l<^SSS«^>iiSj^5SS5S^>SSfSSS^ COLUMBIA LIBRARIES OFFSITE HS00099589 ^^*M* ^' <• ■>■> SAUNDERS' MEDICAL HAND-ATLASES. •o^o- The series of books included under this title are authorized translations into English of the world-famous T^t,^-,^-, KA-J;-:-' whic che£ I ous i most press panic dens( C read serva and t hospi will venie by th hereti of th( enorn jecte< tribut best elega in ch by th. Columbia tBnitttsiitp \ in tfje Citj> of Mt^o |9orfe €oUtQt of S^\i^simni anb burgeons; ^titvtntt l^ibrarp ss, and numer- 1 by the nty im- accom- s a con- d. ■ offer a uch ob- :enters; routine ; books id con- rpreted ion has ecause nd an ;ir pro- inal dis- ses the most ^ached Istrated fferent Danish, languages— German, English, French, Italian, Russian, Spanis Swedish, and Hungarian. The same careful and competent editorial supervision has been secured in »he English edition as in the originals. The translations have been edited by the leading American specialists in the different sub- jects. The volumes are of a uniform and convenient size (5 x 7}i inches), and are substantially bound in cloth. (For List of Books, Prices, etc. see back cover.) Pamphlet containing specimens of the Colored Plates sent free on application. Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/atlasepitomeofdiOOgole ATLAS AND EPITOME DISEASES CAUSED BY ACCIDENTS DR. ED. GOLEBIEWSKI OF BERLIN AUTHORIZED TRANSLATION FROM THE GERMAN, WITH EDITORIAL NOTES AND ADDITIONS PEARCE BAILEY, M.D. CONSULTING NEUROLOGIST TO ST. LUKE's HOSPITAL AND THE ORTHOPEDIC HOSPITAL, NEW YORK, AND TO ST. JOHN's HOSPITAL, YONKERS ; ASSISTANT IN NEUROLOGY, COLUMBIA university; AUTHOR of " ACCIDENT AND INJURY : THEIR RELATIONS TO DISEASES OF THE NERVOUS SYSTEM " 40 COLORED PLATES, AND 143 ILLUSTRATIONS IN BLACK PHILADELPHIA W. B. SAUNDERS & COMPANY 1900 Copyright, 1900, By W. B. SAUNDERS & COMPANY. PRESS OF W. B. SAUNDERS A. COMPANY. PREFACE. The intention in pnblishingthis "Atlas and Epitome" is to present a systematic description of the sequels of injuries caused by accidents. The book is expected to be of in- terest not only to medical practitioners, but also to stu- dents, who, it is hoped, will find it a concise and useful manual supplying a deficiency in medical literature. By reason of its illustrations and the large number of descrip- tive cases, the work should also prove useful to laymen whose interests are connected with accident-insurance. The book is divided into two parts, one treating of in- juries in general, the other of injuries aifecting special structures and regions of the body. The symptomatology of the sequels of the various forms of injury, as given in the text, date either from the time when the surgeon is usually succeeded by his medical col- league, or from the termination of both medical and surgi- cal treatment, when tlie patient is ready to resume work or to receive a certificate of disability, as the case may be. The illustrations conform to the same rule. The symptomatology, therefore, of a large number of the sequels corresponds to the fourteenth week after in- jury ; while in some other cases — the traumatic nervous diseases, for instance — it applies to a much later period. The date chosen for the illustrations is also variable, 11 12 PREFACE. according to the time required for recovery or the ability to resume work. The colored j)lates are copied from original water- colors, done for the most part from life, by Mr. Fink, whose work gives evidence of keen perception t)f medical requirements as well as of artistic merit. The illustrations in black and the pen-and-ink drawings also testify to his ability. The other illustrations and skiagraphs are from ])h()to- graphs, drawings, sole-imprints, etc., made in my hos})ital. The chapters on anatomy are based on original studies on the cadaver as well as on living subjects. The works of other and better known writers have been freely consulted, with due acknowledgment in the text, whenever appropriate. I refer, among others, to the works of Thiem, Wagner and Stolper, F. Konig, Hel- ferich, Hoifa, Kaufman n, Rauber, Poirier, Bardeleben, Ferd. Baelir, and F. Riedinger. The text in general is based on an experience with accident-cases extending over thirteen years, and embracing a total of 5245 cases, a con- siderable number of which have remained under observa- tion since the first few years following the passage of the Accident-insurance Law. Each class of injuries is })ref- accd by a reference to the number of cases personally observed. The "Atlas and Ej)itome " does not claim to cover the subject completely, certain special branches, such as in- juries of the eyes, ears, and female generative organs, not being even touched U])on. The style is condensed, as is to be expected in a work of this character, but much that is omitted in the text is supplied in the descriptive cases. PREFACE. 13 The illustrations of certain chapters have had to be cur- tailed, owing- to technical imperfections in the skiagraphs which made them useless for purposes of reproduction. This applies especially to skiagraphs of the pelvis, hip- joint, and spine. I desire to express my appreciation of the willingness of the publisher to assume the very considerable expense incidental to the preparaticMi of this book. Its readers will recognize that the work is in many re- spects imperfect, entering as it does upon a field in which we still have much to learn from experience. I shall be sincerelv grateful for any suggestion or advice tending to remedy its faults. The Authoe. CONTENTS, PAGE IXTRODUCTION TO THE AMERICAN EDITION 23 I. GENERAL CONSIDERATIONS. Causes of Accidexts 33 Accidents 35 Statistics of Accidents 35 Mortality Table 37 General Remarks on Injuries and Traumatic Disorders 37 General Remarks on Injuries. Injuries and Traumatic Diseases of the 8kin 38 Injuries and Traumatic Diseases of the Nails .... 46 Injuries and Traumatic Diseases of Muscles and Ten- dons .47 Injuries and Traumatic Diseases of Tendons and Ten- don-sheaths 52 Injuries and Traumatic Diseases of Burs.t? 53 Injuries and Traumatic Diseases of Fasci.e 54 Injuries and Traumatic Diseases of Ligaments and Joint-capsules 55 Injuries and Traumatic Diseases of the Blood-vessels 55 Injuries and Traumatic Diseases of the Nerves ... 57 Injuries and Traumatic Diseases of the Bones .... 61 Injuries and Traumatic Diseases of the Joints .... 70 The Influence of Traumatism on the Development of Tumors 80 Intoxications 81 Infectious Diseases 83 15 16 CONTENTS. II. SPECIAL STRUCTURES. PAGE Injuries and Traumatic Diseases of the Head 88 Contusions of the Head 91 Fractures of the Skull iC? Traumatic Diseases of the Brain and Its Meninges 103 Functional Neuroses 107 Injuries of the Face 115 Injuries and Traumatic Diseases of the Neck 121 The Trunk 121 The Vertebral Column 121 General Symptoms of Traumatic Diseases of tlie Spinal Cord 128 Injuries Involving the Spinal Cord; Concussion of the Cord . 132 Injuries Involving the Spinal Meninges 133 Traumatic Hemorrhages in the Spinal Cord 135 Symptoms of Injuries Involving the Spinal Cord 138 Traumatic Diseases of the Spinal Column, Meninges, and Cord 170 Contusion and Crushing of the Back 182 Injuries and Traumatic ^iseases of the Chest .... 186 Contusions of the Thorax 187 Commotio Pectoris 190 Wounds and Cicatrices of the Chest 191 Subcutaneous Rupture of Muscles . 192 Fracture of the Sternum 193 " " Ribs 194 " " Costal Cartilages 201 Dislocation of the Ribs 201 Se((uels of Fractvn'e of the Ribs 202 Injuries and Traumatic Diseases of the Heart and Pericar- dium 208 Injuries and Traumatic Diseases of the Abdomen . . . 212 The Abdominal Wall 212 The Stomach 213 The Intestine and Peritoneum 216 The Liver 219 The Spleen 220 The Pancreas 220 Tlie Kidney 221 The Bladder, Ureters, Testicles, and Penis 224 Hernia 227 CONTENTS. 17 PAGE Injurip:s and Traumatic Diseases of the Upper Ex- tremity 23G The Slioulder 236 The Arm 264 The Elbow-joint . 2S0 The Foreanu 288 The Wrist 304 The Hand and Fingers 317 Injuries and Traumatic Diseases of the Lower Ex- tremity 353 The Telvis 356 The Hip-joint 363 The Thigh 366 The Knee 392 The Leg 417 The Foot and Ankle 448 Index 537 COLORED PLATES. Plate 1. — Diajjram of the Lateral Convexity of the Skull and the Brain Centers Ac^-ording to Bardeleben. Plate 2. — Fig. 1. — Circular Depression and Scar in the Middle of the Forehead after a Compound Fracture. Fig. 2. — Deep Scar and Opening in the Left Frontal Bone after a Coniniinuted Fracture. Plate 3. — Fig. 1. — Represents a Hod-coth Sides of the Foot, in a Case of Compound Fracture (Crushing) of the Toes. (See also skiagraph, Fig. 124, and the sole- impressions, Fig. 123. ) Fig. 2. — Case of Compound Fracture of the Metatarso- phalangeal Joint of the Great Toe, Showing Adherent Sear and Thickening of Joint. (See skiagraph. Fig. 125. ) Plate 40.— Fig. 1. — Scar of Dorsum of Foot Adherent to the Extensor Communis I>revis. Fig. 2. — Traumatic Ciul)-foot Following Fracture and Unreduced Dislocation of the Astragalus. (See skiagra])h, Fig. 132, and sole-impressions, Figs. 133 and 134.) INTRODUCTION TO THE AMER- ICAN EDITION. The past few years have witnessed an appreciable in- crease in the knowledge of diseases induced by physical in- jury and mental shock. The danger to workmen in special occupations is now known in accurate percentages. The relative value of causes is more firmly established. Symp- toms and their significance have been so diligently studied that the outcome of individual diseases can be foretold with remarkable exactness. A variety of causes underlies this advance. Apart from the onward movement of medicine, accidents as causes of disease occupy a place of unprecedented importance. Every year over four thou- sand persons are killed and over thirty-eight thousand are injured on railways in the United States alone. As shown in tlie statistics on page 35 of this "Atlas," during the year 1898 over ninety-seven thousand workmen insured under the German law sustained injury. In the nature of things, the quantum of these injuries is taken to the courts for determination. There we find the subject has attained the same prominence that it has in medicine. Court calendars are everywhere crowded with personal injury cases, and negligence law now has reports of its own. It is estimated that one-half the jury trials in the State of New York concern actions for personal injuries. But even judicial records fail to reflect the real activity in this branch of law, since for one litigated claim there are at least eight claims settled out of court. 23 24 INTRODUCTION TO THE AMERICAN EDITION. So far 118 the writer is iiware, Germany, by the passage of the hiw insuring- workmen against injury, is the only country which has attempted to deal comprehensiycly with the problems inyolyed. An epitome of this law is as follows : Workmen and em})loyees, with the exception of those of commercial, of domestic, and of a few t)ther callings, whose annual wages do not exceed 2000 marks, are in- sured against accidents incident to their vari(jus occupa- tions. Such persons, injured during their work, are en- titled to free medical treatment, and, from the fourteenth week after the accident, to an indemnity of two-thirds of their wages, payable monthly. This applies only to acci- dents occurring at the time of working ; it does not include industrial diseases. But all preexisting diseases which are brought into activity or whose course is hastened by such an accident must be indemnified under the law. In case of the death of the workman, the widow is entitled to burial expenses, and to full indemnity for herself and her children until the latter attain the- ao-e of fifteen years. The insurance to the employees is given and the indenmity paid by the •' Berufsgenossenschaft" — that is, by an association of the employers of the various trades. The establishment of tlie amount of indemnity is usually based ujion a medical certificate and fixed by the Berufsgenossenschaft. The injured workman may appeal from this. If, after settlement, an important change in the injured person's condition takes place, the indemnity may be re- adjusted, either to the advantage of the workman or to that of the employers. The amount of indemnity is graded in accordance with the disability. In cases of total disability the full amount is paid ; when the disability is ])artial, only a part of the amount. If the workman is (lisal)led for his special occu- pation, but can support himself, though not so well, at JNTRODUCTIOJsr TO THE A3IER1CAN EDITION. 25 some other, jwynient is made in proportion to his lessened earning capaeity. Tlie following table shows approximately the propor- tionate indemnity values in various injuries : Severe head iiijm-ies, with concussion of the brain 50 ^ to 100 % Epilepsy 50 ^« to 100 % Slight head injnries which cause headaches and dizziness 30 5<; to 35 % Loss of one eye 25 ^'^ to 33j% " both eyes 100 % " an eye Mhen the other eye A\as already l)lind '. . . . 100 % Deafness in one ear ^^■ith partial deafness in the other (dynamite explosion) 40 % Crushing of chest with fracture of ribs, in- volving diaphragm and lungs 60 % to 75 % Rupture ; one side, 10 ;7^ ; both sides, \'i^/( . All ruptures preventing use of the aljdom- inal muscles 50 ^ Paralysis of the extremities following frac- ture of the spine. The allowance varies with degree of disability. Paralysis of one leg 70 % Pain in the back, diminishing working capacity .... 20 % Loss of all fingers and toes . 100 % Lo.ss of right forearm or ujjper arm .... 75 % to HO ^ Loss of left forearm or upper arm 66f % to 70 % ' ' a great toe 10 % " all the toes of one foot 20 % " one foot 35 f<^- to 50 % All affections of the lower extremities neces- sitating the use of a crutch or a cane . . 50 ^^ to 75 % This law insuring workmen against injury was origin- ally passed in 1884; since then it has received various revisions and extensions. It lays on pliysieians gener- ally the obligation to be familiar with traumatic cases, and it has proved to be a great stimulus to the study of this branch of medicine in Germany. And while the German working-man has derived nuich benefit from its wise provisions, German medicine has also profited by the 26 INTRODUCTION TO THE AMERICAN EDITION. means it offers for the observation of how the human body reacts to various kinds of injuries. The salient difference in the systems as applied in Ger- many and in this country is that the damages under the German law are determined by an harmonious principle applied whether the employer or the employee is negligent. Under the German method every factor except the extent of the injury is fixed and uniform. In the United States nothing is fixed except the abstract principles of law as set forth in the judge's charge to the jury. A hysteric girl, without responsibilities and without the capacity for self-support, may receive a verdict for some trivial mishap very much in excess of that given a working-man for in- juries which disable him for life. One of the wisest provisions of the German law is that the insurance allowance may be • diminished or increased according as the injured person gets better or worse with time. It insures justice to both workman ami employer, and practically does away with the question of exaggera- tion. In America, when the plaintiff gets his money his case is judicially at an end. His disease may become worse, but he is entitled to no further indemnity ; or his condition may improve without his being called upon to make any return of the proceeds. Yet the verdicts are notoriously capricious, often unjustly reflecting the sex and personality of the injured. The contingent fee system, so far as M'orkmen are con- cerned, is avoided by the German law. It is a system that tends to make the lawyer rather more than an advo- cate, and the physician rather more than an expert. These sometimes so far exceed the limits of their respective callings as to become partners with the litigant, whose poverty is the real cause of the system. It is but a step further to the " runners " and the merciless pursuit of injured persons who may iiave claims for damages to bring. The adoption in America of some such plan as the one that Germany has found feasible for the past six- INTRODUCTION TO THE A3IEBICAN EDITION. 27 teen years Mould unquestionably be mutually beneficial to both employers and employees. The middleman, it is true, would suffer, for the money which now goes to him would remain with the companies or would go to the maintenance of disabled wage-earners. Important as this question is in its sociologic and legal connections, its true inwardness, so far as the medical man is concerned, is in the added requirements that the promi- nence of traumatism in general pathology lays upon him. Now, as never before, it is imperative that every practi- tioner be familiar with the effects of injury on the body in health and in disease. To express the l)ranch of medical science which has to do with this relationship, the Germans, with their usual fertility of nomenclature, have created the term " Unfall- heilkunde." Unftdlheilkunde is not, of course, a distinct branch, such as surgery or ophthalmology. It is in one sense broader than any one branch, as it embraces them all ; and it deals with all from the common standpoint of injuiy as a cause. In this respect it can justly claim a place among the departments of medicine with distinctive characteristics. For example, in traumatic cases causes, both predisposing and exciting, demand special considera- tion. The first may have been acquired, or may have been transmitted through generations as mental or physical de- fects. Bodily infirmities, impairment of one or more of the special senses, mental deficiencies, diseases such as epilepsy or general paresis, — in short, anything and every- thing that renders the individual more exposed to in- jury or less capable of taking care of himself, — must be reckoned among the predisposing causes of traumatic diseases. Familiarity with exciting causes falls witliin the pro- vince of special workers. We turn naturally to the rail- way surgeon for detailed information as to the physical effects of railway injuries, to the ophthalmologist for an intimate knowledge of traumatic lesions of the eye, and to 28 INTRODUCTION TO THE AMERICAN EDITION. the neurologist for an exj)]anation of the ]x'culiar disorder.s of recent date, known as the traumatic neuroses, which so frequently result from the combined influence of })]iysical injury and nervous shock. It must not be forgotten that the relationship between traumatisms and disorders that are not inmiediately surgi- cal is often very obscure and difficult of demonstration. In many cases the relationshij) is incontestable, though how it is brought about is uncertain ; in others it can hardly be said, from our present knowledge, to be more than probable. This is especially the case wdien there is a long time-interval between the receipt of the injury and the first appearance of symptoms. Diagnosis in traumatic cases means much more than a simple recognition of the particular injury or disease that has an accident as its starting-point. It means the type of man affected by it quite as much as the injury itself, for what in one individual would be little more than an inconveni- ence would in another be a cause of death. Diagnosis, therefore, implies an estimation of the resistance of the individual quite as much as of the extent of immediate injury ; and the ability to estimate resistance implies not only a knowledge of general physiology, but also a famil- iarity with the social, familiary, and personal conditions that favor or discourage the processes of recuperation and rej)air. It is the ])hysician who considers the problem l)efore him from this point of view who will most often find his prognosis verified by subsequent events. The question of simulation naturally comes up under diagnosis. It is one with which the surgeon has little to do. A man can not simidate a l)roken leg, and self- inflicted disfigurements and mutilations, while occasionally heard of in armies and prisons, are rarely, if ever, at- tempted in personal injury claims. In the obscurer internal diseases, and es]iecially in those afl^ecting the ner- vous system, simulation may be, and sometimes is, suc- cessfully carried out ; but even in nervous diseases the INTRODUCTION TO THE AMERICAN EDITION. 29 subject has received more prominence than it deserves. Nearly all American and European writers agree that the creation of symptoms for the purpose of making money out of them is rarely met with. Golebiewski estimates simulation in German workmen at two per cent. Much has been written on the means of detecting simulation. It may be sunmied up in this : a definite organic type of dis- ease, — such as paralysis, — to be feigned in a way to de- ceive a physician who is careful, skilful, and reasonably resourceful, is practically impossible. On the other hand, there are diseases, such as epilepsy or neurasthenia, the existence of which can not be denied because the exam- ination of the patient is negative. In such cases, if the patient's story as to his symptoms is to be disproved, he must be kept under constant observation. In the United States such a course is always difficult and often impossible. The exaggeration of symptoms actually present is a much more important consideration in accident-cases than simulation. It is found especially in functional ner- vous diseases. No rules for the estimation of the degree of exaggeration in any given case are possible ; but the experienced physician is usually able to tell with a fair degree of accuracy how far symptoms are magnified, and how far the magnification is voluntary or unconscious, depending upon the personal peculiarity of the patient. The medicolegal relations of diseases caused by acci- dents form the most important department of " Unfall- heilkunde." They are the sum of all the considerations previously mentioned, plus their position in law. In es- tablishing them, account must be taken of the individual's previous earning capacity ; of his predisposition ; of the suffering through which he has gone, as well as that which is still in store for him ; of his actual incapacity, and the probability of its increasing, remaining stationary, or be- coming less. These and many other questions must be considered from a purely medical point of view, for it 30 INTRODUCTION TO THE A3IERICAN EDITION. lies beyond our province to enter into legal questions, although every physician who has to do with traumatic cases would profit by a knowledge of law. Enough has been said to show the importance and diffi- culties of the study of these cases. The life of a science, as of a people, is quickly mirrored in its literature, and medical literature has not failed to respond to the demand for collated and progressive information concerning trau- matic diseases. The response has taken the form of various periodicals and numberless monographs, but the present book is the first to attempt a treatment of the whole subject. In the " Atlas and Epitome of Diseases Caused by Ac- cidents " Dr. Golebiewski has given, in brief and succinct form, the present knowledge of this important branch of medicine. As is shown by the number and variety of illustrative cases, his statements are based on an extensive personal experience, and the text embodies a comprehen- sive review of the literature. He treats the subject chiefly from the point of view of ultimate results, and has made an invaluable collection of facts to show the degree of functional disability that may be expected from a given injury. No department of medicine could adapt itself better to illustration, and the illustrations in the " Atlas " have been chosen with discrimination and executed with skill. The collection of skiagraphs is ])articularly valuable. It is a great pleasure to be afforded this opportunity of introducing the book to the English- speaking public. It is a reliable and graphic presenta- tion. To the general practitioner it should serve as a ready book of information and reference, and to the specialist, in addition to furnishing facts outside his im- mediate sphere, it should suggest new lines of inquiry. It should also have a wide field of usefulness in the legal profession. The anatomic and physiologic sum- maries at the beginning of the various sections, togetlior with the illustrations, should make the text intelligible to INTRODUCTION TO THE A3IERICAN EDITION. 31 nonmedical readers ; and a book with these qualifications, on this subject, will certainly be welcomed by lawyers. In preparing the American edition I have taken the liberty of omitting part of the German text and some of the cases, and of adding a few notes. For nearly all of the translation I am indebted to Dr. Marion McD. Grady. Pearce Bailey. New Yokk, June, 1900. PART I. I. GENERAL CONSIDERATIONS. I. THE CAUSES OF ACCIDENTS. The deteriuiuing causes of accidents may be conveni- ently divided intlying the muscle is injured as well, and neuritis or paralysis develops in consequence. In cases of severe crushing, both muscle-substance and skin are apt to be badly toru, and, as foreign bodies are frequently carried into the tissues, purulent inflammation often follows. A^'hen healing finally takes place, the muscle is left shrunken and partly replaced by cicatricial tissue which causes, in time, a contraction of the muscle and in certain cases a contracture of tlie whole limb. Massage, local steam baths, and medicomechanical exer- cises will act favorably on the cicatrices and the disturb- ances to which they give rise, even though a complete cure can not l)e effected. In some cases, however, all treatment fails to relieve the condition. The complications which we need to consider are lacer- ations of the skin and other soft parts and fractures of tlie bones. The muscles may be lacerated or pierced by frac- tured bones. A discussion, however, of these injuries will not be entered upon at this time. When the skin is also pierced, a hernia of the muscle may result, but this may cause no functional disturl^ancc. Partial lacerations due to falls, kicks, and similar accidents can not be dis- tinguished from the contusions and crushings already men- tioned — the diagnosis of muscle-laceration often serves for either of the other conditions. The phrase " muscle strain " denotes slight lacerations of the muscle-substance caused l)y indirect violence. The injury may be looked upon as an early stage of serious 48 DISEASES CAUSED BY ACCIDENTS. subcutaneous ruptures. The latter are most frequently- seated in the biceps of the arm, but may occur also in the muscles of the calf, the upper part of the thigh, and the abdomen. The injury is caused by the forced contraction of a muscle while the limb is in violent motion, as in parrying blows, for instance. In consequence of the retraction of the torn ends of the muscle quite a broad gap may be left between them, and often remains as a perma- nent defect, unless the muscle is repaired by operation. Tlie degree of atrophy of the muscle and the loss of power depend upon the extent of the injury. The point of rup- ture can most readily be distinguished when the muscle is contracted or put on the stretch. During contraction it appears as a ball-like mass, especially n^ cases the term includes a fracture as well, and in con- sequence of the extreme strain upon the ligaments at the time of the accident, a bit of the bone is not infrequently torn off at one of their points of insertion. Sprains are apt to heal more slowly than simple contu- sions of the joint. In many cases the result remains unsatisfactory in spite of a long course of treatment. This is sometimes due to the development of tuberculosis, sometimes to the existence of a subluxation that has occurred subsequently to the original injury. Poor results are in some cases to be ascribed to too prolonged a use of fixation-l)andage, which leads to partial ankylosis. Loose-jointedness is another evil sequel of sprains that is occasionally met with. The condition may depend on the laceration of a ligament or of the capsule, or on the fact of a bit of bone or cartilage having been pulled off by a liga- ment, wiiich remains unattached in consequence. The loose bit of bone or cartilage acts as a foreign body in the joint, causing great pain at times. The treatment of sprains is the same as that for contu- sions ; muscular atropliy and stiffness of the joints demand after-treatment, and loose-jointedness is to be overcome by the restriction of a suitable bandage. 72 DISEASES CAUSED BY ACCIDENTS. (c) Dislocations of Joints. While in case of sprains the articular surfaces immedi- ately right themselves, in dislocations they remain sepa- rated after displacement until artificial reduction is prac- tised. The separation of the articular surfaces is neces- sarily associated with more or less extensive laceration of the capsule and ligaments. The laceration of the capsule, at all events, is a regular accompaniment of a dislocation. Blood-vessels, and very often branches of nerves, are torn, while pieces of bone are chipped off at the same time, in which case the term luxation-fracture is perfectly a]ipli- cable. The swelling that takes place in consequence of a dislocation may not be ap})reciably greater than that seen after sprains. The degree of force required for the reduction of a dis- location often exceeds that which produced the injury ; the process of reduction, therefore, is not unattended by danger. The capsule and ligaments may be further lacer- ated, bits of bone may be chipped oflP, or nerves may be torn. After reduction the joint and the neighboring tis- sues appear swollen. Swelling and ecchymosis are still seen at the time when the fixation-bandage is removed ; and if the part has been kept immobilized for any length of time, the nearest other joint of the limb will show only limited mobility, while the aflPected joint itself is completely stiifencd. When the shoulder-joint has been thus treated, for instance, tlie arm, after removal of the bandage, will be found to be fixed at the annle at which it was held, while the moljility of the elbow is restricted. The muscles about the joint, as well as those extending over the next joint, are seen to be ati'ophicd. In case of injury to the nerves, paralysis of the parts supplied by them will become evident, the permanence of the paralysis depending on the severity of the injury. Mobility of the joint can often be restored by treatment ; in many cases, however, partial ankylosis is caused by cicatricial contrac- SUBLUXATION. 73 tion of the lacerated capsule. The limb necessarily assumes an abnormal position in consequence of these contractions of the capsule ; the muscles and tendons become disj)laced and undergo atrophy. Occasionally, the position, by indi- cating the point of rupture of the capsule, gives a clue to the variety of the dislocation. In favorable cases the ankylosis can be overcome by treatment ; in others, it remains permanent. Sometimes, instead of ankylosis we have hypermobility of the joint — loose-jointodness. The principal therapeutic indication is the recovery of normal mobility, which condition is best achieved by means of passive and active exercise, carried out by the operator and on an appropriate apparatus. The atrophy is overcome at the same time. Massage is helpful for the atroj)hy, but is of little use in the end unless mobility of tlie joint is regained. Exercise, massage, and, above all, electricity, are to be recommended for the paralysis. Hypermobility must be treated by means of a suitable bandage. Subluxation. This injury frequently escapes diagnosis, and being dis- missed as a contusion or a strain, the displacement is not reduced. In other cases an even more harmful blunder is made : that of diagnosing a fracture of the joint and immobilizing the latter. Hence, the consequences of sub- luxation are apt to be serious. While the joint remains swollen, it is difficult to recognize the displacement ; as the swelling goes down, the displacement becomes more and more evident. Diagnosis is less difficult in the more severe cases that approach complete dislocations ; and in these reduction is, of course, practised. In some situa- tions — in the knee-joint, for example — a subluxation closely resembles a healed fracture of the condyle. The characteristic signs of subluxation are as follows : There is mutual dis]ilacement of the articular surfaces, varying in degree. The surfaces remain for the greater 74 DISEASES CAUSED BY ACCIDENTS. part in contact with each other ; the displacement may be entirely lateral or it may be partly rotatory, the muscles and tendons connected with the joint being disi)laced accordingly. The appearance of the joint is changed : it is enlarged, and its outlines, depressions, and folds are less marked than normal ; the muscles with which it stands in relation have atro})hied. The joint is usually flexed. Mobility is impaired ; it is, however, never entirely lost. IVIotion is painful, the pain having a lasting character. The joint may remain in a state of inflammation for a long time ; massage and exercises, unless very cautiously em- ployed, are apt to increase and to prolong the disturbance. As regards treatment, the first aim is to subdue the inflammation by means of rest, favorable position, and compresses. Afterward, when the exact relation of the articular surfaces has been clearly determined, exercise may be begun with great caution. I have found move- ments of resistance to gradually increased force to be especially valuable. If the pain grows worse, exercise should be curtailed. Muscular atrophy is treated, as usual, with massage and electricity. The results of treat- ment are often excellent, but not in all cases ; the condi- tion of the patient is often only })artly relieved by a long course of treatment, and sometimes the pain is not in the least subdued. Fractures of Joints. The prognosis for fractures involving joints is much less favorable than for fractures of the shaft of the bone. The reason for this lies in the structure of the joint itself. The articular cartilages, lined with synovial membrane, are fractured no less than the bone, and an inflammatory exudate is poured out into the joint. The most urgent indications, therefore, are to allay the inflannnation and to cause the absorption of the exudate and the union of the fractured parts. All energetic mechanical treatment hav- ing for its design the preservation of function in the joint must, therefore, be delayed. Under these conditions it is FRACTURES WITH DISLOCATION. 75 often quite impossible to prevent permanent ankylosis, especially when muscular action causes dislocation of the fractured parts of the joint. It is advisable, in view of the foregoing, to begin careful passive movements of the joint at the earliest possible moment — as soon, in fact, as the inflammation and exudation subside. Certain active movements are also permissible. The prognosis is more favorable for fractures that occur in the vicinity of the joint but do not actually involve it. The prevention of ankylosis in these cases is a less diffi- cult matter, but there are a number of causes that lead to it, nevertheless. Sometimes the inflammation extends to the joint, or there may be a dislocation of the latter sec- ondary to a similar complication at the point of fracture ; in other cases the continued immobilization of the joint necessitated by the treatment in itself suffices to produce ankylosis. The limb is often fixed at an angle. A dislo- cated and ankylosed joint is of unfavorable prognosis as to function ; but if movement can be begun early, it is often possible, with patience and unremitting attention, to overcome the adhesions. Fractures with Dislocation. This double injury occurs with comparative frequency ; it is seen in classic form in fractures of the vertebrae, espe- cially in the cervical and lumbar regions ; of the joints of the extremities, the elbow is the one most liable to be in- volved. The prognosis depends almost entirely on the skill shown in reduction and fixation. If improperly treated or if left unreduced, complete ankylosis is sure to follow. If by refracturing an ankylosed joint it can be fixed at an angle more favorable to the usefulness of the limb, the operation sliould be strongly urged. An arm fixed at a right angle at the elbow, for examj^le, is a comparatively useful member, while it is less and less so the straighter it becomes. 76 DISEASES CAUSED BY ACCIDENTS. Traumatic Arthritis. This develops as a result of contusions, sprains, and dislocations, of fractures not only of the joint itself, but occurring in its immediate vicinity, and of cellulitis, etc. Arthritis is often to be regarded as a symptom of one of the injuries enumerated ; the prognosis is generally favor- able for a ra])id recovery, but with advancing years there is a tendency for the acute inflammation to develop into a chronic form. In chronic arthritis the joint is enlarged and there is a proliferation of the synovial folds of the cai3sule, which causes the well-known cracking sounds on motion. In some individuals there seems to exist a ten- dency toward such proliferation. Chronic arthritis is not, as a rule, painful ; nor does it interfere to any marked extent \vith the mobility of the joint. If the inflammation becomes tubercular or purulent, however, or if it is super- seded by an arthritis deformans, the case is thereby given a serious aspect. Articular Rheumatism, Gout, and Arthritis Deformans. Traumatism may act as the indirect cause of acute articular rheumatism by lowering the resistance of the joint, thereby rendering it more susceptible to attack by the cocci of the disease. The question of the traumatic origin of gout can be similarly explained. It is beyond doubt, on the other hand, that arthritis deformans can develop as a direct sequel of traumatism. While fractures are the most com- mon form of injury leading to the disease, it may also develop after contusions, sprains, and dislocations. Being a chronic disease, it develops slowly ; yeai's may elapse before the deformity that it causes reaches an extreme degree. The synonym of *' arthritis pauperum," which is applied to the disease, is doubtless based on the fact that it is most frequently seen in working-men who do hard work and live poorly. There is no doubt that the TUBERCULAR ARTHRITIS. 77 development of arthriti.s deformans is favored by the eifects of hard labor, especially when undertaken too soon after an injury, l)efore the joint has completely recovered, in combination with lack of care and poor and innutritions food. The injuries, whether of trivial or serious nature, to which the joint is exposed during work or at other times are also of etiologic importance. A joint aifected by arthritis deformans gradually be- comes misshapen ; its power of motion is diminished, and in the end is completely lost. The articular ends of the bone in a well-developed case are in part atrophied, in part covered with hypertrophic processes, while ligaments and tendons have undergone ossification — a condition that is well expressed by the term osteo-arthritis. The disease entails a great deal of suifering at times, especially aggra- vated by the presence of free ossified nodules in the joint. The prognosis as to usefulness of the joint is very bad ; the disease is incurable, although some relief may be gained by means of baths, compresses, inunctions, and rest. Massage should not be attempted. Affected indi- viduals can not do heavy work, but are often able to per- form light tasks. Tubercular Arthritis. By causing inflammation of a joint, traumatism may be indirectly responsil)le for the subsequent development of tuberculosis in tlie same. There are two Avays in which infection of the joint may occur : In a tubercular individual the tubercle bacilli may, by the process of metastasis, establish themselves at the site of injury, the resistance of the tissues having been lowered by in- flammation ; or there may be a primary tubercular arthri- tis as the result of infection subsequent to the injury. Tubercular arthritis is more frequently observed after comparatively sliglit injuries, such as contusions and sprains, than after those of a more serious nature, such as fractures. As fractures, however, are doubtless over- 78 DISEASES CAUSED BY ACCIDENTS. looked ill many cases of so-called sprains, their probable influence on the development of the tubercular process must be admitted. I have myself observed a number of cases of tubercular artliritis following fracture. Con- ditions favorable to the development of tuberculosis pre- vail among working people, who do hard work and eat poor food, and scarcely enough of that, while they drink regularly and to excess. They live from hand to mouth, are frequently out of work, and at such times are likely to drink more heavily tlian usual. The dwellings in which they live are poorly built, and are frequently infected with tubercle bacilli, while tuberculous and healthy mem- bers of a family live together in close companionship. It is not to be wondered at that a vigorous working-man who is confined to his room for a time by a sprained ankle, for instance, should, under such conditions, develop a tuber- cular arthritis. Its development is favored, moreover, by a too early use of the injured joint. Tubercular arthritis is characterized by its slow course and its resistance to all methods of treatment. When it develops in consequence of an injury, it is not easily recog- nized in its early stages, and considerable time — in some cases as much as a year — may elapse before a positive diagnosis can be made. The symptoms pointing to the disease are pain, swelling, and diminished mobility of the joint, with gradual changes in its shape. The general health deteriorates at the same time, and the patient loses flesh ])erceptibly. Tubercular arthritis can be diagnosed by means of X-ray photographs before the general symp- toms become apparent. The time required for the development of the disease after the occurrence of the injury is variable. The pro- cess may begin as soon as the acute symptoms of the trau- matism subside, or it may not appear for years afterward. In one case of dislocation of the scaphoid that was under my observation five years elapsed before the tuljcrcular process, which attacked the whole tarsus, became evident. RESECTION OF JOINTS. 79 It is hardly necessary to state that the prognosis of tubercular arthritis is unfavorable. We must not be mis- led by occasional remissions during which the swelling and pain somewhat diminish, for the disease is very liable to crop out in another spot, which it reaches by metastasis. In treating cases of tubercular arthritis we should strictly avoid all active mechanical procedures, such as massage and movements of the Joint, since by these the inflammation is aggravated. Good nourishment and favorable surroundings are the best therapeutic agencies. Arthropathy. The affection of the joints that occurs in syringomyelia, and more especially in tabes, under the name of arthrop- athy, may be directly caused by traumatism. The bones that are affected by the diseases just named become so fragile that the ankle-joint, for instance, may be fractured by a wrench due to a misstep. There is an excessive growth of callus in these cases, leading to deformity of the joint. In tabetic patients the callus is quite characteristic of the disease. In respect to treatment, we are powerless to do more than relieve the condition of the patient to a certain extent ; results in this limited field are often quite satis- factory. Resection of Joints. The most important points connected with ankylosis and loose-jointedness have already been discussed. It remains to mention the conditions that follow resection. As a result of the operation we may have to deal Avith a rigid joint, a loose joint, or a newly formed mobile joint. The chief objects of the operation are to remove the dis- eased or useless portion of a joint and to leave the part in as serviceable a condition as j)<)sslbl('. If a stifl' joint is to be provided, it is to a certain extent in the power of the surgeon to fix it in the most advantageous position. If, 80 DISEASES CAUSED BY ACCIDENTS. because of the removal of a large portion of the joint, the operation results in loose-jointedness, the usefulness of the limb is, as a rule, greatly impaired. A workman in excel- lent health, whose case I have observed for about nine years, has an elbow-joint in this condition. He is obliged to wear a jointed support, l)y the aid of which he is able to move his arm a little ; without it, the arm hangs help- less at his side. Only a very liinited degree of motion can be expected after resection, but it often suffices to facilitate the use of the limb as a whole. 12. THE INFLUENCE OF TRAUMATISM ON THE DEVEL= OPMENT OF TUMORS. Among the malignant tumors that belong under this heading there are only two that demand our special atten- tion : namely, the carcinomata and the sarcomata. [For a very instructive clinical and ])athologic study on the in- fluence of traumatisms in the development of sarcomata, see W. B. Coley's article on " The Relation between Injury and Sarcoma," " Annals of Surgery," March, 1898. — Ed.] The process of development differs in the two varieties of tumor. In some individuals the irritation and inflam- matory reaction following traumatism seem sufficient cause for the development of a sarcoma in hitherto normal tissue. A carcinoma, on the other hand, finds its starting-point in scar-tissue ; whether this has grown as the result of trau- matism or of disease is a matter of no conse(|uence. Constant irritation or repeated traumatism may so aflect the scar-tissue as to cause or favor the development of carcinoma. Traumatism may, furthermore, hasten the development of a growing carcinoma, or it may lead to sudden death by loosening bits of the cancerous tissue, which are then carried into the circulation. The dangers involved in the growth of carcinomata do not need emphasis. In respect to sarcomata, it should be CASES OF POISONING. ■ 81 remembered that when they develop in bones, the hitter become extremely liable to spontaneous fracture. Mention of cases of carcinoma and sarcoma for which insurance was allowed, traumatism having- been recognized as the indirect cause of the disease, can be found in the annals of the State Insurance Bureau. 13. CASES OF POISONING. Accidents due to poisoning are included in the list of accidents for which, according to the Accident Insurance Law, payment of insurance may be demanded. The poi- soning of miners l)y carljon monoxid, or of watchmen in new buildings by the same gas, poisoning by benzol and benzin, poisoning en masf^e by chlorin or by the fumes of petroleum products, are all instances of such accidents. We have not space to discuss the symptomatology of such cases. The law applies more especially, however, to cases of poisoning incidental to employment in special trades and manufactures, which are really better looked upon as diseases peculiar to such trades. Alcoholic Intoxication (Chronic Alcoholism). Alcoholic intoxication is so wide-spread an evil among working people that it deserves some discussion here. The evil is so firmly implanted in all grades of society that it may well l^e regarded as a national disease. Alco- hol is thought by working-men to be a proper and essen- tial article of diet. It is not in place here to cite statistics relative to the consumption of alcohol and the conse- quences of the same. We should, however, bear its effects in mind, especially as they relate to the causation of injuries, and as they influence the prognosis. Acute alcoholic intoxication unquestionably leads to many acci- dents. Chronic alcoholic intoxication, or chronic alcoholism, plays no less important a part in the etiology of accidents, 6 82 DISEASES CAUSED BY ACCIDENTS. entailing, as it does, a loss of power of body and mind, thereby rendering the individual more liable to injury. Chronic alcoholism does not necessarily imply frequent drunkenness. The regular daily consumption of small quantities of alcohol, especially in the form of whisky, very often suffices to cause the disease in individuals who have never been drunk in their lives. Nor does it always depend on the amount regularly consumed : weak, ill- nourished, or nervous individuals, or those in whom there is a hereditary predisposition, develop symptoms of alco- holism after taking relatively small quantities, and in much less time than others of naturally strong constitu- tion. The cumulative action of alcohol is easily under- stood if we remend)er that traces of the poison can be demonstrated from three to seven days after its introduc- tion into the system on a single occasion. Considering that alcohol is taken regularly into the system for years, as is the custom among some working-men, who, more- over, live poorly, and often suffer deprivation, the development of the synq)toms of chronic alcoholism at one time or another seems unavoidable. The symptoms of the disease are manifold, and consist chiefly of patho- logic changes of various organs, as follows : 1. The nervous system, including : («) Central disturb- ances (delirium tremens, paranoia, ])aralytic dementia, epi- lepsy). [This statement should be somewhat qualified. Alcoholism, complicated or uncomplicated by traumatism, may cause an almost endless chain of mental symptoms ; but it can hardly be said to cause either paranoia or para- lytic dementia. Epileptiform convulsions also, when in- duced by alcohol, ditfer in important particulars from true epilepsy. All three of these diseases are essentially incur- able, whereas in the majority of cases symptoms caused by alcohol disappear upon the withdrawal of the poison. — Ed.] (6) Peripheral disturbances (alcoholic neuritis). 2. The circulatory system. 3. The respiratory tract. I INFECTIOUS DISEASES. ^ 83 4. The digestive tract. 5. Muscular system. Any one group of symptoms may predominate in a given patient. It would lead us too far to enter upon a discussion of the far-reaching symptomatology of the dis- ease. ]\Iany diseases of the nervous system, including those of traumatic origin, display symptoms similar to those of chronic alcoholism, which may, in fact, be the underlying cause of these same nervous diseases. We need only to study insane and criminal statistics to appre- ciate that alcoholism is responsible for the development of many mental diseases. A regular consumption of alcohol leads also to heart-disease, while its evil eifects can be directly or indirectly traced in the history of cases of pul- monary tuberculosis, gastric ulcers, diseases of the liver, kidneys, and other organs. We frequently meet with some of these conditions in patients we see in accident-practice. In examining a patient after injuries it is not only valuable, but usually quite essential, before forming an opinion of his case to ascertain his habits regarding the use of alcohol. It is a good plan to question him as to his manner of living, to cause him to tell Avhat he eats and drinks, as in this way we gain a knowledge of his social status that may greatly influence our judgment of the case. 14. INFECTIOUS DISEASES. Traumatism may stand in either direct or indirect rela- tion to infectious diseases ; in the former instance the infectious material enters the body through wounds of the skin, which may be serious or ver\' trivial, as in case of phlegmonous inflammation following sligiit injuries of the finger. The same holds good of other infectious processes, such as malignant ])ustule, tetanus, glanders, and malig- nant edema. The relation between traumatism and infec- tious process is none the less direct when the infectious 84 DISEASES CAUSED BY ACCIDENTS. bacteria enter a wound some time after the injury. This occurs in cases of erysipelas, for instance. The very fact that the local entrance of the bacteria of the diseases pre- viously named presupposes the existence of a wound is suf- ficient evidence of itself of the direct relation that exists between traumatism and the infectious process. Tuber- culosis of the skin may develop similarly, as the result of direct implantation. We are, therefore, warranted in speaking of a tuberculosis of the skin of traumatic origin. The relation between traumatism and the infectious process is, on the other hand, an indirect one in cases of tuberculosis of the lungs and joints, in which the tubercle bacilli enter the body by way of the resjiiratory or diges- tive tract. Traumatism serves to lessen the resistance of the part on which it acts, which is, in consequence, subject to attack by the tubercle bacilli circulating in the blood. The bacilli of anthrax may enter the body through the respiratory and digestive tracts, as well as through wounds. According to the State Insurance Bureau, all such cases are regarded as accidents. Anthrax bacilli are found on the skin, wool, and hair of an animal suflPering from the disease, also on brushes made from such hair. The dis- ease develops as a local affection of the skin under the name of malignant pustule ; when it attacks the lungs or intestine, it is known as " wool-sorters' disease." Cattle and sheep are the animals most subject to the disease ; in human beings it is, therefore, most often seen in butchers, farmers, shepherds, tanners, brush-makers, and produce dealers. The incubation period of malignant pustule is three days. If it remains localized, it is curable ; but if infec- tion becomes general, the prognosis is very grave. Symptoms At first there is a small pustule sur- rounded by a reddened area. The pustule rapidly dries up, leaving a blackened scab. The surrounding tissue is much indurated. The induration spreads raj)idly until the whole extremity becomes the seat of an intense, brawny INFECTIOUS DISEASES. 85 edema. The lymph-nodes are swollen. If the course of the disease is favorable, the scab gradually separates and is thrown oif. Progressive edema and high fever are un- favorable signs : they are liable to be followed by delirium, diarrhea, rapid loss of strength, ending fatally within a week. Prognosis. — Ninety per cent, of these cases recover. Wool-sorters' disease, as the name indicates, affects those who spend their working hours in close contact with wool, and contract the infection by inhalation of anthrax spores. Persons handling infected skins and hides are exposed to the same danger. The symptoms are those of a septic bronchopneumonia ; anthrax spores can be dem- onstrated in the sputum. The onset is marked by a chill, fever rising to 40° C, soon followed by the low temperature of collapse. The subjective symptoms are headache, a feeling of oppression, shortness of breath, and great weakness. The most im])ortant objective symptoms are cyanosis, involvement of the pleura and lungs, cardiac weakness, and cold extremities. Death usually occurs in two days ; in five or six days at the latest. The prognosis is bad. Anthrax of the intestinal tract is characterized by a sudden onset, with intense diarrhea, vomiting, cyanosis, and collapse. The prognosis is bad. Tetanus (lockjaw) is caused by the tetanus bacillus, wdiich invades the body through a wound. The bacillus is found in the soil, in dust, in heaps of refuse, in manure, and in dung. It may be carried into the tissues by a splinter of wood or glass or may enter through any wound of the skin. The symptoms of tetanus may appear almost immediately after the injury, or the incubation period may last for days or weeks. In one case of my own the patient, a boy ten years of age, died in from one to two hours after receiving the injury, with characteristic symptoms of tetanus. He liad been running barefoot over a heap of refuse, and a small sliver of glass had en- tered his sreat toe. 86 DISEASES CAUSED BY ACCIDENTS. Symptoms. — Tonic convulsions, consciousness being retained. At the onset there is pain around the wound, and the patient is restless, sleepless, and anxious. There are aching pains and rigidity of the muscles of the jaw, pharynx, and neck, followed by tetanic muscular spasms. The drawn facial expression is characteristic. Pareses, and even paralyses, are said to be sequels of the disease. The prognosis is grave. Glanders. — This disease may, under certain conditions, also rank as an accident, as when the specific bacillus is carried into a wound by direct contact with an infected horse or ass. Acute glanders is fatal. The incubation period lasts from three to eight days, and is followed by symptoms of gastric disturbances, pains in the limbs, and a feeling of fatigue, Avhile characteristic nodules, and subsequently sup- purating ulcers, develop at the site of infection. A rash appears on the skin, and there is a sanguinopurulent dis- charge from the nose ; the fever increases, and death occurs in from one to three weeks. Chronic glanders is characterized by aching rheumatoid pains, lymphangitis, swelling of the glands, ulcerations, and moderate fever. There are successive crops of ab- scesses, first in one part of the body and then in another. The fever is moderate. The disease may last for months, or even for years. Malignant edema is an infectious disease of which the specific bacillus is found in soil that has been treated with manure, in dirt, in dust, and in drainage. The disease occurs in man in consequence of infection through a wound. The incubation period may be very short ; the edema may begin to appear at the site of the infection in from twenty-four to thirty-six hours. It extends to the surrounding tissues and leads to the formation of foul, decomposing ulcers. The fever rises and l)ecomes very high, and is accompanied by delirium. Death may occur within a few days. JNFECTTOUS DISEASES. S7 Tuberculosis. — Tuberculosis is the most important of all infectious diseases, being the cause of death in more than one-seventh of all cases. The agent of infection, the tubercle bacillus, enters the body, as a rule, through the respiratory organs, but may enter it by way of the diges- tive tract or the skin. Unhygienic dwellings, overcrowding, poor and insuffi- cient food, all act as predisposing causes ; a hereditary tendency is also of recognized importance. The disease is chiefly disseminated by close contact witli infected indi- viduals. It is not surprising, therefore, that tuberculosis is especially rife among working people. We find, in studying the relation between traumatism and tuberculosis, that an accident often awakens latent tuberculosis to local or general activity, or hastens the course of the disease when it is already fully developed. In treatino; accident-cases in tubercular individuals we often find the progress of the case materially influenced by the preexisting disease, and are obliged to modify both treatment and prognosis accordingly. Since diseased tis- sues furnish the favorite nidus for the growth of tubercle bacilli, it is not surjirising that tuberculosis is most liable to develop as a local process after traumatism. Tiie tuberculosis of skin and joints has already been discussed. In the part devoted to special structures we shall meet with many illustrations of its development in other parts of the body. PART II, I. INJURIES AND TRAUMATIC DISEASES OF THE HEAD. Anatom(>phi)siolo(/ic ConsiitJcrations. — The strengtli of the skull varies greatly in different imlividnals. When the cranial Iwnes are thick, severe blows often cause no serious symptoms. The l)ones may be so thin, on the other hand, that even a slight contusion proves fatal. In general, we must rely on the anatomic fact that tlie ))ones of the cranial vault are stronger than tliose at the base, and that the latter have many points of weakness that give way to e.xternal violencte. It is by no means necessary that every force acting on the skull should cause a fracture ; on the contrary, the skull is sufficiently elas tic to endure many blows and concussions without injury. But when the limits of elasticity are exceeded, fracture results. Since the brain is the center of many important vital functions, the question in every head injury at once arises as to whether there is a lesion of the brain or its membranes. For the understanding of many head-injuries it is accordingly of great importance to be familiar with cerebral topography. Plate I (from Bardele))en's "Atlas fur topogr. Anatomic") gives a very clear schematic representation of the centers lying on the lateral convexity of the lirain. From tl)e physiologic standfjoint the whole lateral convexity can be divided into two regions — an anterior and a posterior. The division is made by the fossa of Sylvius, by the poste- rior liml) of the Sylvian fissure, and by the postc^entral fissure. The anterior region is known as the motor region, since it gives rise to the pyramidal tract — the tract of vohintary movements. Irritation of this region causes involuntary contractions of the muscles of the opposite side, or, if the irritation is continued, convulsions (Jacksonian e]ii- lepsy). Destruction of this region causes crossed paralysis. Tims, for example, should a tumor develop in the upper extremity of both left central convolutions at the spot marked Bein (leg), — /. e., in the leg- center, — the pressure of the tumor would act as an irritant and would cause involuntary movements of the right leg. Since the irritation would also affect the neigli))()ring centers, the muscles of the right arm and of the right side of the face would l)e successively thrown into spasm : in other words, a, progressive Jacksonian epileptic attack would result. If, later, as the tumor grew, the paralytic action exceeded the irritative, a progressive paralysis of the right leg would ensue. 88 CEREBRAL TOPOGRAPHY. 89 lujuiy to the region marked Scliril't (writing) causes a loss of the luovemeuts used in writing, while the other movements of the arm are not interfered with. Similarly, injury to Broca's region causes a loss of those finer movements of the lips, palate, larynx, and tongue that are necessary for speech, while the coarse movements in these muscles are retained. The center for the coarser movements of the lips is situated in the region marked Mund (facialis) (mouth — facial uerve) ; that for the coarser movements of the tongue in the region marked Zunge (tongue). The center for the coarser movements of the palate and larynx is prol)ably behind the tongue-center. The motor, .speecli, and wiitnig centers are on the left side of the brain. The function of the corresponding regions in the left hemisphere is not known with certaiuty. Most motor centers are connected with the opposite side of the body only. Tlie centers for the trunk-muscles and eye-muscles are exceptions to tiiis, as both of these centers have connections for both sides of the body. It is to be especially emphasized that individual cerebral centers are not sharply defined, but overlie one another. The sensory region of tlie convexity is divided into three sections : 1. The region of the muscle-sense, in the superior parietal lobule. When this is destroyed on the left side, the patient is unable, vith closed eyes, to recognize the jiositiou of passive movements in the limbs of the right side. 2. The visual area, situated posteriorly to the parieto-occipital fis- sure. It is probable that the part of the visual area situated on the lateral convexity is e.spccially concerned with visual memories, and has nothing to do with sensations of sight. Destruction of this area leads to "mind-blindness" : /. e., the patient .sees perfectly well, ])ut is no longer able to recognize objects. The "reading" area belongs to the visual area. When destroyed, the patient can still see the letters, but does not recognize them. 3. The centers for hearing, taste, and smell, in the temporal lol)e. Injury to the parts marked Hiiren (hearing), Schmecken (taste), and Riechen (smell) causes disturbances in hearing, taste, and smell, most marked on the opposite side. Injury to the region marketoms of importance for many years ; according to some observers, periods as long as thirty years have elapsed before the symptoms of cerelu'al tumor be- came evident. Wounds of the head occur with comparative frequency. FRACTURES OF THE SKULL. 93 In the building trades and mining industry they are often the result of contusions. Wounds of the scalp l)leed very freely ; the hemorrhage is best controlled, after thorough cleansing of the wound, by aseptic or antiseptic dressings and tirm bandaging. Open wounds of the scalp are very frequently the seat of infectious processes, which constitute a special source of danger in this situation because of the venous connec- tion with the diploe and the sinuses of the cranium. Of the infectious diseases that attack the head, erysipe- las is the one with Avhich we most often have to deal. It is easy to understand how infection occurs if we consider the carelessness and uncleanliness shown by working-men in treating their Avounds. Erysipelas usually runs a favorable course, but occasionally it terminates fatally. Purulent meningitis is another complication of open wounds of the scalp. The prognosis is not unfavorable for this disease, as a rule, although death sometimes occurs in severe cases. If the cicatrix resulting from wounds of the scalp is superficial and moves \vith the scalp, it gives rise to no symptoms whatever. If there are deep attachments, how- ev^er, especially if reaching to the bone, serious disturb- ances may be caused. Compression of the nerve-branches leads to neuralgia, or even to epileptiform convulsions. Excision of the scar has effected a cure in a number of such cases. Mental diseases have been known to follow the cicatrization of wounds of the scalp ; a decided pre- disposition doubtless existed in all the individuals thus affected. Excision of the scar is stated to have effected a cure in these cases also. 2. FRACTURES OF THE SKULL. Of the 114 cases of fracture of the skull serving as a basis for this sectiou, there was fracture of the vault in 39 cases aud of the base in 25 cases. The results were as follows : 19 patients made a perfect recovery; of capacity for self-support 14 recovered 20% or less; 29 recovered more than 20%; while in 50 patients complete incapacity for self-support was diagnosed. The sequels were as follows : 13 were 94 DISEASES CAUSED BY ACCIDENTS. attacked by delirium tremens ; 6 became epileptic ; 8 became insane ; a large number were atTected by functional neuroses. There were 4 deatlis : one ilied of paralytic dementia ; two committed suicide ; one succumbed to tuberculosis. Fractures of the vault are always due to direct violence. The theory that the internal table of the bone regularly gives way first, and that it may be fractured even in cases in which the outer table escapes, has of late been disputed, and, in my opinion, not on good grounds. It is a fact that the internal table is more extensively fractured than the external in all cases in which the violence is applied to the latter. The reverse is true also. If the inter- nal table is first struck, — when a l)ullet passes through the skull in a case of suicide, for instance, — the point of exit in the external table is larger than that of entrance Fig. 1. in the internal table. If this statement is correct, we are justified in assuming that depressions of the skull after injury indicate a corresponding convexity of the inner surface of the inner table. Such a deformity on the internal table must necessarily affect the membranes of the brain, and through them the brain itself. Figure 1 (from Helferich's " Atlas of Fractures and Dislocations") de- picts the condition in question. In such a case as this compression of the part of the brain underlying the deformity is inevitable. It would be a grave mistake, however, to look upon every depression to be found on the surface of the skull as a pathologic depression, or to consider that a de- pression necessarily has an injurious effect on the brain. Apart from the fact that we may be misled by the sutures, which sometimes simulate a depression, it has been shown FRACTURES OF THE SKULL. 95 by X-ray photographs that depressions of the skull are more often diagnosed than is warranted by the actual frequency of their occurrence. It is also true that well- marked de])ressions occasionally give rise to no symptoms at all, as illustrated by the following case : -^o' Fig. 2. Figure 2 shows a depression of the skull, 2 cm. deep and 5 cm. long, situated at the upper part of the occipital bone. The .subject of the illustration was a man about tifty years of age ; in his twentieth year he was struck on the head by a block of stone weighing 3j kilos, which fell from the fourth story of a building. He was not attended by a physician and was ill ouly a short time. He never developed symptoms of any importance. Cases of this nature are, however, to l)e regarded as exceptions. As a rule, depressions of the skull give rise to definite symptoms, such as headache, dizziness, paraly- sis, epileptic convulsions, neurasthenic disturbances, etc. 96 DISEASES CAUSED BY ACCIDENTS. PLATE 2. Fig. 1.— Circular Depression and Scar in the Middle of the Forehead Following a Compound Fracture. A carpenter, fifty- four years of ai^e, injured on the '20th of IMareli, 1889, by the fall of a block of building-stone from a height of about fifty feet. He was un- conscious for four days. Subsequnit Symptoms. — Vertigo and pain in the scar. Complete in- capacity for self-support U]) to the 16th of June, 1891 ; from that date up to February 19, 1894, 50% ; from that date up to tlie beginning of 1896, 20% ; from that time on counted as fully capable of self-support, as he did not appear again for examination. Was a heavy drinker. Fig. 2. — Deep Scar and Opening in the Left Frontal Bone Following a Comminuted Fracture. A mason, thirty-one years of age, was injured on the 24th of October, 1894, by a IjIow on the forehead from a hammer (assault). Diagnosis. — Compound comminuted fracture of the frontal bone and severe concussion of the l)rain. The splinters of bone were re- moved in the hospital. SiprqHoms. — At first, dull headache ; later, dizziness on movement of the head ; feeling of pressure in the direction of the point of frac- ture on lowering the head, which ]»revented bending. Signs on Examinalion. — Decided ]Milsation, slight facial paralysis on the right side, dilatation of the right pupil ; pulse, 100. No ner- vous symptoms. Incapacity for self-supjiort since June 12, 1895, 80%. When there is an opening in the sknll due to trephin- ing, the pulsation of the arteries within the sknll ean be felt externally ; vertigo on stooping and a feeling of [)ush- ing and pressure in the direction of the opening are also notable symptoms. There may be paralysis and hysteric and neurasthenic symptoms in addition. The remaining sequels of fracture of the vanlt are similar to those that follow concussion, contusion, and compression of the brain and fracture of the base of the skull. Fractures of the base of the skull occur in the great majority of cases as continuations of fractures of the vault. They are due to indirect violence, and may be caused by blows on the head, by heavy objects falling on the head, or by falls — striking on the head, the buttocks, or even on the chin or the feet. Accordino; to the law of 'lab. ^' Fig.l. FuiJi. I.ilh . An.sl /-.' RoichhoUl, AMitchen . FRACTURES OF THE SKULL. 97 Arans, the lino of f nicture runs by the shortest route from the point at which the violence is applied to the base of the skull. It is, therefore, very important, in obtaining the history of the accident, carefully to note the point of external injury. Without entering into a description of the immediate symptoms of a fracture of the skull, it will suffice to men- tion hemorrhages from the nose, mouth, or ear, and hemat- emesis as symptoms ]K)inting to this lesion. The diagnosis becomes clear if at the same time sym])toms of concussion of the brain or of localized brain-lesions make their appearance. Fractures of the base of the skull are not necessarily accompanied by severe disturbances. Occasionally, there are so few symptoms at first that the lesion is overlooked. This foot is illustrated hy tlie case of a mason who. in falling from a scaffold, fractured his left radius and at the same time injured his head. There was, in addition, a hemorrhage from tlie left ear. He felt dazed for a time, but attributed this to the shock of his fall ; his attention was mainly turned to liis broken wrist. Later on he fre- quently complained of headache. Examination revealed left facial paralysis and a rupture of the left ear-drum, with deafness on that side. The subjective symjitoms that develop in the course of cases of fractures of the base are usually those common to all fractures of the skull. Objective symptoms may be mentioned as follows : Facial asymmetry, asymmetric position of the eyes, prominence of one eyeball, etc.; also ])aralysis of the cranial nerves. AVhile the facial nerve is the one most frequently affected, paralysis of the oculo- motor nerve and of the abducens, olfactory, and fourth cranial nerves is not at all uncommon. Paralysis of these nerves is not necessarily symptomatic of fracture of the base ; however, it also follows fracture of the vault com- plicated by concussion of the brain. The great importance of the question of involvement of tlie brain in all cases of injury to the head warrants a short discussion of the chief forms of injury of the brain 98 DISEASES CAUSED BY ACCIDENTS. PLATE 3. Fm. l.—Stone=carrier,Thirty=nine Years of Age, Fell Back- ward from a Scaffold on the i6th of January, 1895. /.'/V/^'Ho.s/s. — Com pound fracture ol'tho skull (t'roiitiil bone), fraoture of the nasal bone, of the right malar bone, and of the right side of the inferior maxilla, with concussion of the brain. The j)atieut was treated for thirteen weeks in the hospital ; tlien attended the clinic until July 20, 1896. On that day he committed suicide by hanging. Symptoms. — Severe headache ; l)uzzing in the head; feeling of im- pending danger ; dizziness on stooping even slightly ; flashing of light before the eyes ; dancing of letteis before the eyes on reading ; tooth- ache, especially during mastication. In the illustration the patient w^ears an expression of melancholy. A shallow depression is noticeable on the leftside of the tbreliead, or, rather, on the temple. The right eye, the i)upil of which is dilated, has a somewhat fixed gaze; the angle of the right inferior maxilla is distinctly thickened. The light eyebrow is higher than the left. The right na.solabial ibid has disap- peared. The scars on the right side of the forehead and nose are still red. Fig. 2. — Case of Left Facial Paralysis with Atrophy of the Left Side of the Face Following Fracture of the Base of the Skull. The face is somewhat asymmetric and the leit eyeball is sligthly prominent. A painter, twenty-live years of age, fell from a ladder on the 18th of June, 1889, at a height of a1)out twenty-one feet, striking on the back of his head. For six days he was unconscious, and was treated in the hospital lor eight weeks. For the first sixty liours there was a hemorrhage from the left nostril and the left ear, and exojjhthalmos on the left side. After consciousness returned a strong tendency to somnolence persisted. After leaving the hospital the patient was treated V)y massage and faradization of the left side of the face, as a result of which the exophthalmos and facial paralysis were much improved. The left eye could be closed at the end of three months. Remote Sympioms. — Objective: Facial asymmetry, atrophy of the left side of the face, slight left exophthalmos. Constant sjjasmodic con- tractions of the muscles of the left side of the face ; cicatrix in the left ear-drum. Subjeefive: Headache, sudden attacks of vertigo, espe- cially l)rought on by the entrance of foreign bodies into the left eye, and accomi)anied by the tendency to throw the head downward and to the right ; buzzing and ringing in the head and deafness. Later developments were: Unsteadine.ssof gait in the dark when in a strange place ; inability to lie on the left ear ; increase of l)nzzing in the head ; disturbed sleep ; and frequent attacks of conjunctivitis. Other- wise, the general health was good. Inca]iacity for self supjiort during time of treatment was reckoned at \0()'/r ; five months after the acci- dent, at 45% ; and later on, after resuming his trade, at 20%. Tab.:i. riffl ■ '•'.'/•' Lith. An.1t E Reichtwld. Aftinchen . I FRACTURES OF THE SKULL. 99 observed in conneetion with fractures. They are three in nuniher : Concussion of the brain (commotio cerebri), compression of the brain, and contusion of the brain. I . Concussion of the brain (commotio cerebri) occurs as one of the most prominent symptoms of fracture of the skull as well as of simple coniusions of the head. For a description of the immediate symptoms of concussion reference should be made to text-books of surgery. Of these symptoms, unconsciousness is one of the most important, implying, as it does, involvement of the cerebral cortex. It is accompanied by disturl)ances of respiration and of cardiac action, due to involvement of the medulla ob- longata. The face is pale, the ])upils scarcely react at all ; the pulse is slow and is so small and thready as to be hardly perceptible. This condition is soon relieved in mild cases, but in severe cases it persists for some time, and is further accompanied by vomiting and by involun- tary passage of urine and feces. Loss of memory (anniesia) is, in some cases, one of the most characteristic and important symptoms of the later stages of the disorder. Patients thus affected are likely to be unable to recall the occurrences immediately preced- ing the accident. Many patients, on the other hand, complain only of weakness of memory ; they are unable to remember orders, especially if somewhat complicated. Other subjective symptoms are : headache, vertigo (most marked on stooping, bending forward, or looking u})ward), insomnia, restlessness, etc. As objective sym])toms loss or weakness of memory, attacks of dizziness (Romberg's sign), symptoms of functional neurosis, and even paralysis of cranial or peripheral nerves may occur. Simulation is ()ft(>n attempted after concussion of the brain, as, indeed, after all kinds of injury to the head, even of the simplest nature. It is often very difficult to distinguish between simulation and the unconscious ten- dency toward exaggeration characteristic of neurasthenic and hysteric patients. 100 DISEASES CAUSED BY ACCIDENTS. Epilepsy occasionally occurs as a sequel to concussion of the brain — usually, it is true, in individuals in whom a strong hereditary nervous predisposition exists. It also occurs in alcoholic sulijects and in tliose who previously have suffered from syphilis. Of my 449 cases of injury to the head, G were followed by epilepsy. (For furtlier reference to epilepsy see p. 114.) Mental diseases must also be included among; tlie sequels of concussion of the brain ; they may be mani- fested immediately after the accident (primary traumatic insanity) or, more frequently, in a later stage of the lesion. According to Stolper's observations, mental diseases occurred twelve times in a total of 981 injuries to the head, or in 1.'22 ^ of the cases. The percentage in my own group of cases is exactly the same. Mental disease, liowever, may develop in consequence of injuries otiier than those involving the head. It may follow pcri|)heral injury, or, more especially in predisposed individuals, in- sanity may be the outcome of intense and long-continued excitement or of severe and constant neuralgic pain. 2. Compression of the brain may be caused by cere- ])ral hemorrhage, usually due to laceration of the middle meningeal artery ; or, less frequently, it may be the result of pressure from a fractured bone. Compression often occurs in combination with concussion. In respect to symptoms, a slow pulse, due to irritation of the pneumo- gastric nerve, is especially characteristic. In addition, the face is flushed, — in contradistinction to the pallor seen in cases of concussion, — the eyes are bright, and the pupils contracted. The patient is conscious and restless at first ; this condition is followed by one of depression. The patient l)ecomes unconscious, with ra})id pulse, dilated pupils, and irregular respiration. There may be paralysis and invohmtary passage of urine and feces. In fatal cases death soon ensues ; otherwise the symptoms begin to abate in severitv. Tlie secjuels are in part similar to those of concussion of the brain ; in part they are dependent on the manner of absorption of tlie hemorrhage. FRACTURES OF THE SKULL. 101 Compression due to depressed fracture is occasioually followed by cortical epilepsy, as shown by the folloAving case : A workman, thirty-two years of age, was caught under a falling wall, and sufl'ered, among other injuries, a fracture of the occipital hone. After healing a deep depression was left in the bone, which was much thickened at the point of fracture. About eighteen months later the patient developed epileptic attacks and mental dis- turbances. He is often obliged to enter an insane asylum for treat- ment. 3. Contusion of the brain may be caused by a sudden depression of the bone, which may resiune its normal shape immediately after the injury, or by the penetration of a splinter of bone into the l)rain-substance in cases of fracture. Since the lesions thus caused are in alrao.st all cases distinctly localized and limited, the symptoms, of course, correspond, being characteristic of cortical lesions entailing a loss of certain specific functions. (Compare Plate 1, with remarks.) The subjective symptoms to be observed in the later stages of the affection are similar to those of concussion of the brain and of functional neuroses — headache, ver- tigo, weakness of memory, etc. The objective symptoms, also, may resemble those of the functional neuroses or those due to diseases of the brain involving anatomic changes in the latter. The lesions of the cerebellum deserve special consider- ation ; of the symptoms to which they give rise ataxia is the mo.st prominent. Thiem mentions the following symptoms : (1) Occipital |)ain, with stillness of the neck. (2) Vertigo ; unsteady juovements in arising. ('>) Xausea and vomiting. Among other sequels of injury to the brain, two call for discussion here : (1) Diabetes, (2) apoplexy. Diabetes may follow injuries to the head as well as mental excitement or severe physical shock (as in railway accidents, for instance). The symptoms are loss of flesh, furuneulosis, sexual im- 102 DISEASES CAUSED BY ACCIDENTS. PLATE 4. Fig. 1. — Case of Severe Comminuted Fracture of the Skull. Extuiiinatioii reveals ptosis ami iutenial stial)isnius. The patient is markedly delicieut iu intelligence ; shows criminal tenden- cies ; has been imprisoned a number of times. The stupid expression of tlie face is very apparent. Fig. 1 a. — Showing Cicatrix of Figure i. The pulsation of the vessels is clearly percei)tible through the opening in the Ijoue. A workman, twenty-three years of age, was injured by being struck on the liead by a piece of iron. Was in hospital for two mouths. Began to work in three months, but was compelled to stop on account of headache. Entered hospital again and was trephined. Later Symptoms. — Headache, vertigo, frequent spasmodic contrac- tions of the muscles of the calf, epileptic convulsions. On stoopiug, feels pain, running froui the back of the head to the foi'ehead. Memory is weal^. Fig. 2.— Cicatrix, with Long and Rather Deep Depression in the Bone, Located on the Left Side of the Skull. The cicat- rix commences at about the upper angle of tlie occipital bone. A. M., stone-carrier, thirty -three years of age, was struck ou the head on the 13th of April, 1887, by a building-.stoue that fell from the fourth story. The lesion was a compound fracture of the skull caus- ing paralysis of ))oth the upper and lower right extremities. After removal of a piece of the l)Oue the i)aralysis was relieved, except as to the fourth and fifth lingers, in which muscular weakness and a feeling of numbness persisted for a considerable period. A slight weakness also remained in tlie foot. The patient was a heavy drinker. At first his incapacity for self-support was reckoned at 100% ; on the 18th of November, 1888, it was \V.i\//c ; ou the 29th of December, 1889, his capacity for self-support was fully reestablished. About one year later epilepsy developed, accompanied by mental disturljances. Fre- quent institutional treatment was necessitated. Incapacity, 100%. potence, etc. The symptoms do not differ in the least from those of diabetes of nontraumatic origin. Apoplexy may be directly caused by traumatism of the head, esi)ecially when there is concussion of the brain. In the great majority of cases, however, apo])lexy can not rank as an accident. The individual attacked by apoplexy falls suddenly, and in so doing suffers an injury of the head on account of which insurance can be recovered. Such an injury may make it very difficult to decide whether the apoplexy is the result of the foil or vice versa. Tab A. Fuj.1 FajP Fig. 2. ]jll, in.! !■■ Ri'iilihohl Miuirlirn THE BRAIN AND ITS MENINGES. 103 The treatment of injuries of the head must necessarily l)e syniptoniatic. Psychoses demand general treatment ; drugs will nevertheless be tmjuently found necessary. For headache the bromids, antipyrin, phenacetin, and sali- cylic acid can be employed ; for neuralgic pain, niorphin ; for insomnia, sulphonal will prove useful, etc. Galvaniza- tion of the head (anode, one or two milHamperes, for about one minute) or the use of static electricity is often followed by good results. The same may be said of hydrotherapy. Medicomechanical exercises have an excellent effect on digestion, sleep, mental condition, and the general health. A stay in the country is very beneficial. It is advisable to settle the matter of insurance-rate as soon as possible. The length of time required for after-treatment de- pends largely on the age of the patient ; as a rule, young })ers(Mis recover much sooner than older patients. As far as my own cases are concerned, the younger individuals were able to return to work in from four to six weeks, while at least as many months were required for elderly patients. It is also a fact that elderly patients are very unwilling to resume work, and some never do so at all, while young people usually take up their trade again very soon. 3. TRAUMATIC DISEASES OF THE BRAIN AND ITS MENINGES. Inflammation of the Dura Mater; Pachymenin- gitis. — The lesion in pachymeningitis consists of a mem- branous thickening of the dura. This thickening is liable to be the seat of interstitial hemorrhages ; it may involve either the external or the internal surface of the dura. It is stated that pachymeningitis is the form more frequently observed ; both forms occur usually in connection with other diseases of the brain and its meninges, rather than as separate diseases. Pachymeningitis may be caused by traumatism — by contusions or fractures of the skull, for -instance — complicated by hemorrhagic extravasation be- 104 DISEASES CAUSED BY ACCIDENTS. tween the bone and the dura or between the two layers of the dura itself. Pachymeningitis is often observed as an accompaniment of paralytic dementia, but the cause most frequently underlying the disease is chronic alcoholism. The symptoms are apt to be overshadowed by those of the disease of the brain with which the pachymenin- gitis is connected. They consist of headache, vertigo, unilateral epileptic spasms, paralyses, optic neuritis, and fever. In chronic cases the chief symptoms are contin- uous dull headache, vertigo, and mental dej^ression. The treatment is symptomatic ; ice-bags, blood-letting, and the use of bromids may be mentioned. Incapacity for self-support, from 50 to 100^. Illustrative Case. — A stone-carrier, forty-five years of age, fell from a ladder on July 20, 1888, striking his head against an iron heam. Lesion : compound fracture of the frontal bone. On October 16, 1888, I made an examination and found the cicatrix attached to the frontal bone. The patient complained of severe headache and of dizziness. In view of the fact that he was a subject of chronic alcoholism, I made a diagnosis of pachymeningitis. His incapacity for self-support was 50%.' 4. TRAUMATIC INFLAMMATIONS OF THE PIA MATER. Leptomeningitis. — Leptomeningitis usually takes the form of a diffuse sii})})urative inflauimation, following in- fection through the wound of a com])oimd fracture, or excited by extension from an erysipelas of the scalp of traumatic origin. Symptoms. — Headache, partial loss of consciousness, delirium, somnolence, vertigo, hyperesthesia, vomiting, fever, rigidity of the muscles of the neck, disorders of the cranial nerves (o]>tic and facial nerves), loss of pupil- lary reflex, inequality of the jnipils, ptosis, and strabismus. Tubercular basilar meningitis of metastatic origin may also develop after traumatism of the head. Its symptoms are headache, vomiting, delirium, convulsions, fever, somnolence, rigidity of the muscles of the neck, aphasia, and paralyses. I TUMOR OF THE BRAIN. 105 Hemorrhage of the brain is caused by the rupture of a cerebral artery ; the middle cerebral artery is the one most subject to this accident. As a rule, rupture occurs in arteries affected by arterial sclerosis or at the seat of a small aneurysm. Cerebral hemorrhage is, therefore, most frequently observed in cases of chronic alcoholism or chronic lead-poisoning. (Compare with a[)oplexy.) Causes. — Severe muscular strain, mental excitement, fright, acute alcoholism, and, occasionally, traumatism. The symptoms are similar to those of apoplexy. 5. ABSCESS OF THE BRAIN. This lesion may follow an injury to the skull or it may be secondary to another infectious process, such as puru- lent meningitis, caries, etc. The abscess may be located directly under the injured spot, forming a superficial corti-' cal abscess, or the pus may become encapsulated, causing no symptoms for many years. Even ten or twenty years may elapse, and the injury may be quite forgotten, when suddenly there is a violent outbreak. [It should not be forgotten that cerel)ral abscess may be the direct result of scalp wounds that had been regarded as insignificant or had been overlooked altogether. It frequently follows pistol-shot wounds. — Ed.] Symptoms. — Localized cortical symptoms, paralyses, dull headache, vomiting, vertigo, fever, convidsions, etc. 6. TUMOR OF THE BRAIN. Tumors of the brain, originating in the bone, meninges, blood-vessels, or substance of the brain itself, may develop in consequence of traumatism ; gliomata, gummata, and sarcomata are the varieties most frequently observed. The growth of a glioma may cover a period of many years — in one case on record a period of thirty years, dat- ing from the time of accident. (See Adler, " Arch. f. Unfiillheilk.," vol. n, 1898.) 106 DISEASES CAUSED BY ACCIDENTS. [The relationship between traumatism and the develop- ment of tumors in the nervous system is so difficult of demonstration that unless the time-interval between the receipt of the injury and the first a})pearanre of symptoms is reasonably short, the causal connection between the two is little more than conjectural. — Ed.] Symptoms. — Headache, central vomiting-, vertigo, dullness, somnolence, slow pulse, a])oplectiform and epilep- tiform attacks, optic neuritis, and focal symptoms. The localized symptoms vary with the site of the tumor. Treatment. — Symptomatic ; possibly trephining and removal of the tumor. 7. PROGRESSIVE PARALYSIS, DEMENTIA PARALYTICA. Traumatism (injuries of the head, fractures of the skull) may be followed by a process of degeneration in the brain, to Avhich the foregoing name has been given. The signs of cerebral degeneration may become apparent very soon after the injury or not until considerably later. Imbecility, sy])hilis, and chronic alcoholism all act as ])re- disposing factors. In predisposed individuals ])aralytic dementia may also develop after ])eriplieral injuries as the sequel of a traumatic neurosis. [The editor has made; a study of the reports of cases of alleged traumatic general ])aresis and of a number of ])ersonally ol)served cases of the disease in which trauma figured prominently in the history given by the jmtient or his friends. (" Accident and Injury: Their Relations to Diseases of the Nervous System." Bv Pearce Bailey, M.D. D. Appleton & Co., 1898.) From this study the conclusion seems unavoidable that if trauma is ever the sole cause of general paresis, such a causal relationship is extremely unusual and difficult of j^roof, and is to be accepted only after scrupulous in(piiry has eliminated the many opportunities for error. General paresis is a disease characterized by an excitable and iuf'tt'^ntive mental state FUNCTIONAL NEUROSES. 