may be caused by ulcer of the stomach or duodenum, by trauma, by inflammatory affections of the biliary appa- ratus, pancreas, spleen, or intestine, and by tuberculous peritonitis. The symptoms are those of stenosis of the pylorus, or indigestion, with pain, particularly when the organ is distended. X-ray examina- tion may show an abnormal position of the pylorus, too slight or no displacement on different observations in different postures, or deformity of the pylorus or the stomach. The adhesions may be separated [gastrolysis) , and the raw surfaces covered with the omen- tum to prevent recurrence. There is danger of tearing the stomach or opening a latent perforation. If the pylorus be constricted or an ulcer be present, the operation should be completed by a gastro- enterostomy. Bilocular stomach (hour-glass stomach) may be congenital, but is usually due to the cicatricial contraction of a peptic ulcer on the lesser curvature; it may be caused also by perigastric adhesions, cancer, syphilis, tuberculosis, corrosive poisons, and certain opera- tions, e.g., gastrostomy and partial gastrectomy. Biloculation resulting from the pressure of an extragastric tumor is sometimes called false hour-glass stomach. We have operated on one patient with a trilocular stomach. The symptom's, when the constriction is small, are those of chronic gastrectasia, the cardiac pouch being dilated owing to interference with the onward passage of food. Occasionally the sulcus may be seen or felt through the abdominal wall, and an X-ray picture taken after an opaque meal will show the outlines of the stomach (Fig. 392), or at least the cardiac pouch. 696 MANUAL OF SURGERY A diagnosis must never be made, however, from a single skiagram, as a typical picture of an hour-glass contracture may result from a localized spasm of the muscular coat. Repeated plates on different days should be taken or the stomach watched with the fluoroscope. The spasm will sometimes cease after massage, the application of heat or the administration of atropin. Mediogastric spasm may be due to the same causes as pylorospasm as well as to organic pyloric stenosis {vide infra). If the cardiac pouch is filled with fluid, a swelling on the left side of the abdomen may be seen, which gradually passes to the right side, perhaps with an audible gurgle, as the fluid passes through the constriction. In some cases fluid injected into the stomach can only partly be recovered, although a splashing sound persists, and after a time a large quantity of semi-digested food may be returned through the tube. The diagnosis is confirmed Fig. 377. Fig. 378. Fig. 377. — Mediogastric resection. The part to be removed is indicated by- dotted lines. Note situation of the ulcer. Fig. 378. — Mediogastric fesection, gastric segments, anastomosed. by exploratory laparotomy, and one must be careful to examine the whole stomach, otherwise a pyloric stenosis or a constriction near the cardiac orifice will be missed. Volvulus of the pyloric pouch has been reported in several instances. The treatment depends upon the site and nature of the obstruc- tion or obstructions, the state of the ulcer (whether active or healed) , the size and mobility of the pouches, and the general condition of the patient. If the stricture is the result of carcinoma it must, if possible, be excised. In the remarks which follow the hour-glass deformity is supposed to be due to its usual cause, i.e., a peptic ulcer. Circular, or mediogastric resection (Figs. 377,378) is the operation of choice. It removes the ulcer with the constriction and reestab- lishes the normal contour of the stomach. It may, however, be impracticable owing to the large size of the ulcer, the small size of ABDOMEN 697 one of the pouches, extensive adhesions, or to the poor condition of the patient, the operation being longer and more difficult than some of the procedures mentioned below. In order to guard against recurrence the resection must include a wide segment of the stomach. Pylorectomy (P'ig. 379) might be done when the constriction is near the pjdorus, especially if the pylorus also be stenosed, but is Fig. 379. Fig. 380. Fig. 379. — Pylorectomy. Dotted lines indicate the part to be removed. Fig. 380. — Gastro-gastrostomy. The openings shown by the shaded areas are anastomosed. generally contraindicated because of its magnitude (See "Pylorec- tomy"). Gastroga^trostomy (Fig. 380) may be performed when the pouches are large, of nearly the same size, and pliable at the points selected for the anastomosis. Gastroplasty without excision of the ulcer may be employed when the constriction is narrow, and when that portion of the gastric Fig. 381. — Gastroplasty without excision of ulcer. Fig. 382. — Gastroplasty. In- cision closed. wall which is to be reconstucted is freely movable and not indurated. The isthmus may be incised in its axis, and the incision sutured perpendicularly (Fig. 381, 382), or the pouches below the isthmus may be incised and sutured (Figs. 383, 384), using the same technic as in the Finney operation (Cf. "Pyloroplasty"). Gastroplasty with excision of the ulcer may be selected when the 698 MANUAL OF SURGERY ulcer is active and not too large. The operation is illustrated by- Figs. 385, 386, and described under '"'Partial Gastrectomy." Fig. 383. — Gastroplasty Fig. 384. — Gastroplasty. Fig. 385. — Gastroplasty with without excision of ulcer. Incision closed. excision of the ulcer. Gastroenterostomy (Fig. 387) is, as a rule, the best operation for the obstruction when the cardiac pouch is very large, or when medio- PiG. 386. — Gastroplasty. Incision closed. Fig. 387. — Single gastro- enterostomv. gastric resection is inadvisable, and it or pyloroplasty must be com- bined with mediogastric resection, gastrogastrostomy, or gastro- Fig. 388. Fig. 389. Fig. 388. — Double gastroenterostomy. Pig. 389. — Diagram of posterior gastroente ostomy. Dotted lines indicate retro- gastric portion of bowel and site of anastomosis. A, origin of jejunum. plasty when these operations are performed in cases of bilocular stomach with pyloric stenosis. Double gastroenterostomy likewise ABDOMEN" 699 could be used in such cases, if the pyloric pouch were large, and other methods contraindicated. The bowel can be made to run from right to left as shown in Fig. 387, or, by using a longer loop, from left to right (isoperistalic) , and in either single or double gastroenterostomy the jejunum may. if the posterior operation is inapplicable, be attached to the anterior wall of the stomach. Gastroenterostomy for its influence in healing the ulcer, or, if the ulcer has been excised, preventing its recurrence, is advised by some surgeonsas an addition to circular resection, gastrogastrostomy, and gastroplasty, even when the pylorus is open. Stenosis of the pylorus may be congenital (p. 699) or acquired, organic or functional, extrinsic or intrinsic. The extrinsic organic causes are perigastric adhesions, kinking of the pylorus as the result of prolapse of the stomach, and compression by aneurysm, tumors, cysts, or inflammatory aft'ections of the kidney, liver, pancreas, gall-bladder, or lymph glands. The intrinsic organic causes are cicatricial contraction (ulcer, tuberculosis, syphilis, caustics), tumors, and foreign bodies. Functional stenosis, or pylorospasm likewise may be due to a lesion in another abdominal organ, notably cholecystitis and appendicitis, to toxins (nicotin, lead, morphin, etc), to tabes, and to emotional causes, or intrinsic, i.e., due to disease of the stomach, especially ulcer and hyperchlorhydria. The symptoms are those of dilatation of the stomach plus in some cases the detection of a tumor at the pylorus. The treatment of extrin- sic organic stenosis, is removal of the cause, or, if such be impossible, gastroenterostomy. Intrinsic organic stenosis may demand gas- trotomy, e.g., for a foreign body; pylorectomy, e.g., for carcinoma or gastroenterostomy, e.g., for cicatricial stenosis or irremovable carcinoma. Pyloroplasty is occasionally performed, for cicatricial stricture. Pylorospasm may, according to its etiology, require medical treatment, gastroenterostomy, or an operation on an abdominal organ other than the stomach. Stenosis of the cardiac orifice (see "stricture of the esophagus")- Dilatation of the stomach (gastr ectasia) may be acute or chronic. Acute dilatation of the stomach is a sudden paralytic distention of uncertain origin, but probably the result of disturbed innervation. About 40 per cent, of the cases arise after operation, usually on the upper abdomen (hence shock, sepsis, purgation, handling of the viscera, and the anesthetic have been held responsible), 20 per cent, during exhausting fevers (typhoid, pneumonia, etc.), 10 per cent, after errors in diet, particularly the ingestion of enormous quantities of food or drink, and a few from no condition which can 700 MANUAL OF SURGERY be connected with the gastric paralysis. The associated conditions distributed among the remaining cases are trauma, emotional attacks, childbirth, peritonitis, intestinal paralysis (q.v.), and spinal deformity, especially when there is lordosis, which may encourage pressure on the duodenum. The enormously dilated stomach forces the small intestine into the pelvis and renders its mesentery taut. As a consequence the duodenum is compressed between the root of the mesentery and the superior mesenteric vessels in front and the vertebral column behind. _ Some surgeons regard this constriction of the duodenum as primary, hence the terms gastromesenteric ileus and arteriomesentric occlusion. Even if this is not true, it is certain Pig. 390. — Acute dilatation of stomach following compotind fracture of femur. that a secondary factor is thus added which serves to augment and perpetuate the condition. The symptoms are pain; profuse vomiting; severe thirst; distention of the stomach, which interferes with the action of the heart and lungs, and which may be so great as to fill the whole abdomen; gastric splashing sounds on succusion; absence of visible and audible gastric peristalsis, constipation, perhaps with clay-colored stools; scanty urine; and finally collapse, with, if proper treatment is not quickly administered, death in two- thirds of the cases. The diagnosis from peritonitis is made by the absence of fever, leukocytosis, tenderness, and rigidity. In high intestinal obstruction there is little or no distention. The treatment is gastric lavage; no food or water by mouth. ABDOMEN 701 placing the patient on the right side with the pelvis elevated, in the knee-chest posture, or prone, in order to relieve the duodenum of pressure; water by rectum, or salt solution subcutaneously or intra- venously; strychnin, atropin, pituitarin, or escrin salicylate hypo- dermically; electricity to the epigastrium; and, as a last resort, gastrostomy or gastroenterostomy. Chronic dilatation is usually the result of pyloric stenosis, but may be caused also by duodenal obstruction (e.g., from ulcer, cancer, and, in enteroptosis, compression by the superior mesenteric vessels), overeating, chronic gastritis, and general malnutrition {atonic dilatation). The symptoms are dyspepsia, often hunger and thirst, Antrum or Pylorus/ X, Bulb ofJ)uoae??.um, Pi/lorus Gas dudble . UmbiUcus. Fig. 391. — Diagram of X-ray shadow of normal stomach after barium meal, patient standing. and vomiting at intervals of large quantities of decomposing food, some of which has lain in the stomach for several days. The patient emaciates, passes small quantities of urine, is constipated, and may have attacks of tetany. Examination of the stomach contents re- veals the sarcina ventriculi and many other bacteria; the amount of hydrochloric and lactic acids will depend upon the cause 01 the dilata- tion. The stomach is prolapsed to below the umbilicus, and is often visible through the abdominal wall. Peristalsis passing from left to right likewise may be seen at times. On palpation the cushion-like resistance of the stomach may be felt, a splashing sound often elicited, and in some cases a tumor detected in the pyloric •J02 MANUAL OF SURGERY region. The size of the stomach is determined by percussion, after filling the stomach with air or water; by measuring the quantity of fluid which the stomach will hold; or by gastrodiaphany (trans- illumination by means of an electric lamp passed into the stomach). If the patient takes lo grains of salol, which is decomposed and absorbed in the intestine only, salicylic acid may not appear in the urine for many hours; normally it should be detected within one hour. The absorptive power of the stomach is determined by giving several grains of potassium iodid and testing the saliva for iodin, which should be found normally in from ten to fifteen minutes. Fig. 392. — Diagram ot X-ray shadow of hour-glass stomach alter barium meal, patient standing. The size, shape, position, and activity of the stomach may be shown also by the X-rays, after administering from two to four ounces of barium sulphate in a pint of milk or koumyss (Fig. 391). Nor- mally the stomach should be- free of the barium in from three to six hours. Partial retention after six hours, however, is not always due to organic gastric disease. It may be the result of extrinsic pylorospasm {vide supra). With the fluoroscope the peristaltic movements can be kept under continuous observation. A peristaltic wave normally passes over the stomach about every twenty seconds. An increase in the number of waves is seen in stenosis, and also in certain afTections of the nervous system (locomotor ataxia). ABDOMEN 703 One would suspect organic stenosis if there were numerous waves of great depth. Reversed peristalsis may occur in stenosis from any cause. The shape of the stomach is normal in functional stenosis, plate-like, with displacement of the pylorus to the right, in organic stenosis. The treatment in atonic cases is medical, i.e., lavage, regulation of the diet, electricity, etc. If medical treatment fails, gastroenter- ostomy may be performed. In those cases depending upon obstruc- tion to the outlet of the stomach, the treatment is that of pyloric stenosis. Fig. 393. — Diagram of X-ray shadow of gastrectasia, patient standing. Pig. 394. — Diagram of X-ray shadow of stomach with carcinoma of the greater curvature, patient standing. Gastroptosis, or prolapse of the stomach, is usually secondary to gastric dilatation, when the symptoms and treatment will be those of gastrectasia. It forms part also of the general visceral ptosis called Glenard's disease. Primary or essential gastroptosis is probably very rare, and is constantly linked wuth dilatation, from kinking of the pylorus, or from pylorospasm the result of hyper- acidity. The symptoms are therefore usually those of chronic indigestion and gastric stasis. The position of the stomach may be determined by percussion, after filling the stomach with air or water, or by the X-ray (vida supra). Volvulus of the stomach has occurred as a complication of gastroptosis. The treatment 704 MANUAL OF SURGERY of the essential form is gastroenterostomy, with or without gas- tropexy. Carcinoma of the stomach is very frequent, sarcoma and innocent tumors are rare. Carcinoma may involve any portion of the stomach, but most often affects the pylorus (60 per cent.) . often starting from an old ulcer. It is more frequent in the male (55 per cent.), and is unusual before the fortieth year. It may be of any variety, but is generally scirrhous in nature. It always begins in the mucous membrane, infiltrates the remaining coats of the stomach, and finally invades the surrounding organs, particularly the liver and pancreas. The lymphatic glands, especially those along the lesser curvature, are invaded at an early period, and distant metastases also may occur. The ''leather bottle stomach" is a diffuse carcin- omatous infiltration of the whole organ. The disease is fatal in from a few months to two years or longer, according to the nature and situation of the growth. The S5rmptoms which occur in both carcinoma and gastric ulcer are, in order to facilitate comparison, listed in the same order as in the description of "Peptic Ulcer of the Stomach." The indigestion is not so apt to be associated with heart burn. The pain, as a rule, is not so marked as in ulcer, but may be reflected in the same way. It is often continuous and may not be reheved by vomiting, hence may not appear at fixed periods after meals, although eating may increase the discomfort. In some cases pain is absent. Tenderness also may be absent and is seldom pronounced. Muscular rigidity is almost never present. The vomiting may at first be due to pylorospasm, but later is generally the result of gastrectasia following pyloric stenosis, consequently may occur only once in 24 hours or less often, the vomited material being abundant, foul smelling, and containing particles of food ingested one or more days previously. When the cardiac orifice is involved the symptoms are those of stricture of the esophagus. When neither orifice is involved, vomit- ing may be absent unless the tumor has caused an hour-glass con- traction of the stomach. Occasionally vomiting does not occur even when there is marked pyloric stenosis with gastrectasia. Bleeding is usually shght. The blood, like the food, stays in the stomach for many hours, hence is decomposed and gives the so-called coffee- ground vomit. ."Melena may occur when the blood passes through the pylorus. The tumor can be felt in 60 per cent, of the cases, but in only 30 per cent, within the first six months of the onset of the symptoms. It is most apt to be palpable when situated at the pylorus or along the greater curvature, and can never be felt when ABDOMEN 70s located at the cardiac orifice. The appetite is sometimes good, but usually there is anorexia. Intervals of good health do not occur, as in ulcer; the disease is progressive, and marked emaciation, or cachexia, soon appears. The laboratory methods of diagnosis are unreliable in the early stages, and are of the greatest value only when the growth is inoper- able. At this time examination of the gastric contents shows an absence of free hydrochloric acid and an increase in the amount of lactic acid, both of which conditions may be found in other gastric diseases. Microscopic examination of the stomach contents may show small portions of the neoplasm and the Oppler-Boas bacilli, and these bacilli with visible or occult blood may be found in the stools. The motor and absorptive powers of the stomach are lessened. Blood examination shows a reduction in the hemoglobin and an absence of the digestive leukocytosis. Finally may be mentioned the possibility of making a diagnosis by the esophago- scope, introduced into the stomach; by transillumination with an intragastric lamp, showing a tumor on the anterior wall; and by the X-rays, after the ingestion of an emulsion of barium, the tumor appearing as a marked indentation in the outline of the stomach (Fig. 394). The early symptoms are indigestion, distaste for food, pain, and sometimes vomiting. If in spite of careful medical treat- ment, symptoms of this character persist for a month or longer, and are associated with a progressive loss of weight, in a patient past forty, one should always suspect carcinoma, and advise an explora- tory incision, which is the most reliable diagnostic measure. This is the time for successful surgical treatment. Among the late symp- toms are coffee-ground vomit, cachexia, palpable tumor, ascites (from invasion of the liver, portal vein, or peritoneum), distention of the superficial abdominal veins, swelling of the legs, femoral phlebitis, and jaundice owing to involvement of the common bile duct. Enlargement of the lymph glands at the base of the left neck due to metastasis up along the* lymphatics of the mediastinum is a rare sign. Metastases in Douglas's pouch or in the ovaries may occur, and operation should never be performed without first making a rectal or vaginal examination. In addition to the compli- cations mentioned above, perforation, grave hematemesis, and tetany are possibilities. The treatment is exploratory incision, and if possible, removal of the growth by partial or complete gastrectomy. About 25 per cent, of permanent recoveries can be expected after early operation. If the patient is very weak and the growth situated at the pylorus, 7o6 MANUAL OF SURGERY one may perform gastroenterostomy and after the patient has re- gained strength proceed with the pylorectomy. In inoperable growths of the cardiac orifice, gastrostomy is indicated for the pur- poses of feeding. In inoperable cancer of the pylorus gastroentero- stomy may be performed, in order to allow the passage of food into the bowel. The average duration of life after this operation is six months. When the entire stomach is hopelessly invaded, the only possible measure which promises relief is jejunostomy, or the making of an artificial opening into the jejunum in order to feed the patient. Gastritis obliterans {plastic linitis fibromatosis of the stomach) is a rare affection, characterized by great thickening of the walls of the stomach as the result of hyperplasia of the submucosa, and a progressive diminution in the size ot the stomach. It is a cirrhotic inflammation, the cause of which is unknown. It has been attributed to syphilis, tuberculosis, or chronic ulceration, and some believe it to be a precancerous lesion. The symptoms are pain, vomiting im- mediately after taking food, and emaciation. The small size of the stomach can be shown by the X-ray. The treatment is -^ylovo- plasty or gastroenterostomy, when the pyloric portion is chiefly involved; or partial or complete gastrectomy. Volvulus of the stomach also is rare. It may be associated with diaphragmatic hernia, bilocular stomach, or gastroptosis, in each of which a sort of pedicle is formed, around which the stomach may rotate. The symptoms are pain, shock, and the appearance of a tender, rounded tympanitic swelling in the upper abdomen. Vomit- ing cannot occur. The treatment is laparotomy, reduction of the twist, and shortening of the gastrohepatic omentum. Kocher collected i8 cases in which operation had been performed, with 13 recoveries. OPERATIONS ON THE STOMACH Gastric lavage is required in cases of poisoning, as a preHminary to operations on the stomach, and as a therapeutic measure in many gastric diseases, particularly dilatation. The stomach tube is lubricated with glycerin, guided over the epiglottis by the forefinger, and pushed into the stomach while the patient makes efforts at swallowing. Water or other fluid is then poured into the funnel end of the tube until the requisite amount has been introduced, when it is carried to a lower level than the stomach, while still full of liquid, thus syphoning off the contents of the stomach. The washing may be continued until the stomach is clean. ABDOMEN 707 Gastrotomy, or incision into the stomach, may be performed for exploratory purposes, gastric hemorrhage, the removal of foreign bodies from the esophagus or stomach, the excision of benign tumors springing from the inner walls of the stomach, and for the dilatation of stricture of either the cardiac orifice or the pylorus. A median abdominal incision is made, and the stomach drawn into the wound, isolated with gauze, and incised at the desired point. The wound is sutured with catgut, passing through all the coats, and over this is placed a layer of Lembert sutures of silk. The abdomen is closed without drainage. The patient begins to take water after the vomit- ing has ceased, and solid food at the end of two or three weeks. Gastrostomy is the making of an opening into the stomach, for the purpose of feeding a patient. It may be temporary, e.g., when performed to facilitate convalescence after laryngectomy or Fig. 395. — Witzel's gastrostomy, (Binnie.) Pig. 396. — The Stamm-Kader gastro- stomy. (Binnie.) operations on the esophagus, or permanent, e.g., when performed upon a patient with inoperable stricture of the esophagus. The opening should permit feeding, prevent the external leakage of the gastric contents, and be as near the cardiac orifice as possible. Hartmann and others make a vertical incision through the outer border of the left rectus, retract the inner portion of the muscle towards the right, and open the posterior sheath and peritoneum near the middle line. A cone of the stomach is pulled through the wound, and sutured to the parietal peritoneum and the skin. The apex of the cone is opened, and the patient fed with a rubber tube. In the Frank operation a two inch incision is made below and parallel with the left costal margin, then a cone of the stomach is drawn through this incision, and passed upwards under the skin to a second incision, about one inch in length, situated over the costal margin. The stomach is sutured to the muscles of the first incision. 7o8 MANUAL OF SURGERY and to the skin of the second incision, where it is opened and a tube inserted. In Witzel's operation the abdomen is opened through the left rectus, a catheter passed into the stomach through a small opening and there sutured with catgut, and a canal formed about the tube by suturing the walls of the stomach over it with Lembert sutures (Fig. 395). The outer opening of the canal is sutured to the parietal peritoneum and the abdomen closed. This is the best method for temporary gastrostomy, as the canal quickly becomes obliterated after the catheter is withdrawn. ';-^_:%' ^-V., <- Fig. 397. — Gastrostomy. The cutaneous incision. The Stamm-Kader operation is shown in Fig. 396. The author's method for establishing a permanent gastrostomy is described, in the Transactions of the American Surgical Associa- tion for 1918. as follows: "An incision is made from a point just below and to left of the ensiform cartilage downward parallel to the median line for three or four inches. About two or two and a half inches to the left of this incision a second cut is made, the upper end of which is on a level with the upper end of the first incision, the lower end of which is on the level with the lower end of the first incision. The lower extremities of these incisions are connected by a trans- verse incision (Fig. 397) . The rectangular cutaneous flap thus outlined is dissected free, as far as its base, from the subjacent deep fascia, and the two long margins sutured together with catgut over a cathe- ter rXo. 20 F.), the eve of which remains uncovered below thelower XHDOMEN 709 end of the flap (Fi^. 398). 'I'he catheter with its enveloping skin is drawn to one side, the underlying rectus muscle split longitudinally, and a portion of the anterior wall of the stomach drawn from the Fig. 398. — Gastrostomy. Formation of the dermal tube. Fig. 399.— Gastrostomy envelopement of the dermal tube by the anterior gastric- wall. abdominal cavity. A small transverse opening is made in the exposed gastric w^all the inferior extremity of the catheter pushed into the stomach through the opening, and the rim of the lower end 710 MANUAL OF SURGERY of the dermal tube enveloping the catheter sutured with catgut to the edges of the opening in the stomach. The lower half of the dermal tube is buried in the wall of the stomach in the same manner as the catheter is buried in the Witzel operation (Fig. 399) . The upper end of the canal thus formed by the inversion of the anterior wall of the stomach is sutured to the abdominal wall, and the split rectus muscle approximated with catgut around the upper half of the dermal tube. The skin about the raw surface which remains is undermined, and, beginning at the lower left corner of the oblong defect (Fig. 397, B), sutured, the sutures being inserted farther apart on the right (i.e., on the line BCD, Y'lg. 397) than on the left {BA, Fig. 397), until the lower margin of the external orifice of the Fig. 400. — Gastrostomy. The cutaneous incision closed. dermal tube is reached, when the suture line bifurcates to embrace the new stoma. The scar thus resembles a Y, the long tail of which is slightly convex toward the median line (Fig. 400). The catheter is fastened to the skin with a catgut suture and should remain in place until the completion of healing, after which it may be with- drawn, to be reinserted only at the time of the feedings. This method of gastrostomy is designed for those patients, usually suffering from irremovable oesophageal carcinoma, who must for the rest of their lives be nourished through an artificial opening in the stomach. The operation is a trifle longer than the Witzel operation, but has all the advantages of providing a canal lined with epithe- lium, which will not become agglutinated during the intervals ABDOMEN - 711 between the insertions of the catheter. Further, there is no danger, as in the Witzel operation, of leakage between the outer end of the canal in the stomach and the abdominal wall, and no danger of pushing the catheter between the stomach and the abdominal wall and so into the peritoneal cavity. A canal lined by mucous membrane can be constructed, as sug- gested by Depage, Jianu, and others, from a f^ap of the wall of the stomach, and is to be preferred to all other methods of gastrostomy when one desires to build an artificial esophagus, which, later, is to be joined to the external stoma of the canal leading into the stomach, but in the majority of cases of oesophageal occlusion the building of a new oesophagus is not indicated, and to fashion amucosa-linedcanal from the gastric parietes is more complicated and attended by greater risks of infection than is the operation described above (see "Eso- phagoplasty ") . In the Ssbanejew-Franck operation, which also provides a lining of mucous membrane for the canal opening into the stomach, one must often, in view of the small size of the stomach consequent upon the oesophageal obstruction, pull almost the whole stomach from the peritoneal cavity, before exposing the requisite amount of gastric wall to complete the operation, thus producing serious deformity. In addition, the external orifice of the canal retracts beneath the skin and becomes difficult of access, thus rendering catheterization uncertain and attempts at catheterization dangerous. Gastroplication consists in lessening the size of the stomach by the introduction of inversion sutures into its anterior wall. It is doubt- ful if this operation should ever be employed. Gastropexy also is of doubtful value. The stomach has been sutured to the anterior abdominal wall and to the liver. Beyea shortens the gastrohepatic and gastrophrenic ligaments by the intro- duction of reefing sutures. Gastroenterostomy, or the formation of a fistula between the stomach and the intestine, is indicated in pyloric stenosis, gastrecta- sia, and gastric ulcer. The intestine may be united with the anterior or the posterior gastric wall, or, as will be explained under "Pylorec- tomy," with both walls. Anterior gastroenterostomy, or Wolfler's operation (Fig. 401), is indicated in cases in which the posterior operation is not applicable, e.g., because of disease of the posterior wall, short, fatty mesocolon, or adhesions, and in cases of malignancy in which every minute should be saved. Its disadvantages are that the long loop of intestine attached to the stomach may cause obstruction by pressure on the 712 MANUAL OF SURGERY transverse colon, by allowing adjacent coils of bowel to slip into the noose, or by producing angulation of the intestine on either side of the anastomosis, that the segment of jejunum forming the loop is excluded, physiologically, from the rest of the digestive tube, and that peptic ulcer of the jejunum (q.v.) is more apt to occur than after the posterior operation. After opening the abdomen in the middle line above the umbilicus, the omentum is pulled upwards, and a loop Pig. 401.- Proper position for opening in stomach. A. Improper position, allowing formation of intragastric pouch. (Mayo.) of jejunum, about a foot from the duodenum, brought up over the transverse colon and anastomosed with the lowest point on the anterior wall of the stomach (Fig. 401), using the same technic, in regard to clamps and suturing, as in the posterior operation; the Murphy button and the McGraw elastic ligature are no longer employed. The incision in the stomach should be so arranged as to avoid sharp angulation of the intestine; it may, according to the position of the stomach, be parallel with or perpendicular to the ABDOMEN 71,^ greater curvature. The intestine should run from the patient's left towards the right (isoperistaltic). The stomach should be attached to the bowel with a few additional sutures on each side of the ojiening in order to ])revent a sharp kink. Kocher places the afferent limb of intestine posteriorly and invaginates its wall transversely, in order to form a valve which will direct the stomach contents into the efferent limb of intestine. Posterior gastroenterostomy, or Von Hacker's operation, has advanced to its present state of elliciency largely through the labors of Peterson, Czerny, Mikulicz, Moynihan, and Mayo. The gastric opening should be at the lowest point of the posterior wall of the stomach, in the same plane as the cardiac orifice, and directed obliquely from above downward and from the patient's right to left, in order to avoid angulation of the jejunum, which normally passes in this direction Fig. 389. Hartmann, however, states that when the anastomosis is made in the cardiac portion of the stomach the gastric contents flow through the pylorus, when in the pyloric antrum, which is the motor part of the stomach, they pass almost entirely through the anastomosis. The opening in the intestine should be longitudinal and opposite the mesentery, as near the origin of the jejunum as possible, usually from two to four inches, thus utilizing that portion which normally lies immediately behind the stomach and avoiding a loop. Clamps whose blades are covered with rubber tubing, are placed on the intestine and the stomach, to prevent extravasation of contents and bleeding during the operation which is performed as follows: The abdomen is opened by a four inch incision, separating the fibers of the right rectus muscle. The transverse colon and omentum are turned up over the epigastrium, and the mesocolon torn through at a bloodless spot within the loop of the middle colic artery. A fold of the posterior wall of the stomach is drawn through this opening and clamped with long forceps, the heel of which should include a portion of the greater curvature, the great omentum being separated slightly for this purpose (Fig. 402). The jejunum just below^ its origin is found by carrying the finger along the root of the transverse mesocolon to the left of the spine, brought to the surface, and clamped, the heel of the clamp grasping the caudal portion of the loop. Unless care is taken to apply the clamps in the proper direc- tion the upper portion of the intestinal loop may be approximated to the lower portion* of the stomach, thereby producing a twist in the loop. After replacing the colon and the omentum in the abdo- minal cavity the clamps, with the handles in the same direction, 714 MANUAL OF SURGERY are laid side by side and surrounded by gauze pads. With a con- tinuous Lembert suture of silk or celluloid thread the stomach is sutured to the intestine for at least three inches. Both the stomach and intestine are now incised down to the mucous membrane, about one-fourth of an inch in front of the suture line. The mucous membrane exposed by the retraction of the outer coats is excised and the stomach united to the intestine all around the anastomotic opening by a continuous catgut suture, passing through all the coats in order to give firm apposition and stop bleeding (Fig. 403). The clamps are now removed and the continuous Lembert suture con- FiG. 402. — Showing posterior vrall of the stomach drawn through a rent in the trans- verse mesocolon. Note slight separation of gastrocolic omentum from its attachment to the stomach, permitting anterior wall of stomach to appear, and insuring drainage at lower-most level. Black lines mark site of proposed anastomosis; the jejunum shows at its origin. (Mayo.) tinued around the opening to its point of origin. The edges of the tear in the mesocolon are fastened to the stomach to prevent hernia, and the abdomen closed without drainage. After operation the patient is put in the semi-sitting posture and fed as after gas- trotomy. The mortality of gastroenterostomy in benign cases is 3 per cent, in malignant cases 20 per cent., most of the deaths being due to pneumonia, exhaustion, and peritonitis, the last resulting from leakage of the anastomosis, particularly in those •with, carcinomatous cachexia. Secondary operation is required in about 5 per cent, of the cases. ABDOMEN 7^5 In the author's method of gastroenterostomy the stomach is emptied In' lavage shortly before the induction of anesthesia "The posterior wall ot the stomach is exposed, as in the ordinary oper- ation of retrocolic gastroenterostomy, by tearing through the mesocolon. A celluloid suture is passed through the posterior wall of the stomach at or near the greater curvature, and through the antimesenteric border of the jejunum several inches from the duodenojejunal juncture. Upward traction on this suture causes the stomach and the intestine to fall together. A second suture then unites the apposed viscera at a point three inches from the original suture, i.e., three inches nearer the duodenojejunal juncture. Fig. 403. — Forceps in place and anastomosis half completed by suture. (Mayo.) The first suture is drawn towards the patient's left shoulder, the second toward the patient's right hip, thus lifting the parts to be anastomosed from the abdomen and bringing them into taut align- ment. These sutures may be confided to an assistant or kept tense by attaching to each a pair of heavy forceps. The fine of contact between the stomach and the intestine is now made permanent by a continuous seroserous suture, extending from the lower guide suture to the upper guide suture, and tied at the latter point, the end, however, being left long for use during the final step in the anastomosis (Fig. 404) . After shielding the general peritoneal cavity from contamination by means of an encircling gauze pad, the 7i6 MANUAL OF SURGERY peritoneal coat of the stomach is incised close to and parallel with the line of suture, thus exposing the blood-vessels which, with a small bite of the underlying mucous membrane, as yet unopened, are secured wath haemostats at each edge of the incision (Fig. 405). The number of h^mostats required varies with the length of the incision and the vascularity of the part. The average is from live to six on each side of the incision. A smaller number is shown in the illustration for the purpose of clarity. The mucosa is incised between the rows of forceps, thus opening the stomach. Additional haemostats may be needed to control minute vessels which could not be seen before the incision into the stomach was made. A ABDOMEN 717 gauze pad is laid over the gastric incision, and the row of forceps nearer the intestine reflected on to the gauze. In the same way as in dealing with the stomach the outer coat of the intestine is incised, the vessels caught with haemostats (Fig. 406). the mucosa opened, and the opening covered with a gauze pad. This leaves IMM .^^m % the posterior wound edges exposed. Each pair of vessels (one gastric vessel, one intestinal vessel) in these exposed edges is ligated with a single strand of chromicized catgut, after drawing the edges together by means of the two forceps (one on the stomach, one on the intestine) in closest proximity (Fig. 407). These ligatures not only prevent bleeding but also hold the edges in firm apposition. 7i8 MANUAL OF SURGERY If a haemostat does not stand in close relationship with a fellow, an additional forceps may be employed to establish this relationship. After removing the gauze pads which lay over the gastric and the intestinal openings the anterior edges of these openings are drawn together by ligatures, beginning at the end farthest from the surgeon. The two forceps which lie opposite each other are held by an as- sistant. The right end of the ligature is passed around the forceps on the intestine from right to left, the left end around the forceps on the stomach from left to right; thus the ends emerge between the forceps, beneath the loop of the ligature (Fig. 408). The forceps are brought parallel to the long axis of the wound, rolled toward each ABDOMEN 719 Other, thus inverting the mucous edges of the wound, the ligature tied, and the forceps removed. Each succeeding pair of vessels is dealt with in a similar manner. The result is the same as with the posterior wound edges, i.e., haemostasis is assured and the edges are bound firmly together. The rest of the proceeding is much like that ■■j^ 2 usually followed. The seroserous suture is continued along the anterior portion of the anastomosis and tied at its point of origin (Fig. 409). The margins of the rent in the mesocolon are fastened to the stomach or the intestine. The operation is easier to perform and less dangerous than gastroenterostomy in which clamps are employed. After the first guide suture has .been inserted 20 MANUAL OF SURGERY the structures to be joined are already in juxtaposition and there is no risk, even for the beginner, of confusing the relations of the parts, such as is possible during the apphcation of clamps and their subsequent adjustment. Among the unreported disasters following gastroenterostomy there are no doubt some which, thanks to in- vi-. >•.".••'. .-yt,- S.«-*^V ■'-'%^ #. . ^ I ■-•-'* experience and clamps, result from suturing the lower end of the intestinal opening to the upper end of the gastric opening. One of the stated advantages of clamps is that they steady and hold together the concerned viscera. As a matter of fact the stomach and the intestine are necessarily separated by the intervening blades of these instruments, whereas guide sutures not only permit direct ABDOMEN 721 apposition, but at the same time create a ridge at the line of contact which facilitates suturing. 'J'he same degree of close alignment is obtained for the anterior seroserous suture, after the anterior wound edges have been inverted by the ligatures. When clamps are employed the mucous membrane pouts, being squeezed out by o ,^^ pressure, and is usually excised. This excision is not needed in the operation without clamps. Suturing of the anterior edges of the mucous membrane, even after the clamps have been rotated toward each other, is more difificult than the application of ligatures as described above. Further, one draws less stomach and less intestine from the abdomen when using guide sutures instead of 46 72 2 MANUAL OF SURGERY clamps, or, to put it in other words, a longer anastomosis can be made with the aid of guide sutures than can be made with the same amount of stomach and intestine when clamps are employed, a consideration which occasionally is of some importance. The danger of leakage of gastric or intestinal contents during the operation is no greater, perhaps even less, than when clamps are applied. Contusion or crushing of the tissues in the immediate vicinity of the anastomosis is avoided. Damage of this nature is potent for evil, especially in the old, the arteriosclerotic, the cachectic. The possibility of clamp injury predisposing to peptic ulcer of the jejunum, or causing necrosis at the site of anastomosis, although remote, is nevertheless real, and must be included in the evidence against the clamp. The greatest menace, however, is that of bleeding after the clamps have been removed. Like a tourniquet, the clamp increases the tendency to oozing of blood, after the removal of the compression, and when clamps are em- ployed in gastroenterostomy the hemorrhage, if all the severed vessels have not been closed, remains undiscovered until the patient vomits the blood or presents evidences of acute anemia. One is then con- fronted with the alternative of waiting hopefully, or of reopening the abdomen, during a critical period, in order to arrest the bleeding. Even carefully applied sutures are uncertain, so far as haemostasis is concerned, unless the wound is inspected after the clamps have been removed, since even large blood-vessels, unseen because empty, may readily be punctured by the needle. In the operation described above the surgeon ties all the open blood-vessels, and may assure himself that haemostasis is complete (Trans, Amer. Surg. Assoc, 1917). The vicious circle is a term applied to the passage of stomach contents into the afferent limb of gut, thence back into the stomach, which is emptied by vomiting. Kocher's method for preventing this accident has already been mentioned. In operations wdth a loop, an anastamosis may be made between the lowest portion and the jejunum. In addition to this measure the afferent loop may be ligated with silk, fascia, etc., between the two points of anastomosis, or the pylorus may be closed (see Exclusion of the Pylorus). In Roux's method "en Y" the jejunum is divided, the lower segment anastomosed with the stomach, and the upper segment with the side of the lower segment several inches below the stomach. Excluding diseases not consequent upon the opera- tion, acute and atonic gastrectasia, recurrence and cancerization of the ulcer, and "vicious circle," which is rare after the no-loop ABDOMEN 723 operation, persistent vomiting following retrocolic gastroenteros- tomy is due to gastrospasm the result of peptic ulcer of the jejunum (vide infra), to peritonitis, or to obstruction the result of kinking or twisting of the bowel, hernia of the small intestine through the mesocolon, or contraction of the anastomotic opening. The X-ray is of great service in differentiating these lesions. Vomiting due to obstruction requires a secondary operation for the relief of the obstruction. Peptic ulcer of the jejunum may follow gastroenterostomy, owing to the corrosive action of the gastric juice. It is probably more frequent than is generally thought, many cases being unrecognized. Roojen (1910) has collected 89 cases, most of which occurred after the anterior operation, the reason for this being that the upper portion of the jejunum, such as is utilized in the posterior operation, is more resistant to the digestive action of the gastric juice, owing to the presence of bile and pancreatic fluid. The onset of symptoms varied from ten days to nine years after the gastroenterostomy. The ulcer is usually in the desending limb of bowel, but may attack the anastomosis itself or the afferent limb; in several cases there were multiple ulcers. Not one occurred after gastroenterostomy for cancer, hydrochloric acid generally being absent in these cases. The ulcer may perforate into the transverse colon, into the general peri- toneal cavity, or it may cause a localized peritonitis. These cases emphasize the importance of treatment after gastroenterostomy, particularly in the presence of hyperacidity. Some of the patients with acute perforation may be saved by operation. In chronic cases the ulcer may be excised. If this necessitates removal of the anasto- mosis, the stomach and the bowel may be closed separately, if the original ulcer has healed and there is no stenosis of the pylorus. In other cases a new gastroenterostomy may be made as far from the pylorus as possible, in order to avoid the acid-forming portion of the stomach. Temporary jejunostomy may be indicated in patients who are too ill to stand a longer operation. Exclusion or occlusion of the pylorus has been performed to break the vicious circle (vida supra), to promote the healing of a duodenal fistula, to give ulcers of the pylorus and duodenum com- plete rest, and to maintain the patency of a gastroenterostomy open- ing, which, if the pylorus remains open, tends, it is said, to contract and finally to close. The last-mentioned indication is of doubtful importance, since, although the gastric contents after gastroenter- ostomy often prefer the old to the new exit, it is unlikely that a well-made anastomotic opening, unless complicated by ulceration at 724 MANUAL OF SURGERY the suture line, would, even if non-functionating, suffer oblitera- tion. Von Eiselberg's unilateral exclusion of the pylorus is effected by dividing the pyloric antrum between clamps and then closing the wounds on each side of the division. Dobbertin leaves the gastric wound open, and anastomoses it, behind the colon, with the antimesenteric border of the upper jejunum. Bartlett draws up and kinks the pylorus with a skewer, clamps the base of the loop, passes mattress sutures through the four walls between the skewer and the clamp, amputates above the sutures, applies another series of stitches to the four exposed cut edges, and covers them with a continuous Lembert's suture. Biondi incises down to the mucosa, which is separated as a cone without being opened, ligated in two places, and divided between the ligatures. The ends are invagi- nated, and the incision in the outer coats closed. The operation has been modified by simply ligating Fig. 410. — Heineke- Mikulicz pylor- oplasty. A. Direction of incision in pylorus B. Incision sutured. Fig. 411 . — Finney pyloroplasty, the posterior sutures of silk and catgut and the first anterior sutures of cat- gut inserted. the cone of mucosa with a transplant of fascia (Strauss). Girard incises the outer coats of the pylorus transversely to its long axis and sutures parallel with the axis. The pylorus may be occluded by puckering the outer coats with invagination sutures (Doyen), or by ligation with silk (Kelling), wire, aluminium bands (Brewer), etc., or with a transplant of omentum, fascia (Willems), or round ligament of the liver (Polya) . The value of pyloric closure as an adjuvant to gastroenterostomy cannot be doubted. Von Eiselberg's operation is sure to exclude the pylorus, but it increases the risk of death. Ligatures of foreign material usually cut their way into the pylorus, which again becomes permeable. Personally we employ a strip of fascia from the rectus, or the round ligament of the liver. This precedure suppresses, temporarily at least, the passage of the irritat- ing gastric contents over the ulcer, and does not add to the risk of the gastroenterostomy. ABDOMEN 725 Operations for Hour-glass Stomach (see "Bilocular Stomach")- Pyloroplasty is used by a few surgeons for benign pyloric stenosis. The IIciuckc-Mikulicz operation consists in making a longitudinal incision through the stricture and suturing the wound transversely (Fig. 410). This has been superseded by Finney's pyloroplasty, which not only enlarges the pylorus, but also lowers the outlet of the stomach. After applying clamps to the stomach and the duodenum the greater curvature of the stomach is sutured to the posterior surface of the duodenum with silk. An incision is then made in front of these sutures on the inferior surface of the pylorus and con- tinued into the stomach and the duodenum. The posterior, then the anterior, Hps of this incision are united by catgut, the clamps removed, and the Lembert suture continued anteriorly as in gastro- enterostomy (Fig. 41 1) . Rammstedt's pyloroplasty is described under ''Congenital Stenosis of the Pylorus." Gastrectomy may be partial or complete. Partial gastrectomy is performed for ulcer or for localized tumors of the gastric wall. A piece of the anterior wall of the stomach or of the greater curvature is easily excised, the wound being closed as in gastrotomy. Excision of a portion of the lesser curvature, e.g., for ulcer, is more difficult. The method we have adopted is to make an opening in the gastrohepatic, and another in the gastrocolic, omen- tum. Clamps, applied from below, are placed across the whole width of the stomach, on each side of the ulcer. This is much easier than trying to isolate the ulcer alone by clamping the lesser curvature from above. The coronary vessels are ligated to the right and the left of the ulcer; the ulcer is excised by a V-shaped or an elliptical incision; the clamps are lifted and rotated, so as to bring in contact the peritoneal surfaces on each side of the incision in the posterior wall; tenaculum forceps applied to the inverted upper and lower ends of the posterior incision, to maintain the inversion and prevent slipping of the clamps; the posterior peritoneal surfaces sutured, through the anterior wound, with celluloid thread, the posterior mucous surfaces with catgut; then the anterior mucous surfaces with catgut, the anterior peritoneal surfaces with an inversion suture of celluloid thread. The clamps are removed, the openings in the omenta closed. The suture Hne runs perpendicularly to the long axis of the stomach; suturing in the opposite direction produces too much narrowing of the gastric cavity. Balfour's cautery-excision makes a smaller opening in the stomach than the operation just described. The gastro-hepatic omentum over the ulcer is detached, the ulcer destroyed with the actual cautery, the perforation thus 726 MANUAL OF SURGERY produced closed with a double layer of inversion sutures, and the suture line reinforced by sewing the detached omentum over it. If there is a large saddle ulcer or an hour-glass constriction the entire middle segment of the stomach may be removed by circular resection (Fig. 377). Excision of a portion of the posterior wall, e.g., for ulcer, may be accomplished after pushing the posterior wall through an opening in the gastrohepatic or the gastrocolic omentum, or through the transverse mesocolon. When the ulcer is densely adherent Mayo Pig. 412. — (Alayo.) performs trans gastric partial gastrectomy. The anterior wall of the stomach is incised, and through the stomach the ulcer is removed and the resulting wound sutured. The incision in the anterior wall is then closed. Resection of the cardiac orifice is described under "Stricture of the Esophagus." The term pylorectomy may mean not only resection of the pylorus alone, but also resection of the pylorus and a large amount of the stomach. Perhaps it would be better to designate the latter as subtotal gastrectomy. These opera- tions are described below. Pylorectomy is usually performed for carcinoma, occasionally for ABDOMEN 727 peptic ulcer. Pylorectomy for carcinoma should remove the growth and the lymphatic glands into which it drains, i.e., those along the lesser curvature, and those along the greater curvature near the pylorus. The latter group of glands drains the adjacent third of the stomach, the lymph stream flowing from left to right, hence the absence of involvement, in pyloric carci- noma, of the lymph glands along the left two-thirds of the greater curvature. After the pylorus has been removed there are several ways of restoring the continuity of the gastrointestinal canal. In Brillroth's first method the open end of the duodenum was sutured to the lower end of the wound in the stomach, the superfluous part of the stomach wound being closed by sutures; leakage often occurred where the three lines of suture met. Fig. 413.— Polya. Dotted line site of anastomosis. Arrow shows direction of intes- tinal current. A, origin of jejunum . Fig. 414. — (Mayo.) The whole of the gastric wound may be anastomosed with the side of the jejunum by theantecoHc (Kroelein) or theretrocolicroute (Polya). (Fig. 413.) The upper or the lower part of the gastric wound may 728 MANUAL OF SURGERY be closed, and the remaining portion anastomosed with the jejunum (vide infra). In Kocher's method the stomach wound is closed and the end of the duodenum anastomosed to the posterior gastric wall. In Billroth's second method, the procedure now generally employed, both the wound in the stomach and that in the duodenum are closed and an anterior or a posterior gastrojejunostomy performed. Mayo describes the operation as follows: "Open the abdomen by a longi- tudinal incision from the ensiform cartilage to the umbilicus; ligate and divide the gastric artery near the stomach, ligate and divide the gastrohepatic omentum close to the liver and tie the superior pyloric artery. Free the upper part of the duodenum and, with the finger as a guide beneath the pylorus in the lesser peritoneal cavity, ligate the right gastroepiploic or gastroduodenal artery. Tie and sever the gastrocohc omentum near the colon as far as the desired point on the greater curvature and here secure the left gastroepiploic vessels. Apply two short clamps to the duodenum, sever the duo- denum between the clamps with the cautery, and close it by a con- tinuous catgut suture which is buried by a purse-string suture of silk. Double clamp the stomach along the Mikulicz-Hartmann line (Fig. 412), and sever between the clamps with the cautery. Close the stomach by a continuous suture of catgut and a continuous Lembert suture of silk. Perform a gastrojejunostomy (Fig. 414)." After abandoning the operation just described the Mayos tried the Polya method (Fig. 413), in which the beginning of the jejunum is brought up through the transverse mesocolon and anastomosed with the whole length of the opening left after amputation of the stomach, and then the Kroenlein operation, which is the same as that of Polya, except that a long loop of the jejunum, passing up in front of the colon, is used for the anastomosis. At the present time (1919) they close the lower part of the gastric wound, and anastomose the upper part with the side of the jejunum 14 inches from its origin. The apposed stomach and intestine below the anastomosis are sewed together in order to reinforce the gastric suture line (Fig. 422). "The transverse colon naturally sags in its mid portion; by turning the bowel from left to right it is brought to the left of the center, while the stomach delivers along its lesser curvature, the more fixed portion of the viscus.'" At the Mayo clinic the mortality of resection of the stomach for malignant disease is 13.7 per cent.; of the patients who recovered from the operation 37.6 per cent, were well after three years, 25 per cent, after five years (1919). The author's method of subtotal gastrectomy "consists in re- ABDOMEN 729 Fig. 419. Fig. 420. Fig. 421, Figs. 415 to 421. — Subtotal gastrectomy. 730 MANUAL OF SURGEEY moving the diseased segment of stomach from left to right, after performing an end-to-side anastomosis between the lower portion of the incision that amputates the stomach and the upper part of the jejunum, the operation being so conducted that the suturing necessary to unite the stomach to the intestine is completed before either viscus is opened. The gastric artery is doubly Ugated at the upper end of the proposed line of section of the stomach, and divided between the Kgatures. The gastrohepatic omentum is tied in sections and severed. The left gastroepiploic artery is ligated about one half inch on each side of the lower end of the proposed line of section of the stomach, and the segment of artery between the Hgatures excised. The gastrocolic omentum is tied and cut, from a point about two inches to the cardiac side of the selected line of gastric amputation to the duodenum. The transverse mesocolon is drawn taut, without pulh'ng the colon from the abdomi- nal cavity, and a hole torn in this membrane, form the upper side, within the arc of the midcolic artery. The upper end of the jejunum immediately bulges into this opening and is drawn into the lesser peritoneal cavity. A suture is passed through the greater curva- ture of the stomach, midway be- tween the ligatures on the left gastroepiploic artery, and through the antimesenteric border of the jejunum, at a point about five or six inches below the origin of the jejunum, the distance varying ac- cording to the degree of dilatation of the stomach. By pulling upwards on this suture the posterior wall of the stomach and the upper segment of the jejunum are brought in contact. A suture unit- ing the posterior wall of the stomach to the intestine is inserted about three inches above the original suture, and a third suture is passed through the posterior wall of the stomach alone, an inch or more above the second suture (Fig. 415), both of these sutures being on the line through which the stomach is to be amputated. Two sutures are now placed in the anterior wall of the stomach, at points corre- sponding to the upper sutures in the posterior wall (Fig. 416). The point at which each anterior suture is to be inserted may be deter- mined easily by grasping the stomach with the left hand in such a way Fig. 422. — Mayo. Dotted lines in- dicate site of anastomosis and retro colic portion of bowel. Omenta omitted. Arrow indicates direction of intestinal current. A, origin of jejunum. ABDOMEN 731 that the index finger presses the point of insertion on the posterior wall up against the corresponding point on the anterior wall, which point is marked by the thumb. Suture A is now drawn upwards to the right (i.e., towards the patient's right shoulder), sutures B and D downwards to the left (i.e., towards the patient's left hip) and tied together, sutures C and E likewise downwards and to the left and tied together (Figs. 417 and 418). The upper segment of the jejunum is thus surrounded by the stomach, the anterior wall of which lies against the right side of the bowel, the posterior wall against the left side of the bowel. Between sutures B, D and sutures C, E the anterior and the posterior walls of the stomach are in contact which contact is made permanent by the introduction of a sero- serous suture of celluloid thread, which suture is continued from B, D to A, uniting the anterior wall of the stomach to the bowel and from A back to B, D, uniting the posterior wall of the stomach to the bowel (Fig. 418). This seroserous suture is over laid by a through-and-through catgut suture, and sutures B and D are cut off short. The greater curvature of the stomach is grasped with forceps about one-half inch from A (Fig. 419), and the lesser peritoneal cavity filled with gauze. The portion of the antimesenteric border of the in- testine exposed between the rows of sutures is excised, and an incision made in the stomach close to the suture line, begining at G, passing between A and F, and ending at H (Fig. 419). After ligating any vessels which have not been caught by the sutures, thread A is cut and the stomach allowed to straighten itself (Fig. 420). A clamp is placed across the stomach to the pyloric side of the hne of section, and the amputation completed after approximating the anterior and the posterior walls of the stomach, between J and K (Fig. 420), by several through-and-through sutures of catgut, which sutures are buried by an inversion seroserous suture of celluloid thread. It is well but not essential, to insert the uppermost inversion suture before completing the amputation of the stomach, since by pulling on this suture the raw edges, which are already inverted at the lower end (J, Fig. 420), recede between the serous coats, which can then be rapidly sutured (Fig. 421). The pyloric segment of the stomach is drawn from the abdominal cavity and turned over on the patient's right hypochondrium, the superior pyloric and the gastroduodenal arteries secured above and behind the pylorus, the duodenum severed between ligatures, and the duodenal stump inverted. The edges of the rent in the transverse mesocolon may be attached to the jejunum or, if there is much gastrectasia, to the stomach. The operation just described may be performed in any case of gastrectomy in 732 MANUAL OF SURGERY which posterior gastroenterostomy is appHcable, and perhaps in some, in which, owing to the small size of the gastric stump, posterior gastroenterostomy would be injudicious. With equal practice in the two operations the newer one should be less difficult and more rapid ; there is less cutting to be done, consequently less suturing; the lower part of the incision for amputating the stomach serves at the same time for the anastomotic opening. In the newer method the anastomotic opening is at the lowest part of the stomach, and all of the anastomotic sutures and a portion of the sutures which close the stomach above the anastomosis, are in place before either the stomach or the intestine is opened. When the incisions are made the cut edges are in view, unrestrained by clamps ,so that hemostasis may be made absolute '"(trans, of the Amer. Surg. Assoc, 1914). Complete or total gastrectomy has been performed twenty-five times, with thirteen recoveries. It is indicated in the rare cases in which almost the entire stomach is cancerous, but in which the surrounding organs are free. The greater and lesser omenta are ligated and divided ,aDd the entire stomach removed between clamps. The open end of the duodenum is closed, and the esophagus anasto- mosed to the upper jejunum with sutures or a ^Murphy button. In some cases it may be possible to anastomose the esophagus to the duodenum. THE INTESTINES Ulcer of the duodenimi is usually solitary and located on the anterior wall within two inches of the pylorus, at the point where the acid gastric contents, ejected through the pylorus, strike the duo- denal mucosa. It is due to the same causes and occurs twice as often as ulcer of the stomach, is more common in men (4 to i) between the ages of thirty and fifty, and, unHke gastric ulcer, shows little tendency towards carcinomatous degeneration. The symptoms are much like those of gastric ulcer, but vomiting is unusual unless self induced, blood is more apt to be passed by bowel than vomited, so that serious bleeding, although causing faintness, pallor, etc., may not be suspected unless the stools are examined; the pain occurs sev- eral hours after eating, not infrequently after the patient has retired for the night, and is of ten relieved by food (hunger pain), probably because the food gives the hydrochloric acid something to act upon and stimulates the secretion of the alkaline duodenal juices; and the tender point is just above and to the right of the umbilicus (Fig. 376). The X-ray after the ingestion of barium, shows no pylorospasm but rather incontinence of the pylorus, the barium flowing at once from ABDOMEN 733 the stomach, which may be empty at the end of two or three hours, and is always empty at the end of two or three hours, and is always empty at the end of five or six hours. The shadow cast by the "cap" may show irregularities due to spasm, adhesions, or ulceration; a notch with the base towards the duodenum is seen only in very deep ulcers. Perforation is most apt to occur when the ulcer is in the anterior or the right lateral wall, serious hemorrhage when in the posterior or left lateral wall, owing to the proximity of the gastro- duodenal artery. Acute perforation is more frequent, but somewhat less serious, than in gastric ulcer. The contents of the duodenum are relatively small and sterile and, when a leak occurs, tend to gravitate into the right iliac fossa (hence the frequency with which a diagnosis of appendicitis is made), whereas a large quantity of the gastric contents may be quickly diffused over the peritoneal cavity, and fatal hemorrhage may occur. The treatment of duodenal ulcer is that of gastric ulcer. (For Curling's ulcer of the duodenum see "Burns.") Wounds of the intestine (see "Contusions and Wounds of the Abdomen"). Congenital stenosis of the intestine may occur near the common bile duct, and in the lower ileum at a point corresponding to the situation of Meckel's diverticulum. Imperforate anus is considered on a later page. Meckel's diverticulum is a persistent omphalo- mesenteric duct, which generally arises from the ileum about three feet above the ileocecal valve. It exists in 2 per cent, of human beings. It may open at the umbilicus {congenital fecal fistula, see umbilicus), or be obliterated in whole or part, the obliterated portion persisting as a cord attached to the umbiHcus, the mesen- tery, or other viscus. In many cases the diverticulum hangs free in the peritoneal cavity, its interior being Uned with mucous membrane and communicating with the intestine. The structure may become inflamed, the symptoms and treatment being the same as those of appendicitis, or it may cause intestinal obstruction by kinking or twisting the bowel, by invaginating into the bowel {intussusception}, or by acting as a band or noose which constricts or ensnares a coil of intestine. Obstruction is most common in early life and the patient may exhibit other deformities, but there is nothing distinctive in the symptoms. The diverticulum might be shown by the X-ray. When inflamed or giving rise to obstruction, the diverticulum should be excised, and the opening in the bowel closed with Lembert sutures. Acquired diverticula are most frequent in the descending colon and sigmoid of fat constipated men past middle life. They are 734 MANUAL OF SURGERY usually multiple, may be very minute or as large as a cherry, and represent hernial protrusions of the mucosa through the muscularis, often at the point where vessels pierce the bowel wall to enter the appendices epiploicae. Diverticulitis often results from the irrita- tion of a fecal concretion. The symptoms of the acute form are those of appendicitis, except that the trouble is in the left abdomen (Fig. 376). Perforative peritonitis or localized abscess, may follow. In the chronic variety the colon about the diverticulum participates in the inflammation and finally becomes thick, hard, and contracted causing symptoms of chronic obstruction, sometimes pus and blood in the stools, and closely mimicking scirrhous carcinoma. Car- cinoma may indeed, coexist or be due to diverticulitis. The X-ray after an opaque enema may reveal the constriction, as well as the pockets caused by the diverticula. The treatment of perforation is suture; of abscess, drainage; of stricture, excision. Idiopathic dilatation of the colon {Hirschsprung'' s disease) may occur at any period of life, but is usually of congenital origin and most frequent in male infants. Although mild cases may remain stationary, the disease generally progresses, and terminates, in from a few weeks to many years, in death from peritonitis, toxemia, or pneumonia. The whole colon, or only a part, usually the sigmoid, may be involved. The bowel is greatly dilated (the circumference in one case reaching 30 inches), hypertrophied, sometimes elongated, often kinked, and frequently contains stercoral ulcers, which on healing may lead to stenosis. The symptoms are obstinate consti- pation (the bowels may not move for weeks), sometimes alternating with diarrhea; emaciation; possibly convulsions or tetany; bal- looning of the abdomen; diastasis of the recti; distension of the superficial veins; visible, audible, and palpable peristalsis; fore- shortening of the thorax; flaring of the costal margins; and inter- ference with the action of the heart and lungs from pressure. Pain, tenderness and vomiting are often absent. Indican may be found in the urine. The size, shape, and position of the colon can be demonstrated by the X-ray, after the administration of an opaque enema. The treatment is at first medical, viz., liquid diet, tonics, strychnin, colonic lavage, electricity locally, and abdominal massage. If these measures fail appendicostomy and daily irrigations of the colon, short circuiting of the colon by ileosigmoidostomy, or excision of the colon or its most affected part may be performed. In des- perate cases right inguinal colostomy is indicated, more radical measures being adopted after improvement has occurred. Pericolitis has been explained in three ways. The evolutionary ABDOMEN 735 theory is that the membranous bands described below develop to support the intestine, which, owing to the erect posture of man, tends to gravitate toward the pelvis; the developmental theory that the bands result from abnormalities in 'the rotation and descent of the cecum (but the condition may be found also about the descending colon and the sigmoid) ; the infectious theory that the membranes are due to infection transmitted through the walls of the bowel to the peritoneal covering, as the result of chronic colitis or colonic stasis. Pericolitis arising from other causes, e.g., diverticuHtis, is not in- cluded under this heading. The advocates of the infectious theory point out that normally the large gut is firmly attached at its highest point, the splenic flexure, to the diaphragm by the short phrenocolic ligament, and at this point there is a spur, because the adjacent portions of the transverse and the descending colon lie in contact, sometimes for a distance of five or six inches. According to Cannon, "the purpose of this arangement is to prevent the rapid entrance of fecal matter from the upper portions of the colon into the sigmoid. The function of the former is absorptive, of the latter, eliminative. Hence we find that ordinarily the cecum, ascending and transverse colon are distended with fecal matter and gas, while the sigmoid is empty and contracted. A similar though less pro- nounced arrangement exists at the hepatic flexure (Glenard). The resistance offered by the splenic flexure on one side, and by the closure of the ileocecal valve on the other, renders consecutive peristaltic and antiperistaltic locomotion of the intestinal contents between these points possible." If this normal or quasi-normal retardation is exaggerated, undue desiccation takes place above the splenic flexure, and habitual constipation follows, with catarrhal colitis and bacterial penetration of the intestinal wall (Gerster). Pathologically the peritoneum is thickened, and in places, notably the cecum, ascending colon, and splenic flexure, adhesions develop,, often broad and membranous Uacksons membrane) , but sometimes long and cord-like. These adhesions interfere with normal peristal- sis by compressing or stiffening the gut, or by accentuating the normal flexures as the result of the glueing together of the adjacent segments ("double-barrel stenosis"), thus rendering the constipa- tion still more obstinate. Complete obstruction, however, rarely occurs. The symptoms are those of chronic coHtis, chronic constipation, autointoxication, and neurasthenia. There is general abdominal un- easiness ,and sometimes real pain and tenderness over the cecum, w^hich, when thickened and distended, can often be outlined by ■36 MANUAL OF SURGERY palpation. Occasionally there are sharp attacks of coUcky pain in this region, particularly after dietary indiscretions, which attacks are relieved by a free bowel movement or the expulsion of gas. Many of these cases are operated upon for appendicitis, which, it is true, not infrequently is associated with and due to cohtis. Removal of the appendix, however, does not relieve the patient of the colitis or pericolitis, evidences of which conditions should be sought for when- ever the abdomen is opened for nonsuppurative lesions in the right iliac fossa. Willems thinks many of these cases of cecal colic are due, not to fixation of the cecum, but to abnormal laxitv of its attach- FiG. 422a. — Diagram of X-ray shadow of normal colon, after barium ingestion, patient standing. Fig. 423. — Diagram of X-ray shadow of colon in pericolitis, patient standing . ments, a condition which he calls cecum mobile, and which he treats by attaching the cecum to the parietal peritoneum (cecopexy). Others beheve spasm or atony to be the most important factor, hence the terms typhlospasm. iypJdatomy, typhlectasia. In pericolitis. X-ray examination, after a barium meal, shows retention of the bismuth in the cecum, sometimes for 24 or 48 hours, dilatation of the colon, and abnormalities in its position, e.g., ptosis, double-barrel stenosis (Figs. 422a, 423). The treatment of pericoUtis, is first medical measures directed against the chronic catarrhal colitis. If medical treatment fails operation is indicated, care being taken, however, to exclude cases ABDOMEN 737 of neurasthenia and hysteria not secondary to the condition under discussion. Even when operation is undertaken it should be follow- ed by dietary, medicinal, and hygienic measures, if the best results are to be obtained. Usually an incision should be made in the right iliac region, the appendix removed, and any restraining adhesions, if membranous, severed transversely to the direction of the adhesions and sutured longitudinally, or, if cord-like, ligated and divided. In some cases the membranous film over the cecum has been completely detached and sutured behind the cecum, the resulting raw surface being covered with peritoneum. Lane calls attention particularly to adhesions which sometimes are attached to and drag upon the lower end of the ileum, forming a V-shaped kink. In cases in which the colon is hopelessly crippled it may be short circuited by ileo- sigmoidostomy (see "Exclusion of the Intestine") or excised. Appendicostomy or cecostomy is indicated only in severe ulcerative forms of colitis. Typhoidal perforation of the intestine is probably responsible for one-third of the fatalities in enteric fever. The accident usually occurs during the third, fourth, or fifth week, although it may happen at any stage of ,the disease. As a rule the pain is sudden in onset, begins in the right lower quadrant of the abdomen, quickly becomes generalized and persists despite the hebetude of the patient. Tenderness is most marked in the region of the perforation, usually the right iliac fossa, and may be elicited also on rectal or vaginal examination. Rigidity of the abdominal muscles is the most valua- ble sign; it is at first localized over the area of perforation, thence becoming generalized with the spread of the infection. The hard- ening of the belly wall due to meteorism, to emaciation, to the application of cold water, or to associated pulmonary disease should not mislead the surgeon. The remaining symptoms are those of pneumoperitoneum with diffuse peritonitis (q.v.). Typhoidal per- foration may be confounded with almost any other lesion producing a peritonitis, with any form of intestinal obstruction, and with spon- taneous rupture of the spleen, but as the treatment of all these cases is laparotomy, a failure to differentiate them is not productive of harm. One must be most careful, however, to exclude constipation, distention of the urinary bladder, catarrhal cholecystitis, pleurisy, iliac phlebitis, and epididymitis, all of which may simulate perfora- tion, and none of which requires operation (cf. "Unnecessary Abdominal Section" and "Diagnosis of Appendicitis") . The most difficult differential diagnosis is that between intestinal hemorrhage and perforation as the symptoms are sometimes identical; to mistake 738 MANUAL or SURGERY hemorrhage for perforation means an unnecessary operation at a very critical period, to mistake perforation for hemorrhage means death. Blood in the stools is not conclusive, since the two conditions may coexist. A reduction in the number of red cells and in the hemo- globin would point towards hemorrhage, leukocytosis and a rise in the blood pressure towards perforation. Pneumoperitoneum, if pro- nounced, might be shown by the X-ray. Opium should be withheld in cases of hemorrhage in which perforation is suspected, because of the danger of clouding the symptoms. The treatment is immediate operation. Pain, rigidity, and tenderness always demand exploration, which may be conducted under local anesthesia. If the diagnosis is confirmed, ether should be employed, as the operation can be performed more quickly, without subjecting the patient to the deleterious effects of fright and struggling. If shock is present the danger of delay far outweighs the danger of a rapid operation. The incision is made in the right iliac region, as 90 per cent, of all perforations are found in the last twenty or thirty inches of the ileum or in the cecum or appendix. If the perforation is not found in the ileum and there are evidences of peritonitis, the sigmoid, the colon, and the remaining portion of the small intestine should be explored in the order mentioned. The perforation should be sutured with a double row of Lembert sutures of silk, without excising the ulcer. A large perforation may be sutured obhquely, so as not to interfere with the fecal current. Search for a second perforation should always be made, as in 18 per cent, of the cases the openings are multiple. All suspicious spots should be treated as perforations. In some cases suture is impossible because of the size of the opening, the number of openings, or because of gangrene of the bowel. Resection in these cases consumes so much time that surgeons have been afraid to try it. Plugging the hole with omentum, or suturing the omentum over the perforation has been suggested, and isolation of the affected portion of bowel by gauze packing may sometimes be used. The safest plan is to anchor the intestinal loop outside the abdominal cavity, in order to make the isolation more complete; this will also relieve the distention and permit local treatment of the remaining typhoid ulcers. After dealing with the perforation, the treatment is that of the diffuse peritonitis (q.v.) . The author has operated upon forty patients with typhoidal perforation of the intestine; fifteen recovered. Tuberculosis of the intestine is most frequent in the lower ileum and in the cecum, probably because the slow fecal current in this region permits the deposition of the bacilli. There are two forms. ABDOMEN 739 The cnlero- peritoneal form is the result of active caseation. There is little or no tendency towards healing, hence stricture does not occur. A subacute abscess forms in the right iliac fossa and this may finally break externally, often through one of the hernial rings, and eventuate in a fecal listula. Diarrhea with blood and mucus in the stools is caused by ulceration of the mucosa, and phthisis is frequently present. The hyperplastic form arises when the repara- tive forces are in excess. The tubercles are encased in dense fibrous tissue, which converts the gut into a thick, rigid, contracted tube. The mucous membrane is ulcerated and the lymph glands enlarged. The symptoms are those of chronic obstruction, with a hard, movable, cylindrical mass in the right iliac fossa. In either form of intestinal tuberculosis the bacilli may be found in the stools. The treatment is excision. When this is impossible the affected segment may be short circuited by ileosigmoidostomy. Splanchnoptosis, or Glenard^s disease, is a displacement down- wards of the abdominal viscera, and includes gastroptosis, enteroptosis, hepatoptosis, splenoptosis, nephroptosis, retrodisplacement or pro- lapse of the uterus, and sometimes cardioptosis owing to displacement of the diaphragm. The most important cause is relaxation of the abdominal wall, which may be congenital, or the result of trophic changes, pregnancy, ascites, and like conditions. Traumatism, corsets, and kyphosis also have been held responsible for this condition. It is much more common in women than in men. The S3miptoms are usually those of dyspepsia and neurasthenia, although they vary according to the organ which is most affected. The abdomen is flat above and prominent below, the wall flabby, and the recti often widely separated. The displaced organs may be palpated, or out- lined by percussion. The gastrointestinal canal is often narrowed at its most fixed points. This fact, with the position and activity of the stomach and intestines, can be determined by X-ray examina- tion, after the administration of barium. Stiller's sign is abnormal mobility of the tenth rib. The treatment is the application of an abdominal support, massage, electricity, tonics, and often lavage of the stomach. If these measures fail, the fascia between the recti may be excised and these muscles sutured together, in order to lessen the size of the peritoneal cavity and tighten the abdominal wall. One or more of the displaced structures may be fastened in place. In enteroptosis the splenic and hepatic flexures of the colon have been fastened to the abdominal wall. Operations for the fixation of other organs are mentioned in the sections treating of these organs. When intestinal stasis is a prominent feature Lane performs ileosig- 740 MANUAL OF SURGERY moidostomy (end-to-side) and, if there has been much pain, resects the colon down to the anastomosis. Intestinal obstruction, or ileus, may be true (mechanic) or false (intestinal paralysis). True obstruction may be classified, from an etiologic standpoint, as shown in the subjoined table. I. Bands and adhesions. 