107 whicli exposes the victim to all kinds of physical injury, so that an injury that is advanced as a cause may well be one of the results. Furthermore, the onset of the dis- ease is so insidious that it is practically impossible to tell when it begins. If all these tacts are considered, few physicians Avould care to go further, in any given case, than to say that the injury stood in a direct causal rela- tionship with the brain-disease. — Ed.] Symptoms. — Changes in the character; changes in and dimimition of mental ability, memory, and power of speech ; a tendency to excesses ; ine<[uality of the pn})ils and loss of })upillary reflex ; ])aralytic disturbances of speech ; loss of the patellar reflex ; tremor of hands and tongue ; ])aralytic attacks ; delusions, etc. Illustrative Cases. — 1. A workman, foitj'-three years of age, becani« unconscious after falling from a ladder, l)ut soon regaiued conscious- ness. He visited a dispensary, where lie received treatmeut for au injury of the thumb. One year after the injury he began to sutfer from frequent attacks of lieadache, increasing in severity. Six months later he developed acute mania and was placed iu an insane asylum. Diaguosis : progress! re parali/sis. 2. A roofer, thirty-one years of age, fell about fifteen feet, striking on his feet and suftering a compound fracture of the left ankle. Recovery was very j)r()tracted. Two years later he consented to the amputation of his loot. As he Avas unable to pursue his trade, he worked at odd jobs. Four years after the accident a diaguosis was made of dementia ])aralytica. His death occurred six years later. The connection between the accident and the mental disease was recognized iu this case. 8. FUNCTIONAL NEUROSES. Traumatic Neurosis (Oppenheim), Neurasthenia, Hysteria, and Hypochondriasis. Since the passage of the laws relative to accident-insur- ance, /»?K'^'o//a/ nao'oses have been the snbject of wide- spread interest. The ]>ul)licati()n of the work of Op])en- heim on " Traumatic Neuroses " was the signal for the expression of all sorts of opinions on functional neuroses, which, far from casting light on the subject, succeeded in 108 DISEASES CAUSED BY ACCIDENTS. confusing the minds of inexperienced physicians, in creat- ing; dissension in trades-unions, and in doing real harm to the sufferers from accidents, who were led to believe them-, selves entitled to insurance or afflicted \vith imaginary symptoms. The belief that traumatic neuroses were in- curable, and that they led to complete and permanent incapacity for self-support, had a very injurious effect on all interested persons. The general confusion of ideas on the subject has been further heightened by the mistake, committed by many physicians, of making a diagnosis of traumatic neurosis in cases not exhibiting the slightest sign of neurosis, such as internal organic diseases accom- panied by fever and delirium, and in various diseases in which the diagnosis was questionable. The uninitiated soon came to believe that in traumatic neurosis a new, severe, and incurable nervous disease had been discovered. The term "accident-neurosis" may have arisen in this manner. Opj)onlieim gained a large number of adherents at first, among them physicians of prominence. Vigorous oppo- sition was made, on the contrary, to the acceptance of the symptom-complex described by him as characteristic of traumatic neuroses. It was said by some of his oppo- nents, physicians of high standing, that this symptom- complex represented no new disease ; that the symptoms he described were those of neurasthenia, hysteria, or hy- pochondriasis, or combination-forms of these diseases. Further, that it was both unnecessary and undesirable to invent a new name, as it would only give rise to incorrect ideas regarding the nature and significance of functional neuroses. This point of view has now come to be gener- ally accepted as correct. Whenever, therefore, the term *' traumatic neurosis" appears in the text, it is intended to describe one of the functional neuroses known to us under the name of neurasthenia, hysteria, or hypochon- driasis, which has developed under the influence of trau- matism. FUNCTIONAL NEUROSES. 109 We must hear dearly in mind the generally accepted defi- nition of functional neuroses: namely, that they are affections of the nervous system not dependent upon any demonstrated anatomic changes, but recognized by the changes in functional power by which tliey are characterized. Ac- cording- to this definition, we must exclude all diseases of the nervous system that, by reason of the nature of the injury and of the symptoms exhibited, seem clearly to in- volve anatomic chanires in the nervous tissue. [The terms " functional " and '' organic," while indis- pensable for clinical purposes, rest on an uncertain foun- dation. Pathologic inquiry is constantly revealing a material basis for disorders previously regarded as func- tional. It is extremely probable that, in many of the cases that are put in the rubric of " traumatic neurosis," the symptoms following severe traumatisms are due to such demonstrable lesions in the central nervous system as capillary hemorrhages, small foci of softening, etc., with their sequels. But until this probability receives more positive demonstration than it has as yet obtained, such cases must continue to be called '' functional " or, at best, " unclassified." — Ed.] It is worthy of note, too, that functional neuroses do not develop as a result of traumatism except in predis- posed individuals — suljjects of a nervous heredity, alco- holism, etc. For while " strong natures are able to withstand mental shock without wavering, weak natures succumb to physical or psychic traumatism." [This statement requires qualification, for in the ex- perience of the editor, cases of severe functional nervous disturbances following fright or sliglit injuries develop when there is absolutely no predisposition demonstrable, either in the patient himself or in his ancestral history. This is true of both hysteria and 'neurasthenia. — Ed.] Working-men are exposed to the influence of a number of predisposing and accidental factors favoral)le to the development of functional neuroses, such as hereditary 110 DISEASES CAUSED BY ACCIDENTS. teiKlcncio.s to nervous diseases, alcoholism, or epilepsy ; inipcrfeet mental and ])liysi('al development ; unsanitary housing ; poor and insufficient food ; worry and care ; alcoholic excesses, etc. (a) Neurasthenia. [Neurasthenia induced by injury or fright has an event- ful pathologic hist(»ry. It is the "railway spine" of Erichsen, the " railway brain " of later writers, and even to-day is called by these or similarly indefinite terms. With the exception of an unusual prominence of the com- ])laint of pain in the back, and of morbid fevers referable to the accident, its symptomatology is practically the same as that of neurasthenia due to causes other than injury. It is a very frequent source of litigation in personal-injury claims in this country. When the symptoms are pro- nounced and persistent, it is a disabling aft'ection. In the majority of cases, however, the patient is eventually able to resume his occupation. — Ed.] This term designates a condition of morbid weakness and irritability of the psychic and physical activities. A neurasthenic is able to begin physical tasks with energy, but soon tires, and in consequence comes to im- agine that he is actually ill. The symptoms are as follows : Changes in dis})osi- tion ; irrital)ility ; diminution of will-power and of power of work ; lack of power of concentration ; absent-minded- ness ; fatigue on slight exertion ; morbid self-observa- tion ; headache ; sense of ])ressure in the head ; tremor ; flashing before the eyes ; freiiuent attacks of insomnia ; dreams of an unpleasant and exciting nature ; palpitation of the heart ; pains of various kinds ; imperative con- ceptions ; etc. Objective symptoms, such as paresthesias and exag- gerated reflexes, are often present, but not necessarily so. The series of books included under this title are translations into English of the world-famous **Lehinann medicinische Handatlanten/^ For scientific accuracy, pictorial beauty, compact- ness, and cheapness SAUNDERS' MEDICAL HAJSfD-ATLASES these books surpass any similar volumes ever published. Each volume contains from 50 to 100 col- ored plates, executed by the most skilful German lithographers. A full description of each plate is given, together with a condensed outline of the subject to which the book is devoted. <^ t^ The great advantage of natural pictorial repre- sentation is indisputable. For lasting and prac- tical knowledge, one accurate illustration is better than several pages of dry description. ^ ,^ ^ These Atlases offer a ready and satisfactory substitute for clinical observation, available only to the residents of large medical centers. ^ ^ By reason of their projected universal transla- tion and reproduction the publishers have been enabled to secure for these Atlases the best artis- tic and professional talent, to produce them in the most elegant style, and yet to offer them at a price heretofore unapproached in cheapness. The success of the undertaking is demonstrated by the fact that volumes have already appeared in German, English, French, Italian, Russian, Spanish, Japanese, Dutch, Danish, Swedish, Roumanian, Bohemian, and Hungarian. ,^ ^ The same careful and competent editorial su- pervision will be secured in the English edition as in the originals, the translations being edited by the leading American specialists. ^ ^ ,^ For sale by all Booksellers, or sent post-paid on receipt of price. W. B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. Saunders' Medical Hand-Atlases. As it is impossible to realize the beauty and cheapness of these Atlases without an opportunity to examine them, we make the following offer: Any one of these books will be sent, post-paid, upon request. If you want the book, you have merely to remit the price ; if not, return the book. VOLUMES NO\7 READY. Atlas of Internal Medicine and Clinical Diagnosis. By Dr. Chr. Jakob, ol Erlangen. Edited by Augustus A. EsHNER, M.D., Professor of Clinical Medicine, Philadelphia Polyclinic. 68 colored jjlates. Cloth, g3.oo net. Atlas of Legal Medicine. By Dr. E. von Hofmann, of Vienna. Edited by Frederick Peterson, M D., iChief of Clinic, Nervous Uept., College of Physicians and Surgeons, New York. With 120 colored figures on 56 plates ; 193 half-tone illustrations. Cloth, I3.50 net. Atlas of Diseases of the Larynz. By Dr. L. Grhnwald, of Munich. Edited by Charles P. Grayson, M.D., Lecturer on Laryngology and Rhinology in the Uni- versity of Pennsylvania. With 107 colored figures on 44 plates, and 25 text-illustrations. Cloth, I2.50 net. Atlas of Operative Surgery. By Dr. O. Zuckerkandl, of Vienna. Edited by J. Chalmers DaCosta, M.D., Clinical Professor of Surgery, Jetlerson Medical College, Philadelphia; Surgeon to the Philadelphia Hospital. VVith 24 colored plates, and 217 text-illustrations. Cloth, J3.00 net. Atlas of Syphilis and ^e Venereal Diseases. By Prof. Dr. Franz Mracek, of Vienna. Edited by L. Bolton Hangs, A1. D., Professor of Genito-Urinary Surgery, University and Bellcvue Hospital Medical College, New York. With 71 colored plates. Cloth, ;j!3.5o net. Atlas of External Diseases of the Eye. By Dr. O. liAAB, of Zurich. Edited by G. E. de Schweinitz, M.D., Professor ot Ophthalmology, Jefferson Medi- cal College, Philadelphia. With 76 colored illus- trations on 40 plates. Cloth, I3.00 net. Atlas of Skin Diseases. By Prof. Dr. Franz Mracfk, of Vienna. Edited by Henry W. Stelwagon, M.D., Professor of Dermatology, Jefferson Medi- cal College, Philadelijhia. With 63 colored illus- trations and 39 beautiful half-tones. Cloth, j3.5onet. Atlas and Epitome of Special Pathological Histology. By IJk. H. DijRCK, uf Munich. Edited by Ludvig HuKTOEN, M. L)., Professor of Pathology, Rush Medi- cal College, Chicago. Two volumes, with about 120 colored plates, numerous text-illustrations, and copious text, yolume I. ready in April. For sale by all Booksellers, or sent post-paid on receipt of price. W. B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. HYSTERIA. Ill (b) Hypochondriasis. In this aifection the imagination and self-observation of the patient are more concentrated on one special point. While a neurasthenic complains first of one ailment and then of another, sometimes feels better, sometimes worse, and desires to talk about his condition, a hypochondriac clings firmly to his special form of complaint, and broods over it in silence. A belief in abdominal disorders is especially characteristic of hypochondriasis. A Case of Traumatic Neurosis Following Fracture of the Skull and Concussion of the Brain. — A stone-carrier, thirty-seven years of age, was hit on the head bj- a lon.^ board that fell from the second story. Tiie accident happened on tlie 26th of Novenilier, 1888. He was tirst treated by his lodge doctor, then in the hospital. He resumed work for a short period, but was obliged to discontinue it on account of headache and to reenter the hospital, where he was treated for abscess of the brain. I examined the patient on the 25th of Fel)ruary, 1889, and noted the following symptoms : Headache ; attacks of ver- tigo ; flashing before the eyes ; disturbed sleep ; tremor ; unsteady gait, more apparent in the house than on the street. The patient looked well nourished and in good health. He was afterward ex- amined by various alienists, and declared by some to be guilty of sim- ulation ; after much etfort, however, he olitaiued an allowance based on 50 fo incapacity for self-support. (c) Hysteria. [Of all diseases for which compensation is sought at law, none is subject to such gross misconception as trau- matic hysteria. It has a well-established and characteristic symptomatology, yet it seldom is recognized by physicians generally in this coimtry. It is essentially a mental dis- ease, but since its most striking manifestations arc physical (e.g., paralysis, blindness, loss of sensibility, contracture, etc.), the patient has the appearance of a badly crippled man rather than of a person suffering from perverted psychic functions. The result is that ignorant or corrupt experts, and juries, formulate their opinions on the appear- ance of the plaintiff, without stopping to inquire as to the 112 DISEASES CAUSED BY ACCIDENTS. true nature of the disorder. As a eonsequence, excessive verdicts are rendered the phiintiff, on tlie hypothesis that the injuries are incurable and permanent. Now, it can not be denied that as a result of improper treatment or of unfortunate environment traumatic hysteria may become an t^xtremely rebellious affection ; but it should be admitted, with equal candor, that the psychosis is essentially curable in its nature, and that the majority of the patients, with time and proper care, get well ; and that verdicts rendered on the hypothesis that the plaintiff is ruined for life are unjust in the extreme. This subject deserves more atten- tion than it receives. The disease comes frequently to the notice of physicians who have to deal with disorders of the nervous system following accidents, and it is particu- larly liable to lead to litigation. — Ed.] The term hysteria denotes a condition dependent upon morbid mental Gonceptions. If a hysteric patient dreams, for instance, that he has l)een run over, he believes on awakening that the accident has really occurred. The disease is, therefore, of a psychic nature, the morbid con- ceptions on which it is grounded being called forth by suggestion. These conceptions give rise to innumerable functional anomalies, both motor and sensory, which are not based, so far iis can be ascertained, on any organic changes. Hysteric patients are very susceptible to sug- gestion and to autosuggestion. New ideas and concep- tions are, therefore, very readily awakened in them, and they are easily influenced by strangers. Their decisions are not to be counted on ; tiieir attitude toward their associates is capricious ; they are moody, irritable, absent- minded, and likely to act on impulse. The physical symptoms of the disease may be (1) per- man(nit (stigmata) or (2) ])eriodic (hysteric attacks). To the first class belong : 1. Hemianesthesia, complete loss of ordinary sensation of one half of the body ; possil)ly also insensibility to pain. The sense of taste, of smell, and of hearing may l)e abol- HYSTERIA. 113 ished on the affected side ; there may be partial color-blind- ness and retraction (jf the visual field. i^. Hypercdhcmi. — This may aif'ect all of one side of the body or only parts of the same. Hysteric attacks may be brought on by pressure on the hyperesthetic areas. Various morbid sensations also belong to this class, such as the globus hystericus, for instance. 3. Hysteric paralyses, which may disappear as suddenly as they develop. 4. Hysteric Contractures. — Hysteric couvulsive attacks are manifestations of central irritation, exhibiting the most varying forms and combinations of forms. The attacks consist of clonic and tonic spasms of the extremities and the face, the latter Ix'ing distorted by grimaces, while the patient alternately laughs and weeps, and assumes strange postures. Hallucinations frequently accompany the at- tacks. Hysteric convulsions differ from those of true epilepsy in not being accompanied by the deep coma characteristic of the latter disease. In hysteria conscious- ness is invariably retained, and the reflexes are not aflected ; the patients usually fall with the least possible injury to themselves, while epileptics fall face downward. Hysteric patients, furthermore, can be aroused from a convulsive attack by gentle shaking and by sprinkling with cold water. The treatment of hysteria should chiefly be directed toward the removal of all influences calculated to encourage the morbid feelings of the patient. Work is usually the best therapeutic agent for a hysteric or neurasthenic work- ing-man, and, for this reason, in estimating the insurance allowance it is advisable to avoid a high rate, wdienever feasible, in order to compel the patient to work. A high rate of insurance encourages the patient to believe himself to be seriously ill, whereas if he is obliged to go to work, his morbid conception will be overcome, and his recovery will ensue. It is characteristic of accident-neuroses that the mind of the patient is almost altogether occupied wdth 114 DISEASES CA USED BY A CCIDENTS. questions relating to the accident and all that appertains to it, and to the I'ate of insurance to be allowed. Epilepsy not infrequently develops as a sequel of injuries of the head, especially in cases of depressed fracture en- tailing irritation of the brahi-cortex by reason of a thicken- ing of the bone, a cicatrix in the meninges, or an inflam- matory process. It is also observed as a result of the cicatrization of wounds of the scalp. A typical epileptic attack is inaugurated by an aura (headache, vertigo, nausea, general discomfort, etc.). In addition to the convulsions, which are both clonic and tonic in nature, the attack is characterized by the following symptoms : unconsciousness, loss of reflexes, foaming at the mouth, biting the tongue, and clenched fists. After the attack passes off the patient feels dazed, nauseated, de- pressed, and generally unwell. This condition may persist for some time. Of the attack itself the patient has no remembrance whatever. Epilepsy can in some cases be cured by trephining and by removing the irritating cause. Predisposition plays no less important a part in the etiology of this disease than in other nervous diseases following traumatism. An alco- holic heredity is an especially strong predisposing factor. Epileptic attacks may be brought on by peripheral injuries as well as by injuries to the head. Illustrative Case. — A painter, tweuty-uine years of age, who had frequently suflfererl from lead-poisonino;, fell from a height of twenty- five feet on the 80th of April, 1889. Lesion : fracture of the base of the skull with paralysis of the left arm. The patient was treated for one month in the hospital and for another month in the dispensary. He then resumed work. On the 4th of Septeml)er, 1889, he was again examined with reference to insurance, because of headache and dizziness. On the 11th of November, 1889, he felt entirely well, and resumed work. He was then considered to be ftiUi/ capable of self- support. On the 16th of March, 1895, he sufered an epileptic attack, which was repeated at intervals. The connection between the accident and the epilepsy was proved, and he was allowed 100% insurance. INJURIES OF THE FACE. 115 Injuries of the Face. Slight contusions of the face heal without difficulty, unless they occur in connection with concussion of the brain or injuries to the nerves. They do not hinder the patient from working, or do so for a very short time, and they are often not reported at all. Severe contusions, on the other hand, are likely to be associated with fractures or with concussion of the brain. Fig. 3. Figure 3 shows a workman, thirty-seven years of age, who suffered a contusion of the right cheek, as a result of a blow from the haudle of a wheelbarrow that was overturned. The accident occurred on July 17, 1887. The patient developed a typical case of traumatic neurosis, according to Oppenheim ; and I have, therefore, tried to show his facial expression in a photograph. INIental depression was a very prominent feature of the case. This patient was by many observers considered to be guilty of simulation, and the medical faculty of the Berlin University wrote an opinion on his case in 1891. This opinion can be found in the " Aerztl. Vereinsblatt," and also in the "A. N. d. R.-V.-A." of the first of October, 1897, (Compare with Traumatic Neuroses.) 116 DISEASES CA USED BY A CCl DENTS. PLATE 5. Fig. 1. — Adherent Scar Over the Left Malar Bone, Fonow= ing Contusion and a Probable Fracture. Tlie siiir is very ap- parent in the picture, as is also a tliickening of the iiiahir l)one and a conjunctivitis, wliich is more marked on the lel't side. ' The left eye is seen to be watering. The patient was a workman, {'orty-nine years of age, who was struck on the left cheek by a board that fell from a height of about fifty feet. St/mjitoms.- — Pain on the left side of the iace ; headache ; dizziness ; toothache, especially during nuisticatiou ; loss of the sense of smell on the left side of the nose. In examining the patient the constant lacrimation and a loud snuttling were very noticeable points. Diagnosis. — Neuralgia of the left infra-orbital nerve. From mas- sage the best results were obtained. Division of the nerve and loosen- ing of the scar gave no relief. For two years the incai)acity for self- support was reckoned at 50% ; one year later, complete incapacity. FitiiRK 2 Represents the Narrow Entrance of the Right Nostril in the Case of Compound Fracture of the Nasal Bones Referred to in Connection with and illustrated by Figure 4. The patient conij)]ained ol' dithculty in breathing, and was obliged for a long time to breathe through his mouth. Later on, the difficulty gradually disappeared. The ])ictuie was taken six years after the accident. He was receiving 10% allowance ; about eighteen months later he fully recovered bis capacity ibr self-support. Wounds of the face are of greater iiii])()rtaii('e, partly because they are especially subject to infection by ery- sipelas, partly because of the rich nerve-suj)ply of the face and of the clanger of injury to the same. Deep wounds may involve the facial or trigeminal nerve, and so give rise to neuralgia or })aralysis. Deep cicatrices may press on underlying nerve-branches, causing painful spasms of the facial muscles and involuntary lacrimation. Injury to the ophthalmic branch of the facial nerve causes lagoph- thalmos (im])erfcct closure of the lids), as a result of which the eye is exposed to the danger of the entrance of foreign bodies. Burns of the face caused by boiling water, freshly slaked lime, explosions of spirit or kerosene lamps or of gas-})ipes, etc., are likely to lead to extensive cicdfricidl growth and consequently to facial deformities, which in Tab. .7. Tig.l. :^' Ful ^. Lith. Anst F. Reichhold. Aliiiirheii . A Text-Book of DISEASES of WOMEN. By Charles B. Penrose, M.D., Ph.D., Professor of Gyne- cologfy in the Uni- versity of Pennsyl- vania; Surgeon to PENROSE'S DISEASES OF WOMEN the Gynecean Hospital, Philadelphia. Octavo. 531 pages, handsomely illus- trated. Cloth, $3.75 net. J- ^ ^ THIRD EDITION, REVISED. In this work, which has been written for both the student of gynecology and the general prac- titioner, the author presents the best teaching " I shall value very highly the copy of Penrose's ' Diseases of Women ' received. 1 have already recomnieiided it to my class as THE BEST book." — Howard A. Kelly, Professor of Gyve- cology and Obstetrics^ Johns Hopkins University. of modern gynecology untrammelled by anti- quated theories or methods of treatment. In xnost instances but one plan of treatment is " The copy of ' A Text-Book of Diseases of Women,' by Penrose, received to-day. 1 have looked over it and admire it very much. I have nr) doubt it will have a large sale, as it justly merits." — E. E. Montgomhrv. Professor of Cli-n- irnl Gynecology, Jefferson Medical College, P/nla. recommended, to avoid confusing the student or the physician who consults the book for prac- tical guidance. ^ J^ ^ ^ ^ Jt ^ jt For sale by all Booksellers, or sent post-paid on receipt of price. W. B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. A Text-Boofc of MATEEUA MEDICA, THERAPEUTICS, AND PHARMA- COLOGY. By George F. Butler, Ph.G., M.D., Profes- sor of Materia Medica and of BUTLER'S MATERIA MEDICA THERAPEUTICS AND PHARMACOLOGY Clinical Medicine in the College of Physicians and Surgeons, Chicago j Handsome octavo volume of 874 pages. Illustrated. Cloth, $4.00 net ; Sheep or Half Morocco, $5.00 net. ^ THIRD EDITION, REVISED. A clear, concise, and practical text-book, adapted for permanent reference no less than for the re- quirements of the class-room. The arrange- ment (embodying the synthetic classification of " Taken as a whole, the book may be consid- ered as one of the most satisfactory single-volume works on materia medica on the market."— yo?<>-- nal of the American Medical Association. drugs based upon therapeutic affinities) is be- lieved to be at once the most philosoptiical and rational, as "well as that best calculated to engage the interest of those to -whom academic study of the subject is wont to offer no little perplexity. For sale by all Booksellers, or sent post-paid on receipt of price. "W. B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. FRACTURE OF THE BONES OF THE FACE. 117 themselves somewhat incapacitate the patient for self- support, especially in the ease of a woman. Fracture of the Bones of the Face. Fracture of the nasal hones may he caused hv striking the nose in falling or hy hlows from falling ohjects. The Fig. 4. injury results not only in external deformity, but fre- quently also in a narrowing of the nasal orifice. The patient complains of difficulty in breathing and is often obliged to breathe through his mouth. A thorough 118 DISEASES CAUSED BY ACCIDENTS. PLATE 6. A Case of Paralysis of the Sympathetic Nerve on the Left Side, with Atrophy of the Corresponding Side of the Face.— Ou the affected side of the lace is seen a distiuct differeuce in coloring from tliat of the opposite side, which shows a healthy red ; the left side is evidently atrophied, the eyelid droops slightly, and the whole side of the face is covered with a profuse sweat. The patient, who is a mason, tiftj^-one years of age, when passing a building was struck on the head and back by a man falling from the I'ourth story. This hap- pened on December :2(), 1892. For three weeks he was treated in the hospital ; after that at home I examined tin- patient ou March 16, 1893. He was a man of middle height and strong build. In addition to the facial anomalies previously noted, there was a spastic paralysis of both lower extremities, more marked on the right side ; the i)atellar reflexes were exaggerated on both sides ; on the right side examination induced clonic spasms. The patient was unalde to move his right hip-joint l)ecause of the pain caused thereby, and he walked witli diffi- culty, with the aid of two canes. He was mentally intact. Incapac- ity for self-support, 100^. examination should, however, always be made in these cases, since other factors, such as polypi, syphilitic ulcers, etc., may in reality cause the difficulty. Fracture of the nasal bones interferes with work only for the first few weeks after the accident, and in some cases work is not interrupted at all. Permanent incapacity for self-support is seldom rewarded unless a striking degree of deformity follows the injury or unless it is complicated by sinniltane- ous injury of important neighboring })arts. Figure 4 illustrates the case of a boy of fifteen who was injured by a falling weight that caused a compound fractuie of the nasal bones. Very little deformity is apparent ; the chief difficulty concerned his l)reathing. The appearance of the right nostril is shown by figure 2, plate 5. Fracture of the zygoma rarely occurs exce]it in connec- tion with fracture of the superior maxilla and other bones of the head. Among my cases there were five of fracture of the zygoma alone (without fracture of the sknll). Some were caused bv direct blows from falling objects, others by falls from a height. If the fracture is a connuinuted one, it is regularly complicated by lesion of the infra- Dd). 6: Lull. Ansl. F. Reich tialcl. Miinrlifu FRACTURE OF THE INFERIOR MAXILLA. 119 orbital nerve or of a branch of the facial nerve. When the former is involved, the patient is likely to become a snilerer from tic doulourenx, as a result of which he may at times be completely incapacitated for work. In some cases spasms of the facial muscles may be observed years after the accident ; these are likely to cause more or less pain, but may be quite painless. In respect to treatment, some benefit can usually be derived from warm, moist compresses, Priessnitz band- ages, careful massage along the course of the painful nerves, and weak galvanism. If the pain is intense, morphin, antipyrin, and similar remedies should be administered. The degree of incapacity for self-support is usually pro- portionate to the pain ; in severe cases the patient may be totally unfitted for work. Fracture of the Superior Maxilla. This lesion occurs alone only in rare instances, but it is often observed in connection with fractures of the nasal bones and zygomatic arches, as well as with fi'actures of the skull in general. In carpenters and drivers, among others, we frequently meet with compound fractures involving both the malar bone and the superior maxilla. In the one case the injury is due to blows from falling oljjects, and in the other to kicks from horses, etc. Subjective symptoms are tooth- ache, headache, pain on mastication, and distress from loose teeth. Objectively, we often find loose teeth and changes in the shape of the broken jaw, but more partic- ularly in the alveolar process. The lesion itself does not unfit the patient for work, but the pain to which it gives rise may do so. Fracture of the Inferior Maxilla. The under jaw is frequently fractured either alone, by falls or kicks, or as an accompaniment of fractures of the skull caused by falls from a height, cavings-in, etc. In 120 DISEASES CAUSED BY ACCIDENTS. PLATE 7. Contracture of the Left Trapezius in Consequence of Severe Contusions of the Left Side of the Head and Body. — Se(iuel, hysteria. Complete iucapacity Ibv seH-support, partly due to conipli- catious. A paiuter, thirty-eight years of age, fell l)ackwar»4ftl^Vi'"- AN AMERICAN TEXT-BOOK OF GYNECOLOGY, Medical and Sur- gical. By JO AMERICAN TEXT-BOOK OF GYNECOLOGY of the Leading Gynecologists of America. Edited by J. M. Baldy, M.D., Professor of Gynecology in the Philadelphia Poly- clinic. Handsome Imperial Octavo Volume of 7J8 pages, with 34 J illus- trations in the text, and 38 colored and half-tone plates. Cloth, $6.00 net; Sheep or Half Morocco, $7.00 net. «^ SECOND EDITION, REVISED. In the revised edition of this book much new material has been added and some of the old eliminated or modified. More than forty of the old illustrations have been replaced by ne-w ones, which add very materially to the elucidation of the text, as they picture methods, not specimens. The section on the bladder, urethra, and ureters is extensively altered, the chapters on technique and after-treatment have been considerably en- larged, and the portions devoted to plastic work have been so greatly improved as to be prac- tically new. Hysterectomy, both abdominal and vaginal, has been rew^ritten, and all the descriptions of operative procedures have been carefully revised and fully illustrated. ^ S ^ Send post-paid on receipt of price. W. B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. An American Text-Book of APPLIED THERAPEUTICS. For the Use of Practitioners and Students. By 43 Eminent Specialists. Ed- ited by James C. AMERICAN TEXT-BOCaC O APPLIED THERAPEUTICS Wilson, M.D., Professor of tlie Prac- tice of Medicine and of Clinical Medicine, Jefferson Medical College, Philadelphia. Complete in one hand- some octavo volume of 1326 pagfes. Illustrated. Cloth, $7.00 net; Sheep or Half Morocco, $8.00 net. J- J- J- Written from the standpoint of the practitioner, the aim of the work is to facilitate the applica- tion of knowledge to the prevention, cure, and "We have presented to us a series of very valuable treatises on the treatment of different forms of disease. The book may be recommended as a thoroughly practical work, and not too ele- mentary even for experienced practitioners." — British Medical Joiii-nal. alleviation of disease. The endeavor through- out has been to conform to the title of the book —"Applied Therapeutics" — to indicate the course of treatment to be pursued at the bedside, rather than to name a list of drugs that have been used at one time or another. .^ ^ ^ ^ Send post-paid on receipt of price. W. B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. THE VEBTEBBAL COLUMN. 121 Injuries and Traumatic Diseases of the Neck. Injuries of the anterior portion of the neek are very seldom seen alone ; they usually occur in connection with injuries of the head and face or together with a fracture or dislocation of the clavicle. Direct injuries of the neck may be caused by explosions, most frequently in the course of mining or building operations to which blasting is incidental. Burns of the neck are frequently caused by the explosion of alcohol or kerosene lamps, and may lead to contractures causing wry-neck. Severe injuries of the neck involve great danger to the important struc- tures and organs that it contains, often entailing grave consequences — a fact easily understood if we remember the anatomy of the part. The muscles most subject to morbid changes after trau- matism of the neck are the sternocleidomastoid and the trapezius. Contractures of these muscles produce wry- neck (caput obstipum). II. THE BODY. THE VERTEBRAL COLUMN. Anatomicophf/siolof/ic Com^iderotions. — The vertebral colnnin lias tlie function, among others, of supporting the weight of the body and preserving its balance, and, in accordance with this function, it presents certain normal curves. If we look at a living human being from behind, we note that the upper dorsal region of the spine appears convex, while the cervical, lower dorsal, and lumbar regions appear concave. Dejiartnres from these normal curves occur among industrial workers as the result of special vvoik to the requirements of which the spine has adapted itself. This is especially the case if the work in (|uestion entails a one-sided activity. The vertebral column of a stone-carrier serves as an instance of such changes ; the cervical region is likely to be markedly convex posteriorly, the U]iper dorsal regi(m is ky])hoscoliotic, while in the lower dorsal and lumbar regions lordosis is api)art'nt. The position of tlic .scajiuhc and arms, of the pelvis and lower extremities, is, moreover, sccondarih' affected, with the apparent etfect of shortening some parts and of lengthening others. A certain degree of deformity of the thorax is a necessary 122 DISEASES CAUSED BY ACCIDENTS. sequel of the otlier anomalies euniuerated. These anomalies are well known \mder the name of "burden-deformities." They increase gradually and in exact proportion to the ett'ect on the Ijody of the weight it has to support. The ability of tlie spine to support external burdens, as well as the weight of the body, while preserving the. balance of the latter, is a proof of its elasticity. The ehisticity depends cliiefly on the presence of the spongy substance in the bodies of the vertelyrse and upon the intervertebral cartihtges, the other ligaments connecting the vertelu'se acting as contributory factors. By reason of this attribute, the spine is able to adapt itself to compression as well as to stretching. It is compressed, and thereby shortened, by carrying heavy weights, and is lengthened by suspension of tiie body, while compression and stretching both occur constantly as the result of ordinary movements of flexion and extension of the body. The following movements are normal to the vertebral column : (1) Anteflexion and retroflexion ; (2) lateral flexion and oblique flexion ; (3) rotation. Extreme degrees of mobility are demonstrated by contortionists (india-rnbl^er men). Leaving such unusual degrees of elasticity out of consideration, we find the flexibility of the spine to be iu part deter- mined l)y the dimensions of the intervertebral cartilages and the thick- ness of the bodies of the vertebrae. Thin and narrow bodies with thick and narrow cartilages favor nioI)ility. This fact is illustrated in the cervical region, which enjoj's a greater range of motion than any other region of the spine, although this is partly to be ascribed to its position in the body, in which it is peculiarly free from constraint. The hnnbar region holds the second place, while the dorsal region is relatively inflexil)]e — partly because of its costal articulations, partly because of the overlying spinous processes and tlie tliickucss of the bodies of the vertebraj. A consideration of the influence on mobility exerted by the separate articulations and ligaments would lead us too far. In discussing the movements of the cervical region we must refer to those of the head, giving special attention to the two upper vertebrae and their anatomy. The head is not placed in a line perjiendicular to the trunk, but at an angle f)f aV)Out 165 degrees. Neither is the neck perpendicular to either body or head. The head is held in position ])y the antagonistic action of the muscles attaching it to the spine and by their muscular tone. Its greatest degree of flexibility (about 80 de- grees), obtained with the aid of flexion in the Cervical vertebra?, does not bring it to a right angle with the body, but only to an angle of about 85 degrees (165 degrees to 80 degrees). The head is ordinarily flexed ])y its own weight, aided by the rectus capitis major and minor and the lougus colli muscles, the muscles of the back of the neck lieing relaxed. Forced flexion is produced hy the action of the platysma, the scaleni antici, and probably the intertransversales. Ordinary nodding movements take place at the occipito-atloid articulation ; in deep flexion the whole cervical region is called into play. THE VERTEBRAL COLUMN. 123 Wheu slightly rotated posteriorly and laterally flexed, the head can be brought to an angle of Croni 150 to 155 degrees with the vertical axis of the trunk. In this movement the rectus capitis lateralis, the intertrausversales, and the scaleni of one side are concerned. On tlie flexed side the transverse processes are approximated ; on the opposite side they are separated. The oblique processes meanwhile execute a peculiar movement corresponding to the shape of their articular sur- faces, wliich will be referred to agaiu later. Ordinary movements of retroflexion take place, as a rule, in the occipito-atloid articulation, and are produced by the short muscles of the ue(;k, the rectus capitis anticns major and minor, and the superior and inferior obliciue. Marked degrees of retroflexion are due to the additional action of the sternocleidomastoid, tiie spleuius capitis, the trachelomastoid, the complexus and the l)iventer cervicis, the multilidus spina?, and the interspinales. These muscles are also called into play wheu the whole cervical region takes part in the movement of retroflexion, and in this case the superior flljers of the lougissimus dorsi and the ileo- costalis are also involved. The movement in question can only be carried out when the muscles of both sides act in unison, unilateral action always resulting in rotation. Rotation of the head in a vertical axis takes place in the atlo-odon- toid articulation. In order to estimate the angle of rotation we must imagine two axes, a sagittal and a transverse, placed at a right angle to each other. This gives us an angle of rotation of about 75 degrees. This demands the acticm of the whole cervical region of the spine, and, of course, lowers the level of the axis of rotation. Ordiuary rotation at the occipito-atloid articulation is produced by the action of the in- ferior oblique of one side — the right inferior obliipie, for instance, turn- ing the head to the right. Farther degrees of rotation are due to the action of the sternocleidomastoid of the opposite side, causing at the sime time a slight inclination of the face toward the side of the acting muscle. Rotation may call into play all tlie muscles of one side, which, wlien acting in unison with the muscles of the opposite side, produce anteflexion or retroflexion of the neck. According to H. Meyer, the spine, in executing the movement of flexion, — taking the distance between the promontory of the sacrum to the anterior tubercle of the atlas as the radius, — describes an arc of 71 degrees in an anteroposterior plane. The cervical region takes the chief part in this movement. If the radius is expressed h\ the dis- tance between the promontory and the seventh cervical vertel>ra, the angle of flexion eijuals only M degrees, of which .31 degrees are due to the action of the three lower hnnbar verteV)ne. The general rule ajiplies to the spine that the intervertebral discs are compressed during flexion on the concave side of the spine, while tliey are freed from pressure or stretched on its convex side. On anteflexion the ligaments connecting the spinous processes — the interspinous and supraspinous ligaments, as well as the ligamentum flava — are subject to traction. The spinous processes are appreciably separated during this move- ment. At the same time the intervertebral discs undergo compres- sion anteriorly, while posteriorly they are stretched. On flexion, the 124 DISEASES CAUSED BY ACCIDENTS. spine w;is increased exactly 11 o cm. in length in a man twenty-fonr years ol" age, the measurements iucluding the distance from the atlas to the end of the sacrum. The muscles of the back are, of course, included in the stretching of the posterior part of the spine. During the process of anteflexion the articular processes of each vertebra glide upward on the corresponding processes of the vertebra next below it, the whole spine being at the same time slightly rotated on its trans- verse axis. In executing the movement of forced anteflexion tlie thiglis are fixed and both hips take part in the process. In young persons the angle thus formed between trunk and thighs equals about 75 degrees. On anteflexion, to which the weight of the body contributes, the abdominal muscles contract, especially the rectus and iliopsoas of each side, while the muscles of the back are stretclied. Even while stretched these muscles are to a certain extent contracted, as a precau- tion against falling over forward. Since the spinal column is length- ened posteriorly on flexion, we may assume that it is shortened anteri- orly to the same extent. The opposite condition o])tains on retnjflexion, the intravertebral discs being compressed posteriorly, while anteriorly they are freed from pressure. The articular processes of each vertebra glide downward on the corresponding processes of the vertebra next below, while the spine is rotated on its transverse axis in the direction opposite to that which it took on anteflexion. The last two articular processes, those of the fifth luml)ar vi-rtebra, glide down into the lum- bosacral fossa of the first sacral vertc])ra. Retroflexion is chiefly accomplished in the cervical region ; the lumbar region takes the next chief part, while the dorsal region under- goes relatively little change ; its share in the process, however, should not be underrated. In a man tvv(mty-four years of age the cervical region , measuring from the tubercle of the atlas to the spinous process of the seventh cervical vertebra, was shortened posteriorly by 7 cm., while the dor.sal and lumbar region together, measuring from the spinous process of the seventh cervical vertebra to the end of the sa- crum, was shortened by only 6 cm. The total shortening, therefore, was 1 1 cm. Movement in the hip-joint during retroflexion is normally very slight, being greatly limited by the action of the iliofemoral ligament. The long muscles of the back contract, while the abdom- inal muscles, especially tiie rectus and iliopsoas, are stretched. Lateral flexion, if we leave the cervical region out of consideration, is executed almost altogether in the lumbar region, or, rather, in the lumbar region and the two lowest dorsal vertebr;c. Pure lateral flexion without rotation can be carried to an angle of ^r>0 degrees without much diflicully by a man of middle age. Lateral flexion with rotation is accomiilislicd by the action of the semispinalis dor.si and mnltilidus s])inic of one side, and can be carried to an angle of 130 degrees. The interverteliral discs are thereby compres.sed on the flexed side. During this movement the articular processes on the flexed side glide somewhat downward on the sides of the processes of the veitebra next above ; the articular ])rocesses of the opjiosite side (that which is stretched) are correspondingly elevated. The conforma- THE SPINAL C0LU3IN AND RIBS. 125 tion of the boues makes this movemeut necessarily a limited oue. The slaut of the articular surfaces of the articular i)rocesses precludes deep Literal flexiou without rotatiou. The nuiscles that take part in lateral flexion are the iutertransversales, and, in the dorsal region, the internal intercostals as well. Rotation of the spine is chiefly produced bj' muscular action ; the cervical region is most adapted to this movemeut, which is executed with greater difficulty in the luml)ar region and is least possible in the dorsal region. Tlie articular processes move as follows : wlien rotation takes place from left to right, the inferior articular processes of the lett side of each vertebra are pressed against the sujjerior articular processes of the vertebra next below. Relation of the Spinal Column to the Ribs. The dorsal region is the least mobile of the several regions of the spine, a tact which is largely due to its connection with the ribs, especially with the tirst ten, which, by their articulation with the sternum in front, form the l)ony framework of the thorax. The ril)s are connected both with the bodies of the vertebnv and with their transverse processes. The heads of the second to the ninth ribs, in- clusive (sometimes of the first to the tenth, inclusive), articulate each by a double facet with two vertebise. The ridge on the head of the rib separating the two facets lies close to the intervertebral disc, and is attached to the latter by means of a small tibrocartilaginous ligament, by which the articular cavity inside the capsular ligament is divided into two parts. The riljs also articulate with the transverse processes of the vertebrae, and, in addition, there are ligaments passing from the necks of the ribs to the transveise processes of the vertebrae. The ribs, therefore, take part in all movements of the spine. Through their articulations with the bodies and transvei-se processes of the vertebrae they have a little independent action, but this is very limited. On anteflexion of the spine the ribs are separated posteriorly and approximated anteriorly ; on retroflexion this process is reversed ; on lateral flexion they are approximated on the side of flexion and separated on the opposite side. The sympathetic nerve passes down the posterior wall of the thorax beside the spine, in which position it is exposed to injury from fractures of the transverse processes or of the ribs near their vertebral attachments. The interarticular ligaTuent, as well as the other ligamentous at- tachments l)etween the ribs and the vertebnc or their processes, may be lacerated as a result of tbrced movements of the spine. Such in- juries can hardly be diagnosed during life, unless there is a dislocation of the ribs at tlie same ])oints that can be di-scovered liy aid of X-ray photographs. It is well, nevertheless, to remember their possible occurrence. The spinous processes furnish us with the only anatomic means of determining the level of an injury of the verteljrae in a living person, or of the lesion of the cord or spinal nerves that may be conseiiuent upon it. It is important, however, to be acquainted with the relation existing between the spinous processes, spinal nerves, and segments 126 DISEASES CAUSED BV ACCWEXm. Motor. Sternomastoid. 1 Trapezius, j Diaphragm. (uluar lowest). Intercostal niiis cles. Abdominal mu; cles. Flexors of hip. , I j- E.X tensors of knee. Adductors, ^ Abductors. Ex t e n - hip. I sors (?) Flexors of knee(?) I Muscles of leg r moving toot. Perineal and anal muscles. Sensory. Neck and scalp. Neck and shoulder Shoulder. Arm. Hand. Reflex. Front of thorax. Ensiform area. Abdomen (nmbili cus, tenth). Buttock (upper part). Groi n and scrotum (front). router side. Thigh .| front. tinner side Leg, inner side. Buttock, lower part. Back of thigh Leg «.>.' ^"'=«'^' foot Scapular. Epigastric. C r e m a s - teric. • Knee-jerk. and ^e?'<=«P' ' { inner ' ( part. Foot-clonus. Plantar. P e r i n e u m and anus. Skin from coccyx to anus. Fig. 5. — ^Diagram and table showing tbe approximate relation to the f^pinal nerves of the various motor, sensory, and reflex functions of the spinal cord. TEE SPINAL COLUMN AND BIBS. 127 of the spinal cord in respect to level, since they do not by any means correspond in this particular. The accompanying table, according to Gowers (Fig. 5), is a valuable guide in determining these points, as c 2C • 3C 2 4C iC 3 6C JC 4 8C i iD 6 2D sD 7 D 4D 1 5D 2 6D 3 8D 4 7D S 9D 6 lOD 7 iiD I2D 8 iL 9 2L 3L 10 4L 11 5L I 2 3S 4 5 13 L I Co 2 Fig. 6. well as in settling questions of motor, sensory, and reflex functions ; while the schema of Keid (Fig. 6) shows the relation between the spinous processes and segments of the cord. 1 28 DISEASES CA USED BY A CCIDENTS. I. GENERAL SYMPTOMS OF TRAUMATIC DISEASES OF THE SPINAL CORD. In all cases of injury affecting the spinal colnmn the question of involvement of the cord is of vital importance ; a short review of the traumatic diseases of the cord seems, therefore, in place at tliis juncture. It may ))e said, speaking in general terms, that injuries of the cord are followed l)y (1) sensory disturbances and (2) motor disturbances. The sensory disturl)ances consist in anomalies of the tactile, muscle, or temj)erature senses, and of the sense of pain (anesthesia, analgesia, hyperes- thesia, girdle sensation). Motor disturbances are expressed by ])aralysis or exaggerated muscular activity (nuiscular rigidity, sj)asins, contractures, neur(>])athi(^ contractures). The various forms of clonic muscular spasms may also be included among the motor disturbances — muscle-waves, fibrillary contractions, tremor, tetany, etc. The condition of the reflexes is an important index to the diseases of the cord. If they are normal, we can con- clude that the section of the cord through which the reflex loop passes is unaflected. AVhen, on the other hand, the reflexes are found to be exaggerated, diminished, or com- pletely lost, we know that the part of the cord in question is diseased. [The most inq)ortant reflex is the knee-jerk. Innnedi- ately after a severe contusion to any part of the cord, the knee-jerks may be very much diminished or unobtainable. If the injury is above the lumbar region, the absence of the knee-jerk alone is not suflicient evidence for a total transverse lesion ; for with the resorption of blood, and recovery from shock to the nerve-fibers and nerve-cells, the knee-jerks, though they were alisent at first, may return or may become exaggerated. If the knee-jerks have not returned by the end of a week or ten days, however, it is certain that the lesion is extensive and severe. In lesions in the lumbar region and lower down, l)oth THE SPINAL CORD. 129 in the cord and in the nerve-plexus, the i NO INCREASE IN PRICE. A yearly digest of scientific progress and authori- tative opinion in all branches of Medicine and Surgery, dra-wn from journals, monographs, and "We have very carefully gone llirough this work, and repeatedly tested the claim set forth that no significant fact has been omitted. This claim is amply justified, and we unhesitatingly recommend it to the medical profession as an unique and invaluable summary of the progress made in medical science uuring the past year." — Quarterly Medical Journal, S'leffield, England. text-books of the leading American and foreign authors and investigators. Collected and ar- ranged, -with critical editorial comments, by 28 eminent American Specialists and Teachers. <^ Sent post-paid on receipt of price. W. B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. AMERICAN TEXT-BOOK OF DISEASES OF THE EYE, EAR, NOSE, AND THROAT An American Text -Book of DISEASES OF THE EYE, EAR, NOSE, AND TKROAT. Contributions from 60 prominent Ameri- can Specialists. Edited by G. E. de Schweinitz, A.M,, M.D., Professor of Ophthalmology, Jefferson Medical College, Philadelphia; and B. Alex. Randall, A.M., M.D., Clinical Profes- sor of Diseases of the Ear, University of Pennsylvania. Imperial octavo. J25J pages, 766 illustrations, 59 in colors. Cloth, $7.00 net; Sheep or Half Morocco, $8.00 net. J- Jt' J- J- JUST ISSUED. The present work makes a special claim to favor based on an encyclopedic, authoritative, and practical treatment of the subjects. Each section of the book has been entrusted to an author es- pecially identified Tvith the subject, who there- fore presents his case in the manner of an expert. Particular emphasis is laid on the most approved methods of treatment, so that the book shall be one to which the student and practitioner can refer for information in practical work. S r^ ^ Send post-paid on receipt of price. W. B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. THE SPINAL CORD. 137 preseut in the legs, especially the left. At the first examination the verte))ial column appeared normal ; at this second examination there was a kyphosis in the upper dorsal region. The patient liad secured a i)lace as night-watchman, and said he could iieribrm his duties witliout fatigue. Thus in two months from the receipt of the injury this man had recovered from a complete motor para- plegia, witli ])lacl(ler- paralysis, and had again hecome a bread winner. Cose of j)iimy inunctions. I examined him Septeml)er 10, 1896. He was of medium size and of lieaithy appearance. He held his body somewhat inclined forward. The tcntli to twelfth spinous processes were thickened and prominent. His gait was slow, })ut not irregular ; all motion of the spine was difficult and painful. After deep flexion he raised himself by climbing up his thighs with his hands. The patellar reflexes were exaggerated on both sides. He was treated in my hospital for four months, and was then discharged with 20% insurance allowance. At that time he still complained of pain in the spine, but could stooj) easily and quickly. Since January, 1898, he has been in perfect health. Case of healed fracture of the ninth and tenth dorsal vertebras, covipli- 164 DISEASES CAUSED BY ACCIDENTS. catcd hy fracture of the rihs. Sequel : recovery, with serious iunctioual disturlninces. (Compare Plate 11.) A mason, thirty-five years of age, on October 5, 1897, fell from a wall about twenty feet high, striking, so it is said, on the himl»ar region. This point could not be definitely ascer- tained. The patient remained in bed ibr sixteen days, and after that arose at intervals. Urination and defecation were disturbed. I examined him December 28, 1895. He was of medium size, well nourished, but had a look of ill health. He held his body inclined backward and walked with a mincing gait. From the front his neck appeared short and as if sunk into the thorax. Tlie abdomen was boat-shaped and the thorax appeared somewhat asymmetric. There was relatively marked lordosis of the lumbar region, while the upper dorsal region was somewhat abnormally convex posteriorly. Tlie spinous processes of the tenth and eleventh dorsal vertebrse were con- siderably thickened. At the time of his military service the patient A TEXT-BOOK OF OBSTETRICS. By Barton Cooke Hirst, M.D., Pro- fessor of Obstetrics in the University of Pennsylvania. HIRST'S OBSTETRICS Handsome octavo volume of 846 pages* 6t8 illustrations and 7 colored plates. Cloth, $5.00 net; Half Mo- rocco, $6.00 net. J- J- J- J> J- SECOND EDITION. This work is intended as an ideal text-book for the student no less than an advanced treatise for the obstetrician and for general practitioners. It represents the very latest teaching in the practice of obstetrics by a man of extended experience and recognized authority. The book emphasizes especially, as a -work on obstetrics should, the "The illustrations are numerous and are works of art, many of them appearing for the first time. The arrangement of the subject-matter, the foot-notes, and index are beyond criticism. As a true model of what a moderii te.\t-book on obstetrics should be, we feel justified in affirming that Dr. Hirst's book is without a rival."— AVjy Yok Medical Record. practical side of the subject, and to this end pre- sents an unusually large collection of illustra- tions. Most of these are new, and the collec- tion will form a complete atlas of obstetrical practice. This work records the wide experi- ence of the author, which fact, combined with the brilliant presentation of the subject, renders it one of the most notable bocks on obstetrics. For sale by all Booksellers, or sent post-paid on receipt of price. W. B. SAUNDERS, Publisher, 925 Walnut St., Philac^elphia. LECTURES ON THE PRINCI- PLES OF SURGERY. By Charles B. Nancrede, M.D., LL.D., Professor of Surgfery and of Clinical Sur- gery, University of Michigan, NANCREDE'S PRINCIPLES OF SURGERY. Ann Arbor; Emeritus Professor of General and Orthopedic Surgery, Phi- ladelphia Polyclinic Octavo volume of about 350 pages, handsomely illus- trated with original drawings and pho- tographs. Cloth, $2.50 net. ^ J- ^ JUST ISSUED. Although many excellent works have been written treating of the Principles of Surgery, the attempt to render them too comprehensive has marred their usefulness for the undergrad- uate. The present book is based on the lectures delivered by Dr. Nancrede to his undergraduate classes, and is intended as a text-book for stu- dents and a practical help for teachers. By the careful elimination of unnecessary details of pathology, bacteriology, etc., which are amply provided for in other courses of study, space is gained for a more extended consideration of the Principles of Surgery in themselves, and of the application of these principles to methods of practice. -^ ^ ^^ -^ ^ -^ ^ ^ Ji For sale by all Booksellers, or sent post-paid on receipt of price. W. B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. HEALED FRACTURES OF THE SPINE. 165 had measured 1.61 meters. His present height is only 1.57 meters. There were no paralyses or disturl)ances of sensil)iiity. All the reflexes were exaggerated, and the pulse was increased in frequency. Motion of the spine Avas difficult and painful ; the patient walked mincingly and with the help of a cane. Insurance allowance 100^ ; no improvement up to date. Case of fracture of Vie twelfth dorsal and first lumbar vertebras; recovery. A chimney-sweep, thirty-eight years of age, on December 20, 1888, fell from a height of al)Out 200 feet, fracturing his spine and right ankle. He was treated in the hospital. I examined him March 28, 1889, and noticed the forward inclination of the body shown in the accompanying illustration. (Fig. 17.) Tlie lower dorsal and lumbar regions of the spine were slightly thickened. He was unalile to straighten his body. He suffered constantly from diarrhea, which yielded only to large doses of laudanum. Up to the end of 1890 he was frequently treated in the hospital, and at that time was discharged with 25 fo insurance allowance. He afterward resumed his trade, but on July 2, 1897, he again fell from a height, and died on the following day. The spine is generally fixed on movement of the body, giving the patient a stiff appearance. Stooping is often performed by bending the knees, while the spine is held fixed and rather straight, the patient straightening himself up by placing his hands on the thighs. Even if the spine is flexed on stooping, the movement is usually very limited. The patient, as a rule, complains of weakness, of a feeling of insecurity, and of pain (ju movement of the spine in any direction ; the pain can often be local- ized by pressure on the spinous processes or by percussion of the spine. The pain may disappear in the course of time, or it may increase as the compressed intervertebral disc becomes absorl^ed. On lateral flexion of the body the spine is frequently found to be curved in the opposite direction at the point of injury ; in rare instances, on the other hand, there is an abnormal degree of lateral mobility. The jiatients are often unable to walk without a cane. If the injury was complicated by lesions of the cord or by hemorrhages into its substance, the gait of the patient becomes spastic or ataxic. Paralyses of bladder and rectum are not infre(|uently met with, accompanied by albuminuria, etc., causing, in these severe cases, incon- 166 DISEASES CAUSED BY ACCIDENTS. tinenee of urine and feces or the opposite condition of retention. The reflexes may be diminished or lost, or they may be exaggerated. In case of unilateral lesion of the cord we find the patellar reflex diminished or lost on one side and exaggerated on the other. On the side on which it is lost the muscles are usually atrophied, while the skin is cool and insensitive to pain, deep pricks not being felt. The electric irritability may be only diminished, or the reaction of degeneration may be present. The electric irritability may, however, be restored for some time before the disturbances of sensi- bility pass ofl'. The prognosis of fractures of the vertebrae — more ]>ar- ticularly of fractures of the body — is always grave. The j)rognosis as to life is very bad in serious cases complicated by lesion -of the cord, most of the patients dying in the course of two years in consequence of complications. Less severe cases, not terminating fatally, are almost always followed by disturbances of function, as described under Symptomatology. We do not need to give much attention to fractures of the laminte, since they very seldom occur alone. They are always very serious, because of probable injury of the cord ; if the cord, however, escapes, fractures of the laminie are very difficult to diagnose. Fractures of the transverse and articular processes have been referred to under Anatomicophysiohjgic Considera- tions. Case of fnichirr of the lumhar vrvtehrve with fraetnre of several S2)i)ious processes, coinptieated hi/ lesion of the cord. Secjuel : recovery with augii- lar curvature of the spine ; full recovery of fuuctioiuU jjowcr. A painter's apprentice, seventeen years of age, in 1869 fell from a scaffdhling from twenty-five to thirty feet high, striking on his buttocks on a flight of stone steps. He was iu the hospital for twenty-two vreeks, lying on a water bed for eighteen weeks. There were par- alysis of the lower extremities and disturbances of sensibility in the .same ; also paralysis of ))ladder aud rectum. Three weeks after in- jury a bed-sore developed and persisted for four weeks. Fouiteeu weeks after injury the patieut complained of a pricking sensation iu MEALED FRACTURES OF THE SPINE. 167 Fig. 19. Fig. 18. Fig. 20. Fig. 21. 168 DISEASES CAUSED BY ACCIDENTS. the lower extremities. The patient began to walk on crutches nine- teen weeks after the injury. Nine months after the injury he resumed light work, and was able to do his full amount of work in two years. The spine is markedly kyj)h()tic in the lumbar region (Fig. 18), and the thorax appears pointed posteriorly. On anteflexion (Figs. 19 and 20) the spinous processes, which are thickened and further apart than normal, become more prominent. The outline of the spine on flexion is shown in the accompanying drawing. (Fig. 20.) On trying to bend backward (Fig. 21) the dorsolumbar region retains its kyphosis. On lateral flexion the kyphotic part of the .spine is invariably curved in the opposite direction. Figure 22 shows the outline on flexion to the right ; and figure 23 the outline on flexion to the left. The patient has been perfectly able to work and has never suffered from any further symptoms of his accident twenty-nine years ago. In respect to tlie after-treatment of spinal fractures, a long jieriod of rest in bed is to be recommended, espe- cially in consideration of tlie soft cancellous substance of the bodies of the vertebrte. If the patient is allowed to walk too soon, the weight of the body is apt to cause the formation of an angular spinal curvature, as described by Kiimmel. As an additional precaution a supporting cor- set .should be worn when the patient begins to walk about. Removable plaster supports are now made that do not in- terfere with treatment by massage and electricity. The other symptoms — limitation of spinal mobility, with diffi- culty of stooping — may l>e helped by massage and elec- tricity as well as by medicomechanical exercises as soon as it is proper to emj^loy tlie latter. The paralyses are best treated by galvanism, alternating with faradism. In some cases static electricity will be found very useful, especially if it is difficult for the patients to undress them.selves, when the skin is sensitive to the air or to wet electrodes, or when they are especially susceptible to sug- gestive treatment. In other respects treatment is purely symptomatic. In many cases the course of treatment must cover a very long period. In case of serious compression-frac- tures one year of treatment is to })e anticipated, although recovery may take place sooner. The patient, however, may be able to resume work in a comparatively short HEALED FRACTURES OF THE SPINE. 169 time, even in severe cases. We must bear in mind that in cases of compression-fracture there is always an exten- sive growth of calhis and at the same time considerable absorption of bone tissue, and that, in addition, the inter- vertebral discs that were injured at the time of fracture usually undergo com})lete atrophy. It may happen, for these reasons, that an angular cairvature is developed some time after the accident : in many cases, after the lapse of some years. Fracture of a vertebra may give rise to so few symp- toms that it is overlooked in the presence of other more striking injuries. Wagner and Stolper describe a case in which the spinal fracture accompanied fracture of the base of the skull, concussion of the brain, and fracture of the thigh. It was not discovered until three days after the accident, Avhen the patient complained of pain in his back. I have known of cases of spinal fracture that occurred in conjunction with other injuries and that were overlooked, in spite of a long stay in the hospital, for the reason that the cord was uninjured and the patient made no complaint. Such fractures are especially likely to be undiscovered if, after the accident, the patient is able to walk to his home (^r to the doctor's office. Refer- ence to cases of this description can be found in the works of Wagner and Stolper. Case of fracture of the lumbar vei-iebrae, complicated hy a nnilateial lesion of the cord. Sequel : recovery, with paralysis of the right lower extremity, myelitis, ej'stitis, and nephritis. A workman, thirty-three years of age, as he was engaged iu pulling down a wall, on August 6, 1895, was hit on the hack hy a numher of falling stones, heing iu a stooping position at the tiine. He was knocked down and could not arise again. He was treated in the hospital until March 22, 1H96. He sutfered from paralysis of the bladder and rectum, bloody urine, and retention, alternating with in- continence of urine. I examined him on April 9th. He was a rather large man, pale and sickly in appearance ; he walked with difficulty, leaning on two canes. There was a very slight kyphosis of the lum- bar region. Botli legs showed atrophy, the right lieing much more affected. On walking, the right leg was swung foiward from the hip, the patient being uual)le to lift it. The muscles of the left buttock ap- peared very tlabby ; a sup2)urating bed-.sore still persisted iu the neigh- 170 DISEASES CAUSED BY ACCIDENTS. PLATE 9. Case of Fracture of a Lumbar Vertebra Following a Slight Injury. — Sequel, tu})erculosis of the lumbar vertebite. Kyphosis marked. Death occurred seven years later froui tuberculosis of the brain. A mason, thirty-five years of age, on attempting to lift a box of lime felt something "crack" in his back, and had to stop work on account of pain. Three months later I examined him and found the condition here illustrated. He walked with difficulty. No paralyses. One year after injury : paralysis of extremities and beginning dis- turbances of speech. borhood of the anus. The ribs felt thickened on the right side of the back under the scapula. There were no cardiac murmurs ; pulse, 100. The patellar reflex was abolished on the right side, diminished on the left. The temperature was raised. The urine contained considerable albumin ; there was a purulent cystitis. He entered the hospital. I again examined the patient SeptemT)er 7, 1899 ; except in respect to the cystitis, which was cured, there was no change in his condition. Insurance allowance, 100%. Case of healed fracture of the lumhar vertebral, complicated by lesion of the cord. Death occurred from diabetes mellitus after five years. A carpenter, twenty-nine years of age, fell from a scafltblding September 17, 1888. He was treated in the hospital up to Decem- ber 20, 1888. He was a man of moderate height. At the level of tlie first and second lumbar vertebrae there was a slight but distinct angular (;urvature. Other symptoms were sensitiveness to pressure, difficulty of motion, inability to stoop, and paresthesia of the lower extremities ; the ])atellar reflex was exaggerated on the right side ; there was incontinence of urine and of feces. The patient gradually grew worse, and died October 13, 1893, of diabetes. In tlie majority of cases of healed fractures there is a considerable degree of incapacity for self-support ; in my own cases 33 J to 50 ^y insurance was usually allowed. Fully one-third of all cases received 100^. Nevertheless, we sometimes meet with cases of severe injury in which the victim, although outwardly changed in consequence, is able to resume work in a comparatively short time. Traumatic Diseases of the Spine and the Spinal Cord. Tuberculosis (Caries) of the Spine. — The spine in both children and adults is a favorite seat for the develop- Tab. It. / K^^^^ lAth. Anst E Reicfihold, Uunrhen. TUMORS OF THE SPINE. 171 ment of tuberculosis, the cancellous tissue of the bodies of the vertebrae being especially subject to attack. We are not concerned here with frank cases of spinal tuberculosis, but rather with the latent form of the dis- ease as it exists in apparently^ healthy individuals, who are able to do their regular work until some accident occurs as a result of which the latent process is stirred to activitv, permanently incapacitating the aifected person for self-support. The traumatism may take the form of a contusion, a sprain, or a dislocation, or it may be so slight as scarcely to be considered an injury at all. The traumatism frequently results in the fracture of a verte- bra, leading to an inflammation of the cancellous tissue and the fibrocartilaginous discs, which subsequently be- come suppurative ; or the process may be partly reversed, inflammation, suppuration, and fracture being the order of sequence. The final result is the development of an angular curvature of the spine, which is characteristic of the disease under consideration. The two cases illustmted in this section (Figs. 7 and 8 and Plate 9) show this de- formity very plainly. Tuberculous vertebrte are exceedingly fragile, a condi- tion that must necessarily affect the spinal meninges, the nerve-roots, and, lastly, the spinal cord itself. Persons aifected with spinal tuberculosis that has developed in consequence of traumatism are regarded as entitled to insurance. Infectious inflammatory processes of other kinds, of which traumatism may act as the exciting cause, — osteo- myelitis and actinomycosis, for example, — may be con- sidered to belong to this group of spinal diseases, of which tuberculosis is the most prominent member. The Influence of Traumatism on the Development of Tumors of the Spine. — Sdix-oiaata and carclnoinatd may develop secondarily in the spine as a result of metas- tasis from a ])rimary growth in another part of the body, and of this secondary development traumatism may be 172 DISEASES CAUSED BY ACCIDENTS. the exciting cause. In some cases primary sarcomata, carcinomata, and myomata are said to have developed in consequence of traumatism. The tumor involves the vertebrae, their processes, the nerve-roots, and, finally, the cord and its meninges. The bone becomes exceedingly fragile, and slight injuries are likely to lead to fractures, causing lesions of the cord and, consequently, paralyses. In other cases the fragments become displaced gradually, compressing the cord slowly but surely. The relation of the traumatism to the tumor-growth is clear if symptoms begin to appear at once. In the early stages sensitiveness to pressure and pain on movement are the only signs of the troul)le ; later on, localized inflam- mation and the growth of a tumor can be determined, followed in turn by spinal curvature and paralyses, and finally by cachexia. Traumatic Diseases of the Spinal Meninges. The secondary affections of the spinal meninges that concern us here have been referred to in the beginning of this section. Two forms of chronic inflammation remain to be discussed : 1. Hypertrophic cervical pachymeningitis. 2. Chronic syphilitic meningomyelitis. 1. The lesion consists of a layer-like gi'owth of fibrous tissue in the dura mater, by which it is greatly thickened. Adhesions are formed with the periosteum on one hand and with the cord and nerve-roots on the other; the lower part of the cervical cord gradually becomes conq)ressed. As a result of this compression we have the following characteristic sym})toms : Fain in the neck and between the shoulders and in the back of the head ; rigidity of the neck ; sensitiveness to pressure over the cervical vertebrae ; neuritis affecting the ulnar and median nerves ; paresthe- sias : degenerative j)aralyses of the small muscles of the hand and of the flexors of the fingers ; contractures and COMPRESSION MYELITIS. 173 overextension of the wrists, cine to the unbalanced action of tlie extensors. The affection may follow traumatism or other causes, such as strains, exposure to cold, syphilis, and chronic alcoholism. 2. Chronic syphilitic meningomyelitis is, as its name indicates, a specific syphilitic disease of the cord aud its meninges, and, therefore, a descriptiou is not in place here. Its development, however, is said to be called forth by exposure to cold and by traumatism. Compression Myelitis. By the term compression myelitis we understand an in- flammation of the spinal cord caused by pressure from the bones displaced in consequence of dislocation or fracture of the vertebrae. The inflannnation, which is chronic in nature, may also be caused by hemorrhage, and is fre- quently observed in cases of carcinoma and caries. The symptoms are as follows : neuralgic pains in the spine, girdle sensation, pains radiating toward the extremities. In addition, there are special symptoms, varying with the level at which the lesion occurs. The dorsal region is most frequently involved. Lesions here are followed by a spastic paraplegia of the lower extremities, disturbances of sensation, bladder disorders, etc. If only one side of the cord is affected, we have the symptoms described by Brown-Sequard. The prognosis is grave, death usually occurring in the course of one or two years, from cystitis, nephritis, bed- sores, or some other complication. The inflammation may spread in a transverse diameter, giving rise to a myelitis transversa, or it attacks different places in the cord and becomes a myelitis disseminata. The symptoms correspond to those described in the beginning of this section in regard to the pathology of the spinal cord. 174 DISEASES CAUSED BY ACCIDENTS. Secondary Degeneration. When, in consequence of tnunnati.sm, nerve-fibers are severed from their tropliic centers, they undergo degenera- tion, whicli may take a descending or an ascending course according to the position of the centers, whether central or peripheral. In the case cited by Wagner and Stolper the fifth dorsal vertebra was the seat of a carcinoma : The patieut, a man forty-six years of age, had recovered one month previously from a pleurisy Irom which he had suffered for six months, when he was again taken to the liospital for tumor of the ribs. Three days hiter there was paralysis of sensation in both lower extremities, especially in the right one. Two days later the paralysis of sensation had extended upward as far as the seventh rib. Motor paralysis of the lower extremities was manifested soon afterward, with retention of urine, constipation, and cystitis. Death occurred in forty-four days. Traumatic Inflammation of the Neuroglia and Traumatic Syringomyelia. As a result of injuries of the cord a growth of cicatri- cial tissue takes place, involving the supporting frame- work — the neuroglia — as well as the connective tissue of the l)lood- vessels. This hyperplasia of the neuroglia may be based on a congenital tendency. It is often the precursor of destruction of the cord-substance and of cavity formation — syringomyelia. Syringomyelia may also be directly caused by traumatism. It is most fre- quently found in the cervical region. According to Wagner and Stolper, the following })oints are of assistance in determining the traumatic origin of syringomyelia : 1. Signsof a healed fracture or dislocation found in the vertebroe point to traumatism. During life kyphosis is frequently seen, while scoliosis is more characteristic of the nontraumatic form. 2. Traumatic syringomyelia is most frequently seen in the regions especially subject to fracture : i. e., the lower dorsal and lumbar regions ; the nontraumatic form is more likely to occur in the cervical region. TEA UMA TIC S YRINGOMYELIA . 175 3. In traumatic syringomyelia we are likely to find adhesions and hyj^ortrojihy of the meninges, both with each other and M'itli the wall of the vertebral canal. Some exogenous cause is likely to be discovered, whereas in the nontraumatic form of syringomyelia, which de- velops as the result of a central hyperplasia or destruc- tion of the neuroglia, this is not the case. For the same reason we find a proliferation of the pia mater in the one case, but not in the other. 4. In traumatic cases the cavity is likely to be situated in the posterior columns ; otherwise it is found only in the anterior horns ; in the nontraumatic form the posterior commissure is the favorite site. 5. In the traumatic form blood-pigment is often found ; its presence can not be explained on the ground of idio- pathic aftection of the blood-vessels, which is, as a rule, seen in connection with the nontraiunatic form. An ascending neuritis, occurring in consequence of a peripheral injury, is said in some cases to be followed by syringomyelia. Symptoms. — Localized ^ympioms: [We are hardly in a position as yet to speak of trau- matic syringomyelia. There are two possibilities. One is that a trauma, by causing hemorrhage into central gray matter that is already diseased, calls forth into activity a latent myelosyringosis. The other possibility is that cen- tral hematomyelia, as described in the note on page 135, may cause permanent sym])toms similar to those of syrin- gomyelia. But neither possibility would justify the term "traumatic syringomyelia." For, in the first, the trauma would be merely a contributory cause ; and the second, while it might in its symptomatology be identical with syringomyelia, would l)e so different in pathogenesis that nothing would be gained by giving it the name of a chronic progressive disease when its own name of trau- matic hematomyelia so well describes it. — Ed.] 1. Progressive paralysis and muscular atrophy, in- 176 DISEASES CAUSED BY ACCIDENTS. volving one or both sides. In nontraumatic cases the upper extremities are especially involved. The atrophy is of the degenerative type ; fibrillary spasms can be observed, and the electric reaction is that of degeneration. 2. Disturbances of sensation. The tactile sense re- mains unaifected, while analgesia and thermal anesthesia are manifested ; burns are not felt. 3. Trophic disturbances of the fingers, of the feet, and of the corresponding joints, and of the nails; contractures and rigidities ; formation of ulcers. 4. Paralysis of the bladder and rectum, impotence, etc. Case of syringomyelia foUowinff cellulitis of the forearm and ascending neuritis. A workman, twenty -nine years of age (alcoholic), was injured in his left forearm near the elhow-joint by the penetration of a piece of wire, on August 9, 1895. His arm was treated for one week with wet dressings, incision then being practised on account of marked swelling and fever. I examined the patient November 9, 1895. His left elbow was fixed in a position of slight flexion ; the scar on its ex- tensor surface was not quite healed and was still suppurating. The left arm was considerably wasted, especially the hand. Treatment was first directed to the wound ; then to the contracture of the joint. Neuritic .symptoms gradually manifested themselves, at first in the forearm, then ascending as far as the shoulder. The whole arm was the seat of severe pain, which also extended to the shoulder and to the whole leftside of the throat and neck. There was pain on motion of the head and on attempts to rai.se the arm ; also tremor in arm and hand. The patient closed his hand with great difficulty, and was un- able to grasp anything tightly. Atrophy of the nails began to appear, and the distal phalanges showed signs of stiffne.ss, while the muscles of the hand were greatly wasted. There were, in addition, thermal anesthesia, necrotic ulcers on the fingers, tremor of the facial muscles on the left side, marked dilatation of both pupils, and diminution of the pupillary reflex. Insurance allowance, 60%. Tn multiple sclerosis we have another disease giving localized symptoms, in which sclerotic patches are foinid scattered through both the brain and the cord ; it is observed as a sequel of either central or perijiheral traumatism. The symptoms are somewhat variable, as may be expected from the irregular distribution of the SPASTIC PARAPLEGIA. Ill lesion. They include : Disturbances of speech ; a slow, scanning, and monotonous manner of speaking ; nystag- mus ; exaggerated reflexes ; spastic and ataxic gait ; in- tention tremor ; and uncertain, exaggerated movements. The treatment is symptomatic. Chronic Progressive Anterior Poliomyelitis. Disease of the anterior horns may l)e due to injuries and diseases of the central nervous system, or it may follow an ascending neuritis. Tlie muscles supplied by the diseased parts undergo atrophy, but respond to the will as long as any muscle-fibers are left. The reflexes are diminished but not abolished. The application of cold to the skin (sometimes blowing on it will suffice) induces slight spasms in the affected muscles, involving only separate bundles or fibers, which are to be looked u[)on, ' according to Leube, as pathologic reflex contractions (Thiem). The skin of the affected region is reddened or bluish-, red, and occasionally shows a vesicular eruption. A cer- tain amount of improvement may take place ; the prog- nosis, therefore, is not entirely unfavorable. Spastic Paraplegia. [In many of the cases to which this clinical term is given the underlying lesion is probably multiple sclerosis. — ^Ed. ] In this affection of the cord, which may follow either central or peripheral lesions, the lateral ])yramidal tracts are involved. We have, therefore, the following symp- toms : exaggerated reflexes and diminished muscular power, without atrophy or degeneration. If in the course of time the process extends to and in- volves the anterior horns, atrophy will, of course, result. The first symptoms to be manifested are weakness and atrophy of the muscles of the hand. The spastic paresis characterizing the gait is seldom noticeable until some time later. The atrophy extends upward to the shoul- 12 178 DISEASES CAUSED BY ACCIDENTS. der ; the muscles soon show fibrillary contractions and the reaction of degeneration, while the reflexes become exaggerated. The patellar reflex is likewise afl'ected ; foot-clonus and bulbar symptoms also develop. Tabes Dorsalis ; Locomotor Ataxia. [Much the same difficulty as was described for general paresis is met with in the attempt to fix a traumatic causa- tion for locomotor ataxia. Tabes is very insidious in its onset, and most of the early symptoms are of a char- acter that no one but the physician familiar with nervous diseases would recognize. There is no room for doubt that injuries often first bring the disease to the notice of the patient, or that through injury it becomes very much worse. But to show that an injury is the sole cause of it, in the seuse that without the injury the disease would not have occurred, will rarely be possible. — Ed.] As a result of traumatism this disease, which may have been in existence for a number of years without noticeable manifestation, is suddenly awakened into activity and makes rapid progress in its development. Since marked tabetic symptoms in such cases do not appear until after the injury, the term " traumatic tabes " is not altogether out of place. The cases referred to later are interesting in this connection, no tabetic symptoms whatever having been manifested, or at least noticed, previous to injury. The exciting traumatism may act either centrally or peripherally. Instances of central injuries are : hemorrhages into the substance of the cord (from concussion of the cord (?)), con- tusions, and dislocations or fractures of the spine involv- ing lesion of the cord. To the peripheral causes belong : sprains, dislocations, and fractures of the ankle-joint or of any part of the lower extremity, severe contusions, and phlegmonous inflammations. The patient need not be completely incapacitated for self-support, even in cases presenting definite tabetic symp- LOCOMOTOR ATAXIA. 179 toms ; complete incapacity is not tp be recognized until the symptoms become quite marked and until the charac- teristic gait is well developed. The most important symptoms are : (1) Loss of pupil reflex ; (2) loss of patellar reflex ; (3) ataxia (uncertain, stamping gait ; unsteadiness on closing the eyes). The disease is- further characterized in its diflerent stages by paralytic disturbances of sensation and of the functions of the bladder, severe pains, vomiting, cough, difficulty in breathing, ocular paralysis, etc. . In respect to treatment, some improvement may be gained from antisyphilitic remedies, the underlying cause of the disease being specific in the majority of cases. Gymnastic treatment has been highly praised in the last few years ; baths and nerve tonics may also prove bene- ficial. Recovery is, however, out of the question ; the progress of the disease can not be arrested. The arthropathies seen in cases of tabes have already been referred to in the first part of the book. Case of locomoior ataxia following ^^ concussion of the spinal cord.^' A carjjenter, fifty-two years of age, fell from a building on November 14, 1891, striking on his back. He was first treated at home by his lodge physician, and by him sent to a nerve specialist, who treated him for " Inmbago." He was next cared for at home by a doctor who i'ound him in bed with fever and made a diagnosis of " influenza." The physician into whose charge he next fell diagnosed pulmonary phthisis. Finally, in the hospital, a diagnosis was made of incipient tabes, based on the following symptoms : loss of pupillary reflex (pupils much contracteil), marked swaying of the body on clos- ure of the eyes, and loss of the patellar reflexes. I examined the patient February 19, 1892. He was a small, pale- faced man. In addition to the symptoms mentioned, he frequeutly suffered from incontinence of urine and from diarrhea. He declares that he was always well prior U^ his accident. His condition has remained unchanged up to date. Insurance allowance, 100 fo. Case of locomotor ataxia following a sprained ankle. A mason, thirty-nine years of age, sprang from a scaffolding on Novenil)er 4, 1893, in order to save himself from a severe accident that would otherwise have followed a misstep. He landed with his right foot on a stone slab, striking his head against a wall. He imme- diatfly passed a large quantity of urine. He was taken home, where he lay in bed and was treated for a sprained ankle. Four weeks later he attempted to walk, and his peculiar gait was at once noticed by his 180 DISEASES CA USED BY A CCIDENTS. family. Tlie doctor diagnosed the case as one of tabes. The patient is said to have previously suftered from syphilis. I examined him Fel)ruary 26, 1894, and made the following diag- nosis : locomotor ataxia Ibllowiug peiipheral traumatism, consisting of a sprain of the right ankle. Arthropathy of the right foot. In- surance allowance, lOO'/c. No change in his condition up to date. Case of prccxistiiif/ hwomotor ataxia, the progress of ivhich was greatly accelerated hij fracture of the le;/, caused Inj a misstep upon a sharp stone. Sequel, complete incapacity for self-support. A mason, forty-six years of age, stepped on a sharp stone on Janu- ary 20, 1897 causing his leg to give way and throwing him to the ground. A fnictnre of the left leg was diagnosed and appropriate treatment was begun. I examined him March 6, 1897. He was a man of medium height and vigorous l)uild ; his gait was markedly ataxic. Tlie pupils were small and did not react ; patellar reflexes were lost. On closing his eyes, even when sitting, there was marked swaying of the body. Diagnosis, locomotor ataxia. The patient had had sy))liilis twenty years earlier ; he was married, but had no children. In 1896 he had suffered from " rlienmatism " in his arms and legs for eight weeks. At that time he began to notice unsteadiness of gait, but was able to work, even on scaffohlings. Since his accident he has been completely incapacitated for sell-support. His insurance allowance ecjualed 33j% at first; later, it was raised to 66'^% by legal process. The fact of the precxistence of the disease was taken into consideration. Cases of paralysis agitans can occasionally be traced directly to an injury ; the case of my own given later is an instance of such relation. The aftection, which is peculiar to middle and old age, presents characteristic symptoms. The patient holds his body bent forward in a crouching posture, while one forearm is in a state of constant tremor. The tremor ceases during sleep or when the patient is rest- ing quietly, but is induced and increased by excitement. There may be a temporary lull in the symjitoms, simulat- ing an improvement. By reason of the age of the patients they are usually rendered incapable of self-support. Case of paralysis agitans following fracture of the ribs and contusion of the spine. On October 24, 1888, a workman, sixty years of age, slipped and fell to the ground, striking his l)ack against the edge of a wheelt)arrow. Four weeks later, when union had taken place in the broken ribs, he noticed the first symptoms of nervous disease, which I diagno.sed as paralysis agitans on January 18, 1889. The traumatic etiology was recognized, and 100% insurance was allowed. The condition of the patient has remained unchanged. TBA UMA TIC NEURASTHENIA. 181 Spinal Irritability ; Spinal Neurasthenia. The classic researches of Wagner and Stolper have cast a donbt upon the traumatic origin of this atfection, and, indeed, upon its very existence. The symptoms that have been considered to belong to it — pain in the back and loins, sensitiveness to pressure on the spine, exaggerated reflexes — may in reality l)e the forerunners of serious dis- orders of later development. If not, they may be looked upon as symptoms of the functional neuroses. In the two cases of Leyden and Schiitfer cited by Thiem there was a subsequent development of tuberculosis. [This is contrary to the teachings and experiences of most neurologists. Traumatic neurasthenia is generally accepted as the best name for certain types of nervous exhaustion that are frequently the results of accidents. In such cases no evidences of gross structural injury to the central nervous system are apparent or ever become so. The symptoms are almost identical with those of neurasthenia in which injury has had no part. — Ed.] Case of traumatic neurasthenia following contusion of the spine. A man, thirty-nine years of age, was hit in the back by the pole of an omnibus on January 25, 1893. He was treated in a dispensary for four weeks, then in the hospital for two weeks, when clinical treat- ment was resumed. He attempted to work, but was obliged to stop on account of pain in the back. He has not worked since April 27, 1893. He is a large man of moderately vigorous build. Symptoms. — Depressed expression ; easilj' moved to tears ; restless- ness ; insomnia ; dilated pupils, which react slowly. The spine was sensitive to pressure throughout its length, and especially in the dorsal region ; it was fixed on every attempt at motion. The reflexes were exaggerated ; there were no sensory disturbances. Examination did not give definite results. The gait was somewhat dragging. The patient's condition has remained unchanged up to date. He lies abed much of the time, and can not be induced to attempt to work. Case of traumatic neurasthenia of a hypochondriacal character follow- ing a fall from a height. {Siniulntion suspected.) A roofer, twenty-eight years of age, fell from the roof of a five- story hon.se on October 11, 1889. He suffered a slight concussion of the brain, a number of contusion-wounds, and a sprain of the right ankle. He was treated at hoine, lying in bed for four weeks. I ex- amined him January 15, 1890. He was quite a large, powerful man, 182 i)isl:A8Es CA used by a CCIDENTS. of rather pale complexion. Hi? expression was depressed, hut at the same time surly and detiant. Physical examination was complained of as exceedingly painful, and was in part not permitted. There seemed little basis for the innumerable complaints of the patient. Although he declared himself to be unable to do work of any kind, he is known to have worked as a roofer, receiving full pay. He was consequently declared to be capable of self-suppoit, but subsequently was allowed 25 fo insurance b}' the court. Case of traumatic hysteria of a hypocJionihiacaJ character fottowing contusion of the sj)ine. A mason, forty-two years of age, was struck on the back by a heavy stone, which iell from the third story, on April 18, 1887. He felt faint and discontinued work. He was treated for ten days in the hospital, and was then discharged, on his own request, as cured. I examined him on July 19, 1887. He was a large, rather vigor- ously built man. He held his body somewhat inclined i'orward ; his expression was depressed, and his eyes had a somewhat staring, vacant look. The facial muscles were noticeably unmoved when he spoke. The spine was sensitive to pressure and was fixed on motion of the body ; the cutaneous reflexes and tendon-reflexes of the lower extremities were exaggerated; there was a tremor in the latter and muscular weakness in the arms. Sensation was diminished in the right leg and in both forearms ; there was anesthesia to pain in the same parts. The pulse was exceedingly ra])id. The patient com- plained of a feeling of oi)pression and of melancholy. His subsequent conduct has given cause for much displeasure ; he writes threatening and complaining letters to his trades-union, and considers that he is badly treated ])y everybody. Insurance allow- ance, 100%. He has done no work since his accident. Contusion and Crushing of the Back. In preparing the following I have made use of seventy-eight cases of injuries of the back that have come under my own observation. Contusions of the back caused by falls, kicks, or blows from falling objects usually give no trouble after the hem- orrhagic extravasations have been absorbed and the ])ain has disappeared. Individuals thus injured may not find it necessary to interrupt their work at all, and in any case resume it, as a rule, Avithin two to three weeks. Severe cases of crushing, such as are seen after the caving-in of buildings, demand a longer course of treatment, and are followed by a limitation of mobility of the body, affect- ing the patient for a considerable period. All such cases should be examined with the greatest care, or else an injury of the spine may be overlooked. STBAINS OF THE BACK. 183 Wounds and Cicatrices of the Back. Movement of the body nuiy be noticeably limited by the cicatrices that follow extensive wounds of the back. Stooping, for instance, is made difficult for some time by sears in the region of the long extensor muscles of the back. Treatment should be directed chiefly toward obtaining a nonadherent, movable scar. Case of a cicatrix adherent to the twelfth rib on the left side, consequent upon a punctured wound of the back, complicated by lesion of the kidney. A carpenter was injured on August 2:5, 1898, by a chisel, which penetrated his back on throwing his sack of tools over his shoulder. The lesion involved the left kidnej'. He was operated upon in the hospital, where he remaiued for three weeks. I examined him on December 19, 1898, and found the kidneys nor- mal. In the region of the left kidney there was a scar, of recent origin, and about 10 cm. in length, which ran obliquely across the back. It was attached to the twelfth rib and was adherent through- out ; on stooping, the scar became very tense, and prevented deep flexion or flexion to the right side. The muscles of the leftside of the back were atrophied. Insurance allowance, 20%. On May 10, 1898, the scar was found to be paler, nonadherent, and freely movable. He was able to stoop with ease, and could pursue his trade without difficult}'. He showed evidences of attempted sinuilation. Burns of the back lead to the growth of more or less extensive scars, according to the size and intensity of the lesion. When recent, these scars limit mobility to a con- siderable degree. The patients, as a mle, recover full capacity for self-support. Severe cases, however, neces- sitate treatment for a long period. Strains and Lacerations of Muscles and Tendons. Under this title are described various painful affections of the back, usually of traumatic origin, the pains dating from the time of accident. It is quite possible for laceration of muscle-fibers to take place as a result of carrying heavy loads, of awkward movements, of carrying a load on one shoulder, or even of falling on the back on rough ground. There may be almost no external sign of injury, yet the pain may be 184 DISEASES CAUSED BY ACCIDENTS. very severe. Sometimes the pninful point is found to be swollen. In the cases marked by persistent pain, in the absence of swelling a very thorough examination is indi- cated, in view of a possible injury to the spine, such as fracture of one or more of the })rocesses or lacerations of the ligaments. In all cases of so-called traiimatio lumbago exann'nation of the urine for })hosphates is strongly to be recommended, since phosphaturia frequently causes the symptoms of lumbago. It is undoubtedly a fact that lumbago may de- velop after traumatism, giving rise to the ])ains, commonly of a rheumatic nature, that suddenly attack the patient in the shape of a " crick in the back." The same symptoms may be due to direct contusions of the sensory spinal nerves or of their roots. The ])ains in the loins may be so severe as almost to prevent the patient from moving. In less severe cases the fixation of the spine, giving a stiff a])pearance to the patient, is very noticeable ; also the inability to stoop or to rise from a sitting ])osture without the aid of the hands. Reference has already been made to the sprains of the articular processes of the fifth lumbar vertebra, which are momentarily forced into the lumbosacral fossa. The lifting of heavy weights sometimes gives rise to symptoms that are indicative of a lesion of the ligaments in this situation, and that are entirely similar to those of luml)ago. Subcutaneous rupture of muscles has been observed in the long muscles of the back, in the erector s])inie and also in the latissimus dorsi. The cause of this injury is not definitely understood. In the cases that I have seen in which the erector spinre Avas ru])tured by a fall on the back the point of ru])ture was plainly visible. The lower part of the muscle had retracted, forming a thick roll, while the overlying muscles were distinctly atrophied. Stooping was painful at first, but was easily accom])lished later on. In one case, in which the muscle Avas ruj)tured on both sides, a depression could be plainly felt running Fig. 24. 186 DISEASES CAUSED BY ACCIDENTS almost transversely across the buck. Stooping was so painfnl that it was not attempted at first, but improve- ment was evident at the end of two months. The insur- ance allowance in this case was 20^. In a case of rup- ture of the latissimus dorsi cited by Thiem it was very difficult for the patient to raise his arm or to place it behind his back. He recovered, however, by the use of baths, massage, and electricity. III. INJURIES AND TRAUMATIC DISEASES OF THE CHEST. AnatomicopJiysiologic Considerations. — Deformities of tlie tliorax, apart from congeuital abnormalities or those acquired through disease, are often observed in workmen as the result of special forms of work. Reference has already been made to the exaggerated convexity of that side of the thorax on which the load is carried as part of the deformity characterizing stone-carriers. In addition to the convexity, the ribs are usually separated on that side, while on the other the thorax is de- pressed and the ribs are approximated. The shape of the thorax may also undergo modification in consequence of a regularly maintained position of the body. In examining patients these facts should always be borne in mind or serious errors may result. Although familiarity with all the deformities due to work in the various branches of industry is hardly possible, we should, neverthe- less, make detailed inquiry into the employment of the patient, in order that a differential diagnosis ))etween deformities iucidental to such employment and the sequels of traumatism may be made. If we watch the thorax during respiration and during movements of the body, — fiexion, extension, and rotation, — we can observe differeuces in the action of the ribs on the two sides. A few words in I'espect to the term chest as understood by work- men will not be out of place here. It is used l)y them to describe not only the anterior bony wall of the thorax, ])ut also the adjacent part of the abdomen. It is, indeed, almost impossible to draw a sharp line between the two regions externally, since a not inconsiderable part of the abdominal organs are contained in the thorax. A special section being devoted to injuries of the former, they will be left out of consideration in discussing those of the chest, and will be referred to only when absolutely necessary. The thoracic and abdominal cavi- ties, although divided by the diaphragm, bear a very close and inter- dependent relation to each other, as we know from a study of their anatomy and physiology. The relation of the thorax to the upper extremities is also extremely important in regard to the effects of traumatism. Injury of the mus- CONTUSIOA^S OF THE THORAX. l87 cles of the tliorax or of the arm may seriously hamper the fnuctional action of other parts, or even disable them altogether. The mutual interdependence of the different regions of the l)ody and their rela- tions with ueighltoring organs should always be kept in mind in deal- ing with accident-cases. My material embraces 4"36 cases of injury of the thorax — 227 cases of contusions, 184 of fracture of the ribs, and 15 of internal injuries. CONTUSIONS OF THE THORAX. In the majority of cases slight contusions of the wall of the thorax, caused by falls, kicks, or blows, heal rap- idly and without sequels, necessitating only a day or two of rest. Some of the patients simply have a few cups applied and resimie work on the following day. The symptoms may, however, persist somewhat longer, involv- ing a course of treatment of several weeks' duration. Severe contusions, on the other hand, or even slight in- juries to individuals sutfering from an affection of the lungs, cause disturbances that may persist for some months, or even longer, in spite of treatment. Symptoms. — Pains in the chest, which are often diffi- cult to locate with exactness, dyspnea, palpitation of the heart, weakness, inability to stoop or to lift w^eights, fre- quency of anorexia, etc. On examination we may find affections of the pleura (dullness, diminished res[)iratory sounds, friction-sounds, more or less circumscribed tenderness) or of the lungs (traumatic pneumonia) ; also affections of the pericardium or of the cardiac muscle, of the stomach, or of the liver. We may find, in short, a number of morbid conditions that were not noticed at first, since their onset was gradual, but that were made evident and aggravated by a too early resumption of work. AVe shall refer again to these symptoms. Since severe contusions may cause laceration of the thoracic organs, it is only to be expected that similar but more severe lesions should occur in the peculiar cases of crushing of the thorax with which we meet in patients 1. -^ ^ i i Fig. 25. 190 DISEASES CAUSED BY ACCIDENTS. Case of fracture and crushing of several ribs on the right side. Sequel, perfect recovery. A coachman, forty-six years of age, was thrown from the seat of his carriage on January 4, 1898, the hind wheel passing over his chest. On examination a definite diagnosis of fracture could he made only in respect to tlie seventh rib on the right side. On February 7, 1898, examination showed a fibrous pleuri,sy of the right side. He was allowed 30% insurance. On March 8, 1899, he was declared to be perfectly capable of self-support. Case of severe crmhing of thr right side of the thorax and right shoulder, complicnied by fracture of the ribs and injury of the lung. Sequels : pul- monary tuberculosis and complete paralysis of the right arm, right shoulder, and right side of the thorax. A man, twenty-seveu years of age, was caught under a falling build- ing, sustaining the foregoing injuries. The injury of the lung was at once followed by pneumonia, requiring treatment for a long time ; later, tuberculosis is developed, but was brought to a standstill by treatment in a sanitarium. His right arm is completely paralyzed, and is cyanotic and cold ; the right side of the thorax is also para- lyzed ; its expansion is restricted ; no respiratory sounds are percepti- ble on that side, and the muscles of tlie right side of the chest and back are greatly atrophied. Insurance allowance, 100%. Fig. 25. — Case of severe crushing of the thora.v and fracture of several ribs (p. 189). Sequels : chronic pleurisy ; death from tuberculosis. A man, thirty-eight years of age, fell to the ground on June 4, 189(>, in such a way as to cause his hod, filled with lime, to strike on the left side of his chest. He was treated at home by means of compresses and medicine, lying in bed for eleven days. On November 6th he resumed work ; on February 13, 1897, he was obliged to cease work again on account of pleuri-sy on the left side. I examined him on February 17, 1897. He was a large man, but greatly wasted. The left side of the chest at the level of the fifth to the seventh ribs, inclusive, was deeply depressed. The respiratory sounds were diminished in intensity over the entire left side of the thorax, and at the area of depression they could not be heard. On inspiration the left side of the thorax expanded less than tlie right ; movements of the thorax were difficult. A second examination, on June 2, 1897, showed dyspnea, cough, and loud rales over the left apex. The patient was exceedingly emaciated. He died of pulmonary tuberculosis on September 28, 1897. COMMOTFO PECTORIS ; CONCUSSION OF THE CHEST. This lesion is caused by severe contusions, and is immediately followed by unconsciousness. In severe cases death may occur at once ; if less seriously injured, the patient may recover from the shock and may regain his health in part or entirely. Permanent disturbances may, WOUNDS OF THE CHEST. 191 however, result, such as very severe forms of hysteria, leading to complete incapacity for work, of which I have myself seen several instances. Case of commotio pectoris, followed by severe hysteria, tcifh frequent con- vulsions. A mason, forty years of age, fell from a ladder on November 7, 1892, striking with his chest against a box of lime. He was unconscious for a time, but was afterward aV)le to walk home, and after a few weeks of medical treatment resumed woi-k. He soon found himself unable to continue work. I examined him on February' 6, 1893 ; he Avas a fairly large, vigor- ous man. From the beginning of the examination he was greatly excited ; there ■s\as marked tremor of both arms and legs, first on one side, then on the other, accompanied 1)y facial spasms and outbursts of weeping. Muscular spasms were induced by examination of the reflexes or by reference to tlie consequences of the accident. The pupils were contracted and reaction was slow on both sides. Psychic- ally, he exhibited chronic hypochondriacal depression. The reflexes were greatly exaggerated. In testing the cremaster reflex on the left side spasms of the muscles of the left arm were immediately induced. The patient was completely incapacitated for self-support ; his condi- tion has remained unchanged uj) to date. WOUNDS AND CICATRICES OF THE CHEST. The degree of functional disaljility arising from cica- trices in this situation depends upon the size and loca- tion of the wound as well as upon its severity. If the cicatrix is extensive, deeply attached, and retracted, and especially if it is adherent to one or more ribs, consider- able disability may result. The usual symptoms consequent upon adhesions to the ribs are pain and a feeling of tension on deep inspiration, on lifting the arm on the atfected side, and on flexion of the body away from the latter. The muscles often undergo considerable atrophy. Fistulas due to empyema usually heal with deep, circular, and nuich-retracted scars, which give rise to symptoms indicative of involvement of the diapliragm or the intercostal nerves. The symptoms gradually diminish, even without treatment. They can be overcome in a comparatively short time by menus of mechanical treatment. 192 DISEASES CAUSED BY ACCIDENTS. Cicatrices resulting from l)urns are more spread out and superficial, and do not cause functional disturbances unless greatly retracted ; mechanical treatment — in j)artic- ular massage, by Avhich the scar-tissue is loosened and stretched — is also of great benefit in these cases. Ct(sc of severe contusion and ineificd wound of the rif/hf side of the c/icst. Secjuel, recovery, with extensive cicatricial growth ami limitation of mobility of the right shonlder-joint. A glazier, twenty-se\'en years of age, was caught between an overturned glass cupboard and a door on January 6, 1899. In addi- tion to the severe contusion he sustained, he was pierced in the right side of the chest liy the broken glass. He was treated in the hosiiital for five weeks. 1 examined him on ISIarch 6, 1R99, and found a number of scars adherent to the ribs on the right side of the chest ; the muscles of the affected region were git'atly atrophied, as were also those of the right arm. The latter could not be raised at the shoulder-joint to more than an angle of 9.") degrees; the right elbow-joint showed a contrac- ture of KJO degrees. The right ai'ni and the cicatrices were treated by massage. ISIe- chanical exercises were also prescribed, (^n May 2d the patient was discharged from the clinic because of disobedience of orders. He was then able to raise his arm to an angle of 155 degrees, and the mu.scles had increased in size. The pectoral nmscles, both major and minor, may be ruptured subcutancously by direct or indirect \ iolence. The lesion occurs in cases of dislocation of the humerus and in fractures of the coracoid process. The subclavius muscle may suffer a similar injury as a residt of fracture or dislocation of the clavicle or of fracture of the first rib. The muscles are, as a rule, only partly involved, but com- plete ru])tures of the pectoral nuiscles are sometimes seen in patients who have been run over or caught under fall- ing buildings, walls, etc. The remote symj^toms of the lesion are a depression in the groove of Mohrenheim, atro- phy of the muscles of tiie chest, shoulder, and arm, and limited mobility of the latter. Patients complain chit^fly of pain and weakness in the arm. Ivupture of the serra- tus nuignus is sometimes caused by exercises on the hori- zontal bar. This muscle, as well as the intercostals, may also be partly ruptured in cases of fracture of the ribs. FRACTURES OF THE STERNUM. 193 Partial ru})tures are best treated by exercises, baths, compresses, massage, and electricity. Complete rupture of the pectorales is followed by permanent functional dis- ability. Case of partial subcutaneous rupture of the pectoralis major. Sequel, improvement, with moderate degree of functional disability. A mason, thirty-eight years of age, was engaged, together Avith several fellow-workmen, in moving an iron beam, on December 19, 1893, when, in consequence of the blunder of the others, who let go the beam too soon, he recei\ed a very violent and painful strain. In spite of pain in the right side of the chest he kept on A\ith his work until December 2.'M. He treated himself for several days with compresses and inunctions, and began medical treatment on December '27th. I examined him and received him into my hosjjital on June 11, 1894. He was a rather large, vigorous man. On tlie right side the chest showed atrophy, and there was a marked depression in the groove of IMohrenheim, indicating a partial rupture of the pectoralis major. The right deltoid, biceps, and trapezius were atrophied ; the right arm could be raised only to an angle of 95 degrees. There were a tremor of the right arm and crepitation in the lower part of the cervical spine on movement of the heatl. The patient was discharged August 13, 1894, and was considered completely capable of self-sup- port, there being only slight fvinctional disability at this time. He was later allowed 20 % by the court, his symptoms having again in- creased. Fractures of the sternum are unquestionably a rare form of injury. They may be caused by direct violence, such as blows from falling weights, crushing under fall- ing walls, and similar accidents, or by indirect violence. The latter mode of occurrence is met with in cases of fracture of the bodies of the vertebrae from overflexion, and also in cases of similar lesions due to overextension. It is apparent that direct fractures of the sternum in- volve greater danger than the indirect form, both in re- spect to immediate and remote consequences. Symptoms due to changes in the underlying organs that were injured at the time of accident may persist for a long time. Compound fractures of the sternum are followed by cicatricial adhesions, which are likely to cause pain on vigorous movenftnit of the body, on carrying loads, or with rapid respiration, 13 194 DISEASES CAUSED BY ACCIDENTS. FRACTURE OF THE RIBS. I have treated or examined 184 cases of this injury, of which the majority were due to direct violence. In a nitnil)er of cases direct and indirect fractures occuired simultaneously. In order to obtain a clear understanding of the sequels of fracture of the ribs it is imperative to keep the sha])e and position of these hones clearly in mind. Reference has already been made to the remarkable elasticity pos- sessed by the ribs, by means of which they are able to en- dure great pressure without giving way. When the limit of this elasticity is passed, fracture occurs. Direct fractures of the ribs are caused by kicks, by blows with a blunt instrument, or l)v falling and striking on the sharp edge of a wall, table, board, step, etc. The fracture occurs at the point at which the violence is applied, the fragments of bone being pressed inward while the angle of fracture lies externally. In some cases one of the fractured segments is displaced outward, subsequently forming a callous thickening. The same rib may simul- taneously suffer an indirect fracture at another point. The fracture may be complete or incomplete, depending upon the degree of violence, the structure of the ribs, and the age of the individual. Incomplete fractures are very frequently met with, and, as a rule, involve the internal surface of the rib, as is to be expected if we considci* that the injury is usually caused by direct violence. The peri- osteum may remain intact, even if the rib is broken in several places. Fractures of the rib are most often observed in indi- viduals of advanced years. In youth the ribs possess a high degree of elasticity, while in old age they are liable to fracture from very slight causes. Complete fractures are produced l)y the same causes as incomplete fractures, the violence being only more severe. In complete fractures due to direct violence the periosteum, ih? parietal j^leura, the pulmonary pleura, and even the lung-tissue itself, are FRACTURE OF THE RIBS. 195 liable to be penetrated by the sharp fragments of bone. In some cases the pericardium, or even the heart itself, the liver, the spleen, or the kidneys are also involved in the injury. Bloody sputum, for instance, in cases of direct fracture, is indicative of injury to the pulmonary tissue. Indirect fractures are due to the action of a force that causes the ribs to bend to a degree exceeding their flexi- bility. These fractures are found in individuals who have been crushed between car-buffers, run over, etc. The ribs may give way at their angle or at their weakest points : namely, near their sternal or verteliral attachment. Indirect fractures of the ribs are often seen in connection with fractnre or contusion of the arm consequent upon a fall, the arm having been violently forced against the thorax, or accompanying contusion of the clavicle (in the case of the iirst rib) or scapula. The ribs are often broken in connection Avith fracture of the vertebrae — indirectly in cases involving the bodies of the latter directly, as a rule, when the transverse processes are concerned. In indirect fractures the bony fragments are forced outward. This form of lesion is, therefore, fraught with less danger to the lungs than the other — the direct form. INIuscular action alone may suffice to cause fracture of the ribs. A number of cases are recorded in which the fracture was due to coughing or sneezing ; F. Baehr has collected twenty-four such cases out of a total of thirty- five cases caused by muscular action. In most instances such accidents undonljtedly occur in old persons, or as a result of pathologic processes in the ribs. Baehr, however, cites cases of fracture caused by muscular action that can not be thus explained. It is })Ossible, of course, for frac- ture to occur in healthy persons in consequence of antago- nistic action on the part of the abdominal muscles during the lifting of heavy weights. My own observations in- clude several instances of this nature. One cavse concerned a workman, sixty years of af^e, who, immedi- ately after trying to catch a paving-stone that was thrown to him, felt 196 DISEASES CAUSED BY ACCIDENTS. PLATE 11. Case of Direct Fracture of the Eighth, Ninth, and Tenth Right Ribs near the Vertebral Column, and of Indirect Frac= ture of the Seventh and Eighth Ribs, or of Their Cartilages, in the Mammillary Line, Complicated by Fracture of the Body of the Ninth or Tenth Vertebra. Sequel, recover}^ with subsequent severe functional disturbances and intercostal neuralgia (referred to under Fracture of the Vertebraj). A mason, thirty-five years of age, on October 5, 1895, fell from a wall aljout twenty feet high, sustaining the injuries cited above. I examined him December 2>^, 1895, and, in addition to the symptoms due to the spinal lesion, the following were noted : The seventh rib on the right side protruded sharply in the mammillary line; over the lower part of the left lung up to about the nipple there were dullness and diminished respiratory sounds; e\en light percussion was very painful ; the least touch over the region l)etween the eighth, ninth, and tenth ribs caused the patient to start h-M-k violently. Posteriorly along the spine there was sensitiveness to pressure from the eighth to the tenth ribs inclusive. This sensitiveness could be followed in the inter- costal spates to the front of the chest (intercostal neuralgia). The mobility of the right arm at the shoulder-joint was restricted. Insur- ance allowance, 100%. a violent stabbing pain in the left side of his chest. A diagnosis was made of fracture of the left fifth rib near the anterior axillary line. Healing is, as a rule, marked by only a slight growth of callus, although in some cases a relatively large forma- tion can be observ^ed. I have seen callus-tumors of the size of a walnut, or even considerably larger when situated near the cartilage. In an average case of fracture of the ribs in a full- grown man union by callus takes place within three or four weeks ; the process may, however, be completed earlier, or it may require a much longer time. The ribs usually remain in position after fracture, but may be considerably displaced. Sometimes we find two adjacent ribs connected by a bridge of callus. When fracture occurs in the neighborhood of the spine, the pos- terior vertebral fragment is apt to be displaced behind the anterior. In fractures involving the sternal ends of the ribs the reverse holds good. Vertical displacement of Tab. II. i LUh. Atist F. ReidilKiUi . Munclun. FRACTURES OF THE RIBS. 197 the fragments is also seen in some cases. The injuries of the soft parts — such as the periosteum, pleura, and mus- cles — are followed by cicatricial growth leading to adhe- sions and to subsequent contraction of the tissues involved. Aneurysms occasionally develop as a result of laceration of the intercostal arteries, while lacerations or other injury of the intercostal nerves, although causing a great deal of pain at first, may heal perfectly and without secpiels. The result is not always so favorable, however, the dis- turbances sometimes persisting for a long time, or even permanently. Symptoms of healed fractures of the ribs depend on the form of the lesion (whether direct or indirect), the struc- ture of the ribs, the age of the individual, the manner and duration of healing, and the location of the injury. Certain sym])toms, however, are common to all cases. General Symptoms. — In all cases in which the frac- ture involves a numl)er of adjacent ribs, symptoms that continue to incommode the patient for a long time are met with on deep inspiration and on movement of the trunk. He finds stooping difficult, as also the lifting of weights, especially with the arm of the injured side. Pain is caused by flexion toward the opposite side and by deep in- spiration. The mobility of the thorax is even more seri- ously affected if bony union takes place between two or more adjacent ribs ; in these cases the patient is unable to raise his arm easily or to place it behind his back. The prognosis as to function largely depends on whether the fracture is due to direct or to indirect violence. In the former case the outlook is usually less favorable, because of the danger of penetration of the periosteum, ])leura, and lungs, or other organs, by the sharp fragments of bone. Local Symptoms. — Fractures in the neighborhood of the spine aft'ect the action of the costotransverse and costo- vertebral articulations, thereby limiting the mol^ility of the spine and causing })ain on movement. Lacerations 198 DISEASES CAUSED BY ACCIDENTS. of the capsule and of the ligaments of these joints usually accompany the injury. The interarticular ligament, thin and delicate as it is, which binds the head of the rib to the intervertebral discs of two adjacent vertebrae, is doubt- less very frequently ruptured in these cases, and the pain felt in the back is pr()l)ably due in part to this caus(\ Lesions of tlie sympathetic nerve, with their attendant train of symptoms, are regularly observed when the frac- tured bones are forced inward, as occurs in cases of direct fracture due to falls on the back, blows from falling objects, etc., or when the rib is fractured in connection with a similar injury of the body of the corresponding vertebra. The clavicle is likely to be loosened from its attach- ment to the first rib, in cases of fracture of the latter, in consequence of laceration of the subclavius muscle or of the costoclavicular ligament. The same injury leads to com- pression of the subclavian artery, and thereby to disturb- ances of circulation and nutrition of the arm that it sup- plies. The mammary artery is likewise exposed to injury from fracture of the costal cartilages. Direct fractures of certain ribs are likely to injure special organs and structures. Thus, in fracture of the sixth rib anteriorly on either side the pleural siiuis is endangered ; fracture of the sternal end of the fourth, fifth, and sixth ribs on the left side imperils the peri- cardium and branches of the pneumogastric nerve ; in fracture of the seventh, eighth, and ninth ribs on the right side, the liver ; and, in case of the ninth, possibly also the gall-bladder. In fractures of the ninth to the eleventh ribs inclusive, on the left side, and of the twelftli on either side, the spleen and kidneys, respectively, are liable to involvement. The stomach may be injured by forcible compression of the seventh, eighth, and ninth ribs, and the intestine may suffer when the tenth rib is pressed inward or fractured l)y direct violence. The following descriptive cases illustrate the fact that Fig. 26. 200 DISEASES CAUSED BY ACCIDENTS. the symptoms of healed fmetures of the ril)s depend largely on the seat of the lesion ; it will, therefore, be unnecessary to state the various local symptoms in detail. It is iujportant to note that fractures of the ribs can easily l)e overlooked. This is partly due to the fact that some individuals are rather insensitive to pain, and do not call attention to the lesion by their comj^laints ; partly to the sinndtaneons occurrence of other and more serious injuries, which overshadow the one in (piestion. Ca.it' of fractnrc of llic cii/IifJi, iiiiilli, oinl fiiit/i I'ilis on the rii/lif side, foUowed by intercoHfol luurahjid (iiul rvstiiction of iiiohi/ity of tliv lujlit shoulder. (Fi<^. 2(3.) A workman, forty-four years of age, on June 13, 189"*, fell and struck the riglit side of his chest against the edge of a wall. The injury left a slight callous tliickening of the eighth and ninth ril)8 in the scapular line. There was consi(lcra))le sensitiveness to ))ressure in the eighth intercostal space on the right side, and the patient was unable to lift his arm well. The skiagraph shows the point of frac- ture of the eighth rilj, l)etween the scapula and the spine. The pa- tient was dismissed from treatment on October 26, 189S, with an allowance of 20% insurance. Cdse of direct fractiat' of the ninth ril) on the right side, fottoired hij a diaphrdf/inatic hernia. A workman, lifty-se\en years of age, on .Tuly f), 1H95, fell, striking the right side of his chest against a l)ox of lime. He is s.iid to h.ave remainrd unconscious for three days in the h()S])ital. I examined liim on Se])teml)er 2'^, 189."). In the neighborliood of the ninth ril) on the right side, and attached to it in the axillary line, there was a marked callous thickening ; dullness, pleuritic friction- sounds, i)leuritic cough, and dyspnea were also noted. Beneath the ensiform cartilage there was a tumor about the size of a pigeon's egg, which protruded on coughing and could l)e pushed back into the ab- dominal cavity. The i)atient was unable to raise the right arm well or to do any lifting, bisurance allowance, 66|%. Cme of fraetiire of the r//w on the riyht side eoinplie(ded hij injury of the liver. Sc((ui'l, ])artial recovery. A polisher by trade, fifty-seven years of agi', on October 29, 1805, fell from a scaffolding about ten feet high, sticking on his back, while the ))oards of the scaffolding fell ujion his right side. He was treated at home for eleven days and then uudcrlook light duties as an inspector. I examined him February 26, 1S9(J, and found a slight amount of callus on the seventh right rib in the anterior axillary line; also pleu- I'itic friction-sounds, ])leuritic cough, and marked liypertroi)hy and tenderness of the liver. It was dillicnlt for the i)atient to raise the right arm on account of pain in the shoulder of that side. He has DISLOCATION OF THE RIBS. 201 not worked since the last of June of tliat year. I last examined him on Auf!:ust 15, 1896. Tlie liver was further increased in size and was ver^' sensitive to pressure. Case of fracture of a number of ribs due to severe crushing, complicated by an unusual form of fracture of the clavicle. A painter, fifty-four yeai"s of age, was crushed between a w^all and a heavy truck, sustaining a fracture of the right clavicle at its acromial end and a crushing of the thorax. He was treated in the hospital for fourteen days and then began a course of massage. The fracture of tlie ri))s was not diagnosed. I examined the patient on June 18, 1896, and he remained under my care until April of the following year. Skiagraphs showed a frac- ture of the fifth, sixth, seventh, eighth, and ninth ribs close to the spine, in addition to the fracture of the clavicle. The pain that he had felt in the spine, especially on stooping, was hereby explained. He did not suffer from ijain in the chest after December, 1896. FRACTURE OF THE COSTAL CARTILAGES. This lesion may be due to eitlier direct or indirect vio- lence. In old a_o'e, when the cartilages have, as a rule, undergone ossification, it is, of course, incorrect to speak of a fracture of the costal cartilages. Fracture of the cartilages, or of the ribs in their imme- diate neighl)orhood, is not infrequently followed by an ex- cessive growth of callus — in reality, an exostosis. The symptoms of the lesion do not differ from those mentioned in connection with fracture of the ribs. The treatment of healed fractures of the ribs is symp- tomatic. Mechanical treatment is to be recommended for limited thoracic mobility, while massage and electricity of various kinds may also be employed with advantage. DISLOCATION OF THE RIBS. Dislocations involving the costovertebral and the chon- drosternal articulations, and those involving the two lowest ribs, are usually considered separately. Dislocations at the costotransverse articulations are properly included with the costovertebral variety, since we are justified in assum- ing that either one of these lesions leads to the other. 202 DISEASES CAUSED BY ACCIDENTS. Dislocations of the ribs at tlieir spinal attaclinient are usu- ally met with as aeconipanimeuts of fractures of the ver- tebra, and cau usually be recognized in severe eases by local pain, especially marked on attempting to move the trunk, by symptoms of intercostal neuritis, and by disturb- ances due to lesions of the sympathetic nerve. The symptoms in the lighter cases are only slightly marked, and the ])ain in the spine may disappear altogether in the course of a few months, even in cases of dislocation-frac- tures involving several ribs. Dislocations at the chondrosternal articulations are not infrequently seen in workmen who labor in a stooping po- sition or in those who have occasion to lift heavy weights. Frequently, the lesion is really a subluxation, which can easily be reduced by ap})ro])riate movements of retro- flexion. Dislocation of the tirst rib also calls for special mention. The lesion, which, by reason of the peculiar conformation and location of this rib, belongs to the class of dislocations by rotation, occurs at the chondrosternal articulation, and is caused l)y fracture of the rib or by violent contusion of the clavicle. The external border of the I'ib is forced downward, causing both ends to rotate inward and upward. The remote symptoms of the iniury consist of pain in both sternal and vertebral articulations, especially in the latter, pain in the neck, and limited mobility of the head and neck, THE SEQUELS OF FRACTURE OF THE RIBS. I. Intercostal Neuralgia. The consequences of the lesion in question have in large part already been referred to in connection with its .sympto- matology ; we will confine ourselves here to mentioning a few of the after-diseases most frequently observed. Inter- costal neuralgia is very often induced by direct irritation from displaced fragments, or by ])ressure from a growing callus or from adhesions following lesions of the pleura. TRAUMATIC PLEURISY. 203 The characteristic symptoms are pain and extreme sensi- tiveness in the course of the affected nerve. Sensitive- ness can be elicited by pressure, not only at the three points usually tested for diagnosis, but also at any part of the course of the nerve, especially at the points at which it is subjected to the greatest irritation. Other symptoms are limited ability to raise the arm on tlie affected side, and in many cases exaggerated abdominal reflexes, increased irri- tability to the faradic or franklinic current, and dilatation of the ])U[)il on the affected side. Traumatic intercostal neuralgia may soon disappear or may persist for a long time, according to the circumstances of the case; and upon this point depends, to a large ex- tent, the capacity of the patient for self-support. The average incapacity equals 20^, but rises in some cases as high as 50^ or more, in proportion to the severity of the symptoms. Treat'ment consists of warm, moist compresses, massage along the course of the nerve, systematic breathing-exer- cises, and movements of the trunk, the application of the galvanic current, gradually increasing its intensity, and the use of the static machine. 2. Traumatic Pleurisy. Traumatic pleurisy is usually of the fibrous variety, and may deveh)p in consequence of direct penetration of the pleura by fragments of bone, or as a result of incomplete fractures of the ribs, of greater or less extent, due to crushing of the thorax between car-buffers, under wheels, under falling walls, etc. Pleurisy has even been known to follow blows on the chest. The symptoms are dullness, pleuritic friction-sounds, and the cough characteristic of pleuritic irritation, always ])resent in severe cases. In addition, there is pain on deep inspiration, on lying on the affected side, on stooping, and on lifting the arm or weights. The expansion of the affected side of the chest is dimin- ished. For the early treatment of these cases warm, moist 204 DISEASES CAUSED BY ACCIDENTS. PLATE 12. Case of Contusion of the Left Side of the Thorax due to a Fall into a Cellar. Sequels, thickened pleura and tuberculosis, resulting in complete incapacity for self-support. A mason, fifty-three years of age, fell into a cellar on No^'ember 28, 1895, sustaining a fracture of the os calcis of botli feet and a con- tusion on the left side of the chest. He was treated in the hospital for eight weeks, during seven of which he remained in bed. I examined him on Fel)ruary 14, IK^G, and found him to be a man of middle size, of very delicate physiijue, and of tubercular diathesis. There was a marked depression of the left side of the chest from the fifth rib down- ward. (See illustration. ) Tlie depressed area was very sensitive on percussion. Circumscribed dullness, diminished respiratory sounds, jtleuritic friction-sounds, and diminished expansion of the left side of the chest were also noted. On stooping, the lower border of the left ribs became very prominent. Lateral movements of the thorax were limited, especially movement toward the right. The patient was dis- charged after four months' treatment with an allowance of 100%, based on his pulmonary tuberculosis. compresses, rest (in bed, if necessary), and small doses of morpliin are to be recommended. Less severe cases may manifest few or no symptoms. Patients frequently resume hard work after a course of treatment of from ten to twelve days' duration. In a stone-carrier, for instance, whom I had occasion to examine, and who, as usual, was engaoed in hard lal)or, I found ex- treme dullness and ])leuritic friction-sounds. The capacity for self-support varies, it is thus seen, with the personal equation of the patient. The presence of ])lcuritic symj)toms in an otherwise per- fectlv healthy individual should entitle him to an insurance allowance of 20^; severe symptoms may call for a higher allowance, even 100 fo- The pleurisy may clear up comparatively soon or may persist for a long time or even permanently; not infre- quently it is the starting-point for the future development of tuberculosis. The ])leuritic inflammation occasionally takes a serous or suppurative form, requiring a prolonged course of treat- Tab. 12. LUh.Arist E Reichhald Miinrhpn INJURIES OF THE LUNGS. 205 ment. One workman, who developed an empyema after fracture of a rib, was under treatment for three years before the fistula finally closed and the fever disappeared. Contusions of the thoracic wall and healed fractures of the ribs are not infrequently made use of for purposes of simulation. On hasty examination a constant cough in- duced in the larynx or jiharynx may be mistaken for the cough of pleurisy, and an incorrect diagnosis of traumatic pleurisy may be made accordingly. Case of empyema on the left side following crushing of the left thigh, with subsequent ceHulifis and contusion of the left side of the thorax, com- plicated hfi concussion of the brain. Sequels, tliickened pleui'a and a deep cicatrix at the site of the fistula. Four years later, complete recovery of capacity for self-su])port. A workman, thirty-two years of age, fell from a scaffolding two stories high on December :29, 1893, sustaining the injuries men- tioned. There were no thoracic symptoms at tii-st. Four \\eeks later, after the appearance of a cellulitis of the left thigh, pleurisy set in, with cliills and high fever. Improvement followed incision and drainage. I examined the patient on A^iril 17, 1894, and found a fistula, still discharging pus, between the seventh and eighth riljs on the left side. There was dullness over the \\hole left side of the chest. The general health was good as long as drainage remained free; symptoms of fever and chills were manifested whenever the listula closed, Ijut ^vel■e always relieved by reopening the same. The treatment was continued until January, 1897, when the patient was discharged with an insurance allowance of 75 % . He began to work, and ^vas tinally able to perform his duties so well that his allowance was diminisiied to 10 /ir. 3. Injuries and Traumatic Diseases of the Lungs. — Hemop= tysis, Pneumonia, and Pulmonary Emphysema. The lung-tissue is lacerated in case of direct fracture of the ribs ; also in case of violent contusions of the thorax due to falls from a heig-ht and to similar accidents. The immediate symptoms are cough and bloody sputum, and these may be followed by those of inflammation of the lungs. Pneumonia is observed also after less severe contusions of the thorax (contusion-pneumonia) ; the course of the disease is marked by only a slight rise of temperature, so that the patient frequently attempts to resume work, but 206 DISEASES CAUSED BY ACCIDENTS. is soon obliged to discontinue it again. In ])assing we need refer only to the pneumonia induced by catching cold, which in some cases also entitles the patient to insurance allowance. Pulmonary em])hysenui is frequently of traumatic ori- gin, usually developing as a sequel to long-continued pleuritic cough, especially in individuals suifering from chronic bronchitis. Hemoptysis sometimes occurs in consequence of strains — lifting a heavy stone, for instance. This symptom de- pends on laceration of the lung-tissue and its capillaries, and in healthy individuals may cause no further trouble. Pulmonary tuberculosis is, however, very apt to supervene in those who, by reason of their occupation, have a pre- disposition to the disease. Case of pneumonia and plenrisi/ consecutire upon falling into cold ivater. Sequel, myocarditis, myelitis, aucl neurasthenia; subsequent improvement. A workman, fifty-nine years of age, a hea%'y drinker, fell into the water on January 18, 1894. He was treated in the hospital for a lono; time, and was then discharged improved, only to be read- mitted on account of myf)carditis, of which the symptoms had mean- while increased. The following symptoms were noted, in addition: loss of pupillary reflex, ataxic gait, swaying of body on closing the eyes, and exagg-eration of the patellar reflexes. Inca])acity for self- supjwrt, lOO'^ ; later, when the symptoms diminished, 50'^. A c«.5f of hemoptysis due to rupture of the lunf/s from lifting a heavy stone. Sequel, pulmonary tuljerculosis, causing deatli in two years. A stone-mason, forty-ciight years of age, probably already tuber- cular, fell in attempting to lift a heavy stone, on Aiigiist 22, 1889. The accident was immediately followed by hemoptysis. I examined him three months later and found a cavity in the right lung Ijelow the clavicle; also a few rale;, at the left apex. Insurance, which Avas at first denied on the ground that the accident Avas not one covered by the rules of his trades-union, was afterward allowed him at the rate of 100%. He died two years later of pulmonary tuljercu- losis. Case of hemoptysis following the lifting of a heavy beam. Sequel, com- plete recovery. A workman, thirty-seven years of age, in lifting a heavy beam, on July 10, 1894, felt a sudden violent pain and jar in the right side of the chest. Hemoptysis followed. He was treated at home for eight weeks. I examinetl him three months after the injury and found a fibrous pleurisy of moderate intensity on the right side. As TRAUMATIC FULMONABY TUBERCULOSIS. 207 he was able to do full work, he was not considered to l)e entitled to insurance. Case of JicmopiijsiK due to laceration of hni(f-1muc in conneetion ivith fracture of the ribs following a fall from a hcujht of sixty feet. Sequel, emphysema of the lungs. A mason, thirty-live year's of age, fell from a scaffolding sixty feet high, on November Ifi, 1888, sustaining a fracture of the skull, laceration of the lung, and a fracture of the right arm; also a fracture of the ribs on the right sidi', wliich was not diagnosed until later. He was treated in the hosjjital for thirteen weeks and then entered my care, in which he remained for one year. Symptoms, loud rales over the whole of the right lung, bloody sputum, and marked loss of flesh. The symptoms gradually decreavSed in the course of time. At present he is still suffering from emphysema. He was allowed 100%, based on headac^he, attacks of vertigo, and limited mobility at the right shoiilder. Case of hemoptysh followinf) a trifling injurij. The influence of the accident was recognized. A Avorkman, thirty-flve years of age, already tubercular, on Janu- ary 8, ISUG, stepped from the sidewalk into the street in order to de- cipher the number of a house. He states that this action was im- mediately followed by pain in the back. Ten days later he had a hemorrhage from the lung, and was treated in the hospital for a week. He had previously suffered from attacks of hemoptysis. Insurance was denied him by his trades-union because of the tuberculosis; he was declared to be entitled to it, however, by the court whose opinion w^as based on the detiuled and unprejudiced certificate of the physi- cian who examined him. 4. Traumatic Tuberculosis of the Lung. It is undoubtedly iu rare cases only that tuberculosis develops as a direct result of traumatism. As a rule, tuberculous foci are already present and are called into activity by the injury, or the development of the disease is only hastened by the latter. The exciting traumatism does not necessarily involve the region of the tuberculous focus ; the injured part may recover rapidly and com- pletely, while the tubercular process is aroused at a dis- tant spot. The tuberculosis may l)e latent or in the early stages of its development, giving rise to scarcely any symptoms, until active symptoms are induced by traumatism or by long confinement in an unwholesome dwelling infected witli tubercle bacilli. 208 DISEASES CAUSED BY ACCIDENTS. Pulmonary tuberculosis may, however, develop in close connection with traumatism as a sequel to a traumatic hemorrhage, which furnishes a suitable soil for the growth of the invading bacilli. The tubercular process may manifest itself as a primary local lesion after injury to the lung or pleura, or it may be established in some part of the lung as a result of metas- tasis from a tuberculous focus developed after traumatism in some other part of the body. Pulmonary tuberculosis usually incapacitates the patient for work to a very con- siderable degree ; he is always unable to perform hard labor, and in many cases can not undertake even the lightest tasks. INJURIES AND TRAUMATIC DISEASES OF THE HEART AND PERICARDIUM. I. Traumatic Pericarditis. Direct lesions of the pericardium are usually due to its penetration by fractured ribs, but may be caused by pres- sure from ribs forced inward by sudden violence. Diims reports cases of traumatic pericarditis in soldiers who had been injured by blows from bayonets, by kicks, or by falling and strikino' the left side of the chest against the horns of their saddles or by being thrown to the ground from horse- back. Thicm has published a fatal case of traumatic pericarditis and pleurisy due to severe crushing contusion. If the pericardium is already diseased, it is, of course, much more liable to inflanunation as a result of trauma- tism than is normal tissue. The pericardium is in some cases involved secondarily by extension from a traumatic pleurisy. The sym])toms of traumatic pericarditis may be severe from tlie onset or may at first be so slightly marked as to be overlooked until they suddenly break out later on. Two cases are related by Diims, both occurring in soldiers who had been in service until shortly before their deaths. INJURIES OF THE HEART. 209 The autopsy showed the two layers of the pericardium to be adherent almost throughout. Alcoholic or tuberculous subjects are predisposed to peri- carditis. The loud crackling friction-sounds, not neces- sarily associated with the movements of the heart, that characterize the lesion can be heard also in the late stages of the disease. Frequently adhesions take place between the pericardium and the heart-muscle, causing disturb- ances of cardiac action and atrophy of the muscle. As long as the sym]itoms persist the patient is almost com- pletely incapacitated for work, and should be prohibited from all exertion or, at any rate, from all Init the very lightest tasks. Case of periatnlUis followuif/ fradure of the left sixth rib, caused by a fall from a heifjht. A Avorkinan, thirty years of age, fell, on December 20, 1893, from a height of sixteen feet, sustaining a fracture of the sixth rib in the left mammillary line. He was treated for four weeks with ice-bags in the hospital. After his discharge he became a patient at the dispen- sary, Avhere the following symptoms of pericarditis were demonstrated : Dyspnea; a very small, rajiid, and irregular pulse; friction-sounds and increased area of heart-dullness. These symptoms disappeared at the end of three months. He was allowed 50% insurance on the ground of neurasthen' 2. Injuries of the Heart Due to Concussion. Direct cardiac lesions have been reported as occurring in individuals thrown from a moving train (case of Liersch), or in those who have fallen from the upper story of a house, striking on the buttocks (case of Riedinger). In the case described by Liersch autopsy showed hemorrhages under the endocardium. Lacerations of the heart-muscle, also of the papillary muscles, valves, and chordae tendinse, have been found in cases of crushing of the thorax between car-buffers, under falling walls, etc., or as a result of kicks from animals (Stern and Bernstein). The cardiac muscle or the valves may also be lacerated in direct consequence of strains — due to the lifting of 14 210 DISEASES CAUSED BY ACCIDENTS. heavy weights, for instance. A case published by Schin- dler was that of a very strong hod-carrier, who was accus- tomed to carrying a load of forty-two bricks, weighing 165 kilos, on his shoulder, while his fellow-workmen were able to carry only thirty-two, weighing 120 kilos. In attempting to carry forty-eight bricks he broke down, and became ill. One year later, when fully recovered, he again attempted the same extra load, with the same result. A diagnosis was made of acute dilatation of the left ven- tricle, with mitral insufficiency and irregular heart-action, leading to edema and ascites, completely disabling the patient. According to Bernstein, the laceration is most likely to occur in that part of the cardiac structure that is in a state of tension at the moment of injury. Thus, during sys- tole the cardiac muscle suffers ; during the second half of diastole, when the nuiscle is relaxed, the endocar- dium ; and during the whole diastole of the ventricles, the valves that lie in front of them. Bernstein states that the valvular lesion of traumatism is characterized by a rough murmur, audible at a considerable distance, differing from the murmur of gradual development heard in cases of valvular insufficiency of inflanmiatory origin. A murmur audible at a distance of over fifty centimeters may, he says, be assumed to have a traumatic cause. Lesions of this nature have been observed involving the mitral, tri- cuspid, and semilunar valves. The symptoms of traumatic cardiac lesions are, in the main, those of similar lesions of nontraumatic nature ; the patient is usually greatly incapacitated for work, being able to perform only light tasks requiring no physical exertion, if, indeed, he is able to work at all. 3. Influence of Traumatism on Preexisting Heart Disease. Hearts that are already the seat of some morbid process are necessarily much more likely to siiffi'r from the effects of traumatism than are previously healthy organs. TRAUMATIC THORACIC ANEURYSM. 211 Stern gives the following causes for the increase of cardiac symptoms after accidents : 1. Mental excitement. 2. General concussion and direct injuries, such as con- tusions, crushings, etc. 3. Muscular exertion or strain. Thiem adds a fourth cause : namely, sudden cooling of the body. Cases of all these forms of injury can be found in abundance in the literature. 4. Aneurysm of the Thoracic Aorta. A case of this lesion is published by Pauli in which the patient, a coachman, fifty-three years of age, was struck on the left side of the chest by a moving railroad-car. He suffered at first from extreme dyspnea ; then, after a short period of slight improvement, he again became ill, this time with severe symptoms of palpitation of the heart as well as dyspnea. The area of heart-dullness extended to the right margin of the sternum, while the whole region pulsated strongly. The heart-sounds remained normal. The accident occurred on March 3, 1894 ; in October of the same year it was noticed that the second and third left ribs were beginning to protrude. The patient died suddenly on August 28, 1895. Antopsy showed an aneurysm about ten centimeters long ; the heart was greatly hypertrophied, especially the left ventricle ; the first part of the aorta was much dilated, preventing closure of the semilunar valve. Case of mitral insufficiency followint/ sererc crushinf/ of the left side of the chest. Sequel, partial recovery. A mason, thirty-two years of a.sje, on September 16, 1892, was? caught iinder a falling building. He sustained the foregoing injury, and, in addition, a severe contusion of the right hip. He w;us treated at home for three months, with compresses and rest in bed, and then came under my care. He showed symptoms of sciatica on the right side, and complained, in addition, of frecpient attacks of dyspnea. Examination was negati\e, except that there was a rapid pvilse. The heart-symptoms increased a few weeks later, and were accompanied by 212 DISEASES CAUSED BY ACCIDENTS. fever. He was again ordered to remain in bed. Tiie phy.sician in attendance at his home made a diagnosis of endocarditis, ^^^len I examined him snbsetinently, I found tne apex-ljeat disphxced to the left, a blowing systolic murmur, and the area of heart-dullness en- larged toward both sides. Insm'ance allowance, 50^. No change in his condition \\\} to date. IV. INJURIES AND TRAUMATIC DISEASES OF THE ABDOMEN. Although the abdominal organs are not protected from external violence by a bony framework, a.s are the brain, the spinal cord, and the thora(;ic organs, they are never- theless well adapted to evade the effects of traumatism. This is especially true of the stomach and intestines ; less so of the glandular organs — the liver, kidneys, and spleen; the latter, however, by reason of their position in the body, are less exposed to external injury. The ability of the stomach and intestine to escape injury by moving to one side has, of course, its limits, and when filled with gas or food-contents, they are not easily dis})laced, and are, therefore, in much greater danger from traumatism. The lesions of the internal organs do not always cor- respond in situation to the point to which the external violence is applied ; if kicked by a horse, for instance, on the lower left part of the thoracic wall, the individual may suffer comparatively little damage at that point, while the intestine is ruptured at a distance. I. INJURIES OF THE ABDOMINAL WALL. (a) Wounds and Cicatrices of the Abdominal Wall. Superficial wounds in this situation, including those caused by burns, usually heal well, and without sequels of im])ortance. Extensive scars, however, especially if showing a tendency to keloid formation, are likely to give rise to a feeling of tension and pressure. The symp- INJURIES OF THE ST03IACff. 213 toms of scars left 1)y deep wounds are more marked and vary in intensity in projxtrtion to the depth of the scar- tissue and to the adhesions it forms. The broad scars that sometimes follow perforating abdominal wounds lead to the development of omental hernia, and, finally, to hernia of the intestines. (b) Subcutaneous Rupture of Abdominal Muscles. This lesion occurs in consequence of violent contraction when the muscle is in a state of extreme tension, as in lifting and carrying heavy weights Avith the hands, the trunk being inclined backward. Subcutaneous ruptures are also met with when the l)ody is in a position of exten- sion, as, for instance, in hanging from horizontal bars. The rectus is most subject to the injury, the external oblique somewhat less so. I have seen a rupture of the external oblique in a recruit undergoing fatiguing practice on hori- zontal bars, and a rupture of the same muscle in a woman about forty-five years of age as a result of strain in lifting. The muscles heal in from three to six weeks, usually leav- ing a depression or groove at the point of rupture. Hard labor, lifting, and carrying heavy loads are, of course, out of the question at first ; but as strength gradually returns, even such work can once more be undertaken. Incapacity for self-support, 20 ^ to 33^ ^ . 2. INJURIES AND TRAUMATIC DISEASES OF THE STOMACH. (a) Contusions and Crushing of the Stomach. When empty, the stomach usually escapes the effects of a blow or kick by moving aside ; but it may suf- fer serious lesions, as a result of compression against the vertebral c(jlunin, in cases of crushing between car-buf- fers, under falling walls, wheels of wagons, etc. The lesion may consist of lacerations of the nmcous membrane, 214 DISEASES CAUSED BY ACCIDENTS. of hemorrhage between diiferent layers of the stomach- wall, or even of rupture of the latter, doniantling imme- diate operation. When the organ is full, the mucous membrane is sometimes torn as the result of comparatively slight injuries, such as simple contusions or muscular strain in lifting, or concussiim due to falls from a height. As a rule, the stomach, in these cases, is already the seat of some morbid process. Rupture of the gastric mucous membrane is immediately followed by hematemesis or bloody passages from the bowels. In cases of gastric ulcer due to infection of the injured mucous membrane through the stomach-contents hematemesis may occur as a somewhat later symptom. Case of conhmon of ihe chest and stomach due to a blow from, a wagon- pole. Sequels, chronic gastritis, thickened pleura, and pulmonary emphysema. A workman, sixty-four years of age, on October 13, 1892, was struck on the lower anterior Ijorder of the ril)S on the left side by a wagon-pole. He at once became unconscious, and was carried home, where he was treated for traumatic pleurisy. I examined him on January 20, 1893, and found \m\\ to be a small, delicate man, who, however, stated that he never was seriously ill before his accident, having suffered only from paralysis of the vocal cords. The ])atient complained of attacks of nausea, poor appetite, and a feeling of pressure in the stomach; his tongue was coated. Further examination showed a thickening of the left pleura and some emphysema of the lungs ; also tenderness on pressm'e in the region of the stomach. Insurance allowance, 75%. (b) Traumatic Ulcer of the Stomach. These ulcers usually heal rapidly, but in some cases lead to perforation. It is hardly necessary to state that perforation may take place at the site of a nontraumatic; ulcer in cases of traumatism, thereby entitling the patient to receive insurance. The cicatrix left after healing is completed causes no after-trouble in favorable cases, but occasionally proves to be the starting-point of a carci- nomatous growth. Weak, anemic individuals, particularly alcoholics, are predisposed to gastric ulcer. CANCER OF THE STOMACH. 215 The patient should be ordered rest, possibly in bed. The insurance allowance may equal 100^. (c) Carcinoma of the Stomach. Reference has just been made to the origin of carcino- mata at the site of gastric ulcers. Carcinoma seldom occurs in consequence of a single traumatic insult, but is usually the outcome of constant irritation of the scar- tissue. If the mucous membrane is already unhealthy, however, it is also possible for a carcinoma to develop after a single injury. The underlying cause may, for instance, be a chronic gastritis ; the immediate cause, a traumatism that produces a laceration of the nnicous membrane, leading successively to a gastric ulcer, a cica- trix, and finally to the development of a carcinoma. The cases of traumatic carcinoma that have come under my observation occurred in individuals between forty-five and fifty-five years of age, all of whom suffered from chronic gastritis due to alcoliolism. The etiologic connection between traumatism and carci- noma must be clearly proved on scientific grounds ; it will not do, for instance, to try to connect an inflammation of the elbow-joint or a wound of the head with a primary carcinoma of the digestive tract of subsequent develop- ment. In respect to this point, see also the opinions of Schonborn, Senator, and Renvers, published in the official reports of the State Insurance Bureau. Case of carcinoma of the stomach the development of which was hastened by an accident. Fatal termination. A carpenter, fifty years of age, fell from a height of aljout two stories on July 9, 1898, sustaining a fracture of the right scapula com- plicated by concussion of the brain. He was treated for a month or more in the hospital. I examined him on Noveniljer 2, 1898, and found liiin to be a ratlier large, thin man of sickly appearance. The spine of the right scapula was distinctly thickened, and the right arm could not be raised al)o\e a level with the shoulder. He was treated clinically )jy means of exercises of the right shoulder. On December 29, 1H98, he did not appear at the clinic, and was, therefore, visited at his home. He was found to be suffering from gastric disturbances, but had no fever. He stated that he had noticed a loss of appetite 216 DISEASES CA USED ST A CCIDENTS. and rapid loss of strength ever since his accident, and that he was previ- ously (juite liealthy. He confessed to having drunk a moderate amount of whisky daily and to having eaten irregularly. Hematemesis occurred on January 18, 1899, when he was taken to the hospital on account of a tumor of the stomach. He died there soon after^\ard. Autopsy showed a carcinoma of the stomach. The traumatic etiology was admitted. (d) Nervous Dyspepsia. Reference is here made to this utfection for the reason that we often meet with it as a symptom of accident-neu- rosis, and that it very frequently calls for treatment. In addition to other treatment, psychic methods are to be recommended. 3. INJURIES AND TRAUMATIC DISEASES OF THE INTES= TINE AND THE PERITONEUM. (a) Contusions and Crushing of the Intestine. The intestine, like the stomach, is likely to escape injury from external violence, such as falls, blows, or kicks, when it is empty. If, however, it is the seat of typhoid ulcers (in cases of walking typhoid) or of tuber- cular ulcers, rupture of the mucous membrane, or even ])erforation of the intestinal wall, may easily occur. The intestine may be ruptured in healthy persons by crushing of the al)domen, due to being run over, caught under falling buildings, etc. This lesion is more likely to occur when the intestines are filled. The most frequent traumatic causes of intestinal rupture are kicks and vio- lent concussion consequent upon falls from a height. Rupture may occur at the time, or gangrene may set in at the point of injury, leading to perforation several days later. In other cases the lesion in the mucous membrane is in the process of healing, when peristalsis or some movement on the part of the patient causes the weak spot to give way, and a perforation results. If the accident does not cause immediate death, the patient's life may be saved by operative interference. An TRAUMATIC PERITONITIS. 217 instance of this kind, including a description of the sequels, will be found among the illustrative cases. Minute openings in the intestine, several millimeters in length, may heal without difficulty ; even if there is an escape of intestinal contents, these openings may become encapsulated and recovery may take place. Internal ruptures are, therefore, not necessarily fatal accidents. (b) Wounds of the Intestine. These occur in cases of fracture of the ribs, vertebrae, or pelvis, the sharp fragments piercing the intestine ; or they are produced from within by the action of foreign bodies that have been swallowed. The only hope of re- covery lies, as a rule, in immediate operation. (c) Intestinal Stenosis and Occlusion. Stenosis of the intestine, up to complete occlusion, may occur as a result of traumatism. Among the direct causes are foreign bodies in the intestine, cicatricial strictures, and incarcerated hernias. The first aim of treatment should, of course, be the removal of the cause. (d) Traumatic Peritonitis. Lesions of the peritoneum are invariably accompanied by more or less extensive lacerations of the omentum and of the vessels that it contains. The injury and the sub- sequent hemorrhage are follo^ved by a peritonitis, as a result of which the extra vasated blood may become en- capsulated, forming a hematocele. The peritonitis in it- self is rarely of a very serious nature. Hermes mentions the case of a man who fell on a beam from a height of one story, striking upon the abdomen, thereby causing a complete laceration of the omentum between its middle and lower thirds and almost entirely separating the small intestine from its mesentery. Thiem describes an interestins: case of incarceration of a coil of 218 DISEASES CAUSED BY ACCIDENTS. small intestine in a tear in the mesentery, occurring in a man who had k'a})ed across a ditch with the aid of a pole. The peritonitis may assume a suppurative character in consequence of the passage of infectious bacteria either through the uninjured intestinal wall or out of the blood- vessels in which they may be circulating. Traumatic peritonitis often leads to the formation of adhesions with neighboring organs ; these are likely later on to give rise to rather severe, ill-defined pains, often ascribed to hysteria or to simulation, or set down as " colic." Carcinoma of the peritoneum is usually of metastatic origin, the primary focus being seated in the stomach, liver, or rectum, etc. Case of perityphlitis following severe crushing of Ihe abdomen. Se- quel, recovery, with persistence of various syinptoins. A Avorkman, thirty-three years of age, was injured in November, 1887, by a rail falling on the right side of his abdomen. He was treated in the hospital for a number of weeks, and soon after his dis- charge was readmitted on account of a psoas abscess. I examined him on October 27, 1888. I found Iiim to be a man of middle size and vigorous build and of rather pale complexion. He complained of ab- dominal pain, of severe constipation, sometimes lasting for eight days or longer, and of a sense of weight in the right leg. At the lower part of the abdomen on the right side was situated a flat tumor, about the size of tlie palm of the hand, slightly raised aliove the level of the sur- rounding tissue. The whole right side of the abdomen was sensitive to pressure and the right lower extremity was swollen, the circumfer- ence of the thigh being three centimeters greater than that of the left. He was at first allowed full insurance, which was reduced in six months to 50%, and in two years to 20%. At the time of the last examina- tion, early in the year 1899, the tumor in the right side of the abdomen had disappeared and the swelling of tlie right thigh had diminLshed. (e) Laceration of the Thoracic Duct. In his " Manual " Thiem cites a case observed by Man- ley concerning a man thirty-five years of age who was knocked down by a wagon-pole, which struck him in the abdomen, one wheel passing over his body. The injury was followed by severe pain ; a tumor developed over Poupart's ligament on the right side, which Avas tapped eleven days later, yielding a pint of a milky-white fluid. INJURIES OF THE LIVER. 219 4. INJURIES AND TRAUMATIC DISEASES OF THE LIVER. Lesions of this organ may be clue to tlirect or indirect violence. Contusion and crushing of the liver belong to the class of direct injuries, and are met with in individuals who have received blows from butts of guns, horns of animals, or Avagon-poles, or who have been struck Avith the fist or kicked bv horses, cattle, etc. They also occur in persons who have fallen on the abdomen, or Avho have been caught under heavy falling objects, under falling buildings, under wheels, between parts of machinery, car- buffers, etc. Lesions of the liver due to direct violence are not infrequently seen in connection with complete or incomjjlete fractures of the ril>s. Indirect lesions are caused by falls from a height, strik- ing on the feet, the buttocks, the back, or the left side of the abdomen. If diseased, the liver may be ruptured by a slight degree of violence, as when it is the seat of a hydatid cyst ; the consequences of injury, too, both immediate and remote, are likely to be more serious than in the case of a healthy organ. The symptoms of injuries of the liver depend on its phy- siologic condition and on the severity of the lesion ; slight hemorrhages or small tears of the surface are followed by very mild symptoms, or cause only moderate pain. Rest and suitable treatment bring about recoveiy in these cases. Ruptures of the liver, on the other hand, often termi- nate fatally very shortly after the accident ; the lesion is in many cases marked by characteristic pain in the right shoulder. Patients who survive the injury suffer from jaundice, localized peritonitis, or, less frequently, from abscess of the liver, which, as it is well to remember, may remain latent for years. In healing, adhesions are formed between the surface of the liver and its peritoneal coat, causing pain, especially on movements requiring considerable exertion, on unusual 220 DISEASES CAUSED BY ACCIDENTS. degrees of peristalsis, or when the stomach and intestines are full and heavy. In view of the inaljility of the patient to perform hard work, he may be entitled to an insurance allowance of from 33 J ^ to 66|^, or more. Carcinoma of the liver is usually a secondary process, the result of metastasis from a primary growth in the stomach, rectum, esophagus, or intestine ; in rare cases we find a primary carcinoma of the bile-ducts. 5. INJURIES AND TRAUMATIC DISEASES OF THE SPLEEN. Direct contusion and crushing of the spleen may occur in connection with crushing and fracture of the ninth to eleventh ribs, leading to hemorrhage and laceration, and to loosening of its ligamentous attachments, and to subse- quent iuflannnation of tiie organ and its coats. Occasion- ally, a wandering spleen is observed after traumatism. As a result of inflammation, adhesions take place between the spleen and adjacent organs. Chronic hypertrophy and leukemia have likewise been observed. In cases of malaria or leukemia the spleen is occasionally ruptured by trivial accidents. 6. INJURIES AND TRAUMATIC DISEASES OF THE PANCREAS. Hemorrhagic; and sup])urative pancreatitis and necrosis of parts or the Avhole of the organ have been known to occur as the result of a fall or of being run over. Cysts of traumatic origin have lieen observed in a number of cases, giving rise to the following symptoms : a grayish- yellow coloration of the skin, similar to that seen in Addison's disease ; gastric disturbances, vomiting, and neuralgia. INJURIES OF THE KIDNEY. 221 7. INJURIES AND TRAUMATIC DISEASES OF THE KIDNEY. The kidneys may be injured by direct or indirect vio- lence. They are most exposed to direct injury from behind, below the eleventh or twelfth rib, but may also be reached anteriorly or from the side. Fracture of the eleventh or twelfth rib may cause a direct lesion of the kidney, while in case of fracture of the eleventh or twelfth dorsal vertebra, or of the first or second lumbar vertebra, the lesion may be either direct or indirect. Contusion and crushing of the kidney occur in conse- quence of kicks, or blows from sticks, wagon-poles, etc. ; also in individuals who are run over or caught under falling walls, etc. If diseased, the kidney may be indi- rectly injured l)y falls on the buttocks or by muscular contraction — the lifting of heavy weights, for instance. The lesion produced by the various forms of traumat- ism mentioned usually takes the shape of a laceration, accompanied h\ more or less severe hemorrhage and followed by hematuria, which is the most striking symptom produced. It may a})pear at once or may be delayed until the clots that temporarily fill the laceration become detached. In some cases hematuria does not appear ; the blood collects between the layers of the capsule, giving rise to inflammation (traumatic nej)hritis), or forming a cyst, or leading to the development of a perinephritic abscess, accompanied by the formation of calculi and the atrophy of the kidney. Injuries to the kidney are occa- sionally followed l)y anuria, either of reflex origin or due to the fact that the second kidney is diseased or lacking. Albuminuria, causing edema of one or both legs, frequently involving the side opposite to the injured kidney, is another syni])toni of traumatic nephritis. Lacerations of the kidney are not necessarily accom- panied by severe symptoms ; the latter may be quite trivial, causing no discomfort after the first few days. 222 DISEASES CAUSED BY ACCIDENTS. Floating kidney is frequently met with, especially in women, and may depend on one of several cases : dimin- ution in the normal amount of adipose tissue surrounding the kidney, relaxation of the abdominal walls, a tumor of the kidney or neighboring structures, or traumatism. Thiem agrees with Cruveilhier in explaining the trau- matic origin of floating kidney by the narrowing of the niche or groove in which the kidney rests, which takes place as the result of external violence or depends on in- ternal causes. Blows from behind and from the side or falls on the abdomen or against shar])-edged objects have the effect of forcing the lower ril)s toward the spine, thereby narrowing the kidney groove. Muscular contraction may act similarly on the ribs, as when, after slipping, a person tries to regain his equilibrium, and in so doing involuntarily contracts certain nuiscles — the quadratus lumborum, the erector spina?, and the abdominal muscles. Continuous attacks of coughing also reduce the size of the groove C(mtaining the kidney, which explains the appearance of floating kidney subsequent to heavy lifting or to other work requiring severe exertion during which a prolonged attack of coughing occurred. The condition is further favored by lordosis of the spine, which itself may be of traumatic origin. The symptoms of floating kidney are of a kind usually regarded as hysteric. Tiiey consist of anesthesia and hy- peresthesia of the mucous membrane of the bladder ; ]>ain in the lower part of the back and in the loins ; disturb- ances of digestion, which may be due to ])ressure of the displaced kidney on the duodenum ; and jaundice caused by pressure or tension on the common bile-duct. If the pedicle becomes twisted, there may, in addition, be urin- ary disturbances, albuminuria and fever, and even hydro- ne])hrosis. The symptoms can be relieved by a suitable abdominal bandage or can l)e cured l)y surgical interference, with the object of fixing the displaced kidney in position. TRAUMATIC HYDRONEPHROSIS. 223 Traumatic hydronephrosis, in addition to twisting of tiie kidney pedicle, may be due to occlusion of the ureter from the following causes : 1. Traumatic stricture. 2. Presence of a coagulum. 3. Impaction of a renal calculus loosened from the kidney by traumatism. 4. Compression from hemorrhagic extravasation or by tumors of the peritoneum or ureter. Perinephritis sometimes occurs as a sequel to a hemor- rhagic extravasation at the point of injury, which subse- quently became iufected. The abscess either points below the twelfth rib or breaks through the trigonum of Petit, or it descends into the pelvis or inguinal region, to appear- as a psoas abscess. Penetrating wounds of the kidney caused by pointed instruments may run a very favorable course if surgical aid is at once summoned. In one case of my own (men- tioned among the illustrative cases) the patient was able to resume regular work about three months after the injury. The rate of insurance to 1)e allowed for the various injuries of the kidney and their sequels depends on the severity of the symptoms in the later stages of the injury ; these may be so slight as not to interfere in the least with work or they may incapacitate the patient to a large degree. Carcinoma of the kidney occasionally develops after traumatism. In ^a case of Lowenthal's cited by Thiem, in which the etiologic relation was fully established, death occurred seventeen years after the accident. The insurance allowance for the loss of one kidney by operation is from 33|^^ to 50^. Cafie of floating kidney folloicing contusion of the Jmek and '^laceration of the kidnei/." Sequel, decided improvement and complete capacity for self-support. A mason, twenty-seven years of age, on August 30, 1893, fell and struck tlie right side of his back against a jirojecting screw of a ma- chine. Hematuria is said to have occurred immediately afterward. 224 DISEASES CAUSED BV ACCIDENTS. Examination a few weeks later .showed a floating kidney on the right side. The svniptonis were jjain in the l)aek and aI)donien, nausea, and absence of kidnev-diillness oi> the right side. On Ooto))er 11, 1S94, the floating kidney had disappeared ; the patient was, therefore, declared capable of self-support. rw.sc of rupture of the kidney due to a fcdl from a scaffolding. Seqnel, hydronephrosis ; subsequent improvement. A carpenter, twenty-six years of age, fell backward from a scaffold- ing nine feet high on August 28, 1895. He sustained a contusion of the back and a laceration of the left kidney, for which he entered the hospital for treatment. I examined him on January 28, 1896. He was a small, thick -set, pale-faced man. The region of the left kidney posteriori^' wa>s dis- tinctly swollen ; the percussion-note was tympanitic and the l>ounda- ries of kidney -dullness were extended on all sides. Albrmiin was present in the iirine. The patient was treated in the dispensary and hospital, and evinced improvement later on. Insurance allowance, 30%. 8. INJURIES AND TRAUMATIC DISEASES OF THE BLAD= DER, URETERS, TESTICLES, AND PENIS. Lesions of the bladder, including rupture, are met with as the resuU of direct violence in individuals who have been run over, caught between moving objects, under falling walls, etc., or who have sustained a fracture of the ])elvis, the organ having been pierced by the broken bones. Indirectly, the bladder may be injured by lifting heavy weights. It is much more liable to suifer Avhen full than when empty. Immediate operation may save the patient's life and may lead to permanent recovery. Lesions of the bladder may be followed by catarrhal inflammation, calculus, or polyuria ; the last-named affec- tion is especiallv l)urdensome to a working-man. Crushing of the testicle may be followed by hydro- cele, hematocele, or suppurative orchitis. If a hydro- cele is already present, the injury is likely to cause con- siderable hemorrhage, which is best treated by operation, although good resnlts may also be obtain(>d by elevation of the thighs, rest in bed, and the application of com- presses. A suspen.sory bandage should subsecpiently be worn for some time. ( INJURIES OF THE TESTICLES. 225 Cutaneous wounds of the testicle, if properly treated, heal quickly and completely. Unless inflamed, a hydro- cele of moderate size usually causes no troulde 'whatever, and its presence does not neces- sarily interfere with hard work. In estimating the insurance we should, therefore, not allow high rates, unless signs of inflanmia- tion are found, and if so, we should treat the condition. The loss of one testicle is of no special importance so long as the other is healthy. The loss of both testicles not only destroys the power of procreation, but entails, in addition, a series of nervous symptoms. An allow- ance of 50^ is, therefore, fre- quently justitied. Tuberculosis has been known to develop in oneorliotii testicles as the result of crushing. For these cases castration is indi- cated. It is reasonable to believe that carcinoma of the testicles may develop in consecpunce of traumatism, but each case nmst be carefully examined Avith refer- ence to its etiology, since the disease is quite frequently ob- served when no history of injury is given. The strictures of the urethra that usually form after traumatism are difficult micturition, requirins fitting the patient for work. 15 Fig. 27. likely to cause treatment and partly un- An insurance allowance 226 DISEASES CAUSED BY ACCIDENTS. PLATE 13. Case of Acquired Ventral Hernia Intensified by Traumatism. A workman, iifty-three years of age, in trying to extricate himself from a mass of earth which had fallen around liim, co\cring him iip to his knees, felt intense pain at the nmljilicus, at wliicli point there had existed a small hernia for a long time. Tlie hernia is stated to have greatly increased in size after the injiii-y, and at the time of my exami- nation it was about the size of the palm ot the hand. The patient had a rather prominent abdomen. He complained of continual pain in the abdomen, and stated that he wa.s unable to walk \vithout an abdominal bandage. He also suffered from i^eriosteitis of tlie tibite. The total insurance allowance equaled 50^. of from 25^ to 50^ is frequently justified in these cases. Wounds and contusions of the penis may give rise to scars and deformities, sometimes involvino; a loss of functional power. Urethral strictures also occur in this connection. The same rate of insurance is allowed for loss of the penis as for the loss of the testicles. Case of severe contusion of f/ic abdomen and rupinrc of f/ie bladder, due to ihe kick of a horse. (Fig. 27.) Followed by operation and recovery. A driver, twenty-two years of age, was kicked in tlie alidomen by a horse. He became unconscious and was taken at once to a hospital and there operated upon. I examined him on March 20, 1899. He was of medium height and vigorous build. The scar in the linea alba extended almost from the umbilicus to the symi^hysis ; it was of recent appearance and was sen- sitive to pressure, as was also the abdomen. The patient suffered from polyuria (he was o))liged to urinate at least twenty times a day) and constipation. The left lower extremity was swollen and edematous, and there was cyanosis of the foot and of the lo\ver part of the leg (probably due to pressure on the left external or common iliac vein). The abdomen and tlie left leg were su])i)orted by bandages. Full capacity for self-su])port wiis restored in about four months. Case of h'sio)i of the bladder and urethra. Operation was followed by recovery except for persistent polyuria. A painter, thirty-five years of age, was precipitated from a sc^affold- ing, the latter giving way on April 25, 1890. The testicles and urethra were injured by a broken board, which also i)ierced the al)do- men, causing a lesion of the bladder. An operation was undertaken a few hours later in the hospital. The scar left by the incision is still very apparent; it is three centimeters wide, rather thick, adherent, and fixed. It is also sensitive to pressure. The patient suffers from 7'(rb. JJ. J.iUi. Artst F. Re'CfituiUI. Miiurhen,. HERNIA. 227 persistent polyuria. His allowance was at first estimated at 45% ; for the past two years it has been 25 % . C'ase of scrcrc coniiision. of the urefhra dttc to a fall. Followed by stricture and albuminuria. A workman, twenty-five years of age, fell into a trench on November 28, 189:5, sustaining a severe contusion of tiie urethra, which required operation. Since reco^•ery he has suffered from stricture, polyuria, and frequent attacks of albumiiuiria. Insurance allowance, 50/^. 9. HERNIA. Tlie external protrusion of any part of tlie intestine out of tlie abdoniinal cavity or its escape into another body- cavity is called a hernia. The existence of an opening in one of the walls bounding the abdominal cavity is an es- sential factor in the occurrence of a hernia. The opening in the muscular or fibrous tissue composing the abdominal wall may bo congenital or acquired, or it may be produced by traimiatism. Certain natural openings exist for the passage of nerves and vessels, and for the passage of the spermatic cord in males and of the round ligament in females. These openings, however, do not permit the escape of the intestines unless for some reason they be- come stretched or enlarged. Subcutaneous rupture may occur at any jjoint of the abdominal wall as a residt of traumatism, and it is with the hernias that originate thus that wc are here concerned. Case of ventral hernia caufted l)y falling from a scaffold in f/ and sfrik- inff on the abdomen. Seqiiel, traumatic x»eritonitis. A painter, forty-four years of age, fell from a scaffolding, October 2fi, 1890, striking on the abdomen and the right hand. He sustained a fracture of the right radius and a severe contusion of the abdomen, followed l)y peritonitis. He was treated in the hospital for si.K weeks. Wliile there, a diagnosis was made of hernia, which had descended in consequence of the fall. I examined the patient on January 24, 1891. I found a hernia in the linea alba, about a hand's-width below the ensiform cartilage. It was aboiit the size of a fist. From the hernia one could trace a movable, rather thick cord, which extended ob- liquely across to the lower border of the ribs in the left axillary line. An insurance allowance of 60% was made, on account of the pain caused by stooping and because of the inability of the patient to lift anything from the ground. The connection jjetween the traumatism and the hernia was conceded. 228 DISEASES CAUSED BY ACCIDENTS. Cnse of traumntic nmbilicol hernia due to muscular strain. A stone polisher, fifty-two years of age, stout, on September 15, 11^91, in lifting a very heavy block of stone felt an intense cutting l)ain in the region of the umbilicus, accomjianied by the sensation of something having been forced out of his abdomen. On examining the latter he discovered a soft tumor, the size of a cherry, which protruded again every time it was pushed back. The physician whom he con- sulted diagnosed an umbilical hernia. The insurance allowance was estimated at 10 '/r. By the 12th of January, 189:^, the hernia liad in- creased to the size of an apjjle. Since that time it has not grown larger, and is held back liy an abdominal bandage. The patient com- plains of painful defecation and obstinate consti])ation, and of vertigo on stooping. He is unable to lift, even moderate weights, and is occa- sionally obliged to interrupt his work on account of an exacerbation of the symijtoms. Case of ventral hernia (hernia linen? albse) tvith operation and eonse- quent transverse diri.'0,%. About six weeks later I was hurriedly sum- moned to the house, and found in place of the funnel-shaped scar a hernia, as shown in the illustration. I had reason to believe that the hernia was caused l)y violent peristalsis. He complained of abdominal pain and of pain in the right thigh, which he was unable to move freel}'. I ordered rest in bed, compresses, and careful diet. The insu- rance allowance was thereafter reckoned at 50% for three years, when it was raised to 100% on the ground of a certificate from an official examining physician. The man died in July, 1895, of chronic neph- ritis. Femoral hernia, altliougli usually an acquiretl lesion, may also develop as a result of traumatism. The insur- ance allowance is the same as in cases of inguinal hernia. Umbilical hernia is, as a rule, congenital or acquired, and is frequently observed in stout peo])le with thick ab- dominal walls. Occasionally, the lesion is traceable to a trauma, such as a severe contusion, and, as a rule, in the class of people most subject to the acquired form. An umbilical hernia usually disables the ])atient to a greater extent than docs an inguinal hernia, and it is often difficult to apply a suitable truss, especially in case of stout people. Ventral or gastric hernia also occurs in conse- quence of traumatism, although by some — by Rinne, for instance — this is denied. Witzel, on the other hand, asserts that one-half of all ventral hernias are of traumatic origin. The possil)ility of their development after trau- matism is proved by a number of my own cases. The \ ^'f ^\ ■^ Tab. lo. 1,1th . Aiisl F. Reich hold, Miimhi'n . HERNIA AND INSURANCE. 