2. Apertures (including hernia) 3- Volvulus (included here be- A Compression (rarely traction), from causes out- cause the obstruction is due to an adjoining segment of bowel) . side the intestine 4- Extraintestinal tumors and viscera other than the intes- Causes of tine. intestinal I. Congenital strictures. obstruction B. Strictures, from 2. Cicatricial strictures. causes in the 3- Neoplastic strictures. intestinal wall 4. Spasmodic strictures. C Obturation, I. Foreign bodies. from causes in 2. Fecal impaction. the lumen of the 3- Polyps. intestine 4- Intussusception. The conditions enumerated above will be described after a general consideration of the subject of intestinal obstruction. The pathological changes in the bowel above the obstruction are dilatation, congestion, and, if the obstruction lasts long enough, hypertrophy of the muscular coat and ulceration of the mucosa, the last of which may lead to perforative peritonitis, abscess formation, or fecal fistula. Below the obstruction the gut is pale, empty, and contracted. At the site of obstruction in the first three conditions in class A and in intussuception, the intestine may be gangrenous from strangulation (see ''Strangulated Hernia" for details); in class B it exhibits simply the changes incident to the causative lesion; and in class C it may be ulcerated from the pressure of the obturating agent. The pressure exerted by extraintestinal tumors and viscera other than the intestine is seldom great enough to produce ulceration or gangrene. Clinically intestinal obstruction may be divided into three forms, the acute, the subacute, and the chronic. Although the symptoms may appear suddenly or gradually in any of the conditions mentioned above, acute obstruction is usually due to the first three causes in ABDOMEN 741 class A or to ihc lust in class H and (\ subacute obstruction to the tirst three in class C, and chronic obstruction to the lirst three in class B or the last in (Mass A. The symptoms of acute obstruction, in which the lumen of the bowel is suddenly and completely closed, e.g., in volvulus, acute intussusception, and strangulation by bands, adhesions, or apertures, are (i) those of shock, (2) those due solely to the obstruction, and (3) those of acute toxemia, (i) Shock generally indicates strangula- tion, and is more severe, the more sudden the onset, the higher the obstruction, the tighter the strangulation, and the greater the amount of bowel involved. The shock passes after a time, but the pulse remains rapid, and the temperature does not rise above normal until peritonitis supervenes, when all the symptoms of this affection ensue. (2) The most important symptoms of ohstruciion per se are pain, vomiting, constipation, increased peristalsis, and tympanites. The pain is sudden in onset, due to the strangulation; severe and colicky, owing to the violent peristaltic movements of the intestine above the obstructed point ; usually referred to the neighborhood of the umbilicus , rarely to the site of the lesion; and is sometimes relieved by but is often worse after, pressure, also after taking food, purgatives, or enemata. General abdominal tenderness and rigidity are absent until the advent of peritonitis, in the later stages of which pain and peristalsis are no longer present. Vomiting of the contents of the stomach occur soon after the onset of the pain, probably as the result of reflex nervous disturbances. Later, owing to the obstruc- tion, the material becomes bilious and finally stercoraceous, being regurgitated without effort. This regurgitant or gushing vomiting is characteristic, and occurs earlier and is more severe, the nearer the obstruction is to the stomach; rarely, in obstruction of the lower colon it may be absent. As the result of the excessive loss of fluid by vomiting there are oliguria, great thirst, and sometimes cramps in the legs. Indicanuria occurs in many cases. Constipation, if the bowel below the occlusion is empty, becomes absolute, not even gas being expelled. Notwithstanding the constipation peristalsis is increased, and may be felt, heard and occasionally, if the abdominal wall is very thin, seen; as a rule, however, visible peristalsis indicates hypertrophy of the muscular coat of the bowel, hence chronic ob- struction, which, it must be noted, generally terminates with acute symptoms. Tympanites is due principally to bacterial decomposi- tion of the contents of the bowel above the point of obstruction. The lower the obstruction, the greater the distention of the abdomen. (3) Acute toxemia is due to absorption of the decomposing intestinal 742 MANUAL OF SURGERY contents, or to peritonitis as the result of gangrene or perforation of the gut, hence represents the final stage, or the stage of collapse, in which the symptoms are those of exaggerated shock (q.v.). If unrelieved, acute obstruction usually causes death within a week, as the result of toxemia, exhaustion, or interference with the intra- thoracic organs from tympanites. Although rare, spontaneous recovery is possible; thus a fistula may connect the bowel above and below the obstruction or empty externally, a foreign body may pass, a kink be straightened, or the invaginated portion of an intussuscep- tion may slough and separate. The diagnosis is seldom difficult, but the seat and cause are often undetermined until an exploratory incision has been made. In acute gastrectasia (q.x.) intestinal peristalses is not exaggerated, the stomach is dilated, and the distension subsides after gastric lavage. Intestinal paralysis (q.v.) differs from obstruction in the absence of peristalsis, and the presence of the symptoms of the causa- tive lesion, both before and after the onset of obstructive symptoms; thus in peritonitis there will be fever, rigidity, leukocytosis, etc. The seat of obstruction may occasionally be located by the palpation of a mass through the rectum, vagina, or abdominal wall, or by the situation of the pain, tenderness, or area of active peristalsis. The greater the distention, the later the vomiting of stercoraceous mate- rial, and the larger the amount of urine excreted, the lower in the intestine is the obstruction. When tympanites is absent the lesion is in the upper small intestine; when confined to the central portion of the abdomen, in the lower ileum; when marked in the right loin, in the transverse colon; and when marked in both loins, in the sigmoid or the rectum. Tenesmus generally indicates a lesion of the large bowel. Rectal injections of air or water for the purpose of diagnosis are not recommended. It is said that if sLx quarts of water can be introduced, the obstruction is in the small intestine; if but a pint or quart, in the rectum or sigmoid. Aside from conditions that may cast a shadow the X-ray may indicate the site of the les- ion by revealing the extent of the distended gut above the obstruction. TJie cause of obstruction may be an external hernia, which must first be excluded in all cases; if such be found and be irreducible, it should be investigated by incision. If a hernia has been replaced and the symptoms continue, the possibility of a reduction en bloc, i.e. reduc- tion without relief of strangulation, should be recalled. Excluding hernia the most common cause of intestinal obstruction is, in the new-born, imperforate anus; in infants, intussusception or adhesions due to tuberculous peritonitis; in adults, bands, adhesions, or vol- ABDOMEN 743 Villus; in old age carcinoma of the bowel or fecal impaction. Severe collapse indicates a tight strangulation. The previous history should be eUcited particularly with reference to biliary colic, chronic consti- pation, peritonitis, abdominal operations, tuberculosis, syphilis, dysentery, and pelvic disorders. The distinguishing features of the various forms of obstruction are noted in the description of the individual diseases responsible for the obstruction. The treatment is, with few exceptions, abdominal section. While preparations are being made for operation, morphin should be given hypodermatically to quiet peristalsis, the stomach emptied by lavage, and the rectum evacuated by an enema unless such has already been done. Purgatives are contraindicated. In the absence of a definite diagnosis as to the point of obstruction, the abdomen should be opened in the median line below the umbiUcus. If the cecum is dis- tended, explore the sigmoid; if the sigmoid is collapsed, the obstruc- tion is in the large bowel between it and the cecum. If the cecum is collapsed, it will be necessary to follow the small bowel until the obstruction is found. Another rule is to select the most dilated and congested coil of bowel and follow it in the direction of the in- creasing congestion and distention. In the most urgent cases no attempt should be made to find the seat of obstruction, but the abdomen opened under local anesthesia, and an artificial anus estab- lished in the first presenting distended coil of intestine. Before or after dealing with the obstruction, particularly in later cases in which peristalsis is feeble or absent, the great distention may be relieved by incising one or more coils of intestine and allowing the contents to escape, subsequently suturing the wounds. The obstruction itself is dealt with according to its cause (vide infra) . In subacute obstruction the symptoms are midway in intensity and duration between those of acute and those of chronic obstruc- tion. The initial shock is absent, but, in most instances, the ob- struction progresses until the bowel is completely occluded, when the symptoms are those of acute obstruction. In chronic obstruction the gradualy increasing constipation with abdominal uneasiness is often attributed to intestinal indigestion. At irregular intervals there are colicky pain, obstinate constipation, abdominal distention, visible, audible, and palpable peristalsis, and vomiting; the last, however, is often absent in stricture of the colon until the obstruction becomes complete. Purgatives often dislodge the impacted food or feces responsible for the transient obstruction. Diarrhea may thus alternate with constipation. Finally acute and complete obstruction ensues. The treatment is described with the diflferent lesions. 744 MANUAL OF SURGERY Bands and adhesions are a common cause of intestinal obstruc- tion. Congenital peritoneal bands are sometimes encountered, notably in the region of the duodenum. Adhesions result from acute or chronic peritonitis, or from the reparative processes following operation and injuries. They may exist in any portion of the perit- oneal cavity, but are most frequent in the four corners of the abdo- men and in the pelvis, from lesions of the appendix, stomach and duodenum (especially ulcer), gall bladder, perisplenitis, diver- ticulitis, and inflammatory affections of the uterus, tubes, and ovaries. These adhesions may be short and numerous, binding adjacent segments of bowel in a V-, N- or W-shape; they may be broad and membranous, and spread out over the bowel so as to interfere with its peristaltic action or to compress it (see pericolitis) ; or they ma}' be moulded into bands, the bowel being kinked by traction (rare) , or strangulated by passing under or hanging over the band or by slipping into a noose formed by the band (Fig. 424). Opportunity for intestinal strangulation may be pre- sented also when adhesions fix the free end of a pedunculated tumor or cyst (usually ovarian or uterine), or an abdominal organ, e.g., the omentum, appendix, appendices epiploicae. Fallo- pian tubes, or ^Meckel's diverticulum. Fig. 424. — Intestinal obstruction o.™*--,^^.^-, 1,1.^. •iU from a band of adhesions. Symptoms may be absent even with extensive adhesions. When symptoms arise they vary from the mildest form of chronic constipation to the most severe form of acute obstruction. The latter is generally due to acute kinking or strangulation of a coil of the small intestine, usually the lower ileum. Intestinal obstruction from adhesions should be suspected if there is a history of previous peritonitis or of an abdominal operation or injury. The treatment of obstruction due to limited adhesions is separa- tion of the involved coils of bowel, and, if possible, covering of the raw surfaces with peritoneum. When the intestines are extensively and intricately matted together, e.g., in tuberculous peritonitis, an anastomosis may be made between the bowel above and the bowel below. If there is strangulation the band should be divided between ligatures, making sure that such band is not a ^MeckeFs diverticulum, which should be excised in the same way as the appendix. If the bowel is gangrenous it should be treated as described under strangu- lated hernia. ABDOMEN 745 Apertures arc rcsj)onsible for all forms of hernia fq.v.). Abnor- mal openings, either congenital or traumatic, may be found also in the omentum and mesentery. Volvulus, or torsion of the intestine, is most common in the sigmoid flexure, then in the small intestine, then in the cecum and ascending colon. The bowel may be twisted on its mesenteric axis, the usual variety (Fig. 425), on its own axis, or two coils of intestine may be twisted together. When the twist is tight the circulation is suppressed and gangrene follows. Volvulus of the sigmoid flexure is most frequent in constipated men between forty and sixty. The sigmoid is normally predisposed to twisting, in that it forms a long loop whose origin and termination are closely approximated, and this predisposition is accentuated when the loop is elongated by habitual overdistention, or when its limbs are drawn together at their bases by cicatricial contraction of the mesentery. As a rule the proximal limb falls down over the distal in consequence of straining to empty the bowel, stooping to lift a weight, or similar efforts involving a change in position and muscular exertion, and the twisting thus induced may continue for two or even three complete turns. The symptoms usually appear very suddenly, although the initial shock mav be less severe than Fig. 425.— Volvulus in most other forms of acute' obstruction. The l.tUTo^Jhe w distinguishing features aside from the age of the and of the bowel above , , , . . , . . . the obstruction. patient and the history of chronic constipation, are late vomiting; extreme distention of the abdomen; a rounded tympanitic tumor in the left iliac fossa; and often tenesmus, with- out, however the passage of anything from the rectum. Death generally occurs within two or three days, from peritonitis or pressure on the diaphragm. In rare instances a partial twist may straighten out, only to recur at irregular intervals {chronic or intermittent volvulus) . Volvulus of the small intestine may affect one coil or the entire ileum, the twist usually being from left to right. Vomiting occurs early, and sometimes the rounded tympanitic tumor can be felt in the region of the umbilicus. Volvulus of the cecum or ascending colon may occur as the result of congenital malposition, or when these structures possess a long mesentery. The symptoms are not so severe as in sigmoid volvulus, and the rounded tympanitic tumor may be found in the right iliac fossa. 746 MANUAL OF SURGERY The treatment of \-()lvulus is to untwist the loop of intestine. In some cases it may be necessary to evacuate the affected coil of bowel by puncture before this can be accomplished, the puncture being subsequently closed with a purse-string suture. If the gut is viable it may be replaced in the abdomen. Shortening of the mesen- tery or fixation of the bowel to the abdominal wall has been suggested to prevent recurrence, but, in the sigmoid at least, return of the trouble can be surely averted only by resection of the affected loop. If the bowel is gangrenous it must be resected, or if the patient's condition forbids this, brought out of the abdominal wound and an artificial anus established. Chronic volvulus is treated by resection. Extraintestinal tumors, cysts, and abscesses may compress the bowel, as may also viscera other than the intestine, e.g., a pregnant or retroeverted uterus, a floating kidney or spleen. Compression b}- the superior mesenteric vessels is described under ''Acute Dilatation of the Stomach." The rectum or the sigmoid is affected in over half of the cases, not only because of the frequency of pelvic tumors, but also because a tumor in this region cannot expand without encroaching on the bowel, owing to the unyielding nature of the pelvic ring. The possibility of obstruction from the pressure of a gauze pack or a drainage tube should be kept in mind. The symp- toms may be acute or chronic, usually the latter. The treatment is that of the causative lesion. Stricture of the intestine may be congenital (see congenital stenosis of the intestine) or acquired (cicatricial, neoplastic, spas- modic) . Cicatricial strictiu'e is caused by the repair of ulcers due to tuber- culosis, syphilis, dysentery, pressure (e.g., from foreign bodies, con- striction in strangulated hernia), rarely typhoid, as the ulcers in this disease are longitudinal; by the repair of wounds due to partial rup- ture from contusion, or due to extensive lacerations, perforations, or intestinal anastomosis, especially when too much bowel is inverted by the surgeon; and by the repair of areas of inflammation, e.g., due to diverticulitis or pelvic cellulitis. Cicatricial stricture of the small intestine is usually caused by tuberculosis, that of the colon by dysen- tery, that of the rectum by syphilis or pelvic cellulitis (see "Rec- tum"). Neoplastic stricture, in 95 per cent, of the cases, is due to car- cinoma of the colon, which affects the different parts in the following order of frequency: sigmoid, cecum, ascending colon, transverse colon, splenic flexure, hepatic flexure, descending colon. This com- putation does not include carcinoma of the rectum, which is classed ABDOMEN 747 with the diseases of the rectum. Carcinoma of the colon is cylin- drical-celled, and may jiroject into the lumen of the bowel like a cauliflower, or, more frequently, spread around the lumen and pro- duce an annular stricture. It infiltrates contiguous coils of bowel or other viscera, and sometimes ulcerates into them, forming an internal fistula. In the later stages the growth may diffuse itself over the peritoneal cavity (see "Malignant Disease of the Peritoneum'') or metastasize to the liver, lymph glands, or lungs. Metastasis, however, is often postponed for a much longer period than in car- cinoma elsewhere. Carcinoma of the small intestine is rare, and usually involves the duodenum or the lower ileum. Sarcoma is still less frequent, both in the small and in the large bowel, but occurs more often in the former than in the latter, and is more often secondary than primary, the intestinal mucosa being a favorite site for metastases in lymphosarcoma and melanosarcoma. Mention should be made also of leukemic tumors, which occur in leukemia and pseudoleukemia, and which, although not producing obstruction, may, because of ulceration and hemorrhage, lead to an erroneous diagnosis. Benign tumors are generally polypoid in nature, and cause obturation, hence, following the classification we have adopted, will be described after foreign bodies and fecal impaction. The symptoms of cicatricial and malignant stricture are at first those of chronic obstruction, and a tumor of the intestine is seldom suspected unless it interferes with the fecal current. Owing to the liquid character of the contents of the small bowel, its lumen may suffer almost total obliteration before the onset of obstructive symptoms. In stricture of the lower colon the stools may be de- formed or diminished in caliber, and sometimes the stricture can be seen with the sigmoidoscope. After giving barium by mouth or rectum the stricture may show in a skiagram; with the fluoroscope the progress of the barium along the intestine can be kept under continuous observation. In cicatricial stricture the small bowel is more often involved (60 per cent.), and a history of one of the causes mentioned above may be obtained. In carcinoma blood, mucus, and occasionally fragments of the growth may be found in the stools; the tumor can be felt in 40 per cent, of the cases; the patient is usually over 40, but it should be recalled that before 30 carcinoma is more frequent in the colon than in other-situations, and that cachexia is often absent until the growth diffuses itself over the abdominal cavity. Sarcoma of the lymphatic variety may extend in a longi- tudinal direction instead of around the bowel, and produce dilatation rather than stricture, hence the disease occasionally progresses to a 748 MANUAL OF SURGERY fatal termination without causing obstruction, especially in the small intestine, whose contents are liquid. Because it is spread out along a dilated segment of intestine, the tumor sometimes exhibits peristal- tic movements and may crepitate on pressure. As many of these growths are metastatic one should search carefully for a primary tumor in other parts of the body before deciding on operation. The treatment of the forms of stricture mentioned above is enterectomy, with, if the disease be malignant, a V-shaped portion of the mesentery and the lymph glands. In urgent cases an artificial anus should be established and the resection performed at a later date (see "Colectomy")- When the growth is irremovable the intestine above and below may be united by lateral anastomosis, or the affected segment side-tracked as described under "Intestinal Exclusion." Spasmodic stricttire {enterospasm, dynamic obstruction) is due to tetanic contraction of a segment of intestine. It may be caused by lead poisoning, irritating intestinal contents, hysteria (see "Phantom Tumor"), and trauma, hence occasionally follows abdominal opera- tions. It is the first step in the development of many cases of intussusception. The symptoms may be those of acute or subacute obstruction; sometimes the contracted segment of bowel can be be felt. The treatment is directed to the cause; heat to the abdomen and large doses of atropin are of value in relaxing the spasm. Foreign bodies, including gall-stones and enteroliths, rarely cause obstruction. Foreign bodies may be swallowed accidentally, e.g., artificial teeth, or intentionally by children, lunatics, hysterical women, and showmen. The body may lodge in the esophagus, stomach (see "Esophagus and Stomach"), or intestine, and cause obstruction or perforation, but, as a rule, if it passes through the esophagus the rest of its journey along the alimentary canal is uneventful. Foreign bodies that have been left in the peritoneal cavity, e.g., forceps, sponges, etc., may ulcerate into the bowel. Enormous snarls of intestinal worms sometimes form in and occlude the intestine. Gall-stones of sufficient size to produce obstruction must enter the intestinal tract, usually the duodenum, by ulceration. Stones even of large size passing directly into the hepatic flexure rarely block the colon. Enteroliths (intestinal concretions) are composed of phosphate of lime and hardened feces, often with some indigestible material as a nucleus; of masses of vegetable residue, e.g., oatmeal husks, with calcareous salts (avenoliths) ; or of medicinal substances, e.g., bismuth, magnesia, salol. The symptoms of obstruction from foreign bodies are generally of a subacute nature. The diagnosis may be possible if a clear history .\BDOMEN 749 is obtained, if the foreign body can be felt, and if it can be seen with the X-ray. The seat of impaction is usually the lower ileum, since this is the narrowest portion of the bowel. Gall-stone ileus seldom occurs before fifty. The treatment is removal of the foreign body by enterotomy, after displacing it ui)wards to a more healthy portion of the bowel. If the bowel is gangrenous or badly ulcerated it should be resected or isolated extraperitoneally. Fecal impaction is most common in old ladies with chronic con- stipation. The masses may be semisolid or as hard as stone, are generally coated with mucus, and often produce ulcers by pressure (stercoral ulcers), which ulcers occasionally perforate. Fecal impac- tion is most frequent in the sigmoid and rectum, but in some cases the mass fills the entire colon, which is dilated, elongated, hypertrophied, and prolapsed. The symptoms are those of chronic constipation merging into chronic and finally into subacute obstruction. The fecal masses can be felt along the course of the colon or in the rectum, sometimes moved from one portion of the bowel to another, and can be seen on X-ray examination. Pitting on pressure, a characteristic sign of ordinary feces in the colon, is often absent. The stercoral ulcers may betray themselves by fever, tenderness on pressure, and a muco- purulent sanious discharge from the rectum. The last is often associated with tenesmus. The treatment is copious enemata, massage, and laxatives. When situated in the rectum the mass may be broken up with the finger. Purgatives and massage are contraindicated if the bowel is inflamed. The prognosis is good, although death may occur from associated diseases, toxemia, or perforation. Benign intestinal timiors (fibroma, myxoma, lipoma, adenoma) usually project into the lumen of the gut as polyps, are often multiple, and seldom cause obstruction unless there is a kink in the bowel or unless they induce an intussusception. If the polyps ulcerate, blood, mucus, and pus may appear in the stools. Tenesmus occurs when the growths are in the lower bowel, in which situation they may be detected with the finger or the sigmoidoscope, and from which situation they can be removed through the anus (see "Polypus Recti")- Isolated poh-pi causing" obstruction and not accessible through the anus must be excised after enterotomy. Multiple adenomata of the colon generally occur in young adults and show a decided tendency to malignant degeneration; the only remedy for this condition is excision of the colon. 750 M.ANUAL OF SURGERY Intussusception is the telescoping of one part of the intestine into the segment below. The swallowed portion is called the intussus- ceptum, the swallowing segment the intussuscipiens (Fig. 426). The cause is irregular peristalsis, sometimes induced by worms, diarrhea, pohq^oid tumors, or other form of irritation. The author has had two cases of traumatic origin. As the peritoneal surfaces of the entering and returning layers of the intussusceptum tend to adhere, and the mucous surface of the returning layer readily slips over the mucous surface of the intussuscipiens, the intussusception elongates at the expense of the intussuscipiens and the apex is always repre- sented by the same piece of bowel. The intussusception is not straight as in the diagram, but curved like a sausage, with the apex directed towards the mesenteric border. This crescentic arrange- ment is due to the unyielding nature of the mesentery. The mesen- tery is drawn down between the layers of the intussusceptum, hence B C D E Fig. 426. — Diagram of intussusception. A. Apex. B. Neck. C. Entering layer and D. returning layer of intussusceptum. R. Intussuscipiens. F. Peritoneum. G. Muscularis. H. Alucosa. is Stretched, bunched, and constricted. The circulation is further impeded by inflammatory exudation, and this leads to desquamation of the mucous membrane (hence blood and shreds in the stools) , and finally to strangulation and gangrene. Intussusception is respon- sible for 39 per cent, of the cases of intestinal obstruction. The anatomical varieties, in the order of their frequency, are the ileocecal (44 per cent.), in which the ileocecal valve and ileum pass into the colon, the enteric (30 per cent.), usually involving the jejunum, the colic (18 per cent.), involving the colon alone, and the ileocolic (8 per cent.), in which the ileum passes through the ileocecal valve. Multiple retrograde intussusceptions sometimes occur in the dying, probably from rigor mortis. Double intussusception, in which an intussusception slips into the gut below, and triple intussusception, in which a double intussusception slips into the gut below, are extremely rare. ABDOMEN 7 5 I Clinically two forms must be distinguished, the acute, which is the usual variety, and the chronic. The symptoms of acute intussusception are often so typical that no difficulty is experienced in distinguishing the condition from other forms of acute obstruction. Acute intussusception is most frequent in male infants and sometimes follows a straining diarrhea. Distension is not so marked and stercoraceous vomiting not so common as in most other forms of acute obstruction. Tenes- mus, with the passage of small quantities of blood and mucus, is more severe and frequent the nearer the intussusception is to the anus, the passages becoming particularly offensive when the intussus- ceptum sloughs. The sausage-shaped tumor, concave tow^ards the umbilicus, can often be felt in the course of the transverse or the descending colon. The tumor becomes harder and more prominent with each recurrence of the griping pain, and progresses slowly towards the anus, which may be relaxed, and through which the apex of the intussusceptum, feeling like a soft os uteri, may be palpated. The right iliac fossa may feel empty, the bowel in this region haxing passed along the colon. Without treatment death usually takes place in from one to eight days. The symptoms of chronic intussusception are not so typical as those of the acute variety. The condition is most common in men between twenty and forty, is often due to the dragging of a pol>p. and may last for a number of months or even a year. There are attacks of pain, vomiting, and diarrhea, often with tenesmus and the passage of blood and mucus. The tumor can be felt through the abdomen in half of the cases, and by rectum in one-third; sometimes it disappears between the attacks. Visible peristalis and other signs of chronic obstruction are in evidence. Death occurs in about 95 per cent, of the cases, from acute obstruction, peritonitis, or hemorrhage. In about one-fourth of the cases the intussusceptum sloughs and is passed by the bowel, but only a very few^ of these terminate in recovery. The treatment of acute intussusception by the administration of opium and belladonna, and the injection of air or water into the rectum should be discarded. It wastes valuable time, is uncertain, necessitates anesthesia, and may rupture the bow^el, hence is more dangerous than laparotomy. The abdomen should be opened, as early as possible, in the median line, and the intussusception reduced, not by traction, which may tear the bowel, but by milking or pressing the Intussusceptum upwards. It has been suggested, in order to prevent recurrence, to shorten the mesentery or suture it to the 752 MANUAL OF SURGERY ascending mesocolon, or to fix the bowel to the abdominal wall. When reduction is impossible, i.e., in half of the cases, and in almost all of the cases after the second or the third day, the procedure to be adopted depends on the condition of the bowel and of the patient. When the intussusceptum is gangrenous it must be resected (see "Maunsell's Method"), the ends of the bowel being anastomosed if the general condition of the patient is good, or sutured in the wound, thus forming an artificial anus, if, as is usual, the condition of the patient is poor. Resection of the entire intussusception is indicated only when the intussuscipiens is gangrenous. When the bowel is irreducible and in good condition a lateral anastomosis may be made between the intestine above and below the intussusception. In children the mortality is between 30 and 40 per cent, when reduction is easy, and over 90 per cent, when reduction is impossible. In chronic intussusception in adults the best treatment, as a rule, is resection, whether the intussusception is reducible or not, because the condition is often caused by a tumor actually or potentially malignant. The mortality in these cases is not so high as in acute intussusception. Intestinal paralysis, adynamic ileus, or pseudoobstruction, may occur with or without gastric paralysis (see "Acute Dilatation of the Stomach") ; in the former event the term gastrointestinal paralysis is applicable. Intestinal paralysis may be mechanical, reflex, or toxic in origin, but in most instances two of these factors are present. It is most frequently caused by peritonitis, but occurs also in enteritis, acute pancreatitis, thrombosis or embolism of the mesenteric vessels, biliary and renal colic, strangulation of the omentum, diseases of the bladder, prostate, and seminal vesicles, diseases and injuries of the testicle, ovary, and central nervous system, and as a terminal event in other maladies, particularly those accompanied by delirium or coma. Fracture of the spine, uremia, and pneumonia should receive special mention. That form occurring after abdominal section, not due to peritonitis, is caused by the sudden relief of chronic pressure (e.g., the removal of a large tumor) or by undue handling of the intestines. The symptoms are almost identical with those of acute obstruction. There may, however, be evidences of the causative lesion, and peristalsis is absent. In intestinal obstruction increased peristalsis is a cardinal sign which is absent only in the final stage, when paralysis ensues. Rectal ballooning, which is sometimes de- scribed as a sign of appendicitis, obstruction of the bowel, etc., is really an indication of intestinal paralysis from any cause. The treatment is that of the cause. In addition the stomach may be washed out, a tube passed into the colon, enemata administered, and ABDOMEN 753 strychnin, cscrin, pituitarin, atropin given hypodermatically. Intes- tinal paralysis of severe degree is generally fatal. An artificial anus may be established, but usually does not drain more than the coil in which it is made. OPERATIONS ON THE INTESTINES Intestinal Localization. — The large intestine is differentiated from , the small intestine by its mesenteric attachment, greater size, longi- tudinal bands, sacculations, and by its appendices epiploicae. The method for finding the upper end of the jejunum is given under ''Gastroenterostomy." In order to determine the situation and direction of a loop of intestine, the following facts, according to Monks, are of great value: The average length of the small intestine is twenty-one feet. The upper third occupies the left hypochon- drium (duodenum excluded) ; the middle third, the middle section of the abdomen; the lower third, the pelvic and right iliac regions. The intestine, from above downwards, decreases in size and thickness, becomes less opaque, has smaller vessels, which are nearer together, and changes in color from bright pink or red to pinkish or yellowish gray. In the upper jejunum large and numerous valvulse conni- ventes may be felt, but are imperceptible beyond the fourteenth to the sixteenth foot. The fixation of the two ends of the intestine may be palpated; and the consistency of the contents increases from above downwards. The mesentery is thin and transparent at the upper part, thick and opaque in the lower third. The lunettes between the vessels can be seen in the upper eight feet or more, but not in the lower third. Tabs of fat extending onto the intestine begin to appear at about the fourteenth foot and become more and more prominent. In the upper third the mesenteric vessels are large and far apart, form primary loops as far as the fourth foot when second- ary loops appear, and give off long, regular, unbranching vasa recta to the intestine. In the lower third the mesenteric vessels are small and close together, have many loops often obscured by fat, and give oft" small, short, and irregular vasa recta. The root of the mesentery is to the left of the median line above, to the right below. If a loop of bowel is placed parallel with the root of the mesentery, the upper end will be nearer the duodenum, providing there is no twist in the mesentery. Enterotomy signifies an incision into the intestine for the purpose of removing a foreign body or for exploration. After guarding against fecal extravasation (see "Enterectomy") a longitudinal 48 754 MANUAL OF SURGERY incision is made opposite the mesentery, and tlie wound closed by enterorrhaphy. Enterorrhaphy, or suture of the intestine, is performed with at least tw^o rows of sutures. The inner row should be of catgut, and perforate all the coats of the bowel in order to secure firm apposition and control bleeding. The suture may be interrupted or continuous, over and over or mattress, tied externally or within the bowel. In enterorrhaphy a long continuous suture of any variety should, to prevent puckering, be knotted or locked at intervals. The outer row is of fine silk or celluloid thread, introduced with a fine straight round needle. It is essential that the wound be air-tight, and that the edges be inverted so that serous membrane shall come in contact with serous membrane. The Lembert suture is placed at right 10 11 Fig. 427. — Intestinal sutures. I. Wolfler. 2. Czerney-Lembert. 3. Lembert interrupted. 4. Lembert-Dupytren continuous. S. Gushing continuous mattress. 6. End to end intestinal anastomosis. 7. Lembert purse string. 8. Halstead mattress, interrupted. 9. Gely. 10. Gussenbauer. 11. Connell. angles to the wound. The needle is inserted about one-fourth inch from the edge of the wound, goes down to and through the submucous coat but not through the mucous membrane, is brought out one- eighth inch from the edge of the wound, and in a similar manner on the opposite side, so that when tied the edges of the wound are inverted. The stitches are about one-eighth of an inch apart. All other seroserous sutures are inserted with the precautions used in employing the Lembert suture. (Fig. 427-3.) Enterostomy is the making of an opening into the intestine in order to feed a patient or to drain away the contents of the intestine (artificial anus) ; according to the situation of the opening the opera- tion is called duodenostomy, jejunostomy, ileostomy, or colostomy. Duodenostomy or jejunostomy is occasionally performed to ABDOMEN 755 feed the ]')aticnt in s^astric ulcer or cancer, when a gastroenterostomy is inappHcable; only jejunostomy could be employed if the ulcer or growth were in the duodenum or the upper jejunum. As the idea is to introduce food and prevent the escape of intestinal contents, the principles used in the Witzel or the Stamm-Kader gastrostomy should be employed. Complete division of the bowel, with suture of the upper end of the lower segment to the skin, and anastomosis of the upper segment with the side of the lower segment is a much more serious operation and is very rarely indicated. Ileostomy may be demanded in cases of intestinal obstruction, above the ileocecal valve, in which the patient's condition is so bad that search for or removal of the cause of the obstruction is contrain- dicated. The operation is performed in the same manner as colos- tomy. If the patient survives, the obstructing lesion and the artifi- cial anus are removed at a second operation, or the obstruction alone is dealt with at the second operation and the continuity of the ileum restored at a third operation. Closure of the artificial anus, how- ever, must not be delayed longer than is absolutely necessary, be- cause of its interference with nutrition, which is more marked the higher the opening, and because of the digestive effect of the intestinal juices on the skin. Colostomy, or colotomy, as it is sometimes called, is commonly employed for the relief of obstruction, and occasionally for the pur- pose of giving the large bowel rest and alowing irrigation in cases of chronic dysentery or other severe ulcerative lesions. Irrigation ot the colon, without diversion of the fecal current, is best performed through the appendix (see "Appendicostomy"), or when this is not possible, because of stricture of the appendix, through a valvular opening in the cecum [cecostomy) , which is made in the same way as the Stamm-Kader gastrostomy, but which in this region is called Gibson'' s operation. In order to interfere as little as possible with nutrition, an artificial anus should be made as low in the colon as the condition for which it is done permits. Hence when sigmoidos- iomy is contraindicated, because of obstruction in the descending colon, the opening should be made in the transverse colon, and not, as is customary, in the cecum or the ascending colon. Transversos- tomy, in addition to its preserving more of the large bowel for the purpose of nutrition than an artificial anus in the right inguinal region, is, owing to the long transverse mesocolon, easier to perform does not produce so much irritation of the skin, and is easier to close, at least by resection and anastomosis. The incision is made in the abdomen above the umbilicus, through the middle line or the 756 MANUAL OF SURGERY left rectus. The rest of the operation is similar to inguinal colos- tomy, which, since it is the usual procedure, will be described in detail. Inguinal colostomy is performed through an incision, two or three inches long, made at right angles to a line drawn from the anterior superior spine to the umbilicus, its middle crossing this line at the junction of the outer and middle thirds. A loop of the colon is pulled into the wound, the upper limb of the loop being made taut in order to prevent subsequent prolapse, and the gut fastened by passing a glass rod through the mesentery and suturing the parietal peri- toneum and then the skin to the bowel. Instead of the glass rod, gauze or other material may be used, or the middle of the skin incision may be united beneath the bowel. If. owing to absence or extreme Fig. 428. — Immediate enterostomy. brevity of the mesocolon, a sufficiently long loop cannot be obtained the colon should be mobilized by incising the peritoneum on the outer side of the gut (see "Colectomy"). The bowel is opened transversely with scissors or cautery, at the end of two or three days, after protecting adhesions have formed; no anesthetic is required. The gut should not be completel}' divided, however, for a week or ten days, otherwise it may retract within the abdomen. When immediate opening of the intestine is mandatory, there is consider- able risk of infecting the peritoneal cavity with feces. The author prevents this in the following manner : The loop of bowel is emptied by pressure, and a clamp placed at each extremity, the whole being surrounded by gauze. One-half of a Murphy button is inserted into the empty loop of intestine through a small incision and the other half is squeezed into the end of a long rubber tube whose calibre is .\BDOMEN 757 slightly smaller than that of the flange of the button, thus making a tight joint (Fig. 428). The two halves of the button are then pressed together, or in other words a lateral implantation is made between the rubber tube and the bowel. The feces drain through the rubber tube into a receptacle on the floor. By the time the button has sloughed through the bowel, i.e., at the end of two or three days, adhesions will have closed the peritoneal cavity. Often the bowels move only once or twice a day, and give little trouble. If desired, however, a rubber "colostomy bag" may be worn, or the artificial anus may be closed between bowel movements by a hollow rubber bulb, shaped somewhat like a dumb-bell; one end is placed in the intestine and the bulb is then distended with air. The artificial anus may be provided with a more or less satisfactory sphincter by drawing the bowel through the split rectus muscle or through a McBurney incision. Bodine's operation facilitates the closure of the artificial anus. A long loop of bowel is drawn from the abdomen, and the two limbs sutured together for six inches, first near the mesenteric attachment and again near the anterior longitudinal band. The loop is then replaced in the abdomen except for its end. which is sutured to the abdominal wall, and later opened. When the artificial anus has served its purpose, the long spur between the two limbs of the loop is cut through with a heavy clamp, which generally takes about one week. The bowel around the artificial anus is then separated as far as the peritoneum, the opening closed with inversion sutures, and the muscles and the skin drawn together over the suture line. In lumbar colostomy the large bowel is approached extraperi- toneally through the loin. The operation has been abandoned, because, as compared with iliac colostomy, it is more difficult, does not completely divert the feces, and the resulting opening is not well situated for cleanliness. Operative closure of the artificial anus will be required in those cases in which the condition for which it has been established has been removed. The manner of closure after Bodine's operation is described above. In other cases the opening in the bowel is dis- infected with carbolic acid, stuffed with gauze, and closed with sutures. The environing skin is then sterilized, and the abdomen opened by an elliptical incision surrounding the anus, the involved segment of bowel being resected, and the fecal circulation re- established by an end to-end-anastomosis. In many cases the lower segment will be so contracted that the surgeon will prefer a lateral anastomosis. 758 MANUAL OF SURGERY A fecal or intestinal fistula differs from an artificial anus in that only a portion, and not all, of the intestinal contents escape through the abnormal opening. It may be congenital (see "Umbilical Fistula") or follow injury, ulceration, strangulation, and malignant tumors of the bowel, or inflammatory lesions of the abdominal cavity secondarily involving the bowel. Occasionally a fecal fistula is deliberately established by the surgeon. External fistula i.e., opening on the skin, may proceed from any portion of the intestinal canal. The discharge from the duodenum or the upper jejunum is fluid, acid, intensely irritating to the skin, and contains bile and undigested food; that from the lower ileum or the cecum is neutral or alkaline, much less irritating and contains less undigested food; that from the lower colon is semisolid or solid fecal matter. If there is any doubt as to whether the bowel is open or not, e.g., after some operations for appendiceal abscess in which the dis- charge is very foul, methylene blue may be given by mouth; if there is an intestinal fistula the discharge will become blue, the earlier the higher the fistula in the bowel. A high intestinal fistula dis- charges very quickly anything that is taken into the stomach, thus producing rapid emaciation and death. When of large size, an external fecal fistula requires the same treatment as artificial anus. Smaller fistulae, particularly in the large bowel, often close spon- taneously. If the tract is lined by mucous membrane, this should be destroyed with the cautery. When opening into the small bowel even minute fistulae sometimes refuse to heal. In these cases the external opening should be treated as mentioned above for artificial anus, the tract dissected out, and the opening in the bowel closed with sutures. When these methods are inapphcable or inadvisable, exclusion of the intestine, which is described on a latter page, may be performed. An internal fistula between the stomach and the colon causes rapid emaciation, the appearance of undigested food in the stools, and of fecal mattei in the vomit us, between the intes- tine and the bladder, fecal matter in the urine and infection of the urinary tract. If the condition is not due to inoperable tuber- culosis or carcinoma the viscera should be separated and the opening in each closed. Enterectomy, or resection of the intestine, is performed for many conditions, of which the following are the most important: gangrene, extensive injury, tumors, artificial anus, cicatricial stenosis, tuber- culosis, and injury to the vessels supplying the segment of bowel. The portion of gut to be removed is drawn from the body, and the peritoneal cavity protected by gauze packing. The loop is emptied ABDOMEN 75Q by stripping with the finger, and rubber-coated clamps placed on the bowel on each side of the proposed incisions, i.e., four clamps are used. In the absence of intestinal clamps, gauze or rubber tubing may be tied around the bowel. The mesentery is then ligated in sections, a short distance from the bowel, and divided; in maUgnant disease particularly, a V-shaped portion of the mesentery is removed, great care being exercised not to cut oE the blood supply of the bowel which is to remain. The bowel is divided somewhat obliquely, removing more at the free than at the mesenteric border, in order to give a greater circumference, and to assure a good blood supply to the antimesenteric portion. The continuity of the intestine is re-established by circular enterorrhaphy, lateral anasto- mosis, or lateral implantation (vide infra). The opening in the mesentery is closed, and any excess folded and held in place by sutures. Colectomy, or removal of a part or the whole of the colon, requires special consideration, because of the arrangement of the peritoneum around the large bowel. The middle of the sigmoid and the transverse colon can generally be withdrawn from the abdomen, resected like the small intestine, and anastomosed by circular enterorrhaphy. Unlike the small intestine, however, the transverse colon has attached to it three peritoneal shelves that must be dealt with, the gastrocolic omentum, the greater omentum, and the mesocolon, the last containing the blood supply. The ascending and the descending colon are, as a rule, only partly covered with peritoneum, and are fixed to the posterior abdominal wall. Thanks to the arrangement of the vascular supply, however, which approaches the bowel from the mesial side, these portions of the colon can be completely mobilized, and brought to a safe place out- side the abdomen for operative attack, by incising the peritoneum to the outer side of the gut, bluntly separating the loose cellular tissue over the kidney and the ureter, and displacing the gut toward the median line. On the left side the splenic flexure can be liberated by cutting the phrenocolic hgament. Thus, if necessary, the entire colon can be exteriorized, almost bloodlessly, through a median incision. After mobihzation the affected segment can be resected with as little difficulty as a piece of small intestine, and the con- tinuity of the bowel re-established by one of the methods described below. Lateral anastomosis, however, is to be preferred in the ascending and the descending colon, because of the incomplete peritoneal investment; if circular enterorrhaphy is performed in these parts of the large bowel, the anastomosis should be isolated 760 MANUAL OF SURGERY from the general peritoneal cavity by vaselinized gauze, as leakage not infrequently follows. Primary resection of a portion of the colon, unless the bowels have been thoroughly evacuated previously, is so dangerous (^mortality 30 to 40 per cent.) that in all cases of obstruction the patient should be operated upon in two or more stages( mortality 10 per cent.); this statement appHes particularly to cases of malignant disease of the colon. At the first operation the chief indication is to relieve the fecal stasis, by the formation of an artificial anus. At a later period the growth is removed and, if possible, the artificial anus closed; or the work may be done in three stages, by separating the excision of the growth and the closure of the artificial anus by an interval. Since closure of the artificial anus, by resection and anastomosis, is often a formidable undertaking, perhaps the best plan, in suitable cases, is to remedy the mischief in four stages, (i) The loop containing the growth is mobilized, the growth brought out of the abdomen, and the limbs of the loop sutured together and fastened to the abdoininal wall as in Bodine's colostomy. A rubber tube is anastomosed, as described under colostomy, wdth the extraabdominal portion of the bowel above the growth. (2) When the tubes comes away the growth is amputated. (3) At the end of a week the spur between the limbs of the loop is cut through with a clamp. (4) After the clamp has done its work, i.e., about a week, the artificial anus is closed, as after the Bodine operation. The chief objection to the proceeding just outlined is that it prohibits extensive removal of the lymph channels and glands, but, according to Buthn, over 60 per cent, of the deaths from colonic carcinoma are due to obstruc- tion, and occur before metastasis take splace. If one does perform a primary resection for an obstructing growth in the colon, an artificial anus above the anastomosis should be made at the same time. End-to-end anastomosis, or circular enter orrhaphy, may be performed by simple suturing or with the aid of special apparatus. Simple suturing is always to be preferred. The best plan is to bring the clamps together as in gastroenterostomy (Fig. 403), suture the apposed peritoneal surfaces, paying special attention to the mesenteric border as described below, and then to finish the opera- tion like a gastroenterostomy. If this is not done the ends of the intestine may be brought together with two sutures, one opposite the other, passing through the w^alls of both segments, midway between the free border and the mesenteric attachment. These sutures are left long and held by an assistant, in order to act as ABDOMEN 761 guides. A third suture is inserted at the mesenteric border (Figs. 427-429), so as to obliterate the space normally present between the layers of the mesentery at this point. The two segments are now united by a continuous suture of catgut, passing through all the coats in order to secure firm apposition and stop bleeding. After the posterior margins have been united, the suture may be inserted like a Gushing right angle suture, except that it passes Fig. 429. — Mesenteric stitch. Fig. 430. through all the coats (Fig. 430). This layer of sutures is buried by a continuous Lembert or Gushing suture of silk, extending around the whole circumference of the anastomosis. It is well to insert an extra suture at the mesenteric insertion as shown in (Fig. 431). Instead of dividing the bowel obliquely to prevent stenosis, as ex- plained under '"Enterectomy," Mayo incises the antimesenteric border of each segment in the axis of the bowel and sutures the timmmmii imiim h Fig. 431. Fig. 432. incisions together transversely, as in the Heineke- Mikulicz pyloro- plasty. When the ends of the bowel are of unequal size, the larger opening may be partly closed by sutures, or the smaller end may be cut obliquely and the larger transversely; under these circum- stances, however, it is much better to close both ends and perform a lateral anastomosis. In MaunseWs operation the ends of the gut are first united by two sutures, one at the mesenteric and one at the free border, the knots being placed within the lumen and the sutures 762 MANUAL OF SURGERY left long. A longitudinal incision is then made in the free margin of the segment of bowel with the larger diameter, about an inch from its end. These sutures are drawn out through the lateral opening (Fig. 432) and by traction an artificial intussusception is produced (Fig. 433). The edges of the protruded intussusceptum are united by sutures passing through all the coats of the bowel, the intussusception reduced, and the longitudinal opening closed by Lembert sutures. The union may be reinforced by an extra layer of Lembert sutures. Of the many forms of special apparatus which have been sug- gested to facihtate end-to-end anastomosis, the Murphy button alone will be described, although it too is almost never employed at the present time. The button consists of two hollow, flanged, metallic cylinders. When one cylinder is inserted into the other and pressed home the flanges cannot be separated except by un- FiG. 433. — Maunsell's operation. A P B~ Fig. 434. — Murphy button. A, Male half; B, female half. The round holes are for drainage. screwing, there being two spring catches (S.S. Fig. 434) on opposite sides of the smaller cylinder, and a screw thread in the interior of the larger. In one-half of the button there is an additional flange (P. Fig. 415) separated from the first by a spring C. (Fig. 434) which exercises constant pressure on the bowel, and thus induces necrosis and liberates the button, the segments of bowel having in the meantime united. A purse-string suture is inserted into each end of the divided intestine, special attention being given to the mesenteric insertion so that it will be included within the grasp of the button. One-half of the button is inserted into the open end of each segment of bowel and the purse-string suture drawn tight and tied. Any excess of mucous membrane is cut off and the two halves of the button pressed together. The button should be passed with the feces in from two to three weeks. The disadvantages of the button are that it is a foreign body which may become impacted or retained, producing obstruction or ulceration of the bowel, and that its use may be AUDOMKX 763 followed by leakage, the result of a spreading of the necrosis which it necessarily induces. The button should always be tried before operation, as many are defective in construction. Lateral anastomosis is performed to short circuit a portion of the intestinal canal (Fig. 437) and sometimes instead of end-to-end anastomosis after resection of the bowel (Fig. 435)- The advantages over end-to-end anastomosis are that broader contact of the serous surfaces can be secured without narrowing the lumen; that necrosis is less apt to occur, as the mesenteric vessels are not involved in the suture; that the opening can be made as large as desired, hence post-operative contraction may be discounted; and that a difference in the size of the segments makes the operation no more difiEicult or dangerous. The disadvantages are that the feces are apt to be propelled past the opening into the blind end of the proximal seg- ment, which may give way under the pressure; that the circular fibres are cut. thus predisposing to impaction at the site of anasto- FiG. 435- — Lateral anastomosis. Fig. 436. mosis; and that the blind end of the distal segment may invaginate. While surgeons differ as to the importance to be attached to these considerations, all agree that lateral anastomosis is safer when the bowel is not completely surrounded by peritoneum, e.g., in the ascending and descending colon. When selected after resection of the bowel, the open ends of the gut are closed by sutures, and the anastomosis effected as close as possible to the ends of the segments, care being taken to maintain the normal direction of the fecal current whenever possible (Fig. 433). When the ends of the intes- tine cannot be sufficiently mobilized for this purpose, the bowel may be arranged as shown in (Fig. 436). After the loops have been emptied clamps are applied and the operation completed in the same manner as gastroenterostomy with suture. The Murphy button is applied much in the same way as in end-to-end anastomosis. A purse-string suture passing through all the coats is introduced into each segment of bowel opposite its mesenteric attachment, incisions made into each loop of bowel within the area embraced 764 MANUAL OF SURGERY by the suture, each half of the button inserted, the sutures drawn tight and tied, and the button locked. Lateral implantation (Fig. 438), or end-to-side anastomosis may be performed by simple suturing or by means of the Murphy button. Exclusion of intestine whose removal is impossible, e.g.. because of an extensive neoplasm, or whose removal is unnecessary, e.g., in Fig. 437. — Incomplete exclusion of colon. Pig. 438. — Unilateral exclusion of colon. chronic inflammatory lesions, may be performed in three ways. (i) The bowel above and below the diseased segment is united by lateral anastomosis (Fig. 437). This does not divert the fecal current completely and, uaIcss there is total obstruction in the short-circuited bowel, is often followed by contraction of the anasto- motic opening. (2) The bowel above the disease is severed, the distal end closed, and the proximal end united with the bowel below, either by lateral implantation (Fig. 438) or by lateral anastomosis. This operation is called un- ilateral exclusion. Its disadvantages are, when applied to the colon, retrograde trans- portation of the feces and diarrhea. It really creates a long artificial cecum, in which the intestinal secretions and the re- FiG. 439.— Bilateral exclusion gurgitatcd fcccs may accumulatc (fecal im- paction), putrefy (gaspains^ generate toxins (intoxication), and perhaps cause ulceration, perforation, and death. These dangers may be lessened, but not obviated, if the lower end of the ileum is anastomosed with the transverse colon (ileotrans- verseostiomy) . Lane recommends ileosigmoidostomy, end-to-side (Fig. 438), for chronic constipation and for many other ills that he believes are due to intestinal stasis. (3) The bowel is anastomosed as just described, and then the lower end of the excluded segment ABDOMEN 765 divided above the anastomosis and the open ends of the gut closed (bilateral exclusion, Fig. 439). This method necessitates drainage of the excluded segment, which otherwise would become distended with retained secretions, causing pain, toxemia, and jM^ssibly peritonitis from perforation, hence if the excluded segment is not already con- nected with skin by a fistula, one must be established. One or both ends of the excluded bowel may be left open and fastened to the skin. In order to avoid the inconvenience of an external fistula several suggestions have been made. The ileum may be united with the sigmoid by lateral anastomosis in two places, and ligated between the anastomoses. A lateral anastomosis may be made between the cecum and the sigmoid (typhlosigmoidostomy). The sigmoid may be divided, the lower end anastomosed, end-to-end, with the cecum, the upper with the side ot the lower segment (typhlosigmoid- ostomy en Y). In all of these methods both ends of the colon are said to be drained. In the first the ileocecal valve would probably interfere with the drainage of the cecum. In the second and the third, at least some of the feces would prefer the normal to the artificial route, and flow up the ascending colon. In all a stricture above the site of operation, e.g., in the transverse colon, would create two culs de sac. Hence these operations do not exclude the large bowel, and after bilateral exclusion one must accept the external fistula or excise the colon. APPENDICITIS The vermiform appendix varies in length from a fraction of an inch to one foot, but is generally about three inches. It may point in any direction, but most frequently it runs downward and inward or upward and inward. It usually arises from the postero-internal part of the cecum, which it resembles in structure, except that it contains a large amount of lymphoid tissue, a fact which has gained for it the title "abdominal tonsil." Although it may be entirely retroperitoneal, it is almost always supplied with a mesentery (meso- appendix), in whose free border runs the artery of the appendix, which is a branch of the posterior ileocecal; one or two vessels may run also outwards on the body of the organ within the folds of the mesoappendix. In the female the appendix is occasionally con- nected with the ovary by a fold of peritoneum (appendiculo-ovarian ligament) which carries a small artery from the ovarian, thus giving additional blood supply. The orifice of the appendix is slightly narrowed by a mass of lymphoid tissue, called the valve of Gerlach. 766 MANUAL OF SURGERY The function of the human appendix is not known, although some believe it has a sHght influence on digestion by reason of its secretion, , The causes of appendicitis are predisposing and exciting. Among the predisposing causes must first be mentioned the peculiarities of the appendix itself. It is a long, narrow, blind sac communicating with the intestinal canal and often constricted at its orifice. The mesoappendix is often short, thus coiling or kinking the appendix and interfering with its drainage and blood supply. Although it may occur at any age, appendicitis is most frequent between the tenth and thirtieth years. It is sHghtly more common in males, and is probably more frequent in the summer than in the winter. Other conditions w^hich predispose to this affection are tonsillitis, rheumatism, influenza, and disorders of the gastrointestinal canal, e.g., gastroenteritis, dysentery, typhoid fever, and constipation. One attack markedly predisposes to subsequent attacks. The exciting causes are enteritis (including conditions like intestinal indigestion, typhoid, and dysentery) which spreads to the appendix, traumatism, exposure to cold, and foreign bodies. Foreign bodies, such as intestinal parasites, seeds and stones are uncommon, but fecal concretions are often encountered. Tuberculosis, actino- mycosis, and certain neoplasms also may involve the appendix, and inflammation of neighboring structures, e.g., the uterine appendageS; may cause a secondary appendicitis. No matter what the source of irritation, however, the most important factor is infection of the walls with micro-organisms, especially the colon bacillus. The ordinary pyogenic bacteria, particularly the streptococcus pyogenes and less frequently other organisms, also are found, either alone or as a mixed infection. The appendix is normally inhabited by hordes of bacteria, which become vicious only when they enter the wall of the appendix through an abrasion, e.g., by a fecal concretion, or through the lymphatics without an abrasion, e.g., when the drainage of the organ is defective as the result of .kinks, adhesions, tumors, concretions, foreign bodies, or swelKng of the mucous membrane of the cecum. The pathological anatomy varies with the virulence of the infection, the depth of the inflammation, the duration of the process, and the complications. In catarrhal appendicitis the mucous membrane is swollen and congested and sometimes presents hemorrhagic foci ; the process may subside if drainage is free, or it may extend to the outer walls {interstitial appendicitis), the entire organ then being swollen and congested, and containing pus {empyema of the appendix), blood, or feces. Interstitial abscesses also may be found. If the appendix empties its contents into the cecum, the patient may recover ABDOMEN 767 from the attack, but the organ is permanently crippled and a chronic or recurring inllammation ensues. More often the disease pro- gresses to ulceration or gangrene. Ulcerative appendicitis may arise also primarily, e.g., in typhoid fever or dysentery, or from a foreign body. One or more of these ulcers may perforate (perforative appendicitis), either into the free peritoneal cavity, or much more commonly after the general peritoneal cavity has been protected by inflammatory adhesions. In the latter instance a localized abscess will be formed. Ulcers which do not perforate, but cicatrize, cause strictures and deformities of the appendix. When such contraction is universal, the entire cavity may disappear {obliterating appendicitis). The appendix occasionally becomes distended wdth mucus distal to a stricture (hydrops or mucocel of the appendix). Gangrenous appendicitis may follow any of the preceding varieties, a sudden and overwhelming infection, or obstruction to the blood supply, e.g., as the result of kinks, twists, or thrombosis. This variety may develop within a few hours (fulminating appendicitis). The organ undergoes moist gangrene, being soft, swollen, and green or black in color, and soon separates from the healthy tissues. In fulminating cases it may lie free in the peritoneal cavity. In any case, however, in which the inflammation progresses beyond the mucous membrane, adhesions are apt to form about the appendix, thus serving as a protective barrier in the event of gangrene or perforation. The exudate formed may become purulent, even in the absence of perforation and gangrene. The situation of the appendix determines the location of the abscess, which may rupture through the abdominal wall, into a neighboring hollow viscus, or into the general peritoneal cavity. Among the other complications of suppuration about the appendix are intestinal obstruction, fecal fistula, perforation of the iliac vein or artery, psoitis, lymphan- gitis or lymphadenitis, subphrenic abscess, empyema, phlebitis (iliac, femoral, mesenteric, or portal), and pyemia (abscess of the liver, kidney, spleen, or lung, endocarditis, meningitis, and parotitis) . The symptoms may be described under two headings, according to whether the disease is acute or chronic. The most important symptoms of acute appendicitis are pain, tenderness, and rigidity of the muscles over the appendix, which is generally in the right iliac fossa, but may be in the loin, pelvis or any part of the right side of the abdomen; in rare instances it is to the left of the median line. The first symptom is pain, which usually develops suddenly, is paroxysmal in the beginning and confined to the epigastric or 768 MANUAL OF SURGFRY umbilica] region, and later becomes constant and localized in the region of the appendix. The pain in the appendiceal region is increased by direct pressure over the appendix, and by indirect pressure induced by movements of the right thigh, abdominal respiration, and deep palpation of the left abdomen. Traction on the right spermatic cord may, by stretching the peritoneum in the neighborhood of the internal inguinal ring, cause acute pain especially when the appendix is situated in the pelvis. The pain may dis- appear entirely after the onset of gangrene or suppuration. The situation of the most marked tenderness also varies with the situa- tion of the appendix, hence may require rectal or vaginal examination for its development; in most instances, however, it is at McBurney's point (one and one-half to two inches from the anterior superior spine of the right ihum on a line running to the umbilicus. Fig. 376). The skin over the inflamed area also may be hyper esthetic. Rigidity, often board-like in character, likewise is most intense over the appen- dix, and its degree and extent usually indicate the degree and extent of the underlying inflammation. Vomiting occurs with the epigas- tric pain, then subsides, and recurs with the development of peri- tonitis. Constipation is present in about two-thirds of the cases. The temperature usually rises two or three degrees, but in many cases there is no fever until abscess, peritonitis, or other septic complications ensue. Chills are rare and generally indicate gangrene of the appendix or metastatic abscesses. The pulse, in the absence of complications, may be normal or but slightly accelerated; it becomes rapid with the onset of peritonitis. The respirations are costal, but the rate is not influenced to any great extent until the advent of peritonitis develops. The facial expression may be that of pain, but is not characteristic in the absence of peritonitis. The tongue is usually coated. Hematuria may occur when the appendix lies against the ureter or the bladder. The late symptoms, in a progressive case, are those of peritonitis. In the early stages the underlying structures cannot be palpated because of the muscular rigidity, but with the formation of an abscess or a fibrinous exudate about the appendix, a mass may be felt and sometimes seen. This tumor is smooth, fixed, usually tympanitic, and rarely fluctuating. After the infected focus has become well encapsulated, the rigidity, often disappears. Rough or powerful pressure should never be used in acute cases because of the danger of rupturing the appendix or an environing abscess. Leukocytosis, increasing with the extent of the infection, unless such be overwhelming, is a sign of some value when considered with the clinical phenomena. The progress of ABDOMEN 769 the disease varies greatly in different instances. In the mildest forms in which the infection does not extend beyond the appendix, complete recovery may follow in a few days, but subsequent attacks are the rule {recurring appendicitis). In fulminating cases the peritoneum may be involved within a few hours. Unfortunately it is impossible to foretell from the character of the symptoms which cases will recover and which will progress to perforation, gangrene, or abscess formation. In the midst of even the mildest symptoms, sudden perforation or gangrene with their disastrous sequelai may occur. Chronic appendicitis may be such from the beginning or it may follow an acute attack. The symptoms are pain and tenderness in the region of the appendix with chronic indigestion. Occasion- ally a thickened appendix may be felt. Chronic appendicitis in which acute attacks occur at intervals is called relapsing appendicitis. The X-ray signs of chronic appendicitis are fixation tenderness, or distortion of the appendix, which can be seen after an opaque meal. If the appendiceal shadow fails to appear the appendicitis may be obstructed, obliterated, filled with feces, or obscured by the barium- filled cecum. Sometimes the appendiceal shadow persists for months. The diagnosis is generally easy, but may be difficult or impossible. In many cases a failure to make a definite diagnosis entails no serious consequences to the patient, because operation is necessary in order to deal with some intraabdominal surgical lesion. Embar- rassment to the surgeon, however, may arise owing to failure to obtain permission to remove any disease that may be present, especially if the patient be a female, and the disease ovarian. Pain, tenderness, and rigidity are prominent features in this group of cases, which includes among other conditions the following : Perforation of any portion of the gastrointestinal canal, intestinal obstruction, inflammation of Meckel's diverticulum, cholecystitis, acute pan- creatitis, thrombosis or embolism of the mesenteric vessels, volvulus of the omentum, tuberculous peritonitis, extrauterine pregnancy, inflammatory lesions of the right tube or ovary, and ovarian cyst with twisted pedicle. In a second group of cases the trouble lies in the kidney or the ureter, and may be missed even during an intra- peritoneal exploration, or, if discovered, may necessitate a separate incision, and perhaps an emergency nephrectomy without investiga- tion of the functional capacity of the other kidney. Special mention should be made of acute hematogenous infection of the kidney, stone in the kidney or ureter, floating kidney, with twisted ureter, and perinephric abscess. In a third group of cases, in which it is not always possible to avoid a mistake in diagnosis, nooperation is needed. 