235 symptoms are pain in the stomach, indigestion, respiratory disturbances, etc. The patients are unable to carry heavy loads, and should be prohibited from doing hard work. Insurance allowance, 33^^ to 50^. Ventral hernia may appear l)elow the region of the stomach ; it gives rise to practically the same symptoms in all situations. Case of traumatic inguinal hernia of the left side. A liod-carrier, twenty-one years of age, when carryinp- a hod full of lime on his left shoulder was about to step from a ladder to a scaf- folding. At that moment, when his right foot was already on the scaffolding, and as he was aboiit t(j lift his left from the last rung of the ladder, the latter sli})ped to one side. This caused a sudden strain, immediately followed ))y intense pain in tlie left inguinal region. Medical aid was at once oljtained, and an inguinal hernia Avas diag- nosed. The treatment consisted of rest and the subsequent wearing of a truss. \Mien I examined the patient, I found a small hernia the size of a walnut ; on palpation, the external abdominal ring felt notched, and was very sensitive to pressure. The patieut was allowed 20 ^/o insurance on the ground of the .sensitiveness of the lesion. [The attitude of the German law in disregarding the predisposition to hernia and in granting indemnity when hernia directly follows traumatism in the hernial region is judicious. Although it is true that a trau- matic protrusion of the gut rarely, if ever, occurs, except in the case of wounds, without a congenital or acquired weakness in the hernial region, it would be going rather beyond the mark to insist on this point in awarding dam- ages. On the other hand, there is no doubt that, in this country at least, fully developed hernias are often alleged to be the result of an accident when in reality they existed before the accident. To obviate this, many corporations now, before accepting candidates for em- ployment, insist on their physical examination with espe- cial reference to the various hernial regions. — Ed.] 236 DISEASES CAUSED BY ACCIDENTS. V. INJURIES AND TRAUMATIC DISEASES OF THE UPPER EXTREMITY. I. THE SHOULDER. Bcmorls on the Function of the Slionli/rr. — Althongh only a very limited deong- continued fixation leads to ankylosis, which is, however, only of permanent nature in case of old persons or in those affected by some constitutional disease. Leaving fractures, dislocations, and paralyses out of consideration, the effect of the contusion is spent on the skin, muscles, fascise, capsule, tendons, and bursse. After the extravasation is absorbed and the inflamma- tion is subdued certain symptoms remain, which, if severe, may call for after-treatment, but which, if only slightly marked, do not prevent the patient from resuming work. They are as follows : more or less atrophy of the deltoid, possibly also of the trapezius and the muscles of the arm and chest ; limited mobility of the shoulder-joint ; pain on forced movement ; cracking sounds of more or less in- tensity ; and a feeling of weakness in the arm. In some cases displacement — fixation of the arm in pronation or supination — is also seen as a result of the growth of adhesions. The average insurance allowance is about 25^, which can usually be reduced or discontinued three months after the accident. Occasionally, life-long compensation is de- manded, when the patient is old or delicate or rheumatic, or when the injury is followed by some serious disorder. Case of crushinf/ of the left shoulder eaitseif In/ the earing-in of the side of n trench. .Sequels, paralysis of the l)raehial plexus ; trojihoiienrosis of the hand. A \\orkiiian, fifty -two years of age, was injured on July 2(1, 1898, by the caving-in of the sides of the trench in which he was working. He was treated for two weeks with inunctions, and subsequently by electricity. I examined him on October 7, 1898. His left arm conld not be raised at the shoulder-joint, and its extreme elevation ecjualed only seventy-five degrees. Tlie inusc-les of the left shoulder and of the left side of the chest were atrophied. There was a noticeable edematous 240 DISEASES CAUSED BF ACCIDENTS. swelling of the left hand, which symptom had not appeared until two Aveeks after injury. The finger-joints were thickened, and the hand could not be closed. The parts snpjilied by the median and iilnar nerves were paralyzed. (See Plate 30, Fig. 2.) The patient was treated by me until the beginning of September, 1H99. At that time he showed marked impro\ ement ; he could close his hand three-fourths, and could raise the arm at the shoulder-joint to an angle of 155 degrees. Injuries of the burspe prolong the course of treatment to a considerable extent. When the acromial bursa is in- volved, it appears as a small, sharply rounded tumor on the acromion process. This condition is often seen in porters ; it causes, however, very little trouble. Inflammation of the subacromial bursa is said by Dupley to lead to a hyper- plasia of the fibrous tissue of the brachial plexus, and thereby to neuritis of the latter. The subcoracoid bursa is probably also involved in this process. The symptoms are as follows : sensitiveness to pressure under the acromial and coracoid processes and upon the acromial insertion of the deltoid ; pain on forced movement of the shoulder ; movement of the whole shoulder takes place when the arm is abducted above an angle of forty-five degrees (Tliiem). When the subdeltoid bursa or the bursa of the bicipital groove is concerned, the chief symptom is pain on move- ment of the shoulder or arm. Injuries to the subscapularis bursa are of special im- portance because of the danger of extension of the inflam- mation to the capsule of the shoulder-joint with which the bursa is connected. A prolonged course of treatment is nsually necessary in such a case ; the muscles of the whole shoulder atrophy, and the mobility of the shoulder- joint is restricted for a long time — at first on account of pain ; later, on account of adhesions formed within the joint. Among other syn)ptoins observed after recovery from bursitis belong the loud cracking sounds produced by movement, especially when the bursa situated at the su- perior angle of the scapula is involved. The sounds are often audible at a considerable distance, but are not of SPRAINS OF THE SHOULDER. 241 any functional significance, the u.sefulness of the joint re- maining unimpaired. This is true, indeed, of clirouic bur- sitis in general. 2. Sprains of the Shoulder. Among my cases there were twenty-two of uncomplicated sprains of the slioulder. Sprains due to falls or blows on the shoulder, elbow, or hand may involve either the whole shoulder, or the shoulder-joint or acromioclavicular joint alone. The same is true of the lesion when caused by suddenly catch- ing at an oI)ject, by vigorous pulling on an object that is firmly fixed in place, etc. The following symptoms are common to all forms of sprain of the shoulder in the later stages of the injury ; limitation of mobility of the shoulder-joint, cracking sounds on movement, })ain (this may be lacking), and atrophy of the muscles. Sprains of the Acromioclavicular Articulation. The effects of this lesion may be limited to the stretch- ing and straining of the acromioclavicular ligaments, pos- sibly causing partial laceration of the latter, or may be extended also to the acn^nial and subacromial bursse. If the ligament is only slightly torn, the mobility of the joint is seldom permanently impaired. Acute bursitis is followed by chronic inflammation, shown by the cracking sounds already referred to, which are most noticeable when the subacromial bursa is involved. As a rule, this condition causes only slight functional disability ; this is largely an individual matter, however, and in some cases a temporary insurance allowance of 20 ^ is indicated. 3. Fractures of the Clavicle. Of this lesion seventy-four cases liave come under my personal ob- servation. 16 242 DISEASES CAUSED BY ACCIDENTS. Fractures of the clavicle are quite a cominou form of injury ; in surij;i(^al text-l)ooks they are stated as consti- tuting 15^ of all fracture-cases. As a rule, they are caused by indirect violence ; but direct fractures also occur at any part of the bone — most frequently at the outer end. Direct fractures of the outer end are due either to blows from falling objects or to falls on the shoulder. The indirect form is usually produced by falls on the hand when the forearm is extended. The most connnon seat of fracture is the middle third of the Ijone, or a point between the middle and outer thirds, the lesion being due, as a rule, to indirect violence, — such as a fall on the hand with extended forearm, or a fall on the shoulder, — or, less frequently, to the strain of lifting heavy weights. Fractures of the inner third are of conq)aratively in- frequent occurrence. They are caused by indirect vio- lence, usually by violent contraction of the sternocleido- mastoid. Symptoms of Reunited Fractures of the Clavicle. — In order to gain a clear understanding of the dis})lace- ments consequent upon fracture of the chivicle it is neces- sary to think of this bone as a brace l)etween the sternum and the acromion process of the scapula. It is easy to see that a fracture accompanied by displacement of the broken ends must necessarily involve an abnormal posi- tion of the scapula, of the liumerus, and, indirectly, of the head also. Of the symptoms of fracture of the clavicle with which we have to deal after union has taken place, those de- scribed below are of most frequent occurrence. At the point of fracture there is a more or less marked callus-tumor, which diminishes in size in the course of time, and may entirely disappear aftei' a few years. In some cases the callus is not preceptible externally ; we find, instead, a pointed or sharp-edged ])r()minence, con- sisting of one of the fragments of the fractured bone over- SPRAINS OF THE SHOULDER. 243 the other. As a rule, the inner fragment overlies the outer. This displacement of the fragments has the effect of shortening the clavicle, and, consequently, the position of the shoulder is altered. The scapula adapts itself to these new conditions by rotating on its long axis, the external margin turning forward, while the head of the humerus, in following the change of position, rotates slightly inward. When both arms are placed on a level with the shoulder, with the thumbs turned upward, the l)icipital aspect of the arm is seen to be directed down- ward, while the olecranon process looks upward. The shortening of the shoulder and the deformity due to in- ward rotation are clearly seen in this position. In typical cases of fracture in the middle third of the clavicle the shoulder is depressed. When the inner fragment is displaced forward, the sternocleidomastoid becomes very prominent and draws the head slightly to the side, making the neck appear shortened on the side of the fracture, and lengthened on the opposite side (caput obstipum). The trapezius, as well as the muscles of the shoulder, chest, and arm of the injured side, give evidence of atrophy, in consequence of which the shoulder frequently has a pointed appearance. The mobility of the shoulder-joint is restricted, the movements of elevation of the arm above the shoulder and of rotation outward and inward being especially affected. Movement may continue to cause pain for some time, and neuralgic tenderness can sometimes be traced down to the ends of the fingers. Cracking sounds are often pro- duced at the shoulder, and the whole upper extremity re- mains weak for a time. The deltoid is sometimes paralyzed as a result of direct contusion. Case of reunited frdciure of Ihe rifiht clavicle at ifpt outer end, with dis- pJaeement of the outer fragment into the supranpinouH fosm. A paiuter, Hfty-four years of age, was crushed between a track and 244 DISEASES CAUSED BY ACCIDENTS. PLATE IG. Case of Reunited Fracture of the Left Clavicle in Its Middle Third. A ina.s(jn, t\\enty-four j'ears of age, fell from a height of one story on Bepteml)er lo, 1897, sustaining a fracture of the left clavicle. He was treated in the hospital for some weeks. I examined him on October 16, 1897. He had been incapacitated for work for exactly four W'Ceks. In the illustration the displacement of the sternal fragment for- ward and upward and the marked elevation at the point of fracture are shown. The sternocleidomastoid is distinctly seen, and the head is somewhat inclined to the left. The left shoulder and left arm are slightly rotated inward, and there is evidence of atrophy of the muscles of the left shoulder and arm. The shoulder appears a little shortened. At the time the patient came to me for examination he was able to raise his left arm at the shoulder-joint to an angle of 140 degrees. He undertook light work at first and comjilained chiefly of pain on movement of the left shoulder and of inability to use the latter for carrying purpryses. He was allowed 20% insurance. At the present time he is unable to raise his arm above an angle of 160 degrees. a Avail. He sustained a fractui-e of the right clavicle and fractures near the spine of the third to eighth ribs inclusive. He was treated in the hospital for several weeks. I examined him July 17, 1896. He was of medium height. Face rather pale. The deformity of the right shoulder was very evident ; of the clavicle, only the larger sternal fragment was visible, while the acromial process was sharply defined. On palpation a fibrous cord could be felt, passing from the acromial process to the outer third of the clavicle, while ])art of the outer fragment lay in the siipraspinous fossa, which it filled. The muscles of the scapula, the back, and the whole shoulder -were much atrophied, and the shoulder ai)peared to be displaced Ijack^vard. The patient could not raise his right arm above an angle of thirty-five degrees ; on passive motion it could be carried with great difficulty to an angle of sixty -five degrees and caused the patient a great deal of pain. The movement produced cracking sounds in the joint. The scapula was called into action before thirty-fi\e degrees were reached. The sternocleidomastoid was displaced forward, and the head was slightly inclined to the right side. After a further course of treatment the patient was discharged from my clinic on April 26, 1HJ)7, receiving 50% insurance allowance. He was then able to raise his arm with ease to an angle of 115 degrees, and could carry it to 145degrees with effort. The pain had greatly diminished. The skiagraph clearly shows the displaced outer fragment of the clavicle, the acromial end of which lies close to the coracoid process. The points of fracture of the ribs near Tab. 16. I.ith Aii.sl H HpicJtIicild . Miiiirhcii ^■ l. FRACTURES OF THE CLAVICLE. 245 the spinal cohimii, showing their upward dislocation, can also l)e rec- ognized. AMien the jiatient entered my care he complained of pain in the chest and on stooping, which disappeared, however, by Jannary^, 1897. In September, 1897, the patient was allowed 'So^c insurance; in September, 1898, tliis was reduced to 25 % . At that time the arm could l»e raised \-oluntarily to an angle of 150 degrees, and on passive motion to 160 degrees. In comparatively rare instances we may meet with paralyses of the brachial plexus due to direct injury. [Symptoms referable to the brachial plexus resulting from injury to the shoulder are not so very rare, and are often puzzlino'. They result from direct violence, such as blows or falls, with or without fracture or dislocation of bone, rather than from the slow pressure of callus. The musculosj)iral and ulnar are the nerves most fre- quently involved in injuries around the shoulder-joint, although paralysis of the circumflex or the median or the musculocutaneous may be added. The symptoms of these combined paralyses are the sum of the symptoms of palsy of the individual nerves. They are usually the result of severe injuries, and the prognosis is accordingly serious. Injuries to the neck, falls upon the point of the shoulder, and, less frequently, dislocations of the shoulder sometimes cause a peculiarly distributed paralysis, first described by Erb, and often called Erl)'s palsy. The muscles most frequently aifected are the deltoid, biceps, brachialis an- ticus, and supinator longus. - The supraspinatus and in- fraspinatus may also be involved. (Then there is an inward rotation of the arm.) All these muscles, with the exception of the last two, receive their innervation through the fifth and sixth cervical nerve-roots. The supra- scapular nerve, which supplies the supraspinatus and infraspinatus, receives some fibers from the fourth cervical segment, but as most of its fibers come through the fifth and sixth roots, it may easily be injured when these roots are aflPected. Hoedemaker has suggested that, in injuries to the shoulder, paralysis of these nerves may occur by 246 DISEASES CAUSED BY ACCIDENTS. PLATE 17. Case of Fracture of the Sternal Extremity of the Left CIavi= cle Leading to Ankylosis of the Shoulder=joint and Torticollis, Requiring a Prolonged Course of Treatment. JNIaikod iiiipio\ e- meiit later on. A workman, iifty-five years of age, on July 7, 1892, fell, with the ladder on which he was standing, striking the sidewalk on his left shoulder. He was treated in the hospital for se\ en weeks. The patient was a small, delicate man. The illustration shows his condition at the heginning of a course of treatment in my hospital, which lasted from ( )cto])er, 1892, to May, 1893. The almost complete uselessness of the left arm and shoulder was very e^'ident at that time. In the pictirre the thickened prominent sternal end of the left clavicle can be seen, drawing the sternocleidomastoid for\vard. The head is perceptibly inclined to the left, while the acromial end of the clavicle is elevated and displaced back^^•ard. The left shoulder is shortened, the muscles of the left arm and shoulder are atrophied, and the arm is held rather close to the Ijody. Posteriorly, the atrophy of the trape- zius and of the muscles of the whole slioulder is distinctly visible. The treatment consisted in passive movements and gymnastic exer- cises of the left shoulder, and in massage and electricity. The patient was discharged in May, 1893, with an insurance allow- ance of 50%, which he drew until July, 1898, when it was reduced to 25%. At the present date the arm can l)e raised almost to a line with the body, the head is held straight, the l)ackward displacement of the acromial end of the left clavicle has disappeared, and the arm is held in an entirely normal position. The only remaining symptom is a slight weakness of the arm. the fifth and sixth roots .being compressed between the transverse processes of the sixth and seventh cervical vcr- tebne and the middle of the clavicle. In cases in ^vllich the paralysis is severe, Erb's ])alsy is a very disablino; affection. The arm can not be raised from the side, and the forearm can not be flexed or strongly rotated outward. From paralysis of the deltoid, the slioulder of the affected side is lower than its fellow, and there may be a sliy-ht subo::lenoid dislocation of the humerus. Atrophy is often an early sym])tom, and there is usually marked fibrillary twitching in the muscles when they are put in action, if that is possible ; they sometimes are completely paralyzed. The sensory symptoms are never prominent ; there may be numbness and tingling in the 5$ ■ i0^- ERB'S PARALYSIS. 247 region of the shoukler or in the radial distribution of the forearm and hand. The eleetrie reaction soon sliows degenerative changes. All these muscles may, in health, be made to contract by applying the electric current at a point in the neck called Erb's point ; after injury disor- dered electric reactions soon become manifest at this point. The general prognosis of this form of paralysis is good, in that the patients usually recover. Recovery is, how- ever, always tedious, extending over many months. Another form of brachial plexus palsy, named, after its first describer, Klumpke's palsy, involves the first anterior dorsal root. Through this root ])ass the sympathetic fibers for the eye and face. The symptoms are paralysis of the small muscles of the hand and disturbances of tlie sympa- thetic in the face of the same side. There are myosis, diminution in size of the palpebral fissure, loss of the cilio- spinal reflex, sinking-in of the eyeball, and flattening of the side of the face. There are usually no vasomotor dis- turbances. Klumpke's paralysis results from causes similar to those of Erb's paralysis, but it is nuich less frequent. — Ed.] Symptoms ascribable to pressure of the callus on the plexus are also observed at times. Pseudo-arthrosis is another unusual sequel. The following points call for special mention : Fractures of the external third of the clavicle usually lead to only slight displacement, except when the bone is broken between the two divisions of the coracoclavicular ligament, — namely, the conoid and trapezoid ligaments, — and the latter are thereby lacerated. In these cases the outer fragment sometimes l)ecomes fixed at a right angle to the inner fragment, the acromial extremity pointing up- ward, thereby elevating the scapida and the whole shoulder. In other cases the acromial extremity is directed down- ward, or it is entirely displaced and lies in the supraspi- nous fossa. Where such marked deformity exists, the mobility of tlie shoulder-joint is greatly restricted ; com- 248 DISEASES CAUSED BY ACCIDENTS. plete ankylosis may even supervene as a result of bony union with the coracoid process or with the shoulder- joint itself. The consequences of fractures of the inner third of the bone depend to a larji;e extent upon the action of the sternocleidomastoid. At first the head is inclined toward the injured side in order to avoid pain, and the position once taken, it is frequently retained. In addition, we find a growth of callus at the point of fracture, and in some cases partial forward dislocation of the sternal extremity of the clavicle. Further, there is atrophy of the muscles of the shoulder, neck, and chest on the injured side, and limited mobility of the shoulder-joint, movement of which produces crackino; sounds. The ankylosis of the shoulder- joint is almost always due to unnecessarily prolonged fixa- tion, to which cause contractures of the elbow-joint, frequently observed after removal of the fixation-bandage, are also to be ascribed. Fractures of the clavicle may be further complicated by fractures of the ribs. In case of the first rib the lesion is due to direct })ressure ; fractures of the other ribs, however, are indirectly caused by falls on the shoulder. These complicating fractures are frequently overlooked. The chief aim of treatment should be the restoration of function. Massage is particularly to be recommended if the parts are still swollen, while ankylosis is best treated by systematic j)assive movements and gymnastic exercises. Massage and electricity should be employed for muscular atrophy ; for -neuralgia, galvanism and baths are especially beneficial. After-treatment may be indicated for a few weeks only, or, when com])lications exist, for a number of months. Even prolonged treatment may prove unsuccessful iu un- favorable cases, the shoulder-joint remaining permanently ankylosed. It should not be forgotten, however, in considering the DISLOCATIONS OF THE CLAVICLE. 249 serious consequences of the injury, that working-men liave been known to continue work after sustaining a fracture of the chiviele. Case of frdctitrc of f/ir outer third of the elnriele in consequence of a fall from a ladder. No niedifal advice was obtained, work was not discontinued, and recovery took place witliout deformity. A workman, eighteen years of age, fell from a ladder in 1864. Although the clavicle was fractured, he felt only slight pain and went on with his work. Tlie fracture healed while work was continued, the bone being but little displaced. It was shortened by Ik cm. The functional power of the patient was unaffected. He entered the army later, and took pail in the two subsequent ware. 4. Dislocation of the Clavicle. Of this lesion fifteen cases have come under my observation. The clavicle may suffer a forward dislocation at its sternal extremity in consequence of a fall on the anterior part of the shoulder, of being run over, and similar accidents by which the shoidder is violently driven back- ward, while the shaft of the bone, acting as a lever, forces the sternal extremity forward out of its normal position. Partial dislocations of this joint on the side supporting the load are frequently observed in hod-carriers. The symptoms of forward dislocation after healing takes place are as follows : As it is almost impossible to succeed in retaining the dislocated bone in position after reduction, it remains disj)laced forward to a greater or le.ss degree for a long time. The undue mobility of the joint that accompanies the displacement may persist for some years. The sternocleidomastoid is prominent, and is some- what displaced forward, thereby causing tiie neck to appear shortened on that side, while the reverse effect obtains on tlie opi)osite side. The triangle formed by the sternocleidomastoid, the clavicle, and the anterior margin of tlie trapezius is diminished in size. The acromial extremity of the clavicle may be directed backward and downward, or backward and upward, the shoulder being correspondingly lowered or raised. 250 DISEASES CAUSED BY ACCIDENTS. The imisc'les <»f the chest, shoulder, and neck on the injured side show evidence of atrophy, and movement of the shoulder-joint is restricted. All the foregoing symptoms are almost identical with those seen in cases of healed fracture of the sternal end of the clavicle. The symptoms consequent upon upward dislocation of the sternal extremity of the clavicle in cases in which reduction is practised are usually as follows : The inner extremity of the clavicle is sliglitly displaced forward or upward, wliile the acromial end of tlie bone is directed backward, and is at the same time either slightly raised or depressed. The head is somewhat inclined to tlie injured side. The other symptoms of atrophy and diminished mol)ility arc similar to those of the forward dislocation. Backward displacements give rise t(^ external appear- ances similar to those which have been described. They depend chiefly on the position maintained by the sternal extremity of the bone subsequent to healing. In almost all the cases coming under my observation it was slightly displaced forward, giving rise to the symptoms correspond- ing to tliat position. One patient suffered, in addition, from severe neuralgic pain in the arm, brought on by every attempt to lift tlie arm, and also from pain in the side of the neck on tlie injured side. Another case was marked l)y a rapid ])uUe and attacks of dyspnea. The treatment should be directed toward attaining the greatest possible degree of motion in the shoulder-joint. When passive movements are ])ractise(l, tlie dislocated ex- tremity of the bone should meanwhile be carefully main- tained in position. Massage and electricity are also useful in overcoming the atrophy of the muscles. The degree to which the patient is incapacitated for self-support depends on the loss of functional ])ower of the shoulder-joint. A course of treatment should be advised if there is difficulty in lifting the arm to the level of the shoulder, or if this movement is painful. For patients 1 DISLOCATIONS OF THE CLAVICLE. 251 who arc tlius affected an insurance allowance of from 30 '^ to 50^ may be indicated wlien the riii^iit arm is involved ; from 20 fc to 40 ;^ if the left is involved. When the lesion occurs at the acromial end of the clav- icle, the bone is usually dislocated upward. The lesion is produced by falls on the shoulder, when the acromial process receives the brunt of the injury, or by blows from objects falling- on the acromion. In cases of partial dislocation in which the acromio- clavicular ligaments are ])artly torn, the following symptoms arc noted : a slight prominence of the acromial extremity of the clavicle ; a moderate degree of rotation of the clavicle on its long axis ; atrophy of the deltoid and tra})ezius, and possibly also of the nuiscles of the chest and scapula ; pain and lessened mobility of the shoulder- The treatment is symptomatic. The working capacity of the patient is often diminished by from 10^ to 20^ or more. Complete dislocation, involving complete laceration of tlie acromioclavicular ligaments, is recognized in the follow- ing manner : The acromial extremity is displaced upward and is perccptil)le just beneath the skin ; and it may be separated from the acromion by a distance of 2 or 3 cm. or more. It may be difficult or impossible to raise the arm, especially above the level of the shoulder. Move- ment is likely to bring the end of the clavicle into contact with the acromial process, causing loud crcj)itati(in and pain. The nuiscles are more ap|)reciably atrophied than in cases of partial dislocation, and the condition persists for a much longer time. Treatment. — The effect of suturing the bone in posi- tion should certainly be tried, since no (»ther method vields residts worth mentioning. Insurance allowance, 33|^ to50<;^,. Downward dislocation of the acromial end of the clavicle is a rare form (jf injury, produced by a blow on 252 DISEASES CA USED BY A CCIDENTS. the outer end of the clavicle. It is accompanied by ex- tensiv^e laceration of the ligaments, and in some instances by fractnre of the coracoid process. The force of the l)low may also be extended to the head of the liumeriis, compressing it against the scapuUi and leading possibly to paretic disturbances from injury of the brachial plexus. Tlie joint may become partly or totally powerless, move- ment being regained later on in some cases by gradual development of a new joint. If reduction can be maintained, no specially character- istic symptoms are observed ; if the bone remains loose in the joint, the lesion occasionally assumes the appear- ance of an upward dislocation. If the dislocation remains unreduced, the acromion is seen to protrude sharply, while the outer extremity of the clavicle is concealed beneath it. The inner end of the clavicle is prominent and is slightly displaced forward at the sternoclavicular joint, the shoulder being somewhat displaced backward. As a rule, we find marked atrophy of the muscles of the shoulder, the scapula, the ciiest, and of the whole upper extremity, but especially marked in those attached to the humerus. Treatment. — If stiH unreduced, reduction nuist be practised under all circumstances; otherwise, passive movements of the shoulder, massage, etc., are indicated. The degree to which the patient is incapacitated depends on the loss of functional [>ower, 5. Fractures of the Scapula. Ainoiifi my cases of fracture of this bone the body of the ))one was involved in 19 cases ; the spine in 6 ; the ale in thin individuals, but are difficult or impossible to determine in muscular or stout patients. The muscles connected with the scapula and the adij)Ose tissue protecting it undergo more or less atrophy, the pro- cess being frequently extended to the trapezius, supra- spinatus, and deltoid. The inferior angle of the scapula is frequently dis- placed, and in case of transverse fractures it is usually displaced outward. When both arms are elevated to the level of the shoul- der, atrophy of the teres minor, teres major, and latissimus dorsi becomes apparent in the majority of cases. If the fracture involves the inner superior angle of the bone, this is sometimes drawn upward by the levator anguli scapulae. A fracture of the spine in a vertical line can occasionally be recognized by callus or by a convex nick in the bone. Functional power is but very slightly affected, although in some cases treatment is required on account of restricted mobility of the shoulder-joint. (b) Fractures of the acromion are met with more frequently, and in almost all cases are due to direct vio- lence, such as falls on the shoulder or blows from falling objects. Occasionally, they are indirectly caused by falls on the elbow, and in rare instances directly by muscular action alone. When due to direct violence, the fracture is usually seated near the apex of the acromion, whereas when the violence is indirect, it approaches its base. After union takes place the apex of the acromion appears sharply defined, and the supra-acromial bursa is frequently found to be enlarged. Symptoms due to loss 254 DISEASES CAUSED BY ACCIDENTS. of functional power are but slightly marked or are severe, depending on the degree of displacement of the fractured fragment. In some cases the acromion becomes com- pletely separated from the rest of the bone and a})proaches the clavicle. In one case of the kind, which has been under my observation since 1895, abduction is greatly restricted, the patient still being unable to raise his arm above an angle of foi"ty-five degrees. The external ap- pearances in this case are identical with those of a com- plete upward dislocation of the acromial end of the clavicle. Treatment is mainly a question of the restoration of functional jjower. The insurance allowance is estimated according to the functional disability : in very light cases none is required. (c) Fractures of the neck of the scapula frequently involve the articular surface of the glenoid cavity ; they are usuallv caused by blows or falls on or against the shoulder, on the outstretched hand, or on the elbow. The lesion is said to have occurred in consequence of violent contraction of the biceps (short head) andcoracobrachialis.^ It would seem that the only possible lesion that could thus originate in this situation would be an indirect fracture of the surgical neck, since the muscles in question contract in the direction of tiie coracoid process, not in the direction of the neck of the sca})ula. A fracture of the latter might more easily be explained on the ground of violent action on the part of the triceps. After recovery the affected shoulder usually remains shortened, and the head is sometimes sligiitly iucliiicd to that side ; the acroiuioclavicidar joint is sharply ])romiucut, and the head of the humerus is lowered in position. If the line of fracture runs across the glenoid cavity, the mobility of the shoulder-joint remains restricted for a long time, if not peruianently. The nuiscles coimccted with 1 Hoffa, "Luxat. ii. Fract.," 3d ed., p. 190. 256 DISEASES CAUSED BY ACCIDENTS. the shoulder and arm become greatly atrophied, especially the long head of the triceps. Atrophy of the deltoid may also occur in consequence of paralysis of the circumflex nerve. The treatment consists in exercises of the shoulder- joint, etc. The insurance allowance depends on the power of the patient to raise and use his arm ; even as much as 75^ may be granted. Ccise of fracture of the neck of the rirjht scapula, due to a fall into a cel- lar, leading to extendve adhesions and functiomd disorders. A workman, thirty-eifiht years of age, fell into a cellar on June 30, 1894, striking on his right shoulder. He was treated at first at home ; subsequently in the hospital, where, between August, 1^94, and Janu- ary, 1895, the adhesions in the joint were forcibly broken four times under anesthesia. The i)atient entered my hospital on March 1, 1895. He was rather tall and of vigorous build. The right slioulder was shortened and slightly rotated inward ; the muscles of the right side of the chest, the slioulder, and the arm were greatly atrophied, those of the hand being also affected. The arm could not be raised at the shoulder-joint above an angle of eighty-tive degrees, and movement Avas painful. The patient was discharged May 22, 1895, with an allowance of 50%, no essential improvement having been eifected. (d) Fractures of the coracoid process are usually seen in connection with fractures of the acromion, the spine, or the neck of the scapula ; with fractures or dislocations of the clavicle or the humerus ; or with fractures of the ribs. Less frequently they are caused by muscular contraction. The lesion is occasionally produced during the process of reduction of a dislocation of the humerus, but the most frequent cause is a fall on the shoulder. If healing occurs without displacement, functional power is satisfac- torily restored. On the other lianack. The muscles of the forearm were only slightly affected, so that the hand remained useful. He was allowed 40^ insurance. The arm could be raised (at the shoulder-joint) only to an angle of thirty-five degrees. The circumference of the affected arm measured less than that of the other, as follows : at its lower third, 4 cm. less ; at the middle of the biceps, (! cm. less ; at the axilla, 7 cm. less ; at the forearm near the elbo\\', nearly 2 cm. less. Tuberculosis of the lungs was diagnosed in August, 1895, and the patient died one year later. Altliouo'li in some cases the direction of rotation is not clearly niai'ked, there may nevertheless l)e evidence of adhesions and cicatricial contractions dne to the lacera- tion of ligaments, tendons, or muscles, or to the chip- pin(>;-oif of bits of cartilage or bone. It is to complications of this nature that ankylosis is often to be ascribed. Some- times when there is no ])aralysis movement may be greatly restricted, so that it is hardly possible to raise the arm to a level with the shoulder, even with the cooperation of the scapula. Secondary contractures of the elbow-joint are also sometimes observed. When bits of cartilage or bone are broken off, the cal- lus that subsecjuently forms may lead to complete anky- losis of the shoulder-joint. Fracture of structures within or connected with the joint may occur at the time of injury, or during the process of reduction. In this way t>> / K DISLOCATIONS OF THE SHOULDER. 261 the coracoid process, the greater tuberosity, and, less fre- quently, the lesser tuberosity may be broken off, or the humerus may be fractured at its anatomic neck, or occa- sionally at its surgical neck. The paralyses, which are very frequent sequels to dis- locations of the shoulder-joint, may depend on direct laceration of the circumflex nerve or on injuries to the brachial plexus. Usually the latter is only partly in- volved. Paralysis of the ulnar nerve occasionally occurs as a late symptom, leading to claw-hand and to tropho- neurotic disorders. The effects of the paralysis are motor and sensory. Among the sensory symptoms are disturb- ances of the temperature-sense, subjective coldness, formi- cation, etc. Electric irritability may be only depressed or the reaction of degeneration may be present. In severe cases edema and cyanosis of the arm are also observed. Pronounced loss of power in the hand is the rule, although in some cases of severe plexus-injury considerable strength is retained. The prognosis as to function after recovery from dis- locations attended by complications of the kind just de- scribed is unfavorable in tlie majority of cases. Very few patients can be discharged completely cured. The prognosis depends also on the age of the patient, be- coming less favorable with advanciup; years. A certain amount of improvement may, however, gradually take place in the course of years, both as regards paralysis and ankylosis. 1 In case of the latter, improvement is sometimes due to the formation of a new joint. . Although treatment may in some severe cases prove entirely unsuccessful, its value should not for that reason be underrated, since in the great majority of cases much can be accomplished by means of systematic massage, baths, medicomechanical exercises, and electricity. This demands much patience on the part of both doctor and 1 In the strict sense of the word, it is incorrect to speak of "anky- losis " in describing all forms of stiffness of a joint. 262 DISEASES CA USED BY A CCI DENTS. patient, as recovery is usually a very slow process. In severe cases the course of treatment may cover a year or more. The insurance allowance is proportionate to the loss of functional power, and may be as high as 75^. Subspinous dislocations are of comparatively rare occur- rence ; they are usually caused by a fall on the hand or elbow when the arm is directed forward and at the same time strongly abducted. The symptoms subsequent to reduction differ in nowise from those of the subcoracoid variety, except, possibly, in respect to the position of the arm and shoulder. Tlie complications of the two varieties are also identical. Old unreduced dislocations are seldom met with in acci- dent-practice. Even in these cases reduction should be attempted ; otherwise, treatment and prognosis are the same as for ankylosis of the shoulder in general. Sometimes dislocation of the shoulder-joint leads to a condition of recurrent or habitual dislocation ; the head of the humerus is likely to slip out of the glenoid cavity on the slightest provocation, and it becomes necessary for the patient to W(^ar a fixation-bandage in order to perform even light tasks, heavy work being quite out of the ques- tion. Fixation by suture, according to Ricard, is to be recommended. These cases require a high rate of insur- ance allowance. Fractures of the shoulder-joint have already been referred to in one instanc(! — that of fracture of the glenoid cavity. Fracttu'cs of the articular portion of the head of the humerus will be discussed in connection with lesions of the arm. Cfl.se of (litilncation of the rif/lil sJiouldcr-joinf, in irhich rcducfion was practised. Sequel, severe perinauent paralysis of tlie brachial )»lexus. A stone-mason, twenty-seven years of age, was injurt'd hy the cav- ing-in of a building on April 8, 1891. He sustained a dislocation of the shoulder-joint and direct fractures of several ribs, the latter lesion being followed later on by tuberculosis. I examined him July 7, 1891. The right arm hung limp at his side, and his right shoulder was de- TRAUMATIC SYNOVITIS OF THE SHOULDER. 263 pressed. From the elbow do^vni to the ends of the fingers there were edema and cyanosis. There was marked subjective coklness of the part. Active movement of the shonkler-joint was out of the ques- tion ; the mobility of the elbow-joint was comparatively well pre- served. The right hand could be closed with some difficulty and could exercise no pressure whatever. The muscles of the right side of the chest, neck, and Ijack were greatly atrophied. The reaction of degen- eration was present. Insurance allowance, 100%. Thirty-nine cases of healed fracture of the shoulder-joint occurring in my own practice have been utilized in the preparation of the fore- going description. Traumatic Synovitis of the Shoulder=joint. Acute traumatic synovitis of the shoulder-joint develops after contusions, sprains, dislocations, and fractures. The symptoms are swelling, fever, and functional dis- ability. The treatment consists of putting the part at rest, either by ordering the patient to remain in bed or by the use of a bandage ; also in the employment of antiphlogis- tic measures and, later on, in massage and movements of the joint. Chronic synovitis is a sequel to the acute form. The absorption of the exudate is followed by proliferation and hypertrophy of the synovial folds ; adhesions form between the latter, and, if the capsule was lacerated by the injury, it becomes involved in cicatricial contractions. The muscles and the parts of the bones concerned in the move- ments of the shonkler-joint all undergo atrophy. Move- ment is restricted, and on passive motion cracking sounds are both heard and felt in the joint. The condition is, as a rule, only slightly painful. The average insurance allowance is from 20^ to 25^. Tuberculous synovitis of the shoulder-joint develops after traumatism, usually after a contusion or dislocation ; it occurs comparatively often in young people. The acute synovitis is succeeded by a purulent epiphysitis, accom- panied by fever ; fistulas subsequently develop and seques- tra are thrown off. The treatment is purely surgical, and it may be necessary to continue it for a number of years. 264 DISEASES CAUSED BY ACCIDENTS. The fistulas constantly break open again, and new ones form in consequence of metastatic growth, causing rejx'ated attacks of fever and requiring frequent operations. When healing finally takes place, the part remains deeply scarred ; the unfavorable effects of the scar-tissue may, however, be- come modified in time. The arm remains undersized. In some cases the tuberculous process develops very slowly and insidiously, so that years may elapse before suppura- tion sets in. As contractures and ankylosis of the shoulder-joint have already been referred to a number of times, it would be superfluous to discuss them here. Loose-jointedness was mentioned in connection with recurrent dislocation. 2. INJURIES OF THE ARM. The total niiniber of injuries of the arm coming under my oliserva- tioii was 167; this number was made up as follows : 24 cases of contu- sion, with or without accompanying wounds; 5 cases of muscle strain; 8 of subcutiineous rupture; 54 fractures; 71 dislocations of the shoulder-joint; 2 wounds caused by bites ; 2 punctured wounds. The right arm was involved alone in 94 cases, the left in 72 cases; in one case both arms were injured. I. Contusions of the Arm. Slight contusions caused l)y blows, kicks, or falls usually heal quickly and completely. On the other hand, when the arm is severely crushed, as in accidents due to cav- ings-in, etc., recovery is slow. In such cases the soft parts — the skin, fascise, muscles, vessels, and nerves — are all more or less crushed and torn. Extensive laceration of the muscles leads to atrophy and loss of functional power, while the injured nerves remain inflamed (neuriti.s) or paralyzed for a long time. 2. Wounds of the Arm. Simple lacerated or punctured wounds, unless followed by cellulitis, are of little importance. Wounds of large WOUNDS OF THE ABM. 265 size lead to cicatrices that, if deeply attached or much retracted, interfere with the functional action of the part. Deep wounds of the axilla are especially dangerous, and the resulting cicatrices are likely to prevent free abduction of the arm. Extensive scars on the posterior surface of the arm may similarly restrict the action of the elbow- joint. Wounds caused by bites are serious injuries, not only because of the irregularity of the wound and the danger of infection, but also because they are likely to lead to unfavorable conditions of the injured parts of the skin and muscles, and to paralysis of the nerves involved. In one patient of mine, a coachman, who was bitten by a horse, there was paralysis of the radial and median nerves requiring a long course of treatment. The muscles of the arm are occasionally ruptured sub- cutaneously, the long head of the biceps being most fre- quently involved. Eight such cases liave come under my observation. Only in one, in which the tendon of the biceps was completely torn through at a point in its passage through the shoulder-joint, was the injury followed by severe symptoms of functional disability. The patient in this case was a workman, forty-eight years of age, who, in breaking tlu-ough a scaffolding, had clung to it with his right arm. The strength of the arm was considerably dinninished ; he was unable to raise it with the usual degree of force, and flexion at the elbow-joint, and more par- ticularly supination, were much restricted. The lesion in the remain- ing cases was caused by falls from a height ; one patient had fallen with outstretched arms into a box of lime. "\Mien I examined these patients at the end of the thirteenth week, I found comparatively few symptoms of functional disability. If the long head of the biceps is only partly torn across, tlie symptoms of functional disability frequently disappear soon afterward. I have discovered partial rup- tures of this kind when examining workmen for other reasons ; some of the patients dimly remembered having suffered from a slight sprain years iK'fore, while others were unable to give any explanation of the lesion. Subcutaneous ruptures of the biceps present a very 266 DISEASES CAUSED BY ACCIDENTS. PLATE 19. Case of Partial Rupture of the Long Head of the Biceps on the Right Side, Leading to Slight Functional Disability. A workman, forty yearn of ajje, fell clown stairs on April 30, 1898, striking on his right shoulder. He continued working, but complained of pain in the shoulder. The physician whom he consulted i)rescribed inunctions ; subsequently he stopped w'ork and was placed on the sick- list. I examined him on October 20, 1898. The accompanying illus- tration shows the two arms placed in a similar position. When the right arm is compared with the left, its outline is seen to be defective at a point corresponding to the long head of the biceps. The ball-like mass to which the nuiscle had contracted is Ijetter shown in the posterior view. Flexion and sui)iuation were both interfered with in the right arm. This case was not brought up for decision as to insur- ance allowance. characteristic appearance ; on contraction the muscle curls n\) into a round ball, beside which the line of rupture can be easily traced. (Compare with Phite 19.) In addition, the following symptoms are presented : noticeable atrophy of the bicei)s and triceps ; atro])hy of the suj)inators of the forearm ; diminished power of flex- ion and supination of the elbow-joint ; and general weak- ness of the arm. I have seen two cases of ])artial rupture of the short head of the biceps due to violent movements of the arm in pulling. The triceps is sometimes ruptured by falls on the arm when tlie latter is flexed. Occasionally, the muscle and tendon escape and tlie olecranon process is torn off instead. If after complete rupture the triceps tendon is not re- united by suture, the nuiscle rapidly undergoes atrophy. This leads secondarily to atropliy of the flexors. The arm loses in strength ; the power of extending tlie forearm is diminished, if not entirely suspended. Extensive scars arising from burns, if they encircle the shoulder or elbow or are deeply attached, are likely to limit the mobility of the arm by causing abnormal tension of the skin over the joint. ^ .J FRACTURES OF THE HUMERUS. 267 3. Fractures of the Humerus. Fractures of the Head of the Humerus. — Fractures of the head of the humerus occurring as the sole lesion are a rare form of fracture. Nine such cases have, however, come under my observation. In one case the greater tuberosity was also in- volved, the line of fracture passing through the anatomic neck. I liave also seen nine cases of fracture of the surgical neck. In almost all these cases the lesicjn was caused by a fall from a height ( ladder, window, or stairway). One patient was thrown from a wagon; another, a hod-c-arrier, was injured by a hod tilled with Ijricks falling on his outstretched arm. In another case the fracture was produced during the reduction of a dislocation of the shoulder-joint. Fractures of the head of the humerus or of its anatomic neck usually lead to serious functional di.sability. Either the head of the bone is torn oif at its anatomic neck by indirect violence, or the tuberosities are similarly affected ; or, in case of direct fractures, the lesion is often com- plicated by a fracture of the coracoid process, the gle- noid cavity, or the neck of the scapula. The force of the fall or blow on the shoulder that is sufficiently severe to fracture the head of the humerus is very likely to ex- tend to the adjacent bones. Fractures of the head of the humerus are, therefore, likely tt) be followed by the growth of .strong adhesions within the joint, which are very difficult to overcome. The condition may be relieved, to a certain degree, by early employment of massage and pas- sive movements. As in most cases of injury, the best residts are obtained in youthful patients ; recovery is less and less to be hoped for the greater the age of the patient. The same is true of separation of the epiphysis accom- panied by markotion tlie arm could he raised to an angle of 130 degrees; on passi\e motion, to \r){) degrees. The skiagni])]! showed a bony tumor situated at about the surgical neck of the right humerus, while the lesser tuberosity is absent from its normal site; the head of the humerus is somewhat displaced for- ward. Insurance allowance, 25%. Treatment. — When tlic greater or lesser tuberosity is torn off and displaced, it may, after union, be found fixed in a position very unfavorable to the movement of the shoulder. This applies more especially to the greater tuberosity, but in either case operative lueasures are in- dicated for the relief of the condition. Oi)eration is also to be recommended when the biceps tendon is cauoht in the callus after a fracture of one of the tuberosities, therebv producing ankylosis of the shoulder and at the same time a contracture of tlie elbow-joint. Separation of the upper epiphysis of the humerus occurs quite frequently up to the twentieth year ; less frequently between the twentieth and twenty-fifth year. The lesion is caused by a fidl on the shoulder or out- stretched arm. It is of importance chiefly fi)r the reason that the development of the affected arm is likely to re- main j)ermanently impaired and smaller than its fellow, the nuis(^les ])eing smaller and weaker, and tlie hand being usually uny the flexor carjn radialis and the flexor snl)limis digitorum. Displacement is espe- cially likely to occur after rupture of the internal lateral ligament. After union takes place there may be a more or less well-marked 0-position (cubitus varus), the elbow- joint being at tiie same time flexed. All the muscles arising from the internal condyle undergo atrophy. The ulnar nerve is exposed to direct injury in fractures at this point. Fractures of the internal condyle frequently occur in connection with dislocation of the forearm. The external condyle is more frequently fractured than the internal ; union usually takes place in an X- position (cubitus valgus) of the elbow-joint. Fractures of either condyle usually leave the joint flexed and at the same time ankylosed. In case of frac- ture of tiie internal condyle the flexors are primarily affected by atrophy, while in case of fracture of the external condyle it is the extensors that are primarily aflt'cted, the antagonists in both cases becoming atrophied secondarily. Paralysis and trophoneurotic disorders may appear in consequence of injury to the nerves, Sej)aration of the internal epicondyle may be caused by direct violence, but is more fre((uently tiie result of indirect violence in the form of sudden and very forcible abduction of the arm, the epicondyle being torn off' by tlie internal lateral ligament. It is not definitely de- cided whether or not tlie lesion can be produced by con- traction of the pronator radii teres. 280 DISK A SES CA USED BY A CCI DENTS. Separation of the external ejiicondyle is a rare lesion. I^nless decidedly displaced, no permanent functional dis- orders are to be expected in case of separation of either epicondyle ; the muscular atrophy is soon overcome. After-treatment of fracture of the humerus is chiefly directed tc)ward the mobilization of the ankylosed joints. Gradual loosening of the adhesions is to be preferred to forcible rupture, for the reason that the latter is apt to lead to the formation of new adhesions, if to nothing; nrore serious. Forcible rupture is to be recommended only for the purpose of obtaining a more favorable tixed position of the joint. Recovery is best furthered by passive move- ments and medicomechanical exercises, in connection Avith massage, local baths, and electricity. If paralysis is caused by pressure on a nerve, in eonseciuence of the growth of callus, the nerve should be freed from the latter by- operation. The degree to which the patient is incapacitated for self-support depends on his functional disal)ility. If he can raise his arm to an angle of about 110 degrees, 30^; insurance allowance is usually sufficient when the right arm is involved, 25 ^ when the left arm is involved. If he can raise it only to a level with his shoulder, 40 ^, for the right arm and 30^; for the left is an a})propriate allowance, the allowance being estimated at a higher rate for more serious degrees of ankylosis. For recurrent dis- location : if occurring on active motion, 60^ for the right ajnn and 50^ for the left ; if occurring on passive motion, 75^, for the right arm and GO^ for the left. Compen- sation for lesions of the elbow-joint will be discussed in the following chapter. 3. INJURIES AND TRAUMATIC DISEASES OF THE ELBOW=JOINT. Considerations «s to Anatotny and Function. — Movement of tlie elbow- joint is limited to flexion, extension, and rotation, the last beinj^ dis- tinjrnished, according to its direction, as jironation (inward rotation) and supination (outward rotation). INJURIES TO THE ELBOW. 281 Flexion is prodiifod both at the joint between the humerus and the nhia, and at that l)et\veeu the humerus and tlie radius. It is cliiefly executed on the iinier grooved portion of the troeldear surface, which in the right arm is directed to the left, and in the left arm is directed to the riglit. As a result of the inclination of this surface, the forearm does not form a straight line with the arm, either when completely flexed or when completely extended. On flexion it approaches the chest ; on extension it moves in the oi)posite direction, forming, when fully extended, an angle w ith tlie arm the base of which is directed outward. Extension can he carried to an angle of about 180 degrees, some- times more ; it is limited by the contact of the apex of the olecranon with the olecranon fossa. Flexion is limited by contact between the coronoid process of the ulna and the coronoiil fossa, and can he carried to an angle of aV>out 30 degrees. The ft)rearm, therefore, has a total range of motion in flexion and extension of 150 degrees. The olecranon and coronoid fossse are separated by a very thin lamina of bone. Overflexion and overexten- sion are prevented by the tension of the lateral ligaments of the elbow-' joint. The movements of pronation and supination are executed chiefly in the upper radio-ulnar joint, assisted, when the forearm is flexed, by the joint between the humerus and head of the radius, and, lastly, by the lower radio-idnar joint. The range of motion in pronation and supination etjuals an arc of 180 degrees. During rotation the orbicular ligament, which encircles the head of the radius and is inserted into the margins of the lesser sigmoid cavity of the ulna, plays the part of a sliding plane. The capsule of the elbow-joint is thin anteriorly, and still thimier posteriorly ; ))ut in the latter situation it is reinforced by the trice])s and its tendon. Laterally, it is strengthened ])y the internal and ex- ternal lateral ligaments. Flexion of the elbow-joint is produced by the brachialis anticus (supplied by the musculocutaneous nerve), assisted by the l)iceps, which also acts as a supinator of the forearm. The brachialis anticus arises from the internal and external surfaces of the humerus and is inserted into the coronoid process of the ulna ; although it must l)e regarded as the chief agent of flexion, its short leverage disqualifies it for acting jwwerfully A\ithout assistance. The biceps (sup]ilied by the nmsciilocutaneous nerve) must, therefore, not be underrated in its capacity of flexor. The fact that at the same time it acts as a su])inator is sufficiently explained by its insertion into the tuberosity of the radius and the fascia of the anterior surface of the forearm. The elboM' -joint is extended by the triceps, a.ssisted by the anconeus. Pronation is effected liy the following muscles : the pronator radii teres, flexor car\n radialis, pronator quadratus, and supinator longus. Supination is effected by the biceps, by the supinator bre^•is, and, to a certain extent, ])y the supinator longus. Injuries and diseases of the ell)ow-joint or of adjacent structures have the effect of limiting or suspending the functional action of the 282 DISEASES CAUSED BY ACCIDENTS. joint. Functional power is also restricted by patliologie changes in the shoulder or wrist. In examining the elljow-joint the affected joint should first be com- pared with that of the opposite side; its functional action should then be tested, noting the range of the different movements with the aid of the goniometer. Palpation should next be practised, and, finally, the musc^les of the arm, forearm, shoulder, and wrist should be carefully examined. SUdifiiics. — The 103 cases of injury of the elbow-joint upon which the following sections are based were divided as follows : 29 cases of contusions, sprains, and wounds: 7 cases of sim])le s])i-ain; 24 disloca- tion-fractures; 12 simple dislocations; 'M fractures. The right arm Avas involved in 54 cases, the left in 45 cases; both arms were involved in 4 cases. Contusions of the EIbow=joint. Contusions clue to falls g-ive rise to extravasation of blood and to 8\v(>lling', which very soon disapi)ear unless the contusion is complicated by some more serious injury. Com])licatious are, however, not infrequently met with in the shape of a fracture of the humerus (supracondyloid fracture), the olecranon, or some other part of the elbow- joint. The ulnar nerve is sometimes directly affected by the contusion. The olecranon bursa beneath the tendon of the triceps frecpiently becomes the seat of an acute in- flammation, which, unless carefully treated, may lead to suppuration. These various complications serve to delay to a considerable extent the progress of recovery. Sprains of the EIbow=joint. This lesion is produced by a fall on the hand or elbow or by violent traction. It may be simple or may be com- plicated by fracture ; in any case, it is accompanied by partial laceration of the ligaments and capsule of the joint, the consequences of which are seen, after the swelling and inflammation have subsided, in a certain degree of loose- ness and insecurity of the joint, together with atrophy and weakness of the muscles. These symptoms persist for a considerable length of time. The symptoms of contusions and sprains of the elbow- joint to be seen when the acute appearances have subsided DISLOCATION OF THE ELBOW. 283 are : Contractures of the joint by whieli the hitter is fixed at an angle ; musenhir atrophy ; limitation of motion (flexion, extension, rotation) ; weakness of the muscles. The treatment consists of systematic exercises and mas- sage. The average insurance allowance varies from to 20 '/r . External lesions of the elbow-joint, wounds of various kinds, and burns, result in the formation of cicatrices, which sometimes become attached to the bone or to the tendon of the triceps. The contractures of the joint that follow can be relieved, if not entirely overcome, by me- chanical treatment. In severe cases skin-grafting is in- dicated. The cicatrix, if attached to the bone, should be freed by operation. Insurance allowance, up to 20^. Dislocation of the EIbow=joint. Although statistics in general show the elbow-joint to be involved in about 18^ of all cases of dislocation, the lesion is not often seen in workmen who have reached middle age or over. Dislocation of the elbow-joint is usually caused by a fall on the hand. In young persons a dislocation, if reduced in time, is soon followed by complete recovery. The lesion as it occurs in adults is apt to be accompanied by fracture, usually resulting in ankylosis, and invariably so if the dislocation remains unreduced. After firm adhesions have formed reduction can be ac- complished only with great difficulty, and if bony union has taken place, it may be quite impossil)le. In cases in which the joint is fixed at an obtuse angle the condition of the patient is greatly improved by changing the position to one of flexion at a right angle, combined with supination. Even when uncomplicated by fracture and successfully reduced, a dislocation of the elbow-joint can be recognized for some time by certain characteristic symptoms. The joint is more or less fixed in a position of flexion (cubitus valgus or occasionally cid)itus varus), depending on the seat and extent of the tear in the joint-capsule and the 284 DISEASES CAUSED BY ACCIDENTS. consequent amount of cicatricial tissue. The condition frequently calls for systematic treatment by. massage and passive movement. At the time of dislocation the bra- chialis anticus is usually more or less torn at its point of insertion, while the tendon of the biceps and the bicip- ital fascia are subjected to strain. The tendon of the tri- ceps is also likely to be somewhat injured. Atrophy of these muscles frequently occurs, therefore, resulting in diminished power of flexion and extension and in weak- ness of the arm. If, as occasionally happens, the coronoid process is torn off, the atrophy of the brachialis anticus is correspondingly marked and persistent. This lesion is most likely to be found in cases of backward dislocation. Lateral dislocation may be complicated by fracture of one of the condyles, leading to functional disorders which have already been discussed under fractures of the humerus. Backward dislocation is frequently compli- cated by fracture of the olecranon, leading to rapid atro- phy of the triceps, and, secondarily, of its antagonists. Recovery may furthermore be delayed by injury to the blood-vessels. The ulnar nerve has occasionally been found displaced ; functional ])()\ver was, however, restored in the course of a few months. The fractures of the elbow-joint that have not already received mention will be discussed under fractures of the forearm. As already stated, unreduced dislocations of the elbow- joint invariably lead to permanent ankylosis of the latter. The position most favorable to the usefulness of the arm in cases of complete ankylosis is that of flexion at a right angle, combined with a moderate degree of supination. With the arm in this ])osition, although, as a rule, ham- pered by a slight stiftnessof the shoulder-joint, the ])atient is able to perform numerons movements, such as carrying the hand to the mouth, ])uttiiig the hand in the pocket, etc., whereas, if the forearm is fixed in pronation, the arm is practically useless. Fig. 32. 286 DISEASES CA USED BY A CC I DENTS. Partial resection may yield a relatively useful nieniber, but it is sometimes followed by shortening and ankylosis. The statements just made concerning primary ankylosis are equally applicable to postoperative ankylosis. The opera- tion occasionally results in loose-jointedness. which is, as regards function, a most unfavorable outcome in the majoritv of cases. The patient should be provided with a jointed support for the elbow. The insurance allowance is 60^. for the right arm, bO% for the left, when completely ankylosed at an obtuse angle; 40^ for the right, :5()^ for the left, if at a right angle. The allowance for inflanmiation and tuberculosis of the elbow-joint is estimated as in cases of similar lesions in the shoulder-joint. Caw of (lis.]nr(ttion of the had of ilw radium and rcuniti d fradure of the coroHoid process:. ( Fig. 32, p. 285. ) Secjucls, ankylosis of tlie elbow- joint and disorders of mobility of the slioulder-joint and wrist. A mason, thirty-eight years of age, fell from a scaffolding on September 18, 1890, sustaining tlu' foregoing injuries. When I examined him on January 10, 1H91, I found the left elbow- joint held at an angle of I'iO degrees ; llexion was limited to an angle of 75 degrees. Active abiluction carried the arm to 80 degrees ; pas- sive abduction, to 95 degrees. The nuiscles were greatly atrophied. The ^vrist was somewhat stiff at first, but subsequently regained its mol)ility completely. The left arm was the seat of paresthesia. In the accompanying .skiagraph the condition of the elbow-joint is clearly shown ; the notch on the coronoid process is distinctly visible, and tiie head of the radius can be recf)gnized l)e_\ond the ulna. Case of poorly united coiiimiiiitied fraeture of the left eUxnr-Joint, lend- ing to ankylosis and looxe-Jointcdnrss, irith seeondary ankijloxis of the shoulder and wrist. (Fig. 33, p. 287.) A carpenter, thirty-eight years of age, fell from a roof nine feet high on July 1, 1893. After being under treatnumt for fifteen nuHiths for a sprain of the elbow-joint, he fell down-stiiirs, again injuring the elbow. He was sent to me for a c(mrse of after-treatment on Sei)tember 9, 1898, after having been treated by several other ])liysicians. I found the left elbow-joint flexed at an angle of 135 degrees, the fore- arm being at the same time very strongly supinated. The whole left arm was greatly atrophied. The <']bow-joint was in a condition of loose-jointedness and was incapable of active movement, either of flexion or extension. The .shoulder-joint Avas completely, and the wrist-joint partly, ankylosed. No improvement has taken place up to date. Insurance allowance, fiO^. Fig. 33. 288 DISEASES CAUSED BV ACCIDENTS. Case of comminuted fracture of the right elbow-joiut, accompanied by backward dislocatioii of the forearm. (Fig. 34, p. 289. ) A carpenter, twenty-two years of age, fell from a roof two stories high, on March 7, 1H98, sustaining the foregoing injury. He was treated first in the hospifcil, subsequently at home, coming under my care on April 25, 1898. At that time the elbow-joint was completely ankylosed at an angle of 125 degrees, and was at the siune time so strongly supinated that the patient could use it neither in dressing nor in feeding himself. Abduction at the shoulder-joint was limited to 75 degrees ; mobility at the wrist-joint was practically normal. The skiagraph shows the back\\ard dislocation of the forearm, the lines of fracture on the olecranon process and trochlear surface, and the displacement of the fragments in the latter case ; also the bony union with the coronoid process. An attempt to reduce the dislocation was unsuccessful on account of the bony union which had already taken place. The position of the elbow-joint, however, was changed to nearly that of a right angle, and the degree of supination Avas reduced. Suljsequent treatment com- pletely restored the functional power of the right shoulder-joint. AMien discharged, the patient could use his arm for dressing himself for eating and for various other ]mrposes. Insurance allowance, 50%. At the present time he is employed at easy work for eleven hours a day. The accompanying skiagraph shows the condition subse(iuent to the attempted reduction. Case of loose-jointedness of the elbow following resection of the lower end of the hnmertis. A workman, forty years of age, sustained a comminuted fracture of his right luuuerus on May 10, 1889, caused by the fall of a cog-wheel on his outstretched arm. ^ He was treated in the hospital, where a re- section was made of the lower end of the humerus, including the artic- ular surface. I examined him on August 9, 1889. His arm below the line of resection hung limply at his side ; he could move neither foreainn nor fingers. He was supplied with a jointed support, which held the arm at a convenient right angle and enabled him to lift light articles. In- surance allowance, 80 % . 4. INJURIES AND TRAUMATIC DISEASES OF THE FOREARM. Slatisties. — The cases of injury of the forearm serving as a basis for the following sections numl)er, in all, 2(n, l)eing classified as follows : 205 cases of fracture; .'U of contusions and contusion-wounds; 14 of incised and punctured wounds; 11 of burns. The right forearm was involved in 121 cases, the left in 127 cases; both were injured in 13 cases. Fig. 34. 290 DISEASES CAUSED BY ACCIDENTS. PLATE 20. Case of Rupture of Muscles and Tendons of the Forearm in a Case of Injury Due to the Caving=in of a Wall. A hod<"ai-rier, tliirty-four years of age, while employed in tearing down a building Avas caught under a falling A\all, on INIay 7, 18H9. He sustained a severe compound fracture of the skull, and, in addi- tion, his right forearm was badly crushed. He Avas treated in the hospital, Avhere the ruptured tendons were sutured. The accompanying illusti'ation s1k)ws the scar on the anterior sur- face of the forearm and a nuiscle-hernia at the middle of the latter. The effort of the patient to close the hand is also dejjicted ; he w'as unable to Hex the fingers further. The nmscle-hernia was most promi- nent with the hand in this position. The strength of the right arm was not more than half that of the left. The patient was an unusu- ally' strong and vigorous man. The insurance allowance was only 10% . Contusion and Crushing of the Forearm. Unless complicated by serious avouikIs of the skin, by lacerations of muscles, tendons, and nerves, or l)y fracture, contusions of the forearm usually heal without unfavorable consequences. The forearm is, however, exposed io very grave acci- dents, especially among workmen in the trades and manu- factures, as a result of which it may be severely crushed and permanently disabled. Accidents of this nature fre- quently occur during the loadiug and unk)ading of heav^y beams, in overturning heavy blocks of granite, or when, in tearing down a buikliug, a worlvman is caught under fall- ing walls and debris. In tlie latter instauce the injury is likely to be especially serious, since skin, muscles, and tendons may easily be torn by sharp edges or pointed masses. Cases of crushing and mangling of an extremely severe type, involving muscles and tendons and accomj)anied by extensive burns, occur occasionally, although with relative infrequency, in steam laundries when hand and forearm are drawn in between hot rollers. Lao, L'U. ..^ J*' \ \ WOUNDS OF THE FOREARM. 291 Severe case of mnngling of the left hand and forearm accompanied by burns. A working-girl, eighteen years of age, employed in a steam laundry, sustained the injuries of the hand and forearm just mentioned on Decem- ber 16, 1892, the arm Iteing drawn in between hot rollers. She was treated in the hospital until August 27, 1893, when a course of medico- mechanical treatment A\"as t)egun. I examined her on January 29, 1894. The left forearm was pro- nated, the wrist-joint was swollen, and the fingers, wrist-joint, and elbow-joint were ankylosed. They responded slightly to pavssive motion. The extensor surface of the forearm was marked by two long, wide, and adherent scars, reaching up to the elbow-joint, and the whole arm Avas entirely useless. The i)atient Avas discharged on March 17, 1894, with an insurance allowance of 60%. The liand and forearm are also sometimes frightfully mangled by being caught between eog-wheels. No gen- eral statements can be made concerning the consequences of such injuries ; each case must be judged for itself. For the symptoms observed in special instances the reader is referred to the illustrative cases here cited. Wounds of the Forearm, The greatest possible variety of wounds of the forearm is met with in Avorkmen employed in the various trades and manufactures. Reference has already been made to the wounds accom- panying contusions. Incised wounds are produced by pieces of glass, the splinters of which are a})t to remain in the wound ; also by sharp pieces of tin, by knives, saws, pieces of slate, etc. Punctured wounds are caused by penetration of scissor- points and similar instruments. In respect to sequels, extensive scars of the forearm are likely to limit the mobility of the elbow-joint, wrist, and fingers. If a punctured wound happens to sever a large nerve- branch, the consequences are, of course, most serious, as I had occasion to observe in one case of paralysis of the muscles supplied by the musculospiral nerve. This nerve 292 DISEASES CAUSED BY ACCIDENTS. liad been severed by a punctured wound on the extensor surface of the right arm in its upper third. Incised wounds running transversely across the lower third of the forearm, especially if close to the wrist, are attended by the danger of more or less serious injury to tiie uniscles, tendons, and nerves at that point. 8uch wounds are produced by blows from an ax or hatchet, by cuts made by a circular saw or some other sharp machine, or by glass, slate, and thediiferent edged materials of trade. If properly reunited by sutures, the tendons and nerves may be restored to power ; it happens sometimes, however, that the tendons are not properly united at operation, or that the sutures subsequently give way, and in such cases func- tional power is greatly impaired. Even when the nerves are only partly severed, as can l)e determined on examina- tion, the forearm recovers its full pcnver very slowly and gradually, perliaps not until several years have elapsed. The fact that trivial injuries may be followed by cellu- litis, by which the part can be rendered almost useless, does not need further discussion here. Burns of the Forearm. These are of functional importance if tluy- involve the skin over the wrist-joiut or elbow-joint. As the skin of cicatricial tissue is frequently in an atrophic condition, it is likely to break open and is veiy sensitive to cold ; areas of hyperesthesia are, moreover, not infrequently presented. Fractures of the Forearm. The following points may be stated in regard to the fracture of those portions of the bones of the forearm that are contained within the joint. The olecranon may be torn off by muscular action or may be directly fractured by a fall. In either case it is drawn upward by the triceps, the displacement being frequently followed by fibrous rather than by bony union. FRACTURES OF THE FOREARM. 293 The triceps mideriroes primary atr()])liy, Avhieli is followed by seeoudary involvement of the bice})s, braehialis antieus, coracobrachialis, and the muscles of the forearm. In some cases the })atient recovers the full use of the arm ; in others, he is obliged to wear a jointed support for the elbow in order to work to any advantage. The fractured olecranon may become fixed by bony union in or beside the olecranon fossa, rather than at the point of fracture. After fracture of the olecranon the functional power of the arm is always impaired for the time being, and in some cases the disability is permanent. Direct fractures are likely to involve the ulnar nerve, in which case the symptoms of functional disorder are, of course, increased in severity. Case of fracture of the right olecranon due to a fall from the halconi) of a theater. Sequel, displacement of the olecranon, leaving an interval of the width of a finger Ijetween the fragments. One year after iiijuiy the patient was comparatively- well able to support himself at his trade. A mason, thirty-eight years of age, fell, as just described, on No- vember 26, 1889, sustaining a fracture of the right olecranon. He was first treated in the hospital, then in the dispensary. I examined him February 21, 1890, and he remained in my care until December 20th, of the same year. Insurance allowance, 33*^^. During that time the atrophy of the arm increased, while the triceps showed rela- tive impro\"ement. The arm could be alxluctcd to an angle of I.jO degrees ; the elbow-joint was held flexed at an angle of 85 degrees. The patient A\as given a jointed support, by the aid of which he learned to perform most of the work of his trade. Insurance allow- ance since November, 1891, 25%. Case of fracture of the left olecranon caused hy falling and striking on the elbow, folloired hi/ aevere functional disability. A mason, forty-seven years of age, slii)i)ed and fell into a lime-pit on July 18, 1891. He was first treated in a disiiensary, entering my care on October 19, 1891. At that time the left elbow-joint was flexed at an angle of 140 degrees ; the olecranon was displaced upward by the width of a finger and was freely movable. The musc-les were greatly atrophied ; the patient complained of the arm being cold, and was unable to close the hand completelv. Insurance allowance, 60%. When the coronoid process is broken off at its base, union is always succeeded by ankylosis of the joint and atrophy of the braehialis antieus. If the ankylosis is com- 294 DISEASES CAUSED BF ACCIDENTS. plete, the atrophy of tlie muscle becomes, of course, a matter of secondary cunsideration. Fracture of the Ulna in its Upper Third, Accom- panied by Upward Dislocation of the Head of the Radius. — This may be looked U[)ou as one of the typical fractures of the forearm. As I have repeatedly had oc(!a- sion to observe, when allowed to remain unreduced, this lesion presents the following- characteristic signs after union is established : the elbow-joint is flexed and com- pletely or almost completely ankylosed ; the ulna is bent at an angle the concavity of which is directed outward ; the head of the radius shows distinctly under the slcin ; and the whole forearm appears shortened. As is to be expected in all cases of ankylosis of the elbow-joint, the mobilitv of the sii(iuld(M-joint is secondarily im[)aired. Fractures of the Shaft of the Ulna. — Fractures of the shaft are in most cases caused by direct violence, as from a fall on the inner side of the forearm. After union is established the ulna is usually found shortened and bent at an angle the concavity of which is directed inward. Cases are on record, however, in which fracture occurred during the process of lifting heavy weights or of setting them down when the forearm was flexed. A frac- ture occurring under such qucnce of pscudo-arthrosis and ischemic muscular paralysis. Pseudo-arthrosis causes grave functional disal)ility. It usually renders movements demanding tlie exhibition of much strength out of the ([uestion, although a few instances are on record in which considerable power was dis- played some time after injury. Patients are frequently obliged to wear a fi.\ation-bandag(! aroinid the forearm in order to use the hand even for ordinary piirj)oses. The lo^ver fragment is apt to become greatly atrophied, tlie Fig. 35. 298 DISEASES CAUSED BY ACCIDENTS. atrophy involving not only the nuiseles and adipose tissue, but extending in the course of time to the bone as well. In some cases union may finally be established, even when a considerable period has elapsed after injury ; I have known it to occur as long as two years afterward. The development of a new joint is seldom favorable to functional power as far as movements of rotation are concerned. Ischemic nuiscnlar paralysis is a paralysis of the mus- cles of the forearm due to compression from too firm a bandage. Unless treated early, the condition is a very difficult one to overcome. Typical Fractures of the Radius. — My pereonal observation lias covered 14() cases of these fractures. In examining the radius with reference to reunited fractures it is advLsahle to begin ))y inspection, first \vith the arms lianging at the side, then with the thund)s of l)otli liands placed side bv side. The appearance of the extensor and flexor surfaces should Ije carefully noted, also the profile of the part. In practising pal])ation the lower fragment, the head of the ulna, the capsule of the joint, the caqml bones, etc., should be thoroughly gone over. All the joints of the arm should be test'cd as to their functional ability. We are justified in using the term typical fractures of the radius in describing the fractures of the lower end of the l)<)ne, not only because of the frecjuency of their occur- rence, but also because they almo.st all arise under similar circumstances and present characteristic appearances, both before and after consolidation, in s})ite of the great di- versity of their forms. Many cases of so-called s])rains of the wrist are really fractures of this type. The two lesions are, in fiu^t, frequently produced in the same man- ner, — by a fall on the hand, — so tliat it would not seem inappr<»])riate to speak of fractures of the kind imder dis- cussion as "sprain-fractures." The foi'ce of the fall which ])roduces them is not neces- sarily ap[)lied to the palm of the hand ; they may equally well l)e caused by a fall on the back of the hand or on the clenched hand. I have also known cases to occur FRACTURES OF THE RADIUS. 299 from overextension of the wrist when unloading heavy beams, or even as a result of a fall or blow on the lower end of the ulna. The ulna in some instances remained intact, while in others the styloid process was broken oif. The line of fracture varies with the cause which produces it and the manner in which the force is applied. It is important to ascertain all the facts bearing on this jjoint in order to gain a clear understanding of the subsequent displacement and fnnctional disability, ^^'hen the line of fracture runs transversely, as it does when the fracture is caused by a fall on the outstretched hand, the lower frag- ment is almost invarialjly disj)laced backward, while it is usually displaced forward in case of falls on the dorsum of the hand. Union may be established within the first week or two, or may require three or four weeks' time. In one case a skiagraph taken three weeks after the injury occurred showed precisely the same condition as had ex- isted on the fourth day. It does not do, therefore, to maintain a fixation-bandage for the same length of time in all cases. The symptoms of typical fractures of the radius after union is established are as follows : The wrist appears broader and thicker than normal, and the head of the ulna is considerably displaced to the side. The hand is displaced to the radial side, while the fingers often point more to the ulnar side. (This is probably often due to the bandage.) In case of backward displacement of the lower fragment the latter shows as a rounded prominence on the posterior aspect of the forearm close to the wrist ; above the j^rominence there is a hollow. Close to the wrist on tiie flexor surface of the forearm the soft parts (the ])ronator (piadratns mnsde and flexor tendons) project in the form of a soft tnmor. This prominence of the soft parts of the flexor surfiice is a regular accompani- ment of the cases caused by a fall on the palm of the hand, but is not seen in those caused by a fall on the dorsum of 300 DISEASES CAUSED BY ACCIDENTS. the luiml. The shaft of the radius is displaced, as a rule, being rotated outward by the muscles attached to the ex- ternal condyle of the humerus and the external condyloid ridge. Occasionally, however, the shaft is rotated inward. In conse(|uence of this disi)lacement of the shaft of the radius the radius and ulna cross each other, either above or below the normal point. The displacement of the bone of course involves a similar change of position of the muscles surrounding it, as is shown l)y a marked dejires- sion on the radial side of the forearm in its lower third, due to the outward displacement of the point of insertion of the tendon of the supinator longus. Partial disloca- tions, varying in degree, are seen in both the superior and inferior radio-ulnar joints, and in case of the latter the dislocation may even l)e a com])lete one. 'J'lie forearm also very frequently a])pears shortened. In the majority of cases the styloid process of the ulna is broken oflp and the capsule of the wrist-joint is swollen. The muscles of the forearm and hand show signs of atro])hy, and those of the upper extremity are often similarly affected, especially the Inceps. The atro|)hy of the biceps — which is due to the displacement of the shaft of the radius and the restriction of sujiination — diminishes its power as a flexor of the elbow-joint. The elbow-joint is apt to be held flexed at first, allowing neither complete flexion nor com})lete exten- sion. Abduction of the arm is also likely to be somcAvhat restricted. In some cases there is paralysis of the parts sup])lied by the nuisculos})iral, median, or ulnar nerves. The bones of the carpus usually escape injury ; if not, the scaphoid is the one most likely to be involved. The lesion usually takes the form of a fracture ; occasionally, however, the scaphoid is dislocated or is driven into the cancellous tissue of the radius. The relation between the arti(;ular surface of the radius and the carpus is, on the other hand, never normal in these cases, and the ligaments of the carpus are always stretched and loosened. This results in imperfect closure Fig. 302 DISEASES CAUSED BY ACCIDENTS. and weakness of the hand, whicli are noticeable symptoms of the recent injnry, and sometimes persist for a long time. The range of motion at the wrist is considerably dimin- ished, and pronation and supination are restricted in almost all cases. The treatment of the foregoing condition consists of massage and passive motion and of gymnastic exercises for the ])urpose of overcoming the displacem{>nt and anky- losis. Traction made with increasing weights and rotatory movements are very beneficial, while electricity should be employed for the paralysis. As far as duration of treatment is concerned, the ])arts may within a few weeks regain as much functional power as can be hoped for at all, or the course of exercises, etc., may need to be kept up for months, or even for one or two years. Incapacity for self-support, which is proportionate to functional disability, varies from 10^, 15/^, or 20^ in light cases, to bOfo, QOfo, or even 70 fc in serious ones. To the latter class belong the cases of loose-jointedness due to extensive laceration of the capsule of the wrist-joint. As already stated, dislocation or snl)luxation of the inferior radio-ulnar joint is a very frequent complication of typical fractures of the radius. The styloid process of the ulna is occasionally rotated so as to be directed forward or l)ackward, and th(! whole lower end of the ulna may be found al)nornK(lly movable. Cnse of reunited tifpieal fracture of the r<((lim fottowed by perfeet recov- ery. (Fig. 36, p. 301.) " Tlie subject of the acoompanyiuf; skiagraph was a workman, forty years of age, who, wlien pushing a handcart, on August 27, 1H98, struck against a heap of stones, causing his hand to be violently pressed backward. He Avas at first treated for a sprain of the wrist. The skiagraph shows the fracture of the radial epiphysis, completely reunited, the line of fractui'e showing lint very little. Tlie styloid process of the ulna is seen to be broken off, and the ulna is slightly displaced forward, striking against the semilunar bone. The scaphoid is evidently not in normal position. Fig. 37. 304 DISEASES CAUSED BY ACCIDENTS. At the time I examined the patient, on Se])tenil>er (i, 1>^9S, the movements of the Avrist-joint were considerably limited, and the Ihi- gers eonld not be completely closed. Indenniity was not reipiired in this case, as tlie patient made a com- plete recovery before the beginning of the fourteenth week, the time when insurance is first paid. Crtse of typical fracture of the Uft radius. (Fig. 37, p. 303), result iug in partial recovery. A carpenter, forty -eight years of age, fell from a roof, on November 15, 1897, landing on a heap of siind, with his left hand extended. I examined and took a skiagraph of the patient on No\"ember 25, 1897. The fracture is shown in the accompanying illustration. The forearm, wrist, and fingers were greatly swollen ; the fingers could not be closed, and the deformity was extremely well marked. The injured part was placed in temporary plaster jjandages, and was treated also by massage, steam baths, and later on by exercises. The deformity was overcome by refracture of the boUe. The patient was discharged on May 21, 1)^98, a\ ith an insurance allowance of 30^^. The index-finger and middle finger had been mutilated in an earlier accident ; otherwise the hand coidd be completely clo^^ed ; the grip, however, was still weak. Six months later the insurance allowance was reduced to 20%, at which rate it has continued. Case of ii/j)ical fracture of the radius, accompanied hy dislocation of the inferior radio-ulnar joint. A workman, thirtv-one years, of age, fell from a ladder on August 2G, 1898. (Fig. 38, p. 305.') The skiagraph taken on October 10, 1898, showed union to liavc taken place. The wrist, however, was still swollen, and its mobility was restricted. The patient \vas still iinal)le to close the hand, which was very weak. The hea<>() DISEASES CAUSED BY ACCIDENTS. 4. The combination joint lietween the scaphoid, seniilnnar, cunei- form, unciform, os magnum, trapezoid, inner surface f)f the trapezium, and the bases of the second and third metacaipal bones, forming the intercarpal and metacarpal joints. 5. The articulation between the unciform bone and the bases of the fourth and tifth metacarpal Ijones. (!. The articulation between the trapezium and first metacarpal bone. The last-named joint ( reciprocal reception ) is always entirely sepa- rate from the others, while in some individuals all tlie other fi\e joints may be in communication M'ith one another. In such cases we have to deal with two joints, or rather with one joint and one combination joint. The communication existiiig between these fi\'e joints explains the rapid involvement of the whole wrist in some cases of infection. A similar extension of infection to the wrist in cases of injury of the joint between the trapezium and first metacarpal l)one is to lie explained by the destruction of the interosseous ligament. In operating for the removal of the thumb and first metacarpal bone, injury of this ligament should l)e carefully avoided. This can l)est be accomplislied by enter- ing the joint innnediately below the insertion of the tendon of the abductor longiis pollicis (extensor secundi internodii pollicis). The fact that the triangular fibrocartilage occasionally i)resents a per- foration is of importance in dealing with injuries and diseases of the lower radio-ulnar joint. Another point to be borne in mind is the occasional existence of in- terosseous ligaments between the joints which usually intercommuni- cate, thus increasing the number of separate joints in the wrist. The strongest ligament of the wrist-joint is found on its anterior surface; posteriorly, the ligament consists of separate and compara- tively weak filirous bauds connecting adjacent bones. When the wrist-joint becomes filled \\ith a fluid exudate, the capsule of the joint is pressed out between these bands, forming the so-called ganglia of the wrist. In their passage across the back of the wrist the extensor tendons are retained in position by the posterior annular ligament, an exten- sion of the posterior fascia of the forearm. It is strengthened by some additional fibers. It is di\'ided, as a rule, into seven separate com- partments for the various tendons, some of which are usually inclosed in a common synovial meml)rane. The wrist is capable of the following movements: 1. Flexion (anteflexion). 2. Extension (retroflexion). 3. Abduction (movement toward the radial side, radial flexion). 4. Adduction (movement toward the ulnar side, ulnar flexion). 5. Circumduction, which is a combination of the four previous movements. 6. Rotation (pronation and supination) in the inferior radio-ulnar joint. Flexion, extension, abduction, and adduction are executed in the wrist-joint proper — the radiocarpal articulation. Flexion and exten- sion are limited — in addition to the tension of the ligaments — by the AXAT03IV OF THE ]\'IiIST. 307 contact, above or below, between the radius on the one hand and the scaplioid and semilunar on the other. Flexion and extension take place ar(jinul a trans\ei-se axis with very little change of plane. The angle to wliich these movements can be carried varies greatly in dili'erent individuals, and even varies as to the two hands in tJie same indi^-idual. According to the measui'e- ments that 1 have taken on indi\iduals of different ages and in various classes of society, extension is, as a rule, somewhat more limited tlian flexion ; this point, ho\\e\er, often depends upon the profession of the individual. In a nund^er of roofers who were expert in climl)ing I found the angle of extension to exceed that of flexion. The a\erage angle of extension was (iO degrees, carried in special cases to from 8.") to J)0 degrees; the average angle of flexion was 6oh degrees; its extreme limit, 90 degrees. In extreme flexion and extension the wrist-Joint proper is assisted by the joints l)etween the two rows of carpal bones. The axis around which the carpus re\'olves in abduction and adduc- tion does not form a straight line, but, on the contrary, the plane of motion almost constantly changes. The angle of aliduction never equals that of adduction, tlie former, according to my measurements, being represented, on the average, liy 3:3] degrees, the latter ))y nearly 50 degrees. The change in the plane of motion increases as the ex"- tremes of abduction and adduction are reached, especially' in the case of adduction. A certain degree of movement occuis at the same time among tlie joints Ijetween the carpal l)ones, the scaphoid taking part in adduction, the cuneiform in abduction. It is not ^jossible, hoAvever, to enter into a discussion of these points liere. Pronation and supination are executed in the superior and inferior radio-ulnar articulations. Although limited by the tension of liga- ments and tendons, the angle thus ol)tained may equal or exceed 1^0 degrees. The radius during this movement rotates around the ulna. Duchenne maintains that the ulna moves simultaneously. Mobility of tlie wrist is essential to Avorkers employed in the various branches of industry, especially to those A\hose work requires them either to grasp and to hold heavy articles, while directing their further progress with the wrist-joint, or to exert pressure on the hand. Anky- losis of the Avrist-joint following fractures, dislocations, sprains, and inflammatory processes causes a corresponding degree of disability for self-support on the part of the patient. StatMics. — In addition to the 14G ca.ses of typical fracture of the radius, my material includes 87 cases of injuiy of the wrist-joint, observed after healing took place. This number includes 11 cases of injuries due to contusion, 51 cases of sprain, 5 of dislocation of the bones of the carpus, 14 of fracture of the bones of the carpus or of the styloid process of the ulna occurring separately, and 6 of wounds. Sprains of the Wrist=]oint. Sprains of the wrist-joint are ;i very common form of injury. If in describing an injury of the wrist-joint we 308 DISEASES CAUSED BY ACCIDENTS. apply the term sprain strictly in the sense of its definition in the first part of this book, — namely, as a dislocation of only momentary duration, righting itself at once, — we shall be obliged to exclude a number of other injuries of similar etiology which are often covered by the name of sprain. Under '' sprains " we find typical fractures of the radius, fractures and dislocations of the bones of the carpus, dislocations of the inferior radio-ulnar articulation, etc. True sprains, in which the lesion consists only of a strain or slight laceration of the capsule and ligaments of the joint, are" soon cured by rest of the part, together with compresses and massage, although frequently the joint remains weak and the capsule continues relaxed for some time. In almost all cases of sprain coming under my observa- tion for the last three years I have, by the aid of skia- graphs, discovered a dislocation of the inferior radio-ulnar joint. Dislocation of the Radio=uInar Joint. This lesion, which is not at all uncommon, is usually caused by falling on the hand or by twisting the wrist in liftinp: or settino- down heavy burdens. It is also frequently seen as an accompaniment of typical fractures of the radius. AVhen the acute swelling and inflammation have sub- sided, leaving the joint-capsule somewhat thickened, the wrist appears broader than normal, or, to speak more accurately, the transverse diameter of the lower extremities of the radius and ulna is increased. The head of the ulna is usually more moval)le than that of the normal wrist ; the strength of the hand is diminished, and the patient is conscious of weakness of the wa'ist-joint, wdiich is some- what relieved by wearing a bandage around it. Move- ment of the wrist is in most (tases painful rather than restricted. Pronation and supination are usually well DISLOCATIONS AT THE WRIST. 309 preserved, but are apt to cause pain. The muscles of the forearm are but slightly aifectcd, though those on the ulnar side may show signs of atrophy. By the aid of a skiagrapli we can demonstrate the complete dislocation of the inferior radio-ulnar joint, and in a number of cases we also find that the head of the ulna is rotated so that the styloid process points directly forward or backward. Sometimes the head of the ulna is displaced upward or downward, indicating, of course, more or less laceration of the inferior radio-ulnar ligaments. This leads to a secondary displacement of the elbow-joint, which is usually, however, of slight importance, and is not marked by functional disabilitv. The average insurance allowance is 20/,. Dislocation of the Wrist=joint. Simple dislocations of the wrist-joint are rare. The so-called dislocation usually includes a fracture of the radius. The latter is accompanied by displacement of the lower fragment, together with the whole hand ; the wrist- joint, however, remains partly dislocated. A similar subluxation is also frequently to be seen as a result of a sprain. In cases of backward dislocation of the wrist-joint, which are usually caused by the overextension incidental to a fall on the hand, the hand is held flexed ; the bones of the carpus — the scaphoid, semilunar, and cuneiform — are distinctly pron)inent ; movement of the wrist-joint is suspended, and the hand can not be closed. In cases of forward dislocation due to a fall on the dorsum of the hand when the wrist is flexed, tlie lower extremities of the bones of the forearm project distinctly, the hand is flexed and hangs limj), and the mobility of the wrist is almost com- pletely lost. The foregoing characteristic symptoms persist until the dislocation is reduced, whicli in a neglected case may prove a difficult or impossible ])rocedure. If the patient is young and reduction is at once practised, complete recovery 3 1 nisEA SES r. i uhed b y a cci dents. may he cxpceted. In a case oectiri'in^- in a pu})il in a g;yniuasiiuii wl'.o was practising- <»ii a lioi'izoiital bar, im- mediate reduction was followed by a permanently good result. It is worthy of mention that subluxation of the wrist is seen occasionally as a result of special work in indi- viduals employed in certain branches of industry. Made- lung describes a case of this kind in which the lesion was attributed to the strain incidental to the work of his trade. (Cited by Thiem.) Dislocation of the Bones of the Carpus. A dislocation between the two rows of the carj)al bones lias been observed in rare instances, the usual cause being a fall on the hand. Dislocation of one of the carpal bones alone occurs somewhat less infrequently. The dis- location may be the only lesion present, or it may occur in connection with other lesions, such as fractures of the radius or sprains of the wrist-joint ; it may, furthermore, be partial or complete. Partial dislocations are caused by the violent contact between the bones incidental to a fall on the hand or by traction in endeavoring to free the hand when it is caught and held fast. The ligaments connecting the carpal l)ones are more or less torn at the time of injury ; they become lax in consequence, and allow the carpal bones to become displaced. The bones are most likely to be displaced backward, owing to the weakness of the posterior liga- ments. In most cases it is the os magnum which is in- volved, and which can be seen and felt projecting back- ward. Partial dislocations of the carpal bones are fre(|uently seen subsequent to fractures of the radius, and are to be explained, as a rule, by the strain and subsequent laxness of the ligaments. When some time has elapsed after injury, tlu; displaced carpal bone can easily be mistaken DISLOCATIONS OF THE OAF. PUS. 311 for a o'anglion ; the diagnosis is, liowever, inadc clear by a careful examination. In cases of complete dislocation the scaphoid is the bone most frequently involved. In a case occurring in connection with a fracture of the radius due to a fall on the hand I found the scaj)hoid impacted in the substance of the radius. (See Plate 36.) I have seen three cases of backward subluxation of the OS magnum. A|)art from the tumor-like j)rojection on the dorsum of the hand, tlu; only symptom of the lesion was a temporary weakness of the hand. One case of forward dislocation of the trapezium has come under my observation. The ball of the thumb appeared swollen and thickened ; the thumb was some- what dis[)laced forward and its mobility was restricted. For about four months the patient was unable to use the hand for grasping and similar movements. I have had two cases of dislocation of the pisiform bone occurring as the sole lesi<^n, both of which were caused by a fall on the hand. Both eases had been diagnosed as sprains of the wrist. The pisiform bone was displaced above the transverse fold which runs across the anterior surface of the wrist close to the palm of the hand. In one of these cases four months had elapsed since the lesion occurred, and reduction was not indicated. Tlie flexor carpi idnaris and the ball of the little finger were atrophied, and adduction of the wrist was limited ; there was also a slight loss of strength. All the symptoms com})letely dis- aj)peared within three months. The second case ccmcerned a workman whom I examined six weeks after the injury, and who made a rapid recovery. In respect to the rate of insurance allowance, the reader is referred to the illustrative cases. Lenibke, in the " Archiv far Uiifallheilknnde,"' volume iir, desc^ribes aii outward dislocation of the scaphoiil bone. Its conca\'e surface lay against the apex of the styloid ])i-ocess of the radius, to which it had become united, while its convex surface was directed 312 DISEASES CAUSED BY ACCIDENTS. outward. The trapezium and trajiezoid were thereliy displaced forward, togetlier with the first two inetacarpal l)ones and fingers. The senii- hmar, cuneiform, os magnum, and unciform were all fractin-ed. Exten- sion of the wrist-joint could be carried to an angle of fifteen degrees, but flexion was altogether susi)en(led. Abduction and adduction were reduced by one-lialf; the tliund) was limited as to flexion; otherwise the movements of the lingers were normal. The cause of injury in this case was direct violence. Lembke also descrilied a case of backward dislocation of the semi- lunar which likewise accomjianied a fracture of the radius. The case was also complicated liy fracture oi the os magnum and the unciform. Dislocations of the carpometacarpal joints arc also extremely rare lesions, with the exception ot" the tirst carpometacarpal joint, in which dislocation occurs com- Fig. 39. paratively often. I am indebted to G. Schiitz for two cases of dislocation of from the second to the iiftli and from the first to the fourth metacarpal bones, respectively. In both instances the lesion was caused by an accident with a steam-press. In these cases the metacarpal bone is invariably disj)laccd backward, and the appearance of the hand is very char- acteristic. The base of the metacarpal bones i)roject dis- tinctly, and the movements of the wrist-joint, especially flexion and extension, arc t>;reatly restricted. The fingers can not be closed at all, and their power of extension is restricted. I FRACTURES OF THE CARPUS. 313 Case of forward disJocation of the first metacarput bone at the metacarpo- phalamjeal joint. A mason, t\vent\-t\vo years of age, accidentally struck his right hand with a hammer. The lesion was diagnosed as a fracture of the thumh. When I examined tlie patient, on October 15, 1898, I found the liall of the thumb swollen and painful; the fingers were held ilexed, and the thumb could be only slightly moved. A skiagraph showed a forward dislocation of the head of the first metacarpal bone. The course of treatment was interrupted a few weeks later by the arrest and imprisonment of the patient. The accompanying illustra- tion shows the appearance of the hand, including the thickening of the ball of the thumb. Crt.se of a sprain of the wrist-joint accompanied by dislocation of th( pisi- form bone. A workman, forty-nine years of age, fell into a ditch on May 23, 189G. Among other injuries he sustained a sprain of the right wrist. The skiagraph showed a tyjucal dislocation of the inferior radio- ulnar joint and upward dislocation of the pisiform bone. The liead of the ulna was very freely movable; the forearm, especially on its ulnar aspect, was decidedly atrophied, as were also the ball of the little finger and, in part, the ball of the thumb. The hand had lost consid- erably in strength. Insurance allowance, 20 % . Case of dislocation of the pisiform bone., due to a fall on the hand. A mason, forty -four years of age, fell from a scaffolding nine feet high on June 24, 1892. He was treated for some time for a sprain of the wrist. "WTien I examined him, on November 30, 1892, I found the pisiform bone displaced upward above the transverse fold of the ^vrist. The symptoms in this case were exactlj^ similar to those of the preced- ing one. Insurance allowance at firet, 20^ ; six months later, com- plete recovery. Case of suhliLxation of the os magnum caused by a blow from a marble slab which fell upon the hand. A stone-mason, forty-five years of age, was trying to support a marble slab with l)oth hands when it slipped and fell on his right hand, holding it fast. He in\oluiitarily made an effort to extricate the hand. The accident happened on jNIarch 9, 1899. ^\^len I ex- amined him, on March 22d, I found the wrist moderately swollen and distinctly thickened at one point posteriorly. The skiagraph that was taken showed that the carpal bones were placed somewhat un- usually far apart. Extension was somewhat diminished and the hand had slightly lost in strength. No insurance allowance. Fractures of the Bones of the Carpus. The carpal bones may be fractiiretl by direct violence, as when the wrist is crushed under falling objects or mangled between cog-wheels, or In' indirect violence, such as a fall on the hand. Fractures of the carpal bones not infrequently accompany fractures of the radius. 314 DISEASES CAUSED BY ACCIDENTS. PLATE 21. Case of Scar=keloid on the Dorsum of the Left Hand. A mason's apprentice, fifteen years of age, was burned on the left side of the face and on both hands by an explosion of gas. Healing was followed by keloid growth in the scars on both face and hands, especially marked in the case of the left hand. The colored plate sliows the scars on the lower part of the forearm extending down to the midphalangeal joints of from the second to the fifth fingers inclusive, limiting l)oth the flexion and extension of the wrist, as is distinctly to be seen in the accompanying illustrations. (Figs. 40 and 41. ) The patient could close the hand, but was unable to hold anything. Figure 40 shows the extension of the hand, which was limited to an angle of about thirty-five degrees ; in this position the scar-tissue was thrown into folds between the back of the hand and the forearm. In figure 41 the hand is flexed, thereby stretching the scrar. Flexion was limited to an angle of twenty degrees. Insurance allow- ance, 20 ^. The bones of the car})iis are not exposed to extensive degrees of dis})lacement, but the effect on finictional power of even a slight disphicenient which only a practised eye can recognize is not to be underestimated. Trifling elianges of relation between the bones of the carpus have an influence on the position of the metacarpal bones, and are manifested also in certain limitations in the movements of the fingers. There may be, furthermore, a slight subluxation of the radiocarpal joint. Occasionally, the metacarptd bones are involved in the fracture to the extent of being notched at their bases ; they may also be displaced forward or back- ward, and in rare instances ma}' be rotated on their long axes. Displacement of a metacar[)al bone causes tempor- arily a certain awkwardness of movement in the corre- sponding finger. In case of fracture of the l)ones of the car])us without displacement, functional power is only temporarily im- paired, unless the injury is a severe one involving several bones, as when the wrist is crushed or mangled. In the latter case the wrist remains permanently and completely ankylosed. The symptoms which I had the o]i]X)rtunity to observe in two cases of fracture of the trapezoid were T(ih.:^i i.ith.A/ist f-'- RpidduiUl . Miiiirhia ere])itans, of which crack- ling sounds on movement of the wrist, sometimes accom- panied by pain, are among the characteristic symptoms. Chronic tenosynovitis occurs also as a professional dis- ease in various branches of industry, being met with in turners, cabinet-makers, locksmiths, blacksmiths, etc. 6. INJURIES AND TRAUMATIC DISEASES OF THE HAND AND FINGERS. Function of the Jlctdcarpal Bones find Finf/ers. — The five metacarpal bones, which forjn the framework of the hand proper, are somewhat concave anteriorly, slii^litly convex jjosteriorly. The hand presents t\\ o snrfaces — an anterior, called the palm, and a posterior, called the dorsum or back of the hand. The first metacarpal bone, siipporting the ball of the thumb, dis- plays a comparatively Avide range of motion, the mobility of the other four metacarpal bones being extremely limited. Of the latter, the fifth is somewhat more mo\able than the others, while the third is practically immovable. In respect to their mobility, the fingers jtre- sent a marked contrast to the corresijouding metacarpal l)ones. The phalanges are distinguished as the first or jnoximal phalanx, the second or midphalanx, and the thml or distal ])halanx, while the joints of the fingers are known as the metacarpophalangeal, mid- phalangeal, and distal phalangeal joints, respectively. The metacarpophalangeal joints are of the condyloid variety, allow- ing of the folloAving movements: 1. Flexion, which c^an be carried to an angle of 90 degrees; slightly higher in the case of the little finger. 2. Extension. This movement is very limited. On active motion the thumb can be extended to an angle of about 50 degrees; the index-finger to about 80 degrees, the middle finger to about 25 de- grees, while in case of the fourth and fifth fingers there is no power of extension worth mentioning. 3. Lateral movement, abduction, adduction (limited), and spread- ing apart. 4. Rotation (on passive motion). The chief agents of flexion are the long flexors of the fingers, the tendons of which are inserted in the second and third phalanges; the interossei which are attached to the first phalanges acting as a pulley, drawing them toward the middle line when the hand is to be closed, and pulling them apart when it is opened. The capsules of the metacarpophalangeal joints are very thin pos- 318 DIHEA S ES CA USED BY A CCI DENTS. teriorly, and are protected from being caught between the bones and from the injurious effects of too great atmospheric pressure by tlie ex- tensor tendons, wliich form the dorsal a])(jneurosis and are attached to the capsule over the joints. Laterally, the capsules are reinforced by the lateral ligaments, which are put on the stretch when the fingers are flexed, and \\ Inch greatly restrict lateral mo\ ement of the fingers. The movements of the fingers, especially of the fointh finger, are further restricted by the tendinous slips connecting the extensor ten- don of the fourth finger with those of the middle and little fingers, resijectively. On the posterior aspect of the \\rist-joint the synovial sheatl> of the extensor longiis pollicis is frequently found to connect with those of the extensf)r carpi radialis longior and brevior, which also in many cases connnunicate with each other. Opposite the metacatijophalangeal joints the tendons of the extensor muscles of the fingers unite with those of the lumbricales and interossei pro- ceeding from the radial and ulnar sides of the hand, to form a broad aponeurosis, which covers the phalanges posteriorly and is attached to the capsules of the metacarpophalangeal joints. As it passes along the posterior surface of each proximal ijhalanx, to A\hich it is not attached, the extensor tendon, which forms its central poition, divides into three slips; the middle slij) is inserted at the midphalan- geal joint, while the two lateral s]ii)s, in connection with the tendons of the lumltricales and interossei, pass further down the finger, to be inserted into the distal phalangeal joint. Thus, the dorsal ap(meurosis is attached to all three phalangeal joints. On the palmar side there is a communication Ijetween the synovial sheaths of tlie tendons of the thuml) and little finger, as is demonsti'ated ])y the I'apid spread of infection from one tendon to the other when either is involved. [These tendons are usually stated to communicate through the general sheath to which they extend. — Ed.] The palm of the hand provides a receptacle for the objects that are seized and held by the fingers, or, rather, by the fingers and meta- carpal bones on one side and the thumb on the other, like a pair of tongs. The ball of the tlunnl) and that of the little finger also act as opposing forces in the i)rocess of grasping an object with the hand. Normally, when the hand is coni]>letely closed in a fist, the fingers are turned under in the palm of the hand; if, howe\er, the distal phalanges are ankylosed, they lie with their flexor surfaces against the palm of the hand. In grasping an article tightly the distal phalanges are pressed firmly against the palm of the hand by the other phalanges, especially by the middle ones, the wrist Ijeing held retroflexed. "While rough work develoi)s the strength of the hand and fingers, skill of movement and a sensitive toucli are reipiired for the perform- ance of more delicate tasks. In either case it is necessary that the whole mechanism (jf the hand should be in perfect order, a condition with which injuries and diseases of the hand and fingers are not com- patible. CONTUSIONS OF THE HAND. 319 Statisfirs. — This cliapter is ])as('(l on an experience \vitii 7;21 injuries of the hand and lingers, classitied as follows : Injuries due to contusion 222 Crushing and mangling 97 Ordinary fractures 84 Fractures due to crushing of the part 67 Dislocations and sprains 55 Incised wounds 85 Punctured wounds 18 Lacerated wounds caused by nails and splinters 71 Burns 21 Frost-bite 1 721 Cellulitis 78 The separate fingers were involved as follows : Thumb 149 (right side, 80; leftside, 69) Index-finger ... 147 ( " " 66 " " 81) Middle finger . . 172 ( " " 73 " " 99) Fourth finger . . 129 ( " " 54 " " 75) Little finger . . . 80 ( " "34 " " 46) According to this table, the fingers of the left hand are more fre- quently involved than those of the right. Among the total of 677 injuries of the fingers, the metacariial bones were involved in a large number of the cases. The hands are especially exposed to injiirv in every department of industry, hence in statistical tables based on the relative frequency of injuries in ditierent parts of the body they usually stand highest. Injuries of the Hand Due to Contusion. These injuries occur when the hand is hit by an object falling from a height, such as a stone or a piece of wood or iron, or by objects falling against the hand, or by blows from a hammer, etc. If tlie force is applied to the back of the hand, the injury is very likely to consist of a simple or compound fracture of the metacarpal bones. Simple contusions involving the hand or fingers usually heal rapidly and completely. There is one peculiar injury of the contusion class in- volving the ])all of the thumb. This becomes the seat of an inflammation, which may run a severe course, develop- ing into a cellulitis and rapidly extending up the hand and 320 DISEASES CAUSED BY ACCIDENTS. arm. Such an inflammation of the left thumb is most fre- quently seen in masons after vigorous and long-continued counterpressure on the ball of the thuml) in the process of chip])ing unusually hard stones. The lesion occurs in the ball of the right thumb as a result of similar causes, or it may involve the ])almar fascia in the middle of the hand in- stead. If diffuse suppuration sets in, necessitating frequent operation, the hand is usually permanently disabled for its customary work. In less unfavorable cases the inflammation takes a chronic form, the fascia becoming irregularly thickened and contracted, holding the proximal phalanx of one or more fingers in a position of flexion. Caxc of infldinmalion of Ihv pnhnar fascia Jcadin;/ to completp stiffness of the hand ((ini finf/crs. A ■svorkiuan, tliirt,\ -four yt'ars of aj;e, (U'velopcd an inflamiuation of the palm of tlie ri^lit liand ])ro(liK'etl ))y ]on,n-(H)ntimu'(l imcssuic of the wooden liandle of an iron pick which lie had used in chi])])inen. Below the scar the tissues are deeply cyanosed ; thei'e are necrotic ulcers on the thumb and on the tips of the middle and fourth lingers. Tlie i)art is extremely cold, and all the fingers are stiff. Figure 2 shows the atroi)hy of the interossei on the extensor surface of the hand. Insurance allowance, 55 fc. No improvement. in the hand. If his only incapacity is the occasional crack- ing open of the scar, and if he receives fnll pay for his work, from 10 fo to 20^ is nsually a sufficient allowance. Wounds of the hands are met witli in all ])Ossible forms and varieties. In addition to classifying' them according to their clinical appearance, as incised, punctured, lacerated, etc., a classification based on their etiology proves both interesting and instructive, acxpiainting us with the special dangers of the various branches of industry and enabliug us to make more effectual ])rovision for their |)reveution. Scars on the extensor surface of the hand, if adherent to the extensor tendons, have an unfavoral)le effect on functional power by interfering with flexion of the fingers, and finally, by their retraction, they cause the fingers to become fixed in extension. Flexion may in other instances l)e prevented by scars that are adherent to the metacarpal bones. This is the invariable effect of adhesions between the scar and the metacarj)ophalangeal joint. The fingers are at the same time held slightly extended, while the head of the first phalanx is displaced forward. SCAES OF THE HAND. 323 Scars extending down between tlie metacarpal bones restrict the action of the external interossei, as is evidenced by diminished abduction of the tirst phahmges of the affected fingers. If nerves are involved in the scars, we usually find paralysis of the fingers, with symptoms of neuritis or neuralgia. The ol)iect of treatment is to loosen the scars and to restore the functional power of the fingers, and in many cases this can be perfectly accomplished by mechanical treatment alone. If deeply attached, however, the scar should be freed by operation, and the success of the pro- cedure should be insured by subsequent mechanical treat- ment, which should be begun early. The patient is incapacitated for work in proportion to the loss of functional power of the fingers. Scars of the ])alm of the hand interfere with movement of the fingers when adherent to the metacarpophalangeal joints. Such a condition is not always the result of an accident, but is met with likewise after operations. The scars, for instance, consequent upon disarticulation of a 'finger (third or fourth finger) usually show a strong ten- dency to retraction, drawing the palm of the hand together like a boat, the more so if much of the metacarpal bone is removed. The two fingers thus brought side by side by the operation show an inclination to remain flexed and for their tips to a])proximate each other more closely. The other fingers follow suit ; the hand can no longer be prop- erly closed, and becomes weak. In addition, the scars of the palm are particularly sensitive to pressure, and fre- quently give rise to violent attacks of neuritis. A prolonged and tiresome course of treatment may be required, calling fi)r the exercise of considerable patience. AVork should not be resumed until the patient can use the hand for grasping and liolding purposes, except when no further improvement can be looked for. The incapacity for self-su])port is estimated according to the loss of func- tional power. 324 DISEASES CAUSED BY ACCIDENTS. PLATE 23. Case of Contracture of the Wrist in Extension Following Cellulitis. Complete ankylosis of wrist and fingers. A hod -carrier, forty years of age, in his twentieth year took a nap in liis noonday rest, sleeping witli his right hand under his head. AVhen he awoke he was conscious of pain in the back of the hand, but continued to work for several days until symptoms of fever and swell- ing of the hand appeared. He was treated in the hospital for three months ; two months after this he recovered some use of the hand, and although the -wTist and fingers have remained completely stiff, he has worked as Ijefore as a hod-c-arrier. He recei\es no insurance allowance, the injury not having been caused by an accident incidental to his trade. Scars occupying the center of the hand are not infre- quently adherent to the palmar fascia, producing a contrac- tion of the proximal phalanges of the fingers. This condition does not necessarily greatly diminish the useful- ness of the hand, however, unless the scar is raised above the level of the surrounding skin, in which case the pa- tient finds it difficult to take a firm grasp of an object, especially if of a hard material. In addition, the scar is constantly exposed to injury. Scars situated on the ball of the thumb or little finger usually cause no trouljle unless they are deeply attached to the underlying tis.sues. Sprains of the Metacarpophalangeal Joints. Sprains of these joints are most frequently caused by a fall on the closed hand, and unless complicated by frac- PLATE -24. Case of Stiff Hand Following Cellulitis. A workman, lifty-nine years of age, on July 10, 1S91, scratched his right thnml) on a nail projecting from a pail. He was treated in the hospital for the cellulitis tliat followed, a number of incisions being required. The acconi])anying illustration shows the scar of tlie original wound of the thumb and tlie scars conse(|uent upon the incisions in the fore- arm, the ))all (if the thumb, and the ball of the little finger. It also .slious the position of tlie fingers closed u]K)n the palm, rendering the hand entirely useless. Insui'ance allowance, 60 ^/c Tah.:^4. LilA.. Anst E ReUhiwld. Miuuchen. DISLOCATIONS OF THE METACARPAL BONES. 325 ture, they usually heal without auy difficulty. Inflamma- tion should be treated by compresses. Stiffness is easily overcome by massage and passive movements. Dislocations of the Metacarpal Bones. Complete dislocation at the metacarpophalangeal joint occurs with relative frequency in the thumb, but is seldom met with in the other fingers. If a dislocation of this joint in the thumb remains unreduced, it leads to stiff- ness of the joint, atrophy of the nniscles of the thumb, and impairment of the functional power of the hand. The base of the first phalanx projects distinctly backward, while the thumb is held abducted. It is well known that an attempt at reduction often proves unsuccessful ; the capsule of the joint or the sesamoid bone at that jioint may get between the bones, or the tend(in of the flexor longus pollicis may become twisted around the neck of the metacarpal bone. Dislocations of the metacarpophalangeal joints are ac- com|)anied by laceration of the capsules and ligaments, which may lead to a subsequent abnormal position of the proximal })halanges of the affected fingers, even after suc- cessful reduction. Subluxation of the phalanges can best be seen l)y letting the patient first close his hand and then open it, comjxu'ing it meanwhile with the normal side. The mobility of tlie metacarpophalangeal joint may be restricted by adhesions or may be abnormally free ; in either case the patient is unable to flex the finger perfectly, and it often appears atrophied. The atropliy gradually involves the internal interossei, and possibly the lumbri- cales, and extends in the course of time to the other mus- cles of the hand. After the dislocation has been reduced and the swelling- has subsided, but very little after-treatment is called for, as a rule, except in cases complicated by paralysis, or when there is ankylosis of the metacarpophalangeal joint, 326 DISEASES CAUSED BY ACCIDENTS. PLATES 25 AND 26. Case of Atrophy of the Forearm, and Partially of the Arm, Following an Accident to the Right Hand by Which the Index=finger was Wounded and Dislocated at the Metacarpo= phalangeal Joint and the Distal Phalanx of the Thumb Was Fractured. A carpenter, twenty -eight jears of age, snstained the foregoing injuries on July 29, 1898, caused by a beam falling on his right hand and his involuntary effort to extricate his hand from under it. The hand was dressed innnediately. He l)egan a course of treatment in my clinic on August 23, 1898. On the i)alm of the hand near tlie Ijase of the index-linger there was a small scar ; the finger was sliglitly displaced at the metacaqioiihalan- geal joint, and could neither be flexed nor extended completely. Movement produced crei)itation. The atroi)hy of the muscles was most noticeable when the hand was compared witli the opposite side and when it was tightly closed. The right hand could not be so tightly closed as the left. There was but a slight difference in circumference in the two sides. Plate 2() sliows the atrojthy of the muscles of the hand, the ball of the thund), and little finger, as seen from the palmar surface. The flexion of the index-fiuger is imperfect. Sometimes the finger is slightlv rotated to one side or the other. due to the growth of adhesions in tlie joint. The adhe- sions can gradually he loosened by a course of ])assive movements and mechanical exercises. It is very imj)(>r- tant, after reducing the dislocation, to begin the finger- exercises early, before the bandage is removed. Local batlis, massage, and electricity are also beneficial in completing the cure. If the hand still remains weak, or its mobility is restricted, — which in the case of the third, fourth, and fifth finoers mav be due to adhesions or cicatricial con- tractions of the tendinous sli])s connecting tliem, — the patient may be somewhat incapacitated fi)r work. In such cases an insurance allowance of from 20^ to 30^ may be indicated. Fractures of the Metacarpal Bones. Fractures of the metacarj)al bones may occur as the result of direct violence, such as a violent blow or kick II Tab.:^j. Titf.l. LUh. Arist F. ReichhoW. Miiiulicn . Tab.'lh. Fig P l.ith . An.st K ReichiwUl. Miinchen » ^ Fig. 42. 328 DISEASES CAUSED BY ACCIDENTS. PLATE 27. Atrophy of the Muscles of the Hand Subsequent to a Fracture of the Radius. A glazier, forty years of age, fell from a ladder from a height of six feet on August 17, 1898. In falling he tried to sa\'e himself with the right hand. He was at first treated for a sprain of the wrist. For one week ice-compresses were applied, the subsequent treatment consisting of soapsud baths and inunctions. I examined the patient on Aiigust 31, 1898. His wrist was swollen and appeared broader than normal ; the lower end of the radius was thickened, the enlargement extending down to the carpal Ijones. The mobility of the wrist was greatly restricted; flexion and abduction were suspended; retroflexion and adduction coiild l)e carried to an angle of about twenty degrees. The fingers could l)e slightly moved, but not closed. The forearm was shortened and supinated. There was atrophy of the hand, forearm, and arm, and also of the shoulder. The accompanying illustration (Fig. 42) shows Ijotli hands and forearms in a position in which the shortening of the right forearm, the supination of the elbow-joint, the atrophy of the whole arm, in- cluding the hand, and the enlargement of the wrist-joint are distinctly visible. The skiagraph (Fig. 43) shows the impaction of the scaphoid in the cancellous tissue of the radius, slight changes in the relation between the carpal bones, and the disi)l;icement of tlie liand. The colored plate shows a distinct atrophy of the right hand on ])oth the flexor and extenf5or surfaces, and a reddish-blue discoloration of the skin of the fingers of the radial side of the hand, including the middle finger (radial and median nerves). The temperature of this area was noticeably depressed. The patient was discharged from treatment on January 26, 1899, with an insurance allowance of 40%, which he has continued to re- ceive. He works ten hours a day, but the condition here described has not improved. on the back of the hand, or a blow from a heavy object in falling ; or as the result of indirect violence, as in case of a fall on the closed hand, the force of which is met by the first phalan.v. The symptoms after union has been established vary considerably, depending on the direction of the line of fracture, whether transverse, oblique, or longitudinal, and on whether the fracture involves the end or the shaft of the bone. Displace- ment in these cases, although seldom very apparent ex- ternally, is sufficiently marked to be recognizable and to Tab. 2, ' ■!)■■-■ Fin 2 •Jo. 330 DISEASES CAUSED BY ACCIDENTS. offer an explanation of the symptoms of functional disa- bility that avo manifested. As a rule, the fragments are displaced backward, forming a distinct callous convexity on the back of the hand, which can be felt if not seen. The finger appears shortened because of the shortening of the metacarpal bone ; frequently, too, the lower fragment of the latter is distinctly rotated, carrying the finger with it. When the head of the metacarpal bone is displaced toward the median line, the corresponding finger is often found to be directed away from it. In other cases, how- ever, the finger is carried toward the middle line. In addition, the base of the bone may be involved in the de- formity by being displaced forward, backward, or even to the side. The lateral displacement of one metacarpal bone leads not only to secondary displacement of the ad- jacent metacarpal bones, and through them to the displace- ment of the whole row, but affects also the position of the carpal bones and strains the ligament of the carpus. The general displacement thus caused is manifested by dimin- ished mobility and weakness of the fingers and wrist. Occasionally, the head of the metacarpal bone is dis- placed forward, in which case the corresponding finger can not be properly flexed and the patient is unable for some time afterward t(j maintain his grasp on an article. Cane of rcii)} if cd fracture of fJw third and fourth metacarpal bones and the proximal pJialaii.r of the fifth Jiin/er. A niitson, twenty-tive years of afje, was injured on October 29, 1897, by a box of lime fallinoj upon his rij;ht liand. ^\^len I examined liim, on Deccmljer 2, 1^97, his hand was still greatly swollen ; the tliird and fourth metacarpal bones were thickened posteriorly, and the metacar])ophalan,iieal joint and proximal phalanx of the little finger were considerably thickened. The patient was unable to flex the little finger at all, and could flex the others only very slightly. The skiagraph (Fig. 44) shows the fractures, and also the displacement of the third and fourth metacarpal bones and the proxi- mal phalanx of the fifth finger. At the time of his discharge, on June 22, 1898, the patient was able to flex the index-, middle, and fourth fingers so that they almost touched the palm of the hand, while the fifth finger remained about at a right angle. Insurance allowance, 33^ % ■ Fig. 44. Fig. 4.5. 334 DISEASES CAUSED BY ACCIDENTS. The chief cause of this disability is the pressure ex- erted l)y tlie head of the displaced metacarpal bone. AVhen, after fracture of the head or base of the bone, ac- companied by complete lateral dislocation, the bone becomes fixed in this ])Osition, the deformity assumes a serious functional import. Sometimes the base of the metacarpal bone is broken oflp and driven between the adjacent meta- carpal bone and the carj)us, while the head of the bone becomes united with the same metacarpal bone on its oppo- site side. As a natural consequence the hand is l)roadcned and the fingers are considerably displaced. Deformities of this kind are seen when the hand is crushed and man- gled between cog-wheels, etc. Case of deformiiy of the hand due to its beititj crushed Ixiiceen eog- whcels. (Figs. 45 to 48, pp. 332 to 335.) A workman, twenty-four years of age, was injured on October 12, 1897, his right hand 1)eing drawn in lietween cog-wheels. He sustained the fractures tliat are distinctly to be seen in the skiagraph (Fig. 45), which also shows the displacement of the heads of the bones and one of the fragments of the fourth metacarpal bone lying upon the third metacari)al bone. It was necessary to remove the tiiird and fourth fingers. In the accompanying illustiations (Figs. 4G and 47) the ante- rior and posterior aspects of the hand are disi)layed, the fingers Ijcing extended as fiu" as i)Os.sil)le. The third illustraticm (Fig. 48} shows the limit of Hexion of the lingers, a bit of pencil being held between the thumb and index-linger. Wlien I hrst examined the patient, on January li), 1898, his hand was still so much swollen as to make it ai)])ear like a tliick and shape- less mass of flesh, i)ossessing no mobility whatever. Insurance allow- ance at the time of discharge, 75^. The cases in which fracture of the head of the meta- carpal bone involves the whole joint, in('luh (Fig. 50) shows the changes that have taken i)lace in tlie injured joints of the index-finger and middle finger. The thumV) could not be directly ap- proximated to the plate in taking the skiagraph without causing the impression to lose in clearness. Insurance allowance, 45%, based on the inability of the patient to close the affected fingers. usually cut oflf', or the wound extends so deeply into the tissues as to sever muscles, tendons, vessels, nerves, and even the bone. The joints of the fingers are occasionally sprained by violently pulling at an object or by the effort to free the fingers when they are caught fast. The ca})sulcs and lat- eral ligaments of the joints, especially of the metacarpo- phalangeal joints, are strained and slightly torn, leaving the joint weakened, so that for some time afterward the patient finds himself unable to grasj) and hold an object with his accustomed strength. Similar symptoms, but often intensified, are observed after dislocation of the joints of the fingers. The symp- toms of dislocation of the metacarpophalangeal joints have already been discussed. When the other two joints of the finger are involved, the patients comjilain for some time after reduction is practised of pain and a I'eeling of weakness, especially when they close the hand or hold something in it. Sometimes dislocation is accompanied by fracture of the phalanges. Ankylosis of the affected joint is more frequently a sequel of a subluxation than of a complete dislocation, since the former is apt to be treated as a sprain and left unreduced. Treatment, — Mechanical treatment usually proves sue- Tab.l^S Lith. Anst F- ReichhoUI. Miinrhen. Fig. 50. Fig. 51. 340 DISEASES CAUSED BV ACCIDENTS. PLATE 29. Fig. 1. — Case of Loss of the Little Finger, together with the Head of the Fifth Metacarpal Bone, A \v()i'kinaii. fi>ity-one years of age, sustained a comminuted fracture of the nietacarp(>i)halanj;eal joint of the little finfrer of the left hand, caused by the lin,t;er l)('inj2, struek ))y a beam. The little finger and the head of the fifth metacarpal bone were amputated. The colored plate shows the scar left by the operation and the extent to which the hand can l)e closed. The fourth finger does not quite touch the palm of the hand. The accompanying illustration in black and white (Fig. ol ) shows the hand when fully extended. The fourth finger is held slightly al)ducted from the median line by the tension of the scar, causing the slcin over the extensor tendon of the middle finger to appear like a distinct fold. Fiu. 2. — Adherent Scar Over the Metacarpophalangeal Joint of the Index=finger, Due to an Incised Wound Partly Severing the Bone of the Joint. A machinist, thirty-two years of age, was cut in the left hand by a circular saw on January 29, 1892, the wound opening the Joint. The plate shows a star-shaped scar adherent to the bone and a partial for- ward dislocation of the finger. The power of flexion and extension of the finger has never been completely regained, and the strength of the hand is slightly diminished. Insurance allowance, 15 fc . cessful. The patient is, as a rule, only slightly incapaci- tated for self-support. Fractures of the Fingers. These are usually direct fractures, and may be caused by blows from falling objects, blows from a hammer, or by falling and striking on the finger. Indirect fractures of the distal phalanges are said to liave occurred as a result of the tension of the extensor tendons when the fingers were forcibly flexed. The majority of ])halangeal frac- tures occur in consequence of severe crushing of the hand. The following symptoms are manifested after union is established : The finger is usually thickened at the point of fracture ; sometimes it appears broadened and shortened, and not infrequently it appears convex or concave on its flexor or extensor aspect. If the fracture involves a joint, the fin- 7ab.l'/l Fig.l. Fig. 3. I.ith.Anst /.' Heichluild. A/a/irheri . r FRACTURED OF THE FINGERS. 841 ger becomes stiff nnd fixed in a position of" flexion or extension. The position of the adjacent fingers is not infrequently affected, and their mobility may be restricted. Treatment. — Passive movements should be begun early, especially when the fracture involves a joint ; the fingers should be exercised frequently, even while the bandage is maintained, the latter being adjusted with this in view. Crusliing of the distal ])halanges is frequently followed by suppurative inflannnation of the nail-bed. If not removed by the physician, the nail is usually thrown off' of itself, and the new nail that grows in is poorly developed Fig. 52. and misshapen, merging in the surrounding skin. The distal phalanx is held slightly flexed, and can neither be completely flexed nor extended. It may be very painful, especially if a neuroma develops. No after-treatment is required, as a rule, unless the affected phalanx is exceedingly stiff and painful, in which case local baths and massage usually effect a recovery. The presence of one stiff finger is a source of great in- convenience to a working-man, making it difficult to take hold of an object, \vhile the finger itself is constantly hit- ting against something and being freshly injured. ^lore- over, it interferes with free movement on the })art of the adjacent fingers. This is most noticeable when the third 342 DISEASES CAUSED BY ACCIDENTS PLATE :?o. Fig. 1. — Case in Which the Middle Finger Became Shortened and Stiffened as a Result of Gangrene from the Use of Car= bolic Acid. A workman, thii-ty-nine years of age, lacerated his right middle finger on a nail on December 2, 1898. He paid but slight attention to tlie wound, simply sncking it out and binding a rag around it. He continued to work until the third day after the jxccident, when his linger became swollen, intiamed, and very painful. It was opened by a physician, who then A\ashed out the w ound \\ith w hat purported to ])e a 5'/f solution of car1)olic acid. Tlie tip of the linger is said to have turned black at once. The i)atient ^\ould not permit the am- putation of the gangrenous portion, which was tlu'own off by natural processes in the course of al)Out two montlis. Mechanical treatment was then begun, the patient being unable to close his hand. The middle linger was perfectly stiff, the fourth linger and index-finger could be closed one-third, the fifth finger somewhat furtlier. The patient was not able to take hold of anything witli his hand. Treat- ment was continued up to October 24, 18!)8, when he was discharged with an insurance allowance of 40%. The functional power of the hand was sufficiently restored to enable him to take hold of large ol)jects. Fig. 2. — Case of Paralysis of the Ulnar Nerve due toCrush= ing of the Left Shoulder. The illustration show s a \\ell-niarked atrophy of the interossei and the position of flexion in which the fingers are held. The paralysis appeared about two weeks after the injury, the hand at the same time becoming greatly swollen. Mechanical treatment has brought about gradual improvement; the patient has not yet been discharged. or fourth fini[>;er is involved, especially in ease of the third. It is, as a rule, much more disadvantageous to a working- man to have a stiif middle finger than to lose it outright. Case of jmudo-fuihrosis of the left thninlt due to an ineised wound hy a cutting maehine. A workman, twenty-three years of age, A\as cut through the proxi- mal phalanx of the left thumb by a cutting machine on October 20, 1890, the l)one being completely severed. A false joint developed, and the thumlj remained entirely useless for a long time. The illustration (Fig. 52) sliows the deep scar around the thumb and the ball of the thumb. The patient received an insurance allowance of 45% up to March 15, 1892, based on his inaliility to use the hand and the atrophy of the whole arm. Impro\-ement gradually took i)lace, and the allowance was reduced to 25%, at which rate it lias remained. The thumb is still rather weak. l\ih. :U). fiy. fiij.l. FzgP l.i/h Arisl /■: Reirhholcl. Muiirhen Fig. 56. Fig. 55. 344 DISEASES CAUSED BY ACCIDENTS. Cusc of crushing and fracture of the left tliiimfi canned hji an iron pipe falling upon it. The lesion was treated as a simple case of cnishinj^ of the thunih. I examined the i)atient on June 30, 189H, and found the thumb still swollen and reddened, presenting a suppuinting wound on its posterior surface. The wound was dressed at my clinic on July Hth, but the patient did not again return, as he resumed work on the day following. The ac«)mpanying skiagraph (Fig. 5:5, p. :?43) shows the condition of the thumb at that time. No insurance allowance. Case of .luhlu.rafion and tinkylosif^ of the distcd phalangeal joint of the right thumb caused bi/ crushing of the thumb and subse(pient eellulitis. The patient was a workman, thirty-three years of age. A hod filled with lime fell on his right thumb, which he bandaged with a piece of paper and tied with a string, then contiiuiing his day's work. On the following day the part became swollen, the swelling finally extending to the shoulder. When discharged from treatment he was conceded an insurance al- lowance of 20%, based on the partial ankylosis of the thumb and weakness of the hand. The skiagraph (Fig. 54, p. 343) shows the subluxation of the distal phalanx of the thumli and the changes in the V)ones of the joint. Case of bony union in the distal phalangeal Joints of both thundjs follow- ing fracture. (Fig. 55, p. 343.) Sequel, unimj)aired usefulness of the thumbs. The ])atient had injured the right thumb in his fourth year by fall- ing and directly striking upon it; the left tlnnub was injured much later, but also before the passage of the Accident Insurance Law. The functional power of l)oth thumbs is excellent, notwithstanding the fact that the distal phalanx of the right thumb is entirely stiff. A stiff finger, if flexed, is more favoral)le to the use- fulness of the hand than if extended, partly beeause it may aid the other fingers in grasping and holding articles, partly because it is much less in the way. Case of dislocation- fracture of the hft thund), with subsequent ankylosis. (Fig. 56.) The patient was a workman, thirty-nine years of age. On July 12, 1889, a plank fell upon his left thuml), producing a fracture of the proximal phalanx. The upper fragment became displaced backward, and union took place in this position. The thumb can not be com- pletely flexed. Insurance allowance since October 12, 1889, 10% . Contractures of the fingers by which they are retained in a position of flexion are very frequently seen. They may be caused by a contracture of the tendon following a tenosynovitis (a condition quite often nut with as a CONTRACTURES OF THE FINGERS. 345 professional disease in certain trades) or l)y a retracted scar. Occasionally, the canse is a mixed one, the scar left by an operation having become adherent to the flexor tendon. The scars left on the stump of a finger after amputation often become firndy adherent to the bone, and are exceed- ingly sensitive both to pressure and to changes of tem- perature. They are also apt to give rise to a painful feel- ing of tension on closing the hand. Occasionally, such a stump becomes the seat of a neu- roma. This is more likely to occur if the stump is a broad one, as when it includes a part of the distal phalanx. Neuromata develop more frequently in the cases in which the finger is cut off by a machine, such as a circular saw or planing machine, and esj)ecially when it is crushed off Ijetween cog-wheels, than after an amputa- tion by the surgeon. The presence of a neuroma impairs the functional power of the part to a much greater extent than does the simple loss of the tip of the finger. The usefulness of the stump of a finger depends, of course, on its length ; even if only the proximal phalanx is left, it is of assistance in maintaining a grip on an object. If painful and sensitive, a stump is rendered comparatively useless. The scars that follow disarticulation of the finger at the metacarpophalangeal joint become retracted, and in case of removal of the middle or fourth finger, cause the tips of the fingers to either side to approach each other, a change of position often associated with a slight rotation of the fingers. Their flexion is often restricted for a long time afterward. The position of the adjacent fingers is more likely to be thus affected when a portion of the metacarpal bone is also removed ; the scar is therel>y made larger, while the palm of the hand is narrowed or drawn together in the sha])e of a boat. Neuritis is sometimes manifested in severe form in connection with these scars. 346 DISEASES CAUSED BY ACCIDENTS. The removal of tlie fifth finger with a ])()rtiou of its metacarpal bone is usually followed by retraction of the scar, causing the fourth finger to become abducted from the median line and preventing its complete flexion. (See Plate 29, Fig. 1.) Of the diseases of the fingers, we need here consider only the paralyses and the trophoneuroses accompanied by necrotic ulcers. The former occur in consequence of direct injury of the nerves, and also of indirect injury : as, for instance, the paralysis of the median nerve which is quite often met with in cases of fracture of the radius. The latter, the trophoneuroses of the fingers, are observed when the ulnar or median nerve is completely severed. Case of compound comminuted fracture of the proximal phalanx of the left index-finger. A workman, twenty-two years of age, sustained the foregoing injury on March 21, 1H9H, caused by a stone from a wall falling on his left index-linger from a height of two stories. I examined him on Ajn'il 6, li^O?^. The index-linger was swollen and could not be flexed. Up to that time the injury had been treated as a simjjle case of crushed (contused) wound of the linger. When discharged from my treatment, on April 1(J, ISfiH, at his own recjuest, the finger was in tlie condition shown in the accomiianying skiagraph. (See Fig. 57. ) The patient was fully capable of self-support. Case of fixation in cvtension of the right indc.r-finger. The patient in this case was a potter, twenty -four years of age. His right hand was caught between a beam and an overturned barrel of clay, causing a contused wound of the right index-finger, ac«om- l)anied by a partial dislocation-fractmc of the middle jihalanx. When I examined him, on September 2(1, I found the finger moder- ately extended and fixed in that ])osition. It was stiff and much atrophied; the middle ])halanx was encircled by a deep scar. The skiagraph shows the deformity of the bone. In figure 58 the finger lay with its flexor surface against the plate, while in figure 59 the side of the finger was api)lied. The patient has received an insurance allowance of 25% since October 25, 1897, based on the fact that the index-fhiger is stiff, is constantly in the way, and is dejiressed in tem])eiature. (V(.s<' of fracture of the distal jihalanx of the fourth finger of the right hand, caused hg a stone fatting u]>on it. A workman, thirty-three years of age, sustained the foregoing injury. He was treated by cold compresses, and subsequently by ointments. When I examined him, I found the finger swollen. The condition of the bone is shown in the accompanying skiagraph. (Fig. 60, p. 347. ) Fig. 60. Fig. 61. 348 DISEASES CAUSED BY ACCIDENTS. The patient was unal)le to close the iiiiddh', fourth, and little tinj^ers coni]>letely. He continued to work in this condition with the tinj^ers l)au(la^cd, and did not return for treatment. ('(ISC of cnisliiNf/ and fr47. ) The i)atieut was a liodn-arrier, forty years of age. On July 22, 1898, the previously designated lingers of the right hand were crushed be- tween two iron girders. The wound was dressed by his own physician, wlio treated him for a crushed linger until December 12, 1898. At first both distal phalanges were greatly swollen, thickened, and knob- like. When discharged l)y his physician, tlie swelling had disap- peared; nevertheless, the skiagraph showed a sei)aration of the frag- ments, as here rei>roduced. The i)atient was considered by the insurance committee of his trade-union to be able to work, and received no insurance allowance. Case of (I stiff rii/lit indcx-fiiiger with adherent sears on the flexor surface. A workman, fifty-two years of age, lacerated the I'ight index-finger on a splinter wiien engaged in cutting wood. He paid no attention to the wound at first. A few days later the finger became swollen, the swelling extending to the hand and arm. Cellulitis was diagnosed and an operation was performed. The flexor tendon was subseciueutly removed. Insurance allowance, 20%. Ca.se of loss of one-half of index-flnger, of almost one-half of the middle flnger,and of one-half of the distal phalanx of the fourth finger. The patient was a sawyer, thirty-two yeai's of age. On April 9, 1897, his left hand was caught in a planing machine and the fingers cut off, as previously mentioned. After the wounds had healed, the patient was able to flex the fourth and little finger perfectly ; the stump of the middle finger could be flexed at the metacarpoi)halangeal joint to an angle of 11)0 degrees, while the stump of the index-finger could not be flexed at all. The strength of the hand A\as diminished. On October 21, 1897, the patient was conceded an insurance allow- ance of 33J%, which was later raised by legal process to 40%. It was reduced to 25% on April 15, 1898, imj)rovement in respect to flexion and strength having taken i)lace. The patient receives full pay for liis work. Case of dislocation of the third, fourth, and fifth fingers of the left hand at their metaearpophalangcal Joints. The lesion \\as caused by a beam falling on the fingers. The ]iatient, a carpenter, forty-five years of age, sustained the fore- going injury on February 3, 1892. The dislocation was reduced, but the metacarpophalangeal joint of the middle fingei' remained abnor- jnaliy movable. The whole hand, as well as the middle finger, was mucii Aveakened. Tlie ])atient was nnal^le to exert firm pressure with the middle or fourth finger ; symptoms of paresthesia and of ascending neuritis were also manifested. Insurance allowance, 40% ; the patient died subsequently of an internal disorder. CASES OF IXJURIES TO THE FIXGERS. 349 Case of severe erusfiinff of the right middle finf/er. Sequels : The affected finger became much shortened and ankylosed in a position of flexion ; the whole hand could be only j)artly closed. A workman, sixty-three years of age, the subject of this case, is unable to use his hand for work, and receives an insurance allowance of 50^. Case of disarficulotion of the right middle finger. Prolonged course of surgical treatment and severe neuritis lasting for a long time. A workman, twenty-four years of age, was injured on December 6, 1889, by a stone falling on the right middle finger. Sui)puration set in, and the finger was finally disarticulated on August 11, 1891. An attempt had been made to preserve the finger in a position of flexion, but this was gi\en up because the finger became closely pressed against the palm of the hand. The patient su))sequently attended several different clinics, finally going to a clinic for nervous diseases, where he was treated for a neuritis of the median nerve by mass;ige and electricity. On May 1~), 189:i, he was conceded an insurance allowance of (JO 'v , which by legal process was raised to 80%. He was under treatment for three and a quarter years. In 1895 it was disco\'ered that he was again at A\ork, and ■v^•as receiving full I)ay. His insurance allowance was ac- cordingly reduced to '35% . He had not reco^'ered the ])ower of closing his hand until about the year 1895. Case of disitrtieuhdion of the middle finger subsequent to erushinq of the finger and eetlulitis. (Fig. 62. ) " " The subject of the accompanying illustration, which was made on the day of his discharge, was a workman, thirty- one >'ears of age. The imperfect closure and the convergence of the fourth and fifth fingers are distinctly shown. The accident occurred on September 29, 1898, and the finger was disarticulated on I)eceml)er 5, 1898. The patient wa^s given a course of after-treatment lasting from January 6, 1899, to May 20, 1899. Insurance allowance, 25^^. Cose of eontraeture of the right middle finger in a position of flexion, causing severe functional disability of the hand, rendering it useless for a long time. The piitient was a workman, forty years of age. On July 11, 1892, an iron gii'der fell upon the middle finger of his right hand ; the injury was followed by a suppurative inflammation, necessitating deep inci- sions in the finger. Fig. 62. .350 DISEASES CAUSED BY ACCIDENTS. When I examined the patient, on October 6, 1892, I found the middle finger slightly flexed and qnite stiff. The other fingers, with the exception of the thumb, could not be closed. The muscles of the hand were greatly atrophied, the hand felt cold and numb to the patient, while the scar and the whole palm of the hand were exceedingly sensi- tive. The patient remained under treatment until June 20, 1893 ; he was conceded an insurance allowance of 50%, which was later reduced to 40%;. By September 10, 1896, the condition had somewhat improved ; the patient could close his fingers somewhat better, and the hand, although still weak, presented a more normal appearance. The insur- ance allowance could not be reduced. Ccuse of removal of the fourth finger. The patient, a carpenter, forty-fi\e years of age, sustained a com- pound comminuted fracture of his fourth finger on October 25, 1889. The injury was caused by his finger being caught in the guy-rope of a flagstaff. The finger was removed. The operation-scar extended to the ijalm of the hand and prevented the closure of the index-finger and the middle and little fingers. The hand became atrophied and paresthetic ; the scar was exceedingly sensitive. The patient was dis- charged on March 20, 1891, with an insurance allowance of 40%, after- ward raised by legal process to 55 % . Case of complete contracture of the fourth and fifth fingers and almost complete contracture of the indcx-fingcr and middle finger of the left hand, following an accident by which the tendons were severed at the wrist. A roofer, twenty -eight years of age, fell from a roof about fifteen feet high, on April 7, 1887, striking the left wrist against a sharp- edged slate tile. He was treated in the hospital for a number of weeks, and afterward received electric treatment from a nerve spe- cialist. No improvement was attained. Insurance allowance, 60% at firet; raised by legal pi'ocess to 80%, later reduced to 50%. The hand can be used with difficulty as an atljunct to the right hand. Case of crushing of the distal phalanges of the index-finger and of the middle and fourth fingers. Sequels, rudimentaiy formation of the nails and inability to flex com])letely the affected fingers at the distal phalangeal joints. A carpenter, thirty-four years of age, sustained the foregoing in- jury, which wa»s caused by his hand being caught lietween a rope and a cleat. After the wounds had healed, the fingers coidd at first be neither completely flexed nor extended. The patient was allowed 20% insurance on account of the impairment of functional power and of a slight flexion contracture of the fingers. Case of severe contracture of the right middle finger, the tip of the finger being in contact with the jxdm of the hand. The patient was a man thirty-flve years of age, of delicate health. The contracture of the finger dated from a previous injury, but wjis increased by a sui)purative inflannnation, whicii originated in a slight laceration of the finger. The insurance allowance was only 10%. The patient is able to hold articles that are placed in his hand. INSURANCE AND HAND INJURIES. 351 Case of removnl of the dhfal jyhnhnif/es of the index-finger and of the middle and fourth fingers of the left hand. The patient was a workman, fifty-fonr years of age. On Sep- tember 29, 1892, his left hand was caught between the rope and the drum of an elevator, crushing tlie previously mentioned fingei-s, and necessitating amputation of the distal phalanges. The hand became entirely iiseless. Insurance allowance, r>0'/r. On NovemV>er 10, 1893, the patient sustained a fracture of the third metacarpal bone of the right hand, for which injury an insurance allowance of 10^ was conceded, giving a total allowance of 60%. Estimation of Indemnity for the Sequels of Injuries of the Hand and Fingers. The following scale of indemnity rates was at one time employed in a number of trades-unions : Loss of thumb right, '25% ; left, 20% " index-finger. ... " 18%; " 14% " middle finger ... " 13%; "10% fouilh finger ..." 9%; " 7% " little finger .... " 12%; " 9% The loss of a phalanx of the thumb was considered to equal one- half the loss of the entire thumb; in case of the other fingers, the loss of one phalanx equaled one-third the loss of the entire finger. This table has been changed in various ways. It was found to be more practicable to make use of round figures, such as 20% or 15%, instead 18% or 14%. Further changes were induced by a recogni- tion of the justice of placing a higher estimate, in many cases, on the loss of the middle finger than on the loss of the index-finger. I have personally come to allow 30% for the loss of the entire right thumb; 20% for the right middle finger and 15% for one of the other fingers. In case of the left hand, I allow 25% for the thumb, 15% for the middle finger, and 10% for one of the other fingers. In a paper read at the meeting of German naturalists and physi- cians held at Brunswick in 1897, J. Riedinger proposed a different basis for the estimation of indemnity for the fingers, for which he adduced physiologic and practical rea.sons. He states that as the usefulness of the human hand deijends less upon its strength than on the harmonious action of all the fingers, it is unreasonable to dif- ferentiate between them in resjiect to indemnity, except in the case of the thumb. The middle finger is the strongest, as becomes very evi- dent when it is lo.st. The index-finger, however, dii'ects the action of the other fingers, and displays the be,st-joint had become almost normal; there was still slight crepitation on movement, and the circumference of the left thigh measured two centimeters less, and the left calf, one centimeter less than the corresponding part on the opposite side. Insurance allowance, 20%. The skiagraph showed a well-marked fracture of the acetabulum and considerable narro\ving of the left side of the true pelvis. Ckwe of fracture of the left ilium. A carpenter, forty years of age, fell from a roof nine feet high on Octol)er 24, 1894, striking on the left hip and on the left side of the heiul. He was treated in the hosjntal until January V.i, 1895, and sub.sequently at home by the physician of his trade-union. I examined him on October 21, 1H9.5. He was a rather large man, somewhat thin, and a very heavy drinker. When he lay on the back, the left side of the pelvis was higher than that of the right side, and the left leg appeared shortened. Careful measurement, however, showed the length of both extremities to be the same; the left thigh was rotated outward. The left side of the pelvis was narrowed, the left anterior superior spine l)eing placed 2} cm. nearer the median line tlian the right. The left pubic ]>one, near the symphysis, was dis- tinctly thickened. Movement of the hip-joint was only slightly affected, Imt gave rise to pain. The whole extremity was greatly atrojjhied, and dragged in walking. The patient was first conceded an insiu-ance allowance of 33J%, which was later reduced to 20 % . In the course of time sequels of the injury to the head, in the fonn of hysteric convulsions, caused the 1 CASES OF FRACTURE OF THE PELVIS. 361 allowance to be raised to 75 % ■ No improvement has taken place thus far. Cane of fracture of the left ilitt))), teft ascending ramus of the ischium, and tuberosity of the ischium ; also crushing of the left side of the abdomen and testicles and double fracture of the left femur. A mason, thirty years of age, was standing on a staircase, which gave way, causing him to fall with it a distiince of two and a half stories. He sustained the injuries just mentioned, and was treated in the hospital. The accident occurred in November, 1886. I examined him on ]\Iay 2, 1890. He was a man of middle height, rather pale and thin. He walked with difhculty and with the aid of crutches. The left lower extremity was much shortened ; it did not touch the ground when the patient stood upright. AMien he lay on the back, the left side of the pelvis was seen to be higher than the right. The whole pelvis was deformed ; the tuberosity of the left ischium was greatly thickened, being nearly the size of a child's list. A point of callous thickening could also be felt on the ascending ramus of the left ischium. The muscles of the buttocks on the left side were greatly atrophied and very flabbj^, so that the bone could be distinctly felt ; the patient was obliged to use a rubber cushion in order to endure a sitting posture. The circumference of the middle of the left thigh was diminished by four centimeters, and the left .sciatic nerve was exceedingly sensitive. The patellar reflex was exaggerated on that side. The patient received 100% insurance allowance ; the fractures of the femur had reunited very unfavorably, and he was imable to work, either standing or sitting. CW.sf of dislocation of the right hip-joint and fracture of the right ascend- ing ramus of the ischium. Sequel, good recovery. A hodent in bed. Subsequently he attended a clinic, where he was treated by massage and electricity. He received a course of treatment in my hospital lasting from April 17 until July 10, 1899, after which date he attended my clinic until September 16, 1899, when he was tinally disc-harged. He was treated chiefly for a subluxation of the right acromioclavicular joint. Symptoms. — Pain in the left hip-joint, esiiecially on climbing stairs. The left hip appeared somewhat atrophied when compared with the right, as did also the muscles of the thigh. Flexion of the hip-joint on the left side was somewhat restricted ; with the patient lying on the back, the thigh could be flexed to an angle of 40 degrees on the left side and 55 degrees on the right side; when standing upright, the angle between the thigh and the trunk, when the former was flexed, equaled only 130 degrees on the left side In comparison with 90 degrees on the right side. "SVlien the jiatient resumed work, there remained only a slight impairment of mobility of the left hii)-joint. Case of chronic synovitis of the left hijt-joint folloivinfj an accident caused by a caving-in. A mason, twenty-three years of age, was caught in the caving-in of an embankment on May 20, 1897. He Ava.s at first treated at his home; on August 23, 1897, he began a course of treatment in my clinic. The patient Avas a small but vigorous man. His right lower extremity was held flexed and was almost completely ankylosed at both hip-joint and knee-joint. The muscles of the limb were greatly atrophied and displayed marked contractures. Every effort at move- ment caused pain. The thigh formed an angle of 125 degrees with the trank; the knee was fixed at an angle of 150 degrees. The patient was first treated by an extension apparatus, and suV)sequently V)y exer- cises, massfige, electricity, and baths. Later on, he receiAed a suppoi't- ing apparatus, which lie still uses in walking. "Without its aid he can walk only Avith difficulty and by leaning on two canes. When dis- 3(36 DISEASES CAUSED BY ACCIDENTS. charged, the mobility of the hip-joint and of the knee-joint had con- siderably improved, and the limb wtis held less flexed than before. Insurance allowance, 75% Traumatic Coxitis. The symptoms of this tlisorder, wliich is met with in consequence ot" contusions, falls, or kicks on the hip, or when the parts are crushed by more serious accidents, are almost identical with the symptoms of nontraumatic in- flammation of a similar nature. Thiem asserts, however, that the traumatic form is more likely to lead to anky- losis. Suppuration never occurs in these cases. Other symptoms are : flexed position of the hi})-joint and knee- joint ; aj>parent shortening- of the limb ; pnin in the iiip- joint ; atrophy of the muscles of the whole limb, espe- cially of those of the hip and thigh ; difliculty in walk- ing ; and a limping gait. Treatment. — The same as of the nontraumatic form. Insurance allowance, from 60^ to 80^ if there is marked difficulty in walking; from 40^ to 60^ in less severe cases. If the patient is able to walk without a cane, 20^ is sufficient. Tu])ercular inflanmiation of the hij)-j()int may be ex- cited by traumatism in individuals in whom tuberculosis already exists in latent form. It may be manifested primarily in the hi})-joint or may appear there in conse- quence of metastasis. Suppuration frequently sets in and the joint may be in large part destroyed. The course of re(^overy is exceedingly protracted. 3. INJURIES AND TRAUMATIC DISEASES OF THE THIQH. Injuries of the Thigh Due to Contusions. (Ninety Cases, Including Wounds.) Simple contusions of the thigh due to kicks, falls, and the like usually heal in a short time. A long course of INJURIES OF THE THIGH. 367 treatment, on the other hand, is reqnired for severe cases of crushing, caused by being run over, caught under heavy falling objects, etc. The hemorrhagic extravasa- tions thus occasioned are slowly absorbed, and the injury is followed by atrophy of the muscles, especially marked in the case of the quadriceps extensor, which is frequently very resistant to treatment. Recovery may not take place under from four to eight weeks, or even longer. In one case under my care the patient was not able to resume work, even to a limited extent, for two years. The cause of the persistent disa- bility often lies in lesions of the vessels and nerves and in sul)cutaneous rupture of the muscles. Malignant tumors occasionally develop as a sequel to severe contusions of the thigh. The accompany ino; skiaf the effect on functional power of the different forms of fracture of the neck of tlie femur. It is hardly necessary to state that functional power is ])ermanently impaired in cases of ununited intra- capsular fracture. Tlie chief cause of the loss of power lies in the presence of tlie unhealed fractm-e itself; in ad- dition, there is atro[)hy of the muscles of the hip and of those of the extremity. Even in these cases, however, we meet with exceptions. Functional power is also impaired after consolidation of extracapsular fractures ; the shortening of the extremity causes lameness, which, because of the abnormal position of the head of the bone in the acetabulum, and the weak- ness of the joint, is not to be overcome l\y the use of a thick-soled shoe. The following muscles undergo jirimarv atrophy : the glutei, the iliopsoas, the pyriformis, and the obturators. Secondarily, the other muscles of the limb become in- FRACTURES OF THE FEMUR. 375 volvecl, especially those of the thioh. If the fracture heals aclvantageouslj and the functional ])ower of the part is satisfactorily restored, the condition of the muscles will improve proportionately ; otherwise, if union does not take place, they usually remain permanently atrophied. In the majority of cases, however, some improvement of functional power may be expected in the course of one or two years, even in elderly persons. Case of impdcicd frdcturc of the neck of the left femur^ foUoived hy non- union. A workman, forty-seven years of age, fell down-stairs on September 3, 1898, sustaining a fracture of the neck of the left femur. He was treated in the hospital up to November 14th, and subsequently attended my clinic. He was a thick-set man of middle height. He walked with a limp and with the aid of two canes. The middle of the lower extremity ^^■as quite edematous. The circumference of the thigh was two centimeters less tlian that of the op^iosite side. The patient said that in walking he felt as if there were a spring in his hip. The skiagraph showed an ununited fracture of the neck of the femur — apparently an intracapsular fracture. When discharged, the circumference of the left thigh exceeded that of the right thigh by two centimeters; the foot, however, had become decidedly atrophied. There was slight edema of both limbs, more noticeable in the left one. Mo\ement produced cracking sounds in the left hip-joint. Flexion Avas some\\hat restricted on the left side. Insurance allowance, fi6|^c. Cdne of fraelKir of the left femur eaused hy overe.vteimon of the thigh when plaeiiuj a heavy windlass on the shoulder. Sequel, good recovery. A carpenter, thirty-seven years of age, in placing a heavy windlass on his shoulder, on September 21, 1891, caiised an overextension of the left hip-joint. He felt a sudden ^'iolent pain and as if something had cracked, like a stick breaking. He fell to the ground, and had to be Ciirried home. He was treated for several weeks for a ' ' sprain of the hip." He then attempted to work, but was unable to continue. I examined him on November 15, 1893. He was a rather large, vigorous man; the left leg was slightly shortened and slightly rotated outward ; the muscles of the left thigh were atrophied to a moderate degree. He was only slightly lame. A diagnosis of fracture Avas not made at this time. He was soon dischai'ged from clinical treatment, but returned on December 10, 1H94. Tlie muscular atrophy, pain, and lameness had increased. A diagnosis was made of fracture of the neck of the femur; the patient was ])ut to bed and treated by massage and electricity. He was discharged with an insurance allowance of 15%. Case of f met u re of the neek of the left femur caused hy turning the left knee and orere.vtending the hip-joint. A workman, thirty-three years of age, wishing to take something out of a dra\ver that was placed high up in the wall, mounted on au 376 DISEASES CAUSED BY ACCIDENTS. inverted pail. The pail liegan to rf)ek ami the man fell so that his right foot slipped outward and his left hand struck against the wall. He immediately felt a \iolent pain in the left hip, and was unable to walk. In the hospital to A\hieli he was taken he wa-s treated for a sprain of the hip-joint. On September 1, 1897, he entered my hospital for a course of after- treatment. He was a fairly large, vigorous man; lie walked with a limp and used a cane. The left lower extremity was greatly atrophied, especially in the thigh, and was slightly rotated outward. The limb felt somewhat cold. The left thigh measured full 4^ cm. less than the right; the left leg '.i cm. less than the right. Active movement in the thigh was limited and jjainful. Passive movements were less affected. There was no cre])itation. Treatment by massage and electricity proved only slightly benehcijil. The skiagraph showed an imi)acted fracture of the ni'ck of the femur. The neck of the bone had almost disiij )])eare(l and the head and neck of the bone were separated by an almost \ertical, light line; the great trochan- ter was raised somewhat above the level of the head. The patient was disc^harged on December 11, 1.^97, with an insui'ance allowance of 66j%. An examination made on January 18, 1899, showed no improvement; on the contrary, the muscular atrophy had increased ; the circumfer- ence of the thigh measured fully 5 cm. less than that of the opposite side. There was crei)itation on movement of the hip-joint, and the patient still walked with a ciine. Case of unifiiitcd infmcapsular fracture of the tiecl: if the left femur. Sequel, pseudo-arthrosis. A workman, thirty-eight years of age, slipped on an as])halt walk, falling over back\vard. He was treated for nine weeks in a surgical institute for a fracture of the neck of the left femur. An extension appai'atus was empkyyed for three Aveeks; mud compresses were then ap])lied, and, finally, the treatment consisted sinii)ly of rest in bed. I examined the ])atient and took a skiagra])h of him on February l(i, 1^97. He was a tall, thin man; in walking he used two canes, and the left leg dragged. The latter an as greatly atroi)hied and much shortened; it was also rotated outward, and could be only a little raised from the ground. "When the patient was lying downi, the great trf)chanter could be moved back and forth. A skiagraph showed the trochanter to lie considerably aliove the head of the bone; the neck was greatly shortened, and was di\i(led into two parts by a light line of fracture about five millimeters in width. The patient received 1()(»'^ insmanee allowance. Cane offraetiiri' if the uiik of the fi ft femur eanseil tiij i tririal aeeiilent when earrj/iiifj a hoilful of stoiie.'i ( fracture inciilental to spceial work). A hod-carrier, forty years of age, a very vigorous and perfectly liealthy man, was injured on August 1, 18R9, by a stone which fell from the fourth story of a building and whicli, in rebounding, grazed his left hip. He immediately felt a violent pain in the left hip-joint, accompanied by a grinding sensation, and was unal)]e to stand on the left leg. He carefully put down the hodful of stones, and was carried to a hosi)itiil by his comrades, where he remained for about two_ mouths. TROCHANTERIC FRACTURES. 377 He was treated by me clinically from October 31, 1889, until March 20, 1891. He was a vigorous, stout man ; he walked with a crutch and a cane. The left lower extremity \\as much shortened and atro- phied, and was rotated outward. The head of the femur did not seem to lie entirely in the acetabuhim. The mobility of the hip-joint was somewhat restricted. The middle of the thigh measured 11] cm. less in circumference than the opposite side, even so long as seven years after the accident. A skiagraph showed an intracapsular fracture ; the trochanters lay very close to the acetabulum, and the apex of the great trochanter was raised above the head of the bone. Insurance allow- ance, lo'/e , at which figure it has remained. Another case concerned a hod-carrier, thirty-two years of age, who had always been perfectly strong and healthy ; he sustained a fracture of the neck of the right femur in stepping from a ladder to a scaft'old- ing with a load on his shoulder. He said that he felt as if the scaffold- ing was giving waj' under his foot. Union was accompanied by a marked degree of shortening and by forward displacement of the per- ipheral fragment, which appeared as a large tumor in the right in- guinal region. There was, in addition, a marked degree of outward rota- tion. The mol)ility of the hip-joint was restricted, the muscles were atrophied, and the patient walked with a limp. Insurance allowance, 50% (fracture incidental to special work). Case of fracture of the neck of the right femur caused by a trivial acci- dent ichen carrying stones {fracture incidental to special work). A workman, fifty-one years of age, who ha. A workman, fifty-five years of age, was struck in the right thigh by a piece of wood on January 19, 1887. His right ankle was caused to turn outward and he was thrown to the ground. He sustained a com- minuted fracture of the right thigli and a fracture of both malleoli. He was treated in the hospital for about three months. I examined him on October 21, 1887. The right lower extremity was shortened and swol- len, and almost absolutely stiff at the knee and ankle. He could walk with difficulty, leaning on two crutches. On November 4, 1887, he was suddenly seized by fever and chills, with signs of inflammation of the thigh, which became greatly swollen. He was in the h<)si)ital until June 22, 1888. Deep incisions were made on the extensor surface of the thigh, and pus and splinters of bone were removed. I examined the patient again on June 24, 1888, and treated him in myelinic until the end of April, 1889. The right lower extremity was strikingly shortened, being about six centimeters shorter than the left. He com- plained of pain throughout the limb and of numbness of the foot. He was unable to walk or to sit for any length of time, and standing was still more difficult. On the anterior surface of the thigh there was a long scar, reiujhing almost from the inguinal fold to near the knee ; it wjis adherent to the bone throughout. The thigh and leg were edem- atous, and the whole linil) was atrophied. The moljility of the hip- joint and of the ankle-joint was limited, and the knee-joint was com- pletely ankylosed. The right ankle was much thickened and deformed. The patient walked with the aid of a crutch and a cane. He then received 100% insurance ;illowance. An examination on February 17, 1894, showed considerable improvement in respect to mobility of the hip-joint and knee-joint, and the scar was considerably less adherent. Insurance allowance, 33J % . Fractures of the femur in its upper half i)resent a very characteristic ])(cture after union is ostahlislied. The symptoms are as follows : shortening of the limb, especially of the thigh ; a well-marked callous thickening at the point of fracture ; displacement of the fragments, which are usually bent with the convexity directed out- ward ; genu varum or valgum ; outward or inward rota- tion ; atrophy ; and lameness. Fig. G4. 382 DISK A SES CA USED B Y A CCIDENTS. Case of fracture of the left femur, followed by shortening, backward dis- placement, and genu recurvatum. A carpenter, forty-two .years of age, is the siibject of the accompany- ing illustration. (Fig. 64, p. 3H1. ) On Fel)ruary 11, 1H91, he fell with a scaffolding, sustaining the injuries mentioned. The illustration sliows the overextension of the knee-joint, and also a muscle-hernia at the ijoint of laceration of the fascia. The dark shading of the left leg represents the venous congestion that was present. Insurance allow- ance, 66|% at tirst; subsequently, 50%. Case of compound fracture of the right thigh. Secjuels : marked degree of shortening ; genu varum ; ankylosis of hip-joint and knee-joint ; slight ankylosis of ankle. ( Fig. ()5, p. 3h;{. ) A carpenter, thirty-three years of age, fell from a scaffolding on June 24, 1895. He was treated in the hospital for seven weeks; an extension apparatus was used for live weeks. He received a course of after-treatment from September 19, 1895, until June 15, 1896. When discharged, he could bend the knee — which at the beginning of treatment had been completely ankylosed — to an angle of ll^O de- grees, and the hip-joint to an angle of 70 degrees. Instirance allow- ance, 60%. This comparatively high rate was based partly on compli- cating injuries (of head, etc.). No further improvement up to date. Fractures of the lower third of the femur have a very decided effect on the position of the knee-joint, which is disphiced in ])i'oportion to tlie proximity of the fracture to that joint. The symptoms observed in connection with the knee- joint subsecpient to fractures of the lower third of the femur are commonly as follows : 1. Flexion of the knee-joint (forward displacement, the variety most frequently seen). This is a typical form of displacement; the lower fragment is drawn downward by the gastrocnemius. 2. Overextension of the knee-joint, genu recurvatum (backward displacement, the least frequent form). 3. X-position, genu valgum (inward displacement, com- paratively often seen). 4. 0-]><>!^ition, genu varum (outward displacement, com- paratively often seen). Genu valgum is usually associated with flexion. In addition to the special form of displacement of the knee-joint, the following symptoms are always present : shortening of the femur, depression of the pelvis on the Fig. 65. 384 DISEASES CAUSED BY ACCIDENTS. affected side, displacement in the hip-joint and ankle-joint, and atrophy. The abnormal position of the knee-joint limits the movement of the joint, even to the point of complete im- mobility, and without the joint itself being involved in the fracture. Tiie ankylosis may depend upon inflammatory adhesions that are particularly likely to form after com- minuted fractures, or on too prolonged an employment of splints. In the latter case the stiffness can usually be overcome if mechanical treatment is begun in time. If delayed until after the thirteenth week, recovery is doubt- ful ; at the best, a long course of treatment is required. Healing, in cases of compound fracture of the femur, necessarily involves the growth of scar tissue. (See Scars of the Thigh.) Laceration of the fascia leads to the development of a muscle-hernia, which is, however, of no practical func- tional imjiortance. Fractures of the shaft of the femur are usually marked by a heavy growth of callus and by shortening and displacement. As already stated, the effect of the in- juiy on the nearest joint is measured by the proximity of the line of fracture, the other joints of the extremity being secondarily and proportionately affected. After consolidation has taken place the part remains edematous and cyanotic, the cyanosis descending further and further on the leg ; coldness and hyperidrosis of the toes are also to be observed. The muscles of the whole extremity are atrophied, and the skin is relaxed and feels withered ; with advanced atrophy it can be lifted up in folds. The knee remains enlarged and swollen for a longtime, as does also the ankle. Lameness is a constant symptom at first ; patients use a crutch or a cane, and are often very clumsy in their movements for a time. These disadvantages are best overcome by systematic mechanical treatment, consisting of massage, baths, exer- cises, electricity, and, at night, Priessnitz' compresses. PSEUDO-ABTHROSIS OF THE FE3IUR. 385 If a plaster cast is worn, it should, if possible, be made removable, in order to permit of early massage. Other- wise, it is well to apply the static breeze to the whole limb through the plaster cast, or possibly through the boots. Spontaneous fractures of the femur depending on morbid conditions of the bone (locomotor ataxia, syphilis, tuberculosis, sarcoma) may occur in consequence of the most trivial accidents. Such fractures have been caused merely by drawing on a boot, by standing up quickly, by falling on the floor, etc. Healing takes place slowly, and there is always danger of recurrence. The patient is therefore greatly incapacitated for work, and the insurance allowance after recovery must be high — higher than after fractures of normal bcme. Pseudo-arthrosis of the femur is due to the same causes that produce it elsewhere. Unless caused by the interposition of soft parts, the patient should be supplied with an appropriate support, and should be encouraged to walk as soon as possible, as by this method recovery can most quickly be brought about. The symptoms are: shortening; in the beginning, edema of the whole limb, including the foot ; edema in the uninjured extremity also ; abnormal mobility at the point of fracture ; and atrophy, which is especially marked below the fracture. An insurance allowance of from 70 fc to 80 ^ is justi- fied, unless the patient is able to walk, fairly well by the aid of a support, in which case a somewhat lower rate may be granted. Case of supracondyloid fracture of the left femur. Sequels, severe functional disability, ankylosis of the knee-joint. The accompanying; illustrations ( Figs. 66 and 67, p. 387) show the enlargement of the left knee-joint, the position of flexion, and the shortening and atrophy of the limb. The knee is completely anky- losed. Insurance allowance, 50%. The skiagraph (Fig. 68) very beautifully shows tlie manner in which the fracture healed. The ujiper part of the shaft of the femur forms almost a right angle with the con- 25 386 DISEASES CAUSED BY ACCIDENTS. dyles. Posteriorly, the condyles are connected with the shaft by a bridge of callus; the patella is firmly fixed between the condyles and the tibia. The patient in this case was a mason, forty-seven years of age, who had sustained the fracture in question by falling down a stone stairway ten or twelve steps. Case of snpracondylold fracture of the femur, followed by partial recovery. ' (Fig. 69, p. 389.) The subject of this illustration was a workman, fifty years of age, who fell from a ladder, dropping a distance of six feet, on Augiist 24, 1896. The skiagraph greatly reseml)les the jireceding one, but, when closely examined, shows certain points of difference. At first the knee-joint was much enlarged and was swollen and stiff. The course of after-treatment that the patient received in my clinic lasted from November 26, 1896, until May 22, 1897. A\nien discharged, there was considerable improvement; he could fully extend the knee and could flex it to an angle of 70 degrees. He was conceded an allowance of 30%. At present the patient does not limp; he can kneel down without any trouble, and walks well. CW.se of serere comminuted nupracondyloid fracture of the left femur. The accompanying illustration (Fig. 70, p. 390) shows a patient, forty-four years of age, who sustained the foregoing injury by slipping with the left foot and falling to the ground. He was treated at home by the application of plaster casts, the first of which remained in ])osi- tion for two weeks, the second for three weeks; massage and inunc- tions were then employed. I examined him and took a skiagraph on March 24, 1899. The illustration shows marked thickening of the thigh and an extreme degree of shortening. The skiagraph showed the shaft of the femur to lie between the condyles, from each of which a splinter of bone, about twelve centi- meters long, protruded upward. The knee could be flexed to an angle of 90 degrees. The patient is still under treatment. It has not been possible to learn of any previous serious disease in this case, the patient maintaining that he has always been perfectly healthy, except that for one year he was ' ' nervous. ' ' He served three years in the artillery. Paralysis of the Thigh. Paralysis of the crural nerve may be caused by traumatism of a severe nature, such as crushing of the thigh, or by a simple accident, like slipping and falling to the ground. Other causes are tumors, originating in the spinal column, tumors of the pelvis, or a psoas abscess. Oppenheim has reported a case due to an aneurysm of the femoral artery. Fig. 68. I It;. fi9. 