49 770 51.A.NUAL OF. SURGERY A list of such cases will be foand ander ''Unnecessary Abdomi- nal Section."" Excluding the abdominal wall and the appendix, a ^ mass in the right iliac region, may be due to neoplasm of the structures in this region, particularly carcinoma of the cecum and sarcoma of the ilium, ovarian cysts, enlarged l\-mph glands, volvulus of the omentimi or the intestines, hematoma, tuberculosis or actinomysosis of the cecum, foreign body in the intestine, fecal impaction, intus- s isception, aneur}-sm, abscess (from the vertebras or pelvic bones, iliopsoas or abdominal muscles), pelvic celluhtis, inflamed unde- scended testicle, properitoneal hernia, enlarged gall-bladder, dis- placed or ectopic kidney, and phantom tumor. Space cannot be spared in this place to give a separate enumeration of the symptoms of these conditions, but in most instances the differential diagnosis is possible if care is taken to obtain a full histor}- and make a complete examination. The treatment of acute appendicitis is operation as soon as the diagnosis is made. There are certain exceptions to this rule, e.g., the presence of some other grave malady which will render operation extremely dangerous, or the absence of a competent surgeon. Under these circumstances or when operation is refused, the patient should receive the medical treatment ad\ised in the section on ''Peritonitis. " The mortahty with medical treatment is said to be 2^ per cent., that of early operation while the infection is still confined to the appendix is less than i per cent. ; in cases in which a localized abscess has formed the mortaUty of operation is from 5 to 10 per cent., in those with diffuse peritonitis between 10 and 25 per cent. The practitioner is sometimes adx'ised to wait for an interval before operating in cases with mild or subsiding sj-mptoms, but operation in these cases is just as safe as in an interval, and the danger of a sudden exacerbation is precluded. In appendicitis with peritonitis a few surgeons adopt the Ochsner method of treatment (see " Peritonitis "'j. In chronic ap- pendicitis the time of operation may be arranged to suit the conveni- ence of the patient and the surgeon. If a patient has passed through one attack of undoubted appendicitis, removal of the organ is recom- mended because of the danger of subsequent attacks; this ad^■ice becomes progressively stronger with the number of attacks which have been experienced. Operation in clean cases, i.e.. early in an attack, during an inter- val, or in chronic cases, is as follows: The abdomen may be opened by an incision through the outer border of the right rectus muscle, beginning at the level of the umbihcus and extending downward two or more inches, according to the amount of room desired. In the ABDOMEN 771 McBurney method no nerves or muscles are divided and subsequent hernia is practically impossible. A two or three inch skin incision is made in the direction of the fibers of the external oblique, the center of the incision being about one and one-half inches from the anterior superior spine of the ilium on a line to the umbilicus. The libers of the external oblique are separated and retracted, likewise the Fig. 440. — Intermuscular incision. Pig. 441. — Ligation of mesqappendix. fibers of the internal oblique and transversalis muscles, which run almost at right angles to the superficial wound (Fig. 440) . The trans- versalis fascia and peritoneum are severed in the same direction as the internal oblique. Before dealing with the appendix the adjacent intestine, the hernial rings in the immediate vicinity, the ureter, Pig. 442. — Inversion. The hemostat and hands are not shown. and in the female the pelvic organs should be palpated. The appendix may be hooked up as the finger is brought out of the pelvis. In other cases it will be necessary to identify the cecum, and follow the anterior longitudinal band, which always leads to the base of the appendix. If adhesions are encountered, they should never be separated without protecting the general peritoneal cavity with 772 ' MANUAL OF SURGERY gauze, as they may harbor a focus of suppuration. The mesoappen- dix is perforated close to the cecum with an aneurysm needle, armed with catgut (Fig. 441) ligated, and divided. Hemostatic forceps are placed on the appendix near its base, to prevent soiling of the wound during amputation, which may be effected by one of a num- ber of different methods. The easiest plan is to crush the base of the appendix with a second pair of forceps, ligate the crushed tissue with catgut, amputate beyond the ligature, and cover the stump with a purse-string inversion suture of silk or celluloid thread, after touch- ing the exposed mucous membrane with carbolic acid, and then with alcohol. Since this method necessitates the strangulation of infected tissue, which is occasionally followed by abscess, the author proceeds as follows The ligated stump of the mesoappendix is buried by means of a Lembert suture of celluloid thread, which is continued as far as the base of the appendix, when the needle is arrested in its passage through the folds that have been raised on each side of the appendix (Fig. 442), and the appendix amputated close to the cecum, theleft thumb being placed beneath the eye half of the needle, the left index finger beneath the distal half, to insure against retrac- tion of the bowel into the abdomen. After inspecting the cut surface, to make certain that there is no bleeding, the needle is pulled through, thus inverting the edges of the wound, the closure being completed with two or three additional stitches. The suture hne is then buried by a second continuous Lembert suture, made with the same thread, and terminated at the point of origin of the first suture. Rarely a bleeding point is observed at the site of amputation, in which event the wound is made dry with an extra stitch before completing the inversion. If the appendix is normal or not sufficiently diseased to account for the symptoms, the kidney and the intraperitoneal organs not already examined should be palpated, which can be done only through a wound large enough to admit the hand. The McBurney incision can be extended by cutting the sheath of the rectus trans- versely and retracting the muscle toward the middle line. At the completion of the operation the peritoneum is closed with a purse- string suture of catgut, one end of whch is passed from within out wards through the transversalis and the internal oblique muscles and used as a continuous stitch to draw these structures together, after which, in a similar manner, it perforates and approximates the ex- ternal oblique. The sheath of the rectus, if severed, is repaired at the same time. The skin is closed with a continuous suture of silk worm gut. Operation for appendiceal abscess is performed through an ABDOMEN 773 incision made owr the mass. If edema of the abdominal wall be found, the abscess is probably adherent to the parietes, and will be opened on cautiously deepening the wound. All that is then needed is to insert a gauze drain and allow the cavity to heal by granulation. If, however, the appendix is loose in the abscess cavity, or can be removed without opening the general peritoneal cavity, such should be done. In other cases the appendectomy should be performed after the wound has healed, when there is no longer danger of infect- ing the peritoneum. If the mass is not adherent to the parietes, it should be isolated from the general peritoneal cavity by gauze pack- ing. A small opening is then made into the abscess by separating the adhesions with the finger, and the pus removed with gauze pads as quickly as it appears. When the pus ceases to flow, the opening is enlarged with the finger, the cavity dried with gauze, and the appendix removed by one of the methods already mentioned, using catgut, however, for the inversion suture, since a non-absorbable suture in these cases may give rise to a troublesome sinus. The cavity is again dried, and. then drained with gauze; the author uses the Mikulicz drain, as described under "Surgical Technic" (chap. iv). After the outer packing is removed, the superfluous portion of the wound is closed with sutures. For operation for diffuse peritonitis following appendicitis see "Peritonitis." The sequelae of operation in abscess cases, or in those complicated by peritonitis, are secondary abscess, phlebitis, intestinal obstruc- tion, fecal fistula, suppuration of the superficial wound, and hernia. The complications of the disease itself have already been given in the paragraph on the "Pathological anatomy." Appendicostomy (Wier's operation) is employed to permit irriga- tion of the colon in chronic dysentery and other ulcerative lesions of the large bowel. The abdomen is opened by a McBurney incision, the mesoappendix ligated and severed, the appendLx sutured to the parietal peritoneum and the skin, the superfluous portion of the wound closed, the appendix opened to make sure that it is patulous (if strictured a Gibson operation, as described under "Colostomy," is indicated) , a ligature applied to prevent leakage, and after several days the protruding part of the appendix amputated. The colon may now be irrigated daily with salt solution, silver nitrate, 1-5000, bismuth and starch water, i dram to the ounce, etc., by passing a catheter through the appendix and introducing a tube into the rectum When the fistula is no longer needed it may be closed by cauterizing the mucous membrane. 774 MANUAL OF SURGERY THE LIVER For injuries of the liver see contusions and wounds of the abdo- men. Abscess of the liver results from direct infection, e.g., through a wound; infection by contiguity, e.g., from a subphrenic abscess; ascending infection through the bile ducts, e.g., in suppurative cholangitis; lymphogenous infection, e.g., in rectrocecal cellulitis and appendicitis (Munroe) ; or from hematogenous infection. In the last instance, which is the most frequent, the bacteria reach the liver by way of the hepatic artery (general pyemia) ; more commonly, by way of the portal vein (portal pyemia) from infective lesions in the area drained by this vein, e.g., appendicitis, rectal affections, suppuration of the pelvic organs, and dysentery or other forms of intestinal ulceration; or, exceptionally, by way of the hepatic vein (retrograde embolism) ; or, in the new-born, the umbiUcal vein as the result of infection of the umbilicus. The pyogenic organisms most frequently found are streptococci, staphylococci, and the colon bacillus. In tropical abscess, which follows amebic dysentery, cultures are frequently sterile, the pyogenic bacteria originally pres- ent having perished with the lapse of time; the pus is thick, chocolate colored, and contains blood, necrotic liver cells, and a few leukocytes; the ameba is absent in 20 per cent, of the cases. Hydatid cysts may suppurate, and actinomycetes, ascarides, distoma, and coccidia are possible but rare causes of hepatic suppuration. Tropical and traumatic abscesses are usually solitary and occupy the right lobe; pyemic abscesses small, multiple, and hence rarely amenable to treatment. The symptoms in acute and pyemic abscesses are pain reflected to the right shoulder, tenderness and enlargement of the liver, oc- casionally friction sounds owing to involvement of the peritoneum, rarely edema of the skin or fluctuation, chills, fever, sweats, leukocy- tosis, perhaps slight jaundice, and sometimes cough from irritation of the phrenic nerve or invasion of the lung. In chronic and tropical abscesses there may be few or no symptoms, and no leukocytosis. In the latter the ameba may be found in the stools. The X-rays may show the enlargement of the liver and, if the abscess is near the diaphragmatic surface, a dome-shaped projection. The abscess may break into the peritoneal cavity, one of the hollow viscera, the pleura, the lung, the pericardium, or into the vena cava or portal vein; or it may point externally through the abdominal wall. The diagnosis may be confirmed by aspiration, the needle being inserted ABDOMEN 775 in the seventh or eighth intercostal space between the axiUary Hnes, below the costal arch in the right nipple line, or posteriorly in the ninth or tenth interspace vertically below the angle of the scapula. One should be j^repared to proceed immediately with operation if pus is found. The treatment is hepatotoviy by the abdominal or thoracic route, depending upon the situation of the abscess. If the former is chosen, the abdomen is opened, usually by a longitudinal incision, below the costal arch. If the liver is adherent to the abdominal wall, the abscess may be opened without danger of contaminating the peritoneal cavity. In the absence of adhesions the peritoneal cavity must be protected by gauze packing. The abscess is located with hollow needle, and opened by passing a knife or a cautery blade along the needle. The abscess is irrigated, and drained with a rubber tube, the free portion of the cavity being slightly packed with gauze. After removing the gauze which protects the peritoneal cavity, the liver below the opening of the abscess may be sutured to the abdominal wall. When the abscess is high on the dome of the liver, the transpleural or thoracic operation is indicated. The ab- scess is located with the needle as directd above, the rib below the needle excised, and, if the pleural cavity is obliterated at this point by adhesions, the abscess opened as previously described. If there are no adhesions, the two layers of the pleura should be stitched together with catgut. Cysts of the liver arising from dilatation of the lymph spaces are called simple serous cysts. They may be single or multiple, large or small but seldom cause symptoms. Polycystic disease of the liver is usually congenital and often associated with cystic disease of the kidneys; almost the whole organ is converted into serous cysts of various sizes. Both these varieties as well as cystic adenoma and dermoids are very rare. Hydatid cysts are considered in the next paragraph. Hydatid cysts are found more frequently in the liver than in any other portion of the body. The general facts concerning these cysts and the composition of hydatid fluid are given in chap. xiii. The symptoms develop slowly. The swelling moves with respira- tion and is seldom painful. When superficial, fluctuation and hydatid fremitus, or thrill, may be obtained; the latter is due to the rubbing together of the daughter cysts. When deeply situated the cyst may be mistaken tor a neoplasm. Pressure on the lung causes dyspnea; on the stomach or bowel, vomiting and indigestion; on the blood vessels, ascites and edema of the legs; on the bile ducts, jaundice, which is rare. Hydatid urticaria and toxemia occur most 776 MANUAL OF SURGERY often after rupture into the periteoneal acivity. Examination of the blood reveals eosinophilia. The X-rays may give the same informa- tion as in abscess of the liver. Aspiration may be used for diagnostic purposes, but only immediately before operation. The cyst may shrink and the contents become inspissated, or it may enlarge, with or without suppuration, and burst in one of the situations just mentioned under abscess of the liver. The treatment is much like that of abscess, except that the germ- inal layer (endocyst) should, it feasible, be peeled out. After protect- ing the abdominal cavity, the cyst is aspirated, opened with the cautery or the knife, the daughter cysts and the endocyst removed, and the cavity drained, after stitching the edges of the opening to the abdominal wall. Small cysts may be completely excised. Sim- ple aspiration and aspiration followed by injections are not recom- mended. Tumors of the liver are usually secondary, hence multiple. Among the primary tumors are carcinoma, sarcoma, endothelioma, angioma, fibroma, adenoma, lipoma, and myxoma. Gummata and thick-walled hydatid cysts may closely simulate neoplasms. When operable the growth may be resected with the knife or the thermo- cautery, after surrounding it with a series of interlocking ligatures of silk or catgut, introduced with a blunt needle. The circulation can be controled temporarily by compressing the vessels at the hilus. As after rupture of the liver (see "Contusions of the Abdomen") hemostasis may be eflfected by tamponage with muscle, omentum, or fat, and a transplant of fascia employed to prevent tearing out of the sutures. When the growth is pedunculated it may be secured extraperitoneally by transfixing its base with long pins, and then removed after constricting the pedicle below the pins with an elastic ligature, which is left in place. Hepatoptosis, or floating liver, is generally a part of splanchnop- tosis. There may be pain, vomiting, and general weakness, with, in some cases, jaundice and ascites. The prolapsed organ may be outlined by palpation. The treatment is that of splanchnoptosis. When other measures fail, the liver may be sutured to the anterior abdominal wall with a blunt needle and silk or catgut {hepatopexy). In partial ptosis, or floating lobe, e.g., the result of tight lacing or cholelithiasis {RiedeVs lobe), the cause should be removed. The floating lobe can be supported by suturing the ligamentum teres or the gall-bladder to the abdominal wall, but this is rarely necessary. Excision of a linguitorm projection also has been done. ABDOMEN 777 In portal cirrhosis of the liver with ascites, attempts have been made (a) to prevent the elTiision of fluid into the j)eritonel cavity by reheving the venous congestion through an artificial collateral circulation between the portal and the systemic vessels f epiplopexy) , or through an anastomosis between the vena cava and the portal {Eck's fistula) or superior mesenteric vein, or between the superior mesenteric and ovarian veins; and (b) to drain the effusion into the subcutaneous or retroperitoneal cellular tissue (by leaving an opening in the peritoneum, by suturing the edges of the opening in the peri- toneum to the cellular tissues, by placing the omentum in the abdominal wall, by silk threads, wire, tubes), or into the veins by anastomosing the internal saphenous vein with the peritoneum. In epiplopexy {Tabna's operation) the fluid is drawn ofT by a puncture above the pubes, and the abdomen opened above the umbilicus. The external surface of the liver and the spleen and the apposed parietal peritoneum are scrubbed with gauze, after which the omen- tum is sutured to the abdominal wall. The wound is then closed, and the freshened intraperitoneal surfaces held together by a tight bandage or adhesive plaster applied to the upper abdomen. About lo per cent, of the patients thus treated are permanently relieved of the ascites, 20 per cent, temporarily benefited. Direct transference of blood, as in the Eck- fistula, aside from its technical difficulties, may cause emboUsm, alimentary intoxication (because the blood does not flow through the liver), or acute general infection (because the intestinal mucosa does not always oppose a sufficient barrier to microorganisms) , hence cannot be recommended. The drainage opera- tions give only transient relief, as the opening is plugged with omen- tum or closed by cicatrization, the foreign body encapsulated, the vein thrombosed. Our own conclusions are as follows: (i) Cirrhosis of the liver cannot be cured by operation; if it could, the operation ought to be performed before the ascites appears. (2) As syphilitic cirrhosis can be greatly benefited or perhaps cured by medical treat- ment, it should, if possible be excluded in all cases before deciding on operation. (3) The diagnosis of the cause of the ascites, which is merely a symptom, is often difficult. The liver may be large or small in portal cirrhosis. In all forms of ascites, it may be pushed up or rotated, and give a diminished area of dulness on percussion, or the ascites may be so great that the size of the liver cannot be de- termined by external examination; hence, (4) unless there are contraindications (serious disease of the heart, lungs, kidneys, or syphilis), all cases should be operated upon early, for the purpose of diagnosis, and with the hope that something may be found that is 778 MANUAL OF SURGERY amenable to surgical treatment. If cirrhosis is present epiplopexy may be performed; if cholelithiasis, the stones (^^ which may be the cause or the result of cirrhosisj should be removed; if chronic pancreatitis, the gall-bladder may be drained; if splenomegaly, (Banti's disease), splenectomy is to be considered. Mayo suggests splenectomy for the purpose of reducing the amount of blood carried to the liver. Xot infrequently the surgeon will find, instead of hepa- tic cirrhosis, tuberculous peritonitis, and less often an ovarian papil- loma, a tumor in the portal region, carcinomatosis of the peritoneum, or capsular cirrhosis (perihepatitis; , in which the liver is covered with a hyaline fibrous tissue resembling the icing on a cake, and in which there is sometimes a similar change in the peritoneum covering the other abdominal organs, in the pericardium, and in the pleural membranes (polyserositis). The difficulty in diagnosis referred to above promises to diminish with the development of X-ray inves- tigations after the production of an artificial pneumoperitoneum. The ascitic fluid is withdrawn by tapping, and the trocar connected, by means of a rubber tube, -with a rubber bag (such as is used in nitrous oxide anesthesia), which holds three or four litres of oxygen. The abdomen is then inflated by slight pressure on the bag (W. H. Stewart) . The oxygen is absorbed within 24 hours. By this method the parenchymatous organs and solid tumors can be demonstrated with great clearness. Biliary cirrhosis without ascites has been treated by cholecystostomy, cholecystogastrostomy, and cholecysto- duodenostomy. Operation is particularly indicated if there is a complicating cholelithiasis or chronic pancreatitis. One must be sure that the condition is biliary cirrhosis, and not hemolytic jaun- dice, since the latter is curable by splenectomy. THE BILIARY PASSAGES Inflammation may attack the bile ducts and the gall-bladder simultaneously or separately. The cause, excluding poisons like phosphorous and arsenic, is always infection, which ascends from the duodenum, or, more often, arrives by way of the blood stream through one of the paths mentioned under ''Abscess of the Liver." The portal vein is the favorite route, because it drains the intestine which, even normally, contains hordes of bacteria. The hepatic artery serves to convey the microorganisms to the liver in systemic infections, e.g.. typhoid, pneumonia, influenza, septicemia, and pyemia. In hematogenous infection the bacteria are deposited directly from the blood, e.g., in the walls of the gall-bladder, or are ABDOMEN 779 excreted with the l^ile and descend to the affected part. The or- ganisms most freciuently found are the colon bacillus, the tyjihoid bacillus, the paratyphoid bacillus, and the ordinary pyogenic bac- teria, especially the streptococcus. Bacteria excreted by the liver may produce no evil effects, unless there is local irritation, e.g., from a stone, or obstruction to the ducts, which obstruction may be in- trinsic, e.g., from stones (the most frequent cause), plugs of mucus, inspissated bile, ])seudomembrane, inflammatory swelling of the mucosa, stricture, or animal parasites, or extrinsic, e.g., from pan- creatitis, lymphadenitis, adhesions, tumors, aneurysm, or prolapse of the kidney or liver leading to kinking of the ducts. Obstruction is rarely due to congenital absence or atresia of one or more of the biliary passages. Cholangitis, or inflammation of the biliary ducts, may be acute (catarrhal or suppurative) or chronic. Acute catarrhal cholangitis {catarrhal jaundice) is dealt with by the physician and need not be discussed here. Suppurative cholangitis causes the same symptoms as septicemia or pyemia, with an enlarged and tender liver and a varying degree of jaundice. The treatment is that of pyemia, with the removal, if possible, of any obstruction to the flow of bile, and drainage of the gall-bladder or common duct. Chronic catarrhal cholangitis may follow the acute form, but is usually the result of obstruction of the bile ducts. The symtoms are persistent jaundice, in many cases recurring attacks of fever associated wdth sweats {Charcot^ s intermittent fever); and often enlargement and tenderness of the liver, with asthenia and emaciation. The complications are suppurative cholangitis, dift"use hepatitis, abscess of the liver, cirrhosis of the liver, pylephlebitis, chole- cystitis, perforation of the ducts, pancreatitis, endocarditis, pleurisy, pneumonia, and other septic maladies. The treatment is removal of the cause when possible, and drainage of the biliary ducts by one of the operations to be described later. Cholecystitis, or inflammation of the gall-bladder, is, in the majority of cases, associated with gall-stones, either as the cause or the result. As wdth the appendix the pathologic changes depend upon the virulence, depth, and duration of the inflammation, and the complications. Acute cholecystitis of the catarrhal variety may subside if there is no interference with biliary drainage, or eventuate in one of the varieties to be mentioned below\ Acute interstitial cholecystitis, in which the outer walls also are invaded, is more apt to cause per- manent trouble, and, if suppurative, may lead to intramural ab- 780 MANUAL OF SURGERY scesses. Suppurative cholecystitis is often caused or complicated by obstruction to the cystic duct, if not by a calculus, by inflammatory swelling or a plug of mucus; as a consequence the gall-bladder is distended with bile, mucus, and pus {empyema of the gall-bladder) . Ulcerative cholecystitis may follow, or ulceration may arise from the pressure of a stone. In these cases perforation may take place, either into the general peritoneacal cavity, or more often after the formation of adhesions (pericholecystitis), which, likewise, may result from any nonperforative infection of the gall-bladder that has progressed beyond the mucous membrane. In suppurative pericholecystitis the abscess may extend up in front of the liver (subphrenic abscess), or empty into the free peritoneal cavity, the stomach, the intestine, or rarely through the abdominal wall, thus resulting in an internal or an external bihary fistula. Nonperforating ulcers may, by cicatrization, produce strictures of the cystic duct, similar deformities of the gall-bladder, and occasionally, when the contraction is universal, total obliteration of this organ (cf. *' Ob- literating Cholecystitis" below). Gangrene is caused by virulent infection or ischemia, or both. Ischemia is due to over distention of the gall-bladder, or thrombosis or other form of obstruction to the blood supply. A large calculus in the cystic duct may, by damming up the secretions and pressing upon the cystic artery, be responsible for both forms of ischemia. The gangrene is of the the moist variety and the contents of the gall-bladder are mixed with blood. Pseudomemhraneous cholecystitis is very rare. Chronic cholecystitis of the catarrhal variety is often accompanied by enlargement of the glands of the mucosa, forming papillary projections, the apices of which become eroded and stained with bile (strawberry gall-bladder). Sometimes these glands hypertrophy to such an extent as to justify the term papillomatous cholecystitis, and occasionally one or more may become distinctly polypoid {papil- loma of the gall-bladder) ; in these cases cancerization is a possibility. Prolonged obstruction of the cystic duct with chronic catarrhal cholecystitis, i.e., without serious infection, leads to distention of the gall-bladder with mucoid fluid, the bile having been absorbed (hy- drops cystidis felleci). Dilatation of the common and the hepatic ducts follows, for the reasons given under "Cholecystectomy." Chronic interstitial cholecystitis converts the normal net-like rugae of the mucosa into prominent ridges of scar tissue and causes fibroid thickening of the whole wall, which is sometimes followed by great contraction, the gall-bladder being reduced to a fibrous cord (ob- literating cholecystitis). In this event, as in hydrops, the common and the hepatic ducts may become permanently dilated. ABDOMEN 781 The symptoms of cholecystitis with and without calculi are so nearly alike that the two conditions cannot be differentiated, hence the symptomatology of "gall-bladder disease" is considered under "Cholelithiasis." The treatment of acute catarrhal cholecystitis is medical, espe- cially when the condition arises in the course of some general disease like enteric fever and is not associated with severe symptoms. Should the symptoms persist, however, or become severe, operation will be demanded. The indications for cholecystostomy and chole- cystectomy in cholecystitis are noted in the sections dealing with these operations. Cholelithiasis (gall-stones) is found in from 5 to 10 per cent, of all autopsies. It is due to one of the following conditions: (i) infection, (2) bihary stasis, (3) hypercholesterinemia. Which of these is the primary or predominating cause is a matter of dispute, and doubtless varies in individual cases, (i) Infection may reach the gall-bladder in three ways (cf. "Inflammation" at the begin- ning of this section), (a) Ascending infection through the common and the cystic ducts accounts for the etiologic importance of duod- neal catarrh and ulcer in the formation of gall-stones, (b) In des- cending infection the bacteria descend with the bile from the liver, to which they are carried by the hepatic artery in general bactere- mia; or, more frequently, by the portal vein from the intestine in constipation (colon bacillus), or from infective lesions in the area drained by this vein, notably appendicitis and inflammatory proc- esses in the female pelvis, (c) In what may be termed direct hematogenous infection the microorganisms pass through the cystic artery, and are deposited in the walls of. the gall-bladder. Infection can reach the gall-bladder, by one or all of the routes just mentioned, in intestinal diseases associated with bacteremia, e.g., typhoid fever, which, not infrequently, is complicated by cholecystitis and followed by gall-stones. No matter what the source of infection, catarrhal inflammation produces an increased flow of mucus and desquamation of the epithelial cells, the protoplasm of which degenerates and forms cholesterin, which may unite with other constituents of the bile (bilirubin, calcium salts) in varying proportions (vida infra). (2) Biliary stasis may be due to obstruction, the causes of which are listed under "Inflammation" at the beginning of this section. In other cases the bile stagnates or flows slowly because of defective propulsion. Pericystic adhesions and inflammatory rigidity of the walls of the gall-bladder interfere with its contractions. Senescence probably weakens the muscular coat of the gall-bladder; patients 782 MANUAL OF SURGERY coming to operation are usually over forty. Sedentarj^ habits, tight lacing, and large abdominal tumors, including the pregnant uterus, all hinder abdominal respiration, hence the free flow of bile; these conditions, with the greater frequency in women of con- stipation, pelvic infections, and ptosis of the liver and kidney, which may kink the cystic or common ducts, explain why 75 per cent. of the patients are female. Pregnancy not only favors biliary stasis, but is associated with hypercholesterinemia. and may be followed by infection, consequently 90 per cent, of these female patients have borne children. (3) Hypercholesterinemia may result from faulty metabolism, excess of meat. fat. eggs, and fish in the diet (hence the patients are usually stout), pregnancy, lactation, syphilis, tuber- culosis, nephritis, diabetes, arteriosclerosis, malignant tumors, and acute infectious diseases. Those who put most emphasis on the importance of an increased amount of cholesterin (cholesterol) in the blood and the bile think that inflammation is more often the result than the cause of gall-stones. It is true that in more than 50 per cent, of the operations for cholelithiasis, the contents of the gall-bladder are sterile, but in many of these the bacteria orig- inally present have disappeared, lea\'ing the stones. The stones are almost always formed in the gall-bladder, seldom in the biliary ducts, although they may be transported to the latter situation. The nucleus of a stone, when present, is generally a mass of bacteria or desquamated epithelial cells, rarely a blood clot or other foreign body. There may be a single stone or many hundreds of stones. When multiple they are faceted from mutual pressure. The size varies from that of a scarcely visible particle up to that of a goose egg. They are composed of cholesterin, calcium salts, or bile pigments, or, more often, of various com- binations of these substances. Five forms may be noted, (i) The cholesterin-hiliruhin-calcium stones with the cholesterin predominat- ing, are those usually found in the gall-bladder. They are often soft and friable, and may be round (if single) , tetrahedral, or pre- senting multiple facets. A barrel-shaped concretion may be formed in the ducts. The appearance varies with the constituents. If there is a shell of cholesterin the stone is smooth, grey, pearly, and shining; if of bilirubin-calcium, greenish-brown; if of carbonate of calcium, hard, white, and smooth or nodulated. On section the stone shows alternating light and dark concentric laminae. There is often a soft and greasy nucleus. Stones of this sort are said to occur when infection is the primary cause. (2) Pure cholesterin stones are found chiefly in the gall-bladder and common duct. They ABDOMEN 783 are greasy, light in weight, round or oval, smooth or nodular, clear or slightly yellowish, moderately soft, and almost translucent. The cut surface glistens and shows radiating striations. These calculi are the result of obstruction, grow slowly, and may take years to reach the size of a cherry. (3) Pure hiliruhin-calcium stones are dark green or black, hard, nodular, occasionally spiculated, often numerous, and seldom larger than a pea. They are usually formed in the smaller ducts of the liver. (4) Pure calcium carbonate stones (small, white, hard, heavy, and nodular) and (5) pure bilirubin stones (small, friable, round or angular, yellow, green, or black, and light in weight) are very rare. The symptoms vary with the position of the stones and the condition of the biliary apparatus, and these variations will be described after a general consideration of the clinical features of cholelithiasis. The symptoms are caused by inflammation or obstruction, or both. The most important local symptoms of inflammation are pain, tenderness, and rigidity of the upper right rectus; the general symptoms, those of sepsis. The chief local symptoms brought about by obstruction are pain, tenderness, and swelling of the gall-bladder, liver, pancreas, and indirectly the spleen; the general changes, those of jaundice. Reflex gastro- intestinal disturbances may be due to either inflammation or ob- struction in the biliary tract. Biliary colic is caused by acute transient obstruction of one of the ducts, usually the result of the passage or the attempted passage of a stone or plug of mucus, but sometimes the result of other causes, e.g., inflammatory sw^elling of the mucosa, parasites, distension of the duodenum, and kinking of the ducts from adhesions or ptosis of the liver or the kidney. In a severe case there is sudden excruciating pain in the epigastrium or the right hypochrondrium, which radiates to the back and the right shoulder, and is accompanied by vomiting, sweating, and sometimes collapse. Death is possible, but rare. Intestinal paraly- sis is an occasional concomitant. The attack lasts from a few hours to several days, the pain leaving as suddenly as it came, if the stone passes or which is more frequent, drops back into the gall-bladder. Gradual onset and slow subsidence indicate a lodged stone. Jaundice may follow in from 12 to 24 hours or longer, from the passage of the calculus through, or its retention in, the common duct, or from inflammatory obturation of this canal. Typical biliary colic occurs in about 25 per cent, of the cases of cholelithiasis. Between the attacks there may be complete relief; or, if there is a lodged stone or a chronic cholecystitis, dull pain radiating from 784 MANUAL OF SURGERY the right hypochondrium to the epigastrium, around to the back and up to the right scapula. In these cases tenderness may be elicited between the ninth costal cartilage and the umbilicus (Robson's point. Fig. 376), or by pressing the hand well up beneath the right costal arch and asking the patient to take a full breath, which is abruptly checked by acute discomfort. The gall-bladder, when enlarged and distended, may be felt immediately below the ninth costal cartilage, or, if the liver is enlarged, at a lower point. The swelling is smooth, oval, tense, and moves with respiration; dulness on precussion is seldom present unless the tumor is very large. Gall-stone crepitus on manipulation of the gall-bladder is a surgical curiosity. Jaundice is a symptom of cholelithiasis in only 20 per cent, of the cases. The color of the skin varies with the degree of the obstruction, from a light lemon yellow in catarrhal jaundice, to a deep olive or bronzed hue in chronic complete oc- clusion of the choledochus. Recurring jaundice is produced by only two diseases, cholelithiasis and chronic pancreatitis, and in the latter the icterus is generally remittent rather than intermittent. The important phases of obstructive jaundice from a surgical stand- point are its effects on the gall-bladder (vide infra) , the liver (swell- ing, cirrhosis, degeneration, and, if there is infection, cholangitis, and possibly abscess), the pancreas (pancreatitis), the spleen (en- largement secondary to hepatic cirrhosis), the kidneys (choluria. cholemic nephritis, although the latter is probably due more to infection than to the elimination of bile), the stools (clay colored from lack of bile and increase of fat), and the blood (spontaneous bleeding, difficult and uncertain hemostasis after operation, cholemia). Cholemia refers to the toxic effects of icterus. The clinical features are somewhat similar to those of acute yellow atrophy of the liver. The patient has a dry tongue and fever, becomes stupid or delirious, and succumbs in coma, occasionally preceded by convulsions. In many of the cases, however, the cause of the symptoms is a mixed one. since there are at least three sources for the toxemia, the liver (cholemia) , the kidneys (uremia) , and the infection (septic intoxication or septicemia), the last of which is, in itself, capable of producing hemolysis and jaundice. The gas- trointestinal symptoms are indigestion, pylorospasm, cardiospasm (vide infra), and intestinal paralysis from biliary colic (vide sapra) or peritonitis. Gall-stone ileus has been described under " Intestinal Obstruction. " Examination of the stomach contents may reveal hy- perchlorhydria, but in many cases the amount of hydrochloric acid is normal or below normal. By means of the duodenal tube Lyon aspi- ABDOMEN 785 rates the contents of the duodenum which can then be studied chem- ically, bactcriologically, and eytologically. Visible bile cannot be recovered from the fasting duodenum. If 100 c.c. of a 25 per cent, solution of magnesium sulphate are injected through the tube the common duct sphincter relaxes and the gall-bladder contracts, after which the first specimen of bile obtained comes from the common duct, the second from the gall-bladder, and the third from the liver. In choledochitis and cholecystitis the bile is viscid from an excess of mucus, turbid from pus and epithelial cells, and contains bacteria. In cholelithiasis there may be, in addition, crystals of bile salts (Lyon). The blood may show a leukocytosis (in infection), an increase in the coagulation time (in jaundice), or hypercholesterin- emia. An increase in the cholesterol content of the blood, i.e., above 200 m.g. in 100 c.c. , occurs in so many conditions, other than gall- stones (vide supra) , that the value of this test is much impaired . The urine may show bile (in jaundice) or albumen and casts (in nephritis) . The stools are clay colored in duct obstruction, because of the lack of bile and an increase of fat. Sometimes a gall-stone is found; if faceted it indicates that other stones have been or are in the biliary tract. The X-ray density of gall-stone shadows depends upon the amount of calcium salts present. A ring like shadow indicates a calculus with a shell of calcium salts. Pure cholesterin stones are less dense than the bile and give the same appearance as bubbles of air. A thick walled gall-bladder or, after a barium meal, an internal fistula can sometimes be demonstrated in a skia- gram. Owing to the number of cases (50 per cent.) in which the stones do not show, X-ray examination in cholelithiasis is of value chiefly to exclude other conditions, e.g., renal calculi, gastric or duodenal ulcer. The clinical features of cholelithiasis vary according to the state of the bihary tract, and particularly according to whether the calcuH are in (i) the gall-bladder, (2) the cystic duct, (3) the upper or (4) lower common duct, or (5) the hepatic duct. I. Stones in the gall-bladder (a) without symptoms may occur, so long as there is no inflammation or obstruction. However, the number of such cases, at one time thought to be large, is diminishing rapidly since so-called digestive disturbances are more often investi- gated by operation, (b) Chronic cholecystitis, with or without calculi, gives rise to "qualitative food dyspepsia," which occurs after eating fatty and gas-producing foods. Thus the common duct may be compressed by the distended duodenum, and the subsequent expan- sion of the gall-bladder causes pain (C. H. Mayo). Physiologic dilatation of the gall-bladder, owing to the increased secretion of 786 MANUAL OF SURGERY bile after meals, also may cause distress. Reflex pylorospasm leads to vomiting which relieves the pain. Cardiospasm is much less frequent. Severe bihary colic is generally due to stones, mild colic from the passage of plugs of mucus or thick bile. In about one-third of the cases of chronic cholecystitis, calculi are absent. Pericystic adhesions, likewise, may cause colic after distension of the gall bladder, or, according to their attachments, after distension of the stomach, duodenum, or colon. W. J. Mayo states that in simple gall-stone colic the pain is felt in the epigastrium, and that pain in the region of the gall-bladder is an indication of disease of the walls of this viscus; when this occurs the patient does not obtain complete rehef between attacks. Tenderness can almost always be elicited over the gall-bladder, which is sometimes covered by a linguiform projection of the anterior edge of the liver (Riedel's lobe). Remote lesions, like endocarditis and arthritis, have been attributed to chronic cholecystitis. The disease may be confused with gastric or duodenal ulcer, intestinal colic, chronic appendicitis, floating kidney, and epigastric hernia, (c) Carcinoma of the stone-containing gall- bladder is hard, uneven, and only slightly painful. There are at first digestive disturbances, and, later, cachexia, and jaundice and ascites from invasion of the portal glands. 2. Stone in the cystic duct or pelvis of the gall-bladder, causing obturation, may be associated with (a) acute cholecystitis, (b) empy- ema, (c) gangrene, or (d) hydrops, (a) Acute cholecystitis (catarrhal and interstitial) is accompanied by pain, tenderness, and muscular rigidity in the region of the gall-bladder, which is distended and often palpable. Vomiting and constipation are usually present. Jaun- dice may occur from extension of the inflammation to the other ducts, or from the pressure of a large stone or lymph gland on the common or the hepatic duct. There is fever with leukocytosis. The disease is most often confounded with acute appendicitis, occasionally with one of the other conditions resembling appendicitis (q. v.). (b) In empyema of the gall-bladder the symptoms are the same in kind but of greater degree. Palpation of the gall-bladder may be impossible owing to the muscular rigidity. Perforation, with pericystic abscess, is usually not diagnosticated before operation. Perforation into the free peritoneal cavity causes a generalized peritonitis with biHous ascites. Bilious ascites without a discoverable leak in the biliary tract has been attributed to a microscopic perforation, a perforation that has closed, rupture of the intrahepatic ducts, postperitoneal rupture of the common or the hepatic duct, with subsequent rupture into the peritoneum, or to filtration of the bile through the walls of the ABDOMEN 787 gall-bladder or ducts (Buchanan), (c) Gangrene may be suspected if the pain suddenly abates and the other symptoms persist and grow worse, but as a rule the condition cannot be differentiated symptoma- tologically from empyema, (d) Hydrops cystidis felleae may present no symptoms except the tumor. However, pain and Riedel's lobe may be in evidence. The swelling may be mistaken for a floating kidney or a renal tumor, especially hydronephrosis, which may be globular and give no urinary changes. An enlarged gall-bladder is more movable from side to side, immediately returns when depressed toward the back, merges with the liver, both on percussion and palpa- tion, and does not extend through to the loin. The upper end of a renal tumor can often be felt and the hand pushed in between the kidney and the liver. The kidney springs from the loin and is crossed by a band of tympany (colon). Further differentiation is often possible by means of the ureteral catheter and pyelography. 3. Stone in the upper common duct causes (a) acute or chronic (b) incomplete or complete obstruction, (a) Acute transient obstruc- tion produces typical biliary colic, with transient jaundice, (b) Chronic obstruction due to stone is usually incomplete and often inter- mittent, hence the jaundice varies in intensity in different individuals and frequently in the same individual. The color is yellow and never, as in malignant occlusion, olive green or deep brown. Accord- ing to Mayo about 30 per cent, of the patients are without jaundice when they come under observation. The pain and tenderness are near the middle line. Chills, followed by high fever, and sweating [Charcot^ s intermittent fever) occur at irregular intervals, owing to an increase in the cholangitis induced by movements of the calculus or temporary inflammatory obturation. Emaciation is often a promi- nent feature. The liver and sometimes the spleen are enlarged. The ducts above the obstruction dilate, and may become varicose or form cystic diverticula. Such cysts, when in the extra hepatic ducts or when presenting on the surface of the liver, may rupture, causing a bilious ascites (vide supra). Rarely does a cyst of this character attain a large size, although an enormous dilatation of the biliary passages, forming a cavity the size of a child's head, has been reported. The gall-bladder is at first distended, but later, in 80 per cent, of the cases, it grows smaller and smaller, because of chronic inflammation, and because the obstruction is often incomplete or intermittent and the bladder is constantly contracting to empty itself. (c) Complete obstruction is almost always due to tumor, generally a carcinoma of the pancreas or the stomach. However, stricture from gall-stone ulceration or choledochotomy and accidental ligation 788 MANUAL OF SURGERY of the common duct during a cholecystectomy sometimes occur. Obstruction due to carcinoma presents a marked contrast to that due to stone. In the former there is persistent deep green or brown jaundice, with no fever, and slight pain. The gall-bladder is usually distended, whereas in chronic stone obstruction it is usually shrunken {Courvoisier's hvw). 4 . Stone in the lower common duct presents the same symptoms as in the upper common duct, except that pancreatic involvement is much more likely to occur. A stone in the ampulla of Vater may cause pancreatic stasis, and regurgitation of infected bile into the pancreatic duct; in the pancreatic segment of the choledochus, pan- creatic retention from pressure on the canal of Wirsung. The diseased pancreas itself may, in turn, compress and occlude the com- mon duct. 5. Impaction of a stone in the hepatic duct is very rare. The symptoms are identical with those of occlusion of the common duct except that the gall-bladder is never distended. All of the important complications of cholelithiasis, except pneu- monia and pleural empyema, have been mentioned above. The treatment of hepatic colic is the application of heat and the subcutaneous administration of morphin and atropin. For the medical treatment of cholelithiasis the reader is referred to a text- book on medicine. Gall-stones are unaffected by drugs and the aim of the physician is to cure the catarrhal inflammation and prevent the formation of other stones. Medical treatment is indicated in cases in which operation would be too dangerous because of the presence of some independent affection. In all other cases surgical treatment should be advised. In the early stages removal of the stones is easy and safe; after the development of complications, both the difhculties and the danger are vastly increased. Operations on the biliary passages are greatly facihtated by placing a sand bag beneath the spine, in order to push the liver and ducts forward and allow the intestines to fall away from the field of operation. In the presence of chronic jaundice there is great danger of persistent and uncontrollable hemorrhage. In order to avert this catastrophy, the patient may be given blood by transfusion, or horse serum hypodermatically; Robson advises the oral administra- tion of 30 grains of calcium chlorid daily for several days preceding operation, and 60 grains per rectum for a few days after operation. The same author opens the abdomen through the middle of the right rectus muscle, continuing the incision upwards and inwards along the costal margin as far as the ensiform if more room is desired. Perthes ABDOMEN 789 gains a wide exposure, at the same time preserving the nervous supply to the rectus, by making an incision close to the median line from the cnsiform nearly to the umbilicus, thence outward at right angles as far as the costal margin. In order to prevent retraction the rectus muscle is tastened to its anterior sheath before division, and the rectangular musculocutaneous flap turned up from the pos- terior sheath and the peritoneum, which are opened by an oblique incision. The stomach, the duodenum, the liver, the pancreas, and the appendix should be palpated, unless by so doing there is danger of disseminating infection. After packing off the stomach and intestines, and separating any adhesions which may be present, the gall-bladder and cystic duct may be investigated, and a finger passed through the foramen of Winslow, in order to explore the supraduodenal segment of the common duct. The rest of the operation depends upon (i) the local conditions found and (2) the general state of the patient. The indications for cholecystostomy and cholecystectomy are much debated, hence the statements made below do not agree with the conclusions of all teachers. I. The local condition of {a) the gall-bladder influences the decision considerably with many surgeons. Since, in the absence of complica- tions, the mortality of the two operations is almost equal, and after cholecystectomy the convalescence is quicker and smoother, and the recovery much more likely to be permanent, we remove the gall- bladder in all cases in which the disease is confined to this viscus, unless the difficulties of the operation promise to be so great as to cancel its normal superiority over cholecystostomy. If the symp- toms are those of cholecystitis and the gall-bladder looks normal, it should be excised, if the lymph glands along the ducts are enlarged and there is no lesion in the stomach, the duodenum, or the pancreas to account for the lymphadenitis. We have sutured a stab wound of the gall-bladder, but in a severe laceration would probably perform cholecystectomy, (b) Obstruction of the cystic duct from any cause demands cholecystectomy, unless the patient is very ill, when a quick cholecystostomy should be performed, and the gall-bladder removed after the patient has regained strength, (c) In biliary fistula follow- ing injury to the common duct, and in irremovable obstruction to the choledochus, e.g., from carcinoma, chronic pancreatis, cicatricial stricture, or rarely calculus, the bile may be diverted through the gall-bladder to the skin, the stomach, or the intestine. In chole- dochotomy the gall-bladder is of service in drawing up the common duct, and, if drained, reduces the tension on the suture line in the 790 MANUAL OP SURGERY duct. If the common duct is drained instead of sutured, and a cholecystectomy then performed, there is more risk of dislodging the tube in the common duct and soiling the peritoneum. However, in many of these cases we prefer cholecystectomy to cholecystostomy. In performing cholecystectomy one must be sure the common duct is patent, or can be made so. (d) In suppurative cJiolangitis the gall- bladder and the common duct should be drained, (e) Acute pan- creatitis demands cholecystostomy. In chronic pancreatitis with jaundice the bile may be diverted as in irremovable obstruction to the choledochus. In chronic pancreatitis, with gall-bladder disease and without jaundice, cholecystectomy may be performed. 2. If the patient is in poor condition from any cause, e.g., age, sepsis, or an in- dependent affection, cholecystostomy should be chosen rather than cholecystec- tomy. When gall-stones are discovered during a laparotomy for some other condi- tion, according to the nature of the condi- tion and the general state of the patient, the gall-bladder may be drained or removed. In cholecystostomy the gall-bladder is drawn into the wound, aspirated, an incision made in the fundus, and the stones removed with the linger, forceps, or a scoop. A rubber tube is sutured in the gall-bladder with catgut, the edges of the gall-bladder inverted around the tube by depressing it, Fig. 443.- — A. Mattress su- ture everting the skin. B. f jr "r5 r ""uSt' and a purse-string suture applied to maintain the edges of the gall-bladder. C. Suture through the tube the inversion, thus making a tight joint. and the gall-bladder. , . n 1 . . . , r It is well also to pass a mattress suture oi catgut through the skin around the tube, so as to prevent inversion of the cutaneous margin on which the tube rests (Fig. 443). The tube should be long enough to drain into a receptacle at the side of the bed. When the catgut has been absorbed the tube is ready to be removed. The mortality of cholecystostomy for gall-stones is I to 2 per cent. The biliary fistula left after removing the tube should close spontaneously. A persistent fistula discharging bile is due to obstruction of the common duct; discharging mucus to blocking of the cystic duct; in either case a secondary operation is required. In former days a biliary fistula sometimes followed suturing of the gall-bladder to the skin. Cholecystectomy is preceded by aspiration of the gall-bladder, ABDOMEN 791 if it is much distended. The gall-bladder and the anterior edge of the liver are pulled downward, rotated outward through the wound, and held by an assistant, thus making taut the hepatoduodenal ligament, which is further exposed by drawing up the neck of the gall-bladder with forceps, opened by a small incision, and the cystic duct isolated, clamped with forceps, ligated below the forceps, and divided between the forceps and the ligature. The cystic artery is next treated in the same manner. The common duct should be seen, otherwise there is danger of ligating or cutting it. The peritoneal re- flection from the liver is split on each side of the gall-bladder, and the gall-bladder removed from within outwards by blunt dissection. The peritoneal flaps are then stitched together, any oozing from the liver being checked by sutures or gauze packing. If bleeding is controlled absolutely, drainage may be omitted. If drainage of the biliary apparatus is required, the cystic artery alone may be ligated, and a rubber tube sutured to the end of the open cystic duct with catgut, or a choledochotomy may be performed. The mortality of chole- cystectomy for uncomplicated gall-stones is from i to 2 per cent. Owing to the action of the sphincter at the lower end of the chole- dochus the bile is normally discharged into the duodenum intermit- tently, and accumulates in the gall-bladder during the intervals. After cholecystectomy the sphincter continues to act in this manner, and the extrahepatic ducts dilate until they contain as much bile as the gall-bladder, or, more often, until the sphincter itself becomes dilated (Judd and Mann). Thus is explained the dilatation of the choledochus observed also after obstruction to the cystic duct, and the dilatation of the stump of the cystic duct ("new gall-bladder" that is sometimes found after removal of the gall-bladder). Cholecystogastrostomy consists in the formation of a fistula between the gall-bladder and the stomach; cholecystenterostomy, between the gall-bladder and the duodenum, jejunum, or colon. These operations may be employed in biliary fistula depending on stricture or other permanent occlusion of the common duct; in cancer of the head of the pancreas or common duct leading to chronic jaundice; in chronic pancreatitis with jaundice; and rarely in gall- stone impacted in the ducts, when the common duct cannot be exposed and the patient is in no condition to stand a prolonged operation. The operation is performed by means of the Murphy button or by simple suturing (vide infra). Cysticotomy is incision into the cystic duct, usually for the removal of a calculus which cannot be pushed backwards into the gall-bladder. The duct may be sutured with catgut or drained with 792 MANUAL OF SURGERY a rubber tube. In almost all cases of obstruction to the cystic duct cholecystectomy is the better operation. Choledochotomy is incisioni nto the common duct, for the removal of a stone {choledocholithotoniy) , or for the purpose of drainage in cholangitis. When the stone lies in the supraduodenal portion of the duct, which is about three-fourths of an inch in length and runs in the right edge of the gastro-hepatic omentum, it is brought forward by a finger in the foramen of Wmslow. The portal vein and hepatic artery lie to the left. After opening the hepatoduodenal ligament, the choledochus is incised longitudinally, the stone removed, and a finger or a probe passed up into the hepatic duct and then down as far as the duodenum, to make sure that there are no other calculi. If one is certain that no stones have been left the incision in the choledochus may be closed, and a small gauze drain placed in the vicinity of, but not in contact with, the suture line, so as to provide for leakage, should it occur. The sutures may be inserted before the stone, which acts as a guide, is removed. If the stones are soft, friable, or multiple, or there is a cholangitis, a rubber drainage tube should be passed up into the hepatic duct, sutured with catgut to the incision in the choledochus, and the superfluous portion of the wound in the common duct closed. Crushing of the stone without opening the duct (choledocholithotrity) , or breaking it up by the insertion of a needle, is unsatisfactory, because fragments are often left behind. Occasionally a stone in the common duct may be manipulated back into the gall-bladder; it should never be forced towards the duo- denum. The retroduodenal portion of the common duct is about two inches in length, runs in or on the pancreas, and cannot be palpated without loosening the duodenum and turning it inwards. Stones in this situation may be removed by an incision in the upper portion of the duct, or, when occupying the lower third of the chole- dochus, especially if impacted in the diverticulum of Vater, a duo- deno-choledochotomy may be performed. The anterior wall of the duodenum is opened, and the stone removed by enlarging the papilla, or by incising directly down upon it through the posterior wall of the gut. The incision in the anterior wall of the duodenum is then sutured; it is not necessary to place sutures in the posterior wall. The mortahty of choledochohthotomy is lo per cent. Hepaticotomy, or incision into the hepatic duct, has the same indications as choledochotomy, but is seldom performed. According to the situation of an irremovable obstruction a fistula may be estabhshed between an incision in the liver and the intestine {hepaticocholangioenterostomy), stomach {cholangiogastros- ABDOMEN 793 tomy), or skin {cholangiostomy); between the common duct and the intestine (liiolcdochocnicroslomy), stomach (choledocJwgastroslomy), or skin {cholcdochostomy); or between the gall-bladder and the intestine, stomach, or skin (vide supra). Operations connecting the biliary apparatus with the stomach are to be preferred in irremov- able obstruction, since the bile is not lost, as in an external fistula; there is not the same danger of ascending infection as in an intestinal fistula; and the bile emptied into the stomach does not interfere with digestion. When all the bile escapes externally anorexia and emacia- tion may occur; in these cases the bile can be collected and given by mouth. Eliot mentions the possibility of osteoporosis from pro- longed excessive loss of bile. Choledochoplasty, or the reconstruction of the common duct, may be attempted, instead of the operations just described, when the irremovable obstruction is benign, e.g., a cicatricial stricture. Incision of the stricture is only of temporary benefit. Excision with end-to-end anastomosis is probably the best procedure, when appli- cable. A new duct, can be built with fascia, peritoneum, omentum, or with a flap derived from the gall-bladder, stomach, intestine, or abdominal skin. A rubber tube, to be covered later with omentum, can be sutured into the two stumps of the duct, or into the upper stump and the duodenum (Sullivan). The tube finally passes into the bowel and leaves a fistulous tract. A T-shaped tube, or a tube that gains exit through a vahiilar opening in the duodenum may be employed, the tube being withdrawn when the process of repair is nearly completed. An external biliary fistula can be dissected free except for its inner attachment, and anastomosed wdth the lower portion of the duct, the stomach, the duodenum, or a segment of unilaterally excluded intestine. It has been suggested that an artificial choledochus might be made by transplanting the appendix, or a piece ot artery, vein, or ureter. THE PANCREAS For injuries of the pancreas see "Injuries of the Abdomen." Pancreatitis is due to trauma, hematogenous infection in general, infective diseases, infection from contiguous structuers, and most frequently to ascending infection by way of the duct, as the result of catarrhal inflammation of the duodenum or choleHthiasis. Ob- struction of the duodenal papilla by a stone may cause pancreatic stasis and regurgitation of infected bile; a stone lodged in the pan- creatic segment of the common duct may compress the canal of 794 MANUAL OF SURGERY Wirsung and lead to pancreatic retention, thus predisposing to infection. Archibald says the primary lesion is necrosis of the cells, and that infection is secondary; cultures, excepting of frank abscesses, are usually sterile. He thinks the conditions for the pro- duction of pancreatitis are a chemical change in the bile, resulting in an increase of its salts; and a rise in the pressure in the biliary tract induced by hypersecretion, or by spasm of the common duct sphincter of Oddi ; this spasm may be due to hyperacidity, neighboring ulcers, or sudden blocking of the cystic duct by stone or inflammation (see "Cholecystectomy")- Although the disease may occur at any age, it is most common during or after middle life. Three forms are described, the acute, the subacute, and the chronic. Acute pancreatitis is associated with the escape of pancreatic ferments into the periductal tissues. The trypsin digests the walls of the blood vessels and causes bleeding into the gland. The steapsin splits the fat into glycerin and fatty acids, the former being absorbed, and the latter precipitated with calcium salts. As a consequence there are small yellowish-white patches (fat necrosis) in and on the pancreas, in the omentum and mesentery and occasionally in more remote situations. These disseminated areas of necrotic fat, which resemble, superficially, miliary tubercles or metastatic neoplastic nodules, produce a peritonitis, usually aseptic, occasionally septic. The symptoms are sudden violent epigastric pain, vomiting, constipa- tion, sometimes slight jaundice, frequently distention of the abdo- men, and the usual signs of collapse. Owing to the widespread fat necroses there may be tenderness over the whole abdomen and in one or both loins. Death may occur in from twenty-four hours to one week. Acute pancreatitis may be mistaken for intestinal obstruc- tion, perforation of the stomach or duodenum, acute cholecystitis (which it may accompany), appendicitis, acute gastritis the result of swallowing irritant poisons, and acute infection of the kidney. The progress of the disease is so rapid that the stools and the urine seldom show distinctive signs of pancreatic insufficiency (see "Chronic Pancreatitis"). The treatment is drainage. The abdomen will usually be opened in the median line above the umbilicus for exploration. The pan- creas may be exposed by tearing through the gastrohepatic, or, better, the gastrocolic omentum. A gauze drain may then be inserted into the lesser peritoneal cavity. It is seldom necessary to tie the vessels in the pancreas, as the loss of blood is not the cause of death. The pancreas may be drained also by an incision in the loin, preferably the left, the drain gaining exit below the lower pole of the ABDOMEN 795 kidney. Cholecystostomy is indicated if there be gall-stones or cholecystitis. A few patients have recovered with this form of treatment. Subacute pancreatitis is such from the beginning, or follows the acute form if the patient survives, the symptoms at first being much the same but less severe. At a later period suppuration {suppurative pancreatitis) or gangrene {gangrenous pancreatitis) may occur, with septic symptoms, viz., chills, fever, sweats, rapid emaciation, and frequently diarrhea with foul smelling or bloody stools. If an abscess forms, the sweUing may be detected in the epigastrium or in the loin, or the pus may gravitate to either iliac region. The progno- sis is somewhat less gloomy than in the acute form. The treatment is drainage by one of the routes mentioned above, with the removal of gall-stones and drainage of the biliary passages if there be cholelithiasis. Chronic pancreatitis is characterized by a marked increase in the connective tissue, which causes the organ to become large and hard. The fibrosis is more pronounced between the lobules {interlobular pancreatitis) or in the lobules {interacinar pancreatitis) ; in the latter form, which is less common than the interlobular variety, the islands of Langerhans are involved and glycosuria is present. The islands of Langerhans are supposed normally to manufacture an internal secretion which prevents glycosuria. The symptoms are emaciation, pain after eating, paroxysms of pain and vomiting, and tenderness in the epigastrium. The pain radiates to the interscapular region and towards the left shoulder. The pancreatic point of Desjardin, which corresponds with the duodenal opening of the canal of Wirsung, and which is supposed to be the point of greatest tenderness, is situated from 5 to 7 cm. from the umbilicus on a line running to the right axilla (Fig. 376). Intermittent jaundice, when present, may be due to gall-stones; persistent or remittent jaundice, to the pressure of the contracting pancreatic tissue on the common bile duct. Rarely is it possible to outline the pancreas by palpation. The urine may contain sugar (if the islands of Langerhans are involved), fat, glycerin derivatives (Cammidge's test), calcium oxalate crystals, indican, bile, or leucin and tyrosin. An excess of fat and muscle fiber may be demonstrated in the feces, which are sometimes acid and, even when bile is present, grayish-white in color. When salol is administered by mouth it is not decomposed, and carbolic and salicyluric acids do not appear in the urine {SaJdi's sign) . In most cases the laboratory tests for pancreatic insufficiency are negative, and in many the indurated pancreas is discovered only during a routine exploration 796 MANUAL OF SURGERY in the course of an abdominal operation. The treatment is removal of gall-stones, if present, the nature of the procedure depending, as previously stated, on the situation of the stones and the condition of the patient. However, many surgeons insist that the biliary tract should be drained for a much longer time (one to three months) than after operation for uncomplicated cholelithiasis. In cases of persistent jaundice due to chronic pancreatitis the gall-bladder may be anastomosed with the intestine, or, better, with the stomach. Archibald suggests incision of the common duct sphincter, after duodenotomy. Pancreatic calculi are formed much in the same manner as gall- stones, and pancreatic colic is much like gall-stone colic, except that the pain is below and to the inner side of the gall-bladder and may be reflected to the left shoulder. Pancreatic calculi may be associated with gall-stones or with the various forms of pancreatitis, and some- times cause a retention cyst by damming up the secretion of the gland. In a few instancs they have been removed by operation. Tumors of the pancreas include carcinoma, sarcoma, adenoma, and syphiloma. Primary growths are rare. Carcinoma is the most frequent, and affects chiefly the head of the gland. The symp- toms are indigestion, epigastric pain, emaciation, and in the later stages jaundice, painless swelling of the gall-bladder, enlargement of the liver, and the appearance of a tumor. The signs of interference with the functions of the pancreas already mentioned also may be found. The treatment is symptomatic, although it detected at any early period, excision would be indicated. Cholecystogastrostomy or cholecystenterostomy is sometimes performed for the jaundice. Pancreatic cysts are uncommon, generally arise after middle age, and may be true or false. True cysts arise within the gland and include retention cysts (pancreatic ranula), congenital cystic disease, cystadenoma, hydatids, and hemorrhagic cysts. Pseudocysts are usuaUy effusions into the lesser peritoneal cavity, the result of injury or inflammation, but may, however, communicate with the pancreas and contain a proteolytic and an emulsifying ferment. The symptoms are indigestion, vomiting, and frequently epigastric pain. Other symptoms are due to pressure on environing organs, or to interference with the functions of the pancreas, such as have already been men- tioned. The patient usually emaciates and becomes sallow and weak. When of large size the cyst reaches the abdominal wall be- tween the stomach and the colon, although it may be above the stomach or distend the layers of the mesocolon. It is usually im- movable and at least partly covered by gastric tympany. The ABDOMEN 797 treatment in suitable cases is extirpation. In most instances this is ini])t)ssiblc because of adhesions, and the cyst is sutured to the anterior abdominal wall and drained. THE SPLEEN Splenoptosis {wandering or movable spleen) is usually a part of Glenard's disease, or is caused by enlargement of the spleen. The symptoms are indigestion, vomiting, dragging pain, absence of normal splenic dulness, and the presence in the abdomen of a movable tumor with a marked notch. The chief danger is twisting of the pedicle, which may lead to gangrene of the organ. The treatment is the application of a pad or belt. If this is unsuccessful, the spleen may be removed, or sutured to the abdominal wall {splenopexy) . As sutures are apt to cut out and cause profuse bleeding, a better method is to slip the spleen into a pocket formed by separating the parietal peritoneum from the abdominal wall, the peritoneum being sutured to the abdominal wall at the bottom of the pouch (Rydygier's method). Torsion of the pedicle and gangrene require splenectomy. Abscess may be caused by trauma, extension from neighboring organs, acute infectious diseases, chronic malaria, and pyemia. Chronic suppuration may be due to syphilis, tuberculosis, or actino- mycosis. The symptoms are pain, tenderness, and enlargement of the spleen, with the general symptoms of sepsis. The treatment is the same as for abscess of the liver, or splenectomy if much of the organ is disorganized. Splenectomy has been performed for (A) local and (B) general indications. A. (i) Splenoptosis and (2) abscess are discussed above, (3) wr/'wr/V^under contusions of the abdomen." (4) Spontaneous rupture may occur in typhoidal and other splenic enlargements, and may demand splenectomy in order to stop the bleeding. (5) Tumors are rare, the most frequent being sarcoma. (6) Aneurysm of the splenic artery also is rare. (7) Cysts may be hemorrhagic, serous, lymphatic, dermoid or most frequently hydatid. (8) Idiopathic splenomegaly, which is not associated with marked or characteristic blood changes and (9) malarial hypertrophy are indications for splenectomy only when the local discomfort is great; removal of the spleen has no effect on the malaria. (10) Tuberculosis of the spleen is almost never primary, hence seldom amenable to surgical treatment. B. For the discussion of the medical aspects of the diseases mentioned in this group the reader is referred to a text-book on 798 MANUAL OF SURGERY medicine, (i) Splenic anemia, in which there is enlaigement of the spleen, witii diminution in the number of white and red blood cells, and a reduction in the percentage of hemoglobin, responds favorably to splenectomy, a number of apparently permanent recoveries being on record. (2) In BanWs disease (splenomegaly with cirrhosis of the liver) , which many regarded as a later stage of splenic anemia, splenec- tomy should be considered^ although the results are not so good as in splenic anemia. (3) In several cases of anemia infantum {von Jaksch's disease), which may possibly be an infantile form of splenic anemia, removal of the spleen has been followed by marked immediate improvement. (4) Primary splenomegaly ( Gaucher 's disease) has been treated by splenectomy ten times, with eight recoveries and two deaths. (5) Pernicious anemia may be benefited temporarily by splenectomy. The mortality is about 20 per cent. (6) Hemolytic jaundice is characterized by anemia, jaundice, and splenomegaly. Two forms are recognized, the congenital {Chaufard-Minkowski) and the acquired (Hayem-Widal). In both increased hemolysis is indicated by an excess of urobilin in the urine and the feces, but as the jaundice is non-obstructive there is bile in the stools, and none in the urine (acholuria). The erythrocytes exhibit lessened resistance to hypotonic salt solution, and in the acquired form auto-agglutina- tion. In the congenital type the patients are often more icteric than ill, in the acquired type more anemic than jaundiced. Banti believes he has discovered, in what he calls splenomegalie hemolytique, the connecting link between the two varieties outlined above, but his argument is not convincing. In all forms of hemolysis due to ''hypersplenism," i.e., increased destruction of the red cells by the spleen, removal of the organ has been followed by excellent results. Of 48 operations collected by Elliott and Kanavel only two were fatal. The most important sign, so far as the indications for splenectomy are concerned, is the increased quantity of urobilin in the urine and the feces. The principal contraindications to splenectomy are leukemia; erythremia (Vaquez's disease), in which there is enormous increase in the number of erythrocytes, hence possibly due to " hyposplenism ;" splenomegaly of the congestive type, resulting from cardiac or pul- monary disease; marked cachexia; and dense universal adhesions. The operation, in many cases in group B, should be preceded by transfusion of blood. A long incision is made in the left rectus mus- cle. If more room is needed the incision may be extended upwards and inwards, along the costal margin, to the ensiform; or upwards and outwards along the eighth intercostal space, the cartilages of the ABDOMEN 799 eighth, ninth and tenth ribs being excised, after reflection of the musculocutaneous dap. The Hver and gall-bladder should always be explored, and calculi, if found, removed. The phrenosplenic ligament is tied and divided, the spleen delivered through the wound, and each vessel of the pedicle severed between ligatures. The special complications are injury to the stomach; ligation of the tail of the pancreas with the splenic pedicle, an accident that may be followed by fat necrosis; thrombosis of the splenic vein, which may extend into the superior or the in- ferior mesenteric vein, or give rise to embolism; and gastrointestinal hemorrhage, possibly the result of extension of the thrombosis. The mortality of the operation for all conditions is about 25 per cent. The blood changes after splenectomy vary with the condition of the spleen. In some of the forms of anemia mentioned in group B the blood rapidly regenerates. After removal of a healthy adult spleen, e.g., for injury, there is a reduction in the number of red cells and in the percentage of hemoglobin, an increase in the number of white cells and often enlargement of the lymph glands and the thymus, with tenderness of the bones (the red cells are formed by bone marrow) headache, emaciation, and sometimes rapid pulse, fever, thirst, polyuria, and abdominal uneasiness. These symptoms may last for weeks or months before good health is obtained. The changes may be absent, or at least not so decided, because the compensatory organs (hemolymph glands, thymus, and possibly accessory spleens) at once become active, e.g., in children, or are already doing the work of a spleen whose functions have been destroyed by disease. Extract of spleen, thymus, or red bone marrow, with iron, may be of service in lessening the evil after effects of splenectomy. ABDOMINAL HERNIA, OR RUPTURE The word hernia is sometimes employed in connection with the brain, lung, muscle, or other parts, but when used without qualifica- tion refers to an external abdominal hernia, which is a protrusion of a portion of the contents of the abdomen through an opening in the abdominal wall, the protruded parts being covered at least by skin, and almost always by peritoneum. The term internal hernia is applied to a visceral protrusion through the diaphragm, through an intraperitoneal aperture, e.g., the foramen of Winslow. When the abdominal contents escape through a wound, or when an organ is extruded through a normal orifice, e.g., the uterus thorough the vulva, the condition is called prolapse and not hernia. The causes of hernia are congenital and acquired. Among the 8oO MANUAL OF SURGERY congenital causes are (i) non-obliteration of a normal peritoneal diverticulum, e.g., the funicular process, which precedes the testicle in its descent, and passes along the spermatic cord or, in the fernale, the round ligament; (2) abnormal congenital apertures, ie.g., in the mesentery, diaphragm, linea alba, or linea semilunaris; (3) unusually large nomal apertures, e.g., the umbilical, inguinal, and femoral rings; (4) weakness of the abdominal muscles (often inherited); (5) abnormal length of the mesentery or omentum; and (6) imperfectly descended testicles. Among the acquired causes are (i) those which weaken the abdominal wall, e.g., injuries and operations, degeneration (from senescence, lack of exercise, prolonged illness), and over- stretching the result of intraabdominal swellings;(2) those which increase the intraabdominal pressure, e.g., ascites, intraabdominal tumors, pregnancy, obesity, tight belts, and all conditions which necessitate straining, such as laborious occupations, phimosis, en- larged prostate, constipation, and diseases of the air passages associ- ated with persistent cough; and (3) those which drag on the peritoneum, such as cicatrices and tumors, particularly the subperi- toneal lipoma. Hernia is most frequent in the first year of life, 19.6 cases in every loco individuals according to Berger; it then decreases in frequency until the minimum is reached in the twentieth to the twenty-fourth year, and gradually increases, owing to degeneration of the muscles, as age advances. Hernia is three times more fre- quent in males than in females. In structure a hernia consists of (i) an orifice, (2) a sac, (3) the coverings of the sac, and (4) the contents, i. The hernial orifice, often called the ring, is the opening in the parietes; this opening may be canalicular, e.g., in the inguinal region, and possess an inter- nal and an external ring. 2. The sac is the peritoneal pouch enveloping the contents of the hernia. In the early stages of an ac- quired hernia the sac is thin and funnel-shaped; later it becomes larger, thicker, and more globular. It consist* of a neck and a body, and is formed by stretching and sliding of the peritoneum, hence when a hernia appears suddenly, excluding actual ruptures of the abdominal muscles {traumatic hernia), there must have been a pre- formed (congenital) sac. As the result of irritation or inflammation, from pressure or injury, the sac may become adherent to the contents, or be divided into two (hour-glass) or more saccules or diverticula. It is always adherent to its coverings, hence is irreducible, although the contents may be reducible. Occasionally the sac or a saccule be- comes completely shut ofif and filled with fluid (hydrocele of the sac). As the sac is merely a peritoneal diverticulum it may participate in ABDOMEN 8oi any of the affections of the peritoneal cavity, e.g., ascites, carcinoma- tosis, tuberculosis, acute peritonitis. A peritoneal sac is absent in certain sliding hernias, certain hernias following abdominal operations or injuries, and in most internal retroperitoneal hernias. A slidiuf^ hernia is one in which the ascending or the descending colon slip down through the inguinal canals. As these structures usually have no mesentery the posterior portion of the sac is generally absent. 