390 DISEASES CAUSED BY ACCIDENTS. Symptoms. — Paralysis of the iliopsoas or quadriceps extensor and of the sartorius and pectineus. Flexion of the hip-joint is suspended; the patient is unable to rise from a chair unassisted, or to raise the ley when lying on the back with the knee extended. The foot drags in walking, and in crossing a threshold it has to be swung annuid while the toes are lifted. In walking the w^eight is thrown on the opposite knee, while the affected one is held away from the median line. The patel- lar reflex is lost and the muscles are atrophied ; there is anesthesia or hyperesthesia of the parts supplied by the middle and internal cutaneous and the long saphenous nerves : namely, the an- terior and inner surfaces of the thigh, the inner siile of the leg, and the iinier border of the foot almost to the great toe. Paralysis of the trunk of the sciatic nerve of traumatic origin is met with only in rare cases. Symptoms. — Flexion of the knee is suspended ; the leg drags in walking, and the tip of the foot can not be lifted. Fig. 70. FRACTURES OF THE FEMUR. 391 Fracture of the Condyles of the Femur. This lesion is usually part of a fracture of the joint, but even when the joint is not involved, the injury is com- monly followed by ankylosis. It is most frequently caused by a fall — by striking the knee on a stone step, for instance. Symptoms. — The knee is enlarged, or, more properly, broadened ; the joint contains an effusion for a time after consolidation takes place ; subsequently, it becomes anky- losed and fixed in flexion. The limb is shortened, the muscles are atrophied, and the patient walks with a limp. Genu valgum or varum is observed in some cases. Treatment. — Recovery can be attained by means of massage and systematic passive movements when begun early. Insurance allowance : if the knee is ankylosed in a position of extension, from 60 ^ to SO'/c; if slightly flexed (about 160 degrees), 50^; if much flexed, from 70 fo to 80 f,. Case of paralysis of the right thigh {crural nerve, quadriceps muscle) caused by a slip and a misstep. A mai-ble-]iolisher, sixty-five years of age, in lifting a heavy sack filled with soot, slipped, and in so doing stepped on a small, sharp stone, thereby forcibly extending the right liip. He felt a violent pain in the thigh, and was unable to lift the leg. He was treated at home for neuritis, or, ratlier, for concussion of the spinal cord and intramen- ingeal hemorrhage. I examined him on December 14, li^96. The right knee was flexed at an angle of 165 degrees and was ankylosed in that position. The right gluteofemoral crease and the muscles of the right thigh were atrophied, especially the quadriceps. There was slight edema of the right leg and foot. The riglit patellar reflex was lost and there was a considerable degree of anesthesia; pin-pricks were not perceived. The patient was unable to lift the leg when it was extended, and in cross- ing a tlireshold was oldiged to swing the leg over. There was marked anesthesia of the sole of the foot. The patient walked with difficulty and by using a cane. The following cutaneous nerves were involved in the paralysis : anterior crural, peroneal, anterior tibial, musculo- cutaneous, and communicans peronei. The patient was discharged on August 26, 1897, with an insurance allowance of 66|%, afterward raised by the court to 85%, at which rate it has continued. 392 DISEASES CA USED BY A CCI DENTS. 4. INJURIES AND TRAUMATIC DISEASES OF THE KNEE. (263 Cases.) Considerations on Anatomy and Function. — The knee-joint is capable of the following movements : 1. Flexion. 2. Extension. 3. Inward rotation when the knee is flexed. 4. Outward rotation when the knee is flexed. 5. Rotation of the tibia at the beginning and end of flexion and extension. Flexion is produced by the seniitendinosus, the semimembranosus, and the biceps (supplied by the sciatic nerve). During flexion the patella glides downward. Extension is produced by the quatlriceps extensor (supplied by the anterior crural nerve). During extension the patella glides upward. The beginning and end of flexion and extension are both accom- panied by rotation. In addition to its action as a flexor, the biceps serves to rotate the leg out\\ard, while inward rotation is executed l)y the semitendinosus and semimembranosus. Flexion can be carried to an angle of about 40 degrees or something over. This angle is essen- tial in order to kneel for any length of time with ease, while occasion- ally changing position by resting the buttocks on the heels. An angle of 60 degrees to 70 degrees suffices for kneeling ordinarily. A com- fortable sitting posture calls for an angle of 120 degrees at the knee. The articular surface of the patella terminates a finger's width above the apex of the bone; the roughened portion below is filled in by fat and by the subpatellar bursa; this bursa never connnunicates with the knee-joint. The capsule of the joint is attached to the per- iphery of the articular surface, which is covered by a cartilage, and also to the anterior margin of the femur. Under the tendon of the quadriceps extensor, in front of the lower end of the femur, lies the subcrural bursa, Avhich invariably communicates with the joint, and A\hich sometimes extends a handbreadth or more upward on the femur. It is occasionally divided into compartments, some of which may be entirely separated from the others. The extensor tendon is closely attached to this bursa. The capsule of the joint is reinforced anteriorly and laterally by the aponeurosis of the knee-joint, derived from the quadrioe])s extensor, while internally it is additionally strengthened by the internal lateral ligament, to which it is firmly adherent. The internal lateral liga- ment expands as it passes downward, and is firmly attached to the in- ternal semilunar fi))rocartilage, into which its jiosterior fibers are inserted. The anterior ])ortion of the ligament is continued down- ward as a separate band, to be inserted into the tibia. The external lateral ligament is separated from the capsule, or, rather, from the external semilunar fibrocartilage, by the tendon of origin of the popli- teal muscle, which arises from the popliteal depression on the external condj'le of the femur. The posterior portion of the ligament is ANATOMY OF THE KNEE JOINT. 393 inserted into the head of the fibuhi. The Literal ligaments are put on the stretch during extension of the joint; they serve to fix the joint, and they ])revent the movements of rotation, which can be executed when the joint is flexed. The capsule of the joint is reinforced pos- teriorly by fibers derived from the tendon of the semimembranosus, which have received the name of the ol)lique popliteal ligament. The bursa that lies under the tendon of the semimembranosus at the point of its insertion in the tibia is never in communication with the joint. The two heads of the gastrocnemius are attached to the capsule, and the burste that frequently underlie them are alwaj's found to communicate with the joint. The plantaris, too, is adherent to the capsule. There are some thin points in the capsule posteriorly at which it is possible for ganglia to develop. The popliteal artery and vein pass down close to the posterior \\all of the capsiile, separated from it only by the lil)rous tissue surround- ing the vessels, wliile the popliteal nerve is placed more superficially. In the knee-joint are found the two crucial ligaments, Avhich arise in the sjime lateral plane and are inserted respectively in front of and behind the spinous process of the til)ia in the same anteroposterior plane. Thus they cross each other both from before backward and from side to side, and are wound about each other in a spiral fashion. The anterior crucial ligament helps in preventing overflexion ; the pos- terior is put on the stretch bj' extension, thereby limiting this move- ment. The head of the tibia supports the two semilunar fibrocartilages, which are attached by their convex borders to the capsule of the joint, while their sharp concave borders look toward the spinous process of the tibia, to which they are anteriorly and posteriorly attached. The two fibrocartilages are connected in front by the so-called transverse ligaments of the knee. The internal tibrocartilage is lower and less curved than the external. On eacli side of the patella there is a fold of synovial membrane, inclosing adipose tissue, called the ligamentum alaria; the two unite near the femur to form the ligamentum mucosum. A synovial pouch is thus formed, directed upward and backward, in which foreign Ijodies may sometimes be lodged, without producing any irritation. The lig- amentum mucosum frequently di\ides the lower part of the knee-joint into two lateral spaces, which merge a))ove into one; or we can distin- guish two spaces in the joint, one lying above the other. The lower space, which is somewhat the longer, corresjjonds in shape to the semi- lunar fibrocartilages, the upper is more pouch-like. The synovial membrane lining the knee- joint is richly supplied with synovial fringes, some of which are of very large size ( jjliysiologic crepitation ) . A bursa communicating with the joint is invariably found iinder the tendon of the popliteus muscle at its point of origin. The nuiscle is always closely attached to the joint-capsule, and the bursa is ex- tended iinder the muscle down to the superior ti))iofiI)ular articulation, with which, in rare instances, it may communicate. In such a case the knee-joint and superior tibiofibular joint are connected; normally, 394 DISEASES CAUSED BY ACCIDENTS. however, they are entirely separate. The prepatellar bursa, which, as its name indicates, lies in front of the patella, never conunuuicates with the joint; occasionally, more than one bursa is developed in this situation. The tibia and head of the fibula are closely and firmly united liy the superior tilnofibular articulation, the capsule of which is strength- ened by anterior and posterior ligaments. Normally, this articulation is completely isolated. Contusions of the Knee=joint. (175 Cases.) The effects of contusions caused by falls, blows, or kicks, or when the knee is caught and compressed be- tween two objects, may be displayed in an inflammation of one of the numerous bursae around the knee or of the knee-joint itself. It is with the latter class of lesions that we are, for the moment, here concerneil. The symptoms, after the acute stage has passed, are : swelling ; presence of an effusion ; moderate heat in the joint; possibly fixation of the knee in flexion; atrophy of the muscles connected with the knee, particularly of the quadriceps, but also involving the flexors and, to a certain extent, the muscles of the leg. These symptoms persist for a long time. If the effusion is absorbed, the capsule of the joint will be found thickened on palpa- tion. Many cases show no signs of heat or swelling in the morning, while in the evening the joint appears very hot and swollen and contains an effusion. Such cases are not to be looked upon as cured, l)ut should remain under treatment. If a patient complains of his knee being swollen at night, another examination should by all means be made at that time. Later si/mpfoms : restricted mobility of the knee-joint, cracking sounds on movement after the effusion is entirely absorbed, feeling of fatigue, and pain. Treatment. — Rest ; immobilization by means of splints, the knee being extended as far as possible, and SPRAINS OF THE KNEE. 395 suspended if feasible ; in addition, eooling compresses, cold douches, Priessuitz' compresses, or compresses wet with a solution of acetate of aluminium, and acupuncture are to be recommended. Subsequently, massage of the muscles of the thigh and leg, as well as of the knee itself, and electricity, should be employed. In walking, it is often necessary for the patient to wear an elastic knee-cap. The insurance allowance while the knee remains weak and the muscles continue atrophied is usually estimated at Sprains of the Knee-joint. (Fifty-five Cases of Pure Sftrains.) Sprains of this joint may be caused by falling on the knee or on the feet, and by kicks on the knee, the popli- teal space, or the leg near the knee ; they also occur as a result of caving-in accidents, of springing from a carriage or from a flight of steps, or of sim])ly turning the knee (usually inward), and similar accidents. The sprain is accompanied by strain or partial rupture of the ligaments of the joint, as well as of the capsule, bursse, and tendons. AYe sometimes, for example, find a partial or complete rupture of the internal lateral ligament together with a partial tear of the semilunar fibrocartilage at the point at wliich the ligament is inserted into it. The symptoms are swelling, synovial effusion, and fixed position of the joint, as in cases of contusion. In addition, the internal condyle of the femur is often found to project distinctly when the knee is flexed, just as if it had been fractured and displaced and had healed in that position. If a skiagraph is taken, we can see that the spinous process of the tibia does not lie in the intercon- dyloid notch of the femur ; the prominence of the internal condyle is also shown. This condition of subluxation is characteristic of a large proportion of sprains of the knee- joint. The more seriously the internal lateral ligament is 396 DISEASES CAUSED BY ACCIDENTS. torn, the further can tlie bones be separated on the inner side of the joint (loose-jointedness). This causes a weak- ness of the knee and considerable difficulty in walking. Patients learn to hold the knee fixed as much as possible, in order to avoid turnino; it when they walk. The longer the inflammation and effusion persist, the louder, as a rule, is the subsequent crepitation in the joint. The rubbing sounds are due to the proliferation of the synovial fringes, which in the knee-joint are normally present in large number, and which increase in size, as well as in number, when the effusion subsides. They sel- dom, however, have any influence on the action of the joint. The nuiseles of the thigh, especially the quadri- ceps, remain atrophied in proportion to the duration of the effusion. The atrojihy of the vastus internus is often the most striking. I have found the atrophy of the quadri- ceps to last for two years, or even longer, after a sprain. Patients do not, as a ride, complain of much pain in the later stages of the inflammation. Treatment. — The same as that for contusions. In addition, if loose-jointedness be developed in consequence of rupture of one of the lateral ligaments, a jointed support should be worn for walking. The course of treatment re- quired, which for some cases of contusion covers a consid- erable period, is apt to be even more protracted when it is a question of recovery from a sprain. Even slight exertion is likely to bring on a relapse, with renewed swelling and effusion, demanding additional treatment. Insurance allowance, from 20^ to 33^^. Partial Rupture of the Ligamentum Patellae. This lesion occurs in connection with s])rains, when, for example, the knee is turned or gives way suddenly when it is overextended. The injury to the ligament leaves the whole extensor apparatus (quadriceps including liga- mentum patelhe) relaxed and the knee w^eak, while the muscles may remain atrophied for years. Primarily, the BURSITY OF THE KNEE. 397 quadriceps is affected ; secondarily, the atrophy also in- volves the other muscles of the thijj-h. A carpenter, twenty-five years of age, slipped on a smooth plank ; his knee gave way and he fell on his kick. He felt a pain in the knee and was unahle to rise. An effusion took place into the joint. A skiagraph taken somewhat later showed the partial rupture of the liga- mentum patellaj and the displacement of the patella upward. In addition, the muscles of the thigh were greatly atrophied (circumfer- ence diminislied by four centimeters), and the knee was exceedingly weak. The patient was able to extend liis knee to 145 degrees, and to flex it to 55 degrees. The patellar reflex was lost. Insurance allow- ance, 50^. Complete Rupture of the Ligamentum Patellae. This lesion is seen even less frequently than the preced- ing. It occurs under the same conditions as do the frac- tures of the patella that are produced by muscular action. The symptoms subsequent to the acute stage are : eifu- sion ; swelling ; and, unless the ruptured tendon is sutured, loose-jointedness ; and an extreme degree of atroj^hy of the quadriceps. The knee feels weak and insecure, as does the whole limb, and the patient is unable to extend the knee or to fix the patella. Treatment. — The tendon should be sutured (Plel- ferich's method) in all cases. In other respects the treat- ment is the same as for sprain. Injuries of the Bursse of the Knee. The bursae are sometimes injured in cases of contusion or sprain of the knee-joint. When a communication exists between the affected bursse and the knee-joint, we find a diffuse effusion, making the outlines of the patella indistinct. The symptoms in such cases are identical with those of a synovitis of the knee. When no such communication exists, it is possible for the exudate in the acute stage of the bursitis to break through into the joint. The pain usually disappears before the subacute or chronic stage is reached, unless melon-seed bodies should develop, as frequently happens when the prepatellar bursa is in- 398 DISEASES CAUSED BV ACCIDENTS. volved. In other respects this bursa gives less trouble than any of the others. When one of the isolated bursse is attacked by inflammation, the symptoms vary somewhat, according to the location. In case, for instance, of a pre- patellar hygroma the quadriceps, after absorption of the effusion, may show no appreciable evidences of atrophy, while it is, as a rule, noticeably affected by a hygroma under the tendon below the patella. Treatment. — AV hen the effusion is absorbed, massage and electricity should be employed, and a knee-cap should be ordered. Exertion is likely to produce a relapse. Insurance allowance, from 20 ^ to 25 ^ . In one case under my observation the patient, a carpenter, forty- eight years of age, suffered from a bursitis under the lieads of the gas- trocnemius, brought on by twisting tlie knee, in January, 1898. A tense elastic tumor could be felt under the heads of the muscle; the knee-joint was swollen and contained an effusion; it was also weak, and its mobility was restricted. The muscles were atrophied and the leg was edematous. The patient was under treatment from August 27, 18f)8, liefore which date he had not obtained medical advice, until July 28, 1899. Insurance allowance at first, 83j fo . Wounds and Scars of the Knee. AVounds of the knee are met with in carpenters and wood-choppers, as the result of a blow from an ax or hatchet ; punctured wounds caused by a sharp instrument, such as a chisel, are likewise seen. As such wounds are likely to extend deeply into the tissues, and to involve the bone, subsequently forming cicatricial adhesions with the latter, their effect on the functional action of the joint becomes very serious. The process of healing and the subsequent effect of the scar depend largely on the question of infection of the wound. Punctured wounds which directly pierce the ca])sule of the joint may be very quickly followed by a suppurative synovitis. Even simple contused wounds may lead to a cellulitis, and subsequently to ankylosis, the latter depending on the operation-scars, as well as on iutra-articular adhesions. Extensive scars situated over WOUNDS OF THE KNEE. 399 the knee or close to it limit its action to a very consider- able degree. As a rule, the patient finds it easiest to keep the knee slightly flexed, on whatever part of the knee the scar is situated. Unless the knee is moved with some caution, the scars are very likely to break open. This is especially the case when the scar lies upon, and is adher- ent to, the patella, in which situation it is likely to be injured by unguarded or frequently repeated movements of flexion, while scars of the popliteal region may be torn open by movements of extension. Similar effects are seen when the scars are situated at the side of the joint. In addition to this constant danger of injury to the scar, recovery is further interfered with by more or less atrophy of the muscles. Treatment. — Gradually to stretch the scar-tissue, and so to restore the mobility of the joint, is the aim of treat- ment, and is accomplished by means of warm baths, warm packs, massage, exercises, and galvinism. In some cases only a certain degree of improvement can be reached ; the scars, hoAvever, often become gradually loosened spontaneously, although the process may cover a number of years. The working capacity of the patient, when the mobility of the joint is much affected, may be very considerably reduced. Insurance allowance in light cases 25^ ; in severe cases from 50^ to 60^. Punctured wound of the left knee folJowcd by suppurative inflammation and anki/tosis. A carpenter's apprentice, seventeen years of age, injured his left knee with a chisel. It became swollen and inflamed, and suppuration set in. He was treated in the hospital from September 8, 1894, until January 16, 1895, the knee having been opened in several places. He then attended my clinic until September 24, 1895. At first the knee was entirely stiff, and was set at an angle of 150 degrees; when the patient was discharged, it was held at an angle of 170 degrees, and could be flexed to l25 degrees, thus allowing of a flexion of 45 de- grees. The knee was marked with deep scars, in part attached to the bone; the nuiscles of the thigh were greatly atrophied, the circumfer- ence being diminished five or six centimeters. Insurance allowance, 400 DISEASES CAUSED BY ACCIDENTS. 45%. At the time of an examination made on April IR, 1898, no noteworthy improvement was apparent; the patient was unable to kneel. Another case of injury of the knee-joint, caused by a blow from an ax, and followed by sujipuration, concerned a carpenter, fift^'-four years of age, who was treated at home from the day of his accident, August 30, 1890, until September 22, 1890, when he entered the hos- pital for operation, remaining there until January 24, 1891. He attended my clinic from April 10, 1891, until October 23, 1891. The scars on the knee were adherent to the bone, and flexion was limited to 115 degrees, the knee being held at an angle of 180 degrees. The muscles were atrophied and the patient was unable to kneel. Insur- ance allowance, 4(t % . Case of retracted cicatrices over the patella and on the outer surface of the knee-joint, caused by a contusion and suppurative inflammation. Sequel, tubercular arthritis of the knee; death from pulmonary tuber- culosis. A workman, twenty-seven years of age, was struck on the left knee by a stone, on November 23, 1891. The injury was followed by swell- ing, inflammation, and suppuration. The patient entered the hospital for treatment; skin grafting was attempted, but was unsuccessful. The wounds required treatment until December 30, 1892. Afterward there was left a deep scar extending along the whole outer side of the thigh, down to the knee. The scar over the patella showed signs of inflammation, and could be broken open when the knee was flexed to an angle of 85 degrees. The leg was edematous and the muscles of the thigh were greatly atrophied. JMovements of the knee-joint caused crei>itation. Subsequently, the patient was able to work and to mount ladders, and received full ])ay. The first signs of local tuberculosis appeared at the end of IHix;, and the patient succumbed to pulmonary tuljerculosis at the end of 1897. Dislocations of the Knee=joint. (Sixteen Cases of Reduced Dislocation Form the Basis of This Section. ) Dislocations of tlie knee-joint are seldom seen, an ex- treme degree of violence being required for their pro- duction. The joint remains swollen for a long time after reduc- tion, and, in addition, we find the following symptoms: subluxation of the joint ; loose-jointedness or more; or less complete ankylosis ; genu valgum or varum ; crepitation on movement ; atrophy of the whole limb, especially of the (piadriceps ; restricted mobility ; and difficulty in walkin was atrophied. The circumference of the middle of the tlii^h was diminished 6 cm., that of the knee 5 cm., and that of the calf nearly '2 cm. The patient was obliged to wear a supporting apparatus. At the time of another examination, in November, 1896, I found the atrophy still more ad\ance(i; the circum- ference at the level of the iliofemoral crease was diminished 8 cm., that of the middle of the thigh 9 cm., and the knee 2 cm. Insurance allowance, (JU^. No improvement up to the present time. Case of indirect fmctnre nf the patella caused by viuscular action, on the occasion of a fall from a netiffolding. (Fig. 72, p. 407.) A Avorkman, twenty-six years of age, sustained a fracture of the pa- tella as just stated. Some improvement has gradually taken place in the course of time, since the lateral portions of the extensor aponeuro- sis remained intact. The interval between the fragments admitted the full width of the liand. The atrophy was extreme at tirst, the circumference of the thigh being diminished 6^ cm. At the pres- ent time there is only a slight difference in the measurement of the two sides. The patient can walk very well and can do light work. Insurance allowance, 50 ^ ; later, 33 J % . Case of direct fracture of the right patella. (Fig. 73, p. 409.) A mason, thirty-eight yeare of age, fell from a scaffolding on April 13, 1897, striking on the right knee and left hand. An extension ap- paratus was applied for seven weeks in the hospital. Tlie patient \\as subsequently treated in my clinic from July 14, 1897, until June 3:3, 1898. He was a tall, stout man ; the right knee was completely anky- losed and greatly swollen ; it was fixed at an angle of 175 degrees, and the muscles were greatly atrophied. The accompanying skiagraph was taken four week after the first examination. The lower fragment was firmly fixed between the tibia and the femur. When discharged, the knee could be actively flexed only to an angle of 120 degrees; there has been no subsequent improvement. The patient has mean- while developed a severe case of tuberculosis. Case of direct comminuted fracture of the right patellar. (Fig. 74, p. 410. ) The knee was put up in plaster for fourteen and a half weeks, and the patient was then allowed to walk. He was treated in my clinic from January 13, 1898, until March 19, 1898. The knee-joint was swollen, and the outline of the patella was indistinct. On palpation tlie patella felt somewhat uneven. Flexion was limited to an angle of 125 degrees. At the time of his discharge flexion was increased to an angle of 85 degrees, and there was no difficulty in walking. The shape and displacement of the patella are ch-ariy shown in the skiagraph, in which the line of fracture can also be eiisily traced. Fig. 73. Fig. 74. TUBERCULOSIS OF THE KNEE. 411 Fractures of the Knee-joint. (Fourteen Cases Involving the Femur or Tibia. ) The lesion may consist of a fracture of the articular extremity of the femur, of the tibia, or of both. The knee is usually left weak, ankylosed, and fixed in exten- sion or flexion. The nuiscles connected with the joint undergo atrophy. The disadvantage of a stiff knee to a workman is usually greater when the knee is extended than when moderately flexed — say, at an angle of from 145 to 155 degrees. Lameness in the latter case can be obviated by wearing a raised shoe, and the patient may then be able to mount and ascend a ladder with a load on his shoulder. He is also better able to put on and take oft* his trousers, to board horse-cars, omnibusses, etc., than if the leg were fixed in extension. The prognosis is more favorable as to functional ])Ower if only partial ankylosis exists, or if the fixation is due to a contracture which still permits of some movement of the joint. When the stiftiiess is due to resection, the insurance allowance is usually rated higher than other- wise, because of the additional shortness of the limb. Insurance allowance, when the knee is fully extended, from 50^ to 60^ ; Avhen flexed at an angle of about 160 degrees, from 25^ to 33^^ ; wdien greatly flexed, necessitating the wearing of a wooden leg, from 70 ^ to 80^. The rate is considerably affected by the ability or inability of the patient to kneel. Tuberculosis of the Knee==joint. Traumatism, when it affects a tuberculous individual, not infrequently acts as the exciting cause of tubercular inflammation of the knee-joint. The injury may be slight or serious, such as a contusion, a sprain, a frac- ture, etc. It may be possible to prevent the local de- 412 DISEASES CAUSED BY ACCIDENTS. velopraent of the disease if the patient is phiced under treatment immediately after the accident, but if the syno- vitis once gains headway, it leads to the development of an obstinate and destructive inflammatory process, which may progress indefinitely, doing irreparable damage to the joint. Resection is often indicated. Sometimes the pus works its way to the surface and the inflammatory process comes to an end, leaving the joint stiff and deformed and marred by scars. Symptoms. — Insidious onset and development of the inflannnation ; swelling of the knee, marked by tension and absence of effusion ; gradual change of shape of the part ; fever, atrophy, etc. Insurance allowance during the acute or subacute stage, 100^. Chronic Traumatic Inflammation of the Knee=joint ; Arthritis Deformans ; Osteo=arthritis of the Knee. When the knee-joint is severely contused or crushed it may become the seat of a chronic inflammation (arthritis deformans), especially if the affected individual is subject to frequent attacks of rheumatism. The functional power of the joint is considerably diminished, and the patient is frequently obliged to stop work on account of pain in the joint, especially when the weatlier is changeable. The knee-joint becomes greatly enlarged and deformed ; it is completely or partly ankylosed, and, as a rule, is flexed and partly dislocated. It may be many years before the patient is completely incapacitated for self-support. Insurance allowance, according to the severity of the case, 33 J ^ or more. Case of traumatic arthritic deformans iiivolriii;/ the knee. A woman forty-five years of age sustained in her twentietli year, a fracture of tlie left tiliia just below the knee. She was under treat- ment for eight months, afterward resuming work in a factory. In con- sequence of repeated contusions received during subsequent years the left knee gradually became more and more swollen and misshapen. INJURIES OF THE LEG. 413 When I examined her, on March 3, 1899, I found the knee greatly deformed; it was much enlarged, flexed, and in a position of varus ; it was almost completely aid^ylosed and was very painful. Tlie muscles were atrophied and tlie part was cold. The patient com- plained of severe pain. Insurance allowance, 50%. 5. INJURIES AND TRAUMATIC DISEASES OF THE LEG. Injuries Due to Contusion. (156 Cases, Including Wounds. ) Slight contusions of tlie tibia are usually followed by rapid and perfect recovery. Even in case of extensive blood extravasations, which, on account of the vascularity of the part, are frequent, the injury, if properly treated, does not lead to subsequent functional disability. The periosteitis caused by contusions seldom gives rise to much, if to any, pain, and does not, as a rule, prevent the patient from working. If, on the other hand, the periosteitis appears in connection with a contused wound, which subsequently becomes infected, the consequences may be very serious. A workman, thirty-five years of age, grazed his right shin in using a heavy hammer, causing a slight abrasion of the skin. A suppurative periosteitis developed ; the wound continued to disc^harge for a year, when it finally healed, leaving a broad, shining scar, adherent to the bone and exceedingly sensitive. The slightest touch, even of the surrounding skin, would cause violent contractions, and very Intense and long-continued tetanic spasms could be produced by testing the patellar reflex. The knee was weak and was fixed in flexion; the patient walked with difficulty, leaning on two canes. Insurance allowance, 100 % . Contusions of the Calf. These usually run a favorable course, absorption of the hemorrhagic extravasation being quickly promoted by appropriate treatment — rest, compresses, etc. The same may be said of contusions affecting the tendo Achillis. The prognosis becomes more serious, however, when the leg is crushed under heavy ol))ects, such as beams, stone slabs, iron rails, etc., or when the individual is caught in 414 DISEASES CAUSED BY ACCIDENTS. a cavino:-in or is run over. Such accidents are likely to cause extensive wounds, simple or compound fractures, ruptures of muscles and teudons, and lacerations of the fasciae. When fractures are jiresent, the usefulness of the part is usually permanently impaired ; otherwise, if ]>roper- ly treated, no permanent functional disability need follow. The course of treatment, however, is apt to l)e protracted. Although in simple cases of crushing of the leg a favorable result may usually be expected, the outlook becomes very different when the leg is the seat of some morbid process. Quite ajiart from the disproportionate effects of slight injuries in the presence of a constitu- tional disease, such as locomotor ataxia, — when simple contusions, for instance, may cause a fracture, — when the leg is affected by varicose veins or cicatrized vari- cose ulcers it needs only the irritation consequent upon a contusion or slight abrasion to excite an inflamma- tion leading to the development of new ulcers or to the reopening of old ones. The ulcers may become as large as the palm of the hand, and unless the process is brought to a termination, may be followed in the course of time by swelling and inflammation of the whole leg (elephan- tiasis cruris traumatica). When the inflammation is severe, the patient should remain in bed, with the leg elevated, and the wound should be kept scrupulously clean. A 2fc to 4^ solution of acetate of aluminium is sometimes remarkably efficacious. If there is no marked inflamma- tory reaction in the surrounding tissue, and it is only a question of cicatrization of the ulcers, it is advisable in many cases to use a prepared zinc bandage, which enables the patient to continue work and may not need renewal for a week or two. These zinc bandages are certainly of great service to working-men suffering from varicose ulcers. If such a man were to be sent to the hospital every time a healed ulcer should break down afresh, he and his family would be reduced to starvation. The bandages are highly valued by both doctors and patients ; WOUXBS OF THE LEG. 415 many workmen treat them^ielves, indeed, on the same principle, although imperfectly, by nsing ointments and bandages, and perform the same tasks, year in, year ont, as their healthy comrades, although the ulcers remain open and suppurating. We should, however, insist on seeing a patient at least once or twice a week, changing the bandage as soon as it is soiled through by secretion. The patient must be impressed with the necessity of going at once to the physician when this occurs. As the traumatism is usually responsible, at the most, for no more than a new outbreak of the old trouble, 20^ is ordinarily a sufficient insurance allowance when the patient is able to work, with due consideration for the likelihood of recurrences. In respect to wounds of the leg, incised wounds are among the most important. They are seen in carpenters and others whose work exposes them to accidents with hatchets or axes, or in farm-hands who handle scythes. They heal, as a rule, without difficulty, and the scars give no trouble, unless by reason of deep attachments. The results are, of course, serious when tendons, vessels, or nerves are involved in the cut. Infected woiuids of the leg, Avhich in healing form cicatricial adhesions with the bone, are characterized by extreme sensitiveness, which in some cases rather increases than diminishes after the scar is fully formed. The wounds of the back of the leg, with which we have to deal, are usually caused by a scythe, and involve either the calf or the tendo Achillis. Wounds of the calf usually heal without further difficulty. Healing, when the tendo Achillis is severed, is a slower process, but is likely to terminate favorably. Unless primary union takes place, a cicatricial contracture of the tendon is likely to be developed, causing flexion of the knee and talipes equinus. The action of the ankle-joint is restricted and cramps of the muscles of the calf are frequently observed. These unfavorable results can be entirely overcome, however, by massage, baths, and electricity. 416 DISEASES CAUSED BY ACCIDENTS. Cane of division of the tendo Acliillis, followed by eietdrieird eontnietion and relaiively slif/Jit functional dis(d/iliti/. A workman, forty-five years of age, cut the back of his leg -witli a bread-knife, completely severing the tendo Achillis, on June 2fi, 1897. He was treated in the hospital, Avhere the tendon was sutured ; the wound, liowever, healed ^ery slowly. It was still open when the patient came under my care, on October 23, 1897. After healing it left a firmly adherent scar, extending to the internal malleolus. The knee was slightly flexed, and there was a slight tendency toward talipes equinus. The muscles of the calf were atrophied and were sub- ject to cramps. Tlie mobility of the ankle and toes was some^vhat restricted, and there was a feeling of numbness in the heel and the sole of the foot. The patient made considerable improvement. Insurance allowance, 20%. Burns and Scalds of the Leg. In severe cases healing is very protracted, and wlien it finally takes place patients find it very difficult to walk or to bear their weigiit on the aifected leg for a long time. At first they are obliged to use crutches, and always com- plain of a feeling of great insecurity in the leg, which is only slowly and gradually overcome. The scars in some cases present zones of extreme hyperesthesia, while in other cases analgesia is manifested. Subcutaneous ruptures of the muscles of the calf occur in the lower part of their course, usually as the result of reflex contraction of the muscles, following a fall or a leap, landing on the feet. Occasionally, only the posterior extremity of the os calcis is torn oif ; less frequently, the muscles give way where they merge into the tendo Achillis, and in rare cases the extremity of the os calcis is torn off and the tendo Achillis is ruptured at the same time. The subject will be referred to again under Frac- tures of the Os Calcis. Case of scald of both legs and feet followed hij very protracted recovery. A painter, thirty-three years of age, fell from a scaffolding into a boiler full of boiling water on June 4, 1889, sustaining the foregoing injuries. He was treated in the hospital until September 20, 1889. I examined him at his home on Septemlier 23, 1889. He was utterly unable to walk, or even to stand. About three months later he began to walk with two crutches. Both ankles were encircled by smooth, sujierficial scars; both legs, more particularly the right, were like- FRACTURES OF THE LEG. 417 wise badly scarred. The muscles were slightly atrophied and the temperature of the skin was lowered. The scars were extremely sensiti\e and the legs appeared strikingly weak. The jmtient was discharged on April 21, 1891, with an insurance allowance of 33J % . On October 14, 1^96, he appeared for examination, complaining of feeling worse. There were fibrillary and clonic contractions of the muscles of both legs; the ])atellar reflexes were extremely exaggerated and ankle-clonus could be obtained on both sides. The patient walked very cautiously and slowly, and swayed when his eyes were closed. There was numbness of the soles of l)oth feet. The muscles were not atrophied. Pulse, 100; irregular. The insurance allowance was rai.sed to 50 % . Fractures of the Leg. (190 Cases.) Fractures of the Upper End of the Tibia. — The typical fracture in this situation is due to compression of the bone in its long axis, as a result of such accidents as falling squarely on the feet from a height, jumping from a bicycle, etc. AVhen the injury is slight, the tibia is only fissured ; in severe cases the upper end of the bone is driven more or less into the shaft, or the U23per articular surface is flat- tened and broadened, or the effect of the violence may be still differently manifested — by a concave depression in the head of the tibia corresponding to the convexity of one of the condyles of the femur which was forced into it. The fibula is always involved in cases of severe com- pression. As these fractures involve the joint, they may be further complicated by injuries of the semilunar fibro- cartilages, which are sometimes thrown out of position, and perhaps also by a fracture of the spinous process of the tibia. Symptoms of inflammation of the knee-joint are always ]n*eseut at first. Symptoms subsequent to consolidation : The leg is shortened ; the knee is thickened and enlarged ; the head of the til)ia presents an increased circumference and a de- formity which remains after the swelling subsides ; the joint is in a position of subluxation, with varus or per- 27 418 DISEASES CAUSED BY ACCIDENTS. PLATE 33. Case of Compression=fracture of the Left Tibia and Head of the Fibula, Due to Falling from a Scaffolding, Landing on the Feet, (Sec Fig. 75, p. 419.) A mason, thirty-eight years of age, sustained the foregoing injuries on June 11, 1896. He was treated in the hospital for eleven weeks, and su))sequently in an "institute for mechanical treatment" for thirteen weeks. He began to attend my clinic on February 28, 1898. The accompanying ilhistratif)n was made shortly l)efore his discharge. The left leg is distinctly shortened, the knee-joint is thickened and slightly rotated outward, there is a slight degree of genu \arum, the leg is somewhat swollen, and the thigh is atroi^hied. The skiagraph (Fig. 75, p. 419) shows the fracture very clearly. haps valgus ; the whole leg shows signs of atrophy ; the knee-joint is partly or completely ankylosed ; if move- ment is permitted, it is accom])anied by crepitation. Farther symptoms are lameness, pain, secondary displace- ments of the hip and ankle, and, frequently, an inability to kneel. Treatment. — The knee is to be mobilized by exercises and massage ; a boot with raised sole is sometimes to be recommended. A very long course of treatment is re- quired in unfavorable cases, the symptoms previously named being very persistent. Insurance allowance, from 25^ to 50^. Fractures of the Leg Near the Knee. — The con.se- quences of these fractures are manifested ])oth by dis- placement and loss of functional power of the knee-joint. We find the leg shortened and the knee-joint thickened, as is also the head of the fibula, if this was involved in the fracture. There is genu valgum or varum, the muscles are atrophied, the mobility of the knee-joint is restricted, and there is difficulty in walking. Corresponding secondary disjilacements are manifested in both the hip-joint and the ankle-joint. Separation of the tubercle of the tibia caused by mus- cular action is never more than a ])artial separation, and is rarely met with in adults. The lesion is usually of a Tab. 33. ( Fi'i 1 j_. Lirh. Anst F. ReLchlwld., Mundu Fig. 75. 420 DISEASES CAUSED BY ACCIDENTS. PLATE 34. Case of Genu Valgum Following a Fracture of the Leg Just Below the Knee. (See Fig. 76, p. 4-21.) A workman, twenty-seven years of age, ^^as injured as just stated on February 4, 1898, by a pail falling against tbe outer side of his left leg. The patient was treated at home in the country; splints were applied for one day, a plaster cast being substituted on the following day. Eight weeks after the accident he began to walk with the aid of a crutch and a cane. He was treated in my hospital from May 15, until August 18, 1898. The form of the fi'acture is shown in the accompanying skiagraph. In the colored plate we can see the edema and atrophy of the leg, the atrophy of the thigh, the venous conges- tion of the leg and foot, and the genu valgum. Insurance allowance, 20%. The functional power of the knee was completely restored by the treatment. The skiagraph ( Fig. 76 ) is to be regarded as a mirror- picture. trivial nature. As a result the tubercle is found thick- ened, the ligauientum patellse is somewhat loosened, and the quadriceps shows signs of slight atrophy. Fractures of the head of the fibula have already been referred to ; they are directly produced by kicks or falls, or by the trauniatisiu incidental to a caving-in, or occur indirectly in consequence of falling from a height and landing on the feet, in connection \vith compression-frac- tures of the tibia. Sometimes the lesion takes the form of a comminuted fracture. Occasionally the head of the fibula is torn off by the action of the biceps. Healing is characterized by a well-marked growth of callus, by which the bone is left more or less distinctly thickened ; the biceps undergoes atrophy, and occasionally is found extremely tense or definitely contracted, causing outward rotation of the leg and outward disphicement of the head of the fibula. Severe cases may be accompanied by \mv- alysis of the peroneal nerve, due to its direct injury. The knee-joint is not affected by isolated fractures of the head of the fibula, except in the unusual instances in which it is in communication with the superior tibiofibular Tab. J4. Fiij Lull. An.st H Heidihold. Huiui. Fig. 76. 422 DISEASES CAUSED BY ACCIDENTS. PLATE 35. Atrophy of the Left Lower Extremity After a Fracture of the Tibia, Involving the Bony Ridge Anterior to the inferior Tibiofibular Articulation, and Contusion of the Leg. The subject of the accompany in<>; ilhistr-ation was a mason, thirty- eiffht years of age, who was injured on May 1, 1897, by a beam falling against his left leg. ITe was at first treated at home, subsequently entering a hospital, where he remained for three weeks. He was a patient in my hospital from Fe))ruary 'js, until June 14, 1H98, when he was discharged with an insurance allowance of 50/^. The atrophy in this case, which in\(>lved the whole extremity, was particularly re- sistant to treatment; the temperature of the foot, including the sole, was reduced. The illustration shows the general atrophy of the limb very well; the affected muscles included the gluteus medius, sartorius, quadriceps extensor, tibialis anticus, gastrocnemius, aljductor pollicis, etc. The muscles of the foot are evidently involved as well ; even the left heel is smaller than the right, and the impression (Fig. 77) of the sole indicates a similar condition of the muscles in that situation. joint, when it is likely to share the inflammation of the latter. Dislocation of the head of tlic filnila is very rarely seen as a separate lesion ; it usually occurs as a secondary effect in cases of fracture of the tibia accom])anied by marked displacement of the fra,s»;nients. Fractures of the head of the fibula are regularly conij)licated by partial dislocation, due to the action of the biceps. In one case of forward dislocation of the head of the left fibula which came under my observation I found the knee flexed and the tendon of the bicejjs very prominent, \\hile the muscle itself was tensely contracted. The jieroneal ner\i' \\as very sensitive, and move- ment of the knee was rendered difficult; there was talipes valgus, and, in addition, .slight atrophy of the muscles of the thigh. The abnormal position of the head of the fibula in cases of dislocation induces a secondary displacement of the external malleolus and the foot, frequently resembling the displacement due to fracture of the malleolus. This secondary cflFect on the inferior tibiofibular joint is only slightly marked, if at all, in cases of displacement follow- ing fracture of the head of the fibula. I'nh.Xl. 424 DISEASES CAUSED BY ACCIDENTS. PLATE 36. Case of Pseudo=arthrosis of the Left Leg Following a Compound Fracture. A roofer, twenty-four years of age, fell from a roof on July 16, 1898, sustainiiifr a compound fracture of the left le^, and, in addition, a contusion of the lumbar ^ ertelna' and a fracture of the riJj.s. He spent five months in bed in a hospital, and when discharged at the end of that time, tlie fracture still remained ununited. Tlie point of frac- ture presented a well-marked angular deformity. He entered my hos- pital on January (i, 1899. At the time the accomi)anying illustration was made, in the beginning of Febriiary, 1899, there A\as already some impro\'ement in respect to gait, as a result of medicomechanical treat- ment and the use of a local support. The picture shows tlie scar, the displacement, shortening, venous congestion, and atrophy, and, in addition, the diminished size of the foot and the talipes varus. The malposition of the foot is also evidenced in the impressions of the sole. ( Fig. 78. ) The temperature of the whole extremity was reduced, more especially below the point of fracture. Considerable improve- ment has since taken place. Figure 1 h of the plate shows the scar of the leg more in detail. Insurance allowance, when discharged, 50%. Fractures of the Leg in Its Middle Third and Lower Half. — These fractures are usually due to direct violence, and are met with as a result of many different accidents. Wheels in passing over the leg may break it ; it may be struck by heavy falling objects, violently com- pressed, or, again, may be fractured by a fall from a height, etc. All varieties of the lesion are seen, from a simple trans- verse to the most extensive comminuted fracture. The symptoms subsequent to consolidation are as follows : The bone is thickened at the point of fracture; some- times the leg, from the knee to the tips of the toes, is swollen and cyanosed ; it is shortened and the fragments are dis])laced forward, backward, or to the sides ; the knee and pelvis are lower on the affected side ; the muscles of the whole extremity are atrophied and there is difficulty in walking, the patient being obliged to use crutches or a cane for a time. Compound fractures are further character- ized by scars and cicatricial adhesions. lab. :i(>. . Anst K ReichhvUl. Minrhcri Fig. 79. 426 DISEASES CAUSED BY ACCIDENTS. Displacement is secondarily manifested in the knee- joint and ankle-joint by a position of valgus or varus or by overextension. Genu reeurvatum and talipes equinus or talipes calcaneus are not often seen. Abnormalities of position are dis})layed in the foot itself, as well as in the ankle-joint and malleoli. Restricted mobility of both knee-joint and ankle-joint is a frequent symptom. Pain is complained of for a long time, especially after exertion or when the weather suddenly changes. The treatment is symj)tomatic. If the leg is much shortened, a laced siioe with a raised sole should be worn ; if the patient is unable to bear his weight on the leg, a re- movable plaster cast should be tried. These removable casts are constantly in use in my clinic, and render valuable service ; they are very light, are easily put on and removed, and frequently take the place of a more expensive support. The leg and whole extremity should be massaged regu- larly ; electricity and baths are also beneficial. Insurance allowance from 20^, to 50^, or more, ac- cording to the functional disability. If the patient has to depend on a cane for walking, the rate can not well be made less than 50^;. In some cases it can be lowered by supplying the patient with a good supporting appa- ratus. Cam' offmclHi-e of the left leg. (Fig. 79, p. 425. ) A painter, twenty-tliiee years of age, fell from a scaffolding on May 9, 189H, breaking his right leg. He was treated in the hospital until June 10, 189i-<, and subsequently attended my clinic from July 29, until October 18, 1H98. The symptoms, in addition to swelling, were marked thickening at the point of fracture, shortening, and genu val- gum. At first there was considerable lameness, but at the time of the patient's discharge this had disappeared, and his gait was excellent. The skiagraph shows the condition of the bone at the time of discharge from treatment. Insurance allowance, 2.5% until March 10, 1899, when it was entirely discontinued, the patient ha\ing fully recovered. Case of fracture of the left teg due to a fall from a height, in which the fibula healed very sloroly. ( Fig. 80, p. 427. ) A carpenter, thirtv-five vears of age. fell from a scaffolding six feet high on October 15, 1894, breaking the left leg in its lower half. The leg was very edematous at first, and was shortened ; the knee was over- Fig. SO. 428 DISEASES CAUSED BY ACCIDENTS. extended. In addition, the fragments of the fihnla failed to unite for nearly a year. The patient was under treatment until December 21, Fig. 81. 1895; at that time the limb was in a much more normal position. The insurance allowance was at first fixed at 45 % : reduced, after com- Fig. 82. 430 DISEASES CAUSED BY ACCIDENTS. plete consolidation of the fibula, to 20%, at which rate it has con- tinued. The man is unable to work at his trade, and has become a cab-driver. Case of compound fracture of the right leg. Sequels: marked back- ward displacement; a moderate degree of genu recurvatum; .severe functional disability. ( Fig. 81, p. 428, and Fig. 82, p. 429. ) A polisher, sixty-three years of age, fell from a scaffolding about six feet high on January 21, 1889, sustaining a compound, comminuted fracture of the right leg. The lower fragments pierced the calf. He was treated at first in a hospital; subsequently at his home, until October 23, 1890. The wound continued to suppurate and fragments of bone to be throAvn off for a long time; finally healing took place, leaving scars which were adherent to the J)one, lioth l>ehind, over the calf, and in front, over the tibia. The illustration shows the shorten- ing, the curvature of the bone Ijackward, and the adherent scar over the tibia; also the forward displacement of the foot at the ankle-joint. In the skiagraph the union between the tibia and fibula and tlie dis- placement of the bones backward are distinctly displa^'ed. Insurance allowance, 100%. The patient is obliged to use two canes in walking. Fracture of the leg in its Imver-half followed by marked displacem.ent, genu valgum., and talipes valgus. A carpenter, forty-four years of age, sustained a fracture of the left leg on August 13, 1891, caused hy its being caught l)etween two iron beams. He was treated in the hospital, where the leg was kept in plaster for seven weeks, afterward attending my clinic from November 14, 1891, until January 21, 1892. The leg was much shortened; the lower fragment, together with the foot, \\as displaced out\vard to a striking degree, and the bones at the point of fracture \\ere greatly thickened. Genu valgum and talipes valgus were also present. The leg was atrophied. Insurance allowance, 20%. The man is able to do most of tlie work appertaining to his trade. The skiagraph (Fig. 83, p. 431) illustrates the case of a workman, thirty-four years of age, who fell out of a second-story window on July 5, 1897, sustaining a severe comminuted fracture of the right leg and fracture of l)oth ankles. On tlie right side the fracture involved the malleoli, and on the left, the malleoli and the os calcis. The manner in which union took place in the fracture of the leg is beautifully exhibited in the skiagraph. The accomi)anying picture (Fig. 84, p. 432) shows the bony thickening at the point of fracture. The patient remained in the hosjjital until August 30, 1897, his course of treat- ment with me lasting until August 11, 1898. When discharged, he was granted 50% insurance allowance, raised to 75% by the court, at which rate it has continued. Case of pseudo-arthrosis of the tibia and reunited fracture of the fihida. (Fig. 85," p. 433, and Fig. 86, p. 435. ) A ma,s()n, thirty ye£irs of age, sustained, among other injuries, a fracture of tlie leg caused by a blow from an iron girder, on October 16, 1889. He was treated in the hospital for a littk' over one year, being then discharged at his wife's request. A plaster cast \vas applied for eight weeks, the subsequent treatment consisting of baths and Fiy. «:;. 432 DISEASES CA USED BY A CCI DENTS. electricity. Figure 85 shows the scar, the point of fracture, the de- formity, and tlie thickening of the l)one; also the atrophy of both legs and the shortening of the affected one. The atrophy, especially of the left buttock, is very noticeable in the rear view. In the skiagraph (Fig. 86, p. 435) the pseudo-artlirosis, the bony thickening, and the backward displacement of the fragments of the fil)ula are clearly Fig. 84. visible. The patient wears a supporting apparatus and walks with a cane. Insurance allowance, 100%, partly based on a badly healed fracture of the radius. There lias been no improvement up to the present time. The accompanying illustrations were made at the beginning of 1899. FRACTURES OF THE LEG. 433 The skiagraph (Fig. 87, p. 436) illustrates the case of a workman, twenty-one years of age, in whom the tibia was broken on June 3, Fig. 85. 1897, by a blow from an iron column ^vhich struck it in falling. He was treated in the hospital until September 2, 1897, and subsequently in my 434 DISEASES CAUSED BY ACCIDENTS. clinic until January 14, 1898. The symptoms were shortening, genu valgiini, talipes valgus, swelling, lameness, and atrophy. At the time of the patient's discharge the malposition of the knee-joint and ankle-joint had almost disappeared, the swelling had largely subsided, and the atrophy was only slightly marked. The skiagraph was taken at that time. It was not until a year later that an X-ray examination showed the fracture to be completely healed. The man is uov\' able to do any kind of hard work, and receives no insurance allowance. Fractures of the Shaft of the Tibia. — These frac- tures, involving the middle of the l)one or its lower half, occur under the same conditions as the fractures of both bones of the leg at these points. The symptoms, too, are very similar ; the displacement, however, is usually much less marked. Displacement of the fragments of the tibia causes a secondary malposition of the lower and upper tibiofibular joints, which is likely to interfere with the action of the ankle-joint. Insurance allowance, from 20^ to ^S^fc, or more. If the patient subsequently regains good use of the leg, and it is only slightly shortened, the insurance allowance is altogether discontinued. In cases of fracture of the fibula alone, the displace- ment is most unfavorably manifested at the inferior tibio- fibular joint ; talipes varus is quite a frequent sequel of the injury. Fractures of the leg sometimes heal in bad position in spite of careful treatment in the best hospitals. I have collected a consideral)le number of sucli cases, of many of which I have taken photographs or skiagraphs or made plaster models. Since poor results are seen even in hos- pitals in which the most improved methods and appli- ances are in use, we certainly have no riglit to jump to the conclusion that the local doctor is to blame when such cases are brought to us from the country. We must re- member that he may have had to contend with the con- ditions most unfavorable to success. Fractures of the lower tliird of the leg are quite fre- quently caused by turning the ankle. The patients are Fig. 87. Fig. 438 DISEASES CAUSED BY ACCIDENTS. often found to be sufferers from loeomotor ataxia the pre- vious symptoms of wliicli were not sufficiently marked to interfere with their work. We are usually able to observ^e a rapid development of the disease subsequently to the injury. The accident also occurs, however, in individuals who are apparently perfectly healthy. Crt.se of fracture of the right (ibid in its lower third caused by turning the ankle and followed bij very protracted reeovcri/, complicated by osteo- myelitis. (Fig. 88, p. 437.) A mason, forty-one years of age, slipped and fell to the floor in 1888. A fracture of the tibia was diagnosed, and the patient remained in bed for nineteen weeks. Suppuration took pla<>e one year later; a fistula formed and secpiestra were thrown off. The patient gradually became able to walk, but could do very little work. Suppura- tion continued for three years. Sub.secpiently the patient frequently suffered from an inflannnatory condition of the scar, which was adher- ent to the bone. No insurance allowance was granted, i^ there was no trade-accident involved. Figure 89, page 439, illustrates a case of reunited supramalleolar fnicture occurring in a workman forty-six years of age before the Acci- dent-insurance Law was passed. He remained in bed for four weeks, and two weeks later began to do light work. The fracture was com- pletely consolidated at the end of eight weeks, and gave no further trouble. Case of reunited fracture of the leg in Us lower third, with bitckward and lateral displacement of the fragments. (Fig. 90, p. 440.) The lateral displacement is clearly shown in the skiagraph. As a result of this displacement, the malleoli were pushed slightly forward, especially the internal malleolus; the change of position in the external malleolus was somewhat less marked. The leg was somewhat short- ened, genu \algum and talipes valgus were also slightly noticeable, and the moljility of both joints was somewhat restricted. Insurance allowance, from May 1'2, 1899, onward, "25;^. Fractures of the Leg in Its Lower Third in the Vicinity of the Ankle-joint. — Tliese fractures have a direct etfcct on the position aud functioual power of the aidatient still had to u.se a cane. 2. Separation of the Epiphyses. — This lesion, occur- ring at the lower extremity of the bones of the leg, is met with only in young people, as the result of turning Fig. 93. Fig. 94. FRACTUEEH OF THE TIBIA. 445 the ankle in sprino;ing from a wagon or from a lieight, or it may be caused by direct violence, such as a blow from a falling object. The damage is usually repaired quickly and perfectly ; in one case coming under my observation, in addition to the separation of the epiphyses, there was a fracture of the fibula, yet the patient, a boy of sixteen, Fig. 95. was able to resume work in precisely four weeks from the time of accident. Compression-fractures of the Lower End of the Tibia. — The cause is the same as of similar fractures of th(; upper end of the bone. The lesion may occur in con- nection with a compression-fracture of the os calcis or of a 446 DISEASES CAUSED BY ACCIDENTS. PLATE 37. Fig. 1. — Scars Situated in the Popliteal Space, on the Calf, and around the Ankle=joint, with Venous Congestion. The subject of this illustration, a workman, sixty-two years of age, suffered from a cellulitis of the right ankle and leg, following an abrasion of the skin. The scar in the popliteal space became greatly retracted, and would break open every time the knee was forcibly ex- tended. In consequence of this constant irritation new cicatricial tissue continiied to form, causing flexion of the knee. The patient was in my care from INIarch 19, until June IS, IRJtrt, when he was dis- charged with an insurance allowance of 40^, which he continues to receive. He regained complete ability to extend the knee without causing injury to the scar, but still comjilains of pain and heaviness in the leg. Fig. 2. — A workman, thirty-five years of age, was very severely scalded about the legs by boiling water on November 26, 1894. At the same time the boiler containing the water fell upon and crushed his legs, the left leg being more severely injured. The wounds remained open and suppurating for a long time. Skin-grafting was performed, and the patient was under treatment for nearly two years in all. Even after his discharge he was several times obliged to re- sume treatment. The illustration shows the extensive scars over the left leg and ankle. The ankle is quite stiff and the patient walks with two canes. Insurance allowance, 90^. During the past year his gait has im- proved. vertebra, and it is usually accompanied by fracture of the external malleolus. Suhsecjuent stiffness of the ankle-joint can be avoided by a timely diagnosis and appropriate prophylactic measures. The after-symptoms of the injury are as follows : The lower part of the leg and the ankle nnnain thick- ened, perhaps swollen ; the leg is shortened or the malleoli are displaced ; there may be talipes valgus or talipes varus ; the whole extremity shows signs of atrophy, the mobility of the ankle-j(Mnt is restricted and the gait is affected. In one case of compression-fracture of the os calcis and the lower end of the tibia, accompanied by frac- ture of the external malleolus the patient, a man of forty, and a liea\'y drinker, was incapacitated for work for a period of nine months. Tab.:) 7. \ Fiff.l. .f/> /V/.,^. /.it/i. A/IS/ /■' Hcxcliltolil . Miuirliiri PSEUD0-ARTHR0SI8 OF THE LEG. 447 Pseudo=arthrosis of the Leg. A false joint may develop after fracture of either one or both bones of the leg. When the tibia is involved, the usefulness of the leg is greatly impaired, although in exceptional cases workmen have been known to do their ordinary work in spite of the false joint. I once knew a mason — it was, to be sure, before the time of the Accident-insurance Law — wlio mounted a scailolding and performed the regular duties of his trade in spite of an unhealed fracture of the tibia. He kept the leg put up in plaster, Avhieh he himself prop- erly renewed. After the lapse of two years the Itones appeared to the patient to be firmly united. When I examined him, fifteen years later, on the occasion of another injury, I was able to confirm his observation. Pseudo-arthrosis of the leg gives rise to the following symptoms : A false point of motion is very apparent, both to the physician and to the patient himself. In order to use the leg in walking, the bones must be held in position by a supporting apjmratus or a firm bandage, and, in addition, the patient finds it necessary to use a cane. In cases of compound fracture the point of fracture is usually marked by an exostosis, to which the scar is adherent, and which is likely to increase gradually in size. The bones below the point of fracture — in other words, the lower fragment of the leg-bones, including the bones of the foot — are poorly nourished, hence the aifected foot is usually found smaller than the other and has a wasted a])pearance. The leg is also atrophied above the point of fracture, but less strikingly so. Tiie footprint is much reduced in size. For several months the skin of the aifected leg remains cyanotic and cool to the touch, especially below the point of fracture. As the cyanosis gradually disappears, the skin becomes abnormally pale ; this is most noticeable on the sole of the foot, and is permanent. The tem- perature of the skin also remains somewhat reduced. If the false joint is situated quite near the ankle-joint, 448 DISEASES CA USED BY ACCIDENTS. complete ankylosis of the latter may result. Occasionally pseudo-artlirosis is accomj)anied by a great deal of pain. Treatment. — When union is delayed, the patient should begin to walk early, the leg being properly sup- ported by a bandage or by an ajiparatus, ^vhile the usual treatment by massage, baths, and electricity is not neglected. Medicomechanical gymnastics should be practised, if possible. Insurance allowance : The rate is necessarily always high — from 50 % to 60 % or over. 6. INJURIES AND TRAUMATIC DISEASES OF THE FOOT AND ANKLE. ConHidcndions on Anatomy and Function. — The weight of the body is transmitted from the tiVjia to the foot, or rather to the astragalus, through which it is conveyed to the hones that rest upon the ground. When at rest, the dorsum of the foot jjresents a doultle convexity, and tlie plantar surface a double concavity. Its shape changes the moment the weight of the botly is put upon it; the convexity of the dorsal surface becoming decidedly diminished, while the plantar concavity sinks downward and assumes a simpler form; the outer liorder of the foot is pressed against the ground, causing the outer arch to disajipear. The metatarsal bones and phalanges are ])ushed foiward and are spread out to both sides in fan-sliape, making the foot ai)pear longer and broader. The foot in this jtosition is hollowed out underneath, in the sliape of a half dome, directed inward, while the two feet, when placed together with their inner borders in contact, form a complete dome. "Wlien the foot changes its shape, under the influence of the weight of the body, as previously described, the ligaments, tendons, and muscles are thereby ])ut on the stretch. This stretching process is limited by the reflex contraction of the muscles, especially of the short muscles of the foot. If the weight which the foot is called upon to sup])ort is excessive, or is too suddenly applied, the foot gives way at the point of gi-eatest pres.sure or of least resistance, and there results a rupture of the ligaments, or a fracture. The shape of the foot in the ditt'erent positions which it assumes in walking varies consideral)ly from that which characterizes it in the upright position when standing still. As an illustration, let us, without entering into details, take the position of the foot at one special moment in the series of movements executed in walking — when one foot rests on the ground in front in a ))osition of inversion, the knee of that leg being flexed, while the other foot, with knee ex- tended, is sujtported on the toes. The sha])e of the two feet at this moment is very different. The parts of the foot which especially eerve to preserve the balance of the body in standing are the posterior ANATOMY OF THE FOOT. 449 extremity of the os calcis and the heads of the first and fifth metatarsal bones. The action of these tliree parts accords with the mathematic tlieory of the preservation of balance by three bases of supjiort. According to the studies of H. v. Meyers, the arch of the foot finds its chief support anteriorly in the head of the third metatarsal bone, an assumption which he baone, being distinctly perceptible on the inner border of the foot. There is a slight degree of talipes valgus, and the outlines of the external malleolus can barely be discerned. Flexion and extension of the ankle-joint are relatively well preserved, but lateral movement is restricted. The muscles of the calf are usually found atrophied. It is often necessary for the patient to wear a laced boot with an appropriate pad ; in especially severe cases side sup- ports may also be required. Insurance allowance, from 20^ to 25^, on the average. Subluxation of the whole bono outward, witli conse- quent talipes varus, is also met with, l)ut less frequently than the form previously described, and usually occurs in 458 DISEASES CAUSED BY ACCIDENTS. connection with a fractnre of the external malleolns or shaft of the fibula. Unreiluced dislocations of the astragalus lead to serious functional disability, which is all the more marked if the lesion is complicated by a fracture. (Compare with Fractures.) Symptoms. — The deformity of the foot, especially at the ankle, is very striking; the leg is shortened or length- ened according to the form of dislocation ; the ankle is stiff, there is talipes valgus or varus, and the muscles of the whole extremity show signs of atrophy. Lameness is a marked symptom. Treatment. — Reduction should be performed by opera- tion. Insurance allowance, usually 50^ or more. Dislocations of the astragalus, when properly reduced, usually leave the joint in good condition. Adhesions, however, sometimes produce ankylosis, and lead to mus- cular atrophy. If the head of the astragalus is forced through the soft parts and skin, making a compound dislocation, there is, of course, the added danger of infection ; even if this is happily avoided, the subsequent stiffness is increased by the presence of an adherent scar. Other unfiivorable cases are followed by loose-jointed- ness. Typical Fractures of the Malleoli. (412 Cases.) Eversion-fractures, in which the fibula is fractured just above the external malleolus, and the internal malleolus is torn off by the tension of the deltoid ligament, are caused by the ankle being violently turned inward, the foot thus being everted and carried outward. The deformity char- acteristic of these fractures is a marked feature, even after consolidation takes place. FRACTURES OF THE iVALLEOLI. 459 Symptoms. — At the time when the patient is dis- missed from surgical treatment he is usually lame, and may be unable to walk at all without the support of one or even two canes. The injured foot and leg are congested and edematous, reddisli-blue in color, and frequently extremely cold to the touch. The whole ex- tremity, from the buttocks down, is noticeably atrophied. The foot often appears small, and narrowed across the toes and metatarsus in consequence of the atrophy of the muscles ; while the sole is soft, thin, and pale or slightly cyanotic. If the patient is placed on a high stool, with the feet parallel, the internal malleolus is seen to be much thickened and to project considerably ; it is also somewhat directed downward. The external malleolus ap- pears flattened and is raised in proportion as the inner one is depressed. Just above it a distinct depression is notice- able. In many cases the internal malleolus is found dis- placed forward, the external malleolus being displaced backward to a corresponding degree ; consequently, the inner border of the dorsum of the foot is more or less shortened. The astragalus, having lost the support of the deltoid ligament, sinks somewhat downward and inward, carrying the scaphoid with it. In short, we have a rota- tion of the foot by which its inner border is lowered and its outer border correspondingly raised. The articular surface of the tibia frequently becomes partly displaced from the trochlea of the astragalus, and the mobility of the ankle-joint is restricted or completely suspended. Of the movements of the joint, flexion and extension are rel- atively best preserved, lateral movement being much more seriously aff^ected. There is often distinct crepitus under the malleoli perceptible to the touch, and some- times loud enough to be heard at a distance. Lame- ness is a more or less well-marked symptom, and fre- quently depends not only on the deformity of the foot as previously descril)ed, but also on the malposition of the knee-joint and hip-joint that accompany it. This con- 460 DISEASES CAUSED BY ACCIDENTS. sists of genu valgum, together witJi flexion and inward rotation of the leg, and inward rotation of the head of the femur. The after-treatment for these typietd malleolar fractures may extend over several months, or even a whole year if the individual is no longer young. A laced and padded shoe should be worn to prevent an increase of the deformity. Splints, by reliev- ing the foot of the weight of tlie body, sometimes render excellent service, and effect a more rapid cure than could otherwise be ac- complished. If the valgus is exti'eme and the patient is very stout, it is well to strengthen the inner l)ar of the splint by a small horizontal l)ar running from it to the iieel. This also adds considerably to the support of the foot. Massage, electric stinuda- tion of the muscles, and medico- mechanical exercises are also of great value. Insurance allowance, from 25^ to 33^, or more, depending on the deformity. Tlie accompanying picture (Fig. 98) illustratefs the case of a workman, thirty- four 3'ears of age, who .sustained a typical eversion-fracture of tlie internal malleolus caused hy a \\heel passing o\cr his left ankle. The inner malleolus is thickened and very prominent, the foot is displaced outward, and the muscles of the whole extremity, especially of the leg, are atrophied. Case of iypical ever>ii<)ti-frears of age, who had fallen from a scaffolding seven feet high on September 21, 1894, landing on the feet. He was treated at home at first, subse- quently attending my clinic from December 21, 1894, until August FRACTURES OF THE OS C ALOIS. 481 24, 1895. Insurance allowance, 33 j ^/r , which was reduced in October, 1898, to 25%. The accompanying sole-impressions (Fig 109, p. 482) illustrate the case of a carpenter, thirty -nine years of age, who sustained a compression- fracture of the right os calcis on December 18, 1893, as a result of a fall from a ladder. The heel sul)sequently became coiisideraJjly (broadened ; talipes varus and flat-foot developed. The impressions of the soles show the thickening of the heel and the difierence between the two soles, the outer Ijorder of the affected one approaching the outer boun- dary-line. Insurance allowance, 33j. fo Symptoms after con- solidation : At first the foot is swollen, especially around the ankle and over the heel, the swelling ex- tending to the leg as well. The OS calcis appears broadened, particularly at its posterior extremity, and the tubercles on its under surface may be thickened. Similar thickening of the astrag- alus and the malleoli is to be observed, if these were involved in the fracture. The leg is shortened in proportion to the loss of height of the os calcis, the malleoli lie on a lower plane than normally, and the depressions on either side of the tendo Achillis are filled out ; the anterior portion of the foot, especially its tip, is narrowed. More or less well-defined flat-foot is a common l)ut not an invariable symptom ; talipes valgus or varus or talipes planus varus are sometimes observed, more particularly in cases complicated by fracture of the malleoli. Added sym])toms are atrophy of the sole, cicatricial nodules in the plantar tascia, dis- 31 Fig. 108. Fig. 109. Fig. 110. 484 DISEASES CAUSED BY ACCIDENTS. location of the tendons of tlie pcronei opposite the external malleolns, atrophy of the muscles of the leg, especially of the calf, and, in most cases, muscular atrophy of the thigh and buttocks also. Paresthesia, such as sensations of cold, formication, venous congestion, etc., may also be in evi- dence. Flexion and extension of the ankle-joint are usually only slightly aifected, whereas rotatory movements, or circumduction, are restricted or quite suspended. In- version and eversion of the foot are likely to be more or less abolished, and if ossification takes place between the astragalus and os calcis, they can never be recovered. The gait is often very unnatural at first ; the foot is fre- quently held abducted in walking. Treatment. — From the first the patient sliould be warned by the surgeon against standing or walking until it is quite safe to use the injured foot. This is especially true of large, heavy individuals, in whom slow recovery and poor results are frequently attril)utable solely to neglect of this precaution. A shoe with side supports should be worn for a time ; if the under surface of the os calcis is thickened, this should be allowed for by an appropriate pad. If, nevertheless, relief is not afforded and the patient is unable to walk, the exuberant callus should be chiseled off. Vapor baths, electricity, and massage should be employed as usual. The patient may be sufficiently incapacitated for work to warrant an insurance allowance of from 20^ to 50^, or even more ; if there is only slight difficulty in walking and standing, 20 fo should suffice. Case of fracture of the os calcis and dislocnfion of the external malleo- lus; also jmrtial fracture of the posterior extremifji of the os ealeis due to muscular action. (Fig. 110, p. 483.) A polisher, forty-eight years of age, fell from a scaffolding about five feet high on March 13, 1896. When I examined liim, on April 23, 1896, I found the left os calcis broader than normal, the malleoli somewhat thickened, and the external one displaced backward; the leg was slightly shortened, and there was a tendency to talii)es valgus. Step- ping on the foot caused pain in the os calcis; the foot could not be inverted and everted. The skiagraijh shows the line of fracture in the Fit;. 111. 486 DISEASES CAUSED BY ACCIDENTS. anterior portion of the os calcis very beantif ully ; it also shows a small portion of bone to be lacking from the upper part of the posterior extremity of the os calcis. The patient was nnder treatment from June 6, 1896, until January 25, 1897. Insurance allowance, at first, 50 fo ; reduced, on May 10, 1897, to 30%. Caac of fracture of the posterior extremitij of the os calcis due to mus- cular violence. In the skiagraph (Fig. Ill, \). 485) we can see the gap in the pos- terior extremity of the os calcis. The lesion occurred on January 21, 1897, when the patient, a mason, thirty-eight years of age, fell from a scaffolding about five feet high. He was treated at home with com- presses and inunctions, remaining in bed for a week. The course of after-treatment lasted until August 21, 1897, when he was discharged with an insurance allowance of 25 % . He was af ter\\ard able to do the regular work of a mason without difficulty. His allowance was reduced to 15% in June, 1898, and has since then been entirely dis- continued. The symptoms were slight stiffness of the left ankle-joint and slight atrophy of the leg. In the summer of 1897 the gap in the OS calcis was much larger than it appears in the skiagraph, reacliingto about the middle of the Ijone, and the posterior extremity of the bone presented a distinct callosity. The posterior extremity of the os calcis is sometimes broken off by violent contraction of the mnscles of the calf in connection with a fall or blow on the heel, the lesion being primarily dne to the direct violence. The bone subseqnently becomes considerably thickened from above downward and the tendo Achillis passes upward over it in a curved line, with tlic concavity of the curve directed upward. If a skiao;i'a])h is taken, we see a tri- angular interval in the bone, in shape like an " ojxii duck- bill." Pressure of the shoe on the skin over the thick- ened bone is likely to produce an ulcer or a callosity. Unless there arc complications, the working capacity of the patient is usually l)ut slightly affected. In some cases of transverse fracture of the os calcis the posterior fragment is drawn upward, its sharp-edged end being so directed downward as to make walking painful or even impossible. If the OS calcis resists the violent contraction of the calf muscles, the muscles themselves may give way in- stead, the rupture usually occurring at the point of their insertion into the tendo Achillis. In some cases we find FRACTURES OF THE OS C ALOIS. 487 the muscle ruptured and the broken extremity of the os calcis dispkiced upward at the same time. The point of rupture in the calf is marked by a thick- ening of the muscles or by an interval between the rup- tured portions. In the first instance we find a contracture of the muscles and flexion of the knee, causing a certain degree of talipes equinus ; in the second the ruptured muscle becomes extremely atrophied. Shortening of the sole of the foot, or, rather, a diminution of the surface used in walking, is a characteristic symptom of upward displacement of the posterior extremity of the OS calcis. This is best demonstrated l)y an impres- sion of the sole made on paper coated with lamp- black. 'a^ ;I 4 '■iu K » f'^;, Case of fracture of the posterior If H extremity of the os calcis, due to muscular violence, accompanied by partial rupture of the muscles of the calf at the point of their inser- tion into the tendo Achillis. (Fig. 112.) A workman, fifty-four years of age, sustained the foregoing ^^ _, injuries on April 27, 1895, when, '°' in throwing liimself backA\ard on a wall from which he was in danger of falling, he struck his right heel against a slab of granite. The illustration shows the thickened extremity of the os calcis and the increased size of the tendo Achillis; also the atrophy of the calf muscles. In addition, the knee being held somewhat flexed, tlie patient was unable to extend it completely; flexion and extension of tlie ankle-joint wej-e limited, and the sole of the foot was atrophied. He walked with a limp. The course of treatment lasted from June 4, 1895, until December 21, 1895. The ankylosis of the knee and limited i)ower of extension were entirely- cured. Insurance allowance, 33j%. The accompanying sole-impressions (Figs. 113 and 114, p. 489) illus- 488 DISEASES CAUSED BY ACCIDENTS. trate the ca.se of a workman, thirty-eight years of age, who fractured the posterior extremity of the right os calcis by slipping from a board on December 10, 1895. The fracture was accompanied by marked up- ward displacement. The impression in figure 113 shows the limited use of the heel in walking, in consideration of which an insurance allowance of 50% was granted by the court. Walking was very diffi- cult at first, but became quite easy later on. On April 17, 1897, the patient again injured the same foot, on this occasion sustaining a fracture of both malleoli, as well as a fracture of the OS calcis. This injury liad an excellent result, as shown by figure 114, the foot regaining an almost normal position for walking. The insurance allowance was therefore reduced to 15%. Fractures of the greater process usually occur iu con- nection with fractures of the body. If its articular sur- face is involved, the calcaneocuboid joint is likely to remain ankylosed, entailing a permanent loss of the move- ments of inversion and eversion of the foot. In rare instances a severe sprain may cause a fracture of the greater process alone. Fractures of the sustentaculum tali are frequently ob- served as an accompaniment of the so-called comj^res- sion-fractures previously described. They may occur as separate lesions, although infrequently ; I have myself, however, seen a number of such cases. The functional importance of this fracture is easily explained by the anatomic relations of the process. If the whole process is broken off, — which is fortunately a very rare accident, — the astragalus is deprived of its su})port, and slips down- ward and inward, causing the foot to become everted. The inferior calcaneoscaphoid ligament is partly torn, or, at any rate, becomes relaxed, and the deltoid ligament is also lacerated. In consequence of these injuries to the ligaments passing from the os calcis to the scaphoid, the latter bone lacks proper support. There is always danger of injury to the tendon of the flexor communis digitorum, which passes down on the border of the sustentaculum, and to that of the flexor longus pollicis, which runs in a groove on its under surface. If the sustentaculum is badly crushed, the tendons are likely to be overgrown by 490 DISEASES CAUSED BY ACCIDENTS. callus, leading to contracture of the toes. found a well-marked hallux flexus. In one case I Case of comminuted fracture of the sufttentaculum tali and the internal matlcolus. (Fig. 11.5.) Sequel, serious loss of functional power, due to contracture of the great toe. A workman, thirty-nine years of age, was injured on August ^, Fig. 115. 1894, by a stone falling from the height of one story, striking the internal malleolus of his right foot. He was treated at home by the lodge doctor, lying in bed for five weeks; for three months afterward he remained without medical julvice. He was in my care from Feb- ruary 18, 1895, until July 17, 1H95. Tliere was a marked growth of callus around and below the internal malleolus, and the great toe was so much flexed as to make the end touch the ground. The patient's condition has gi'adually grown worse, and he is now unable to tread FRACTURES OF THE OS C ALOIS. 491 on the whole sole of the foot. The other toes have become contracted as well and the foot has grown more and more deformed. The portion of the sole used in walking is shown in the accompanying impression. (Fig. 115, p. 490.) Insurance allowance, 'i'iz'A- These contractures may very seriously interfere with the usefuhiess of the foot. Amputation of the oifending toes is the best treatment ; but if the patient objects, a laced shoe, appro})riately shaped and padded, affords a certain amount of relief. The fracture leaves the sustentaculum thickened, as is evidenced by a prominence below the internal malleolus. The posterior process of the astragalus is usually fractured at the same time, and, if so, it is also thickened. The foot and whole extremity aj)pear atrophied ; rotatory move- ments, including inyersion and eversion, are abolished, and flexion and extension at the ankle-joint are restricted. Bony union between the os calcis and astragalus takes place regularly after fracture of the sustentaculum, as well as after compression-fractures of the os calcis ; and, in addition, the ligaments connecting the bones — the inter- osseous ligament in the interosseous groove, for instance — may undergo ossification. Tiie insurance allowance in severe cases amounts to from 30^ to 50/^, or more; in light cases, from 15^ to Fracture of tiie internal tul)ercle on the inferior sur- face of the OS calcis is a very interesting lesion, both from an etiologic and a functional standpoint. The tubercle is pulled forward by the strong plantar muscles and the tense ligaments which are attached to it, appearing at the middle of the under surface of the bone as a rounded, thick, bony ])rominence, making walking very painful and difficult. As early as 1895 I called attention to these fractures at the Conven- tion of Scientists at Llibeok. Thiem at that time denied their occur- rence. Affirmative proofs were subsequently furnished by Ehret in an article published in the " Archiv fiir Unfallheilkunde," volume I. One such aise has occurred in my practice. 492 DISEASES CAUSED BY ACCIDENTS. Case of fracture of the internal tuhercJe of the os calcis, consequent upon a fill, leadin;/ to sliyht functional (lisabiliti/. The thickened tubercle is shown in the accompanying illustration. The condition is most noticeable with the feet placed parallel, as in figure 116. The tubercle was carried for\\ard by the plantar muscles after its separation. Insurance allowance since August, 1898, 20%. It is unuecessary to speak further of the symptoms of the lesion, as they are essentially similar to those refen-ed to in connection with the transverse fractures of the bone and the subsequent thickening of its lower surface. Separation of the tubercle on the external surface of the OS calcis may accompany fracture of the body, or, in very rare cases, may occur alone as a result of direct violence. The development of the tubercle is very much an individual matter ; it is entirely lacking in some cases, while in others it forms a marked prominence. Sometimes there are two tubercles, and Hyrtl has even observed three. The tubercle most constantly present is the larger one, lying below the external malleolus ; the tendon of the ]ieroneus longus passes down behind it, and it is conceivable that it might pull off the tubercle, if the latter ^'s- 116. were of large size and the foot were very for- cibly su])inated. It is, however, out of the question for the tubercle into which the calcaueofibular division of the ex- ternal lateral ligament is inserted to be separated by traction on the part of the latter. I liave never seen a case of indirect fracture of this tubercle myself, although I have known it to be broken off by direct violence — in one case by a blow from a falling stone, and in another, by falling Fig. 117. 494 DISEASES CAUSED BY ACCIDENTS. and striking the outer side of the foot on a sharp-edged stone. In a case in which the tendons of the peronei had become involved in the calhis there was spasm of the an- tagonistic muscles of the leg, causing a talipes varus and making the foot almost useless. The outcome is more favorable when the peronei form for themselves a groove in the callus in which they can glide. A very unusual accident is cited below, with an illus- tration (Fig. 118), in which the os calcis was fractured by a stroke of lightning. Ca.'ie of spontaneous fractitre of the os calcis {compression-frncture). Predisposin<>; cause, tuberculosis of the os calcis; exciting cause, un- known. (Fig. 117, p. 493.) A workman, thirty-nine years of age, while carrying a load of stones, suddenly felt a pain in the right foot. He also noticed that the foot appeared swollen. He began medical treatment and applied for insurance allowance. I took a skiagraph of the foot on July 7, 1897. A diagnosis was thereujjon made of tuberculosis. The patient Avas small, delicate, and poorly nourished. The lungs were normal. At the time of my examination the f frequently than complete dis- location ; splinters are apt to be chijiped off the adjacent bones at the same time. The lesion is caused by direct violence when heavy objects fall on the foot, displacing the bone downward. Indirectly, it occurs when a person catches the toes in an oj)ening and falls over backward, thus forcibly bending the foot. Subluxation, too, is most often met with in the first cuneiform bone. In cases of downward displacement our attention is first attracted to the lesion by the prominence of the scaphoid or the base of the first metatarsal bone on the back of the foot ; the first cuneiform can be felt to jn'oject on the ])lantar surfac(>, and is usually sensitive to pressure. The inner bordei- of the foot remains swollen for some time, and if the foot is only slightly arched, the patient avoids stej)ping on it, and walks on the outer part of the sole. If the arch is a high one, tlusre is no abnormality of gait, but standing for any length of time or carrying heavy weights becomes painful. DISLOCATION OF THE CUBOID. 