3. The coverings of the sac vary with the situation of the hernia and are enumerated with the individual forms. 4. The contents may be any abdominal viscus, but only those organs requir- ing special mention are noted below. The sac usually contains small intestine {enterocele) , omentum (epiplocele), or both (enteroepiplocele) . When only a portion of the circumference of the intestine lies within the sac (partial enterocele, or Richter's hernia), the hernia is very small, and if strangulation occurs, the symptoms of obstruction are not complete. Littre^s hernia is a hernia of Meckel's diverticulum. The cecum, with or without the appendix, has been found in even a left femoral hernia {cecocele). As it usually has a mesentery, it generally lies within the hernial sac; but when the mesentery is absent, the cecum may be partly within and partly without the hernial sac, the so-called sliding hernia of the cecum. The bladder may be encountered in a direct inguinal hernia (cystocele). As a rule, the herniated portion of the bladder is partly covered with peritoneum and partly extraperitoneal, but it may be wholly within or without the sac. The condition may be suspected if the bladder is irritable, if the hernia increases in size when the bladder is filled and lessens in size when it is emptied, and if pressure upon the hernia causes a desire to urinate. The diagnosis may be confirmed by injecting water into the bladder, when the herniated pouch will distend; by cystoscopic examination, when the lateral displacement of the vesical wall can be seen; and possibly by filling the bladder with collargol solution and taking a skiagram. The same diagnostic remarks apply to the rare hernia of a vesical diverticulum, which is devoid of muscular fibres. The ovary is normally a pelvic organ, but may be arrested in its descent near the internal inguinal ring, or be raised to this level by enlargement of the uterus (pregnancy, tumors), hence ovarian hernia is most frequent in infants, and in women who have borne children. The swelling is often irreducible, and attempts at reduction cause a sickening pain. The treatment of the condi- tions mentioned above is considered later. Loose bodies, sometimes as large as marbles and probably representing detached appendices epiploicae, are occasionally found in the sac of a hernia. 51 8o2 MANUAL OF SURGERY The signs of an uncomplicated enterocele are: (i) a soft swelling, (2) which is in the usual situation of a hernia, (3) is inseparable from the abdominal wall, (4) has an expansile impulse on coughing, (5) is tympanitic on percussion, (6) disappears, often suddenly and with a gurgle, on recumbency or pressure, (7) when the hernial orifice may be felt, and (8) which reappears when the patient stands or strains. An epiplocele is dull on percussion, feels more doughy, has a less marked impulse, and reduction is more difficult and unaccom- panied by a gurgle. The patient may complain of pain, indigestion, and constipation. The treatment may be palliative (trusses) or radical (operation), but such is best considered with the special forms of hernia. SPECUL FORMS OF HERNIA Inguinal hernia constitutes about 80 per cent, of all hernias; it is much more common in males, because of the larger size of the inguinal canal, the frequency of imperfect closure of the processus vaginaHs, and the influence of strenuous occupation; and, owing to the later descent of the right testicle, which keeps the inguinal canal patent for a longer period, is more often encountered on the right side. A classification of the principal forms of inguinal hernia is given in the subjoined table. 1. Acquired } a. Incomplete I b. Complete (scrotal or labial) 2. Congenital a. Vaginal I b. Funicular I c. Infantile I d. Encysted infantile II. Direct (always acquired) f i. Intraparietal | Intrailiac III. Interstitial (usually congenital) 2. Interparietal | Antevesical [ 3. Extraparietal I. — The indirect or oblique inguinal hernia, enters the internal ring in the external inguinal fossa, external to the deep epigastric artery. It is more frequent on the right side, for the reason given above, and in about one-third of the cases a similar hernia appears, sooner or later, in the opposite inguinal region. I . Acquired indirect inguinal hernia (Fig. 446) , in which the sac is gradually formed from the parietal peritoneum, may (a) distend the inguinal canal only {incomplete inguinal hernia or bubonocele), or it I. Indirect or oblique ABDOMEN 803 may (b) i)ass into the scrotum [scrotal hernia) or, in the female, in- to the labium majus {labial hernia), when it constitutes a complete inguinal hernia (Fig. 444). The coverings of a complete indirect inguinal hernia are the sac, with subperitoneal fat; infundibuliform fascia, derived from the transversalis fascia; cremasteric fascia and. muscle, derived from the internal oblique; intercolumnar fascia, de- rived from the external oblique; deep and superficial fasciae; and the skin. In old cases the internal ring may be directly behind the external ring, simulating very closely a direct hernia. The sac always lies in front of the sper- matic cord. 2. Congenital indirect in- guinal hernia owes its existence to non-obliteration of the funi- cular process of peritoneum. It usually appears at or soon after birth, although it is not, as the term congenital implies, always present at this time, but may -j. occur at any period of life as the Fig. 444. — Complete oblique hernia on the left, bubonocele on the right. Fig. 445. — Double congenital hernia. result of a sudden strain forcing apart the apposed peritoneal layers, indeed, some authors go so far as to attribute practically all hernias to a persistent antenatal sac. The hernia is never gradual in onset but becomes complete at once, and the sac is. invariably -densely adherent to the cord. Inguinal hernia in the female is almost always congenital, the patent tube of peritoneum (canal of Nuck) following the round hgament. (a) In the vaginal form (^Figs. 440 and 447) the bowel passes directly into the tunica vaginalis, surrounding and concealing the testicle, (b) In funicular hernia (Fig. 448), which is the most frequent variety of all inguinal hernias, the funicular process remains patent for a variable distance, 8o4 MANUAL OF SURGERY but is always shut off from the tunica vaginaUs. (c) In infantile hernia (Fig. 449), which is very rare, the funicular process is closed at its abdominal end only, the hernia (in a special sac) passing downwards behind the process or (d) invaginating it {encysted infantile hernia) ; thus there are three layers of peritoneum in front of the hernia (Fig. 450). Any inguinal hernia, but more particu- V V V ^/ ^ Pig. 446. Fig. 447. Fig. 448. Fig. 449. Fig. 450. Fig. 446. — Acquired inguinal hernia. Fig. 447. — Vaginal form of congenitalinguinal hernia. Fig. 448. — Hernia into funicular process. FiG. 449. — Infantile hernia. FiG. 450. — Encysted infantile hernia. Diagram'of herniae. C. Cord. S. Sac. T. Testicle. V. Tunica vaginalis. larly the congenital forms, may be associated with a hydrocele of the cord or testicle. 11.^ — Direct inguinal hernia (Fig. 451) is always acquired, gen- erally appears late in life, is hemispherical in shape, never descends into the scrotum, rarely becomes strangulated, and is bilateral in one-half of the cases. It originates in the internal inguinal fossa, to the inner side of the deep epigastric artery, i.e., in Hesselbach's triangle. The spermatic cord generally lies to the outer side of the hernia, which emerges at the outer side of the conjoined tendon, or splits or pushes that structure before it, thus entering the inguinal canal and appearing at the external ring. When passing to the outer side of the conjoined tendon its coverings are the same as those of in- direct inguinal hernia, except that the transversahs fascia is sub- stituted for the inf undibulif orm fascia ; the conjoined tendon also is added to the coverings when the hernia pushes that structure before it. III.— Interstitial hernia, instead of passing regularly through the inguinal canal, insinuates itself between the layers of the abdominal wall. Over one-half of the cases are cryptrochids. Three forms are described: (i) In properitoneal or intraparietal hernia, the sac Fig. 451. — Direct inguinal hernia. ABDOMEN 805 lies between the peritoneum and tlie transversulis fascia, either extending outwards iiiilra iliac) or inwards (antevesical). If there is also a sac in the scrotum the condition is called hernia en bissac. (2) In intcrparielal Jiernia the sac may be between the transversalis muscle and fascia, the external and internal oblique, or between the external oblique and the transversalis fascia, the other muscles having been pushed aside. (3) Superficial inguinal Jiernia iexlra- parietal) is the most frequent variety. The sac passes through the inguinal canal, thence outwards and upwards along Poupart's ligament, between the external oblique and the skin, or more rarely outwards and downwards beneath the skin of the thigh, thus pre- senting a superficial resemblance to femoral hernia. In any strang- ulated interstitial hernia in which the sac is bilocular, the bowel may be pushed from the superticial into the deeper sac, and the sym.ptoms of strangulation persist after apparent reduction; this is the explana- tion of the so-called reduction en masse, or en bloc, it being very doubtful whether a hernial sac is ever torn from its attachments and reduced w'ith the contents. The signs of an inguinal hernia are those already mentioned in describing the general features of hernia (p. 802). The swelling increases in size from above downwards and the testicle lies below and behind. In the male the external inguinal ring may be felt by invaginating the skin of the scrotum with the index finger; if it enters, the ring is abnormally large. The diagnosis is usually easy, but may be difficult or impossible without operation. In oblique hernia the canal, at least in the beginning, passes upwards and outwards, and in rare instances the deep epigastric artery may be felt to the inner side. Direct hernia occurs in adults, usually stops at the root of the scrotum, has the deep epigastric artery to its outer side, and passes directly backwards through the abdominal wall. The conditions which may be mistaken for inguinal hernia are : I. — Reducible swellings which give (a) an expansile or (b) a nonexpansile (lifting) impulse on coughing. (a) Reducible swellings with an expansile impulse: (i) In femoral Jiernia the orifice is below Poupart's ligament and to the outer side of the pubic spine, in inguinal hernia above Poupart's liga- ment and internal to the pubic spine (Fig. 457). In the former the in- guinal canal remains empty. In inguinal hernia reduction is effected by pushing upwards, outwards and backwards and in femoral hernia, downwards and then upwards and backwards. (2) Con- genital Jiydrocele is translucent, and slowly reducible without a 8o6 MANUAL OF SURGERY gurgle, but is very apt to be associated with a hernia. (3) Varicocele feels like a "bag of worms," is dull on percussion, and reappears from below upwards after compression, even when the finger blocks the inguinal canal. (4) A psoas or other chronic abscess communi- cating with the abdominal cavity fluctuates, is dull on percussion; may be on either side of the femoral vessels, and may be associated with other signs indicating its nature, e.g., kyphosis, mass in the iliac region. If it proceeds from bone the X-ray may show the osseous lesion. (b) Reducible swellings with a nonexpansile impulse are dull on percussion, (i) Subperitoneal lipoma always has the same shape and consistency; it may, however, be the pilot of a hernial sac. (2.) In undescended testicle the scrotum is empty; the swelling is elastic, more or less circumscribed, and gives the testicular sensa- tion on pressure. There is usually, however, a hernia above the testicle. An inflamed or twisted undescended testicle may give symp- toms almost identical with those of strangulated hernia. II. — Irreducible swellings, all of which are dull on percussion, may have a lifting, but never an expansile, impulse: (i) Enlarged inguinal glands are lobulated, and caused by irritation in the area which they drain; the inguinal canal is free. (2) Encysted hydrocele of the cord is translucent, elastic, circumscribed, and cannot be reduced when traction is made on the cord. (3) In hydrocele of the testis the swelling develops slowly, beginning, below and spreading upwards; stands out from the abdomen, from which it may be separated by the fingers; is translucent (unless the walls are very thick, or blood or spermatic fluid be the contents), and not reducible (excepting those which communicate with the abdomen or with a second sac). (4) Hematocele of the cord follows injury and is associ- ated with pain and ecchymosis. (5) Swelling in the lower scrotum, e.g., spermatocele, hematocele, orchitis, tumors of the testicle, etc., are generally readily differentiated from hernia by the freedom of the cord above, and the absence of a swelling in the inguinal canal. The treatment may be palliative or radical. Palliative treatment consists in the application of a truss and the removal of all sources of straining. A year or two of this treatment in children will often result in cure. The younger the child, the greater the chances of cure. A truss consists of a pad for the hernia, held in place by a steel spring, which passes backward on the same side, midway between the crest of the ilium and the top of the tro- chanter, to just behind the anterior superior spine of the opposite ABDOMEN 807 side, whence it is continued with a strap, which is fastened to the pad. A second strap passing beneath the thigh may be necessary to hold the truss in place. The pad may be of vulcanite, rubber, etc., and should be placed over the internal ring in oblique hernia, over the external ring in direct hernia. It should rest on the soft tissues only, and not be so small or so convex as to project into and dilate the opening; the spring should be strong enough to retain the hernia under all strains, but without injurious pressure. In adults the truss is ordinarily worn during the day, being put on before rising and removed after retiring. In young children, in whom there is a chance of cure, the truss should be worn also at night, as a single escape of the hernia, even after months of treat- ment, will cancel all the good which has been done. In irreducible herniae cup or bag trusses are sometimes employed. The radical treatment of inguinal hernia is recommended inall cases after the age of three, if truss treatment has failed, and up to the age of sixty, providing there is no visceral disease to contraindicate operation. The mortality is less than one per cent., recurrence less than two per cent. ; 80 per cent, of the latter occur within the first year. These statements do not apply to enormous hernias, in which the danger of operation is by no means small, and the chances of recurrence very great. Direct hernias also are prone to recur, because of the flabbiness of the muscles, the large size of the orifice, the absence of a canal, and because the sac is often formed partly by the bladder and therefore cannot be completely removed. While a patient with a reducible hernia and a comfortable truss may be offered operation, one with a hernia which is irreducible, which a truss does not retain, which occasionaly becomes incarcerated or inflamed, or which is associated with an undescended testicle or a reducible hydrocele, should be urged to accept radical treatment. Of the many operation? that have been advocated for this purpose only two will be described. Bassini's operation is the one most frequently employed. An incision is made parallel with and one-half inch above Poupart's liga- ment, from the external to just above the internal ring. The super- ficial epigastric and the superficial external pudic vessels are secured, and the aponeurosis of the external oblique divided in the direction of its fibres, from the external ring upwards and outwards, the flaps being separated from the subjacent tissues. The sac is now separated from the spermatic cord by blunt dissection, opened to make sure there are no adherent structures, hgated, as high as possible, with cat- gut, and severed beyond the ligature, the stump retracting into the 8o8 MANUAL OF SURGERY abdominal cavity. The spermatic cord is separated from its bed, and held aside by a blunt hook or loop of gauze while the internal oblique and transversalis muscles, as one layer, are sutured to shelving margin of Poupart's ligament beneath the cord. A suture should be placed also above the cord (Fig. 452) . The cord is now placed on this suture hne and the incision in the external oblique closed. The skin is sutured with silkworm gut, after ligating all bleeding points. Chromicized catgut or kangaroo tendon is used for the buried sutures. In children it is well to seal the wound with collodion before applying the spica of the groin. The scrotum is supported for the first week. The patient remains in bed for two weeks, and should undertake no straining efforts for six months. A truss is not needed after operation. The chief objection to the Bassini operation is that edema of the cord, hydrocele, and orchitis occasion- //VT. OBLIQUE ATRANSVEHSaLIS , ]. • • r FXT. OBLIQUE pouPARJs iiG. ally follow, owmg to the haudhug of the cord and its compression between the layers of the abdominal wall. The author's method combines some of the features of the foregoing and the Ferguson operations, with imbrication of the layers of the ab- dominal wall in a manner which, although devised independently, is much like that previously suggested by Andrews. After incising the skin Fio. 452. — Bassini's operation. i i i- i m- • and the external oblique the ilioingu- inal nerve is retracted , the cremasteric muscle and tascia and the in un- dibuliform fascia are raised from the cord and divided longitudinally, and the sac, which lies immediately beneath, is isolated by gentle gauze dissection, so as to injure the cord as little as possible, and opened. Adherent omentum is divided between ligatures; adherent intestine gently separated, unless the adhesions are dense, when it is better to leave a portion of the sac, thus preventing the raw surface which would otherwise result. A finger is passed into the abdomen, and the internal inguinal ring of the opposite side and both internal femoral rings palpated. The vicinity of the internal ring on the side of operation is now explored for diverticula, properitoneal hernia, and laxity of the peritoneum to the inner side of the deep epigastric vessels (potential direct hernia) . If another hernia is found it may be dealt with through the same incision, if on the same side; or, later, through a separate incision, if on the opposite side. The neck ABDOMEN 809 of the sac, which is recognized by following the peritoneum until it expands l)encath the j^arictcs, where it is covered with properitoneal fat, and by identifying and pushing aside the deep epigastric vessels, is palpated for thickening. If the thickening is soft one should suspect hernia of the bladder or sliding hernia of the colon, conditions in /M 08 LI 00 E S TM us VERSA us EXT. 0BIIQU£^ POOPARTS Og . -" SKi/i ; CO/iO EXT.OBLIQUE Fig. 453. — The transversalis, internal oblique, and external oblique muscles, as one layer, are sutured to Poupart's ligament. Pig. 454. — Alternate deep and super- ficial sutures inserted. EXT. OBLIQUE K'O/iD which the affected viscus may readily be injured in ligating the sac. The parietal peritoneum above the neck of the sac is now transfixed and ligated with catgut, and the stump transplanted upwards and inwards beneath the transversalis fascia, by carrying the ends of the ligature through the fascia and muscles and tying them. This transplantation is particularly in- dicated in sliding hernias and in cases in which the peritoneum to the inner side of the epigastric vessels is lax. The internal ring is made snug by passing one or two sutures through the transversalis fascia above the cord. The canal is closed over the cord, by suturing all the struc- tures on the inner side (transversalis, Fi<^- 455- internal oblique, external oblique) to Poupart's ligament, beginning below and extending up as far as the attachment of the muscles to Poupart's ligament (Fig. 453). The fascia of the external oblique thus acts as a splint for the muscular fibres, which, if sutured alone, tend to separate. The needle should be passed, from without inwards, through the structures on the inner side of the canal, then, from within outwards, through Poupart's ligament while a finger protects the femoral vessels. In order to Imbrication of the external oblique. 8lO MANUAL OF SURGERY secure accurate coaptation alternate deep and superficial sutures are employed, this also prevents the tearing apart of the muscular and fascial bundles that sometimes follows when all the sutures are in- serted in the same plane (Fig. 454). The lower is now sutured up over the upper flap of the external oblique (Fig. 455) and the skin closed. Variations in the operations detailed above, which operations apply particularly to the ordinary acquired form of oblique inguinal hernia in the male, may be desirable or necessary under certain circumstances. In the female the round ligament may be treated like the sperma- tic cord, but as there is some difficulty in dissecting the sac from the ligament, and as removal of the ligament in the inguinal canal permits complete obliteration of the canal, it is better to tie the round liga- ment and the sac together, transplanting the stump to the inner aspect of the abdominal wall as previously described. In congenital hernia in the male (vaginal form) the entire sac, ex- cept the testicular layer of the tunica vaginalis, may be excised, a difficult and tedious proceeding; the upper portion of the sac may be removed, and the opening in the lower portion sutured to form the tunica vaginahs; or, what is more simple, the neck of the sac may be ligated, divided below the Hgature, and the sac turned inside out, as in the eversion operation for hydrocele. Direct hernia is exposed in the same manner as the obhque form, except that instead of incising the infundibuHform, fascia over the cord, the transversalis fascia must be divided in Hesselbach's triangle, the fascia subsequently being overlapped by means of sutures. The internal ring is not concerned in direct hernia, but should be treated as in obhque hernia if it seems too large. The inguinal canal is closed as already indicated for indirect hernia, most operators pre- ferring transplantation of the cord, as in the Bassini operation, in order to fortify Hesselbach's triangle with a layer of muscle. Transplantation of periosteum or fascia lata has been employed in cases in which the hernial orifice is large and the muscular struc- tures atrophied. A pedunculated flap may be turned outwards and downwards from the sheath of the rectus muscle and sutured to Poupart's ligament, or the sheath may be incised and the muscular fibers drawn down to the ligament, but as both these procedures weaken the rectus they are not recommended. In interstitial hernia, in addition to tracing carefully the relations of the sac, it will usually be necessary to deal with an undescended testicle (q.v.). In the only case of preperitoneal inguinal hernia in ABDOMEN 8ll which we have operated, the incision was made in the median Hne, owing to failure to recognize the cause of the obstructive symptoms, and the sac obHterated from within the abdomen. In sliding hernia of the colon there are three dangers to be re- membered. The extraperitoneal portion of the bowel may be incised for the sac. The peritoneal reflections from the bowel may be mis- taken for adhesions, sej^aration of which on the mesial side may result in damage to the nutrient vessels and gangrene of the intestine. When a large hernia of the ordinary variety grows chiefly at the expense of the parietal peritoneum on the outer side of the internal inguinal ring, a small section of the colon, partly covered with peri- toneum, may appear in the neck of the sac, and, being regarded as merely a thickening of the tissues at this point, be ligated with the sac. If one suspects a sliding hernia of the colon the sac should never be opened to the outer side or posteriorly, and never without making certain that only the peritoneum is being divided ; adhesions and thickenings must always be carefully investigated. After incising the sac well to the inner side, the flap of peritoneum thus formed can be wrapped around the bowel and fastened with a few stitches, so as to form a mesocolon. The bowel may then be reduced, and the remaining opening in the peritoneum closed with sutures. In order to prevent recurrence some surgeons advise suturing the herniated bowel to the anterior abdominal wall (colopexy) through a separate incision. Our own practice is to excise the sac, close the peri- toneal opening with a purse-string suture, and transplant the puckered closure in the manner already described for transplantation of the stump of the sac in ordinary oblique hernia, except that the displace- ment is upwards and outwards, instead of upwards and inwards; the herniated colon is thus carried nearer to its normal situation, and fixed to the abdominal wall. Hernia of the bladder, as pointed out in the general remarks on the structure of hernia, may be diagnosticated before operation. In most instances, however, the condition is not recognized until the bladder is exposed, and, in some instances, incised, an extraperi- toneal vesical pouch being mistaken for the sac. In the event of such an accident the wound should be sutured like a wound in the intestine, and a retention catheter passed into the bladder through the urethra. Ligation of a portion of the bladder with the sac like- wise has occurred, urine escaping, after the ligated piece of bladder has sloughed, into the peritoneum or the extraperitoneal cellular tissue. The bladder lies to the inner side of and behind the other contents of the rupture, and is usually covered with a large quantity 8l2 MANUAL OF SURGERY of fat. As a rule, it can be easily recognized by palpation, after opening the sac well to the outer side. The appearance of the muscu- lar fibres is distinctive, but they may be absent in a diverticulum of the bladder. If there is tloubt, the bladder may be distended or a sound passed into it. A vesical diverticulum should be excised, but a protrusion consisting of all the coats of the bladder should be reduced, and, after transplanting the neck of the sac upwards and inwards, the inguinal canal closed in the usual manner. A herniated ovary, Fallopian tube, or uterus should be reduced if healthy, removed if diseased. Femoral hernia (Fig. 456) constitutes 10 per cent, of all hernias, and is more frequent in females owing to the larger size of the crural canal, consequent upon the wider pelvis, but even in females it is less common than the inguinal variety. The hernia passes along the femoral canal and protrudes through the saphenous opening. The internal ring is formed by Poupart's ligament in front, the pectineal line and fascia behind, Gimbernat's ligament on the in- side, and the inner septum of the femoral sheath on the outside. The external ring is formed by the saphenous opening. Occasionally the obturator artery arises from the deep epigastric and passes along the edge of Gimbernat's ligament. The coverings of a femoral hernia are peritoneum, septum crurale, anterior layer of the femoral sheath, cribriform fascia, deep and superficial fasciae, and the skin. After the hernia has passed through the saphenous opening, it is bent at an angle, and usually passes upwards and outwards, because of the attachment of the deep layer of the superficial fascia. The signs are those of other forms of hernia (p. 802) . The swell- ing is seldom large, and, owing to the amount of fat on the sac, is usually more or less lobular, and may still be perceptible even after reduction of the contents. The neck lies to the inside of the femoral vessels, to the outer side of the pubic spine, and below Poupart's ligament. The diagnosis is facilitated by determining the exact situation of the swelling. (Fig. 457). The distinguishing features of inguinal hernia, enlarged glands, lipoma, and psoas abscess are given under the Diagnosis of Inguinal Hernia. An iliopsoas bursa limits extension Fig. 456. — Femoral hernia. ABDOMEN 813 of the hip appears outside the femoral vessels and is dull on percus- sion. Wirix of the saphenous vein at the saphenous opening has all the signs of an enteroccle, except that it is dull on percussion. How- ever, the walls of a sacular venous dilatation are thin (not thick and fatty) and the contents fluid. The swelling may be reduced, but with a thrill instead of a gurgle, and it reappears from below upwards, even when the linger blocks the femoral canal. The veins below are often dilated, and if one taps on them a wave can be felt in the tumor, and vice versa. Obturator hernia lies deep under the adductor mus- cles and is very rare (vide infra). POUPARJS I/O 4NT CRURAL NERU : FEMORM VESSELS. ^ ..,1<;^^, / ; S/lFNfA'OUS VE/V. ^%x%S^n/" ; \£XT.//VG.R//VG. ^ ^ J^ci ^'^ '•. CORD. Fig. 457. — Situation of swellings in the groin, (i) Inguinal hernia. (2) Femoral hernia; saphenous opening. (3) Obturator hernia. (4) Iliopsoas bursa. (5, 5, 5) Inguinal lymph glands. (2 and 6) Femoral lymph glands. The treatment may be palliative, a truss somewhat similar to that used for inguinal hernia being employed, except that the pad rests over the femoral canal at the level of Gimbernat's ligament. The operative treatment is simple, safe, and satisfactory. Bas- sini's operation is as follows: An incision, parallel with and below Poupart's ligament, is made over the sac, which is isolated, opened, and ligated as in inguinal hernia. Poupart's ligament is then sutured to the pectineal fascia, to close the internal ring, and the plica falci- formis of the fascia lata is sutured to the pectineal fascia, thus closing the canal (Fig. 458). Care should be taken not to injure or compress the femoral vein. In cases in which there is a coexisting inguinal and femoral hernia, the latter can be dealt with through the inguinal canal. Indeed 8l4 MANUAL OF SURGERY some operators prefer the inguinal route for all cases of femoral hernia, pointing out that, when approached from above, the sac is more certain to be removed in its entirety and the internal femoral ring more efifectively sutured. The inguinal canal is opened as for inguinal hernia; the round ligament or spermatic cord retracted upwards; the transversalis fascia in Hesselbach's triangle incised parallel with and close to Poupart's ligament, care being taken not to injure the deep epigastric vessels; the peritoneum opened; the sac drawn from its canal by steady traction, aided, if need be, by snip- ping the border of Gimbernat's ligament, or, in cases in which the sac is closely adherent beneath the skin, by undermining the lower edge of the cutaneous incision; the sac excised after ligation of its neck; the internal femoral ring obliterated by passing sutures through Cooper's and Poupart's hgaments; the transversalis fascia sutured; and the inguinal sac closed as in the operation for inguinal hernia. POUPARTS LIG FEMORAL VESSELS PLICA FALCIFORMIS SAPHENOUS VEIN Fig. 458. — Bassini's operation for femoral hernia. Umbilical hernia represents 5 per cent, of all hernias. There are three forms: 1. Congenital umbilical hernia, or exomphalos, is the result of imperfect closure of the abdominal walls, the contents varying from a small loop of bowel to a large part of the viscera {ectopia viscerum). The hernia is covered by a transparent membrane composed of peritoneum and tissues of the umbilical cord. The condition is rare and if overlooked the bowel may be tied with the cord. The treat- ment of a small hernia is an aseptic dressing, with pressure. In larger protusions the contents should be reduced, the sac removed, and the opening closed with sutures, as cases in which operation is with- held are quickly fatal from sloughing of the sac. 2. Infantile umbilical hernia is due to stretching of the umbilical cicatrix, consequently does not appear as a rule until the child is several weeks or months old. The hernia is usually of small size and tends towards spontaneous recovery. Operation is therefore seldom required, unless the rupture persists after puberty. All sources of straining, e.g., constipation, phimosis, etc., should be ABDOMEN 815 removed, and reduction maintained by a flat pad, larger than the ring (a covered penny is often employed), held in place by a broad strap of adhesive plaster. 3. Umbilical hernia of adults is caused by stretching or rupture of the tissues in the immediate vicinity of the umbiUcus, as the result of increased intraabdominal pressure, hence is most frequent in obese women who have borne many children. In most cases the protrusion begins at the point where the umbilical vein passed into the abdomen, i.e., at the upper margin of the naval, which is dis- placed downwards or to one side. The hernia often attains a large size, and as it is exposed to various forms of irritation, the contents are prone to become adherent to one another and to the sac. Not infrequently, therefore, the sac is divided into several parts, and the hernia is often irreducible, thus predisposing to strangulation. The coverings are peritoneum, transversalis fascia, and skin, or, in some instances, only peritoneum and very thin skin. Ulceration of the ■SKIN -SUTURED PERITONEUM -APONEUROSIS Fig. 459. — Mayo's operation. coverings may occur, but perforation or actual rupture is the exception. The treatment should be palliative, if, in the absence of serious complications, the patient is advanced in years and extremely fat. A pad truss should be worn, unless the rupture is irreducible, when some form of cup or bag truss may be needed. The Mayo operation is the most satisfactory in cases in which radical treatment is indicated. The hernia is surrounded by trans- verse elliptical incisions and the aponeurotic structures about the ring exposed. The sac is opened, and divided at its neck, adherent intestines separated and reduced; adherent omentum ligated, and removed with the sac and skin. The peritoneum is separated from the edges of the ring and sutured transversely. Mattress sutures of chromicized catgut are introduced an inch or more above the edge of the upper flap, catching the margin of the lower flap en route, thus sliding it into the space between the peritoneum and upper flap (Fig. 459). The lower edge of the upper flap is sutured to the 8l6 MANUAL OF SURGERY aponeurosis below. Konig suggests fortifying the line of suture, in operations for umbilical and other forms of hernia, by covering it with a free transplant of fascia or periosteum, which is fixed in place with catgut stitches. Very large hernial orifices have been closed by the implantation of a perforated celluloid plate or a network of silver wire Ventral hernia is a hernia in any portion of the anterior abdomi- nal wall, excepting those mentioned above. It may be median or lateral. There are two principal varieties of median hernia. I. Hernia of the linea alba forms i per cent, of all cases of hernia. It is most frequent about midway between the umbiHcus and the ensiform {epigastric hernia), at the point where the middle linea transversa of the rectus joins the median line, because at this point the greatest strain occurs when the recti are brought into action; it is usually preceded by a subperitoneal lipoma, which insinuates itself between the meshes of the Hnea alba and draws a sac of peri- toneum after it. Sometimes a lipoma, with or without a hernial sac, appears just above the umbiHcus, at the juncture of the lowest linea transversa with the median line, and occasionally there are several lipomata between the ensiform and the umbilicus. Con- genital apertures in the linea alba are very rare. Epigastric hernia is most common in healthy, hard working men, and is frequently insignificant in size, hence overlooked. It may cause epigastric pain, vomiting, and other gastric symptoms. Truss treatment is inapphcable as the hernia is seldom reducible. The lipoma should be excised with the sac, and the opening in the abdominal wall closed with sutures. The stomach and adjacent organs should always be explored at the same time, to make sure that the symp- toms are not due to some graver disease. 2. Diastasis of the recti muscles is most commonly observed in multipara; it causes a stretch- ing of the linea alba, which encourages a prolapse of all the abdominal viscera. The diagnosis is readily made by having the patient, when lying down, fold the arms and raise the head and shoulders, the whole linea alba bulging forwards in a long mound-hke eminence, reaching from the ensiform to the pubes The treatment is that of Glenard's disease. In some cases marked benefit has been obtained by suturing the recti together, or, better, by overlapping them, with the redundant linea alba. Lateral ventral hernia is most frequent in the senilunar line at a point where it is crossed by the omphalo- spinous line, owing to the fact that a branch of the epigastric artery pierces the wall in this situation. It is the result of increased intra- abdominal pressure. Postoperative or postincisional herniae may, ABDOMEN 817 of course, occur in any portion of the abdomen, and are particularly prone to develop if the wound suppurates or if drainage has been em])loyed. As the contents of the hernia are often adherent to the coverings, and a peritoneal sac may be absent, instead of incising directly over the protrusion, it is usually safer to enter the abdomen above or below the old wound, and then, after exploration, excise the cutaneous scar, separate adhesions, reduce the extruded parts, and close the wound by imbrication of the individual layers of the abdominal wall. Among the rarer forms of hernia are the following: Obturator hernia passes through the obturator foramen with the obturator vessels, appearing deep in the thigh on the inner side of the femoral vessels (Fig. 457). Eckstein (191 2) collected 194 cases. The condition is more common in women (8 to i) because of the larger size of the foramen. There may be pain in the hip and along the inside of the thigh and knee, due to pressure on the obturator nerve. Bimanual examination may reveal a cord-like mass extending to the foramen. The diagnosis is seldom made; even when the hernia is strangulated, the condition is rarely suspected until after the abdomen has been opened for intestinal obstruction. The sac may be exposed by an incision in the upper and inner angle of Scarpa's triangle, and the constriction relieved by cutting inwards, since the obturator artery usually lies below and to the outer side. The opening may be closed with a flap of muscle or periosteum. The mortality is 70 per cent. Lumbar hernia occurs in Petit 's triangle, and is treated as a ventral hernia. Sciatic hernia emerges from the pelvis through one of the sciatic foramina, and appears in the gluteal region. Perineal hernias aret hose passing through the pelvic diaphragm and appearing in the perineum, towards the rectum (rectal hernia), vagina {vaginal hernia), or in the lower part of the labium {pudendal hernia). Inguinal perineal hernia is one which follows an aberrant testicle into the perineum. Internal hernia occurs in two forms, (i) the diaphragmatic, and (2) the retroperitoneal. I. Diaphragmatic hernia is more frequent on the left side, because the diaphragm is weaker at this point, and because the liver is on the right side. Although any of the abdominal viscera may pass into the thorax, the stomach and transverse colon are the organs usually herniated. The hernia may be (a) congenital or (b) acquired. 52 8l8 MANUAL OF SURGERY (a) The congenital form is the more frequent. When, as is usually the case, it arises before the separation of the thorax from the abdomen, it passes through a developemental defect in the diaphragm, and has no sac (false diaphragmatic hernia). When it protrudes through an unusually large normal aperture, e.g., the esophageal opening, it may have a sac {true diaphragmatic hernia). (b) The acquired form may follow a crush of the thorax or a severe twist of the body, resulting in rupture of the diaphragm, or it may follow a stab or gunshot wound, hence, has no sac (false diaphragmatic hernia). The symptoms are abdominal pain, dyspnea, vomiting, some- times hematemesis, and, in the event of strangulation, those of acute intestinal obstruction. Volvulus of the stomach (q.v.) is a possibility. It must be noted that, in many instances, the con- genital form causes no trouble. In traumatic cases the history of an injury followed by shock, dyspnea, cyanosis, intense pain, cough, thirst, and hiccough may be obtained. The signs are those of pneumothorax, limited to the lower chest, and displacement of the heart to the right. The tympanitic note is extended and inten- sified by distending the stomach or the colon with air, and perhaps re- placed by dulness when these organs are filled with water. Litten 's sign is usually absent. The X-ray shows the displacement of the heart, an irregular or incomplete diaphragmatic shadow, and a clear area above the line of the diaphragm, through which area the mottled shadow of the lung may be seen. This clear area may be rendered dense by injecting barium into the stomach or the colon. With the fluoroscope a paradoxical movement of the diaphragm may be observed, i.e., during inspiration the affected side ascends while the normal side descends, during expiration the affected side descends while the normal side ascends. If, however, the abdominal muscles are strongly contracted during expiration the aft'ected side of the diaphragm is forced upwards. The diagnosis has been made before operation or death is only 15 of the 160 cases reported (Giffin). but if the possibility of diaphragmatic hernia is kept in mind and all suspected cases are carefully studied this condition should be recog- nized more often in the future. Diaphragmatic hernia may be confused with pneumothorax and elevation of the diaphragm. In pneumothorax the tympany usually extends over the whole thorax, and is uninfluenced by distention of the stomach or the colon with air or water. The breath sounds may be amphoric, distant, or absent, while in diaphragmatic hernia the breath sounds ABDOMEN 819 and vocal fremitus may be present, and the metallic tinkling coin- cides with the peristaltic movements of the stomach or intestine rather than with respiration. The coin test is positive more fre- quently in pneumothorax, and repeated vomiting less apt to occur. A skiagram will show an intact diaphragm, and no change in the clear area after a bismuth meal. Elevation of the diaphragm is a condition in which one side of the diaphragm usually the left, is much higher than normal. It may be transient, probably as the result of some temporary affection of the phrenic nerve, or perma- nent. It is differentiated from diaphragmatic hernia by means of the X-ray. The diaphragmatic shadow, though elevated, is normal in outline, and beneath it are the shadows of the stomach and the colon. The treatment consists,underintratrachcalinsufflationanesthesia, in opening the lower part of the thorax, possibly by reflecting a section of the eighth and the ninth ribs, reducing the hernia, and suturing the wound. in the diaphragm. If the opening is too large to be sutured it may be patched with a free transplant of fascia lata. In most of the cases of diaphragmatic hernia in which the abdomen has been opened in order to deal with an intestinal obstruction of unknown origin the diaphragm has been closed from below. Even in these cases it would perhaps be better, after the diagnosis has been established by abdominal section, to open the thorax, since reduction of the hernia and suture of the orifice are thus facilitated. Scudder collected 53 operations, 11 thoracic, 42 abdominal; 14 of the patients recovered. 2. Retroperitoneal hernia occurs in the following situations: (a) Foramen of Winslow. (b) Recessus duodeno-jejunalis; the margin of this fossa contains the inferior mesenteric vein or coHca sinistra artery, a fact to be remembered if, in a case of strangulated hernia in this vicinity, enlargement of the opening is necessary, (c) Pericecal fossae, of which theie are three, the retrocecal, behind the cecum and external to the mesoappendix; the superior ileocecal, in the upper angle formed by the junction of the ileum and cecum; and the inferior ileocecal, in the lower angle formed by the ileum and cecum, (d.) Intersigmoid fossa, at the root of the mesocolon on the left side, (e.) Retrovesical fossa. A retroperitoneal hernia rarely causes trouble unless it become strangulated, when the symptoms are those of intestinal obstruction. The treatment is laparotomy and reduction of the hernia. Obliteration of the hernial orifice by sutures may be attempted in suitable cases. 820 MANUAL OF SURGFRY ACCIDENTS OF HERNIA Irreducible hernia that is not inflammed, incarcerated, or stran- gulated presents all the signs of a reducible one, except that it cannot be replaced within the abdomen and is apt to be more firm in consistence. Irreducibility is most frequent in umbilical hernia? (of adults), then in femoral, then in large scrotal hernias. The causes are: i. Adhesions (a) between the contents and the sac, (b) among the contents, forming a mass which will not pass through the ring, (c) giving rise to cystic accumulations, or (d) causing thickening of the neck or other portion of the sac. 2. Excessive deposit of fat, either in the herniated omentum or mesentery, or within the abdomen, in the latter instance the hernia cannot be returned because of want of room. An irreducible hernia resulting from the causes just mentioned is always liable to become inflamed, incarcerated, or strangulated. The treatment in most cases is operation; when this is inadvisable because of the general condition of the patient, the hernia may be supported by a bag truss. When due to fat, the hernia may again become reducible after strict dieting. An inflamed hernia is one in which there is a localized peritonitis, involving the sac and possibly the peritoneal covering of the con- tained viscera. The causes are external, e.g., blows, badly fitting trusses, and strenuous taxis; and internal, e.g., inflammation; ulceration, or perforation of a herniated appendix or coil of bowel, peritonitis arising within the abdomen and extending to the sac; also incarceration and strangulation, but these are considered in separate classes. The symptoms are pain, tenderness, swelling, increased heat, sometimes redness and edema of the skin and occa- sionally suppuration; in addition there are general fever and often vomiting and constipation. The hernia is likely to be irreducible and hence strangulation is strongly suggested, but in the latter there are shock instead of fever, absence of an impulse on coughing, absolute constipation, and fecal vomiting. The treatment is im- mediate operation, on the hernia in those cases depending upon external causes or causes within the sac, or on the primary lesion in those depending upon an intraabdominal infection. Incarcerated or obstructed hernia is an irreducible hernia in which the fecal (not the blood) circulation is interrupted. It is generally due to undigested food or impacted feces. It is most common in umbilical hernias, because of the frequency of adhesions, which interfeie with peristalsis, and because of the presence of the ABDOMEN 821 transverse colon, which contains solid feces. The ^iymptoms are those of an irreducible hernia which becomes tender and painful, harder and larger than usual, and dull on percussion; it may be diminished in size by pressure, and has an impulse on coughing. The abdomen becomes distended and there are vomiting (not fecal) , constipation (not absolute), and colicky pain. The hernia may become inflamed or strangulated. The treatment is operation, unless the patient is old, or in poor condition from some independent affection, when gentle taxis, may be tried, but even under these circumstances if treatment is not quickly successful, or if symptoms of strangulation ensue, operation should be performed. Taxis or the manipulations for the reduction of a hernia, should always be gentle, because of the danger of rupture of the bowel. It should not be employed in the presence of inflammation or strangulation. Reduction is facilitated by having the patient recumbent, the thighs flexed (and that of the affected side adducted in femoral or inguinal hernia), and the pelvis raised. The adminis- tration of opium and belladonna and the application of heat also are useful in securing relaxation. One hand is used to steady the neck of the sac, while with the other the hernia is compressed and pushed back into the abdomen. In direct inguinal and umbilical hernia the pressure is backwards ; in oblique inguinal hernia upwards, outwards, and backwards; in femoral hernia at first downwards and inwards, then upwards and backwards. The successful re- duction of bowel is sudden and accompanied by a gurgle; omentum is forced back slowly without gurgling. The continuance of symp- toms after apparent reduction may be due to (i) incomplete reduction, (2) reduction en masse (see "Interstitial Hernia"), (3) recurrence of the hernia, (4) the presence of some other form of intestinal obstruction, (5) paralysis of the bowel, (6) peritonitis, (7) reduction of gangrenous or perforated bowel, (8) reduction of bowel which is obstructed by adhesions or through a slit in the omentum, or to (9) the effects of an anesthetic, which, it must be added, should not be employed unless one intends to perform herniotomy. With the exception of the last named condition, the persistence of symp- toms after apparent reduction calls for operation. Strangulated hernia is one in which the contents are so firmly constricted that the circulation of blood is cut off. Interference with the fecal circulation is usual but not essential, since the hernia may be an epiplocele or a Richter's hernia. The cause of strangulation is sudden augmentation in the size of the hernia, from the extrusion of additional contents, from con- 82 2 MANUAL OF SURGERY gestion or inflammation, or from fecal or gaseous accumulations. In adults the varieties of hernia in which strangulation is most likely to occur are the indirect inguinal, the femoral, the umbiHcal, and the postoperative. The smaller the orifice the greater the chance of its gripping an extruded coil of bowel; a pure epiplocele is seldom caught. Strangulation is infrequent in children, and rare in epigastric hernia and direct inguinal hernia. The site of con- striction is usually the hernial orifice, but it may be in the neck of the sac alone, or elsewhere in the sac as the result of adhesions or constrictions. At this point the intestine is furrowed and, if the constriction has lasted long enough, ulcerated. Occasionally this ulcerated area perforates after reduction of the bowel, or by healing causes an annular stricture and intestinal obstruction. The strangu- lated loop is distended with gas, and varies in appearance according to the degree and the duration of the strangulation. In the first stage, in which the venous circulation only is affected, the gut wall is thickened from congestion and edema, dark red in color, smooth and elastic to the touch, and glistening in appearance, although in places small ecchymoses may be seen. The vessels can be emptied by pressure, and refill promptly when the pressure is removed. In this stage relief of the constriction is followed by complete recovery of the gut. Later, owing to the swelling of the hernial contents, the arterial circulation is arrested, and this leads to moist gangrene. The gut becomes sodden, black, lusterless; the vessels are throm- bosed and cannot be emptied by pressure; and bacteria escape in large numbers through the intestinal wall. Finally perforation may occur, either spontaneously or as the result of manipulations. The changes in the bowel above and below the seat of strangulation are identical with those in other forms of acute obstruction (see intestinal obstruction). Even when obstruction is not complete, e.g., in a Richter's hernia, the bowel may be paralyzed. The sac is inflamed, owing to the passage of bacteria through the intestinal walls, and usually contains fluid, which is at first clear, but in the later stages becomes bloody and finally dark brown in color and offensive in odor. Sloughing of the sac is rarely seen; it may be due to the inflammation or to strangulation of the sac. The parts about the sac are usually unaffected, but occasionally in unrelieved cases they become inflamed and break down, thus leading in rare instances to spontaneous cure by the formation of an artificial anus. Retrograde strangulation is a condition in which the end of a piece of bowel or omentum in a hernia passes back into- the abdomen, becoming strangulated at the hernial orifice, the remaining portion ABDOMEN 823 of the hernia being uninvolved. Doubtless some of the cases of so-called retrograde strangulation are due to the escape of two coils of intestine (hernia en W), the connecting loop within the abdomen becoming strangulated; to the reduction of a strangulated segment. the sac then filling with healthy bowel or omentum; or twisting of the end that reenters the abdomen. The symptoms are those of inleslinal obstruction, viz., shock, abdominal pain and distention, vomiting which finally becomes stercoraceous, increased peristalsis, and absolute constipation. In the final stage the picture is that of generalized peritonitis. In even a strangulated Richter's, Littre's, or omental hernia, there may be symptoms of complete obstruction, possibly from reflex paralysis of the intestine. The hernia is irreducible, tense, tender, and painful, and has no impulse on coughing. With the onset of gangrene pain and tenderness disappear, and the hernia becomes softer and some- times crepitates. Two facts must be emphasized. First, the symptoms may be mild and the cause overlooked, especially in old women who have long had a small irreducible femoral hernia that they deem of no importance and do not mention to the physician, or who have a small umbilical hernia that is concealed beneath a thick layer of fat. In all doubttul cases one should not only inquire, but look for hernia. Secondly, gangrene depends, not so much on the duration, as on the tightness of the strangulation, hence may occur in a few hours. The treatment is immediate operation. If the circulation in the afTected loop of bowel is really suppressed, taxis is contraindicated. In many instances in which a so-called strangulated hernia has been replaced without evil affects following, the temporary irreducibility was the result of incarceration, not strangulation, the dift'erentiation symptomatically, between these conditions often being difficult, sometimes impossible. Operation for incarcerated and strangulated hernia, or herni- otomy, as it is sometimes called, should be preceded by gastric lavage, especially when a general anesthetic is to be given. Local anesthesia is much safer, if the patient is in poor condition. The cutaneous incisions suitable for the various forms of hernia have already been described. The sac is recognized by its bluish color, the presence of subperitoneal fat, and by its gliding over the contained viscera. It almost always contains fluid, hence can be opened, unless there are adhesions, without much danger of injuring the bowel. The nail of the left forefinger is insinuated within the stricture, which is nicked sufficiently to release the gut, with blunt pointed scissors or a hernia knife (curved blunt-ended bistoury) introduced along the linger. 824 MANUAL OF SURGERY In inguinal hernia the direction of the nick is directly upwards, in femora] hernia directly inwards. Many surgeons divide the con- stricting tissues from the surface towards the hernia, so that if any important vessels are cut they may be caught at once and tied. The bowel must be carefully examined to ascertain whether it is viable or not, and it should be withdrawn a little from the abdomen, in order to deterinine its condition at the point of constriction and to make sure there is no retrograde strangulation or torsion; the omen- tum should be treated in a like manner. The bowel is viable if it retains its normal luster and elasticity, if the arteries pulsate, if the veins can be emptied by pressure and refill promptly when the pres- sure is removed, if peristalsis can be induced by pinching, and if the color, although bluish or dark red, improves quickly on the applica- tion of hot water. The bowel is gangrenous if it is lusterless, black, sodden; if the arteries do not pulsate; and if the veins are throm" bosed. Between these extremes there are numerous gradations, and in some cases even an experienced surgeon is unable to say whether the bowel will live or not. If the hernial contents are healthy, they should be replaced, and the radical operation per- formed if the patient's condition permits. Any small ulcer at the site of constriction should be inverted with Lembert sutures. If the bowel is gangrenous it should be resected, taking care to go well above and below the apparent limits of the gangrene, else sloughing at the site of anastomosis may follow. In femoral hernia it will usually be necessary to make a second incision above Poupart's ligament for this purpose. If the patient's condition forbids resection, the bowel may be opened and an artificial anus established ; this is dealt with at a later period as described elsewhere. If the condition of the bowel is doubtful, it should be resected if the surgeon is skillful and the patient's condition good; under other circumstances it may be surrounded with gauze and the wound left open. Should gangrene or perforation follow, the intestinal contents will be discharged through the wound; if gangrene does not supervene, the bowel may be replaced and the wound closed at a later period. When the condition of the omentum is doubtful, it should be removed. The mortality mounts from about 5 per cent, when the herniotomy is done within a few hours of the onset of the strangulation up to 50 per cent, when done on the third day, after which recovery is exceptional. Sometimes blood appears in the stools after operation, and although, as a rule, of no serious import, such an occurrence always causes anxiety, since it may be due to thrombosis or deep ulceration. Rarely a cicatricial stricture develops at the site of the original constriction. CHAPTER XXVIII RECTUM AND ANUS Since rectal symptoms, and indeed rectal diseases, may be due to, or associated with, affections of the genito-urinary apparatus, it, too, should be reviewed when the rectum and anus are investi- gated . Examination of the anus and rectum may be made in the Sims, knee-chest, lithotomy, or squatting position, or with the patient standing and bending over the back of a chair. A preliminary examination, before the use of laxatives or enemata, will reveal the character of any feces or discharge that may be present (pus, blood, mucus, etc.). The external parts may then be cleansed and the rectum emptied with an enema. Inspection of the external parts may reveal the orifice of a fistula, external piles, protruding internal piles, fissure, skin diseases, abscess, condylomata, mucous patches, parasites on the anal hairs, anal tumors, and similar conditions. By separating the buttocks and having the patient strain, internal piles, polypi, or a procidentia may appear. Digital examination permits exploration of the lower four inches of the rectum. A rubber glove should always be worn, and the index finger, lubricated with sterile vaselin (light oil or lubricating fluids cause more pain), introduced gently, first upwards and for- wards towards the umbilicus, until the internal sphincter is passed, then backwards in the hollow of the sacrum. The sphincter is twitching and spasmodic in an acute lesion of the anus; hard, un- yielding, and hypertrophied in chronic disease; relaxed in exhausting general maladies. The finger may detect an abscess, an ulceration, a foreign body, a tumor, a stricture, indurated internal hemorrhoids, procidentia, or the internal orifice or the tract of a fistula. A growth just beyond the reach of the finger may become palpable if pressure is made on the lower abdomen with the other hand (bimanual exami- nation), or if the patient strains while in the squatting posture. The coccyx, the prostate, the seminal vesicles, the female perineum and pelvic organs also must be investigated. Instrumental examination of the anal canal and the lower rectum can be made with a short rectal speculum of the cylindric or valvular type [proctoscope) , but for inspection of the upper rectum and the 82s 826 MANUAL OF SURGERY sigmoid the sigmoidoscope, preferably that devised by Tuttle, is needed. Tuttle's instrument is a long hollow cylinder with an elec- tric lamp at the distal end. The patient assumes the knee-chest posture, and, with the obturator in position, the "scope" is introduced through the anus, towards the umbihcus, until the internal sphincter is passed. The obturator is then withdrawn, and if the rectum fails to distend under atmospheric pressure, a plug, containing a glass window, is inserted in the proximal end of the instrument, and the inflation made by means of a hand bulb, which is connected with a small tube running through the plug. The instru- ment may then be passed to its lull extent, fourteen inches, under guidance of the eye. Long applicators, forceps, etc., are made tor diagnostic or therapeutic manipulations through the sigmoidoscope. Probing is employed chiefly for the diagnosis of fistula. The size and the shape of the rectum, or of rectal sinuses or diverticula, can Fig. 460. — Imperforate anus. Fig. 461. — Imperforate rectum. be demonstrated with the X-ray, after the injection of a barium mixture. Congenital Malformations. — Normally, in the early stages of development the hind-gut communicates in front with the allantois and behind with the neurenteric canal. At a later period the gut and the genitourinary canal open externally in a common passage, called the cloaca. By the growth of a posterior and two lateral folds, the perineum is formed, and the gut separated from the genito- urinary cavity. A pit called the proctodeum extends inward from the perineum, until finally it meets and communicates with the rectum. According to the extent to which development has pro- gressed, the following malformations may be encountered. Anal stricture may be enlarged by cutting backwards towards the coccyx, and the opening maintained by the subsequent passage of bougies. Imperforate anus (Fig. 460) is a condition in which the rectum is developed, but there is no proctodeum. When the infant cries, the RECTUM AND ANUS 827 rectum is felt to bulge at the point where the anal oriiice should he. Imperforate rectum (Fig. 461), in which both the rectum and the proctodeum are developed, but have not united, is the most common malformation, the septum being about an inch above the anus. Absent rectum (Fig. 462) is a malformation in which the rectum ends blindly high up, perhaps above the pelvic brim. The proctodeum may or may not be present. When the septum which Fig. 462. — Absent rectum. Atresia ani vesicalis. should divide the cloaca is defective the rectum may open into the bladder (atresia ani vesicalis, Fig. 463), urethra (atresia ani ure- thralis, Fig. 464), or vagina (atresia ani vaginalis, Fig. 465). The treatment in all cases, except anal stricture {vide supra) and atresia ani vaginalis, must be prompt, otherwise the patient dies of intestinal obstruction. If no anus is present, an incision is made Fig. 464. — Atresia ani urethralis. Fig. 465. — Atresia ani vaginalis in the midline of the perineum and deepened until the rectum is encountered, care being taken not to injure the bladder. One may follow the concavity of the sacrum as high as its promontory, excis- ing, when necessary, the coccyx and lower segment of the sacrum; when the rectum is found, it is pulled down to the external opening, incised, and stitched to the skin. If the rectum cannot be found, the sigmoid may be brought down into the wound, or an artificial 828 MANUAL OF SURGERY anus made in the inguinal region. When the anus is present, the septum separating it from the rectum should be incised or excised, the opening thus formed being maintained by the passage of bougies. In atresia ani vaginalis the feces escape without hindrance, hence operation may be postponed until the infant is several years old. The rectum is detached from the vagina and fastened to the perineum and the opening in the vagina closed with sutures. Injuries of the rectum are usually caused by falHng on a pointed object, e.g., a spike, by the breaking of a china bedroom utensil, by childbirth (see "Lacerations of the Perineum" and "Rectovaginal Fistula"), by gunshot or bayonet wounds, by fractures of the pelvis, and by foreign bodies {vide infra). The rectum may be wounded during operations, e.g., perineorrhaphy, prostatectomy, perineal section, divulsion of the sphincter, reduction of rectal prolapse, and pelvic operations, also by the passage of a urethral or a rectal bougie, a proctoscope, or an enema nozzle, particularly if the bowel is friable, e.g., from carcinomatous infiltration. The rectum has been ruptured by the colpeurynter, by the injection of compressed air, and by the introduction of the hand for diagnostic purposes. The symptoms are pain, hemorrhage, and in most cases shock; the complications sepsis, periproctitis, peritonitis, and secondary hemorrhage; the sequelae stricture, incontinence, and the various forms of fistula. The treatment should be preceded by a careful examination to deter- mine the extent of the wound, bearing in mind the possibility of injury to the urethra, bladder, vagina, and small intestine. In uncompHcated wounds of the rectum above the sphincters and below the peritoneum the sphincters should be dilated, the parts irrigated with salt solution, the wound sutured with catgut, and a short rubber tube, covered with vaselinized gauze, inserted through the anus to lessen intrarectal tension, which might force fecal matter into the perirectal cellular tissues. Injuries to adjacent viscera should be repaired as described in the sections dealing with those viscera. Foreign bodies that have been swallowed, that have formed in, or ulcerated into, the intestine (see "Foreign Bodies in the Intestine"), or that have been introduced through the anus by degenerates, lunatics, or criminals, may be found in the rectum. The symptoms are tenesmus, the passage of blood and mucus (owing to ulceration) , and possibly obstruction or suppurative periproctitis. Large foreign bodies may press on the bladder and cause frequent micturition, or on the sacral plexus and cause shooting pains in the lower extremities. The diagnosis may be made with the finger, the speculum, or the X- ray. The treatment is extraction with the finger or with forceps. RECTUM AND ANUS 829 In some cases it may be necessary to give a general anesthetic and split the anal canal backwards towards the coccyx. When the foreign body is impacted up near the sigmoid it may be safer to y)erform la]iar()t(.)my and rem()\'e it from above. Pruritus ani, or itching, is a symptom which may be caused by local conditions, such as piles, fissure, fistula, proctitis, worms, pediculi, uncleanliness, herpes, eczema, and diseases of the urethra, bladder, prostate, vagina, uterus, or ovaries, or by general conditions like gout, disorders of digestion, nephritis, diabetes, jaundice, con- stipation, mental and nervous disorders, and the opium, alcohol, tea, and tobacco habits. The treatment is removal of the cause and attention to the general health. The parts should be kept scrupu- lously clean. The itching may be relieved by lotions or ointments containing carbolic acid (1-15) or menthol (1-30), or by painting the skin with silver nitrate (i-io) or compound tincture of benzoin; "in the worst cases the sensory nerves supplying the part may be in- jected with alcohol or divided, or the affected skin excised. Fissure of the anus is caused by the passage of hardened feces, and not infrequentl}^ accompanies hemorrhoids and other local dis- eases. It is usually at the posterior margin of the anus, and there is often a "sentinel" external pile at its outer extremity. The principal symptom is burning pain on defecation, and sometimes on walking or coughing. Constipation is thus encouraged, and when the hardened feces pass, they may be streaked with pus or blood. The ulcer is seen on separating the folds of the anus and the sphincter is found spasmodically contracted. The treatment is laxatives and the appli- cation of silver nitrate; if this fails, the patient should be anesthe- tized, and the sphincter stretched with the thumbs, thus causing a paralysis for from five to ten days, during which time the ulcer heals. The same result may be secured by dividing the superficial fibers of the external sphincter through the base of the ulcer. Piles should, of course, be removed at the same time. Large ulcers may be excised. Proctitis, or inflammation of the rectum, arises from foreign bodies, polypi, piles, parasites, gonorrhea, repeated catharsis, irritat- ing enemata, dysentery, and other forms of colitis. The symptoms are tenesmus, frequent bowel movements, with mucus, pus, or blood, and a sensation of heat and fullness. The bladder also may be irritable. The rectal mucous membrane may prolapse, and in chronic cases there may be ulceration followed by stricture formation. By digital examination the rectum is found to be hot and tender, and by inspection with the proctoscope the red and swollen mucous 830 MANUAL OF SURGERY membrane can be seen. The treatment is removal of the cause, rest in bed, liquid diet, suppositories of opium and belladonna, hot sitz baths, and irrigation with very weak solutions of silver nitrate. Periproctitis (cellulitis) is usually caused by infection from the rectum, as the result of disease (piles, fissure, fistula, cancer, etc.) or injury (hardened feces, swallowed fish bone, etc). It may be caused also by abrasions of the skin and affections of the surrounding tissues, including the bladder, urethra, prostate, and female pelvic organs. The diffuse form spreads rapidly, results in extensive sloughing, is usually seen in the old and asthenic, and is very apt to cause death. It is treated by free drainage and vigorous stimulation. In the circumscribed variety an abscess forms below (ischiorectal abscess) or above the levator ani ('pelvirectal abscess). These abscesses are described in the next section. Abscesses about the anus and rectum occur chiefly in four situa- tions (Fig. 466), in and beneath the skin of the anus, beneath the Fig. 466.- -Diagram of anorectal abscesses, i. Anal abscess. 2. Submucous abscess. 3. Ischiorectal abscess. 4. Pelvirectal abscess. mucous membrane of the rectum, and, as mentioned in the preceding paragraph, in the perirectal cellular tissue below (ischiorectal ab- scess) or above the levator ani (pelvirectal abscess). An anal abscess is due to infection of a hair foUicle or a sebaceous gland (follicular abscess, really a furuncle), or to a fissure or a sup- purating external hemorrhoid {marginal abscess). Follicular ab- scesses, like boils elsewhere, may be multiple, but seldom give rise to fistulae. A marginal abscess is generally single and may cause a fistula superficial to the external sphincter. The symptoms are itching and throbbing pain, worse on defecation and walking. As the condition is superficial it is easily recognized. The treatment is incision, removal of undermined skin, disinfection, drainage. If the abscess is due to a fissure, or an external pile extending into the anal canal, the sphincter should be stretched. A submucous abscess, i.e., between the mucosa and the mus- RECTUM AND ANUS 83 1 cularis, is generally the result of a superficial injury by a foreign body, or of an ulcerated polyp or hemorrhoid. The symptoms are those of the preceding variety, and the abscess can be felt by digital examination. The treatment is divulsion of the sphincter, incision, removal of undermined mucous membrane, and, later, applications of silver nitrate. Gauze drainage is not needed. Acute ischiorectal abscess is a form of periproctitis, hence due to the same causes. Left to itself the abscess usually breaks through the weakest portions of its wall, i.e., through the skin along side of the anus, and through the mucous membrane towards the back of the anal canal (between the sphincters) at the point where the posterior edges of the levators ani join the anococcygeal ligaments, thus forming a complete fistula. Sometimes it burrows across the median line to the opposite ischiorectal fossa (horseshoe abscess). The symptoms are throbbing pain, intensified by coughing, walking, sit- ting, and defecation, sometimes retention of urine, and always con- stitutional evidences of sepsis. Between the anus and the ischial tuberosity is a hot, red, tender, brawny, and edematous induration, and on passing the finger into the anal canal a tender, elastic swelling can be felt on the corresponding side. The treatment should be prompt, in order to avoid the formation of a fistula. A free antero- posterior incision is made between the anus and the tuber ischii, and the cavity irrigated with salt solution and packed with iodoform gauze. The pus is fetid and .often contains bubbles of gas (colon bacillus) ; it may be thick and yellow or, from the presence of altered blood clot, dark brown. Chronic ischiorectal abscess is usually tuberculous, occasionally syphilitic. There is at first a painless induration, which subsequently softens; in the later stages it is often infected with pyrogenic organisms, the symptoms then being those of an acute abscess. The local treatment is that of acute abscess. A pelvirectal abscess is one occurring above the levator ani, be- tween it and the rectum. This space is continuous with the pelvic cellular tissue, hence a pelvirectal abscess is due more often to disease of the urethra, bladder, prostate, or female pelvic organs, than to affections of the rectum. Occasionally a psoas or an appendiceal abscess, or an abscess proceeding from the pelvic bone points in this region, and sometimes the pus perforates the levator ani and appears in the ischiorectal fossa. The symptoms are those of the causative lesion, with painful defecation and sepsis. The abscess may be felt bulging into the rectum above the level of the internal sphincter. The treatment is that of the cause, with divulsion of the sphincter and evacuation of the abscess. 832 MANUAL OF SURGERY Fistula in ano means not only, as the term indicates, a iistula opening into the anal canal, but also a fistula running from the peri- neal skin to the rectum, or a sinus opening into any portion of the anorectal canal or upon the skin in the neighborhood of the anus. Fistulae connecting the rectum with other viscera (bladder, vagina, etc.), however, are not included under this heading. Excepting punctured wounds, and the rare non-inflammatory fistula, lined by epithelium and possibly due to a small pressure diverticulum, fistula in ano is always caused by the breaking of an abscess through the skin, through the mucous membrane, or in both situations, hence there are three varieties, the blind external, the blind internal, and the complete. These suppurating tracts refuse to heal because of im- perfect drainage, continual reinfection, constant motion, and, in the complete variety, because of the escape of gas and feces through the Fig. 467. — Diagram of anorectal fistulas. Blind external fistulas following (i)an anal abscess and (2) an ischiorectal abscess. 3. Sinus from disease of the ischium. Blind internal fistulse following (4) a submucous abscess and (5) a pelvirectal abscess. 6. Complete fistula following an ischiorectal abscess. tract. Further, syphilis may be responsible, and, according to some authorities, about one-half of the cases are tuberculous. While phthisis is present in only a small proportion of those submitting to operation, many develop the disease subsequently, hence the con- clusion that fistula in ano is often the primary source of tuberculous infection. The blind external fistula (really as inus) opens externally, but does not communicate with the bowel. It is short, subcutaneous, and close to the anus when due to the breaking of an anal abscess; deep and farther away from the anus when due to the breaking of an ischiorectal abscess (Fig. 467), many of the so-called blind external fistula are, in reality, complete, the internal orifice being so small as to escape detection. If the opening is in front of the anus one should suspect a perineal fistula (see "Stricture of the Urethra") ; if RECTUM AND ANUS 833 near the tuber ischii, disase of the bone; if near the coccyx, a post- anal dimple or a suppurating dermoid. The blind internal fistula (really a sinus) opens into the bowel, but has no external opening. It is comparatively infrequent, oc- curring in about lo per cent, of the cases of anorectal fistula. The submucous form usually opens into the anal canal, the pelvirectal above the internal sphincter. In either case the orifice is generally on the posterior or the lateral wall of the anorectal canal; a sinus opening on the anterior wall may follow the breaking of a prostatic abscess. The complete or true fistula opens both externally and internally. It occurs in about 75 per cent, of the cases and is usually the result of an ischiorectal abscess, the internal opening being between the two sphincters, the external within an inch and a half of the anus. When following a pelvirectal abscess, however, the internal opening maybe above the internal sphincter, or when following an anal abscess, outside the external sphincter. A horseshoe fistula extends partly around the bowel, accross the median line, and opens externally on each side; as a rule there is only one internal opening. The symptoms of fistula in ano are pain during defecation, tenes- mus, especially when there is an internal opening, a purulent dis- charge from the anus or the external opening, and in the complete variety the passage of feces and gas through the fistula; recurring abscesses may form, owing to healing or blocking of the openings. These abscesses may make new outlets for themselves, thus a blind external or internal fistula may become a complete fistula, and a com- plete fistula may establish numerous side tracts extending in various directions (Fig. 468). When there is an external opening, the diag- nosis is readily made by inspection and the use of a probe. When there is no external opening, it will be necessary to use a speculum in order to expose the orifice. Digital examination will reveal spasm of the sphincters, a cord-like area of induration on one side of the rec- tum, and possibly the internal orifice of the fistula. The lungs should always be examined for evidences of phthisis. The treatment is the conversion of the fistula into an open wound, so that it may heal from the bottom. A grooved director is passed through the fistula into the rectum, and the overlying tissues severed with a bistoury. In order to avoid incontinence the external sphinc- ter should be cut but once, and always at right angles to its fibers and the internal sphincter should never be cut. If the fistula enters the bowel above the internal sphincter the tract should be opened into the bowel at its lower part only. All branching sinuses likewise 834 MANUAL OF SURGERY should be opened, and all fibrous tissue and undermined skin cut away with scissors. The bleeding is then checked, and the wound packed with iodoform gauze. If the fistula is lined with mu- cous membrane it must be completely excised. A blind external or internal fistula may be converted into a complete one and treated as outlined above, or a blind external fistula may be excised and the wound sutured. The bowels are confined for the first three or four days, and the wound dressed after each defecation, being irrigated with salt solution and repacked with iodoform gauze. Mackensie makes a large incision alongside of the anus, excises the fistula, sutures the opening in the rectum, and then closes the wound in the Fig. 468. — Multiple fistulae in ano. overlying tissues, except at one point, where a small drain is inserted. This operation might be of service in some cases in which the internal opening of the fistula is above the internal sphincter. Elting begins as in the Whitehead operation for piles, raising the cuff of mucous membrane to a point above the internal orifice of the fistula; when the cuff is amputated and the margin of mucous membrane sutured to the skin. Hemorrhoids, or piles, are swellings due to varicose veins about the lower end of the rectum. The causes are those which induce con- gestion in this region, such as sedentary habits, rectal disorders, tumors, inflammatory affections in the pelvis, cirrhosis of the liver and other conditions which interfere with the portal circulation. RECTUM AND AMUS 835 diseases of the heart and lungs, and repeated straining efforts to empty the bladder or the bowel, e.g., phimosis, urethral stricture, enlarged prostate, vesical calculus, and, most important of all, chronic constipation. The hemorrhoidal veins pierce the muscular coat of the rectum, run between it and the mucous membrane in a longitudinal direction, form a plexus around and above the anus and constitute one of the principal communications between the portal and systemic circulations; they have but little support, possess no valves, and are massaged downwards by hardened feces. There are two varieties of hemorrhoids, the external and the internal, which, however, often coexist. External hemorrhoids occur at the margin of the anus, are covered with skin, originate from the inferior hemorrhoidal plexus and consist of dilated veins surrounded by librocellular tissue. They cause no symptoms, except possibly itching or a Httle irritation, unless they are inflamed, when the veins become thrombosed, painful, and tender and appear as tense bluish masses which cannot be emptied by pres- sure. When the attack subsides, the piles are harder and thicker than before. The treatment is the relief of constipation, cleanliness, and, the use of soft paper or cotton, after defecation. The parts may be washed with a lotion containing witch-hazel. Operation is rarely required unless the piles become inflamed, when they should be incised, the clot turned out, and the cavity filled with gauze. When operating on internal hemorrhoids it is advisable to remove any coexisting external piles with scissors, the cuts radiating from the anus. If too much skin is removed, however, stenosis may follow. Internal hemorrhoids aie covered with mucous membrane, originate from the superior hemorrhoidal plexus, and consist of dilated veins, arterial twigs, and connective tissue. They cause pain, a sense of fullness, and often bleeding and a mucous discharge. They may protrude through the anus, and in some cases become strangulated from the grip of the sphincter and undergo sloughing. When inflamed (attack of piles), they swell and become intensely painful. Ulceration or suppuration, and occasionally abscess of the liver or pyemia may follow. The diagnosis is easily made with the speculum, but one must examine the whole rectum in order to exclude carcinoma. The treatment is removal of the cause, if such be possible. Alco- hol and spices should be avoided, regular exercise taken, and the bowels moved daily with mineral oil, which acts as a lubricant, aided, if need be, by small doses of cascara sagrada. Enemata and 836 MANUAL OF SURGERY drastic purges are contraindicated. The parts should be kept clean, bathed with cold water after defecation, and dried with a soft rag. Ointments or suppositories containing an astringent and, if there is much pain, opium and belladonna may be used. The fol- lowing is an example: acid gallic gr. x, ex. opii gr. iv, ex. bellad. gr. iv, ung. petrolat. §iv. apply night and morning. A simpler remedy is aqua hamamelidis, applied with cotton once a day, or more often. Strangulated piles should be reduced after anoint- ing them with oil or, if this is unsuccessful, removed by operation. Operation is indicated also when there is prolapse, ulceration, recurring hemorrhages, attacks of inflammation, or pain requiring the frequent use of opium. The liver should always be examined before operation, as in some cases the bleeding is beneficial rather than harmful. A laxative should be given forty-eight hours before, and an enema the day before operation, thus preventing soiling on the table. Many operators omit shaving. The patient is anesthe- tized and put in the lithotomy position, the anus thoroughly stretched and one of the operations described below performed. Ligation is easy, safe, and sure. The hemorrhoid is picked up with forceps and encircled with an incision going through the mucous membrane; the base is then transfixed with a double silk ligature, which is tied on each side, and the mass cut away. Operation by the clamp and cautery is favored by many surgeons. The pile is caught with forceps, and a Smith's clamp, the blades of which, in order to prevent burning, are covered with ivory on the side which rests against the mucous membrane, applied to the base of the pile, in the long axis of the rectum. The pile is then removed with scissors, and the base seared with the cautery at a dull red heat, after which the clamp is removed. Whitehead's operation consists in removal of the entire pile bearing areas, and is indicated when there are masses of varicose veins which occupy the whole of this region. A circular incision is made at the junction of the skin and mucous membrane; the tube of mucous membrane containing the varicose veins is then dissected up and amputated, and the divided mucous membrane sutured to the skin. Stricture and incontinence occasionally follow this operation. Linear excision is the operation we prefer, since it is as safe, so far as bleeding is concerned, as ligation, and does not leave strangulated tissue to be eliminated later. The lower extremity of the pile is caught with forceps and drawn downwards. The artery supplying the pile is felt pulsating above its upper end. RECTUM AND ANUS 837 and tiefl with a suture-ligature of catgut. The suture is pulled upwards, the forceps downwards, and the pile above the forceps snipped off with scissors in the axis of the bowel. The wound, which bleeds very little if the artery has been ligated, is closed by continuing the suture down to the forceps, which are removed by cutting beneath them, and the edges of small raw surface thus left brought together with an additional stitch. After any of these operations the parts are protected with a sterile gauze pad, and washed each day with salt solution. The patient takes a half ounce of mineral oil three times a day, and, if the bowels have not moved by the third or fourth day, several ounces of the oil with an ounce of glycerin are given by enema. It is often necessary to catheterize the patient for the first day or two, owing to reflex retention of urine. The treatment of hemorrhoids by ignipuncture, and by the injec- tion of carbolic acid or other substances, is not recommended. Prolapse of the rectum may involve the mucous membrane only {incomplete prolapse, or prolapsus ani) or the entire rectal wall {complete prolapse or prolapsus recti). Complete prolapse presents itself in there forms. 1. The sigmoid or the upper rectum becomes invaginated (intussusception), but does not protrude through the anus. 2. The intussusceptum, beginning at any point in the rectum or the sigmoid, passes through the anal canal, which acts as the intussuscipiens, hence there is a deep sulcus between the skin and the outer surface of the prolapsed bowel. 3. The anal canal also is turned inside out, and merges with the surrounding skin without the intervention of a groove. This form may or may not be the result of the first or the second form. The causes are relaxation of the tissues, such as is seen in the de- biliated, and conditions which give rise to repeated and violent straining e.g., enlarged prostate, urethral stricture, stone in the blad- der, phimosis, constipation, diarrhea, and various kinds of rectal irritation, especially worms and pol>TDi. An incomplete prolapse appears as a reducible, red or purplish cuft" of mucous membrane. In complete prolapse the mass may be of large size, irreducible, dry, and sometimes ulcerated or even strangulated. If the upper rectum or the sigmoid is extruded, coils of small intestine or the uterus or ovaries may be found between the ascending and the descending layers of the prolapse. The treatment is removal of the cause, and reduction of the pro- lapse by pressing the finger in the orifice after the parts have been 838 MANUAL OF SURGERY oiled; reduction is maintained by strapping the buttocks together with adhesive plaster, leaving an opening for the passage of feces. In children cure is often thus obtained, if care is taken to prevent constipation. In adults the parts may be kept in place by a T- bandage, and a daily movement of the bowels secured while the patient lies on one side. An enema of cold water containing an astringent, such as tannin or fluid extract of hydrastis, also is useful. When these measures fail in the incomplete variety, longitudinal strips of mucous membrane may be excised and the wounds sutured, or the same result obtained by the use of caustics or the cautery. In the first form of complete prolapse the sigmoid may be fastened to the abdominal wall through an incision in the iliac region {colopexy) . In the second and the third forms, particularly when irreducible, the prolapsed gut may be amputated, its continuity being restored by sutures. Numerous other methods are described, operations designed to narrow the anus, e.g., by a wire suture, injection of paraffin, excision of a wedge of tissue, are generally useless. Sutur- ing the rectum to the sacrum, and the coccyx (proctopexy) through a postanal incision is occasionally successful. In Mosclicowitz's operation the abdomen is opened, the rectum pulled upwards, and the cul de sac of Douglas obliterated with sutures which include the pelvic fascia. Ulcer of the rectum may be simple (due to foreign body, abrasion of feces, etc.); specific, e.g., syphiHtic, gonorrheal (these two especially in women), tuberculous, dysenteric, or typhoidal; or malignant. The symptoms are those of rectal irritation, with constipation or diarrhea, and the discharge of mucus, pus, or blood. The diagnosis is made by digital examination and the speculum. The nature of the ulcer may be ascertained from the history, the local characteristics, which are much the same here as elsewhere, from bacteriologic and histologic studies, and from other tests for the diseases mentioned above. The treatment in non-malignant cases is local applications of silver nitrate, 20 or 30 to grains the ounce, after cleansing the rectum with hot water. Iodoform is useful, particularly in tuberculous cases; appendicostomy or tempo- rary colostomy may be indicated if the ulcer is extensive and recal- citrant. The general health should receive attention, and in specific or syphilitic cases appropriate internal treatment administered. Tumors of the rectum are considered below. Stenosis or stricture of the erctum may be caused by pelvic neoplasms or cellulitis, and by the cicatrization of wounds or ulcers of the rectum. It may be also congenital or due to malignant RECTUM AND ANUS 839 tumors in this region; the hitter will be considered separately. Excluding carcinoma most rectal strictures are syphilitic, and these are much more frequent in women. The bowel is dilated above the stricture and secondary fistulas may form. The symptoms are pain, discharge (mucus, pus, or blood), constipation, deformity of the stool (ribbon or pipe-stem), occasionally attacks of diarrhea, due to enteritis from the irritation of retained feces, and finally in some cases complete obstruction. The diagnosis is made with the finger, the speculum and, after a barium enema, with the X-ray. The treatment in the extrinsic variety is removal of the cause, e.g., a pelvic neoplasm, in the intrinsic form gradual dilatation with bougies. When in the lower part of the rectum, the stricture may be incised posteriorly. In suitable cases the fiarrowed segment may be excised, and the ends of the bowel united by suture. In extensive and intractable cases colostomy may be the only possible remedy. Any constitutional disease, e.g., syphilis or tuberculosis, should receive treatment. Tumors of the anus are uncommon. Epithelioma in this region presents its usual features, and causes enlargement of the inguinal glands. Cancer of the anus, however, is usually secondary to that of the rectum. The treatment is excision, with the inguinal glands. Tumors of the Rectum, — Polypus recti is the most common benign tumor, is most frequent in children and is an adenoma with a long pedicle. Often there are several polypi, and sometimes a great number. In adults cancerization is a possibility. The symptoms are rectal irritation, the passage of blood or mucus, and occasionally prolapse or intussusception. The treatment is removal, after ligating the pedicle. Papilloma is unusual, but may occur as a cauliflower mass, the chief symptoms of which are hemorrhage and rectal irritability. The treatment is removal, with a portion of the environing mucosa. A microscopic examination should always be made to exclude malignant disease. Sarcoma is rare; it appears as a large flesjiy mass, without primary ulceration. The symptoms are the same as those of cancer, but occur at an earlier age. The treatment is extirpation. Leukemic tumors, which may occur in leukemia and Hodgkin's disease, although exceptional, should be mentioned because, owing to ulceration and hemorrhage, they may be mistaken for other lesions. Cancer of the rectum is usually cyhndrical-celled, and forms 60 per cent, of the carcinomata of the large bowel. The disease may begin as an ulcer, or as a nodule beneath the mucous membrane which reaches a large size before ulcerating. In the former instance the 840 MANUAL OF SURGEEY growth ordinarily extends annularly around the rectum, in the latter it increases equally in all directions. The consistency varies with the amount of fibrous tissue present ; thus the mass may be soft, f ungating and friable, or extremely dense with an ulcerated surface, the margins of which are hard and everted. The softer varieties are the more malignant. Metastases may occur in the lumbar glands, liver, and peritoneum, but are comparatively rare and late. The disease is most common in and after middle life, but it may occur earlier and has been seen even in childhood. The symptoms are (i) those of ulcer, i.e., pain, rectal irritability, and the discharge of pus, blood, or mucus; (2) those of stricture, i.e., diarrhea, consti- pation, deformed stools (ribbon or pipe-stem), and finally complete obstruction, which is less frequent than one would think, since, particularly in soft growths, the ulceration keeps the canal open; and in the final stage (3) those of carcinomatous cachexia. In many cases the symptoms are slight or absent, until the disease is far advanced. Of considerable significance is a sense of fullness in the rectum, and "morning diarrhea." The bowels move after breakfast, without, however, complete, satisfaction and later there is another call or perhaps frequent calls to stool, a small quantity of bloody mucus and gas being discharged with tenesmus; this gives no relief or only temporary relief. In the later stages secondary fistulae into the bladder, vagina, or opening externally may form. The diagnosis is made with the finger, the speculum, and, after a barium injection, with the X-ray. In doubtful cases a piece may be excised for microscopic study. Death occurs in from one to five years, from exhaustion, obstruction, hemorrhage, or peritonitis. The treatment may be palliative or radical. Palliative treatment is indicated when the growth cannot be removed. The rectum is irrigated daily with salt solution, opium given for pain, and colostomy performed at an early period and not postponed until obstructive symptoms supervene, as it diverts the fecal current and thus di- minishes pain and retards the progress of the disease. Radiotherapy also may be used. Radical treatment, or excision of the rectum, is indicated when the growth is movable and metastases are not present. If the sacrum, base of the bladder, or uterus is involved, operation is useless. The mortality of complete excision of the rectum is about 25 per cent., and cure results in about the same proportion. Surgeons differ as to the necessity of a preliminary inguinal colostomy. We believe it should always be performed, because as soon as the abdomen is opened the upper limits of the growth can be determined with RECTUM AND ANUS 841 accuracy, and the liver, the lymph glands, and the peritoneum explored for metastases; because as soon as the bowel is opened the obstruction, if such exists, is overcome, and the intestinal tract drained of toxic material, thus permitting liberal feeding and assisting in recuperation of the patient before the larger operation; because, owing to subsidence of the inflammation consequent upon functional activity, the mass often diminishes in size; and because the rectum can be thoroughly irrigated before, and the field of opera- tion kept clean and quiet after, the .tumor is excised. The chief ob- jections arc the additional risk involved in closing the artilicial anus, if such be desirable, and the interference with thorough mobilization of the rectum at the time of excision; the latter objection loses its force if the sigmoid is pulled well down at the time of the colostomy, or if, owing to a short mesosigmoid, the artificial anus is made in the ascending or transverse colon. The following are the routes by which the rectum may be excised: The vaginal route is indicated when a small growth exists on the anterior wall. The posterior wall of the vagina is split, the growth excised, and the vagina and rectum sutured. The anal route is indicated when the growth is very low. The anus is dilated, a circular incision made through the rectal wall above the external sphincter, the rectum pulled out through the anus and amputated, and the two ends sutured. If the anus is involved it also must be removed, the primary incision then being made around the anus externally. The perineal route is indicated in growths occupying the lower two or three inches of the rectum, and is much the same as the pre- ceding, except that the incision extends back to the coccyx and, if necessary, as far forward as the scrotum. In some cases the external sphincter may be preserved. The sacral route (Kraske^s operation) is indicated in higher growths. With the patient on the right side, an incision is made from the posterior margin of the anus, upwards in the middle line, to the second piece of the sacrum. The coccyx is excised, the left side of the sacrum below the third foramen (the third sacral nerve sends a branch to the bladder) removed with the chisel, and the rectum extirpated. If the sphincter is not involved, the upper segment may be sutured to the lower. When this is impossible, the upper segment of bowel may be sutured in the sacral wound, or the end may be closed by sutures, providing, of course, a prelimi- nary colostomy has been made. In the Kraske operation the perito- neum is often opened, subsequently being sutured, or packed with 842 MANUAL OF SURGERY gauze. There are several modifications of this operation, involving more extensive removal of bone or osteoplastic resection. The ab domino -perineal route is indicated in cases in which the growth extends too high to be removed by any of the preceding methods. In Quenu '5 operation the abdomen is opened in the middle line, both internal iliac arteries tied, the sigmoid divided, the upper segment of the bowel brought out through an incision in the left iliac region, thus making a permanent artificial anus, and the lower segment separated as far down as possible. The abdominal wound is then closed, and the rectum removed thrcugh the perineum. In Weir's operation the abdomen is opened, the gut divided above the tumor, the upper end of the lower segment invaginated and pulled out through the anus, and the involved segment amputated. The lower end of the upper segment is then drawn through the anus, and united to the lower segment by sutures (Maunsell's method). (^HAP! KR XXTX URINARY ORGANS KIDNEY AND URETER Congenital abnormalities of the kidney include (a) absence or atrophy of one organ, the other being hypertrophied {single kidney); (h) fusion of the kdneys (solitary kidney), constituting a disc shaped mass lying in the middle line, or if the lower poles are joined, the horseshoe kidney; (c) lobulation, which is normal in fetal life and in some animals; (d) doubling of the ureter in whole or in part; (e) stric- ture of the ureter; (f) two or more renal arteries for the same organ; and (g) displacement of the kidney, which may be freely movable and supplied with a mesonephron {congenital floating kidney) , or fixed at any point as low as the sacrum or the internal abdominal ring {ectopic kidney), it probably being drawn to the latter situation by the descent of the testicle; (h) sarcoma, hydronephrosis, and cystic disease also may be congenital. Examination of the Kidney.^(i) To palpate the kidney one hand is placed under the loin and the other in front beneath the ribs, while the patient breathes deeply. The patient should be on the back, on the opposite side, or in some cases standing up. The normal kidney descends slightly on deep inspiration but ordinarily cannot be palpated. An enlarged ureter can sometimes be felt through the rectum, vagina, or abdominal wall. (2) The chief value of percussion is in determining the relations of a swelling in the loin to the colon; the kidney is always behind the colon. (3) The X-rays may show the normal kidney, enlargements of various sorts, tuberculous foci, stones, the ureter (after the passage of an opaque catheter), or the ureter and the renal pelvis (after the injection of an opaque solution — Pyelography, Fig. 469). As food, fecal matter, and gas within the intestines produce confusing shadows, the diet should be limited to liquids for 24 hours and the bowels cleared by purgation before the picture is taken. The urine should be examined chem- ically, microscopically, and in some cases bacteriologically, and a record kept of the quantity secreted. (5) Cystoscopy allows direct inspection of the ureteral orifices (see "Examination of the Bladder") and catheterization of the ureters. The latter permits the collection of unmixed urine from each kidney, and is of great value in determin- ing the presence of both kidneys, the location of disease in one or both 843 844 MANUAL OF SURGERY organs, the patency of the ureter, the size of the pelvis, and Hke condi- tions. The technic is given in the section on "Cystoscopy." (6) The functional capacity of the kidneys is considered below. (7) Pig. 469. — Skiagraph inade after injecting collargol (lo per cent.) into the real pelvis (pyelography), showing the size, shape, and position of the renal pelvis and ureter. Thorium nitrate (15 per cent.), potassium iodid, sodium bromide (25 per cent.), argyrol. and other substances opaque to the X-ray may be employed instead of collargol. Irregularities in the outline of the pelvis may be seen in pyelitis, tumors, tuberculosis, hydronephrosis, and pyonephrosis. The position of the shadow will aid in the differen- tiation of abdominal tumors, in the detection of solitary, ectopic, and horseshoe kidney, and in the localization of renal calcuU (calculi in the cortex will appear distinct from the pelvic shadow). Various forms of ureteral obstruction and dilatation also can be demon- strated. Care must be exercised in making the injection, which should be discontinued if the patient complains of pain. If too much pressure is used the collargol may be forced into the parenchyma 01 the kidney, or into a ruptured vein, thus causing collargol embolism. Several deaths have occurred after pyelography. Exploratory incision is indicated when all other methods fail to give the desired information, but only in cases in which the symptoms are sufficiently grave to demand operation. URINARY ORGANS 845 The functional capacity of the kidneys is determined before performing a >c'ri()us ()i)irati()n on one or^^an, and it is important to ascertain that the other kichiey is not only present and healthy, but also sufficiently active to preserve the patient. After collecting the urine from each organ separately and simultaneously, one or more of a number of different methods may be employed, but only the few that are of actual service will be mentioned. (i) The amount and composition of the urine secreted by each kidney in a given time is determined. The normal output of each kidney in twenty-four hours is 500 to 750 cc. of urine, 10 to 15 grams of urea, 5 to 6 grams of chlorids. A decrease of one-third in these quantities indicates that the kidney is incompetent to sustain life. (2) The pJiloridzin test consists in the subcutaneous administration of 5 milligrams of phloridzin, which is transformed into sugar by the secreting cells of the kidney. If these cells are normal, sugar should appear in the urine in from fifteen to thirty minutes, and continue to be excreted for four hours. Delayed or prolonged elimination points to renal insufficiency. (3) Chromocystosco py consists in watching the ureteral orifices for the excretion of blue urine, after the intramuscular injection of methylene blue (15 minims of a 5 per cent, solution) or indigocarmin (4 cc. of a 4 per cent, solution). A simpler plan is to insert ureteral catheters and note when the blue urine appears externally. Nor- mally this should occur in from 10 to 20 minutes and continue 24 to 48 hours. If the blue is late in appearing or disappearing the renal parench}Tna is diseased. The phenolsulphonephthalein test is the one Usually employed. Six milligrams of this agent are injected intramuscularly. The urine drains from the catheter into a test- tube containing i drop of a 25 per cent, sodium hydroxid solution, which becomes pinkish when the drug appears in the urine. As acid urine shows only a faint orange tinge, it is made decidedly alkahne by adding more sodium hydroxid solution, when it turns to a brilliant red. The urine excreted during the first hour is collectedseparately from that excreted during the second hour; each hour's output is now diluted to i liter with distilled water, and a small filtered portion compared, by means of a colorimeter, with a standard con- sisting of 3 milligrams of phenolsulphonephthalein and i or 2 drops of sodium hydroxid solution (25 per cent.) in i liter of water. The reading must be divided by two, since the standard solution contains only half the amount injected, thus if the standard is adjusted to the 10 mark, and the colored urine reaches 20, the excretion is 50 per cent, of the 3 milligrams of the standard, or 25 per cent, of the 6 846 MANUAL OF SURGFEY milligrams injected. Normally the drug appears in the urine in from 5 to 10 minutes, 50 per cent, being eliminated during the lirst hour, 15 to 25 per cent, during the second hour. If the drug is given intravenously it appears in the urine in from three to live minutes, 30 per cent, being excreted in the lirst 15 minutes, and from 70 to 80 per cent, in the first hour. (4) Chemical examination of the blood promises to be of decided value in estimating the renal function. Normally the nonprotein nitrogen content is below 30 milligrams to the 100 cc. of blood, the urea nitrogen about one-half of this amount, and the creatinin from one to two milligrams. When the first reaches 60 or 70 and the last 2 or 3, there is decided danger in operating, while over 100 milligrams of nonprotein nitrogen is rarely found in conditions other than uremia. The presence of two kidneys may be determined by the cysto- scope (presence of two ureteral orifices) , by the segregator, by palpa- tion externally (occasionally) or through an incision, and in some instances by the X-ray. Hematuria, or blood in the urine, may be due to local or general causes. Among the local causes are inflammation, congestion, trau- matism, embolism, thrombosis, calculus, tumors, ulceration, and parasites in any portion of the urinary tract. The most important parasite is the Bilharzia hematobia, which, in portions of Africa, enters the body with the drinking water and later develops in the veins of the intestine or urinary apparatus. The hemorrhage is caused by the discharge of ova through the mucous membrane. Bleeding may be produced also by disease in neighboring structures, e.g., appendicitis, pelvic neoplasms and inflammations and in the female bloody urine may be the result of contamination with the menstrual fluid. Among the general causes are bacterial toxemia, e.g., from sepsis, variola, measles, scarlet fever, enteric fever, yellow fever, malaria, plague, and pneumonia; certain blood diseases, e.g., scurvy, leukemia, purpura, and hemophilia; intoxications, such as jaundice or those due to mercury, lead, arsenic, cantharides, turpen- tine, and quinin; hysteria; and vicarious menstruation. When the cause for the bleeding cannot be found the condition is called essential hematuria (vide infra). The color of the urine varies from red to black. It should be recalled that senna, rhubarb, beet root, and sorrel make the urine red ; and carbolic and salicylic acids, brown or black. Hemoglobinuria is characterized by the absence of corpuscles. It may be due to any of the causes mentioned above; to certain ner- vous affections, e.g., angio-neurotic edema, Raynaud's disease, or URINARY ORGANS 847 Henoch's ]nir]nira; or to hemolysis, the result of extensive burns, freezing, large extravasations of blood (especially into the abdomen), transfusion of blood, infusion of salt solution, paroxysmal hemo- globinuria, or hemolytic poisons, e.g., ether, chloroform, snake- venom, phosphorus, carbolic acid, carbon monoxid. In rental hematuria the blood is intimately mixed with the urine, and may con- tain blood casts of the renal tubules or ureter. By cystoscopic examination blood may be seen issuing from the ureter. In ureteral hemorrhage bleeding is often slight and detectable only by microscopic examination. In vesical or prostatic hematuria the urine is often alkaline, contains clots, and most of the blood is passed at the end of micturition. In urethral hematuria blood drips from the urethra independently of micturition, and the final urine passed may be quite clear. Pyuria, or pus in the urine, may be due to inflammation, or rupture of an abscess, into any portion of the urinary tract. In women with leukorrhea pyuria should not be diagnosticated unless the specimen is obtained by catheter. In renal pyuria the urine is usually acid and the pus can be washed quickly from the bladder, in vesical pyuria the urine is generally alkaline, and it is diffi.cult to make the washings clear. Pus from the prostate may be expressed into the urethra by pressure through the rectum, and pus from the urethra appears in the first portion of urine passed. The source may often be located with the cytoscope or the urethroscope. Chyluria may be due to obstruction of the thoracic duct (tumor of the duct, pyloric carcinoma, calcified lymph glands, gravid uterus, dilated right auricle) , but is usually caused by filariasis. Anuria is the condition in which no urine is passed and the bladder is empty. It should not be confused with retention of urine, in which the bladder is distended (see "Bladder ") . Anuria may be obstructive or non-obstructive. Obstructive anuria may be caused by obstruc- tion of the ureter of the only existing or only functionating kidney, or in rare instances by obstruction of both ureters simultaneously. The causes of ureteral obstruction are given under "Hydronephro- sis." In this variety of anuria uremia may not supervene for a number of days, even though no urine is passed. The treatment is nephrotomy upon the obstructed side, in order to allow the urine to escape. The side to be operated upon will usually be indicated by pain, tenderness, muscular rigidity, and possibly by enlargement of the kidney. Removal of the cause of obstruction, unless very easy, should be undertaken at a later date. Non-obstructive anuria {suppression of urine) may be reflex or due to degenerative changes in 848 MANUAL OF SURGERY the kidneys. Among the reflex causes are operations on or injuries to any portion of the genitourinary apparatus, obstruction to one ureter the other remaining free, hysteria, and extensive burns; in this group also uremia may be postponed for some days. The treatment is at first medical, and later nephrotomy upon one or both kidneys. Degenerative changes in the kidneys may be caused by nephritis; acute infectious diseases, including septicemia; poisons, such as phos- phorus, turpentine, carbolic acid, cantharides, ether, and chloroform; and by lesions like tumors, tuberculosis, and cystic disease of both kidneys. In these cases uremia accompanies or precedes the anuria. The treatment is usually medical, although in a few instances favor- able results have followed nephrotomy. For rupture of the kidney and ureter see "Contusions of the Abdomen." Wounds of the kidney give the same symptoms as ruptures, plus an external wound, from which blood and urine may escape. The treatment is that of ruptures. Wounds of the ureter may be produced by stabs, bullets, and most frequently by the surgeon during abdominal operations, espe- cially hysterectomy. The result is peritonitis, localized or generalized, and if the patient survive, a urinary fistula. The immediate treatment of a lateral wound is suture; of complete division, anastomosis. Ligation of the ureter, which is sometimes unintentionally per- formed, particularly during gynecological operations, causes atrophy of the kidney or, owing to ulceration of the ligature through the ureteral walls, an abscess, which on breaking leaves a fistula. If, owing to anuria and pain in the back, ligation of the ureter is sus- pected, the diagnosis may be confirmed by the ureteral catheter, and the ligature removed, or the crushed segment resected and one of the operations described under ''Ureteral Anastomosis" performed. Ureteral fistulae, in addition to ruptures, wounds, and ligation, may be caused by sloughing following labor, or ulceration the result of conditions like tuberculosis, carcinoma, and calculus. The fistula may open into one of the hollow viscera, the vagina, or on the skin. The diagnosis from vesical fistula can be made by injecting colored fluid into the bladder and by cystoscopy. The first step in treatment should be the passage of a catheter along the ureter, from the bladder, in order to determine whether the defect is lateral or complete and to make sure the canal below the fistula is pervious. If the defect is lateral and no obstruction exists spontaneous healing may occur. Cutaneous fistulae in which sppotaneous closure is URINARY ORGANS 849 unlikely shoukl be treated by some form of ureteral anastomosis (q.v.); vaginal listulx- as described under "Vagina." Movable kidney, or nephroptosis, is to be distinguished from floating kidney; in the latter condition, which is said to be always congenital, the kidney passes forward into the abdominal cavity and is completely surrounded by peritoneum, being attached to the pos- terior abdominal wall by a mesonephron. In movable kidney the organ is excessively mobile behind the peritoneum. Eighty per cent, occur in women, and the right kidney is involved in about the same proportion. It is most common between twenty and forty, , but may be seen at any time of life. The adrenal gland remains in place, since it lies in a separate compartment of the perirenal fascia. The causes are conditions which render the abdominal walls flaccid, such as pregnancy, emaciation, and the removal of abdominal tumors; Glenard's disease; tight lacing; trauma; and conditions which increase the size or weight of the kidney. In many cases no cause can be found, beyond the fact that the patient has a long and slender waist, and this bodily conformation is inherited, hence movable kidney may exist in several members of the same family. According to the symptoms the cases may be divided into four classes, (i) In most cases symptoms are absent. (2) In others there is dragging pain in the loin, with indigestion and nervousness. (3) In this class complications arise. If the ureter becomes kinked or twisted, there is transient hydronephrosis, with violent pain in the kidney and epigastrium, vomiting, collapse, and subsequently elevation of temperature and the discharge of a large quantity of urine (Dietl's crisis) ; if the pedicle becomes twisted gangrene of the kidney may ensue. Dragging on the duodenum or bile ducts may cause gastric and biliary disturbances and even jaundice, and the conditicn is not infrequently as-^ociated with chronic appendicitis or mucous colitis. Albuminuria, pyuria, and occasionally hematuria may octur, from congestion of the kidney or pyelitis. (4) In this group the prolapse is secondary to tuberculosis, tumor, hydro- nephrosis, or some similar malady, hence presents the same symp- toms as the primary trouble. In all cases the symptoms are inten- sified by exercise or by lying on the sound side, and are usually •reheved by lying on the back. The diagnosis is made by feeling the kidney descend below its normal level on deep inspiration. In the severe forms the hands can be approximated above the kidney, and in the worse cases the kidney may be found in the pelvis; percussion over the loin is said to give resonance, but the sign is fallacious. The X-ray may show the position of the kidney and reveal unsus- pected conditions, e.g., a calculus. 850 MANUAL OF SURGERY Xo treatment is required in class i ; above all the patient should not be told that the kidney is movable. The treatment in class 2 is the application of a straight front corset, adjusted while the patient is lying down, forced feeding, tonics, and rest; in class 3, nephropexy in class 4. that of the cause. Essential hematuria (renal hcmo philia) is a condition in which there is constant or intermittent bleeding from one kidney, which on exploration appears to be normal. Even microscopic examination of sections removed at operation may reveal nothing pathologic, although in some instances the tissue shows the changes of a diffuse interstitial nephritis. There may be pain in the loin and sometimes, owing to the passage of clots down the ureter, renal colic. Cysto- scopic examination shows blood isfuing from the ureter on the aft'ected side. The kidney should be explored for diagnostic pur- poses. If a lesion is found, the hematuria ceases to be ''essential," and the treatment is that of the cause; if no lesion is found the kidney may be decapsulated, but in many instances, especially if a large amount of blood has been lost, nephrectomy is the better procedure. Hydronephrosis, or uronephrosis, is distention of the pelvis and calices with urine, as the result of gradual or intermittent obstruction of one of the passages below. Sudden and complete obstruction to a ureter results in cessation of the urinary secretion as soon as the back pressure is sufficiently high, and after a time in renal atrophy; if, however, the obstruction is removed within a few wrecks restoration of the function of the kidney may follow. The causes are congenital and acquired. Congenital hydronephrosis is due to atresia of some portion of the urinary passages; acquired hydronephrosis to obstruc- tion of the ureter by calculus, blood clot, parasites, plugs of mucus or pus, or stricture; by tumors, abscesses, cysts, pregnant uterus, or other forms of external pressure; by valve formation at the junction of the pelvis and ureter owing to oblique insertion; by kinking, e.g., over an accessory renal artery or from excessive mobility of the kid- ney and less commonly to obstructions in the urethra. In the last instance the hydronephrosis may be double. As the result of the accumulation of urine in the pelvis of the kidney the cortex becomes thin and in the linal stages disappears, the kidney being converted into a large, thin walled, irregular cyst. At this time the fluid may not contain urea or other urinary solids. Infection and consequent pyonephrosis may occur at any time.. The symptoms are combined with those of the causative lesion. Distention of the kidney gives rise to pain and a tumor in the loin, which fluctuates, is dull on percussion, lies behind the colon, and may URINARY ORGANS 85I disappear with the ])assagc of a hirge amount of urine. Alternating ischuria and polyuria is known as the jlush-lank symptom. The cystoscopc will show absence of urine on the afTected side, and the ureteral catheter may reveal the obstruction. If the catheter passes the obstruction the size of the pelvis may be determined by mea.^uring the quantity of water (colored with methylene blue or collargol, 2 per cent.) which can be injected before it escapes from the ureter alongside of the catheter (normal pelvis holds from 5 to 30 cc), or by taking a pyelogram (Fig. 469). Calculi also may be detected with the X-ray. Death occurs from uremia, sepsis, pressure on important organs, or rupture into the peritoneal cavity. The treatment is removal of the cause if possible, and preservation of the kidney. Aspiration is not recommended. If the kidney is totally destroyed, or if the obstruction cannot be removed, or if a permanent sinus follows a previous nephrotomy, nephrectomy should be performed, provided the other kidney is sufficiently active to maintain life. Pyelitis, or inflamrhation of the pelvis of the kidney, is caused by the colon bacillus in 75 per cent, of the cases, either alone or mixed with other pyogenic organisms, the most frequent of which are the streptococcus and the staphylococcus. The bacteria reach the renal pelvis by one of five routes (i) ascending infection travels up the ureter by continuity, or by means of regurgitated urine {urogenous) . It is the result of obstruction or inflammation in the lower urinary passages (ureter, bladder, urethra). (2) Hematogenous infection occurs in acute fevers, such as the exanthemata, typhoid, diphtheria, pyemia; and possibly in those cases depending primarily upon localized forms of irritation, e.g., calculus, parasites, (the chief of which is the Bilharzia hematobia), tuberculosis, tumor, contusion, and the excretion of drugs like turpentine and cantharides. It may be stated that ordinarily bacteria excreted by the kidneys produce no evil effects, unless there is some local irritation or some obstruction to the free discharge of urine. Pressure of the gravid uterus on the ureter may thus contribute to the etiology of the pyelitis of preg- nancy. (3) Lymphatic injection accounts for the frequency of the colon bacillus; the lymph vessels from the ascending and descending colon pass over the renal capsule of the corresponding side, and communicate with the lymph vessels of the kidney. It may be possible also for bacteria to travel from the bladder along the lym- phatics of the ureter. (4) Direct injection is the consequence of wounds or fistulae. (5) Injection by contiguity is due to inflammation extending from the surrounding structures. 852 MANUAL OF SURGERY The symptoms are pain and tenderness in the kidney, frequent micturition, intermittent pyuria, and fever during the absence of the pus from the urine, which is acid unless there is a coexisting cystitis with decomposition of the urine. Owing to the obstruction to the urinary flow caused by swelKng of the mucous membrane or other lesion, a pyonephrosis may develop and extension to the kidney occur {pyelonephritis) ; suppuration may extend also to the surrounding tissues. The treatment is hot fomentations, alkaline waters, diuretics, urinary antiseptics, and. to decrease the number of colon bacilli in the large bowel, laxatives. The external genitals, especially in infants, must be kept clean; circumcision should be performed if there is phimosis; and, in order to lessen the pressure on the ureters, pregnant women may assume the knee-chest position several times daily, and, when sleeping, lie on the side instead of on the back. Autogenous vaccins are of doubtful value. Lavage with a weak solution of one of the silver salts, introduced through a ureteral catheter, is beneficial in some cases. If the condition be caused by an ascending infection, the bladder should receive appropriate treatment. Other causes if evident should be removed. If no cause can be ascertained and the symptoms persist, the kidney should be explored, since in many cases the distinction between pyelitis, pyelonephritis, and other septic conditions of the kidney cannot be made with certainty. Pyelonephritis is pyogenic inflammation of the pelvis of the kid- ney and of the renal parenchjona, and is due to the same causes as pyeHtis. The symptoms are chills, fever, pain and tenderness in the kidney, vomiting, headache, and later signs of exhaustion and uremia. The urine is small in amount, usually contains pus, and sometimes blood. The treatment is that of pyeHtis. If both kidneys are afifected the prognosis is extremely grave. Pyonephrosis, or distention of the pelvis of the kidney with pus, is the result of infection of a hydronephrosis, or retention of pus in pyelitis. The cortex is invaded and the kidney finally represented by a large multilocular pus sac (Fig. 470), surrounded by adhesions, through which the pus may break establishing a fistulous communi- cation with the bowel or the skin, or setting up a fatal peri- tonitis. The symptoms are those of hydronephrosis, plus those of sepsis. The quantity of pus in the urine depends upon the degree of obstruction. It may be intermittent or entirely absent. Death occurs from sepsis or uremia. The treatment in unilateral cases is nephrotomy, removal of the cause if possible, and drainage, or if the kidney is hopelessly disorganized, nephrectomy. If both organs are URINARY ORGANS 853 involved treatment is usually hopeless, although double nephrotomy may be employed in suitable cases. Abscess of the kidney is due to the same causes as pyelitis. Pyemic abscesses are always small and multiple, and generally bilateral, hence not amenable to treatment. Chronic abscesses are usually tuberculous. The symptoms of an acute solitary abscess are pain, tenderness, and muscular rigidity on the affected side, and the constitutional symptoms of sepsis. The abscess cannot be detected by palpation unless it is of large size. Pyuria may be present or absent. The treatment is nephrotomy and drainage, or, if the whole kidney is destroyed, nephrectomy. Acute unilateral hematogenous infection of the kidney is due to pyogenic cocci which have been brought from a distance, e.g., from the tonsil or a furuncle. The kidney is swollen, and studded with minute reddish areas, which suppurate. Several of these abscesses may then coalesce, and the process extend to the pelvis. The symp- toms are sudden severe pain in the back and sometimes in the abdo- men; tenderness, which is most marked in the costovertebral angle; muscular rigidity; and general evidences of sepsis, frequently ter- minating in dehrium, coma, and death. The urine on the affected side, as determined by cystoscopy and ureteral catheterization, may be scanty and contain pus and blood, but if the pelvis is not involved the urine may be clear. The condition is not infrequently confused wuth intraabdominal affections, especially when right sided, with appendicitis. The treatment is nephrectomy. Perinephritis, or inflammation of the perinephritic fat, may be caused by trauma, infection from the blood, and extension from environing parts (spine, pleura, ribs, liver, intestine), but is usually secondary to suppurative processes in the kidney. The symptoms are pain, tenderness, muscular rigidity, and if suppuration occurs, fever, and the presence of a mass in the loin. A perinephritic ab- scess usually points alongside of the erector spinae, but may descend into the iHac fossa or burst into the pleura, peritoneum, or intestine. The treatment of perinephritis in the absence of suppuration is hot fomentations, sedatives, and attention to the general health; a peri- nephritic abscess should be opened and drained. In all cases the cause should, if possible, be determined and removed. Spontaneous perirenal hematoma is due to the rupture of one of the blood vessels of the renal capsule, or, more rarely, to the rupture of a vessel in the neighborhood of the kidney. The blood collects beneath the capsule, or breaks through the capsule and infiltrates the retroperitoneal tissues, sometimes extending as far as the dia- 854 MANUAL OF SURGERY phragm and the scrotum. In most cases the kidney is chronically inflamed and the arteries sclerotic. The symptoms in a severe case are those of internal hemorrhage, with sudden violent pain and a rapidly developing tumor in the region of the kidney. Blood is often not found in the urine. The treatment is nephrectomy, or, in mild cases, evacuation of the hematoma and tamponage. Of i6 cases operated upon recovery followed in ii, of seven not operated upon death ensued in all (Lippens) . Ureteritis, or inflammation of the ureter, is practically always secondary to pyelitis or cystitis. Primary ureteritis is possible, e.g., from calculus or injury, but is very rare. In the acute variety there is a pyogenic inflammation of the mucosa. Clironic ureteritis presents itself in two forms, (i) In the dilated form the ureter is dilated and tortuous from obstruction, the muscular coat under- going h}-pertrophy and the mucosa cystic changes. (2) In the fibroid form the ureter is straight, thickened, shortened, densely adherent, and strictured in numerous places. The symptoms are usually masked by the causative pyelitis or cystitis. Occasionally tenderness can be elicited through the ab- dominal wall, and the thickened ureter can often be felt through the vagina and sometimes through the rectum. The ureteral orifice, as seen with the cytoscope, is dilated or contracted, retracted or pouting, and almost always rigid (noncontracting) and reddened. Strictures are revealed by the ureteral catheter. The treatment is that of the cause. Tuberculosis of the kidney may be ascending or descending. In the former, which is more frequent in men, the original focus is often in the prostate or epididymis, from which the infection spreads to the bladder, thence ascends the ureter and invades the pelvis and finally the parenchyma, hence both organs are generally affected. In the descending type, which represents about two-thirds of the cases, and which is more common in women (3 to i), the bacilh are deposited from the blood and the disease is called primary, i.e., it is primary so far as the urinary organs are concerned, but generally secondary to a lesion in some other portion of the body, notably the lungs. This t>^e is usually unilateral, commences in the paren- chyma, extends to the pelvis and ureter, and in about half the cases to the bladder and the other kidney. The changes are those of tubercu- losis elsewhere. Caseation occurs and the abscesses open into the pehis or exceptionally through the capsule. In the later stages the kidney is densely adherent from perinephritis, thus rendering neph- URINARY ORGANS 855 rectomy difficult and dangerous. The symptoms are frequent mic- turition with dysuria, slight pain, or from transient blocking of the ureter severe colic, pyuria, occasionally hematuria, and in the later stages chills, fever, and sweats, due to secondary infection with pyogenic organisms. The kidney is tender and enlarged, but one should not rely on this sign alone, as the larger organ, even though tender, may be the healthy one, greatly hypertrophied because it is doing the work of both. Nodules may be detected in the prostate, epididymis, vas, or seminal vesicle. Tubercle bacilli are sometimes found in the urine. If they are not found the urine may be inocu- lated into a guinea pig. A sterile pyuria, in itself, is highly suggestive of tuberculosis. The cytoscope reveals a dilated, rigid (noncon- tracting), and, owing to the thickening and shortening of the ureter, retracted ureteral orifice, which is often surrounded by ulcers or tubercles (Fig. 473). The thickened ureter can be felt through the vagina and sometimes through the rectum or abdominal wall. The X-ray may show the tuberculous focus, which, owing to calcareous infiltration, sometimes casts a dense shadow closely resembling that of a calculus. The prognosis is favorable if all of the disease can be removed; decidedly unfavorable in all other cases, death occurring usually from uremia, sepsis, or generalized tuberculosis. Circum- scribed tuberculosis of the bladder due to infection from the kidney may, however, subside after ureteronephrectomy. The treatment is medical if both kidneys are involved. Perinephritic abscesses should of course be incised. If the disease is unilateral the kidney should be explored. If the focus is strictly limited, a partial nephrectomy ^^dth subsequent suture of the wound may be tried, but in most instances the disease will be found so extensive that the entire organ, with the ureter, will require removal. Renal calculi {nephrolithiasis) are formed by the precipitation of urinary salts, which are then bound together by an albuminoid substance derived from the mucous membrane as the result of a preexisting inflammation or as the result of the irritation induced by the deposited salts. The causes are general and local. The most important general cause is faulty metabohsm from overeating, improper diet (excess of nitrogenous food, sugar, and acids, too little w^ater) , alcohol, indiges- tion neurasthenia, lack of exercise, and debilitating diseases character- ized by anemia and wasting. According to the substance which appears in excess in the urine the condition is called the uric acid diathesis (lithemia), oxaluria, phosphaturia, etc. Lithemia and the tendency to the formation of uric acid stones may be inherited. 856 MANUi^L OF SURGERY Renal calculi occur at all ages, are more frequent in males, and are bilateral in 30 per cent, of the cases. The endemic nature of nephro- lithiasis in certain districts has been attributed to the presence of large quantities of lime in the drinking water, or, owing to a warmer climate, to the increased density of the urine as the result of excessive perspiration. In India, Egypt, China, and other tropical countries, where stone is very prevalent, the Bilharzia hematobia orthefilaria sanguinis hominis is held responsible, the ova of the former or the embryos of the latter forming the nuclei for the stones. The chief local causes are infection of the kidney or its pelvis and obstruction to the outflow of urine. Here must be mentioned also the possi- bility of a nucleus, which may be composed of epithelium, bacteria, blood clot, pus cells, a foreign body, or, as mentioned above, animal parasites. The appearance of a renal stone varies with its composition, which, it must be noted, is not always the same throughout. Stones usually consist of uric acid or urates, sometimes of oxalate or phos- phate of lime, and very rarely of carbonates, cystin, or xanthin. Uric acid calcuH are oval, smooth, brownish, very dense, usually laminated, frequently multiple, and sometimes of large size. Those composed of urates are lighter in color, less dense, and not so dis- tinctly laminated. The oxalate of lime calculus is round or oval, very heavy and hard, distinctly laminated, dark brown or black in color, and spiculated or nodular, hence the name mulberry calculus; it develops very slowly, is seldom of large size, and is usually single. Phosphatic calculi are composed of triple phosphates, are whitish, soft, friable, usually fetid and rarely laminated. They form when the urine becomes alkaline from retention and decomposition or from the drinking of alkaline waters, and may attain a large size. Any stone or foreign body may have a phosphatic coating. Car- bonate of Hme calculi are round, hard, and white; cystin calculi small, soft, smooth, friable, and waxy in appearance; xanthin calculi reddish-brown in color, small, and hard. Renal calcuH are multiple in two-thirds of the cases, in which event they are often faceted. They vary in size from fine granules (gravel) to a mass almost as large as the kidney itself (Fig. 470). Stones in the parenchyma are usually rounded; in the pelvis often pyramidal, dendritic, or coral- like, in some cases forming a cast of the pelvis; in the ureter oval. The symptoms vary with the situation of the calculus. If it is situated in the parenchyma (20 per cent, of renal stones) and is smooth there may be no symptoms. As a rule, however, there is pain in the loin, which is increased by jolting, and which may be URINARY ORGANS 857 felt also in the groin, thigh, testicle (sometimes with retraction of this organ), and occasionally along the back of the lower limb as far as the heel. In rare instances it is referred to the other kidney. There may be no urinary changes. Tenderness on pressure can almost always be elicited. Abscess of the kidney may follow. When the stone lies in the pelvis of the kidney (80 per cent, of renal stones) it usually causes pyehtis (pyuria, hematuria, frequent micturition, etc.). If the stone passes douii the ureter symptoms of renal colic follow, viz., sudden, excruciating, paroxysmal pain, passing from the loin along the ureter to the testicle, which is re- tracted; vomiting; collapse; strangury; and hematuria, which is often detectable only by the microscope. The pain ceases if the calculus slips back into the pelvis, or if it reaches the bladder. The stone may lodge near the pelvis of the kidney, close to the bladder, or at the brim of the bony pelvis, the point of impaction being excessively tender. Sudden and complete obstruction is followed by suppression of urine on the corresponding side and atrophy of the kidney, or by death if the other kidney is not functionally active. Occasionally the other kidney, even when healthy, suddenly ceases to secrete urine {reflex anuria) . In- complete or intermittent obstruc- tion causes hydronephrosis or pyonephrosis. In some cases the stone ulcerates through the wall of the ureter into the abdomen or retroperitoneal tissues. Having passed through the ureter the stone may remain in the bladder as a vesical calculus, be passed with the urine, or, particularly in male children, become impacted in the urethra. A calculus in the lower portion of the ureter may occasionally be palpated through the vagina or rectum. The cystoscope may show edema of, or a stone in, the ureteral meatus, a dilated meatus, a difference in the urine on the two sides, or absence of the urine on the affected side. As a catheter sometimes passes Fig. 470. — Skiagram shown. Fig. 471. Calculous pyonephrosis. 858 MANUAL OF SURGERY a stone, Kelly suggests the use of a wax-tipped ureteral bougie, upon which scratches will be made if a calculus is present. The X-rays (Fig. 471) detect the stones in 90 per cent, of the cases. They may fail to show very small stones, pure uric acid stones, and stones hidden beneath the twelfth rib. Failure in the last instance may be avoided by taking two plates at different angles. They may apparently show a stone when none exists, the source of error being a defective plate, or shadows cast by phleboliths, atheromatous plates, appendical concretions, gall stone, tuberculous foci, calcified lymph glands, centers of ossification in the pelvic ligaments, der- FiG. 471. — Skiagram of multiple renal calculi. Specimen shown Fig. 470. moids, foreign bodies, and fecal masses (hence the necessity of preliminary purgation). The shadows of ureteral calculi are gener- ally oval , with the long axis in the line of the ureter. That the shadow is cast by a stone in the ureter (Fig. 472) can be proved by passing an X-ray (leaded) catheter into the ureter and taking stereoscopic plates, or by making a ureterogram, i.e., a skiagram of the ureter filled with an opaque solution. Braasch determines the exact site of a renal stone by means of the pyelogram. If the stone is in the renal pelvis, it may show through the pyelogram, if in a calyx, on the edge of the pyelogram; and if in the parenchyma, separate from the pyelogram. As calculi are present in both the kidneys URINARY ORGANS 859 iind tlu' ureter in 5 per cent, of the cases, and are bilateral in 30 per cent, of the cases the skiagram should always include both kidnevs and both ureters. Fig. 472. — -Skiagram of a ureteral calculus impacted near the bladder. An X-ray catheter was passed into each ureter; oh the affected side the catheter met with obstruc- tion three-fourths of an inch from the ureteral orifice; on the opposite side the catheter passed up the ureter without difficulty. The stone, which was removed e.xtraperi- toneally, through an incision above and parallel with Poupart's ligament, is shown, actual size, in the right lower corner of the illustration. The diagnosis is often missed because of atypical symptoms, thus of 607 patients with nephrolithiasis (combined statistics of Cabot and Braasch) 169, or almost 28 per cent., had had an un- necessary abdominal operation performed. The cases in which confusion is hkely to occur are (a) those in which renal calcuh are 86o MANUAL OF SURGERY mistaken for other conditions, and (b) those in which other conditions are taken for renal calcuh. (a) Gastrointestinal symptoms in nephrolithiasis may arise from pylorospasm, uremia, or, when there is renal cohc, from intestinal paralysis; the gall-bladder, the pylorus, the duodenum, the colon, and the kidney are in close proximity, and the appendix may overlie the ureter; hence the principal con- ditions which renal or ureteral calculi may simulate are gall-stones, gastric or duodenal ulcer, colitis, intestinal obstruction, and most frequently appendicitis. Persistent albuminuria, without casts or other evidences of nephritis, should always suggest the possibility of stone, (b) The principal conditions which may simulate renal or ureteral calculi are diseases of the kidney and ureter other than those produced by stones, vesiculitis, testicular lesions, incipient inguinal hernia with neuralgia of the spermatic cord, appendicits with hematuria, the crises of locomotor ataxia, and spondylitis; all of these, except spondylitis, may give genitourinary symptoms. Of the greatest importance in the differential diagnosis of nephro- lithiasis are (i) the character of the pain in relation to the other symptoms, it often being very severe without muscular rigidity, fever, or leukocytosis, unless there are septic compHcations; (2) costovertebral tenderness, which, owing to distension of the renal pelvis, is frequently present even in ureteral stone; (3) the absence of muscular rigidity, although rigidity is possible, especially in the presence of inflammation, but is then lumbar as well as lateral, and more lumbar than lateral; (4) hematuria, which may be revealed only by the microscope, and which is present in 80 per cent, of the cases; (5) the cystoscope; and (6) the X-ray. The diagnosis can be made with certainty in 90 per cent, of the cases, if one only suspects the condition and has a skiagram made; and it can be made in more than 90 per cent, of the cases, if one employs the cysto- scope and the ureteral catheter. The treatment, if the stone is small, quiescent, and in the parenchyma, may be directed to the lithemia, in order to prevent augmentation of the stone or the formation of others; this consists in exercise, regulation of the diet, attention to the bowels, plenty of water, alkaline diuretics, and piperazin. Under even these circumstances, however, the possibihty of evil effects is by no means small, and unless there are serious contraindications nephrohthotomy is probably the safer course, an operation which becomes imperative if symptoms or complications arise. A stone in the pelvis practically always causes trouble, and, unless minute enough to pass down the ureter, should be removed by pyelohthotomy. A stone moving URINARY ORGANS 86l down the ureter causes renal colic, which requires hot fomentations, hot drinks, and the hypodermatic administration of atropin and morphin. If impaction with complete obstruction occurs immediate operation is demanded to save the kidney, or if there is anuria to save life. In impaction with incomplete obstruction large quantities of water by mouth and injections of sweet oil into the ureter through a catheter may be tried. A calculus projecting into the bladder may be dislodged with forceps introduced through the operating cystoscope; if the calculus is just above the ureteral meatus, the meatus is sometimes dilated, occasionally split. If these measures fail to dislodge the stone it should be removed by one of the forms of ureterolithotomy or, in some cases, when situated near the kidney, by pyelotomy after it has been pushed back into the pelvis. Nephrectomy is indicated only when the kidney is totally destroyed and the other organ is healthy. Recurrence of the stones after operation occurs in 9.8 per cent, of the cases. Naturally some of the so-called recurrences are due to stones that have been over- looked at the time of operation. Tumors of the kidney are relatively infrequent, and include cancer, sarcoma, and hypernephroma, the last forming 80 per cent, of the cases. Sarcoma is most often seen in childhood, hyper- nephroma in and after middle life. Angioma, papilloma, adenoma, and rarely other benign tumors also have been observed. The symptoms are pain, hematuria, and the presence of a growth in the loin, the tumor lying behind the colon, moving slightly with respira- tion, and having the shape of the kidney. The differential diagnosis between renal tumor and an enlarged gall-bladder is given under "Hydrops of the Gall-bladder." Hematuria occurs in 75 per cent, of the cases, and is often profuse, intermittent, and painless. In one of our cases the diseased kidney, probably owdng to its vascularity, secreted more urine than its fellow. In malignant cases acute varicocele may occur from the pressure of enlarged glands on the root of the spermatic vein, and cachexia sooner or later develops. Pig- mentation of the skin indicates invasion of the suprarenal body. Sarcoma, including hypernephroma, may give rise to metastases in the lungs, liver, and bones, indeed secondary growths in the last situation may be the first sign of trouble. Papilloma of the renal pelvis is very likely to become malignant; it may cause death from hemorrhage, and occasionally some of the villous tufts become detached and appear in the urine. In renal tumor the pyelogram may show an indentation or other irregularity in the outline of the- pelvis. The treatment is nephrectomy, unless the growth is benign 862 MANUAL OF SURGERY and small, when it alone should be removed. Recurrence after operation for malignant disease of the kidney takes place in 90 per cent, of the cases. Cysts result from interstitial nephritis (small and not treated surgically), from obstruction to one of the ducts, or from hydatid disease. Dermoid cysts also have been observed. When of large size they may be detected by palpation. In hydatid disease the hooklets may sometimes be found in the urine. The treatment is enucleation, or in the worst cases nephrectomy. Congenital cystic disease of the kidney is characterized by large multilocular cysts, probably the result of defective development of the Wolffian body. The symptoms are the presence of a tumor, and occasionally pain, albuminuria, and hematuria. As both kidneys are involved in 98 per cent, of the cases, surgical treatment is, as a rule, contraindicated ; one may be forced to operate, however, for complications, viz., suppuration, severe hematuria, hydronephrosis, anuria, intestinal obstruction, painful crises due to displacement. When one organ alone is involved, it may be excised; if both organs are affected the operation must be conservative, i.e., nephrotomy, nephropexy, or decapsulation with excision or puncture of the cysts. OPERATIONS ON THE KIDNEY AND URETER The kidney may be exposed through the abdomen or through the loin. The abdominal route is selected if a very large tumor is to be attacked. The incision is made through the semilunar line, the peritoneal cavity opened, and the organ exposed by an incision through the posterior parietal peritoneum at the outer side of the colon. The lumbar route is chosen whenever possible. The patient should be placed upon the sound side with the thighs and knees flexed and a sand bag or air cushion under the loin, in order to widen the costoiliac space and push the kidney up into the wound. The incision may be vertical or oblique. The vertical incision runs close to the outer border of the erector spinae, from one-half inch below the last rib to the crest of the ilium. The fibers of the latissimus dorsi are separated, the lumbar fascia incised, and the quadra tus lumborum and the erector spinae retracted inwards. The last thoracic, the iliohypogastric, and the ilioguinal nerves lie beneath the quadratus and should be drawn aside, or, if severed, sutured at the end of the operation. The kidney is exposed by tearing through the perirenal fat. If more room is needed, the incision may be extended outwards in a transverse direction above the crest of the ilium. The oblique URINARY ORGANS 863 incision extends from the outer l)or(ler of the erector spina^, one-half inch below the twelfth rib, downwards and outwards towards the anterior s]nne of the ilium. The latissimus dorsi, external oblique, internal obliciue, and the transversalis muscle and fascia are divided. Nephropexy has been performed in many different ways, but only the most important can be mentioned. Edehohls delivers the kidney through the wound, excises the fatty capsule, makes an incision through the fibrous capsule along the convex border of the kidney, turns the capsule half way back towards the pelvis, passes two mat- tress sutures through the reflected capsule on each side of the kidney, and replaces the kidney. The sutures are not tied until they have been passed from within outwards through the muscles. The wound is then closed. It has been suggested also to tunnel under the fibrous capsule, and thread the tunnel on the twelfth rib ; to throw a free transplant of fascia lata around the kidney and suture the sling to the fascia of the back. The passage of sutures through the parenchyma is undesirable. Da Costa passes a strip of gauze, com- posed of two pieces sutured together with catgut, around each pole of the kidney, and ties the strips over additional gauze which fills the wound superficial to the kidney. After the catgut is ab- sorbed the strips are easily removed. The gauze creates a bed of cicatricial tissue which holds the kidney in place. Nephrotomy, or incision of the kidney, is performed after deliver- ing the kidney through the wound, whenever possible. The length and direction of the incision will vary with the condition to be treated. When done for exploratory purposes, the incision is made along the convex border, just behind the mesial plane, at which place the ven- tral and dorsal vessels meet and the least bleeding occurs. If neces- sary the whole kidney may be split and laid open like a book. An assistant should compress the renal vessels during this procedure in order to prevent hemorrhage. Through the incision the interior of the kidney and the pelvis can be explored and bougies passed down the ureter. The wound may be closed with mattress sutures of catgut, which necessarily interrupt the vascular supply to portions of the parenchyma. If bleeding continues tamponage with fat or muscle, as described under rupture of the kidney, should be con- sidered. As a rule the wound cannot be made dry, and drainage must be inserted. We have had several dangerous secondary hemorrhages after nephrotomy, demanding removal of the kidney, hence never perform it unless forced to do so. Nephrolithotomy is nephrotomy, plus the removal of stones with the finger or with forceps. The calculi, if not accurately localized by the X-ray, 864 MANUAL OF SURGERY may be found by palpation, or by puncturing the organ with a needle. Drainage will usually be required. Pyelotomy, or incision of the pelvis of the kidney, is called pyelo- lithotomy when done for stone. The kidney is delivered, the poste- rior wall of the pelvis opened transversely to avoid the vessels, and the wound subsequently sutured or drained, according to indica- tions. In pyelohthotomy one should disturb the fat over the pos- terior wall of the pelvis no more than is absolutely necessary; it reinforces the suture line and helps to prevent the escape of urine; in many cases thus treated urine never flows through the wound in the loin. The old belief that urinary fistula is more apt to follow than after nephrotomy has been proved untrue. Nephrostomy is the making of an opening into the pelvis of the kidney through the parenchyma for the purpose of diverting the urine from the ureter and the bladder. A similar purpose may be served by pyelostomy, or, when the bladder alone is to be put at rest, by ureterostomy or ureteroenterostomy . Watson recommends double nephrostomy, instead of the other operations just mentioned, before total cystectomy, and in cases of inoperable tumor or tuberculosis of the bladder. The ureter is tied close to the renal pelvis, the kidney incised, and a tube inserted. After the fistula is established the urine is collected in a specially constructed reservoir, which is strapped to the back. Nephrectomy, or removal of the kidney, should not be performed until the presence and, if possible, the functionating capacity of the other kidney have been ascertained. The kidney may be removed through the abdomen or by the lumbar route. The advantage? of the abdominal route are that the pedicle can be more easily controlled and the other kidney palpated ; the latter maneuver may be accom- plished also in the lumbar operation, after incising the peritoneum ou the outer side of the colon. The great objection is that the perito- neum is opened, hence it is employed only when the organ is too large to be dealt with through the loin. In either method the kidney is shelled from its bed, and the ureter and renal vessels tied separately. It should be recalled that accessory renal vessels exist in 20 per cent, of the cases. When the operation is done for malignant disease, the fatty capsule also should be removed; if for tuberculosis, the ureter, when involved, likewise should be excised. Partial nephrectomy is performed by removing a wedge-shaped portion of the kidney and suturing the wound. Decapsulation of the kidneys for chronic nephritis consists in exposing the kidneys, peeling off the fibrous capsules, and dropping URINARY ORGANS 865 the kidneys back into pkice. Inijirovement follows in some cases, but the exact value of the operation has not yet been determined. The ureter may be palpated through an abdominal incision, as suggested by Gibbon, but should not be opened by this route, because of the danger of peritonitis. The upper ureter may be exposed through the lumbar incision made for operations on the kidney; the lower ureter by an incision running from just above the anterior superior spine of the ilium, downward and forward, one-half inch above and parallel with Poupart's ligament, to the inguinal canal; the whole ureter by combining these incisions. The peri- toneum is stripped trom the parietes until the ureter is reached. In operating through the lower incision the ureter is usually found by following the external iliac artery to its origin; the ureter crosses the vessels at, or just above or below, this point. Identification is ordinarily simple, because, in the presence of disease, the ureter is almost always dilated or thickened, or both. The lower end of the ureter may be attacked also through the bladder, vagina, perineum, or by a modified Kraske operation. Ureteropyelostomy, or anastomosis between the ureter and the pelvis of the kidney, has been performed in cases of hydronephrosis due to impermeable stricture of the upper end of the ureter or kinking of the ureter over the renal vessels. The same result has been ob- tained by an operation similar to pyloroplasty, or by excising the valve which is sometimes found between the hydronephrotic sac and the ureter. Ureterolithotomy consists in opening the ureter by a longitudinal incision and removing the calculus, after the ureter has been exposed by one of the routes mentioned above. If near the bladder the stone may sometimes be displaced upwards to a more favorable site for attack, or the ureter may be incised in an easily accessible region and the stone extracted with long slender forceps. The ureteral wound may be sutured with fine catgut, or drained, and allowed to close at a later period. Ureteral anastomosis may be performed in the same manner as lateral anastomosis of the intestine. In lateral implantation {Van Hook's operation) the end of the lower segment of the ureter is ligated, and an opening made below the ligature, into which the lower end of the upper segment is drawn by a catgut suture which passes through this end and then into the lateral opening and out through the ureteral wall about one quarter of an inch below the opening, the end of the upper segment having been previously split in a longitudi- nal direction to prevent stenosis. When this operation is not feasi- 866 MANUAL OF SURGERY ble, the ureter may be anastomosed to the bladder [ureterocystostomy) , to the pelvis of the kidney (ureteropyelostomy) , or even to the intes- tine (ureteroenterostomy) ; the last method, however, is very likely to be followed by peritonitis or infection of the kidney. When a great length of the ureter has been injured or destroyed, it may be neces- sary to suture the ureter to the skin {ureterostomy) or to remove the corresponding kidney. Substitution of a piece of vein for a seg- ment of the ureter has been successfully accomphshed in the dog. THE BLADDER Attention has already been called to congenital umbilical -and rectal fistulse communicating with the bladder. Ectopia vesicae, or extroversion of the bladder, is a congenital absence of the anterior wall of the bladder, the soft tissues which should overlie it, and of the symphysis pubis. It is most common in males, the upper wall of the urethra also being wanting [complete epispadias). The posterior wall of the bladder with the ureteral openings is pressed forwards and becomes inflamed owing to ex- posure. The urine dribbles away constantly and the inflammation may spread up the ureters to the kidneys. The treatment is very unsatisiactory. The patient may wear a urinal or be subjected to operation. Efforts may be made to close the bladder by suturing the mucous edges together, or by utilizing flaps from the neighboring skin or a piece of intestine. To facilitate the approximation of a large opening the sacroiliac ligaments have been divided, and the cleft in the symphysis pubis obliterated by forcible compression. The urethra has been patched with a skin flap. A new urethra, opening within the sphincter ani, so as to avoid incontinence, has been made from the skin of the perineum and the wall of the rectum. The rectum has been severed, in order to create a bladder from the distal segment, the lower end of the upper segment being sutured to the skin just behind the anus but within the sphincter ani. A new bladder has been made from the cecum, the appendix acting as the urethra. In order to prevent the urine from flowing over the in- flamed vesical mucous membrane the ureters have been implanted in. the urethra, vagina, skin of the abdominal wall. The ureters have been anastomosed with the intestine in various ways; probably the best method is that in which the ureters with the trigone are im- planted into the sigmoid. The valvular openings of the ureters are thus preserved and bacteria prevented from ascending to the kidney; urine collects in the sigmoid and is voided at intervals. URINARY ORGANS 867 For injuries of the bladder sec " Contusions of the Abdomen." Examination of the bladdernuiy Ix' made by palpation through tlic hypogastrium, rectum, or in the female through the vagina or even the dilated urethra. Percussion and inspection of the hypo- gastrium also may give information. The introduction of a sound through the urethra may detect a calculus or tumor. The X-ray is of value chiefly for the detection of stones and foreign bodies, the size, shape, and position of the bladder can be demonstrated after in- jecting air or a solution opaque to the a;-rays. Cystoscopy is de- scribed below. Since vesical symptoms may be of genital or rectal origin, these organs should always be investigated after the bladder has been examined. Owing to the perfection of the cystoscope exploratory cystotomy is rarely indicated. Cystoscopy is the most important and, indeed, excluding ex- ploratory incision, sometimes the only method for diagnosticating endovesical conditions. It permits inspection also of the prostate and ureteral orifices, the introduction of catheters into the ureters, lavage and medication of these ducts and of the renal pelvis, topical applications to the bladder, and the removal of small intravesical growths, stones, and foreign bodies. It cannot be used when the urethra is too small to admit the instrument, e.g., in stricture and in young children, and when the bladder will not hold the requisite amount of fluid; and it is generally contraindicated in acute injiam- matory troubles of the urethra, bladder, and prostate; in tuberculosis of the bladder, unless the diagnosis cannot be made by other means; and, because of the danger of suppression of urine, in acute nephritis. Boys over 10 and girls over 6 years can be cystoscoped with an in- strument whose caliber is 16 or 18 F. The cystoscope consists of a hollow shaft, shaped like a stone sound, with an electric light at the end, and one or more telescopes which slide into the shaft. The lens system in the telescope is so arranged as to enable the examiner to see that part of the bladder toward which the instrument is directed (direct system), or the part at right angles to the instrument (indirect system) . In some cystoscopes both systems may be used with the same shaft, which also contains channels for the passage of ureteral catheters, operating instruments, and channels for irrigating the bladder. When the indirect system[is used for catheterizing the ureters, the catheter is directed towards the ureteral orifice by a lever on the end of the cystoscope, which is raised or lowered by a screw on the external end. A special cystoscope may be employed for endovesical operations. The male cystoscope answers equally well in the female. The cystoscope and ureteral catheters 868 MANUAL OF SURGERY may be sterilized by immersion in a solution of formalin (2 per cent.) for thirty minutes, after which all traces of the antiseptic should be removed with sterile water. For ordinary examinations anesthesia is not required ; if the urethra is sensitive, however, about 4 drams of a 10 per cent, solution of procain may be instilled into the urethra and bladder portion by a urethral syringe or a catheter; occasionally in nervous patients a general anesthetic must be employed. The buttocks are elevated and brought over the end of the table, the thighs being separated and slightly flexed, the feet resting on chairs; a special table is convenient but not essential. The external genitals are disinfected and washed with sterile water. The light is then turned on for a moment to test the lamp; the instrument lubricated with glyoerin or liquid vaselin and passed into the bladder like a sound; the bladder irrigated with cool sterile water until it is clean, adding, however, adrenalin chlorid in the proportion of i to 10,000, if there is bleeding; at least 5 ounces of the fluid, but preferably 10 or 12, allowed to remain in the bladder, so as to distend it and prevent burning; the telescope slipped into the sheath; and the light turned on. If the fluid quickly becomes turbid the examination may be made under continuous irrigation. If catheterization of the ureters is desired the instrument is brought to the middle line and slowly withdrawn until the interureteral bar (which forms the posterior boundary of the trigone) comes into view; this is followed laterally until the slit-like ureteral meatus appears (Fig. 474), which is usually on the summit of a Httle teat, and may be identified by noting that at intervals, generally varying from 30 to 60 seconds or more, it opens like a fish mouth, ejects a swirl of urine, and closes again. The catheter is protruded from the instrument, gently pressed against the orifice, and then passed up the ureter (Fig. 476). The procedure is next repeated on the opposite side, the light turned off, the fluid allowed to escape from the bladder, and the catheters fed through the cystoscope as it is withdrawn, so as not to pull them from the ureters. Each catheter is passed into a test tube, which is plugged with cotton, and fastened by means of adhesive plaster to the corresponding thigh. It is a good plan to use a catheter of different color for each side so that no confusion as to which is which can arise. As a rule, even with the gentlest manipulation, some blood will be found in the samples, hence it is advisable to collect the urine from each side in two or three tubes, allowing each to remain in position one-half hour or longer, accord- ing to the amount of urine excreted. If a catheter does not drain, gentle suction with a syringe should be tried; failing this not more URINARY ORGANS 869 than 2 diiid drams of sterile water may be injected. The functional capacity of the kidney?, pyelography, and chromocystoscopy are considered under "Examination of the Kidney;" the means of measuring the pelvis, under "Hydronephrosis;" the use of opaque catheters, under "Renal Calculi." Incontinence of urine is the involuntary escape of urine, (i) In true or passive inconlinence the urine flows out of the bladder as soon Fig. 473. Fig. 474. Fig. 475. Fig. 476. Pigs. 473 to 476.