503 The toes remain stiif for a time, especially the great toe, and the plantar muscles are temporarily atrophied. Considerable relief is afibrded the patient by a suitable shoe. Insurance allowance, from 15^ to 25^, or more. In cases of upward dis[)lacement the symptoms are similar, except that the dorsum of the foot appears ab- normally prominent and no projection is felt on the sole. Dislocation of the Cuboid. (The Cuboid Was Injured in Twentj'-two of My Cases.) Complete dislocation of the cuboid is a very unusual lesion. Subluxation occurs more often ; it is observed when the back of the foot is crushed, especially when it is com- pressed between two objects, and violent efforts are made to extricate it. When the bone is displaced upward, it appears as a distinct prominence on the outer border of the foot. The belly of the extensor comnumis brevis stands out more distinctly than on the uninjured foot, and the outer toes are somewhat extended by the tension of their respective tendons. There may be talipes varus, the patient walking on the outer border of the foot, but in some cases we find talipes valgus. Downward dis- placement leaves a depression on the outer side of the back of the foot, and the foot is held everted. Patients usually complain of pain on the outer part of the back of the foot, and along its outer border, running across the sole to the point of insertion of the ])eroneus longus. A laced shoe, appropriately padded, will some- what relieve the pain and discomfort experienced on stand- ing and walking, wliich are also favorably affected by massage and medicomechanical exercises systematically carried out. Operative interference is sometimes indi- cated. The rule for all except the most severe cases is that the symptoms entirely disappear by the end of six months. Insurance allowance, from 20^ to 33^^. 504 DISEASES CAUSED BY ACCIDENTS. The dislocation-fractures of the cuboid are usually mul- tiple or conuiiiuutcd, occurriuo; when the foot is badly crushed. The fragments are likely to be displaced (piite irregularly. Fractures of the Cuboid. Direct violence to the foot in cases of caving-in accidents or when the foot is struck by heavy falling objects, or oc- curring in the form of a fall or leap from a height, is the usual cause of these fractures. They generally involve the adjacent bones ; the tubercle on the base of the fifth meta- tarsal bone is most likely to suffer ; the greater process of the OS calcis, however, and the bases of the fourth and fifth metatarsals are usually fractured also. The subse({uent thickening of the bone is most percep- tible through the sole of the foot, which is held everted in walking, partly because of the pain caused by pressure, partly because of the j)r()minence of the bone on the outer border. The strain put on the tendon of the peroneus longus by the maintenance of this position is likely to cause an irritation or inflammation of the latter. In some cases, however, this is to be attributed to direct injury from pressure of the callus. Genu valgum is frequently observed. The patient should wear a shoe so made as to relieve the cuboid from pressure. Dislocation and Subluxation of the Metatarsal Bones. Partial dislocation of the metatarsal bones at their basal extremities occurs under the same conditions as do similar lesions of the cuboid, and gives rise to almost identical symptoms. The disj)lacement may be upward or down- ward. Uj)ward displacement of the bases of all five metatarsal bones ])rodu('es talij)(^s cavus, shortening the foot. Displacement downward brings about the opposite condition of flat-foot. If the head of one or more of the metatarsal bones is dislocated downward, its base may be DISLOCATIONS OF THE METATARSUS. 505 proportionately displaced uj)\vard. In such a case the patient always complains of pain on bearing his weight on the foot, and tries to avoid stepping on the painful part. If the fourth metatarsals are involved, therefore, the foot will be held everted in walking. The position of the heads is indicated by a rounded eminence on the sole of the foot, and the affected toes are usually fixed in more or less pronounced extension. The gait is affected in proportion to the deformity. A laced shoe, padded to allow for the projection of the dislocated bones on the tread, is a very necessary requirement. The average insurance allowance is 20 ^ . The symptoms which develop when the heads of the metatarsal bones are displaced u})ward have an even more unfavorable influence on the ability of the patient to walk or stand. The affected toes are usually flexed. Lateral dislocation of individual metatarsal bones is possible only in the case of the first and fifth, and occurs, doubtless, in all cases in connection with fracture of their bases. Unless the dislocation or subluxation is completely reduced, the foot becomes abnormally broad, or flat-foot may develop. In case of inward dislocation of the first metatarsal bone tlie foot is narrowed in the middle of its transverse arch. The joint between the first meta- tarsal and the first cuneiform becomes enlarged, and per- haps inflamed. AVe occasionally meet with lateral dislocation of the metatarsal bones as a whole at the tarsometatarsal joints in connection with fracture of the latter. The metatarsal bones usually remain displaced either outward or inward, and flat-foot or club-foot is likely to develop. Walking is very difficult for a time, and a well fitting and properly padded laced shoe is an important factor in restoring the usefulness of the foot. Insurance allowance, from 25^ to 33^^. 506 DISEASES CAUSED BY ACCIDENTS. PLATE 39. Fig. 1. — A workman, thirty-eight years of age, sustained a compound fracture of tlie bones of all five toes of the right foot on November 1, 1897, caused by tliree Ijeams falling upon the l)ack of the foot. The first t\\o toes had to be amputated. The contracture of the re- maining three toes and the extensive scars on the back of the foot are shown in the illustration. The skin appears cyanotic. The skiagraph (Fig. 124, p. 508) sho^^•s the fractures of the metatarsal bones and the position in which the heads of these bones became consolidated. The extreme degree to which the foot was shortened is shown in the sole- impressions of figure 123, page 507. Insurance allowance, 33^%. Fig. 2. — This illustrates the case of a workman, twenty-eight years of age, the great toe of whose left foot was fractured on November 18, 1897, by the fall of an iron bolt. The fracture was compound. The line of fracture is visilde in the accompanying skiagraph. (Fig. 125, p. 509.) The scar over the metatarsophalangeal joint of the great toe, the glossy skin of the part, and the I'etraction of the scar, throwing the skin into radiating folds, are shown in figure 2. It was at first ^•ery difficult for the patient to place the inner border of the foot to the ground, on account of the protrusion of the ball of the great toe. The appearance of the foot at the time of the patient's dis- charge, on Augiist 6, 1898, was identical with this illustration, but the gait was excellent. Insurance allowance, 33^ ^ , at first, advanced by the court to 50% ; in February, 1899, it was reduced to 20%. Fractures of the Metatarsal Bones. (112 Cases.) These fractures are of fre(jiient occurrence in the build- ing and allied trades, in which the foot is exposed to injury i'vom falling objects. They are usually of the direct variety, and often pass unrecognized under the diagnosis of " crushed foot." Indirect fractures are caused by turning the ankle, especially when a workman, in carrying a heavy load, catches the foot in something, in Avhich case the fourth and fifth metatarsals are most likely to be the seat of fracture. The second and third are less frequently involved. Sometimes the fracture occurs as the ivsiilt of putting tiie foot down very heavily to mark time in marching. Direct fractures of the first three metatarsal bones lead to the development of flat-foot. This is the necessary CO I FRACTURES OF THE METATARSUS. 507 consequence of the lesion, caused, as it is, bv the impact of a heavy object on the posterior extremity of the bones, since these do not rest on the ground, l)ut rely for their support on the various ligaments which maintain the shape of the arch. Fi'actures of the first metatarsal bone are likely to lead to deformities which seriously interfere with the usefulness Fig. 123. of the foot. This is especially the case when one or l)otli fragments are displaced downward. Consolidation is ac- companied by a well-marked growth of callus, which adds to tiie deformity — the more so tiie nearer the fracture lies to the so-callo heads of the metatarsal bones into the metatarsophalangeal joints, ankylosis of the latter is an invariable sequel. After fracture of the fifth metatarsal bone, accompanied by lateral dislocation, the foot becomes broadened, as in cases of fracture of the first metatarsal bone. I have seen two cases in which separation of the tubercle at the base of the fifth metatarsal bone formed the sole lesion. One patient was a workman, about forty-five years old, who had caught his foot in a roof-gutter, and had fallen down on the roof. He did not stop work. The other case occurred in a tall, heavily built hod- carrier, who had fallen from a ladder. He remained in bed for six weeks, as walking was painful, but resumed work soon afterward. Fig. 132. 620 DISEASES CAUSED BY ACCIDENTS. Traumatic Flat=foot. Notwithstanding the tact that the traumatic develop- ment of flat-foot does not accord witli tlie ordinary theory of origin of the deformity, it seems proper to use this term when the arch of the foot, in consequence of trau- matism, becomes so much lowered as to allow it to touch the ground in walking. This condition is met with after fractures involving the bones of the inner arch (os calcis, scaphoid, cuneiform bones, and first to third metatarsal bones). Traumatic flat-foot gives rise to the same painful symptoms as the nontraumatic variety. The treatment, besides wearing an aj)propriate shoe, in- cludes massage, baths, etc. The rate of insurance allowance is estimated according to the functional disability ; as a rule, it amounts to from 25 fo to 33^ '/o or more. Flat-foot (talipes planus) is to be distinguished from talipes valgus, which -is a different deformity, although it may represent a ])reliminary stage of tiie former. The term is sometimes loosely applied in describing a condi- tion which in reality is a valgus. In old cases of flat-foot, giving no trouble whatever, a sprained ankle or severe contusion may cause the develop- ment of all the acute symptoms of a recent case of trau- matic origin, requiring the same careful treatment and entitling the })atient to the same insurance allowance. Such a case is covered by the clause relative to the exacer- bation of a chronic disorder in consequence of an acci- dent. The sole-impressions shown in figure 185, page 522, ilhistrate the case of a mason, sixty-fonr years of age, who fell from u scaffolding on September IS, 181)3, sustaining a typical inversion-fracture of the ankle- joint. As talipes varus existed to an extreme degree, and the ankle was completely stiff, an o])eration was performed in the hos])ital for the substitution of a tali])es \algus. I'lie foot remained in i)laster for eighteen weeks. At the time at which I examined the patient only TBA UMA TIG FLA T-FOO T. 523 the inner border of the foot ^\as used in walking, as is shown in the accompanying impression. (Fig. 11^7.) The patient is still obliged to use a cane; the ankle and leg remain greatly swollen and the ankle is completely ankylosed. He receives 100^ insurance allowance, partly in consideration of his advanced years. The sole-impressions shown in figure 136, page 522, are taken from the case of a carpenter, thirty -four years of age, who leaped from a wall one story high on November 5, 1897, spraining the right ankle. ¥\g. 1.37. This lesion was accompanied by a dislocation of the inferior tibio- fil)u]ar articulation and a fracture of the external malleolus. When 1 examined the patient, on Decendier l(i, 1>''!)7, I found a marked ease of tali])es varus; the toes did not touch the grotind. The portion of the sole used in walkhig is shown in the accom])anying im- pression. (Fig. 136.) There was a slight genu valgum, and the muscles of the foot and legajjpeared atrophii'd. The i)atient was under treatment until July 29, ls<)S, when he was discharged with 50 '/< in- surance allowance. His gait had somewhat improved. 524 DISEASES CAUSED BY ACCIDENTS. PLATE 40. Fig. 1. — A potter, forty-tliree years of age, on Septenilier 9, 1897, fell, with the ladder on wliicli he was standing, a piece of iron falling on his foot at the same time. The contused wound over the point of origin of the extensor communis brevis became the seat of an adherent scar, which interfereil with flexion of the toes for a consid- erable length of time. Insurance allowance, 30%, partly on account of the atrophy of the foot; this was reduced in June, 1899, to 15%. The patient was under treatment for a full half year. Fig. 2. — A painter, thirty-nine years of age, fell from a scaffolding on September 10, 1897, sustaining a compound dislocation-fracture of the astragalus. He was treated in the liospital, where a plaster cast was applied. A club-foot resulted, and the leg was lengthened by the malposition of the tibia on the astragalus, the margins of the lower articular surface of the former resting across the margins of the trochlea of the latter. The ankle-joint was entirely stiffened and the leg was greatly atrophied. The illustration shows a convex prominence be- tween the leg and the l)ack of the foot and the scar on the outer side of the ankle. In the skiagraph (Fig. Il5r2) is seen the displacement at the ankle-joint and the projection of the head of the astragalus. The comparison between the sole-impressions taken at the commence- ment and at the end of the medicomechanical course of treatment is very interesting. When the patient entered my hospital, on March 28,'lH98, he Avas unable to stand with the feet placed parallel, but was obliged to put the right foot in front of the left. Very little of the foot was used in walking, as is shown in figure 133, page 521, in which the extreme degree of talipes varus that existed can also be recognized. When discliarged, on August (5, 1H9H, the varus liad been overcome to a consi(leral)le degree, the feet could be placed parallel, and the gait was strikingly improved. (Fig. 134, p. 521.) Insurance allowance, 75%. The skiagraph taken at the time of his discharge showed the ex- ternal malleolus to be entirely disj)laced from the tibia at the inferior til)iofibular joint; the anterior extremity of the os calcis was disjjlaced upward at the calcaneocuboid joint; the head of the astragalus was also displaced tip ward, and the tibia was slightly rotated on the tnx'hlea of the astragalus. Tlic insurance allowance was reduced in IMarch, 1^99, to 30/.. The sole-impressions shown in figure 137, page 523, illustrate the case of a mason, thirty-three years of age, who stei)])ed on a small stone and sprained his ankle on Decendjer 12, 189(5. In addition to the sprain, there was a dislocation of the external malleolus and a slight splintering of the greater process of the os calcis. When I examined the patient later on, there was marked talipes varus; the patient walked entirely on the outer edge of his foot, which, in addition, presented internally a concave, and externally a TabAo. Fitj.l. "> FiffJ^. TEA UMA TIC CL UB-FOO T. 525 convex, deformity. The skiagraph shoAvs a t^T^ica! displacement of the ankle-joint, niid-tarsal joint, and inferior tibiofibular joint. The part remained extremely painful for a long time, and the atrophy of the whole extremity \vas very persistent. The patient was discharged on September 24, 1><97, with an insurance allowance of oOVc, reduced in April, 189S, to 2(1%, the condition of the foot having gradually im- proved. There has been no change as to rate since that time. Traumatic Club=foot. This develops as a setjuel of fracture or dislocation of the astragalus (outward dislocation), fracture of the os calcis and astragalus both, or fracture of the metatarsus. The most striking deformities are seen after fractures of the os calcis and astragalus or after disloc^ation-frac- tures of the latter. ( See Plate 40, Fig. 2. ) True club-foot must be dis- tinguished from talipes varus, which may e.xist without constitut- ing a club-foot. Functional disability is ustially extreme in cases of traumatic chd> foot, and a long couise of treatment is required. Insurance allowance, from 33A% to 50%. The suljject of the accompany- ing illustration (Fig. 138) was a workman, forty years of age. who sustained a comminuted fracture of the internal malleolus and the sustentaculum tali. The great toe gradually became flexed and contracted tt) such a degree that at the present time the nail touches the ground when the i)atient is standing. The muscles of the foot are greatly atrophied. Insurance Pi„ 133 allowance, 33J%, at first; at pres- ent it is 50 % . Ca^c of tmumnlic Uilipcs rarm and flat-foot caused by fracture of the second toe, irhirh lois suhseqnentltj removed, together with a jjortion of the Corresjio)idiin/ iik laliirsiil Ixiiie. The patient was a carpenter, fifty years of age, who was injured in Augtist, 1894, l)y a piece of wood' falling on the tip of his left foot. The talipes varus is marked; the third and fourth toes override the first; the extensor tendons appear very tense, especially that of the tibialis anticus, and the muscles of the leg are atrophied. Insurance allowance, 33^%. The condition of the jiatient is rather worse, if anything, than formerly. e526 DISEASES CAUSED BY ACCIDENTS. Case of left talipes irinis^ folloiriiii/ a fraeture of the left ley, irith dis- placement ancf slioiieitiiu/. (Fig. V.id, p. 5'27. ) A mason, t\vent,v-.se\-en years of age, feU from a ladder on Deeember 10, 1H!)2, fraotui'ing his left leg in its lower third. Tiie bones healed with lateral disi)la(ement, the convexity being directed outward, the concavity inward; there \va.s an extensive growth of callus and the leg was distinctly shortened. The patient was treated in the hospital for nine weeks, receiving sul)sequently an insurance allowance of 4t)'/r , reduced in Deceml)er, ls!)3, to 20yr. There has been no important change in his condition since that time. The sole-imjjressions (P'ig. 139) show the difference between the two feet very well; the left imprint is smaller than the right and the foot presents a curvature which is convex externally, conca\ e internally. The sole-impressions of tigure 140, page 5:37, show a slight talipes varus and atrophy of the foot, with Ci)nse(]uent decrease of size of the tread, following a fracture of the right thigii. Tlie bones were much displaced at the point of fracture, causing a well-marked genu varum. The jxitient was a workman, thirty-iive years of age, who was crushed by a wagon against an iron column. He was treated at home by splints and extension, and received a course of after-treatment in my hospital from October 24, 1898, until January 2^, 1899. Insurance allowance, 30;;^. Dislocations of the Toes. Unless reduced, tlie usefulness of the foot may bo con- siderably affected by these dislocations. Dorsal disloca- tion is the most frequent form, and is most often seen in the case of the great toe. Permanent upward displace- ment of any of the toes is always a serious matter. The ])atient is forced to pay great attention to his shoe, to see that it is properly shaped and well made; yet, even with this precaution, iujury of the skin over the ])rojectiug toes can not well be avoided, and abrasions frequently occur, requiring surgical treatment. The toes being more or less stiff, the mid-tarsal joint and ankle-joiut become secondarily aft'ected ; muscular atrophy, Ix'gimiiug in the foot, proceeds U})ward along the leg and thigh initil even the buttocks become wasted on the affected side. Patients complain of the foot feeling cold, es])ecially in winter. These sym])toms are in many cases gradually oxcrcome to a certain extent, but they never completely disapjiear. Permanent dislocation of the toes downward interferes 528 DISEASES CAUSED BY ACCIDENTS. greatly with walking and standing. This form of dislo- cation is most often seen in the fourth and fifth toes. The accompanying sole-impressions (Fig. 141 ) illustrate the case of a workman, tliirty-five years of age, who sustained a compound comminuted fracture of the toes and metatarsal bones of the right foot, Fig. 141. which was crushed under a heavy l>eam. A marked case of club-foot was the result. The great toe is displaced upward to a eonsideralile extent, and is (luitc stiff; the second and third toes had to be removed; the fourth and fifth are tightly flexed and touch the gi'ouud in walk- ing, Insurance allowance, 100;^, FRACTURES OF THE TOES. 529 Disarticulation leaves the foot much more useful than it can possibly be when the toes are permanently dislo- cated, and patients should be strongly advised to submit to this operation or to amputation of the toes. In cases of permanent partial or complete dislocation of the toes upward the working capacity is diminished by 33^^ to 50^, or over, and an equally high rate may be warranted in cases of dislocation downward. Fractures of the Toes. (117 Cases. ) These fractures, which occur when the foot is crushed, are likely to be compound and to extend to adjacent parts of the metatarsal bones. They are produced by the im- pact of heavy objects, such as stones, slabs of granite, beams, iron rails, etc. The severity of the injury depends both on the surface on which the foot rests at the time of accident and on the weight of the object by which it is crushed. We frequently have to deal with badly commi- nuted fractures requiring the amputation of a portion or of the whole of the foot. The very effort of the surge(»n to preserve as much of the foot as possible sometimes, far from giving the patient a relatively serviceable member, results in a deformity which greatly adds to his functional disability. (See Plate 39, Fig. 1.) The great toe is the one which most often suffers alone. The fractures of the metatarsophalangeal joint, having already been discussed in connection with the metatarsal bones, can be passed over here. Nor does the ankylosis which follows tliese fractures need any ex))hination. After a compound fracture at this joint the circulation of the great toe is likely to be imj)ed('(l by the scar encircling the injured joint. Tlie toe therefore apjiears cyanotic for a long time after recovery (see Plate 39, Fig. 2) ; the tem]>erature of the part is lowered, or, occasionally, is somewhat raised. The toe is exceedingly sensitive to 34 530 DISEASES CAUSED BY ACCIDENTS. cold, a matter of considerable importance to workmen employed out of doors during the winter. An insurance allowance is justified on this point alone; it is also based, however, on the stiffness of the metatarsophalangeal joint, which in many cases obliges the patient to walk on the outer border of the foot. In view of these facts it would be unreasonable to agree to the position taken by some that a stiff great toe does not warrant an insurance allowance. Ankylosis of the distal phalangeal joint has a less unfavorable effect, but even this is to a large extent an individual matter. Compound or comminuted fractures of this joint often require a comparatively long course of treatment, aud jxiin and disturbances of gait may be marked symptoms. Fractures accompanied by crushing of the distal pha- lanx lead almost invariably to the destruction of the nail-bed ; a suppurative onychia frequently follows the injury, the nail is tlirown off, and the whole distal phalanx becomes wasted ancT deformed. I have sometimes observed a subsequent rudimentary growth of the nail, but have never known it to cover the whole nail-bed. It is likely to grow very tliick at the posterior border of the matrix, constantly requiring careful trinnning to avoid pressure from the shoe ; but although processes of apparently healthy nail frequently grow out forward, they always fall off again, leaving the whole front part of the nail- bed covered by a soft corneous layer, which completely merges into the skin in front and at the sides. In one such case, which I have had under observation for ten years, the condition of his toe still causes the i)atient con- siderable discomfort. The effect of the ankylosis of individual toes on the usefulness of the foot depends, among other things, on the position of the affected toe. The extent to which the patient may be disabled has already been discussed. The stiffness and deformity of the toes after severe iMg. H2 532 DISEASES CAUSED BY ACCIDENTS. couimiuuted fractures may so lessen the usefulness of the foot as to render their amputation or disarticulation desir- able. Even after such operations, especially if parts of the corresponding metatarsal bone have to be sacrificed, there may remain serious interference with function. Case of frndure of the disfal phalan.r of the (jrcal foe. (Fig. 142, p. 531.) A workman, forty-seven years of age, sustained tlie foregoing lesion in September, 1898, when a heavy stone fell on and crushed his great right toe. The blood extravasation was opened by tlie surgeon who dressed the foot. Tlie patient lay in bed for two weeks and began to work at the end of the third \veek. He made a perfect recovery. Case of fracture of the distal jihulanx of the great toe whieh icas crushed hy an iron rail. (Fig. 14:>, p. ^).\\\.) The accompanying skiagraph (Fig. 143) shows the line of fracture on the tip of the great toe \ery distinctly. The treatment in this C£ise consisted of compresses and rest in lied; the patient began to walk two weeks after tlie accident, and resumed work in four weeks. The skiagraph was taken at the latter time. The scar resulting from the amputation of the great toe and a portion of- the first metatarsal bone is sensitive to pressure, and interferes with walking if it extends out on the under surface of the ball of the great toe ; hence the patient steps on the outer part of the sole. He has, in addition, lost the sujiport of the head of the metatarsal bone. Disarticulation of the toe at the metatarsophalan- geal joint has an equally unfavorable effect if the scar is so placed as to interfere Avith walking. Even when the latter is not ex])osed to ])ressure, it may give trouble fir some time by forming adhesions with the bone. Many cases of disarticulation at this joint, however, have a very favorable functional result. The opposite eifect, as to position of the foot, is seen after removal of the fifth toe or of the fourth and fifth toes, together with a portion of their metatarsal bones, the patient using the inner border of the foot in walking, both on account of the location of the scar and because the normal outer suj)])ort of the foot is lacking. These dis- advantages are not found after disarticulation of the fifth Fig. 14:3. 534 DISEASES CAUSED BY ACCIDENTS. toe or of the fourth and fifth toes at the metatarsophalan- geal joints. The retraction of the cicatrix after amputation of the second toe and a portion of the second metatarsal bone may go so far as to cause the third toe to override the great toe. The insurance allowance for loss of the great toe is rated at from 10^ to 15^. An unfavorable scar and inability to walk on the inner border of the foot further increase the incajiacity, and raise tlie rate accordingly. The loss of each of the other toes is compensated for by 5fc ; here, too, a higher rate is allowed in unfavorable cases. Amputation of all the toes may, if the scar is favorably located, leave a comparatively useful member, the patient being able to perform heavy work. If so, an insurance allowance of from 20 fo to 25 ^ is sufficient. The usefulness of the foot is much more impaired l)y the loss of all the metatarsal bones (Lisfranc's opera- tion). For workmen who are obliged to be on their feet, and possibly to carry heavy loads, from 33^^ to 40^ should certainly be the mininunn rate. In a few cases per- sonally known to me the ])atient has received 60^ for several years. After Chopart's o])eration, and to a still greater degree after Pirogotf 's operation, the patient is quite unfitted for heavy work or to carry weights. For these cases an in- surance allowance of 50^; is indicated. It should be borne in mind that steadiness in walking and standing depends on the size of the surface of the foot Avhich comes in contact with the ground. When this is dinn'nislu'd by contracted scars, by atrophy of the nuiscles and the [)lantar fat, or by deformity of any kind, the gait suffers a proportionate loss of steadiness. INJURIES OF THE FOOT AND INSURANCE. 535 Traumatic Tuberculosis of the Foot. Tuberculous foci are frequently developed in the bones of the tarsus or in the ankle-joint, especially as a result of slight injuries, such as contusions or sprains. Many such instances have been reported. I have cited a number in the foregoing pages, accompanying some of them with illustrations. Rate of Indemnity for Deformities of the Foot. A rate of 33J^ is ample for an absolutely stiff ankle, unless talipes valgus or varus exists at the same timCj when it may need to be higher. Among the paralyses of the foot and leg with which we have to deal the paralysis of the muscles supplied by the peroneal nerve deserves special consideration. This is most apt to occur in alcoholic subjects, but is not con- fined to them. The sym})tonis are often quite severe. In one case coming iinder my observation the muscles in question ■were completely paralyzed, and the patient was obliged to wear a shoe with side braces in order to walk at all. He received 40^ insurance allowance. In another case the patient, who was a heavy drinker, suffered from a complete sensory paralysis of the area supplied by the peroneal nerve for t\\ o days after eveiy spree. Deep pin-jiricks cau.sed no pain. The anesthesia was followed by extreme hyperesthesia. Paralyses of liaV)it are sometimes observed. A patient, for instance, walks on the outer border of the foot because of some painful condition of the inner portion of the sole; the tibialis anticus becomes contracted, which finally leads to spastic paralysis of the antagonists, and to permanent deformity of the foot. In making an examination of the lower extremities it is essential to compare the two sides — first with the patient lying on the back, then standing, with the feet placed ])arallel. " The examination-stool which I have designed will be found very serviceable. The gait should 536 DISEASES CAUSED BT ACCIDENTS. be tested, and the condition of the sole of the foot should be ascertained ; finally, it is necessary to determine the strength of the injured foot or leg, both in itself and in comparison with that of the other side. INDEX. Abdomen, injuries and traumatic diseases of, "ilS Abdominal hernia, PI. 15 muscles, subcutaneous rupture of, 213 wall, wounds of, 212 Abrasions, 44 Abscess of brain, 105 Accident-neiu-osis, 108 Accidents, causes of, 33 classification of, 35 due to poisoning, 81 fatal cases, 37 statistics of, 35 Acliillodynia, traumatic, 477 Acromioclavicular articulation, sprains of, 241 Acromion, fractures of, 253 Alcoholic intoxication, 81 symptoms, 82 neuritis, 61 Alcoholism, chronic, 81. See also Alcoholic intoxication. Amputation of toes, 529, 532 Anemia of skin, 45 Aneur^'sm of thoracic aorta, 211 traumatic, 50 Ankle, function of, 448 injuries and traumatic diseases of, 448 scars of, 476 Ankle-joint, "dislocation" of, 456, 457 fractures of, 468 movements at, 450 scars on, PI. 37 "sprain" of, 451, 457, 476 Ankylosis of elbow-joint, position inj^ 284 Ankylosis of shoulder-joint due to fracture of cla\acle, PI. 17 Anthrax, 84 of intestmal tract, 85 Aorta, thoracic, aneurysm of, 211 Apoplexy from head-injuries, 102 Arm, wounds of, 264 bites, 265 deep, of axilla, 265 rupt\ires of triceps, 266 subcutaneous ruptures of bi- ceps, 265; PI. 19 Arteriosclerosis, 56 ArthritLs deformans, 76 of knee-joint, 412 pauperum, 76 traumatic, 76 tubercular, 77 prognosis, 79 sjTuptoms, 78 treatment, 79 Arthropathy, 79 Articular rheiimatisin, 76 Astragalus, dislocations of, 457 fractures of, 469 body, 469 head, 470 involving tubercle, 475 neck, 470 Atony, muscular, 49 Atrophy, muscular, 49 diagnosis, 50 prognosis, 51 treatment, 51 "of disuse," 49 of muscles of hand, PI. 27 of nails, 46 53- 538 INDEX. Babinski's reflex, 129 Back, burns of, 183 cicatrices of, 183 contusions of, 182 lacerations of muscles of, 183 subcutaneous rupture of mus- cles of, 184 wounds of, 183 Biceps of arm, rupture of, 2G5, PI. 19 Bladder, injuries and traumatic diseases of, 224 Blood-poisoning, 41 Blood-vessels, injuries and trau- matic diseases of, 55 Bones, contusions of, 67 fractures of, 62 function of, 61 injuries and traumatic diseases of, 61 structure of, 61 Brachial plexus, paralysis of, due to injury of shoulder, 245 Brain, abscess of, 105 centers of, PI. 1 compression of, 100 concussion of, 99 contusion of, 101 ; PI. 1 hemorrhage of, 105 traumatic diseases of, 103 tumor of, 105 Bullet-wounds, 40 " Burden -deformities, " 122 Burns of back, 183 of face, 116 of fingers, 321 of forearm, 292 of hand, 321 of leg, 416 of neck, 121 ti'eatment of, 44 Bursa, intertrochanteric, inflam- mation of, 363 Bursa;, injuries and traumatic diseases of, 53 of knee, injuries of, 397 of shoulder, injuries of, 240 Bursitis, 53 Buttocks, contusions of, 356 Calf, rupture of muscles of, 486 Capsules, injuries and traumatic diseases of, 55 Caput obstipum, 121, 156, 243 Carcinoma of kidney, 223 of liver, 220 of peritoneum, 218 of stomach, 215 of testicle, 225 Carcinomata of spine, 171 Caries of spine, 170; PI. 9 Carpus, dislocations of bones of, 310; PL 36 at carpometacarpal joints, 312 pisiform, 311 fractures of bones of, 313 Cauda equina, lesions of, 140 Centers of brain, 88; PI. 1 Cerebral hemorrhages, 92 Chest, cicatrices of, 191 concussion of, 190 injuries and traumatic diseases of, 186 wounds of, 191 Chronic alcoholism, 81. See also A Icokolic i)i toxication. Cicatrices of back, 183 of chest, 191 Cicatrix atrophica, 42 hypertrophica, 42 Clavicle, dislocation of, 249 backward, 250 complete, 251 downward, 251 forward, 249 upward, 250 fractures of, 241 external third, 247 followed by ankylosis of shoulder-joint, PI. 17 inner third, 248 reunited, 242; PI. 16 treatment, 248 Club-foot, 505, 525 Commotio cerebri, 99 See also Co7icussion of brain. pectoris, 190 Compression myelitis, 173 of brain, 100 INDEX. 539 Compression, traumatic, of spinal cord, 132 Concussion of lirain, 99 of chest, 190 of spinal cord, 133 Concussion -injuries of heart, 209 Contortionists, 122 Contracture of trapezius due to contusions, PI. 7 of wrist, PI. 23 Contractures, hysteric, 113 of fingere, 344 Contusion of brain, 101 ; PI. 1 Contusion-pneumonia, 205 Contusions of arm, 264 of back, 182 of bones, 67 of buttocks, 356 of elbow-joint, 282 of face, 115; PI. 5 of forearm, 290 of hand, 319 of head, 91 of hiiHJoint, 363 of joints, 70 of kidney, 221 of knee-joint, 394 of leg, 35, 413 of liver, 219 of penis, 226 of shoulder, 238 of skin, 38 of spine, 141 of stomach, 213 of thigh, 366 of thora.x, 187; PI. 12 Conus terminalis, lesions of, 140 Coracoid process, fractures of, 256. See also Scapula, fractures of. "Crick in the back," 184 Crushing of foot, 478 of forearm, 290 of hand, 291 of testicle, 224 of toes, 478 Costal cartilages, fracture of, 201 Coxa valga, 379 vara, 379 Coxitis, traumatic, 366 Cubitus valgus, 276, 279, 283 varus, 276, 279, 283 Cuboid, dislocations of, 503 fractures of, 504 Cuneiform bones, dislocations of, 502 fracture of, 498, 500 " Decollejiext traumatique, " 141 "Deformities, burden-," 122 of foot, rate of indemnity for, 535 Dementia paralytica, 106 Diabetes as sequel to head-injury, 101 Diplegia brachialis traumatica, 136 Dislocation of ankle-joints, 456 of astragalus, 457 of carpus, 310 of clavicle, 249 of cuboid, 503 of cuneiform bones, 502 of elbow-joint, 283 of fibula, head, 422 of hip-joint, 364 of inferior maxilla, 120 of joints, 72 of knee-joint, 400 of metacarpal bones, 325 of metatarsiil bones, 504 of patella, 403 of pelvic l)ones, 362 of peronei tendons, 477 of radio-ulnar joint, 308 of radius, head, 294 of ribs, 201 of sacrum, 362 of sca]>h()itl, 494 of semilunar tibrocartilages, 402 of shoulder-joint, 257 of spine, 147. See also Spine, dinlocdfionx of. of sulx-alcaneoid Ijursji, 479 of toes, 526 of vertebrae, 147 of wrist-joint, 309 540 INDEX. Dislocation-fractures of scaphoid, 494 Dura mater, inflaniniation of, 103. See also Paehymtninfiitis. Dyspepsia, nervous, clue to injury to stomach, 216 Edema, malignant, 86 Elbow-joint, anatomic considera- tions, 280 contusions of, 282 dislocations of, 283 functions of, 280 injuries and traumatic diseases of, 280 sprains of, 282 Elephantiasis cruris traumatica, 414 Emphysema, pulmonary, 206 Epilepsy, 100, 114 Epiphyses of leg, separation of, 442 Erb's palsy, 245, 246 Erysipelas, 46 of head, 93 Extramedullary hemorrhage, 134 Extremities, lower, injuries and traumatic diseases of, 353. See also Lower extremities. Face, burns of, 116 contusions of, 115; PI. 5 fracture of bones of, 116 injuries of, 115 paralysis of, with atrophy, PI. 6 wounds of, 116 Fasciae, injuries and diseases of, 54 Femoral hernia, 234 Femur, fractures of, 370 condyles, 391 head, 371 in region of trochanters, 377 lower third, 382 neck, 371 shaft, 384 spontaneous, 385 symptoms, 382 Femur, fractures of, upper half, 380 upper third, 378 function of, 370 pseudo-arthrosis of, 385 Fibula, dislocations of, head, PI. 35 fractures of, head, 420; PI. 33 Finger, little, loss of, 346; PI. 29 shortened and stiffened as re- sult of gangrene, PL 30 Fingers, burns of, 321 contractures of, 344 fractures of, 340 function of, 317 incised wounds of, 337 injuries and traumatic diseases of, 337 indemnity for, 351 insurance allowance for loss of, mutilation of, PI. 28 paralyses of, 346 sprains of, 338 stumps of, 345 trophoneuroses of, 346 Flat-foot, 505, 506, 520 Floating kidney, 222 Foot, crushing of, 478 deformities of, rate of indem- nity, 535 injuries and traumatic diseases of, 448 scars of, 477 traumatic tuberculosis of, 535 wounds of, 477 Forearm, ))urns of, 292 contusions of, 290 crushings of, 290 fractures of, 292. See also Ulna and Ii(i(Iii(». injuries and traumatic diseases of, 288 rupture of muscles and tendons of, PI. 20 wounds of, 291 Fracture, compound, of sternum, PI. 10 malleolar, 457, 476 of bones of face, 117 I INDEX. 541 Fracture of costal cartilages, 201 of inferior maxilla, 119 of nasal bones, PL 5 of ribs, ununited, PI. 10 of superior maxilla, 119 Fractures, fatal results of, 67 healed, symptoms of, 64 of acromion, "253 of ankle-joint, 468 of astragalus, 469. See also Aftrayaltis, fractures of. of bones, 62 in special occupations, 66 of cfirpus, 313 of cervical vertebra;, 151 of clavicle, 241 of cuboid, 504 of cuneiform bones, 498, 500 of dorsal vertebrte, 158. See also Dorsal vertebrse. of femur, 370. See also Femur, fractures of. of fingers, 340. See also Fin- gers, fractures of of forearm, 292. See also Ulna and Badius. of humerus, 267. See also Ilidiifrus, fractures of. of joints, 74 of knee-joint, 411 of leg, 417. See also Leg, frac- tures of of lumbar vertebrae, 158. See also Lumbar vertebne. of malleoli, 458 of metacarpal bones, 326 of metatarsiil Itones, 506 of fts calcis, 4H0 of patella, 403 of ]jelvis, 357. See also PeMs, fractures of. of radius, 295. See also Radius, fractures of. of* ribs, 194;" PI. 11. See also RU)S, fractures of. of sacrum, 359 of scai)hoid, 496 of scapula, 252 of skull, 93; PI. 2, 3, 4 of spine, 150, 162 Fractures of sternum, 193 of tibia, 417 of toes, 529 of ulna, 294. See also Ulna, fractures of. of vertebrae, 150 spontaneous, 66 supramalleolar, 438 Frost-bites, 45 Functional neuroses, 107, 109 CtAXGeexe, 45 Gastric hernia, 234 Genu valgum after leg fracture, 418; PI. 34 Glanders, SQ Gloasy skin, 41, 45 Gout, 76 Hallux valgus, 510 varus, 510 Hand, atrophy of muscles of, PI. 27 burns of, 321 contusions of, 319 crushing of, 291 injuries and traumatic diseases of, 317 indemnity for, 351 stiff, Pi. 24 trophoneurosis of , 58; PI. 22 wounds of, 322 Head, contusions of, 91 ervsi]«'las of, \)'.\ injuries and traumatic diseases of, 88 Heart, injuries and traumatic dis- eases of, 208 Heart-disease, influence of trau- matism on })rcexisting, 210 Hematocele of testicle due to crushing, 224 Hematomyelia, traumatic, 135 Hcmatorriiachis, 134 Hemianesthesia, 112 Hemoptysis from fractured rib, 206 542 INDEX. Hemorrhage, extrameduUary, 134 of brain, 105 Hemorrhages, cerebral, 92 intramedullary, 137 traumatic, in spinal cord, 135 Hernia, 227 abdominal, PL 15 femoral, 234 gastric, 234 inguinal, 228 compensation for, 231 strangulated, cicatrix after, PI. 14 treatment, 231 umbilical, 234 ventral, 234 intensified by traumatism, PI. 13 Hip-joint, anatomy, 353 contusions of, 363 dislocations of, 364 function of, 353 inflammation of, 306 injuries and traumatic diseases of, 363 movements of, 355 sprains of, 363 Humerus, fractures of, 267 after-treatment, 280 greater tuberosity of, 270 symptoms, 270 head of, 267 symi)toms, 268 lesser tuberosity of, 271 treatment, 272 lower articular extremity, 279 end, 275 cubitus valgus, 276 varus, 276 svmptoms, 276 half, 275 middle half, 275 position of varus, 274 separation of upper epiphy- sis in, 272 surgical neck of, 273 united, 272 upper half of, 274 third of, 274 Hydrocele due to crushing of tes- ticle, 224 Hydronephrosis, traumatic, 223 Hyperesthesia, 113 Hypertrophic cervical pachymen- ingitis, 172 Hyijertrophy, miiscular, 49 Hypochondriasis, 111 Hysteria, 111 symptoms, hemianesthesia, 112 hyperesthesia, 113 hysteric contractures, 113 paralysis, 113 treatment, 113 Hysteric contractures, 113 iNfiSED wounds, 39 India-rubber men, 122 Infected wounds, 40 Infectious diseases, traumatism and, 83 Inflammation of dura mater, 103. See also Pachymeningitis. of kidney, 221 of pericardium, 208 of spinal cord, 173 traumatic, of pia mater, 104 Inguinal hernia, 22^ Injuries and traumatic diseases of abdomen, 212 of ankle, 448 of arm, 264 of liladder, 224 of blood-vessels, 55 of bones, 61 of capsules, 55 of chest, 186 of elbow-joint, 280 of face, 115 of fascia;, 54 of fingers, 337 of foot, 448 of forearm, 288 of hand, 317 of head, 88 of heart, 208 of hip-joint, 363 of intestines, 216 of joints, 70 INDEX. 543 Injuries and traumatic diseases of kidney, 2'21. See also Kidney. of knee, 392 of leg, 413 of ligaments, 55 of liver, 219 of lower extremities, 353. See also Lower extremities of lungs, 205 of muscles, 47 of nails, 46 of neck, 121 of nerves, 57 of pancreas, 220 of pelvis, 356 of penis, 226 of pericardium, 208 of peritoneum, 216 of skin, 38 of spleen, 220 of stomach, 213 of tendons, 52 of thigh, 366 of ureters, 225 of wrist-joint, 304 of spinal cord, 132 symptoms, 138 meninges, 133 of spine, 141 Intercostal neuralgia, 202 Intertrochanteric bursa, inflam- mation of, 363 Intestinal occlusion, 217 stenosis, 217 tract, anthrax of, 85 Intestines, injuries and traumatic diseases of, 216 Intoxication, alcoholic, ^\ Intramedullary hemorrhages, 137 Ischemic paralysis of forearm after fracture,' 296, 298 Joints, contusions of, 70 dislocations of, 72 fractures of, 74 injuries and traumatic diseases of, 70 resection of, 79 Kidney, carcinoma of, 223 contusion of, 221 crushing of, 221 floating, 222 inflammation of, 221 injuries and traumatic diseases of, 221 lacerations of, 221 penetrating wounds of, 223 Klumpke's palsy, 247 Knee, function of, 392 injuries and traumatic diseases of, 392 of bursse, 397 scare of, 398 wounds of, 398 Knee-jerk in injury to spinal cord, 128 Knee-joint, arthritis deformans, 412 chronic traumatic inflammation of, 412 contusions of, 394 dislocations of, 400 fractures of, 411 osteo-arthritis of, 412 sprains of, 395 subluxation of, 401 tuberculosis, 411 Kummel's disease, 144, 163 Lacerated wounds, 39 Lacerations of kidney, 221 of mus<'les of hack, 183 of ))lantai- fascia, 478 of tlioracic duct, 218 Leg, burns of, 416 contusions of, 413; PI. 35 of calf, 413 fractures of, 417 lower half, 424 third, 4:54. 438 near ankle-joint, 438 middle tliird, 424 near knee, n>< pseudo-arthrosis aftei-, 447; PL :U) inflammation of, 414 544 INDEX. Leg, injuries and traumatic dis- eases of, 413 scalds of, 416 separation of epiphyses, 442 wounds of, 415 Leptomeningitis, 104, 134 Ligaments, injuries and trauma- tic diseases of, 55 Ligamentum patellse, ruptures of, 396, 397 Liver, carcinoma of, 220 contusious of, 219 crushing of, 219 injuries and traumatic diseases of, 219 ruptures of, 219 Lockjaw, 85 Locomotor ataxia, 178 symptoms, 179 treatment, 179 Lumbago, traumatic, 184 Lungs, injuries and traumatic diseases of, 205 tuberculosis of, traumatic, 207 Maligxaxt edema, 85 " ]\Ialleolar fracture," 457 Malleoli, fractures of, typical, 458 inversion, 464 uncomplicated, 468 Maxilla, inferior, dislocation of, 120 fracture of, 119 pseudo-arthroses in, 120 superior, fracture of, 119 Meninges of brain, traumatic dis- eases of, 103 spinal, injuries of, 1 33 Meningitis, tubercular basilar, 104 "Meningocele spuria trauma- tica," 141 Meningomyelitis, acute, 134 chronic syphilitic, 173 Metacarpal bones, dislocations of, 325 fractures of, 326 head, 334 Metacarpal bones, fractures of, sj'mptoms, 328 treatment, 336 Metacarpophalangeal joint, scar over, 346; PI. 29 joints, sprains of, 324 Metatarsjil bones, dislocations of, 504 fractures of, 506 Mind-blindness, 89 Motor-paralyses, 129 Multiple sclerosis, 176 Muscle strain, 47 Muscles, injuries and traumatic diseases of, 47 Muscular atony, 49 atrophy, 49 difignosis, 50 prognosis, 51 treatment, 51 hyiiertrophy, 49 Myelitis, compression, 173 Myomata of spine, 172 Nails, atrophy of, 46 injuries and traumatic diseases of, 46 Neck, burns of, 121 injiuies and traumatic diseases of, 121 wry-, 121 Nephritis, traumatic, 221 Nerves, dislocations of, 58 injuries and traumatic diseases of, 57 Nervous dyspepsia due to injury to stomach, 216 Neuralgia, 59 intercostal, 202 Neurasthenia, 110 spinal, 181 Neuritis, 57, 58, 60 alcoholic, 61 Neiu'oglia, traumatic inflamma- tion of, 174 Neuroses, functional, 107, 109 Neurosis, accident-, 108 traumatic, 107 Nose, fracture of bones of, PI. 5 i INDEX. 545 OccLUSiox, mteptinal, 217 O-position in fracture of humerus, 276, 279, 283 Orchitis, suppurative, due to cnisliiiig of testicle, 224 Os calcis, fractures of, 480 compression, 480 internal tubercle, 491 "open duck-bill," 486 sustentaculum tali, 488 symptoms, 481 treatment, 484 subluxation of, 479 Osteitis, tubercular, 69 Osteo-arthritis of knee-joint, 412 Osteomyelitis, traumatic, 68 Pachymexixgitis, 103 hypertrophic cervical, 172 spinal, 134 Palsy, Erb's, 245, 246 Pancreas, injuries and traumatic diseases of, 220 Paralysis, 57, 58 agitans, 180 Erb's, 245, 246 Klumpke's, 247 of fingers, 346 of thigh, 38(;. See also Tliigh, parnhjsiii of. of tilnar nerve due to crushing of shoulder, PI. 30 progressive, 106 Paraplegia, spastic, 177 Patella, dislocations of, 40:? fractures of, 403 Pectoral muscles, wounds of, 192 Pelvis, anatomy of, 353 disloc-ation of ])ones, 362 fractures of, 357 function of, 353 injuries of, 356 Penis, contusions of, 226 injuries and traumatic diseases of, 226 wounds of, 226 Pericarditis, traumatic, 208 Pericardium, inflannnation of, 208 35 Pericardium, injuries and trau- matic diseases of, 208 Perinephritis, 223 Peritoneum, carcinoma of, 218 injuries and traumatic diseases of, 216 Peritonitis, traumatic, 217 Peronei tendons, dislocation of, 477 Phalanges, function of, 317 Phj'sical injuries, general consid- erations of, 38 Pia mater, traumatic inflanmia- tions of, 104 Plantar fascia, laceration of, 478 Pleurisy, traumatic, 203 Pneumonia, contusion-, 205 from fractured ribs, 205 traumatic, 187 Poisoning, accidents due to, 81 Poliomyelitis, chronic progressive anterior, 177 Popliteal space, scars in, PI. 37 Progressive paralysis, 106 Pseudo-arthrosis after fracture of forearm, 296 in inferior maxilla, 120 of femur, 385 of leg, after fracture, 447: PI. 3() Pidmonary emphysema, 206 I'unctured \\()unds, 39 Radio-vlxak joint, dislocations of, 30H Radius, dislocations of head, 294 fractures of, examination for, 298 head, 295 involving bones of carpus, 300 shaft, 295 prognosis, 295 "sprain-fractures," 298 tyi)ic;il, 298 diskx-ations with, 300 treiitment, 302 Railway lirain, 110. See also Neurasthtnia. 546 INDEX. Eailway sijine, 110. 8ee also Neurasthenia. Reflexes, cutaneous, 129 tendon-, 130 Resection of joints, 79 Rheiiniatisni, articular, 76 Ribs, dislocation of, 201 fractures of, 194 ; PI. 11 healing, 196 sequels of, intercostal neu- ralgia, 202 traumatic pleurisy, 203 tuberculosis of lungs, 207 symptoms, 197 relation of vertebral column to, 125 ununited fracture of, PI. 10 Ru})ture of abdominal muscles, 213 of ligamentum patellse, 396, 397 of pectoral muscles, 192 of semilunar flbrocartilages, 402 Ruptures of calf muscles,^ 486 of liver, 219 of thigh, subcutaneous, 367 ; PI. 31 of triceps of arm, 266 Sacru:m, dislocations of, 362 fractures of, symptoms, 360 Sarcomata of spine, 171 Scalds of leg, 416 Scaphoid, dislocations of, 494 dislocation-fractures of, 494 fratitures of, 496 Scapula, fractures of acromion of, 253 treatment, 254 body of, 253 coracoid process, 256 neck of, 254 Scars on ankle, 476 ; PL 37 on calf, PI. 37 on foot, 477 on knee, 398. See also Knee.^ scars. Seal's on popliteal space, PI. 37 on thigh, 368 on wrist, 315 Scar-keloids, 43 ; PI. 21 Sclerosis, multiple, 176 Secondary degeneration, trauma- tic, 174 Semilunar flbrocartilages, disloca- tion of, 402 rupture of, 402 Shoulder, contusions of, 2.38 functions of, 236 injuries of, statistics, 237 loose-jointedness, 237 loss of function of, 237 paralyses of brachial jdexus d^^e to injury of, 245 sprains of, 241 Shoulder-joint, dislocations of, 257; PI. 18 synovitis of, 263 Skin, anemia of, 45 contusions of, 38 injuries and traumatic diseases of, 38 tuberculo.sis of, 46 Skull, fractures of, 93 ; PL 2, 3, 4 symptoms, 97 Spastic ])araplegia, 177 Spinal cord, concussion of, 133 inflammation of, 173 injuries of, 132 lesions of cervical region, 138 of dorsal region, 139 of lumbar region, 140 strains of, 146 traumatic compression of, 132 diseases of, 128-132, 170 hemorrhages in, 135 irritability, 181 meninges, injuries of, 133 traumatic diseases of, 172 neurasthenia, 181 pachymeningitis, 134 Spine, carcinomata of, 171 caries of, 170; PL 9 compression-fracture of, 163 contusions of, 141 INDEX. 547 Spine, dislocations of, 147 fractures of, 150, 162 injuries of, 141 niyoniata of, 172 railway, 110. See also Neuras- thenia. sarcomata of, 171 sprains of, 145 ti'auniatic diseases of, 170 tuberculosis of, 170; PI. 9 tumors of, influence of trauma- tism on development of, 171 Spleen, injuries and traumatic diseases of, 220 Spondylitis traumatica, 144 Spontaneous fractures, 06 Sprain-fractures of radius, 298 Sprains, 70 definition, 70, 30.-^ of acromiocla\ icular articula- tion, 241 of ankle-joint, 451 of elbow-joint, 282 of fingers, 338 of hii>-joint, 363 of knee-joint, 395 of metacarpophalangeal joints, 324 of shoulder, 241 of spinal cord, 146 of spine, 145 of wri.st-joint, 307 Statistics of accidents, 35 Stenosis, intestinal, 217 Sternum, wjmpound fracture of, PI. 10 fractures of, 193 Stiff hand, PI. 24 Stomach, carcinoma of, 215 contusions of, 213 crushing of, 213 injuries and traumatic diseases of, 213 traumatic ulcer of, 214 Strains of muscles of back, 1^3 Subcalcaneoid ])ursa, dislocation of, 479 Sul)luxation, 73 of knee-joint, 401 of OS Ciilcis, 479 Supramalleolar fractures, 438 Sustentaculum tali, fractures of, 488 Synovitis of shoulder-joint, 263 Syringomyelia, traumatic, 174 Tabes dorsalis, 178. See also Locomotor ataxia. traumatic, 178 Talipes planus, 520 valgus, 503 varus, 494, 503, 525 Tenalgia crepitans of wrist, 317 Tendon-sheaths, injuries and trau- matic diseases of, 52 Tendons, injuries and traumatic diseases of, 52 Tenosynovitis, 52 chronic, at wrist, 317 Testicle, carcinoma of, 225 crushing of, 224 cutaneous wounds of, 225 injuries and traumatic diseases of, 224 loss of one, 225 tuberculosis of, 225 Tetanus, 85 Thigh, contusions of, 366 injuries and traumatic diseases of, 366 paralysis of, 386 crural, 3^6 symptoms, 390 tmnk f)f sciatic nerve, 390 rupture of, suteutaueous, 367; PI. 31 scars of, 368 wounds of, 368 Thoracic duct, laceration of, 218 Thorax, contusion of, PI. 12 contusions of, 187 Tibia, fractures of, 417 ati-ophy after, PI. 35 compression-, PI. 33 lower end, 445 shaft, 434 upper end, 417 sym]>tonis, 417 treatment, 418 548 INDEX. Toes, amputation of, 529, 5;}2 crushing of, 478 dislocations of, 526 fractures of, 529; PL 39 injury to nail-bed, 530 Torticollis due to fracture of clav- icle, PI. 17 Trapezius, contracture of, due to contusions, PI. 7 Traumatic arthritis, 76 diseases of spinal cord, 128-131 disorders, general considera- tions of, 37 flat-foot, 520 lumbago, 184 osteomyelitis, 68 pericarditis, 208 peritonitis, 217 pneumonia, 187 tabes, 178 Traumatism, general considera- tions of, 37 influence on development of tumors, 80 preexisting heart-disea»se, 210 Trophoneuroses of fingers, 346 Trophoneurosis, 58 of hand, 58; PI. 22 Tul)ercular arthritis, 77. See also Arfhrifis. basilar meningitis, 104 osteitis, 69 Tuberculosis, 87 of foot, traumatic, 535 of knee-joint, 411 of lungs, traumatic, 207 of skin, 46 of spine, 170; PI. 9 of testicle, 225 Tuberculous synovitisof .shoulder- joint, 2()3 Tumor of brain, 105 Tumors, influence of traumatism on development of, 80 of spine, influence of trauma- tism on development of, 171 Ulcer, traumatic, of stomach, 214 Ulna, fractures of, shaft, 294 upper third with dislocation of head of radius, 294 Ulnar nerve, paralysis of, due to cru.shing of shoulder, PI. 30 Umbilical hernia, 234 Ureters, injuries and traumatic diseases of, 225 Vakicose veins, 56 Ventral hernia, 234 Vertebrse, dislocations of, 147 fractures of, 150 cervical, 151 dorsal, 158 lumbar, 158 Vertebral column, anatomico- phvsiologic considerations of," 121-125 mobility of, 122 relation to ribs, 125 Wool-sorters' disease, 84, 85 Wounds, 39 bullet-, 40 caused by crushing, 39 incised, 39 infect«l, 40 lacerated, 39 of atxlominal wall, 212 of arm, 264. See also Arm, troiuKh of. of back, 183 of chest, 191 of face, 116 of foot, 477 of forearm, 291. See also Fore- arm, iroiuuJs of. of hand, 322 of intestine, 217 of kidnej', penetrating, 223 of knee, 398 of leg, 415 of penis, 226 of testicle; 225 of thigh, 368 punctured, 39 treatment of, 42 INDEX. 549 Wrist, chronic tenosynovitis of, 317 contracture of, PL 23 scars on, 315 tenalgia crepitans, 317 Wrist-joint, dislocations of, 309 f nnctions of, 304 injuries and traumatic diseases, of, 304 mobility of, 307 Wrist-joint, movements of, 306 sprains of, 307 Wry-neck, 121 due to fracture of clavicle, PI. 17 X-POSITION in fracture of hum- erus, -276, 279, 283 Medical and Surgical Works PUBLISHED BY W. B. SAUNDERS, 925 Walnut Street, Philadelphia, Pa. PAGE Abbott on Transmissible Diseases . . . . i8 American Pocket Medical Dictionary . . 35 *American Text-Book of Applied Thera- peutics 8 *American Text-Book of Dis. of Children . 13 *An American Text-Book of Diseases of the Eye, Ear, Nose, and Throat 15 *An American Text-Book of Genito-Uri- nary and Skin Diseases 14 ♦American Text-Book of Gynecology ... 12 ♦American Text-Book of Legal Medicine . 44 ♦.■\merican Text-Book of Obstetrics ... 9 ♦American Text-Book of Pathology . . . 44 ♦American Text-Book of Physiology ... 7 ♦American Text-Book of Practice .... 10 ♦American Text-Book of Surgery . . 11 Anders' Theory and Practice of Medicine . 21 Ashton's Obstetrics 43 Atlas of Skin Diseases 28 Ball's Bacteriology 43 Bastin's Laboratory Exercises in Botany . 36 Beck's Surgical Asepsis 41 Boisliniere's Obstetric Accidents 39 Brockway's Physics 43 Burr's Nervous Diseases 41 Butler's Materia Medica and Therapeutics 24 Cerna's Notes on the Newer Remedies . . 32 Chapin's Compendium of Insanity .... 35 Chapman's Medical Jurisprudence . . . . 41 Church and Peterson's Nervous and Men- tal Diseases 17 Clarkson's Histology 33 Cohen and Eshner's Diagnosis 43 Corwin's Diagnosis of the Thorax .... 37 Cragin's Gynaecology 43 Crookshank's Text-Book of Bacteriology . 27 DaCosta's Manual of Surgery 23 De Schweinitz's Diseases of the Eye ... 29 Dorland's Pocket Medical Dictionary . . 35 Dorland's Obstetrics 41 Frothingham's Bacteriological Guide . . .30 Garrigues' Diseases of Women 34 Gleason's Diseases of the Ear 43 ♦Gould and Pyle's Curiosities of Medicine . 17 Grafstrom's Massage 28 Griffith's Care of the Baby 38 Griffith's Infant's Weight Chart 39 Gross's Autobiography 26 Hampton's Nursing 39 Hare's Physiology 43 Hart's Diet in Sickness and In Health . . 36 Haynes' Manual of Anatomy 41 Heisler's Embryology 19 Hirst's Obstetrics 20 Hyde's Syphilis and Venereal Diseases . . 41 International Text-Book of Surgery ... 6 Jackson's Diseases of the Eye 19 Jackson and Gleason's Diseases of the Eye, Nose, and Throat 43 Keating's Pronouncing Dictionary .... 26 Keating's Life Insurance 39 Keen's Operation Blanks 36 Keen's Surgery of Typhoid Fever .... 22 Kyle's Diseases of Nose and Throat ... 18 Laine's Temperature Charts 32 Levy & Klemperer's Clinical Bacteriology 44 Lockwood's Practice of Medicine .... 41 Long's Syllabus of Gynecology 34 Macdonald's Surgical Diagnosis and Treat- ment 22 McFarland's Pathogenic Bacteria .... 30 Mallory and Wright's Pathological Tech- nique 22 Martin's Surgery 43 Martin's Minor Surgery, Bandaging, and Venereal Diseases 43 Meigs' Feeding in Early Infancy 30 Moore's Orthopedic Surgery 23 Morris' Materia Medica and Therapeutics 43 Morris' Practice of Medicine ...... 43 Morten's Nurses' Dictionary 38 Nancrede's Anatomy and Dissection ... 31 Nancrede's Anatomy 43 Nancrede's Principles of Surgery .... 19 Norris' Syllabus of Obstetrical Lectures . 37 Penrose's Diseases of Women 24 Powell's Diseases of Children 43 Pryor's Pelvic Inflammations 33 Pye's Bandaging and Surgical Dressing . 23 Raymond's Physiology 41 Saundby's Renal and Urinary Diseases . . 25 ♦Saunders' American Year-Book of Medi- cine and Surgery 16 Saunders' Medical Hand-Atlases . . . 3, 4, 5 Saunders' Pocket Medical Formulary . . 35 Saunders' New Series of Manuals . . . 40, 41 Saunders' Series of Question Compends 42, 43 Sayre's Practice of Pharmacy 43 Semple's Pathology and Morbid Anatomy 43 Semplc's Legal Medicine and Toxicology. 43 Senn's (jenito-Urinary Tuberculosis ... 24 Senn's Tumors 25 Senn's Syllabus of Lectures on Surgery . . 37 Shaw's Nervous Diseases and Insanity . . 43 Starr's Diet-Lists for Children 38 Stelwagon's Diseases of the Skin 43 Stengel's Pathology 20 Stevens' Materia Sledica and Therapeutics 32 Stevens' Practice of Medicine 31 Stewart's Manual of Physiology 37 Stewart and Lawrance's Medical Elec- tricity 43 Stoney's Materia Medica for Nurses ... 31 Stoney's Practical Points in Nursing ... 27 Sutton and Giles' Diseases of Women . 29,41 Thomas's Diet-List and Sick-Rooni ... 38 Thornton's Dose-Book and Manual of Pre- scription-Writing .... 41 Van Valzah and Nisbet's Diseases of the Stomach 21 Vecki's Sexual Impotence 33 Vierordt and Stuart's Medical Diagnosis . 28 Warren's Surgical I'athology 25 Watson's Handbook for Nurses 26 Wolff's Chemistry 43 WolfTs Examination of Urine 43 GENERAL INFORMATION. One Prioe. Orders. Cash or Credit. How to Send Money by MaU. Shipments. Subscription Books. Miscellaneous Books. Latest Editions. Bindings. One price absolutely without deviation. No discounts allowed, regardless of the number of books purchased at one time. Prices on all works have been fixed extremely low, with the view to selling them strictly net and for cash. An order accompanied by remittance will receive prompt attention, books being sent to any address iu the United States, by mail or express, all charges prepaid. We prefer to send books by express when possible. To physicians of approved credit who furnish satisfactory references our books will be sent free of C. 0. D. One -volume or two on thirty days' time if credit is desired; larger purchases on monthly payment plan. See offer below. There are four ways by which money can be sent at our risk, namely: a post-office money order, an express money order, a bank-check (draft), and in a registered letter. Money sent in any other way is at the sender's risk. Silver should not be sent through the mail. All books, being packed in patent metal-edged boxes, neces- sarily reach our patrons by mail or express in excellent condi- tion. Books in this catalogue marked with a star (*) are for sale by subscription only, and may be secured by ordering them through any of our authorized travelling salesmen, or direct from tlie Philadelphia office : they are not for sale by booksellers. All other books in our catalogue can be procured of any bookseller at the advertised price, or directly from us. We carry in stock only our own publications, but can supply the publications of other houses (except subscription books) on receipt of publisher's price. In every instance the latest revised edition is sent. In ordering, be careful to state the style of binding desired- Cloth, Sheep, or Half Morocco. Special Offer. To physicians of approved credit who furnish satisfactory Monthly references books will be sent express prepaid ; terms, $5.00 cash Payment upon delivery of books, and monthly payments nf f J 00 thereafter Plan. until full amount is paid. Any of the publications of W. B. .Saunders (100 titles to select from) may be had in this way at catalogue price, including the American Text-Book Series, the Medical Hand- Atlases, etc. All payments to be made by mail or otherwise, free of all expense to us. SAU NDERS' MEDICAL HAND-ATLASES. The series of books included under this title consists of authorized translations into English of the world-famous Lehmann Medicinische Handatlanten, which for scientific accuracy, pictorial beauty, compactness, and cheap- ness surpass any similar volumes ever published. Each volume contains from 50 to 100 colored plates, executed by the most skilful German lithographers, besides numerous illustrations in the text. There is a full and appropriate de- scription, and each book contains a condensed but adequate outline of the subject to which it is devoted. In planning this series arrangements were made with representative pub- lishers in the chief medical centers of the world for the publication of transla- tions of the atlases into nine different languages, the lithographic plates for all being made in Germany, where work of this kind has been brought to the greatest perfection. The enormous expense of making the plates being shared by the various publishers, the cost to each one was reduced to practically one-tenth. Thus by reason of their universal translation and reproduction, affording in- ternational distribution, the publishers have been enabled to secure for these atlases the best artistic and professional talent, to produce them in the most elegant style, and yet to ofter them at a price heretofore unapproached in cheapness. The great success of the undertaking is demonstrated by the fact that the volumes have already appeared in thirteen different languages — German, English, French, Italian, Russian, Spanish, Japanese, Dutch, Danish, Swedish, Roumanian, Bohemian, and Hungarian. In view of the unprecedented success of these works, Mr. Saunders has con- tracted with the publisher of the original German edition for one hundred thousand copies of the atlases. In consideration of this enormous under- taking, the publisher has been enabled to prepare and furnish special additional colored plates, making the series even handsomer and more complete than was originally intended. As an indication of the great practical value of the atlases and of the im- mense favor with which they have been received, it should be noted that the Medical Department of the U. S. Army has adopted the "Atlas of Opera- tive Surgery," as its standard, and has ordered the book in large quantities for distribution to the various regiments and army posts. The same careful and competent editorial supervision has been secured in the English edition as in the originals. The translations have been edited by the leading American specialists in the different subjects. {For List of Volumes in this Series, see next two pages. ) 3 SAUNDERS^ MEDI CAL H AND-ATLASES« VOLUMES NOW READY. Atlas and Epitome of Internal Medicine and Clinical Diagnosis. By Dr. Chr. Jakob, of Erlangen. Edited by Augustus A. Eshner, M. D., Professor of Clinical Medicine, Philadelphia Polyclinic. With 68 colored plates, 64 text-illustrations, and 259 pages of text. Cloth, #3.00 net. "The charm of the book is its clearness, conciseness, and the accuracy and beauty of its illustrations. It deals with facts. It vividly illustrates those facts. It is a scientific wforlc put together for ready reference." — Brooklyn Medical Journal. Atlas of Legal Medicine. By Dr. E. R. von Hofmann, of Vienna. Edited by Frederick Peterson, M. D., Chief of Clinic, Nervous Dept., College of Physicians and Surgeons, New York. With 120 colored figures on 56 plates, and 193 beautiful half-tone illustrations. Cloth, ^3.50 net. " Hofmann's 'Atlas of Legal Medicine' is a unique work. This immense field finds in this book a pictorial presentation that far excels anything with which we are familiar in any other work." — Pliiladelfihia Medical Journal . Atlas and Epitome of Diseases of the Larynx. By Dr. L. Grunwald, of Munich. Edited by Charles P. Grayson, M. D., Physician-in-Charge, Throat and Nose Department, Hospital of the University of Pennsylvania. With 107 colored figures on 44 plates, 25 text-illustrations, and 103 pages of text. Cloth, ^2.50 net. "Aided as it is by jnagnificently executed illustrations in color, it cannot fail of being of the greatest advantage to students, general practitioners, and expert laryngologists." — St. Louis Medical and Surgical Journal. Atlas and Epitome of Operative Surgery. By Dr. O. Zuckerkandl, of Vienna. Edited by J. Chalmers DaCosta, M. D., Professor of Prac- tice of Surgery and Clinical Surgery, Jefferson Medical College, Philadel- phia. With 24 colored plates, 217 text-illustrations, and 395 pages of text. Cloth, ;S3.oo net. " We know of no other work that combines such a wealth of beautiful illustrations with clearness and conciseness of language, that is so entirely abreast of the latest achievements, and so useful both for the beginner and for one who wishes to increase his knowledge of oper- ative surgery." — Miinchener medicinische Wochenschrift. Atlas and Epitome of Syphilis and the Venereal Diseases. By Prof. Dr. Franz Mracek, of Vienna. Edited by L. Bolion Bangs, M. D., Professor of Genito-Urinary Surgery, University and Bellevue Hos- pital Medical College, New York. With 71 colored plates, 16 black-and- white illustrations, and 122 pages of text. Cloth, ^3.50 net. "A glance through the book is almost like actual attendance upon a famous clinic." — Journal of the American Medical .4ssociation. Atlas and Epitome of External Diseases of the Eye. By Dr. O- Haab, of Zurich. Edited by G. E. nE ScHWEiNiTZ, M. D., Professor of Ophthalmology, Jefferson Medical College, Philadelphia. With 76 colored illustrations on 40 plates, and 228 pages of text. Cloth, I3.00 net. "It is always difficult to represent pathological appearances in colored plates, but this work seems to have overcome these difficulties, and the plates, with one or two exceptions, are absolutely satisfactory." — Boston Medical and Surgical Journal. Atlas and Epitome of Skin Diseases. By Prof, Dr. Franz Mracek, of Vienna. Edited by Henry W. Stelwagon, M. D., Clinical Professor of Dermatology, Jefferson Medical College, Philadelphia. With 63 colored plates, 39 half- tone illustration.s and 200 pages of text. Cloth, 53-5° "^t- "The importance of per.sonal inspection of cases in the study of cutaneous diseases is readily appreciated, and next to the living subjects are pictures which will show the appear- ance of the disease under consideration. Altogether the work will be found of very great value to the general practitioner."— ybarwa/^ the American Medical Association. 4 SAUNDERS^ MEDICAL HAND-ATLASES. VOLUMES IN PRESS FOR EARLY PUBLICATION. Atlas and Epitome of Diseases Caused by Accidents. By Dr. Ed. GOLEBIEWSK.1, of Berlin. 'I'ran4ated and edited with additions by Pearce Bailey, M.D., Attending Physician to the Department of Corrections and to the Almshouse and Incurable Hospitals, New York. With 40 colored plates, 143 text-illustrations, and 600 pages of text. Atlas and Epitome of Special Pathological Histology. By Dr. H. DOrck, of Munich. Edited by LuDViG Hektoen, M.D., Professor of Pathology, Rush Medical College, Chicago. Two volumes, with about 120 colored plates, numerous text-illustrations, and copious text. Atlas and Epitome of General Pathological Histology. With an Appendix on Patho-histological Technic. By Dr. H. DOrck, of Munich. Edited by LuDViG Hektoen, M.D., Professor of Pathology, Rush Medi- cal College, Chicago. With 80 colored plates, numerous text-illustrations, and copious text. Atlas and Epitome of Gynecology. By Dr. O. Schaffer, of the University of Heidelberg. With 90 colored plates, 65 text- illustrations, and 308 pages of text. Edited by Richard C. Norris, A. M., M. D., Gynecologist to the Philadelphia and the Methodist Episcopal Hospitals. IN PREPARATION. Atlas and Epitome of Orthopedic Surgery. By Dr. Schui.tess and Dr. I-unint,, of Zurich. About loo colored illustrations. Atlas and Epitome of Operative Gynecology. By Dr. O. Schaffer, of Heidelberg. With 40 colored plates and numerous illustrations in black and white from original 'paintings. Atlas and Epitome of Diseases of the Ear. Edited by Pr(m\ Dr. Politzer, of Vienna, and Dr. G. Briiil, of Berlin. With 120 colored illustrations and about 200 pages of text. Atlas and Epitome of General Surgery. Edited by Dr. Marwedel, with the cooperation of Prof. Dr. Czerny. With about 200 colored illustrations. Atlas and Epitome of Psychiatry. By Dr. Wit.ii. Wevcandt, of Wurz burg. With about 120 colored illustrations. Atlas and Epitome of Normal Histology. I'.y Dr. Johannes Sohotta. of Wiirzburg. With 80 colored plates and numerous illustrations. Atlas and Epitome of Topographical Anatomy. By Prof. Dr. SCHULTZE, of Wiirzburg. About lOO colored illustrations and a very copious text. 5 IV. B. SAUNDERS' *THE INTERNATIONAL TEXT-BOOK OF SURGERY. In two volumes. By American and British authors. Edited by J. Col- lins Warren, M.D.,LL.D., Professor of Surgery, Harvard Medical School, Boston ; Surgeon to the Massachusetts General Hospital ; and A. Pearce Gould, M. S., F. R. C. S., Eng., Lecturer on Practical Surgery and Teacher of Operative Surgery, Middlesex Hospital Medical School; Surgeon to the Middlesex Hospital, London, England. Vol. I. — General and Operative Surgery. — Handsome octavo volume of 947 pages, with 458 lieautiful illustrations, and 9 lithographic plates. Vol. H. — Special or Regional Surgery. — Handsome octavo volume of 1050 pages, with over 500 wood- cuts and half-tones, and 8 lithographic plates. Prices per volume : Cloth, $5.00 net; Half-Morocco, ^6.00 net. Just Issued. In presenting a new work on surgery to the medical profession the publisher feels that he need offer no apology for making an addition to the list of excellent works already in existence. Modern surgery is still in the transition stage of its development. The art and science of surgery are advancing rapidly, and the number of workers is now so great and so widely spread through the whole o* the civilized world that there is certainly room for another work of reference which shall be untrammelled by many of the traditions of the past, and shall at the same time present with due discrimination the results of modern progress. There is a real need among practitioners and advanced students for a work on surgery encyclopedic in scope, yet so condensed in style and arrangement that the matter usually diffused through four or five volumes shall be given in one- half the space and at a correspondingly moderate cost. The ever-widening-field of surgery has been developed largely by special work, and this method of progress has made it practically impossible for one man to write authoritatively on the vast range of subjects embraced in a modern text-book of surgery. In order, therefore, to accomplish their object, the editors have sought the aid of men of wide experience and established reputation in the various departments of surgery. C OSTTRIBIITORS : Dr Robert W. Abbe. C. H. Golding Bird. E. H. Bradford. W. T. Bull. T. G. A. Burns. Herbert L. Hurrell. R. C. Cibot. I. H. Cameron. James Cantlie. W. Watson Cheyne. William B. Cl.irke. William B. Coley. Edw. Treacher Collins. H. Holbrook Curtis. J. Chalmers Da Costa. N. P. D.Tndridge. John B. De.iver. J. W. Elliot. Harold Ernst. Dr. Christian Fenger. W. H. Forwood. George R. Fowler. George W. Gay. A. Pearce Gould. J. Orne Green. John B. Hamilton. M. L. Harris. Fernand Henrotin. G. H. Makins. Rudolph Matas. Charles Mcliurncy. A. J. McCosh. L. S. McMurtry. J. Ewing Mears. George H. Monks. John Murray. Robert W. Parker. . Rushton Parker. George A. Peters. Franz Pfaff. Lewis S. Pilcher. James J. Putnam. M. H. Richardson. A. W. Mayo Robson. W. L. Rodman. C. A. Siegfried. G. B. Smith. W. G. Spencer. J. Bland Sutton. L. McLane Tiffany. H. Tuholske. Weller Van Hook. James P. VVarbasse. J. Collins Warren. De Forest Willard. CATALOGUE OF MEDICAL WORKS. 7 *AN AMERICAN TEXT-BOOK OF PHYSIOLOGY. Edited by William H. Howell, Ph. D., M. D., Professor of Physiology in the Johns Hopkins University, Baltimore, Md. One handsome octavo volume of 1052 pages, fully illustrated. Prices : Cloth, ;JS6.CX) net; Sheep or Half- Morocco, $7.00 net. This work is the most notable attempt yet made in America to combine ii? one volume the entire subject of Human Physiology by well-known teachers who have given especial study to that part of the subject upon which they write. The completed work represents the present status of the science of Physiology, particularly from the standpoint of the student of medicine and of the medical practitioner. The collaboration of several teachers in the preparation of an elementary text- book of physiology is unusual, the almost invariable rule heretofore having been for a single author to write the entire book. One of the advantages to be derived from this collaboration method is that the more limited literature necessary for consultation by each author has enabled him to base his elementary account upon a comprehensive knowledge of the subject assigned to him; another, and perhaps the most important, advantage is that the student gains the point of view of a number of teachers. In a measure he reaps the same benefit as would be obtained by following courses of instruction under different teachers. The different .standpoints assumed, and the differences in emphasis laid upon the various lines of procedure, chemical, physical, and anatomical, should give the student a better insight into the methods of the science as it exists to-day. The work will also be found useful to many medical practitioners who may wish to keep in touch with the development of modern physiology. rONTRIBlTTORS : HENRY P. BOWDITCH, M. D., Professor of Physiology, Harvard Medi- cal School. JOHN G. CURTIS, M. D., Professor of Physiology, Columbiii Uni- versity, N. Y. (College of Physicians and Surgeons). HENRY H. DONALDSON, Ph.D., Head-Professor of Neurology, Univer- sity of Chicago. W. H. HOWELL, Ph. D.,M.D., Professor of Physiology, Johns Hopkins University. FREDERIC S. LEE, Ph. D., Adjunct Professor of Physiology, Cohim- WARREN P. LOMBARD, M.D., Professor of Physiology, University of Michigan. GRAHAM LUSK, Ph.D., Professor of Physiology, Yale Medica/ School. W. T. PORTER. M. D., Assistant Professor of Physiology, Har- vard Medical School. EDWARD T. REICHERT, M.D., Professor of Physiology, University of Pennsylvania. HENRY SEW ALL, Ph. D., M.D.. bia University. N. Y. (College of | Professor of Physiology. Medical lleparfr Physicians and Surgeons). ' ment. University of Denver. " We can commend it most heartily, not only to all students of physiology, but to every physician and pathologist, as a valuable and comprehensive work of reference, written by men who are of eminent authority in their own special f,uh]ec\.s." — London Lancet. " To the practitioner of medicine and to the advanced student this volume constitutes, we believe, the best exposition of the present stilus of the science of physiology in the Eng- lish language." — American yournal of the Medical Sciences. 8 IV. B. SAUNDERS' *AN AMERICAN TEXT-BOOK OF APPLIED THERAPEU- . TICS. For the Use of Practitioners and Students. Edited by James C. Wilson, M. D., Professor of the Practice of Medicine and of Clinical Medicine in the Jefferson Medical College. One handsome octavo volume of 1326 pages. Illustrated. Prices; Cloth, ^7.00 net; Sheep or Half- Morocco, $8.00 net. The arrangement of this volume has been based, so far as possible, upon modern pathologic doctrines, beginning with the intoxications, and following with infections, diseases due to internal parasites, diseases of undetermined origin, and finally the disorders of the several bodily systems — digestive, re- spiratory, circulatory, renal, nervous, and cutaneous. It was thought proper to include also a consideration of the disorders of pregnancy. The articles, with two exceptions, are the contributions of American writers. Written from the stnndpoint of the practitioner, the aim of the work is to facili- tate the application of knowledge to the prevention, the cure, and the allevia- tion of disease. The endeavor throughout has been to conform to the title of the book — Applied Therapeutics — to indicate the course of treatment to be pursued at the bedside, rather than to name a list of drugs that have been used at one time or another. The list of contributors comprises the names of many who have acquired dis- tinction as practitioners and teachers of practice, of clinical medicine, and of the specialties. tOSTRIBUTORS : Dr. I. E. Atkinson, Ealtimore, Md. Sanger Brown, Chicago, til. John B. Chapin, Philadelphia, Pa. William C Dabney, Charlottesville, Va. John Chalmers DaCosta, Philada., Pa. I. N. Uanforth, Chicago, III. John L. Dawson, Jr., Charleston, S. C. F. X. Dercum, Philadelphia. Pa. George Dock, Ann Arbor, Mich. Robert T. Edes, Jamaica Plain. Mass. Augustus A. Eshner, Philadelphia, Pa. 1. T. Eskridge, Denver, Col. F. Forchheimer, Cincinnafi, O. Carl Frese, Philadelphia, Pa. Edwin E. Graham, Philadelphia, Pa. John Guiteras, Philadelphia, Pa. Frederick P. Henry, Philadelphia, Pa. Guy Hinsdale, Philadelphia, P.t. Orviile Horwitz, Philadelphia, Pa. W. W. Johnston, Washington, D. C. Ernest Laplace, Philadelphia, Pa. A. Laveran, Pans, France. Dr. James Hendrie Lloyd, Philadelphia, Pa. John Noland Mackenzie, Baltimore, Md. J. W. McLaughlin, Austin, Texas. A. Lawrence Mason, Boston, Mass. Charles K. Mills, Philadelphia, Pa. John K. Mitchell. Philadelphia, Pa. \V. P. Northrup, New York City. Williain Osier, Baltimore, Md. Frederick A. Packard, Philadelphia, Pa. Theophilus Parvin, Philadelphia, Pa. Beaven Kake, London, England. E. O. Shakespeare, Philadelphia, Pa. Wharton Sinkler, Philadelphia, Pa. Louis Starr, Philadelphia, Pa. Henry W. Stelwagon, Philadelphia, Pa. James Stewart, Montreal, Canada. Charles G. Stockton, Buffalo, N. Y. James Tyson, Philadelphia, Pa. Victor C. Vaughan, Ann Arbor, Mich. James T. Whittaker, Cincinnati, O. J. C. Wilson, Philadelphia, Pa. "As a work either for study or reference it will be of great value to the practitioner, as it is virtually an exposition of such clinical therapeutics as experience has taught to be of the most value. Taking it all in all, no recent publication on therapeutics can be compared with this one in practical value to the working physician." — Chicago Clinical JRevieiu. "The whole field of medicine has been well covered. The work is thoroughly practical, and while it is intended for practitioners and students, it is a better book for the general practitioner than for the student. The young practitioner especially will find it extremely suggestive and helpful " — The Indian Lancet. CATALOGUE OF MEDICAL WORKS. *AN AMERICAN TEXT-BOOK OF OBSTETRICS. Edited by Richard C. Norris, M. D. ; Art Editor, Robert L. Dickinson, M.'D. One handsome octavo volume of over looo pages, with nearly 900 colored and half-tone illustrations. Prices : Cloth, ^7.00 net ; Sheep or Half Morocco, ;^8.oo net. The advent of each successive volume of the series of the American Text- Books has been signalized by the most flattering comment from both the Press and the Profession. The high consideration received by these text-books, and their attainment to an authoritative position in current medical literature, have been matters of deep international interest, which finds its fullest expression in the demand for these publications from all parts of the civilized world. In the preparation of the "American Text-Book of Obstetrics" the editor has called to his aid proficient collaborators whose professional prominence entitles them to recognition, and whose disquisitions exemplify Practical Obstetrics. While these writers were each assigned special themes for dis- cussion, the correlation of the subject-matter is, nevertheless, such as ensures logical connection in treatment, the deductions of which thoroughly represent the latest advances in the science, and which elucidate the best vtodern methods of procedure. The more conspicuous feature of the treatise is its wealth of illustrative matter. The production of the illustrations had been in progress for several years, under the personal supervision of Robert L. Dickinson, M. D., to whose artistic judgment and professional experience is due the most sumptuously illustrated work of the period. By means of the photographic art, combined with the skill of the artist and draughtsman, conventional illustration is super- seded by rational methods of delineation. Furthermore, the volume is a revelation as to the possibilities that may be reached in mechanical execution, through the unsparing hand of its publisher. CODTTRIBUTORS : Dr. James C. Cameron. Edward P. Davis. Robert L. Dickinson. Charles Warrington Earle. James H. Eiheridge. Henry J. Ciarricues. Barton Cooke Hirst. Charles Jewett. Dr. Howard A. Kelly. Richard C. Norris. Chauncey D. Palmer. TheophiUis Parvin. George A. Piersol. Edward Reynolds. Henry Schwarz. " At first glance we are overwhelmed by the magnitude of this work in several respects, viz. : First, by the size of the volume, then by the arr.iy of eminent teachers in this depart- ment who have taken part in its production, then by the profuseness and character of the illustrations, and last, but not least, the conciseness and clearness with which the text is ren- dered This is an entirely new composition, embodying the highest knowledge of the art as it stands to-day by authors who occupy the fnmt rank in their specialty, and there are many of them. We cannot turn over these pages without being struck by the superb illustrations which adorn so many of them. We are confident that this most practical work will find instant appreciation by practitioners as well as students." — New Yor/; Medical Times. Permit me to say that your American Text-Book of Obstetrics is the most magnificent medical work that 1 have ever seen. I congratulate you and thank you for this superb work, which alone is sufficient to place you first in the ranks of medical publishers. With profound respect I am sincerely yours, Ai-KX. J. C. Skene. PRACTICE OF MEDICINE. By American Teachers. Edited by William Pepper, M. D., LL.D., Provost and Professor of the Theory and Practice of Medicine and of Clinical Medicine in the University of Pennsylvania. Complete in two handsome royal- octavo volumes of about looo pages each, with illustrations to elucidate the text wherever necessary. Price per Volume : Cloth, ^5.00 net ; Sheep or Half-Morocco, ^6.00 net. VOLilIME I. CONTAINS: Hygiene. — Fevers (Ephemeral, Simple Con- tinued, Typhus, Typhoid, Epidemic Cerebro- spinal Meningitis, and Relapsing). — Scarla- tina, Measles, Rotheln, Variola, Varioloid, Vaccinia, Varicella, Mumps, Whooping-cough, Anthrax, Hydrophobia, Trichinosis, Actino- mycosis, Glanders, and Tetanus. — Tubercu- loois, Scrofula, Syphilis, Diphtheria, Erysipe- las, Malaria, Cholera, and Yellow Fever. — Nervous, Muscular, and Mental Diseases etc. VOtlJME II. CONTAINS! Urine (Chemistry and Microscopy). — Kid- ney and Lungs. — Air-passages (Larynx and Bronchi) and Pleura. — Pharynx, CEsophagus, Stomach and Intestines (including Intestinal Parasites), Heart, Aorta, Arteries and Veins. — Peritoneum, Liver, and Pp.ncreas. — Diathet- ic Diseases (Rheumatism, Rheumatoid Ar- thritis, Gout, Lithsemia, and Diabetes.) — Blood and Spleen. — Inflammation, Embolism, Thrombosis, Fever, and Bacteriology. The articles are not written as though addressed to student'^ in lectures, but are exhaustive descriptions of diseases, with the newest facts as regards Causa- tion, Symptomatology, Diagnosis, Prognosis, and Treatment, including a large number of approved formulae. The recent advances made in the study of the bacterial origin of various diseases are fully described, as well as the bearing of the knowledge so gained upon prevention and cure. The subjects of Bacteriology as a whole and of Immunity are fully considered in a separate section. Methods of diagnosis are given the most minute and careful attention, thus enabling the reader to learn the very latest methods of investigation without consulting works specially devoted to the subject. CONTRIBUTORS : Dr. J. S. Billings, Philadelphia. Francis Delafield, New York. Reginald H, Fitz, Boston. James W. Holland, Philadelphia. Henry M. Lyman, Chicago. V/illiam Osier, Baltimore. Dr. William Pepper, Philadelphia. W. Oilman Thompson, New York. W. H. Welch, Baltimore. James T. Whiltaker, Cincinnati. James C. Wilson, Philadeiphia. Hontfo C. Wood, Philadelphia. " We reviewed the first volume of this work, and said : ' It is undoubtedly one ol the best text-books on the practice of medicine which we possess.' A consideration of the second and last volume leads us to modify that verdict and to say that the completed work is, in our opinion, the best of its kind it has ever been our fortune to see. It is complete, thorough, accurate, and clear. It is well written, well arranged, well printed, well illustrated, and well bound. It is a model of what the modern text-book should be." — rfew York Medical yournal. " A library upon modern medical art. The work must promote the wider difl'usion of sound knowledge." — American Lane*. " A trusty counsellor for the practitioner oi- senior student, on which he may implicitly 'ely.' — Edinburgh Medical yournal. CATALOGUE OF MEDICAL WORKS. II *AN AMERICAN TEXT-BOOK OF SURGERY. Edited by Wil- liam W. Keen, M. D., LL.D., and J. William White, M. D., Ph. D. Forming one handsome royal octavo volume of 1230 pages (10x7 inches), with 496 wood-cuts in text, and 37 colored and halftone plates, many of them engraved from original photographs and drawings furnished by the authors. Price : Cloth, ^7.00 net; Sheep or Half Morocco, gS.oo net. THIRD EDITION. THOROUGHLY REVISED. in the present edition, among the new topics introduced are a full considera- tion of serum-theiapy ; leucocytosis ; post-operative insanity; the use of dry heat at high tem|)eratures ; Kronlein's method of locating the cerebral fissures; Hoffa's and I.orenz's operations of congenital dislocations of the hip; Allis's re- searches on dislocations of the hip-joint ; lumbar puncture ; the forcible reposi- tion of the spine in Pott's disease ; the treatment of exophthalmic goiter ; the surgery of typhoid fever; gastrectomy and other operations on the stomach; new methodsof operating upon the intestines; the use of Kelly's rectal specula; the surgery of the ureter; Schleich's infiltration-method and the use of eucain for local anesthesia; Krause's method of skin-grafting; the newer metiiods of disinfecting the hands; the use of gloves, etc. The sections on Appendicitis, on Fractures, and on Gynecological Operations have been revised and enlarged. A considerable number of new illustrations have been added, and enhance the value of the work. The text of the entire book has been submitted to all the authors for their mutual criticism and revision — an idea in book-making that is entirely new and original. The book as a whole, therefore, expresses on all the important sur- gical topics of the day the consensus of opinion of the eminent surgeons who have joined in its preparation. One of the most attractive features of the book is its illustrations. Very many of them are original and faithful reproductions of photographs taken directly from patients or from specimens, CONTKIBITTORS : Dr. Phineas S. Conner, Cincinnati. Frederic S. Dennis, New York. William W. Keen, Philadelphia. Charle.s B Nancrede, Ann Arbor. Mich. Ros.well Park. Buffalo, New York. Lewis S. Pilcher. New York. Dr. Nicholas Senn, Chicago. Francis J. Shepherd, Montreal, Canada. Lewis A. Stimson, New York. J. Collins Warren, I'oston. J. William White, Philadelphia. " If this text-book is a fair reflex of the present position of American surgery, we must admit it is of a very high order of merit, and that English surgeons will have to look very carefully to their laurels if they are to preserve a position in the van of surgical practice." — London Lancet. Personally, f should not mind it being called THE Tf.xt-Kook (instead of A Text- Rook), for 1 know ot no single volume which contains so readable and complete an account of the science and art of Surgery as this does." — Edmunij Owen, K. R. C. S., Member of the Board nf Examiners of the Royal College 0/ Surgeons, hntrmna 12 IV. B. SAUNDERS' * AN AMERICAN TEXT-BOOK OF GYNECOLOGY, MEDICAL AND SURGICAL, for the use of Students and Practitioners. Edited by J. M. Baluy, M. D. Forming a handsome royal-octavo volume of 718 pages, with 341 illustrations in the text and 38 colored and half- tone plates. Prices : Cloth, ^6.00 net; Sheep or Half-Morocco, $7.00 net. SECOND EDITION, THOROUGHLY REVISED. In this volume all anatomical descriptions, excepting those essential to a clear understanding of the text, have been omitted, the illustrations being largely de- pended upon to elucidate the anatomy of the parts. This work, which is thoroughly practical in its teachings, is intended, as its title implies, to be a working text-book for physicians and students. A clear line of treatment has been laid down in every case, and although no attempt has been made to dis- cuss mooted points, slili the most important of these have been noted and ex- plained. The operations recommended are fully illustrated, so that the reader, having a jiicture of the procedure described in the text under his eye, cannot fail to grasp the idea. All extraneous matter and discussions have been carefully excluded, the attempt being made to allow no unnecessary details to cumber the text. The subject-matter is brought up to date at every point, and the work is as nearly as possible the combined opinions of the ten specialists who figure as the authors. In the revised edition much new material has been added, and some of the old eliminated or modified. More than forty of the old illustrations have been replaced by new ones, which add very materially to the elucidation of the text, as they picture methods, not specimens. The chapters on technique and after-treatment have been considerably enlarged, and the portions devoted to plastic work have been so greatly improred as to be practically new. Hyste- rectomy has been rewritten, and all the descriptions of operative procedures have been carefully revised and fully illustrated. CONTRIBrTORS : Dr. Henry T. Byford. John M. Baldy. Edwin Cragin. H. Etheridge. William Goodell. Wil Dr. Howard A. Kelly. Florian Krug. E. E. Montgomery. William R. Pryor. George M. Tuttle. "The most notable contribution to gynecological literature since 1887 and the most complete exponent of gynecology which we have. No subject seems to have been neglected, .... and the gynecologist and surgeon, and the general practitioner who has any desire to practise diseases of women, will find it of practical value. In the matter of illustrations and plates the book surpasses anything we have seen." — Boston Medical and Surgical yournal. " A thoroughly modern text-book, and gives reliable and well-tempered advice and in- struction." — Edinburgh Medical Journal. " The harmony of its conclusions and the homogeneity of its style give it an individuality which suggests a single rather than a multiple authorship."— .,4««a/.f 0/ Surgery. " It must command attention and respect as a worthy representation of our advanced clinical teaching." — American yournal of Medical Sciences. CATALOGUE OF MEDICAL WORKS. 13 *AN AMERICAN TEXT-BOOK OF THE DISEASES OF CHIL- DREN. By American Teachers. Edited by Louis Starr, M. D., assisted by THOMPSON S, Westcott, M. D. In one handsome r©yal-8vr> volume of 1244 pages, profusely illustrated with wood-cuts, half-tone and colored plates. Net Prices: Cloth, $'j.oo; Sheep or Half-Morocco, ^8.00. SECOND EDITION, REVISED AND ENLARGED. The plan of this work embraces a series of original articles written by some sixty well-known poediatrists, representing collectively the teachmgs of the most prominent medical schools and colleges of America. The work is intended to be a PRACTICAL book, suitable for constant and handy reference by the practi- tioner and the advanced student. Especial attention has been given to the latest accepted teachings upon the etiology, symptoms, pathology, diagnosis, and treatment of the disorders of chil- dren, with the introduction of many special formul^e and therapeutic procedures. In this new edition the whole subject matter has been carefully revised; new articles added, some original papers emended, and a number entirely rewritten. The new articles include "Modified Milk and Percentage Milk-Mixtures," " Lithemia," and a section on " Orthopedics." Those rewritten are " Typhoid Fever," "Rubella," "Chicken-pox," "Tuberculous Meningitis," "Hydroceph- alus," and "Scurvy;" while extensive revision has been made in "Infant Feeding," " Measles," " Diphtheria," and " Cretinism." The volume has thus been much increased in size by the introduction of fresh material. CONTRIBUTORS 1 Dr. S. S. Adams, Washington. John Ashhurst, Jr., Philadelphia. A. D. Blackader, Montreal, Canada. D.ivid Bovaird, ^few York. Dillon Brown, New York. Edward M. Buckingham, Boston. Charles W. Burr, Philadelphia. W. E. Casselberry, Chicago. Henry Dwight Chapin, New York. W. S. Christopher, Chicago. Archibald Chuich, Chicago. Floyd M. Crandall, New York. Andrew F. Currier, New York. Roland G. Ciirtin, Philadelphia J. M. DaCos'a, Philadelphia. I. N. Danforth, Chicago. Edward P. Davis, Philadelphia. John B. Deaver, Philadelphia. G. E. de Schweinitz, Philadelphia. John Doming, New York. Charles Warrington Earle, Chicago. Wm. A. Edwards, San Diego, Cal. F. Forchheimer, Cincinnati. t Henry Fruitnight, New York. P. Crozer Griffith, Philadelphia. . A. Hardaway. St. Louis. M. P Hatfield, Chicago. Barton Cooke Hirst, Philadelphia. H. Illoway, Cincinnati. Henry Jackson, Boston. Charles G. Jennings, Detroit Henry Koplik. New York. Dr. Thomas S. Latimer, Baltimore. Albert R. Leeds, Hoboken, N. J. J. Hendrie Lloyd, Philadelphia. George Roe Lockwood, New York. Henry M. Lyman, Chicago. Francis T. Miles, Baltimore. Charles K Mills, Philadelphia. James E Moore, Minneapolis. F. Gordon Morrill, Boston. John H. Musser, Philadelphia. Thomas R. Neilson, Philadelphia. W. P. Northrup, New York. William Osier, Baltimore. Frederick A. Packard, Philadelphia. William Pepper, Philadelphia. P'rederick Peterson, New York. W. T. Plant, Syracuse, New York William .