— Cystoscopic pictures. Fig. 473 .—Dilated, rigid (noncontracting) , retracted ureteral meatus, surrounded by- ulcers and tubercles, characteristic of renal tuberculosis. Fig. 474. — Normal ureteral meatus. Fig. 475. — Jet of pus coming from ureter. Fig. 476. — Catheter entering ureter. as it flows in, and the bladder is never distended. It is seen in conditions like ectopia vesicae, fistulae leading into the bladder, paralysis of the bladder, and paralysis of the sphincter vesicae the result of disease or injury of the vesical sphincter or of its center in the spinal cord; it occurs also from propping open of the internal meatus by a growth or calculus. (2) Active incontinence is due to exaggeration of the vesical reflex. It is most common in children, Syo MANUAL OF SURGERY occurring, as a rule, only during sleep. It may be symptomatic, i.e., due to phimosis, stone, highly acid urine, seat worms, spinal disease, rectal disorders, or constipation, but in most cases it is idiopathic, i.e., no cause can be found, except perhaps that the child is neurotic. These cases are treated by removing any existing irritation, admin- istering belladonna and tonics, waking the child at night to pass water, and by sending the patient to bed thirsty. Imperative urination, coming on every few minutes, and due to inflammation or other form of irritation, is sometimes called false incontinence. (3) The incontinence of retention (paradoxical ischuria) is the over- flow of a distended bladder, due to some obstruction, such as stric- ture or enlarged prostate, or to paralysis of the detrusor, such as may occur in spinal diseases and injuries. Retention of urine is distention of the bladder owing to inability to pass urine. The causes of retention are: i. Obstruction, such as phimosis; hgature about the penis; tumor or abscess of the perineum; stricture, calculus, foreign body, rupture, tumor, abscess, or con- genital occlusion of the urethra, inflammation, abscess, tumor, hypertrophy, or calculus of the prostate; and external pressure, such as fecal impaction and uterine tumors. 2. Non-obstructive lesions, such as atony or paralysis of the bladder, reflex inhibition (e.g., after injuries of or operations on the rectum), hysteria, fevers, shock, and drugs like belladonna, opium, and cantharides. The most common cause in the new born is occlusion of the urethra, in infants phimosis, in children impacted calculus, in youth one of the complications of gonorrhea (male) or hysteria or foreign body in the bladder (female) , in men stricture, in women pelvic disease, and in old age prostatic hypertrophy. In acute obstructive retention the bladder wall is greatly thinned; in chronic obstructive retention, usually greatly thickened (excentric hypertrophy), and often trabeculated, the tra- becalae representing hypertrophied muscular fasciculi, which cross in a net-like manner, thus forming deep sacculations in the mucous coat. Trabeculation from increased work may be due also to vesical irritation, e.g., from chronic cystitis, calculi, tumors, tuberculosis, or foreign bodies; in these cases, if there is no obstruction, the bladder is contracted (concentric hypertrophy). The symptoms in obstructive cases are pain, intense desire but inability to urinate, and frequent straining eft'orts. The bladder may be seen and felt above the pubes as a median, symmetrical, pyriform, fluctuating tumor, which is dull on percussion, and pressure upon which increases the desire to urinate. It may be palpated also through the rectum or vagina. The obstruction is URINARY ORGANS 871 encountered on attcmi)tin' of the vas, although the author has had two cases in which the testicle subsequentl}^ became gangrenous. A pocket is then made in the scrotum by the fingers, the testicle placed therein, and the mouth of the pocket closed by a purse-string suture. The wound is closed as in Bassini's operation, except that the cord is not displaced, but allowed to emerge at the lower angle of the wound. Castration is advised by many surgeons, but should never be done if the condition is bilateral, for though sterile, the patient may be potent, and removal of both organs has a serious effect upon development, owing to the absence of the internal secretion of the testicle. 904 MANUAL OF SURGERY Torsion of the spermatic cord may occur during severe exertion if there is a long mesorchium. In about half the cases the testicle is imperfectly descended. The symptoms resemble strangulated hernia in that there are sudden pain, swelling, tenderness, and vomiting, but, unlike strangulated hernia, there is apt to be fever and no intes- tinal obstruction. In some cases the twisting of the cord and the rotation of the testicle may be made out by palpation. In the severe forms the testicle becomes gangrenous. The treatment in recent cases is exploratory incision, with untwisting of the cord and suturing the testicle to the scrotum. A gangrenous testicle should be removed. Acute orchitis, or inflammation of the secreting part of the testicle, is usually due to hematogenous infection, e.g. in mumps, t}^hoid fever, and less frequently in other infectious diseases; it may result also from injury or be secondary to epididymitis. The symptoms are sickening pain extending upward along the cord and often Pig. 502. — Diagrammatic sections of (A) orchitis, (B) epididymitis, and (C) hydrocele of the tunica vaginalis. Ho, Testis, A'', epididy- mis; Hy, hydrocele. (Tillmanns.) Pig. 503. — Adhesive plaster strapping for testicle. (Heath.) to the loin; great tenderness, uniform sweUing of the testicle, fever, redness and edema of the scrotum, and often acute hydro- cele. Atrophy commonly follows, but abscess and gangrene are rare. Since in right-sided orchitis or epididymitis there may be pain and tenderness in the right ihac fossa, with vomiting, acute appendicitis may be simulated, especially if the testicular trouble is concealed, as it sometimes is when a youth is examined in the presence of his family. Acute epididymitis may, in rare instances, be due to the same causes as orchitis, but is abnost always the result of infection spread- ing from the deep urethra, usually arising from gonorrhea, and oc- casionally from prostatitis, the passage of instruments, or other forms of irritation. The process often extends to the testicle. The symptoms usually arise in the latter stages of gonorrhea and are those of orchitis, but the character of the swelling is somewhat different (Fig. 502), the vas is generally swollen and tender, and on rectal GENITAL ORGANS 905 examination swellinfj; and tenderness of the corresponding seminal vesicle and lobe of the prostate can often be detected. Acute hydro- cele is common, abscess and gangrene rare. In bilateral cases there may be sterility from blocking of the ducts, but sexual potency is retained unless the testicle atrophies, which is not usual. Chronic orchitis and epididymitis may follow the acute form; those cases which are chronic from the beginning are generally due to syphilis or tuberculosis. The treatment of acute orchitis or epididymitis is rest in bed, elevation of the scrotum, the application of lead-water and laudanum or pultices, and, in the decUning stages, pressure by a rubber band- age or by strapping the testicle with adhesive plaster (Fig. 503). Local treatment to the urethra is abandoned ; this does not worry the patient as the discharge has probably disappeared with the onset of the inflammation. In acute orchitis with excessive pain or threat- ened gangrene, the tunica albuginea may be cut subcutaneously with a tenotome. In acute epididymitis Frayser advises epididymotomy through an external incision, whereby it is said the duration of the disease is considerably shortened. Recurring epididymitis has been successfully treated by ligation of the vas deferens (Chetwood). Chronic inflammation of the testicle is treated by strapping, or by inunctions of ichthyol and mercury and the internal administration of potassium iodid. Tuberculosis of the epididymis and testicle usually begins in the globus major of the epididymis, as the result of a deposition of the tubercle bacilli from the blood, or a descending infection from the seminal vesicles or prostate. As in other affections of the epididymis and testicle the left side is more frequently involved owing to its more sluggish circulation. The disease is most common between the fifteenth and thirtieth years, in those who are predisposed to tubercu- losis, and it is often preceded by inflammation or a slight injury. The process spreads to the body of the testicle and up the vas deferens, affecting the other genitourinary organs, including in many cases the opposite epididymis and testicle. In favorable cases the tuber- culous mass may become encapsulated and calcify, but more often it undergoes caseation, and forms an abscess, which, breaking through the capsule of the epididymis, gravitates to the lower postero-lateral corner of the scrotum, and gives rise to a sinus. The symptoms may be acute, resembling an acute epididymitis which fails to subside and is followed by abscesses. As a rule the onset is insidious, and perhaps the nodular enlargement of the epidi- dymis is discovered accidentally. At a later period the whole organ 9o6 MANUAL OF SURGERY is enlarged, effusion into the tunica vaginalis is apt to occur, the vas deferens is thickened and knotty, and finally symptoms referable to the other genitourinary organs appear, while evidences of the disease in the lungs may be detected. Pain and tenderness are not marked until sinuses of the scrotum form. The sexual power is unimpaired unless both organs are destroyed. The differential diagnosis is given under "Tumors of the Testicle." The treatment is the wearing of a suspensory, and general treat- ment as for tuberculosis elsewhere. Injections of iodoform or zinc sulphate are not recommended. If the disease progresses, epididymectomy should be performed, with removal of the vas if it is thickened; this operation does not cause atrophy of the testicle or Fig. 504. — ^Fungus of testicle following gumma. impotency. When the testicle is extensively diseased, castration should be performed when the process is unilateral; when bilateral, the worse testicle should be removed, and at least a portion of the other preserved. Tuberculosis in other portions of the genitourinary apparatus sometimes subsides after removal of the testicular foci, and should not. therefore, be attacked at the same time. Syphilis of the testicle during the secondary period appears as a bilateral, painless epididymitis, affecting principally the globus major; it is sometimes associated with hydrocele, and disappears with anti- syphilitic treatment. During the tertiary period syphilitic orchitis, or sarcocele, occurs as a diffuse overgrowth of the connective tisues, causing atrophy of the tubules, or as a nodular, gummy degeneration. The symptoms appear slowly. The testicle is enlarged, hard, smooth GENITAL ORGANS 907 or perhaps nodular, unduly heavy for its size, and neither painful nor tender; hydrocele may occur, and if a gumma oi)enson the surface, it will present the characteristic features of a syphilitic ulcer. The treatment is a suspensory bandage and the internal administration of antisyphilitic remedies. If the testicle is extensively destroyed by ulceration, however, castration should be performed. Hernia, or fungus of the testicle, is a protrusion of the interior of the testicle or a fungus growth therefrom, through the skin of the scrotum (Fig. 504). It may be due to a wound, malignant disease, abscess, syphilis, or tuberculosis. The treatment is that of the cause. In cases following abscess or trauma, the fungus may be cauterized and pressure applied, or amputated and the skin sutured over the stump. Tumors of the testicle are usually malignant and of a mixed type. The most common non-malignant tumor is cystic fibroma, or adenoma, which consists of fibrous tissue with multiple serous cysts; it may, however, contain other forms of tissue and in the later stages is apt to become malignant Dermoid, teratoma, chon- droma, osteoma, fibroma and myxoma also have been observed. Of the malignant tumors sarcoma is the more frequent, carcinoma is almost always of the medullary variety. Malignant disease may be secondary to benign tumors and is often cystic in character. Both sarcoma and carcinoma spread along the cord, invade the lumbar glands, break through the scrotum, and then involve the inguinal glands. The diagnosis of the exact nature of a neoplasm of the testicle is seldom possible before exploratory incision. The chnician is usually content to distinguish a neoplasm from other lesions not requiring castration. If this distinction cannot be made by external examination an exploratory incision should be made. Rarely an acute orchitis may be simulated by a rapidly growing neoplasm, with pain, tenderness, increased local heat, and fever. A hydrocele with thick walls, which prevent the transmission of light, is very chronic-, increases slowly in size, and may yield hydrocele fluid on tapping. An old hematocele that has become organized is heavy, regular in form, and remains stationary or decreases in size. As with tumor, it may follow injury and yield blood on aspiration. In both vaginal hydrocele and hematocele the cord is uninvolved. Excluding the conditions just mentioned a tumor of the testicle is most likely to be confused with chronic epididymitis, tuberculosis, or sarcocele. The following table modified from Keyes, shows the main points in the diagnosis of these diseases. 9o8 MANUAL Of SURGERY Chronic Epididymitis Tuberculosis Syphilitic orchitis Tumor Gonorrhea, strict- ure, or hyper- trophy of pro- state. Tuberculosis , family or per- sonal. Syphilis inherited or acquired. Perhaps trauma. Frequency Uncommon. Frequent. Frequent. Rare. Size Small between [attacks. Does not reach any great size. Does not reach any great size. May reach any size. Tenderness Yes. Not marked until sinus forms. No. No. Between attacks testis normal, nodules often in globus minor. Nodules in globus major in the be- ginning. Testis not involved un- less acute or an- cient. Testis evenly en- larged, slightly nodular, epididy- mis usually free. Testis greatly en- larged. Later ir- regular soft out- growths. No char- acteristic involve- ment of epididy- mis. Cord May be slightly thickened. Thick and nodu- lar. Free. Free in early stage. Later involved. Seminal vesicles... Usually distended. Tuberculous. Uninfluenced. Uninfluenced. Prostate Posterior urethra inflamed. Congested or tu- berculous. Uninfluenced. Uninfluenced. Cloudy. Cloudy, may con- tain bacilli. Clear. Clear. Hydrocele Unusual. Often. Nearly always. Unusual, but possible. Onset Usually acute. Usually chronic. Chronic. Chronic. Age Adult life. Not often after 30. Middle life. Any age. Epididymis. Epididymis. Testicle. Testicle. Recurring acute attacks. Chronic. Very chronic. Usually rapid. Suppuration Unusual. Common. Sinus lower postero- lateral corner scrotum. Rare. Anterior or lateral fungus possible. None, but fungus common in later stages. Atrophy of testis. . Rare, potency un- impaired. Rare, potency somewhat im- paired. Common, potency somewhat im- paired. Never, potency un- impaired. Opposite testicle. . Often involved si- multaneously. Usually involved subsequently. Usually free. Free. 1 Malignant disease is the only condition likely to cause enlarge- ment of the iliac, lumbar, and inguinal glands. The aspirator and antisyphilitic remedies may be of value in diagnosis, also the labora- GENITAL ORGANS 909 tory tests for syphilis, gonorrhea, and tuberculosis. The X-ray might reveal a dermoid, teratoma, chondroma, osteoma, or, in tuberculosis or an old hydrocele, areas of calcitication. The treatment of tumors of the testicle is castration. Castration is best performed through an incision over the external inguinal ring. The cord is isolated, crushed with forceps, tied en masse, severed below the ligature, and each vessel secured by an individual ligature. The testicle is next pushed up through the wound stripped from the scrotum, and removed, any bleeding points being ligated. This incision may be modified to include sinuses or diseased skin. When the operation is done for tuberculosis, the inguinal canal should be opened, and the vas followed until it may be tied and cauterized close to the seminal vesicle. In malig- nant disease the vessels should be secured as high as possible, and any accessible lymph glands removed. If the scrotum is invaded, the inguinal glands should be excised whether they are enlarged or not. Neuralgia of the testicle may be caused by ungratified sexual desire, sexual irregularities, incipient inguinal hernia, or by some local or remote disease, e.g., varicocele, prostatic engorgement, and vesical or renal calculus. The treatment is removal of the cause. Hydrocele is a collection of serous fluid in the tunica vaginaUs, or in connection with the cord or testicle. Vaginal hydrocele (Fig. 505), or a collection of fluid in the tunica vaginalis, may be sympto- matic or idiopathic. Symptomatic hydrocele {serous vaginalitis) is often acute may be caused by injury or any disease of the testicle or epididymis, and sometimes follows operation for inguinal hernia. Idiopathic hydrocele is always chronic, is most common in the middle aged, and is of unknown origin. The fluid is straw colored, and contains albumin, fibrinogen, inorganic salts, often cholesterin crystals, and occasionally fibrous bodies containing phosphates, carbonates, and fibrin. The tunica vaginalis, in old cases, becomes thickened and fibrous, or even cartilaginous or calcified. Warty growths may arise from the tunic or the testicle. The signs of a vaginal hydrocele are a tense, pear-shaped, fluctuating swelling, which grows from below upward, and which is usually situated in front of the testicle, but occasionally lies behind or envelops this organ. " It is flat on percussion, and has no impulse on coughing unless it extends into the inguinal canal. By placing a Ught on one side of the swelling, translucency will be demonstrated, unless the tunica vaginalis is very thick or the fluid bloody or mucoid. The situation of the testicle may be determined by the light test, gio MANUAL OF SURGERY and by the peculiar sensation experienced by the patient when the organ is squeezed. The treatment may be palUative or radical. Palliative treatment consists in tapping, the needle being entered at the front and lower part of the swelling. The position of the testicle should always be ascertained just before the operation. After the fluid has been withdrawn the puncture should be sealed with collodion. Tapping is often curative in children, and sometimes in symptomatic hydrocele, but practically never in the idiopathic variety, the sac refilling after the lapse of a few months. Radical treatment may be carried out by injection or by an open operation. Of the many substances recommended for injection pure carbohc acid is the best, from lo m. to a dram being injected into the sac and diffused, by manipulation Fig. 505. Fig. 506. Fig. 507. Fig. 508. Fig. 509. Vaginal Congenital Infantile Bilocular Encysted hydro- hydrocele. hydrocele. hydrocele. hydrocele. cele of cord. Diagram of various forms of hydrocele. H, hydrocele; T, testicle; E, epididymis; F, funicular process; C, cord. after all the fluid has been withdrawn. There is some inflammatory reaction, and retapping may be necessary if there is much effusion. Open operation possesses the advantage of allowing inspection of the testicle, and is always indicated if the sac is thickened. The patient's permission to deal with any testicular lesion which may be present should always be obtained, particularly if the hydrocele has formed rapidly. Open operation may be by incision, excision, or eversion of the sac. Incision of the sac, followed by packing it with iodoform gauze, should be obsolete. Excision consists in removing the entire parietal layer of the tunica vaginalis. It is indicated in cases in which the wall of the sac is very thick. Eversion of the sac is the best operation, when the sac wall is thin. The sac is opened by a small incision, turned inside out, and so held by a few catgut sutures passed through its edges above the testicle and behind the cord. GENITAL ORGANS QII The testicle is then replaced within the scrotum and the wound closed. Congenital or reducible hydrocele (Fig. 506) is one which communicates with the peritoneal cavity through an unclosed funicular process, hence is associated with hernia, the treatment is that of congenital inguinal hernia. Injections should never be used. Infantile hydrocele (Fig. 507) is one which distends the tunica vaginalis and the funicular process, the latter, however, not communi- cating with the peritoneal cavity. The treatment is tapping, the walls of the sac being scratched with the end of the needle. If this fails the sac should be excised or everted. Bilocular abdominal hydrocele (Fig. 508) is an infantile hydro- cele in which the upper end of the funicular process, distended with fluid, lies between the peritoneum and the abdominal wall. The treatment is excision. Inguinal hydrocele is one about a retained testicle; it is dealt with by excision or eversion, and the organ brought down into the scrotum. Encysted hydrocele of the testis is a cyst, or collection of cysts, occuring in or about the epididymis {Cysts of the epididymis) or rarely in the testicle. There are two varieties : (i) Small cysts occur late in life; contain spermatozoa, and cause little or no disturbance; they are said to be due to senile changes causing a dilatation of the tubules. (2) Large cysts occur before middle age and contain a milky fluid filled with spermatozoa {spermatocele) ; they are due to dilatation of the vasa elTerentia, or to cystic changes in persisting fetal remains, being in this respect similar to parovarian cysts. The treatment is injection or excision. Diffuse hydrocele of the cord is a smooth boggy enlargement of the cord, which may be due to edema, spermatocele, multilocular encysted hydrocele of the cord, lymphangioma, cysts of fetal remains, or echinococcus cysts. The treatment, excepting edema, is excision. Encysted hydrocele of the cord (Fig. 509) is due to distention of the funicular process which has been closed for a variable distance above and below, or rarely to an accumulation of fluid in an old hernial sac which has been shut off above. In the female the canal of Xuck may be likewise affected, constituting a hydrocele of the round ligament. The condition may be mistaken for hernia, owing to the fact that it may enter the inguinal canal, but if the cord is drawn dow^nwards. the cyst is fixed, and presents the features of a hydrocele elsewhere. The treatment is injection or, better, excision. 912 MANUAL OF SURGERY Chylocele, or chylous hydrocele, is a collection of lymph in the tunica vaginalis, due to the rupture of dilated lymph vessels, and often associated with hlariasis. The treatment is that of hematocele, with possibly ligation or excision of the dilated lymph vessels. Hematocele is a collection of blood in or about the testicle or cord. It follows injury or operations, and occasionally occurs spontaneously, e.g., in mahgnant disease and hemophilia. According to its situa- tion it may be a vaginal hematocele, i.e., in the tunica vaginahs, an encysted or diffuse hematocele of the cord, or an encysted hematocele of the testicle. The signs are those of hydrocele, except that the swell- ing is doughy or solid, and not translucent, and there is apt to be ecchymosis of the skin. An old hematocele that has become organ- ized may be mistaken for a neoplasm, (cf. Diagnosis, of Tumors of the Testicle). The treatment is rest and the application of cold, or in the presence of continued bleeding, incision and ligation or pack- ing. In old cases in which the blood has not been absorbed, incision and evacuation may be indicated. Rupture of the vas deferens, as the result of operations or injuries, should be treated by anastomosis in a manner similar to anastomosis of the ureter. Varicocele is a condition in which the veins of the pampiniform plexus are dilated, thickened, and tortuous. It is very common, and is most frequent in young men. ■ It is almost always on the left side, because the left testicle hangs lower, because the left spermatic vein opens into the renal vein at right angles and has no valves, while that on the right has valves and opens obhquely into the vena cava, and because the left vein lies behind the sigmoid flexure and is apt to be compressed when the latter is distended. The cause is said to be unrelieved sexual desire. It may be due also to the pressure of a truss or an abdominal tumor, and is then usually acute, and occurs on either side at any time of life. The condition is readily recognized, the veins feeling Hke a "bag of earth worms;" it has a sHght impulse on coughing, disappears on lying down, and refils from below upwards if pressure is made over the external ring and the patient is asked to stand. The symptoms, when they exist, are neuralgia and hypochondria. The treatment is the use of suspensory bandage, and the apphcation of cold water night and morning. There is no danger of impotence. Operation is indicated when the condition is the source of constant anxiety. Our plan is as follows: The inguinal canal is opened as in the operat-on for hernia, the testicle pulled up into the wound, and the veins separated from the vas and its vessels and excised, the cremaster muscle being GENITAT. ORGANS 913 shortened if the cord is very long. Search is always made for a small hernial sac, which may be responsible for the "neuralgia." As the inguinal canal has been dilated by the varicocle, it is obliterated as in the operation for hernia, since removal of the veins leaves an open canal. The subcutaneous operation and injections are not recommended. Acute seminal vesiculitis is caused by posterior urethritis, usually gonorrheal in nature. The symptoms are pain in the perineum, rectum, hip, or back, increased by urination and defecation; frequent micturition; and sometimes priapism and painful, bloody emissions. There is fever, and the distended, tender vesicle can be felt by rectal examination, above and to the outer side of the prostate. The treatment is that of acute prostatitis. If suppuration occurs, the abscess should be opened through the perineum. Chronic seminal vesiculitis follows the acute form, when it constitutes one of the causes of gleet, or it is due to sexual irregulari- ties or prostatic disease. The symptoms are those of the acute form, but much milder in degree. There is sexual feebleness but increased desire, and usually marked depression of the spirits. Recurring epididymitis is common. We have seen several cases in which, because of backache and hematuria, the diagnosis of renal calculus had been made. Chronic seminal vesiculitis has been held responsi- ble for many chronic joint infections. The treatment is a hot rectal douche daily, and massage of the vesicles once a week. Massage is performed while the bladder is full and the patient bends over a chair. A finger is inserted into the rectum and the vesicles gently stripped from above downwards. Autogenous vaccins are recommended by some surgeons. The accompanying neurasthenia and posterior urethritis also should receive attention. In inveterate cases collar- gol (10 per cent.) may be injected into the vesicles by inserting the needle into each vas deferens (vasopuncture), the vesicles may be opened and drained (vesiculotomy) through the perineum, or excised (vesiculectomy) by one of the routes mentioned below. Tuberculosis of the seminal vesicle may be primary, or sec- ondary to the same disease iti the prostate or epididymis, the symp- toms of which usually bring the patient to the surgeon. On rectal examination the vesicles are found tender and dilated, or even nodular. The bacilli may occasionally be found in the fluid ex- pressed from the vesicles by massage. The treatment includes the general measures suitable for tuberculosis elsewhere, with the removal of more accessible foci, e.g., in the epididymis. If the disease con- tinues to progress, the vesicles may be removed through the per- 914 MANUAL OF SURGERY inciim. by the transsacral route as in Kraske's operation on the rectum or by a suprapubic or inguinal incision, through which the vesicles are reached cxtraperitoneally. The dangers of veseculectomy and vesiculotomy are injury to the urethra, bladder, ureter, rectum, and peritoneum. PROSTATE GLAND Acute prostatitis is caused by posterior urethritis, usually gonor- rheal in nature, but occasionally following the passage of instruments or calcuH. The symptoms are frequent micturition; prostatic shreds or pus in the urine; pain, tenderness, heat, and weight in the peri- neum, increased by defecation and urination; chills and fever; and sometimes priapism, hematuria, or retention of urine. On rectal examination the prostate feels hot. swollen, tender, and. if suppura- tion has occurred, boggy or fluctuating. A prostatic abscess usually opens into the urethra, sometimes into the rectum or through the perineum, and rarely into the bladder. The treatment consists of laxatives, hot rectal douches, opium suppositories, and poultices to the perineum. If suppuration occurs, the abscess may sometimes break into the urethra on the passage of a catheter; if this does not occur, or if the abscess is large, it should be opened by a median perineal incision. Chronic prostatitis may follow the acute form, but is usually chronic from the beginning. The symptoms are enlargement and tenderness of the prostate, pain on urination and defecation, and the discharge from the urethra of a thin, milky fluid containing prostatic casts iprostatorrhca). especially after defecation. Prostatorrhea may occur also without prostatitis, and then has the same causes and the same treatment as urethrorrhea. In some of these cases there is atonic impotence and frequent nocturnal emissions. The treatment is tonics, gentle massage of the prostate, the passage of a large sound twice a week, and instillations of a few drops of a 5 per cent, solution of silver nitrate into the posterior urethra. Kot rectal douches, suppositories of ichthyol, and counterirritation to the perineum also have been recommended. Should an abscess form, it is treated as described above. Tuberculosis of the prostate is usually secondary to that of the seminal vesicles and epididymis. The prostate becomes nodular, and later suppuration ensues. The symptoms are painful and fre- quent micturition, hematuria, pyuria, and pain in the back and peri- neum. Tubercle bacilh may be found in the urine. The treatment is that of tuberculosis elsewhere. In suitable cases the prostate GENITAL ORGANS 915 may be removed throujiii the ])erineLini, or abscesses opened, curetted, and jvuked with iodoform gauze. Prostatic calculi are caused by thede])ositionof j)hosphatesorjn- spissated prostatic secretion. They may cause prostatitis, abscess of the prostate, or retention of urine. They may show on a skia- gram, and occasionally they may be felt with a urethral sound or by rectal examination. NVhen producing trouble, they should be re- moved by a median j)erineal section. Hypertrophy of the prostate is a senile enlargement of the gland, the cause of which is not known. It is very rare before fifty, but is said to be present in one-third of all men who have reached the sixtieth year, producing symptoms, however, in only one-half of these. All the elements of the gland hypertrophy, but, according to the tissue which predominates, the growth may be hard and fibrous or soft and adenomatous. As a rule the changes are more marked in certain portions of the gland, so that the specimen consists of a number of encapsulated tumors, which may be fibroadcnomatous or adenofibromaious , depending upon which tissue is in excess. In about 20 per cent, of those removed at operation carcinomatous elements Fig. 510.— Hypertrophy of the pros- nrp found ProQfntir hvnprtrnnhv ^^*®- Note retroprostatic pouch and are lOUna. Prostatic nypertropny residual urine, the marked, anterior curve lengthens the prostatic urethra, and increased length of the prostatic ... urethra. and sometimes gives it a tortuous course, owing to the irregular enlargement of different portions of the gland. The outlet of the bladder is always elevated, thus creating a pouch behind the prostate and preventing complete evacuation of the bladder (Fig. 510). In some cases the commissure between the lateral lobes may constitute a bar across the urethra, or a peduncu- lated growth, the so-called third lobe, which obstructs the internal urinary meatus like a ball-valve. The anterior commissure is rarely involved. The symptoms are frequent urination, especially at night, and difficulty in urination. The stream is hard to start, has httle force, and is terminated by dribbling. The difficulty is increased rather than lessened by straining, which may be so great as to cause hema- turia, hernia, or prolapse of the anus. There may be pain and a sense of fulness in the perineum, and priapism sometimes occurs 91 6 MANUAL OF SURGERY owing to the congestion about the neck of the bladder. These sjTnptoms are insidious in onset and gradually grow worse, the residual urine progressively increasing in amount. At this period indulgence in alcohol or catching cold is apt to increase the congestion and lead to retention of urine, which, unless reheved by the catheter, results in overflow (the incontinence of retention). The patient may have several of these attacks, until finally the bladder remains full all the time, the urine constantly dribbling away. The bladder is now dilated, atonic, and fasciculated, and the back pressure of the urine leads to dilatation of the ureters and of the pelves of the kidnej's. Either spontaneously or as the result of instrumentation the bladder and prostate become inflamed, and the urine ammoniacal and purulent, the patient finally dying from an ascending infection of the kidneys. Phosphatic vesical calculi may form, and epidid\Tnitis may occur, particularly after the passage of a catheter. The diagnosis is confirmed by rectal examination, which is greatly fac- ilitated by making firm pressure over the h}'pogastrium (bimanual examination), the bladder being empty, the legs flexed, and the mouth open. The finger readih- detects the enlarged lateral lobes of the gland. In about 20 per cent, of the cases rectal examination is fallacious, because the chief enlargement is forwards and not back- wards. In these cases the obstruction at the neck of the bladder will be appreciated by the passage of a catheter, which may be used to ascertain also the length of the urethra and the amount of residual urine, i.e., the quantity of urine which may be drawn off immediately after the patient has passed water. The bladder should always be searched for stones. In cases in which it can be used, the cystoscope may be employed to outline accurately the nature of the obstruction. The X-ray is of value, not only for the detection of stones, but also, especially if the bladder is distended with air, for showing the size of a hard prostate. "WTien there are s}Tnptoms of prostatic re- tention without any hypertrophy of the prostate, the essential lesion is a contracture of the neck of the Madder''^ (Keyes). This is usually due to posterior urethritis and is curable by perineal cystotomy. The treatment in the early stages consists in attention to the general health, the drinking of plenty of water, and the avoidance of cold, wet, alcohol, and overeating. When the residual urine amounts to two ounces, the bladder should be catheterized every evening before retiring; each additional two ounces of residual urine will require an additional catheterization, the intervals always being regular. This the patient must be taught to do in a surgically GENITAL ORGANS 917 clean maiiiuT, laying cmj)hasis upon the ease with which infection occurs, and the great dangers which follow. Hexamethylenamine, grains lo three times a day, or other urinary antiseptics should be administered, and the bladder irrigated with hot boric acid solution once daily. If the ordinary soft catheter cannot be passed, and this applies equally in cases of acute retention, a soft coude or bicoude (Figs. 492 and 493) catheter may mount the obstruction and enter the bladder; if these fail, it will be necessary to use a silver prostatic catheter (Fig. 511), which, owing to its greater length and larger curve, may reach the bladder when pressed well down between the thighs. If catheterization is difficult, if there is marked irritability of the bladder, if the residual urine steadily increases in quantity, or if there is stone or persistent cystitis, catheterization should be aban- doned and operation advised. Seriously damaged kidneys or the presence of septicemia is an indication that operation has been postponed too long. Prostatic catheter. Prostatotomy, or incision of theprostate, may be performed with the knife or the cautery, either through the perineum, or after the bladder has been opened above the pubes, the situation of the cut varying according to which lobe is chiefly enlarged; but these operations are seldom employed. Most surgeons think prostatec- tomy, as complete as possible, to be the operation of choice. Prostatectomy, or removal of the prostate, may be complete or partial, and effected either through the perineum (intra- or extra- vesically) or by the suprapubic route. The mortaHty is from 5 to 10 per cent., but the vast majority of those who recover are cured. The operation may be rendered safer by estimating the functional capacity of the kidneys (q.v.) ; performing suprapubic cystotomy^ under local anesthesia, for drainage; and, after a week, or when the patient's general condition has improved and the renal activity has been restored as much as possible, removing the prostate under nitrous oxid-oxygen anesthesia. Most of the deaths after operation are due to uremia, pneumonia, sepsis, or a combination of these evils. 9l8 MANUAL OF SURGERY Among the sequelae are impotence, incontinence of urine, epididy- mitis, urinary fistula, rectal fistula, and urethral stricture. Suprapubic prostatectomy is the operation generally employed. It is performed by opening the bladder as in suprapubic cystotomy, tearing through the mucous membrane over the prostate with the finger-nail or blunt scissors, and enucleating the gland by working between the true and the false prostatic capsules, while the prostate is pushed upwards by a finger in the rectum. If the lateral lobes are removed separately, the ejaculatory ducts may occasionally be preserved. The hemorrhage is controlled by irrigation with hot water, or temporary gauze packing, and the bladder drained as after suprapubic cystotomy. The operation is easy, quick, requires no special instruments, permits full exploration of the bladder, does not injure the rectum, is rarely followed by a permanent fistula, and does not always destroy the sexual function. The urine begins to pass through the urethra in from one to two weeks, and the suprapubic wound is healed in from two to four weeks. Perineal prostatectomy may be performed through a curved transverse incision, convexity forward, reaching from one ischial tuberosity to the other, or one of its modifications, but the easiest and simplest is the median incision as in perineal cystotomy. The membranous urethra is opened, and the prostate pulled downwards by a sound passed into the bladder, or by special tractors devised for this purpose, and enucleated after incising its fibrous sheath. The bladder is drained by a tube emerging through the perineum, and the wound packed with gauze. The drain may be removed in a few days, the after treatment being the same as that of perineal cysto- tomy. Young incises the capsule outside of the seminal ducts, in order to preserve these structures, and removes the rest of the gland. Dittel, Rydygier, and others make a transverse perineal incision, and excise V-shaped portions of the lateral lobes without opening the urethra or bladder (extravesical prostatectomy) . The perineal opera- tion is more difficulty than suprapubic prostatectomy, and has the special danger of injury to the rectum. If the symptoms are severe, and prostatectomy cannot be prac- ticed because of the poor general condition of the patient, the only operation which promises relief is CA-'stotomy, either suprapubic or perineal, for the purpose of drainage. Carcinoma of the prostate, as previously mentioned, is found in about 20 per cent, of the glands removed for supposed benign hyper- troph5^ Sarcoma is rare, and may occur in early life. The symp- toms of carcinoma are much like those of hypertrophy of the prostate, GKNITAL ORGANS QI9 but the pain is greater, the growth more rai)i(l, "hematuria more common, and the gland stony hard and nodular. In the later stages the tumor breaks through the cai)sule, invades the bladder, urethra, and rectum, causes metastases in the pelvic and inguinal lymphatic glands, and induces cachexia. The treatment, if the patient is seen early enough, is removal of the entire prostate, the seminal vesicles, and the anterior two-thirds of the trigone, through the perineum, the bladder being anastomosed with the membranous urethra. Young has performed this operation six times, one patient being well at the end of live years. When excision is out of the question, some relief may be obtained by suprapubic cystotomy and radiotherapy. FEMALE GENITAL ORGANS Examination of the female generative organs is [usually made with the patient in the dorsal position, the knees being drawn'up and Fig. si 2. — Goodell's speculum. the thighs abducted, and the bladder and rectum having previously been emptied. The external genitals should first be inspected. By separating the labia, the urethra, the hymen or its remains, and the perineum may be seen, and if the patient strains, a cystocele or rectocele may be detected. For inspecting the inner parts a specu- lum is necessary, the most serviceable of which is one of the bivalve variety (Fig. 512). The instrument is warmed and lubricated, and introducecl with the blades closed and facing laterally; it is then turned so that the edges are lateral, and the blades separated. The Sims speculum is used with the patient in the Sims position (Fig. 513) , i.e., lying upon the left side, with the left arm behind the back, the right shoulder near the table, and the hips flexed, the right more than the left. The speculum is introduced, then turned transversely, so as to retract the posterior vaginal wall, the right buttock being lifted with the disengaged hand. The cylindrical speculum of Fergusson consisting of glass or hard rubber, and having the inner extremity beveled, is seldom employed. By vaginal palpatiou may be deter- mined the condition of the perineum, whether or not the vulvo- 920 MANUAL OP SURGERY vaginal glands are enlarged, the presence of spasm and tenderness, the amount of heat and moisture, the condition of the vaginal walls, the presence or absence of tumors or masses, and the size, shape, posi- tion, mobility, and consistency of the cervix and uterus. Either the index, or the index and middle fingers, according to whether the patient is single or married, are lubricated and passed into the vagina over the perineum; by placing the other hand over the lower abdo- FiG. 513. — Sims' position. (Montgomery.) men {bimanual examination) the uterus, tubes, and ovaries may be palpated between the fingers and their condition determined. The right side of the pelvis is best examined with the right hand internally, the left with the left hand internally. In virgins, instead of a vaginal examination, and always in others as supplemental to a vaginal examination, it is desirable to pass a finger into the rectum and examine the parts bimanually. This examination is facilitated, if Fig. 514. — Volsella forceps. at the same time the cervLx is drawn downward by volsella forceps (Fig. 514) . In order to determine the degree of prolapsus uteri some surgeons examine the patient in the erect posture. The patient stands with the legs apart, while the examiner, kneeling on one knee and facing the patient, passes the fingers into the vagina, sup- porting his elbow with the other knee. Before or after the internal examination the abdomen should always be examined externally by GENITAL ORGANS 92 1 inspection, palpation, and percussion, and sometimes by ausculta- tion. When these examinations are unsatisfactory, it may be necessary to anesthetize the patient in order to secure complete relaxation. The uterine sound (Fig. 515) may be used to determine the length, permeability, and direction of the uterine canal, the presence of growths, the condition of the endometrium, and occa- sionally to replace a displaced uterus. It is seldom employed, how- ever, because of the dangers of sepsis, perforation, or abortion, and it is absolutely contraindicated in acute inflammatory troubles, in cancer, during the menstrual period, and in cases in which there is the slightest suspicion of pregnancy. The vagina and the sound should be sterilized, and the instrument, properly curved, introduced under the guidance of the eye, the position of the uterus having been pre- FiG. 515. — Sims' uterine sound. viously determined. The interior of the uterus may be explored also with the linger, after the cervix has been dilated, or a portion of the endometrium may be removed with a curette for micro- scopic examination. THE VULVA Any or all parts of the vulva may be absent, rudimentary, or hyper trophied. Enormous hypertrophy of the labia minora is seen in the Hottentot apron. Epispadias and h}^pospadias also occur. Thus hermaphrodism (presence of both ovaries and testicles) does not occur, but pseudohermaphrodism, in which the external genitals resemble those of both sexes, is sometimes seen. The vulva is subject to the same diseases and injuries as other parts covered by skin and mucous membrane, and only a few of these need special description. Vulvitis is usually gonorrheal in origin, but may be caused by irritating discharges, uncleanliness, diabetic urine, parasites, infec- tious fevers, traumatism, caustics, pregnancy, and excessive mas- turbation or coitus. Follicular vulvitis is acne. Cellulitis of the vulva is called phlegmonous vulvitis. During the acute exanthemata or other debihtating diseases the parts may become gangrenous {gangrenous vulvitis, noma pudendi), or covered with a false mem- brane {croupous vulvitis); true diphtheria also occurs. The symp- 92 2 MANUAL OF SURGERY toms are localized pain and burning, more marked on walking or during micturition. The parts are swollen, reddened, and covered with a mucopurulent discharge. The treatment is removal of the cause, and cleanliness. Rest in bed, sitz baths, and local applica- tions of the medicaments recommended for injection in gonorrhea are indicated. In the severer forms tonics and stimulants are needed, while cellulitis will call for incision, and gangrene for excision and cauterization. Abscess of the vulvovaginal or Bartholin's gland is caused by vulvitis, and presents the usual signs of an abscess. The treatment is incision, or excision with partial closure of the wound and drainage. A cyst of the vulvovaginal gland caused by occlusion of its duct likewise is treated by excision. Pruritus vulvae, or intense itching of the vulva, is a symptom rather than a disease, and may be caused by uncleanliness, local skin diseases, irritating discharges, diabetic urine, parasites, mas- turbation, rectal diseases, digestive disorders, gout and rheumatism, pregnancy, the menopause, diseases of the internal generative organs, and kraurosis vulvae. The itching is worse after exercise and at night and leads to excoriation and trophic changes in the skin; melan- cholia sometimes follows. The treatment is removal of the cause, attention to the general health, and local cleanliness. The itching may be relieved by lead-water and laudanum, carbolic solution (5 per cent.), cocain (5 per cent.), by painting the parts with silver nitrate (10 grains to the ounce) and sometimes by radiotherapy. Excision of the affected skin, or resection of the nerves supplying it with sensation has been performed in inveterate cases. Kraurosis vulvae is an atrophic change in the vulvar skin leading to shrinking and thickening of the parts, which become white and smooth. The cause is unknown, and the symptoms are usually pruritus and sometimes intense hyperesthesia. The treatment is that of pruritus. Urethral caruncle is a dark-red tumor growing from the mucous membrane in or near the urethral meatus. The growth is a papil- loma, angioma, or adenoma, and is exceedingly sensitive, causing dysuria, pain on walking or intercourse, and marked nervous symp- toms. The treatment is excision. THE VAGINA The vagina may be double owing to failure of union of the lower portions of Miiller's ducts, lateral if one of the ducts fails to develop, GENITAL ORGANS 923 or iihsciil or rudimentary, in whole or in j)art (sec also "Atresia Ani X'aginalis''). Atresia of the vagina (complete closure) occurs at the hymen {atresia hymenal is) or at a higher level {atresia vaginalis). It may be congenital, or be caused by cicatricial contraction the result of traumatism, operations, caustics, or the severer forms of vaginitis. The symptoms are caused by retention of menstrual fluid. At the time of the periods there are all the symptoms of menstruation except the appearance of blood. The vagina becomes distended {hcmatoeolpos), and after a time the uterus {/lematometra), and then the tubes {hematosalpinx). When the distention becomes extreme, the blood may burst through any poition of the genital tract, or through the atresia, an accident which is often followed by infection and death. The treatment is puncture or incision of the obstruction, in order to allow the blood, which may be as thick as tar, to escape slowly. The opening is then enlarged, the cavity irrigated with a mild antiseptic solution, and the opening maintained by gauze, or by a rubber or glass plug. If the tubes are distended, they are probably adherent, hence collapse of the uterus and vagina often results in their rupture and peritonitis; the condition of the tubes should therefore be investigated before operating on the atresia, and if distended, they should first be removed by abdominal section. In absence or obliteration of the vagina efforts have been made to construct a canal by flaps from the labia, by skin grafting, by the substitution of a portion of the rectum, and by the transplantation of a segment of the small intestine. We have obtained an almost perfect result by the method last mentioned. Stenosis of the vagina (incomplete closure) results from the same causes as atresia, and may interfere with intercourse, drainage of the vagina, and labor. The treatment is gradual dilatation with bougies, or a plastic operation. Injuries of the vagina may be caused in a great variety of ways, e.g., by coitus, bullets, falls astride some sharp object, and rough instrumentation. They are treated on general surgical principles. If the peritoneal cavity has been penetrated by some pointed object, the abdomen should be opened in order to search for wounds of the intestines. By far the most frequent and important injuries are those occurring during labor. Laceration of the perineum is usually caused by childbirth, rarely by external injuries. According to position the laceration mav be lateral, the fibers of the levator ani, on one or both sides, being 924 MANUAL OF SURGERY torn; median; or central, a rare form in which the child is born through a perforation of the perineum, the vulva remaining intact. According to degree the laceration may be incomplete or complete the latter passing through the sphincter ani. Perineal relaxation is a term used for those cases in which there has been a submucous tear of the levator ani fibers. The symptoms are a feeling of insecurity in the parts, dragging pain, and reflex nervous disorders. Incomplete median tears may give no symptoms. When the levator ani is torn, the anus falls back- wards, the rectum bulges forward as a tumor {rectocele — Fig. 516), causing constipation, and the stretching of the posterior wall leads to retroversion and prolapse of the uterus. These conditions cause congestion, and hence hemorrhoids and endometritis. The anterior vaginal wall also may prolapse from lack of support of the posterior Fig. 510. — J^acerat'.on oi perineum and large rectocele. Fig. 517. — Diagram of cystocele and rectocele. Dotted lines represent residual urine. The uterus is displaced downwards and backwards. wall, or from descent of the uterus, causing a bulging downwards and outwards of the bladder {cystocele) , a condition which may exist likewise without laceration of the perineum, owing to the submucous strippirg of the anterior vaginal wall from the underlying parts during labor. A cystocele causes dysuria, and sometimes cystitis from the decomposition of residual urine (Fig. 517). A complete tear causes incontinence of feces and gas. The gaping of the vaginal orifice, the backward displacement of the anus, and the rectocele or cystocele are readily detected by inspection, especially when the patient strains. By palpation wdth a finger in the vagina and the thumb externally or in the rectum, the gap in the muscles may be felt. The treatment should be immediate repair after labor (perineor- rhaphy, or posterior colporrhaphy), the divided structures being GENITAL ORGANS 925 approximated with twenty-day catgut. Non-chromicized catgut is absorbed very rapidly in these cases and should not be employed. Of the secondary operations, i.e., those in which the laceration is repaired after the completion of cicatrization, the most important are described below. Lateral tears are best repaired by the Emmet operation. With the patient in the lithotomy position, guide sutures or tenacula are passed through the apex of the rectocele, and through each labium majus at the lowest carunculae myrtiformes. By drawing on the lateral suture and pulling the central suture downward and to the opposite side, the lateral sulcus appears as a triangle with the apex up in the vagina. This triangle is denuded of mucous membrane by Fig. 518. — Emmet's operation, showing area of denudation. A, A, A, Guide sutures; B, upper suture passed in lateral sulcus. Fig. 519. — Sulci closed, stitch. A, Crown cutting off long strips by means of forceps and scissors, or by dis- secting the mucous membrane off in one piece. The triangle on the opposite side is treated in the same manner, and the denudation completed by removing the mucous membrane between the bases of the triangles and below the central suture (Fig. 518). Each lateral triangle is closed by a continuous suture of chromicized catgut. The needle, which should be curved, is entered near the margin of the wound on the outer side, passed deeply to catch the fibers of the levator ani, and brought out at the bottom of the sulcus, at a point nearer the operator; it is then reinserted at the bottom of the sulcus, and passed upwards and backwards in the rectocele, to emerge opposite the point of the original insertion. The opposite 926 MANUAL OF SURGERY triangle is treated in the same manner, which leaves a small raw ai ea externally to be closed (Fig. 519). The upper or ' ' crown stitch ' ' passes through the skin of the perineum below the lateral guide suture, then through the rectocele below the central guide suture, and finally through the tissues below the opposite guide stitch. As many sutures as may be necessary are inserted below this. The external genitals are irrigated with weak bichlorid of mercury solu- tion after each urination; catheterization should, if possible, be avoided. The bowels are moved on the second day. Internal douches are not needed unless there be infection. The patient should be kept in bed two weeks, and heavy work and sexual inter- course forbidden for three months. Fig. 521. — Flap-splitting method of perineorrhaphy. Flap elevated and sutures passed through the levator ani on each side. Hegar's operation (Fig. 520) is indicated in median tears. Lat- eral guide sutures are placed as in the Emmet operation and a central guide suture is inserted in the middle line of the posterior vaginal wall as high as may be necessary. The triangle thus out- lined is denuded, and the raw surface closed by interrupted sutures passing beneath the entire denuded area, care being taken to catch the transverse perineal muscle. The flap-splitting method may be employed in either lateral or median tears. An incision is made around the lower margin of the vulva, joining the terminations of the nymphae; the flap separated from the rectum and drawn upwards; the levator ani on each side clearly defined, and the muscular edges sutured together (Fig. 521); GENITAL ORGANS 927 the skin and tissues over the muscles approximated; and the flap fixed in position with a few additional sutures. In the operation for complete laceration the rectovaginal septum is split laterally, thus separating the vagina from the rectum for a short distance and exposing the ends of the sphincter ani. The wound in the rectum is then closed by two layers of chromicized catgut sutures, one for the mucous membrane and a second for the outer coats. The sphincter ani is approximated by two or three additional catgut sutures. The operation is then completed by any one of the methods just described, the lowest external suture being passed through the sphincter ani. In order to avoid fecal contamina- tion of the wound and the possibility of rectovaginal fistula, Ristine, Watkins, and others make a vaginal flap with the base downwards. The depressions corresponding to the torn ends of the sphincter ani are joined by a curved incision, through the vaginal mucosa, extend- ing a half inch or more above the anal margin. This "apron" is reflected downwards over the anus, and the sphincter ani united without opening the rectum, thus converting a complete into and incomplete tear, which is closed as in the Hegar or, better, as in the flap-spHtting operation. The "apron" may be fastened up over the perineal sutures, so as to protect the wound from the rectal discharges. Anterior colporrhaphy, or the operation for cystocele, consists in removing an elliptical piece of the anterior vaginal wall, extending from just behind the urinary meatus almost to the cervix, the width depending upon the degree of relaxation. The cervix is pulled down with a tenaculum, the cellular space between the bladder and the vagina opened by a short longitudinal incision near the cervix, at which point there is little danger of wounding the bladder, blunt scissors pushed through this incision almost to the external meatus, the blades separated and withdrawn, and the space thus created exposed by continuing the longitudinal incision towards the meatus. Each lateral flap is now raised from the bladder by blunt dissection, and resected by a curved incision as far out as may be necessary. The wound is then closed with two or three layers of continuous catgut sutures. Fistulae are usually caused by sloughing following a long labor, but are occasionally due to other injuries, and sometimes to disease, such as syphilis, tuberculosis, or cancer. Those due to disease are not, as a rule, suitable for plastic operations. Urinary fistulae may be urethrovaginal, vesicovaginal (the most common), vesicouterine, ureter ova ginal, or ureteroiiterine. The most common fecal fistula is 928 MANUAL OF SURGERY the rectovaginal, but occasionally, as a result of a vaginal operation or injury, the vagina communicates with the small bowel {entero- vaginal fistula). These fistulae, with the exception of the urethro- vaginal, in which leakage occurs only during micturition, cause, according to their character, an involuntary escape of urine, feces, or gas from the vagina, and all give rise to vulvovaginitis as the result of the irritation of the discharges. Urinary fistulse may be compli- cated by cystitis, ureteritis, and pyelonephritis. The diagnosis is made by passing a probe or finger through the fistula, or, when the orifice is very small, by injecting a colored fluid into the bladder or rectum and watching for its escape through the fistula. In ureteral fistulas a small quantity of urine constantly dribbles from the vagina despite the fact that micturition is normal, and the color and quan- tity of the fluid escaping from the fistula is not influenced by the injection of a colored solution into the bladder. The treatment of recent small fistulae is daily irrigation of the vagina with boric acid solution or salt solution, never with strong antiseptics; if spontaneous healing does not occur after three months, operation should be advised. Large or old fistulae, with the excep- tions noted above, always require operation. Often, however, it is first necessary to remove phosphatic deposits, to combat cystitis and ulcerations, and to improve the general health, A vesicovaginal fistula may be closed by paring the edges of the orifice, a ad then uniting them with silkworm gut sutures, which penetrate to, but not through, the bladder mucous membrane. The patient is usually placed in the Sims position during the operation, and a retention catheter remains in the bladder after operation. The sutures are removed in ten days. If the edges do not come together without tension, a longitudinal incision, which is subsequently sutured transversely, may be made on each side of the opening. In some cases it may be necessary to separate the bladder from the vagina for some distance, and suture each cavity separately. Suture of the fistula from above, after the bladder has been opened above the pubes, may be indicated when the fistula is high and diflicult to reach through the vagina, when vaginal operations fail, when one suspects that the ureters are close to the orifice, A flirther advantage is that the bladder is put at rest after operation, by suprapubic drainage. Of thirty-three cases in which the transvesical operation was per- formed, success followed a single attempt in 60 per cent. (Francey.) In the worst cases which cannot be remedied by other means, the vagina may be closed below the opening {colpocleisis) , thus converting the bladder and vagina into one cavity. Urethrovaginal and recto- GEXITAL ORGANS 929 vaginal fistula are treated on the same principles as a vesicovaginal fistula. A rectovaginal fistula close to the vulva may be incised like a fistula in ano, and then treated like a complete laceration of the peri- neum. A vesicouterine fistula may be reached by dilating or splitting the cerN^x. Probably the best operation is to make an incision in front of the cervLx. separate the bladder, and close the opening in it with catgut sutures. Ureteral fistulce may be treated by establishing a vesicovaginal fistula alongside the opening in the ureter, and later closing the vesicovaginal fistula, which now includes the ureteral opening, by denuding the vaginal mucous membrane about the orifice of the fistula, and subsequently suturing the raw surfaces. The ureter may be dissected from its bed. either through the vagina or abdomen, and anastomosed with the bladder. Anastomosis with the bowel is not advisable. When all other plans have failed or cannot be used, and the opposite kidney is healthy, the ureter may be tied. Wlien the kidney of the affected side is extensively damaged from an ascending infection, it may be removed. An enterovaginal fistula usually demands laparotomy, the intestine being separated from the vagina, and the opening in each closed with sutures. Vaginitis is usually caused by gonorrhea, but may be due to foreign bodies, or other conditions mentioned under vulvitis. In old age the epithelium is prone to desquamate, leaving ulcers {senile or ulcerative vaginitis), which may result in stenosis or atresia. As in vulvitis, gangrenous and croupous inflammation may occur, but cellulitis {paracolpitis) is rare. The symptoms of the acute form are pain and heat in the vagina and pelvis, vesical and rectal irritability, a mucopurulent discharge, and reddening of the mucous membrane, which is frequently studded with enlarged papillae. Chronic vaginitis may have nothing but a leukorrhea to indicate its existence. Gonor- rheal vaginitis can be diagnosticated with certainty only by finding the gonococci, although its symptoms are often very acute, and it is more apt to be associated with vulvitis, urethritis, and infection of the vulvo-vaginal glands. Extension to the uterus, tubes, ovaries, and peritoneum also is common. The treatment of acute vaginitis is rest in bed and the general measures advised in the treatment of gonorrhea. Douches of bichlorid of mercury (i to 5,000) or permanganate of potassium (i to 10,000) may be given several times a day, while applications of a 5 per cent, argyrol solution may be made through a speculum once daily, and the vagina lightly packed with gauze between treatments. In the later stages, or in chronic cases, the vaginal mucous membrane may be painted with silver nitrate fgr. 30 to the ounce) several times 59 930 MANUAL OF SURGERY a week, and an astringent douche of zinc sulphate and powdered alum (each half an ounce to a quart of water) may be ordered. Ul- cerations are treated by the appHcation of silver nitrate. Vaginismus is a spasmodic contraction of the perivaginal muscles, preventing coitus and associated with excessive hyperesthesia of the structures about the vulva. It may be caused by a urethral caruncle or other local disease, and is most common in the neurasthenic. The treatment is the correction of any local disease, and gradual dilatation by means of bougies, or forcible dilatation under a general anesthetic. Inveterate cases have been treated by excising the hy- men, or by incising the perineum in a longitudinal direction and clos- ing the wound transversely. Cysts of the vagina are rare. They may arise from retention of secretion in one of the vaginal glands, from distention of lymph vessels or spaces, from a hematoma, from the echinococcus. A cyst of Miiller's duct is the result of exudation into the rudimentary portion of a double vagina; it; may reach as high as the cervix uteri. A cyst of Gartners duct may extend up through the wall of the uterus, and even as far as the parovarium (cf. "Cysts of the Parovarium"). Gas cysts (emphysematous vaginitis) are small and multiple, and are probably the result of saprophytic decomposition of the secretion retained in numerous glands. The treatment is excision, except in the last instance, in which the cysts may be punctured, and the vagina douched with an antiseptic solution. THE UTERUS Malformations of the Uterus. — The uterus may be absent or rudimentary, in the latter case existing as a thin band of muscle and connective tissue. Congenital atrophy of the uterus is a condition in which the uterus is exceedingly small, the size of the cervLx being proportionate to that of the body. An infantile uterus is small, but the cervix is two or three times longer than the body, a condition which is normally present at birth. The remaining malformations of the uterus are due to non-union or imperfect fusion of the ducts of Miiller. Uterus septus is one in which the uterus is divided longitudinally by an antero-posterior septum. Uterus bicornis is one in which the uterus is divided into two horns by an antero-posterior groove across the fundus. When this cleft extends to the vagina there are two uteri, each with a tube and ovary (uterus didelphys). When one of the canals of IM tiller GENITAL ORGANS 93 1 (Irx'clops and the other rciiiaiiis rudimentary, the uterus is deflected to one side (uterus unicornis) . In. the uterus bipartitus both horns are rudimentar)-, hut may he lioUow and eoiuu-cted witli the \-agina and with each other by the cervix. Some of these malformations cause steriUty, others miscarriages or great difficulty in labor. When the uterus is so poorly developed that menstruation amounts to agony, the ovaries may be removed. When the uterus is divided by a septum, such may be crushed with forceps, which are left in place until they come away of themselves. When conception takes place in a rudimentary horn, the condition resembles ectopic preg- nancy, in that the walls may break and a fatal hemorrhage occur; in such a case the rudimentary horn should be removed. The uterus didelphys has been mistaken for pus tubes and one of the organs removed before the mistake was discovered; excision is the proper procedure if there is a unilateral hematometra or pyometra. Atresia of the cervix (complete closure) may be congenital, or it may be acquired as the result of tumors of the cervix, or cicatrization following the application of caustics, ulceration due to infectious fevers, injuries of childbirth, or a badly performed trachelorrhaphy. There is retention of menstrual blood {hematometra) , mucus (hydro- metra), pus {pyometra)^ or, in cases infected by saprophytes or the gas bacillus, gas (physometra) . There is amenorrhea with the sub- jective symptoms of menstruation at the regular periods, except in hydrometra, which usually occurs after the menopause. In pyo- metra and physometra septic phenomena are in evidence. The uterus is enlarged and cystic in fluid accumulations, tympanitic or crepitating if there is a collection of gas. The treatment is punc- ture or incision of the cervix, irrigation of the uterine cavity with salt solution, and the subsequent passage of bougies to maintain the patency of the canal. The condition of the tubes should be ascer- tained before operation, and if they also are distended, they should be removed by abdominal section before emptying the uterus, as such is apt to rupture them and cause peritonitis. Stenosis of the cervix (partial closure) may be due to the same causes as atresia. In the congenital form the cervix is conical and the uterus small and antefiexed. The symptoms are dysmenorrhea and sterility, the latter usually being caused by an endocervicitis, which induces also leukorrhea. The treatment is dilatation of the cervical canal by a glove-stretcher dilator (Fig. 522), and the subse- quent passage of bougies at regular intervals. The operation is performed by seizing the anterior lip of the cervix with a double tenaculum, and gently passing into the uterus a small dilator, the 93- MANUAL OF SURGERY blades of which are separated laterally, and then in other directions, so as not to tear the cervix. A larger and more powerful dilator may then be used if needed. Dilatation by means of tents (sponge, laminaria. tupelo. corn stalk, etc.) which expand by absorbing mois- ture after their introduction into the cervix, is slow, painful, and dangerous because they are difficult to render and keep sterile. Dilatation may be effected also by repeated packings with gauze, or bv the Barnes bag; the latter consists of india rubber and is intro- PiG. 522. — Goodell's uterine dilator. duced into the cervLx collapsed, after which it is slowly distended with air or water. In rare instances it may be necessary to incise the cerv'ix. Hypertrophy of the cervix may involve the supravaginal or infra vaginal portion; the former is associated with prolapse of the uterus and eversion of the vaginal mucous membrane, the latter is congenital and is not associated with displacement of the fundus of Fig. 523. — (Auvard.) Pig. 524- the Uterus or obliteration of the vaginal fornices. In the congenital variety the os is small and the cervdx long and conical. Hyper- trophy of the cer\^ix may cause leukorrhea, sterility, and dysmenor- rhea, and if the cervix protrudes from the \-ulva. it may become ulcerated and interfere with locomotion. The treatment is amputa- tion of the cervix. The anterior and posterior hps of the cervix are seized with double tenacula, the cervix split transversely, each lip amputated by a wedge-shaped incision, and the wound closed by GICNITAL ORGANS 933 sutures as shown in P'ig. 523. Shroeder's method, which is indicated when the cervical mucous membrane is badly diseased is shown in Fig. 524. The cervix is split as in the ])revious ()])eration, and each flap amputated in a manner similar to removal of the distal phalanx of the finger when a long palmar flap is used. Chromicized catgut is the best suture material. Laceration of the cervix is usually the result of childbirth, but occasionally follows attempts at abortion or dilatation of the cervix. The laceration may be partial or complete, the latter extending through the whole cervix. The line of cleavage is apt to correspond with the right oblique diameter of the pelvis, because the most frequent presentation is the left occipito-anterior. The laceration may be unilateral, bilateral, or stellate, i.e., having more than two branches radiating from the cervical canal. Extensive lacerations may open the cellular tissue of the broad ligaments or even the I)eritoneum, and be followed by cellulitis or peritonitis. Symptoms may be absent, particularly in unilateral lacerations. In a bilateral laceration the lips are separated, exposing the cervical mucous membrane {ectropion or eversion), which becomes raw and inflamed (erosion of the cervix), and frequently studded with small retention cysts, owing to obstruction of the mouths of the cervical glands {cysts or ovules of Naboth) . These changes, with the irritation of the cicatrices, lead to subinvolution and chronic inflammation of the uterus, and predispose to its displacement, sterility, abortion, and epithelioma. The most prominent symptoms are usually a feeling of weight and discomfort in the pelvis, menorrhagia, leukorrhea, suboccipital headache, and neurasthenia. The diagnosis is readily made by palpation, and by inspection with the aid of a speculum. Treatment at the time of laceration is not advisable unless there is excessive hemorrhage, when the laceration should be closed with sutures. After the puerperium erosions may be touched every other day with silver nitrate (grains 20 to the ounce), the cysts of Naboth punctured, tampons saturated with boroglycerid inserted into the vagina every other day, and copious douches of hot water given daily. If this treatment fails to relieve, operation is indicated. Emmet^s trachelorrhaphy, or suture of the laceration, is per- formed as follows : The cervix is exposed by retracting the perineum with a speculum, and each lip caught with a double tenaculum. The edges of the laceration are denuded with scissors or knife, leaving a strip of mucous membrane in the middle for the cervical canal, all the scar tissue excised, and sutures of chromic catgut inserted and tied (Fig. 525). It is usually advisable to precede 934 MANUAL OP SURGERY this operation by curetting the uterus. In stellate tears with much scar formation and hypertrophy of the cervix, amputation is gen- erally the better operation. Endometritis, or inflammation of the mucous membrane lining the uterus, may be acute or chronic. Acute endometritis involves both the cervical and corporeal endometrium and extends to the underlying tissues. It is usually caused by infection following labor or abortion, by gonorrhea, or by the use of infected instruments, but it may be due also to acute infectious fevers, and exposure to cold during menstruation. The mucous membrane is swollen, softened, and intensely hyperemic. There may be extravasations of blood into the uterine walls and the formation of abscesses. The symptoms in mild cases are a mucopurulent discharge, often bloodstained, pain in the back and pelvis, irritability of the bladder, and a little fever. The uterus is slightly enlarged and tender, the cervLx softened, and the os fre- quently surrounded by an area of erosion. In the severer forms the discharge is very foul, the tender- ness more marked, and the general symptoms those of sepsis. The infection often spreads to the Fallopian tubes and peritoneum; in other instances it involves the body of the uterus, or causes a phlebitis of the pelvic or other veins; and finally it may spread through the lymphatics and cause a pelvic cellulitis. The treatment is rest in bed, liquid diet, saline laxatives, hot vaginal douches of bichlorid (i to 5,000) twice daily, and an ice cap tojthe hypogastrium. In the more severe forms the uterine cavity itself may be irrigated with a solution of bichlorid (i to 10,000) or normal salt solution. When occurring after labor or abortion, the uterine cavity should be explored with the finger and any decompos- ing secundines or blood clot removed. Curettage is, as a rule, contraindicated. Septicemia will require appropriate general treat- ment. In the worst cases, particularly if abscesses form in the uterine wall, hysterectomy may be indicated. Chronic endometritis may involve the entire endometrium, but is often localized to the cervical or corporeal portion. Pig. 525. — Trachelorrhaphy. GENITAL ORGANS 935 Chronic cervical endometritis or catarrh (endocerviciiis) may be due to any of the conditions producing a vaginitis or endometritis, the inflammation spreading to the cervix from these regions. Lacer- ations and gonorrhea are the most frequent causes. It may be due also to stenosis of the cervix. The entire cervix, including the epithelium, the glands, and the connective tissue, is involved. The cylindrical epithelium lining the cervix spreads out over the vaginal portion, giving it a raw appearance, which is called an erosion, and sometimes erroneously an ulceration. True ulceration of the cervix is seen in chancre, chancroid, tuberculosis, neoplasms, prolapse of the uterus, and after traumatism. In endocervicitis the mucous membrane is often thrown into transverse folds, and the blood vessels may be dilated as to resemble hemorrhoids. The enlarged glands are often constricted by the increased amount of connective tissue, thus forming retention cysts (ovules of Naboth). The symptoms are pain in the back, irregular menstruation, and leukorrhea. The discharge from the cervix is thick and viscid, and this is often sufficient to prevent conception. The cervix is usually enlarged and tender. The changes described above may be made out by palpation and by the use of the speculum. The treatment is attention to the general health, and the use of hot vaginal douches containing sulphate of zinc (one dram to the pint) or corrosive sublimate (i to 5,000). If stenosed, the cervix should be dilated; if lacerated, sutured. Cysts should be punctured, and the cervix may be scarified if there is much congestion. In some cases it may be necessary to apply tincture of iodin, ichthyol (25 per cent, in lanolin), or silver nitrate (gr. 30 to the ounce) to the cervical canal, following the application by a glycerin tampon. Displacement of the uterus or other complication should of course be corrected. In inveterate cases the uterus should be curetted and packed with gauze, or Schroeder's operation performed. Chronic corporeal endometritis may follow the acute form, but is more often chronic from the beginning; in the latter instance it is due to the extension of an endocervicitis or vaginitis, or to any condition which induces congestion, e.g., excessive coitus, dis- placements of the uterus, pelvic tumors, and in fact almost any pelvic disease, as well as tight lacing, and chronic disease of the heart, lungs, liver, or blood. In many of these cases no bacteria can be recovered from the endometrium. According to the tissue more involved the inflammation is designated glandular or interstitial. When the changes are equally distributed, the mucous membrane is thick, soft, and smooth; when some portions are more involved 936 MANUAL OF SURGERY than others, the surface presents vascular or glandular vegetations {villus or fungous endometritis) . As in the cervix, the orifices of the glands may be occluded and cysts formed. In exfoliative endo- metritis, or membranous dysmenorrhea, at each menstruation the epithelium is thrown off in shreds, or in one whole piece as a cast of the uterus. The symptoms are pain in the pelvis and back, mucopurulent leukorrhea, menorrhagia or metrorrhagia, dysmenor- rhea, reflex nervous disturbances, and often sterility or abortions. The uterus is usually enlarged and slightly tender. WTien the disease occurs after the menopause {senile endometritis), the dis- charge may be retained, giving rise to an offensive odor which Fig. 526.^ — Sims' sharp curette. suggests malignant disease, a suspicion which may be dispelled by a microscopic examination of the tissue removed by the curette. As in acute endometritis, the inflammation may spread to the extrauterine structures. The treatment in the absence of acute inflammation in the periuterine structures, is curettage. With the patient in the Hthotomy position, the anterior lip of the cervix is grasped with tenaculum forceps, and the canal dilated with the glove-stretcher dilator. The curette (Fig. 526) is then introduced and the walls of the cavity systematically gone over several times, a grating sensation being imparted to the hand when the mucous membrane Fig. 527. — Martin's curette. has been removed. For curettage of the fundus and cornua the IMartin curette (Fig. 527) should be employed. The uterine cavity is irrigated with bichlorid of mercury solution (i to 10,000) and the vagina filled with sterile gauze. The uterus should not be packed unless there is free bleeding, as the gauze plug interferes with drain- age. All gauze should be removed at the end of twenty-four hours, and a daily vaginal douche of bichlorid of mercury (i to 10,000) given thereafter. The dangers of the operation are perforation of the uterus, inflammation of the adnexa, and peritonitis. The patient should remain in bed one week. The cause of the endo- metritis, e.g., lacerations, displacements, etc., should, if possible. GKNITAL ORGANS 937 be removed at the time of the curettage. Strychnin and ergot may be given after operation, in order to encourage contraction of the uterus. Acute metritis, or inflammation of the uterine muscle, is due to the same causes as acute endometritis, with which it is always associated, and from which it cannot be differentiated clinically. The symptoms and treatment are, therefore, those of acute endometritis. Chronic metritis, chronic parenchymatous inflammation oj the uterus, difuse interstitial metritis, or subinvolution, as it is called when following labor, may be due to (a) causes which interfere with normal involution of the puerperal uterus, e.g., retained secundines, cervical laceration, acute endomeritis, pelvic inflammation, rising too soon after confinement, nonlactation, and repeated miscarriages; and to (b) causes which produce repeated or protracted congestion such as chronic endometritis, uterine displacements, pelvic tumors, excessive coitus or masturbation, tight lacing, and chronic disease of the heart, lungs, or liver. At first the uterus is large, soft, tender, and h}Tperemic, later the connective tissue gradually increases in amount and compresses the blood vessels, rendering the organ hard and anemic. The symptoms are those of the compHcating chronic endometritis, with a feehng of weight in the pelvis, chronic in- validism, and neurasthenia. The increase in the size, weight, and firmness of the uterus is readily detected by bimanual examination. The cervical canal is dilated and the uterine cavity uniformly enlarged. The complications are displacement of the uterus, chronic endo- metritis, and extension of the inflammation to the appendages and the peritoneum. The treatment is removal of the cause (displacements, lacer- ations, tumors, etc.) , curettage for the chronic endometritis, copious hot vaginal douches, glycerin tampons, the internal administration of ergot and strychnin, and the general treatment for neurasthenia. The cervix may be scarified, or painted with iodin, or, if it is much enlarged, it may be amputated. Atrophy of the uterus is normal after the menopause. It may follow destruction or removal of the ovaries, exhausting general diseases, and certain nervous affections. When following labor, it is called superinvolution. The symptoms are amenorrhea, sterility, and reflex nervous disorders. The treatment is unsatisfactory. Attention to the general health and electricity locally may be useful. Displacements of the uterus are pathological when they are more or less permanent and interfere with the normal mobility of the 938 MANUAL OF SURGERY organ. The uterus may be displaced upwards (ascent) or downwards (prolapsus); it may be tilted (version) or bent (flexion) forwards (anfeversion or anteflexion) backwards (retroversion or retroflexion), or laterally (later over sion or later o flexion); it may be turned inside out (inversion) ; and the body may be twisted on the cervix (torsion of the uterus). Dislocation of the uterus is a displacement of the whole organ, wdth little or no change in its axis; it may be forwards (anteposition) , backwards (retro position) , or lateral (latero position) . Ascent, latero version, lateroflexion, torison, and dislocation of the uterus are due to exudates or neoplasms which push the uterus, or to adhesions which pull the uterus, into its abnormal position; the treatment is that of the causative lesion. Anteversion (Fig. 528) may be caused by any condition which increases the weight of the uterus (e.g., metritis and tumors), and bv adhesions which draw the fundus forward or the cervix backward. Fig. 528. — Anteversion of uterus. (Montgomery.) Fig. 529. — Acute anteflexion. (Montgomery.) The symptoms are those of the causative lesion, with those of pres- sure on the bladder, i.e., frequent micturition and hypogastric pain. The treatment is directed to the condition producing the displacement. Anteflexion (Fig. 529) is an exaggeration of the normal forward bend in the uterus, with rigidity at the point of flexion. It may be congenital, or the result of metritis, inflammation of the uterosacral hgaments which draws the upper part of the cervix upwards and backwards, irregular involution after labor, or tumors of the fundus. In some cases the uterus falls backwards (retroversion with ante- flexion). The symptoms are dysmenorrhea, sterility, frequent micturition, leukorrhea, and the symptoms of any accompanying inflammation. The cervix is often conical, with a small os, and lies in the axis of the vagina, while the fundus may be felt anteriorly. The condition is dift'erentiated from tumors and exudates in front GENITAL ORGANS 939 of the uterus, by dellnitcly locating the fundus by bimanual or rectal examination. The sound should rarely be employed to determine the direction of the canal and the position of the fundus. The treatment is dilatation of the cervix, curettage of the uterus, and the maintenance of dilatation by the passage of graduated sounds weekly for a month or more. Stem-pessaries and tents are dangerous. Any extrauterine inflammation should of course receive appropriate treatment. Dudley spUts the posterior lip of the cervix and removes a wedge-shaped piece from each margin of the incision, subsequently uniting the diamond-shaped wound with transverse sutures, thus enlarging the os posteriorly. Noiirse splits the cervix laterally, and attempts to straighten the uterus by pulling on the posterior lip, which is then sutured in its new position. Others have divided the uterosacral ligaments, or re- moved a wedge-shaped portion of the posterior wall of the uterus opposite the flexion, the canal being straight- ened by suturing the incision. Retroflexion and retroversion are com- monly associated, constituting the condition called retroversio-fiexio (Fig. 530). As a rule the uterus first retroverts, and is later bent backwards by the action of the intraabdomi- nal pressure upon the anterior face of the fundus. The causes are subinvolution and relaxation of the ligaments following labor, particularly if the patient gets up too early; violent jars or severe straining; salpingitis, the tubes f alHng backwards and carrying the fundus with them ; pelvic adhesions; tumors of the uterus or tissues in front of it; lacerations of the perineum; and habitually allowing the bladder to become over- distended. Some cases are said to be congenital, the posterior wall of the vagina failing to elongate, thus pulhng the uterus backward. The uterus'^is usually enlarged and congested, and there is practically always a compHcating endometritis. Symptoms, in the absence of complications, are often absent. In a typical case there is. lum- bosacral pain, occipital headache, a feeling of weight in the pelvis, leukorrhea. menorrhagia, dysmenorrhea, frequent micturition from pressure of the cervix on the bladder, constipation and hemorrhoids from pressure on the rectum, sterility or abortions, and neurasthenia or hysteria. On examination the uterus is found low in the pelvis, the cervix often pointing forward, and the fundus is found posteriorly. In tumors or exudates in Douglas's cul de sac, and in feces in the Fig. 530. — Retroversio-flexio. (Montgomery). 940 MANUAL OF SURGERY rectum, the fundus is found anteriorly, a fact which may, if necessary, be verified with the sound. The direction of the cervix is not of much value in differential diagnosis. Feces have a doughy feel and can be identified by passing a finger into the rectum. The treatment varies according to whether the retroversion is acute or chronic, and according to the presence or absence of compli- cations. Acute retroversion, i.e.. occurring after labor, miscarriage or an accident, should be treated by replacing the uterus, and the assumption of the knee chest posture (Fig. 531) for five minutes night and morning. WTien involution is complete (six weeks after labor), a pessary may be inserted and worn for several months. About one-third of the cases are thus cured. If the displacement recurs after the removal of the pessary, the patient should be allowed to choose between an operation and the permanent use of a pessary. A chronic retroversion without symptoms or complications requires no treatment. If there are symptoms, the patient may choose between operation and the permanent use of a pessary, if such can be worn with comfort. The pes- sary in chronic cases is to be regarded as a crutch, as it is very rarely curative. Retrover- sion with complications (lacera- FiG. 53i.-^^enupectoral position. ^^^^^ ^^ ^-^^ ^^^^.^^ ^^ perineum, endometritis, salpingitis, adhe- sions, etc.) requires operation primarily for the complications, the uterus being brought forward and held in place by some operative procedure at the same sitting. Reposition of a retroverted uterus may be efi'ected by placing the patient in the dorsal position, and pressing the fundus upwards with two fingers in the vagina until it can be caught by the external hand, when the vaginal fingers press backwards on the cervLx. If the fundus is caught behind the promontory of the sacrum, the cervix may first be dra^Ti downwards with tenaculum forceps. Another method is to place the patient in the Sims or knee chest posture, and then to press the fundus upwards and forwards with two fingers in the vagina until it passes the sacral promontory, when the vaginal fingers draw the cer^-ix backwards. Reposition by introducing a sound into the cavity of the uterus and using it as a lever is dangerous and should not be employed. WTien the uterus is fixed by adhesions, abdominal section is the best treatment. If the patient refuses this and the surgeon can assure himseh that there are no pus collections, GENITAL ORGANS 94 1 gradual reposition may be tried, the adhesions being stretched by greatly pushing the fundus upward, and then the posterior vaginal fornix packed with a tampon. This is repeated every forty-eight hours, and when the fundus has ascended well into the abdomen, the tampon is packed into the anterior fornix, in order to press the cervix backwards. Schultze's method of forcibly breaking up the adhesions under an anesthetic is too dangerous to be recommended. Pessaries are used to hold the uterus in a forward position after it has been replaced. They should be made of hard rubber, and various sizes will be needed for individual cases. Those most commonly employed are shown in Figs. 532, 533, 534. The advant- age of the Smith pessary is the bend of the anterior bar, which pre- vents pressure on the urethra; the Hodge pessary does not possess this bend, but is more useful in a relaxed vagina; the Thomas pessary possesses a broad posterior bar, which more equally distributes pressure, thus avoiding ulceration. A pessary acts by stretching the posterior vaginal wall and pulling the cervix backwards, and not by supporting the fundus of the uterus. It is contraindi- cated in the presence of acute in- flammation, and should be em- ployed only after the uterus has been replaced. It may be im- p^^ ^3^ p^^ ^^3 p^^ ^^^ possible to retain a pessary if the Hodge Smith Thomas , ^, . pessary. pessary. pessary. cervix IS very short or the peri- neum extensively torn; in the latter instance the' difficulty may be remedied by perineorrhaphy, but it is better to perform an opera- tion for the cure of the retrodisplacement at the same sitting. The length and breadth of the pessary needed may be ascertained by passing two fingers well up into the posterior fornix and separating them. The shape of the pessary may be modified after oiling it and heating it over a lamp; it is then rendered firm by plunging it into cold water. The pessary is introduced as follows, the patient being in the dorsal or the Sims position: It is held by its smaller end and the broader extremity passed into the vagina parallel with the labia, pressure being made downward against the perineum. It is then turned transversely, the broader extremity curving upwards and the narrow end downwards. The index finger of the disengaged hand is passed beneath the pessary and over its inner end, which is thus guided upwards and backwards behind the cervix. The lower end of the pessary should reach the middle of the urethra, and it should 942 MANUAL OF SURGERY be possible to pass the finger-tip between the pessary and vaginal wall at all points. If the pessary is too large, ulceration may follow. The patient should take a daily douiche, and the pessary should be removed, cleansed, and reinserted every month or two. Operations for retroversion are very numerous and no one is ideal. Those which are most frequently employed are Alexander's operation, hysteropexy, and intraabdominal shortening of the round ligaments. Alexander's operation consists in opening each inguinal canal as in a hernia operation, and drawing out the round ligaments until the fundus reaches the anterior abdominal wall, the peritoneum being stripped from the ligament as it is pulled outwards. The wounds are closed as in the Bassini operation, the sutures including the round ligament, the excess of which is cut off. The operation is indicated in cases in which the uterus is freely movable, and in which there are no intraabdominal complications. The disadvantages are its limited field, the difficulty sometimes encountered in finding the ligaments, the occasional breaking of a ligament, and the possibility of hernia from the pulling out of a pouch of peritoneum, an accident which can always be avoided. Hysteroplexy, or ventral suspension is performed through a small medium abdominal incision or through the Pfannenstiel incision. The latter runs in a slight curve, with the convexity downward, within the hair line of the pubes and across the recti muscles. The skin, subcu- taneous tissues and the anterior sheaths of the recti are dissected up as one layer, the recti separated in the direction of their fibres, the trans- versalis fascia and the peritoneum opened by a vertical cut. This incision leaves an inconspicuous cicatrix and is a safe guard against hernia. It is particularly indicated in conservative operations; contraindicated in suppurative 'lesions because of the extensive dissection of the cellular tissue. In hysteropexy the uterus is brought forward and the fundus sutured to the lower angle of the wound by two silk sutures, each passing through the peritoneum and subperitoneal connective tissue a,nd the fundus, the first on a line with the Fallopian tubes and the second about one-third inch post- eriorly, thus anteverting the uterus. In time the uterus recedes from the abdominal wall by stretching the bond of union, thus form- ing an artificial ligament. The operation allows the separation of adhesions and the treatment of other intraabdominal complications, but has the disadvantages of occasionally interfering with labor, and of forming a band, about which intestinal strangulation may occur. Ventrofixation is a term applied to the same operation when the sutures fixing the uterus pass through the muscles and aponeurosis GENITAL ORGANS 943 of the abdominal wall; it should never be employed unless the ovaries have been removed or the menopause has arrived. Intraabdominal shortening of the round ligaments possesses the advantages of hysteropexy and the Alexander operation and the disadvantages of neither. Operations which shorten these ligaments by folding them on themselves, by fastening them to the anterior surface of the uterus, or by drawing them through the broad ligament and fastening them together behind the uterus, are objectionable in that the greatest strain is brought to bear upon the weakest portion of the round ligament in the inguinal canal. The Gilliam-Fergusoti operation utilizes the strongest part of the ligament. After open- ing the abdomen in the median line a pair of forceps is pushed through the outer edge of the rectus muscle, and the round ligament grasped about two inches from its uterine end; the forcep is withdrawn and the ligament sutured to the fascia covering the rectus muscle. Montgomery has modified the Simpson operation. A silk Hgature is passed beneath each round ligament about one and one-half inches from the uterus. The two ends of the ligature are threaded into a pedicle needle, which is introduced between the layers of the broad ligament, and carried forward extraperitoneally until it reaches the outer border of the rectus muscle, through which it is thrust, the round ligament being rendered taut to facilitate this maneuver. The ligature is withdrawn from the needle, and serves to pull the ligament through the abdominal wall, where it is fastened with cat- gut sutures. As there is some danger of hernia occurring at the point where the round ligament passes through the rectus, we have further modified this operation by carrying the ligament between the rectus and its superficial sheath, to the median line, where it is sutured to its fellow. Prolapse or descent of the uterus is divided into three degrees, (i) retroversion with sinking of the organ in the pelvis, (2) presenta- tion of the OS at the vulva, and (3) prolapse of the uterus between the thighs (Fig. 535). The first and second are called incomplete, the last complete prolapse, or procindentia. The causes are (i) lack of support due to relaxation of the uterine ligaments or of the pelvic floor, particularly following laceration of the perineum ; (2) increased weight of the uterus, especially subinvolution after labor; and (3) increased intraabdominal pressure, such as is produced by straining, lifting heavy weights, improper clothing, and abdominal tumors. Occasionally prolapse is suddenly produced by a severe injury, such as a crush, or a fall from a height. The symptoms in an acute case are severe pain, and possibly internal hemorrhage and peritonitis. 944 MANUAL OF SURGERY In the ordinary chronic f(jrm there are first rectocele and cystocele, then retroversion and gradual descent of the uterus, which causes a dragging sensation in the pelvis and back, dysuria, and constipation ; in complete prolapse there may be difficulty in walking, and ulcera- tion of the protruding mass is not uncommon. As chronic endometri- tis is always present the symptoms of this affection are added to those just mentioned. In pseudo prolapse, or hypertrophy of the Pig. 535. — Complete prolapse or procidenture. cervix, the fundus is found in its normal situation and the vaginal walls are not displaced. Inversion of the uterus presents no os, but shows the orifices of the Fallopian tubes; it is smaller above than below, and on bimanual examination a depression is found in the region where the fundus ought to be. The treatment is reduction of the prolapse, and maintenance of the uterus in its normal position by pessaries or by operation. Reduc- GENITAL ORGANS 945 lion is occasiDiially dilTicult because of edema; strangulation with gangrene of the uterus has occurred in rare cases. If edema prevents reduction, multiple punctures should be made, cold compresses applied, and the foot of the bed elevated for some hours. Pessaries are not curative, but may be employed if the patient refuses opera- tion, or if operation is contraindicated. If the perineum is intact, a retroversion pessary may be tried, or if this fails, a ring pessary. When pessaries of this character cannot be retained, the uterus may be held up by a cup and stem pessary (Fig. 536) which is fastened to an abdominal belt. The operative treatment consists in curettage, amputation of the cervix to lessen the weight of the uterus, anterior colporrhaphy and perineorrhaphy to narrow the vagina and support the uterus, and intraabdominal shortening of the round ligaments before, and ventrofixation after, the menopause. If the uterus is badly diseased or contains ''fibroids." a supravaginal hysterectomy may be performed and the stump sutured to the abdominal wall. Wat- FiG. 536. — Goddard pessary. kins and Wertheim have recently revived vaginal fixation of the uterus in the treatment of prolapse after the menopause. The anterior vaginal wall is incised longitudinally, the bladder separated from the vagina and the uterus by blunt dissection, and the vesicouterine fold of peritoneum opened. The fundus of the uterus is then brought down into the vagina, the vesical fold of peritoneum sutured to the posterior surface of the uterus near the cervix, and the fundus attached to the vaginal flaps near the urethra. The incision in the vagina is now closed by suturing the flaps together. Thus the uterus, turned upside down, lies between the bladder and the anterior wall of the vagina. Inversion of the uterus is a condition in which the uterus is partly or completely turned inside out. There are three degrees: (i) the intrauterine, in which the depressed fundus does not protrude from the cervix, (2) the intravaginal, in which the fundus protrudes through the cervix, and (3) the extravaginal, in which the inverted 60 946 MANUAL OF SURGERY Uterus protrudes from the vulva. It arises during the puerperium as the result of traction on the cord, or pressure on the fundus of the uterus (acute inversion), or in non-puerperal cases as the result of the dragging of a pedunculated intrauterine tumor (chronic inversion). An intussusception is thus formed, the depressed portion being swallowed by the undepressed portion. The tubes and ovaries may or may not lie within the inverted uterus. The symptoms of acute inversion are pain, shock, hemorrhage, and the detection of a mass in the vagina. Chronic cases develop gradually and are asso- ciated with metrorrhagia, leukorrhea. dragging pains in the pelvis and back, and, from pressure on the bladder and rectum, dysuria and constipation. In intrauterine or partial inversion a cupping of the fundus may be felt on bimanual examination, and the depressed portion may be detected by a sound in the uterus. When the inver- sion is complete, the mass is detected in the vagina or outside the vulva, the uterus cannot be found in its normal situation, and the cup-shaped depression may be felt on bimanual examination. A sound, or, better, the finger, may be passed around the tumor, but will enter the cervix for a short distance only, or not at all. The mass is sensitive, bleeds easily, is larger below than above, and may show the orifices of the Fallopian tubes. The condition must be differentiated from prolapse (q.v.) and from polypi. In the latter the uterus is in its normal situation, and a sound cannot be passed all around the base of the tumor, but enters the uterine cavity at one side and reveals it to be of normal or increased depth. The treatment is reduction, usually with the aid of a general anesthetic. Emmet's method consists in passing the fingers around the tumor and into the cervix, in order to press upon the fundus with the palm of the hand while the fingers dilate the cervical ring, counter- pressure being made with the other hand through the abdominal wall. Xoeggerath pushes on one horn of the uterus with the finger, thus reinverting the fundus and finally the body. Prolonged pres- sure on the fundus may be employed by gauze packing or an elastic vaginal bag. Special apparatus also has been invented to make pressure on the fundus and pull down the cervLx. If these measures fail the posterior lip of the cervix may be cut through in the median line, the uterus reduced, and the cervical wound sutured. Other operations for this condition are stretching of the cer^'ical ring through an abdominal incision, and reduction by traction on the fundus; opening the peritoneal cavity through the mass, followed by dilatation of the cerv-ical ring, suture of the wound, and reposition of the uterus; and vaginal hysterectomy. GENITAL ORGANS 947 Fibromyomata or "fibroids" of the uterus are slow-growing, encapsulated tumors composed of fibrous and muscular tissue, the fibrous tissue being in excess. When the muscular tissue pre- dominates, the term myofibroma is applicable. Pure myomata are rare, grow rapidly, and are not encapsulated. Fibroids arise during the period of sexual activity, and never before puberty or after the menopause, in fact, subsequent to the climacteric they usually remain stationary or atrophy. They are most frequent in the colored race and in the married, sexual excitement and pregnancy both in- creasing the rate of growth. Twenty per cent, of all women who have reached the age of thirty-five are said to have fibroids. These tumors are almost always multiple and vary greatly in size. The body of the uterus, particularly the posterior wall, is the favorite situation. According to their relations with the uterine wall, they may be interstitial, submucous, or sub- peritoneal (Fig. 537); the second and subpehitoiheal ,.. third varieties may be sessile or pedun- culated. A pedunculated submucous growth is called a fibrous polyp. The uterus is enlarged, and the mucous mem- brane hypertrophied and sometimes ulce- rated. According to the situation of the growth, the uterus may ascend, descend, ^^^bmucoos. or be pushed toward one of the walls of the pelvis, while a submucous growth may cause inversion. In 40 per cent, of Pig- 537.— Diagram showing the ^, /-r-,1 1 \ 1 .1 ,1 varieties of uterine fibromyomata. the cases (rleck) there is brown atrophy of the heart, a fact accounting fox some of the sudden deaths after operation. In 54 per cent. (Tait) there are inflammatory changes in the tubes or ovaries. The changes which may occur in the tumor itself are edema, suppuration, gangrene, calcification, atrophy (es- pecially after castration or the menopause), and fatty, amyloid, myxomatous, cystic, or sarcomatous degeneration (1-2 per cent.). The growth may be associated also with chondroma or osteoma, or carcinoma of the endometrium. The symptoms are (i) hemorihage (menorrhagia, metrorrhagia, and delayed menopause), especially in the submucous variety; (2) pain due to dysmenorrhea, particularly in submucous growths, or caused by peritonitis or pressure on the pelvic nerves; (3) sterility or miscarriages; and (4) those due to pressure on the urethra or bladder (dysuria, frequent micturition, retention, cystitis), on the ureter (hydronephrosis, pyonephrosis), on the rectum (con- 948 MANUAL OF SURGERY stipation, tenesmus, obstruction, hemorrhoids), on the pelvic nerves (pain or numbness) , on the pelvic veins (varicosities and edema of the leg, phlebitis), and during labor (dystocia). Symptoms may, how- ever, be absent in even large growths. The uterus is irregularly enlarged and often filled with hard masses. A submucous fibroid may be recognized with the sound, or with the finger after dilatation of the cervix. Pregnancy, particularly when associated with bleed- ing, may be mistaken for a fibroid. In these cases the cervix is softened and the positive signs of pregnancy will sooner or later be detected. It should be remembered that the uterine souffle may often be heard in large fibroids and that intermittent contractions of the uterus can sometimes be felt. Examination with the Rontgen rays may show the fetus after the fourth month of pregnancy. Per- haps Abderhalden's sero-diagnosis for pregnancy may prove of value. In doubtful cases the best diagnostic agent is time. It is not unusual to mistake other tumors or chronic inflammatory troubles of the pelvis for a fibroid. A subperitoneal fibroid with a long pedicle may easily simulate a growth of a neighboring organ. Treatment is not needed in the absence of symptoms. If s}Tnp- toms are present the treatment may be palliative or radical. Pallia- tive treatment maybe indicated if the general condition of the patient is bad because of some independent affection, or if the symptoms are shght, complications absent, and the menopause is near. Drugs like ergot, hamamelis, hydrastis, thyroid extract, pituitarin, and ad- renalin may be given internally for hemorrhage, and such occasion- ally lessen the size of the growth. Hygienic treatment includes rest in bed for a portion of each day, and the avoidance of constipation, coitus, tight corsets, prolonged walking, and, in short, anything which induces pelvic congestion. Electrical treatment requires special apparatus, is not free from risk, and should never be used in complicated cases; it is said to reduce the size of the tumor, but is of most value as a hemostatic. The positive pole is attached to a uterine sound, which is passed into the uterus, while the negative pole is placed on the abdomen, the current is then gradually turned on to the point of tolerance and so maintained for five minutes; this may be repeated once or twice a week. Radiotherafy (radium, X- rays) has proved of service as a hemostatic agent, and, indeed, accord- ing to some enthusiasts, may cause the growth to disappear. A preliminary curettage is always done to exclude malignancy, and to remove any polj-pi that may be present. Radiotherapy, owing to its destructive action on the ovaiies. produces an artificial menopause, and is attended with the risk of burning. Fistulas have followed the GENITAL ORGANS 949 introduction of radium into the uterus. Althoujijh final conclusions cannot be drawn at the present time, our own practice is to advise against radiotherapy in all operable cases. In the young the ovaries can be left when the uterus is removed; at or after the menopause the danger of malignancy is removed with the uterus. Curettage followed by packing with iodoform gauze is a valuable measure for controll- ing hemorrhage. Intrauterine applications of iodin, carbolic acid^ and other hemostatics also have been used for the metrorrhagia. Salpingo-obphorectomy checks the bleeding and diminishes the size of the growth, and may be employed in cases in which hysterectomy is contraindicated, because of its difficulty or the general condition of the patient. Radical treatment consists in removal of the growth alone, or the entire uterus, either through the vagina or through the abdomen. Removal of fibrous polypi when small may be effected with the curette; growths of larger size may be twisted off, or the pedicle may be cut with scissors or with the wire ecraseur. Hemorrhage following any of these operations is controlled by gauze packing. Vaginal enucleation of submucous fibroids may be performed after dilatation or incision of the cervix, the capsule being incised^ and the tumor shelled out with the finger or a blunt instrument. If the tumor is too large to be delivered, it may be reduced in size by cutting sections out of it {morcellement) . Vaginal hysterectomy is rarely indicated for libromyomata, as a tumor large enough to demand radical treatment is better dealt with through the abdominal wall. The patient is placed in the lithotomy position, and the cervix exposed by perineal and lateral retractors, and seized with strong tenaculum forceps. The peritoneal cavity is opened by a curved incision behind the cervix and by a curved incision in front of the cervix, care being taken not to injure the bladder. The uterine artery on each side is then ligated, making sure that the ureter is not included in the ligature. The broad liga- ment between the ligature and the uterus is cut, the uterus drawn farther down, and the broad ligament ligated in sections and cut until the uterus is freed. The final ligature is placed to the outer or inner side of the ovary, according to whether it is desirable or not to remove that organ. After separating the cervix from the vagina some operators turn the uterus upside down, thus bringing the fundus into the vagina, and ligate and cut the broad ligament from above downward. Others, instead of ligatures, use clamps which are re- moved at the end of two or three days; this method facihtates the operation, but increases the danger of secondary hemorrhage. When 950 MANUAL OF SURGERY the uterus is too large to be delivered through the vagina, it may be divided into halves in the median line and each half removed sepa- rately, or, if it is still too large, wedge-shaped portions may be ex- cised (morcellement) from its center. After removal of the uterus, the peritoneum and vagina maybe sutured or the wound filled with gauze. Abdominal myomectomy consists in exposing the tumor through an abdominal incision, incising its capsule, enucleating the growth, and closing the uterine wound with catgut sutures. The operation is sometimes advised in the young in whom the growths are few and easily accessible, but should be seldom performed because of the danger of leaving unnoticed fibroids, and because, if the patient subsequently becomes pregnant, the scar predisposes to uterine rupture. In pedunculated subperitoneal tumors, the pedicle may be ligated if small, or it may be excised by a wedge-shaped in- cision and the wound in the uterus closed with sutures. Abdominal hysterectomy may be partial or complete. Partial or supravaginal hysterec- tomy is the operation of choice in Fig. 538.— Diagram of siipravaginai hys- the majority of cascs, particularly terectomy, showing ligatures, from above . . downward, on the ovarian artery, the round m large tumOrS, m the presence Of If ^"i''"^u ^""t ^^^ ""T'^^ artery The degenerative changes, and when bladder has been pushed downward, and '^ . the uterus amputated by a wedge-shaped the tubeS Or OVaricS are diseased. incision. The dotted lines indicate the rr ^.t. • U IfVi A •(■V. situation of the ureters, which pass under ^^ ^^ne ovaries are ncaitny and tne the uterine arteries about three-fourths of patient yOUng, at Icast OnC should an inch from the cervix. be preserved, in order to avoid the nervous s>Tnptoms induced by an artificial menopause. A median incision is made below the umbihcus, adhesions separated, the uterus delivered through the wound, the foot of the table raised (Trende- lenburg posture), the intestines pushed upward and held in place with gauze pads, and each broad Hgament severed after tying, with catgut, the ovarian artery, the round ligament, and the uterine artery, clamps or hgatures being placed on the uterine edge of the broad ligament to prevent reflux hemorrhage. The ligatures are passed through the broad ligament by an aneurysm or pedicle needle and may be of silk or catgut. The ovarian artery may be tied to the outer or the inner side of the ovary, according to whether this organ is to be removed or retained. In securing the uterine artery, the needle must be passed close to the cervix, in order to avoid the ureter. The two incisions in the broad ligaments are GENITAL ORGANS 951 now joined by cutting the peritoneum across the uterus just above the bladder, which is jnished downward with the handle of the knife. A similar incision is made posteriorly, and the uterus ampu- tated at the level of the internal os by a wedge-shaped incision (Fig. 538). The cervix is now closed with cagut sutures which, to pre- vent prolapse, should include the ends of the round ligaments, and the peritoneum approximated over the stumps of the arteries and the cervix with a continuous catgut suture. The abdomen is closed without drainage. Complete hysterectomy, or panhysterectomy, is to be preferred if there is associated malignant disease or infection of the tumor, or fibroid growths in the cervix. The broad hgaments are ligated and divided and the bladder stripped from the cervix, as in the previous operation. An incision is then made into the vagina through Douglas's cul de sac, and, aided by a finger passed through this opening into the vagina, the incision is continued all around the cervix and the uterus removed. The opening in the vagina is then closed with sutures, or it may give exit to a gauze drain if such be needed. When there are intraligamentary fibroids, it is often better to sever first the broad ligament on the unaffected side, then to cut through or around the cervix, and ligate and divide the opposite broad ligament from below upward while the uterus is rolled strongly toward the affected side; by this procedure an intraligamentary growth is turned out of its bed and the danger of injury to the ureter minimized. Polypi of the uterus are pedunculated tumors springing from the mucous membrane of the body, or more frequently the neck of the uterus. Fibrous polypi have been considered above. Mucous polypi are soft red growths composed of mucous membrane. Pedun- culated Nahothian follicles are retention cysts of the cervical glands which have acquired pedicles. Placental polypi are undetached por- tions of the placenta which retain a vascular connection with the uterus. A papillomatous polypus may spring from the cervix, and is very apt to become malignant. The symptoms are bleeding, leukorrhea, cramp-like pains due to the expulsive efforts of the uterus, dysmenorrhea, and sterility. When the polypus protrudes from the OS, it is easily detected with the finger and the speculum. Before this time it may be overlooked, but may be recognized either with the sound, or with the finger after dilatation of the cervix. The treatment is removal by seizing the tumor with a pair of forceps, and twisting it until the pedicle gives way, or the pedicle may be cut with scissors, the galvano-cautery, or the wire ecraseur. Small soft polypi may be removed with the curette. In all cases the growth should be studied microscopically to exclude malignant disease. 952 MANUAL OF SURGERY Sarcoma of the uterus i- uncommon, is most frequent in the body of the uterus, and is often a degenerative process in a fibro- myoma. It is usually of the spindle-celled variety, and has the same tendencies here as elsewhere. The symptoms are pain, uterine hemorrhages, watery leukorrhea, emaciation, a rapidly growing tumor, and in some cases ascites. A fibroid which grows rapidly, continues to increase in size after the menopause, or which recurs after removal, strongly suggests sarcomatous degeneration. The treatment is complete hysterectomy. Carcinoma of the uterus is, following carcinoma of the stomach, the most frequent form of malignant disease in the human body. It is most common after the fortieth year, but may arise in early life. The influence of heredity is doubtful, but any local irritation, such as laceration of the cervix, polj-pus, and chronic endometritis, favors its development. In over 80 per cent, of the cases the disease origi- nates in the cervix. It may be squamous-ceUed (epitheHo?na) when springing from the vaginal portion of the cervix, or cyhndrical-celled (adenocarcinoma) when attacking the cervical canal or corporeal endometrium. Epithelioma of the cervix begins as a nodule in the vaginal portion of the mucosa, from which, after a time, finger-like projections spring, forming a cauliflower-like mass; or as the result of necrosis, the growth appears as an excavated ulcer with hardened everted edges. Extension is most rapid in the direction of the vagina, and the growth involves the bladder at an early period. Adenocarci- noma of the cervical endometrium soon causes enlargement of the cerv- ical canal, either by ulceration, or by pressure from papillary growths. The disease is prone to extend outward into the parametrium along the bases of the broad Ugaments, and upward into the body of the uterus, long before it invades the vaginal portion of the cervix; the bladder, and less frequently the rectum, may be involved in the later stages. Cancer of the fundus projects into the uterine cavity as a fungous mass, which ulcerates, and extends through the uterine wall to the environing structures. Cancer of the uterus in most instances involves the regional lymph glands, only after it has ex- tended to the parametrium; this is said to be due to the small size of the lymph vessels of the uterus and the large size of the epithehal cells. Metastases to distant portions of the body are therefore com- paratively infrequent. Unchecked, the disease is usually fatal in from SLX months to two years. The symptoms, in the usual order of their appearance, are hemor- rhage, offensive discharge, pain, and cachexia. Pain is often absent until the peritoneum or parametrium is involved, while cachexia is GENITAL OIU'.ANS 953 often i)()stpoiu'(l uiUil near the end; consequently to wait for these signs before making a diagnosis is usually to wait until the case is inoperable. Pressure symptoms similar to those induced by fibromyomata (q.v.) and urinary or fecal fistulae from ulceration involving the bladder or rectum may arise in the final stages. Epi- thelioma of the vaginal portion of the cervix can be recognized with the linger or speculum, as a friable, f ungating, easily bleeding mass. In carcinoma of the cervical canal the cervix is enlarged, firmer than normal, and sometimes inliltrated with nodules, and the growth may be felt by inserting the finger into the cervical canal. Cancer of the fundus causes enlargement of the uterus and may be felt with the sound. In doubtful cases a portion should be removed for micro- scopic examination, by excision when the disease is in the cervix, and by the curette when in the body of the uterus. Menorrhagia at, or metrorrhagia subsequent to the menopause, is so strongly suggestive of cancer as to demand a most careful investigation, including microscopic examination of suspected tissue. The treatment is palliative or radical. Palliative treatment is indicated in inoperable cases, which, unfortunately, constitute the vast majority of those coming under observation. When the uterus is fixed in the pelvis, indicating invasion of the parametrium, or when the bladder or rectum is involved, radical operation is gen- erally contraindicated, although attempts are sometimes made to remove a portion of all these structures with the uterus. Hemor- rhage and discharge are greatly lessened, and life prolonged, by re- moving as much of the growth as possible with a curette, and cauteriz- ing the raw surfaces with the Paquelin cautery; the cavity is filled with iodoform gauze, which is removed at the end of twenty-four hours, and douches of permanganate of potassium, creohn, or other antiseptic deodorant given daily. Care should be taken not to perforate the uterus during this operation. Instead of, or in addition to the PaqueUn cautery, some surgeons insert into the cavity a tampon containing a 50 per cent, solution of chlorid of zinc, which is allowed to remain several days. The vagina should first be coated with an ointment consisting of one part of sodium bicarbonate to three parts of vaselin. Radiotherapy may lessen the discharge, the fetor, and the pain. Nothing short of opium is of value for the excruciating pain in the later stages. Radical treatment consists in removal of the uterus through the vagina, through the abdomen, or by the combined method. Vaginal hysterectomy may be employed when the vagina is large, the uterus small, and the patient very stout. The operation is similar to that 954 MANUAL OF SURGERY already described for fibromyoma, except that any protruding carcinomatous tissue should first be removed with the curette and the cervix closed with sutures, and hemisection of the uterus or morcella- tion should never be employed. Complete abdominal hysterectomy is the operation of choice, as it allows the wide removal of the para- metrium and of any enlarged retroperitoneal lymph glands. The operation is identical with that described for fibroids, except that the uterus should first be curetted, packed with gauze, and the cervix closed with sutures in order to prevent infection of the peritoneum when the vagina is opened, and the uterine arteries should be ligated, not close to the cervix, but to the outer side of the ureters. Com- bined vaginal and abdominal hysterectomy is preferred by some oper- ators. The cervix may be isolated from the vagina and the operation completed through the abdomen; or the broad ligaments may be tied and divided from above, the abdomen closed, and the operation completed through the vagina. The mortality of hysterectomy for carcinoma is from lo to 20 per cent. The chances of permanent cure are about 5 per cent, in carcinoma of the cervix, and about 75 per cent, in carcinoma of the fundus. Endothelioma of the uterus is rare and cannot be differentiated clinically from carcinoma. The treatment is complete hysterectomy. Chorio -epithelioma, deciduoma malignum, or synctioma malignum, is a malignant growth springing from the chorionic epithehum following pregnancy. The growth resembles placental tissue in- filtrated with blood. The symptoms usually arise a few weeks or months after a normal labor or an abortion, particularly if there has been a hydatidiform mole. There are metrorrhagia and a foul smelling, watery discharge, and later pain. The os is dilated, and the uterus laige and its cavity filled with a friable, purplish mass, which recurs after removal, extends to the surrounding parts, and quickly gives rise to distant metastases. The diagnosis is made with the microscope. The treatment is immediate complete hysterectomy. DISORDERS OF MENSTRUATION Amenorrhea, or absence of menstruation, is normal before puberty, after the menopause, and during pregnancy and lactation. The pathological causes are atresia of the genital canal {concealed menstruation), non-development or atrophy of the generative organs, destruction of the ovaries and tubes by disease or their removal by operation, exposure to the X-rays or radium, obesity, emotional disturbances, hysteria, neurasthenia, debihtating diseases, change of GENITAL ORGANS 955 climate, catching cold during menstruation, opium and other drug habits, hypothyroidism, hypopituitarism, and most frequently of all chlorosis. I'lu' treatment is that of the cause. Suppression of the menses due to cold is treated by hot drinks and hot applications. Emmenagogues are rarely indicated, and should never be employed unless pregnancy can be positively excluded. Vicarious menstruation is the periodic discharge of blood from some other part of the body than the uterine mucosa. It may occur from any mucous membrane, the skin, or from an ulcer, and is usually associated with amenorrhea or scanty menstruation. At- tempts may be made to induce normal menstruation by hot douches, electricity locally, and the internal use of emmenagogues, such as iron, oxalic acid, aloes, apiolin, or the salicylates. Irritating appli- cations to the endometrium are dangerous. Menorrhagia is prolonged or increased menstrual bleeding. Metrorrhagia is bleeding from the uterus between the menstrual periods. Among the local causes are inflammatory diseases, dis- placements, injuries, and neoplasms of the uterus or appendages, foreign bodies in the uterus, pelvic tumors not connected with the uterus, placenta previa, detachment of the placenta, hydatidiform degeneration of the chorion, ectopic pregnancy, abortion, sclerosis of the uterine vessels, and most common of all fungous endometritis. Among the general causes are anemia, hemophilia, acute infectious diseases, emotional disturbances, gout, scurvy, sj^Dhilis, malaria, lead poisoning, and diseases of the heart, lungs, and liver (cf. '^Spon- taneous Hemorrhage," chap. xv). H}-perthyroidism should probably be included among these causes; also, from a theoretic standpoint. h>Tperpituitarism, although positive evidence of the influence of the latter on the menses is lacking. The treatment is that of the cause. If the cause cannot be found and the loss of blood is excessive radiotherapy is the best hemostatic. In an emergency the bleeding may be checked by packing the uterus tightly with gauze, the transfusion of human blood and giving horse serum hypodermatically. Various other measures can be used for the same purpose (see "Styptics," chap. xv). Uncontrollable bleed- ing at the menopause may demand hysterectomy. Dysmenorrhea is excessive pain just before, during, or immedi- ately after the menses. Like amenorrhea, menorrhagia, and metror- rhagia, dysmenorrhea is a symptom, not a disease. The following varieties are described: Neuralgic dysmenorrhea is most frequent in the anemic and nervous, and may or may not be associated with disease of the pelvic 956 MANUAL OF SURGERY organs. The pain is neuralgic in character, and may be referred to the uterus, to the ovaries, or elsewhere. It is apt to be most severe before, and is occasionally relieved by the flow. There may be neuralgia in other parts of the body. The treatment is attention to the general health, anemia, gout, rheumatism, or indigestion and the giving of appropriate remedies. In some instances, according to the rhinologists, the dysmenorrhea depends upon an affection of the nose. Any local disease should be removed, and the pain itself relieved by hot applications and the administration of antineuralgic remedies like acetphenetidin, cannabis indica, and belladonna; elixir of valerianate of ammonium (f 5ii) or fluid extract of viburnum prunifolium (f 5i)> every three or four hours, is frequently employed. In cases which resist all other forms of treatment, removal of the ovaries may be indicated. Congestive dysmenorrhea is due to exposure to cold, uterine displacement, pelvic tumors, and inflammations of the uterus, the appendages, or the environing structures. These conditions, except- ting the first, cause intermenstrual symptoms and may be recognized by pelvic examination. The symptoms are worst at the beginning of menstruation, and are often relieved by a free flow. The treatment during the attack is hot applications, hot sitz baths, diuretics, and diaphoretics. Between attacks the cause should be removed. Mechanical or obstructive dysmenorrhea is due to some obstruc- tion to the egress of menstrual fluid, such as stenosis of the cervix, flexions of the uterus, tumors (particularly polyps), and spasmodic contraction of the internal os. There are severe, cramp-like pains {uterine colic), followed by a gush of blood or the expulsion of clots, which usuafly gives relief. Between the periods the passage of a sound may reveal hyperesthesia of the endometrium, particularly about the internal os. The treatment is dilatation of the cervical canal if there be stenosis, and curettage of the uterus if there be endometritis. Polypi should, of course, be removed. The treat- ment of flexions has already been considered. Obstructive dysmen- orrhea is often cured by labor, which permanently dilates the cervical canal. Ovarian dysmenorrhea is associated with disease of the ovaries, the symptoms referable to these organs being intensified during the menstrual period. The treatment is that of the causative lesion. Membranous dysmenorrhea is characterized by the expulsion of a membrane, the decidua menstrualis, either in shreds or as a cast of the uterus. It is differentiated from an early abortion by its regular occurrence, and by the absence of chorionic villi in the membrane. GENITAL ORGANS 957 It is a form of endometritis, and is usually associated with sterility. The treatment is dilatation and curettage, which may require repeti- tion. Sterility in the female is normal before puberty, after the meno- jiause, and during lactation, although conception may occur during Tnptoms, 159 treatment, 160 Fulguration, 219 Fulminating appendicitis, 767 Fumigation by mercury in treating syphilis, 202 Fungi, see bacteria Fungus cerebri, 524 hematodes, 218 testis, 906 Funicular inguinal hernia, 803 Furbringer's method of sterilization of hands, 64 Furuncle, 247 Fusiform aneurysm, 296 Gait in diagnosis. 11 Galactocele, 633 Gall-bladder, affections of, 780 new gall-bladder, 791 papilloma of, 780 rupture of, 672 stones in, 785 Gall-stones, 781 in intestine, 748 pancreatitis due to, 793 symptoms of, 783 Ganglion, 365 compound palmar, 366 Gangrene, 126 direct, 132 bed sores, 132 burns and scalds (Chapter XI), 155 corrosive chemicals, 133 crushes, 132 frost bites (Chapter XI), 155, 159 prolonged pressure, 132 X-ray, 134 dry, 126, 131 emphysematous, 134 etiology, 127 indirect, 127 Ainhum, 130 diabetic, 129 embolic, 130 ergot, 130 ligature of principal artery, 131 obstruction of principal artery and vein, 131 post-febrile, 129 presenile, 128 Raynaud's or symmetrical, 1 29 spontaneous, 128 thrombosis of artery, 131 treatment, 128 micro bic, 127, 134 emphysematous, 134 hospital, 134 malignant edema, 134 multiple cutaneous areas, 248 moist, 126 signs of, 126 termination, 127 INDEX I04S Gangrenous appendicitis, 767 cellulitis, 177 inflammation, 93 pancreatitis, 795 stomatitis, 136 urticaria, 248 Garre-pneumectomy operation, 618 Gartner's duct, cj'st of, 967, 232 Gaseous swelling in tumor, 240 Gas gangrene, symptoms of, 135 treatment, 136, 134 Gasoline, 54 Gasserian ganglion, removal of, 352 Gastrectasia, 699 Gastrectomy, 725 complete or total, 732 partial, 725 subtotal, 726 Stewart's method, 728 Gastric fistula, 698 hemorrhage, 694 lavage, 706, 23 tetany, 695 ulcer and its effects, 689 Gastritis obliterans, 706 Gastrodiaphany, 702 Gastroenterostomy, 698 vicious circle after, 722 Gastrogastrostomy, 697 Gastrointestinal tract, sterilization of, 65 Gastrojejunostomy, 728 Gastrolysis, 695 Gastromesenteric ileus, 700 Gastropexy, 711 Gastroplasty, 697 Gastroplication, 711 Gastroptosis, 703 Gastrorrhagia, 694 Gastrostomy, 707, 662 Gastrotomy, 707 Gaucher's disease, 798 Gauntlet bandage, 82 Gauze bandage, 76 pads, 62 Gelatin as a hemostatic, 310 injection of aneurysms, 300 Gelatinous carcinoma, 218 General anesthesia, 21 lymphadenosis, 339 Genital chancre, 194 organs, female, 919 male, 882 Genitourinary canal, 843 Genupectoral position, 940 Genu recurvatum, 991 rhachiticum, 989 staticum, 990 valgum, 989 varum, 990 Gerdy's extension cravat, 88 Germicide, 52, 51 Germinal infection, 46 Gerster's operation for amputation of breast, 629 Giant-celled sarcoma, 230 Gibson's bandage, 78 operation, 755 Giere-pneumectomy operation, 618 Gigli saw, 508 Gilles' modification in rhinoplasty, 589 Gilliam-Ferguson operation of shortening the round ligaments, 943 Girard, pyloroplasty, 724 Glanders, 187, 188 Glands, lymphatic, affections of, 340 malignant, 340 mesenteric, 687 Glandular carcinoma, 218 Glass arm, 362 Glaucoma, 361 Gleet, 885 Glenard's disease, 739 Glioma, 228 Gliosarcoma, 228 Gliosis, 228 Globus hystericus, 660 Glossitis, 643 acute parenchymatous, 643 superficial, 643 chronic superficial, 643 syphilitic, 645 Glossopharyngeal nerve, affections of, 354 Glottis, burns of, 159 edema of, 603 Glover's stitch, 140 Gluteal artery, ligation of, 330 Glutol, 54 Glycosuria, 36 symptoms after anesthesia, 36 Goddard pessary, 945 Goiter, 578 carcinoma in, 579 heart, 583 symptoms, 579 treatment, 580 varieties, 578 form fruste, 583 Gonococcus, 885, 107, 44 1046 INDEX Gonorrhea, 885 acute treatment, 887 chronic treatment, 888 complications, 886 prophylaxis, 887 U. S. military regulations in treat- ment, 887 Gonorrheal arthritis, 479, 886 conjunctivitis, 886 cystitis, 886 epididymitis, 886 iritis, 886 proctitis, 886 rheumatism, 479, 433 rhinitis, 886 sclerotitis, 886 serum, 479 synovitis, 477 tenosynovitis, 365 urethritis, 885 Gooch's flexible wooden splints, 381 Goodell's speculum, 919 uterine dilator, 932 Gouty arthritis, 487 deposits in bursas, 373 neuritis, 342 Graduated compress, 311 Grafting, bone, 436 free fat transplantation, 263 mucous membrane, 263 nerve, 348 skin, 260 Mangoldt's, 263 pedunculated flap, 257 Reverdin's, 262 Thiersch, 260 Wolf's, 260 tendon, 370 Granny knot, 142 Granulation tissue, 102 exuberant, 103 Gravel, 856 Graves' disease, 582 Great sciatic nerve, affections of, 360 Greenish discoloration, in diagnosis, 6 Greenstick fracture, 374 Grey's salt sac drain, 152 Gritti's supracondyloid amputation, 1021 Grossich method of disinfection, 66 Growth of tumors, 237 Guillotine, 1006 Gum boil, 648 Gumma, 199, see also special regions Gummata, tuberculous, 250 Gummatous arthritis, 480 degeneration, 199 osteomyelitis, 439 synovitis, 480 Gums, epithelioma of, 650 Gun powder stains, 146 Gunshot fracture, 375, 381 wounds, 144 Gutta-percha, uses of, in bone cavities, 436 Gutter fracture, 516 Gynecomazia, 622 Habit, in diagnosis, 4 Hahn's tracheotomy tube, 607 Hallux rigidus (H. flexus), 998 valgus, 997 Halstead's operation for amputation of breast, 628 subcuticular stitch, 141 suture, intestinal, 754 Hammer nose, 586 toe, 998 Hammond's wire splint for fracture of lower jaw, 389 Hanche a ressort, 988 Hand, amputation of, 1008 deformities of, 977 ulcerating gumma, 199 Handkerchief bandages, 78 for lower extremities, 88 for suspending breast, 86 for upper extremities, 83 Handley, treatment of lymphedema, 336 Hands, sterilization of, 64 Haptophore, 49 Hard corns, 248 Hardening in tumors, 241 Hare-lip, 634 Harrison's sulcus, 441 Hartley-Krause operation for removal of Gasserian ganglion, 352 Hartman's operation for gastrostomy, 707 Head, 500, see fractures of skull injuries of brain, cerebral Healing of wounds, see repair Heart, compression of, 273 concussion of, 273, 610 fetal sounds in diagnosis, 9 massage of, 274, 34 overdistension, 272 wounds of, 272 diagnosis, 273 symptoms, 272 treatment, 274 INDEX 1047 Heat in hemorrhage, 310 inllammation, 99, 94 treatment of inflammation, 99 Hebcrden's nodes, 488 Hectic fever, 113, 167 flush, 113 Hedonal in anesthesia, 28 Hegar's operation for laceration of peri- neum, 926 Height, in diagnosis, 10 Heineke-Mikulicz operation of pyloro- plasty, 725 Helioalpintherapy, 211 Heliotherapy in tuberculosis, 211 Hemangioendothelioma, 230 Hemangioma, 226 Hemarthrosis, 490 Hematemesis, 694 Hematocele, pelvic, 972 of cord, 806 scrotal, 912 Hematocolpos, 923 Hematogenous jaundice, 168 Hematoma, 138 arterial, 293 of abdominal walls, 670 of dura mater, 529 of ear, 566 of scalp, 500 Hematometra, 923, 931, 970 Hematomyelia, 551 Hematorrhachis, 551 Hematosalpinx, 923, 958 Hematuria, 846, 268 essential, 850 Hemianopsia, 506 Hemiglossitis, 643 Hemoglobin, 12 Hemoglobinuria, 846 Hemolysis, 14 Hemolytic jaundice, 798 tests, 14 Hemopericardium, 275 Hemophilia, 318, 850 joints in, 490 Hemopneumothorax, 611 Hemoptysis, 694, 610 Hemorrhage, 306 bandage for, 80 constitutional symptoms, 307 diagnosis, 309 from shock, 164 natural arrest, 308 resume, 317 see special regions Hemorrhage, treatment, 310 acupressure, 313 cold, 310 compression, 311 elevation, 310 forcipressure, 314 heat, 310 ligation, 314 styptics, 310 suture of blood vessels, 315 torsion, 314 varieties, 306 Hemorrhagic diathesis, 318 effusion in pericardium, 275 fever, 308 infarct, 268 inflammation, 93 Hemorrhoids, 834 external, 835 treatment of, 835 internal, 835 treatment of, 835 Hemostasis, 308, 139 varieties, 308, 309 Hemostatic forceps, 314 Hemostatics, 311 Hemothorax, 307 Henderson, respiratory failure, 53 Hepatic abscess, 774 colic, 668, 788 cysts, 787 duct, stone in, 788 Hepaticocholangioenterostomy, 792 Hepaticotomy, 792 Hepatopexy, 776 Hepatoptosis, 776 Hepatotomy, 775 Hereditary syphilis, 206, 191 Hermaphrodism, 921 Hernia, 799, see also special regions accidents of, 820 appendix in, 801 bladder in, 801, 811 causes of, 799 cecum in, 801 cerebri, 523 contents of, 801 coverings of, 801 en bissac, 805 foreign bodies in, 801 hour-glass sac, 799 hydrocele of sac, 799 incarceration of, 820 inflammation of, 820 intestine in, 801 1048 INDEX Hernia, irreducible, 820 mouth of, 799 obstructed, 820 sac of, 799 signs of, 802, 805 sliding, 801 special, 802 strangulated, 821 complications after taxis for, 821 operative treatment of, see special regions signs and symptoms of, 823 taxis in, 821 stretching in, 105 structure of, 799 traumatic, 800 treatment of, 802, see special regions varieties of, 802 Herniotomy, 823 Herpes, gangrenous, 248 labialis, 637 Herpetic ulceration, 195 Herpetiform syphilide, 197 Hesselbach's triangle, 804 Hexamethyl violet, 55 Hexamethyleamin, 66, 507 Hey's amputation, 1015 Hiccough, 34 Hilton's method of opening abscesses, III, 575 Hind gut, 826 Hip, ankylosis of, 485 diagnosis of injuries about, 416 disease, 483 diagnosis from sacroiliac disease, 483 dislocation of, congenital, 453 traumatic, 455 effusion into, 476 excision of, 497 varieties of, 466, 467, 468 Hip-joint, amputation at, 1023 anterior incision of, 497 disease, 483 osteoarthritis of, 489 tuberculous disease of, 483 Hippocratic face, 1 1 Hirschsprung's disease, 734 History in diagnosis, 4 of tumors, 235 Hodgen's splint, 418 Hodgkin's disease, 339, 14 Hoffa's operation for congenital displace- ment of hip, 454 Hoffmeister's method of sterilizing catgut, 60, 61 Hollow foot, 996 Hopkin's dressing for fractured patella, 422 Horn, 249 sebaceous, 254 Horse hair, 62 probang, 660 shoe kidney, 844 Horsley's cyrtometer, 503 dural separators, 508 operation for the removal of the Gas- serian ganglion, 353 wax, 510 Hot air apparatus, 99 Hottentot apron, 921 Hour glass stomach, 695 hernia, 799 Housemaid's knee, 373 Howard method of artificial respiration, 34 Howship's lacunas, 438 Hudson's burrs, 508 modification of the DeVilbiss forceps, 509 Hull's paraffin treatment of burns, 157 Humerus, dislocation of, 459 condyles, 404 fractures of, 395 anatomical neck, 395 treatment, 397 head, 398 intercondyloid, 403 lower extremity, 400 separation of epiphysis, lower, 404 upper, 398 shaft, 399 supracondyloid, 400, 401 surgical neck, 397 triangle splint, 397 tuberosities, 398 Hunter's canal, ligation of femoral artery in, 331 operation for aneurysm, 302 Hunterian chancre, 193 Huntington's operation for transplanting bone, 450 Hutchinson's teeth, 207 Hydatid cysts, 233, see also special regions disease, 7 moles, 225 of Morgagni, 966 Hydrargyrism, 202 Hydrarthrosis, 477, see hydrops articuli Hydrocele, 909, see also special regions bilocular, 911 INDEX 1049 Hydrocele, chylous, 912 congenital, 911, 805 encysted, of cord, 911, 806 testis, 911, 806 i'peremia, 95 reduction of, 95 Hyperkeratosis linguae, 644 Hypernephroma, 231 Hyperpituitarism, 443, 437 Hyperplastic ovaritis, 964 Hypertrichosis, Rontgen rays in treat- ment of, 18 Hypertrophic osteoarthropathy, 431 Hj'pertrophied scar, 105 Hypertrophy, see special regions H\-pochlorus acid, 56 H\'podermoclysis, 288 H>T>oglossal nerve, injuries of, 354 Hypomycetes, 51 H^-pophysis cerebri, 537 Hypopituitarism, 537 Hypospadias, 883 balanitic, 883 penile, 883 peroneal, 883 Hysterectomy, abdominal, 950, 949 vaginal, 949 Hysteria, 180, in spinal injuries, 547 Hysterical edema, 7 joints, 490 Hysteroneurasthenia, 547 Hysteropexy, 942 Ichthyol in inflammation, 98 Ichthyosis lingu3e, 643 Icterus, see jaundice Idiocy, 577 Idiopathic aneurysm, 296 dilatation of the colon, 734 epilepsy, 537 erysipelas, 175 fragilitas ossium, 442 hydrocele, 909 hydrocephalous, 525 inflammation, 93 multiple hemorrhagic sarcoma, 253 tetanus, 178 Ileosigmoidostomy, 764 Ileostomy, 755 Ileus, 740 Iliac colostomy, 755 veins, inflammation of, 278 vessels, ligation of, see common, external and internal Iliopectineal bursa, 373 Iliopsoas, 373 Ilium, fractures of, 410 Immobility in tumor diagnosis, 240 Immune bodies, 49 serums, 49 Immunity, 48, 47 Colics', 192 Profeta's, 192 Impacted calculus, in ureter, 857 cerumen, 566 embolus, 267 feces, 749 fracture, 374 urethral calculus, 885 Impaction of foreign bodies in bowel, 748 Impassable stricture, of urethra, 893 Imperforate anus, 826 Impermeable stricture of urethra, 893 Impetigo, syphilitic, 197 Implantation dermoids, 233 io;o INDEX Impotence, 901 Impression fracture, 515 Incarcerated hernia, 820 Incised wounds, 142 Incision, exploratory, 6 Incisions, relaxation, 256 technic in, 6q Incomplete dislocation, 455 fracture, 374 inguinal hernia, 802 Incontinence of urine, 869 retention, 870, 916 Indian method of complete rhinoplasty, 589 Indifferent tissue, 92 Indirect fracture, 375 gangrene, 127 inguinal hernia, 802 congenital, 803 Induced thrombus, 266 Induration, foliaceous, 193 nodular, 193 parchment, 193 Infantile arthritis, 432 hydrocele, 911 inguinal hernia, 804 palsy, 484, 2, 564 scurvy, 433, 441 sv'philis, 206 umbilical hernia, 814 uterus, 930 Infarct, 268 Infection, 42 determining factors, 47 extends, 46 increased susceptibilitj-, 47 Infections, prevented by, 49 Infectious leukocytosis, 13 Infective arthritis, 479 inflammation, 93 osteomyelitis, acute, see osteomyelitis phlebitis, 277 thrombophlebitis, 277 thrombosis of cerebral sinuses, 529, thrombus, 266 Inferior dental nerve, operations on, 352 maxilla, see lower jaw maxillary nerve, operations on, 352 thjToid artery, compression of, 313 ligation of, 326, 580 Inflamed hernia, 820 Inflammation, 91, see also special regions absorption in, 97 causes of, 91, see also susceptibility, 47 Inflammation, cellulitis, 176 constitutional treatment, loi extends (infection Chapter III) extension of, 46 exudation in, 91 non-vascular tissue, 92 pathology, 92 symptoms of, 93 termination of, 93 tissue changes, 92 treatment of, 95 Bier's, 97, 211, 112 varieties of, 93 vascular changes in, 91, 92 Infraction, 374 Infraorbital nerve, operation on, 351 Infrapatellar bursa, 373 Infusion of salt solution, 287 Ingrowing toe nail, 255 Inguinal adenitis, 338 bubo, 193, 338, 897 colostomy, 756 hernia, 802 diagnosis of, 805 treatment of, 806, 807 variations in operations for, 810 varieties of, 802 hydrocele, 911 perineal hernia, 817 Inhaler, Esmarch, 29 Inhalers in anesthesia, 24 Inherited s\'philis, 206 bone affections in, 438, 207 Injections for cure of aneurysm, 302 in gonorrhea, 888 intramuscular, in syphilis, 201 of hydrocele, 911 Injuries, see special regions in diagnosis, 4 Innominate artery, ligature of, 320 Inoperable carcinoma, 219 malignant disease, treatment of, 219, 231 tumor, 18 sarcomata, 231 Insanity, 538, 36, 174 Insect bites and stings, 153 Inspection, in diagnosis, 5 Instruments, preparation of, for opera- tions, 59 Insufflation of ether, 25, 26, 27 Intelligence, center of, 506 Interacinous cysts of breast, 633 Intercondyloid T-fracture, 403 Intercostal artery, hemorrhage from, 610 INDEX io;i Interdental splints, 389 Interilio-abdominal amputation, 1024 Intermaxilla. in hare-lip, 634 Intermediate hemorrhage, 307 syphilis. 191 Intermuscular lipomata, 222 Internal anthrax, 186 carotid artery, hemorrhage from, 567 derangement of knee joint, 471 epicondyle, fracture, 403 ligation of, t,22 wounds of, 521 hemorrhage, 307 hernia. 817 iliac artery, ligation of, 330 jugular vein, hemorrhage from, 567 mammary arterj', hemorrhage from, 610 ligation of, 326 popliteal nerve, affections of, 361 pudic arter\', ligation of, 330 urethrotomy, 893 Interpretation of X-ray pictures, 15, 16 Interscapulothoracic amputation, 1002, 1014 Intersigmoid fossa, hernia into, 820 Interstitial appendicitis, 766 cholecystitis. 780 hernia, inguinal, 804 inflammation, 93 keratitis. 207 mastitis, 623 Intestinal adhesions. 744 anastomosis, 760 bands, 744 diverticula, 733 exclusion, 764 fistula, 758 localization, 753 obstruction, 823, 740, 68 chronic, 743 subacute, 743 paralysis, 752 polyps, 749 ptosis, 739 sutures, 760 worms, 748 Intestines, affections of, 732 anastomosis of, 760 carcinoma of, 747 congenital malformations of, 733 enteroptosis, 739 exclusion of, 764 foreign bodies in, 748 gangrene of, 823, 686 Intestines, intussusception, 750 acute, 75: chronic. 751 lateral implantation of, 764 operations on, 753 perforation of, typhoid, 737 rupture of, 671 segregation of, 764 stenosis, 733 stricture of, 746 cicatricial, 746 neoplastic, 746 spasmodic, 748 tuberculosis of, 738 tumors of, 746, 749 volvulus of, 745 wounds of, 670 Intraabdominal gauze pads, 62 inflammation, 14 shortening of round ligaments, 943 Intraarticular ankylosis, 491 fracture, 374 Intracanalicular fibroma. 625 Intracapsular fracture of femur, 412 humerus, 397 Intracranial abscesses, 532, 570, see also cerebral, head, skull, brain blood vessels, injuries of. 520 complications of otitis media, 567 hemorrhage, 519, 514 in the new-bom, 521 inflammation, 529 tumors, 534, see also head, skull, brain, cerebral Intrailiac hernia, 805 Intramammar>' abscess, 622 Intramedullary hemorrhage of spinal cord. 551 Intraparietal hernia, 804 sulcus, 503 Intraperitoneal abscess. 684 IntrapharjTigeal insufHation of ether, 26 Intraspinal hemorrhage, 551 tumor, 564 Intratracheal insuflBation of ether, 34, 26 Intrauterine fractures. 375 Intravenous etherization. 