\1. Powell. Atlantic City. B. K. Rachford, Cincinnati. B. Alexander Randall, Philadelphia. Edward O. Shakespeare, Philadelphia F. C. Shattuck, Boston. J. Lewis Smith, New York. Louis Starr, Philadelphia. M. Allen Starr, New York. Charles W. Townsend, Boston. lames Tyson, Philadelphia. W. S. Thayer, Baltimore. Victor C. Vaughan, Ann Arbor, Mich Thompson S. Westcott, Philadelphia. Henry R. Wharton, Philadelphia. J William White, Philadelphia. J. C. Wilson, Philadelphia. H IV. B. SAUNDERS' *AN AMERICAN TEXT-BOOK OF GENITO-URINARY AND SKIN DISEASES. By 47 Eminent Specialists and Teachers. Edited by L. Bolton Bangs, M. D., Professor of Genito-Urinary Surgery, Uni- versity and Bellevue Hospital Medical College, New York ; and W. A. Hardaway, M. D., Professor of Diseases of the Skin, Missouri Medical College. Imperial octavo volume of 1229 pages, with 300 engravings and 20 full-page colored plates. Cloth, $7.00 net; Sheep or Half Morocco, $8.00 net. This addition to the series of " American Text-Books," it is confidently be- lieved, will meet the requirements of both students and practitioners, giving, as it does, a comprehensive and detailed presentation of the Diseases of the Genito-Urinary Organs, of the Venereal Diseases, and of the Affections of the Skin. Having secured the collaboration of well-known authorities in the branches represented in the undertaking, the editors have not restricted the contributors ii. regard to the particular views set forth, but have offered every facility for the free expression of their individual opinions. The work will therefore be found to be original, yet homogeneous and fully representative of the several depart- ments of medical science with which it is concernea. CONTRIBUTORS : Dr. Chas. W. Allen; New York. I. E. Atkinson, Baltimore. L Bolton Bangs, New York. P. R. Bolton, New York. Lewis C. Bosher, Richmond, Va. John T. Bowen, Boston. J. Abbott Cantrell. Philadelphia. William T. Corlett, Cleveland, Ohio. B. Farquhar Curtis, New York. Condict W. Cutler, New York. Isadore Dyer, New Orleans. Christian Fenger, Chicago. John A. Fordyce, New York. Eugene Fuller, New York. R. H. Greene, New York. Joseph Grindon, St. Louis. Graeme ^L Hammond, New York. W. A. Hardaway, St. Louis. M. B. Hartzell, Philadelphia. Louis Heitzmann, New York. James S. Howe, Boston. George T. Jackson, New York. Abraham Jacobi. New York. James C. lohnslon. New York. Dr. Hermann G. Klotz, New York. J. H. Linsley, Burlington, Vt, G. F. Lydston, Chicago. Hartwell N. Lyon. St. Louis. Edward Martin, Philadelphia. D. G. Montgomery, San Francisco. James Pedersen, New York. S. Pollitzer, New York. Thomas R. Pooley, New York. A. R. Robinson, New York. A. E. Rtgensburger, San Francisco. Francis J. Shepherd, Montreal, Can. S. C. Stanton, Chicago, ill. Emmanuel J. Stout, iPhiladelphia. Alonzo E. Taylor Philadelphia. Robert W. Taylor, New York. Paul Thorndike, Boston. H. Tuholske, St. I^ouis. Arthur Van Harlingen, Philadelphia. Francis S. Watson, Boston, J. William White, Philadelphia. J. McF. Wiufield, Brooklyn. Alfred C. Wood, Philadelpma. "This voluminous work is thoroughly up to date, and the chapters on genito-unnarv ois- eases are especially valuable. The illustrations are fine and are mostly original. The section on dermatology is concise and in every way admirable."— y<;«r«a/ of the American Medical Association. "This volume is one of the best yet issued of the publisher's series of 'American Text- Books.' The list of contributors represents an extraordinary array of talent and extended experience. The book will easily take the place in comprehensiveness and value of the half dozen or more costly works on these subjects which have hitherto been necessary to a well-equipped library." — New York Polvclinic. CATALOGUE OF MEDICAL WORKS. 15 * AN AMERICAN TEXT-BOOK OF DISEASES OF THE EYE, EAR, NOSE, AND THROAT. Edited by George E. de Schweinitz, A. M., M. D., Professor of Ophthalmology, Jefferson Medical College; and B. Alexander Randall, A. M., M. D., Clinical Professor of Diseases of the Ear, University of Pennsylvania. One handsome imperial octavo volume of 1251 pages; 766 illustrations, 59 of them colored. Prices: Clot'i., S7.00 net; Sheep or Half- Morocco, $8.00 net. Just Issued. The present work is the only book ever published embracing diseases of the intimately related organs of the eye, ear, nose, and tHroat. Its special claim to favor is based on encyclopedic, authoritative, and practical treatment of the subjects. Each section of the book has been entrusted to aa author who is specially identified with the subject on which he writes, and who therefore presents his case in the manner of an expert. Uniformity is secured and overlapping pre- vented by careful editing and by a system of cross-references which forms a special feature of the volume, enabling the reader to come into touch with all that is said on any subject in different portions of the book. Particular emphasis is laid on the most approved methods of treatment, so that the book shall be one to which the student and practitioner can refer for information in practical work. Anatomical and physiological problems, also, are fully discussed for the benefit of those who desire to investigate the more abstruse problems of the subject. CONTRIBUTORS : .Dr. Henry A. Alderton, Brooklyn. Harrison .411en, Philadelphia. Frank Allport, Chicago. Morris J. Asch. New York. S. C. Ayres, Cincinnati. R. O. Beard, Minneapolis. Clarence J. Blake, Boston. Arthur .A.. Bliss, Philadelphia. Albert P. Brub;iker, Philadelphia. J. H. Bryan, Washington, D. C. Albert H. Buck, New York. F. Buller, Montreal, Can. Swan M. Burnett, Washington, D C. I" lemming Carrow, Ann Arbor, Mich. V/. E. Casselberry, Chicago. Colman W. Cutler, New York. Edward B. Dench, New York. William S. Dennett, New York. George E. de Schweinitz, Philadelphia. Alexander Duane, New York. John W. Farlow, Boston, Mass. Walter J freeman, Philadelphia. H. Giffbrd, Omaha, Neb. W. C. Glasgow, St. Louis. T- Orne Green, Boston. Ward A. Holden, New York. Christian R. Holmes, Cincinnati. William E. Hopkins, San Francisco. F. C Hotz, Chicago. Lucien Howe, Bunalo, N. Y. Dr. Alvin A. Hubbell, Buffalo, N. Y. Edward Jackson, Philadelphia. J. Ellis Jennings, St. Louis. Herman Knapp, New York, ("has. W. Kollock, Charleston, S. C. \'i. A Leland, Boston. J. A. LippiHcott, Pittsburg. Pa. O. Hudson Makuen, Philadelphia. Tohn H. McCoUom, Boston. H. G. Miller, Providence, R. L B. L. Jlilliken, Cleveland, Ohio. F'.obert C. Myles, New York, James E. Newcomb, New York. R. J. Phillips, Philadelphia. George A. Piersol, Philadelphia. W. P. Porcher, Ch.irleston. S. C. B. Alex. Randall, Philadelphia. Robert L. Randolph, Baltimore. John O. Roe, Rochester, N. Y. Charles E. de M. Sajous, Philadelphia. J. E. Sheppard, Brooklyn, N. Y. E. L. Shurly. Detroit, Mich. William M. Sweet, Philadelphia. Samuel Theobald. Baltimore, Md. A. G. Thomson, Philadelphia. Clarence A. Veasey, Philadelphia. John E. Weeks, New York. Casey A. Wood, Chicago, 111. Jonathan Wright, Brooklyn. H. V. Wiirdemann, Milwaukee, Wit. i6 IV. B. SAUNDERS' *AN AMERICAN YEAR-BOOK OF MEDICINE AND SUR- GERY. A Yearly Digest of Scientific Progress and Authoritative Opinion in all branches of Medicine and Surgery, drawn from journals> monographs, and text-books of the leading American and Foreign authors and investigators. Collected and arranged, with critical editorial com- ments, by eminent American specialists and teachers, under the general editorial charge of George M. Gould, M. D. Volumes for 1896, '97, '98, and '99 each a handsome imperial octayo volume of about 1200 pages. Prices : Cloth, $6.50 net ; Half-Morocco, ^7.50 net. Year- Book for 1900 in two octavo volumes of about 600 pages each. Prices per volume : Cloth, ;^3.oo net; Half- Morocco, $3.75 net. In Two Volumes. No Increase in Price. In response to a widespread demand from the medical profession, the pub- lisher of the "American Year- Book of Medicine and Surgery" has decided to issue that well-known work in two volumes, Vol. I. treating of General Medi- cine, Vol. II. of General Surgery. Each volume is complete in itself, and the work is sold either separately or in sets. This division is made in such a way as to appeal to physicians from a class standpoint, one volume being distinctly medical, and the other distinctly surgi- cal. This arrangement has a two-fold advantage. To the physician who uses the entire book, it offers an increased amount of matter in the most convenient form for easy consultation, and without any increase in price; while the man who wants either the medical or the surgical section alone secures the complete consideration of his branch without the necessity of purchasing matter for which he has no use. CONTBIBUTORS : Vol. I. Dr. Samuel W. Abbott. Boston. Archibald Church, Chicago. Louis A. Duhring, Philadelphia. D. I.. Edsall, Philadelphia. Alfred Hand, Jr., Philadelphia. M. B. Hartzell, Philadelphia. Keid Hunt, Baltimore. Wyatt Johnston, Montre.il. Walter Jones, Baltimore. David Riesman. Philadelphia. Louis Starr, Philadelphia. Alfred Stengel, Philadelphia. A. A. Stevens, Philadelphia. G. N. Stewart. Cleveland. Reynold W. Wilcox, New York City. Vol. IL Dr. J Montgomery Baldy, Philadelphia. Charles H. Burnett, Philadelphia. J. Chalmers DaCosta. Philadelphia. W. A. N. Dorland, Philadelphia. Virgil P. Gibney, New York City. C. H. Hamann, Cleveland. Howard F. Hansell, Philadelphia. Barton Cooke Hirst, Philadelphia. E. Fletcher Ingals, Chicago. W. W. Keen, Philadelphia. Henry G. Ohls, Chicago. Wendell Reber, Philadelphia. J. Hilton Waterman, New York City. "It is difficult to know which to admire most— the research and industry of tne distin- guished band of experts whom Dr. Gould has enlisted in the service of the \ ear-Book, or the wealth and abundance of the contributions to every department of science that have been deemed worthy of analysis. ... It is much mors than a mere compilation of abstracts tor, as each section is entrusted to experienced and able contributors, the reader has the advan- tage of certain critical commentaries and expositions . . . proceeding from writers tully qualified to perform these tasks. ... It is emphatically a book which should find a place in every medical library, and is in several respects more useful than the famous Jahrbucner of Germany." — London Lancet. CATALOGUE OF MEDICAL WORKS. 1 7 * ANOMALIES AND CURIOSITIES OF MEDICINE. By George M. Gould, M.D., and Walter L. Pyle, M.D. An encyclopedic collec- tion of are and extraordinary cases and of the most striking instances of abnormality in all branches of Medicine and Surgery, derived from an ex- haustive research of medical literature from its origin to the present day, abstracted, classified, annotated, and indexed. Handsome imperial octavo volume of 968 pages, with 295 engravings in the text, and 12 full-page plates. Cloth, $3.00 net ; Half-Morocco, S4.00 net. POPULAR EDITION REDUCED FROM $6.00 to $3.00. In view of the great success of this magnificent work, the publisher has decided to issue a " Popular Edition" at a price so low that it may be procured by every student and practitioner of medicine. Notwithstanding the great reduction in price, there will be no depreciation in the excellence of typography, paper, and binding that characterized the earlier editions. Several years of exhaustive research have been spent by the authors in the great medical libraries of the United States and Europe in collecting the mate- rial for this work. Medical literature of all ages and all languages has been carefully searched, as a glance at the Bibliographic Index will show. The facts, which will be of extreme value to the author and lecturer, have been arranged and annotated, and full reference footnotes given. "One of the most valuable contributions ever made to medical literature. It is, so far as we know, absolutely unique, and every page is as fascinating as a novel. Not alone for the medical profession has this volume value : it will serve as a book of reference for all who are interested in general scientific, sociologic, or medico-legal topics." — Brooklyn Medical yoiir- nal. NERVOUS AND MENTAL DISEASES. By Archibald Church, M. D., Professor of Clinical Neurology, Mental Diseases, and Medical Jurisprudence, Northwestern University Medical School; and Fredkrick Peterson, M. D., Clinical Professor of Mental Diseases, Woman's Medi- cal College, New York. Handsome octavo volume of 843 pages, with over 300 illustrations. Prices: Cloth, $5.00 net; Half- Morocco, $6.00 net. Second Edition. This book is intended to furnish students and practitioners with a practical, working knowledge of nervous and mental diseases. Written by men of wide experience and authority, it presents the many recent additions to the suiyect. The book is not iilied with an extended dissertation on anatomy and pathology, but, treating these [loints in connection with special conditions, it lays |)articular stress on methods of examination, diagnosis, and treatment. In this respect the work is unusually complete and valuable, laying down the definite courses of procedure which the authors have found to be most generally satisfactory. "The work is an epitome of what is to-day known of nervous diseases prepared for the student and practitioner in the light of the author's experience . . . We believe that no work presents the difficult subject of insanity in such a reasonable and readable way." — Chicago Medical Recorder. 1 8 W. B. SAUNDERS' DISEASES OF THE NOSE AND THROAT. By D. Braden Kyle, M. D., Clinical Professor of Laryngology and Rhinology, Jefferson Medi- cal College, Philadelphia; Consulting Laryngologist, Rhinologist, and Otologist, St. Agnes' Hospital. Octavo volume of 646 pages, vvith over 150 illustrations and 6 lithographic plates. Cloth, $4.00 net; Half-Mo- rocco, $5.00 net. Just Issued. This book presents the subject of Diseases of the Nose and Throat ui as con- cise a manner as is consistent with clearness, keeping in mind the needs of the student and general practitioner as well as those of the specialist. Tiie arrange- ment and classification are based on modern pathology, and the pathological views advanced are supported by drawings of microscopical sections made in the author's own laboratory. These and the other illustrations are particularly fine, being chiefly original. With the practical purpose of the book in mind, ex- tended consideration has been given to details of treatment, each disease being considered in full, and definite courses being laid down to meet special condi- tions and symptoms. " It is a thorough, full, and systematic treatise, so classified and arranged as greatly to facili- tate the teaching of laryngology and rhinology to classes, and must prove most convenient and satisfactory as a reference book, both for students and practitioners." — International Medical Magazine. THE HYGIENE OF TRANSMISSIBLE DISEASES : their Causa- tion, Modes of Dissemination, and Methods of Prevention. By A. C. Abbott, M. D., Professor of Hygiene in the University of Pennsyl- vania; Director of the Laboratory of Hygiene. Octavo volume of 311 pages, with charts and maps, and numerous illustrations. Cloth, $2.00 net. Just Issued. It is not the purpose of this woik to present the subject of Hygiene in the comprehensive sense ordinarily im])lied by the word, but rather to deal directly with but a section, certainly not the least important, of the subject — viz., that embracing a knowledge of the preventable specific diseases. The book aims to furnish information concerning the detailed management of transmissible dis- eases. Incidentally there are discussed those numerous and varied factors that have not only a direct bearing upon the incidence and suppression of such dis- eases, but are of general sanitary importance as well. " The work is admirable in conception and no less so in execution. It is a practical work, simply and lucidly written, and it should prove a most helpful aid in that department of medicine which is becoming daily of increasing importance and application — namely, prophy- laxis." — I'hiladcl/>liia Medical Journal. " It is scientific, but not too technical ; it is as complete as our present-day knowledge of hygiene and sanitation allows, and it is in harmony with the efforts of the profession, which are tending more and more to methods of prophylaxis. For the student and for the practi- tioner it is well nigh indispensable." — Medical News, New York. CATALOGUE OF MEDICAL WORKS. ig A TEXT-BOOK OF EMBRYOLOGY, By John C. Heisler, M. D, Professor of Anatomy in the Medico-Chirurgical College, Philadelphia Octavo volume of 405 pages, with 190 illustrations, 26 in colors. Cloth ;?2.5o net. Just Issued. The facts of embryology having acquired in recent years such great interest in connection with the teaching and with the proper comprehension of human anatomy, it is of first importance to the student of medicine that a concise and yet sufficiently full te.xt-book upon the subject be available. It was with the aim of presenting such a book that this volume was written, the author, in his experience as a teacher of anatomy, having been impressed with the fact that students were seriously handicapped in their study of the subject of embryology by the lack of a text-book full enough to be intelligible, and yet without that minuteness of detail which characterizes the larger treatises, and which so often serves only to confuse and discourage the beginner. " In short, the book is written to fill a want which has distinctly existed and which it definitely meets ; commendation greater than this it is not possible to give to anything." — Medical News, New York. A MANUAL OF DISEASES OF THE EYE. By Edward Jack- son, A. M., M. D., sometime Professor of Diseases of the Eye in the Phila- delphia Polyclinic and College for Graduates in Medicine. i2mo, 604 pages, with 178 illustrations from drawings by the author. Cloth, ^2.50 net. Jnst Issued. This book is intended to meet the needs of the general practitioner of medi- cine and the beginner in ophthalmology. More attention is given to the condi- tions that must be met and dealt with early in ophthalmic practice than to the rarer diseases and more difficult operations that may come later. It is designed to furnish efficient aid in the actual work of dealing with dis- ease, and therefore gives the place of first importance to the recognition and management of the conditions that present themselves in actual clinical work. LECTURES ON THE PRINCIPLES OF SURGERY. By Charles B. Nancrede, M. D., LL.D., Professor of Surgery and of Clinical Surgery, University of Michigan, Ann Arbor. Handsome octavo, 398 pages, illus- trated. Cloth, ;^2.50 net. Just Issued. The present book is based on the lectures delivered by Dr. Nancrede to his undergraduate classes, and is intended as a text-book for students and a practi- cal help for teachers. By the careful elimination of unnecessary details of pathology, bacteriology, etc., which are amply jirovided for in other courses of study, space is gained for a more extended consideration of the Principles of Surgery in themselves, and of the application of these principles to methods of practice. 20 I'V. B. SAUNDERS' A TEXT-BOOK OF PATHOLOGY. By Alfred Stengel, M. D., Professor of Clinical Medicine in the University of Pennsylvania; Physi- cian to the Philadelphia Hospital ; Physician to the Children's Hospital, Philadelphia. Handsome octavo volume of 848 pages, with 362 illustra- tions, many of which are in colors. Prices : Cloth, #4.00 net ; Half- Morocco, ^5.00 net. Second Edition. In this work the practical application of pathological facts to clinical medicine is considered more fully than is customary in works on pathology. While the subject of pathology is treated in the broadest way consistent with the size of the book, an effort has been made to present the subject from the point of view of the clinician. The general relations of bacteriology to pathology are dis- cussed at considerable length, as the importance of these branches deserves. It will be found that the recent knowledge is fully considered, as well as older and more widely-known facts. " I consider the work abreast of modern pathology, and useful to both students and prac- titioners. It presents in a concise and well-considered form the essential facts of general and special pathological anatomy, with more than usual emphasis upon pathological physiology." — William H. Welch, Frofcssor of PatJiology, Joltns Hopkins University, Baltimore, Md. " I regard it as the most serviceable text-book for students on this subject yet written by an American author." — L. Hkktoen, Professor of Patliology, Rush JMedical College, Chicago, III. A TEXT-BOOK OF OBSTETRICS. By Barton Cooke Hirst, M.D., Professor of Obstetrics in the University of Pennsylvania. Handsome oc- tavo volume of 846 pages, with 618 illustrations and seven colored plates. Prices: Cloth, ;^5.00 net; Half- Morocco, ^6.00 net. Second Edition. This work, which has been in course of preparation for several years, is in- tended as an ideal text-book for the student no less than an advanced treatise for the obstetrician and for general practitioners. It represents the very latest teaching in the practice of obstetrics by a man of extended experience and recognized authority. The book emphasizes especially, as a work on obstetrics should, the practical side of the subject, and to this end presents an unusually large collection of illustrations. A great number of these are new and original, and the whole collection will form a complete atlas of obstetrical practice. An extremely valuable feature of the book is the large number of refer- ences to cases, authorities, sources, etc., forming, as it does, a valuable bib- liography of the most recent and authoritative literature on the subject of obstetrics. As already stated, this work records the wide practical ex- perience of the author, which fact, combined with the brilliant presentation of the subject, will doubtless render this one of the most notable books on obstetrics that has yet appeared. " The illustrations are numerous and are works of art, many of them appearing for the first time. The arrangement of the subject-matter, the foot-notes, and index are beyond criticism. The author's style, though condensed, is singularly clear, so that it is never necessary to re-read a sentence in order to grasp its meaning. As a true model of what a modern text-book in obstetrics should be, we feel justified in affirming that Dr. Hirst's book is without a rival." — Neiv York Medical Record. CATALOGUE OF MEDICAL WORKS. 21 A TEXT-BOOK OF THE PRACTICE OF MEDICINE. By James M. Anders, M.D., Ph.D., LL.D., Professor of the Practice of Medicine and of Clinical Medicine, Medico-Chirurgical College, Philadel- phia. In one handsome octavo volume of 1292 pages, fully illustrated. Cloth, $5.50 net ; Sheep or Half-Morocco, ;^6.5o net. THIRD EDITION, THOROUGHLY REVISED. The present edition is the result of a careful and thorough revision. A few new subjects have been introduced : Glandular Fever, Ether-pneumonia, Splenic Anemia, Meralgia Paresthetica, and Periodic Paralysis. The affections that have been substantially rewritten are: Plague, Malta Fever, Diseases of the Thymus Gland, Liver Cin^hoses, and Progressive Spinal Muscular Atrophy. The following articles have been extensively revised : Typhoid Fever, Yellow Fever, Lobar Pneumonia, Dengue, Tuberculosis, Diabetes Mellitus, Gout, Ar- thritis Deformans, Autumnal Catarrh, Diseases of the Circulatory System-, more particularly Hypertrophy and Dilatation of the Heart, Arteriosclerosis and Thoracic Aneurysm, Pancreatic Hemorrhage, Jaundice, Acute Peritonitis, Acute Yellow Atrophy, Hematoma of Duia Mater, and Scleroses of the Brain. The preliminary chapter on Nervous Diseases is new, and deals with the subject of localization and the various methods of investigating nervous affections. "It is an excellent book — concise, comprehensive, thorough, and up to date. It is a credit to you; but, more than that, it is a credit to the profession of Philadelphia — to us." — James C. Wilson, Professor of the Practice of Medicine and Clinical Medicine, Jeffer- son Medical College, Philadelphia. " The book can be unreservedly recommended to students and practitioners as a safe, full compendium of the knowledge of internal medicine of the present day ... It is a work thoroughly modern in every sense." — Medical News, New York. DISEASES OF THE STOMACH. By William W. Van Vat.zah, M. D., Professor of General M-- Jicine and Diseases of the Digestive System and the Blood, New York Polyclinic; and J. Douglas Nisbet, M. D., Adjunct Professor of General Medicine and Diseases of the Digestive Sys- tem and the Blood, New York Polyclinic. Octavo volume of 674 pages, illustrated. Cloth, ^3.50 net. An eminently practical book, intended as a guide to the student, an aid to the physician, and a contribution to scientific medicine. It aims to give a complete description of the modern methods of diagnosis and treatment of diseases of the stomach, and to reconstruct the pathology of the stomach in keeping with the revelations of scientific research. The book is clear, practical, and complete, and contains the results of the authors' investigations and of their extensive ex- perience as specialists. Particular attention is given to the important subject of dietetic treatment. The diet-lists are very complete, and are so arranged that selections can readily be made to suit individual cases. "This is the most satisfactorj' work on the subject in the English language." — Chicago Medical Recorder. " The article on diet and general medication is one of the most valuable in the book, and should be read by every practising physician." — Nezv York Medical fournal. 22 fV. £. SAUNDERS' SURGICAL DIAGNOSIS AND TREATMENT. By J. W. Mac- DONALD, M. D., Edin., F. R. C. S., Edin., Professor of the Practice of Sur- gery and of Clinical Surgery in Hamline University ; Visiting Surgeon to St. Barnabas' Hospital, Minneapolis, etc. Handsome octavo volume of 800 pages, profusely illustrated. Cloth, $5.00 net; Half-Morocco, $6.00 net. This work aims in a comprehensive manner to furnish a guide in matters of surgical diagnosis. It sets forth in a systematic way the necessities of examina- tions and the proper methods of making them. The various portions of the body are then taken up in order and the diseases and injuries thereof succinctly considered and the treatment briefly indicated. Practically all the modern and approved operations are described with thoroughness and clearness. The work concludes with a chapter on the use of the Rontgen rays in surgery. " The work is brimful of just the kind of practical information that is useful alike to students and practitioners. It is a pleasure to commend the book because of its intrinsic value to the medical practitioner." — Cincinnati La?icei- Clinic. PATHOLOGICAL TECHNIQUE. A Practical Manual for Laboratory Work in Pathology, Bacteriology, and Morbid Anatomy, with chapters on Post- Mortem Technique and the Performance of Autopsies. By Frank B. Mallory, A. M., M. D., Assistant Professor of Pathology, Harvard University Medical School, Boston ; and James H. Wright, A. M., M. D., Instructor in Pathology, Harvard University Medical School, Boston. Oc- tavo volume of 396 pages, handsomely illustrated. Cloth, ^2.50 net. This book is designed especially for practical use in pathological laboratories, both as a guide to beginners and as a source of reference for the advanced. The book will also meet the wants of practitioners who have opportunity to do general pathological work. Besides the methods of post-mortem examinations and of bacteriological and histological investigations connected with autopsies, the special methods employed in clinical bacteriology and pathology have been fully discussed. " One of the most complete works on the subject, and one which should be in the library of every physician who hopes to keep pace with the great advances made in pathology." — yournal of American Medical Association. THE SURGICAL COMPLICATIONS AND SEQUELS OF TY- PHOID FEVER. By Wm. W. Kekn, M. D., LL.D., Professor of the Principles of Surgery and of Clinical Surgery, Jefferson Medical College, Philadelphia. Octavo volume of 386 pages, illustrated. Cloth, $3.00 net. This monograph is the only one in any language covering the entire subject of the Surgical Complications and Sequels of Typhoid Fever. The work will prove to be of importance and interest not only to the general surgeon and phy- sician, but also to many specialists — laryngologists, ophthalmologists, gynecolo- gists, pathologists, and bacteriologists — as the subject has an important bearing upon each one of their spheres. The author's conclusions are based on reports of over 1700 cases, including practically all those recorded in the last fifty years. Reports of cases have been lirought down to date, many having been added while the work was in press. " This is probably the first and only work in the English language that gives the reader a clear view of what typhoid fever really is, and what it does and can do to the human organ- ism. This book should be in the possession of every medical man in America." — American Medico-Surgical Bulletin. CATALOGUE. OF MEDICAL WORKS. 23 MODERN SURGERY, GENERAL AND OPERATIVE. By John Chalmers DaCosta, M. D., Professor of Practice of Surgery and Clin- ical Surgeiy, Jefferson Medical College, Philadelphia; Surgeon to the Phil- adelphia Hospital, etc. Handsome octavo volume of 911 pages, profusely illustrated. Cloth, ^4.00 net; Half-Morocco, ^5.00 net. Second Edition, Rewritten and Greatly Enlarged. The remarkable success attending DaCosta's Manual of Surgery, and the general favor with which it has been received, have led the author in this revision to produce a complete treatise on modern surgery along the same lines that made the former edition so successful. The book has been entirely re- written and very much enlarged. The old edition has long been a favorite not only with students and teachers, but also with practising physicians and sur- geons, and it is believed that the present work will find an even wider field of usefuhiess. " We know of no small work on surgery in the English hingiiage which so well fulfils the requirements of the modern student." — Medico-Chirnrgiail Journal , Bristol, England. " The author has presented concisely and accurately the principles of modern surgery. The book is a valuable one which can be recommended to students and is of great value to the general practitioner." — American Journal of the Medical Sciences. A MANUAL OF ORTHOPEDIC SURGERY. By James E. Moore, M.D., Professor of Orthopedics and Adjunct Professor of Clinical Surgery, University of Minnesota, College of Medicine and Surgery. Octavo volume of 356 pages, with 177 beautiful illustrations from photographs made spec- ially for this work. Cloth, ^2.50 net. A practical book based upon the author's experience, in which special stress is laid upon early diagnosis and treatment such as can be carried out by the general practitioner. The teachings of the author are in accordance with his belief that true conservatism is to be found in the middle course between the surgeon who operates too frequently and the orthopedist who seldom operates. "A very demonstrative work, every illustration of which conveys a lesson. The work is a most excellent and commendable one, which we can certainly endorse with pleasure." — SI. Louis Medical and Surgical yournal. ELEMENTARY BANDAGING AND SURGICAL DRESSING, With Directions concerning the Immediate Treatment of Cases of Emer- gency. For the use of Dressers and Nurses. By Walter Pye, F.R.C.S., late Surgeon to St. Mary's Hospital, London. Small i2mo, with over 80 illustrations. Cloth, flexible covers, 75 cents net. This little book is chiefly a condens.ition of those portions of Pye's " .Surgical Handicraft" which ileal with bandaging, sjilinting, etc., and of those which treat of the management in the first instance of cases of emergency. The directions given are thoroughly practical, and the book will prove extremely use- ful to students, surgical nurses, and dressers. " The author writes well, the di.igrams are clear, and the book itself is small and portable, although the paper and type are good." — British Medical yournal. 24 iV. B. SAUNDERS' A TEXT-BOOK OF MATERIA MEDICA, THERAPEUTICS AND PHARMACOLOGY. By George F. Butler, Ph.G., M.D., Professor of Materia Medica and of Clinical Medicine in the College of Physicians and Surgeons, Chicago; Professor of Materia Medica and Therapeutics, Northwestern University, Woman's Medical School, etc Octavo, 874 pages, illustrated. Cloth, ^4.00 net ; Sheep, ^5.00 net. Third Edition, Thoroughly Revised. A clear, concise, and practical text-book, adapted for permanent reference no less than for the requirements of the class-room. The recent important additions made to our knowledge of the physiological action of drugs are fully discussed in the present edition. The book has been thoroughly revised and many additions have been made. " Taken as a whole, the book may fairly be considered as one of the most satisfactory of any single-volume works on materia medica in the market." — Journal 0/ the American Medical Associatiuti. TUBERCULOSIS OF THE GENITO-URINARY ORGANS, MALE AND FEMALE. By Nichola.s Senn, M.D., Ph.D., LL.D., Professor of the Practice of Surgery and of Clinical Surgery, Rush Medical College, Chicago. Handsome octavo volume of 320 pages, illustrated^ Cloth, $3.00 net. Tuberculosis of the male and female genito-urinary organs is such a frequent, distressing, and fatal affection that a special treatise on the subject appears to fill a gap in medical literature. In the present work the bacteriology of the sub- ject has received due attention, the modern resources employed in the differen- tial diagnosis between tubercular and other inflammatory affections are fully described, and the medical and surgical therapeutics are discussed in detail. "An important book upon an important subject, and written by a man of mature judg- ment and wide experience. The author has given us an instructive book upon one of the most important subjects of the day." — Clinical Reporter. " A work which adds another to the many obligations the profession owes the talented author." — Chicago Medical Recorder. A TEXT-BOOK OF DISEASES OF WOMEN. By Charles B. Penrose, M.D., Ph.D., Professor of Gynecology in the University of Pennsylvania; Surgeon to the Gynecean Hospital, Philadelphia. Octavo volume of 531 pages, with 317 illustrations, nearly all from drawings made for this work. Cloth, ^3.75 net. Third Edition, Revised. In this work, which has been written for both the student of gynecology and the general practitioner, the author presents the best teaching of modern gyne- cology untrammelled by antiquated theories or methods of treatment. In most instances but one plan of treatment is recommended, to avoid confusing the student or the physician wlio consults the book for practical guidance. " I shall value very highly the copy of Penrose's ' Diseases of Women' received. 1 have already recommended it to my class as THE BEST book." — Howard A. Kelly, Professor 0/ Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Aid. " The book is to be commended without reserve, not only to the student but to the general practitioner who wishes to have the latest and best modes of treatment explained with absolute clearness." — Therapeutic Gazette. CATALOGUE OF MEDICAL WORKS. 25 SURGICAL PATHOLOGY AND THERAPEUTICS. By John Collins Warren, M. D., LL.D., Professor of Surgery, Medical Depart- ment Harvard University. Handsome octavo, 832 pages, with 136 relief and lithograpliic illustrations, 33 of which are printed in colors. Second Edition, with an Appendix devoted to the Scientific Aids to Surgical Diagnosis, and a series of articles on Regional Bacteriology. Cloth, ^5.00 net; Half- Morocco, $6.00 net. Without Exception, the Illustrations are the Best ever Seen in a "Work of this Kind. "A most striking and very excellent feature of this book is its illustrations. Without ex- ception, from the point of accuracy and artistic merit, they are the best ever seen in a work of this kind. * * * Many of those representing microscopic pictures are so perfect in their coloring and detail as almost to give the beholder the impression that he is looking down the barrel of a microscope at a well-mounted section." — Annals of Surgery, Philadelphia. " It is the handsomest specimen of book-making * * * that has ever been issued from the American medical press." — American Journal of the Medical Sciences, Philadelphia. PATHOLOGY AND SURGICAL TREATMENT OF TUMORS. By N. Senn, M. D., Ph. D., LL. D., Professor of Practice of Surgery and of Clinical Surgery, Rush Medical College ; Professor of Surgery, Chicago Polyclinic ; Attending Surgeon to Presbyterian Hospital ; Surgeon-in-Chief, St. Joseph's Hospital, Chicago. One volume of 710 pages, with 515 engravings, including full-page colored plates. New and enlarged Edition in Preparation. Books specially devoted to this subject are few, and in our text-books and systems of surgeiy this part of surgical pathologj' is usually condensed to a de- gree incompatible with its scientific and clinical importance. The author spent many years in collecting the material for this work, and has taken great pains to present it in a manner that should prove useful as a text-book for the student, a work of reference for the practitioner, and a reliable guide for the surgeon. "The most exhaustive of any recent book in Engli.sh on this subject. It is well illus- trated, and will doubtless remain as the principal monograph on the subject in our language for some years. The book is handsomely illustrated and printed, .... and the author has given a notable and lasting contribution to surgery." — Journal of the American Medical Association , Chicago. LECTURES ON RENAL AND URINARY DISEASES. By RoiiERT Saundky, M. D., Edin., Fellow of the Royal College of Physicians, London, and of the Royal Medico-Chirurgical Society; Physician to the General Hospital. Octavo volume of 434 pages, with numerous illustra- tions and 4 colored plates. Cloth, $2.50 net. " The volume makes a favorable impression at once. The style is clear and succinct. We cannot find any part of the subject in which the views expressed are not carefully thought out and fortified by evidence drawn from the most recent sources. The book may be cordially recommended." — British Medical yournal. 26 W. B. SAUNDERS' A HANDBOOK FOR NURSES. By J. K. Watson, M. D., Edin., Assistant House-Surgeon, Sheffield Royal Hospital. American Edition, under the supervision of A. A. Stevens, A. M., M. D., Professor of Pathology, Woman's Medical College, Philadelphia. l2mo, 413 pages, 73 illustrations. Cloth, $1.50 net. This work aims to supply in one volume that information which so many nurses at the present time are trying to extract from various medical works, and to present that information in a suitable form. Nurses must necessarily acquire a certain amount of medical knowledge, and the author of this book has aimed judiciously to cater to this need with the object of directing the nurses' pursuit of medical information in proper and legitimate channels. The book represents an entirely new departure in nursing literature, insomuch as it contains useful information on medical and surgical matters hitherto only to be obtained from expensive works written expressly for medical mer. A NEW PRONOUNCING DICTIONARY OF MEDICINE, with Phonetic Pronunciation, Accentuation, Etymology, etc. By John M. Keating, M. D., LL.D., Fellow of the College of Physicians of Phila- delphia; Editor "Cyclopaedia of the Diseases of Children," etc.; and Henry Hamilton, with the Collaboration of J. Chalmers DaCosta, M. D., and Frederick A. Packard, M. D. One very attractive volume of over 800 pages. Second Revised Edition. Prices: Cloth, ;^5. 00 net; Sheep or Half-Morocco, ^6.00 net; with Denison's Patent Ready-Refer- ence Index; without patent index. Cloth, $4.00 net; Sheep or Half- Morocco, ^5.00 net. PROFESSIONAL OPISTIONS. " I am much pleased with Keating's Dictionary, and shall take pleasure in recommending ft to my classes." Hbnky M. Lyman, M. D., Professor of Principles and Practice of Medicine, Rush Medical College, Chicago, III. 'I am convinced that it will De a very valuable adjunct to my study-table, convenient in size and sufficiently full for ordinary use." C. A. LiNDSLEY, M. D., trofessor of Theory and Practice 0/ Medicine, Medical Dept. Yale UniTersity : iiecretary Connecticut State Board 0/ Health, New Haven. Conn. AUTOBIOGRAPHY OF SAMUEL D. GROSS, M. D., Emeritus Pro- fes.sor of Surgery in the Jefferson Medical College of Philadelphia, with Reminiscences of His Times and Contemporaries. Edited by his sons, Samuel W. Gross, M. D., LL.D., and A. Haller Gross, A. M., of the Philadelphia Bar. Preceded by a Memoir of Dr. Gross, by the late Austin Flint, M. D., LL.D. In two handsome volumes, each containing over 400 pages, demy 8vo, extra cloth, gilt tops, with fine Fronti.spiece engraved on steel. Price per Volume, ^2.50 net. CATALOGUE OF MEDICAL WORKS. 2/ PRACTICAL POINTS IN NURSING. For Nurses in Private Practice. By Emily A. M. Stoney, Graduate of the Training-School lor Nurses, Lawrence, Mass. ; Superintendent of the Training-School for Nurses, Carney Hospital, South Boston, Mass. 456 pages, handsomely illustrated with 73 engravings in the text, and 9 colored and half-tone Dlates. Cloth. Price, ti.i^ ne«. SECOND EDITION, THOROUGHLY REVISED. In this volume the author explains, in popular language and in the shortest possible form, the entire range oi pi-ivate nursing as distinguished from hospital nursing, and the nurse is instructed how best to meet the various emergencies of medical and surgical cases when distant from medical or surgical aid or when thrown on her own resources. nn especially valuable feature of the work will be found in the directions to the nurse how to improvise everything ordinarily needed in the sick-room, where the embarrassment of the nurse, owing to the want of proper appliances, is fre- quently extreme. The work has been logically divided into the followins sections : I. The Nurse : her responsibilities, qualihcations, equipment, etc. II. The Sick-Room : its selection, preparation, and management. 'II. The Patient : duties of the nurse in medical, surgical, obstetric, and gyne- cologic cases. IV. Nursing in Accidents and Emergencies. V. Nursing in Special Medical Cases. VI. Nursing of the New-born and Sick Chiiaren. VII. Physiology and Descriptive Anatomy. The Appendix contpins much information in compact form that will be found of great value to the nurse, including Rules for Feeding the Sick ; Recipes for Invalid Foods and Beverages ; Tables of Weights and Measures ; Table for Computing the Date of Labor; List of Abbreviations ; Dose-List; and a full and complete Glossary of Medical Terms and Nursing Treatment. "This is a well-written, eminently practical volume, which covers the entire range of private nursing as distinguished from hospital nursing, and instructs the nurse how best to meet the various emergencies which may arise and how to prepare everything ordinarily needed in the illness of her patient." — American Journal of Obstetrics and Diseases of Women and Children, Aug., i8q6. A TEXT-BOOK OF BACTERIOLOGY, including the Etiology and Prevention of Infective Diseases and an account of Yeasts and Moulds, Haematozoa, and Psorosperms. By Edgar M. Crckikshank, M. B., Pro- tessor of Comparative Pathology and Bacteriology, King's College, London. A handsome octavo volume of 700 pages, with 273 engravings in the text, and 22 original and colored plates. Price. S6.50 net. This book, though nominally a Fouith Edition 9f Professor Crookshank's "Manual of Bacteriology," is practically a new work, the old one having t)een reconstructed, greatly enlarged, revised throughout, and largely rewritten, lorming a text-book for the Bacteriological Laboratory, for Medical Ofticers of Health, and for Veterinary Insoectors. 28 PV. B. SAUNDERS' MEDICAL DIAGNOSIS. By Dr. Oswald Vierordt, Professor of Medicine at the University of Heidelberg. Translated, with additions, from the Fifth Enlarged German Edition, with the author's permission, by Francis H. Stuart, A. M., M. D. In one handsome royal-octavo volume of 600 pages. 194 fine wood-cuts m the text, many of them in colors. Prices: Cloth, ^4.00 net; Sheep or Half- Morocco, ^5.00 net. FOURTH AMERICAN EDITION, FROM THE FIFTH REVISED AND ENLARGED GERMAN EDITION. In this work, as in no other hitherto published, are given full and accurate explanations of the phenomena observed at the bedside. It is distinctly a clin- ical work by a master teacher, characterized by thoroughness, fulness, and accu- racy. It is a mine of information upon the points that are so often passed over without explanation. Especial attention has been given to the germ-theory as a factor in the origin of disease. The present edition of this highly successful work has been translated from the fifth German edition. Many alterations have been made throughout the book, but especially in the sections on Gastric Digestion and the Nervous System. It will be found that all the qualities which served to make the earlier editions so acceptable have been developed with the evolution of the work to its present form. THE PICTORIAL ATLAS OF SKIN DISEASES AND SYPHI- LITIC AFFECTIONS. (American Edition.) Translation from the French. Edited by J. J. Pringle, M. B., F. R. C. P., Assistant Phy- sician to, and Physician to the department for Diseases of the Skin at, the Middlesex Hospital, London. Photo-lithochromes from the famous models of dermatological and syphilitic cases in the Museum of the Saint-Louis Hospital, Paris, with explanatory wood-cuts and letter-press. In 12 Parts, at ^3.00 per Part. " Of all the atlases of skin diseases which have been published in recent years, the present one promises to be of greatest interest and value, especially from the standpoint of the general practitioner." — American Medico-Surgical Bulletin, Feb. 22, 1896. "The introduction of explanatory wood-cuts in the text is a novel and most important feature which greatly furthers the easier understanding of the excellent plates, than which nothing, we venture to say, has been seen better in point of correctness, beauty, and general merit." — New York Medical Journal, Feb. 15, 1896. " An interesting feature of the Atlas is the descriptive text, which is written for each picture by the physician who treated the case or at whose instigation the models have been made. We predict for this truly beautiful work a large circulation in all parts of the medical world where the names St. Louis and Baretta have preceded iX.."— Medical Record, N. Y., Feb. i, 1896. A TEXT-BOOK OF MECHANO-THERAPY (MASSAGE AND MEDICAL GYMNASTICS). By Axel V. Grafstrom, B. Sc, M. D., late Lieutenant in the Royal Swedish Army; late House Physi- cian, City Hospital, Blackwell's Island, New York. i2mo, 139 pages, illustrated. Cloth, Jgi. 00 net. CATALOGUE OF MEDICAL WORKS. 2g DISEASES OF THE EYE. A Hand-Book of Ophthalmic Prac- tice. By G. E. DE SCHWEINITZ, M. D., Professor of Ophthalmology in the Jefferson Medical College, Philadelphia, etc. A handsome royal- octavo volume of 696 pages, with 255 fine illustrations, many of which are original, and 2 chromo-lithographic plates. Prices : Cloth, i^4.oo net ; Sheep or Half-Morocco, ^5.00 net. THIRD EDITION, THOROUGHLY REVISED. In the third edition of this text-book, destined, it is hoped, to meet the favor- able reception which has been accorded to its predecessors, the work has been revised thoroughly, and much new matter has been introduced. Particular attention has been given to the important relations wiiich micro-organisms bear to many ocular diseases. A number of special paragraphs on new subjects have been introduced, and certain articles, including a portion of the chapter on Operations, have been largely rewritten, or at least materially changed. A number of new illustrations have been added. The Appendix contains a full description of the method of determining the corneal astigmatism with the ophthalmometer of Javal and Schiotz, and the rotation of the eyes with the tropometer of Stevens. "A work that will meet the requirements not only of the specialist, but of the general practitioner in a rare degree. I am satisfied that unusual success awaits it." William Pepper, M. D. Provost and Professor of Theory and Practice of Medicine and Clinical Medicine in the University of Pennsylvania. "A clearly written, comprehensive manual. . . . One which we can commend to students as a reliable text-book, written with an evident knowledge of the wants of those entering upon the study of this special branch of medical science." — British Medical Journal. " It is hardly too much to say that for the student and practitioner beginning the study of Ophthalmology, it is the best single volume at present published." — Medical 2\'ews. " It is a very useful, satisfactory, and safe guide for the student and the practitioner, and one of the best works of this scope in the English language." — Annals of Ophthaltnolo^y . DISEASES OF WOMEN. By J. Bland Sutton, F. R. C. S., Assistant Surgeon to Middlesex Hospital, and Surgeon to Chelsea Hospital, London ; and Arthur E. Giles, M. D., B. Sc, Lond., F. R.C. S., Edin., Assistant Surgeon to Chelsea Hospital, London. 436 pages, handsomely illustrated. Cloth, $2.50 net. The authors have placed in the hands of the physician and student a concise yet comprehensive guide to the study of gynecology in its most modern develop- ment. It has been their aim to relate facts and describe methods belonging to the science and art of gynecology in a way that will prove useful to students for examination purposes, and which will also enable the general physician to prac- tice this important department of surgery with advantage to his patients and with satisfaction to himself. " The book is very well prepared, and is certain to be well received by the medical public." — British Medical Journal. "The text has been carefully prepared. Nothing essential has been omitted, and its teachings are those recommended by the leading authorities of the A?iy ." ^Journal of the American Medical Association. 30 m: JB. SAUNDEkS^ TEXT-BOOK UPON THE PATHOGENIC BACTERIA. Spe- cially written for Students of Medicine. By Joseph McFarland, M. D., Frofessor of Pathology and Bacteriology in the Medico-Chirurgical College of Philadelphia, etc. 497 pages, finely illustrated. Price, Cloth, ^2.50 net. SECOND EDITION, REVISED AND GREATLY ENLARGED. The woik is intended to be a text-book for the medical student and for the practitioner who has had no recent laboratory training ni this department of medi- cal science. The instructions given as to needed apparatus, cultures, stainings, microscopic examinations, etc. are ample for the student's needs, and will afford to the physician much information that will interest and profit him relative to a subject which modern science shows to go far in explaining the etiology ol many diseased conditions. In this second edition the work has been brought up to date in all depart- ments of the subject, and numerous additions have been made to the technique m the endeavor to make the book fulfil the double purpose of a systematic work upon bacteria and a laboratory guide. " It is excellently adapted for the medical students and practitioners for whom it is avowedly written. . . . The descriptions given are accurate and readable, and the book should prove useful to those for whom it is written. — London Lancet, Aug. 29, 1896. " The author has sncceded admirably in presenting the essential details of bacteriological technics, together with a judiciously chosen summary of our present knowledge of pathogenic bacteria. . . . The work, we think, should have a wide circulation among English-speaking students of medicine." — N. Y. Medical Journal, April 4, 1896. " The book will be found of considerable use by medical men who have not had a special bacteriological training, and who desire to understand this important branch of medical science." — Edinburgh Medical Journal, July, i8y&. LABORATORY GUIDE FOR THE BACTERIOLOGIST. By Langdon Frothingham, M. D. V., Assistant in Bacteriology and Veteri- nary Science, Sheffield Scientific School, Yale University. Illustrated, Price, Clotn, 75 cents. The technical methods involved in bacteria-culture, methods of staining, ana microscopical study are fully described and arranged as simply and concisely as possible. The book is especially intended for use in laboratory work " It is a convenient and useful little work, and will more than repay the outlay necessary for its purchase in the saving of time which would otherwise be consumed in looking up trie various points of technique so clearly and concisely laid down in its pages." — American Mea.- ^urg. Bulletin. FEEDING IN EARLY INFANCY. By Arthur V. Meigs, M. D. Bound in limp cloth, flush edges. Price, 25 cents net. Synopsis : Analyses of Milk — Importance of the Subject of Feeding in Early Infancy — Proportion of Casein and Sugar in Human Milk — Time to Begin Arti- ficial Feeding of Infants — Amount of Food to be Administered at Each Feed- ing — Intervals between Feedings — Increase in Amount of Food at Different Periods of Infant Development — Unsuitableness of Condensed Milk as a Sub- stitute for Mother's Milk — Objections to Sterilization or " Pasteurization *' ot Milk — Advances made in the Method of Artificial Feeding of Infants. CATALOGUE OF MEDICAL WORKS. 3 1 MATERIA MEDICA FOR NURSES. By Emily A. M. Stoney, Graduate of the Training-school for Nurses, Lawrence, Mass. ; late Superintendent of the Training-school for Nurses, Carney Hospital, South Boston, Mass. Handsome octavo, 300 pages. Cloth, 1^1.50 net. The present book differs from other similar works in several features, all of which are introduced to render it more practical and generally useful. The general plan of contents follows the lines laid down in training-schools for nurses, but the book contains much useful matter not usually included in works of this character, such as Poison-emergencies, Ready Dose-list, Weights and Measures, etc., as well as a Glossary, defining all tlie terms in Materia Medica, and describing all the latest drugs and remedies, which have been generally neglected by other books of the kind. ESSENTIALS OF ANATOMY AND MANUAL OF PRACTI» CAL DISSECTION, containing " Hints on Dissection " By Charles B. Nancrede. M. D., Professor of Surgery and Clinical Surgery in the University of Michigan, Ann Arbor; Corresponding Member of the Royal Academy of Medicine, Rome, Italy ; late Surgeon Jefferson Medical Col- lege, etc. Fourth and revised edition. Post 8vo, over 500 pages, with handsome full-page lithographic plates in colors, and over 200 illustrations. Price : Extra Cloth or Oilcloth for the dissection-room, ^2.00 net. Neither pains nor expense has been spared to make this work the most ex- haustive yet concise Student's Manual of Anatomy and Dissection ever pub- lished, either in America or in Europe. The colored plates are designed to aid the student in dissecting the muscles arteries, veins, and nerves. The wood-cuts have all been specially drawn and engraved, and an Appendix added containing 60 illustrations representing the structure of the entire human skeleton, the whole being based on the eleventh edition of Gray's Anatomy, A MANUAL OF PRACTICE OF MEDICINE. By A. A. Stevens, A. M., M. D., Instructor in Physical Diagnosis in the University of Penn- sylvania, and Professor of Pathology in the Woman's Medical College of Pennsylvania. Specially intended for students preparing ftir graduation and hospital examinations. Post 8vo, 519 pages. Numerous illustrations and selected formula;. Price, bound in flexible leather, ^2.00 net. FIFTH EDITION, REVISED AND ENLARGED. Contributions to the science ol medicine have poured in so rapidly during the last quarter of a century that it is well-nigh impossible for the student, with the limited time at his disposal, to master elaborate treatises or to cull from them that knowledge which is absolutely essential. From an extended experience in teaching, the author has been enableti, by classification, to group allied symp- toms, and by the judicious elimination of theories and redundant explanations to bnng withir. r. """finarative'.v small compass a comolete outline of the prac- tice ol medicine. 32 IV. B. SAUNDERS' MANUAL OF MATERIA MEDICA AND THERAPEUTICS. By A. A. Stevens, A. M., M. D., Instructor of Physical Diagnosis in the University of Pennsylvania, and Professor of Pathology in the Woman's Medical College of Pennsylvania. 445 pages. Price, bound in flexible leather, 52.25. SECOND EDITION, REVISED. This wholly new volume, which is based on the last edition of the Pharma- copoeia, comprehends the following sections : Physiological Action of Drugs ; Drugs ; Remedial Measures other than Drugs ; Applied Therapeutics ; Incom- patibility in Prescriptions; Table of Doses; Index of Drugs; and Index of Diseases; the treatment being elucidated by more than two hundred formulae. " The author is to be congratulated upon having presented the medical student with as ;iccurate a manual of therapeutics as it is possible to prepare." — Therapeutic Gazette. " Far superior to most of its class ; in fact, it is very good. Moreover, the book is reliable and accurate." — New York Medical Journal. " The author has faithfully presented modern therapeutics in a comprehensive work, . . . and it will be found a reliable guide." — University Medical Magazine. NOTES ON THE NEWER REMEDIES: their Therapeutic Ap- plications and Modes of Administration. By David Cerna, M. D., Ph. D., Demonstrator of and Lecturer on Experimental Therapeutics in the University of Pennsylvania. Post-octavo, 253 pages. Price, $1.25. SECOND EDITION, RE-WRITTEN AND GREATLY ENLARGED. The work takes up in alphabetical order all the newer remedies, giving their physical properties, solubility, therapeutic applications, administration, and chemical formula. It thus forms a very valuable addition to the various works on therapeutics now in existence. Chemists are so multiplying compounds, that,, if each compound is to be thor- oughly studied, investigations must be carried far enough to determine the prac- tical importance of the new agents. " Especially valuable because of its completeness, its accuracy, its systematic consider- ation of the properties and therapy of many remedies of which doctors generally know but little, expressed in a brief yet terse manner." — Chicago Clinical Review. TEMPERATURE CHART. Prepared by D. t. Laine, M. D. Size 8x 13^ inches. Price, per pad of 25 charts, 50 cents. A conveniently arranged chart for recording Temperature, with columns for daily amounts of Urinary and Fecal Excretions, Food, Remarks, etc. On the back of each chart is given in full the method of Brand in the treatment (^ Typhoid Fever. I CATALOGUE OF MEDICAL WORKS. 33 A TEXT-BOOK OF HISTOLOGY, DESCRIPTIVE AND PRAC- TICAL. For the Use of Students. By Arthur Clarkson, M. B., C. M., Edin., formerly Demonstrator of Physiology in the Owen's College, Manchester; late Demonstrator of Physiology in the Yorkshire College, Leeds. Large 8vo, 554 pages, with 22 engravings in the text, and 174 beautifully colored original illustrations. Price, strongly bound in Cloth, ^4.00 net. The purpose of the writer in this work has been to furnish the student of His- tology, in one volume, wilh both the descriptive and the practical part of the science. The first two chapters are devoted to the consideration of the general methods of Histology ; subsequently, in each chapter, the structure of the tissue or organ is first systematically described, the student is then taken tutorially over the specimens illustrating it, and, finally, an appendix affords a short note of the methods of preparation. " The work must be considered a valuable addition to the list of available text-books, and is to be highly recommended." — Ne7v York Medical Journal. " One of the best works for students we have ever noticed. We predict that the book will attain a well-deserved popularity among our students." — Chicago Medical Recorder. THE PATHOLOGY AND TREATMENT OF SEXUAL IM- POTENCE. By Victor G. Vecki, M. D. From the second Ger- man edition, revised 'and rewritten. Demi-octavo, about 300 pages. Cloth, $2.00 net. The subject of impotence has but seldom been treated in this country in the truly scientific spirit that it deserves, and this volume will come to many as a revelation of the possibilities of therapeusis in this important field. Dr. Vecki's work has long been favoralily known, and the German book has received the highest consideration. This edition is more than a mere translation, for, although based on the German edition, it has been entirely rewritten by the author in English. " The work can be recommended as a scholarly treatise on its subject, and it can be read with advantage by many practitioners."— /oz^rwa/ of the American Medical Association. THE TREATMENT OF PELVIC INFLAMMATIONS THROUGH THE VAGINA. By W. R. Pryor, M. D., Pro- fessor of Gynecology in the New York Polyclinic. l2mo, 248 pages, handsomely illustrated. Cloth, $2.00 net. In this book the author directs the attention of the general practitioner to a surgical treatment of the pelvic diseases of women. There exists the utmost confusion in the profession regarding the most successful methods of treating pelvic inflammations; and inasmuch as inflammatory lesions constitute the ma- jority of all pelvic diseases, the subject is an important one. It has been the endeavor of the author to put down every little detail, no matter how insig- nificant, which might be of service. 34 ^. B. SAUNDERS' DISEASES OF WOMEN. By Henry J. Garrigues, A.M., M. D., Professor of Gynecology in the New York School of Clinical Medicine; Gynecologist to St. Mark's Hospital and to the German Dispensary, New ' York City. In one handsome octavo volume of 728 pages, illustrated by 335 engravings and colored plates. Prices: Cloth, ^4.00 net; Sheep or Half-'Morocco, ^5.00 net. A PRACTICAL work on gynecology for the use of students and practitioners, written in a terse and concise manner. The importance of a thorough know- ledge of the anatomy of the female pelvic organs has been fully recognized by the author, and considerable space has been devoted to the subject. The chap- ters on Operations and on Treatment are thoroughly modern, and are based upon the large hospital and private practice of the author. The text is eluci- dated by a large number of illustrations and colored plates, many of them being original, and forming a complete atlas for studying embryology and the anatomy of \.\\t female genitalia, besides exemplifying, whenever needed, morbid condi- tions, instruments, apparatus, and operations. Second Edition, Thorougfilij Revised. The first edition of this work met with a most appreciative reception by the medical press and profession both in this country and abroad, and was adopted as a text-book or recommended as a book of reference by nearly one htmdred colleges in the United States and Canada. The author has availed himself of the opportunity afforded by this revision to embody the latest approved advances in the treatment employed in this important branch of Medicine. He has also more extensively expressed his own opinion on the comparative value of the different methods of treatment employed. "One of the best text-bonks for students and practitioners which has been published in the English language; it is condensed, clear, and comprehensive. The profound learning and great clinical experience of the distinguished aiuhor find expression in this book in a most attractive and instructive form. Young practitioners, to whom experienced consultants may not be available, will find in this book invaluable counsel and help." Thad. a. Rbamy, M. D., LL.D., Professor 0/ Clinical Gynecology, Medical College of Ohio ; Gynecologist to the Good Samaritan and Cincinnati Hospitals. A SYLLABUS OF GYNECOLOGY, arranged in conformity with "An American Text-Book of Gynecology." By J. W. Long, M. D., Professor of Diseases of Women and Children, Medical College of Vir- ginia, etc. Price, Cloth (interleaved), iJSi.oo net. Based upon the teaching and methods laid down in the larger work, this will not only be useful as a supplementary volume, but to those who do not already possess the text-book it will also have an independent value as an aid to the practitioner in gynecological work, and to the student as a guide in the lecture- roora, as the subject is presented in a manner at once systematic, clear, succinct, -pnd practical. CATALOGUE OF MEDICAL WORKS. 35 THE AMERICAN POCKET MEDICAL DICTIONARY. Edited by W. A. Newman Dorland, M. D., Assistant Obstetrician to the Hospital of the University of Pennsylvania ; Fellow of the American Academy of Medicine. Containing the pronunciation and definition of all the principal vifords used in medicine and the kindred sciences, with 64 extensive tables. Handsomely bound in flexible leather, limp, with gold edges and patent thumb index. Price, $1.00 net ; with thumb index, ^1.25 net. SECOND EDITION, REVISED. This is the ideal pocket lexicon. It is an absolutely new book, and not a re- vision of any old work. It is complete, defining all the terms of modern medi- cine and forming an unusually complete vocabulary. It gives the pronunciation of all the terms. It makes a special feature of the newer words neglected by other dictionaries. It contains a wealth of anatomical tables of special value to students. It forms a handy volume, indispensable to every medical man. SAUNDERS' POCKET MEDICAL FORMULARY. By William M. Powell, M. D., Attending Physician to the Mercer House for Invalid Women at Atlantic City. Containing 1800 Formulse, selected from several hundred of the best-known authorities. Forming a handsome and con- venient pocket companion of nearly 300 printed pages, with blank leaves for Additions ; with an Appendix containing Posological Table, Formulse and Doses for Hypodermatic Medication, Poisons and their Antidotes, Diameters of the Female Pelvis and Foetal Head, Obstetrical Table, Diet List for Various Diseases, Materials and Drugs used in Antiseptic Surgery, Treatment of Asphyxia from Drowning, Surgical Remembrancer, Tables of Incompatibles, Eruptive Fevers, Weights and Measures, etc. Hand- somely bound in morocco, with side index, wallet, and flap. Price, §1.75 net. FIFTH EDITION, THOROUGHLY REVISED. "This little book, that can be conveniently carried in the pocket, contains an immense amount of material. It is very useful, and as the name of the author of each prescription is given, is unusually reliable." — New York Medical Record. A COMPENDIUM OF INSANITY. By John B. Chapin, M.D., LL.D., I'hysician-in-Chief, Pennsylvania Hospital for the Insane ; late Physician- Superintendent of the Willaid State Hospital, New York ; Honorary Mem- ber of the Medico-Psychological Society of Great Britain, of the Society of Mental Medicine of Belgium. lamo, 234 pages, illust. Cloth, $1.25 net. The author has given, in a condensed and concise form, a compendium of Diseases of the Mind, for the convenient use and aid of physicians and students. It contains a clear, concise statement of the clinical aspects of the various ab- normal mental conditions, with directions as to the most approved methods of managing and treating the insane " The pr.-ictical parts of Dr. Chapin's book are what constitute its distinctive merit. A desire especially, however, to call attention to the fact that in the subject of the thcrapeut of insanity the work is exceedingly valuable. The author has made a distinct addition to t literature of his %^i.c\v\\.y ." —Philadelphia Medical Journal. \\'e tics the 36 W. B. SAUNDERS' AN OPERATION BLANK, with Lists of Instruments, etc. re- quired in Various Operations. Prepared by W. W. Keen, M. D., LL.D., Professor of Principles of Surgery in the Jefferson Medical Col- lege, Philadelphia. Price per Pad, containing Blanks for fifty operations, 50 cents net. SECOND EDITION, REVISED FORM. A convenient blank, suitable for all operations, giving complete instructions regarding necessary preparation of patient, etc., with a full list of dressings and medicines to be employed. On the back of each blank is a list of instruments used — viz. general instru ments, etc., required for all operations ; and special instruments for surgery of the brain and spine, mouth and throat, abdomen, rectum, male and female genito-urinary organs, the bones, etc. The whole forming a neat pad, arranged for hanging on the wall of a sur- geon's office or in the hospital operating-room. " Will serve a useful purpose for the surgeon in reminding him of the details of prepa- ration for the patient and the room as well as for the instruments, dressings, and antiseptics needed " — New York Medical Record " Covers about all that can be needed in any operation." — American Lancet. " The plan is a capital one."— Boston Medical and Surgical Journal . LABORATORY EXERCISES IN BOTANY. By Edson S. Bastin, M. A., Professor of Materia Medica and Botany in the Philadelphia Col- lege of Pharmacy. Octavo volume of 536 pages, 87 full-page plates. Price, Cloth, ^2.50. This work is intended for the beginner and the advanced student, and it fully covers the structure of flowering plants, roots, ordinary stems, rhizomes, tubers, bulbs, leaves, flowers, fruits, and seeds. Particular attention is given to the gross and microscopical structure of plants, and to those used in medicine. Illustra- tions have freely been used to elucidate the text, and a complete index to facil- itate reference has been added. " There is no work like it in the pharmaceutical or botanical literature of this country, and we predict for it a wide circulation." — American yournal of Pharmacy. DIET IN SICKNESS AND IN HEALTH. By Mrs. Ernest Hart, formerly Student of the Faculty of Medicine of Paris and of the London School of Medicine for Women ; with an Introduction by Sir Henry Thompson, F. R. C. S., M. D., London. 220 pages ; illustrated. Price, Cloth, $1.50. Useful to those who have to nurse, feed, and prescribe for the sick. In each case the accepted causation of the disease and the reasons for the special diet prescribed are briefly described. Medical men will find the dietaries and recipes practically useful, and likely to save them trouble in directing the dietetic treatment of patients. CATALOGUE OF MEDICAL WORKS. 37 A MANUAL OF PHYSIOLOGY, with Practical Exercises. For Students and Practitioners. By G. N. Stewart, M. A., M. D., D. Sc, lately Examiner in Physiology, University of Aberdeen, and of the New Museums, Cambridge University ; Professor of Physiology in the Western Reserve University, Cleveland, Ohio. Handsome octavo volume of 848 pages, with 300 illustrations in the text, and 5 colored plates. Price, Cloth, ^3.75 net. THIRD EDITION, REVISED. "It will make its way by sheer force of merit, and amply deserves to do so. It is one oj the very best English text-books on the subject." — London Lancet. " Of the many text-books of physiology published, we do not know of one that so nearly comes up to the ideal as does Professor Stewart's volume." — British Medical Journal. ESSENTIALS OF PHYSICAL DIAGNOSIS OF THE THORAX. By Arthur M. Corwin, A. M., M. D., Demonstrator of Physical Diagno- sis in the Rush Medical College, Chicago; Attending Physician to the Central Free Dispensary, Department of Rhinology, Laryngology, and Diseases of the Chest. 219 pages. Illustrated. Cloth, flexible covers. Price, $1.25 net. THIRD EDITION, THOROUGHLY REVISED AND ENLARGED. SYLLABUS OF OBSTETRICAL LECTURES in the Medical Department, University of Pennsylvania. By Richard C. Norris, A. M., M. D., Lecturer on Clinical and Operative Obstetrics, University of Pennsylvania. Third edition, thoroughly revised and enlarged. Crown 8vo. Price, Cloth, interleaved for notes, ^2.00 net. " This work is so far superior to others on the same subject that we take pleasure in call- ing attention briefly to its excellent features. It covers the subject thoroughly, and will prove invaluable both to the student and the practitioner. The author has introduced a number of valuable hints which would only occur to one who was himself an experienced teacher of obstetrics. The subject-matter is clear, forcible, and modern. We are especially pleased with the portion devoted to the practical duties of the accoucheur, care of the child, etc. The paragraphs on antiseptics are admirable; there is no doubtful tone in the direc- tions given. No details are regarded as unimportant ; no minor rnatters omitted. We ven- ture to say that even the old practitioner will find useful hints in this direction which he can- not afford to despise." — New York Medical Record. A SYLLABUS OF LECTURES ON THE PRACTICE OF SUR- GERY, arranged in conformity with •' An American Text-Book of Surgery." By N. Senn, M. D., Ph. D., Professor of Surgery in Rusl Medical College, Chicago, and in the Chicago Polyclinic. Price, ;^2.00. This work by so eminent an author, himself one of the contributors to •'An American TextBuok of Surgery," will prove of exceptional value to the advanced student wlio has adopted that work as his text-book. It is not only the syllabus of an unrivalled course of surgical practice, but it is also an epitome of or supplement to the larger work. " The autlior has evidently spared no pains in making his Syllabus thoroughly comprehen- sive, and has added new matter and alluded to the most recent authors and operations. Full references are also given to all requisite details of surgical anatomy and pathology." — Britith Medical Journal, London. 38 PV. B. SAUNDERS' THE CARE OF THE BABY. By J. P. Crozer Griffith, M. D., Clinical Professor of Diseases of Children, University of Pennsylvania; Physician to the Children's Hospital, Philadelphia, etc. 404 pages, with 67 illustrations in the text, and 5 plates. lamo. Price, ^1.50. SECOND EDITION, REVISED. A reliable guide not only for mothers, but also for medical students and practitioners whose opportunities for observing children have been limited. " The whole book is characterized by rare good sense, and is evidently written by a mas- ter hand. It can be read with benefit not only by mothers, but by medical students and by any practitioners who have not had large opportunities for observing children." — American Journal of Obstetrics. THE NURSE'S DICTIONARY of Medical Terms and Nursing Treatment, containing Definitions of the Principal Medical and Nursing Terms, Abbreviations, and Physiological Names, and Descriptions of the Instruments, Drugs, Diseases, Accidents, Treatments, Operations, Foods, Appliances, etc. encountered m the ward or the sick-room. By Honnor Morten, author of "How to Become a Nurse," "Sketches of Hospital Life," etc. i6mo, 140 pages. Price, Cloth, $1.00. This little volume is intended for use merely as a small reference-book which can be consulted at the bedside or in the ward. It gives sufficient explanation to the nurse to enable her to comprehend a case until she has leisure to look up larger and fuller works on the subject. DIET LISTS AND SICK-ROOM DIETARY. By Jerome B. Thomas, M. D., Visiting Physician to the Home for Friendless Women and Children and to the Newsboys' Home ; Assistant Visiting Physician to the Kings County Hospital; Assistant Bacteriologist, Brooklyn Health Department. Price, Cloth, ;^i.50 (Send for specimen List.) One hundred and sixty detachable (perforated) diet lists for Albuminuria, Ansemia and Debility, Constipation, Diabetes, Diarrhoea, Dyspepsia, Fevers, Gout or Uric-Acid Diathesis, Obesity, and Tuberculosis. Also forty detachable sheets of Sick-Room Dietary, containing full instructions for preparation of easily-digested foods necessary for invalids. Each list is numbered only, the disease for which it is to be used in no case being mentioned, an index key being reserved for the physician's private use. DIETS FOR INFANTS AND CHILDREN IN HEALTH AND IN DISEASE. By Louis Starr, M. D., Editor of "An American Text-Book of the Diseases of Children." 230 blanks (pocket-book size), perforated and neatly bound in flexible morocco. Price, ^1.25 net. The first series of blanks are prepared for the first seven months of infant life; each blank indicates the ingredients, but not the quantities, of the food, the 'latter directions being left for the physician. After the seventh month, modifications being less necessary, the diet lists are printed in full. Formula foi tne preparation of diluents and foods are appended. CATALOGUE OF MEDICAL WORKS. 39 HOW TO EXAMINE FOR LIFE INSURANCE. By Jokn M. Keating, M. D., Fellow of the College of Physicians and Surgeons of Philadelphia; Vice-President of the American Psediatric Society; Ex- President of the Association of Life Insurance Medical Directors. Royal 8vo, 211 pages, with two large half-tone illustrations, and a plate prepared by Dr. McClellan from special dissections; also, numerous cuts to elucidate the text. Third edition. Price, Cloth, ^2.00 net. " This is by far the most useful book v/hich has yet appeared on insurance examination, a subject of growing interest and importance. Not the least valuable portion of the volume is Part II., which consists of instructions issued to their examining physicians by twenty-four representative companies of th-s country. As the proofs of these instructions were corrected by the directors of the companies, they form the latest instructions obtainable. If for these alone, the book should be at the right hand of every physician interested in this special branch of medical science." — The Medical News, Philadelphia. NURSING: ITS PRINCIPLES AND PRACTICE. By Isabel Adams Hampton, Graduate of the New York Training School for Nurses attached to Bellevue Hospital ; Superintendent of Nurses and Principal of the Training School for Nurses, Johns Hopkins Hospital, Baltimore, Md. ; late Superintendent of Nurses, Illinois Training School for Nurses, Chicago, 111. In one very handsome l2mo volume of 512 pages, illustrated. Price, Cloth, ^2.00 net. SECOND EDITION, REVISED AND ENLARGED. This original work on the important subject of nursing is at once comprehensive and systematic. It is written in a clear, accurate, and readable style, suitable alike to the student and the lay reader. Such a work has long been a desidera- tum with those entrusted with the management of hospitals and liie instruction of nurses in training-schools. It is also of especial value to the graduated nurse who desires to acquire a practical working knowledge of the care of the sick and the hygiene of the sick-room. OBSTETRIC ACCIDENTS, EMERGENCIES, AND OPERA- TIONS. By L. Ch. Boisi.iniere, M. D., late Emeritus Professor of Obstetrics in the St. Louis Medical College. 381 pages, handsomely illus- trated. Price, ^2.00 net. " For the use of the practitioner who, when away from home, has not the opportunity of consulting a library or of calling a friend in consultation. He then, being thrown upon his own resources, will find this book of benefit in guiding and assisting him in emergencies." INFANT'S WEIGHT CHART, Designed by J. P. Crozer Griffith, M. D., Clinical Professor of Diseases of Children in the University of Peniv sylvania. 25 charts in each pad. Price per pad, 50 cents net. A convenient blank for keeping a record of the child's weight during the first two years of life. Printed on each chart is a curve representing the average weight of a healthy infant, so that any deviation from the normal can readily be detected. Saunders' New Series OF Manuals for Students and Practitioners* ■' I 'HAT there exists a need for thoroughly reliable hand-books on the leading •*■ branches of Medicine and Surgery is a fact amply demonstrated by the favor with which the SAUNDERS NEW SERIES OF MANUALS have been received by medical students and practitioners and by the Medical Press. These manuals are not merely condensations from present literature, but are ably written by well-known authors and practitioners, most of them being teachers in representative American colleges. Each volume is concisely and authoritatively written and exhaustive in detail, without being encumbered with the introduction of "cases," which so largely expand the ordinary text- book. These manuals will therefore form an admirable collection of advanced lectures, useful alike to the medical student and the practitioner : to the latter, loo busy to search through page after page of elaborate treatises for what he wants to know, they will prove of inestimable value ; to the former they will afford safe guides to the essential points of study. The SAUNDERS NEW SERIES OF MANUALS are conceded to be superior to any similar books now on the market. No other manuals afford so much information in such a concise and available form. A liberal expenditure has enabled the publisher to render the mechanical portion of the work worthy of the high literary standard attained by these books. Any of these Manuals will be mailed on receipt of price (see next page for List). SAUNDERS' NEW SERIES OF MANUALS. VOLUMES PUBLISHED. PHYSIOLOGY. By Joseph Howard Raymond, A. M., M. D., Professor of Physiology and Hygiene and Lecturer on Gynecology in the Long Island College Hospital, etc. Price, 5l-25 net. SURGERY, General and Operative. By John Chalmers DaCosta, M. D., Professor of Practice of Surgery and Clinical Surgery, Jefferson Medical College, Philadel(ihia. Second edition, revised and greatly en- larged. Octavo, 911 pages, 386 illustrations. Cloth, $4.00 net; Hall'- Morocco, ^5.00 net. DOSE-BOOK AND MANUAL OF PRESCRIPTION-WRITING. By E. Q. Thornton, M. D., Demonstrator of Therapeutics, Jefferson Medical College, Philadelphia. Price, #1.25 net. MEDICAL JURISPRUDENCE. By Henry C. Chapman, M. D., Pro- fessor of Institutes of Medicine and Medical Jurisprudence in the Jeffer- son Medical College of Philadelphia, etc Price, ^1.50 net. SURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark's Hospital and to the German Poliklinik ; Instructor in Surgery, New York Post-Graduate Medical School, etc. Price, $l.2S net. MANUAL OF ANATOMY. By Irving S. Haynes, M.D., Adjunct Professor of Anatomy and Demonstrator of Anatomy, Medical Department of the New York University, etc. Price, S2.50 net. SYPHILIS AND THE VENEREAL DISEASES. By James Nevins Hyde, M. D , Professor of Skin and Venereal Diseases, and Frank H. Montgomery, M. D., Lecturer on Dermatology and Genito- urinary Diseases in Rush Medical College, Chicago. Price, ^2.50 net. PRACTICE OF MEDICINE. By George Roe Lockwood, M. D., Professor of Practice in the Woman's Medical College of the New York Infirmary, etc. Price, ^2.50 net. OBSTETRICS. By W. A. Newman Dorland, M. D., Assistant Demon- strator of Obstetrics, University of Pennsylvania; Chief of Gynecological Dispensary, Pennsylvania Hospital. Price, $2.50 net. DISEASES OF WOMEN. By J. Bland Sutton, F. R. C. S., Assistant Surgeon to the Middlesex Hospital, and Surgeon to the Chelsea Hospital for Women, London ; and Arthur E. Giles, M. D., B. Sc. Lond., F. R. C. S. Edin., Assistant Surgeon to the Chelsea Hospital for Women, London. 436 pages, handsomely illustrated. Price, $2.50 net. IN PREPARATION. NERVOUS DISEASES. By Charles W. Burr, M. D., Clinical Profes- sor of Nervous Diseases, Medico-Chirurgical College, Philadelphia, etc. *** There will be published in the same series, at short intervals, carefully prepared works on various subjects, by prominent specialists. 41 SAUNDERS' QUESTION COMPENDS. Arranged in Question and Answer Form. THE LATEST, MOST COMPLETE, and BEST ILLUSTRATED SEEIES OF COMPENDS EVER ISSUED. Now the Standard Authorities in Medical Literature Students and Practitioners in every City of the United States and Canada. THE REASON WHY. They are the advance guard of " Student's Helps " — that DO help; they are the leaders in their special line, well and authoritatively written by able men, who, as teachers in the large colleges, know exactly luhat is wanted by a student preparing for his examinations. The judgment exercised in the selection of authors is fully demonstrated by their professional elevation. Chosen from the ranks of Demonstrators, Quiz-masters, and Assistants, most of them have be- come Professors and Lecturers in their respective colleges. Each book is of convenient size (5x7 inches), containing on an average 250 pages, profusely illustrated, and elegantly printed in clear, readable type, on fine paper. The entire series, numbering twenty- four subjects, has been kept thoroughly revised and enlarged when necessary, many of them being In their fourth and fifth editions. TO SUM UP. Although there are numerous other Quizzes, Manuals, Aids, etc. in the mar- ket, none of them approach the " Blue Series of Question Compends;" and the claim is made for the following points of excellence : 1. Professional distinction and reputation of authors. 2. Conciseness, clearness, and soundness of treatment. 3. Size of type and quality of paper and binding. *,s.* Any of these Compends will be mailed on receipt of price (see next page for List). SAUNDERS* QUESTION-COMPEND SERIES, Price, Qoth, $1.00 per copy, except when otherwise noted. 1. ESSENTIALS OF PHYSIOLOGY. 4th edition. Illustrated. Revised and enlarged By H. A. Hare, iM. D. (Price, ^i.oo net.) 2. ESSENTIALS OF SURGERY. 7th edition, with a chapter on Appendicitis. 90 illus- trations. By Edwahd Mahtin, M. D. (Price, jiSt.oo net ) 3. ESSENTIALS OF ANATOMY. 6th edition, thoroughly revised. 151 illustrations. By Charles B. Nancrede, M. D. (Price, $1.00 net.) 4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC. 5th edition, revised, with an Appendix. By Lawrence Wolff, M. D. (^i. 00 net.) 5. ESSENTIALS OF OBSTETRICS. 4th edition, revised and enlarged. 75 illustra- tions. By W. Easterly Ashton, M. D. 6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. 7th thousand. 46 illustrations. By C. E. Armand Semple, M. D. 7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE- SCRIPTION-WRITING. 5th edition. By Henry Morris, M. D. 8. g. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, M. D. An .'Vppeiidi.'c on Urine Examin ation. Illustrated. By Lawrence Wolff, M. D. 3d edition, enlarged by some 300 Essential Formulae, selected from eminent authori- ties, by Wm. M. Powell, INI. D. (Double number, price ^2.00.) 10. ESSENTIALS OF GYN/ECOLOGY. 4th edition, revised. With 62 illustrations. By Edwin B. Cragin, M. D. 11. ESSENTIALS OF DISEASES OF THE SKIN. 4th edition, revised and enlarged. 71 letter-press cuts and 15 half-tone illustrations. By Henry W. Stelwagon, M.D. (Price, jSi.oo net.) 12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL DISEASES. 2d edition, revised and enlarged. 78 illustrations. By Edward Martin, M. D. 13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. 130 illustrations. By C. E, Armand Semi-le, M. D. 14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. 124 illustrations, 2d edition, revised. By Euwabd Jackson, M. D., and E. Baldwin Gleason, M. D. 15. ESSENTIALS OF DISEASES OF CHILDREN. 2d edition. By William M. Powell, M.D. 16. ESSENTIALS OF EXAMINATION OF URINE. Colored " Vogel Scale." and numerous illustrations. By Lawrence Wolff, M. D. (Price, 75 cents.) 17. ESSENTIALS OF" DIAGNOSIS. 2d edition, thoroughly revised. 60 illustrations. By S. SiiLis-CoHiiN, .M. i^., and A. A. Esmner, M. D. (Price, jfi.oonet.) 18. ESSENTIALS OF PRACTICE OF PHARMACY. 2d edition, revised. By L. E. Sayre. 20. ESSENTIALS OF BACTERIOLOGY. 3d edition. 82 illustrations. By M. V. Ball, M. D. 21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY, 48 illustrations. 3d edition, revised. By John C. Shaw, M. D. 22. ESSENTIALS OF MEDICAL PHYSICS. 155 illustrations. 2d edition, revised. By Fred J. Bkockway, M. I). (Price, Ji.oo net.) 23. ESSENTIALS OF MEDICAL ELECTRICITY. 65 illustrations. By David D. Stewart, M. D., and Edward S. Lawrance, M. D. 24. ESSENTIALS OF DISEASES OF THE EAR. 114 illustrations. 2d edition, re- vised and enlarged. By E. Baldwin Gleason, M. D. Some of the Books in Preparation for Publication during 1900. AMERICAN Text=Book of Pa= thology. Edited by Ludvig Hektoen, M.D., Pro- fessor of Pathology, Rush Medical College, Chicago; and David Riesman, M.D., De- monstrator of Pathological Histology, Uni- versity of Pennsylvania. AMERICAN Text=Book of Legal Medicine and Toxicology. Edited by Frederick Peterson, M.D., Chief of Clinic, Nervous Department, College of Physicians and Surgeons, New York City ; and Walter S. Haines, M.D., Professor of Chemistry, Pharmacy, and Toxicology, Rush Medical College, Chicago. BECK— Fractures. By Carl Beck, M.D., Professor of Surgery in the N. Y. School of Clinical Medicine. BOHM, DAVIDOFF, and HU= BER-A Text=Bookof Human Histology. Including Microscopic Technic. By Dr. a. a. Bohm and Dr. M. von Davidoff, of the Anatomical Institute of Munich, and G. C. HuBER, M.D., Junior Professor of Anat- omy and Histology ."University of Michigan, Ann Arbor. EICHHORST— A Text=Book of the Practice of Medicine. By Dr. Herman Eichhorst, Professor of Special Pathol igy and Therapeutics and Di- rector of the Medical Clinic, University of Zurich. Translated and edited by Augustus A. Eshner, M D , Professor of Clinical Medicine in the Philadelphia Polyclinic. FRIEDRICH — Rhinology, La= ryngology, and Otology in their Relations to General Medicine. By Dr. E. P. Friedrich, of the Univer- sity of Leipsig. LEVY AND KLEMPERER — The Elements of Clinical Bac° teriology. By Dr. Ernst Levy, Professor in the University of Stra.ssburg, and Dr. Felix Klemperer, Privat-Docent in the Univer- sity of Strassburg. Translated and edited by Augustus A. Eshner, M.D., Professor of Clinical Medicine in the Philadelphia Poly- clinic. Just Ready. Cloth, J2. 50 net. McFARLAND— A Text=Book of Pathology. By Joseph McFarland, M.D., Professor of Pathology and Bacteriology, Mcdico-Chi- rurgical College, Philadelphia. OGDEN — Clinical Examination of the Urine. By J. Bergen Ogden, M.D., Assistant in Chemistry, Harvard Medical School. PYLE— A Manual of Personal Hygiene. Edited by Walter L. Pyle, M.D., Assis- tantSurgeon to Wills' Eye Hospital, Philada. SCU ODER— The Treatment of Fractures. By Charles L. Scudder, M.D., Assistant in Clinical and Operative Surgery, Harvard University. SENN— Practical Surgery. By Nicholas Senn, M.D., Ph.D., LL.D., Professor of the Practice of Surgery and of Clinical Surgery, Rush Medical College, Chi- cago. Octavo volume of about 800 pages, profusely illustrated. The Pathology and Treatment of Tumors. By Nicholas Senn, M.D., Ph.D., LL.D., Professor of the Practice of Surgery and of Clinical Surgery, Rush Medical College, Chi- cago. A New and Thoroughly Revised Edi- tion in preparation. STENGEL AND WHITE — The Blood in its Clinical and Patho=' logical Relations. By Alfred Stengel, M.D., Professor of Clinical Medicine, University of Pennsyl- vania; and C. Y. White, M.D., Instruc- tor in Clinical Medicine, University of Penn- sylvania. STEVENS— The Physical Diag= nosis of Diseases of the Chest. By A. A. Stevens, A.M., M.D., Lecturer on Terminology, and Instructor in Physical Diagnosis, University of Pennsylvania. STONEY — Surgical Technique for Nurses. By Emmy A. M. Stoney, late Superin- tendent of the Training Schools for Nurses, Carney Hospital, South Boston, Mass. GRIFTITH ON THE BABY THE CARE OF THE BABY. By J. P. Crozer Griffith, M.D., Clinical Professor of Diseases of Cfiildren, University of Pennsylvania ; Physi- cian to the Children's Hospital, Philadelphia, etc. Octavo. 404 pages. Illustrated. Cloth, $1.50. SECOND EDITION, REVISED. The author has endeavored to furnish a reliable guide for mothers anxious to inform themselves with regard to the best way of caring for their "The best book for the use of the young mother with which we are acquainted. There are very few general practitioners who could not read the work through with advantage." — Archives of Pediatrics. children in sickness and in health. He has made Iiis statements plain and easily understood, in the hope that the volume may be of service " The whole book is characterized by rare good sense, and is evidently written by a master hand. It can be read with benefit not only by mothers but by medical students and by any practitioners who have not had large opportuni- ties for observing children." — American Journal of Obstetrics. not only to mot' .ers and nurses but also to med- ical students and to practitioners whose oppor- tunities for observing cliildren luve been limited. For sale by all Booksellers, or sent post-paid on receipt of price. W. B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. Atlas of General Surgery. /tiias ui f syciiiairy. Atlas of Diseases of the Ear. NERVOUS AND MENTAL DIS- EASES. By Archibald Church, M.D., Professor of Clinical Neu- rologfy, Mental Diseases, and Medical Juris- CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES prudence. Northwestern University ; and Frederick Peterson, M.D., Chief of Clinic, Nervous Department, College of Physicians and Surgfeons, New York. Handsome octavo, 843 pages, with over 300 illustrations. Cloth, $5.00 net; Half Morocco, $6.00 net. SECOND EDITION. This book is intended to furnish sludcnts and practitioners with a practical, working knowl- edge of nervous and mencal diseases. Written by men of wide experience and authority, it ■will present the many recent additions to the subject. The book is not filled w^ith an ex- tended dissertation on anatomy and pathology, but, treating these points in connection with special conditions, it lays particular stress on methods of examination, diagnosis, and treat- ment. In this respect the work is unusually complete and valuable, laying dow^n the defi- nite courses of procedure which the authors have found the most generally satisfactory. For sale by all Booksellers, or sent post-paid on receipt of price. W. B. SAUNDERS, Publisher, 925 Walnut St., Philadelphia. VOLUMES NOW READY. J "^ ^C^ Atlas of Internal Dr. Chr. Jakob EsHNER, M.D., Prll delphia Polyclinic ; Hospital. 68 colo Atlas of Legal M< Vienna. Edited t Professor of Menta York; Chief of CI and Surgeons, I' plates, and 193 1 Atlas of Disease of Munich. Ec turer on Laryn^ Pennsylvania ; I ment, Hospital c figures on 44 plat Atlas of Operati Vienna. Edite<| Professor of Sur, Surgeon to the P and 217 illustrai Atlas of Syphili Dr. Franz Mi Bangs, M.D., 1 Diseases, New "V pital. With 71 A. SCHMITSON Atlas of Extern of Zurich. Ec sor of Ophthal phia. With 7 113.00 net. Atlas of Skin r>