28 infusion, 287 Intraventricular injection, 528 Intubation of lar>Tix, 608 Intussusception, 750 congenital, 733 varieties of, 750 Intussusceptum, 750 Intussuscipiens, 750 I0^2 INDEX Inunction of mercury, 201 Inversion of testis, 902 uterus, 945 Inveterate headache, 538 Involucrum, 435 Involuntary seminal emissions, 900 Involution cysts, 633 Inward dislocation of hip, 468 lodin, tincture of, 54, 66 Iodoform, 55 emulsion, 114, 55, 481 gauze, 63 poisoning, 55 lodophilia, 13 Iritis, 198, 886 Iron wire, 62 Irradiation, 517 Irreducible swellings, 806 hernia, 806, 820 Irrigation, constant, 177 of chronic abscesses, 112 Irritants, 100 Ischemia, 47 see trench foot, 160 Ischiorectal abscess, 830, 831 Island flaps, 257 Isopral in anesthesia, 28 Italian method of rhinoplasty, 591 Jackson's bronchoscope, 601 membrane, 735 Jacksonian epilepsy, 538 Jacob's ulcer, 177 Janet's method of irrigating the urethra, 888 Jarisch-Herxheimer reaction, 204 Jaundice, catarrhal, 779 hematogenous, 168 recurring, 784 Jaw, lower, cleft of, 636 closure of, 651 cysts of, 648 dislocation of, 457 epulis, 649 excision of, 650 fibrocystic disease of, 649, 227 fracture of, 388 necrosis of, 648, 434 temporary resection, 650 tumors of, 649 enchondroma, 649 epithelioma, 650 epulis, 649 fibroma, 649 osteoma, 649 Jaw, tumors of, sarcoma, 649 upper, cysts of, 648 epulis, 649 excision of, 650 fracture of, 388 necrosis of, 648 tumors of, 649 see lower Jejunostomy, 754 Jejunum, peptic ulcer of, 723 Jiann operation for salivary fistula, 642 Joints, 452 affections in syringomyelia, 489 ankylosis of, 491, 493, 494 aspiration of, 475 Charcot's, 489 diseases of, 473 local examination in, 474 dislocations of, 453 effusion into, evidences of, 476, 475 empyema of, 477 examination of, 473 excision of, 495 false, 385 gonorrheal affections of, 479 gouty, 487 hemophilic disease of, see hemar- throsis hysterical, 490 incision of, 475 infection, 473 injuries of, 452 involvement of in infectious fevers, 473, 455 lipoma aborescens, 222, 491 loose bodies in, 490, 489 mice, 490 neuralgic, 490, 474 pyemic, 477 resection, 495 rheumatic, 487, 488 ruptured semilunar cartilages in, 471 sprains of, 452 syphilis of, 480, 198 tuberculous disease of, 482 wounds of, 452 Jones' cock-up splint, 408 position, 403 Jonnesco's operation for excision of the cervical sympathetic, 361 Jugular vein, hemorrhage from, 567 ligation of, 279, 531 Jumping hip, 988 Jury mast, Sayre's, 562 INDFX 1053 Kadcr's gastrostomy, 708 Kanavel operation for trifacial neural^'ia, 351 Kangaroo tendon, 62 Karyokinesis, 102 Katzenstein's operation for varicose veins, 284 Keen's double brain electrode, 510 rongeur forceps, 508 Keloid, cicatricial, 220 false, 253, 220, 105 spontaneous, 253 true, 253, 220 Keratitis, interstitial, 207 Keratosis senilis, 252 Kemig's sign, 530 Keyes-Ultzman syringe, 889 Kidneys and ureters, afifections of. 843 abscess of, 853 amyloid disease of, 112 blood examination in, 846 calculus, 855 carcinoma, 861 congenital affections of, 843, 861 cystic disease of, 862 cysts, 862 decapsulation, 864 degenerative changes, 848 ectopic, 843 examination of, 843 exploration of, 844 floating, 843 functional capacity of, 845 hematogenous infection of, 853 horse shoe, 843 hydronephrosis, 850, 843 hypernephroma, 861 injuries of, 673, 848 irrigation of pelvis of, 852 movable, 849 nephritis, operation for, 863 operations on, 862 presence of both kidneys, 846 pyelitis, 851 pyelonephritis, 852 pyonephrosis, 852 rupture, 673 sarcoma, 861, 843 solitary, 843 surgical, 852 tuberculous disease of, 854 tumors, 861 twisting of pedicle, 849 wounds, 848 Killian's operation for empyema of the frontal sinus, 597 Kimpton method of blood transfusion, 286 Kingsley's interdental splint, 390 Kleb's tuberculocidin, 213 Klumpke paralysis, 355 Knee-chest posture, 940 Knee-joint, amputation through, 102 1 ankylosis of, 491 dislocation of, 469, 471 effusion into, 476 erasion of, 486 excision of, 498, 489, 486 gonorrheal infection of, 479 housemaid's, 373 incisions for drainage, 476 internal derangement of, 471 semilunar cartilage, dislocation of . 471 tuberculous disease of, 486 Knock-knee, 989 Knots, 142 Knotted bandage, 80 Kobelt's tubes, cysts of, 232, 967 Koch's postulates, 45 tuberculin, 212 Kocher's method of gastroenterostomy, 713 method of treating dislocation of the humerus, 460 operation of pylorectomy, 728 for excision of the hip, 497 for removal of the tongue, 647 temporary resection of upper jaws for exposing nasopharyngeal growths, 650 Kondoleon's operation for lymphedema, 337 Kraske's method of excision of rectum, 841 Kraurosis vulvae, 922 Kraus normal bovine serum, 187 Kroelein method in pylorectomy, 728 Kronlein's method of craniocerebral to- pography, 504 Kuettner's infusion of salt solution with oxygen, 288 Kummel's anesthesia, 28 Kussmaul's sign, 277 Kjrphosis, 556 Labial abscess, 922 artery, compression of, 313 chancre, 195 hernia, 803 I054 INDEX Laborde's method of artificial respiration, 34 Labyrinth, suppuration of, 567 Lacerated wounds, 143 Laceration, see special regions Lachrymal bone, fracture of, 387 Lacteal cysts, 633 Lacunar abscess, 109 Lambotte's apparatus for fixation of frac- tures, 383 Laminae, fracture of, see spine Laminectomy, 544, 551 Lancereaux treatment of aneurysm, 300 Lane's forceps, 382 kink, 703 operative treatment of fractures, 382 plate for fracture, 383 Langenbeck's operation of excision of ankle, 497 elbow, 496 hip. 497 incision of wrist, 496 on nose, 586 Laparotomy, 666 Lardaceous disease, 113 Larrey's amputation at shoulder joint, 1014 Laryngeal cartilage, fracture of, 390 crises, 600 stenosis, 600 Laryngectomy, 605 Laryngismus stridulus, 600 Laryngitis, edematous, 603 Laryngocele, 571 Laryngoscope, 599, 6 Laryngotomy, 606 Laryngotracheotomy, 606 Larj'nx, abscess of, 603 acute edema of, 603, see also edema of glottis, 603 artificial, 605 chondritis, 603 congenital fissures, 571, 599 fistulae, 571, 599 diseases of, 599, 571 epithelioma of, 604 foreign bodies in, 599 fractures of, 389, 600 gumma of, 604 injuries of, 604 intubation of, 608 papilloma of, 604 paralysis of, 355, 604 stenosis of, 600 syphilis of, 603 Larynx, tuberculous disease of, 604 tumors of, 604 ulceration of, 600 Lateral anastomosis of intestine, 763 curvature of spine, 554 in hip disease, 483 flap amputation, 1005 implantation of intestine, 764 ligature, 315 lithotomy, 880 sinus, drainage of, 532, 278 hemorrhage from, 567 thrombophlebitis of, 531, 168 thrombosis, 534 ventral hernia, 816 ventricle, puncture of, 528, 529 Lavage of stomach, 706, 71 Lawn-tennis arm, 362 Lead poisoning, 535 Lead-water and laudanum, 97 Leaking aneurysm, 298, 694 Leather-bottle stomach, 704 Lee's solution for burns, 158 technic, 58 Leech, artificial, 96, 568 Leeching, 96 Le Fort's amputation at the ankle joint, 1017 Leg, amputation of, 1017 Barbadoes, 336 fracture of both bones, 428, 429 Leiomyoma, 225 Leiter's tubes, 97 Lembert's intestinal suture, 754 Lenticular carcinoma, 252 papules, 197 Leontiasis leprosa, 190 ossea, 443, 225 Lepra, 190 mutilans, 190 Leprosy, 190 Leptomeningitis, 529 acute, 530, 563 chronic, 530, 563 Leptothrix, see bacteria Leukemia, 12, 306 IjTnphatic, 340 Leukemic tumors, 253, 229 Leukocytes, enumeration of, 13 migration of, in inflammation, 92 , phagocytic action, 45 Leukocytosis, 339, 169, 166, 92, 45, 13, 12 in abscess, 109 infectious, 13 noninfectious, 12 INDEX lO :)D Leukopenia, 14 Leukoplakia, 253. O43, 5 Levis apparatus for reduction of disloca- tion of phalanges, 465 splint. 407 Lewisohn method blood transfusion, 287 Ligation of arteries, effects of, 315 for aneurysm, 301 epilepsy, 537 gangrene following, 132 hemorrhage, 314 malignant growths, 219 trigeminal neuralgia, 350 in continuity, 319 technic for, 319 Ligatures, 60 types, 314 Light, electric, 6 Lightning stroke, 161 Linear discoloration, in diagnosis, 6 excision for hemorrhoids, 836 Lingual arter\-, ligature of, 323 goiter, 576 nerve, operation on, 352 Linnitus aurium, 307 Lipoma, 221 arborescens, 222, 491 diffuse, 222 fibrolipoma, 222 intermuscular, 222 nevolipoma, 222 subcutaneous, 222 subfacial, 222 submucous, 222 subserous, 222 Lips, affections of, 634 chancre of, 194, 637 cleft of, 636 cysts of, 638 epithelioma of, 638, 217, 251 horns of, 636 strumous, 638 warts of, 625 Liquefaction of thrombus, 266 Liquid air, 37 Lisfranc's amputation of foot, 1015 Lister's modified flap and circular ampu- tation, 1 006 Litholapaxy, 878 Lithopedion, 962 Lithotomy, lateral, 880 median, 880 perineal, 880 position. 880 suprapubic, 879 Lithotrites, 878 Litten phenomena, 686 Little's disease, 521 Littre's hernia, 801 Littre-Maydl operation of colostomy, 756 Liver, abscess of, 774 affections of, 774 cirrhosis of, 3, 777 cysts of, 775 hemorrhage from, 672 hydatid cysts, 775 injuries, 672 laceration of, 672 see also hepatic tumors of, 776 Lobar mastitis, 623 Lobular mastitis, 623 Local anesthesia, see anesthesia anesthetics, method of injection, 38 examination in diagnosis of tumors, 244 shock, 163 Locality, in diagnosis, 2 Localization, in cerebral injuries, 502 intestinal, 753 of foreign bodies b}' the X-ray, 1 7 spinal, 539 Lock jaw, 180, 178 Locomotor ataxia, 489, 116, 8, 115 Longitudinal fissure, 502 fracture, 374 Loose bodies in joints, 490 knees, 990 Lordosis, 557 Lorenz's method of treating congenital dislocation of hip, 454 Lowenberg's forceps, 596 Lower jaw, see jaw Lowman's plate-holding apparatus for fractures, 383 Lucas-Championiere on fracture, 381 Ludloff's sign, 416 Ludwig's angina, 575 Lues, 204 Lumbago, 483 Lumbar abscess, 559 caries, 558 colostomy, 757 disease, 554, 555, 556 hernia. 817 incision for exposing kidney, 862 plexus, injury of, 359 puncture, 544, 517, 528 Lumpy- jaw, 188 Lungs, abscess of, 613, 611, 619 1056 INDEX Lungs, cysts of, 619 decortication of, 617 discission of, 617 foreign bodies in, 599, 610 gangrene, 618 hemorrhage from, 610 hernia of, 6n operations upon, 617 prolapse of, 611 rupture of, 610 stones, 599 tuberculosis, operation for, 618 wounds, 610 Lupoid ulcer, 250, 118 Lupoma, 250 Lupus, 250, 644 erythematosus, 251 exedens, 250 exfoliativus, 250 exulcerans, 250 hypertrophicus, 250 treatment of, by Finsen light. 251 X-rays, 251 vulgaris, 251, 250 Luschka's tonsil, 595 Luxatio erecta, 459 Luxation of joints, 453 Lymphadenitis, acute, 337 chronic, 338 syphilitic, 339, 196 tuberculous, 338 Lymphadenoma, 227, 338 Lymphadenosis, general, 339 Lymphangiectasis, 335, 227 Lymphangioendothelioma, 341, 230 Lymphangioma, 227, 337 Lymphangitis, 337, 6 acute, 337 chronic, 337 Lymphatic edema, 336 fistula, 336 glands, affections of, 340 secondary growths in, see sarcoma and carcinoma simulating hernia, 806 syphilis of, 339, 196 tuberculosis of, 338 leukemia, 340 malignancy, 340 nevus, 226, 335 system, 335 varix, 336 vessels, diseases of, 335 warts, 336 Lymphatism, 341 Lymphedema, 336, 227 Lymphocytoma, 340 Lymphoma, 227, 338 Lymphorrhea, 335 Lymphosarcoma, 229, 340 Lysins, 48 Lysol, 54 Lyssa, 182 Lyssophobia, 185 ( McBurney's operation for appendicitis, 771 point, 768 McGraw's elastic ligature, 717 Mclntyre splint, 418 McWilliams bone transplantation, 499 Macewen's operation for knock-knee (os- teotomy), 990 treatment of aneurysm, 301 triangle, 569 Mackensie's operation for fistulae in ano, 834 Macrocheilia, 637, 227, 335 Macrodactylia, 979, 443 Macroglossia, 643, 227, 335 Macrostoma, 636 Macrotia, 566 Madelung's deformity, 978 Magnet for the removal of iron bodies, 602 Mahler's symptom, 278 Maisonneuve's urethrotome, 894 Makkas' operation for filling bone cavities, 437 Malachite green, 55 Malar, fracture of, 387 Malaria, 13, 51, 170 Male genital organs, 882 Malignant cysts of neck, 572 dermatitis, 620 edema, 134 epulis, 649 goiter, 577 pustule, 185 tumors, 214 ulcers, 116 Mallein, 188 Malleolo-phalangeal bandage, 88 Malleolus, ligation behind, :iss Mallet finger, 980 Malleus, 187 Mai perforant, 999 Malpositions of testis, 902 Malum senile, 488 Mamma, see breast Mammilitis, 620, 622 INDEX 1057 ^landiblc, see lower jaw MaiiKoldt's method of skin graftiiifj, 263 Mania a potu, 173 Marie's disease, 431 Marjolin's ulcer, 218, 105 Marmourian's operation for \aricose veins, 283 Marshall Hall's method for artificial respiration, :is Marsupialization of ovarian cyst, qyi Martin's canvas for reduction of fractures, 382 mercury treatment in syphilis, 202 rubber bandage, 122 uterine curette, 936 Mason's pin, 387 Massage, 98 danger of, 98 aneurysm, 98 in treatment of fractures, 381 of inflammation, 98 of heart, 274, 34 Mastitis, 622 acute, 622 chronic, 622 circumscribed, 623 diffuse, 623 lobar, 623 lobular, 623 interstitial, 623 suppurative, 623 Mastodynia, 621 Mastoid antrum, suppuration in, 568 disease, 534 Mastoiditis, 568, 534 Matas operation for aneurj'sm, 303 splint for fracture of lower jaw, 390, 391 test for efficiency of collateral circula- tion, 1000, 303 Maunsell's method of end-to-end anasto- mosis, 761 of resection of the rectum, 842 Maxillarj'' nerves, operation upon, 352 sinus, empyema of, 597 Mayo's end-to-end anastomosis, 761 method of gastroenterostomy, 726 operation for partial excision of gall- bladder, 789 for partial thyroidectomy, 581 pylorectom)', 728 transgastric partial gastrectomy, 726 for umbilical hernia, 815 for varicose veins, 283 of pylorectomy, 724 67 Meatotomy, 882 Mechanic injuries, 138 Mechanical dysmenorrhea, 956 sterilization, 51 Meckel's diverticulum, 733, 677 ganglion, 351 Median cervical fistula, 571, 572 hare-lip, 634 hernia, 816 lithotomy, 880 nerve, affections of, 357 Mediastinopericarditis, 277 Mediastinum abscess, 619 tumors, 619 Mediogastric resection, 696 Medulla of bone, inflammation of, see os- teomyelitis Medullary carcinoma, 218 narcosis, 40 of breast, 626 Melanotic sarcoma, 230 Melon-seed bodies, see also rice bodies, 365, 372 Meltzer-Auer intratracheal insufflation of ether, 26 Membrane grafting, 263 Membranous dysmenorrhea, 956, 936 Meningeal hemorrhage, cerebral, 519 spinal, 551 Meningitis, cerebral, acute, 530, 563 cerebro-spinal, epidemic, 530 spinal, 563 Meningocele, 524, 552 spurious, 501 traumatic, 501 Meningoencephalitis, 529, 535 Meningoencephalocele, see encephalocele Meningomyelocele, 552 Menorrhagia, 955 Menstruation, disorders of, 954 Mercurial inunction, 98 necrosis of jaw, 648, 434 Mercurialism, 202 Mercury in treatment of syphilis, 201 Mesarteritis, 290 Mesentery, affections of, 672, 686 cysts, 687 embolism of arteries of, 687 thrombosis of veins of, 687 Mesoblastic tumors, 220, 215 innocent, 220 chondromata, 223 fibromata, 220 glioma, 228 hemangiomata, 226 I058 INDEX Mesoblastic tumors, innocent, lipomata, 221 lymphangiomata, 227 myxoma, 225 neuroma, Chapter XVII odontoma, 227 osteoma, 225 malignant or sarcomata, 228 endothelioma, 230 giant cell, 230 hypernephroma, 231 melanotic, 230 round cell, 229 spindle cell, 230 Metacarpal bones, dislocations of, 464 fractures of, 410 Metacarpophalangeal joint, amputation at, 1009 dislocation at, 465 Metastatic abscess, 109, 168, 268 erysipelas, 175 growths, 243 inflammation, 93 Metasyphilis, 200 Metatarsal bones, dislocation of, 473 fracture of, 430 Metatarsalgia, 996 Methyl chlorid, 37 Metritis, 937 varieties, 937 Metrorrhagia, 955, 307 Metsehnihoff's prophylaxis for syphilis, 201 Michel clamps, 140 Microbic gangrene, 134, 127 Microcephalus, 529 Micrococcus tetragenus, 107 pyogenes tenuis, 107 Micromazia, 620 Micromelia, 442 Microstoma, 636 Microtia, 566 Middle-ear disease, see otitis media Middle meningeal artery, hemorrhage from, 519, 520, 567 Midtarsal joint, amputation through, 1016 Mikulicz-Hartmann line, 728 Mikulicz's disease, 640 drain, 71 law, 12 operation for torticollis, 574 Miliary tubercle, 208 tuberculosis, 210, 567 Military wounds, 146 Milk fistulc-e, 622 Milk leg, 277 Milzbrand, 185 Miner's elbow, 373 Mirault's operation for hare-lip, 636 Mitosis, 102 Mixed chancre, 193 infection, 45 parotid tumor, 641 thrombus, 265 treatment of syphilis, 203 tumors, 215, 230 Mobility in diagnosis, 9 of tumors, 239 Moebius's sign, 583 IMoeller-Barlow disease, 441 Moist gangrene, 126 heat, 51 Mole, 249, s lipomatodes, 249 pigmentosus, 249 pilosus, 249 spilus, 249 verrucosus, 249 Mollities ossium, 443 Molluscum contagiosum, 51 fibrosum, 220, 344 Monococci, 42 Monod and Vanvert's method for tendon lengthening, 369 for tendon shortening, 371 Monoplegia, 506 Monsel's solution, 226, 302 Montgomery method of shortening the round ligaments, 943 Moore's method of treatment of aneu- rysm, 301 Moore-Corradi treatment of aneurysm, 301 Moorhof's wax, 437 Morbus coxae, 483 senilis, 489 jMorcellement of uterus, 950 Morgagni, hydatid of, cysts from, 966 Moriarty's splint for fracture of jaw, 389, Morison's bip, 151 Mormorek's serum, 176 Morning diarrhea, 840 Moro's tuberculin test, 211 Morphea, 253 Morphin, injection hypodermic, in anes- thesia, 30 objections to administering, 31 Mortification, 126 Morton's disease, 996 fluid, 552, 528 INDEX 1059 Morton's opcralion for transplanting bone, 450 Moschcowitz's operation in prolapse of rectum, 838 osteoplastic amputation of leg, 1018 Moss' division of individuals by blood groups, 285 Moszkowitz test for gangrene, 1000, 128 -Mother's mark, 226 Motion, absence of, in diagnosis, 6 Motor aphasia, 506 area, topography of, 505 oculi nerve, afifections of, 349 Mouth, affections of, 647 burns of, 159 chancre of, 195 sterilization of, 65, 67 Movable kidney, 849 spleen, 797 Moynihan's treatment of gastric ulcer, 692 Mucocele of appendix, 767 of frontal sinus, 596 Mucous patches, 198 fistula, 678 polypi, 594 Miiller's law, 214 Multiple fracture, 374 neuritis, 342 neurofibromata, 344 Mummification, 126 IMumps, 640 Mural thrombus, 265 Murphy's button, 762 treatment of arthritis, 479 of peritonitis, 682 of pulmonary tuberculosis, 618 Muscles, affections of, 362 carcinoma of, 365 contusion of, 362 hernia of, 362 inflammation of, 364 injuries of, 362 massage of, 364 ossification of, 364 reaction after nerve section, 347 rupture, 362 strains, 362 suppuration of, 364 tumors of, 365 Muscular excitement in anesthesia, 29 Musculospiral nerve, injury of, 357 Mycelial fungi, X-ray treatment, 18 Mycetoma, 189 Mycosis fungoides, 229, 253 see trench foot, 160 Myelocele, 552 Myeloid sarcoma, 230 Myelomata, 230 primary multiple, 447 Myeloplasty of Clairmont-Erlich, 461 Myer, pneumcctomy operation, 61 3 Myoma, 225, 364 cavernosum, 225 Myomectomy, 950 Myopia, 556 Myositis, 364 ischemic, 976, 364 ossificans, 364, 225 Myxedema, 577, 444, 7 Myxoma, 225, 364, 444 Myxter's operation on fifth nerve, 352 Nabothian cyst, 935 Nails, affections of, 255, 198 Nares, packing of, 593 Nasal bone, fracture of. 386 cavities, tumors of, 594 feeding, 182 polypi, 594 septum, deviation of, 592 fracture of, 386 spurs, 592 Nasofrontal duct, catheterization of, 597 Nasoorbital fissure, 636 Nasopharyngeal polypus, 594 Natiform skull, 207 Nationality in diagnosis, 2 Neck, abscess of, 574 affections of, 570 cellulitis of, 574 cysts of, 571, 604 acquired, 572 bursal, 572 hydatid (Chapter XIII) malignant, 572 sebaceous (ChapterjXIV) thyroid, see cystic goiter congenital, 571 blood, 572 branchial, 571 lymphangioma, 572 thyroglossal, 571 development of, 570 fistulas of, 570 hydrocele of, 571 tuberculous glands of, 338 tumors of, 341, 570 Necrosis, acute, 432, 431, 434, 126 after compound fracture, 378 fat, 794 io6o INDEX Necrosis, mercurial, 434 quiet, 435 syphilitic, 440 tuberculous, 438 typhoid, 434 Needle wounds, 143 Negri bodies, 182 Nekton's line, 413 operation for filling bone cavities, 437 Neoarsphenamin, 205 Neoplasms, 214 Neosalvarsan, 205 Nephrectomy, 864, 850 Nephritis, operation for, 864 Nephrolithiasis, 855 Nephrolithotomy, 863 Nephropexy, 863 Nephroptosis, 849 Nephrostomy, 864 Nephrotomy, 863, 851 Nerve anastomosis, 347 grafting, 348 stretching, 348 suture, 347 a distance, 348 transplantation, 348 tubulization, 348 Nerves, affections of, 342 special, 349 compression of, 345 contusions of, 345 degeneration of, 346 inflammation of, 342 injuries of, 344 partial section of mixed, 349 regeneration of, 347 rupture of, 345 changes following, 346 see also the special nerves suture of, 349 tumors of, 343 Nervous system, syphilis of, 200 Nervousness, postoperative, 72 Neuber's operation for filling bone cavi- ties, 437 Neuralgia, 343, 9 of joints, 490 of stumps, 1007 secondary, 343 symptomatic, 343 see also special regions trifacial, 350 Neuralgic dysmenorrhea, 955 ulcers, 990, 116 Neurasthenia, traumatic, 547 Neurectasy, 342 Neurectomy, 342 Neurenteric canal, 821, 553 Neuritis, 342 peripheral, 999 Neurofibromatosis, 344 varieties, 344 Neurolysis, 345 Neuroma, 343, 227 false, 343 true, 343 Neuromimesis, 490 Neuropathic arthritis, 489 Neuroplasty, 348 Neurorrhaphy, 347 Neurotomy, 342 Nevolipoma, 222 Nevus flammeus, 226 lymphatic, 227, 335 pigmentosus, 249 prominens, 226 simple, 226 venous, 226 Nichol's operation for resection of bone, 437 Night cries, 481, 484 pains, 197 sweats, 113 Nipple, affections of, 620 Nitrous oxid gas, 29, 30, 22, 21 Nocturnal pollutions, 900 Nodes, gouty, 487 Heberden's, 488 Parrot's, 440 syphilitic, 208, 502 Nodules, in tumor diagnosis, 243 Noeggerath's treatment of inversion of uterus, 946 Noguchi serum reaction for syphilis, see Wassermann reaction Noma, 136, 137, 2 pudendi, 136 Non-infectious leukocytosis, 1 2 Non-pathogenic organisms, 43 Non-pulsating tumors of scalp, 502 Non-union of fractures, 378, 385, 399 Normal salt solution, 62 Nose, absence of, 588 adenoids, 595 chronic atrophic rhinitis, 595 clefts, 586 crooked, 592 deformities, 586 epithelioma of, 215 fibromata of, 594 INDEX 1061 Nose, foreign bodies in, 594 frog, 586 hammer, 586 lupus of, 250, 588 ozena of, 594 plastic operation on, 586 pol\-pi of, 594 saddle, 586 sterilization of, 67 surgery of, 586 synechia of, 594 syphilis of, 250, 586 tuberculosis of, 250, 594 tuberous, 586 Nourse, operation for anteflexion of uterus, 939 Novocain, 38 in anesthesia, 31 Objective sj'raptoms, in diagnosis, 2 Oblique bandage, 77, 79 facial cleft, 636 fractures, 374 inguinal hernia, 802 . Obliterating appendicitis, 767 cholecystitis, 780 Obliteration of arteries, 303 Obstructed hernia, 820 Obstruction, intestinal, 741, 823 of bile ducts, 787 venous, 6, 7, see thrombosis Obstructive dysmenorrhea, 956 Obturating thrombus, 266 Obturator dislocation of hip, 466 hernia, 813, 817 nerves, affections of, 359 Occipital artery, compression of, 312 frontal bandage, 80, 81 ligation of, 324 Occluding thrombus, 266 Occupation, in diagnosis, 3 Ochsner's operation for esophageal stric- ture, 662 treatment of peritonitis, 680, 769 Oculomotor nerve, affections, 24S Odontomata, 227 cementoma, 228 composite, 228 compound follicular, 228 epithelial, 227 fibrous, 228 follicular, 228 radicular, 228 O'Dwyer's intubation tubes, 608 Oidium albicans, 51, 647 Oil of cade, 6 Oiled silk, 60 Ointments, in burns, 157 Olecranon bursa, 373 fracture of, 404 Olfactory nerve, affections of, 349 Oligocythemia, 12 Oilier, bone transplantation, 450 Omental hernia, see epiplocele Omentum, affections of, 686 cysts of, 687 tears of, 672 tumors of, 686 volvulus of, 686 Omphalomesenteric duct, 733, 677 Onset, in diagnosis of tumors, 235 Onychauxis, 255 Onychia, 254, 198 maligna, 255 Onychocryptosis, 255 Onychogryposis, 255 Oophorectomy, 959 for cancer of breast, 220 for fibroids of uterus, 949 for osteomalacia, 443 see also ovary Oophoron, cysts of, 966 Open fractures, 374 Operating room, essentials of, 68 technic, 68, 69 Operation, after-treatment, 71 in private house, 73 plastic, 256 preparation of, 65 assistants, 68 nurses, 68 patient, 69, 70, ;i, 72 surgeon, 68 Operative treatment of fractures, 381 Opisthotonos, 179, 8 Opium, 170 poisoning, 514 Opsonic index, 50 Opsonins, 48 Optic atrophy, 349 nerve, affections of, 349 neuritis, 349, 535 Orbital cellulitis, 597 Orbitonasal cleft, 634 Orchitis, acute, 904 chronic, 905 complicating parotitis, 640 syphilitic, 906, 198 tuberculous, 905 Organic stricture of urethra, 890 io62 INDEX Organization of blood clot, 102 of thrombus, 266 Oriental boil, 247 Origin of tumors, 214 Orthopnea, 8 Orthotonos, 179 Os calcis, fracture of, 430 see talipes for osteotomy of, policeman's heel, ostitis of, in flat-foot, etc. magnum, dislocation of, see tarsal bones Osmic acid, injection for neuralgia, 349 Ossicles of ear, necrosis of, 567 Ossification of muscle, 364, 225 Osteoarthritis, 488, 7 Osteoarthropathy, hypertrophic, pul- monary, 431 Osteoblasts, 379 Osteochondritis, syphilitic, 440 Osteoclasis, 991 Osteoclasts, 438 Osteocopic pains, 198, 438 Osteodystrophia juvenalis of Mikulicz, 448 Osteogenesis imperfecta, 442 Osteoma, 225, see also special regions durum, 225 eburnated, 225 spongiosum, 225 Osteomalacia, 443, 375, 2, 3, 447 Osteomyelitis, 4, 432 acute infectious, 432, 2 chronic, 434 diagnosis, 433 gummatous, 439 multiple, 433 prognosis, 433 recidiva, 433 septic, 432 syphilitic, 439 treatment, 432 tuberculous, 439 typhoidal, 432, 434 Osteoperiostitis, 431 Osteophytes, 488, 431, 489 Osteoplastic amputations. Bier's, 1019 Gritti's, 102 1 Moschcowitz, 1018 Sabanejeff's, 1022 resection of nose, 594 skull, 508 spine, 556 Osteoporosis, 437, 431 Osteopsathyrosis, 442 Osteosarcoma, 229, 446 Osteosclerosis, 434, 431 Osteoscopic pains, 198 Osteotomy, Adam's, 493 cuneiform, 991 for, bow-legs, 991 Colles fracture, 408 flat-foot, 996 hallux valgus, 998 knock-knee, 989 talipes, 991 Macewen's, 990 subtrochanteric, 493 Ostitis, chronic, 434 condensing, 434, 431 deformans, 445 see osteoarthritis fibrosa, 445, 438 rarefying, 437, 43 1 tuberculous, 480, 437 typhoid, 434 Othematoma, 566 Otitis, complications of, 567 cranial, 567 carious or necrotic ossicles, 567 facial paralysis, 567 granulations and polypi, 567 hemorrhages, 567 mastoiditis, 568 extracranial, 567 intracranial, 570 Otoplasty, 566 Otorrhea, intracranial complications, 570 Outward dislocation of hip, 467 Oval method of amputation, 1004 Ovarian cysts, 966, 964 complications of, 967 diagnosis of, 969 symptoms of, 967 treatment of, 970 dermoids, 969, 967, 233 dysmenorrhea, 956 hydrocele, 967 pregnancy, 961 Ovaries, 963 apoplexy of, 965 atrophy of, 965 cirrhosis of, 964 congenital malformation, 964 cysts of, 964, 233 hematoma of, 965 hemorrhage from, 965 inflammation of, 964 prolapse of, 963 removal of, 965, 440 INDEX 1063 Ovaries, tuberculosis of, 965 tumors of, 965 Ovariotomy, 970 Ovaritis, 964 Ovules of Xaboth, 933 Ox> butyric acid, 129 Oxygen combined with ether or chloro- form, 29 Ozena. 595 Pachydermatocele, 221, 344 Pachymeningitis, 529, 563 external, 529 internal, 529 Pagenstecher's thread, 62 Paget's disease, 444, 445 disease of nipple, 620, 252 bone, see ostitis deformans Pain in diagnosis, 8 character, 8 in inflammation, 93 osteocopic, 198 significance of, in diagnosis of tumors. 238 also see special regions Painful feet, 998 heel. 99S scars, 105 stump, 1007 subcutaneous tubercle, 343 Palate, cleft, 652 perforation of, 654 Palmar abscess, 985 cellulitis, 986 fascia, contraction of, 980 foreign bodies, 980 ganglion, compound, 366 sac, 366 synovitis, 985 Palpation in diagnosis, 9, 7 Panaritium, see paronychia Panarthritis, 478 Pancreas, affections of, 793 calculi of, 796 cysts of, 796 inflammation of, 793, 673 rupture of, 673 tumors of, 796 Pancreatic point of Desjardin, 795 Pancreatitis, 793, 790 acute, 794, 790 chronic, 795 gangrenous, 795 interacinar, 795 interlobular, 795 Pancreatitis, subacute, 795 suppurative, 795 Panhysterectomy, 951 Panostitis, acute, 432 Papillitis, 349 Papillomata, 215 malignant, 215 Papillomatous cholecystitis, 780 Papules, 197 Papulo-squamous syphilides. 197 Paquelin cautery, 100, loi Paracentesis abdominis, 684 auriculi, 272 pericardii, 276 thoracis, 614 ventriculi, 527 vesicae, 871 Paracolpitis, 929 Paradoxical embolism, 267 Paraflin, use of, for cure of deformed nose, 586 prolapse of rectum, 837 Paraldehyd, 28 Paralysis, agitans, 545 after injur>^ to brain, 512, et. seq. spinal disease, 559, 563 injuries. 546 brachial birth, 356 following injury to nerves, 345 infantile, 564, 484, 2 intestinal, 752 post-anesthetic, 34, 356 Paralytic torticollis, 440 Parametritis, 972 Paraphimosis, 898 Parasites, 43 Parasitic cysts, 233 organisms, 43 Parasyphilis, 200 Parathyroid glands, 576 tetany, 576 Parchment crepitus, 8 Parenchymatous glossitis, 643 goiter, 578 hemorrhage, 307 inflammation, 93 Paresis, 342 Parietal mural thrombus, 265 Parietooccipital fissure, 50^ Park and Nicoll's treatment of tetanus, 181 Paronychia, 254, 198 Paroophoron cysts, 967 Parotid gland, excision of, 641 IjTnph gland, affections of, 641 1064 INDEX Parotid tumors, 641 Parotitis, 640 suppurative, 640 Parovarian cysts, 965, 967 Parrot's nodes, 440 Partial gastrectomy, 725, 695 hysterectomy, 950 nephrectomy, 864 Passage of urethral bougies, 892 Passive incontinence of urine, 869 Pasteur's treatment of hydrophobia, 184 Patella, dislocation of, 470 fractures of, 421 Pathetic nerve, affections of, ,350 Pathogenic organisms, 45 Pathological dislocations, 455 fracture, 374 treatment, 417 nonoperative, 422 operative, 423 prognosis, 424 Patten, 485 Payr's treatment of inoperable angioma, 227 of hydrocephalous, 529 Pearls, 217 Pedunculated flaps, 257 Pels-Leusden treatment, spina ventosa, 439 Pelvic cellulitis, 972 hematocele, 972 hematoma, 973 neoplasms of connective tissue, 974 peritonitis, 971 Pelvirectal abscess, 830, 831 Pelvis, dislocation of, 465 fracture of, 410 of false, 410 of true, 410 Penis, affections of, 882 amputation of, 899 balanitis of, 898 chancre of, 193 chancroid of, 896 congenital malformation, 882 epithelioma of, 898 extirpation of, 899 fracture of, 896 herpes of, 195 injuries of, 896 paraphimosis of, 898 phimosis of, 897 warts of, 897 Peptic ulcers, 689 Peptic ulcers of jejunum following gastro- enterostomy, 723 Percussion in diagnosis, 9 Perforating ulcer of duodenum, 732, 156 of foot, 999, 117 of stomach, 603 typhoid ulcer, 737 Perforative appendicitis, 767 peritonitis, 678, 5 Periadenitis, 337 Periarteritis, 290 Pericardial effusions, 275 Pericarditis, 275 Pericardium, 275 Pericardotomy, 276 Pericholecystitis, 780 Pericolitis, 734 Pericystitis, 873 Perigastric adhesions, 695 inflammation, 695 Perihepatitis, 778 Perineal cystotomy, 880 fistula, 891 hernia, 817 lithotomy, 880 prostatectomy, 918 relaxation, 924 section, 880 Perineorrhaphy, 924 Perinephritic abscess, 853 Perinephritis, 853 Perineum, laceration of, 923 Periosteal nodes, 440 sarcoma, 446 Periostitis, 431 acute, 431 albuminosa, 431 chronic, 431 ossifying, 431 osteoplastic, 431 purulent, 431 serosa, 431 simple, 431 Peripheral neuritis, 999 Periphlebitis, 277 Periproctitis, 830 Perirectal suppuration, 829 Perirenal hematoma, 853 Perithelioma, 231 Peritoneal bands, 744 Peritoneum, malignant disease of, 684 Peritonitis, 678 acute diffuse, 679 localized, 678 chronic simple, 682 INDEX 1065 Peritonitis, pelvic, 971 perforative, 679, 5 tuberculous, 682 Periurethral abscess, 889 Permanent torticollis, 573 Permanganate of potash, 54 Pernicious anemia, 306, 798 Pernio, 160 Peroneal artery, ligation of, 334 Peronei tendons, tenotomy of, 366 Perthes' operation on biliary passages, 788 Pertussis, 600 Pes cavus, 996 planus, 994 Pesquin's operation for aneurysm, 303 Pessaries, 941 Petechiae, 138, 6, 168 Petit de la Villeon's method removing foreign bodies from lungs, 611 Petit's tourniquet, 312 Petrissage, 98 Petrosal sinus, hemorrhage from, 567 thrombosis of, 532 Pfannenstiel incision, 942 Phagedena, 120, 897 Phagocytosis, 48 Phalanges, amputation of, 1009, 1015 dislocation of, 465 fracture of, 430, 410 Phantom tumor of abdomen, 677 Pharyngocele, 657 Pharyngotomy, subhyoid, 605 transhyoid, 605 Pharynx, burns of, 159 epithelioma of, 217 Phelps' operation for talipes, 993 for varicose veins, 283 Phenol, s^ Phenolsulphonephthalein test of kidney function, 845 Phimosis, 2, 897, 538 Phlebectasia, 279 Phlebitis, 277 acute, 277 chronic, 279 exudative, 277 pathology of, 277 post-operative, 277 prophylaxis of, 278 suppurative, 277 Phleboliths, 266 Phleborrhaphy, 316 Phlebosclerosis, 279 Phlebotomy, 284 Phlegmasia alba dolens, 278 Phlegmone ligneuse du cou, 575 Phlegmonous erysipelas, 175 inflammation, 93 Phloridzin test of kidney function, 845 Phosphorous burns, 159 poisoning, 306, 3 Phosphorus necrosis of jaw, 435, 648, 650 Photophobia, 534 Phrenic nerve, injury of, 354 Physical examination, in diagnosis, i Physiologic salt solution, 63 Physometra, 931 Picric acid in treatment of burns, 157 Piles, 834 Pirogoff's amputation, 1017 Pituitary body, tumors of, 537 Placenta, retained, 167 Plague, 49 Plantar fascia, tenotomy of, 367 Plantaris muscle, rupture of, 991 Plasmodium malariae, 51 Plaster-of-Paris dressing, 89 splints, 89, 76 Plastic, arteritis, 290 inflammation, 93 linitis, 706 splints, 381 surgery, 255 Pleiad of Ricord, 193 Pleural cavity, affections of, 611 aspiration of, 614 effusion into, 613 tapping of, 614 Pleurectomy, 617 Pleurisy, 613, 6 Pleuropneumonia, 269 Pleurosthotonos, 179, 11 Plexiform angioma, 226, 294 neuroma, 344 sarcoma, 231 Pneumatocele, 525 Pneumectomy, 618 Pneumocele, 611 Pneumococcal arthritis, 479 empyema, 614. Pneumococcus, 107, 432, 613 Pneumogastric nerve, affections of, 354, 580 Pneumohemothorax, 273, 610 Pneumolysis, 618 Pneumonia, 14, 35, 170, 173, 273, 611 Pneumothorax, 611, 818 Pneumotomy, 617 Point of Desjardin, 795 io66 INDEX Points douloureux, 343, 350 Poisoned wounds, 152 Poisoning, alcohol, 514, 342 arsenic, 342 bichlorid of mercury, 52, 53 blood, 166 carbolic acid, 53 chloroform, 34, 172 cocain hydrochlorid, 37 ergot, 130, 6 iodm, 54 iodoform, 55 lead, 535 opium, 514 phosphorous, 306, 3 snake, 154, 6 strychnia, 180 Policeman's heel, 998 Poliomyelitis, acute anterior, 564 Pollutions, diurnal, 900 nocturnal, 900 Polonium, 20 Polya's method in pylorectomy, 72S Polycystic disease of liver, 775 Pohxythemia, 156, 11 Polydactjdism, 978 Polymastia, 620 Polymorphonuclear leukocytes, 12, 13 Polymyositis, 364 Polyneuritis, 342 Polynuclear count, 13 Polyorchism, 902 Polypi, 220 see special regions Polyserositis, 778 Polythelia, 620 Pond-shaped fracture, 51& Poole's operation, thyroid gland, 576 Popliteal arter}', compression of, 313 ligature of, 332 bursae, 373 nerve, injury of, see internal and ex- ternal Portal cirrhosis of the liver, 777 Post-anal dimple, see spina bifida occulta gut, 554 Post-anesthetic paralysis, 36, 356 Post-calcaneal bursitis, 998 Posterior colporrhaphy, 924 gastroenterostomy, 713 thoracic nerve, injury of, 357 tibial artery, compression of, 313 ligature of, ^3^ Post-febrile gangrene, 129 Posthitis, 898 Post-incisional hernia, 816 Post-mortem wounds, 152 Post-nasal adenoids, 595 Post-operative backache, 72 constipation, 72 dressings, 73 feeding, 73 fever, 72 hemorrhage, 72 hernia, 816 insomnia, 72 nervousness, 72 pain, 72 phlebitis, 278 pulse, 72 retention of urine, 71 shock, 71 thirst, 72 treatment, 71 vomiting, 72 Post-pharyngeal abscess, 559, 655 Posture in diagnosis, 11 Potassium permanganate, 54 Pott's disease, 557, see spine tubercu- losis fracture, 426, 471 symptoms, 428 treatment, 428 puffy tumor, 532 Poultice, 99 Powders, in aseptic wounds, 55 Precancerous dermatoses, 252, 242 Precentral sulcus, 503 Precipitins, 48 Pregnancy, 970, 279 abdominal, 961 ectopic, 961 Preliminary colostomy, 841 tracheotomy, 606 Preparation of instruments, 59 patients for operation, 65 Prepatellar bursa, 373 Prepuce, incision of, 898 Presenile gangrene, 128 Pressure, gangrene following, 132, 127, 378, 312, 98, 76 symptoms, in tumor diagnosis, 238 treatment for aneurysm, 301 ulcers, 117 Preternatural mobility in fracture, 377 Priapism, 899 Primary anesthesia, 25 hemorrhage, 307 syphilis, 191 thrombus, 265 INDEX 1067 Primary union of wounds, 102 Primitive aneurysm, 296 Private house, operation in, 73 Procain, 38 Procidentia, 943 Proctectomy, 841 Proctitis, 829, 9 gonorrheal, 886 Proctodeum, 826 Proctolysis, 682 Proctopexy, 838 Productive arteritis, 290 Profeta's law, 192 Proflavine, 55 Prognathism, 444 Progress of tumors in diagnosis, 236 Progressive muscular atrophy, 557 pernicious anemia, 306 Prolapse, see special organs Proliferous mammary cyst, 625 Prominent ears, 566 Propagating thrombus, 266 Preperitoneal hernia, 804 Proptosis, see exophthalmos Prostate, affections of, 914 abscess, 914 calculi, 915 carcinoma of, 915, 918 hemorrhage from, 847 hyTsertroph}^ of, 915 tuberculosis, 914 Prostatectomy, 917 Prostatitis, 914 Prostatorrhea, 914 Prostatotomy, 917 Protopathic nerve-fibers, 346 Protozoa, 51 Proud flesh, 103 Pruritus ani, 829 vulvae, 922 Psammoma, 230 Pseudoarthrosis, 456, 385 Pseudodiverticula, esophageal, 657 Pseudoelephantiasis, 336 Pseudohermaphrodism, 921 Pseudohydrophobia, 185 Pseudohypertrophic paralysis, 557 Pseudoleukemia, 339, 796 Pseudomembranous cholecystitis, 780 inflammation, 93 Pseudoobstruction, intestinal, 752 Pseudopodium, 92 Pseudoprolapse of uterus, 944 Pseudotrichinosis, 364 Psoas abscess, 559, 806 Psoriasis linguae, 643 palmar, 197 plantar, 197 syphilitic, 197 Ptomains, 45 Ptosis, 349, 533 Ptyalism, 202 Pubic dislocation of hip, 466 Pudendal hernia, 817 Puerperal peritonitis, see peritonitis Pulmonary affections in anesthesia, 35 alveolar emphysema, 619 decortication, 617 embolism, 269 gymnastics, 617 hemorrhage, 610 hypertrophic osteoarthropathy, 431 tuberculosis, operation for, 618 Pulpy degeneration of synovial mem- brane, 480 Pulsating empyema, 613 exophthalmos, 521 tumors of bone, 446, 447 of scalp, 501 Psulsation, in diagnosis, 6 Pulse, character of, after operation, 72 in diagnosis, 10 in septicemia, 168 Pulsus paradoxus, 275 Punctured fracture, 375, 516 wounds, 144 Purgation, in sepsis, 172 Purpura, 245 hemorrhagica, 306, 592 Purulent effusion of pericardium, 275 infiltration, 177 inflammation, 93 Pus, 108 varieties of, 108 Pusey's method for inoperable angiomata, 227 treatment for nevi, 227 Pustule, 197 Pyelitis, 851 modes of infection in, 851 Pyelography, 843 Pyelolithotomy, 864 Pyelonephritis, 852 Pyelostomj', 864 Pyelotomy, 864 Pyemia, 6, 275, 289, 567, 169, 171 actinomycotic, 189 acute, 169 chronic, 169 in diseases of bones, 433 io68 INDEX Pyemia in diseases of the ear, 567 in joint' diseases, 477, 479 lateral sinus, 531, 279 symptoms, 169 Pyemic abscess, 109 synovitis, 477 Pylephlebitis, 169 Pylorectomy, 726, 695, 697 Pylorodiosis, 728 Pyloroplasty, 725 Pylorus, stenosis of, 699 exclusion, 723 occlusion, 723 congenital, 688 tumors of, 723 Pyogenic bacteremia, 168 bacteria, 106 infections, 167 toxemia, 167 ulcer, 116 Pyometra, 931 Pyonephrosis, 852 Pyopericarditis, 275 Pyorrhea alveolaris, 648 Pyosalpinx, 958 Pyothorax, 613 Pyrexia, 1&7 Pyuria, 847 Qualitative food dyspepsia, 785 Quenu's operation for excision of the rectum, 842 Quiet necrosis, 435 Quilled suture, 141 Quinine-urea hydrochloride, 38 Quinsy, 654 Rabic tubercles of Babes, 183 Rabies, 183, 182 Racemose adenoma, 216 aneurysm, 226, 294 Rachischisis, 551 Rachitic rosary, 441 Rachitis, 440 Racquet method of amputation, 1005 Radial artery, compression of, 313 ligation of, 328 Radical resection of joints, 495 Radicular odontoma, 228 Radiograph, 15, 16 interpretation of, 15 Radiography, 15 Radiotherapy, 19 Radium, 20 bromid, 20 Radium, in diagnosis, 20 rays, 20 therapy, 20 Radius, congenital absence of, 978 dislocation of, 463 fractures of, 405 head, 405 lower end (Colics'), 406 neck, 405 shaft, 406 separation of lower epiphysis, 408 subluxation of head of, 463 Radius and ulna, dislocations of, 463 fractures of, 408 Railway brain, 546 spine, 546 Rammstedt operation for congenital stenosis of pylorus, 689 Randolph bandage, 122 Ransohoff's arterial anesthesia, 39, 40 discission of the lungs, 617 skeletal calipers, 419 Ranula, 641, 232 Rapid spiral bandage, 77 Rarefaction of bone, 437, 431 Rashes of bichlorid of mercury, 170 carbolic acid, 170 ether, 170 iodoform, 170 septic, 170 syphilis, 197 Ray fungus, 188 Raynaud's disease, 127, 129, 3, 6 gangrene, 129 Reactionary fever, 166 hemorrhage, 307 Reactions of degeneration, 346 Reason, center of, 506 Receptors, 48 Recklinghausen's disease, 344 Rectal anesthesia, 28 hernia, 817 Rectocele, 924 Rectovaginal septum, laceration of, 923 fistula, 928 Rectovesical fistula, 928 Rectum, abscess, 830 absence of, 827 afi'ections of, 825 atresia of, 827 carcinoma of, 839 cellulitis about, 830 colostomy in carcinoma of, 840 congenital malformation of, 826 control of hemorrhage from, 311 INDEX 1069 Rectum, excision of, 840 abdomino-pcrincal route, 842 anal route, 841 perineal, 841 sacral. 841 vaginal route, 841 foreign bodies in, 828 imperforate, 827 inflammation of, 829 injuries of, 828 papilloma, 839 polypi, 839 prolapse, 837 sarcoma, 839 sterilization of, 67 stricture of, 838 syphilis of, 838 tuberculous disease of, 838 tumors of, 839 ulcers of, 838 Rectus abdominis muscle, diastasis of, 816 Recurrent appendicitis, 769 hemorrhage, 307 laryngeal nerve, pressure upon, 580, 297 shoulder dislocation, 461 bandage, 77, 79 Red blood corpuscles, 1 1 basophilic granulations in, 14 in inflammation, 91 infarct, 268 thrombus, 265 death, 135 Redness in inflammation, 94 in diagnosis, 6 Reducible hydrocele, 911 swellings, 805 in diagnosis, 241 Reduction en bloc of a hernia, 805, 742 en masse of a hernia, 805 of dislocations, 457, 461, 468 of fracture, 380 Reef knot, 142, 320 Reel feet, 992 Referred pain, 8 in hip disease, 483 renal disease, 856 spinal caries, 561 vesical calculus, 876, 877 Reflex anuria, 848, 857 inflammation, 93 Regeneration, 103 of brain, 523, 103 glandular organs, 103 Regeneration of lymphatic tissue, 103 nerves, 347, 104 spinal cord, 551, 103 Rehn's method of controlling hemorrhage while suturing the heart, 274 Reid's method of compressing aneurysms, 300 Relapsing appendicitis, 769 Relaxation incisions, 256 Renal calculus, 855 appearance, 856 causes, 855 symptoms, 856 treatment, 860 colic, 668, 857 complications in anesthesia, 36 function, estimation of, 846 hematuria, 847 hemophilia, 850 Repair, 102 granulation, 102 healing by first intention, 102 non-vascular tissue, 103 second intention, 102 third intention, 103 of bone, 103 (also Chapter XIX) blood vessels, 103 cartilage, 103 fractures, 378 muscles, 103 skin, 103 tendons, 103 of tissue, loi phenomena of, 102 primary union, 102 Reposition of a retroverted uterus, 940 Resection, see special regions Residual abscess, 109 urine, 916, 871 Resolution in inflammation, 93 Resorption fever, 166 Respiration, artificial, 33 Cheyne-Stokes, 512, 533, 535 Respiratory system, surgery of, 586 difiiculties during anesthesia, 28 Rest, in inflammation, 95 Restlessness, significance in diagnosis, 11 Restoration of function in treatment of fractures, 381 Retained placenta, 167 testis, 903 Retention cysts, 232 of fractures, 380 of urine, 71, 870 suture, 141 1070 INDEX Retiform l\-mphangitis, 337 Retinal hemorrhage, 520 Retinochoroiditis, 199 Retractors, 1002 Retrocalcaneal bursa, 998, 573 Retrocollis, 572 Retroflexion of uterus, 938, 939 Retrograde embolism, 267 esophageal dilatation, 662 strangulated hernia, 823 Retroperitoneal abscess, 687 hernia, 819 locations of, 819 tumors, 687 Retrophar\-ngeal abscess, 559,^655 Retroversion of uterus, 938, 939, 942 Reverdin's method of skin grafting, 262 Rhabdomyoma, 225 Rhagades, 207 Rheumatic arthritis, 487 gout, 488 myositis, 364 synovitis, 475 torticollis, 572 Rheumatism, gonorrheal, 479, 433 Rheumatoid arthritis, see osteoarthritis Rhinitis, 596 gonorrheal, 886 Rhinolith, 594 Rhinophyma, 586 Rhinoplasty, 586 Rhinoscleroma, 586 Rhinoscopy, 594 Ribs, cervical, 574 dislocation of, 465 fracture of, 391 resection of, 616 Rice bodies, 490, 365, 372, 481, see also melon-seed bodies Richter's hernia, 801 Rickets, 2, 377, 440 Rider's bone, 364 leg, 362 Riedel's lobe of liver, 776, 786 Rigg's disease, 648 Risus sardonicus, 179, 11 Riziform bodies, see rice bodies Roberts' operation for fracture of patella, 423 pericardotomy, 276 pins, 592, 387 splint, 407 Robson's operation on biliary passages, 788 point, 784 Rodent ulcer, 251, 19 Rogers' treatment of tetanus, 181 Rogers & Torreys treatment of gonor- rheal arthritis, 480 Roidium albicans, 51 Rolando, fissure of, 503 Roller bandage, 76 Rollier's sun bath, 212 Roman nose, 586 Rongeur forceps, 508 Rontgen rays, 14 burns, acute, 19 chronic, 252, 19 danger from, 19 detection of foreign bodies, 17, 144, 523 renal calculus, 857, 858 ureteral calculus, 857, 858, 17 vesical calculus, 17 diagnosis, 17 aneurj-sm, 298 fractures, 17, 378 of diseases of bone, 447 pericardial effusions, 275 stomach, size, shape, position, and activitN' of, 702 gangrene following, 19, 134 interpretation of pictures, 15, 16 stereoscopic plates, 18, 19 therapeutic effects of, 18 treatment of acne, 18 actinomycosis, 188 blastomycosis, 18, 246 carcinoma, 19, 250, 219 comedo, 18 favus, 18 goiter, 18, 578, 579 hemangioma, 220 h\-pertrichosis, 18 keloid, 249 rodent ulcer, 18, 220, 249 sarcoma, 231, 19 of skin, 251 tenia barbae, 18 tonsurans, 18 treatment of lupus, 18, 248 tuberculous lesions, 212 untoward effects, 19 Rosary, rachitic, 440 Rose position, 635 operation for the removal ofithe^Gas- serian ganglion, 353 Rotch's sign, 275 Round-celled sarcoma, 229, 445 Round ligament, hydrocele of, 911 INDEX IO71 Round ligament, shortening of, 943 Roux's gastroenterostomy, 722 Rubber bandage, 76 Rubber gloves, 64 sterilization of, 64 Rubefacients, 100 Run around, 254 Rupia, 197 Rupture, 799 of organs and tissues, see special regions Rydygier's method of splenopexy, 797 Sabanejeff's amputation of femur, 1022 Sabre blade deformity, 991 Sac of hernia, 800 Saccharomycetes, 51 Sacculated aneurysm, 296 Sacral cysts, 553 plexus, injuries to, 360 tumors, congenital, 553 Sacrococcygeal fistulae, 554 tumors, 553 varieties, 553 Sacroiliac joint, tuberculosis of, 482 Sacro-pubic bandage, 88 Sacrum, fractures of, 411 sarcoma of, 553 Saddle nose, 586 Sahli's sign of pancreatitis, 795 Saline infusion, 287 Salivary calculus, 641 cysts, 641 fistula, 642 * glands, affections of, 640 Salivation, 202 Salpingitis, 957 tuberculous, 965 Salpingo-oophorectomy, 959 Salpingostomy, 960 Salt solution, normal, 38, 63 Salvarsan, 203 Sanitary tube in treatment of gonorrhea, 887 Sapremia, 167 Saprophytes, 43, 107 Sarcinae, 42 Sarcocele, syphilitic, 906, 198 Sarcoma, 228, 231 alveolar, 229 curative action of erysipelas on, 231 skin, 253 see mesoblastic tumors see also special regions Sarcomatosis, 229 saucer fracture, 516 Satellite bubo, 193 Sauerbruch's operating cabinet, 612 Sayre's jury mast, 562 plaster jacket, 561 treatment of fracture of clavicle, 392, 394 tripod, 563 Scalds, 155 Scalp, affections of, 500 abscess, 501 contusions, 500 hematoma, 500 meningocele, 501 spuris, 501 traumatic, 501 pachydermatocele, 502 tumors, 501 wounds, 501 Scalpel, methods of holding, 70 Scaphoid bone, bipartite, 409 excision of, 409 fracture of, 409 Scapula, alatum, 975 acromion process, 395 anatomical neck, 394, 395 body, 394 coracoid process, 395 surgical neck, 395 congenital elevation of, 975 dislocation of, 975 fracture of, 395 winged, 975 Scarlatina, surgical 169 Scarlatinal arthritis, 478 Scarpa's triangle, ligation of femoral artery in, 334 Scars, 104, 105 epithelioma in, 104 Schafer's method for artificial respiration, 34 Schede's operation for varicose veins, 283 of thoracoplasty, 617 Schizomycetes, 42 Schleich s solution, 38 Schnappende Hiifte, 988 Schreiber's procedure in administering neoarsphenamin, 205 Schultz's treatment of ulcers, 123 Schwartze's operation for mastoid disease, 568 Schwartze-Stacke operation for mastoid disease, 569 1072 INDEX Sciatic artery, ligation of, 330 dislocation of hip, 466 hernia, 817 nerve, operation on, 360 Sciatica, 360, 483 Scirrhus, carcinoma, 218 of breast, 626 ulcer, 626 see special regions Sclavo's serum, 187 Sclerosis of bone, 434 diffuse, 199 of testicle, 198 Sclerotitis, gonorrheal, 887 Scoliosis, 554, 4 pathological anatomy of, 554 symptoms, 554 treatment, 556 Scopolamin-morphin anesthesia, 31 Scorbutic ulcers, 118 Scotch douche, 100 Scrofula, 208 Scrofuloderma, 250 Scrotal tumors, general diagnosis of, 907 bandage, 88 hernia, 802, 806 Scultetus' bandage, 86 Scurvy, infantile, 433, 441 rickets, 433, 441 Sebaceous cysts, 232, 254 horn, 254 Secondary hemorrhage, 307 infection, 45 neuralgia, 34^ neurorrhaphy, 347 perineorrhaphy^, 924 sarcoma of bone, 445 suture, 149 syphilis, 171 thrombus, 266 union of wounds, 102 Section of nerves, 345 perineal, 880 Sedillot's excision of tongue, 647 Segregation of the intestine, 764 Semilunar cartilage, displacement of, 471 Semimembranous tendon, tenotomy of, 367 Seminal vesicles, affections of, 913 emissions, involuntary, 900 tuberculosis, 913 Semitendinosus tendon, tenotomy of, 367 Senile atrophy of bone, 442 enlargement of prostate, 915 gangrene, 127 Senile keratosis, 252 tuberculosis, 209 Senn's decalcified bone chips, 436 method of amputation of the hip, 1024 operation for floating kidney, 848 Sensation in diagnosis, 8 nerve fibers of deep, 346 Sensory aphasia, 506 Sentinel pile, 829 Separation of epiphyses, 375 Sepsis, 166 causative lesion of, 170 diagnosis of, 170 forms of, 170 treatment of, 171 Septic arthritis, 478 emboli, see pyemia intoxication, 167, 171 chronic, 167 symptoms, 167 Septicemia, 168 cryptogenic, 168 local manifestations, 169 primary, 168 secondary, 168 symptoms, 168 Septum, deviation of, 592 nasi, fracture of, 386 Sequestration dermoids, 233 Sequestrotomy, 436 Sequestrum, 434, 435, 126 Serodiagnosis, 14 Serotherapy, 49 Serous cysts, 232 effusion, in pericardium, 275 pleural, 613 inflammation 93 membranes, inflammation of, 8 synovitis, 475 Serum, antidiphtheritic, 25, loi antistreptococcic, 171 disease, 49 immunity, 49 antitoxic, 49 bactericidal, 49 Seventh nerve, affections of, 353 Sex, in diagnosis, 3 Shape of lesion in diagnosis, 5 tumors, in diagnosis, 239 Sheep serum, 185 Sherman black sheets, 69 Shock, 163, 171 causes, 163 prophylaxis, 164 INDEX 1073 Shock, symptoms, 164 treatment, 165, 13Q apathetic, 164 dehiyed, 164 eresthistic, 164 secondary, 164 torpid, 164 Short-circuiting operation on intestine, 764 Shoulder, amputation through, 1012 ankylosis of, 491 congenital elevation of, 975 dislocation of, 459, 463 effusion into, 476 excision of, 496 osteoarthritis of, 489 tuberculosis of, 482 Shroeder's amputation of cervix, 933 Side-chain theory of Ehrlich, 48 Sigmoid flexure, volvulus of, 745 Sigmoidoscope, 826 Sigmoidostomy, 755 Signs, in diagnosis, 7 Silicate of soda dressing, 90, 76 Silk, 60 Silkworm gut, 60 Silver nitrate, 55 salts of, 55 wire, 62 Simple carcinoma, 218 of breast, 626 dislocation, 453 Simple fracture, 374 goiter, 577 inflammation, 91 ulcer, 116, 119 Sims' position, 919 for peritonitis, 68 1 sound, 921 speculum, 919 uterine curette, 936 Simulation of surgical conditions, 14 Sinus, 124 affections of, 596 see also special regions treatment, 124 Situation of lesion, in diagnosis, 5 of tumors in diagnosis, 238 Sitz bath, 99 Sixth ner\-e, injuries of, 353 Size of lesion, in diagnosis, 5, 538 tumors, in diagnosis, 237, 239 Skeletal calipers, 419 Skey's method of amputating foot, 1016 Skiagraph, 15 6S Skiagraph, interpretation of, 15 Skiagraphy, see Rontgen rays, 14 Skin, anesthesia of, following section of nerves, 345 carcinoma, 252 lenticular, 252 treatment of, 252 color of, changes in, 5 disinfection, 54 epithelioma of, 251 deep, 252 nodular, 252 superficial, 251 grafting, 260 hemorrhagic, 245 idiopathic multiple, 253 in relation to tumors, 243 lesions in syphilis, 196 leukemic tumors, 253 mycosis fungoides, 253 pedunculated flaps, 257 preparation of, for operation, 66 sarcoma, 253 surgery of, 245, 256 tuberculosis of, 249 tumors of, 242 warts, 216 Skinner's inhaler, 28 mask, 28 Skull, atrophy of, 443 fracture of, 515, 516 base, 517 vault, 516 gunshot injuries of, 516, 14S natiform, 207 necrosis of, 207 syphilitic necrosis, 440 trephining of, 507 varieties, 515, 516 Sleeping sickness, 51 Sliding hernia, 799 Slough, 126, 116 Sloughing, 126 Small-pox, 50 Small sciatic ner\^e, affections of, 360 Smell, sense of, in diagnosis, 10 Smith's, Xathan R., splint, 418 Stephen, clamps for hemorrhoids, 836 treatment of dislocation of shoul- der, 461 Snake bites, 154, 153 poisoning, 154, 54, 53 Snap-finger, 979 Snapping hip, 988 Snare, 594 I074 INDEX Snuffles in syphilis, 206 Social condition, in diagnosis, 3 Sodium cacodylate for syphilis, 205 citrate method blood transfusion, 287 Soft carcinoma, 218 chancre, 896 corn, 248 of breast, 626 Softening in tumors, 241 Solar plexus blow, 611 Sole, perforating ulcer of, 999 Solitary kidney, 843 Soot warts, 252 Sounding the urinary bladder, method of, 877 Sounds, see special regions Spasm of esophagus, 660 intestine, 748 of pharyngeal muscles, 179 of respiratory muscles, 32 Spasmodic croup, 599 stricture of urethra, 890 stump, 1007 torticollis, 572 Spastic ileus, 748 paraplegia, 544 Special fractures, 386 Specific inflammation, 93 ulcer, 116 Spence's amputation at shoulder joint, 1013 Spermatic cord, hematocele of, 912 hj^drocele of, 911 torsion of, 904 Spermatocele, 911 Spermatorrhea, 900 Sphacelation, 126 Sphacelus, 126 Sphenoidal sinuses, diseases of, 597 Spica bandage, 77 descending, 83 of foot, 87 of groins, 87 of shoulder, 82 of thumb, 81 Spiller-Frazier operation for the removal of the Gasserian ganglion, 353 Spina bifida, 551 anterior, 552 occulta, 551 ventosa, 438 Spinal accessory nerve, affections of, 354 stretching of, 573 anesthesia, 40 caries, 558 Spinal cord, compression of, 547 concussion of, 546 contusion of, 546 diseases of, 11, 552 edema of, 547 hemorrhage into, 548, 549, 550 injuries of, 546 pressure on, in Pott's disease, 562 resection of posterior roots of, 544 total transverse lesion of, 541 tumors of, 564 wounds of, 551 curvature, 554 hemorrhage, 551, 546, 547 localization, 539 membranes, tumors of, 564 meningitis, 563 neurasthenia, 547 puncture, 544, see lumbar puncture rickets, 556, 551 traumatic neurosis, 546 Spindle-celled sarcoma, 230 Spine, abscess from, 559, 562 aneurN^smal erosion of, 556 ankylosis of, 489, 557 caries of, 558 concussion of, 535 congenital malformation of, 553 curvatures of, 554 deformities of, 554, 3 diseases of, 551, 483 dislocations of, 549 varieties, 549 fracture of, 547 fracture-dislocation of, 547 injuries of, 546 osteoarthritis of, 558 osteomyelitis of, 557 sprains of, 546 surgery of, 539 tuberculosis of, 557 diagnosis, 560 local symptoms, 564 abscess, 559, 563 deformity, 562 pain, 558 paralysis, 560, 563 rigidity, 558 pathology, 558 treatment, 560 of abscess, 563 tumors of, 553, 564 Spiral bandage, 77 of finger, 81 of chest, 84 INDEX i075 Spiral biiiula^e, reversed, S2 fracture, 374 reversed banduRC, 77 of lower extremity, 87 Spirilla, 42 Spirochcta pallida, 191, 43, 5r, 194 Splanchnoptosis, 739 Splay foot, 994 Spleen, abscess, 797 affections of, 797 rupture of, 672, 797 Splenectomy, 797 blood changes after, 799 contraindications, 798 Splenic anemia, 798 fever, 185 Splenomegaly, 797 Splenopexy, 797 Splenoptosis, 797 Splint, 381, 396 Agnew, 422, 396 Band, 390 Bond, 396, 407 Dupuytren, 428, 396 Gooch, 381 Hammond, 389 Hodgen, 418 interdental, 389 Jones' cock-up, 408 Kingsley's interdental, '390 Levis, 407 Mclntyre, 418 Matas, 390 Moriarty's, 389 Plaster of Paris, 89 pressure, causing gangrene, 381, 131 Roberts, 407 Smith. 418 Stromeyer, 402 Thomas, 415, 380 triangle, 397 knee, 487 Van Arsdale, 420 Splintered fracture, 374 Splints, plastic, 381 Splitting fracture of skull, 516 Spondylitis, 557 deformans, 557, 489 Spondylolisthesis, 557 Spondylosis rhizomelique, 489 Sponges, preparation and sterilization of, 62 Spontaneous aneurysm, 296 dislocation, 453 fracture, 374 Spontaneous gangrene, 128 hemorrhage, 306, 519 hemostasis, 305 Spores, 42 Sporothrix Schcnckii, 246 Sporotrichosis, 246, 51 Sporulation, 42 Sprains of joints, 452 Sprengel's deformity, 975 Springing hip, 988 Spurious meningocele, 501 valgus, 994 Squamous epithelioma, 217 Square cap bandage, 81 Ssbanejew-Franck operation for gastros- tomy 711 Stab wounds, 144 Stacke's operation for mastoid disease, 568 Stains, gunpowder, 146 Stamm-Kader operation of gastrostomy, 708 St. Anthony's fire, 174 Staphylococcic infections, 42, 432, 613 Staphylococcus pyogenes, albus, 106 aureus, 247, 106 cereus albus, 107 flavus, 107 citreus, 106 epidermidis albus, 106, 141 fiavescens, 107 Staphylorrhaphy, 652 Starch bandages, 90, 76 Starting pains, 481, 484 Static machine, 14 Status lymphaticus, 341, 583 presens, 2 Stay knot, 320 Steel plates for fixation of fractures, 381 Steinmann's nail extension, 419 Stellate fracture, 374, 516 Stellwag's sign, 582 Stellwagon's instrument for making trap- door in skull, 509 Steno's duct, affections of, 642 Stercoraceous vomiting, 741, 9 Stercoral ulcers, 749 Stereognostic center, 506 Stereoscopic plates, in X-ray diagnosis, 17, 378 localizing foreign bodies, 16, 17 Sterility, 902, 957, 20 due to X-ray exposure, 20 Sterilization, 51, 42 after operation, 69 1076 INDEX Sterilization, chemical, 52, 149 fractional, 60 mechanical, 51, 148, 139 of bladder, 67 of Cargile membrane, 63 of catgut, 60, 61 of catheters, 63 of cotton goods, 63 of dressings, 62, 52 of ear, 67 of enamel ware, 63 of glass, 63 of gloves, 64 of hands, 64 of hard rubber, 63 of instruments, 63, 59 of leather, 63 of mouth, 65, 67 of normal salt solution, 63 of nose, 67 of oiled silk, 63 of paraffin paper, 63 of patient, skin of, 64 of rectum, 67 of rubber tissue, 63 of silver foil, 63 of soft rubber, 63 of sutures and ligatures, 62 of syringes, 63 of vagina, 67 of water, 63 of wounds, 54, 139 thermal, 51 Sterilizer, 59 Sternomastoid in torticollis, 573 division of, 562 Sternum, dislocation of, 465 fractures of, 392 necrosis of, 393 Stertorous respiration, 513, 531 Stewart's enterostomy, 755, 756 gastroenterostomy method, 715 gastrostomy, 708 operation for cancer of the breast, 629 for inguinal hernia, 808 subtotal gastrectomy, 728 Sthenic inflammation, 93 fever, 167 Stiles' operation for hydrocephalus, 529 Stiller's sign, 739 Stimson and Weir's method of steriliza- tion of hands, 64 Stings of insects, 153 Stitch abscess, 73 Stomach, absorptive power of, testing, 702 affections of, 688 bilocular, 695 carcinoma of, 704 congenital stenosis of pylorus, 688 dilatation of, 699 foreign bodies in, 689 hourglass, 695 injuries to, 670 lavage of, 706 operations on, 706 peristaltic movements of, 701 prolapse, 702 rupture of, 670 stenosis of pylorus, 688 ulcer of, 689, 690, 2 perforation of, 693 volvulus of, 703, 706 Stomatitis, 647 aphthous, 647 gangrenous, see noma mercurial, 202 ulcerative, 648 Stone, see calculus forceps, 879 scoop, 879 sound, 877 Stovain, 38 Strabismus, 531, 534, 572 Strains, 362 Strangulated hernia, 821, 132 Strangulation of intestine by bands, 743 Strauss, pj'loroplasty, 725 Strawberry gall-bladder, 780 Streptobacilli, 42 Streptococcic infections, 42, 432, 613 Streptococcus erysipelatis, 174, 231 pyogenes, 174, 166 Streptothricoses, 51 Strep tothrix madurse, 1S9 Stretching, in scars, 105 in skin surgery, 256 Stricture, see special regions from gummata, 200 Stromeyer splint, 403 Struma, 578 Strumitis, 577 Strumous, 208 lip, 638 Strj'chnin poisoning, 9, 180 Stumps, amputation, affections of, 1006 Stupe, 99 Styloid process, fracture of, 405 Styptics, 310 Subacromial bursitis, 373, 975 INDEX 1077 Subaponeurotic abscess, 502 hematoma, 500 lipoma, 502 Subastragaloid amputation, 1017 dislocation, 472 Subclavian artery, compression of, 313 ligation of, 325 vein, ligation of, 572 vessels, injuries of, 393 Subclavicular dislocation of shoulder, 459 Subconjunctival ecchymosis, 572, 519 Subcoracoid dislocation of shoulder, 450 Subcutaneous injection of paraflSn, 586 emphysema, 263 hematoma, 500 symptoms, 264 treatment, 264 Subdeltoid bursa, affection of, 373, 975 Subdural abscess, 532, 533 hemorrhage, 520, 551 Subglenoid dislocation of shoulder, 459 Subhyoid cysts, 572 pharyngotomy, 605 Subinfection, 46 Subinvolution of uterus, 937 Subjective symptoms in diagnosis, 2 Sublingual dermoids, 572 Subluxation, 455 of head of radius, 463 of humerus, 460 of knee, 471 Submammary abscess, 622 Submaxillar}' cellulitis, see angina Ludovici Subpericranial hematoma, 500 Subperiosteal fracture, 374 gummata, 438 resection of joints, 495 whitlow, 981 Subphrenic abscess, 6S4, 780 locations of, 684 Subserous lipoma, see lipoma Subspinous dislocation of shoulder, 459 Subsynovial lipomata, 222 Subtemporal decompression, 512 Subungual exostosis, 225 Suffusion, 138 Sugillation, 138 Sulcus, intraparietal, 503 precentral, 503 Sun baths in tuberculosis, 212 Sunburn, 155 Superficial epithelioma, 251 Superinvolution of uterus, 937 Superior gluteal nerve, affections of, 360 longitudinal sinus, thrombosis of, 5,Si, 532 maxilla, affections of, sec upper jaw fraction of, 388 maxillary nerve, resection of, 351 thyroid artery, ligation of, 323, 581 Supernumerary digits, 978 Supersensitiveness, see anaphylaxis, 50 Suppression of urine, 847 Suppuration, 106 pathology of, 107 see also special regions Suppurative synovitis, 477 Supracondyloid amputation of thigh, 1021 fracture of femur, 420 humerus, 400, 401 Supracoracoid dislocation of humerus, 459 Supramammary abscess, 622 Supramarginal convolution, 504 Suprameatal triangle, 569 Supraorbital nerve, operations on, 351 Suprapubic aspiration of bladder, 871 cystotomy, 879 lithotomy, 879 prostatectomy, 918 Suprarenal extract, see adrenalin, 583 Supratrochlear nerve, operation upon,. 351 Supravaginal hysterectomy, 950 Surgeon's knot, 142 Surgical anesthesia, 21 emphysema, 611 kidney, 852 scarlatina, 169 technic, 59 Suspension and extension apparatus of Blake, 399 Suspensory bandage, 84 Suture a distance, 348 of blood vessels, 315 of bone, 62 of heart, 172 Suture-ligature, 314 Sutures, 60, 149, 140 see also special regions Swallowing in anesthesia, 34 Sweep's cancer, 252 Swelling in inflammation, 94 in tumors, 240, 241 Swift-Ellis treatment of syphilis, 204 Sycosis, X-ray treatment, 18 Sylvester's artificial respiration, 33 Sylvius, fissure of, 503 Symbiosis, 46, 178 loyS INDEX Syme's amputation, 1017 external urethrotomy, 804 staff, 894 Symmetrical gangrene, 1 2g Symond's tube for esophageal stricture, 662 Sympathetic ganglia, cervical, excision of, 361, 584, 537 inflammation, 92 nerve, afJections of, 360 Symptomatic hydrocele, 909 fragilitas ossium, 442 Symptoms, objective, i subjective, i Syncope, 163 Syncytioma malignum, 954, 219 Syndactylism, 979 Syndesmotomy, 993 Synechia, 595 Synorchism, 902 Synovial inflammation, in diagnosis, 7 membrane, pulpy degeneration of, 479 Synovitis, acute, 475 chronic, 477 gonorrheal, 473 gummatous, 478, 19S lipomatosis, 222 pj'cmic, 477 rheumatic, 476 serous, 475 sj^philitic, 473, 198 tuberculous, see joints typhoid, 473 Syphilides, 197, 196 pigmentary, 198 tubercular, 198 Syphilis, 191, 51 acquired, 191 chancre, 192 conceptional, 191 congenital or hereditary, 206, 207, 191 immunity in, 191 CoUes, 192 Profetas, 192 incubation period, 192 insonitum, 191 methods of injection, igi prognosis, 200 quarternary, 200 stages, 192 intermediate, 199 primary, see chancre secondary, 196 alopecia in, 198 Syphilis, stages, secondary, condylomata, 198 fever of eruption 196 lymphatic involvement, 196 mucous patches, 198 skin rashes, 198 syphilides, 198 tertiary, 199 diagnosis of, 200 diffuse sclerosis, 199 gumma, 199 syphilides in, 199 treatment, 201 continuous, 201 fumigation, 201 intermittent, 201 intramuscular, 201 intravenous, 201 inunctions, 201 local, 206 mixed, 203 neosalvarsan, 205 salvarsan, 203 serum, 201 see also special regions Swift-Ellis method, 204 Syphilitic arteritis, 291, 480 bubo, 193 fever, 196 lichen, 197 S3'philodermata, see syphilides Syringes, sterilization of, 62 Syringomyelia, joint affections in, 4S9 Syringomyelocele, 552 T-bandage of perineum, 86 T-fracture, 374, 400 Tachycardia, 583 Tailed bandage, 78, 86 Talipes, 991 acquired, 992 decubitus, 992 paralytic, 992 spastic, 992 traumatic, 992 calcaneus, 140, 994 congenital, 991 equinus, 140, 994 varus, 992 valgus, 140, 994 varus, 140, 994 Talma's operation, 777 Tamponage of heart, 274 Tampons, vaginal, 958 Tampotement, 98 INDEX 1079 Tangenital wounds of brain, 523 Tapping, sec special regions Tarsectomy, 99.? Tarsometatarsal joints, amputation through, 1015 Tarsus, amputation througli, ioi() dislocation of, 47,^ fracture of, 430 tul)erculous disease of, 486 Taxis, S.M Teale's amputation of leg, 1018 probe gorget, 895 Technic of modern surgery, 59 -see also special regions Teeth, carious, 338, 598 Hutchinson, 207 in congenital syphilis, 207, 5 in rickets, 440 tumors in connection with, see odon- toma Telangiectatic angioma, 226 sarcoma, 230 Temperature, local, in diagnosis, 9 Temporal artery, compression of, 313 ligation of, 324 Temporary hemostasis, 139 Temporomaxillary joint, ankylosis of, 650 joint, arthritis, suppurative, 568 dislocation of, 457 excision of, 651 Temporosphenoidal abscess, 533 Tenderness in abdominal affections, 691 in diagnosis, 8 Tendo-Achillis, synovitis of, 998 tenotomy of, 366, 419 Tendon sheaths, diseases of, 366 Tendons, affections of, 362 displacement of, 363 lengthening of, 369 operations on, 366 rupture of, 362 shortening of, 370 subluxation, 364 suppurative, 365 transplantation of, 370, 994 Tenesmus, 7 Tenia barbae, 18 echinococcus, 233 saginata, 235 solium, 235 tonsuranus, treatment with Rontgen rays, 18 Tennis leg, 991 Tenoplasty, 368 Tenorrhaphy, 367, 368J Tenosynovitis, 365 suppurative, 983 tuberculous, 365 Tenotomy, 366, 993 see also individual tendons Tenth nerve, affections of, 354 Tents for dilatation of os uteri, 932 Teratomata, 232, 215 of sacrum, 553 Tertiary syphilis, 191 Testis, affections of, 902, 8 atrophy of, 90S, 903 congenital malformation of, 902 cysts of, 907 ectopic, 903 fungus of, 906 hematocele of, 912 hernia of, 907 hydrocele of, 911 inflammation, 905 inversion, 902 malposition of, 902 neuralgia of, 909 retained, 902 sclerosis of, 198 syphilis of, 906 torsion of, 904 tuberculosis of, 905 tumors of, 907 undescended, 902, 806 Tetanolysin, 179 Tetanospasmin, 179 Tetanotoxin, 179 Tetanus, 178, 181, 46 acute, 179 cause, 178 chronic, 179 hydrophobicus, 180 idiopathic, 178 late, 180 local, 180 neonatorum, 180 paralyticus, 180 prophylaxis, 181 risus sardonicus of, 179, 9 treatment, 18 1 Tetany, 180, 46 parathyreopriva, 576 Tetracocci, 42 Thecal whitlow, 982 Thecitis, 365 suppurative, 982, 983 Therapeutic effects of the X-ray, 19 Thermal injuries, 155 sterilization, 51 j I060 INDEX Thiersch's method of skin grafting, 260 operation for epispadias, 882 Thigh, amputation of, 1022 Third nerve, affections of, 349 Thomas's incision for capsulotomy, 461 knee splint, 487 splint, 380, 379, 485 wrench, 993 Thoracic duct, ligation of, 335 obstruction of, 9 wounds of, 335 Thoracoplasty, 616 Thoracotomy, 615 Thorax, surgery of, 609 Thorium, 20 Thrill, 8 Throat cut, 575 Thromboangitis obliterans, 128 Thrombophlebitis, 277, 248, 280 Thrombosis, 265, 277, 597 arterial, 290 changes in, 266 gangrene from, 290, 131 localization, 266 of cerebral sinuses, 531 cavernous sinus, 532 lateral sinus, 531, 534, 169 mesenteric vessels, 687 petrosal sinus, 532 superior longitudinal sinus, 531 results, 266 types, 265 venous, 266 Thrush, 647, 51 Thumb, amputation of, 1008 dislocation of, 464, 465 fracture of, 409 Thymic asthma, 584 stenosis of trachea, 584 Thymus gland, enlargement of, 341, 584 Thyroglossal cyst, 571 fistula, 570 Thyroid cysts, 577 dislocation of hip, 469, 466 extract, 580 gland, accessory, 576 absence, 577 actinomycosis, 577 atrophy, 577 congestion, 577 tumors of, 577 vessels, ligation of, 580 wounds, 576 Thyroidectomy, 580, 581 Thyroidism, 580 Thyroiditis, 577 Thyrotomy, 604; 605 Tibia, fracture of, 424 epiphyseal separation of lower end, 425 of upper end, 425 fracture of 424 internal malleolus, 425 shaft, 425 tubercle, 424 upper end, 424 osteotomy of, 991 rachitic, 991 syphilitic, 991 Tibial arteries, see anterior and posterior Tibialis anticus, tenotomy of, 366 posticus, tenotomy of, 367 Tic convulsif, 350 douloureux, 350 facial, 350 Tinnitus aurium, 307 Tissue, repair of, loi Tissues, consistency of in diagnosis, 7 Toe-nail, ingrowing, 255 Toes, amputation of, 1014 deformities of, 998 dislocation of, 473 Tongue, affections of, 642 abscess of, 643 actinomycosis, 644 cancer of, 646 chancre of, 645 epithelioma of, 645 gumma of, 645 lupus, 644 removal of, 646 syphilis, 645 tie, 642 ulceration of, 644, 19& tuberculous, 196, 645 wounds, 643 Tonsiliotome, 655 Tonsillotomy, 654 Tonsils, affections of, 654 enucleation of, 654 hypertrophy, 654 suppuration, 654 tumors, 655 Tophi, 487, 372 Topography, craniocerebral, 502 Torsion fracture, 375 in treatment of hemorrhage, 314, 70 of omentum, 686 of ovarian cyst, 968 of spermatic cord, 904 INDEX I081 Torticollis, 572 false, 572 true or chronic, 572 permanent, 573 spasmodic, 572 Total empyema, 613 Tourniquets, 312 Toxalbumins, 45 Toxemia, 45, 166 Toxins, 45 Toxophore, 49 Trachea, cicatrices in, 599 diseases of, 599 foreign bodies in, 599 intussusception of, 599 rupture of, 610 stenosis of, 599 tumors of, 604 ulceration of, 608 wounds of, 575 Trachelorrhaphy, 933 Tracheocele, 571 Tracheotomy, 606, 32 high, 606 low, 607 preliminary, 606 tubes, 607 Trachoma, 209 Transfusion of blood, 285 Transhyoid pharyngotomy, 605 Transient obstruction of bile duct, 787 Transillumination of antrum, 596 stomach, 702 Transplantation of mucous membrane, 263 of bone, 449, 382 flap method, 450 free method, 450 of cartilage, 451 Transverse fracture, 374 Transversotomy, 755 Traumatic aneurj^sm, 293, 296 apoplexy, 519 arteritis, 292 asphj^xia, 610 delirium, 173 dermoid, 233 diabetes, 166 dislocations, 455, 456 epilepsy, 537 fever, 166 fracture, 374 gangrene, 132, 133 hemorrhage, 306, 519 hernia, 778, 791, 804 Traumatic hysteria, 547 inflammation, 93 insanity, 538 meningocele, 501 myositis, 364 neurasthenia, 547 neuritis, 347 neuroses, 546 spreading gangrene, 134 ulcers, 116 Trench foot, 160 Trendelenburg's varicose veins, 283 position, 950 test for valvular incompetence in varicose veins, 281 tracheal tampon, 605 Trephining, 507 for epilepsy, 538 fracture of skull, 517 insanity, 538 intracranial abscess, 535 intrameningeal hemorrhage, 520 inveterate headache, 538 lateral sinus thrombosis, 531 meningitis, 531 for middle meningeal hemorrhage, 520, 507 puncture of lateral ventricle, 529 tumors of brain, 537 Treponema pallida, 191 Treves' operation for lumbar caries, 563 Triangle of election, 321 of necessity, 321, 322 splint, 397 Trichiniasis, 364, 13 Trident hand, 442 Trifacial nerve, affections of, 350 neuralgia, 350 Trigeminal nerve, 350 Trigger finger, 979 Tripod, Sayre's, 562 Tripolith bandage, 89 Tripperfaden, 886 Trismus, 180, 179, 651 nascentium, 180 Trochanter, bursa, 373 fracture of, 415, 416 Tropacocain, 38 Trophic gangrene, 132 changes following section of nerves, 346 True keloid, 249, 220 neuromata, 343 Trusses, 806, 807 see special herniae io82 INDEX Trypanosomiasis, 51 Tubal abortion, 961 gestation, 961 rupture of, '961 Tube, Crooke's, 14 Tubercle, 209 anatomical, 250 bacilli, see bacillus Tuberculin, 211, 50 dose, 212 Koch's, 213 new (T. R.), 212 old, 212 test, 210 Tuberculocidin, 213 Tuberculosis, 208 diagnosis, 210 etiology, 209 gummata, 250 iodoform in, 55 mode of extension, 210 prognosis, 211 treatment, 211 ulcerosa, 250 see also special regions Tuberculous diathesis, 208 gummata, 250 Tuber ischii bursitis, 373 Tubes, Fallopian, disease of, 957 Tubo-ovarian cysts, 967 Tubular adenoma, 216 lymphangitis, 337 Tubulated aneurysm, 296 Tubulo-dermoids, 233 Tufnell's treatment of aneurysm, 300 Tumors, 214, 235, 215 see also various regions consistency of, 240 diagnosis of, 235 margins of, in diagnosis, 239 Tunica vaginalis, hydrocele of, 911 Turpentine stupe, 54 Tuttle's sigmoidoscope, 826 Twelfth nerve, injuries of, 354 Twisted suture, 141 T\^mpanum, rupture of, 518 Typhlatomy, 736 Typhlectasia, 736 Typhlospasm, 736 Typhoid arthritis, 478 bacillus, see bacillus in gall-bladder, 434 osteomyelitis, 433, 434 spine, 557 state, 168 Typhoid ulcer, perforation of, 437 Widal reaction, 14, 48 Ulceration, 116 see also special regions herpetic, 195 in scars, 105 in tumor diagnosis, 243 Ulcerative appendicitis, 767 ulcerosa tuberculosis, 250 Ulcere des phthisiques, 250 Ulcers, acute, 121, 118 bone, 437 callous, 122 carcinomatous, 118 chancroid, 896, 193 chronic, 122 Curling's, 156 diagnosis of, 117 discharge, 119 dyspeptic, 644 eczematous, 122 edges, 118 embolic, 116 epitheliomatous, see epithelioma erethistic, 122, 116 floor of, 118 following Rontgen-ray burns, 19 gastric, 690 glandular involvement, 118 gummatous, 199 healing, 123, 118 indolent, 122, 118 inflamed, 119 irritable, 122 lupoid, 250, 118 malignant, 116 Marjolin's, 218 neuralgic, 122, 116 of anthrax, 116 of benign tumors, 243 of congenital syphilis, 206 of glanders, 116 of leprosy, 116 pathology of, 116 peptic, 690 perforating, of sole of foot, 116, 999 phagedenic, 116 pressure, 117 pyogenic, 116 rodent, 251, 18 scirrhous, 626 scorbutic, ii8 serpiginous, 199 simple, 116 INDEX 1083 Ulcers, specific, 116 stercoral, 749 syphilitic, 118, 193 traumatic, iiS treatment of, 119 trophic, 118 tuberculous, 250, 196, 118, 250 typhoid, 737 varicose, 282, 118, 116 see also special regions Ulna, dislocation of, 463, 464 fracture of, 404 coronoid process, 405 olecranon, 404 radius and ulna, 408 shaft, 405 styloid process, 405 Ulnar artery, compression of, 313 ligation of, 328 nerve, dislocation of, 358 injury of, 358, 404 Umbilical fistula, 677 hernia, 814 adult, 81S congenital or exomphalos, 814 infantile, 814 sinuses, 678 Umbilicus, affections of, 677 Unconsciousness, 514, 5^9 diagnosis, 514 varieties, 519 Undescended testis, 902 Ungual whitlow, 254 Union of fractures, 385 wounds, 103 Unna's paste, 122 treatment of ulcers, 125 Unreduced dislocation, 457 Ununited fractures, 385 Upper common duct, stone in, 787 digestive apparatus, 634 extremity, deformities of, 977 jaw, see jaw Urachal cysts, 677, 233 Uranium, 20 Uranoplasty, 653 Uremia, 515, 534 Ureteral anastomosis, 865 bougie, 858 calculus, 857 caruncle, 922 fistulae, 848, 929 Ureteritis, 854 Ureters, calculus in, 857 catheterization of, 843, 868 Ureters, exploration of, 863 hemorrhage from, 846 ligation of, 848 operation on, 862 rupture of, 674 wounds of, 848 Ureterocystostomy, 866 Ureteroenterostomy, 864, 866 Ureterolithotomy, 865 Ureteropyelostomy, 865, 866 Ureterostomy, 864, 866 Uretero uterine fistula, 927 vaginal fistula, 927 Urethra, abscess of, 889 affections of, 882 calculus, impacted in, 885 caruncles, 922 chancre, 195 chancroid, 897 congenital malformation of, 882 absence, 882 epispadius, 882 hypospadius, 883 narrow meatus, 882 occlusion, 882 stricture, 882 contusions of, 884 false passage of, 895 folliculitis of, 889 foreign bodies in, 884 hemorrhage from, 847 irrigation of, 888 rupture of, 884 stricture of, 890 dilatation of, 891 symptoms, 891 treatment, 892 dilatation, 893 urethrectomy, 895 urethrotomy, 893 varieties, 890 Urethral bougies, 892 fever, 895 syringe, 889 Urethrectomy, 895 Urethritis, 885 simple, 885 specific or gonorrheal, 885 Urethrorrhea, 889 Urethroscope, 889 Urethrotome, 893 Urethrotomy, external, 893 internal, 893 Urethrovaginal fistulae, 927 Urinary fever, 895 1084 INDEX Urinary fistula, 890, 927, 678 organs, diseases of, 843 Urination, spontaneous, 71 Urine, extravasation of, 884 incontinence of, 869 in septicemia, 168 pus in, 846 residual, 917, 871 retention of, 870, 71 incontinence of, 869 suppression of, 847 Uronephrosis, 850 Urticaria, gangrenous, 248 Uterine colic, 956 sound, 921 Uterus, abscess of wall, 935 affections of, 930 amputation of cervix, 932 atrophy of, 937, 930 carcinoma of, 952 varieties, 952 congenital malformations, 930 atrophy, 930 bicornis, 930 bipartitus, 931 didelphis, 930 infantile, 930 Uterus, congenital unicornis, 931 curettage of, 949 deciduoma malignum, 954, 219 dilatation of cervix, 931 dislocation of, 938 displacements of, 937 erosion of cervix, 933 eversion of cervix, 933 fibroids of, 947 varieties, 947 h>'pertrophy of cervix, 932 inflammation of, 937 inversion of, 945, 946 laceration of cervix, 933 morcellement of, 949 myoma of, 947 polypi of, 947, 951 prolapse of, 943 reposition of, 940 sarcoma of, 952 septus, 930 stenosis of cervix, 931 subinvolution of, 937 superinvolution of, 937 syncytioma malignum, 954, 219 tumors of, 947, 951 ulceration of cervix, 934 Uvula, elongation of, 654 V-shaped fracture, 374 incision, 256 Vaccin, 50 Vaccination, 184 Vacquez's disease, 798 Vagina, affections of, 922 atresia, 923 cysts of, 930 injuries, 923 stenosis, 923 sterilization of, 68 / Vaginal enucleation of fibroids, 949 fistula, 927 hematocele, 912 hernia, 817, 803 hydrocele, 909 hysterectomy, 949, 953 speculae, 919 Vaginalitis, serous, 909 Vaginismus, 930 Vaginitis, 929, 930 Valentine's urethroscope, 889 Valgus, acquired, 995 Van Arsdale's splint, 420 Vanghetti's operation, ion Van Hook's operation for ureteral anasto- mosis, 865 Vaporizing apparatus for anesthesia, 25, 26 Varicocele, 912, 806, 973 Varicose aneurysm, 305 ulcers, 282, 116 vein, choice of operation, 284 veins, 279 Variola, 51 Varix, 279 aneurysmal, 304 arterial, 294, 226 causes, 279 complications, 282 eczema, 282 excision of, 283 lymphangitis, 281 pathology of, 280 rupture, 282 symptoms, 281 thrombophlebitis, 280, 282 treatment, 282 ulceration, 282 Vascular goiter, 579 tumor, 243 Vas deferens, anastomosis of, 912 ligation of, for recurring epididymitis, 905 rupture of, 912 tuberculous disease of, 905 INDEX 1085 Vasotribc, 314 Veins, affections of, 277 canalization of, 265 contusions, 289 entrance of air into, 270 ligation of, 314 transplantation of, 289 varicose, 279 wounds of, 289 Velpeau's bandage, 84, 394 Venereal warts, 897, 216 Venesection, 284, i^, it 2 Venous hemorrhage, 306 nevus, 226 obstruction, 5, 6 sinuses, thrombosis of, 531 thrombosis, 266 wounds, 289 Ventral hernia, 816 suspension, 942 Ventriculography, 527 Ventrofixation, 942 Vermiform appendix, 765 Veronal in anesthesia, 28 Verruca, 249, 250 Vertebra;, see spine Vertebral artery, compression of, 313 ligation of, 326, 537 Vertical sulcus, 503 traction in fracture of femur, 421 Vertico-mental triangle, 81 Vesical calculus, 876 hematuria, 846, 876 Vesicouterine fistula, 927 Vesicovaginal fistula, 927 Vesiculse seminales, affections of, 913 Vesiculitis, 913 Vibrios, 43 Vicarious menstruation, 955, 592, 694 Vicious union of fractures, 386 circle after gastroenterostomy, 711 Villous tumor of bladder, see papilloma warts, 216 Virchow's law, 214 Virus, 50, 182 fixe, 184 Viscera, injuries of, 670 Volkmann's contracture, 976, 364 operation for hydrocele, 911 Volsella forceps, 920 Volvulus, of intestine, 745 cecum or ascending colon, 745 omentum, 686 sigmoid flexure, 745 stomach, 703, 706 Vomiting, cerebral, 535 continued, 72 persistent in anesthesia, 34, 35 stercoraceous, 741 see also special conditions Von Bergmann's operation for hydrocele, 911 treatment of gastric ulcer, 692 Von Eiselberg's unilateral exclusion of pylorus, 724 Von Esmarch's tourniquet, 312 Von Graefe's sign, 582 Von Hacker's method of gastro-enteros- tomy, 713 Von Jaksch's disease, 798 Von Pirquet's tuberculin test, 211 Von Recklinghausen's ostitis fibrosa, 445 Vulpius, tenorrhaphy, 368, 370 Vulva, affections of, 921 Vulvitis, 921 Vulvovaginal gland, abscess of, 922 Wallerian degeneration, 347 Wardrop's operation for aneurysm, 303 Wart horn, 249 Warts, 249, 215 anatomical, 249 lymphatic, 335 soot, 252 venereal, 897, 216 Wassermann serum reaction for syphilis, 197 test for chancre, 194 ' Water bed, 548 glass bandage, see silicate of soda sterilization, 63 Watkin's operation, 945, 927 Watson's double nephrostomy, 864 Wax, Horsley's, 510 in ear, 566 Moorhof's, 437 Waxy degeneration, 113 Weaver's bottom, 373 Webbed fingers, 979 Wedge fracture of skull, 516 Weight, in diagnosis, 10 Weir's appendicostomj^, 773 operation for hallux valgus, 997 resection of the rectum, 842 Wen, 254, 232 Wertheim's operation, 945 Wet drip, 97 Wheelhouse's operation for impassable stricture, 894 staff, 894 io86 INDEX White patches, in diagnosis, 6 infarct, 268 swelling, 112, 480, 486 thrombus, 265 Whitehead's operation for hemorrhoids, 836 on tongue, 646 varnish, 647 White's operation for excision of hip, 497 Whitlow, 981, 194 thecal, 982 ungual, 254 Widal, agglutination reaction, 14 reaction, 47, 14 in sporotrichosis, 246 Will, center of, 506 Willem's drainage of joints, 452 treatment, suppurative arthritis, 479 Wilm's operation for cecum mobile, 737 treatment of gastric ulcer, 692 Wire, aluminium bronze, 62 iron, 62 silver, 62 Withering scirrhus, 218, 627 Witzel's method of gastrostomy, 708 Wolf's method of skin grafting, 260 Wolfler's method of gastroenterostomy, 711 Wooden phlegmon, 575 Wool-sorter's disease, 185 Word deafness, 506 Wounds, 138 contused, 143 disinfection of, 139 dissection and post-mortem, 152 drainage, 71 dressings, 71 gunshot, 144 incised, 142 insect stings, 153 lacerated, 143 military, 146 Wounds, poisoned, 152 puncture and stab, 144 repair, 103 snake bite, 153 special infections, 163 treatment, 148, 145, 144, 142 see also special regions Wright's solution, 151 Wrist drop, 357 joint, amputation at, 1009 dislocation at, 464 effusion into, 478 excision of, 496 gonorrheal infection of, 479 tuberculous disease of, 482 Wry neck, 572 Wyeth's method of controlling hemor- rhage in amputation at hip, 1023 at shoulder, 1012 X-ray, 14 see Rontgen ray as an anodyne, 19 burn, 19, 252 Coolidge tube, 15 destructive action of, 18 filters, 19 gangrene, 134 interpretation of pictures, 15 therapeutic effects of, 18 Xanthoma, 222 Xeroderma pigmentosum, 252 Yeasts, 51 Yellow tubercle, 209 Yellowish discoloration in diagnosis, 5 Y-fracture, 400 Young's method of perineal prostatec- tomy, 918 Zooglea, 42 Zygoma, fracture of, 388 Zymogenic bacteria, 44 ^\ l« \^ ^